Caresourceformulary PDF

CareSource Advantage (HMO SNP)
Ohio Comprehensive Formulary
H6178_OHMSNP660
CMS File and Use 9/29/2012
Printed on 10/2/2012
CareSource Advantage (HMO SNP)

2013 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE

DRUGS WE COVER IN THIS PLAN.
Note to existing members: This formulary has changed since last year. Please
review this document to make sure that it still contains the drugs you take.
Disclaimers
Beneficiaries must use network pharmacies to access their prescription drug
benefit. Benefits, formulary, pharmacy network, premium and/or
copayments/coinsurance may change on January 1, 2014.
CareSource Advantage is a coordinated care plan with a Medicare Advantage
contract and a contract with the Ohio Medicaid Program.
To receive material in an alternate format or language, please call CareSource
Advantages Member Services Department at 1-800-708-8729 (TTY/TDD:
1-800-750-0750 or 711).
H6178_OHMSNP660
CMS File and Use: 9/29/2012
HPMS Approved Formulary File Submission ID# 00013034, Version 14

Last Updated 11/1/2013
What is the CareSource Advantage Formulary?

A formulary is a list of covered drugs selected by CareSource Advantage in
consultation with a team of health care providers, which represents the
prescription therapies believed to be a necessary part of a quality treatment
program. CareSource Advantage will generally cover the drugs listed in our
formulary as long as the drug is medically necessary, the prescription is filled
at a CareSource Advantage network pharmacy, and other plan rules are
followed. For more information on how to fill your prescriptions, please review
your Evidence of Coverage.
Can the Formulary change?

Generally, if you are taking a drug on our 2013 formulary that was covered at
the beginning of the year, we will not discontinue or reduce coverage of the
drug during the 2013 coverage year except when a new, less expensive
generic drug becomes available or when new adverse information about the
safety or effectiveness of a drug is released. Other types of formulary
changes, such as removing a drug from our formulary, will not affect members
who are currently taking the drug. It will remain available at the same costsharing for those members taking it for the remainder of the coverage year.
We feel it is important that you have continued access for the remainder of the
coverage year to the formulary drugs that were available when you chose our
plan, except for cases in which you can save additional money or we can
ensure your safety.
If we remove drugs from our formulary or add prior authorization, quantity
limits and/or step therapy restrictions on a drug or move a drug to a higher
cost-sharing tier, we must notify affected members of the change at least 60
days before the change becomes effective, or at the time the member
requests a refill of the drug, at which time the member will receive a 60-day
supply of the drug. If the Food and Drug Administration deems a drug on our
formulary to be unsafe or the drugs manufacturer removes the drug from the
market, we will immediately remove the drug from our formulary and provide
notice to members who take the drug. The enclosed formulary is current as of
November 1, 2013. To get updated information about the drugs covered by
CareSource Advantage, please visit our Web site at www.caresource.com or
call our Member Services Department at 1-800-708-8729, Monday Friday,
8 a.m. to 8 p.m. TTY/TDD users should call 1-800-750-0750 or 711. Mid-year
non-maintenance formulary changes occurring after the date the formulary
was last updated will be distributed via appropriate member materials and will
also be posted on our website at www.caresource.com.
ii
How do I use the Formulary?

There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 1. The drugs in this formulary are grouped into
categories depending on the type of medical conditions that they are used to
treat. For example, drugs used to treat a heart condition are listed under the
category, Cardiac Drugs. If you know what your drug is used for, look for the
category name in the list that begins on page 1. Then look under the category
name for your drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug
in the Index that begins on page 89. The Index provides an alphabetical list of
all of the drugs included in this document. Both brand name drugs and generic
drugs are listed in the Index. Look in the Index and find your drug. Next to your
drug, you will see the page number where you can find coverage information.
Turn to the page listed in the Index and find the name of your drug in the first
column of the list.
What are generic drugs?

CareSource Advantage covers both brand name drugs and generic drugs. A
generic drug is approved by the FDA as having the same active ingredient as
the brand name drug. Generally, generic drugs cost less than brand name
drugs.
Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage.
These requirements and limits may include:
Prior Authorization: CareSource Advantage requires you or your

physician to get prior authorization for certain drugs. This means that you
will need to get approval from CareSource Advantage before you fill your
prescriptions. If you dont get approval, CareSource Advantage may not
cover the drug.
Quantity Limits: For certain drugs, CareSource Advantage limits the

amount of the drug that CareSource Advantage will cover. For example,
CareSource Advantage provides 30 tablets per prescription for Atorvastatin
80 mg. This may be in addition to a standard one-month or three-month
supply.
iii
Step Therapy: In some cases, CareSource Advantage requires you to first

try certain drugs to treat your medical condition before we will cover another
drug for that condition. For example, if Drug A and Drug B both treat your
medical condition, CareSource Advantage may not cover Drug B unless you
try Drug A first. If Drug A does not work for you, CareSource Advantage will
then cover Drug B.
You can find out if your drug has any additional requirements or limits by
looking in the formulary that begins on page 1. You can also get more
information about the restrictions applied to specific covered drugs by visiting
our Web site at www.caresource.com.
You can ask CareSource Advantage to make an exception to these
restrictions or limits. See the section, How do I request an exception to the
CareSource Advantage formulary? on page iv for information about how to
request an exception.
What if my drug is not on the Formulary?

If your drug is not included in this formulary, you should first contact Member
Services and confirm that your drug is not covered. If you learn that
CareSource Advantage does not cover your drug, you have two options:
You can ask Member Services for a list of similar drugs that are
covered by CareSource Advantage. When you receive the list, show it
to your doctor and ask him or her to prescribe a similar drug that is
covered by CareSource Advantage.
You can ask CareSource Advantage to make an exception and cover

your drug. See below for information about how to request an exception.
How do I request an exception to the CareSource Advantage

Formulary?
You can ask CareSource Advantage to make an exception to our coverage
rules. There are several types of exceptions that you can ask us to make.
You can ask us to cover your drug even if it is not on our formulary.
You can ask us to waive coverage restrictions or limits on your drug.

For example, for certain drugs, CareSource Advantage limits the
amount of the drug that we will cover. If your drug has a quantity limit,
you can ask us to waive the limit and cover more.
You can ask us to provide a higher level of coverage for your drug. If
your drug is contained in our non-preferred/highest tier subject to the
tiering exceptions process tier, you can ask us to cover it at the costsharing amount that applies to drugs in the preferred/lowest tier subject
to the tiering exceptions process tier instead. This would lower the
iv
amount you must pay for your drug. Please note, if we grant your
request to cover a drug that is not on our formulary, you may not ask us
to provide a higher level of coverage for the drug.
Generally, CareSource Advantage will only approve your request for an
exception if the alternative drugs included on the plans formulary, the lowertiered drug or additional utilization restrictions would not be as effective in
treating your condition and/or would cause you to have adverse medical
effects.
You should contact us to ask us for an initial coverage decision for a formulary,
tiering or utilization restriction exception. When you are requesting a
formulary, tiering or utilization restriction exception, you should submit a
statement from your physician supporting your request. Generally, we
must make our decision within 72 hours of getting your prescribers or
prescribing physicians supporting statement. You can request an expedited
(fast) exception if you or your doctor believe that your health could be seriously
harmed by waiting up to 72 hours for a decision. If your request to expedite is
granted, we must give you a decision no later than 24 hours after we get your
prescribers or prescribing physicians supporting statement.
What do I do before I can talk to my doctor about changing my

drugs or requesting an exception?
As a new or continuing member in our plan, you may be taking drugs that are
not on our formulary. Or, you may be taking a drug that is on our formulary but
your ability to get it is limited. For example, you may need a prior authorization
from us before you can fill your prescription. You should talk to your doctor to
decide if you should switch to an appropriate drug that we cover or request a
formulary exception so that we will cover the drug you take. While you talk to
your doctor to determine the right course of action for you, we may cover your
drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your
drugs is limited, we will cover a temporary 30-day supply (unless you have a
prescription written for fewer days) when you go to a network pharmacy. After
your first 30-day supply, we will not pay for these drugs, even if you have been
a member of the plan less than 90 days.
If you are a resident of a long-term care facility, we will allow you to refill your
prescription until we have provided you with at least 91 and may be up to a 98
day transition supply, consistent with the dispensing increment (unless you
have a prescription written for fewer days). We will cover more than one refill
of these drugs for the first 90 days you are a member of our plan. If you need a
drug that is not on our formulary or if your ability to get your drugs is limited,
but you are past the first 90 days of membership in our plan, we will cover a
31-day emergency supply of that drug (unless you have a prescription for
fewer days) while you pursue a formulary exception.
New members in our plan may be taking drugs that arent on our formulary or
that are subject to certain restrictions, such as prior authorization or step
therapy. Current members may also be affected by changes in our formulary
from one year to the next. Members should talk to their doctors to decide if
they should switch to a different drug that we cover or request a formulary
exception in order to get coverage for the drug. Please contact Member
Services if your drug is not on our formulary, is subject to certain restrictions,
such as prior authorization or step therapy, or will no longer be on our
formulary next year and you need help switching to a different drug that we
cover or requesting a formulary exception.
During the period of time members are talking to their doctors to determine the
right course of action, we may provide a temporary supply of the non-formulary
drug if those members need a refill for the drug during the first 90 days of new
membership in our plan. If you are a current member affected by a formulary
change from one year to the next, we will provide you with the opportunity to
request a formulary exception in advance for the following year.
When a member goes to a network pharmacy and we provide a temporary
supply of a drug that isnt on our formulary, or that has coverage restrictions or
limits (but is otherwise considered a Part D drug), we will cover a 30-day
supply (unless the prescription is written for fewer days). After we cover the
temporary 30-day supply, we generally will not pay for these drugs as part of
our transition policy again. We will provide you with a written notice after we
cover your temporary supply. This notice will explain the steps you can take to
request an exception and how to work with your doctor to decide if you should
switch to an appropriate drug that we cover.
If a new member is a resident of a long-term care facility (like a nursing home),
we will cover at least 91 and up to a 98 day transition supply, consistent with
the dispensing increments (unless the prescription is written for fewer days).
We will cover more than one refill of these drugs during the first 90 days a new
member is enrolled in our plan. If the resident has been enrolled in our plan for
more than 90 days and needs a drug that isnt on our formulary or is subject to
other restrictions, such as step therapy or dosage limits, we will cover a
temporary 31-day emergency supply of that drug (unless the prescription is for
fewer days) while the new member pursues a formulary exception.
Please note that our transition policy applies only to those drugs that are Part
D drugs and bought at a network pharmacy. The transition policy cant be
used to buy a non-Part D drug or a drug out of network, unless you qualify for
out-of-network access.
vi
For more information

For more detailed information about your CareSource Advantage prescription
drug coverage, please review your Evidence of Coverage and other plan
materials.
If you have questions about CareSource Advantage, please call Member
Services at 1-800-708-8729, Monday Friday, 8 a.m. to 8 p.m. TTY/TDD
users should call 1-800-750-0750 or 711. Or visit www.caresource.com.
If you have general questions about Medicare prescription drug coverage,
please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/
7 days a week. TTY/TDD users should call 1-877-486-2048. Or visit
www.medicare.gov.
vii
CareSource Advantages Formulary

The formulary that begins on the next page provides coverage information
about some of the drugs covered by CareSource Advantage. If you have
trouble finding your drug in the list, turn to the Index that begins on page 89.
The first column of the chart lists the drug name. Brand name drugs are
capitalized (e.g., COUMADIN) and generic drugs are listed in lower-case
italics (e.g., warfarin sodium). The information in the Requirements/Limits
column tells you if CareSource Advantage has any special requirements for
coverage of your drug.
2013 COMPREHENSIVE FORMULARY ABBREVIATIONS

B/D: Indicates that the prescription can be covered through the Part B or D
benefit depending on the situation. Information may need to be submitted
describing the use and setting of the drug to make the determination.
LA: Indicates a prescription may be available only at certain pharmacies.
NM: Indicates that the drug is not available at mail-order.
PA: Indicates that prior authorization may apply.
QL: Indicates that quantities dispensed may be limited.
ST: Indicates that step therapy may apply.
Drug Name
Drug Tier
Requirements/Limits
Cardiovascular Agents Drugs to treat high blood pressure

amlodipine besylate-benazepril
CAP 5-40 MG
propranolol TAB 10 MG
(QL) 30 tabs/30days
Central Nervous System Drugs to treat seizures

DILANTIN CHW 50MG
VIMPAT TAB 50MG
(QL) 180 tabs/30days
Endocrine and Metabolic (Antidiabetic) Drugs to treat high blood sugar

metformin TAB 750 MG ER
(QL) 60 tabs/30days
PRANDIN TAB 2MG
(QL) 240 tabs/30days
viii
Drug Name
Drug Tier Requirements/Limits
ANALGESICS
GOUT
allopurinol sodium for inj 500 mg
allopurinol tab 100 mg
allopurinol tab 300 mg
colchicine w/ probenecid tab 0.5-500 mg
COLCRYS TAB 0.6MG
probenecid tab 500 mg
ULORIC TAB 40MG
ULORIC TAB 80MG
1
1
1
1
2
1
2
2
QL (60 tabs / 30 days)

ST
ST
NARCOTIC ANALGESICS
acetaminophen w/ codeine soln 120-12
1
mg/5ml
acetaminophen w/ codeine tab 300-15 mg 1
butorphanol tartrate inj 1 mg/ml
1
butorphanol tartrate inj 2 mg/ml
1
co-gesic tab 5-500mg
1
hydrocodone-acetaminophen soln 7.5-500 1
mg/15ml
hydrocodone-acetaminophen tab 2.5-500 1
mg
hydrocodone-acetaminophen tab 5-325 mg 1
hydrocodone-acetaminophen tab 5-500 mg 1
mg
mg
mg
mg
hydrocodone-acetaminophen tab 10-325 1
mg
mg
mg
mg
PA - Prior Authorization
available at mail-order
QL (5000 mL / 30 days)

QL (3600 mL / 30 days)
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
B/D This drug may be covered under Medicare Part B or D depending upon the
circumstances. Information may need to be submitted describing the use and setting of the
drug to make the determination.
Drug Name
hydrocodone-acetaminophen tab 10-750
mg
hydrocodone-ibuprofen tab 7.5-200 mg
stagesic cap 5-500mg

1
1
1

QL (240 caps / 30 days)
astramorph inj 1mg/2ml

astramorph inj 10/10ml
AVINZA CAP 30MG
AVINZA CAP 45MG
AVINZA CAP 60MG
AVINZA CAP 75MG
AVINZA CAP 90MG
AVINZA CAP 120MG
DILAUDID-5 LIQ 1MG/ML
DURAMORPH INJ 0.5MG/ML
DURAMORPH INJ 1MG/ML
endocet tab 5-325mg
endocet tab 7.5-325
endocet tab 7.5-500m
endocet tab 10-325mg
endocet tab 10-650mg
ENDODAN TAB
EXALGO TAB 8MG
EXALGO TAB 12MG
EXALGO TAB 16MG
EXALGO TAB 32MG
fentanyl citrate lollipop 200 mcg
1
1
3
3
3
3
3
3
2
1
1
1
1
1
1
1
1
2
2
2
2
4
B/D
B/D
QL (60
QL (60
QL (60
QL (60
QL (60
QL (60
fentanyl
fentanyl
fentanyl
fentanyl
1
1
1
1
NARCOTIC ANALGESICS, CII
td
td
td
td
patch
patch
patch
patch
72hr
72hr
72hr
72hr
12
25
50
75
mcg/hr
mcg/hr
mcg/hr
mcg/hr
ea
ea
ea
ea
ea
ea
/
/
/
/
/
/
30
30
30
30
30
30
days)
days)
days)
days)
days)
days)
B/D
B/D
QL (60 ea / 30 days)
QL (120 lpop / 30 days),
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
QL (10 ea / 30 days), PA
ST - Step Therapy
NM - Not
LA - Limited Access
Drug Name
fentanyl td patch 72hr 100 mcg/hr
hydromorphone hcl liqd 1 mg/ml
hydromorphone hcl preservative free (pf)
inj 10 mg/ml
hydromorphone hcl tab 2 mg
KADIAN CAP 10MG CR
KADIAN CAP 20MG CR
KADIAN CAP 30MG CR
KADIAN CAP 40MG CR
KADIAN CAP 50MG CR
KADIAN CAP 60MG CR
KADIAN CAP 70MG CR
KADIAN CAP 80MG CR
KADIAN CAP 100MG CR
KADIAN CAP 130MG CR
KADIAN CAP 150MG CR
KADIAN CAP 200MG CR
LAZANDA SPR 100MCG

1
1
1
B/D
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
4
LAZANDA SPR 400MCG
methadone hcl conc 10 mg/ml

methadone hcl soln 5 mg/5ml
methadone hcl soln 10 mg/5ml
methadone hcl tab 5 mg
methadone hcl tab 10 mg
methadose tab 10mg
MORPHINE SUL INJ 4MG/ML
MORPHINE SUL SOL 10MG/5ML
MORPHINE SUL SOL 20MG/5ML
MORPHINE SUL SOL 20MG/ML
MORPHINE SUL TAB 15MG
MORPHINE SUL TAB 30MG
morphine sulfate inj pf 0.5 mg/ml
morphine sulfate inj pf 1 mg/ml
morphine sulfate tab cr 15 mg
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

QL (8 bottles / 30 days),
NM, PA
QL (8 bottles / 30 days),
NM, PA

B/D
B/D
B/D
B/D

B/D
B/D
ST - Step Therapy
NM - Not
LA - Limited Access
Drug Name
1
1
1
OXYCODONE CAP 5MG
1
OXYCODONE CON 20MG/ML
1
oxycodone hcl tab 5 mg
1
1
1
1
1
OXYCODONE SOL 5MG/5ML
1
oxycodone w/ acetaminophen cap 5-500 mg1
oxycodone w/ acetaminophen tab 2.5-325 1
mg
oxycodone w/ acetaminophen tab 5-325 mg1
mg
mg
oxycodone w/ acetaminophen tab 10-325 1
mg
oxycodone w/ acetaminophen tab 10-650 1
mg
oxycodone-aspirin tab 4.8355-325 mg
1
roxicet sol 5-325/5
2
QL (1800 mL / 30 days)
NON-NARCOTIC ANALGESICS
tramadol hcl tab 50 mg
1
tramadol-acetaminophen tab 37.5-325 mg 1

NSAIDS
CELEBREX
CELEBREX
CELEBREX
CELEBREX
CAP
CAP
CAP
CAP
50MG
100MG
200MG
400MG
diclofenac
diclofenac
mg
diclofenac
mg
diclofenac
mg
diclofenac
potassium tab 50 mg
sodium tab delayed release 25
1
1
sodium tab sr 24hr 100 mg
2
2
2
2
QL
QL
QL
QL
PA
(60
(60
(60
(60
caps
caps
caps
caps
/
/
/
/
30
30
30
30
days)
days)
days)
days),
ST - Step Therapy
NM - Not
LA - Limited Access
Drug Name
diflunisal tab 500 mg
etodolac cap 200 mg
etodolac cap 300 mg
etodolac er tab 400mg
etodolac tab 400 mg
etodolac tab 500 mg
flurbiprofen tab 50 mg
flurbiprofen tab 100 mg
ibuprofen susp 100 mg/5ml
ibuprofen tab 400 mg
ketoprofen cap 50 mg
ketoprofen cap 75 mg
ketoprofen cap sr 24hr 200 mg
MELOXICAM SUS 7.5/5ML
meloxicam tab 7.5 mg
meloxicam tab 15 mg
nabumetone tab 500 mg
nabumetone tab 750 mg
naproxen dr tab 375mg
naproxen dr tab 500mg
naproxen sodium tab 275 mg
naproxen sodium tab 550 mg
naproxen susp 125 mg/5ml
naproxen tab 250 mg
naproxen tab 375 mg
naproxen tab 500 mg
oxaprozin tab 600 mg
piroxicam cap 10 mg
piroxicam cap 20 mg
sulindac tab 150 mg
sulindac tab 200 mg

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ANESTHETICS
LOCAL ANESTHETICS
lidocaine hcl local preservative free (pf) inj 1
0.5%
lidocaine hcl local preservative free (pf) inj 1
1%
ST - Step Therapy
NM - Not
LA - Limited Access
Drug Name
ANTI-INFECTIVES
ANTIBACTERIALS
amikacin sulfate inj 1 gm/4ml (250 mg/ml) 1
amikacin sulfate inj 100 mg/2ml (50 mg/ml)1
amoxicillin & k clavulanate chew tab
1
200-28.5 mg
amoxicillin & k clavulanate chew tab 400-571
mg
amoxicillin & k clavulanate for susp
1
200-28.5 mg/5ml
1
250-62.5 mg/5ml
amoxicillin & k clavulanate for susp 400-57 1
mg/5ml
1
600-42.9 mg/5ml
amoxicillin & k clavulanate tab 250-125 mg 1
amoxicillin & k clavulanate tab sr 12hr
1
1000-62.5 mg
amoxicillin (trihydrate) cap 250 mg
1
amoxicillin (trihydrate) cap 500 mg
1
amoxicillin (trihydrate) chew tab 125 mg 1
amoxicillin (trihydrate) chew tab 250 mg 1
amoxicillin (trihydrate) for susp 125 mg/5ml1
amoxicillin (trihydrate) tab 500 mg
1
amoxicillin (trihydrate) tab 875 mg
1
ampicillin & sulbactam sodium for inj 2-1 gm1
ampicillin & sulbactam sodium for inj 10-5 1
gm
ampicillin & sulbactam sodium for iv soln 1
10-5 gm
ampicillin cap 250 mg
1
ampicillin cap 500 mg
1
ampicillin for susp 125 mg/5ml
1
ampicillin for susp 250 mg/5ml
1
ampicillin sodium for inj 1 gm
1
ampicillin sodium for inj 125 mg
1
ST - Step Therapy
NM - Not
LA - Limited Access
Drug Name
ampicillin sodium for iv soln 10 gm
1
AVELOX ABC TAB 400MG
2
AVELOX INJ
2
AVELOX TAB 400MG
2
azithromycin for susp 100 mg/5ml
1
azithromycin for susp 200 mg/5ml
1
azithromycin iv for soln 500 mg
1
azithromycin tab 250 mg
1
1
1
BICILLIN C-R INJ 900/300
3
BICILLIN C-R INJ 1200000
3
BICILLIN L-A INJ 600000
3
3
3
cefaclor cap 250 mg
1
cefaclor cap 500 mg
1
cefaclor for susp 125 mg/5ml
1
1
1
cefaclor monohydrate tab sr 12hr 500 mg 2
cefadroxil cap 500 mg
1
cefadroxil for susp 250 mg/5ml
1
cefadroxil for susp 500 mg/5ml
1
cefadroxil tab 1 gm
1
cefazolin in d5w inj 1 gm/50ml
2
cefazolin sodium for inj 1 gm
1
cefazolin sodium for inj 10 gm
1
cefazolin sodium for inj 500 mg
1
cefdinir cap 300 mg
1
cefdinir for susp 125 mg/5ml
1
cefdinir for susp 250 mg/5ml
1
cefepime hcl for inj 1 gm
1
cefepime hcl for inj 2 gm
1
cefotaxime sodium for inj 1 gm
1
1
1
cefotaxime sodium for inj 500 mg
1
cefoxitin sodium for inj 1 gm
1
1
1
cefpodoxime proxetil for susp 50 mg/5ml 1
ST - Step Therapy
NM - Not
7
LA - Limited Access
Drug Name
cefpodoxime proxetil for susp 100 mg/5ml
cefpodoxime proxetil tab 100 mg
cefpodoxime proxetil tab 200 mg
cefprozil for susp 125 mg/5ml
cefprozil for susp 250 mg/5ml
cefprozil tab 250 mg
cefprozil tab 500 mg
ceftazidime for inj 1 gm
CEFTAZIDIME/ SOL D5W 1GM
CEFTAZIDIME/ SOL D5W 2GM
ceftriaxone sodium for inj 10 gm
ceftriaxone sodium for inj 250 mg
ceftriaxone sodium for inj 500 mg
ceftriaxone sodium for iv soln 1 gm
ceftriaxone sodium for iv soln 2 gm
cefuroxime axetil tab 250 mg
cefuroxime axetil tab 500 mg
cefuroxime sodium for inj 1.5 gm
cefuroxime sodium for inj 7.5 gm
cefuroxime sodium for inj 750 mg
cephalexin cap 250 mg
cephalexin cap 500 mg
cephalexin for susp 125 mg/5ml
cephalexin for susp 250 mg/5ml
CIPRO (5%) SUS 250MG/5
CIPRO (10%) SUS 500MG/5
ciprofloxacin 200 mg/100ml in d5w
ciprofloxacin hcl tab 100 mg (base equiv)
ciprofloxacin iv soln 400 mg/40ml (1%)
ciprofloxacin-ciprofloxacin hcl tab sr 24hr
500 mg (base eq)
1000 mg(base eq)
clarithromycin for susp 125 mg/5ml
clarithromycin for susp 250 mg/5ml
clarithromycin tab 250 mg
clarithromycin tab 500 mg

1
1
1
1
1
1
1
1
1
1
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
3
1
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
Drug Name
clarithromycin tab sr 24hr 500 mg
1
dicloxacillin sodium cap 250 mg
1
dicloxacillin sodium cap 500 mg
1
DIFICID TAB 200MG
4
NM, ST
doxycycline hyclate cap 50 mg
1
doxycycline hyclate cap 100 mg
1
doxycycline hyclate for inj 100 mg
1
doxycycline hyclate tab 20 mg
1
doxycycline hyclate tab 100 mg
1
doxycycline monohydrate tab 50 mg
1
1
1
e.e.s. 400 tab 400mg
1
E.E.S. GRAN SUS 200/5ML
2
ery-tab tab 250mg ec
2
2
2
ERYPED SUS 200/5ML
2
ERYPED SUS 400/5ML
2
erythrocin tab 250mg
1
erythromycin ethylsuccinate tab 400 mg
1
erythromycin tab 250 mg
1
erythromycin tab 500 mg
1
gentamicin in saline inj 0.8 mg/ml
1
3
gentamicin in saline inj 1 mg/ml
1
1
3
1
gentamicin sulfate inj 40 mg/ml
1
gentamicin sulfate iv soln 10 mg/ml
1
levofloxacin in d5w iv soln 500 mg/100ml 1
levofloxacin iv soln 25 mg/ml
1
levofloxacin oral soln 25 mg/ml
1
levofloxacin tab 250 mg
1
1
1
minocycline hcl cap 50 mg
1
1
1
nafcillin sodium for inj 1 gm
1
nafcillin sodium for inj 10 gm
1
ST - Step Therapy
NM - Not
9
LA - Limited Access
Drug Name
neomycin sulfate tab 500 mg
oxacillin sodium for inj 1 gm
oxacillin sodium for inj 10 gm
paromomycin sulfate cap 250 mg
PENICILL GK/ INJ DEX 2MU
PENICILL GK/ INJ DEX 3MU
penicillin g potassium for inj 5000000 unit
penicillin g procaine intramuscular susp
600000 unit/ml
penicillin g sodium for inj 5000000 unit
penicillin v potassium for soln 125 mg/5ml
penicillin v potassium tab 250 mg
penicillin v potassium tab 500 mg
piperacillin sodium-tazobactam sodium for
inj 3-0.375 gm
piperacillin sodium-tazobactam sodium for
inj 4-0.5 gm
streptomycin sulfate for inj 1 gm
sulfadiazine tab 500 mg
SUPRAX CAP 400MG
suprax chw 100mg
suprax chw 200mg
suprax sus 100/5ml
suprax sus 200/5ml
SUPRAX SUS 500/5ML
suprax tab 400mg
tazicef inj 1gm
tazicef inj 2gm
tazicef inj 6gm
tetracycline hcl cap 250 mg
tetracycline hcl cap 500 mg
TIMENTIN INJ 3.1GM
tobramycin sulfate inj 0.8 mg/ml in saline
tobramycin sulfate inj 10 mg/ml
tobramycin sulfate inj 80 mg/2ml (40
mg/ml)
VIBRAMYCIN SYP 50MG/5ML
ZMAX SUS 2GM

1
1
1
1
2
2
1
2
1
1
1
1
1
1
1
1
2
2
3
3
2
2
2
2
1
1
1
1
1
3
2
2
1
1
2
2
ANTIFUNGALS
ABELCET INJ 5MG/ML
B/D, NM
ST - Step Therapy
NM - Not
LA - Limited Access
10
Drug Name
AMBISOME INJ 50MG
amphotericin b for inj 50 mg
CANCIDAS INJ 50MG
CANCIDAS INJ 70MG
ERAXIS INJ 100MG
fluconazole for susp 10 mg/ml
fluconazole for susp 40 mg/ml
fluconazole in dextrose inj 400 mg/200ml
fluconazole tab 50 mg
flucytosine cap 250 mg
flucytosine cap 500 mg
griseofulvin microsize susp 125 mg/5ml
griseofulvin microsize tab 500 mg
griseofulvin ultramicrosize tab 125 mg
griseofulvin ultramicrosize tab 250 mg
itraconazole cap 100 mg
ketoconazole tab 200 mg
MYCAMINE INJ 50MG
MYCAMINE INJ 100MG
NOXAFIL SUS 40MG/ML
nystatin tab 500000 unit
terbinafine hcl tab 250 mg
VFEND SUS 40MG/ML
VORICONAZOLE INJ 200MG
voriconazole tab 50 mg
voriconazole tab 200 mg

4
B/D, NM
1
B/D
4
NM
4
NM
4
NM
1
1
1
1
1
1
1
4
NM
4
NM
1
1
1
1
1
PA
1
4
NM
4
NM
4
NM
1
1
QL (90 tabs / year)
4
NM
1
4
NM
4
NM
ANTIMALARIALS
atovaquone-proguanil hcl tab 250-100 mg 1
chloroquine phosphate tab 250 mg
1
chloroquine phosphate tab 500 mg
1
COARTEM TAB 20-120MG
3
DARAPRIM TAB 25MG
3
mefloquine hcl tab 250 mg
1
PRIMAQUINE TAB 26.3MG
2
ANTIRETROVIRAL AGENTS
abacavir sulfate tab 300 mg (base equiv)
APTIVUS CAP 250MG
APTIVUS SOL
1
4
4
NM
NM
ST - Step Therapy
NM - Not
LA - Limited Access
11
Drug Name
ATRIPLA TAB
4
NM
COMPLERA TAB
4
NM
CRIXIVAN CAP 200MG
3
CRIXIVAN CAP 400MG
3
didanosine delayed release capsule 125 mg 1
EDURANT TAB 25MG
4
NM
EMTRIVA CAP 200MG
2
EMTRIVA SOL 10MG/ML
2
EPIVIR SOL 10MG/ML
2
EPZICOM TAB 600-300
4
NM
FUZEON KIT
4
NM
INTELENCE TAB 25MG
3
INTELENCE TAB 100MG
4
NM
INTELENCE TAB 200MG
4
NM
INVIRASE CAP 200MG
3
INVIRASE TAB 500MG
4
NM
ISENTRESS CHW 25MG
2
ISENTRESS CHW 100MG
4
NM
ISENTRESS TAB 400MG
4
NM
KALETRA SOL
4
NM
KALETRA TAB 100-25MG
2
KALETRA TAB 200-50MG
4
NM
lamivudine tab 150 mg
1
lamivudine tab 300 mg
1
lamivudine-zidovudine tab 150-300 mg
4
NM
LEXIVA SUS 50MG/ML
3
LEXIVA TAB 700MG
3
NEVIRAPINE SUS 50MG/5ML
1
nevirapine tab 200 mg
1
NORVIR CAP 100MG
2
NORVIR SOL 80MG/ML
2
NORVIR TAB 100MG
2
PREZISTA SUS 100MG/ML
4
NM
PREZISTA TAB 75MG
2
PREZISTA TAB 150MG
4
NM
PREZISTA TAB 400MG
4
NM
PREZISTA TAB 600MG
4
NM
PREZISTA TAB 800MG
4
NM
RESCRIPTOR TAB 100 MG
3
ST - Step Therapy
NM - Not
12
LA - Limited Access
Drug Name
RESCRIPTOR TAB 200MG
RETROVIR INJ 10MG/ML
REYATAZ CAP 100MG
REYATAZ CAP 150MG
REYATAZ CAP 200MG
REYATAZ CAP 300MG
SELZENTRY TAB 150MG
SELZENTRY TAB 300MG
stavudine cap 15 mg
stavudine cap 20 mg
stavudine cap 30 mg
stavudine cap 40 mg
stavudine for oral soln 1 mg/ml
STRIBILD TAB
SUSTIVA CAP 50MG
SUSTIVA CAP 200MG
SUSTIVA TAB 600MG
TRIZIVIR TAB
TRUVADA TAB 200-300
VIDEX SOL 2GM
VIRACEPT TAB 250MG
VIRACEPT TAB 625MG
VIRAMUNE SUS 50MG/5ML
VIRAMUNE XR TAB 100MG
VIRAMUNE XR TAB 400MG
VIREAD POW 40MG/GM
VIREAD TAB 150MG
VIREAD TAB 200MG
VIREAD TAB 250MG
VIREAD TAB 300MG
ZIAGEN SOL 20MG/ML
zidovudine cap 100 mg
zidovudine syrup 10 mg/ml
zidovudine tab 300 mg

3
2
2
2
2
2
4
NM
4
NM
1
1
1
1
1
4
NM
2
2
2
4
NM
4
NM
3
4
NM
4
NM
3
3
3
4
NM
4
NM
4
NM
4
NM
4
NM
3
1
1
1
ANTITUBERCULAR AGENTS
CAPASTAT SUL INJ 1GM
ethambutol hcl tab 100 mg
ethambutol hcl tab 400 mg
isoniazid inj 100 mg/ml
isoniazid syrup 50 mg/5ml
isoniazid tab 100 mg
3
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
13
Drug Name
isoniazid tab 300 mg
MYCOBUTIN CAP 150MG
PASER GRA 4GM
PRIFTIN TAB 150MG
pyrazinamide tab 500 mg
rifampin cap 150 mg
rifampin cap 300 mg
rifampin for inj 600 mg
SEROMYCIN CAP 250MG
SIRTURO TAB 100MG
TRECATOR TAB 250MG

1
2
3
2
1
1
1
1
3
4
NM, LA, PA
2
ANTIVIRALS
acyclovir cap 200 mg
acyclovir sodium for inj 500 mg
acyclovir susp 200 mg/5ml
acyclovir tab 400 mg
acyclovir tab 800 mg
adefovir dipivoxil tab 10 mg
BARACLUDE SOL .05MG/ML
BARACLUDE TAB 0.5MG
BARACLUDE TAB 1MG
EPIVIR HBV SOL 5MG/ML
EPIVIR HBV TAB 100MG
famciclovir tab 125 mg
ganciclovir sodium for inj 500 mg
HEPSERA TAB 10MG
INCIVEK TAB 375MG
REBETOL SOL 40MG/ML
RELENZA MIS DISKHALE
1
1
1
1
1
4
2
2
2
2
2
1
1
1
1
4
4
4
2
B/D
NM, ST
B/D
NM, ST
NM, PA
NM, PA
QL (3 inhalers / 180
days)
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
ribapak mis 600/day

4
ribapak pak 800/day
4
ribapak pak 1000/day
4
ribapak pak 1200/day
4
ribasphere tab 400mg
4
ribasphere tab 600mg
4
ribavirin cap 200 mg
1
ribavirin tab 200 mg
1
rimantadine hydrochloride tab 100 mg
1
TAMIFLU CAP 30MG
2
ST - Step Therapy
NM - Not
14
LA - Limited Access
Drug Name
TAMIFLU CAP 45MG
TAMIFLU CAP 75MG
TAMIFLU SUS 6MG/ML
TYZEKA TAB 600MG
valacyclovir hcl tab 1 gm
valacyclovir hcl tab 500 mg
VALCYTE SOL 50MG/ML
VALCYTE TAB 450MG
VICTRELIS CAP 200MG

2
2
2
QL (540 mL / 180 days)
3
1
1
4
NM
4
NM
4
NM, PA
MISCELLANEOUS
ALBENZA TAB 200MG
ALINIA SUS 100MG/5M
ALINIA TAB 500MG
AZACTAM INJ 2GM
AZACTAM/DEX INJ 1GM
AZACTAM/DEX INJ 2GM
aztreonam for inj 1 gm
BILTRICIDE TAB 600MG
clindamycin hcl cap 75 mg
clindamycin palmitate hcl for soln 75
mg/5ml (base equiv)
clindamycin phosphate iv soln 600 mg/4ml
colistimethate sodium for inj 150 mg
CUBICIN SOL 500MG
dapsone tab 25 mg
dapsone tab 100 mg
DORIBAX INJ 500MG
imipenem-cilastatin intravenous for soln
250 mg
500 mg
INVANZ INJ 1GM
MACRODANTIN CAP 25MG
MEPRON SUS
meropenem iv for soln 500 mg
methenamine hippurate tab 1 gm
metronidazole cap 375 mg
metronidazole in nacl 0.79% iv soln 500
mg/100ml
metronidazole tab 250 mg
3
3
3
3
3
3
1
2
1
1
1
1
1
1
4
1
1
3
1
QL (540 mL / 30 days)
B/D, NM
1
3
2
4
1
1
1
1
PA
NM
ST - Step Therapy
NM - Not
LA - Limited Access
15
Drug Name
metronidazole tab 500 mg
1
NEBUPENT INH 300MG
3
B/D
nitrofurantoin macrocrystalline cap 50 mg 1
PA
nitrofurantoin monohydrate
1
PA
macrocrystalline cap 100 mg
sulfamethoxazole-trimethoprim iv soln
1
400-80 mg/5ml
sulfamethoxazole-trimethoprim susp
1
200-40 mg/5ml
sulfamethoxazole-trimethoprim tab 400-80 1
mg
sulfamethoxazole-trimethoprim tab
1
800-160 mg
trimethoprim tab 100 mg
1
TYGACIL INJ 50MG
4
NM
vancomycin hcl cap 125 mg
4
NM
vancomycin hcl cap 250 mg
4
NM
vancomycin hcl for inj 10 gm
1
B/D
vancomycin hcl for inj 500 mg
1
B/D
vancomycin hcl for inj 1000 mg
1
B/D
ZYVOX SOL 2MG/ML
4
NM
ZYVOX SUS 100MG/5M
4
NM
ZYVOX TAB 600MG
4
NM
ANTINEOPLASTIC AGENTS
ALKYLATING AGENTS
BICNU INJ 100MG
BUSULFEX INJ 6MG/ML
CEENU CAP 10MG
CEENU CAP 40MG
CEENU CAP 100MG
cyclophosphamide tab 25 mg
cyclophosphamide tab 50 mg
dacarbazine for inj 200 mg
EMCYT CAP 140MG
HEXALEN CAP 50MG
IFEX INJ 3GM
ifosfamide for inj 1 gm
LEUKERAN TAB 2MG
melphalan hcl for inj 50 mg (base equiv)
MUSTARGEN INJ 10MG
TREANDA INJ 100MG
3
3
2
2
2
1
1
1
2
4
3
1
2
4
3
4
B/D
B/D
B/D
B/D
B/D
NM
B/D
B/D
B/D, NM
B/D
B/D, NM
ANTHRACYCLINES
ST - Step Therapy
NM - Not
LA - Limited Access
16
Drug Name
adriamycin inj 2mg/ml
daunorubicin hcl inj 5 mg/ml (base equiv)
DOXIL INJ 2MG/ML
doxorubicin hcl inj 2 mg/ml
epirubicin hcl inj 50 mg/25ml (2 mg/ml)
idarubicin hcl iv inj 10 mg/10ml (1 mg/ml)

1
B/D
1
B/D
4
B/D, NM
1
B/D
1
B/D
4
B/D, NM
ANTIBIOTICS
bleomycin sulfate for inj 30 unit
COSMEGEN INJ 0.5MG
mitomycin for inj 20 mg
1
4
1
B/D
B/D, NM
B/D
4
1
1
1
4
1
1
1
1
4
2
4
B/D, NM
B/D
B/D
B/D
B/D, NM
ANTIMETABOLITES
ALIMTA INJ 500MG
cytarabine for inj 500 mg
cytarabine inj 20 mg/ml
fluorouracil inj 2.5 gm/50ml (50 mg/ml)
gemcitabine hcl for inj 1 gm
mercaptopurine tab 50 mg
methotrexate sodium for inj 1 gm
methotrexate sodium inj 25 mg/ml
methotrexate sodium inj pf 25 mg/ml
pentostatin for inj 10 mg
TABLOID TAB 40MG
VIDAZA INJ 100MG
B/D
B/D
B/D
B/D, NM
B/D, NM
ANTIMITOTIC, TAXOIDS
DOCETAXEL INJ 80MG/4ML
4
DOCETAXEL INJ 80MG/8ML
4
docetaxel inj 140/7ml
4
paclitaxel iv conc 300 mg/50ml (6 mg/ml) 1
TAXOTERE INJ 80MG/2ML
4
TAXOTERE INJ 80MG/4ML
4
B/D,
B/D,
B/D,
B/D
B/D,
B/D,
NM
NM
NM
NM
NM
ANTIMITOTIC, VINCA ALKALOIDS

vinblastine sulfate for inj 10 mg
vincasar pfs inj 1mg/ml
vincristine sulfate iv soln 1 mg/ml
vinorelbine tartrate inj 50 mg/5ml (10
mg/ml)
2
1
1
1
B/D
B/D
B/D
B/D
4
4
4
4
B/D, NM
B/D, NM
NM, LA, PA
B/D, NM
BIOLOGIC RESPONSE MODIFIERS

AVASTIN INJ
CAMPATH INJ 30MG/ML
ERIVEDGE CAP 150MG
HERCEPTIN INJ 440MG
ST - Step Therapy
NM - Not
LA - Limited Access
17
Drug Name
ISTODAX INJ 10MG
KADCYLA INJ 100MG
KADCYLA INJ 160MG
ONTAK INJ 150/ML
PROLEUKIN INJ 22MU
RITUXAN INJ 500MG
VELCADE INJ 3.5MG
ZOLINZA CAP 100MG

4
B/D, NM
4
B/D, NM
4
B/D, NM
4
B/D, NM
4
B/D, NM
4
NM, PA
4
B/D, NM
4
NM
HORMONAL ANTINEOPLASTIC AGENTS

anastrozole tab 1 mg
bicalutamide tab 50 mg
DEPO-PROVERA INJ 400/ML
exemestane tab 25 mg
FARESTON TAB 60MG
FASLODEX INJ 250MG
flutamide cap 125 mg
letrozole tab 2.5 mg
leuprolide acetate inj kit 5 mg/ml
LUPR DEP-PED INJ 11.25MG
LUPR DEP-PED INJ 11.25MG
1
1
2
1
3
4
1
1
1
4
4
LUPR DEP-PED INJ 15MG

LUPRON DEPOT INJ 3.75MG
4
4
LYSODREN TAB 500MG

MEGACE ES SUS 625/5ML
megestrol acetate susp 40 mg/ml
megestrol acetate tab 20 mg
megestrol acetate tab 40 mg
NILANDRON TAB 150MG
SOLTAMOX SOL 10MG/5ML
tamoxifen citrate tab 10 mg (base
equivalent)
equivalent)
TRELSTAR DEP INJ 3.75MG
4
2
1
1
1
3
3
1
TRELSTAR LA INJ 11.25MG
XTANDI CAP 40MG

ZYTIGA TAB 250MG
4
4

B/D
ST
B/D, NM
ST
NM, PA
NM, PA
QL (1 box / 84 days),
NM, PA
NM, PA
QL (1 box / 30 days),
NM, PA
NM
QL (150 mL / 30 days)
1
4
QL (1 vial / 28 days), NM,

PA
PA
NM, LA, PA
QL (120 tabs / 30 days),
NM, PA
ST - Step Therapy
NM - Not
LA - Limited Access
18
Drug Name
KINASE INHIBITORS
AFINITOR
AFINITOR
AFINITOR
AFINITOR
DIS TAB 2MG

DIS TAB 3MG
DIS TAB 5MG
TAB 2.5MG
4
4
4
4
AFINITOR TAB 5MG
AFINITOR TAB 7.5MG
AFINITOR TAB 10MG
BOSULIF TAB 100MG
BOSULIF TAB 500MG
CAPRELSA TAB 100MG

CAPRELSA TAB 300MG
COMETRIQ KIT 60MG
COMETRIQ KIT 100MG
COMETRIQ KIT 140MG
GLEEVEC TAB 100MG
4
4
4
4
4
4
GLEEVEC TAB 400MG
ICLUSIG TAB 15MG

ICLUSIG TAB 45MG
INLYTA TAB 1MG
INLYTA TAB 5MG
JAKAFI TAB 5MG
4
4
4
4
4
JAKAFI TAB 10MG
JAKAFI TAB 15MG
JAKAFI TAB 20MG
JAKAFI TAB 25MG
MEKINIST TAB 0.5MG

MEKINIST TAB 2MG
NEXAVAR TAB 200MG
4
4
4
NM
NM
NM
NM
NM
NM
NM
NM, PA
NM, PA
NM, LA, PA
NM, LA, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, PA
NM, PA
NM, LA, PA
ST - Step Therapy
NM - Not
LA - Limited Access
19
Drug Name
SPRYCEL TAB
SPRYCEL TAB
SPRYCEL TAB
SPRYCEL TAB
SPRYCEL TAB
20MG
50MG
70MG
80MG
100MG
SPRYCEL TAB 140MG

STIVARGA TAB 40MG
SUTENT CAP 12.5MG
SUTENT CAP 25MG
SUTENT CAP 50MG
TAFINLAR CAP 50MG
TAFINLAR CAP 75MG
TARCEVA TAB 25MG
TARCEVA TAB 100MG
TARCEVA TAB 150MG
TASIGNA CAP 150MG
TASIGNA CAP 200MG
TYKERB TAB 250MG
VOTRIENT TAB 200MG
XALKORI CAP 200MG
XALKORI CAP 250MG
ZELBORAF TAB 240MG

4
NM, PA
4
NM, PA
4
NM, PA
4
NM, PA
4
NM, PA
4
NM, PA
4
NM, LA, PA
4
QL (112 caps / 28 days),
NM, PA
4
NM, PA
4
NM, PA
4
NM, PA
4
NM, PA
4
NM, PA
4
NM, PA
4
NM, PA
4
NM, PA
4
NM, PA
4
NM, LA
4
NM
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
MISCELLANEOUS
DROXIA CAP 200MG
DROXIA CAP 300MG
DROXIA CAP 400MG
ELSPAR INJ 10000UNT
hydroxyurea cap 500 mg
irinotecan hcl inj 100 mg/5ml (20 mg/ml)
2
2
2
3
1
4
B/D, NM
B/D, NM
ST - Step Therapy
NM - Not
LA - Limited Access
20
Drug Name
MATULANE CAP 50MG
4
NM
mitoxantrone hcl inj conc 25 mg/12.5ml (2 1
B/D, NM
mg/ml)
POMALYST CAP 1MG
4
NM, LA, PA
POMALYST CAP 2MG
4
NM, LA, PA
POMALYST CAP 3MG
4
NM, LA, PA
POMALYST CAP 4MG
4
NM, LA, PA
SYLATRON KIT 296MCG
4
NM, PA
SYLATRON KIT 444MCG
4
NM, PA
SYLATRON KIT 888MCG
4
NM, PA
TARGRETIN CAP 75MG
4
NM, PA
tretinoin cap 10 mg
4
NM
TRISENOX SOL 10MG/10M
4
B/D, NM
NUCLEOSIDE ANALOGS
cladribine inj 1 mg/ml
fludarabine phosphate for inj 50 mg
fludarabine phosphate inj 25 mg/ml
4
1
1
B/D, NM
B/D
B/D
1
1
4
B/D
B/D
B/D, NM
4
4
4
1
1
1
1
1
1
1
4
B/D, NM
B/D, NM
B/D, NM
B/D
B/D
1
1
4
B/D
B/D
B/D, NM
PLATINUM COORDINATION COMPLEX

carboplatin iv soln 150 mg/15ml
cisplatin inj 100 mg/100ml (1 mg/ml)
oxaliplatin iv soln 100 mg/20ml
PROTECTIVE AGENTS
amifostine crystalline for inj 500 mg
dexrazoxane for inj 500 mg
ELITEK INJ 1.5MG
leucovorin calcium for inj 100 mg
leucovorin calcium for inj 350 mg
leucovorin calcium tab 5 mg
mesna inj 100 mg/ml
MESNEX TAB 400MG
B/D
NM
TOPOISOMERASE INHIBITORS
etoposide inj 500mg/25ml (20 mg/ml)
toposar inj 1gm/50ml
topotecan hcl for inj 4 mg
CARDIOVASCULAR
ACE INHIBITOR COMBINATIONS
amlodipine besylate-benazepril hcl cap
2.5-10 mg
ST - Step Therapy
NM - Not
LA - Limited Access
21
Drug Name
amlodipine besylate-benazepril hcl cap 5-101
mg
mg
mg
1
10-20 mg
1
10-40 mg
benazepril & hydrochlorothiazide tab 5-6.251
mg
benazepril & hydrochlorothiazide tab
1
10-12.5 mg
1
20-12.5 mg
benazepril & hydrochlorothiazide tab 20-25 1
mg
captopril & hydrochlorothiazide tab 25-15 1
mg
mg
mg
mg
enalapril maleate & hydrochlorothiazide tab1
5-12.5 mg
enalapril maleate & hydrochlorothiazide tab1
10-25 mg
fosinopril sodium & hydrochlorothiazide tab 1
10-12.5 mg
fosinopril sodium & hydrochlorothiazide tab 1
20-12.5 mg
lisinopril & hydrochlorothiazide tab 10-12.5 1
mg
lisinopril & hydrochlorothiazide tab 20-12.5 1
mg
lisinopril & hydrochlorothiazide tab 20-25 1
mg
moexipril-hydrochlorothiazide tab 7.5-12.5 1
mg
moexipril-hydrochlorothiazide tab 15-12.5 1
mg
ST - Step Therapy
NM - Not
LA - Limited Access
22
Drug Name
moexipril-hydrochlorothiazide tab 15-25 mg1
quinapril-hydrochlorothiazide tab 10-12.5 1
mg
quinapril-hydrochlorothiazide tab 20-12.5 1
mg
quinapril-hydrochlorothiazide tab 20-25 mg 1
ACE INHIBITORS
benazepril hcl tab 5 mg
1
1
1
1
captopril tab 12.5 mg
1
captopril tab 25 mg
1
captopril tab 50 mg
1
captopril tab 100 mg
1
enalapril maleate tab 2.5 mg
1
enalapril maleate tab 5 mg
1
1
1
fosinopril sodium tab 10 mg
1
1
1
lisinopril tab 2.5 mg
1
lisinopril tab 5 mg
1
lisinopril tab 10 mg
1
1
1
1
moexipril hcl tab 7.5 mg
1
moexipril hcl tab 15 mg
1
perindopril erbumine tab 2 mg
1
1
1
quinapril hcl tab 5 mg
1
1
1
1
ramipril cap 1.25 mg
1
ramipril cap 2.5 mg
1
ramipril cap 5 mg
1
ramipril cap 10 mg
1
trandolapril tab 1 mg
1
ST - Step Therapy
NM - Not
LA - Limited Access
23
Drug Name

1
1
ADRENOLYTICS, CENTRAL
clonidine hcl tab 0.1 mg
1
1
1
clonidine hcl td patch weekly 0.1 mg/24hr 1
guanfacine hcl tab 1 mg
1
guanfacine hcl tab 2 mg
1
ALDOSTERONE RECEPTOR ANTAGONISTS

eplerenone tab 25 mg
eplerenone tab 50 mg
spironolactone tab 25 mg
1
1
1
1
1
PA
PA
1
1
1
1
1
1
1
1
1
1
1
QL
QL
QL
QL
ALPHA BLOCKERS
doxazosin mesylate tab 1
prazosin hcl cap 1 mg
terazosin hcl cap 1 mg
mg
mg
mg
mg
(30
(30
(30
(60
tabs
tabs
tabs
tabs
/
/
/
/
30
30
30
30
days)
days)
days)
days)
30
30
30
30
30
30
30
30
30
30
30
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS

AZOR TAB 5-20MG
AZOR TAB 5-40MG
AZOR TAB 10-20MG
AZOR TAB 10-40MG
BENICAR HCT TAB 20-12.5
BENICAR HCT TAB 40-12.5
BENICAR HCT TAB 40-25MG
EXFORGE TAB 5-160MG
EXFORGE TAB 5-320MG
EXFORGE TAB 10-160MG
EXFORGE TAB 10-320MG
2
2
2
2
2
2
2
2
2
2
2
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
(30
(30
(30
(30
(30
(30
(30
(30
(30
(30
(30
tabs
tabs
tabs
tabs
tabs
tabs
tabs
tabs
tabs
tabs
tabs
/
/
/
/
/
/
/
/
/
/
/
ST - Step Therapy
NM - Not
LA - Limited Access
24
Drug Name
EXFORGEH/5- TAB 160-12.5
2
EXFORGEH/5- TAB 160-25
2
EXFORGEH/10- TAB 160-12.5
2
2
2
losartan potassium & hydrochlorothiazide 1
tab 50-12.5 mg
tab 100-12.5 mg
tab 100-25 mg
TRIBENZOR20- TAB 5-12.5MG
2
TRIBENZOR40- TAB 5-12.5MG
2
TRIBENZOR40- TAB 5-25MG
2
TRIBENZOR40- TAB 10-12.5
2
TRIBENZOR40- TAB 10-25MG
2
valsartan-hydrochlorothiazide tab 80-12.5 1
mg
mg
valsartan-hydrochlorothiazide tab 160-25 1
mg
mg
valsartan-hydrochlorothiazide tab 320-25 1
mg
ANGIOTENSIN II RECEPTOR ANTAGONISTS

BENICAR TAB 5MG
BENICAR TAB 20MG
BENICAR TAB 40MG
DIOVAN TAB 40MG
DIOVAN TAB 80MG
DIOVAN TAB 160MG
DIOVAN TAB 320MG
losartan potassium tab 25 mg
2
2
2
2
2
2
2
1
1
1
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
(60
(30
(30
(60
(60
(60
(30
(60
(60
(30
tabs
tabs
tabs
tabs
tabs
tabs
tabs
tabs
tabs
tabs
/
/
/
/
/
/
/
/
/
/
30
30
30
30
30
30
30
30
30
30
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
ANTIARRHYTHMICS
amiodarone
amiodarone
amiodarone
amiodarone
hcl
hcl
hcl
hcl
inj 150 mg/3ml (50 mg/ml)1

tab 100 mg
1
tab 200 mg
1
tab 400 mg
1
ST - Step Therapy
NM - Not
LA - Limited Access
25
Drug Name
disopyramide phosphate cap 100 mg
disopyramide phosphate cap 150 mg
flecainide acetate tab 50 mg
mexiletine hcl cap 150 mg
MULTAQ TAB 400MG
NORPACE CAP 100MG CR
NORPACE CAP 150MG CR
pacerone tab 100mg
pacerone tab 200mg
pacerone tab 400mg
propafenone hcl cap sr 12hr 225 mg
propafenone hcl tab 150 mg
quinidine gluconate tab cr 324 mg
quinidine sulfate tab 200 mg
quinidine sulfate tab 300 mg
quinidine sulfate tab cr 300 mg
sorine tab 80mg
sorine tab 120mg
sorine tab 160mg
sorine tab 240mg
sotalol hcl (afib/afl) tab 120 mg
sotalol hcl tab 80 mg
TIKOSYN CAP 125MCG
TIKOSYN CAP 250MCG
TIKOSYN CAP 500MCG

1
1
1
1
1
1
1
1
3
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
NM
3
NM
3
NM
ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS

atorvastatin calcium tab 10 mg (base
equivalent)
equivalent)
equivalent)
ST - Step Therapy
NM - Not
LA - Limited Access
26
Drug Name
equivalent)
CRESTOR TAB 5MG
CRESTOR TAB 10MG
CRESTOR TAB 20MG
CRESTOR TAB 40MG
lovastatin tab 10 mg
pravastatin sodium tab 10 mg
simvastatin tab 5 mg

1
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
(30 tabs / 30 days)

(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(120 tabs / 30 days)
(60 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
ANTILIPEMICS, MISCELLANEOUS
cholestyramine light powder packets 4 gm 1
cholestyramine powder 4 gm/dose
1
cholestyramine powder packets 4 gm
1
colestipol hcl granules 5 gm
1
colestipol hcl tab 1 gm
1
fenofibrate micronized cap 43 mg
1
1
1
1
1
fenofibrate tab 48 mg
1
1
1
1
gemfibrozil tab 600 mg
1
LOVAZA CAP 1GM
2
NIASPAN TAB 500MG ER
2
NIASPAN TAB 750MG ER
2
NIASPAN TAB 1000 ER
2
prevalite pow 4gm
1
SIMCOR TAB 500-20MG
2
SIMCOR TAB 500-40MG
2
SIMCOR TAB 750-20MG
2
ST - Step Therapy
NM - Not
27
LA - Limited Access
Drug Name
SIMCOR TAB 1000-20
SIMCOR TAB 1000-40
VASCEPA CAP 1GM
WELCHOL PAK 3.75GM
WELCHOL TAB 625MG
ZETIA TAB 10MG

2
2
3
2
2
2
BETA-BLOCKER/DIURETIC COMBINATIONS
atenolol & chlorthalidone tab 50-25 mg
1
1
bisoprolol & hydrochlorothiazide tab
1
2.5-6.25 mg
bisoprolol & hydrochlorothiazide tab 5-6.25 1
mg
1
10-6.25 mg
metoprolol & hydrochlorothiazide tab 50-251
mg
metoprolol & hydrochlorothiazide tab
1
100-25 mg
1
100-50 mg
propranolol & hydrochlorothiazide tab 40-251
mg
propranolol & hydrochlorothiazide tab 80-251
mg
BETA-BLOCKERS
acebutolol hcl cap 200 mg
acebutolol hcl cap 400 mg
atenolol tab 25 mg
atenolol tab 50 mg
atenolol tab 100 mg
bisoprolol fumarate tab 5 mg
bisoprolol fumarate tab 10 mg
BYSTOLIC TAB 2.5MG
BYSTOLIC TAB 5MG
BYSTOLIC TAB 10MG
BYSTOLIC TAB 20MG
carvedilol tab 3.125 mg
carvedilol tab 25 mg
labetalol hcl tab 100 mg
1
1
1
1
1
1
1
2
2
2
2
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
28
Drug Name
metoprolol succinate tab sr 24hr 25 mg
metoprolol tartrate inj 1 mg/ml
metoprolol tartrate tab 25 mg
nadolol tab 20 mg
nadolol tab 40 mg
nadolol tab 80 mg
pindolol tab 5 mg
pindolol tab 10 mg
propranolol hcl cap sr 24hr 60 mg
propranolol hcl inj 1 mg/ml
propranolol hcl oral soln 20 mg/5ml
propranolol hcl oral soln 40 mg/5ml
propranolol hcl tab 10 mg
timolol maleate tab 5 mg

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
CALCIUM CHANNEL BLOCKERS

afeditab tab 30mg cr
afeditab tab 60mg cr
amlodipine besylate tab 2.5 mg
amlodipine besylate tab 5 mg
amlodipine besylate tab 10 mg
cartia xt cap 120/24hr
dilt-cd cap 120mg
1
1
1
1
1
1
1
1
1
1
QL
QL
QL
QL
QL
QL
(60
(30
(45
(45
(30
(30
tabs / 30 days)
tabs / 30 days)
tabs / 30 days)
tabs / 30 days)
tabs / 30 days)
caps / 30 days)
ST - Step Therapy
NM - Not
LA - Limited Access
29
Drug Name
dilt-cd cap 300mg
1
dilt-xr cap 180mg
1
dilt-xr cap 240mg
1
diltiazem hcl cap sr 12hr 60 mg
1
1
1
diltiazem hcl coated beads cap sr 24hr 120 1
mg
mg
mg
mg
diltiazem hcl extended release beads cap sr1
24hr 180 mg
24hr 360 mg
24hr 420 mg
diltiazem hcl iv soln 50 mg/10ml (5 mg/ml)1
diltiazem hcl tab 30 mg
1
1
1
1
diltzac cap 120mg/24
1
1
1
1
felodipine tab sr 24hr 2.5 mg
1
felodipine tab sr 24hr 5 mg
1
felodipine tab sr 24hr 10 mg
1
isradipine cap 2.5 mg
1
isradipine cap 5 mg
1
matzim la tab 180mg/24
1
1
1
1
1
nicardipine hcl cap 20 mg
1
nicardipine hcl cap 30 mg
1
nifediac cc tab 30mg er
1
ST - Step Therapy
NM - Not
LA - Limited Access
30
Drug Name
nifedical xl tab 30mg
nifedical xl tab 60mg
nifedipine tab 30mg er
nifedipine tab sr 24hr 60 mg
nimodipine cap 30 mg
NYMALIZE SOL 60/20ML
taztia xt cap 120mg/24
verapamil hcl cap sr 24hr 100 mg
VERAPAMIL HCL CAP SR 24HR 360 MG
verapamil hcl iv soln 2.5 mg/ml
verapamil hcl tab 40 mg
verapamil hcl tab cr 120 mg

1
1
1
1
1
1
1
1
1
1
4
NM
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
DIGITALIS GLYCOSIDES
digoxin inj 0.25 mg/ml
DIGOXIN SOL 50MCG/ML
digoxin tab 0.25 mg
digoxin tab 0.125 mg
LANOXIN TAB 0.25MG
LANOXIN TAB 0.125MG
1
1
1
1
2
2
DIRECT RENIN INHIBITORS/COMBINATIONS

AMTURNIDE150 TAB -5-12.5
AMTURNIDE300 TAB -5-25MG
2
2
2

ST - Step Therapy
NM - Not
LA - Limited Access
31
Drug Name
AMTURNIDE300 TAB -10-25MG
TEKAMLO TAB 150-5MG
TEKAMLO TAB 150-10MG
TEKAMLO TAB 300-5MG
TEKAMLO TAB 300-10MG
TEKTURNA HCT TAB 150-12.5
TEKTURNA HCT TAB 150-25MG
TEKTURNA HCT TAB 300-12.5
TEKTURNA HCT TAB 300-25MG
TEKTURNA TAB 150MG
TEKTURNA TAB 300MG

2
2
2
2
2
2
2
2
2
2
2
2
DIURETICS
acetazolamide cap sr 12hr 500 mg
1
acetazolamide tab 125 mg
1
acetazolamide tab 250 mg
1
amiloride & hydrochlorothiazide tab 5-50 1
mg
amiloride hcl tab 5 mg
1
bumetanide inj 0.25 mg/ml
1
bumetanide tab 0.5 mg
1
bumetanide tab 1 mg
1
bumetanide tab 2 mg
1
chlorothiazide tab 250 mg
1
chlorothiazide tab 500 mg
1
chlorthalidone tab 25 mg
1
chlorthalidone tab 50 mg
1
DIURIL SUS 250/5ML
2
DYRENIUM CAP 50MG
3
DYRENIUM CAP 100MG
3
EDECRIN TAB 25MG
3
furosemide inj 10 mg/ml
1
furosemide oral soln 8 mg/ml
3
furosemide oral soln 10 mg/ml
1
furosemide tab 20 mg
1
1
1
hydrochlorothiazide cap 12.5 mg
1
hydrochlorothiazide tab 12.5 mg
1
hydrochlorothiazide tab 25 mg
1
hydrochlorothiazide tab 50 mg
1
indapamide tab 1.25 mg
1
ST - Step Therapy
NM - Not
LA - Limited Access
32
Drug Name
indapamide tab 2.5 mg
methazolamide tab 25 mg
methazolamide tab 50 mg
methyclothiazide tab 5 mg
metolazone tab 2.5 mg
metolazone tab 5 mg
metolazone tab 10 mg
spironolactone & hydrochlorothiazide tab
25-25 mg
THALITONE TAB 15MG
torsemide iv soln 20 mg/2ml (10 mg/ml)
torsemide tab 5 mg
torsemide tab 10 mg
torsemide tab 20 mg
torsemide tab 100 mg
triamterene & hydrochlorothiazide cap
37.5-25 mg
triamterene & hydrochlorothiazide tab
37.5-25 mg
75-50 mg

1
1
1
1
1
1
1
1
2
3
1
1
1
1
1
1
1
MISCELLANEOUS
DIBENZYLINE CAP 10MG
hydralazine hcl inj 20 mg/ml
hydralazine hcl tab 10 mg
midodrine hcl tab 2.5 mg
midodrine hcl tab 5 mg
midodrine hcl tab 10 mg
minoxidil tab 2.5 mg
minoxidil tab 10 mg
RANEXA TAB 500MG
3
1
1
1
1
1
1
1
1
1
1
3
RANEXA TAB 1000MG

PA
PA
NITRATES
isosorbide
isosorbide
isosorbide
isosorbide
dinitrate
dinitrate
dinitrate
dinitrate
sl tab 2.5 mg
sl tab 5 mg
tab 5 mg
tab 10 mg
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
33
Drug Name
isosorbide dinitrate tab 20 mg
1
isosorbide dinitrate tab 30 mg
1
isosorbide dinitrate tab cr 40 mg
1
isosorbide mononitrate tab 10 mg
1
isosorbide mononitrate tab 20 mg
1
isosorbide mononitrate tab sr 24hr 30 mg 1
minitran dis 0.1mg/hr
1
1
1
1
nitro-bid oin 2%
2
NITRO-DUR DIS 0.3MG/HR
3
NITRO-DUR DIS 0.8MG/HR
3
nitroglycerin td patch 24hr 0.1 mg/hr
1
1
1
1
NITROLINGUAL SPR PUMPSPRA
2
NITROSTAT SUB 0.3MG
2
NITROSTAT SUB 0.4MG
2
NITROSTAT SUB 0.6MG
2
PULMONARY ARTERIAL HYPERTENSION

ADCIRCA TAB 20MG
LETAIRIS TAB 5MG
LETAIRIS TAB 10MG
REMODULIN INJ 1MG/ML

REMODULIN INJ 2.5MG/ML
sildenafil citrate tab 20 mg
4
4
4
4
4
TRACLEER TAB 62.5MG
TRACLEER TAB 125MG

NM, PA
NM, LA, PA
NM, LA, PA
B/D, NM, LA
B/D, NM, LA
B/D, NM, LA
B/D, NM, LA
NM, PA
NM, LA, PA
NM, LA, PA
CENTRAL NERVOUS SYSTEM

ANTIANXIETY
ST - Step Therapy
NM - Not
LA - Limited Access
34
Drug Name
alprazolam con 1 mg/ml
alprazolam tab 0.5 mg
alprazolam tab 0.25 mg
alprazolam tab 1 mg
alprazolam tab 2 mg
buspirone hcl tab 5 mg
buspirone hcl tab 7.5 mg
fluvoxamine maleate tab 25 mg
lorazepam con 2mg/ml
lorazepam inj 2 mg/ml
lorazepam inj 4 mg/ml
lorazepam tab 0.5 mg
lorazepam tab 1 mg
lorazepam tab 2 mg

1
QL (300 ml / 30 days)
1
1
1
1
1
1
1
1
1
1
1
1
1
QL (150 mls / 30 days)
1
1
1
1
1
ANTICONVULSANTS
BANZEL SUS 40MG/ML
3
BANZEL TAB 200MG
3
BANZEL TAB 400MG
3
carbamazepine cap sr 12hr 100 mg
1
1
1
carbamazepine chew tab 100 mg
1
carbamazepine susp 100 mg/5ml
1
carbamazepine tab 200 mg
1
carbamazepine tab sr 12hr 200 mg
1
carbamazepine tab sr 12hr 400 mg
1
CELONTIN CAP 300MG
3
clonazepam orally disintegrating tab 0.5 mg1
clonazepam orally disintegrating tab 0.25 1
mg
clonazepam orally disintegrating tab 0.125 1
mg
clonazepam orally disintegrating tab 1 mg 1
clonazepam orally disintegrating tab 2 mg 1
clonazepam tab 0.5 mg
1
clonazepam tab 1 mg
1
clonazepam tab 2 mg
1
ST - Step Therapy
NM - Not
35
LA - Limited Access
Drug Name
clorazepate dipotassium tab 3.75 mg

1
PA
clorazepate dipotassium tab 7.5 mg
1
PA
clorazepate dipotassium tab 15 mg
1
PA
diazepam con 5mg/ml
1
QL (240 ml / 30 days),
PA
DIAZEPAM GEL 2.5MG
1
DIAZEPAM GEL 10MG
1
DIAZEPAM GEL 20MG
1
diazepam inj 5 mg/ml
1
diazepam soln 1 mg/ml
1
QL (1200mL / 30 days),
PA
diazepam tab 2 mg
1
PA
diazepam tab 5 mg
1
PA
diazepam tab 10 mg
1
PA
dilantin cap 30mg
2
dilantin cap 100mg
2
dilantin chw 50mg
2
DILANTIN-125 SUS 125/5ML
2
divalproex sodium cap sprinkle 125 mg
1
divalproex sodium tab delayed release 125 1
mg
mg
mg
divalproex sodium tab sr 24 hr 250 mg
1
divalproex sodium tab sr 24 hr 500 mg
1
epitol tab 200mg
1
ethosuximide cap 250 mg
1
ethosuximide soln 250 mg/5ml
1
felbamate susp 600 mg/5ml
1
felbamate tab 400 mg
1
felbamate tab 600 mg
1
gabapentin cap 100 mg
1
1
1
gabapentin oral soln 250 mg/5ml
1
QL (2160 mL / 30 days)
ST - Step Therapy
NM - Not
LA - Limited Access
36
Drug Name
gabapentin tab 600 mg
1
gabapentin tab 800 mg
1
GABITRIL TAB 12MG
3
GABITRIL TAB 16MG
3
lamotrigine tab 25 mg
1
1
1
1
lamotrigine tab chewable dispersible 5 mg 1
lamotrigine tab chewable dispersible 25 mg 1
lamotrigine tab sr 24hr 25 mg
1
1
1
1
1
1
levetiracetam inj 500 mg/5ml (100 mg/ml) 1
levetiracetam oral soln 100 mg/ml
1
levetiracetam tab 250 mg
1
1
1
1
levetiracetam tab sr 24hr 500 mg
1
levetiracetam tab sr 24hr 750 mg
1
LYRICA CAP 25MG
2
LYRICA CAP 50MG
2
LYRICA CAP 75MG
2
LYRICA CAP 100MG
2
LYRICA CAP 150MG
2
LYRICA CAP 200MG
2
LYRICA CAP 225MG
2
LYRICA CAP 300MG
2
LYRICA SOL 20MG/ML
2
QL (946mL / 30 days)
ONFI SUS 2.5MG/ML
3
ONFI TAB 5MG
3
ONFI TAB 10MG
3
ONFI TAB 20MG
3
oxcarbazepine susp 300 mg/5ml (60
1
mg/ml)
oxcarbazepine tab 150 mg
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
37
Drug Name
PEGANONE TAB 250MG
phenobarbital elixir 20 mg/5ml
phenobarbital sodium inj 65 mg/ml
phenobarbital sodium inj 130 mg/ml
phenobarbital tab 15 mg
phenobarbital tab 16.2 mg
PHENYTEK CAP 200MG
PHENYTEK CAP 300MG
phenytoin chew tab 50 mg
phenytoin sodium extended cap 100 mg
phenytoin sodium inj 50 mg/ml
phenytoin susp 125 mg/5ml
POTIGA TAB 50MG
POTIGA TAB 200MG
POTIGA TAB 300MG
POTIGA TAB 400MG
primidone tab 50 mg
primidone tab 250 mg
SABRIL POW 500MG
SABRIL TAB 500MG
TEGRETOL CHW 100MG
TEGRETOL SUS 100/5ML
TEGRETOL TAB 200MG
TEGRETOL-XR TAB 100MG
tiagabine hcl tab 2 mg
tiagabine hcl tab 4 mg
topiramate sprinkle cap 15 mg
topiramate sprinkle cap 25 mg
topiramate tab 25 mg

3
1
1
1
1
1
1
1
1
1
1
1
3
3
1
1
1
1
1
1
3
3
3
3
1
1
4
QL (180 packets / 30
days), NM, LA, PA
4
NM, LA, PA
3
3
3
3
3
3
1
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
38
Drug Name
1
1
TRILEPTAL SUS 300MG/5M
3
valproate sodium inj 100 mg/ml
1
valproate sodium syrup 250 mg/5ml (base 1
equiv)
valproic acid cap 250 mg
1
VIMPAT INJ 200MG/20
3
QL (1200 mL / 30 days)
VIMPAT SOL 10MG/ML
3
QL (1200 mL / 30 days)
VIMPAT TAB 50MG
3
VIMPAT TAB 100MG
3
VIMPAT TAB 150MG
3
VIMPAT TAB 200MG
3
zonisamide cap 25 mg
1
1
1
ANTIDEMENTIA
ARICEPT TAB 23MG
donepezil hydrochloride orally
disintegrating tab 5 mg
disintegrating tab 10 mg
donepezil hydrochloride tab 5 mg
EXELON DIS 4.6MG/24
EXELON DIS 9.5MG/24
EXELON DIS 13.3/24
EXELON SOL 2MG/ML
galantamine hydrobromide cap sr 24hr 8
mg
mg
mg
galantamine hydrobromide oral soln 4
mg/ml
galantamine hydrobromide tab 4 mg
NAMENDA SOL 10MG/5ML
NAMENDA TAB 5-10MG
2
1
1
1
1
3
3
3
3
1

QL (180 mL / 30 days)
1
1
1
2
2
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
(30 ea / 30 days)
(30 ea / 30 days)
(30 ea / 30 days)
(180 mL / 30 days)
(30 caps / 30 days)

(90 tabs / 30 days)
(60 tabs / 30 days)
(360 mL / 30 days)
(1 pack / 28 days)
ST - Step Therapy
NM - Not
LA - Limited Access
39
Drug Name
NAMENDA TAB 5MG
NAMENDA TAB 10MG
rivastigmine tartrate cap
1.5 mg
3 mg
4.5 mg
6 mg

2
2
1
1
1
1
ANTIDEPRESSANTS
amitriptyline hcl tab 10 mg
amoxapine tab 25 mg
amoxapine tab 50 mg
amoxapine tab 100 mg
amoxapine tab 150 mg
budeprion tab 100mg sr
budeprion tab 150mg sr
bupropion hcl tab 75 mg
bupropion hcl tab 100 mg
bupropion hcl tab sr 12hr 100 mg
citalopram hydrobromide oral soln 10
mg/5ml
citalopram hydrobromide tab 10 mg (base
equiv)
equiv)
equiv)
clomipramine hcl cap 25 mg
CYMBALTA CAP 20MG
CYMBALTA CAP 30MG
CYMBALTA CAP 60MG
desipramine hcl tab 10 mg
1
1
1
1
1
1
2
2
2
2
1
1
1
1
1
1
1
1
1
1
QL (600 mL / 30 days)
1
1
1
2
2
2
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
40
Drug Name
1
1
1
1
doxepin hcl cap 10 mg
1
1
1
1
1
1
doxepin hcl conc 10 mg/ml
1
EMSAM DIS 6MG/24HR
3
EMSAM DIS 9MG/24HR
3
EMSAM DIS 12MG/24H
3
escitalopram oxalate soln 5 mg/5ml (base 1
QL (600 ml / 30 days)
equiv)
escitalopram oxalate tab 5 mg (base equiv)1
escitalopram oxalate tab 10 mg (base
1
equiv)
1
equiv)
fluoxetine hcl cap 10 mg
1
1
1
fluoxetine hcl solution 20 mg/5ml
1
QL (600 mL / 30 days)
fluoxetine hcl tab 10 mg
1
fluoxetine hcl tab 20 mg
1
imipramine hcl tab 10 mg
1
1
1
maprotiline hcl tab 25 mg
1
1
1
MARPLAN TAB 10MG
3
mirtazapine orally disintegrating tab 15 mg 1
mirtazapine tab 7.5 mg
1
mirtazapine tab 15 mg
1
1
1
nefazodone hcl tab 50 mg
1
ST - Step Therapy
NM - Not
LA - Limited Access
41
Drug Name
nortriptyline hcl cap 10 mg
nortriptyline hcl soln 10 mg/5ml
paroxetine hcl tab 10 mg
paroxetine hcl tab sr 24hr 12.5 mg
paroxetine hcl tab sr 24hr 25 mg
paroxetine hcl tab sr 24hr 37.5 mg
PAXIL SUS 10MG/5ML
phenelzine sulfate tab 15 mg
PRISTIQ TAB 50MG
PRISTIQ TAB 100MG
protriptyline hcl tab 5 mg
protriptyline hcl tab 10 mg
sertraline hcl oral conc 20 mg/ml
sertraline hcl tab 25 mg
tranylcypromine sulfate tab 10 mg
trazodone hcl tab 50 mg
trimipramine maleate cap 25 mg
venlafaxine hcl cap sr 24hr 37.5 mg (base
equivalent)
venlafaxine hcl cap sr 24hr 75 mg (base
equivalent)
equivalent)
venlafaxine hcl tab 25 mg
venlafaxine hcl tab 37.5 mg

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
3
QL (900 mL / 30 days)
1
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
42
Drug Name
VIIBRYD KIT
VIIBRYD TAB 10MG
VIIBRYD TAB 20MG
VIIBRYD TAB 40MG

1
1
2
2
2
2
ANTIPARKINSONIAN AGENTS
amantadine hcl cap 100 mg
amantadine hcl syrup 50 mg/5ml
amantadine hcl tab 100 mg
APOKYN INJ 10MG/ML
AZILECT TAB 0.5MG
AZILECT TAB 1MG
benztropine mesylate inj 1 mg/ml
benztropine mesylate tab 0.5 mg
benztropine mesylate tab 1 mg
benztropine mesylate tab 2 mg
bromocriptine mesylate cap 5 mg
bromocriptine mesylate tab 2.5 mg
CARB/LEVO100 TAB /ENTACAP
CARB/LEVO 50 TAB /ENTACAP
CARB/LEVO 75 TAB /ENTACAP
carbidopa & levodopa orally disintegrating
tab 10-100 mg
tab 25-100 mg
tab 25-250 mg
carbidopa & levodopa tab 10-100 mg
carbidopa & levodopa tab cr 25-100 mg
entacapone tab 200 mg
LODOSYN TAB 25MG
NEUPRO DIS 1MG/24HR
NEUPRO DIS 2MG/24HR
NEUPRO DIS 3MG/24HR
NEUPRO DIS 4MG/24HR
1
1
1
4
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
NM, LA
1
1
1
1
1
1
1
1
3
3
3
3
3
ST - Step Therapy
NM - Not
LA - Limited Access
43
Drug Name
NEUPRO DIS 6MG/24HR
NEUPRO DIS 8MG/24HR
pramipexole dihydrochloride tab 0.5 mg
pramipexole dihydrochloride tab 1 mg
ropinirole hydrochloride tab 0.5 mg
ropinirole hydrochloride tab 0.25 mg
ropinirole hydrochloride tab 1 mg
selegiline hcl cap 5 mg
selegiline hcl tab 5 mg
STALEVO 50 TAB
STALEVO 75 TAB
STALEVO 100 TAB
STALEVO 125 TAB
STALEVO 150 TAB
STALEVO 200 TAB
trihexyphenidyl hcl elixir 0.4 mg/ml
trihexyphenidyl hcl tab 2 mg
trihexyphenidyl hcl tab 5 mg

3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
1
1
1
ANTIPSYCHOTICS
ABILIFY
ABILIFY
ABILIFY
ABILIFY
DISC TAB 10MG

DISC TAB 15MG
INJ 9.75MG
MAIN INJ 300MG
2
2
3
4
ABILIFY MAIN INJ 400MG

QL (3 vials / 1 day)
PA
PA
QL (900 mL / 30 days)
ABILIFY SOL 1MG/ML

2
ABILIFY TAB 2MG
2
ABILIFY TAB 5MG
2
ABILIFY TAB 10MG
2
ABILIFY TAB 15MG
2
ABILIFY TAB 20MG
2
ABILIFY TAB 30MG
2
chlorpromazine hcl inj 25 mg/ml
3
ST - Step Therapy
NM - Not
LA - Limited Access
44
Drug Name
chlorpromazine hcl tab 10 mg
CLOZAPINE TAB 12.5/ODT
clozapine tab 25 mg
CLOZAPINE TAB 25MG ODT
clozapine tab 50 mg
clozapine tab 100 mg
CLOZAPINE TAB 100/ODT
clozapine tab 200 mg
FANAPT PAK
FANAPT TAB 1MG
FANAPT TAB 2MG
FANAPT TAB 4MG
FANAPT TAB 6MG
FANAPT TAB 8MG
FANAPT TAB 10MG
FANAPT TAB 12MG
FAZACLO TAB 12.5/ODT
FAZACLO TAB 25MG ODT
FAZACLO TAB 100/ODT
FAZACLO TAB 150MG
FAZACLO TAB 200MG
fluphenazine decanoate inj 25 mg/ml
fluphenazine hcl elixir 2.5 mg/5ml
fluphenazine hcl inj 2.5 mg/ml
fluphenazine hcl oral conc 5 mg/ml
fluphenazine hcl tab 1 mg
fluphenazine hcl tab 2.5 mg
GEODON INJ 20MG
haloperidol decanoate im soln 50 mg/ml

1
1
1
1
1
1
1
1
1
1
1
QL (270 ea / 30 days)
1
3
QL (1 pack / 30 days), ST
3
ST
3
ST
3
ST
3
ST
3
ST
3
ST
3
ST
3
3
3
3
3
1
1
1
1
1
1
1
1
3
QL (6 mL / 3 days)
1
ST - Step Therapy
NM - Not
LA - Limited Access
45
Drug Name
haloperidol lactate inj 5 mg/ml
haloperidol lactate oral conc 2 mg/ml
haloperidol tab 0.5 mg
haloperidol tab 1 mg
INVEGA SUST INJ 39/0.25
INVEGA SUST INJ 78/0.5ML
INVEGA SUST INJ 156MG/ML
INVEGA TAB 1.5MG
INVEGA TAB 3MG
INVEGA TAB 6MG
INVEGA TAB 9MG
LATUDA TAB 20MG
LATUDA TAB 40MG
LATUDA TAB 60MG
LATUDA TAB 80MG
LATUDA TAB 120MG
loxapine succinate cap 5 mg
olanzapine for im inj 10 mg
olanzapine orally disintegrating
olanzapine tab 2.5 mg
olanzapine tab 5 mg
olanzapine tab 7.5 mg
olanzapine tab 10 mg

1
1
1
1
1
1
1
1
1
3
QL (0.25 mL / 28 days),
PA
3
QL (0.5 mL / 28 days),
PA
4
QL (0.75 mL / 28 days),
NM, PA
4
QL (1 mL / 28 days), NM,
PA
4
QL (1.5 mL / 28 days),
NM, PA
3
3
3
3
3
3
3
3
3
1
1
1
1
1
QL (3 vials / 1 day)
tab 5 mg 1
tab 10 mg 1
tab 15 mg 1
tab 20 mg 1
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
46
Drug Name
ORAP TAB 1MG
ORAP TAB 2MG
perphenazine tab 2 mg
quetiapine fumarate tab 25 mg
RISPERDAL INJ 12.5MG
RISPERDAL INJ 25MG
RISPERDAL INJ 37.5MG

1
2
2
1
1
1
1
1
1
1
1
1
1
3
QL (2 inj / 28 days), PA
3
QL (2 inj / 28 days), PA
4
QL (2 inj / 28 days), NM,
PA
RISPERDAL INJ 50MG
4
QL (2 inj / 28 days), NM,
PA
risperidone orally disintegrating tab 0.5 mg 1
risperidone orally disintegrating tab 0.25 1
mg
risperidone orally disintegrating tab 1 mg 1
risperidone soln 1 mg/ml
1
QL (240 mL / 30 days)
risperidone tab 0.5 mg
1
risperidone tab 0.25 mg
1
risperidone tab 1 mg
1
1
1
1
SAPHRIS SUB 5MG
3
ST
SAPHRIS SUB 10MG
3
ST
SEROQUEL XR TAB 50MG
2
QL (120 ea / 30 days)
2
2
2
2
ST - Step Therapy
NM - Not
LA - Limited Access
47
Drug Name
thioridazine hcl tab 10 mg
thiothixene cap 1 mg
trifluoperazine hcl tab 1 mg
ziprasidone hcl cap 20 mg

1
PA
1
PA
1
PA
1
PA
1
1
1
1
1
1
1
1
1
1
1
1
ATTENTION DEFICIT HYPERACTIVITY DISORDER

amphetamine-dextroamphetamine
24hr 5 mg
24hr 10 mg
24hr 15 mg
24hr 20 mg
24hr 25 mg
24hr 30 mg
mg
mg
mg
mg
mg
mg
mg
cap sr
cap sr
cap sr
cap sr
cap sr
cap sr
tab 5
tab 7.5 1
tab 10 1
tab 12.51
tab 15 1
tab 20 1
tab 30 1
ST - Step Therapy
NM - Not
LA - Limited Access
48
Drug Name
INTUNIV TAB 1MG
INTUNIV TAB 2MG
INTUNIV TAB 3MG
INTUNIV TAB 4MG
metadate tab 20mg er
methylphenidate hcl soln 5 mg/5ml
methylphenidate hcl soln 10 mg/5ml
methylphenidate hcl tab 5 mg
methylphenidate hcl tab cr 20 mg
STRATTERA CAP 10MG
STRATTERA CAP 18MG
STRATTERA CAP 25MG
STRATTERA CAP 40MG
STRATTERA CAP 60MG
STRATTERA CAP 80MG
STRATTERA CAP 100MG

3
ST
3
ST
3
ST
3
ST
1
1
1
1
1
1
1
3
ST
3
ST
3
ST
3
ST
3
ST
3
ST
3
ST
HYPNOTICS
LUNESTA TAB 1MG
LUNESTA TAB 2MG
LUNESTA TAB 3MG
zaleplon cap 5 mg
zaleplon cap 10 mg
zolpidem tartrate tab 5 mg
zolpidem tartrate tab 10 mg
2
2
2
1
1
1
1
QL
QL
QL
QL
QL
QL
QL
(30
(30
(30
(30
(30
(30
(30
tabs / 30 days)
tabs / 30 days)
tabs / 30 days)
caps / 30 days)
caps / 30 days)
tabs / 30 days)
tabs / 30 days)
3
1
1
1
2
2
1
QL
QL
QL
QL
QL
(9 tabs / 30 days)
(9 tabs / 30 days)
(12 tabs / 30 days)
(12 tabs / 30 days)
(12 ea / 30 days)
MIGRAINE
cafergot tab 1-100mg
dihydroergotamine mesylate inj 1 mg/ml
naratriptan hcl tab 1 mg (base equiv)
naratriptan hcl tab 2.5 mg (base equiv)
RELPAX TAB 20MG
RELPAX TAB 40MG
rizatriptan benzoate orally disintegrating
tab 5 mg
ST - Step Therapy
NM - Not
LA - Limited Access
49
Drug Name
1
tab 10 mg
rizatriptan benzoate tab 5 mg
1
rizatriptan benzoate tab 10 mg
1
SUMATRIPTAN INJ 4MG/0.5
1
QL (4 mL / 30 days)
sumatriptan nasal spray 5 mg/act
1
QL (12 sprays / 30 days)
sumatriptan nasal spray 20 mg/act
1
QL (12 sprays / 30 days)
sumatriptan succinate inj 6 mg/0.5ml
1
QL (4 mL / 30 days)
sumatriptan succinate tab 25 mg
1
1
1
zolmitriptan orally disintegrating tab 2.5 mg1
zolmitriptan orally disintegrating tab 5 mg 1
zolmitriptan tab 2.5 mg
1
zolmitriptan tab 5 mg
1
MISCELLANEOUS
lithium carbonate cap 150 mg
lithium carbonate tab 300 mg
lithium carbonate tab cr 300 mg
lithium carbonate tab cr 450 mg
LITHIUM CITR SOL 8MEQ/5ML
MESTINON SYP 60MG/5ML
MESTINON TAB TIMESPAN
NUEDEXTA CAP 20-10MG
1
1
1
1
1
1
2
2
2
2
pyridostigmine bromide tab 60 mg

REGONOL INJ 5MG/ML
RILUTEK TAB 50MG
riluzole tab 50 mg
SAVELLA MIS TITR PAK
SAVELLA TAB 12.5MG
SAVELLA TAB 25MG
SAVELLA TAB 50MG
SAVELLA TAB 100MG
XENAZINE TAB 12.5MG
1
2
4
1
2
2
2
2
2
4
XENAZINE TAB 25MG

PA
NM

NM, LA, PA
NM, LA, PA
MULTIPLE SCLEROSIS AGENTS

ST - Step Therapy
NM - Not
LA - Limited Access
50
Drug Name
AMPYRA TAB 10MG
AVONEX KIT 30MCG
AVONEX PREFL KIT 30MCG
BETASERON INJ 0.3MG
COPAXONE KIT 20MG/ML
GILENYA CAP 0.5MG

4
NM, LA, PA
4
QL (4 boxes / 28 days),
NM, PA
4
NM, PA
4
QL (14 vials / 28 days),
NM, PA
4
NM, PA
4
NM, PA
MUSCULOSKELETAL THERAPY AGENTS

baclofen tab 10 mg
baclofen tab 20 mg
dantrolene sodium cap 25 mg
tizanidine hcl tab 2 mg
tizanidine hcl tab 4 mg
1
1
1
1
1
1
1
NARCOLEPSY/CATAPLEXY
modafinil tab 100 mg
modafinil tab 200 mg
XYREM SOL 500MG/ML

NM, PA
NM, PA
QL (540mL / 30 days),
NM, LA, PA
PSYCHOTHERAPEUTIC-MISC
acamprosate calcium tab delayed release 1
333 mg
buprenorphine hcl sl tab 2 mg (base equiv) 1
buprenorphine hcl sl tab 8 mg (base equiv) 1
buprenorphine hcl-naloxone hcl sl tab 2-0.51
mg (base equiv)
buprenorphine hcl-naloxone hcl sl tab 8-2 1
mg (base equiv)
buproban tab 150mg
1
CAMPRAL TAB 333MG
3
CHANTIX PAK 0.5& 1MG
3
CHANTIX TAB 0.5MG
3
CHANTIX TAB 1MG
3
disulfiram tab 250 mg
1
PA
PA
QL (120 ea / 30 days),
PA
QL (120 ea / 30 days),
PA
QL (106 tabs / year), PA

ST - Step Therapy
NM - Not
LA - Limited Access
51
Drug Name
disulfiram tab 500 mg
naloxone hcl inj 0.4 mg/ml
naloxone hcl inj 1 mg/ml
naltrexone hcl tab 50 mg
NICOTROL INH
NICOTROL NS SPR 10MG/ML
SUBOXONE MIS 2-0.5MG
SUBOXONE MIS 4-1MG
SUBOXONE MIS 8-2MG
SUBOXONE MIS 12-3MG

1
1
1
1
3
QL (16 inhalers / year)
3
QL (36 bottles / year)
3
QL (120 ea / 30 days),
PA
3
QL (120 ea / 30 days),
PA
3
QL (120 ea / 30 days),
PA
3
ENDOCRINE AND METABOLIC

ANDROGENS
ANDROGEL GEL 1%(25MG)
ANDROGEL GEL 1%(50MG)
ANDROGEL GEL 1.62%
ANDROGEL GEL PUMP 1%
androxy tab 10mg

oxandrolone tab 2.5 mg
oxandrolone tab 10 mg
TESTIM GEL 1%(50MG)
2
1
1
3
QL
PA
QL
PA
QL
PA
QL
PA
PA
PA
PA
QL
PA
(300 gm / 30 days),
(300 gm / 30 days),
(150 gm / 30 days),
(300 gm / 30 days),
(300 gm / 30 days),
testosterone cypionate im in oil 100 mg/ml 1

testosterone cypionate im in oil 200 mg/ml 1
testosterone enanthate im in oil 200 mg/ml1
ANTIDIABETICS, INJECTABLE
alcohol swabs
BYETTA INJ 5MCG
BYETTA INJ 10MCG
gauze pads 2" x 2"
HUMULIN R INJ U-500
insulin pen needle
insulin syringe
LANTUS INJ 100/ML
LANTUS INJ SOLOSTAR
LEVEMIR INJ
2
3
3
2
2
2
2
2
2
2
QL (1 pen / 30 days), PA
QL (1 pen / 30 days), PA
B/D
ST - Step Therapy
NM - Not
LA - Limited Access
52
Drug Name
LEVEMIR INJ FLEXPEN
NOVOLIN INJ 70/30
NOVOLIN N INJ U-100
NOVOLIN R INJ U-100
NOVOLOG INJ 100/ML
NOVOLOG INJ FLEXPEN
NOVOLOG MIX INJ 70/30
NOVOLOG MIX INJ FLEXPEN
SYMLINPEN 60 INJ 1000MCG
SYMLNPEN 120 INJ 1000MCG
VICTOZA INJ 18MG/3ML

2
2
RELION not covered
2
RELION not covered
2
RELION not covered
2
2
2
2
3
QL (8 vials / 30 days), PA
3
QL (4 vials / 30 days), PA
2
QL (3 pens / 30 days)
ANTIDIABETICS, ORAL
acarbose tab 25 mg
acarbose tab 50 mg
acarbose tab 100 mg
glimepiride tab 1 mg
glipizide tab 5 mg
glipizide tab 10 mg
glipizide tab sr 24hr 2.5 mg
glipizide tab sr 24hr 5 mg
glipizide tab sr 24hr 10 mg
glipizide-metformin hcl tab 2.5-250 mg
glipizide-metformin hcl tab 5-500 mg
glyburide micronized tab 1.5 mg
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
glyburide micronized tab 3 mg
glyburide micronized tab 6 mg
glyburide tab 1.25 mg
glyburide tab 2.5 mg
glyburide tab 5 mg
glyburide-metformin tab 1.25-250 mg
glyburide-metformin tab 2.5-500 mg
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
PA
QL
PA
QL
PA
QL
PA
QL
PA
QL
PA
QL
PA
QL
PA

(60 tabs / 30 days)
(240 ea / 30 days)
(120 ea / 30 days)
(60 ea / 30 days)
(240 tabs / 30 days),
(120 tabs / 30 days),
(60 tabs / 30 days),
(480 tabs / 30 days),
(240 tabs / 30 days),
(120 tabs / 30 days),
(240 tabs / 30 days),
(120 tabs / 30 days),
ST - Step Therapy
NM - Not
LA - Limited Access
53
Drug Name
glyburide-metformin tab 5-500 mg

1
PA
JANUMET TAB 50-500MG
2
JANUMET TAB 50-1000
2
JANUMET XR TAB 50-500MG
2
JANUMET XR TAB 50-1000
2
JANUMET XR TAB 100-1000
2
JANUVIA TAB 25MG
2
JANUVIA TAB 50MG
2
JANUVIA TAB 100MG
2
JENTADUETO TAB 2.5-500
2
2
2
JUVISYNC TAB 50-10MG
2
2
2
2
2
2
metformin hcl tab 500 mg
1
1
1
metformin hcl tab sr 24hr 500 mg
1
QL (120 ea / 30 days)
metformin hcl tab sr 24hr 750 mg
1
nateglinide tab 60 mg
1
nateglinide tab 120 mg
1
pioglitazone hcl tab 15 mg (base equiv)
1
1
1
pioglitazone hcl-glimepiride tab 30-2 mg
1
1
pioglitazone hcl-metformin hcl tab 15-500 1
mg
pioglitazone hcl-metformin hcl tab 15-850 1
mg
PRANDIN TAB 0.5MG
3
PRANDIN TAB 1MG
3
PRANDIN TAB 2MG
3
repaglinide tab 0.5 mg
1
repaglinide tab 1 mg
1
repaglinide tab 2 mg
1
RIOMET SOL
2
QL (946mL / 30 days)
ST - Step Therapy
NM - Not
LA - Limited Access
54
Drug Name
TRADJENTA TAB 5MG

2
BISPHOSPHONATES
alendronate
alendronate
alendronate
alendronate
alendronate
BONIVA INJ
sodium tab
sodium tab
sodium tab
sodium tab
sodium tab
3MG/3ML
5 mg
10 mg
35 mg
40 mg
70 mg
ibandronate sodium tab 150 mg (base

equivalent)
zoledronic acid inj conc for iv infusion 4
mg/5ml
ZOMETA INJ 4MG/100
1
1
1
1
1
3
B/D, QL (1 syringe / 90
days)
B/D, QL (1 tab / 30 days)
B/D, NM
B/D, NM
CALCITONINS
calcitonin (salmon) nasal soln 200 unit/act 1
FORTICAL SPR 200/ACT
2
CALCIUM RECEPTOR ANTAGONISTS

SENSIPAR TAB 30MG
SENSIPAR TAB 60MG
SENSIPAR TAB 90MG

NM
NM
NM
CHELATING AGENTS
CHEMET CAP 100MG
3
EXJADE TAB 125MG
4
EXJADE TAB 250MG
4
EXJADE TAB 500MG
4
kionex pow usp
1
sodium polystyrene sulfonate oral susp 15 1
gm/60ml
SYPRINE CAP 250MG
4
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM
CONTRACEPTIVES
apri tab
1
aranelle tab
1
aviane tab
1
balziva tab
1
briellyn tab
1
camila tab 0.35mg
1
cryselle-28 tab 28 tabs
1
cyclafem tab 1/35
1
ST - Step Therapy
NM - Not
LA - Limited Access
55
Drug Name
cyclafem tab 7/7/7
drospirenone-ethinyl estradiol tab 3-0.03
mg
ELLA TAB 30MG
emoquette tab
enpresse-28 tab
errin tab 0.35mg
GIANVI TAB 3-0.02MG
gildagia tab 0.4-35
introvale tab
JOLIVETTE TAB 0.35MG
junel 1.5/30 tab
junel 1/20 tab
junel fe tab 1.5/30
junel fe tab 1/20
kariva tab 28 day
kelnor tab 1/35
LEENA TAB
lessina tab
levonest tab
levonorgestrel & ethinyl estradiol (91-day)
tab 0.15-0.03 mg
levonorgestrel tab 0.75 mg
levonorgestrel tab 1.5 mg
levora-28 tab 0.15/30
loryna tab 3-0.02mg
low-ogestrel tab
lutera tab
lyza tab 0.35mg
marlissa tab 0.15/30
medroxyprogesterone acetate im susp 150
mg/ml
microgestin tab 1.5/30
microgestin tab 1/20
microgestin tab fe1.5/30
microgestin tab fe 1/20
MONONESSA TAB
my way tab 1.5mg
myzilra tab
necon tab 0.5/35
necon tab 1/35
NECON TAB 7/7/7

1
1
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
QL (1 vial / 90 days)
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
56
Drug Name
NECON TAB 10/11-28
next choice tab 1.5mg
NORA-BE TAB 0.35MG
norethindrone tab 0.35 mg
nortrel tab 0.5/35
nortrel tab 1/35
nortrel tab 7/7/7
NUVARING MIS
OCELLA TAB 3-0.03MG
ogestrel tab
orsythia tab
ORTHO EVRA DIS WEEK
ORTHO TRI- TAB CYCLN LO
philith tab 0.4-35
pirmella tab 1/35
portia-28 tab
previfem tab
quasense tab
reclipsen tab
SOLIA TAB
sprintec 28 tab 28 day
sronyx tab
tri-legest tab fe
tri-previfem tab
tri-sprintec tab
TRINESSA TAB
trivora-28 tab
velivet pak
vestura tab 3-0.02mg
viorele tab
zovia 1/35e tab
zovia 1/50e tab

3
1
1
1
1
1
1
3
1
1
1
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ENDOMETRIOSIS
danazol cap 50 mg
danazol cap 100 mg
danazol cap 200 mg
SYNAREL SOL 2MG/ML
1
1
1
4
NM
4
4
4
NM, LA
NM, LA
NM
ENZYME REPLACEMENTS
ADAGEN INJ 250/ML
ALDURAZYME INJ 2.9MG/5M
BUPHENYL TAB 500MG
ST - Step Therapy
NM - Not
LA - Limited Access
57
Drug Name
CARBAGLU TAB 200MG
CEREZYME INJ 200UNIT
CYSTADANE POW
CYSTAGON CAP 50MG
CYSTAGON CAP 150MG
ELAPRASE INJ 6MG/3ML
ELELYSO INJ 200UNIT
FABRAZYME INJ 35MG
KUVAN TAB 100MG
levocarnitine inj 200 mg/ml
levocarnitine oral soln 1 gm/10ml (10%)
levocarnitine tab 330 mg
LUMIZYME INJ 50MG
MYOZYME INJ 50MG
NAGLAZYME INJ 1MG/ML
ORFADIN CAP 2MG
ORFADIN CAP 5MG
ORFADIN CAP 10MG
PROCYSBI CAP 25MG
PROCYSBI CAP 75MG
sodium phenylbutyrate oral powder 3
gm/teaspoonful
VPRIV INJ 400UNIT
ZAVESCA CAP 100MG

4
NM, LA
4
NM
4
NM
2
NM
2
NM
4
NM
4
NM, PA
4
NM
4
NM
1
B/D
1
B/D
1
B/D
4
NM, PA
4
NM
4
NM, LA
4
NM, LA
4
NM, LA
4
NM, LA
4
NM, LA, PA
4
NM, LA, PA
4
NM
4
4
NM, PA
NM, LA
ESTROGEN/PROGESTINS
COMBIPATCH DIS .05/.14
COMBIPATCH DIS .05/.25
jinteli tab 1mg-5mcg
3
3
1
ESTROGENS
estradiol tab 0.5 mg
estradiol tab 1 mg
estradiol tab 2 mg
estradiol td patch weekly 0.1 mg/24hr
(37.5 mcg/24hr)
estradiol valerate im in oil 10 mg/ml
1
1
1
1
1
1
1
1
1
PA
PA
PA
PA
PA
PA
PA
PA
PA
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
58
Drug Name
MENEST TAB 0.3MG
MENEST TAB 0.625MG
MENEST TAB 1.25MG
MENEST TAB 2.5MG
PREMARIN VAG CRE 0.625MG
VAGIFEM TAB 10MCG

1
2
PA
2
PA
2
PA
2
PA
3
3
GLUCOCORTICOIDS
a-hydrocort inj 100mg
1
a-methapred inj 125mg
1
cortisone acetate tab 25 mg
1
dexamethason con 1mg/ml
3
dexamethasone elixir 0.5 mg/5ml
1
dexamethasone sodium phosphate inj 4
1
mg/ml
dexamethasone tab 0.5 mg
1
1
dexamethasone tab 1 mg
1
1
1
1
1
fludrocortisone acetate tab 0.1 mg
1
hydrocortisone tab 5 mg
1
1
1
methylprednisolone acetate inj susp 40
1
mg/ml
1
mg/ml
methylprednisolone sodium succinate for inj1
40 mg
125 mg
1000 mg
methylprednisolone tab 4 mg
1
methylprednisolone tab 4 mg dose pack
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
59
Drug Name
prednisolone sod phosph oral soln 6.7
1
mg/5ml (5 mg/5ml base)
prednisolone sod phosphate oral soln 15
1
mg/5ml (base equiv)
prednisolone sodium phosphate oral soln 251
mg/5ml (base eq)
prednisone con 5mg/ml
2
prednisone oral soln 5 mg/5ml
1
prednisone tab 1 mg
1
prednisone tab 2.5 mg
1
prednisone tab 5 mg
1
prednisone tab 10 mg
1
1
1
SOLU-CORTEF INJ 250MG
2
GLUCOSE ELEVATING AGENTS

GLUCAGEN INJ HYPOKIT
GLUCAGON KIT 1MG
PROGLYCEM SUS 50MG/ML
2
2
4
NM
4
4
4
4
4
NM,
NM,
NM,
NM,
NM,
HUMAN GROWTH HORMONES

NORDITROPIN INJ 5/1.5ML
NORDITROPIN INJ 30/3ML
TEV-TROPIN INJ 5MG
PA
PA
PA
PA
PA
MISCELLANEOUS
cabergoline tab 0.5 mg
INCRELEX INJ 40MG/4ML
methylergonovine maleate tab 0.2 mg
octreotide acetate inj 50 mcg/ml (0.05
mg/ml)
mg/ml)
mg/ml)
mg/ml)
octreotide acetate inj 1000 mcg/ml (1
mg/ml)
PROLIA SOL 60MG/ML
1
4
1
1
SANDOSTATIN KIT LAR 10MG
NM, LA, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
QL (1 syringe / 180
days), NM
NM, PA
ST - Step Therapy
NM - Not
LA - Limited Access
60
Drug Name
SOMATULINE INJ 60/0.2ML
SOMATULINE INJ 90/0.3ML
SOMATULINE INJ 120/.5ML
SOMAVERT INJ 10MG
SOMAVERT INJ 15MG
SOMAVERT INJ 20MG

4
NM, PA
4
NM, PA
4
NM, PA
4
NM, PA
4
NM, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
PARATHYROID HORMONES
FORTEO SOL 600/2.4
QL (1 pen / 28 days),
NM, PA
PHOSPHATE BINDER AGENTS

calcium acetate (phosphate binder) cap 6671
mg (169 mg ca)
FOSRENOL CHW 500MG
3
FOSRENOL CHW 750MG
3
FOSRENOL CHW 1000MG
3
PHOSLO CAP 667MG
2
PHOSLYRA SOL
2
RENVELA PAK 0.8GM
2
RENVELA PAK 2.4GM
2
RENVELA TAB 800MG
2
PROGESTINS
medroxyprogesterone acetate tab 2.5 mg
medroxyprogesterone acetate tab 5 mg
norethindrone acetate tab 5 mg
1
1
1
1
SELECTIVE ESTROGEN RECEPTOR MODULATORS

EVISTA TAB 60MG
THYROID AGENTS
LEVOTHROID
LEVOTHROID
LEVOTHROID
LEVOTHROID
LEVOTHROID
LEVOTHROID
LEVOTHROID
LEVOTHROID
LEVOTHROID
LEVOTHROID
LEVOTHROID
TAB
TAB
TAB
TAB
TAB
TAB
TAB
TAB
TAB
TAB
TAB
25MCG
50MCG
75MCG
88MCG
100MCG
112MCG
125MCG
137MCG
150MCG
175MCG
200MCG
1
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
61
Drug Name
LEVOTHROID TAB 300MCG
1
levothyroxine sodium tab 25 mcg
1
1
1
1
1
1
1
1
1
1
1
1
LEVOXYL TAB 25MCG
1
LEVOXYL TAB 50MCG
1
LEVOXYL TAB 75MCG
1
LEVOXYL TAB 88MCG
1
LEVOXYL TAB 100MCG
1
LEVOXYL TAB 112MCG
1
LEVOXYL TAB 125MCG
1
LEVOXYL TAB 137MCG
1
LEVOXYL TAB 150MCG
1
LEVOXYL TAB 175MCG
1
LEVOXYL TAB 200MCG
1
liothyronine sodium tab 5 mcg
1
1
1
methimazole tab 5 mg
1
methimazole tab 10 mg
1
propylthiouracil tab 50 mg
1
SYNTHROID TAB 25MCG
2
SYNTHROID TAB 50MCG
2
SYNTHROID TAB 75MCG
2
SYNTHROID TAB 88MCG
2
SYNTHROID TAB 100MCG
2
2
2
2
2
2
2
2
ST - Step Therapy
NM - Not
62
LA - Limited Access
Drug Name
UNITHROID
UNITHROID
UNITHROID
UNITHROID
UNITHROID
UNITHROID
UNITHROID
UNITHROID
UNITHROID
UNITHROID
UNITHROID
TAB
TAB
TAB
TAB
TAB
TAB
TAB
TAB
TAB
TAB
TAB
25MCG
50MCG
75MCG
88MCG
100MCG
112MCG
125MCG
150MCG
175MCG
200MCG
300MCG

1
1
1
1
1
1
1
1
1
1
1
VASOPRESSINS
desmopressin acetate inj 4 mcg/ml
desmopressin acetate nasal spray soln
0.01%
0.01% (refrigerated)
desmopressin acetate tab 0.1 mg
desmopressin acetate tab 0.2 mg
DESMOPRESSIN SOL 0.01%
1
1
1
1
1
1
GASTROINTESTINAL
ANTIEMETICS
compro sup 25mg
dronabinol cap 2.5 mg
1
1
dronabinol cap 5 mg
dronabinol cap 10 mg
EMEND CAP 40MG

EMEND CAP 80MG
3
3
EMEND CAP 125MG
EMEND PAK 80 & 125
granisetron hcl inj 0.1 mg/ml

granisetron hcl inj 1 mg/ml
granisetron hcl tab 1 mg
meclizine hcl tab 12.5 mg
meclizine hcl tab 25 mg
metoclopramide hcl inj 5 mg/ml
1
1
1
1
1
1
B/D, QL (60 caps / 30

days)
B/D, QL (60 caps / 30
days)
B/D, QL (60 caps / 30
days), NM
B/D, QL (4 caps / 30
days)
B/D, QL (2 caps / 30
days)
B/D, QL (12 caps / 30
days)
B/D
ST - Step Therapy
NM - Not
LA - Limited Access
63
Drug Name
metoclopramide hcl soln 5 mg/5ml (10
1
mg/10ml)
metoclopramide hcl tab 5 mg
1
metoclopramide hcl tab 10 mg
1
ondansetron hcl inj 4 mg/2ml (2 mg/ml) 1
ondansetron hcl inj 40 mg/20ml (2 mg/ml) 1
ondansetron hcl oral soln 4 mg/5ml
1
B/D
ondansetron hcl tab 4 mg
1
B/D
1
B/D
1
B/D
ondansetron orally disintegrating tab 4 mg 1
B/D
ondansetron orally disintegrating tab 8 mg 1
B/D
phenadoz sup 12.5mg
1
phenadoz sup 25mg
1
prochlorperazine edisylate inj 5 mg/ml
1
prochlorperazine maleate tab 5 mg
1
prochlorperazine maleate tab 10 mg
1
prochlorperazine suppos 25 mg
1
promethazine hcl inj 25 mg/ml
1
promethazine hcl inj 50 mg/ml
1
promethazine hcl suppos 12.5 mg
1
promethazine hcl suppos 25 mg
1
promethegan sup 25mg
1
promethegan sup 50mg
1
TRANSDERM-SC DIS 1.5MG
3
QL (10 ptch / 30 days),
PA
ANTISPASMODICS
CUVPOSA SOL 1MG/5ML
dicyclomine hcl cap 10 mg
dicyclomine hcl oral soln 10 mg/5ml
dicyclomine hcl tab 20 mg
glycopyrrolate inj 4 mg/20ml (0.2 mg/ml)
glycopyrrolate tab 1 mg
glycopyrrolate tab 2 mg
3
1
1
1
1
1
1
H2-RECEPTOR ANTAGONISTS
famotidine for susp 40 mg/5ml
1
famotidine in nacl 0.9% iv soln 20 mg/50ml1
famotidine inj 10 mg/ml
1
famotidine tab 20 mg
1
famotidine tab 40 mg
1
ranitidine hcl inj 150 mg/6ml (25 mg/ml) 1
ST - Step Therapy
NM - Not
LA - Limited Access
64
Drug Name
ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 1
ranitidine hcl tab 150 mg
1
ranitidine hcl tab 300 mg
1
INFLAMMATORY BOWEL DISEASE

APRISO CAP 0.375GM
ASACOL HD TAB 800MG
ASACOL TAB 400MG DR
balsalazide disodium cap 750 mg
budesonide cap sr 24hr 3 mg
CANASA SUP 1000MG
colocort ene 100mg
DELZICOL CAP 400MG
hydrocortisone enema 100 mg/60ml
LIALDA TAB 1.2GM
mesalamine rectal enema 4 gm & cleanser
wipe kit
PENTASA CAP 250MG CR
PENTASA CAP 500MG CR
sulfasalazine tab 500 mg
sulfazine ec tab 500mg
UCERIS TAB 9MG
2
3
3
1
4
2
1
3
1
3
1
NM
QL (30 supp / 30 days)
3
3
1
1
3
LAXATIVES
constulose sol 10gm/15
enulose sol 10gm/15
gavilyte-c sol
gavilyte-g sol
gavilyte-n sol flav pk
generlac sol 10gm/15
lactulose solution 10 gm/15ml
MOVIPREP SOL
polyethylene glycol 3350 oral powder
RELISTOR KIT 12/0.6ML
trilyte sol
1
1
1
1
1
1
1
3
1
3
1
PA
MISCELLANEOUS
AMITIZA CAP 8MCG
AMITIZA CAP 24MCG

ST
ST
QL (1 box / year)
amoxicillin cap-clarithro tab-lansopraz cap 1

dr therapy pack
CARAFATE SUS 1GM/10ML
3
cromolyn sodium oral conc 100 mg/5ml
1
ST - Step Therapy
NM - Not
LA - Limited Access
65
Drug Name
diphenoxylate w/ atropine liq 2.5-0.025
1
PA
mg/5ml
diphenoxylate w/ atropine tab 2.5-0.025 mg1
PA
HELIDAC MIS
3
loperamide hcl cap 2 mg
1
LOTRONEX TAB 0.5MG
4
NM
LOTRONEX TAB 1MG
4
NM
misoprostol tab 100 mcg
1
misoprostol tab 200 mcg
1
PREVPAC MIS
3
QL (1 box / year)
PYLERA CAP
3
SUCRAID SOL 8500/ML
3
sucralfate tab 1 gm
1
ursodiol cap 300 mg
1
ursodiol tab 250 mg
1
ursodiol tab 500 mg
1
XIFAXAN TAB 550MG
4
NM, PA
PANCREATIC ENZYMES
CREON CAP 3000UNIT
CREON CAP 6000UNIT
CREON CAP 12000UNT
CREON CAP 24000UNT
CREON CAP 36000UNT
ZENPEP CAP 3000UNIT
ZENPEP CAP 5000UNIT
ZENPEP CAP 10000UNT
ZENPEP CAP 15000UNT
ZENPEP CAP 20000UNT
ZENPEP CAP 25000UNT
3
3
3
3
3
2
2
2
2
2
2
PROTON PUMP INHIBITORS

DEXILANT CAP 30MG DR
DEXILANT CAP 60MG DR
NEXIUM CAP 20MG
NEXIUM CAP 40MG
NEXIUM GRA 2.5MG DR
NEXIUM GRA 5MG DR
NEXIUM GRA 10MG DR
NEXIUM GRA 20MG DR
NEXIUM GRA 40MG DR
NEXIUM I.V. INJ 20MG
NEXIUM I.V. INJ 40MG
2
2
2
2
2
2
2
2
2
3
3
QL
QL
QL
QL
(30
(30
(30
(30
ea
ea
ea
ea
/
/
/
/
30
30
30
30
days)
days)
days)
days)
ST - Step Therapy
NM - Not
LA - Limited Access
66
Drug Name
omeprazole cap delayed release 10 mg
pantoprazole sodium ec tab 20 mg (base
equiv)
equiv)

1
1
1
1
1
1
2
1
2
1
QL
QL
QL
QL
QL
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA
alfuzosin hcl tab sr 24hr 10 mg
AVODART CAP 0.5MG
finasteride tab 5 mg
JALYN CAP
tamsulosin hcl cap 0.4 mg
(30
(30
(30
(30
(60
ea / 30 days)
caps / 30 days)
tabs / 30 days)
caps / 30 days)
caps / 30 days)
MISCELLANEOUS
bethanechol chloride tab 5 mg
1
1
1
1
ELMIRON CAP 100MG
3
potassium citrate tab cr 5 meq (540 mg) 1
potassium citrate tab cr 10 meq (1080 mg) 1
URINARY ANTISPASMODICS
DETROL LA CAP 2MG
DETROL LA CAP 4MG
oxybutynin chloride syrup 5 mg/5ml
oxybutynin chloride tab 5 mg
oxybutynin chloride tab sr 24hr 5 mg
tolterodine tartrate tab 1 mg
tolterodine tartrate tab 2 mg
TOVIAZ TAB 4MG
TOVIAZ TAB 8MG
trospium chloride tab 20 mg
VESICARE TAB 5MG
VESICARE TAB 10MG
2
2
1
1
1
1
1
1
1
2
2
1
3
3
QL
QL
QL
QL
QL
(30
(30
(60
(30
(30
ea / 30 days)
ea / 30 days)
tabs / 30 days)
tabs / 30 days)
tabs / 30 days)
VAGINAL ANTI-INFECTIVES
CLEOCIN SUP 100MG
2
clindamycin phosphate vaginal cream 2% 1
metronidazole vaginal gel 0.75%
1
ST - Step Therapy
NM - Not
LA - Limited Access
67
Drug Name
terconazole vaginal cream 0.4%
terconazole vaginal cream 0.8%
terconazole vaginal suppos 80 mg
VANDAZOLE GEL 0.75%
zazole cre 0.4%
ZAZOLE CRE 0.8%

1
1
1
1
1
1
HEMATOLOGIC
ANTICOAGULANTS
COUMADIN TAB 1MG
COUMADIN TAB 2.5MG
COUMADIN TAB 2MG
COUMADIN TAB 3MG
COUMADIN TAB 4MG
COUMADIN TAB 5MG
COUMADIN TAB 6MG
COUMADIN TAB 7.5MG
COUMADIN TAB 10MG
ELIQUIS TAB 2.5MG
ELIQUIS TAB 5MG
enoxaparin sodium inj 30 mg/0.3ml
3
3
3
3
3
3
3
3
3
2
2
1
QL (200 syringes / 180

days)
1
days)
1
days)
1
days)
enoxaparin sodium inj 100 mg/ml
4
days), NM
4
days), NM
enoxaparin sodium inj 150 mg/ml
4
days), NM
enoxaparin sodium inj 300 mg/3ml
4
QL (60mL / 180 days),
NM
fondaparinux sodium inj 2.5 mg/0.5ml
1
days)
fondaparinux sodium inj 5 mg/0.4ml
4
days), NM
fondaparinux sodium inj 7.5 mg/0.6ml
4
days), NM
fondaparinux sodium inj 10 mg/0.8ml
4
days), NM
ST - Step Therapy
NM - Not
68
LA - Limited Access
Drug Name
HEP SOD/D5W INJ 20000UNT
1
HEP SOD/NACL INJ 2UNIT/ML
1
HEP SOD/NACL INJ 25000UNT
2
HEPARIN SOD INJ 2000/ML
2
B/D
heparin sodium (porcine) inj 1000 unit/ml 1
B/D
B/D
B/D
B/D
jantoven tab 1mg
1
jantoven tab 2.5mg
1
jantoven tab 2mg
1
jantoven tab 3mg
1
jantoven tab 4mg
1
jantoven tab 5mg
1
jantoven tab 6mg
1
jantoven tab 7.5mg
1
jantoven tab 10mg
1
PRADAXA CAP 75MG
2
PRADAXA CAP 150MG
2
warfarin sodium tab 1 mg
1
1
warfarin sodium tab 2.5 mg
1
1
1
1
1
warfarin sodium tab 7.5 mg
1
1
XARELTO TAB 10MG
2
XARELTO TAB 15MG
2
XARELTO TAB 20MG
2
HEMATOPOIETIC GROWTH FACTORS

ARANESP INJ 25MCG
ARANESP INJ 40MCG
ARANESP INJ 60MCG
ARANESP INJ 100MCG
ARANESP INJ 150MCG
ARANESP INJ 200MCG
ARANESP INJ 300MCG
ARANESP INJ 500MCG
LEUKINE INJ 250MCG
2
2
2
4
4
4
4
4
4
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
PA
PA
PA
PA
PA
PA
PA
PA
PA
ST - Step Therapy
NM - Not
LA - Limited Access
69
Drug Name
LEUKINE INJ 500 MCG
MOZOBIL INJ
NEUMEGA INJ 5MG
NEUPOGEN INJ 300/0.5
NEUPOGEN INJ 480/0.8
NEUPOGEN INJ 480MCG
PROCRIT INJ 2000/ML
PROCRIT INJ 3000/ML
PROCRIT INJ 4000/ML
PROCRIT INJ 10000/ML

4
NM, PA
4
QL (8 vials / 4 days), NM,
PA
4
NM
4
NM, PA
4
NM, PA
4
NM, PA
2
NM, PA
2
NM, PA
2
NM, PA
2
NM, PA
4
NM, PA
4
NM, PA
MISCELLANEOUS
anagrelide hcl cap 0.5 mg
anagrelide hcl cap 1 mg
cilostazol tab 50 mg
cilostazol tab 100 mg
pentoxifylline tab cr 400 mg
PROMACTA TAB 12.5MG
PROMACTA TAB 25MG
PROMACTA TAB 50MG
PROMACTA TAB 75MG
1
1
1
1
1
4
4
4
4
tranexamic acid inj 100 mg/ml

tranexamic acid tab 650 mg
1
1
PA
PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
PLATELET AGGREGATION INHIBITORS

AGGRENOX CAP 25-200MG
3
BRILINTA TAB 90MG
3
clopidogrel bisulfate tab 75 mg (base equiv)1
EFFIENT TAB 5MG
3
EFFIENT TAB 10MG
3
IMMUNOLOGIC AGENTS
DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS)
ACTEMRA INJ 200/10ML
ENBREL INJ 25/0.5ML
4
4
ENBREL INJ 25MG
ENBREL INJ 50MG/ML
NM, PA
QL (8 syringes / 28
days), NM, PA
NM, PA
QL (8 syringes / 28
days), NM, PA
ST - Step Therapy
NM - Not
LA - Limited Access
70
Drug Name
HUMIRA KIT 20MG/0.4
HUMIRA KIT 40MG/0.8
HUMIRA PEN KIT 40MG/0.8
HUMIRA PEN KIT CROHNS
hydroxychloroquine sulfate tab 200 mg
leflunomide tab 10 mg
leflunomide tab 20 mg
methotrexate sodium tab 2.5 mg (base
equiv)
REMICADE INJ 100MG

4
NM, PA
4
NM, PA
4
NM, PA
4
NM, PA
1
1
1
1
4
NM, PA
4
4
2
4
4
4
4
4
4
4
4
4
4
4
NM, PA
NM, PA
B/D, NM
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
4
4
4
4
4
4
3
4
4
4
4
4
4
NM, LA, PA
NM, PA
NM, PA
B/D, NM
B/D, NM
B/D, NM
B/D, NM
B/D, NM
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
IMMUNOGLOBULINS
CARIMUNE NF INJ 3GM
FLEBOGAMMA INJ 5%
GAMASTAN S/D INJ
GAMMAGARD INJ 2.5GM/25
GAMMAKED INJ 1GM/10ML
GAMMAPLEX INJ 10GM
GAMUNEX-C INJ 1GM/10ML
GAMUNEX-C INJ 5GM/50ML
GAMUNEX-C INJ 10GM/100
GAMUNEX-C INJ 20GM/200
HIZENTRA INJ 1GM/5ML
OCTAGAM INJ 1GM
PRIVIGEN INJ 20GRAMS
PRIVIGEN INJ 40GRAMS
IMMUNOMODULATORS
ACTIMMUNE INJ 2MU/0.5
ARCALYST INJ 220MG
INFERGEN INJ 15MCG
INTRON-A INJ 3MU PEN
INTRON-A INJ 10MU
INTRON-A INJ 18MU
PEG-INTRON KIT 50MCG
PEG-INTRON KIT 50MCG RP
PEG-INTRON KIT 80MCG RP
PEG-INTRON KIT 120 RP
PEG-INTRON KIT 150 RP
ST - Step Therapy
NM - Not
LA - Limited Access
71
Drug Name
PEGASYS INJ 180MCG/M
PEGASYS INJ PROCLICK
PEGASYS KIT
REVLIMID CAP 2.5MG
REVLIMID CAP 5MG
REVLIMID CAP 10MG
REVLIMID CAP 15MG
REVLIMID CAP 20MG
REVLIMID CAP 25MG
THALOMID CAP 50MG
THALOMID CAP 100MG
THALOMID CAP 150MG
THALOMID CAP 200MG

4
NM, PA
4
NM, PA
4
NM, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, LA, PA
4
NM, PA
4
NM, PA
4
NM, PA
4
NM, PA
IMMUNOSUPPRESSANTS
azathioprine sodium for inj 100 mg
1
azathioprine tab 50 mg
1
CELLCEPT SUS 200MG/ML
4
cyclosporine cap 25 mg
1
cyclosporine cap 100 mg
1
cyclosporine iv soln 50 mg/ml
1
cyclosporine modified cap 25 mg
1
1
1
cyclosporine modified oral soln 100 mg/ml 1
gengraf cap 25mg
1
gengraf cap 100mg
1
gengraf sol 100mg/ml
1
mycophenolate mofetil cap 250 mg
1
mycophenolate mofetil tab 500 mg
1
MYFORTIC TAB 180MG
3
MYFORTIC TAB 360MG
4
NEORAL CAP 25MG
2
NEORAL CAP 100MG
2
NEORAL SOL 100MG/ML
2
NULOJIX INJ 250MG
4
PROGRAF CAP 0.5MG
3
B/D
B/D
B/D, NM
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D, NM
B/D
B/D
B/D
B/D, NM
B/D
ST - Step Therapy
NM - Not
LA - Limited Access
72
Drug Name
PROGRAF CAP 1MG
PROGRAF CAP 5MG
RAPAMUNE SOL 1MG/ML
RAPAMUNE TAB 0.5MG
RAPAMUNE TAB 1MG
RAPAMUNE TAB 2MG
SANDIMMUNE CAP 25MG
SANDIMMUNE CAP 100MG
SANDIMMUNE SOL 100MG/ML
tacrolimus cap 0.5 mg
tacrolimus cap 1 mg
tacrolimus cap 5 mg
ZORTRESS TAB 0.5MG
ZORTRESS TAB 0.25MG
ZORTRESS TAB 0.75MG

3
B/D
4
B/D, NM
4
B/D, NM
3
B/D
4
B/D, NM
4
B/D, NM
2
B/D
2
B/D
2
B/D
1
B/D
1
B/D
4
B/D, NM
4
B/D, NM
4
B/D, NM
4
B/D, NM
VACCINES
ACTHIB INJ
ADACEL INJ
BOOSTRIX INJ
CERVARIX INJ
COMVAX INJ
DAPTACEL INJ
DECAVAC INJ 5-2LF
DIP/TET PED INJ 25-5LFU
ENGERIX-B INJ 10/0.5ML
ENGERIX-B INJ 20MCG/ML
GARDASIL INJ
HAVRIX INJ 720UNIT
HAVRIX INJ 1440UNIT
IMOVAX RABIE INJ 2.5/ML
INFANRIX INJ
IPOL INJ INACTIVE
IXIARO INJ
M-M-R II INJ LIVE
MENACTRA INJ
MENHIBRIX INJ
MENOMUNE INJ A/C/Y/W
MENVEO INJ
PEDVAX HIB INJ
PROQUAD INJ
RABAVERT INJ
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
B/D
B/D
B/D
B/D
ST - Step Therapy
NM - Not
LA - Limited Access
73
Drug Name
RECOMBIVA HB INJ 10MCG/ML
RECOMBIVA-HB INJ 40MCG/ML
ROTATEQ SOL
TET/DIP TOX INJ 2-2 LF
TETANUS TOX INJ 5LF ADS
TWINRIX INJ
TYPHIM VI INJ
VAQTA INJ 25/0.5ML
VARIVAX INJ
YF-VAX INJ
ZOSTAVAX INJ

2
B/D
2
B/D
2
2
B/D
2
B/D
2
B/D
2
2
2
2
2
QL (1 vial)
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES
KLOR-CON 8 TAB 8MEQ ER
1
KLOR-CON 10 TAB 10MEQ ER
1
KLOR-CON M15 TAB
3
klor-con m20 tab 20meq er
1
MAGNESIUM SU INJ 40MG/ML
2
MAGNESIUM SU INJ 80MG/ML
2
magnesium sulfate inj 50%
1
MG SO4/D5W INJ 10MG/ML
2
potassium chloride cap cr 8 meq
1
potassium chloride cap cr 10 meq
1
potassium chloride microencapsulated crys 1
cr tab 10 meq
potassium chloride microencapsulated crys 1
cr tab 20 meq
SOD CHLORIDE INJ 2.5/ML
1
sod fluoride 2.2mg tab
1
TPN ELECTROL INJ
1
B/D
IV NUTRITION
amino acid infusion 6%
AMINOSYN II INJ 7%
AMINOSYN II INJ 8.5%
AMINOSYN II INJ 8.5/LYTE
AMINOSYN II INJ 10%
AMINOSYN INJ 8.5%
AMINOSYN INJ 8.5/LYTE
AMINOSYN INJ 10%
AMINOSYN M INJ 3.5%
AMINOSYN-HBC INJ 7%
1
3
3
1
3
3
1
3
3
3
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
ST - Step Therapy
NM - Not
LA - Limited Access
74
Drug Name
AMINOSYN-PF INJ 7%
AMINOSYN-PF INJ 10%
CLINIMIX E INJ 2.75/D5W
CLINIMIX E INJ 2.75/D10
CLINIMIX E INJ 4.25/D5W
CLINIMIX E INJ 4.25/D25
CLINIMIX E INJ 5%/D15W
CLINIMIX INJ 2.75/D5W
CLINIMIX INJ 4.25/D5W
CLINIMIX INJ 4.25/D10
CLINIMIX INJ 5%/D15W
CLINISOL SF INJ 15%
FREAMINE III INJ 3%
FREAMINE III INJ 8.5%
HEPATAMINE SOL 8%
hepatasol inj 8%
INTRALIPID INJ 20%
INTRALIPID INJ 30%
NEPHRAMINE INJ 5.4%
premasol sol 10%
PROCALAMINE INJ 3%
PROSOL INJ 20%
TRAVASOL INJ 10%
TROPHAMINE INJ 10%

3
B/D
3
B/D
3
B/D
3
B/D
3
B/D
3
B/D
3
B/D
3
B/D
3
B/D
3
B/D
3
B/D
3
B/D
3
B/D
3
B/D
3
B/D
3
B/D
3
B/D
1
B/D
3
B/D
1
B/D
1
B/D
1
B/D
1
B/D
2
B/D
3
B/D
3
B/D
3
B/D
3
B/D
3
B/D
3
B/D
IV REPLACEMENT SOLUTIONS
D2.5W/NACL INJ 0.45%
D5W/LR INJ
D5W/LYTES INJ #48
D5W/NACL INJ 0.2%
D5W/NACL INJ 0.9%
D5W/NACL INJ 0.33%
D5W/NACL INJ 0.45%
D5W/NACL INJ 0.225%
D10W/NACL INJ 0.2%
D10W/NACL INJ 0.45%
1
1
2
1
1
1
1
1
3
1
ST - Step Therapy
NM - Not
LA - Limited Access
75
Drug Name
DEXTROSE INJ 5%
DEXTROSE INJ 10%
IONOSOL-B/ INJ D5W
IONOSOL-MB INJ /D5W
ISOLYTE-H INJ /D5W
isolyte-m inj /d5w
isolyte-p inj /d5w
isolyte-s inj
isolyte-s inj /d5w
kcl 20 meq/l (0.15%) in nacl 0.45% inj
KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ
KCL/D5W INJ 0.3%
KCL/D5W INJ 0.15%
KCL/D5W INJ 0.224%
KCL/D5W/NACL INJ 0.3/0.9%
KCL/D5W/NACL INJ 0.3/0.45
KCL/D5W/NACL INJ .15/.33%
KCL/D5W/NACL INJ .15/.45%
KCL/D5W/NACL INJ .22/.45
KCL/D5W/NACL INJ .075/.45
KCL/NACL INJ 0.15-0.9
LACTATED RIN INJ
normosol -m inj /d5w
NORMOSOL -R INJ /D5W
NORMOSOL-R INJ PH 7.4
PLASMA-LYTE INJ 56/D5W
PLASMA-LYTE INJ -148
PLASMA-LYTE INJ -A
potassium chloride inj 2 meq/ml
potassium chloride inj 10 meq/50 ml
ringer's solution
SOD CHLORIDE INJ 0.9%
SOD CHLORIDE INJ 0.45%
SOD CHLORIDE INJ 3%
SOD CHLORIDE INJ 5%

1
1
3
3
2
1
3
3
3
1
1
1
1
1
2
1
1
2
1
1
1
1
1
1
1
1
3
3
3
3
3
1
1
1
1
1
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
76
Drug Name
VITAMINS
calcitriol cap 0.5 mcg
calcitriol cap 0.25 mcg
calcitriol inj 1 mcg/ml
calcitriol oral soln 1 mcg/ml
prenatal vitamin/folic acid > 0.8 mg
(generic)
ZEMPLAR CAP 1MCG
ZEMPLAR CAP 2MCG
ZEMPLAR CAP 4MCG
ZEMPLAR INJ 2MCG/ML
ZEMPLAR INJ 5MCG/ML
1
1
1
1
1
B/D
B/D
B/D
B/D
2
2
2
3
3
B/D
B/D
B/D
B/D
B/D
OPHTHALMIC
ANTI-INFECTIVE/ANTI-INFLAMMATORY
bacitracin-polymyxin-neomycin-hc ophth
oint 1%
blephamide oin s.o.p.
neomycin-polymyxin-dexamethasone
ophth oint 0.1%
ophth susp 0.1%
neomycin-polymyxin-hc ophth susp
sulfacetamide sodium-prednisolone ophth
soln 10-0.23(0.25)%
TOBRADEX OIN 0.3-0.1%
TOBRADEX ST SUS 0.3-0.05
tobramycin-dexamethasone ophth susp
0.3-0.1%
ZYLET SUS 0.5-0.3%
1
2
1
1
1
1
2
2
1
2
ANTI-INFECTIVES
AZASITE SOL 1%
bacitracin ophth oint 500 unit/gm
bacitracin-polymyxin b ophth oint
BESIVANCE SUS 0.6%
CILOXAN OIN 0.3% OP
ciprofloxacin hcl ophth soln 0.3%
erythromycin ophth oint 5 mg/gm
gentak oin 0.3% op
gentamicin sulfate ophth soln 0.3%
MOXEZA SOL 0.5%
NATACYN SUS 5% OP
2
1
1
2
2
1
1
1
1
2
3
ST - Step Therapy
NM - Not
LA - Limited Access
77
Drug Name
neomycin-bacitrac zn-polymyx
1
5(3.5)mg-400unt-10000unt op oin
neomycin-polymyx-gramicid op sol
1
1.75-10000-0.25mg-unt-mg/ml
ofloxacin ophth soln 0.3%
1
polymyxin b-trimethoprim ophth soln 100001
unit/ml-0.1%
sulfacetamide sodium ophth oint 10%
1
sulfacetamide sodium ophth soln 10%
1
tobramycin sulfate ophth soln 0.3%
1
TOBREX OIN 0.3% OP
2
trifluridine ophth soln 1%
1
VIGAMOX DRO 0.5%
2
ZYMAXID SOL 0.5%
3
ANTI-INFLAMMATORIES
ALREX SUS 0.2%
BROMDAY SOL 0.09%
dexamethasone sodium phosphate ophth
soln 0.1%
diclofenac sodium ophth soln 0.1%
DUREZOL EMU 0.05%
FLUOROMETHOL SUS 0.1% OP
flurbiprofen sodium ophth soln 0.03%
FML FORTE SUS 0.25% OP
FML OIN 0.1% OP
ILEVRO DRO 0.3% OP
ketorolac tromethamine ophth soln 0.4%
LOTEMAX GEL 0.5%
LOTEMAX OIN 0.5%
LOTEMAX SUS 0.5%
MAXIDEX SUS 0.1% OP
NEVANAC SUS 0.1%
PRED MILD SUS 0.12% OP
prednisolone sodium phosphate ophth soln
1%
PREDNISOLONE SUS 1% OP
2
2
1
1
2
1
1
2
2
2
1
1
2
2
2
3
2
2
2
1
ANTIALLERGICS
azelastine hcl ophth soln 0.05%
BEPREVE DRO 1.5%
cromolyn sodium ophth soln 4%
PATADAY SOL 0.2%
1
2
1
2
ST - Step Therapy
NM - Not
LA - Limited Access
78
Drug Name
PATANOL SOL 0.1% OP

2
ANTIGLAUCOMA
ALPHAGAN P SOL 0.1%
2
ALPHAGAN P SOL 0.15%
2
AZOPT SUS 1% OP
2
betaxolol hcl ophth soln 0.5%
1
BETOPTIC-S SUS 0.25% OP
2
BRIMONIDINE SOL 0.15%
1
brimonidine tartrate ophth soln 0.2%
1
carteolol hcl ophth soln 1%
1
COMBIGAN SOL 0.2/0.5%
2
dorzolamide hcl ophth soln 2%
1
dorzolamide hcl-timolol maleate ophth soln 1
22.3-6.8 mg/ml
ISOPTO CARP SOL 1% OP
3
3
3
ISTALOL SOL 0.5% OP
2
latanoprost ophth soln 0.005%
1
levobunolol hcl ophth soln 0.5%
1
LEVOBUNOLOL SOL 0.25% OP
1
LUMIGAN SOL 0.01%
2
LUMIGAN SOL 0.03%
2
metipranolol ophth soln 0.3%
1
PHOSPHOLINE SOL 0.125%OP
3
PILOCARPINE HCL OPHTH SOLN 1%
1
1
1
PILOPINE HS GEL 4% OP
2
TIMOLOL GEL SOL 0.5% OP
1
TIMOLOL GEL SOL 0.25% OP
1
timolol maleate ophth soln 0.5%
1
timolol maleate ophth soln 0.25%
1
TRAVATAN Z DRO 0.004%
2
MISCELLANEOUS
naphazoline sol 0.1% op
PROLENSA SOL 0.07%
proparacaine hcl ophth soln 0.5%
RESTASIS EMU 0.05%
tropicamide ophth soln 0.5%
tropicamide ophth soln 1%
1
2
1
2
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
79
Drug Name
RESPIRATORY
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS
COMBIVENT AER
3
COMBIVENT AER RESPIMAT
3
ipratropium-albuterol nebu soln 0.5-2.5(3) 1
mg/3ml
QL (2 inhalers / 30 days)
B/D
ANTICHOLINERGICS
ATROVENT HFA AER 17MCG
3
ipratropium bromide inhal soln 0.02%
1
ipratropium bromide nasal soln 0.03% (21 1
mcg/spray)
ipratropium bromide nasal soln 0.06% (42 1
mcg/spray)
SPIRIVA CAP HANDIHLR
2
B/D
ANTIHISTAMINES
ASTEPRO SPR 0.15%
2
azelastine hcl nasal spray 137 mcg/spray (11
mg/ml)
cetirizine hcl syrup 1 mg/ml (5 mg/5ml)
1
diphenhydramine hcl inj 50 mg/ml
1
hydroxyzine hcl im soln 25 mg/ml
1
hydroxyzine hcl im soln 50 mg/ml
1
levocetirizine dihydrochloride soln 2.5
1
mg/5ml (0.5 mg/ml)
levocetirizine dihydrochloride tab 5 mg
1
PATANASE SPR 0.6%
2
BETA AGONISTS
albuterol sulfate soln nebu 0.5% (5 mg/ml)1
albuterol sulfate soln nebu 0.63 mg/3ml
1
(base equiv)
albuterol sulfate soln nebu 0.083% (2.5
1
mg/3ml)
1
(base equiv)
albuterol sulfate syrup 2 mg/5ml
1
albuterol sulfate tab 2 mg
1
albuterol sulfate tab 4 mg
1
albuterol sulfate tab sr 12hr 4 mg
1
albuterol sulfate tab sr 12hr 8 mg
1
FORADIL CAP AEROLIZE
2
levalbuterol hcl soln nebu conc 1.25
1
mg/0.5ml (base equiv)
B/D
B/D
B/D
B/D

B/D
ST - Step Therapy
NM - Not
LA - Limited Access
80
Drug Name
PERFOROMIST NEB 20MCG
PROAIR HFA AER
SEREVENT DIS AER 50MCG
terbutaline sulfate inj 1 mg/ml
terbutaline sulfate tab 2.5 mg
terbutaline sulfate tab 5 mg
XOPENEX HFA AER

3
B/D
2
3
QL (1 inhaler / 30 days)
1
1
1
2
LEUKOTRIENE RECEPTOR ANTAGONISTS

montelukast sodium chew tab 4 mg (base 1
equiv)
montelukast sodium chew tab 5 mg (base 1
equiv)
montelukast sodium oral granules packet 4 1
mg (base equiv)
montelukast sodium tab 10 mg (base equiv)1
zafirlukast tab 10 mg
1
zafirlukast tab 20 mg
1

QL (30 packets / 30
days)
MAST CELL STABILIZERS

cromolyn sodium soln nebu 20 mg/2ml
B/D
acetylcysteine inhal soln 10%

acetylcysteine inhal soln 20%
ARALAST NP INJ 400MG
AUVI-Q INJ 0.3MG
AUVI-Q INJ 0.15MG
CAYSTON INH 75MG
DALIRESP TAB 500MCG
EPIPEN 2-PAK INJ 0.3MG
EPIPEN-JR INJ 2-PAK
GLASSIA INJ
PROLASTIN-C INJ 1000MG
PULMOZYME SOL 1MG/ML
TOBI NEB 300/5ML
XOLAIR SOL 150MG
1
1
4
2
2
4
2
2
2
4
4
4
4
4
B/D
B/D
NM, LA, PA
ZEMAIRA INJ 1000MG
MISCELLANEOUS
NM, LA, PA
NM, LA, PA
NM, LA, PA
B/D, NM
B/D, NM
QL (6 vials / 30 days),
NM, LA, PA
NM, LA, PA
NASAL STEROIDS
flunisolide nasal soln 25 mcg/act (0.025%) 1
fluticasone propionate nasal susp 50
1
mcg/act
NASONEX SPR 50MCG/AC
2
ST - Step Therapy
NM - Not
LA - Limited Access
81
Drug Name
triamcinolone acetonide nasal inhal 55
mcg/act

1
STEROID INHALANTS
ASMANEX 14 AER 220MCG
budesonide inhalation susp 0.5 mg/2ml
FLOVENT DISK AER 50MCG
FLOVENT HFA AER 44MCG
PULMICORT SUS 1MG/2ML
QVAR AER 40MCG
QVAR AER 80MCG
2
2
2
2
2
1
1
2
2
2
2
2
2
3
2
2
QL (2
QL (2
QL (2
QL (2
QL (2
B/D
B/D
QL (2
QL (2
QL (4
QL (2
QL (2
QL (2
B/D
QL (3
QL (3
inhalers
inhalers
inhalers
inhalers
inhalers
/
/
/
/
/
30
30
30
30
30
days)
days)
days)
days)
days)
inhalers
inhalers
inhalers
inhalers
inhalers
inhalers
/
/
/
/
/
/
30
30
30
30
30
30
days)
days)
days)
days)
days)
days)
inhalers / 30 days)
inhalers / 30 days)
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
inhaler
inhaler
inhaler
inhaler
inhaler
inhaler
inhaler
inhaler
inhaler
inhaler
STEROID/BETA-AGONIST COMBINATIONS
ADVAIR DISKU AER 100/50
ADVAIR HFA AER 45/21
DULERA AER 100-5MCG
DULERA AER 200-5MCG
SYMBICORT AER 80-4.5
SYMBICORT AER 160-4.5
2
2
2
2
2
2
2
2
2
2
(1
(1
(1
(1
(1
(1
(1
(1
(1
(1
/
/
/
/
/
/
/
/
/
/
30
30
30
30
30
30
30
30
30
30
days)
days)
days)
days)
days)
days)
days)
days)
days)
days)
XANTHINES
aminophylline inj 25 mg/ml
ELIXOPHYLLIN ELX 80/15ML
THEO-24 CAP 100MG CR
THEO-24 CAP 400MG ER
theophylline tab 100mg cr
theophylline tab 200mg cr
theophylline tab 300mg er
theophylline tab 450mg er
1
3
3
3
3
3
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
82
Drug Name
theophylline tab sr 24hr 400 mg
theophylline tab sr 24hr 600 mg

1
1
TOPICAL
DERMATOLOGY, ACNE
adapalene cream 0.1%
adapalene gel 0.1%
amnesteem cap 10mg
amnesteem cap 20mg
amnesteem cap 40mg
AVITA CRE 0.025%
AVITA GEL 0.025%
benzoyl peroxide-erythromycin gel 5-3%
claravis cap 10mg
claravis cap 20mg
claravis cap 30mg
claravis cap 40mg
clindamycin phosphate gel 1%
clindamycin phosphate lotion 1%
clindamycin phosphate soln 1%
clindamycin phosphate swab 1%
ery pad 2%
erythromycin gel 2%
erythromycin soln 2%
myorisan cap 10mg
myorisan cap 20mg
myorisan cap 40mg
sulfacetamide sodium lotion 10% (acne)
tretinoin cream 0.1%
tretinoin gel 0.01%
tretinoin gel 0.025%
zenatane cap 10mg
zenatane cap 20mg
zenatane cap 40mg
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
DERMATOLOGY, ACTINIC KERATOSIS

CARAC CRE 0.5%
FLUOROPLEX CRE 1%
fluorouracil cream 5%
fluorouracil soln 2%
fluorouracil soln 5%
3
3
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
83
Drug Name
SOLARAZE GEL 3% W/W

3
PA
DERMATOLOGY, ANTIBIOTICS
gentamicin sulfate cream 0.1%
1
gentamicin sulfate oint 0.1%
1
mafenide acetate packet for topical soln 5%1
(50 gm)
mupirocin oint 2%
1
SILVER SULFA CRE 1%
1
SSD CRE 1%
1
SULFAMYLON CRE 85MG/GM
3
DERMATOLOGY, ANTIFUNGALS
ciclopirox gel 0.77%
1
ciclopirox olamine cream 0.77% (base
1
equiv)
ciclopirox olamine susp 0.77% (base equiv)1
ciclopirox shampoo 1%
1
clotrimazole cream 1%
1
clotrimazole soln 1%
1
econazole nitrate cream 1%
1
ketoconazole cream 2%
1
nyamyc pow 100000
1
nystatin cream 100000 unit/gm
1
nystatin oint 100000 unit/gm
1
nystatin topical powder
1
nystop pow 100000
1
pedi-dri pow 100000
1
DERMATOLOGY, ANTIPRURITIC
proctocream cre hc 2.5%
proctozone cre -hc 2.5%
PRUDOXIN CRE 5%
ZONALON CRE 5%
1
1
1
3
DERMATOLOGY, ANTIPSORIATICS
acitretin cap 10 mg
acitretin cap 17.5 mg
acitretin cap 25 mg
calcipotriene cream 0.005%
calcipotriene oint 0.005%
calcipotriene soln 0.005% (50 mcg/ml)
OXSORALEN-UL CAP 10MG
SORIATANE CAP 10MG
SORIATANE CAP 17.5MG
4
4
4
1
1
1
4
4
4
NM, PA
NM, PA
NM, PA
NM
NM, PA
NM, PA
ST - Step Therapy
NM - Not
LA - Limited Access
84
Drug Name
SORIATANE CAP 25MG
TAZORAC CRE 0.1%
TAZORAC CRE 0.05%
TAZORAC GEL 0.1%
TAZORAC GEL 0.05%

4
NM, PA
3
3
3
3
DERMATOLOGY, ANTISEBORRHEICS
ketoconazole shampoo 2%
selenium sulfide lotion 2.5%
1
1
DERMATOLOGY, ANTIVIRALS
acyclovir oint 5%
DENAVIR CRE 1%
ZOVIRAX CRE 5%
1
3
3
DERMATOLOGY, CORTICOSTEROIDS
ala cort cre 1%
1
alclometasone dipropionate cream 0.05% 1
alclometasone dipropionate oint 0.05%
1
amcinonide cream 0.1%
1
amcinonide lotion 0.1%
1
amcinonide oint 0.1%
3
betamethasone dipropionate augmented
1
cream 0.05%
betamethasone dipropionate augmented gel1
0.05%
1
lotion 0.05%
1
oint 0.05%
betamethasone dipropionate cream 0.05% 1
betamethasone dipropionate lotion 0.05% 1
betamethasone dipropionate oint 0.05%
1
betamethasone valerate cream 0.1%
1
betamethasone valerate lotion 0.1%
1
betamethasone valerate oint 0.1%
1
clobetasol e cre 0.05%
1
clobetasol propionate gel 0.05%
1
clobetasol propionate oint 0.05%
1
clobetasol propionate soln 0.05%
1
DESONIDE CRE 0.05%
1
desonide lotion 0.05%
1
desonide oint 0.05%
1
DESOXIMETAS OIN 0.05%
1
desoximetasone cream 0.05%
1
ST - Step Therapy
NM - Not
LA - Limited Access
85
Drug Name
desoximetasone cream 0.25%
1
desoximetasone gel 0.05%
1
desoximetasone oint 0.25%
1
diflorasone diacetate cream 0.05%
1
diflorasone diacetate oint 0.05%
1
fluocin acet oil body
1
fluocinolone acetonide cream 0.01%
1
fluocinolone acetonide cream 0.025%
1
fluocinolone acetonide oint 0.025%
1
fluocinolone acetonide soln 0.01%
1
fluocinonide emulsified base cream 0.05% 1
fluocinonide gel 0.05%
1
fluocinonide oint 0.05%
1
fluocinonide soln 0.05%
1
fluticasone propionate cream 0.05%
1
fluticasone propionate oint 0.005%
1
halobetasol propionate cream 0.05%
1
halobetasol propionate oint 0.05%
1
hydrocortisone butyrate cream 0.1%
1
hydrocortisone butyrate oint 0.1%
1
hydrocortisone butyrate soln 0.1%
1
hydrocortisone cream 1%
1
hydrocortisone cream 2.5%
1
hydrocortisone lotion 2.5%
1
hydrocortisone oint 1%
1
hydrocortisone oint 2.5%
1
hydrocortisone valerate cream 0.2%
1
hydrocortisone valerate oint 0.2%
1
lokara lot 0.05%
1
mometasone furoate cream 0.1%
1
mometasone furoate oint 0.1%
1
mometasone furoate solution 0.1% (lotion) 1
procto-pak cre 1%
1
triamcinolone acetonide cream 0.1%
1
1
1
triamcinolone acetonide lotion 0.1%
1
triamcinolone acetonide lotion 0.025%
1
triamcinolone acetonide oint 0.1%
1
1
1
triderm cre 0.1%
1
ST - Step Therapy
NM - Not
86
LA - Limited Access
Drug Name
DERMATOLOGY, LOCAL ANESTHETICS

lidocaine hcl gel 2%
lidocaine hcl soln 4%
lidocaine oint 5%
lidocaine patch 5%
lidocaine-prilocaine cream 2.5-2.5%
LIDODERM DIS 5%
1
1
1
1
1
2
QL (3 ptch / 1 day), PA
B/D
QL (3 ptch / 1 day), PA
DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE

CONDYLOX GEL 0.5%
3
ELIDEL CRE 1%
3
imiquimod cream 5%
1
laclotion lot 12%
1
lactic acid (ammonium lactate) cream 12% 1
lactic acid (ammonium lactate) lotion 12% 1
metronidazole cream 0.75%
1
metronidazole gel 0.75%
1
metronidazole lotion 0.75%
1
PANRETIN GEL 0.1%
4
podofilox soln 0.5%
1
PROTOPIC OIN 0.1%
3
PROTOPIC OIN 0.03%
3
TARGRETIN GEL 1%
4
VOLTAREN GEL 1%
2
PA
NM
PA
PA
NM, PA
DERMATOLOGY, SCABICIDES AND PEDICULIDES

EURAX CRE 10%
EURAX LOT 10%
malathion lotion 0.5%
permethrin cream 5%
3
3
1
1
DERMATOLOGY, WOUND CARE AGENTS

REGRANEX GEL 0.01%
SANTYL OIN 250/GM
SODIUM CHLOR SOL 0.9% IRR
STERIL WATER SOL IRRIG
4
3
1
1
NM, PA
MOUTH/THROAT/DENTAL AGENTS
cevimeline hcl cap 30 mg
chlorhexidine gluconate soln 0.12%
clotrimazole troche 10 mg
lidocaine hcl viscous soln 2%
nystatin susp 100000 unit/ml
periogard sol 0.12%
pilocarpine hcl tab 5 mg
1
1
1
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
87
Drug Name
pilocarpine hcl tab 7.5 mg
1
triamcinolone acetonide dental paste 0.1% 1
OTIC
acetic acid otic soln 2%
CIPRODEX SUS 0.3-0.1%
fluocinolone acetonide (otic) oil 0.01%
neomycin-polymyxin-hc otic soln 1%
neomycin-polymyxin-hc otic susp 3.5
mg/ml-10000 unit/ml-1%
ofloxacin otic soln 0.3%
1
2
1
1
1
1
ST - Step Therapy
NM - Not
LA - Limited Access
88
Index
A
abacavir sulfate tab 300 mg (base equiv)
......................................................11
ABELCET INJ 5MG/ML ........................10
ABILIFY DISC TAB 10MG....................44
ABILIFY DISC TAB 15MG....................44
ABILIFY INJ 9.75MG ..........................44
ABILIFY MAIN INJ 300MG ..................44
ABILIFY MAIN INJ 400MG ..................44
ABILIFY SOL 1MG/ML ........................44
ABILIFY TAB 10MG ............................44
ABILIFY TAB 15MG ............................44
ABILIFY TAB 20MG ............................44
ABILIFY TAB 2MG .............................44
ABILIFY TAB 30MG ............................44
ABILIFY TAB 5MG .............................44
acamprosate calcium tab delayed release
333 mg ...........................................51
acarbose tab 100 mg.........................53
acarbose tab 25 mg ..........................53
acarbose tab 50 mg ..........................53
acebutolol hcl cap 200 mg .................28
acebutolol hcl cap 400 mg .................28
acetaminophen w/ codeine soln 120-12
mg/5ml ............................................ 1
acetaminophen w/ codeine tab 300-15 mg
....................................................... 1
....................................................... 1
....................................................... 1
acetazolamide cap sr 12hr 500 mg ......32
acetazolamide tab 125 mg .................32
acetazolamide tab 250 mg .................32
acetic acid otic soln 2% .....................88
acetylcysteine inhal soln 10% .............81
acetylcysteine inhal soln 20% .............81
acitretin cap 10 mg ...........................84
acitretin cap 17.5 mg ........................84
acitretin cap 25 mg ...........................84
ACTEMRA INJ 200/10ML ....................70
ACTHIB INJ ......................................73
ACTIMMUNE INJ 2MU/0.5...................71
acyclovir cap 200 mg ........................14
acyclovir oint 5% ..............................85
acyclovir sodium for inj 500 mg ..........14
acyclovir susp 200 mg/5ml ................14
acyclovir tab 400 mg ........................ 14

acyclovir tab 800 mg ........................ 14
ADACEL INJ ..................................... 73
ADAGEN INJ 250/ML ......................... 57
adapalene cream 0.1% ..................... 83
adapalene gel 0.1% .......................... 83
ADCIRCA TAB 20MG ......................... 34
adefovir dipivoxil tab 10 mg .............. 14
adriamycin inj 2mg/ml ...................... 17
ADVAIR DISKU AER 100/50 ............... 82
ADVAIR DISKU AER 250/50 ............... 82
ADVAIR DISKU AER 500/50 ............... 82
ADVAIR HFA AER 115/21 .................. 82
ADVAIR HFA AER 230/21 .................. 82
ADVAIR HFA AER 45/21 .................... 82
afeditab tab 30mg cr ........................ 29
afeditab tab 60mg cr ........................ 29
AFINITOR DIS TAB 2MG .................... 19
AFINITOR TAB 10MG ........................ 19
AFINITOR TAB 2.5MG ....................... 19
AFINITOR TAB 5MG .......................... 19
AFINITOR TAB 7.5MG ....................... 19
AGGRENOX CAP 25-200MG ............... 70
a-hydrocort inj 100mg ...................... 59
ala cort cre 1% ................................ 85
ALBENZA TAB 200MG ....................... 15
albuterol sulfate soln nebu 0.083% (2.5
mg/3ml) ......................................... 80
albuterol sulfate soln nebu 0.5% (5
mg/ml) ........................................... 80
(base equiv) .................................... 80
(base equiv) .................................... 80
albuterol sulfate syrup 2 mg/5ml ....... 80
albuterol sulfate tab 2 mg ................. 80
albuterol sulfate tab 4 mg ................. 80
albuterol sulfate tab sr 12hr 4 mg ...... 80
albuterol sulfate tab sr 12hr 8 mg ...... 80
alclometasone dipropionate cream 0.05%
...................................................... 85
alclometasone dipropionate oint 0.05%
...................................................... 85
alcohol swabs .................................. 52
ALDURAZYME INJ 2.9MG/5M ............. 57
89
alendronate sodium tab 10 mg ...........55

alendronate sodium tab 5 mg .............55
alfuzosin hcl tab sr 24hr 10 mg...........67
ALIMTA INJ 500MG ...........................17
ALINIA SUS 100MG/5M .....................15
ALINIA TAB 500MG ...........................15
allopurinol sodium for inj 500 mg ......... 1
allopurinol tab 100 mg........................ 1
allopurinol tab 300 mg........................ 1
ALPHAGAN P SOL 0.1% .....................79
ALPHAGAN P SOL 0.15% ...................79
alprazolam con 1 mg/ml ....................35
alprazolam tab 0.25 mg .....................35
alprazolam tab 0.5 mg.......................35
alprazolam tab 1 mg .........................35
alprazolam tab 2 mg .........................35
ALREX SUS 0.2% ..............................78
amantadine hcl cap 100 mg ...............43
amantadine hcl syrup 50 mg/5ml ........43
amantadine hcl tab 100 mg................43
AMBISOME INJ 50MG ........................11
amcinonide cream 0.1% ....................85
amcinonide lotion 0.1% .....................85
amcinonide oint 0.1% .......................85
a-methapred inj 125mg .....................59
amifostine crystalline for inj 500 mg....21
amikacin sulfate inj 1 gm/4ml (250
mg/ml) ............................................. 6
amikacin sulfate inj 100 mg/2ml (50
mg/ml) ............................................. 6
amiloride & hydrochlorothiazide tab 5-50
mg ..................................................32
amiloride hcl tab 5 mg .......................32
amino acid infusion 6% .....................74
aminophylline inj 25 mg/ml ................82
AMINOSYN II INJ 10%.......................74
AMINOSYN II INJ 7% ........................74
AMINOSYN II INJ 8.5%......................74
AMINOSYN II INJ 8.5/LYTE.................74
AMINOSYN INJ 10% ..........................74
AMINOSYN INJ 8.5% .........................74
AMINOSYN INJ 8.5/LYTE ....................74
AMINOSYN M INJ 3.5%......................74
AMINOSYN-HBC INJ 7% ....................74
AMINOSYN-PF INJ 10% .....................75
AMINOSYN-PF INJ 7% ...................... 75

amiodarone hcl inj 150 mg/3ml (50
mg/ml) ........................................... 25
amiodarone hcl tab 100 mg ............... 25
AMITIZA CAP 24MCG ........................ 65
AMITIZA CAP 8MCG .......................... 65
amitriptyline hcl tab 10 mg................ 40
amitriptyline hcl tab 100 mg .............. 40
amitriptyline hcl tab 150 mg .............. 40
amlodipine besylate tab 10 mg .......... 29
amlodipine besylate tab 2.5 mg ......... 29
amlodipine besylate tab 5 mg ............ 29
10-20 mg ........................................ 22
10-40 mg ........................................ 22
2.5-10 mg ....................................... 21
5-10 mg.......................................... 22
5-20 mg.......................................... 22
5-40 mg.......................................... 22
amnesteem cap 10mg ...................... 83
amnesteem cap 20mg ...................... 83
amnesteem cap 40mg ...................... 83
amoxapine tab 100 mg ..................... 40
amoxapine tab 150 mg ..................... 40
amoxapine tab 25 mg ....................... 40
amoxapine tab 50 mg ....................... 40
200-28.5 mg ..................................... 6
400-57 mg ........................................ 6
200-28.5 mg/5ml ............................... 6
250-62.5 mg/5ml ............................... 6
400-57 mg/5ml.................................. 6
600-42.9 mg/5ml ............................... 6
90
amoxicillin & k clavulanate tab 250-125

mg ................................................... 6
mg ................................................... 6
mg ................................................... 6
amoxicillin & k clavulanate tab sr 12hr
1000-62.5 mg ................................... 6
amoxicillin (trihydrate) cap 250 mg ...... 6
amoxicillin (trihydrate) cap 500 mg ...... 6
amoxicillin (trihydrate) chew tab 125 mg
....................................................... 6
amoxicillin (trihydrate) chew tab 250 mg
....................................................... 6
amoxicillin (trihydrate) for susp 125
mg/5ml ............................................ 6
mg/5ml ............................................ 6
mg/5ml ............................................ 6
mg/5ml ............................................ 6
amoxicillin (trihydrate) tab 500 mg ...... 6
amoxicillin (trihydrate) tab 875 mg ...... 6
amoxicillin cap-clarithro tab-lansopraz
cap dr therapy pack ..........................65
amphetamine-dextroamphetamine cap sr
24hr 10 mg ......................................48
24hr 15 mg ......................................48
24hr 20 mg ......................................48
24hr 25 mg ......................................48
24hr 30 mg ......................................48
24hr 5 mg........................................48
amphetamine-dextroamphetamine tab 10
mg ..................................................48
amphetamine-dextroamphetamine tab
12.5 mg ..........................................48
mg ..................................................48
mg ..................................................48
mg ..................................................48
mg ................................................. 48
amphetamine-dextroamphetamine tab
7.5 mg............................................ 48
amphotericin b for inj 50 mg ............. 11
ampicillin & sulbactam sodium for inj 10-5
gm ................................................... 6
ampicillin & sulbactam sodium for inj 2-1
gm ................................................... 6
ampicillin & sulbactam sodium for iv soln
10-5 gm............................................ 6
ampicillin cap 250 mg ......................... 6
ampicillin cap 500 mg ......................... 6
ampicillin for susp 125 mg/5ml ............ 6
ampicillin for susp 250 mg/5ml ............ 6
ampicillin sodium for inj 1 gm .............. 6
ampicillin sodium for inj 125 mg .......... 6
ampicillin sodium for iv soln 10 gm....... 7
AMPYRA TAB 10MG........................... 51
AMTURNIDE150 TAB -5-12.5 ............. 31
AMTURNIDE300 TAB -10-12.5 ........... 32
AMTURNIDE300 TAB -10-25MG.......... 32
AMTURNIDE300 TAB -5-12.5 ............. 31
AMTURNIDE300 TAB -5-25MG ........... 31
anagrelide hcl cap 0.5 mg ................. 70
anagrelide hcl cap 1 mg .................... 70
anastrozole tab 1 mg ........................ 18
ANDROGEL GEL 1%(25MG) ............... 52
ANDROGEL GEL 1%(50MG) ............... 52
ANDROGEL GEL 1.62% ..................... 52
ANDROGEL GEL PUMP 1% ................. 52
androxy tab 10mg ............................ 52
APOKYN INJ 10MG/ML ...................... 43
apri tab ........................................... 55
APRISO CAP 0.375GM ....................... 65
APTIVUS CAP 250MG ........................ 11
APTIVUS SOL ................................... 11
ARALAST NP INJ 400MG .................... 81
aranelle tab ..................................... 55
ARANESP INJ 100MCG ...................... 69
ARANESP INJ 150MCG ...................... 69
ARANESP INJ 200MCG ...................... 69
ARANESP INJ 25MCG ........................ 69
ARANESP INJ 300MCG ...................... 69
ARANESP INJ 40MCG ........................ 69
ARANESP INJ 500MCG ...................... 69
ARANESP INJ 60MCG ........................ 69
ARCALYST INJ 220MG ....................... 71
91
ARICEPT TAB 23MG...........................39

ASACOL HD TAB 800MG ....................65
ASACOL TAB 400MG DR.....................65
ASMANEX 120 AER 220MCG ...............82
ASMANEX 14 AER 220MCG .................82
ASMANEX 30 AER 110MCG .................82
ASMANEX 30 AER 220MCG .................82
ASMANEX 60 AER 220MCG .................82
ASTEPRO SPR 0.15% ........................80
astramorph inj 10/10ml ...................... 2
astramorph inj 1mg/2ml ..................... 2
......................................................28
......................................................28
atenolol tab 100 mg ..........................28
atenolol tab 25 mg ............................28
atenolol tab 50 mg ............................28
equivalent) ......................................26
equivalent) ......................................26
equivalent) ......................................26
equivalent) ......................................27
atovaquone-proguanil hcl tab 250-100 mg
......................................................11
ATRIPLA TAB ....................................12
ATROVENT HFA AER 17MCG ...............80
AUVI-Q INJ 0.15MG ..........................81
AUVI-Q INJ 0.3MG ............................81
AVASTIN INJ ....................................17
AVELOX ABC TAB 400MG .................... 7
AVELOX INJ....................................... 7
AVELOX TAB 400MG ........................... 7
aviane tab........................................55
AVINZA CAP 120MG ........................... 2
AVINZA CAP 30MG ............................. 2
AVINZA CAP 45MG ............................. 2
AVINZA CAP 60MG ............................. 2
AVINZA CAP 75MG ............................. 2
AVINZA CAP 90MG ............................. 2
AVITA CRE 0.025% ...........................83
AVITA GEL 0.025% ...........................83
AVODART CAP 0.5MG ........................67
AVONEX KIT 30MCG ..........................51
AVONEX PREFL KIT 30MCG ................51
AZACTAM INJ 2GM ........................... 15

AZACTAM/DEX INJ 1GM .................... 15
AZACTAM/DEX INJ 2GM .................... 15
AZASITE SOL 1% ............................. 77
azathioprine sodium for inj 100 mg .... 72
azathioprine tab 50 mg ..................... 72
azelastine hcl nasal spray 137 mcg/spray
(1 mg/ml) ....................................... 80
azelastine hcl ophth soln 0.05% ......... 78
AZILECT TAB 0.5MG ......................... 43
AZILECT TAB 1MG ............................ 43
azithromycin for susp 100 mg/5ml ....... 7
azithromycin for susp 200 mg/5ml ....... 7
azithromycin iv for soln 500 mg ........... 7
azithromycin tab 250 mg .................... 7
AZOPT SUS 1% OP ........................... 79
AZOR TAB 10-20MG ......................... 24
AZOR TAB 10-40MG ......................... 24
AZOR TAB 5-20MG ........................... 24
AZOR TAB 5-40MG ........................... 24
aztreonam for inj 1 gm ..................... 15
B
bacitracin ophth oint 500 unit/gm ...... 77
bacitracin-polymyxin b ophth oint ...... 77
bacitracin-polymyxin-neomycin-hc ophth
oint 1% .......................................... 77
baclofen tab 10 mg .......................... 51
baclofen tab 20 mg .......................... 51
balsalazide disodium cap 750 mg ....... 65
balziva tab ...................................... 55
BANZEL SUS 40MG/ML ..................... 35
BANZEL TAB 200MG ......................... 35
BANZEL TAB 400MG ......................... 35
BARACLUDE SOL .05MG/ML ............... 14
BARACLUDE TAB 0.5MG .................... 14
BARACLUDE TAB 1MG ....................... 14
10-12.5 mg ..................................... 22
20-12.5 mg ..................................... 22
20-25 mg ........................................ 22
5-6.25 mg ....................................... 22
benazepril hcl tab 10 mg ................... 23
benazepril hcl tab 20 mg ................... 23
92
benazepril hcl tab 40 mg ...................23

benazepril hcl tab 5 mg .....................23
BENICAR HCT TAB 20-12.5 ................24
BENICAR HCT TAB 40-12.5 ................24
BENICAR HCT TAB 40-25MG ..............24
BENICAR TAB 20MG ..........................25
BENICAR TAB 40MG ..........................25
BENICAR TAB 5MG ............................25
benzoyl peroxide-erythromycin gel 5-3%
......................................................83
benztropine mesylate inj 1 mg/ml .......43
benztropine mesylate tab 0.5 mg ........43
benztropine mesylate tab 1 mg ..........43
benztropine mesylate tab 2 mg ..........43
BEPREVE DRO 1.5% ..........................78
BESIVANCE SUS 0.6%.......................77
cream 0.05% ...................................85
gel 0.05% ........................................85
lotion 0.05% ....................................85
oint 0.05% .......................................85
betamethasone dipropionate cream
0.05% .............................................85
betamethasone dipropionate lotion 0.05%
......................................................85
betamethasone dipropionate oint 0.05%
......................................................85
betamethasone valerate cream 0.1% ..85
betamethasone valerate lotion 0.1% ...85
betamethasone valerate oint 0.1%......85
BETASERON INJ 0.3MG......................51
betaxolol hcl ophth soln 0.5% ............79
bethanechol chloride tab 10 mg ..........67
bethanechol chloride tab 5 mg ............67
BETOPTIC-S SUS 0.25% OP ...............79
bicalutamide tab 50 mg .....................18
BICILLIN C-R INJ 1200000 .................. 7
BICILLIN C-R INJ 900/300 .................. 7
BICILLIN L-A INJ 1200000 .................. 7
BICILLIN L-A INJ 2400000 .................. 7
BICILLIN L-A INJ 600000 .................... 7
BICNU INJ 100MG .............................16
BILTRICIDE TAB 600MG ....................15

10-6.25 mg ..................................... 28
2.5-6.25 mg .................................... 28
5-6.25 mg ....................................... 28
bisoprolol fumarate tab 10 mg ........... 28
bisoprolol fumarate tab 5 mg ............. 28
bleomycin sulfate for inj 30 unit ......... 17
blephamide oin s.o.p. ....................... 77
BONIVA INJ 3MG/3ML ....................... 55
BOOSTRIX INJ ................................. 73
BOSULIF TAB 100MG ........................ 19
BOSULIF TAB 500MG ........................ 19
briellyn tab ...................................... 55
BRILINTA TAB 90MG ......................... 70
BRIMONIDINE SOL 0.15% ................. 79
brimonidine tartrate ophth soln 0.2% . 79
BROMDAY SOL 0.09%....................... 78
bromocriptine mesylate cap 5 mg....... 43
bromocriptine mesylate tab 2.5 mg .... 43
budeprion tab 100mg sr .................... 40
budeprion tab 150mg sr .................... 40
budesonide cap sr 24hr 3 mg............. 65
...................................................... 82
...................................................... 82
bumetanide inj 0.25 mg/ml ............... 32
bumetanide tab 0.5 mg ..................... 32
bumetanide tab 1 mg ....................... 32
bumetanide tab 2 mg ....................... 32
BUPHENYL TAB 500MG ..................... 57
buprenorphine hcl sl tab 2 mg (base
equiv) ............................................. 51
buprenorphine hcl sl tab 8 mg (base
equiv) ............................................. 51
buprenorphine hcl-naloxone hcl sl tab
2-0.5 mg (base equiv) ...................... 51
buprenorphine hcl-naloxone hcl sl tab 8-2
mg (base equiv)............................... 51
buproban tab 150mg ........................ 51
bupropion hcl tab 100 mg ................. 40
bupropion hcl tab 75 mg ................... 40
bupropion hcl tab sr 12hr 100 mg ...... 40
93
bupropion hcl tab sr 24hr 300 mg .......40

buspirone hcl tab 10 mg ....................35
buspirone hcl tab 5 mg ......................35
buspirone hcl tab 7.5 mg ...................35
BUSULFEX INJ 6MG/ML ......................16
butorphanol tartrate inj 1 mg/ml ......... 1
butorphanol tartrate inj 2 mg/ml ......... 1
BYETTA INJ 10MCG ...........................52
BYETTA INJ 5MCG .............................52
BYSTOLIC TAB 10MG .........................28
BYSTOLIC TAB 2.5MG ........................28
BYSTOLIC TAB 20MG .........................28
BYSTOLIC TAB 5MG ..........................28
C
cabergoline tab 0.5 mg ......................60
cafergot tab 1-100mg........................49
calcipotriene cream 0.005% ...............84
calcipotriene oint 0.005% ..................84
calcipotriene soln 0.005% (50 mcg/ml)
......................................................84
calcitonin (salmon) nasal soln 200 unit/act
......................................................55
calcitriol cap 0.25 mcg .......................77
calcitriol cap 0.5 mcg ........................77
calcitriol inj 1 mcg/ml ........................77
calcitriol oral soln 1 mcg/ml ...............77
calcium acetate (phosphate binder) cap
667 mg (169 mg ca) .........................61
camila tab 0.35mg ............................55
CAMPATH INJ 30MG/ML .....................17
CAMPRAL TAB 333MG ........................51
CANASA SUP 1000MG .......................65
CANCIDAS INJ 50MG .........................11
CANCIDAS INJ 70MG .........................11
CAPASTAT SUL INJ 1GM ....................13
CAPRELSA TAB 100MG ......................19
CAPRELSA TAB 300MG ......................19
captopril & hydrochlorothiazide tab 25-15
mg ..................................................22
mg ..................................................22
mg ..................................................22
mg ..................................................22
captopril tab 100 mg .........................23
captopril tab 12.5 mg ....................... 23

captopril tab 25 mg .......................... 23
captopril tab 50 mg .......................... 23
CARAC CRE 0.5% ............................. 83
CARAFATE SUS 1GM/10ML ................ 65
CARB/LEVO 50 TAB /ENTACAP ........... 43
CARB/LEVO 75 TAB /ENTACAP ........... 43
CARB/LEVO100 TAB /ENTACAP .......... 43
CARBAGLU TAB 200MG ..................... 58
carbamazepine cap sr 12hr 100 mg .... 35
carbamazepine chew tab 100 mg ....... 35
carbamazepine susp 100 mg/5ml ....... 35
carbamazepine tab 200 mg ............... 35
carbamazepine tab sr 12hr 200 mg .... 35
carbamazepine tab sr 12hr 400 mg .... 35
tab 10-100 mg................................. 43
tab 25-100 mg................................. 43
tab 25-250 mg................................. 43
carbidopa & levodopa tab 10-100 mg . 43
...................................................... 43
...................................................... 43
carboplatin iv soln 150 mg/15ml ........ 21
CARIMUNE NF INJ 3GM ..................... 71
carteolol hcl ophth soln 1% ............... 79
cartia xt cap 120/24hr ...................... 29
cartia xt cap 180/24hr ...................... 29
cartia xt cap 240/24hr ...................... 29
cartia xt cap 300/24hr ...................... 29
carvedilol tab 12.5 mg ...................... 28
carvedilol tab 25 mg ......................... 28
carvedilol tab 3.125 mg .................... 28
carvedilol tab 6.25 mg ...................... 28
CAYSTON INH 75MG ......................... 81
CEENU CAP 100MG ........................... 16
CEENU CAP 10MG ............................ 16
CEENU CAP 40MG ............................ 16
94
cefaclor cap 250 mg ........................... 7

cefaclor cap 500 mg ........................... 7
cefaclor for susp 125 mg/5ml .............. 7
cefaclor monohydrate tab sr 12hr 500 mg
....................................................... 7
cefadroxil cap 500 mg ........................ 7
cefadroxil for susp 250 mg/5ml ........... 7
cefadroxil for susp 500 mg/5ml ........... 7
cefadroxil tab 1 gm ............................ 7
cefazolin in d5w inj 1 gm/50ml ............ 7
cefazolin sodium for inj 1 gm............... 7
cefazolin sodium for inj 10 gm ............. 7
cefazolin sodium for inj 500 mg ........... 7
cefdinir cap 300 mg ........................... 7
cefdinir for susp 125 mg/5ml............... 7
cefdinir for susp 250 mg/5ml............... 7
cefepime hcl for inj 1 gm .................... 7
cefepime hcl for inj 2 gm .................... 7
cefotaxime sodium for inj 1 gm ........... 7
cefotaxime sodium for inj 10 gm .......... 7
cefotaxime sodium for inj 2 gm ........... 7
cefotaxime sodium for inj 500 mg ........ 7
cefoxitin sodium for inj 1 gm ............... 7
cefoxitin sodium for inj 10 gm ............. 7
cefoxitin sodium for inj 2 gm ............... 7
....................................................... 8
....................................................... 7
cefpodoxime proxetil tab 100 mg ......... 8
cefpodoxime proxetil tab 200 mg ......... 8
cefprozil for susp 125 mg/5ml ............. 8
cefprozil for susp 250 mg/5ml ............. 8
cefprozil tab 250 mg .......................... 8
cefprozil tab 500 mg .......................... 8
ceftazidime for inj 1 gm ...................... 8
CEFTAZIDIME/ SOL D5W 1GM ............. 8
CEFTAZIDIME/ SOL D5W 2GM ............. 8
ceftriaxone sodium for inj 10 gm ......... 8
ceftriaxone sodium for inj 250 mg ........ 8
ceftriaxone sodium for inj 500 mg ........ 8
ceftriaxone sodium for iv soln 1 gm ...... 8
ceftriaxone sodium for iv soln 2 gm ...... 8
cefuroxime axetil tab 250 mg .............. 8
cefuroxime axetil tab 500 mg .............. 8

cefuroxime sodium for inj 1.5 gm ......... 8
cefuroxime sodium for inj 7.5 gm ......... 8
cefuroxime sodium for inj 750 mg ........ 8
CELEBREX CAP 100MG ........................ 4
CELEBREX CAP 200MG ........................ 4
CELEBREX CAP 400MG ........................ 4
CELEBREX CAP 50MG.......................... 4
CELLCEPT SUS 200MG/ML ................. 72
CELONTIN CAP 300MG ...................... 35
cephalexin cap 250 mg ....................... 8
cephalexin cap 500 mg ....................... 8
cephalexin for susp 125 mg/5ml .......... 8
cephalexin for susp 250 mg/5ml .......... 8
CEREZYME INJ 200UNIT .................... 58
CERVARIX INJ.................................. 73
cetirizine hcl syrup 1 mg/ml (5 mg/5ml)
...................................................... 80
cevimeline hcl cap 30 mg .................. 87
CHANTIX PAK 0.5& 1MG ................... 51
CHANTIX TAB 0.5MG ........................ 51
CHANTIX TAB 1MG ........................... 51
CHEMET CAP 100MG ......................... 55
chlorhexidine gluconate soln 0.12%.... 87
chloroquine phosphate tab 250 mg ..... 11
chloroquine phosphate tab 500 mg ..... 11
chlorothiazide tab 250 mg ................. 32
chlorothiazide tab 500 mg ................. 32
chlorpromazine hcl inj 25 mg/ml ........ 44
chlorpromazine hcl tab 10 mg ............ 45
chlorpromazine hcl tab 100 mg .......... 45
chlorpromazine hcl tab 200 mg .......... 45
chlorthalidone tab 25 mg .................. 32
chlorthalidone tab 50 mg .................. 32
cholestyramine light powder packets 4 gm
...................................................... 27
cholestyramine powder 4 gm/dose ..... 27
cholestyramine powder packets 4 gm . 27
ciclopirox gel 0.77% ......................... 84
ciclopirox olamine cream 0.77% (base
equiv) ............................................. 84
ciclopirox olamine susp 0.77% (base
equiv) ............................................. 84
ciclopirox shampoo 1% ..................... 84
cilostazol tab 100 mg........................ 70
cilostazol tab 50 mg ......................... 70
95
CILOXAN OIN 0.3% OP ......................77

CIPRO (10%) SUS 500MG/5 ................ 8
CIPRO (5%) SUS 250MG/5 ................. 8
CIPRODEX SUS 0.3-0.1% ..................88
ciprofloxacin 200 mg/100ml in d5w ...... 8
ciprofloxacin hcl ophth soln 0.3%........77
....................................................... 8
....................................................... 8
....................................................... 8
....................................................... 8
ciprofloxacin iv soln 400 mg/40ml (1%) 8
1000 mg(base eq) ............................. 8
500 mg (base eq) .............................. 8
cisplatin inj 100 mg/100ml (1 mg/ml) .21
citalopram hydrobromide oral soln 10
mg/5ml ...........................................40
equiv) .............................................40
equiv) .............................................40
equiv) .............................................40
cladribine inj 1 mg/ml .......................21
claravis cap 10mg .............................83
claravis cap 20mg .............................83
claravis cap 30mg .............................83
claravis cap 40mg .............................83
clarithromycin for susp 125 mg/5ml ..... 8
clarithromycin for susp 250 mg/5ml ..... 8
clarithromycin tab 250 mg .................. 8
clarithromycin tab 500 mg .................. 8
clarithromycin tab sr 24hr 500 mg ....... 9
CLEOCIN SUP 100MG ........................67
clindamycin hcl cap 150 mg ...............15
clindamycin hcl cap 300 mg ...............15
clindamycin hcl cap 75 mg .................15
clindamycin palmitate hcl for soln 75
mg/5ml (base equiv) .........................15
clindamycin phosphate gel 1% ...........83
clindamycin phosphate iv soln 600
mg/4ml ...........................................15
clindamycin phosphate lotion 1% ........83
clindamycin phosphate soln 1% ......... 83

clindamycin phosphate swab 1% ........ 83
clindamycin phosphate vaginal cream 2%
...................................................... 67
CLINIMIX E INJ 2.75/D10 .................. 75
CLINIMIX E INJ 2.75/D5W ................. 75
CLINIMIX E INJ 4.25/D25 .................. 75
CLINIMIX E INJ 4.25/D5W ................. 75
CLINIMIX E INJ 5%/D15W................. 75
CLINIMIX E INJ 5%/D20W................. 75
CLINIMIX E INJ 5%/D25W................. 75
CLINIMIX INJ 2.75/D5W ................... 75
CLINIMIX INJ 4.25/D10 .................... 75
CLINIMIX INJ 4.25/D20 .................... 75
CLINIMIX INJ 4.25/D25 .................... 75
CLINIMIX INJ 4.25/D5W ................... 75
CLINIMIX INJ 5%/D15W ................... 75
CLINIMIX INJ 5%/D20W ................... 75
CLINIMIX INJ 5%/D25W ................... 75
CLINISOL SF INJ 15%....................... 75
clobetasol e cre 0.05% ..................... 85
clobetasol propionate gel 0.05% ........ 85
clobetasol propionate oint 0.05% ....... 85
clobetasol propionate soln 0.05% ....... 85
clomipramine hcl cap 25 mg .............. 40
clonazepam orally disintegrating tab
0.125 mg ........................................ 35
clonazepam orally disintegrating tab 0.25
mg ................................................. 35
clonazepam orally disintegrating tab 0.5
mg ................................................. 35
clonazepam orally disintegrating tab 1 mg
...................................................... 35
clonazepam orally disintegrating tab 2 mg
...................................................... 35
clonazepam tab 0.5 mg..................... 35
clonazepam tab 1 mg ....................... 35
clonazepam tab 2 mg ....................... 35
clonidine hcl tab 0.1 mg .................... 24
clonidine hcl td patch weekly 0.1 mg/24hr
...................................................... 24
...................................................... 24
96
......................................................24
clopidogrel bisulfate tab 75 mg (base
equiv) .............................................70
clorazepate dipotassium tab 15 mg .....36
clorazepate dipotassium tab 3.75 mg ..36
clorazepate dipotassium tab 7.5 mg ....36
clotrimazole cream 1% ......................84
clotrimazole soln 1% .........................84
clotrimazole troche 10 mg..................87
clozapine tab 100 mg ........................45
CLOZAPINE TAB 100/ODT ..................45
CLOZAPINE TAB 12.5/ODT .................45
clozapine tab 200 mg ........................45
clozapine tab 25 mg ..........................45
CLOZAPINE TAB 25MG ODT................45
clozapine tab 50 mg ..........................45
COARTEM TAB 20-120MG ..................11
co-gesic tab 5-500mg......................... 1
colchicine w/ probenecid tab 0.5-500 mg
....................................................... 1
COLCRYS TAB 0.6MG.......................... 1
colestipol hcl granules 5 gm ...............27
colestipol hcl tab 1 gm.......................27
colistimethate sodium for inj 150 mg...15
colocort ene 100mg ..........................65
COMBIGAN SOL 0.2/0.5%..................79
COMBIPATCH DIS .05/.14 ..................58
COMBIPATCH DIS .05/.25 ..................58
COMBIVENT AER ...............................80
COMBIVENT AER RESPIMAT ...............80
COMETRIQ KIT 100MG ......................19
COMETRIQ KIT 140MG ......................19
COMETRIQ KIT 60MG ........................19
COMPLERA TAB ................................12
compro sup 25mg .............................63
COMVAX INJ.....................................73
CONDYLOX GEL 0.5%........................87
constulose sol 10gm/15 .....................65
COPAXONE KIT 20MG/ML ...................51
cortisone acetate tab 25 mg ...............59
COSMEGEN INJ 0.5MG.......................17
COUMADIN TAB 10MG .......................68
COUMADIN TAB 1MG .........................68
COUMADIN TAB 2.5MG ......................68
COUMADIN TAB 2MG .........................68
COUMADIN TAB 3MG .........................68
COUMADIN TAB 4MG .........................68
COUMADIN TAB 5MG .........................68
COUMADIN TAB 6MG ........................ 68

COUMADIN TAB 7.5MG ..................... 68
CREON CAP 12000UNT...................... 66
CREON CAP 24000UNT...................... 66
CREON CAP 3000UNIT ...................... 66
CREON CAP 36000UNT...................... 66
CREON CAP 6000UNIT ...................... 66
CRESTOR TAB 10MG ......................... 27
CRESTOR TAB 20MG ......................... 27
CRESTOR TAB 40MG ......................... 27
CRESTOR TAB 5MG .......................... 27
CRIXIVAN CAP 200MG ...................... 12
CRIXIVAN CAP 400MG ...................... 12
cromolyn sodium ophth soln 4% ........ 78
cromolyn sodium oral conc 100 mg/5ml
...................................................... 65
cromolyn sodium soln nebu 20 mg/2ml
...................................................... 81
cryselle-28 tab 28 tabs ..................... 55
CUBICIN SOL 500MG ........................ 15
CUVPOSA SOL 1MG/5ML ................... 64
cyclafem tab 1/35 ............................ 55
cyclafem tab 7/7/7 ........................... 56
cyclophosphamide tab 25 mg............. 16
cyclophosphamide tab 50 mg............. 16
cyclosporine cap 100 mg ................... 72
cyclosporine cap 25 mg..................... 72
cyclosporine iv soln 50 mg/ml ............ 72
cyclosporine modified cap 100 mg ...... 72
cyclosporine modified cap 25 mg........ 72
cyclosporine modified cap 50 mg........ 72
cyclosporine modified oral soln 100 mg/ml
...................................................... 72
CYMBALTA CAP 20MG ....................... 40
CYMBALTA CAP 30MG ....................... 40
CYMBALTA CAP 60MG ....................... 40
CYSTADANE POW ............................. 58
CYSTAGON CAP 150MG ..................... 58
CYSTAGON CAP 50MG ...................... 58
cytarabine for inj 500 mg .................. 17
cytarabine inj 20 mg/ml .................... 17
D
D10W/NACL INJ 0.2% ...................... 75
D10W/NACL INJ 0.45% ..................... 75
D2.5W/NACL INJ 0.45%.................... 75
D5W/LR INJ ..................................... 75
D5W/LYTES INJ #48 ......................... 75
D5W/NACL INJ 0.2% ........................ 75
97
D5W/NACL INJ 0.225% .....................75

D5W/NACL INJ 0.33% .......................75
D5W/NACL INJ 0.45% .......................75
D5W/NACL INJ 0.9% .........................75
dacarbazine for inj 200 mg ................16
DALIRESP TAB 500MCG .....................81
danazol cap 100 mg ..........................57
danazol cap 200 mg ..........................57
danazol cap 50 mg ............................57
dantrolene sodium cap 100 mg ...........51
dantrolene sodium cap 25 mg ............51
dantrolene sodium cap 50 mg ............51
dapsone tab 100 mg .........................15
dapsone tab 25 mg ...........................15
DAPTACEL INJ ..................................73
DARAPRIM TAB 25MG ........................11
daunorubicin hcl inj 5 mg/ml (base equiv)
......................................................17
DECAVAC INJ 5-2LF ..........................73
DELZICOL CAP 400MG .......................65
DENAVIR CRE 1% .............................85
DEPO-PROVERA INJ 400/ML ...............18
desipramine hcl tab 10 mg .................40
desipramine hcl tab 100 mg ...............41
desipramine hcl tab 150 mg ...............41
desmopressin acetate inj 4 mcg/ml .....63
0.01% .............................................63
0.01% (refrigerated) .........................63
desmopressin acetate tab 0.1 mg .......63
desmopressin acetate tab 0.2 mg .......63
DESMOPRESSIN SOL 0.01%...............63
DESONIDE CRE 0.05% ......................85
desonide lotion 0.05% .......................85
desonide oint 0.05% .........................85
DESOXIMETAS OIN 0.05% .................85
desoximetasone cream 0.05% ............85
desoximetasone cream 0.25% ............86
desoximetasone gel 0.05% ................86
desoximetasone oint 0.25% ...............86
DETROL LA CAP 2MG .........................67
DETROL LA CAP 4MG .........................67
dexamethason con 1mg/ml ................59
dexamethasone elixir 0.5 mg/5ml .......59
dexamethasone sodium phosphate inj 4

mg/ml ............................................ 59
dexamethasone sodium phosphate ophth
soln 0.1% ....................................... 78
dexamethasone tab 0.5 mg ............... 59
dexamethasone tab 0.75 mg ............. 59
dexamethasone tab 1 mg .................. 59
dexamethasone tab 1.5 mg ............... 59
DEXILANT CAP 30MG DR ................... 66
DEXILANT CAP 60MG DR ................... 66
dexrazoxane for inj 500 mg ............... 21
DEXTROSE INJ 10% ......................... 76
DEXTROSE INJ 5% ........................... 76
diazepam con 5mg/ml ...................... 36
DIAZEPAM GEL 10MG ....................... 36
DIAZEPAM GEL 2.5MG ...................... 36
DIAZEPAM GEL 20MG ....................... 36
diazepam inj 5 mg/ml ....................... 36
diazepam soln 1 mg/ml ..................... 36
diazepam tab 10 mg ......................... 36
diazepam tab 2 mg........................... 36
diazepam tab 5 mg........................... 36
DIBENZYLINE CAP 10MG ................... 33
diclofenac potassium tab 50 mg ........... 4
diclofenac sodium ophth soln 0.1% .... 78
diclofenac sodium tab delayed release 25
mg ................................................... 4
mg ................................................... 4
mg ................................................... 4
diclofenac sodium tab sr 24hr 100 mg .. 4
dicloxacillin sodium cap 250 mg ........... 9
dicloxacillin sodium cap 500 mg ........... 9
dicyclomine hcl cap 10 mg ................ 64
dicyclomine hcl oral soln 10 mg/5ml ... 64
dicyclomine hcl tab 20 mg ................. 64
didanosine delayed release capsule 125
mg ................................................. 12
mg ................................................. 12
mg ................................................. 12
mg ................................................. 12
98
DIFICID TAB 200MG........................... 9

diflorasone diacetate cream 0.05% .....86
diflorasone diacetate oint 0.05%.........86
diflunisal tab 500 mg .......................... 5
digoxin inj 0.25 mg/ml ......................31
DIGOXIN SOL 50MCG/ML ...................31
digoxin tab 0.125 mg ........................31
digoxin tab 0.25 mg ..........................31
dihydroergotamine mesylate inj 1 mg/ml
......................................................49
dilantin cap 100mg ...........................36
dilantin cap 30mg .............................36
dilantin chw 50mg ............................36
DILANTIN-125 SUS 125/5ML ..............36
DILAUDID-5 LIQ 1MG/ML .................... 2
dilt-cd cap 120mg .............................29
dilt-cd cap 300mg .............................30
diltiazem hcl cap sr 12hr 120 mg ........30
diltiazem hcl cap sr 12hr 60 mg ..........30
diltiazem hcl cap sr 12hr 90 mg ..........30
diltiazem hcl coated beads cap sr 24hr 120
mg ..................................................30
mg ..................................................30
mg ..................................................30
mg ..................................................30
diltiazem hcl extended release beads cap
sr 24hr 180 mg ................................30
sr 24hr 360 mg ................................30
sr 24hr 420 mg ................................30
diltiazem hcl iv soln 50 mg/10ml (5
mg/ml) ............................................30
diltiazem hcl tab 120 mg ...................30
diltiazem hcl tab 30 mg .....................30
dilt-xr cap 180mg .............................30
dilt-xr cap 240mg .............................30
diltzac cap 120mg/24 ........................30
diltzac cap 180mg/24 ........................30
diltzac cap 240mg/24 ........................30
diltzac cap 300mg/24 ........................30
DIOVAN TAB 160MG..........................25
DIOVAN TAB 320MG..........................25
DIOVAN TAB 40MG ........................... 25

DIOVAN TAB 80MG ........................... 25
DIP/TET PED INJ 25-5LFU ................. 73
diphenhydramine hcl inj 50 mg/ml ..... 80
diphenoxylate w/ atropine liq 2.5-0.025
mg/5ml ........................................... 66
diphenoxylate w/ atropine tab 2.5-0.025
mg ................................................. 66
disopyramide phosphate cap 100 mg .. 26
disopyramide phosphate cap 150 mg .. 26
disulfiram tab 250 mg ....................... 51
disulfiram tab 500 mg ....................... 52
DIURIL SUS 250/5ML........................ 32
divalproex sodium cap sprinkle 125 mg
...................................................... 36
divalproex sodium tab delayed release
125 mg ........................................... 36
250 mg ........................................... 36
500 mg ........................................... 36
divalproex sodium tab sr 24 hr 250 mg36
divalproex sodium tab sr 24 hr 500 mg36
docetaxel inj 140/7ml ....................... 17
DOCETAXEL INJ 80MG/4ML ............... 17
DOCETAXEL INJ 80MG/8ML ............... 17
disintegrating tab 10 mg ................... 39
disintegrating tab 5 mg ..................... 39
donepezil hydrochloride tab 10 mg ..... 39
donepezil hydrochloride tab 23 mg ..... 39
donepezil hydrochloride tab 5 mg ....... 39
DORIBAX INJ 500MG ........................ 15
dorzolamide hcl ophth soln 2% .......... 79
dorzolamide hcl-timolol maleate ophth
soln 22.3-6.8 mg/ml ......................... 79
doxazosin mesylate tab 1 mg ............ 24
doxepin hcl cap 10 mg ...................... 41
doxepin hcl cap 100 mg .................... 41
doxepin hcl cap 150 mg .................... 41
doxepin hcl conc 10 mg/ml ................ 41
99
DOXIL INJ 2MG/ML ...........................17

doxorubicin hcl inj 2 mg/ml ................17
doxycycline hyclate cap 100 mg .......... 9
doxycycline hyclate cap 50 mg ............ 9
doxycycline hyclate for inj 100 mg ....... 9
doxycycline hyclate tab 100 mg ........... 9
doxycycline hyclate tab 20 mg ............. 9
doxycycline monohydrate tab 150 mg .. 9
doxycycline monohydrate tab 50 mg .... 9
doxycycline monohydrate tab 75 mg .... 9
dronabinol cap 10 mg ........................63
dronabinol cap 2.5 mg .......................63
dronabinol cap 5 mg .........................63
drospirenone-ethinyl estradiol tab 3-0.03
mg ..................................................56
DROXIA CAP 200MG ..........................20
DROXIA CAP 300MG ..........................20
DROXIA CAP 400MG ..........................20
DULERA AER 100-5MCG.....................82
DULERA AER 200-5MCG.....................82
DURAMORPH INJ 0.5MG/ML ................ 2
DURAMORPH INJ 1MG/ML ................... 2
DUREZOL EMU 0.05% .......................78
DYRENIUM CAP 100MG ......................32
DYRENIUM CAP 50MG........................32
E
e.e.s. 400 tab 400mg ......................... 9
E.E.S. GRAN SUS 200/5ML .................. 9
econazole nitrate cream 1% ...............84
EDECRIN TAB 25MG ..........................32
EDURANT TAB 25MG .........................12
EFFIENT TAB 10MG ...........................70
EFFIENT TAB 5MG .............................70
ELAPRASE INJ 6MG/3ML ....................58
ELELYSO INJ 200UNIT .......................58
ELIDEL CRE 1% ................................87
ELIQUIS TAB 2.5MG ..........................68
ELIQUIS TAB 5MG .............................68
ELITEK INJ 1.5MG .............................21
ELIXOPHYLLIN ELX 80/15ML ..............82
ELLA TAB 30MG ................................56
ELMIRON CAP 100MG ........................67
ELSPAR INJ 10000UNT ......................20
EMCYT CAP 140MG ...........................16
EMEND CAP 125MG ...........................63
EMEND CAP 40MG .............................63
EMEND CAP 80MG .............................63
EMEND PAK 80 & 125 ........................63
emoquette tab ................................. 56

EMSAM DIS 12MG/24H ..................... 41
EMSAM DIS 6MG/24HR ..................... 41
EMSAM DIS 9MG/24HR ..................... 41
EMTRIVA CAP 200MG........................ 12
EMTRIVA SOL 10MG/ML .................... 12
enalapril maleate & hydrochlorothiazide
tab 10-25 mg .................................. 22
enalapril maleate & hydrochlorothiazide
tab 5-12.5 mg ................................. 22
enalapril maleate tab 10 mg .............. 23
enalapril maleate tab 2.5 mg ............. 23
enalapril maleate tab 20 mg .............. 23
enalapril maleate tab 5 mg ................ 23
ENBREL INJ 25/0.5ML ....................... 70
ENBREL INJ 25MG ............................ 70
ENBREL INJ 50MG/ML ....................... 70
endocet tab 10-325mg........................ 2
endocet tab 10-650mg........................ 2
endocet tab 5-325mg ......................... 2
endocet tab 7.5-325 ........................... 2
endocet tab 7.5-500m ........................ 2
ENDODAN TAB ................................... 2
ENGERIX-B INJ 10/0.5ML .................. 73
ENGERIX-B INJ 20MCG/ML ................ 73
enoxaparin sodium inj 100 mg/ml ...... 68
enoxaparin sodium inj 120 mg/0.8ml.. 68
enoxaparin sodium inj 150 mg/ml ...... 68
enoxaparin sodium inj 30 mg/0.3ml ... 68
enoxaparin sodium inj 300 mg/3ml .... 68
enpresse-28 tab ............................... 56
entacapone tab 200 mg .................... 43
enulose sol 10gm/15 ........................ 65
EPIPEN 2-PAK INJ 0.3MG .................. 81
EPIPEN-JR INJ 2-PAK ........................ 81
epirubicin hcl inj 50 mg/25ml (2 mg/ml)
...................................................... 17
epitol tab 200mg .............................. 36
EPIVIR HBV SOL 5MG/ML .................. 14
EPIVIR HBV TAB 100MG .................... 14
EPIVIR SOL 10MG/ML ....................... 12
eplerenone tab 25 mg ....................... 24
eplerenone tab 50 mg ....................... 24
EPZICOM TAB 600-300 ..................... 12
ERAXIS INJ 100MG ........................... 11
100
ERIVEDGE CAP 150MG ......................17

errin tab 0.35mg ..............................56
ery pad 2% ......................................83
ERYPED SUS 200/5ML ........................ 9
ERYPED SUS 400/5ML ........................ 9
ery-tab tab 250mg ec ......................... 9
ery-tab tab 333mg ec ......................... 9
ery-tab tab 500mg ec ......................... 9
erythrocin tab 250mg ......................... 9
erythromycin ethylsuccinate tab 400 mg
....................................................... 9
erythromycin gel 2% .........................83
erythromycin ophth oint 5 mg/gm.......77
erythromycin soln 2% .......................83
erythromycin tab 250 mg.................... 9
erythromycin tab 500 mg.................... 9
escitalopram oxalate soln 5 mg/5ml (base
equiv) .............................................41
equiv) .............................................41
equiv) .............................................41
equiv) .............................................41
estradiol tab 0.5 mg ..........................58
estradiol tab 1 mg.............................58
estradiol tab 2 mg.............................58
......................................................58
(37.5 mcg/24hr) ...............................58
......................................................58
......................................................58
......................................................58
estradiol td patch weekly 0.1 mg/24hr 58
estradiol valerate im in oil 10 mg/ml ...58
ethambutol hcl tab 100 mg ................13
ethambutol hcl tab 400 mg ................13
ethosuximide cap 250 mg ..................36
ethosuximide soln 250 mg/5ml ...........36
etodolac cap 200 mg .......................... 5
etodolac cap 300 mg .......................... 5
etodolac er tab 400mg ....................... 5
etodolac er tab 500mg ........................ 5

etodolac er tab 600mg ........................ 5
etodolac tab 400 mg ........................... 5
etodolac tab 500 mg ........................... 5
etoposide inj 500mg/25ml (20 mg/ml) 21
EURAX CRE 10% .............................. 87
EURAX LOT 10% .............................. 87
EVISTA TAB 60MG ............................ 61
EXALGO TAB 12MG............................. 2
EXALGO TAB 16MG............................. 2
EXALGO TAB 32MG............................. 2
EXALGO TAB 8MG .............................. 2
EXELON DIS 13.3/24 ........................ 39
EXELON DIS 4.6MG/24 ..................... 39
EXELON DIS 9.5MG/24 ..................... 39
EXELON SOL 2MG/ML ....................... 39
exemestane tab 25 mg ..................... 18
EXFORGE TAB 10-160MG .................. 24
EXFORGE TAB 10-320MG .................. 24
EXFORGE TAB 5-160MG .................... 24
EXFORGE TAB 5-320MG .................... 24
EXFORGEH/10- TAB 160-12.5 ............ 25
EXFORGEH/10- TAB 160-25............... 25
EXFORGEH/10- TAB 320-25............... 25
EXFORGEH/5- TAB 160-12.5.............. 25
EXFORGEH/5- TAB 160-25 ................ 25
EXJADE TAB 125MG.......................... 55
EXJADE TAB 250MG.......................... 55
EXJADE TAB 500MG.......................... 55
F
FABRAZYME INJ 35MG ...................... 58
famciclovir tab 125 mg ..................... 14
famotidine for susp 40 mg/5ml .......... 64
famotidine in nacl 0.9% iv soln 20
mg/50ml ......................................... 64
famotidine inj 10 mg/ml .................... 64
famotidine tab 20 mg ....................... 64
famotidine tab 40 mg ....................... 64
FANAPT PAK .................................... 45
FANAPT TAB 10MG ........................... 45
FANAPT TAB 12MG ........................... 45
FANAPT TAB 1MG ............................. 45
FANAPT TAB 2MG ............................. 45
FANAPT TAB 4MG ............................. 45
FANAPT TAB 6MG ............................. 45
FANAPT TAB 8MG ............................. 45
101
FARESTON TAB 60MG ........................18

FASLODEX INJ 250MG .......................18
FAZACLO TAB 100/ODT .....................45
FAZACLO TAB 12.5/ODT ....................45
FAZACLO TAB 150MG ........................45
FAZACLO TAB 200MG ........................45
FAZACLO TAB 25MG ODT ...................45
felbamate susp 600 mg/5ml ...............36
felbamate tab 400 mg .......................36
felbamate tab 600 mg .......................36
felodipine tab sr 24hr 10 mg ..............30
felodipine tab sr 24hr 2.5 mg .............30
felodipine tab sr 24hr 5 mg ................30
fenofibrate micronized cap 130 mg .....27
fenofibrate micronized cap 43 mg .......27
fenofibrate micronized cap 67 mg .......27
fenofibrate tab 145 mg ......................27
fenofibrate tab 160 mg ......................27
fenofibrate tab 48 mg ........................27
fenofibrate tab 54 mg ........................27
fentanyl citrate lollipop 1200 mcg ........ 2
fentanyl citrate lollipop 1600 mcg ........ 2
fentanyl citrate lollipop 200 mcg .......... 2
fentanyl td patch 72hr 100 mcg/hr....... 3
fentanyl td patch 72hr 12 mcg/hr ........ 2
finasteride tab 5 mg ..........................67
FLEBOGAMMA INJ 5% .......................71
flecainide acetate tab 100 mg.............26
flecainide acetate tab 150 mg.............26
flecainide acetate tab 50 mg ..............26
FLOVENT DISK AER 100MCG ..............82
FLOVENT DISK AER 250MCG ..............82
FLOVENT DISK AER 50MCG ................82
FLOVENT HFA AER 110MCG................82
FLOVENT HFA AER 220MCG................82
FLOVENT HFA AER 44MCG .................82
fluconazole for susp 10 mg/ml ............11
fluconazole for susp 40 mg/ml ............11
fluconazole in dextrose inj 400 mg/200ml
......................................................11
fluconazole tab 100 mg ..................... 11

fluconazole tab 50 mg....................... 11
flucytosine cap 250 mg ..................... 11
flucytosine cap 500 mg ..................... 11
fludarabine phosphate for inj 50 mg ... 21
fludarabine phosphate inj 25 mg/ml ... 21
fludrocortisone acetate tab 0.1 mg ..... 59
flunisolide nasal soln 25 mcg/act
(0.025%) ........................................ 81
fluocin acet oil body.......................... 86
fluocinolone acetonide (otic) oil 0.01% 88
fluocinolone acetonide cream 0.01% .. 86
fluocinolone acetonide cream 0.025% . 86
fluocinolone acetonide oint 0.025% .... 86
fluocinolone acetonide soln 0.01% ..... 86
fluocinonide emulsified base cream 0.05%
...................................................... 86
fluocinonide gel 0.05% ..................... 86
fluocinonide oint 0.05% .................... 86
fluocinonide soln 0.05% .................... 86
FLUOROMETHOL SUS 0.1% OP .......... 78
FLUOROPLEX CRE 1% ....................... 83
fluorouracil cream 5% ...................... 83
fluorouracil inj 2.5 gm/50ml (50 mg/ml)
...................................................... 17
fluorouracil soln 2%.......................... 83
fluorouracil soln 5%.......................... 83
fluoxetine hcl cap 10 mg ................... 41
fluoxetine hcl solution 20 mg/5ml ...... 41
fluoxetine hcl tab 10 mg ................... 41
fluoxetine hcl tab 20 mg ................... 41
fluphenazine decanoate inj 25 mg/ml . 45
fluphenazine hcl elixir 2.5 mg/5ml ...... 45
fluphenazine hcl inj 2.5 mg/ml ........... 45
fluphenazine hcl oral conc 5 mg/ml .... 45
fluphenazine hcl tab 1 mg ................. 45
fluphenazine hcl tab 10 mg ............... 45
fluphenazine hcl tab 2.5 mg .............. 45
fluphenazine hcl tab 5 mg ................. 45
flurbiprofen sodium ophth soln 0.03% 78
flurbiprofen tab 100 mg ...................... 5
flurbiprofen tab 50 mg ........................ 5
flutamide cap 125 mg ....................... 18
fluticasone propionate cream 0.05% ... 86
102
fluticasone propionate nasal susp 50

mcg/act ...........................................81
fluticasone propionate oint 0.005% .....86
fluvoxamine maleate tab 100 mg ........35
fluvoxamine maleate tab 25 mg..........35
fluvoxamine maleate tab 50 mg..........35
FML FORTE SUS 0.25% OP.................78
FML OIN 0.1% OP .............................78
fondaparinux sodium inj 10 mg/0.8ml .68
fondaparinux sodium inj 2.5 mg/0.5ml 68
fondaparinux sodium inj 5 mg/0.4ml ...68
fondaparinux sodium inj 7.5 mg/0.6ml 68
FORADIL CAP AEROLIZE ....................80
FORTEO SOL 600/2.4 ........................61
FORTICAL SPR 200/ACT .....................55
fosinopril sodium & hydrochlorothiazide
tab 10-12.5 mg ................................22
fosinopril sodium & hydrochlorothiazide
tab 20-12.5 mg ................................22
fosinopril sodium tab 10 mg ...............23
FOSRENOL CHW 1000MG ...................61
FOSRENOL CHW 500MG ....................61
FOSRENOL CHW 750MG ....................61
FREAMINE III INJ 3% ........................75
FREAMINE III INJ 8.5% .....................75
furosemide inj 10 mg/ml....................32
furosemide oral soln 10 mg/ml ...........32
furosemide oral soln 8 mg/ml .............32
furosemide tab 20 mg .......................32
FUZEON KIT .....................................12
G
gabapentin cap 100 mg .....................36
gabapentin oral soln 250 mg/5ml........36
gabapentin tab 600 mg .....................37
gabapentin tab 800 mg .....................37
GABITRIL TAB 12MG .........................37
GABITRIL TAB 16MG .........................37
mg ..................................................39
mg ..................................................39
mg ................................................. 39
galantamine hydrobromide oral soln 4
mg/ml ............................................ 39
galantamine hydrobromide tab 12 mg 39
galantamine hydrobromide tab 4 mg .. 39
galantamine hydrobromide tab 8 mg .. 39
GAMASTAN S/D INJ .......................... 71
GAMMAGARD INJ 2.5GM/25 .............. 71
GAMMAKED INJ 1GM/10ML ................ 71
GAMMAPLEX INJ 10GM...................... 71
GAMUNEX-C INJ 10GM/100 ............... 71
GAMUNEX-C INJ 1GM/10ML ............... 71
GAMUNEX-C INJ 20GM/200 ............... 71
GAMUNEX-C INJ 5GM/50ML ............... 71
ganciclovir sodium for inj 500 mg ....... 14
GARDASIL INJ ................................. 73
gauze pads 2" x 2" ........................... 52
gavilyte-c sol ................................... 65
gavilyte-g sol ................................... 65
gavilyte-n sol flav pk ........................ 65
gemcitabine hcl for inj 1 gm .............. 17
gemfibrozil tab 600 mg ..................... 27
generlac sol 10gm/15 ....................... 65
gengraf cap 100mg .......................... 72
gengraf cap 25mg ............................ 72
gengraf sol 100mg/ml....................... 72
gentak oin 0.3% op .......................... 77
gentamicin in saline inj 0.8 mg/ml........ 9
gentamicin in saline inj 1 mg/ml .......... 9
gentamicin sulfate cream 0.1% .......... 84
gentamicin sulfate inj 40 mg/ml ........... 9
gentamicin sulfate iv soln 10 mg/ml ..... 9
gentamicin sulfate oint 0.1% ............. 84
gentamicin sulfate ophth soln 0.3% .... 77
GEODON INJ 20MG........................... 45
GIANVI TAB 3-0.02MG ...................... 56
gildagia tab 0.4-35 ........................... 56
GILENYA CAP 0.5MG ......................... 51
GLASSIA INJ.................................... 81
GLEEVEC TAB 100MG ....................... 19
GLEEVEC TAB 400MG ....................... 19
glimepiride tab 1 mg ........................ 53
103
glipizide tab 10 mg ...........................53

glipizide tab 5 mg .............................53
glipizide tab sr 24hr 10 mg ................53
glipizide tab sr 24hr 2.5 mg ...............53
glipizide tab sr 24hr 5 mg ..................53
......................................................53
......................................................53
glipizide-metformin hcl tab 5-500 mg ..53
GLUCAGEN INJ HYPOKIT ....................60
GLUCAGON KIT 1MG .........................60
glyburide micronized tab 1.5 mg .........53
glyburide micronized tab 3 mg ...........53
glyburide micronized tab 6 mg ...........53
glyburide tab 1.25 mg .......................53
glyburide tab 2.5 mg .........................53
glyburide tab 5 mg ............................53
glyburide-metformin tab 1.25-250 mg .53
glyburide-metformin tab 2.5-500 mg ..53
glyburide-metformin tab 5-500 mg .....54
glycopyrrolate inj 4 mg/20ml (0.2 mg/ml)
......................................................64
glycopyrrolate tab 1 mg .....................64
glycopyrrolate tab 2 mg .....................64
granisetron hcl inj 0.1 mg/ml .............63
granisetron hcl inj 1 mg/ml ................63
granisetron hcl tab 1 mg ....................63
griseofulvin microsize susp 125 mg/5ml
......................................................11
griseofulvin microsize tab 500 mg .......11
griseofulvin ultramicrosize tab 125 mg 11
griseofulvin ultramicrosize tab 250 mg 11
guanfacine hcl tab 1 mg ....................24
guanfacine hcl tab 2 mg ....................24
H
halobetasol propionate cream 0.05% ..86
halobetasol propionate oint 0.05% ......86
......................................................46
......................................................45
haloperidol lactate inj 5 mg/ml ...........46
haloperidol lactate oral conc 2 mg/ml ..46
haloperidol tab 0.5 mg ......................46
haloperidol tab 1 mg .........................46
haloperidol tab 10 mg .......................46
haloperidol tab 2 mg .........................46
haloperidol tab 20 mg ....................... 46

haloperidol tab 5 mg......................... 46
HAVRIX INJ 1440UNIT ...................... 73
HAVRIX INJ 720UNIT ........................ 73
HELIDAC MIS ................................... 66
HEP SOD/D5W INJ 20000UNT ............ 69
HEP SOD/NACL INJ 25000UNT ........... 69
HEP SOD/NACL INJ 2UNIT/ML ............ 69
HEPARIN SOD INJ 2000/ML ............... 69
heparin sodium (porcine) inj 1000 unit/ml
...................................................... 69
heparin sodium (porcine) inj 10000
unit/ml ........................................... 69
heparin sodium (porcine) inj 20000
unit/ml ........................................... 69
heparin sodium (porcine) inj 5000 unit/ml
...................................................... 69
HEPATAMINE SOL 8% ....................... 75
hepatasol inj 8% .............................. 75
HEPSERA TAB 10MG ......................... 14
HERCEPTIN INJ 440MG ..................... 17
HEXALEN CAP 50MG ......................... 16
HIZENTRA INJ 1GM/5ML ................... 71
HUMIRA KIT 20MG/0.4 ..................... 71
HUMIRA KIT 40MG/0.8 ..................... 71
HUMIRA PEN KIT 40MG/0.8 ............... 71
HUMIRA PEN KIT CROHNS ................. 71
HUMULIN R INJ U-500 ...................... 52
hydralazine hcl inj 20 mg/ml ............. 33
hydralazine hcl tab 10 mg ................. 33
hydralazine hcl tab 100 mg ............... 33
hydrochlorothiazide cap 12.5 mg........ 32
hydrochlorothiazide tab 12.5 mg ........ 32
hydrochlorothiazide tab 25 mg ........... 32
hydrochlorothiazide tab 50 mg ........... 32
hydrocodone-acetaminophen soln
7.5-500 mg/15ml ............................... 1
mg ................................................... 1
mg ................................................... 1
mg ................................................... 1
mg ................................................... 1
104
mg ................................................... 2
hydrocodone-acetaminophen tab 2.5-500
mg ................................................... 1
mg ................................................... 1
mg ................................................... 1
mg ................................................... 1
mg ................................................... 1
mg ................................................... 1
mg ................................................... 1
hydrocodone-ibuprofen tab 7.5-200 mg 2
hydrocortisone butyrate cream 0.1%...86
hydrocortisone butyrate oint 0.1% ......86
hydrocortisone butyrate soln 0.1%......86
hydrocortisone cream 1% ..................86
hydrocortisone cream 2.5% ...............86
hydrocortisone enema 100 mg/60ml ...65
hydrocortisone lotion 2.5% ................86
hydrocortisone oint 1% .....................86
hydrocortisone oint 2.5% ...................86
hydrocortisone tab 10 mg ..................59
hydrocortisone tab 20 mg ..................59
hydrocortisone tab 5 mg ....................59
hydrocortisone valerate cream 0.2% ...86
hydrocortisone valerate oint 0.2% ......86
hydromorphone hcl liqd 1 mg/ml ......... 3
hydromorphone hcl preservative free (pf)
inj 10 mg/ml ..................................... 3
hydromorphone hcl tab 2 mg .............. 3
hydroxychloroquine sulfate tab 200 mg
......................................................71
hydroxyurea cap 500 mg ...................20
hydroxyzine hcl im soln 25 mg/ml .......80
hydroxyzine hcl im soln 50 mg/ml .......80
I
ibandronate sodium tab 150 mg (base
equivalent) ......................................55
ibuprofen susp 100 mg/5ml ................ 5
ibuprofen tab 400 mg ......................... 5
ibuprofen tab 600 mg ......................... 5
ibuprofen tab 800 mg ......................... 5
ICLUSIG TAB 15MG .......................... 19

ICLUSIG TAB 45MG .......................... 19
idarubicin hcl iv inj 10 mg/10ml (1 mg/ml)
...................................................... 17
IFEX INJ 3GM .................................. 16
ifosfamide for inj 1 gm ...................... 16
ILEVRO DRO 0.3% OP ...................... 78
250 mg ........................................... 15
500 mg ........................................... 15
imipramine hcl tab 10 mg ................. 41
imiquimod cream 5%........................ 87
IMOVAX RABIE INJ 2.5/ML ................ 73
INCIVEK TAB 375MG ........................ 14
INCRELEX INJ 40MG/4ML .................. 60
indapamide tab 1.25 mg ................... 32
indapamide tab 2.5 mg ..................... 33
INFANRIX INJ .................................. 73
INFERGEN INJ 15MCG....................... 71
INLYTA TAB 1MG .............................. 19
INLYTA TAB 5MG .............................. 19
insulin pen needle ............................ 52
insulin syringe ................................. 52
INTELENCE TAB 100MG .................... 12
INTELENCE TAB 200MG .................... 12
INTELENCE TAB 25MG ...................... 12
INTRALIPID INJ 20% ........................ 75
INTRALIPID INJ 30% ........................ 75
INTRON-A INJ 10MU ......................... 71
INTRON-A INJ 10MU PEN .................. 71
INTRON-A INJ 18MU ......................... 71
INTRON-A INJ 3MU PEN .................... 71
INTRON-A INJ 5MU PEN .................... 71
introvale tab .................................... 56
INTUNIV TAB 1MG ............................ 49
INTUNIV TAB 2MG ............................ 49
INTUNIV TAB 3MG ............................ 49
INTUNIV TAB 4MG ............................ 49
INVANZ INJ 1GM .............................. 15
INVEGA SUST INJ 117/0.75 ............... 46
INVEGA SUST INJ 156MG/ML ............. 46
INVEGA SUST INJ 234/1.5 ................ 46
INVEGA SUST INJ 39/0.25 ................ 46
INVEGA SUST INJ 78/0.5ML .............. 46
INVEGA TAB 1.5MG .......................... 46
105
INVEGA TAB 3MG .............................46

INVEGA TAB 6MG .............................46
INVEGA TAB 9MG .............................46
INVIRASE CAP 200MG .......................12
INVIRASE TAB 500MG .......................12
IONOSOL-B/ INJ D5W .......................76
IONOSOL-MB INJ /D5W .....................76
IPOL INJ INACTIVE............................73
ipratropium bromide inhal soln 0.02% .80
ipratropium bromide nasal soln 0.03% (21
mcg/spray) ......................................80
ipratropium bromide nasal soln 0.06% (42
mcg/spray) ......................................80
ipratropium-albuterol nebu soln
0.5-2.5(3) mg/3ml ............................80
irinotecan hcl inj 100 mg/5ml (20 mg/ml)
......................................................20
ISENTRESS CHW 100MG....................12
ISENTRESS CHW 25MG .....................12
ISENTRESS TAB 400MG .....................12
ISOLYTE-H INJ /D5W ........................76
isolyte-m inj /d5w .............................76
isolyte-p inj /d5w ..............................76
isolyte-s inj ......................................76
isolyte-s inj /d5w ..............................76
isoniazid inj 100 mg/ml .....................13
isoniazid syrup 50 mg/5ml .................13
isoniazid tab 100 mg .........................13
isoniazid tab 300 mg .........................14
ISOPTO CARP SOL 1% OP ..................79
isosorbide dinitrate sl tab 2.5 mg ........33
isosorbide dinitrate sl tab 5 mg ...........33
isosorbide dinitrate tab 10 mg ............33
isosorbide dinitrate tab 5 mg ..............33
isosorbide dinitrate tab cr 40 mg ........34
isosorbide mononitrate tab 10 mg .......34
isosorbide mononitrate tab 20 mg .......34
isosorbide mononitrate tab sr 24hr 120
mg ..................................................34
isosorbide mononitrate tab sr 24hr 30 mg
......................................................34
isosorbide mononitrate tab sr 24hr 60 mg
......................................................34
isradipine cap 2.5 mg ........................30
isradipine cap 5 mg .......................... 30

ISTALOL SOL 0.5% OP...................... 79
ISTODAX INJ 10MG .......................... 18
itraconazole cap 100 mg ................... 11
IXIARO INJ ...................................... 73
J
JAKAFI TAB 10MG ............................ 19
JAKAFI TAB 15MG ............................ 19
JAKAFI TAB 20MG ............................ 19
JAKAFI TAB 25MG ............................ 19
JAKAFI TAB 5MG .............................. 19
JALYN CAP....................................... 67
jantoven tab 10mg ........................... 69
jantoven tab 1mg ............................. 69
jantoven tab 2.5mg .......................... 69
jantoven tab 2mg ............................. 69
jantoven tab 3mg ............................. 69
jantoven tab 4mg ............................. 69
jantoven tab 5mg ............................. 69
jantoven tab 6mg ............................. 69
jantoven tab 7.5mg .......................... 69
JANUMET TAB 50-1000 ..................... 54
JANUMET TAB 50-500MG .................. 54
JANUMET XR TAB 100-1000............... 54
JANUMET XR TAB 50-1000 ................ 54
JANUMET XR TAB 50-500MG.............. 54
JANUVIA TAB 100MG ........................ 54
JANUVIA TAB 25MG .......................... 54
JANUVIA TAB 50MG .......................... 54
JENTADUETO TAB 2.5-1000 ............... 54
JENTADUETO TAB 2.5-500 ................ 54
JENTADUETO TAB 2.5-850 ................ 54
jinteli tab 1mg-5mcg ........................ 58
JOLIVETTE TAB 0.35MG .................... 56
junel 1.5/30 tab ............................... 56
junel 1/20 tab .................................. 56
junel fe tab 1.5/30 ........................... 56
junel fe tab 1/20 .............................. 56
JUVISYNC TAB 100-10MG ................. 54
JUVISYNC TAB 100-20MG ................. 54
JUVISYNC TAB 100-40MG ................. 54
JUVISYNC TAB 50-10MG ................... 54
JUVISYNC TAB 50-20MG ................... 54
JUVISYNC TAB 50-40MG ................... 54
K
KADCYLA INJ 100MG ........................ 18
KADCYLA INJ 160MG ........................ 18
KADIAN CAP 100MG CR ...................... 3
106
KADIAN CAP 10MG CR ........................ 3

KADIAN CAP 130MG CR ...................... 3
KADIAN CAP 150MG CR ...................... 3
KADIAN CAP 200MG CR ...................... 3
KADIAN CAP 20MG CR ........................ 3
KADIAN CAP 30MG CR ........................ 3
KADIAN CAP 40MG CR ........................ 3
KADIAN CAP 50MG CR ........................ 3
KADIAN CAP 60MG CR ........................ 3
KADIAN CAP 70MG CR ........................ 3
KADIAN CAP 80MG CR ........................ 3
KALETRA SOL ...................................12
KALETRA TAB 100-25MG ...................12
KALETRA TAB 200-50MG ...................12
kariva tab 28 day ..............................56
kcl 20 meq/l (0.15%) in nacl 0.45% inj
......................................................76
KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ
......................................................76
KCL/D5W INJ 0.15% .........................76
KCL/D5W INJ 0.224% .......................76
KCL/D5W INJ 0.3% ...........................76
KCL/D5W/NACL INJ .075/.45..............76
KCL/D5W/NACL INJ .15/.33% ............76
KCL/D5W/NACL INJ .15/.45% ............76
KCL/D5W/NACL INJ .22/.45 ...............76
KCL/D5W/NACL INJ 0.15/0.2..............76
KCL/D5W/NACL INJ 0.15/0.9..............76
KCL/D5W/NACL INJ 0.3/0.45..............76
KCL/D5W/NACL INJ 0.3/0.9% ............76
KCL/NACL INJ 0.15-0.9 .....................76
kelnor tab 1/35 ................................56
ketoconazole cream 2% .....................84
ketoconazole shampoo 2%.................85
ketoconazole tab 200 mg ...................11
ketoprofen cap 50 mg ........................ 5
ketoprofen cap 75 mg ........................ 5
ketoprofen cap sr 24hr 200 mg............ 5
......................................................78
......................................................78
kionex pow usp ................................55
KLOR-CON 10 TAB 10MEQ ER .............74
KLOR-CON 8 TAB 8MEQ ER ................74
KLOR-CON M15 TAB ..........................74
klor-con m20 tab 20meq er ................74
KUVAN TAB 100MG ...........................58
L
labetalol hcl tab 100 mg .................... 28
laclotion lot 12% .............................. 87
LACTATED RIN INJ ........................... 76
lactic acid (ammonium lactate) cream
12% ............................................... 87
lactic acid (ammonium lactate) lotion 12%
...................................................... 87
lactulose solution 10 gm/15ml ........... 65
lamivudine tab 150 mg ..................... 12
lamivudine tab 300 mg ..................... 12
lamivudine-zidovudine tab 150-300 mg
...................................................... 12
lamotrigine tab 100 mg ..................... 37
lamotrigine tab 25 mg ...................... 37
lamotrigine tab chewable dispersible 25
mg ................................................. 37
lamotrigine tab chewable dispersible 5 mg
...................................................... 37
lamotrigine tab sr 24hr 100 mg.......... 37
lamotrigine tab sr 24hr 25 mg ........... 37
lamotrigine tab sr 24hr 50 mg ........... 37
LANOXIN TAB 0.125MG ..................... 31
LANOXIN TAB 0.25MG ...................... 31
LANTUS INJ 100/ML ......................... 52
LANTUS INJ SOLOSTAR ..................... 52
latanoprost ophth soln 0.005% .......... 79
LATUDA TAB 120MG ......................... 46
LATUDA TAB 20MG ........................... 46
LATUDA TAB 40MG ........................... 46
LATUDA TAB 60MG ........................... 46
LATUDA TAB 80MG ........................... 46
LAZANDA SPR 100MCG ....................... 3
LAZANDA SPR 400MCG ....................... 3
LEENA TAB ...................................... 56
leflunomide tab 10 mg ...................... 71
leflunomide tab 20 mg ...................... 71
lessina tab....................................... 56
LETAIRIS TAB 10MG ......................... 34
LETAIRIS TAB 5MG ........................... 34
letrozole tab 2.5 mg ......................... 18
107
leucovorin calcium for inj 100 mg .......21

leucovorin calcium for inj 350 mg .......21
leucovorin calcium tab 10 mg .............21
leucovorin calcium tab 5 mg ...............21
LEUKERAN TAB 2MG..........................16
LEUKINE INJ 250MCG ........................69
LEUKINE INJ 500 MCG .......................70
leuprolide acetate inj kit 5 mg/ml .......18
levalbuterol hcl soln nebu conc 1.25
mg/0.5ml (base equiv) ......................80
LEVEMIR INJ ....................................52
LEVEMIR INJ FLEXPEN .......................53
levetiracetam inj 500 mg/5ml (100
mg/ml) ............................................37
levetiracetam oral soln 100 mg/ml ......37
levetiracetam tab 1000 mg ................37
levetiracetam tab 250 mg ..................37
levetiracetam tab sr 24hr 500 mg .......37
levetiracetam tab sr 24hr 750 mg .......37
levobunolol hcl ophth soln 0.5% .........79
LEVOBUNOLOL SOL 0.25% OP............79
levocarnitine inj 200 mg/ml ...............58
levocarnitine oral soln 1 gm/10ml (10%)
......................................................58
levocarnitine tab 330 mg ...................58
levocetirizine dihydrochloride soln 2.5
mg/5ml (0.5 mg/ml) .........................80
levocetirizine dihydrochloride tab 5 mg 80
levofloxacin in d5w iv soln 500 mg/100ml
....................................................... 9
levofloxacin iv soln 25 mg/ml .............. 9
levofloxacin oral soln 25 mg/ml ........... 9
levofloxacin tab 250 mg...................... 9
levonest tab .....................................56
levonorgestrel & ethinyl estradiol
(91-day) tab 0.15-0.03 mg ................56
levonorgestrel tab 0.75 mg ................56
levonorgestrel tab 1.5 mg ..................56
levora-28 tab 0.15/30 .......................56
LEVOTHROID TAB 100MCG ................61
LEVOTHROID TAB 137MCG ................ 61

LEVOTHROID TAB 25MCG ................. 61
levothyroxine sodium tab 100 mcg ..... 62
levothyroxine sodium tab 25 mcg ....... 62
LEVOXYL TAB 100MCG ...................... 62
LEVOXYL TAB 112MCG ...................... 62
LEVOXYL TAB 125MCG ...................... 62
LEVOXYL TAB 137MCG ...................... 62
LEVOXYL TAB 150MCG ...................... 62
LEVOXYL TAB 175MCG ...................... 62
LEVOXYL TAB 200MCG ...................... 62
LEVOXYL TAB 25MCG........................ 62
LEVOXYL TAB 50MCG........................ 62
LEVOXYL TAB 75MCG........................ 62
LEVOXYL TAB 88MCG........................ 62
LEXIVA SUS 50MG/ML ...................... 12
LEXIVA TAB 700MG .......................... 12
LIALDA TAB 1.2GM ........................... 65
lidocaine hcl gel 2% ......................... 87
lidocaine hcl local preservative free (pf) inj
0.5% ................................................ 5
lidocaine hcl local preservative free (pf) inj
1% ................................................... 5
lidocaine hcl soln 4% ........................ 87
lidocaine hcl viscous soln 2% ............. 87
lidocaine oint 5% ............................. 87
lidocaine patch 5% ........................... 87
lidocaine-prilocaine cream 2.5-2.5% ... 87
LIDODERM DIS 5% .......................... 87
liothyronine sodium tab 25 mcg ......... 62
liothyronine sodium tab 5 mcg ........... 62
108
liothyronine sodium tab 50 mcg ..........62

lisinopril & hydrochlorothiazide tab
10-12.5 mg ......................................22
lisinopril & hydrochlorothiazide tab
20-12.5 mg ......................................22
lisinopril & hydrochlorothiazide tab 20-25
mg ..................................................22
lisinopril tab 10 mg ...........................23
lisinopril tab 2.5 mg ..........................23
lisinopril tab 5 mg .............................23
lithium carbonate cap 150 mg ............50
lithium carbonate tab 300 mg.............50
lithium carbonate tab cr 300 mg .........50
lithium carbonate tab cr 450 mg .........50
LITHIUM CITR SOL 8MEQ/5ML ............50
LODOSYN TAB 25MG .........................43
lokara lot 0.05% ...............................86
loperamide hcl cap 2 mg ....................66
lorazepam con 2mg/ml ......................35
lorazepam inj 2 mg/ml ......................35
lorazepam inj 4 mg/ml ......................35
lorazepam tab 0.5 mg .......................35
lorazepam tab 1 mg ..........................35
lorazepam tab 2 mg ..........................35
loryna tab 3-0.02mg .........................56
losartan potassium & hydrochlorothiazide
tab 100-12.5 mg ..............................25
tab 100-25 mg .................................25
tab 50-12.5 mg ................................25
losartan potassium tab 100 mg ..........25
losartan potassium tab 25 mg ............25
losartan potassium tab 50 mg ............25
LOTEMAX GEL 0.5% ..........................78
LOTEMAX OIN 0.5% ..........................78
LOTEMAX SUS 0.5%..........................78
LOTRONEX TAB 0.5MG ......................66
LOTRONEX TAB 1MG .........................66
lovastatin tab 10 mg .........................27
LOVAZA CAP 1GM .............................27
low-ogestrel tab ............................... 56

loxapine succinate cap 10 mg ............ 46
loxapine succinate cap 5 mg .............. 46
LUMIGAN SOL 0.01% ....................... 79
LUMIGAN SOL 0.03% ....................... 79
LUMIZYME INJ 50MG ........................ 58
LUNESTA TAB 1MG ........................... 49
LUNESTA TAB 2MG ........................... 49
LUNESTA TAB 3MG ........................... 49
LUPR DEP-PED INJ 11.25MG .............. 18
LUPR DEP-PED INJ 15MG .................. 18
LUPRON DEPOT INJ 3.75MG .............. 18
lutera tab ........................................ 56
LYRICA CAP 100MG .......................... 37
LYRICA CAP 150MG .......................... 37
LYRICA CAP 200MG .......................... 37
LYRICA CAP 225MG .......................... 37
LYRICA CAP 25MG ............................ 37
LYRICA CAP 300MG .......................... 37
LYRICA CAP 50MG ............................ 37
LYRICA CAP 75MG ............................ 37
LYRICA SOL 20MG/ML....................... 37
LYSODREN TAB 500MG ..................... 18
lyza tab 0.35mg ............................... 56
M
MACRODANTIN CAP 25MG ................. 15
mafenide acetate packet for topical soln
5% (50 gm) .................................... 84
MAGNESIUM SU INJ 40MG/ML ........... 74
MAGNESIUM SU INJ 80MG/ML ........... 74
magnesium sulfate inj 50% ............... 74
malathion lotion 0.5% ...................... 87
maprotiline hcl tab 25 mg ................. 41
marlissa tab 0.15/30 ........................ 56
MARPLAN TAB 10MG ......................... 41
MATULANE CAP 50MG ....................... 21
matzim la tab 180mg/24 ................... 30
matzim la tab 240mg/24 ................... 30
matzim la tab 300mg/24 ................... 30
matzim la tab 360mg/24 ................... 30
matzim la tab 420mg/24 ................... 30
MAXIDEX SUS 0.1% OP .................... 78
meclizine hcl tab 12.5 mg ................. 63
meclizine hcl tab 25 mg .................... 63
109
medroxyprogesterone acetate im susp

150 mg/ml .......................................56
......................................................61
medroxyprogesterone acetate tab 2.5 mg
......................................................61
......................................................61
mefloquine hcl tab 250 mg .................11
MEGACE ES SUS 625/5ML ..................18
megestrol acetate susp 40 mg/ml .......18
megestrol acetate tab 20 mg ..............18
megestrol acetate tab 40 mg ..............18
MEKINIST TAB 0.5MG ........................19
MEKINIST TAB 2MG ..........................19
MELOXICAM SUS 7.5/5ML ................... 5
meloxicam tab 15 mg ......................... 5
meloxicam tab 7.5 mg ........................ 5
melphalan hcl for inj 50 mg (base equiv)
......................................................16
MENACTRA INJ .................................73
MENEST TAB 0.3MG ..........................59
MENEST TAB 0.625MG .......................59
MENEST TAB 1.25MG ........................59
MENEST TAB 2.5MG ..........................59
MENHIBRIX INJ ................................73
MENOMUNE INJ A/C/Y/W ...................73
MENVEO INJ .....................................73
MEPRON SUS ...................................15
mercaptopurine tab 50 mg .................17
meropenem iv for soln 500 mg ...........15
mesalamine rectal enema 4 gm & cleanser
wipe kit ...........................................65
mesna inj 100 mg/ml ........................21
MESNEX TAB 400MG .........................21
MESTINON SYP 60MG/5ML .................50
MESTINON TAB TIMESPAN .................50
metadate tab 20mg er .......................49
metformin hcl tab 1000 mg ................54
metformin hcl tab 500 mg..................54
metformin hcl tab 850 mg..................54
metformin hcl tab sr 24hr 500 mg ......54
metformin hcl tab sr 24hr 750 mg ......54
methadone hcl conc 10 mg/ml............. 3
methadone hcl soln 10 mg/5ml ........... 3
methadone hcl soln 5 mg/5ml ............. 3
methadone hcl tab 10 mg ................... 3
methadone hcl tab 5 mg ..................... 3
methadose tab 10mg .......................... 3

methazolamide tab 25 mg ................. 33
methazolamide tab 50 mg ................. 33
methenamine hippurate tab 1 gm ...... 15
methimazole tab 10 mg .................... 62
methimazole tab 5 mg ...................... 62
methotrexate sodium for inj 1 gm ...... 17
methotrexate sodium inj 25 mg/ml .... 17
methotrexate sodium inj pf 25 mg/ml . 17
methotrexate sodium tab 2.5 mg (base
equiv) ............................................. 71
methyclothiazide tab 5 mg ................ 33
methylergonovine maleate tab 0.2 mg 60
methylphenidate hcl soln 10 mg/5ml .. 49
methylphenidate hcl soln 5 mg/5ml .... 49
methylphenidate hcl tab 10 mg .......... 49
methylphenidate hcl tab 20 mg .......... 49
methylphenidate hcl tab 5 mg............ 49
methylphenidate hcl tab cr 20 mg ...... 49
mg/ml ............................................ 59
mg/ml ............................................ 59
methylprednisolone sodium succinate for
inj 1000 mg..................................... 59
inj 125 mg ...................................... 59
inj 40 mg ........................................ 59
methylprednisolone tab 16 mg ........... 59
methylprednisolone tab 32 mg ........... 59
methylprednisolone tab 4 mg ............ 59
methylprednisolone tab 4 mg dose pack
...................................................... 59
methylprednisolone tab 8 mg ............ 59
metipranolol ophth soln 0.3% ............ 79
metoclopramide hcl inj 5 mg/ml ......... 63
metoclopramide hcl soln 5 mg/5ml (10
mg/10ml)........................................ 64
metoclopramide hcl tab 10 mg ........... 64
metoclopramide hcl tab 5 mg ............ 64
metolazone tab 10 mg ...................... 33
metolazone tab 2.5 mg ..................... 33
metolazone tab 5 mg ........................ 33
100-25 mg ...................................... 28
100-50 mg ...................................... 28
110

50-25 mg ........................................28
......................................................29
......................................................29
......................................................29
......................................................29
metoprolol tartrate inj 1 mg/ml ..........29
metoprolol tartrate tab 100 mg ..........29
metoprolol tartrate tab 25 mg ............29
metoprolol tartrate tab 50 mg ............29
metronidazole cap 375 mg .................15
metronidazole cream 0.75% ..............87
metronidazole gel 0.75% ...................87
metronidazole in nacl 0.79% iv soln 500
mg/100ml ........................................15
metronidazole lotion 0.75% ...............87
metronidazole tab 250 mg .................15
metronidazole tab 500 mg .................16
metronidazole vaginal gel 0.75% ........67
mexiletine hcl cap 150 mg .................26
MG SO4/D5W INJ 10MG/ML ...............74
microgestin tab 1.5/30 ......................56
microgestin tab 1/20 .........................56
microgestin tab fe 1/20 .....................56
microgestin tab fe1.5/30....................56
midodrine hcl tab 10 mg ....................33
midodrine hcl tab 2.5 mg ...................33
midodrine hcl tab 5 mg ......................33
minitran dis 0.1mg/hr .......................34
minocycline hcl cap 100 mg ................ 9
minocycline hcl cap 50 mg .................. 9
minocycline hcl cap 75 mg .................. 9
minoxidil tab 10 mg ..........................33
minoxidil tab 2.5 mg .........................33
mirtazapine orally disintegrating tab 15
mg ..................................................41
mg ..................................................41
mg ................................................. 41
mirtazapine tab 15 mg ...................... 41
mirtazapine tab 7.5 mg ..................... 41
misoprostol tab 100 mcg ................... 66
misoprostol tab 200 mcg ................... 66
mitomycin for inj 20 mg .................... 17
mitoxantrone hcl inj conc 25 mg/12.5ml
(2 mg/ml) ....................................... 21
M-M-R II INJ LIVE ............................ 73
modafinil tab 100 mg........................ 51
modafinil tab 200 mg........................ 51
moexipril hcl tab 15 mg .................... 23
moexipril hcl tab 7.5 mg ................... 23
moexipril-hydrochlorothiazide tab
15-12.5 mg ..................................... 22
moexipril-hydrochlorothiazide tab 15-25
mg ................................................. 23
moexipril-hydrochlorothiazide tab
7.5-12.5 mg .................................... 22
mometasone furoate cream 0.1% ...... 86
mometasone furoate oint 0.1% .......... 86
mometasone furoate solution 0.1%
(lotion) ........................................... 86
MONONESSA TAB ............................. 56
montelukast sodium chew tab 4 mg (base
equiv) ............................................. 81
montelukast sodium chew tab 5 mg (base
equiv) ............................................. 81
montelukast sodium oral granules packet
4 mg (base equiv) ............................ 81
montelukast sodium tab 10 mg (base
equiv) ............................................. 81
MORPHINE SUL INJ 10MG/ML .............. 3
MORPHINE SUL INJ 15MG/ML .............. 3
MORPHINE SUL INJ 4MG/ML ................ 3
MORPHINE SUL INJ 8MG/ML ................ 3
MORPHINE SUL SOL 10MG/5ML ........... 3
MORPHINE SUL SOL 20MG/5ML ........... 3
MORPHINE SUL SOL 20MG/ML ............. 3
MORPHINE SUL TAB 15MG .................. 3
MORPHINE SUL TAB 30MG .................. 3
morphine sulfate inj pf 0.5 mg/ml ........ 3
morphine sulfate inj pf 1 mg/ml ........... 3
morphine sulfate tab cr 100 mg ........... 4
morphine sulfate tab cr 15 mg ............. 3
morphine sulfate tab cr 200 mg ........... 4
111

MOVIPREP SOL .................................65
MOXEZA SOL 0.5% ...........................77
MOZOBIL INJ ...................................70
MULTAQ TAB 400MG .........................26
mupirocin oint 2% ............................84
MUSTARGEN INJ 10MG ......................16
my way tab 1.5mg ............................56
MYCAMINE INJ 100MG .......................11
MYCAMINE INJ 50MG ........................11
MYCOBUTIN CAP 150MG ....................14
mycophenolate mofetil cap 250 mg .....72
mycophenolate mofetil tab 500 mg .....72
MYFORTIC TAB 180MG ......................72
MYFORTIC TAB 360MG ......................72
myorisan cap 10mg...........................83
myorisan cap 20mg...........................83
myorisan cap 40mg...........................83
MYOZYME INJ 50MG ..........................58
myzilra tab.......................................56
N
nabumetone tab 500 mg..................... 5
nabumetone tab 750 mg..................... 5
nadolol tab 20 mg .............................29
nadolol tab 40 mg .............................29
nadolol tab 80 mg .............................29
nafcillin sodium for inj 1 gm ................ 9
nafcillin sodium for inj 10 gm .............. 9
NAGLAZYME INJ 1MG/ML ...................58
naloxone hcl inj 0.4 mg/ml.................52
naloxone hcl inj 1 mg/ml ...................52
naltrexone hcl tab 50 mg ...................52
NAMENDA SOL 10MG/5ML .................39
NAMENDA TAB 10MG ........................40
NAMENDA TAB 5-10MG .....................39
NAMENDA TAB 5MG ..........................40
naphazoline sol 0.1% op ....................79
naproxen dr tab 375mg ...................... 5
naproxen dr tab 500mg ...................... 5
naproxen sodium tab 275 mg .............. 5
naproxen sodium tab 550 mg .............. 5
naproxen susp 125 mg/5ml................. 5
naproxen tab 250 mg ......................... 5
naproxen tab 375 mg ......................... 5
naproxen tab 500 mg ......................... 5
naratriptan hcl tab 1 mg (base equiv)..49
naratriptan hcl tab 2.5 mg (base equiv)
...................................................... 49
NASONEX SPR 50MCG/AC ................. 81
NATACYN SUS 5% OP ....................... 77
nateglinide tab 120 mg ..................... 54
nateglinide tab 60 mg ....................... 54
NEBUPENT INH 300MG ..................... 16
necon tab 0.5/35 ............................. 56
necon tab 1/35 ................................ 56
NECON TAB 10/11-28 ....................... 57
NECON TAB 7/7/7 ............................ 56
nefazodone hcl tab 100 mg ............... 42
nefazodone hcl tab 50 mg ................. 41
neomycin sulfate tab 500 mg............. 10
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin ..... 78
neomycin-polymyx-gramicid op sol
1.75-10000-0.25mg-unt-mg/ml ......... 78
ophth oint 0.1% ............................... 77
ophth susp 0.1% .............................. 77
neomycin-polymyxin-hc ophth susp .... 77
neomycin-polymyxin-hc otic soln 1% .. 88
neomycin-polymyxin-hc otic susp 3.5
mg/ml-10000 unit/ml-1% ................. 88
NEORAL CAP 100MG ......................... 72
NEORAL CAP 25MG ........................... 72
NEORAL SOL 100MG/ML .................... 72
NEPHRAMINE INJ 5.4% ..................... 75
NEUMEGA INJ 5MG ........................... 70
NEUPOGEN INJ 300/0.5 .................... 70
NEUPOGEN INJ 480/0.8 .................... 70
NEUPOGEN INJ 480MCG .................... 70
NEUPRO DIS 1MG/24HR .................... 43
NEUPRO DIS 2MG/24HR .................... 43
NEUPRO DIS 3MG/24HR .................... 43
NEUPRO DIS 4MG/24HR .................... 43
NEUPRO DIS 6MG/24HR .................... 44
NEUPRO DIS 8MG/24HR .................... 44
NEVANAC SUS 0.1% ......................... 78
NEVIRAPINE SUS 50MG/5ML ............. 12
nevirapine tab 200 mg ...................... 12
NEXAVAR TAB 200MG ....................... 19
NEXIUM CAP 20MG ........................... 66
NEXIUM CAP 40MG ........................... 66
112
NEXIUM GRA 10MG DR ......................66

NEXIUM GRA 2.5MG DR .....................66
NEXIUM GRA 20MG DR ......................66
NEXIUM GRA 40MG DR ......................66
NEXIUM GRA 5MG DR ........................66
NEXIUM I.V. INJ 20MG ......................66
NEXIUM I.V. INJ 40MG ......................66
next choice tab 1.5mg .......................57
NIASPAN TAB 1000 ER ......................27
NIASPAN TAB 500MG ER....................27
NIASPAN TAB 750MG ER....................27
nicardipine hcl cap 20 mg ..................30
nicardipine hcl cap 30 mg ..................30
NICOTROL INH .................................52
NICOTROL NS SPR 10MG/ML ..............52
nifediac cc tab 30mg er .....................30
nifedical xl tab 30mg .........................31
nifedical xl tab 60mg .........................31
nifedipine tab 30mg er ......................31
nifedipine tab sr 24hr 60 mg ..............31
NILANDRON TAB 150MG ....................18
nimodipine cap 30 mg .......................31
nitro-bid oin 2% ...............................34
NITRO-DUR DIS 0.3MG/HR ................34
NITRO-DUR DIS 0.8MG/HR ................34
nitrofurantoin macrocrystalline cap 50 mg
......................................................16
nitrofurantoin monohydrate
macrocrystalline cap 100 mg ..............16
nitroglycerin td patch 24hr 0.1 mg/hr ..34
NITROLINGUAL SPR PUMPSPRA ..........34
NITROSTAT SUB 0.3MG .....................34
NITROSTAT SUB 0.4MG .....................34
NITROSTAT SUB 0.6MG .....................34
NORA-BE TAB 0.35MG .......................57
NORDITROPIN INJ 10/1.5ML ..............60
NORDITROPIN INJ 15/1.5ML ..............60
NORDITROPIN INJ 30/3ML .................60
NORDITROPIN INJ 5/1.5ML ................60
norethindrone acetate tab 5 mg ..........61
norethindrone tab 0.35 mg ................57
normosol -m inj /d5w ....................... 76

NORMOSOL -R INJ /D5W ................... 76
NORMOSOL-R INJ PH 7.4 .................. 76
NORPACE CAP 100MG CR .................. 26
NORPACE CAP 150MG CR .................. 26
nortrel tab 0.5/35 ............................ 57
nortrel tab 1/35 ............................... 57
nortrel tab 7/7/7 .............................. 57
nortriptyline hcl cap 10 mg ................ 42
nortriptyline hcl soln 10 mg/5ml ........ 42
NORVIR CAP 100MG ......................... 12
NORVIR SOL 80MG/ML...................... 12
NORVIR TAB 100MG ......................... 12
NOVOLIN INJ 70/30.......................... 53
NOVOLIN N INJ U-100 ...................... 53
NOVOLIN R INJ U-100 ...................... 53
NOVOLOG INJ 100/ML ...................... 53
NOVOLOG INJ FLEXPEN..................... 53
NOVOLOG MIX INJ 70/30 .................. 53
NOVOLOG MIX INJ FLEXPEN .............. 53
NOXAFIL SUS 40MG/ML .................... 11
NUEDEXTA CAP 20-10MG .................. 50
NULOJIX INJ 250MG ......................... 72
NUVARING MIS ................................ 57
nyamyc pow 100000 ........................ 84
NYMALIZE SOL 60/20ML ................... 31
nystatin cream 100000 unit/gm ......... 84
nystatin oint 100000 unit/gm ............ 84
nystatin susp 100000 unit/ml ............ 87
nystatin tab 500000 unit ................... 11
nystatin topical powder ..................... 84
nystop pow 100000 .......................... 84
O
OCELLA TAB 3-0.03MG ..................... 57
OCTAGAM INJ 1GM ........................... 71
mg/ml) ........................................... 60
octreotide acetate inj 1000 mcg/ml (1
mg/ml) ........................................... 60
mg/ml) ........................................... 60
mg/ml) ........................................... 60
mg/ml) ........................................... 60
113
ofloxacin ophth soln 0.3% ..................78

ofloxacin otic soln 0.3% .....................88
ogestrel tab .....................................57
olanzapine for im inj 10 mg ................46
olanzapine orally disintegrating tab 10 mg
......................................................46
......................................................46
......................................................46
......................................................46
olanzapine tab 10 mg ........................46
olanzapine tab 2.5 mg .......................46
olanzapine tab 5 mg ..........................46
olanzapine tab 7.5 mg .......................46
omeprazole cap delayed release 10 mg67
ondansetron hcl inj 4 mg/2ml (2 mg/ml)
......................................................64
ondansetron hcl inj 40 mg/20ml (2
mg/ml) ............................................64
ondansetron hcl oral soln 4 mg/5ml ....64
ondansetron hcl tab 24 mg ................64
ondansetron hcl tab 4 mg ..................64
ondansetron hcl tab 8 mg ..................64
ondansetron orally disintegrating tab 4
mg ..................................................64
ondansetron orally disintegrating tab 8
mg ..................................................64
ONFI SUS 2.5MG/ML .........................37
ONFI TAB 10MG ................................37
ONFI TAB 20MG ................................37
ONFI TAB 5MG .................................37
ONTAK INJ 150/ML ...........................18
ORAP TAB 1MG .................................47
ORAP TAB 2MG .................................47
ORFADIN CAP 10MG ..........................58
ORFADIN CAP 2MG ...........................58
ORFADIN CAP 5MG ...........................58
orsythia tab .....................................57
ORTHO EVRA DIS WEEK ....................57
ORTHO TRI- TAB CYCLN LO ................57
oxacillin sodium for inj 1 gm ..............10
oxacillin sodium for inj 10 gm .............10
oxaliplatin iv soln 100 mg/20ml ......... 21

oxandrolone tab 10 mg ..................... 52
oxandrolone tab 2.5 mg .................... 52
oxaprozin tab 600 mg ......................... 5
oxcarbazepine susp 300 mg/5ml (60
mg/ml) ........................................... 37
oxcarbazepine tab 150 mg ................ 37
OXSORALEN-UL CAP 10MG ................ 84
oxybutynin chloride syrup 5 mg/5ml ... 67
oxybutynin chloride tab 5 mg ............ 67
oxybutynin chloride tab sr 24hr 10 mg 67
oxybutynin chloride tab sr 24hr 15 mg 67
oxybutynin chloride tab sr 24hr 5 mg . 67
OXYCODONE CAP 5MG ........................ 4
OXYCODONE CON 20MG/ML ................ 4
oxycodone hcl tab 10 mg .................... 4
oxycodone hcl tab 5 mg ...................... 4
OXYCODONE SOL 5MG/5ML ................. 4
oxycodone w/ acetaminophen cap 5-500
mg ................................................... 4
oxycodone w/ acetaminophen tab 10-325
mg ................................................... 4
mg ................................................... 4
oxycodone w/ acetaminophen tab 2.5-325
mg ................................................... 4
mg ................................................... 4
mg ................................................... 4
mg ................................................... 4
oxycodone-aspirin tab 4.8355-325 mg .. 4
P
pacerone tab 100mg......................... 26
pacerone tab 200mg......................... 26
pacerone tab 400mg......................... 26
paclitaxel iv conc 300 mg/50ml (6 mg/ml)
...................................................... 17
PANRETIN GEL 0.1% ........................ 87
equiv) ............................................. 67
114
equiv) .............................................67
paromomycin sulfate cap 250 mg .......10
paroxetine hcl tab 10 mg ...................42
paroxetine hcl tab sr 24hr 12.5 mg .....42
paroxetine hcl tab sr 24hr 25 mg ........42
paroxetine hcl tab sr 24hr 37.5 mg .....42
PASER GRA 4GM ...............................14
PATADAY SOL 0.2% ..........................78
PATANASE SPR 0.6% ........................80
PATANOL SOL 0.1% OP .....................79
PAXIL SUS 10MG/5ML .......................42
pedi-dri pow 100000 .........................84
PEDVAX HIB INJ ...............................73
PEGANONE TAB 250MG .....................38
PEGASYS INJ 180MCG/M ...................72
PEGASYS INJ PROCLICK ....................72
PEGASYS KIT ...................................72
PEG-INTRON KIT 120 RP....................71
PEG-INTRON KIT 150 RP....................71
PEG-INTRON KIT 50MCG ...................71
PEG-INTRON KIT 50MCG RP ...............71
PEG-INTRON KIT 80MCG RP ...............71
PENICILL GK/ INJ DEX 2MU................10
PENICILL GK/ INJ DEX 3MU................10
penicillin g potassium for inj 5000000 unit
......................................................10
penicillin g procaine intramuscular susp
600000 unit/ml.................................10
penicillin g sodium for inj 5000000 unit
......................................................10
......................................................10
......................................................10
penicillin v potassium tab 250 mg .......10
penicillin v potassium tab 500 mg .......10
PENTASA CAP 250MG CR ...................65
PENTASA CAP 500MG CR ...................65
pentostatin for inj 10 mg ...................17
pentoxifylline tab cr 400 mg ...............70
PERFOROMIST NEB 20MCG ................81
perindopril erbumine tab 2 mg ...........23
periogard sol 0.12% ..........................87
permethrin cream 5% ....................... 87

perphenazine tab 16 mg ................... 47
perphenazine tab 2 mg ..................... 47
phenadoz sup 12.5mg ...................... 64
phenadoz sup 25mg ......................... 64
phenelzine sulfate tab 15 mg ............. 42
phenobarbital elixir 20 mg/5ml .......... 38
phenobarbital sodium inj 130 mg/ml .. 38
phenobarbital sodium inj 65 mg/ml .... 38
phenobarbital tab 100 mg ................. 38
phenobarbital tab 15 mg ................... 38
phenobarbital tab 16.2 mg ................ 38
PHENYTEK CAP 200MG...................... 38
PHENYTEK CAP 300MG...................... 38
phenytoin chew tab 50 mg ................ 38
...................................................... 38
...................................................... 38
...................................................... 38
phenytoin sodium inj 50 mg/ml ......... 38
phenytoin susp 125 mg/5ml .............. 38
philith tab 0.4-35 ............................. 57
PHOSLO CAP 667MG ......................... 61
PHOSLYRA SOL ................................ 61
PHOSPHOLINE SOL 0.125%OP ........... 79
PILOCARPINE HCL OPHTH SOLN 1% ... 79
pilocarpine hcl tab 5 mg .................... 87
pilocarpine hcl tab 7.5 mg ................. 88
PILOPINE HS GEL 4% OP .................. 79
pindolol tab 10 mg ........................... 29
pindolol tab 5 mg ............................. 29
...................................................... 54
...................................................... 54
...................................................... 54
115

......................................................54
......................................................54
pioglitazone hcl-metformin hcl tab 15-500
mg ..................................................54
pioglitazone hcl-metformin hcl tab 15-850
mg ..................................................54
piperacillin sodium-tazobactam sodium
for inj 3-0.375 gm ............................10
piperacillin sodium-tazobactam sodium
for inj 4-0.5 gm ................................10
pirmella tab 1/35 ..............................57
piroxicam cap 10 mg .......................... 5
piroxicam cap 20 mg .......................... 5
PLASMA-LYTE INJ -148 ......................76
PLASMA-LYTE INJ 56/D5W .................76
PLASMA-LYTE INJ -A .........................76
podofilox soln 0.5% ..........................87
polyethylene glycol 3350 oral powder ..65
polymyxin b-trimethoprim ophth soln
10000 unit/ml-0.1% .........................78
POMALYST CAP 1MG .........................21
POMALYST CAP 2MG .........................21
POMALYST CAP 3MG .........................21
POMALYST CAP 4MG .........................21
portia-28 tab ....................................57
potassium chloride cap cr 10 meq .......74
potassium chloride cap cr 8 meq .........74
potassium chloride inj 10 meq/100 ml .76
potassium chloride inj 10 meq/50 ml ...76
potassium chloride inj 2 meq/ml .........76
potassium chloride inj 20 meq/50 ml ...76
potassium chloride inj 30 meq/100 ml .76
potassium chloride microencapsulated
crys cr tab 10 meq ............................74
potassium chloride microencapsulated
crys cr tab 20 meq ............................74
potassium citrate tab cr 10 meq (1080
mg) ................................................67
potassium citrate tab cr 5 meq (540 mg)
......................................................67
POTIGA TAB 200MG ..........................38
POTIGA TAB 300MG ..........................38
POTIGA TAB 400MG ..........................38
POTIGA TAB 50MG ............................38
PRADAXA CAP 150MG........................69
PRADAXA CAP 75MG .........................69
pramipexole dihydrochloride tab 0.125

mg ................................................. 44
...................................................... 44
...................................................... 44
...................................................... 44
pramipexole dihydrochloride tab 1 mg 44
...................................................... 44
PRANDIN TAB 0.5MG ........................ 54
PRANDIN TAB 1MG ........................... 54
PRANDIN TAB 2MG ........................... 54
pravastatin sodium tab 10 mg ........... 27
prazosin hcl cap 1 mg ....................... 24
PRED MILD SUS 0.12% OP ................ 78
prednisolone sod phosph oral soln 6.7
mg/5ml (5 mg/5ml base) .................. 60
prednisolone sod phosphate oral soln 15
mg/5ml (base equiv) ........................ 60
prednisolone sodium phosphate ophth
soln 1% .......................................... 78
prednisolone sodium phosphate oral soln
25 mg/5ml (base eq) ........................ 60
PREDNISOLONE SUS 1% OP .............. 78
prednisone con 5mg/ml .................... 60
prednisone oral soln 5 mg/5ml ........... 60
prednisone tab 1 mg......................... 60
prednisone tab 10 mg ....................... 60
prednisone tab 2.5 mg ...................... 60
prednisone tab 5 mg......................... 60
PREMARIN VAG CRE 0.625MG ............ 59
premasol sol 10% ............................ 75
prenatal vitamin/folic acid > 0.8 mg
(generic) ......................................... 77
prevalite pow 4gm............................ 27
previfem tab .................................... 57
PREVPAC MIS .................................. 66
PREZISTA SUS 100MG/ML ................. 12
PREZISTA TAB 150MG ...................... 12
116
PREZISTA TAB 400MG .......................12

PREZISTA TAB 600MG .......................12
PREZISTA TAB 75MG .........................12
PREZISTA TAB 800MG .......................12
PRIFTIN TAB 150MG..........................14
PRIMAQUINE TAB 26.3MG ..................11
primidone tab 250 mg .......................38
primidone tab 50 mg .........................38
PRISTIQ TAB 100MG .........................42
PRISTIQ TAB 50MG ...........................42
PRIVIGEN INJ 20GRAMS ....................71
PRIVIGEN INJ 40GRAMS ....................71
PROAIR HFA AER ..............................81
probenecid tab 500 mg ....................... 1
PROCALAMINE INJ 3%.......................75
prochlorperazine edisylate inj 5 mg/ml 64
prochlorperazine maleate tab 10 mg ...64
prochlorperazine maleate tab 5 mg .....64
prochlorperazine suppos 25 mg ..........64
PROCRIT INJ 10000/ML .....................70
PROCRIT INJ 2000/ML .......................70
PROCRIT INJ 20000/ML .....................70
PROCRIT INJ 3000/ML .......................70
PROCRIT INJ 4000/ML .......................70
PROCRIT INJ 40000/ML .....................70
proctocream cre hc 2.5% ...................84
procto-pak cre 1% ............................86
proctozone cre -hc 2.5%....................84
PROCYSBI CAP 25MG ........................58
PROCYSBI CAP 75MG ........................58
PROGLYCEM SUS 50MG/ML ................60
PROGRAF CAP 0.5MG ........................72
PROGRAF CAP 1MG ...........................73
PROGRAF CAP 5MG ...........................73
PROLASTIN-C INJ 1000MG .................81
PROLENSA SOL 0.07% ......................79
PROLEUKIN INJ 22MU........................18
PROLIA SOL 60MG/ML .......................60
PROMACTA TAB 12.5MG ....................70
PROMACTA TAB 25MG .......................70
PROMACTA TAB 50MG .......................70
PROMACTA TAB 75MG .......................70
promethazine hcl inj 25 mg/ml ...........64
promethazine hcl inj 50 mg/ml ...........64
promethazine hcl suppos 12.5 mg .......64
promethazine hcl suppos 25 mg .........64
promethegan sup 25mg .....................64
promethegan sup 50mg .....................64
propafenone hcl cap sr 12hr 225 mg... 26

propafenone hcl tab 150 mg .............. 26
proparacaine hcl ophth soln 0.5% ...... 79
propranolol & hydrochlorothiazide tab
40-25 mg ........................................ 28
propranolol & hydrochlorothiazide tab
80-25 mg ........................................ 28
propranolol hcl cap sr 24hr 120 mg .... 29
propranolol hcl cap sr 24hr 160 mg .... 29
propranolol hcl cap sr 24hr 60 mg ...... 29
propranolol hcl cap sr 24hr 80 mg ...... 29
propranolol hcl inj 1 mg/ml ............... 29
propranolol hcl oral soln 20 mg/5ml ... 29
propranolol hcl oral soln 40 mg/5ml ... 29
propranolol hcl tab 10 mg ................. 29
propylthiouracil tab 50 mg................. 62
PROQUAD INJ .................................. 73
PROSOL INJ 20% ............................. 75
PROTOPIC OIN 0.03% ...................... 87
PROTOPIC OIN 0.1% ........................ 87
protriptyline hcl tab 10 mg ................ 42
protriptyline hcl tab 5 mg .................. 42
PRUDOXIN CRE 5% .......................... 84
PULMICORT SUS 1MG/2ML ................ 82
PULMOZYME SOL 1MG/ML ................. 81
PYLERA CAP..................................... 66
pyrazinamide tab 500 mg .................. 14
pyridostigmine bromide tab 60 mg ..... 50
Q
quasense tab ................................... 57
quetiapine fumarate tab 100 mg ........ 47
quetiapine fumarate tab 25 mg .......... 47
quetiapine fumarate tab 50 mg .......... 47
quinapril hcl tab 10 mg ..................... 23
quinapril hcl tab 5 mg ....................... 23
117
quinapril-hydrochlorothiazide tab 10-12.5

mg ..................................................23
quinapril-hydrochlorothiazide tab 20-12.5
mg ..................................................23
quinapril-hydrochlorothiazide tab 20-25
mg ..................................................23
quinidine gluconate tab cr 324 mg ......26
quinidine sulfate tab 200 mg ..............26
quinidine sulfate tab 300 mg ..............26
quinidine sulfate tab cr 300 mg ..........26
QVAR AER 40MCG .............................82
QVAR AER 80MCG .............................82
R
RABAVERT INJ ..................................73
ramipril cap 1.25 mg .........................23
ramipril cap 10 mg ............................23
ramipril cap 2.5 mg ...........................23
ramipril cap 5 mg .............................23
RANEXA TAB 1000MG ........................33
RANEXA TAB 500MG .........................33
ranitidine hcl inj 150 mg/6ml (25 mg/ml)
......................................................64
ranitidine hcl syrup 15 mg/ml (75
mg/5ml) ..........................................65
ranitidine hcl tab 150 mg ...................65
ranitidine hcl tab 300 mg ...................65
RAPAMUNE SOL 1MG/ML....................73
RAPAMUNE TAB 0.5MG ......................73
RAPAMUNE TAB 1MG .........................73
RAPAMUNE TAB 2MG .........................73
REBETOL SOL 40MG/ML .....................14
reclipsen tab ....................................57
RECOMBIVA HB INJ 10MCG/ML ...........74
RECOMBIVA-HB INJ 40MCG/ML ..........74
REGONOL INJ 5MG/ML ......................50
REGRANEX GEL 0.01% ......................87
RELENZA MIS DISKHALE....................14
RELISTOR KIT 12/0.6ML ....................65
RELPAX TAB 20MG ............................49
RELPAX TAB 40MG ............................49
REMICADE INJ 100MG .......................71
REMODULIN INJ 10MG/ML .................34
REMODULIN INJ 1MG/ML ...................34
REMODULIN INJ 2.5MG/ML ................34
REMODULIN INJ 5MG/ML ...................34
RENVELA PAK 0.8GM .........................61
RENVELA PAK 2.4GM .........................61
RENVELA TAB 800MG ........................61
repaglinide tab 0.5 mg ...................... 54

repaglinide tab 1 mg......................... 54
repaglinide tab 2 mg......................... 54
RESCRIPTOR TAB 100 MG ................. 12
RESCRIPTOR TAB 200MG .................. 13
RESTASIS EMU 0.05% ...................... 79
RETROVIR INJ 10MG/ML ................... 13
REVLIMID CAP 10MG ........................ 72
REVLIMID CAP 15MG ........................ 72
REVLIMID CAP 2.5MG ....................... 72
REVLIMID CAP 20MG ........................ 72
REVLIMID CAP 25MG ........................ 72
REVLIMID CAP 5MG .......................... 72
REYATAZ CAP 100MG ....................... 13
REYATAZ CAP 150MG ....................... 13
REYATAZ CAP 200MG ....................... 13
REYATAZ CAP 300MG ....................... 13
ribapak mis 600/day ......................... 14
ribapak pak 1000/day ....................... 14
ribapak pak 1200/day ....................... 14
ribapak pak 800/day......................... 14
ribasphere tab 400mg....................... 14
ribasphere tab 600mg....................... 14
ribavirin cap 200 mg......................... 14
ribavirin tab 200 mg ......................... 14
rifampin cap 150 mg ........................ 14
rifampin cap 300 mg ........................ 14
rifampin for inj 600 mg ..................... 14
RILUTEK TAB 50MG .......................... 50
riluzole tab 50 mg ............................ 50
rimantadine hydrochloride tab 100 mg 14
ringer's solution ............................... 76
RIOMET SOL .................................... 54
RISPERDAL INJ 12.5MG .................... 47
RISPERDAL INJ 25MG ....................... 47
RISPERDAL INJ 37.5MG .................... 47
RISPERDAL INJ 50MG ....................... 47
risperidone orally disintegrating tab 0.25
mg ................................................. 47
risperidone orally disintegrating tab 0.5
mg ................................................. 47
risperidone orally disintegrating tab 1 mg
...................................................... 47
...................................................... 47
...................................................... 47
118
......................................................47
risperidone soln 1 mg/ml ...................47
risperidone tab 0.25 mg ....................47
risperidone tab 0.5 mg ......................47
risperidone tab 1 mg .........................47
RITUXAN INJ 500MG .........................18
rivastigmine tartrate cap 1.5 mg .........40
rivastigmine tartrate cap 3 mg ...........40
rivastigmine tartrate cap 4.5 mg .........40
rivastigmine tartrate cap 6 mg ...........40
tab 10 mg ........................................50
tab 5 mg..........................................49
rizatriptan benzoate tab 10 mg ...........50
rizatriptan benzoate tab 5 mg.............50
ropinirole hydrochloride tab 0.25 mg ...44
ropinirole hydrochloride tab 0.5 mg .....44
ropinirole hydrochloride tab 1 mg .......44
ROTATEQ SOL ..................................74
roxicet sol 5-325/5............................. 4
S
SABRIL POW 500MG .........................38
SABRIL TAB 500MG...........................38
SANDIMMUNE CAP 100MG .................73
SANDIMMUNE CAP 25MG ...................73
SANDIMMUNE SOL 100MG/ML ............73
SANDOSTATIN KIT LAR 10MG ............60
SANTYL OIN 250/GM .........................87
SAPHRIS SUB 10MG ..........................47
SAPHRIS SUB 5MG............................47
SAVELLA MIS TITR PAK .....................50
SAVELLA TAB 100MG ........................50
SAVELLA TAB 12.5MG .......................50
SAVELLA TAB 25MG ..........................50
SAVELLA TAB 50MG ..........................50
selegiline hcl cap 5 mg ......................44
selegiline hcl tab 5 mg .......................44
selenium sulfide lotion 2.5% ..............85
SELZENTRY TAB 150MG .................... 13

SELZENTRY TAB 300MG .................... 13
SENSIPAR TAB 30MG ........................ 55
SENSIPAR TAB 60MG ........................ 55
SENSIPAR TAB 90MG ........................ 55
SEREVENT DIS AER 50MCG ............... 81
SEROMYCIN CAP 250MG ................... 14
SEROQUEL XR TAB 150MG ................ 47
SEROQUEL XR TAB 50MG .................. 47
sertraline hcl oral conc 20 mg/ml ....... 42
sertraline hcl tab 100 mg .................. 42
sertraline hcl tab 25 mg .................... 42
sertraline hcl tab 50 mg .................... 42
sildenafil citrate tab 20 mg ................ 34
SILVER SULFA CRE 1% ..................... 84
SIMCOR TAB 1000-20 ....................... 28
SIMCOR TAB 1000-40 ....................... 28
SIMCOR TAB 500-20MG .................... 27
SIMCOR TAB 500-40MG .................... 27
SIMCOR TAB 750-20MG .................... 27
simvastatin tab 10 mg ...................... 27
simvastatin tab 5 mg ........................ 27
SIRTURO TAB 100MG ....................... 14
SOD CHLORIDE INJ 0.45% ................ 76
SOD CHLORIDE INJ 0.9%.................. 76
SOD CHLORIDE INJ 2.5/ML ............... 74
SOD CHLORIDE INJ 3% .................... 76
SOD CHLORIDE INJ 5% .................... 76
sod fluoride 2.2mg tab ...................... 74
SODIUM CHLOR SOL 0.9% IRR .......... 87
sodium phenylbutyrate oral powder 3
gm/teaspoonful ................................ 58
sodium polystyrene sulfonate oral susp 15
gm/60ml ......................................... 55
SOLARAZE GEL 3% W/W ................... 84
SOLIA TAB ...................................... 57
SOLTAMOX SOL 10MG/5ML ............... 18
SOLU-CORTEF INJ 250MG ................. 60
SOMATULINE INJ 120/.5ML ............... 61
SOMATULINE INJ 60/0.2ML ............... 61
SOMATULINE INJ 90/0.3ML ............... 61
SOMAVERT INJ 10MG ....................... 61
119
SOMAVERT INJ 15MG ........................61

SOMAVERT INJ 20MG ........................61
SORIATANE CAP 10MG ......................84
SORIATANE CAP 17.5MG ...................84
SORIATANE CAP 25MG ......................85
sorine tab 120mg..............................26
sorine tab 160mg..............................26
sorine tab 240mg..............................26
sorine tab 80mg ...............................26
sotalol hcl (afib/afl) tab 120 mg ..........26
sotalol hcl tab 160 mg .......................26
sotalol hcl tab 240 mg .......................26
sotalol hcl tab 80 mg .........................26
SPIRIVA CAP HANDIHLR ....................80
spironolactone & hydrochlorothiazide tab
25-25 mg ........................................33
spironolactone tab 100 mg .................24
spironolactone tab 25 mg ..................24
spironolactone tab 50 mg ..................24
sprintec 28 tab 28 day.......................57
SPRYCEL TAB 100MG ........................20
SPRYCEL TAB 140MG ........................20
SPRYCEL TAB 20MG ..........................20
SPRYCEL TAB 50MG ..........................20
SPRYCEL TAB 70MG ..........................20
SPRYCEL TAB 80MG ..........................20
sronyx tab .......................................57
SSD CRE 1% ....................................84
stagesic cap 5-500mg ........................ 2
STALEVO 100 TAB.............................44
STALEVO 125 TAB.............................44
STALEVO 150 TAB.............................44
STALEVO 200 TAB.............................44
STALEVO 50 TAB ..............................44
STALEVO 75 TAB ..............................44
stavudine cap 15 mg .........................13
stavudine cap 20 mg .........................13
stavudine cap 30 mg .........................13
stavudine cap 40 mg .........................13
stavudine for oral soln 1 mg/ml ..........13
STERIL WATER SOL IRRIG .................87
STIVARGA TAB 40MG ........................20
STRATTERA CAP 100MG ....................49
STRATTERA CAP 10MG ......................49
STRATTERA CAP 18MG ......................49
STRATTERA CAP 25MG ......................49
STRATTERA CAP 40MG ......................49
STRATTERA CAP 60MG ......................49
STRATTERA CAP 80MG...................... 49

streptomycin sulfate for inj 1 gm........ 10
STRIBILD TAB.................................. 13
SUBOXONE MIS 12-3MG ................... 52
SUBOXONE MIS 2-0.5MG .................. 52
SUBOXONE MIS 4-1MG ..................... 52
SUBOXONE MIS 8-2MG ..................... 52
SUCRAID SOL 8500/ML ..................... 66
sucralfate tab 1 gm .......................... 66
sulfacetamide sodium lotion 10% (acne)
...................................................... 83
sulfacetamide sodium ophth oint 10% 78
sulfacetamide sodium ophth soln 10% 78
sulfacetamide sodium-prednisolone ophth
soln 10-0.23(0.25)% ........................ 77
sulfadiazine tab 500 mg .................... 10
sulfamethoxazole-trimethoprim iv soln
400-80 mg/5ml................................ 16
sulfamethoxazole-trimethoprim susp
200-40 mg/5ml................................ 16
400-80 mg ...................................... 16
800-160 mg .................................... 16
SULFAMYLON CRE 85MG/GM ............. 84
sulfasalazine tab 500 mg................... 65
sulfazine ec tab 500mg ..................... 65
sulindac tab 150 mg ........................... 5
sulindac tab 200 mg ........................... 5
SUMATRIPTAN INJ 4MG/0.5 ............... 50
sumatriptan nasal spray 20 mg/act .... 50
sumatriptan nasal spray 5 mg/act ...... 50
sumatriptan succinate inj 6 mg/0.5ml . 50
sumatriptan succinate tab 100 mg ..... 50
sumatriptan succinate tab 25 mg ....... 50
sumatriptan succinate tab 50 mg ....... 50
SUPRAX CAP 400MG ......................... 10
suprax chw 100mg ........................... 10
suprax chw 200mg ........................... 10
suprax sus 100/5ml .......................... 10
suprax sus 200/5ml .......................... 10
SUPRAX SUS 500/5ML ...................... 10
suprax tab 400mg ............................ 10
SUSTIVA CAP 200MG ........................ 13
SUSTIVA CAP 50MG.......................... 13
SUSTIVA TAB 600MG ........................ 13
SUTENT CAP 12.5MG ........................ 20
SUTENT CAP 25MG ........................... 20
120
SUTENT CAP 50MG ...........................20

SYLATRON KIT 296MCG .....................21
SYLATRON KIT 444MCG .....................21
SYLATRON KIT 888MCG .....................21
SYMBICORT AER 160-4.5 ...................82
SYMBICORT AER 80-4.5.....................82
SYMLINPEN 60 INJ 1000MCG .............53
SYMLNPEN 120 INJ 1000MCG .............53
SYNAREL SOL 2MG/ML ......................57
SYNTHROID TAB 100MCG ..................62
SYNTHROID TAB 25MCG ....................62
SYPRINE CAP 250MG .........................55
T
TABLOID TAB 40MG ..........................17
tacrolimus cap 0.5 mg .......................73
tacrolimus cap 1 mg ..........................73
tacrolimus cap 5 mg ..........................73
TAFINLAR CAP 50MG .........................20
TAFINLAR CAP 75MG .........................20
TAMIFLU CAP 30MG ..........................14
TAMIFLU CAP 45MG ..........................15
TAMIFLU CAP 75MG ..........................15
TAMIFLU SUS 6MG/ML .......................15
equivalent) ......................................18
equivalent) ......................................18
tamsulosin hcl cap 0.4 mg .................67
TARCEVA TAB 100MG ........................20
TARCEVA TAB 150MG ........................20
TARCEVA TAB 25MG ..........................20
TARGRETIN CAP 75MG ......................21
TARGRETIN GEL 1% ..........................87
TASIGNA CAP 150MG ........................20
TASIGNA CAP 200MG ........................20
TAXOTERE INJ 80MG/2ML ..................17
TAXOTERE INJ 80MG/4ML ..................17
tazicef inj 1gm .................................10
tazicef inj 2gm ................................. 10

tazicef inj 6gm ................................. 10
TAZORAC CRE 0.05% ....................... 85
TAZORAC CRE 0.1% ......................... 85
TAZORAC GEL 0.05% ....................... 85
TAZORAC GEL 0.1% ......................... 85
taztia xt cap 120mg/24 ..................... 31
taztia xt cap 180mg/24 ..................... 31
taztia xt cap 240mg/24 ..................... 31
taztia xt cap 300mg/24 ..................... 31
taztia xt cap 360mg/24 ..................... 31
TEGRETOL CHW 100MG .................... 38
TEGRETOL SUS 100/5ML ................... 38
TEGRETOL TAB 200MG ..................... 38
TEGRETOL-XR TAB 100MG ................ 38
TEKAMLO TAB 150-10MG .................. 32
TEKAMLO TAB 150-5MG .................... 32
TEKAMLO TAB 300-10MG .................. 32
TEKAMLO TAB 300-5MG .................... 32
TEKTURNA HCT TAB 150-12.5 ........... 32
TEKTURNA HCT TAB 150-25MG .......... 32
TEKTURNA HCT TAB 300-12.5 ........... 32
TEKTURNA HCT TAB 300-25MG .......... 32
TEKTURNA TAB 150MG ..................... 32
TEKTURNA TAB 300MG ..................... 32
terazosin hcl cap 1 mg ...................... 24
terazosin hcl cap 10 mg .................... 24
terbinafine hcl tab 250 mg ................ 11
terbutaline sulfate inj 1 mg/ml ........... 81
terbutaline sulfate tab 2.5 mg ............ 81
terbutaline sulfate tab 5 mg .............. 81
terconazole vaginal cream 0.4% ........ 68
terconazole vaginal cream 0.8% ........ 68
terconazole vaginal suppos 80 mg ...... 68
TESTIM GEL 1%(50MG) .................... 52
testosterone cypionate im in oil 100
mg/ml ............................................ 52
testosterone cypionate im in oil 200
mg/ml ............................................ 52
testosterone enanthate im in oil 200
mg/ml ............................................ 52
TET/DIP TOX INJ 2-2 LF .................... 74
TETANUS TOX INJ 5LF ADS ............... 74
tetracycline hcl cap 250 mg ............... 10
121
tetracycline hcl cap 500 mg................10

TEV-TROPIN INJ 5MG ........................60
THALITONE TAB 15MG.......................33
THALOMID CAP 100MG ......................72
THALOMID CAP 150MG ......................72
THALOMID CAP 200MG ......................72
THALOMID CAP 50MG ........................72
THEO-24 CAP 100MG CR....................82
THEO-24 CAP 200MG CR....................82
THEO-24 CAP 300MG CR....................82
THEO-24 CAP 400MG ER ....................82
theophylline tab 100mg cr .................82
theophylline tab 200mg cr .................82
theophylline tab 300mg er .................82
theophylline tab 450mg er .................82
theophylline tab sr 24hr 400 mg .........83
theophylline tab sr 24hr 600 mg .........83
thioridazine hcl tab 10 mg..................48
thioridazine hcl tab 100 mg ................48
thiothixene cap 1 mg.........................48
thiothixene cap 10 mg .......................48
tiagabine hcl tab 2 mg .......................38
tiagabine hcl tab 4 mg .......................38
TIKOSYN CAP 125MCG ......................26
TIKOSYN CAP 250MCG ......................26
TIKOSYN CAP 500MCG ......................26
TIMENTIN INJ 3.1GM .........................10
TIMOLOL GEL SOL 0.25% OP .............79
TIMOLOL GEL SOL 0.5% OP ...............79
timolol maleate ophth soln 0.25% .......79
timolol maleate ophth soln 0.5% ........79
timolol maleate tab 10 mg .................29
timolol maleate tab 20 mg .................29
timolol maleate tab 5 mg ...................29
tizanidine hcl tab 2 mg ......................51
tizanidine hcl tab 4 mg ......................51
TOBI NEB 300/5ML ...........................81
TOBRADEX OIN 0.3-0.1% ..................77
TOBRADEX ST SUS 0.3-0.05 ..............77
......................................................10
......................................................10
tobramycin sulfate inj 10 mg/ml .........10
tobramycin sulfate inj 80 mg/2ml (40

mg/ml) ........................................... 10
tobramycin sulfate ophth soln 0.3% ... 78
tobramycin-dexamethasone ophth susp
0.3-0.1% ........................................ 77
TOBREX OIN 0.3% OP ...................... 78
tolterodine tartrate tab 1 mg ............. 67
tolterodine tartrate tab 2 mg ............. 67
topiramate sprinkle cap 15 mg ........... 38
topiramate sprinkle cap 25 mg ........... 38
topiramate tab 100 mg ..................... 39
topiramate tab 200 mg ..................... 39
topiramate tab 25 mg ....................... 38
topiramate tab 50 mg ....................... 38
toposar inj 1gm/50ml ....................... 21
topotecan hcl for inj 4 mg ................. 21
torsemide iv soln 20 mg/2ml (10 mg/ml)
...................................................... 33
torsemide tab 10 mg ........................ 33
torsemide tab 100 mg ...................... 33
torsemide tab 20 mg ........................ 33
torsemide tab 5 mg .......................... 33
TOVIAZ TAB 4MG ............................. 67
TOVIAZ TAB 8MG ............................. 67
TPN ELECTROL INJ ........................... 74
TRACLEER TAB 125MG ...................... 34
TRACLEER TAB 62.5MG ..................... 34
TRADJENTA TAB 5MG ....................... 55
tramadol hcl tab 50 mg ....................... 4
tramadol-acetaminophen tab 37.5-325
mg ................................................... 4
trandolapril tab 1 mg ........................ 23
tranexamic acid inj 100 mg/ml .......... 70
tranexamic acid tab 650 mg .............. 70
TRANSDERM-SC DIS 1.5MG............... 64
tranylcypromine sulfate tab 10 mg ..... 42
TRAVASOL INJ 10%.......................... 75
TRAVATAN Z DRO 0.004% ................ 79
trazodone hcl tab 100 mg ................. 42
trazodone hcl tab 150 mg ................. 42
trazodone hcl tab 50 mg ................... 42
TREANDA INJ 100MG ........................ 16
TRECATOR TAB 250MG ..................... 14
TRELSTAR DEP INJ 3.75MG ............... 18
TRELSTAR LA INJ 11.25MG ................ 18
tretinoin cap 10 mg .......................... 21
122
tretinoin cream 0.025% .....................83

tretinoin cream 0.05%.......................83
tretinoin cream 0.1% ........................83
tretinoin gel 0.01% ...........................83
tretinoin gel 0.025% .........................83
......................................................86
triamcinolone acetonide cream 0.1% ...86
triamcinolone acetonide cream 0.5% ...86
triamcinolone acetonide dental paste
0.1% ...............................................88
triamcinolone acetonide lotion 0.025% 86
triamcinolone acetonide lotion 0.1% ....86
triamcinolone acetonide nasal inhal 55
mcg/act ...........................................82
triamcinolone acetonide oint 0.025%...86
triamcinolone acetonide oint 0.1% ......86
triamcinolone acetonide oint 0.5% ......86
triamterene & hydrochlorothiazide cap
37.5-25 mg ......................................33
37.5-25 mg ......................................33
75-50 mg ........................................33
TRIBENZOR20- TAB 5-12.5MG............25
TRIBENZOR40- TAB 10-12.5 ..............25
TRIBENZOR40- TAB 10-25MG.............25
TRIBENZOR40- TAB 5-12.5MG............25
TRIBENZOR40- TAB 5-25MG ..............25
triderm cre 0.1% ..............................86
trifluoperazine hcl tab 1 mg................48
trifluoperazine hcl tab 10 mg ..............48
trifluridine ophth soln 1% ..................78
trihexyphenidyl hcl elixir 0.4 mg/ml ....44
trihexyphenidyl hcl tab 2 mg ..............44
trihexyphenidyl hcl tab 5 mg ..............44
tri-legest tab fe ................................57
TRILEPTAL SUS 300MG/5M ................39
trilyte sol .........................................65
trimethoprim tab 100 mg ...................16
trimipramine maleate cap 100 mg.......42
trimipramine maleate cap 25 mg ........42
trimipramine maleate cap 50 mg ........42
TRINESSA TAB .................................57
tri-previfem tab ................................57
TRISENOX SOL 10MG/10M .................21
tri-sprintec tab ................................. 57

trivora-28 tab .................................. 57
TRIZIVIR TAB .................................. 13
TROPHAMINE INJ 10% ...................... 75
tropicamide ophth soln 0.5% ............. 79
tropicamide ophth soln 1% ................ 79
trospium chloride tab 20 mg .............. 67
TRUVADA TAB 200-300 ..................... 13
TWINRIX INJ ................................... 74
TYGACIL INJ 50MG ........................... 16
TYKERB TAB 250MG ......................... 20
TYPHIM VI INJ ................................. 74
TYZEKA TAB 600MG ......................... 15
U
UCERIS TAB 9MG ............................. 65
ULORIC TAB 40MG ............................. 1
ULORIC TAB 80MG ............................. 1
UNITHROID TAB 100MCG .................. 63
UNITHROID TAB 25MCG.................... 63
ursodiol cap 300 mg ......................... 66
ursodiol tab 250 mg ......................... 66
ursodiol tab 500 mg ......................... 66
V
VAGIFEM TAB 10MCG ....................... 59
valacyclovir hcl tab 1 gm ................... 15
valacyclovir hcl tab 500 mg ............... 15
VALCYTE SOL 50MG/ML .................... 15
VALCYTE TAB 450MG ........................ 15
valproate sodium inj 100 mg/ml ........ 39
valproate sodium syrup 250 mg/5ml
(base equiv) .................................... 39
valproic acid cap 250 mg................... 39
valsartan-hydrochlorothiazide tab
160-12.5 mg ................................... 25
valsartan-hydrochlorothiazide tab 160-25
mg ................................................. 25
320-12.5 mg ................................... 25
valsartan-hydrochlorothiazide tab 320-25
123
mg ..................................................25
80-12.5 mg ......................................25
vancomycin hcl cap 125 mg ...............16
vancomycin hcl cap 250 mg ...............16
vancomycin hcl for inj 10 gm..............16
vancomycin hcl for inj 1000 mg ..........16
vancomycin hcl for inj 500 mg ............16
VANDAZOLE GEL 0.75% ....................68
VAQTA INJ 25/0.5ML .........................74
VARIVAX INJ ....................................74
VASCEPA CAP 1GM ...........................28
VELCADE INJ 3.5MG ..........................18
velivet pak .......................................57
equivalent) ......................................42
venlafaxine hcl cap sr 24hr 37.5 mg (base
equivalent) ......................................42
equivalent) ......................................42
venlafaxine hcl tab 100 mg ................43
venlafaxine hcl tab 25 mg ..................42
venlafaxine hcl tab 37.5 mg ...............42
verapamil hcl cap sr 24hr 100 mg .......31
VERAPAMIL HCL CAP SR 24HR 360 MG 31
verapamil hcl iv soln 2.5 mg/ml ..........31
verapamil hcl tab 120 mg ..................31
verapamil hcl tab 40 mg ....................31
verapamil hcl tab 80 mg ....................31
verapamil hcl tab cr 120 mg ...............31
VESICARE TAB 10MG ........................67
VESICARE TAB 5MG ..........................67
vestura tab 3-0.02mg........................57
VFEND SUS 40MG/ML ........................11
VIBRAMYCIN SYP 50MG/5ML ..............10
VICTOZA INJ 18MG/3ML ....................53
VICTRELIS CAP 200MG ......................15
VIDAZA INJ 100MG ...........................17
VIDEX SOL 2GM ...............................13
VIGAMOX DRO 0.5% ........................ 78

VIIBRYD KIT .................................... 43
VIIBRYD TAB 10MG .......................... 43
VIIBRYD TAB 20MG .......................... 43
VIIBRYD TAB 40MG .......................... 43
VIMPAT INJ 200MG/20 ...................... 39
VIMPAT SOL 10MG/ML ...................... 39
VIMPAT TAB 100MG.......................... 39
VIMPAT TAB 150MG.......................... 39
VIMPAT TAB 200MG.......................... 39
VIMPAT TAB 50MG ........................... 39
vinblastine sulfate for inj 10 mg ......... 17
vincasar pfs inj 1mg/ml .................... 17
vincristine sulfate iv soln 1 mg/ml ...... 17
vinorelbine tartrate inj 50 mg/5ml (10
mg/ml) ........................................... 17
viorele tab ....................................... 57
VIRACEPT TAB 250MG ...................... 13
VIRACEPT TAB 625MG ...................... 13
VIRAMUNE SUS 50MG/5ML ................ 13
VIRAMUNE XR TAB 100MG ................ 13
VIRAMUNE XR TAB 400MG ................ 13
VIREAD POW 40MG/GM .................... 13
VIREAD TAB 150MG ......................... 13
VIREAD TAB 200MG ......................... 13
VIREAD TAB 250MG ......................... 13
VIREAD TAB 300MG ......................... 13
VOLTAREN GEL 1% .......................... 87
VORICONAZOLE INJ 200MG............... 11
voriconazole tab 200 mg ................... 11
voriconazole tab 50 mg ..................... 11
VOTRIENT TAB 200MG ...................... 20
VPRIV INJ 400UNIT .......................... 58
W
warfarin sodium tab 1 mg ................. 69
warfarin sodium tab 10 mg................ 69
warfarin sodium tab 2.5 mg............... 69
warfarin sodium tab 7.5 mg............... 69
WELCHOL PAK 3.75GM ..................... 28
WELCHOL TAB 625MG ...................... 28
X
XALKORI CAP 200MG ........................ 20
XALKORI CAP 250MG ........................ 20
124
XARELTO TAB 10MG ..........................69

XARELTO TAB 15MG ..........................69
XARELTO TAB 20MG ..........................69
XENAZINE TAB 12.5MG .....................50
XENAZINE TAB 25MG ........................50
XIFAXAN TAB 550MG ........................66
XOLAIR SOL 150MG ..........................81
XOPENEX HFA AER ............................81
XTANDI CAP 40MG ............................18
XYREM SOL 500MG/ML ......................51
Y
YF-VAX INJ ......................................74
Z
zafirlukast tab 10 mg ........................81
zafirlukast tab 20 mg ........................81
zaleplon cap 10 mg ...........................49
zaleplon cap 5 mg .............................49
ZAVESCA CAP 100MG ........................58
zazole cre 0.4% ................................68
ZAZOLE CRE 0.8% ............................68
ZELBORAF TAB 240MG ......................20
ZEMAIRA INJ 1000MG .......................81
ZEMPLAR CAP 1MCG .........................77
ZEMPLAR CAP 2MCG .........................77
ZEMPLAR CAP 4MCG .........................77
ZEMPLAR INJ 2MCG/ML .....................77
ZEMPLAR INJ 5MCG/ML .....................77
zenatane cap 10mg ...........................83
zenatane cap 20mg ...........................83
zenatane cap 40mg ...........................83
ZENPEP CAP 10000UNT .....................66
ZENPEP CAP 15000UNT .....................66
ZENPEP CAP 20000UNT .....................66
ZENPEP CAP 25000UNT .....................66
ZENPEP CAP 3000UNIT ......................66
ZENPEP CAP 5000UNIT ......................66
ZETIA TAB 10MG ..............................28
ZIAGEN SOL 20MG/ML ......................13
zidovudine cap 100 mg ..................... 13

zidovudine syrup 10 mg/ml ............... 13
zidovudine tab 300 mg ..................... 13
ziprasidone hcl cap 20 mg ................. 48
ZMAX SUS 2GM ............................... 10
zoledronic acid inj conc for iv infusion 4
mg/5ml ........................................... 55
ZOLINZA CAP 100MG........................ 18
zolmitriptan orally disintegrating tab 2.5
mg ................................................. 50
zolmitriptan orally disintegrating tab 5 mg
...................................................... 50
zolmitriptan tab 2.5 mg .................... 50
zolmitriptan tab 5 mg ....................... 50
zolpidem tartrate tab 10 mg .............. 49
zolpidem tartrate tab 5 mg ................ 49
ZOMETA INJ 4MG/100 ...................... 55
ZONALON CRE 5% ........................... 84
zonisamide cap 100 mg .................... 39
zonisamide cap 25 mg ...................... 39
zonisamide cap 50 mg ...................... 39
ZORTRESS TAB 0.25MG .................... 73
ZORTRESS TAB 0.5MG ...................... 73
ZORTRESS TAB 0.75MG .................... 73
ZOSTAVAX INJ ................................. 74
zovia 1/35e tab ................................ 57
zovia 1/50e tab ................................ 57
ZOVIRAX CRE 5% ............................ 85
ZYLET SUS 0.5-0.3% ........................ 77
ZYMAXID SOL 0.5% ......................... 78
ZYTIGA TAB 250MG .......................... 18
ZYVOX SOL 2MG/ML ......................... 16
ZYVOX SUS 100MG/5M ..................... 16
ZYVOX TAB 600MG ........................... 16
125
H6178_OHMSNP660
www.caresource.com 2012 CareSource. All Rights Reserved.

Caresourceformulary PDF

Transféré par

Informations du document

Titre original

Copyright

Formats disponibles

Partager ce document

Partager ou intégrer le document

Options de partage

Avez-vous trouvé ce document utile ?

Ce contenu est-il inapproprié ?

Droits d'auteur :

Formats disponibles

Caresourceformulary PDF

Transféré par

Droits d'auteur :

Formats disponibles

CareSource Advantage (HMO SNP)

Ohio Comprehensive Formulary

CareSource Advantage (HMO SNP)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE

CMS File and Use: 9/29/2012

HPMS Approved Formulary File Submission ID# 00013034, Version 14

What is the CareSource Advantage Formulary?

Can the Formulary change?

How do I use the Formulary?

What are generic drugs?

Are there any restrictions on my coverage?

Prior Authorization: CareSource Advantage requires you or your

Quantity Limits: For certain drugs, CareSource Advantage limits the

Step Therapy: In some cases, CareSource Advantage requires you to first

What if my drug is not on the Formulary?

You can ask CareSource Advantage to make an exception and cover

How do I request an exception to the CareSource Advantage

You can ask us to waive coverage restrictions or limits on your drug.

What do I do before I can talk to my doctor about changing my

For more information

CareSource Advantages Formulary

2013 COMPREHENSIVE FORMULARY ABBREVIATIONS

Cardiovascular Agents Drugs to treat high blood pressure

Central Nervous System Drugs to treat seizures

VIMPAT TAB 50MG

(QL) 180 tabs/30days

Endocrine and Metabolic (Antidiabetic) Drugs to treat high blood sugar

PRANDIN TAB 2MG

(QL) 240 tabs/30days

Drug Tier Requirements/Limits

QL (60 tabs / 30 days)

QL (240 tabs / 30 days)

Drug Tier Requirements/Limits

QL (150 tabs / 30 days)

astramorph inj 1mg/2ml

fentanyl citrate lollipop 400 mcg

fentanyl citrate lollipop 600 mcg

fentanyl citrate lollipop 800 mcg

fentanyl citrate lollipop 1200 mcg

fentanyl citrate lollipop 1600 mcg

NARCOTIC ANALGESICS, CII

Drug Tier Requirements/Limits

LAZANDA SPR 400MCG

methadone hcl conc 10 mg/ml

QL (60 caps / 30 days)

QL (240 tabs / 30 days)

QL (180 tabs / 30 days)

QL (240 tabs / 30 days)

sodium tab delayed release 50

sodium tab delayed release 75

sodium tab sr 24hr 100 mg

Drug Tier Requirements/Limits

Drug Tier Requirements/Limits

Drug Tier Requirements/Limits

Drug Tier Requirements/Limits

Drug Tier Requirements/Limits

Drug Tier Requirements/Limits

Drug Tier Requirements/Limits

ribapak mis 600/day

Drug Tier Requirements/Limits

Drug Tier Requirements/Limits

ANTIMITOTIC, VINCA ALKALOIDS

BIOLOGIC RESPONSE MODIFIERS