Formulary / Formulario
2016
Member Services / Departamento de Servicios
para Miembros (888) 665-1328, TTY/TDD 711
7 days a week, 8 a.m. - 8 p.m. local time.
Los 7 días de la semana, de 8:00 a.m. a
8:00 p.m., hora local.
Y0050_16_1085_0001_LRCompRx
Y0050_16_1085_0001_LRCompRxSp
Accepted
1
Accepted
HPMS Approved Formulary File
Submission 00016109, Version 16
2785875MED1116
Molina Medicare Options Plus HMO SNP/Molina
Medicare Options HMO/Molina Medicare Choice
HMO SNP
2016 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
HPMS Approved Formulary File Submission 00016109, Version 16
This formulary was updated on 11/2016. For more recent information or other questions,
please contact us, Molina Medicare Options Plus/Molina Medicare Options/Molina
Medicare Choice Member Services, at (888) 665-1328 or, for TTY users, 711, 7 days a
week, 8 a.m. – 8 p.m., local time, or visit www.molinahealthcare.com/medicare.
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.
When this drug list (formulary) refers to “we,” “us”, or “our,” it means Molina
Healthcare. When it refers to “plan” or “our plan,” it means Molina Medicare Options
Plus/Molina Medicare Options/Molina Medicare Choice.
This document includes a list of the drugs (formulary) for our plan which is current as of
11/2016. For an updated formulary, please contact us. Our contact information, along
with the date we last updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit.
Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on
January 1, 2017, and from time to time during the year.
i
What is the Molina Medicare Options Plus/Molina Medicare
Options/Molina Medicare Choice Comprehensive Formulary?
A formulary is a list of covered drugs selected by Molina Medicare Options Plus/Molina
Medicare Options/Molina Medicare Choice 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. Molina Medicare Options Plus/Molina Medicare
Options/Molina Medicare Choice will generally cover the drugs listed in our formulary as
long as the drug is medically necessary, the prescription is filled at a Molina Medicare
Options Plus/Molina Medicare Options/Molina Medicare Choice 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 (drug list) change?
Generally, if you are taking a drug on our 2016 formulary that was covered at the
beginning of the year, we will not discontinue or reduce coverage of the drug during the
2016 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
cost-sharing 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 drug’s 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, 2016. To get updated information about the drugs covered by Molina Medicare
Options Plus/Molina Medicare Options/Molina Medicare Choice, please contact us. Our
contact information appears on the front and back cover pages.
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
ii
example, drugs used to treat a heart condition are listed under the category,
“cardiovascular drugs”. If you know what your drug is used for, look for the category
name in the list that begins below. 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 95. 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?
Molina Medicare Options Plus/Molina Medicare Options/Molina Medicare Choice
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: Molina Medicare Options Plus/Molina Medicare
Options/Molina Medicare Choice requires you or your physician to get prior
authorization for certain drugs. This means that you will need to get approval
from Molina Medicare Options Plus/Molina Medicare Options/Molina Medicare
Choice before you fill your prescriptions. If you don’t get approval, Molina
Medicare Options Plus/Molina Medicare Options/Molina Medicare Choice may
not cover the drug.
•
Quantity Limits: For certain drugs, Molina Medicare Options Plus/Molina
Medicare Options/Molina Medicare Choice limits the amount of the drug that
Molina Medicare Options Plus/Molina Medicare Options/ Molina Medicare
Choice will cover. For example, Molina Medicare Options Plus/Molina Medicare
Options/Molina Medicare Choice provides 30 tablets per 30 days per prescription
for Crestor. This may be in addition to a standard one-month or three-month
supply.
•
Step Therapy: In some cases, Molina Medicare Options Plus/Molina Medicare
Options/Molina Medicare Choice 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, Molina
Medicare Options Plus/Molina Medicare Options/ Molina Medicare Choice may
iii
not cover Drug B unless you try Drug A first. If Drug A does not work for you,
Molina Medicare Options Plus/Molina Medicare Options/ Molina Medicare
Choice 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. We have posted on
line documents that explain our prior authorization and step therapy restrictions. You
may also ask us to send you a copy. Our contact information, along with the date we last
updated the formulary, appears on the front and back cover pages.
You can ask Molina Medicare Options Plus/Molina Medicare Options/ Molina Medicare
Choice to make an exception to these restrictions or limits or for a list of other, similar
drugs that may treat your health condition. See the section, “How do I request an
exception to the Molina Medicare Options Plus/Molina Medicare Options/Molina
Medicare Choice 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 (list of covered drugs), you should first
contact Member Services and ask if your drug is covered.
If you learn that Molina Medicare Options Plus/Molina Medicare Options/ Molina
Medicare Choice does not cover your drug, you have two options:
•
You can ask Member Services for a list of similar drugs that are covered by
Molina Medicare Options Plus/Molina Medicare Options/Molina Medicare
Choice. When you receive the list, show it to your doctor and ask him or her to
prescribe a similar drug that is covered by Molina Medicare Options Plus/Molina
Medicare Options/ Molina Medicare Choice.
•
You can ask Molina Medicare Options Plus/Molina Medicare Options/Molina
Medicare Choice to make an exception and cover your drug. See below for
information about how to request an exception.
iv
How do I request an exception to the Molina Medicare Options
Plus/Molina Medicare Options/ Molina Medicare Choice’s Formulary?
You can ask Molina Medicare Options Plus/Molina Medicare Options/ Molina Medicare
Choice 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 a drug even if it is not on our formulary. If approved, this
drug will be covered at a pre-determined cost-sharing level, and you would not be
able to ask us to provide the drug at a lower cost-sharing level.
•
You can ask us to cover a formulary drug at a lower cost-sharing level if this drug
is not on the specialty tier. If approved this would lower the amount you must
pay for your drug.
•
You can ask us to waive coverage restrictions or limits on your drug. For
example, for certain drugs, Molina Medicare Options Plus/Molina Medicare
Options/ Molina Medicare Choice 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 a greater amount.
Generally, Molina Medicare Options Plus/Molina Medicare Options/ Molina Medicare
Choice will only approve your request for an exception if the alternative drugs included
on the plan’s formulary, the lower cost-sharing 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 request a formulary tiering or utilization
restriction exception you should submit a statement from your prescriber or
physician supporting your request. Generally, we must make our decision within 72
hours of getting your prescriber’s 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 a supporting statement from your
doctor or other prescriber.
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
v
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 31-day supply (unless you have a prescription written
for fewer days) when you go to a network pharmacy. After your first 31-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 a 91-day transition supply, consistent with
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 31day emergency supply of that drug (unless you have a prescription for fewer days) while
you pursue a formulary exception.
Exceptions are available in situations where you experience a change in the level of care
you are receiving that also requires you to transition from one facility or treatment center
to another. In such circumstances, you would be eligible for a temporary, one-time fill
exception even if you are outside of the first 90 days as a member of the plan.
For more information
For more detailed information about your Molina Medicare Options Plus/Molina
Medicare Options/Molina Medicare Choice prescription drug coverage, please review
your Evidence of Coverage and other plan materials.
If you have questions about Molina Medicare Options Plus/Molina Medicare Options/
Molina Medicare Choice, please contact us. Our contact information, along with the date
we last updated the formulary, appears on the front and back cover pages.
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
users should call 1-877-486-2048. Or, visit http://www.medicare.gov.
Molina Medicare Options Plus/Molina Medicare Options/ Molina
Medicare Choice’s Formulary
The comprehensive formulary below provides coverage information about all the drugs
covered by Molina Medicare Options Plus/Molina Medicare Options/ Molina Medicare
Choice. If you have trouble finding your drug in the list, turn to the Index that begins on
page 95.
vi
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g.,
CLEOCIN EXAMPLE) and generic drugs are listed in lower-case italics (e.g.,
clindamycin).
The information in the Requirements/Limits column tells you if Molina Medicare
Options Plus/Molina Medicare Options/Molina Medicare Choice has any special
requirements for coverage of your drug.
You can find information on what the symbols and abbreviations on this table mean by
going to the bottom of each page or the beginning of this table.
B/D stands for this drug may be covered under Medicare Part B or D depending upon the
circumstances
LA stands for Limited Access Drug - This prescription may be available only at certain
pharmacies. For more information consult your Pharmacy Directory or call Member
Services at (888) 665-1328, 7 days a week, 8 a.m. – 8 p.m., local time. TTY users should
call 711.
NM stands for Non Mail Order Drug
PA stands for Prior Authorization
QL stands for Quality Limits - Quantity limits for certain drugs are indicated below on
the drug table under the Requirements/Limits column.
STC stands for Step Therapy Criteria
Y0050_16_1085_0001_LRCompRx
Accepted
vii
Molina Medicare Options Plus HMO SNP/ Molina
Medicare Options HMO/ Molina Medicare Choice
HMO SNP
Formulario 2016
(Lista de los medicamentos cubiertos)
FAVOR DE LEER: ESTE DOCUMENTO CONTIENE INFORMACIÓN
ACERCA DE LOS MEDICAMENTOS QUE CUBRIMOS EN ESTE PLAN
HPMS Approved Formulary File Submission 00016109, Version 16
Este formulario se actualizó en 11/2016. Para obtener más información o si tiene otras
preguntas, por favor comuníquese con nosotros al Departamento de Servicios para
Miembros de, Molina Medicare Options Plus/Molina Medicare Options/Molina Medicare
Choice, al (888) 665-1328, o los usuarios del servicio TTY llamen al 711, los 7 días de la
semana de 8:00 a. m. a 8:00 p. m., hora local, o visite nuestra página web
www.molinahealthcare.com/medicare.
Aviso para miembros actuales: este formulario ha cambiado desde el año pasado. Por
favor, repase este documento para asegurarse que aún contiene los medicamentos que
usted toma.
Cuando esta lista de medicamentos (formulario) se refiere a "nosotros" o "nuestro",
significa Molina Healthcare. Cuando se refiere al “plan” o “nuestro plan”, significa
Molina Medicare Options Plus/Molina Medicare Options/Molina Medicare Choice.
Este documento incluye una lista de los medicamentos (formulario) de nuestro plan, el
cual está vigente a partir del 11/2016. Comuníquese con nosotros para recibir un
formulario actualizado. Nuestra información de contacto y la última fecha de
actualización del formulario aparecen en las páginas de la portada y contraportada.
Generalmente, debe usar farmacias que participan en la red para usar su beneficio de
medicamentos recetados. Los beneficios, formulario, red de farmacias o copagos /
coseguro pueden cambiar el 1.o de enero del 2017 y de vez en cuando durante el año.
viii
¿Qué es el formulario detallado de Molina Medicare Options
Plus/Molina Medicare Options/Molina Medicare Choice?
Un formulario es una lista de los medicamentos cubiertos y seleccionados por Molina
Medicare Options Plus/Molina Medicare Options/Molina Medicare Choice conforme al
consejo de un grupo de proveedores médicos, los cuales representan las terapias de
medicamentos recetados que se determinan necesarios como parte de un programa de
tratamiento de calidad. Generalmente, Molina Medicare Options Plus/Molina Medicare
Options/Molina Medicare Choice cubrirá los medicamentos incluidos en el formulario
siempre y cuando sean médicamente necesarios, las recetas médicas se surtan en una
farmacia que participa en la red de Molina Medicare Options Plus/Molina Medicare
Options/Molina Medicare Choice y se respeten las otras reglas del plan. Para más
información sobre cómo surtir sus medicamentos recetados, por favor consulte su
Evidencia de cobertura.
¿El formulario (lista de medicamentos) podría cambiar?
Normalmente, si usted está tomando un medicamento que aparece en el formulario del
2016 que estaba cubierto a principios del año, no discontinuaremos ni reduciremos la
cobertura del medicamento durante la cobertura del año 2016, salvo cuando un
medicamento genérico y menos costoso está disponible o cuando se publica nueva
información adversa acerca de la seguridad o eficacia del medicamento. Otros tipos de
cambios al formulario, tal como quitar un medicamento de nuestro formulario, no
afectarán a los miembros que están actualmente tomando el medicamento. Permanecerá
disponible al mismo costo compartido para aquellos miembros que lo están tomando
durante el resto del año de cobertura. Creemos que es importante que usted continúe
teniendo acceso a los medicamentos del formulario durante el resto del año de cobertura
que estaban disponibles cuando usted eligió nuestro plan, salvo en los casos cuando usted
puede ahorrar dinero adicional o nosotros podemos garantizar su seguridad.
Si nosotros quitamos medicamentos de nuestro formulario o añadimos una autorización
previa, límites de cantidades o restricciones de terapia escalonada a un medicamento, o si
movemos un medicamento a una categoría de costo compartido más alto, nosotros
debemos notificarle a los miembros afectados acerca del cambio por lo menos 60 días
antes de que el cambio entre en vigor; o en el momento en que el miembro solicite surtir
su medicamento de nuevo y en dicho momento, el miembro recibirá un suministro del
medicamento para 60 días. Si la Administración de Alimentos y Medicamentos
determina que un medicamento en nuestro formulario es inseguro o el fabricante del
medicamento quita el medicamento del mercado, nosotros inmediatamente quitaremos el
medicamento de nuestro formulario y proporcionaremos un aviso a nuestros miembros
que usan el medicamento. El formulario adjunto está actualizado a partir del 1.o de
noviembre del 2016. Comuníquese con nosotros para obtener información actualizada
acerca de los medicamentos cubiertos por Molina Medicare Options Plus/Molina
Medicare Options/Molina Medicare Choice. Nuestra información de contacto aparece en
las páginas de la portada y la contraportada.
ix
¿Cómo utilizo el formulario?
Puede encontrar su medicamento en el formulario en dos formas:
Condición médica
El formulario empieza en la página 1. Los medicamentos en este formulario están
agrupados en categorías según el tipo de condición médica que el medicamento trata.
Por ejemplo, los medicamentos utilizados para el tratamiento de una condición del
corazón se enumeran bajo la categoría, "medicamentos cardiovasculares". Si usted
conoce el propósito de su medicamento, vea el nombre de la categoría en la lista que
empieza más adelante. Después vea bajo el nombre de la categoría de su
medicamento.
Lista alfabética
Si no está seguro de la categoría, busque su medicamento usando el índice que
empieza en la página 95. El índice le proporciona una lista alfabética de todos los
medicamentos incluidos en este documento. Se incluyen en el índice ambos
medicamentos genéricos y de marca registrada. Consulte el índice y encuentre su
medicamento. Al lado del nombre de su medicamento verá el número de la página
donde encontrará información acerca de la cobertura. Pase a la página enumerada en
el índice y encuentre el nombre de su medicamento en la primera columna de la lista.
¿Qué son los medicamentos genéricos?
Molina Medicare Options Plus/Molina Medicare Options/Molina Medicare Choice
cubre ambos medicamentos genéricos y de marca registrada. Un medicamento
genérico está aprobado por la FDA por tener el mismo ingrediente activo como el
medicamento de marca registrada. Usualmente, los medicamentos genéricos cuestan
menos que los medicamentos de marca registrada.
¿Existe alguna restricción en mi cobertura?
Algunos medicamentos cubiertos pueden tener requerimientos adicionales o límites en
cobertura. Estos requerimientos y límites pueden incluir:
•
Autorización previa: Molina Medicare Options Plus/Molina Medicare
Options/Molina Medicare Choice le requiere a usted y a su médico que obtengan
una autorización previa para determinados medicamentos. Esto significa que
usted necesitará recibir aprobación de Molina Medicare Options Plus/Molina
Medicare Options/Molina Medicare Choice antes de surtir sus recetas médicas. Si
usted no recibe aprobación, es posible que Molina Medicare Options Plus/Molina
Medicare Options/Molina Medicare Choice no cubra su medicamento.
x
•
Límite de cantidades: Molina Medicare Options Plus/Molina Medicare
Options/Molina Medicare Choice impone un límite de cantidades para
determinados medicamentos que Molina Medicare Options Plus/Molina Medicare
Options/Molina Medicare Choice cubre. Por ejemplo, Molina Medicare Options
Plus/Molina Medicare Options/ Molina Medicare Choice proporciona 30 tabletas
para 30 días por cada receta médica de Crestor. Esto puede ser además de un
suministro estándar de un mes o tres meses.
•
Terapia escalonada: En algunos casos, Molina Medicare Options Plus/Molina
Medicare Options/Molina Medicare Choice requiere que primero pruebe
determinados medicamentos para el tratamiento de su condición médica antes de
cubrir otro medicamento para esa condición. Por ejemplo, si ambos Medicamento
A y Medicamento B se usan como tratamiento para su condición médica, es
posible que Molina Medicare Options Plus/Molina Medicare Options/Molina
Medicare Choice no cubra el Medicamento B a menos que primero intente el
Medicamento A. Si el Medicamento A no le ayuda, entonces Molina Medicare
Options Plus/Molina Medicare Options/ Molina Medicare Choice cubrirá el
Medicamento B.
Usted puede enterarse si su medicamento tiene cualquier requerimiento o límite adicional
repasando el formulario que empieza en la página 1. También puede obtener más
información acerca de las restricciones impuestas sobre determinados medicamentos
recetados si visita nuestra página web. Se han publicado documentos en línea que
explican nuestras restricciones de autorización previa y terapia escalonada. También
puede pedir que se le envíe una copia. Nuestra información de contacto y la última fecha
de actualización del formulario aparecen en las páginas de la portada y contraportada.
Puede pedirle a Molina Medicare Options Plus/Molina Medicare Options/ Molina
Medicare Choice que permita una excepción a estas restricciones o límites; o bien, puede
pedir una lista de otros medicamentos recetados comparables que pueden tratar su
condición médica. Consulte la sección, "¿Cómo solicito una excepción del formulario de
Molina Medicare Options Plus/Molina Medicare Options/ Molina Medicare Choice?” en
la página xii para información sobre cómo solicitar una excepción.
¿Qué ocurre si mi medicamento no está incluido en el formulario?
Si su medicamento no está incluido en el formulario (lista de medicamentos recetados
cubiertos), usted primero debe ponerse en contacto con el Departamento de Servicios
para Miembros para preguntar si su medicamento está cubierto.
Si se entera que Molina Medicare Options Plus/Molina Medicare Options/ Molina
Medicare Choice no cubre su medicamento, usted tendrá dos opciones:
xi
•
Puede pedir una lista de los medicamentos semejantes que están cubiertos por
Molina Medicare Options Plus/Molina Medicare Options/Molina Medicare
Choice al Departamento de Servicios para Miembros. Cuando usted reciba la
lista, enséñesela a su médico y pida que le recete un medicamento semejante que
esté cubierto por Molina Medicare Options Plus/Molina Medicare Options/
Molina Medicare Choice.
•
Usted puede pedirle a Molina Medicare Options Plus/Molina Medicare Options/
Molina Medicare Choice que permita una excepción y cubra su medicamento.
Consulte la información sobre cómo solicitar una excepción, a continuación.
¿Cómo solicito una excepción del formulario de Molina Medicare
Options Plus/Molina Medicare Options/ Molina Medicare Choice ?
Usted puede pedirle a Molina Medicare Options Plus/Molina Medicare Options/ Molina
Medicare Choice que haga una excepción a las reglas de cobertura. Existen varios tipos
de excepciones que usted puede solicitar.
•
Puede pedirnos que se cubra un medicamento aun si no está en nuestro
formulario. Si se aprueba, este medicamento se cubrirá a un nivel de costo
compartido predeterminado y no podrá pedirnos que se le proporcione el
medicamento a un nivel de costo compartido más bajo.
•
Puede pedirnos que se cubra un medicamento del formulario a un nivel de costo
compartido más bajo si este medicamento no se incluye en la categoría de
especialidad. Si se aprueba, se reducirá la cantidad que debe pagar por este
medicamento.
•
Puede pedirnos que no se apliquen las restricciones o límites de cobertura de su
medicamento. Por ejemplo, para determinados medicamentos, Molina Medicare
Options Plus/ Molina Medicare Options/Molina Medicare Choice impone un
límite de cantidades para determinados medicamentos que cubriremos. Si su
medicamento tiene un límite de cantidad, usted puede pedirnos que no se aplique
el límite y que se cubra una cantidad mayor.
Generalmente, Molina Medicare Options Plus/Molina Medicare Options/ Molina
Medicare Choice solamente aprobará su solicitud para una excepción si los
medicamentos alternativos incluidos en el formulario del plan, el medicamento con un
costo compartido más bajo o las restricciones adicionales de utilización no son igual de
eficaces para el tratamiento de su condición o si le causará efectos médicos adversos.
Usted debe comunicarse con nosotros para pedirnos una determinación inicial de
cobertura para una excepción de formulario, categoría o restricción en utilización.
Cuando solicita una excepción de formulario, categoría o restricción en utilización,
xii
usted debe presentar una declaración de su proveedor recetador o su médico para
apoyar su petición. Usualmente, debemos tomar nuestra decisión dentro de 72 horas de
haber recibido la declaración de apoyo de su proveedor recetador. Usted puede pedir una
excepción acelerada (rápida) si usted o su médico creen que su salud podría estar
gravemente perjudicada si espera hasta 72 horas por una decisión. Si su petición para
acelerar la decisión se autoriza, debemos darle la determinación a más tardar en 24 horas
después de recibir la declaración de apoyo de su médico u otro proveedor recetador.
¿Qué debo hacer antes de hablar con mi médico acerca de cambiar mi
medicamento o pedir una excepción?
Como un miembro nuevo o continuo en nuestro plan, es posible que esté tomando
medicamentos que no se incluyen en nuestro formulario. O bien, puede ser que esté
tomando un medicamento que está en nuestro formulario, pero que su capacidad para
obtenerlo esté limitada. Por ejemplo, es posible que necesite una autorización previa de
nosotros antes de surtir su receta médica. Debe hablar con su médico para decidir si debe
cambiarse a un medicamento apropiado que nosotros cubrimos o si debe pedir una
excepción de formulario para que cubramos el medicamento que usted toma. Mientras
habla con su médico para determinar el curso de acción adecuado para usted, es posible
que cubramos su medicamento en ciertos casos durante los primeros 90 días de ser
miembro con nuestro plan.
Para cada uno de sus medicamentos que no están incluidos en nuestro formulario, o si su
capacidad para obtener su medicamento está limitada, nosotros cubriremos un suministro
provisional de 31 días (a menos que tenga una receta médica escrita para menos días)
cuando usted usa una farmacia que participa en la red. Después de su primer suministro
de 31 días, nosotros no pagaremos por estos medicamentos, aun si ha sido un miembro
del plan durante menos de 90 días.
Si usted es un residente en un centro de cuidados a largo plazo, nosotros le permitiremos
surtir de nuevo su receta médica hasta que le hayamos proporcionado un suministro de
transición de 91 días, de acuerdo con el incremento de dispensación (a menos que usted
tenga una receta médica escrita para menos días). Cubriremos más de una renovación de
estos medicamentos durante los primeros 90 días de su membresía en nuestro plan. Si
usted necesita un medicamento que no está incluido en nuestro formulario o si su
capacidad para obtener su medicamento está limitada, pero ya han pasado los primeros 90
días de su membresía con el plan, nosotros cubriremos un suministro de emergencia de
31 días para ese medicamento (a menos que tenga una receta médica para menos días)
mientras que usted solicita una excepción del formulario.
Se considerarán excepciones en situaciones donde está pasando por un cambio en el nivel
de cuidado que usted recibe que también requiere que sea trasladado de un centro de
atención a otro. En dichas circunstancias, usted será elegible para una excepción
provisional una sola vez, aun si han pasado los primeros 90 días de su membresía con el
plan.
xiii
Para obtener más información
Para obtener más información detallada sobre su cobertura de medicamentos recetados de
Molina Medicare Options Plus/Molina Medicare Options/ Molina Medicare Choice, por
favor consulte su Evidencia de cobertura y otros materiales del plan.
Comuníquese con nosotros si tiene preguntas acerca de Molina Medicare Options
Plus/Molina Medicare Options/ Molina Medicare Choice. Nuestra información de
contacto y la última fecha de actualización del formulario aparecen en las páginas de la
portada y contraportada.
Si usted tiene preguntas generales sobre la cobertura de medicamentos recetados de
Medicare, por favor comuníquese con Medicare al 1-800-MEDICARE (1-800-633-4227),
las 24 horas al día, los 7 días de la semana. Los usuarios de TTY deben llamar al 1-877486-2048. O bien, visite http://www.medicare.gov.
Formulario de Molina Medicare Options Plus/Molina Medicare
Options/ Molina Medicare Choice
El formulario detallado a continuación proporciona información de cobertura acerca de
todos los medicamentos cubiertos por Molina Medicare Options Plus/Molina Medicare
Options/ Molina Medicare Choice. Si usted no puede encontrar su medicamento en la
lista, consulte el índice que comienza en la página 95.
La primera columna de la gráfica indica el nombre del medicamento. Los medicamentos
de marca registrada están escritos en mayúsculas (p. ej.: CLEOCIN) y los medicamentos
genéricos están escritos en cursivas minúsculas (p. ej.: clindamycin).
La información en la columna Requerimientos / Límites indica si Molina Medicare
Options Plus/Molina Medicare Options/ Molina Medicare Choice tiene algún
requerimiento especial para la cobertura de su medicamento.
Usted puede obtener información sobre el significado de los símbolos y abreviaciones de
esta tabla en la parte inferior de cada página o al principio de cada tabla.
B/D significa este medicamento puede ser cubierto bajo Medicare Parte B o Parte D,
dependiendo de las circunstancias.
LA significa medicamento con acceso limitado - Este medicamento puede estar
disponible solamente en ciertas farmacias. Para obtener más información, consulte su
Directorio de farmacias o comuníquese con el Departamento de Servicios para
Miembros al (888) 665-1328, los 7 días de la semana, de 8:00 a. m. a 8:00 p. m., hora
local. Los usuarios de TTY deben llamar al 711.
NM significa medicamento no disponible para servicio por correo
PA significa autorización previa
xiv
QL significa límites de cantidades - Los límites de cantidades para determinados
medicamentos se indican en la tabla de medicamentos a continuación, en la columna
Requerimientos / Límites.
STC significa criterio de terapia escalonada
Y0050_16_1085_0001_LRCompRxSp
Accepted
xv
MOLINA_CY16_5T_STND eff 11/01/2016
Drug Name
ANALGESICS
GOUT
Drug Tier Requirements/Limits
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
NSAIDS
1
1
2
3
2
3
3
celecoxib cap 50 mg
2
celecoxib cap 100 mg
2
celecoxib cap 200 mg
2
celecoxib cap 400 mg
2
diclofenac potassium tab 50 mg
2
diclofenac sodium tab delayed release 25 mg2
diclofenac sodium tab delayed release 50 mg2
diclofenac sodium tab delayed release 75 mg2
diclofenac sodium tab sr 24hr 100 mg
2
diflunisal tab 500 mg
2
etodolac cap 200 mg
2
etodolac cap 300 mg
2
etodolac tab 400 mg
2
etodolac tab 500 mg
2
etodolac tab sr 24hr 400 mg
2
etodolac tab sr 24hr 500 mg
2
etodolac tab sr 24hr 600 mg
2
flurbiprofen tab 50 mg
2
flurbiprofen tab 100 mg
2
ibuprofen susp 100 mg/5ml
2
ibuprofen tab 400 mg
1
ibuprofen tab 600 mg
1
ibuprofen tab 800 mg
1
ketoprofen cap 50 mg
2
ketoprofen cap 75 mg
2
MELOXICAM SUSP 7.5 MG/5ML
2
meloxicam tab 7.5 mg
1
meloxicam tab 15 mg
1
nabumetone tab 500 mg
2
nabumetone tab 750 mg
2
naproxen dr tab 375mg
1
naproxen dr tab 500mg
1
PA - Prior Authorization
available at mail-order
QL (120 tabs / 30 days)
ST
ST
QL
QL
QL
QL
(60
(60
(60
(60
caps
caps
caps
caps
/
/
/
/
30
30
30
30
days)
days)
days)
days)
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
1
Drug Name
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
piroxicam cap 10 mg
piroxicam cap 20 mg
sulindac tab 150 mg
sulindac tab 200 mg
OPIOID ANALGESICS
acetaminophen w/ codeine soln 120-12
mg/5ml
acetaminophen w/ codeine tab 300-15 mg
acetaminophen w/ codeine tab 300-30 mg
acetaminophen w/ codeine tab 300-60 mg
butorphanol tartrate inj 1 mg/ml
butorphanol tartrate inj 2 mg/ml
nalbuphine hcl inj 10 mg/ml
nalbuphine hcl inj 20 mg/ml
tramadol hcl tab 50 mg
tramadol-acetaminophen tab 37.5-325 mg
Drug Tier Requirements/Limits
1
1
2
1
1
1
2
2
1
1
2
QL (5000 mL / 30 days)
2
2
2
2
2
2
2
2
2
QL (400 tabs / 30 days)
QL (400 tabs / 30 days)
QL (400 tabs / 30 days)
DURAMORPH INJ 0.5MG/ML
2
DURAMORPH INJ 1MG/ML
2
endocet tab 5-325mg
2
endocet tab 7.5-325
2
endocet tab 10-325mg
2
fentanyl citrate lozenge on a handle 200 mcg5
B/D
B/D
QL (360 tabs / 30 days)
QL (360 tabs / 30 days)
QL (360 tabs / 30 days)
QL (120 lozenges / 30
days), PA
QL (120 lozenges / 30
days), PA
QL (120 lozenges / 30
days), PA
QL (120 lozenges / 30
days), PA
QL (120 lozenges / 30
days), PA
QL (120 lozenges / 30
days), PA
QL (10 patches / 30
days)
QL (10 patches / 30
days)
QL (10 patches / 30
days), PA
OPIOID ANALGESICS, CII
fentanyl citrate lozenge on a handle 400 mcg5
fentanyl citrate lozenge on a handle 600 mcg5
fentanyl citrate lozenge on a handle 800 mcg5
fentanyl citrate lozenge on a handle 1200
mcg
fentanyl citrate lozenge on a handle 1600
mcg
fentanyl td patch 72hr 12 mcg/hr
5
fentanyl td patch 72hr 25 mcg/hr
2
fentanyl td patch 72hr 50 mcg/hr
2
PA - Prior Authorization
available at mail-order
5
2
QL (240 tabs / 30 days)
QL (240 tabs / 30 days)
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
2
Drug Name
fentanyl td patch 72hr 75 mcg/hr
fentanyl td patch 72hr 100 mcg/hr
FENTORA TAB 100MCG
FENTORA TAB 200MCG
FENTORA TAB 400MCG
FENTORA TAB 600MCG
FENTORA TAB 800MCG
Drug Tier Requirements/Limits
2
QL (10 patches / 30
days), PA
2
QL (10 patches / 30
days), PA
5
QL (120 tabs / 30 days),
PA
5
QL (120 tabs / 30 days),
PA
5
QL (120 tabs / 30 days),
PA
5
QL (120 tabs / 30 days),
PA
5
QL (120 tabs / 30 days),
PA
2
QL (5400 mL / 30 days)
hydrocodone-acetaminophen soln 7.5-325
mg/15ml
hydrocodone-acetaminophen tab 5-325 mg 2
hydrocodone-acetaminophen tab 7.5-325 mg2
hydrocodone-acetaminophen tab 10-325 mg 2
hydrocodone-ibuprofen tab 7.5-200 mg
2
hydromorphone hcl liqd 1 mg/ml
2
hydromorphone hcl preservative free (pf) inj 2
10 mg/ml
hydromorphone hcl tab 2 mg
2
hydromorphone hcl tab 4 mg
2
hydromorphone hcl tab 8 mg
2
methadone con 10mg/ml
2
methadone hcl soln 5 mg/5ml
2
methadone hcl soln 10 mg/5ml
2
methadone hcl tab 5 mg
2
methadone hcl tab 10 mg
2
MORPHINE SUL INJ 2MG/ML
2
MORPHINE SUL INJ 4MG/ML
2
MORPHINE SUL INJ 8MG/ML
2
morphine sulfate beads cap sr 24hr 30 mg 2
morphine sulfate beads cap sr 24hr 45 mg 2
morphine sulfate beads cap sr 24hr 60 mg 2
morphine sulfate beads cap sr 24hr 75 mg 2
morphine sulfate beads cap sr 24hr 90 mg 2
morphine sulfate beads cap sr 24hr 120 mg 2
morphine sulfate cap sr 24hr 10 mg
2
morphine sulfate cap sr 24hr 20 mg
2
morphine sulfate cap sr 24hr 30 mg
2
morphine sulfate cap sr 24hr 50 mg
2
morphine sulfate cap sr 24hr 60 mg
2
morphine sulfate cap sr 24hr 80 mg
5
PA - Prior Authorization
available at mail-order
QL
QL
QL
QL
(360
(360
(360
(150
tabs
tabs
tabs
tabs
/
/
/
/
30
30
30
30
days)
days)
days)
days)
B/D
QL (270 tabs / 30 days)
QL (270 tabs / 30 days)
QL (270 tabs / 30 days)
QL (120 mL / 30 days)
QL (600 mL / 30 days)
QL (600 mL / 30 days)
QL (240 tabs / 30 days)
QL (240 tabs / 30 days)
B/D
B/D
B/D
QL (60 caps / 30 days)
QL (60 caps / 30 days)
QL (60 caps / 30 days)
QL (60 caps / 30 days)
QL (60 caps / 30 days)
QL (60 caps / 30 days)
QL (60 caps / 30 days)
QL (60 caps / 30 days)
QL (60 caps / 30 days)
QL (60 caps / 30 days)
QL (60 caps / 30 days)
QL (60 caps / 30 days)
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
3
Drug Name
Drug Tier Requirements/Limits
morphine sulfate cap sr 24hr 100 mg
5
QL (60 caps / 30 days)
morphine sulfate inj pf 0.5 mg/ml
2
B/D
morphine sulfate inj pf 1 mg/ml
2
B/D
MORPHINE SULFATE IV SOLN 1 MG/ML
2
B/D
morphine sulfate iv soln pf 4 mg/ml
2
B/D
morphine sulfate iv soln pf 8 mg/ml
2
B/D
MORPHINE SULFATE IV SOLN PF 10 MG/ML 2
B/D
MORPHINE SULFATE IV SOLN PF 15 MG/ML 2
B/D
MORPHINE SULFATE ORAL SOLN 10 MG/5ML 2
MORPHINE SULFATE ORAL SOLN 20 MG/5ML 2
MORPHINE SULFATE ORAL SOLN 100 MG/5ML2
(20 MG/ML)
MORPHINE SULFATE TAB 15 MG
2
QL (180 tabs / 30 days)
MORPHINE SULFATE TAB 30 MG
2
QL (180 tabs / 30 days)
morphine sulfate tab cr 15 mg
2
QL (90 tabs / 30 days)
morphine sulfate tab cr 30 mg
2
QL (90 tabs / 30 days)
morphine sulfate tab cr 60 mg
2
QL (90 tabs / 30 days)
morphine sulfate tab cr 100 mg
2
QL (90 tabs / 30 days)
morphine sulfate tab cr 200 mg
2
QL (60 tabs / 30 days)
oxycodone hcl cap 5 mg
2
QL (180 caps / 30 days)
oxycodone hcl conc 100 mg/5ml (20 mg/ml) 2
OXYCODONE HCL SOLN 5 MG/5ML
2
oxycodone hcl tab 5 mg
2
QL (180 tabs / 30 days)
oxycodone hcl tab 10 mg
2
QL (180 tabs / 30 days)
oxycodone hcl tab 15 mg
2
QL (180 tabs / 30 days)
oxycodone hcl tab 20 mg
2
QL (180 tabs / 30 days)
oxycodone hcl tab 30 mg
2
QL (180 tabs / 30 days)
oxycodone w/ acetaminophen soln 5-325
2
QL (1800 mL / 30 days)
mg/5ml
oxycodone w/ acetaminophen tab 2.5-325 2
QL (360 tabs / 30 days)
mg
oxycodone w/ acetaminophen tab 5-325 mg 2
QL (360 tabs / 30 days)
oxycodone w/ acetaminophen tab 7.5-325 2
QL (360 tabs / 30 days)
mg
oxycodone w/ acetaminophen tab 10-325 mg2
QL (360 tabs / 30 days)
ANESTHETICS
LOCAL ANESTHETICS
lidocaine
lidocaine
lidocaine
lidocaine
lidocaine
0.5%
lidocaine
1%
hcl
hcl
hcl
hcl
hcl
local
local
local
local
local
inj 0.5%
inj 1%
inj 1.5%
inj 2%
preservative free (pf) inj
2
2
2
2
2
B/D
B/D
B/D
B/D
B/D
hcl local preservative free (pf) inj
2
B/D
ANTI-INFECTIVES
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
4
Drug Name
ANTI-BACTERIALS - MISCELLANEOUS
Drug Tier Requirements/Limits
amikacin sulfate inj 1 gm/4ml (250 mg/ml) 2
amikacin sulfate inj 500 mg/2ml (250 mg/ml)2
gentam/nacl inj 0.9mg/ml
2
gentam/nacl inj 1.4mg/ml
2
gentamicin in saline inj 0.8 mg/ml
2
gentamicin in saline inj 1 mg/ml
2
gentamicin in saline inj 1.2 mg/ml
2
gentamicin in saline inj 1.6 mg/ml
2
gentamicin in saline inj 2 mg/ml
2
gentamicin sulfate inj 10 mg/ml
2
gentamicin sulfate inj 40 mg/ml
2
gentamicin sulfate iv soln 10 mg/ml
2
neomycin sulfate tab 500 mg
2
paromomycin sulfate cap 250 mg
2
streptomycin sulfate for inj 1 gm
2
sulfadiazine tab 500mg
4
tobramycin nebu soln 300 mg/5ml
5
tobramycin sulfate for inj 1.2 gm
2
tobramycin sulfate inj 1.2 gm/30ml (40
2
mg/ml) (base equiv)
tobramycin sulfate inj 2 gm/50ml (40 mg/ml)2
(base equiv)
tobramycin sulfate inj 10 mg/ml (base
2
equivalent)
tobramycin sulfate inj 80 mg/2ml (40 mg/ml)2
(base equiv)
B/D, NM
ANTI-INFECTIVES - MISCELLANEOUS
ALBENZA TAB 200MG
4
ALINIA SUS 100/5ML
4
ALINIA TAB 500MG
4
atovaquone susp 750 mg/5ml
5
AZACTAM/DEX INJ 1GM
4
AZACTAM/DEX INJ 2GM
5
aztreonam for inj 1 gm
2
aztreonam for inj 2 gm
2
BILTRICIDE TAB 600MG
3
CAYSTON INH 75MG
5
clindamycin hcl cap 75 mg
1
clindamycin hcl cap 150 mg
1
clindamycin hcl cap 300 mg
1
clindamycin palmitate hcl for soln 75 mg/5ml2
(base equiv)
clindamycin phosphate in d5w iv soln 300
2
mg/50ml
PA - Prior Authorization
available at mail-order
NM, LA, PA
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
5
Drug Name
Drug Tier Requirements/Limits
clindamycin phosphate in d5w iv soln 600
2
mg/50ml
clindamycin phosphate in d5w iv soln 900
2
mg/50ml
clindamycin phosphate inj 9 gm/60ml
2
clindamycin phosphate inj 300 mg/2ml
2
clindamycin phosphate inj 600 mg/4ml
2
clindamycin phosphate inj 900 mg/6ml
2
clindamycin phosphate iv soln 300 mg/2ml 2
clindamycin phosphate iv soln 600 mg/4ml 2
clindamycin phosphate iv soln 900 mg/6ml 2
colistimethate sodium for inj 150 mg
2
CUBICIN SOL 500MG
5
dapsone tab 25 mg
2
dapsone tab 100 mg
2
daptomycin for iv soln 500 mg
5
DARAPRIM TAB 25MG
4
emverm chw 100mg
4
imipenem-cilastatin intravenous for soln 250 2
mg
imipenem-cilastatin intravenous for soln 500 2
mg
INVANZ INJ 1GM
4
ivermectin tab 3 mg
2
LINEZOLID FOR SUSP 100 MG/5ML
5
LINEZOLID IN SODIUM CHLORIDE IV SOLN 5
600 MG/300ML-0.9%
linezolid iv soln 600 mg/300ml (2 mg/ml)
5
LINEZOLID TAB 600 MG
5
meropenem iv for soln 1 gm
2
meropenem iv for soln 500 mg
2
methenamine hippurate tab 1 gm
2
metronidazole in nacl 0.79% iv soln 500
2
mg/100ml
metronidazole tab 250 mg
1
metronidazole tab 500 mg
1
NEBUPENT INH 300MG
4
B/D
nitrofurantoin macrocrystalline cap 50 mg
4
PA; PA applies if 65 years
and older after a 90 day
supply in a calendar year
nitrofurantoin macrocrystalline cap 100 mg 4
PA; PA applies if 65 years
and older after a 90 day
supply in a calendar year
nitrofurantoin monohydrate macrocrystalline 4
PA; PA applies if 65 years
cap 100 mg
and older after a 90 day
supply in a calendar year
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
6
Drug Name
Drug Tier Requirements/Limits
PENTAM 300 INJ 300MG
4
SIVEXTRO INJ 200MG
5
SIVEXTRO TAB 200MG
5
sulfamethoxazole-trimethoprim iv soln
2
400-80 mg/5ml
sulfamethoxazole-trimethoprim susp 200-40 2
mg/5ml
sulfamethoxazole-trimethoprim tab 400-80 1
mg
sulfamethoxazole-trimethoprim tab 800-160 1
mg
SYNERCID INJ 500MG
5
trimethoprim tab 100 mg
1
TYGACIL INJ 50MG
5
vancomycin hcl cap 125 mg
5
vancomycin hcl cap 250 mg
5
vancomycin hcl for inj 10 gm
2
vancomycin hcl for inj 500 mg
2
vancomycin hcl for inj 1000 mg
2
vancomycin hcl for inj 5000 mg
2
VANCOMYCIN INJ 1 GM
4
VANCOMYCIN INJ 500MG
4
vancomycin inj 750mg
2
VANCOMYCIN INJ 750MG
4
ZYVOX TAB 600MG
5
ANTIFUNGALS
ABELCET INJ 5MG/ML
AMBISOME INJ 50MG
amphotericin b for inj 50 mg
CANCIDAS INJ 50MG
CANCIDAS INJ 70MG
fluconazole for susp 10 mg/ml
fluconazole for susp 40 mg/ml
fluconazole in dextrose inj 200 mg/100ml
fluconazole in dextrose inj 400 mg/200ml
fluconazole in nacl 0.9% inj 200 mg/100ml
fluconazole in nacl 0.9% inj 400 mg/200ml
fluconazole tab 50 mg
fluconazole tab 100 mg
fluconazole tab 150 mg
fluconazole tab 200 mg
fluconazole/ inj nacl 100
flucytosine cap 250 mg
flucytosine cap 500 mg
griseofulvin microsize susp 125 mg/5ml
PA - Prior Authorization
available at mail-order
5
5
2
5
5
2
2
2
2
2
2
2
2
2
2
2
5
5
2
B/D
B/D
B/D
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
7
Drug Name
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
NOXAFIL TAB 100MG
nystatin tab 500000 unit
terbinafine hcl tab 250 mg
voriconazole for inj 200 mg
voriconazole for susp 40 mg/ml
voriconazole tab 50 mg
voriconazole tab 200 mg
ANTIMALARIALS
atovaquone-proguanil hcl tab 62.5-25 mg
atovaquone-proguanil hcl tab 250-100 mg
chloroquine phosphate tab 250 mg
chloroquine phosphate tab 500 mg
COARTEM TAB 20-120MG
mefloquine hcl tab 250 mg
PRIMAQUINE TAB 26.3MG
quinine sulfate cap 324 mg
ANTIRETROVIRAL AGENTS
abacavir sulfate tab 300 mg (base equiv)
APTIVUS CAP 250MG
APTIVUS SOL
CRIXIVAN CAP 200MG
CRIXIVAN CAP 400MG
didanosine delayed release capsule 125 mg
didanosine delayed release capsule 200 mg
didanosine delayed release capsule 250 mg
didanosine delayed release capsule 400 mg
EDURANT TAB 25MG
EMTRIVA CAP 200MG
EMTRIVA SOL 10MG/ML
FUZEON INJ 90MG
INTELENCE TAB 25MG
INTELENCE TAB 100MG
INTELENCE TAB 200MG
INVIRASE CAP 200MG
INVIRASE TAB 500MG
ISENTRESS CHW 25MG
ISENTRESS CHW 100MG
PA - Prior Authorization
available at mail-order
Drug Tier Requirements/Limits
2
2
2
2
PA
2
PA
5
5
5
5
2
1
QL (90 tabs / 365 days)
2
5
5
5
2
2
2
2
4
2
3
2
2
5
5
4
4
2
2
2
2
5
3
3
5
4
5
5
5
5
3
5
PA
NM
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
8
Drug Name
ISENTRESS POW 100MG
ISENTRESS TAB 400MG
lamivudine oral soln 10 mg/ml
lamivudine tab 150 mg
lamivudine tab 300 mg
LEXIVA SUS 50MG/ML
LEXIVA TAB 700MG
NEVIRAPINE SUSP 50 MG/5ML
nevirapine tab 200 mg
nevirapine tab sr 24hr 100 mg
nevirapine tab sr 24hr 400 mg
NORVIR CAP 100MG
NORVIR SOL 80MG/ML
NORVIR TAB 100MG
PREZISTA SUS 100MG/ML
PREZISTA TAB 75MG
PREZISTA TAB 150MG
PREZISTA TAB 600MG
PREZISTA TAB 800MG
RESCRIPTOR TAB 100 MG
RESCRIPTOR TAB 200MG
RETROVIR INJ 10MG/ML
REYATAZ CAP 150MG
REYATAZ CAP 200MG
REYATAZ CAP 300MG
REYATAZ POW 50MG
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
SUSTIVA CAP 50MG
SUSTIVA CAP 200MG
SUSTIVA TAB 600MG
TIVICAY TAB 10MG
TIVICAY TAB 25MG
TIVICAY TAB 50MG
TYBOST TAB 150MG
VIDEX SOL 2GM
VIDEX SOL 4GM
VIRACEPT TAB 250MG
VIRACEPT TAB 625MG
VIRAMUNE XR TAB 100MG
PA - Prior Authorization
available at mail-order
Drug Tier Requirements/Limits
3
5
2
2
2
4
5
2
2
2
2
3
3
3
5
3
3
5
5
4
4
3
5
5
5
5
5
5
2
2
2
2
2
3
3
5
3
5
5
3
4
4
5
5
4
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
9
Drug Name
VIREAD POW 40MG/GM
VIREAD TAB 150MG
VIREAD TAB 200MG
VIREAD TAB 250MG
VIREAD TAB 300MG
VITEKTA TAB 85MG
VITEKTA TAB 150MG
ZIAGEN SOL 20MG/ML
zidovudine cap 100 mg
zidovudine syrup 10 mg/ml
zidovudine tab 300 mg
Drug Tier Requirements/Limits
5
5
5
5
5
5
5
3
2
2
2
ANTIRETROVIRAL COMBINATION AGENTS
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg
ATRIPLA TAB
COMPLERA TAB
DESCOVY TAB 200/25
EPZICOM TAB 600-300
EVOTAZ TAB 300-150
GENVOYA TAB
KALETRA SOL
KALETRA TAB 100-25MG
KALETRA TAB 200-50MG
lamivudine-zidovudine tab 150-300 mg
ODEFSEY TAB
PREZCOBIX TAB 800-150
STRIBILD TAB
TRIUMEQ TAB
TRUVADA TAB 100-150
TRUVADA TAB 133-200
TRUVADA TAB 167-250
TRUVADA TAB 200-300
ANTITUBERCULAR AGENTS
CAPASTAT SUL INJ 1GM
cycloserine cap 250 mg
ethambutol hcl tab 100 mg
ethambutol hcl tab 400 mg
isoniazid inj 100 mg/ml
isoniazid syrup 50 mg/5ml
isoniazid tab 100 mg
isoniazid tab 300 mg
paser gra 4gm
PRIFTIN TAB 150MG
pyrazinamide tab 500 mg
rifabutin cap 150 mg
PA - Prior Authorization
available at mail-order
5
5
5
5
5
5
5
5
3
5
5
5
5
5
5
5
5
5
5
QL
QL
QL
QL
(60
(30
(30
(30
tabs
tabs
tabs
tabs
/
/
/
/
30
30
30
30
days)
days)
days)
days)
4
5
2
2
2
2
1
1
3
4
2
2
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
10
Drug Name
rifampin cap 150 mg
rifampin cap 300 mg
rifampin for inj 600 mg
RIFATER TAB
SIRTURO TAB 100MG
TRECATOR TAB 250MG
ANTIVIRALS
acyclovir cap 200 mg
acyclovir sodium for inj 500 mg
acyclovir sodium iv soln 50 mg/ml
acyclovir susp 200 mg/5ml
acyclovir tab 400 mg
acyclovir tab 800 mg
adefovir dipivoxil tab 10 mg
BARACLUDE SOL .05MG/ML
DAKLINZA TAB 30MG
DAKLINZA TAB 60MG
DAKLINZA TAB 90MG
entecavir tab 0.5 mg
entecavir tab 1 mg
EPIVIR HBV SOL 5MG/ML
famciclovir tab 125 mg
famciclovir tab 250 mg
famciclovir tab 500 mg
ganciclovir sodium for inj 500 mg
HARVONI TAB 90-400MG
lamivudine tab 100 mg (hbv)
moderiba pak 600/day
moderiba pak 800/day
moderiba pak 1000/day
MODERIBA PAK 1200/DAY
PEG-INTRON KIT 50MCG RP
PEG-INTRON KIT 80MCG RP
PEG-INTRON KIT 120 RP
PEG-INTRON KIT 150 RP
PEGASYS INJ
PEGASYS INJ 180MCG/M
PEGASYS INJ PROCLICK
PEGINTRON KIT 50MCG
PEGINTRON KIT 80MCG
PEGINTRON KIT 120MCG
PEGINTRON KIT 150MCG
REBETOL SOL 40MG/ML
RELENZA MIS DISKHALE
ribapak pak 600/day
PA - Prior Authorization
available at mail-order
Drug Tier Requirements/Limits
2
2
2
4
5
LA, PA
4
1
2
2
2
1
1
5
3
5
5
5
5
5
4
2
2
2
2
5
2
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
3
5
B/D
B/D
NM, PA
NM, PA
NM, PA
B/D
NM, PA
NM
NM
NM
NM
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
NM
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
11
Drug Name
ribapak pak 800/day
ribapak pak 1000/day
ribapak pak 1200/day
ribasphere cap 200mg
ribasphere tab 200mg
ribasphere tab 400mg
ribasphere tab 600mg
ribavirin cap 200 mg
ribavirin tab 200 mg
rimantadine hydrochloride tab 100 mg
SOVALDI TAB 400MG
TAMIFLU CAP 30MG
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
valganciclovir hcl tab 450 mg (base
equivalent)
CEPHALOSPORINS
cefaclor cap 250 mg
cefaclor cap 500 mg
cefaclor er tab 500mg
cefaclor for susp 125 mg/5ml
cefaclor for susp 250 mg/5ml
cefaclor for susp 375 mg/5ml
cefadroxil cap 500 mg
cefadroxil for susp 250 mg/5ml
cefadroxil for susp 500 mg/5ml
cefadroxil tab 1 gm
cefazolin inj 1gm/50ml
cefazolin sodium for inj 1 gm
cefazolin sodium for inj 10 gm
cefazolin sodium for inj 20 gm
cefazolin sodium for inj 500 mg
cefazolin sodium for iv soln 1 gm
CEFAZOLIN SOL
cefdinir cap 300 mg
cefdinir for susp 125 mg/5ml
cefdinir for susp 250 mg/5ml
cefepime hcl for inj 1 gm
cefepime hcl for inj 2 gm
cefixime for susp 100 mg/5ml
PA - Prior Authorization
available at mail-order
Drug Tier Requirements/Limits
5
NM
5
NM
5
NM
2
NM
2
NM
2
NM
5
NM
2
NM
2
NM
2
5
NM, PA
3
3
3
3
5
2
2
5
5
2
2
3
2
2
2
1
2
2
2
3
2
2
2
2
2
3
2
2
2
2
2
2
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
12
Drug Name
cefixime for susp 200 mg/5ml
cefotaxime sodium for inj 1 gm
cefotaxime sodium for inj 2 gm
cefotaxime sodium for inj 500 mg
cefoxitin sodium for inj 10 gm
cefoxitin sodium for iv soln 1 gm
cefoxitin sodium for iv soln 2 gm
cefpodoxime proxetil for susp 50 mg/5ml
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 for inj 2 gm
ceftazidime for inj 6 gm
CEFTAZIDIME/ SOL D5W 1GM
CEFTAZIDIME/ SOL D5W 2GM
ceftriaxone sodium for inj 1 gm
ceftriaxone sodium for inj 2 gm
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
cefuroxime sodium for iv soln 1.5 gm
cephalexin cap 250 mg
cephalexin cap 500 mg
cephalexin for susp 125 mg/5ml
cephalexin for susp 250 mg/5ml
SUPRAX CAP 400MG
suprax chw 100mg
suprax chw 200mg
SUPRAX SUS 500/5ML
tazicef inj 1gm
tazicef inj 2gm
tazicef inj 6gm
TEFLARO INJ 400MG
PA - Prior Authorization
available at mail-order
Drug Tier Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
4
2
2
2
2
2
2
2
2
2
2
2
2
2
1
1
2
2
3
4
4
3
2
2
2
4
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
13
Drug Name
TEFLARO INJ 600MG
Drug Tier Requirements/Limits
4
ERYTHROMYCINS/MACROLIDES
azithromycin for susp 100 mg/5ml
2
azithromycin for susp 200 mg/5ml
2
azithromycin iv for soln 500 mg
2
AZITHROMYCIN POWD PACK FOR SUSP 1 GM2
azithromycin tab 250 mg
1
azithromycin tab 500 mg
1
azithromycin tab 600 mg
1
clarithromycin for susp 125 mg/5ml
2
clarithromycin for susp 250 mg/5ml
2
clarithromycin tab 250 mg
2
clarithromycin tab 500 mg
2
clarithromycin tab sr 24hr 500 mg
2
DIFICID TAB 200MG
5
e.e.s. 400 tab 400mg
2
ery-tab tab 250mg ec
2
ery-tab tab 333mg ec
2
ery-tab tab 500mg ec
2
erythrocin inj 500mg
4
erythrocin tab 250mg
2
erythromycin ethylsuccinate tab 400 mg
2
erythromycin tab 250 mg
2
erythromycin tab 500 mg
2
erythromycin w/ delayed release particles cap2
250 mg
FLUOROQUINOLONES
ciprofloxacin 200 mg/100ml in d5w
2
ciprofloxacin 400 mg/200ml in d5w
2
ciprofloxacin for oral susp 250 mg/5ml (5%) 2
(5 gm/100ml)
ciprofloxacin for oral susp 500 mg/5ml (10%)2
(10 gm/100ml)
ciprofloxacin hcl tab 100 mg (base equiv)
1
ciprofloxacin hcl tab 250 mg (base equiv)
1
ciprofloxacin hcl tab 500 mg (base equiv)
1
ciprofloxacin hcl tab 750 mg (base equiv)
1
ciprofloxacin iv soln 200 mg/20ml (1%)
2
ciprofloxacin iv soln 400 mg/40ml (1%)
2
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 5002
mg (base eq)
ciprofloxacin-ciprofloxacin hcl tab sr 24hr
2
1000 mg(base eq)
levofloxacin in d5w iv soln 250 mg/50ml
2
levofloxacin in d5w iv soln 500 mg/100ml
2
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
14
Drug Name
levofloxacin
levofloxacin
levofloxacin
levofloxacin
levofloxacin
levofloxacin
in d5w iv soln 750 mg/150ml
iv soln 25 mg/ml
oral soln 25 mg/ml
tab 250 mg
tab 500 mg
tab 750 mg
Drug Tier Requirements/Limits
2
2
2
1
1
1
PENICILLINS
amoxicillin & k clavulanate chew tab 200-28.52
mg
amoxicillin & k clavulanate chew tab 400-57 2
mg
amoxicillin & k clavulanate for susp 200-28.52
mg/5ml
amoxicillin & k clavulanate for susp 250-62.52
mg/5ml
amoxicillin & k clavulanate for susp 400-57 2
mg/5ml
amoxicillin & k clavulanate for susp 600-42.92
mg/5ml
amoxicillin & k clavulanate tab 250-125 mg 2
amoxicillin & k clavulanate tab 500-125 mg 2
amoxicillin & k clavulanate tab 875-125 mg 2
amoxicillin & k clavulanate tab sr 12hr
2
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/5ml 1
amoxicillin (trihydrate) for susp 200 mg/5ml 1
amoxicillin (trihydrate) for susp 250 mg/5ml 1
amoxicillin (trihydrate) for susp 400 mg/5ml 1
amoxicillin (trihydrate) tab 500 mg
1
amoxicillin (trihydrate) tab 875 mg
1
ampicillin & sulbactam sodium for inj 1.5
2
(1-0.5) gm
ampicillin & sulbactam sodium for inj 3 (2-1) 2
gm
ampicillin & sulbactam sodium for inj 15
2
(10-5) gm
ampicillin & sulbactam sodium for iv soln 3 2
(2-1) gm
ampicillin & sulbactam sodium for iv soln 15 2
(10-5) gm
ampicillin cap 250 mg
1
ampicillin cap 500 mg
1
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
15
Drug Name
Drug Tier Requirements/Limits
ampicillin for susp 125 mg/5ml
2
ampicillin for susp 250 mg/5ml
2
ampicillin sodium for inj 1 gm
2
ampicillin sodium for inj 2 gm
2
ampicillin sodium for inj 125 mg
2
ampicillin sodium for inj 250 mg
2
ampicillin sodium for inj 500 mg
2
ampicillin sodium for iv soln 1 gm
2
ampicillin sodium for iv soln 2 gm
2
ampicillin sodium for iv soln 10 gm
2
BICILLIN L-A INJ 600000
4
BICILLIN L-A INJ 1200000
4
BICILLIN L-A INJ 2400000
4
dicloxacillin sodium cap 250 mg
2
dicloxacillin sodium cap 500 mg
2
nafcillin sodium for inj 1 gm
2
nafcillin sodium for inj 2 gm
5
nafcillin sodium for inj 10 gm
5
nafcillin sodium for iv soln 1 gm
2
nafcillin sodium for iv soln 2 gm
5
oxacillin sodium for inj 1 gm
2
oxacillin sodium for inj 2 gm
2
oxacillin sodium for inj 10 gm
5
pen g proc inj 600000
3
PENICILL GK/ INJ DEX 2MU
4
PENICILL GK/ INJ DEX 3MU
4
penicillin g potassium for inj 5000000 unit 2
penicillin g potassium for inj 20000000 unit 2
penicillin g sodium for inj 5000000 unit
2
penicillin v potassium for soln 125 mg/5ml 1
penicillin v potassium for soln 250 mg/5ml 1
penicillin v potassium tab 250 mg
1
penicillin v potassium tab 500 mg
1
piperacillin sod-tazobactam na for inj 3.375 2
gm (3-0.375 gm)
piperacillin sod-tazobactam sod for inj 2.25 2
gm (2-0.25 gm)
piperacillin sod-tazobactam sod for inj 4.5 gm2
(4-0.5 gm)
piperacillin sod-tazobactam sod for inj 40.5 2
gm (36-4.5 gm)
TETRACYCLINES
doxy 100 inj 100mg
doxycycline hyclate cap 50 mg
doxycycline hyclate cap 100 mg
PA - Prior Authorization
available at mail-order
2
2
2
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
16
Drug Name
doxycycline hyclate for inj 100 mg
doxycycline hyclate tab 20 mg
doxycycline hyclate tab 100 mg
doxycycline monohydrate cap 50 mg
doxycycline monohydrate cap 100 mg
doxycycline monohydrate tab 50 mg
doxycycline monohydrate tab 75 mg
doxycycline monohydrate tab 100 mg
doxycycline monohydrate tab 150 mg
minocycline hcl cap 50 mg
minocycline hcl cap 75 mg
minocycline hcl cap 100 mg
morgidox cap 1x50mg
ANTINEOPLASTIC AGENTS
ALKYLATING AGENTS
BENDEKA INJ 100/4ML
BICNU INJ 100MG
BUSULFEX INJ 6MG/ML
CYCLOPHOSPH CAP 25MG
CYCLOPHOSPH CAP 50MG
cyclophosphamide for inj 1 gm
cyclophosphamide for inj 2 gm
cyclophosphamide for inj 500 mg
dacarbazine for inj 100 mg
dacarbazine for inj 200 mg
EMCYT CAP 140MG
GLEOSTINE CAP 5MG
GLEOSTINE CAP 10MG
GLEOSTINE CAP 40MG
GLEOSTINE CAP 100MG
HEXALEN CAP 50MG
IFEX INJ 3GM
ifosfamide for inj 1 gm
IFOSFAMIDE INJ 3GM
ifosfamide iv inj 1 gm/20ml (50 mg/ml)
ifosfamide iv inj 3 gm/60ml (50 mg/ml)
LEUKERAN TAB 2MG
melphalan hcl for inj 50 mg (base equiv)
MUSTARGEN INJ 10MG
TREANDA INJ 25MG
TREANDA INJ 45/0.5ML
TREANDA INJ 100MG
TREANDA INJ 180/2ML
ANTHRACYCLINES
daunorubicin hcl inj 5 mg/ml (base equiv)
PA - Prior Authorization
available at mail-order
Drug Tier Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
5
4
5
4
4
5
2
5
2
2
4
4
4
4
4
5
4
2
4
2
2
4
5
4
5
5
5
5
B/D, NM
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
2
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
NM
NM
NM
NM
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
17
Drug Name
Drug Tier Requirements/Limits
doxorubicin hcl for inj 50 mg
2
B/D
doxorubicin hcl inj 2 mg/ml
2
B/D
doxorubicin hcl liposomal inj (for iv infusion) 25
B/D
mg/ml
epirubicin hcl iv soln 50 mg/25ml (2 mg/ml) 2
B/D
epirubicin hcl iv soln 200 mg/100ml (2
2
B/D
mg/ml)
idarubicin hcl iv inj 5 mg/5ml (1 mg/ml)
5
B/D
idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 5
B/D
idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) 5
B/D
ANTIBIOTICS
bleomycin sulfate for
bleomycin sulfate for
mitomycin for iv soln
mitomycin for iv soln
mitomycin for iv soln
inj 15 unit
inj 30 unit
5 mg
20 mg
40 mg
ANTIMETABOLITES
2
2
2
2
2
adrucil inj 2.5g/50m
2
adrucil inj 5gm/100m
2
adrucil inj 500/10ml
2
ALIMTA INJ 100MG
5
ALIMTA INJ 500MG
5
azacitidine for inj 100 mg
5
cladribine iv soln 10 mg/10ml (1 mg/ml)
5
cytarabine inj 20 mg/ml
2
fludarabine phosphate for inj 50 mg
2
fludarabine phosphate inj 25 mg/ml
2
fluorouracil inj 1 gm/20ml (50 mg/ml)
2
fluorouracil inj 2.5 gm/50ml (50 mg/ml)
2
fluorouracil inj 5 gm/100ml (50 mg/ml)
2
fluorouracil inj 500 mg/10ml (50 mg/ml)
2
gemcitabine hcl for inj 1 gm
5
gemcitabine hcl for inj 2 gm
5
gemcitabine hcl for inj 200 mg
5
GEMCITABINE HCL INJ 1 GM/26.3ML (38
5
MG/ML) (BASE EQUIV)
GEMCITABINE HCL INJ 2 GM/52.6ML (38
5
MG/ML) (BASE EQUIV)
GEMCITABINE HCL INJ 200 MG/5.26ML (38 5
MG/ML) (BASE EQUIV)
mercaptopurine tab 50 mg
2
methotrexate sodium for inj 1 gm
2
METHOTREXATE SODIUM INJ 50 MG/2ML (252
MG/ML)
methotrexate sodium inj 250 mg/10ml (25 2
mg/ml)
PA - Prior Authorization
available at mail-order
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
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
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
18
Drug Name
Drug Tier Requirements/Limits
methotrexate sodium inj pf 50 mg/2ml (25 2
B/D
mg/ml)
methotrexate sodium inj pf 100 mg/4ml (25 2
B/D
mg/ml)
methotrexate sodium inj pf 200 mg/8ml (25 2
B/D
mg/ml)
methotrexate sodium inj pf 250 mg/10ml (252
B/D
mg/ml)
methotrexate sodium inj pf 1000 mg/40ml 2
B/D
(25 mg/ml)
NIPENT INJ 10MG
5
B/D
PURIXAN SUS 20MG/ML
5
NM
TABLOID TAB 40MG
4
ANTIMITOTIC, TAXOIDS
ABRAXANE INJ 100MG
DOCETAXEL FOR INJ CONC 20 MG/ML
DOCETAXEL FOR INJ CONC 80 MG/4ML (20
MG/ML)
DOCETAXEL INJ 20MG/2ML
DOCETAXEL INJ 80MG/8ML
docetaxel inj 140/7ml
DOCETAXEL INJ 160/16ML
DOCETAXEL INJ 200MG/20
paclitaxel iv conc 30 mg/5ml (6 mg/ml)
paclitaxel iv conc 100 mg/16.7ml (6 mg/ml)
paclitaxel iv conc 150 mg/25ml (6 mg/ml)
paclitaxel iv conc 300 mg/50ml (6 mg/ml)
5
5
5
B/D
B/D
B/D
2
5
5
5
5
2
2
2
2
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
vinblastine sulfate inj 1 mg/ml
3
vincasar pfs inj 1mg/ml
2
vincristine sulfate iv soln 1 mg/ml
2
vinorelbine tartrate inj 10 mg/ml (base equiv)2
vinorelbine tartrate inj 50 mg/5ml (10
2
mg/ml) (base equiv)
B/D
B/D
B/D
B/D
B/D
ANTIMITOTIC, VINCA ALKALOIDS
BIOLOGIC RESPONSE MODIFIERS
AVASTIN INJ
AVASTIN INJ 400/16ML
BELEODAQ INJ 500MG
ERIVEDGE CAP 150MG
FARYDAK CAP 10MG
FARYDAK CAP 15MG
FARYDAK CAP 20MG
HERCEPTIN INJ 440MG
IBRANCE CAP 75MG
IBRANCE CAP 100MG
IBRANCE CAP 125MG
PA - Prior Authorization
available at mail-order
5
5
5
5
5
5
5
5
5
5
5
B/D, NM, LA
B/D, NM, LA
NM, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
B/D, NM
NM, LA, PA
NM, LA, PA
NM, LA, PA
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
19
Drug Name
ISTODAX INJ 10MG
KADCYLA INJ 100MG
KADCYLA INJ 160MG
KEYTRUDA INJ 100MG/4M
KEYTRUDA SOL 50MG
LYNPARZA CAP 50MG
NINLARO CAP 2.3MG
NINLARO CAP 3MG
NINLARO CAP 4MG
PROLEUKIN INJ 22MU
RITUXAN INJ 100MG
RITUXAN INJ 500MG
TECENTRIQ INJ 1200/20
VELCADE INJ 3.5MG
VENCLEXTA TAB 10MG
VENCLEXTA TAB 50MG
VENCLEXTA TAB 100MG
VENCLEXTA TAB START PK
YERVOY INJ 50MG
YERVOY INJ 200MG
ZOLINZA CAP 100MG
Drug Tier Requirements/Limits
5
B/D, NM
5
B/D, NM
5
B/D, NM
5
NM, PA
5
NM, PA
5
NM, LA, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
B/D, NM
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
B/D, NM
4
NM, LA, PA
4
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, PA
5
NM, PA
5
NM, PA
HORMONAL ANTINEOPLASTIC AGENTS
anastrozole tab 1 mg
2
bicalutamide tab 50 mg
2
DEPO-PROVERA INJ 400/ML
4
exemestane tab 25 mg
2
FARESTON TAB 60MG
5
FASLODEX INJ 250MG
5
flutamide cap 125 mg
2
hydroxyprogesterone caproate im in oil 1.25 4
gm/5ml
letrozole tab 2.5 mg
2
leuprolide acetate inj kit 5 mg/ml
2
LUPR DEP-PED INJ 7.5MG
5
LUPR DEP-PED INJ 11.25MG
5
LUPR DEP-PED INJ 15MG
5
LUPR DEP-PED INJ 30MG
5
LUPRON DEPOT INJ 3.75MG
5
LUPRON DEPOT INJ 11.25MG
5
LYSODREN TAB 500MG
3
megestrol acetate susp 40 mg/ml
4
MEGESTROL ACETATE SUSP 625 MG/5ML
megestrol acetate tab 20 mg
PA - Prior Authorization
available at mail-order
5
4
B/D
B/D
B/D
NM,
NM,
NM,
NM,
NM,
NM,
NM,
PA
PA
PA
PA
PA
PA
PA
PA; PA if 65 years and
older
PA
PA; PA if 65 years and
older
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
20
Drug Name
megestrol acetate tab 40 mg
Drug Tier Requirements/Limits
4
PA; PA if 65 years and
older
NILANDRON TAB 150MG
5
nilutamide tab 150 mg
5
SOLTAMOX SOL 10MG/5ML
4
tamoxifen citrate tab 10 mg (base equivalent)1
tamoxifen citrate tab 20 mg (base equivalent)1
TRELSTAR MIX INJ 3.75MG
5
NM, PA
TRELSTAR MIX INJ 11.25MG
5
NM, PA
XTANDI CAP 40MG
5
NM, LA, PA
ZYTIGA TAB 250MG
5
NM, LA, PA
KINASE INHIBITORS
AFINITOR DIS TAB 2MG
AFINITOR DIS TAB 3MG
AFINITOR DIS TAB 5MG
AFINITOR TAB 2.5MG
AFINITOR TAB 5MG
AFINITOR TAB 7.5MG
AFINITOR TAB 10MG
ALECENSA CAP 150MG
BOSULIF TAB 100MG
BOSULIF TAB 500MG
CABOMETYX TAB 20MG
CABOMETYX TAB 40MG
CABOMETYX TAB 60MG
CAPRELSA TAB 100MG
CAPRELSA TAB 300MG
COMETRIQ KIT 60MG
COMETRIQ KIT 100MG
COMETRIQ KIT 140MG
COTELLIC TAB 20MG
GILOTRIF TAB 20MG
GILOTRIF TAB 30MG
GILOTRIF TAB 40MG
ICLUSIG TAB 15MG
ICLUSIG TAB 45MG
imatinib mesylate tab 100 mg (base
equivalent)
imatinib mesylate tab 400 mg (base
equivalent)
IMBRUVICA CAP 140MG
INLYTA TAB 1MG
INLYTA TAB 5MG
IRESSA TAB 250MG
JAKAFI TAB 5MG
JAKAFI TAB 10MG
PA - Prior Authorization
available at mail-order
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
PA
PA
PA
PA
PA
PA
PA
LA,
PA
PA
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
LA,
PA
5
NM, PA
5
5
5
5
5
5
NM,
NM,
NM,
NM,
NM,
NM,
LA,
LA,
LA,
LA,
LA,
LA,
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
21
Drug Name
JAKAFI TAB 15MG
JAKAFI TAB 20MG
JAKAFI TAB 25MG
LENVIMA CAP 8 MG
LENVIMA CAP 10 MG
LENVIMA CAP 14 MG
LENVIMA CAP 18 MG
LENVIMA CAP 20 MG
LENVIMA CAP 24 MG
MEKINIST TAB 0.5MG
MEKINIST TAB 2MG
NEXAVAR TAB 200MG
SPRYCEL TAB 20MG
SPRYCEL TAB 50MG
SPRYCEL TAB 70MG
SPRYCEL TAB 80MG
SPRYCEL TAB 100MG
SPRYCEL TAB 140MG
STIVARGA TAB 40MG
SUTENT CAP 12.5MG
SUTENT CAP 25MG
SUTENT CAP 37.5MG
SUTENT CAP 50MG
TAFINLAR CAP 50MG
TAFINLAR CAP 75MG
TAGRISSO TAB 40MG
TAGRISSO TAB 80MG
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
ZYDELIG TAB 100MG
ZYDELIG TAB 150MG
ZYKADIA CAP 150MG
MISCELLANEOUS
bexarotene cap 75 mg
DROXIA CAP 200MG
DROXIA CAP 300MG
DROXIA CAP 400MG
hydroxyurea cap 500 mg
PA - Prior Authorization
available at mail-order
Drug Tier Requirements/Limits
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, LA, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, PA
5
NM, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
3
3
3
2
NM, PA
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
22
Drug Name
LONSURF TAB 15-6.14
LONSURF TAB 20-8.19
MATULANE CAP 50MG
mitoxantrone hcl inj conc 20 mg/10ml (2
mg/ml)
mitoxantrone hcl inj conc 25 mg/12.5ml (2
mg/ml)
mitoxantrone hcl inj conc 30 mg/15ml (2
mg/ml)
ODOMZO CAP 200MG
POMALYST CAP 1MG
POMALYST CAP 2MG
POMALYST CAP 3MG
POMALYST CAP 4MG
SYLATRON KIT 200MCG
SYLATRON KIT 300MCG
SYLATRON KIT 600MCG
SYNRIBO INJ 3.5MG
tretinoin cap 10 mg
TRISENOX SOL 10MG/10M
PLATINUM-BASED AGENTS
carboplatin iv soln 50 mg/5ml
carboplatin iv soln 150 mg/15ml
carboplatin iv soln 450 mg/45ml
carboplatin iv soln 600 mg/60ml
cisplatin inj 50 mg/50ml (1 mg/ml)
cisplatin inj 100 mg/100ml (1 mg/ml)
cisplatin inj 200 mg/200ml (1 mg/ml)
oxaliplatin for iv inj 50 mg
oxaliplatin for iv inj 100 mg
oxaliplatin iv soln 50 mg/10ml
oxaliplatin iv soln 100 mg/20ml
PROTECTIVE AGENTS
amifostine crystalline for inj 500 mg
dexrazoxane for inj 250 mg
ELITEK INJ 1.5MG
ELITEK INJ 7.5MG
FUSILEV INJ 50MG
leucovorin calcium for inj 50 mg
leucovorin calcium for inj 100 mg
leucovorin calcium for inj 200 mg
leucovorin calcium for inj 350 mg
leucovorin calcium for inj 500 mg
leucovorin calcium tab 5 mg
leucovorin calcium tab 10 mg
leucovorin calcium tab 15 mg
PA - Prior Authorization
available at mail-order
Drug Tier Requirements/Limits
5
NM, PA
5
NM, PA
5
LA
2
B/D, NM
2
B/D, NM
2
B/D, NM
5
5
5
5
5
5
5
5
5
5
5
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
2
2
2
2
2
2
2
5
5
5
5
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
5
5
5
5
5
2
2
2
2
2
2
2
2
B/D
B/D
B/D
B/D
B/D, NM
B/D
B/D
B/D
B/D
B/D
LA,
LA,
LA,
LA,
LA,
PA
PA
PA
PA
PA
PA
PA
PA
PA
B/D
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
23
Drug Name
Drug Tier Requirements/Limits
leucovorin calcium tab 25 mg
2
levoleucovor sol 250mg/25
5
B/D, NM
levoleucovorin calcium for iv inj 50 mg (base 5
B/D, NM
equiv)
levoleucovorin calcium inj 175 mg/17.5ml
5
B/D, NM
(base equiv)
mesna inj 100 mg/ml
2
B/D
MESNEX TAB 400MG
5
TOPOISOMERASE INHIBITORS
etoposide inj 500 mg/25ml (20 mg/ml)
irinotecan hcl inj 40 mg/2ml (20 mg/ml)
irinotecan hcl inj 100 mg/5ml (20 mg/ml)
irinotecan hcl inj 500 mg/25ml (20 mg/ml)
toposar inj 1gm/50ml
topotecan hcl for inj 4 mg
CARDIOVASCULAR
ACE INHIBITOR COMBINATIONS
2
2
2
2
2
5
amlodipine besylate-benazepril hcl cap
1
2.5-10 mg
amlodipine besylate-benazepril hcl cap 5-10 1
mg
amlodipine besylate-benazepril hcl cap 5-20 1
mg
amlodipine besylate-benazepril hcl cap 5-40 1
mg
amlodipine besylate-benazepril hcl cap 10-201
mg
amlodipine besylate-benazepril hcl cap 10-401
mg
benazepril & hydrochlorothiazide tab 5-6.25 1
mg
benazepril & hydrochlorothiazide tab 10-12.51
mg
benazepril & hydrochlorothiazide tab 20-12.51
mg
benazepril & hydrochlorothiazide tab 20-25 1
mg
captopril & hydrochlorothiazide tab 25-15 mg1
captopril & hydrochlorothiazide tab 25-25 mg1
captopril & hydrochlorothiazide tab 50-15 mg1
captopril & hydrochlorothiazide tab 50-25 mg1
enalapril maleate & hydrochlorothiazide tab 1
5-12.5 mg
enalapril maleate & hydrochlorothiazide tab 1
10-25 mg
PA - Prior Authorization
available at mail-order
B/D
B/D
B/D
B/D
B/D
B/D
QL (30 caps / 30 days)
QL (30 caps / 30 days)
QL (30 caps / 30 days)
QL (30 caps / 30 days)
QL (30 caps / 30 days)
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
24
Drug Name
Drug Tier Requirements/Limits
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 mg1
moexipril-hydrochlorothiazide tab 7.5-12.5 1
mg
moexipril-hydrochlorothiazide tab 15-12.5 1
mg
moexipril-hydrochlorothiazide tab 15-25 mg 1
quinapril-hydrochlorothiazide tab 10-12.5 mg1
quinapril-hydrochlorothiazide tab 20-12.5 mg1
quinapril-hydrochlorothiazide tab 20-25 mg 1
ACE INHIBITORS
benazepril hcl tab 5 mg
benazepril hcl tab 10 mg
benazepril hcl tab 20 mg
benazepril hcl tab 40 mg
captopril tab 12.5 mg
captopril tab 25 mg
captopril tab 50 mg
captopril tab 100 mg
enalapril maleate tab 2.5 mg
enalapril maleate tab 5 mg
enalapril maleate tab 10 mg
enalapril maleate tab 20 mg
fosinopril sodium tab 10 mg
fosinopril sodium tab 20 mg
fosinopril sodium tab 40 mg
lisinopril tab 2.5 mg
lisinopril tab 5 mg
lisinopril tab 10 mg
lisinopril tab 20 mg
lisinopril tab 30 mg
lisinopril tab 40 mg
moexipril hcl tab 7.5 mg
moexipril hcl tab 15 mg
perindopril erbumine tab 2 mg
perindopril erbumine tab 4 mg
perindopril erbumine tab 8 mg
quinapril hcl tab 5 mg
PA - Prior Authorization
available at mail-order
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
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
25
Drug Name
quinapril hcl tab 10 mg
quinapril hcl tab 20 mg
quinapril hcl tab 40 mg
ramipril cap 1.25 mg
ramipril cap 2.5 mg
ramipril cap 5 mg
ramipril cap 10 mg
trandolapril tab 1 mg
trandolapril tab 2 mg
trandolapril tab 4 mg
Drug Tier Requirements/Limits
1
1
1
1
1
1
1
1
1
1
ALDOSTERONE RECEPTOR ANTAGONISTS
eplerenone tab 25 mg
eplerenone tab 50 mg
spironolactone tab 25 mg
spironolactone tab 50 mg
spironolactone tab 100 mg
ALPHA BLOCKERS
doxazosin mesylate tab 1
doxazosin mesylate tab 2
doxazosin mesylate tab 4
doxazosin mesylate tab 8
prazosin hcl cap 1 mg
prazosin hcl cap 2 mg
prazosin hcl cap 5 mg
terazosin hcl cap 1 mg
terazosin hcl cap 2 mg
terazosin hcl cap 5 mg
terazosin hcl cap 10 mg
mg
mg
mg
mg
2
2
1
1
1
2
2
2
2
2
2
2
1
1
1
1
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS
amlodipine besylate-valsartan tab 5-160 mg 1
amlodipine besylate-valsartan tab 5-320 mg 1
amlodipine besylate-valsartan tab 10-160 mg1
amlodipine besylate-valsartan tab 10-320 mg1
amlodipine-valsartan-hydrochlorothiazide
1
tab 5-160-12.5 mg
amlodipine-valsartan-hydrochlorothiazide
1
tab 5-160-25 mg
amlodipine-valsartan-hydrochlorothiazide
1
tab 10-160-12.5 mg
amlodipine-valsartan-hydrochlorothiazide
1
tab 10-160-25 mg
amlodipine-valsartan-hydrochlorothiazide
1
tab 10-320-25 mg
AZOR TAB 5-20MG
3
AZOR TAB 5-40MG
3
PA - Prior Authorization
available at mail-order
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
26
Drug Name
Drug Tier Requirements/Limits
AZOR TAB 10-20MG
3
QL (30 tabs / 30 days)
AZOR TAB 10-40MG
3
BENICAR HCT TAB 20-12.5
3
BENICAR HCT TAB 40-12.5
3
BENICAR HCT TAB 40-25MG
3
ENTRESTO TAB 24-26MG
4
PA
ENTRESTO TAB 49-51MG
4
PA
ENTRESTO TAB 97-103MG
4
PA
irbesartan-hydrochlorothiazide tab 150-12.5 1
mg
irbesartan-hydrochlorothiazide tab 300-12.5 1
mg
losartan potassium & hydrochlorothiazide tab1
50-12.5 mg
losartan potassium & hydrochlorothiazide tab1
100-12.5 mg
losartan potassium & hydrochlorothiazide tab1
100-25 mg
TRIBENZOR20- TAB 5-12.5MG
3
QL (30 tabs / 30 days)
TRIBENZOR40- TAB 5-12.5MG
3
QL (30 tabs / 30 days)
TRIBENZOR40- TAB 5-25MG
3
QL (30 tabs / 30 days)
TRIBENZOR40- TAB 10-12.5
3
QL (30 tabs / 30 days)
TRIBENZOR40- TAB 10-25MG
3
valsartan-hydrochlorothiazide tab 80-12.5 1
mg
valsartan-hydrochlorothiazide tab 160-12.5 1
mg
valsartan-hydrochlorothiazide tab 160-25 mg1
valsartan-hydrochlorothiazide tab 320-12.5 1
mg
valsartan-hydrochlorothiazide tab 320-25 mg1
ANGIOTENSIN II RECEPTOR ANTAGONISTS
BENICAR TAB 5MG
BENICAR TAB 20MG
BENICAR TAB 40MG
irbesartan tab 75 mg
irbesartan tab 150 mg
irbesartan tab 300 mg
losartan potassium tab 25 mg
losartan potassium tab 50 mg
losartan potassium tab 100 mg
valsartan tab 40 mg
valsartan tab 80 mg
valsartan tab 160 mg
valsartan tab 320 mg
3
3
3
1
1
1
1
1
1
1
1
1
1
ANTIARRHYTHMICS
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
27
Drug Name
Drug Tier Requirements/Limits
amiodarone hcl inj 150 mg/3ml (50 mg/ml) 2
amiodarone hcl inj 450 mg/9ml (50 mg/ml) 2
amiodarone hcl inj 900 mg/18ml (50 mg/ml) 2
amiodarone hcl tab 100 mg
2
amiodarone hcl tab 200 mg
1
amiodarone hcl tab 400 mg
2
disopyramide phosphate cap 100 mg
4
PA; PA if 65 years and
older
disopyramide phosphate cap 150 mg
4
PA; PA if 65 years and
older
dofetilide cap 125 mcg (0.125 mg)
2
NM
dofetilide cap 250 mcg (0.25 mg)
2
NM
dofetilide cap 500 mcg (0.5 mg)
2
NM
flecainide acetate tab 50 mg
2
flecainide acetate tab 100 mg
2
flecainide acetate tab 150 mg
2
mexiletine hcl cap 150 mg
2
mexiletine hcl cap 200 mg
2
mexiletine hcl cap 250 mg
2
MULTAQ TAB 400MG
4
NORPACE CAP 100MG CR
4
PA; PA if 65 years and
older
NORPACE CAP 150MG CR
4
PA; PA if 65 years and
older
pacerone tab 100mg
2
pacerone tab 200mg
1
pacerone tab 400mg
2
propafenone hcl cap sr 12hr 225 mg
2
propafenone hcl cap sr 12hr 325 mg
2
propafenone hcl cap sr 12hr 425 mg
2
propafenone hcl tab 150 mg
2
propafenone hcl tab 225 mg
2
propafenone hcl tab 300 mg
2
quinidine gluconate tab cr 324 mg
2
quinidine sulfate tab 200 mg
2
quinidine sulfate tab 300 mg
2
sorine tab 80mg
2
sorine tab 120mg
2
sorine tab 160mg
2
sorine tab 240mg
2
sotalol hcl (afib/afl) tab 80 mg
2
sotalol hcl (afib/afl) tab 120 mg
2
sotalol hcl (afib/afl) tab 160 mg
2
sotalol hcl tab 80 mg
1
sotalol hcl tab 120 mg
1
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
28
Drug Name
sotalol hcl tab 160 mg
sotalol hcl tab 240 mg
TIKOSYN CAP 125MCG
TIKOSYN CAP 250MCG
TIKOSYN CAP 500MCG
Drug Tier Requirements/Limits
1
1
4
NM
4
NM
4
NM
ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS
atorvastatin calcium tab 10 mg (base
equivalent)
atorvastatin calcium tab 20 mg (base
equivalent)
atorvastatin calcium tab 40 mg (base
equivalent)
atorvastatin calcium tab 80 mg (base
equivalent)
CRESTOR TAB 5MG
CRESTOR TAB 10MG
CRESTOR TAB 20MG
CRESTOR TAB 40MG
lovastatin tab 10 mg
lovastatin tab 20 mg
lovastatin tab 40 mg
pravastatin sodium tab 10 mg
pravastatin sodium tab 20 mg
pravastatin sodium tab 40 mg
pravastatin sodium tab 80 mg
rosuvastatin calcium tab 5 mg
rosuvastatin calcium tab 10 mg
rosuvastatin calcium tab 20 mg
rosuvastatin calcium tab 40 mg
simvastatin tab 5 mg
simvastatin tab 10 mg
simvastatin tab 20 mg
simvastatin tab 40 mg
simvastatin tab 80 mg
1
QL (30 tabs / 30 days)
1
QL (30 tabs / 30 days)
1
QL (30 tabs / 30 days)
1
QL (30 tabs / 30 days)
3
3
3
3
1
1
1
1
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
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)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
(30 tabs / 30 days)
ANTILIPEMICS, MISCELLANEOUS
cholestyramine light powder 4 gm/dose
2
cholestyramine light powder packets 4 gm 2
cholestyramine powder 4 gm/dose
2
cholestyramine powder packets 4 gm
2
choline fenofibrate cap dr 45 mg (fenofibric 2
acid equiv)
choline fenofibrate cap dr 135 mg (fenofibric 2
acid equiv)
colestipol hcl granule packets 5 gm
2
colestipol hcl granules 5 gm
2
colestipol hcl tab 1 gm
2
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
29
Drug Name
fenofibrate micronized cap 67 mg
fenofibrate micronized cap 134 mg
fenofibrate micronized cap 200 mg
fenofibrate tab 48 mg
fenofibrate tab 54 mg
fenofibrate tab 145 mg
fenofibrate tab 160 mg
gemfibrozil tab 600 mg
JUXTAPID CAP 5MG
JUXTAPID CAP 10MG
JUXTAPID CAP 20MG
JUXTAPID CAP 30MG
JUXTAPID CAP 40MG
JUXTAPID CAP 60MG
KYNAMRO INJ 200MG/ML
niacin tab cr 500 mg (antihyperlipidemic)
niacin tab cr 750 mg (antihyperlipidemic)
niacin tab cr 1000 mg (antihyperlipidemic)
niacor tab 500mg
omega-3-acid ethyl esters cap 1 gm
PRALUENT INJ 75MG/ML
PRALUENT INJ 150MG/ML
prevalite pow 4gm
prevalite pow 4gm pk
VASCEPA CAP 1GM
WELCHOL PAK 3.75GM
WELCHOL TAB 625MG
ZETIA TAB 10MG
Drug Tier Requirements/Limits
2
2
2
2
2
2
2
1
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, PA
2
QL (90 tabs / 30 days)
2
2
2
2
5
NM, PA
5
NM, PA
2
2
4
3
3
3
BETA-BLOCKER/DIURETIC COMBINATIONS
atenolol & chlorthalidone tab 50-25 mg
2
atenolol & chlorthalidone tab 100-25 mg
2
bisoprolol & hydrochlorothiazide tab 2.5-6.251
mg
bisoprolol & hydrochlorothiazide tab 5-6.25 1
mg
bisoprolol & hydrochlorothiazide tab 10-6.25 1
mg
metoprolol & hydrochlorothiazide tab 50-25 2
mg
metoprolol & hydrochlorothiazide tab 100-25 2
mg
metoprolol & hydrochlorothiazide tab 100-50 2
mg
propranolol & hydrochlorothiazide tab 40-25 2
mg
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
30
Drug Name
Drug Tier Requirements/Limits
propranolol & hydrochlorothiazide tab 80-25 2
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 6.25 mg
carvedilol tab 12.5 mg
carvedilol tab 25 mg
labetalol hcl tab 100 mg
labetalol hcl tab 200 mg
labetalol hcl tab 300 mg
metoprolol succinate tab sr 24hr 25 mg
(tartrate equiv)
metoprolol succinate tab sr 24hr 50 mg
(tartrate equiv)
metoprolol succinate tab sr 24hr 100 mg
(tartrate equiv)
metoprolol succinate tab sr 24hr 200 mg
(tartrate equiv)
metoprolol tartrate inj 1 mg/ml
metoprolol tartrate tab 25 mg
metoprolol tartrate tab 50 mg
metoprolol tartrate tab 100 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 cap sr 24hr 80 mg
propranolol hcl cap sr 24hr 120 mg
propranolol hcl cap sr 24hr 160 mg
propranolol hcl inj 1 mg/ml
propranolol hcl oral soln 20 mg/5ml
propranolol hcl oral soln 40 mg/5ml
PA - Prior Authorization
available at mail-order
1
1
1
1
1
2
2
4
4
4
4
1
1
1
1
2
2
2
2
QL (60 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (45 tabs / 30 days)
2
2
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
31
Drug Name
propranolol hcl tab 10 mg
propranolol hcl tab 20 mg
propranolol hcl tab 40 mg
propranolol hcl tab 60 mg
propranolol hcl tab 80 mg
timolol maleate tab 5 mg
timolol maleate tab 10 mg
timolol maleate tab 20 mg
CALCIUM CHANNEL BLOCKERS
Drug Tier Requirements/Limits
1
1
1
1
1
2
2
2
afeditab tab 30mg cr
2
afeditab tab 60mg cr
2
amlodipine besylate tab 2.5 mg
1
amlodipine besylate tab 5 mg
1
amlodipine besylate tab 10 mg
1
diltiazem hcl cap sr 12hr 60 mg
2
diltiazem hcl cap sr 12hr 90 mg
2
diltiazem hcl cap sr 12hr 120 mg
2
diltiazem hcl cap sr 24hr 120 mg
2
diltiazem hcl cap sr 24hr 180 mg
2
diltiazem hcl cap sr 24hr 240 mg
2
diltiazem hcl coated beads cap sr 24hr 120 2
mg
diltiazem hcl coated beads cap sr 24hr 180 2
mg
diltiazem hcl coated beads cap sr 24hr 240 2
mg
diltiazem hcl coated beads cap sr 24hr 300 2
mg
diltiazem hcl coated beads cap sr 24hr 360 2
mg
diltiazem hcl extended release beads cap sr 2
24hr 120 mg
diltiazem hcl extended release beads cap sr 2
24hr 180 mg
diltiazem hcl extended release beads cap sr 2
24hr 240 mg
diltiazem hcl extended release beads cap sr 2
24hr 300 mg
diltiazem hcl extended release beads cap sr 2
24hr 360 mg
diltiazem hcl extended release beads cap sr 2
24hr 420 mg
diltiazem hcl iv soln 25 mg/5ml (5 mg/ml) 2
diltiazem hcl iv soln 50 mg/10ml (5 mg/ml) 2
diltiazem hcl iv soln 125 mg/25ml (5 mg/ml) 2
diltiazem hcl tab 30 mg
1
PA - Prior Authorization
available at mail-order
QL (60 tabs / 30 days)
QL (45 tabs / 30 days)
QL (45 tabs / 30 days)
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
32
Drug Name
Drug Tier Requirements/Limits
diltiazem hcl tab 60 mg
1
diltiazem hcl tab 90 mg
1
diltiazem hcl tab 120 mg
1
felodipine tab sr 24hr 2.5 mg
2
QL (30 tabs / 30 days)
felodipine tab sr 24hr 5 mg
2
QL (60 tabs / 30 days)
felodipine tab sr 24hr 10 mg
2
isradipine cap 2.5 mg
2
isradipine cap 5 mg
2
nicardipine hcl cap 20 mg
2
nicardipine hcl cap 30 mg
2
nifedical xl tab 30mg
2
QL (30 tabs / 30 days)
nifedical xl tab 60mg
2
nifedipine tab sr 24hr 30 mg
2
QL (60 tabs / 30 days)
nifedipine tab sr 24hr 60 mg
2
nifedipine tab sr 24hr 90 mg
2
nifedipine tab sr 24hr osmotic release 30 mg 2
QL (30 tabs / 30 days)
nifedipine tab sr 24hr osmotic release 60 mg 2
nifedipine tab sr 24hr osmotic release 90 mg 2
nimodipine cap 30 mg
5
NYMALIZE SOL 60/20ML
5
taztia xt cap 120mg/24
2
taztia xt cap 180mg/24
2
taztia xt cap 240mg/24
2
taztia xt cap 300mg/24
2
taztia xt cap 360mg/24
2
verapamil hcl cap sr 24hr 100 mg
2
verapamil hcl cap sr 24hr 120 mg
2
verapamil hcl cap sr 24hr 180 mg
2
verapamil hcl cap sr 24hr 200 mg
2
verapamil hcl cap sr 24hr 240 mg
2
verapamil hcl cap sr 24hr 300 mg
2
VERAPAMIL HCL CAP SR 24HR 360 MG
2
verapamil hcl iv soln 2.5 mg/ml
2
verapamil hcl tab 40 mg
1
verapamil hcl tab 80 mg
1
verapamil hcl tab 120 mg
1
verapamil hcl tab cr 120 mg
1
verapamil hcl tab cr 180 mg
1
verapamil hcl tab cr 240 mg
1
DIGITALIS GLYCOSIDES
digitek tab 0.25mg
2
digitek tab 0.125mg
digoxin inj 0.25 mg/ml
2
2
PA - Prior Authorization
available at mail-order
PA; PA if 65 years and
older
QL (30 tabs / 30 days)
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
33
Drug Name
DIGOXIN ORAL SOLN 0.05 MG/ML
digoxin tab 125 mcg (0.125 mg)
digoxin tab 250 mcg (0.25 mg)
Drug Tier Requirements/Limits
2
PA; PA if 65 years and
older
2
QL (30 tabs / 30 days)
2
PA; PA if 65 years and
older
DIRECT RENIN INHIBITORS/COMBINATIONS
TEKTURNA
TEKTURNA
TEKTURNA
TEKTURNA
TEKTURNA
TEKTURNA
HCT TAB 150-12.5
HCT TAB 150-25MG
HCT TAB 300-12.5
HCT TAB 300-25MG
TAB 150MG
TAB 300MG
3
3
3
3
3
3
QL (30 tabs / 30 days)
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
DIURETICS
acetazolamide cap sr 12hr 500 mg
2
acetazolamide tab 125 mg
2
acetazolamide tab 250 mg
2
amiloride & hydrochlorothiazide tab 5-50 mg 1
amiloride hcl tab 5 mg
2
bumetanide inj 0.25 mg/ml
2
bumetanide tab 0.5 mg
2
bumetanide tab 1 mg
2
bumetanide tab 2 mg
2
chlorothiazide tab 250 mg
2
chlorothiazide tab 500 mg
2
chlorthalidone tab 25 mg
2
chlorthalidone tab 50 mg
2
furosemide inj 10 mg/ml
2
FUROSEMIDE INJ 10 MG/ML
2
furosemide oral soln 8 mg/ml
1
furosemide oral soln 10 mg/ml
1
furosemide tab 20 mg
1
furosemide tab 40 mg
1
furosemide tab 80 mg
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
indapamide tab 2.5 mg
1
methazolamide tab 25 mg
2
methazolamide tab 50 mg
2
methyclothiazide tab 5 mg
2
metolazone tab 2.5 mg
2
metolazone tab 5 mg
2
metolazone tab 10 mg
2
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
34
Drug Name
Drug Tier Requirements/Limits
spironolactone & hydrochlorothiazide tab
2
25-25 mg
torsemide inj 50mg/5ml
2
torsemide tab 5 mg
1
torsemide tab 10 mg
1
torsemide tab 20 mg
1
torsemide tab 100 mg
1
triamterene & hydrochlorothiazide cap
1
37.5-25 mg
triamterene & hydrochlorothiazide tab
1
37.5-25 mg
triamterene & hydrochlorothiazide tab 75-50 1
mg
MISCELLANEOUS
clonidine hcl tab 0.1 mg
clonidine hcl tab 0.2 mg
clonidine hcl tab 0.3 mg
clonidine hcl td patch weekly 0.1 mg/24hr
clonidine hcl td patch weekly 0.2 mg/24hr
clonidine hcl td patch weekly 0.3 mg/24hr
DEMSER CAP 250MG
hydralazine hcl inj 20 mg/ml
hydralazine hcl tab 10 mg
hydralazine hcl tab 25 mg
hydralazine hcl tab 50 mg
hydralazine hcl tab 100 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
RANEXA TAB 1000MG
NITRATES
isosorbide dinitrate tab
isosorbide dinitrate tab
isosorbide dinitrate tab
isosorbide dinitrate tab
isosorbide dinitrate tab
isosorbide mononitrate
isosorbide mononitrate
isosorbide mononitrate
isosorbide mononitrate
isosorbide mononitrate
minitran dis 0.1mg/hr
PA - Prior Authorization
available at mail-order
5 mg
10 mg
20 mg
30 mg
cr 40 mg
tab 10 mg
tab 20 mg
tab sr 24hr 30 mg
tab sr 24hr 60 mg
tab sr 24hr 120 mg
1
1
1
2
2
2
5
2
2
2
2
2
2
2
2
2
2
3
3
2
2
2
2
2
1
1
1
1
1
2
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
35
Drug Name
minitran dis 0.2mg/hr
minitran dis 0.4mg/hr
minitran dis 0.6mg/hr
nitro-bid oin 2%
NITRO-DUR DIS 0.3MG/HR
NITRO-DUR DIS 0.8MG/HR
nitroglycerin sl tab 0.3 mg
nitroglycerin sl tab 0.4 mg
nitroglycerin sl tab 0.6 mg
nitroglycerin td patch 24hr 0.1
nitroglycerin td patch 24hr 0.2
nitroglycerin td patch 24hr 0.4
nitroglycerin td patch 24hr 0.6
NITROSTAT SUB 0.3MG
NITROSTAT SUB 0.4MG
NITROSTAT SUB 0.6MG
mg/hr
mg/hr
mg/hr
mg/hr
Drug Tier Requirements/Limits
2
2
2
3
4
4
2
2
2
2
2
2
2
3
3
3
PULMONARY ARTERIAL HYPERTENSION
ADEMPAS TAB 0.5MG
5
ADEMPAS TAB 1.5MG
5
ADEMPAS TAB 1MG
5
ADEMPAS TAB 2.5MG
5
ADEMPAS TAB 2MG
5
LETAIRIS TAB 5MG
5
LETAIRIS TAB 10MG
5
OPSUMIT TAB 10MG
5
REMODULIN INJ 1MG/ML
REMODULIN INJ 2.5MG/ML
REMODULIN INJ 5MG/ML
REMODULIN INJ 10MG/ML
REVATIO SUS 10MG/ML
5
5
5
5
5
sildenafil citrate tab 20 mg
2
TRACLEER TAB 62.5MG
5
TRACLEER TAB 125MG
5
UPTRAVI TAB 200/800
5
PA - Prior Authorization
available at mail-order
QL (90 tabs / 30 days),
NM, LA, PA
QL (90 tabs / 30 days),
NM, LA, PA
QL (90 tabs / 30 days),
NM, LA, PA
QL (90 tabs / 30 days),
NM, LA, PA
QL (90 tabs / 30 days),
NM, LA, PA
QL (30 tabs / 30 days),
NM, LA, PA
QL (30 tabs / 30 days),
NM, LA, PA
QL (30 tabs / 30 days),
NM, LA, PA
B/D, NM, LA
B/D, NM, LA
B/D, NM, LA
B/D, NM, LA
QL (224 mL / 30 days),
NM, PA
QL (90 tabs / 30 days),
NM, PA
QL (120 tabs / 30 days),
NM, LA, PA
QL (60 tabs / 30 days),
NM, LA, PA
NM, LA, PA
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
36
Drug Name
UPTRAVI TAB 200MCG
UPTRAVI TAB 400MCG
UPTRAVI TAB 600MCG
UPTRAVI TAB 800MCG
UPTRAVI TAB 1000MCG
UPTRAVI TAB 1200MCG
UPTRAVI TAB 1400MCG
UPTRAVI TAB 1600MCG
CENTRAL NERVOUS SYSTEM
ANTIANXIETY
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
buspirone hcl tab 10 mg
buspirone hcl tab 15 mg
buspirone hcl tab 30 mg
fluvoxamine maleate tab 25 mg
fluvoxamine maleate tab 50 mg
fluvoxamine maleate tab 100 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
ANTICONVULSANTS
APTIOM TAB 200MG
APTIOM TAB 400MG
APTIOM TAB 600MG
APTIOM TAB 800MG
BANZEL SUS 40MG/ML
BANZEL TAB 200MG
BANZEL TAB 400MG
BRIVIACT INJ 50MG/5ML
BRIVIACT SOL 10MG/ML
PA - Prior Authorization
available at mail-order
Drug Tier Requirements/Limits
5
QL (480 tabs / 30 days),
NM, LA, PA
5
QL (240 tabs / 30 days),
NM, LA, PA
5
QL (150 tabs / 30 days),
NM, LA, PA
5
QL (120 tabs / 30 days),
NM, LA, PA
5
QL (90 tabs / 30 days),
NM, LA, PA
5
QL (60 tabs / 30 days),
NM, LA, PA
5
QL (60 tabs / 30 days),
NM, LA, PA
5
QL (60 tabs / 30 days),
NM, LA, PA
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
1
1
1
QL
QL
QL
QL
4
5
5
5
5
4
5
4
5
QL
QL
QL
QL
PA
PA
PA
PA
PA
(240
(480
(120
(150
tabs
tabs
tabs
tabs
/
/
/
/
30
30
30
30
days)
days)
days)
days)
QL (45 tabs / 30 days)
QL (45 tabs / 30 days)
QL (150 mL / 30 days)
QL (150 tabs / 30 days)
QL (150 tabs / 30 days)
QL (150 tabs / 30 days)
(180 tabs / 30 days)
(90 tabs / 30 days)
(60 tabs / 30 days)
(30 tabs / 30 days)
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
37
Drug Name
Drug Tier Requirements/Limits
BRIVIACT TAB 10MG
5
PA
BRIVIACT TAB 25MG
5
PA
BRIVIACT TAB 50MG
5
PA
BRIVIACT TAB 75MG
5
PA
BRIVIACT TAB 100MG
5
PA
carbamazepine cap sr 12hr 100 mg
2
carbamazepine cap sr 12hr 200 mg
2
carbamazepine cap sr 12hr 300 mg
2
carbamazepine chew tab 100 mg
2
carbamazepine susp 100 mg/5ml
2
carbamazepine tab 200 mg
2
carbamazepine tab sr 12hr 100 mg
2
carbamazepine tab sr 12hr 200 mg
2
carbamazepine tab sr 12hr 400 mg
2
CELONTIN CAP 300MG
4
clonazepam orally disintegrating tab 0.5 mg 2
QL (240 tabs / 30 days)
clonazepam orally disintegrating tab 0.25 mg2
QL (480 tabs / 30 days)
clonazepam orally disintegrating tab 0.125 2
QL (960 tabs / 30 days)
mg
clonazepam orally disintegrating tab 1 mg
2
QL (120 tabs / 30 days)
clonazepam orally disintegrating tab 2 mg
2
QL (300 tabs / 30 days)
clonazepam tab 0.5 mg
1
QL (240 tabs / 30 days)
clonazepam tab 1 mg
1
QL (120 tabs / 30 days)
clonazepam tab 2 mg
1
QL (300 tabs / 30 days)
clorazepate dipotassium tab 3.75 mg
2
QL (120 tabs / 30 days),
PA
clorazepate dipotassium tab 7.5 mg
2
QL (120 tabs / 30 days),
PA
clorazepate dipotassium tab 15 mg
2
QL (180 tabs / 30 days),
PA
diazepam con 5mg/ml
2
QL (240 mL / 30 days),
PA
diazepam inj 5 mg/ml
2
diazepam oral soln 1 mg/ml
2
QL (1200 mL / 30 days),
PA
DIAZEPAM RECTAL GEL DELIVERY SYSTEM 2
2.5 MG
DIAZEPAM RECTAL GEL DELIVERY SYSTEM 2
10 MG
DIAZEPAM RECTAL GEL DELIVERY SYSTEM 2
20 MG
diazepam tab 2 mg
1
QL (120 tabs / 30 days),
PA
diazepam tab 5 mg
1
QL (120 tabs / 30 days),
PA
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
38
Drug Name
diazepam tab 10 mg
dilantin cap 30mg
dilantin cap 100mg
dilantin chw 50mg
DILANTIN-125 SUS 125/5ML
divalproex sodium cap delayed release
sprinkle 125 mg
divalproex sodium tab delayed release 125
mg
divalproex sodium tab delayed release 250
mg
divalproex sodium tab delayed release 500
mg
divalproex sodium tab sr 24 hr 250 mg
divalproex sodium tab sr 24 hr 500 mg
epitol tab 200mg
ethosuximide cap 250 mg
ethosuximide soln 250 mg/5ml
felbamate susp 600 mg/5ml
felbamate tab 400 mg
felbamate tab 600 mg
FYCOMPA SUS 0.5MG/ML
Drug Tier Requirements/Limits
1
QL (120 tabs / 30 days),
PA
3
3
3
3
2
2
2
2
2
2
2
2
2
5
2
2
4
FYCOMPA TAB 2MG
4
FYCOMPA TAB 4MG
4
FYCOMPA TAB 6MG
4
FYCOMPA TAB 8MG
4
FYCOMPA TAB 10MG
4
FYCOMPA TAB 12MG
4
gabapentin cap 100 mg
gabapentin cap 300 mg
gabapentin cap 400 mg
gabapentin oral soln 250 mg/5ml
gabapentin tab 600 mg
gabapentin tab 800 mg
GABITRIL TAB 12MG
GABITRIL TAB 16MG
lamotrigine tab 25 mg
lamotrigine tab 100 mg
1
1
1
2
2
2
4
4
1
1
PA - Prior Authorization
available at mail-order
QL
PA
QL
PA
QL
PA
QL
PA
QL
PA
QL
PA
QL
PA
QL
QL
QL
QL
QL
QL
(720 mL / 30 days),
(180 tabs / 30 days),
(90 tabs / 30 days),
(60 tabs / 30 days),
(30 tabs / 30 days),
(30 tabs / 30 days),
(30 tabs / 30 days),
(1080 caps / 30 days)
(360 caps / 30 days)
(270 caps / 30 days)
(2160 mL / 30 days)
(180 tabs / 30 days)
(120 tabs / 30 days)
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
39
Drug Name
Drug Tier Requirements/Limits
lamotrigine tab 150 mg
1
lamotrigine tab 200 mg
1
lamotrigine tab chewable dispersible 5 mg 2
lamotrigine tab chewable dispersible 25 mg 2
lamotrigine tab sr 24hr 25 mg
2
lamotrigine tab sr 24hr 50 mg
2
lamotrigine tab sr 24hr 100 mg
2
lamotrigine tab sr 24hr 200 mg
2
lamotrigine tab sr 24hr 250 mg
2
lamotrigine tab sr 24hr 300 mg
2
LEVETIRACETA INJ 5MG/ML
4
LEVETIRACETA INJ 10MG/ML
4
LEVETIRACETA INJ 15MG/ML
4
levetiracetam inj 500 mg/5ml (100 mg/ml) 2
levetiracetam oral soln 100 mg/ml
2
levetiracetam tab 250 mg
2
levetiracetam tab 500 mg
2
levetiracetam tab 750 mg
2
levetiracetam tab 1000 mg
2
levetiracetam tab sr 24hr 500 mg
2
levetiracetam tab sr 24hr 750 mg
2
LYRICA CAP 25MG
3
QL (120 caps / 30 days)
LYRICA CAP 50MG
3
QL (120 caps / 30 days)
LYRICA CAP 75MG
3
QL (120 caps / 30 days)
LYRICA CAP 100MG
3
QL (120 caps / 30 days)
LYRICA CAP 150MG
3
QL (120 caps / 30 days)
LYRICA CAP 200MG
3
QL (90 caps / 30 days)
LYRICA CAP 225MG
3
QL (60 caps / 30 days)
LYRICA CAP 300MG
3
QL (60 caps / 30 days)
LYRICA SOL 20MG/ML
3
QL (946 mL / 30 days)
ONFI SUS 2.5MG/ML
5
PA
ONFI TAB 10MG
4
PA
ONFI TAB 20MG
5
PA
oxcarbazepine susp 300 mg/5ml (60 mg/ml) 2
oxcarbazepine tab 150 mg
2
oxcarbazepine tab 300 mg
2
oxcarbazepine tab 600 mg
2
PEGANONE TAB 250MG
4
PHENOBARB INJ 65MG/ML
4
PA; PA if 65 years and
older
phenobarbital elixir 20 mg/5ml
4
PA; PA if 65 years and
older
phenobarbital sodium inj 130 mg/ml
4
PA; PA if 65 years and
older
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
40
Drug Name
phenobarbital tab 15 mg
phenobarbital tab 16.2 mg
phenobarbital tab 30 mg
phenobarbital tab 32.4 mg
phenobarbital tab 60 mg
phenobarbital tab 64.8 mg
phenobarbital tab 97.2 mg
phenobarbital tab 100 mg
phenytek cap 200mg
phenytek cap 300mg
phenytoin chew tab 50 mg
phenytoin sodium extended cap 100 mg
phenytoin sodium extended cap 200 mg
phenytoin sodium extended cap 300 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
roweepra tab 500mg
SABRIL POW 500MG
SABRIL TAB 500MG
SPRITAM TAB 250MG
SPRITAM TAB 500MG
SPRITAM TAB 750MG
SPRITAM TAB 1000MG
TEGRETOL SUS 100/5ML
TEGRETOL TAB 200MG
TEGRETOL-XR TAB 100MG
TEGRETOL-XR TAB 200MG
TEGRETOL-XR TAB 400MG
tiagabine hcl tab 2 mg
tiagabine hcl tab 4 mg
PA - Prior Authorization
available at mail-order
Drug Tier Requirements/Limits
4
PA; PA if 65 years and
older
4
PA; PA if 65 years and
older
4
PA; PA if 65 years and
older
4
PA; PA if 65 years and
older
4
PA; PA if 65 years and
older
4
PA; PA if 65 years and
older
4
PA; PA if 65 years and
older
4
PA; PA if 65 years and
older
3
3
2
2
2
2
2
2
4
5
QL (180 tabs / 30 days)
5
QL (90 tabs / 30 days)
5
QL (90 tabs / 30 days)
2
2
2
5
QL (180 packets / 30
days), NM, LA, PA
5
QL (180 tabs / 30 days),
NM, LA, PA
4
4
4
4
4
4
4
4
4
2
2
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
41
Drug Name
topiramate sprinkle cap 15 mg
topiramate sprinkle cap 25 mg
topiramate tab 25 mg
topiramate tab 50 mg
topiramate tab 100 mg
topiramate tab 200 mg
valproate sodium inj 100 mg/ml
valproate sodium syrup 250 mg/5ml (base
equiv)
valproic acid cap 250 mg
VIMPAT INJ 200MG/20
VIMPAT SOL 10MG/ML
VIMPAT TAB 50MG
VIMPAT TAB 100MG
VIMPAT TAB 150MG
VIMPAT TAB 200MG
zonisamide cap 25 mg
zonisamide cap 50 mg
zonisamide cap 100 mg
ANTIDEMENTIA
donepezil hydrochloride
tab 5 mg
donepezil hydrochloride
tab 10 mg
donepezil hydrochloride
donepezil hydrochloride
donepezil hydrochloride
EXELON DIS 4.6MG/24
Drug Tier Requirements/Limits
2
2
1
1
1
1
2
2
2
4
4
4
5
5
5
2
2
2
orally disintegrating 2
(1200 mL / 30 days)
(180 tabs / 30 days)
(60 tabs / 30 days)
(60 tabs / 30 days)
(60 tabs / 30 days)
QL (30 tabs / 30 days)
orally disintegrating 2
tab 5 mg
tab 10 mg
tab 23 mg
2
2
2
4
EXELON DIS 9.5MG/24
4
EXELON DIS 13.3/24
4
galantamine hydrobromide cap sr 24hr 8 mg 2
galantamine hydrobromide cap sr 24hr 16 mg2
galantamine hydrobromide cap sr 24hr 24 mg2
galantamine hydrobromide oral soln 4 mg/ml2
galantamine hydrobromide tab 4 mg
2
galantamine hydrobromide tab 8 mg
2
galantamine hydrobromide tab 12 mg
2
memantine hcl oral solution 2 mg/ml
2
memantine hcl tab 5 mg
2
memantine hcl tab 10 mg
2
NAMENDA XR CAP 7MG
4
NAMENDA XR CAP 14MG
4
NAMENDA XR CAP 21MG
4
PA - Prior Authorization
available at mail-order
QL
QL
QL
QL
QL
QL (30 tabs / 30 days)
QL (30
days)
QL (30
days)
QL (30
days)
QL (30
QL (30
patches / 30
patches / 30
patches / 30
caps / 30 days)
caps / 30 days)
QL (180 tabs / 30 days)
QL (90 tabs / 30 days)
PA;
PA;
PA;
PA;
PA;
PA;
PA
PA
PA
PA
PA
PA
if
if
if
if
if
if
<
<
<
<
<
<
30
30
30
30
30
30
yrs
yrs
yrs
yrs
yrs
yrs
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
42
Drug Name
NAMENDA XR CAP 28MG
NAMENDA XR CAP TITRATIO
NAMZARIC CAP 7-10MG
NAMZARIC CAP 14-10MG
NAMZARIC CAP 21-10MG
NAMZARIC CAP 28-10MG
rivastigmine tartrate cap 1.5 mg
rivastigmine tartrate cap 3 mg
rivastigmine tartrate cap 4.5 mg
rivastigmine tartrate cap 6 mg
rivastigmine td patch 24hr 4.6 mg/24hr
rivastigmine td patch 24hr 9.5 mg/24hr
rivastigmine td patch 24hr 13.3 mg/24hr
ANTIDEPRESSANTS
Drug Tier Requirements/Limits
4
PA; PA if < 30 yrs
4
PA; PA if < 30 yrs
4
4
4
4
2
2
2
2
2
QL (30 patches / 30
days)
2
QL (30 patches / 30
days)
2
QL (30 patches / 30
days)
amitriptyline hcl tab 10 mg
4
amitriptyline hcl tab 25 mg
4
amitriptyline hcl tab 50 mg
4
amitriptyline hcl tab 75 mg
4
amitriptyline hcl tab 100 mg
4
amitriptyline hcl tab 150 mg
4
amoxapine tab 25 mg
2
amoxapine tab 50 mg
2
amoxapine tab 100 mg
2
amoxapine tab 150 mg
2
BRINTELLIX TAB 5MG
4
BRINTELLIX TAB 10MG
4
BRINTELLIX TAB 20MG
4
bupropion hcl tab 75 mg
2
bupropion hcl tab 100 mg
2
bupropion hcl tab sr 12hr 100 mg
2
bupropion hcl tab sr 12hr 150 mg
2
bupropion hcl tab sr 12hr 200 mg
2
bupropion hcl tab sr 24hr 150 mg
2
bupropion hcl tab sr 24hr 300 mg
2
citalopram hydrobromide oral soln 10 mg/5ml2
citalopram hydrobromide tab 10 mg (base 1
equiv)
PA - Prior Authorization
available at mail-order
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
QL (120 tabs / 30 days)
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
QL (90 tabs / 30 days)
QL (30 tabs / 30 days)
QL (45 tabs / 30 days)
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
43
Drug Name
citalopram hydrobromide tab 20 mg (base
equiv)
citalopram hydrobromide tab 40 mg (base
equiv)
clomipramine hcl cap 25 mg
Drug Tier Requirements/Limits
1
QL (45 tabs / 30 days)
1
QL (30 tabs / 30 days)
4
PA; PA if 65 years and
older
PA; PA if 65 years and
older
PA; PA if 65 years and
older
clomipramine hcl cap 50 mg
4
clomipramine hcl cap 75 mg
4
desipramine hcl tab 10 mg
desipramine hcl tab 25 mg
desipramine hcl tab 50 mg
desipramine hcl tab 75 mg
desipramine hcl tab 100 mg
desipramine hcl tab 150 mg
doxepin hcl cap 10 mg
2
2
2
2
2
2
4
doxepin hcl cap 25 mg
4
doxepin hcl cap 50 mg
4
doxepin hcl cap 75 mg
4
doxepin hcl cap 100 mg
4
doxepin hcl cap 150 mg
4
doxepin hcl conc 10 mg/ml
4
duloxetine hcl enteric coated pellets cap 20 2
mg
duloxetine hcl enteric coated pellets cap 30 2
mg
duloxetine hcl enteric coated pellets cap 60 2
mg
EMSAM DIS 6MG/24HR
5
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
QL (60
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
caps / 30 days)
QL (60 caps / 30 days)
QL (60 caps / 30 days)
EMSAM DIS 9MG/24HR
5
EMSAM DIS 12MG/24H
5
escitalopram
equiv)
escitalopram
escitalopram
escitalopram
2
QL (30 patches / 30
days), PA
QL (30 patches / 30
days), PA
QL (30 patches / 30
days), PA
QL (600 mL / 30 days)
oxalate tab 5 mg (base equiv) 2
oxalate tab 10 mg (base equiv) 2
oxalate tab 20 mg (base equiv) 2
QL (45 tabs / 30 days)
QL (45 tabs / 30 days)
QL (60 tabs / 30 days)
oxalate soln 5 mg/5ml (base
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
44
Drug Name
FETZIMA CAP 20MG
FETZIMA CAP 40MG
FETZIMA CAP 80MG
FETZIMA CAP 120MG
FETZIMA CAP TITRATIO
fluoxetine hcl cap 10 mg
fluoxetine hcl cap 20 mg
fluoxetine hcl cap 40 mg
fluoxetine hcl solution 20 mg/5ml
fluoxetine hcl tab 10 mg
fluoxetine hcl tab 20 mg
imipramine hcl tab 10 mg
Drug Tier Requirements/Limits
4
QL (180 caps / 30 days)
4
QL (90 caps / 30 days)
4
QL (30 caps / 30 days)
4
QL (30 caps / 30 days)
4
1
QL (30 caps / 30 days)
1
QL (120 caps / 30 days)
1
2
2
QL (45 tabs / 30 days)
2
4
PA; PA if 65 years and
older
imipramine hcl tab 25 mg
4
PA; PA if 65 years and
older
imipramine hcl tab 50 mg
4
PA; PA if 65 years and
older
maprotiline hcl tab 25 mg
2
maprotiline hcl tab 50 mg
2
maprotiline hcl tab 75 mg
2
MARPLAN TAB 10MG
4
QL (180 tabs / 30 days)
mirtazapine orally disintegrating tab 15 mg 2
QL (30 tabs / 30 days)
mirtazapine orally disintegrating tab 30 mg 2
mirtazapine orally disintegrating tab 45 mg 2
mirtazapine tab 7.5 mg
1
QL (45 tabs / 30 days)
mirtazapine tab 15 mg
1
QL (45 tabs / 30 days)
mirtazapine tab 30 mg
1
mirtazapine tab 45 mg
1
nefazodone hcl tab 50 mg
2
nefazodone hcl tab 100 mg
2
nefazodone hcl tab 150 mg
2
nefazodone hcl tab 200 mg
2
nefazodone hcl tab 250 mg
2
nortriptyline hcl cap 10 mg
1
nortriptyline hcl cap 25 mg
1
nortriptyline hcl cap 50 mg
1
nortriptyline hcl cap 75 mg
1
nortriptyline hcl soln 10 mg/5ml
2
paroxetine hcl tab 10 mg
1
QL (45 tabs / 30 days)
paroxetine hcl tab 20 mg
1
QL (45 tabs / 30 days)
paroxetine hcl tab 30 mg
1
QL (60 tabs / 30 days)
paroxetine hcl tab 40 mg
1
QL (45 tabs / 30 days)
PAXIL SUS 10MG/5ML
4
QL (900 mL / 30 days)
phenelzine sulfate tab 15 mg
2
PRISTIQ TAB 25MG
3
QL (30 tabs / 30 days)
PRISTIQ TAB 50MG
3
QL (30 tabs / 30 days)
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
45
Drug Name
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
sertraline hcl tab 50 mg
sertraline hcl tab 100 mg
SURMONTIL CAP 25MG
SURMONTIL CAP 50MG
SURMONTIL CAP 100MG
tranylcypromine sulfate tab 10 mg
trazodone hcl tab 50 mg
trazodone hcl tab 100 mg
trazodone hcl tab 150 mg
trimipramine maleate cap 25 mg
trimipramine maleate cap 50 mg
trimipramine maleate cap 100 mg
TRINTELLIX TAB 5MG
TRINTELLIX TAB 10MG
TRINTELLIX TAB 20MG
venlafaxine hcl cap sr 24hr 37.5 mg (base
equivalent)
venlafaxine hcl cap sr 24hr 75 mg (base
equivalent)
venlafaxine hcl cap sr 24hr 150 mg (base
equivalent)
venlafaxine hcl tab 25 mg
venlafaxine hcl tab 37.5 mg
venlafaxine hcl tab 50 mg
venlafaxine hcl tab 75 mg
venlafaxine hcl tab 100 mg
VIIBRYD KIT
VIIBRYD KIT STARTER
VIIBRYD TAB 10MG
PA - Prior Authorization
available at mail-order
Drug Tier Requirements/Limits
3
QL (30 tabs / 30 days)
2
2
2
1
QL (45 tabs / 30 days)
1
QL (45 tabs / 30 days)
1
4
QL (240 caps / 30 days),
PA; PA if 65 years and
older
4
QL (120 caps / 30 days),
PA; PA if 65 years and
older
4
QL (60 caps / 30 days),
PA; PA if 65 years and
older
2
1
1
1
4
QL (240 caps / 30 days),
PA; PA if 65 years and
older
4
QL (120 caps / 30 days),
PA; PA if 65 years and
older
4
QL (60 caps / 30 days),
PA; PA if 65 years and
older
4
QL (120 tabs / 30 days)
4
QL (60 tabs / 30 days)
4
QL (30 tabs / 30 days)
2
QL (30 caps / 30 days)
2
QL (30 caps / 30 days)
2
QL (60 caps / 30 days)
2
2
2
2
2
4
4
4
QL (30 tabs / 30 days)
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
46
Drug Name
VIIBRYD TAB 20MG
VIIBRYD TAB 40MG
Drug Tier Requirements/Limits
4
QL (30 tabs / 30 days)
4
QL (30 tabs / 30 days)
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
2
2
2
5
3
3
2
4
benztropine mesylate tab 1 mg
4
benztropine mesylate tab 2 mg
4
bromocriptine mesylate cap 5 mg (base
2
equivalent)
bromocriptine mesylate tab 2.5 mg (base
2
equivalent)
carbidopa & levodopa orally disintegrating tab2
10-100 mg
carbidopa & levodopa orally disintegrating tab2
25-100 mg
carbidopa & levodopa orally disintegrating tab2
25-250 mg
carbidopa & levodopa tab 10-100 mg
2
carbidopa & levodopa tab 25-100 mg
2
carbidopa & levodopa tab 25-250 mg
2
carbidopa & levodopa tab cr 25-100 mg
2
carbidopa & levodopa tab cr 50-200 mg
2
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 2
12.5-50-200 MG
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 2
18.75-75-200 MG
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 2
25-100-200 MG
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 2
31.25-125-200 MG
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 2
37.5-150-200 MG
CARBIDOPA-LEVODOPA-ENTACAPONE TABS 2
50-200-200 MG
ENTACAPONE TAB 200 MG
2
NEUPRO DIS 1MG/24HR
4
NEUPRO DIS 2MG/24HR
4
PA - Prior Authorization
available at mail-order
NM, LA, PA
PA; PA if 65 years and
older
PA; PA if 65 years and
older
PA; PA if 65 years and
older
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
47
Drug Name
NEUPRO DIS 3MG/24HR
NEUPRO DIS 4MG/24HR
NEUPRO DIS 6MG/24HR
NEUPRO DIS 8MG/24HR
pramipexole dihydrochloride tab 0.5 mg
pramipexole dihydrochloride tab 0.25 mg
pramipexole dihydrochloride tab 0.75 mg
pramipexole dihydrochloride tab 0.125 mg
pramipexole dihydrochloride tab 1 mg
pramipexole dihydrochloride tab 1.5 mg
ropinirole hydrochloride tab 0.5 mg
ropinirole hydrochloride tab 0.25 mg
ropinirole hydrochloride tab 1 mg
ropinirole hydrochloride tab 2 mg
ropinirole hydrochloride tab 3 mg
ropinirole hydrochloride tab 4 mg
ropinirole hydrochloride tab 5 mg
selegiline hcl cap 5 mg
selegiline hcl tab 5 mg
trihexyphenidyl hcl elixir 0.4 mg/ml
trihexyphenidyl hcl tab 2 mg
trihexyphenidyl hcl tab 5 mg
ANTIPSYCHOTICS
Drug Tier Requirements/Limits
4
4
4
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
PA; PA if 65 years and
older
3
PA; PA if 65 years and
older
3
PA; PA if 65 years and
older
ABILIFY DISC TAB 10MG
5
ABILIFY MAIN INJ 300MG
5
ABILIFY MAIN INJ 400MG
5
aripiprazole oral solution 1 mg/ml
5
aripiprazole orally disintegrating tab 10 mg 5
aripiprazole orally disintegrating tab 15 mg 5
aripiprazole tab 2 mg
5
aripiprazole tab 5 mg
5
aripiprazole tab 10 mg
5
aripiprazole tab 15 mg
5
aripiprazole tab 20 mg
5
aripiprazole tab 30 mg
5
chlorpromaz inj 25mg/ml
4
chlorpromaz inj 50mg/2ml
4
chlorpromazine hcl tab 10 mg
2
chlorpromazine hcl tab 25 mg
2
chlorpromazine hcl tab 50 mg
2
chlorpromazine hcl tab 100 mg
2
chlorpromazine hcl tab 200 mg
2
PA - Prior Authorization
available at mail-order
QL (60 tabs / 30 days)
QL (1 injection / 28 days)
QL (1 injection / 28 days)
QL (900ml / 30 days)
QL (60 tabs / 30 days)
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
48
Drug Name
CLOZAPINE ORALLY DISINTEGRATING
12.5 MG
CLOZAPINE ORALLY DISINTEGRATING
25 MG
CLOZAPINE ORALLY DISINTEGRATING
100 MG
CLOZAPINE ORALLY DISINTEGRATING
150 MG
CLOZAPINE ORALLY DISINTEGRATING
200 MG
clozapine tab 25 mg
clozapine tab 50 mg
clozapine tab 100 mg
clozapine tab 200 mg
FANAPT PAK
FANAPT TAB 1MG
Drug Tier Requirements/Limits
TAB 2
PA
TAB 2
PA
TAB 2
QL (270 tabs / 30 days),
PA
QL (180 tabs / 30 days),
PA
QL (135 tabs / 30 days),
PA
TAB 5
TAB 5
2
2
2
2
4
4
FANAPT TAB 2MG
4
FANAPT TAB 4MG
4
FANAPT TAB 6MG
4
FANAPT TAB 8MG
4
FANAPT TAB 10MG
4
FANAPT TAB 12MG
4
FAZACLO TAB 150 ODT
5
FAZACLO TAB 200 ODT
5
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
fluphenazine hcl tab 5 mg
fluphenazine hcl tab 10 mg
GEODON INJ 20MG
haloperidol decanoate im soln 50 mg/ml
haloperidol decanoate im soln 100 mg/ml
haloperidol lactate inj 5 mg/ml
haloperidol lactate oral conc 2 mg/ml
2
2
2
2
2
2
2
2
4
2
2
2
2
PA - Prior Authorization
available at mail-order
QL
QL
ST
QL
ST
QL
ST
QL
ST
QL
ST
QL
ST
QL
ST
QL
ST
QL
PA
QL
PA
(270 tabs / 30 days)
(135 tabs / 30 days)
(60 tabs / 30 days),
(60 tabs / 30 days),
(60 tabs / 30 days),
(60 tabs / 30 days),
(60 tabs / 30 days),
(60 tabs / 30 days),
(60 tabs / 30 days),
(180 tabs / 30 days),
(135 tabs / 30 days),
QL (6 mL / 3 days)
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
49
Drug Name
haloperidol tab 0.5 mg
haloperidol tab 1 mg
haloperidol tab 2 mg
haloperidol tab 5 mg
haloperidol tab 10 mg
haloperidol tab 20 mg
INVEGA SUST INJ 39/0.25
INVEGA SUST INJ 78/0.5ML
INVEGA SUST INJ 117/0.75
INVEGA SUST INJ 156MG/ML
INVEGA SUST INJ 234/1.5
INVEGA TAB 1.5MG
INVEGA TAB 3MG
INVEGA TAB 6MG
INVEGA TAB 9MG
INVEGA TRINZ INJ 273MG
INVEGA TRINZ INJ 410MG
INVEGA TRINZ INJ 546MG
INVEGA TRINZ INJ 819MG
LATUDA TAB 20MG
LATUDA TAB 40MG
LATUDA TAB 60MG
LATUDA TAB 80MG
LATUDA TAB 120MG
loxapine succinate cap 5 mg
loxapine succinate cap 10 mg
loxapine succinate cap 25 mg
loxapine succinate cap 50 mg
molindone hcl tab 5 mg
molindone hcl tab 10 mg
molindone hcl tab 25 mg
NUPLAZID TAB 17MG
olanzapine for im inj 10 mg
olanzapine orally disintegrating tab
olanzapine orally disintegrating tab
olanzapine orally disintegrating tab
olanzapine orally disintegrating tab
olanzapine tab 2.5 mg
olanzapine tab 5 mg
olanzapine tab 7.5 mg
olanzapine tab 10 mg
olanzapine tab 15 mg
olanzapine tab 20 mg
paliperidone tab sr 24hr 1.5 mg
paliperidone tab sr 24hr 3 mg
PA - Prior Authorization
available at mail-order
5 mg
10 mg
15 mg
20 mg
Drug Tier Requirements/Limits
2
2
2
2
2
2
4
QL (1 injection / 28 days)
5
QL (1 injection / 28 days)
5
QL (1 injection / 28 days)
5
QL (1 injection / 28 days)
5
QL (1 injection / 28 days)
4
QL (30 tabs / 30 days)
4
QL (30 tabs / 30 days)
4
QL (60 tabs / 30 days)
4
QL (30 tabs / 30 days)
5
QL (1 syringe / 90 days)
5
QL (1 syringe / 90 days)
5
QL (1 syringe / 90 days)
5
QL (1 syringe / 90 days)
4
QL (240 tabs / 30 days)
4
QL (30 tabs / 30 days)
4
QL (60 tabs / 30 days)
4
QL (60 tabs / 30 days)
4
QL (30 tabs / 30 days)
2
2
2
2
2
2
2
5
QL (60 tabs / 30 days),
NM, LA, PA
2
QL (3 vials / 1 day)
2
QL (30 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (30 tabs / 30 days)
2
QL (30 tabs / 30 days)
2
QL (30 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (30 tabs / 30 days)
2
QL (30 tabs / 30 days)
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
50
Drug Name
paliperidone tab sr 24hr 6 mg
paliperidone tab sr 24hr 9 mg
perphenazine tab 2 mg
perphenazine tab 4 mg
perphenazine tab 8 mg
perphenazine tab 16 mg
pimozide tab 1 mg
pimozide tab 2 mg
quetiapine fumarate tab 25 mg
quetiapine fumarate tab 50 mg
quetiapine fumarate tab 100 mg
quetiapine fumarate tab 200 mg
quetiapine fumarate tab 300 mg
quetiapine fumarate tab 400 mg
REXULTI TAB 0.5MG
REXULTI TAB 0.25MG
REXULTI TAB 1MG
REXULTI TAB 2MG
REXULTI TAB 3MG
REXULTI TAB 4MG
RISPERDAL INJ 12.5MG
RISPERDAL INJ 25MG
RISPERDAL INJ 37.5MG
RISPERDAL INJ 50MG
risperidone
risperidone
risperidone
risperidone
risperidone
risperidone
risperidone
risperidone
risperidone
risperidone
risperidone
risperidone
orally disintegrating
orally disintegrating
orally disintegrating
orally disintegrating
orally disintegrating
orally disintegrating
soln 1 mg/ml
tab 0.5 mg
tab 0.25 mg
tab 1 mg
tab 2 mg
tab 3 mg
PA - Prior Authorization
available at mail-order
tab
tab
tab
tab
tab
tab
Drug Tier Requirements/Limits
2
QL (60 tabs / 30 days)
2
QL (30 tabs / 30 days)
2
2
2
2
2
2
2
QL (90 tabs / 30 days)
2
QL (90 tabs / 30 days)
2
QL (90 tabs / 30 days)
2
QL (90 tabs / 30 days)
2
QL (90 tabs / 30 days)
2
QL (90 tabs / 30 days)
5
QL (180 tabs / 30 days),
ST
5
QL (360 tabs / 30 days),
ST
5
QL (90 tabs / 30 days),
ST
5
QL (60 tabs / 30 days),
ST
5
QL (30 tabs / 30 days),
ST
5
QL (30 tabs / 30 days),
ST
4
QL (2 injections / 28
days)
4
QL (2 injections / 28
days)
5
QL (2 injections / 28
days)
5
QL (2 injections / 28
days)
0.5 mg 2
QL (90 tabs / 30 days)
0.25 mg 2
QL (90 tabs / 30 days)
1 mg
2
QL (60 tabs / 30 days)
2 mg
2
QL (60 tabs / 30 days)
3 mg
2
QL (60 tabs / 30 days)
4 mg
2
QL (120 tabs / 30 days)
2
QL (240 mL / 30 days)
2
QL (90 tabs / 30 days)
2
QL (90 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (60 tabs / 30 days)
2
QL (60 tabs / 30 days)
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
51
Drug Name
risperidone tab 4 mg
SAPHRIS SUB 2.5MG
SAPHRIS SUB 5MG
SAPHRIS SUB 10MG
SEROQUEL XR TAB 50MG
SEROQUEL XR TAB 150MG
SEROQUEL XR TAB 200MG
SEROQUEL XR TAB 300MG
SEROQUEL XR TAB 400MG
thioridazine hcl tab 10 mg
thioridazine hcl tab 25 mg
thioridazine hcl tab 50 mg
thioridazine hcl tab 100 mg
thiothixene cap 1 mg
thiothixene cap 2 mg
thiothixene cap 5 mg
thiothixene cap 10 mg
trifluoperazine hcl tab 1 mg
trifluoperazine hcl tab 2 mg
trifluoperazine hcl tab 5 mg
trifluoperazine hcl tab 10 mg
VERSACLOZ SUS 50MG/ML
VRAYLAR CAP 1.5-3MG
VRAYLAR CAP 1.5MG
VRAYLAR CAP 3MG
VRAYLAR CAP 4.5MG
VRAYLAR CAP 6MG
ziprasidone hcl
ziprasidone hcl
ziprasidone hcl
ziprasidone hcl
ZYPREXA RELP
ZYPREXA RELP
ZYPREXA RELP
cap 20 mg
cap 40 mg
cap 60 mg
cap 80 mg
INJ 210MG
INJ 300MG
INJ 405MG
Drug Tier Requirements/Limits
2
QL (120 tabs / 30 days)
4
QL (240 tabs / 30 days)
4
QL (120 tabs / 30 days)
4
QL (60 tabs / 30 days)
4
QL (120 tabs / 30 days)
4
QL (30 tabs / 30 days)
4
QL (30 tabs / 30 days)
4
QL (60 tabs / 30 days)
4
QL (60 tabs / 30 days)
4
PA; PA if 65 years and
older
4
PA; PA if 65 years and
older
4
PA; PA if 65 years and
older
4
PA; PA if 65 years and
older
2
2
2
2
2
2
2
2
5
QL (600 mL / 30 days),
PA
4
ST
5
QL (120 caps / 30 days),
ST
5
QL (60 caps / 30 days),
ST
5
QL (30 caps / 30 days),
ST
5
QL (30 caps / 30 days),
ST
2
QL (60 caps / 30 days)
2
QL (60 caps / 30 days)
2
QL (90 caps / 30 days)
2
QL (90 caps / 30 days)
5
QL (2 vials / 28 days), PA
5
QL (2 vials / 28 days), PA
5
QL (1 vial / 28 days), PA
ATTENTION DEFICIT HYPERACTIVITY DISORDER
amphetamine-dextroamphetamine cap sr
24hr 5 mg
PA - Prior Authorization
available at mail-order
2
QL (90 caps / 30 days)
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
52
Drug Name
Drug Tier Requirements/Limits
amphetamine-dextroamphetamine cap sr
2
QL (90 caps / 30 days)
24hr 10 mg
amphetamine-dextroamphetamine cap sr
2
QL (30 caps / 30 days)
24hr 15 mg
amphetamine-dextroamphetamine cap sr
2
QL (30 caps / 30 days)
24hr 20 mg
amphetamine-dextroamphetamine cap sr
2
QL (30 caps / 30 days)
24hr 25 mg
amphetamine-dextroamphetamine cap sr
2
QL (30 caps / 30 days)
24hr 30 mg
amphetamine-dextroamphetamine tab 5 mg 2
QL (360 tabs / 30 days)
amphetamine-dextroamphetamine tab 7.5 2
QL (240 tabs / 30 days)
mg
amphetamine-dextroamphetamine tab 10 mg2
QL (180 tabs / 30 days)
amphetamine-dextroamphetamine tab 12.5 2
QL (144 tabs / 30 days)
mg
amphetamine-dextroamphetamine tab 15 mg2
QL (120 tabs / 30 days)
amphetamine-dextroamphetamine tab 20 mg2
QL (90 tabs / 30 days)
amphetamine-dextroamphetamine tab 30 mg2
QL (60 tabs / 30 days)
guanfacine hcl tab sr 24hr 1 mg (base equiv)4
PA; PA if 65 years and
older
guanfacine hcl tab sr 24hr 2 mg (base equiv)4
PA; PA if 65 years and
older
guanfacine hcl tab sr 24hr 3 mg (base equiv)4
PA; PA if 65 years and
older
guanfacine hcl tab sr 24hr 4 mg (base equiv)4
PA; PA if 65 years and
older
methylphenidate hcl soln 5 mg/5ml
2
QL (1800 mL / 30 days)
methylphenidate hcl soln 10 mg/5ml
2
QL (900 mL / 30 days)
methylphenidate hcl tab 5 mg
2
QL (180 tabs / 30 days)
methylphenidate hcl tab 10 mg
2
QL (180 tabs / 30 days)
methylphenidate hcl tab 20 mg
2
QL (90 tabs / 30 days)
methylphenidate hcl tab cr 10 mg
2
QL (90 tabs / 30 days)
methylphenidate hcl tab cr 20 mg
2
QL (90 tabs / 30 days)
STRATTERA CAP 10MG
4
QL (120 caps / 30 days)
STRATTERA CAP 18MG
4
QL (120 caps / 30 days)
STRATTERA CAP 25MG
4
QL (120 caps / 30 days)
STRATTERA CAP 40MG
4
QL (60 caps / 30 days)
STRATTERA CAP 60MG
4
QL (30 caps / 30 days)
STRATTERA CAP 80MG
4
QL (30 caps / 30 days)
STRATTERA CAP 100MG
4
QL (30 caps / 30 days)
HYPNOTICS
HETLIOZ CAP 20MG
ROZEREM TAB 8MG
SILENOR TAB 3MG
SILENOR TAB 6MG
PA - Prior Authorization
available at mail-order
5
4
3
3
NM, LA, PA
QL (30 tabs / 30 days)
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
53
Drug Name
temazepam cap 7.5 mg
temazepam cap 15 mg
zolpidem tartrate tab 5 mg
zolpidem tartrate tab 10 mg
Drug Tier Requirements/Limits
2
QL (30 caps / 30 days),
PA; PA applies if 65 years
and older after a 90 day
supply in a calendar year
2
QL (60 caps / 30 days),
PA; PA applies if 65 years
and older after a 90 day
supply in a calendar year
4
QL (30 tabs / 30 days),
PA; PA applies if 65 years
and older after a 90 day
supply in a calendar year
4
QL (30 tabs / 30 days),
PA; PA applies if 65 years
and older after a 90 day
supply in a calendar year
MIGRAINE
dihydroergotamine mesylate inj 1 mg/ml
2
naratriptan hcl tab 1 mg (base equiv)
2
naratriptan hcl tab 2.5 mg (base equiv)
2
RELPAX TAB 20MG
3
RELPAX TAB 40MG
3
rizatriptan benzoate oral disintegrating tab 5 2
mg (base eq)
rizatriptan benzoate oral disintegrating tab 102
mg (base eq)
rizatriptan benzoate tab 5 mg (base
2
equivalent)
rizatriptan benzoate tab 10 mg (base
2
equivalent)
SUMATRIPTAN NASAL SPRAY 5 MG/ACT
2
SUMATRIPTAN NASAL SPRAY 20 MG/ACT
2
sumatriptan succinate inj 6 mg/0.5ml
2
sumatriptan succinate solution auto-injector
4 mg/0.5ml
sumatriptan succinate solution auto-injector
6 mg/0.5ml
SUMATRIPTAN SUCCINATE SOLUTION
CARTRIDGE 4 MG/0.5ML
SUMATRIPTAN SUCCINATE SOLUTION
CARTRIDGE 6 MG/0.5ML
sumatriptan succinate solution prefilled
syringe 6 mg/0.5ml
sumatriptan succinate tab 25 mg
2
PA - Prior Authorization
available at mail-order
2
2
2
2
2
QL
QL
QL
QL
QL
(9 tabs / 30 days)
(9 tabs / 30 days)
(12 tabs / 30 days)
(12 tabs / 30 days)
(18 tabs / 30 days)
QL (18 tabs / 30 days)
QL (18 tabs / 30 days)
QL (18 tabs / 30 days)
QL (24 inhalers / 30
days)
QL (12 inhalers / 30
days)
QL (12 injections / 30
days)
QL (12 injections / 30
days)
QL (12 injections / 30
days)
QL (12 injections / 30
days)
QL (12 injections / 30
days)
QL (12 injections / 30
days)
QL (9 tabs / 30 days)
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
54
Drug Name
sumatriptan succinate tab 50 mg
sumatriptan succinate tab 100 mg
zolmitriptan orally disintegrating tab 2.5 mg
zolmitriptan orally disintegrating tab 5 mg
zolmitriptan tab 2.5 mg
zolmitriptan tab 5 mg
MISCELLANEOUS
Drug Tier Requirements/Limits
2
QL (9 tabs / 30 days)
2
QL (9 tabs / 30 days)
2
QL (12 tabs / 30 days)
2
QL (12 tabs / 30 days)
2
QL (12 tabs / 30 days)
2
QL (12 tabs / 30 days)
lithium carbonate cap 150 mg
lithium carbonate cap 300 mg
lithium carbonate cap 600 mg
lithium carbonate tab 300 mg
lithium carbonate tab cr 300 mg
lithium carbonate tab cr 450 mg
LITHIUM SOL 8MEQ/5ML
NUEDEXTA CAP 20-10MG
pyridostigmine bromide tab 60 mg
riluzole tab 50 mg
tetrabenazine tab 12.5 mg
1
1
1
1
2
2
3
3
2
2
5
tetrabenazine tab 25 mg
5
MULTIPLE SCLEROSIS AGENTS
AMPYRA TAB 10MG
BETASERON INJ 0.3MG
5
5
COPAXONE INJ 40MG/ML
5
GILENYA CAP 0.5MG
5
glatopa inj 20mg/ml
5
TYSABRI INJ 300/15ML
5
PA
QL (240 tabs / 30 days),
NM, PA
QL (120 tabs / 30 days),
NM, PA
NM, LA, PA
QL (14 syringes / 28
days), NM, PA
QL (12 syringes / 28
days), NM, PA
QL (28 caps / 28 days),
NM, PA
QL (30 syringes / 30
days), NM, PA
NM, LA, PA
MUSCULOSKELETAL THERAPY AGENTS
baclofen tab 10 mg
baclofen tab 20 mg
carisoprodol tab 350 mg
2
2
3
cyclobenzaprine hcl tab 5 mg
3
cyclobenzaprine hcl tab 10 mg
3
dantrolene sodium cap 25 mg
dantrolene sodium cap 50 mg
dantrolene sodium cap 100 mg
2
2
2
PA - Prior Authorization
available at mail-order
QL (120 tabs / 30 days),
PA; PA if 65 years and
older
PA; PA if 65 years and
older
PA; PA if 65 years and
older
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
55
Drug Name
methocarbamol tab 500 mg
methocarbamol tab 750 mg
tizanidine hcl tab 2 mg (base equivalent)
tizanidine hcl tab 4 mg (base equivalent)
NARCOLEPSY/CATAPLEXY
Drug Tier Requirements/Limits
3
PA; PA if 65 years and
older
3
PA; PA if 65 years and
older
2
2
armodafinil tab 50 mg
2
armodafinil tab 150 mg
2
ARMODAFINIL TAB 200 MG
2
armodafinil tab 250 mg
2
NUVIGIL TAB 50MG
4
NUVIGIL TAB 150MG
4
NUVIGIL TAB 200MG
4
NUVIGIL TAB 250MG
4
XYREM SOL 500MG/ML
5
QL (150 tabs / 30 days),
PA
QL (60 tabs / 30 days),
PA
QL (30 tabs / 30 days),
PA
QL (30 tabs / 30 days),
PA
QL (150 tabs / 30 days),
PA
QL (60 tabs / 30 days),
PA
QL (30 tabs / 30 days),
PA
QL (30 tabs / 30 days),
PA
QL (540 mL / 30 days),
LA, PA
PSYCHOTHERAPEUTIC-MISC
acamprosate calcium tab delayed release 3332
mg
buprenorphine hcl sl tab 2 mg (base equiv) 2
buprenorphine hcl sl tab 8 mg (base equiv) 2
buprenorphine hcl-naloxone hcl sl tab 2-0.5 2
mg (base equiv)
buprenorphine hcl-naloxone hcl sl tab 8-2 mg2
(base equiv)
bupropion hcl (smoking deterrent) tab sr 12hr2
150 mg
CHANTIX PAK 0.5& 1MG
4
CHANTIX PAK 1MG
4
CHANTIX TAB 0.5MG
4
CHANTIX TAB 1MG
4
disulfiram tab 250 mg
2
disulfiram tab 500 mg
2
naloxone hcl inj 0.4 mg/ml
2
naloxone hcl inj 4 mg/10ml
2
naloxone hcl soln cartridge 0.4 mg/ml
2
naloxone hcl soln prefilled syringe 2 mg/2ml 2
PA - Prior Authorization
available at mail-order
PA
PA
QL (120 tabs / 30 days),
PA
QL (120 tabs / 30 days),
PA
PA
PA
PA
PA
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
56
Drug Name
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
ENDOCRINE AND METABOLIC
ANDROGENS
Drug Tier Requirements/Limits
2
4
4
4
QL (120 SL films / 30
days), PA
4
QL (120 SL films / 30
days), PA
4
QL (120 SL films / 30
days), PA
4
QL (60 SL films / 30
days), PA
ANDRODERM DIS 2MG/24HR
4
ANDRODERM DIS 4MG/24HR
4
AXIRON SOL 30MG/ACT
3
oxandrolone tab 2.5 mg
2
oxandrolone tab 10 mg
5
testosterone cypionate im inj in oil 100 mg/ml2
testosterone cypionate im inj in oil 200 mg/ml2
testosterone enanthate im inj in oil 200
2
mg/ml
ANTIDIABETICS, INJECTABLE
ALCOHOL SWABS
BYDUREON INJ 2MG
BYDUREON PEN INJ 2MG
BYETTA INJ 5MCG
BYETTA INJ 10MCG
GAUZE PADS 2" X 2"
HUMULIN R INJ U-500
HUMULIN R INJ U-500
INSULIN PEN NEEDLE
INSULIN SAFETY NEEDLES
INSULIN SYRINGE
LANTUS INJ 100/ML
LANTUS INJ SOLOSTAR
LEVEMIR INJ
LEVEMIR INJ FLEXTOUC
NOVOLIN INJ 70/30
3
3
3
4
4
3
5
5
3
3
3
3
3
3
3
3
NOVOLIN N INJ U-100
3
PA - Prior Authorization
available at mail-order
QL (30 patches / 30
days), PA
QL (30 patches / 30
days), PA
QL (440 mL / 30 days),
PA
PA
PA
PA
PA
PA
QL
QL
QL
QL
(4
(4
(1
(1
vials / 28 days)
pens / 28 days)
pen / 30 days)
pen / 30 days)
B/D
(brand RELION not
covered)
(brand RELION not
covered)
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
57
Drug Name
NOVOLIN R INJ U-100
NOVOLOG INJ 100/ML
NOVOLOG INJ FLEXPEN
NOVOLOG INJ PENFILL
NOVOLOG MIX INJ 70/30
NOVOLOG MIX INJ FLEXPEN
SYMLINPEN 60 INJ 1000MCG
SYMLNPEN 120 INJ 1000MCG
TOUJEO SOLO INJ 300IU/ML
TRESIBA FLEX INJ 100UNIT
TRESIBA FLEX INJ 200UNIT
TRULICITY INJ 0.75/0.5
TRULICITY INJ 1.5/0.5
VICTOZA INJ 18MG/3ML
ANTIDIABETICS, ORAL
Drug Tier Requirements/Limits
3
(brand RELION not
covered)
3
3
3
3
3
4
QL (8 pens / 30 days), PA
5
QL (4 pens / 30 days), PA
3
3
3
4
QL (4 pens / 28 days)
4
QL (4 pens / 28 days)
3
QL (3 pens / 30 days)
acarbose tab 25 mg
acarbose tab 50 mg
acarbose tab 100 mg
FARXIGA TAB 5MG
FARXIGA TAB 10MG
glimepiride tab 1 mg
glimepiride tab 2 mg
glimepiride tab 4 mg
glipizide tab 5 mg
glipizide tab 10 mg
glipizide tab sr 24hr 2.5 mg
GLIPIZIDE TAB SR 24HR 2.5 MG
glipizide tab sr 24hr 5 mg
glipizide tab sr 24hr 10 mg
GLIPIZIDE XL TAB 5MG
glipizide-metformin hcl tab 2.5-250 mg
glipizide-metformin hcl tab 2.5-500 mg
glipizide-metformin hcl tab 5-500 mg
glyburide micronized tab 1.5 mg
2
2
2
3
3
1
1
1
1
1
1
1
1
1
1
1
1
1
3
glyburide micronized tab 3 mg
3
glyburide micronized tab 6 mg
3
glyburide tab 1.25 mg
3
PA - Prior Authorization
available at mail-order
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
QL (240 tabs / 30 days)
QL (120 tabs / 30 days)
QL (60 tabs / 30 days)
QL (240 tabs / 30 days)
QL (120 tabs / 30 days)
QL (240 tabs / 30 days)
QL (240 tabs / 30 days)
QL (120 tabs / 30 days)
QL (60 tabs / 30 days)
QL (120 tabs / 30 days)
QL (240 tabs / 30 days)
QL (120 tabs / 30 days)
QL (120 tabs / 30 days)
QL (240 tabs / 30 days),
PA; PA if 65 years and
older
QL (120 tabs / 30 days),
PA; PA if 65 years and
older
QL (60 tabs / 30 days),
PA; PA if 65 years and
older
QL (480 tabs / 30 days),
PA; PA if 65 years and
older
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
58
Drug Name
glyburide tab 2.5 mg
glyburide tab 5 mg
INVOKAMET TAB 50-500MG
INVOKAMET TAB 50-1000
INVOKAMET TAB 150-500
INVOKAMET TAB 150-1000
INVOKANA TAB 100MG
INVOKANA TAB 300MG
JANUMET TAB 50-500MG
JANUMET TAB 50-1000
JANUMET XR TAB 50-500MG
JANUMET XR TAB 50-1000
JANUMET XR TAB 100-1000
JANUVIA TAB 25MG
JANUVIA TAB 50MG
JANUVIA TAB 100MG
JENTADUETO TAB 2.5-500
JENTADUETO TAB 2.5-850
JENTADUETO TAB 2.5-1000
JENTADUETO TAB XR
JENTADUETO TAB XR
metformin hcl tab 500 mg
metformin hcl tab 850 mg
metformin hcl tab 1000 mg
metformin hcl tab sr 24hr 500 mg
metformin hcl tab sr 24hr 750 mg
nateglinide tab 60 mg
nateglinide tab 120 mg
pioglitazone hcl tab 15 mg (base equiv)
pioglitazone hcl tab 30 mg (base equiv)
pioglitazone hcl tab 45 mg (base equiv)
repaglinide tab 0.5 mg
repaglinide tab 1 mg
repaglinide tab 2 mg
TRADJENTA TAB 5MG
XIGDUO XR TAB 5-500MG
XIGDUO XR TAB 5-1000MG
XIGDUO XR TAB 10-500MG
XIGDUO XR TAB 10-1000
BISPHOSPHONATES
alendronate sodium tab 5 mg
alendronate sodium tab 10 mg
PA - Prior Authorization
available at mail-order
Drug Tier Requirements/Limits
3
QL (240 tabs / 30 days),
PA; PA if 65 years and
older
3
QL (120 tabs / 30 days),
PA; PA if 65 years and
older
3
QL (120 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (90 tabs / 30 days)
3
QL (30 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (30 tabs / 30 days)
3
QL (30 tabs / 30 days)
3
QL (30 tabs / 30 days)
3
QL (30 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (30 tabs / 30 days)
3
QL (60 tabs / 30 days)
1
QL (150 tabs / 30 days)
1
QL (90 tabs / 30 days)
1
QL (75 tabs / 30 days)
1
QL (120 tabs / 30 days)
1
QL (60 tabs / 30 days)
1
QL (90 tabs / 30 days)
1
QL (90 tabs / 30 days)
1
QL (30 tabs / 30 days)
1
QL (30 tabs / 30 days)
1
QL (30 tabs / 30 days)
1
QL (120 tabs / 30 days)
1
QL (120 tabs / 30 days)
1
QL (240 tabs / 30 days)
3
QL (30 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (60 tabs / 30 days)
3
QL (30 tabs / 30 days)
3
QL (30 tabs / 30 days)
1
1
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
59
Drug Name
alendronate sodium tab 35 mg
alendronate sodium tab 40 mg
alendronate sodium tab 70 mg
ibandronate sodium tab 150 mg (base
equivalent)
pamidronate disodium iv soln 3 mg/ml
pamidronate disodium iv soln 9 mg/ml
pamidronate inj 6mg/ml
zoledronic acid inj conc for iv infusion 4
mg/5ml
zoledronic acid iv soln 5 mg/100ml
Drug Tier Requirements/Limits
1
QL (4 tabs / 28 days)
1
1
QL (4 tabs / 28 days)
2
B/D, QL (1 tab / 30 days)
2
2
2
2
B/D
B/D
B/D
B/D, NM
2
B/D, NM
SENSIPAR TAB 30MG
3
SENSIPAR TAB 60MG
5
SENSIPAR TAB 90MG
5
QL (120 tabs / 30 days),
NM
QL (60 tabs / 30 days),
NM
QL (120 tabs / 30 days),
NM
CALCIUM RECEPTOR AGONISTS
CHELATING AGENTS
CHEMET CAP 100MG
DEPEN TITRA TAB 250MG
EXJADE TAB 125MG
EXJADE TAB 250MG
EXJADE TAB 500MG
FERRIPROX SOL 100MG/ML
FERRIPROX TAB 500MG
kionex pow
kionex sus 15gm/60
sodium polystyrene sulfonate oral susp 15
gm/60ml
sodium polystyrene sulfonate powder
sps sus 15gm/60
SYPRINE CAP 250MG
CONTRACEPTIVES
altavera tab
apri tab
aranelle tab
aubra tab 0.1-0.02
aviane tab
balziva tab
bekyree tab
blisovi fe tab 1.5/30
blisovi fe tab 1/20
briellyn tab
camila tab 0.35mg
PA - Prior Authorization
available at mail-order
4
5
5
5
5
5
5
2
2
2
NM,
NM,
NM,
NM,
NM,
LA,
LA,
LA,
LA,
LA,
PA
PA
PA
PA
PA
2
2
5
2
2
2
2
2
2
2
2
2
2
2
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
60
Drug Name
Drug Tier Requirements/Limits
caziant pak
2
cryselle-28 tab 28 tabs
2
cyclafem tab 1/35
2
cyclafem tab 7/7/7
2
deblitane tab 0.35mg
2
delyla tab 0.1-0.02
2
desogest-eth estrad & eth estrad tab
2
0.15-0.02/0.01 mg(21/5)
desogestrel & ethinyl estradiol tab 0.15
2
mg-30 mcg
drospirenone-ethinyl estradiol tab 3-0.02 mg2
DROSPIRENONE-ETHINYL ESTRADIOL TAB 2
3-0.02 MG
drospirenone-ethinyl estradiol tab 3-0.03 mg2
DROSPIRENONE-ETHINYL ESTRADIOL TAB 2
3-0.03 MG
ELLA TAB 30MG
4
emoquette tab
2
enpresse-28 tab
2
errin tab 0.35mg
2
falmina tab
2
gildagia tab 0.4-35
2
gildess tab 1.5/30
2
heather tab 0.35mg
2
introvale tab
2
JOLIVETTE TAB 0.35MG
2
juleber tab
2
junel 1.5/30 tab
2
junel 1/20 tab
2
junel fe tab 1.5/30
2
junel fe tab 1/20
2
kariva tab 28 day
2
kelnor tab 1/35
2
kimidess tab
2
larin fe tab 1.5/30
2
larin fe tab 1/20
2
larin tab 1.5/30
2
larin tab 1/20
2
larissia tab
2
leena tab
2
lessina tab
2
levonest tab
2
levonorgestrel & ethinyl estradiol (91-day) 2
tab 0.15-0.03 mg
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
61
Drug Name
Drug Tier Requirements/Limits
LEVONORGESTREL & ETHINYL ESTRADIOL 2
(91-DAY) TAB 0.15-0.03 MG
levonorgestrel & ethinyl estradiol tab 0.1
2
mg-20 mcg
levonorgestrel tab 0.75 mg
2
levonorgestrel tab 1.5 mg
2
levonorgestrel-eth estra tab
2
0.05-30/0.075-40/0.125-30mg-mcg
levora-28 tab 0.15/30
2
loryna tab 3-0.02mg
2
lutera tab
2
lyza tab 0.35mg
2
marlissa tab 0.15/30
2
medroxyprogesterone acetate im susp 150 2
mg/ml
MEDROXYPROGESTERONE ACETATE IM SUSP2
PREFILLED SYR 150 MG/ML
MONONESSA TAB
2
myzilra tab
2
necon tab 0.5/35
2
necon tab 1/35
2
NECON TAB 1/50-28
2
NECON TAB 7/7/7
2
necon tab 10/11-28
3
nikki tab 3-0.02mg
2
norelgestromin-ethinyl estradiol td ptwk
2
150-35 mcg/24hr
NORETHINDRONE ACE & ETHINYL
2
ESTRADIOL TAB 1 MG-20 MCG
NORETHINDRONE ACE & ETHINYL
2
ESTRADIOL TAB 1.5 MG-30 MCG
NORETHINDRONE ACE & ETHINYL
2
ESTRADIOL-FE TAB 1 MG-20 MCG
NORETHINDRONE ACE & ETHINYL
2
ESTRADIOL-FE TAB 1.5 MG-30 MCG
norethindrone tab 0.35 mg
2
NORETHINDRONE TAB 0.35 MG
2
norgestimate & ethinyl estradiol tab 0.25
2
mg-35 mcg
norgestimate-eth estrad tab
2
0.18-35/0.215-35/0.25-35 mg-mcg
norgestrel & ethinyl estradiol tab 0.3 mg-30 2
mcg
norlyroc tab 0.35mg
2
nortrel tab 0.5/35
2
nortrel tab 1/35
2
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
62
Drug Name
nortrel tab 7/7/7
NUVARING MIS
orsythia tab
philith tab 0.4-35
pimtrea tab
pirmella tab 1/35
portia-28 tab
previfem tab
quasense tab
reclipsen tab
sharobel tab 0.35mg
sprintec 28 tab 28 day
tarina fe tab 1/20
tri-legest tab fe
tri-previfem tab
tri-sprintec tab
TRINESSA TAB
trivora-28 tab
velivet pak
vienva tab 0.1-20
viorele tab
vyfemla tab 0.4-35
zarah tab 3-0.03mg
zenchent tab
zovia 1/35e tab
zovia 1/50e tab
ENDOMETRIOSIS
danazol cap 50 mg
danazol cap 100 mg
danazol cap 200 mg
SYNAREL SOL 2MG/ML
ENZYME REPLACEMENTS
ADAGEN INJ 250/ML
ALDURAZYME INJ 2.9MG/5M
BUPHENYL TAB 500MG
CARBAGLU TAB 200MG
CERDELGA CAP 84MG
CEREZYME INJ 200UNIT
CEREZYME INJ 400UNIT
CYSTADANE POW
CYSTAGON CAP 50MG
CYSTAGON CAP 150MG
FABRAZYME INJ 5MG
FABRAZYME INJ 35MG
KUVAN POW 100MG
PA - Prior Authorization
available at mail-order
Drug Tier Requirements/Limits
2
4
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
2
2
5
5
5
5
5
5
5
5
5
4
4
5
5
5
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
LA,
LA,
LA,
LA,
PA
LA,
LA,
LA
LA,
LA,
LA,
LA,
LA,
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
63
Drug Name
KUVAN POW 500MG
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
ORFADIN CAP 20MG
ORFADIN SUS 4MG/ML
RAVICTI LIQ 1.1GM/ML
sodium phenylbutyrate oral powder 3
gm/teaspoonful
ZAVESCA CAP 100MG
ESTROGENS
Drug Tier Requirements/Limits
5
NM, LA, PA
5
NM, LA, PA
2
B/D
2
B/D
2
B/D
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, PA
5
NM
5
DELESTROGEN INJ 10MG/ML
estrace vag cre 0.1mg/gm
estradiol tab 0.5 mg
4
4
4
estradiol tab 1 mg
4
estradiol tab 2 mg
4
estradiol td patch weekly 0.1 mg/24hr
4
estradiol td patch weekly 0.05 mg/24hr
4
estradiol td patch weekly 0.06 mg/24hr
4
estradiol td patch weekly 0.025 mg/24hr
4
estradiol td patch weekly 0.075 mg/24hr
4
estradiol td patch weekly 0.0375 mg/24hr
(37.5 mcg/24hr)
estradiol valerate im in oil 20 mg/ml
estradiol valerate im in oil 40 mg/ml
jinteli tab 1mg-5mcg
4
2
2
4
norethindrone acetate-ethinyl estradiol tab 1 4
mg-5 mcg
VAGIFEM TAB 10MCG
4
NM, LA, PA
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
PA; PA
older
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
if 65 years and
PA; PA if 65 years and
older
PA; PA if 65 years and
older
GLUCOCORTICOIDS
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
64
Drug Name
a-hydrocort inj 100mg
cortisone acetate tab 25 mg
dexamethason con 1mg/ml
dexamethasone elixir 0.5 mg/5ml
dexamethasone sod phosphate preservative
free inj 10 mg/ml
dexamethasone sodium phosphate inj 4
mg/ml
dexamethasone sodium phosphate inj 10
mg/ml
dexamethasone sodium phosphate inj 20
mg/5ml
dexamethasone sodium phosphate inj 100
mg/10ml
dexamethasone sodium phosphate inj 120
mg/30ml
dexamethasone soln 0.5 mg/5ml
dexamethasone tab 0.5 mg
dexamethasone tab 0.75 mg
dexamethasone tab 1 mg
dexamethasone tab 1.5 mg
dexamethasone tab 2 mg
dexamethasone tab 4 mg
dexamethasone tab 6 mg
fludrocortisone acetate tab 0.1 mg
hydrocortisone tab 5 mg
hydrocortisone tab 10 mg
hydrocortisone tab 20 mg
methylprednisolone acetate inj susp 40
mg/ml
methylprednisolone acetate inj susp 80
mg/ml
methylprednisolone sodium succinate for inj
40 mg
methylprednisolone sodium succinate for inj
125 mg
methylprednisolone sodium succinate for inj
1000 mg
methylprednisolone tab 4 mg
methylprednisolone tab 8 mg
methylprednisolone tab 16 mg
methylprednisolone tab 32 mg
methylprednisolone tab therapy pack 4 mg
(21)
prednisolone sod phosph oral soln 6.7
mg/5ml (5 mg/5ml base)
PA - Prior Authorization
available at mail-order
Drug Tier Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
1
1
1
1
1
1
1
2
2
2
2
2
B/D
2
B/D
2
B/D
2
B/D
2
B/D
2
2
2
2
2
B/D
B/D
B/D
B/D
2
B/D
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
65
Drug Name
prednisolone sod phosphate oral soln 15
mg/5ml (base equiv)
prednisolone sodium phosphate oral soln 25
mg/5ml (base eq)
prednisolone syrup 15 mg/5ml (usp solution
equivalent)
prednisone con 5mg/ml
prednisone oral soln 5 mg/5ml
prednisone tab 1 mg
prednisone tab 2.5 mg
prednisone tab 5 mg
prednisone tab 10 mg
prednisone tab 20 mg
prednisone tab 50 mg
prednisone tab therapy pack 5 mg (21)
prednisone tab therapy pack 5 mg (48)
prednisone tab therapy pack 10 mg (21)
prednisone tab therapy pack 10 mg (48)
SOLU-CORTEF INJ 250MG
GLUCOSE ELEVATING AGENTS
GLUCAGEN INJ HYPOKIT
GLUCAGON KIT 1MG
KORLYM TAB 300MG
PROGLYCEM SUS 50MG/ML
HUMAN GROWTH HORMONES
NORDITROPIN
NORDITROPIN
NORDITROPIN
NORDITROPIN
INJ
INJ
INJ
INJ
5/1.5ML
10/1.5ML
15/1.5ML
30/3ML
Drug Tier Requirements/Limits
2
B/D
2
B/D
1
B/D
3
2
1
1
1
1
1
1
2
2
2
2
4
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
3
3
5
4
5
5
5
5
NM, LA, PA
NM,
NM,
NM,
NM,
PA
PA
PA
PA
MISCELLANEOUS
cabergoline tab 0.5 mg
2
calcitonin (salmon) nasal soln 200 unit/act 2
FORTICAL SPR 200/ACT
3
INCRELEX INJ 40MG/4ML
5
methylergonovine maleate tab 0.2 mg
2
MIACALCIN INJ 200/ML
5
octreotide acetate inj 50 mcg/ml (0.05
2
mg/ml)
octreotide acetate inj 100 mcg/ml (0.1
2
mg/ml)
octreotide acetate inj 200 mcg/ml (0.2
5
mg/ml)
octreotide acetate inj 500 mcg/ml (0.5
5
mg/ml)
octreotide acetate inj 1000 mcg/ml (1 mg/ml)5
PA - Prior Authorization
available at mail-order
NM, LA, PA
B/D
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
66
Drug Name
PROLIA SOL 60MG/ML
raloxifene hcl tab 60 mg
SANDOSTATIN KIT LAR 10MG
SANDOSTATIN KIT LAR 20MG
SANDOSTATIN KIT LAR 30MG
SIGNIFOR INJ 0.3MG/ML
SIGNIFOR INJ 0.6MG/ML
SIGNIFOR INJ 0.9MG/ML
SOMATULINE INJ 60/0.2ML
SOMATULINE INJ 90/0.3ML
SOMATULINE INJ 120/.5ML
SOMAVERT INJ 10MG
SOMAVERT INJ 15MG
SOMAVERT INJ 20MG
SOMAVERT INJ 25MG
SOMAVERT INJ 30MG
XGEVA INJ
PARATHYROID HORMONES
Drug Tier Requirements/Limits
4
QL (1 syringe / 180
days), NM
2
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, LA, PA
5
NM, PA
FORTEO SOL 600/2.4
5
NATPARA
NATPARA
NATPARA
NATPARA
5
5
5
5
INJ
INJ
INJ
INJ
25MCG
50MCG
75MCG
100MCG
PHOSPHATE BINDER AGENTS
calcium acetate (phosphate binder) cap 667
mg (169 mg ca)
calcium acetate (phosphate binder) tab 667
mg
RENVELA PAK 0.8GM
RENVELA PAK 2.4GM
RENVELA TAB 800MG
PROGESTINS
medroxyprogesterone acetate tab 2.5 mg
medroxyprogesterone acetate tab 5 mg
medroxyprogesterone acetate tab 10 mg
norethindrone acetate tab 5 mg
THYROID AGENTS
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
levothyroxine
sodium
sodium
sodium
sodium
sodium
sodium
PA - Prior Authorization
available at mail-order
tab
tab
tab
tab
tab
tab
25 mcg
50 mcg
75 mcg
88 mcg
100 mcg
112 mcg
QL (1 pen / 28 days), NM,
PA
NM, PA
NM, PA
NM, PA
NM, PA
2
2
5
5
5
1
1
1
2
1
1
1
1
1
1
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
67
Drug Name
levothyroxine sodium tab 125 mcg
levothyroxine sodium tab 137 mcg
levothyroxine sodium tab 150 mcg
levothyroxine sodium tab 175 mcg
levothyroxine sodium tab 200 mcg
levothyroxine sodium tab 300 mcg
LEVOXYL TAB 25MCG
LEVOXYL TAB 50MCG
LEVOXYL TAB 75MCG
LEVOXYL TAB 88MCG
LEVOXYL TAB 100MCG
LEVOXYL TAB 112MCG
LEVOXYL TAB 125MCG
LEVOXYL TAB 137MCG
LEVOXYL TAB 150MCG
LEVOXYL TAB 175MCG
LEVOXYL TAB 200MCG
liothyronine sodium tab 5 mcg
liothyronine sodium tab 25 mcg
liothyronine sodium tab 50 mcg
methimazole tab 5 mg
methimazole tab 10 mg
propylthiouracil tab 50 mg
SYNTHROID TAB 25MCG
SYNTHROID TAB 50MCG
SYNTHROID TAB 75MCG
SYNTHROID TAB 88MCG
SYNTHROID TAB 100MCG
SYNTHROID TAB 112MCG
SYNTHROID TAB 125MCG
SYNTHROID TAB 137MCG
SYNTHROID TAB 150MCG
SYNTHROID TAB 175MCG
SYNTHROID TAB 200MCG
SYNTHROID TAB 300MCG
UNITHROID TAB 25MCG
UNITHROID TAB 50MCG
UNITHROID TAB 75MCG
UNITHROID TAB 88MCG
UNITHROID TAB 100MCG
UNITHROID TAB 112MCG
UNITHROID TAB 125MCG
UNITHROID TAB 150MCG
UNITHROID TAB 175MCG
UNITHROID TAB 200MCG
PA - Prior Authorization
available at mail-order
Drug Tier Requirements/Limits
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
1
1
2
4
4
4
4
4
4
4
4
4
4
4
4
1
1
1
1
1
1
1
1
1
1
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
68
Drug Name
UNITHROID TAB 300MCG
Drug Tier Requirements/Limits
1
VASOPRESSINS
desmopressin acetate inj 4 mcg/ml
2
DESMOPRESSIN ACETATE NASAL SOLN
2
0.01% (REFRIGERATED)
desmopressin acetate nasal spray soln 0.01%2
desmopressin acetate nasal spray soln 0.01%2
(refrigerated)
desmopressin acetate tab 0.1 mg
2
desmopressin acetate tab 0.2 mg
2
GASTROINTESTINAL
ANTIEMETICS
compro sup 25mg
dronabinol cap 2.5 mg
2
2
dronabinol cap 5 mg
2
dronabinol cap 10 mg
5
EMEND CAP 40MG
EMEND CAP 80MG
EMEND CAP 125MG
EMEND PAK 80 & 125
EMEND SUS 125MG
granisetron hcl inj 0.1 mg/ml
granisetron hcl inj 1 mg/ml
granisetron hcl inj 4 mg/4ml (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
metoclopramide hcl soln 5 mg/5ml (10
mg/10ml)
metoclopramide hcl tab 5 mg
metoclopramide hcl tab 10 mg
ondansetron hcl inj 4 mg/2ml (2 mg/ml)
ondansetron hcl inj 40 mg/20ml (2 mg/ml)
ondansetron hcl oral soln 4 mg/5ml
ondansetron hcl tab 4 mg
ondansetron hcl tab 8 mg
ondansetron hcl tab 24 mg
ondansetron orally disintegrating tab 4 mg
ondansetron orally disintegrating tab 8 mg
phenadoz sup 12.5mg
4
4
4
4
4
2
2
2
2
2
2
2
1
PA - Prior Authorization
available at mail-order
1
1
2
2
2
2
2
2
2
2
4
B/D, QL (60 caps / 30
days)
B/D, QL (60 caps / 30
days)
B/D, QL (60 caps / 30
days)
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
PA; PA if 65 years and
older
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
69
Drug Name
phenergan sup 12.5mg
phenergan sup 25mg
phenergan sup 50mg
prochlorperazine edisylate inj 5 mg/ml
prochlorperazine maleate tab 5 mg (base
equivalent)
prochlorperazine maleate tab 10 mg (base
equivalent)
prochlorperazine suppos 25 mg
promethazine hcl inj 25 mg/ml
Drug Tier Requirements/Limits
4
PA; PA if 65 years and
older
4
PA; PA if 65 years and
older
4
PA; PA if 65 years and
older
2
1
1
2
4
promethazine hcl inj 50 mg/ml
4
promethazine hcl suppos 12.5 mg
4
promethazine hcl suppos 25 mg
4
promethazine hcl suppos 50 mg
4
promethazine hcl syrup 6.25 mg/5ml
4
promethazine hcl tab 12.5 mg
4
promethazine hcl tab 25 mg
4
promethazine hcl tab 50 mg
4
promethegan sup 25mg
4
promethegan sup 50mg
4
TRANSDERM-SC DIS 1MG
4
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
PA; PA if 65 years and
older
PA; PA if 65 years and
older
PA; PA if 65 years and
older
PA; PA if 65 years and
older
PA; PA if 65 years and
older
PA; PA if 65 years and
older
PA; PA if 65 years and
older
PA; PA if 65 years and
older
PA; PA if 65 years and
older
PA; PA if 65 years and
older
PA; PA if 65 years and
older
QL (10 patches / 30
days), PA; PA if 65 years
and older
4
1
2
1
2
2
2
H2-RECEPTOR ANTAGONISTS
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
70
Drug Name
famotidine for susp 40 mg/5ml
famotidine in nacl 0.9% iv soln 20 mg/50ml
famotidine inj 20 mg/2ml
famotidine inj 40 mg/4ml
famotidine inj 200 mg/20ml
famotidine tab 20 mg
famotidine tab 40 mg
ranitidine hcl inj 50 mg/2ml (25 mg/ml)
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)
ranitidine hcl tab 150 mg
ranitidine hcl tab 300 mg
ranitidine inj 150/6ml
Drug Tier Requirements/Limits
2
2
2
2
2
1
1
2
2
1
1
2
INFLAMMATORY BOWEL DISEASE
APRISO CAP 0.375GM
3
ASACOL HD TAB 800MG
4
balsalazide disodium cap 750 mg
2
budesonide delayed release particles cap 3 5
mg
CANASA SUP 1000MG
5
DELZICOL CAP 400MG
4
DIPENTUM CAP 250MG
5
hydrocortisone enema 100 mg/60ml
2
HYDROCORTISONE ENEMA 100 MG/60ML
2
mesalamine enema 4 gm
2
mesalamine rectal enema 4 gm & cleanser 2
wipe kit
MESALAMINE TAB DELAYED RELEASE 800 MG2
sulfasalazin tab 500mg dr
2
sulfasalazine tab 500 mg
2
UCERIS TAB 9MG
5
LAXATIVES
bisacodyl tab & peg 3350-kcl-sod bicarb-nacl2
for soln kit
constulose sol 10gm/15
2
enulose sol 10gm/15
2
gavilyte-c sol
1
gavilyte-g sol
1
gavilyte-n sol flav pk
2
generlac sol 10gm/15
2
GOLYTELY SOL
3
lactulose (encephalopathy) solution 10
2
gm/15ml
lactulose solution 10 gm/15ml
2
MOVIPREP SOL
4
NULYTELY SOL FLAV PKS
3
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
71
Drug Name
Drug Tier Requirements/Limits
PEG 3350-KCL-NA BICARB-NACL-NA
1
SULFATE FOR SOLN 236 GM
PEG 3350-KCL-NA BICARB-NACL-NA
1
SULFATE FOR SOLN 240 GM
peg 3350-kcl-sod bicarb-nacl for soln 420 gm2
polyethylene glycol 3350 oral packet
2
polyethylene glycol 3350 oral powder
2
RELISTOR INJ 8/0.4ML
5
PA
RELISTOR INJ 12/0.6ML
5
PA
SUPREP BOWEL SOL PREP
4
trilyte sol
2
MISCELLANEOUS
alosetron hcl tab 0.5 mg (base equiv)
5
alosetron hcl tab 1 mg (base equiv)
5
AMITIZA CAP 8MCG
3
AMITIZA CAP 24MCG
3
cromolyn sodium oral conc 100 mg/5ml
5
diphenoxylate w/ atropine liq 2.5-0.025
2
mg/5ml
diphenoxylate w/ atropine tab 2.5-0.025 mg 2
GATTEX KIT 5MG
5
LINZESS CAP 145MCG
3
LINZESS CAP 290MCG
3
loperamide hcl cap 2 mg
1
misoprostol tab 100 mcg
2
misoprostol tab 200 mcg
2
MOVANTIK TAB 12.5MG
3
MOVANTIK TAB 25MG
3
SUCRAID SOL 8500/ML
5
sucralfate tab 1 gm
2
ursodiol cap 300 mg
2
ursodiol tab 250 mg
2
ursodiol tab 500 mg
2
XIFAXAN TAB 550MG
5
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
PA - Prior Authorization
available at mail-order
PA
PA
QL (60 caps / 30 days)
QL (60 caps / 30 days)
NM, LA, PA
QL (60 caps / 30 days)
QL (30 caps / 30 days)
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
LA
PA
3
3
3
3
3
4
4
4
4
4
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
72
Drug Name
ZENPEP CAP 25000UNT
ZENPEP CAP 40000UNT
Drug Tier Requirements/Limits
4
4
PROTON PUMP INHIBITORS
DEXILANT CAP 30MG DR
3
DEXILANT CAP 60MG DR
3
esomeprazole magnesium cap delayed
2
release 20 mg (base eq)
esomeprazole magnesium cap delayed
2
release 40 mg (base eq)
esomeprazole sodium for intravenous soln 202
mg (base equiv)
esomeprazole sodium for intravenous soln 402
mg (base equiv)
NEXIUM CAP 20MG
3
NEXIUM CAP 40MG
3
NEXIUM GRA 2.5MG DR
3
NEXIUM GRA 5MG DR
3
NEXIUM GRA 10MG DR
3
NEXIUM GRA 20MG DR
3
NEXIUM GRA 40MG DR
3
omeprazole cap delayed release 10 mg
1
omeprazole cap delayed release 20 mg
1
omeprazole cap delayed release 40 mg
1
pantoprazole sodium ec tab 20 mg (base
1
equiv)
pantoprazole sodium ec tab 40 mg (base
1
equiv)
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA
alfuzosin hcl tab sr 24hr 10 mg
dutasteride cap 0.5 mg
dutasteride-tamsulosin hcl cap 0.5-0.4 mg
finasteride tab 5 mg
tamsulosin hcl cap 0.4 mg
MISCELLANEOUS
bethanechol chloride tab 5 mg
bethanechol chloride tab 10 mg
bethanechol chloride tab 25 mg
bethanechol chloride tab 50 mg
ELMIRON CAP 100MG
POTASSIUM CITRATE TAB CR 5 MEQ (540
MG)
POTASSIUM CITRATE TAB CR 10 MEQ (1080
MG)
potassium citrate tab cr 15 meq (1620 mg)
PA - Prior Authorization
available at mail-order
2
2
2
1
2
QL (30 caps / 30 days)
QL (30 caps / 30 days)
QL (30 caps / 30 days)
QL (30 caps / 30 days)
QL (30 caps / 30 days)
QL (30 caps / 30 days)
QL (30 packets / 30 days)
QL (30 packets / 30 days)
QL (30 packets / 30 days)
QL (30 caps / 30 days)
QL (60 caps / 30 days)
QL (30 caps / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 tabs / 30 days)
QL (30 caps / 30 days)
QL (30 caps / 30 days)
2
2
2
2
4
2
2
2
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
73
Drug Name
URINARY ANTISPASMODICS
MYRBETRIQ TAB 25MG
MYRBETRIQ TAB 50MG
oxybutynin chloride syrup 5 mg/5ml
oxybutynin chloride tab 5 mg
oxybutynin chloride tab sr 24hr 5 mg
oxybutynin chloride tab sr 24hr 10 mg
oxybutynin chloride tab sr 24hr 15 mg
tolterodine tartrate cap sr 24hr 2 mg
tolterodine tartrate cap sr 24hr 4 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
VAGINAL ANTI-INFECTIVES
clindamycin phosphate vaginal cream 2%
metronidazole vaginal gel 0.75%
terconazole vaginal cream 0.4%
terconazole vaginal cream 0.8%
TERCONAZOLE VAGINAL CREAM 0.8%
terconazole vaginal suppos 80 mg
VANDAZOLE GEL 0.75%
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
enoxaparin sodium inj 40 mg/0.4ml
enoxaparin sodium inj 60 mg/0.6ml
enoxaparin sodium inj 80 mg/0.8ml
enoxaparin sodium inj 100 mg/ml
enoxaparin sodium inj 120 mg/0.8ml
enoxaparin sodium inj 150 mg/ml
PA - Prior Authorization
available at mail-order
Drug Tier Requirements/Limits
4
4
1
2
2
2
2
2
2
2
2
3
3
2
4
4
QL (60 tabs / 30 days)
QL (30 tabs / 30 days)
QL
QL
QL
QL
QL
(30
(60
(60
(30
(30
tabs / 30 days)
tabs / 30 days)
tabs / 30 days)
caps / 30 days)
caps / 30 days)
QL
QL
QL
QL
QL
(30
(30
(60
(30
(30
tabs
tabs
tabs
tabs
tabs
/
/
/
/
/
30
30
30
30
30
days)
days)
days)
days)
days)
2
2
2
2
2
2
2
4
4
4
4
4
4
4
4
4
3
3
2
2
2
2
5
5
5
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
74
Drug Name
Drug Tier Requirements/Limits
enoxaparin sodium inj 300 mg/3ml
2
fondaparinux sodium subcutaneous inj 2.5 2
mg/0.5ml
fondaparinux sodium subcutaneous inj 5
5
mg/0.4ml
fondaparinux sodium subcutaneous inj 7.5 5
mg/0.6ml
fondaparinux sodium subcutaneous inj 10
5
mg/0.8ml
HEP SOD/NACL INJ 25000UNT
3
HEPARIN SODIUM (PORCINE) 40 UNIT/ML IN3
D5W
HEPARIN SODIUM (PORCINE) 50 UNIT/ML IN3
D5W
HEPARIN SODIUM (PORCINE) 100 UNIT/ML 3
IN D5W
heparin sodium (porcine) inj 1000 unit/ml
2
B/D
heparin sodium (porcine) inj 5000 unit/ml
2
B/D
heparin sodium (porcine) inj 10000 unit/ml 2
B/D
heparin sodium (porcine) inj 20000 unit/ml 2
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
3
PRADAXA CAP 110MG
3
PRADAXA CAP 150MG
3
warfarin sodium tab 1 mg
1
warfarin sodium tab 2 mg
1
warfarin sodium tab 2.5 mg
1
warfarin sodium tab 3 mg
1
warfarin sodium tab 4 mg
1
warfarin sodium tab 5 mg
1
warfarin sodium tab 6 mg
1
warfarin sodium tab 7.5 mg
1
warfarin sodium tab 10 mg
1
XARELTO STAR TAB 15/20MG
3
XARELTO TAB 10MG
3
XARELTO TAB 15MG
3
XARELTO TAB 20MG
3
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
75
Drug Name
HEMATOPOIETIC GROWTH FACTORS
GRANIX INJ 300/0.5
GRANIX INJ 480/0.8
LEUKINE INJ 250MCG
MOZOBIL INJ
NEUMEGA INJ 5MG
NEUPOGEN INJ 300/0.5
NEUPOGEN INJ 300MCG
NEUPOGEN INJ 480/0.8
NEUPOGEN INJ 480MCG
PROCRIT INJ 2000/ML
PROCRIT INJ 3000/ML
PROCRIT INJ 4000/ML
PROCRIT INJ 10000/ML
PROCRIT INJ 20000/ML
PROCRIT INJ 40000/ML
MISCELLANEOUS
Drug Tier Requirements/Limits
5
5
5
5
5
5
5
5
5
3
3
3
3
5
5
anagrelide hcl cap 0.5 mg
anagrelide hcl cap 1 mg
cilostazol tab 50 mg
cilostazol tab 100 mg
CINRYZE SOL 500 UNIT
FIRAZYR INJ 30MG/3ML
pentoxifylline tab cr 400 mg
PROMACTA TAB 12.5MG
2
2
2
2
5
5
2
5
PROMACTA TAB 25MG
5
PROMACTA TAB 50MG
5
PROMACTA TAB 75MG
5
tranexamic acid iv soln 1000 mg/10ml (100 2
mg/ml)
tranexamic acid tab 650 mg
2
NM,
NM,
NM,
NM,
NM
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
NM, LA, PA
NM, PA
QL (360 tabs / 30 days),
NM, LA, PA
QL (180 tabs / 30 days),
NM, LA, PA
QL (90 tabs / 30 days),
NM, LA, PA
QL (60 tabs / 30 days),
NM, LA, PA
PLATELET AGGREGATION INHIBITORS
AGGRENOX CAP 25-200MG
ASPIRIN-DIPYRIDAMOLE CAP SR 12HR
25-200 MG
BRILINTA TAB 60MG
BRILINTA TAB 90MG
clopidogrel bisulfate tab 75 mg (base equiv)
EFFIENT TAB 5MG
EFFIENT TAB 10MG
ZONTIVITY TAB 2.08MG
PA - Prior Authorization
available at mail-order
4
2
3
3
1
4
4
4
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
76
Drug Name
Drug Tier Requirements/Limits
IMMUNOLOGIC AGENTS
DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS)
CIMZIA KIT
CIMZIA KIT STARTER
CIMZIA PREFL KIT 200MG/ML
HUMIRA INJ 10MG/0.2
HUMIRA KIT 20MG/0.4
HUMIRA KIT 40MG/0.8
HUMIRA PEDIA INJ CROHNS
HUMIRA PEN INJ 40MG/0.8
HUMIRA PEN INJ CROHNS
HUMIRA PEN INJ PSORIASI
hydroxychloroquine sulfate tab 200 mg
leflunomide tab 10 mg
leflunomide tab 20 mg
methotrexate sodium tab 2.5 mg (base
equiv)
REMICADE INJ 100MG
IMMUNOGLOBULINS
BIVIGAM INJ 10%
CARIMUNE NF INJ 6GM
CARIMUNE NF INJ 12GM
FLEBOGAMMA INJ 5%
FLEBOGAMMA INJ 10/200ML
FLEBOGAMMA INJ 20/400ML
FLEBOGAMMA INJ DIF 5%
FLEBOGAMMA INJ DIF 10%
GAMASTAN S/D INJ
GAMMAGARD INJ 1GM/10ML
GAMMAGARD INJ 2.5GM/25
GAMMAGARD INJ 5GM/50ML
GAMMAGARD INJ 10GM/100
GAMMAGARD INJ 20GM/200
GAMMAGARD INJ 30GM/300
GAMMAGARD SD INJ 2.5GM HU
GAMMAGARD SD INJ 5GM HU
GAMMAGARD SD INJ 10GM HU
GAMMAKED INJ 1GM/10ML
GAMMAKED INJ 2.5GM/25
GAMMAKED INJ 5GM/50ML
GAMMAKED INJ 10GM/100
GAMMAKED INJ 20GM/200
GAMMAPLEX INJ 2.5GM
GAMMAPLEX INJ 5GM
GAMMAPLEX INJ 10GM
GAMUNEX-C INJ 1GM/10ML
PA - Prior Authorization
available at mail-order
5
5
5
5
5
5
5
5
5
5
2
2
2
2
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
NM,
PA
PA
PA
PA
PA
PA
PA
PA
PA
PA
5
NM, PA
5
5
5
5
5
5
5
5
3
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
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
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
77
Drug Name
GAMUNEX-C INJ 2.5GM/25
GAMUNEX-C INJ 5GM/50ML
GAMUNEX-C INJ 10GM/100
GAMUNEX-C INJ 20GM/200
GAMUNEX-C INJ 40/400ML
OCTAGAM INJ 1GM
OCTAGAM INJ 2.5GM
OCTAGAM INJ 2GM/20ML
OCTAGAM INJ 5GM
OCTAGAM INJ 10GM
OCTAGAM INJ 25GM
PRIVIGEN INJ 5 GRAMS
PRIVIGEN INJ 10GRAMS
PRIVIGEN INJ 20GRAMS
PRIVIGEN INJ 40GRAMS
IMMUNOMODULATORS
ACTIMMUNE INJ 2MU/0.5
ARCALYST INJ 220MG
INTRON A INJ 10MU
INTRON A INJ 18MU
INTRON A INJ 25MU
INTRON A INJ 50MU
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
IMMUNOSUPPRESSANTS
azathioprine inj 100mg
azathioprine tab 50 mg
BENLYSTA INJ 120MG
BENLYSTA INJ 400MG
cyclosporine cap 25 mg
cyclosporine cap 100 mg
cyclosporine iv soln 50 mg/ml
cyclosporine modified cap 25 mg
cyclosporine modified cap 50 mg
cyclosporine modified cap 100 mg
cyclosporine modified oral soln 100 mg/ml
gengraf cap 25mg
gengraf cap 50mg
PA - Prior Authorization
available at mail-order
Drug Tier Requirements/Limits
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
NM, PA
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
5
NM, LA, PA
NM, PA
B/D, NM
B/D, NM
B/D, NM
B/D, NM
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, LA, PA
NM, PA
NM, PA
NM, PA
NM, PA
2
2
5
5
2
2
2
2
2
2
2
2
2
B/D
B/D
NM, PA
NM, PA
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
78
Drug Name
gengraf cap 100mg
gengraf sol 100mg/ml
mycophenolate mofetil cap 250 mg
mycophenolate mofetil for oral susp 200
mg/ml
mycophenolate mofetil tab 500 mg
mycophenolate sodium tab dr 180 mg
(mycophenolic acid equiv)
mycophenolate sodium tab dr 360 mg
(mycophenolic acid equiv)
NEORAL CAP 25MG
NEORAL CAP 100MG
NEORAL SOL 100MG/ML
NULOJIX INJ 250MG
PROGRAF CAP 0.5MG
PROGRAF CAP 1MG
PROGRAF CAP 5MG
RAPAMUNE SOL 1MG/ML
SANDIMMUNE SOL 100MG/ML
sirolimus tab 0.5 mg
sirolimus tab 1 mg
SIROLIMUS TAB 2 MG
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
VACCINES
ACTHIB INJ
ADACEL INJ
BCG VACCINE INJ
BEXSERO INJ
BOOSTRIX INJ
CERVARIX INJ
COMVAX INJ
DAPTACEL INJ
DIP/TET PED INJ 25-5LFU
ENGERIX-B INJ 10/0.5ML
ENGERIX-B INJ 20MCG/ML
GARDASIL 9 INJ
GARDASIL INJ
HAVRIX INJ 720UNIT
HAVRIX INJ 1440UNIT
HIBERIX SOL 10MCG
IMOVAX RABIE INJ 2.5/ML
PA - Prior Authorization
available at mail-order
Drug Tier Requirements/Limits
2
B/D
2
B/D
2
B/D
5
B/D
2
2
B/D
B/D
5
B/D
3
3
3
5
4
4
5
5
3
2
2
5
2
2
5
5
4
5
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
B/D
B/D
B/D
B/D
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
B/D
B/D
B/D
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
79
Drug Name
INFANRIX INJ
IPOL INJ INACTIVE
IXIARO INJ
KINRIX INJ
M-M-R II INJ
MENACTRA INJ
MENHIBRIX INJ
MENOMUNE INJ A/C/Y/W
MENVEO INJ
PEDIARIX INJ 0.5ML
PEDVAX HIB INJ
PENTACEL INJ
PROQUAD INJ
QUADRACEL INJ
RABAVERT INJ
RECOMBIVA HB INJ 5MCG/0.5
RECOMBIVA HB INJ 10MCG/ML
RECOMBIVA-HB INJ 40MCG/ML
ROTARIX SUS
ROTATEQ SOL
SYNAGIS INJ 50MG
SYNAGIS INJ 100MG/ML
TENIVAC INJ 5-2LF
TET/DIP TOX INJ 2-2 LF
TRUMENBA INJ
TWINRIX INJ
TYPHIM VI INJ
VAQTA INJ 25/0.5ML
VAQTA INJ 50UNT/ML
VARIVAX INJ
YF-VAX INJ
ZOSTAVAX INJ
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES
KLOR-CON 8 TAB 8MEQ ER
KLOR-CON 10 TAB 10MEQ ER
klor-con m15 tab 15meq er
klor-con pow 20meq
MAGNESIUM SU INJ 2GM/50ML
MAGNESIUM SU INJ 4G/100ML
MAGNESIUM SU INJ 20/500ML
MAGNESIUM SU INJ 40G/1000
MAGNESIUM SU INJ 80MG/ML
magnesium sulfate inj 50%
MAGNESIUM SULFATE INJ 50%
PA - Prior Authorization
available at mail-order
Drug Tier Requirements/Limits
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
B/D
3
B/D
3
B/D
3
3
5
NM
5
NM
3
B/D
3
B/D
3
3
3
3
3
3
3
3
QL (1 vial per lifetime)
2
2
2
2
3
3
3
3
3
2
2
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
80
Drug Name
Drug Tier Requirements/Limits
magnesium sulfate iv soln 2 gm/50ml (40
2
mg/ml)
MG SO4/D5W INJ 10MG/ML
3
MG SO4/D5W INJ 20MG/ML
3
potassium chloride cap cr 8 meq
2
potassium chloride cap cr 10 meq
2
potassium chloride microencapsulated crys cr2
tab 10 meq
potassium chloride microencapsulated crys cr2
tab 20 meq
POTASSIUM CHLORIDE ORAL SOLN 10% (20 2
MEQ/15ML)
POTASSIUM CHLORIDE ORAL SOLN 20% (40 2
MEQ/15ML)
potassium chloride tab cr 8 meq (600 mg) 2
POTASSIUM CHLORIDE TAB CR 10 MEQ
2
POTASSIUM CHLORIDE TAB CR 20 MEQ
2
(1500 MG)
SODIUM CHLORIDE INJ 2.5 MEQ/ML (14.6%)2
SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) 2
MG/ML SOLN
TPN ELECTROL INJ
4
B/D
IV NUTRITION
amino acid infusion 6%
AMINOSYN 7% INJ /LYTES
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%
AMINOSYN-PF INJ 7%
AMINOSYN-PF INJ 10%
AMINOSYN-RF INJ 5.2%
CLINIMIX INJ 2.75/D5W
CLINIMIX INJ 4.25/D5W
CLINIMIX INJ 4.25/D10
CLINIMIX INJ 4.25/D20
CLINIMIX INJ 4.25/D25
CLINIMIX INJ 5%/D15W
CLINIMIX INJ 5%/D20W
CLINIMIX INJ 5%/D25W
FAT EMULSION IV SOLN 20%
PA - Prior Authorization
available at mail-order
2
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
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
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
B/D
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
81
Drug Name
FREAMINE HBC INJ 6.9%
FREAMINE III INJ 10%
HEPATAMINE SOL 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%
Drug Tier Requirements/Limits
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
4
B/D
IV REPLACEMENT SOLUTIONS
D5W/LYTES INJ #48
3
D5W/NACL INJ 0.3%
2
D10W/NACL INJ 0.2%
3
DEXTROSE 2.5% W/ SODIUM CHLORIDE
2
0.45%
DEXTROSE 5% IN LACTATED RINGERS
2
DEXTROSE 5% W/ SODIUM CHLORIDE 0.2% 2
DEXTROSE 5% W/ SODIUM CHLORIDE 0.9% 2
DEXTROSE 5% W/ SODIUM CHLORIDE
2
0.33%
DEXTROSE 5% W/ SODIUM CHLORIDE
2
0.45%
DEXTROSE 5% W/ SODIUM CHLORIDE
2
0.225%
DEXTROSE 10% W/ SODIUM CHLORIDE
2
0.45%
DEXTROSE INJ 5%
2
DEXTROSE INJ 10%
2
DEXTROSE INJ 50%
2
DEXTROSE INJ 70%
2
IONOSOL-B/ INJ D5W
4
IONOSOL-MB INJ /D5W
4
ISOLYTE-P INJ /D5W
4
ISOLYTE-S INJ
4
KCL 10 MEQ/L (0.075%) IN DEXTROSE 5% &2
NACL 0.45% INJ
KCL 20 MEQ/L (0.15%) IN DEXTROSE 5% & 2
NACL 0.2% INJ
KCL 20 MEQ/L (0.15%) IN DEXTROSE 5% & 2
NACL 0.9% INJ
KCL 20 MEQ/L (0.15%) IN DEXTROSE 5% & 2
NACL 0.33% INJ
KCL 20 MEQ/L (0.15%) IN DEXTROSE 5% & 2
NACL 0.45% INJ
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
82
Drug Name
Drug Tier Requirements/Limits
KCL 20 MEQ/L (0.15%) IN NACL 0.9% INJ 2
kcl 20 meq/l (0.15%) in nacl 0.45% inj
2
KCL 20 MEQ/L (0.15%) IN NACL 0.45% INJ 2
KCL 30 MEQ/L (0.224%) IN DEXTROSE 5% &2
NACL 0.45% INJ
KCL 40 MEQ/L (0.3%) IN DEXTROSE 5% & 2
NACL 0.45% INJ
KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ
2
KCL/D5W/NACL INJ 0.3/0.9%
2
KCL/D5W/NACL INJ 0.15/0.2
3
LACTATED RINGER'S SOLUTION
2
NORMOSOL -M INJ /D5W
2
NORMOSOL -R INJ /D5W
4
NORMOSOL-R INJ PH 7.4
4
PLASMA-LYTE INJ 56/D5W
4
PLASMA-LYTE INJ -148
4
PLASMA-LYTE INJ -A
4
POTASSIUM CHLORIDE 20 MEQ/L (0.15%) IN2
DEXTROSE 5% INJ
POTASSIUM CHLORIDE 40 MEQ/L (0.3%) IN 2
DEXTROSE 5% INJ
potassium chloride inj 2 meq/ml
2
POTASSIUM CHLORIDE INJ 10 MEQ/50ML
2
POTASSIUM CHLORIDE INJ 10 MEQ/100ML 2
POTASSIUM CHLORIDE INJ 20 MEQ/50ML
2
POTASSIUM CHLORIDE INJ 20 MEQ/100ML 2
POTASSIUM CHLORIDE INJ 40 MEQ/100ML 2
RINGER'S SOLUTION
2
SODIUM CHLORIDE INJ 0.45%
2
SODIUM CHLORIDE INJ 3%
2
SODIUM CHLORIDE INJ 5%
2
SODIUM CHLORIDE IV SOLN 0.9%
2
VITAMINS
calcitriol cap 0.5 mcg
calcitriol cap 0.25 mcg
calcitriol inj 1 mcg/ml
calcitriol oral soln 1 mcg/ml
paricalcitol cap 1 mcg
paricalcitol cap 2 mcg
paricalcitol cap 4 mcg
PRENATAL VITAMIN/FOLIC ACID > 0.8 MG
(GENERIC)
2
2
2
2
2
2
2
2
B/D
B/D
B/D
B/D
B/D
B/D
B/D
OPHTHALMIC
ANTI-INFECTIVE/ANTI-INFLAMMATORY
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
83
Drug Name
Drug Tier Requirements/Limits
bacitracin-polymyxin-neomycin-hc ophth oint2
1%
blephamide oin s.o.p.
4
neomycin-polymyxin-dexamethasone ophth 2
oint 0.1%
neomycin-polymyxin-dexamethasone ophth 2
susp 0.1%
neomycin-polymyxin-hc ophth susp
2
sulfacetamide sodium-prednisolone ophth
2
soln 10-0.23(0.25)%
TOBRADEX OIN 0.3-0.1%
3
TOBRADEX ST SUS 0.3-0.05
3
tobramycin-dexamethasone ophth susp
2
0.3-0.1%
ZYLET SUS 0.5-0.3%
3
ANTI-INFECTIVES
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
gatifloxacin ophth soln 0.5%
gentak oin 0.3% op
gentamicin sulfate ophth oint 0.3%
gentamicin sulfate ophth soln 0.3%
ilotycin oin op
MOXEZA SOL 0.5%
NATACYN SUS 5% OP
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml
ofloxacin ophth soln 0.3%
polymyxin b-trimethoprim ophth soln 10000
unit/ml-0.1%
sulfacetamide sodium ophth oint 10%
sulfacetamide sodium ophth soln 10%
tobramycin ophth soln 0.3%
TOBREX OIN 0.3% OP
trifluridine ophth soln 1%
VIGAMOX DRO 0.5%
ZIRGAN GEL 0.15%
ANTI-INFLAMMATORIES
ALREX SUS 0.2%
PA - Prior Authorization
available at mail-order
2
2
3
3
2
1
2
2
2
1
1
3
4
2
2
2
1
2
2
1
4
2
3
4
3
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
84
Drug Name
BROMFENAC SODIUM OPHTH SOLN 0.09%
(BASE EQUIV) (ONCE-DAILY)
bromfenac sodium ophth soln 0.09% (base
equivalent)
dexamethasone sodium phosphate ophth
soln 0.1%
diclofenac sodium ophth soln 0.1%
DUREZOL EMU 0.05%
FLUOROMETHOLONE OPHTH SUSP 0.1%
flurbiprofen sodium ophth soln 0.03%
ILEVRO DRO 0.3% OP
ketorolac tromethamine ophth soln 0.4%
ketorolac tromethamine ophth soln 0.5%
LOTEMAX GEL 0.5%
LOTEMAX OIN 0.5%
LOTEMAX SUS 0.5%
MAXIDEX SUS 0.1% OP
pred sod pho sol 1% op
PREDNISOLONE ACETATE OPHTH SUSP 1%
ANTIALLERGICS
azelastine hcl ophth soln 0.05%
BEPREVE DRO 1.5%
cromolyn sodium ophth soln 4%
LASTACAFT SOL 0.25%
PATADAY SOL 0.2%
PAZEO DRO 0.7%
ANTIGLAUCOMA
ALPHAGAN P SOL 0.1%
AZOPT SUS 1% OP
betaxolol hcl ophth soln 0.5%
BETOPTIC-S SUS 0.25% OP
brimonidine tartrate ophth soln 0.2%
BRIMONIDINE TARTRATE OPHTH SOLN
0.15%
carteolol hcl ophth soln 1%
COMBIGAN SOL 0.2/0.5%
dorzolamide hcl ophth soln 2%
dorzolamide hcl-timolol maleate ophth soln
22.3-6.8 mg/ml
ISTALOL SOL 0.5% OP
latanoprost ophth soln 0.005%
levobunolol hcl ophth soln 0.5%
LUMIGAN SOL 0.01%
metipranolol ophth soln 0.3%
PHOSPHOLINE SOL 0.125%OP
PA - Prior Authorization
available at mail-order
Drug Tier Requirements/Limits
2
2
2
2
3
2
1
3
2
2
3
3
3
3
3
2
2
3
1
4
3
3
3
3
2
3
1
2
1
3
2
2
3
1
2
3
2
4
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
85
Drug Name
PILOCARPINE HCL OPHTH SOLN 1%
PILOCARPINE HCL OPHTH SOLN 2%
PILOCARPINE HCL OPHTH SOLN 4%
SIMBRINZA SUS 1-0.2%
TIMOLOL MALEATE OPHTH GEL FORMING
SOLN 0.5%
TIMOLOL MALEATE OPHTH GEL FORMING
SOLN 0.25%
timolol maleate ophth soln 0.5%
timolol maleate ophth soln 0.25%
TRAVATAN Z DRO 0.004%
MISCELLANEOUS
naphazoline hcl ophth soln 0.1%
PROLENSA SOL 0.07%
proparacaine hcl ophth soln 0.5%
RESTASIS EMU 0.05%
Drug Tier Requirements/Limits
2
2
2
3
2
2
1
1
3
1
3
1
3
QL (64 vials / 30 days)
RESPIRATORY
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS
ANORO ELLIPT AER 62.5-25
3
COMBIVENT AER 20-100
ipratropium-albuterol nebu soln 0.5-2.5(3)
mg/3ml
4
2
ANTICHOLINERGICS
ATROVENT HFA AER 17MCG
INCRUSE ELPT INH 62.5MCG
ipratropium bromide inhal soln 0.02%
ipratropium bromide nasal soln 0.03% (21
mcg/spray)
ipratropium bromide nasal soln 0.06% (42
mcg/spray)
ANTIHISTAMINES
4
3
2
2
QL (2 inhalers / 30 days)
QL (1 inhaler / 30 days)
B/D
2
ASTEPRO SPR 0.15%
azelastine hcl nasal spray 0.1% (137
mcg/spray)
azelastine hcl nasal spray 0.15% (205.5
mcg/spray)
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)
diphenhydramine hcl inj 50 mg/ml
hydroxyzine hcl im soln 25 mg/ml
3
2
hydroxyzine hcl im soln 50 mg/ml
4
hydroxyzine hcl syrup 10 mg/5ml
3
PA - Prior Authorization
available at mail-order
QL (60 inhalations / 30
days)
QL (2 inhalers / 30 days)
B/D
2
2
2
4
PA; PA if 65 years and
older
PA; PA if 65 years and
older
PA; PA if 65 years and
older
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
86
Drug Name
hydroxyzine hcl tab 10 mg
hydroxyzine hcl tab 25 mg
hydroxyzine hcl tab 50 mg
hydroxyzine pamoate cap 25 mg
hydroxyzine pamoate cap 50 mg
hydroxyzine pamoate cap 100 mg
levocetirizine dihydrochloride soln 2.5
mg/5ml (0.5 mg/ml)
levocetirizine dihydrochloride tab 5 mg
olopatadine hcl nasal soln 0.6%
BETA AGONISTS
Drug Tier Requirements/Limits
3
PA; PA if 65 years and
older
3
PA; PA if 65 years and
older
3
PA; PA if 65 years and
older
3
PA; PA if 65 years and
older
3
PA; PA if 65 years and
older
3
PA; PA if 65 years and
older
2
2
2
albuterol sulfate soln nebu 0.5% (5 mg/ml)
albuterol sulfate soln nebu 0.63 mg/3ml
(base equiv)
albuterol sulfate soln nebu 0.083% (2.5
mg/3ml)
albuterol sulfate soln nebu 1.25 mg/3ml
(base equiv)
albuterol sulfate syrup 2 mg/5ml
albuterol sulfate tab 2 mg
albuterol sulfate tab 4 mg
albuterol sulfate tab sr 12hr 4 mg
albuterol sulfate tab sr 12hr 8 mg
levalbuterol hcl soln nebu conc 1.25
mg/0.5ml (base equiv)
PERFOROMIST NEB 20MCG
SEREVENT DIS AER 50MCG
2
2
B/D
B/D
2
B/D
2
B/D
1
2
2
2
2
2
B/D
terbutaline sulfate inj 1 mg/ml
terbutaline sulfate tab 2.5 mg
terbutaline sulfate tab 5 mg
VENTOLIN HFA AER
XOPENEX HFA AER
5
2
2
3
3
4
3
B/D
QL (60 inhalations / 30
days)
QL (2 inhalers / 30 days)
QL (2 inhalers / 30 days)
LEUKOTRIENE RECEPTOR ANTAGONISTS
montelukast sodium chew tab 4 mg (base
2
equiv)
montelukast sodium chew tab 5 mg (base
2
equiv)
montelukast sodium oral granules packet 4 2
mg (base equiv)
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
87
Drug Name
Drug Tier Requirements/Limits
montelukast sodium tab 10 mg (base equiv) 2
zafirlukast tab 10 mg
2
zafirlukast tab 20 mg
2
MAST CELL STABILIZERS
cromolyn sodium soln nebu 20 mg/2ml
MISCELLANEOUS
acetylcysteine inhal soln 10%
acetylcysteine inhal soln 20%
ARALAST NP INJ 500MG
ARALAST NP INJ 1000MG
DALIRESP TAB 500MCG
EPIPEN 2-PAK INJ 0.3MG
EPIPEN-JR INJ 2-PAK
ESBRIET CAP 267MG
KALYDECO PAK 50MG
KALYDECO PAK 75MG
KALYDECO TAB 150MG
OFEV CAP 100MG
OFEV CAP 150MG
ORKAMBI TAB 200-125
PROLASTIN-C INJ 1000MG
PULMOZYME SOL 1MG/ML
XOLAIR SOL 150MG
ZEMAIRA INJ 1000MG
2
B/D
2
2
5
5
4
3
3
5
5
5
5
5
5
5
5
5
5
5
B/D
B/D
NM, LA, PA
NM, LA, PA
NASAL STEROIDS
flunisolide nasal soln 25 mcg/act (0.025%) 2
fluticasone propionate nasal susp 50 mcg/act2
mometasone furoate nasal susp 50 mcg/act 2
NASONEX SPR 50MCG/AC
3
STEROID INHALANTS
ARNUITY ELPT INH 100MCG
3
ARNUITY ELPT INH 200MCG
3
budesonide inhalation susp 0.5 mg/2ml
budesonide inhalation susp 0.25 mg/2ml
FLOVENT DISK AER 50MCG
2
2
3
FLOVENT DISK AER 100MCG
3
FLOVENT DISK AER 250MCG
3
FLOVENT HFA AER 44MCG
FLOVENT HFA AER 110MCG
FLOVENT HFA AER 220MCG
3
3
3
PA - Prior Authorization
available at mail-order
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, PA
NM, LA, PA
B/D, NM
NM, LA, PA
NM, LA, PA
QL
QL
QL
QL
(2
(1
(2
(2
bottles / 30 days)
bottle / 30 days)
bottles / 30 days)
inhalers / 30 days)
QL (30 inhalations / 30
days)
QL (30 inhalations / 30
days)
B/D
B/D
QL (120 inhalations / 30
days)
QL (120 inhalations / 30
days)
QL (240 inhalations / 30
days)
QL (2 inhalers / 30 days)
QL (2 inhalers / 30 days)
QL (2 inhalers / 30 days)
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
88
Drug Name
PULMICORT INH 90MCG
PULMICORT INH 180MCG
Drug Tier Requirements/Limits
3
QL (2 inhalers / 30 days)
3
QL (2 inhalers / 30 days)
STEROID/BETA-AGONIST COMBINATIONS
ADVAIR DISKU AER 100/50
3
ADVAIR DISKU AER 250/50
3
ADVAIR DISKU AER 500/50
3
ADVAIR HFA AER 45/21
ADVAIR HFA AER 115/21
ADVAIR HFA AER 230/21
BREO ELLIPTA INH 100-25
BREO ELLIPTA INH 200-25
SYMBICORT AER 80-4.5
SYMBICORT AER 160-4.5
3
3
3
3
3
3
3
XANTHINES
aminophylline inj 25 mg/ml
elixophyllin elx 80/15ml
theo-24 cap 100mg cr
theo-24 cap 200mg cr
theo-24 cap 300mg cr
theo-24 cap 400mg er
theophylline soln 80 mg/15ml
theophylline tab sr 12hr 100 mg
theophylline tab sr 12hr 200 mg
theophylline tab sr 12hr 300 mg
theophylline tab sr 12hr 450 mg
theophylline tab sr 24hr 400 mg
theophylline tab sr 24hr 600 mg
TOPICAL
DERMATOLOGY, ACNE
adapalene cream 0.1%
adapalene gel 0.1%
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
clindamax gel 1%
clindamycin phosphate gel 1%
clindamycin phosphate lotion 1%
clindamycin phosphate soln 1%
PA - Prior Authorization
available at mail-order
QL (60 inhalations / 30
days)
QL (60 inhalations / 30
days)
QL (60 inhalations / 30
days)
QL (1 inhaler / 30 days)
QL (1 inhaler / 30 days)
QL (1 inhaler / 30 days)
QL (60 blisters / 30 days)
QL (60 blisters / 30 days)
QL (1 inhaler / 30 days)
QL (1 inhaler / 30 days)
2
4
4
4
4
4
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
89
Drug Name
clindamycin phosphate swab 1%
erythromycin gel 2%
erythromycin pads 2%
erythromycin soln 2%
isotretinoin cap 10 mg
isotretinoin cap 20 mg
isotretinoin cap 40 mg
myorisan cap 10mg
myorisan cap 20mg
myorisan cap 30mg
myorisan cap 40mg
sulfacetamide sodium lotion 10% (acne)
tretinoin cream 0.1%
tretinoin cream 0.05%
tretinoin cream 0.025%
TRETINOIN GEL 0.01%
tretinoin gel 0.025%
zenatane cap 10mg
zenatane cap 20mg
zenatane cap 30mg
zenatane cap 40mg
DERMATOLOGY, ANTIBIOTICS
gentamicin sulfate cream 0.1%
gentamicin sulfate oint 0.1%
mupirocin oint 2%
SILVER SULFADIAZINE CREAM 1%
SSD CRE 1%
SULFAMYLON CRE 85MG/GM
SULFAMYLON PAK 5%
Drug Tier Requirements/Limits
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
1
2
2
4
5
DERMATOLOGY, ANTIFUNGALS
ciclopirox gel 0.77%
2
ciclopirox olamine cream 0.77% (base equiv)2
ciclopirox olamine susp 0.77% (base equiv) 2
ciclopirox shampoo 1%
2
clotrimazole cream 1%
2
clotrimazole soln 1%
2
econazole nitrate cream 1%
2
ketoconazole cream 2%
2
nyamyc pow 100000
2
nystatin cream 100000 unit/gm
2
nystatin oint 100000 unit/gm
2
nystatin topical powder
2
nystop pow 100000
2
DERMATOLOGY, ANTIPRURITIC
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
90
Drug Name
DOXEPIN HCL CREAM 5%
hydrocortisone rectal cream 2.5%
procto-med cre hc 2.5%
procto-pak cre 1%
proctozone cre -hc 2.5%
PRUDOXIN CRE 5%
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)
calcitrene oin 0.005%
8-MOP CAP 10MG
TAZORAC CRE 0.1%
TAZORAC CRE 0.05%
DERMATOLOGY, ANTISEBORRHEICS
ketoconazole shampoo 2%
selenium sulfide lotion 2.5%
Drug Tier Requirements/Limits
2
2
2
2
2
2
5
5
5
2
2
2
2
4
4
4
PA
PA
PA
PA
PA
1
1
DERMATOLOGY, CORTICOSTEROIDS
ala cort cre 1%
1
alclometasone dipropionate cream 0.05%
2
alclometasone dipropionate oint 0.05%
2
betamethasone dipropionate augmented
2
cream 0.05%
betamethasone dipropionate augmented gel 2
0.05%
betamethasone dipropionate augmented
2
lotion 0.05%
betamethasone dipropionate augmented oint 2
0.05%
betamethasone dipropionate cream 0.05% 2
betamethasone dipropionate lotion 0.05%
2
betamethasone dipropionate oint 0.05%
2
betamethasone valerate cream 0.1%
2
betamethasone valerate lotion 0.1%
2
betamethasone valerate oint 0.1%
2
clobetasol propionate cream 0.05%
2
clobetasol propionate emollient base cream 2
0.05%
clobetasol propionate gel 0.05%
2
clobetasol propionate oint 0.05%
2
clobetasol propionate soln 0.05%
2
cormax scalp sol 0.05%
2
PA - Prior Authorization
available at mail-order
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
91
Drug Name
DESONIDE CREAM 0.05%
desonide lotion 0.05%
desonide oint 0.05%
desoximetasone cream 0.05%
desoximetasone cream 0.25%
desoximetasone gel 0.05%
DESOXIMETASONE OINT 0.05%
desoximetasone oint 0.25%
diflorasone diacetate cream 0.05%
diflorasone diacetate oint 0.05%
fluocin acet oil body
fluocin acet oil scalp
fluocinolone acetonide cream 0.01%
fluocinolone acetonide cream 0.025%
fluocinolone acetonide oint 0.025%
fluocinolone acetonide soln 0.01%
fluocinonide cream 0.05%
fluocinonide emulsified base cream 0.05%
fluocinonide gel 0.05%
fluocinonide oint 0.05%
fluocinonide soln 0.05%
fluticasone propionate cream 0.05%
fluticasone propionate oint 0.005%
halobetasol propionate cream 0.05%
halobetasol propionate oint 0.05%
hydrocortisone butyrate cream 0.1%
hydrocortisone butyrate oint 0.1%
hydrocortisone butyrate soln 0.1%
hydrocortisone cream 1%
hydrocortisone cream 2.5%
hydrocortisone lotion 2.5%
hydrocortisone oint 1%
hydrocortisone oint 2.5%
hydrocortisone valerate cream 0.2%
hydrocortisone valerate oint 0.2%
lokara lot 0.05%
mometasone furoate cream 0.1%
mometasone furoate oint 0.1%
mometasone furoate solution 0.1% (lotion)
texacort sol 2.5%
triamcinolone acetonide cream 0.1%
triamcinolone acetonide cream 0.5%
triamcinolone acetonide cream 0.025%
triamcinolone acetonide lotion 0.1%
triamcinolone acetonide lotion 0.025%
PA - Prior Authorization
available at mail-order
Drug Tier Requirements/Limits
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
2
2
2
1
1
2
1
1
2
2
2
2
2
2
4
1
1
1
2
2
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
92
Drug Name
triamcinolone acetonide oint 0.1%
triamcinolone acetonide oint 0.5%
triamcinolone acetonide oint 0.025%
triderm cre 0.1%
DERMATOLOGY, LOCAL ANESTHETICS
lidocaine
lidocaine
lidocaine
lidocaine
hcl gel 2%
hcl soln 4%
oint 5%
patch 5%
lidocaine-prilocaine cream 2.5-2.5%
Drug Tier Requirements/Limits
1
1
1
1
2
1
2
2
2
QL (3 patches / 1 day),
PA
B/D
DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE
acyclovir oint 5%
diclofenac sodium gel 1%
ELIDEL CRE 1%
fluorouracil cream 5%
fluorouracil soln 2%
fluorouracil soln 5%
imiquimod cream 5%
lactic acid (ammonium lactate) cream 12%
lactic acid (ammonium lactate) lotion 12%
metronidazole cream 0.75%
metronidazole gel 0.75%
metronidazole lotion 0.75%
PANRETIN GEL 0.1%
podofilox soln 0.5%
rosadan cre 0.75%
tacrolimus oint 0.1%
tacrolimus oint 0.03%
TARGRETIN GEL 1%
VALCHLOR GEL 0.016%
VOLTAREN GEL 1%
2
2
4
2
2
2
2
2
2
2
2
2
5
2
2
2
2
5
5
3
PA
PA
PA
NM, PA
NM, LA, PA
DERMATOLOGY, SCABICIDES AND PEDICULIDES
EURAX CRE 10%
EURAX LOT 10%
malathion lotion 0.5%
permethrin cream 5%
4
4
2
2
DERMATOLOGY, WOUND CARE AGENTS
acetic acid irrigation soln 0.25%
1
REGRANEX GEL 0.01%
5
SANTYL OIN 250/GM
4
SODIUM CHLORIDE IRRIGATION SOLN 0.9% 1
WATER FOR IRRIGATION, STERILE
2
IRRIGATION SOLN
PA - Prior Authorization
available at mail-order
PA
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
93
Drug Name
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
pilocarpine hcl tab 7.5 mg
triamcinolone acetonide dental paste 0.1%
Drug Tier Requirements/Limits
2
1
2
1
2
1
2
2
2
OTIC
acetic acid 2% in aluminum acetate otic soln 2
acetic acid otic soln 2%
2
CIPRODEX SUS 0.3-0.1%
3
fluocinolone acetonide (otic) oil 0.01%
2
neomycin-polymyxin-hc otic soln 1%
2
neomycin-polymyxin-hc otic susp 3.5
2
mg/ml-10000 unit/ml-1%
ofloxacin otic soln 0.3%
2
_PART B
DIABETIC METERS AND TEST STRIPS
TRUE METRIX KIT AIR
TRUE METRIX KIT METER
TRUE METRIX TES
PA - Prior Authorization
available at mail-order
Part B
Part B
Part B
$0 Copay
$0 Copay
$0 Copay
QL - Quantity Limits
ST - Step Therapy
NM - Not
B/D - Covered under Medicare B or D
LA - Limited Access
94
Index
8
8-MOP CAP 10MG .............................91
A
abacavir sulfate tab 300 mg (base equiv)
....................................................... 8
abacavir sulfate-lamivudine-zidovudine
tab 300-150-300 mg .........................10
ABELCET INJ 5MG/ML ......................... 7
ABILIFY DISC TAB 10MG....................48
ABILIFY MAIN INJ 300MG ..................48
ABILIFY MAIN INJ 400MG ..................48
ABRAXANE INJ 100MG .......................19
acamprosate calcium tab delayed release
333 mg ...........................................56
acarbose tab 100 mg.........................58
acarbose tab 25 mg ..........................58
acarbose tab 50 mg ..........................58
acebutolol hcl cap 200 mg .................31
acebutolol hcl cap 400 mg .................31
acetaminophen w/ codeine soln 120-12
mg/5ml ............................................ 2
acetaminophen w/ codeine tab 300-15 mg
....................................................... 2
acetaminophen w/ codeine tab 300-30 mg
....................................................... 2
acetaminophen w/ codeine tab 300-60 mg
....................................................... 2
acetazolamide cap sr 12hr 500 mg ......34
acetazolamide tab 125 mg .................34
acetazolamide tab 250 mg .................34
acetic acid 2% in aluminum acetate otic
soln.................................................94
acetic acid irrigation soln 0.25% .........93
acetic acid otic soln 2% .....................94
acetylcysteine inhal soln 10% .............88
acetylcysteine inhal soln 20% .............88
acitretin cap 10 mg ...........................91
acitretin cap 17.5 mg ........................91
acitretin cap 25 mg ...........................91
ACTHIB INJ ......................................79
ACTIMMUNE INJ 2MU/0.5...................78
acyclovir cap 200 mg ........................11
acyclovir oint 5% ..............................93
acyclovir sodium for inj 500 mg ..........11
acyclovir sodium iv soln 50 mg/ml ......11
acyclovir susp 200 mg/5ml ................11
acyclovir tab 400 mg .........................11
acyclovir tab 800 mg ........................ 11
ADACEL INJ ..................................... 79
ADAGEN INJ 250/ML ......................... 63
adapalene cream 0.1% ..................... 89
adapalene gel 0.1% .......................... 89
adefovir dipivoxil tab 10 mg .............. 11
ADEMPAS TAB 0.5MG ....................... 36
ADEMPAS TAB 1.5MG ....................... 36
ADEMPAS TAB 1MG .......................... 36
ADEMPAS TAB 2.5MG ....................... 36
ADEMPAS TAB 2MG .......................... 36
adrucil inj 2.5g/50m ......................... 18
adrucil inj 500/10ml ......................... 18
adrucil inj 5gm/100m ....................... 18
ADVAIR DISKU AER 100/50 ............... 89
ADVAIR DISKU AER 250/50 ............... 89
ADVAIR DISKU AER 500/50 ............... 89
ADVAIR HFA AER 115/21 .................. 89
ADVAIR HFA AER 230/21 .................. 89
ADVAIR HFA AER 45/21 .................... 89
afeditab tab 30mg cr ........................ 32
afeditab tab 60mg cr ........................ 32
AFINITOR DIS TAB 2MG .................... 21
AFINITOR DIS TAB 3MG .................... 21
AFINITOR DIS TAB 5MG .................... 21
AFINITOR TAB 10MG ........................ 21
AFINITOR TAB 2.5MG ....................... 21
AFINITOR TAB 5MG .......................... 21
AFINITOR TAB 7.5MG ....................... 21
AGGRENOX CAP 25-200MG ............... 76
a-hydrocort inj 100mg ...................... 65
ala cort cre 1% ................................ 91
ALBENZA TAB 200MG ......................... 5
albuterol sulfate soln nebu 0.083% (2.5
mg/3ml) ......................................... 87
albuterol sulfate soln nebu 0.5% (5
mg/ml) ........................................... 87
albuterol sulfate soln nebu 0.63 mg/3ml
(base equiv) .................................... 87
albuterol sulfate soln nebu 1.25 mg/3ml
(base equiv) .................................... 87
albuterol sulfate syrup 2 mg/5ml ....... 87
albuterol sulfate tab 2 mg ................. 87
albuterol sulfate tab 4 mg ................. 87
albuterol sulfate tab sr 12hr 4 mg ...... 87
albuterol sulfate tab sr 12hr 8 mg ...... 87
alclometasone dipropionate cream 0.05%
95
......................................................91
alclometasone dipropionate oint 0.05%
......................................................91
ALCOHOL SWABS .............................57
ALDURAZYME INJ 2.9MG/5M ..............63
ALECENSA CAP 150MG ......................21
alendronate sodium tab 10 mg ...........59
alendronate sodium tab 35 mg ...........60
alendronate sodium tab 40 mg ...........60
alendronate sodium tab 5 mg .............59
alendronate sodium tab 70 mg ...........60
alfuzosin hcl tab sr 24hr 10 mg...........73
ALIMTA INJ 100MG ...........................18
ALIMTA INJ 500MG ...........................18
ALINIA SUS 100/5ML ......................... 5
ALINIA TAB 500MG ............................ 5
allopurinol tab 100 mg........................ 1
allopurinol tab 300 mg........................ 1
alosetron hcl tab 0.5 mg (base equiv) .72
alosetron hcl tab 1 mg (base equiv) ....72
ALPHAGAN P SOL 0.1% .....................85
alprazolam tab 0.25 mg .....................37
alprazolam tab 0.5 mg.......................37
alprazolam tab 1 mg .........................37
alprazolam tab 2 mg .........................37
ALREX SUS 0.2% ..............................84
altavera tab .....................................60
amantadine hcl cap 100 mg ...............47
amantadine hcl syrup 50 mg/5ml ........47
amantadine hcl tab 100 mg................47
AMBISOME INJ 50MG ......................... 7
amifostine crystalline for inj 500 mg....23
amikacin sulfate inj 1 gm/4ml (250
mg/ml) ............................................. 5
amikacin sulfate inj 500 mg/2ml (250
mg/ml) ............................................. 5
amiloride & hydrochlorothiazide tab 5-50
mg ..................................................34
amiloride hcl tab 5 mg .......................34
amino acid infusion 6% .....................81
aminophylline inj 25 mg/ml ................89
AMINOSYN 7% INJ /LYTES .................81
AMINOSYN II INJ 10%.......................81
AMINOSYN II INJ 7% ........................81
AMINOSYN II INJ 8.5%......................81
AMINOSYN II INJ 8.5/LYTE.................81
AMINOSYN INJ 10% ..........................81
AMINOSYN INJ 8.5% .........................81
AMINOSYN INJ 8.5/LYTE ................... 81
AMINOSYN M INJ 3.5% ..................... 81
AMINOSYN-HBC INJ 7% .................... 81
AMINOSYN-PF INJ 10% ..................... 81
AMINOSYN-PF INJ 7% ...................... 81
AMINOSYN-RF INJ 5.2% ................... 81
amiodarone hcl inj 150 mg/3ml (50
mg/ml) ........................................... 28
amiodarone hcl inj 450 mg/9ml (50
mg/ml) ........................................... 28
amiodarone hcl inj 900 mg/18ml (50
mg/ml) ........................................... 28
amiodarone hcl tab 100 mg ............... 28
amiodarone hcl tab 200 mg ............... 28
amiodarone hcl tab 400 mg ............... 28
AMITIZA CAP 24MCG ........................ 72
AMITIZA CAP 8MCG .......................... 72
amitriptyline hcl tab 10 mg................ 43
amitriptyline hcl tab 100 mg .............. 43
amitriptyline hcl tab 150 mg .............. 43
amitriptyline hcl tab 25 mg................ 43
amitriptyline hcl tab 50 mg................ 43
amitriptyline hcl tab 75 mg................ 43
amlodipine besylate tab 10 mg .......... 32
amlodipine besylate tab 2.5 mg ......... 32
amlodipine besylate tab 5 mg ............ 32
amlodipine besylate-benazepril hcl cap
10-20 mg ........................................ 24
amlodipine besylate-benazepril hcl cap
10-40 mg ........................................ 24
amlodipine besylate-benazepril hcl cap
2.5-10 mg ....................................... 24
amlodipine besylate-benazepril hcl cap
5-10 mg.......................................... 24
amlodipine besylate-benazepril hcl cap
5-20 mg.......................................... 24
amlodipine besylate-benazepril hcl cap
5-40 mg.......................................... 24
amlodipine besylate-valsartan tab 10-160
mg ................................................. 26
amlodipine besylate-valsartan tab 10-320
mg ................................................. 26
amlodipine besylate-valsartan tab 5-160
mg ................................................. 26
amlodipine besylate-valsartan tab 5-320
mg ................................................. 26
amlodipine-valsartan-hydrochlorothiazide
tab 10-160-12.5 mg ......................... 26
96
amlodipine-valsartan-hydrochlorothiazide
tab 10-160-25 mg ............................26
amlodipine-valsartan-hydrochlorothiazide
tab 10-320-25 mg ............................26
amlodipine-valsartan-hydrochlorothiazide
tab 5-160-12.5 mg ...........................26
amlodipine-valsartan-hydrochlorothiazide
tab 5-160-25 mg ..............................26
amoxapine tab 100 mg ......................43
amoxapine tab 150 mg ......................43
amoxapine tab 25 mg........................43
amoxapine tab 50 mg........................43
amoxicillin & k clavulanate chew tab
200-28.5 mg ....................................15
amoxicillin & k clavulanate chew tab
400-57 mg .......................................15
amoxicillin & k clavulanate for susp
200-28.5 mg/5ml .............................15
amoxicillin & k clavulanate for susp
250-62.5 mg/5ml .............................15
amoxicillin & k clavulanate for susp
400-57 mg/5ml ................................15
amoxicillin & k clavulanate for susp
600-42.9 mg/5ml .............................15
amoxicillin & k clavulanate tab 250-125
mg ..................................................15
amoxicillin & k clavulanate tab 500-125
mg ..................................................15
amoxicillin & k clavulanate tab 875-125
mg ..................................................15
amoxicillin & k clavulanate tab sr 12hr
1000-62.5 mg ..................................15
amoxicillin (trihydrate) cap 250 mg .....15
amoxicillin (trihydrate) cap 500 mg .....15
amoxicillin (trihydrate) chew tab 125 mg
......................................................15
amoxicillin (trihydrate) chew tab 250 mg
......................................................15
amoxicillin (trihydrate) for susp 125
mg/5ml ...........................................15
amoxicillin (trihydrate) for susp 200
mg/5ml ...........................................15
amoxicillin (trihydrate) for susp 250
mg/5ml ...........................................15
amoxicillin (trihydrate) for susp 400
mg/5ml ...........................................15
amoxicillin (trihydrate) tab 500 mg .....15
amoxicillin (trihydrate) tab 875 mg .....15
amphetamine-dextroamphetamine cap sr
24hr 10 mg ..................................... 53
amphetamine-dextroamphetamine cap sr
24hr 15 mg ..................................... 53
amphetamine-dextroamphetamine cap sr
24hr 20 mg ..................................... 53
amphetamine-dextroamphetamine cap sr
24hr 25 mg ..................................... 53
amphetamine-dextroamphetamine cap sr
24hr 30 mg ..................................... 53
amphetamine-dextroamphetamine cap sr
24hr 5 mg ....................................... 52
amphetamine-dextroamphetamine tab 10
mg ................................................. 53
amphetamine-dextroamphetamine tab
12.5 mg .......................................... 53
amphetamine-dextroamphetamine tab 15
mg ................................................. 53
amphetamine-dextroamphetamine tab 20
mg ................................................. 53
amphetamine-dextroamphetamine tab 30
mg ................................................. 53
amphetamine-dextroamphetamine tab 5
mg ................................................. 53
amphetamine-dextroamphetamine tab
7.5 mg............................................ 53
amphotericin b for inj 50 mg ............... 7
ampicillin & sulbactam sodium for inj 1.5
(1-0.5) gm ...................................... 15
ampicillin & sulbactam sodium for inj 15
(10-5) gm ....................................... 15
ampicillin & sulbactam sodium for inj 3
(2-1) gm ......................................... 15
ampicillin & sulbactam sodium for iv soln
15 (10-5) gm................................... 15
ampicillin & sulbactam sodium for iv soln 3
(2-1) gm ......................................... 15
ampicillin cap 250 mg ....................... 15
ampicillin cap 500 mg ....................... 15
ampicillin for susp 125 mg/5ml .......... 16
ampicillin for susp 250 mg/5ml .......... 16
ampicillin sodium for inj 1 gm ............ 16
ampicillin sodium for inj 125 mg ........ 16
ampicillin sodium for inj 2 gm ............ 16
ampicillin sodium for inj 250 mg ........ 16
ampicillin sodium for inj 500 mg ........ 16
ampicillin sodium for iv soln 1 gm ...... 16
ampicillin sodium for iv soln 10 gm..... 16
97
ampicillin sodium for iv soln 2 gm .......16
AMPYRA TAB 10MG ...........................55
anagrelide hcl cap 0.5 mg ..................76
anagrelide hcl cap 1 mg .....................76
anastrozole tab 1 mg ........................20
ANDRODERM DIS 2MG/24HR..............57
ANDRODERM DIS 4MG/24HR..............57
ANORO ELLIPT AER 62.5-25 ...............86
APOKYN INJ 10MG/ML .......................47
apri tab ...........................................60
APRISO CAP 0.375GM .......................71
APTIOM TAB 200MG ..........................37
APTIOM TAB 400MG ..........................37
APTIOM TAB 600MG ..........................37
APTIOM TAB 800MG ..........................37
APTIVUS CAP 250MG .......................... 8
APTIVUS SOL .................................... 8
ARALAST NP INJ 1000MG ...................88
ARALAST NP INJ 500MG ....................88
aranelle tab ......................................60
ARCALYST INJ 220MG .......................78
aripiprazole oral solution 1 mg/ml .......48
aripiprazole orally disintegrating tab 10
mg ..................................................48
aripiprazole orally disintegrating tab 15
mg ..................................................48
aripiprazole tab 10 mg.......................48
aripiprazole tab 15 mg.......................48
aripiprazole tab 2 mg ........................48
aripiprazole tab 20 mg.......................48
aripiprazole tab 30 mg.......................48
aripiprazole tab 5 mg ........................48
armodafinil tab 150 mg .....................56
ARMODAFINIL TAB 200 MG ................56
armodafinil tab 250 mg .....................56
armodafinil tab 50 mg .......................56
ARNUITY ELPT INH 100MCG ...............88
ARNUITY ELPT INH 200MCG ...............88
ASACOL HD TAB 800MG ....................71
ASPIRIN-DIPYRIDAMOLE CAP SR 12HR
25-200 MG .......................................76
ASTEPRO SPR 0.15% ........................86
atenolol & chlorthalidone tab 100-25 mg
......................................................30
atenolol & chlorthalidone tab 50-25 mg
......................................................30
atenolol tab 100 mg ..........................31
atenolol tab 25 mg ............................31
atenolol tab 50 mg ........................... 31
atorvastatin calcium tab 10 mg (base
equivalent) ...................................... 29
atorvastatin calcium tab 20 mg (base
equivalent) ...................................... 29
atorvastatin calcium tab 40 mg (base
equivalent) ...................................... 29
atorvastatin calcium tab 80 mg (base
equivalent) ...................................... 29
atovaquone susp 750 mg/5ml .............. 5
atovaquone-proguanil hcl tab 250-100 mg
........................................................ 8
atovaquone-proguanil hcl tab 62.5-25 mg
........................................................ 8
ATRIPLA TAB ................................... 10
ATROVENT HFA AER 17MCG .............. 86
aubra tab 0.1-0.02 ........................... 60
AVASTIN INJ ................................... 19
AVASTIN INJ 400/16ML..................... 19
aviane tab ....................................... 60
AVITA CRE 0.025% .......................... 89
AVITA GEL 0.025% .......................... 89
AXIRON SOL 30MG/ACT .................... 57
azacitidine for inj 100 mg .................. 18
AZACTAM/DEX INJ 1GM ...................... 5
AZACTAM/DEX INJ 2GM ...................... 5
azathioprine inj 100mg ..................... 78
azathioprine tab 50 mg ..................... 78
azelastine hcl nasal spray 0.1% (137
mcg/spray) ..................................... 86
azelastine hcl nasal spray 0.15% (205.5
mcg/spray) ..................................... 86
azelastine hcl ophth soln 0.05% ......... 85
AZILECT TAB 0.5MG ......................... 47
AZILECT TAB 1MG ............................ 47
azithromycin for susp 100 mg/5ml ..... 14
azithromycin for susp 200 mg/5ml ..... 14
azithromycin iv for soln 500 mg ......... 14
AZITHROMYCIN POWD PACK FOR SUSP 1
GM ................................................. 14
azithromycin tab 250 mg .................. 14
azithromycin tab 500 mg .................. 14
azithromycin tab 600 mg .................. 14
AZOPT SUS 1% OP ........................... 85
AZOR TAB 10-20MG ......................... 27
AZOR TAB 10-40MG ......................... 27
AZOR TAB 5-20MG ........................... 26
AZOR TAB 5-40MG ........................... 26
98
aztreonam for inj 1 gm ....................... 5
aztreonam for inj 2 gm ....................... 5
B
bacitracin ophth oint 500 unit/gm .......84
bacitracin-polymyxin b ophth oint .......84
bacitracin-polymyxin-neomycin-hc ophth
oint 1% ...........................................84
baclofen tab 10 mg ...........................55
baclofen tab 20 mg ...........................55
balsalazide disodium cap 750 mg ........71
balziva tab .......................................60
BANZEL SUS 40MG/ML ......................37
BANZEL TAB 200MG ..........................37
BANZEL TAB 400MG ..........................37
BARACLUDE SOL .05MG/ML ...............11
BCG VACCINE INJ .............................79
bekyree tab......................................60
BELEODAQ INJ 500MG.......................19
benazepril & hydrochlorothiazide tab
10-12.5 mg ......................................24
benazepril & hydrochlorothiazide tab
20-12.5 mg ......................................24
benazepril & hydrochlorothiazide tab
20-25 mg ........................................24
benazepril & hydrochlorothiazide tab
5-6.25 mg .......................................24
benazepril hcl tab 10 mg ...................25
benazepril hcl tab 20 mg ...................25
benazepril hcl tab 40 mg ...................25
benazepril hcl tab 5 mg .....................25
BENDEKA INJ 100/4ML ......................17
BENICAR HCT TAB 20-12.5 ................27
BENICAR HCT TAB 40-12.5 ................27
BENICAR HCT TAB 40-25MG ..............27
BENICAR TAB 20MG ..........................27
BENICAR TAB 40MG ..........................27
BENICAR TAB 5MG ............................27
BENLYSTA INJ 120MG .......................78
BENLYSTA INJ 400MG .......................78
benzoyl peroxide-erythromycin gel 5-3%
......................................................89
BENZTROPINE MESYLATE INJ 1 MG/ML 47
benztropine mesylate tab 0.5 mg ........47
benztropine mesylate tab 1 mg ..........47
benztropine mesylate tab 2 mg ..........47
BEPREVE DRO 1.5% ..........................85
BESIVANCE SUS 0.6%.......................84
betamethasone dipropionate augmented
cream 0.05%................................... 91
betamethasone dipropionate augmented
gel 0.05% ....................................... 91
betamethasone dipropionate augmented
lotion 0.05% ................................... 91
betamethasone dipropionate augmented
oint 0.05% ...................................... 91
betamethasone dipropionate cream
0.05% ............................................ 91
betamethasone dipropionate lotion 0.05%
...................................................... 91
betamethasone dipropionate oint 0.05%
...................................................... 91
betamethasone valerate cream 0.1% . 91
betamethasone valerate lotion 0.1% .. 91
betamethasone valerate oint 0.1% ..... 91
BETASERON INJ 0.3MG ..................... 55
betaxolol hcl ophth soln 0.5% ............ 85
bethanechol chloride tab 10 mg ......... 73
bethanechol chloride tab 25 mg ......... 73
bethanechol chloride tab 5 mg ........... 73
bethanechol chloride tab 50 mg ......... 73
BETOPTIC-S SUS 0.25% OP .............. 85
bexarotene cap 75 mg ...................... 22
BEXSERO INJ ................................... 79
bicalutamide tab 50 mg .................... 20
BICILLIN L-A INJ 1200000 ................ 16
BICILLIN L-A INJ 2400000 ................ 16
BICILLIN L-A INJ 600000 .................. 16
BICNU INJ 100MG ............................ 17
BILTRICIDE TAB 600MG ...................... 5
bisacodyl tab & peg 3350-kcl-sod
bicarb-nacl for soln kit ...................... 71
bisoprolol & hydrochlorothiazide tab
10-6.25 mg ..................................... 30
bisoprolol & hydrochlorothiazide tab
2.5-6.25 mg .................................... 30
bisoprolol & hydrochlorothiazide tab
5-6.25 mg ....................................... 30
bisoprolol fumarate tab 10 mg ........... 31
bisoprolol fumarate tab 5 mg ............. 31
BIVIGAM INJ 10% ............................ 77
bleomycin sulfate for inj 15 unit ......... 18
bleomycin sulfate for inj 30 unit ......... 18
blephamide oin s.o.p. ....................... 84
blisovi fe tab 1.5/30 ......................... 60
blisovi fe tab 1/20 ............................ 60
BOOSTRIX INJ ................................. 79
99
BOSULIF TAB 100MG.........................21
BOSULIF TAB 500MG.........................21
BREO ELLIPTA INH 100-25 .................89
BREO ELLIPTA INH 200-25 .................89
briellyn tab ......................................60
BRILINTA TAB 60MG .........................76
BRILINTA TAB 90MG .........................76
BRIMONIDINE TARTRATE OPHTH SOLN
0.15% .............................................85
brimonidine tartrate ophth soln 0.2% ..85
BRINTELLIX TAB 10MG ......................43
BRINTELLIX TAB 20MG ......................43
BRINTELLIX TAB 5MG ........................43
BRIVIACT INJ 50MG/5ML ...................37
BRIVIACT SOL 10MG/ML ....................37
BRIVIACT TAB 100MG .......................38
BRIVIACT TAB 10MG .........................38
BRIVIACT TAB 25MG .........................38
BRIVIACT TAB 50MG .........................38
BRIVIACT TAB 75MG .........................38
BROMFENAC SODIUM OPHTH SOLN
0.09% (BASE EQUIV) (ONCE-DAILY) ...85
bromfenac sodium ophth soln 0.09%
(base equivalent) ..............................85
bromocriptine mesylate cap 5 mg (base
equivalent) ......................................47
bromocriptine mesylate tab 2.5 mg (base
equivalent) ......................................47
budesonide delayed release particles cap
3 mg ...............................................71
budesonide inhalation susp 0.25 mg/2ml
......................................................88
budesonide inhalation susp 0.5 mg/2ml
......................................................88
bumetanide inj 0.25 mg/ml ................34
bumetanide tab 0.5 mg .....................34
bumetanide tab 1 mg ........................34
bumetanide tab 2 mg ........................34
BUPHENYL TAB 500MG ......................63
buprenorphine hcl sl tab 2 mg (base
equiv) .............................................56
buprenorphine hcl sl tab 8 mg (base
equiv) .............................................56
buprenorphine hcl-naloxone hcl sl tab
2-0.5 mg (base equiv) .......................56
buprenorphine hcl-naloxone hcl sl tab 8-2
mg (base equiv) ...............................56
bupropion hcl (smoking deterrent) tab sr
12hr 150 mg ................................... 56
bupropion hcl tab 100 mg ................. 43
bupropion hcl tab 75 mg ................... 43
bupropion hcl tab sr 12hr 100 mg ...... 43
bupropion hcl tab sr 12hr 150 mg ...... 43
bupropion hcl tab sr 12hr 200 mg ...... 43
bupropion hcl tab sr 24hr 150 mg ...... 43
bupropion hcl tab sr 24hr 300 mg ...... 43
buspirone hcl tab 10 mg ................... 37
buspirone hcl tab 15 mg ................... 37
buspirone hcl tab 30 mg ................... 37
buspirone hcl tab 5 mg ..................... 37
buspirone hcl tab 7.5 mg .................. 37
BUSULFEX INJ 6MG/ML ..................... 17
butorphanol tartrate inj 1 mg/ml .......... 2
butorphanol tartrate inj 2 mg/ml .......... 2
BYDUREON INJ 2MG ......................... 57
BYDUREON PEN INJ 2MG................... 57
BYETTA INJ 10MCG .......................... 57
BYETTA INJ 5MCG ............................ 57
BYSTOLIC TAB 10MG ........................ 31
BYSTOLIC TAB 2.5MG ....................... 31
BYSTOLIC TAB 20MG ........................ 31
BYSTOLIC TAB 5MG .......................... 31
C
cabergoline tab 0.5 mg ..................... 66
CABOMETYX TAB 20MG ..................... 21
CABOMETYX TAB 40MG ..................... 21
CABOMETYX TAB 60MG ..................... 21
calcipotriene cream 0.005% .............. 91
calcipotriene oint 0.005%.................. 91
calcipotriene soln 0.005% (50 mcg/ml)
...................................................... 91
calcitonin (salmon) nasal soln 200 unit/act
...................................................... 66
calcitrene oin 0.005% ....................... 91
calcitriol cap 0.25 mcg ...................... 83
calcitriol cap 0.5 mcg ........................ 83
calcitriol inj 1 mcg/ml ....................... 83
calcitriol oral soln 1 mcg/ml ............... 83
calcium acetate (phosphate binder) cap
667 mg (169 mg ca)......................... 67
calcium acetate (phosphate binder) tab
667 mg ........................................... 67
camila tab 0.35mg ........................... 60
CANASA SUP 1000MG ....................... 71
CANCIDAS INJ 50MG .......................... 7
CANCIDAS INJ 70MG .......................... 7
100
CAPASTAT SUL INJ 1GM ....................10
CAPRELSA TAB 100MG ......................21
CAPRELSA TAB 300MG ......................21
captopril & hydrochlorothiazide tab 25-15
mg ..................................................24
captopril & hydrochlorothiazide tab 25-25
mg ..................................................24
captopril & hydrochlorothiazide tab 50-15
mg ..................................................24
captopril & hydrochlorothiazide tab 50-25
mg ..................................................24
captopril tab 100 mg .........................25
captopril tab 12.5 mg ........................25
captopril tab 25 mg ...........................25
captopril tab 50 mg ...........................25
CARBAGLU TAB 200MG ......................63
carbamazepine cap sr 12hr 100 mg.....38
carbamazepine cap sr 12hr 200 mg.....38
carbamazepine cap sr 12hr 300 mg.....38
carbamazepine chew tab 100 mg ........38
carbamazepine susp 100 mg/5ml........38
carbamazepine tab 200 mg ................38
carbamazepine tab sr 12hr 100 mg .....38
carbamazepine tab sr 12hr 200 mg .....38
carbamazepine tab sr 12hr 400 mg .....38
carbidopa & levodopa orally disintegrating
tab 10-100 mg .................................47
carbidopa & levodopa orally disintegrating
tab 25-100 mg .................................47
carbidopa & levodopa orally disintegrating
tab 25-250 mg .................................47
carbidopa & levodopa tab 10-100 mg ..47
carbidopa & levodopa tab 25-100 mg ..47
carbidopa & levodopa tab 25-250 mg ..47
carbidopa & levodopa tab cr 25-100 mg
......................................................47
carbidopa & levodopa tab cr 50-200 mg
......................................................47
CARBIDOPA-LEVODOPA-ENTACAPONE
TABS 12.5-50-200 MG .......................47
CARBIDOPA-LEVODOPA-ENTACAPONE
TABS 18.75-75-200 MG .....................47
CARBIDOPA-LEVODOPA-ENTACAPONE
TABS 25-100-200 MG ........................47
CARBIDOPA-LEVODOPA-ENTACAPONE
TABS 31.25-125-200 MG ...................47
CARBIDOPA-LEVODOPA-ENTACAPONE
TABS 37.5-150-200 MG .....................47
CARBIDOPA-LEVODOPA-ENTACAPONE
TABS 50-200-200 MG ....................... 47
carboplatin iv soln 150 mg/15ml ........ 23
carboplatin iv soln 450 mg/45ml ........ 23
carboplatin iv soln 50 mg/5ml ............ 23
carboplatin iv soln 600 mg/60ml ........ 23
CARIMUNE NF INJ 12GM ................... 77
CARIMUNE NF INJ 6GM ..................... 77
carisoprodol tab 350 mg ................... 55
carteolol hcl ophth soln 1% ............... 85
carvedilol tab 12.5 mg ...................... 31
carvedilol tab 25 mg ......................... 31
carvedilol tab 3.125 mg .................... 31
carvedilol tab 6.25 mg ...................... 31
CAYSTON INH 75MG ........................... 5
caziant pak ...................................... 61
cefaclor cap 250 mg ......................... 12
cefaclor cap 500 mg ......................... 12
cefaclor er tab 500mg ....................... 12
cefaclor for susp 125 mg/5ml ............ 12
cefaclor for susp 250 mg/5ml ............ 12
cefaclor for susp 375 mg/5ml ............ 12
cefadroxil cap 500 mg....................... 12
cefadroxil for susp 250 mg/5ml .......... 12
cefadroxil for susp 500 mg/5ml .......... 12
cefadroxil tab 1 gm .......................... 12
cefazolin inj 1gm/50ml ..................... 12
cefazolin sodium for inj 1 gm ............. 12
cefazolin sodium for inj 10 gm ........... 12
cefazolin sodium for inj 20 gm ........... 12
cefazolin sodium for inj 500 mg ......... 12
cefazolin sodium for iv soln 1 gm ....... 12
CEFAZOLIN SOL ............................... 12
cefdinir cap 300 mg .......................... 12
cefdinir for susp 125 mg/5ml ............. 12
cefdinir for susp 250 mg/5ml ............. 12
cefepime hcl for inj 1 gm................... 12
cefepime hcl for inj 2 gm................... 12
cefixime for susp 100 mg/5ml............ 12
cefixime for susp 200 mg/5ml............ 13
cefotaxime sodium for inj 1 gm .......... 13
cefotaxime sodium for inj 2 gm .......... 13
cefotaxime sodium for inj 500 mg ...... 13
cefoxitin sodium for inj 10 gm ........... 13
cefoxitin sodium for iv soln 1 gm ........ 13
cefoxitin sodium for iv soln 2 gm ........ 13
cefpodoxime proxetil for susp 100 mg/5ml
...................................................... 13
101
cefpodoxime proxetil for susp 50 mg/5ml
......................................................13
cefpodoxime proxetil tab 100 mg ........13
cefpodoxime proxetil tab 200 mg ........13
cefprozil for susp 125 mg/5ml ............13
cefprozil for susp 250 mg/5ml ............13
cefprozil tab 250 mg .........................13
cefprozil tab 500 mg .........................13
ceftazidime for inj 1 gm .....................13
ceftazidime for inj 2 gm .....................13
ceftazidime for inj 6 gm .....................13
CEFTAZIDIME/ SOL D5W 1GM ............13
CEFTAZIDIME/ SOL D5W 2GM ............13
ceftriaxone sodium for inj 1 gm ..........13
ceftriaxone sodium for inj 10 gm ........13
ceftriaxone sodium for inj 2 gm ..........13
ceftriaxone sodium for inj 250 mg .......13
ceftriaxone sodium for inj 500 mg .......13
ceftriaxone sodium for iv soln 1 gm .....13
ceftriaxone sodium for iv soln 2 gm .....13
cefuroxime axetil tab 250 mg .............13
cefuroxime axetil tab 500 mg .............13
cefuroxime sodium for inj 1.5 gm .......13
cefuroxime sodium for inj 7.5 gm .......13
cefuroxime sodium for inj 750 mg .......13
cefuroxime sodium for iv soln 1.5 gm ..13
celecoxib cap 100 mg ......................... 1
celecoxib cap 200 mg ......................... 1
celecoxib cap 400 mg ......................... 1
celecoxib cap 50 mg ........................... 1
CELONTIN CAP 300MG ......................38
cephalexin cap 250 mg ......................13
cephalexin cap 500 mg ......................13
cephalexin for susp 125 mg/5ml .........13
cephalexin for susp 250 mg/5ml .........13
CERDELGA CAP 84MG........................63
CEREZYME INJ 200UNIT ....................63
CEREZYME INJ 400UNIT ....................63
CERVARIX INJ ..................................79
cetirizine hcl oral soln 1 mg/ml (5
mg/5ml) ..........................................86
cevimeline hcl cap 30 mg ...................94
CHANTIX PAK 0.5& 1MG ....................56
CHANTIX PAK 1MG ............................56
CHANTIX TAB 0.5MG .........................56
CHANTIX TAB 1MG ............................56
CHEMET CAP 100MG .........................60
chlorhexidine gluconate soln 0.12% ....94
chloroquine phosphate tab 250 mg ....... 8
chloroquine phosphate tab 500 mg ....... 8
chlorothiazide tab 250 mg ................. 34
chlorothiazide tab 500 mg ................. 34
chlorpromaz inj 25mg/ml .................. 48
chlorpromaz inj 50mg/2ml ................ 48
chlorpromazine hcl tab 10 mg ............ 48
chlorpromazine hcl tab 100 mg .......... 48
chlorpromazine hcl tab 200 mg .......... 48
chlorpromazine hcl tab 25 mg ............ 48
chlorpromazine hcl tab 50 mg ............ 48
chlorthalidone tab 25 mg .................. 34
chlorthalidone tab 50 mg .................. 34
cholestyramine light powder 4 gm/dose
...................................................... 29
cholestyramine light powder packets 4 gm
...................................................... 29
cholestyramine powder 4 gm/dose ..... 29
cholestyramine powder packets 4 gm . 29
choline fenofibrate cap dr 135 mg
(fenofibric acid equiv) ....................... 29
choline fenofibrate cap dr 45 mg
(fenofibric acid equiv) ....................... 29
ciclopirox gel 0.77% ......................... 90
ciclopirox olamine cream 0.77% (base
equiv) ............................................. 90
ciclopirox olamine susp 0.77% (base
equiv) ............................................. 90
ciclopirox shampoo 1% ..................... 90
cilostazol tab 100 mg........................ 76
cilostazol tab 50 mg ......................... 76
CILOXAN OIN 0.3% OP ..................... 84
CIMZIA KIT ..................................... 77
CIMZIA KIT STARTER ....................... 77
CIMZIA PREFL KIT 200MG/ML ............ 77
CINRYZE SOL 500 UNIT .................... 76
CIPRODEX SUS 0.3-0.1% .................. 94
ciprofloxacin 200 mg/100ml in d5w .... 14
ciprofloxacin 400 mg/200ml in d5w .... 14
ciprofloxacin for oral susp 250 mg/5ml
(5%) (5 gm/100ml).......................... 14
ciprofloxacin for oral susp 500 mg/5ml
(10%) (10 gm/100ml) ...................... 14
ciprofloxacin hcl ophth soln 0.3% ....... 84
ciprofloxacin hcl tab 100 mg (base equiv)
...................................................... 14
ciprofloxacin hcl tab 250 mg (base equiv)
...................................................... 14
102
ciprofloxacin hcl tab 500 mg (base equiv)
......................................................14
ciprofloxacin hcl tab 750 mg (base equiv)
......................................................14
ciprofloxacin iv soln 200 mg/20ml (1%)
......................................................14
ciprofloxacin iv soln 400 mg/40ml (1%)
......................................................14
ciprofloxacin-ciprofloxacin hcl tab sr 24hr
1000 mg(base eq) ............................14
ciprofloxacin-ciprofloxacin hcl tab sr 24hr
500 mg (base eq) .............................14
cisplatin inj 100 mg/100ml (1 mg/ml) .23
cisplatin inj 200 mg/200ml (1 mg/ml) .23
cisplatin inj 50 mg/50ml (1 mg/ml) .....23
citalopram hydrobromide oral soln 10
mg/5ml ...........................................43
citalopram hydrobromide tab 10 mg (base
equiv) .............................................43
citalopram hydrobromide tab 20 mg (base
equiv) .............................................44
citalopram hydrobromide tab 40 mg (base
equiv) .............................................44
cladribine iv soln 10 mg/10ml (1 mg/ml)
......................................................18
claravis cap 10mg .............................89
claravis cap 20mg .............................89
claravis cap 30mg .............................89
claravis cap 40mg .............................89
clarithromycin for susp 125 mg/5ml ....14
clarithromycin for susp 250 mg/5ml ....14
clarithromycin tab 250 mg .................14
clarithromycin tab 500 mg .................14
clarithromycin tab sr 24hr 500 mg ......14
clindamax gel 1% .............................89
clindamycin hcl cap 150 mg ................ 5
clindamycin hcl cap 300 mg ................ 5
clindamycin hcl cap 75 mg .................. 5
clindamycin palmitate hcl for soln 75
mg/5ml (base equiv) .......................... 5
clindamycin phosphate gel 1% ...........89
clindamycin phosphate in d5w iv soln 300
mg/50ml .......................................... 5
clindamycin phosphate in d5w iv soln 600
mg/50ml .......................................... 6
clindamycin phosphate in d5w iv soln 900
mg/50ml .......................................... 6
clindamycin phosphate inj 300 mg/2ml . 6
clindamycin phosphate inj 600 mg/4ml . 6
clindamycin phosphate inj 9 gm/60ml ... 6
clindamycin phosphate inj 900 mg/6ml . 6
clindamycin phosphate iv soln 300
mg/2ml ............................................. 6
clindamycin phosphate iv soln 600
mg/4ml ............................................. 6
clindamycin phosphate iv soln 900
mg/6ml ............................................. 6
clindamycin phosphate lotion 1% ....... 89
clindamycin phosphate soln 1% ......... 89
clindamycin phosphate swab 1% ........ 90
clindamycin phosphate vaginal cream 2%
...................................................... 74
CLINIMIX INJ 2.75/D5W ................... 81
CLINIMIX INJ 4.25/D10 .................... 81
CLINIMIX INJ 4.25/D20 .................... 81
CLINIMIX INJ 4.25/D25 .................... 81
CLINIMIX INJ 4.25/D5W ................... 81
CLINIMIX INJ 5%/D15W ................... 81
CLINIMIX INJ 5%/D20W ................... 81
CLINIMIX INJ 5%/D25W ................... 81
clobetasol propionate cream 0.05% .... 91
clobetasol propionate emollient base
cream 0.05%................................... 91
clobetasol propionate gel 0.05% ........ 91
clobetasol propionate oint 0.05% ....... 91
clobetasol propionate soln 0.05% ....... 91
clomipramine hcl cap 25 mg .............. 44
clomipramine hcl cap 50 mg .............. 44
clomipramine hcl cap 75 mg .............. 44
clonazepam orally disintegrating tab
0.125 mg ........................................ 38
clonazepam orally disintegrating tab 0.25
mg ................................................. 38
clonazepam orally disintegrating tab 0.5
mg ................................................. 38
clonazepam orally disintegrating tab 1 mg
...................................................... 38
clonazepam orally disintegrating tab 2 mg
...................................................... 38
clonazepam tab 0.5 mg..................... 38
clonazepam tab 1 mg ....................... 38
clonazepam tab 2 mg ....................... 38
clonidine hcl tab 0.1 mg .................... 35
clonidine hcl tab 0.2 mg .................... 35
clonidine hcl tab 0.3 mg .................... 35
clonidine hcl td patch weekly 0.1 mg/24hr
103
......................................................35
clonidine hcl td patch weekly 0.2 mg/24hr
......................................................35
clonidine hcl td patch weekly 0.3 mg/24hr
......................................................35
clopidogrel bisulfate tab 75 mg (base
equiv) .............................................76
clorazepate dipotassium tab 15 mg .....38
clorazepate dipotassium tab 3.75 mg ..38
clorazepate dipotassium tab 7.5 mg ....38
clotrimazole cream 1% ......................90
clotrimazole soln 1% .........................90
clotrimazole troche 10 mg..................94
CLOZAPINE ORALLY DISINTEGRATING
TAB 100 MG .....................................49
CLOZAPINE ORALLY DISINTEGRATING
TAB 12.5 MG ....................................49
CLOZAPINE ORALLY DISINTEGRATING
TAB 150 MG .....................................49
CLOZAPINE ORALLY DISINTEGRATING
TAB 200 MG .....................................49
CLOZAPINE ORALLY DISINTEGRATING
TAB 25 MG .......................................49
clozapine tab 100 mg ........................49
clozapine tab 200 mg ........................49
clozapine tab 25 mg ..........................49
clozapine tab 50 mg ..........................49
COARTEM TAB 20-120MG ................... 8
colchicine w/ probenecid tab 0.5-500 mg
....................................................... 1
COLCRYS TAB 0.6MG.......................... 1
colestipol hcl granule packets 5 gm .....29
colestipol hcl granules 5 gm ...............29
colestipol hcl tab 1 gm.......................29
colistimethate sodium for inj 150 mg.... 6
COMBIGAN SOL 0.2/0.5%..................85
COMBIVENT AER 20-100....................86
COMETRIQ KIT 100MG ......................21
COMETRIQ KIT 140MG ......................21
COMETRIQ KIT 60MG ........................21
COMPLERA TAB ................................10
compro sup 25mg .............................69
COMVAX INJ.....................................79
constulose sol 10gm/15 .....................71
COPAXONE INJ 40MG/ML ...................55
cormax scalp sol 0.05% .....................91
cortisone acetate tab 25 mg ...............65
COTELLIC TAB 20MG .........................21
COUMADIN TAB 10MG ...................... 74
COUMADIN TAB 1MG ........................ 74
COUMADIN TAB 2.5MG ..................... 74
COUMADIN TAB 2MG ........................ 74
COUMADIN TAB 3MG ........................ 74
COUMADIN TAB 4MG ........................ 74
COUMADIN TAB 5MG ........................ 74
COUMADIN TAB 6MG ........................ 74
COUMADIN TAB 7.5MG ..................... 74
CREON CAP 12000UNT...................... 72
CREON CAP 24000UNT...................... 72
CREON CAP 3000UNIT ...................... 72
CREON CAP 36000UNT...................... 72
CREON CAP 6000UNIT ...................... 72
CRESTOR TAB 10MG ......................... 29
CRESTOR TAB 20MG ......................... 29
CRESTOR TAB 40MG ......................... 29
CRESTOR TAB 5MG .......................... 29
CRIXIVAN CAP 200MG ........................ 8
CRIXIVAN CAP 400MG ........................ 8
cromolyn sodium ophth soln 4% ........ 85
cromolyn sodium oral conc 100 mg/5ml
...................................................... 72
cromolyn sodium soln nebu 20 mg/2ml
...................................................... 88
cryselle-28 tab 28 tabs ..................... 61
CUBICIN SOL 500MG .......................... 6
CUVPOSA SOL 1MG/5ML ................... 70
cyclafem tab 1/35 ............................ 61
cyclafem tab 7/7/7 ........................... 61
cyclobenzaprine hcl tab 10 mg ........... 55
cyclobenzaprine hcl tab 5 mg ............. 55
CYCLOPHOSPH CAP 25MG ................. 17
CYCLOPHOSPH CAP 50MG ................. 17
cyclophosphamide for inj 1 gm .......... 17
cyclophosphamide for inj 2 gm .......... 17
cyclophosphamide for inj 500 mg ....... 17
cycloserine cap 250 mg..................... 10
cyclosporine cap 100 mg ................... 78
cyclosporine cap 25 mg..................... 78
cyclosporine iv soln 50 mg/ml ............ 78
cyclosporine modified cap 100 mg ...... 78
cyclosporine modified cap 25 mg........ 78
cyclosporine modified cap 50 mg........ 78
cyclosporine modified oral soln 100 mg/ml
...................................................... 78
CYSTADANE POW ............................. 63
CYSTAGON CAP 150MG ..................... 63
104
CYSTAGON CAP 50MG .......................63
cytarabine inj 20 mg/ml ....................18
D
D10W/NACL INJ 0.2% .......................82
D5W/LYTES INJ #48 .........................82
D5W/NACL INJ 0.3% .........................82
dacarbazine for inj 100 mg ................17
dacarbazine for inj 200 mg ................17
DAKLINZA TAB 30MG ........................11
DAKLINZA TAB 60MG ........................11
DAKLINZA TAB 90MG ........................11
DALIRESP TAB 500MCG .....................88
danazol cap 100 mg ..........................63
danazol cap 200 mg ..........................63
danazol cap 50 mg ............................63
dantrolene sodium cap 100 mg ...........55
dantrolene sodium cap 25 mg ............55
dantrolene sodium cap 50 mg ............55
dapsone tab 100 mg .......................... 6
dapsone tab 25 mg ............................ 6
DAPTACEL INJ ..................................79
daptomycin for iv soln 500 mg ............ 6
DARAPRIM TAB 25MG ......................... 6
daunorubicin hcl inj 5 mg/ml (base equiv)
......................................................17
deblitane tab 0.35mg ........................61
DELESTROGEN INJ 10MG/ML ..............64
delyla tab 0.1-0.02 ...........................61
DELZICOL CAP 400MG .......................71
DEMSER CAP 250MG .........................35
DEPEN TITRA TAB 250MG ..................60
DEPO-PROVERA INJ 400/ML ...............20
DESCOVY TAB 200/25 .......................10
desipramine hcl tab 10 mg .................44
desipramine hcl tab 100 mg ...............44
desipramine hcl tab 150 mg ...............44
desipramine hcl tab 25 mg .................44
desipramine hcl tab 50 mg .................44
desipramine hcl tab 75 mg .................44
desmopressin acetate inj 4 mcg/ml .....69
DESMOPRESSIN ACETATE NASAL SOLN
0.01% (REFRIGERATED) ....................69
desmopressin acetate nasal spray soln
0.01% .............................................69
desmopressin acetate nasal spray soln
0.01% (refrigerated) .........................69
desmopressin acetate tab 0.1 mg .......69
desmopressin acetate tab 0.2 mg .......69
desogest-eth estrad & eth estrad tab
0.15-0.02/0.01 mg(21/5).................. 61
desogestrel & ethinyl estradiol tab 0.15
mg-30 mcg ..................................... 61
DESONIDE CREAM 0.05% ................. 92
desonide lotion 0.05% ...................... 92
desonide oint 0.05%......................... 92
desoximetasone cream 0.05% ........... 92
desoximetasone cream 0.25% ........... 92
desoximetasone gel 0.05%................ 92
DESOXIMETASONE OINT 0.05% ........ 92
desoximetasone oint 0.25% .............. 92
dexamethason con 1mg/ml ............... 65
dexamethasone elixir 0.5 mg/5ml ...... 65
dexamethasone sod phosphate
preservative free inj 10 mg/ml ........... 65
dexamethasone sodium phosphate inj 10
mg/ml ............................................ 65
dexamethasone sodium phosphate inj 100
mg/10ml ......................................... 65
dexamethasone sodium phosphate inj 120
mg/30ml ......................................... 65
dexamethasone sodium phosphate inj 20
mg/5ml ........................................... 65
dexamethasone sodium phosphate inj 4
mg/ml ............................................ 65
dexamethasone sodium phosphate ophth
soln 0.1% ....................................... 85
dexamethasone soln 0.5 mg/5ml ....... 65
dexamethasone tab 0.5 mg ............... 65
dexamethasone tab 0.75 mg ............. 65
dexamethasone tab 1 mg .................. 65
dexamethasone tab 1.5 mg ............... 65
dexamethasone tab 2 mg .................. 65
dexamethasone tab 4 mg .................. 65
dexamethasone tab 6 mg .................. 65
DEXILANT CAP 30MG DR ................... 73
DEXILANT CAP 60MG DR ................... 73
dexrazoxane for inj 250 mg ............... 23
DEXTROSE 10% W/ SODIUM CHLORIDE
0.45% ............................................ 82
DEXTROSE 2.5% W/ SODIUM CHLORIDE
0.45% ............................................ 82
DEXTROSE 5% IN LACTATED RINGERS82
DEXTROSE 5% W/ SODIUM CHLORIDE
0.2% .............................................. 82
DEXTROSE 5% W/ SODIUM CHLORIDE
0.225% .......................................... 82
105
DEXTROSE 5% W/ SODIUM CHLORIDE
0.33% .............................................82
DEXTROSE 5% W/ SODIUM CHLORIDE
0.45% .............................................82
DEXTROSE 5% W/ SODIUM CHLORIDE
0.9% ...............................................82
DEXTROSE INJ 10% ..........................82
DEXTROSE INJ 5% ............................82
DEXTROSE INJ 50% ..........................82
DEXTROSE INJ 70% ..........................82
diazepam con 5mg/ml .......................38
diazepam inj 5 mg/ml .......................38
diazepam oral soln 1 mg/ml ...............38
DIAZEPAM RECTAL GEL DELIVERY
SYSTEM 10 MG .................................38
DIAZEPAM RECTAL GEL DELIVERY
SYSTEM 2.5 MG ................................38
DIAZEPAM RECTAL GEL DELIVERY
SYSTEM 20 MG .................................38
diazepam tab 10 mg .........................39
diazepam tab 2 mg ...........................38
diazepam tab 5 mg ...........................38
diclofenac potassium tab 50 mg ........... 1
diclofenac sodium gel 1% ..................93
diclofenac sodium ophth soln 0.1% .....85
diclofenac sodium tab delayed release 25
mg ................................................... 1
diclofenac sodium tab delayed release 50
mg ................................................... 1
diclofenac sodium tab delayed release 75
mg ................................................... 1
diclofenac sodium tab sr 24hr 100 mg .. 1
dicloxacillin sodium cap 250 mg ..........16
dicloxacillin sodium cap 500 mg ..........16
dicyclomine hcl cap 10 mg .................70
dicyclomine hcl oral soln 10 mg/5ml....70
dicyclomine hcl tab 20 mg .................70
didanosine delayed release capsule 125
mg ................................................... 8
didanosine delayed release capsule 200
mg ................................................... 8
didanosine delayed release capsule 250
mg ................................................... 8
didanosine delayed release capsule 400
mg ................................................... 8
DIFICID TAB 200MG..........................14
diflorasone diacetate cream 0.05% .....92
diflorasone diacetate oint 0.05%.........92
diflunisal tab 500 mg .......................... 1
digitek tab 0.125mg ......................... 33
digitek tab 0.25mg ........................... 33
digoxin inj 0.25 mg/ml...................... 33
DIGOXIN ORAL SOLN 0.05 MG/ML...... 34
digoxin tab 125 mcg (0.125 mg) ........ 34
digoxin tab 250 mcg (0.25 mg) .......... 34
dihydroergotamine mesylate inj 1 mg/ml
...................................................... 54
dilantin cap 100mg ........................... 39
dilantin cap 30mg ............................ 39
dilantin chw 50mg ............................ 39
DILANTIN-125 SUS 125/5ML ............. 39
diltiazem hcl cap sr 12hr 120 mg ....... 32
diltiazem hcl cap sr 12hr 60 mg ......... 32
diltiazem hcl cap sr 12hr 90 mg ......... 32
diltiazem hcl cap sr 24hr 120 mg ....... 32
diltiazem hcl cap sr 24hr 180 mg ....... 32
diltiazem hcl cap sr 24hr 240 mg ....... 32
diltiazem hcl coated beads cap sr 24hr 120
mg ................................................. 32
diltiazem hcl coated beads cap sr 24hr 180
mg ................................................. 32
diltiazem hcl coated beads cap sr 24hr 240
mg ................................................. 32
diltiazem hcl coated beads cap sr 24hr 300
mg ................................................. 32
diltiazem hcl coated beads cap sr 24hr 360
mg ................................................. 32
diltiazem hcl extended release beads cap
sr 24hr 120 mg ................................ 32
diltiazem hcl extended release beads cap
sr 24hr 180 mg ................................ 32
diltiazem hcl extended release beads cap
sr 24hr 240 mg ................................ 32
diltiazem hcl extended release beads cap
sr 24hr 300 mg ................................ 32
diltiazem hcl extended release beads cap
sr 24hr 360 mg ................................ 32
diltiazem hcl extended release beads cap
sr 24hr 420 mg ................................ 32
diltiazem hcl iv soln 125 mg/25ml (5
mg/ml) ........................................... 32
diltiazem hcl iv soln 25 mg/5ml (5 mg/ml)
...................................................... 32
diltiazem hcl iv soln 50 mg/10ml (5
mg/ml) ........................................... 32
diltiazem hcl tab 120 mg ................... 33
106
diltiazem hcl tab 30 mg .....................32
diltiazem hcl tab 60 mg .....................33
diltiazem hcl tab 90 mg .....................33
DIP/TET PED INJ 25-5LFU ..................79
DIPENTUM CAP 250MG ......................71
diphenhydramine hcl inj 50 mg/ml ......86
diphenoxylate w/ atropine liq 2.5-0.025
mg/5ml ...........................................72
diphenoxylate w/ atropine tab 2.5-0.025
mg ..................................................72
disopyramide phosphate cap 100 mg ..28
disopyramide phosphate cap 150 mg ..28
disulfiram tab 250 mg .......................56
disulfiram tab 500 mg .......................56
divalproex sodium cap delayed release
sprinkle 125 mg................................39
divalproex sodium tab delayed release
125 mg ...........................................39
divalproex sodium tab delayed release
250 mg ...........................................39
divalproex sodium tab delayed release
500 mg ...........................................39
divalproex sodium tab sr 24 hr 250 mg39
divalproex sodium tab sr 24 hr 500 mg39
DOCETAXEL FOR INJ CONC 20 MG/ML .19
DOCETAXEL FOR INJ CONC 80 MG/4ML
(20 MG/ML)......................................19
docetaxel inj 140/7ml ........................19
DOCETAXEL INJ 160/16ML .................19
DOCETAXEL INJ 200MG/20 ................19
DOCETAXEL INJ 20MG/2ML ................19
DOCETAXEL INJ 80MG/8ML ................19
dofetilide cap 125 mcg (0.125 mg) .....28
dofetilide cap 250 mcg (0.25 mg) .......28
dofetilide cap 500 mcg (0.5 mg) .........28
donepezil hydrochloride orally
disintegrating tab 10 mg ....................42
donepezil hydrochloride orally
disintegrating tab 5 mg .....................42
donepezil hydrochloride tab 10 mg ......42
donepezil hydrochloride tab 23 mg ......42
donepezil hydrochloride tab 5 mg .......42
dorzolamide hcl ophth soln 2% ...........85
dorzolamide hcl-timolol maleate ophth
soln 22.3-6.8 mg/ml .........................85
doxazosin mesylate tab 1 mg .............26
doxazosin mesylate tab 2 mg .............26
doxazosin mesylate tab 4 mg .............26
doxazosin mesylate tab 8 mg ............ 26
doxepin hcl cap 10 mg ...................... 44
doxepin hcl cap 100 mg .................... 44
doxepin hcl cap 150 mg .................... 44
doxepin hcl cap 25 mg ...................... 44
doxepin hcl cap 50 mg ...................... 44
doxepin hcl cap 75 mg ...................... 44
doxepin hcl conc 10 mg/ml ................ 44
DOXEPIN HCL CREAM 5% ................. 91
doxorubicin hcl for inj 50 mg ............. 18
doxorubicin hcl inj 2 mg/ml ............... 18
doxorubicin hcl liposomal inj (for iv
infusion) 2 mg/ml ............................ 18
doxy 100 inj 100mg ......................... 16
doxycycline hyclate cap 100 mg ......... 16
doxycycline hyclate cap 50 mg........... 16
doxycycline hyclate for inj 100 mg ..... 17
doxycycline hyclate tab 100 mg ......... 17
doxycycline hyclate tab 20 mg ........... 17
doxycycline monohydrate cap 100 mg 17
doxycycline monohydrate cap 50 mg .. 17
doxycycline monohydrate tab 100 mg . 17
doxycycline monohydrate tab 150 mg . 17
doxycycline monohydrate tab 50 mg .. 17
doxycycline monohydrate tab 75 mg .. 17
dronabinol cap 10 mg ....................... 69
dronabinol cap 2.5 mg ...................... 69
dronabinol cap 5 mg ......................... 69
drospirenone-ethinyl estradiol tab 3-0.02
mg ................................................. 61
DROSPIRENONE-ETHINYL ESTRADIOL
TAB 3-0.02 MG ................................ 61
drospirenone-ethinyl estradiol tab 3-0.03
mg ................................................. 61
DROSPIRENONE-ETHINYL ESTRADIOL
TAB 3-0.03 MG ................................ 61
DROXIA CAP 200MG ......................... 22
DROXIA CAP 300MG ......................... 22
DROXIA CAP 400MG ......................... 22
duloxetine hcl enteric coated pellets cap
20 mg............................................. 44
duloxetine hcl enteric coated pellets cap
30 mg............................................. 44
duloxetine hcl enteric coated pellets cap
60 mg............................................. 44
DURAMORPH INJ 0.5MG/ML ................. 2
DURAMORPH INJ 1MG/ML ................... 2
DUREZOL EMU 0.05% ....................... 85
107
dutasteride cap 0.5 mg ......................73
dutasteride-tamsulosin hcl cap 0.5-0.4
mg ..................................................73
E
e.e.s. 400 tab 400mg ........................14
econazole nitrate cream 1% ...............90
EDURANT TAB 25MG .......................... 8
EFFIENT TAB 10MG ...........................76
EFFIENT TAB 5MG .............................76
ELIDEL CRE 1% ................................93
ELIQUIS TAB 2.5MG ..........................74
ELIQUIS TAB 5MG .............................74
ELITEK INJ 1.5MG .............................23
ELITEK INJ 7.5MG .............................23
elixophyllin elx 80/15ml .....................89
ELLA TAB 30MG ................................61
ELMIRON CAP 100MG ........................73
EMCYT CAP 140MG ...........................17
EMEND CAP 125MG ...........................69
EMEND CAP 40MG .............................69
EMEND CAP 80MG .............................69
EMEND PAK 80 & 125 ........................69
EMEND SUS 125MG...........................69
emoquette tab ..................................61
EMSAM DIS 12MG/24H ......................44
EMSAM DIS 6MG/24HR ......................44
EMSAM DIS 9MG/24HR ......................44
EMTRIVA CAP 200MG ......................... 8
EMTRIVA SOL 10MG/ML ...................... 8
emverm chw 100mg .......................... 6
enalapril maleate & hydrochlorothiazide
tab 10-25 mg ...................................24
enalapril maleate & hydrochlorothiazide
tab 5-12.5 mg ..................................24
enalapril maleate tab 10 mg ...............25
enalapril maleate tab 2.5 mg ..............25
enalapril maleate tab 20 mg ...............25
enalapril maleate tab 5 mg ................25
endocet tab 10-325mg ....................... 2
endocet tab 5-325mg ......................... 2
endocet tab 7.5-325 ........................... 2
ENGERIX-B INJ 10/0.5ML...................79
ENGERIX-B INJ 20MCG/ML .................79
enoxaparin sodium inj 100 mg/ml .......74
enoxaparin sodium inj 120 mg/0.8ml ..74
enoxaparin sodium inj 150 mg/ml .......74
enoxaparin sodium inj 30 mg/0.3ml ....74
enoxaparin sodium inj 300 mg/3ml .....75
enoxaparin sodium inj 40 mg/0.4ml ... 74
enoxaparin sodium inj 60 mg/0.6ml ... 74
enoxaparin sodium inj 80 mg/0.8ml ... 74
enpresse-28 tab ............................... 61
ENTACAPONE TAB 200 MG ................ 47
entecavir tab 0.5 mg ........................ 11
entecavir tab 1 mg ........................... 11
ENTRESTO TAB 24-26MG .................. 27
ENTRESTO TAB 49-51MG .................. 27
ENTRESTO TAB 97-103MG ................ 27
enulose sol 10gm/15 ........................ 71
EPIPEN 2-PAK INJ 0.3MG .................. 88
EPIPEN-JR INJ 2-PAK ........................ 88
epirubicin hcl iv soln 200 mg/100ml (2
mg/ml) ........................................... 18
epirubicin hcl iv soln 50 mg/25ml (2
mg/ml) ........................................... 18
epitol tab 200mg .............................. 39
EPIVIR HBV SOL 5MG/ML .................. 11
eplerenone tab 25 mg ....................... 26
eplerenone tab 50 mg ....................... 26
EPZICOM TAB 600-300 ..................... 10
ERIVEDGE CAP 150MG ...................... 19
errin tab 0.35mg .............................. 61
ery-tab tab 250mg ec ....................... 14
ery-tab tab 333mg ec ....................... 14
ery-tab tab 500mg ec ....................... 14
erythrocin inj 500mg ........................ 14
erythrocin tab 250mg ....................... 14
erythromycin ethylsuccinate tab 400 mg
...................................................... 14
erythromycin gel 2% ........................ 90
erythromycin ophth oint 5 mg/gm ...... 84
erythromycin pads 2% ...................... 90
erythromycin soln 2% ....................... 90
erythromycin tab 250 mg .................. 14
erythromycin tab 500 mg .................. 14
erythromycin w/ delayed release particles
cap 250 mg ..................................... 14
ESBRIET CAP 267MG ........................ 88
escitalopram oxalate soln 5 mg/5ml (base
equiv) ............................................. 44
escitalopram oxalate tab 10 mg (base
equiv) ............................................. 44
escitalopram oxalate tab 20 mg (base
equiv) ............................................. 44
escitalopram oxalate tab 5 mg (base
equiv) ............................................. 44
108
esomeprazole magnesium cap delayed
release 20 mg (base eq) ....................73
esomeprazole magnesium cap delayed
release 40 mg (base eq) ....................73
esomeprazole sodium for intravenous soln
20 mg (base equiv) ...........................73
esomeprazole sodium for intravenous soln
40 mg (base equiv) ...........................73
estrace vag cre 0.1mg/gm .................64
estradiol tab 0.5 mg ..........................64
estradiol tab 1 mg.............................64
estradiol tab 2 mg.............................64
estradiol td patch weekly 0.025 mg/24hr
......................................................64
estradiol td patch weekly 0.0375 mg/24hr
(37.5 mcg/24hr) ...............................64
estradiol td patch weekly 0.05 mg/24hr
......................................................64
estradiol td patch weekly 0.06 mg/24hr
......................................................64
estradiol td patch weekly 0.075 mg/24hr
......................................................64
estradiol td patch weekly 0.1 mg/24hr 64
estradiol valerate im in oil 20 mg/ml ...64
estradiol valerate im in oil 40 mg/ml ...64
ethambutol hcl tab 100 mg ................10
ethambutol hcl tab 400 mg ................10
ethosuximide cap 250 mg ..................39
ethosuximide soln 250 mg/5ml ...........39
etodolac cap 200 mg .......................... 1
etodolac cap 300 mg .......................... 1
etodolac tab 400 mg .......................... 1
etodolac tab 500 mg .......................... 1
etodolac tab sr 24hr 400 mg ............... 1
etodolac tab sr 24hr 500 mg ............... 1
etodolac tab sr 24hr 600 mg ............... 1
etoposide inj 500 mg/25ml (20 mg/ml)
......................................................24
EURAX CRE 10%...............................93
EURAX LOT 10% ...............................93
EVOTAZ TAB 300-150........................10
EXELON DIS 13.3/24 .........................42
EXELON DIS 4.6MG/24 ......................42
EXELON DIS 9.5MG/24 ......................42
exemestane tab 25 mg ......................20
EXJADE TAB 125MG ..........................60
EXJADE TAB 250MG ..........................60
EXJADE TAB 500MG ..........................60
F
FABRAZYME INJ 35MG ...................... 63
FABRAZYME INJ 5MG ........................ 63
falmina tab ...................................... 61
famciclovir tab 125 mg ..................... 11
famciclovir tab 250 mg ..................... 11
famciclovir tab 500 mg ..................... 11
famotidine for susp 40 mg/5ml .......... 71
famotidine in nacl 0.9% iv soln 20
mg/50ml ......................................... 71
famotidine inj 20 mg/2ml .................. 71
famotidine inj 200 mg/20ml .............. 71
famotidine inj 40 mg/4ml .................. 71
famotidine tab 20 mg ....................... 71
famotidine tab 40 mg ....................... 71
FANAPT PAK .................................... 49
FANAPT TAB 10MG ........................... 49
FANAPT TAB 12MG ........................... 49
FANAPT TAB 1MG ............................. 49
FANAPT TAB 2MG ............................. 49
FANAPT TAB 4MG ............................. 49
FANAPT TAB 6MG ............................. 49
FANAPT TAB 8MG ............................. 49
FARESTON TAB 60MG ....................... 20
FARXIGA TAB 10MG ......................... 58
FARXIGA TAB 5MG ........................... 58
FARYDAK CAP 10MG ......................... 19
FARYDAK CAP 15MG ......................... 19
FARYDAK CAP 20MG ......................... 19
FASLODEX INJ 250MG ...................... 20
FAT EMULSION IV SOLN 20% ............ 81
FAZACLO TAB 150 ODT ..................... 49
FAZACLO TAB 200 ODT ..................... 49
felbamate susp 600 mg/5ml .............. 39
felbamate tab 400 mg ...................... 39
felbamate tab 600 mg ...................... 39
felodipine tab sr 24hr 10 mg.............. 33
felodipine tab sr 24hr 2.5 mg............. 33
felodipine tab sr 24hr 5 mg ............... 33
fenofibrate micronized cap 134 mg ..... 30
fenofibrate micronized cap 200 mg ..... 30
fenofibrate micronized cap 67 mg....... 30
fenofibrate tab 145 mg ..................... 30
fenofibrate tab 160 mg ..................... 30
fenofibrate tab 48 mg ....................... 30
fenofibrate tab 54 mg ....................... 30
fentanyl citrate lozenge on a handle 1200
mcg .................................................. 2
109
fentanyl citrate lozenge on a handle 1600
mcg ................................................. 2
fentanyl citrate lozenge on a handle 200
mcg ................................................. 2
fentanyl citrate lozenge on a handle 400
mcg ................................................. 2
fentanyl citrate lozenge on a handle 600
mcg ................................................. 2
fentanyl citrate lozenge on a handle 800
mcg ................................................. 2
fentanyl td patch 72hr 100 mcg/hr ....... 3
fentanyl td patch 72hr 12 mcg/hr ........ 2
fentanyl td patch 72hr 25 mcg/hr ........ 2
fentanyl td patch 72hr 50 mcg/hr ........ 2
fentanyl td patch 72hr 75 mcg/hr ........ 3
FENTORA TAB 100MCG ....................... 3
FENTORA TAB 200MCG ....................... 3
FENTORA TAB 400MCG ....................... 3
FENTORA TAB 600MCG ....................... 3
FENTORA TAB 800MCG ....................... 3
FERRIPROX SOL 100MG/ML................60
FERRIPROX TAB 500MG .....................60
FETZIMA CAP 120MG.........................45
FETZIMA CAP 20MG ..........................45
FETZIMA CAP 40MG ..........................45
FETZIMA CAP 80MG ..........................45
FETZIMA CAP TITRATIO .....................45
finasteride tab 5 mg ..........................73
FIRAZYR INJ 30MG/3ML .....................76
FLEBOGAMMA INJ 10/200ML ..............77
FLEBOGAMMA INJ 20/400ML ..............77
FLEBOGAMMA INJ 5% .......................77
FLEBOGAMMA INJ DIF 10% ................77
FLEBOGAMMA INJ DIF 5% .................77
flecainide acetate tab 100 mg.............28
flecainide acetate tab 150 mg.............28
flecainide acetate tab 50 mg ..............28
FLOVENT DISK AER 100MCG ..............88
FLOVENT DISK AER 250MCG ..............88
FLOVENT DISK AER 50MCG ................88
FLOVENT HFA AER 110MCG................88
FLOVENT HFA AER 220MCG................88
FLOVENT HFA AER 44MCG .................88
fluconazole for susp 10 mg/ml ............. 7
fluconazole for susp 40 mg/ml ............. 7
fluconazole in dextrose inj 200 mg/100ml
....................................................... 7
fluconazole in dextrose inj 400 mg/200ml
........................................................ 7
fluconazole in nacl 0.9% inj 200
mg/100ml ......................................... 7
fluconazole in nacl 0.9% inj 400
mg/200ml ......................................... 7
fluconazole tab 100 mg ....................... 7
fluconazole tab 150 mg ....................... 7
fluconazole tab 200 mg ....................... 7
fluconazole tab 50 mg......................... 7
fluconazole/ inj nacl 100 ..................... 7
flucytosine cap 250 mg ....................... 7
flucytosine cap 500 mg ....................... 7
fludarabine phosphate for inj 50 mg ... 18
fludarabine phosphate inj 25 mg/ml ... 18
fludrocortisone acetate tab 0.1 mg ..... 65
flunisolide nasal soln 25 mcg/act
(0.025%) ........................................ 88
fluocin acet oil body.......................... 92
fluocin acet oil scalp ......................... 92
fluocinolone acetonide (otic) oil 0.01% 94
fluocinolone acetonide cream 0.01% .. 92
fluocinolone acetonide cream 0.025% . 92
fluocinolone acetonide oint 0.025% .... 92
fluocinolone acetonide soln 0.01% ..... 92
fluocinonide cream 0.05% ................. 92
fluocinonide emulsified base cream 0.05%
...................................................... 92
fluocinonide gel 0.05% ..................... 92
fluocinonide oint 0.05% .................... 92
fluocinonide soln 0.05% .................... 92
FLUOROMETHOLONE OPHTH SUSP 0.1%
...................................................... 85
fluorouracil cream 5% ...................... 93
fluorouracil inj 1 gm/20ml (50 mg/ml) 18
fluorouracil inj 2.5 gm/50ml (50 mg/ml)
...................................................... 18
fluorouracil inj 5 gm/100ml (50 mg/ml)
...................................................... 18
fluorouracil inj 500 mg/10ml (50 mg/ml)
...................................................... 18
fluorouracil soln 2%.......................... 93
fluorouracil soln 5%.......................... 93
fluoxetine hcl cap 10 mg ................... 45
fluoxetine hcl cap 20 mg ................... 45
fluoxetine hcl cap 40 mg ................... 45
fluoxetine hcl solution 20 mg/5ml ...... 45
fluoxetine hcl tab 10 mg ................... 45
fluoxetine hcl tab 20 mg ................... 45
110
fluphenazine decanoate inj 25 mg/ml ..49
fluphenazine hcl elixir 2.5 mg/5ml ......49
fluphenazine hcl inj 2.5 mg/ml ...........49
fluphenazine hcl oral conc 5 mg/ml .....49
fluphenazine hcl tab 1 mg ..................49
fluphenazine hcl tab 10 mg ................49
fluphenazine hcl tab 2.5 mg ...............49
fluphenazine hcl tab 5 mg ..................49
flurbiprofen sodium ophth soln 0.03% .85
flurbiprofen tab 100 mg ...................... 1
flurbiprofen tab 50 mg ........................ 1
flutamide cap 125 mg........................20
fluticasone propionate cream 0.05% ...92
fluticasone propionate nasal susp 50
mcg/act ...........................................88
fluticasone propionate oint 0.005% .....92
fluvoxamine maleate tab 100 mg ........37
fluvoxamine maleate tab 25 mg..........37
fluvoxamine maleate tab 50 mg..........37
fondaparinux sodium subcutaneous inj 10
mg/0.8ml ........................................75
fondaparinux sodium subcutaneous inj
2.5 mg/0.5ml ...................................75
fondaparinux sodium subcutaneous inj 5
mg/0.4ml ........................................75
fondaparinux sodium subcutaneous inj
7.5 mg/0.6ml ...................................75
FORTEO SOL 600/2.4 ........................67
FORTICAL SPR 200/ACT .....................66
fosinopril sodium & hydrochlorothiazide
tab 10-12.5 mg ................................25
fosinopril sodium & hydrochlorothiazide
tab 20-12.5 mg ................................25
fosinopril sodium tab 10 mg ...............25
fosinopril sodium tab 20 mg ...............25
fosinopril sodium tab 40 mg ...............25
FREAMINE HBC INJ 6.9% ...................82
FREAMINE III INJ 10% ......................82
furosemide inj 10 mg/ml....................34
FUROSEMIDE INJ 10 MG/ML ...............34
furosemide oral soln 10 mg/ml ...........34
furosemide oral soln 8 mg/ml .............34
furosemide tab 20 mg .......................34
furosemide tab 40 mg .......................34
furosemide tab 80 mg .......................34
FUSILEV INJ 50MG ............................23
FUZEON INJ 90MG ............................. 8
FYCOMPA SUS 0.5MG/ML ...................39
FYCOMPA TAB 10MG ......................... 39
FYCOMPA TAB 12MG ......................... 39
FYCOMPA TAB 2MG .......................... 39
FYCOMPA TAB 4MG .......................... 39
FYCOMPA TAB 6MG .......................... 39
FYCOMPA TAB 8MG .......................... 39
G
gabapentin cap 100 mg .................... 39
gabapentin cap 300 mg .................... 39
gabapentin cap 400 mg .................... 39
gabapentin oral soln 250 mg/5ml ....... 39
gabapentin tab 600 mg ..................... 39
gabapentin tab 800 mg ..................... 39
GABITRIL TAB 12MG......................... 39
GABITRIL TAB 16MG......................... 39
galantamine hydrobromide cap sr 24hr 16
mg ................................................. 42
galantamine hydrobromide cap sr 24hr 24
mg ................................................. 42
galantamine hydrobromide cap sr 24hr 8
mg ................................................. 42
galantamine hydrobromide oral soln 4
mg/ml ............................................ 42
galantamine hydrobromide tab 12 mg 42
galantamine hydrobromide tab 4 mg .. 42
galantamine hydrobromide tab 8 mg .. 42
GAMASTAN S/D INJ .......................... 77
GAMMAGARD INJ 10GM/100 .............. 77
GAMMAGARD INJ 1GM/10ML ............. 77
GAMMAGARD INJ 2.5GM/25 .............. 77
GAMMAGARD INJ 20GM/200 .............. 77
GAMMAGARD INJ 30GM/300 .............. 77
GAMMAGARD INJ 5GM/50ML ............. 77
GAMMAGARD SD INJ 10GM HU .......... 77
GAMMAGARD SD INJ 2.5GM HU ......... 77
GAMMAGARD SD INJ 5GM HU ............ 77
GAMMAKED INJ 10GM/100 ................ 77
GAMMAKED INJ 1GM/10ML ................ 77
GAMMAKED INJ 2.5GM/25 ................. 77
GAMMAKED INJ 20GM/200 ................ 77
GAMMAKED INJ 5GM/50ML ................ 77
GAMMAPLEX INJ 10GM...................... 77
GAMMAPLEX INJ 2.5GM..................... 77
GAMMAPLEX INJ 5GM ....................... 77
GAMUNEX-C INJ 10GM/100 ............... 78
GAMUNEX-C INJ 1GM/10ML ............... 77
GAMUNEX-C INJ 2.5GM/25 ................ 78
GAMUNEX-C INJ 20GM/200 ............... 78
111
GAMUNEX-C INJ 40/400ML ................78
GAMUNEX-C INJ 5GM/50ML ...............78
ganciclovir sodium for inj 500 mg .......11
GARDASIL 9 INJ ...............................79
GARDASIL INJ ..................................79
gatifloxacin ophth soln 0.5% ..............84
GATTEX KIT 5MG ..............................72
GAUZE PADS 2" X 2" .........................57
gavilyte-c sol ....................................71
gavilyte-g sol ...................................71
gavilyte-n sol flav pk .........................71
gemcitabine hcl for inj 1 gm ...............18
gemcitabine hcl for inj 2 gm ...............18
gemcitabine hcl for inj 200 mg ...........18
GEMCITABINE HCL INJ 1 GM/26.3ML (38
MG/ML) (BASE EQUIV) ......................18
GEMCITABINE HCL INJ 2 GM/52.6ML (38
MG/ML) (BASE EQUIV) ......................18
GEMCITABINE HCL INJ 200 MG/5.26ML
(38 MG/ML) (BASE EQUIV).................18
gemfibrozil tab 600 mg ......................30
generlac sol 10gm/15 ........................71
gengraf cap 100mg ...........................79
gengraf cap 25mg .............................78
gengraf cap 50mg .............................78
gengraf sol 100mg/ml .......................79
gentak oin 0.3% op...........................84
gentam/nacl inj 0.9mg/ml................... 5
gentam/nacl inj 1.4mg/ml................... 5
gentamicin in saline inj 0.8 mg/ml ....... 5
gentamicin in saline inj 1 mg/ml .......... 5
gentamicin in saline inj 1.2 mg/ml ....... 5
gentamicin in saline inj 1.6 mg/ml ....... 5
gentamicin in saline inj 2 mg/ml .......... 5
gentamicin sulfate cream 0.1% ..........90
gentamicin sulfate inj 10 mg/ml .......... 5
gentamicin sulfate inj 40 mg/ml .......... 5
gentamicin sulfate iv soln 10 mg/ml ..... 5
gentamicin sulfate oint 0.1% ..............90
gentamicin sulfate ophth oint 0.3% .....84
gentamicin sulfate ophth soln 0.3% ....84
GENVOYA TAB ..................................10
GEODON INJ 20MG ...........................49
gildagia tab 0.4-35 ............................61
gildess tab 1.5/30 .............................61
GILENYA CAP 0.5MG .........................55
GILOTRIF TAB 20MG .........................21
GILOTRIF TAB 30MG .........................21
GILOTRIF TAB 40MG......................... 21
glatopa inj 20mg/ml ......................... 55
GLEOSTINE CAP 100MG .................... 17
GLEOSTINE CAP 10MG ...................... 17
GLEOSTINE CAP 40MG ...................... 17
GLEOSTINE CAP 5MG........................ 17
glimepiride tab 1 mg ........................ 58
glimepiride tab 2 mg ........................ 58
glimepiride tab 4 mg ........................ 58
glipizide tab 10 mg ........................... 58
glipizide tab 5 mg............................. 58
glipizide tab sr 24hr 10 mg ................ 58
glipizide tab sr 24hr 2.5 mg ............... 58
GLIPIZIDE TAB SR 24HR 2.5 MG ........ 58
glipizide tab sr 24hr 5 mg ................. 58
GLIPIZIDE XL TAB 5MG ..................... 58
glipizide-metformin hcl tab 2.5-250 mg
...................................................... 58
glipizide-metformin hcl tab 2.5-500 mg
...................................................... 58
glipizide-metformin hcl tab 5-500 mg . 58
GLUCAGEN INJ HYPOKIT ................... 66
GLUCAGON KIT 1MG ........................ 66
glyburide micronized tab 1.5 mg ........ 58
glyburide micronized tab 3 mg ........... 58
glyburide micronized tab 6 mg ........... 58
glyburide tab 1.25 mg ...................... 58
glyburide tab 2.5 mg ........................ 59
glyburide tab 5 mg ........................... 59
glycopyrrolate inj 4 mg/20ml (0.2 mg/ml)
...................................................... 70
glycopyrrolate tab 1 mg .................... 70
glycopyrrolate tab 2 mg .................... 70
GOLYTELY SOL................................. 71
granisetron hcl inj 0.1 mg/ml............. 69
granisetron hcl inj 1 mg/ml ............... 69
granisetron hcl inj 4 mg/4ml (1 mg/ml)
...................................................... 69
granisetron hcl tab 1 mg ................... 69
GRANIX INJ 300/0.5 ......................... 76
GRANIX INJ 480/0.8 ......................... 76
griseofulvin microsize susp 125 mg/5ml 7
griseofulvin microsize tab 500 mg ........ 8
griseofulvin ultramicrosize tab 125 mg .. 8
griseofulvin ultramicrosize tab 250 mg .. 8
guanfacine hcl tab sr 24hr 1 mg (base
equiv) ............................................. 53
guanfacine hcl tab sr 24hr 2 mg (base
112
equiv) .............................................53
guanfacine hcl tab sr 24hr 3 mg (base
equiv) .............................................53
guanfacine hcl tab sr 24hr 4 mg (base
equiv) .............................................53
H
halobetasol propionate cream 0.05% ..92
halobetasol propionate oint 0.05% ......92
haloperidol decanoate im soln 100 mg/ml
......................................................49
haloperidol decanoate im soln 50 mg/ml
......................................................49
haloperidol lactate inj 5 mg/ml ...........49
haloperidol lactate oral conc 2 mg/ml ..49
haloperidol tab 0.5 mg ......................50
haloperidol tab 1 mg .........................50
haloperidol tab 10 mg .......................50
haloperidol tab 2 mg .........................50
haloperidol tab 20 mg .......................50
haloperidol tab 5 mg .........................50
HARVONI TAB 90-400MG ...................11
HAVRIX INJ 1440UNIT .......................79
HAVRIX INJ 720UNIT.........................79
heather tab 0.35mg ..........................61
HEP SOD/NACL INJ 25000UNT............75
HEPARIN SODIUM (PORCINE) 100
UNIT/ML IN D5W ..............................75
HEPARIN SODIUM (PORCINE) 40 UNIT/ML
IN D5W ...........................................75
HEPARIN SODIUM (PORCINE) 50 UNIT/ML
IN D5W ...........................................75
heparin sodium (porcine) inj 1000 unit/ml
......................................................75
heparin sodium (porcine) inj 10000
unit/ml ............................................75
heparin sodium (porcine) inj 20000
unit/ml ............................................75
heparin sodium (porcine) inj 5000 unit/ml
......................................................75
HEPATAMINE SOL 8% .......................82
HERCEPTIN INJ 440MG ......................19
HETLIOZ CAP 20MG ..........................53
HEXALEN CAP 50MG ..........................17
HIBERIX SOL 10MCG .........................79
HUMIRA INJ 10MG/0.2 ......................77
HUMIRA KIT 20MG/0.4 ......................77
HUMIRA KIT 40MG/0.8 ......................77
HUMIRA PEDIA INJ CROHNS...............77
HUMIRA PEN INJ 40MG/0.8 ............... 77
HUMIRA PEN INJ CROHNS ................. 77
HUMIRA PEN INJ PSORIASI ............... 77
HUMULIN R INJ U-500 ...................... 57
hydralazine hcl inj 20 mg/ml ............. 35
hydralazine hcl tab 10 mg ................. 35
hydralazine hcl tab 100 mg ............... 35
hydralazine hcl tab 25 mg ................. 35
hydralazine hcl tab 50 mg ................. 35
hydrochlorothiazide cap 12.5 mg........ 34
hydrochlorothiazide tab 12.5 mg ........ 34
hydrochlorothiazide tab 25 mg ........... 34
hydrochlorothiazide tab 50 mg ........... 34
hydrocodone-acetaminophen soln
7.5-325 mg/15ml ............................... 3
hydrocodone-acetaminophen tab 10-325
mg ................................................... 3
hydrocodone-acetaminophen tab 5-325
mg ................................................... 3
hydrocodone-acetaminophen tab 7.5-325
mg ................................................... 3
hydrocodone-ibuprofen tab 7.5-200 mg 3
hydrocortisone butyrate cream 0.1% .. 92
hydrocortisone butyrate oint 0.1% ..... 92
hydrocortisone butyrate soln 0.1% ..... 92
hydrocortisone cream 1% ................. 92
hydrocortisone cream 2.5% ............... 92
hydrocortisone enema 100 mg/60ml .. 71
HYDROCORTISONE ENEMA 100 MG/60ML
...................................................... 71
hydrocortisone lotion 2.5%................ 92
hydrocortisone oint 1% ..................... 92
hydrocortisone oint 2.5% .................. 92
hydrocortisone rectal cream 2.5% ...... 91
hydrocortisone tab 10 mg ................. 65
hydrocortisone tab 20 mg ................. 65
hydrocortisone tab 5 mg ................... 65
hydrocortisone valerate cream 0.2% .. 92
hydrocortisone valerate oint 0.2% ...... 92
hydromorphone hcl liqd 1 mg/ml.......... 3
hydromorphone hcl preservative free (pf)
inj 10 mg/ml ..................................... 3
hydromorphone hcl tab 2 mg ............... 3
hydromorphone hcl tab 4 mg ............... 3
hydromorphone hcl tab 8 mg ............... 3
hydroxychloroquine sulfate tab 200 mg
...................................................... 77
hydroxyprogesterone caproate im in oil
113
1.25 gm/5ml ....................................20
hydroxyurea cap 500 mg ...................22
hydroxyzine hcl im soln 25 mg/ml .......86
hydroxyzine hcl im soln 50 mg/ml .......86
hydroxyzine hcl syrup 10 mg/5ml .......86
hydroxyzine hcl tab 10 mg .................87
hydroxyzine hcl tab 25 mg .................87
hydroxyzine hcl tab 50 mg .................87
hydroxyzine pamoate cap 100 mg.......87
hydroxyzine pamoate cap 25 mg ........87
hydroxyzine pamoate cap 50 mg ........87
I
ibandronate sodium tab 150 mg (base
equivalent) ......................................60
IBRANCE CAP 100MG ........................19
IBRANCE CAP 125MG ........................19
IBRANCE CAP 75MG ..........................19
ibuprofen susp 100 mg/5ml ................ 1
ibuprofen tab 400 mg ......................... 1
ibuprofen tab 600 mg ......................... 1
ibuprofen tab 800 mg ......................... 1
ICLUSIG TAB 15MG ...........................21
ICLUSIG TAB 45MG ...........................21
idarubicin hcl iv inj 10 mg/10ml (1 mg/ml)
......................................................18
idarubicin hcl iv inj 20 mg/20ml (1 mg/ml)
......................................................18
idarubicin hcl iv inj 5 mg/5ml (1 mg/ml)
......................................................18
IFEX INJ 3GM ...................................17
ifosfamide for inj 1 gm ......................17
IFOSFAMIDE INJ 3GM ........................17
ifosfamide iv inj 1 gm/20ml (50 mg/ml)
......................................................17
ifosfamide iv inj 3 gm/60ml (50 mg/ml)
......................................................17
ILEVRO DRO 0.3% OP .......................85
ilotycin oin op ...................................84
imatinib mesylate tab 100 mg (base
equivalent) ......................................21
imatinib mesylate tab 400 mg (base
equivalent) ......................................21
IMBRUVICA CAP 140MG .....................21
imipenem-cilastatin intravenous for soln
250 mg ............................................ 6
imipenem-cilastatin intravenous for soln
500 mg ............................................ 6
imipramine hcl tab 10 mg ..................45
imipramine hcl tab 25 mg ................. 45
imipramine hcl tab 50 mg ................. 45
imiquimod cream 5%........................ 93
IMOVAX RABIE INJ 2.5/ML ................ 79
INCRELEX INJ 40MG/4ML .................. 66
INCRUSE ELPT INH 62.5MCG ............. 86
indapamide tab 1.25 mg ................... 34
indapamide tab 2.5 mg ..................... 34
INFANRIX INJ .................................. 80
INLYTA TAB 1MG .............................. 21
INLYTA TAB 5MG .............................. 21
INSULIN PEN NEEDLE ....................... 57
INSULIN SAFETY NEEDLES ................ 57
INSULIN SYRINGE ............................ 57
INTELENCE TAB 100MG ...................... 8
INTELENCE TAB 200MG ...................... 8
INTELENCE TAB 25MG ........................ 8
INTRALIPID INJ 20% ........................ 82
INTRALIPID INJ 30% ........................ 82
INTRON A INJ 10MU ......................... 78
INTRON A INJ 18MU ......................... 78
INTRON A INJ 25MU ......................... 78
INTRON A INJ 50MU ......................... 78
introvale tab .................................... 61
INVANZ INJ 1GM ................................ 6
INVEGA SUST INJ 117/0.75 ............... 50
INVEGA SUST INJ 156MG/ML ............. 50
INVEGA SUST INJ 234/1.5 ................ 50
INVEGA SUST INJ 39/0.25 ................ 50
INVEGA SUST INJ 78/0.5ML .............. 50
INVEGA TAB 1.5MG .......................... 50
INVEGA TAB 3MG ............................. 50
INVEGA TAB 6MG ............................. 50
INVEGA TAB 9MG ............................. 50
INVEGA TRINZ INJ 273MG................. 50
INVEGA TRINZ INJ 410MG................. 50
INVEGA TRINZ INJ 546MG................. 50
INVEGA TRINZ INJ 819MG................. 50
INVIRASE CAP 200MG ........................ 8
INVIRASE TAB 500MG ........................ 8
INVOKAMET TAB 150-1000 ............... 59
INVOKAMET TAB 150-500 ................. 59
INVOKAMET TAB 50-1000 ................. 59
INVOKAMET TAB 50-500MG .............. 59
INVOKANA TAB 100MG ..................... 59
INVOKANA TAB 300MG ..................... 59
IONOSOL-B/ INJ D5W ....................... 82
IONOSOL-MB INJ /D5W .................... 82
114
IPOL INJ INACTIVE............................80
ipratropium bromide inhal soln 0.02% .86
ipratropium bromide nasal soln 0.03% (21
mcg/spray) ......................................86
ipratropium bromide nasal soln 0.06% (42
mcg/spray) ......................................86
ipratropium-albuterol nebu soln
0.5-2.5(3) mg/3ml ............................86
irbesartan tab 150 mg .......................27
irbesartan tab 300 mg .......................27
irbesartan tab 75 mg .........................27
irbesartan-hydrochlorothiazide tab
150-12.5 mg ....................................27
irbesartan-hydrochlorothiazide tab
300-12.5 mg ....................................27
IRESSA TAB 250MG ..........................21
irinotecan hcl inj 100 mg/5ml (20 mg/ml)
......................................................24
irinotecan hcl inj 40 mg/2ml (20 mg/ml)
......................................................24
irinotecan hcl inj 500 mg/25ml (20
mg/ml) ............................................24
ISENTRESS CHW 100MG..................... 8
ISENTRESS CHW 25MG ...................... 8
ISENTRESS POW 100MG ..................... 9
ISENTRESS TAB 400MG ...................... 9
ISOLYTE-P INJ /D5W .........................82
ISOLYTE-S INJ..................................82
isoniazid inj 100 mg/ml .....................10
isoniazid syrup 50 mg/5ml .................10
isoniazid tab 100 mg .........................10
isoniazid tab 300 mg .........................10
isosorbide dinitrate tab 10 mg ............35
isosorbide dinitrate tab 20 mg ............35
isosorbide dinitrate tab 30 mg ............35
isosorbide dinitrate tab 5 mg ..............35
isosorbide dinitrate tab cr 40 mg ........35
isosorbide mononitrate tab 10 mg .......35
isosorbide mononitrate tab 20 mg .......35
isosorbide mononitrate tab sr 24hr 120
mg ..................................................35
isosorbide mononitrate tab sr 24hr 30 mg
......................................................35
isosorbide mononitrate tab sr 24hr 60 mg
......................................................35
isotretinoin cap 10 mg .......................90
isotretinoin cap 20 mg .......................90
isotretinoin cap 40 mg .......................90
isradipine cap 2.5 mg ....................... 33
isradipine cap 5 mg .......................... 33
ISTALOL SOL 0.5% OP...................... 85
ISTODAX INJ 10MG .......................... 20
itraconazole cap 100 mg ..................... 8
ivermectin tab 3 mg ........................... 6
IXIARO INJ ...................................... 80
J
JAKAFI TAB 10MG ............................ 21
JAKAFI TAB 15MG ............................ 22
JAKAFI TAB 20MG ............................ 22
JAKAFI TAB 25MG ............................ 22
JAKAFI TAB 5MG .............................. 21
jantoven tab 10mg ........................... 75
jantoven tab 1mg ............................. 75
jantoven tab 2.5mg .......................... 75
jantoven tab 2mg ............................. 75
jantoven tab 3mg ............................. 75
jantoven tab 4mg ............................. 75
jantoven tab 5mg ............................. 75
jantoven tab 6mg ............................. 75
jantoven tab 7.5mg .......................... 75
JANUMET TAB 50-1000 ..................... 59
JANUMET TAB 50-500MG .................. 59
JANUMET XR TAB 100-1000............... 59
JANUMET XR TAB 50-1000 ................ 59
JANUMET XR TAB 50-500MG.............. 59
JANUVIA TAB 100MG ........................ 59
JANUVIA TAB 25MG .......................... 59
JANUVIA TAB 50MG .......................... 59
JENTADUETO TAB 2.5-1000 ............... 59
JENTADUETO TAB 2.5-500 ................ 59
JENTADUETO TAB 2.5-850 ................ 59
JENTADUETO TAB XR ........................ 59
jinteli tab 1mg-5mcg ........................ 64
JOLIVETTE TAB 0.35MG .................... 61
juleber tab ...................................... 61
junel 1.5/30 tab ............................... 61
junel 1/20 tab .................................. 61
junel fe tab 1.5/30 ........................... 61
junel fe tab 1/20 .............................. 61
JUXTAPID CAP 10MG ........................ 30
JUXTAPID CAP 20MG ........................ 30
JUXTAPID CAP 30MG ........................ 30
JUXTAPID CAP 40MG ........................ 30
JUXTAPID CAP 5MG .......................... 30
JUXTAPID CAP 60MG ........................ 30
115
K
KADCYLA INJ 100MG .........................20
KADCYLA INJ 160MG .........................20
KALETRA SOL ...................................10
KALETRA TAB 100-25MG ...................10
KALETRA TAB 200-50MG ...................10
KALYDECO PAK 50MG ........................88
KALYDECO PAK 75MG ........................88
KALYDECO TAB 150MG ......................88
kariva tab 28 day ..............................61
KCL 10 MEQ/L (0.075%) IN DEXTROSE
5% & NACL 0.45% INJ ......................82
KCL 20 MEQ/L (0.15%) IN DEXTROSE 5%
& NACL 0.2% INJ ..............................82
KCL 20 MEQ/L (0.15%) IN DEXTROSE 5%
& NACL 0.33% INJ ............................82
KCL 20 MEQ/L (0.15%) IN DEXTROSE 5%
& NACL 0.45% INJ ............................82
KCL 20 MEQ/L (0.15%) IN DEXTROSE 5%
& NACL 0.9% INJ ..............................82
kcl 20 meq/l (0.15%) in nacl 0.45% inj
......................................................83
KCL 20 MEQ/L (0.15%) IN NACL 0.45%
INJ ..................................................83
KCL 20 MEQ/L (0.15%) IN NACL 0.9% INJ
......................................................83
KCL 30 MEQ/L (0.224%) IN DEXTROSE
5% & NACL 0.45% INJ ......................83
KCL 40 MEQ/L (0.3%) IN DEXTROSE 5% &
NACL 0.45% INJ ...............................83
KCL 40 MEQ/L (0.3%) IN NACL 0.9% INJ
......................................................83
KCL/D5W/NACL INJ 0.15/0.2..............83
KCL/D5W/NACL INJ 0.3/0.9% ............83
kelnor tab 1/35 ................................61
ketoconazole cream 2% .....................90
ketoconazole shampoo 2%.................91
ketoconazole tab 200 mg .................... 8
ketoprofen cap 50 mg ........................ 1
ketoprofen cap 75 mg ........................ 1
ketorolac tromethamine ophth soln 0.4%
......................................................85
ketorolac tromethamine ophth soln 0.5%
......................................................85
KEYTRUDA INJ 100MG/4M .................20
KEYTRUDA SOL 50MG .......................20
kimidess tab.....................................61
KINRIX INJ.......................................80
kionex pow ...................................... 60
kionex sus 15gm/60 ......................... 60
KLOR-CON 10 TAB 10MEQ ER ............ 80
KLOR-CON 8 TAB 8MEQ ER................ 80
klor-con m15 tab 15meq er ............... 80
klor-con pow 20meq ......................... 80
KORLYM TAB 300MG ......................... 66
KUVAN POW 100MG ......................... 63
KUVAN POW 500MG ......................... 64
KUVAN TAB 100MG .......................... 64
KYNAMRO INJ 200MG/ML .................. 30
L
labetalol hcl tab 100 mg .................... 31
labetalol hcl tab 200 mg .................... 31
labetalol hcl tab 300 mg .................... 31
LACTATED RINGER'S SOLUTION ........ 83
lactic acid (ammonium lactate) cream
12% ............................................... 93
lactic acid (ammonium lactate) lotion 12%
...................................................... 93
lactulose (encephalopathy) solution 10
gm/15ml ......................................... 71
lactulose solution 10 gm/15ml ........... 71
lamivudine oral soln 10 mg/ml ............. 9
lamivudine tab 100 mg (hbv)............. 11
lamivudine tab 150 mg ....................... 9
lamivudine tab 300 mg ....................... 9
lamivudine-zidovudine tab 150-300 mg
...................................................... 10
lamotrigine tab 100 mg ..................... 39
lamotrigine tab 150 mg ..................... 40
lamotrigine tab 200 mg ..................... 40
lamotrigine tab 25 mg ...................... 39
lamotrigine tab chewable dispersible 25
mg ................................................. 40
lamotrigine tab chewable dispersible 5 mg
...................................................... 40
lamotrigine tab sr 24hr 100 mg.......... 40
lamotrigine tab sr 24hr 200 mg.......... 40
lamotrigine tab sr 24hr 25 mg ........... 40
lamotrigine tab sr 24hr 250 mg.......... 40
lamotrigine tab sr 24hr 300 mg.......... 40
lamotrigine tab sr 24hr 50 mg ........... 40
LANTUS INJ 100/ML ......................... 57
LANTUS INJ SOLOSTAR ..................... 57
larin fe tab 1.5/30 ............................ 61
larin fe tab 1/20 ............................... 61
larin tab 1.5/30 ................................ 61
116
larin tab 1/20 ...................................61
larissia tab .......................................61
LASTACAFT SOL 0.25% .....................85
latanoprost ophth soln 0.005% ...........85
LATUDA TAB 120MG ..........................50
LATUDA TAB 20MG ...........................50
LATUDA TAB 40MG ...........................50
LATUDA TAB 60MG ...........................50
LATUDA TAB 80MG ...........................50
leena tab .........................................61
leflunomide tab 10 mg.......................77
leflunomide tab 20 mg.......................77
LENVIMA CAP 10 MG .........................22
LENVIMA CAP 14 MG .........................22
LENVIMA CAP 18 MG .........................22
LENVIMA CAP 20 MG .........................22
LENVIMA CAP 24 MG .........................22
LENVIMA CAP 8 MG ...........................22
lessina tab .......................................61
LETAIRIS TAB 10MG ..........................36
LETAIRIS TAB 5MG ...........................36
letrozole tab 2.5 mg ..........................20
leucovorin calcium for inj 100 mg .......23
leucovorin calcium for inj 200 mg .......23
leucovorin calcium for inj 350 mg .......23
leucovorin calcium for inj 50 mg .........23
leucovorin calcium for inj 500 mg .......23
leucovorin calcium tab 10 mg .............23
leucovorin calcium tab 15 mg .............23
leucovorin calcium tab 25 mg .............24
leucovorin calcium tab 5 mg ...............23
LEUKERAN TAB 2MG..........................17
LEUKINE INJ 250MCG ........................76
leuprolide acetate inj kit 5 mg/ml .......20
levalbuterol hcl soln nebu conc 1.25
mg/0.5ml (base equiv) ......................87
LEVEMIR INJ ....................................57
LEVEMIR INJ FLEXTOUC .....................57
LEVETIRACETA INJ 10MG/ML..............40
LEVETIRACETA INJ 15MG/ML..............40
LEVETIRACETA INJ 5MG/ML ...............40
levetiracetam inj 500 mg/5ml (100
mg/ml) ............................................40
levetiracetam oral soln 100 mg/ml ......40
levetiracetam tab 1000 mg ................40
levetiracetam tab 250 mg ..................40
levetiracetam tab 500 mg ..................40
levetiracetam tab 750 mg ..................40
levetiracetam tab sr 24hr 500 mg ...... 40
levetiracetam tab sr 24hr 750 mg ...... 40
levobunolol hcl ophth soln 0.5%......... 85
levocarnitine inj 200 mg/ml ............... 64
levocarnitine oral soln 1 gm/10ml (10%)
...................................................... 64
levocarnitine tab 330 mg................... 64
levocetirizine dihydrochloride soln 2.5
mg/5ml (0.5 mg/ml) ........................ 87
levocetirizine dihydrochloride tab 5 mg 87
levofloxacin in d5w iv soln 250 mg/50ml
...................................................... 14
levofloxacin in d5w iv soln 500 mg/100ml
...................................................... 14
levofloxacin in d5w iv soln 750 mg/150ml
...................................................... 15
levofloxacin iv soln 25 mg/ml ............ 15
levofloxacin oral soln 25 mg/ml.......... 15
levofloxacin tab 250 mg .................... 15
levofloxacin tab 500 mg .................... 15
levofloxacin tab 750 mg .................... 15
levoleucovor sol 250mg/25................ 24
levoleucovorin calcium for iv inj 50 mg
(base equiv) .................................... 24
levoleucovorin calcium inj 175 mg/17.5ml
(base equiv) .................................... 24
levonest tab .................................... 61
levonorgestrel & ethinyl estradiol
(91-day) tab 0.15-0.03 mg ............... 61
LEVONORGESTREL & ETHINYL
ESTRADIOL (91-DAY) TAB 0.15-0.03 MG
...................................................... 62
levonorgestrel & ethinyl estradiol tab 0.1
mg-20 mcg ..................................... 62
levonorgestrel tab 0.75 mg ............... 62
levonorgestrel tab 1.5 mg ................. 62
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg... 62
levora-28 tab 0.15/30....................... 62
levothyroxine sodium tab 100 mcg ..... 67
levothyroxine sodium tab 112 mcg ..... 67
levothyroxine sodium tab 125 mcg ..... 68
levothyroxine sodium tab 137 mcg ..... 68
levothyroxine sodium tab 150 mcg ..... 68
levothyroxine sodium tab 175 mcg ..... 68
levothyroxine sodium tab 200 mcg ..... 68
levothyroxine sodium tab 25 mcg ....... 67
levothyroxine sodium tab 300 mcg ..... 68
117
levothyroxine sodium tab 50 mcg .......67
levothyroxine sodium tab 75 mcg .......67
levothyroxine sodium tab 88 mcg .......67
LEVOXYL TAB 100MCG ......................68
LEVOXYL TAB 112MCG ......................68
LEVOXYL TAB 125MCG ......................68
LEVOXYL TAB 137MCG ......................68
LEVOXYL TAB 150MCG ......................68
LEVOXYL TAB 175MCG ......................68
LEVOXYL TAB 200MCG ......................68
LEVOXYL TAB 25MCG ........................68
LEVOXYL TAB 50MCG ........................68
LEVOXYL TAB 75MCG ........................68
LEVOXYL TAB 88MCG ........................68
LEXIVA SUS 50MG/ML ........................ 9
LEXIVA TAB 700MG ............................ 9
lidocaine hcl gel 2% ..........................93
lidocaine hcl local inj 0.5% .................. 4
lidocaine hcl local inj 1%..................... 4
lidocaine hcl local inj 1.5% .................. 4
lidocaine hcl local inj 2%..................... 4
lidocaine hcl local preservative free (pf) inj
0.5% ................................................ 4
lidocaine hcl local preservative free (pf) inj
1% .................................................. 4
lidocaine hcl soln 4% .........................93
lidocaine hcl viscous soln 2% .............94
lidocaine oint 5% ..............................93
lidocaine patch 5%............................93
lidocaine-prilocaine cream 2.5-2.5% ...93
LINEZOLID FOR SUSP 100 MG/5ML ...... 6
LINEZOLID IN SODIUM CHLORIDE IV
SOLN 600 MG/300ML-0.9% ................ 6
linezolid iv soln 600 mg/300ml (2 mg/ml)
....................................................... 6
LINEZOLID TAB 600 MG ..................... 6
LINZESS CAP 145MCG .......................72
LINZESS CAP 290MCG .......................72
liothyronine sodium tab 25 mcg ..........68
liothyronine sodium tab 5 mcg............68
liothyronine sodium tab 50 mcg ..........68
lisinopril & hydrochlorothiazide tab
10-12.5 mg ......................................25
lisinopril & hydrochlorothiazide tab
20-12.5 mg ......................................25
lisinopril & hydrochlorothiazide tab 20-25
mg ..................................................25
lisinopril tab 10 mg ...........................25
lisinopril tab 2.5 mg ......................... 25
lisinopril tab 20 mg........................... 25
lisinopril tab 30 mg........................... 25
lisinopril tab 40 mg........................... 25
lisinopril tab 5 mg ............................ 25
lithium carbonate cap 150 mg............ 55
lithium carbonate cap 300 mg............ 55
lithium carbonate cap 600 mg............ 55
lithium carbonate tab 300 mg ............ 55
lithium carbonate tab cr 300 mg ........ 55
lithium carbonate tab cr 450 mg ........ 55
LITHIUM SOL 8MEQ/5ML ................... 55
lokara lot 0.05% .............................. 92
LONSURF TAB 15-6.14 ...................... 23
LONSURF TAB 20-8.19 ...................... 23
loperamide hcl cap 2 mg ................... 72
lorazepam con 2mg/ml ..................... 37
lorazepam inj 2 mg/ml ...................... 37
lorazepam inj 4 mg/ml ...................... 37
lorazepam tab 0.5 mg ....................... 37
lorazepam tab 1 mg ......................... 37
lorazepam tab 2 mg ......................... 37
loryna tab 3-0.02mg......................... 62
losartan potassium & hydrochlorothiazide
tab 100-12.5 mg .............................. 27
losartan potassium & hydrochlorothiazide
tab 100-25 mg................................. 27
losartan potassium & hydrochlorothiazide
tab 50-12.5 mg................................ 27
losartan potassium tab 100 mg .......... 27
losartan potassium tab 25 mg............ 27
losartan potassium tab 50 mg............ 27
LOTEMAX GEL 0.5% ......................... 85
LOTEMAX OIN 0.5% ......................... 85
LOTEMAX SUS 0.5% ......................... 85
lovastatin tab 10 mg......................... 29
lovastatin tab 20 mg......................... 29
lovastatin tab 40 mg......................... 29
loxapine succinate cap 10 mg ............ 50
loxapine succinate cap 25 mg ............ 50
loxapine succinate cap 5 mg .............. 50
loxapine succinate cap 50 mg ............ 50
LUMIGAN SOL 0.01% ....................... 85
LUMIZYME INJ 50MG ........................ 64
LUPR DEP-PED INJ 11.25MG .............. 20
LUPR DEP-PED INJ 15MG .................. 20
LUPR DEP-PED INJ 30MG .................. 20
LUPR DEP-PED INJ 7.5MG ................. 20
118
LUPRON DEPOT INJ 11.25MG .............20
LUPRON DEPOT INJ 3.75MG ...............20
lutera tab .........................................62
LYNPARZA CAP 50MG ........................20
LYRICA CAP 100MG ...........................40
LYRICA CAP 150MG ...........................40
LYRICA CAP 200MG ...........................40
LYRICA CAP 225MG ...........................40
LYRICA CAP 25MG ............................40
LYRICA CAP 300MG ...........................40
LYRICA CAP 50MG ............................40
LYRICA CAP 75MG ............................40
LYRICA SOL 20MG/ML .......................40
LYSODREN TAB 500MG ......................20
lyza tab 0.35mg ...............................62
M
MAGNESIUM SU INJ 20/500ML ...........80
MAGNESIUM SU INJ 2GM/50ML ..........80
MAGNESIUM SU INJ 40G/1000 ...........80
MAGNESIUM SU INJ 4G/100ML ...........80
MAGNESIUM SU INJ 80MG/ML ............80
magnesium sulfate inj 50% ................80
MAGNESIUM SULFATE INJ 50% ..........80
magnesium sulfate iv soln 2 gm/50ml (40
mg/ml) ............................................81
malathion lotion 0.5% .......................93
maprotiline hcl tab 25 mg ..................45
maprotiline hcl tab 50 mg ..................45
maprotiline hcl tab 75 mg ..................45
marlissa tab 0.15/30 .........................62
MARPLAN TAB 10MG .........................45
MATULANE CAP 50MG .......................23
MAXIDEX SUS 0.1% OP .....................85
meclizine hcl tab 12.5 mg ..................69
meclizine hcl tab 25 mg .....................69
medroxyprogesterone acetate im susp
150 mg/ml .......................................62
MEDROXYPROGESTERONE ACETATE IM
SUSP PREFILLED SYR 150 MG/ML .......62
medroxyprogesterone acetate tab 10 mg
......................................................67
medroxyprogesterone acetate tab 2.5 mg
......................................................67
medroxyprogesterone acetate tab 5 mg
......................................................67
mefloquine hcl tab 250 mg .................. 8
megestrol acetate susp 40 mg/ml .......20
MEGESTROL ACETATE SUSP 625 MG/5ML
...................................................... 20
megestrol acetate tab 20 mg ............. 20
megestrol acetate tab 40 mg ............. 21
MEKINIST TAB 0.5MG ....................... 22
MEKINIST TAB 2MG .......................... 22
MELOXICAM SUSP 7.5 MG/5ML ............ 1
meloxicam tab 15 mg ......................... 1
meloxicam tab 7.5 mg ........................ 1
melphalan hcl for inj 50 mg (base equiv)
...................................................... 17
memantine hcl oral solution 2 mg/ml .. 42
memantine hcl tab 10 mg ................. 42
memantine hcl tab 5 mg ................... 42
MENACTRA INJ ................................ 80
MENHIBRIX INJ ................................ 80
MENOMUNE INJ A/C/Y/W .................. 80
MENVEO INJ .................................... 80
mercaptopurine tab 50 mg ................ 18
meropenem iv for soln 1 gm ................ 6
meropenem iv for soln 500 mg ............ 6
mesalamine enema 4 gm .................. 71
mesalamine rectal enema 4 gm & cleanser
wipe kit ........................................... 71
MESALAMINE TAB DELAYED RELEASE 800
MG ................................................. 71
mesna inj 100 mg/ml ....................... 24
MESNEX TAB 400MG......................... 24
metformin hcl tab 1000 mg ............... 59
metformin hcl tab 500 mg ................. 59
metformin hcl tab 850 mg ................. 59
metformin hcl tab sr 24hr 500 mg ...... 59
metformin hcl tab sr 24hr 750 mg ...... 59
methadone con 10mg/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
methazolamide tab 25 mg ................. 34
methazolamide tab 50 mg ................. 34
methenamine hippurate tab 1 gm ........ 6
methimazole tab 10 mg .................... 68
methimazole tab 5 mg ...................... 68
methocarbamol tab 500 mg............... 56
methocarbamol tab 750 mg............... 56
methotrexate sodium for inj 1 gm ...... 18
methotrexate sodium inj 250 mg/10ml
(25 mg/ml) ..................................... 18
METHOTREXATE SODIUM INJ 50 MG/2ML
119
(25 MG/ML)......................................18
methotrexate sodium inj pf 100 mg/4ml
(25 mg/ml) ......................................19
methotrexate sodium inj pf 1000
mg/40ml (25 mg/ml) ........................19
methotrexate sodium inj pf 200 mg/8ml
(25 mg/ml) ......................................19
methotrexate sodium inj pf 250 mg/10ml
(25 mg/ml) ......................................19
methotrexate sodium inj pf 50 mg/2ml
(25 mg/ml) ......................................19
methotrexate sodium tab 2.5 mg (base
equiv) .............................................77
methyclothiazide tab 5 mg .................34
methylergonovine maleate tab 0.2 mg 66
methylphenidate hcl soln 10 mg/5ml ...53
methylphenidate hcl soln 5 mg/5ml.....53
methylphenidate hcl tab 10 mg ..........53
methylphenidate hcl tab 20 mg ..........53
methylphenidate hcl tab 5 mg ............53
methylphenidate hcl tab cr 10 mg .......53
methylphenidate hcl tab cr 20 mg .......53
methylprednisolone acetate inj susp 40
mg/ml .............................................65
methylprednisolone acetate inj susp 80
mg/ml .............................................65
methylprednisolone sodium succinate for
inj 1000 mg .....................................65
methylprednisolone sodium succinate for
inj 125 mg .......................................65
methylprednisolone sodium succinate for
inj 40 mg .........................................65
methylprednisolone tab 16 mg ...........65
methylprednisolone tab 32 mg ...........65
methylprednisolone tab 4 mg .............65
methylprednisolone tab 8 mg .............65
methylprednisolone tab therapy pack 4
mg (21) ...........................................65
metipranolol ophth soln 0.3%.............85
metoclopramide hcl inj 5 mg/ml .........69
metoclopramide hcl soln 5 mg/5ml (10
mg/10ml) ........................................69
metoclopramide hcl tab 10 mg ...........69
metoclopramide hcl tab 5 mg .............69
metolazone tab 10 mg .......................34
metolazone tab 2.5 mg ......................34
metolazone tab 5 mg ........................34
metoprolol & hydrochlorothiazide tab
100-25 mg ...................................... 30
metoprolol & hydrochlorothiazide tab
100-50 mg ...................................... 30
metoprolol & hydrochlorothiazide tab
50-25 mg ........................................ 30
metoprolol succinate tab sr 24hr 100 mg
(tartrate equiv) ................................ 31
metoprolol succinate tab sr 24hr 200 mg
(tartrate equiv) ................................ 31
metoprolol succinate tab sr 24hr 25 mg
(tartrate equiv) ................................ 31
metoprolol succinate tab sr 24hr 50 mg
(tartrate equiv) ................................ 31
metoprolol tartrate inj 1 mg/ml .......... 31
metoprolol tartrate tab 100 mg .......... 31
metoprolol tartrate tab 25 mg............ 31
metoprolol tartrate tab 50 mg............ 31
metronidazole cream 0.75% .............. 93
metronidazole gel 0.75% .................. 93
metronidazole in nacl 0.79% iv soln 500
mg/100ml ......................................... 6
metronidazole lotion 0.75% ............... 93
metronidazole tab 250 mg................... 6
metronidazole tab 500 mg................... 6
metronidazole vaginal gel 0.75% ....... 74
mexiletine hcl cap 150 mg................. 28
mexiletine hcl cap 200 mg................. 28
mexiletine hcl cap 250 mg................. 28
MG SO4/D5W INJ 10MG/ML ............... 81
MG SO4/D5W INJ 20MG/ML ............... 81
MIACALCIN INJ 200/ML ..................... 66
midodrine hcl tab 10 mg ................... 35
midodrine hcl tab 2.5 mg .................. 35
midodrine hcl tab 5 mg ..................... 35
minitran dis 0.1mg/hr ....................... 35
minitran dis 0.2mg/hr ....................... 36
minitran dis 0.4mg/hr ....................... 36
minitran dis 0.6mg/hr ....................... 36
minocycline hcl cap 100 mg ............... 17
minocycline hcl cap 50 mg ................ 17
minocycline hcl cap 75 mg ................ 17
minoxidil tab 10 mg.......................... 35
minoxidil tab 2.5 mg......................... 35
mirtazapine orally disintegrating tab 15
mg ................................................. 45
mirtazapine orally disintegrating tab 30
mg ................................................. 45
mirtazapine orally disintegrating tab 45
120
mg ..................................................45
mirtazapine tab 15 mg ......................45
mirtazapine tab 30 mg ......................45
mirtazapine tab 45 mg ......................45
mirtazapine tab 7.5 mg .....................45
misoprostol tab 100 mcg ...................72
misoprostol tab 200 mcg ...................72
mitomycin for iv soln 20 mg ...............18
mitomycin for iv soln 40 mg ...............18
mitomycin for iv soln 5 mg .................18
mitoxantrone hcl inj conc 20 mg/10ml (2
mg/ml) ............................................23
mitoxantrone hcl inj conc 25 mg/12.5ml
(2 mg/ml) ........................................23
mitoxantrone hcl inj conc 30 mg/15ml (2
mg/ml) ............................................23
M-M-R II INJ ....................................80
moderiba pak 1000/day .....................11
MODERIBA PAK 1200/DAY .................11
moderiba pak 600/day ......................11
moderiba pak 800/day ......................11
moexipril hcl tab 15 mg .....................25
moexipril hcl tab 7.5 mg ....................25
moexipril-hydrochlorothiazide tab
15-12.5 mg ......................................25
moexipril-hydrochlorothiazide tab 15-25
mg ..................................................25
moexipril-hydrochlorothiazide tab
7.5-12.5 mg .....................................25
molindone hcl tab 10 mg ...................50
molindone hcl tab 25 mg ...................50
molindone hcl tab 5 mg .....................50
mometasone furoate cream 0.1% .......92
mometasone furoate nasal susp 50
mcg/act ...........................................88
mometasone furoate oint 0.1% ..........92
mometasone furoate solution 0.1%
(lotion) ............................................92
MONONESSA TAB .............................62
montelukast sodium chew tab 4 mg (base
equiv) .............................................87
montelukast sodium chew tab 5 mg (base
equiv) .............................................87
montelukast sodium oral granules packet
4 mg (base equiv) ............................87
montelukast sodium tab 10 mg (base
equiv) .............................................88
morgidox cap 1x50mg .......................17
MORPHINE SUL INJ 2MG/ML ................ 3
MORPHINE SUL INJ 4MG/ML ................ 3
MORPHINE SUL INJ 8MG/ML ................ 3
morphine sulfate beads cap sr 24hr 120
mg ................................................... 3
morphine sulfate beads cap sr 24hr 30 mg
........................................................ 3
morphine sulfate beads cap sr 24hr 45 mg
........................................................ 3
morphine sulfate beads cap sr 24hr 60 mg
........................................................ 3
morphine sulfate beads cap sr 24hr 75 mg
........................................................ 3
morphine sulfate beads cap sr 24hr 90 mg
........................................................ 3
morphine sulfate cap sr 24hr 10 mg ..... 3
morphine sulfate cap sr 24hr 100 mg ... 4
morphine sulfate cap sr 24hr 20 mg ..... 3
morphine sulfate cap sr 24hr 30 mg ..... 3
morphine sulfate cap sr 24hr 50 mg ..... 3
morphine sulfate cap sr 24hr 60 mg ..... 3
morphine sulfate cap sr 24hr 80 mg ..... 3
morphine sulfate inj pf 0.5 mg/ml ........ 4
morphine sulfate inj pf 1 mg/ml ........... 4
MORPHINE SULFATE IV SOLN 1 MG/ML . 4
MORPHINE SULFATE IV SOLN PF 10
MG/ML .............................................. 4
MORPHINE SULFATE IV SOLN PF 15
MG/ML .............................................. 4
morphine sulfate iv soln pf 4 mg/ml ..... 4
morphine sulfate iv soln pf 8 mg/ml ..... 4
MORPHINE SULFATE ORAL SOLN 10
MG/5ML ............................................ 4
MORPHINE SULFATE ORAL SOLN 100
MG/5ML (20 MG/ML) .......................... 4
MORPHINE SULFATE ORAL SOLN 20
MG/5ML ............................................ 4
MORPHINE SULFATE TAB 15 MG .......... 4
MORPHINE SULFATE TAB 30 MG .......... 4
morphine sulfate tab cr 100 mg ........... 4
morphine sulfate tab cr 15 mg ............. 4
morphine sulfate tab cr 200 mg ........... 4
morphine sulfate tab cr 30 mg ............. 4
morphine sulfate tab cr 60 mg ............. 4
MOVANTIK TAB 12.5MG .................... 72
MOVANTIK TAB 25MG ....................... 72
MOVIPREP SOL ................................ 71
MOXEZA SOL 0.5% .......................... 84
121
MOZOBIL INJ ...................................76
MULTAQ TAB 400MG .........................28
mupirocin oint 2% ............................90
MUSTARGEN INJ 10MG ......................17
MYCAMINE INJ 100MG ........................ 8
MYCAMINE INJ 50MG ......................... 8
mycophenolate mofetil cap 250 mg .....79
mycophenolate mofetil for oral susp 200
mg/ml .............................................79
mycophenolate mofetil tab 500 mg .....79
mycophenolate sodium tab dr 180 mg
(mycophenolic acid equiv)..................79
mycophenolate sodium tab dr 360 mg
(mycophenolic acid equiv)..................79
myorisan cap 10mg...........................90
myorisan cap 20mg...........................90
myorisan cap 30mg...........................90
myorisan cap 40mg...........................90
MYOZYME INJ 50MG ..........................64
MYRBETRIQ TAB 25MG ......................74
MYRBETRIQ TAB 50MG ......................74
myzilra tab.......................................62
N
nabumetone tab 500 mg..................... 1
nabumetone tab 750 mg..................... 1
nadolol tab 20 mg .............................31
nadolol tab 40 mg .............................31
nadolol tab 80 mg .............................31
nafcillin sodium for inj 1 gm ...............16
nafcillin sodium for inj 10 gm .............16
nafcillin sodium for inj 2 gm ...............16
nafcillin sodium for iv soln 1 gm .........16
nafcillin sodium for iv soln 2 gm .........16
NAGLAZYME INJ 1MG/ML ...................64
nalbuphine hcl inj 10 mg/ml ................ 2
nalbuphine hcl inj 20 mg/ml ................ 2
naloxone hcl inj 0.4 mg/ml.................56
naloxone hcl inj 4 mg/10ml ................56
naloxone hcl soln cartridge 0.4 mg/ml .56
naloxone hcl soln prefilled syringe 2
mg/2ml ...........................................56
naltrexone hcl tab 50 mg ...................57
NAMENDA XR CAP 14MG ....................42
NAMENDA XR CAP 21MG ....................42
NAMENDA XR CAP 28MG ....................43
NAMENDA XR CAP 7MG .....................42
NAMENDA XR CAP TITRATIO ..............43
NAMZARIC CAP 14-10MG ...................43
NAMZARIC CAP 21-10MG .................. 43
NAMZARIC CAP 28-10MG .................. 43
NAMZARIC CAP 7-10MG .................... 43
naphazoline hcl ophth soln 0.1% ........ 86
naproxen dr tab 375mg ...................... 1
naproxen dr tab 500mg ...................... 1
naproxen sodium tab 275 mg .............. 2
naproxen sodium tab 550 mg .............. 2
naproxen susp 125 mg/5ml ................. 2
naproxen tab 250 mg ......................... 2
naproxen tab 375 mg ......................... 2
naproxen tab 500 mg ......................... 2
naratriptan hcl tab 1 mg (base equiv) . 54
naratriptan hcl tab 2.5 mg (base equiv)
...................................................... 54
NASONEX SPR 50MCG/AC ................. 88
NATACYN SUS 5% OP ....................... 84
nateglinide tab 120 mg ..................... 59
nateglinide tab 60 mg ....................... 59
NATPARA INJ 100MCG ...................... 67
NATPARA INJ 25MCG ........................ 67
NATPARA INJ 50MCG ........................ 67
NATPARA INJ 75MCG ........................ 67
NEBUPENT INH 300MG ....................... 6
necon tab 0.5/35 ............................. 62
necon tab 1/35 ................................ 62
NECON TAB 1/50-28 ......................... 62
necon tab 10/11-28 .......................... 62
NECON TAB 7/7/7 ............................ 62
nefazodone hcl tab 100 mg ............... 45
nefazodone hcl tab 150 mg ............... 45
nefazodone hcl tab 200 mg ............... 45
nefazodone hcl tab 250 mg ............... 45
nefazodone hcl tab 50 mg ................. 45
neomycin sulfate tab 500 mg............... 5
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin ..... 84
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml ....... 84
neomycin-polymyxin-dexamethasone
ophth oint 0.1% ............................... 84
neomycin-polymyxin-dexamethasone
ophth susp 0.1% .............................. 84
neomycin-polymyxin-hc ophth susp .... 84
neomycin-polymyxin-hc otic soln 1% .. 94
neomycin-polymyxin-hc otic susp 3.5
mg/ml-10000 unit/ml-1% ................. 94
NEORAL CAP 100MG ......................... 79
122
NEORAL CAP 25MG ...........................79
NEORAL SOL 100MG/ML ....................79
NEPHRAMINE INJ 5.4% .....................82
NEUMEGA INJ 5MG ...........................76
NEUPOGEN INJ 300/0.5 .....................76
NEUPOGEN INJ 300MCG ....................76
NEUPOGEN INJ 480/0.8 .....................76
NEUPOGEN INJ 480MCG ....................76
NEUPRO DIS 1MG/24HR ....................47
NEUPRO DIS 2MG/24HR ....................47
NEUPRO DIS 3MG/24HR ....................48
NEUPRO DIS 4MG/24HR ....................48
NEUPRO DIS 6MG/24HR ....................48
NEUPRO DIS 8MG/24HR ....................48
NEVIRAPINE SUSP 50 MG/5ML ............ 9
nevirapine tab 200 mg ....................... 9
nevirapine tab sr 24hr 100 mg ............ 9
nevirapine tab sr 24hr 400 mg ............ 9
NEXAVAR TAB 200MG........................22
NEXIUM CAP 20MG ...........................73
NEXIUM CAP 40MG ...........................73
NEXIUM GRA 10MG DR ......................73
NEXIUM GRA 2.5MG DR .....................73
NEXIUM GRA 20MG DR ......................73
NEXIUM GRA 40MG DR ......................73
NEXIUM GRA 5MG DR ........................73
niacin tab cr 1000 mg
(antihyperlipidemic) ..........................30
niacin tab cr 500 mg (antihyperlipidemic)
......................................................30
niacin tab cr 750 mg (antihyperlipidemic)
......................................................30
niacor tab 500mg .............................30
nicardipine hcl cap 20 mg ..................33
nicardipine hcl cap 30 mg ..................33
NICOTROL INH .................................57
NICOTROL NS SPR 10MG/ML ..............57
nifedical xl tab 30mg .........................33
nifedical xl tab 60mg .........................33
nifedipine tab sr 24hr 30 mg ..............33
nifedipine tab sr 24hr 60 mg ..............33
nifedipine tab sr 24hr 90 mg ..............33
nifedipine tab sr 24hr osmotic release 30
mg ..................................................33
nifedipine tab sr 24hr osmotic release 60
mg ..................................................33
nifedipine tab sr 24hr osmotic release 90
mg ..................................................33
nikki tab 3-0.02mg ........................... 62
NILANDRON TAB 150MG ................... 21
nilutamide tab 150 mg ...................... 21
nimodipine cap 30 mg ...................... 33
NINLARO CAP 2.3MG ........................ 20
NINLARO CAP 3MG ........................... 20
NINLARO CAP 4MG ........................... 20
NIPENT INJ 10MG............................. 19
nitro-bid oin 2% ............................... 36
NITRO-DUR DIS 0.3MG/HR ................ 36
NITRO-DUR DIS 0.8MG/HR ................ 36
nitrofurantoin macrocrystalline cap 100
mg ................................................... 6
nitrofurantoin macrocrystalline cap 50 mg
........................................................ 6
nitrofurantoin monohydrate
macrocrystalline cap 100 mg ............... 6
nitroglycerin sl tab 0.3 mg................. 36
nitroglycerin sl tab 0.4 mg................. 36
nitroglycerin sl tab 0.6 mg................. 36
nitroglycerin td patch 24hr 0.1 mg/hr . 36
nitroglycerin td patch 24hr 0.2 mg/hr . 36
nitroglycerin td patch 24hr 0.4 mg/hr . 36
nitroglycerin td patch 24hr 0.6 mg/hr . 36
NITROSTAT SUB 0.3MG .................... 36
NITROSTAT SUB 0.4MG .................... 36
NITROSTAT SUB 0.6MG .................... 36
NORDITROPIN INJ 10/1.5ML.............. 66
NORDITROPIN INJ 15/1.5ML.............. 66
NORDITROPIN INJ 30/3ML ................ 66
NORDITROPIN INJ 5/1.5ML ............... 66
norelgestromin-ethinyl estradiol td ptwk
150-35 mcg/24hr ............................. 62
NORETHINDRONE ACE & ETHINYL
ESTRADIOL TAB 1 MG-20 MCG .......... 62
NORETHINDRONE ACE & ETHINYL
ESTRADIOL TAB 1.5 MG-30 MCG........ 62
NORETHINDRONE ACE & ETHINYL
ESTRADIOL-FE TAB 1 MG-20 MCG ...... 62
NORETHINDRONE ACE & ETHINYL
ESTRADIOL-FE TAB 1.5 MG-30 MCG ... 62
norethindrone acetate tab 5 mg ......... 67
norethindrone acetate-ethinyl estradiol
tab 1 mg-5 mcg ............................... 64
norethindrone tab 0.35 mg ................ 62
NORETHINDRONE TAB 0.35 MG ......... 62
norgestimate & ethinyl estradiol tab 0.25
mg-35 mcg ..................................... 62
123
norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg ....62
norgestrel & ethinyl estradiol tab 0.3
mg-30 mcg ......................................62
norlyroc tab 0.35mg ..........................62
NORMOSOL -M INJ /D5W ...................83
NORMOSOL -R INJ /D5W ...................83
NORMOSOL-R INJ PH 7.4 ...................83
NORPACE CAP 100MG CR ...................28
NORPACE CAP 150MG CR ...................28
nortrel tab 0.5/35 .............................62
nortrel tab 1/35 ................................62
nortrel tab 7/7/7 ...............................63
nortriptyline hcl cap 10 mg ................45
nortriptyline hcl cap 25 mg ................45
nortriptyline hcl cap 50 mg ................45
nortriptyline hcl cap 75 mg ................45
nortriptyline hcl soln 10 mg/5ml .........45
NORVIR CAP 100MG ........................... 9
NORVIR SOL 80MG/ML ....................... 9
NORVIR TAB 100MG ........................... 9
NOVOLIN INJ 70/30 ..........................57
NOVOLIN N INJ U-100 .......................57
NOVOLIN R INJ U-100 .......................58
NOVOLOG INJ 100/ML .......................58
NOVOLOG INJ FLEXPEN .....................58
NOVOLOG INJ PENFILL ......................58
NOVOLOG MIX INJ 70/30 ...................58
NOVOLOG MIX INJ FLEXPEN ...............58
NOXAFIL SUS 40MG/ML ...................... 8
NOXAFIL TAB 100MG.......................... 8
NUEDEXTA CAP 20-10MG ...................55
NULOJIX INJ 250MG ..........................79
NULYTELY SOL FLAV PKS ...................71
NUPLAZID TAB 17MG ........................50
NUVARING MIS.................................63
NUVIGIL TAB 150MG .........................56
NUVIGIL TAB 200MG .........................56
NUVIGIL TAB 250MG .........................56
NUVIGIL TAB 50MG ...........................56
nyamyc pow 100000 .........................90
NYMALIZE SOL 60/20ML ....................33
nystatin cream 100000 unit/gm ..........90
nystatin oint 100000 unit/gm .............90
nystatin susp 100000 unit/ml .............94
nystatin tab 500000 unit..................... 8
nystatin topical powder......................90
nystop pow 100000...........................90
O
OCTAGAM INJ 10GM ......................... 78
OCTAGAM INJ 1GM ........................... 78
OCTAGAM INJ 2.5GM ........................ 78
OCTAGAM INJ 25GM ......................... 78
OCTAGAM INJ 2GM/20ML .................. 78
OCTAGAM INJ 5GM ........................... 78
octreotide acetate inj 100 mcg/ml (0.1
mg/ml) ........................................... 66
octreotide acetate inj 1000 mcg/ml (1
mg/ml) ........................................... 66
octreotide acetate inj 200 mcg/ml (0.2
mg/ml) ........................................... 66
octreotide acetate inj 50 mcg/ml (0.05
mg/ml) ........................................... 66
octreotide acetate inj 500 mcg/ml (0.5
mg/ml) ........................................... 66
ODEFSEY TAB .................................. 10
ODOMZO CAP 200MG ....................... 23
OFEV CAP 100MG ............................. 88
OFEV CAP 150MG ............................. 88
ofloxacin ophth soln 0.3% ................. 84
ofloxacin otic soln 0.3% .................... 94
olanzapine for im inj 10 mg ............... 50
olanzapine orally disintegrating tab 10 mg
...................................................... 50
olanzapine orally disintegrating tab 15 mg
...................................................... 50
olanzapine orally disintegrating tab 20 mg
...................................................... 50
olanzapine orally disintegrating tab 5 mg
...................................................... 50
olanzapine tab 10 mg ....................... 50
olanzapine tab 15 mg ....................... 50
olanzapine tab 2.5 mg ...................... 50
olanzapine tab 20 mg ....................... 50
olanzapine tab 5 mg ......................... 50
olanzapine tab 7.5 mg ...................... 50
olopatadine hcl nasal soln 0.6% ......... 87
omega-3-acid ethyl esters cap 1 gm ... 30
omeprazole cap delayed release 10 mg73
omeprazole cap delayed release 20 mg73
omeprazole cap delayed release 40 mg73
ondansetron hcl inj 4 mg/2ml (2 mg/ml)
...................................................... 69
ondansetron hcl inj 40 mg/20ml (2
mg/ml) ........................................... 69
ondansetron hcl oral soln 4 mg/5ml .... 69
124
ondansetron hcl tab 24 mg ................69
ondansetron hcl tab 4 mg ..................69
ondansetron hcl tab 8 mg ..................69
ondansetron orally disintegrating tab 4
mg ..................................................69
ondansetron orally disintegrating tab 8
mg ..................................................69
ONFI SUS 2.5MG/ML .........................40
ONFI TAB 10MG ................................40
ONFI TAB 20MG ................................40
OPSUMIT TAB 10MG ..........................36
ORFADIN CAP 10MG ..........................64
ORFADIN CAP 20MG ..........................64
ORFADIN CAP 2MG ...........................64
ORFADIN CAP 5MG ...........................64
ORFADIN SUS 4MG/ML ......................64
ORKAMBI TAB 200-125 .....................88
orsythia tab .....................................63
oxacillin sodium for inj 1 gm ..............16
oxacillin sodium for inj 10 gm .............16
oxacillin sodium for inj 2 gm ..............16
oxaliplatin for iv inj 100 mg................23
oxaliplatin for iv inj 50 mg .................23
oxaliplatin iv soln 100 mg/20ml ..........23
oxaliplatin iv soln 50 mg/10ml ............23
oxandrolone tab 10 mg......................57
oxandrolone tab 2.5 mg.....................57
oxcarbazepine susp 300 mg/5ml (60
mg/ml) ............................................40
oxcarbazepine tab 150 mg .................40
oxcarbazepine tab 300 mg .................40
oxcarbazepine tab 600 mg .................40
oxybutynin chloride syrup 5 mg/5ml ...74
oxybutynin chloride tab 5 mg .............74
oxybutynin chloride tab sr 24hr 10 mg 74
oxybutynin chloride tab sr 24hr 15 mg 74
oxybutynin chloride tab sr 24hr 5 mg ..74
oxycodone hcl cap 5 mg ..................... 4
oxycodone hcl conc 100 mg/5ml (20
mg/ml) ............................................. 4
OXYCODONE HCL SOLN 5 MG/5ML ....... 4
oxycodone hcl tab 10 mg .................... 4
oxycodone hcl tab 15 mg .................... 4
oxycodone hcl tab 20 mg .................... 4
oxycodone hcl tab 30 mg .................... 4
oxycodone hcl tab 5 mg ...................... 4
oxycodone w/ acetaminophen soln 5-325
mg/5ml ............................................ 4
oxycodone w/ acetaminophen tab 10-325
mg ................................................... 4
oxycodone w/ acetaminophen tab 2.5-325
mg ................................................... 4
oxycodone w/ acetaminophen tab 5-325
mg ................................................... 4
oxycodone w/ acetaminophen tab 7.5-325
mg ................................................... 4
P
pacerone tab 100mg......................... 28
pacerone tab 200mg......................... 28
pacerone tab 400mg......................... 28
paclitaxel iv conc 100 mg/16.7ml (6
mg/ml) ........................................... 19
paclitaxel iv conc 150 mg/25ml (6 mg/ml)
...................................................... 19
paclitaxel iv conc 30 mg/5ml (6 mg/ml)
...................................................... 19
paclitaxel iv conc 300 mg/50ml (6 mg/ml)
...................................................... 19
paliperidone tab sr 24hr 1.5 mg ......... 50
paliperidone tab sr 24hr 3 mg ............ 50
paliperidone tab sr 24hr 6 mg ............ 51
paliperidone tab sr 24hr 9 mg ............ 51
pamidronate disodium iv soln 3 mg/ml 60
pamidronate disodium iv soln 9 mg/ml 60
pamidronate inj 6mg/ml.................... 60
PANRETIN GEL 0.1% ........................ 93
pantoprazole sodium ec tab 20 mg (base
equiv) ............................................. 73
pantoprazole sodium ec tab 40 mg (base
equiv) ............................................. 73
paricalcitol cap 1 mcg ....................... 83
paricalcitol cap 2 mcg ....................... 83
paricalcitol cap 4 mcg ....................... 83
paromomycin sulfate cap 250 mg ......... 5
paroxetine hcl tab 10 mg .................. 45
paroxetine hcl tab 20 mg .................. 45
paroxetine hcl tab 30 mg .................. 45
paroxetine hcl tab 40 mg .................. 45
paser gra 4gm ................................. 10
PATADAY SOL 0.2% ......................... 85
PAXIL SUS 10MG/5ML ....................... 45
PAZEO DRO 0.7% ............................ 85
PEDIARIX INJ 0.5ML ......................... 80
PEDVAX HIB INJ ............................... 80
PEG 3350-KCL-NA BICARB-NACL-NA
SULFATE FOR SOLN 236 GM .............. 72
125
PEG 3350-KCL-NA BICARB-NACL-NA
SULFATE FOR SOLN 240 GM...............72
peg 3350-kcl-sod bicarb-nacl for soln 420
gm ..................................................72
PEGANONE TAB 250MG .....................40
PEGASYS INJ ....................................11
PEGASYS INJ 180MCG/M ...................11
PEGASYS INJ PROCLICK ....................11
PEG-INTRON KIT 120 RP....................11
PEGINTRON KIT 120MCG ...................11
PEG-INTRON KIT 150 RP....................11
PEGINTRON KIT 150MCG ...................11
PEGINTRON KIT 50MCG .....................11
PEG-INTRON KIT 50MCG RP ...............11
PEGINTRON KIT 80MCG .....................11
PEG-INTRON KIT 80MCG RP ...............11
pen g proc inj 600000 .......................16
PENICILL GK/ INJ DEX 2MU................16
PENICILL GK/ INJ DEX 3MU................16
penicillin g potassium for inj 20000000
unit .................................................16
penicillin g potassium for inj 5000000 unit
......................................................16
penicillin g sodium for inj 5000000 unit
......................................................16
penicillin v potassium for soln 125 mg/5ml
......................................................16
penicillin v potassium for soln 250 mg/5ml
......................................................16
penicillin v potassium tab 250 mg .......16
penicillin v potassium tab 500 mg .......16
PENTACEL INJ ..................................80
PENTAM 300 INJ 300MG ..................... 7
pentoxifylline tab cr 400 mg ...............76
PERFOROMIST NEB 20MCG ................87
perindopril erbumine tab 2 mg ...........25
perindopril erbumine tab 4 mg ...........25
perindopril erbumine tab 8 mg ...........25
periogard sol 0.12% ..........................94
permethrin cream 5% .......................93
perphenazine tab 16 mg ....................51
perphenazine tab 2 mg ......................51
perphenazine tab 4 mg ......................51
perphenazine tab 8 mg ......................51
phenadoz sup 12.5mg .......................69
phenelzine sulfate tab 15 mg..............45
phenergan sup 12.5mg ......................70
phenergan sup 25mg ........................70
phenergan sup 50mg ........................ 70
PHENOBARB INJ 65MG/ML ................ 40
phenobarbital elixir 20 mg/5ml .......... 40
phenobarbital sodium inj 130 mg/ml .. 40
phenobarbital tab 100 mg ................. 41
phenobarbital tab 15 mg ................... 41
phenobarbital tab 16.2 mg ................ 41
phenobarbital tab 30 mg ................... 41
phenobarbital tab 32.4 mg ................ 41
phenobarbital tab 60 mg ................... 41
phenobarbital tab 64.8 mg ................ 41
phenobarbital tab 97.2 mg ................ 41
phenytek cap 200mg ........................ 41
phenytek cap 300mg ........................ 41
phenytoin chew tab 50 mg ................ 41
phenytoin sodium extended cap 100 mg
...................................................... 41
phenytoin sodium extended cap 200 mg
...................................................... 41
phenytoin sodium extended cap 300 mg
...................................................... 41
phenytoin sodium inj 50 mg/ml ......... 41
phenytoin susp 125 mg/5ml .............. 41
philith tab 0.4-35 ............................. 63
PHOSPHOLINE SOL 0.125%OP ........... 85
PILOCARPINE HCL OPHTH SOLN 1% ... 86
PILOCARPINE HCL OPHTH SOLN 2% ... 86
PILOCARPINE HCL OPHTH SOLN 4% ... 86
PILOCARPINE HCL TAB 5 MG ............. 94
pilocarpine hcl tab 7.5 mg ................. 94
pimozide tab 1 mg ........................... 51
pimozide tab 2 mg ........................... 51
pimtrea tab ..................................... 63
pindolol tab 10 mg ........................... 31
pindolol tab 5 mg ............................. 31
pioglitazone hcl tab 15 mg (base equiv)
...................................................... 59
pioglitazone hcl tab 30 mg (base equiv)
...................................................... 59
pioglitazone hcl tab 45 mg (base equiv)
...................................................... 59
piperacillin sod-tazobactam na for inj
3.375 gm (3-0.375 gm) .................... 16
piperacillin sod-tazobactam sod for inj
2.25 gm (2-0.25 gm)........................ 16
piperacillin sod-tazobactam sod for inj 4.5
gm (4-0.5 gm) ................................. 16
piperacillin sod-tazobactam sod for inj
126
40.5 gm (36-4.5 gm) ........................16
pirmella tab 1/35 ..............................63
piroxicam cap 10 mg .......................... 2
piroxicam cap 20 mg .......................... 2
PLASMA-LYTE INJ -148 ......................83
PLASMA-LYTE INJ 56/D5W .................83
PLASMA-LYTE INJ -A .........................83
podofilox soln 0.5% ..........................93
polyethylene glycol 3350 oral packet ...72
polyethylene glycol 3350 oral powder ..72
polymyxin b-trimethoprim ophth soln
10000 unit/ml-0.1% .........................84
POMALYST CAP 1MG .........................23
POMALYST CAP 2MG .........................23
POMALYST CAP 3MG .........................23
POMALYST CAP 4MG .........................23
portia-28 tab ....................................63
POTASSIUM CHLORIDE 20 MEQ/L
(0.15%) IN DEXTROSE 5% INJ ...........83
POTASSIUM CHLORIDE 40 MEQ/L (0.3%)
IN DEXTROSE 5% INJ .......................83
potassium chloride cap cr 10 meq .......81
potassium chloride cap cr 8 meq .........81
POTASSIUM CHLORIDE INJ 10
MEQ/100ML .....................................83
POTASSIUM CHLORIDE INJ 10 MEQ/50ML
......................................................83
potassium chloride inj 2 meq/ml .........83
POTASSIUM CHLORIDE INJ 20
MEQ/100ML .....................................83
POTASSIUM CHLORIDE INJ 20 MEQ/50ML
......................................................83
POTASSIUM CHLORIDE INJ 40
MEQ/100ML .....................................83
potassium chloride microencapsulated
crys cr tab 10 meq ............................81
potassium chloride microencapsulated
crys cr tab 20 meq ............................81
POTASSIUM CHLORIDE ORAL SOLN 10%
(20 MEQ/15ML) ................................81
POTASSIUM CHLORIDE ORAL SOLN 20%
(40 MEQ/15ML) ................................81
POTASSIUM CHLORIDE TAB CR 10 MEQ
......................................................81
POTASSIUM CHLORIDE TAB CR 20 MEQ
(1500 MG) .......................................81
potassium chloride tab cr 8 meq (600 mg)
......................................................81
POTASSIUM CITRATE TAB CR 10 MEQ
(1080 MG) ...................................... 73
potassium citrate tab cr 15 meq (1620
mg) ................................................ 73
POTASSIUM CITRATE TAB CR 5 MEQ (540
MG) ................................................ 73
POTIGA TAB 200MG ......................... 41
POTIGA TAB 300MG ......................... 41
POTIGA TAB 400MG ......................... 41
POTIGA TAB 50MG ........................... 41
PRADAXA CAP 110MG ....................... 75
PRADAXA CAP 150MG ....................... 75
PRADAXA CAP 75MG ......................... 75
PRALUENT INJ 150MG/ML ................. 30
PRALUENT INJ 75MG/ML ................... 30
pramipexole dihydrochloride tab 0.125
mg ................................................. 48
pramipexole dihydrochloride tab 0.25 mg
...................................................... 48
pramipexole dihydrochloride tab 0.5 mg
...................................................... 48
pramipexole dihydrochloride tab 0.75 mg
...................................................... 48
pramipexole dihydrochloride tab 1 mg 48
pramipexole dihydrochloride tab 1.5 mg
...................................................... 48
pravastatin sodium tab 10 mg ........... 29
pravastatin sodium tab 20 mg ........... 29
pravastatin sodium tab 40 mg ........... 29
pravastatin sodium tab 80 mg ........... 29
prazosin hcl cap 1 mg ....................... 26
prazosin hcl cap 2 mg ....................... 26
prazosin hcl cap 5 mg ....................... 26
pred sod pho sol 1% op .................... 85
PREDNISOLONE ACETATE OPHTH SUSP
1% ................................................. 85
prednisolone sod phosph oral soln 6.7
mg/5ml (5 mg/5ml base) .................. 65
prednisolone sod phosphate oral soln 15
mg/5ml (base equiv) ........................ 66
prednisolone sodium phosphate oral soln
25 mg/5ml (base eq) ........................ 66
prednisolone syrup 15 mg/5ml (usp
solution equivalent) .......................... 66
prednisone con 5mg/ml .................... 66
prednisone oral soln 5 mg/5ml ........... 66
prednisone tab 1 mg......................... 66
prednisone tab 10 mg ....................... 66
127
prednisone tab 2.5 mg ......................66
prednisone tab 20 mg .......................66
prednisone tab 5 mg .........................66
prednisone tab 50 mg .......................66
prednisone tab therapy pack 10 mg (21)
......................................................66
prednisone tab therapy pack 10 mg (48)
......................................................66
prednisone tab therapy pack 5 mg (21)
......................................................66
prednisone tab therapy pack 5 mg (48)
......................................................66
premasol sol 10% .............................82
PRENATAL VITAMIN/FOLIC ACID > 0.8
MG (GENERIC) .................................83
prevalite pow 4gm ............................30
prevalite pow 4gm pk ........................30
previfem tab ....................................63
PREZCOBIX TAB 800-150 ..................10
PREZISTA SUS 100MG/ML................... 9
PREZISTA TAB 150MG ........................ 9
PREZISTA TAB 600MG ........................ 9
PREZISTA TAB 75MG .......................... 9
PREZISTA TAB 800MG ........................ 9
PRIFTIN TAB 150MG..........................10
PRIMAQUINE TAB 26.3MG ................... 8
primidone tab 250 mg .......................41
primidone tab 50 mg .........................41
PRISTIQ TAB 100MG .........................46
PRISTIQ TAB 25MG ...........................45
PRISTIQ TAB 50MG ...........................45
PRIVIGEN INJ 10GRAMS ....................78
PRIVIGEN INJ 20GRAMS ....................78
PRIVIGEN INJ 40GRAMS ....................78
PRIVIGEN INJ 5 GRAMS .....................78
probenecid tab 500 mg ....................... 1
PROCALAMINE INJ 3%.......................82
prochlorperazine edisylate inj 5 mg/ml 70
prochlorperazine maleate tab 10 mg (base
equivalent) ......................................70
prochlorperazine maleate tab 5 mg (base
equivalent) ......................................70
prochlorperazine suppos 25 mg ..........70
PROCRIT INJ 10000/ML .....................76
PROCRIT INJ 2000/ML .......................76
PROCRIT INJ 20000/ML .....................76
PROCRIT INJ 3000/ML .......................76
PROCRIT INJ 4000/ML .......................76
PROCRIT INJ 40000/ML..................... 76
procto-med cre hc 2.5% ................... 91
procto-pak cre 1% ........................... 91
proctozone cre -hc 2.5% ................... 91
PROGLYCEM SUS 50MG/ML ............... 66
PROGRAF CAP 0.5MG ........................ 79
PROGRAF CAP 1MG .......................... 79
PROGRAF CAP 5MG .......................... 79
PROLASTIN-C INJ 1000MG ................ 88
PROLENSA SOL 0.07% ...................... 86
PROLEUKIN INJ 22MU ....................... 20
PROLIA SOL 60MG/ML ...................... 67
PROMACTA TAB 12.5MG .................... 76
PROMACTA TAB 25MG ...................... 76
PROMACTA TAB 50MG ...................... 76
PROMACTA TAB 75MG ...................... 76
promethazine hcl inj 25 mg/ml .......... 70
promethazine hcl inj 50 mg/ml .......... 70
promethazine hcl suppos 12.5 mg ...... 70
promethazine hcl suppos 25 mg ......... 70
promethazine hcl suppos 50 mg ......... 70
promethazine hcl syrup 6.25 mg/5ml.. 70
promethazine hcl tab 12.5 mg ........... 70
promethazine hcl tab 25 mg .............. 70
promethazine hcl tab 50 mg .............. 70
promethegan sup 25mg .................... 70
promethegan sup 50mg .................... 70
propafenone hcl cap sr 12hr 225 mg... 28
propafenone hcl cap sr 12hr 325 mg... 28
propafenone hcl cap sr 12hr 425 mg... 28
propafenone hcl tab 150 mg .............. 28
propafenone hcl tab 225 mg .............. 28
propafenone hcl tab 300 mg .............. 28
proparacaine hcl ophth soln 0.5% ...... 86
propranolol & hydrochlorothiazide tab
40-25 mg ........................................ 30
propranolol & hydrochlorothiazide tab
80-25 mg ........................................ 31
propranolol hcl cap sr 24hr 120 mg .... 31
propranolol hcl cap sr 24hr 160 mg .... 31
propranolol hcl cap sr 24hr 60 mg ...... 31
propranolol hcl cap sr 24hr 80 mg ...... 31
propranolol hcl inj 1 mg/ml ............... 31
propranolol hcl oral soln 20 mg/5ml ... 31
propranolol hcl oral soln 40 mg/5ml ... 31
propranolol hcl tab 10 mg ................. 32
propranolol hcl tab 20 mg ................. 32
propranolol hcl tab 40 mg ................. 32
128
propranolol hcl tab 60 mg ..................32
propranolol hcl tab 80 mg ..................32
propylthiouracil tab 50 mg .................68
PROQUAD INJ ...................................80
PROSOL INJ 20% ..............................82
protriptyline hcl tab 10 mg .................46
protriptyline hcl tab 5 mg...................46
PRUDOXIN CRE 5% ...........................91
PULMICORT INH 180MCG ...................89
PULMICORT INH 90MCG ....................89
PULMOZYME SOL 1MG/ML ..................88
PURIXAN SUS 20MG/ML.....................19
pyrazinamide tab 500 mg ..................10
pyridostigmine bromide tab 60 mg ......55
Q
QUADRACEL INJ ...............................80
quasense tab ....................................63
quetiapine fumarate tab 100 mg .........51
quetiapine fumarate tab 200 mg .........51
quetiapine fumarate tab 25 mg...........51
quetiapine fumarate tab 300 mg .........51
quetiapine fumarate tab 400 mg .........51
quetiapine fumarate tab 50 mg...........51
quinapril hcl tab 10 mg ......................26
quinapril hcl tab 20 mg ......................26
quinapril hcl tab 40 mg ......................26
quinapril hcl tab 5 mg........................25
quinapril-hydrochlorothiazide tab 10-12.5
mg ..................................................25
quinapril-hydrochlorothiazide tab 20-12.5
mg ..................................................25
quinapril-hydrochlorothiazide tab 20-25
mg ..................................................25
quinidine gluconate tab cr 324 mg ......28
quinidine sulfate tab 200 mg ..............28
quinidine sulfate tab 300 mg ..............28
quinine sulfate cap 324 mg ................. 8
R
RABAVERT INJ ..................................80
raloxifene hcl tab 60 mg ....................67
ramipril cap 1.25 mg .........................26
ramipril cap 10 mg ............................26
ramipril cap 2.5 mg ...........................26
ramipril cap 5 mg .............................26
RANEXA TAB 1000MG ........................35
RANEXA TAB 500MG .........................35
ranitidine hcl inj 50 mg/2ml (25 mg/ml)
......................................................71
ranitidine hcl syrup 15 mg/ml (75
mg/5ml) ......................................... 71
ranitidine hcl tab 150 mg .................. 71
ranitidine hcl tab 300 mg .................. 71
ranitidine inj 150/6ml ....................... 71
RAPAMUNE SOL 1MG/ML ................... 79
RAVICTI LIQ 1.1GM/ML ..................... 64
REBETOL SOL 40MG/ML .................... 11
reclipsen tab .................................... 63
RECOMBIVA HB INJ 10MCG/ML .......... 80
RECOMBIVA HB INJ 5MCG/0.5 ........... 80
RECOMBIVA-HB INJ 40MCG/ML .......... 80
REGRANEX GEL 0.01% ..................... 93
RELENZA MIS DISKHALE ................... 11
RELISTOR INJ 12/0.6ML .................... 72
RELISTOR INJ 8/0.4ML ..................... 72
RELPAX TAB 20MG ........................... 54
RELPAX TAB 40MG ........................... 54
REMICADE INJ 100MG ...................... 77
REMODULIN INJ 10MG/ML ................. 36
REMODULIN INJ 1MG/ML .................. 36
REMODULIN INJ 2.5MG/ML ................ 36
REMODULIN INJ 5MG/ML .................. 36
RENVELA PAK 0.8GM ........................ 67
RENVELA PAK 2.4GM ........................ 67
RENVELA TAB 800MG ....................... 67
repaglinide tab 0.5 mg ...................... 59
repaglinide tab 1 mg......................... 59
repaglinide tab 2 mg......................... 59
RESCRIPTOR TAB 100 MG ................... 9
RESCRIPTOR TAB 200MG .................... 9
RESTASIS EMU 0.05% ...................... 86
RETROVIR INJ 10MG/ML ..................... 9
REVATIO SUS 10MG/ML .................... 36
REVLIMID CAP 10MG ........................ 78
REVLIMID CAP 15MG ........................ 78
REVLIMID CAP 2.5MG ....................... 78
REVLIMID CAP 20MG ........................ 78
REVLIMID CAP 25MG ........................ 78
REVLIMID CAP 5MG .......................... 78
REXULTI TAB 0.25MG ....................... 51
REXULTI TAB 0.5MG ......................... 51
REXULTI TAB 1MG ............................ 51
REXULTI TAB 2MG ............................ 51
REXULTI TAB 3MG ............................ 51
REXULTI TAB 4MG ............................ 51
REYATAZ CAP 150MG ......................... 9
REYATAZ CAP 200MG ......................... 9
129
REYATAZ CAP 300MG ......................... 9
REYATAZ POW 50MG .......................... 9
ribapak pak 1000/day .......................12
ribapak pak 1200/day .......................12
ribapak pak 600/day .........................11
ribapak pak 800/day .........................12
ribasphere cap 200mg .......................12
ribasphere tab 200mg .......................12
ribasphere tab 400mg .......................12
ribasphere tab 600mg .......................12
ribavirin cap 200 mg .........................12
ribavirin tab 200 mg..........................12
rifabutin cap 150 mg .........................10
rifampin cap 150 mg .........................11
rifampin cap 300 mg .........................11
rifampin for inj 600 mg ......................11
RIFATER TAB ....................................11
riluzole tab 50 mg .............................55
rimantadine hydrochloride tab 100 mg 12
RINGER'S SOLUTION .........................83
RISPERDAL INJ 12.5MG .....................51
RISPERDAL INJ 25MG ........................51
RISPERDAL INJ 37.5MG .....................51
RISPERDAL INJ 50MG ........................51
risperidone orally disintegrating tab 0.25
mg ..................................................51
risperidone orally disintegrating tab 0.5
mg ..................................................51
risperidone orally disintegrating tab 1 mg
......................................................51
risperidone orally disintegrating tab 2 mg
......................................................51
risperidone orally disintegrating tab 3 mg
......................................................51
risperidone orally disintegrating tab 4 mg
......................................................51
risperidone soln 1 mg/ml ...................51
risperidone tab 0.25 mg ....................51
risperidone tab 0.5 mg ......................51
risperidone tab 1 mg .........................51
risperidone tab 2 mg .........................51
risperidone tab 3 mg .........................51
risperidone tab 4 mg .........................52
RITUXAN INJ 100MG .........................20
RITUXAN INJ 500MG .........................20
rivastigmine tartrate cap 1.5 mg .........43
rivastigmine tartrate cap 3 mg ...........43
rivastigmine tartrate cap 4.5 mg .........43
rivastigmine tartrate cap 6 mg ........... 43
rivastigmine td patch 24hr 13.3 mg/24hr
...................................................... 43
rivastigmine td patch 24hr 4.6 mg/24hr
...................................................... 43
rivastigmine td patch 24hr 9.5 mg/24hr
...................................................... 43
rizatriptan benzoate oral disintegrating
tab 10 mg (base eq) ......................... 54
rizatriptan benzoate oral disintegrating
tab 5 mg (base eq)........................... 54
rizatriptan benzoate tab 10 mg (base
equivalent) ...................................... 54
rizatriptan benzoate tab 5 mg (base
equivalent) ...................................... 54
ropinirole hydrochloride tab 0.25 mg .. 48
ropinirole hydrochloride tab 0.5 mg .... 48
ropinirole hydrochloride tab 1 mg ....... 48
ropinirole hydrochloride tab 2 mg ....... 48
ropinirole hydrochloride tab 3 mg ....... 48
ropinirole hydrochloride tab 4 mg ....... 48
ropinirole hydrochloride tab 5 mg ....... 48
rosadan cre 0.75% ........................... 93
rosuvastatin calcium tab 10 mg ......... 29
rosuvastatin calcium tab 20 mg ......... 29
rosuvastatin calcium tab 40 mg ......... 29
rosuvastatin calcium tab 5 mg ........... 29
ROTARIX SUS .................................. 80
ROTATEQ SOL.................................. 80
roweepra tab 500mg ........................ 41
ROZEREM TAB 8MG .......................... 53
S
SABRIL POW 500MG ......................... 41
SABRIL TAB 500MG .......................... 41
SANDIMMUNE SOL 100MG/ML ........... 79
SANDOSTATIN KIT LAR 10MG ............ 67
SANDOSTATIN KIT LAR 20MG ............ 67
SANDOSTATIN KIT LAR 30MG ............ 67
SANTYL OIN 250/GM ........................ 93
SAPHRIS SUB 10MG ......................... 52
SAPHRIS SUB 2.5MG ........................ 52
SAPHRIS SUB 5MG ........................... 52
selegiline hcl cap 5 mg ...................... 48
selegiline hcl tab 5 mg ...................... 48
selenium sulfide lotion 2.5% .............. 91
SELZENTRY TAB 150MG ...................... 9
SELZENTRY TAB 300MG ...................... 9
SENSIPAR TAB 30MG ........................ 60
130
SENSIPAR TAB 60MG ........................60
SENSIPAR TAB 90MG ........................60
SEREVENT DIS AER 50MCG ................87
SEROQUEL XR TAB 150MG .................52
SEROQUEL XR TAB 200MG .................52
SEROQUEL XR TAB 300MG .................52
SEROQUEL XR TAB 400MG .................52
SEROQUEL XR TAB 50MG...................52
sertraline hcl oral conc 20 mg/ml ........46
sertraline hcl tab 100 mg ...................46
sertraline hcl tab 25 mg .....................46
sertraline hcl tab 50 mg .....................46
sharobel tab 0.35mg .........................63
SIGNIFOR INJ 0.3MG/ML ...................67
SIGNIFOR INJ 0.6MG/ML ...................67
SIGNIFOR INJ 0.9MG/ML ...................67
sildenafil citrate tab 20 mg .................36
SILENOR TAB 3MG ............................53
SILENOR TAB 6MG ............................53
SILVER SULFADIAZINE CREAM 1% .....90
SIMBRINZA SUS 1-0.2%....................86
simvastatin tab 10 mg .......................29
simvastatin tab 20 mg .......................29
simvastatin tab 40 mg .......................29
simvastatin tab 5 mg.........................29
simvastatin tab 80 mg .......................29
sirolimus tab 0.5 mg .........................79
sirolimus tab 1 mg ............................79
SIROLIMUS TAB 2 MG .......................79
SIRTURO TAB 100MG ........................11
SIVEXTRO INJ 200MG ........................ 7
SIVEXTRO TAB 200MG ....................... 7
SODIUM CHLORIDE INJ 0.45% ...........83
SODIUM CHLORIDE INJ 2.5 MEQ/ML
(14.6%) ..........................................81
SODIUM CHLORIDE INJ 3% ...............83
SODIUM CHLORIDE INJ 5% ...............83
SODIUM CHLORIDE IRRIGATION SOLN
0.9% ...............................................93
SODIUM CHLORIDE IV SOLN 0.9% .....83
SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5
F) MG/ML SOLN ................................81
sodium phenylbutyrate oral powder 3
gm/teaspoonful ................................64
sodium polystyrene sulfonate oral susp 15
gm/60ml .........................................60
sodium polystyrene sulfonate powder ..60
SOLTAMOX SOL 10MG/5ML ................21
SOLU-CORTEF INJ 250MG ................. 66
SOMATULINE INJ 120/.5ML ............... 67
SOMATULINE INJ 60/0.2ML ............... 67
SOMATULINE INJ 90/0.3ML ............... 67
SOMAVERT INJ 10MG ....................... 67
SOMAVERT INJ 15MG ....................... 67
SOMAVERT INJ 20MG ....................... 67
SOMAVERT INJ 25MG ....................... 67
SOMAVERT INJ 30MG ....................... 67
sorine tab 120mg ............................. 28
sorine tab 160mg ............................. 28
sorine tab 240mg ............................. 28
sorine tab 80mg ............................... 28
sotalol hcl (afib/afl) tab 120 mg ......... 28
sotalol hcl (afib/afl) tab 160 mg ......... 28
sotalol hcl (afib/afl) tab 80 mg ........... 28
sotalol hcl tab 120 mg ...................... 28
sotalol hcl tab 160 mg ...................... 29
sotalol hcl tab 240 mg ...................... 29
sotalol hcl tab 80 mg ........................ 28
SOVALDI TAB 400MG ....................... 12
spironolactone & hydrochlorothiazide tab
25-25 mg ........................................ 35
spironolactone tab 100 mg ................ 26
spironolactone tab 25 mg .................. 26
spironolactone tab 50 mg .................. 26
sprintec 28 tab 28 day ...................... 63
SPRITAM TAB 1000MG ...................... 41
SPRITAM TAB 250MG ........................ 41
SPRITAM TAB 500MG ........................ 41
SPRITAM TAB 750MG ........................ 41
SPRYCEL TAB 100MG ........................ 22
SPRYCEL TAB 140MG ........................ 22
SPRYCEL TAB 20MG.......................... 22
SPRYCEL TAB 50MG.......................... 22
SPRYCEL TAB 70MG.......................... 22
SPRYCEL TAB 80MG.......................... 22
sps sus 15gm/60.............................. 60
SSD CRE 1% ................................... 90
stavudine cap 15 mg .......................... 9
stavudine cap 20 mg .......................... 9
stavudine cap 30 mg .......................... 9
stavudine cap 40 mg .......................... 9
stavudine for oral soln 1 mg/ml ........... 9
STIVARGA TAB 40MG ....................... 22
STRATTERA CAP 100MG .................... 53
STRATTERA CAP 10MG...................... 53
STRATTERA CAP 18MG...................... 53
131
STRATTERA CAP 25MG ......................53
STRATTERA CAP 40MG ......................53
STRATTERA CAP 60MG ......................53
STRATTERA CAP 80MG ......................53
streptomycin sulfate for inj 1 gm ......... 5
STRIBILD TAB ..................................10
SUBOXONE MIS 12-3MG ....................57
SUBOXONE MIS 2-0.5MG ...................57
SUBOXONE MIS 4-1MG......................57
SUBOXONE MIS 8-2MG......................57
SUCRAID SOL 8500/ML .....................72
sucralfate tab 1 gm ...........................72
sulfacetamide sodium lotion 10% (acne)
......................................................90
sulfacetamide sodium ophth oint 10% .84
sulfacetamide sodium ophth soln 10% .84
sulfacetamide sodium-prednisolone ophth
soln 10-0.23(0.25)% .........................84
sulfadiazine tab 500mg....................... 5
sulfamethoxazole-trimethoprim iv soln
400-80 mg/5ml ................................. 7
sulfamethoxazole-trimethoprim susp
200-40 mg/5ml ................................. 7
sulfamethoxazole-trimethoprim tab
400-80 mg ........................................ 7
sulfamethoxazole-trimethoprim tab
800-160 mg ...................................... 7
SULFAMYLON CRE 85MG/GM ..............90
SULFAMYLON PAK 5% .......................90
sulfasalazin tab 500mg dr ..................71
sulfasalazine tab 500 mg ...................71
sulindac tab 150 mg ........................... 2
sulindac tab 200 mg ........................... 2
SUMATRIPTAN NASAL SPRAY 20 MG/ACT
......................................................54
SUMATRIPTAN NASAL SPRAY 5 MG/ACT
......................................................54
sumatriptan succinate inj 6 mg/0.5ml .54
sumatriptan succinate solution
auto-injector 4 mg/0.5ml ...................54
sumatriptan succinate solution
auto-injector 6 mg/0.5ml ...................54
SUMATRIPTAN SUCCINATE SOLUTION
CARTRIDGE 4 MG/0.5ML ....................54
SUMATRIPTAN SUCCINATE SOLUTION
CARTRIDGE 6 MG/0.5ML ....................54
sumatriptan succinate solution prefilled
syringe 6 mg/0.5ml ...........................54
sumatriptan succinate tab 100 mg ..... 55
sumatriptan succinate tab 25 mg ....... 54
sumatriptan succinate tab 50 mg ....... 55
SUPRAX CAP 400MG ......................... 13
suprax chw 100mg ........................... 13
suprax chw 200mg ........................... 13
SUPRAX SUS 500/5ML ...................... 13
SUPREP BOWEL SOL PREP ................. 72
SURMONTIL CAP 100MG ................... 46
SURMONTIL CAP 25MG ..................... 46
SURMONTIL CAP 50MG ..................... 46
SUSTIVA CAP 200MG .......................... 9
SUSTIVA CAP 50MG............................ 9
SUSTIVA TAB 600MG .......................... 9
SUTENT CAP 12.5MG ........................ 22
SUTENT CAP 25MG ........................... 22
SUTENT CAP 37.5MG ........................ 22
SUTENT CAP 50MG ........................... 22
SYLATRON KIT 200MCG .................... 23
SYLATRON KIT 300MCG .................... 23
SYLATRON KIT 600MCG .................... 23
SYMBICORT AER 160-4.5 .................. 89
SYMBICORT AER 80-4.5 .................... 89
SYMLINPEN 60 INJ 1000MCG ............. 58
SYMLNPEN 120 INJ 1000MCG ............ 58
SYNAGIS INJ 100MG/ML ................... 80
SYNAGIS INJ 50MG .......................... 80
SYNAREL SOL 2MG/ML ...................... 63
SYNERCID INJ 500MG ......................... 7
SYNRIBO INJ 3.5MG ......................... 23
SYNTHROID TAB 100MCG ................. 68
SYNTHROID TAB 112MCG ................. 68
SYNTHROID TAB 125MCG ................. 68
SYNTHROID TAB 137MCG ................. 68
SYNTHROID TAB 150MCG ................. 68
SYNTHROID TAB 175MCG ................. 68
SYNTHROID TAB 200MCG ................. 68
SYNTHROID TAB 25MCG ................... 68
SYNTHROID TAB 300MCG ................. 68
SYNTHROID TAB 50MCG ................... 68
SYNTHROID TAB 75MCG ................... 68
SYNTHROID TAB 88MCG ................... 68
SYPRINE CAP 250MG ........................ 60
T
TABLOID TAB 40MG ......................... 19
tacrolimus cap 0.5 mg ...................... 79
tacrolimus cap 1 mg ......................... 79
tacrolimus cap 5 mg ......................... 79
132
tacrolimus oint 0.03% .......................93
tacrolimus oint 0.1% .........................93
TAFINLAR CAP 50MG .........................22
TAFINLAR CAP 75MG .........................22
TAGRISSO TAB 40MG ........................22
TAGRISSO TAB 80MG ........................22
TAMIFLU CAP 30MG ..........................12
TAMIFLU CAP 45MG ..........................12
TAMIFLU CAP 75MG ..........................12
TAMIFLU SUS 6MG/ML .......................12
tamoxifen citrate tab 10 mg (base
equivalent) ......................................21
tamoxifen citrate tab 20 mg (base
equivalent) ......................................21
tamsulosin hcl cap 0.4 mg .................73
TARCEVA TAB 100MG ........................22
TARCEVA TAB 150MG ........................22
TARCEVA TAB 25MG ..........................22
TARGRETIN GEL 1% ..........................93
tarina fe tab 1/20 .............................63
TASIGNA CAP 150MG ........................22
TASIGNA CAP 200MG ........................22
tazicef inj 1gm .................................13
tazicef inj 2gm .................................13
tazicef inj 6gm .................................13
TAZORAC CRE 0.05% ........................91
TAZORAC CRE 0.1% ..........................91
taztia xt cap 120mg/24 .....................33
taztia xt cap 180mg/24 .....................33
taztia xt cap 240mg/24 .....................33
taztia xt cap 300mg/24 .....................33
taztia xt cap 360mg/24 .....................33
TECENTRIQ INJ 1200/20 ....................20
TEFLARO INJ 400MG .........................13
TEFLARO INJ 600MG .........................14
TEGRETOL SUS 100/5ML ...................41
TEGRETOL TAB 200MG ......................41
TEGRETOL-XR TAB 100MG .................41
TEGRETOL-XR TAB 200MG .................41
TEGRETOL-XR TAB 400MG .................41
TEKTURNA HCT TAB 150-12.5 ............34
TEKTURNA HCT TAB 150-25MG ..........34
TEKTURNA HCT TAB 300-12.5 ............34
TEKTURNA HCT TAB 300-25MG ..........34
TEKTURNA TAB 150MG ......................34
TEKTURNA TAB 300MG ......................34
temazepam cap 15 mg ......................54
temazepam cap 7.5 mg .....................54
TENIVAC INJ 5-2LF ........................... 80
terazosin hcl cap 1 mg ...................... 26
terazosin hcl cap 10 mg .................... 26
terazosin hcl cap 2 mg ...................... 26
terazosin hcl cap 5 mg ...................... 26
terbinafine hcl tab 250 mg .................. 8
terbutaline sulfate inj 1 mg/ml ........... 87
terbutaline sulfate tab 2.5 mg ............ 87
terbutaline sulfate tab 5 mg .............. 87
terconazole vaginal cream 0.4% ........ 74
terconazole vaginal cream 0.8% ........ 74
TERCONAZOLE VAGINAL CREAM 0.8% 74
terconazole vaginal suppos 80 mg ...... 74
testosterone cypionate im inj in oil 100
mg/ml ............................................ 57
testosterone cypionate im inj in oil 200
mg/ml ............................................ 57
testosterone enanthate im inj in oil 200
mg/ml ............................................ 57
TET/DIP TOX INJ 2-2 LF .................... 80
tetrabenazine tab 12.5 mg ................ 55
tetrabenazine tab 25 mg ................... 55
texacort sol 2.5% ............................. 92
THALOMID CAP 100MG ..................... 78
THALOMID CAP 150MG ..................... 78
THALOMID CAP 200MG ..................... 78
THALOMID CAP 50MG ....................... 78
theo-24 cap 100mg cr ...................... 89
theo-24 cap 200mg cr ...................... 89
theo-24 cap 300mg cr ...................... 89
theo-24 cap 400mg er ...................... 89
theophylline soln 80 mg/15ml ............ 89
theophylline tab sr 12hr 100 mg ........ 89
theophylline tab sr 12hr 200 mg ........ 89
theophylline tab sr 12hr 300 mg ........ 89
theophylline tab sr 12hr 450 mg ........ 89
theophylline tab sr 24hr 400 mg ........ 89
theophylline tab sr 24hr 600 mg ........ 89
thioridazine hcl tab 10 mg ................. 52
thioridazine hcl tab 100 mg ............... 52
thioridazine hcl tab 25 mg ................. 52
thioridazine hcl tab 50 mg ................. 52
thiothixene cap 1 mg ........................ 52
thiothixene cap 10 mg ...................... 52
thiothixene cap 2 mg ........................ 52
thiothixene cap 5 mg ........................ 52
tiagabine hcl tab 2 mg ...................... 41
tiagabine hcl tab 4 mg ...................... 41
133
TIKOSYN CAP 125MCG ......................29
TIKOSYN CAP 250MCG ......................29
TIKOSYN CAP 500MCG ......................29
TIMOLOL MALEATE OPHTH GEL FORMING
SOLN 0.25% ....................................86
TIMOLOL MALEATE OPHTH GEL FORMING
SOLN 0.5% ......................................86
timolol maleate ophth soln 0.25% .......86
timolol maleate ophth soln 0.5% ........86
timolol maleate tab 10 mg .................32
timolol maleate tab 20 mg .................32
timolol maleate tab 5 mg ...................32
TIVICAY TAB 10MG ............................ 9
TIVICAY TAB 25MG ............................ 9
TIVICAY TAB 50MG ............................ 9
tizanidine hcl tab 2 mg (base equivalent)
......................................................56
tizanidine hcl tab 4 mg (base equivalent)
......................................................56
TOBRADEX OIN 0.3-0.1% ..................84
TOBRADEX ST SUS 0.3-0.05 ..............84
tobramycin nebu soln 300 mg/5ml ....... 5
tobramycin ophth soln 0.3% ..............84
tobramycin sulfate for inj 1.2 gm ......... 5
tobramycin sulfate inj 1.2 gm/30ml (40
mg/ml) (base equiv) .......................... 5
tobramycin sulfate inj 10 mg/ml (base
equivalent) ....................................... 5
tobramycin sulfate inj 2 gm/50ml (40
mg/ml) (base equiv) .......................... 5
tobramycin sulfate inj 80 mg/2ml (40
mg/ml) (base equiv) .......................... 5
tobramycin-dexamethasone ophth susp
0.3-0.1% .........................................84
TOBREX OIN 0.3% OP .......................84
tolterodine tartrate cap sr 24hr 2 mg ..74
tolterodine tartrate cap sr 24hr 4 mg ..74
tolterodine tartrate tab 1 mg ..............74
tolterodine tartrate tab 2 mg ..............74
topiramate sprinkle cap 15 mg ...........42
topiramate sprinkle cap 25 mg ...........42
topiramate tab 100 mg ......................42
topiramate tab 200 mg ......................42
topiramate tab 25 mg........................42
topiramate tab 50 mg........................42
toposar inj 1gm/50ml ........................24
topotecan hcl for inj 4 mg ..................24
torsemide inj 50mg/5ml ....................35
torsemide tab 10 mg ........................ 35
torsemide tab 100 mg ...................... 35
torsemide tab 20 mg ........................ 35
torsemide tab 5 mg .......................... 35
TOUJEO SOLO INJ 300IU/ML ............. 58
TOVIAZ TAB 4MG ............................. 74
TOVIAZ TAB 8MG ............................. 74
TPN ELECTROL INJ ........................... 81
TRACLEER TAB 125MG ...................... 36
TRACLEER TAB 62.5MG ..................... 36
TRADJENTA TAB 5MG ....................... 59
tramadol hcl tab 50 mg ....................... 2
tramadol-acetaminophen tab 37.5-325
mg ................................................... 2
trandolapril tab 1 mg ........................ 26
trandolapril tab 2 mg ........................ 26
trandolapril tab 4 mg ........................ 26
tranexamic acid iv soln 1000 mg/10ml
(100 mg/ml).................................... 76
tranexamic acid tab 650 mg .............. 76
TRANSDERM-SC DIS 1MG ................. 70
tranylcypromine sulfate tab 10 mg ..... 46
TRAVASOL INJ 10%.......................... 82
TRAVATAN Z DRO 0.004% ................ 86
trazodone hcl tab 100 mg ................. 46
trazodone hcl tab 150 mg ................. 46
trazodone hcl tab 50 mg ................... 46
TREANDA INJ 100MG ........................ 17
TREANDA INJ 180/2ML ..................... 17
TREANDA INJ 25MG .......................... 17
TREANDA INJ 45/0.5ML .................... 17
TRECATOR TAB 250MG ..................... 11
TRELSTAR MIX INJ 11.25MG .............. 21
TRELSTAR MIX INJ 3.75MG ............... 21
TRESIBA FLEX INJ 100UNIT ............... 58
TRESIBA FLEX INJ 200UNIT ............... 58
tretinoin cap 10 mg .......................... 23
tretinoin cream 0.025% .................... 90
tretinoin cream 0.05% ...................... 90
tretinoin cream 0.1% ........................ 90
TRETINOIN GEL 0.01% ..................... 90
tretinoin gel 0.025% ......................... 90
triamcinolone acetonide cream 0.025%
...................................................... 92
triamcinolone acetonide cream 0.1% .. 92
triamcinolone acetonide cream 0.5% .. 92
triamcinolone acetonide dental paste
0.1% .............................................. 94
134
triamcinolone acetonide lotion 0.025% 92
triamcinolone acetonide lotion 0.1% ....92
triamcinolone acetonide oint 0.025%...93
triamcinolone acetonide oint 0.1% ......93
triamcinolone acetonide oint 0.5% ......93
triamterene & hydrochlorothiazide cap
37.5-25 mg ......................................35
triamterene & hydrochlorothiazide tab
37.5-25 mg ......................................35
triamterene & hydrochlorothiazide tab
75-50 mg ........................................35
TRIBENZOR20- TAB 5-12.5MG............27
TRIBENZOR40- TAB 10-12.5 ..............27
TRIBENZOR40- TAB 10-25MG.............27
TRIBENZOR40- TAB 5-12.5MG............27
TRIBENZOR40- TAB 5-25MG ..............27
triderm cre 0.1% ..............................93
trifluoperazine hcl tab 1 mg................52
trifluoperazine hcl tab 10 mg ..............52
trifluoperazine hcl tab 2 mg................52
trifluoperazine hcl tab 5 mg................52
trifluridine ophth soln 1% ..................84
trihexyphenidyl hcl elixir 0.4 mg/ml ....48
trihexyphenidyl hcl tab 2 mg ..............48
trihexyphenidyl hcl tab 5 mg ..............48
tri-legest tab fe ................................63
trilyte sol .........................................72
trimethoprim tab 100 mg .................... 7
trimipramine maleate cap 100 mg.......46
trimipramine maleate cap 25 mg ........46
trimipramine maleate cap 50 mg ........46
TRINESSA TAB .................................63
TRINTELLIX TAB 10MG ......................46
TRINTELLIX TAB 20MG ......................46
TRINTELLIX TAB 5MG ........................46
tri-previfem tab ................................63
TRISENOX SOL 10MG/10M .................23
tri-sprintec tab .................................63
TRIUMEQ TAB...................................10
trivora-28 tab ...................................63
TROPHAMINE INJ 10% ......................82
trospium chloride tab 20 mg ..............74
TRUE METRIX KIT AIR .......................94
TRUE METRIX KIT METER ...................94
TRUE METRIX TES.............................94
TRULICITY INJ 0.75/0.5 .....................58
TRULICITY INJ 1.5/0.5 ......................58
TRUMENBA INJ .................................80
TRUVADA TAB 100-150 ..................... 10
TRUVADA TAB 133-200 ..................... 10
TRUVADA TAB 167-250 ..................... 10
TRUVADA TAB 200-300 ..................... 10
TWINRIX INJ ................................... 80
TYBOST TAB 150MG ........................... 9
TYGACIL INJ 50MG ............................. 7
TYKERB TAB 250MG ......................... 22
TYPHIM VI INJ ................................. 80
TYSABRI INJ 300/15ML ..................... 55
TYZEKA TAB 600MG ......................... 12
U
UCERIS TAB 9MG ............................. 71
ULORIC TAB 40MG ............................. 1
ULORIC TAB 80MG ............................. 1
UNITHROID TAB 100MCG .................. 68
UNITHROID TAB 112MCG .................. 68
UNITHROID TAB 125MCG .................. 68
UNITHROID TAB 150MCG .................. 68
UNITHROID TAB 175MCG .................. 68
UNITHROID TAB 200MCG .................. 68
UNITHROID TAB 25MCG.................... 68
UNITHROID TAB 300MCG .................. 69
UNITHROID TAB 50MCG.................... 68
UNITHROID TAB 75MCG.................... 68
UNITHROID TAB 88MCG.................... 68
UPTRAVI TAB 1000MCG .................... 37
UPTRAVI TAB 1200MCG .................... 37
UPTRAVI TAB 1400MCG .................... 37
UPTRAVI TAB 1600MCG .................... 37
UPTRAVI TAB 200/800 ...................... 36
UPTRAVI TAB 200MCG ...................... 37
UPTRAVI TAB 400MCG ...................... 37
UPTRAVI TAB 600MCG ...................... 37
UPTRAVI TAB 800MCG ...................... 37
ursodiol cap 300 mg ......................... 72
ursodiol tab 250 mg ......................... 72
ursodiol tab 500 mg ......................... 72
V
VAGIFEM TAB 10MCG ....................... 64
valacyclovir hcl tab 1 gm ................... 12
valacyclovir hcl tab 500 mg ............... 12
VALCHLOR GEL 0.016% .................... 93
VALCYTE SOL 50MG/ML .................... 12
valganciclovir hcl tab 450 mg (base
equivalent) ...................................... 12
valproate sodium inj 100 mg/ml ........ 42
valproate sodium syrup 250 mg/5ml
135
(base equiv) .....................................42
valproic acid cap 250 mg ...................42
valsartan tab 160 mg ........................27
valsartan tab 320 mg ........................27
valsartan tab 40 mg ..........................27
valsartan tab 80 mg ..........................27
valsartan-hydrochlorothiazide tab
160-12.5 mg ....................................27
valsartan-hydrochlorothiazide tab 160-25
mg ..................................................27
valsartan-hydrochlorothiazide tab
320-12.5 mg ....................................27
valsartan-hydrochlorothiazide tab 320-25
mg ..................................................27
valsartan-hydrochlorothiazide tab
80-12.5 mg ......................................27
vancomycin hcl cap 125 mg ................ 7
vancomycin hcl cap 250 mg ................ 7
vancomycin hcl for inj 10 gm............... 7
vancomycin hcl for inj 1000 mg ........... 7
vancomycin hcl for inj 500 mg ............. 7
vancomycin hcl for inj 5000 mg ........... 7
VANCOMYCIN INJ 1 GM ...................... 7
VANCOMYCIN INJ 500MG .................... 7
vancomycin inj 750mg........................ 7
VANCOMYCIN INJ 750MG .................... 7
VANDAZOLE GEL 0.75% ....................74
VAQTA INJ 25/0.5ML .........................80
VAQTA INJ 50UNT/ML ........................80
VARIVAX INJ ....................................80
VASCEPA CAP 1GM ...........................30
VELCADE INJ 3.5MG ..........................20
velivet pak .......................................63
VENCLEXTA TAB 100MG ....................20
VENCLEXTA TAB 10MG ......................20
VENCLEXTA TAB 50MG ......................20
VENCLEXTA TAB START PK ................20
venlafaxine hcl cap sr 24hr 150 mg (base
equivalent) ......................................46
venlafaxine hcl cap sr 24hr 37.5 mg (base
equivalent) ......................................46
venlafaxine hcl cap sr 24hr 75 mg (base
equivalent) ......................................46
venlafaxine hcl tab 100 mg ................46
venlafaxine hcl tab 25 mg ..................46
venlafaxine hcl tab 37.5 mg ...............46
venlafaxine hcl tab 50 mg ..................46
venlafaxine hcl tab 75 mg ..................46
VENTOLIN HFA AER .......................... 87
verapamil hcl cap sr 24hr 100 mg ...... 33
verapamil hcl cap sr 24hr 120 mg ...... 33
verapamil hcl cap sr 24hr 180 mg ...... 33
verapamil hcl cap sr 24hr 200 mg ...... 33
verapamil hcl cap sr 24hr 240 mg ...... 33
verapamil hcl cap sr 24hr 300 mg ...... 33
VERAPAMIL HCL CAP SR 24HR 360 MG 33
verapamil hcl iv soln 2.5 mg/ml ......... 33
verapamil hcl tab 120 mg .................. 33
verapamil hcl tab 40 mg ................... 33
verapamil hcl tab 80 mg ................... 33
verapamil hcl tab cr 120 mg .............. 33
verapamil hcl tab cr 180 mg .............. 33
verapamil hcl tab cr 240 mg .............. 33
VERSACLOZ SUS 50MG/ML ................ 52
VESICARE TAB 10MG ........................ 74
VESICARE TAB 5MG.......................... 74
VICTOZA INJ 18MG/3ML ................... 58
VIDEX SOL 2GM ................................. 9
VIDEX SOL 4GM ................................. 9
vienva tab 0.1-20 ............................. 63
VIGAMOX DRO 0.5% ........................ 84
VIIBRYD KIT .................................... 46
VIIBRYD KIT STARTER ...................... 46
VIIBRYD TAB 10MG .......................... 46
VIIBRYD TAB 20MG .......................... 47
VIIBRYD TAB 40MG .......................... 47
VIMPAT INJ 200MG/20 ...................... 42
VIMPAT SOL 10MG/ML ...................... 42
VIMPAT TAB 100MG.......................... 42
VIMPAT TAB 150MG.......................... 42
VIMPAT TAB 200MG.......................... 42
VIMPAT TAB 50MG ........................... 42
vinblastine sulfate inj 1 mg/ml ........... 19
vincasar pfs inj 1mg/ml .................... 19
vincristine sulfate iv soln 1 mg/ml ...... 19
vinorelbine tartrate inj 10 mg/ml (base
equiv) ............................................. 19
vinorelbine tartrate inj 50 mg/5ml (10
mg/ml) (base equiv)......................... 19
viorele tab ....................................... 63
VIRACEPT TAB 250MG ........................ 9
VIRACEPT TAB 625MG ........................ 9
VIRAMUNE XR TAB 100MG .................. 9
VIREAD POW 40MG/GM .................... 10
VIREAD TAB 150MG ......................... 10
VIREAD TAB 200MG ......................... 10
136
VIREAD TAB 250MG ..........................10
VIREAD TAB 300MG ..........................10
VITEKTA TAB 150MG .........................10
VITEKTA TAB 85MG ...........................10
VOLTAREN GEL 1% ...........................93
voriconazole for inj 200 mg ................. 8
voriconazole for susp 40 mg/ml ........... 8
voriconazole tab 200 mg ..................... 8
voriconazole tab 50 mg ...................... 8
VOTRIENT TAB 200MG ......................22
VRAYLAR CAP 1.5-3MG ......................52
VRAYLAR CAP 1.5MG .........................52
VRAYLAR CAP 3MG ............................52
VRAYLAR CAP 4.5MG .........................52
VRAYLAR CAP 6MG ............................52
vyfemla tab 0.4-35 ...........................63
W
warfarin sodium tab 1 mg ..................75
warfarin sodium tab 10 mg ................75
warfarin sodium tab 2 mg ..................75
warfarin sodium tab 2.5 mg ...............75
warfarin sodium tab 3 mg ..................75
warfarin sodium tab 4 mg ..................75
warfarin sodium tab 5 mg ..................75
warfarin sodium tab 6 mg ..................75
warfarin sodium tab 7.5 mg ...............75
WATER FOR IRRIGATION, STERILE
IRRIGATION SOLN ............................93
WELCHOL PAK 3.75GM ......................30
WELCHOL TAB 625MG .......................30
X
XALKORI CAP 200MG ........................22
XALKORI CAP 250MG ........................22
XARELTO STAR TAB 15/20MG.............75
XARELTO TAB 10MG ..........................75
XARELTO TAB 15MG ..........................75
XARELTO TAB 20MG ..........................75
XGEVA INJ .......................................67
XIFAXAN TAB 550MG ........................72
XIGDUO XR TAB 10-1000 ..................59
XIGDUO XR TAB 10-500MG ................59
XIGDUO XR TAB 5-1000MG ................59
XIGDUO XR TAB 5-500MG .................59
XOLAIR SOL 150MG ..........................88
XOPENEX HFA AER ............................87
XTANDI CAP 40MG ............................21
XYREM SOL 500MG/ML ......................56
Y
YERVOY INJ 200MG .......................... 20
YERVOY INJ 50MG ............................ 20
YF-VAX INJ ...................................... 80
Z
zafirlukast tab 10 mg ........................ 88
zafirlukast tab 20 mg ........................ 88
zarah tab 3-0.03mg.......................... 63
ZAVESCA CAP 100MG ....................... 64
ZELBORAF TAB 240MG...................... 22
ZEMAIRA INJ 1000MG ....................... 88
zenatane cap 10mg .......................... 90
zenatane cap 20mg .......................... 90
zenatane cap 30mg .......................... 90
zenatane cap 40mg .......................... 90
zenchent tab ................................... 63
ZENPEP CAP 10000UNT..................... 72
ZENPEP CAP 15000UNT..................... 72
ZENPEP CAP 20000UNT..................... 72
ZENPEP CAP 25000UNT..................... 73
ZENPEP CAP 3000UNIT ..................... 72
ZENPEP CAP 40000UNT..................... 73
ZENPEP CAP 5000UNIT ..................... 72
ZETIA TAB 10MG.............................. 30
ZIAGEN SOL 20MG/ML ...................... 10
zidovudine cap 100 mg ..................... 10
zidovudine syrup 10 mg/ml ............... 10
zidovudine tab 300 mg ..................... 10
ziprasidone hcl cap 20 mg ................. 52
ziprasidone hcl cap 40 mg ................. 52
ziprasidone hcl cap 60 mg ................. 52
ziprasidone hcl cap 80 mg ................. 52
ZIRGAN GEL 0.15% .......................... 84
zoledronic acid inj conc for iv infusion 4
mg/5ml ........................................... 60
zoledronic acid iv soln 5 mg/100ml..... 60
ZOLINZA CAP 100MG........................ 20
zolmitriptan orally disintegrating tab 2.5
mg ................................................. 55
zolmitriptan orally disintegrating tab 5 mg
...................................................... 55
zolmitriptan tab 2.5 mg .................... 55
zolmitriptan tab 5 mg ....................... 55
zolpidem tartrate tab 10 mg .............. 54
zolpidem tartrate tab 5 mg ................ 54
zonisamide cap 100 mg .................... 42
zonisamide cap 25 mg ...................... 42
zonisamide cap 50 mg ...................... 42
137
ZONTIVITY TAB 2.08MG ....................76
ZORTRESS TAB 0.25MG .....................79
ZORTRESS TAB 0.5MG ......................79
ZORTRESS TAB 0.75MG .....................79
ZOSTAVAX INJ .................................80
zovia 1/35e tab ................................63
zovia 1/50e tab ................................63
ZYDELIG TAB 100MG.........................22
ZYDELIG TAB 150MG ........................ 22
ZYKADIA CAP 150MG ........................ 22
ZYLET SUS 0.5-0.3% ........................ 84
ZYPREXA RELP INJ 210MG................. 52
ZYPREXA RELP INJ 300MG................. 52
ZYPREXA RELP INJ 405MG................. 52
ZYTIGA TAB 250MG .......................... 21
ZYVOX TAB 600MG ............................. 7
138
Molina Medicare Options Plus/Molina Medicare Choice HMO SNP is a Health Plan with
a Medicare Contract and a contract with the state Medicaid program. Enrollment in
Molina Medicare Options Plus/Molina Medicare Choice depends on contract renewal.
Molina Medicare Options HMO is a Health Plan with a Medicare Contract. Enrollment in
Molina Medicare Options depends on contract renewal.
This information is available in other formats such as Braille, large print and audio.
This information is available for free in other languages. Please call our customer service
number at (888) 665-1328, TTY/TDD 711, 7 days a week, 8 a.m. - 8 p.m., local time.
Esta información está disponible gratuitamente en otros idiomas. Por favor, comuníquese
a nuestro número de teléfono para servicio al cliente al (888) 665-1328, TTY/TDD 711,
los 7 días de la semana, de 8 a.m. a 8 p.m., hora local.
Molina Medicare Options Plus/Molina Medicare Choice HMO SNP es un plan de salud
con un contrato con Medicare y un contrato con el programa estatal de Medicaid. La
inscripción en Molina Medicare Options Plus/Molina Medicare Choice depende de la
renovación del contrato.
Molina Medicare Options HMO es un plan de salud con un contrato con Medicare. La
inscripción en Molina Medicare Options depende de la renovación del contrato.
Esta información está disponible en otros formatos, que incluyen Braille, letra grande y
audio.
xvi
This formulary was updated on 11/2016. For more recent information or other questions,
please contact us, Molina Medicare Options Plus/Molina Medicare Options/ Molina
Medicare Choice Member Services, at (888) 665-1328 or, for TTY users, 711, 7 days a
week, 8 a.m. – 8 p.m., local time, or visit www.molinahealthcare.com/medicare.
Este formulario se actualizó en 11/2016. Para obtener información más reciente o si tiene
otras preguntas, por favor comuníquese con nosotros al Departamento de Servicios para
Miembros de, Molina Medicare Options Plus/Molina Medicare Options/ Molina
Medicare Choice, al (888) 665-1328, los usuarios del servicio TTY llamen al 711, los 7
días de la semana de 8:00 a.m. a 8:00 p.m., hora local. O bien, visite
www.molinahealthcare.com/medicare.
xvii
xviii
Member Services (888) 665-1328, TTY/TDD 711
7 days a week, 8 a.m. - 8 p.m. local time
Departamento de Servicios para Miembros (888) 665-1328, TTY/TDD 711
Los 7 días de la semana, de 8:00 a.m. a 8:00 p.m., hora local
HPMS Approved Formulary File Submission 00016109,
xix Version 16