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RxSense Performance Formulary

July 2019

RxSense Performance Formulary July 2019 II

Introduction The RxSense Performance Formulary contains covered drugs for a broad range of diseases.

Generics drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand drug in (parentheses). Some generic products have no reference brand.

Brand prescription drugs are shown in capital letters followed by the generic name.

The RxSense Performance Formulary is organized into broad categories (e.g. Anti-Infective drugs). Within most categories, drugs are sub-grouped by drug class (e.g. Penicillins) or by use for a specific medical condition (e.g. Diabetes).

Pharmacy Benefits To save the most money on prescription drugs, take this drug list with you each time you visit your physician. Consider asking your physician to prescribe generic (p or np) and preferred (P) formulary medications, if appropriate. Decisions about the need for a prescription drug and dosage of a prescription drug must be made solely by you and your physician in accordance with the patient/physician relationship.

The RxSense Performance formulary is multi-tiered, placing prescription medication into copayment levels. Members should refer to his or her Summary of Benefits and Coverage documents to see which copayment structure applies to them below.

Drug Type Tier Designation Symbol Preferred Generics p Non-Preferred Generics np Preferred Brands P Non-Preferred Brands NP Non-Covered Medications NC

Drug Type 3 Tier Copay Plan 4 Tier Copay Plan 5 Tier Copay Plan Preferred Generics 1 1 1 Non-Preferred Generics 1 1 2 Preferred Brands 2 2 3 Non-Preferred Brands 3 3 4 Preferred Specialty 2 4 5 Non-Preferred Specialty 3 4 5

Coverage considerations Most prescription drug benefit plans provide coverage for up to a 30-day supply of medication, with some exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications. Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood pressure, diabetes or high cholesterol. Some plans may exclude coverage for certain agents or drug categories, like those used for erectile dysfunction, weight loss or infertility.

Over-the-counter exclusions: The NetResults Formulary may not provide coverage for prescription medications that have an over-the-counter version. You should refer to your benefit plan material for details about your particular benefits.

Compounded medications: Your benefit plan may not provide coverage for compounded medications. Please see your plan materials or call the number on the back of your ID card to determine whether compounded

RxSense Performance Formulary July 2019 III

medications are covered and/or verify your payment amount.

Repackaged medications: Repackaged versions of medications already available on the market are not covered.

Prior Authorization Some drugs require prior authorization (PA) to ensure appropriate use. This means that your doctor will need to submit a PA request for coverage. Coverage may be approved after certain criteria are met. If a PA is required for a drug listed in this document, it will be noted next to the drug with a dot under the PA column.

Step Therapy A step therapy (ST) program means you may need to try an alternative drug before coverage may be available for the requested drug included in the ST program. ST programs help redirect members to safe, effective and less expensive alternatives. If a ST is required for a drug listed in this document, it will be noted next to the drug with a dot under the ST column.

Dispensing Limits Dispensing limits (DL) help encourage drug use as intended by the Food and Drug Administration. The DL is the maximum quantity that can be dispensed over a given period of time. These limits help encourage safe and proper use. If a DL is required for a drug listed in this document, it will be noted next to the drug with a dot under the DL column.

Specialty Drugs Specialty drugs require special handling, patient monitoring, and unique education prior to use.

Non-Covered Drug Certain drugs are non-covered (NC) on RxSense Performance Formulary. If you fill a prescription for a NC drug, you will likely pay full retail price. Please talk to your physician about prescribing a preferred alternative. If a drug is NC, it will be noted under the Tier Designation column as NC.

Notice The purpose of the RxSense Performance Formulary is to provide a guide to coverage. Decisions about the need for a prescription drug and dosage of a prescription drug must be made solely by you and your physician in accordance with the patient/physician relationship.

Abbreviation/acronym key

caps ...................................................... capsules chew .................................................... chewable conc .................................................. concentrate cr ............................................ controlled release dr ............................................... delayed release ec .................................................. enteric coated effe .................................................. effervescent equiv ................................................... equivalent er ............................................. extended release inhal ..................................................... inhalation inj ........................................................... injection liq ................................................................ liquid lotn .............................................................. lotion nebu ..................................................... nebulizer

odt ............................ orally disintegrating tablets oint ......................................................... ointment ophth ................................................. ophthalmic osm ............................................ osmotic release powd ........................................................ powder sa .............................................. sustained action sl ......................................................... sublingual soln ......................................................... solution sr ............................................ sustained release suppos ........................................... suppositories susp .................................................. suspension tab ............................................................ tablets td ..................................................... transdermal

2019

RxSense Performance Formulary July 2019 1

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ANTI-INFECTIVE AGENTSPENICILLINSAMOXICILLIN- amoxicillin (trihydrate)

chew tab 125 mgNP

AMOXICILLIN- amoxicillin (trihydrate)chew tab 250 mg

NP

amoxicillin (trihydrate) cap 250 mg p

amoxicillin (trihydrate) cap 500 mg p

amoxicillin (trihydrate) for susp125 mg/5ml

p


p


p


p

amoxicillin (trihydrate) tab 500 mg p

amoxicillin (trihydrate) tab 875 mg p

amoxicillin & k clavulanate for susp200-28.5 mg/5ml

p

amoxicillin & k clavulanate for susp250-62.5 mg/5ml (Augmentin)

np

amoxicillin & k clavulanate for susp400-57 mg/5ml

p

amoxicillin & k clavulanate for susp600-42.9 mg/5ml (Augmentines-600)

p

amoxicillin & k clavulanate tab er12hr 1000-62.5 mg (Augmentin xr)

np

amoxicillin & k clavulanate tab250-125 mg

np

amoxicillin & k clavulanate tab500-125 mg (Augmentin)

p

amoxicillin & k clavulanate tab875-125 mg (Augmentin)

p

AMOXICILLIN/CLAVULANATE P-amoxicillin & k clavulanate chew tab200-28.5 mg

NP

AMOXICILLIN/CLAVULANATE P-amoxicillin & k clavulanate chew tab400-57 mg

NP

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AMPICILLIN- ampicillin cap 500 mg NP

AUGMENTIN- amoxicillin& k clavulanate for susp125-31.25 mg/5ml

NP

dicloxacillin sodium cap 250 mg np

dicloxacillin sodium cap 500 mg np

MOXATAG- amoxicillin (trihydrate) taber 24hr 775 mg

NP

PENICILLIN V POTASSIUM- penicillinv potassium for soln 125 mg/5ml

NP

PENICILLIN V POTASSIUM- penicillinv potassium for soln 250 mg/5ml

NP

penicillin v potassium tab 250 mg p

penicillin v potassium tab 500 mg p

CEPHALOSPORINSCEFACLOR- cefaclor for susp

125 mg/5mlNC

CEFACLOR- cefaclor for susp250 mg/5ml

NC

CEFACLOR- cefaclor for susp375 mg/5ml

NC

cefaclor cap 250 mg np

cefaclor cap 500 mg np

CEFACLOR ER- cefaclormonohydrate tab er 12hr 500 mg

NC

cefadroxil cap 500 mg p

cefadroxil for susp 250 mg/5ml np

cefadroxil for susp 500 mg/5ml np

cefadroxil tab 1 gm np

cefdinir cap 300 mg p

cefdinir for susp 125 mg/5ml np

cefdinir for susp 250 mg/5ml np

CEFDITOREN PIVOXIL- cefditorenpivoxil tab 200 mg (base equivalent)

NC

CEFDITOREN PIVOXIL- cefditorenpivoxil tab 400 mg (base equivalent)

NC

cefixime for susp 100 mg/5ml(Suprax)

np

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cefixime for susp 200 mg/5ml(Suprax)

np

cefpodoxime proxetil for susp50 mg/5ml

p

cefpodoxime proxetil for susp100 mg/5ml

np

cefpodoxime proxetil tab 100 mg np

cefpodoxime proxetil tab 200 mg np

cefprozil for susp 125 mg/5ml np

cefprozil for susp 250 mg/5ml np

cefprozil tab 250 mg np

cefprozil tab 500 mg np

cefuroxime axetil tab 250 mg np

cefuroxime axetil tab 500 mg np

CEPHALEXIN- cephalexin tab 250 mg NC

CEPHALEXIN- cephalexin tab 500 mg NC

cephalexin cap 250 mg (Keflex) p

cephalexin cap 500 mg (Keflex) p

cephalexin cap 750 mg (Keflex) np

cephalexin for susp 125 mg/5ml np

cephalexin for susp 250 mg/5ml np

SPECTRACEF- cefditoren pivoxil tab400 mg (base equivalent)

NC

SUPRAX- cefixime cap 400 mg P

SUPRAX- cefixime chew tab 100 mg P

SUPRAX- cefixime chew tab 200 mg P

SUPRAX- cefixime for susp500 mg/5ml

P

MACROLIDESAZITHROMYCIN- azithromycin powd

pack for susp 1 gmP

azithromycin for susp 100 mg/5ml(Zithromax)

np

azithromycin for susp 200 mg/5ml(Zithromax)

np

azithromycin tab 250 mg(Zithromax)

p

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p


np

CLARITHROMYCIN- clarithromycinfor susp 125 mg/5ml

NP

CLARITHROMYCIN- clarithromycinfor susp 250 mg/5ml

NP

clarithromycin tab er 24hr 500 mg np

clarithromycin tab 250 mg np

clarithromycin tab 500 mg (Biaxin) np

DIFICID- fidaxomicin tab 200 mg NP

E.E.S. 400- erythromycinethylsuccinate tab 400 mg

NP

ERY-TAB- erythromycin tab delayedrelease 250 mg

NP


NP


NP

ERYPED 400- erythromycinethylsuccinate for susp 400 mg/5ml

NP

ERYTHROCIN STEARATE-erythromycin stearate tab 250 mg

P

ERYTHROMYCIN ETHYLSUCCINA-erythromycin ethylsuccinate tab400 mg

NP

erythromycin ethylsuccinate forsusp 200 mg/5ml (E.e.s. granules)

np

erythromycin tab 250 mg np

erythromycin tab 500 mg np

erythromycin w/ delayed releaseparticles cap 250 mg

np

ZITHROMAX- azithromycin powdpack for susp 1 gm

NP

TETRACYCLINESdemeclocycline hcl tab 150 mg np

demeclocycline hcl tab 300 mg np

DORYX MPC- doxycycline hyclate tabdelayed release 120 mg

NC

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DOXYCYCLINE HYCLATE-doxycycline hyclate tab 50 mg

NC

doxycycline hyclate cap 50 mg np

doxycycline hyclate cap 100 mg(Vibramycin)

np

doxycycline hyclate tab delayedrelease 50 mg (Doryx)

NC

doxycycline hyclate tab delayedrelease 75 mg

NC


NC


NC

doxycycline hyclate tab delayedrelease 200 mg (Doryx)

NC

doxycycline hyclate tab 20 mg np

doxycycline hyclate tab 75 mg(Acticlate)

np

doxycycline hyclate tab 100 mg np

doxycycline hyclate tab 150 mg(Acticlate)

np

doxycycline monohydrate cap50 mg

p

doxycycline monohydrate cap75 mg (Monodox)

np

doxycycline monohydrate cap100 mg (Monodox)

p

doxycycline monohydrate cap150 mg (Adoxa)

np

doxycycline monohydrate for susp25 mg/5ml (Vibramycin)

np

doxycycline monohydrate tab50 mg

np


np


np


np

minocycline hcl cap 50 mg(Minocin)

p

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np


np

minocycline hcl tab er 24hr 45 mg NC

minocycline hcl tab er 24hr 65 mg(Solodyn)

np


minocycline hcl tab er 24hr 115 mg(Solodyn)

np


minocycline hcl tab 50 mg np



SOLODYN- minocycline hcl tab er24hr 55 mg

P


P


P

TARGADOX- doxycycline hyclate tab50 mg

NC

tetracycline hcl cap 250 mg(Tetracycline hcl)

np

tetracycline hcl cap 500 mg(Tetracycline hcl)

np

VIBRAMYCIN- doxycycline calciumsyrup 50 mg/5ml

NC

XIMINO- minocycline hcl cap er 24hr45 mg (base equivalent)

NC


NC


NC

FLUOROQUINOLONESBAXDELA- delafloxacin meglumine

tab 450 mg (base equiv)NP

CIPRO- ciprofloxacin for oral susp250 mg/5ml (5%) (5 gm/100ml)

NP

2019


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ciprofloxacin for oral susp500 mg/5ml (10%) (10 gm/100ml)(Cipro)

np

CIPROFLOXACIN HCL- ciprofloxacinhcl tab 100 mg (base equiv)

NP

ciprofloxacin hcl tab 250 mg (baseequiv) (Cipro)

p

ciprofloxacin hcl tab 500 mg (baseequiv) (Cipro)

p

ciprofloxacin hcl tab 750 mg (baseequiv)

p

ciprofloxacin-ciprofloxacin hcl taber 24hr 500 mg (base eq) (Ciproxr)

np

ciprofloxacin-ciprofloxacin hcl taber 24hr 1000 mg(base eq) (Ciproxr)

np

levofloxacin oral soln 25 mg/ml np

levofloxacin tab 250 mg (Levaquin) p



moxifloxacin hcl tab 400 mg (baseequiv) (Avelox)

np

OFLOXACIN- ofloxacin tab 300 mg P

ofloxacin tab 400 mg np

AMINOGLYCOSIDESBETHKIS- tobramycin nebu soln

300 mg/4mlNP •

KITABIS PAK- tobramycin nebu soln300 mg/5ml

NP •

neomycin sulfate tab 500 mg p

paromomycin sulfate cap 250 mg np

TOBI PODHALER- tobramycin inhalcap 28 mg

NP •

TOBRAMYCIN- tobramycin nebu soln300 mg/5ml

NP •

tobramycin nebu soln 300 mg/5ml(Tobi)

np •

SULFONAMIDES

Drug Name Tier

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SULFADIAZINE- sulfadiazine tab500 mg

P

ANTIMYCOBACTERIAL AGENTSCYCLOSERINE- cycloserine cap

250 mgNP

ethambutol hcl tab 100 mg(Myambutol)

np

ethambutol hcl tab 400 mg(Myambutol)

np

ISONIAZID- isoniazid syrup50 mg/5ml

NP

isoniazid tab 100 mg p

isoniazid tab 300 mg p

PASER- aminosalicylic acider granules packet 4 gm

NP

PRIFTIN- rifapentine tab 150 mg P

pyrazinamide tab 500 mg np

rifabutin cap 150 mg (Mycobutin) np

RIFAMATE- isoniazid & rifampin cap150-300 mg

NP

rifampin cap 150 mg (Rifadin) np

rifampin cap 300 mg np

RIFATER- isoniazid-rifampin w/pyrazinamide tab 50-120-300 mg

NP

SIRTURO- bedaquiline fumarate tab100 mg (base equiv)

NP

TRECATOR- ethionamide tab 250 mg NP

ANTIFUNGALSCRESEMBA- isavuconazonium

sulfate cap 186 mgNP •

fluconazole for susp 10 mg/ml(Diflucan)

p

fluconazole for susp 40 mg/ml(Diflucan)

np

fluconazole tab 50 mg (Diflucan) p




flucytosine cap 250 mg (Ancobon) np

2019


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flucytosine cap 500 mg (Ancobon) np

griseofulvin microsize susp125 mg/5ml

np

griseofulvin microsize tab 500 mg np

griseofulvin ultramicrosize tab125 mg (Gris-peg)

np

griseofulvin ultramicrosize tab250 mg (Gris-peg)

np

itraconazole cap 100 mg(Sporanox)

np

itraconazole oral soln 10 mg/ml(Sporanox)

np

ketoconazole tab 200 mg NC

NOXAFIL- posaconazole susp 40 mg/ml

P •

NOXAFIL- posaconazole tab delayedrelease 100 mg

P •

nystatin tab 500000 unit np

SPORANOX- itraconazole oral soln10 mg/ml

NP

terbinafine hcl tab 250 mg (Lamisil) p

voriconazole for susp 40 mg/ml(Vfend)

np •

voriconazole tab 50 mg (Vfend) np •voriconazole tab 200 mg (Vfend) np •ANTIVIRALSabacavir sulfate soln 20 mg/ml

(base equiv) (Ziagen)np •

abacavir sulfate tab 300 mg (baseequiv) (Ziagen)

np •

abacavir sulfate-lamivudine tab600-300 mg (Epzicom)

np •

abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg(Trizivir)

np •

acyclovir cap 200 mg (Zovirax) p

acyclovir susp 200 mg/5ml(Zovirax)

np

acyclovir tab 400 mg (Zovirax) p

acyclovir tab 800 mg (Zovirax) p

Drug Name Tier

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adefovir dipivoxil tab 10 mg(Hepsera)

np

APTIVUS- tipranavir cap 250 mg NP •APTIVUS- tipranavir oral soln 100 mg/

mlNP •

atazanavir sulfate cap 150 mg (baseequiv) (Reyataz)

np •


np •


np •

ATRIPLA- efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg

P •

BARACLUDE- entecavir oral soln0.05 mg/ml

P

BIKTARVY- bictegravir-emtricitabine-tenofovir af tab 50-200-25 mg

P •

CIMDUO- lamivudine-tenofovirdisoproxil fumarate tab 300-300 mg

P •

COMPLERA- emtricitabine-rilpivirine-tenofovir df tab 200-25-300 mg

NP •

CRIXIVAN- indinavir sulfate cap200 mg

NP •

CRIXIVAN- indinavir sulfate cap400 mg

NP •

DAKLINZA- daclatasvirdihydrochloride tab 30 mg (baseequivalent)

NC


NC


NC

DESCOVY- emtricitabine-tenofoviralafenamide fumarate tab200-25 mg

P •

didanosine delayed release capsule200 mg (Videx ec)

np •


np •

2019


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np •

EDURANT- rilpivirine hcl tab 25 mg(base equivalent)

NP •

efavirenz cap 50 mg (Sustiva) np •efavirenz cap 200 mg (Sustiva) np •efavirenz tab 600 mg (Sustiva) np •EMTRIVA- emtricitabine caps 200 mg NP •EMTRIVA- emtricitabine soln 10 mg/

mlNP •

entecavir tab 0.5 mg (Baraclude) np

entecavir tab 1 mg (Baraclude) np

EPCLUSA- sofosbuvir-velpatasvir tab400-100 mg

P • •

EPIVIR HBV- lamivudine oral soln5 mg/ml (hbv)

NP

EVOTAZ- atazanavir sulfate-cobicistattab 300-150 mg (base equiv)

P •

famciclovir tab 125 mg np



FLUMADINE- rimantadinehydrochloride tab 100 mg

NC

fosamprenavir calcium tab 700 mg(base equiv) (Lexiva)

np •

FUZEON- enfuvirtide for inj 90 mg NP • •GENVOYA- elvitegrav-cobic-

emtricitab-tenofov af tab150-150-200-10 mg

P •

HARVONI- ledipasvir-sofosbuvir tab90-400 mg

P • •

INTELENCE- etravirine tab 25 mg P •INTELENCE- etravirine tab 100 mg P •INTELENCE- etravirine tab 200 mg P •INVIRASE- saquinavir mesylate cap

200 mgNP •

INVIRASE- saquinavir mesylate tab500 mg

NP •

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ISENTRESS- raltegravir potassiumchew tab 25 mg (base equiv)

P •

ISENTRESS- raltegravir potassiumchew tab 100 mg (base equiv)

P •

ISENTRESS- raltegravir potassiumpacket for susp 100 mg (base equiv)

P •

ISENTRESS- raltegravir potassiumtab 400 mg (base equiv)

P •

ISENTRESS HD- raltegravirpotassium tab 600 mg (base equiv)

P •

JULUCA- dolutegravir sodium-rilpivirine hcl tab 50-25 mg (base eq)

NP •

KALETRA- lopinavir-ritonavir tab100-25 mg

P •

KALETRA- lopinavir-ritonavir tab200-50 mg

P •

lamivudine oral soln 10 mg/ml(Epivir)

np •

lamivudine tab 100 mg (hbv) (Epivirhbv)

np

lamivudine tab 150 mg (Epivir) np •lamivudine tab 300 mg (Epivir) np •lamivudine-zidovudine tab

150-300 mg (Combivir)np •

LEXIVA- fosamprenavir calcium susp50 mg/ml (base equiv)

NP •

lopinavir-ritonavir soln400-100 mg/5ml (80-20 mg/ml)(Kaletra)

np •

MAVYRET- glecaprevir-pibrentasvirtab 100-40 mg

P • •

MODERIBA- ribavirin tab 200 mg &ribavirin 400 mg tab therapy pack

NP •

MODERIBA- ribavirin tab 400 mg &ribavirin 600 mg tab therapy pack

NP •

MODERIBA 1200 DOSE PACK-ribavirin tab 600 mg

NP •

MODERIBA 800 DOSE PACK-ribavirin tab 400 mg

NP •

nevirapine susp 50 mg/5ml(Viramune)

np •

2019


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nevirapine tab er 24hr 100 mg(Viramune xr)

np •

nevirapine tab er 24hr 400 mg(Viramune xr)

np •

nevirapine tab 200 mg (Viramune) p •NORVIR- ritonavir oral soln 80 mg/ml P •NORVIR- ritonavir powder packet

100 mgNP •

ODEFSEY- emtricitabine-rilpivirine-tenofovir af tab 200-25-25 mg

P •

oseltamivir phosphate cap 30 mg(base equiv) (Tamiflu)

np •


np •


np •

oseltamivir phosphate for susp6 mg/ml (base equiv) (Tamiflu)

np •

PEGASYS- peginterferon alfa-2a inj180 mcg/ml

P • •

PEGASYS- peginterferon alfa-2a inj180 mcg/0.5ml

P • •

PEGASYS PROCLICK- peginterferonalfa-2a inj 135 mcg/0.5ml

P • •

PEGASYS PROCLICK- peginterferonalfa-2a inj 180 mcg/0.5ml

P • •

PEGINTRON- peginterferon alfa-2bfor inj kit 50 mcg/0.5ml

NP • •

PREVYMIS- letermovir tab 240 mg NP •PREVYMIS- letermovir tab 480 mg NP •PREZCOBIX- darunavir-cobicistat tab

800-150 mgP •

PREZISTA- darunavir ethanolate susp100 mg/ml (base equiv)

P •

PREZISTA- darunavir ethanolate tab75 mg (base equiv)

P •


P •


P •

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P •

REBETOL- ribavirin soln 40 mg/ml NP •RELENZA DISKHALER- zanamivir

aero powder breath activated 5 mg/blister

NP •

RESCRIPTOR- delavirdine mesylatetab 100 mg

NP •

RESCRIPTOR- delavirdine mesylatetab 200 mg

NP •

REYATAZ- atazanavir sulfate oralpowder packet 50 mg (base equiv)

NP •

RIBASPHERE- ribavirin tab 400 mg NP •RIBASPHERE- ribavirin tab 600 mg NP •RIBASPHERE RIBAPAK- ribavirin

tab 200 mg & ribavirin 400 mg tabtherapy pack

NP •

RIBASPHERE RIBAPAK- ribavirintab 400 mg & ribavirin 600 mg tabtherapy pack

NP •

RIBASPHERE RIBAPAK- ribavirin tab400 mg

NP •

RIBASPHERE RIBAPAK- ribavirin tab600 mg

NP •

ribavirin cap 200 mg (Rebetol) np •ribavirin for inhal soln 6 gm

(Virazole)np

ribavirin tab 200 mg (Copegus) np •rimantadine hydrochloride tab

100 mg (Flumadine)NC

ritonavir tab 100 mg (Norvir) np •SELZENTRY- maraviroc oral soln

20 mg/mlNP •

SELZENTRY- maraviroc tab 25 mg NP •SELZENTRY- maraviroc tab 75 mg NP •SELZENTRY- maraviroc tab 150 mg NP •SELZENTRY- maraviroc tab 300 mg NP •SITAVIG- acyclovir buccal tab 50 mg NC

SOVALDI- sofosbuvir tab 400 mg P • •stavudine cap 15 mg (Zerit) np •

2019


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stavudine cap 20 mg (Zerit) np •stavudine cap 30 mg (Zerit) np •stavudine cap 40 mg (Zerit) np •STRIBILD- elvitegrav-cobic-emtricitab-

tenofovdf tab 150-150-200-300 mgNP •

SYMFI- efavirenz-lamivudine-tenofovirdf tab 600-300-300 mg

P •

SYMFI LO- efavirenz-lamivudine-tenofovir df tab 400-300-300 mg

P •

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

NC

TECHNIVIE- ombitasvir-paritaprevir-ritonavir tab 12.5-75-50 mg

NC

tenofovir disoproxil fumarate tab300 mg (Viread)

np •

TIVICAY- dolutegravir sodium tab10 mg (base equiv)

P •


P •


P •

TRIUMEQ- abacavir-dolutegravir-lamivudine tab 600-50-300 mg

P •

TRUVADA- emtricitabine-tenofovirdisoproxil fumarate tab 100-150 mg

P •


P •


P •


P •

TYBOST- cobicistat tab 150 mg NP •valacyclovir hcl tab 500 mg

(Valtrex)p

valacyclovir hcl tab 1 gm (Valtrex) p

valganciclovir hcl for soln 50 mg/ml(base equiv) (Valcyte)

np

valganciclovir hcl tab 450 mg (baseequivalent) (Valcyte)

np

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VEMLIDY- tenofovir alafenamidefumarate tab 25 mg

NC

VIDEX- didanosine for soln 2 gm P •VIDEX- didanosine for soln 4 gm P •VIDEX EC- didanosine delayed

release capsule 125 mgNP •

VIEKIRA PAK- ombitas-paritapre-riton & dasab tab pak 12.5-75-50 &250 mg

NC

VIEKIRA XR- dasab-ombit-paritap-riton tab er 24hr200-8.33-50-33.33 mg

NC

VIRACEPT- nelfinavir mesylate tab250 mg

NP •

VIRACEPT- nelfinavir mesylate tab625 mg

NP •

VIRAMUNE- nevirapine susp50 mg/5ml

P •

VIREAD- tenofovir disoproxil fumarateoral powder 40 mg/gm

P •

VIREAD- tenofovir disoproxil fumaratetab 150 mg

P •


P •


P •

VOSEVI- sofosbuvir-velpatasvir-voxilaprevir tab 400-100-100 mg

P • •

ZEPATIER- elbasvir-grazoprevir tab50-100 mg

NC

zidovudine cap 100 mg (Retrovir) np •zidovudine syrup 10 mg/ml

(Retrovir)np •

zidovudine tab 300 mg np •ANTIMALARIALSatovaquone-proguanil hcl tab

62.5-25 mg (Malarone)np

atovaquone-proguanil hcl tab250-100 mg (Malarone)

np

CHLOROQUINE PHOSPHATE-chloroquine phosphate tab 250 mg

P

2019


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chloroquine phosphate tab 500 mg np

COARTEM- artemether-lumefantrinetab 20-120 mg

NP

DARAPRIM- pyrimethamine tab25 mg

P

hydroxychloroquine sulfate tab200 mg (Plaquenil)

np

MEFLOQUINE HCL- mefloquine hcltab 250 mg

P

PRIMAQUINE PHOSPHATE-primaquine phosphate tab 26.3 mg(15 mg base)

P

quinine sulfate cap 324 mg(Qualaquin)

np

AMEBICIDESSOLOSEC- secnidazole granules

packet 2 gmNP

ANTHELMINTICSalbendazole tab 200 mg (Albenza) np

ALBENZA- albendazole tab 200 mg P

BENZNIDAZOLE- benznidazole tab12.5 mg

P

BENZNIDAZOLE- benznidazole tab100 mg

P

EMVERM- mebendazole chew tab100 mg

NC

ivermectin tab 3 mg (Stromectol) np

praziquantel tab 600 mg (Biltricide) np

ANTI-INFECTIVE AGENTS - MISC.ALINIA- nitazoxanide for susp

100 mg/5mlP

ALINIA- nitazoxanide tab 500 mg P

atovaquone susp 750 mg/5ml(Mepron)

np

CAYSTON- aztreonam lysine for inhalsoln 75 mg (base equivalent)

NP •

clindamycin hcl cap 75 mg(Cleocin)

p


p

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p

clindamycin palmitate hcl for soln75 mg/5ml (base equiv) (Cleocinpediatric gr)

np

dapsone tab 25 mg np

dapsone tab 100 mg np

FIRVANQ- vancomycin hcl for oralsoln 25 mg/ml (base equivalent)

NP

FIRVANQ- vancomycin hcl for oralsoln 50 mg/ml (base equivalent)

NP

IMPAVIDO- miltefosine cap 50 mg P

linezolid for susp 100 mg/5ml(Zyvox)

np

linezolid tab 600 mg (Zyvox) np

metronidazole cap 375 mg (Flagyl) np

metronidazole tab 250 mg (Flagyl) p

metronidazole tab 500 mg (Flagyl) p

NEBUPENT- pentamidine isethionatefor nebulization soln 300 mg

NP

PRIMSOL- trimethoprim hcl oral soln50 mg/5ml (base equiv)

NP

SIVEXTRO- tedizolid phosphate tab200 mg

NP

sulfamethoxazole-trimethoprimsusp 200-40 mg/5ml

np

sulfamethoxazole-trimethoprim tab400-80 mg (Bactrim)

p

sulfamethoxazole-trimethoprim tab800-160 mg (Bactrim ds)

p

tinidazole tab 250 mg np

tinidazole tab 500 mg (Tindamax) np

trimethoprim tab 100 mg p

TRIMPEX- trimethoprim hcl oral soln50 mg/5ml (base equiv)

NP

vancomycin hcl cap 125 mg (baseequivalent) (Vancocin hcl)

np

vancomycin hcl cap 250 mg (baseequivalent) (Vancocin hcl)

np

XIFAXAN- rifaximin tab 200 mg NP

2019


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XIFAXAN- rifaximin tab 550 mg P

BIOLOGICALSVACCINESACTHIB- haemophilus b

polysaccharide conjugate vaccinefor inj

P

AFLURIA PF 2018-2019- influenzavirus vaccine split pf susp prefsyringe 0.5 ml

P

AFLURIA QUADRIVALENT 2018-influenza virus vac split quadrivalentsusp pref syr 0.5ml

P

AFLURIA QUADRIVALENT 2018-influenza virus vaccine splitquadrivalent im inj

P

AFLURIA 2018-2019- influenza virusvaccine split im susp

P

BEXSERO- meningococcal vac b(recomb omv adjuv) inj prefilledsyringe

P

ENGERIX-B- hepatitis b vaccine(recombinant) susp 10 mcg/0.5ml

P

ENGERIX-B- hepatitis b vaccine(recombinant) susp 20 mcg/ml

P

ENGERIX-B- hepatitis b vaccine(recombinant) 10 mcg/0.5ml

P

ENGERIX-B- hepatitis b vaccine(recombinant) 20 mcg/ml

P

FLUAD 2018-2019- influenza vac typea&b surface ant adj susp pref syr0.5 ml

P

FLUARIX QUADRIVALENT 2018-influenza virus vac split quadrivalentsusp pref syr 0.5ml

P

FLUBLOK QUADRIVALENT 2018-influenza vac recomb ha quad pfsoln pref syr 0.5 ml

P

FLUCELVAX QUADRIVALENT 20-influenza vac tiss-cult subunt quadsusp pref syr 0.5 ml

P

Drug Name Tier

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FLUCELVAX QUADRIVALENT 20-influenza vac tissue-cultured subunitquadrivalent im susp

P

FLULAVAL QUADRIVALENT 201-influenza virus vac split quadrivalentsusp pref syr 0.5ml

P

FLULAVAL QUADRIVALENT 201-influenza virus vaccine splitquadrivalent im inj

P

FLUMIST QUADRIVALENT- influenzavirus vaccine live quadrivalentintranasal susp

P

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

P

FLUZONE QUADRIVALENT 2018-influenza virus vac split quadrivalentsusp pref syr 0.25 ml

P

FLUZONE QUADRIVALENT 2018-influenza virus vac split quadrivalentsusp pref syr 0.5ml

P

FLUZONE QUADRIVALENT 2018-influenza virus vaccine splitquadrivalent im inj

P

FLUZONE QUADRIVALENT 2018-influenza virus vaccine splitquadrivalent inj 0.5 ml

P

GARDASIL 9- human papillomavirus(hpv) 9-valent recomb vac im susp

P

GARDASIL 9- human papillomavirus(hpv) 9-valent recomb vac susp prefsyr

P

HAVRIX- hepatitis a vaccine inj susp720 el unit/0.5ml

P

HAVRIX- hepatitis a vaccine inj susp1440 el unit/ml

P

HEPLISAV-B- hepatitis b vaccinerecomb adjuvanted pref syr20 mcg/0.5ml

P

HEPLISAV-B- hepatitis b vaccinerecombinant adjuvanted20 mcg/0.5ml

P

2019


Drug Name Tier

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HIBERIX- haemophilus bpolysaccharide conjugate vac for inj10 mcg

P

IMOVAX RABIES (H.D.C.V.)- rabiesvirus vaccine, hdc inj

P

IPOL INACTIVATED IPV- poliovirusvaccine, ipv injection

P

M-M-R II- measles, mumps & rubellavirus vaccines for inj

P

MENACTRA- meningococcal (a, c, y,and w-135) conjugate vaccine inj

P

MENVEO- meningococcal (a, c, y, andw-135) oligo conj vac for inj

P

PEDVAX HIB- haemophilus bpolysaccharide conj vac im susp7.5 mcg/0.5 ml

P

PNEUMOVAX 23- pneumococcalvaccine polyvalent inj 25 mcg/0.5ml

P

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

P

PREVNAR 13- pneumococcal 13-valent conjugate vaccine inj

P

PROQUAD- measles-mumps-rubella-varicella virus vaccines for susp

P

RABAVERT- rabies vaccine, pcec forinj

P

RECOMBIVAX HB- hepatitis b vaccine(recombinant) susp 5 mcg/0.5ml

P

RECOMBIVAX HB- hepatitis b vaccine(recombinant) susp 10 mcg/ml

P

RECOMBIVAX HB- hepatitis b vaccine(recombinant) susp 40 mcg/ml

P

ROTARIX- rotavirus vaccine, live fororal susp

P

ROTATEQ- rotavirus vaccine, live oralpentavalent soln

P

SHINGRIX- zoster vac recombinantadjuvanted for im inj 50 mcg/0.5ml

P

TRUMENBA- meningococcal group bvac (recomb) im susp prefilled syr

P

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TWINRIX- hepatitis a (inact)-hep b(recomb) vac inj 720-20 elu-mcg/ml

P

VAQTA- hepatitis a vaccine inj susp25 unit/0.5ml

P

VAQTA- hepatitis a vaccine inj susp50 unit/ml

P

VARIVAX- varicella virus vac live forsubcutaneous inj 1350 pfu/0.5ml

P

VIVOTIF- typhoid vaccine cap delayedrelease

NP

ZOSTAVAX- zoster vaccine livefor subcutaneous susp 19400unit/0.65ml

P

TOXOIDSADACEL- tet tox-diph-acell pertuss ad

inj 5-2-15.5 lf-lf-mcg/0.5mlP

BOOSTRIX- tet tox-diph-acell pertussad inj 5-2.5-18.5 lf-lf-mcg/0.5ml

P

DAPTACEL- diph, acellular pert & tettox inj 15 lf-23 mcg-5 lf/0.5ml

P

DIPHTHERIA/TETANUS TOXOID-diphtheria-tetanus tox adsorbed (dt)im inj 25-5 unit/0.5ml

P

INFANRIX- diph, acellular pert & tettox inj 25 lf-58 mcg-10 lf/0.5ml

P

KINRIX- diph-tetanus tox ad-acell pert& polio virus, ipv vac inj

P

PEDIARIX- diph-tetanus tox-acellpert-hepatitis b-polio ipv vac inj

P

PENTACEL- diph-ac per-tet tox ad-poliov-haemoph b poly vac for imsusp

P

QUADRACEL- diph-tetanus tox ad-acell pert & polio virus, ipv vac inj

P

TENIVAC- tetanus-diphtheria toxoids(td) inj 5-2 lfu

P

TETANUS/DIPHTHERIA TOXOID-tetanus-diphtheria toxoids (td) inj2-2 lf/0.5ml

P

BIOLOGICALS MISC

2019


Drug Name Tier

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GRASTEK- timothy grass pollenallergen ext sl tab 2800 bau

NP • •

ODACTRA- dust mite mixed ext sl tab12 sq-hdm

NP • •

ORALAIR- grass mixed pollen ext sltab 300 ir (index of reactivity)

NP • •

RAGWITEK- short ragweed pollenallergen extract sl tab 12 amb a 1-u

NP • •

ANTINEOPLASTIC AGENTSANTINEOPLASTICSACTIMMUNE- interferon gamma-1b

inj 100 mcg/0.5ml (2000000unit/0.5ml)

P •

AFINITOR- everolimus tab 2.5 mg P • • •AFINITOR- everolimus tab 5 mg P • • •AFINITOR- everolimus tab 7.5 mg P • • •AFINITOR- everolimus tab 10 mg P • • •AFINITOR DISPERZ- everolimus tab

for oral susp 2 mgP • • •

AFINITOR DISPERZ- everolimus tabfor oral susp 3 mg

P • • •

AFINITOR DISPERZ- everolimus tabfor oral susp 5 mg

P • • •

ALECENSA- alectinib hcl cap 150 mg(base equivalent)

P • • •

ALUNBRIG- brigatinib tab initiationtherapy pack 90 mg & 180 mg

P • • •

ALUNBRIG- brigatinib tab 30 mg P • • •ALUNBRIG- brigatinib tab 90 mg P • • •ALUNBRIG- brigatinib tab 180 mg P • • •anastrozole tab 1 mg (Arimidex) p

bexarotene cap 75 mg (Targretin) np • •bicalutamide tab 50 mg (Casodex) np •BOSULIF- bosutinib tab 100 mg P • • •BOSULIF- bosutinib tab 400 mg P • • •BOSULIF- bosutinib tab 500 mg P • • •BRAFTOVI- encorafenib cap 50 mg NP • • •BRAFTOVI- encorafenib cap 75 mg NP • • •

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CABOMETYX- cabozantinib s-malatetab 20 mg (base equivalent)

NP • • •


NP • • •


NP • • •

CALQUENCE- acalabrutinib cap100 mg

NP • • •

capecitabine tab 150 mg (Xeloda) np • •capecitabine tab 500 mg (Xeloda) np • •CAPRELSA- vandetanib tab 100 mg P • • •CAPRELSA- vandetanib tab 300 mg P • • •COMETRIQ- cabozantinib s-mal cap 1

x 80 mg & 1 x 20 mg (100 dose) kitP • • •

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

P • • •

COMETRIQ- cabozantinib s-malatecap 3 x 20 mg (60 mg dose) kit

P • • •

COTELLIC- cobimetinib fumarate tab20 mg (base equivalent)

P • • •

cyclophosphamide cap 25 mg(Cyclophosphamide)

np •

cyclophosphamide cap 50 mg(Cyclophosphamide)

np •

ELIGARD- leuprolide acetate (3month) for subcutaneous inj kit22.5mg

NP •

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

NP •

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

NP •

ELIGARD- leuprolide acetate forsubcutaneous inj kit 7.5 mg

NP •

EMCYT- estramustine phosphatesodium cap 140 mg

P •

ERIVEDGE- vismodegib cap 150 mg P • • •ERLEADA- apalutamide tab 60 mg P • • •ETOPOSIDE- etoposide cap 50 mg P •

2019


Drug Name Tier

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exemestane tab 25 mg (Aromasin) np

FARESTON- toremifene citrate tab60 mg (base equivalent)

P •

FARYDAK- panobinostat lactate cap10 mg (base equivalent)

P • • •


P • • •


P • • •

flutamide cap 125 mg np •GILOTRIF- afatinib dimaleate tab

20 mg (base equivalent)P • • •

GILOTRIF- afatinib dimaleate tab30 mg (base equivalent)

P • • •

GILOTRIF- afatinib dimaleate tab40 mg (base equivalent)

P • • •

GLEOSTINE- lomustine cap 10 mg P •GLEOSTINE- lomustine cap 40 mg P •GLEOSTINE- lomustine cap 100 mg P •HYCAMTIN- topotecan hcl cap

0.25 mg (base equiv)P • •

HYCAMTIN- topotecan hcl cap 1 mg(base equiv)

P • •

hydroxyurea cap 500 mg (Hydrea) np •IBRANCE- palbociclib cap 75 mg P • • •IBRANCE- palbociclib cap 100 mg P • • •IBRANCE- palbociclib cap 125 mg P • • •ICLUSIG- ponatinib hcl tab 15 mg

(base equiv)P • • •

ICLUSIG- ponatinib hcl tab 45 mg(base equiv)

P • • •

IDHIFA- enasidenib mesylate tab50 mg (base equivalent)

NP • • •

IDHIFA- enasidenib mesylate tab100 mg (base equivalent)

NP • • •

imatinib mesylate tab 100 mg (baseequivalent) (Gleevec)

np • • •

imatinib mesylate tab 400 mg (baseequivalent) (Gleevec)

np • • •

IMBRUVICA- ibrutinib cap 70 mg P • • •

Drug Name Tier

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IMBRUVICA- ibrutinib cap 140 mg P • • •IMBRUVICA- ibrutinib tab 140 mg P • • •IMBRUVICA- ibrutinib tab 280 mg P • • •IMBRUVICA- ibrutinib tab 420 mg P • • •IMBRUVICA- ibrutinib tab 560 mg P • • •INLYTA- axitinib tab 1 mg P • • •INLYTA- axitinib tab 5 mg P • • •INTRON A- interferon alfa-2b inj

6000000 unit/mlP •

INTRON A- interferon alfa-2b inj10000000 unit/ml

P •

INTRON A- interferon alfa-2b for inj10000000 unit

P •


P •


P •

IRESSA- gefitinib tab 250 mg P • • •JAKAFI- ruxolitinib phosphate tab


JAKAFI- ruxolitinib phosphate tab10 mg (base equivalent)

P • • •


P • • •


P • • •


P • • •

KISQALI- ribociclib succinate tab200 mg (base equiv)

P • • •

KISQALI FEMARA 200 DOSE-ribociclib tab 200 mg & letrozole tab2.5 mg therapy pack

P • • •


P • • •


P • • •

2019


Drug Name Tier

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LENVIMA 10 MG DAILY DOSE-lenvatinib cap therapy pack 10 mg(10 mg daily dose)

P • • •

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

P • • •

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

P • • •

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

P • • •

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

P • • •

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

P • • •

LENVIMA 4 MG DAILY DOSE-lenvatinib cap therapy pack 4 mg(4 mg daily dose)

P • • •

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

P • • •

letrozole tab 2.5 mg (Femara) p

LEUCOVORIN CALCIUM- leucovorincalcium tab 10 mg

P

LEUCOVORIN CALCIUM- leucovorincalcium tab 15 mg

P

leucovorin calcium tab 5 mg np

leucovorin calcium tab 25 mg np

LEUKERAN- chlorambucil tab 2 mg P •leuprolide acetate inj kit 5 mg/ml np •LONSURF- trifluridine-tipiracil tab

15-6.14 mgP • • •

LONSURF- trifluridine-tipiracil tab20-8.19 mg

P • • •

LUPRON DEPOT (1-MONTH)-leuprolide acetate for inj kit 3.75 mg

P •

LUPRON DEPOT (1-MONTH)-leuprolide acetate for inj kit 7.5 mg

P •

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LUPRON DEPOT (3-MONTH)-leuprolide acetate (3 month) for injkit 11.25 mg

P •

LUPRON DEPOT (3-MONTH)-leuprolide acetate (3 month) for injkit 22.5 mg

P •

LUPRON DEPOT (4-MONTH)-leuprolide acetate (4 month) for injkit 30 mg

P •

LUPRON DEPOT (6-MONTH)-leuprolide acetate (6 month) for injkit 45 mg

P •

LYNPARZA- olaparib tab 100 mg P • • •LYNPARZA- olaparib tab 150 mg P • • •LYSODREN- mitotane tab 500 mg P • •MATULANE- procarbazine hcl cap

50 mgP • •

megestrol acetate susp 40 mg/ml(Megace oral)

np

megestrol acetate tab 20 mg p

megestrol acetate tab 40 mg p

MEKINIST- trametinib dimethylsulfoxide tab 0.5 mg (baseequivalent)

P • • •

MEKINIST- trametinib dimethylsulfoxide tab 2 mg (base equivalent)

P • • •

MEKTOVI- binimetinib tab 15 mg NP • • •melphalan tab 2 mg (Alkeran) np •mercaptopurine tab 50 mg np •MESNEX- mesna tab 400 mg P

METHOTREXATE SODIUM-methotrexate sodium inj250 mg/10ml (25 mg/ml)

NP

methotrexate sodium for inj 1 gm np

methotrexate sodium inj pf50 mg/2ml (25 mg/ml)

p


p


np

2019


Drug Name Tier

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

p

methotrexate sodium tab 2.5 mg(base equiv)

np

MYLERAN- busulfan tab 2 mg P •NERLYNX- neratinib maleate tab

40 mg (base equivalent)NP • • •

NEXAVAR- sorafenib tosylate tab200 mg (base equivalent)

P • • •

nilutamide tab 150 mg (Nilandron) np •NINLARO- ixazomib citrate cap

2.3 mg (base equivalent)P • • •

NINLARO- ixazomib citrate cap 3 mg(base equivalent)

P • • •

NINLARO- ixazomib citrate cap 4 mg(base equivalent)

P • • •

ODOMZO- sonidegib phosphate cap200 mg (base equivalent)

P • • •

POMALYST- pomalidomide cap 1 mg P • • •POMALYST- pomalidomide cap 2 mg P • • •POMALYST- pomalidomide cap 3 mg P • • •POMALYST- pomalidomide cap 4 mg P • • •PURIXAN- mercaptopurine susp

2000 mg/100ml (20 mg/ml)P •

RUBRACA- rucaparib camsylate tab200 mg (base equivalent)

NP • • •


NP • • •


NP • • •

RYDAPT- midostaurin cap 25 mg P • • •SOLTAMOX- tamoxifen citrate oral

soln 10 mg/5ml (base equivalent)P

SPRYCEL- dasatinib tab 20 mg P • • •SPRYCEL- dasatinib tab 50 mg P • • •SPRYCEL- dasatinib tab 70 mg P • • •SPRYCEL- dasatinib tab 80 mg P • • •SPRYCEL- dasatinib tab 100 mg P • • •SPRYCEL- dasatinib tab 140 mg P • • •

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STIVARGA- regorafenib tab 40 mg P • • •SUTENT- sunitinib malate cap

12.5 mg (base equivalent)P • • •

SUTENT- sunitinib malate cap 25 mg(base equivalent)

P • • •

SUTENT- sunitinib malate cap37.5 mg (base equivalent)

P • • •

SUTENT- sunitinib malate cap 50 mg(base equivalent)

P • • •

SYLATRON- peginterferon alfa-2b forinj kit 200 mcg

P • •


P • •


P • •

SYNRIBO- omacetaxinemepesuccinate for inj 3.5 mg

P •

TABLOID- thioguanine tab 40 mg P •TAFINLAR- dabrafenib mesylate cap


TAFINLAR- dabrafenib mesylate cap75 mg (base equivalent)

P • • •

TAGRISSO- osimertinib mesylate tab40 mg (base equivalent)

P • • •

TAGRISSO- osimertinib mesylate tab80 mg (base equivalent)

P • • •

tamoxifen citrate tab 10 mg (baseequivalent)

p

tamoxifen citrate tab 20 mg (baseequivalent)

np

TARCEVA- erlotinib hcl tab 25 mg(base equivalent)

P • • •


P • • •


P • • •

TASIGNA- nilotinib hcl cap 50 mg(base equivalent)

P • • •


P • • •

2019


Drug Name Tier

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Lim

its


P • • •

temozolomide cap 5 mg (Temodar) np • •temozolomide cap 20 mg (Temodar) np • •temozolomide cap 100 mg

(Temodar)np • •

temozolomide cap 140 mg(Temodar)

np • •


np • •


np • •

TIBSOVO- ivosidenib tab 250 mg NP • • •tretinoin cap 10 mg np • •TREXALL- methotrexate sodium tab

5 mg (base equiv)NP

TREXALL- methotrexate sodium tab7.5 mg (base equiv)

NP

TREXALL- methotrexate sodium tab10 mg (base equiv)

NP

TREXALL- methotrexate sodium tab15 mg (base equiv)

NP

TYKERB- lapatinib ditosylate tab250 mg (base equiv)

P • • •

VENCLEXTA- venetoclax tab 10 mg NP • • •VENCLEXTA- venetoclax tab 50 mg NP • • •VENCLEXTA- venetoclax tab 100 mg NP • • •VENCLEXTA STARTING PACK-

venetoclax tab therapy starter pack10 & 50 & 100 mg

NP • • •

VERZENIO- abemaciclib tab 50 mg NP • • •VERZENIO- abemaciclib tab 100 mg NP • • •VERZENIO- abemaciclib tab 150 mg NP • • •VERZENIO- abemaciclib tab 200 mg NP • • •VOTRIENT- pazopanib hcl tab

200 mg (base equiv)P • • •

XALKORI- crizotinib cap 200 mg P • • •XALKORI- crizotinib cap 250 mg P • • •

Drug Name Tier

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ing

Lim

its

XATMEP- methotrexate oral soln2.5 mg/ml

NC

XTANDI- enzalutamide cap 40 mg P • • •YONSA- abiraterone acetate tab

125 mgP • • •

ZEJULA- niraparib tosylate cap100 mg (base equivalent)

NP • • •

ZELBORAF- vemurafenib tab 240 mg P • • •ZOLINZA- vorinostat cap 100 mg P • • •ZYDELIG- idelalisib tab 100 mg P • • •ZYDELIG- idelalisib tab 150 mg P • • •ZYKADIA- ceritinib cap 150 mg P • • •ZYTIGA- abiraterone acetate tab

250 mgP • • •

ZYTIGA- abiraterone acetate tab500 mg

P • • •

ENDOCRINE AND METABOLIC DRUGSCORTICOSTEROIDSbudesonide delayed release

particles cap 3 mg (Entocort ec)np

budesonide tab er 24hr 9 mg(Uceris)

NC

CORTISONE ACETATE- cortisoneacetate tab 25 mg

P

DEXAMETHASONE- dexamethasonesoln 0.5 mg/5ml

NP

DEXAMETHASONE- dexamethasonetab 1 mg

P

DEXAMETHASONE- dexamethasonetab 2 mg

P

dexamethasone elixir 0.5 mg/5ml np

DEXAMETHASONE INTENSOL-dexamethasone conc 1 mg/ml

NP

dexamethasone tab therapy pack1.5 mg (21) (Dexpak 6 day)

NC


NC


NC

dexamethasone tab 0.5 mg p

2019


Drug Name Tier

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Lim

its



dexamethasone tab 4 mg p

dexamethasone tab 6 mg p

DEXPAK 10 DAY- dexamethasone tabtherapy pack 1.5 mg (35)

NC


NC


NC

fludrocortisone acetate tab 0.1 mg p

hydrocortisone tab 5 mg (Cortef) np



MEDROL- methylprednisolone tab2 mg

NP

methylprednisolone tab therapypack 4 mg (21) (Medrol dosepak)

p

methylprednisolone tab 4 mg(Medrol)

np


np


np


p

MILLIPRED- prednisolone tab 5 mg NC

MILLIPRED DP- prednisolone tabtherapy pack 5 mg (21)

NC

MILLIPRED DP- prednisolone tabtherapy pack 5 mg (48)

NC

PREDNISOLONE- prednisolone syrup15 mg/5ml (usp solution equivalent)

NP

prednisolone sod phos orallydisintegr tab 10 mg (base eq)(Orapred odt)

np


np

Drug Name Tier

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its


np

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

np

prednisolone sod phosphate oralsoln 15 mg/5ml (base equiv)

p

prednisolone sod phosphate oralsoln 10 mg/5ml (base equiv)(Millipred)

np

prednisolone sod phosphate oralsoln 20 mg/5ml (base equiv)(Veripred 20)

np

PREDNISOLONE SODIUM PHOSP-prednisolone sodium phosphate oralsoln 25 mg/5ml (base eq)

NP

PREDNISONE- prednisone oral soln5 mg/5ml

P

PREDNISONE- prednisone tabtherapy pack 5 mg (21)

NP


NP


NP


NP

PREDNISONE- prednisone tab 50 mg NP

PREDNISONE INTENSOL-prednisone conc 5 mg/ml

NP

prednisone tab 1 mg p

prednisone tab 2.5 mg p




RAYOS- prednisone tab delayedrelease 1 mg

NP


NP


NP

2019


Drug Name Tier

Des

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ty

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ing

Lim

its

TAPERDEX 12-DAY- dexamethasonetab therapy pack 1.5 mg (49)

NC

TAPERDEX 6-DAY- dexamethasonetab therapy pack 1.5 mg (21)

NC

ANDROGEN-ANABOLICANADROL-50- oxymetholone tab

50 mgNP •

ANDRODERM- testosterone td patch24hr 2 mg/24hr

NC

ANDRODERM- testosterone td patch24hr 4 mg/24hr

NC

ANDROGEL- testosterone td gel20.25 mg/1.25gm (1.62%)

P • •

ANDROGEL- testosterone td gel40.5 mg/2.5gm (1.62%)

P • •

ANDROGEL PUMP- testosteronetd gel 20.25 mg/act (1.62%)

P • •

AVEED- testosterone undecanoate iminj in oil 750 mg/3ml (250mg/ml)

NC

danazol cap 50 mg np •danazol cap 100 mg np •danazol cap 200 mg np •FORTESTA- testosterone td gel

10mg/act (2%)NC

METHITEST- methyltestosterone oraltab 10 mg

NP •

METHYLTESTOSTERONE-methyltestosterone cap 10 mg

NP •

NATESTO- testosterone nasal gel5.5 mg/act

NC

oxandrolone tab 2.5 mg (Oxandrin) np •oxandrolone tab 10 mg (Oxandrin) np •STRIANT- testosterone buccal

mucoadhesive system 30 mgNC

TESTOSTERONE- testosterone td gel25 mg/2.5gm (1%)

NC

TESTOSTERONE- testosterone td gel50 mg/5gm (1%)

NC

TESTOSTERONE- testosterone td gel10mg/act (2%)

NC

Drug Name Tier

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ty

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Lim

its

testosterone cypionate im inj in oil100 mg/ml (Depo-testosterone)

np • •

testosterone cypionate im inj in oil200 mg/ml (Depo-testosterone)

np • •

testosterone enanthate im inj in oil200 mg/ml

np • •

TESTOSTERONE PUMP-testosterone td gel 12.5 mg/act (1%)

NC

testosterone td gel 25 mg/2.5gm(1%) (Androgel)

np • •

testosterone td gel 50 mg/5gm (1%)(Androgel)

np • •

testosterone td gel 50 mg/5gm (1%)(Testim)

NC

testosterone td gel 12.5 mg/act (1%) np • •testosterone td soln 30 mg/act

(Axiron)np • •

VOGELXO- testosterone td gel50 mg/5gm (1%)

NC

VOGELXO PUMP- testosterone td gel12.5 mg/act (1%)

NC

ESTROGENSALORA- estradiol td patch twice

weekly 0.025 mg/24hrNP

ALORA- estradiol td patch twiceweekly 0.05 mg/24hr

NP


NP


NP

ANGELIQ- drospirenone-estradiol tab0.25-0.5 mg

NP

ANGELIQ- drospirenone-estradiol tab0.5-1 mg

NP

CLIMARA PRO- estradiol-levonorgestrel td patch weekly0.045-0.015 mg/day

P

COMBIPATCH- estradiol-norethindrone ace td pttw0.05-0.14 mg/day

NP

2019


Drug Name Tier

Des

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pens

ing

Lim

its

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

NP

DELESTROGEN- estradiol valerateim in oil 10 mg/ml

NP

DEPO-ESTRADIOL- estradiolcypionate im in oil 5 mg/ml

NP

DIVIGEL- estradiol td gel0.25 mg/0.25gm (0.1%)

P

DIVIGEL- estradiol td gel0.5 mg/0.5gm (0.1%)

P

DIVIGEL- estradiol td gel 1 mg/gm(0.1%)

P

DUAVEE- conjugated estrogens-bazedoxifene tab 0.45-20 mg

NP

ELESTRIN- estradiol gel 0.06%(0.52 mg/0.87 gm metered-dosepump)

NP

estradiol & norethindrone acetatetab 0.5-0.1 mg (Activella)

np

estradiol & norethindrone acetatetab 1-0.5 mg (Activella)

np

estradiol tab 0.5 mg (Estrace) p

estradiol tab 1 mg (Estrace) p

estradiol tab 2 mg (Estrace) p

estradiol td patch twice weekly0.025 mg/24hr (Vivelle-dot)

np


np


np


np


np

estradiol td patch weekly0.025 mg/24hr (Climara)

np

estradiol td patch weekly0.0375 mg/24hr (37.5 mcg/24hr)(Climara)

np

Drug Name Tier

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ty

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its


np


np


np


np

estradiol valerate im in oil 20 mg/ml(Delestrogen)

np

estradiol valerate im in oil 40 mg/ml(Delestrogen)

np

ESTROGEL- estradiol gel 0.06%(0.75 mg/1.25 gm metered-dosepump)

P

EVAMIST- estradiol transdermal spray1.53 mg/spray

NP

MENEST- esterified estrogens tab0.3 mg

NP


NP


NP

MENOSTAR- estradiol td patchweekly 14 mcg/24hr

NP

MINIVELLE- estradiol td patch twiceweekly 0.025 mg/24hr

NP


NP


NP


NP


NP

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

np

norethindrone acetate-ethinylestradiol tab 1 mg-5 mcg

np

2019


Drug Name Tier

Des

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ty

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ing

Lim

its

PREFEST- estradiol tab 1 mg(15)/estrad-norgestimate tab1-0.09mg(15)

NP

PREMARIN- estrogens, conjugatedtab 0.3 mg

P


P


P


P


P

PREMPHASE- conj est 0.625(14)/conj est-medroxypro ac tab0.625-5mg(14)

P

PREMPRO- conjugated estrogen-medroxyprogest acetate tab0.3-1.5 mg

P


P


P

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

P

CONTRACEPTIVESBALCOLTRA- levonorgestrel-ethinyl

estradiol-fe tab 0.1 mg-20 mcg (21)NC

DEPO-SUBQ PROVERA 104-medroxyprogesterone acetate susppref syr 104 mg/0.65ml

NP

desogest-eth estrad & eth estradtab 0.15-0.02/0.01 mg(21/5)(Mircette)

np

desogest-ethin est tab0.1-0.025/0.125-0.025/0.15-0.025mg-mg (Cyclessa)

np

desogestrel & ethinyl estradiol tab0.15 mg-30 mcg (Desogen)

p

Drug Name Tier

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Lim

its

drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg(Beyaz)

np

drospirenone-ethinyl estrad-levomefolate tab 3-0.03-0.451 mg(Safyral)

np

drospirenone-ethinyl estradiol tab3-0.02 mg (Yaz)

np

drospirenone-ethinyl estradiol tab3-0.03 mg (Yasmin 28)

np

ELLA- ulipristal acetate tab 30 mg P

ethynodiol diacetate & ethinylestradiol tab 1 mg-35 mcg

np

ethynodiol diacetate & ethinylestradiol tab 1 mg-50 mcg

np

FALESSA- levonorgest-eth estrad tab0.1 mg-20 mcg & fa tab 1 mg kit

NP

levonor-eth est tab0.15-0.02/0.025/0.03 mg &eth est0.01 mg (Quartette)

np

levonorg-eth est tab 0.1-0.02mg(84)& eth est tab 0.01mg(7)(Loseasonique)

np

levonorg-eth est tab0.15-0.03mg(84) & eth est tab0.01mg(7) (Seasonique)

np

levonorgestrel & ethinyl estradiol(91-day) tab 0.15-0.03 mg

np

levonorgestrel & ethinyl estradioltab 0.1 mg-20 mcg

p

levonorgestrel & ethinyl estradioltab 0.15 mg-30 mcg

p

levonorgestrel tab 1.5 mg np

levonorgestrel-eth estra tab0.05-30/0.075-40/0.125-30mg-mcg

p

levonorgestrel-ethinyl estradiol(continuous) tab 90-20 mcg

np

LO LOESTRIN FE- norethin-ethestradiol-fe tab 1 mg-10 mcg(24)/10 mcg (2)

P

2019


Drug Name Tier

Des

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tion

Spe

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ty

Prio

r Aut

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n

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Dis

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ing

Lim

its

medroxyprogesterone acetate imsusp prefilled syr 150 mg/ml(Depo-provera contrac)

np

medroxyprogesterone acetate imsusp 150 mg/ml (Depo-proveracontrac)

np

NATAZIA- estradiol valerate-dienogesttab 3 mg /2-2 mg/2-3 mg/1 mg

NP

norethindrone & ethinyl estradioltab 0.4 mg-35 mcg (Ovcon-35)

np

norethindrone & ethinyl estradioltab 0.5 mg-35 mcg (Brevicon-28)

np

norethindrone & ethinyl estradioltab 1 mg-35 mcg (Norinyl 1+35)

p

norethindrone & ethinyl estradiol-fechew tab 0.4 mg-35 mcg (Femconfe)

np

norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg(Generess fe)

np

norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg(Estrostep fe)

np

norethindrone ace & ethinylestradiol tab 1 mg-20 mcg(Loestrin 1/20-21)

p

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

np

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

p

norethindrone ace & ethinylestradiol-fe tab 1.5 mg-30 mcg(Loestrin fe 1.5/30)

p

norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24)(Minastrin 24 fe)

np

norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24)

np

norethindrone tab 0.35 mg (Orthomicronor)

p

Drug Name Tier

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ty

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Lim

its

norethindrone-eth estradiol tab0.5-35/0.75-35/1-35 mg-mcg(Ortho-novum 7/7/7)

p

norethindrone-eth estradiol tab0.5-35/1-35/0.5-35 mg-mcg (Tri-norinyl 28)

np

norgestimate & ethinyl estradiol tab0.25 mg-35 mcg (Ortho-cyclen)

p

norgestimate-eth estrad tab0.18-25/0.215-25/0.25-25 mg-mcg(Ortho tri-cyclen lo)

p

norgestimate-eth estrad tab0.18-35/0.215-35/0.25-35 mg-mcg(Ortho tri-cyclen)

p

norgestrel & ethinyl estradiol tab0.3 mg-30 mcg

p

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

P

OGESTREL- norgestrel & ethinylestradiol tab 0.5 mg-50 mcg

P

TAYTULLA- norethindrone ace-ethinylestradiol-fe cap 1 mg-20 mcg (24)

NC

XULANE- norelgestromin-ethinylestradiol td ptwk 150-35 mcg/24hr

P

PROGESTINSmedroxyprogesterone acetate tab

2.5 mg (Provera)p

medroxyprogesterone acetate tab5 mg (Provera)

p

medroxyprogesterone acetate tab10 mg (Provera)

p

megestrol acetate susp 625 mg/5ml(Megace es)

np

norethindrone acetate tab 5 mg(Aygestin)

np

progesterone im in oil 50 mg/ml np

progesterone micronized cap100 mg (Prometrium)

np

progesterone micronized cap200 mg (Prometrium)

np

2019


Drug Name Tier

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its

ANTIDIABETICSAntidiabeticsacarbose tab 25 mg (Precose) np

acarbose tab 50 mg (Precose) np

acarbose tab 100 mg (Precose) np

ACTOPLUS MET XR- pioglitazonehcl-metformin hcl tab er 24hr15-1000 mg

NP

ACTOPLUS MET XR- pioglitazonehcl-metformin hcl tab er 24hr30-1000 mg

NP

ADLYXIN- lixisenatide soln pen-injector 20 mcg/0.2ml (100 mcg/ml)

NC

ADLYXIN STARTER PACK-lixisenatide pen-inj starter kit10 mcg/0.2ml & 20 mcg/0.2ml

NC

ALOGLIPTIN- alogliptin benzoate tab6.25 mg (base equiv)

NC

ALOGLIPTIN- alogliptin benzoate tab12.5 mg (base equiv)

NC

ALOGLIPTIN- alogliptin benzoate tab25 mg (base equiv)

NC

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

NC

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

NC

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

NC


NC


NC

ALOGLIPTIN/PIOGLITAZONE-alogliptin-pioglitazone tab 25-15 mg

NC


NC

Drug Name Tier

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its


NC

AVANDIA- rosiglitazone maleate tab2 mg (base equiv)

NC

AVANDIA- rosiglitazone maleate tab4 mg (base equiv)

NC

BYDUREON- exenatide for injextended release susp 2 mg

NP •

BYDUREON BCISE- exenatideextended release susp auto-injector2 mg/0.85ml

NP •

BYDUREON PEN- exenatideextended release for susp pen-injector 2 mg

NP •

BYETTA- exenatide soln pen-injector5 mcg/0.02ml

NC

BYETTA- exenatide soln pen-injector10 mcg/0.04ml

NC

CHLORPROPAMIDE- chlorpropamidetab 100 mg

NP

CHLORPROPAMIDE- chlorpropamidetab 250 mg

NP

CYCLOSET- bromocriptine mesylatetab 0.8 mg (base equivalent)

NC

FARXIGA- dapagliflozin propanedioltab 5 mg (base equivalent)

NP •

FARXIGA- dapagliflozin propanedioltab 10 mg (base equivalent)

NP •

glimepiride tab 1 mg (Amaryl) p



glipizide tab er 24hr 2.5 mg(Glucotrol xl)

p

glipizide tab er 24hr 5 mg (Glucotrolxl)

p

glipizide tab er 24hr 10 mg(Glucotrol xl)

p

glipizide tab 5 mg (Glucotrol) p

glipizide tab 10 mg (Glucotrol) p

glipizide-metformin hcl tab2.5-250 mg

np

2019


Drug Name Tier

Des

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Prio

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n

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y

Dis

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ing

Lim

its

glipizide-metformin hcl tab2.5-500 mg

np

glipizide-metformin hcl tab5-500 mg

np

GLUCAGEN HYPOKIT- glucagon hcl(rdna) for inj 1 mg (base equiv)

NP

GLUCAGON EMERGENCYKIT- glucagon (rdna) for inj kit 1 mg

P

glyburide micronized tab 1.5 mg(Glynase)

p

glyburide micronized tab 3 mg(Glynase)

p

glyburide micronized tab 6 mg(Glynase)

p

glyburide tab 1.25 mg p

glyburide tab 2.5 mg p

glyburide tab 5 mg p

glyburide-metformin tab1.25-250 mg

p

glyburide-metformin tab 2.5-500 mg(Glucovance)

p

glyburide-metformin tab 5-500 mg(Glucovance)

p

GLYXAMBI- empagliflozin-linagliptintab 10-5 mg

P •

GLYXAMBI- empagliflozin-linagliptintab 25-5 mg

P •

INVOKAMET- canagliflozin-metforminhcl tab 50-500 mg

P •


P •


P •


P •

INVOKAMET XR- canagliflozin-metformin hcl tab er 24hr 50-500 mg

P •

INVOKAMET XR- canagliflozin-metformin hcl tab er 24hr50-1000 mg

P •

Drug Name Tier

Des

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its


P •


P •

INVOKANA- canagliflozin tab 100 mg P •INVOKANA- canagliflozin tab 300 mg P •JANUMET- sitagliptin-metformin hcl

tab 50-500 mgP •

JANUMET- sitagliptin-metformin hcltab 50-1000 mg

P •

JANUMET XR- sitagliptin-metforminhcl tab er 24hr 50-500 mg

P •


P •


P •

JANUVIA- sitagliptin phosphate tab25 mg (base equiv)

P •


P •


P •

JARDIANCE- empagliflozin tab 10 mg P •JARDIANCE- empagliflozin tab 25 mg P •JENTADUETO- linagliptin-metformin

hcl tab 2.5-500 mgNP •

JENTADUETO- linagliptin-metforminhcl tab 2.5-850 mg

NP •

JENTADUETO- linagliptin-metforminhcl tab 2.5-1000 mg

NP •

JENTADUETO XR- linagliptin-metformin hcl tab er 24hr2.5-1000 mg

NP •

JENTADUETO XR- linagliptin-metformin hcl tab er 24hr 5-1000 mg

NP •

KAZANO- alogliptin-metformin hcl tab12.5-500 mg

NC

KAZANO- alogliptin-metformin hcl tab12.5-1000 mg

NC

2019


Drug Name Tier

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Lim

its

KOMBIGLYZE XR- saxagliptin-metformin hcl tab er 24hr2.5-1000 mg

P •

KOMBIGLYZE XR- saxagliptin-metformin hcl tab er 24hr 5-500 mg

P •

KOMBIGLYZE XR- saxagliptin-metformin hcl tab er 24hr 5-1000 mg

P •

KORLYM- mifepristone tab 300 mg NP • • •metformin hcl tab er 24hr 500 mg

(Glucophage xr)p •

metformin hcl tab er 24hr 750 mg(Glucophage xr)

p •

metformin hcl tab er 24hr osmotic500 mg (Fortamet)

NC

metformin hcl tab er 24hr osmotic1000 mg (Fortamet)

NC

metformin hcl tab er 24hr modifiedrelease 500 mg (Glumetza)

NC

metformin hcl tab er 24hr modifiedrelease 1000 mg (Glumetza)

NC

metformin hcl tab 500 mg(Glucophage)

p


p


p

METFORMIN HYDROCHLORIDE-metformin hcl oral soln 500 mg/5ml

NC

miglitol tab 25 mg (Glyset) np



nateglinide tab 60 mg (Starlix) np

nateglinide tab 120 mg (Starlix) np

NESINA- alogliptin benzoate tab6.25 mg (base equiv)

NC

NESINA- alogliptin benzoate tab12.5 mg (base equiv)

NC

NESINA- alogliptin benzoate tab25 mg (base equiv)

NC

Drug Name Tier

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ONGLYZA- saxagliptin hcl tab 2.5 mg(base equiv)

P •

ONGLYZA- saxagliptin hcl tab 5 mg(base equiv)

P •

OSENI- alogliptin-pioglitazone tab12.5-15 mg

NC


NC


NC

OSENI- alogliptin-pioglitazone tab25-15 mg

NC


NC


NC

OZEMPIC- semaglutide soln pen-inj0.25 or 0.5 mg/dose (2 mg/1.5ml)

P •

OZEMPIC- semaglutide soln pen-inj1 mg/dose (2 mg/1.5ml)

P •

pioglitazone hcl tab 15 mg (baseequiv) (Actos)

p


p


p

pioglitazone hcl-glimepiride tab30-2 mg (Duetact)

NC

pioglitazone hcl-glimepiride tab30-4 mg (Duetact)

NC

pioglitazone hcl-metformin hcl tab15-500 mg (Actoplus met)

np

pioglitazone hcl-metformin hcl tab15-850 mg (Actoplus met)

np

PROGLYCEM- diazoxide susp 50 mg/ml

NP

QTERN- dapagliflozin-saxagliptin tab10-5 mg

NP •

repaglinide tab 0.5 mg np

repaglinide tab 1 mg (Prandin) np

repaglinide tab 2 mg (Prandin) np

2019


Drug Name Tier

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REPAGLINIDE/METFORMIN HYD-repaglinide-metformin hcl tab1-500 mg

NP

REPAGLINIDE/METFORMIN HYD-repaglinide-metformin hcl tab2-500 mg

NP

RIOMET- metformin hcl oral soln500 mg/5ml

NC

SEGLUROMET- ertugliflozin-metformin hcl tab 2.5-500 mg

NC


NC


NC


NC

SOLIQUA 100/33- insulin glargine-lixisenatide sol pen-inj 100-33 unit-mcg/ml

P • •

STEGLATRO- ertugliflozin l-pyroglutamic acid tab 5 mg (baseequiv)

NC

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

NC

STEGLUJAN- ertugliflozin-sitagliptintab 5-100 mg

NC

STEGLUJAN- ertugliflozin-sitagliptintab 15-100 mg

NC

SYMLINPEN 120- pramlintide acetatepen-inj 2700 mcg/2.7ml (1000 mcg/ml)

NC

SYMLINPEN 60- pramlintide acetatepen-inj 1500 mcg/1.5ml (1000 mcg/ml)

NC

SYNJARDY- empagliflozin-metforminhcl tab 5-500 mg

P •

SYNJARDY- empagliflozin-metforminhcl tab 5-1000 mg

P •

SYNJARDY- empagliflozin-metforminhcl tab 12.5-500 mg

P •

Drug Name Tier

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SYNJARDY- empagliflozin-metforminhcl tab 12.5-1000 mg

P •

SYNJARDY XR- empagliflozin-metformin hcl tab er 24hr 5-1000 mg

P •

SYNJARDY XR- empagliflozin-metformin hcl tab er 24hr10-1000 mg

P •

SYNJARDY XR- empagliflozin-metformin hcl tab er 24hr12.5-1000 mg

P •

SYNJARDY XR- empagliflozin-metformin hcl tab er 24hr25-1000 mg

P •

TOLAZAMIDE- tolazamide tab 250 mg NP

TOLAZAMIDE- tolazamide tab 500 mg NP

TOLBUTAMIDE- tolbutamide tab500 mg

NP

TRADJENTA- linagliptin tab 5 mg NP •TRULICITY- dulaglutide soln pen-

injector 0.75 mg/0.5mlP •

TRULICITY- dulaglutide soln pen-injector 1.5 mg/0.5ml

P •

VICTOZA- liraglutide soln pen-injector18 mg/3ml (6 mg/ml)

P •

XIGDUO XR- dapagliflozin-metforminhcl tab er 24hr 2.5-1000 mg

NP •

XIGDUO XR- dapagliflozin-metforminhcl tab er 24hr 5-500 mg

NP •


NP •


NP •


NP •

XULTOPHY 100/3.6- insulin degludec-liraglutide sol pen-inj 100-3.6 unit-mg/ml

P • •

Rapid-Acting InsulinsADMELOG- insulin lispro inj 100 unit/

mlNC

2019


Drug Name Tier

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ADMELOG SOLOSTAR- insulin lisprosoln pen-injector 100 unit/ml

NC

APIDRA- insulin glulisine inj 100 unit/ml

NC

APIDRA SOLOSTAR- insulin glulisinesoln pen-injector inj 100 unit/ml

NC

FIASP- insulin aspart inj 100 unit/ml P •FIASP FLEXTOUCH- insulin aspart

soln pen-injector 100 unit/mlP •

HUMALOG- insulin lispro inj 100 unit/ml

NC

HUMALOG- insulin lispro solncartridge 100 unit/ml

NC

HUMALOG JUNIOR KWIKPEN-insulin lispro soln pen-injector 100unit/ml

NC

HUMALOG KWIKPEN- insulin lisprosoln pen-injector 100 unit/ml

NC

HUMALOG KWIKPEN- insulin lisprosoln pen-injector 200 unit/ml

NC

NOVOLOG- insulin aspart inj 100 unit/ml

P •

NOVOLOG FLEXPEN- insulin aspartsoln pen-injector 100 unit/ml

P •

NOVOLOG PENFILL- insulin aspartsoln cartridge 100 unit/ml

P •

Short-Acting InsulinsAFREZZA- insulin regular (human) inh

powd 4 & 8 & 12 unit/cart (60)NC

AFREZZA- insulin regular (human)inhal powd 4 (90) & 8 (90) unit/cart

NC

AFREZZA- insulin regular (human)inhalation powder 4 unit/cartridge

NC


NC


NC

HUMULIN R- insulin regular (human)inj 100 unit/ml

NC

Drug Name Tier

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HUMULIN R U-500 (CONCENTR-insulin regular (human) inj 500 unit/ml

P •

HUMULIN R U-500 KWIKPEN- insulinregular (human) soln pen-injector500 unit/ml

P •

NOVOLIN R- insulin regular (human)inj 100 unit/ml

P •

NOVOLIN R RELION- insulin regular(human) inj 100 unit/ml

P •

Intermediate-Acting InsulinsHUMALOG MIX 50/50- insulin lispro

protamine & lispro inj 100 unit/ml(50-50)

NC

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

NC

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

NC

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

NC

HUMULIN N- insulin nph (human)(isophane) inj 100 unit/ml

NC

HUMULIN N KWIKPEN- insulin nph(human) (isophane) susp pen-injector 100 unit/ml

NC

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

NC

HUMULIN 70/30 KWIKPEN- insulinnph & regular susp pen-inj 100 unit/ml (70-30)

NC

NOVOLIN N- insulin nph (human)(isophane) inj 100 unit/ml

P •

NOVOLIN N RELION- insulin nph(human) (isophane) inj 100 unit/ml

P •

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

P •

2019


Drug Name Tier

Des

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NOVOLIN 70/30 RELION- insulin nphisophane & regular human inj 100unit/ml (70-30)

P •

NOVOLOG MIX 70/30- insulin aspartprot & aspart (human) inj 100 unit/ml(70-30)

P •

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

P •

Basal InsulinsBASAGLAR KWIKPEN-

insulin glargine soln pen-injector100 unit/ml

NC

LANTUS- insulin glargine inj 100 unit/ml

P •

LANTUS SOLOSTAR- insulin glarginesoln pen-injector 100 unit/ml

P •

LEVEMIR- insulin detemir inj 100 unit/ml

P •

LEVEMIR FLEXTOUCH- insulindetemir soln pen-injector 100 unit/ml

P •

TOUJEO MAX SOLOSTAR-insulin glargine soln pen-injector300 unit/ml

P •

TOUJEO SOLOSTAR- insulin glarginesoln pen-injector 300 unit/ml

P •

TRESIBA FLEXTOUCH- insulindegludec soln pen-injector 100 unit/ml

P •

TRESIBA FLEXTOUCH- insulindegludec soln pen-injector 200 unit/ml

P •

THYROID AGENTSARMOUR THYROID- thyroid tab

15 mg (1/4 grain)NP

ARMOUR THYROID- thyroid tab30 mg (1/2 grain)

NP

ARMOUR THYROID- thyroid tab60 mg (1 grain)

NP

ARMOUR THYROID- thyroid tab90 mg (1 1/2 grain)

NP

Drug Name Tier

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NP


NP


NP


NP

levothyroxine sodium tab 25 mcg(Synthroid)

p


p


p


p


p


p


p


p


p


p


p


np

liothyronine sodium tab 5 mcg(Cytomel)

p


p


np

methimazole tab 5 mg (Tapazole) p

methimazole tab 10 mg (Tapazole) p

2019


Drug Name Tier

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its

NATURE-THROID- thyroid tab16.25 mg

NP


NP

NATURE-THROID- thyroid tab48.75 mg (3/4 grain)

NP

NATURE-THROID- thyroid tab 65 mg NP


NP


NP


NP




NATURE-THROID- thyroid tab 325 mg(5 grain)

NP


NP

NATURE-THROID NT-2.5- thyroid tab162.5 mg (2 1/2 grain)

NP

propylthiouracil tab 50 mg np

SYNTHROID- levothyroxine sodiumtab 25 mcg

NP


NP


NP


NP


NP


NP


NP


NP

Drug Name Tier

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its


NP


NP


NP


NP

thyroid tab 15 mg (1/4 grain)(Armour thyroid)

p

thyroid tab 30 mg (1/2 grain)(Armour thyroid)

p

thyroid tab 60 mg (1 grain) (Armourthyroid)

p

thyroid tab 90 mg (1 1/2 grain)(Armour thyroid)

np

thyroid tab 120 mg (2 grain)(Armour thyroid)

np

THYROLAR-1- liotrix (t3-t4) tab 60 mg(12.5-50 mcg)

NP

THYROLAR-1/2- liotrix (t3-t4) tab30 mg (6.25-25 mcg)

NP

THYROLAR-1/4- liotrix (t3-t4) tab15 mg (3.1-12.5 mcg)

NP

THYROLAR-2- liotrix (t3-t4) tab120 mg (25-100 mcg)

NP

THYROLAR-3- liotrix (t3-t4) tab180 mg (37.5-150 mcg)

NP

TIROSINT- levothyroxine sodium cap13 mcg

NP


NP


NP


NP


NP


NP

2019


Drug Name Tier

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NP


NP


NP


NP

WESTHROID- thyroid tab 32.5 mg NP

WESTHROID- thyroid tab 65 mg NP

WESTHROID- thyroid tab 97.5 mg NP



WP THYROID- thyroid tab 16.25 mg NP


WP THYROID- thyroid tab 48.75 mg(3/4 grain)

NP

WP THYROID- thyroid tab 65 mg NP




WP THYROID- thyroid tab 130 mg NP

OXYTOCICSCERVIDIL- dinoprostone vaginal

inserts 10 mgNP

methylergonovine maleate tab0.2 mg

np

PREPIDIL- dinoprostone cervical gel0.5 mg/3gm

NP

PROSTIN E2- dinoprostone vaginalsuppos 20 mg

NP

ENDOCRINE and METABOLIC AGENTS - MISC.ALENDRONATE SODIUM-

alendronate sodium oral soln70 mg/75ml

NP

ALENDRONATE SODIUM-alendronate sodium tab 40 mg

NP

alendronate sodium tab 5 mg p


Drug Name Tier

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its


alendronate sodium tab 70 mg(Fosamax)

p

BINOSTO- alendronate sodiumeffervescent tab 70 mg

NC

BRAVELLE- urofollitropin purified forinj 75 unit

NC

cabergoline tab 0.5 mg np

calcitonin (salmon) nasal soln 200unit/act

np

calcitriol cap 0.25 mcg (Rocaltrol) p

calcitriol cap 0.5 mcg (Rocaltrol) np

calcitriol oral soln 1 mcg/ml(Rocaltrol)

np

CARBAGLU- carglumic acid tab200 mg

NP • •

CETROTIDE- cetrorelix acetate for injkit 0.25 mg

NP • • •

CHORIONIC GONADOTROPIN-chorionic gonadotropin for im inj10000 unit

NC

CLOMIPHENE CITRATE- clomiphenecitrate tab 50 mg

P

CYSTADANE- betaine powder for oralsolution

P

DDAVP- desmopressin acetate nasalsoln 0.01% (refrigerated)

NP

desmopressin acetate inj 4 mcg/ml(Ddavp)

np

desmopressin acetate nasal spraysoln 0.01% (Ddavp)

np

desmopressin acetate nasal spraysoln 0.01% (refrigerated)

np

desmopressin acetate tab 0.1 mg(Ddavp)

np

desmopressin acetate tab 0.2 mg(Ddavp)

np

doxercalciferol cap 0.5 mcg(Hectorol)

np

doxercalciferol cap 1 mcg(Hectorol)

np

2019


Drug Name Tier

Des

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its

doxercalciferol cap 2.5 mcg(Hectorol)

np

EGRIFTA- tesamorelin acetate for inj1 mg (base equiv)

NC

ETIDRONATE DISODIUM- etidronatedisodium tab 200 mg

NC

ETIDRONATE DISODIUM- etidronatedisodium tab 400 mg

NC

FOLLISTIM AQ- follitropin beta inj 300unit/0.36ml

P • • •


P • • •


P • • •

FORTEO- teriparatide (recombinant)inj 600 mcg/2.4ml

NC

FOSAMAX PLUS D- alendronatesodium-cholecalciferol tab70-2800 mg-unit

NC

FOSAMAX PLUS D- alendronatesodium-cholecalciferol tab70-5600 mg-unit

NC

GANIRELIX ACETATE- ganirelixacetate inj 250 mcg/0.5ml

NP • • •

GENOTROPIN- somatropin for inj12 mg (13.8 mg overfill)

NC

GENOTROPIN- somatropin forsubcutaneous inj 5 mg

NC

GENOTROPIN MINIQUICK-somatropin for inj 0.2 mg

NC


NC


NC


NC

GENOTROPIN MINIQUICK-somatropin for inj 1 mg

NC


NC

Drug Name Tier

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NC


NC


NC

GENOTROPIN MINIQUICK-somatropin for inj 2 mg

NC

GONAL-F- follitropin alfa for inj 450unit

NC

GONAL-F- follitropin alfa for inj 1050unit

NC

GONAL-F RFF- follitropin alfa forsubcutaneous inj 75 unit

NC

GONAL-F RFF REDIJECT- follitropinalfa inj 300 unit/0.5ml

NC


NC


NC

H.P. ACTHAR- corticotropin inj gel 80unit/ml

NP • •

HUMATROPE- somatropin for inj 6 mg(18 unit)

NC

HUMATROPE- somatropin for inj12 mg (36 unit)

NC

HUMATROPE- somatropin for inj24 mg

NC

HUMATROPE COMBO PACK-somatropin for inj 5 mg

NC

ibandronate sodium tab 150 mg(base equivalent) (Boniva)

np

INCRELEX- mecasermin inj40 mg/4ml (10 mg/ml)

P •

JYNARQUE- tolvaptan tab therapypack 45 & 15 mg

NP • • •


NP • • •


NP • • •

2019


Drug Name Tier

Des

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its

KUVAN- sapropterin dihydrochloridepowder packet 100 mg

NP • •

KUVAN- sapropterin dihydrochloridepowder packet 500 mg

NP • •

KUVAN- sapropterin dihydrochloridesoluble tab 100 mg

NP • •

levocarnitine oral soln 1 gm/10ml(10%) (Carnitor)

np

levocarnitine tab 330 mg (Carnitor) np

LUPANETA PACK- leuprolide (1 mon)inj 3.75 mg & norethindrone tab5 mg kit

NP •

LUPANETA PACK- leuprolide (3 mon)inj 11.25 mg & norethindrone tab5 mg kit

NP •

LUPRON DEPOT-PED (1-MONTH-leuprolide acetate for inj pediatric kit7.5 mg

P •

LUPRON DEPOT-PED (1-MONTH-leuprolide acetate for inj pediatric kit11.25 mg

P •

LUPRON DEPOT-PED (1-MONTH-leuprolide acetate for inj pediatric kit15 mg

P •

LUPRON DEPOT-PED (3-MONTH-leuprolide acetate (3 month) for injpediatric kit 11.25 mg

P •

LUPRON DEPOT-PED (3-MONTH-leuprolide acetate (3 month) for injpediatric kit 30 mg

P •

MENOPUR- menotropins forsubcutaneous inj 75 unit

NP • • •

MIACALCIN- calcitonin (salmon) inj200 unit/ml

NP

MYALEPT- metreleptin forsubcutaneous inj 11.3 mg

NP • •

NATPARA- parathyroid hormone(recombinant) for inj cartridge25 mcg

NP • • •


NP • • •

Drug Name Tier

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NP • • •


NP • • •

NITYR- nitisinone tab 2 mg P •NITYR- nitisinone tab 5 mg P •NITYR- nitisinone tab 10 mg P •NOCTIVA- desmopressin

acetate nasal emulsion spray0.83 mcg/0.1ml

NP • •

NOCTIVA- desmopressinacetate nasal emulsion spray1.66 mcg/0.1ml

NP • •

NORDITROPIN FLEXPRO-somatropin inj 5 mg/1.5ml

NC


NC


NC

NORDITROPIN FLEXPRO-somatropin inj 30 mg/3ml

NC

NOVAREL- chorionic gonadotropin forim inj 5000 unit

NC

NOVAREL- chorionic gonadotropin forim inj 10000 unit

NC

NUTROPIN AQ NUSPIN 10-somatropin inj 10 mg/2ml

NC


NC


NC

octreotide acetate inj 50 mcg/ml(0.05 mg/ml) (Sandostatin)

np •


np •


np •


np •

2019


Drug Name Tier

Des

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Prio

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Lim

its

octreotide acetate inj 1000 mcg/ml(1 mg/ml) (Sandostatin)

np •

OMNITROPE- somatropin for inj5.8 mg

P • •

OMNITROPE- somatropin inj5 mg/1.5ml

P • •

OMNITROPE- somatropin inj10 mg/1.5ml

P • •

ORFADIN- nitisinone cap 2 mg P •ORFADIN- nitisinone cap 5 mg P •ORFADIN- nitisinone cap 10 mg P •ORFADIN- nitisinone cap 20 mg P •ORFADIN- nitisinone susp 4 mg/ml P •OSPHENA- ospemifene tab 60 mg NC

OVIDREL- choriogonadotropin alfa inj250 mcg/0.5ml

P • • •

PALYNZIQ- pegvaliase-pqpzsubcutaneous soln pref syringe2.5 mg/0.5ml

NP • •

PALYNZIQ- pegvaliase-pqpzsubcutaneous soln pref syringe10 mg/0.5ml

NP • •

PALYNZIQ- pegvaliase-pqpzsubcutaneous soln pref syringe20 mg/ml

NP • •

paricalcitol cap 1 mcg (Zemplar) np

paricalcitol cap 2 mcg (Zemplar) np

paricalcitol cap 4 mcg np

PREGNYL W/DILUENT BENZYL-chorionic gonadotropin for im inj10000 unit

NC

raloxifene hcl tab 60 mg (Evista) np

RAVICTI- glycerol phenylbutyrateliquid 1.1 gm/ml

NP • •

RAYALDEE- calcifediol cap er 30 mcg NP

risedronate sodium tab delayedrelease 35 mg (Atelvia)

np

risedronate sodium tab 5 mg(Actonel)

np

Drug Name Tier

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np


np


np

SAIZEN- somatropin (non-refrigerated) for inj 5 mg

NC

SAIZEN- somatropin (non-refrigerated) for inj 8.8 mg

NC

SAIZENPREP RECONSTITUTION-somatropin (non-refrigerated) for inj8.8 mg

NC

SAMSCA- tolvaptan tab 15 mg NP • •SAMSCA- tolvaptan tab 30 mg NP • •SENSIPAR- cinacalcet hcl tab 30 mg

(base equiv)P

SENSIPAR- cinacalcet hcl tab 60 mg(base equiv)

P

SENSIPAR- cinacalcet hcl tab 90 mg(base equiv)

P

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

NC


NC


NC

SIGNIFOR- pasireotide diaspartate inj0.3 mg/ml (base equiv)

NP •


NP •


NP •

sodium phenylbutyrate oral powder3 gm/teaspoonful (Buphenyl)

np • •

sodium phenylbutyrate tab 500 mg(Buphenyl)

np • •

2019


Drug Name Tier

Des

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its

SOMAVERT- pegvisomant for inj10 mg (as protein)

NP •


NP •


NP •


NP •


NP •

STIMATE- desmopressin acetatenasal soln 1.5 mg/ml

P

STRENSIQ- asfotase alfasubcutaneous inj 18 mg/0.45ml

P • •


P • •

STRENSIQ- asfotase alfasubcutaneous inj 40 mg/ml

P • •


P • •

SYNAREL- nafarelin acetate nasalsoln 2 mg/ml (200 mcg/act) (baseeq)

NP

TYMLOS- abaloparatidesubcutaneous soln pen-injector3120 mcg/1.56ml

P • • •

XURIDEN- uridine triacetateoral granules packet 2 gm

NC

ZOMACTON- somatropin for inj 10 mg NC

ZOMACTON- somatropin forsubcutaneous inj 5 mg

NC

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

NC

CARDIOVASCULAR AGENTSCARDIOTONICSDIGOXIN- digoxin oral soln 0.05 mg/

mlNP

digoxin tab 125 mcg (0.125 mg)(Lanoxin)

np

Drug Name Tier

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ing

Lim

its

digoxin tab 250 mcg (0.25 mg)(Lanoxin)

np

LANOXIN- digoxin tab 62.5 mcg(0.0625 mg)

NP

LANOXIN- digoxin tab 125 mcg(0.125 mg)

NP

LANOXIN- digoxin tab 187.5 mcg(0.1875 mg)

NP

LANOXIN- digoxin tab 250 mcg(0.25 mg)

NP

ANTIANGINAL AGENTSDILATRATE SR- isosorbide dinitrate

cap er 40 mgNP

GONITRO- nitroglycerin sublingualpowder packet 400 mcg

NC

ISORDIL TITRADOSE- isosorbidedinitrate tab 40 mg

NP

ISOSORBIDE DINITRATE ER-isosorbide dinitrate tab er 40 mg

NP

isosorbide dinitrate tab 5 mg(Isordil titradose)

np

isosorbide dinitrate tab 10 mg np



isosorbide mononitrate tab er 24hr30 mg

p


p


p

isosorbide mononitrate tab 10 mg p

isosorbide mononitrate tab 20 mg p

NITRO-BID- nitroglycerin oint 2% NP

NITRO-DUR- nitroglycerin td patch24hr 0.3 mg/hr

NP

NITRO-DUR- nitroglycerin td patch24hr 0.8 mg/hr

NP

nitroglycerin cap er 2.5 mg np

nitroglycerin cap er 6.5 mg np

nitroglycerin cap er 9 mg np

2019


Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

nitroglycerin sl tab 0.3 mg(Nitrostat)

np


p


np

nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)

np


p


np


np

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

np

NITROMIST- nitroglycerin lingualaerosol 400 mcg/spray

NP

RANEXA- ranolazine tab er 12hr500 mg

NP

RANEXA- ranolazine tab er 12hr1000 mg

NP

BETA BLOCKERSacebutolol hcl cap 200 mg p

acebutolol hcl cap 400 mg p

atenolol tab 25 mg (Tenormin) p



betaxolol hcl tab 10 mg np

betaxolol hcl tab 20 mg np

bisoprolol fumarate tab 5 mg p

bisoprolol fumarate tab 10 mg p

BYSTOLIC- nebivolol hcl tab 2.5 mg(base equivalent)

NP

BYSTOLIC- nebivolol hcl tab 5 mg(base equivalent)

NP


NP

Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its


NP

carvedilol phosphate cap er 24hr10 mg (Coreg cr)

NC


NC


NC


NC

carvedilol tab 3.125 mg (Coreg) p



carvedilol tab 25 mg (Coreg) p

HEMANGEOL- propranolol hcl oralsoln 4.28 mg/ml (3.75 mg/ml baseequiv)

NC

INDERAL XL- propranolol hclsustained-release beads cap er24hr 80 mg

NC

INDERAL XL- propranolol hclsustained-release beads cap er24hr 120 mg

NC

INNOPRAN XL- propranolol hclsustained-release beads cap er24hr 80 mg

NC

INNOPRAN XL- propranolol hclsustained-release beads cap er24hr 120 mg

NC

KAPSPARGO SPRINKLE- metoprololsucc cap er 24hr sprinkle 25 mg(tartrate equiv)

NC


NC


NC


NC

labetalol hcl tab 100 mg p

2019


Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

labetalol hcl tab 200 mg np

labetalol hcl tab 300 mg np

metoprolol succinate tab er 24hr25 mg (tartrate equiv) (Toprol xl)

p


p


p


np

METOPROLOL TARTRATE-metoprolol tartrate tab 37.5 mg

NP

METOPROLOL TARTRATE-metoprolol tartrate tab 75 mg

NP

metoprolol tartrate tab 25 mg p

metoprolol tartrate tab 50 mg(Lopressor)

p

metoprolol tartrate tab 100 mg(Lopressor)

p

nadolol tab 20 mg (Corgard) np



pindolol tab 5 mg np

pindolol tab 10 mg np

PROPRANOLOL HCL- propranolol hcloral soln 20 mg/5ml

P

PROPRANOLOL HCL- propranolol hcloral soln 40 mg/5ml

P

propranolol hcl cap er 24hr 60 mg(Inderal la)

np


np


np


np

propranolol hcl tab 10 mg p



Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

propranolol hcl tab 60 mg np

propranolol hcl tab 80 mg np

sotalol hcl (afib/afl) tab 80 mg(Betapace af)

np


np


np

sotalol hcl tab 80 mg (Betapace) p



sotalol hcl tab 240 mg p

SOTYLIZE- sotalol hcl oral solution5 mg/ml

NC

TIMOLOL MALEATE- timolol maleatetab 5 mg

NC


NC


NC

CALCIUM CHANNEL BLOCKERSamlodipine besylate tab 2.5 mg

(base equivalent) (Norvasc)p

amlodipine besylate tab 5 mg (baseequivalent) (Norvasc)

p

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

p

CARDIZEM LA- diltiazem hcl coatedbeads tab er 24hr 120 mg

NP

diltiazem hcl cap er 12hr 60 mg np



diltiazem hcl cap er 24hr 120 mg p

diltiazem hcl cap er 24hr 180 mg p


diltiazem hcl coated beads cap er24hr 120 mg (Cardizem cd)

p


p

2019


Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its


p

diltiazem hcl coated beads cap er24hr 300 mg

np


np

diltiazem hcl coated beads tab er24hr 180 mg (Cardizem la)

np


np


np


np


np

diltiazem hcl extended releasebeads cap er 24hr 120 mg (Tiazac)

p


p


np


np


np


np

diltiazem hcl tab 30 mg (Cardizem) p

diltiazem hcl tab 60 mg (Cardizem) p

diltiazem hcl tab 90 mg np

diltiazem hcl tab 120 mg (Cardizem) np

felodipine tab er 24hr 2.5 mg p

felodipine tab er 24hr 5 mg p

felodipine tab er 24hr 10 mg p

isradipine cap 2.5 mg np

isradipine cap 5 mg np

nicardipine hcl cap 20 mg np

nicardipine hcl cap 30 mg np

Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

nifedipine cap 10 mg (Procardia) np

nifedipine cap 20 mg np

nifedipine tab er 24hr 30 mg (Adalatcc)

p


np


np

nifedipine tab er 24hr osmoticrelease 30 mg (Procardia xl)

p


p


np

nimodipine cap 30 mg np

NISOLDIPINE ER- nisoldipine tab er24hr 20 mg

NP

NISOLDIPINE ER- nisoldipine tab er24hr 25.5 mg

NP


NP


NP

nisoldipine tab er 24hr 8.5 mg(Sular)

NC

nisoldipine tab er 24hr 17 mg(Sular)

NC

nisoldipine tab er 24hr 34 mg(Sular)

NC

NYMALIZE- nimodipine oral soln60 mg/20ml

NP

verapamil hcl cap er 24hr 100 mg(Verelan pm)

np

verapamil hcl cap er 24hr 120 mg(Verelan)

np


np


np


np

2019


Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its


np

VERAPAMIL HCL SR- verapamil hclcap er 24hr 360 mg

NP

verapamil hcl tab er 120 mg (Calansr)

p


p


p

verapamil hcl tab 40 mg p

verapamil hcl tab 80 mg (Calan) p

verapamil hcl tab 120 mg (Calan) p

ANTIARRHYTHMICSamiodarone hcl tab 100 mg np

amiodarone hcl tab 200 mg p

amiodarone hcl tab 400 mg np

disopyramide phosphate cap100 mg (Norpace)

np

disopyramide phosphate cap150 mg (Norpace)

np

dofetilide cap 125 mcg (0.125 mg)(Tikosyn)

np


np


np

flecainide acetate tab 50 mg p

flecainide acetate tab 100 mg np

flecainide acetate tab 150 mg np

mexiletine hcl cap 150 mg np



MULTAQ- dronedarone hcl tab400 mg (base equivalent)

P

NORPACE- disopyramide phosphatecap 100 mg

NP

NORPACE- disopyramide phosphatecap 150 mg

NP

Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

NORPACE CR- disopyramidephosphate cap er 12hr 100 mg

NP

NORPACE CR- disopyramidephosphate cap er 12hr 150 mg

NP

propafenone hcl cap er 12hr225 mg (Rythmol sr)

np


np


np

propafenone hcl tab 150 mg p

propafenone hcl tab 225 mg np

propafenone hcl tab 300 mg np

quinidine gluconate tab er 324 mg np

QUINIDINE SULFATE- quinidinesulfate tab 200 mg

P

QUINIDINE SULFATE- quinidinesulfate tab 300 mg

P

ANTIHYPERTENSIVESamlodipine besylate-benazepril hcl

cap 2.5-10 mgp

amlodipine besylate-benazepril hclcap 5-10 mg (Lotrel)

p


p

amlodipine besylate-benazepril hclcap 5-40 mg

p


p


p

amlodipine besylate-olmesartanmedoxomil tab 5-20 mg (Azor)

np


np


np


np

2019


Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

amlodipine besylate-valsartan tab5-160 mg (Exforge)

p


np


np


np

amlodipine-valsartan-hydrochlorothiazide tab5-160-12.5 mg (Exforge hct)

np

amlodipine-valsartan-hydrochlorothiazide tab5-160-25 mg (Exforge hct)

np

amlodipine-valsartan-hydrochlorothiazide tab10-160-12.5 mg (Exforge hct)

np


np


np

atenolol & chlorthalidone tab50-25 mg (Tenoretic 50)

p

atenolol & chlorthalidone tab100-25 mg (Tenoretic 100)

p

benazepril & hydrochlorothiazidetab 5-6.25 mg

np

benazepril & hydrochlorothiazidetab 10-12.5 mg (Lotensin hct)

np

benazepril & hydrochlorothiazidetab 20-12.5 mg (Lotensin hct)

np

benazepril & hydrochlorothiazidetab 20-25 mg (Lotensin hct)

np

benazepril hcl tab 5 mg p

benazepril hcl tab 10 mg p

benazepril hcl tab 20 mg (Lotensin) p

benazepril hcl tab 40 mg (Lotensin) p

bisoprolol & hydrochlorothiazidetab 2.5-6.25 mg (Ziac)

p

Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

bisoprolol & hydrochlorothiazidetab 5-6.25 mg (Ziac)

p

bisoprolol & hydrochlorothiazidetab 10-6.25 mg (Ziac)

p

BYVALSON- nebivolol-valsartan tab5-80 mg

NC

candesartan cilexetil tab 4 mg(Atacand)

np


np


np


np

candesartan cilexetil-hydrochlorothiazide tab16-12.5 mg (Atacand hct)

np

candesartan cilexetil-hydrochlorothiazide tab32-12.5 mg (Atacand hct)

np

candesartan cilexetil-hydrochlorothiazide tab 32-25 mg(Atacand hct)

np

captopril tab 12.5 mg np

captopril tab 25 mg np



CAPTOPRIL/HYDROCHLOROTHIA-captopril & hydrochlorothiazide tab25-15 mg

NC


NC


NC


NC

clonidine hcl tab 0.1 mg (Catapres) p


2019


Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its


clonidine td patch weekly0.1 mg/24hr (Catapres-tts-1)

np


np


np

DEMSER- metyrosine cap 250 mg NC

doxazosin mesylate tab 1 mg(Cardura)

p


p


p


p

DUTOPROL- metoprolol &hydrochlorothiazide tab er 24hr25-12.5 mg

NC


NC


NC

EDARBI- azilsartan medoxomil tab40 mg

NP

EDARBI- azilsartan medoxomil tab80 mg

NP

EDARBYCLOR- azilsartanmedoxomil-chlorthalidone tab40-12.5 mg

NP

EDARBYCLOR- azilsartanmedoxomil-chlorthalidone tab40-25 mg

NP

enalapril maleate &hydrochlorothiazide tab 5-12.5 mg

p

enalapril maleate &hydrochlorothiazide tab 10-25 mg(Vaseretic)

p

enalapril maleate tab 2.5 mg(Vasotec)

p

Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

enalapril maleate tab 5 mg(Vasotec)

p


p


p

EPANED- enalapril maleate oral soln1 mg/ml

NP

eplerenone tab 25 mg (Inspra) np

eplerenone tab 50 mg (Inspra) np

EPROSARTAN MESYLATE-eprosartan mesylate tab 600 mg

NC

fosinopril sodium &hydrochlorothiazide tab10-12.5 mg

np

fosinopril sodium &hydrochlorothiazide tab20-12.5 mg

np

fosinopril sodium tab 10 mg p



guanfacine hcl tab 1 mg p

guanfacine hcl tab 2 mg p

hydralazine hcl tab 10 mg p




irbesartan tab 75 mg (Avapro) p



irbesartan-hydrochlorothiazide tab150-12.5 mg (Avalide)

p

irbesartan-hydrochlorothiazide tab300-12.5 mg (Avalide)

p

lisinopril & hydrochlorothiazide tab10-12.5 mg (Zestoretic)

p

lisinopril & hydrochlorothiazide tab20-12.5 mg (Zestoretic)

p

2019


Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

lisinopril & hydrochlorothiazide tab20-25 mg (Zestoretic)

p

lisinopril tab 2.5 mg (Zestril) p

lisinopril tab 5 mg (Prinivil) p



lisinopril tab 30 mg (Zestril) p

lisinopril tab 40 mg (Zestril) p

losartan potassium &hydrochlorothiazide tab50-12.5 mg (Hyzaar)

p

losartan potassium &hydrochlorothiazide tab100-12.5 mg (Hyzaar)

p

losartan potassium &hydrochlorothiazide tab100-25 mg (Hyzaar)

p

losartan potassium tab 25 mg(Cozaar)

p


p


p

methyldopa tab 250 mg p

methyldopa tab 500 mg np

METHYLDOPA/HYDROCHLOROTHI-methyldopa & hydrochlorothiazidetab 250-15 mg

NC

METHYLDOPA/HYDROCHLOROTHI-methyldopa & hydrochlorothiazidetab 250-25 mg

NC

metoprolol & hydrochlorothiazidetab 50-25 mg (Lopressor hct)

np

metoprolol & hydrochlorothiazidetab 100-25 mg

np

METOPROLOL SUCCINATE ER/H-metoprolol & hydrochlorothiazidetab er 24hr 25-12.5 mg

NC


NC

Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its


NC

METOPROLOL/HYDROCHLOROTHI-metoprolol & hydrochlorothiazidetab 100-50 mg

NP

minoxidil tab 2.5 mg p

minoxidil tab 10 mg p

moexipril hcl tab 7.5 mg np

moexipril hcl tab 15 mg np

moexipril-hydrochlorothiazide tab7.5-12.5 mg

np

moexipril-hydrochlorothiazide tab15-12.5 mg

np

moexipril-hydrochlorothiazide tab15-25 mg

np

nadolol & bendroflumethiazide tab40-5 mg (Corzide)

np

olmesartan medoxomil tab 5 mg(Benicar)

np


np


np

olmesartan medoxomil-hydrochlorothiazide tab20-12.5 mg (Benicar hct)

np

olmesartan medoxomil-hydrochlorothiazide tab40-12.5 mg (Benicar hct)

np

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

np

olmesartan-amlodipine-hydrochlorothiazide tab20-5-12.5 mg (Tribenzor)

np


np

olmesartan-amlodipine-hydrochlorothiazide tab40-5-25 mg (Tribenzor)

np

2019


Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its


np

olmesartan-amlodipine-hydrochlorothiazide tab40-10-25 mg (Tribenzor)

np

perindopril erbumine tab 2 mg p

perindopril erbumine tab 4 mg(Aceon)

p

perindopril erbumine tab 8 mg(Aceon)

np

phenoxybenzamine hcl cap 10 mg(Dibenzyline)

np

prazosin hcl cap 1 mg (Minipress) np



PRESTALIA- perindopril arginine-amlodipine besylate tab 3.5-2.5 mg

NC

PRESTALIA- perindopril arginine-amlodipine besylate tab 7-5 mg

NC

PRESTALIA- perindopril arginine-amlodipine besylate tab 14-10 mg

NC

PROPRANOLOL/HYDROCHLOROTH- propranolol &hydrochlorothiazide tab 40-25 mg

NP

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

NP

QBRELIS- lisinopril oral soln 1 mg/ml NP

quinapril hcl tab 5 mg (Accupril) p




quinapril-hydrochlorothiazide tab10-12.5 mg (Accuretic)

p

quinapril-hydrochlorothiazide tab20-12.5 mg (Accuretic)

np

quinapril-hydrochlorothiazide tab20-25 mg (Accuretic)

p

ramipril cap 1.25 mg (Altace) p

Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

ramipril cap 2.5 mg (Altace) p

ramipril cap 5 mg (Altace) p

ramipril cap 10 mg (Altace) p

TEKTURNA- aliskiren fumarate tab150 mg (base equivalent)

NC

TEKTURNA- aliskiren fumarate tab300 mg (base equivalent)

NC

TEKTURNA HCT- aliskiren-hydrochlorothiazide tab150-12.5 mg

NC

TEKTURNA HCT- aliskiren-hydrochlorothiazide tab 150-25 mg

NC

TEKTURNA HCT- aliskiren-hydrochlorothiazide tab300-12.5 mg

NC

TEKTURNA HCT- aliskiren-hydrochlorothiazide tab 300-25 mg

NC

telmisartan tab 20 mg (Micardis) np



telmisartan-amlodipine tab 40-5 mg(Twynsta)

np

telmisartan-amlodipine tab40-10 mg (Twynsta)

np

telmisartan-amlodipine tab 80-5 mg(Twynsta)

np

telmisartan-amlodipine tab80-10 mg (Twynsta)

np

telmisartan-hydrochlorothiazide tab40-12.5 mg (Micardis hct)

np

telmisartan-hydrochlorothiazide tab80-12.5 mg (Micardis hct)

np

telmisartan-hydrochlorothiazide tab80-25 mg (Micardis hct)

np

terazosin hcl cap 1 mg (baseequivalent)

p


p


p

2019


Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its


p

trandolapril tab 1 mg (Mavik) p

trandolapril tab 2 mg (Mavik) p

trandolapril tab 4 mg p

trandolapril-verapamil hcl tab er2-180 mg (Tarka)

np


np


np

TRANDOLAPRIL/VERAPAMIL HC-trandolapril-verapamil hcl tab er1-240 mg

NP

valsartan tab 40 mg (Diovan) p




valsartan-hydrochlorothiazide tab80-12.5 mg (Diovan hct)

p


p

valsartan-hydrochlorothiazide tab160-25 mg (Diovan hct)

p


p

valsartan-hydrochlorothiazide tab320-25 mg (Diovan hct)

p

VECAMYL- mecamylamine hcl tab2.5 mg

NP

DIURETICSacetazolamide cap er 12hr 500 mg

(Diamox)np

acetazolamide tab 125 mg np

acetazolamide tab 250 mg np

ALDACTAZIDE- spironolactone &hydrochlorothiazide tab 50-50 mg

NP

amiloride & hydrochlorothiazide tab5-50 mg

p

amiloride hcl tab 5 mg np

Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

bumetanide tab 0.5 mg (Bumex) np

bumetanide tab 1 mg (Bumex) np

bumetanide tab 2 mg (Bumex) np

CAROSPIR- spironolactone susp25 mg/5ml

NC

CHLOROTHIAZIDE- chlorothiazidetab 250 mg

NP

chlorothiazide tab 500 mg np

chlorthalidone tab 25 mg np

chlorthalidone tab 50 mg np

DIURIL- chlorothiazide susp250 mg/5ml

NP

DYRENIUM- triamterene cap 50 mg NP

DYRENIUM- triamterene cap 100 mg NP

ethacrynic acid tab 25 mg (Edecrin) NC

FUROSEMIDE- furosemide oral soln8 mg/ml

NC

furosemide oral soln 10 mg/ml p

furosemide tab 20 mg (Lasix) p



hydrochlorothiazide cap 12.5 mg(Microzide)

p

hydrochlorothiazide tab 12.5 mg p

hydrochlorothiazide tab 25 mg p

hydrochlorothiazide tab 50 mg p

indapamide tab 1.25 mg p

indapamide tab 2.5 mg p

KEVEYIS- dichlorphenamide tab50 mg

NC

methazolamide tab 25 mg(Neptazane)

np

methazolamide tab 50 mg(Neptazane)

np

METHYCLOTHIAZIDE-methyclothiazide tab 5 mg

NP

metolazone tab 2.5 mg np

metolazone tab 5 mg np

2019


Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

metolazone tab 10 mg np

spironolactone &hydrochlorothiazide tab 25-25 mg(Aldactazide)

np

spironolactone tab 25 mg(Aldactone)

p


p


p

torsemide tab 5 mg p

torsemide tab 10 mg (Demadex) p

torsemide tab 20 mg (Demadex) p

torsemide tab 100 mg p

triamterene & hydrochlorothiazidecap 37.5-25 mg (Dyazide)

p

triamterene & hydrochlorothiazidetab 37.5-25 mg (Maxzide-25)

p

triamterene & hydrochlorothiazidetab 75-50 mg (Maxzide)

p

VASOPRESSORSAUVI-Q- epinephrine solution auto-

injector 0.1 mg/0.1mlNC

AUVI-Q- epinephrine solution auto-injector 0.15 mg/0.15ml (1:1000)

NC

AUVI-Q- epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)

NC

EPINEPHRINE- epinephrine solutionauto-injector 0.15 mg/0.15ml(1:1000)

NC

EPINEPHRINE- epinephrine solutionauto-injector 0.3 mg/0.3ml (1:1000)

NC

EPINEPHRINE (Mylan Products)-epinephrine solution auto-injector0.15 mg/0.3ml (1:2000)

np

EPINEPHRINE (Mylan Products)-epinephrine solution auto-injector0.3 mg/0.3ml (1:1000)

np

EPIPEN 2-PAK- epinephrine solutionauto-injector 0.3 mg/0.3ml (1:1000)

P

Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

EPIPEN-JR 2-PAK- epinephrinesolution auto-injector 0.15 mg/0.3ml(1:2000)

P

midodrine hcl tab 2.5 mg np

midodrine hcl tab 5 mg np

midodrine hcl tab 10 mg np

NORTHERA- droxidopa cap 100 mg NC



ANTIHYPERLIPIDEMICSALTOPREV- lovastatin tab er 24hr

20 mgNC

ALTOPREV- lovastatin tab er 24hr40 mg

NC

ALTOPREV- lovastatin tab er 24hr60 mg

NC

ANTARA- fenofibrate micronized cap30 mg

NC

ANTARA- fenofibrate micronized cap90 mg

NC

atorvastatin calcium tab 10 mg(base equivalent) (Lipitor)

p


p


p


p

cholestyramine light powderpackets 4 gm

np

cholestyramine light powder 4 gm/dose (Questran light)

np

cholestyramine powder packets4 gm (Questran)

np

cholestyramine powder 4 gm/dose(Questran)

np

choline fenofibrate cap dr 45 mg(fenofibric acid equiv) (Trilipix)

np

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

np

2019


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colesevelam hcl packet for susp3.75 gm (Welchol)

np

colesevelam hcl tab 625 mg(Welchol)

np

colestipol hcl granule packets 5 gm(Colestid flavored)

np

colestipol hcl granules 5 gm(Colestid)

np

colestipol hcl tab 1 gm (Colestid) np

ezetimibe tab 10 mg (Zetia) np

ezetimibe-simvastatin tab 10-10 mg(Vytorin)

np


np


np


np

FENOFIBRATE- fenofibrate cap50 mg

NC

FENOFIBRATE- fenofibrate cap150 mg

NC

fenofibrate micronized cap 43 mg np

fenofibrate micronized cap 67 mg(Lofibra)

np

fenofibrate micronized cap 130 mg np


np


np

fenofibrate tab 40 mg (Fenoglide) np

fenofibrate tab 48 mg (Tricor) p

fenofibrate tab 54 mg (Lofibra) p

fenofibrate tab 120 mg (Fenoglide) np

fenofibrate tab 145 mg (Tricor) np

fenofibrate tab 160 mg (Lofibra) np

FENOFIBRIC ACID- fenofibric acidtab 35 mg

NC

FENOFIBRIC ACID- fenofibric acidtab 105 mg

NC

Drug Name Tier

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FIBRICOR- fenofibric acid tab 35 mg NC

FIBRICOR- fenofibric acid tab 105 mg NC

FLOLIPID- simvastatin susp20 mg/5ml (4 mg/ml)

NC

FLOLIPID- simvastatin susp40 mg/5ml (8 mg/ml)

NC

fluvastatin sodium cap 20 mg np

fluvastatin sodium cap 40 mg np

fluvastatin sodium tab er 24 hr80 mg (Lescol xl)

np

gemfibrozil tab 600 mg (Lopid) p

JUXTAPID- lomitapide mesylate cap5 mg (base equiv)

NP • • •


NP • • •


NP • • •


NP • • •


NP • • •


NP • • •

KYNAMRO- mipomersen sodium solnprefilled syringe 200 mg/ml

NP • • •

LIPOFEN- fenofibrate cap 50 mg P

LIPOFEN- fenofibrate cap 150 mg P

LIVALO- pitavastatin calcium tab 1 mg(base equiv)

P


P


P

lovastatin tab 10 mg p



niacin tab er 500 mg(antihyperlipidemic) (Niaspan)

np


np

2019


Drug Name Tier

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np

NIACOR- niacin (antihyperlipidemic)tab 500 mg

NC

omega-3-acid ethyl esters cap 1 gm(Lovaza)

NC

PRALUENT- alirocumabsubcutaneous soln pen-injector75 mg/ml

NC

PRALUENT- alirocumabsubcutaneous soln pen-injector150 mg/ml

NC

pravastatin sodium tab 10 mg p

pravastatin sodium tab 20 mg(Pravachol)

p


p


p

REPATHA- evolocumab subcutaneoussoln prefilled syringe 140 mg/ml

P • • •

REPATHA PUSHTRONEX SYSTEM-evolocumab subcutaneous solncartridge/infusor 420 mg/3.5ml

P • • •

REPATHA SURECLICK- evolocumabsubcutaneous soln auto-injector140 mg/ml

P • • •

rosuvastatin calcium tab 5 mg(Crestor)

p


p


p


p

simvastatin tab 5 mg (Zocor) p





TRIGLIDE- fenofibrate tab 160 mg NC

Drug Name Tier

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VASCEPA- icosapent ethyl cap 0.5 gm P

VASCEPA- icosapent ethyl cap 1 gm P

WELCHOL- colesevelam hcl packetfor susp 3.75 gm

P

ZYPITAMAG- pitavastatin magnesiumtab 1 mg (base equiv)

NC


NC


NC

CARDIOVASCULAR AGENTS - MISC.ADCIRCA- tadalafil tab 20 mg (pah) NP • • •ADEMPAS- riociguat tab 0.5 mg NP • • •ADEMPAS- riociguat tab 1 mg NP • • •ADEMPAS- riociguat tab 1.5 mg NP • • •ADEMPAS- riociguat tab 2 mg NP • • •ADEMPAS- riociguat tab 2.5 mg NP • • •amlodipine besylate-atorvastatin

calcium tab 2.5-10 mgnp

amlodipine besylate-atorvastatincalcium tab 2.5-20 mg

np

amlodipine besylate-atorvastatincalcium tab 2.5-40 mg

np

amlodipine besylate-atorvastatincalcium tab 5-10 mg (Caduet)

np


np


np


np


np


np


np


np

2019


Drug Name Tier

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BIDIL- isosorbide dinitrate-hydralazinehcl tab 20-37.5 mg

NP

CORLANOR- ivabradine hcl tab 5 mg(base equiv)

NP • •

CORLANOR- ivabradine hcl tab7.5 mg (base equiv)

NP • •

ENTRESTO- sacubitril-valsartan tab24-26 mg

P


P


P

LETAIRIS- ambrisentan tab 5 mg P • • •LETAIRIS- ambrisentan tab 10 mg P • • •OPSUMIT- macitentan tab 10 mg P • • •ORENITRAM- treprostinil diolamine

tab er 0.125 mg (base equiv)NP • •

ORENITRAM- treprostinil diolaminetab er 0.25 mg (base equiv)

NP • •

ORENITRAM- treprostinil diolaminetab er 1 mg (base equiv)

NP • •

ORENITRAM- treprostinil diolaminetab er 2.5 mg (base equiv)

NP • •

ORENITRAM- treprostinil diolaminetab er 5 mg (base equiv)

NP • •

REVATIO- sildenafil citrate forsuspension 10 mg/ml

NP • • •

sildenafil citrate tab 20 mg(Revatio)

np • • •

tadalafil tab 20 mg (pah) (Adcirca) np • • •TRACLEER- bosentan tab for oral

susp 32 mgP • • •

TRACLEER- bosentan tab 62.5 mg P • • •TRACLEER- bosentan tab 125 mg P • • •TYVASO- treprostinil inhalation

solution 0.6 mg/mlNP • • •

TYVASO REFILL- treprostinilinhalation solution 0.6 mg/ml

NP • • •

TYVASO STARTER- treprostinilinhalation solution 0.6 mg/ml

NP • • •

Drug Name Tier

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UPTRAVI- selexipag tab therapy pack200 mcg (140) & 800 mcg (60)

P • • •

UPTRAVI- selexipag tab 200 mcg P • • •UPTRAVI- selexipag tab 400 mcg P • • •UPTRAVI- selexipag tab 600 mcg P • • •UPTRAVI- selexipag tab 800 mcg P • • •UPTRAVI- selexipag tab 1000 mcg P • • •UPTRAVI- selexipag tab 1200 mcg P • • •UPTRAVI- selexipag tab 1400 mcg P • • •UPTRAVI- selexipag tab 1600 mcg P • • •VENTAVIS- iloprost inhalation solution

10 mcg/mlNP • • •

VENTAVIS- iloprost inhalation solution20 mcg/ml

NP • • •

ERECTILE DYSFUNCTIONCAVERJECT- alprostadil for inj

20 mcgNP

CAVERJECT- alprostadil for inj40 mcg

NP

CAVERJECT IMPULSE- alprostadilfor inj kit 10 mcg

NP

CAVERJECT IMPULSE- alprostadilfor inj kit 20 mcg

NP

CIALIS- tadalafil tab 2.5 mg P •CIALIS- tadalafil tab 5 mg P •CIALIS- tadalafil tab 10 mg P •CIALIS- tadalafil tab 20 mg P •EDEX- alprostadil for inj kit 10 mcg NP

EDEX- alprostadil for inj kit 20 mcg NP

EDEX- alprostadil for inj kit 40 mcg NP

LEVITRA- vardenafil hcl tab 2.5 mg NP •LEVITRA- vardenafil hcl tab 5 mg NP •LEVITRA- vardenafil hcl tab 10 mg NP •LEVITRA- vardenafil hcl tab 20 mg NP •MUSE- alprostadil urethral pellet

125 mcgNP

MUSE- alprostadil urethral pellet250 mcg

NP

2019


Drug Name Tier

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NP


NP

sildenafil citrate tab 25 mg (Viagra) np •sildenafil citrate tab 50 mg (Viagra) np •sildenafil citrate tab 100 mg (Viagra) np •STAXYN- vardenafil hcl orally

disintegrating tab 10 mgNP •

STENDRA- avanafil tab 50 mg NP •STENDRA- avanafil tab 100 mg NP •STENDRA- avanafil tab 200 mg NP •tadalafil tab 2.5 mg (Cialis) np •tadalafil tab 5 mg (Cialis) np •tadalafil tab 10 mg (Cialis) np •tadalafil tab 20 mg (Cialis) np •RESPIRATORY AGENTSANTIHISTAMINEScarbinoxamine maleate soln

4 mg/5mlp

carbinoxamine maleate tab 4 mg np

carbinoxamine maleate tab 6 mg NC

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

NC

CLARINEX- desloratadine syrup0.5 mg/ml

NC

CLEMASTINE FUMARATE-clemastine fumarate tab 2.68 mg

NP

cyproheptadine hcl syrup 2 mg/5ml np

cyproheptadine hcl tab 4 mg np

DESLORATADINE ODT-desloratadine tab orallydisintegrating 2.5 mg

NC

DESLORATADINE ODT-desloratadine tab orallydisintegrating 5 mg

NC

desloratadine tab 5 mg (Clarinex) NC

diphenhydramine hcl elixir12.5 mg/5ml

NC

Drug Name Tier

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KARBINAL ER- carbinoxaminemaleate extended release susp4 mg/5ml

NC

levocetirizine dihydrochloride soln2.5 mg/5ml (0.5 mg/ml) (Xyzal)

NC

levocetirizine dihydrochloride tab5 mg (Xyzal)

NC

promethazine hcl suppos 12.5 mg np

promethazine hcl suppos 25 mg np

promethazine hcl suppos 50 mg np

promethazine hcl syrup6.25 mg/5ml

p

promethazine hcl tab 12.5 mg p

promethazine hcl tab 25 mg p

promethazine hcl tab 50 mg p

NASAL AGENTS - SYSTEMIC and TOPICALazelastine hcl nasal spray 0.1%

(137 mcg/spray)p •

azelastine hcl nasal spray 0.15%(205.5 mcg/spray) (Astepro)

NC

BACTROBAN NASAL- mupirocincalcium nasal oint 2%

NP

BECONASE AQ- beclomethasonedipropionate monohyd nasal susp42 mcg/spray

NC

DYMISTA- azelastine hcl-fluticasoneprop nasal spray 137-50 mcg/act

NP •

FLUNISOLIDE- flunisolide nasal soln25 mcg/act (0.025%)

NC

fluticasone propionate nasal susp50 mcg/act

p •

ipratropium bromide nasal soln0.03% (21 mcg/spray)

np •

ipratropium bromide nasal soln0.06% (42 mcg/spray)

np •

mometasone furoate nasal susp50 mcg/act (Nasonex)

NC

olopatadine hcl nasal soln 0.6%(Patanase)

NC

2019


Drug Name Tier

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OMNARIS- ciclesonide nasal susp50 mcg/act

NC

QNASL- beclomethasonedipropionate nasal aerosol 80 mcg/act

NC

QNASL CHILDRENS-beclomethasone dipropionate nasalaerosol 40 mcg/act

NC

triamcinolone acetonide nasalaerosol suspension 55 mcg/act

NC

XHANCE- fluticasone propionatenasal exhaler susp 93 mcg/act

NC

ZETONNA- ciclesonide nasal aerosolsoln 37 mcg/act (50 mcg/valve)

NC

COUGH/COLD/ALLERGYacetylcysteine inhal soln 10% np

acetylcysteine inhal soln 20% np

benzonatate cap 100 mg (Tessalonperles)

p

benzonatate cap 150 mg np

benzonatate cap 200 mg p

CLARINEX-D 12 HOUR-desloratadine & pseudoephedrinetab er 12hr 2.5-120 mg

NC

hydrocod polst-chlorphen polster susp 10-8 mg/5ml (Tussionexpennkineti)

np

HYDROCODONE BITARTRATE/CH- pseudoeph-chlorphen w/hydrocodone soln 60-4-5 mg/5ml

NP

hydrocodone w/ homatropine syrup5-1.5 mg/5ml

np

hydrocodone w/ homatropine tab5-1.5 mg

np

promethazine & phenylephrinesyrup 6.25-5 mg/5ml

np

promethazine w/ codeine syrup6.25-10 mg/5ml

p

promethazine-dm syrup6.25-15 mg/5ml

p

Drug Name Tier

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promethazine-phenylephrine-codeine syrup 6.25-5-10 mg/5ml

np

pseudoephed-bromphen-dm syrup30-2-10 mg/5ml

NC

SEMPREX-D- acrivastine &pseudoephedrine cap 8-60 mg

NC

TUSSICAPS- hydrocod polst-chlorphen polst cap er 12hr 5-4 mg

NC

TUSSICAPS- hydrocod polst-chlorphen polst cap er 12hr 10-8 mg

NC

TUZISTRA XR- codeine polist-chlorphen polist er susp14.7-2.8 mg/5ml

NC

ANTIASTHMATIC and BRONCHODILATOR AGENTSADVAIR DISKUS- fluticasone-

salmeterol aer powder ba100-50 mcg/dose

P •

ADVAIR DISKUS- fluticasone-salmeterol aer powder ba250-50 mcg/dose

P •

ADVAIR DISKUS- fluticasone-salmeterol aer powder ba500-50 mcg/dose

P •

ADVAIR HFA- fluticasone-salmeterolinhal aerosol 45-21 mcg/act

P •


P •


P •

AIRDUO RESPICLICK 113/14-fluticasone-salmeterol aer powderba 113-14 mcg/act

NC


NC


NC

ALBUTEROL SULFATE ER- albuterolsulfate tab er 12hr 4 mg

NP

ALBUTEROL SULFATE ER- albuterolsulfate tab er 12hr 8 mg

NP

2019


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albuterol sulfate soln nebu 0.083%(2.5 mg/3ml)

p

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

np

albuterol sulfate soln nebu0.63 mg/3ml (base equiv)

np

albuterol sulfate soln nebu1.25 mg/3ml (base equiv)

np

albuterol sulfate syrup 2 mg/5ml p

albuterol sulfate tab 2 mg np

albuterol sulfate tab 4 mg np

ALVESCO- ciclesonide inhal aerosol80 mcg/act

NC

ALVESCO- ciclesonide inhal aerosol160 mcg/act

NC

ANORO ELLIPTA- umeclidinium-vilanterol aero powd ba62.5-25 mcg/inh

P •

ARCAPTA NEOHALER- indacaterolmaleate inhal powder cap 75 mcg(base equiv)

NP •

ARMONAIR RESPICLICK 113-fluticasone propionate aer pow ba113 mcg/act

NC


NC


NC

ARNUITY ELLIPTA- fluticasonefuroate aerosol powder breath activ50 mcg/act

P •


P •


P •

ASMANEX HFA- mometasone furoateinhal aerosol suspension 100 mcg/act

P •

Drug Name Tier

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ASMANEX HFA- mometasone furoateinhal aerosol suspension 200 mcg/act

P •

ASMANEX TWISTHALER 120 ME-mometasone furoate inhal powd220 mcg/inh (breath activated)

P •

ASMANEX TWISTHALER 30 MET-mometasone furoate inhal powd110 mcg/inh (breath activated)

P •


P •


P •

ATROVENT HFA- ipratropium bromidehfa inhal aerosol 17 mcg/act

NP •

BEVESPIAEROSPHERE- glycopyrrolate-formoterol fumarate aerosol9-4.8 mcg/act

NC

BREO ELLIPTA- fluticasone furoate-vilanterol aero powd ba 100-25 mcg/inh

P •

BREO ELLIPTA- fluticasone furoate-vilanterol aero powd ba 200-25 mcg/inh

P •

BROVANA- arformoterol tartrate solnnebu 15 mcg/2ml (base equiv)

P

budesonide inhalation susp0.25 mg/2ml (Pulmicort)

np

budesonide inhalation susp0.5 mg/2ml (Pulmicort)

np

budesonide inhalation susp1 mg/2ml (Pulmicort)

np

COMBIVENT RESPIMAT-ipratropium-albuterol inhal aerosolsoln 20-100 mcg/act

NP •

cromolyn sodium soln nebu20 mg/2ml

np

DALIRESP- roflumilast tab 250 mcg NP

DALIRESP- roflumilast tab 500 mcg NP

2019


Drug Name Tier

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DULERA- mometasone furoate-formoterol fumarate aerosol100-5 mcg/act

P •

DULERA- mometasone furoate-formoterol fumarate aerosol200-5 mcg/act

P •

ELIXOPHYLLIN- theophylline elixir80 mg/15ml

NP

FLOVENT DISKUS- fluticasonepropionate aer pow ba 50 mcg/blister

P •


P •


P •

FLOVENT HFA- fluticasonepropionate hfa inhal aero 44 mcg/act (50/valve)

P •

FLOVENT HFA- fluticasonepropionate hfa inhal aer 110 mcg/act(125/valve)

P •

FLOVENT HFA- fluticasonepropionate hfa inhal aer 220 mcg/act (250/valve)

P •

FLUTICASONE PROPIONATE/SA-fluticasone-salmeterol aer powderba 55-14 mcg/act

np •


np •


np •

INCRUSE ELLIPTA- umeclidinium braero powd breath act 62.5 mcg/inh(base eq)

P •

ipratropium bromide inhal soln0.02%

p

ipratropium-albuterol nebu soln0.5-2.5(3) mg/3ml

np

Drug Name Tier

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levalbuterol hcl soln nebu conc1.25 mg/0.5ml (base equiv)(Xopenex concentrate)

np

levalbuterol hcl soln nebu0.31 mg/3ml (base equiv)(Xopenex)

np


np


np

LEVALBUTEROL TARTRATE HFA-levalbuterol tartrate inhal aerosol45 mcg/act (base equiv)

NC

LONHALA MAGNAIR REFILLKI- glycopyrrolate inhal solution25 mcg/ml

NC

LONHALA MAGNAIR STARTERK- glycopyrrolate inhal solution25 mcg/ml

NC

METAPROTERENOL SULFATE-metaproterenol sulfate syrup10 mg/5ml

NC

METAPROTERENOL SULFATE-metaproterenol sulfate tab 10 mg

NC

METAPROTERENOL SULFATE-metaproterenol sulfate tab 20 mg

NC

montelukast sodium chew tab 4 mg(base equiv) (Singulair)

p •

montelukast sodium chew tab 5 mg(base equiv) (Singulair)

p •

montelukast sodium oral granulespacket 4 mg (base equiv)(Singulair)

NC

montelukast sodium tab 10 mg(base equiv) (Singulair)

p •

PERFOROMIST- formoterol fumaratesoln nebu 20 mcg/2ml

NC

PROAIR HFA- albuterol sulfate inhalaero 108 mcg/act (90mcg baseequiv)

P •

2019


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PROAIR RESPICLICK- albuterolsulfate aer pow ba 108 mcg/act(90 mcg base equiv)

P •

PROVENTIL HFA- albuterol sulfateinhal aero 108 mcg/act (90mcg baseequiv)

NC

PULMICORT FLEXHALER-budesonide inhal aero powd90 mcg/act (breath activated)

NC

PULMICORT FLEXHALER-budesonide inhal aero powd180 mcg/act (breath activated)

NC

QVAR REDIHALER- beclomethasonediprop hfa breath act inh aer40 mcg/act

P •

QVAR REDIHALER- beclomethasonediprop hfa breath act inh aer80 mcg/act

P •

SEEBRI NEOHALER- glycopyrrolateinhal cap 15.6 mcg

NC

SEREVENT DISKUS- salmeterolxinafoate aer pow ba 50 mcg/dose(base equiv)

P •

SPIRIVA HANDIHALER- tiotropiumbromide monohydrate inhal cap18 mcg (base equiv)

P •

SPIRIVA RESPIMAT- tiotropiumbromide monohydrate inhal aerosol1.25 mcg/act

P •

SPIRIVA RESPIMAT- tiotropiumbromide monohydrate inhal aerosol2.5 mcg/act

P •

STIOLTO RESPIMAT- tiotropiumbr-olodaterol inhal aero soln2.5-2.5 mcg/act

P •

STRIVERDI RESPIMAT- olodaterolhcl inhal aerosol soln 2.5 mcg/act(base equiv)

P •

SYMBICORT- budesonide-formoterolfumarate dihyd aerosol 80-4.5 mcg/act

P •

Drug Name Tier

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

P •

terbutaline sulfate tab 2.5 mg np

terbutaline sulfate tab 5 mg np

THEO-24- theophylline cap er 24hr100 mg

NP


NP


NP


NP

theophylline soln 80 mg/15ml np

theophylline tab er 12hr 100 mg p

theophylline tab er 12hr 200 mg p

theophylline tab er 12hr 300 mg np




TRELEGY ELLIPTA- fluticasone-umeclidinium-vilanterol aepb100-62.5-25 mcg/inh

P •

TUDORZA PRESSAIR- aclidiniumbromide aerosol powd breathactivated 400 mcg/act

NC

UTIBRON NEOHALER- indacaterol-glycopyrrolate inhal cap27.5-15.6 mcg

NC

VENTOLIN HFA- albuterol sulfateinhal aero 108 mcg/act (90mcg baseequiv)

P •

XOPENEX HFA- levalbuterol tartrateinhal aerosol 45 mcg/act (baseequiv)

NC

zafirlukast tab 10 mg (Accolate) np •zafirlukast tab 20 mg (Accolate) np •zileuton tab er 12hr 600 mg (Zyflo

cr)NC

ZYFLO- zileuton tab 600 mg NC

2019


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ZYFLO CR- zileuton tab er 12hr600 mg

NC

RESPIRATORY AGENTS - MISC.ESBRIET- pirfenidone cap 267 mg NP • • •ESBRIET- pirfenidone tab 267 mg NP • • •ESBRIET- pirfenidone tab 801 mg NP • • •GLASSIA- alpha1-proteinase inhibitor

(human) inj 1000 mg/50mlNP •

KALYDECO- ivacaftor packet 50 mg P • • •KALYDECO- ivacaftor packet 75 mg P • • •KALYDECO- ivacaftor tab 150 mg P • • •OFEV- nintedanib esylate cap 100 mg

(base equivalent)NP • • •

OFEV- nintedanib esylate cap 150 mg(base equivalent)

NP • • •

ORKAMBI- lumacaftor-ivacaftor granules packet100-125 mg

NP • • •

ORKAMBI- lumacaftor-ivacaftor granules packet150-188 mg

NP • • •

ORKAMBI- lumacaftor-ivacaftor tab100-125 mg

NP • • •

ORKAMBI- lumacaftor-ivacaftor tab200-125 mg

NP • • •

PULMOZYME- dornase alfa inhal soln1 mg/ml

P •

SYMDEKO- tezacaftor-ivacaftor100-150 mg & ivacaftor 150 mg tabtbpk

NP • • •

GASTROINTESTINAL AGENTSLAXATIVESbisacodyl tab & peg 3350-kcl-sod

bicarb-nacl for soln kitnp

CLENPIQ- sod picosulfate-mg ox-citric ac sol10 mg-3.5 gm-12 gm/160ml

NC

GIALAX- polyethylene glycol 3350 - kit NC

GOLYTELY- peg 3350-kcl-na bicarb-nacl-na sulfate packet 227.1 gm

NC

Drug Name Tier

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KRISTALOSE- lactulose oral crystalpacket 10 gm

NC

KRISTALOSE- lactulose oral crystalpacket 20 gm

NC

lactulose oral crystal packet 10 gm(Kristalose)

NC

lactulose solution 10 gm/15ml p

MOVIPREP- peg 3350-kcl-nacl-nasulfate-na ascorbate-c for soln100 gm

NC

OSMOPREP- sod phos mono-sodphos di tabs 1.102-0.398 gm(1.5gmna phos)

NC

PCP 100- mag cit-bisacodyl-petrolat-peg-metoclopramide-electrol kit

NC

peg 3350-kcl-sod bicarb-nacl forsoln 420 gm (Nulytely/flavor pack)

p

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

p

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

p

polyethylene glycol 3350 oralpacket

NC

polyethylene glycol 3350 oralpowder

NC

PREPOPIK- sod picosulfate-mg oxide-citric acid pack10 mg-3.5 gm-12 gm

NC

SUPREP BOWEL PREP KIT- sodsulfate-pot sulf-mg sulf oral sol17.5-3.13-1.6 gm/177ml

NP

ANTIDIARRHEALSdiphenoxylate w/ atropine tab

2.5-0.025 mg (Lomotil)np

DIPHENOXYLATE/ATROPINE-diphenoxylate w/ atropine liq2.5-0.025 mg/5ml

NP

loperamide hcl cap 2 mg NC

MOTOFEN- difenoxin w/ atropine tab1-0.025 mg

NP

2019


Drug Name Tier

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MYTESI- crofelemer tab delayedrelease 125 mg

NP

ULCER DRUGSACIPHEX SPRINKLE- rabeprazole

sodium capsule sprinkle dr 5 mgNC

ACIPHEX SPRINKLE- rabeprazolesodium capsule sprinkle dr 10 mg

NC

amoxicillin cap-clarithro tab-lansopraz cap dr therapy pack(Prevpac)

NC

CARAFATE- sucralfate susp1 gm/10ml

NC

chlordiazepoxide hcl-clidiniumbromide cap 5-2.5 mg (Librax)

NC

CIMETIDINE HCL- cimetidine hcl soln300 mg/5ml

NC

cimetidine tab 200 mg NC




CUVPOSA- glycopyrrolate oral soln1 mg/5ml

NP

DEXILANT- dexlansoprazole capdelayed release 30 mg

NP •

DEXILANT- dexlansoprazole capdelayed release 60 mg

NP •

dicyclomine hcl cap 10 mg (Bentyl) p

dicyclomine hcl oral soln10 mg/5ml

np

dicyclomine hcl tab 20 mg p

DONNATAL- pb-hyoscy-atrop-scopol elix16.2-0.1037-0.0194-0.0065 mg/5ml

NC

DONNATAL- pb-hyoscy-atrop-scopoltab 16.2-0.1037-0.0194-0.0065 mg

NC

esomeprazole magnesium capdelayed release 20 mg (base eq)(Nexium)

NC

esomeprazole magnesium capdelayed release 40 mg (base eq)(Nexium)

NC

Drug Name Tier

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ESOMEPRAZOLE STRONTIUM-esomeprazole strontium capdelayed release 49.3 mg

NC

famotidine for susp 40 mg/5ml(Pepcid)

NC

famotidine tab 20 mg (Pepcid) NC

famotidine tab 40 mg (Pepcid) p

GLYCATE- glycopyrrolate tab 1.5 mg NC

glycopyrrolate tab 1 mg (Robinul) np

glycopyrrolate tab 2 mg (Robinulforte)

np

lansoprazole cap delayed release15 mg (Prevacid)

NC

lansoprazole cap delayed release30 mg (Prevacid)

NC

lansoprazole tab delayed releaseorally disintegrating 15 mg(Prevacid solutab)

NC

lansoprazole tab delayed releaseorally disintegrating 30 mg(Prevacid solutab)

NC

LIBRAX- chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg

NC

methscopolamine bromide tab2.5 mg (Pamine)

np

methscopolamine bromide tab5 mg (Pamine forte)

np

misoprostol tab 100 mcg (Cytotec) p

misoprostol tab 200 mcg (Cytotec) p

NEXIUM- esomeprazole magnesiumfor delayed release susp packet5 mg

P •


P •


P •


P •

2019


Drug Name Tier

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NEXIUM- esomeprazole magnesiumfor delayed release susp pack2.5 mg

P •

NIZATIDINE- nizatidine oral soln15 mg/ml

NC

nizatidine cap 150 mg NC

nizatidine cap 300 mg NC

OMECLAMOX-PAK- amoxicillin cap-clarithro tab w/ omepraz cap drtherapy pack

NC

omeprazole cap delayed release10 mg

p •


p •


p •

omeprazole-sodium bicarbonatecap 20-1100 mg (Zegerid)

NC

omeprazole-sodium bicarbonatecap 40-1100 mg (Zegerid)

NC

omeprazole-sodium bicarbonatepowd pack for susp 20-1680 mg(Zegerid)

NC

omeprazole-sodium bicarbonatepowd pack for susp 40-1680 mg(Zegerid)

NC

pantoprazole sodium ec tab 20 mg(base equiv) (Protonix)

p •

pantoprazole sodium ec tab 40 mg(base equiv) (Protonix)

p •

PRILOSEC- omeprazole magnesiumfor delayed release susp packet2.5 mg

NC

PRILOSEC- omeprazole magnesiumfor delayed release susp packet10 mg

NC

PROPANTHELINE BROMIDE-propantheline bromide tab 15 mg

NP

PROTONIX- pantoprazole sodium fordelayed release susp packet 40 mg

NC

Drug Name Tier

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PYLERA- bismuth subcit-metronidazole-tetracycline cap140-125-125 mg

NC

rabeprazole sodium ec tab 20 mg(Aciphex)

NC

ranitidine hcl cap 150 mg NC

ranitidine hcl cap 300 mg NC

ranitidine hcl syrup 15 mg/ml(75 mg/5ml)

p

ranitidine hcl tab 150 mg (Zantac) NC

ranitidine hcl tab 300 mg (Zantac) p

sucralfate tab 1 gm (Carafate) np

ANTIEMETICSAKYNZEO- netupitant-palonosetron

cap 300-0.5 mgNP •

ANZEMET- dolasetron mesylate tab50 mg

NP •

ANZEMET- dolasetron mesylate tab100 mg

NP •

aprepitant capsule therapy pack 80& 125 mg (Emend)

np •

aprepitant capsule 40 mg (Emend) np

aprepitant capsule 80 mg (Emend) np •aprepitant capsule 125 mg (Emend) np •BONJESTA- doxylamine-pyridoxine

tab er 20-20 mgNP

CESAMET- nabilone cap 1 mg NP •DICLEGIS- doxylamine-pyridoxine tab

delayed release 10-10 mgNP

dronabinol cap 2.5 mg (Marinol) np

dronabinol cap 5 mg (Marinol) np

dronabinol cap 10 mg (Marinol) np

EMEND- aprepitant for oral susp125 mg (125 mg/5ml)

P •

granisetron hcl tab 1 mg np •meclizine hcl tab 12.5 mg NC

meclizine hcl tab 25 mg NC

ondansetron hcl oral soln 4 mg/5ml(Zofran)

np •

2019


Drug Name Tier

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ondansetron hcl tab 4 mg (Zofran) p •ondansetron hcl tab 8 mg (Zofran) p •ondansetron hcl tab 24 mg np •ondansetron orally disintegrating

tab 4 mg (Zofran odt)p •

ondansetron orally disintegratingtab 8 mg (Zofran odt)

p •

SANCUSO- granisetron td patch3.1 mg/24hr (contains 34.3 mg)

NC

SYNDROS- dronabinol soln 5 mg/ml NC

TRANSDERM-SCOP- scopolamine tdpatch 72hr 1 mg/3days

NP

trimethobenzamide hcl cap 300 mg(Tigan)

np

VARUBI- rolapitant hcl tab 90 mg(base equiv)

NP •

ZUPLENZ- ondansetron oral solublefilm 4 mg

NC

ZUPLENZ- ondansetron oral solublefilm 8 mg

NC

DIGESTIVE AIDSCREON- pancrelipase (lip-prot-amyl)

dr cap 3000-9500-15000 unitP

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

P


P


P


P

PANCREAZE- pancrelipase (lip-prot-amyl) dr cap 2600-6200-10850 unit

NC

PANCREAZE- pancrelipase (lip-prot-amyl) dr cap 4200-14200-24600 unit

NC

PANCREAZE- pancrelipase (lip-prot-amyl) dr cap 10500-35500-61500unit

NC


NC

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NC

PERTZYE- pancrelipase (lip-prot-amyl) dr cap 4000-14375-15125 unit

NC

PERTZYE- pancrelipase (lip-prot-amyl) dr cap 8000-28750-30250 unit

NC

PERTZYE- pancrelipase (lip-prot-amyl) dr cap 16000-57500-60500unit

NC

PERTZYE- pancrelipase (lip-prot-amyl) dr cap 24000-86250-90750unit

NC

SUCRAID- sacrosidase soln 8500unit/ml

NP •

VIOKACE- pancrelipase (lip-prot-amyl) tab 10440-39150-39150 unit

NC

VIOKACE- pancrelipase (lip-prot-amyl) tab 20880-78300-78300 unit

NC

ZENPEP- pancrelipase (lip-prot-amyl)dr cap 3000-10000-14000 unit

P


P


P


P


P


P


P

GASTROINTESTINAL AGENTS- MISC.alosetron hcl tab 0.5 mg (base

equiv) (Lotronex)NC

alosetron hcl tab 1 mg (base equiv)(Lotronex)

NC

AMITIZA- lubiprostone cap 8 mcg NP

AMITIZA- lubiprostone cap 24 mcg NP

2019


Drug Name Tier

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APRISO- mesalamine cap er 24hr0.375 gm

P

ASACOL HD- mesalamine tabdelayed release 800 mg

P

AURYXIA- ferric citrate tab 1 gm(210 mg ferric iron)

NP

balsalazide disodium cap 750 mg(Colazal)

np

calcium acetate (phosphate binder)cap 667 mg (169 mg ca)

np

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

NC

CANASA- mesalamine suppos1000 mg

P

CHENODAL- chenodiol tab 250 mg P •CHOLBAM- cholic acid cap 50 mg NP •CHOLBAM- cholic acid cap 250 mg NP •CIMZIA- certolizumab pegol for inj kit

2 x 200 mgNC

CIMZIA- certolizumab pegol inj kit 2 x200 mg/ml

NC

CIMZIA STARTER KIT- certolizumabpegol inj kit 6 x 200 mg/ml

NC

cromolyn sodium oral conc100 mg/5ml (Gastrocrom)

np

DELZICOL- mesalamine cap dr400 mg

P

DIPENTUM- olsalazine sodium cap250 mg

NC

FOSRENOL- lanthanum carbonateoral powder pack 750 mg(elemental)

NP

FOSRENOL- lanthanum carbonateoral powder pack 1000 mg(elemental)

NP

GATTEX- teduglutide (rdna) for inj kit5 mg

NP • •

lactulose (encephalopathy) solution10 gm/15ml

p

lanthanum carbonate chew tab500 mg (elemental) (Fosrenol)

np

Drug Name Tier

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np


np

LINZESS- linaclotide cap 72 mcg P



mesalamine enema 4 gm np

mesalamine tab delayed release800 mg (Asacol hd)

np

mesalamine tab delayed release1.2 gm (Lialda)

np

metoclopramide hcl soln 5 mg/5ml(10 mg/10ml) (base equiv)

p

metoclopramide hcl tab 5 mg (baseequivalent) (Reglan)

p

metoclopramide hcl tab 10 mg(base equivalent) (Reglan)

p

METOCLOPRAMIDE ODT-metoclopramide hcl orallydisintegrating tab 5 mg (base eq)

NP

METOCLOPRAMIDE ODT-metoclopramide hcl orallydisintegrating tab 10 mg (base eq)

NP

MOVANTIK- naloxegol oxalate tab12.5 mg (base equivalent)

NP

MOVANTIK- naloxegol oxalate tab25 mg (base equivalent)

NP

OCALIVA- obeticholic acid tab 5 mg NP • • •OCALIVA- obeticholic acid tab 10 mg NP • • •PENTASA- mesalamine cap er

250 mgNC

PENTASA- mesalamine cap er500 mg

NC

PHOSLYRA- calcium acetate(phosphate binder) oral soln667 mg/5ml

NP

RELISTOR- methylnaltrexone bromideinj 8 mg/0.4ml (20 mg/ml)

NP

RELISTOR- methylnaltrexone bromideinj 12 mg/0.6ml (20 mg/ml)

NP

2019


Drug Name Tier

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RELISTOR- methylnaltrexone bromidetab 150 mg

NP

RENAGEL- sevelamer hcl tab 800 mg NP

sevelamer carbonate packet 0.8 gm(Renvela)

np

sevelamer carbonate packet 2.4 gm(Renvela)

np

sevelamer carbonate tab 800 mg(Renvela)

np

SFROWASA- mesalamine sulfite-free(sf) enema 4 gm/60ml

NP

sulfasalazine tab delayed release500 mg (Azulfidine en-tabs)

np

sulfasalazine tab 500 mg(Azulfidine)

np

SYMPROIC- naldemedine tosylate tab0.2 mg (base equivalent)

NP

TRULANCE- plecanatide tab 3 mg NP

ursodiol cap 300 mg (Actigall) np

ursodiol tab 250 mg (Urso 250) np

ursodiol tab 500 mg (Urso forte) np

VELPHORO- sucroferric oxyhydroxidechew tab 500 mg

P

VIBERZI- eluxadoline tab 75 mg P

VIBERZI- eluxadoline tab 100 mg P

XERMELO- telotristat etiprate tab250 mg (telotristat ethyl equiv)

NP • • •

GENITOURINARY AGENTSURINARY ANTI-INFECTIVESmethenamine hippurate tab 1 gm

(Hiprex)np

MONUROL- fosfomycin tromethaminepowd pack 3 gm (base equivalent)

NP

nitrofurantoin macrocrystalline cap25 mg (Macrodantin)

np


np


np

Drug Name Tier

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nitrofurantoin monohydratemacrocrystalline cap 100 mg(Macrobid)

p

nitrofurantoin susp 25 mg/5ml(Furadantin)

np

URINARY ANTISPASMODICSbethanechol chloride tab 5 mg

(Urecholine)np

bethanechol chloride tab 10 mg(Urecholine)

np


np


np

darifenacin hydrobromide taber 24hr 7.5 mg (base equiv)(Enablex)

NC

darifenacin hydrobromide tab er24hr 15 mg (base equiv) (Enablex)

NC

flavoxate hcl tab 100 mg NC

GELNIQUE- oxybutynin chloride td gel10%

NC

GELNIQUE PUMP- oxybutyninchloride td gel 10%

NC

MYRBETRIQ- mirabegron tab er 24 hr25 mg

P

MYRBETRIQ- mirabegron tab er 24 hr50 mg

P

oxybutynin chloride syrup5 mg/5ml

p

oxybutynin chloride tab er 24hr5 mg (Ditropan xl)

np


np


np

oxybutynin chloride tab 5 mg np

OXYTROL- oxybutynin td patch twiceweekly 3.9 mg/24hr

NC

tolterodine tartrate cap er 24hr2 mg (Detrol la)

np

2019


Drug Name Tier

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tolterodine tartrate cap er 24hr4 mg (Detrol la)

np

tolterodine tartrate tab 1 mg(Detrol)

np

tolterodine tartrate tab 2 mg(Detrol)

np

TOVIAZ- fesoterodine fumarate tab er24hr 4 mg

NC

TOVIAZ- fesoterodine fumarate tab er24hr 8 mg

NC

trospium chloride cap er 24hr60 mg

np

trospium chloride tab 20 mg np

VESICARE- solifenacin succinate tab5 mg

P

VESICARE- solifenacin succinate tab10 mg

P

VAGINAL PRODUCTSAVC- sulfanilamide vaginal cream

15%NP

CLEOCIN- clindamycin phosphatevaginal suppos 100 mg

NC

clindamycin phosphate vaginalcream 2% (Cleocin)

np

CLINDESSE- clindamycin phosphate(one dose) vaginal cream 2%

NP

CRINONE- progesterone vaginal gel4%

P

CRINONE- progesterone vaginal gel8%

P

ENCARE- nonoxynol-9 vaginalsuppos 100 mg

P

ENDOMETRIN- progesterone vaginalinsert 100 mg

NC

estradiol vaginal cream 0.1 mg/gm(Estrace)

np

estradiol vaginal tab 10 mcg(Vagifem)

NC

ESTRING- estradiol vaginal ring 2 mg(7.5 mcg/24hrs)

NP

Drug Name Tier

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FEMRING- estradiol acetate vaginalring 0.05 mg/24hr

NP

FEMRING- estradiol acetate vaginalring 0.1 mg/24hr

NP

GYNAZOLE-1- butoconazole nitrate(one dose) vaginal cream 2%

NP

IMVEXXY MAINTENANCE PACK-estradiol vaginal insert 4 mcg

NC

IMVEXXY MAINTENANCE PACK-estradiol vaginal insert 10 mcg

NC

IMVEXXY STARTER PACK- estradiolvaginal insert 4 mcg

NC

IMVEXXY STARTER PACK- estradiolvaginal insert 10 mcg

NC

INTRAROSA- prasterone vaginalinsert 6.5 mg

NC

metronidazole vaginal gel 0.75%(Metrogel-vaginal)

np

MICONAZOLE 3- miconazole nitratevaginal suppos 200 mg

NP

nonoxynol-9 gel 4% np

NUVESSA- metronidazole vaginal gel1.3%

NP

OPTIONS GYNOL II VAGINAL-nonoxynol-9 gel 3%

P

PREMARIN- estrogens, conjugatedvaginal cream 0.625 mg/gm

NP

SHUR-SEAL- nonoxynol-9 gel 2% P

TERCONAZOLE- terconazole vaginalcream 0.8%

NP

terconazole vaginal cream 0.4%(Terazol 7)

np

terconazole vaginal suppos 80 mg np

TODAY SPONGE- nonoxynol-9vaginal sponge 1000 mg

P

VAGIFEM- estradiol vaginal tab10 mcg

np

VCF VAGINAL CONTRACEPTIVE-nonoxynol-9 film 28%

P

VCF VAGINAL CONTRACEPTIVE-nonoxynol-9 foam 12.5%

P

2019


Drug Name Tier

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GENITOURINARY AGENTS - MISC.alfuzosin hcl tab er 24hr 10 mg

(Uroxatral)p

CARDURA XL- doxazosin mesylatetab er 24 hr 4 mg (base equiv)

NC

CARDURA XL- doxazosin mesylatetab er 24 hr 8 mg (base equiv)

NC

CYSTAGON- cysteamine bitartratecap 50 mg

P •

CYSTAGON- cysteamine bitartratecap 150 mg

P •

dutasteride cap 0.5 mg (Avodart) p

dutasteride-tamsulosin hcl cap0.5-0.4 mg (Jalyn)

np

ELMIRON- pentosan polysulfatesodium caps 100 mg

NP •

finasteride tab 5 mg (Proscar) p

K-PHOS NO 2- potassium & sodiumacid phosphates tab 305-700 mg

P

LITHOSTAT- acetohydroxamic acidtab 250 mg

NP

potassium citrate tab er 5 meq(540 mg) (Urocit-k 5)

np


np


np

PROCYSBI- cysteamine bitartrate capdelayed release 25 mg (base equiv)

NP •

PROCYSBI- cysteamine bitartrate capdelayed release 75 mg (base equiv)

NP •

RAPAFLO- silodosin cap 4 mg NC

RAPAFLO- silodosin cap 8 mg NC

sodium citrate & citric acid soln500-334 mg/5ml (Shohls solutionmodi)

np

tamsulosin hcl cap 0.4 mg (Flomax) p

THIOLA- tiopronin tab 100 mg NP

CENTRAL NERVOUS SYSTEM DRUGSANTIANXIETY AGENTS

Drug Name Tier

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ALPRAZOLAM INTENSOL-alprazolam conc 1 mg/ml

NP

alprazolam orally disintegrating tab0.25 mg

np

alprazolam orally disintegrating tab0.5 mg

np

alprazolam orally disintegrating tab1 mg

np

alprazolam orally disintegrating tab2 mg

np

alprazolam tab er 24hr 0.5 mg(Xanax xr)

p

alprazolam tab er 24hr 1 mg (Xanaxxr)

np


np


np

alprazolam tab 0.25 mg (Xanax) p

alprazolam tab 0.5 mg (Xanax) p

alprazolam tab 1 mg (Xanax) p

alprazolam tab 2 mg (Xanax) p

buspirone hcl tab 5 mg p

buspirone hcl tab 7.5 mg np



buspirone hcl tab 30 mg np

chlordiazepoxide hcl cap 5 mg p



clorazepate dipotassium tab3.75 mg

np

clorazepate dipotassium tab 7.5 mg(Tranxene t)

np

clorazepate dipotassium tab 15 mg np

DIAZEPAM- diazepam oral soln 1 mg/ml

P

diazepam conc 5 mg/ml np

diazepam tab 2 mg (Valium) p

2019


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hydroxyzine hcl syrup 10 mg/5ml p

hydroxyzine hcl tab 10 mg p



HYDROXYZINE PAMOATE-hydroxyzine pamoate cap 100 mg

NP

hydroxyzine pamoate cap 25 mg(Vistaril)

p

hydroxyzine pamoate cap 50 mg(Vistaril)

p

lorazepam conc 2 mg/ml np

lorazepam tab 0.5 mg (Ativan) p

lorazepam tab 1 mg (Ativan) p

lorazepam tab 2 mg (Ativan) p

meprobamate tab 200 mg NC

meprobamate tab 400 mg NC

OXAZEPAM- oxazepam cap 30 mg NP

oxazepam cap 10 mg np

oxazepam cap 15 mg np

ANTIDEPRESSANTSamitriptyline hcl tab 10 mg p

amitriptyline hcl tab 25 mg (Elavil) p

amitriptyline hcl tab 50 mg p

amitriptyline hcl tab 75 mg np



AMOXAPINE- amoxapine tab 25 mg NC




APLENZIN- bupropion hbr tab er 24hr174 mg

NC


NC

Drug Name Tier

Des

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tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its


NC

bupropion hcl tab er 12hr 100 mg(Wellbutrin sr)

p •


p •


p •

bupropion hcl tab er 24hr 150 mg(Wellbutrin xl)

np •

bupropion hcl tab er 24hr 300 mg(Wellbutrin xl)

np •

bupropion hcl tab 75 mg p •bupropion hcl tab 100 mg np •BUPROPION HYDROCHLORIDE E-

bupropion hcl tab er 24hr 450 mgNC

citalopram hydrobromide oral soln10 mg/5ml

np •

citalopram hydrobromide tab 10 mg(base equiv) (Celexa)

p •


p •


p •

clomipramine hcl cap 25 mg(Anafranil)

np


np


np

desipramine hcl tab 10 mg(Norpramin)

np

desipramine hcl tab 25 mg(Norpramin)

np

desipramine hcl tab 50 mg np




DESVENLAFAXINE ER-desvenlafaxine tab er 24hr 50 mg

NP •

2019


Drug Name Tier

Des

igna

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Spe

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ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

DESVENLAFAXINE ER-desvenlafaxine tab er 24hr 100 mg

NP •

desvenlafaxine succinate tab er24hr 25 mg (base equiv) (Pristiq)

np •


np •


np •

doxepin hcl cap 10 mg p

doxepin hcl cap 25 mg np





doxepin hcl conc 10 mg/ml p

duloxetine hcl enteric coatedpellets cap 20 mg (base eq)(Cymbalta)

np •


p •

duloxetine hcl enteric coatedpellets cap 40 mg (base eq)

NC


p •

EMSAM- selegiline td patch 24hr6 mg/24hr

NP


NP


NP

escitalopram oxalate soln 5 mg/5ml(base equiv)

np •

escitalopram oxalate tab 5 mg(base equiv) (Lexapro)

p •


p •


p •

Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

FETZIMA- levomilnacipran hcl cap er24hr 20 mg (base equivalent)

NP •


NP •


NP •


NP •

FETZIMA TITRATION PACK-levomilnacipran hcl cap er 24hr 20 &40 mg therapy pack

NP •

FLUOXETINE DR- fluoxetine hcl capdelayed release 90 mg

NP •

fluoxetine hcl cap 10 mg (Prozac) p •fluoxetine hcl cap 20 mg (Prozac) p •fluoxetine hcl cap 40 mg (Prozac) p •fluoxetine hcl solution 20 mg/5ml p •fluoxetine hcl tab 10 mg np •fluoxetine hcl tab 20 mg np •fluoxetine hcl tab 60 mg (Fluoxetine

hcl)NC

fluvoxamine maleate cap er 24hr100 mg

NC

fluvoxamine maleate cap er 24hr150 mg

NC

fluvoxamine maleate tab 25 mg p •fluvoxamine maleate tab 50 mg p •fluvoxamine maleate tab 100 mg p •FORFIVO XL- bupropion hcl tab er

24hr 450 mgNC

imipramine hcl tab 10 mg (Tofranil) p



imipramine pamoate cap 75 mg np




KHEDEZLA- desvenlafaxine tab er24hr 50 mg

NC

2019


Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

r Aut

horiz

atio

n

Ste

p Th

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y

Dis

pens

ing

Lim

its

KHEDEZLA- desvenlafaxine tab er24hr 100 mg

NC

MAPROTILINE HCL- maprotiline hcltab 25 mg

NC


NC


NC

MARPLAN- isocarboxazid tab 10 mg NP

mirtazapine orally disintegratingtab 15 mg (Remeron soltab)

np •


np •


np •

mirtazapine tab 7.5 mg np •mirtazapine tab 15 mg (Remeron) p •mirtazapine tab 30 mg (Remeron) p •mirtazapine tab 45 mg (Remeron) p •NEFAZODONE HCL- nefazodone hcl

tab 100 mgNC

NEFAZODONE HCL- nefazodone hcltab 150 mg

NC

NEFAZODONE HYDROCHLORIDE-nefazodone hcl tab 50 mg

NC


NC


NC

NORTRIPTYLINE HCL- nortriptylinehcl soln 10 mg/5ml

np

nortriptyline hcl cap 10 mg(Pamelor)

p


p


p


p

Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

r Aut

horiz

atio

n

Ste

p Th

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y

Dis

pens

ing

Lim

its

paroxetine hcl tab er 24hr 12.5 mg(Paxil cr)

NC

paroxetine hcl tab er 24hr 25 mg(Paxil cr)

NC

paroxetine hcl tab er 24hr 37.5 mg(Paxil cr)

NC

paroxetine hcl tab 10 mg (Paxil) p •paroxetine hcl tab 20 mg (Paxil) p •paroxetine hcl tab 30 mg (Paxil) p •paroxetine hcl tab 40 mg (Paxil) p •PAXIL- paroxetine hcl oral susp

10 mg/5ml (base equiv)NC

PEXEVA- paroxetine mesylate tab10 mg (base equiv)

NC


NC


NC


NC

phenelzine sulfate tab 15 mg(Nardil)

np

protriptyline hcl tab 5 mg np

protriptyline hcl tab 10 mg np

sertraline hcl oral concentrate forsolution 20 mg/ml (Zoloft)

np •

sertraline hcl tab 25 mg (Zoloft) p •sertraline hcl tab 50 mg (Zoloft) p •sertraline hcl tab 100 mg (Zoloft) p •tranylcypromine sulfate tab 10 mg

(Parnate)np

trazodone hcl tab 50 mg p



trazodone hcl tab 300 mg np

trimipramine maleate cap 25 mg(Surmontil)

np


np

2019


Drug Name Tier

Des

igna

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Spe

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ty

Prio

r Aut

horiz

atio

n

Ste

p Th

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y

Dis

pens

ing

Lim

its


np

TRINTELLIX- vortioxetine hbr tab5 mg (base equiv)

NP •


NP •


NP •

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

p •

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

p •

venlafaxine hcl cap er 24hr 150 mg(base equivalent) (Effexor xr)

p •

venlafaxine hcl tab er 24hr 37.5 mg(base equivalent) (Venlafaxine hcler)

np •

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

np •

venlafaxine hcl tab er 24hr 150 mg(base equivalent) (Venlafaxine hcler)

np •

venlafaxine hcl tab er 24hr 225 mg(base equivalent)

NC

venlafaxine hcl tab 25 mg p •venlafaxine hcl tab 37.5 mg p •venlafaxine hcl tab 50 mg p •venlafaxine hcl tab 75 mg p •venlafaxine hcl tab 100 mg p •VIIBRYD- vilazodone hcl tab 10 mg NP •VIIBRYD- vilazodone hcl tab 20 mg NP •VIIBRYD- vilazodone hcl tab 40 mg NP •VIIBRYD STARTER PACK-

vilazodone hcl tab starter kit 10 (7)& 20 (23) mg

NP •

ANTIPSYCHOTICSADASUVE- loxapine aerosol powder

breath activated 10 mgNP

aripiprazole oral solution 1 mg/ml np •

Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

r Aut

horiz

atio

n

Ste

p Th

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y

Dis

pens

ing

Lim

its

aripiprazole orally disintegratingtab 10 mg

np •

aripiprazole orally disintegratingtab 15 mg

np •

aripiprazole tab 2 mg (Abilify) np •aripiprazole tab 5 mg (Abilify) np •aripiprazole tab 10 mg (Abilify) np •aripiprazole tab 15 mg (Abilify) np •aripiprazole tab 20 mg (Abilify) np •aripiprazole tab 30 mg (Abilify) np •chlorpromazine hcl tab 10 mg np

chlorpromazine hcl tab 25 mg np




CLOZAPINE ODT- clozapine orallydisintegrating tab 150 mg

NP • •

CLOZAPINE ODT- clozapine orallydisintegrating tab 200 mg

NP • •

clozapine orally disintegrating tab12.5 mg (Fazaclo)

np •

clozapine orally disintegrating tab25 mg (Fazaclo)

np •

clozapine orally disintegrating tab100 mg (Fazaclo)

np •

clozapine tab 25 mg (Clozaril) np •clozapine tab 50 mg np •clozapine tab 100 mg (Clozaril) np •clozapine tab 200 mg np •EQUETRO- carbamazepine

(antipsychotic) cap er 12hr 100 mgNP

EQUETRO- carbamazepine(antipsychotic) cap er 12hr 200 mg

NP

EQUETRO- carbamazepine(antipsychotic) cap er 12hr 300 mg

NP

FANAPT- iloperidone tab 1 mg NP • •FANAPT- iloperidone tab 2 mg NP • •FANAPT- iloperidone tab 4 mg NP • •

2019


Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

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Dis

pens

ing

Lim

its

FANAPT- iloperidone tab 6 mg NP • •FANAPT- iloperidone tab 8 mg NP • •FANAPT- iloperidone tab 10 mg NP • •FANAPT- iloperidone tab 12 mg NP • •FANAPT TITRATION PACK-

iloperidone tab 1 mg & 2 mg & 4 mg& 6 mg titration pak

NP • •

FAZACLO- clozapine orallydisintegrating tab 150 mg

NP • •

FAZACLO- clozapine orallydisintegrating tab 200 mg

NP • •

FLUPHENAZINE HCL- fluphenazinehcl elixir 2.5 mg/5ml

NP

FLUPHENAZINE HCL- fluphenazinehcl oral conc 5 mg/ml

NP

fluphenazine hcl tab 1 mg np

fluphenazine hcl tab 2.5 mg np



haloperidol lactate oral conc 2 mg/ml

p

haloperidol tab 0.5 mg p

haloperidol tab 1 mg p

haloperidol tab 2 mg p

haloperidol tab 5 mg np



LATUDA- lurasidone hcl tab 20 mg NP • •LATUDA- lurasidone hcl tab 40 mg NP • •LATUDA- lurasidone hcl tab 60 mg NP • •LATUDA- lurasidone hcl tab 80 mg NP • •LATUDA- lurasidone hcl tab 120 mg NP • •LITHIUM- lithium oral solution 8

meq/5mlP

LITHIUM CARBONATE- lithiumcarbonate cap 150 mg

NP

LITHIUM CARBONATE- lithiumcarbonate cap 600 mg

NP

Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

r Aut

horiz

atio

n

Ste

p Th

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y

Dis

pens

ing

Lim

its

lithium carbonate cap 150 mg(Lithium carbonate)

p

lithium carbonate cap 300 mg p

lithium carbonate cap 600 mg(Lithium carbonate)

p

lithium carbonate tab er 300 mg(Lithobid)

p

lithium carbonate tab er 450 mg p

lithium carbonate tab 300 mg p

LITHOBID- lithium carbonate tab er300 mg

NP

loxapine succinate cap 5 mg np




NUPLAZID- pimavanserin tartrate cap34 mg (base equivalent)

NC

NUPLAZID- pimavanserin tartrate tab10 mg (base equivalent)

NC

NUPLAZID- pimavanserin tartrate tab17 mg (base equivalent)

NC

olanzapine orally disintegrating tab5 mg (Zyprexa zydis)

np •


np •


np •


np •

olanzapine tab 2.5 mg (Zyprexa) p •olanzapine tab 5 mg (Zyprexa) p •olanzapine tab 7.5 mg (Zyprexa) p •olanzapine tab 10 mg (Zyprexa) p •olanzapine tab 15 mg (Zyprexa) p •olanzapine tab 20 mg (Zyprexa) p •paliperidone tab er 24hr 1.5 mg

(Invega)np •

paliperidone tab er 24hr 3 mg(Invega)

np •

2019


Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

r Aut

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n

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Dis

pens

ing

Lim

its


np •


np •

perphenazine tab 2 mg np




prochlorperazine maleate tab 5 mg(base equivalent)

p

prochlorperazine maleate tab 10 mg(base equivalent)

p

prochlorperazine suppos 25 mg np

quetiapine fumarate tab er 24hr50 mg (Seroquel xr)

np •


np •


np •


np •


np •

quetiapine fumarate tab 25 mg(Seroquel)

p •


p •


p •


p •


p •


p •

REXULTI- brexpiprazole tab 0.25 mg NP • •REXULTI- brexpiprazole tab 0.5 mg NP • •REXULTI- brexpiprazole tab 1 mg NP • •REXULTI- brexpiprazole tab 2 mg NP • •REXULTI- brexpiprazole tab 3 mg NP • •

Drug Name Tier

Des

igna

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Spe

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ty

Prio

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Dis

pens

ing

Lim

its

REXULTI- brexpiprazole tab 4 mg NP • •RISPERIDONE ODT- risperidone

orally disintegrating tab 0.25 mgNP • •

risperidone orally disintegrating tab0.5 mg (Risperdal m-tab)

np •

risperidone orally disintegrating tab1 mg (Risperdal m-tab)

np •


np •


np •


np •

risperidone soln 1 mg/ml(Risperdal)

np •

risperidone tab 0.25 mg (Risperdal) p •risperidone tab 0.5 mg (Risperdal) p •risperidone tab 1 mg (Risperdal) p •risperidone tab 2 mg (Risperdal) p •risperidone tab 3 mg (Risperdal) p •risperidone tab 4 mg (Risperdal) p •SAPHRIS- asenapine maleate sl tab

2.5 mg (base equiv)NP • •

SAPHRIS- asenapine maleate sl tab5 mg (base equiv)

NP • •

SAPHRIS- asenapine maleate sl tab10 mg (base equiv)

NP • •

thioridazine hcl tab 10 mg NC




thiothixene cap 1 mg np




trifluoperazine hcl tab 1 mg (baseequivalent)

np


np

2019


Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

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atio

n

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y

Dis

pens

ing

Lim

its


np


np

VERSACLOZ- clozapine susp 50 mg/ml

NP • •

VRAYLAR- cariprazine hcl captherapy pack 1.5 mg (1) & 3 mg (6)

NP • •

VRAYLAR- cariprazine hcl cap 1.5 mg(base equivalent)

NP • •

VRAYLAR- cariprazine hcl cap 3 mg(base equivalent)

NP • •

VRAYLAR- cariprazine hcl cap 4.5 mg(base equivalent)

NP • •

VRAYLAR- cariprazine hcl cap 6 mg(base equivalent)

NP • •

ziprasidone hcl cap 20 mg(Geodon)

np •


np •


np •


np •

HYPNOTICSBELSOMRA- suvorexant tab 5 mg P • •BELSOMRA- suvorexant tab 10 mg P • •BELSOMRA- suvorexant tab 15 mg P • •BELSOMRA- suvorexant tab 20 mg P • •BUTISOL SODIUM- butabarbital

sodium tab 30 mgNC

DORAL- quazepam tab 15 mg NP

EDLUAR- zolpidem tartrate sl tab5 mg

NC

EDLUAR- zolpidem tartrate sl tab10 mg

NC

estazolam tab 1 mg np

estazolam tab 2 mg np

eszopiclone tab 1 mg (Lunesta) np •eszopiclone tab 2 mg (Lunesta) p •

Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

r Aut

horiz

atio

n

Ste

p Th

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y

Dis

pens

ing

Lim

its

eszopiclone tab 3 mg (Lunesta) p •FLURAZEPAM HCL- flurazepam hcl

cap 15 mgNP

FLURAZEPAM HCL- flurazepam hclcap 30 mg

NP

HALCION- triazolam tab 0.25 mg NC

HETLIOZ- tasimelteon capsule 20 mg NP • •phenobarbital elixir 20 mg/5ml np

phenobarbital tab 15 mg np

phenobarbital tab 16.2 mg np







QUAZEPAM- quazepam tab 15 mg NP

ROZEREM- ramelteon tab 8 mg NC

SECONAL SODIUM- secobarbitalsodium cap 100 mg

NC

SILENOR- doxepin hcl (sleep) tab3 mg (base equiv)

NP • •

SILENOR- doxepin hcl (sleep) tab6 mg (base equiv)

NP • •

temazepam cap 7.5 mg (Restoril) np

temazepam cap 15 mg (Restoril) p

temazepam cap 22.5 mg (Restoril) np

temazepam cap 30 mg (Restoril) p

TRIAZOLAM- triazolam tab 0.125 mg NC

triazolam tab 0.25 mg (Halcion) NC

zaleplon cap 5 mg (Sonata) p •zaleplon cap 10 mg (Sonata) p •zolpidem tartrate sl tab 1.75 mg

(Intermezzo)np •

zolpidem tartrate sl tab 3.5 mg(Intermezzo)

np •

zolpidem tartrate tab er 6.25 mg(Ambien cr)

np •

2019


Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

zolpidem tartrate tab er 12.5 mg(Ambien cr)

np •

zolpidem tartrate tab 5 mg (Ambien) p •zolpidem tartrate tab 10 mg

(Ambien)p •

ZOLPIMIST- zolpidem tartrate oralspray 5 mg/act

NC

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTSADDERALL XR- amphetamine-

dextroamphetamine cap er 24hr5 mg

np •

ADDERALL XR- amphetamine-dextroamphetamine cap er 24hr10 mg

np •


np •


np •


np •


np •

ADZENYS ER- amphetamineextended release susp 1.25 mg/ml

NC

ADZENYS XR-ODT- amphetaminetab extended release disintegrating3.1 mg

NC


NC


NC


NC

Drug Name Tier

Des

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tion

Spe

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ty

Prio

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ing

Lim

its


NC


NC

amphetamine-dextroamphetaminecap er 24hr 5 mg (Adderall xr)

NC


NC


NC


NC


NC


NC

amphetamine-dextroamphetaminetab 5 mg (Adderall)

np •

amphetamine-dextroamphetaminetab 7.5 mg (Adderall)

np •


np •

amphetamine-dextroamphetaminetab 12.5 mg (Adderall)

np •


np •


np •


np •

APTENSIO XR- methylphenidate hclcap er 24hr 10 mg (xr)

NC


NC


NC


NC

2019


Drug Name Tier

Des

igna

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Spe

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ty

Prio

r Aut

horiz

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n

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p Th

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Dis

pens

ing

Lim

its


NC


NC


NC

armodafinil tab 50 mg (Nuvigil) np • •armodafinil tab 150 mg (Nuvigil) np • •armodafinil tab 200 mg (Nuvigil) np • •armodafinil tab 250 mg (Nuvigil) np • •atomoxetine hcl cap 10 mg (base

equiv) (Strattera)np •

atomoxetine hcl cap 18 mg (baseequiv) (Strattera)

np •


np •


np •


np •


np •


np •

BELVIQ- lorcaserin hcl tab 10 mg NP • •BELVIQ XR- lorcaserin hcl tab er 24hr

20 mgNP • •

benzphetamine hcl tab 25 mg(Regimex)

NC

benzphetamine hcl tab 50 mg NC

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

np

clonidine hcl tab er 12hr 0.1 mg(Kapvay)

np •

CONCERTA- methylphenidate hcl taber osmotic release (osm) 18 mg

np •


np •


np •

Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

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horiz

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n

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Dis

pens

ing

Lim

its


np •

CONTRAVE- naltrexone hcl-bupropionhcl tab er 12hr 8-90 mg

NP • •

COTEMPLA XR-ODT-methylphenidate tab extendedrelease disintegrating 8.6 mg

NC


NC


NC

DAYTRANA- methylphenidate tdpatch 10 mg/9hr

NC


NC


NC


NC

dexmethylphenidate hcl cap er 24hr 5 mg (Focalin xr)

np •


np •


np •


np •


np •


np •


np •


np •

dexmethylphenidate hcl tab 2.5 mg(Focalin)

np •

dexmethylphenidate hcl tab 5 mg(Focalin)

np •

2019


Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

r Aut

horiz

atio

n

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p Th

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y

Dis

pens

ing

Lim

its

dexmethylphenidate hcl tab 10 mg(Focalin)

np •

dextroamphetamine sulfate cap er24hr 5 mg (Dexedrine)

np •


np •


np •

dextroamphetamine sulfate oralsolution 5 mg/5ml (Procentra)

np •

dextroamphetamine sulfate tab5 mg

np •

dextroamphetamine sulfate tab10 mg

np •

DIETHYLPROPION HCL ER-diethylpropion hcl tab er 24hr 75 mg

NC

diethylpropion hcl tab 25 mg(Diethylpropion hcl)

NC

DYANAVEL XR- amphetamineextended release susp 2.5 mg/ml

NC

EVEKEO- amphetamine sulfate tab5 mg

NC

EVEKEO- amphetamine sulfate tab10 mg

NC

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

np •


np •


np •


np •

LOMAIRA- phentermine hcl tab 8 mg NP • •methamphetamine hcl tab 5 mg

(Desoxyn)np •

methylphenidate hcl cap er 10 mg(cd)

np •


np •


np •

Drug Name Tier

Des

igna

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Spe

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ty

Prio

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Dis

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ing

Lim

its


np •


np •


np •

methylphenidate hcl cap er 24hr10 mg (la) (Ritalin la)

NC


np •


np •


np •

methylphenidate hcl chew tab2.5 mg

np •

methylphenidate hcl chew tab 5 mg np •methylphenidate hcl chew tab

10 mgnp •

methylphenidate hcl soln 5 mg/5ml(Methylin)

np •

methylphenidate hcl soln10 mg/5ml (Methylin)

np •

methylphenidate hcl tab er osmoticrelease (osm) 18 mg (Concerta)

NC


NC


NC


NC

methylphenidate hcl tab er osmoticrelease (osm) 72 mg

NC

methylphenidate hcl tab er 10 mg np •methylphenidate hcl tab er 20 mg np •methylphenidate hcl tab 5 mg

(Ritalin)np •

methylphenidate hcl tab 10 mg(Ritalin)

np •

methylphenidate hcl tab 20 mg(Ritalin)

np •

2019


Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

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horiz

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n

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Dis

pens

ing

Lim

its

METHYLPHENIDATE HYDROCHLO-methylphenidate hcl cap er 24hr60 mg (la)

NC

METHYLPHENIDATE HYDROCHLO-methylphenidate hcl tab er 24hr18 mg

NC


NC


NC


NC

modafinil tab 100 mg (Provigil) np • •modafinil tab 200 mg (Provigil) np • •MYDAYIS- amphetamine-

dextroamphetamine 3-bead cap er24hr 12.5 mg

NC

MYDAYIS- amphetamine-dextroamphetamine 3-bead cap er24hr 25 mg

NC

MYDAYIS- amphetamine-dextroamphetamine 3-bead cap er24hr 37.5 mg

NC

MYDAYIS- amphetamine-dextroamphetamine 3-bead cap er24hr 50 mg

NC

PHENDIMETRAZINE TARTRATE-phendimetrazine tartrate cap er 24hr105 mg

NC

phendimetrazine tartrate tab 35 mg NC

phentermine hcl cap 15 mg p • •phentermine hcl cap 30 mg p • •phentermine hcl cap 37.5 mg

(Adipex-p)p • •

phentermine hcl tab 37.5 mg(Adipex-p)

p • •

QSYMIA- phentermine hcl-topiramatecap er 24hr 3.75-23 mg

NP • •

Drug Name Tier

Des

igna

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Spe

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ty

Prio

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Lim

its


NP • •


NP • •

QSYMIA- phentermine hcl-topiramatecap er 24hr 15-92 mg

NP • •

REGIMEX- benzphetamine hcl tab25 mg

NC

SAXENDA- liraglutide (weight mngmt)soln pen-inj 18 mg/3ml (6 mg/ml)

NP • •

VYVANSE- lisdexamfetaminedimesylate cap 10 mg

P •


P •


P •


P •


P •


P •


P •

VYVANSE- lisdexamfetaminedimesylate chew tab 10 mg

P •


P •


P •


P •


P •


P •

XENICAL- orlistat cap 120 mg NP • •ZENZEDI- dextroamphetamine sulfate

tab 2.5 mgNC

ZENZEDI- dextroamphetamine sulfatetab 7.5 mg

NC

2019


Drug Name Tier

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ZENZEDI- dextroamphetamine sulfatetab 15 mg

NC


NC


NC

PSYCHOTHERAPEUTIC and NEUROLOGICALAGENTS - MISC.acamprosate calcium tab delayed

release 333 mgnp

ADDYI- flibanserin tab 100 mg NP • •AMPYRA- dalfampridine tab er 12hr

10 mgNP • • •

AUBAGIO- teriflunomide tab 7 mg P • • •AUBAGIO- teriflunomide tab 14 mg P • • •AUSTEDO- deutetrabenazine tab

6 mgNP • • •

AUSTEDO- deutetrabenazine tab9 mg

NP • • •

AUSTEDO- deutetrabenazine tab12 mg

NP • • •

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

P • • •

AVONEX- interferon beta-1a imprefilled syringe kit 30 mcg/0.5ml

P • • •

AVONEX PEN- interferon beta-1a imauto-injector kit 30 mcg/0.5ml

P • • •

BETASERON- interferon beta-1b forinj kit 0.3 mg

P • • •

bupropion hcl (smoking deterrent)tab er 12hr 150 mg (Zyban)

np

CHANTIX- varenicline tartrate tab0.5 mg (base equiv)

P

CHANTIX- varenicline tartrate tab1 mg (base equiv)

P

CHANTIX CONTINUING MONTH-varenicline tartrate tab 1 mg (baseequiv)

P

CHANTIX STARTING MONTH PA-varenicline tartrate tab 0.5 mg x 11& tab 1 mg x 42 pack

P

Drug Name Tier

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CHLORDIAZEPOXIDE/AMITRIPT-chlordiazepoxide-amitriptyline tab5-12.5 mg

NP

CHLORDIAZEPOXIDE/AMITRIPT-chlordiazepoxide-amitriptyline tab10-25 mg

NP

COPAXONE- glatiramer acetate solnprefilled syringe 20 mg/ml

P • • •

COPAXONE- glatiramer acetate solnprefilled syringe 40 mg/ml

P • • •

dalfampridine tab er 12hr 10 mg(Ampyra)

np • • •

disulfiram tab 250 mg (Antabuse) np

disulfiram tab 500 mg (Antabuse) np

donepezil hydrochloride orallydisintegrating tab 5 mg

p

donepezil hydrochloride orallydisintegrating tab 10 mg

p

donepezil hydrochloride tab 5 mg(Aricept)

p


p


np

ERGOLOID MESYLATES- ergoloidmesylates tab 1 mg

NC

EXTAVIA- interferon beta-1b for inj kit0.3 mg

NC

FLUOXETINE- fluoxetine hcl (pmdd)cap 10 mg

NP

FLUOXETINE- fluoxetine hcl (pmdd)cap 20 mg

NP

fluoxetine hcl (pmdd) tab 10 mg(Sarafem)

NC

fluoxetine hcl (pmdd) tab 20 mg(Sarafem)

NC

GALANTAMINEHYDROBROMIDE- galantaminehydrobromide oral soln 4 mg/ml

NP

galantamine hydrobromide cap er24hr 8 mg (Razadyne er)

np

2019


Drug Name Tier

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np


np

galantamine hydrobromide tab4 mg (Razadyne)

np


np


np

GILENYA- fingolimod hcl cap 0.5 mg(base equiv)

P • • •

glatiramer acetate soln prefilledsyringe 20 mg/ml (Copaxone)

np • • •

glatiramer acetate soln prefilledsyringe 40 mg/ml (Copaxone)

np • • •

GRALISE- gabapentin (once-daily) tab300 mg

NP • •

GRALISE- gabapentin (once-daily) tab600 mg

NP • •

GRALISE STARTER- gabapentin(once-daily) tab pack 300 mg (9) &600 mg (69)

NP • •

HORIZANT- gabapentin enacarbil taber 300 mg

NP • •

HORIZANT- gabapentin enacarbil taber 600 mg

NP • •

INGREZZA- valbenazine tosylate cap40 mg (base equiv)

NP • • •

INGREZZA- valbenazine tosylate cap80 mg (base equiv)

NP • • •

LUCEMYRA- lofexidine hcl tab0.18 mg (base equivalent)

NP • •

LYRICA CR- pregabalin tab er 24hr82.5 mg

NC

LYRICA CR- pregabalin tab er 24hr165 mg

NC

LYRICA CR- pregabalin tab er 24hr330 mg

NC

memantine hcl cap er 24hr 7 mg(Namenda xr)

NC

Drug Name Tier

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NC


NC


NC

memantine hcl oral solution 2 mg/ml (Namenda)

np

memantine hcl tab 5 mg (Namenda) p

memantine hcl tab 10 mg(Namenda)

p

memantine hcl tab 5 mg (28) &10 mg (21) titration pak (Namendatitration pa)

np

NAMENDA XR TITRATION PACK-memantine hcl cap er 24hr 7 mg &14 mg & 21 mg & 28 mg pack

NC

NAMZARIC- memantine hcl-donepezilhcl cap er 24hr 7-10 mg

NC


NC


NC


NC

NAMZARIC- memantine-donepezilcap er 24hr 7 & 14 & 21 & 28-10 mgpack

NC

nicotine polacrilex gum 2 mg np

nicotine polacrilex gum 4 mg np

nicotine polacrilex lozenge 2 mg np

nicotine polacrilex lozenge 4 mg np

nicotine td patch 24hr 7 mg/24hr np



NICOTINE TRANSDERMALSYST- nicotine td patch 24 hr kit21-14-7 mg/24hr

P

NICOTROL INHALER- nicotineinhaler system 10 mg (4 mgdelivered)

P

2019


Drug Name Tier

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NICOTROL NS- nicotine nasal spray10 mg/ml (0.5 mg/spray)

P

NUEDEXTA- dextromethorphan hbr-quinidine sulfate cap 20-10 mg

P

olanzapine-fluoxetine hcl cap3-25 mg (Symbyax)

NC


NC


NC


NC


NC

paroxetine mesylate cap 7.5 mg(base equiv) (Brisdelle)

NC

PERPHENAZINE/AMITRIPTYLIN-perphenazine-amitriptyline tab2-10 mg

NP


NP


NP


NP


NP

pimozide tab 1 mg (Orap) np

pimozide tab 2 mg (Orap) np

PLEGRIDY- peginterferon beta-1asoln pen-injector 125 mcg/0.5ml

P • • •

PLEGRIDY- peginterferon beta-1asoln prefilled syringe 125 mcg/0.5ml

P • • •

PLEGRIDY STARTER PACK-peginterferon beta-1a soln pen-inj63 & 94 mcg/0.5ml pack

P • • •

Drug Name Tier

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PLEGRIDY STARTER PACK-peginterferon beta-1a soln pref syr63 & 94 mcg/0.5ml pack

P • • •

REBIF- interferon beta-1a soln prefsyr 22 mcg/0.5ml (12mu/ml)

P • • •

REBIF- interferon beta-1a soln prefsyr 44 mcg/0.5ml (24mu/ml)

P • • •

REBIF REBIDOSE- interferon beta-1asoln auto-inj 22 mcg/0.5ml (12mu/ml)

P • • •

REBIF REBIDOSE- interferon beta-1asoln auto-inj 44 mcg/0.5ml (24mu/ml)

P • • •

REBIF REBIDOSE TITRATION-interferon beta-1a auto-inj6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml

P • • •

REBIF TITRATION PACK- interferonbeta-1a pref syr 6x8.8 mcg/0.2ml &6x22 mcg/0.5ml

P • • •

rivastigmine tartrate cap 1.5 mg(base equivalent)

np

rivastigmine tartrate cap 3 mg(base equivalent)

np

rivastigmine tartrate cap 4.5 mg(base equivalent)

np

rivastigmine tartrate cap 6 mg(base equivalent)

np

rivastigmine td patch 24hr4.6 mg/24hr (Exelon)

np


np


np

SAVELLA- milnacipran hcl tab12.5 mg

P •

SAVELLA- milnacipran hcl tab 25 mg P •SAVELLA- milnacipran hcl tab 50 mg P •SAVELLA- milnacipran hcl tab 100 mg P •SAVELLA TITRATION PACK-

milnacipran hcl tab 12.5 mg (5) &25 mg (8) & 50 mg (42) pak

P •

2019


Drug Name Tier

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TECFIDERA- dimethyl fumaratecapsule delayed release 120 mg

P • • •

TECFIDERA- dimethyl fumaratecapsule delayed release 240 mg

P • • •

TECFIDERA STARTER PACK-dimethyl fumarate capsule dr starterpack 120 mg & 240 mg

P • • •

tetrabenazine tab 12.5 mg(Xenazine)

np • • •

tetrabenazine tab 25 mg (Xenazine) np • • •XYREM- sodium oxybate oral solution

500 mg/mlNP • • •

ANALGESICS AND ANESTHETICSANALGESICS - NON-NARCOTICALLZITAL- butalbital-acetaminophen

tab 25-325 mgNC

aspirin chew tab 81 mg p

aspirin tab delayed release 81 mg p

butalbital-acetaminophen tab50-300 mg

NC

butalbital-acetaminophen tab50-325 mg

np •

butalbital-acetaminophen-caffeinecap 50-300-40 mg (Fioricet)

np •

butalbital-acetaminophen-caffeinecap 50-325-40 mg

np •

butalbital-acetaminophen-caffeinetab 50-325-40 mg (Esgic)

np •

butalbital-aspirin-caffeine cap50-325-40 mg (Fiorinal)

np •

BUTALBITAL/ACETAMINOPHEN-butalbital-acetaminophen cap50-300 mg

NC

BUTALBITAL/ASPIRIN/CAFFEI-butalbital-aspirin-caffeine tab50-325-40 mg

NP •

diflunisal tab 500 mg np

TENCON- butalbital-acetaminophentab 50-325 mg

NP •

Drug Name Tier

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VANATOL LQ- butalbital-acetaminophen-caffeine soln50-325-40 mg/15ml

NC

VANATOL S- butalbital-acetaminophen-caffeine soln50-325-40 mg/15ml

NC

ANALGESICS - NARCOTICABSTRAL- fentanyl citrate sl tab

100 mcg (base equiv)NC

ABSTRAL- fentanyl citrate sl tab200 mcg (base equiv)

NC


NC


NC


NC


NC

acetaminophen w/ codeine soln120-12 mg/5ml

p •

acetaminophen w/ codeine tab300-15 mg (Tylenol/codeine)

p •

acetaminophen w/ codeine tab300-30 mg (Tylenol/codeine #3)

p •

acetaminophen w/ codeine tab300-60 mg (Tylenol/codeine #4)

p •

acetaminophen-caffeine-dihydrocodeine tab 325-30-16 mg

NC

ACETAMINOPHEN/CAFFEINE/DI- acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg

NP •

ARYMO ER- morphine sulfate tab erabuse-deterrent 15 mg

NC


NC


NC

BELBUCA- buprenorphine hcl buccalfilm 75 mcg (base equivalent)

NC

2019


Drug Name Tier

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its


NC


NC


NC


NC


NC


NC

BUNAVAIL- buprenorphine-naloxonebuccal film 2.1-0.3 mg (base equiv)

NC

BUNAVAIL- buprenorphine-naloxonebuccal film 4.2-0.7 mg (base equiv)

NC

BUNAVAIL- buprenorphine-naloxonebuccal film 6.3-1 mg (base equiv)

NC

BUPRENORPHINE- buprenorphine tdpatch weekly 5 mcg/hr

NC

BUPRENORPHINE- buprenorphine tdpatch weekly 7.5 mcg/hr

NC


NC


NC


NC

buprenorphine hcl sl tab 2 mg(base equiv)

np •

buprenorphine hcl sl tab 8 mg(base equiv)

np •

buprenorphine hcl-naloxone hcl sltab 2-0.5 mg (base equiv)

np •

buprenorphine hcl-naloxone hcl sltab 8-2 mg (base equiv)

np •

butalbital-acetaminophen-caffw/ cod cap 50-300-40-30 mg(Fioricet/codeine)

NC

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

np •

Drug Name Tier

Des

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Lim

its

butalbital-aspirin-caff w/ codeinecap 50-325-40-30 mg (Fiorinal/codeine #3)

np •

butorphanol tartrate nasal soln10 mg/ml

np •

BUTRANS- buprenorphine td patchweekly 5 mcg/hr

NC

BUTRANS- buprenorphine td patchweekly 7.5 mcg/hr

NC


NC


NC


NC

codeine sulfate tab 15 mg (Codeinesulfate)

np •


np •


np •

CONZIP- tramadol hcl cap er 24hrbiphasic release 100 mg

NC


NC


NC

EMBEDA- morphine-naltrexone cap er20-0.8 mg

NC


NC

EMBEDA- morphine-naltrexone cap er50-2 mg

NC


NC


NC

EMBEDA- morphine-naltrexone cap er100-4 mg

NC

fentanyl citrate lozenge on a handle200 mcg (Actiq)

np • •

2019


Drug Name Tier

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its


np • •


np • •


np • •


np • •


np • •

fentanyl td patch 72hr 12 mcg/hr(Duragesic)

np • •


np • •

fentanyl td patch 72hr 37.5 mcg/hr NC


np • •



np • •



np • •

FENTORA- fentanyl citrate buccal tab100 mcg (base equiv)

NC


NC


NC


NC


NC

hydrocodone-acetaminophen soln7.5-325 mg/15ml (Hycet)

np •

hydrocodone-acetaminophen tab2.5-325 mg

np •

hydrocodone-acetaminophen tab10-325 mg (Norco)

p •

hydrocodone-acetaminophen tab5-300 mg (Xodol)

np •

Drug Name Tier

Des

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its

hydrocodone-acetaminophen tab7.5-300 mg (Xodol)

np •

hydrocodone-acetaminophen tab5-325 mg (Norco)

p •

hydrocodone-acetaminophen tab7.5-325 mg (Norco)

p •

hydrocodone-acetaminophen tab10-300 mg (Xodol)

np •

hydrocodone-ibuprofen tab5-200 mg (Reprexain)

np •

hydrocodone-ibuprofen tab7.5-200 mg

p •

hydrocodone-ibuprofen tab10-200 mg (Ibudone)

np •

hydromorphone hcl liqd 1 mg/ml(Dilaudid)

np •

hydromorphone hcl tab er 24hrdeter 8 mg (Exalgo)

NC


NC


NC


NC

hydromorphone hcl tab 2 mg(Dilaudid)

p •


p •


np •

HYSINGLA ER- hydrocodonebitartrate tab er 24hr deter 20 mg

NC


NC


NC


NC


NC

2019


Drug Name Tier

Des

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its


NC


NC

KADIAN- morphine sulfate cap er 24hr40 mg

NC

KADIAN- morphine sulfate cap er 24hr200 mg

NC

LAZANDA- fentanyl citrate nasalspray 100 mcg/act (base equiv)

NC


NC


NC

LEVORPHANOL TARTRATE-levorphanol tartrate tab 2 mg

NC

LORTAB- hydrocodone-acetaminophen soln10-300 mg/15ml

NC

MEPERIDINE HCL- meperidine hcloral soln 50 mg/5ml

NC

meperidine hcl tab 50 mg NC

meperidine hcl tab 100 mg(Demerol)

NC

methadone hcl conc 10 mg/ml(Methadose)

np •

methadone hcl soln 5 mg/5ml(Methadone hcl)

np •

methadone hcl soln 10 mg/5ml(Methadone hcl)

np •

methadone hcl tab for oral susp40 mg

np •

methadone hcl tab 5 mg(Dolophine)

p •

methadone hcl tab 10 mg(Dolophine)

p •

MORPHABOND ER- morphine sulfatetab er 12hr deter 15 mg

NC


NC

Drug Name Tier

Des

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Lim

its


NC


NC

MORPHINE SULFATE- morphinesulfate tab 15 mg

P •

MORPHINE SULFATE- morphinesulfate tab 30 mg

P •

morphine sulfate cap er 24hr 10 mg(Kadian)

np • •


np • •


np • •


np • •


np • •


np • •

morphine sulfate cap er 24hr100 mg (Kadian)

np • •

MORPHINE SULFATE ER- morphinesulfate beads cap er 24hr 30 mg

NC


NC


NC


NC


NC


NC

morphine sulfate oral soln10 mg/5ml

p •

morphine sulfate oral soln20 mg/5ml

np •

morphine sulfate oral soln100 mg/5ml (20 mg/ml)

np •

2019


Drug Name Tier

Des

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its

morphine sulfate tab er 15 mg (Mscontin)

np • •


np • •


np • •


np • •


np • •

NALOCET- oxycodone w/acetaminophen tab 2.5-300 mg

NC

NUCYNTA- tapentadol hcl tab 50 mg NC



NUCYNTA ER- tapentadol hcl tab er12hr 50 mg

P • •


P • •


P • •


P • •


P • •

OXAYDO- oxycodone hcl tab abusedeter 5 mg

NC

OXAYDO- oxycodone hcl tab abusedeter 7.5 mg

NC

oxycodone hcl cap 5 mg np •oxycodone hcl conc 100 mg/5ml

(20 mg/ml)np •

OXYCODONE HCL ER- oxycodonehcl tab er 12hr deter 10 mg

NC


NC


NC


NC

Drug Name Tier

Des

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its


NC


NC


NC

oxycodone hcl soln 5 mg/5ml np •oxycodone hcl tab 5 mg

(Roxicodone)p •

oxycodone hcl tab 10 mg np •oxycodone hcl tab 15 mg

(Roxicodone)np •

oxycodone hcl tab 20 mg np •oxycodone hcl tab 30 mg

(Roxicodone)np •

oxycodone w/ acetaminophen tab2.5-325 mg (Percocet)

np •

oxycodone w/ acetaminophen tab5-325 mg (Percocet)

p •

oxycodone w/ acetaminophen tab7.5-325 mg (Percocet)

np •

oxycodone w/ acetaminophen tab10-325 mg (Percocet)

np •

oxycodone-aspirin tab4.8355-325 mg

np •

OXYCODONE/IBUPROFEN-oxycodone-ibuprofen tab 5-400 mg

NP •

OXYCONTIN- oxycodone hcl tab er12hr deter 10 mg

P • •


P • •


P • •


P • •


P • •


P • •


P • •

2019


Drug Name Tier

Des

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tion

Spe

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ty

Prio

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Lim

its

oxymorphone hcl tab 5 mg (Opana) np •oxymorphone hcl tab 10 mg

(Opana)np •

OXYMORPHONEHYDROCHLORIDE- oxymorphonehcl tab er 12hr 5 mg

NP • •

OXYMORPHONEHYDROCHLORIDE- oxymorphonehcl tab er 12hr 7.5 mg

NP • •


NP • •


NP • •


NP • •


NP • •


NP • •

pentazocine w/ naloxone tab50-0.5 mg

NC

PRIMLEV- oxycodone w/acetaminophen tab 5-300 mg

NC

PRIMLEV- oxycodone w/acetaminophen tab 7.5-300 mg

NC

PRIMLEV- oxycodone w/acetaminophen tab 10-300 mg

NC

ROXYBOND- oxycodone hcl tababuse deter 5 mg

NC


NC


NC

SUBOXONE- buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (baseequiv)

P •

Drug Name Tier

Des

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its

SUBOXONE- buprenorphine hcl-naloxone hcl sl film 4-1 mg (baseequiv)

P •


P •


P •

SUBSYS- fentanyl sublingual spray100 mcg

NC


NC


NC


NC


NC

SUBSYS- fentanyl sublingual spray1200 mcg (600 mcg x 2)

NC

SUBSYS- fentanyl sublingual spray1600 mcg (800 mcg x 2)

NC

TRAMADOL HCL ER- tramadol hclcap er 24hr biphasic release 100 mg

NC


NC


NC


NC

tramadol hcl tab er 24hr 100 mg np • •tramadol hcl tab er 24hr 200 mg np • •tramadol hcl tab er 24hr 300 mg np • •tramadol hcl tab er 24hr biphasic

release 100 mgnp • •

tramadol hcl tab er 24hr biphasicrelease 200 mg

np • •

tramadol hcl tab er 24hr biphasicrelease 300 mg

np • •

tramadol hcl tab 50 mg (Ultram) p •

2019


Drug Name Tier

Des

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Spe

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ty

Prio

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Lim

its

tramadol-acetaminophen tab37.5-325 mg (Ultracet)

p •

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

NP •

XTAMPZA ER- oxycodone cap er 12hrabuse-deterrent 9 mg

NP • •

XTAMPZA ER- oxycodone cap er 12hrabuse-deterrent 13.5 mg

NP • •


NP • •


NP • •


NP • •

ZOHYDRO ER- hydrocodonebitartrate cap er 12hr abuse-deterrent 10 mg

NP • •


NP • •


NP • •


NP • •


NP • •


NP • •

ZUBSOLV- buprenorphine hcl-naloxone hcl sl tab 0.7-0.18 mg(base eq)

NP •


NP •


NP •

Drug Name Tier

Des

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Spe

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Lim

its

ZUBSOLV- buprenorphine hcl-naloxone hcl sl tab 5.7-1.4 mg (baseeq)

NP •

ZUBSOLV- buprenorphine hcl-naloxone hcl sl tab 8.6-2.1 mg (baseeq)

NP •


NP •

ANALGESICS - ANTI-INFLAMMATORYACTEMRA- tocilizumab subcutaneous

soln prefilled syringe 162 mg/0.9mlNP • • •

ARCALYST- rilonacept for inj 220 mg NP • • •celecoxib cap 50 mg (Celebrex) np

celecoxib cap 100 mg (Celebrex) np



diclofenac potassium tab 50 mg np

diclofenac sodium tab delayedrelease 25 mg

np


p


p

diclofenac sodium tab er 24hr100 mg

p

diclofenac w/ misoprostol tabdelayed release 50-0.2 mg(Arthrotec 50)

np

diclofenac w/ misoprostol tabdelayed release 75-0.2 mg(Arthrotec 75)

np

DUEXIS- ibuprofen-famotidine tab800-26.6 mg

NP

ENBREL- etanercept forsubcutaneous inj 25 mg

P • • •

ENBREL- etanercept subcutaneoussoln prefilled syringe 25 mg/0.5ml

P • • •

ENBREL- etanercept subcutaneoussoln prefilled syringe 50 mg/ml

P • • •

2019


Drug Name Tier

Des

igna

tion

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ty

Prio

r Aut

horiz

atio

n

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p Th

erap

y

Dis

pens

ing

Lim

its

ENBREL MINI- etanerceptsubcutaneous solution cartridge50 mg/ml

P • • •

ENBREL SURECLICK- etanerceptsubcutaneous solution auto-injector50 mg/ml

P • • •

etodolac cap 200 mg np

etodolac cap 300 mg np

etodolac tab er 24hr 400 mg np



etodolac tab 400 mg (Lodine) np

etodolac tab 500 mg np

FENOPROFEN CALCIUM-fenoprofen calcium cap 200 mg

NC

FENOPROFEN CALCIUM-fenoprofen calcium cap 400 mg

NC

fenoprofen calcium tab 600 mg NC

FENORTHO- fenoprofen calcium cap200 mg

NC

flurbiprofen tab 50 mg p

flurbiprofen tab 100 mg p

HUMIRA- adalimumab prefilledsyringe kit 10 mg/0.1ml

P • • •


P • • •


P • • •


P • • •


P • • •


P • • •

HUMIRA PEDIATRIC CROHNS D-adalimumab prefilled syringe kit40 mg/0.8ml

P • • •

HUMIRA PEDIATRIC CROHNS D-adalimumab prefilled syringe kit80 mg/0.8ml

P • • •

Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

r Aut

horiz

atio

n

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p Th

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y

Dis

pens

ing

Lim

its

HUMIRA PEDIATRIC CROHNS D-adalimumab prefilled syringe kit80 mg/0.8ml & 40 mg/0.4ml

P • • •

HUMIRA PEN- adalimumab pen-injector kit 40 mg/0.8ml

P • • •

HUMIRA PEN- adalimumab pen-injector kit 40 mg/0.4ml

P • • •

HUMIRA PEN-CD/UC/HS START-adalimumab pen-injector kit40 mg/0.8ml

P • • •

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

P • • •

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

P • • •

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

P • • •

ibuprofen susp 100 mg/5ml NC

ibuprofen tab 400 mg p



INDOCIN- indomethacin suppos50 mg

NC

INDOCIN- indomethacin susp25 mg/5ml

NC

indomethacin cap er 75 mg np

indomethacin cap 25 mg p

indomethacin cap 50 mg p

KETOPROFEN- ketoprofen cap25 mg

NP •

KETOPROFEN ER- ketoprofen cap er24hr 200 mg

NC

ketorolac tromethamine tab 10 mg np •KEVZARA- sarilumab subcutaneous

soln prefilled syringe 150 mg/1.14mlNC

KEVZARA- sarilumab subcutaneoussoln prefilled syringe 200 mg/1.14ml

NC

KEVZARA- sarilumab subcutaneoussolution auto-injector 150 mg/1.14ml

NC

2019


Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

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n

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p Th

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y

Dis

pens

ing

Lim

its

KEVZARA- sarilumab subcutaneoussolution auto-injector 200 mg/1.14ml

NC

KINERET- anakinra subcutaneoussoln prefilled syringe 100 mg/0.67ml

NC

leflunomide tab 10 mg (Arava) np

leflunomide tab 20 mg (Arava) np

MECLOFENAMATE SODIUM-meclofenamate sodium cap 50 mg

NC

MECLOFENAMATE SODIUM-meclofenamate sodium cap 100 mg

NC

mefenamic acid cap 250 mg(Ponstel)

np

meloxicam tab 7.5 mg (Mobic) p

meloxicam tab 15 mg (Mobic) p

nabumetone tab 500 mg p

nabumetone tab 750 mg p

NALFON- fenoprofen calcium cap400 mg

NC

NAPRELAN- naproxen sodium tab er24hr 750 mg (base equiv)

NC

naproxen sodium tab er 24hr375 mg (base equiv) (Naprelan)

NC

naproxen sodium tab er 24hr500 mg (base equiv) (Naprelan)

NC

naproxen sodium tab 275 mg np

naproxen sodium tab 550 mg(Anaprox ds)

np

naproxen susp 125 mg/5ml(Naprosyn)

np

naproxen tab ec 375 mg (Ec-naprosyn)

p

naproxen tab ec 500 mg (Ec-naprosyn)

p

naproxen tab 250 mg p

naproxen tab 375 mg p

naproxen tab 500 mg (Naprosyn) p

OLUMIANT- baricitinib tab 2 mg NC

ORENCIA- abatacept subcutaneoussoln prefilled syringe 50 mg/0.4ml

NP • • •

Drug Name Tier

Des

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tion

Spe

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ty

Prio

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pens

ing

Lim

its

ORENCIA- abatacept subcutaneoussoln prefilled syringe 87.5 mg/0.7ml

NP • • •

ORENCIA- abatacept subcutaneoussoln prefilled syringe 125 mg/ml

NP • • •

ORENCIA CLICKJECT- abataceptsubcutaneous soln auto-injector125 mg/ml

NP • • •

OTEZLA- apremilast tab startertherapy pack 10 mg & 20 mg &30 mg

P • • •

OTEZLA- apremilast tab 30 mg P • • •OTREXUP- methotrexate soln pf auto-

injector 10 mg/0.4mlNP

OTREXUP- methotrexate soln pf auto-injector 12.5 mg/0.4ml

NP

OTREXUP- methotrexate soln pf auto-injector 15 mg/0.4ml

NP


NP


NP


NP


NP

oxaprozin tab 600 mg (Daypro) np

piroxicam cap 10 mg (Feldene) np

piroxicam cap 20 mg (Feldene) np

RASUVO- methotrexate soln pf auto-injector 7.5 mg/0.15ml

NP

RASUVO- methotrexate soln pf auto-injector 10 mg/0.2ml

NP


NP


NP


NP


NP

2019


Drug Name Tier

Des

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tion

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ty

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ing

Lim

its


NP


NP


NP

RIDAURA- auranofin cap 3 mg NP

SIMPONI- golimumab subcutaneoussoln auto-injector 50 mg/0.5ml

P • • •

SIMPONI- golimumab subcutaneoussoln auto-injector 100 mg/ml

P • • •

SIMPONI- golimumab subcutaneoussoln prefilled syringe 50 mg/0.5ml

P • • •

SIMPONI- golimumab subcutaneoussoln prefilled syringe 100 mg/ml

P • • •

SPRIX- ketorolac tromethamine nasalspray 15.75 mg/spray

NC

sulindac tab 150 mg p

sulindac tab 200 mg p

TIVORBEX- indomethacin cap 20 mg NC

TIVORBEX- indomethacin cap 40 mg NC

TOLMETIN SODIUM- tolmetin sodiumcap 400 mg

NP

TOLMETIN SODIUM- tolmetin sodiumtab 200 mg

NC

TOLMETIN SODIUM- tolmetin sodiumtab 600 mg

NC

VIMOVO- naproxen-esomeprazolemagnesium tab dr 375-20 mg

NP

VIMOVO- naproxen-esomeprazolemagnesium tab dr 500-20 mg

NP

VIVLODEX- meloxicam cap 5 mg NC

VIVLODEX- meloxicam cap 10 mg NC

XELJANZ- tofacitinib citrate tab 5 mg(base equivalent)

NP • • •

XELJANZ- tofacitinib citrate tab 10 mg(base equivalent)

NP • • •

XELJANZ XR- tofacitinib citrate tab er24hr 11 mg (base equivalent)

NP • • •

Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

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horiz

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n

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y

Dis

pens

ing

Lim

its

ZIPSOR- diclofenac potassium cap25 mg

NC

ZORVOLEX- diclofenac cap 18 mg NC

ZORVOLEX- diclofenac cap 35 mg NC

MIGRAINE PRODUCTSAIMOVIG- erenumab-aooe

subcutaneous soln auto-injector70 mg/ml

NC

almotriptan malate tab 6.25 mg(Axert)

NC

almotriptan malate tab 12.5 mg(Axert)

NC

CAMBIA- diclofenac potassium packet50 mg

NP

DIHYDROERGOTAMINE MESYLAT-dihydroergotamine mesylate nasalspray 4 mg/ml

NP

dihydroergotamine mesylate inj1 mg/ml (D.h.e. 45)

NC

eletriptan hydrobromide tab 20 mg(base equivalent) (Relpax)

np •

eletriptan hydrobromide tab 40 mg(base equivalent) (Relpax)

np •

ERGOMAR- ergotamine tartrate sl tab2 mg

NP

ergotamine w/ caffeine tab1-100 mg (Cafergot)

np

frovatriptan succinate tab 2.5 mg(base equivalent) (Frova)

NC

MIGERGOT- ergotamine w/ caffeinesuppos 2-100 mg

NP

MIGRANAL- dihydroergotaminemesylate nasal spray 4 mg/ml

P

naratriptan hcl tab 1 mg (baseequiv) (Amerge)

np •

naratriptan hcl tab 2.5 mg (baseequiv) (Amerge)

np •

ONZETRA XSAIL- sumatriptansuccinate exhaler powder 11 mg/nosepiece

NC

2019


Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

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y

Dis

pens

ing

Lim

its

rizatriptan benzoate oraldisintegrating tab 5 mg (base eq)(Maxalt-mlt)

p •

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

p •

rizatriptan benzoate tab 5 mg (baseequivalent) (Maxalt)

p •

rizatriptan benzoate tab 10 mg(base equivalent) (Maxalt)

p •

sumatriptan nasal spray 5 mg/act(Imitrex)

np •

sumatriptan nasal spray 20 mg/act(Imitrex)

np •

sumatriptan succinate inj6 mg/0.5ml (Imitrex)

np •

sumatriptan succinate solutionauto-injector 4 mg/0.5ml (Imitrexstatdose sys)

np •

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

np •

sumatriptan succinate solutioncartridge 4 mg/0.5ml (Imitrexstatdose ref)

np •

sumatriptan succinate solutioncartridge 6 mg/0.5ml (Imitrexstatdose ref)

np •

sumatriptan succinate tab 25 mg(Imitrex)

p •


p •


p •

sumatriptan-naproxen sodium tab85-500 mg (Treximet)

np •

TREXIMET- sumatriptan-naproxensodium tab 10-60 mg

NP • •

ZEMBRACE SYMTOUCH-sumatriptan succinate solution auto-injector 3 mg/0.5ml

NC

Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

r Aut

horiz

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n

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Dis

pens

ing

Lim

its

zolmitriptan orally disintegratingtab 2.5 mg (Zomig zmt)

np •

zolmitriptan orally disintegratingtab 5 mg (Zomig zmt)

np •

zolmitriptan tab 2.5 mg (Zomig) np •zolmitriptan tab 5 mg (Zomig) np •ZOMIG- zolmitriptan nasal spray

2.5 mg/spray unitNC

ZOMIG- zolmitriptan nasal spray5 mg/spray unit

NC

GOUT AGENTSallopurinol tab 100 mg (Zyloprim) p

allopurinol tab 300 mg (Zyloprim) p

COLCHICINE- colchicine cap 0.6 mg NC

COLCHICINE- colchicine tab 0.6 mg NC

colchicine w/ probenecid tab0.5-500 mg

np

COLCRYS- colchicine tab 0.6 mg P

DUZALLO- lesinurad-allopurinol tab200-200 mg

NC

DUZALLO- lesinurad-allopurinol tab200-300 mg

NC

MITIGARE- colchicine cap 0.6 mg NC

probenecid tab 500 mg np

ULORIC- febuxostat tab 40 mg NP

ULORIC- febuxostat tab 80 mg NP

ZURAMPIC- lesinurad tab 200 mg NC

NEUROMUSCULAR DRUGSANTICONVULSANTSAPTIOM- eslicarbazepine acetate tab

200 mgNP

APTIOM- eslicarbazepine acetate tab400 mg

NP


NP


NP

BANZEL- rufinamide susp 40 mg/ml NP

BANZEL- rufinamide tab 200 mg NP

2019


Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

r Aut

horiz

atio

n

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y

Dis

pens

ing

Lim

its

BANZEL- rufinamide tab 400 mg NP

BRIVIACT- brivaracetam oral soln10 mg/ml

NC

BRIVIACT- brivaracetam tab 10 mg NC





carbamazepine cap er 12hr 100 mg(Carbatrol)

np


np


np

carbamazepine chew tab 100 mg np

carbamazepine susp 100 mg/5ml(Tegretol)

np

carbamazepine tab er 12hr 100 mg(Tegretol-xr)

np


np


np

carbamazepine tab 200 mg(Tegretol)

np

CARBATROL- carbamazepine cap er12hr 100 mg

NP


NP


NP

CELONTIN- methsuximide cap300 mg

NP

clonazepam orally disintegratingtab 0.125 mg

np


np


np

Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

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y

Dis

pens

ing

Lim

its

clonazepam orally disintegratingtab 1 mg

np

clonazepam orally disintegratingtab 2 mg

np

clonazepam tab 0.5 mg (Klonopin) p

clonazepam tab 1 mg (Klonopin) p

clonazepam tab 2 mg (Klonopin) p

DEPAKENE- valproate sodium oralsoln 250 mg/5ml (base equiv)

NP

DEPAKENE- valproic acid cap 250 mg NP

DIASTAT ACUDIAL- diazepamrectal gel delivery system 10 mg

P

DIASTAT ACUDIAL- diazepamrectal gel delivery system 20 mg

P

DIASTAT PEDIATRIC- diazepamrectal gel delivery system 2.5 mg

P

DIAZEPAM RECTAL GEL- diazepamrectal gel delivery system 2.5 mg

NP

DIAZEPAM RECTAL GEL- diazepamrectal gel delivery system 10 mg

NP

DIAZEPAM RECTAL GEL- diazepamrectal gel delivery system 20 mg

NP

DILANTIN- phenytoin sodiumextended cap 30 mg

P

DILANTIN- phenytoin sodiumextended cap 100 mg

NP

DILANTIN INFATABS- phenytoin chewtab 50 mg

NP

DILANTIN-125- phenytoin susp125 mg/5ml

NP

divalproex sodium cap delayedrelease sprinkle 125 mg(Depakote sprinkles)

np

divalproex sodium tab delayedrelease 125 mg (Depakote)

p


p


p

divalproex sodium tab er 24 hr250 mg (Depakote er)

np

2019


Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

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y

Dis

pens

ing

Lim

its

divalproex sodium tab er 24 hr500 mg (Depakote er)

np

ethosuximide cap 250 mg(Zarontin)

np

ethosuximide soln 250 mg/5ml(Zarontin)

np

felbamate susp 600 mg/5ml(Felbatol)

np

felbamate tab 400 mg (Felbatol) np

felbamate tab 600 mg (Felbatol) np

FYCOMPA- perampanel susp 0.5 mg/ml

NP

FYCOMPA- perampanel tab 2 mg NP






gabapentin cap 100 mg (Neurontin) p



gabapentin oral soln 250 mg/5ml(Neurontin)

np

gabapentin tab 600 mg (Neurontin) p

gabapentin tab 800 mg (Neurontin) p

LAMICTAL ODT- lamotrigine tab disint25 mg (21) & 50 mg (7) titration kit

NP

LAMICTAL ODT- lamotrigine tab disint50 mg (42)- 100 mg(14) titration kit

NP

LAMICTAL ODT- lamotrigine tab disint25 (14) & 50 mg (14) & 100 mg (7)kit

NP

LAMICTAL XR- lamotrigine tab er 24hr25 mg (21) & 50 mg (7) titration kit

NP

LAMICTAL XR- lamotrigine tab er 24hr25 (14) & 50 mg (14) & 100 mg(7)kit

NP

LAMICTAL XR- lamotrigine tab er 24hr50 (14) & 100 mg(14) & 200 mg(7)kit

NP

Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

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y

Dis

pens

ing

Lim

its

lamotrigine orally disintegrating tab25 mg (Lamictal odt)

np


np


np


np

lamotrigine tab chewabledispersible 5 mg (Lamictalchewable di)

np

lamotrigine tab chewabledispersible 25 mg (Lamictalchewable di)

np

lamotrigine tab er 24hr 25 mg(Lamictal xr)

np


np


np


np


np


np

lamotrigine tab 25 mg (Lamictal) p




lamotrigine tab 25 mg (35) starterkit (Lamictal starter/tak)

np

lamotrigine tab 25 mg (42) &100 mg (7) starter kit (Lamictalstarter/not)

np

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

np

levetiracetam oral soln 100 mg/ml(Keppra)

p

2019


Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

levetiracetam tab er 24hr 500 mg(Keppra xr)

np

levetiracetam tab er 24hr 750 mg(Keppra xr)

np

levetiracetam tab 250 mg (Keppra) p



levetiracetam tab 1000 mg (Keppra) np

LYRICA- pregabalin cap 25 mg P •LYRICA- pregabalin cap 50 mg P •LYRICA- pregabalin cap 75 mg P •LYRICA- pregabalin cap 100 mg P •LYRICA- pregabalin cap 150 mg P •LYRICA- pregabalin cap 200 mg P •LYRICA- pregabalin cap 225 mg P •LYRICA- pregabalin cap 300 mg P •LYRICA- pregabalin soln 20 mg/ml P •MYSOLINE- primidone tab 50 mg NP

MYSOLINE- primidone tab 250 mg NP

ONFI- clobazam suspension 2.5 mg/ml

NP

ONFI- clobazam tab 10 mg NP

ONFI- clobazam tab 20 mg NP

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

np

oxcarbazepine tab 150 mg(Trileptal)

p


np


np

OXTELLAR XR- oxcarbazepine tab er24hr 150 mg

NP


NP


NP

PEGANONE- ethotoin tab 250 mg NP

Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

r Aut

horiz

atio

n

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Dis

pens

ing

Lim

its

PHENYTEK- phenytoin sodiumextended cap 200 mg

NP

PHENYTEK- phenytoin sodiumextended cap 300 mg

NP

phenytoin chew tab 50 mg (Dilantininfatabs)

np

phenytoin sodium extended cap100 mg (Dilantin)

np

phenytoin sodium extended cap200 mg (Phenytek)

np

phenytoin sodium extended cap300 mg (Phenytek)

np

phenytoin susp 125 mg/5ml(Dilantin-125)

np

primidone tab 50 mg (Mysoline) p

primidone tab 250 mg (Mysoline) p

QUDEXY XR- topiramate cap er 24hrsprinkle 25 mg

NP • •


NP • •


NP • •


NP • •


NP • •

SABRIL- vigabatrin tab 500 mg NP

SPRITAM- levetiracetam tabdisintegrating soluble 250 mg

NP


NP


NP


NP

TEGRETOL- carbamazepine susp100 mg/5ml

NP

TEGRETOL- carbamazepine tab200 mg

NP

TEGRETOL-XR- carbamazepine taber 12hr 100 mg

NP

2019


Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

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n

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p Th

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y

Dis

pens

ing

Lim

its


NP


NP

tiagabine hcl tab 2 mg (Gabitril) np




TOPIRAMATE ER- topiramate cap er24hr sprinkle 25 mg

NP • •


NP • •


NP • •


NP • •


NP • •

topiramate sprinkle cap 15 mg(Topamax sprinkle)

np

topiramate sprinkle cap 25 mg(Topamax sprinkle)

np

topiramate tab 25 mg (Topamax) p




TROKENDI XR- topiramate cap er24hr 25 mg

NP • •


NP • •


NP • •


NP • •

valproate sodium oral soln250 mg/5ml (base equiv)(Depakene)

np

valproic acid cap 250 mg(Depakene)

np

Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

vigabatrin powd pack 500 mg(Sabril)

np

VIMPAT- lacosamide oral solution10 mg/ml

NP

VIMPAT- lacosamide tab 50 mg NP




ZARONTIN- ethosuximide cap250 mg

NP

ZARONTIN- ethosuximide soln250 mg/5ml

NP

zonisamide cap 25 mg (Zonegran) p

zonisamide cap 50 mg p

zonisamide cap 100 mg (Zonegran) p

ANTIPARKINSON AGENTSamantadine hcl cap 100 mg np

amantadine hcl syrup 50 mg/5ml p

amantadine hcl tab 100 mg np

APOKYN- apomorphine hcl solncartridge 30 mg/3ml

NP •

benztropine mesylate tab 0.5 mg p

benztropine mesylate tab 1 mg p

benztropine mesylate tab 2 mg p

bromocriptine mesylate cap 5 mg(base equivalent) (Parlodel)

np

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

np

carbidopa & levodopa orallydisintegrating tab 10-100 mg

np


np


np

carbidopa & levodopa tab er25-100 mg (Sinemet cr)

np

carbidopa & levodopa tab er50-200 mg (Sinemet cr)

np

2019


Drug Name Tier

Des

igna

tion

Spe

cial

ty

Prio

r Aut

horiz

atio

n

Ste

p Th

erap

y

Dis

pens

ing

Lim

its

carbidopa & levodopa tab10-100 mg (Sinemet)

p


p


np

carbidopa tab 25 mg (Lodosyn) np

CARBIDOPA/LEVODOPA/ENTACA-carbidopa-levodopa-entacaponetabs 12.5-50-200 mg

NP


NP

CARBIDOPA/LEVODOPA/ENTACA-carbidopa-levodopa-entacaponetabs 25-100-200 mg

NP


NP


NP

CARBIDOPA/LEVODOPA/ENTACA-carbidopa-levodopa-entacaponetabs 50-200-200 mg

NP

DUOPA- carbidopa-levodopa enteralsusp 4.63-20 mg/ml

NP

entacapone tab 200 mg (Comtan) np

GOCOVRI- amantadine hcl cap er24hr 68.5 mg (base equivalent)

NC

GOCOVRI- amantadine hcl cap er24hr 137 mg (base equivalent)

NC

NEUPRO- rotigotine td patch 24hr1 mg/24hr

NP


NP


NP


NP


NP

Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

r Aut

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n

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ing

Lim

its


NP

OSMOLEX ER- amantadine hcl tab er24hr 129 mg (base equivalent)

NC


NC


NC

pramipexole dihydrochloride tab er24hr 0.375 mg (Mirapex er)

np


np


np


np

pramipexole dihydrochloride tab er24hr 3 mg (Mirapex er)

np


np


np

pramipexole dihydrochloride tab0.125 mg (Mirapex)

p


p


p


p

pramipexole dihydrochloride tab1 mg (Mirapex)

p


p

rasagiline mesylate tab 0.5 mg(base equiv) (Azilect)

np

rasagiline mesylate tab 1 mg (baseequiv) (Azilect)

np

ropinirole hydrochloride tab er 24hr2 mg (base equivalent) (Requip xl)

np

2019


Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

r Aut

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n

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p Th

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y

Dis

pens

ing

Lim

its


np


np


np

ropinirole hydrochloride tab er 24hr12 mg (base equivalent) (Requipxl)

np

ropinirole hydrochloride tab0.25 mg (Requip)

p

ropinirole hydrochloride tab 0.5 mg(Requip)

p

ropinirole hydrochloride tab 1 mg(Requip)

p


p


p


p


p

RYTARY- carbidopa & levodopa caper 23.75-95 mg

NP


NP


NP


NP

selegiline hcl cap 5 mg (Eldepryl) np

selegiline hcl tab 5 mg np

STALEVO 100- carbidopa-levodopa-entacapone tabs 25-100-200 mg

NP

STALEVO 125- carbidopa-levodopa-entacapone tabs 31.25-125-200 mg

NP


NP

STALEVO 200- carbidopa-levodopa-entacapone tabs 50-200-200 mg

NP

Drug Name Tier

Des

igna

tion

Spe

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ty

Prio

r Aut

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Lim

its


NP


NP

tolcapone tab 100 mg (Tasmar) np

trihexyphenidyl hcl elixir 0.4 mg/ml np

trihexyphenidyl hcl tab 2 mg p

trihexyphenidyl hcl tab 5 mg p

XADAGO- safinamide mesylate tab50 mg (base equiv)

NC

XADAGO- safinamide mesylate tab100 mg (base equiv)

NC

ZELAPAR- selegiline hcl orallydisintegrating tab 1.25 mg

NC

NEUROMUSCULAR AGENTSEXONDYS 51- eteplirsen iv soln

100 mg/2ml (50 mg/ml)NC

EXONDYS 51- eteplirsen iv soln500 mg/10ml (50 mg/ml)

NC

riluzole tab 50 mg (Rilutek) np

MUSCULOSKELETAL THERAPY AGENTSAMRIX- cyclobenzaprine hcl cap er

24hr 15 mgNC

AMRIX- cyclobenzaprine hcl cap er24hr 30 mg

NC

BACLOFEN- baclofen tab 5 mg NC

baclofen tab 10 mg p

baclofen tab 20 mg np

carisoprodol tab 250 mg (Soma) NC

carisoprodol tab 350 mg (Soma) NC

carisoprodol w/ aspirin & codeinetab 200-325-16 mg

NC

carisoprodol w/ aspirin tab200-325 mg

NC

CHLORZOXAZONE- chlorzoxazonetab 250 mg

NC

CHLORZOXAZONE- chlorzoxazonetab 500 mg

NP

cyclobenzaprine hcl tab 5 mg p

2019


Drug Name Tier

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cyclobenzaprine hcl tab 7.5 mg(Fexmid)

np

cyclobenzaprine hcl tab 10 mg p

dantrolene sodium cap 25 mg(Dantrium)

np

dantrolene sodium cap 50 mg(Dantrium)

np

dantrolene sodium cap 100 mg np

LORZONE- chlorzoxazone tab375 mg

NC

LORZONE- chlorzoxazone tab750 mg

NC

METAXALONE- metaxalone tab400 mg

NP

metaxalone tab 800 mg (Skelaxin) np

methocarbamol tab 500 mg(Robaxin)

p

methocarbamol tab 750 mg(Robaxin-750)

p

orphenadrine citrate tab er 12hr100 mg

p

SOMA- carisoprodol tab 250 mg NC

SOMA- carisoprodol tab 350 mg NC

tizanidine hcl cap 2 mg (baseequivalent) (Zanaflex)

np


np


np

tizanidine hcl tab 2 mg (baseequivalent)

p

tizanidine hcl tab 4 mg (baseequivalent) (Zanaflex)

p

ANTIMYASTHENIC AGENTSGUANIDINE HCL- guanidine hcl tab

125 mgNP

MESTINON- pyridostigmine bromidesyrup 60 mg/5ml

NP

pyridostigmine bromide tab er180 mg (Mestinon timespan)

np

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pyridostigmine bromide tab 60 mg(Mestinon)

np

NUTRITIONAL PRODUCTSVITAMINSergocalciferol cap 50000 unit p

phytonadione tab 5 mg (Mephyton) np

MULTIVITAMINSATABEX EC- prenatal vit w/ dss-iron

carbonyl-fa tab dr 29-1 mgNC

ATABEX OB- prenatal vit w/ febisglycinate chelate-fa tab 29-1 mg

NC

BAL-CARE DHA- prenat w/fe poly-nafered-fa tab 27-1 & omega cap dr430mg

NC

C-NATE DHA- prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg

NC

CITRANATAL ASSURE- prenat w/o aw/fecbn-fegl-dss-fa tab & dha cap300 mg pack

NC

CITRANATAL B-CALM- prenat w/o aw/fecbn-feglu-fa tab 20-1 mg & vitb6 tab pak

NC

CITRANATAL BLOOM- prenatal vit w/dss-fe cbn-fe gluc-fa tab 90-1 mg

NC

CITRANATAL BLOOM DHA- prenat w/o a w/fecbn-fegl-dss-fa tab 90 &dhacap 300mg pak

NC

CITRANATAL DHA- prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap250 mg pack

NC

CITRANATAL HARMONY- prenat w/o a w/fe fum-fe cbn-dss-fa-dha cap27-1-260 mg

NC

CITRANATAL MEDLEY- prenat w/o a w/fe fum-fe cbn-fa-dha cap27-1-200 mg

NC

CITRANATAL RX- prenatal w/o a w/ fecarbonyl-fe gluc-dss-fa tab 27-1mg

NC

CITRANATAL 90 DHA- prenat w/o aw/fecbn-fegl-dss-fa tab 90 &dha cap300mg pak

NC

2019


Drug Name Tier

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CO-NATAL FA- prenatal vit w/ fefumarate-fa tab 29-1 mg

NC

COMPLETE NATAL DHA- prenat-febis-fe prot succ-fa-ca tab & omega 3cap 250 pk

NC

COMPLETENATE- prenatal vit w/ fefumarate-fa chew tab 29-1 mg

NC

CONCEPT DHA- prenatal w/fe fum-fepoly -fa-omega 3 cap 53.5-38-1 mg

NC

CONCEPT OB- prenatal w/o a w/fefum-fe poly-fa cap 130-92.4-1 mg

NC

DOTHELLE DHA- prenatal w/fefum-fe poly -fa-omega 3 cap53.5-38-1 mg

NC

DUET DHA BALANCED- prenat w/fepoly-na fered-fa tab 25-1 & omegacap 267 mg

NC

DUET DHA 400- prenat w/fe poly-na fered-fa tab 25-1 & omega cap400 mg

NC

ELITE-OB- prenatal vit w/ ironcarbonyl-fa tab 50-1.25 mg

NC

ENBRACE HR- prenatal vit w/ fe glycys-fa-omega 3 fatty acids cap

NC

FOLET DHA- prenat w/fecbn-bisg-methylf-dss tab dr & dha cap pak

NC

FOLET ONE- prenat w/o a w/fecbn-bisg-methylf-dss-dha cap38-1-225 mg

NC

FOLIVANE-OB- prenatal w/o a w/fefum-fe poly-fa cap 130-92.4-1 mg

NC

HEMENATAL OB- prenat vit-fepoly cmplx-fe heme poly-fa tab28-6-1 mg

NC

HEMENATAL OB + DHA- prenat-fepoly cmplx-fe heme poly-fa tab &omega 3 cap pck

NC

INATAL GT- prenatal vit w/ dss-ironcarbonyl-fa tab 90-1 mg

NC

KOSHER PRENATAL PLUS IRON-prenatal vit w/ iron carbonyl-fa tab30-1 mg

NC

Drug Name Tier

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M-VIT- prenatal vit w/ fe fumarate-fatab 27-1 mg

NC

MARNATAL-F- prenatal w/o vit a w/ fepolysac cmplx-fa cap 60-1 mg

NC

MYNATAL- prenatal multivitamins &minerals w/ iron & fa cap 1 mg

NC

MYNATAL ADVANCE- prenatal vit w/dss-iron carbonyl-fa tab 90-1 mg

P

MYNATAL PLUS- prenatal vit w/ fefumarate-fa tab 65-1 mg

P

MYNATAL ULTRACAPLET- prenatalvit w/ dss-iron carbonyl-fa tab90-1 mg

P

MYNATAL-Z- prenatal vit w/ fefumarate-fa tab 65-1 mg

P

MYNATE 90 PLUS- prenatal vit w/dss-fe fumarate-fa tab er 90-1 mg

NC

NATACHEW- prenatal vit w/ fe fum-febisglycin-fa chew tab 28-1 mg

NC

NATALVIT- prenatal vit w/ fe fumarate-fa tab 75-1 mg

NC

NATELLE ONE- prenatal w/o vit a w/fe fum-fa-omega 3 cap 28-1-250 mg

NC

NEEVO DHA- prenat w/o a w/fefum-methylfol-omegas cap 27-1.13 mg

NC

NEONATAL PLUS- prenatal vit w/ fefumarate-fa tab 27-1 mg

NC

NEONATAL VITAMIN- prenatal vit w/fe fumarate-fa tab 27-0.8 mg

NC

NESTABS- prenatal vit w/o vit a w/ febisglycinate-fa tab 32-1 mg

NC

NESTABS ABC- prenatal w/o vit a w/fe polysac-fa-ca tab & omega 3 cap

NC

NESTABS DHA- prenat w/o a w/ febisglyc-fa tab 32-1 mg & omega cappack

NC

NESTABS ONE- prenat w/o aw/fecbn-bisg-methylf-dha cap38-1-225 mg

NC

NEWGEN- prenatal vit w/o vit a w/ febisglycinate-fa tab 32-1 mg

NC

2019


Drug Name Tier

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NEXA PLUS- prenatal w/o vit a w/ fefum-doc-fa-dha cap 29-1.25-350 mg

NC

NIVA-PLUS- prenatal vit w/ fefumarate-fa tab 27-1 mg

NC

O-CAL FA- prenatal vit w/ fe fumarate-fa tab 27-1 mg

NC

O-CAL PRENATAL- prenatal vit w/ fefumarate-fa tab 15-1 mg

NC

OB COMPLETE- prenatal vit w/ ironcarbonyl-fa tab 50-1.25 mg

NC

OB COMPLETE GOLD- prenat w/o a w/fecbn-methfol-fa-dha cap27.5-1-200 mg

NC

OB COMPLETE ONE- prenatal w/oa w/fecbn-fe asp glyc-fa-fish cap50-1-476 mg

NC

OB COMPLETE PETITE- prenat w/oa w/fecbn-feaspglyc-fa-omega cap35-5-1-200 mg

NC

OB COMPLETE PREMIER- prenatalvit w/ fe cbn-fe asp glyc-fa tab30-20-1 mg

NC

OB COMPLETE/DHA- prenat w/iron cbn-fe asp glyc-fa-omega cap30-10-1-200 mg

NC

OBSTETRIX DHA- prenat w/fecbn-fa-dss tab 29-1 mg & omega 3 cap387 mg pak

NC

OBSTETRIX EC- prenatal vit w/ dss-iron carbonyl-fa tab 29-1 mg

NC

OBSTETRIX ONE- prenat w/o a w/fecbn-bisg-methylf-dss-dha cap38-1-225 mg

NC

PNV FOLIC ACID + IRON MUL-prenatal vit w/ fe fumarate-fa tab27-1 mg

NC

PNV OB+DHA- prenat w/o a w/fecbn-fegl-dss-fa tab & dha cap 250 mgpack

NC

PNV PRENATAL PLUS MULTIVI-prenat w/ fe fum-fa tab 27-1 mg &omega 3 cap 312 mg pak

NC

Drug Name Tier

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PNV PRENATAL PLUS MULTIVI-prenatal vit w/ fe fumarate-fa tab27-1 mg

NC

PNV TABS 29-1- prenatal vit w/ ironcarbonyl-fa tab 29-1 mg

NC

PNV-DHA- prenat w/o a w/fefum-methfol-fa-dha cap27-0.6-0.4-300 mg

NC

PNV-DHA+DOCUSATE- prenatal w/o vit a w/ fe fum-dss-fa-dha cap27-1.25-300 mg

NC

PNV-OMEGA- prenat w/o a w/ fefumerate-methylfolate-fa-omega 3cap

NC

PNV-SELECT- prenatal vit w/ fe fum-methylfolate-fa tab 27-0.6-0.4 mg

NC

PR NATAL 400- prenat-fe bis-fe protsucc-fa-ca tab & omega 3 cap 400pk

NC

PR NATAL 400 EC- prenat-fe bis-feprot succ-fa-ca tab & omega cap dr400 pk

NC

PR NATAL 430- prenat-fe bis-fe protsucc-fa-ca tab & omega 3 cap 430pk

NC

PR NATAL 430 EC- prenat-fe bis-feprot succ-fa-ca tab & omega cap dr430 pk

NC

PREMESISRX- prenatal w/ calcium-vitb6-vit b12-fa-ginger tab 1 mg

NC

PRENA 1 TRUE- prenat w/o a w/fechel-fa tab 30-1.4 mg & dha cap300mg pk

NC

PRENAISSANCE- prenatal w/ovit a w/ fe fum-dss-fa-dha cap29-1.25-325 mg

NC

PRENAISSANCE PLUS- prenatalw/o a w/fe cbn-dss-fa-dha cap28-1-250 mg

NC

PRENATA- prenatal w/o a vit w/ fefum-fa tab chew 29-1 mg

NC

PRENATABS RX- prenatal vit w/ ironcarbonyl-fa tab 29-1 mg

P

2019


Drug Name Tier

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its

PRENATAL- prenatal vit w/ fefumarate-fa tab 27-1 mg

NC

PRENATAL + DHA- prenatal w/o aw/fe fum-fa tab 27-1 mg & dha cap250 mg

NC

PRENATAL PLUS- prenatal vit w/ fefumarate-fa tab 27-1 mg

NC

PRENATAL PLUS IRON- prenatal vitw/ iron carbonyl-fa tab 29-1 mg

P

PRENATAL VITAMINS PLUS LO-prenatal vit w/ fe fumarate-fa tab27-1 mg

P

PRENATAL 19- prenatal vit w/ dss-fefumarate-fa tab 29-1 mg

P

PRENATAL 19- prenatal vit w/ fefumarate-fa chew tab 29-1 mg

P

PRENATAL-U- prenatal w/o a vit w/ fefumarate-fa cap 106.5-1 mg

P

PRENATE- prenat mv & min w/ l-methylfolate-fa chew tab 0.6-0.4 mg

NC

PRENATE AM- prenatal w/ calcium-vitb6-vit b12-fa-ginger tab 1 mg

NC

PRENATE DHA- prenat w/o aw/feaspg-methfol-fa-dha cap18-0.6-0.4-300 mg

NC

PRENATE ELITE- prenatal w/fe asp gly-l methylfol-fa tab20-0.6-0.4 mg

NC

PRENATE ENHANCE- prenat w/o a w/fefum-methfol-fa-dha cap28-0.6-0.4-400 mg

NC

PRENATE ESSENTIAL- prenat w/o a w/feaspg-methfol-fa-dha cap18-0.6-0.4-300 mg

NC

PRENATE MINI- prenat w/oa w/fecb-feasp-meth-fa-dha cap18-0.6-0.4-350 mg

NC

PRENATE PIXIE- prenat w/o aw/feaspg-methfol-fa-dha cap10-0.6-0.4-200 mg

NC

Drug Name Tier

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PRENATE RESTORE- prenat w/o a w/fefum-methfol-fa-dha cap27-0.6-0.4-400 mg

NC

PRENA1 CHEW- prenat w/ b2-b6-b12-d3-folic acid chew tab 1.4 mg

NC

PRENA1 PEARL- prenat w/oa w/fefum-na fered-fa-dha cap er30-1.4-200 mg

NC

PREPLUS- prenatal vit w/ fefumarate-fa tab 27-1 mg

NC

PRETAB- prenatal vit w/ fe fumarate-fa tab 29-1 mg

NC

PRIMACARE- prenat w/o a w/feasp-methlf-fa-omeg cap30-0.75-0.25-470mg

NC

PROVIDA DHA- prenat w/o aw/fe fum-fe poly-fa-dha cap16-16-1.25-110 mg

NC

PROVIDA OB- prenatal w/o a w/fefum-fe poly-fa cap 20-20-1.25 mg

NC

PUREFE OB PLUS- prenatalw/o a w/fe fum-fe poly-fa cap162.115.2-1 mg

NC

R-NATAL OB- prenatal w/o a w/fe cbn-fa-dha cap 20-1-320 mg

NC

RELNATE DHA- prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg

NC

SE-NATAL 19- prenatal vit w/ dss-fefumarate-fa tab 29-1 mg

P

SE-NATAL 19- prenatal vit w/ fefumarate-fa chew tab 29-1 mg

P

SELECT-OB- prenat w/ fepolycmplx-methylfol-fa chew tab 29-0.6-0.4 mg

NC

SELECT-OB- prenatal vit w/ fepolysac cmplx-fa chew tab 29-1 mg

NC

SELECT-OB+DHA- prenatal mv w/fe poly-fa chw 29-1 mg & dha cap250 mg pak

NC

TARON-BC- prenat w/o a w/ fe cbnyl-fa tab 20-1 mg & vit b6 tab pak

NC

TARON-C DHA- prenatal w/fe fum-fepoly -fa-omega 3 cap 53.5-38-1 mg

NC

2019


Drug Name Tier

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TARON-PREX- prenatal w/o vit a w/ fefum-dss-fa-dha cap 30-1.2-265 mg

NC

THRIVITE RX- prenatal vit w/ ironcarbonyl-fa tab 29-1 mg

NC

THRIVITE 19- prenatal vit w/ dss-fefumarate-fa tab 29-1 mg

NC

TL FOLATE- prenatal vit w/ fe fum-methylfolate-fa tab 27-0.5-0.5 mg

NC

TL-CARE DHA- prenatal w/fefumarate-fa-dss-fish oil cap27-1-500 mg

NC

TL-SELECT- prenatal w/o vit a w/ fefum-dss-fa-dha cap 29-1.25-325 mg

NC

TRI-TABS DHA- prenat w/o a w/ febisglyc-fa tab 32-1 mg & omega cappack

NC

TRICARE- prenatal vit w/ fe fumarate-fa tab 27-1 mg

NC

TRICARE PRENATAL- prenat w/o vita w/ fe pyrophos-methylf chew tab4.5-1 mg

NC

TRICARE PRENATAL COMPLEAT-prenat w/o a fefum-fa tab 27-1 mg &fish oil chew cap pak

NC

TRICARE PRENATAL DHA ONE-prenatal w/fe fumarate-fa-dss-fish oilcap 27-1-500 mg

NC

TRICARE PRENATAL DHA ONE/-prenatal multivitamins & minerals w/iron & fa cap 0.8 mg

NC

TRINATAL RX 1- prenatal vit w/ fefumarate-fa tab 60-1 mg

NC

TRINATE- prenatal vit w/ fe fumarate-fa tab 28-1 mg

P

TRISTART DHA- prenat w/o aw/fecbn-methylf-fa-dha cap31-0.6-0.4-200 mg

NC

TRISTART ONE- prenat w/o aw/fecbn-methylf-fa-dha cap35-1-215 mg

NC

Drug Name Tier

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TRIVEEN-DUO DHA- prenat-fe bis-feprot succ-fa-ca tab & omega 3 cap400 pk

NC

ULTIMATECARE ONE- prenatal vit w/fe cbn-fe asp glyc-fa-omega 3 cap27-1mg

NC

VENA-BAL DHA- prenat w/fe poly-nafered-fa tab 27-1 & omega cap dr430mg

NC

VIL-RX- prenatal vit w/ iron carbonyl-fa tab 29-1 mg

NC

VINATE DHA RF- prenat w/o aw/fefum-methylfol-omegas cap27-1.13 mg

NC

VINATE II- prenatal vit w/ febisglycinate chelate-fa tab 29-1 mg

P

VINATE M- prenatal vit w/ sel-fefumarate-fa tab 27-1 mg

P

VINATE ONE- prenatal vit w/ fefumarate-fa tab 60-1 mg

P

VIRT-C DHA- prenatal w/fe fum-fepoly -fa-omega 3 cap 53.5-38-1 mg

NC

VIRT-NATE DHA- prenatal vit w/ fefum-fa-omega 3 cap 28-1-200 mg

NC

VIRT-PN- prenatal vit w/ fe fum-methylfolate-fa tab 27-0.6-0.4 mg

NC

VIRT-PN DHA- prenat w/o aw/fefum-methfol-fa-dha cap27-0.6-0.4-300 mg

NC

VIRT-PN PLUS- prenat w/o a w/ fefumerate-methylfolate-fa-omega 3cap

NC

VITAFOL FE+- prenat-fepoly-methol-fa-dha cap 90-1-200 mg & dss50mg cap

NC

VITAFOL GUMMIES- prenat vitw/ fe phos-fa-omega chew tab3.33-0.333-34.8 mg

NC

VITAFOL ULTRA- prenat w/fe poly-methylfol-fa-dha cap29-0.6-0.4-200 mg

NC

2019


Drug Name Tier

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VITAFOL-NANO- prenatal w/oa w/ fefum-l methylfol-fa tab18-0.6-0.4 mg

NC

VITAFOL-OB- prenatal vit w/ fefumarate-fa tab 65-1 mg

NC

VITAFOL-OB+DHA- prenatal mv w/fe fum-fa tab 65-1 mg & dha cap250 mg pack

NC

VITAFOL-ONE- prenatal mv w/fe polysac cmplx-fa-dha cap29-1-200 mg

NC

VITAMEDMD ONE RX/QUATREFO-prenat w/o a w/fefum-methfol-fa-dhacap 30-0.6-0.4-200 mg

NC

VITAMEDMD REDICHEW RX- prenatw/ b2-b6-b12-d3-folic acid chew tab1.4 mg

NC

VITAPEARL- prenat w/oa w/fefum-nafered-fa-dha cap er 30-1.4-200 mg

NC

VITATRUE- prenat w/o a w/fe chel-fatab 30-1.4 mg & dha cap 300mg pk

NC

VIVA DHA- prenatal vit w/ fe fum-fa-omega 3 cap 28-1-200 mg

NC

VOL-NATE- prenatal vit w/ fefumarate-fa tab 28-1 mg

NC

VOL-PLUS- prenatal vit w/ fefumarate-fa tab 27-1 mg

NC

VOL-TAB RX- prenatal vit w/ ironcarbonyl-fa tab 29-1 mg

NC

VP-HEME OB + DHA- prenat-fe polycmplx-fe heme poly-fa tab & omega3 cap pck

NC

VP-PNV-DHA- prenatal vit w/ fe fum-fa-omega 3 cap 28-1-215.8 mg

NC

ZATEAN-PN DHA- prenat w/oa w/fefum-methfol-fa-dha cap27-0.6-0.4-300 mg

NC

ZATEAN-PN PLUS- prenat w/o a w/ fefumerate-methylfolate-fa-omega 3cap

NC

MINERALS and ELECTROLYTES

Drug Name Tier

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FLORIVA- sodium fluoride-vitamin dliqd drops 0.25 mg/ml-400 unit/ml

NP

FLUORABON- sodium fluoride soln0.25 mg/0.6ml (from 0.55 mg/0.6mlnaf)

NP

FLURA-DROPS- sodium fluoride soln0.25 mg/drop f (from 0.55 mg/dropnaf)

P

GALZIN- zinc acetate cap 25 mg(elemental zinc)

NP

GALZIN- zinc acetate cap 50 mg(elemental zinc)

NP

K-PHOS- potassium phosphatemonobasic tab 500 mg

P

K-TAB- potassium chloride tab er 8meq (600 mg)

NP

K-TAB- potassium chloride tab er 20meq (1500 mg)

NP

KLOR-CON M15- potassium chloridemicroencapsulated crys er tab 15meq

NP

pot phos monobasic w/sod phos di& monobas tab 155-852-130mg(K-phos neutral)

np

potassium chloride cap er 8 meq(Micro-k)

np

potassium chloride cap er 10 meq(Micro-k)

p

POTASSIUM CHLORIDE ER-potassium chloride tab er 8 meq(600 mg)

P

POTASSIUM CHLORIDE ER-potassium chloride tab er 20 meq(1500 mg)

NP

potassium chloridemicroencapsulated crys er tab 10meq

p

potassium chloridemicroencapsulated crys er tab 20meq

p

potassium chloride oral soln 10%(20 meq/15ml)

np

2019


Drug Name Tier

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potassium chloride oral soln 20%(40 meq/15ml)

np

potassium chloride powder packet20 meq

np

potassium chloride tab er 8 meq(600 mg)

p

potassium chloride tab er 10 meq(K-tab)

p

SODIUM FLUORIDE- sodium fluoridetab 0.5 mg f (from 1.1 mg naf)

P

SODIUM FLUORIDE- sodium fluoridetab 1 mg f (from 2.2 mg naf)

P

sodium fluoride chew tab 0.25 mg f(from 0.55 mg naf)

p

sodium fluoride chew tab 0.5 mg f(from 1.1 mg naf)

p

sodium fluoride chew tab 1 mg f(from 2.2 mg naf)

p

sodium fluoride soln 0.125 mg/dropf (0.275 mg/drop naf)

np

sodium fluoride soln 0.5 mg/ml f(from 1.1 mg/ml naf)

p

NUTRIENTSamino acids cap NC

NUTRESTORE- glutamine powd pack5 gm

NP

DIETARY PRODUCTSCAMINO PRO 15PE- nutritional

supplement liquidNC

folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2 mg

np

GLYTACTIN BETTERMILK DE-L-nutritional supplement pack

NC

GLYTACTIN BETTERMILK 15-nutritional supplement pack

NC

GLYTACTIN BUILD 10PE- nutritionalsupplement pack

NC

GLYTACTIN BUILD 20/20 PKU-nutritional supplement pack

NC

GLYTACTIN COMPLETE 10PE-nutritional supplement bar

NC

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GLYTACTIN RESTORE LITE 10-nutritional supplement pack

NC

GLYTACTIN RESTORE 5- nutritionalsupplement pack

NC

GLYTACTIN RTD LITE 15- nutritionalsupplement liquid

NC

GLYTACTIN RTD 10- nutritionalsupplement liquid

NC

GLYTACTIN RTD 15- nutritionalsupplement liquid

NC

HOMACTIN AA PLUS- nutritionalsupplement liquid

NC

ISOVACTIN AA PLUS- nutritionalsupplement liquid

NC

KETOVIE- nutritional supplementliquid

NC

KETOVIE PEPTIDE- nutritionalsupplement liquid

NC

PHENACTIN AA PLUS- nutritionalsupplement liquid

NC

TYLACTIN RESTORE 10- nutritionalsupplement liquid

NC

TYLACTIN RESTORE 5PE- nutritionalsupplement pack

NC

TYLACTIN RTD 15- nutritionalsupplement liquid

NC

VILACTIN AA PLUS- nutritionalsupplement liquid

NC

HEMATOLOGICAL AGENTSHEMATOPOIETIC AGENTSARANESP ALBUMIN FREE-

darbepoetin alfa soln inj 25 mcg/mlP • •

ARANESP ALBUMIN FREE-darbepoetin alfa soln inj 40 mcg/ml

P • •


P • •


P • •


P • •

2019


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P • •

ARANESP ALBUMIN FREE-darbepoetin alfa soln prefilledsyringe 10 mcg/0.4ml

P • •


P • •


P • •


P • •


P • •


P • •


P • •


P • •

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

P • •

carbonyl iron susp 15 mg/1.25ml(elemental iron)

p

CERDELGA- eliglustat tartrate cap84 mg (base equivalent)

NP • • •

cyanocobalamin inj 1000 mcg/ml p

DOPTELET- avatrombopag maleatetab 20 mg (base equiv)

NC

DROXIA- hydroxyurea cap 200 mg NP



ENDARI- glutamine (sickle cell) powdpack 5 gm

NP • •

EPOGEN- epoetin alfa inj 2000 unit/ml NP • •

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EPOGEN- epoetin alfa inj 3000 unit/ml NP • •EPOGEN- epoetin alfa inj 4000 unit/ml NP • •EPOGEN- epoetin alfa inj 10000 unit/

mlNP • •

EPOGEN- epoetin alfa inj 20000 unit/ml

NP • •

FERROUS SULFATE- ferrous sulfateliquid 220 mg/5ml (44 mg/5mlelemental fe)

P

FERROUS SULFATE- ferrous sulfatesyrup 300 mg/5ml (60 mg/5mlelemental fe)

P

ferrous sulfate elixir 220 mg/5ml(44 mg/5ml elemental fe)

p

ferrous sulfate soln 75 mg/ml(15 mg/ml elemental fe)

p

folic acid cap 0.8 mg p

folic acid tab 400 mcg p

folic acid tab 800 mcg p

folic acid tab 1 mg p

FULPHILA- pegfilgrastim-jmdb solnprefilled syringe 6 mg/0.6ml

P •

GRANIX- tbo-filgrastim soln prefilledsyringe 300 mcg/0.5ml

P •

GRANIX- tbo-filgrastim soln prefilledsyringe 480 mcg/0.8ml

P •

HYDROXOCOBALAMIN-hydroxocobalamin acetate inj1000 mcg/ml (base equivalent)

NP

IRON UP- polysaccharide ironcomplex liquid 15 mg/0.5ml (feequiv)

P

LEUKINE- sargramostim lyophilizedfor inj 250 mcg

NP •

miglustat cap 100 mg (Zavesca) np • • •MIRCERA- methoxy peg-epoetin beta

soln prefilled syr 30 mcg/0.3mlNP •

MIRCERA- methoxy peg-epoetin betasoln prefilled syr 50 mcg/0.3ml

NP •


NP •

2019


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NP •


NP •


NP •

NASCOBAL- cyanocobalamin nasalspray 500 mcg/0.1ml

NP

NEULASTA- pegfilgrastim solnprefilled syringe 6 mg/0.6ml

P •

NEULASTA ONPRO KIT-pegfilgrastim soln prefilled syringekit 6 mg/0.6ml

P •

NEUPOGEN- filgrastim inj 300 mcg/ml P •NEUPOGEN- filgrastim inj

480 mcg/1.6ml (300 mcg/ml)P •

NEUPOGEN- filgrastim soln prefilledsyringe 300 mcg/0.5ml

P •

NEUPOGEN- filgrastim soln prefilledsyringe 480 mcg/0.8ml (600 mcg/ml)

P •

NOVAFERRUM PEDIATRIC DROP-polysaccharide iron complex liquid15 mg/ml (fe equiv)

P

PROCRIT- epoetin alfa inj 2000 unit/ml

P • •


P • •


P • •


P • •


P • •


P • •

PROMACTA- eltrombopag olaminetab 12.5 mg (base equiv)

NP • • •

PROMACTA- eltrombopag olaminetab 25 mg (base equiv)

NP • • •


NP • • •

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NP • • •

RETACRIT- epoetin alfa-epbx inj 2000unit/ml

P • •


P • •


P • •

RETACRIT- epoetin alfa-epbx inj10000 unit/ml

P • •

RETACRIT- epoetin alfa-epbx inj40000 unit/ml

P • •

SIKLOS- hydroxyurea tab 100 mg NP •ZARXIO- filgrastim-sndz soln prefilled

syringe 300 mcg/0.5mlP •

ZARXIO- filgrastim-sndz soln prefilledsyringe 480 mcg/0.8ml

P •

ANTICOAGULANTSBEVYXXA- betrixaban maleate cap

40 mg (base equivalent)NP •

BEVYXXA- betrixaban maleate cap80 mg (base equivalent)

NP •

COUMADIN- warfarin sodium tab1 mg

NP


NP

COUMADIN- warfarin sodium tab2.5 mg

NP


NP


NP


NP


NP

COUMADIN- warfarin sodium tab7.5 mg

NP


NP

ELIQUIS- apixaban tab 2.5 mg P •

2019


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ELIQUIS- apixaban tab 5 mg P •ELIQUIS STARTER PACK- apixaban

tab 5 mgP •

enoxaparin sodium inj 30 mg/0.3ml(Lovenox)

np •


np •


np •


np •

enoxaparin sodium inj 100 mg/ml(Lovenox)

np •

enoxaparin sodium inj120 mg/0.8ml (Lovenox)

np •

enoxaparin sodium inj 150 mg/ml(Lovenox)

np •

enoxaparin sodium inj 300 mg/3ml(Lovenox)

np •

fondaparinux sodiumsubcutaneous inj 2.5 mg/0.5ml(Arixtra)

np •

fondaparinux sodiumsubcutaneous inj 5 mg/0.4ml(Arixtra)

np •

fondaparinux sodiumsubcutaneous inj 7.5 mg/0.6ml(Arixtra)

np •

fondaparinux sodiumsubcutaneous inj 10 mg/0.8ml(Arixtra)

np •

FRAGMIN- dalteparin sodium inj10000 unit/ml

NP •

FRAGMIN- dalteparin sodium inj 2500unit/0.2ml

NP •


NP •


NP •

FRAGMIN- dalteparin sodium inj12500 unit/0.5ml

NP •

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NP •


NP •


NP •

heparin sodium (porcine) inj 1000unit/ml

np


np


np


np

heparin sodium (porcine) pf inj5000 unit/0.5ml

np

PRADAXA- dabigatran etexilatemesylate cap 75 mg (etexilate baseeq)

NP •

PRADAXA- dabigatran etexilatemesylate cap 110 mg (etexilate baseeq)

NP •

PRADAXA- dabigatran etexilatemesylate cap 150 mg (etexilatebase eq)

NP •

SAVAYSA- edoxaban tosylate tab15 mg (base equivalent)

NP •


NP •


NP •

warfarin sodium tab 1 mg(Coumadin)

p


p

warfarin sodium tab 2.5 mg(Coumadin)

p


p


p

2019


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p


p

warfarin sodium tab 7.5 mg(Coumadin)

p


p

XARELTO- rivaroxaban tab 10 mg P •XARELTO- rivaroxaban tab 15 mg P •XARELTO- rivaroxaban tab 20 mg P •XARELTO STARTER PACK-

rivaroxaban tab starter therapy pack15 mg & 20 mg

P •

HEMOSTATICSAMICAR- aminocaproic acid oral soln

0.25 gm/mlNP

AMICAR- aminocaproic acid tab500 mg

NP

AMICAR- aminocaproic acid tab1000 mg

NP

ARTISS- fibrin sealant componentsolution

NP

RECOTHROM- thrombin(recombinant) for soln 5000 unit

NP

RECOTHROM- thrombin(recombinant) for soln 20000 unit

NP

RECOTHROM SPRAY KIT- thrombin(recombinant) for soln 20000 unit

NP

THROMBIN-JMI DILUENT- thrombinfor soln 5000 unit

NP

THROMBIN-JMI DILUENT- thrombinfor soln 20000 unit

NP

THROMBIN-JMI EPISTAXIS-thrombin for soln kit 5000 unit

NP

THROMBIN-JMI SYRINGE SPRA-thrombin for soln kit 5000 unit

NP

THROMBIN-JMI SYRINGE SPRA-thrombin for soln kit 20000 unit

NP

THROMBIN-JMI W/DIL SPRAY-thrombin for soln kit 20000 unit

NP

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TISSEEL- fibrin sealant component kit2 ml

NP


NP


NP

TISSEEL- fibrin sealant componentsolution

NP

TISSEEL VH- fibrin sealantcomponent kit 2 ml

NP


NP


NP

tranexamic acid tab 650 mg(Lysteda)

np

HEMATOLOGICAL AGENTS - MISC.ADVATE- antihemophilic factor rahf-

pfm for inj 250 unitP •

ADVATE- antihemophilic factor rahf-pfm for inj 500 unit

P •


P •


P •


P •


P •


P •

ADYNOVATE- antihemophilic factorrecomb pegylated for inj 250 unit

P •


P •


P •


P •


P •

2019


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P •


P •

AFSTYLA- antihemophilic fact rcmbsingle chain for inj kit 250 unit

P •


P •


P •


P •


P •


P •


P •

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

P •


P •


P •


P •


P •

ALPHANINE SD- coagulation factor ixfor inj 500 unit

P •


P •


P •

ALPROLIX- coagulation factor ix(recomb) (rfixfc) for inj 250 unit

P •

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P •


P •


P •


P •


P •

anagrelide hcl cap 0.5 mg (Agrylin) np

anagrelide hcl cap 1 mg np

aspirin-dipyridamole cap er 12hr25-200 mg (Aggrenox)

np

BEBULIN- factor ix complex for inj200-1200 unit

P •

BENEFIX- coagulation factor ix(recombinant) for inj kit 250 unit

P •


P •


P •


P •


P •

BERINERT- c1 esterase inhibitor(human) for iv inj kit 500 unit

NP • • •

BRILINTA- ticagrelor tab 60 mg P

BRILINTA- ticagrelor tab 90 mg P

cilostazol tab 50 mg p

cilostazol tab 100 mg p

clopidogrel bisulfate tab 75 mg(base equiv) (Plavix)

p

clopidogrel bisulfate tab 300 mg(base equiv) (Plavix)

np

COAGADEX- coagulation factor x(human) for inj 250 unit

P •

COAGADEX- coagulation factor x(human) for inj 500 unit

P •

2019


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CORIFACT- factor xiii concentrate(human) for inj kit 1000-1600 unit

P •

dipyridamole tab 25 mg p

dipyridamole tab 50 mg np

dipyridamole tab 75 mg np

DURLAZA- aspirin capsule er 24hr162.5 mg

NC

ELOCTATE- antihemophilic factor(recomb) rfviiifc for inj 250 unit

P •


P •


P •


P •


P •


P •


P •


P •


P •


P •

FEIBA- antiinhibitor coagulantcomplex for inj

P •

FIRAZYR- icatibant acetate inj30 mg/3ml (base equivalent)

P • • •

HAEGARDA- c1 esterase inhibitor(human) for subcutaneous inj 2000unit

P • • •

HAEGARDA- c1 esterase inhibitor(human) for subcutaneous inj 3000unit

P • • •

HELIXATE FS- antihemophilic factor(recombinant) for inj kit 250 unit

P •


P •

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P •


P •


P •

HEMLIBRA- emicizumab-kxwhsubcutaneous soln 30 mg/ml

P • • •

HEMLIBRA- emicizumab-kxwhsubcutaneous soln 60 mg/0.4ml(150 mg/ml)

P • • •

HEMLIBRA- emicizumab-kxwhsubcutaneous soln 105 mg/0.7ml(150 mg/ml)

P • • •

HEMLIBRA- emicizumab-kxwhsubcutaneous soln 150 mg/ml

P • • •

HEMOFIL M- antihemophilic factor(human) for inj 250 unit

P •


P •


P •


P •

HUMATE-P- antihemophilic factor/vwf(human) for inj 250-600 unit

P •


P •


P •

IDELVION- coagulation factor ix(recomb) (rix-fp) for inj 250 unit

P •


P •


P •


P •


P •

2019


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IXINITY- coagulation factor ix(recombinant) for inj 250 unit

P •


P •


P •


P •


P •


P •

KOATE- antihemophilic factor (human)for inj 250 unit

P •


P •


P •

KOATE-DVI- antihemophilic factor(human) for inj 250 unit

P •


P •


P •

KOGENATE FS- antihemophilic factor(recombinant) for inj kit 250 unit

P •


P •


P •


P •


P •

KOGENATE FS BIO-SET-antihemophilic factor (recombinant)for inj kit 1000 unit

P •


P •

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P •

KOVALTRY- antihemophilic factor(recombinant) for inj 250 unit

P •


P •


P •


P •


P •

MONOCLATE-P- antihemophilic factor(human) for inj kit 1000 unit

P •

MONOCLATE-P- antihemophilic factor(human) for inj kit 1500 unit

P •

MONONINE- coagulation factor ix forinj 1000 unit

P •

NOVOEIGHT- antihemophilic factor(recombinant) for inj 250 unit

P •


P •


P •


P •


P •


P •

NOVOSEVEN RT- coagulationfactor viia (recomb) for inj 1 mg(1000 mcg)

P •


P •


P •

2019


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P •

NUWIQ- antihemophilic factor (bdd-rfviii) for inj kit 250 unit

P •


P •


P •


P •


P •


P •


P •

NUWIQ- antihemophilic factor (bdd-rfviii) for inj 250 unit

P •


P •


P •


P •


P •


P •


P •

OBIZUR- antihemophilic factor(recomb porc) rpfviii for inj 500 unit

P •

pentoxifylline tab er 400 mg p

prasugrel hcl tab 5 mg (base equiv)(Effient)

np

prasugrel hcl tab 10 mg (baseequiv) (Effient)

np

PROFILNINE- factor ix complex for inj500 unit

P •

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P •


P •

PROFILNINE SD- factor ix complexfor inj 500 unit

P •


P •


P •

REBINYN- coagulation factor ixrecomb glycopegylated for inj 500unt

P •


P •


P •

RECOMBINATE- antihemophilic factor(recombinant) for inj 220-400 unit

P •


P •


P •


P •


P •

RIASTAP- fibrinogen conc (human) injapproximately 1 gm (900-1300 mg)

P

RIXUBIS- coagulation factor ix(recombinant) for inj 250 unit

P •


P •


P •


P •


P •

2019


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RUCONEST- c1 esterase inhibitor(recombinant) for iv inj 2100 unit

NP • • •

TAVALISSE- fostamatinib disodiumtab 100 mg (base equivalent)

NP • • •

TAVALISSE- fostamatinib disodiumtab 150 mg (base equivalent)

NP • • •

TRETTEN- coagulation factor xiii a-subunit for inj 2000-3125 unit

P •

VONVENDI- von willebrand factor(recombinant) for inj 650 unit

P •

VONVENDI- von willebrand factor(recombinant) for inj 1300 unit

P •

WILATE- antihemophilic factor/vwf(human) for inj 500-500 unit kit

P •

WILATE- antihemophilic factor/vwf(human) for inj 1000-1000 unit kit

P •

XYNTHA- antihemophilic factorrecombinant paf for inj kit 250 unit

P •


P •


P •


P •

XYNTHA SOLOFUSE- antihemophilicfactor recombinant paf for inj kit 250unit

P •

XYNTHA SOLOFUSE- antihemophilicfactor recombinant paf for inj kit 500unit

P •

XYNTHA SOLOFUSE- antihemophilicfactor recombinant paf for inj kit1000 unit

P •


P •


P •

YOSPRALA- aspirin-omeprazole tabdelayed release 81-40 mg

NC

Drug Name Tier

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YOSPRALA- aspirin-omeprazole tabdelayed release 325-40 mg

NC

ZONTIVITY- vorapaxar sulfate tab2.08 mg (base equivalent)

NP

TOPICAL PRODUCTSOPHTHALMIC AGENTSACUVAIL- ketorolac tromethamine (pf)

ophth soln 0.45%NC

AKTEN- lidocaine hcl ophth gel 3.5% NP

ALOCRIL- nedocromil sodium ophthsoln 2%

NC

ALOMIDE- lodoxamide tromethamineophth soln 0.1%

NC

ALPHAGAN P- brimonidine tartrateophth soln 0.1%

NC

ALREX- loteprednol etabonate ophthsusp 0.2%

P

apraclonidine hcl ophth soln 0.5%(base equivalent) (Iopidine)

np

ATROPINE SULFATE- atropinesulfate ophth soln 1%

NP

AZASITE- azithromycin ophth soln 1% NC

azelastine hcl ophth soln 0.05% np

AZOPT- brinzolamide ophth susp 1% P

BACITRACIN- bacitracin ophth oint500 unit/gm

P

bacitracin-polymyxin b ophth oint p

bacitracin-polymyxin-neomycin-hcophth oint 1%

np

BEPREVE- bepotastine besilate ophthsoln 1.5%

NC

BESIVANCE- besifloxacin hcl ophthsusp 0.6% (base equiv)

P

BETADINE OPHTHALMIC PREP-povidone-iodine ophth soln 5%

NC

betaxolol hcl ophth soln 0.5% np

BETIMOL- timolol ophth soln 0.25% NC

BETIMOL- timolol ophth soln 0.5% NC

BETOPTIC-S- betaxolol hcl ophthsusp 0.25%

NC

2019


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bimatoprost ophth soln 0.03% NC

BLEPHAMIDE- sulfacetamide sodium-prednisolone ophth susp 10-0.2%

NP

BLEPHAMIDE S.O.P.- sulfacetamidesodium-prednisolone ophth oint10-0.2%

NP

brimonidine tartrate ophth soln0.15% (Alphagan p)

np

brimonidine tartrate ophth soln0.2%

p

BROMFENAC- bromfenac sodiumophth soln 0.09% (base equiv)(once-daily)

NP

BROMSITE- bromfenac sodium ophthsoln 0.075% (base equivalent)

NP

CARTEOLOL HCL- carteolol hcl ophthsoln 1%

NP

CILOXAN- ciprofloxacin hcl ophth oint0.3%

NC

ciprofloxacin hcl ophth soln 0.3%(Ciloxan)

p

COMBIGAN- brimonidine tartrate-timolol maleate ophth soln 0.2-0.5%

NC

COSOPT PF- dorzolamide hcl-timololmaleate ophth sol 22.3-6.8 mg/ml pf

NC

cromolyn sodium ophth soln 4% p

CYCLOMYDRIL- cyclopentolate w/phenylephrine ophth soln 0.2-1%

NP

cyclopentolate hcl ophth soln 0.5%(Cyclogyl)

np

cyclopentolate hcl ophth soln 1%(Cyclogyl)

p

cyclopentolate hcl ophth soln 2%(Cyclogyl)

np

CYSTARAN- cysteamine hcl ophthsoln 0.44% (base equivalent)

NP •

DEXAMETHASONE SODIUM PHOS-dexamethasone sodium phosphateophth soln 0.1%

P

diclofenac sodium ophth soln 0.1% p

Drug Name Tier

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dorzolamide hcl ophth soln 2%(Trusopt)

p

dorzolamide hcl-timolol maleateophth soln 22.3-6.8 mg/ml(Cosopt)

p

dorzolamide hcl-timolol maleateophth sol 22.3-6.8 mg/ml pf(Cosopt pf)

NC

DUREZOL- difluprednate ophthemulsion 0.05%

NC

EMADINE- emedastine difumarateophth soln 0.05% (base equiv)

NC

epinastine hcl ophth soln 0.05%(Elestat)

NC

erythromycin ophth oint 5 mg/gm p

FLAREX- fluorometholone acetateophth susp 0.1%

NP

fluorometholone ophth susp 0.1%(Fml liquifilm)

np

flurbiprofen sodium ophth soln0.03% (Ocufen)

p

FML- fluorometholone ophth oint 0.1% NC

FML FORTE- fluorometholone ophthsusp 0.25%

NC

gatifloxacin ophth soln 0.5%(Zymaxid)

np

GENTAK- gentamicin sulfate ophthoint 0.3%

NP

gentamicin sulfate ophth soln 0.3% p

ILEVRO- nepafenac ophth susp 0.3% NP

IOPIDINE- apraclonidine hcl ophthsoln 1% (base equivalent)

NC

ISOPTO ATROPINE- atropine sulfateophth soln 1%

NP

ketorolac tromethamine ophth soln0.4% (Acular ls)

np

ketorolac tromethamine ophth soln0.5% (Acular)

p

LACRISERT- artificial tear ophth insert NC

LASTACAFT- alcaftadine ophth soln0.25%

NC

2019


Drug Name Tier

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latanoprost ophth soln 0.005%(Xalatan)

p •

levobunolol hcl ophth soln 0.5%(Betagan)

p

levofloxacin ophth soln 0.5% np

LOTEMAX- loteprednol etabonateophth gel 0.5%

P

LOTEMAX- loteprednol etabonateophth oint 0.5%

P

LOTEMAX- loteprednol etabonateophth susp 0.5%

P

LUMIGAN- bimatoprost ophth soln0.01%

P •

MAXIDEX- dexamethasone ophthsusp 0.1%

NP

METIPRANOLOL- metipranolol ophthsoln 0.3%

NP

MITOSOL- mitomycin for ophth solnkit 0.2 mg

NC

MOXEZA- moxifloxacin hcl ophth soln0.5% (base eq) (2 times daily)

P

moxifloxacin hcl ophth soln 0.5%(base equiv) (Vigamox)

np

NATACYN- natamycin ophth susp 5% P

neomycin-bacitrac zn-polymyx5(3.5)mg-400unt-10000unt op oin

np

neomycin-polymy-gramicid op sol1.75-10000-0.025mg-unt-mg/ml(Neosporin)

np

neomycin-polymyxin-dexamethasone ophth oint 0.1%(Maxitrol)

p

neomycin-polymyxin-dexamethasone ophth susp 0.1%(Maxitrol)

p

NEOMYCIN/POLYMYXIN/HYDROC-neomycin-polymyxin-hc ophth susp

NP

NEVANAC- nepafenac ophth susp0.1%

NC

ofloxacin ophth soln 0.3% (Ocuflox) p

Drug Name Tier

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olopatadine hcl ophth soln 0.1%(base equivalent) (Patanol)

NC

olopatadine hcl ophth soln 0.2%(base equivalent) (Pataday)

np

PAZEO- olopatadine hcl ophth soln0.7% (base equivalent)

P

phenylephrine hcl ophth soln 2.5% np

phenylephrine hcl ophth soln 10% np

PHOSPHOLINE IODIDE-echothiophate iodide ophth for soln0.125%

NC

pilocarpine hcl ophth soln 1%(Isopto carpine)

np


np


np

polymyxin b-trimethoprim ophthsoln 10000 unit/ml-0.1% (Polytrim)

p

PRED MILD- prednisolone acetateophth susp 0.12%

NC

PRED-G- gentamicin-prednisoloneace ophth susp 0.3-1%

NP

PRED-G S.O.P.- gentamicin-prednisolone ace ophth oint0.3-0.6%

NP

prednisolone acetate ophth susp1% (Pred forte)

np

PREDNISOLONE SODIUM PHOSP-prednisolone sodium phosphateophth soln 1%

NP

PROLENSA- bromfenac sodium ophthsoln 0.07% (base equivalent)

NC

proparacaine hcl ophth soln 0.5% np

RESTASIS- cyclosporine (ophth)emulsion 0.05%

P

RESTASIS MULTIDOSE- cyclosporine(ophth) emulsion 0.05%

P

RHOPRESSA- netarsudil dimesylateophth soln 0.02%

NC

2019


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SIMBRINZA- brinzolamide-brimonidine tartrate ophth susp1-0.2%

P

SULFACETAMIDE SODIUM-sulfacetamide sodium ophth oint10%

NP

sulfacetamide sodium ophth soln10% (Bleph-10)

np

sulfacetamide sodium-prednisolone ophth soln10-0.23(0.25)%

p

tetracaine hcl ophth soln 0.5% p

timolol maleate ophth soln 0.25%(Timoptic)

p

timolol maleate ophth soln 0.5%(Timoptic)

p

timolol maleate ophth soln 0.5%(once-daily) (Istalol)

NC

TIMOLOL MALEATE OPHTHALMI-timolol maleate ophth gel formingsoln 0.25%

NP

TIMOLOL MALEATE OPHTHALMI-timolol maleate ophth gel formingsoln 0.5%

NP

TIMOPTIC OCUDOSE- timololmaleate preservative free ophth soln0.25%

NC

TIMOPTIC OCUDOSE- timololmaleate preservative free ophth soln0.5%

NC

TIMOPTIC-XE- timolol maleateophth gel forming soln 0.25%

NP

TIMOPTIC-XE- timolol maleateophth gel forming soln 0.5%

NP

TOBRADEX- tobramycin-dexamethasone ophth oint 0.3-0.1%

NC

TOBRADEX ST- tobramycin-dexamethasone ophth susp0.3-0.05%

NC

tobramycin ophth soln 0.3%(Tobrex)

p

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tobramycin-dexamethasone ophthsusp 0.3-0.1% (Tobradex)

np

TOBREX- tobramycin ophth oint 0.3% NC

TRAVATAN Z- travoprost ophth soln0.004% (benzalkonium free) (bakfree)

P •

trifluridine ophth soln 1% (Viroptic) np

VYZULTA- latanoprostene bunodophth soln 0.024%

NP •

XIIDRA- lifitegrast ophth soln 5% P

ZIOPTAN- tafluprost ophth soln0.0015%

NC

ZIRGAN- ganciclovir ophth gel 0.15% NC

ZYLET- loteprednol etabonate-tobramycin ophth susp 0.5-0.3%

NP

OTIC AGENTSacetic acid otic soln 2% np

CETRAXAL- ciprofloxacin hcl otic soln0.2% (base equivalent)

NP

CIPRO HC- ciprofloxacin-hydrocortisone otic susp 0.2-1%

NC

CIPRODEX- ciprofloxacin-dexamethasone otic susp 0.3-0.1%

P

CIPROFLOXACIN- ciprofloxacin hclotic soln 0.2% (base equivalent)

NP

COLY-MYCIN S- neomycin-colistin-hc-thonzonium otic susp3.3-3-10-0.5 mg/ml

NP

fluocinolone acetonide (otic) oil0.01% (Dermotic)

np

hydrocortisone w/ acetic acid oticsoln 1-2%

np

neomycin-polymyxin-hc otic soln1%

np

neomycin-polymyxin-hc otic susp3.5 mg/ml-10000 unit/ml-1%

np

ofloxacin otic soln 0.3% (Floxinotic)

np

OTOVEL- ciprofloxacin-fluocinoloneaceton (pf) otic soln 0.3-0.025%

NC

2019


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MOUTH/THROAT/DENTAL AGENTSARESTIN- minocycline hcl subgingival

powder cartridge 1 mgNC

cevimeline hcl cap 30 mg (Evoxac) np

chlorhexidine gluconate soln 0.12%(Peridex)

p

clotrimazole troche 10 mg np

LIDOCAINE HCL- lidocaine hcllaryngotracheal soln 4%

NP

lidocaine hcl viscous soln 2% p

NAFRINSE DAILY/ACIDULATED-sodium fluoride-phosphoric acid forsoln 1 mg/5ml (f equiv)

NP

NAFRINSE DAILY/NEUTRAL- sodiumfluoride for soln rinse 0.05%

NP

NAFRINSE WEEKLY- sodium fluoridefor soln rinse 0.2%

NP

nystatin susp 100000 unit/ml np

ORAVIG- miconazole buccal tab50 mg (mouth-throat)

NP

pilocarpine hcl tab 5 mg (Salagen) np

pilocarpine hcl tab 7.5 mg (Salagen) np

sodium fluoride cream 1.1%(Prevident 5000 plus)

p

sodium fluoride gel 1.1% (0.5% f)(Prevident fluoride)

p

sodium fluoride paste 1.1%(Prevident 5000 boost)

p

sodium fluoride rinse 0.2% p

sodium fluoride-potassium nitratepaste 1.1-5% (Prevident 5000sensi)

p

stannous fluoride conc 0.63% (Gel-kam oral care ri)

p

stannous fluoride gel 0.4% np

triamcinolone acetonide dentalpaste 0.1%

np

ANORECTAL AGENTS

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ANALPRAM-HC- hydrocortisoneacetate w/ pramoxine rectal lotn2.5-1%

NP

CORTIFOAM- hydrocortisone acetaterectal foam 10% (90 mg/dose)

P

hydrocortisone acetate w/pramoxine rectal cream 1-1%(Analpram-hc)

np

hydrocortisone enema 100 mg/60ml(Cortenema)

np

hydrocortisone rectal cream 1%(Proctocort)

np

hydrocortisone rectal cream 2.5%(Anusol-hc)

np

PROCTOFOAM HC- hydrocortisoneacetate w/ pramoxine rectal foam1-1%

NP

RECTIV- nitroglycerin oint 0.4% NP

UCERIS- budesonide rectal foam2 mg/act

NP

DERMATOLOGICALSABSORICA- isotretinoin cap 10 mg P

ABSORICA- isotretinoin cap 20 mg P





ACANYA- clindamycin phosphate-benzoyl peroxide gel 1.2-2.5%

P

acitretin cap 10 mg (Soriatane) np

acitretin cap 17.5 mg (Soriatane) np

acitretin cap 25 mg (Soriatane) np

acyclovir oint 5% (Zovirax) NC

ACZONE- dapsone gel 7.5% NC

ADAPALENE- adapalene lotion 0.1% NC

ADAPALENE- adapalene soln 0.1% NC

adapalene cream 0.1% (Differin) NC

adapalene gel 0.1% (Differin) NC

adapalene gel 0.3% (Differin) NC

2019


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its

adapalene-benzoyl peroxide gel0.1-2.5% (Epiduo)

np

AKTIPAK- benzoyl peroxide-erythromycin gel pack 5-3%

NC

ALA SCALP- hydrocortisone lotion 2% NC

alclometasone dipropionate cream0.05%

np

alclometasone dipropionate oint0.05%

np

ALTABAX- retapamulin oint 1% NC

AMCINONIDE- amcinonide cream0.1%

NC

AMCINONIDE- amcinonide lotion0.1%

NC

AMCINONIDE- amcinonide oint 0.1% NC

AMELUZ- aminolevulinic acid hcl gel10%

NC

APEXICON E- diflorasone diacetateemollient base cream 0.05%

NC

AUGMENTED BETAMETHASONED- betamethasone dipropionateaugmented gel 0.05%

NP

AZELEX- azelaic acid cream 20% NC

benzoyl peroxide-erythromycin gel5-3% (Benzamycin)

NC

betamethasone dipropionateaugmented cream 0.05%(Diprolene af)

np

betamethasone dipropionateaugmented lotion 0.05%(Diprolene)

np

betamethasone dipropionateaugmented oint 0.05% (Diprolene)

np

betamethasone dipropionate cream0.05%

np

betamethasone dipropionate lotion0.05%

np

betamethasone dipropionate oint0.05%

np

betamethasone valerate aerosolfoam 0.12% (Luxiq)

np

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betamethasone valerate cream0.1% (base equivalent)

np

betamethasone valerate lotion 0.1%(base equivalent)

np

betamethasone valerate oint 0.1%(base equivalent)

np

calcipotriene cream 0.005%(Dovonex)

np

calcipotriene oint 0.005% np

calcipotriene soln 0.005% (50 mcg/ml)

np

calcipotriene-betamethasonedipropionate oint 0.005-0.064%(Taclonex)

NC

CALCITRIOL- calcitriol oint 3 mcg/gm NC

CAPEX- fluocinolone acetonideshampoo 0.01%

NC

CARAC- fluorouracil cream 0.5% P

CENTANY- mupirocin oint 2% NC

ciclopirox gel 0.77% np

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

np

ciclopirox olamine susp 0.77%(base equiv) (Loprox)

np

ciclopirox shampoo 1% (Loproxshampoo)

np

ciclopirox solution 8% (Penlac NailLacquer)

np

CLINDAGEL- clindamycinphosphate gel 1%

NC

clindamycin phosph-benzoylperoxide (refrig) gel 1.2 (1)-5%(Duac)

np

CLINDAMYCIN PHOSPHATE-clindamycin phosphate gel 1%

NC

clindamycin phosphate foam 1%(Evoclin)

NC

clindamycin phosphate gel 1%(Cleocin-t)

np

clindamycin phosphate lotion 1%(Cleocin-t)

np

2019


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its

clindamycin phosphate soln 1%(Cleocin-t)

np

clindamycin phosphate swab 1%(Cleocin-t)

np

clindamycin phosphate-benzoylperoxide gel 1-5% (Benzaclin)

np

clindamycin phosphate-tretinoin gel 1.2-0.025% (Ziana)

NC

CLINDAMYCIN PHOSPHATE/BEN-clindamycin phosphate-benzoylperoxide gel 1.2-2.5%

P

clobetasol propionate cream 0.05%(Temovate)

np

clobetasol propionate emollientbase cream 0.05%

np

clobetasol propionate emulsionfoam 0.05% (Olux-e)

NC

clobetasol propionate foam 0.05%(Olux)

NC

clobetasol propionate gel 0.05%(Temovate)

np

clobetasol propionate lotion 0.05%(Clobex)

np

clobetasol propionate oint 0.05%(Temovate)

np

clobetasol propionate shampoo0.05% (Clobex)

np

clobetasol propionate soln 0.05%(Temovate)

np

clobetasol propionate spray 0.05%(Clobex)

NC

CLOCORTOLONE PIVALATE-clocortolone pivalate cream 0.1%

NC

CLOCORTOLONE PIVALATE PUM-clocortolone pivalate cream 0.1%

NC

CLODERM- clocortolone pivalatecream 0.1%

NC

CLODERM PUMP- clocortolonepivalate cream 0.1%

NC

clotrimazole cream 1% NC

clotrimazole soln 1% NC

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clotrimazole w/ betamethasonecream 1-0.05% (Lotrisone)

np

clotrimazole w/ betamethasonelotion 1-0.05%

np

CONDYLOX- podofilox gel 0.5% NP

CORDRAN- flurandrenolide tape4 mcg/sqcm

NC

CORTISPORIN- bacitracin-polymyxin-neomycin hc oint 1%

NC

CORTISPORIN- neomycin-polymyxin-hc crm 3.5 mg/gm-10000 unt/gm-0.5%

NC

COSENTYX- secukinumabsubcutaneous soln prefilled syringe150 mg/ml

P • • •

COSENTYX SENSOREADY PEN-secukinumab subcutaneous solnauto-injector 150 mg/ml

P • • •

crotamiton lotion 10% (Eurax) np

dapsone gel 5% (Aczone) NC

DENAVIR- penciclovir cream 1% NC

DESONATE- desonide gel 0.05% NC

desonide cream 0.05% (Desowen) np

desonide lotion 0.05% (Desowen) np

desonide oint 0.05% np

desoximetasone cream 0.05%(Topicort)

NC

desoximetasone cream 0.25%(Topicort)

np

desoximetasone gel 0.05%(Topicort)

np

desoximetasone oint 0.05%(Topicort)

NC

desoximetasone oint 0.25%(Topicort)

np

desoximetasone spray 0.25%(Topicort)

NC

diclofenac sodium (actinickeratoses) gel 3% (Solaraze)

np

diclofenac sodium gel 1% (Voltaren) np •

2019


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diclofenac sodium soln 1.5% np •DIFFERIN- adapalene lotion 0.1% NC

DIFLORASONE DIACETATE-diflorasone diacetate cream 0.05%

NC

diflorasone diacetate oint 0.05% NC

DOXEPIN HYDROCHLORIDE-doxepin hcl cream 5%

NC

DOXYCYCLINE- doxycycline(rosacea) cap delayed release40 mg

NC

DUPIXENT- dupilumab subcutaneoussoln prefilled syringe 300 mg/2ml

NC

econazole nitrate cream 1% np

ECOZA- econazole nitrate foam 1% NC

ELIDEL- pimecrolimus cream 1% P

ENSTILAR- calcipotriene-betamethasone dipropionate foam0.005-0.064%

P

EPIDUO FORTE- adapalene-benzoylperoxide gel 0.3-2.5%

P

EPIFOAM- pramoxine-hc aerosolfoam 1-1%

NC

ERTACZO- sertaconazole nitratecream 2%

NC

erythromycin gel 2% (Erygel) np

erythromycin pads 2% np

erythromycin soln 2% np

EUCRISA- crisaborole oint 2% P

EURAX- crotamiton cream 10% NP

EURAX- crotamiton lotion 10% NP

EXELDERM- sulconazole nitratecream 1%

NC

EXELDERM- sulconazole nitratesolution 1%

NC

FABIOR- tazarotene (acne) foam0.1%

NC

FINACEA- azelaic acid foam 15% P

FINACEA- azelaic acid gel 15% P

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FLECTOR- diclofenac epolaminepatch 1.3%

NC

fluocinolone acetonide cream0.01%

np

fluocinolone acetonide cream0.025% (Synalar)

np

fluocinolone acetonide oil 0.01%(body oil) (Derma-smoothe/fsbod)

np

fluocinolone acetonide oil 0.01%(scalp oil) (Derma-smoothe/fssca)

np

fluocinolone acetonide oint 0.025%(Synalar)

np

fluocinolone acetonide soln 0.01%(Synalar)

np

fluocinonide cream 0.05% np

fluocinonide cream 0.1% (Vanos) NC

fluocinonide emulsified base cream0.05%

np

fluocinonide gel 0.05% np

fluocinonide oint 0.05% np

fluocinonide soln 0.05% np

FLUOROPLEX- fluorouracil cream 1% NC

FLUOROURACIL- fluorouracil cream0.5%

NC

FLUOROURACIL- fluorouracil soln2%

NP

FLUOROURACIL- fluorouracil soln5%

NP

fluorouracil cream 5% (Efudex) np

flurandrenolide cream 0.05%(Cordran)

NC

flurandrenolide lotion 0.05%(Cordran)

NC

flurandrenolide oint 0.05%(Cordran)

NC

fluticasone propionate cream 0.05%(Cutivate)

np

2019


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fluticasone propionate lotion 0.05%(Cutivate)

NC

fluticasone propionate oint 0.005% np

gentamicin sulfate cream 0.1% np

gentamicin sulfate oint 0.1% np

halobetasol propionate cream0.05% (Ultravate)

np

halobetasol propionate oint 0.05%(Ultravate)

np

HALOG- halcinonide cream 0.1% NC

HALOG- halcinonide oint 0.1% NC

hydrocortisone butyrate cream0.1% (Locoid)

np

hydrocortisone butyratehydrophilic lipo base cream 0.1%(Locoid lipocream)

NC

hydrocortisone butyrate lotion 0.1%(Locoid)

NC

hydrocortisone butyrate oint 0.1%(Locoid)

np

hydrocortisone butyrate soln 0.1%(Locoid)

np

hydrocortisone cream 1% NC

hydrocortisone cream 2.5% p

hydrocortisone lotion 2.5% np

hydrocortisone oint 1% NC

hydrocortisone oint 2.5% p

hydrocortisone valerate cream0.2%

np

hydrocortisone valerate oint 0.2%(Westcort)

np

imiquimod cream 5% (Aldara) np

IMIQUIMOD PUMP- imiquimod cream3.75%

NP

IMPOYZ- clobetasol propionate cream0.025%

NC

isotretinoin cap 10 mg NC



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JUBLIA- efinaconazole soln 10% P

KERYDIN- tavaborole soln 5% P

ketoconazole cream 2% np

ketoconazole foam 2% (Extina) NC

ketoconazole shampoo 2% (Nizoral) p

lactic acid (ammonium lactate)cream 12% (Lac-hydrin)

NC

lactic acid (ammonium lactate)lotion 12% (Lac-hydrin)

NC

LEVULAN KERASTICK-aminolevulinic acid hcl for soln 20%(stick applicator)

NP

LIDOCAINE AND TETRACAINE-lidocaine-tetracaine cream 7-7%

NC

lidocaine hcl gel 2% NC

lidocaine hcl soln 4% (Xylocaine) p

lidocaine oint 5% NC

lidocaine patch 5% (Lidoderm) np • •lidocaine-prilocaine cream 2.5-2.5% np

LINDANE- lindane shampoo 1% NP

LULICONAZOLE- luliconazole cream1%

NC

LUZU- luliconazole cream 1% NC

mafenide acetate packet for topicalsoln 5% (50 gm) (Sulfamylon)

NC

malathion lotion 0.5% (Ovide) np

MENTAX- butenafine hcl cream 1% NC

methoxsalen rapid cap 10 mg(Oxsoralen ultra)

np

metronidazole cream 0.75%(Metrocream)

np

metronidazole gel 0.75% np

metronidazole gel 1% (Metrogel) np

metronidazole lotion 0.75%(Metrolotion)

np

MICORT-HC- hydrocortisone acetatecream 2.5%

NC

2019


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MIRVASO- brimonidine tartrate gel0.33% (base equivalent)

NP

mometasone furoate cream 0.1%(Elocon)

p

mometasone furoate oint 0.1%(Elocon)

p

mometasone furoate solution 0.1%(lotion) (Elocon)

p

mupirocin calcium cream 2%(Bactroban)

np

mupirocin oint 2% p

naftifine hcl cream 1% NC

naftifine hcl cream 2% (Naftin) NC

NAFTIN- naftifine hcl gel 1% NC

NAFTIN- naftifine hcl gel 2% NC

NATROBA- spinosad susp 0.9% NP

NEO-SYNALAR- neomycin sulfate-fluocinolone acetonide cream0.5-0.025%

NC

NORITATE- metronidazole cream 1% NC

nystatin cream 100000 unit/gm p

nystatin oint 100000 unit/gm p

nystatin topical powder 100000unit/gm

np

nystatin-triamcinolone cream100000-0.1 unit/gm-%

NC

nystatin-triamcinolone oint100000-0.1 unit/gm-%

NC

ONEXTON- clindamycin phosphate-benzoyl peroxide gel 1.2-3.75%

P

ORACEA- doxycycline (rosacea) capdelayed release 40 mg

P

oxiconazole nitrate cream 1%(Oxistat)

NC

OXISTAT- oxiconazole nitrate lotion1%

NC

PANDEL- hydrocortisone probutatecream 0.1%

NC

PANRETIN- alitretinoin gel 0.1% NC

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PENNSAID- diclofenac sodium soln2%

NP •

permethrin cream 5% (Elimite) np

PICATO- ingenol mebutate gel0.015%

P

PICATO- ingenol mebutate gel 0.05% P

PLIAGLIS- lidocaine-tetracaine cream7-7%

NC

PLIXDA- adapalene pads 0.1% NC

podofilox soln 0.5% (Condylox) np

PRAMOSONE- pramoxine-hc cream1-1%

NC

PRAMOSONE- pramoxine-hc lotion1-1%

NC

PRAMOSONE- pramoxine-hc lotion1-2.5%

NC

PREDNICARBATE- prednicarbatecream 0.1%

NP

PREDNICARBATE- prednicarbate oint0.1%

NP

PRUDOXIN- doxepin hcl cream 5% NC

PSORCON- diflorasone diacetatecream 0.05%

NC

REGRANEX- becaplermin gel 0.01% NP

RETIN-A MICRO- tretinoinmicrosphere gel 0.06%

NC

RETIN-A MICRO PUMP- tretinoinmicrosphere gel 0.08%

NC

RHOFADE- oxymetazoline hcl cream1%

NC

SANTYL- collagenase oint 250 unit/gm

NP

selenium sulfide lotion 2.5% p

SERNIVO- betamethasonedipropionate spray emulsion 0.05%(base equiv)

NC

SILIQ- brodalumab subcutaneous solnprefilled syringe 210 mg/1.5ml

NC

silver sulfadiazine cream 1%(Silvadene)

p

2019


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SKLICE- ivermectin lotion 0.5% NP

SOOLANTRA- ivermectin cream 1% P

SORILUX- calcipotriene foam 0.005% NC

SPINOSAD- spinosad susp 0.9% NP

STELARA- ustekinumab inj45 mg/0.5ml

P • • •

STELARA- ustekinumab soln prefilledsyringe 45 mg/0.5ml

P • • •

STELARA- ustekinumab soln prefilledsyringe 90 mg/ml

P • • •

sulfacetamide sodium lotion 10%(acne) (Klaron)

np

SULFAMYLON- mafenide acetatecream 85 mg/gm

NP

SYNERA- lidocaine-tetracaine topicalpatch 70-70 mg

NC

TACLONEX- calcipotriene-betamethasone dipropionate susp0.005-0.064%

P

tacrolimus oint 0.03% (Protopic) np

tacrolimus oint 0.1% (Protopic) np

TALTZ- ixekizumab subcutaneoussoln auto-injector 80 mg/ml

NC

TALTZ- ixekizumab subcutaneoussoln prefilled syringe 80 mg/ml

NC

TARGRETIN- bexarotene gel 1% NC

tazarotene cream 0.1% (Tazorac) np •TAZORAC- tazarotene cream 0.05% P

TAZORAC- tazarotene gel 0.05% P

TAZORAC- tazarotene gel 0.1% P

TEXACORT- hydrocortisone soln2.5%

NC

TOLAK- fluorouracil cream 4% NC

TOPICORT- desoximetasone spray0.25%

NC

TREMFYA- guselkumab soln prefilledsyringe 100 mg/ml

NC

tretinoin cream 0.025% (Retin-a) np •tretinoin cream 0.05% (Retin-a) np •

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tretinoin cream 0.1% (Retin-a) np •tretinoin gel 0.01% (Retin-a) np •tretinoin gel 0.025% (Retin-a) np •tretinoin gel 0.05% (Atralin) np •tretinoin microsphere gel 0.04%

(Retin-a micro)NC

tretinoin microsphere gel 0.1%(Retin-a micro)

NC

triamcinolone acetonide aerosolsoln 0.147 mg/gm (Kenalog)

np

triamcinolone acetonide cream0.025%

p


p


p

triamcinolone acetonide lotion0.025%

np

triamcinolone acetonide lotion 0.1% np

triamcinolone acetonide oint0.025%

p

triamcinolone acetonide oint 0.1% p

triamcinolone acetonide oint 0.5% p

TRIANEX- triamcinolone acetonideoint 0.05%

NC

ULESFIA- benzyl alcohol lotion 5% NP

ULTRAVATE- halobetasol propionatelotion 0.05%

NC

VALCHLOR- mechlorethamine hcl gel0.016% (base equivalent)

P •

VECTICAL- calcitriol oint 3 mcg/gm NC

VELTIN- clindamycin phosphate-tretinoin gel 1.2-0.025%

NC

VERDESO- desonide foam 0.05% NC

VEREGEN- sinecatechins oint 15% NP

VUSION- miconazole-zinc oxide-whitepetrolatum oint 0.25-15-81.35%

NC

XERESE- acyclovir-hydrocortisonecream 5-1%

NC

2019


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XOLEGEL- ketoconazole gel 2% NC

ZONALON- doxepin hcl cream 5% NC

ZOVIRAX- acyclovir cream 5% NC

ZYCLARA- imiquimod cream 3.75% P

ZYCLARA PUMP- imiquimod cream2.5%

P

ZYCLARA PUMP- imiquimod cream3.75%

P

MISCELLANEOUS PRODUCTSANTIDOTESCETYLEV- acetylcysteine

effervescent tab 500 mgNP

CETYLEV- acetylcysteineeffervescent tab 2.5 gm

NP

CHEMET- succimer cap 100 mg P

EVZIO- naloxone hcl solution auto-injector 2 mg/0.4ml

NC

EXJADE- deferasirox tab for oral susp125 mg

NP •


NP •


NP •

FERRIPROX- deferiprone oral soln100 mg/ml

NP •

FERRIPROX- deferiprone tab 500 mg NP •JADENU- deferasirox tab 90 mg NP •JADENU- deferasirox tab 180 mg NP •JADENU- deferasirox tab 360 mg NP •JADENU SPRINKLE-

deferasirox granules packet 90 mgNP •

JADENU SPRINKLE-deferasirox granules packet 180 mg

NP •

JADENU SPRINKLE-deferasirox granules packet 360 mg

NP •

NALOXONE HCL- naloxone hcl solncartridge 0.4 mg/ml

NP

NALOXONE HCL- naloxone hcl solnprefilled syringe 2 mg/2ml

NP

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naloxone hcl inj 0.4 mg/ml np

naloxone hcl inj 4 mg/10ml np

naltrexone hcl tab 50 mg np

NARCAN- naloxone hcl nasal spray4 mg/0.1ml

P

RADIOGARDASE- prussian blueinsoluble cap 0.5 gm

NP

VISTOGARD- uridine triacetateoral granules packet 10 gm

NC

DIAGNOSTIC PRODUCTSACCU-CHEK AVIVA PLUS- glucose

blood test stripNC

ACCU-CHEK COMPACTPLUS- glucose blood test strip

NC

ACCU-CHEK COMPACTSTRIPS- glucose blood test strip

NC

ACCU-CHEK COMPACT TESTDR- glucose blood test strip

NC

ACCU-CHEK GUIDE- glucose bloodtest strip

NC

ACCU-CHEK SMARTVIEWSTRIP- glucose blood test strip

NC

ACCUTREND GLUCOSE- glucoseblood test strip

NC

ADVANCE INTUITION TESTST- glucose blood test strip

NC

ADVANCE MICRO-DRAW TESTS- glucose blood test strip

NC

ADVOCATE REDI-CODE- glucoseblood test strip

NC

ADVOCATE REDI-CODE+TEST- glucose blood test strip

NC

ADVOCATE TEST STRIPS- glucoseblood test strip

NC

AGAMATRIX AMP NO CODETES- glucose blood test strip

NC

AGAMATRIX JAZZ TESTSTRIP- glucose blood test strip

NC

AGAMATRIX KEYNOTE TESTST- glucose blood test strip

NC

2019


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AGAMATRIX PRESTO TESTSTR- glucose blood test strip

NC

ASSURE II- glucose blood test strip NC

ASSURE II CHECK STRIP- glucoseblood test strip

NC

ASSURE II TEST STRIPS- glucoseblood test strip

NC

ASSURE PLATINUM TESTSTRI- glucose blood test strip

NC

ASSURE PRISM MULTI TESTS- glucose blood test strip

NC

ASSURE PRO TESTSTRIPS- glucose blood test strip

NC

ASSURE 3 TEST STRIPS- glucoseblood test strip

NC

ASSURE 4 TEST STRIPS- glucoseblood test strip

NC

AT LAST TEST STRIPS- glucoseblood test strip

NC

BAYER BREEZE 2 TESTDISC- glucose blood test disk

P •

BAYER CONTOUR BLOODGLUCO- glucose blood test strip

P •

BIOSCANNER GLUCOSE TESTS- glucose blood test strip

NC

BLOOD GLUCOSE TESTSTRIPS- glucose blood test strip

NC

CAREONE BLOOD GLUCOSETES- glucose blood test strip

NC

CARESENS N BLOODGLUCOSE- glucose blood test strip

NC

CARETOUCH BLOOD GLUCOSET- glucose blood test strip

NC

CLEVER CHEK AUTO-CODETES- glucose blood test strip

NC

CLEVER CHEK AUTO-CODEVOI- glucose blood test strip

NC

CLEVER CHEK TESTSTRIPS- glucose blood test strip

NC

CLEVER CHOICE AUTO-CODEP- glucose blood test strip

NC

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CLEVER CHOICE MICROTEST- glucose blood test strip

NC

CLEVER CHOICE NO CODINGT- glucose blood test strip

NC

CLEVER CHOICE TALK NOCOD- glucose blood test strip

NC

CONTOUR NEXT BLOODGLUCOS- glucose blood test strip

P •

COOL BLOOD GLUCOSE TESTS- glucose blood test strip

NC

CVS ADVANCED GLUCOSEMETE- glucose blood test strip

NC

DIATRUE PLUS BLOODGLUCOS- glucose blood test strip

NC

DUO-CARE TEST STRIPS- glucoseblood test strip

NC

EASY PLUS BLOOD GLUCOSET- glucose blood test strip

NC

EASY PLUS II BLOODGLUCOS- glucose blood test strip

NC

EASY STEP TEST STRIPS- glucoseblood test strip

NC

EASY TALK BLOOD GLUCOSET- glucose blood test strip

NC

EASY TOUCH GLUCOSE TESTS- glucose blood test strip

NC

EASY TOUCH HEALTHPROGLUC- glucose blood test strip

NC

EASY TRAK BLOOD GLUCOSET- glucose blood test strip

NC

EASYGLUCO- glucose blood test strip NC

EASYGLUCO PLUS- glucose bloodtest strip

NC

EASYMAX TEST STRIPS- glucoseblood test strip

NC

EASYMAX 15 TEST STRIPS- glucoseblood test strip

NC

EASYPLUS BLOOD GLUCOSETE- glucose blood test strip

NC

EASYPRO BLOOD GLUCOSETES- glucose blood test strip

NC

2019


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EASYPRO PLUS- glucose blood teststrip

NC

ELEMENT COMPACT TESTSTRI- glucose blood test strip

NC

ELEMENT TEST STRIPS- glucoseblood test strip

NC

EMBRACE BLOOD GLUCOSETES- glucose blood test strip

NC

EMBRACE EVO BLOODGLUCOSE- glucose blood test strip

NC

EMBRACE PRO BLOODGLUCOSE- glucose blood test strip

NC

EQ BLOOD GLUCOSE TESTSTR- glucose blood test strip

NC

EVENCARE + BLOODGLUCOSE- glucose blood test strip

NC

EVENCARE BLOOD GLUCOSETE- glucose blood test strip

NC

EVENCARE G2 TESTSTRIPS- glucose blood test strip

NC

EVENCARE G3 TESTSTRIPS- glucose blood test strip

NC

EVENCARE MINI BLOODGLUCO- glucose blood test strip

NC

EVOLUTION AUTOCODE- glucoseblood test strip

NC

EXACTECH R-S-G TESTSTRIP- glucose blood test strip

NC

EXACTECH TEST STRIPS- glucoseblood test strip

NC

EZ SMART BLOOD GLUCOSETE- glucose blood test strip

NC

EZ SMART PLUS BLOODGLUCO- glucose blood test strip

NC

FIFTY50 GLUCOSE TESTSTRI- glucose blood test strip

NC

FORA BLOOD GLUCOSE TESTS- glucose blood test strip

NC

FORA D15G BLOOD GLUCOSET- glucose blood test strip

NC

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FORA D20 BLOOD GLUCOSETE- glucose blood test strip

NC

FORA D40/G31 BLOODGLUCOS- glucose blood test strip

NC

FORA GD20 TEST STRIPS- glucoseblood test strip

NC

FORA GD50 BLOOD GLUCOSET- glucose blood test strip

NC

FORA G20 BLOOD GLUCOSETE- glucose blood test strip

NC

FORA G30/PREMIUM V10BLOO- glucose blood test strip

NC

FORA TN'G/TN'G VOICEBLOO- glucose blood test strip

NC

FORA V10 BLOOD GLUCOSETE- glucose blood test strip

NC


NC


NC

FORA V30A BLOOD GLUCOSET- glucose blood test strip

NC

FORACARE GD40- glucose bloodtest strip

NC

FORACARE PREMIUM V10TEST- glucose blood test strip

NC

FORACARE TEST N GO TESTS- glucose blood test strip

NC

FORTISCARE BLOODGLUCOSE- glucose blood test strip

NC

FREESTYLE INSULINXBLOOD- glucose blood test strip

NC

FREESTYLE LITE TESTSTRIP- glucose blood test strip

NC

FREESTYLE PRECISION NEOB- glucose blood test strip

NC

FREESTYLE TEST STRIPS- glucoseblood test strip

NC

GENSTRIP 50- glucose blood teststrip

NC

2019


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GENULTIMATE TESTSTRIPS- glucose blood test strip

NC

GE100 BLOOD GLUCOSETEST- glucose blood test strip

NC

GHT TEST STRIPS- glucose bloodtest strip

NC

GLUCO PERFECT 3 TESTSTRI- glucose blood test strip

NC

GLUCOCARD EXPRESSIONBLOO- glucose blood test strip

NC

GLUCOCARD SHINE TESTSTRI- glucose blood test strip

NC

GLUCOCARD VITAL TESTSTRI- glucose blood test strip

NC

GLUCOCARD X-SENSOR- glucoseblood test strip

NC

GLUCOCARD 01 SENSORPLUS- glucose blood test strip

NC

GLUCOCOM TEST STRIPS- glucoseblood test strip

NC

GLUCONAVII BLOODGLUCOSE- glucose blood test strip

NC

GLUCOSE METER TESTSTRIPS- glucose blood test strip

NC

GNP EASY TOUCH GLUCOSETE- glucose blood test strip

NC

GOODSENSE PREMIUM BLOODG- glucose blood test strip

NC

IGLUCOSE BLOOD GLUCOSETE- glucose blood test strip

NC

IN TOUCH BLOOD GLUCOSETE- glucose blood test strip

NC

INFINITY BLOOD GLUCOSETE- glucose blood test strip

NC

INFINITY VOICE- glucose blood teststrip

NC

KROGER BLOOD GLUCOSETEST- glucose blood test strip

NC

KROGER PREMIUM BLOODGLUC- glucose blood test strip

NC

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KROGER TEST STRIPS- glucoseblood test strip

NC

LIBERTY NEXT GENERATIONB- glucose blood test strip

NC

LIBERTY TEST STRIPS- glucoseblood test strip

NC

MEIJER BLOOD GLUCOSETEST- glucose blood test strip

NC

MEIJER ESSENTIAL BLOODGL- glucose blood test strip

NC

MEIJER PREMIUM BLOODGLUC- glucose blood test strip

NC

MEIJER TRUETEST BLOODGLU- glucose blood test strip

NC

MEIJER TRUETRACK BLOODGL- glucose blood test strip

NC

MICRODOT TEST STRIPS- glucoseblood test strip

NC

MM EASY TOUCH GLUCOSETES- glucose blood test strip

NC

MYGLUCOHEALTH BLOODGLUCO- glucose blood test strip

NC

NEUTEK 2TEK TESTSTRIPS- glucose blood test strip

NC

NOVA MAX GLUCOSE TESTSTR- glucose blood test strip

NC

ON CALL EXPRESS BLOODGLU- glucose blood test strip

NC

ON CALL PLUS BLOODGLUCOS- glucose blood test strip

NC

ON CALL VIVID BLOODGLUCO- glucose blood test strip

NC

ONETOUCH ULTRA BLUE- glucoseblood test strip

NC

ONETOUCH ULTRA TESTSTRIP- glucose blood test strip

NC

ONETOUCH VERIO TESTSTRIP- glucose blood test strip

NC

OPTIUM TEST STRIPS- glucoseblood test strip

NC

2019


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OPTIUMEZ TEST STRIPS- glucoseblood test strip

NC

OPTUMRX BLOOD GLUCOSETES- glucose blood test strip

NC

PHARMACIST CHOICEAUTOCOD- glucose blood test strip

NC

PHARMACIST CHOICE NOCODI- glucose blood test strip

NC

POCKETCHEM EZ BLOODGLUCO- glucose blood test strip

NC

PRECISION PCX- glucose blood teststrip

NC

PRECISION PCX PLUS TESTS- glucose blood test strip

NC

PRECISION POINT OF CARET- glucose blood test strip

NC

PRECISION QID TESTSTRIPS- glucose blood test strip

NC

PRECISION SOF-TACT TESTS- glucose blood test strip

NC

PRECISION XTRA BLOODGLUC- glucose blood test strip

NC

PREMIUM BLOOD GLUCOSETES- glucose blood test strip

NC

PRESTIGE TEST STRIPS- glucoseblood test strip

NC

PRO VOICE V8/V9 BLOODGLU- glucose blood test strip

NC

PRODIGY NO CODING BLOODG- glucose blood test strip

NC

PTS PANELS GLUCOSETEST- glucose blood test strip

NC

QUICKTEK TEST STRIPS- glucoseblood test strip

NC

QUINTET AC BLOODGLUCOSE- glucose blood test strip

NC

QUINTET BLOOD GLUCOSETES- glucose blood test strip

NC

RA TRUETEST STRIPS- glucoseblood test strip

NC

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REFUAH PLUS BLOODGLUCOSE- glucose blood test strip

NC

RELION BLOOD GLUCOSETEST- glucose blood test strip

NC

RELION CONFIRM/MICROTEST- glucose blood test strip

NC

RELION PREMIER BLOODGLUC- glucose blood test strip

NC

RELION PRIME BLOODGLUCOS- glucose blood test strip

NC

RELION ULTIMA BLOODGLUCO- glucose blood test strip

NC

RELION ULTIMA TESTSTRIPS- glucose blood test strip

NC

REVEAL BLOOD GLUCOSETEST- glucose blood test strip

NC

REXALL BLOOD GLUCOSETEST- glucose blood test strip

NC

RIGHTEST GS100 BLOODGLUC- glucose blood test strip

NC


NC


NC

SMART SENSE PREMIUMBLOOD- glucose blood test strip

NC

SMART SENSE VALUE BLOODG- glucose blood test strip

NC

SMARTEST BLOOD GLUCOSETE- glucose blood test strip

NC

SOLUS V2 AUDIBLE TEST- glucoseblood test strip

NC

SUPREME TEST STRIPS- glucoseblood test strip

NC

SURE EDGE BLOOD GLUCOSET- glucose blood test strip

NC

SURE-TEST EASYPLUS MINIB- glucose blood test strip

NC

SURECHEK BLOOD GLUCOSETE- glucose blood test strip

NC

2019


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TELCARE BLOOD GLUCOSETES- glucose blood test strip

NC

TGT BLOOD GLUCOSE TESTST- glucose blood test strip

NC

TRUE FOCUS SELFMONITORIN- glucose blood teststrip

NC

TRUE METRIX BLOODGLUCOSE- glucose blood test strip

NC

TRUE METRIX SELFMONITORI- glucose blood test strip

NC

TRUETEST BLOOD GLUCOSET- glucose blood test strip

NC

TRUETEST STRIPS- glucose bloodtest strip

NC

TRUETRACK BLOOD GLUCOSET- glucose blood test strip

NC

TRUETRACK TEST- glucose bloodtest strip

NC

ULTIMA TEST STRIPS- glucose bloodtest strip

NC

ULTRATRAK PRO TESTSTRIPS- glucose blood test strip

NC

ULTRATRAK ULTIMATE TESTS- glucose blood test strip

NC

UNISTRIP1 GENERIC- glucose bloodtest strip

NC

VERASENS BLOOD GLUCOSETE- glucose blood test strip

NC

VICTORY AGM-4000 TESTSTR- glucose blood test strip

NC

VOCAL POINT BLOODGLUCOSE- glucose blood test strip

NC

WAVESENSE PRESTO TESTSTR- glucose blood test strip

NC

MEDICAL DEVICESADULT MASK- respiratory therapy

supplies - devicesP

AEROBIKA- respiratory therapysupplies - devices

P

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AEROCHAMBER MINI AEROSOL-spacer/aerosol-holding chambers -device

P

AEROCHAMBER MV- spacer/aerosol-holding chambers - device

P

AEROCHAMBER PLUS FLOW-VU-spacer/aerosol-holding chambers -device

P

AEROCHAMBER PLUS FLOW-VU/-spacer/aerosol-holding chambers -device

P

AEROCHAMBER Z-STAT PLUS V-spacer/aerosol-holding chambers -device

P

AEROCHAMBER Z-STAT PLUS/F-spacer/aerosol-holding chambers -device

P

AEROCHAMBER Z-STAT PLUS/L-spacer/aerosol-holding chambers -device

P

AEROCHAMBER Z-STAT PLUS/M-spacer/aerosol-holding chambers -device

P

AEROCHAMBER Z-STAT PLUS/S-spacer/aerosol-holding chambers -device

P

AEROVENT PLUS HOLDING CHA-spacer/aerosol-holding chambers -device

P

ALL FLOW 1000 PFT FILTER-respiratory therapy supplies -devices

P


P


P


P

2019


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P


P


P

AMIELLE RESTORE VAGINAL E-misc. devices

P

ARIAL CHAMBER- spacer/aerosol-holding chambers - device

P

BAYER BREEZE 2 HIGH CONTR-blood glucose calibration - liquid -high

P

BAYER BREEZE 2 LOW CONTRO-blood glucose calibration - liquid -low

P

BAYER BREEZE 2 NORMAL CON-blood glucose calibration - liquid -normal

P

BAYER CONTOUR HIGH CONTRO-blood glucose calibration - liquid -high

P

BAYER CONTOUR LOW CONTROL-blood glucose calibration - liquid -low

P

BAYER CONTOUR NORMAL CONT-blood glucose calibration - liquid -normal

P

BREATHERITE- spacer/aerosol-holding chambers - device

P

BREATHERITE COLLAPSIBLE-spacer/aerosol-holding chambers -device

P

BREATHERITE RIGID SPACER-spacer/aerosol-holding chambers -device

P

BREATHERITE VALVED MDI CH-respiratory therapy supplies -devices

P

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BREATHERITE W/LARGE MASK-spacer/aerosol-holding chambers -device

P

BREATHERITE W/MEDIUM MASK-spacer/aerosol-holding chambers -device

P

BREATHERITE W/SMALL MASK-spacer/aerosol-holding chambers -device

P

CAYA- diaphragm arc-spring P

CLEVER CHOICE ANTI-STATIC-spacer/aerosol-holding chambers -device

P

CO MONITOR- respiratory therapysupplies - devices

P

COMPACT SPACE CHAMBER/ANT-spacer/aerosol-holding chambers -device

P

CONTOUR NEXT CONTROL LEVE-blood glucose calibration - liquid -low

P

CONTOUR NEXT CONTROL LEVE-blood glucose calibration - liquid -normal

P

EASIVENT- spacer/aerosol-holdingchambers - device

P

EASIVENT/MASK-LARGE- spacer/aerosol-holding chambers - device

P

EASIVENT/MASK-MEDIUM- spacer/aerosol-holding chambers - device

P

EASIVENT/MASK-SMALL- spacer/aerosol-holding chambers - device

P

FC FEMALE CONDOM- condoms -female

P

FC2 FEMALE CONDOM- condoms -female

P

FEMCAP- cervical cap 22 mm P



FLEXICHAMBER- spacer/aerosol-holding chambers - device

P

2019


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FLEXICHAMBER ADULT MASK/S-spacer/aerosol-holding chambersupplies - masks

P

FLEXICHAMBER CHILD MASK/L-spacer/aerosol-holding chambersupplies - masks

P

FLEXICHAMBER CHILD MASK/S-spacer/aerosol-holding chambersupplies - masks

P

IN-CHECK DIAL INSPIRATORY-respiratory therapy supplies -devices

P

IN-CHECK INSPIRATORY FLOW-respiratory therapy supplies -devices

P

INSPIRACHAMBER/ANTI-STATI-spacer/aerosol-holding chambers -device

P

INSPIRACHAMBER/LARGE- spacer/aerosol-holding chambers - device

P

INSPIRACHAMBER/SOOTHERMAS-spacer/aerosol-holding chambers -device

P

INSPIREASE DRUG DELIVERY-spacer/aerosol-holding chambers -device

P

INSPIREASE RESERVOIR BAGS-spacer/aerosol-holding chambersupplies - bags

P

INSULIN PEN NEEDLES – VARIOUS P

INSULIN SYRINGES – VARIOUS P

LANCETS – VARIOUS P

LITEAIRE- spacer/aerosol-holdingchambers - device

P

MASK VORTEX/BABY WHIRL DU-spacer/aerosol-holding chambersupplies - masks

P

MASK VORTEX/CHILD/FROG-spacer/aerosol-holding chambersupplies - masks

P

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MASK VORTEX/SPINNER THE D-spacer/aerosol-holding chambersupplies - masks

P

MASK VORTEX/TODDLER/LADY-spacer/aerosol-holding chambersupplies - masks

P

MICROCHAMBER- spacer/aerosol-holding chambers - device

P

MICROSPACER- spacer/aerosol-holding chambers - device

P

MISC NEEDLES & SYRINGES –VARIOUS

P

MISTASSIST- respiratory therapysupplies - devices

P

NEBULIZER CUP/TUBING-respiratory therapy supplies -devices

P

OMBRA TABLE TOP COMPRESSO-respiratory therapy supplies -devices

P

OMNIFLEX DIAPHRAGM-diaphragms

P

ONE FLOW FVC MONITORINGS- respiratory therapy supplies -devices

P

OPTICHAMBER- spacer/aerosol-holding chambers - device

P

OPTICHAMBER ADVANTAGE/LAR-spacer/aerosol-holding chambers -device

P

OPTICHAMBER ADVANTAGE/MED-spacer/aerosol-holding chambers -device

P

OPTICHAMBER ADVANTAGE/SMA-spacer/aerosol-holding chambers -device

P

OPTICHAMBER DIAMOND- spacer/aerosol-holding chambers - device

P

OPTICHAMBER DIAMOND/LARGE-spacer/aerosol-holding chambers -device

P

2019


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OPTICHAMBER DIAMOND/MEDIU-spacer/aerosol-holding chambers -device

P

OPTICHAMBER DIAMOND/SMALL-spacer/aerosol-holding chambers -device

P

OPTICHAMBER FACE MASK/LAR-spacer/aerosol-holding chambers -device

P

OPTICHAMBER FACE MASK/MED-spacer/aerosol-holding chambers -device

P

OPTICHAMBER FACE MASK/SMA-spacer/aerosol-holding chambers -device

P

OPTIHALER- spacer/aerosol-holdingchambers - device

P

OPTIHALER MDI DRUG DELIVE-spacer/aerosol-holding chambers -device

P

PANDA MASK LARGE- spacer/aerosol-holding chamber supplies -masks

P

PANDA MASK MEDIUM- spacer/aerosol-holding chamber supplies -masks

P

PANDA MASK SMALL- spacer/aerosol-holding chamber supplies -masks

P

PARI MANUAL INTERRUPTER-respiratory therapy supplies -devices

P

PARI TREK S COMBO PACK-respiratory therapy supplies -devices

P

PEDIATRIC PANDA MASK- spacer/aerosol-holding chamber supplies -masks

P

POCKET CHAMBER- spacer/aerosol-holding chambers - device

P

POCKET SPACER- spacer/aerosol-holding chambers - device

P

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PRIMEAIRE DUAL-VALVED HOL-respiratory therapy supplies -devices

P

PULMONEB LT COMPRESSOR/NE- respiratory therapy supplies -devices

P

QUAKE- respiratory therapy supplies -devices

P

RITEFLO- spacer/aerosol-holdingchambers - device

P

SPIRO PD- respiratory therapysupplies - devices

P

THRESHOLD PEP- respiratorytherapy supplies - devices

P

VALVED HOLDING CHAMBER-spacer/aerosol-holding chambers -device

P

VORTEX HOLDING CHAMBER/MA- respiratory therapy supplies -devices

P

VORTEX VALVED HOLDING CHA-spacer/aerosol-holding chambers -device

P

WATCHHALER- spacer/aerosol-holding chambers - device

P

WIDE-SEAL SILICONE DIAPHR-diaphragm wide seal 60 mm

P


P


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P


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P


P


P

ASSORTED CLASSES

2019


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ASTAGRAF XL- tacrolimus cap er24hr 0.5 mg

NP

ASTAGRAF XL- tacrolimus cap er24hr 1 mg

NP

ASTAGRAF XL- tacrolimus cap er24hr 5 mg

NP

AZASAN- azathioprine tab 75 mg NP

AZASAN- azathioprine tab 100 mg NP

azathioprine tab 50 mg (Imuran) np

BENLYSTA- belimumab subcutaneoussolution auto-injector 200 mg/ml

NP • • •

BENLYSTA- belimumab subcutaneoussolution prefilled syringe 200 mg/ml

NP • • •

CELLCEPT- mycophenolate mofetilcap 250 mg

NP

CELLCEPT- mycophenolate mofetiltab 500 mg

NP

CUPRIMINE- penicillamine cap250 mg

P •

cyclosporine cap 25 mg(Sandimmune)

np

cyclosporine cap 100 mg(Sandimmune)

np

CYCLOSPORINE MODIFIED-cyclosporine modified cap 50 mg

P

cyclosporine modified cap 25 mg(Neoral)

np

cyclosporine modified cap 100 mg(Neoral)

np

cyclosporine modified oral soln100 mg/ml (Neoral)

np

DEPEN TITRATABS- penicillaminetab 250 mg

P •

ENVARSUS XR- tacrolimus tab er24hr 0.75 mg

NP

ENVARSUS XR- tacrolimus tab er24hr 1 mg

NP

ENVARSUS XR- tacrolimus tab er24hr 4 mg

NP

IMURAN- azathioprine tab 50 mg NP

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mycophenolate mofetil cap 250 mg(Cellcept)

np

mycophenolate mofetil for oralsusp 200 mg/ml (Cellcept)

np

mycophenolate mofetil tab 500 mg(Cellcept)

np

mycophenolate sodium tab dr180 mg (mycophenolic acidequiv) (Myfortic)

np

mycophenolate sodium tab dr360 mg (mycophenolic acidequiv) (Myfortic)

np

MYFORTIC- mycophenolate sodiumtab dr 180 mg (mycophenolic acidequiv)

NP

MYFORTIC- mycophenolate sodiumtab dr 360 mg (mycophenolic acidequiv)

NP

NEORAL- cyclosporine modified cap25 mg

NP

NEORAL- cyclosporine modified cap100 mg

NP

NEORAL- cyclosporine modified oralsoln 100 mg/ml

NP

PROGRAF- tacrolimus cap 0.5 mg NP

PROGRAF- tacrolimus cap 1 mg NP

PROGRAF- tacrolimus cap 5 mg NP

RAPAMUNE- sirolimus oral soln 1 mg/ml

NP

REVLIMID- lenalidomide caps 2.5 mg P • • •REVLIMID- lenalidomide cap 5 mg P • • •REVLIMID- lenalidomide cap 10 mg P • • •REVLIMID- lenalidomide cap 15 mg P • • •REVLIMID- lenalidomide cap 20 mg P • • •REVLIMID- lenalidomide cap 25 mg P • • •SANDIMMUNE- cyclosporine cap

25 mgNP

SANDIMMUNE- cyclosporine cap100 mg

NP

2019


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SANDIMMUNE- cyclosporine oral soln100 mg/ml

NP

sirolimus tab 0.5 mg (Rapamune) np

sirolimus tab 1 mg (Rapamune) np

sirolimus tab 2 mg (Rapamune) np

sodium polystyrene sulfonate oralsusp 15 gm/60ml

np

sodium polystyrene sulfonatepowder (Kayexalate)

np

sodium polystyrene sulfonaterectal susp 30 gm/120ml

np

tacrolimus cap 0.5 mg (Prograf) np

tacrolimus cap 1 mg (Prograf) np

tacrolimus cap 5 mg (Prograf) np

THALOMID- thalidomide cap 50 mg P • • •THALOMID- thalidomide cap 100 mg P • • •THALOMID- thalidomide cap 150 mg P • • •THALOMID- thalidomide cap 200 mg P • • •trientine hcl cap 250 mg (Syprine) np •VELTASSA- patiromer sorbitex

calcium for susp packet 8.4 gm(base eq)

NP

VELTASSA- patiromer sorbitexcalcium for susp packet 16.8 gm(base eq)

NP

VELTASSA- patiromer sorbitexcalcium for susp packet 25.2 gm(base eq)

NP

ZORTRESS- everolimus tab 0.25 mg NP



2019


INDEX

Aabacavir sulfate-lamivudine tab 600-300 mg

(Epzicom)......................................................................... 5abacavir sulfate-lamivudine-zidovudine tab

300-150-300 mg (Trizivir)................................................5abacavir sulfate soln 20 mg/ml (base equiv)

(Ziagen).............................................................................5abacavir sulfate tab 300 mg (base equiv) (Ziagen)........5ABSORICA -isotretinoin cap 10 mg................................ 110ABSORICA -isotretinoin cap 20 mg................................ 110ABSORICA -isotretinoin cap 25 mg................................ 110ABSORICA -isotretinoin cap 30 mg................................ 110ABSORICA -isotretinoin cap 35 mg................................ 110ABSORICA -isotretinoin cap 40 mg................................ 110ABSTRAL -fentanyl citrate sl tab 100 mcg (base

equiv)...............................................................................74ABSTRAL -fentanyl citrate sl tab 200 mcg (base





equiv)...............................................................................74acamprosate calcium tab delayed release 333 mg......71ACANYA -clindamycin phosphate-benzoyl peroxide gel

1.2-2.5%........................................................................ 110acarbose tab 25 mg (Precose)....................................... 22acarbose tab 50 mg (Precose)....................................... 22acarbose tab 100 mg (Precose)..................................... 22ACCU-CHEK AVIVA PLUS -glucose blood test strip...... 117ACCU-CHEK COMPACT PLUS -glucose blood test

strip................................................................................117ACCU-CHEK COMPACT STRIPS -glucose blood test

strip................................................................................117ACCU-CHEK COMPACT TEST DR -glucose blood test

strip................................................................................117ACCU-CHEK GUIDE -glucose blood test strip............... 117ACCU-CHEK SMARTVIEW STRIP -glucose blood test

strip................................................................................117ACCUTREND GLUCOSE -glucose blood test strip........117acebutolol hcl cap 200 mg............................................. 34acebutolol hcl cap 400 mg............................................. 34ACETAMINOPHEN/CAFFEINE/DI -acetaminophen-

caffeine-dihydrocodeine cap 320.5-30-16 mg................74acetaminophen-caffeine-dihydrocodeine tab

325-30-16 mg................................................................. 74acetaminophen w/ codeine soln 120-12 mg/5ml..........74acetaminophen w/ codeine tab 300-15 mg (Tylenol/

codeine)..........................................................................74

acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3).................................................................... 74

acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4).................................................................... 74

acetazolamide cap er 12hr 500 mg (Diamox)............... 42acetazolamide tab 125 mg..............................................42acetazolamide tab 250 mg..............................................42acetic acid otic soln 2%................................................109acetylcysteine inhal soln 10%........................................48acetylcysteine inhal soln 20%........................................48ACIPHEX SPRINKLE -rabeprazole sodium capsule

sprinkle dr 5 mg..............................................................53ACIPHEX SPRINKLE -rabeprazole sodium capsule

sprinkle dr 10 mg............................................................53acitretin cap 10 mg (Soriatane)....................................110acitretin cap 17.5 mg (Soriatane).................................110acitretin cap 25 mg (Soriatane)....................................110ACTEMRA -tocilizumab subcutaneous soln prefilled

syringe 162 mg/0.9ml..................................................... 80ACTHIB -haemophilus b polysaccharide conjugate

vaccine for inj..................................................................10ACTIMMUNE -interferon gamma-1b inj 100 mcg/0.5ml

(2000000 unit/0.5ml).......................................................12ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab

er 24hr 15-1000 mg........................................................22ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab

er 24hr 30-1000 mg........................................................22ACUVAIL -ketorolac tromethamine (pf) ophth soln

0.45%.............................................................................106acyclovir cap 200 mg (Zovirax)........................................5acyclovir oint 5% (Zovirax)...........................................110acyclovir susp 200 mg/5ml (Zovirax).............................. 5acyclovir tab 400 mg (Zovirax)........................................ 5acyclovir tab 800 mg (Zovirax)........................................ 5ACZONE -dapsone gel 7.5%.......................................... 110ADACEL -tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-

mcg/0.5ml........................................................................11ADAPALENE -adapalene lotion 0.1%............................. 110ADAPALENE -adapalene soln 0.1%............................... 110adapalene-benzoyl peroxide gel 0.1-2.5%

(Epiduo)........................................................................ 111adapalene cream 0.1% (Differin)..................................110adapalene gel 0.1% (Differin)....................................... 110adapalene gel 0.3% (Differin)....................................... 110ADASUVE -loxapine aerosol powder breath activated 10

mg....................................................................................63ADCIRCA -tadalafil tab 20 mg (pah).................................45ADDERALL XR -amphetamine-dextroamphetamine cap

er 24hr 5 mg...................................................................67ADDERALL XR -amphetamine-dextroamphetamine cap

er 24hr 10 mg.................................................................67ADDERALL XR -amphetamine-dextroamphetamine cap



er 24hr 25 mg.................................................................67

2019


ADDERALL XR -amphetamine-dextroamphetamine caper 24hr 30 mg.................................................................67

ADDYI -flibanserin tab 100 mg......................................... 71adefovir dipivoxil tab 10 mg (Hepsera)...........................5ADEMPAS -riociguat tab 0.5 mg.......................................45ADEMPAS -riociguat tab 1 mg..........................................45ADEMPAS -riociguat tab 1.5 mg.......................................45ADEMPAS -riociguat tab 2 mg..........................................45ADEMPAS -riociguat tab 2.5 mg.......................................45ADLYXIN -lixisenatide soln pen-injector 20 mcg/0.2ml

(100 mcg/ml)................................................................... 22ADLYXIN STARTER PACK -lixisenatide pen-inj starter kit

10 mcg/0.2ml & 20 mcg/0.2ml....................................... 22ADMELOG -insulin lispro inj 100 unit/ml...........................25ADMELOG SOLOSTAR -insulin lispro soln pen-injector

100 unit/ml.......................................................................26ADULT MASK -respiratory therapy supplies -

devices.......................................................................... 122ADVAIR DISKUS -fluticasone-salmeterol aer powder ba

100-50 mcg/dose............................................................ 48ADVAIR DISKUS -fluticasone-salmeterol aer powder ba

250-50 mcg/dose............................................................ 48ADVAIR DISKUS -fluticasone-salmeterol aer powder ba

500-50 mcg/dose............................................................ 48ADVAIR HFA -fluticasone-salmeterol inhal aerosol 45-21

mcg/act............................................................................ 48ADVAIR HFA -fluticasone-salmeterol inhal aerosol 115-21

mcg/act............................................................................ 48ADVAIR HFA -fluticasone-salmeterol inhal aerosol 230-21

mcg/act............................................................................ 48ADVANCE INTUITION TEST ST -glucose blood test

strip................................................................................117ADVANCE MICRO-DRAW TEST S -glucose blood test

strip................................................................................117ADVATE -antihemophilic factor rahf-pfm for inj 250

unit................................................................................. 101ADVATE -antihemophilic factor rahf-pfm for inj 500






unit................................................................................. 101ADVOCATE REDI-CODE+ TEST -glucose blood test

strip................................................................................117ADVOCATE REDI-CODE -glucose blood test strip........ 117ADVOCATE TEST STRIPS -glucose blood test strip..... 117ADYNOVATE -antihemophilic factor recomb pegylated for

inj 250 unit.................................................................... 101ADYNOVATE -antihemophilic factor recomb pegylated for

inj 500 unit.................................................................... 101

ADYNOVATE -antihemophilic factor recomb pegylated forinj 750 unit.................................................................... 101

ADYNOVATE -antihemophilic factor recomb pegylated forinj 1000 unit.................................................................. 101




ADZENYS ER -amphetamine extended release susp 1.25mg/ml...............................................................................67

ADZENYS XR-ODT -amphetamine tab extended releasedisintegrating 3.1 mg...................................................... 67



ADZENYS XR-ODT -amphetamine tab extended releasedisintegrating 12.5 mg.................................................... 67



AEROBIKA -respiratory therapy supplies - devices........122AEROCHAMBER MINI AEROSOL -spacer/aerosol-

holding chambers - device........................................... 122AEROCHAMBER MV -spacer/aerosol-holding chambers -

device............................................................................ 122AEROCHAMBER PLUS FLOW-VU/ -spacer/aerosol-

holding chambers - device........................................... 122AEROCHAMBER PLUS FLOW-VU -spacer/aerosol-

holding chambers - device........................................... 122AEROCHAMBER Z-STAT PLUS/F -spacer/aerosol-

holding chambers - device........................................... 122AEROCHAMBER Z-STAT PLUS/L -spacer/aerosol-

holding chambers - device........................................... 122AEROCHAMBER Z-STAT PLUS/M -spacer/aerosol-

holding chambers - device........................................... 122AEROCHAMBER Z-STAT PLUS/S -spacer/aerosol-

holding chambers - device........................................... 122AEROCHAMBER Z-STAT PLUS V -spacer/aerosol-

holding chambers - device........................................... 122AEROVENT PLUS HOLDING CHA -spacer/aerosol-

holding chambers - device........................................... 122AFINITOR DISPERZ -everolimus tab for oral susp 2

mg....................................................................................12AFINITOR DISPERZ -everolimus tab for oral susp 3

mg....................................................................................12AFINITOR DISPERZ -everolimus tab for oral susp 5

mg....................................................................................12AFINITOR -everolimus tab 2.5 mg....................................12AFINITOR -everolimus tab 5 mg.......................................12AFINITOR -everolimus tab 7.5 mg....................................12AFINITOR -everolimus tab 10 mg.....................................12AFLURIA 2018-2019 -influenza virus vaccine split im

susp................................................................................. 10

2019


AFLURIA PF 2018-2019 -influenza virus vaccine split pfsusp pref syringe 0.5 ml.................................................10

AFLURIA QUADRIVALENT 2018 -influenza virus vaccinesplit quadrivalent im inj...................................................10

AFLURIA QUADRIVALENT 2018 -influenza virus vac splitquadrivalent susp pref syr 0.5ml....................................10

AFREZZA -insulin regular (human) inhalation powder 4unit/cartridge....................................................................26



AFREZZA -insulin regular (human) inhal powd 4 (90) & 8(90) unit/cart....................................................................26

AFREZZA -insulin regular (human) inh powd 4 & 8 & 12unit/cart (60)....................................................................26

AFSTYLA -antihemophilic fact rcmb single chain for inj kit250 unit......................................................................... 102

AFSTYLA -antihemophilic fact rcmb single chain for inj kit500 unit......................................................................... 102

AFSTYLA -antihemophilic fact rcmb single chain for inj kit1000 unit....................................................................... 102





AGAMATRIX AMP NO CODE TES -glucose blood teststrip................................................................................117

AGAMATRIX JAZZ TEST STRIP -glucose blood teststrip................................................................................117

AGAMATRIX KEYNOTE TEST ST -glucose blood teststrip................................................................................117

AGAMATRIX PRESTO TEST STR -glucose blood teststrip................................................................................118

AIMOVIG -erenumab-aooe subcutaneous soln auto-injector 70 mg/ml............................................................ 83

AIRDUO RESPICLICK 113/14 -fluticasone-salmeterol aerpowder ba 113-14 mcg/act.............................................48

AIRDUO RESPICLICK 232/14 -fluticasone-salmeterol aerpowder ba 232-14 mcg/act.............................................48

AIRDUO RESPICLICK 55/14 -fluticasone-salmeterol aerpowder ba 55-14 mcg/act...............................................48

AKTEN -lidocaine hcl ophth gel 3.5%.............................106AKTIPAK -benzoyl peroxide-erythromycin gel pack

5-3%.............................................................................. 111AKYNZEO -netupitant-palonosetron cap 300-0.5 mg.......54ALA SCALP -hydrocortisone lotion 2%...........................111albendazole tab 200 mg (Albenza).................................. 9ALBENZA -albendazole tab 200 mg................................... 9ALBUTEROL SULFATE ER -albuterol sulfate tab er 12hr

4 mg................................................................................ 48ALBUTEROL SULFATE ER -albuterol sulfate tab er 12hr

8 mg................................................................................ 48

albuterol sulfate soln nebu 0.083% (2.5 mg/3ml).........49albuterol sulfate soln nebu 0.5% (5 mg/ml)..................49albuterol sulfate soln nebu 0.63 mg/3ml (base

equiv).............................................................................. 49albuterol sulfate soln nebu 1.25 mg/3ml (base

equiv).............................................................................. 49albuterol sulfate syrup 2 mg/5ml...................................49albuterol sulfate tab 2 mg...............................................49albuterol sulfate tab 4 mg...............................................49alclometasone dipropionate cream 0.05%................. 111alclometasone dipropionate oint 0.05%......................111ALDACTAZIDE -spironolactone & hydrochlorothiazide tab

50-50 mg......................................................................... 42ALECENSA -alectinib hcl cap 150 mg (base

equivalent).......................................................................12ALENDRONATE SODIUM -alendronate sodium oral soln

70 mg/75ml..................................................................... 29ALENDRONATE SODIUM -alendronate sodium tab 40

mg....................................................................................29alendronate sodium tab 5 mg........................................ 29alendronate sodium tab 10 mg...................................... 29alendronate sodium tab 35 mg...................................... 29alendronate sodium tab 70 mg (Fosamax)...................29alfuzosin hcl tab er 24hr 10 mg (Uroxatral)..................59ALINIA -nitazoxanide for susp 100 mg/5ml.........................9ALINIA -nitazoxanide tab 500 mg....................................... 9ALL FLOW 1000 PFT FILTER -respiratory therapy

supplies - devices.........................................................122ALL FLOW 2000 PFT FILTER -respiratory therapy






supplies - devices.........................................................123allopurinol tab 100 mg (Zyloprim)................................. 84allopurinol tab 300 mg (Zyloprim)................................. 84ALLZITAL -butalbital-acetaminophen tab 25-325 mg....... 74almotriptan malate tab 6.25 mg (Axert).........................83almotriptan malate tab 12.5 mg (Axert).........................83ALOCRIL -nedocromil sodium ophth soln 2%................ 106ALOGLIPTIN/METFORMIN HCL -alogliptin-metformin hcl

tab 12.5-500 mg............................................................. 22ALOGLIPTIN/METFORMIN HCL -alogliptin-metformin hcl

tab 12.5-1000 mg........................................................... 22ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab

12.5-15 mg......................................................................22ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab

12.5-30 mg......................................................................22ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab

12.5-45 mg......................................................................22

2019


ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab25-15 mg......................................................................... 22



ALOGLIPTIN -alogliptin benzoate tab 6.25 mg (baseequiv)...............................................................................22

ALOGLIPTIN -alogliptin benzoate tab 12.5 mg (baseequiv)...............................................................................22

ALOGLIPTIN -alogliptin benzoate tab 25 mg (baseequiv)...............................................................................22

ALOMIDE -lodoxamide tromethamine ophth soln0.1%...............................................................................106

ALORA -estradiol td patch twice weekly 0.025mg/24hr........................................................................... 18

ALORA -estradiol td patch twice weekly 0.05 mg/24hr.....18ALORA -estradiol td patch twice weekly 0.075

mg/24hr........................................................................... 18ALORA -estradiol td patch twice weekly 0.1 mg/24hr.......18alosetron hcl tab 0.5 mg (base equiv) (Lotronex)........55alosetron hcl tab 1 mg (base equiv) (Lotronex)...........55ALPHAGAN P -brimonidine tartrate ophth soln 0.1%.....106ALPHANATE/VON WILLEBRAND -antihemophilic factor/

vwf (human) for inj 250 unit......................................... 102ALPHANATE/VON WILLEBRAND -antihemophilic factor/

vwf (human) for inj 500 unit......................................... 102ALPHANATE/VON WILLEBRAND -antihemophilic factor/

vwf (human) for inj 1000 unit....................................... 102ALPHANATE/VON WILLEBRAND -antihemophilic factor/

vwf (human) for inj 1500 unit....................................... 102ALPHANATE/VON WILLEBRAND -antihemophilic factor/

vwf (human) for inj 2000 unit....................................... 102ALPHANINE SD -coagulation factor ix for inj 500

unit................................................................................. 102ALPHANINE SD -coagulation factor ix for inj 1000

unit................................................................................. 102ALPHANINE SD -coagulation factor ix for inj 1500

unit................................................................................. 102ALPRAZOLAM INTENSOL -alprazolam conc 1 mg/

ml..................................................................................... 59alprazolam orally disintegrating tab 0.25 mg...............59alprazolam orally disintegrating tab 0.5 mg.................59alprazolam orally disintegrating tab 1 mg....................59alprazolam orally disintegrating tab 2 mg....................59alprazolam tab er 24hr 0.5 mg (Xanax xr).....................59alprazolam tab er 24hr 1 mg (Xanax xr)........................59alprazolam tab er 24hr 2 mg (Xanax xr)........................59alprazolam tab er 24hr 3 mg (Xanax xr)........................59alprazolam tab 0.25 mg (Xanax).................................... 59alprazolam tab 0.5 mg (Xanax)...................................... 59alprazolam tab 1 mg (Xanax)..........................................59alprazolam tab 2 mg (Xanax)..........................................59ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj

250 unit......................................................................... 102ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj

500 unit......................................................................... 102

ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj1000 unit....................................................................... 102




ALREX -loteprednol etabonate ophth susp 0.2%........... 106ALTABAX -retapamulin oint 1%.......................................111ALTOPREV -lovastatin tab er 24hr 20 mg........................ 43ALTOPREV -lovastatin tab er 24hr 40 mg........................ 43ALTOPREV -lovastatin tab er 24hr 60 mg........................ 43ALUNBRIG -brigatinib tab initiation therapy pack 90 mg &

180 mg............................................................................ 12ALUNBRIG -brigatinib tab 30 mg......................................12ALUNBRIG -brigatinib tab 90 mg......................................12ALUNBRIG -brigatinib tab 180 mg....................................12ALVESCO -ciclesonide inhal aerosol 80 mcg/act............. 49ALVESCO -ciclesonide inhal aerosol 160 mcg/act........... 49amantadine hcl cap 100 mg........................................... 88amantadine hcl syrup 50 mg/5ml.................................. 88amantadine hcl tab 100 mg............................................ 88AMCINONIDE -amcinonide cream 0.1%........................ 111AMCINONIDE -amcinonide lotion 0.1%..........................111AMCINONIDE -amcinonide oint 0.1%.............................111AMELUZ -aminolevulinic acid hcl gel 10%..................... 111AMICAR -aminocaproic acid oral soln 0.25 gm/ml......... 101AMICAR -aminocaproic acid tab 500 mg........................101AMICAR -aminocaproic acid tab 1000 mg......................101AMIELLE RESTORE VAGINAL E -misc. devices...........123amiloride & hydrochlorothiazide tab 5-50 mg..............42amiloride hcl tab 5 mg.................................................... 42amino acids cap...............................................................97amiodarone hcl tab 100 mg............................................37amiodarone hcl tab 200 mg............................................37amiodarone hcl tab 400 mg............................................37AMITIZA -lubiprostone cap 8 mcg.................................... 55AMITIZA -lubiprostone cap 24 mcg.................................. 55amitriptyline hcl tab 10 mg.............................................60amitriptyline hcl tab 50 mg.............................................60amitriptyline hcl tab 75 mg.............................................60amitriptyline hcl tab 100 mg...........................................60amitriptyline hcl tab 150 mg...........................................60amitriptyline hcl tab 25 mg (Elavil)................................60amlodipine besylate-atorvastatin calcium tab 2.5-10

mg................................................................................... 45amlodipine besylate-atorvastatin calcium tab 2.5-20

mg................................................................................... 45amlodipine besylate-atorvastatin calcium tab 2.5-40

mg................................................................................... 45amlodipine besylate-atorvastatin calcium tab 5-10 mg

(Caduet).......................................................................... 45amlodipine besylate-atorvastatin calcium tab 5-20 mg

(Caduet).......................................................................... 45amlodipine besylate-atorvastatin calcium tab 5-40 mg

(Caduet).......................................................................... 45

2019


amlodipine besylate-atorvastatin calcium tab 5-80 mg(Caduet).......................................................................... 45

amlodipine besylate-atorvastatin calcium tab 10-10mg (Caduet)................................................................... 45




amlodipine besylate-benazepril hcl cap 2.5-10 mg......37amlodipine besylate-benazepril hcl cap 5-40 mg.........37amlodipine besylate-benazepril hcl cap 5-10 mg

(Lotrel)............................................................................ 37amlodipine besylate-benazepril hcl cap 5-20 mg



(Lotrel)............................................................................ 37amlodipine besylate-olmesartan medoxomil tab 5-20

mg (Azor)....................................................................... 37amlodipine besylate-olmesartan medoxomil tab 5-40



mg (Azor)....................................................................... 37amlodipine besylate tab 2.5 mg (base equivalent)

(Norvasc)........................................................................35amlodipine besylate tab 5 mg (base equivalent)

(Norvasc)........................................................................35amlodipine besylate tab 10 mg (base equivalent)

(Norvasc)........................................................................35amlodipine besylate-valsartan tab 5-160 mg

(Exforge).........................................................................38amlodipine besylate-valsartan tab 5-320 mg



(Exforge).........................................................................38amlodipine-valsartan-hydrochlorothiazide tab

5-160-12.5 mg (Exforge hct)........................................ 38amlodipine-valsartan-hydrochlorothiazide tab

5-160-25 mg (Exforge hct)........................................... 38amlodipine-valsartan-hydrochlorothiazide tab

10-160-12.5 mg (Exforge hct)...................................... 38amlodipine-valsartan-hydrochlorothiazide tab

10-160-25 mg (Exforge hct)......................................... 38amlodipine-valsartan-hydrochlorothiazide tab

10-320-25 mg (Exforge hct)......................................... 38AMOXAPINE -amoxapine tab 25 mg................................60AMOXAPINE -amoxapine tab 50 mg................................60AMOXAPINE -amoxapine tab 100 mg..............................60AMOXAPINE -amoxapine tab 150 mg..............................60

AMOXICILLIN/CLAVULANATE P -amoxicillin & kclavulanate chew tab 200-28.5 mg.................................. 1

AMOXICILLIN/CLAVULANATE P -amoxicillin & kclavulanate chew tab 400-57 mg..................................... 1

amoxicillin & k clavulanate for susp 200-28.5mg/5ml.............................................................................. 1

amoxicillin & k clavulanate for susp 400-57 mg/5ml..... 1amoxicillin & k clavulanate for susp 250-62.5 mg/5ml

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

(Augmentin es-600)........................................................ 1amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg

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

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

(Augmentin)..................................................................... 1AMOXICILLIN -amoxicillin (trihydrate) chew tab 125

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

mg......................................................................................1amoxicillin cap-clarithro tab-lansopraz cap dr therapy

pack (Prevpac).............................................................. 53amoxicillin (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 500 mg..................................1amoxicillin (trihydrate) tab 875 mg..................................1amphetamine-dextroamphetamine cap er 24hr 5 mg

(Adderall xr)...................................................................67amphetamine-dextroamphetamine cap er 24hr 10 mg





(Adderall xr)...................................................................67amphetamine-dextroamphetamine tab 5 mg

(Adderall)........................................................................67amphetamine-dextroamphetamine tab 7.5 mg

(Adderall)........................................................................67amphetamine-dextroamphetamine tab 10 mg

(Adderall)........................................................................67amphetamine-dextroamphetamine tab 12.5 mg



(Adderall)........................................................................67

2019


amphetamine-dextroamphetamine tab 30 mg(Adderall)........................................................................67

AMPICILLIN -ampicillin cap 500 mg................................... 1AMPYRA -dalfampridine tab er 12hr 10 mg..................... 71AMRIX -cyclobenzaprine hcl cap er 24hr 15 mg.............. 90AMRIX -cyclobenzaprine hcl cap er 24hr 30 mg.............. 90ANADROL-50 -oxymetholone tab 50 mg..........................18anagrelide hcl cap 1 mg............................................... 102anagrelide hcl cap 0.5 mg (Agrylin)............................ 102ANALPRAM-HC -hydrocortisone acetate w/ pramoxine

rectal lotn 2.5-1%..........................................................110anastrozole tab 1 mg (Arimidex)................................... 12ANDRODERM -testosterone td patch 24hr 2 mg/24hr..... 18ANDRODERM -testosterone td patch 24hr 4 mg/24hr..... 18ANDROGEL PUMP -testosterone td gel 20.25 mg/act

(1.62%)............................................................................ 18ANDROGEL -testosterone td gel 20.25 mg/1.25gm

(1.62%)............................................................................ 18ANDROGEL -testosterone td gel 40.5 mg/2.5gm

(1.62%)............................................................................ 18ANGELIQ -drospirenone-estradiol tab 0.25-0.5 mg..........18ANGELIQ -drospirenone-estradiol tab 0.5-1 mg...............18ANORO ELLIPTA -umeclidinium-vilanterol aero powd ba

62.5-25 mcg/inh.............................................................. 49ANTARA -fenofibrate micronized cap 30 mg.................... 43ANTARA -fenofibrate micronized cap 90 mg.................... 43ANZEMET -dolasetron mesylate tab 50 mg..................... 54ANZEMET -dolasetron mesylate tab 100 mg................... 54APEXICON E -diflorasone diacetate emollient base

cream 0.05%.................................................................111APIDRA -insulin glulisine inj 100 unit/ml...........................26APIDRA SOLOSTAR -insulin glulisine soln pen-injector inj

100 unit/ml.......................................................................26APLENZIN -bupropion hbr tab er 24hr 174 mg................ 60APLENZIN -bupropion hbr tab er 24hr 348 mg................ 60APLENZIN -bupropion hbr tab er 24hr 522 mg................ 60APOKYN -apomorphine hcl soln cartridge 30 mg/3ml......88apraclonidine hcl ophth soln 0.5% (base equivalent)

(Iopidine)...................................................................... 106aprepitant capsule 40 mg (Emend)............................... 54aprepitant capsule 80 mg (Emend)............................... 54aprepitant capsule 125 mg (Emend)............................. 54aprepitant capsule therapy pack 80 & 125 mg

(Emend).......................................................................... 54APRISO -mesalamine cap er 24hr 0.375 gm................... 56APTENSIO XR -methylphenidate hcl cap er 24hr 10 mg

(xr)................................................................................... 67APTENSIO XR -methylphenidate hcl cap er 24hr 15 mg





(xr)................................................................................... 68

APTENSIO XR -methylphenidate hcl cap er 24hr 60 mg(xr)................................................................................... 68

APTIOM -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........................................5APTIVUS -tipranavir oral soln 100 mg/ml........................... 5ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 25

mcg/ml............................................................................. 97ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 40





mcg/ml............................................................................. 98ARANESP ALBUMIN FREE -darbepoetin alfa soln

prefilled syringe 10 mcg/0.4ml....................................... 98ARANESP ALBUMIN FREE -darbepoetin alfa soln

prefilled syringe 25 mcg/0.42ml..................................... 98ARANESP ALBUMIN FREE -darbepoetin alfa soln







prefilled syringe 500 mcg/ml.......................................... 98ARCALYST -rilonacept for inj 220 mg...............................80ARCAPTA NEOHALER -indacaterol maleate inhal powder

cap 75 mcg (base equiv)................................................49ARESTIN -minocycline hcl subgingival powder cartridge 1

mg..................................................................................110ARIAL CHAMBER -spacer/aerosol-holding chambers -

device............................................................................ 123aripiprazole orally disintegrating tab 10 mg.................63aripiprazole orally disintegrating tab 15 mg.................63aripiprazole 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)......................................63armodafinil tab 50 mg (Nuvigil)......................................68armodafinil tab 150 mg (Nuvigil)................................... 68armodafinil tab 200 mg (Nuvigil)................................... 68

2019


armodafinil tab 250 mg (Nuvigil)................................... 68ARMONAIR RESPICLICK 113 -fluticasone propionate aer

pow ba 113 mcg/act....................................................... 49ARMONAIR RESPICLICK 232 -fluticasone propionate aer

pow ba 232 mcg/act....................................................... 49ARMONAIR RESPICLICK 55 -fluticasone propionate aer

pow ba 55 mcg/act......................................................... 49ARMOUR THYROID -thyroid tab 15 mg (1/4 grain)......... 27ARMOUR THYROID -thyroid tab 30 mg (1/2 grain)......... 27ARMOUR THYROID -thyroid tab 90 mg (1 1/2 grain)...... 27ARMOUR THYROID -thyroid tab 60 mg (1 grain)............ 27ARMOUR THYROID -thyroid tab 120 mg (2 grain).......... 27ARMOUR THYROID -thyroid tab 180 mg (3 grain).......... 27ARMOUR THYROID -thyroid tab 240 mg (4 grain).......... 27ARMOUR THYROID -thyroid tab 300 mg (5 grain).......... 27ARNUITY ELLIPTA -fluticasone furoate aerosol powder

breath activ 50 mcg/act.................................................. 49ARNUITY ELLIPTA -fluticasone furoate aerosol powder

breath activ 100 mcg/act................................................49ARNUITY ELLIPTA -fluticasone furoate aerosol powder

breath activ 200 mcg/act................................................49ARTISS -fibrin sealant component solution.................... 101ARYMO ER -morphine sulfate tab er abuse-deterrent 15

mg....................................................................................74ARYMO ER -morphine sulfate tab er abuse-deterrent 30

mg....................................................................................74ARYMO ER -morphine sulfate tab er abuse-deterrent 60

mg....................................................................................74ASACOL HD -mesalamine tab delayed release 800

mg....................................................................................56ASMANEX HFA -mometasone furoate inhal aerosol

suspension 100 mcg/act.................................................49ASMANEX HFA -mometasone furoate inhal aerosol

suspension 200 mcg/act.................................................49ASMANEX TWISTHALER 120 ME -mometasone furoate

inhal powd 220 mcg/inh (breath activated)....................49ASMANEX TWISTHALER 30 MET -mometasone furoate

inhal powd 110 mcg/inh (breath activated).................... 49ASMANEX TWISTHALER 30 MET -mometasone furoate

inhal powd 220 mcg/inh (breath activated)....................49ASMANEX TWISTHALER 60 MET -mometasone furoate

inhal powd 220 mcg/inh (breath activated)....................49aspirin chew tab 81 mg...................................................74aspirin-dipyridamole cap er 12hr 25-200 mg

(Aggrenox)................................................................... 102aspirin tab delayed release 81 mg.................................74ASSURE II CHECK STRIP -glucose blood test strip......118ASSURE II -glucose blood test strip............................... 118ASSURE II TEST STRIPS -glucose blood test strip.......118ASSURE PLATINUM TEST STRI -glucose blood test

strip................................................................................118ASSURE PRISM MULTI TEST S -glucose blood test

strip................................................................................118ASSURE PRO TEST STRIPS -glucose blood test

strip................................................................................118ASSURE 3 TEST STRIPS -glucose blood test strip.......118ASSURE 4 TEST STRIPS -glucose blood test strip.......118

ASTAGRAF XL -tacrolimus cap er 24hr 0.5 mg..............126ASTAGRAF XL -tacrolimus cap er 24hr 1 mg................ 126ASTAGRAF XL -tacrolimus cap er 24hr 5 mg................ 126ATABEX EC -prenatal vit w/ dss-iron carbonyl-fa tab dr

29-1 mg........................................................................... 91ATABEX OB -prenatal vit w/ fe bisglycinate chelate-fa tab

29-1 mg........................................................................... 91atazanavir sulfate cap 150 mg (base equiv)

(Reyataz)...........................................................................5atazanavir sulfate cap 200 mg (base equiv)

(Reyataz)...........................................................................5atazanavir sulfate cap 300 mg (base equiv)

(Reyataz)...........................................................................5atenolol & chlorthalidone tab 50-25 mg (Tenoretic

50)....................................................................................38atenolol & chlorthalidone tab 100-25 mg (Tenoretic

100)..................................................................................38atenolol tab 25 mg (Tenormin).......................................34atenolol tab 50 mg (Tenormin).......................................34atenolol tab 100 mg (Tenormin).....................................34AT LAST TEST STRIPS -glucose blood test strip.......... 118atomoxetine hcl cap 10 mg (base equiv)

(Strattera)....................................................................... 68atomoxetine hcl cap 18 mg (base equiv)






(Strattera)....................................................................... 68atorvastatin calcium tab 10 mg (base equivalent)

(Lipitor)........................................................................... 43atorvastatin calcium tab 20 mg (base equivalent)



(Lipitor)........................................................................... 43atovaquone-proguanil hcl tab 62.5-25 mg

(Malarone)........................................................................ 8atovaquone-proguanil hcl tab 250-100 mg

(Malarone)........................................................................ 8atovaquone susp 750 mg/5ml (Mepron)......................... 9ATRIPLA -efavirenz-emtricitabine-tenofovir df tab

600-200-300 mg................................................................5ATROPINE SULFATE -atropine sulfate ophth soln

1%..................................................................................106ATROVENT HFA -ipratropium bromide hfa inhal aerosol

17 mcg/act.......................................................................49AUBAGIO -teriflunomide tab 7 mg....................................71AUBAGIO -teriflunomide tab 14 mg..................................71

2019


AUGMENTED BETAMETHASONE D -betamethasonedipropionate augmented gel 0.05%............................. 111

AUGMENTIN -amoxicillin & k clavulanate for susp125-31.25 mg/5ml.............................................................1

AURYXIA -ferric citrate tab 1 gm (210 mg ferric iron).......56AUSTEDO -deutetrabenazine tab 6 mg............................71AUSTEDO -deutetrabenazine tab 9 mg............................71AUSTEDO -deutetrabenazine tab 12 mg..........................71AUVI-Q -epinephrine solution auto-injector 0.1

mg/0.1ml..........................................................................43AUVI-Q -epinephrine solution auto-injector 0.15

mg/0.15ml (1:1000).........................................................43AUVI-Q -epinephrine solution auto-injector 0.3 mg/0.3ml

(1:1000)........................................................................... 43AVANDIA -rosiglitazone maleate tab 2 mg (base

equiv)...............................................................................22AVANDIA -rosiglitazone maleate tab 4 mg (base

equiv)...............................................................................22AVC -sulfanilamide vaginal cream 15%............................ 58AVEED -testosterone undecanoate im inj in oil 750

mg/3ml (250mg/ml).........................................................18AVONEX -interferon beta-1a for im inj kit 30mcg

(33mcg(6.6 mu)/vial).......................................................71AVONEX -interferon beta-1a im prefilled syringe kit 30

mcg/0.5ml........................................................................71AVONEX PEN -interferon beta-1a im auto-injector kit 30

mcg/0.5ml........................................................................71AZASAN -azathioprine tab 75 mg...................................126AZASAN -azathioprine tab 100 mg.................................126AZASITE -azithromycin ophth soln 1%...........................106azathioprine tab 50 mg (Imuran)..................................126azelastine hcl nasal spray 0.1% (137 mcg/spray)........ 47azelastine hcl nasal spray 0.15% (205.5 mcg/spray)

(Astepro).........................................................................47azelastine hcl ophth soln 0.05%.................................. 106AZELEX -azelaic acid cream 20%.................................. 111AZITHROMYCIN -azithromycin powd pack for susp 1

gm......................................................................................2azithromycin for susp 100 mg/5ml (Zithromax)............. 2azithromycin for susp 200 mg/5ml (Zithromax)............. 2azithromycin tab 250 mg (Zithromax)............................. 2azithromycin tab 500 mg (Zithromax)............................. 2azithromycin tab 600 mg (Zithromax)............................. 2AZOPT -brinzolamide ophth susp 1%.............................106

BBACITRACIN -bacitracin ophth oint 500 unit/gm............106bacitracin-polymyxin b ophth oint.............................. 106bacitracin-polymyxin-neomycin-hc ophth oint

1%..................................................................................106BACLOFEN -baclofen tab 5 mg........................................90baclofen tab 10 mg..........................................................90baclofen tab 20 mg..........................................................90BACTROBAN NASAL -mupirocin calcium nasal oint

2%....................................................................................47BAL-CARE DHA -prenat w/fe poly-na fered-fa tab 27-1 &

omega cap dr 430mg..................................................... 91

BALCOLTRA -levonorgestrel-ethinyl estradiol-fe tab 0.1mg-20 mcg (21).............................................................. 20

balsalazide disodium cap 750 mg (Colazal)................. 56BANZEL -rufinamide susp 40 mg/ml.................................84BANZEL -rufinamide tab 200 mg...................................... 84BANZEL -rufinamide tab 400 mg...................................... 85BARACLUDE -entecavir oral soln 0.05 mg/ml....................5BASAGLAR KWIKPEN -insulin glargine soln pen-injector

100 unit/ml.......................................................................27BAXDELA -delafloxacin meglumine tab 450 mg (base

equiv)................................................................................. 3BAYER BREEZE 2 HIGH CONTR -blood glucose

calibration - liquid - high...............................................123BAYER BREEZE 2 LOW CONTRO -blood glucose

calibration - liquid - low................................................ 123BAYER BREEZE 2 NORMAL CON -blood glucose

calibration - liquid - normal...........................................123BAYER BREEZE 2 TEST DISC -glucose blood test

disk................................................................................ 118BAYER CONTOUR BLOOD GLUCO -glucose blood test

strip................................................................................118BAYER CONTOUR HIGH CONTRO -blood glucose

calibration - liquid - high...............................................123BAYER CONTOUR LOW CONTROL -blood glucose

calibration - liquid - low................................................ 123BAYER CONTOUR NORMAL CONT -blood glucose

calibration - liquid - normal...........................................123BEBULIN -factor ix complex for inj 200-1200 unit.......... 102BECONASE AQ -beclomethasone dipropionate monohyd

nasal susp 42 mcg/spray............................................... 47BELBUCA -buprenorphine hcl buccal film 75 mcg (base

equivalent).......................................................................74BELBUCA -buprenorphine hcl buccal film 150 mcg (base






equivalent).......................................................................75BELSOMRA -suvorexant tab 5 mg................................... 66BELSOMRA -suvorexant tab 10 mg................................. 66BELSOMRA -suvorexant tab 15 mg................................. 66BELSOMRA -suvorexant tab 20 mg................................. 66BELVIQ -lorcaserin hcl tab 10 mg.....................................68BELVIQ XR -lorcaserin hcl tab er 24hr 20 mg.................. 68benazepril & hydrochlorothiazide tab 5-6.25 mg......... 38benazepril & hydrochlorothiazide tab 10-12.5 mg

(Lotensin hct)................................................................ 38benazepril & hydrochlorothiazide tab 20-12.5 mg

(Lotensin hct)................................................................ 38benazepril & hydrochlorothiazide tab 20-25 mg

(Lotensin hct)................................................................ 38

2019


benazepril hcl tab 5 mg.................................................. 38benazepril hcl tab 10 mg................................................ 38benazepril hcl tab 20 mg (Lotensin)..............................38benazepril hcl tab 40 mg (Lotensin)..............................38BENEFIX -coagulation factor ix (recombinant) for inj kit

250 unit......................................................................... 102BENEFIX -coagulation factor ix (recombinant) for inj kit

500 unit......................................................................... 102BENEFIX -coagulation factor ix (recombinant) for inj kit

1000 unit....................................................................... 102BENEFIX -coagulation factor ix (recombinant) for inj kit

2000 unit....................................................................... 102BENEFIX -coagulation factor ix (recombinant) for inj kit

3000 unit....................................................................... 102BENLYSTA -belimumab subcutaneous solution auto-

injector 200 mg/ml........................................................ 126BENLYSTA -belimumab subcutaneous solution prefilled

syringe 200 mg/ml........................................................ 126BENZNIDAZOLE -benznidazole tab 12.5 mg..................... 9BENZNIDAZOLE -benznidazole tab 100 mg...................... 9benzonatate cap 150 mg.................................................48benzonatate cap 200 mg.................................................48benzonatate cap 100 mg (Tessalon perles)..................48benzoyl peroxide-erythromycin gel 5-3%

(Benzamycin)...............................................................111benzphetamine hcl tab 50 mg........................................68benzphetamine hcl tab 25 mg (Regimex)..................... 68benztropine mesylate tab 0.5 mg.................................. 88benztropine mesylate tab 1 mg..................................... 88benztropine mesylate tab 2 mg..................................... 88BEPREVE -bepotastine besilate ophth soln 1.5%..........106BERINERT -c1 esterase inhibitor (human) for iv inj kit 500

unit................................................................................. 102BESIVANCE -besifloxacin hcl ophth susp 0.6% (base

equiv).............................................................................106BETADINE OPHTHALMIC PREP -povidone-iodine ophth

soln 5%......................................................................... 106betamethasone dipropionate augmented cream 0.05%

(Diprolene af)...............................................................111betamethasone dipropionate augmented lotion 0.05%

(Diprolene)................................................................... 111betamethasone dipropionate augmented oint 0.05%

(Diprolene)................................................................... 111betamethasone dipropionate cream 0.05%................ 111betamethasone dipropionate lotion 0.05%.................111betamethasone dipropionate oint 0.05%.................... 111betamethasone valerate aerosol foam 0.12%

(Luxiq)...........................................................................111betamethasone valerate cream 0.1% (base

equivalent)................................................................... 111betamethasone valerate lotion 0.1% (base

equivalent)................................................................... 111betamethasone valerate oint 0.1% (base

equivalent)................................................................... 111BETASERON -interferon beta-1b for inj kit 0.3 mg...........71betaxolol hcl ophth soln 0.5%......................................106betaxolol hcl tab 10 mg.................................................. 34

betaxolol hcl tab 20 mg.................................................. 34bethanechol chloride tab 5 mg (Urecholine)................57bethanechol chloride tab 10 mg (Urecholine)..............57bethanechol chloride tab 25 mg (Urecholine)..............57bethanechol chloride tab 50 mg (Urecholine)..............57BETHKIS -tobramycin nebu soln 300 mg/4ml.................... 4BETIMOL -timolol ophth soln 0.25%...............................106BETIMOL -timolol ophth soln 0.5%.................................106BETOPTIC-S -betaxolol hcl ophth susp 0.25%.............. 106BEVESPI AEROSPHERE -glycopyrrolate-formoterol

fumarate aerosol 9-4.8 mcg/act..................................... 49BEVYXXA -betrixaban maleate cap 40 mg (base

equivalent).......................................................................99BEVYXXA -betrixaban maleate cap 80 mg (base

equivalent).......................................................................99bexarotene cap 75 mg (Targretin)..................................12BEXSERO -meningococcal vac b (recomb omv adjuv) inj

prefilled syringe...............................................................10bicalutamide tab 50 mg (Casodex)................................12BIDIL -isosorbide dinitrate-hydralazine hcl tab 20-37.5

mg....................................................................................46BIKTARVY -bictegravir-emtricitabine-tenofovir af tab

50-200-25 mg....................................................................5bimatoprost ophth soln 0.03%.....................................107BINOSTO -alendronate sodium effervescent tab 70

mg....................................................................................29BIOSCANNER GLUCOSE TEST S -glucose blood test

strip................................................................................118bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln

kit.....................................................................................52bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg

(Ziac)............................................................................... 38bisoprolol & hydrochlorothiazide tab 5-6.25 mg

(Ziac)............................................................................... 38bisoprolol & hydrochlorothiazide tab 10-6.25 mg

(Ziac)............................................................................... 38bisoprolol fumarate tab 5 mg.........................................34bisoprolol fumarate tab 10 mg.......................................34BLEPHAMIDE S.O.P. -sulfacetamide sodium-

prednisolone ophth oint 10-0.2%................................. 107BLEPHAMIDE -sulfacetamide sodium-prednisolone ophth

susp 10-0.2%................................................................ 107BLOOD GLUCOSE TEST STRIPS -glucose blood test

strip................................................................................118BONJESTA -doxylamine-pyridoxine tab er 20-20 mg.......54BOOSTRIX -tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-

lf-mcg/0.5ml.....................................................................11BOSULIF -bosutinib tab 100 mg....................................... 12BOSULIF -bosutinib tab 400 mg....................................... 12BOSULIF -bosutinib tab 500 mg....................................... 12BRAFTOVI -encorafenib cap 50 mg................................. 12BRAFTOVI -encorafenib cap 75 mg................................. 12BRAVELLE -urofollitropin purified for inj 75 unit............... 29BREATHERITE COLLAPSIBLE -spacer/aerosol-holding

chambers - device........................................................ 123BREATHERITE RIGID SPACER -spacer/aerosol-holding

chambers - device........................................................ 123

2019


BREATHERITE -spacer/aerosol-holding chambers -device............................................................................ 123

BREATHERITE VALVED MDI CH -respiratory therapysupplies - devices.........................................................123

BREATHERITE W/LARGE MASK -spacer/aerosol-holdingchambers - device........................................................ 123

BREATHERITE W/MEDIUM MASK -spacer/aerosol-holding chambers - device........................................... 123

BREATHERITE W/SMALL MASK -spacer/aerosol-holdingchambers - device........................................................ 123

BREO ELLIPTA -fluticasone furoate-vilanterol aero powdba 100-25 mcg/inh..........................................................49

BREO ELLIPTA -fluticasone furoate-vilanterol aero powdba 200-25 mcg/inh..........................................................49

BRILINTA -ticagrelor tab 60 mg...................................... 102BRILINTA -ticagrelor tab 90 mg...................................... 102brimonidine tartrate ophth soln 0.2%......................... 107brimonidine tartrate ophth soln 0.15% (Alphagan

p)................................................................................... 107BRIVIACT -brivaracetam oral soln 10 mg/ml....................85BRIVIACT -brivaracetam tab 10 mg................................. 85BRIVIACT -brivaracetam tab 25 mg................................. 85BRIVIACT -brivaracetam tab 50 mg................................. 85BRIVIACT -brivaracetam tab 75 mg................................. 85BRIVIACT -brivaracetam tab 100 mg............................... 85BROMFENAC -bromfenac sodium ophth soln 0.09%

(base equiv) (once-daily)..............................................107bromocriptine mesylate cap 5 mg (base equivalent)

(Parlodel)........................................................................88bromocriptine mesylate tab 2.5 mg (base equivalent)

(Parlodel)........................................................................88BROMSITE -bromfenac sodium ophth soln 0.075% (base

equivalent).....................................................................107BROVANA -arformoterol tartrate soln nebu 15 mcg/2ml

(base equiv).................................................................... 49budesonide delayed release particles cap 3 mg

(Entocort ec)..................................................................16budesonide inhalation susp 0.25 mg/2ml

(Pulmicort)......................................................................49budesonide inhalation susp 0.5 mg/2ml

(Pulmicort)......................................................................49budesonide inhalation susp 1 mg/2ml (Pulmicort)......49budesonide tab er 24hr 9 mg (Uceris).......................... 16bumetanide tab 0.5 mg (Bumex)....................................42bumetanide tab 1 mg (Bumex).......................................42bumetanide tab 2 mg (Bumex).......................................42BUNAVAIL -buprenorphine-naloxone buccal film 2.1-0.3

mg (base equiv)..............................................................75BUNAVAIL -buprenorphine-naloxone buccal film 4.2-0.7

mg (base equiv)..............................................................75BUNAVAIL -buprenorphine-naloxone buccal film 6.3-1 mg

(base equiv).................................................................... 75BUPRENORPHINE -buprenorphine td patch weekly 5

mcg/hr..............................................................................75BUPRENORPHINE -buprenorphine td patch weekly 7.5

mcg/hr..............................................................................75

BUPRENORPHINE -buprenorphine td patch weekly 10mcg/hr..............................................................................75



buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (baseequiv).............................................................................. 75

buprenorphine hcl-naloxone hcl sl tab 8-2 mg (baseequiv).............................................................................. 75

buprenorphine hcl sl tab 2 mg (base equiv)................ 75buprenorphine hcl sl tab 8 mg (base equiv)................ 75bupropion hcl (smoking deterrent) tab er 12hr 150 mg

(Zyban)............................................................................71bupropion hcl tab er 12hr 100 mg (Wellbutrin sr)........60bupropion hcl tab er 12hr 150 mg (Wellbutrin sr)........60bupropion hcl tab er 12hr 200 mg (Wellbutrin sr)........60bupropion hcl tab er 24hr 150 mg (Wellbutrin xl)........ 60bupropion hcl tab er 24hr 300 mg (Wellbutrin xl)........ 60bupropion hcl tab 75 mg................................................ 60bupropion hcl tab 100 mg.............................................. 60BUPROPION HYDROCHLORIDE E -bupropion hcl tab er

24hr 450 mg....................................................................60buspirone hcl tab 5 mg...................................................59buspirone hcl tab 7.5 mg................................................59buspirone hcl tab 10 mg.................................................59buspirone hcl tab 15 mg.................................................59buspirone hcl tab 30 mg.................................................59BUTALBITAL/ACETAMINOPHEN -butalbital-

acetaminophen cap 50-300 mg..................................... 74BUTALBITAL/ASPIRIN/CAFFEI -butalbital-aspirin-caffeine

tab 50-325-40 mg........................................................... 74butalbital-acetaminophen-caffeine cap 50-325-40

mg................................................................................... 74butalbital-acetaminophen-caffeine cap 50-300-40 mg

(Fioricet)......................................................................... 74butalbital-acetaminophen-caffeine tab 50-325-40 mg

(Esgic).............................................................................74butalbital-acetaminophen-caff w/ cod cap

50-325-40-30 mg............................................................75butalbital-acetaminophen-caff w/ cod cap

50-300-40-30 mg (Fioricet/codeine)............................ 75butalbital-acetaminophen tab 50-300 mg......................74butalbital-acetaminophen tab 50-325 mg......................74butalbital-aspirin-caffeine cap 50-325-40 mg

(Fiorinal)......................................................................... 74butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg

(Fiorinal/codeine #3).....................................................75BUTISOL SODIUM -butabarbital sodium tab 30 mg.........66butorphanol tartrate nasal soln 10 mg/ml.................... 75BUTRANS -buprenorphine td patch weekly 5 mcg/hr.......75BUTRANS -buprenorphine td patch weekly 7.5 mcg/

hr......................................................................................75BUTRANS -buprenorphine td patch weekly 10 mcg/

hr......................................................................................75BUTRANS -buprenorphine td patch weekly 15 mcg/

hr......................................................................................75

2019


BUTRANS -buprenorphine td patch weekly 20 mcg/hr......................................................................................75

BYDUREON BCISE -exenatide extended release suspauto-injector 2 mg/0.85ml...............................................22

BYDUREON -exenatide for inj extended release susp 2mg....................................................................................22

BYDUREON PEN -exenatide extended release for susppen-injector 2 mg............................................................22

BYETTA -exenatide soln pen-injector 5 mcg/0.02ml........ 22BYETTA -exenatide soln pen-injector 10 mcg/0.04ml...... 22BYSTOLIC -nebivolol hcl tab 2.5 mg (base

equivalent).......................................................................34BYSTOLIC -nebivolol hcl tab 5 mg (base equivalent).......34BYSTOLIC -nebivolol hcl tab 10 mg (base

equivalent).......................................................................34BYSTOLIC -nebivolol hcl tab 20 mg (base

equivalent).......................................................................34BYVALSON -nebivolol-valsartan tab 5-80 mg.................. 38

Ccabergoline tab 0.5 mg................................................... 29CABOMETYX -cabozantinib s-malate tab 20 mg (base

equivalent).......................................................................12CABOMETYX -cabozantinib s-malate tab 40 mg (base

equivalent).......................................................................12CABOMETYX -cabozantinib s-malate tab 60 mg (base

equivalent).......................................................................12caffeine citrate oral soln 60 mg/3ml (10 mg/ml base

equiv).............................................................................. 68calcipotriene-betamethasone dipropionate oint

0.005-0.064% (Taclonex)............................................ 111calcipotriene cream 0.005% (Dovonex).......................111calcipotriene oint 0.005%..............................................111calcipotriene soln 0.005% (50 mcg/ml)....................... 111calcitonin (salmon) nasal soln 200 unit/act..................29CALCITRIOL -calcitriol oint 3 mcg/gm............................ 111calcitriol cap 0.25 mcg (Rocaltrol).................................29calcitriol cap 0.5 mcg (Rocaltrol)...................................29calcitriol oral soln 1 mcg/ml (Rocaltrol)........................29calcium acetate (phosphate binder) cap 667 mg (169

mg ca).............................................................................56calcium acetate (phosphate binder) tab 667 mg

(Eliphos)......................................................................... 56CALQUENCE -acalabrutinib cap 100 mg......................... 12CAMBIA -diclofenac potassium packet 50 mg..................83CAMINO PRO 15PE -nutritional supplement liquid.......... 97CANASA -mesalamine suppos 1000 mg.......................... 56candesartan cilexetil-hydrochlorothiazide tab 16-12.5

mg (Atacand hct).......................................................... 38candesartan cilexetil-hydrochlorothiazide tab 32-12.5

mg (Atacand hct).......................................................... 38candesartan cilexetil-hydrochlorothiazide tab 32-25

mg (Atacand hct).......................................................... 38candesartan cilexetil tab 4 mg (Atacand)..................... 38candesartan cilexetil tab 8 mg (Atacand)..................... 38candesartan cilexetil tab 16 mg (Atacand)................... 38candesartan cilexetil tab 32 mg (Atacand)................... 38

capecitabine tab 150 mg (Xeloda)................................. 12capecitabine tab 500 mg (Xeloda)................................. 12CAPEX -fluocinolone acetonide shampoo 0.01%...........111CAPRELSA -vandetanib tab 100 mg................................ 12CAPRELSA -vandetanib tab 300 mg................................ 12CAPTOPRIL/HYDROCHLOROTHIA -captopril &

hydrochlorothiazide tab 25-15 mg..................................38CAPTOPRIL/HYDROCHLOROTHIA -captopril &



hydrochlorothiazide tab 50-25 mg..................................38captopril tab 12.5 mg...................................................... 38captopril tab 25 mg......................................................... 38captopril tab 50 mg......................................................... 38captopril tab 100 mg....................................................... 38CARAC -fluorouracil cream 0.5%....................................111CARAFATE -sucralfate susp 1 gm/10ml........................... 53CARBAGLU -carglumic acid tab 200 mg..........................29carbamazepine cap er 12hr 100 mg (Carbatrol)...........85carbamazepine cap er 12hr 200 mg (Carbatrol)...........85carbamazepine cap er 12hr 300 mg (Carbatrol)...........85carbamazepine chew tab 100 mg.................................. 85carbamazepine 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)...........................85CARBATROL -carbamazepine cap er 12hr 100 mg......... 85CARBATROL -carbamazepine cap er 12hr 200 mg......... 85CARBATROL -carbamazepine cap er 12hr 300 mg......... 85CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopa-

entacapone tabs 12.5-50-200 mg.................................. 89CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopa-

entacapone tabs 18.75-75-200 mg................................ 89CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopa-

entacapone tabs 25-100-200 mg................................... 89CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopa-

entacapone tabs 31.25-125-200 mg..............................89CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopa-

entacapone tabs 37.5-150-200 mg................................ 89CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopa-

entacapone tabs 50-200-200 mg................................... 89carbidopa & levodopa orally disintegrating tab 10-100

mg................................................................................... 88carbidopa & levodopa orally disintegrating tab 25-100

mg................................................................................... 88carbidopa & levodopa orally disintegrating tab 25-250

mg................................................................................... 88carbidopa & levodopa tab er 25-100 mg (Sinemet

cr).................................................................................... 88carbidopa & levodopa tab er 50-200 mg (Sinemet

cr).................................................................................... 88carbidopa & levodopa tab 10-100 mg (Sinemet)..........89carbidopa & levodopa tab 25-100 mg (Sinemet)..........89carbidopa & levodopa tab 25-250 mg (Sinemet)..........89

2019


carbidopa tab 25 mg (Lodosyn).....................................89carbinoxamine maleate soln 4 mg/5ml......................... 47carbinoxamine maleate tab 4 mg.................................. 47carbinoxamine maleate tab 6 mg.................................. 47carbonyl iron susp 15 mg/1.25ml (elemental iron)...... 98CARDIZEM LA -diltiazem hcl coated beads tab er 24hr

120 mg............................................................................ 35CARDURA XL -doxazosin mesylate tab er 24 hr 4 mg

(base equiv).................................................................... 59CARDURA XL -doxazosin mesylate tab er 24 hr 8 mg

(base equiv).................................................................... 59CAREONE BLOOD GLUCOSE TES -glucose blood test

strip................................................................................118CARESENS N BLOOD GLUCOSE -glucose blood test

strip................................................................................118CARETOUCH BLOOD GLUCOSE T -glucose blood test

strip................................................................................118carisoprodol tab 250 mg (Soma)................................... 90carisoprodol tab 350 mg (Soma)................................... 90carisoprodol w/ aspirin & codeine tab 200-325-16

mg................................................................................... 90carisoprodol w/ aspirin tab 200-325 mg........................90CAROSPIR -spironolactone susp 25 mg/5ml................... 42CARTEOLOL HCL -carteolol hcl ophth soln 1%.............107carvedilol phosphate cap er 24hr 10 mg (Coreg

cr).................................................................................... 34carvedilol phosphate cap er 24hr 20 mg (Coreg



cr).................................................................................... 34carvedilol tab 3.125 mg (Coreg).....................................34carvedilol tab 6.25 mg (Coreg).......................................34carvedilol tab 12.5 mg (Coreg).......................................34carvedilol tab 25 mg (Coreg)..........................................34CAVERJECT -alprostadil for inj 20 mcg............................46CAVERJECT -alprostadil for inj 40 mcg............................46CAVERJECT IMPULSE -alprostadil for inj kit 10 mcg...... 46CAVERJECT IMPULSE -alprostadil for inj kit 20 mcg...... 46CAYA -diaphragm arc-spring........................................... 123CAYSTON -aztreonam lysine for inhal soln 75 mg (base

equivalent)......................................................................... 9cefaclor cap 250 mg.......................................................... 1cefaclor cap 500 mg.......................................................... 1CEFACLOR -cefaclor for susp 125 mg/5ml........................ 1CEFACLOR -cefaclor for susp 250 mg/5ml........................ 1CEFACLOR -cefaclor for susp 375 mg/5ml........................ 1CEFACLOR ER -cefaclor monohydrate tab er 12hr 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...........................................................1cefdinir for susp 125 mg/5ml........................................... 1cefdinir for susp 250 mg/5ml........................................... 1

CEFDITOREN PIVOXIL -cefditoren pivoxil tab 200 mg(base equivalent).............................................................. 1

CEFDITOREN PIVOXIL -cefditoren pivoxil tab 400 mg(base equivalent).............................................................. 1

cefixime for susp 100 mg/5ml (Suprax).......................... 1cefixime for susp 200 mg/5ml (Suprax).......................... 2cefpodoxime proxetil for susp 50 mg/5ml......................2cefpodoxime proxetil for susp 100 mg/5ml....................2cefpodoxime proxetil tab 100 mg.................................... 2cefpodoxime proxetil tab 200 mg.................................... 2cefprozil for susp 125 mg/5ml..........................................2cefprozil for susp 250 mg/5ml..........................................2cefprozil tab 250 mg..........................................................2cefprozil tab 500 mg..........................................................2cefuroxime axetil tab 250 mg...........................................2cefuroxime axetil tab 500 mg...........................................2celecoxib cap 50 mg (Celebrex).................................... 80celecoxib cap 100 mg (Celebrex).................................. 80celecoxib cap 200 mg (Celebrex).................................. 80celecoxib cap 400 mg (Celebrex).................................. 80CELLCEPT -mycophenolate mofetil cap 250 mg........... 126CELLCEPT -mycophenolate mofetil tab 500 mg............ 126CELONTIN -methsuximide cap 300 mg............................85CENTANY -mupirocin oint 2%.........................................111cephalexin cap 250 mg (Keflex).......................................2cephalexin cap 500 mg (Keflex).......................................2cephalexin cap 750 mg (Keflex).......................................2CEPHALEXIN -cephalexin tab 250 mg...............................2CEPHALEXIN -cephalexin tab 500 mg...............................2cephalexin for susp 125 mg/5ml......................................2cephalexin for susp 250 mg/5ml......................................2CERDELGA -eliglustat tartrate cap 84 mg (base

equivalent).......................................................................98CERVIDIL -dinoprostone vaginal inserts 10 mg............... 29CESAMET -nabilone cap 1 mg......................................... 54cetirizine hcl oral soln 1 mg/ml (5 mg/5ml).................. 47CETRAXAL -ciprofloxacin hcl otic soln 0.2% (base

equivalent).....................................................................109CETROTIDE -cetrorelix acetate for inj kit 0.25 mg........... 29CETYLEV -acetylcysteine effervescent tab 2.5 gm........ 117CETYLEV -acetylcysteine effervescent tab 500 mg....... 117cevimeline hcl cap 30 mg (Evoxac).............................110CHANTIX CONTINUING MONTH -varenicline tartrate tab

1 mg (base equiv).......................................................... 71CHANTIX STARTING MONTH PA -varenicline tartrate tab

0.5 mg x 11 & tab 1 mg x 42 pack.................................71CHANTIX -varenicline tartrate tab 0.5 mg (base

equiv)...............................................................................71CHANTIX -varenicline tartrate tab 1 mg (base equiv).......71CHEMET -succimer cap 100 mg.................................... 117CHENODAL -chenodiol tab 250 mg................................. 56CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxide-

amitriptyline tab 5-12.5 mg.............................................71CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxide-

amitriptyline tab 10-25 mg..............................................71chlordiazepoxide hcl cap 5 mg......................................59chlordiazepoxide hcl cap 10 mg....................................59

2019


chlordiazepoxide hcl cap 25 mg....................................59chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg

(Librax)........................................................................... 53chlorhexidine gluconate soln 0.12% (Peridex)...........110CHLOROQUINE PHOSPHATE -chloroquine phosphate

tab 250 mg........................................................................8chloroquine phosphate tab 500 mg................................ 9CHLOROTHIAZIDE -chlorothiazide tab 250 mg...............42chlorothiazide tab 500 mg.............................................. 42chlorpromazine hcl tab 10 mg....................................... 63chlorpromazine hcl tab 25 mg....................................... 63chlorpromazine hcl tab 50 mg....................................... 63chlorpromazine hcl tab 100 mg..................................... 63chlorpromazine hcl tab 200 mg..................................... 63CHLORPROPAMIDE -chlorpropamide tab 100 mg.......... 22CHLORPROPAMIDE -chlorpropamide tab 250 mg.......... 22chlorthalidone tab 25 mg................................................42chlorthalidone tab 50 mg................................................42CHLORZOXAZONE -chlorzoxazone tab 250 mg............. 90CHLORZOXAZONE -chlorzoxazone tab 500 mg............. 90CHOLBAM -cholic acid cap 50 mg................................... 56CHOLBAM -cholic acid cap 250 mg................................. 56cholestyramine light powder 4 gm/dose (Questran

light)................................................................................ 43cholestyramine 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).............................................................. 43choline fenofibrate cap dr 135 mg (fenofibric acid

equiv) (Trilipix).............................................................. 43CHORIONIC GONADOTROPIN -chorionic gonadotropin

for im inj 10000 unit........................................................29CIALIS -tadalafil tab 2.5 mg.............................................. 46CIALIS -tadalafil tab 5 mg................................................. 46CIALIS -tadalafil tab 10 mg............................................... 46CIALIS -tadalafil tab 20 mg............................................... 46ciclopirox gel 0.77%...................................................... 111ciclopirox olamine cream 0.77% (base equiv)

(Loprox)........................................................................111ciclopirox olamine susp 0.77% (base equiv)

(Loprox)........................................................................111ciclopirox shampoo 1% (Loprox shampoo)............... 111ciclopirox solution 8% (Penlac Nail Lacquer)............ 111cilostazol tab 50 mg...................................................... 102cilostazol tab 100 mg.................................................... 102CILOXAN -ciprofloxacin hcl ophth oint 0.3%.................. 107CIMDUO -lamivudine-tenofovir disoproxil fumarate tab

300-300 mg.......................................................................5CIMETIDINE HCL -cimetidine hcl soln 300 mg/5ml..........53cimetidine tab 200 mg.....................................................53cimetidine tab 300 mg.....................................................53cimetidine tab 400 mg.....................................................53cimetidine tab 800 mg.....................................................53CIMZIA -certolizumab pegol for inj kit 2 x 200 mg............56CIMZIA -certolizumab pegol inj kit 2 x 200 mg/ml............ 56

CIMZIA STARTER KIT -certolizumab pegol inj kit 6 x 200mg/ml...............................................................................56

CIPRO -ciprofloxacin for oral susp 250 mg/5ml (5%) (5gm/100ml)..........................................................................3

CIPRODEX -ciprofloxacin-dexamethasone otic susp0.3-0.1%........................................................................ 109

CIPROFLOXACIN -ciprofloxacin hcl otic soln 0.2% (baseequivalent).....................................................................109

ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000mg(base eq) (Cipro xr)...................................................4

ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 mg(base eq) (Cipro xr)........................................................ 4

ciprofloxacin for oral susp 500 mg/5ml (10%) (10gm/100ml) (Cipro)........................................................... 4

CIPROFLOXACIN HCL -ciprofloxacin hcl tab 100 mg(base equiv)...................................................................... 4

ciprofloxacin hcl ophth soln 0.3% (Ciloxan).............. 107ciprofloxacin hcl tab 750 mg (base equiv)..................... 4ciprofloxacin hcl tab 250 mg (base equiv) (Cipro).........4ciprofloxacin hcl tab 500 mg (base equiv) (Cipro).........4CIPRO HC -ciprofloxacin-hydrocortisone otic susp

0.2-1%........................................................................... 109citalopram hydrobromide oral soln 10 mg/5ml............60citalopram hydrobromide tab 10 mg (base equiv)

(Celexa)...........................................................................60citalopram hydrobromide tab 20 mg (base equiv)

(Celexa)...........................................................................60citalopram hydrobromide tab 40 mg (base equiv)

(Celexa)...........................................................................60CITRANATAL ASSURE -prenat w/o a w/fecbn-fegl-dss-fa

tab & dha cap 300 mg pack...........................................91CITRANATAL B-CALM -prenat w/o a w/fecbn-feglu-fa tab

20-1 mg & vit b6 tab pak............................................... 91CITRANATAL BLOOM DHA -prenat w/o a w/fecbn-fegl-

dss-fa tab 90 &dha cap 300mg pak...............................91CITRANATAL BLOOM -prenatal vit w/ dss-fe cbn-fe gluc-

fa tab 90-1 mg................................................................ 91CITRANATAL DHA -prenat w/o a w/fecbn-fegl-dss-fa tab

& dha cap 250 mg pack.................................................91CITRANATAL 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa

tab 90 &dha cap 300mg pak..........................................91CITRANATAL HARMONY -prenat w/o a w/fe fum-fe cbn-

dss-fa-dha cap 27-1-260 mg..........................................91CITRANATAL MEDLEY -prenat w/o a w/fe fum-fe cbn-fa-

dha cap 27-1-200 mg..................................................... 91CITRANATAL RX -prenatal w/o a w/ fe carbonyl-fe gluc-

dss-fa tab 27-1mg...........................................................91CLARINEX -desloratadine syrup 0.5 mg/ml......................47CLARINEX-D 12 HOUR -desloratadine &

pseudoephedrine tab er 12hr 2.5-120 mg..................... 48CLARITHROMYCIN -clarithromycin for susp 125

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

mg/5ml...............................................................................2clarithromycin tab er 24hr 500 mg.................................. 2clarithromycin tab 250 mg................................................2clarithromycin tab 500 mg (Biaxin)................................. 2

2019


CLEMASTINE FUMARATE -clemastine fumarate tab 2.68mg....................................................................................47

CLENPIQ -sod picosulfate-mg ox-citric ac sol 10 mg-3.5gm-12 gm/160ml.............................................................52

CLEOCIN -clindamycin phosphate vaginal suppos 100mg....................................................................................58

CLEVER CHEK AUTO-CODE TES -glucose blood teststrip................................................................................118

CLEVER CHEK AUTO-CODE VOI -glucose blood teststrip................................................................................118

CLEVER CHEK TEST STRIPS -glucose blood teststrip................................................................................118

CLEVER CHOICE ANTI-STATIC -spacer/aerosol-holdingchambers - device........................................................ 123

CLEVER CHOICE AUTO-CODE P -glucose blood teststrip................................................................................118

CLEVER CHOICE MICRO TEST -glucose blood teststrip................................................................................118

CLEVER CHOICE NO CODING T -glucose blood teststrip................................................................................118

CLEVER CHOICE TALK NO COD -glucose blood teststrip................................................................................118

CLIMARA PRO -estradiol-levonorgestrel td patch weekly0.045-0.015 mg/day........................................................18

CLINDAGEL -clindamycin phosphate gel 1%.................111clindamycin hcl cap 75 mg (Cleocin)..............................9clindamycin hcl cap 150 mg (Cleocin)............................9clindamycin hcl cap 300 mg (Cleocin)............................9clindamycin palmitate hcl for soln 75 mg/5ml (base

equiv) (Cleocin pediatric gr)..........................................9CLINDAMYCIN PHOSPHATE/BEN -clindamycin

phosphate-benzoyl peroxide gel 1.2-2.5%.................. 112clindamycin phosphate-benzoyl peroxide gel 1-5%

(Benzaclin)................................................................... 112CLINDAMYCIN PHOSPHATE -clindamycin phosphate gel

1%..................................................................................111clindamycin phosphate foam 1% (Evoclin)................ 111clindamycin phosphate gel 1% (Cleocin-t).................111clindamycin phosphate lotion 1% (Cleocin-t)............ 111clindamycin phosphate soln 1% (Cleocin-t)...............112clindamycin phosphate swab 1% (Cleocin-t)............. 112clindamycin phosphate-tretinoin gel 1.2-0.025%

(Ziana)...........................................................................112clindamycin phosphate vaginal cream 2%

(Cleocin)......................................................................... 58clindamycin phosph-benzoyl peroxide (refrig) gel 1.2

(1)-5% (Duac)............................................................... 111CLINDESSE -clindamycin phosphate (one dose) vaginal

cream 2%........................................................................58clobetasol propionate cream 0.05% (Temovate)........112clobetasol propionate emollient base cream

0.05%.............................................................................112clobetasol propionate emulsion foam 0.05% (Olux-

e)....................................................................................112clobetasol propionate foam 0.05% (Olux).................. 112clobetasol propionate gel 0.05% (Temovate)............. 112clobetasol propionate lotion 0.05% (Clobex)............. 112

clobetasol propionate oint 0.05% (Temovate)............112clobetasol propionate shampoo 0.05% (Clobex).......112clobetasol propionate soln 0.05% (Temovate)........... 112clobetasol propionate spray 0.05% (Clobex)............. 112CLOCORTOLONE PIVALATE -clocortolone pivalate

cream 0.1%...................................................................112CLOCORTOLONE PIVALATE PUM -clocortolone pivalate

cream 0.1%...................................................................112CLODERM -clocortolone pivalate cream 0.1%...............112CLODERM PUMP -clocortolone pivalate cream

0.1%...............................................................................112CLOMIPHENE CITRATE -clomiphene citrate tab 50

mg....................................................................................29clomipramine hcl cap 25 mg (Anafranil).......................60clomipramine hcl cap 50 mg (Anafranil).......................60clomipramine hcl cap 75 mg (Anafranil).......................60clonazepam 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)....................68clonidine hcl tab 0.1 mg (Catapres).............................. 38clonidine hcl tab 0.2 mg (Catapres).............................. 38clonidine hcl tab 0.3 mg (Catapres).............................. 39clonidine td patch weekly 0.1 mg/24hr (Catapres-

tts-1)................................................................................39clonidine td patch weekly 0.2 mg/24hr (Catapres-

tts-2)................................................................................39clonidine td patch weekly 0.3 mg/24hr (Catapres-

tts-3)................................................................................39clopidogrel bisulfate tab 75 mg (base equiv)

(Plavix)..........................................................................102clopidogrel bisulfate tab 300 mg (base equiv)

(Plavix)..........................................................................102clorazepate dipotassium tab 3.75 mg........................... 59clorazepate dipotassium tab 15 mg.............................. 59clorazepate dipotassium tab 7.5 mg (Tranxene t)........59clotrimazole cream 1%..................................................112clotrimazole soln 1%..................................................... 112clotrimazole troche 10 mg............................................110clotrimazole w/ betamethasone cream 1-0.05%

(Lotrisone)....................................................................112clotrimazole w/ betamethasone lotion 1-0.05%..........112CLOZAPINE ODT -clozapine orally disintegrating tab 150

mg....................................................................................63CLOZAPINE ODT -clozapine orally disintegrating tab 200

mg....................................................................................63clozapine orally disintegrating tab 12.5 mg

(Fazaclo)......................................................................... 63clozapine orally disintegrating tab 25 mg

(Fazaclo)......................................................................... 63clozapine orally disintegrating tab 100 mg

(Fazaclo)......................................................................... 63

2019


clozapine tab 50 mg........................................................ 63clozapine tab 200 mg...................................................... 63clozapine tab 25 mg (Clozaril)........................................63clozapine tab 100 mg (Clozaril)..................................... 63C-NATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap

28-1-200 mg....................................................................91COAGADEX -coagulation factor x (human) for inj 250

unit................................................................................. 102COAGADEX -coagulation factor x (human) for inj 500

unit................................................................................. 102COARTEM -artemether-lumefantrine tab 20-120 mg......... 9codeine sulfate tab 15 mg (Codeine sulfate)................75codeine sulfate tab 30 mg (Codeine sulfate)................75codeine sulfate tab 60 mg (Codeine sulfate)................75COLCHICINE -colchicine cap 0.6 mg............................... 84COLCHICINE -colchicine tab 0.6 mg................................84colchicine w/ probenecid tab 0.5-500 mg..................... 84COLCRYS -colchicine tab 0.6 mg.....................................84colesevelam hcl packet for susp 3.75 gm

(Welchol)........................................................................ 44colesevelam hcl tab 625 mg (Welchol)......................... 44colestipol hcl granule packets 5 gm (Colestid

flavored)......................................................................... 44colestipol hcl granules 5 gm (Colestid)........................44colestipol hcl tab 1 gm (Colestid)..................................44COLY-MYCIN S -neomycin-colistin-hc-thonzonium otic

susp 3.3-3-10-0.5 mg/ml.............................................. 109COMBIGAN -brimonidine tartrate-timolol maleate ophth

soln 0.2-0.5%................................................................ 107COMBIPATCH -estradiol-norethindrone ace td pttw

0.05-0.14 mg/day............................................................18COMBIPATCH -estradiol-norethindrone ace td pttw

0.05-0.25 mg/day............................................................19COMBIVENT RESPIMAT -ipratropium-albuterol inhal

aerosol soln 20-100 mcg/act..........................................49COMETRIQ -cabozantinib s-malate cap 3 x 20 mg (60 mg

dose) kit...........................................................................12COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 1 x 20

mg (100 dose) kit............................................................12COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 3 x 20

mg (140 dose) kit............................................................12CO MONITOR -respiratory therapy supplies -

devices.......................................................................... 123COMPACT SPACE CHAMBER/ANT -spacer/aerosol-

holding chambers - device........................................... 123COMPLERA -emtricitabine-rilpivirine-tenofovir df tab

200-25-300 mg..................................................................5COMPLETE NATAL DHA -prenat-fe bis-fe prot succ-fa-ca

tab & omega 3 cap 250 pk............................................ 92COMPLETENATE -prenatal vit w/ fe fumarate-fa chew tab

29-1 mg........................................................................... 92CO-NATAL FA -prenatal vit w/ fe fumarate-fa tab 29-1

mg....................................................................................92CONCEPT DHA -prenatal w/fe fum-fe poly -fa-omega 3

cap 53.5-38-1 mg........................................................... 92CONCEPT OB -prenatal w/o a w/fe fum-fe poly-fa cap

130-92.4-1 mg.................................................................92

CONCERTA -methylphenidate hcl tab er osmotic release(osm) 18 mg....................................................................68




CONDYLOX -podofilox gel 0.5%.................................... 112CONTOUR NEXT BLOOD GLUCOS -glucose blood test

strip................................................................................118CONTOUR NEXT CONTROL LEVE -blood glucose

calibration - liquid - low................................................ 123CONTOUR NEXT CONTROL LEVE -blood glucose

calibration - liquid - normal...........................................123CONTRAVE -naltrexone hcl-bupropion hcl tab er 12hr

8-90 mg........................................................................... 68CONZIP -tramadol hcl cap er 24hr biphasic release 100

mg....................................................................................75CONZIP -tramadol hcl cap er 24hr biphasic release 200

mg....................................................................................75CONZIP -tramadol hcl cap er 24hr biphasic release 300

mg....................................................................................75COOL BLOOD GLUCOSE TEST S -glucose blood test

strip................................................................................118COPAXONE -glatiramer acetate soln prefilled syringe 20

mg/ml...............................................................................71COPAXONE -glatiramer acetate soln prefilled syringe 40

mg/ml...............................................................................71CORDRAN -flurandrenolide tape 4 mcg/sqcm............... 112CORIFACT -factor xiii concentrate (human) for inj kit

1000-1600 unit..............................................................103CORLANOR -ivabradine hcl tab 5 mg (base equiv)......... 46CORLANOR -ivabradine hcl tab 7.5 mg (base equiv)...... 46CORTIFOAM -hydrocortisone acetate rectal foam 10%

(90 mg/dose).................................................................110CORTISONE ACETATE -cortisone acetate tab 25 mg.....16CORTISPORIN -bacitracin-polymyxin-neomycin hc oint

1%..................................................................................112CORTISPORIN -neomycin-polymyxin-hc crm 3.5 mg/

gm-10000 unt/gm-0.5%................................................ 112COSENTYX -secukinumab subcutaneous soln prefilled

syringe 150 mg/ml........................................................ 112COSENTYX SENSOREADY PEN -secukinumab

subcutaneous soln auto-injector 150 mg/ml................ 112COSOPT PF -dorzolamide hcl-timolol maleate ophth sol

22.3-6.8 mg/ml pf..........................................................107COTELLIC -cobimetinib fumarate tab 20 mg (base

equivalent).......................................................................12COTEMPLA XR-ODT -methylphenidate tab extended

release disintegrating 8.6 mg.........................................68COTEMPLA XR-ODT -methylphenidate tab extended

release disintegrating 17.3 mg.......................................68COTEMPLA XR-ODT -methylphenidate tab extended

release disintegrating 25.9 mg.......................................68COUMADIN -warfarin sodium tab 1 mg............................99COUMADIN -warfarin sodium tab 2 mg............................99

2019


COUMADIN -warfarin sodium tab 2.5 mg.........................99COUMADIN -warfarin sodium tab 3 mg............................99COUMADIN -warfarin sodium tab 4 mg............................99COUMADIN -warfarin sodium tab 5 mg............................99COUMADIN -warfarin sodium tab 6 mg............................99COUMADIN -warfarin sodium tab 7.5 mg.........................99COUMADIN -warfarin sodium tab 10 mg..........................99CREON -pancrelipase (lip-prot-amyl) dr cap

3000-9500-15000 unit.....................................................55CREON -pancrelipase (lip-prot-amyl) dr cap

6000-19000-30000 unit...................................................55CREON -pancrelipase (lip-prot-amyl) dr cap

12000-38000-60000 unit................................................ 55CREON -pancrelipase (lip-prot-amyl) dr cap

24000-76000-120000 unit.............................................. 55CREON -pancrelipase (lip-prot-amyl) dr cap

36000-114000-180000 unit.............................................55CRESEMBA -isavuconazonium sulfate cap 186 mg.......... 4CRINONE -progesterone vaginal gel 4%..........................58CRINONE -progesterone vaginal gel 8%..........................58CRIXIVAN -indinavir sulfate cap 200 mg............................ 5CRIXIVAN -indinavir sulfate cap 400 mg............................ 5cromolyn sodium ophth soln 4%................................ 107cromolyn sodium oral conc 100 mg/5ml

(Gastrocrom)..................................................................56cromolyn sodium soln nebu 20 mg/2ml....................... 49crotamiton lotion 10% (Eurax)..................................... 112CUPRIMINE -penicillamine cap 250 mg......................... 126CUVPOSA -glycopyrrolate oral soln 1 mg/5ml................. 53CVS ADVANCED GLUCOSE METE -glucose blood test

strip................................................................................118cyanocobalamin inj 1000 mcg/ml.................................. 98cyclobenzaprine hcl tab 5 mg........................................90cyclobenzaprine hcl tab 10 mg......................................91cyclobenzaprine hcl tab 7.5 mg (Fexmid).....................91CYCLOMYDRIL -cyclopentolate w/ phenylephrine ophth

soln 0.2-1%................................................................... 107cyclopentolate hcl ophth soln 0.5% (Cyclogyl)..........107cyclopentolate hcl ophth soln 1% (Cyclogyl).............107cyclopentolate hcl ophth soln 2% (Cyclogyl).............107cyclophosphamide cap 25 mg

(Cyclophosphamide).................................................... 12cyclophosphamide cap 50 mg

(Cyclophosphamide).................................................... 12CYCLOSERINE -cycloserine cap 250 mg.......................... 4CYCLOSET -bromocriptine mesylate tab 0.8 mg (base

equivalent).......................................................................22cyclosporine cap 25 mg (Sandimmune)..................... 126cyclosporine cap 100 mg (Sandimmune)................... 126cyclosporine modified cap 25 mg (Neoral).................126cyclosporine modified cap 100 mg (Neoral)...............126CYCLOSPORINE MODIFIED -cyclosporine modified cap

50 mg............................................................................ 126cyclosporine modified oral soln 100 mg/ml

(Neoral)......................................................................... 126cyproheptadine hcl syrup 2 mg/5ml..............................47cyproheptadine hcl tab 4 mg......................................... 47

CYSTADANE -betaine powder for oral solution................29CYSTAGON -cysteamine bitartrate cap 50 mg.................59CYSTAGON -cysteamine bitartrate cap 150 mg...............59CYSTARAN -cysteamine hcl ophth soln 0.44% (base

equivalent).....................................................................107

DDAKLINZA -daclatasvir dihydrochloride tab 30 mg (base

equivalent)......................................................................... 5DAKLINZA -daclatasvir dihydrochloride tab 60 mg (base

equivalent)......................................................................... 5DAKLINZA -daclatasvir dihydrochloride tab 90 mg (base

equivalent)......................................................................... 5dalfampridine tab er 12hr 10 mg (Ampyra)...................71DALIRESP -roflumilast tab 250 mcg.................................49DALIRESP -roflumilast tab 500 mcg.................................49danazol cap 50 mg.......................................................... 18danazol cap 100 mg........................................................ 18danazol cap 200 mg........................................................ 18dantrolene sodium cap 100 mg..................................... 91dantrolene sodium cap 25 mg (Dantrium)....................91dantrolene sodium cap 50 mg (Dantrium)....................91dapsone gel 5% (Aczone).............................................112dapsone tab 25 mg............................................................9dapsone tab 100 mg..........................................................9DAPTACEL -diph, acellular pert & tet tox inj 15 lf-23

mcg-5 lf/0.5ml................................................................. 11DARAPRIM -pyrimethamine tab 25 mg.............................. 9darifenacin hydrobromide tab er 24hr 7.5 mg (base

equiv) (Enablex)............................................................ 57darifenacin hydrobromide tab er 24hr 15 mg (base

equiv) (Enablex)............................................................ 57DAYTRANA -methylphenidate td patch 10 mg/9hr...........68DAYTRANA -methylphenidate td patch 15 mg/9hr...........68DAYTRANA -methylphenidate td patch 20 mg/9hr...........68DAYTRANA -methylphenidate td patch 30 mg/9hr...........68DDAVP -desmopressin acetate nasal soln 0.01%

(refrigerated)....................................................................29DELESTROGEN -estradiol valerate im in oil 10 mg/

ml..................................................................................... 19DELZICOL -mesalamine cap dr 400 mg...........................56demeclocycline hcl tab 150 mg....................................... 2demeclocycline hcl tab 300 mg....................................... 2DEMSER -metyrosine cap 250 mg................................... 39DENAVIR -penciclovir cream 1%.................................... 112DEPAKENE -valproate sodium oral soln 250 mg/5ml

(base equiv).................................................................... 85DEPAKENE -valproic acid cap 250 mg.............................85DEPEN TITRATABS -penicillamine tab 250 mg............. 126DEPO-ESTRADIOL -estradiol cypionate im in oil 5 mg/

ml..................................................................................... 19DEPO-SUBQ PROVERA 104 -medroxyprogesterone

acetate susp pref syr 104 mg/0.65ml.............................20DESCOVY -emtricitabine-tenofovir alafenamide fumarate

tab 200-25 mg...................................................................5desipramine hcl tab 50 mg.............................................60desipramine hcl tab 75 mg.............................................60

2019


desipramine hcl tab 100 mg...........................................60desipramine hcl tab 150 mg...........................................60desipramine hcl tab 10 mg (Norpramin)....................... 60desipramine hcl tab 25 mg (Norpramin)....................... 60DESLORATADINE ODT -desloratadine tab orally

disintegrating 2.5 mg...................................................... 47DESLORATADINE ODT -desloratadine tab orally

disintegrating 5 mg......................................................... 47desloratadine tab 5 mg (Clarinex)................................. 47desmopressin acetate inj 4 mcg/ml (Ddavp)................29desmopressin acetate nasal spray soln 0.01%

(Ddavp)........................................................................... 29desmopressin acetate nasal spray soln 0.01%

(refrigerated).................................................................. 29desmopressin acetate tab 0.1 mg (Ddavp)...................29desmopressin acetate tab 0.2 mg (Ddavp)...................29desogest-eth estrad & eth estrad tab 0.15-0.02/0.01

mg(21/5) (Mircette)........................................................20desogest-ethin est tab

0.1-0.025/0.125-0.025/0.15-0.025mg-mg(Cyclessa).......................................................................20

desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg(Desogen).......................................................................20

DESONATE -desonide gel 0.05%...................................112desonide cream 0.05% (Desowen).............................. 112desonide lotion 0.05% (Desowen)............................... 112desonide oint 0.05%...................................................... 112desoximetasone cream 0.05% (Topicort)....................112desoximetasone cream 0.25% (Topicort)....................112desoximetasone gel 0.05% (Topicort)......................... 112desoximetasone oint 0.05% (Topicort)........................112desoximetasone oint 0.25% (Topicort)........................112desoximetasone spray 0.25% (Topicort).....................112DESVENLAFAXINE ER -desvenlafaxine tab er 24hr 50

mg....................................................................................60DESVENLAFAXINE ER -desvenlafaxine tab er 24hr 100

mg....................................................................................61desvenlafaxine succinate tab er 24hr 25 mg (base

equiv) (Pristiq)...............................................................61desvenlafaxine succinate tab er 24hr 50 mg (base

equiv) (Pristiq)...............................................................61desvenlafaxine succinate tab er 24hr 100 mg (base

equiv) (Pristiq)...............................................................61DEXAMETHASONE -dexamethasone soln 0.5

mg/5ml.............................................................................16DEXAMETHASONE -dexamethasone tab 1 mg...............16DEXAMETHASONE -dexamethasone tab 2 mg...............16dexamethasone elixir 0.5 mg/5ml.................................. 16DEXAMETHASONE INTENSOL -dexamethasone conc 1

mg/ml...............................................................................16DEXAMETHASONE SODIUM PHOS -dexamethasone

sodium phosphate ophth soln 0.1%.............................107dexamethasone tab 0.5 mg............................................ 16dexamethasone tab 0.75 mg.......................................... 17dexamethasone tab 1.5 mg............................................ 17dexamethasone tab 4 mg............................................... 17dexamethasone tab 6 mg............................................... 17

dexamethasone tab therapy pack 1.5 mg (21) (Dexpak6 day)..............................................................................16

dexamethasone tab therapy pack 1.5 mg (35) (Dexpak10 day)............................................................................16

dexamethasone tab therapy pack 1.5 mg (51) (Dexpak13 day)............................................................................16

DEXILANT -dexlansoprazole cap delayed release 30mg....................................................................................53

DEXILANT -dexlansoprazole cap delayed release 60mg....................................................................................53

dexmethylphenidate hcl cap er 24 hr 5 mg (Focalinxr).................................................................................... 68








dexmethylphenidate hcl tab 2.5 mg (Focalin).............. 68dexmethylphenidate hcl tab 5 mg (Focalin)................. 68dexmethylphenidate hcl tab 10 mg (Focalin)............... 69DEXPAK 10 DAY -dexamethasone tab therapy pack 1.5

mg (35)............................................................................17DEXPAK 13 DAY -dexamethasone tab therapy pack 1.5

mg (51)............................................................................17DEXPAK 6 DAY -dexamethasone tab therapy pack 1.5

mg (21)............................................................................17dextroamphetamine sulfate cap er 24hr 5 mg

(Dexedrine).....................................................................69dextroamphetamine sulfate cap er 24hr 10 mg

(Dexedrine).....................................................................69dextroamphetamine sulfate cap er 24hr 15 mg

(Dexedrine).....................................................................69dextroamphetamine sulfate oral solution 5 mg/5ml

(Procentra)..................................................................... 69dextroamphetamine sulfate tab 5 mg........................... 69dextroamphetamine sulfate tab 10 mg......................... 69DIASTAT ACUDIAL -diazepam rectal gel delivery system

10 mg.............................................................................. 85DIASTAT ACUDIAL -diazepam rectal gel delivery system

20 mg.............................................................................. 85DIASTAT PEDIATRIC -diazepam rectal gel delivery

system 2.5 mg................................................................ 85DIATRUE PLUS BLOOD GLUCOS -glucose blood test

strip................................................................................118diazepam conc 5 mg/ml..................................................59DIAZEPAM -diazepam oral soln 1 mg/ml..........................59DIAZEPAM RECTAL GEL -diazepam rectal gel delivery

system 2.5 mg................................................................ 85

2019


DIAZEPAM RECTAL GEL -diazepam rectal gel deliverysystem 10 mg................................................................. 85

DIAZEPAM RECTAL GEL -diazepam rectal gel deliverysystem 20 mg................................................................. 85

diazepam tab 2 mg (Valium)...........................................59diazepam tab 5 mg (Valium)...........................................60diazepam tab 10 mg (Valium).........................................60DICLEGIS -doxylamine-pyridoxine tab delayed release

10-10 mg......................................................................... 54diclofenac potassium tab 50 mg................................... 80diclofenac sodium (actinic keratoses) gel 3%

(Solaraze)..................................................................... 112diclofenac sodium gel 1% (Voltaren)...........................112diclofenac sodium ophth soln 0.1%............................107diclofenac sodium soln 1.5%....................................... 113diclofenac sodium tab delayed release 25 mg.............80diclofenac sodium tab delayed release 50 mg.............80diclofenac sodium tab delayed release 75 mg.............80diclofenac sodium tab er 24hr 100 mg......................... 80diclofenac w/ misoprostol tab delayed release 50-0.2

mg (Arthrotec 50)..........................................................80diclofenac w/ misoprostol tab delayed release 75-0.2

mg (Arthrotec 75)..........................................................80dicloxacillin sodium cap 250 mg..................................... 1dicloxacillin sodium cap 500 mg..................................... 1dicyclomine hcl cap 10 mg (Bentyl)..............................53dicyclomine hcl oral soln 10 mg/5ml............................ 53dicyclomine hcl tab 20 mg............................................. 53didanosine delayed release capsule 200 mg (Videx

ec)......................................................................................5didanosine delayed release capsule 250 mg (Videx

ec)......................................................................................5didanosine delayed release capsule 400 mg (Videx

ec)......................................................................................6DIETHYLPROPION HCL ER -diethylpropion hcl tab er

24hr 75 mg......................................................................69diethylpropion hcl tab 25 mg (Diethylpropion hcl)...... 69DIFFERIN -adapalene lotion 0.1%..................................113DIFICID -fidaxomicin tab 200 mg........................................2DIFLORASONE DIACETATE -diflorasone diacetate

cream 0.05%.................................................................113diflorasone diacetate oint 0.05%................................. 113diflunisal tab 500 mg.......................................................74DIGOXIN -digoxin oral soln 0.05 mg/ml............................33digoxin tab 125 mcg (0.125 mg) (Lanoxin)................... 33digoxin tab 250 mcg (0.25 mg) (Lanoxin)..................... 33DIHYDROERGOTAMINE MESYLAT -dihydroergotamine

mesylate nasal spray 4 mg/ml....................................... 83dihydroergotamine mesylate inj 1 mg/ml (D.h.e.

45)....................................................................................83DILANTIN INFATABS -phenytoin chew tab 50 mg........... 85DILANTIN -phenytoin sodium extended cap 30 mg......... 85DILANTIN -phenytoin sodium extended cap 100 mg........85DILANTIN-125 -phenytoin susp 125 mg/5ml.................... 85DILATRATE SR -isosorbide dinitrate cap er 40 mg.......... 33diltiazem hcl cap er 12hr 60 mg.....................................35diltiazem hcl cap er 12hr 90 mg.....................................35

diltiazem hcl cap er 12hr 120 mg...................................35diltiazem hcl cap er 24hr 120 mg...................................35diltiazem hcl cap er 24hr 180 mg...................................35diltiazem hcl cap er 24hr 240 mg...................................35diltiazem hcl coated beads cap er 24hr 300 mg...........36diltiazem hcl coated beads cap er 24hr 120 mg

(Cardizem cd)................................................................ 35diltiazem hcl coated beads cap er 24hr 180 mg



(Cardizem cd)................................................................ 36diltiazem hcl coated beads tab er 24hr 180 mg

(Cardizem la)................................................................. 36diltiazem hcl coated beads tab er 24hr 240 mg




(Cardizem la)................................................................. 36diltiazem hcl extended release beads cap er 24hr 120

mg (Tiazac).................................................................... 36diltiazem hcl extended release beads cap er 24hr 180





mg (Tiazac).................................................................... 36diltiazem hcl tab 90 mg...................................................36diltiazem hcl tab 30 mg (Cardizem)...............................36diltiazem hcl tab 60 mg (Cardizem)...............................36diltiazem hcl tab 120 mg (Cardizem).............................36DIPENTUM -olsalazine sodium cap 250 mg.....................56diphenhydramine hcl elixir 12.5 mg/5ml.......................47DIPHENOXYLATE/ATROPINE -diphenoxylate w/ atropine

liq 2.5-0.025 mg/5ml.......................................................52diphenoxylate w/ atropine tab 2.5-0.025 mg

(Lomotil)......................................................................... 52DIPHTHERIA/TETANUS TOXOID -diphtheria-tetanus tox

adsorbed (dt) im inj 25-5 unit/0.5ml............................... 11dipyridamole tab 25 mg................................................ 103dipyridamole tab 50 mg................................................ 103dipyridamole tab 75 mg................................................ 103disopyramide phosphate cap 100 mg (Norpace).........37disopyramide phosphate cap 150 mg (Norpace).........37disulfiram tab 250 mg (Antabuse)................................. 71disulfiram tab 500 mg (Antabuse)................................. 71DIURIL -chlorothiazide susp 250 mg/5ml......................... 42divalproex sodium cap delayed release sprinkle 125

mg (Depakote sprinkles)..............................................85

2019


divalproex sodium tab delayed release 125 mg(Depakote)......................................................................85



divalproex sodium tab er 24 hr 250 mg (Depakoteer).................................................................................... 85

divalproex sodium tab er 24 hr 500 mg (Depakoteer).................................................................................... 86

DIVIGEL -estradiol td gel 0.25 mg/0.25gm (0.1%)........... 19DIVIGEL -estradiol td gel 0.5 mg/0.5gm (0.1%)............... 19DIVIGEL -estradiol td gel 1 mg/gm (0.1%)....................... 19dofetilide cap 125 mcg (0.125 mg) (Tikosyn)................37dofetilide cap 250 mcg (0.25 mg) (Tikosyn)..................37dofetilide cap 500 mcg (0.5 mg) (Tikosyn)....................37donepezil hydrochloride orally disintegrating tab 5

mg................................................................................... 71donepezil hydrochloride orally disintegrating tab 10

mg................................................................................... 71donepezil hydrochloride tab 5 mg (Aricept).................71donepezil hydrochloride tab 10 mg (Aricept)...............71donepezil hydrochloride tab 23 mg (Aricept)...............71DONNATAL -pb-hyoscy-atrop-scopol elix

16.2-0.1037-0.0194-0.0065 mg/5ml...............................53DONNATAL -pb-hyoscy-atrop-scopol tab

16.2-0.1037-0.0194-0.0065 mg......................................53DOPTELET -avatrombopag maleate tab 20 mg (base

equiv)...............................................................................98DORAL -quazepam tab 15 mg..........................................66DORYX MPC -doxycycline hyclate tab delayed release

120 mg.............................................................................. 2dorzolamide hcl ophth soln 2% (Trusopt).................. 107dorzolamide hcl-timolol maleate ophth sol 22.3-6.8

mg/ml pf (Cosopt pf).................................................. 107dorzolamide hcl-timolol maleate ophth soln 22.3-6.8

mg/ml (Cosopt)............................................................107DOTHELLE DHA -prenatal w/fe fum-fe poly -fa-omega 3

cap 53.5-38-1 mg........................................................... 92doxazosin mesylate tab 1 mg (Cardura).......................39doxazosin mesylate tab 2 mg (Cardura).......................39doxazosin mesylate tab 4 mg (Cardura).......................39doxazosin mesylate tab 8 mg (Cardura).......................39doxepin hcl cap 10 mg....................................................61doxepin hcl cap 25 mg....................................................61doxepin hcl cap 50 mg....................................................61doxepin hcl cap 75 mg....................................................61doxepin hcl cap 100 mg..................................................61doxepin hcl cap 150 mg..................................................61doxepin hcl conc 10 mg/ml............................................ 61DOXEPIN HYDROCHLORIDE -doxepin hcl cream

5%..................................................................................113doxercalciferol cap 0.5 mcg (Hectorol).........................29doxercalciferol cap 1 mcg (Hectorol)............................29doxercalciferol cap 2.5 mcg (Hectorol).........................30DOXYCYCLINE -doxycycline (rosacea) cap delayed

release 40 mg...............................................................113

doxycycline hyclate cap 50 mg....................................... 3doxycycline hyclate cap 100 mg (Vibramycin)...............3DOXYCYCLINE HYCLATE -doxycycline hyclate tab 50

mg......................................................................................3doxycycline hyclate tab delayed release 75 mg............ 3doxycycline hyclate tab delayed release 100 mg.......... 3doxycycline hyclate tab delayed release 150 mg.......... 3doxycycline hyclate tab delayed release 50 mg

(Doryx).............................................................................. 3doxycycline hyclate tab delayed release 200 mg

(Doryx).............................................................................. 3doxycycline hyclate tab 20 mg........................................ 3doxycycline hyclate tab 100 mg...................................... 3doxycycline hyclate tab 75 mg (Acticlate)......................3doxycycline hyclate tab 150 mg (Acticlate)....................3doxycycline monohydrate cap 50 mg............................. 3doxycycline monohydrate cap 150 mg (Adoxa).............3doxycycline monohydrate cap 75 mg (Monodox)..........3doxycycline monohydrate cap 100 mg (Monodox)........3doxycycline monohydrate for susp 25 mg/5ml

(Vibramycin).....................................................................3doxycycline monohydrate tab 50 mg..............................3doxycycline monohydrate tab 75 mg..............................3doxycycline monohydrate tab 100 mg............................3doxycycline monohydrate tab 150 mg............................3dronabinol cap 2.5 mg (Marinol)....................................54dronabinol cap 5 mg (Marinol).......................................54dronabinol cap 10 mg (Marinol).....................................54drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin

28)....................................................................................20drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz).....20drospirenone-ethinyl estrad-levomefolate tab

3-0.02-0.451 mg (Beyaz)...............................................20drospirenone-ethinyl estrad-levomefolate tab

3-0.03-0.451 mg (Safyral)............................................. 20DROXIA -hydroxyurea cap 200 mg.................................. 98DROXIA -hydroxyurea cap 300 mg.................................. 98DROXIA -hydroxyurea cap 400 mg.................................. 98DUAVEE -conjugated estrogens-bazedoxifene tab

0.45-20 mg......................................................................19DUET DHA BALANCED -prenat w/fe poly-na fered-fa tab

25-1 & omega cap 267 mg............................................ 92DUET DHA 400 -prenat w/fe poly-na fered-fa tab 25-1 &

omega cap 400 mg........................................................ 92DUEXIS -ibuprofen-famotidine tab 800-26.6 mg.............. 80DULERA -mometasone furoate-formoterol fumarate

aerosol 100-5 mcg/act....................................................50DULERA -mometasone furoate-formoterol fumarate

aerosol 200-5 mcg/act....................................................50duloxetine hcl enteric coated pellets cap 40 mg (base

eq)................................................................................... 61duloxetine hcl enteric coated pellets cap 20 mg (base

eq) (Cymbalta)............................................................... 61duloxetine hcl enteric coated pellets cap 30 mg (base

eq) (Cymbalta)............................................................... 61duloxetine hcl enteric coated pellets cap 60 mg (base

eq) (Cymbalta)............................................................... 61

2019


DUO-CARE TEST STRIPS -glucose blood test strip......118DUOPA -carbidopa-levodopa enteral susp 4.63-20 mg/

ml..................................................................................... 89DUPIXENT -dupilumab subcutaneous soln prefilled

syringe 300 mg/2ml...................................................... 113DUREZOL -difluprednate ophth emulsion 0.05%........... 107DURLAZA -aspirin capsule er 24hr 162.5 mg................ 103dutasteride cap 0.5 mg (Avodart).................................. 59dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn)......59DUTOPROL -metoprolol & hydrochlorothiazide tab er

24hr 25-12.5 mg............................................................. 39DUTOPROL -metoprolol & hydrochlorothiazide tab er

24hr 50-12.5 mg............................................................. 39DUTOPROL -metoprolol & hydrochlorothiazide tab er

24hr 100-12.5 mg........................................................... 39DUZALLO -lesinurad-allopurinol tab 200-200 mg.............84DUZALLO -lesinurad-allopurinol tab 200-300 mg.............84DYANAVEL XR -amphetamine extended release susp 2.5

mg/ml...............................................................................69DYMISTA -azelastine hcl-fluticasone prop nasal spray

137-50 mcg/act............................................................... 47DYRENIUM -triamterene cap 50 mg.................................42DYRENIUM -triamterene cap 100 mg...............................42

EEASIVENT/MASK-LARGE -spacer/aerosol-holding

chambers - device........................................................ 123EASIVENT/MASK-MEDIUM -spacer/aerosol-holding

chambers - device........................................................ 123EASIVENT/MASK-SMALL -spacer/aerosol-holding

chambers - device........................................................ 123EASIVENT -spacer/aerosol-holding chambers -

device............................................................................ 123EASYGLUCO -glucose blood test strip...........................118EASYGLUCO PLUS -glucose blood test strip................ 118EASYMAX TEST STRIPS -glucose blood test strip....... 118EASYMAX 15 TEST STRIPS -glucose blood test

strip................................................................................118EASYPLUS BLOOD GLUCOSE TE -glucose blood test

strip................................................................................118EASY PLUS BLOOD GLUCOSE T -glucose blood test

strip................................................................................118EASY PLUS II BLOOD GLUCOS -glucose blood test

strip................................................................................118EASYPRO BLOOD GLUCOSE TES -glucose blood test

strip................................................................................118EASYPRO PLUS -glucose blood test strip..................... 119EASY STEP TEST STRIPS -glucose blood test strip.....118EASY TALK BLOOD GLUCOSE T -glucose blood test

strip................................................................................118EASY TOUCH GLUCOSE TEST S -glucose blood test

strip................................................................................118EASY TOUCH HEALTHPRO GLUC -glucose blood test

strip................................................................................118EASY TRAK BLOOD GLUCOSE T -glucose blood test

strip................................................................................118econazole nitrate cream 1%......................................... 113

ECOZA -econazole nitrate foam 1%...............................113EDARBI -azilsartan medoxomil tab 40 mg........................39EDARBI -azilsartan medoxomil tab 80 mg........................39EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab

40-12.5 mg......................................................................39EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab

40-25 mg......................................................................... 39EDEX -alprostadil for inj kit 10 mcg.................................. 46EDEX -alprostadil for inj kit 20 mcg.................................. 46EDEX -alprostadil for inj kit 40 mcg.................................. 46EDLUAR -zolpidem tartrate sl tab 5 mg............................66EDLUAR -zolpidem tartrate sl tab 10 mg..........................66EDURANT -rilpivirine hcl tab 25 mg (base equivalent).......6E.E.S. 400 -erythromycin ethylsuccinate tab 400 mg......... 2efavirenz cap 50 mg (Sustiva)..........................................6efavirenz cap 200 mg (Sustiva)........................................6efavirenz tab 600 mg (Sustiva)........................................ 6EGRIFTA -tesamorelin acetate for inj 1 mg (base

equiv)...............................................................................30ELEMENT COMPACT TEST STRI -glucose blood test

strip................................................................................119ELEMENT TEST STRIPS -glucose blood test strip........119ELESTRIN -estradiol gel 0.06% (0.52 mg/0.87 gm

metered-dose pump)...................................................... 19eletriptan hydrobromide tab 20 mg (base equivalent)

(Relpax).......................................................................... 83eletriptan hydrobromide tab 40 mg (base equivalent)

(Relpax).......................................................................... 83ELIDEL -pimecrolimus cream 1%................................... 113ELIGARD -leuprolide acetate for subcutaneous inj kit 7.5

mg....................................................................................12ELIGARD -leuprolide acetate (3 month) for subcutaneous

inj kit 22.5mg...................................................................12ELIGARD -leuprolide acetate (4 month) for subcutaneous

inj kit 30 mg.................................................................... 12ELIGARD -leuprolide acetate (6 month) for subcutaneous

inj kit 45 mg.................................................................... 12ELIQUIS -apixaban tab 2.5 mg......................................... 99ELIQUIS -apixaban tab 5 mg.......................................... 100ELIQUIS STARTER PACK -apixaban tab 5 mg..............100ELITE-OB -prenatal vit w/ iron carbonyl-fa tab 50-1.25

mg....................................................................................92ELIXOPHYLLIN -theophylline elixir 80 mg/15ml...............50ELLA -ulipristal acetate tab 30 mg....................................20ELMIRON -pentosan polysulfate sodium caps 100

mg....................................................................................59ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj

250 unit......................................................................... 103ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj



1000 unit....................................................................... 103ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj

1500 unit....................................................................... 103

2019


ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj2000 unit....................................................................... 103





EMADINE -emedastine difumarate ophth soln 0.05%(base equiv).................................................................. 107

EMBEDA -morphine-naltrexone cap er 20-0.8 mg........... 75EMBEDA -morphine-naltrexone cap er 30-1.2 mg........... 75EMBEDA -morphine-naltrexone cap er 50-2 mg.............. 75EMBEDA -morphine-naltrexone cap er 60-2.4 mg........... 75EMBEDA -morphine-naltrexone cap er 80-3.2 mg........... 75EMBEDA -morphine-naltrexone cap er 100-4 mg............ 75EMBRACE BLOOD GLUCOSE TES -glucose blood test

strip................................................................................119EMBRACE EVO BLOOD GLUCOSE -glucose blood test

strip................................................................................119EMBRACE PRO BLOOD GLUCOSE -glucose blood test

strip................................................................................119EMCYT -estramustine phosphate sodium cap 140

mg....................................................................................12EMEND -aprepitant for oral susp 125 mg (125

mg/5ml)............................................................................54EMSAM -selegiline td patch 24hr 6 mg/24hr.................... 61EMSAM -selegiline td patch 24hr 9 mg/24hr.................... 61EMSAM -selegiline td patch 24hr 12 mg/24hr.................. 61EMTRIVA -emtricitabine caps 200 mg................................ 6EMTRIVA -emtricitabine soln 10 mg/ml.............................. 6EMVERM -mebendazole chew tab 100 mg........................9enalapril maleate & hydrochlorothiazide tab 5-12.5

mg................................................................................... 39enalapril maleate & hydrochlorothiazide tab 10-25 mg

(Vaseretic)...................................................................... 39enalapril maleate tab 2.5 mg (Vasotec).........................39enalapril maleate tab 5 mg (Vasotec)............................39enalapril maleate tab 10 mg (Vasotec)..........................39enalapril maleate tab 20 mg (Vasotec)..........................39ENBRACE HR -prenatal vit w/ fe gly cys-fa-omega 3 fatty

acids cap......................................................................... 92ENBREL -etanercept for subcutaneous inj 25 mg............ 80ENBREL -etanercept subcutaneous soln prefilled syringe

25 mg/0.5ml.................................................................... 80ENBREL -etanercept subcutaneous soln prefilled syringe

50 mg/ml......................................................................... 80ENBREL MINI -etanercept subcutaneous solution

cartridge 50 mg/ml..........................................................81ENBREL SURECLICK -etanercept subcutaneous solution

auto-injector 50 mg/ml....................................................81ENCARE -nonoxynol-9 vaginal suppos 100 mg............... 58ENDARI -glutamine (sickle cell) powd pack 5 gm............ 98ENDOMETRIN -progesterone vaginal insert 100 mg....... 58

ENGERIX-B -hepatitis b vaccine (recombinant) 10mcg/0.5ml........................................................................10

ENGERIX-B -hepatitis b vaccine (recombinant) 20 mcg/ml..................................................................................... 10

ENGERIX-B -hepatitis b vaccine (recombinant) susp 10mcg/0.5ml........................................................................10

ENGERIX-B -hepatitis b vaccine (recombinant) susp 20mcg/ml............................................................................. 10

enoxaparin sodium inj 30 mg/0.3ml (Lovenox)..........100enoxaparin sodium inj 40 mg/0.4ml (Lovenox)..........100enoxaparin sodium inj 60 mg/0.6ml (Lovenox)..........100enoxaparin sodium inj 80 mg/0.8ml (Lovenox)..........100enoxaparin sodium inj 100 mg/ml (Lovenox).............100enoxaparin sodium inj 120 mg/0.8ml (Lovenox)........100enoxaparin sodium inj 150 mg/ml (Lovenox).............100enoxaparin sodium inj 300 mg/3ml (Lovenox)...........100ENSTILAR -calcipotriene-betamethasone dipropionate

foam 0.005-0.064%...................................................... 113entacapone tab 200 mg (Comtan)................................. 89entecavir tab 0.5 mg (Baraclude).....................................6entecavir tab 1 mg (Baraclude)........................................6ENTRESTO -sacubitril-valsartan tab 24-26 mg................ 46ENTRESTO -sacubitril-valsartan tab 49-51 mg................ 46ENTRESTO -sacubitril-valsartan tab 97-103 mg.............. 46ENVARSUS XR -tacrolimus tab er 24hr 0.75 mg........... 126ENVARSUS XR -tacrolimus tab er 24hr 1 mg................ 126ENVARSUS XR -tacrolimus tab er 24hr 4 mg................ 126EPANED -enalapril maleate oral soln 1 mg/ml................. 39EPCLUSA -sofosbuvir-velpatasvir tab 400-100 mg............6EPIDUO FORTE -adapalene-benzoyl peroxide gel

0.3-2.5%........................................................................ 113EPIFOAM -pramoxine-hc aerosol foam 1-1%.................113epinastine hcl ophth soln 0.05% (Elestat).................. 107EPINEPHRINE -epinephrine solution auto-injector 0.15

mg/0.15ml (1:1000).........................................................43EPINEPHRINE -epinephrine solution auto-injector 0.3

mg/0.3ml (1:1000)...........................................................43EPINEPHRINE (Mylan Products) -epinephrine solution

auto-injector 0.15 mg/0.3ml (1:2000).............................43EPINEPHRINE (Mylan Products) -epinephrine solution

auto-injector 0.3 mg/0.3ml (1:1000)............................... 43EPIPEN-JR 2-PAK -epinephrine solution auto-injector

0.15 mg/0.3ml (1:2000).................................................. 43EPIPEN 2-PAK -epinephrine solution auto-injector 0.3

mg/0.3ml (1:1000)...........................................................43EPIVIR HBV -lamivudine oral soln 5 mg/ml (hbv)...............6eplerenone tab 25 mg (Inspra).......................................39eplerenone tab 50 mg (Inspra).......................................39EPOGEN -epoetin alfa inj 2000 unit/ml.............................98EPOGEN -epoetin alfa inj 3000 unit/ml.............................98EPOGEN -epoetin alfa inj 4000 unit/ml.............................98EPOGEN -epoetin alfa inj 10000 unit/ml...........................98EPOGEN -epoetin alfa inj 20000 unit/ml...........................98EPROSARTAN MESYLATE -eprosartan mesylate tab 600

mg....................................................................................39EQ BLOOD GLUCOSE TEST STR -glucose blood test

strip................................................................................119

2019


EQUETRO -carbamazepine (antipsychotic) cap er 12hr100 mg............................................................................ 63



ergocalciferol cap 50000 unit.........................................91ERGOLOID MESYLATES -ergoloid mesylates tab 1

mg....................................................................................71ERGOMAR -ergotamine tartrate sl tab 2 mg.................... 83ergotamine w/ caffeine tab 1-100 mg (Cafergot)..........83ERIVEDGE -vismodegib cap 150 mg............................... 12ERLEADA -apalutamide tab 60 mg.................................. 12ERTACZO -sertaconazole nitrate cream 2%.................. 113ERYPED 400 -erythromycin ethylsuccinate for susp 400

mg/5ml...............................................................................2ERY-TAB -erythromycin tab delayed release 250 mg........ 2ERY-TAB -erythromycin tab delayed release 333 mg........ 2ERY-TAB -erythromycin tab delayed release 500 mg........ 2ERYTHROCIN STEARATE -erythromycin stearate tab

250 mg.............................................................................. 2ERYTHROMYCIN ETHYLSUCCINA -erythromycin

ethylsuccinate tab 400 mg............................................... 2erythromycin ethylsuccinate for susp 200 mg/5ml

(E.e.s. granules).............................................................. 2erythromycin gel 2% (Erygel).......................................113erythromycin ophth oint 5 mg/gm...............................107erythromycin pads 2%.................................................. 113erythromycin soln 2%................................................... 113erythromycin tab 250 mg..................................................2erythromycin tab 500 mg..................................................2erythromycin w/ delayed release particles cap 250

mg......................................................................................2ESBRIET -pirfenidone cap 267 mg...................................52ESBRIET -pirfenidone tab 267 mg....................................52ESBRIET -pirfenidone tab 801 mg....................................52escitalopram oxalate soln 5 mg/5ml (base equiv)....... 61escitalopram oxalate tab 5 mg (base equiv)

(Lexapro)........................................................................ 61escitalopram oxalate tab 10 mg (base equiv)

(Lexapro)........................................................................ 61escitalopram oxalate tab 20 mg (base equiv)

(Lexapro)........................................................................ 61esomeprazole magnesium cap delayed release 20 mg

(base eq) (Nexium)....................................................... 53esomeprazole magnesium cap delayed release 40 mg

(base eq) (Nexium)....................................................... 53ESOMEPRAZOLE STRONTIUM -esomeprazole

strontium cap delayed release 49.3 mg.........................53estazolam tab 1 mg......................................................... 66estazolam tab 2 mg......................................................... 66estradiol & norethindrone acetate tab 0.5-0.1 mg

(Activella)....................................................................... 19estradiol & norethindrone acetate tab 1-0.5 mg

(Activella)....................................................................... 19estradiol tab 0.5 mg (Estrace)........................................19estradiol tab 1 mg (Estrace)...........................................19

estradiol tab 2 mg (Estrace)...........................................19estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-

dot).................................................................................. 19estradiol td patch twice weekly 0.0375 mg/24hr

(Vivelle-dot)....................................................................19estradiol td patch twice weekly 0.05 mg/24hr (Vivelle-

dot).................................................................................. 19estradiol td patch twice weekly 0.075 mg/24hr (Vivelle-

dot).................................................................................. 19estradiol td patch twice weekly 0.1 mg/24hr (Vivelle-

dot).................................................................................. 19estradiol td patch weekly 0.025 mg/24hr (Climara)......19estradiol td patch weekly 0.05 mg/24hr (Climara)........19estradiol td patch weekly 0.06 mg/24hr (Climara)........19estradiol td patch weekly 0.075 mg/24hr (Climara)......19estradiol td patch weekly 0.1 mg/24hr (Climara)..........19estradiol td patch weekly 0.0375 mg/24hr (37.5

mcg/24hr) (Climara)...................................................... 19estradiol vaginal cream 0.1 mg/gm (Estrace)...............58estradiol vaginal tab 10 mcg (Vagifem).........................58estradiol valerate im in oil 20 mg/ml (Delestrogen).....19estradiol valerate im in oil 40 mg/ml (Delestrogen).....19ESTRING -estradiol vaginal ring 2 mg (7.5

mcg/24hrs).......................................................................58ESTROGEL -estradiol gel 0.06% (0.75 mg/1.25 gm

metered-dose pump)...................................................... 19eszopiclone tab 1 mg (Lunesta).................................... 66eszopiclone tab 2 mg (Lunesta).................................... 66eszopiclone tab 3 mg (Lunesta).................................... 66ethacrynic acid tab 25 mg (Edecrin)............................. 42ethambutol hcl tab 100 mg (Myambutol)........................ 4ethambutol hcl tab 400 mg (Myambutol)........................ 4ethosuximide cap 250 mg (Zarontin)............................ 86ethosuximide soln 250 mg/5ml (Zarontin).................... 86ethynodiol diacetate & ethinyl estradiol tab 1 mg-35

mcg................................................................................. 20ethynodiol diacetate & ethinyl estradiol tab 1 mg-50

mcg................................................................................. 20ETIDRONATE DISODIUM -etidronate disodium tab 200

mg....................................................................................30ETIDRONATE DISODIUM -etidronate disodium tab 400

mg....................................................................................30etodolac cap 200 mg....................................................... 81etodolac cap 300 mg....................................................... 81etodolac tab er 24hr 400 mg.......................................... 81etodolac tab er 24hr 500 mg.......................................... 81etodolac tab er 24hr 600 mg.......................................... 81etodolac tab 500 mg........................................................81etodolac tab 400 mg (Lodine)........................................ 81ETOPOSIDE -etoposide cap 50 mg..................................12EUCRISA -crisaborole oint 2%....................................... 113EURAX -crotamiton cream 10%......................................113EURAX -crotamiton lotion 10%....................................... 113EVAMIST -estradiol transdermal spray 1.53 mg/spray..... 19EVEKEO -amphetamine sulfate tab 5 mg.........................69EVEKEO -amphetamine sulfate tab 10 mg.......................69

2019


EVENCARE + BLOOD GLUCOSE -glucose blood teststrip................................................................................119

EVENCARE BLOOD GLUCOSE TE -glucose blood teststrip................................................................................119

EVENCARE G2 TEST STRIPS -glucose blood teststrip................................................................................119

EVENCARE G3 TEST STRIPS -glucose blood teststrip................................................................................119

EVENCARE MINI BLOOD GLUCO -glucose blood teststrip................................................................................119

EVOLUTION AUTOCODE -glucose blood test strip.......119EVOTAZ -atazanavir sulfate-cobicistat tab 300-150 mg

(base equiv)...................................................................... 6EVZIO -naloxone hcl solution auto-injector 2

mg/0.4ml........................................................................117EXACTECH R-S-G TEST STRIP -glucose blood test

strip................................................................................119EXACTECH TEST STRIPS -glucose blood test strip..... 119EXELDERM -sulconazole nitrate cream 1%...................113EXELDERM -sulconazole nitrate solution 1%................ 113exemestane tab 25 mg (Aromasin)................................13EXJADE -deferasirox tab for oral susp 125 mg.............. 117EXJADE -deferasirox tab for oral susp 250 mg.............. 117EXJADE -deferasirox tab for oral susp 500 mg.............. 117EXONDYS 51 -eteplirsen iv soln 100 mg/2ml (50 mg/

ml)....................................................................................90EXONDYS 51 -eteplirsen iv soln 500 mg/10ml (50 mg/

ml)....................................................................................90EXTAVIA -interferon beta-1b for inj kit 0.3 mg.................. 71ezetimibe-simvastatin tab 10-10 mg (Vytorin)..............44ezetimibe-simvastatin tab 10-20 mg (Vytorin)..............44ezetimibe-simvastatin tab 10-40 mg (Vytorin)..............44ezetimibe-simvastatin tab 10-80 mg (Vytorin)..............44ezetimibe tab 10 mg (Zetia)............................................ 44EZ SMART BLOOD GLUCOSE TE -glucose blood test

strip................................................................................119EZ SMART PLUS BLOOD GLUCO -glucose blood test

strip................................................................................119

FFABIOR -tazarotene (acne) foam 0.1%.......................... 113FALESSA -levonorgest-eth estrad tab 0.1 mg-20 mcg & fa

tab 1 mg kit.....................................................................20famciclovir tab 125 mg......................................................6famciclovir tab 250 mg......................................................6famciclovir tab 500 mg......................................................6famotidine for susp 40 mg/5ml (Pepcid).......................53famotidine tab 20 mg (Pepcid).......................................53famotidine tab 40 mg (Pepcid).......................................53FANAPT -iloperidone tab 1 mg......................................... 63FANAPT -iloperidone tab 2 mg......................................... 63FANAPT -iloperidone tab 4 mg......................................... 63FANAPT -iloperidone tab 6 mg......................................... 64FANAPT -iloperidone tab 8 mg......................................... 64FANAPT -iloperidone tab 10 mg....................................... 64FANAPT -iloperidone tab 12 mg....................................... 64

FANAPT TITRATION PACK -iloperidone tab 1 mg & 2 mg& 4 mg & 6 mg titration pak...........................................64

FARESTON -toremifene citrate tab 60 mg (baseequivalent).......................................................................13

FARXIGA -dapagliflozin propanediol tab 5 mg (baseequivalent).......................................................................22

FARXIGA -dapagliflozin propanediol tab 10 mg (baseequivalent).......................................................................22

FARYDAK -panobinostat lactate cap 10 mg (baseequivalent).......................................................................13



FAZACLO -clozapine orally disintegrating tab 150 mg..... 64FAZACLO -clozapine orally disintegrating tab 200 mg..... 64FC FEMALE CONDOM -condoms - female....................123FC2 FEMALE CONDOM -condoms - female..................123FEIBA -antiinhibitor coagulant complex for inj................ 103felbamate susp 600 mg/5ml (Felbatol).......................... 86felbamate tab 400 mg (Felbatol).................................... 86felbamate tab 600 mg (Felbatol).................................... 86felodipine tab er 24hr 2.5 mg......................................... 36felodipine tab er 24hr 5 mg............................................ 36felodipine tab er 24hr 10 mg.......................................... 36FEMCAP -cervical cap 22 mm........................................123FEMCAP -cervical cap 26 mm........................................123FEMCAP -cervical cap 30 mm........................................123FEMRING -estradiol acetate vaginal ring 0.05

mg/24hr........................................................................... 58FEMRING -estradiol acetate vaginal ring 0.1 mg/24hr..... 58FENOFIBRATE -fenofibrate cap 50 mg............................ 44FENOFIBRATE -fenofibrate cap 150 mg.......................... 44fenofibrate micronized cap 43 mg.................................44fenofibrate micronized cap 130 mg...............................44fenofibrate micronized cap 67 mg (Lofibra)................. 44fenofibrate micronized cap 134 mg (Lofibra)............... 44fenofibrate micronized cap 200 mg (Lofibra)............... 44fenofibrate tab 40 mg (Fenoglide)................................. 44fenofibrate tab 120 mg (Fenoglide)............................... 44fenofibrate tab 54 mg (Lofibra)...................................... 44fenofibrate tab 160 mg (Lofibra).................................... 44fenofibrate tab 48 mg (Tricor)........................................ 44fenofibrate tab 145 mg (Tricor)...................................... 44FENOFIBRIC ACID -fenofibric acid tab 35 mg................. 44FENOFIBRIC ACID -fenofibric acid tab 105 mg............... 44FENOPROFEN CALCIUM -fenoprofen calcium cap 200

mg....................................................................................81FENOPROFEN CALCIUM -fenoprofen calcium cap 400

mg....................................................................................81fenoprofen calcium tab 600 mg..................................... 81FENORTHO -fenoprofen calcium cap 200 mg................. 81fentanyl citrate lozenge on a handle 200 mcg

(Actiq)............................................................................. 75fentanyl citrate lozenge on a handle 400 mcg

(Actiq)............................................................................. 76

2019


fentanyl citrate lozenge on a handle 600 mcg(Actiq)............................................................................. 76




fentanyl td patch 72hr 37.5 mcg/hr................................76fentanyl td patch 72hr 62.5 mcg/hr................................76fentanyl td patch 72hr 87.5 mcg/hr................................76fentanyl td patch 72hr 12 mcg/hr (Duragesic)..............76fentanyl td patch 72hr 25 mcg/hr (Duragesic)..............76fentanyl td patch 72hr 50 mcg/hr (Duragesic)..............76fentanyl td patch 72hr 75 mcg/hr (Duragesic)..............76fentanyl td patch 72hr 100 mcg/hr (Duragesic)............76FENTORA -fentanyl citrate buccal tab 100 mcg (base

equiv)...............................................................................76FENTORA -fentanyl citrate buccal tab 200 mcg (base




equiv)...............................................................................76FERRIPROX -deferiprone oral soln 100 mg/ml.............. 117FERRIPROX -deferiprone tab 500 mg............................117ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental

fe).....................................................................................98FERROUS SULFATE -ferrous sulfate liquid 220 mg/5ml

(44 mg/5ml elemental fe)............................................... 98FERROUS SULFATE -ferrous sulfate syrup 300 mg/5ml

(60 mg/5ml elemental fe)............................................... 98ferrous sulfate soln 75 mg/ml (15 mg/ml elemental

fe).....................................................................................98FETZIMA -levomilnacipran hcl cap er 24hr 20 mg (base

equivalent).......................................................................61FETZIMA -levomilnacipran hcl cap er 24hr 40 mg (base



equivalent).......................................................................61FETZIMA TITRATION PACK -levomilnacipran hcl cap er

24hr 20 & 40 mg therapy pack...................................... 61FIASP FLEXTOUCH -insulin aspart soln pen-injector 100

unit/ml.............................................................................. 26FIASP -insulin aspart inj 100 unit/ml.................................26FIBRICOR -fenofibric acid tab 35 mg............................... 44FIBRICOR -fenofibric acid tab 105 mg............................. 44FIFTY50 GLUCOSE TEST STRI -glucose blood test

strip................................................................................119FINACEA -azelaic acid foam 15%.................................. 113FINACEA -azelaic acid gel 15%..................................... 113finasteride tab 5 mg (Proscar)....................................... 59

FIRAZYR -icatibant acetate inj 30 mg/3ml (baseequivalent).....................................................................103

FIRVANQ -vancomycin hcl for oral soln 25 mg/ml (baseequivalent)......................................................................... 9

FIRVANQ -vancomycin hcl for oral soln 50 mg/ml (baseequivalent)......................................................................... 9

FLAREX -fluorometholone acetate ophth susp 0.1%..... 107flavoxate hcl tab 100 mg.................................................57flecainide acetate tab 50 mg.......................................... 37flecainide acetate tab 100 mg........................................ 37flecainide acetate tab 150 mg........................................ 37FLECTOR -diclofenac epolamine patch 1.3%................ 113FLEXICHAMBER ADULT MASK/S -spacer/aerosol-

holding chamber supplies - masks.............................. 124FLEXICHAMBER CHILD MASK/L -spacer/aerosol-

holding chamber supplies - masks.............................. 124FLEXICHAMBER CHILD MASK/S -spacer/aerosol-

holding chamber supplies - masks.............................. 124FLEXICHAMBER -spacer/aerosol-holding chambers -

device............................................................................ 123FLOLIPID -simvastatin susp 20 mg/5ml (4 mg/ml)........... 44FLOLIPID -simvastatin susp 40 mg/5ml (8 mg/ml)........... 44FLORIVA -sodium fluoride-vitamin d liqd drops 0.25 mg/

ml-400 unit/ml................................................................. 96FLOVENT DISKUS -fluticasone propionate aer pow ba 50

mcg/blister....................................................................... 50FLOVENT DISKUS -fluticasone propionate aer pow ba

100 mcg/blister................................................................50FLOVENT DISKUS -fluticasone propionate aer pow ba

250 mcg/blister................................................................50FLOVENT HFA -fluticasone propionate hfa inhal aer 110

mcg/act (125/valve)........................................................ 50FLOVENT HFA -fluticasone propionate hfa inhal aer 220

mcg/act (250/valve)........................................................ 50FLOVENT HFA -fluticasone propionate hfa inhal aero 44

mcg/act (50/valve)...........................................................50FLUAD 2018-2019 -influenza vac type a&b surface ant

adj susp pref syr 0.5 ml................................................. 10FLUARIX QUADRIVALENT 2018 -influenza virus vac split

quadrivalent susp pref syr 0.5ml....................................10FLUBLOK QUADRIVALENT 2018 -influenza vac recomb

ha quad pf soln pref syr 0.5 ml......................................10FLUCELVAX QUADRIVALENT 20 -influenza vac tiss-cult

subunt quad susp pref syr 0.5 ml.................................. 10FLUCELVAX QUADRIVALENT 20 -influenza vac tissue-

cultured subunit quadrivalent im susp........................... 10fluconazole for susp 10 mg/ml (Diflucan).......................4fluconazole for susp 40 mg/ml (Diflucan).......................4fluconazole tab 50 mg (Diflucan).....................................4fluconazole tab 100 mg (Diflucan)...................................4fluconazole tab 150 mg (Diflucan)...................................4fluconazole tab 200 mg (Diflucan)...................................4flucytosine cap 250 mg (Ancobon)................................. 4flucytosine cap 500 mg (Ancobon)................................. 5fludrocortisone acetate tab 0.1 mg............................... 17FLULAVAL QUADRIVALENT 201 -influenza virus vaccine

split quadrivalent im inj...................................................10

2019


FLULAVAL QUADRIVALENT 201 -influenza virus vac splitquadrivalent susp pref syr 0.5ml....................................10

FLUMADINE -rimantadine hydrochloride tab 100 mg.........6FLUMIST QUADRIVALENT -influenza virus vaccine live

quadrivalent intranasal susp...........................................10FLUNISOLIDE -flunisolide nasal soln 25 mcg/act

(0.025%).......................................................................... 47fluocinolone acetonide cream 0.01%.......................... 113fluocinolone acetonide cream 0.025% (Synalar)........113fluocinolone acetonide oil 0.01% (body oil) (Derma-

smoothe/fs bod)..........................................................113fluocinolone acetonide oil 0.01% (scalp oil) (Derma-

smoothe/fs sca)...........................................................113fluocinolone acetonide oint 0.025% (Synalar)............113fluocinolone acetonide (otic) oil 0.01%

(Dermotic).................................................................... 109fluocinolone acetonide soln 0.01% (Synalar).............113fluocinonide cream 0.05%............................................ 113fluocinonide cream 0.1% (Vanos)................................ 113fluocinonide emulsified base cream 0.05%................113fluocinonide gel 0.05%..................................................113fluocinonide oint 0.05%................................................ 113fluocinonide soln 0.05%................................................113FLUORABON -sodium fluoride soln 0.25 mg/0.6ml (from

0.55 mg/0.6ml naf)..........................................................96fluorometholone ophth susp 0.1% (Fml liquifilm)..... 107FLUOROPLEX -fluorouracil cream 1%...........................113fluorouracil cream 5% (Efudex)................................... 113FLUOROURACIL -fluorouracil cream 0.5%....................113FLUOROURACIL -fluorouracil soln 2%.......................... 113FLUOROURACIL -fluorouracil soln 5%.......................... 113FLUOXETINE DR -fluoxetine hcl cap delayed release 90

mg....................................................................................61FLUOXETINE -fluoxetine hcl (pmdd) cap 10 mg..............71FLUOXETINE -fluoxetine hcl (pmdd) cap 20 mg..............71fluoxetine hcl cap 10 mg (Prozac).................................61fluoxetine hcl cap 20 mg (Prozac).................................61fluoxetine hcl cap 40 mg (Prozac).................................61fluoxetine hcl (pmdd) tab 10 mg (Sarafem).................. 71fluoxetine hcl (pmdd) tab 20 mg (Sarafem).................. 71fluoxetine hcl solution 20 mg/5ml................................. 61fluoxetine hcl tab 10 mg................................................. 61fluoxetine hcl tab 20 mg................................................. 61fluoxetine hcl tab 60 mg (Fluoxetine hcl)..................... 61FLUPHENAZINE HCL -fluphenazine hcl elixir 2.5

mg/5ml.............................................................................64FLUPHENAZINE HCL -fluphenazine hcl oral conc 5 mg/

ml..................................................................................... 64fluphenazine hcl tab 1 mg.............................................. 64fluphenazine hcl tab 2.5 mg........................................... 64fluphenazine hcl tab 5 mg.............................................. 64fluphenazine hcl tab 10 mg............................................ 64FLURA-DROPS -sodium fluoride soln 0.25 mg/drop f

(from 0.55 mg/drop naf)................................................. 96flurandrenolide cream 0.05% (Cordran)......................113flurandrenolide lotion 0.05% (Cordran).......................113flurandrenolide oint 0.05% (Cordran)..........................113

FLURAZEPAM HCL -flurazepam hcl cap 15 mg.............. 66FLURAZEPAM HCL -flurazepam hcl cap 30 mg.............. 66flurbiprofen sodium ophth soln 0.03% (Ocufen)........107flurbiprofen tab 50 mg.................................................... 81flurbiprofen tab 100 mg.................................................. 81flutamide cap 125 mg......................................................13FLUTICASONE PROPIONATE/SA -fluticasone-salmeterol

aer powder ba 55-14 mcg/act........................................ 50FLUTICASONE PROPIONATE/SA -fluticasone-salmeterol

aer powder ba 113-14 mcg/act...................................... 50FLUTICASONE PROPIONATE/SA -fluticasone-salmeterol

aer powder ba 232-14 mcg/act...................................... 50fluticasone propionate cream 0.05% (Cutivate).........113fluticasone propionate lotion 0.05% (Cutivate)..........114fluticasone propionate nasal susp 50 mcg/act............ 47fluticasone propionate oint 0.005%.............................114fluvastatin sodium cap 20 mg........................................44fluvastatin sodium cap 40 mg........................................44fluvastatin sodium tab er 24 hr 80 mg (Lescol xl)........44fluvoxamine maleate cap er 24hr 100 mg.....................61fluvoxamine maleate cap er 24hr 150 mg.....................61fluvoxamine maleate tab 25 mg.....................................61fluvoxamine maleate tab 50 mg.....................................61fluvoxamine maleate tab 100 mg...................................61FLUZONE HIGH-DOSE PF 2018 -influenza virus vac split

high-dose pf susp pref syr 0.5ml....................................10FLUZONE QUADRIVALENT 2018 -influenza virus

vaccine split quadrivalent im inj..................................... 10FLUZONE QUADRIVALENT 2018 -influenza virus

vaccine split quadrivalent inj 0.5 ml............................... 10FLUZONE QUADRIVALENT 2018 -influenza virus vac

split quadrivalent susp pref syr 0.25 ml......................... 10FLUZONE QUADRIVALENT 2018 -influenza virus vac

split quadrivalent susp pref syr 0.5ml............................ 10FML -fluorometholone ophth oint 0.1%...........................107FML FORTE -fluorometholone ophth susp 0.25%..........107FOLET DHA -prenat w/fecbn-bisg-methylf-dss tab dr &

dha cap pak.................................................................... 92FOLET ONE -prenat w/o a w/fecbn-bisg-methylf-dss-dha

cap 38-1-225 mg............................................................ 92folic acid cap 0.8 mg.......................................................98folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2

mg................................................................................... 97folic acid tab 400 mcg.....................................................98folic acid tab 800 mcg.....................................................98folic acid tab 1 mg...........................................................98FOLIVANE-OB -prenatal w/o a w/fe fum-fe poly-fa cap

130-92.4-1 mg.................................................................92FOLLISTIM AQ -follitropin beta inj 300 unit/0.36ml.......... 30FOLLISTIM AQ -follitropin beta inj 600 unit/0.72ml.......... 30FOLLISTIM AQ -follitropin beta inj 900 unit/1.08ml.......... 30fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml

(Arixtra).........................................................................100fondaparinux sodium subcutaneous inj 5 mg/0.4ml

(Arixtra).........................................................................100fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml

(Arixtra).........................................................................100

2019


fondaparinux sodium subcutaneous inj 10 mg/0.8ml(Arixtra).........................................................................100

FORA BLOOD GLUCOSE TEST S -glucose blood teststrip................................................................................119

FORACARE GD40 -glucose blood test strip...................119FORACARE PREMIUM V10 TEST -glucose blood test

strip................................................................................119FORACARE TEST N GO TEST S -glucose blood test

strip................................................................................119FORA D40/G31 BLOOD GLUCOS -glucose blood test

strip................................................................................119FORA D20 BLOOD GLUCOSE TE -glucose blood test

strip................................................................................119FORA D15G BLOOD GLUCOSE T -glucose blood test

strip................................................................................119FORA G30/PREMIUM V10 BLOO -glucose blood test

strip................................................................................119FORA G20 BLOOD GLUCOSE TE -glucose blood test

strip................................................................................119FORA GD50 BLOOD GLUCOSE T -glucose blood test

strip................................................................................119FORA GD20 TEST STRIPS -glucose blood test

strip................................................................................119FORA TN'G/TN'G VOICE BLOO -glucose blood test

strip................................................................................119FORA V30A BLOOD GLUCOSE T -glucose blood test

strip................................................................................119FORA V10 BLOOD GLUCOSE TE -glucose blood test



strip................................................................................119FORFIVO XL -bupropion hcl tab er 24hr 450 mg............. 61FORTEO -teriparatide (recombinant) inj 600

mcg/2.4ml........................................................................30FORTESTA -testosterone td gel 10mg/act (2%)...............18FORTISCARE BLOOD GLUCOSE -glucose blood test

strip................................................................................119FOSAMAX PLUS D -alendronate sodium-cholecalciferol

tab 70-2800 mg-unit....................................................... 30FOSAMAX PLUS D -alendronate sodium-cholecalciferol

tab 70-5600 mg-unit....................................................... 30fosamprenavir calcium tab 700 mg (base equiv)

(Lexiva)............................................................................. 6fosinopril sodium & hydrochlorothiazide tab 10-12.5

mg................................................................................... 39fosinopril sodium & hydrochlorothiazide tab 20-12.5

mg................................................................................... 39fosinopril sodium tab 10 mg.......................................... 39fosinopril sodium tab 20 mg.......................................... 39fosinopril sodium tab 40 mg.......................................... 39FOSRENOL -lanthanum carbonate oral powder pack 750

mg (elemental)................................................................ 56FOSRENOL -lanthanum carbonate oral powder pack

1000 mg (elemental).......................................................56FRAGMIN -dalteparin sodium inj 10000 unit/ml..............100

FRAGMIN -dalteparin sodium inj 2500 unit/0.2ml...........100FRAGMIN -dalteparin sodium inj 5000 unit/0.2ml...........100FRAGMIN -dalteparin sodium inj 7500 unit/0.3ml...........100FRAGMIN -dalteparin sodium inj 12500 unit/0.5ml.........100FRAGMIN -dalteparin sodium inj 15000 unit/0.6ml.........100FRAGMIN -dalteparin sodium inj 18000 unit/0.72ml.......100FRAGMIN -dalteparin sodium inj 95000 unit/3.8ml.........100FREESTYLE INSULINX BLOOD -glucose blood test

strip................................................................................119FREESTYLE LITE TEST STRIP -glucose blood test

strip................................................................................119FREESTYLE PRECISION NEO B -glucose blood test

strip................................................................................119FREESTYLE TEST STRIPS -glucose blood test

strip................................................................................119frovatriptan succinate tab 2.5 mg (base equivalent)

(Frova).............................................................................83FULPHILA -pegfilgrastim-jmdb soln prefilled syringe 6

mg/0.6ml..........................................................................98FUROSEMIDE -furosemide oral soln 8 mg/ml..................42furosemide oral soln 10 mg/ml...................................... 42furosemide tab 20 mg (Lasix)........................................ 42furosemide tab 40 mg (Lasix)........................................ 42furosemide tab 80 mg (Lasix)........................................ 42FUZEON -enfuvirtide for inj 90 mg..................................... 6FYCOMPA -perampanel susp 0.5 mg/ml..........................86FYCOMPA -perampanel tab 2 mg.................................... 86FYCOMPA -perampanel tab 4 mg.................................... 86FYCOMPA -perampanel tab 6 mg.................................... 86FYCOMPA -perampanel tab 8 mg.................................... 86FYCOMPA -perampanel tab 10 mg.................................. 86FYCOMPA -perampanel tab 12 mg.................................. 86

Ggabapentin cap 100 mg (Neurontin)..............................86gabapentin cap 300 mg (Neurontin)..............................86gabapentin cap 400 mg (Neurontin)..............................86gabapentin oral soln 250 mg/5ml (Neurontin)..............86gabapentin tab 600 mg (Neurontin)...............................86gabapentin tab 800 mg (Neurontin)...............................86galantamine hydrobromide cap er 24hr 8 mg

(Razadyne er)................................................................ 71galantamine hydrobromide cap er 24hr 16 mg

(Razadyne er)................................................................ 72galantamine hydrobromide cap er 24hr 24 mg

(Razadyne er)................................................................ 72GALANTAMINE HYDROBROMIDE -galantamine

hydrobromide oral soln 4 mg/ml.................................... 71galantamine hydrobromide tab 4 mg (Razadyne)........72galantamine hydrobromide tab 8 mg (Razadyne)........72galantamine hydrobromide tab 12 mg (Razadyne)......72GALZIN -zinc acetate cap 25 mg (elemental zinc)........... 96GALZIN -zinc acetate cap 50 mg (elemental zinc)........... 96GANIRELIX ACETATE -ganirelix acetate inj 250

mcg/0.5ml........................................................................30GARDASIL 9 -human papillomavirus (hpv) 9-valent

recomb vac im susp....................................................... 10

2019


GARDASIL 9 -human papillomavirus (hpv) 9-valentrecomb vac susp pref syr...............................................10

gatifloxacin ophth soln 0.5% (Zymaxid)..................... 107GATTEX -teduglutide (rdna) for inj kit 5 mg......................56GE100 BLOOD GLUCOSE TEST -glucose blood test

strip................................................................................120GELNIQUE -oxybutynin chloride td gel 10%.................... 57GELNIQUE PUMP -oxybutynin chloride td gel 10%.........57gemfibrozil tab 600 mg (Lopid)......................................44GENOTROPIN MINIQUICK -somatropin for inj 0.2

mg....................................................................................30GENOTROPIN MINIQUICK -somatropin for inj 0.4



mg....................................................................................30GENOTROPIN MINIQUICK -somatropin for inj 1 mg.......30GENOTROPIN MINIQUICK -somatropin for inj 1.2




mg....................................................................................30GENOTROPIN MINIQUICK -somatropin for inj 2 mg.......30GENOTROPIN -somatropin for inj 12 mg (13.8 mg

overfill)............................................................................. 30GENOTROPIN -somatropin for subcutaneous inj 5

mg....................................................................................30GENSTRIP 50 -glucose blood test strip..........................119GENTAK -gentamicin sulfate ophth oint 0.3%................ 107gentamicin sulfate cream 0.1%....................................114gentamicin sulfate oint 0.1%........................................114gentamicin sulfate ophth soln 0.3%............................107GENULTIMATE TEST STRIPS -glucose blood test

strip................................................................................120GENVOYA -elvitegrav-cobic-emtricitab-tenofov af tab

150-150-200-10 mg.......................................................... 6GHT TEST STRIPS -glucose blood test strip................. 120GIALAX -polyethylene glycol 3350 - kit............................ 52GILENYA -fingolimod hcl cap 0.5 mg (base equiv)...........72GILOTRIF -afatinib dimaleate tab 20 mg (base

equivalent).......................................................................13GILOTRIF -afatinib dimaleate tab 30 mg (base

equivalent).......................................................................13GILOTRIF -afatinib dimaleate tab 40 mg (base

equivalent).......................................................................13GLASSIA -alpha1-proteinase inhibitor (human) inj 1000

mg/50ml...........................................................................52glatiramer acetate soln prefilled syringe 20 mg/ml

(Copaxone).....................................................................72glatiramer acetate soln prefilled syringe 40 mg/ml

(Copaxone).....................................................................72GLEOSTINE -lomustine cap 10 mg.................................. 13GLEOSTINE -lomustine cap 40 mg.................................. 13

GLEOSTINE -lomustine cap 100 mg................................ 13glimepiride tab 1 mg (Amaryl)........................................22glimepiride tab 2 mg (Amaryl)........................................22glimepiride tab 4 mg (Amaryl)........................................22glipizide-metformin hcl tab 2.5-250 mg.........................22glipizide-metformin hcl tab 2.5-500 mg.........................23glipizide-metformin hcl tab 5-500 mg............................23glipizide tab er 24hr 2.5 mg (Glucotrol xl).................... 22glipizide tab er 24hr 5 mg (Glucotrol xl)....................... 22glipizide tab er 24hr 10 mg (Glucotrol xl)..................... 22glipizide tab 5 mg (Glucotrol).........................................22glipizide tab 10 mg (Glucotrol).......................................22GLUCAGEN HYPOKIT -glucagon hcl (rdna) for inj 1 mg

(base equiv).................................................................... 23GLUCAGON EMERGENCY KIT -glucagon (rdna) for inj

kit 1 mg........................................................................... 23GLUCOCARD EXPRESSION BLOO -glucose blood test

strip................................................................................120GLUCOCARD 01 SENSOR PLUS -glucose blood test

strip................................................................................120GLUCOCARD SHINE TEST STRI -glucose blood test

strip................................................................................120GLUCOCARD VITAL TEST STRI -glucose blood test

strip................................................................................120GLUCOCARD X-SENSOR -glucose blood test strip...... 120GLUCOCOM TEST STRIPS -glucose blood test

strip................................................................................120GLUCONAVII BLOOD GLUCOSE -glucose blood test

strip................................................................................120GLUCO PERFECT 3 TEST STRI -glucose blood test

strip................................................................................120GLUCOSE METER TEST STRIPS -glucose blood test

strip................................................................................120glyburide-metformin tab 1.25-250 mg........................... 23glyburide-metformin tab 2.5-500 mg (Glucovance)..... 23glyburide-metformin tab 5-500 mg (Glucovance)........ 23glyburide micronized tab 1.5 mg (Glynase)..................23glyburide micronized tab 3 mg (Glynase).....................23glyburide micronized tab 6 mg (Glynase).....................23glyburide tab 1.25 mg..................................................... 23glyburide tab 2.5 mg....................................................... 23glyburide tab 5 mg.......................................................... 23GLYCATE -glycopyrrolate tab 1.5 mg............................... 53glycopyrrolate tab 1 mg (Robinul).................................53glycopyrrolate tab 2 mg (Robinul forte)........................53GLYTACTIN BETTERMILK DE-L -nutritional supplement

pack................................................................................. 97GLYTACTIN BETTERMILK 15 -nutritional supplement

pack................................................................................. 97GLYTACTIN BUILD 20/20 PKU -nutritional supplement

pack................................................................................. 97GLYTACTIN BUILD 10PE -nutritional supplement

pack................................................................................. 97GLYTACTIN COMPLETE 10PE -nutritional supplement

bar....................................................................................97GLYTACTIN RESTORE LITE 10 -nutritional supplement

pack................................................................................. 97

2019


GLYTACTIN RESTORE 5 -nutritional supplementpack................................................................................. 97

GLYTACTIN RTD LITE 15 -nutritional supplementliquid................................................................................ 97

GLYTACTIN RTD 10 -nutritional supplement liquid.......... 97GLYTACTIN RTD 15 -nutritional supplement liquid.......... 97GLYXAMBI -empagliflozin-linagliptin tab 10-5 mg............ 23GLYXAMBI -empagliflozin-linagliptin tab 25-5 mg............ 23GNP EASY TOUCH GLUCOSE TE -glucose blood test

strip................................................................................120GOCOVRI -amantadine hcl cap er 24hr 68.5 mg (base

equivalent).......................................................................89GOCOVRI -amantadine hcl cap er 24hr 137 mg (base

equivalent).......................................................................89GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate

packet 227.1 gm............................................................. 52GONAL-F -follitropin alfa for inj 450 unit...........................30GONAL-F -follitropin alfa for inj 1050 unit.........................30GONAL-F RFF -follitropin alfa for subcutaneous inj 75

unit................................................................................... 30GONAL-F RFF REDIJECT -follitropin alfa inj 300

unit/0.5ml......................................................................... 30GONAL-F RFF REDIJECT -follitropin alfa inj 450

unit/0.75ml.......................................................................30GONAL-F RFF REDIJECT -follitropin alfa inj 900

unit/1.5ml......................................................................... 30GONITRO -nitroglycerin sublingual powder packet 400

mcg.................................................................................. 33GOODSENSE PREMIUM BLOOD G -glucose blood test

strip................................................................................120GRALISE -gabapentin (once-daily) tab 300 mg................72GRALISE -gabapentin (once-daily) tab 600 mg................72GRALISE STARTER -gabapentin (once-daily) tab pack

300 mg (9) & 600 mg (69)............................................. 72granisetron hcl tab 1 mg................................................ 54GRANIX -tbo-filgrastim soln prefilled syringe 300

mcg/0.5ml........................................................................98GRANIX -tbo-filgrastim soln prefilled syringe 480

mcg/0.8ml........................................................................98GRASTEK -timothy grass pollen allergen ext sl tab 2800

bau...................................................................................12griseofulvin microsize susp 125 mg/5ml........................ 5griseofulvin microsize tab 500 mg.................................. 5griseofulvin ultramicrosize tab 125 mg (Gris-peg)........ 5griseofulvin ultramicrosize tab 250 mg (Gris-peg)........ 5guanfacine hcl tab er 24hr 1 mg (base equiv)

(Intuniv).......................................................................... 69guanfacine hcl tab er 24hr 2 mg (base equiv)



(Intuniv).......................................................................... 69guanfacine hcl tab 1 mg................................................. 39guanfacine hcl tab 2 mg................................................. 39GUANIDINE HCL -guanidine hcl tab 125 mg................... 91

GYNAZOLE-1 -butoconazole nitrate (one dose) vaginalcream 2%........................................................................58

HHAEGARDA -c1 esterase inhibitor (human) for

subcutaneous inj 2000 unit.......................................... 103HAEGARDA -c1 esterase inhibitor (human) for

subcutaneous inj 3000 unit.......................................... 103HALCION -triazolam tab 0.25 mg..................................... 66halobetasol propionate cream 0.05% (Ultravate).......114halobetasol propionate oint 0.05% (Ultravate)...........114HALOG -halcinonide cream 0.1%................................... 114HALOG -halcinonide oint 0.1%....................................... 114haloperidol lactate oral conc 2 mg/ml...........................64haloperidol tab 0.5 mg.................................................... 64haloperidol tab 1 mg....................................................... 64haloperidol tab 2 mg....................................................... 64haloperidol tab 5 mg....................................................... 64haloperidol tab 10 mg..................................................... 64haloperidol tab 20 mg..................................................... 64HARVONI -ledipasvir-sofosbuvir tab 90-400 mg................ 6HAVRIX -hepatitis a vaccine inj susp 720 el

unit/0.5ml......................................................................... 10HAVRIX -hepatitis a vaccine inj susp 1440 el unit/ml....... 10HELIXATE FS -antihemophilic factor (recombinant) for inj

kit 250 unit.................................................................... 103HELIXATE FS -antihemophilic factor (recombinant) for inj

kit 500 unit.................................................................... 103HELIXATE FS -antihemophilic factor (recombinant) for inj

kit 1000 unit.................................................................. 103HELIXATE FS -antihemophilic factor (recombinant) for inj

kit 2000 unit.................................................................. 103HELIXATE FS -antihemophilic factor (recombinant) for inj

kit 3000 unit.................................................................. 103HEMANGEOL -propranolol hcl oral soln 4.28 mg/ml (3.75

mg/ml base equiv).......................................................... 34HEMENATAL OB + DHA -prenat-fe poly cmplx-fe heme

poly-fa tab & omega 3 cap pck......................................92HEMENATAL OB -prenat vit-fe poly cmplx-fe heme poly-

fa tab 28-6-1 mg.............................................................92HEMLIBRA -emicizumab-kxwh subcutaneous soln 30 mg/

ml................................................................................... 103HEMLIBRA -emicizumab-kxwh subcutaneous soln 150

mg/ml.............................................................................103HEMLIBRA -emicizumab-kxwh subcutaneous soln 60

mg/0.4ml (150 mg/ml).................................................. 103HEMLIBRA -emicizumab-kxwh subcutaneous soln 105

mg/0.7ml (150 mg/ml).................................................. 103HEMOFIL M -antihemophilic factor (human) for inj 250

unit................................................................................. 103HEMOFIL M -antihemophilic factor (human) for inj 500



unit................................................................................. 103heparin sodium (porcine) inj 1000 unit/ml..................100

2019


heparin sodium (porcine) inj 5000 unit/ml..................100heparin sodium (porcine) inj 10000 unit/ml................100heparin sodium (porcine) inj 20000 unit/ml................100heparin sodium (porcine) pf inj 5000 unit/0.5ml........ 100HEPLISAV-B -hepatitis b vaccine recomb adjuvanted pref

syr 20 mcg/0.5ml............................................................ 10HEPLISAV-B -hepatitis b vaccine recombinant adjuvanted

20 mcg/0.5ml.................................................................. 10HETLIOZ -tasimelteon capsule 20 mg..............................66HIBERIX -haemophilus b polysaccharide conjugate vac

for inj 10 mcg..................................................................11HOMACTIN AA PLUS -nutritional supplement liquid........97HORIZANT -gabapentin enacarbil tab er 300 mg.............72HORIZANT -gabapentin enacarbil tab er 600 mg.............72H.P. ACTHAR -corticotropin inj gel 80 unit/ml...................30HUMALOG -insulin lispro inj 100 unit/ml...........................26HUMALOG -insulin lispro soln cartridge 100 unit/ml.........26HUMALOG JUNIOR KWIKPEN -insulin lispro soln pen-

injector 100 unit/ml......................................................... 26HUMALOG KWIKPEN -insulin lispro soln pen-injector 100

unit/ml.............................................................................. 26HUMALOG KWIKPEN -insulin lispro soln pen-injector 200

unit/ml.............................................................................. 26HUMALOG MIX 75/25 -insulin lispro prot & lispro inj 100

unit/ml (75-25).................................................................26HUMALOG MIX 50/50 -insulin lispro protamine & lispro inj

100 unit/ml (50-50)......................................................... 26HUMALOG MIX 50/50 KWIKPEN -insulin lispro prot &

lispro sus pen-inj 100 unit/ml (50-50).............................26HUMALOG MIX 75/25 KWIKPEN -insulin lispro prot &

lispro sus pen-inj 100 unit/ml (75-25).............................26HUMATE-P -antihemophilic factor/vwf (human) for inj

250-600 unit.................................................................. 103HUMATE-P -antihemophilic factor/vwf (human) for inj

500-1200 unit................................................................ 103HUMATE-P -antihemophilic factor/vwf (human) for inj

1000-2400 unit..............................................................103HUMATROPE COMBO PACK -somatropin for inj 5

mg....................................................................................30HUMATROPE -somatropin for inj 24 mg.......................... 30HUMATROPE -somatropin for inj 6 mg (18 unit).............. 30HUMATROPE -somatropin for inj 12 mg (36 unit)............ 30HUMIRA -adalimumab prefilled syringe kit 10

mg/0.1ml..........................................................................81HUMIRA -adalimumab prefilled syringe kit 10





mg/0.4ml..........................................................................81HUMIRA PEDIATRIC CROHNS D -adalimumab prefilled

syringe kit 40 mg/0.8ml.................................................. 81

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..........................................................................81

HUMIRA PEN -adalimumab pen-injector kit 40mg/0.4ml..........................................................................81

HUMIRA PEN-CD/UC/HS START -adalimumab pen-injector kit 40 mg/0.8ml.................................................. 81

HUMIRA PEN-CD/UC/HS START -adalimumab pen-injector kit 80 mg/0.8ml.................................................. 81

HUMIRA PEN-PS/UV STARTER -adalimumab pen-injector kit 40 mg/0.8ml.................................................. 81

HUMIRA PEN-PS/UV STARTER -adalimumab pen-injector kit 80 mg/0.8ml & 40 mg/0.4ml......................... 81

HUMULIN 70/30 -insulin nph isophane & regular humaninj 100 unit/ml (70-30).................................................... 26

HUMULIN 70/30 KWIKPEN -insulin nph & regular susppen-inj 100 unit/ml (70-30)............................................. 26

HUMULIN N -insulin nph (human) (isophane) inj 100 unit/ml..................................................................................... 26

HUMULIN N KWIKPEN -insulin nph (human) (isophane)susp pen-injector 100 unit/ml......................................... 26

HUMULIN R -insulin regular (human) inj 100 unit/ml........26HUMULIN R U-500 (CONCENTR -insulin regular (human)

inj 500 unit/ml..................................................................26HUMULIN R U-500 KWIKPEN -insulin regular (human)

soln pen-injector 500 unit/ml.......................................... 26HYCAMTIN -topotecan hcl cap 0.25 mg (base equiv)......13HYCAMTIN -topotecan hcl cap 1 mg (base equiv)...........13hydralazine hcl tab 10 mg.............................................. 39hydralazine hcl tab 25 mg.............................................. 39hydralazine hcl tab 50 mg.............................................. 39hydralazine hcl tab 100 mg............................................ 39hydrochlorothiazide cap 12.5 mg (Microzide).............. 42hydrochlorothiazide tab 12.5 mg................................... 42hydrochlorothiazide tab 25 mg...................................... 42hydrochlorothiazide tab 50 mg...................................... 42hydrocodone-acetaminophen soln 7.5-325 mg/15ml

(Hycet).............................................................................76hydrocodone-acetaminophen tab 2.5-325 mg..............76hydrocodone-acetaminophen tab 7.5-325 mg

(Norco)............................................................................76hydrocodone-acetaminophen tab 5-325 mg

(Norco)............................................................................76hydrocodone-acetaminophen tab 10-325 mg

(Norco)............................................................................76hydrocodone-acetaminophen tab 7.5-300 mg

(Xodol)............................................................................ 76hydrocodone-acetaminophen tab 5-300 mg

(Xodol)............................................................................ 76hydrocodone-acetaminophen tab 10-300 mg

(Xodol)............................................................................ 76HYDROCODONE BITARTRATE/CH -pseudoeph-

chlorphen w/ hydrocodone soln 60-4-5 mg/5ml.............48hydrocodone-ibuprofen tab 7.5-200 mg........................76

2019


hydrocodone-ibuprofen tab 10-200 mg (Ibudone)....... 76hydrocodone-ibuprofen tab 5-200 mg (Reprexain)......76hydrocodone w/ homatropine syrup 5-1.5 mg/5ml......48hydrocodone w/ homatropine tab 5-1.5 mg..................48hydrocod polst-chlorphen polst er susp 10-8 mg/5ml

(Tussionex pennkineti).................................................48hydrocortisone acetate w/ pramoxine rectal cream

1-1% (Analpram-hc)....................................................110hydrocortisone butyrate cream 0.1% (Locoid)...........114hydrocortisone butyrate hydrophilic lipo base cream

0.1% (Locoid lipocream)............................................114hydrocortisone butyrate lotion 0.1% (Locoid)........... 114hydrocortisone butyrate oint 0.1% (Locoid)...............114hydrocortisone butyrate soln 0.1% (Locoid)..............114hydrocortisone cream 1%.............................................114hydrocortisone cream 2.5%..........................................114hydrocortisone enema 100 mg/60ml

(Cortenema)................................................................. 110hydrocortisone lotion 2.5%.......................................... 114hydrocortisone oint 1%.................................................114hydrocortisone oint 2.5%..............................................114hydrocortisone rectal cream 2.5% (Anusol-hc)......... 110hydrocortisone rectal cream 1% (Proctocort)............110hydrocortisone tab 5 mg (Cortef).................................. 17hydrocortisone tab 10 mg (Cortef)................................ 17hydrocortisone tab 20 mg (Cortef)................................ 17hydrocortisone valerate cream 0.2%...........................114hydrocortisone valerate oint 0.2% (Westcort)............114hydrocortisone w/ acetic acid otic soln 1-2%............ 109hydromorphone hcl liqd 1 mg/ml (Dilaudid).................76hydromorphone hcl tab er 24hr deter 8 mg

(Exalgo).......................................................................... 76hydromorphone hcl tab er 24hr deter 12 mg



(Exalgo).......................................................................... 76hydromorphone hcl tab 2 mg (Dilaudid).......................76hydromorphone hcl tab 4 mg (Dilaudid).......................76hydromorphone hcl tab 8 mg (Dilaudid).......................76HYDROXOCOBALAMIN -hydroxocobalamin acetate inj

1000 mcg/ml (base equivalent)......................................98hydroxychloroquine sulfate tab 200 mg (Plaquenil)......9hydroxyurea cap 500 mg (Hydrea)................................ 13hydroxyzine hcl syrup 10 mg/5ml................................. 60hydroxyzine hcl tab 10 mg............................................. 60hydroxyzine hcl tab 25 mg............................................. 60hydroxyzine hcl tab 50 mg............................................. 60hydroxyzine pamoate cap 25 mg (Vistaril)................... 60hydroxyzine pamoate cap 50 mg (Vistaril)................... 60HYDROXYZINE PAMOATE -hydroxyzine pamoate cap

100 mg............................................................................ 60HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter

20 mg.............................................................................. 76HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter

30 mg.............................................................................. 76

HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter40 mg.............................................................................. 76



HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter100 mg............................................................................ 77

HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter120 mg............................................................................ 77

Iibandronate sodium tab 150 mg (base equivalent)

(Boniva).......................................................................... 30IBRANCE -palbociclib cap 75 mg..................................... 13IBRANCE -palbociclib cap 100 mg................................... 13IBRANCE -palbociclib cap 125 mg................................... 13ibuprofen susp 100 mg/5ml............................................81ibuprofen tab 400 mg...................................................... 81ibuprofen tab 600 mg...................................................... 81ibuprofen tab 800 mg...................................................... 81ICLUSIG -ponatinib hcl tab 15 mg (base equiv)............... 13ICLUSIG -ponatinib hcl tab 45 mg (base equiv)............... 13IDELVION -coagulation factor ix (recomb) (rix-fp) for inj

250 unit......................................................................... 103IDELVION -coagulation factor ix (recomb) (rix-fp) for inj

500 unit......................................................................... 103IDELVION -coagulation factor ix (recomb) (rix-fp) for inj

1000 unit....................................................................... 103IDELVION -coagulation factor ix (recomb) (rix-fp) for inj

2000 unit....................................................................... 103IDELVION -coagulation factor ix (recomb) (rix-fp) for inj

3500 unit....................................................................... 103IDHIFA -enasidenib mesylate tab 50 mg (base

equivalent).......................................................................13IDHIFA -enasidenib mesylate tab 100 mg (base

equivalent).......................................................................13IGLUCOSE BLOOD GLUCOSE TE -glucose blood test

strip................................................................................120ILEVRO -nepafenac ophth susp 0.3%............................ 107imatinib mesylate tab 100 mg (base equivalent)

(Gleevec)........................................................................ 13imatinib mesylate tab 400 mg (base equivalent)

(Gleevec)........................................................................ 13IMBRUVICA -ibrutinib cap 70 mg..................................... 13IMBRUVICA -ibrutinib cap 140 mg................................... 13IMBRUVICA -ibrutinib tab 140 mg.................................... 13IMBRUVICA -ibrutinib tab 280 mg.................................... 13IMBRUVICA -ibrutinib tab 420 mg.................................... 13IMBRUVICA -ibrutinib tab 560 mg.................................... 13imipramine hcl tab 10 mg (Tofranil).............................. 61imipramine hcl tab 25 mg (Tofranil).............................. 61imipramine hcl tab 50 mg (Tofranil).............................. 61imipramine pamoate cap 75 mg.................................... 61imipramine pamoate cap 100 mg.................................. 61imipramine pamoate cap 125 mg.................................. 61imipramine pamoate cap 150 mg.................................. 61

2019


imiquimod cream 5% (Aldara)......................................114IMIQUIMOD PUMP -imiquimod cream 3.75%................114IMOVAX RABIES (H.D.C.V.) -rabies virus vaccine, hdc

inj..................................................................................... 11IMPAVIDO -miltefosine cap 50 mg......................................9IMPOYZ -clobetasol propionate cream 0.025%..............114IMURAN -azathioprine tab 50 mg................................... 126IMVEXXY MAINTENANCE PACK -estradiol vaginal insert

4 mcg...............................................................................58IMVEXXY MAINTENANCE PACK -estradiol vaginal insert

10 mcg............................................................................ 58IMVEXXY STARTER PACK -estradiol vaginal insert 4

mcg.................................................................................. 58IMVEXXY STARTER PACK -estradiol vaginal insert 10

mcg.................................................................................. 58INATAL GT -prenatal vit w/ dss-iron carbonyl-fa tab 90-1

mg....................................................................................92IN-CHECK DIAL INSPIRATORY -respiratory therapy

supplies - devices.........................................................124IN-CHECK INSPIRATORY FLOW -respiratory therapy

supplies - devices.........................................................124INCRELEX -mecasermin inj 40 mg/4ml (10 mg/ml)..........30INCRUSE ELLIPTA -umeclidinium br aero powd breath

act 62.5 mcg/inh (base eq)............................................ 50indapamide tab 1.25 mg..................................................42indapamide tab 2.5 mg....................................................42INDERAL XL -propranolol hcl sustained-release beads

cap er 24hr 80 mg..........................................................34INDERAL XL -propranolol hcl sustained-release beads

cap er 24hr 120 mg........................................................34INDOCIN -indomethacin suppos 50 mg............................81INDOCIN -indomethacin susp 25 mg/5ml.........................81indomethacin cap er 75 mg............................................81indomethacin cap 25 mg................................................ 81indomethacin cap 50 mg................................................ 81INFANRIX -diph, acellular pert & tet tox inj 25 lf-58

mcg-10 lf/0.5ml............................................................... 11INFINITY BLOOD GLUCOSE TE -glucose blood test

strip................................................................................120INFINITY VOICE -glucose blood test strip......................120INGREZZA -valbenazine tosylate cap 40 mg (base

equiv)...............................................................................72INGREZZA -valbenazine tosylate cap 80 mg (base

equiv)...............................................................................72INLYTA -axitinib tab 1 mg..................................................13INLYTA -axitinib tab 5 mg..................................................13INNOPRAN XL -propranolol hcl sustained-release beads

cap er 24hr 80 mg..........................................................34INNOPRAN XL -propranolol hcl sustained-release beads

cap er 24hr 120 mg........................................................34INSPIRACHAMBER/ANTI-STATI -spacer/aerosol-holding

chambers - device........................................................ 124INSPIRACHAMBER/LARGE -spacer/aerosol-holding

chambers - device........................................................ 124INSPIRACHAMBER/SOOTHERMAS -spacer/aerosol-

holding chambers - device........................................... 124

INSPIREASE DRUG DELIVERY -spacer/aerosol-holdingchambers - device........................................................ 124

INSPIREASE RESERVOIR BAGS -spacer/aerosol-holding chamber supplies - bags................................. 124

INSULIN PEN NEEDLES – VARIOUS............................124INSULIN SYRINGES – VARIOUS...................................124INTELENCE -etravirine tab 25 mg......................................6INTELENCE -etravirine tab 100 mg....................................6INTELENCE -etravirine tab 200 mg....................................6IN TOUCH BLOOD GLUCOSE TE -glucose blood test

strip................................................................................120INTRAROSA -prasterone vaginal insert 6.5 mg............... 58INTRON A -interferon alfa-2b for inj 10000000 unit..........13INTRON A -interferon alfa-2b for inj 18000000 unit..........13INTRON A -interferon alfa-2b for inj 50000000 unit..........13INTRON A -interferon alfa-2b inj 6000000 unit/ml............ 13INTRON A -interferon alfa-2b inj 10000000 unit/ml.......... 13INVIRASE -saquinavir mesylate cap 200 mg..................... 6INVIRASE -saquinavir mesylate tab 500 mg...................... 6INVOKAMET -canagliflozin-metformin hcl tab 50-500

mg....................................................................................23INVOKAMET -canagliflozin-metformin hcl tab 150-500



mg....................................................................................23INVOKAMET XR -canagliflozin-metformin hcl tab er 24hr

50-500 mg.......................................................................23INVOKAMET XR -canagliflozin-metformin hcl tab er 24hr

50-1000 mg.....................................................................23INVOKAMET XR -canagliflozin-metformin hcl tab er 24hr

150-500 mg.....................................................................23INVOKAMET XR -canagliflozin-metformin hcl tab er 24hr

150-1000 mg...................................................................23INVOKANA -canagliflozin tab 100 mg.............................. 23INVOKANA -canagliflozin tab 300 mg.............................. 23IOPIDINE -apraclonidine hcl ophth soln 1% (base

equivalent).....................................................................107IPOL INACTIVATED IPV -poliovirus vaccine, ipv

injection........................................................................... 11ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml..... 50ipratropium bromide inhal soln 0.02%..........................50ipratropium bromide nasal soln 0.03% (21 mcg/

spray)..............................................................................47ipratropium bromide nasal soln 0.06% (42 mcg/

spray)..............................................................................47irbesartan-hydrochlorothiazide tab 150-12.5 mg

(Avalide)..........................................................................39irbesartan-hydrochlorothiazide tab 300-12.5 mg

(Avalide)..........................................................................39irbesartan tab 75 mg (Avapro)....................................... 39irbesartan tab 150 mg (Avapro)..................................... 39irbesartan tab 300 mg (Avapro)..................................... 39IRESSA -gefitinib tab 250 mg........................................... 13IRON UP -polysaccharide iron complex liquid 15

mg/0.5ml (fe equiv).........................................................98

2019


ISENTRESS HD -raltegravir potassium tab 600 mg (baseequiv)................................................................................. 6

ISENTRESS -raltegravir potassium chew tab 25 mg (baseequiv)................................................................................. 6

ISENTRESS -raltegravir potassium chew tab 100 mg(base equiv)...................................................................... 6

ISENTRESS -raltegravir potassium packet for susp 100mg (base equiv)................................................................6

ISENTRESS -raltegravir potassium tab 400 mg (baseequiv)................................................................................. 6

ISONIAZID -isoniazid syrup 50 mg/5ml.............................. 4isoniazid tab 100 mg......................................................... 4isoniazid tab 300 mg......................................................... 4ISOPTO ATROPINE -atropine sulfate ophth soln 1%.....107ISORDIL TITRADOSE -isosorbide dinitrate tab 40

mg....................................................................................33ISOSORBIDE DINITRATE ER -isosorbide dinitrate tab er

40 mg.............................................................................. 33isosorbide dinitrate tab 10 mg.......................................33isosorbide dinitrate tab 20 mg.......................................33isosorbide dinitrate tab 30 mg.......................................33isosorbide dinitrate tab 5 mg (Isordil titradose).......... 33isosorbide mononitrate tab er 24hr 30 mg................... 33isosorbide mononitrate tab er 24hr 60 mg................... 33isosorbide mononitrate tab er 24hr 120 mg................. 33isosorbide mononitrate tab 10 mg................................ 33isosorbide mononitrate tab 20 mg................................ 33isotretinoin cap 10 mg.................................................. 114isotretinoin cap 20 mg.................................................. 114isotretinoin cap 30 mg.................................................. 114isotretinoin cap 40 mg.................................................. 114ISOVACTIN AA PLUS -nutritional supplement liquid........97isradipine cap 2.5 mg......................................................36isradipine cap 5 mg.........................................................36itraconazole cap 100 mg (Sporanox).............................. 5itraconazole oral soln 10 mg/ml (Sporanox).................. 5ivermectin tab 3 mg (Stromectol).................................... 9IXINITY -coagulation factor ix (recombinant) for inj 250

unit................................................................................. 104IXINITY -coagulation factor ix (recombinant) for inj 500





unit................................................................................. 104

JJADENU -deferasirox tab 90 mg.....................................117JADENU -deferasirox tab 180 mg...................................117JADENU -deferasirox tab 360 mg...................................117JADENU SPRINKLE -deferasirox granules packet 90

mg..................................................................................117

JADENU SPRINKLE -deferasirox granules packet 180mg..................................................................................117

JADENU SPRINKLE -deferasirox granules packet 360mg..................................................................................117

JAKAFI -ruxolitinib phosphate tab 5 mg (baseequivalent).......................................................................13





JANUMET -sitagliptin-metformin hcl tab 50-500 mg.........23JANUMET -sitagliptin-metformin hcl tab 50-1000 mg.......23JANUMET XR -sitagliptin-metformin hcl tab er 24hr

50-500 mg.......................................................................23JANUMET XR -sitagliptin-metformin hcl tab er 24hr

50-1000 mg.....................................................................23JANUMET XR -sitagliptin-metformin hcl tab er 24hr

100-1000 mg...................................................................23JANUVIA -sitagliptin phosphate tab 25 mg (base

equiv)...............................................................................23JANUVIA -sitagliptin phosphate tab 50 mg (base

equiv)...............................................................................23JANUVIA -sitagliptin phosphate tab 100 mg (base

equiv)...............................................................................23JARDIANCE -empagliflozin tab 10 mg............................. 23JARDIANCE -empagliflozin tab 25 mg............................. 23JENTADUETO -linagliptin-metformin hcl tab 2.5-1000

mg....................................................................................23JENTADUETO -linagliptin-metformin hcl tab 2.5-500

mg....................................................................................23JENTADUETO -linagliptin-metformin hcl tab 2.5-850

mg....................................................................................23JENTADUETO XR -linagliptin-metformin hcl tab er 24hr

2.5-1000 mg....................................................................23JENTADUETO XR -linagliptin-metformin hcl tab er 24hr

5-1000 mg.......................................................................23JUBLIA -efinaconazole soln 10%....................................114JULUCA -dolutegravir sodium-rilpivirine hcl tab 50-25 mg

(base eq)........................................................................... 6JUXTAPID -lomitapide mesylate cap 5 mg (base

equiv)...............................................................................44JUXTAPID -lomitapide mesylate cap 10 mg (base





equiv)...............................................................................44JYNARQUE -tolvaptan tab therapy pack 45 & 15 mg.......30JYNARQUE -tolvaptan tab therapy pack 60 & 30 mg.......30

2019


JYNARQUE -tolvaptan tab therapy pack 90 & 30 mg.......30

KKADIAN -morphine sulfate cap er 24hr 40 mg................. 77KADIAN -morphine sulfate cap er 24hr 200 mg............... 77KALETRA -lopinavir-ritonavir tab 100-25 mg......................6KALETRA -lopinavir-ritonavir tab 200-50 mg......................6KALYDECO -ivacaftor packet 50 mg................................ 52KALYDECO -ivacaftor packet 75 mg................................ 52KALYDECO -ivacaftor tab 150 mg....................................52KAPSPARGO SPRINKLE -metoprolol succ cap er 24hr

sprinkle 25 mg (tartrate equiv)....................................... 34KAPSPARGO SPRINKLE -metoprolol succ cap er 24hr

sprinkle 50 mg (tartrate equiv)....................................... 34KAPSPARGO SPRINKLE -metoprolol succ cap er 24hr

sprinkle 100 mg (tartrate equiv)..................................... 34KAPSPARGO SPRINKLE -metoprolol succ cap er 24hr

sprinkle 200 mg (tartrate equiv)..................................... 34KARBINAL ER -carbinoxamine maleate extended release

susp 4 mg/5ml................................................................ 47KAZANO -alogliptin-metformin hcl tab 12.5-1000 mg.......23KAZANO -alogliptin-metformin hcl tab 12.5-500 mg.........23KERYDIN -tavaborole soln 5%........................................114ketoconazole cream 2%................................................114ketoconazole foam 2% (Extina)................................... 114ketoconazole shampoo 2% (Nizoral)...........................114ketoconazole tab 200 mg..................................................5KETOPROFEN ER -ketoprofen cap er 24hr 200 mg........81KETOPROFEN -ketoprofen cap 25 mg............................ 81ketorolac tromethamine ophth soln 0.5%

(Acular)......................................................................... 107ketorolac tromethamine ophth soln 0.4% (Acular

ls)...................................................................................107ketorolac tromethamine tab 10 mg............................... 81KETOVIE -nutritional supplement liquid............................97KETOVIE PEPTIDE -nutritional supplement liquid........... 97KEVEYIS -dichlorphenamide tab 50 mg........................... 42KEVZARA -sarilumab subcutaneous soln prefilled syringe

150 mg/1.14ml................................................................ 81KEVZARA -sarilumab subcutaneous soln prefilled syringe

200 mg/1.14ml................................................................ 81KEVZARA -sarilumab subcutaneous solution auto-injector

150 mg/1.14ml................................................................ 81KEVZARA -sarilumab subcutaneous solution auto-injector

200 mg/1.14ml................................................................ 82KHEDEZLA -desvenlafaxine tab er 24hr 50 mg............... 61KHEDEZLA -desvenlafaxine tab er 24hr 100 mg............. 62KINERET -anakinra subcutaneous soln prefilled syringe

100 mg/0.67ml................................................................ 82KINRIX -diph-tetanus tox ad-acell pert & polio virus, ipv

vac inj.............................................................................. 11KISQALI FEMARA 200 DOSE -ribociclib tab 200 mg &

letrozole tab 2.5 mg therapy pack..................................13KISQALI FEMARA 400 DOSE -ribociclib tab 200 mg &

letrozole tab 2.5 mg therapy pack..................................13KISQALI FEMARA 600 DOSE -ribociclib tab 200 mg &

letrozole tab 2.5 mg therapy pack..................................13

KISQALI -ribociclib succinate tab 200 mg (baseequiv)...............................................................................13

KITABIS PAK -tobramycin nebu soln 300 mg/5ml.............. 4KLOR-CON M15 -potassium chloride microencapsulated

crys er tab 15 meq......................................................... 96KOATE -antihemophilic factor (human) for inj 250

unit................................................................................. 104KOATE -antihemophilic factor (human) for inj 500

unit................................................................................. 104KOATE -antihemophilic factor (human) for inj 1000

unit................................................................................. 104KOATE-DVI -antihemophilic factor (human) for inj 250



unit................................................................................. 104KOGENATE FS -antihemophilic factor (recombinant) for

inj kit 250 unit............................................................... 104KOGENATE FS -antihemophilic factor (recombinant) for

inj kit 500 unit............................................................... 104KOGENATE FS -antihemophilic factor (recombinant) for

inj kit 1000 unit............................................................. 104KOGENATE FS -antihemophilic factor (recombinant) for

inj kit 2000 unit............................................................. 104KOGENATE FS -antihemophilic factor (recombinant) for

inj kit 3000 unit............................................................. 104KOGENATE FS BIO-SET -antihemophilic factor

(recombinant) for inj kit 1000 unit................................ 104KOGENATE FS BIO-SET -antihemophilic factor

(recombinant) for inj kit 2000 unit................................ 104KOGENATE FS BIO-SET -antihemophilic factor

(recombinant) for inj kit 3000 unit................................ 104KOMBIGLYZE XR -saxagliptin-metformin hcl tab er 24hr

2.5-1000 mg....................................................................24KOMBIGLYZE XR -saxagliptin-metformin hcl tab er 24hr

5-500 mg......................................................................... 24KOMBIGLYZE XR -saxagliptin-metformin hcl tab er 24hr

5-1000 mg.......................................................................24KORLYM -mifepristone tab 300 mg.................................. 24KOSHER PRENATAL PLUS IRON -prenatal vit w/ iron

carbonyl-fa tab 30-1 mg................................................. 92KOVALTRY -antihemophilic factor (recombinant) for inj

250 unit......................................................................... 104KOVALTRY -antihemophilic factor (recombinant) for inj

500 unit......................................................................... 104KOVALTRY -antihemophilic factor (recombinant) for inj

1000 unit....................................................................... 104KOVALTRY -antihemophilic factor (recombinant) for inj

2000 unit....................................................................... 104KOVALTRY -antihemophilic factor (recombinant) for inj

3000 unit....................................................................... 104K-PHOS NO 2 -potassium & sodium acid phosphates tab

305-700 mg.....................................................................59K-PHOS -potassium phosphate monobasic tab 500

mg....................................................................................96KRISTALOSE -lactulose oral crystal packet 10 gm.......... 52

2019


KRISTALOSE -lactulose oral crystal packet 20 gm.......... 52KROGER BLOOD GLUCOSE TEST -glucose blood test

strip................................................................................120KROGER PREMIUM BLOOD GLUC -glucose blood test

strip................................................................................120KROGER TEST STRIPS -glucose blood test strip......... 120K-TAB -potassium chloride tab er 8 meq (600 mg)...........96K-TAB -potassium chloride tab er 20 meq (1500 mg).......96KUVAN -sapropterin dihydrochloride powder packet 100

mg....................................................................................31KUVAN -sapropterin dihydrochloride powder packet 500

mg....................................................................................31KUVAN -sapropterin dihydrochloride soluble tab 100

mg....................................................................................31KYNAMRO -mipomersen sodium soln prefilled syringe

200 mg/ml....................................................................... 44

Llabetalol hcl tab 100 mg..................................................34labetalol hcl tab 200 mg..................................................35labetalol hcl tab 300 mg..................................................35LACRISERT -artificial tear ophth insert...........................107lactic acid (ammonium lactate) cream 12% (Lac-

hydrin).......................................................................... 114lactic acid (ammonium lactate) lotion 12% (Lac-

hydrin).......................................................................... 114lactulose (encephalopathy) solution 10 gm/15ml........56lactulose oral crystal packet 10 gm (Kristalose)..........52lactulose solution 10 gm/15ml....................................... 52LAMICTAL ODT -lamotrigine tab disint 25 (14) & 50 mg

(14) & 100 mg (7) kit......................................................86LAMICTAL ODT -lamotrigine tab disint 25 mg (21) & 50

mg (7) titration kit............................................................86LAMICTAL ODT -lamotrigine tab disint 50 mg (42)- 100

mg(14) titration kit...........................................................86LAMICTAL XR -lamotrigine tab er 24hr 25 (14) & 50 mg

(14) & 100 mg(7) kit....................................................... 86LAMICTAL XR -lamotrigine tab er 24hr 50 (14) & 100

mg(14) & 200 mg(7) kit.................................................. 86LAMICTAL XR -lamotrigine tab er 24hr 25 mg (21) & 50

mg (7) titration kit............................................................86lamivudine oral soln 10 mg/ml (Epivir)........................... 6lamivudine tab 150 mg (Epivir)........................................ 6lamivudine tab 300 mg (Epivir)........................................ 6lamivudine tab 100 mg (hbv) (Epivir hbv).......................6lamivudine-zidovudine tab 150-300 mg (Combivir)....... 6lamotrigine orally disintegrating tab 25 mg (Lamictal

odt).................................................................................. 86lamotrigine orally disintegrating tab 50 mg (Lamictal



odt).................................................................................. 86lamotrigine tab chewable dispersible 5 mg (Lamictal

chewable 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)....................................................86lamotrigine tab 25 mg (84) & 100 mg (14) starter kit

(Lamictal starter/tak).................................................... 86lamotrigine 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).................................................................................. 86LANCETS – VARIOUS.................................................... 124LANOXIN -digoxin tab 62.5 mcg (0.0625 mg).................. 33LANOXIN -digoxin tab 125 mcg (0.125 mg)..................... 33LANOXIN -digoxin tab 187.5 mcg (0.1875 mg)................ 33LANOXIN -digoxin tab 250 mcg (0.25 mg)....................... 33lansoprazole cap delayed release 15 mg

(Prevacid)....................................................................... 53lansoprazole cap delayed release 30 mg

(Prevacid)....................................................................... 53lansoprazole tab delayed release orally disintegrating

15 mg (Prevacid solutab).............................................53lansoprazole tab delayed release orally disintegrating

30 mg (Prevacid solutab).............................................53lanthanum carbonate chew tab 500 mg (elemental)

(Fosrenol).......................................................................56lanthanum carbonate chew tab 750 mg (elemental)

(Fosrenol).......................................................................56lanthanum carbonate chew tab 1000 mg (elemental)

(Fosrenol).......................................................................56LANTUS -insulin glargine inj 100 unit/ml.......................... 27LANTUS SOLOSTAR -insulin glargine soln pen-injector

100 unit/ml.......................................................................27LASTACAFT -alcaftadine ophth soln 0.25%................... 107latanoprost ophth soln 0.005% (Xalatan)....................108LATUDA -lurasidone hcl tab 20 mg...................................64LATUDA -lurasidone hcl tab 40 mg...................................64LATUDA -lurasidone hcl tab 60 mg...................................64LATUDA -lurasidone hcl tab 80 mg...................................64LATUDA -lurasidone hcl tab 120 mg.................................64LAZANDA -fentanyl citrate nasal spray 100 mcg/act (base

equiv)...............................................................................77LAZANDA -fentanyl citrate nasal spray 300 mcg/act (base

equiv)...............................................................................77LAZANDA -fentanyl citrate nasal spray 400 mcg/act (base

equiv)...............................................................................77leflunomide tab 10 mg (Arava).......................................82leflunomide tab 20 mg (Arava).......................................82LENVIMA 14 MG DAILY DOSE -lenvatinib cap therapy

pack 10 & 4 mg (14 mg daily dose)...............................14

2019


LENVIMA 18 MG DAILY DOSE -lenvatinib cap therapypack 10 & 4 (2) mg (18 mg daily dose)......................... 14

LENVIMA 24 MG DAILY DOSE -lenvatinib cap therapypack 10 (2) & 4 mg (24 mg daily dose)......................... 14

LENVIMA 10 MG DAILY DOSE -lenvatinib cap therapypack 10 mg (10 mg daily dose)..................................... 14

LENVIMA 12MG DAILY DOSE -lenvatinib cap therapypack 4 (3) mg (12 mg daily dose)..................................14

LENVIMA 20 MG DAILY DOSE -lenvatinib cap therapypack 10 (2) mg (20 mg daily dose)................................14

LENVIMA 4 MG DAILY DOSE -lenvatinib cap therapypack 4 mg (4 mg daily dose)......................................... 14

LENVIMA 8 MG DAILY DOSE -lenvatinib cap therapypack 4 (2) mg (8 mg daily dose)....................................14

LETAIRIS -ambrisentan tab 5 mg..................................... 46LETAIRIS -ambrisentan tab 10 mg................................... 46letrozole tab 2.5 mg (Femara)........................................ 14LEUCOVORIN CALCIUM -leucovorin calcium tab 10

mg....................................................................................14LEUCOVORIN CALCIUM -leucovorin calcium tab 15

mg....................................................................................14leucovorin calcium tab 5 mg..........................................14leucovorin calcium tab 25 mg........................................14LEUKERAN -chlorambucil tab 2 mg................................. 14LEUKINE -sargramostim lyophilized for inj 250 mcg........ 98leuprolide acetate inj kit 5 mg/ml.................................. 14levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base

equiv) (Xopenex concentrate).....................................50levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)

(Xopenex)....................................................................... 50levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv)

(Xopenex)....................................................................... 50levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv)

(Xopenex)....................................................................... 50LEVALBUTEROL TARTRATE HFA -levalbuterol tartrate

inhal aerosol 45 mcg/act (base equiv)...........................50LEVEMIR FLEXTOUCH -insulin detemir soln pen-injector

100 unit/ml.......................................................................27LEVEMIR -insulin detemir inj 100 unit/ml..........................27levetiracetam oral soln 100 mg/ml (Keppra).................86levetiracetam tab er 24hr 500 mg (Keppra xr)..............87levetiracetam tab er 24hr 750 mg (Keppra xr)..............87levetiracetam tab 250 mg (Keppra)............................... 87levetiracetam tab 500 mg (Keppra)............................... 87levetiracetam tab 750 mg (Keppra)............................... 87levetiracetam tab 1000 mg (Keppra)............................. 87LEVITRA -vardenafil hcl tab 2.5 mg................................. 46LEVITRA -vardenafil hcl tab 5 mg.................................... 46LEVITRA -vardenafil hcl tab 10 mg.................................. 46LEVITRA -vardenafil hcl tab 20 mg.................................. 46levobunolol hcl ophth soln 0.5% (Betagan)............... 108levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)..... 31levocarnitine tab 330 mg (Carnitor)...............................31levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5

mg/ml) (Xyzal)................................................................47levocetirizine dihydrochloride tab 5 mg (Xyzal)...........47levofloxacin ophth soln 0.5%.......................................108

levofloxacin oral soln 25 mg/ml.......................................4levofloxacin tab 250 mg (Levaquin)................................ 4levofloxacin tab 500 mg (Levaquin)................................ 4levofloxacin tab 750 mg (Levaquin)................................ 4levonor-eth est tab 0.15-0.02/0.025/0.03 mg &eth est

0.01 mg (Quartette).......................................................20levonorgestrel & ethinyl estradiol (91-day) tab

0.15-0.03 mg.................................................................. 20levonorgestrel & ethinyl estradiol tab 0.1 mg-20

mcg................................................................................. 20levonorgestrel & ethinyl estradiol tab 0.15 mg-30

mcg................................................................................. 20levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg...............................20levonorgestrel-ethinyl estradiol (continuous) tab

90-20 mcg.......................................................................20levonorgestrel tab 1.5 mg...............................................20levonorg-eth est tab 0.1-0.02mg(84) & eth est tab

0.01mg(7) (Loseasonique)........................................... 20levonorg-eth est tab 0.15-0.03mg(84) & eth est tab

0.01mg(7) (Seasonique)............................................... 20LEVORPHANOL TARTRATE -levorphanol tartrate tab 2

mg....................................................................................77levothyroxine sodium tab 25 mcg (Synthroid).............27levothyroxine sodium tab 50 mcg (Synthroid).............27levothyroxine sodium tab 75 mcg (Synthroid).............27levothyroxine sodium tab 88 mcg (Synthroid).............27levothyroxine sodium tab 100 mcg (Synthroid)...........27levothyroxine sodium tab 112 mcg (Synthroid)...........27levothyroxine sodium tab 125 mcg (Synthroid)...........27levothyroxine sodium tab 137 mcg (Synthroid)...........27levothyroxine sodium tab 150 mcg (Synthroid)...........27levothyroxine sodium tab 175 mcg (Synthroid)...........27levothyroxine sodium tab 200 mcg (Synthroid)...........27levothyroxine sodium tab 300 mcg (Synthroid)...........27LEVULAN KERASTICK -aminolevulinic acid hcl for soln

20% (stick applicator)................................................... 114LEXIVA -fosamprenavir calcium susp 50 mg/ml (base

equiv)................................................................................. 6LIBERTY NEXT GENERATION B -glucose blood test

strip................................................................................120LIBERTY TEST STRIPS -glucose blood test strip..........120LIBRAX -chlordiazepoxide hcl-clidinium bromide cap

5-2.5 mg.......................................................................... 53LIDOCAINE AND TETRACAINE -lidocaine-tetracaine

cream 7-7%...................................................................114lidocaine hcl gel 2%...................................................... 114LIDOCAINE HCL -lidocaine hcl laryngotracheal soln

4%..................................................................................110lidocaine hcl soln 4% (Xylocaine)............................... 114lidocaine hcl viscous soln 2%..................................... 110lidocaine oint 5%........................................................... 114lidocaine patch 5% (Lidoderm).................................... 114lidocaine-prilocaine cream 2.5-2.5%............................114LINDANE -lindane shampoo 1%.....................................114linezolid for susp 100 mg/5ml (Zyvox)............................9linezolid tab 600 mg (Zyvox)............................................ 9

2019


LINZESS -linaclotide cap 72 mcg..................................... 56LINZESS -linaclotide cap 145 mcg................................... 56LINZESS -linaclotide cap 290 mcg................................... 56liothyronine sodium tab 5 mcg (Cytomel).................... 27liothyronine sodium tab 25 mcg (Cytomel).................. 27liothyronine sodium tab 50 mcg (Cytomel).................. 27LIPOFEN -fenofibrate cap 50 mg......................................44LIPOFEN -fenofibrate cap 150 mg....................................44lisinopril & hydrochlorothiazide tab 10-12.5 mg

(Zestoretic).....................................................................39lisinopril & hydrochlorothiazide tab 20-12.5 mg

(Zestoretic).....................................................................39lisinopril & hydrochlorothiazide tab 20-25 mg

(Zestoretic).....................................................................40lisinopril tab 5 mg (Prinivil)............................................40lisinopril tab 10 mg (Prinivil)..........................................40lisinopril tab 20 mg (Prinivil)..........................................40lisinopril tab 2.5 mg (Zestril).......................................... 40lisinopril tab 30 mg (Zestril)........................................... 40lisinopril tab 40 mg (Zestril)........................................... 40LITEAIRE -spacer/aerosol-holding chambers -

device............................................................................ 124lithium carbonate cap 300 mg....................................... 64lithium carbonate cap 150 mg (Lithium carbonate).....64lithium carbonate cap 600 mg (Lithium carbonate).....64LITHIUM CARBONATE -lithium carbonate cap 150

mg....................................................................................64LITHIUM CARBONATE -lithium carbonate cap 600

mg....................................................................................64lithium carbonate tab er 450 mg....................................64lithium carbonate tab er 300 mg (Lithobid).................. 64lithium carbonate tab 300 mg........................................ 64LITHIUM -lithium oral solution 8 meq/5ml.........................64LITHOBID -lithium carbonate tab er 300 mg.................... 64LITHOSTAT -acetohydroxamic acid tab 250 mg...............59LIVALO -pitavastatin calcium tab 1 mg (base equiv)........ 44LIVALO -pitavastatin calcium tab 2 mg (base equiv)........ 44LIVALO -pitavastatin calcium tab 4 mg (base equiv)........ 44LO LOESTRIN FE -norethin-eth estradiol-fe tab 1 mg-10

mcg (24)/10 mcg (2).......................................................20LOMAIRA -phentermine hcl tab 8 mg...............................69LONHALA MAGNAIR REFILL KI -glycopyrrolate inhal

solution 25 mcg/ml..........................................................50LONHALA MAGNAIR STARTER K -glycopyrrolate inhal

solution 25 mcg/ml..........................................................50LONSURF -trifluridine-tipiracil tab 15-6.14 mg................. 14LONSURF -trifluridine-tipiracil tab 20-8.19 mg................. 14loperamide hcl cap 2 mg................................................ 52lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)

(Kaletra)............................................................................ 6lorazepam conc 2 mg/ml.................................................60lorazepam tab 0.5 mg (Ativan)....................................... 60lorazepam tab 1 mg (Ativan).......................................... 60lorazepam tab 2 mg (Ativan).......................................... 60LORTAB -hydrocodone-acetaminophen soln 10-300

mg/15ml...........................................................................77LORZONE -chlorzoxazone tab 375 mg............................ 91

LORZONE -chlorzoxazone tab 750 mg............................ 91losartan potassium & hydrochlorothiazide tab 50-12.5

mg (Hyzaar)....................................................................40losartan potassium & hydrochlorothiazide tab

100-12.5 mg (Hyzaar)....................................................40losartan potassium & hydrochlorothiazide tab 100-25

mg (Hyzaar)....................................................................40losartan potassium tab 25 mg (Cozaar)........................40losartan potassium tab 50 mg (Cozaar)........................40losartan potassium tab 100 mg (Cozaar)......................40LOTEMAX -loteprednol etabonate ophth gel 0.5%.........108LOTEMAX -loteprednol etabonate ophth oint 0.5%........108LOTEMAX -loteprednol etabonate ophth susp 0.5%......108lovastatin tab 10 mg........................................................44lovastatin tab 20 mg........................................................44lovastatin tab 40 mg........................................................44loxapine succinate cap 5 mg......................................... 64loxapine succinate cap 10 mg....................................... 64loxapine succinate cap 25 mg....................................... 64loxapine succinate cap 50 mg....................................... 64LUCEMYRA -lofexidine hcl tab 0.18 mg (base

equivalent).......................................................................72LULICONAZOLE -luliconazole cream 1%.......................114LUMIGAN -bimatoprost ophth soln 0.01%......................108LUPANETA PACK -leuprolide (1 mon) inj 3.75 mg &

norethindrone tab 5 mg kit............................................. 31LUPANETA PACK -leuprolide (3 mon) inj 11.25 mg &

norethindrone tab 5 mg kit............................................. 31LUPRON DEPOT (1-MONTH) -leuprolide acetate for inj

kit 3.75 mg...................................................................... 14LUPRON DEPOT (1-MONTH) -leuprolide acetate for inj

kit 7.5 mg........................................................................ 14LUPRON DEPOT (3-MONTH) -leuprolide acetate (3

month) for inj kit 11.25 mg............................................. 14LUPRON DEPOT (3-MONTH) -leuprolide acetate (3

month) for inj kit 22.5 mg............................................... 14LUPRON DEPOT (4-MONTH) -leuprolide acetate (4

month) for inj kit 30 mg.................................................. 14LUPRON DEPOT (6-MONTH) -leuprolide acetate (6

month) for inj kit 45 mg.................................................. 14LUPRON DEPOT-PED (1-MONTH -leuprolide acetate for

inj pediatric kit 7.5 mg.................................................... 31LUPRON DEPOT-PED (1-MONTH -leuprolide acetate for

inj pediatric kit 11.25 mg................................................ 31LUPRON DEPOT-PED (1-MONTH -leuprolide acetate for

inj pediatric kit 15 mg..................................................... 31LUPRON DEPOT-PED (3-MONTH -leuprolide acetate (3

month) for inj pediatric kit 11.25 mg...............................31LUPRON DEPOT-PED (3-MONTH -leuprolide acetate (3

month) for inj pediatric kit 30 mg................................... 31LUZU -luliconazole cream 1%.........................................114LYNPARZA -olaparib tab 100 mg......................................14LYNPARZA -olaparib tab 150 mg......................................14LYRICA CR -pregabalin tab er 24hr 82.5 mg................... 72LYRICA CR -pregabalin tab er 24hr 165 mg.................... 72LYRICA CR -pregabalin tab er 24hr 330 mg.................... 72LYRICA -pregabalin cap 25 mg.........................................87

2019


LYRICA -pregabalin cap 50 mg.........................................87LYRICA -pregabalin cap 75 mg.........................................87LYRICA -pregabalin cap 100 mg.......................................87LYRICA -pregabalin cap 150 mg.......................................87LYRICA -pregabalin cap 200 mg.......................................87LYRICA -pregabalin cap 225 mg.......................................87LYRICA -pregabalin cap 300 mg.......................................87LYRICA -pregabalin soln 20 mg/ml...................................87LYSODREN -mitotane tab 500 mg....................................14

Mmafenide acetate packet for topical soln 5% (50 gm)

(Sulfamylon).................................................................114malathion lotion 0.5% (Ovide)......................................114MAPROTILINE HCL -maprotiline hcl tab 25 mg...............62MAPROTILINE HCL -maprotiline hcl tab 50 mg...............62MAPROTILINE HCL -maprotiline hcl tab 75 mg...............62MARNATAL-F -prenatal w/o vit a w/ fe polysac cmplx-fa

cap 60-1 mg....................................................................92MARPLAN -isocarboxazid tab 10 mg............................... 62MASK VORTEX/BABY WHIRL DU -spacer/aerosol-

holding chamber supplies - masks.............................. 124MASK VORTEX/CHILD/FROG -spacer/aerosol-holding

chamber supplies - masks........................................... 124MASK VORTEX/SPINNER THE D -spacer/aerosol-

holding chamber supplies - masks.............................. 124MASK VORTEX/TODDLER/LADY -spacer/aerosol-

holding chamber supplies - masks.............................. 124MATULANE -procarbazine hcl cap 50 mg........................ 14MAVYRET -glecaprevir-pibrentasvir tab 100-40 mg........... 6MAXIDEX -dexamethasone ophth susp 0.1%................ 108meclizine hcl tab 12.5 mg...............................................54meclizine hcl tab 25 mg..................................................54MECLOFENAMATE SODIUM -meclofenamate sodium

cap 50 mg.......................................................................82MECLOFENAMATE SODIUM -meclofenamate sodium

cap 100 mg.....................................................................82MEDROL -methylprednisolone tab 2 mg.......................... 17medroxyprogesterone acetate im susp 150 mg/ml

(Depo-provera contrac)................................................21medroxyprogesterone acetate im susp prefilled syr

150 mg/ml (Depo-provera contrac).............................21medroxyprogesterone acetate tab 2.5 mg

(Provera).........................................................................21medroxyprogesterone acetate tab 5 mg (Provera)......21medroxyprogesterone acetate tab 10 mg

(Provera).........................................................................21mefenamic acid cap 250 mg (Ponstel)..........................82MEFLOQUINE HCL -mefloquine hcl tab 250 mg............... 9megestrol acetate susp 625 mg/5ml (Megace es)........21megestrol acetate susp 40 mg/ml (Megace oral)......... 14megestrol acetate tab 20 mg..........................................14megestrol acetate tab 40 mg..........................................14MEIJER BLOOD GLUCOSE TEST -glucose blood test

strip................................................................................120MEIJER ESSENTIAL BLOOD GL -glucose blood test

strip................................................................................120

MEIJER PREMIUM BLOOD GLUC -glucose blood teststrip................................................................................120

MEIJER TRUETEST BLOOD GLU -glucose blood teststrip................................................................................120

MEIJER TRUETRACK BLOOD GL -glucose blood teststrip................................................................................120

MEKINIST -trametinib dimethyl sulfoxide tab 0.5 mg(base equivalent)............................................................ 14

MEKINIST -trametinib dimethyl sulfoxide tab 2 mg (baseequivalent).......................................................................14

MEKTOVI -binimetinib tab 15 mg......................................14meloxicam tab 7.5 mg (Mobic).......................................82meloxicam tab 15 mg (Mobic)........................................82melphalan tab 2 mg (Alkeran)........................................14memantine hcl cap er 24hr 7 mg (Namenda xr)........... 72memantine hcl cap er 24hr 14 mg (Namenda xr)......... 72memantine hcl cap er 24hr 21 mg (Namenda xr)......... 72memantine hcl cap er 24hr 28 mg (Namenda xr)......... 72memantine hcl oral solution 2 mg/ml (Namenda)........72memantine hcl tab 5 mg (28) & 10 mg (21) titration pak

(Namenda titration pa)................................................. 72memantine hcl tab 5 mg (Namenda)............................. 72memantine hcl tab 10 mg (Namenda)........................... 72MENACTRA -meningococcal (a, c, y, and w-135)

conjugate vaccine inj...................................................... 11MENEST -esterified estrogens tab 0.3 mg....................... 19MENEST -esterified estrogens tab 0.625 mg................... 19MENEST -esterified estrogens tab 1.25 mg..................... 19MENOPUR -menotropins for subcutaneous inj 75

unit................................................................................... 31MENOSTAR -estradiol td patch weekly 14 mcg/24hr....... 19MENTAX -butenafine hcl cream 1%................................114MENVEO -meningococcal (a, c, y, and w-135) oligo conj

vac for inj........................................................................ 11MEPERIDINE HCL -meperidine hcl oral soln 50

mg/5ml.............................................................................77meperidine hcl tab 50 mg...............................................77meperidine hcl tab 100 mg (Demerol)...........................77meprobamate tab 200 mg...............................................60meprobamate tab 400 mg...............................................60mercaptopurine tab 50 mg............................................. 14mesalamine enema 4 gm................................................56mesalamine tab delayed release 1.2 gm (Lialda).........56mesalamine tab delayed release 800 mg (Asacol

hd)................................................................................... 56MESNEX -mesna tab 400 mg...........................................14MESTINON -pyridostigmine bromide syrup 60

mg/5ml.............................................................................91METAPROTERENOL SULFATE -metaproterenol sulfate

syrup 10 mg/5ml............................................................. 50METAPROTERENOL SULFATE -metaproterenol sulfate

tab 10 mg........................................................................50METAPROTERENOL SULFATE -metaproterenol sulfate

tab 20 mg........................................................................50METAXALONE -metaxalone tab 400 mg..........................91metaxalone tab 800 mg (Skelaxin)................................ 91metformin hcl tab er 24hr 500 mg (Glucophage xr).....24

2019


metformin hcl tab er 24hr 750 mg (Glucophage xr).....24metformin hcl tab er 24hr modified release 500 mg

(Glumetza)......................................................................24metformin hcl tab er 24hr modified release 1000 mg

(Glumetza)......................................................................24metformin hcl tab er 24hr osmotic 500 mg

(Fortamet).......................................................................24metformin hcl tab er 24hr osmotic 1000 mg

(Fortamet).......................................................................24metformin hcl tab 500 mg (Glucophage)...................... 24metformin hcl tab 850 mg (Glucophage)...................... 24metformin hcl tab 1000 mg (Glucophage).................... 24METFORMIN HYDROCHLORIDE -metformin hcl oral

soln 500 mg/5ml............................................................. 24methadone hcl conc 10 mg/ml (Methadose)................ 77methadone hcl soln 5 mg/5ml (Methadone hcl)...........77methadone hcl soln 10 mg/5ml (Methadone hcl).........77methadone hcl tab for oral susp 40 mg........................77methadone hcl tab 5 mg (Dolophine)............................77methadone hcl tab 10 mg (Dolophine)..........................77methamphetamine hcl tab 5 mg (Desoxyn)..................69methazolamide tab 25 mg (Neptazane).........................42methazolamide tab 50 mg (Neptazane).........................42methenamine hippurate tab 1 gm (Hiprex)...................57methimazole tab 5 mg (Tapazole)..................................27methimazole tab 10 mg (Tapazole)................................27METHITEST -methyltestosterone oral tab 10 mg.............18methocarbamol tab 750 mg (Robaxin-750)...................91methocarbamol tab 500 mg (Robaxin)..........................91methotrexate sodium for inj 1 gm................................. 14methotrexate sodium inj 50 mg/2ml (25 mg/ml)...........15methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)...... 14methotrexate sodium inj pf 250 mg/10ml (25 mg/

ml)................................................................................... 14methotrexate sodium inj pf 1000 mg/40ml (25 mg/

ml)................................................................................... 14METHOTREXATE SODIUM -methotrexate sodium inj 250

mg/10ml (25 mg/ml)........................................................14methotrexate sodium tab 2.5 mg (base equiv).............15methoxsalen rapid cap 10 mg (Oxsoralen ultra)........114methscopolamine bromide tab 2.5 mg (Pamine)......... 53methscopolamine bromide tab 5 mg (Pamine

forte)................................................................................53METHYCLOTHIAZIDE -methyclothiazide tab 5 mg..........42METHYLDOPA/HYDROCHLOROTHI -methyldopa &

hydrochlorothiazide tab 250-15 mg................................40METHYLDOPA/HYDROCHLOROTHI -methyldopa &

hydrochlorothiazide tab 250-25 mg................................40methyldopa tab 250 mg.................................................. 40methyldopa tab 500 mg.................................................. 40methylergonovine maleate tab 0.2 mg..........................29methylphenidate hcl cap er 24hr 10 mg (la) (Ritalin

la).....................................................................................69methylphenidate hcl cap er 24hr 20 mg (la) (Ritalin

la).....................................................................................69methylphenidate hcl cap er 24hr 30 mg (la) (Ritalin

la).....................................................................................69

methylphenidate hcl cap er 24hr 40 mg (la) (Ritalinla).....................................................................................69

methylphenidate hcl cap er 10 mg (cd)........................ 69methylphenidate hcl cap er 20 mg (cd)........................ 69methylphenidate hcl cap er 30 mg (cd)........................ 69methylphenidate hcl cap er 40 mg (cd)........................ 69methylphenidate hcl cap er 50 mg (cd)........................ 69methylphenidate hcl cap er 60 mg (cd)........................ 69methylphenidate hcl chew tab 2.5 mg.......................... 69methylphenidate hcl chew tab 5 mg............................. 69methylphenidate hcl chew tab 10 mg........................... 69methylphenidate hcl soln 5 mg/5ml (Methylin)............ 69methylphenidate hcl soln 10 mg/5ml (Methylin).......... 69methylphenidate hcl tab er 10 mg.................................69methylphenidate hcl tab er 20 mg.................................69methylphenidate hcl tab er osmotic release (osm) 72

mg................................................................................... 69methylphenidate hcl tab er osmotic release (osm) 18

mg (Concerta)................................................................69methylphenidate hcl tab er osmotic release (osm) 27



mg (Concerta)................................................................69methylphenidate hcl tab 5 mg (Ritalin).........................69methylphenidate hcl tab 10 mg (Ritalin).......................69methylphenidate hcl tab 20 mg (Ritalin).......................69METHYLPHENIDATE HYDROCHLO -methylphenidate

hcl cap er 24hr 60 mg (la)............................................. 70METHYLPHENIDATE HYDROCHLO -methylphenidate

hcl tab er 24hr 18 mg.....................................................70METHYLPHENIDATE HYDROCHLO -methylphenidate



hcl tab er 24hr 54 mg.....................................................70methylprednisolone tab 4 mg (Medrol).........................17methylprednisolone tab 8 mg (Medrol).........................17methylprednisolone tab 16 mg (Medrol).......................17methylprednisolone tab 32 mg (Medrol).......................17methylprednisolone tab therapy pack 4 mg (21)

(Medrol dosepak).......................................................... 17METHYLTESTOSTERONE -methyltestosterone cap 10

mg....................................................................................18METIPRANOLOL -metipranolol ophth soln 0.3%........... 108metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base

equiv).............................................................................. 56metoclopramide hcl tab 5 mg (base equivalent)

(Reglan).......................................................................... 56metoclopramide hcl tab 10 mg (base equivalent)

(Reglan).......................................................................... 56METOCLOPRAMIDE ODT -metoclopramide hcl orally

disintegrating tab 5 mg (base eq).................................. 56METOCLOPRAMIDE ODT -metoclopramide hcl orally

disintegrating tab 10 mg (base eq)................................ 56

2019


metolazone tab 2.5 mg....................................................42metolazone tab 5 mg.......................................................42metolazone tab 10 mg.....................................................43METOPROLOL/HYDROCHLOROTHI -metoprolol &

hydrochlorothiazide tab 100-50 mg................................40metoprolol & hydrochlorothiazide tab 100-25 mg....... 40metoprolol & hydrochlorothiazide tab 50-25 mg

(Lopressor hct)..............................................................40METOPROLOL SUCCINATE ER/H -metoprolol &

hydrochlorothiazide tab er 24hr 25-12.5 mg..................40METOPROLOL SUCCINATE ER/H -metoprolol &

hydrochlorothiazide tab er 24hr 50-12.5 mg..................40METOPROLOL SUCCINATE ER/H -metoprolol &

hydrochlorothiazide tab er 24hr 100-12.5 mg................40metoprolol succinate tab er 24hr 25 mg (tartrate

equiv) (Toprol xl)...........................................................35metoprolol succinate tab er 24hr 50 mg (tartrate



equiv) (Toprol xl)...........................................................35METOPROLOL TARTRATE -metoprolol tartrate tab 37.5

mg....................................................................................35METOPROLOL TARTRATE -metoprolol tartrate tab 75

mg....................................................................................35metoprolol tartrate tab 25 mg........................................ 35metoprolol tartrate tab 50 mg (Lopressor)................... 35metoprolol tartrate tab 100 mg (Lopressor)................. 35metronidazole cap 375 mg (Flagyl)................................. 9metronidazole cream 0.75% (Metrocream)................. 114metronidazole gel 0.75%...............................................114metronidazole gel 1% (Metrogel)................................. 114metronidazole lotion 0.75% (Metrolotion)...................114metronidazole tab 250 mg (Flagyl).................................. 9metronidazole tab 500 mg (Flagyl).................................. 9metronidazole vaginal gel 0.75% (Metrogel-

vaginal)........................................................................... 58mexiletine hcl cap 150 mg..............................................37mexiletine hcl cap 200 mg..............................................37mexiletine hcl cap 250 mg..............................................37MIACALCIN -calcitonin (salmon) inj 200 unit/ml...............31MICONAZOLE 3 -miconazole nitrate vaginal suppos 200

mg....................................................................................58MICORT-HC -hydrocortisone acetate cream 2.5%.........114MICROCHAMBER -spacer/aerosol-holding chambers -

device............................................................................ 124MICRODOT TEST STRIPS -glucose blood test strip..... 120MICROSPACER -spacer/aerosol-holding chambers -

device............................................................................ 124midodrine hcl tab 2.5 mg................................................43midodrine hcl tab 5 mg...................................................43midodrine hcl tab 10 mg.................................................43MIGERGOT -ergotamine w/ caffeine suppos 2-100

mg....................................................................................83miglitol tab 25 mg (Glyset)............................................. 24miglitol tab 50 mg (Glyset)............................................. 24

miglitol tab 100 mg (Glyset)........................................... 24miglustat cap 100 mg (Zavesca)....................................98MIGRANAL -dihydroergotamine mesylate nasal spray 4

mg/ml...............................................................................83MILLIPRED DP -prednisolone tab therapy pack 5 mg

(21).................................................................................. 17MILLIPRED DP -prednisolone tab therapy pack 5 mg

(48).................................................................................. 17MILLIPRED -prednisolone tab 5 mg................................. 17MINIVELLE -estradiol td patch twice weekly 0.025

mg/24hr........................................................................... 19MINIVELLE -estradiol td patch twice weekly 0.0375




mg/24hr........................................................................... 19minocycline hcl cap 50 mg (Minocin)............................. 3minocycline hcl cap 75 mg (Minocin)............................. 3minocycline hcl cap 100 mg (Minocin)........................... 3minocycline hcl tab er 24hr 45 mg..................................3minocycline hcl tab er 24hr 90 mg..................................3minocycline hcl tab er 24hr 135 mg................................3minocycline hcl tab er 24hr 65 mg (Solodyn)................ 3minocycline hcl tab er 24hr 115 mg (Solodyn)...............3minocycline hcl tab 50 mg............................................... 3minocycline hcl tab 75 mg............................................... 3minocycline hcl tab 100 mg............................................. 3minoxidil tab 2.5 mg........................................................40minoxidil tab 10 mg.........................................................40MIRCERA -methoxy peg-epoetin beta soln prefilled syr 30

mcg/0.3ml........................................................................98MIRCERA -methoxy peg-epoetin beta soln prefilled syr 50

mcg/0.3ml........................................................................98MIRCERA -methoxy peg-epoetin beta soln prefilled syr 75

mcg/0.3ml........................................................................98MIRCERA -methoxy peg-epoetin beta soln prefilled syr

100 mcg/0.3ml................................................................ 99MIRCERA -methoxy peg-epoetin beta soln prefilled syr

150 mcg/0.3ml................................................................ 99MIRCERA -methoxy peg-epoetin beta soln prefilled syr

200 mcg/0.3ml................................................................ 99mirtazapine orally disintegrating tab 15 mg (Remeron

soltab).............................................................................62mirtazapine orally disintegrating tab 30 mg (Remeron

soltab).............................................................................62mirtazapine orally disintegrating tab 45 mg (Remeron

soltab).............................................................................62mirtazapine tab 7.5 mg....................................................62mirtazapine tab 15 mg (Remeron)................................. 62mirtazapine tab 30 mg (Remeron)................................. 62mirtazapine tab 45 mg (Remeron)................................. 62MIRVASO -brimonidine tartrate gel 0.33% (base

equivalent).....................................................................115MISC NEEDLES & SYRINGES – VARIOUS.................. 124

2019


misoprostol tab 100 mcg (Cytotec)............................... 53misoprostol tab 200 mcg (Cytotec)............................... 53MISTASSIST -respiratory therapy supplies - devices..... 124MITIGARE -colchicine cap 0.6 mg....................................84MITOSOL -mitomycin for ophth soln kit 0.2 mg..............108MM EASY TOUCH GLUCOSE TES -glucose blood test

strip................................................................................120M-M-R II -measles, mumps & rubella virus vaccines for

inj..................................................................................... 11modafinil tab 100 mg (Provigil)......................................70modafinil tab 200 mg (Provigil)......................................70MODERIBA 1200 DOSE PACK -ribavirin tab 600 mg........ 6MODERIBA 800 DOSE PACK -ribavirin tab 400 mg.......... 6MODERIBA -ribavirin tab 200 mg & ribavirin 400 mg tab

therapy pack......................................................................6MODERIBA -ribavirin tab 400 mg & ribavirin 600 mg tab

therapy pack......................................................................6moexipril hcl tab 7.5 mg................................................. 40moexipril hcl tab 15 mg.................................................. 40moexipril-hydrochlorothiazide tab 7.5-12.5 mg........... 40moexipril-hydrochlorothiazide tab 15-12.5 mg............ 40moexipril-hydrochlorothiazide tab 15-25 mg............... 40mometasone furoate cream 0.1% (Elocon)................ 115mometasone furoate nasal susp 50 mcg/act

(Nasonex)....................................................................... 47mometasone furoate oint 0.1% (Elocon).................... 115mometasone furoate solution 0.1% (lotion)

(Elocon)........................................................................ 115MONOCLATE-P -antihemophilic factor (human) for inj kit

1000 unit....................................................................... 104MONOCLATE-P -antihemophilic factor (human) for inj kit

1500 unit....................................................................... 104MONONINE -coagulation factor ix for inj 1000 unit........ 104montelukast sodium chew tab 4 mg (base equiv)

(Singulair).......................................................................50montelukast sodium chew tab 5 mg (base equiv)

(Singulair).......................................................................50montelukast sodium oral granules packet 4 mg (base

equiv) (Singulair)...........................................................50montelukast sodium tab 10 mg (base equiv)

(Singulair).......................................................................50MONUROL -fosfomycin tromethamine powd pack 3 gm

(base equivalent)............................................................ 57MORPHABOND ER -morphine sulfate tab er 12hr deter

15 mg.............................................................................. 77MORPHABOND ER -morphine sulfate tab er 12hr deter



100 mg............................................................................ 77morphine sulfate cap er 24hr 10 mg (Kadian)..............77morphine sulfate cap er 24hr 20 mg (Kadian)..............77morphine sulfate cap er 24hr 30 mg (Kadian)..............77morphine sulfate cap er 24hr 50 mg (Kadian)..............77morphine sulfate cap er 24hr 60 mg (Kadian)..............77morphine sulfate cap er 24hr 80 mg (Kadian)..............77

morphine sulfate cap er 24hr 100 mg (Kadian)............77MORPHINE SULFATE ER -morphine sulfate beads cap

er 24hr 30 mg.................................................................77MORPHINE SULFATE ER -morphine sulfate beads cap





er 24hr 120 mg...............................................................77MORPHINE SULFATE -morphine sulfate tab 15 mg........77MORPHINE SULFATE -morphine sulfate tab 30 mg........77morphine sulfate oral soln 10 mg/5ml.......................... 77morphine sulfate oral soln 20 mg/5ml.......................... 77morphine sulfate oral soln 100 mg/5ml (20 mg/ml)..... 77morphine sulfate tab er 15 mg (Ms contin).................. 78morphine sulfate tab er 30 mg (Ms contin).................. 78morphine sulfate tab er 60 mg (Ms contin).................. 78morphine sulfate tab er 100 mg (Ms contin)................ 78morphine sulfate tab er 200 mg (Ms contin)................ 78MOTOFEN -difenoxin w/ atropine tab 1-0.025 mg............52MOVANTIK -naloxegol oxalate tab 12.5 mg (base

equivalent).......................................................................56MOVANTIK -naloxegol oxalate tab 25 mg (base

equivalent).......................................................................56MOVIPREP -peg 3350-kcl-nacl-na sulfate-na ascorbate-c

for soln 100 gm...............................................................52MOXATAG -amoxicillin (trihydrate) tab er 24hr 775 mg......1MOXEZA -moxifloxacin hcl ophth soln 0.5% (base eq) (2

times daily)....................................................................108moxifloxacin hcl ophth soln 0.5% (base equiv)

(Vigamox)..................................................................... 108moxifloxacin hcl tab 400 mg (base equiv) (Avelox).......4MULTAQ -dronedarone hcl tab 400 mg (base

equivalent).......................................................................37mupirocin calcium cream 2% (Bactroban)................. 115mupirocin oint 2%..........................................................115MUSE -alprostadil urethral pellet 125 mcg....................... 46MUSE -alprostadil urethral pellet 250 mcg....................... 46MUSE -alprostadil urethral pellet 500 mcg....................... 47MUSE -alprostadil urethral pellet 1000 mcg..................... 47M-VIT -prenatal vit w/ fe fumarate-fa tab 27-1 mg............ 92MYALEPT -metreleptin for subcutaneous inj 11.3 mg...... 31mycophenolate mofetil cap 250 mg (Cellcept)...........126mycophenolate mofetil for oral susp 200 mg/ml

(Cellcept)...................................................................... 126mycophenolate mofetil tab 500 mg (Cellcept)............126mycophenolate sodium tab dr 180 mg (mycophenolic

acid equiv) (Myfortic)................................................. 126mycophenolate sodium tab dr 360 mg (mycophenolic

acid equiv) (Myfortic)................................................. 126MYDAYIS -amphetamine-dextroamphetamine 3-bead cap

er 24hr 12.5 mg..............................................................70

2019


MYDAYIS -amphetamine-dextroamphetamine 3-bead caper 24hr 25 mg.................................................................70

MYDAYIS -amphetamine-dextroamphetamine 3-bead caper 24hr 37.5 mg..............................................................70

MYDAYIS -amphetamine-dextroamphetamine 3-bead caper 24hr 50 mg.................................................................70

MYFORTIC -mycophenolate sodium tab dr 180 mg(mycophenolic acid equiv)............................................126

MYFORTIC -mycophenolate sodium tab dr 360 mg(mycophenolic acid equiv)............................................126

MYGLUCOHEALTH BLOOD GLUCO -glucose blood teststrip................................................................................120

MYLERAN -busulfan tab 2 mg..........................................15MYNATAL ADVANCE -prenatal vit w/ dss-iron carbonyl-fa

tab 90-1 mg.....................................................................92MYNATAL PLUS -prenatal vit w/ fe fumarate-fa tab 65-1

mg....................................................................................92MYNATAL -prenatal multivitamins & minerals w/ iron & fa

cap 1 mg......................................................................... 92MYNATAL ULTRACAPLET -prenatal vit w/ dss-iron

carbonyl-fa tab 90-1 mg................................................. 92MYNATAL-Z -prenatal vit w/ fe fumarate-fa tab 65-1

mg....................................................................................92MYNATE 90 PLUS -prenatal vit w/ dss-fe fumarate-fa tab

er 90-1 mg...................................................................... 92MYRBETRIQ -mirabegron tab er 24 hr 25 mg..................57MYRBETRIQ -mirabegron tab er 24 hr 50 mg..................57MYSOLINE -primidone tab 50 mg.................................... 87MYSOLINE -primidone tab 250 mg.................................. 87MYTESI -crofelemer tab delayed release 125 mg............53

Nnabumetone tab 500 mg................................................. 82nabumetone tab 750 mg................................................. 82nadolol & bendroflumethiazide tab 40-5 mg

(Corzide)......................................................................... 40nadolol tab 20 mg (Corgard).......................................... 35nadolol tab 40 mg (Corgard).......................................... 35nadolol tab 80 mg (Corgard).......................................... 35NAFRINSE DAILY/ACIDULATED -sodium fluoride-

phosphoric acid for soln 1 mg/5ml (f equiv).................110NAFRINSE DAILY/NEUTRAL -sodium fluoride for soln

rinse 0.05%................................................................... 110NAFRINSE WEEKLY -sodium fluoride for soln rinse

0.2%...............................................................................110naftifine hcl cream 1%.................................................. 115naftifine hcl cream 2% (Naftin).................................... 115NAFTIN -naftifine hcl gel 1%...........................................115NAFTIN -naftifine hcl gel 2%...........................................115NALFON -fenoprofen calcium cap 400 mg.......................82NALOCET -oxycodone w/ acetaminophen tab 2.5-300

mg....................................................................................78naloxone hcl inj 0.4 mg/ml........................................... 117naloxone hcl inj 4 mg/10ml.......................................... 117NALOXONE HCL -naloxone hcl soln cartridge 0.4 mg/

ml................................................................................... 117

NALOXONE HCL -naloxone hcl soln prefilled syringe 2mg/2ml...........................................................................117

naltrexone hcl tab 50 mg..............................................117NAMENDA XR TITRATION PACK -memantine hcl cap er

24hr 7 mg & 14 mg & 21 mg & 28 mg pack.................. 72NAMZARIC -memantine-donepezil cap er 24hr 7 & 14 &

21 & 28-10 mg pack.......................................................72NAMZARIC -memantine hcl-donepezil hcl cap er 24hr

7-10 mg........................................................................... 72NAMZARIC -memantine hcl-donepezil hcl cap er 24hr

14-10 mg......................................................................... 72NAMZARIC -memantine hcl-donepezil hcl cap er 24hr

21-10 mg......................................................................... 72NAMZARIC -memantine hcl-donepezil hcl cap er 24hr

28-10 mg......................................................................... 72NAPRELAN -naproxen sodium tab er 24hr 750 mg (base

equiv)...............................................................................82naproxen sodium tab er 24hr 375 mg (base equiv)

(Naprelan).......................................................................82naproxen sodium tab er 24hr 500 mg (base equiv)

(Naprelan).......................................................................82naproxen 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...................................................... 82naproxen tab 500 mg (Naprosyn).................................. 82naratriptan hcl tab 1 mg (base equiv) (Amerge).......... 83naratriptan hcl tab 2.5 mg (base equiv) (Amerge)....... 83NARCAN -naloxone hcl nasal spray 4 mg/0.1ml............ 117NASCOBAL -cyanocobalamin nasal spray 500

mcg/0.1ml........................................................................99NATACHEW -prenatal vit w/ fe fum-fe bisglycin-fa chew

tab 28-1 mg.....................................................................92NATACYN -natamycin ophth susp 5%............................108NATALVIT -prenatal vit w/ fe fumarate-fa tab 75-1 mg......92NATAZIA -estradiol valerate-dienogest tab 3 mg /2-2

mg/2-3 mg/1 mg............................................................. 21nateglinide tab 60 mg (Starlix).......................................24nateglinide tab 120 mg (Starlix).....................................24NATELLE ONE -prenatal w/o vit a w/ fe fum-fa-omega 3

cap 28-1-250 mg............................................................ 92NATESTO -testosterone nasal gel 5.5 mg/act.................. 18NATPARA -parathyroid hormone (recombinant) for inj

cartridge 25 mcg.............................................................31NATPARA -parathyroid hormone (recombinant) for inj



cartridge 100 mcg...........................................................31NATROBA -spinosad susp 0.9%.....................................115NATURE-THROID NT-2.5 -thyroid tab 162.5 mg (2 1/2

grain)................................................................................28NATURE-THROID -thyroid tab 16.25 mg..........................28

2019


NATURE-THROID -thyroid tab 32.5 mg............................28NATURE-THROID -thyroid tab 65 mg...............................28NATURE-THROID -thyroid tab 81.25 mg..........................28NATURE-THROID -thyroid tab 97.5 mg............................28NATURE-THROID -thyroid tab 113.75 mg........................28NATURE-THROID -thyroid tab 130 mg.............................28NATURE-THROID -thyroid tab 146.25 mg....................... 28NATURE-THROID -thyroid tab 195 mg.............................28NATURE-THROID -thyroid tab 260 mg.............................28NATURE-THROID -thyroid tab 48.75 mg (3/4 grain)........28NATURE-THROID -thyroid tab 325 mg (5 grain)..............28NEBULIZER CUP/TUBING -respiratory therapy supplies -

devices.......................................................................... 124NEBUPENT -pentamidine isethionate for nebulization

soln 300 mg...................................................................... 9NEEVO DHA -prenat w/o a w/fefum-methylfol-omegas

cap 27-1.13 mg...............................................................92NEFAZODONE HCL -nefazodone hcl tab 100 mg........... 62NEFAZODONE HCL -nefazodone hcl tab 150 mg........... 62NEFAZODONE HYDROCHLORIDE -nefazodone hcl tab

50 mg.............................................................................. 62NEFAZODONE HYDROCHLORIDE -nefazodone hcl tab

200 mg............................................................................ 62NEFAZODONE HYDROCHLORIDE -nefazodone hcl tab

250 mg............................................................................ 62NEOMYCIN/POLYMYXIN/HYDROC -neomycin-

polymyxin-hc ophth susp..............................................108neomycin-bacitrac zn-polymyx

5(3.5)mg-400unt-10000unt op oin.............................108neomycin-polymy-gramicid op sol

1.75-10000-0.025mg-unt-mg/ml (Neosporin)........... 108neomycin-polymyxin-dexamethasone ophth oint 0.1%

(Maxitrol)...................................................................... 108neomycin-polymyxin-dexamethasone ophth susp

0.1% (Maxitrol).............................................................108neomycin-polymyxin-hc otic soln 1%.........................109neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000

unit/ml-1%.................................................................... 109neomycin sulfate tab 500 mg...........................................4NEONATAL PLUS -prenatal vit w/ fe fumarate-fa tab 27-1

mg....................................................................................92NEONATAL VITAMIN -prenatal vit w/ fe fumarate-fa tab

27-0.8 mg........................................................................92NEORAL -cyclosporine modified cap 25 mg...................126NEORAL -cyclosporine modified cap 100 mg.................126NEORAL -cyclosporine modified oral soln 100 mg/

ml................................................................................... 126NEO-SYNALAR -neomycin sulfate-fluocinolone acetonide

cream 0.5-0.025%........................................................ 115NERLYNX -neratinib maleate tab 40 mg (base

equivalent).......................................................................15NESINA -alogliptin benzoate tab 6.25 mg (base

equiv)...............................................................................24NESINA -alogliptin benzoate tab 12.5 mg (base

equiv)...............................................................................24NESINA -alogliptin benzoate tab 25 mg (base equiv).......24

NESTABS ABC -prenatal w/o vit a w/fe polysac-fa-ca tab& omega 3 cap............................................................... 92

NESTABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg& omega cap pack......................................................... 92

NESTABS ONE -prenat w/o a w/fecbn-bisg-methylf-dhacap 38-1-225 mg............................................................ 92

NESTABS -prenatal vit w/o vit a w/ fe bisglycinate-fa tab32-1 mg........................................................................... 92

NEULASTA ONPRO KIT -pegfilgrastim soln prefilledsyringe kit 6 mg/0.6ml.................................................... 99

NEULASTA -pegfilgrastim soln prefilled syringe 6mg/0.6ml..........................................................................99

NEUPOGEN -filgrastim inj 300 mcg/ml.............................99NEUPOGEN -filgrastim inj 480 mcg/1.6ml (300 mcg/

ml)....................................................................................99NEUPOGEN -filgrastim soln prefilled syringe 300

mcg/0.5ml........................................................................99NEUPOGEN -filgrastim soln prefilled syringe 480

mcg/0.8ml (600 mcg/ml).................................................99NEUPRO -rotigotine td patch 24hr 1 mg/24hr.................. 89NEUPRO -rotigotine td patch 24hr 2 mg/24hr.................. 89NEUPRO -rotigotine td patch 24hr 3 mg/24hr.................. 89NEUPRO -rotigotine td patch 24hr 4 mg/24hr.................. 89NEUPRO -rotigotine td patch 24hr 6 mg/24hr.................. 89NEUPRO -rotigotine td patch 24hr 8 mg/24hr.................. 89NEUTEK 2TEK TEST STRIPS -glucose blood test

strip................................................................................120NEVANAC -nepafenac ophth susp 0.1%........................ 108nevirapine susp 50 mg/5ml (Viramune).......................... 6nevirapine tab er 24hr 100 mg (Viramune xr).................7nevirapine tab er 24hr 400 mg (Viramune xr).................7nevirapine tab 200 mg (Viramune)...................................7NEWGEN -prenatal vit w/o vit a w/ fe bisglycinate-fa tab

32-1 mg........................................................................... 92NEXA PLUS -prenatal w/o vit a w/ fe fum-doc-fa-dha cap

29-1.25-350 mg...............................................................93NEXAVAR -sorafenib tosylate tab 200 mg (base

equivalent).......................................................................15NEXIUM -esomeprazole magnesium for delayed release

susp packet 5 mg........................................................... 53NEXIUM -esomeprazole magnesium for delayed release

susp packet 10 mg......................................................... 53NEXIUM -esomeprazole magnesium for delayed release



susp pack 2.5 mg........................................................... 54niacin tab er 500 mg (antihyperlipidemic)

(Niaspan)........................................................................ 44niacin tab er 750 mg (antihyperlipidemic)

(Niaspan)........................................................................ 44niacin tab er 1000 mg (antihyperlipidemic)

(Niaspan)........................................................................ 45NIACOR -niacin (antihyperlipidemic) tab 500 mg............. 45nicardipine hcl cap 20 mg.............................................. 36nicardipine hcl cap 30 mg.............................................. 36

2019


nicotine polacrilex gum 2 mg.........................................72nicotine polacrilex gum 4 mg.........................................72nicotine polacrilex lozenge 2 mg...................................72nicotine polacrilex lozenge 4 mg...................................72nicotine td patch 24hr 7 mg/24hr...................................72nicotine td patch 24hr 14 mg/24hr.................................72nicotine td patch 24hr 21 mg/24hr.................................72NICOTINE TRANSDERMAL SYST -nicotine td patch 24

hr kit 21-14-7 mg/24hr....................................................72NICOTROL INHALER -nicotine inhaler system 10 mg (4

mg delivered).................................................................. 72NICOTROL NS -nicotine nasal spray 10 mg/ml (0.5 mg/

spray)...............................................................................73nifedipine cap 20 mg.......................................................36nifedipine cap 10 mg (Procardia).................................. 36nifedipine tab er 24hr 30 mg (Adalat cc).......................36nifedipine tab er 24hr 60 mg (Adalat cc).......................36nifedipine tab er 24hr 90 mg (Adalat cc).......................36nifedipine tab er 24hr osmotic release 30 mg

(Procardia xl)................................................................. 36nifedipine tab er 24hr osmotic release 60 mg

(Procardia xl)................................................................. 36nifedipine tab er 24hr osmotic release 90 mg

(Procardia xl)................................................................. 36nilutamide tab 150 mg (Nilandron)................................ 15nimodipine cap 30 mg.....................................................36NINLARO -ixazomib citrate cap 2.3 mg (base

equivalent).......................................................................15NINLARO -ixazomib citrate cap 3 mg (base

equivalent).......................................................................15NINLARO -ixazomib citrate cap 4 mg (base

equivalent).......................................................................15NISOLDIPINE ER -nisoldipine tab er 24hr 20 mg............ 36NISOLDIPINE ER -nisoldipine tab er 24hr 25.5 mg......... 36NISOLDIPINE ER -nisoldipine tab er 24hr 30 mg............ 36NISOLDIPINE ER -nisoldipine tab er 24hr 40 mg............ 36nisoldipine tab er 24hr 8.5 mg (Sular)...........................36nisoldipine tab er 24hr 17 mg (Sular)............................36nisoldipine tab er 24hr 34 mg (Sular)............................36NITRO-BID -nitroglycerin oint 2%..................................... 33NITRO-DUR -nitroglycerin td patch 24hr 0.3 mg/hr..........33NITRO-DUR -nitroglycerin td patch 24hr 0.8 mg/hr..........33nitrofurantoin macrocrystalline cap 25 mg

(Macrodantin).................................................................57nitrofurantoin macrocrystalline cap 50 mg

(Macrodantin).................................................................57nitrofurantoin macrocrystalline cap 100 mg

(Macrodantin).................................................................57nitrofurantoin monohydrate macrocrystalline cap 100

mg (Macrobid)............................................................... 57nitrofurantoin susp 25 mg/5ml (Furadantin)................ 57nitroglycerin cap er 2.5 mg............................................ 33nitroglycerin cap er 6.5 mg............................................ 33nitroglycerin cap er 9 mg............................................... 33nitroglycerin sl tab 0.3 mg (Nitrostat)........................... 34nitroglycerin sl tab 0.4 mg (Nitrostat)........................... 34nitroglycerin sl tab 0.6 mg (Nitrostat)........................... 34

nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur).........34nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur).........34nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur).........34nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur).........34nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)

(Nitrolingual pumpspr).................................................34NITROMIST -nitroglycerin lingual aerosol 400 mcg/

spray................................................................................34NITYR -nitisinone tab 2 mg...............................................31NITYR -nitisinone tab 5 mg...............................................31NITYR -nitisinone tab 10 mg.............................................31NIVA-PLUS -prenatal vit w/ fe fumarate-fa tab 27-1

mg....................................................................................93nizatidine cap 150 mg..................................................... 54nizatidine cap 300 mg..................................................... 54NIZATIDINE -nizatidine oral soln 15 mg/ml...................... 54NOCTIVA -desmopressin acetate nasal emulsion spray

0.83 mcg/0.1ml............................................................... 31NOCTIVA -desmopressin acetate nasal emulsion spray

1.66 mcg/0.1ml............................................................... 31nonoxynol-9 gel 4%.........................................................58NORDITROPIN FLEXPRO -somatropin inj 5

mg/1.5ml..........................................................................31NORDITROPIN FLEXPRO -somatropin inj 10



mg/3ml.............................................................................31norethindrone & ethinyl estradiol-fe chew tab 0.4

mg-35 mcg (Femcon fe)...............................................21norethindrone & ethinyl estradiol-fe chew tab 0.8

mg-25 mcg (Generess fe)............................................ 21norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg

(Brevicon-28)................................................................. 21norethindrone & ethinyl estradiol tab 1 mg-35 mcg

(Norinyl 1+35)................................................................ 21norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg

(Ovcon-35)......................................................................21norethindrone ace & ethinyl estradiol-fe tab 1 mg-20

mcg (Loestrin fe 1/20).................................................. 21norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30

mcg (Loestrin fe 1.5/30)...............................................21norethindrone ace & ethinyl estradiol tab 1 mg-20

mcg (Loestrin 1/20-21)................................................. 21norethindrone ace & ethinyl estradiol tab 1.5 mg-30

mcg (Loestrin 1.5/30-21).............................................. 21norethindrone ace-eth estradiol-fe chew tab 1 mg-20

mcg (24) (Minastrin 24 fe)............................................21norethindrone ace-ethinyl estradiol-fe tab 1 mg-20

mcg (24)......................................................................... 21norethindrone acetate-ethinyl estradiol tab 1 mg-5

mcg................................................................................. 19norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5

mcg (Femhrt low dose)................................................19norethindrone acetate tab 5 mg (Aygestin)..................21

2019


norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35mg-mcg (Estrostep fe)................................................. 21

norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35mg-mcg (Ortho-novum 7/7/7)...................................... 21

norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg (Tri-norinyl 28)...................................................... 21

norethindrone tab 0.35 mg (Ortho micronor)...............21norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg

(Ortho-cyclen)................................................................21norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35

mg-mcg (Ortho tri-cyclen)........................................... 21norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25

mg-mcg (Ortho tri-cyclen lo).......................................21norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg........21NORITATE -metronidazole cream 1%.............................115NORPACE CR -disopyramide phosphate cap er 12hr 100

mg....................................................................................37NORPACE CR -disopyramide phosphate cap er 12hr 150

mg....................................................................................37NORPACE -disopyramide phosphate cap 100 mg........... 37NORPACE -disopyramide phosphate cap 150 mg........... 37NORTHERA -droxidopa cap 100 mg................................ 43NORTHERA -droxidopa cap 200 mg................................ 43NORTHERA -droxidopa cap 300 mg................................ 43nortriptyline hcl cap 10 mg (Pamelor)...........................62nortriptyline hcl cap 25 mg (Pamelor)...........................62nortriptyline hcl cap 50 mg (Pamelor)...........................62nortriptyline hcl cap 75 mg (Pamelor)...........................62NORTRIPTYLINE HCL -nortriptyline hcl soln 10

mg/5ml.............................................................................62NORVIR -ritonavir oral soln 80 mg/ml.................................7NORVIR -ritonavir powder packet 100 mg..........................7NOVAFERRUM PEDIATRIC DROP -polysaccharide iron

complex liquid 15 mg/ml (fe equiv)................................ 99NOVA MAX GLUCOSE TEST STR -glucose blood test

strip................................................................................120NOVAREL -chorionic gonadotropin for im inj 5000

unit................................................................................... 31NOVAREL -chorionic gonadotropin for im inj 10000

unit................................................................................... 31NOVOEIGHT -antihemophilic factor (recombinant) for inj

250 unit......................................................................... 104NOVOEIGHT -antihemophilic factor (recombinant) for inj

500 unit......................................................................... 104NOVOEIGHT -antihemophilic factor (recombinant) for inj

1000 unit....................................................................... 104NOVOEIGHT -antihemophilic factor (recombinant) for inj



3000 unit....................................................................... 104NOVOLIN 70/30 -insulin nph isophane & regular human

inj 100 unit/ml (70-30).................................................... 26NOVOLIN 70/30 RELION -insulin nph isophane & regular

human inj 100 unit/ml (70-30)........................................ 27

NOVOLIN N -insulin nph (human) (isophane) inj 100 unit/ml..................................................................................... 26

NOVOLIN N RELION -insulin nph (human) (isophane) inj100 unit/ml.......................................................................26

NOVOLIN R -insulin regular (human) inj 100 unit/ml........26NOVOLIN R RELION -insulin regular (human) inj 100

unit/ml.............................................................................. 26NOVOLOG FLEXPEN -insulin aspart soln pen-injector

100 unit/ml.......................................................................26NOVOLOG -insulin aspart inj 100 unit/ml......................... 26NOVOLOG MIX 70/30 -insulin aspart prot & aspart

(human) inj 100 unit/ml (70-30)......................................27NOVOLOG MIX 70/30 PREFILL -insulin aspart prot &

aspart sus pen-inj 100 unit/ml (70-30)........................... 27NOVOLOG PENFILL -insulin aspart soln cartridge 100

unit/ml.............................................................................. 26NOVOSEVEN RT -coagulation factor viia (recomb) for inj

1 mg (1000 mcg).......................................................... 104NOVOSEVEN RT -coagulation factor viia (recomb) for inj



8 mg (8000 mcg).......................................................... 105NOXAFIL -posaconazole susp 40 mg/ml............................5NOXAFIL -posaconazole tab delayed release 100 mg.......5NUCYNTA ER -tapentadol hcl tab er 12hr 50 mg.............78NUCYNTA ER -tapentadol hcl tab er 12hr 100 mg...........78NUCYNTA ER -tapentadol hcl tab er 12hr 150 mg...........78NUCYNTA ER -tapentadol hcl tab er 12hr 200 mg...........78NUCYNTA ER -tapentadol hcl tab er 12hr 250 mg...........78NUCYNTA -tapentadol hcl tab 50 mg............................... 78NUCYNTA -tapentadol hcl tab 75 mg............................... 78NUCYNTA -tapentadol hcl tab 100 mg............................. 78NUEDEXTA -dextromethorphan hbr-quinidine sulfate cap

20-10 mg......................................................................... 73NUPLAZID -pimavanserin tartrate cap 34 mg (base

equivalent).......................................................................64NUPLAZID -pimavanserin tartrate tab 10 mg (base

equivalent).......................................................................64NUPLAZID -pimavanserin tartrate tab 17 mg (base

equivalent).......................................................................64NUTRESTORE -glutamine powd pack 5 gm.................... 97NUTROPIN AQ NUSPIN 10 -somatropin inj 10

mg/2ml.............................................................................31NUTROPIN AQ NUSPIN 20 -somatropin inj 20

mg/2ml.............................................................................31NUTROPIN AQ NUSPIN 5 -somatropin inj 5 mg/2ml.......31NUVARING -etonogestrel-ethinyl estradiol va ring

0.120-0.015 mg/24hr...................................................... 21NUVESSA -metronidazole vaginal gel 1.3%.....................58NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 250

unit................................................................................. 105NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 500

unit................................................................................. 105NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 1000

unit................................................................................. 105

2019


NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 2000unit................................................................................. 105




NUWIQ -antihemophilic factor (bdd-rfviii) for inj 250unit................................................................................. 105







NYMALIZE -nimodipine oral soln 60 mg/20ml..................36nystatin cream 100000 unit/gm....................................115nystatin oint 100000 unit/gm........................................115nystatin susp 100000 unit/ml....................................... 110nystatin tab 500000 unit....................................................5nystatin topical powder 100000 unit/gm.....................115nystatin-triamcinolone cream 100000-0.1 unit/gm-

%....................................................................................115nystatin-triamcinolone oint 100000-0.1 unit/gm-

%....................................................................................115OOB COMPLETE/DHA -prenat w/ iron cbn-fe asp glyc-fa-

omega cap 30-10-1-200 mg...........................................93OB COMPLETE GOLD -prenat w/o a w/fecbn-methfol-fa-

dha cap 27.5-1-200 mg..................................................93OB COMPLETE ONE -prenatal w/o a w/fecbn-fe asp

glyc-fa-fish cap 50-1-476 mg..........................................93OB COMPLETE PETITE -prenat w/o a w/fecbn-

feaspglyc-fa-omega cap 35-5-1-200 mg........................93OB COMPLETE PREMIER -prenatal vit w/ fe cbn-fe asp

glyc-fa tab 30-20-1 mg................................................... 93OB COMPLETE -prenatal vit w/ iron carbonyl-fa tab

50-1.25 mg......................................................................93OBIZUR -antihemophilic factor (recomb porc) rpfviii for inj

500 unit......................................................................... 105OBSTETRIX DHA -prenat w/fecbn-fa-dss tab 29-1 mg &

omega 3 cap 387 mg pak.............................................. 93OBSTETRIX EC -prenatal vit w/ dss-iron carbonyl-fa tab

29-1 mg........................................................................... 93OBSTETRIX ONE -prenat w/o a w/fecbn-bisg-methylf-

dss-dha cap 38-1-225 mg.............................................. 93O-CAL FA -prenatal vit w/ fe fumarate-fa tab 27-1 mg......93OCALIVA -obeticholic acid tab 5 mg.................................56OCALIVA -obeticholic acid tab 10 mg...............................56

O-CAL PRENATAL -prenatal vit w/ fe fumarate-fa tab 15-1mg....................................................................................93

octreotide acetate inj 50 mcg/ml (0.05 mg/ml)(Sandostatin)................................................................. 31




octreotide acetate inj 1000 mcg/ml (1 mg/ml)(Sandostatin)................................................................. 32

ODACTRA -dust mite mixed ext sl tab 12 sq-hdm........... 12ODEFSEY -emtricitabine-rilpivirine-tenofovir af tab

200-25-25 mg....................................................................7ODOMZO -sonidegib phosphate cap 200 mg (base

equivalent).......................................................................15OFEV -nintedanib esylate cap 100 mg (base

equivalent).......................................................................52OFEV -nintedanib esylate cap 150 mg (base

equivalent).......................................................................52OFLOXACIN -ofloxacin tab 300 mg....................................4ofloxacin ophth soln 0.3% (Ocuflox)...........................108ofloxacin otic soln 0.3% (Floxin otic)..........................109ofloxacin tab 400 mg.........................................................4OGESTREL -norgestrel & ethinyl estradiol tab 0.5 mg-50

mcg.................................................................................. 21olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax)......73olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax)......73olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax)......73olanzapine-fluoxetine hcl cap 12-25 mg

(Symbyax)...................................................................... 73olanzapine-fluoxetine hcl cap 12-50 mg

(Symbyax)...................................................................... 73olanzapine orally disintegrating tab 5 mg (Zyprexa

zydis)...............................................................................64olanzapine orally disintegrating tab 10 mg (Zyprexa



zydis)...............................................................................64olanzapine tab 2.5 mg (Zyprexa)................................... 64olanzapine tab 5 mg (Zyprexa)...................................... 64olanzapine tab 7.5 mg (Zyprexa)................................... 64olanzapine tab 10 mg (Zyprexa).................................... 64olanzapine tab 15 mg (Zyprexa).................................... 64olanzapine tab 20 mg (Zyprexa).................................... 64olmesartan-amlodipine-hydrochlorothiazide tab

20-5-12.5 mg (Tribenzor).............................................. 40olmesartan-amlodipine-hydrochlorothiazide tab

40-5-12.5 mg (Tribenzor).............................................. 40olmesartan-amlodipine-hydrochlorothiazide tab

40-5-25 mg (Tribenzor)................................................. 40olmesartan-amlodipine-hydrochlorothiazide tab

40-10-12.5 mg (Tribenzor)............................................41

2019


olmesartan-amlodipine-hydrochlorothiazide tab40-10-25 mg (Tribenzor)............................................... 41

olmesartan medoxomil-hydrochlorothiazide tab20-12.5 mg (Benicar hct)..............................................40

olmesartan medoxomil-hydrochlorothiazide tab40-12.5 mg (Benicar hct)..............................................40

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

olmesartan medoxomil tab 5 mg (Benicar).................. 40olmesartan medoxomil tab 20 mg (Benicar)................ 40olmesartan medoxomil tab 40 mg (Benicar)................ 40olopatadine hcl nasal soln 0.6% (Patanase).................47olopatadine hcl ophth soln 0.2% (base equivalent)

(Pataday)...................................................................... 108olopatadine hcl ophth soln 0.1% (base equivalent)

(Patanol)....................................................................... 108OLUMIANT -baricitinib tab 2 mg....................................... 82OMBRA TABLE TOP COMPRESSO -respiratory therapy

supplies - devices.........................................................124OMECLAMOX-PAK -amoxicillin cap-clarithro tab w/

omepraz cap dr therapy pack........................................ 54omega-3-acid ethyl esters cap 1 gm (Lovaza)............. 45omeprazole cap delayed release 10 mg........................54omeprazole cap delayed release 20 mg........................54omeprazole cap delayed release 40 mg........................54omeprazole-sodium bicarbonate cap 20-1100 mg

(Zegerid)......................................................................... 54omeprazole-sodium bicarbonate cap 40-1100 mg

(Zegerid)......................................................................... 54omeprazole-sodium bicarbonate powd pack for susp

20-1680 mg (Zegerid)....................................................54omeprazole-sodium bicarbonate powd pack for susp

40-1680 mg (Zegerid)....................................................54OMNARIS -ciclesonide nasal susp 50 mcg/act................ 48OMNIFLEX DIAPHRAGM -diaphragms.......................... 124OMNITROPE -somatropin for inj 5.8 mg.......................... 32OMNITROPE -somatropin inj 5 mg/1.5ml.........................32OMNITROPE -somatropin inj 10 mg/1.5ml.......................32ON CALL EXPRESS BLOOD GLU -glucose blood test

strip................................................................................120ON CALL PLUS BLOOD GLUCOS -glucose blood test

strip................................................................................120ON CALL VIVID BLOOD GLUCO -glucose blood test

strip................................................................................120ondansetron hcl oral soln 4 mg/5ml (Zofran)...............54ondansetron hcl tab 24 mg............................................ 55ondansetron hcl tab 4 mg (Zofran)................................55ondansetron hcl tab 8 mg (Zofran)................................55ondansetron orally disintegrating tab 4 mg (Zofran

odt).................................................................................. 55ondansetron orally disintegrating tab 8 mg (Zofran

odt).................................................................................. 55ONE FLOW FVC MONITORING S -respiratory therapy

supplies - devices.........................................................124ONETOUCH ULTRA BLUE -glucose blood test strip..... 120ONETOUCH ULTRA TEST STRIP -glucose blood test

strip................................................................................120

ONETOUCH VERIO TEST STRIP -glucose blood teststrip................................................................................120

ONEXTON -clindamycin phosphate-benzoyl peroxide gel1.2-3.75%...................................................................... 115

ONFI -clobazam suspension 2.5 mg/ml............................87ONFI -clobazam tab 10 mg...............................................87ONFI -clobazam tab 20 mg...............................................87ONGLYZA -saxagliptin hcl tab 2.5 mg (base equiv)......... 24ONGLYZA -saxagliptin hcl tab 5 mg (base equiv)............ 24ONZETRA XSAIL -sumatriptan succinate exhaler powder

11 mg/nosepiece.............................................................83OPSUMIT -macitentan tab 10 mg.....................................46OPTICHAMBER ADVANTAGE/LAR -spacer/aerosol-

holding chambers - device........................................... 124OPTICHAMBER ADVANTAGE/MED -spacer/aerosol-

holding chambers - device........................................... 124OPTICHAMBER ADVANTAGE/SMA -spacer/aerosol-

holding chambers - device........................................... 124OPTICHAMBER DIAMOND/LARGE -spacer/aerosol-

holding chambers - device........................................... 124OPTICHAMBER DIAMOND/MEDIU -spacer/aerosol-

holding chambers - device........................................... 125OPTICHAMBER DIAMOND/SMALL -spacer/aerosol-

holding chambers - device........................................... 125OPTICHAMBER DIAMOND -spacer/aerosol-holding

chambers - device........................................................ 124OPTICHAMBER FACE MASK/LAR -spacer/aerosol-

holding chambers - device........................................... 125OPTICHAMBER FACE MASK/MED -spacer/aerosol-

holding chambers - device........................................... 125OPTICHAMBER FACE MASK/SMA -spacer/aerosol-

holding chambers - device........................................... 125OPTICHAMBER -spacer/aerosol-holding chambers -

device............................................................................ 124OPTIHALER MDI DRUG DELIVE -spacer/aerosol-holding

chambers - device........................................................ 125OPTIHALER -spacer/aerosol-holding chambers -

device............................................................................ 125OPTIONS GYNOL II VAGINAL -nonoxynol-9 gel 3%....... 58OPTIUMEZ TEST STRIPS -glucose blood test strip...... 121OPTIUM TEST STRIPS -glucose blood test strip...........120OPTUMRX BLOOD GLUCOSE TES -glucose blood test

strip................................................................................121ORACEA -doxycycline (rosacea) cap delayed release 40

mg..................................................................................115ORALAIR -grass mixed pollen ext sl tab 300 ir (index of

reactivity)......................................................................... 12ORAVIG -miconazole buccal tab 50 mg (mouth-

throat)............................................................................ 110ORENCIA -abatacept subcutaneous soln prefilled syringe

50 mg/0.4ml.................................................................... 82ORENCIA -abatacept subcutaneous soln prefilled syringe

87.5 mg/0.7ml................................................................. 82ORENCIA -abatacept subcutaneous soln prefilled syringe

125 mg/ml....................................................................... 82ORENCIA CLICKJECT -abatacept subcutaneous soln

auto-injector 125 mg/ml..................................................82

2019


ORENITRAM -treprostinil diolamine tab er 0.125 mg(base equiv).................................................................... 46

ORENITRAM -treprostinil diolamine tab er 0.25 mg (baseequiv)...............................................................................46

ORENITRAM -treprostinil diolamine tab er 1 mg (baseequiv)...............................................................................46

ORENITRAM -treprostinil diolamine tab er 2.5 mg (baseequiv)...............................................................................46

ORENITRAM -treprostinil diolamine tab er 5 mg (baseequiv)...............................................................................46

ORFADIN -nitisinone cap 2 mg.........................................32ORFADIN -nitisinone cap 5 mg.........................................32ORFADIN -nitisinone cap 10 mg.......................................32ORFADIN -nitisinone cap 20 mg.......................................32ORFADIN -nitisinone susp 4 mg/ml.................................. 32ORKAMBI -lumacaftor-ivacaftor granules packet 100-125

mg....................................................................................52ORKAMBI -lumacaftor-ivacaftor granules packet 150-188

mg....................................................................................52ORKAMBI -lumacaftor-ivacaftor tab 100-125 mg............. 52ORKAMBI -lumacaftor-ivacaftor tab 200-125 mg............. 52orphenadrine citrate tab er 12hr 100 mg...................... 91oseltamivir phosphate cap 30 mg (base equiv)

(Tamiflu)............................................................................7oseltamivir phosphate cap 45 mg (base equiv)

(Tamiflu)............................................................................7oseltamivir phosphate cap 75 mg (base equiv)

(Tamiflu)............................................................................7oseltamivir phosphate for susp 6 mg/ml (base equiv)

(Tamiflu)............................................................................7OSENI -alogliptin-pioglitazone tab 12.5-15 mg.................24OSENI -alogliptin-pioglitazone tab 12.5-30 mg.................24OSENI -alogliptin-pioglitazone tab 12.5-45 mg.................24OSENI -alogliptin-pioglitazone tab 25-15 mg....................24OSENI -alogliptin-pioglitazone tab 25-30 mg....................24OSENI -alogliptin-pioglitazone tab 25-45 mg....................24OSMOLEX ER -amantadine hcl tab er 24hr 129 mg (base

equivalent).......................................................................89OSMOLEX ER -amantadine hcl tab er 24hr 193 mg (base

equivalent).......................................................................89OSMOLEX ER -amantadine hcl tab er 24hr 258 mg (base

equivalent).......................................................................89OSMOPREP -sod phos mono-sod phos di tabs

1.102-0.398 gm(1.5gm na phos)....................................52OSPHENA -ospemifene tab 60 mg...................................32OTEZLA -apremilast tab 30 mg........................................ 82OTEZLA -apremilast tab starter therapy pack 10 mg & 20

mg & 30 mg....................................................................82OTOVEL -ciprofloxacin-fluocinolone aceton (pf) otic soln

0.3-0.025%.................................................................... 109OTREXUP -methotrexate soln pf auto-injector 10

mg/0.4ml..........................................................................82OTREXUP -methotrexate soln pf auto-injector 12.5

mg/0.4ml..........................................................................82OTREXUP -methotrexate soln pf auto-injector 15

mg/0.4ml..........................................................................82

OTREXUP -methotrexate soln pf auto-injector 17.5mg/0.4ml..........................................................................82

OTREXUP -methotrexate soln pf auto-injector 20mg/0.4ml..........................................................................82

OTREXUP -methotrexate soln pf auto-injector 22.5mg/0.4ml..........................................................................82

OTREXUP -methotrexate soln pf auto-injector 25mg/0.4ml..........................................................................82

OVIDREL -choriogonadotropin alfa inj 250 mcg/0.5ml..... 32oxandrolone tab 2.5 mg (Oxandrin).............................. 18oxandrolone tab 10 mg (Oxandrin)............................... 18oxaprozin tab 600 mg (Daypro)..................................... 82OXAYDO -oxycodone hcl tab abuse deter 5 mg.............. 78OXAYDO -oxycodone hcl tab abuse deter 7.5 mg............78oxazepam cap 10 mg...................................................... 60oxazepam cap 15 mg...................................................... 60OXAZEPAM -oxazepam cap 30 mg..................................60oxcarbazepine susp 300 mg/5ml (60 mg/ml)

(Trileptal)........................................................................ 87oxcarbazepine tab 150 mg (Trileptal)............................ 87oxcarbazepine tab 300 mg (Trileptal)............................ 87oxcarbazepine tab 600 mg (Trileptal)............................ 87oxiconazole nitrate cream 1% (Oxistat)...................... 115OXISTAT -oxiconazole nitrate lotion 1%......................... 115OXTELLAR XR -oxcarbazepine tab er 24hr 150 mg........ 87OXTELLAR XR -oxcarbazepine tab er 24hr 300 mg........ 87OXTELLAR 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/IBUPROFEN -oxycodone-ibuprofen tab

5-400 mg......................................................................... 78oxycodone-aspirin tab 4.8355-325 mg.......................... 78oxycodone hcl cap 5 mg................................................ 78oxycodone hcl conc 100 mg/5ml (20 mg/ml)................78OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter

10 mg.............................................................................. 78OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter






80 mg.............................................................................. 78oxycodone hcl soln 5 mg/5ml........................................78oxycodone hcl tab 10 mg............................................... 78oxycodone hcl tab 20 mg............................................... 78oxycodone hcl tab 5 mg (Roxicodone).........................78

2019


oxycodone hcl tab 15 mg (Roxicodone).......................78oxycodone hcl tab 30 mg (Roxicodone).......................78oxycodone w/ acetaminophen tab 2.5-325 mg

(Percocet).......................................................................78oxycodone w/ acetaminophen tab 5-325 mg

(Percocet).......................................................................78oxycodone w/ acetaminophen tab 7.5-325 mg

(Percocet).......................................................................78oxycodone w/ acetaminophen tab 10-325 mg

(Percocet).......................................................................78OXYCONTIN -oxycodone hcl tab er 12hr deter 10 mg.....78OXYCONTIN -oxycodone hcl tab er 12hr deter 15 mg.....78OXYCONTIN -oxycodone hcl tab er 12hr deter 20 mg.....78OXYCONTIN -oxycodone hcl tab er 12hr deter 30 mg.....78OXYCONTIN -oxycodone hcl tab er 12hr deter 40 mg.....78OXYCONTIN -oxycodone hcl tab er 12hr deter 60 mg.....78OXYCONTIN -oxycodone hcl tab er 12hr deter 80 mg.....78oxymorphone hcl tab 5 mg (Opana)..............................79oxymorphone hcl tab 10 mg (Opana)............................79OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl

tab er 12hr 5 mg.............................................................79OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl

tab er 12hr 7.5 mg..........................................................79OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl

tab er 12hr 10 mg...........................................................79OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl




tab er 12hr 40 mg...........................................................79OXYTROL -oxybutynin td patch twice weekly 3.9

mg/24hr........................................................................... 57OZEMPIC -semaglutide soln pen-inj 1 mg/dose (2

mg/1.5ml).........................................................................24OZEMPIC -semaglutide soln pen-inj 0.25 or 0.5 mg/dose

(2 mg/1.5ml)....................................................................24

Ppaliperidone tab er 24hr 1.5 mg (Invega)......................64paliperidone tab er 24hr 3 mg (Invega).........................64paliperidone tab er 24hr 6 mg (Invega).........................65paliperidone tab er 24hr 9 mg (Invega).........................65PALYNZIQ -pegvaliase-pqpz subcutaneous soln pref

syringe 2.5 mg/0.5ml...................................................... 32PALYNZIQ -pegvaliase-pqpz subcutaneous soln pref

syringe 10 mg/0.5ml....................................................... 32PALYNZIQ -pegvaliase-pqpz subcutaneous soln pref

syringe 20 mg/ml............................................................ 32PANCREAZE -pancrelipase (lip-prot-amyl) dr cap

2600-6200-10850 unit.....................................................55PANCREAZE -pancrelipase (lip-prot-amyl) dr cap

4200-14200-24600 unit...................................................55PANCREAZE -pancrelipase (lip-prot-amyl) dr cap

10500-35500-61500 unit................................................ 55

PANCREAZE -pancrelipase (lip-prot-amyl) dr cap16800-56800-98400 unit................................................ 55

PANCREAZE -pancrelipase (lip-prot-amyl) dr cap21000-54700-83900 unit................................................ 55

PANDA MASK LARGE -spacer/aerosol-holding chambersupplies - masks...........................................................125

PANDA MASK MEDIUM -spacer/aerosol-holding chambersupplies - masks...........................................................125

PANDA MASK SMALL -spacer/aerosol-holding chambersupplies - masks...........................................................125

PANDEL -hydrocortisone probutate cream 0.1%............115PANRETIN -alitretinoin gel 0.1%.....................................115pantoprazole sodium ec tab 20 mg (base equiv)

(Protonix)........................................................................54pantoprazole sodium ec tab 40 mg (base equiv)

(Protonix)........................................................................54paricalcitol cap 4 mcg.....................................................32paricalcitol cap 1 mcg (Zemplar)................................... 32paricalcitol cap 2 mcg (Zemplar)................................... 32PARI MANUAL INTERRUPTER -respiratory therapy

supplies - devices.........................................................125PARI TREK S COMBO PACK -respiratory therapy

supplies - devices.........................................................125paromomycin sulfate cap 250 mg................................... 4paroxetine hcl tab er 24hr 12.5 mg (Paxil cr)............... 62paroxetine hcl tab er 24hr 25 mg (Paxil cr).................. 62paroxetine hcl tab er 24hr 37.5 mg (Paxil cr)............... 62paroxetine hcl tab 10 mg (Paxil)....................................62paroxetine hcl tab 20 mg (Paxil)....................................62paroxetine hcl tab 30 mg (Paxil)....................................62paroxetine hcl tab 40 mg (Paxil)....................................62paroxetine mesylate cap 7.5 mg (base equiv)

(Brisdelle).......................................................................73PASER -aminosalicylic acid er granules packet 4 gm........ 4PAXIL -paroxetine hcl oral susp 10 mg/5ml (base

equiv)...............................................................................62PAZEO -olopatadine hcl ophth soln 0.7% (base

equivalent).....................................................................108PCP 100 -mag cit-bisacodyl-petrolat-peg-

metoclopramide-electrol kit.............................................52PEDIARIX -diph-tetanus tox-acell pert-hepatitis b-polio ipv

vac inj.............................................................................. 11PEDIATRIC PANDA MASK -spacer/aerosol-holding

chamber supplies - masks........................................... 125PEDVAX HIB -haemophilus b polysaccharide conj vac im

susp 7.5 mcg/0.5 ml....................................................... 11PEGANONE -ethotoin tab 250 mg....................................87PEGASYS -peginterferon alfa-2a inj 180 mcg/ml............... 7PEGASYS -peginterferon alfa-2a inj 180 mcg/0.5ml.......... 7PEGASYS PROCLICK -peginterferon alfa-2a inj 135

mcg/0.5ml.......................................................................... 7PEGASYS PROCLICK -peginterferon alfa-2a inj 180

mcg/0.5ml.......................................................................... 7PEGINTRON -peginterferon alfa-2b for inj kit 50

mcg/0.5ml.......................................................................... 7peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240

gm (Colyte-flavor packs)............................................. 52

2019


peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236gm (Golytely)................................................................. 52

peg 3350-kcl-sod bicarb-nacl for soln 420 gm(Nulytely/flavor pack)................................................... 52

PENICILLIN V POTASSIUM -penicillin v potassium forsoln 125 mg/5ml............................................................... 1

PENICILLIN V POTASSIUM -penicillin v potassium forsoln 250 mg/5ml............................................................... 1

penicillin v potassium tab 250 mg...................................1penicillin v potassium tab 500 mg...................................1PENNSAID -diclofenac sodium soln 2%.........................115PENTACEL -diph-ac per-tet tox ad-poliov-haemoph b poly

vac for im susp............................................................... 11PENTASA -mesalamine cap er 250 mg............................56PENTASA -mesalamine cap er 500 mg............................56pentazocine w/ naloxone tab 50-0.5 mg........................79pentoxifylline tab er 400 mg.........................................105PERFOROMIST -formoterol fumarate soln nebu 20

mcg/2ml........................................................................... 50perindopril erbumine tab 2 mg...................................... 41perindopril erbumine tab 4 mg (Aceon)........................41perindopril erbumine tab 8 mg (Aceon)........................41permethrin cream 5% (Elimite).................................... 115PERPHENAZINE/AMITRIPTYLIN -perphenazine-

amitriptyline tab 2-10 mg................................................73PERPHENAZINE/AMITRIPTYLIN -perphenazine-




amitriptyline tab 4-50 mg................................................73perphenazine tab 2 mg................................................... 65perphenazine tab 4 mg................................................... 65perphenazine tab 8 mg................................................... 65perphenazine tab 16 mg................................................. 65PERTZYE -pancrelipase (lip-prot-amyl) dr cap

4000-14375-15125 unit...................................................55PERTZYE -pancrelipase (lip-prot-amyl) dr cap

8000-28750-30250 unit...................................................55PERTZYE -pancrelipase (lip-prot-amyl) dr cap

16000-57500-60500 unit................................................ 55PERTZYE -pancrelipase (lip-prot-amyl) dr cap

24000-86250-90750 unit................................................ 55PEXEVA -paroxetine mesylate tab 10 mg (base

equiv)...............................................................................62PEXEVA -paroxetine mesylate tab 20 mg (base



equiv)...............................................................................62PHARMACIST CHOICE AUTOCOD -glucose blood test

strip................................................................................121PHARMACIST CHOICE NO CODI -glucose blood test

strip................................................................................121

PHENACTIN AA PLUS -nutritional supplement liquid...... 97PHENDIMETRAZINE TARTRATE -phendimetrazine

tartrate cap er 24hr 105 mg........................................... 70phendimetrazine tartrate tab 35 mg.............................. 70phenelzine sulfate tab 15 mg (Nardil)........................... 62phenobarbital elixir 20 mg/5ml...................................... 66phenobarbital tab 15 mg.................................................66phenobarbital tab 16.2 mg..............................................66phenobarbital tab 30 mg.................................................66phenobarbital tab 32.4 mg..............................................66phenobarbital tab 60 mg.................................................66phenobarbital tab 64.8 mg..............................................66phenobarbital tab 97.2 mg..............................................66phenobarbital tab 100 mg...............................................66phenoxybenzamine hcl cap 10 mg (Dibenzyline)........ 41phentermine hcl cap 15 mg............................................70phentermine hcl cap 30 mg............................................70phentermine hcl cap 37.5 mg (Adipex-p)......................70phentermine hcl tab 37.5 mg (Adipex-p).......................70phenylephrine hcl ophth soln 2.5%.............................108phenylephrine hcl ophth soln 10%..............................108PHENYTEK -phenytoin sodium extended cap 200

mg....................................................................................87PHENYTEK -phenytoin sodium extended cap 300

mg....................................................................................87phenytoin 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)................... 87PHOSLYRA -calcium acetate (phosphate binder) oral soln

667 mg/5ml..................................................................... 56PHOSPHOLINE IODIDE -echothiophate iodide ophth for

soln 0.125%.................................................................. 108phytonadione tab 5 mg (Mephyton).............................. 91PICATO -ingenol mebutate gel 0.015%.......................... 115PICATO -ingenol mebutate gel 0.05%............................ 115pilocarpine hcl ophth soln 1% (Isopto carpine).........108pilocarpine hcl ophth soln 2% (Isopto carpine).........108pilocarpine hcl ophth soln 4% (Isopto carpine).........108pilocarpine hcl tab 5 mg (Salagen)..............................110pilocarpine hcl tab 7.5 mg (Salagen)...........................110pimozide tab 1 mg (Orap)...............................................73pimozide tab 2 mg (Orap)...............................................73pindolol tab 5 mg.............................................................35pindolol tab 10 mg...........................................................35pioglitazone hcl-glimepiride tab 30-2 mg (Duetact).....24pioglitazone hcl-glimepiride tab 30-4 mg (Duetact).....24pioglitazone hcl-metformin hcl tab 15-500 mg

(Actoplus met)...............................................................24pioglitazone hcl-metformin hcl tab 15-850 mg

(Actoplus met)...............................................................24pioglitazone hcl tab 15 mg (base equiv) (Actos)..........24pioglitazone hcl tab 30 mg (base equiv) (Actos)..........24pioglitazone hcl tab 45 mg (base equiv) (Actos)..........24

2019


piroxicam cap 10 mg (Feldene)..................................... 82piroxicam cap 20 mg (Feldene)..................................... 82PLEGRIDY -peginterferon beta-1a soln pen-injector 125

mcg/0.5ml........................................................................73PLEGRIDY -peginterferon beta-1a soln prefilled syringe

125 mcg/0.5ml................................................................ 73PLEGRIDY STARTER PACK -peginterferon beta-1a soln

pen-inj 63 & 94 mcg/0.5ml pack.................................... 73PLEGRIDY STARTER PACK -peginterferon beta-1a soln

pref syr 63 & 94 mcg/0.5ml pack...................................73PLIAGLIS -lidocaine-tetracaine cream 7-7%.................. 115PLIXDA -adapalene pads 0.1%...................................... 115PNEUMOVAX 23/1 DOSE -pneumococcal vaccine

polyvalent inj 25 mcg/0.5ml............................................11PNEUMOVAX 23 -pneumococcal vaccine polyvalent inj

25 mcg/0.5ml.................................................................. 11PNV-DHA+DOCUSATE -prenatal w/o vit a w/ fe fum-dss-

fa-dha cap 27-1.25-300 mg............................................93PNV-DHA -prenat w/o a w/fefum-methfol-fa-dha cap

27-0.6-0.4-300 mg.......................................................... 93PNV FOLIC ACID + IRON MUL -prenatal vit w/ fe

fumarate-fa tab 27-1 mg.................................................93PNV OB+DHA -prenat w/o a w/fecbn-fegl-dss-fa tab &

dha cap 250 mg pack.....................................................93PNV-OMEGA -prenat w/o a w/ fe fumerate-methylfolate-

fa-omega 3 cap...............................................................93PNV PRENATAL PLUS MULTIVI -prenatal vit w/ fe

fumarate-fa tab 27-1 mg.................................................93PNV PRENATAL PLUS MULTIVI -prenat w/ fe fum-fa tab

27-1 mg & omega 3 cap 312 mg pak............................ 93PNV-SELECT -prenatal vit w/ fe fum-methylfolate-fa tab

27-0.6-0.4 mg..................................................................93PNV TABS 29-1 -prenatal vit w/ iron carbonyl-fa tab 29-1

mg....................................................................................93POCKET CHAMBER -spacer/aerosol-holding chambers -

device............................................................................ 125POCKETCHEM EZ BLOOD GLUCO -glucose blood test

strip................................................................................121POCKET SPACER -spacer/aerosol-holding chambers -

device............................................................................ 125podofilox soln 0.5% (Condylox)...................................115polyethylene glycol 3350 oral packet............................52polyethylene glycol 3350 oral powder.......................... 52polymyxin b-trimethoprim ophth soln 10000 unit/

ml-0.1% (Polytrim)...................................................... 108POMALYST -pomalidomide cap 1 mg.............................. 15POMALYST -pomalidomide cap 2 mg.............................. 15POMALYST -pomalidomide cap 3 mg.............................. 15POMALYST -pomalidomide cap 4 mg.............................. 15potassium chloride cap er 8 meq (Micro-k)..................96potassium chloride cap er 10 meq (Micro-k)................96POTASSIUM CHLORIDE ER -potassium chloride tab er 8

meq (600 mg)................................................................. 96POTASSIUM CHLORIDE ER -potassium chloride tab er

20 meq (1500 mg)..........................................................96potassium chloride microencapsulated crys er tab 10

meq................................................................................. 96

potassium chloride microencapsulated crys er tab 20meq................................................................................. 96

potassium chloride oral soln 10% (20 meq/15ml)........96potassium chloride oral soln 20% (40 meq/15ml)........97potassium chloride powder packet 20 meq................. 97potassium chloride tab er 10 meq (K-tab).................... 97potassium chloride tab er 8 meq (600 mg)...................97potassium citrate tab er 5 meq (540 mg) (Urocit-k

5)......................................................................................59potassium citrate tab er 10 meq (1080 mg) (Urocit-k

10)....................................................................................59potassium citrate tab er 15 meq (1620 mg) (Urocit-k

15)....................................................................................59pot phos monobasic w/sod phos di & monobas tab

155-852-130mg (K-phos neutral).................................96PRADAXA -dabigatran etexilate mesylate cap 75 mg

(etexilate base eq)........................................................100PRADAXA -dabigatran etexilate mesylate cap 110 mg

(etexilate base eq)........................................................100PRADAXA -dabigatran etexilate mesylate cap 150 mg

(etexilate base eq)........................................................100PRALUENT -alirocumab subcutaneous soln pen-injector

75 mg/ml......................................................................... 45PRALUENT -alirocumab subcutaneous soln pen-injector

150 mg/ml....................................................................... 45pramipexole dihydrochloride tab er 24hr 0.375 mg

(Mirapex er)....................................................................89pramipexole dihydrochloride tab er 24hr 0.75 mg



(Mirapex er)....................................................................89pramipexole dihydrochloride tab er 24hr 3 mg



(Mirapex er)....................................................................89pramipexole dihydrochloride tab 0.125 mg

(Mirapex).........................................................................89pramipexole dihydrochloride tab 0.25 mg

(Mirapex).........................................................................89pramipexole dihydrochloride tab 0.5 mg (Mirapex).....89pramipexole dihydrochloride tab 0.75 mg

(Mirapex).........................................................................89pramipexole dihydrochloride tab 1 mg (Mirapex)........89pramipexole dihydrochloride tab 1.5 mg (Mirapex).....89PRAMOSONE -pramoxine-hc cream 1-1%.................... 115PRAMOSONE -pramoxine-hc lotion 1-1%......................115PRAMOSONE -pramoxine-hc lotion 1-2.5%...................115prasugrel hcl tab 5 mg (base equiv) (Effient).............105prasugrel hcl tab 10 mg (base equiv) (Effient)...........105pravastatin sodium tab 10 mg....................................... 45pravastatin sodium tab 20 mg (Pravachol)...................45pravastatin sodium tab 40 mg (Pravachol)...................45pravastatin sodium tab 80 mg (Pravachol)...................45

2019


praziquantel tab 600 mg (Biltricide)................................ 9prazosin hcl cap 1 mg (Minipress)................................ 41prazosin hcl cap 2 mg (Minipress)................................ 41prazosin hcl cap 5 mg (Minipress)................................ 41PRECISION PCX -glucose blood test strip.....................121PRECISION PCX PLUS TEST S -glucose blood test

strip................................................................................121PRECISION POINT OF CARE T -glucose blood test

strip................................................................................121PRECISION QID TEST STRIPS -glucose blood test

strip................................................................................121PRECISION SOF-TACT TEST S -glucose blood test

strip................................................................................121PRECISION XTRA BLOOD GLUC -glucose blood test

strip................................................................................121PRED-G -gentamicin-prednisolone ace ophth susp

0.3-1%........................................................................... 108PRED-G S.O.P. -gentamicin-prednisolone ace ophth oint

0.3-0.6%........................................................................ 108PRED MILD -prednisolone acetate ophth susp

0.12%.............................................................................108PREDNICARBATE -prednicarbate cream 0.1%............. 115PREDNICARBATE -prednicarbate oint 0.1%..................115prednisolone acetate ophth susp 1% (Pred forte).....108PREDNISOLONE -prednisolone syrup 15 mg/5ml (usp

solution equivalent).........................................................17PREDNISOLONE SODIUM PHOSP -prednisolone

sodium phosphate ophth soln 1%................................108PREDNISOLONE SODIUM PHOSP -prednisolone

sodium phosphate oral soln 25 mg/5ml (base eq).........17prednisolone sod phos orally disintegr tab 10 mg

(base eq) (Orapred odt)............................................... 17prednisolone sod phos orally disintegr tab 15 mg

(base eq) (Orapred odt)............................................... 17prednisolone sod phos orally disintegr tab 30 mg

(base eq) (Orapred odt)............................................... 17prednisolone sod phosphate oral soln 15 mg/5ml

(base equiv)................................................................... 17prednisolone sod phosphate oral soln 10 mg/5ml

(base equiv) (Millipred)................................................ 17prednisolone sod phosphate oral soln 20 mg/5ml

(base equiv) (Veripred 20)........................................... 17prednisolone sod phosph oral soln 6.7 mg/5ml (5

mg/5ml base) (Pediapred)............................................17PREDNISONE INTENSOL -prednisone conc 5 mg/ml.....17PREDNISONE -prednisone oral soln 5 mg/5ml................17PREDNISONE -prednisone tab 50 mg............................. 17PREDNISONE -prednisone tab therapy pack 5 mg

(21).................................................................................. 17PREDNISONE -prednisone tab therapy pack 5 mg



(48).................................................................................. 17prednisone tab 1 mg....................................................... 17prednisone tab 2.5 mg.................................................... 17

prednisone tab 5 mg....................................................... 17prednisone tab 10 mg..................................................... 17prednisone tab 20 mg..................................................... 17PREFEST -estradiol tab 1 mg(15)/estrad-norgestimate

tab 1-0.09mg(15)............................................................ 20PREGNYL W/DILUENT BENZYL -chorionic gonadotropin

for im inj 10000 unit........................................................32PREMARIN -estrogens, conjugated tab 0.3 mg............... 20PREMARIN -estrogens, conjugated tab 0.45 mg............. 20PREMARIN -estrogens, conjugated tab 0.625 mg........... 20PREMARIN -estrogens, conjugated tab 0.9 mg............... 20PREMARIN -estrogens, conjugated tab 1.25 mg............. 20PREMARIN -estrogens, conjugated vaginal cream 0.625

mg/gm..............................................................................58PREMESISRX -prenatal w/ calcium-vit b6-vit b12-fa-

ginger tab 1 mg.............................................................. 93PREMIUM BLOOD GLUCOSE TES -glucose blood test

strip................................................................................121PREMPHASE -conj est 0.625(14)/conj est-medroxypro ac

tab 0.625-5mg(14).......................................................... 20PREMPRO -conjugated estrogen-medroxyprogest

acetate tab 0.3-1.5 mg................................................... 20PREMPRO -conjugated estrogen-medroxyprogest

acetate tab 0.45-1.5 mg................................................. 20PREMPRO -conjugated estrogen-medroxyprogest

acetate tab 0.625-2.5 mg............................................... 20PREMPRO -conjugated estrogen-medroxyprogest

acetate tab 0.625-5 mg.................................................. 20PRENA1 CHEW -prenat w/ b2-b6-b12-d3-folic acid chew

tab 1.4 mg.......................................................................94PRENAISSANCE PLUS -prenatal w/o a w/fe cbn-dss-fa-

dha cap 28-1-250 mg..................................................... 93PRENAISSANCE -prenatal w/o vit a w/ fe fum-dss-fa-dha

cap 29-1.25-325 mg....................................................... 93PRENA1 PEARL -prenat w/oa w/fefum-na fered-fa-dha

cap er 30-1.4-200 mg.....................................................94PRENATABS RX -prenatal vit w/ iron carbonyl-fa tab 29-1

mg....................................................................................93PRENATAL + DHA -prenatal w/o a w/fe fum-fa tab 27-1

mg & dha cap 250 mg................................................... 94PRENATAL PLUS IRON -prenatal vit w/ iron carbonyl-fa

tab 29-1 mg.....................................................................94PRENATAL PLUS -prenatal vit w/ fe fumarate-fa tab 27-1

mg....................................................................................94PRENATAL 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1

mg....................................................................................94PRENATAL 19 -prenatal vit w/ fe fumarate-fa chew tab

29-1 mg........................................................................... 94PRENATAL -prenatal vit w/ fe fumarate-fa tab 27-1

mg....................................................................................94PRENATAL-U -prenatal w/o a vit w/ fe fumarate-fa cap

106.5-1 mg......................................................................94PRENATAL VITAMINS PLUS LO -prenatal vit w/ fe

fumarate-fa tab 27-1 mg.................................................94PRENATA -prenatal w/o a vit w/ fe fum-fa tab chew 29-1

mg....................................................................................93

2019


PRENATE AM -prenatal w/ calcium-vit b6-vit b12-fa-ginger tab 1 mg.............................................................. 94

PRENATE DHA -prenat w/o a w/feaspg-methfol-fa-dhacap 18-0.6-0.4-300 mg................................................... 94

PRENATE ELITE -prenatal w/ fe asp gly-l methylfol-fa tab20-0.6-0.4 mg..................................................................94

PRENATE ENHANCE -prenat w/o a w/fefum-methfol-fa-dha cap 28-0.6-0.4-400 mg............................................94

PRENATE ESSENTIAL -prenat w/o a w/feaspg-methfol-fa-dha cap 18-0.6-0.4-300 mg....................................... 94

PRENATE MINI -prenat w/oa w/fecb-feasp-meth-fa-dhacap 18-0.6-0.4-350 mg................................................... 94

PRENATE PIXIE -prenat w/o a w/feaspg-methfol-fa-dhacap 10-0.6-0.4-200 mg................................................... 94

PRENATE -prenat mv & min w/ l-methylfolate-fa chew tab0.6-0.4 mg.......................................................................94

PRENATE RESTORE -prenat w/o a w/fefum-methfol-fa-dha cap 27-0.6-0.4-400 mg............................................94

PRENA 1 TRUE -prenat w/o a w/fe chel-fa tab 30-1.4 mg& dha cap 300mg pk......................................................93

PREPIDIL -dinoprostone cervical gel 0.5 mg/3gm............29PREPLUS -prenatal vit w/ fe fumarate-fa tab 27-1 mg..... 94PREPOPIK -sod picosulfate-mg oxide-citric acid pack 10

mg-3.5 gm-12 gm........................................................... 52PRESTALIA -perindopril arginine-amlodipine besylate tab

3.5-2.5 mg.......................................................................41PRESTALIA -perindopril arginine-amlodipine besylate tab

7-5 mg............................................................................. 41PRESTALIA -perindopril arginine-amlodipine besylate tab

14-10 mg......................................................................... 41PRESTIGE TEST STRIPS -glucose blood test strip.......121PRETAB -prenatal vit w/ fe fumarate-fa tab 29-1 mg........94PREVNAR 13 -pneumococcal 13-valent conjugate

vaccine inj....................................................................... 11PREVYMIS -letermovir tab 240 mg.................................... 7PREVYMIS -letermovir tab 480 mg.................................... 7PREZCOBIX -darunavir-cobicistat tab 800-150 mg............7PREZISTA -darunavir ethanolate susp 100 mg/ml (base

equiv)................................................................................. 7PREZISTA -darunavir ethanolate tab 75 mg (base




equiv)................................................................................. 7PRIFTIN -rifapentine tab 150 mg........................................ 4PRILOSEC -omeprazole magnesium for delayed release

susp packet 2.5 mg........................................................ 54PRILOSEC -omeprazole magnesium for delayed release

susp packet 10 mg......................................................... 54PRIMACARE -prenat w/o a w/feasp-methlf-fa-omeg cap

30-0.75-0.25-470mg........................................................94PRIMAQUINE PHOSPHATE -primaquine phosphate tab

26.3 mg (15 mg base)......................................................9

PRIMEAIRE DUAL-VALVED HOL -respiratory therapysupplies - devices.........................................................125

primidone tab 50 mg (Mysoline).................................... 87primidone tab 250 mg (Mysoline).................................. 87PRIMLEV -oxycodone w/ acetaminophen tab 5-300

mg....................................................................................79PRIMLEV -oxycodone w/ acetaminophen tab 7.5-300

mg....................................................................................79PRIMLEV -oxycodone w/ acetaminophen tab 10-300

mg....................................................................................79PRIMSOL -trimethoprim hcl oral soln 50 mg/5ml (base

equiv)................................................................................. 9PR NATAL 400 EC -prenat-fe bis-fe prot succ-fa-ca tab &

omega cap dr 400 pk..................................................... 93PR NATAL 430 EC -prenat-fe bis-fe prot succ-fa-ca tab &

omega cap dr 430 pk..................................................... 93PR NATAL 400 -prenat-fe bis-fe prot succ-fa-ca tab &

omega 3 cap 400 pk...................................................... 93PR NATAL 430 -prenat-fe bis-fe prot succ-fa-ca tab &

omega 3 cap 430 pk...................................................... 93PROAIR HFA -albuterol sulfate inhal aero 108 mcg/act

(90mcg base equiv)........................................................50PROAIR RESPICLICK -albuterol sulfate aer pow ba 108

mcg/act (90 mcg base equiv).........................................51probenecid tab 500 mg................................................... 84prochlorperazine maleate tab 5 mg (base

equivalent)......................................................................65prochlorperazine maleate tab 10 mg (base

equivalent)......................................................................65prochlorperazine suppos 25 mg....................................65PROCRIT -epoetin alfa inj 2000 unit/ml............................99PROCRIT -epoetin alfa inj 3000 unit/ml............................99PROCRIT -epoetin alfa inj 4000 unit/ml............................99PROCRIT -epoetin alfa inj 10000 unit/ml..........................99PROCRIT -epoetin alfa inj 20000 unit/ml..........................99PROCRIT -epoetin alfa inj 40000 unit/ml..........................99PROCTOFOAM HC -hydrocortisone acetate w/

pramoxine rectal foam 1-1%........................................ 110PROCYSBI -cysteamine bitartrate cap delayed release 25

mg (base equiv)..............................................................59PROCYSBI -cysteamine bitartrate cap delayed release 75

mg (base equiv)..............................................................59PRODIGY NO CODING BLOOD G -glucose blood test

strip................................................................................121PROFILNINE -factor ix complex for inj 500 unit............. 105PROFILNINE -factor ix complex for inj 1000 unit........... 105PROFILNINE -factor ix complex for inj 1500 unit........... 105PROFILNINE SD -factor ix complex for inj 500 unit........105PROFILNINE SD -factor ix complex for inj 1000 unit......105PROFILNINE SD -factor ix complex for inj 1500 unit......105progesterone im in oil 50 mg/ml....................................21progesterone micronized cap 100 mg

(Prometrium)..................................................................21progesterone micronized cap 200 mg

(Prometrium)..................................................................21PROGLYCEM -diazoxide susp 50 mg/ml......................... 24PROGRAF -tacrolimus cap 0.5 mg.................................126

2019


PROGRAF -tacrolimus cap 1 mg....................................126PROGRAF -tacrolimus cap 5 mg....................................126PROLENSA -bromfenac sodium ophth soln 0.07% (base

equivalent).....................................................................108PROMACTA -eltrombopag olamine tab 12.5 mg (base

equiv)...............................................................................99PROMACTA -eltrombopag olamine tab 25 mg (base



equiv)...............................................................................99promethazine & phenylephrine syrup 6.25-5

mg/5ml............................................................................ 48promethazine-dm syrup 6.25-15 mg/5ml.......................48promethazine hcl suppos 12.5 mg................................ 47promethazine hcl suppos 25 mg................................... 47promethazine hcl suppos 50 mg................................... 47promethazine hcl syrup 6.25 mg/5ml............................ 47promethazine hcl tab 12.5 mg........................................47promethazine hcl tab 25 mg...........................................47promethazine hcl tab 50 mg...........................................47promethazine-phenylephrine-codeine syrup 6.25-5-10

mg/5ml............................................................................ 48promethazine w/ codeine syrup 6.25-10 mg/5ml..........48propafenone hcl cap er 12hr 225 mg (Rythmol sr)...... 37propafenone hcl cap er 12hr 325 mg (Rythmol sr)...... 37propafenone hcl cap er 12hr 425 mg (Rythmol sr)...... 37propafenone hcl tab 150 mg.......................................... 37propafenone hcl tab 225 mg.......................................... 37propafenone hcl tab 300 mg.......................................... 37PROPANTHELINE BROMIDE -propantheline bromide tab

15 mg.............................................................................. 54proparacaine hcl ophth soln 0.5%...............................108PROPRANOLOL/HYDROCHLOROTH -propranolol &

hydrochlorothiazide tab 40-25 mg..................................41PROPRANOLOL/HYDROCHLOROTH -propranolol &

hydrochlorothiazide tab 80-25 mg..................................41propranolol hcl cap er 24hr 60 mg (Inderal la).............35propranolol hcl cap er 24hr 80 mg (Inderal la).............35propranolol hcl cap er 24hr 120 mg (Inderal la)...........35propranolol hcl cap er 24hr 160 mg (Inderal la)...........35PROPRANOLOL HCL -propranolol hcl oral soln 20

mg/5ml.............................................................................35PROPRANOLOL HCL -propranolol hcl oral soln 40

mg/5ml.............................................................................35propranolol hcl tab 10 mg.............................................. 35propranolol hcl tab 20 mg.............................................. 35propranolol hcl tab 40 mg.............................................. 35propranolol hcl tab 60 mg.............................................. 35propranolol hcl tab 80 mg.............................................. 35propylthiouracil tab 50 mg............................................. 28PROQUAD -measles-mumps-rubella-varicella virus

vaccines for susp............................................................11PROSTIN E2 -dinoprostone vaginal suppos 20 mg......... 29PROTONIX -pantoprazole sodium for delayed release

susp packet 40 mg......................................................... 54

protriptyline hcl tab 5 mg............................................... 62protriptyline hcl tab 10 mg............................................. 62PROVENTIL HFA -albuterol sulfate inhal aero 108 mcg/

act (90mcg base equiv)..................................................51PROVIDA DHA -prenat w/o a w/fe fum-fe poly-fa-dha cap

16-16-1.25-110 mg..........................................................94PROVIDA OB -prenatal w/o a w/fe fum-fe poly-fa cap

20-20-1.25 mg.................................................................94PRO VOICE V8/V9 BLOOD GLU -glucose blood test

strip................................................................................121PRUDOXIN -doxepin hcl cream 5%............................... 115pseudoephed-bromphen-dm syrup 30-2-10

mg/5ml............................................................................ 48PSORCON -diflorasone diacetate cream 0.05%............ 115PTS PANELS GLUCOSE TEST -glucose blood test

strip................................................................................121PULMICORT FLEXHALER -budesonide inhal aero powd

90 mcg/act (breath activated).........................................51PULMICORT FLEXHALER -budesonide inhal aero powd

180 mcg/act (breath activated)...................................... 51PULMONEB LT COMPRESSOR/NE -respiratory therapy

supplies - devices.........................................................125PULMOZYME -dornase alfa inhal soln 1 mg/ml............... 52PUREFE OB PLUS -prenatal w/o a w/fe fum-fe poly-fa

cap 162.115.2-1 mg........................................................94PURIXAN -mercaptopurine susp 2000 mg/100ml (20 mg/

ml)....................................................................................15PYLERA -bismuth subcit-metronidazole-tetracycline cap

140-125-125 mg..............................................................54pyrazinamide tab 500 mg..................................................4pyridostigmine bromide tab er 180 mg (Mestinon

timespan)........................................................................91pyridostigmine bromide tab 60 mg (Mestinon)............91QQBRELIS -lisinopril oral soln 1 mg/ml...............................41QNASL -beclomethasone dipropionate nasal aerosol 80

mcg/act............................................................................ 48QNASL CHILDRENS -beclomethasone dipropionate

nasal aerosol 40 mcg/act............................................... 48QSYMIA -phentermine hcl-topiramate cap er 24hr 3.75-23

mg....................................................................................70QSYMIA -phentermine hcl-topiramate cap er 24hr 7.5-46

mg....................................................................................70QSYMIA -phentermine hcl-topiramate cap er 24hr

11.25-69 mg.................................................................... 70QSYMIA -phentermine hcl-topiramate cap er 24hr 15-92

mg....................................................................................70QTERN -dapagliflozin-saxagliptin tab 10-5 mg.................24QUADRACEL -diph-tetanus tox ad-acell pert & polio

virus, ipv vac inj..............................................................11QUAKE -respiratory therapy supplies - devices..............125QUAZEPAM -quazepam tab 15 mg.................................. 66QUDEXY XR -topiramate cap er 24hr sprinkle 25 mg......87QUDEXY XR -topiramate cap er 24hr sprinkle 50 mg......87QUDEXY XR -topiramate cap er 24hr sprinkle 100

mg....................................................................................87

2019


QUDEXY XR -topiramate cap er 24hr sprinkle 150mg....................................................................................87

QUDEXY XR -topiramate cap er 24hr sprinkle 200mg....................................................................................87

quetiapine fumarate tab er 24hr 50 mg (Seroquelxr).................................................................................... 65





quetiapine fumarate tab 25 mg (Seroquel)................... 65quetiapine fumarate tab 50 mg (Seroquel)................... 65quetiapine fumarate tab 100 mg (Seroquel)................. 65quetiapine fumarate tab 200 mg (Seroquel)................. 65quetiapine fumarate tab 300 mg (Seroquel)................. 65quetiapine fumarate tab 400 mg (Seroquel)................. 65QUICKTEK TEST STRIPS -glucose blood test strip...... 121quinapril hcl tab 5 mg (Accupril)...................................41quinapril hcl tab 10 mg (Accupril).................................41quinapril hcl tab 20 mg (Accupril).................................41quinapril hcl tab 40 mg (Accupril).................................41quinapril-hydrochlorothiazide tab 10-12.5 mg

(Accuretic)......................................................................41quinapril-hydrochlorothiazide tab 20-12.5 mg

(Accuretic)......................................................................41quinapril-hydrochlorothiazide tab 20-25 mg

(Accuretic)......................................................................41quinidine gluconate tab er 324 mg................................37QUINIDINE SULFATE -quinidine sulfate tab 200 mg....... 37QUINIDINE SULFATE -quinidine sulfate tab 300 mg....... 37quinine sulfate cap 324 mg (Qualaquin).........................9QUINTET AC BLOOD GLUCOSE -glucose blood test

strip................................................................................121QUINTET BLOOD GLUCOSE TES -glucose blood test

strip................................................................................121QVAR REDIHALER -beclomethasone diprop hfa breath

act inh aer 40 mcg/act....................................................51QVAR REDIHALER -beclomethasone diprop hfa breath

act inh aer 80 mcg/act....................................................51

RRABAVERT -rabies vaccine, pcec for inj.......................... 11rabeprazole sodium ec tab 20 mg (Aciphex)................54RADIOGARDASE -prussian blue insoluble cap 0.5

gm..................................................................................117RAGWITEK -short ragweed pollen allergen extract sl tab

12 amb a 1-u.................................................................. 12raloxifene hcl tab 60 mg (Evista)...................................32ramipril cap 1.25 mg (Altace)......................................... 41ramipril cap 2.5 mg (Altace)........................................... 41ramipril cap 5 mg (Altace).............................................. 41ramipril cap 10 mg (Altace)............................................ 41RANEXA -ranolazine tab er 12hr 500 mg.........................34

RANEXA -ranolazine tab er 12hr 1000 mg.......................34ranitidine hcl cap 150 mg............................................... 54ranitidine hcl cap 300 mg............................................... 54ranitidine hcl syrup 15 mg/ml (75 mg/5ml)................... 54ranitidine hcl tab 150 mg (Zantac).................................54ranitidine hcl tab 300 mg (Zantac).................................54RAPAFLO -silodosin cap 4 mg..........................................59RAPAFLO -silodosin cap 8 mg..........................................59RAPAMUNE -sirolimus oral soln 1 mg/ml.......................126rasagiline mesylate tab 0.5 mg (base equiv)

(Azilect)...........................................................................89rasagiline mesylate tab 1 mg (base equiv)

(Azilect)...........................................................................89RASUVO -methotrexate soln pf auto-injector 7.5

mg/0.15ml........................................................................82RASUVO -methotrexate soln pf auto-injector 10

mg/0.2ml..........................................................................82RASUVO -methotrexate soln pf auto-injector 12.5






mg/0.5ml..........................................................................83RASUVO -methotrexate soln pf auto-injector 30

mg/0.6ml..........................................................................83RA TRUETEST STRIPS -glucose blood test strip..........121RAVICTI -glycerol phenylbutyrate liquid 1.1 gm/ml...........32RAYALDEE -calcifediol cap er 30 mcg............................. 32RAYOS -prednisone tab delayed release 1 mg................ 17RAYOS -prednisone tab delayed release 2 mg................ 17RAYOS -prednisone tab delayed release 5 mg................ 17REBETOL -ribavirin soln 40 mg/ml..................................... 7REBIF -interferon beta-1a soln pref syr 22 mcg/0.5ml

(12mu/ml)........................................................................ 73REBIF -interferon beta-1a soln pref syr 44 mcg/0.5ml

(24mu/ml)........................................................................ 73REBIF REBIDOSE -interferon beta-1a soln auto-inj 22

mcg/0.5ml (12mu/ml)...................................................... 73REBIF REBIDOSE -interferon beta-1a soln auto-inj 44

mcg/0.5ml (24mu/ml)...................................................... 73REBIF REBIDOSE TITRATION -interferon beta-1a auto-

inj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml..........................73REBIF TITRATION PACK -interferon beta-1a pref syr

6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml...............................73REBINYN -coagulation factor ix recomb glycopegylated

for inj 500 unt................................................................105REBINYN -coagulation factor ix recomb glycopegylated

for inj 1000 unt..............................................................105REBINYN -coagulation factor ix recomb glycopegylated

for inj 2000 unt..............................................................105

2019


RECOMBINATE -antihemophilic factor (recombinant) forinj 220-400 unit............................................................. 105

RECOMBINATE -antihemophilic factor (recombinant) forinj 401-800 unit............................................................. 105

RECOMBINATE -antihemophilic factor (recombinant) forinj 801-1240 unit...........................................................105

RECOMBINATE -antihemophilic factor (recombinant) forinj 1241-1800 unit.........................................................105

RECOMBINATE -antihemophilic factor (recombinant) forinj 1801-2400 unit.........................................................105

RECOMBIVAX HB -hepatitis b vaccine (recombinant)susp 5 mcg/0.5ml........................................................... 11

RECOMBIVAX HB -hepatitis b vaccine (recombinant)susp 10 mcg/ml.............................................................. 11

RECOMBIVAX HB -hepatitis b vaccine (recombinant)susp 40 mcg/ml.............................................................. 11

RECOTHROM SPRAY KIT -thrombin (recombinant) forsoln 20000 unit............................................................. 101

RECOTHROM -thrombin (recombinant) for soln 5000unit................................................................................. 101

RECOTHROM -thrombin (recombinant) for soln 20000unit................................................................................. 101

RECTIV -nitroglycerin oint 0.4%..................................... 110REFUAH PLUS BLOOD GLUCOSE -glucose blood test

strip................................................................................121REGIMEX -benzphetamine hcl tab 25 mg........................70REGRANEX -becaplermin gel 0.01%............................. 115RELENZA DISKHALER -zanamivir aero powder breath

activated 5 mg/blister........................................................7RELION BLOOD GLUCOSE TEST -glucose blood test

strip................................................................................121RELION CONFIRM/MICRO TEST -glucose blood test

strip................................................................................121RELION PREMIER BLOOD GLUC -glucose blood test

strip................................................................................121RELION PRIME BLOOD GLUCOS -glucose blood test

strip................................................................................121RELION ULTIMA BLOOD GLUCO -glucose blood test

strip................................................................................121RELION ULTIMA TEST STRIPS -glucose blood test

strip................................................................................121RELISTOR -methylnaltrexone bromide inj 8 mg/0.4ml (20

mg/ml)..............................................................................56RELISTOR -methylnaltrexone bromide inj 12 mg/0.6ml

(20 mg/ml).......................................................................56RELISTOR -methylnaltrexone bromide tab 150 mg......... 57RELNATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap

28-1-200 mg....................................................................94RENAGEL -sevelamer hcl tab 800 mg............................. 57REPAGLINIDE/METFORMIN HYD -repaglinide-metformin

hcl tab 1-500 mg.............................................................25REPAGLINIDE/METFORMIN HYD -repaglinide-metformin

hcl tab 2-500 mg.............................................................25repaglinide tab 0.5 mg.................................................... 24repaglinide tab 1 mg (Prandin)...................................... 24repaglinide tab 2 mg (Prandin)...................................... 24

REPATHA -evolocumab subcutaneous soln prefilledsyringe 140 mg/ml.......................................................... 45

REPATHA PUSHTRONEX SYSTEM -evolocumabsubcutaneous soln cartridge/infusor 420 mg/3.5ml....... 45

REPATHA SURECLICK -evolocumab subcutaneous solnauto-injector 140 mg/ml..................................................45

RESCRIPTOR -delavirdine mesylate tab 100 mg.............. 7RESCRIPTOR -delavirdine mesylate tab 200 mg.............. 7RESTASIS -cyclosporine (ophth) emulsion 0.05%......... 108RESTASIS MULTIDOSE -cyclosporine (ophth) emulsion

0.05%.............................................................................108RETACRIT -epoetin alfa-epbx inj 2000 unit/ml................. 99RETACRIT -epoetin alfa-epbx inj 3000 unit/ml................. 99RETACRIT -epoetin alfa-epbx inj 4000 unit/ml................. 99RETACRIT -epoetin alfa-epbx inj 10000 unit/ml............... 99RETACRIT -epoetin alfa-epbx inj 40000 unit/ml............... 99RETIN-A MICRO PUMP -tretinoin microsphere gel

0.08%.............................................................................115RETIN-A MICRO -tretinoin microsphere gel 0.06%........115REVATIO -sildenafil citrate for suspension 10 mg/ml....... 46REVEAL BLOOD GLUCOSE TEST -glucose blood test

strip................................................................................121REVLIMID -lenalidomide cap 5 mg.................................126REVLIMID -lenalidomide cap 10 mg...............................126REVLIMID -lenalidomide cap 15 mg...............................126REVLIMID -lenalidomide cap 20 mg...............................126REVLIMID -lenalidomide cap 25 mg...............................126REVLIMID -lenalidomide caps 2.5 mg............................ 126REXALL BLOOD GLUCOSE TEST -glucose blood test

strip................................................................................121REXULTI -brexpiprazole tab 0.25 mg............................... 65REXULTI -brexpiprazole tab 0.5 mg................................. 65REXULTI -brexpiprazole tab 1 mg.................................... 65REXULTI -brexpiprazole tab 2 mg.................................... 65REXULTI -brexpiprazole tab 3 mg.................................... 65REXULTI -brexpiprazole tab 4 mg.................................... 65REYATAZ -atazanavir sulfate oral powder packet 50 mg

(base equiv)...................................................................... 7RHOFADE -oxymetazoline hcl cream 1%.......................115RHOPRESSA -netarsudil dimesylate ophth soln

0.02%.............................................................................108RIASTAP -fibrinogen conc (human) inj approximately 1

gm (900-1300 mg)........................................................105RIBASPHERE RIBAPAK -ribavirin tab 400 mg...................7RIBASPHERE RIBAPAK -ribavirin tab 600 mg...................7RIBASPHERE RIBAPAK -ribavirin tab 200 mg & ribavirin

400 mg tab therapy pack................................................. 7RIBASPHERE RIBAPAK -ribavirin tab 400 mg & ribavirin

600 mg tab therapy pack................................................. 7RIBASPHERE -ribavirin tab 400 mg................................... 7RIBASPHERE -ribavirin tab 600 mg................................... 7ribavirin cap 200 mg (Rebetol).........................................7ribavirin for inhal soln 6 gm (Virazole)........................... 7ribavirin tab 200 mg (Copegus)....................................... 7RIDAURA -auranofin cap 3 mg.........................................83rifabutin cap 150 mg (Mycobutin)....................................4RIFAMATE -isoniazid & rifampin cap 150-300 mg..............4

2019


rifampin cap 300 mg..........................................................4rifampin cap 150 mg (Rifadin)..........................................4RIFATER -isoniazid-rifampin w/ pyrazinamide tab

50-120-300 mg..................................................................4RIGHTEST GS100 BLOOD GLUC -glucose blood test

strip................................................................................121RIGHTEST GS300 BLOOD GLUC -glucose blood test

strip................................................................................121RIGHTEST GS550 BLOOD GLUC -glucose blood test

strip................................................................................121riluzole tab 50 mg (Rilutek)............................................ 90rimantadine hydrochloride tab 100 mg (Flumadine)..... 7RIOMET -metformin hcl oral soln 500 mg/5ml..................25risedronate sodium tab delayed release 35 mg

(Atelvia).......................................................................... 32risedronate sodium tab 5 mg (Actonel)........................ 32risedronate sodium tab 30 mg (Actonel)...................... 32risedronate sodium tab 35 mg (Actonel)...................... 32risedronate sodium tab 150 mg (Actonel).................... 32RISPERIDONE ODT -risperidone orally disintegrating tab

0.25 mg........................................................................... 65risperidone orally disintegrating tab 0.5 mg (Risperdal

m-tab)..............................................................................65risperidone orally disintegrating tab 1 mg (Risperdal




m-tab)..............................................................................65risperidone soln 1 mg/ml (Risperdal)............................65risperidone tab 0.25 mg (Risperdal)..............................65risperidone tab 0.5 mg (Risperdal)................................65risperidone tab 1 mg (Risperdal)...................................65risperidone tab 2 mg (Risperdal)...................................65risperidone tab 3 mg (Risperdal)...................................65risperidone tab 4 mg (Risperdal)...................................65RITEFLO -spacer/aerosol-holding chambers -

device............................................................................ 125ritonavir tab 100 mg (Norvir)............................................7rivastigmine tartrate cap 1.5 mg (base equivalent)..... 73rivastigmine tartrate cap 3 mg (base equivalent)........ 73rivastigmine tartrate cap 4.5 mg (base equivalent)..... 73rivastigmine tartrate cap 6 mg (base equivalent)........ 73rivastigmine td patch 24hr 4.6 mg/24hr (Exelon).........73rivastigmine td patch 24hr 9.5 mg/24hr (Exelon).........73rivastigmine td patch 24hr 13.3 mg/24hr (Exelon).......73RIXUBIS -coagulation factor ix (recombinant) for inj 250

unit................................................................................. 105RIXUBIS -coagulation factor ix (recombinant) for inj 500



unit................................................................................. 105

RIXUBIS -coagulation factor ix (recombinant) for inj 3000unit................................................................................. 105

rizatriptan benzoate oral disintegrating tab 5 mg (baseeq) (Maxalt-mlt)............................................................. 84

rizatriptan benzoate oral disintegrating tab 10 mg(base eq) (Maxalt-mlt).................................................. 84

rizatriptan benzoate tab 5 mg (base equivalent)(Maxalt)........................................................................... 84

rizatriptan benzoate tab 10 mg (base equivalent)(Maxalt)........................................................................... 84

R-NATAL OB -prenatal w/o a w/fe cbn-fa-dha cap20-1-320 mg....................................................................94

ropinirole hydrochloride tab er 24hr 2 mg (baseequivalent) (Requip xl).................................................89





ropinirole hydrochloride tab 0.25 mg (Requip)............90ropinirole hydrochloride tab 0.5 mg (Requip)..............90ropinirole hydrochloride tab 1 mg (Requip).................90ropinirole hydrochloride tab 2 mg (Requip).................90ropinirole hydrochloride tab 3 mg (Requip).................90ropinirole hydrochloride tab 4 mg (Requip).................90ropinirole hydrochloride tab 5 mg (Requip).................90rosuvastatin calcium tab 5 mg (Crestor)...................... 45rosuvastatin calcium tab 10 mg (Crestor).................... 45rosuvastatin calcium tab 20 mg (Crestor).................... 45rosuvastatin calcium tab 40 mg (Crestor).................... 45ROTARIX -rotavirus vaccine, live for oral susp.................11ROTATEQ -rotavirus vaccine, live oral pentavalent

soln.................................................................................. 11ROXYBOND -oxycodone hcl tab abuse deter 5 mg......... 79ROXYBOND -oxycodone hcl tab abuse deter 15 mg....... 79ROXYBOND -oxycodone hcl tab abuse deter 30 mg....... 79ROZEREM -ramelteon tab 8 mg.......................................66RUBRACA -rucaparib camsylate tab 200 mg (base

equivalent).......................................................................15RUBRACA -rucaparib camsylate tab 250 mg (base

equivalent).......................................................................15RUBRACA -rucaparib camsylate tab 300 mg (base

equivalent).......................................................................15RUCONEST -c1 esterase inhibitor (recombinant) for iv inj

2100 unit....................................................................... 106RYDAPT -midostaurin cap 25 mg.....................................15RYTARY -carbidopa & levodopa cap er 23.75-95 mg.......90RYTARY -carbidopa & levodopa cap er 36.25-145

mg....................................................................................90RYTARY -carbidopa & levodopa cap er 48.75-195

mg....................................................................................90RYTARY -carbidopa & levodopa cap er 61.25-245

mg....................................................................................90

2019


SSABRIL -vigabatrin tab 500 mg........................................ 87SAIZENPREP RECONSTITUTION -somatropin (non-

refrigerated) for inj 8.8 mg..............................................32SAIZEN -somatropin (non-refrigerated) for inj 5 mg......... 32SAIZEN -somatropin (non-refrigerated) for inj 8.8 mg...... 32SAMSCA -tolvaptan tab 15 mg......................................... 32SAMSCA -tolvaptan tab 30 mg......................................... 32SANCUSO -granisetron td patch 3.1 mg/24hr (contains

34.3 mg).......................................................................... 55SANDIMMUNE -cyclosporine cap 25 mg....................... 126SANDIMMUNE -cyclosporine cap 100 mg..................... 126SANDIMMUNE -cyclosporine oral soln 100 mg/ml.........127SANTYL -collagenase oint 250 unit/gm.......................... 115SAPHRIS -asenapine maleate sl tab 2.5 mg (base

equiv)...............................................................................65SAPHRIS -asenapine maleate sl tab 5 mg (base

equiv)...............................................................................65SAPHRIS -asenapine maleate sl tab 10 mg (base

equiv)...............................................................................65SAVAYSA -edoxaban tosylate tab 15 mg (base

equivalent).....................................................................100SAVAYSA -edoxaban tosylate tab 30 mg (base

equivalent).....................................................................100SAVAYSA -edoxaban tosylate tab 60 mg (base

equivalent).....................................................................100SAVELLA -milnacipran hcl tab 12.5 mg............................73SAVELLA -milnacipran hcl tab 25 mg...............................73SAVELLA -milnacipran hcl tab 50 mg...............................73SAVELLA -milnacipran hcl tab 100 mg.............................73SAVELLA TITRATION PACK -milnacipran hcl tab 12.5 mg

(5) & 25 mg (8) & 50 mg (42) pak................................. 73SAXENDA -liraglutide (weight mngmt) soln pen-inj 18

mg/3ml (6 mg/ml)............................................................70SECONAL SODIUM -secobarbital sodium cap 100

mg....................................................................................66SEEBRI NEOHALER -glycopyrrolate inhal cap 15.6

mcg.................................................................................. 51SEGLUROMET -ertugliflozin-metformin hcl tab 2.5-1000

mg....................................................................................25SEGLUROMET -ertugliflozin-metformin hcl tab 2.5-500



mg....................................................................................25SELECT-OB+DHA -prenatal mv w/fe poly-fa chw 29-1 mg

& dha cap 250 mg pak...................................................94SELECT-OB -prenatal vit w/ fe polysac cmplx-fa chew tab

29-1 mg........................................................................... 94SELECT-OB -prenat w/ fepolycmplx-methylfol-fa chew

tab 29-0.6-0.4 mg........................................................... 94selegiline hcl cap 5 mg (Eldepryl)................................. 90selegiline hcl tab 5 mg....................................................90selenium sulfide lotion 2.5%........................................ 115SELZENTRY -maraviroc oral soln 20 mg/ml...................... 7

SELZENTRY -maraviroc tab 25 mg....................................7SELZENTRY -maraviroc tab 75 mg....................................7SELZENTRY -maraviroc tab 150 mg..................................7SELZENTRY -maraviroc tab 300 mg..................................7SEMPREX-D -acrivastine & pseudoephedrine cap 8-60

mg....................................................................................48SE-NATAL 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1

mg....................................................................................94SE-NATAL 19 -prenatal vit w/ fe fumarate-fa chew tab

29-1 mg........................................................................... 94SENSIPAR -cinacalcet hcl tab 30 mg (base equiv).......... 32SENSIPAR -cinacalcet hcl tab 60 mg (base equiv).......... 32SENSIPAR -cinacalcet hcl tab 90 mg (base equiv).......... 32SEREVENT DISKUS -salmeterol xinafoate aer pow ba 50

mcg/dose (base equiv)................................................... 51SERNIVO -betamethasone dipropionate spray emulsion

0.05% (base equiv).......................................................115SEROSTIM -somatropin (non-refrigerated) for

subcutaneous inj 4 mg................................................... 32SEROSTIM -somatropin (non-refrigerated) for

subcutaneous inj 5 mg................................................... 32SEROSTIM -somatropin (non-refrigerated) for

subcutaneous inj 6 mg................................................... 32sertraline hcl oral concentrate for solution 20 mg/ml

(Zoloft)............................................................................ 62sertraline hcl tab 25 mg (Zoloft).................................... 62sertraline hcl tab 50 mg (Zoloft).................................... 62sertraline hcl tab 100 mg (Zoloft).................................. 62sevelamer carbonate packet 0.8 gm (Renvela)............ 57sevelamer carbonate packet 2.4 gm (Renvela)............ 57sevelamer carbonate tab 800 mg (Renvela)................. 57SFROWASA -mesalamine sulfite-free (sf) enema 4

gm/60ml...........................................................................57SHINGRIX -zoster vac recombinant adjuvanted for im inj

50 mcg/0.5ml.................................................................. 11SHUR-SEAL -nonoxynol-9 gel 2%....................................58SIGNIFOR -pasireotide diaspartate inj 0.3 mg/ml (base

equiv)...............................................................................32SIGNIFOR -pasireotide diaspartate inj 0.6 mg/ml (base

equiv)...............................................................................32SIGNIFOR -pasireotide diaspartate inj 0.9 mg/ml (base

equiv)...............................................................................32SIKLOS -hydroxyurea tab 100 mg.................................... 99sildenafil citrate tab 20 mg (Revatio)............................ 46sildenafil citrate tab 25 mg (Viagra).............................. 47sildenafil citrate tab 50 mg (Viagra).............................. 47sildenafil citrate tab 100 mg (Viagra)............................ 47SILENOR -doxepin hcl (sleep) tab 3 mg (base equiv)......66SILENOR -doxepin hcl (sleep) tab 6 mg (base equiv)......66SILIQ -brodalumab subcutaneous soln prefilled syringe

210 mg/1.5ml................................................................ 115silver sulfadiazine cream 1% (Silvadene)................... 115SIMBRINZA -brinzolamide-brimonidine tartrate ophth

susp 1-0.2%.................................................................. 109SIMPONI -golimumab subcutaneous soln auto-injector 50

mg/0.5ml..........................................................................83

2019


SIMPONI -golimumab subcutaneous soln auto-injector100 mg/ml....................................................................... 83

SIMPONI -golimumab subcutaneous soln prefilled syringe50 mg/0.5ml.................................................................... 83

SIMPONI -golimumab subcutaneous soln prefilled syringe100 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)............................... 127sirolimus tab 1 mg (Rapamune).................................. 127sirolimus tab 2 mg (Rapamune).................................. 127SIRTURO -bedaquiline fumarate tab 100 mg (base

equiv)................................................................................. 4SITAVIG -acyclovir buccal tab 50 mg..................................7SIVEXTRO -tedizolid phosphate tab 200 mg......................9SKLICE -ivermectin lotion 0.5%...................................... 116SMARTEST BLOOD GLUCOSE TE -glucose blood test

strip................................................................................121SMART SENSE PREMIUM BLOOD -glucose blood test

strip................................................................................121SMART SENSE VALUE BLOOD G -glucose blood test

strip................................................................................121sodium citrate & citric acid soln 500-334 mg/5ml

(Shohls solution modi)................................................ 59sodium fluoride chew tab 0.25 mg f (from 0.55 mg

naf).................................................................................. 97sodium fluoride chew tab 0.5 mg f (from 1.1 mg

naf).................................................................................. 97sodium fluoride chew tab 1 mg f (from 2.2 mg naf).....97sodium fluoride cream 1.1% (Prevident 5000

plus).............................................................................. 110sodium fluoride gel 1.1% (0.5% f) (Prevident

fluoride)........................................................................ 110sodium fluoride paste 1.1% (Prevident 5000

boost)............................................................................110sodium fluoride-potassium nitrate paste 1.1-5%

(Prevident 5000 sensi)............................................... 110sodium fluoride rinse 0.2%...........................................110SODIUM FLUORIDE -sodium fluoride tab 0.5 mg f (from

1.1 mg naf)......................................................................97SODIUM FLUORIDE -sodium fluoride tab 1 mg f (from

2.2 mg naf)......................................................................97sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop

naf).................................................................................. 97sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml

naf).................................................................................. 97sodium phenylbutyrate oral powder 3 gm/teaspoonful

(Buphenyl)......................................................................32sodium phenylbutyrate tab 500 mg (Buphenyl)...........32sodium polystyrene sulfonate oral susp 15

gm/60ml........................................................................127sodium polystyrene sulfonate powder

(Kayexalate)................................................................. 127

sodium polystyrene sulfonate rectal susp 30gm/120ml......................................................................127

SOLIQUA 100/33 -insulin glargine-lixisenatide sol pen-inj100-33 unit-mcg/ml......................................................... 25

SOLODYN -minocycline hcl tab er 24hr 55 mg.................. 3SOLODYN -minocycline hcl tab er 24hr 80 mg.................. 3SOLODYN -minocycline hcl tab er 24hr 105 mg................ 3SOLOSEC -secnidazole granules packet 2 gm..................9SOLTAMOX -tamoxifen citrate oral soln 10 mg/5ml (base

equivalent).......................................................................15SOLUS V2 AUDIBLE TEST -glucose blood test strip.....121SOMA -carisoprodol tab 250 mg.......................................91SOMA -carisoprodol tab 350 mg.......................................91SOMAVERT -pegvisomant for inj 10 mg (as protein)....... 33SOMAVERT -pegvisomant for inj 15 mg (as protein)....... 33SOMAVERT -pegvisomant for inj 20 mg (as protein)....... 33SOMAVERT -pegvisomant for inj 25 mg (as protein)....... 33SOMAVERT -pegvisomant for inj 30 mg (as protein)....... 33SOOLANTRA -ivermectin cream 1%.............................. 116SORILUX -calcipotriene foam 0.005%............................116sotalol hcl (afib/afl) tab 80 mg (Betapace af)................35sotalol hcl (afib/afl) tab 120 mg (Betapace af)..............35sotalol hcl (afib/afl) tab 160 mg (Betapace af)..............35sotalol hcl tab 240 mg.....................................................35sotalol hcl tab 80 mg (Betapace)...................................35sotalol hcl tab 120 mg (Betapace).................................35sotalol hcl tab 160 mg (Betapace).................................35SOTYLIZE -sotalol hcl oral solution 5 mg/ml.................... 35SOVALDI -sofosbuvir tab 400 mg....................................... 7SPECTRACEF -cefditoren pivoxil tab 400 mg (base

equivalent)......................................................................... 2SPINOSAD -spinosad susp 0.9%................................... 116SPIRIVA HANDIHALER -tiotropium bromide monohydrate

inhal cap 18 mcg (base equiv).......................................51SPIRIVA RESPIMAT -tiotropium bromide monohydrate

inhal aerosol 1.25 mcg/act............................................. 51SPIRIVA RESPIMAT -tiotropium bromide monohydrate

inhal aerosol 2.5 mcg/act............................................... 51spironolactone & hydrochlorothiazide tab 25-25 mg

(Aldactazide).................................................................. 43spironolactone tab 25 mg (Aldactone)..........................43spironolactone tab 50 mg (Aldactone)..........................43spironolactone tab 100 mg (Aldactone)........................43SPIRO PD -respiratory therapy supplies - devices.........125SPORANOX -itraconazole oral soln 10 mg/ml....................5SPRITAM -levetiracetam tab disintegrating soluble 250

mg....................................................................................87SPRITAM -levetiracetam tab disintegrating soluble 500



mg....................................................................................87SPRIX -ketorolac tromethamine nasal spray 15.75 mg/

spray................................................................................83SPRYCEL -dasatinib tab 20 mg........................................15SPRYCEL -dasatinib tab 50 mg........................................15

2019


SPRYCEL -dasatinib tab 70 mg........................................15SPRYCEL -dasatinib tab 80 mg........................................15SPRYCEL -dasatinib tab 100 mg......................................15SPRYCEL -dasatinib tab 140 mg......................................15STALEVO 100 -carbidopa-levodopa-entacapone tabs

25-100-200 mg................................................................90STALEVO 125 -carbidopa-levodopa-entacapone tabs

31.25-125-200 mg.......................................................... 90STALEVO 150 -carbidopa-levodopa-entacapone tabs

37.5-150-200 mg.............................................................90STALEVO 200 -carbidopa-levodopa-entacapone tabs

50-200-200 mg................................................................90STALEVO 50 -carbidopa-levodopa-entacapone tabs

12.5-50-200 mg...............................................................90STALEVO 75 -carbidopa-levodopa-entacapone tabs

18.75-75-200 mg.............................................................90stannous fluoride conc 0.63% (Gel-kam oral care

ri)................................................................................... 110stannous fluoride gel 0.4%...........................................110stavudine cap 15 mg (Zerit)..............................................7stavudine cap 20 mg (Zerit)..............................................8stavudine cap 30 mg (Zerit)..............................................8stavudine cap 40 mg (Zerit)..............................................8STAXYN -vardenafil hcl orally disintegrating tab 10

mg....................................................................................47STEGLATRO -ertugliflozin l-pyroglutamic acid tab 5 mg

(base equiv).................................................................... 25STEGLATRO -ertugliflozin l-pyroglutamic acid tab 15 mg

(base equiv).................................................................... 25STEGLUJAN -ertugliflozin-sitagliptin tab 5-100 mg..........25STEGLUJAN -ertugliflozin-sitagliptin tab 15-100 mg........25STELARA -ustekinumab inj 45 mg/0.5ml........................116STELARA -ustekinumab soln prefilled syringe 45

mg/0.5ml........................................................................116STELARA -ustekinumab soln prefilled syringe 90 mg/

ml................................................................................... 116STENDRA -avanafil tab 50 mg......................................... 47STENDRA -avanafil tab 100 mg....................................... 47STENDRA -avanafil tab 200 mg....................................... 47STIMATE -desmopressin acetate nasal soln 1.5 mg/

ml..................................................................................... 33STIOLTO RESPIMAT -tiotropium br-olodaterol inhal aero

soln 2.5-2.5 mcg/act....................................................... 51STIVARGA -regorafenib tab 40 mg...................................15STRENSIQ -asfotase alfa subcutaneous inj 18

mg/0.45ml........................................................................33STRENSIQ -asfotase alfa subcutaneous inj 28

mg/0.7ml..........................................................................33STRENSIQ -asfotase alfa subcutaneous inj 40 mg/ml..... 33STRENSIQ -asfotase alfa subcutaneous inj 80

mg/0.8ml..........................................................................33STRIANT -testosterone buccal mucoadhesive system 30

mg....................................................................................18STRIBILD -elvitegrav-cobic-emtricitab-tenofovdf tab

150-150-200-300 mg........................................................ 8STRIVERDI RESPIMAT -olodaterol hcl inhal aerosol soln

2.5 mcg/act (base equiv)................................................51

SUBOXONE -buprenorphine hcl-naloxone hcl sl film 2-0.5mg (base equiv)..............................................................79

SUBOXONE -buprenorphine hcl-naloxone hcl sl film 4-1mg (base equiv)..............................................................79



SUBSYS -fentanyl sublingual spray 100 mcg...................79SUBSYS -fentanyl sublingual spray 200 mcg...................79SUBSYS -fentanyl sublingual spray 400 mcg...................79SUBSYS -fentanyl sublingual spray 600 mcg...................79SUBSYS -fentanyl sublingual spray 800 mcg...................79SUBSYS -fentanyl sublingual spray 1200 mcg (600 mcg x

2)......................................................................................79SUBSYS -fentanyl sublingual spray 1600 mcg (800 mcg x

2)......................................................................................79SUCRAID -sacrosidase soln 8500 unit/ml........................ 55sucralfate tab 1 gm (Carafate)....................................... 54sulfacetamide sodium lotion 10% (acne) (Klaron).....116sulfacetamide sodium ophth soln 10%

(Bleph-10).....................................................................109sulfacetamide sodium-prednisolone ophth soln

10-0.23(0.25)%............................................................. 109SULFACETAMIDE SODIUM -sulfacetamide sodium ophth

oint 10%........................................................................ 109SULFADIAZINE -sulfadiazine tab 500 mg.......................... 4sulfamethoxazole-trimethoprim susp 200-40

mg/5ml.............................................................................. 9sulfamethoxazole-trimethoprim tab 400-80 mg

(Bactrim)...........................................................................9sulfamethoxazole-trimethoprim tab 800-160 mg

(Bactrim ds)..................................................................... 9SULFAMYLON -mafenide acetate cream 85 mg/gm......116sulfasalazine tab delayed release 500 mg (Azulfidine

en-tabs)...........................................................................57sulfasalazine tab 500 mg (Azulfidine)........................... 57sulindac tab 150 mg........................................................ 83sulindac tab 200 mg........................................................ 83sumatriptan-naproxen sodium tab 85-500 mg

(Treximet)....................................................................... 84sumatriptan 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)................................. 84sumatriptan succinate solution auto-injector 6

mg/0.5ml (Imitrex statdose sys)................................. 84sumatriptan succinate solution cartridge 4 mg/0.5ml

(Imitrex statdose ref)....................................................84sumatriptan succinate solution cartridge 6 mg/0.5ml

(Imitrex statdose ref)....................................................84sumatriptan succinate tab 25 mg (Imitrex)...................84sumatriptan succinate tab 50 mg (Imitrex)...................84sumatriptan succinate tab 100 mg (Imitrex).................84SUPRAX -cefixime cap 400 mg.......................................... 2SUPRAX -cefixime chew tab 100 mg................................. 2

2019


SUPRAX -cefixime chew tab 200 mg................................. 2SUPRAX -cefixime for susp 500 mg/5ml............................ 2SUPREME TEST STRIPS -glucose blood test strip.......121SUPREP BOWEL PREP KIT -sod sulfate-pot sulf-mg sulf

oral sol 17.5-3.13-1.6 gm/177ml.................................... 52SURECHEK BLOOD GLUCOSE TE -glucose blood test

strip................................................................................121SURE EDGE BLOOD GLUCOSE T -glucose blood test

strip................................................................................121SURE-TEST EASYPLUS MINI B -glucose blood test

strip................................................................................121SUTENT -sunitinib malate cap 12.5 mg (base

equivalent).......................................................................15SUTENT -sunitinib malate cap 25 mg (base

equivalent).......................................................................15SUTENT -sunitinib malate cap 37.5 mg (base

equivalent).......................................................................15SUTENT -sunitinib malate cap 50 mg (base

equivalent).......................................................................15SYLATRON -peginterferon alfa-2b for inj kit 200 mcg...... 15SYLATRON -peginterferon alfa-2b for inj kit 300 mcg...... 15SYLATRON -peginterferon alfa-2b for inj kit 600 mcg...... 15SYMBICORT -budesonide-formoterol fumarate dihyd

aerosol 80-4.5 mcg/act...................................................51SYMBICORT -budesonide-formoterol fumarate dihyd

aerosol 160-4.5 mcg/act.................................................51SYMDEKO -tezacaftor-ivacaftor 100-150 mg & ivacaftor

150 mg tab tbpk..............................................................52SYMFI -efavirenz-lamivudine-tenofovir df tab

600-300-300 mg................................................................8SYMFI LO -efavirenz-lamivudine-tenofovir df tab

400-300-300 mg................................................................8SYMLINPEN 120 -pramlintide acetate pen-inj 2700

mcg/2.7ml (1000 mcg/ml)...............................................25SYMLINPEN 60 -pramlintide acetate pen-inj 1500

mcg/1.5ml (1000 mcg/ml)...............................................25SYMPROIC -naldemedine tosylate tab 0.2 mg (base

equivalent).......................................................................57SYMTUZA -darunavir-cobic-emtricitab-tenofov af tab

800-150-200-10 mg.......................................................... 8SYNAREL -nafarelin acetate nasal soln 2 mg/ml (200

mcg/act) (base eq)..........................................................33SYNDROS -dronabinol soln 5 mg/ml................................55SYNERA -lidocaine-tetracaine topical patch 70-70

mg..................................................................................116SYNJARDY -empagliflozin-metformin hcl tab 12.5-1000

mg....................................................................................25SYNJARDY -empagliflozin-metformin hcl tab 12.5-500

mg....................................................................................25SYNJARDY -empagliflozin-metformin hcl tab 5-500

mg....................................................................................25SYNJARDY -empagliflozin-metformin hcl tab 5-1000

mg....................................................................................25SYNJARDY XR -empagliflozin-metformin hcl tab er 24hr

5-1000 mg.......................................................................25SYNJARDY XR -empagliflozin-metformin hcl tab er 24hr

10-1000 mg.....................................................................25

SYNJARDY XR -empagliflozin-metformin hcl tab er 24hr12.5-1000 mg..................................................................25

SYNJARDY XR -empagliflozin-metformin hcl tab er 24hr25-1000 mg.....................................................................25

SYNRIBO -omacetaxine mepesuccinate for inj 3.5mg....................................................................................15

SYNTHROID -levothyroxine sodium tab 25 mcg..............28SYNTHROID -levothyroxine sodium tab 50 mcg..............28SYNTHROID -levothyroxine sodium tab 75 mcg..............28SYNTHROID -levothyroxine sodium tab 88 mcg..............28SYNTHROID -levothyroxine sodium tab 100 mcg............28SYNTHROID -levothyroxine sodium tab 112 mcg............ 28SYNTHROID -levothyroxine sodium tab 125 mcg............28SYNTHROID -levothyroxine sodium tab 137 mcg............28SYNTHROID -levothyroxine sodium tab 150 mcg............28SYNTHROID -levothyroxine sodium tab 175 mcg............28SYNTHROID -levothyroxine sodium tab 200 mcg............28SYNTHROID -levothyroxine sodium tab 300 mcg............28

TTABLOID -thioguanine tab 40 mg..................................... 15TACLONEX -calcipotriene-betamethasone dipropionate

susp 0.005-0.064%.......................................................116tacrolimus cap 0.5 mg (Prograf).................................. 127tacrolimus cap 1 mg (Prograf)..................................... 127tacrolimus cap 5 mg (Prograf)..................................... 127tacrolimus oint 0.03% (Protopic)................................. 116tacrolimus oint 0.1% (Protopic)................................... 116tadalafil tab 2.5 mg (Cialis).............................................47tadalafil tab 5 mg (Cialis)................................................47tadalafil tab 10 mg (Cialis)..............................................47tadalafil tab 20 mg (Cialis)..............................................47tadalafil tab 20 mg (pah) (Adcirca)................................ 46TAFINLAR -dabrafenib mesylate cap 50 mg (base

equivalent).......................................................................15TAFINLAR -dabrafenib mesylate cap 75 mg (base

equivalent).......................................................................15TAGRISSO -osimertinib mesylate tab 40 mg (base

equivalent).......................................................................15TAGRISSO -osimertinib mesylate tab 80 mg (base

equivalent).......................................................................15TALTZ -ixekizumab subcutaneous soln auto-injector 80

mg/ml.............................................................................116TALTZ -ixekizumab subcutaneous soln prefilled syringe

80 mg/ml....................................................................... 116tamoxifen citrate tab 10 mg (base equivalent).............15tamoxifen citrate tab 20 mg (base equivalent).............15tamsulosin hcl cap 0.4 mg (Flomax)............................. 59TAPERDEX 12-DAY -dexamethasone tab therapy pack

1.5 mg (49)..................................................................... 18TAPERDEX 6-DAY -dexamethasone tab therapy pack 1.5

mg (21)............................................................................18TARCEVA -erlotinib hcl tab 25 mg (base equivalent)....... 15TARCEVA -erlotinib hcl tab 100 mg (base equivalent)..... 15TARCEVA -erlotinib hcl tab 150 mg (base equivalent)..... 15TARGADOX -doxycycline hyclate tab 50 mg......................3TARGRETIN -bexarotene gel 1%....................................116

2019


TARON-BC -prenat w/o a w/ fe cbnyl-fa tab 20-1 mg & vitb6 tab pak.......................................................................94

TARON-C DHA -prenatal w/fe fum-fe poly -fa-omega 3cap 53.5-38-1 mg........................................................... 94

TARON-PREX -prenatal w/o vit a w/ fe fum-dss-fa-dhacap 30-1.2-265 mg......................................................... 95

TASIGNA -nilotinib hcl cap 50 mg (base equivalent)........15TASIGNA -nilotinib hcl cap 150 mg (base equivalent)......15TASIGNA -nilotinib hcl cap 200 mg (base equivalent)......16TAVALISSE -fostamatinib disodium tab 100 mg (base

equivalent).....................................................................106TAVALISSE -fostamatinib disodium tab 150 mg (base

equivalent).....................................................................106TAYTULLA -norethindrone ace-ethinyl estradiol-fe cap 1

mg-20 mcg (24).............................................................. 21tazarotene cream 0.1% (Tazorac).................................116TAZORAC -tazarotene cream 0.05%..............................116TAZORAC -tazarotene gel 0.05%................................... 116TAZORAC -tazarotene gel 0.1%..................................... 116TECFIDERA -dimethyl fumarate capsule delayed release

120 mg............................................................................ 74TECFIDERA -dimethyl fumarate capsule delayed release

240 mg............................................................................ 74TECFIDERA STARTER PACK -dimethyl fumarate

capsule dr starter pack 120 mg & 240 mg.....................74TECHNIVIE -ombitasvir-paritaprevir-ritonavir tab

12.5-75-50 mg...................................................................8TEGRETOL -carbamazepine susp 100 mg/5ml............... 87TEGRETOL -carbamazepine tab 200 mg.........................87TEGRETOL-XR -carbamazepine tab er 12hr 100 mg...... 87TEGRETOL-XR -carbamazepine tab er 12hr 200 mg...... 88TEGRETOL-XR -carbamazepine tab er 12hr 400 mg...... 88TEKTURNA -aliskiren fumarate tab 150 mg (base

equivalent).......................................................................41TEKTURNA -aliskiren fumarate tab 300 mg (base

equivalent).......................................................................41TEKTURNA HCT -aliskiren-hydrochlorothiazide tab

150-12.5 mg....................................................................41TEKTURNA HCT -aliskiren-hydrochlorothiazide tab

150-25 mg.......................................................................41TEKTURNA HCT -aliskiren-hydrochlorothiazide tab

300-12.5 mg....................................................................41TEKTURNA HCT -aliskiren-hydrochlorothiazide tab

300-25 mg.......................................................................41TELCARE BLOOD GLUCOSE TES -glucose blood test

strip................................................................................122telmisartan-amlodipine tab 40-5 mg (Twynsta)............ 41telmisartan-amlodipine tab 80-5 mg (Twynsta)............ 41telmisartan-amlodipine tab 40-10 mg (Twynsta).......... 41telmisartan-amlodipine tab 80-10 mg (Twynsta).......... 41telmisartan-hydrochlorothiazide tab 40-12.5 mg

(Micardis hct).................................................................41telmisartan-hydrochlorothiazide tab 80-12.5 mg

(Micardis hct).................................................................41telmisartan-hydrochlorothiazide tab 80-25 mg

(Micardis hct).................................................................41telmisartan tab 20 mg (Micardis)................................... 41

telmisartan tab 40 mg (Micardis)................................... 41telmisartan tab 80 mg (Micardis)................................... 41temazepam cap 7.5 mg (Restoril).................................. 66temazepam cap 15 mg (Restoril)................................... 66temazepam cap 22.5 mg (Restoril)................................ 66temazepam cap 30 mg (Restoril)................................... 66temozolomide cap 5 mg (Temodar)...............................16temozolomide cap 20 mg (Temodar).............................16temozolomide cap 100 mg (Temodar)...........................16temozolomide cap 140 mg (Temodar)...........................16temozolomide cap 180 mg (Temodar)...........................16temozolomide cap 250 mg (Temodar)...........................16TENCON -butalbital-acetaminophen tab 50-325 mg........ 74TENIVAC -tetanus-diphtheria toxoids (td) inj 5-2 lfu......... 11tenofovir disoproxil fumarate tab 300 mg (Viread)........ 8terazosin hcl cap 1 mg (base equivalent).....................41terazosin hcl cap 2 mg (base equivalent).....................41terazosin hcl cap 5 mg (base equivalent).....................41terazosin hcl cap 10 mg (base equivalent)...................42terbinafine hcl tab 250 mg (Lamisil)................................5terbutaline sulfate tab 2.5 mg........................................ 51terbutaline sulfate tab 5 mg........................................... 51TERCONAZOLE -terconazole vaginal cream 0.8%..........58terconazole vaginal cream 0.4% (Terazol 7).................58terconazole vaginal suppos 80 mg............................... 58testosterone cypionate im inj in oil 100 mg/ml (Depo-

testosterone)..................................................................18testosterone cypionate im inj in oil 200 mg/ml (Depo-

testosterone)..................................................................18testosterone enanthate im inj in oil 200 mg/ml............18TESTOSTERONE PUMP -testosterone td gel 12.5 mg/act

(1%)................................................................................. 18testosterone td gel 12.5 mg/act (1%).............................18testosterone td gel 25 mg/2.5gm (1%) (Androgel)....... 18testosterone td gel 50 mg/5gm (1%) (Androgel).......... 18testosterone td gel 50 mg/5gm (1%) (Testim)...............18testosterone td soln 30 mg/act (Axiron)....................... 18TESTOSTERONE -testosterone td gel 10mg/act

(2%)................................................................................. 18TESTOSTERONE -testosterone td gel 25 mg/2.5gm

(1%)................................................................................. 18TESTOSTERONE -testosterone td gel 50 mg/5gm

(1%)................................................................................. 18TETANUS/DIPHTHERIA TOXOID -tetanus-diphtheria

toxoids (td) inj 2-2 lf/0.5ml..............................................11tetrabenazine tab 12.5 mg (Xenazine)........................... 74tetrabenazine tab 25 mg (Xenazine).............................. 74tetracaine hcl ophth soln 0.5%.................................... 109tetracycline hcl cap 250 mg (Tetracycline hcl)...............3tetracycline hcl cap 500 mg (Tetracycline hcl)...............3TEXACORT -hydrocortisone soln 2.5%.......................... 116TGT BLOOD GLUCOSE TEST ST -glucose blood test

strip................................................................................122THALOMID -thalidomide cap 50 mg............................... 127THALOMID -thalidomide cap 100 mg............................. 127THALOMID -thalidomide cap 150 mg............................. 127THALOMID -thalidomide cap 200 mg............................. 127

2019


theophylline soln 80 mg/15ml........................................ 51theophylline tab er 12hr 100 mg....................................51theophylline tab er 12hr 200 mg....................................51theophylline tab er 12hr 300 mg....................................51theophylline tab er 12hr 450 mg....................................51theophylline tab er 24hr 400 mg....................................51theophylline tab er 24hr 600 mg....................................51THEO-24 -theophylline cap er 24hr 100 mg..................... 51THEO-24 -theophylline cap er 24hr 200 mg..................... 51THEO-24 -theophylline cap er 24hr 300 mg..................... 51THEO-24 -theophylline cap er 24hr 400 mg..................... 51THIOLA -tiopronin tab 100 mg.......................................... 59thioridazine hcl tab 10 mg..............................................65thioridazine hcl tab 25 mg..............................................65thioridazine hcl tab 50 mg..............................................65thioridazine hcl tab 100 mg............................................65thiothixene cap 1 mg.......................................................65thiothixene cap 2 mg.......................................................65thiothixene cap 5 mg.......................................................65thiothixene cap 10 mg.....................................................65THRESHOLD PEP -respiratory therapy supplies -

devices.......................................................................... 125THRIVITE 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1

mg....................................................................................95THRIVITE RX -prenatal vit w/ iron carbonyl-fa tab 29-1

mg....................................................................................95THROMBIN-JMI DILUENT -thrombin for soln 5000

unit................................................................................. 101THROMBIN-JMI DILUENT -thrombin for soln 20000

unit................................................................................. 101THROMBIN-JMI EPISTAXIS -thrombin for soln kit 5000

unit................................................................................. 101THROMBIN-JMI SYRINGE SPRA -thrombin for soln kit

5000 unit....................................................................... 101THROMBIN-JMI SYRINGE SPRA -thrombin for soln kit

20000 unit..................................................................... 101THROMBIN-JMI W/DIL SPRAY -thrombin for soln kit

20000 unit..................................................................... 101thyroid tab 15 mg (1/4 grain) (Armour thyroid)............ 28thyroid tab 30 mg (1/2 grain) (Armour thyroid)............ 28thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)......... 28thyroid tab 60 mg (1 grain) (Armour thyroid)............... 28thyroid tab 120 mg (2 grain) (Armour thyroid)............. 28THYROLAR-1/2 -liotrix (t3-t4) tab 30 mg (6.25-25

mcg).................................................................................28THYROLAR-1/4 -liotrix (t3-t4) tab 15 mg (3.1-12.5

mcg).................................................................................28THYROLAR-1 -liotrix (t3-t4) tab 60 mg (12.5-50 mcg)......28THYROLAR-2 -liotrix (t3-t4) tab 120 mg (25-100

mcg).................................................................................28THYROLAR-3 -liotrix (t3-t4) tab 180 mg (37.5-150

mcg).................................................................................28tiagabine hcl tab 2 mg (Gabitril).................................... 88tiagabine hcl tab 4 mg (Gabitril).................................... 88tiagabine hcl tab 12 mg (Gabitril).................................. 88tiagabine hcl tab 16 mg (Gabitril).................................. 88TIBSOVO -ivosidenib tab 250 mg.....................................16

TIMOLOL MALEATE OPHTHALMI -timolol maleate ophthgel forming soln 0.25%.................................................109

TIMOLOL MALEATE OPHTHALMI -timolol maleate ophthgel forming soln 0.5%...................................................109

timolol maleate ophth soln 0.5% (once-daily)(Istalol)..........................................................................109

timolol maleate ophth soln 0.25% (Timoptic).............109timolol maleate ophth soln 0.5% (Timoptic)...............109TIMOLOL MALEATE -timolol maleate tab 5 mg............... 35TIMOLOL MALEATE -timolol maleate tab 10 mg............. 35TIMOLOL MALEATE -timolol maleate tab 20 mg............. 35TIMOPTIC OCUDOSE -timolol maleate preservative free

ophth soln 0.25%..........................................................109TIMOPTIC OCUDOSE -timolol maleate preservative free

ophth soln 0.5%............................................................109TIMOPTIC-XE -timolol maleate ophth gel forming soln

0.25%.............................................................................109TIMOPTIC-XE -timolol maleate ophth gel forming soln

0.5%...............................................................................109tinidazole tab 250 mg........................................................ 9tinidazole tab 500 mg (Tindamax)....................................9TIROSINT -levothyroxine sodium cap 13 mcg..................28TIROSINT -levothyroxine sodium cap 25 mcg..................28TIROSINT -levothyroxine sodium cap 50 mcg..................28TIROSINT -levothyroxine sodium cap 75 mcg..................28TIROSINT -levothyroxine sodium cap 88 mcg..................28TIROSINT -levothyroxine sodium cap 100 mcg................28TIROSINT -levothyroxine sodium cap 112 mcg................29TIROSINT -levothyroxine sodium cap 125 mcg................29TIROSINT -levothyroxine sodium cap 137 mcg................29TIROSINT -levothyroxine sodium cap 150 mcg................29TISSEEL -fibrin sealant component kit 2 ml................... 101TISSEEL -fibrin sealant component kit 4 ml................... 101TISSEEL -fibrin sealant component kit 10 ml................. 101TISSEEL -fibrin sealant component solution.................. 101TISSEEL VH -fibrin sealant component kit 2 ml............. 101TISSEEL VH -fibrin sealant component kit 4 ml............. 101TISSEEL VH -fibrin sealant component kit 10 ml........... 101TIVICAY -dolutegravir sodium tab 10 mg (base equiv).......8TIVICAY -dolutegravir sodium tab 25 mg (base equiv).......8TIVICAY -dolutegravir sodium tab 50 mg (base equiv).......8TIVORBEX -indomethacin cap 20 mg.............................. 83TIVORBEX -indomethacin cap 40 mg.............................. 83tizanidine hcl cap 2 mg (base equivalent)

(Zanaflex)........................................................................91tizanidine hcl cap 4 mg (base equivalent)

(Zanaflex)........................................................................91tizanidine hcl cap 6 mg (base equivalent)

(Zanaflex)........................................................................91tizanidine hcl tab 2 mg (base equivalent).....................91tizanidine hcl tab 4 mg (base equivalent)

(Zanaflex)........................................................................91TL-CARE DHA -prenatal w/fe fumarate-fa-dss-fish oil cap

27-1-500 mg....................................................................95TL FOLATE -prenatal vit w/ fe fum-methylfolate-fa tab

27-0.5-0.5 mg..................................................................95

2019


TL-SELECT -prenatal w/o vit a w/ fe fum-dss-fa-dha cap29-1.25-325 mg...............................................................95

TOBI PODHALER -tobramycin inhal cap 28 mg.................4TOBRADEX ST -tobramycin-dexamethasone ophth susp

0.3-0.05%...................................................................... 109TOBRADEX -tobramycin-dexamethasone ophth oint

0.3-0.1%........................................................................ 109tobramycin-dexamethasone ophth susp 0.3-0.1%

(Tobradex).................................................................... 109tobramycin nebu soln 300 mg/5ml (Tobi)....................... 4tobramycin ophth soln 0.3% (Tobrex).........................109TOBRAMYCIN -tobramycin nebu soln 300 mg/5ml............4TOBREX -tobramycin ophth oint 0.3%........................... 109TODAY SPONGE -nonoxynol-9 vaginal sponge 1000

mg....................................................................................58TOLAK -fluorouracil cream 4%........................................116TOLAZAMIDE -tolazamide tab 250 mg.............................25TOLAZAMIDE -tolazamide tab 500 mg.............................25TOLBUTAMIDE -tolbutamide tab 500 mg.........................25tolcapone tab 100 mg (Tasmar)..................................... 90TOLMETIN SODIUM -tolmetin sodium cap 400 mg......... 83TOLMETIN SODIUM -tolmetin sodium tab 200 mg..........83TOLMETIN SODIUM -tolmetin sodium tab 600 mg..........83tolterodine tartrate cap er 24hr 2 mg (Detrol la).......... 57tolterodine tartrate cap er 24hr 4 mg (Detrol la).......... 58tolterodine tartrate tab 1 mg (Detrol)............................ 58tolterodine tartrate tab 2 mg (Detrol)............................ 58TOPICORT -desoximetasone spray 0.25%.................... 116TOPIRAMATE ER -topiramate cap er 24hr sprinkle 25

mg....................................................................................88TOPIRAMATE ER -topiramate cap er 24hr sprinkle 50




mg....................................................................................88topiramate sprinkle cap 15 mg (Topamax

sprinkle)..........................................................................88topiramate sprinkle cap 25 mg (Topamax

sprinkle)..........................................................................88topiramate tab 25 mg (Topamax)...................................88topiramate tab 50 mg (Topamax)...................................88topiramate tab 100 mg (Topamax).................................88topiramate tab 200 mg (Topamax).................................88torsemide tab 5 mg......................................................... 43torsemide tab 100 mg..................................................... 43torsemide tab 10 mg (Demadex)....................................43torsemide tab 20 mg (Demadex)....................................43TOUJEO MAX SOLOSTAR -insulin glargine soln pen-

injector 300 unit/ml......................................................... 27TOUJEO SOLOSTAR -insulin glargine soln pen-injector

300 unit/ml.......................................................................27TOVIAZ -fesoterodine fumarate tab er 24hr 4 mg............ 58TOVIAZ -fesoterodine fumarate tab er 24hr 8 mg............ 58TRACLEER -bosentan tab for oral susp 32 mg................46

TRACLEER -bosentan tab 62.5 mg..................................46TRACLEER -bosentan tab 125 mg...................................46TRADJENTA -linagliptin tab 5 mg.....................................25tramadol-acetaminophen tab 37.5-325 mg

(Ultracet).........................................................................80TRAMADOL HCL ER -tramadol hcl cap er 24hr biphasic

release 100 mg...............................................................79TRAMADOL HCL ER -tramadol hcl cap er 24hr biphasic



release 300 mg...............................................................79tramadol hcl tab er 24hr biphasic release 100 mg.......79tramadol hcl tab er 24hr biphasic release 200 mg.......79tramadol hcl tab er 24hr biphasic release 300 mg.......79tramadol hcl tab er 24hr 100 mg....................................79tramadol hcl tab er 24hr 200 mg....................................79tramadol hcl tab er 24hr 300 mg....................................79tramadol hcl tab 50 mg (Ultram)....................................79TRANDOLAPRIL/VERAPAMIL HC -trandolapril-verapamil

hcl tab er 1-240 mg........................................................42trandolapril tab 4 mg.......................................................42trandolapril tab 1 mg (Mavik)......................................... 42trandolapril tab 2 mg (Mavik)......................................... 42trandolapril-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)........................ 101TRANSDERM-SCOP -scopolamine td patch 72hr 1

mg/3days......................................................................... 55tranylcypromine sulfate tab 10 mg (Parnate)...............62TRAVATAN Z -travoprost ophth soln 0.004%

(benzalkonium free) (bak free).....................................109trazodone hcl tab 50 mg.................................................62trazodone hcl tab 100 mg...............................................62trazodone hcl tab 150 mg...............................................62trazodone hcl tab 300 mg...............................................62TRECATOR -ethionamide tab 250 mg................................4TRELEGY ELLIPTA -fluticasone-umeclidinium-vilanterol

aepb 100-62.5-25 mcg/inh............................................. 51TREMFYA -guselkumab soln prefilled syringe 100 mg/

ml................................................................................... 116TRESIBA FLEXTOUCH -insulin degludec soln pen-

injector 100 unit/ml......................................................... 27TRESIBA FLEXTOUCH -insulin degludec soln pen-

injector 200 unit/ml......................................................... 27tretinoin cap 10 mg......................................................... 16tretinoin cream 0.025% (Retin-a)................................. 116tretinoin cream 0.05% (Retin-a)................................... 116tretinoin cream 0.1% (Retin-a)..................................... 116tretinoin gel 0.05% (Atralin)..........................................116tretinoin gel 0.01% (Retin-a).........................................116tretinoin gel 0.025% (Retin-a).......................................116tretinoin microsphere gel 0.04% (Retin-a micro)....... 116tretinoin microsphere gel 0.1% (Retin-a micro)......... 116

2019


TRETTEN -coagulation factor xiii a-subunit for inj2000-3125 unit..............................................................106

TREXALL -methotrexate sodium tab 5 mg (baseequiv)...............................................................................16

TREXALL -methotrexate sodium tab 7.5 mg (baseequiv)...............................................................................16



TREXIMET -sumatriptan-naproxen sodium tab 10-60mg....................................................................................84

TREZIX -acetaminophen-caffeine-dihydrocodeine cap320.5-30-16 mg...............................................................80

triamcinolone acetonide aerosol soln 0.147 mg/gm(Kenalog)......................................................................116

triamcinolone acetonide cream 0.025%......................116triamcinolone acetonide cream 0.1%..........................116triamcinolone acetonide cream 0.5%..........................116triamcinolone acetonide dental paste 0.1%............... 110triamcinolone acetonide lotion 0.025%.......................116triamcinolone acetonide lotion 0.1%...........................116triamcinolone acetonide nasal aerosol suspension 55

mcg/act........................................................................... 48triamcinolone acetonide oint 0.025%..........................116triamcinolone acetonide oint 0.1%.............................. 116triamcinolone acetonide oint 0.5%.............................. 116triamterene & hydrochlorothiazide cap 37.5-25 mg

(Dyazide).........................................................................43triamterene & hydrochlorothiazide tab 37.5-25 mg

(Maxzide-25)...................................................................43triamterene & hydrochlorothiazide tab 75-50 mg

(Maxzide)........................................................................ 43TRIANEX -triamcinolone acetonide oint 0.05%.............. 116triazolam tab 0.25 mg (Halcion)..................................... 66TRIAZOLAM -triazolam tab 0.125 mg...............................66TRICARE PRENATAL COMPLEAT -prenat w/o a fefum-fa

tab 27-1 mg & fish oil chew cap pak..............................95TRICARE PRENATAL DHA ONE/ -prenatal multivitamins

& minerals w/iron & fa cap 0.8 mg.................................95TRICARE PRENATAL DHA ONE -prenatal w/fe fumarate-

fa-dss-fish oil cap 27-1-500 mg..................................... 95TRICARE PRENATAL -prenat w/o vit a w/ fe pyrophos-

methylf chew tab 4.5-1 mg.............................................95TRICARE -prenatal vit w/ fe fumarate-fa tab 27-1 mg...... 95trientine hcl cap 250 mg (Syprine).............................. 127trifluoperazine hcl tab 1 mg (base equivalent).............65trifluoperazine hcl tab 2 mg (base equivalent).............65trifluoperazine hcl tab 5 mg (base equivalent).............66trifluoperazine hcl tab 10 mg (base equivalent)...........66trifluridine ophth soln 1% (Viroptic)............................109TRIGLIDE -fenofibrate tab 160 mg................................... 45trihexyphenidyl hcl elixir 0.4 mg/ml.............................. 90trihexyphenidyl hcl tab 2 mg..........................................90trihexyphenidyl hcl tab 5 mg..........................................90trimethobenzamide hcl cap 300 mg (Tigan)................. 55trimethoprim tab 100 mg.................................................. 9

trimipramine maleate cap 25 mg (Surmontil)...............62trimipramine maleate cap 50 mg (Surmontil)...............62trimipramine maleate cap 100 mg (Surmontil).............63TRIMPEX -trimethoprim hcl oral soln 50 mg/5ml (base

equiv)................................................................................. 9TRINATAL RX 1 -prenatal vit w/ fe fumarate-fa tab 60-1

mg....................................................................................95TRINATE -prenatal vit w/ fe fumarate-fa tab 28-1 mg.......95TRINTELLIX -vortioxetine hbr tab 5 mg (base equiv).......63TRINTELLIX -vortioxetine hbr tab 10 mg (base equiv).....63TRINTELLIX -vortioxetine hbr tab 20 mg (base equiv).....63TRISTART DHA -prenat w/o a w/fecbn-methylf-fa-dha cap

31-0.6-0.4-200 mg.......................................................... 95TRISTART ONE -prenat w/o a w/fecbn-methylf-fa-dha cap

35-1-215 mg....................................................................95TRI-TABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg

& omega cap pack......................................................... 95TRIUMEQ -abacavir-dolutegravir-lamivudine tab

600-50-300 mg..................................................................8TRIVEEN-DUO DHA -prenat-fe bis-fe prot succ-fa-ca tab

& omega 3 cap 400 pk...................................................95TROKENDI XR -topiramate cap er 24hr 25 mg................88TROKENDI XR -topiramate cap er 24hr 50 mg................88TROKENDI XR -topiramate cap er 24hr 100 mg..............88TROKENDI XR -topiramate cap er 24hr 200 mg..............88trospium chloride cap er 24hr 60 mg............................58trospium chloride tab 20 mg..........................................58TRUE FOCUS SELF MONITORIN -glucose blood test

strip................................................................................122TRUE METRIX BLOOD GLUCOSE -glucose blood test

strip................................................................................122TRUE METRIX SELF MONITORI -glucose blood test

strip................................................................................122TRUETEST BLOOD GLUCOSE T -glucose blood test

strip................................................................................122TRUETEST STRIPS -glucose blood test strip................122TRUETRACK BLOOD GLUCOSE T -glucose blood test

strip................................................................................122TRUETRACK TEST -glucose blood test strip.................122TRULANCE -plecanatide tab 3 mg................................... 57TRULICITY -dulaglutide soln pen-injector 0.75

mg/0.5ml..........................................................................25TRULICITY -dulaglutide soln pen-injector 1.5

mg/0.5ml..........................................................................25TRUMENBA -meningococcal group b vac (recomb) im

susp prefilled syr.............................................................11TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab

100-150 mg.......................................................................8TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab



200-300 mg.......................................................................8TUDORZA PRESSAIR -aclidinium bromide aerosol powd

breath activated 400 mcg/act.........................................51

2019


TUSSICAPS -hydrocod polst-chlorphen polst cap er 12hr5-4 mg............................................................................. 48

TUSSICAPS -hydrocod polst-chlorphen polst cap er 12hr10-8 mg........................................................................... 48

TUZISTRA XR -codeine polist-chlorphen polist er susp14.7-2.8 mg/5ml..............................................................48

TWINRIX -hepatitis a (inact)-hep b (recomb) vac inj720-20 elu-mcg/ml.......................................................... 11

TYBOST -cobicistat tab 150 mg..........................................8TYKERB -lapatinib ditosylate tab 250 mg (base

equiv)...............................................................................16TYLACTIN RESTORE 10 -nutritional supplement

liquid................................................................................ 97TYLACTIN RESTORE 5PE -nutritional supplement

pack................................................................................. 97TYLACTIN RTD 15 -nutritional supplement liquid............ 97TYMLOS -abaloparatide subcutaneous soln pen-injector

3120 mcg/1.56ml............................................................ 33TYVASO REFILL -treprostinil inhalation solution 0.6 mg/

ml..................................................................................... 46TYVASO STARTER -treprostinil inhalation solution 0.6

mg/ml...............................................................................46TYVASO -treprostinil inhalation solution 0.6 mg/ml.......... 46

UUCERIS -budesonide rectal foam 2 mg/act....................110ULESFIA -benzyl alcohol lotion 5%................................ 116ULORIC -febuxostat tab 40 mg.........................................84ULORIC -febuxostat tab 80 mg.........................................84ULTIMATECARE ONE -prenatal vit w/ fe cbn-fe asp glyc-

fa-omega 3 cap 27-1mg.................................................95ULTIMA TEST STRIPS -glucose blood test strip............122ULTRATRAK PRO TEST STRIPS -glucose blood test

strip................................................................................122ULTRATRAK ULTIMATE TEST S -glucose blood test

strip................................................................................122ULTRAVATE -halobetasol propionate lotion 0.05%........ 116UNISTRIP1 GENERIC -glucose blood test strip.............122UPTRAVI -selexipag tab 200 mcg.....................................46UPTRAVI -selexipag tab 400 mcg.....................................46UPTRAVI -selexipag tab 600 mcg.....................................46UPTRAVI -selexipag tab 800 mcg.....................................46UPTRAVI -selexipag tab 1000 mcg...................................46UPTRAVI -selexipag tab 1200 mcg...................................46UPTRAVI -selexipag tab 1400 mcg...................................46UPTRAVI -selexipag tab 1600 mcg...................................46UPTRAVI -selexipag tab therapy pack 200 mcg (140) &

800 mcg (60)...................................................................46ursodiol cap 300 mg (Actigall).......................................57ursodiol tab 250 mg (Urso 250)..................................... 57ursodiol tab 500 mg (Urso forte)................................... 57UTIBRON NEOHALER -indacaterol-glycopyrrolate inhal

cap 27.5-15.6 mcg..........................................................51

VVAGIFEM -estradiol vaginal tab 10 mcg...........................58valacyclovir hcl tab 1 gm (Valtrex).................................. 8

valacyclovir hcl tab 500 mg (Valtrex).............................. 8VALCHLOR -mechlorethamine hcl gel 0.016% (base

equivalent).....................................................................116valganciclovir hcl for soln 50 mg/ml (base equiv)

(Valcyte)............................................................................8valganciclovir hcl tab 450 mg (base equivalent)

(Valcyte)............................................................................8valproate sodium oral soln 250 mg/5ml (base equiv)

(Depakene)..................................................................... 88valproic acid cap 250 mg (Depakene)...........................88valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan

hct).................................................................................. 42valsartan-hydrochlorothiazide tab 160-12.5 mg

(Diovan hct)................................................................... 42valsartan-hydrochlorothiazide tab 160-25 mg (Diovan

hct).................................................................................. 42valsartan-hydrochlorothiazide tab 320-12.5 mg

(Diovan hct)................................................................... 42valsartan-hydrochlorothiazide tab 320-25 mg (Diovan

hct).................................................................................. 42valsartan tab 40 mg (Diovan)......................................... 42valsartan tab 80 mg (Diovan)......................................... 42valsartan tab 160 mg (Diovan)....................................... 42valsartan tab 320 mg (Diovan)....................................... 42VALVED HOLDING CHAMBER -spacer/aerosol-holding

chambers - device........................................................ 125VANATOL LQ -butalbital-acetaminophen-caffeine soln

50-325-40 mg/15ml.........................................................74VANATOL S -butalbital-acetaminophen-caffeine soln

50-325-40 mg/15ml.........................................................74vancomycin hcl cap 125 mg (base equivalent)

(Vancocin hcl)..................................................................9vancomycin hcl cap 250 mg (base equivalent)

(Vancocin hcl)..................................................................9VAQTA -hepatitis a vaccine inj susp 25 unit/0.5ml............11VAQTA -hepatitis a vaccine inj susp 50 unit/ml.................11VARIVAX -varicella virus vac live for subcutaneous inj

1350 pfu/0.5ml................................................................ 11VARUBI -rolapitant hcl tab 90 mg (base equiv)................ 55VASCEPA -icosapent ethyl cap 0.5 gm............................ 45VASCEPA -icosapent ethyl cap 1 gm............................... 45VCF VAGINAL CONTRACEPTIVE -nonoxynol-9 film

28%..................................................................................58VCF VAGINAL CONTRACEPTIVE -nonoxynol-9 foam

12.5%...............................................................................58VECAMYL -mecamylamine hcl tab 2.5 mg.......................42VECTICAL -calcitriol oint 3 mcg/gm................................116VELPHORO -sucroferric oxyhydroxide chew tab 500

mg....................................................................................57VELTASSA -patiromer sorbitex calcium for susp packet

8.4 gm (base eq).......................................................... 127VELTASSA -patiromer sorbitex calcium for susp packet

16.8 gm (base eq)........................................................ 127VELTASSA -patiromer sorbitex calcium for susp packet

25.2 gm (base eq)........................................................ 127VELTIN -clindamycin phosphate-tretinoin gel

1.2-0.025%.................................................................... 116

2019


VEMLIDY -tenofovir alafenamide fumarate tab 25 mg....... 8VENA-BAL DHA -prenat w/fe poly-na fered-fa tab 27-1 &

omega cap dr 430mg..................................................... 95VENCLEXTA STARTING PACK -venetoclax tab therapy

starter pack 10 & 50 & 100 mg......................................16VENCLEXTA -venetoclax tab 10 mg.................................16VENCLEXTA -venetoclax tab 50 mg.................................16VENCLEXTA -venetoclax tab 100 mg...............................16venlafaxine hcl cap er 24hr 37.5 mg (base equivalent)

(Effexor xr).....................................................................63venlafaxine hcl cap er 24hr 75 mg (base equivalent)

(Effexor xr).....................................................................63venlafaxine hcl cap er 24hr 150 mg (base equivalent)

(Effexor xr).....................................................................63venlafaxine hcl tab er 24hr 225 mg (base

equivalent)......................................................................63venlafaxine hcl tab er 24hr 37.5 mg (base equivalent)

(Venlafaxine hcl er).......................................................63venlafaxine hcl tab er 24hr 75 mg (base equivalent)

(Venlafaxine hcl er).......................................................63venlafaxine hcl tab er 24hr 150 mg (base equivalent)

(Venlafaxine hcl er).......................................................63venlafaxine hcl tab 25 mg...............................................63venlafaxine hcl tab 37.5 mg............................................63venlafaxine hcl tab 50 mg...............................................63venlafaxine hcl tab 75 mg...............................................63venlafaxine hcl tab 100 mg.............................................63VENTAVIS -iloprost inhalation solution 10 mcg/ml........... 46VENTAVIS -iloprost inhalation solution 20 mcg/ml........... 46VENTOLIN HFA -albuterol sulfate inhal aero 108 mcg/act

(90mcg base equiv)........................................................51verapamil hcl cap er 24hr 120 mg (Verelan).................36verapamil hcl cap er 24hr 180 mg (Verelan).................36verapamil hcl cap er 24hr 240 mg (Verelan).................36verapamil hcl cap er 24hr 100 mg (Verelan pm)...........36verapamil hcl cap er 24hr 200 mg (Verelan pm)...........36verapamil hcl cap er 24hr 300 mg (Verelan pm)...........37VERAPAMIL HCL SR -verapamil hcl cap er 24hr 360

mg....................................................................................37verapamil hcl tab er 120 mg (Calan sr).........................37verapamil hcl tab er 180 mg (Calan sr).........................37verapamil hcl tab er 240 mg (Calan sr).........................37verapamil hcl tab 40 mg................................................. 37verapamil hcl tab 80 mg (Calan)....................................37verapamil hcl tab 120 mg (Calan)..................................37VERASENS BLOOD GLUCOSE TE -glucose blood test

strip................................................................................122VERDESO -desonide foam 0.05%..................................116VEREGEN -sinecatechins oint 15%................................116VERSACLOZ -clozapine susp 50 mg/ml.......................... 66VERZENIO -abemaciclib tab 50 mg................................. 16VERZENIO -abemaciclib tab 100 mg............................... 16VERZENIO -abemaciclib tab 150 mg............................... 16VERZENIO -abemaciclib tab 200 mg............................... 16VESICARE -solifenacin succinate tab 5 mg..................... 58VESICARE -solifenacin succinate tab 10 mg................... 58VIBERZI -eluxadoline tab 75 mg.......................................57

VIBERZI -eluxadoline tab 100 mg.....................................57VIBRAMYCIN -doxycycline calcium syrup 50 mg/5ml........3VICTORY AGM-4000 TEST STR -glucose blood test

strip................................................................................122VICTOZA -liraglutide soln pen-injector 18 mg/3ml (6 mg/

ml)....................................................................................25VIDEX -didanosine for soln 2 gm........................................8VIDEX -didanosine for soln 4 gm........................................8VIDEX EC -didanosine delayed release capsule 125

mg......................................................................................8VIEKIRA PAK -ombitas-paritapre-riton & dasab tab pak

12.5-75-50 & 250 mg....................................................... 8VIEKIRA XR -dasab-ombit-paritap-riton tab er 24hr

200-8.33-50-33.33 mg...................................................... 8vigabatrin powd pack 500 mg (Sabril).......................... 88VIIBRYD STARTER PACK -vilazodone hcl tab starter kit

10 (7) & 20 (23) mg....................................................... 63VIIBRYD -vilazodone hcl tab 10 mg..................................63VIIBRYD -vilazodone hcl tab 20 mg..................................63VIIBRYD -vilazodone hcl tab 40 mg..................................63VILACTIN AA PLUS -nutritional supplement liquid...........97VIL-RX -prenatal vit w/ iron carbonyl-fa tab 29-1 mg........95VIMOVO -naproxen-esomeprazole magnesium tab dr

375-20 mg.......................................................................83VIMOVO -naproxen-esomeprazole magnesium tab dr

500-20 mg.......................................................................83VIMPAT -lacosamide oral solution 10 mg/ml.................... 88VIMPAT -lacosamide tab 50 mg........................................88VIMPAT -lacosamide tab 100 mg......................................88VIMPAT -lacosamide tab 150 mg......................................88VIMPAT -lacosamide tab 200 mg......................................88VINATE DHA RF -prenat w/o a w/fefum-methylfol-omegas

cap 27-1.13 mg...............................................................95VINATE II -prenatal vit w/ fe bisglycinate chelate-fa tab

29-1 mg........................................................................... 95VINATE M -prenatal vit w/ sel-fe fumarate-fa tab 27-1

mg....................................................................................95VINATE ONE -prenatal vit w/ fe fumarate-fa tab 60-1

mg....................................................................................95VIOKACE -pancrelipase (lip-prot-amyl) tab

10440-39150-39150 unit................................................ 55VIOKACE -pancrelipase (lip-prot-amyl) tab

20880-78300-78300 unit................................................ 55VIRACEPT -nelfinavir mesylate tab 250 mg.......................8VIRACEPT -nelfinavir mesylate tab 625 mg.......................8VIRAMUNE -nevirapine susp 50 mg/5ml............................8VIREAD -tenofovir disoproxil fumarate oral powder 40

mg/gm................................................................................8VIREAD -tenofovir disoproxil fumarate tab 150 mg............ 8VIREAD -tenofovir disoproxil fumarate tab 200 mg............ 8VIREAD -tenofovir disoproxil fumarate tab 250 mg............ 8VIRT-C DHA -prenatal w/fe fum-fe poly -fa-omega 3 cap

53.5-38-1 mg...................................................................95VIRT-NATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap

28-1-200 mg....................................................................95VIRT-PN DHA -prenat w/o a w/fefum-methfol-fa-dha cap

27-0.6-0.4-300 mg.......................................................... 95

2019


VIRT-PN PLUS -prenat w/o a w/ fe fumerate-methylfolate-fa-omega 3 cap...............................................................95

VIRT-PN -prenatal vit w/ fe fum-methylfolate-fa tab27-0.6-0.4 mg..................................................................95

VISTOGARD -uridine triacetate oral granules packet 10gm..................................................................................117

VITAFOL FE+ -prenat-fepoly-methol-fa-dha cap 90-1-200mg & dss 50mg cap....................................................... 95

VITAFOL GUMMIES -prenat vit w/ fe phos-fa-omegachew tab 3.33-0.333-34.8 mg........................................ 95

VITAFOL-NANO -prenatal w/o a w/ fefum-l methylfol-fatab 18-0.6-0.4 mg........................................................... 96

VITAFOL-OB+DHA -prenatal mv w/fe fum-fa tab 65-1 mg& dha cap 250 mg pack.................................................96

VITAFOL-OB -prenatal vit w/ fe fumarate-fa tab 65-1mg....................................................................................96

VITAFOL-ONE -prenatal mv w/ fe polysac cmplx-fa-dhacap 29-1-200 mg............................................................ 96

VITAFOL ULTRA -prenat w/fe poly-methylfol-fa-dha cap29-0.6-0.4-200 mg.......................................................... 95

VITAMEDMD ONE RX/QUATREFO -prenat w/o a w/fefum-methfol-fa-dha cap 30-0.6-0.4-200 mg................ 96

VITAMEDMD REDICHEW RX -prenat w/ b2-b6-b12-d3-folic acid chew tab 1.4 mg............................................. 96

VITAPEARL -prenat w/oa w/fefum-na fered-fa-dha cap er30-1.4-200 mg.................................................................96

VITATRUE -prenat w/o a w/fe chel-fa tab 30-1.4 mg & dhacap 300mg pk................................................................. 96

VIVA DHA -prenatal vit w/ fe fum-fa-omega 3 cap28-1-200 mg....................................................................96

VIVLODEX -meloxicam cap 5 mg.....................................83VIVLODEX -meloxicam cap 10 mg...................................83VIVOTIF -typhoid vaccine cap delayed release................11VOCAL POINT BLOOD GLUCOSE -glucose blood test

strip................................................................................122VOGELXO PUMP -testosterone td gel 12.5 mg/act

(1%)................................................................................. 18VOGELXO -testosterone td gel 50 mg/5gm (1%).............18VOL-NATE -prenatal vit w/ fe fumarate-fa tab 28-1

mg....................................................................................96VOL-PLUS -prenatal vit w/ fe fumarate-fa tab 27-1

mg....................................................................................96VOL-TAB RX -prenatal vit w/ iron carbonyl-fa tab 29-1

mg....................................................................................96VONVENDI -von willebrand factor (recombinant) for inj

650 unit......................................................................... 106VONVENDI -von willebrand factor (recombinant) for inj

1300 unit....................................................................... 106voriconazole for susp 40 mg/ml (Vfend).........................5voriconazole tab 50 mg (Vfend).......................................5voriconazole tab 200 mg (Vfend).....................................5VORTEX HOLDING CHAMBER/MA -respiratory therapy

supplies - devices.........................................................125VORTEX VALVED HOLDING CHA -spacer/aerosol-

holding chambers - device........................................... 125VOSEVI -sofosbuvir-velpatasvir-voxilaprevir tab

400-100-100 mg................................................................8

VOTRIENT -pazopanib hcl tab 200 mg (base equiv)....... 16VP-HEME OB + DHA -prenat-fe poly cmplx-fe heme poly-

fa tab & omega 3 cap pck..............................................96VP-PNV-DHA -prenatal vit w/ fe fum-fa-omega 3 cap

28-1-215.8 mg.................................................................96VRAYLAR -cariprazine hcl cap 1.5 mg (base

equivalent).......................................................................66VRAYLAR -cariprazine hcl cap 3 mg (base

equivalent).......................................................................66VRAYLAR -cariprazine hcl cap 4.5 mg (base

equivalent).......................................................................66VRAYLAR -cariprazine hcl cap 6 mg (base

equivalent).......................................................................66VRAYLAR -cariprazine hcl cap therapy pack 1.5 mg (1) &

3 mg (6).......................................................................... 66VUSION -miconazole-zinc oxide-white petrolatum oint

0.25-15-81.35%.............................................................116VYVANSE -lisdexamfetamine dimesylate cap 10 mg.......70VYVANSE -lisdexamfetamine dimesylate cap 20 mg.......70VYVANSE -lisdexamfetamine dimesylate cap 30 mg.......70VYVANSE -lisdexamfetamine dimesylate cap 40 mg.......70VYVANSE -lisdexamfetamine dimesylate cap 50 mg.......70VYVANSE -lisdexamfetamine dimesylate cap 60 mg.......70VYVANSE -lisdexamfetamine dimesylate cap 70 mg.......70VYVANSE -lisdexamfetamine dimesylate chew tab 10

mg....................................................................................70VYVANSE -lisdexamfetamine dimesylate chew tab 20





mg....................................................................................70VYZULTA -latanoprostene bunod ophth soln

0.024%.......................................................................... 109

Wwarfarin sodium tab 1 mg (Coumadin)....................... 100warfarin sodium tab 2 mg (Coumadin)....................... 100warfarin sodium tab 2.5 mg (Coumadin).................... 100warfarin sodium tab 3 mg (Coumadin)....................... 100warfarin sodium tab 4 mg (Coumadin)....................... 100warfarin sodium tab 5 mg (Coumadin)....................... 101warfarin sodium tab 6 mg (Coumadin)....................... 101warfarin sodium tab 7.5 mg (Coumadin).................... 101warfarin sodium tab 10 mg (Coumadin)..................... 101WATCHHALER -spacer/aerosol-holding chambers -

device............................................................................ 125WAVESENSE PRESTO TEST STR -glucose blood test

strip................................................................................122WELCHOL -colesevelam hcl packet for susp 3.75 gm.....45WESTHROID -thyroid tab 32.5 mg................................... 29WESTHROID -thyroid tab 65 mg...................................... 29WESTHROID -thyroid tab 97.5 mg................................... 29

2019


WESTHROID -thyroid tab 130 mg.................................... 29WESTHROID -thyroid tab 195 mg.................................... 29WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 60

mm.................................................................................125WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 65







mm.................................................................................125WILATE -antihemophilic factor/vwf (human) for inj

500-500 unit kit............................................................. 106WILATE -antihemophilic factor/vwf (human) for inj

1000-1000 unit kit.........................................................106WP THYROID -thyroid tab 16.25 mg................................29WP THYROID -thyroid tab 32.5 mg..................................29WP THYROID -thyroid tab 65 mg.....................................29WP THYROID -thyroid tab 81.25 mg................................29WP THYROID -thyroid tab 97.5 mg..................................29WP THYROID -thyroid tab 113.75 mg.............................. 29WP THYROID -thyroid tab 130 mg...................................29WP THYROID -thyroid tab 48.75 mg (3/4 grain).............. 29

XXADAGO -safinamide mesylate tab 50 mg (base

equiv)...............................................................................90XADAGO -safinamide mesylate tab 100 mg (base

equiv)...............................................................................90XALKORI -crizotinib cap 200 mg...................................... 16XALKORI -crizotinib cap 250 mg...................................... 16XARELTO -rivaroxaban tab 10 mg..................................101XARELTO -rivaroxaban tab 15 mg..................................101XARELTO -rivaroxaban tab 20 mg..................................101XARELTO STARTER PACK -rivaroxaban tab starter

therapy pack 15 mg & 20 mg.......................................101XATMEP -methotrexate oral soln 2.5 mg/ml.....................16XELJANZ -tofacitinib citrate tab 5 mg (base

equivalent).......................................................................83XELJANZ -tofacitinib citrate tab 10 mg (base

equivalent).......................................................................83XELJANZ XR -tofacitinib citrate tab er 24hr 11 mg (base

equivalent).......................................................................83XENICAL -orlistat cap 120 mg.......................................... 70XERESE -acyclovir-hydrocortisone cream 5-1%............116XERMELO -telotristat etiprate tab 250 mg (telotristat ethyl

equiv)...............................................................................57XHANCE -fluticasone propionate nasal exhaler susp 93

mcg/act............................................................................ 48XIFAXAN -rifaximin tab 200 mg.......................................... 9

XIFAXAN -rifaximin tab 550 mg........................................ 10XIGDUO XR -dapagliflozin-metformin hcl tab er 24hr

2.5-1000 mg....................................................................25XIGDUO XR -dapagliflozin-metformin hcl tab er 24hr

5-500 mg......................................................................... 25XIGDUO XR -dapagliflozin-metformin hcl tab er 24hr

5-1000 mg.......................................................................25XIGDUO XR -dapagliflozin-metformin hcl tab er 24hr

10-500 mg.......................................................................25XIGDUO XR -dapagliflozin-metformin hcl tab er 24hr

10-1000 mg.....................................................................25XIIDRA -lifitegrast ophth soln 5%....................................109XIMINO -minocycline hcl cap er 24hr 45 mg (base

equivalent)......................................................................... 3XIMINO -minocycline hcl cap er 24hr 90 mg (base

equivalent)......................................................................... 3XIMINO -minocycline hcl cap er 24hr 135 mg (base

equivalent)......................................................................... 3XOLEGEL -ketoconazole gel 2%.................................... 117XOPENEX HFA -levalbuterol tartrate inhal aerosol 45

mcg/act (base equiv)...................................................... 51XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent 9

mg....................................................................................80XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent

13.5 mg........................................................................... 80XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent

18 mg.............................................................................. 80XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent

27 mg.............................................................................. 80XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent

36 mg.............................................................................. 80XTANDI -enzalutamide cap 40 mg....................................16XULANE -norelgestromin-ethinyl estradiol td ptwk 150-35

mcg/24hr..........................................................................21XULTOPHY 100/3.6 -insulin degludec-liraglutide sol pen-

inj 100-3.6 unit-mg/ml.....................................................25XURIDEN -uridine triacetate oral granules packet 2

gm....................................................................................33XYNTHA -antihemophilic factor recombinant paf for inj kit

250 unit......................................................................... 106XYNTHA -antihemophilic factor recombinant paf for inj kit

500 unit......................................................................... 106XYNTHA -antihemophilic factor recombinant paf for inj kit

1000 unit....................................................................... 106XYNTHA -antihemophilic factor recombinant paf for inj kit

2000 unit....................................................................... 106XYNTHA SOLOFUSE -antihemophilic factor recombinant

paf for inj kit 250 unit................................................... 106XYNTHA SOLOFUSE -antihemophilic factor recombinant

paf for inj kit 500 unit................................................... 106XYNTHA SOLOFUSE -antihemophilic factor recombinant

paf for inj kit 1000 unit................................................. 106XYNTHA SOLOFUSE -antihemophilic factor recombinant

paf for inj kit 2000 unit................................................. 106XYNTHA SOLOFUSE -antihemophilic factor recombinant

paf for inj kit 3000 unit................................................. 106XYREM -sodium oxybate oral solution 500 mg/ml........... 74

2019


YYONSA -abiraterone acetate tab 125 mg......................... 16YOSPRALA -aspirin-omeprazole tab delayed release

81-40 mg.......................................................................106YOSPRALA -aspirin-omeprazole tab delayed release

325-40 mg.....................................................................106

Zzafirlukast tab 10 mg (Accolate).................................... 51zafirlukast tab 20 mg (Accolate).................................... 51zaleplon cap 5 mg (Sonata)............................................66zaleplon cap 10 mg (Sonata)..........................................66ZARONTIN -ethosuximide cap 250 mg............................ 88ZARONTIN -ethosuximide soln 250 mg/5ml.....................88ZARXIO -filgrastim-sndz soln prefilled syringe 300

mcg/0.5ml........................................................................99ZARXIO -filgrastim-sndz soln prefilled syringe 480

mcg/0.8ml........................................................................99ZATEAN-PN DHA -prenat w/o a w/fefum-methfol-fa-dha

cap 27-0.6-0.4-300 mg................................................... 96ZATEAN-PN PLUS -prenat w/o a w/ fe fumerate-

methylfolate-fa-omega 3 cap..........................................96ZEJULA -niraparib tosylate cap 100 mg (base

equivalent).......................................................................16ZELAPAR -selegiline hcl orally disintegrating tab 1.25

mg....................................................................................90ZELBORAF -vemurafenib tab 240 mg.............................. 16ZEMBRACE SYMTOUCH -sumatriptan succinate solution

auto-injector 3 mg/0.5ml.................................................84ZENPEP -pancrelipase (lip-prot-amyl) dr cap

3000-10000-14000 unit...................................................55ZENPEP -pancrelipase (lip-prot-amyl) dr cap

5000-17000-24000 unit...................................................55ZENPEP -pancrelipase (lip-prot-amyl) dr cap

10000-32000-42000 unit................................................ 55ZENPEP -pancrelipase (lip-prot-amyl) dr cap



25000-79000-105000 unit.............................................. 55ZENPEP -pancrelipase (lip-prot-amyl) dr cap

40000-126000-168000 unit............................................ 55ZENZEDI -dextroamphetamine sulfate tab 2.5 mg...........70ZENZEDI -dextroamphetamine sulfate tab 7.5 mg...........70ZENZEDI -dextroamphetamine sulfate tab 15 mg............71ZENZEDI -dextroamphetamine sulfate tab 20 mg............71ZENZEDI -dextroamphetamine sulfate tab 30 mg............71ZEPATIER -elbasvir-grazoprevir tab 50-100 mg.................8ZETONNA -ciclesonide nasal aerosol soln 37 mcg/act (50

mcg/valve)....................................................................... 48zidovudine cap 100 mg (Retrovir)................................... 8zidovudine syrup 10 mg/ml (Retrovir).............................8zidovudine tab 300 mg......................................................8zileuton tab er 12hr 600 mg (Zyflo cr)...........................51ZIOPTAN -tafluprost ophth soln 0.0015%.......................109

ziprasidone hcl cap 20 mg (Geodon)............................ 66ziprasidone hcl cap 40 mg (Geodon)............................ 66ziprasidone hcl cap 60 mg (Geodon)............................ 66ziprasidone hcl cap 80 mg (Geodon)............................ 66ZIPSOR -diclofenac potassium cap 25 mg.......................83ZIRGAN -ganciclovir ophth gel 0.15%............................ 109ZITHROMAX -azithromycin powd pack for susp 1 gm....... 2ZOHYDRO ER -hydrocodone bitartrate cap er 12hr

abuse-deterrent 10 mg................................................... 80ZOHYDRO ER -hydrocodone bitartrate cap er 12hr





abuse-deterrent 50 mg................................................... 80ZOLINZA -vorinostat cap 100 mg..................................... 16zolmitriptan orally disintegrating tab 2.5 mg (Zomig

zmt)................................................................................. 84zolmitriptan orally disintegrating tab 5 mg (Zomig

zmt)................................................................................. 84zolmitriptan tab 2.5 mg (Zomig).....................................84zolmitriptan tab 5 mg (Zomig)........................................84zolpidem tartrate sl tab 1.75 mg (Intermezzo)..............66zolpidem tartrate sl tab 3.5 mg (Intermezzo)................66zolpidem tartrate tab er 6.25 mg (Ambien cr)...............66zolpidem tartrate tab er 12.5 mg (Ambien cr)...............67zolpidem tartrate tab 5 mg (Ambien).............................67zolpidem tartrate tab 10 mg (Ambien)...........................67ZOLPIMIST -zolpidem tartrate oral spray 5 mg/act.......... 67ZOMACTON -somatropin for inj 10 mg.............................33ZOMACTON -somatropin for subcutaneous inj 5 mg....... 33ZOMIG -zolmitriptan nasal spray 2.5 mg/spray unit..........84ZOMIG -zolmitriptan nasal spray 5 mg/spray unit............ 84ZONALON -doxepin hcl cream 5%................................. 117zonisamide cap 50 mg.................................................... 88zonisamide cap 25 mg (Zonegran)................................ 88zonisamide cap 100 mg (Zonegran).............................. 88ZONTIVITY -vorapaxar sulfate tab 2.08 mg (base

equivalent).....................................................................106ZORBTIVE -somatropin (non-refrigerated) for

subcutaneous inj 8.8 mg................................................ 33ZORTRESS -everolimus tab 0.25 mg.............................127ZORTRESS -everolimus tab 0.5 mg...............................127ZORTRESS -everolimus tab 0.75 mg.............................127ZORVOLEX -diclofenac cap 18 mg.................................. 83ZORVOLEX -diclofenac cap 35 mg.................................. 83ZOSTAVAX -zoster vaccine live for subcutaneous susp

19400 unit/0.65ml........................................................... 11ZOVIRAX -acyclovir cream 5%....................................... 117ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab

0.7-0.18 mg (base eq)....................................................80ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab

1.4-0.36 mg (base eq)....................................................80

2019


ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab2.9-0.71 mg (base eq)....................................................80

ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 5.7-1.4mg (base eq)...................................................................80



ZUPLENZ -ondansetron oral soluble film 4 mg................ 55ZUPLENZ -ondansetron oral soluble film 8 mg................ 55ZURAMPIC -lesinurad tab 200 mg................................... 84ZYCLARA -imiquimod cream 3.75%...............................117ZYCLARA PUMP -imiquimod cream 2.5%..................... 117ZYCLARA PUMP -imiquimod cream 3.75%................... 117ZYDELIG -idelalisib tab 100 mg........................................16ZYDELIG -idelalisib tab 150 mg........................................16ZYFLO CR -zileuton tab er 12hr 600 mg..........................52ZYFLO -zileuton tab 600 mg.............................................51ZYKADIA -ceritinib cap 150 mg........................................ 16ZYLET -loteprednol etabonate-tobramycin ophth susp

0.5-0.3%........................................................................ 109ZYPITAMAG -pitavastatin magnesium tab 1 mg (base

equiv)...............................................................................45ZYPITAMAG -pitavastatin magnesium tab 2 mg (base

equiv)...............................................................................45ZYPITAMAG -pitavastatin magnesium tab 4 mg (base

equiv)...............................................................................45ZYTIGA -abiraterone acetate tab 250 mg.........................16ZYTIGA -abiraterone acetate tab 500 mg.........................16

rxsense performance formulary july 2019 · rxsense performance iiformulary july 2019 introduction...

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