Health Insurance Marketplace 5 Tier Drug List

October 2017
Health Insurance Marketplace 5 Tier Drug List
Please consider talking to your doctor about prescribing preferred medications, which
may help reduce your out-of-pocket costs. This list may help guide you and your doctor in
selecting an appropriate medication for you. The drug list is regularly updated. Please
visit bcbsil.com for the most up-to-date information.
To find a contracting pharmacy, please access the link below:

https://www.myprime.com/en/find-pharmacy.html
Contents Therapeutic Class Drug List

Introduction ...................................................................... I Anti-Infective Agents ....................................................... 1
How drugs are selected ................................................... I Biologicals ..................................................................... 12
How member payment is determined .............................. I Antineoplastic Agents ................................................... 14
How to use this list .......................................................... II Endocrine and Metabolic Drugs ................................... 20
Drugs used to treat multiple conditions .......................... II Cardiovascular Agents .................................................. 37
Generic drugs ................................................................. II Respiratory Agents ....................................................... 51
Consider talking to your doctor about generic Gastrointestinal Agents ................................................. 56
drugs ........................................................................... II Genitourinary Agents .................................................... 62
Coverage considerations ............................................... III Central Nervous System Drugs .................................... 64
Specialty drugs ............................................................... V Analgesics and Anesthetics .......................................... 80
Prime Specialty by AllianceRx Walgreens Neuromuscular Drugs ................................................. 91
Prime........................................................................... V Nutritional Products .................................................... 99
Abbreviation key ............................................................ VI Hematological Agents ................................................. 125
Topical Products ......................................................... 134
Miscellaneous Products .............................................. 146
Index ........................................................................... 150
To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or
go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking
for and click on Search.
2656-G IL HIM Prime Therapeutics LLC 10/17

Introduction
Members are encouraged to show this list to their physicians and pharmacists. Physicians are
encouraged to prescribe drugs on this list, when right for the member. However decisions regarding
therapy and treatment are always between members and their physician.
Drug list updates This list is regularly updated as generic drugs become available and changes take place in
the pharmaceuticals market. For the most up-to-date information, visit bcbsil.com and log in to
Blue Access for MembersSM or call the number on the back of your ID card. Physicians can access the list from
the provider portal at bcbsil.com.
How drugs are selected

Drugs on this list are selected based on the recommendations of a committee made up of physicians and
pharmacists from throughout the country. The committee, which includes at least one representative from BCBSIL,
reviews drugs regulated by the U.S. Food and Drug Administration (FDA).
Both drugs that are newly approved by the FDA as well as those that have been on the market for some time are
considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on
the list.
How member payment is determined

This list shows prescription drug products in tiers. Generally, each drug is placed into one of five member
payment tiers: Preferred Generic (Tier 1), Non-Preferred Generic (Tier 2), Preferred Brand (Tier 3),
Non-Preferred Brand (Tier 4) and Specialty (Tier 5). Please refer to the ACA Preventive (ACA) section for drugs
marked with an "A" in the drug tier column. To verify your payment amount for a drug, visit bcbsil.com and log in
to Blue Access for Members or call the number on the back of your ID card.
Your pharmacy benefit includes coverage for many prescription drugs, although some exclusions may apply.
Generally, if a drug is not listed on the formulary it is not covered. For example, drugs indicated for cosmetic
purposes, e.g., Propecia, for hair growth, may not be covered. Drugs that are not FDA-approved for self-
administration may be available through your medical benefit.
BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 I

How to use this list
Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand
drug in (parentheses). Some generic products have no reference brand.
Example: atorvastatin (Lipitor brand is NF)
Brand prescription drugs are shown in capital letters followed by the generic name.
Drugs used to treat multiple conditions
Some drugs in the same dosage form may be used to treat more than one medical condition. In these instances,
each medication is classified according to its first FDA-approved use. Please check the index if you do not find
your particular medication in the class/condition section that corresponds to your use.
Generic drugs
Using generic drugs, when right for you, can help you save on your out-of-pocket medication costs. Generic drugs
must be approved by the FDA just as brand drugs are, and must meet the same standards.
There are two types of generic drugs:

A generic equivalent is made with the same active ingredient(s) at the same dosage as the reference drug.
A generic alternative is a drug typically used to treat the same condition, but the active ingredient(s)
differs from the brand drug.
According to the FDA, compared to its brand counterpart, an FDA-approved generic drug:
Is chemically the same
Works just as well in the body
Is as safe and effective
Meets the same standards set by the FDA
The main difference between the reference brand drug and the generic equivalent is that the generic often costs
much less.
Preferred brand drugs typically move to a non-preferred brand tier after a generic equivalent becomes available.
You may be responsible for the brand member payment amount plus the difference in cost between the brand
and generic equivalent if you or your doctor requests the reference brand rather than the generic. Generic drugs
have the lowest member payment amount.
Consider talking to your doctor about generic drugs
If your doctor writes a prescription for a brand drug that does not have a generic equivalent, consider asking if an
appropriate generic alternative is available.
You can also let your pharmacist know that you would like a generic equivalent for a brand drug, whenever one is
available. Your pharmacist can usually substitute a generic equivalent for its brand counterpart without a new
prescription from your doctor.
Only your doctor can determine whether a generic alternative is right for you and must prescribe the medication.
BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 II

Coverage considerations
Most prescription drug benefit plans provide coverage for up to a 30-day supply of medication, with some
exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications.
Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood
pressure, diabetes or high cholesterol.
Over-the-counter exclusions: Your benefit plan does not provide coverage for prescription medications that
have an over-the-counter version. You should refer to your benefit plan materials for details about your particular
benefits.
Compounded medications: Your benefit plan does not provide coverage for compounded medications. Please
see your plan materials or call the number on the back of your ID card to determine whether compounded
medications are covered and/or verify your payment amount.
Repackaged medications: Repackaged versions of medications already available on the market are not covered.
Prior Authorization (PA): Your benefit plan may require prior authorization for certain drugs. This means that
your doctor will need to submit a prior authorization request for coverage of these medications, and the request
will need to be approved, before the medication will be covered under your plan. For the preferred medications
listed in this document, if a prior authorization is commonly required, it will be noted next to the medication with a
dot under the prior authorization column. Some plans may have prior authorization on additional medications
beyond those noted in this document.
Step Therapy (ST): Your benefit plan may include a step therapy program. This means you may need to try
another proven, cost-effective medication before coverage may be available for the drug included in the program.
Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. For the
preferred medications listed in this document, if a step therapy is commonly required it will generally be noted
next to the medication with a dot under the step therapy column. Some plans may have step therapy programs on
additional medications beyond those noted in this document.
Dispensing Limits (DL): Drug Dispensing limits are designed to help encourage medication use as intended by
the FDA. Coverage limits are placed on medications in certain drug categories. For the preferred medications
listed in this document, if a dispensing limit applies, it will generally be noted next to the medication with a dot
under the dispensing limits column. Limits may include: quantity of covered medication per prescription, quantity
of covered medication in a given time period, coverage only for members within a certain age range, and
coverage only for members of a specific gender. If your doctor prescribes a greater quantity of medication than
what the dispensing limit allows, you can still get the medication. However, you will be responsible for the full cost
of the prescription beyond what your coverage allows.* For a list of medications and their dispensing limits, visit
bcbsil.com.
*Please note: For certain controlled substance medications, some state laws may not allow coverage by a health
benefit plan of such medication if dispensed in a quantity beyond what the dispensing limit allows. You will be
responsible for the full cost of the prescription with no benefits applied if the dispensed quantity exceeds the
dispensing limit.
Limited Distribution (LD): Medicines marked as "Limited Distribution" have restrictions on where you may obtain
a medication. This may include requiring the use of a designated pharmacy to fill a prescription.
BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 III
ACA Preventive (ACA): Medicines marked in the ACA column are under the Affordable Care Act coverage of
preventive services. These products have limited or $0 member cost-sharing (copay or co-insurance), when
meeting the conditions as outlined under the regulation. These are also indicated with an "A" in the drug tier
column. Examples of these drug categories include aspirin, breast cancer preventive, fluoride supplements, folic
acid supplements, gonorrhea prophylaxis (newborn), iron supplements, tobacco cessation, vaccines, vitamin D
supplements, and some FDA approved contraceptive methods. To see what contraceptive products may be
covered, visit www.bcbsil.com/PDF/rx/contraceptive-list-il.pdf.
Remember, medication decisions are between you and your doctor. Only you and your doctor can determine
which medication is right for you. Discuss any questions or concerns you have about medications you are taking
or are prescribed with your doctor. BCBSIL does not provide health care services and, therefore, cannot
guarantee any results or outcomes.
BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 IV

Specialty drugs
Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis
and rheumatoid arthritis. Specialty drugs may be oral, topical, or injectable medications that can either be self-
administered or administered by a health care professional. For a current list of specialty medications,
visit myprime.com or bcbsil.com and log in to Blue Access for Members.
Note that some drug classes may be excluded by some plans and therefore may not be covered under your
pharmacy benefit. Your plan may have a different coverage level for self-administered specialty drugs. If you
have questions about your coverage for specialty medications or your prescription drug benefit, call the
number on the back of your ID card.
Prime Specialty by AllianceRx Walgreens Prime
Through Prime Specialty by AllianceRx Walgreens Prime, members can have covered specialty medications
delivered directly to them or their doctors office. When you receive specialty medications through Prime Specialty
by AllianceRx Walgreens Prime, you also receive at no additional charge the following services:
Coordination of coverage between you, your doctor and your health plan
Educational materials about your particular condition and information about managing potential
medication side effects
Syringes, sharps containers and other supplies with every shipment for self-injectables
24/7/365 phone access to a pharmacist for urgent medication issues
To order through Prime Specialty by AllianceRx Walgreens Prime:
Have your doctor call or fax your prescription to Prime Specialty by AllianceRx Walgreens Prime. Your
doctor can call 877-627-6337 or fax to 877-828-3939.
If you have an existing prescription for a covered specialty medication, you can call 877-627-6337 to
transfer your prescription.
A coordinator will contact you to arrange delivery of your medication.
The prescription can be shipped directly to you or your prescribing doctors office. Each package is
individually marked for each member. Refrigerated drugs are shipped in temperature-controlled
packaging.
If you have questions, please contact Prime Specialty by AllianceRx Walgreens Prime at 877-627-6337,
visit www.alliancerxwp.com, or call the number on the back of your ID card.
Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC).
HCSC is an independent licensee of the Blue Cross Blue Shield Association. HCSC contracts with Prime Therapeutics to provide
pharmacy benefit management and mail order pharmacy services and to administer this specialty pharmacy program. HCSC, as
well as several other independent Blue Cross and Blue Shield licensees, has an ownership interest in Prime Therapeutics LLC.
BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 V

Abbreviation key
cap ...................................................................... capsules odt ............................................. orally disintegrating tabs

chew .................................................................. chewable oint ..................................................................... ointment
conc ............................................................. concentrate ophth ................................................................. opthalmic
cr .......................................................... controlled release osm .......................................................... osmotic release
dr ............................................................. delayed release powd ..................................................................... powder
ec ................................................................enteric coated sa ............................................................ sustained action
effe................................................................. effervescent sl ...................................................................... sublingual
equiv ................................................................ equivalent soln ....................................................................... solution
er ...........................................................extended release sr .......................................................... sustained release
inhal................................................................... inhalation suppos ........................................................ suppositories
inj ......................................................................... injection susp ................................................................ suspension
liq .............................................................................. liquid tab ...........................................................................tablets
lotn ........................................................................... lotion td ................................................................... transdermal
nebu ................................................................... nebulizer
You, your prescribing health care provider, or your authorized representative, can ask for a Drug List exception if your
drug is not on (or is being removed from) the Drug List (also known as a formulary), or the drug required as part of
step therapy or dispensing limits has been found to be (or likely to be) not right for you or does not work as well in
treating your condition. To request this exception, you, your prescriber, or your authorized representative, can call
the number on the back of your ID card to ask for a review. BCBSIL will let you, your prescriber (or authorized
representative) know the coverage decision within 72 hours after they receive your request. If the coverage request
is denied, BCBSIL will let you and your prescriber (or authorized representative) know why it was denied and offer
you a covered alternative drug (if applicable).
If you have a health condition that may jeopardize your life, health or keep you from regaining function, or your current
drug therapy uses a non-covered drug, you, your prescriber, or your authorized representative, may be able to ask for
an expedited review process. BCBSIL will let you, your prescriber (or authorized representative) know the coverage
decision within 24 hours after they receive your request for an expedited review. If the coverage request is denied,
BCBSIL will let you and your prescriber (or authorized representative) know why it was denied and offer you a
covered alternative drug (if applicable). Call the number on the back of your ID card if you have any questions.
BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 VI

bcbsil.com
Health care coverage is important for everyone.
We provide free communication aids and services for anyone with a disability or who needs language assistance.
We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability.
To receive language or communication assistance free of charge, please call us at 855-710-6984.
If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance.
Office of Civil Rights Coordinator Phone: 855-664-7270 (voicemail)
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U.S. Dept. of Health & Human Services Phone: 800-368-1019
200 Independence Avenue SW TTY/TDD: 800-537-7697
Room 509F, HHH Building 1019 Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Washington, DC 20201 Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html
bcbsil.com
2017
Limited Distribution
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
ANTI-INFECTIVE AGENTS amoxicillin & k clavulanate 2
PENICILLINS tab 875-125 mg
(Augmentin)
AMOXICILLIN - amoxicillin 4
AMOXICILLIN/CLAVULANATE 4
(trihydrate) chew tab 125 mg
P - amoxicillin & k
AMOXICILLIN - amoxicillin 4
clavulanate chew tab
(trihydrate) chew tab 250 mg 200-28.5 mg
amoxicillin (trihydrate) cap 1 4
AMOXICILLIN/CLAVULANATE
250 mg P - amoxicillin & k
amoxicillin (trihydrate) cap 1 clavulanate chew tab 400-57
500 mg mg
amoxicillin (trihydrate) for 1 ampicillin cap 500 mg 1
susp 125 mg/5ml AUGMENTIN - amoxicillin 4
amoxicillin (trihydrate) for 1 & k clavulanate for susp
susp 200 mg/5ml 125-31.25 mg/5ml
amoxicillin (trihydrate) for 1 dicloxacillin sodium cap 1
susp 250 mg/5ml 250 mg
amoxicillin (trihydrate) for 1 dicloxacillin sodium cap 2
amoxicillin (trihydrate) tab 1 MOXATAG - amoxicillin 4
500 mg (trihydrate) tab er 24hr 775
amoxicillin (trihydrate) tab 1 mg
875 mg penicillin v potassium for 1
amoxicillin & k clavulanate 2 soln 125 mg/5ml
for susp 200-28.5 mg/5ml penicillin v potassium for 1
amoxicillin & k clavulanate 2 soln 250 mg/5ml
for susp 250-62.5 mg/5ml penicillin v potassium tab 1
(Augmentin) 250 mg
amoxicillin & k clavulanate 2 penicillin v potassium tab 1
for susp 400-57 mg/5ml 500 mg
amoxicillin & k clavulanate 2 CEPHALOSPORINS
for susp 600-42.9 mg/5ml CEDAX - ceftibuten cap 400 4
(Augmentin es-600) mg
amoxicillin & k clavulanate 2 4
CEDAX - ceftibuten for susp
tab er 12hr 1000-62.5 mg 180 mg/5ml
(Augmentin xr)
CEFACLOR - cefaclor for susp 4
amoxicillin & k clavulanate 2
125 mg/5ml
tab 250-125 mg
amoxicillin & k clavulanate 2
250 mg/5ml
tab 500-125 mg
(Augmentin)
375 mg/5ml
BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 1

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
cefaclor cap 250 mg 2 CEFTIBUTEN - ceftibuten cap 4
cefaclor cap 500 mg 2 400 mg
4 CEFTIBUTEN - ceftibuten for 4
CEFACLOR ER - cefaclor
monohydrate tab er 12hr susp 180 mg/5ml
500 mg CEFTIN - cefuroxime axetil for 3
cefadroxil cap 500 mg 1 susp 125 mg/5ml
2 CEFTIN - cefuroxime axetil for 4
cefadroxil for susp
250 mg/5ml susp 250 mg/5ml
2 cefuroxime axetil tab 250 mg 2
cefadroxil for susp
500 mg/5ml (Ceftin)
2 cefuroxime axetil tab 500 mg 2
cefadroxil tab 1 gm
(Ceftin)
cefdinir cap 300 mg 2
CEPHALEXIN - cephalexin tab 4
cefdinir for susp 125 mg/5ml 2
250 mg
cefdinir for susp 250 mg/5ml 2 4
CEPHALEXIN - cephalexin tab
CEFDITOREN PIVOXIL - 4 500 mg
cefditoren pivoxil tab 200 mg cephalexin cap 250 mg 1
(base equivalent) (Keflex)
CEFDITOREN PIVOXIL - 4 1
cephalexin cap 500 mg
cefditoren pivoxil tab 400 mg (Keflex)
(base equivalent)
cephalexin cap 750 mg 2
cefixime for susp 2
(Keflex)
100 mg/5ml (Suprax)
cephalexin for susp 2
cefixime for susp 2
125 mg/5ml
200 mg/5ml (Suprax)
cephalexin for susp 2
cefpodoxime proxetil for 2
250 mg/5ml
susp 50 mg/5ml
SPECTRACEF - cefditoren 4
cefpodoxime proxetil for 2
pivoxil tab 400 mg (base
susp 100 mg/5ml equivalent)
cefpodoxime proxetil tab 2 4
SUPRAX - cefixime cap 400
100 mg mg
cefpodoxime proxetil tab 2 4
SUPRAX - cefixime chew tab
200 mg 100 mg
cefprozil for susp 2 4
SUPRAX - cefixime chew tab
125 mg/5ml 200 mg
cefprozil for susp 2 4
SUPRAX - cefixime for susp
250 mg/5ml 100 mg/5ml
cefprozil tab 250 mg 2 4
SUPRAX - cefixime for susp
cefprozil tab 500 mg 2 200 mg/5ml

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
SUPRAX - cefixime for susp 4 ERYPED 200 - erythromycin 4
500 mg/5ml ethylsuccinate for susp 200
MACROLIDES mg/5ml
4 ERYPED 400 - erythromycin 4
AZITHROMYCIN -
azithromycin powd pack for ethylsuccinate for susp 400
susp 1 gm mg/5ml
2 ERYTHROCIN STEARATE - 4
azithromycin for susp
100 mg/5ml (Zithromax) erythromycin stearate tab
250 mg
azithromycin for susp 2
ERYTHROMYCIN BASE - 4
200 mg/5ml (Zithromax)
erythromycin tab 250 mg
azithromycin tab 250 mg 1 4
(Zithromax) ERYTHROMYCIN BASE -
erythromycin tab 500 mg
azithromycin tab 500 mg 1 4
(Zithromax) ERYTHROMYCIN
ETHYLSUCCINA -
azithromycin tab 600 mg 2 erythromycin ethylsuccinate
(Zithromax) tab 400 mg
clarithromycin for susp 2
erythromycin ethylsuccinate 2
125 mg/5ml for susp 200 mg/5ml (E.e.s.
clarithromycin for susp 2 granules)
250 mg/5ml (Biaxin) erythromycin w/ delayed 2
clarithromycin tab er 24hr 2 release particles cap
500 mg 250 mg
clarithromycin tab 250 mg 2 PCE - erythromycin w/ enteric 4
(Biaxin) coated particles tab 333 mg
clarithromycin tab 500 mg 2 PCE - erythromycin w/ enteric 4
(Biaxin) coated particles tab 500 mg
DIFICID - fidaxomicin tab 200 4 ZITHROMAX - azithromycin 4
mg powd pack for susp 1 gm
E.E.S. GRANULES - 4 ZMAX - azithromycin extended 4
erythromycin ethylsuccinate release for oral susp 2 gm
for susp 200 mg/5ml TETRACYCLINES
E.E.S. 400 - erythromycin 4 2
demeclocycline hcl tab
ethylsuccinate tab 400 mg 150 mg
ERY-TAB - erythromycin tab 4 2
demeclocycline hcl tab
delayed release 250 mg 300 mg
doxycycline hyclate cap
delayed release 333 mg 50 mg
doxycycline hyclate cap
delayed release 500 mg 100 mg (Vibramycin)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
doxycycline hyclate tab 2 minocycline hcl tab 100 mg 2
20 mg TETRACYCLINE HCL - 4
doxycycline hyclate tab 2 tetracycline hcl cap 250 mg
100 mg TETRACYCLINE HCL - 4
doxycycline monohydrate 2 tetracycline hcl cap 500 mg
cap 50 mg tetracycline hcl cap 250 mg 2
doxycycline monohydrate 2 (Tetracycline hcl)
cap 75 mg (Monodox) tetracycline hcl cap 500 mg 2
doxycycline monohydrate 2 (Tetracycline hcl)
cap 100 mg (Monodox) FLUOROQUINOLONES
doxycycline monohydrate 2 ciprofloxacin for oral 2
cap 150 mg (Adoxa) susp 250 mg/5ml (5%)
doxycycline monohydrate 2 (5 gm/100ml) (Cipro)
for susp 25 mg/5ml ciprofloxacin for oral 2
(Vibramycin) susp 500 mg/5ml (10%)
doxycycline monohydrate 2 (10 gm/100ml) (Cipro)
tab 50 mg (Adoxa) CIPROFLOXACIN HCL - 4
doxycycline monohydrate 2 ciprofloxacin hcl tab 100 mg
tab 75 mg (Adoxa) (base equiv)
doxycycline monohydrate 2 ciprofloxacin hcl tab 250 mg 1
tab 100 mg (Adoxa pak (base equiv) (Cipro)
1/100) ciprofloxacin hcl tab 500 mg 1
doxycycline monohydrate 2 (base equiv) (Cipro)
tab 150 mg (Adoxa pak ciprofloxacin hcl tab 750 mg 1
1/150) (base equiv)
minocycline hcl cap 50 mg 2 2
ciprofloxacin-ciprofloxacin
(Minocin) hcl tab er 24hr 500 mg
minocycline hcl cap 75 mg 2 (base eq) (Cipro xr)
(Minocin) ciprofloxacin-ciprofloxacin 2
minocycline hcl cap 100 mg 2 hcl tab er 24hr
(Minocin) 1000 mg(base eq) (Cipro xr)
MINOCYCLINE HCL ER - 2 FACTIVE - gemifloxacin 4
minocycline hcl tab er 24hr mesylate tab 320 mg (base
45 mg equiv)
minocycline hcl tab er 24hr 2 LEVOFLOXACIN - levofloxacin 2
90 mg oral soln 25 mg/ml
minocycline hcl tab er 24hr 2 levofloxacin tab 250 mg 1
135 mg (Levaquin)
minocycline hcl tab 50 mg 2 levofloxacin tab 500 mg 1
minocycline hcl tab 75 mg 2 (Levaquin)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
levofloxacin tab 750 mg 1 pyrazinamide tab 500 mg 2
(Levaquin) rifabutin cap 150 mg 2
moxifloxacin hcl tab 400 mg 2 (Mycobutin)
(base equiv) (Avelox) RIFAMATE - isoniazid & 4
OFLOXACIN - ofloxacin tab 4 rifampin cap 150-300 mg
300 mg rifampin cap 150 mg (Rifadin) 2
ofloxacin tab 400 mg 2
rifampin cap 300 mg (Rifadin) 2
AMINOGLYCOSIDES RIFATER - isoniazid-rifampin 4
BETHKIS - tobramycin nebu 5 w/ pyrazinamide tab
soln 300 mg/4ml 50-120-300 mg
KITABIS PAK - tobramycin 5 SIRTURO - bedaquiline 4
nebu soln 300 mg/5ml fumarate tab 100 mg (base
neomycin sulfate tab 500 mg 1 equiv)
2 TRECATOR - ethionamide tab 4
paromomycin sulfate cap
250 mg 250 mg
TOBI PODHALER - tobramycin 5 ANTIFUNGALS

inhal cap 28 mg CRESEMBA - 4
TOBRAMYCIN - tobramycin 5 isavuconazonium sulfate cap
nebu soln 300 mg/5ml 186 mg
2
tobramycin nebu soln 5 fluconazole for susp 10 mg/
300 mg/5ml (Tobi) ml (Diflucan)
fluconazole for susp 40 mg/ 2
SULFONAMIDES
ml (Diflucan)
SULFADIAZINE - sulfadiazine 3
fluconazole tab 50 mg 1
tab 500 mg
(Diflucan)
ANTIMYCOBACTERIAL AGENTS
CYCLOSERINE - cycloserine 4
(Diflucan)
cap 250 mg
ethambutol hcl tab 100 mg 2
(Diflucan)
(Myambutol)
ethambutol hcl tab 400 mg 2
(Diflucan)
(Myambutol)
flucytosine cap 250 mg 2
ISONIAZID - isoniazid syrup 50 4 (Ancobon)
mg/5ml
flucytosine cap 500 mg 2
isoniazid tab 100 mg 1
(Ancobon)
isoniazid tab 300 mg 1 2
griseofulvin microsize susp
PASER - aminosalicylic acid er 4 125 mg/5ml
granules packet 4 gm griseofulvin microsize tab 2
PRIFTIN - rifapentine tab 150 3 500 mg (Grifulvin v)
mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
griseofulvin ultramicrosize 2 APTIVUS - tipranavir cap 250 4
tab 125 mg (Gris-peg) mg
griseofulvin ultramicrosize 2 APTIVUS - tipranavir oral soln 4
tab 250 mg (Gris-peg) 100 mg/ml
itraconazole cap 100 mg 2 ATRIPLA - efavirenz- 3
(Sporanox) emtricitabine-tenofovir df tab
NOXAFIL - posaconazole susp 3 600-200-300 mg
40 mg/ml BARACLUDE - entecavir oral 3
NOXAFIL - posaconazole tab 3 soln 0.05 mg/ml
delayed release 100 mg COMPLERA - emtricitabine- 4
nystatin tab 500000 unit 2 rilpivirine-tenofovir df tab
200-25-300 mg
SPORANOX - itraconazole oral 4
soln 10 mg/ml CRIXIVAN - indinavir sulfate 4
cap 200 mg
terbinafine hcl tab 250 mg 1
(Lamisil) CRIXIVAN - indinavir sulfate 4
cap 400 mg
voriconazole for susp 2
40 mg/ml (Vfend) DAKLINZA - daclatasvir 5
dihydrochloride tab 30 mg
voriconazole tab 50 mg 2 (base equivalent)
(Vfend)
DAKLINZA - daclatasvir 5
voriconazole tab 200 mg 2 dihydrochloride tab 60 mg
(Vfend) (base equivalent)
ANTIVIRALS DAKLINZA - daclatasvir 5
abacavir sulfate tab 300 mg 2 dihydrochloride tab 90 mg
(base equiv) (Ziagen) (base equivalent)
abacavir sulfate-lamivudine 2 DESCOVY - emtricitabine- 3
tab 600-300 mg (Epzicom) tenofovir alafenamide
abacavir sulfate- 2 fumarate tab 200-25 mg
lamivudine-zidovudine tab didanosine delayed release 2
300-150-300 mg (Trizivir) capsule 125 mg (Videx ec)
acyclovir cap 200 mg 1 didanosine delayed release 2
(Zovirax) capsule 200 mg (Videx ec)
acyclovir susp 200 mg/5ml 2 didanosine delayed release 2
acyclovir tab 400 mg 1 didanosine delayed release 2
acyclovir tab 800 mg 1 EDURANT - rilpivirine hcl tab 4
(Zovirax) 25 mg (base equivalent)
adefovir dipivoxil tab 10 mg 2 EMTRIVA - emtricitabine caps 4
(Hepsera) 200 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
EMTRIVA - emtricitabine soln 4 ISENTRESS - raltegravir 3
10 mg/ml potassium chew tab 100 mg
entecavir tab 0.5 mg 2 (base equiv)
(Baraclude) ISENTRESS - raltegravir 3
entecavir tab 1 mg 2 potassium packet for susp
(Baraclude) 100 mg (base equiv)
EPCLUSA - sofosbuvir- 5 ISENTRESS - raltegravir 3

velpatasvir tab 400-100 mg potassium tab 400 mg (base
equiv)
EPIVIR HBV - lamivudine oral 4
soln 5 mg/ml (hbv) ISENTRESS HD - raltegravir 3
potassium tab 600 mg (base
EPZICOM - abacavir sulfate- 3 equiv)
lamivudine tab 600-300 mg
KALETRA - lopinavir-ritonavir 3
EVOTAZ - atazanavir sulfate- 4 soln 400-100 mg/5ml (80-20
cobicistat tab 300-150 mg mg/ml)
(base equiv)
2
famciclovir tab 125 mg tab 100-25 mg
(Famvir)
2
famciclovir tab 250 mg tab 200-50 mg
(Famvir)
2
lamivudine oral soln 10 mg/ 2
famciclovir tab 500 mg ml (Epivir)
(Famvir)
lamivudine tab 100 mg (hbv) 2
FUZEON - enfuvirtide for inj 90 5 (Epivir hbv)
mg
lamivudine tab 150 mg 2
GENVOYA - elvitegrav-cobic- 3 (Epivir)
emtricitab-tenofov af tab
150-150-200-10 mg lamivudine tab 300 mg 2
(Epivir)
HARVONI - ledipasvir- 5
sofosbuvir tab 90-400 mg lamivudine-zidovudine tab 2
150-300 mg (Combivir)
INTELENCE - etravirine tab 25 3
mg LEXIVA - fosamprenavir 4
calcium susp 50 mg/ml
INTELENCE - etravirine tab 3 (base equiv)
100 mg
LEXIVA - fosamprenavir 4
INTELENCE - etravirine tab 3 calcium tab 700 mg (base
200 mg equiv)
INVIRASE - saquinavir 4 lopinavir-ritonavir soln 2
mesylate cap 200 mg 400-100 mg/5ml (80-20 mg/
INVIRASE - saquinavir 4 ml) (Kaletra)
mesylate tab 500 mg MODERIBA - ribavirin tab 200 5
ISENTRESS - raltegravir 3 mg & ribavirin tab 400 mg
potassium chew tab 25 mg dose pack
(base equiv)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
MODERIBA - ribavirin tab 400 5 PEGASYS PROCLICK - 5
mg & ribavirin tab 600 mg peginterferon alfa-2a inj 180
dose pack mcg/0.5ml
MODERIBA 1200 DOSE 5 PEGINTRON - peginterferon 5
PACK - ribavirin tab 600 mg alfa-2b for inj kit 50
MODERIBA 800 DOSE PACK - 5 mcg/0.5ml
ribavirin tab 400 mg PEGINTRON - peginterferon 5
nevirapine tab er 24hr 2 alfa-2b for inj kit 80
100 mg (Viramune xr) mcg/0.5ml
nevirapine tab er 24hr 2 PEGINTRON - peginterferon 5

400 mg (Viramune xr) alfa-2b for inj kit 120
mcg/0.5ml
nevirapine tab 200 mg 1
(Viramune) PEGINTRON - peginterferon 5
alfa-2b for inj kit 150
NORVIR - ritonavir cap 100 mg 4 mcg/0.5ml
NORVIR - ritonavir oral soln 80 3 PREZCOBIX - darunavir- 4
mg/ml cobicistat tab 800-150 mg
NORVIR - ritonavir tab 100 mg 3 PREZISTA - darunavir 3
ODEFSEY - emtricitabine- 3 ethanolate susp 100 mg/ml
rilpivirine-tenofovir af tab (base equiv)
200-25-25 mg PREZISTA - darunavir 3
OLYSIO - simeprevir sodium 5 ethanolate tab 75 mg (base
cap 150 mg (base equiv)
equivalent) PREZISTA - darunavir 3
oseltamivir phosphate 2 ethanolate tab 150 mg (base
cap 30 mg (base equiv) equiv)
(Tamiflu) PREZISTA - darunavir 3
(Tamiflu) PREZISTA - darunavir 3
(Tamiflu) REBETOL - ribavirin soln 40 5
PEGASYS - peginterferon 5 mg/ml
alfa-2a inj 180 mcg/ml RELENZA DISKHALER - 4
PEGASYS - peginterferon 5 zanamivir aero powder
alfa-2a inj 180 mcg/0.5ml breath activated 5 mg/blister
PEGASYS PROCLICK - 5 RESCRIPTOR - delavirdine 4
peginterferon alfa-2a inj 135 mesylate tab 100 mg
mcg/0.5ml RESCRIPTOR - delavirdine 4
mesylate tab 200 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
REYATAZ - atazanavir sulfate 3 SELZENTRY - maraviroc tab 4
cap 150 mg (base equiv) 300 mg
REYATAZ - atazanavir sulfate 3 SITAVIG - acyclovir buccal tab 4
REYATAZ - atazanavir sulfate 3 SOVALDI - sofosbuvir tab 400 5
cap 300 mg (base equiv) mg
REYATAZ - atazanavir sulfate 4 stavudine cap 15 mg (Zerit) 2
oral powder packet 50 mg stavudine cap 20 mg (Zerit) 2
(base equiv)
stavudine cap 30 mg (Zerit) 2
RIBASPHERE - ribavirin tab 5
400 mg stavudine cap 40 mg (Zerit) 2
RIBASPHERE - ribavirin tab 5 STRIBILD - elvitegrav-cobic- 3
600 mg emtricitab-tenofovdf tab
150-150-200-300 mg
RIBASPHERE RIBAPAK - 5
ribavirin tab 400 mg SUSTIVA - efavirenz cap 50 3
mg
ribavirin tab 600 mg SUSTIVA - efavirenz cap 200 3
mg
ribavirin tab 200 mg & SUSTIVA - efavirenz tab 600 3
ribavirin tab 400 mg dose mg
pack TAMIFLU - oseltamivir 4
RIBASPHERE RIBAPAK - 5 phosphate cap 30 mg (base
ribavirin tab 400 mg & equiv)
ribavirin tab 600 mg dose TAMIFLU - oseltamivir 4
pack phosphate cap 45 mg (base
ribavirin cap 200 mg 5 equiv)
(Rebetol) TAMIFLU - oseltamivir 4
ribavirin for inhal soln 6 gm 2 phosphate cap 75 mg (base
(Virazole) equiv)
ribavirin tab 200 mg 5 TAMIFLU - oseltamivir 4
(Copegus) phosphate for susp 6 mg/ml
(base equiv)
rimantadine hydrochloride 2
tab 100 mg (Flumadine) TECHNIVIE - ombitasvir- 5
paritaprevir-ritonavir tab
SELZENTRY - maraviroc oral 4 12.5-75-50 mg
soln 20 mg/ml
TIVICAY - dolutegravir sodium 3
SELZENTRY - maraviroc tab 4 tab 10 mg (base equiv)
25 mg
75 mg
150 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
TRIUMEQ - abacavir- 4 VIRACEPT - nelfinavir 4
dolutegravir-lamivudine tab mesylate tab 625 mg
600-50-300 mg VIRAMUNE - nevirapine susp 3
TRUVADA - emtricitabine- 3 50 mg/5ml
tenofovir disoproxil fumarate VIRAZOLE - ribavirin for inhal 4
tab 100-150 mg soln 6 gm
TRUVADA - emtricitabine- 3 VIREAD - tenofovir disoproxil 3
tenofovir disoproxil fumarate fumarate oral powder 40 mg/
tab 133-200 mg gm
TRUVADA - emtricitabine- 3 VIREAD - tenofovir disoproxil 3
tenofovir disoproxil fumarate fumarate tab 150 mg
tab 167-250 mg
VIREAD - tenofovir disoproxil 3
TRUVADA - emtricitabine- 3 fumarate tab 200 mg
tenofovir disoproxil fumarate
tab 200-300 mg VIREAD - tenofovir disoproxil 3
fumarate tab 250 mg
TYBOST - cobicistat tab 150 4
mg VIREAD - tenofovir disoproxil 3
fumarate tab 300 mg
valacyclovir hcl tab 500 mg 2
(Valtrex) ZEPATIER - elbasvir- 5
grazoprevir tab 50-100 mg
valacyclovir hcl tab 1 gm 2
(Valtrex) ZERIT - stavudine for oral soln 4
1 mg/ml
VALCYTE - valganciclovir hcl 3
for soln 50 mg/ml (base ZIAGEN - abacavir sulfate soln 3
equiv) 20 mg/ml (base equiv)
valganciclovir hcl for soln 2 zidovudine cap 100 mg 2
50 mg/ml (base equiv) (Retrovir)
(Valcyte) zidovudine syrup 10 mg/ml 2
valganciclovir hcl tab 2 (Retrovir)
450 mg (base equivalent) zidovudine tab 300 mg 2
(Valcyte) ANTIMALARIALS
VIDEX - didanosine for soln 2 3 atovaquone-proguanil hcl 2
gm tab 62.5-25 mg (Malarone)
VIDEX - didanosine for soln 4 3 atovaquone-proguanil hcl 2
gm tab 250-100 mg (Malarone)
VIEKIRA PAK - ombitas- 5 CHLOROQUINE 1
paritapre-riton & dasab tab PHOSPHATE - chloroquine
pak 12.5-75-50 & 250 mg phosphate tab 250 mg
VIEKIRA XR - dasab-ombit- 5 chloroquine phosphate tab 1
paritap-riton tab er 24hr 500 mg (Aralen)
200-8.33-50-33.33 mg
COARTEM - artemether- 4
VIRACEPT - nelfinavir 4 lumefantrine tab 20-120 mg
mesylate tab 250 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
DARAPRIM - pyrimethamine 3 IMPAVIDO - miltefosine cap 50 3
tab 25 mg mg
hydroxychloroquine sulfate 2 linezolid for susp 2
tab 200 mg (Plaquenil) 100 mg/5ml (Zyvox)
mefloquine hcl tab 250 mg 2 linezolid tab 600 mg (Zyvox) 2
PRIMAQUINE PHOSPHATE - 3 metronidazole cap 375 mg 2
primaquine phosphate tab (Flagyl)
26.3 mg (15 mg base) metronidazole tab 250 mg 1
quinine sulfate cap 324 mg 2 (Flagyl)
(Qualaquin) metronidazole tab 500 mg 1
ANTHELMINTICS (Flagyl)
ALBENZA - albendazole tab 3 NEBUPENT - pentamidine 4
200 mg isethionate for nebulization
BILTRICIDE - praziquantel tab 3 soln 300 mg
600 mg PRIMSOL - trimethoprim hcl 4
EMVERM - mebendazole chew 4 oral soln 50 mg/5ml (base
tab 100 mg equiv)
2 SIVEXTRO - tedizolid 4
ivermectin tab 3 mg
(Stromectol) phosphate tab 200 mg
sulfamethoxazole- 2
ANTI-INFECTIVE AGENTS - MISC.
trimethoprim susp
ALINIA - nitazoxanide for susp 4 200-40 mg/5ml
100 mg/5ml
sulfamethoxazole- 1
ALINIA - nitazoxanide tab 500 4 trimethoprim tab
mg 400-80 mg (Bactrim)
atovaquone susp 2 1
sulfamethoxazole-
750 mg/5ml (Mepron) trimethoprim tab
CAYSTON - aztreonam lysine 5 800-160 mg (Bactrim ds)
for inhal soln 75 mg (base tinidazole tab 250 mg 2
equivalent) (Tindamax)
clindamycin hcl cap 75 mg 1 2
tinidazole tab 500 mg
(Cleocin) (Tindamax)
clindamycin hcl cap 150 mg 1 1
trimethoprim tab 100 mg
(Cleocin)
vancomycin hcl cap 125 mg 2
clindamycin hcl cap 300 mg 1
(Vancocin hcl)
(Cleocin)
vancomycin hcl cap 250 mg 2
clindamycin palmitate hcl 2
(Vancocin hcl)
for soln 75 mg/5ml (base
equiv) (Cleocin pediatric gr) XIFAXAN - rifaximin tab 200 4
mg
dapsone tab 25 mg 2
2
XIFAXAN - rifaximin tab 550 3
dapsone tab 100 mg mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
BIOLOGICALS FLUARIX QUADRIVALENT A
VACCINES 2017 - influenza virus vac
split quadrivalent susp pref
AFLURIA PF 2015-2016 - A syr 0.5ml
influenza virus vaccine split
pf susp pref syringe 0.5 ml FLUBLOK QUADRIVALENT A
2017 - influenza vac recomb
AFLURIA PF 2017-2018 - A ha quad pf soln pref syr 0.5
influenza virus vaccine split ml
pf susp pref syringe 0.5 ml
FLUBLOK 2015-2016 - A
AFLURIA QUADRIVALENT A influenza virus vac
2017 - influenza virus vac recombinant hemagglutinin
split quadrivalent susp pref (ha) inj
syr 0.5ml
FLUBLOK 2017-2018 - A
AFLURIA QUADRIVALENT A influenza virus vac
2017 - influenza virus recombinant hemagglutinin
vaccine split quadrivalent im (ha) inj
inj
FLUCELVAX QUADRIVALENT A
AFLURIA 2015-2016 - A 20 - influenza vac tiss-cult
influenza virus vaccine split subunt quad susp pref syr
im susp 0.5 ml
AFLURIA 2017-2018 - A FLUCELVAX QUADRIVALENT A
influenza virus vaccine split 20 - influenza vac tissue-
im susp cultured subunit quadrivalent
ENGERIX-B - hepatitis b A im susp
vaccine (recombinant) susp FLULAVAL QUADRIVALENT A
10 mcg/0.5ml 201 - influenza virus vac split
ENGERIX-B - hepatitis b A quadrivalent susp pref syr
vaccine (recombinant) susp 0.5ml
20 mcg/ml FLULAVAL QUADRIVALENT A
ENGERIX-B - hepatitis b A 201 - influenza virus vaccine
vaccine (recombinant) 10 split quadrivalent im inj
mcg/0.5ml FLUVIRIN 2015-2016 - A
ENGERIX-B - hepatitis b A influenza vac type a&b
vaccine (recombinant) 20 surface antigen susp pref syr
mcg/ml 0.5 ml
FLUAD 2016-2017 - influenza A FLUVIRIN 2015-2016 - A
vac type a&b surface ant adj influenza virus vaccine types
susp pref syr 0.5 ml a & b surface antigen im
FLUAD 2017-2018 - influenza A susp
vac type a&b surface ant adj FLUVIRIN 2016-2017 - A
susp pref syr 0.5 ml influenza vac type a&b
surface antigen susp pref syr
0.5 ml

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
FLUVIRIN 2016-2017 - A MEDICAL PROVIDER A
influenza virus vaccine types SINGLE U - influenza virus
a & b surface antigen im vaccine split pf susp pref syr
susp kit 0.5 ml
FLUVIRIN 2017-2018 - A PNEUMOVAX 23 - A
influenza vac type a&b pneumococcal vaccine
surface antigen susp pref syr polyvalent inj 25 mcg/0.5ml
0.5 ml PNEUMOVAX 23/1 DOSE - A
FLUVIRIN 2017-2018 - A pneumococcal vaccine
influenza virus vaccine types polyvalent inj 25 mcg/0.5ml
a & b surface antigen im PREVNAR 13 - pneumococcal A
susp 13-valent conjugate vaccine
FLUZONE HIGH-DOSE PF A inj
2017 - influenza virus vac RABAVERT - rabies vaccine, A
split high-dose pf susp pref pcec for inj
syr 0.5ml
RECOMBIVAX HB - hepatitis b A
FLUZONE INTRADERMAL A vaccine (recombinant) susp
QUADR - influenza virus vac 5 mcg/0.5ml
split quad intradermal pen 9
mcg/strain RECOMBIVAX HB - hepatitis b A
vaccine (recombinant) susp
FLUZONE QUADRIVALENT A 10 mcg/ml
2017 - influenza virus vac
split quadrivalent susp pref RECOMBIVAX HB - hepatitis b A
syr 0.25 ml vaccine (recombinant) susp
40 mcg/ml
FLUZONE QUADRIVALENT A 4
2017 - influenza virus vac VIVOTIF - typhoid vaccine cap
split quadrivalent susp pref delayed release
syr 0.5ml ZOSTAVAX - zoster vaccine A
FLUZONE QUADRIVALENT A live for subcutaneous susp
2017 - influenza virus 19400 unit/0.65ml
vaccine split quadrivalent im TOXOIDS
inj ADACEL - tet tox-diph-acell A
IMOVAX RABIES (H.D.C.V.) - A pertuss ad inj 5-2-15.5 lf-lf-
rabies virus vaccine, hdc inj mcg/0.5ml
MEDICAL PROVIDER A BOOSTRIX - tet tox-diph-acell A
SINGLE U - influenza virus pertuss ad inj 5-2.5-18.5 lf-lf-
vac split quad inj prefilled syr mcg/0.5ml
kit 0.25 ml DAPTACEL - diph, acellular 4
MEDICAL PROVIDER A pert & tet tox inj 15 lf-10
SINGLE U - influenza virus mcg-5 lf/0.5ml
vac types a & b pf pref
syringe kit 0.5 ml

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
DIPHTHERIA/TETANUS 4 GRASTEK - timothy grass 4
TOXOID - diphtheria-tetanus pollen allergen ext tab sl
tox adsorbed (dt) im inj 25-5 2800 bau
unit/0.5ml ORALAIR - grass mixed pollen 4
INFANRIX - diph, acellular pert 4 ext tab sl 300 ir (index of
& tet tox inj 25 lf-58 mcg-10 reactivity)
lf/0.5ml RAGWITEK - short ragweed 4
KINRIX - diph-tetanus tox ad- 4 pollen allergen extract tab sl
acell pert & polio virus, ipv 12 amb a 1-u
vac inj ANTINEOPLASTIC AGENTS
PEDIARIX - diph-tetanus tox- 4
ANTINEOPLASTICS
acell pert-hepatitis b-polio
ipv vac inj ACTIMMUNE - interferon 5
gamma-1b inj 100
PENTACEL - diph-ac per-tet 4
mcg/0.5ml (2000000
tox ad-poliov-haemoph b unit/0.5ml)
poly vac for im susp
4
AFINITOR - everolimus tab 2.5 5
QUADRACEL - diph-tetanus mg
tox ad-acell pert & polio
virus, ipv vac inj AFINITOR - everolimus tab 5 5
mg
TENIVAC - tetanus-diphtheria 4
toxoids (td) inj 5-2 lfu AFINITOR - everolimus tab 7.5 5
mg
TETANUS/DIPHTHERIA 4
TOXOID - tetanus-diphtheria AFINITOR - everolimus tab 10 5
toxoids (td) inj 2-2 lf/0.5ml mg
PASSIVE IMMUNIZING AGENTS AFINITOR DISPERZ - 5
everolimus tab for oral susp
HYQVIA - immun glob inj 2.5 4 2 mg
gm/25ml-hyaluron inj 200
unt/1.25 ml kit AFINITOR DISPERZ - 5
HYQVIA - immun glob inj 5 4 3 mg
unt/2.5 ml kit AFINITOR DISPERZ - 5
HYQVIA - immun glob inj 10 4 5 mg
unt/5 ml kit ALECENSA - alectinib hcl cap 5
150 mg (base equivalent)
HYQVIA - immun glob inj 20 4 3
gm/200ml-hyaluron inj 1600 ALKERAN - melphalan tab 2
unt/10 ml kit mg
HYQVIA - immun glob inj 30 4 ALUNBRIG - brigatinib tab 30 5
gm/300ml-hyaluron inj 2400 mg
unt/15 ml kit anastrozole tab 1 mg 1
BIOLOGICALS MISC (Arimidex)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
bexarotene cap 75 mg 5 CYCLOPHOSPHAMIDE - 4
(Targretin) cyclophosphamide cap 50
bicalutamide tab 50 mg 1 mg
(Casodex) ELIGARD - leuprolide acetate 5
BOSULIF - bosutinib tab 100 5 (3 month) for subcutaneous
mg inj kit 22.5mg
BOSULIF - bosutinib tab 500 5 ELIGARD - leuprolide acetate 5

mg (4 month) for subcutaneous
inj kit 30 mg
CABOMETYX - cabozantinib 5
s-malate tab 20 mg (base ELIGARD - leuprolide acetate 5
equivalent) (6 month) for subcutaneous
inj kit 45 mg
CABOMETYX - cabozantinib 5
s-malate tab 40 mg (base ELIGARD - leuprolide acetate 5
equivalent) for subcutaneous inj kit 7.5
mg
CABOMETYX - cabozantinib 5 4
s-malate tab 60 mg (base EMCYT - estramustine
equivalent) phosphate sodium cap 140
mg
capecitabine tab 150 mg 5
(Xeloda) ERIVEDGE - vismodegib cap 5
150 mg
capecitabine tab 500 mg 5 4
(Xeloda) ETOPOSIDE - etoposide cap
50 mg
CAPRELSA - vandetanib tab 5 2
100 mg exemestane tab 25 mg
(Aromasin)
CAPRELSA - vandetanib tab 5
300 mg FARESTON - toremifene citrate 4
tab 60 mg (base equivalent)
COMETRIQ - cabozantinib s- 5
mal cap 1 x 80 mg & 1 x 20 FARYDAK - panobinostat 5
mg (100 dose) kit lactate cap 10 mg (base
equivalent)
mal cap 1 x 80 mg & 3 x 20 FARYDAK - panobinostat 5
mg (140 dose) kit lactate cap 15 mg (base
equivalent)
malate cap 3 x 20 mg (60 FARYDAK - panobinostat 5
mg dose) kit lactate cap 20 mg (base
equivalent)
COTELLIC - cobimetinib 5 2
fumarate tab 20 mg (base flutamide cap 125 mg
equivalent) GILOTRIF - afatinib dimaleate 5
CYCLOPHOSPHAMIDE - 4 tab 20 mg (base equivalent)
cyclophosphamide cap 25 GILOTRIF - afatinib dimaleate 5
mg tab 30 mg (base equivalent)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
GILOTRIF - afatinib dimaleate 5 IMBRUVICA - ibrutinib cap 140 5
tab 40 mg (base equivalent) mg
GLEEVEC - imatinib 5 INLYTA - axitinib tab 1 mg 5
mesylate tab 100 mg (base INLYTA - axitinib tab 5 mg 5
equivalent)
INTRON A - interferon alfa-2b 5
GLEEVEC - imatinib 5 inj 6000000 unit/ml
mesylate tab 400 mg (base
equivalent) INTRON A - interferon alfa-2b 5
inj 10000000 unit/ml
GLEOSTINE - lomustine cap 5 4
mg INTRON A - interferon alfa-2b 5
for inj 10000000 unit
GLEOSTINE - lomustine cap 4
10 mg INTRON A - interferon alfa-2b 5
40 mg INTRON A - interferon alfa-2b 5
100 mg INTRON A W/DILUENT - 5
interferon alfa-2b for inj
HEXALEN - altretamine cap 50 5 10000000 unit
mg
INTRON A W/DILUENT - 5
HYCAMTIN - topotecan hcl cap 5 interferon alfa-2b for inj
0.25 mg (base equiv) 18000000 unit
HYCAMTIN - topotecan hcl cap 5 INTRON A W/DILUENT - 5
1 mg (base equiv) interferon alfa-2b for inj
hydroxyurea cap 500 mg 2 50000000 unit
(Hydrea) IRESSA - gefitinib tab 250 mg 5
IBRANCE - palbociclib cap 75 5 JAKAFI - ruxolitinib phosphate 5
ICLUSIG - ponatinib hcl tab 15 5 JAKAFI - ruxolitinib phosphate 5
mg (base equiv) tab 20 mg (base equivalent)
ICLUSIG - ponatinib hcl tab 45 5 JAKAFI - ruxolitinib phosphate 5
mg (base equiv) tab 25 mg (base equivalent)
imatinib mesylate tab 5 KISQALI - ribociclib succinate 5
100 mg (base equivalent) tab 200 mg (base equiv)
(Gleevec)
KISQALI FEMARA 200 DOSE - 5
imatinib mesylate tab 5 ribociclib tab 200 mg &
400 mg (base equivalent) letrozole tab 2.5 mg therapy
(Gleevec) pack

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
KISQALI FEMARA 400 DOSE - 5 LONSURF - trifluridine-tipiracil 5
ribociclib tab 200 mg & tab 15-6.14 mg
letrozole tab 2.5 mg therapy LONSURF - trifluridine-tipiracil 5
pack tab 20-8.19 mg
KISQALI FEMARA 600 DOSE - 5 LYNPARZA - olaparib cap 50 5
ribociclib tab 200 mg & mg
letrozole tab 2.5 mg therapy
pack LYSODREN - mitotane tab 500 5
mg
LENVIMA 10 MG DAILY 5
DOSE - lenvatinib cap MATULANE - procarbazine hcl 5
therapy pack 10 mg (10 mg cap 50 mg
daily dose) megestrol acetate susp 2
LENVIMA 14 MG DAILY 5 40 mg/ml (Megace oral)
DOSE - lenvatinib cap megestrol acetate tab 20 mg 1
therapy pack 10 & 4 mg (14 megestrol acetate tab 40 mg 1
mg daily dose)
MEKINIST - trametinib dimethyl 5
LENVIMA 18 MG DAILY 5 sulfoxide tab 0.5 mg (base
DOSE - lenvatinib cap equivalent)
therapy pack 10 & 4 (2) mg
(18 mg daily dose) MEKINIST - trametinib dimethyl 5
sulfoxide tab 2 mg (base
LENVIMA 20 MG DAILY 5 equivalent)
DOSE - lenvatinib cap
therapy pack 10 (2) mg (20 melphalan tab 2 mg (Alkeran) 2
mg daily dose) mercaptopurine tab 50 mg 2
LENVIMA 24 MG DAILY 5 MESNEX - mesna tab 400 mg 4
DOSE - lenvatinib cap 4
METHOTREXATE SODIUM -
therapy pack 10 (2) & 4 mg
methotrexate sodium inj 250
(24 mg daily dose)
mg/10ml (25 mg/ml)
LENVIMA 8 MG DAILY DOSE - 5 methotrexate sodium for inj 2
lenvatinib cap therapy pack
1 gm
4 (2) mg (8 mg daily dose)
methotrexate sodium inj pf 1
letrozole tab 2.5 mg (Femara) 1
50 mg/2ml (25 mg/ml)
LEUCOVORIN CALCIUM - 3
leucovorin calcium tab 10
100 mg/4ml (25 mg/ml)
mg
LEUCOVORIN CALCIUM - 3
200 mg/8ml (25 mg/ml)
mg
2 250 mg/10ml (25 mg/ml)
leucovorin calcium tab 5 mg
1000 mg/40ml (25 mg/ml)
25 mg
methotrexate sodium inj 1
LEUKERAN - chlorambucil tab 3
50 mg/2ml (25 mg/ml)
2 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
methotrexate sodium tab 2 RYDAPT - midostaurin cap 25 5
2.5 mg (base equiv) mg
MYLERAN - busulfan tab 2 mg 3 SOLTAMOX - tamoxifen citrate 4
NEXAVAR - sorafenib 5 oral soln 10 mg/5ml (base
tosylate tab 200 mg (base equivalent)
equivalent) SPRYCEL - dasatinib tab 20 5
NILANDRON - nilutamide tab 4 mg
150 mg SPRYCEL - dasatinib tab 50 5
nilutamide tab 150 mg 2 mg
(Nilandron) SPRYCEL - dasatinib tab 70 5
NINLARO - ixazomib 5 mg
citrate cap 2.3 mg (base SPRYCEL - dasatinib tab 80 5
equivalent) mg
NINLARO - ixazomib citrate 5 SPRYCEL - dasatinib tab 100 5
cap 3 mg (base equivalent) mg
NINLARO - ixazomib citrate 5 SPRYCEL - dasatinib tab 140 5
cap 4 mg (base equivalent) mg
ODOMZO - sonidegib 5 STIVARGA - regorafenib tab 40 5
phosphate cap 200 mg mg
(base equivalent) SUTENT - sunitinib malate cap 5
POMALYST - pomalidomide 5 12.5 mg (base equivalent)
cap 1 mg SUTENT - sunitinib malate cap 5
POMALYST - pomalidomide 5 25 mg (base equivalent)
POMALYST - pomalidomide 5 37.5 mg (base equivalent)
POMALYST - pomalidomide 5 50 mg (base equivalent)
cap 4 mg SYLATRON - peginterferon 5
PURIXAN - mercaptopurine 5 alfa-2b for inj kit 200 mcg
susp 2000 mg/100ml (20 SYLATRON - peginterferon 5
mg/ml) alfa-2b for inj kit 300 mcg
RUBRACA - rucaparib 5 SYLATRON - peginterferon 5
camsylate tab 200 mg (base alfa-2b for inj kit 600 mcg
equivalent)
TABLOID - thioguanine tab 40 4
RUBRACA - rucaparib 5 mg
camsylate tab 250 mg (base
equivalent) TAFINLAR - dabrafenib 5
mesylate cap 50 mg (base
RUBRACA - rucaparib 5 equivalent)
camsylate tab 300 mg (base
equivalent) TAFINLAR - dabrafenib 5
equivalent)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
TAGRISSO - osimertinib 5 TREXALL - methotrexate 4
mesylate tab 40 mg (base sodium tab 10 mg (base
equivalent) equiv)
TAGRISSO - osimertinib 5 TREXALL - methotrexate 4
mesylate tab 80 mg (base sodium tab 15 mg (base
equivalent) equiv)
tamoxifen citrate tab 10 mg 1 TYKERB - lapatinib ditosylate 5
(base equivalent) tab 250 mg (base equiv)
tamoxifen citrate tab 20 mg 1 VENCLEXTA - venetoclax tab 5
(base equivalent) 10 mg
TARCEVA - erlotinib hcl tab 25 5 VENCLEXTA - venetoclax tab 5
mg (base equivalent) 50 mg
TARCEVA - erlotinib hcl tab 5 VENCLEXTA - venetoclax tab 5
100 mg (base equivalent) 100 mg
TARCEVA - erlotinib hcl tab 5 VENCLEXTA STARTING 5
150 mg (base equivalent) PACK - venetoclax tab
TASIGNA - nilotinib hcl cap 150 5 therapy starter pack 10 & 50
mg (base equivalent) & 100 mg
TASIGNA - nilotinib hcl cap 200 5 VOTRIENT - pazopanib hcl tab 5

mg (base equivalent) 200 mg (base equiv)
temozolomide cap 5 mg 5 XALKORI - crizotinib cap 200 5

(Temodar) mg
temozolomide cap 20 mg 5 XALKORI - crizotinib cap 250 5

(Temodar) mg
temozolomide cap 100 mg 5 XTANDI - enzalutamide cap 40 5

(Temodar) mg
temozolomide cap 140 mg 5 ZEJULA - niraparib tosylate 5

(Temodar) cap 100 mg (base
equivalent)
temozolomide cap 180 mg 5
(Temodar) ZELBORAF - vemurafenib tab 5
240 mg
temozolomide cap 250 mg 5
(Temodar) ZOLINZA - vorinostat cap 100 5
mg
tretinoin cap 10 mg 5
4
ZYDELIG - idelalisib tab 100 5
TREXALL - methotrexate mg
sodium tab 5 mg (base
equiv) ZYDELIG - idelalisib tab 150 5
mg
TREXALL - methotrexate 4
sodium tab 7.5 mg (base ZYKADIA - ceritinib cap 150 5
equiv) mg
ZYTIGA - abiraterone acetate 5
tab 250 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
ZYTIGA - abiraterone acetate 5 JTT PHYSICIANS KIT - 4
tab 500 mg triamcinolone inj 40 mg/ml &
ENDOCRINE AND METABOLIC DRUGS lidocaine 1% & ammonia inh
kit
CORTICOSTEROIDS
MEDROL - methylprednisolone 4
budesonide delayed 2
tab 2 mg
release particles cap 3 mg
methylprednisolone tab 2
(Entocort ec)
therapy pack 4 mg (21)
CORTISONE ACETATE - 3
(Medrol dosepak)
cortisone acetate tab 25 mg
DEXAMETHASONE - 4
4 mg (Medrol)
dexamethasone soln 0.5
mg/5ml
8 mg (Medrol)
DEXAMETHASONE - 4
dexamethasone tab 1 mg
16 mg (Medrol)
DEXAMETHASONE - 4
dexamethasone tab 2 mg
32 mg (Medrol)
dexamethasone elixir 2
MILLIPRED - prednisolone 4
0.5 mg/5ml
sod phosphate oral soln 10
DEXAMETHASONE 4
mg/5ml (base equiv)
INTENSOL - dexamethasone
MILLIPRED - prednisolone tab 4
conc 1 mg/ml
5 mg
dexamethasone tab 0.5 mg 1
MILLIPRED DP - prednisolone 4
dexamethasone tab 0.75 mg 1
tab therapy pack 5 mg (21)
dexamethasone tab 1.5 mg 1 4
MILLIPRED DP - prednisolone
dexamethasone tab 4 mg 1 tab therapy pack 5 mg (48)
dexamethasone tab 6 mg 1 PHYSICIANS EZ USE JOINT 4
fludrocortisone acetate tab 1 T - triamcinolone inj 40 mg/ml
0.1 mg & lidocaine 1% & ammonia
inh kit
hydrocortisone tab 5 mg 2
prednisolone sod phos 2
(Cortef)
orally disintegr tab 10 mg
(base eq) (Orapred odt)
(Cortef) 2
prednisolone sod phos
orally disintegr tab 15 mg
(Cortef) (base eq) (Orapred odt)
INTERARTICULAR JOINT 4 2
prednisolone sod phos
KIT - triamcinolone inj 40 orally disintegr tab 30 mg
mg/ml & lidocaine 1% & (base eq) (Orapred odt)
ammonia inh kit

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
prednisolone sod phosph 2 VERIPRED 20 - prednisolone 4
oral soln 6.7 mg/5ml sod phosphate oral soln 20
(5 mg/5ml base) mg/5ml (base equiv)
(Pediapred) ANDROGEN-ANABOLIC
1
prednisolone sod phosphate ANADROL-50 - oxymetholone 4
oral soln 15 mg/5ml (base tab 50 mg
equiv)
2
ANDRODERM - testosterone 4
prednisolone sod phosphate td patch 24hr 2 mg/24hr
oral soln 10 mg/5ml (base
equiv) (Millipred) ANDRODERM - testosterone 4
td patch 24hr 4 mg/24hr
prednisolone sod phosphate 2
oral soln 20 mg/5ml (base ANDROGEL - testosterone 3
equiv) (Veripred 20) td gel 20.25 mg/1.25gm
(1.62%)
PREDNISOLONE SODIUM 4
PHOSP - prednisolone ANDROGEL - testosterone td 3
sodium phosphate oral soln gel 40.5 mg/2.5gm (1.62%)
25 mg/5ml (base eq) ANDROGEL PUMP - 3
prednisolone syrup 1 testosterone td gel 20.25
15 mg/5ml (usp solution mg/act (1.62%)
equivalent) ANDROXY - fluoxymesterone 4
PREDNISONE - prednisone 4 tab 10 mg
oral soln 5 mg/5ml AXIRON - testosterone td soln 3
PREDNISONE - prednisone 4 30 mg/act
tab therapy pack 5 mg (21) danazol cap 50 mg 2
PREDNISONE - prednisone 4 danazol cap 100 mg 2
tab therapy pack 5 mg (48) danazol cap 200 mg 2
4
PREDNISONE - prednisone DEPO-TESTOSTERONE - 4
tab therapy pack 10 mg (21) testosterone cypionate im inj
PREDNISONE - prednisone 4 in oil 100 mg/ml
tab therapy pack 10 mg (48) DEPO-TESTOSTERONE - 4
PREDNISONE - prednisone 4 testosterone cypionate im inj
tab 50 mg in oil 200 mg/ml
PREDNISONE INTENSOL - 4 METHITEST - 4
prednisone conc 5 mg/ml methyltestosterone oral tab
prednisone tab 1 mg 1 10 mg
prednisone tab 2.5 mg 1 methyltestosterone cap 2
10 mg (Testred)
prednisone tab 5 mg 1
1
oxandrolone tab 2.5 mg 2
prednisone tab 10 mg (Oxandrin)
1
prednisone tab 20 mg oxandrolone tab 10 mg 2
UCERIS - budesonide tab er 4 (Oxandrin)
24hr 9 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
testosterone cypionate im 2 DIVIGEL - estradiol td gel 0.5 3
inj in oil 100 mg/ml (Depo- mg/0.5gm (0.1%)
testosterone) DIVIGEL - estradiol td gel 1 3
testosterone cypionate im 2 mg/gm (0.1%)
inj in oil 200 mg/ml (Depo- DUAVEE - conjugated 4
testosterone) estrogens-bazedoxifene tab
testosterone enanthate im 2 0.45-20 mg
inj in oil 200 mg/ml ELESTRIN - estradiol gel 4
testosterone td gel 2 0.06% (0.52 mg/0.87 gm
25 mg/2.5gm (1%) metered-dose pump)
(Androgel) estradiol & norethindrone 2
testosterone td gel 2 acetate tab 0.5-0.1 mg
50 mg/5gm (1%) (Androgel) (Activella)
testosterone td gel 12.5 mg/ 2 estradiol & norethindrone 2
act (1%) (Androgel pump) acetate tab 1-0.5 mg
testosterone td soln 30 mg/ 2 (Activella)
act (Axiron) estradiol tab 0.5 mg (Estrace) 1
ESTROGENS estradiol tab 1 mg (Estrace) 1
ALORA - estradiol td patch 4 estradiol tab 2 mg (Estrace) 1
twice weekly 0.025 mg/24hr estradiol td patch twice 2
ALORA - estradiol td patch 4 weekly 0.025 mg/24hr
twice weekly 0.05 mg/24hr (Vivelle-dot)
ALORA - estradiol td patch 4 estradiol td patch twice 2
twice weekly 0.075 mg/24hr weekly 0.0375 mg/24hr
ALORA - estradiol td patch 4 (Vivelle-dot)
twice weekly 0.1 mg/24hr estradiol td patch twice 2
ANGELIQ - drospirenone- 4 weekly 0.05 mg/24hr
estradiol tab 0.25-0.5 mg (Vivelle-dot)
ANGELIQ - drospirenone- 4 estradiol td patch twice 2

estradiol tab 0.5-1 mg weekly 0.075 mg/24hr
(Vivelle-dot)
CLIMARA PRO - estradiol- 4
levonorgestrel td patch estradiol td patch twice 2
weekly 0.045-0.015 mg/day weekly 0.1 mg/24hr
(Vivelle-dot)
COMBIPATCH - estradiol- 3
norethindrone ace td pttw estradiol td patch weekly 2
0.05-0.14 mg/day 0.025 mg/24hr (Climara)
COMBIPATCH - estradiol- 3 estradiol td patch 2

norethindrone ace td pttw weekly 0.0375 mg/24hr
0.05-0.25 mg/day (37.5 mcg/24hr) (Climara)
DIVIGEL - estradiol td gel 0.25 3 estradiol td patch weekly 2

mg/0.25gm (0.1%) 0.05 mg/24hr (Climara)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
estradiol td patch weekly 2 norethindrone acetate- 2
0.06 mg/24hr (Climara) ethinyl estradiol tab
estradiol td patch weekly 2 0.5 mg-2.5 mcg (Femhrt low
0.075 mg/24hr (Climara) dose)
2
estradiol td patch weekly 2 norethindrone acetate-
0.1 mg/24hr (Climara) ethinyl estradiol tab
1 mg-5 mcg
estradiol valerate im in oil 2
PREFEST - estradiol tab 1 4
20 mg/ml (Delestrogen)
mg(15)/estrad-norgestimate
estradiol valerate im in oil 2
tab 1-0.09mg(15)
40 mg/ml (Delestrogen)
PREMARIN - estrogens, 4
ESTROGEL - estradiol gel 4
conjugated tab 0.3 mg
0.06% (0.75 mg/1.25 gm
metered-dose pump)
ESTROPIPATE - estropipate 4
tab 0.75 mg
tab 1.5 mg
tab 3 mg
EVAMIST - estradiol 4
PREMPHASE - conj est 4
transdermal spray 1.53 mg/
spray 0.625(14)/conj est-
medroxypro ac tab
MENEST - esterified estrogens 4
0.625-5mg(14)
tab 0.3 mg
PREMPRO - conjugated 4
MENEST - esterified estrogens 4
estrogen-medroxyprogest
tab 0.625 mg acetate tab 0.3-1.5 mg
MENEST - esterified estrogens 4 4
PREMPRO - conjugated
tab 1.25 mg estrogen-medroxyprogest
MENOSTAR - estradiol td 4 acetate tab 0.45-1.5 mg
patch weekly 14 mcg/24hr PREMPRO - conjugated 4
MINIVELLE - estradiol td patch 4 estrogen-medroxyprogest
twice weekly 0.025 mg/24hr acetate tab 0.625-2.5 mg
MINIVELLE - estradiol td 4 PREMPRO - conjugated 4
patch twice weekly 0.0375 estrogen-medroxyprogest
mg/24hr acetate tab 0.625-5 mg
MINIVELLE - estradiol td patch 4 CONTRACEPTIVES
twice weekly 0.05 mg/24hr BEYAZ - drospirenone-ethinyl 4
MINIVELLE - estradiol td patch 4 estrad-levomefolate tab
twice weekly 0.075 mg/24hr 3-0.02-0.451 mg
MINIVELLE - estradiol td patch 4
twice weekly 0.1 mg/24hr

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
DEPO-PROVERA A GENERESS FE - 4
CONTRACEPTIV - norethindrone & ethinyl
medroxyprogesterone estradiol-fe chew tab 0.8
acetate im susp prefilled syr mg-25 mcg
150 mg/ml levonor-eth est tab A
DEPO-PROVERA A 0.15-0.02/0.025/0.03 mg
CONTRACEPTIV - &eth est 0.01 mg
medroxyprogesterone (Quartette)
acetate im susp 150 mg/ml levonorg-eth est tab A
DEPO-SUBQ PROVERA A 0.1-0.02mg(84) & eth
104 - medroxyprogesterone est tab 0.01mg(7)
acetate susp pref syr 104 (Loseasonique)
mg/0.65ml levonorg-eth est tab A
desogest-eth estrad A 0.15-0.03mg(84) & eth est
& eth estrad tab tab 0.01mg(7) (Seasonique)
0.15-0.02/0.01 mg(21/5) levonorgestrel & ethinyl A
(Mircette) estradiol (91-day) tab
desogest-ethin est tab A 0.15-0.03 mg
0.1-0.025/0.125-0.025/0.15-0.025mg- levonorgestrel & A
mg (Cyclessa) ethinyl estradiol tab
desogestrel & ethinyl A 0.1 mg-20 mcg
estradiol tab levonorgestrel & A
0.15 mg-30 mcg (Desogen) ethinyl estradiol tab
drospirenone-ethinyl A 0.15 mg-30 mcg
estrad-levomefolate tab LEVONORGESTREL AND A
3-0.02-0.451 mg (Beyaz) ETHINY - levonorgestrel-
drospirenone-ethinyl A ethinyl estradiol (continuous)
estradiol tab 3-0.02 mg tab 90-20 mcg
(Yaz) levonorgestrel tab 1.5 mg A
drospirenone-ethinyl A levonorgestrel-eth estra tab A
estradiol tab 3-0.03 mg 0.05-30/0.075-40/0.125-30mg-
(Yasmin 28) mcg
ELLA - ulipristal acetate tab 30 A LO LOESTRIN FE - norethin- A
mg eth estradiol-fe tab 1 mg-10
ethynodiol diacetate & A mcg (24)/10 mcg (2)
ethinyl estradiol tab medroxyprogesterone A
1 mg-35 mcg acetate im susp prefilled
ethynodiol diacetate & A syr 150 mg/ml (Depo-
ethinyl estradiol tab provera contrac)
1 mg-50 mcg (Zovia 1/50e) medroxyprogesterone A
FALESSA - levonorgest-eth 4 acetate im susp 150 mg/ml
estrad tab 0.1 mg-20 mcg & (Depo-provera contrac)
fa tab 1 mg kit

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
MINASTRIN 24 FE - 4 norethindrone ace & A
norethindrone ace-eth ethinyl estradiol-fe tab
estradiol-fe chew tab 1 1.5 mg-30 mcg (Loestrin fe
mg-20 mcg (24) 1.5/30)
NATAZIA - estradiol valerate- A norethindrone ace-eth 2
dienogest tab 3 mg /2-2 estradiol-fe chew tab
mg/2-3 mg/1 mg 1 mg-20 mcg (24) (Minastrin
NECON 1/50-28 - A 24 fe)
norethindrone & mestranol norethindrone ace- A
tab 1 mg-50 mcg ethinyl estradiol-fe tab
norethindrone & A 1 mg-20 mcg (24)
ethinyl estradiol tab Norethindrone tab 0.35 mg A
0.4 mg-35 mcg (Ovcon-35) (Nor-qd)
norethindrone & A norethindrone-eth estradiol A
ethinyl estradiol tab 0.5-35/0.75-35/1-35 mg-
tab 0.5 mg-35 mcg mcg (Ortho-novum 7/7/7)
(Brevicon-28) norethindrone-eth estradiol A
norethindrone & ethinyl A tab 0.5-35/1-35/0.5-35 mg-
estradiol tab 1 mg-35 mcg mcg (Tri-norinyl 28)
(Norinyl 1+35) norgestimate & A
norethindrone & ethinyl A ethinyl estradiol tab
estradiol-fe chew tab 0.25 mg-35 mcg (Ortho-
0.4 mg-35 mcg (Femcon fe) cyclen)
norethindrone & ethinyl A norgestimate-eth estrad tab A
estradiol-fe chew tab 0.18-25/0.215-25/0.25-25 mg-
0.8 mg-25 mcg (Generess mcg (Ortho tri-cyclen lo)
fe) norgestimate-eth estrad tab A
norethindrone ac- A 0.18-35/0.215-35/0.25-35 mg-
ethinyl estrad-fe tab mcg (Ortho tri-cyclen)
1-20/1-30/1-35 mg-mcg norgestrel & ethinyl A
(Estrostep fe) estradiol tab
norethindrone ace & ethinyl A 0.3 mg-30 mcg
estradiol tab 1 mg-20 mcg NUVARING - etonogestrel- A
(Loestrin 1/20-21) ethinyl estradiol va ring
norethindrone ace & A 0.120-0.015 mg/24hr
ethinyl estradiol tab OGESTREL - norgestrel & A
1.5 mg-30 mcg (Loestrin ethinyl estradiol tab 0.5
1.5/30-21) mg-50 mcg
norethindrone ace & A ORTHO TRI-CYCLEN LO - 4
ethinyl estradiol-fe tab norgestimate-eth estrad tab
1 mg-20 mcg (Loestrin fe 0.18-25/0.215-25/0.25-25
1/20) mg-mcg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
PARAGARD INTRAUTERINE A ACTOPLUS MET XR - 4
COP - copper iud pioglitazone hcl-metformin
QUARTETTE - levonor-eth est A hcl tab er 24hr 15-1000 mg
tab 0.15-0.02/0.025/0.03 mg ACTOPLUS MET XR - 4
&eth est 0.01 mg pioglitazone hcl-metformin
SAFYRAL - drospirenone- 4 hcl tab er 24hr 30-1000 mg
ethinyl estrad-levomefolate ALOGLIPTIN - alogliptin 4
tab 3-0.03-0.451 mg benzoate tab 6.25 mg (base
TAYTULLA - norethindrone A equiv)
ace-ethinyl estradiol-fe cap 1 ALOGLIPTIN - alogliptin 4
mg-20 mcg (24) benzoate tab 12.5 mg (base
XULANE - norelgestromin- A equiv)
ethinyl estradiol td ptwk ALOGLIPTIN - alogliptin 4
150-35 mcg/24hr benzoate tab 25 mg (base
PROGESTINS equiv)
medroxyprogesterone 1 ALOGLIPTIN/METFORMIN 4
acetate tab 2.5 mg HCL - alogliptin-metformin
(Provera) hcl tab 12.5-500 mg
medroxyprogesterone 1 ALOGLIPTIN/METFORMIN 4
acetate tab 5 mg (Provera) HCL - alogliptin-metformin
hcl tab 12.5-1000 mg
medroxyprogesterone 1
acetate tab 10 mg (Provera) ALOGLIPTIN/ 4
PIOGLITAZONE - alogliptin-
megestrol acetate susp 2
pioglitazone tab 12.5-15 mg
625 mg/5ml (Megace es)
2
ALOGLIPTIN/ 4
norethindrone acetate tab PIOGLITAZONE - alogliptin-
5 mg (Aygestin) pioglitazone tab 12.5-30 mg
progesterone im in oil 2 4
ALOGLIPTIN/
50 mg/ml PIOGLITAZONE - alogliptin-
progesterone micronized 2 pioglitazone tab 12.5-45 mg
cap 100 mg (Prometrium) ALOGLIPTIN/ 4
progesterone micronized 2 PIOGLITAZONE - alogliptin-
cap 200 mg (Prometrium) pioglitazone tab 25-15 mg
ANTIDIABETICS ALOGLIPTIN/ 4
acarbose tab 25 mg 2 PIOGLITAZONE - alogliptin-
(Precose) pioglitazone tab 25-30 mg
acarbose tab 50 mg 2 ALOGLIPTIN/ 4

(Precose) PIOGLITAZONE - alogliptin-
pioglitazone tab 25-45 mg
acarbose tab 100 mg 2
AVANDIA - rosiglitazone 4
(Precose)
maleate tab 2 mg (base
equiv)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
AVANDIA - rosiglitazone 4 glipizide tab 10 mg 1
maleate tab 4 mg (base (Glucotrol)
equiv) glipizide-metformin hcl tab 2
BYDUREON - exenatide for inj 4 2.5-250 mg
extended release susp 2 mg glipizide-metformin hcl tab 2
BYDUREON PEN - exenatide 4 2.5-500 mg
extended release for susp glipizide-metformin hcl tab 2
pen-injector 2 mg 5-500 mg
BYETTA - exenatide soln pen- 4 GLUCAGEN HYPOKIT - 4
injector 5 mcg/0.02ml glucagon hcl (rdna) for inj 1
BYETTA - exenatide soln pen- 4 mg (base equiv)
injector 10 mcg/0.04ml GLUCAGON EMERGENCY 3
CHLORPROPAMIDE - 4 KIT - glucagon (rdna) for inj
chlorpropamide tab 100 mg kit 1 mg
CHLORPROPAMIDE - 4 GLUMETZA - metformin hcl tab 4
chlorpropamide tab 250 mg er 24hr modified release 500
CYCLOSET - bromocriptine 4 mg
mesylate tab 0.8 mg (base GLUMETZA - metformin hcl 4
equivalent) tab er 24hr modified release
DEX4 QUICK DISSOLVE 4 1000 mg
GLUCO - glucose chew tab 4 glyburide micronized tab 1
gm 1.5 mg (Glynase)
FARXIGA - dapagliflozin 4 glyburide micronized tab 1
propanediol tab 5 mg (base 3 mg (Glynase)
equivalent) glyburide micronized tab 1
FARXIGA - dapagliflozin 4 6 mg (Glynase)
propanediol tab 10 mg (base glyburide tab 1.25 mg 1
equivalent)
glyburide tab 2.5 mg 1
glimepiride tab 1 mg 1
glyburide tab 5 mg 1
(Amaryl)
1 glyburide-metformin tab 1
glimepiride tab 2 mg
(Amaryl) 1.25-250 mg (Glucovance)
glimepiride tab 4 mg
(Amaryl) 2.5-500 mg (Glucovance)
glipizide tab er 24hr 2.5 mg
(Glucotrol xl) 5-500 mg (Glucovance)
1 GLYSET - miglitol tab 25 mg 4
glipizide tab er 24hr 5 mg
(Glucotrol xl) GLYSET - miglitol tab 50 mg 4
glipizide tab er 24hr 10 mg 1 GLYSET - miglitol tab 100 mg 4
(Glucotrol xl) GLYXAMBI - empagliflozin- 4
glipizide tab 5 mg (Glucotrol) 1 linagliptin tab 10-5 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
GLYXAMBI - empagliflozin- 4 JANUMET XR - sitagliptin- 3
linagliptin tab 25-5 mg metformin hcl tab er 24hr
INVOKAMET - canagliflozin- 3 100-1000 mg
metformin hcl tab 50-500 mg JANUVIA - sitagliptin 3
INVOKAMET - canagliflozin- 3 phosphate tab 25 mg (base
metformin hcl tab 50-1000 equiv)
mg JANUVIA - sitagliptin 3
mg JANUVIA - sitagliptin 3
mg JARDIANCE - empagliflozin 3
INVOKAMET XR - 3 tab 10 mg
canagliflozin-metformin hcl JARDIANCE - empagliflozin 3
tab er 24hr 50-500 mg tab 25 mg
INVOKAMET XR - 3 JENTADUETO - linagliptin- 4
canagliflozin-metformin hcl metformin hcl tab 2.5-500
tab er 24hr 50-1000 mg mg
INVOKANA - canagliflozin tab 3 JENTADUETO XR - linagliptin- 4
100 mg metformin hcl tab er 24hr
INVOKANA - canagliflozin tab 3 2.5-1000 mg
300 mg JENTADUETO XR - linagliptin- 4
JANUMET - sitagliptin- 3 metformin hcl tab er 24hr
metformin hcl tab 50-500 mg 5-1000 mg
JANUMET - sitagliptin- 3 KAZANO - alogliptin-metformin 4

metformin hcl tab 50-1000 hcl tab 12.5-500 mg
mg KAZANO - alogliptin-metformin 4
JANUMET XR - sitagliptin- 3 hcl tab 12.5-1000 mg
metformin hcl tab er 24hr KOMBIGLYZE XR - 3
50-500 mg saxagliptin-metformin hcl tab
JANUMET XR - sitagliptin- 3 er 24hr 2.5-1000 mg
metformin hcl tab er 24hr KOMBIGLYZE XR - 3
50-1000 mg saxagliptin-metformin hcl tab
er 24hr 5-500 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
KOMBIGLYZE XR - 3 ONGLYZA - saxagliptin hcl tab 3
saxagliptin-metformin hcl tab 2.5 mg (base equiv)
er 24hr 5-1000 mg ONGLYZA - saxagliptin hcl tab 3
KORLYM - mifepristone tab 5 5 mg (base equiv)
300 mg OSENI - alogliptin-pioglitazone 4
metformin hcl tab er 24hr 1 tab 12.5-15 mg
500 mg (Glucophage xr) OSENI - alogliptin-pioglitazone 4
750 mg (Glucophage xr) OSENI - alogliptin-pioglitazone 4
osmotic 500 mg (Fortamet) OSENI - alogliptin-pioglitazone 4
metformin hcl tab er 2 tab 25-15 mg
24hr osmotic 1000 mg OSENI - alogliptin-pioglitazone 4
(Fortamet) tab 25-30 mg
metformin hcl tab er 24hr 2 OSENI - alogliptin-pioglitazone 4
modified release 500 mg tab 25-45 mg
(Glumetza)
pioglitazone hcl tab 15 mg 1
metformin hcl tab er 24hr 2 (base equiv) (Actos)
modified release 1000 mg
(Glumetza)
(base equiv) (Actos)
metformin hcl tab 500 mg 1
(Glucophage)
(base equiv) (Actos)
pioglitazone hcl-metformin 2
(Glucophage)
hcl tab 15-500 mg (Actoplus
met)
(Glucophage)
pioglitazone hcl-metformin 2
miglitol tab 25 mg (Glyset) 2
hcl tab 15-850 mg (Actoplus
miglitol tab 50 mg (Glyset) 2 met)
miglitol tab 100 mg (Glyset) 2 PROGLYCEM - diazoxide susp 4
nateglinide tab 60 mg 2 50 mg/ml
(Starlix) repaglinide tab 0.5 mg 2
nateglinide tab 120 mg 2 (Prandin)
(Starlix) repaglinide tab 1 mg 2
NESINA - alogliptin benzoate 4 (Prandin)
tab 6.25 mg (base equiv) repaglinide tab 2 mg 2
NESINA - alogliptin benzoate 4 (Prandin)
tab 12.5 mg (base equiv) REPAGLINIDE/METFORMIN 4
NESINA - alogliptin benzoate 4 HYD - repaglinide-metformin
tab 25 mg (base equiv) hcl tab 1-500 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
REPAGLINIDE/METFORMIN 4 TRULICITY - dulaglutide soln 4
HYD - repaglinide-metformin pen-injector 1.5 mg/0.5ml
hcl tab 2-500 mg VICTOZA - liraglutide soln pen- 3
RIOMET - metformin hcl oral 4 injector 18 mg/3ml (6 mg/ml)
soln 500 mg/5ml WALGREENS GLUCOSE - 4
SYNJARDY - empagliflozin- 4 glucose chew tab 4 gm
metformin hcl tab 5-500 mg XIGDUO XR - dapagliflozin- 4
SYNJARDY - empagliflozin- 4 metformin hcl tab er 24hr
metformin hcl tab 5-1000 mg 5-500 mg
SYNJARDY - empagliflozin- 4 XIGDUO XR - dapagliflozin- 4
metformin hcl tab 12.5-500 metformin hcl tab er 24hr
mg 5-1000 mg
SYNJARDY - empagliflozin- 4 XIGDUO XR - dapagliflozin- 4
metformin hcl tab 12.5-1000 metformin hcl tab er 24hr
mg 10-500 mg
SYNJARDY XR - 4 XIGDUO XR - dapagliflozin- 4
empagliflozin-metformin hcl metformin hcl tab er 24hr
tab er 24hr 5-1000 mg 10-1000 mg
SYNJARDY XR - 4 Rapid-Acting Insulins
empagliflozin-metformin hcl APIDRA - insulin glulisine inj 4
tab er 24hr 10-1000 mg 100 unit/ml
SYNJARDY XR - 4 APIDRA SOLOSTAR - insulin 4
empagliflozin-metformin hcl glulisine soln pen-injector inj
tab er 24hr 12.5-1000 mg 100 unit/ml
SYNJARDY XR - 4 HUMALOG - insulin lispro inj 4
empagliflozin-metformin hcl 100 unit/ml
tab er 24hr 25-1000 mg
HUMALOG - insulin lispro soln 4
TANZEUM - albiglutide for soln 4 cartridge 100 unit/ml
pen-injector 30 mg
HUMALOG KWIKPEN - insulin 4
TANZEUM - albiglutide for soln 4 lispro soln pen-injector 100
pen-injector 50 mg unit/ml
4
TOLAZAMIDE - tolazamide tab HUMALOG KWIKPEN - insulin 4
250 mg lispro soln pen-injector 200
TOLAZAMIDE - tolazamide tab 4 unit/ml
500 mg NOVOLOG - insulin aspart inj 2
TOLBUTAMIDE - tolbutamide 4 100 unit/ml
tab 500 mg NOVOLOG FLEXPEN - insulin 2
TRADJENTA - linagliptin tab 5 4 aspart soln pen-injector 100
mg unit/ml
TRULICITY - dulaglutide soln 4
pen-injector 0.75 mg/0.5ml

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
NOVOLOG PENFILL - insulin 2 RELION R - insulin regular 3
aspart soln cartridge 100 (human) inj 100 unit/ml
unit/ml Intermediate-Acting Insulins
Short-Acting Insulins HUMALOG MIX 50/50 - insulin 4
AFREZZA - insulin regular 4 lispro protamine & lispro inj
(human) inh powd 8 (60) & 100 unit/ml (50-50)
12 (30) unit/cart HUMALOG MIX 50/50 4
AFREZZA - insulin regular 4 KWIKPEN - insulin lispro prot
(human) inh powd 4 & 8 & & lispro sus pen-inj 100 unit/
12 unit/cart (60) ml (50-50)
AFREZZA - insulin regular 4 HUMALOG MIX 75/25 - insulin 4
(human) inhal powd 4 (30) & lispro prot & lispro inj 100
8 (60) unit/cart unit/ml (75-25)
AFREZZA - insulin regular 4 HUMALOG MIX 75/25 4
(human) inhal powd 4 (60) & KWIKPEN - insulin lispro prot
8 (30) unit/cart & lispro sus pen-inj 100 unit/
AFREZZA - insulin regular 4 ml (75-25)
(human) inhal powd 4 (90) & HUMULIN N - insulin nph 4
8 (90) unit/cart (human) (isophane) inj 100
AFREZZA - insulin regular 4 unit/ml
(human) inhalation powder 4 HUMULIN N KWIKPEN - 4
unit/cartridge insulin nph (human)
AFREZZA - insulin regular 4 (isophane) susp pen-injector
(human) inhalation powder 8 100 unit/ml
unit/cartridge HUMULIN 70/30 - insulin nph 4
AFREZZA - insulin regular 4 isophane & regular human
(human) inhalation powder inj 100 unit/ml (70-30)
12 unit/cartridge HUMULIN 70/30 KWIKPEN - 4
HUMULIN R - insulin regular 4 insulin nph & regular susp
(human) inj 100 unit/ml pen-inj 100 unit/ml (70-30)
HUMULIN R U-500 3 NOVOLIN N - insulin nph 2

(CONCENTR - insulin regular (human) (isophane) inj 100
(human) inj 500 unit/ml unit/ml
HUMULIN R U-500 3 NOVOLIN N RELION - insulin 2

KWIKPEN - insulin regular nph (human) (isophane) inj
(human) soln pen-injector 100 unit/ml
500 unit/ml NOVOLIN 70/30 - insulin nph 2
NOVOLIN R - insulin regular 2 isophane & regular human
(human) inj 100 unit/ml inj 100 unit/ml (70-30)
NOVOLIN R RELION - insulin 2 NOVOLIN 70/30 RELION - 2

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

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
NOVOLOG MIX 70/30 - insulin 2 levothyroxine sodium tab 1
aspart prot & aspart (human) 50 mcg (Synthroid)
inj 100 unit/ml (70-30) levothyroxine sodium tab 1
NOVOLOG MIX 70/30 2 75 mcg (Synthroid)
PREFILL - insulin aspart prot levothyroxine sodium tab 1
& aspart sus pen-inj 100 88 mcg (Synthroid)
unit/ml (70-30)
levothyroxine sodium tab 1
Basal Insulins 100 mcg (Synthroid)
LANTUS - insulin glargine inj 3 levothyroxine sodium tab 1
100 unit/ml 112 mcg (Synthroid)
LANTUS SOLOSTAR - insulin 3 levothyroxine sodium tab 1
glargine soln pen-injector 125 mcg (Synthroid)
100 unit/ml
LEVEMIR - insulin detemir inj 3 137 mcg (Synthroid)
100 unit/ml
LEVEMIR FLEXTOUCH - 3 150 mcg (Synthroid)
insulin detemir soln pen-
injector 100 unit/ml
175 mcg (Synthroid)
TOUJEO SOLOSTAR - insulin 3 1
glargine soln pen-injector levothyroxine sodium tab
300 unit/ml 200 mcg (Synthroid)
3 levothyroxine sodium tab 1
TRESIBA FLEXTOUCH -
insulin degludec soln pen- 300 mcg (Synthroid)
injector 100 unit/ml liothyronine sodium tab 2
TRESIBA FLEXTOUCH - 3 5 mcg (Cytomel)
insulin degludec soln pen- liothyronine sodium tab 2
injector 200 unit/ml 25 mcg (Cytomel)
THYROID AGENTS liothyronine sodium tab 2
ARMOUR THYROID - thyroid 4 50 mcg (Cytomel)
tab 15 mg (1/4 grain) methimazole tab 5 mg 1
ARMOUR THYROID - thyroid 4 (Tapazole)
tab 120 mg (2 grain) methimazole tab 10 mg 1
ARMOUR THYROID - thyroid 4 (Tapazole)
tab 180 mg (3 grain) NATURE-THROID - thyroid tab 4
ARMOUR THYROID - thyroid 4 16.25 mg
ARMOUR THYROID - thyroid 4 32.5 mg
levothyroxine sodium tab 1 48.75 mg (3/4 grain)
25 mcg (Synthroid) NATURE-THROID - thyroid tab 4
65 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
NATURE-THROID - thyroid tab 4 SYNTHROID - levothyroxine 4
81.25 mg sodium tab 300 mcg
NATURE-THROID - thyroid tab 4 thyroid tab 30 mg (1/2 grain) 1
97.5 mg (Armour thyroid)
NATURE-THROID - thyroid tab 4 thyroid tab 60 mg (1 grain) 1
113.75 mg (Armour thyroid)
NATURE-THROID - thyroid tab 4 thyroid tab 90 mg (1 1
130 mg 1/2 grain) (Armour thyroid)
NATURE-THROID - thyroid tab 4 thyroid tab 120 mg (2 grain) 1
195 mg (Armour thyroid)
NATURE-THROID - thyroid tab 4 THYROLAR-1 - liotrix (t3-t4) 4
260 mg tab 60 mg (12.5-50 mcg)
NATURE-THROID - thyroid tab 4 THYROLAR-1/2 - liotrix (t3-t4) 4
325 mg (5 grain) tab 30 mg (6.25-25 mcg)
NATURE-THROID - thyroid tab 4 THYROLAR-1/4 - liotrix (t3-t4) 4
146.25 mg tab 15 mg (3.1-12.5 mcg)
propylthiouracil tab 50 mg 2 THYROLAR-2 - liotrix (t3-t4) 4
SYNTHROID - levothyroxine 4 tab 120 mg (25-100 mcg)
sodium tab 25 mcg THYROLAR-3 - liotrix (t3-t4) 4
SYNTHROID - levothyroxine 4 tab 180 mg (37.5-150 mcg)
sodium tab 50 mcg TIROSINT - levothyroxine 4
SYNTHROID - levothyroxine 4 sodium cap 13 mcg
sodium cap 150 mcg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
WESTHROID - thyroid tab 32.5 4 alendronate sodium tab 1
mg 5 mg
WESTHROID - thyroid tab 65 4 alendronate sodium tab 1
mg 10 mg
WESTHROID - thyroid tab 97.5 4 alendronate sodium tab 1
mg 35 mg
WESTHROID - thyroid tab 130 4 alendronate sodium tab 1
mg 70 mg (Fosamax)
WESTHROID - thyroid tab 195 4 BRAVELLE - urofollitropin 5
mg purified for inj 75 unit
WP THYROID - thyroid tab 4 BUPHENYL - sodium 5
16.25 mg phenylbutyrate tab 500 mg
WP THYROID - thyroid tab 4 cabergoline tab 0.5 mg 2
32.5 mg calcitonin (salmon) 2
WP THYROID - thyroid tab 4 nasal soln 200 unit/act
48.75 mg (3/4 grain) (Miacalcin)
WP THYROID - thyroid tab 65 4 calcitriol cap 0.25 mcg 2
mg (Rocaltrol)
WP THYROID - thyroid tab 4 calcitriol cap 0.5 mcg 2
81.25 mg (Rocaltrol)
WP THYROID - thyroid tab 4 calcitriol oral soln 1 mcg/ml 2
97.5 mg (Rocaltrol)
WP THYROID - thyroid tab 4 CARBAGLU - carglumic acid 5
113.75 mg tab 200 mg
WP THYROID - thyroid tab 130 4 CETROTIDE - cetrorelix 5
mg acetate for inj kit 0.25 mg
OXYTOCICS CHORIONIC 5
CERVIDIL - dinoprostone 4 GONADOTROPIN - chorionic
vaginal inserts 10 mg gonadotropin for inj 10000
unit
METHERGINE - 2
CLOMIPHENE CITRATE - 1
methylergonovine maleate
tab 0.2 mg clomiphene citrate tab 50 mg
PREPIDIL - dinoprostone 4 CYSTADANE - betaine powder 4

cervical gel 0.5 mg/3gm for oral solution
4 desmopressin acetate inj 2
PROSTIN E2 - dinoprostone
vaginal suppos 20 mg 4 mcg/ml (Ddavp)
desmopressin acetate nasal 2
ENDOCRINE and METABOLIC AGENTS - MISC.
soln 0.01% (refrigerated)
ALENDRONATE SODIUM - 4 (Ddavp)
alendronate sodium tab 40
desmopressin acetate nasal 2
mg
spray soln 0.01% (Ddavp)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
desmopressin acetate 2 GONAL-F - follitropin alfa for inj 5
nasal spray soln 0.01% 450 unit
(refrigerated) GONAL-F - follitropin alfa for inj 5
desmopressin acetate tab 2 1050 unit
0.1 mg (Ddavp) GONAL-F RFF - follitropin alfa 5
desmopressin acetate tab 2 for inj 75 unit
0.2 mg (Ddavp) GONAL-F RFF REDIJECT - 5
doxercalciferol cap 0.5 mcg 2 follitropin alfa inj 300
(Hectorol) unit/0.5ml
doxercalciferol cap 1 mcg 2 GONAL-F RFF REDIJECT - 5
(Hectorol) follitropin alfa inj 450
doxercalciferol cap 2.5 mcg 2 unit/0.75ml
(Hectorol) GONAL-F RFF REDIJECT - 5
EGRIFTA - tesamorelin acetate 5 follitropin alfa inj 900
for inj 1 mg (base equiv) unit/1.5ml
ETIDRONATE DISODIUM - 4 H.P. ACTHAR - corticotropin inj 5

etidronate disodium tab 200 gel 80 unit/ml
mg ibandronate sodium tab 2
FOLLISTIM AQ - follitropin beta 5 150 mg (base equivalent)
inj 75 unit/0.5ml (Boniva)
FOLLISTIM AQ - follitropin beta 5 INCRELEX - mecasermin inj 40 5

inj 300 unit/0.36ml mg/4ml (10 mg/ml)
FOLLISTIM AQ - follitropin beta 5 KUVAN - sapropterin 5

inj 600 unit/0.72ml dihydrochloride powder
packet 100 mg
FOLLISTIM AQ - follitropin beta 5
inj 900 unit/1.08ml KUVAN - sapropterin 5
dihydrochloride powder
FORTEO - teriparatide 5 packet 500 mg
(recombinant) inj 600
mcg/2.4ml KUVAN - sapropterin 5
dihydrochloride soluble tab
FOSAMAX PLUS D - 4 100 mg
alendronate sodium-
levocarnitine oral soln 2
cholecalciferol tab 70-2800
mg-unit 1 gm/10ml (10%) (Carnitor)
2
FOSAMAX PLUS D - 4 levocarnitine tab 330 mg
alendronate sodium- (Carnitor)
cholecalciferol tab 70-5600 MENOPUR - menotropins for 5
mg-unit subcutaneous inj 75 unit
GANIRELIX ACETATE - 5 MYALEPT - metreleptin for 5
ganirelix acetate inj 250 subcutaneous inj 11.3 mg
mcg/0.5ml

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
NOVAREL - chorionic 5 PREGNYL W/DILUENT 5
gonadotropin for inj 10000 BENZYL - chorionic
unit gonadotropin for inj 10000
octreotide acetate inj 5 unit
50 mcg/ml (0.05 mg/ml) raloxifene hcl tab 60 mg 2
(Sandostatin) (Evista)
octreotide acetate inj 5 RAVICTI - glycerol 5
100 mcg/ml (0.1 mg/ml) phenylbutyrate liquid 1.1 gm/
(Sandostatin) ml
octreotide acetate inj 5 risedronate sodium tab 2
200 mcg/ml (0.2 mg/ml) delayed release 35 mg
(Sandostatin) (Atelvia)
octreotide acetate inj 5 risedronate sodium tab 5 mg 2
500 mcg/ml (0.5 mg/ml) (Actonel)
(Sandostatin) risedronate sodium tab 2
octreotide acetate inj 5 30 mg (Actonel)
1000 mcg/ml (1 mg/ml) risedronate sodium tab 2
(Sandostatin) 35 mg (Actonel)
OMNITROPE - somatropin for 5 risedronate sodium tab 2
inj 5.8 mg 150 mg (Actonel)
OMNITROPE - somatropin inj 5 5 SAMSCA - tolvaptan tab 15 mg 5
mg/1.5ml
SAMSCA - tolvaptan tab 30 mg 5
OMNITROPE - somatropin inj 5 3
10 mg/1.5ml SENSIPAR - cinacalcet hcl tab
30 mg (base equiv)
ORFADIN - nitisinone cap 2 mg 5 3
SENSIPAR - cinacalcet hcl tab
ORFADIN - nitisinone cap 5 mg 5 60 mg (base equiv)
ORFADIN - nitisinone cap 10 5 SENSIPAR - cinacalcet hcl tab 3
mg 90 mg (base equiv)
ORFADIN - nitisinone cap 20 5 SIGNIFOR - pasireotide 5
mg diaspartate inj 0.3 mg/ml
ORFADIN - nitisinone susp 4 5 (base equiv)
mg/ml SIGNIFOR - pasireotide 5
OVIDREL - choriogonadotropin 5 diaspartate inj 0.6 mg/ml
alfa inj 250 mcg/0.5ml (base equiv)
paricalcitol cap 1 mcg 2 SIGNIFOR - pasireotide 5
(Zemplar) diaspartate inj 0.9 mg/ml
paricalcitol cap 2 mcg 2 (base equiv)
(Zemplar) sodium phenylbutyrate oral 5
paricalcitol cap 4 mcg 2 powder 3 gm/teaspoonful
(Buphenyl)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
SOMAVERT - pegvisomant for 5 LANOXIN - digoxin tab 187.5 4
inj 10 mg (as protein) mcg (0.1875 mg)
SOMAVERT - pegvisomant for 5 LANOXIN - digoxin tab 250 4
inj 15 mg (as protein) mcg (0.25 mg)
SOMAVERT - pegvisomant for 5 ANTIANGINAL AGENTS
inj 20 mg (as protein) DILATRATE SR - isosorbide 4
SOMAVERT - pegvisomant for 5 dinitrate cap er 40 mg
inj 25 mg (as protein) ISORDIL TITRADOSE - 4
SOMAVERT - pegvisomant for 5 isosorbide dinitrate tab 40
inj 30 mg (as protein) mg
STIMATE - desmopressin 3 ISOSORBIDE DINITRATE ER - 4
acetate nasal soln 1.5 mg/ml isosorbide dinitrate tab er 40
STRENSIQ - asfotase alfa 5 mg
subcutaneous inj 18 isosorbide dinitrate tab 5 mg 2
mg/0.45ml (Isordil titradose)
STRENSIQ - asfotase alfa 5 isosorbide dinitrate tab 2
subcutaneous inj 28 10 mg
mg/0.7ml isosorbide dinitrate tab 2
STRENSIQ - asfotase alfa 5 20 mg
subcutaneous inj 40 mg/ml isosorbide dinitrate tab 2
STRENSIQ - asfotase alfa 5 30 mg
subcutaneous inj 80 isosorbide mononitrate tab 1
mg/0.8ml er 24hr 30 mg
SYNAREL - nafarelin acetate 4 1
isosorbide mononitrate tab
nasal soln 2 mg/ml (200 er 24hr 60 mg
mcg/act) (base eq)
isosorbide mononitrate tab 2
TYMLOS - abaloparatide 5 er 24hr 120 mg
subcutaneous soln pen-
injector 3120 mcg/1.56ml
10 mg
CARDIOVASCULAR AGENTS
CARDIOTONICS 20 mg
DIGOXIN - digoxin oral soln 4 4
NITRO-BID - nitroglycerin oint
0.05 mg/ml 2%
digoxin tab 125 mcg 2 4
NITRO-DUR - nitroglycerin td
(0.125 mg) (Lanoxin) patch 24hr 0.3 mg/hr
digoxin tab 250 mcg 2 4
NITRO-DUR - nitroglycerin td
(0.25 mg) (Lanoxin) patch 24hr 0.8 mg/hr
LANOXIN - digoxin tab 62.5 4 2
nitroglycerin cap er 2.5 mg
mcg (0.0625 mg)
nitroglycerin cap er 6.5 mg 2
LANOXIN - digoxin tab 125 4
nitroglycerin cap er 9 mg 2
mcg (0.125 mg)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
NITROGLYCERIN LINGUAL - 4 atenolol tab 50 mg 1
nitroglycerin lingual aerosol (Tenormin)
400 mcg/spray atenolol tab 100 mg 1
nitroglycerin sl tab 0.3 mg 2 (Tenormin)
(Nitrostat) betaxolol hcl tab 10 mg 2
nitroglycerin sl tab 0.4 mg 2 (Kerlone)
(Nitrostat) betaxolol hcl tab 20 mg 2
nitroglycerin sl tab 0.6 mg 2 (Kerlone)
(Nitrostat) bisoprolol fumarate tab 5 mg 1
nitroglycerin td patch 24hr 2 (Zebeta)
0.1 mg/hr (Nitro-dur) bisoprolol fumarate tab 1
nitroglycerin td patch 24hr 2 10 mg (Zebeta)
0.2 mg/hr (Nitro-dur) BYSTOLIC - nebivolol hcl tab 4
nitroglycerin td patch 24hr 2 2.5 mg (base equivalent)
0.4 mg/hr (Nitro-dur) BYSTOLIC - nebivolol hcl tab 5 4
nitroglycerin td patch 24hr 2 mg (base equivalent)
0.6 mg/hr (Nitro-dur) BYSTOLIC - nebivolol hcl tab 4
nitroglycerin tl soln 0.4 mg/ 2 10 mg (base equivalent)
spray (400 mcg/spray) BYSTOLIC - nebivolol hcl tab 4
(Nitrolingual pumpspr) 20 mg (base equivalent)
NITROMIST - nitroglycerin 4 1
carvedilol tab 3.125 mg
lingual aerosol 400 mcg/ (Coreg)
spray
carvedilol tab 6.25 mg 1
NITROSTAT - nitroglycerin sl 3
(Coreg)
tab 0.3 mg
carvedilol tab 12.5 mg 1
(Coreg)
tab 0.4 mg
carvedilol tab 25 mg (Coreg) 1
COREG CR - carvedilol 4
tab 0.6 mg
phosphate cap er 24hr 10
RANEXA - ranolazine tab er 4
mg
12hr 500 mg
COREG CR - carvedilol 4
RANEXA - ranolazine tab er 4
phosphate cap er 24hr 20
12hr 1000 mg mg
BETA BLOCKERS COREG CR - carvedilol 4
acebutolol hcl cap 200 mg 1 phosphate cap er 24hr 40
(Sectral) mg
acebutolol hcl cap 400 mg 1 COREG CR - carvedilol 4
(Sectral) phosphate cap er 24hr 80
atenolol tab 25 mg 1 mg
(Tenormin) labetalol hcl tab 100 mg 2
(Trandate)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
labetalol hcl tab 200 mg 2 propranolol hcl tab 80 mg 1
(Trandate) sotalol hcl (afib/afl) tab 2
labetalol hcl tab 300 mg 2 80 mg (Betapace af)
(Trandate) sotalol hcl (afib/afl) tab 2
metoprolol succinate tab er 1 120 mg (Betapace af)
24hr 25 mg (tartrate equiv) sotalol hcl (afib/afl) tab 2
(Toprol xl) 160 mg (Betapace af)
metoprolol succinate tab er 1 1
sotalol hcl tab 80 mg
24hr 50 mg (tartrate equiv) (Betapace)
(Toprol xl)
sotalol hcl tab 120 mg 1
metoprolol succinate tab 2
(Betapace)
er 24hr 100 mg (tartrate
equiv) (Toprol xl)
(Betapace)
metoprolol succinate tab 2
er 24hr 200 mg (tartrate
equiv) (Toprol xl) TIMOLOL MALEATE - timolol 4
metoprolol tartrate tab 1 maleate tab 5 mg
25 mg TIMOLOL MALEATE - timolol 4
50 mg (Lopressor) TIMOLOL MALEATE - timolol 4
100 mg (Lopressor) CALCIUM CHANNEL BLOCKERS
nadolol tab 20 mg (Corgard) 2 amlodipine besylate tab 1
nadolol tab 40 mg (Corgard) 2 2.5 mg (Norvasc)
2 amlodipine besylate tab 1
nadolol tab 80 mg (Corgard)
5 mg (Norvasc)
pindolol tab 5 mg 2
amlodipine besylate tab 1
pindolol tab 10 mg 2
10 mg (Norvasc)
propranolol hcl cap er 24hr 2 4
CARDIZEM LA - diltiazem hcl
60 mg (Inderal la) coated beads tab er 24hr
propranolol hcl cap er 24hr 2 120 mg
80 mg (Inderal la) diltiazem hcl cap er 12hr 2
propranolol hcl tab 10 mg 1 120 mg
propranolol hcl tab 20 mg 1 diltiazem hcl cap er 24hr 1
propranolol hcl tab 40 mg 1 120 mg
2 diltiazem hcl cap er 24hr 1
propranolol hcl tab 60 mg
180 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
diltiazem hcl cap er 24hr 1 diltiazem hcl extended 2
240 mg release beads cap er 24hr
diltiazem hcl coated beads 1 300 mg (Tiazac)
cap er 24hr 120 mg diltiazem hcl extended 2
(Cardizem cd) release beads cap er 24hr
cap er 24hr 180 mg diltiazem hcl extended 2
(Cardizem cd) release beads cap er 24hr
cap er 24hr 240 mg diltiazem hcl tab 30 mg 1
(Cardizem cd) (Cardizem)
diltiazem hcl coated beads 2 diltiazem hcl tab 60 mg 1
cap er 24hr 300 mg (Cardizem)
diltiazem hcl coated beads 2 diltiazem hcl tab 90 mg 1
cap er 24hr 360 mg diltiazem hcl tab 120 mg 1
(Cardizem cd) (Cardizem)
diltiazem hcl coated beads 2 2
felodipine tab er 24hr 2.5 mg
tab er 24hr 180 mg
felodipine tab er 24hr 5 mg 2
(Cardizem la)
2 felodipine tab er 24hr 10 mg 2
diltiazem hcl coated beads
tab er 24hr 240 mg isradipine cap 2.5 mg 2
(Cardizem la) isradipine cap 5 mg 2
diltiazem hcl coated beads 2 2
nicardipine hcl cap 20 mg
tab er 24hr 300 mg
nicardipine hcl cap 30 mg 2
(Cardizem la)
2 nifedipine cap 10 mg 2
diltiazem hcl coated beads
tab er 24hr 360 mg (Procardia)
(Cardizem la) nifedipine cap 20 mg 2
diltiazem hcl coated beads 2 nifedipine tab er 24hr 30 mg 1
tab er 24hr 420 mg (Adalat cc)
(Cardizem la) 2
nifedipine tab er 24hr 60 mg
diltiazem hcl extended 2 (Adalat cc)
release beads cap er 24hr 2
nifedipine tab er 24hr 90 mg
120 mg (Tiazac)
(Adalat cc)
diltiazem hcl extended 2
nifedipine tab er 24hr 1
release beads cap er 24hr
osmotic release 30 mg
180 mg (Tiazac)
(Procardia xl)
diltiazem hcl extended 2
nifedipine tab er 24hr 2
release beads cap er 24hr
osmotic release 60 mg
240 mg (Tiazac)
(Procardia xl)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
nifedipine tab er 24hr 2 verapamil hcl tab 40 mg 2
osmotic release 90 mg verapamil hcl tab 80 mg 1
(Procardia xl) (Calan)
nimodipine cap 30 mg 2 1
verapamil hcl tab 120 mg
NISOLDIPINE ER - nisoldipine 4 (Calan)
tab er 24hr 20 mg ANTIARRHYTHMICS
NISOLDIPINE ER - nisoldipine 4 2
amiodarone hcl tab 100 mg
tab er 24hr 25.5 mg
amiodarone hcl tab 200 mg 1
NISOLDIPINE ER - nisoldipine 4
(Cordarone)
tab er 24hr 30 mg
amiodarone hcl tab 400 mg 2
NISOLDIPINE ER - nisoldipine 4
disopyramide phosphate 2
tab er 24hr 40 mg
cap 100 mg (Norpace)
nisoldipine tab er 24hr 2
disopyramide phosphate 2
8.5 mg (Sular)
cap 150 mg (Norpace)
dofetilide cap 125 mcg 2
17 mg (Sular)
(0.125 mg) (Tikosyn)
34 mg (Sular)
(0.25 mg) (Tikosyn)
NYMALIZE - nimodipine oral 4
soln 60 mg/20ml
(0.5 mg) (Tikosyn)
verapamil hcl cap er 24hr 2
flecainide acetate tab 50 mg 2
100 mg (Verelan pm)
2 flecainide acetate tab 2
verapamil hcl cap er 24hr
120 mg (Verelan) 100 mg
2 flecainide acetate tab 2
180 mg (Verelan) 150 mg
2 mexiletine hcl cap 150 mg 2
200 mg (Verelan pm) mexiletine hcl cap 200 mg 2
verapamil hcl cap er 24hr 2 mexiletine hcl cap 250 mg 2
240 mg (Verelan) MULTAQ - dronedarone hcl tab 4
verapamil hcl cap er 24hr 2 400 mg (base equivalent)
300 mg (Verelan pm) NORPACE - disopyramide 4
verapamil hcl cap er 24hr 2 phosphate cap 100 mg
360 mg (Verelan) NORPACE - disopyramide 4
verapamil hcl tab er 120 mg 1 phosphate cap 150 mg
(Calan sr) NORPACE CR - disopyramide 4
verapamil hcl tab er 180 mg 1 phosphate cap er 12hr 100
(Calan sr) mg
verapamil hcl tab er 240 mg 1
(Calan sr)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
NORPACE CR - disopyramide 4 amlodipine besylate- 1
phosphate cap er 12hr 150 benazepril hcl cap
mg 10-20 mg (Lotrel)
propafenone hcl cap er 12hr 2 amlodipine besylate- 1
225 mg (Rythmol sr) benazepril hcl cap
propafenone hcl cap er 12hr 2 10-40 mg (Lotrel)
325 mg (Rythmol sr) amlodipine besylate- 2
propafenone hcl cap er 12hr 2 valsartan tab 5-160 mg
425 mg (Rythmol sr) (Exforge)
2 amlodipine besylate- 2
propafenone hcl tab 150 mg
(Rythmol) valsartan tab 5-320 mg
(Exforge)
propafenone hcl tab 225 mg 2
amlodipine besylate- 2
(Rythmol)
valsartan tab 10-160 mg
propafenone hcl tab 300 mg 2
(Exforge)
quinidine gluconate tab er 2 2
amlodipine besylate-
324 mg valsartan tab 10-320 mg
QUINIDINE SULFATE - 4 (Exforge)
quinidine sulfate tab 200 mg amlodipine-valsartan- 2
QUINIDINE SULFATE - 4 hydrochlorothiazide tab
quinidine sulfate tab 300 mg 5-160-12.5 mg (Exforge hct)
TIKOSYN - dofetilide cap 125 4 amlodipine-valsartan- 2
mcg (0.125 mg) hydrochlorothiazide tab
TIKOSYN - dofetilide cap 250 4 5-160-25 mg (Exforge hct)
mcg (0.25 mg) amlodipine-valsartan- 2
TIKOSYN - dofetilide cap 500 4 hydrochlorothiazide tab
mcg (0.5 mg) 10-160-12.5 mg (Exforge
hct)
ANTIHYPERTENSIVES 2
amlodipine-valsartan-
hydrochlorothiazide tab
benazepril hcl cap 10-160-25 mg (Exforge hct)
2.5-10 mg (Lotrel) 2
amlodipine-valsartan-
benazepril hcl cap 5-10 mg 10-320-25 mg (Exforge hct)
(Lotrel) 1
atenolol & chlorthalidone
tab 50-25 mg (Tenoretic 50)
benazepril hcl cap 5-20 mg 1
(Lotrel) atenolol & chlorthalidone
tab 100-25 mg (Tenoretic
100)
benazepril hcl cap 5-40 mg 2
(Lotrel) benazepril &
5-6.25 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
benazepril & 2 candesartan cilexetil- 2
hydrochlorothiazide tab hydrochlorothiazide tab
10-12.5 mg (Lotensin hct) 16-12.5 mg (Atacand hct)
20-12.5 mg (Lotensin hct) 32-12.5 mg (Atacand hct)
20-25 mg (Lotensin hct) 32-25 mg (Atacand hct)
benazepril hcl tab 5 mg 1 captopril tab 12.5 mg 2
benazepril hcl tab 10 mg 1 captopril tab 25 mg 2
(Lotensin) captopril tab 50 mg 2
benazepril hcl tab 20 mg 1 2
captopril tab 100 mg
(Lotensin)
clonidine hcl tab 0.1 mg 1
benazepril hcl tab 40 mg 1
(Catapres)
(Lotensin)
BENICAR - olmesartan 4
(Catapres)
medoxomil tab 5 mg
(Catapres)
medoxomil tab 20 mg
clonidine hcl td patch 2
weekly 0.1 mg/24hr
medoxomil tab 40 mg (Catapres-tts-1)
bisoprolol & 1 2
clonidine hcl td patch
hydrochlorothiazide tab weekly 0.2 mg/24hr
2.5-6.25 mg (Ziac) (Catapres-tts-2)
bisoprolol & 1 2
clonidine hcl td patch
hydrochlorothiazide tab weekly 0.3 mg/24hr
5-6.25 mg (Ziac) (Catapres-tts-3)
bisoprolol & 1 4
DEMSER - metyrosine cap 250
hydrochlorothiazide tab mg
10-6.25 mg (Ziac)
doxazosin mesylate tab 1
candesartan cilexetil tab 2
1 mg (Cardura)
4 mg (Atacand)
2 mg (Cardura)
8 mg (Atacand)
4 mg (Cardura)
16 mg (Atacand)
8 mg (Cardura)
32 mg (Atacand)
EDARBI - azilsartan medoxomil 4
tab 40 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
EDARBI - azilsartan medoxomil 4 irbesartan tab 75 mg 1
tab 80 mg (Avapro)
enalapril maleate & 1 irbesartan tab 150 mg 1
hydrochlorothiazide tab (Avapro)
5-12.5 mg irbesartan tab 300 mg 1
enalapril maleate & 1 (Avapro)
hydrochlorothiazide tab irbesartan- 1
10-25 mg (Vaseretic) hydrochlorothiazide tab
enalapril maleate tab 2.5 mg 1 150-12.5 mg (Avalide)
(Vasotec) irbesartan- 1
enalapril maleate tab 5 mg 1 hydrochlorothiazide tab
(Vasotec) 300-12.5 mg (Avalide)
enalapril maleate tab 10 mg 1 lisinopril & 1
(Vasotec) hydrochlorothiazide tab
enalapril maleate tab 20 mg 2 10-12.5 mg (Zestoretic)
(Vasotec) lisinopril & 1
eplerenone tab 25 mg 2 hydrochlorothiazide tab
(Inspra) 20-12.5 mg (Zestoretic)
2 lisinopril & 1
eplerenone tab 50 mg
(Inspra) hydrochlorothiazide tab
20-25 mg (Zestoretic)
EPROSARTAN MESYLATE - 4
lisinopril tab 2.5 mg (Zestril) 1
eprosartan mesylate tab 600
mg lisinopril tab 5 mg (Prinivil) 1
fosinopril sodium & 2 lisinopril tab 10 mg (Prinivil) 1
hydrochlorothiazide tab lisinopril tab 20 mg (Prinivil) 1
10-12.5 mg
lisinopril tab 30 mg (Zestril) 1
fosinopril sodium & 2
lisinopril tab 40 mg (Zestril) 1
20-12.5 mg losartan potassium & 1
fosinopril sodium tab 10 mg 1 hydrochlorothiazide tab
50-12.5 mg (Hyzaar)
fosinopril sodium tab 20 mg 1
losartan potassium & 1
fosinopril sodium tab 40 mg 1
guanfacine hcl tab 1 mg 1 100-12.5 mg (Hyzaar)
(Tenex) losartan potassium & 1
guanfacine hcl tab 2 mg 1 hydrochlorothiazide tab
(Tenex) 100-25 mg (Hyzaar)
hydralazine hcl tab 10 mg 1 losartan potassium tab 1
hydralazine hcl tab 25 mg 1 25 mg (Cozaar)
1 losartan potassium tab 1
hydralazine hcl tab 50 mg
50 mg (Cozaar)
hydralazine hcl tab 100 mg 1

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
losartan potassium tab 1 perindopril erbumine tab 1
100 mg (Cozaar) 2 mg
methyldopa tab 250 mg 1 perindopril erbumine tab 1
methyldopa tab 500 mg 1 4 mg (Aceon)
2 perindopril erbumine tab 1
metoprolol &
hydrochlorothiazide tab 8 mg (Aceon)
50-25 mg (Lopressor hct) phenoxybenzamine hcl cap 2
metoprolol & 2 10 mg (Dibenzyline)
hydrochlorothiazide tab prazosin hcl cap 1 mg 2
100-25 mg (Lopressor hct) (Minipress)
METOPROLOL/ 2 prazosin hcl cap 2 mg 2
HYDROCHLOROTHI - (Minipress)
metoprolol & prazosin hcl cap 5 mg 2
hydrochlorothiazide tab (Minipress)
100-50 mg
quinapril hcl tab 5 mg 1
minoxidil tab 2.5 mg 1
(Accupril)
minoxidil tab 10 mg 1 1
quinapril hcl tab 10 mg
moexipril hcl tab 7.5 mg 2 (Accupril)
moexipril hcl tab 15 mg 2 quinapril hcl tab 20 mg 1
moexipril- 2 (Accupril)
hydrochlorothiazide tab quinapril hcl tab 40 mg 1
7.5-12.5 mg (Accupril)
moexipril- 2 quinapril- 2
15-12.5 mg 10-12.5 mg (Accuretic)
moexipril- 2 quinapril- 2
15-25 mg 20-12.5 mg (Accuretic)
nadolol & 2 quinapril- 2
bendroflumethiazide tab hydrochlorothiazide tab
40-5 mg (Corzide) 20-25 mg (Accuretic)
nadolol & 2 ramipril cap 1.25 mg (Altace) 1
bendroflumethiazide tab ramipril cap 2.5 mg (Altace) 1
80-5 mg (Corzide)
ramipril cap 5 mg (Altace) 1
olmesartan medoxomil tab 2
ramipril cap 10 mg (Altace) 1
5 mg (Benicar)
2 TEKTURNA - aliskiren 4
olmesartan medoxomil tab
20 mg (Benicar) fumarate tab 150 mg (base
equivalent)
olmesartan medoxomil tab 2
40 mg (Benicar)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
TEKTURNA - aliskiren 4 terazosin hcl cap 10 mg 1
fumarate tab 300 mg (base trandolapril tab 1 mg (Mavik) 1
equivalent)
trandolapril tab 2 mg (Mavik) 1
TEKTURNA HCT - aliskiren- 4
trandolapril tab 4 mg (Mavik) 1
150-12.5 mg trandolapril-verapamil hcl 2
TEKTURNA HCT - aliskiren- 4 tab er 1-240 mg (Tarka)
hydrochlorothiazide tab trandolapril-verapamil hcl 2
150-25 mg tab er 2-180 mg (Tarka)
TEKTURNA HCT - aliskiren- 4 trandolapril-verapamil hcl 2
hydrochlorothiazide tab tab er 2-240 mg (Tarka)
300-12.5 mg trandolapril-verapamil hcl 2
TEKTURNA HCT - aliskiren- 4 tab er 4-240 mg (Tarka)
hydrochlorothiazide tab valsartan tab 40 mg (Diovan) 1
300-25 mg
valsartan tab 80 mg (Diovan) 1
telmisartan tab 20 mg 2
valsartan tab 160 mg 1
(Micardis)
2 (Diovan)
telmisartan tab 40 mg
valsartan tab 320 mg 1
(Micardis)
2 (Diovan)
telmisartan tab 80 mg
valsartan- 1
(Micardis)
2 hydrochlorothiazide tab
telmisartan-amlodipine tab 80-12.5 mg (Diovan hct)
40-5 mg (Twynsta)
valsartan- 1
telmisartan-amlodipine tab 2
40-10 mg (Twynsta) 160-12.5 mg (Diovan hct)
telmisartan-amlodipine tab 2 1
valsartan-
80-5 mg (Twynsta) hydrochlorothiazide tab
telmisartan-amlodipine tab 2 160-25 mg (Diovan hct)
80-10 mg (Twynsta) valsartan- 1
telmisartan- 2 hydrochlorothiazide tab
hydrochlorothiazide tab 320-12.5 mg (Diovan hct)
40-12.5 mg (Micardis hct) valsartan- 1
telmisartan- 2 hydrochlorothiazide tab
hydrochlorothiazide tab 320-25 mg (Diovan hct)
80-12.5 mg (Micardis hct) VECAMYL - mecamylamine hcl 4
telmisartan- 2 tab 2.5 mg
hydrochlorothiazide tab DIURETICS
80-25 mg (Micardis hct)
acetazolamide cap er 12hr 2
terazosin hcl cap 1 mg 1
500 mg (Diamox)
terazosin hcl cap 2 mg 1 2
acetazolamide tab 125 mg
terazosin hcl cap 5 mg 1 2
acetazolamide tab 250 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
ALDACTAZIDE - 4 indapamide tab 2.5 mg 1
spironolactone & methazolamide tab 25 mg 2
hydrochlorothiazide tab (Neptazane)
50-50 mg
methazolamide tab 50 mg 2
amiloride & 1
(Neptazane)
METHYCLOTHIAZIDE - 4
5-50 mg
methyclothiazide tab 5 mg
amiloride hcl tab 5 mg 2
metolazone tab 2.5 mg 2
bumetanide tab 0.5 mg 2
metolazone tab 5 mg 2
bumetanide tab 1 mg 2
metolazone tab 10 mg 2
bumetanide tab 2 mg 2
spironolactone & 2
CHLOROTHIAZIDE - 4
chlorothiazide tab 250 mg 25-25 mg (Aldactazide)
chlorothiazide tab 500 mg 2 1
spironolactone tab 25 mg
chlorthalidone tab 25 mg 2 (Aldactone)
chlorthalidone tab 50 mg 2 spironolactone tab 50 mg 1
DIURIL - chlorothiazide susp 4 (Aldactone)
250 mg/5ml spironolactone tab 100 mg 1
DYRENIUM - triamterene cap 4 (Aldactone)
50 mg torsemide tab 5 mg 1
DYRENIUM - triamterene cap 4 (Demadex)
EDECRIN - ethacrynic acid tab 4 (Demadex)
ethacrynic acid tab 25 mg 2 (Demadex)
1 torsemide tab 100 mg 1
furosemide oral soln 10 mg/
ml (Demadex)
1 triamterene & 1
furosemide tab 20 mg (Lasix)
hydrochlorothiazide cap
furosemide tab 40 mg (Lasix) 1
37.5-25 mg (Dyazide)
furosemide tab 80 mg (Lasix) 1 1
triamterene &
hydrochlorothiazide cap 1 hydrochlorothiazide tab
12.5 mg (Microzide) 37.5-25 mg (Maxzide-25)
hydrochlorothiazide tab 1 triamterene & 1
12.5 mg hydrochlorothiazide tab
hydrochlorothiazide tab 1 75-50 mg (Maxzide)
25 mg TRIAMTERENE/ 4
hydrochlorothiazide tab 1 HYDROCHLOROTH -
50 mg triamterene &
hydrochlorothiazide cap
indapamide tab 1.25 mg 1
50-25 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
VASOPRESSORS cholestyramine light powder 2
EPINEPHRINE - epinephrine 4 4 gm/dose (Questran light)
solution auto-injector 0.15 cholestyramine powder 2
mg/0.15ml (1:1000) packets 4 gm (Questran)
EPINEPHRINE - epinephrine 4 cholestyramine powder 2
solution auto-injector 0.3 4 gm/dose (Questran)
mg/0.3ml (1:1000) choline fenofibrate cap dr 2
EPINEPHRINE - 3 45 mg (fenofibric acid
AUTHORIZED GENERIC equiv) (Trilipix)
TO EPIPEN - epinephrine choline fenofibrate cap dr 2
solution auto-injector 0.15 135 mg (fenofibric acid
mg/0.3ml (1:2000) equiv) (Trilipix)
EPINEPHRINE - 3 2
colestipol hcl granule
AUTHORIZED GENERIC packets 5 gm (Colestid
TO EPIPEN - epinephrine flavored)
solution auto-injector 0.3
colestipol hcl granules 5 gm 2
mg/0.3ml (1:1000)
(Colestid flavored)
EPIPEN 2-PAK - epinephrine 3
colestipol hcl tab 1 gm 2
solution auto-injector 0.3
mg/0.3ml (1:1000) (Colestid)
EPIPEN-JR 2-PAK - 3 CRESTOR - rosuvastatin 4
epinephrine solution auto- calcium tab 5 mg
injector 0.15 mg/0.3ml CRESTOR - rosuvastatin 4
(1:2000) calcium tab 10 mg
midodrine hcl tab 2.5 mg 2 CRESTOR - rosuvastatin 4
midodrine hcl tab 5 mg 2 calcium tab 20 mg
midodrine hcl tab 10 mg 2 CRESTOR - rosuvastatin 4
calcium tab 40 mg
ANTIHYPERLIPIDEMICS
1
ezetimibe tab 10 mg (Zetia) 2
atorvastatin calcium tab
10 mg (base equivalent) fenofibrate micronized cap 2
(Lipitor) 43 mg
atorvastatin calcium tab 1 fenofibrate micronized cap 2
20 mg (base equivalent) 67 mg (Lofibra)
(Lipitor) fenofibrate micronized cap 2
atorvastatin calcium tab 1 130 mg
40 mg (base equivalent) fenofibrate micronized cap 2
(Lipitor) 134 mg (Lofibra)
atorvastatin calcium tab 1 fenofibrate tab 48 mg (Tricor) 2
80 mg (base equivalent) fenofibrate tab 54 mg 2
(Lipitor) (Lofibra)
cholestyramine light powder 2
packets 4 gm

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
fenofibrate tab 145 mg 2 lovastatin tab 40 mg 1
(Tricor) (Mevacor)
fenofibrate tab 160 mg 2 niacin tab er 500 mg 2
(Lofibra) (antihyperlipidemic)
fluvastatin sodium cap 2 (Niaspan)
20 mg (Lescol) niacin tab er 750 mg 2
fluvastatin sodium cap 2 (antihyperlipidemic)
40 mg (Lescol) (Niaspan)
2 niacin tab er 1000 mg 2
fluvastatin sodium tab er 24
hr 80 mg (Lescol xl) (antihyperlipidemic)
(Niaspan)
gemfibrozil tab 600 mg 1
(Lopid) PRALUENT - alirocumab 5
JUXTAPID - lomitapide 5 injector 75 mg/ml
equiv) PRALUENT - alirocumab 5
JUXTAPID - lomitapide 5 injector 150 mg/ml
pravastatin sodium tab 1
equiv)
10 mg
JUXTAPID - lomitapide 5 1
mesylate cap 20 mg (base pravastatin sodium tab
equiv) 20 mg (Pravachol)
1
JUXTAPID - lomitapide 5 pravastatin sodium tab
mesylate cap 30 mg (base 40 mg (Pravachol)
equiv) pravastatin sodium tab 1
JUXTAPID - lomitapide 5 80 mg (Pravachol)
mesylate cap 40 mg (base REPATHA - evolocumab 5
equiv) subcutaneous soln prefilled
JUXTAPID - lomitapide 5 syringe 140 mg/ml
mesylate cap 60 mg (base REPATHA PUSHTRONEX 5
equiv) SYSTEM - evolocumab
KYNAMRO - mipomersen 5 subcutaneous soln cartridge/
sodium soln prefilled syringe infusor 420 mg/3.5ml
200 mg/ml REPATHA SURECLICK - 5
LIVALO - pitavastatin calcium 4 evolocumab subcutaneous
tab 1 mg (base equiv) soln auto-injector 140 mg/ml
2
LIVALO - pitavastatin calcium 4 rosuvastatin calcium tab
tab 2 mg (base equiv) 5 mg (Crestor)
2
LIVALO - pitavastatin calcium 4 rosuvastatin calcium tab
tab 4 mg (base equiv) 10 mg (Crestor)
1 rosuvastatin calcium tab 2
lovastatin tab 10 mg
20 mg (Crestor)
lovastatin tab 20 mg 1

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
rosuvastatin calcium tab 2 CORLANOR - ivabradine hcl 4
40 mg (Crestor) tab 5 mg (base equiv)
simvastatin tab 5 mg (Zocor) 1 CORLANOR - ivabradine hcl 4
simvastatin tab 10 mg 1 tab 7.5 mg (base equiv)
(Zocor) ENTRESTO - sacubitril- 3
simvastatin tab 20 mg 1 valsartan tab 24-26 mg
(Zocor) LETAIRIS - ambrisentan tab 5 5
VASCEPA - icosapent ethyl cap 3 mg
0.5 gm LETAIRIS - ambrisentan tab 10 5
VASCEPA - icosapent ethyl cap 3 mg
1 gm OPSUMIT - macitentan tab 10 5
WELCHOL - colesevelam hcl 3 mg
packet for susp 3.75 gm ORENITRAM - treprostinil 5
WELCHOL - colesevelam hcl 3 diolamine tab er 0.125 mg
tab 625 mg (base equiv)
ZETIA - ezetimibe tab 10 mg 4 ORENITRAM - treprostinil 5

diolamine tab er 0.25 mg
CARDIOVASCULAR AGENTS - MISC. (base equiv)
ADCIRCA - tadalafil tab 20 mg 5 ORENITRAM - treprostinil 5
(pah) diolamine tab er 1 mg (base
ADEMPAS - riociguat tab 0.5 5 equiv)
mg ORENITRAM - treprostinil 5
ADEMPAS - riociguat tab 1 mg 5 diolamine tab er 2.5 mg
ADEMPAS - riociguat tab 1.5 5 (base equiv)
mg ORENITRAM - treprostinil 5
ADEMPAS - riociguat tab 2 mg 5 diolamine tab er 5 mg (base
equiv)
ADEMPAS - riociguat tab 2.5 5
mg REVATIO - sildenafil citrate for 5
suspension 10 mg/ml
BIDIL - isosorbide dinitrate- 4
hydralazine hcl tab 20-37.5 sildenafil citrate tab 20 mg 5
mg (Revatio)
CIALIS - tadalafil tab 2.5 mg 3 TRACLEER - bosentan tab 5

62.5 mg
CIALIS - tadalafil tab 5 mg 3
TRACLEER - bosentan tab 125 5
CIALIS - tadalafil tab 10 mg 3 mg
CIALIS - tadalafil tab 20 mg 3 TYVASO - treprostinil 5
inhalation solution 0.6 mg/ml

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
TYVASO REFILL - treprostinil 5 CLEMASTINE FUMARATE - 1
inhalation solution 0.6 mg/ml clemastine fumarate tab
TYVASO STARTER - 5 2.68 mg
treprostinil inhalation cyproheptadine hcl syrup 2
solution 0.6 mg/ml 2 mg/5ml
UPTRAVI - selexipag tab 5 cyproheptadine hcl tab 4 mg 2
therapy pack 200 mcg (140) DESLORATADINE ODT - 4
& 800 mcg (60) desloratadine tab orally
UPTRAVI - selexipag tab 200 5 disintegrating 2.5 mg
mcg DESLORATADINE ODT - 4
UPTRAVI - selexipag tab 400 5 desloratadine tab orally
mcg disintegrating 5 mg
UPTRAVI - selexipag tab 600 5 desloratadine tab 5 mg 2
mcg (Clarinex)
UPTRAVI - selexipag tab 800 5 KARBINAL ER - carbinoxamine 4
mcg maleate extended release
UPTRAVI - selexipag tab 1000 5 susp 4 mg/5ml
mcg levocetirizine 2
UPTRAVI - selexipag tab 1200 5 dihydrochloride soln
mcg 2.5 mg/5ml (0.5 mg/ml)
(Xyzal)
UPTRAVI - selexipag tab 1400 5 1
mcg levocetirizine
dihydrochloride tab 5 mg
UPTRAVI - selexipag tab 1600 5 (Xyzal)
mcg
promethazine hcl suppos 2
VENTAVIS - iloprost inhalation 5 12.5 mg
solution 10 mcg/ml
VENTAVIS - iloprost inhalation 5 25 mg
solution 20 mcg/ml
ERECTILE DYSFUNCTION 50 mg
CIALIS - tadalafil tab 2.5 mg 3 promethazine hcl syrup 1
CIALIS - tadalafil tab 5 mg 3 6.25 mg/5ml
CIALIS - tadalafil tab 10 mg 3 promethazine hcl tab 1
CIALIS - tadalafil tab 20 mg 3 12.5 mg
promethazine hcl tab 25 mg 1
RESPIRATORY AGENTS
promethazine hcl tab 50 mg 1
ANTIHISTAMINES
carbinoxamine maleate soln 2 NASAL AGENTS - SYSTEMIC and TOPICAL
4 mg/5ml azelastine hcl nasal spray 2
carbinoxamine maleate tab 2 0.1% (137 mcg/spray)
4 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
azelastine hcl nasal spray 2 guaifenesin-codeine liquid 2
0.15% (205.5 mcg/spray) 225-7.5 mg/5ml
(Astepro) guaifenesin-codeine soln 1
BACTROBAN NASAL - 4 100-6.3 mg/5ml
mupirocin calcium nasal oint guaifenesin-codeine soln 1
2% 100-10 mg/5ml
budesonide nasal susp 2 HISTEX-AC - phenylephrine- 4
32 mcg/act (Rhinocort triprolidine-codeine syrup
aqua) 10-2.5-10 mg/5ml
FLUNISOLIDE - flunisolide 2 2
hydrocod polst-chlorphen
nasal soln 25 mcg/act polst er susp 10-8 mg/5ml
(0.025%) (Tussionex pennkineti)
fluticasone propionate nasal 1 hydrocodone w/ 2
susp 50 mcg/act homatropine syrup
ipratropium bromide nasal 2 5-1.5 mg/5ml
soln 0.03% (21 mcg/spray) hydrocodone w/ 2
(Atrovent) homatropine tab 5-1.5 mg
ipratropium bromide nasal 2 M-END PE - phenylephrine- 4
soln 0.06% (42 mcg/spray) bromphen w/ codeine liqd
(Atrovent) 3.33-1.33-6.33 mg/5ml
mometasone furoate nasal 2 MAR-COF BP - 4
susp 50 mcg/act (Nasonex) pseudoephedrine-
olopatadine hcl nasal soln 2 bromphen-codeine liqd
0.6% (Patanase) 30-2-7.5 mg/5ml
OMNARIS - ciclesonide nasal 4 NINJACOF-XG - guaifenesin- 1
susp 50 mcg/act codeine liquid 200-8 mg/5ml
triamcinolone acetonide 2 POLY-TUSSIN AC - 4
nasal aerosol suspension phenylephrine-bromphen
55 mcg/act w/ codeine liquid 10-4-10
COUGH/COLD/ALLERGY mg/5ml
2 PRO-CLEAR AC - codeine- 4
acetylcysteine inhal soln
10% pyrilamine syrup 9-8.33
mg/5ml
acetylcysteine inhal soln 2
PRO-RED AC - phenylephrine- 4
20%
dexchlorphenir-codeine
benzonatate cap 100 mg 1
syrup 5-1-9 mg/5ml
(Tessalon perles)
promethazine & 2
benzonatate cap 150 mg 2
phenylephrine syrup
benzonatate cap 200 mg 1 6.25-5 mg/5ml
CAPCOF - phenylephrine- 4 promethazine w/ codeine 1
chlorphen w/ codeine syrup syrup 6.25-10 mg/5ml
5-2-10 mg/5ml

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
promethazine-dm syrup 1 albuterol sulfate soln nebu 2
6.25-15 mg/5ml 0.5% (5 mg/ml)
promethazine- 2 albuterol sulfate soln nebu 2
phenylephrine-codeine 0.63 mg/3ml (base equiv)
syrup 6.25-5-10 mg/5ml albuterol sulfate soln nebu 2
pseudoeph-chlorphen 2 1.25 mg/3ml (base equiv)
w/ hydrocodone soln albuterol sulfate syrup 1
60-4-5 mg/5ml (Zutripro) 2 mg/5ml
pseudoephed-bromphen-dm 2 2
albuterol sulfate tab er 12hr
syrup 30-2-10 mg/5ml 4 mg (Vospire er)
pseudoephedrine w/ cod-gg 2 2
albuterol sulfate tab er 12hr
soln 30-10-100 mg/5ml 8 mg (Vospire er)
TUSNEL C - pseudoephedrine 2 2
albuterol sulfate tab 2 mg
w/ cod-gg syrup 30-10-100
albuterol sulfate tab 4 mg 2
mg/5ml
VITUZ - hydrocodone- 4 ANORO ELLIPTA - 3
chlorpheniramine soln 5-4 umeclidinium-vilanterol aero
mg/5ml powd ba 62.5-25 mcg/inh
Z-TUSS AC - chlorpheniramine 4 ARCAPTA NEOHALER - 4
w/ codeine liquid 2-9 mg/5ml indacaterol maleate inhal
powder cap 75 mcg (base
ANTIASTHMATIC and BRONCHODILATOR AGENTS equiv)
ADVAIR DISKUS - fluticasone- 3 ARNUITY ELLIPTA - 3
salmeterol aer powder ba fluticasone furoate aerosol
100-50 mcg/dose powder breath activ 100
ADVAIR DISKUS - fluticasone- 3 mcg/act
salmeterol aer powder ba ARNUITY ELLIPTA - 3
250-50 mcg/dose fluticasone furoate aerosol
ADVAIR DISKUS - fluticasone- 3 powder breath activ 200
salmeterol aer powder ba mcg/act
500-50 mcg/dose ASMANEX HFA - mometasone 3
ADVAIR HFA - fluticasone- 3 furoate inhal aerosol
salmeterol inhal aerosol suspension 100 mcg/act
45-21 mcg/act ASMANEX HFA - mometasone 3
ADVAIR HFA - fluticasone- 3 furoate inhal aerosol
salmeterol inhal aerosol suspension 200 mcg/act
115-21 mcg/act ASMANEX TWISTHALER 120 3
ADVAIR HFA - fluticasone- 3 ME - mometasone furoate
salmeterol inhal aerosol inhal powd 220 mcg/inh
230-21 mcg/act (breath activated)
albuterol sulfate soln nebu 1
0.083% (2.5 mg/3ml)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
ASMANEX TWISTHALER 30 3 DULERA - mometasone 3
MET - mometasone furoate furoate-formoterol fumarate
inhal powd 110 mcg/inh aerosol 200-5 mcg/act
(breath activated) ELIXOPHYLLIN - theophylline 4
ASMANEX TWISTHALER 30 3 elixir 80 mg/15ml
MET - mometasone furoate FLOVENT DISKUS - 3
inhal powd 220 mcg/inh fluticasone propionate aer
(breath activated) pow ba 50 mcg/blister
ASMANEX TWISTHALER 60 3 FLOVENT DISKUS - 3
MET - mometasone furoate fluticasone propionate aer
inhal powd 220 mcg/inh pow ba 100 mcg/blister
(breath activated)
FLOVENT DISKUS - 3
ATROVENT HFA - ipratropium 4 fluticasone propionate aer
bromide hfa inhal aerosol 17 pow ba 250 mcg/blister
mcg/act
FLOVENT HFA - fluticasone 3
BREO ELLIPTA - fluticasone 3 propionate hfa inhal aero 44
furoate-vilanterol aero powd mcg/act (50/valve)
ba 100-25 mcg/inh
BREO ELLIPTA - fluticasone 3 propionate hfa inhal aer 110
furoate-vilanterol aero powd mcg/act (125/valve)
ba 200-25 mcg/inh
4
BROVANA - arformoterol propionate hfa inhal aer 220
tartrate soln nebu 15 mcg/act (250/valve)
mcg/2ml (base equiv)
FLUTICASONE 3
budesonide inhalation susp 2 PROPIONATE/SA -
0.25 mg/2ml (Pulmicort) fluticasone-salmeterol aer
budesonide inhalation susp 2 powder ba 55-14 mcg/act
0.5 mg/2ml (Pulmicort) FLUTICASONE 3
budesonide inhalation susp 2 PROPIONATE/SA -
1 mg/2ml (Pulmicort) fluticasone-salmeterol aer
COMBIVENT RESPIMAT - 4 powder ba 113-14 mcg/act
ipratropium-albuterol inhal FLUTICASONE 3
aerosol soln 20-100 mcg/act PROPIONATE/SA -
CROMOLYN SODIUM - 4 fluticasone-salmeterol aer
cromolyn sodium soln nebu powder ba 232-14 mcg/act
20 mg/2ml INCRUSE ELLIPTA - 3
DALIRESP - roflumilast tab 500 4 umeclidinium br aero powd
mcg breath act 62.5 mcg/inh
(base eq)
DULERA - mometasone 3
furoate-formoterol fumarate ipratropium bromide inhal 1
aerosol 100-5 mcg/act soln 0.02%
ipratropium-albuterol nebu 2
soln 0.5-2.5(3) mg/3ml

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
levalbuterol hcl soln nebu 2 QVAR - beclomethasone 3
conc 1.25 mg/0.5ml diprop inhal aero soln 80
(base equiv) (Xopenex mcg/act (100/valve)
concentrate) SEREVENT DISKUS - 3
levalbuterol hcl soln nebu 2 salmeterol xinafoate aer
0.31 mg/3ml (base equiv) pow ba 50 mcg/dose (base
(Xopenex) equiv)
levalbuterol hcl soln nebu 2 SPIRIVA HANDIHALER - 3
0.63 mg/3ml (base equiv) tiotropium bromide
(Xopenex) monohydrate inhal cap 18
levalbuterol hcl soln nebu 2 mcg (base equiv)
1.25 mg/3ml (base equiv) SPIRIVA RESPIMAT - 3
(Xopenex) tiotropium bromide
METAPROTERENOL 4 monohydrate inhal aerosol
SULFATE - metaproterenol 1.25 mcg/act
sulfate syrup 10 mg/5ml SPIRIVA RESPIMAT - 3
METAPROTERENOL 4 tiotropium bromide
SULFATE - metaproterenol monohydrate inhal aerosol
sulfate tab 20 mg 2.5 mcg/act
montelukast sodium chew 1 STIOLTO RESPIMAT - 3

tab 4 mg (base equiv) tiotropium br-olodaterol inhal
(Singulair) aero soln 2.5-2.5 mcg/act
montelukast sodium chew 1 STRIVERDI RESPIMAT - 3

tab 5 mg (base equiv) olodaterol hcl inhal aerosol
(Singulair) soln 2.5 mcg/act (base
equiv)
montelukast sodium tab 1
10 mg (base equiv) SYMBICORT - budesonide- 3
(Singulair) formoterol fumarate dihyd
aerosol 80-4.5 mcg/act
NUCALA - mepolizumab for inj 5
100 mg SYMBICORT - budesonide- 3
formoterol fumarate dihyd
PERFOROMIST - formoterol 4
aerosol 160-4.5 mcg/act
fumarate soln nebu 20
terbutaline sulfate tab 2
mcg/2ml
2.5 mg
PROAIR HFA - albuterol sulfate 3 2
inhal aero 108 mcg/act terbutaline sulfate tab 5 mg
(90mcg base equiv) THEO-24 - theophylline cap er 4
PROAIR RESPICLICK - 3 24hr 100 mg
albuterol sulfate aer pow ba THEO-24 - theophylline cap er 4
108 mcg/act (90 mcg base 24hr 200 mg
equiv) THEO-24 - theophylline cap er 4
QVAR - beclomethasone 3 24hr 300 mg
diprop inhal aero soln 40
mcg/act (50/valve)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
THEO-24 - theophylline cap er 4 ESBRIET - pirfenidone tab 801 5
24hr 400 mg mg
theophylline soln 2 INFASURF - calfactant in nacl 4
80 mg/15ml 0.9% intratracheal susp 35
theophylline tab er 12hr 1 mg/ml
100 mg KALYDECO - ivacaftor packet 5
theophylline tab er 12hr 2 50 mg
200 mg KALYDECO - ivacaftor packet 5
theophylline tab er 12hr 2 75 mg
300 mg KALYDECO - ivacaftor tab 150 5
theophylline tab er 12hr 2 mg
450 mg OFEV - nintedanib esylate cap 5
theophylline tab er 24hr 2 100 mg (base equivalent)
400 mg OFEV - nintedanib esylate cap 5
theophylline tab er 24hr 2 150 mg (base equivalent)
600 mg ORKAMBI - lumacaftor- 5
VENTOLIN HFA - albuterol 3 ivacaftor tab 100-125 mg
sulfate inhal aero 108 mcg/ ORKAMBI - lumacaftor- 5
act (90mcg base equiv) ivacaftor tab 200-125 mg
zafirlukast tab 10 mg 2 PULMOZYME - dornase alfa 5
(Accolate) inhal soln 1 mg/ml
zafirlukast tab 20 mg 2 SURVANTA 4
(Accolate) INTRATRACHEAL -
zileuton tab er 12hr 600 mg 2 beractant in nacl 0.9%
(Zyflo cr) intratracheal susp 25 mg/ml
ZYFLO - zileuton tab 600 mg 4 GASTROINTESTINAL AGENTS
ZYFLO CR - zileuton tab er 4 LAXATIVES

12hr 600 mg bisacodyl tab & peg 3350- 2
RESPIRATORY AGENTS - MISC. kcl-sod bicarb-nacl for
soln kit
CUROSURF - poractant alfa 4
GIALAX - polyethylene glycol 4
intratracheal susp 120
mg/1.5ml 3350 - kit
4 GOLYTELY - peg 3350-kcl-na 4
CUROSURF - poractant alfa
intratracheal susp 240 bicarb-nacl-na sulfate packet
mg/3ml 227.1 gm
4
ESBRIET - pirfenidone cap 267 5 KRISTALOSE - lactulose oral
mg crystal packet 10 gm
4
ESBRIET - pirfenidone tab 267 5 KRISTALOSE - lactulose oral
mg crystal packet 20 gm
lactulose solution 1
10 gm/15ml

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
MOVIPREP - peg 3350- 4 CARAFATE - sucralfate susp 1 4
kcl-nacl-na sulfate-na gm/10ml
ascorbate-c for soln 100 gm cimetidine hcl soln 2
OSMOPREP - sod phos 4 300 mg/5ml
mono-sod phos di tabs cimetidine tab 300 mg 1
1.102-0.398 gm(1.5gm na
cimetidine tab 400 mg 2
phos)
4 cimetidine tab 800 mg 2
PCP 100 - mag cit-
bisacodyl-petrolat-peg- CUVPOSA - glycopyrrolate oral 4
metoclopramide-electrol kit soln 1 mg/5ml
peg 3350-kcl-sod bicarb-nacl 1 DEXILANT - dexlansoprazole 4
for soln 420 gm (Nulytely/ cap delayed release 30 mg
flavor pack) DEXILANT - dexlansoprazole 4
peg 3350-kcl-na bicarb-nacl- 1 cap delayed release 60 mg
na sulfate for soln 236 gm dicyclomine hcl cap 10 mg 1
(Golytely) (Bentyl)
peg 3350-kcl-na bicarb-nacl- 1 dicyclomine hcl oral soln 2
na sulfate for soln 240 gm 10 mg/5ml
(Colyte-flavor packs)
dicyclomine hcl tab 20 mg 1
polyethylene glycol 3350 2
(Bentyl)
oral packet
1 esomeprazole magnesium 2
polyethylene glycol 3350 cap delayed release 20 mg
oral powder (base eq) (Nexium)
4
PREPOPIK - sod picosulfate- esomeprazole magnesium 2
mg oxide-citric acid pack 10 cap delayed release 40 mg
mg-3.5 gm-12 gm (base eq) (Nexium)
SUPREP BOWEL PREP KIT - 4 2
famotidine for susp
sodium sulfate-potassium 40 mg/5ml (Pepcid)
sulfate-magnesium sulfate
famotidine tab 40 mg 1
oral soln
(Pepcid)
ANTIDIARRHEALS
glycopyrrolate tab 1 mg 2
diphenoxylate w/ atropine 2
(Robinul)
tab 2.5-0.025 mg (Lomotil)
glycopyrrolate tab 2 mg 2
DIPHENOXYLATE/ 4
(Robinul forte)
ATROPINE - diphenoxylate
w/ atropine liq 2.5-0.025 lansoprazole cap delayed 2
mg/5ml release 15 mg (Prevacid)
MOTOFEN - difenoxin w/ 4 lansoprazole cap delayed 2
atropine tab 1-0.025 mg release 30 mg (Prevacid)
4 methscopolamine bromide 2
MYTESI - crofelemer tab
delayed release 125 mg tab 2.5 mg (Pamine)
ULCER DRUGS

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
methscopolamine bromide 2 rabeprazole sodium ec tab 2
tab 5 mg (Pamine forte) 20 mg (Aciphex)
misoprostol tab 100 mcg 1 ranitidine hcl cap 150 mg 2
(Cytotec) ranitidine hcl cap 300 mg 2
misoprostol tab 200 mcg 1 1
ranitidine hcl syrup 15 mg/
(Cytotec) ml (75 mg/5ml)
NEXIUM - esomeprazole 4 ranitidine hcl tab 300 mg 1
magnesium for delayed (Zantac)
release susp packet 5 mg
sucralfate tab 1 gm 2
NEXIUM - esomeprazole 4 (Carafate)
magnesium for delayed
release susp packet 10 mg ANTIEMETICS
NEXIUM - esomeprazole 4 AKYNZEO - netupitant- 4
magnesium for delayed palonosetron cap 300-0.5
release susp packet 20 mg mg
NEXIUM - esomeprazole 4 ANZEMET - dolasetron 4
magnesium for delayed mesylate tab 50 mg
release susp packet 40 mg ANZEMET - dolasetron 4
NEXIUM - esomeprazole 4 mesylate tab 100 mg
magnesium for delayed aprepitant capsule therapy 2
release susp pack 2.5 mg pack 80 & 125 mg (Emend)
NIZATIDINE - nizatidine oral 4 aprepitant capsule 80 mg 2
soln 15 mg/ml (Emend)
nizatidine cap 150 mg 1 CESAMET - nabilone cap 1 mg 4
nizatidine cap 300 mg (Axid) 2 DICLEGIS - doxylamine- 4
omeprazole cap delayed 1 pyridoxine tab delayed
release 10 mg (Prilosec) release 10-10 mg
omeprazole cap delayed 1 dronabinol cap 2.5 mg 2
release 20 mg (Prilosec) (Marinol)
omeprazole cap delayed 1 dronabinol cap 5 mg 2
release 40 mg (Prilosec) (Marinol)
pantoprazole sodium ec 1 dronabinol cap 10 mg 2
tab 20 mg (base equiv) (Marinol)
(Protonix) EMEND - aprepitant capsule 3
pantoprazole sodium ec 1 40 mg
tab 40 mg (base equiv) EMEND - aprepitant capsule 3
(Protonix) 80 mg
PROPANTHELINE BROMIDE - 4 EMEND - aprepitant capsule 3
propantheline bromide tab 125 mg
15 mg EMEND - aprepitant for oral 3
susp 125 mg (125 mg/5ml)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
EMEND TRIPACK - aprepitant 3 CREON - pancrelipase 3
capsule therapy pack 80 & (lip-prot-amyl) dr cap
125 mg 36000-114000-180000 unit
granisetron hcl tab 1 mg 2 PANCREAZE - pancrelipase 4
ondansetron hcl oral soln 2 (lip-prot-amyl) dr cap
4 mg/5ml (Zofran) 2600-6200-10850 unit
4
ondansetron hcl tab 4 mg 1 PANCREAZE - pancrelipase
(Zofran) (lip-prot-amyl) dr cap
4200-14200-24600 unit
ondansetron hcl tab 8 mg 1 4
(Zofran) PANCREAZE - pancrelipase
(lip-prot-amyl) dr cap
ondansetron hcl tab 24 mg 2 10500-35500-61500 unit
ondansetron orally 1 PANCREAZE - pancrelipase 4
disintegrating tab 4 mg (lip-prot-amyl) dr cap
(Zofran odt) 16800-56800-98400 unit
ondansetron orally 1 PANCREAZE - pancrelipase 4
disintegrating tab 8 mg (lip-prot-amyl) dr cap
(Zofran odt) 21000-54700-83900 unit
scopolamine td patch 72hr 2 4
PERTZYE - pancrelipase
1 mg/3days (Transderm- (lip-prot-amyl) dr cap
scop) 4000-14375-15125 unit
TRANSDERM-SCOP - 4 4
scopolamine td patch 72hr 1 (lip-prot-amyl) dr cap
mg/3days 8000-28750-30250 unit
trimethobenzamide hcl cap 2 4
300 mg (Tigan) (lip-prot-amyl) dr cap
VARUBI - rolapitant hcl tab 90 4 16000-57500-60500 unit
mg (base equiv) PERTZYE - pancrelipase 4
DIGESTIVE AIDS (lip-prot-amyl) dr cap
CREON - pancrelipase 3 24000-86250-90750 unit
(lip-prot-amyl) dr cap SUCRAID - sacrosidase soln 5
3000-9500-15000 unit 8500 unit/ml
CREON - pancrelipase 3 VIOKACE - pancrelipase 4
(lip-prot-amyl) dr cap (lip-prot-amyl) tab
6000-19000-30000 unit 10440-39150-39150 unit
CREON - pancrelipase 3 VIOKACE - pancrelipase 4
(lip-prot-amyl) dr cap (lip-prot-amyl) tab
12000-38000-60000 unit 20880-78300-78300 unit
CREON - pancrelipase 3 ZENPEP - pancrelipase 3
(lip-prot-amyl) dr cap (lip-prot-amyl) dr cap
24000-76000-120000 unit 3000-10000-16000 unit

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
ZENPEP - pancrelipase 3 CHOLBAM - cholic acid cap 50 5
(lip-prot-amyl) dr cap mg
5000-17000-27000 unit CHOLBAM - cholic acid cap 5
ZENPEP - pancrelipase 3 250 mg
(lip-prot-amyl) dr cap CIMZIA - certolizumab pegol inj 5
10000-34000-55000 unit kit 2 x 200 mg/ml
3
ZENPEP - pancrelipase CIMZIA STARTER KIT - 5
(lip-prot-amyl) dr cap certolizumab pegol inj kit 6 x
15000-51000-82000 unit 200 mg/ml
ZENPEP - pancrelipase 3 2
cromolyn sodium oral conc
(lip-prot-amyl) dr cap 100 mg/5ml (Gastrocrom)
20000-68000-109000 unit
DELZICOL - mesalamine cap 4
ZENPEP - pancrelipase 3
dr 400 mg
(lip-prot-amyl) dr cap
DIPENTUM - olsalazine 4
25000-85000-136000 unit
sodium cap 250 mg
ZENPEP - pancrelipase 3
(lip-prot-amyl) dr cap ENTEREG - alvimopan cap 12 4
40000-136000-218000 unit mg
FOSRENOL - lanthanum 4
GASTROINTESTINAL AGENTS- MISC.
carbonate chew tab 500 mg
alosetron hcl tab 0.5 mg 2 (elemental)
(base equiv) (Lotronex)
FOSRENOL - lanthanum 4
alosetron hcl tab 1 mg (base 2 carbonate chew tab 750 mg
equiv) (Lotronex) (elemental)
APRISO - mesalamine cap er 4 4
FOSRENOL - lanthanum
24hr 0.375 gm carbonate chew tab 1000
ASACOL HD - mesalamine tab 4 mg (elemental)
delayed release 800 mg FOSRENOL - lanthanum 4
AURYXIA - ferric citrate tab 1 4 carbonate oral powder pack
gm (210 mg ferric iron) 750 mg (elemental)
balsalazide disodium cap 2 FOSRENOL - lanthanum 4
750 mg (Colazal) carbonate oral powder pack
calcium acetate (phosphate 2 1000 mg (elemental)
binder) cap 667 mg GATTEX - teduglutide (rdna) 5
(169 mg ca) (Phoslo) for inj kit 5 mg
calcium acetate (phosphate 2 GIAZO - balsalazide disodium 4
binder) tab 667 mg tab 1.1 gm
(Eliphos) lactulose (encephalopathy) 1
CANASA - mesalamine suppos 3 solution 10 gm/15ml
1000 mg LIALDA - mesalamine tab 4
CHENODAL - chenodiol tab 5 delayed release 1.2 gm
250 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
LINZESS - linaclotide cap 72 3 RENAGEL - sevelamer hcl tab 4
mcg 400 mg
LINZESS - linaclotide cap 145 3 RENAGEL - sevelamer hcl tab 4
mcg 800 mg
LINZESS - linaclotide cap 290 3 RENVELA - sevelamer 3
mcg carbonate packet 0.8 gm
MESALAMINE DR - 4 RENVELA - sevelamer 3
mesalamine tab delayed carbonate packet 2.4 gm
release 800 mg RENVELA - sevelamer 3
mesalamine enema 4 gm 2 carbonate tab 800 mg
mesalamine tab delayed 2 sevelamer carbonate packet 2
release 1.2 gm (Lialda) 0.8 gm (Renvela)
metoclopramide hcl soln 1 sevelamer carbonate packet 2
5 mg/5ml (10 mg/10ml) 2.4 gm (Renvela)
metoclopramide hcl tab 1 sevelamer carbonate tab 2
5 mg (Reglan) 800 mg (Renvela)
metoclopramide hcl tab 1 SFROWASA - mesalamine 4
10 mg (Reglan) sulfite-free (sf) enema 4
METOCLOPRAMIDE ODT - 2 gm/60ml
metoclopramide hcl orally sulfasalazine tab delayed 2
disintegrating tab 5 mg release 500 mg (Azulfidine
METOCLOPRAMIDE ODT - 4 en-tabs)
metoclopramide hcl orally sulfasalazine tab 500 mg 2
disintegrating tab 10 mg (Azulfidine)
MOVANTIK - naloxegol 3 TRULANCE - plecanatide tab 3 4
oxalate tab 12.5 mg (base mg
equivalent) ursodiol cap 300 mg 2
MOVANTIK - naloxegol oxalate 3 (Actigall)
tab 25 mg (base equivalent) ursodiol tab 250 mg (Urso 2
OCALIVA - obeticholic acid tab 5 250)
5 mg ursodiol tab 500 mg (Urso 2
OCALIVA - obeticholic acid tab 5 forte)
10 mg VELPHORO - sucroferric 3
PENTASA - mesalamine cap er 4 oxyhydroxide chew tab 500
250 mg mg
PENTASA - mesalamine cap er 4 VIBERZI - eluxadoline tab 75 3
500 mg mg
PHOSLYRA - calcium acetate 4 VIBERZI - eluxadoline tab 100 3
(phosphate binder) oral soln mg
667 mg/5ml

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
XERMELO - telotristat etiprate 5 ENABLEX - darifenacin 4
tab 250 mg (telotristat ethyl hydrobromide tab er 24hr
equiv) 7.5 mg (base equiv)
GENITOURINARY AGENTS ENABLEX - darifenacin 4
URINARY ANTI-INFECTIVES hydrobromide tab er 24hr 15
mg (base equiv)
methenamine hippurate tab 2
flavoxate hcl tab 100 mg 2
1 gm (Hiprex)
4 MYRBETRIQ - mirabegron tab 3
MONUROL - fosfomycin
tromethamine powd pack 3 er 24 hr 25 mg
gm (base equivalent) MYRBETRIQ - mirabegron tab 3
nitrofurantoin 2 er 24 hr 50 mg
macrocrystalline cap oxybutynin chloride syrup 1
25 mg (Macrodantin) 5 mg/5ml
nitrofurantoin 2 oxybutynin chloride tab er 2
macrocrystalline cap 24hr 5 mg (Ditropan xl)
50 mg (Macrodantin) oxybutynin chloride tab er 2
nitrofurantoin 2 24hr 10 mg (Ditropan xl)
macrocrystalline cap oxybutynin chloride tab er 2
100 mg (Macrodantin) 24hr 15 mg (Ditropan xl)
nitrofurantoin monohydrate 2 2
oxybutynin chloride tab
macrocrystalline cap 5 mg
100 mg (Macrobid)
tolterodine tartrate cap er 2
nitrofurantoin susp 2
24hr 2 mg (Detrol la)
25 mg/5ml (Furadantin)
tolterodine tartrate cap er 2
URINARY ANTISPASMODICS 24hr 4 mg (Detrol la)
bethanechol chloride tab 2 2
tolterodine tartrate tab 1 mg
5 mg (Urecholine) (Detrol)
tolterodine tartrate tab 2 mg
10 mg (Urecholine) (Detrol)
TOVIAZ - fesoterodine
25 mg (Urecholine) fumarate tab er 24hr 4 mg
TOVIAZ - fesoterodine
50 mg (Urecholine) fumarate tab er 24hr 8 mg
darifenacin hydrobromide 2 2
trospium chloride cap er
tab er 24hr 7.5 mg (base 24hr 60 mg
equiv) (Enablex)
trospium chloride tab 20 mg 2
darifenacin hydrobromide 2
VESICARE - solifenacin 3
tab er 24hr 15 mg (base
equiv) (Enablex) succinate tab 5 mg
VESICARE - solifenacin 3
succinate tab 10 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
VAGINAL PRODUCTS OPTIONS GYNOL II A
AVC - sulfanilamide vaginal 4 VAGINAL - nonoxynol-9 gel
cream 15% 3%
4 PREMARIN - estrogens, 4
CLEOCIN - clindamycin
phosphate vaginal suppos conjugated vaginal cream
100 mg 0.625 mg/gm
clindamycin phosphate 2 SHUR-SEAL - nonoxynol-9 gel A

vaginal cream 2% (Cleocin) 2%
4 terconazole vaginal cream 2
CLINDESSE - clindamycin
phosphate (one dose) 0.4% (Terazol 7)
vaginal cream 2% terconazole vaginal cream 2
CRINONE - progesterone 4 0.8% (Terazol 3)
vaginal gel 4% terconazole vaginal suppos 2
CRINONE - progesterone 4 80 mg
vaginal gel 8% TODAY SPONGE - A
ENCARE - nonoxynol-9 vaginal A nonoxynol-9 vaginal sponge
suppos 100 mg 1000 mg
VAGIFEM - estradiol vaginal 3
ENDOMETRIN - progesterone 4
vaginal insert 100 mg tab 10 mcg
ESTRACE - estradiol vaginal 3 VCF VAGINAL A

cream 0.1 mg/gm CONTRACEPTIVE -
nonoxynol-9 film 28%
estradiol vaginal tab 10 mcg 2
(Vagifem) VCF VAGINAL A
CONTRACEPTIVE -
ESTRING - estradiol vaginal 4
nonoxynol-9 foam 12.5%
ring 2 mg (7.5 mcg/24hrs)
GENITOURINARY AGENTS - MISC.
FEMRING - estradiol acetate 4
alfuzosin hcl tab er 24hr 1
vaginal ring 0.05 mg/24hr
10 mg (Uroxatral)
FEMRING - estradiol acetate 4
vaginal ring 0.1 mg/24hr CYSTAGON - cysteamine 5
bitartrate cap 50 mg
GYNAZOLE-1 - butoconazole 4
nitrate (one dose) vaginal CYSTAGON - cysteamine 5
cream 2% bitartrate cap 150 mg
2 dutasteride cap 0.5 mg 2
metronidazole vaginal gel
0.75% (Metrogel-vaginal) (Avodart)
4 dutasteride-tamsulosin hcl 2
MICONAZOLE 3 - miconazole
nitrate vaginal suppos 200 cap 0.5-0.4 mg (Jalyn)
mg ELMIRON - pentosan 4
nonoxynol-9 gel 4% A polysulfate sodium caps 100
mg
NUVESSA - metronidazole 4
finasteride tab 5 mg 1
vaginal gel 1.3%
(Proscar)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
LITHOSTAT - acetohydroxamic 4 alprazolam tab 0.25 mg 1
acid tab 250 mg (Xanax)
potassium citrate tab er 5 2 alprazolam tab 0.5 mg 1
meq (540 mg) (Urocit-k 5) (Xanax)
potassium citrate tab er 10 2 alprazolam tab 1 mg (Xanax) 1
meq (1080 mg) (Urocit-k 10) alprazolam tab 2 mg (Xanax) 1
potassium citrate tab er 15 2 1
buspirone hcl tab 5 mg
meq (1620 mg) (Urocit-k 15)
buspirone hcl tab 7.5 mg 2
PROCYSBI - cysteamine 5 1
bitartrate cap delayed buspirone hcl tab 10 mg
release 25 mg (base equiv) buspirone hcl tab 15 mg 1
PROCYSBI - cysteamine 5 buspirone hcl tab 30 mg 2
bitartrate cap delayed chlordiazepoxide hcl cap 1
release 75 mg (base equiv) 5 mg
RAPAFLO - silodosin cap 4 mg 4 chlordiazepoxide hcl cap 1
RAPAFLO - silodosin cap 8 mg 4 10 mg
tamsulosin hcl cap 0.4 mg 1 chlordiazepoxide hcl cap 1
(Flomax) 25 mg
THIOLA - tiopronin tab 100 mg 4 clorazepate dipotassium tab 1
CENTRAL NERVOUS SYSTEM DRUGS 3.75 mg (Tranxene t)
clorazepate dipotassium tab 1
ANTIANXIETY AGENTS
7.5 mg (Tranxene t)
ALPRAZOLAM INTENSOL - 4
clorazepate dipotassium tab 2
alprazolam conc 1 mg/ml
15 mg (Tranxene t)
alprazolam orally 2
DIAZEPAM - diazepam oral 4
disintegrating tab 0.25 mg
(Niravam) soln 1 mg/ml
2 diazepam conc 5 mg/ml 2
alprazolam orally
disintegrating tab 0.5 mg diazepam tab 2 mg (Valium) 1
alprazolam orally 2 diazepam tab 5 mg (Valium) 1
disintegrating tab 1 mg diazepam tab 10 mg (Valium) 1
alprazolam orally 2 1
hydroxyzine hcl syrup
disintegrating tab 2 mg 10 mg/5ml
alprazolam tab er 24hr 1 1
hydroxyzine hcl tab 10 mg
0.5 mg (Xanax xr)
hydroxyzine hcl tab 25 mg 1
alprazolam tab er 24hr 1 mg 2
hydroxyzine hcl tab 50 mg 1
(Xanax xr)
2 HYDROXYZINE PAMOATE - 4
alprazolam tab er 24hr 2 mg
(Xanax xr) hydroxyzine pamoate cap
2 100 mg
alprazolam tab er 24hr 3 mg
(Xanax xr)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
hydroxyzine pamoate cap 1 bupropion hcl tab er 24hr 2
25 mg (Vistaril) 300 mg (Wellbutrin xl)
hydroxyzine pamoate cap 1 bupropion hcl tab 75 mg 2
50 mg (Vistaril) (Wellbutrin)
lorazepam conc 2 mg/ml 2 bupropion hcl tab 100 mg 2
(Lorazepam intensol) (Wellbutrin)
lorazepam tab 0.5 mg 1 citalopram hydrobromide 2
(Ativan) oral soln 10 mg/5ml
lorazepam tab 1 mg (Ativan) 1 citalopram hydrobromide 1
lorazepam tab 2 mg (Ativan) 1 tab 10 mg (base equiv)
(Celexa)
meprobamate tab 200 mg 2
citalopram hydrobromide 1
meprobamate tab 400 mg 2
oxazepam cap 10 mg 2 (Celexa)
oxazepam cap 15 mg 2 citalopram hydrobromide 1
oxazepam cap 30 mg 2 tab 40 mg (base equiv)
(Celexa)
ANTIDEPRESSANTS 2
clomipramine hcl cap 25 mg
amitriptyline hcl tab 10 mg 1
(Anafranil)
amitriptyline hcl tab 25 mg 1 2
clomipramine hcl cap 50 mg
amitriptyline hcl tab 50 mg 1 (Anafranil)
amitriptyline hcl tab 75 mg 2 clomipramine hcl cap 75 mg 2
2 (Anafranil)
amitriptyline hcl tab 100 mg
desipramine hcl tab 10 mg 2
amitriptyline hcl tab 150 mg 2
(Norpramin)
AMOXAPINE - amoxapine tab 4
25 mg
(Norpramin)
50 mg
(Norpramin)
100 mg
(Norpramin)
150 mg
(Norpramin)
bupropion hcl tab er 12hr 1
100 mg (Wellbutrin sr)
(Norpramin)
desvenlafaxine succinate 2
equiv) (Pristiq)
desvenlafaxine succinate 2
150 mg (Wellbutrin xl) equiv) (Pristiq)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
desvenlafaxine succinate 2 FLUOXETINE DR - fluoxetine 2
tab er 24hr 100 mg (base hcl cap delayed release 90
equiv) (Pristiq) mg
DOXEPIN HCL - doxepin hcl 4 fluoxetine hcl cap 10 mg 1
cap 75 mg (Prozac)
doxepin hcl cap 10 mg 2 fluoxetine hcl cap 20 mg 1
doxepin hcl cap 25 mg 2 (Prozac)
2 fluoxetine hcl cap 40 mg 1
doxepin hcl cap 50 mg
(Prozac)
doxepin hcl cap 100 mg 2
fluoxetine hcl solution 1
doxepin hcl cap 150 mg 2
20 mg/5ml
doxepin hcl conc 10 mg/ml 1 2
fluoxetine hcl tab 10 mg
DULOXETINE HCL - 4 fluoxetine hcl tab 20 mg 2
duloxetine hcl enteric coated
fluvoxamine maleate tab 1
pellets cap 40 mg
25 mg
duloxetine hcl enteric 2 1
coated pellets cap 20 mg fluvoxamine maleate tab
(Cymbalta) 50 mg
1
duloxetine hcl enteric 2 fluvoxamine maleate tab
coated pellets cap 30 mg 100 mg
(Cymbalta) imipramine hcl tab 10 mg 1
duloxetine hcl enteric 2 (Tofranil)
coated pellets cap 60 mg imipramine hcl tab 25 mg 1
(Cymbalta) (Tofranil)
EMSAM - selegiline td patch 4 imipramine hcl tab 50 mg 1
24hr 6 mg/24hr (Tofranil)
EMSAM - selegiline td patch 4 imipramine pamoate cap 2
24hr 9 mg/24hr 75 mg (Tofranil-pm)
EMSAM - selegiline td patch 4 imipramine pamoate cap 2
24hr 12 mg/24hr 100 mg (Tofranil-pm)
escitalopram oxalate soln 2 imipramine pamoate cap 2
5 mg/5ml (base equiv) 125 mg (Tofranil-pm)
(Lexapro) imipramine pamoate cap 2
escitalopram oxalate 1 150 mg (Tofranil-pm)
tab 5 mg (base equiv) MAPROTILINE HCL - 4
(Lexapro) maprotiline hcl tab 25 mg
1
escitalopram oxalate MAPROTILINE HCL - 4
tab 10 mg (base equiv) maprotiline hcl tab 50 mg
(Lexapro)
1
MAPROTILINE HCL - 4
escitalopram oxalate maprotiline hcl tab 75 mg
(Lexapro)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
MARPLAN - isocarboxazid tab 4 paroxetine hcl tab 10 mg 1
10 mg (Paxil)
mirtazapine orally 2 paroxetine hcl tab 20 mg 1
disintegrating tab 15 mg (Paxil)
(Remeron soltab) paroxetine hcl tab 30 mg 1
mirtazapine orally 2 (Paxil)
disintegrating tab 30 mg paroxetine hcl tab 40 mg 1
(Remeron soltab) (Paxil)
mirtazapine orally 2 2
phenelzine sulfate tab 15 mg
disintegrating tab 45 mg (Nardil)
(Remeron soltab)
2
PRISTIQ - desvenlafaxine 4
mirtazapine tab 7.5 mg succinate tab er 24hr 25 mg
mirtazapine tab 15 mg 1 (base equiv)
(Remeron) PRISTIQ - desvenlafaxine 4
mirtazapine tab 30 mg 1 succinate tab er 24hr 50 mg
(Remeron) (base equiv)
mirtazapine tab 45 mg 1 PRISTIQ - desvenlafaxine 4
(Remeron) succinate tab er 24hr 100
NEFAZODONE HCL - 4 mg (base equiv)
nefazodone hcl tab 100 mg protriptyline hcl tab 5 mg 2
NEFAZODONE HCL - 4 protriptyline hcl tab 10 mg 2
nefazodone hcl tab 150 mg sertraline hcl oral conc 2
NEFAZODONE HCL - 4 20 mg/ml (Zoloft)
nefazodone hcl tab 200 mg sertraline hcl tab 25 mg 1
nefazodone hcl tab 50 mg 2 (Zoloft)
nefazodone hcl tab 250 mg 2 sertraline hcl tab 50 mg 1
NORTRIPTYLINE HCL - 4 (Zoloft)
nortriptyline hcl soln 10 sertraline hcl tab 100 mg 1
mg/5ml (Zoloft)
nortriptyline hcl cap 10 mg 1 SURMONTIL - trimipramine 4
(Pamelor) maleate cap 25 mg
nortriptyline hcl cap 75 mg 1 tranylcypromine sulfate tab 2
(Pamelor) 10 mg (Parnate)
paroxetine hcl tab er 24hr 2 trazodone hcl tab 50 mg 1
25 mg (Paxil cr) trazodone hcl tab 100 mg 1
trazodone hcl tab 150 mg 1

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
trazodone hcl tab 300 mg 2 ADASUVE - loxapine aerosol 4
trimipramine maleate cap 2 powder breath activated 10
25 mg (Surmontil) mg
trimipramine maleate cap 2 aripiprazole oral solution 2

50 mg (Surmontil) 1 mg/ml
trimipramine maleate cap 2 aripiprazole orally 2

100 mg (Surmontil) disintegrating tab 10 mg
venlafaxine hcl cap er 24hr 1 aripiprazole orally 2

37.5 mg (base equivalent) disintegrating tab 15 mg
(Effexor xr) aripiprazole tab 2 mg (Abilify) 2
venlafaxine hcl cap er 24hr 1 aripiprazole tab 5 mg (Abilify) 2
75 mg (base equivalent) aripiprazole tab 10 mg 2
(Effexor xr) (Abilify)
1
venlafaxine hcl cap er 24hr aripiprazole tab 15 mg 2
150 mg (base equivalent) (Abilify)
(Effexor xr)
2
aripiprazole tab 20 mg 2
venlafaxine hcl tab er 24hr (Abilify)
37.5 mg (base equivalent)
(Venlafaxine hcl er) aripiprazole tab 30 mg 2
(Abilify)
venlafaxine hcl tab er 24hr 2
chlorpromazine hcl tab 2
75 mg (base equivalent)
(Venlafaxine hcl er) 10 mg
2 chlorpromazine hcl tab 2
venlafaxine hcl tab er 24hr
150 mg (base equivalent) 25 mg
(Venlafaxine hcl er) chlorpromazine hcl tab 2
venlafaxine hcl tab 25 mg 1 50 mg
1 chlorpromazine hcl tab 2
venlafaxine hcl tab 37.5 mg
100 mg
venlafaxine hcl tab 50 mg 1
chlorpromazine hcl tab 2
venlafaxine hcl tab 75 mg 1
200 mg
1
venlafaxine hcl tab 100 mg CLOZAPINE ODT - clozapine 4
VIIBRYD - vilazodone hcl tab 4 orally disintegrating tab 12.5
10 mg mg
VIIBRYD - vilazodone hcl tab 4 CLOZAPINE ODT - clozapine 4
20 mg orally disintegrating tab 150
VIIBRYD - vilazodone hcl tab 4 mg
40 mg CLOZAPINE ODT - clozapine 4
VIIBRYD STARTER PACK - 4 orally disintegrating tab 200
vilazodone hcl tab starter kit mg
10 (7) & 20 (23) mg clozapine orally 2
ANTIPSYCHOTICS disintegrating tab 25 mg
(Fazaclo)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
clozapine orally 2 FLUPHENAZINE HCL - 3
disintegrating tab 100 mg fluphenazine hcl oral conc 5
(Fazaclo) mg/ml
clozapine tab 25 mg 2 fluphenazine hcl tab 1 mg 1
(Clozaril) fluphenazine hcl tab 2.5 mg 1
(Clozaril)
haloperidol lactate oral conc 1
clozapine tab 200 mg 2 2 mg/ml
EQUETRO - carbamazepine 4 1
haloperidol tab 0.5 mg
(antipsychotic) cap er 12hr
haloperidol tab 1 mg 1
100 mg
4 haloperidol tab 2 mg 2
EQUETRO - carbamazepine
(antipsychotic) cap er 12hr haloperidol tab 5 mg 2
200 mg haloperidol tab 10 mg 2
EQUETRO - carbamazepine 4 2
haloperidol tab 20 mg
(antipsychotic) cap er 12hr
300 mg LATUDA - lurasidone hcl tab 20 4
mg
FANAPT - iloperidone tab 1 mg 4
LATUDA - lurasidone hcl tab 40 4
FANAPT - iloperidone tab 2 mg 4 mg
FANAPT - iloperidone tab 4 mg 4 LATUDA - lurasidone hcl tab 60 4
FANAPT - iloperidone tab 6 mg 4 mg
FANAPT - iloperidone tab 8 mg 4 LATUDA - lurasidone hcl tab 80 4
FANAPT - iloperidone tab 10 4 mg
mg LATUDA - lurasidone hcl tab 4
FANAPT - iloperidone tab 12 4 120 mg
mg LITHIUM - lithium oral solution 4
FANAPT TITRATION PACK - 4 8 meq/5ml
iloperidone tab 1 mg & 2 mg LITHIUM CARBONATE - 4
& 4 mg & 6 mg titration pak lithium carbonate cap 150
FAZACLO - clozapine orally 4 mg
disintegrating tab 12.5 mg LITHIUM CARBONATE - 4
FAZACLO - clozapine orally 4 lithium carbonate cap 600
disintegrating tab 150 mg mg
4 lithium carbonate cap 1
FAZACLO - clozapine orally
disintegrating tab 200 mg 150 mg (Lithium carbonate)
3 lithium carbonate cap 1
FLUPHENAZINE HCL -
fluphenazine hcl elixir 2.5 300 mg
mg/5ml lithium carbonate cap 1
600 mg (Lithium carbonate)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
lithium carbonate tab er 1 olanzapine tab 20 mg 1
300 mg (Lithobid) (Zyprexa)
lithium carbonate tab er 1 paliperidone tab er 24hr 2
450 mg 1.5 mg (Invega)
lithium carbonate tab 1 paliperidone tab er 24hr 2
300 mg 3 mg (Invega)
LITHOBID - lithium carbonate 4 paliperidone tab er 24hr 2
tab er 300 mg 6 mg (Invega)
loxapine succinate cap 5 mg 2 paliperidone tab er 24hr 2
loxapine succinate cap 2 9 mg (Invega)
10 mg perphenazine tab 2 mg 2
loxapine succinate cap 2 perphenazine tab 4 mg 2
25 mg perphenazine tab 8 mg 2
loxapine succinate cap 2 2
perphenazine tab 16 mg
50 mg
prochlorperazine maleate 1
NUPLAZID - pimavanserin 4 tab 5 mg (base equivalent)
tartrate tab 17 mg (base (Compazine)
equivalent)
prochlorperazine maleate 1
olanzapine orally 2 tab 10 mg (base
disintegrating tab 5 mg equivalent) (Compazine)
(Zyprexa zydis)
prochlorperazine suppos 2
olanzapine orally 2 25 mg
disintegrating tab 10 mg
(Zyprexa zydis) quetiapine fumarate tab er 2
24hr 50 mg (Seroquel xr)
olanzapine orally 2
disintegrating tab 15 mg quetiapine fumarate tab er 2
(Zyprexa zydis) 24hr 150 mg (Seroquel xr)
olanzapine orally 2 quetiapine fumarate tab er 2
disintegrating tab 20 mg 24hr 200 mg (Seroquel xr)
(Zyprexa zydis) quetiapine fumarate tab er 2
olanzapine tab 2.5 mg 1 24hr 300 mg (Seroquel xr)
(Zyprexa) quetiapine fumarate tab er 2
olanzapine tab 5 mg 1 24hr 400 mg (Seroquel xr)
(Zyprexa) quetiapine fumarate tab 1
olanzapine tab 7.5 mg 1 25 mg (Seroquel)
olanzapine tab 10 mg 1 50 mg (Seroquel)
olanzapine tab 15 mg 1 100 mg (Seroquel)
200 mg (Seroquel)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
quetiapine fumarate tab 1 risperidone tab 2 mg 1
300 mg (Seroquel) (Risperdal)
quetiapine fumarate tab 1 risperidone tab 3 mg 1
400 mg (Seroquel) (Risperdal)
REXULTI - brexpiprazole tab 4 risperidone tab 4 mg 1
0.25 mg (Risperdal)
REXULTI - brexpiprazole tab 4 SAPHRIS - asenapine maleate 4
0.5 mg sl tab 2.5 mg (base equiv)
REXULTI - brexpiprazole tab 1 4 SAPHRIS - asenapine maleate 4
mg sl tab 5 mg (base equiv)
REXULTI - brexpiprazole tab 2 4 SAPHRIS - asenapine maleate 4
mg sl tab 10 mg (base equiv)
REXULTI - brexpiprazole tab 3 4 SEROQUEL XR - quetiapine 3
mg fumarate tab er 24hr 50 mg
REXULTI - brexpiprazole tab 4 4 SEROQUEL XR - quetiapine 3
mg fumarate tab er 24hr 150 mg
risperidone orally 2 SEROQUEL XR - quetiapine 3
disintegrating tab 0.25 mg fumarate tab er 24hr 200 mg
risperidone orally 2 SEROQUEL XR - quetiapine 3
disintegrating tab 0.5 mg fumarate tab er 24hr 300 mg
(Risperdal m-tab) SEROQUEL XR - quetiapine 3
risperidone orally 2 fumarate tab er 24hr 400 mg
disintegrating tab 1 mg thioridazine hcl tab 10 mg 2
(Risperdal m-tab)
thioridazine hcl tab 25 mg 2
risperidone orally 2 2
disintegrating tab 2 mg thioridazine hcl tab 50 mg
(Risperdal m-tab) thioridazine hcl tab 100 mg 2
risperidone orally 2 thiothixene cap 1 mg 2
disintegrating tab 3 mg thiothixene cap 2 mg 2
(Risperdal m-tab)
thiothixene cap 5 mg 2
risperidone orally 2
thiothixene cap 10 mg 2
(Risperdal m-tab) trifluoperazine hcl tab 1 mg 2
risperidone soln 1 mg/ml 2 trifluoperazine hcl tab 2 mg 2
(Risperdal) 2
trifluoperazine hcl tab 5 mg
risperidone tab 0.25 mg 1 trifluoperazine hcl tab 10 mg 2
(Risperdal)
1 VERSACLOZ - clozapine susp 4
risperidone tab 0.5 mg
50 mg/ml
(Risperdal)
1 ziprasidone hcl cap 20 mg 2
risperidone tab 1 mg
(Geodon)
(Risperdal)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
ziprasidone hcl cap 40 mg 2 ROZEREM - ramelteon tab 8 4
(Geodon) mg
ziprasidone hcl cap 60 mg 2 temazepam cap 7.5 mg 2
(Geodon) (Restoril)
ziprasidone hcl cap 80 mg 2 temazepam cap 15 mg 1
(Geodon) (Restoril)
HYPNOTICS temazepam cap 22.5 mg 2
DORAL - quazepam tab 15 mg 4 (Restoril)
2 temazepam cap 30 mg 1
estazolam tab 1 mg
(Restoril)
estazolam tab 2 mg 2
zaleplon cap 5 mg (Sonata) 1
eszopiclone tab 1 mg 2
(Lunesta) zaleplon cap 10 mg (Sonata) 1
eszopiclone tab 2 mg 2 zolpidem tartrate sl tab 2
(Lunesta) 1.75 mg (Intermezzo)
eszopiclone tab 3 mg 2 zolpidem tartrate sl tab 2

(Lunesta) 3.5 mg (Intermezzo)
FLURAZEPAM HCL - 4 zolpidem tartrate tab er 2

flurazepam hcl cap 15 mg 6.25 mg (Ambien cr)
FLURAZEPAM HCL - 4 zolpidem tartrate tab er 2

flurazepam hcl cap 30 mg 12.5 mg (Ambien cr)
HETLIOZ - tasimelteon capsule 4 zolpidem tartrate tab 5 mg 1

20 mg (Ambien)
PHENOBARBITAL - 4 zolpidem tartrate tab 10 mg 1

phenobarbital tab 15 mg (Ambien)
PHENOBARBITAL - 4 ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/
phenobarbital tab 30 mg ANOREXIANTS
PHENOBARBITAL - 4 ADDERALL XR - 3
phenobarbital tab 60 mg amphetamine-
dextroamphetamine cap er
PHENOBARBITAL - 4
24hr 5 mg
phenobarbital tab 100 mg
2
ADDERALL XR - 3
phenobarbital elixir amphetamine-
20 mg/5ml dextroamphetamine cap er
phenobarbital tab 16.2 mg 2 24hr 10 mg
phenobarbital tab 32.4 mg 2 ADDERALL XR - 3
phenobarbital tab 64.8 mg 2 amphetamine-
dextroamphetamine cap er
phenobarbital tab 97.2 mg 2
24hr 15 mg
QUAZEPAM - quazepam tab 4
15 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
ADDERALL XR - 3 amphetamine- 2
amphetamine- dextroamphetamine tab
dextroamphetamine cap er 15 mg (Adderall)
24hr 20 mg amphetamine- 2
ADDERALL XR - 3 dextroamphetamine tab
amphetamine- 20 mg (Adderall)
dextroamphetamine cap er amphetamine- 2
24hr 25 mg dextroamphetamine tab
ADDERALL XR - 3 30 mg (Adderall)
amphetamine- APTENSIO XR - 4
dextroamphetamine cap er methylphenidate hcl cap er
24hr 30 mg 24hr 10 mg (xr)
amphetamine- 2 APTENSIO XR - 4
24hr 5 mg (Adderall xr) 24hr 15 mg (xr)
amphetamine- 2 armodafinil tab 50 mg 2
dextroamphetamine tab (Nuvigil)
5 mg (Adderall)
armodafinil tab 150 mg 2
amphetamine- 2 (Nuvigil)
dextroamphetamine tab
7.5 mg (Adderall) armodafinil tab 200 mg 2
(Nuvigil)
amphetamine- 2
dextroamphetamine tab armodafinil tab 250 mg 2
10 mg (Adderall) (Nuvigil)
amphetamine- 2 atomoxetine hcl cap 10 mg 2
dextroamphetamine tab (base equiv) (Strattera)
12.5 mg (Adderall) atomoxetine hcl cap 18 mg 2
(base equiv) (Strattera)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
atomoxetine hcl cap 25 mg 2 dexmethylphenidate hcl cap 2
(base equiv) (Strattera) er 24 hr 40 mg (Focalin xr)
atomoxetine hcl cap 40 mg 2 dexmethylphenidate hcl tab 2
(base equiv) (Strattera) 2.5 mg (Focalin)
(base equiv) (Strattera) 5 mg (Focalin)
(base equiv) (Strattera) 10 mg (Focalin)
atomoxetine hcl cap 100 mg 2 dextroamphetamine 2
(base equiv) (Strattera) sulfate cap er 24hr 5 mg
caffeine citrate oral soln 2 (Dexedrine)
60 mg/3ml (10 mg/ml base dextroamphetamine 2
equiv) sulfate cap er 24hr 10 mg
clonidine hcl tab er 12hr 2 (Dexedrine)
0.1 mg (Kapvay) dextroamphetamine 2
CONCERTA - methylphenidate 3 sulfate cap er 24hr 15 mg
hcl tab er osmotic release (Dexedrine)
(osm) 18 mg dextroamphetamine sulfate 2
CONCERTA - methylphenidate 3 oral solution 5 mg/5ml
hcl tab er osmotic release (Procentra)
(osm) 27 mg dextroamphetamine sulfate 2
CONCERTA - methylphenidate 3 tab 5 mg
hcl tab er osmotic release dextroamphetamine sulfate 2
(osm) 36 mg tab 10 mg
CONCERTA - methylphenidate 3 FOCALIN XR - 4
hcl tab er osmotic release dexmethylphenidate hcl cap
(osm) 54 mg er 24 hr 25 mg
dexmethylphenidate hcl cap 2 FOCALIN XR - 4
er 24 hr 5 mg (Focalin xr) dexmethylphenidate hcl cap
dexmethylphenidate hcl cap 2 er 24 hr 35 mg
er 24 hr 10 mg (Focalin xr) guanfacine hcl tab er 24hr 2
dexmethylphenidate hcl cap 2 1 mg (base equiv) (Intuniv)
er 24 hr 30 mg (Focalin xr) methamphetamine hcl tab 2
dexmethylphenidate hcl cap 2 5 mg (Desoxyn)
er 24 hr 35 mg (Focalin xr)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
METHYLPHENIDATE HCL - 2 methylphenidate hcl soln 2
methylphenidate hcl chew 10 mg/5ml (Methylin)
tab 2.5 mg methylphenidate hcl tab 2
METHYLPHENIDATE HCL - 2 er osmotic release (osm)
methylphenidate hcl chew 18 mg (Concerta)
tab 5 mg methylphenidate hcl tab 2
METHYLPHENIDATE HCL - 2 er osmotic release (osm)
methylphenidate hcl chew 27 mg (Concerta)
tab 10 mg methylphenidate hcl tab 2
methylphenidate hcl cap er 2 er osmotic release (osm)
10 mg (cd) 36 mg (Concerta)
methylphenidate hcl cap er 2 methylphenidate hcl tab 2
20 mg (cd) er osmotic release (osm)
methylphenidate hcl cap er 2 54 mg (Concerta)
30 mg (cd) methylphenidate hcl tab er 2
methylphenidate hcl cap er 2 10 mg
40 mg (cd) methylphenidate hcl tab er 2
methylphenidate hcl cap er 2 20 mg
50 mg (cd) methylphenidate hcl tab 2
methylphenidate hcl cap er 2 5 mg (Ritalin)
60 mg (cd) methylphenidate hcl tab 2
24hr 20 mg (la) (Ritalin la) methylphenidate hcl tab 2
24hr 30 mg (la) (Ritalin la) modafinil tab 100 mg 2
methylphenidate hcl cap er 2 (Provigil)
24hr 40 mg (la) (Ritalin la) modafinil tab 200 mg 2
METHYLPHENIDATE HCL 2 (Provigil)
ER - methylphenidate hcl tab NUVIGIL - armodafinil tab 50 4
er 24hr 18 mg mg
METHYLPHENIDATE HCL 2 NUVIGIL - armodafinil tab 150 4
ER - methylphenidate hcl tab mg
er 24hr 27 mg NUVIGIL - armodafinil tab 200 4
METHYLPHENIDATE HCL 2 mg
ER - methylphenidate hcl tab NUVIGIL - armodafinil tab 250 4
er 24hr 36 mg mg
METHYLPHENIDATE HCL 2 STRATTERA - atomoxetine hcl 4
ER - methylphenidate hcl tab cap 10 mg (base equiv)
er 24hr 54 mg
STRATTERA - atomoxetine hcl 4
methylphenidate hcl soln 2 cap 18 mg (base equiv)
5 mg/5ml (Methylin)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
STRATTERA - atomoxetine hcl 4 AMPYRA - dalfampridine tab er 5
cap 25 mg (base equiv) 12hr 10 mg
STRATTERA - atomoxetine hcl 4 AUBAGIO - teriflunomide tab 7 5
cap 40 mg (base equiv) mg
STRATTERA - atomoxetine hcl 4 AUBAGIO - teriflunomide tab 5
STRATTERA - atomoxetine hcl 4 AUSTEDO - deutetrabenazine 5
cap 80 mg (base equiv) tab 6 mg
STRATTERA - atomoxetine hcl 4 AUSTEDO - deutetrabenazine 5
cap 100 mg (base equiv) tab 9 mg
VYVANSE - lisdexamfetamine 3 AUSTEDO - deutetrabenazine 5
dimesylate cap 10 mg tab 12 mg
VYVANSE - lisdexamfetamine 3 AVONEX - interferon beta-1a 5
dimesylate cap 20 mg for im inj kit 30mcg
VYVANSE - lisdexamfetamine 3 (33mcg(6.6 mu)/vial)
dimesylate cap 30 mg AVONEX - interferon beta-1a 5
VYVANSE - lisdexamfetamine 3 im prefilled syringe kit 30
dimesylate cap 40 mg mcg/0.5ml
VYVANSE - lisdexamfetamine 3 AVONEX PEN - interferon 5

dimesylate cap 50 mg beta-1a im auto-injector kit
30 mcg/0.5ml
VYVANSE - lisdexamfetamine 3
dimesylate cap 60 mg BETASERON - interferon 5
beta-1b for inj kit 0.3 mg
VYVANSE - lisdexamfetamine 3
dimesylate cap 70 mg bupropion hcl (smoking A
deterrent) tab er 12hr
VYVANSE - lisdexamfetamine 3 150 mg (Zyban)
dimesylate chew tab 10 mg
CHANTIX - varenicline tartrate A
VYVANSE - lisdexamfetamine 3 tab 0.5 mg (base equiv)
CHANTIX - varenicline tartrate A
VYVANSE - lisdexamfetamine 3 tab 1 mg (base equiv)
CHANTIX CONTINUING A
VYVANSE - lisdexamfetamine 3 MONTH - varenicline tartrate
dimesylate chew tab 40 mg tab 1 mg (base equiv)
VYVANSE - lisdexamfetamine 3 CHANTIX STARTING MONTH A
dimesylate chew tab 50 mg PA - varenicline tartrate tab
VYVANSE - lisdexamfetamine 3 0.5 mg x 11 & tab 1 mg x 42
dimesylate chew tab 60 mg pack
PSYCHOTHERAPEUTIC and NEUROLOGICAL CHLORDIAZEPOXIDE/ 4
AGENTS - MISC. AMITRIPT -
acamprosate calcium tab 2 chlordiazepoxide-
delayed release 333 mg amitriptyline tab 5-12.5 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
CHLORDIAZEPOXIDE/ 4 GALANTAMINE 4
AMITRIPT - HYDROBROMIDE -
chlordiazepoxide- galantamine hydrobromide
amitriptyline tab 10-25 mg oral soln 4 mg/ml
COMMIT - nicotine polacrilex A galantamine hydrobromide 2
lozenge 2 mg cap er 24hr 8 mg
COMMIT - nicotine polacrilex A (Razadyne er)
lozenge 4 mg galantamine hydrobromide 2
COPAXONE - glatiramer 5 cap er 24hr 16 mg
acetate soln prefilled syringe (Razadyne er)
20 mg/ml galantamine hydrobromide 2
COPAXONE - glatiramer 5 cap er 24hr 24 mg
acetate soln prefilled syringe (Razadyne er)
40 mg/ml galantamine hydrobromide 2
disulfiram tab 250 mg 2 tab 4 mg (Razadyne)
(Antabuse) galantamine hydrobromide 2
disulfiram tab 500 mg 2 tab 8 mg (Razadyne)
(Antabuse) galantamine hydrobromide 2
donepezil hydrochloride 1 tab 12 mg (Razadyne)
orally disintegrating tab GILENYA - fingolimod hcl cap 5
5 mg 0.5 mg (base equiv)
donepezil hydrochloride 1 glatiramer acetate soln 5
orally disintegrating tab prefilled syringe 20 mg/ml
10 mg (Copaxone)
donepezil hydrochloride tab 1 GRALISE - gabapentin (once- 4
5 mg (Aricept) daily) tab 300 mg
donepezil hydrochloride tab 1 GRALISE - gabapentin (once- 4
10 mg (Aricept) daily) tab 600 mg
donepezil hydrochloride tab 2 GRALISE STARTER - 4
23 mg (Aricept) gabapentin (once-daily) tab
ERGOLOID MESYLATES - 4 pack 300 mg (9) & 600 mg
ergoloid mesylates tab 1 mg (69)
EXTAVIA - interferon beta-1b 5 HORIZANT - gabapentin 4

for inj kit 0.3 mg enacarbil tab er 300 mg
FLUOXETINE - fluoxetine hcl 4 HORIZANT - gabapentin 4

(pmdd) cap 10 mg enacarbil tab er 600 mg
FLUOXETINE - fluoxetine hcl 4 INGREZZA - valbenazine 5

(pmdd) cap 20 mg tosylate cap 40 mg (base
equiv)
memantine hcl oral solution 2
2 mg/ml (Namenda)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
memantine hcl tab 5 mg 2 NICORETTE - nicotine A
(Namenda) polacrilex gum 2 mg
memantine hcl tab 10 mg 2 NICORETTE - nicotine A
(Namenda) polacrilex gum 4 mg
memantine hcl tab 5 mg (28) 2 NICORETTE - nicotine A
& 10 mg (21) titration pak polacrilex lozenge 2 mg
(Namenda titration pa) NICORETTE - nicotine A
NAMENDA XR - memantine 4 polacrilex lozenge 4 mg
hcl cap er 24hr 7 mg NICORETTE MINI - nicotine A
hcl cap er 24hr 14 mg NICORETTE MINI - nicotine A
hcl cap er 24hr 21 mg NICORETTE STARTER KIT - A
NAMENDA XR - memantine 4 nicotine polacrilex gum 2 mg
hcl cap er 24hr 28 mg NICORETTE STARTER KIT - A
NAMENDA XR TITRATION 4 nicotine polacrilex gum 4 mg
PACK - memantine hcl cap er nicotine polacrilex gum A
24hr 7 mg & 14 mg & 21 mg 2 mg
& 28 mg pack
4
nicotine polacrilex gum A
NAMZARIC - memantine hcl- 4 mg
donepezil hcl cap er 24hr
7-10 mg nicotine polacrilex lozenge A
2 mg
NAMZARIC - memantine hcl- 4
donepezil hcl cap er 24hr nicotine polacrilex lozenge A
14-10 mg 4 mg
NAMZARIC - memantine hcl- 4 nicotine td patch 24hr A
donepezil hcl cap er 24hr 7 mg/24hr
21-10 mg nicotine td patch 24hr A
NAMZARIC - memantine hcl- 4 14 mg/24hr
donepezil hcl cap er 24hr nicotine td patch 24hr A
28-10 mg 21 mg/24hr
NAMZARIC - memantine- 4 NICOTINE TRANSDERMAL A
donepezil cap er 24hr 7 & 14 SYST - nicotine td patch 24
& 21 & 28-10 mg pack hr kit 21-14-7 mg/24hr
NICODERM CQ - nicotine td A NICOTROL INHALER - A
patch 24hr 7 mg/24hr nicotine inhaler system 10
NICODERM CQ - nicotine td A mg (4 mg delivered)
patch 24hr 14 mg/24hr NICOTROL NS - nicotine nasal A
NICODERM CQ - nicotine td A spray 10 mg/ml (0.5 mg/
patch 24hr 21 mg/24hr spray)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
NUEDEXTA - 3 PLEGRIDY - peginterferon 5
dextromethorphan hbr- beta-1a soln prefilled syringe
quinidine sulfate cap 20-10 125 mcg/0.5ml
mg PLEGRIDY STARTER PACK - 5
olanzapine-fluoxetine hcl 2 peginterferon beta-1a soln
cap 3-25 mg (Symbyax) pen-inj 63 & 94 mcg/0.5ml
olanzapine-fluoxetine hcl 2 pack
cap 6-25 mg (Symbyax) PLEGRIDY STARTER PACK - 5
olanzapine-fluoxetine hcl 2 peginterferon beta-1a soln
cap 6-50 mg (Symbyax) pref syr 63 & 94 mcg/0.5ml
pack
olanzapine-fluoxetine hcl 2
cap 12-25 mg (Symbyax) REBIF - interferon beta-1a 5
soln pref syr 22 mcg/0.5ml
olanzapine-fluoxetine hcl 2
(12mu/ml)
cap 12-50 mg (Symbyax)
4
REBIF - interferon beta-1a 5
ORAP - pimozide tab 1 mg soln pref syr 44 mcg/0.5ml
ORAP - pimozide tab 2 mg 4 (24mu/ml)
PERPHENAZINE/ 4 REBIF REBIDOSE - interferon 5
AMITRIPTYLIN - beta-1a soln auto-inj 22
perphenazine-amitriptyline mcg/0.5ml (12mu/ml)
tab 2-10 mg REBIF REBIDOSE - interferon 5
PERPHENAZINE/ 4 beta-1a soln auto-inj 44
AMITRIPTYLIN - mcg/0.5ml (24mu/ml)
perphenazine-amitriptyline REBIF REBIDOSE 5
tab 2-25 mg TITRATION - interferon
PERPHENAZINE/ 4 beta-1a auto-inj 6x8.8
AMITRIPTYLIN - mcg/0.2ml & 6x22
perphenazine-amitriptyline mcg/0.5ml
tab 4-10 mg REBIF TITRATION PACK - 5
PERPHENAZINE/ 4 interferon beta-1a pref syr
AMITRIPTYLIN - 6x8.8 mcg/0.2ml & 6x22
perphenazine-amitriptyline mcg/0.5ml
tab 4-25 mg rivastigmine tartrate cap 2
PERPHENAZINE/ 4 1.5 mg (Exelon)
AMITRIPTYLIN - rivastigmine tartrate cap 2
perphenazine-amitriptyline 3 mg (Exelon)
tab 4-50 mg
rivastigmine tartrate cap 2
pimozide tab 1 mg (Orap) 2
4.5 mg (Exelon)
pimozide tab 2 mg (Orap) 2 2
rivastigmine tartrate cap
PLEGRIDY - peginterferon 5 6 mg (Exelon)
beta-1a soln pen-injector rivastigmine td patch 24hr 2
125 mcg/0.5ml 4.6 mg/24hr (Exelon)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
rivastigmine td patch 24hr 2 butalbital-acetaminophen 2
9.5 mg/24hr (Exelon) tab 50-325 mg
rivastigmine td patch 24hr 2 butalbital-acetaminophen- 2
13.3 mg/24hr (Exelon) caffeine cap 50-300-40 mg
SAVELLA - milnacipran hcl tab 4 (Fioricet)
12.5 mg butalbital-acetaminophen- 2
SAVELLA - milnacipran hcl tab 4 caffeine cap 50-325-40 mg
25 mg butalbital-acetaminophen- 2
SAVELLA - milnacipran hcl tab 4 caffeine tab 50-325-40 mg
50 mg (Esgic)
2
SAVELLA - milnacipran hcl tab 4 butalbital-aspirin-caffeine
100 mg cap 50-325-40 mg (Fiorinal)
4
SAVELLA TITRATION PACK - 4 BUTALBITAL/ASPIRIN/
milnacipran hcl tab 12.5 mg CAFFEI - butalbital-aspirin-
(5) & 25 mg (8) & 50 mg (42) caffeine tab 50-325-40 mg
pak diflunisal tab 500 mg 2
TECFIDERA - dimethyl 5 TENCON - butalbital- 2
fumarate capsule delayed acetaminophen tab 50-325
release 120 mg mg
TECFIDERA - dimethyl 5 ANALGESICS - NARCOTIC
fumarate capsule delayed ABSTRAL - fentanyl citrate sl 4
release 240 mg tab 100 mcg (base equiv)
TECFIDERA STARTER 5 ABSTRAL - fentanyl citrate sl 4
PACK - dimethyl fumarate tab 200 mcg (base equiv)
capsule dr starter pack 120
mg & 240 mg ABSTRAL - fentanyl citrate sl 4
tab 300 mcg (base equiv)
tetrabenazine tab 12.5 mg 5
(Xenazine) ABSTRAL - fentanyl citrate sl 4
tetrabenazine tab 25 mg 5
(Xenazine) ABSTRAL - fentanyl citrate sl 4
XYREM - sodium oxybate oral 5
solution 500 mg/ml ABSTRAL - fentanyl citrate sl 4
ZYBAN - bupropion hcl A 1
(smoking deterrent) tab er acetaminophen w/ codeine
12hr 150 mg soln 120-12 mg/5ml
acetaminophen w/ codeine 1
ANALGESICS AND ANESTHETICS
tab 300-15 mg (Tylenol/
ANALGESICS - NON-NARCOTIC codeine)
aspirin chew tab 81 mg A acetaminophen w/ codeine 1
aspirin tab delayed release A tab 300-30 mg (Tylenol/
81 mg codeine #3)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
acetaminophen w/ codeine 1 BUPRENORPHINE - 4
tab 300-60 mg (Tylenol/ buprenorphine td patch
codeine #4) weekly 15 mcg/hr
ACETAMINOPHEN/ 2 BUPRENORPHINE - 4
CAFFEINE/DI - buprenorphine td patch
acetaminophen-caffeine- weekly 20 mcg/hr
dihydrocodeine cap buprenorphine hcl sl tab 2
320.5-30-16 mg 2 mg (base equiv)
BELBUCA - buprenorphine hcl 4 buprenorphine hcl sl tab 2
buccal film 75 mcg (base 8 mg (base equiv)
equivalent)
buprenorphine hcl-naloxone 2
BELBUCA - buprenorphine hcl 4 hcl sl tab 2-0.5 mg (base
buccal film 150 mcg (base equiv)
equivalent)
buprenorphine hcl-naloxone 2
BELBUCA - buprenorphine hcl 4 hcl sl tab 8-2 mg (base
buccal film 300 mcg (base equiv)
equivalent)
butalbital-acetaminophen- 2
BELBUCA - buprenorphine hcl 4 caff w/ cod cap
buccal film 750 mcg (base 50-300-40-30 mg (Fioricet/
equivalent) codeine)
BELBUCA - buprenorphine hcl 4 butalbital-acetaminophen- 2
buccal film 900 mcg (base caff w/ cod cap
equivalent) 50-325-40-30 mg
BUNAVAIL - buprenorphine- 4 butalbital-aspirin- 2
naloxone buccal film 2.1-0.3 caff w/ codeine cap
mg (base equiv) 50-325-40-30 mg (Fiorinal/
BUNAVAIL - buprenorphine- 4 codeine #3)
naloxone buccal film 4.2-0.7 butorphanol tartrate nasal 2
mg (base equiv) soln 10 mg/ml
BUNAVAIL - buprenorphine- 4 BUTRANS - buprenorphine td 4
naloxone buccal film 6.3-1 patch weekly 5 mcg/hr
mg (base equiv)
BUTRANS - buprenorphine td 4
BUPRENORPHINE - 4 patch weekly 7.5 mcg/hr
buprenorphine td patch
weekly 5 mcg/hr BUTRANS - buprenorphine td 4
patch weekly 10 mcg/hr
BUPRENORPHINE - 4
buprenorphine td patch BUTRANS - buprenorphine td 4
weekly 7.5 mcg/hr patch weekly 15 mcg/hr
BUPRENORPHINE - 4 BUTRANS - buprenorphine td 4
buprenorphine td patch patch weekly 20 mcg/hr
weekly 10 mcg/hr codeine sulfate tab 15 mg 2
(Codeine sulfate)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
codeine sulfate tab 30 mg 2 fentanyl td patch 72hr 2
(Codeine sulfate) 50 mcg/hr (Duragesic)
codeine sulfate tab 60 mg 2 fentanyl td patch 72hr 2
(Codeine sulfate) 75 mcg/hr (Duragesic)
EMBEDA - morphine- 4 fentanyl td patch 72hr 2
naltrexone cap er 20-0.8 mg 100 mcg/hr (Duragesic)
EMBEDA - morphine- 4 FENTORA - fentanyl citrate 4
naltrexone cap er 30-1.2 mg buccal tab 100 mcg (base
EMBEDA - morphine- 4 equiv)
naltrexone cap er 50-2 mg FENTORA - fentanyl citrate 4
EMBEDA - morphine- 4 buccal tab 200 mcg (base
naltrexone cap er 60-2.4 mg equiv)
EMBEDA - morphine- 4 FENTORA - fentanyl citrate 4

naltrexone cap er 80-3.2 mg buccal tab 400 mcg (base
equiv)
EMBEDA - morphine- 4
naltrexone cap er 100-4 mg FENTORA - fentanyl citrate 4
buccal tab 600 mcg (base
EXALGO - hydromorphone hcl 4 equiv)
tab er 24hr deter 32 mg
FENTORA - fentanyl citrate 4
FENTANYL - fentanyl td patch 4 buccal tab 800 mcg (base
72hr 37.5 mcg/hr equiv)
FENTANYL - fentanyl td patch 4 hydrocodone- 2
72hr 62.5 mcg/hr acetaminophen soln
FENTANYL - fentanyl td patch 4 7.5-325 mg/15ml (Hycet)
72hr 87.5 mcg/hr hydrocodone- 2
fentanyl citrate lozenge on a 2 acetaminophen tab
handle 200 mcg (Actiq) 2.5-325 mg
fentanyl citrate lozenge on a 2 hydrocodone- 2
handle 400 mcg (Actiq) acetaminophen tab
fentanyl citrate lozenge on a 2 10-325 mg (Norco)
handle 600 mcg (Actiq) hydrocodone- 2
fentanyl citrate lozenge on a 2 acetaminophen tab
handle 800 mcg (Actiq) 5-300 mg (Xodol)
2
fentanyl citrate lozenge on a 2 hydrocodone-
handle 1200 mcg (Actiq) acetaminophen tab
7.5-300 mg (Xodol)
fentanyl citrate lozenge on a 2 1
handle 1600 mcg (Actiq) hydrocodone-
acetaminophen tab
fentanyl td patch 72hr 2 5-325 mg (Norco)
12 mcg/hr (Duragesic) 1
hydrocodone-
fentanyl td patch 72hr 2 acetaminophen tab
25 mcg/hr (Duragesic) 7.5-325 mg (Norco)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
hydrocodone- 2 HYSINGLA ER - hydrocodone 4
acetaminophen tab bitartrate tab er 24hr deter
10-300 mg (Xodol) 100 mg
hydrocodone-ibuprofen tab 2 HYSINGLA ER - hydrocodone 4
5-200 mg (Reprexain) bitartrate tab er 24hr deter
hydrocodone-ibuprofen tab 2 120 mg
7.5-200 mg (Vicoprofen) IONSYS - fentanyl hcl 4
hydrocodone-ibuprofen tab 2 iontophoretic td system 40
10-200 mg (Ibudone) mcg/act (base equiv)
hydromorphone hcl liqd 2 LAZANDA - fentanyl citrate 4

1 mg/ml (Dilaudid) nasal spray 100 mcg/act
(base equiv)
hydromorphone hcl tab er 2
24hr deter 8 mg (Exalgo) LAZANDA - fentanyl citrate 4
nasal spray 300 mcg/act
hydromorphone hcl tab er 2 (base equiv)
24hr deter 12 mg (Exalgo)
LAZANDA - fentanyl citrate 4
hydromorphone hcl tab er 2 nasal spray 400 mcg/act
24hr deter 16 mg (Exalgo) (base equiv)
hydromorphone hcl tab er 2 LEVORPHANOL TARTRATE - 4
24hr deter 32 mg (Exalgo) levorphanol tartrate tab 2 mg
hydromorphone hcl tab 1 4
MEPERIDINE HCL -
2 mg (Dilaudid) meperidine hcl oral soln 50
hydromorphone hcl tab 1 mg/5ml
4 mg (Dilaudid) methadone hcl conc 10 mg/ 2
hydromorphone hcl tab 2 ml (Methadose)
8 mg (Dilaudid) methadone hcl soln 2
HYSINGLA ER - hydrocodone 4 5 mg/5ml (Methadone hcl)
bitartrate tab er 24hr deter methadone hcl soln 2
20 mg 10 mg/5ml (Methadone hcl)
HYSINGLA ER - hydrocodone 4 methadone hcl tab for oral 2
bitartrate tab er 24hr deter susp 40 mg
30 mg
methadone hcl tab 5 mg 2
HYSINGLA ER - hydrocodone 4 (Dolophine hcl)
bitartrate tab er 24hr deter
methadone hcl tab 10 mg 2
40 mg
(Dolophine)
HYSINGLA ER - hydrocodone 4 3
bitartrate tab er 24hr deter MORPHINE SULFATE -
60 mg morphine sulfate tab 15 mg
3
HYSINGLA ER - hydrocodone 4 MORPHINE SULFATE -
bitartrate tab er 24hr deter morphine sulfate tab 30 mg
80 mg morphine sulfate cap er 24hr 2
10 mg (Kadian)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
morphine sulfate cap er 24hr 2 morphine sulfate tab er 2
20 mg (Kadian) 60 mg (Ms contin)
morphine sulfate cap er 24hr 2 OPANA ER (CRUSH 4
60 mg (Kadian) RESISTANT - oxymorphone
morphine sulfate cap er 24hr 2 hcl tab er 12hr deter 5 mg
80 mg (Kadian) OPANA ER (CRUSH 4
morphine sulfate cap er 24hr 2 RESISTANT - oxymorphone
100 mg (Kadian) hcl tab er 12hr deter 7.5 mg
MORPHINE SULFATE ER - 4 OPANA ER (CRUSH 4

morphine sulfate beads cap RESISTANT - oxymorphone
er 24hr 30 mg hcl tab er 12hr deter 10 mg




4
MORPHINE SULFATE ER - 4 OXAYDO - oxycodone hcl tab
morphine sulfate beads cap abuse deter 5 mg
er 24hr 120 mg OXAYDO - oxycodone hcl tab 4
morphine sulfate oral soln 2 abuse deter 7.5 mg
10 mg/5ml oxycodone hcl cap 5 mg 2
morphine sulfate oral soln 2 oxycodone hcl conc 2
20 mg/5ml 100 mg/5ml (20 mg/ml)
morphine sulfate oral soln 2 (Oxycodone hcl)
100 mg/5ml (20 mg/ml) OXYCODONE HCL ER - 4
morphine sulfate tab er 2 oxycodone hcl tab er 12hr
15 mg (Ms contin) deter 10 mg
morphine sulfate tab er 2 OXYCODONE HCL ER - 4

30 mg (Ms contin) oxycodone hcl tab er 12hr
deter 15 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
OXYCODONE HCL ER - 4 OXYCODONE/ 2
oxycodone hcl tab er 12hr ACETAMINOPHEN -
deter 20 mg oxycodone w/
OXYCODONE HCL ER - 4 acetaminophen soln 5-325
oxycodone hcl tab er 12hr mg/5ml
deter 30 mg OXYCODONE/IBUPROFEN - 4
OXYCODONE HCL ER - 4 oxycodone-ibuprofen tab
oxycodone hcl tab er 12hr 5-400 mg
deter 40 mg OXYCONTIN - oxycodone hcl 3
OXYCODONE HCL ER - 4 tab er 12hr deter 10 mg
oxycodone hcl tab er 12hr OXYCONTIN - oxycodone hcl 3
deter 60 mg tab er 12hr deter 15 mg
OXYCODONE HCL ER - 4 OXYCONTIN - oxycodone hcl 3
oxycodone hcl tab er 12hr tab er 12hr deter 20 mg
deter 80 mg OXYCONTIN - oxycodone hcl 3
oxycodone hcl soln 2 tab er 12hr deter 30 mg
5 mg/5ml (Oxycodone hcl) OXYCONTIN - oxycodone hcl 3
oxycodone hcl tab 5 mg 1 tab er 12hr deter 40 mg
(Roxicodone) OXYCONTIN - oxycodone hcl 3
oxycodone hcl tab 10 mg 2 tab er 12hr deter 60 mg
oxycodone hcl tab 15 mg 2 OXYCONTIN - oxycodone hcl 3
(Roxicodone) tab er 12hr deter 80 mg
oxycodone hcl tab 20 mg 2 oxymorphone hcl tab 5 mg 2
oxycodone hcl tab 30 mg 2 (Opana)
(Roxicodone) oxymorphone hcl tab 10 mg 2
oxycodone w/ 2 (Opana)
acetaminophen tab OXYMORPHONE 2
2.5-325 mg (Percocet) HYDROCHLORIDE -
oxycodone w/ 1 oxymorphone hcl tab er 12hr
acetaminophen tab 5 mg
5-325 mg (Percocet) OXYMORPHONE 2
oxycodone w/ 2 HYDROCHLORIDE -
acetaminophen tab oxymorphone hcl tab er 12hr
7.5-325 mg (Percocet) 7.5 mg
oxycodone w/ 2 OXYMORPHONE 2
acetaminophen tab HYDROCHLORIDE -
10-325 mg (Percocet) oxymorphone hcl tab er 12hr
10 mg
oxycodone-aspirin tab 2
4.8355-325 mg (Percodan) OXYMORPHONE 2
HYDROCHLORIDE -
oxymorphone hcl tab er 12hr
15 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
OXYMORPHONE 2 tramadol hcl tab er 24hr 2
HYDROCHLORIDE - 200 mg
oxymorphone hcl tab er 12hr tramadol hcl tab er 24hr 2
20 mg 300 mg
OXYMORPHONE 2 tramadol hcl tab er 24hr 2
HYDROCHLORIDE - biphasic release 100 mg
oxymorphone hcl tab er 12hr
30 mg tramadol hcl tab er 24hr 2
biphasic release 200 mg
OXYMORPHONE 2
HYDROCHLORIDE - tramadol hcl tab er 24hr 2
oxymorphone hcl tab er 12hr biphasic release 300 mg
40 mg tramadol hcl tab 50 mg 1
SUBOXONE - buprenorphine 4 (Ultram)
hcl-naloxone hcl sl film 2-0.5 tramadol-acetaminophen tab 1
mg (base equiv) 37.5-325 mg (Ultracet)
SUBOXONE - buprenorphine 4 XTAMPZA ER - oxycodone cap 4
hcl-naloxone hcl sl film 4-1 er 12hr abuse-deterrent 9
mg (base equiv) mg
hcl-naloxone hcl sl film 8-2 er 12hr abuse-deterrent 13.5
mg (base equiv) mg
hcl-naloxone hcl sl film 12-3 er 12hr abuse-deterrent 18
mg (base equiv) mg
SUBSYS - fentanyl sublingual 4 XTAMPZA ER - oxycodone cap 4
spray 100 mcg er 12hr abuse-deterrent 27
SUBSYS - fentanyl sublingual 4 mg
spray 200 mcg XTAMPZA ER - oxycodone cap 4
SUBSYS - fentanyl sublingual 4 er 12hr abuse-deterrent 36
spray 400 mcg mg
SUBSYS - fentanyl sublingual 4 ZOHYDRO ER - hydrocodone 4
spray 600 mcg bitartrate cap er 12hr abuse-
deterrent 10 mg
SUBSYS - fentanyl sublingual 4
spray 800 mcg ZOHYDRO ER - hydrocodone 4
bitartrate cap er 12hr abuse-
SUBSYS - fentanyl sublingual 4 deterrent 15 mg
spray 1200 mcg (600 mcg x
2) ZOHYDRO ER - hydrocodone 4
SUBSYS - fentanyl sublingual 4 deterrent 20 mg
spray 1600 mcg (800 mcg x
2) ZOHYDRO ER - hydrocodone 4
tramadol hcl tab er 24hr 2 deterrent 30 mg
100 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
ZOHYDRO ER - hydrocodone 4 diclofenac sodium tab 2
bitartrate cap er 12hr abuse- delayed release 25 mg
deterrent 40 mg diclofenac sodium tab 1
ZOHYDRO ER - hydrocodone 4 delayed release 50 mg
bitartrate cap er 12hr abuse- diclofenac sodium tab 1
deterrent 50 mg delayed release 75 mg
ZUBSOLV - buprenorphine hcl- 4 diclofenac sodium tab er 1
naloxone hcl sl tab 0.7-0.18 24hr 100 mg
mg (base eq)
diclofenac w/ misoprostol 2
ZUBSOLV - buprenorphine hcl- 4 tab delayed release
naloxone hcl sl tab 1.4-0.36 50-0.2 mg (Arthrotec 50)
mg (base eq)
diclofenac w/ misoprostol 2
ZUBSOLV - buprenorphine hcl- 4 tab delayed release
naloxone hcl sl tab 2.9-0.71 75-0.2 mg (Arthrotec 75)
mg (base eq)
ENBREL - etanercept for 5
ZUBSOLV - buprenorphine hcl- 4 subcutaneous inj 25 mg
naloxone hcl sl tab 5.7-1.4
mg (base eq) ENBREL - etanercept 5
subcutaneous soln prefilled
ZUBSOLV - buprenorphine hcl- 4 syringe 25 mg/0.5ml
mg (base eq) ENBREL - etanercept 5
ZUBSOLV - buprenorphine hcl- 4 syringe 50 mg/ml
mg (base eq) ENBREL SURECLICK - 5
etanercept subcutaneous
ANALGESICS - ANTI-INFLAMMATORY solution auto-injector 50 mg/
ACTEMRA - tocilizumab 5 ml
subcutaneous soln prefilled etodolac cap 200 mg 2
syringe 162 mg/0.9ml
etodolac cap 300 mg 2
ARCALYST - rilonacept for inj 5
etodolac tab er 24hr 400 mg 2
220 mg
2 etodolac tab er 24hr 500 mg 2
celecoxib cap 50 mg
(Celebrex) etodolac tab er 24hr 600 mg 2
celecoxib cap 100 mg 2 etodolac tab 400 mg 2
(Celebrex) etodolac tab 500 mg 2
celecoxib cap 200 mg 2 FENOPROFEN CALCIUM - 4
(Celebrex) fenoprofen calcium cap 200
celecoxib cap 400 mg 2 mg
(Celebrex) FENOPROFEN CALCIUM - 4
diclofenac potassium tab 2 fenoprofen calcium cap 400
50 mg mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
FENOPROFEN CALCIUM - 4 leflunomide tab 10 mg 2
fenoprofen calcium tab 600 (Arava)
mg leflunomide tab 20 mg 2
flurbiprofen tab 50 mg 1 (Arava)
flurbiprofen tab 100 mg 1 MECLOFENAMATE SODIUM - 4
HUMIRA - adalimumab 5 meclofenamate sodium cap
prefilled syringe kit 10 50 mg
mg/0.2ml MECLOFENAMATE SODIUM - 4
HUMIRA - adalimumab 5 meclofenamate sodium cap
prefilled syringe kit 20 100 mg
mg/0.4ml mefenamic acid cap 250 mg 2
HUMIRA - adalimumab 5 (Ponstel)
prefilled syringe kit 40 meloxicam tab 7.5 mg 1
mg/0.8ml (Mobic)
HUMIRA PEDIATRIC 5 meloxicam tab 15 mg (Mobic) 1
CROHNS D - adalimumab nabumetone tab 500 mg 1
prefilled syringe kit 40
nabumetone tab 750 mg 1
mg/0.8ml
5 naproxen sodium tab er 2
HUMIRA PEN - adalimumab
pen-injector kit 40 mg/0.8ml 24hr 375 mg (base equiv)
(Naprelan)
HUMIRA PEN-CROHNS 5 2
DISEASE - adalimumab pen- naproxen sodium tab er
injector kit 40 mg/0.8ml 24hr 500 mg (base equiv)
(Naprelan)
HUMIRA PEN-PSORIASIS 5 1
STAR - adalimumab pen- naproxen sodium tab
injector kit 40 mg/0.8ml 275 mg (Anaprox)
1 naproxen sodium tab 1
ibuprofen tab 400 mg
550 mg (Anaprox ds)
ibuprofen tab 600 mg 1
naproxen susp 125 mg/5ml 2
ibuprofen tab 800 mg 1
naproxen tab ec 375 mg (Ec- 1
indomethacin cap er 75 mg 2
naprosyn)
indomethacin cap 25 mg 1 1
naproxen tab ec 500 mg (Ec-
indomethacin cap 50 mg 1 naprosyn)
ketoprofen cap 50 mg 2 naproxen tab 250 mg 1
ketoprofen cap 75 mg 2 (Naprosyn)
1
ketorolac tromethamine tab 1 naproxen tab 375 mg
10 mg (Naprosyn)
1
KINERET - anakinra 5 naproxen tab 500 mg
subcutaneous soln prefilled (Naprosyn)
syringe 100 mg/0.67ml

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
ORENCIA - abatacept 5 RASUVO - methotrexate 4
subcutaneous soln prefilled soln pf auto-injector 7.5
syringe 50 mg/0.4ml mg/0.15ml
ORENCIA - abatacept 5 RASUVO - methotrexate soln 4
subcutaneous soln prefilled pf auto-injector 10 mg/0.2ml
syringe 87.5 mg/0.7ml RASUVO - methotrexate 4
ORENCIA - abatacept 5 soln pf auto-injector 12.5
subcutaneous soln prefilled mg/0.25ml
syringe 125 mg/ml RASUVO - methotrexate soln 4
ORENCIA CLICKJECT - 5 pf auto-injector 15 mg/0.3ml
abatacept subcutaneous RASUVO - methotrexate 4
soln auto-injector 125 mg/ml soln pf auto-injector 17.5
OTEZLA - apremilast tab 5 mg/0.35ml
starter therapy pack 10 mg & RASUVO - methotrexate soln 4
20 mg & 30 mg pf auto-injector 20 mg/0.4ml
OTEZLA - apremilast tab 30 5 RASUVO - methotrexate 4
mg soln pf auto-injector 22.5
OTREXUP - methotrexate soln 4 mg/0.45ml
pf auto-injector 10 mg/0.4ml RASUVO - methotrexate soln 4
OTREXUP - methotrexate 4 pf auto-injector 25 mg/0.5ml
soln pf auto-injector 12.5 RASUVO - methotrexate soln 4
mg/0.4ml pf auto-injector 30 mg/0.6ml
OTREXUP - methotrexate soln 4
RIDAURA - auranofin cap 3 mg 4
pf auto-injector 15 mg/0.4ml
4
SIMPONI - golimumab 5
OTREXUP - methotrexate subcutaneous soln auto-
soln pf auto-injector 17.5 injector 50 mg/0.5ml
mg/0.4ml
4
SIMPONI - golimumab 5
OTREXUP - methotrexate soln subcutaneous soln auto-
pf auto-injector 20 mg/0.4ml injector 100 mg/ml
4
OTREXUP - methotrexate SIMPONI - golimumab 5
soln pf auto-injector 22.5 subcutaneous soln prefilled
mg/0.4ml syringe 50 mg/0.5ml
4
OTREXUP - methotrexate soln SIMPONI - golimumab 5
pf auto-injector 25 mg/0.4ml subcutaneous soln prefilled
oxaprozin tab 600 mg 2 syringe 100 mg/ml
(Daypro) sulindac tab 150 mg 1
piroxicam cap 10 mg 2 1
sulindac tab 200 mg
(Feldene)
TOLMETIN SODIUM - tolmetin 2
piroxicam cap 20 mg 2
sodium cap 400 mg
(Feldene)
XELJANZ - tofacitinib citrate 5

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
XELJANZ XR - tofacitinib 5 rizatriptan benzoate oral 2
citrate tab er 24hr 11 mg disintegrating tab 10 mg
(base equivalent) (base eq) (Maxalt-mlt)
MIGRAINE PRODUCTS rizatriptan benzoate tab 2
almotriptan malate tab 2 5 mg (base equivalent)
6.25 mg (Axert) (Maxalt)
almotriptan malate tab 2 rizatriptan benzoate tab 2

12.5 mg (Axert) 10 mg (base equivalent)
(Maxalt)
dihydroergotamine mesylate 2
inj 1 mg/ml (D.h.e. 45) sumatriptan nasal spray 2
5 mg/act (Imitrex)
eletriptan hydrobromide tab 2
20 mg (base equivalent) sumatriptan nasal spray 2
(Relpax) 20 mg/act (Imitrex)
eletriptan hydrobromide tab 2 sumatriptan succinate inj 2

40 mg (base equivalent) 6 mg/0.5ml (Imitrex)
(Relpax) sumatriptan succinate 2
ERGOMAR - ergotamine 4 solution auto-injector
tartrate sl tab 2 mg 4 mg/0.5ml (Imitrex statdose
sys)
ergotamine w/ caffeine tab 2
1-100 mg (Cafergot) sumatriptan succinate 2
solution auto-injector
FROVA - frovatriptan succinate 4 6 mg/0.5ml (Imitrex statdose
tab 2.5 mg (base equivalent) sys)
frovatriptan succinate tab 2 sumatriptan succinate 2
2.5 mg (base equivalent) solution cartridge
(Frova) 4 mg/0.5ml (Imitrex statdose
MIGRANAL - 4 ref)
dihydroergotamine mesylate sumatriptan succinate 2
nasal spray 4 mg/ml solution cartridge
naratriptan hcl tab 1 mg 2 6 mg/0.5ml (Imitrex statdose
(base equiv) (Amerge) ref)
naratriptan hcl tab 2.5 mg 2 sumatriptan succinate tab 1
(base equiv) (Amerge) 25 mg (Imitrex)
RELPAX - eletriptan 4 sumatriptan succinate tab 1
hydrobromide tab 20 mg 50 mg (Imitrex)
(base equivalent) sumatriptan succinate tab 1
RELPAX - eletriptan 4 100 mg (Imitrex)
hydrobromide tab 40 mg zolmitriptan orally 2
(base equivalent) disintegrating tab 2.5 mg
rizatriptan benzoate oral 2 (Zomig zmt)
(base eq) (Maxalt-mlt)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
zolmitriptan orally 2 BANZEL - rufinamide tab 200 4
disintegrating tab 5 mg mg
(Zomig zmt) BANZEL - rufinamide tab 400 4
zolmitriptan tab 2.5 mg 2 mg
(Zomig) BRIVIACT - brivaracetam oral 4
zolmitriptan tab 5 mg 2 soln 10 mg/ml
(Zomig) BRIVIACT - brivaracetam tab 4
ZOMIG - zolmitriptan nasal 4 10 mg
spray 2.5 mg/spray unit BRIVIACT - brivaracetam tab 4
GOUT AGENTS 25 mg
allopurinol tab 100 mg 1 BRIVIACT - brivaracetam tab 4
(Zyloprim) 50 mg
allopurinol tab 300 mg 1 BRIVIACT - brivaracetam tab 4
(Zyloprim) 75 mg
COLCHICINE - colchicine cap 4 BRIVIACT - brivaracetam tab 4
0.6 mg 100 mg
COLCHICINE - colchicine tab 4 carbamazepine cap er 12hr 2
0.6 mg 100 mg (Carbatrol)
colchicine w/ probenecid tab 2 carbamazepine cap er 12hr 2
0.5-500 mg 200 mg (Carbatrol)
COLCRYS - colchicine tab 0.6 4 carbamazepine cap er 12hr 2
mg 300 mg (Carbatrol)
MITIGARE - colchicine cap 0.6 4 carbamazepine chew tab 2
mg 100 mg
probenecid tab 500 mg 2 carbamazepine susp 2
ULORIC - febuxostat tab 40 mg 4 100 mg/5ml (Tegretol)
carbamazepine tab er 12hr 2
ULORIC - febuxostat tab 80 mg 4
100 mg (Tegretol-xr)
NEUROMUSCULAR DRUGS
carbamazepine tab er 12hr 2
ANTICONVULSANTS 200 mg (Tegretol-xr)
APTIOM - eslicarbazepine 4 2
carbamazepine tab er 12hr
acetate tab 200 mg 400 mg (Tegretol-xr)
carbamazepine tab 200 mg
acetate tab 400 mg (Tegretol)
CARBATROL - carbamazepine
acetate tab 600 mg cap er 12hr 100 mg
acetate tab 800 mg cap er 12hr 200 mg
BANZEL - rufinamide susp 40 4 4
mg/ml cap er 12hr 300 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
CELONTIN - methsuximide cap 4 divalproex sodium cap 2
300 mg delayed release sprinkle
clonazepam orally 2 125 mg (Depakote
disintegrating tab sprinkles)
0.125 mg divalproex sodium tab 1
clonazepam orally 2 delayed release 125 mg
disintegrating tab 0.25 mg (Depakote)
2 divalproex sodium tab 1
clonazepam orally
disintegrating tab 0.5 mg delayed release 250 mg
(Depakote)
clonazepam orally 2
divalproex sodium tab 1
delayed release 500 mg
clonazepam orally 2
(Depakote)
divalproex sodium tab er 24 2
clonazepam tab 0.5 mg 1
hr 250 mg (Depakote er)
(Klonopin)
divalproex sodium tab er 24 2
clonazepam tab 1 mg 1
hr 500 mg (Depakote er)
(Klonopin)
ethosuximide cap 250 mg 2
clonazepam tab 2 mg 1
(Zarontin)
(Klonopin)
ethosuximide soln 2
DEPAKENE - valproate sodium 4 250 mg/5ml (Zarontin)
oral soln 250 mg/5ml (base
felbamate susp 600 mg/5ml 2
equiv)
(Felbatol)
DEPAKENE - valproic acid cap 4
felbamate tab 400 mg 2
250 mg
(Felbatol)
DIASTAT ACUDIAL - diazepam 3
felbamate tab 600 mg 2
rectal gel delivery system 10
mg (Felbatol)
FYCOMPA - perampanel susp 4
DIASTAT ACUDIAL - diazepam 3
rectal gel delivery system 20 0.5 mg/ml
mg FYCOMPA - perampanel tab 2 4
DIASTAT PEDIATRIC - 3 mg
diazepam rectal gel delivery FYCOMPA - perampanel tab 4 4
system 2.5 mg mg
DILANTIN - phenytoin sodium 4 FYCOMPA - perampanel tab 6 4
extended cap 30 mg mg
DILANTIN - phenytoin sodium 4 FYCOMPA - perampanel tab 8 4
extended cap 100 mg mg
DILANTIN INFATABS - 4 FYCOMPA - perampanel tab 4
phenytoin chew tab 50 mg 10 mg
DILANTIN-125 - phenytoin 4 FYCOMPA - perampanel tab 4

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
gabapentin cap 100 mg 1 lamotrigine orally 2
(Neurontin) disintegrating tab 100 mg
gabapentin cap 300 mg 1 (Lamictal odt)
(Neurontin) lamotrigine orally 2
gabapentin cap 400 mg 1 disintegrating tab 200 mg
(Neurontin) (Lamictal odt)
2 lamotrigine tab chewable 2
gabapentin oral soln
250 mg/5ml (Neurontin) dispersible 5 mg (Lamictal
chewable di)
gabapentin tab 600 mg 2
lamotrigine tab chewable 2
(Neurontin)
dispersible 25 mg (Lamictal
gabapentin tab 800 mg 2
chewable di)
(Neurontin)
lamotrigine tab disint 25 mg 2
GABITRIL - tiagabine hcl tab 4
(21) & 50 mg (7) titration
12 mg kit (Lamictal odt)
GABITRIL - tiagabine hcl tab 4 2
lamotrigine tab disint 50 mg
16 mg (42)- 100 mg(14) titration
LAMICTAL STARTER/NOT 4 kit (Lamictal odt)
TAKI - lamotrigine tab 25 mg lamotrigine tab disint 25 (14) 2
(42) & 100 mg (7) starter kit & 50 mg (14) & 100 mg (7)
LAMICTAL STARTER/TAKING 4 kit (Lamictal odt)
C - lamotrigine tab 25 mg lamotrigine tab er 24hr 2
(84) & 100 mg (14) starter kit 25 mg (Lamictal xr)
LAMICTAL STARTER/TAKING 4 2
lamotrigine tab er 24hr
V - lamotrigine tab 25 mg 50 mg (Lamictal xr)
(35) starter kit
lamotrigine tab er 24hr 2
LAMICTAL XR - lamotrigine tab 4 100 mg (Lamictal xr)
er 24hr 25 mg (21) & 50 mg
(7) titration kit
200 mg (Lamictal xr)
LAMICTAL XR - lamotrigine tab 4
er 24hr 25 (14) & 50 mg (14)
& 100 mg(7) kit 250 mg (Lamictal xr)
4 lamotrigine tab er 24hr 2
LAMICTAL XR - lamotrigine
tab er 24hr 50 (14) & 100 300 mg (Lamictal xr)
mg(14) & 200 mg(7) kit lamotrigine tab 25 mg 1
lamotrigine orally 2 (Lamictal)
disintegrating tab 25 mg lamotrigine tab 100 mg 1
(Lamictal odt) (Lamictal)
lamotrigine orally 2 lamotrigine tab 150 mg 1
disintegrating tab 50 mg (Lamictal)
(Lamictal odt) lamotrigine tab 200 mg 1
(Lamictal)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
levetiracetam oral soln 2 oxcarbazepine tab 150 mg 1
100 mg/ml (Keppra) (Trileptal)
levetiracetam tab er 24hr 2 oxcarbazepine tab 300 mg 2
500 mg (Keppra xr) (Trileptal)
levetiracetam tab er 24hr 2 oxcarbazepine tab 600 mg 2
750 mg (Keppra xr) (Trileptal)
levetiracetam tab 250 mg 1 OXTELLAR XR - 4
(Keppra) oxcarbazepine tab er 24hr
levetiracetam tab 500 mg 1 150 mg
(Keppra) OXTELLAR XR - 4
levetiracetam tab 750 mg 2 oxcarbazepine tab er 24hr
(Keppra) 300 mg
2 OXTELLAR XR - 4
levetiracetam tab 1000 mg
(Keppra) oxcarbazepine tab er 24hr
600 mg
LYRICA - pregabalin cap 25 4 4
mg PEGANONE - ethotoin tab 250
mg
LYRICA - pregabalin cap 50 4 4
mg PHENYTEK - phenytoin
sodium extended cap 200
LYRICA - pregabalin cap 75 4 mg
mg
PHENYTEK - phenytoin 4
LYRICA - pregabalin cap 100 4 sodium extended cap 300
mg mg
LYRICA - pregabalin cap 150 4 phenytoin chew tab 50 mg 2
mg (Dilantin infatabs)
LYRICA - pregabalin cap 200 4 phenytoin sodium extended 2
mg cap 100 mg (Dilantin)
mg cap 200 mg (Phenytek)
mg cap 300 mg (Phenytek)
LYRICA - pregabalin soln 20 4 phenytoin susp 125 mg/5ml 2
mg/ml (Dilantin-125)
ONFI - clobazam suspension 4 1
primidone tab 50 mg
2.5 mg/ml (Mysoline)
ONFI - clobazam tab 10 mg 4 1
primidone tab 250 mg
ONFI - clobazam tab 20 mg 4 (Mysoline)
oxcarbazepine susp 2 QUDEXY XR - topiramate cap 4
300 mg/5ml (60 mg/ml) er 24hr sprinkle 25 mg
(Trileptal) QUDEXY XR - topiramate cap 4
er 24hr sprinkle 50 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
QUDEXY XR - topiramate cap 4 topiramate tab 25 mg 1
er 24hr sprinkle 100 mg (Topamax)
SABRIL - vigabatrin powd pack 3 topiramate tab 200 mg 1
500 mg (Topamax)
SABRIL - vigabatrin tab 500 3 TROKENDI XR - topiramate 4
mg cap er 24hr 25 mg
TEGRETOL - carbamazepine 4 TROKENDI XR - topiramate 4
susp 100 mg/5ml cap er 24hr 50 mg
TEGRETOL - carbamazepine 4 TROKENDI XR - topiramate 4
tab 200 mg cap er 24hr 100 mg
TEGRETOL-XR - 4 TROKENDI XR - topiramate 4
carbamazepine tab er 12hr cap er 24hr 200 mg
100 mg valproate sodium oral soln 2
TEGRETOL-XR - 4 250 mg/5ml (base equiv)
carbamazepine tab er 12hr (Depakene)
200 mg valproic acid cap 250 mg 2
TEGRETOL-XR - 4 (Depakene)
carbamazepine tab er 12hr VIMPAT - lacosamide oral 4
400 mg solution 10 mg/ml
tiagabine hcl tab 2 mg 2 4
VIMPAT - lacosamide tab 50
(Gabitril) mg
tiagabine hcl tab 4 mg 2 4
(Gabitril) mg
TOPIRAMATE ER - topiramate 4 4
cap er 24hr sprinkle 25 mg mg
cap er 24hr sprinkle 50 mg mg
ZARONTIN - ethosuximide cap
cap er 24hr sprinkle 100 mg 250 mg
TOPIRAMATE ER - topiramate 4
ZARONTIN - ethosuximide soln 4
cap er 24hr sprinkle 150 mg 250 mg/5ml
zonisamide cap 25 mg
cap er 24hr sprinkle 200 mg (Zonegran)
topiramate sprinkle cap 2 2
zonisamide cap 50 mg
15 mg (Topamax sprinkle)
zonisamide cap 100 mg 2
topiramate sprinkle cap 2
(Zonegran)
25 mg (Topamax sprinkle)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
ANTIPARKINSON AGENTS carbidopa & levodopa tab 2
amantadine hcl cap 100 mg 2 25-250 mg (Sinemet)
1 carbidopa tab 25 mg 2
amantadine hcl syrup
50 mg/5ml (Lodosyn)
2 CARBIDOPA/LEVODOPA/ 4
amantadine hcl tab 100 mg
ENTACA - carbidopa-
APOKYN - apomorphine hcl 5 levodopa-entacapone tabs
soln cartridge 30 mg/3ml 12.5-50-200 mg
AZILECT - rasagiline mesylate 4 4
CARBIDOPA/LEVODOPA/
tab 0.5 mg (base equiv) ENTACA - carbidopa-
AZILECT - rasagiline mesylate 4 levodopa-entacapone tabs
tab 1 mg (base equiv) 18.75-75-200 mg
benztropine mesylate tab 1 CARBIDOPA/LEVODOPA/ 4
0.5 mg ENTACA - carbidopa-
benztropine mesylate tab 1 levodopa-entacapone tabs
1 mg 25-100-200 mg
1 CARBIDOPA/LEVODOPA/ 4
benztropine mesylate tab
2 mg ENTACA - carbidopa-
levodopa-entacapone tabs
bromocriptine mesylate cap 2
31.25-125-200 mg
5 mg (base equivalent) 4
(Parlodel) CARBIDOPA/LEVODOPA/
ENTACA - carbidopa-
bromocriptine mesylate tab 2
2.5 mg (base equivalent) 37.5-150-200 mg
(Parlodel) 4
CARBIDOPA/LEVODOPA/
carbidopa & levodopa 2
ENTACA - carbidopa-
orally disintegrating tab levodopa-entacapone tabs
10-100 mg 50-200-200 mg
DUOPA - carbidopa-levodopa 4
orally disintegrating tab enteral susp 4.63-20 mg/ml
25-100 mg 2
entacapone tab 200 mg
(Comtan)
orally disintegrating tab 4
25-250 mg NEUPRO - rotigotine td patch
24hr 1 mg/24hr
carbidopa & levodopa tab er 2
NEUPRO - rotigotine td patch 4
25-100 mg (Sinemet cr)
24hr 2 mg/24hr
carbidopa & levodopa tab er 2
50-200 mg (Sinemet cr)
24hr 3 mg/24hr
carbidopa & levodopa tab 1
10-100 mg (Sinemet)
24hr 4 mg/24hr
carbidopa & levodopa tab 2
25-100 mg (Sinemet)
24hr 6 mg/24hr

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
NEUPRO - rotigotine td patch 4 ropinirole hydrochloride 2
24hr 8 mg/24hr tab er 24hr 2 mg (base
pramipexole dihydrochloride 2 equivalent) (Requip xl)
tab er 24hr 0.375 mg ropinirole hydrochloride 2
(Mirapex er) tab er 24hr 4 mg (base
tab er 24hr 1.5 mg (Mirapex ropinirole hydrochloride 2
er) tab er 24hr 8 mg (base
tab er 24hr 3 mg (Mirapex ropinirole hydrochloride tab 1
er) 0.25 mg (Requip)
pramipexole dihydrochloride 2 ropinirole hydrochloride tab 1
tab er 24hr 3.75 mg 0.5 mg (Requip)
(Mirapex er) ropinirole hydrochloride tab 1
pramipexole dihydrochloride 2 1 mg (Requip)
tab er 24hr 4.5 mg (Mirapex ropinirole hydrochloride tab 1
er) 2 mg (Requip)
pramipexole dihydrochloride 1 1
ropinirole hydrochloride tab
tab 0.125 mg (Mirapex) 3 mg (Requip)
RYTARY - carbidopa &
tab 0.75 mg (Mirapex) levodopa cap er 23.75-95
pramipexole dihydrochloride 1 mg
tab 1 mg (Mirapex) RYTARY - carbidopa & 4
pramipexole dihydrochloride 1 levodopa cap er 36.25-145
tab 1.5 mg (Mirapex) mg
rasagiline mesylate tab 2 RYTARY - carbidopa & 4
0.5 mg (base equiv) levodopa cap er 48.75-195
(Azilect) mg
rasagiline mesylate tab 1 mg 2 RYTARY - carbidopa & 4
(base equiv) (Azilect) levodopa cap er 61.25-245
mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
selegiline hcl cap 5 mg 2 chlorzoxazone tab 500 mg 1
(Eldepryl) (Parafon forte dsc)
selegiline hcl tab 5 mg 2 cyclobenzaprine hcl tab 1
STALEVO 100 - carbidopa- 4 5 mg
levodopa-entacapone tabs cyclobenzaprine hcl tab 2
25-100-200 mg 7.5 mg (Fexmid)
STALEVO 125 - carbidopa- 4 cyclobenzaprine hcl tab 1
levodopa-entacapone tabs 10 mg
31.25-125-200 mg dantrolene sodium cap 2
STALEVO 150 - carbidopa- 4 25 mg (Dantrium)
levodopa-entacapone tabs dantrolene sodium cap 2
37.5-150-200 mg 50 mg (Dantrium)
STALEVO 200 - carbidopa- 4 2
dantrolene sodium cap
levodopa-entacapone tabs 100 mg
50-200-200 mg
METAXALONE - metaxalone 4
STALEVO 50 - carbidopa- 4
tab 400 mg
metaxalone tab 800 mg 2
12.5-50-200 mg
(Skelaxin)
STALEVO 75 - carbidopa- 4
methocarbamol tab 500 mg 1
18.75-75-200 mg (Robaxin)
4 methocarbamol tab 750 mg 1
TASMAR - tolcapone tab 100
mg (Robaxin-750)
2 orphenadrine citrate tab er 2
tolcapone tab 100 mg
(Tasmar) 12hr 100 mg
trihexyphenidyl hcl elixir 2 tizanidine hcl cap 2 mg 2
0.4 mg/ml (base equivalent)
(Zanaflex)
trihexyphenidyl hcl tab 2 mg 1
1
tizanidine hcl cap 4 mg 2
trihexyphenidyl hcl tab 5 mg (base equivalent)
ZELAPAR - selegiline hcl orally 4 (Zanaflex)
disintegrating tab 1.25 mg tizanidine hcl cap 6 mg 2
NEUROMUSCULAR AGENTS (base equivalent)
riluzole tab 50 mg (Rilutek) 2 (Zanaflex)
MUSCULOSKELETAL THERAPY AGENTS tizanidine hcl tab 2 mg (base 1

equivalent)
baclofen tab 10 mg 1
2
tizanidine hcl tab 4 mg (base 1
baclofen tab 20 mg equivalent) (Zanaflex)
carisoprodol tab 250 mg 2
ANTIMYASTHENIC AGENTS
(Soma)
GUANIDINE HCL - guanidine 4
carisoprodol tab 350 mg 1
hcl tab 125 mg
(Soma)

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
MESTINON - pyridostigmine 4 phytonadione inj 1 mg/0.5ml 2
bromide syrup 60 mg/5ml (2 mg/ml)
pyridostigmine bromide 2 SUPER DAILY D3 - A
tab er 180 mg (Mestinon cholecalciferol drops 1000
timespan) unit/0.03ml (per drop)
pyridostigmine bromide tab 2 VITAMELTS VITAMIN D - A
60 mg (Mestinon) cholecalciferol orally
NUTRITIONAL PRODUCTS disintegrating tab 1000 unit
VITAMINS VITAMIN D2 - ergocalciferol A

tab 400 unit
BABY DDROPS - A
cholecalciferol drops 400 VITAMIN D3 - cholecalciferol A
unit/0.03ml (per drop) oral liquid 1200 unit/15ml
cholecalciferol cap 400 unit A VITAMIN D3 - cholecalciferol A

spray 1000 unit/spray
cholecalciferol cap 1000 unit A
1
WELLESSE VITAMIN D3 - A
cholecalciferol cap 50000 cholecalciferol oral liquid
unit 1000 unit/10ml
cholecalciferol chew tab 400 A MULTIVITAMINS
unit
ACTIVE OB - prenatal w/o a w/ 4
cholecalciferol chew tab A fe cbn-fa-dha cap 20-1-320
1000 unit mg
cholecalciferol drops 5000 A BAL-CARE DHA - prenat w/fe 4
unit/ml (1000 unit/0.2ml) poly-na fered-fa tab 27-1 &
cholecalciferol drops 400 A omega cap dr 430mg
unit/0.03ml (per drop) BP FOLINATAL PLUS 4
cholecalciferol oral liquid A B - prenatal w/ calcium
400 unit/ml carbonate-b6-b12-fa tab 1
cholecalciferol tab 400 unit A mg
4
cholecalciferol tab 1000 unit A BP MULTINATAL PLUS -
prenatal w/o a vit w/ fe fum-
cholecalciferol tab 50000 2
fa tab chew 40-1 mg
unit 4
BP MULTINATAL PLUS -
D-VI-SOL - cholecalciferol oral A prenatal w/o a vit w/ fe
liquid 400 unit/ml fumarate-fa tab 30-1 mg
DDROPS - cholecalciferol A C-BUFF - multiple vitamins w/ 4
drops 1000 unit/0.03ml (per minerals powder
drop) 4
C-NATE DHA - prenatal vit
ergocalciferol cap 50000 unit 1
w/ fe fum-fa-omega 3 cap
(Drisdol) 28-1-200 mg
MEPHYTON - phytonadione 3 4
CALCIUM PNV - prenatal w/o
tab 5 mg vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
CITRANATAL ASSURE - 4 DUET DHA 400 - prenat w/fe 4
prenat w/o a w/fecbn-fegl- poly-na fered-fa tab 25-1 &
dss-fa tab & dha cap 300 mg omega cap 400 mg
pack ELITE-OB - prenatal vit w/ iron 4
CITRANATAL B-CALM - prenat 4 carbonyl-fa tab 50-1.25 mg
w/o a w/fecbn-feglu-fa tab ENBRACE HR - prenatal vit w/ 4
20-1 mg & vit b6 tab pak fe gly cys-fa-omega 3 fatty
CITRANATAL DHA - prenat w/ 4 acids cap
o a w/fecbn-fegl-dss-fa tab & END FATIGUE DAILY 4
dha cap 250 mg pack ENERGY - multiple vitamins
CITRANATAL HARMONY - 4 w/ minerals powder
prenat w/o a w/fe fum-fe EXTRA-VIRT PLUS DHA - 4
cbn-dss-fa-dha cap 27-1-260 prenatal w/o vit a w/ fe fum-
mg doc-fa-dha cap 29-1.25-350
CITRANATAL RX - prenatal w/ 4 mg
o a w/ fe carbonyl-fe gluc- FOCALGIN CA - prenat w/o 4
dss-fa tab 27-1mg a w/fecbn-fegl-dss-fa tab &
CITRANATAL 90 DHA - prenat 4 dha cap 300 mg pack
w/o a w/fecbn-fegl-dss-fa tab FOCALGIN 90 DHA - prenat w/ 4
90 &dha cap 300mg pak o a w/fecbn-fegl-dss-fa tab
CO-NATAL FA - prenatal vit w/ 4 90 &dha cap 300mg pak
fe fumarate-fa tab 29-1 mg FOLCAL DHA - prenatal w/o vit 4
COMPLETE NATAL DHA - 4 a w/ fe fum-dss-fa-dha cap
prenat-fe bis-fe prot succ-fa- 27-1.25-300 mg
ca tab & omega 3 cap 250 FOLCAPS OMEGA 3 - prenatal 4
pk vit w/ fe cbn-fe asp glyc-fa-
COMPLETENATE - prenatal vit 4 omega 3 cap 27-1mg
w/ fe fumarate-fa chew tab FOLET DHA - prenat w/fecbn- 4
29-1 mg bisg-methylf-dss tab dr &
CONCEPT DHA - prenatal w/fe 4 dha cap pak
fum-fe poly -fa-omega 3 cap FOLET ONE - prenat w/o a w/ 4
53.5-38-1 mg fecbn-bisg-methylf-dss-dha
CONCEPT OB - prenatal w/ 4 cap 38-1-225 mg
o a w/fe fum-fe poly-fa cap FOLIVANE-OB - prenatal w/ 4
130-92.4-1 mg o a w/fe fum-fe poly-fa cap
DOTHELLE DHA - prenatal w/ 4 130-92.4-1 mg
fe fum-fe poly -fa-omega 3 HEMENATAL OB - prenat vit-fe 4
cap 53.5-38-1 mg poly cmplx-fe heme poly-fa
DUET DHA BALANCED - 4 tab 28-6-1 mg
prenat w/fe poly-na fered-fa HEMENATAL OB + DHA - 4
tab 25-1 & omega cap 267 prenat-fe poly cmplx-fe
mg heme poly-fa tab & omega 3
cap pck
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
INATAL ADVANCE - prenatal 4 NATELLE ONE - prenatal w/o 4
vit w/ dss-iron carbonyl-fa vit a w/ fe fum-fa-omega 3
tab 90-1 mg cap 28-1-250 mg
INATAL GT - prenatal vit w/ 4 NEEVO DHA - prenat w/o a w/ 4
dss-iron carbonyl-fa tab 90-1 fefum-methylfol-omegas cap
mg 27-1.13 mg
INATAL ULTRA - prenatal vit w/ 4 NESTABS - prenatal vit w/o vit 4
dss-iron carbonyl-fa tab 90-1 a w/ fe bisglycinate-fa tab
mg 32-1 mg
INFANATE BALANCE - 4 NESTABS ABC - prenatal w/o 4
prenatal w/o a w/fe cbn-dss- vit a w/fe polysac-fa-ca tab &
fa-dha cap 29-1-265 mg omega 3 cap
M-VIT - prenatal vit w/ fe 4 NESTABS DHA - prenat w/o a 4
fumarate-fa tab 27-1 mg w/ fe bisglyc-fa tab 32-1 mg
MARNATAL-F - prenatal w/o vit 4 & omega cap pack
a w/ fe polysac cmplx-fa cap NEWGEN - prenatal vit w/o vit 4
60-1 mg a w/ fe bisglycinate-fa tab
MEGA MULTIVITAMIN - 4 32-1 mg
multiple vitamins w/ minerals NEXA PLUS - prenatal w/o vit 4
powder a w/ fe fum-doc-fa-dha cap
MYNATAL - prenatal 4 29-1.25-350 mg
multivitamins & minerals w/ NIVA-PLUS - prenatal vit w/ fe 4
iron & fa cap 1 mg fumarate-fa tab 27-1 mg
MYNATAL ADVANCE - 4 O-CAL FA - prenatal vit w/ fe 4
prenatal vit w/ dss-iron fumarate-fa tab 27-1 mg
carbonyl-fa tab 90-1 mg O-CAL PRENATAL - prenatal 4
MYNATAL PLUS - prenatal vit 4 vit w/ fe fumarate-fa tab 15-1
w/ fe fumarate-fa tab 65-1 mg
mg OB COMPLETE - prenatal 4
MYNATAL ULTRACAPLET - 4 vit w/ iron carbonyl-fa tab
prenatal vit w/ dss-iron 50-1.25 mg
carbonyl-fa tab 90-1 mg OB COMPLETE GOLD - 4
MYNATAL-Z - prenatal vit w/ fe 4 prenat w/o a w/fecbn-
fumarate-fa tab 65-1 mg methfol-fa-dha cap
MYNATE 90 PLUS - prenatal 4 27.5-1-200 mg
vit w/ dss-fe fumarate-fa tab OB COMPLETE ONE - 4
er 90-1 mg prenatal w/o a w/fecbn-
NATACHEW - prenatal vit w/ fe 4 fe asp glyc-fa-fish cap
fum-fe bisglycin-fa chew tab 50-1-476 mg
28-1 mg OB COMPLETE PETITE - 4
NATALVIT - prenatal vit w/ fe 4 prenat w/o a w/fecbn-
fumarate-fa tab 75-1 mg feaspglyc-fa-omega cap
35-5-1-200 mg
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
OB COMPLETE PREMIER - 4 PNV-TOTAL - prenat w/ fe 4
prenatal vit w/ fe cbn-fe asp cbn-fe bisglyc-fa-fish oil cap
glyc-fa tab 30-20-1 mg 35-5-1.2 mg
OB COMPLETE/DHA - prenat 4 PNV-VP-U - prenatal w/o a 4
w/ iron cbn-fe asp glyc-fa- vit w/ fe fumarate-fa cap
omega cap 30-10-1-200 mg 106.5-1 mg
OBSTETRIX DHA - prenat w/ 4 PR NATAL 400 - prenat-fe 4
fecbn-fa-dss tab 29-1 mg & bis-fe prot succ-fa-ca tab &
omega 3 cap 387 mg pak omega 3 cap 400 pk
OBSTETRIX EC - prenatal vit 4 PR NATAL 400 EC - prenat-fe 4
w/ dss-iron carbonyl-fa tab bis-fe prot succ-fa-ca tab &
29-1 mg omega cap dr 400 pk
OBSTETRIX ONE - prenat w/o 4 PR NATAL 430 - prenat-fe 4
a w/fecbn-bisg-methylf-dss- bis-fe prot succ-fa-ca tab &
dha cap 38-1-225 mg omega 3 cap 430 pk
PHLEXY-VITS - multiple 4 PR NATAL 430 EC - prenat-fe 4
vitamins w/ minerals powder bis-fe prot succ-fa-ca tab &
PNV FERROUS FUMARATE/ 4 omega cap dr 430 pk
DOCU - prenatal vit w/ dss-fe PREFERA OB - prenat vit-fe 4
fumarate-fa tab 29-1 mg poly cmplx-fe heme poly-fa
PNV OB+DHA - prenat w/o a 4 tab 34-1 mg
w/fecbn-fegl-dss-fa tab & PREFERAOB +DHA - prenat- 4
dha cap 250 mg pack fe poly cmplx 28mg-fe heme
PNV PRENATAL PLUS 4 poly-fa tab&dha cap pack
MULTIVI - prenatal vit w/ fe PREFERAOB ONE - prenat-fe 4
fumarate-fa tab 27-1 mg poly cmplx-fe heme poly-fa-
PNV TABS 29-1 - prenatal vit 4 dha cap 22-6-1-200 mg
w/ iron carbonyl-fa tab 29-1 PRENAISSANCE - prenatal w/ 4
mg o vit a w/ fe fum-dss-fa-dha
PNV-DHA - prenat w/o a w/ 4 cap 29-1.25-325 mg
fefum-methfol-fa-dha cap PRENAISSANCE BALANCE - 4
27-0.6-0.4-300 mg prenatal w/o vit a w/ fe cbn-
PNV-DHA+DOCUSATE - 4 dss-fa-dha cap 30-1-260 mg
prenatal w/o vit a w/ fe fum- PRENAISSANCE HARMONY 4
dss-fa-dha cap 27-1.25-300 DHA - prenat w/fe poly-na
mg fered-fa tab 27-1 & omega
PNV-OMEGA - prenat w/o a w/ 4 cap dr 380mg
fe fumerate-methylfolate-fa- PRENAISSANCE NEXT - 4
omega 3 cap prenatal w/ calcium-vit b6-fa-
PNV-SELECT - prenatal vit w/ 4 ginger tab 1.2 mg
fe fum-methylfolate-fa tab PRENAISSANCE NEXT-B - 4
27-0.6-0.4 mg prenatal w/ calcium-vit b6-fa-
ginger tab 1.22 mg
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
PRENAISSANCE PLUS - 4 PRENATE ELITE - prenatal w/ 4
prenatal w/o a w/fe cbn-dss- fe asp gly-l methylfol-fa tab
fa-dha cap 28-1-250 mg 20-0.6-0.4 mg
PRENATABS RX - prenatal vit 4 PRENATE ENHANCE - prenat 4
w/ iron carbonyl-fa tab 29-1 w/o a w/fefum-methfol-fa-
mg dha cap 28-0.6-0.4-400 mg
PRENATAL - prenatal vit w/ fe 4 PRENATE ESSENTIAL - 4
fumarate-fa tab 27-1 mg prenat w/o a w/feasp-
PRENATAL PLUS - prenatal vit 3 methylf-fa-omeg cap
w/ fe fumarate-fa tab 27-1 29-0.6-0.4-340 mg
mg PRENATE ESSENTIAL - 4
PRENATAL PLUS IRON - 4 prenat w/o a w/feaspg-
prenatal vit w/ iron carbonyl- methfol-fa-dha cap
fa tab 29-1 mg 18-0.6-0.4-300 mg
3 PRENATE MINI - prenat w/o a 4
PRENATAL VITAMINS PLUS
LO - prenatal vit w/ fe w/fecbn-methylf-fa-dha cap
fumarate-fa tab 27-1 mg 29-0.6-0.4-350 mg
4 PRENATE MINI - prenat w/oa 4
PRENATAL 19 - prenatal vit w/
dss-fe fumarate-fa tab 29-1 w/fecb-feasp-meth-fa-dha
mg cap 18-0.6-0.4-350 mg
4 PRENATE PIXIE - prenat w/o a 4
PRENATAL 19 - prenatal vit w/
fe fumarate-fa chew tab 29-1 w/feaspg-methfol-fa-dha cap
mg 10-0.6-0.4-200 mg
4 PRENATE RESTORE - prenat 4
PRENATAL-U - prenatal w/o
a vit w/ fe fumarate-fa cap w/o a w/fefum-methfol-fa-
106.5-1 mg dha cap 27-0.6-0.4-400 mg
4 PRENA1 CHEW - prenat w/ 4
PRENATE - prenat mv & min
w/ l-methylfolate-fa chew tab b2-b6-b12-d3-folic acid chew
0.6-0.4 mg tab 1.4 mg
4 PRENA1 PEARL - prenat w/oa 4
PRENATE AM - prenatal w/
calcium-vit b6-vit b12-fa- w/fefum-na fered-fa-dha cap
ginger tab 1 mg er 30-1.4-200 mg
4 PREPLUS - prenatal vit w/ fe 4
PRENATE DHA - prenat w/o a
w/feaspg-methfol-fa-dha cap fumarate-fa tab 27-1 mg
18-0.6-0.4-300 mg PRETAB - prenatal vit w/ fe 4
PRENATE DHA - prenat w/o a 4 fumarate-fa tab 29-1 mg
w/fefum-methfol-fa-dha cap PROVIDA DHA - prenat w/o a 4
28-0.6-0.4-300 mg w/fe fum-fe poly-fa-dha cap
PRENATE ELITE - prenatal vit 4 16-16-1.25-110 mg
w/ fe fum-methylfolate-fa tab PROVIDA OB - prenatal w/o 4
26-0.6-0.4 mg a w/fe fum-fe poly-fa cap
20-20-1.25 mg
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
PUREFE OB PLUS - prenatal 4 TL-CARE DHA - prenatal w/fe 4
w/o a w/fe fum-fe poly-fa cap fumarate-fa-dss-fish oil cap
162.115.2-1 mg 27-1-500 mg
R-NATAL OB - prenatal w/ 4 TL-SELECT - prenatal w/o vit 4
o a w/fe cbn-fa-dha cap a w/ fe fum-dss-fa-dha cap
20-1-320 mg 29-1.25-325 mg
RELNATE DHA - prenatal vit 4 TRI-TABS DHA - prenat w/o a 4
w/ fe fum-fa-omega 3 cap w/ fe bisglyc-fa tab 32-1 mg
28-1-200 mg & omega cap pack
SE-NATAL 19 - prenatal vit w/ 4 TRIADVANCE - prenatal vit w/ 4
dss-fe fumarate-fa tab 29-1 dss-iron carbonyl-fa tab 90-1
mg mg
SE-NATAL 19 - prenatal vit w/ 4 TRICARE - prenatal vit w/ fe 4
fe fumarate-fa chew tab 29-1 fumarate-fa tab 27-1 mg
mg TRICARE PRENATAL - prenat 4
SELECT-OB - prenat w/ 4 w/o vit a w/ fe pyrophos-
fepolycmplx-methylfol-fa methylf chew tab 4.5-1 mg
chew tab 29-0.6-0.4 mg TRICARE PRENATAL 4
SELECT-OB - prenatal vit w/ fe 4 COMPLEAT - prenat w/o a
polysac cmplx-fa chew tab fefum-fa tab 27-1 mg & fish
29-1 mg oil chew cap pak
SUPER NU-THERA - multiple 4 TRICARE PRENATAL 4
vitamins w/ minerals powder DHA ONE - prenatal w/fe
TARON-BC - prenat w/o a w/ fe 4 fumarate-fa-dss-fish oil cap
cbnyl-fa tab 20-1 mg & vit b6 27-1-500 mg
tab pak TRINATAL GT - prenatal vit w/ 4
TARON-C DHA - prenatal w/fe 4 dss-iron carbonyl-fa tab 90-1
fum-fe poly -fa-omega 3 cap mg
53.5-38-1 mg TRINATAL RX 1 - prenatal vit 4
TARON-PREX - prenatal w/o 4 w/ fe fumarate-fa tab 60-1
vit a w/ fe fum-dss-fa-dha mg
cap 30-1.2-265 mg TRINATE - prenatal vit w/ fe 4
THRIVITE RX - prenatal vit w/ 4 fumarate-fa tab 28-1 mg
iron carbonyl-fa tab 29-1 mg TRISTART DHA - prenat w/o a 4
THRIVITE 19 - prenatal vit w/ 4 w/fecbn-methylf-fa-dha cap
dss-fe fumarate-fa tab 29-1 31-0.6-0.4-200 mg
mg TRIVEEN-DUO DHA - prenat- 4
TL FOLATE - prenatal vit w/ 4 fe bis-fe prot succ-fa-ca tab
fe fum-methylfolate-fa tab & omega 3 cap 400 pk
27-0.5-0.5 mg TRIVEEN-PRX RNF - prenatal 4
w/o vit a w/ fe fum-dss-fa-
dha cap 26-1.2-300 mg
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
ULTIMATECARE ONE - 4 VIRT-PN PLUS - prenat w/o a 4
prenatal vit w/ fe cbn-fe asp w/ fe fumerate-methylfolate-
glyc-fa-omega 3 cap 27-1mg fa-omega 3 cap
ULTIMATECARE ONE NF - 4 VIRT-SELECT - prenatal w/o 4
prenatal w/fe cbnyl-fe asp vit a w/ fe fum-dss-fa-dha
glyc-fa-dss-omega cap cap 29-1.25-325 mg
20-7-1 mg VIRT-VITE GT - prenatal vit w/ 4
VEMAVITE-PRX 2 - prenatal w/ 4 dss-iron carbonyl-fa tab 90-1
o vit a w/ fe fum-dss-fa-dha mg
cap 27-1.25-300 mg VIRTPREX - prenatal w/o vit 4
VENA-BAL DHA - prenat w/fe 4 a w/ fe fum-dss-fa-dha cap
poly-na fered-fa tab 27-1 & 26-1.2-300 mg
omega cap dr 430mg VITA-PREN - prenatal vit w/ 4
VINATE DHA RF - prenat w/o 4 docusate-iron-fa tab 65-1 mg
a w/fefum-methylfol-omegas VITAFOL FE+ - prenat-fepoly- 4
cap 27-1.13 mg methol-fa-dha cap 90-1-200
VINATE II - prenatal vit w/ fe 4 mg & dss 50mg cap
bisglycinate chelate-fa tab VITAFOL-NANO - prenatal w/o 4
29-1 mg a w/ fefum-l methylfol-fa tab
VINATE M - prenatal vit w/ sel- 4 18-0.6-0.4 mg
fe fumarate-fa tab 27-1 mg VITAFOL-OB - prenatal vit w/ fe 4
VINATE ONE - prenatal vit w/ 4 fumarate-fa tab 65-1 mg
fe fumarate-fa tab 60-1 mg VITAFOL-OB+DHA - prenatal 4
VIRT NATE - prenatal vit w/ fe 4 mv w/fe fum-fa tab 65-1 mg
fumarate-fa tab 28-1 mg & dha cap 250 mg pack
VIRT-ADVANCE - prenatal vit 4 VITAFOL-ONE - prenatal mv w/ 4
w/ dss-iron carbonyl-fa tab fe polysac cmplx-fa-dha cap
90-1 mg 29-1-200 mg
VIRT-C DHA - prenatal w/fe 4 VITAMEDMD ONE RX/ 4
fum-fe poly -fa-omega 3 cap QUATREFO - prenat w/o a
53.5-38-1 mg w/fefum-methfol-fa-dha cap
VIRT-NATE DHA - prenatal vit 4 30-0.6-0.4-200 mg
w/ fe fum-fa-omega 3 cap VITAMEDMD REDICHEW RX - 4
28-1-200 mg prenat w/ b2-b6-b12-d3-folic
VIRT-PN - prenatal vit w/ fe 4 acid chew tab 1.4 mg
fum-methylfolate-fa tab VITAPEARL - prenat w/oa w/ 4
27-0.6-0.4 mg fefum-na fered-fa-dha cap er
VIRT-PN DHA - prenat w/o a 4 30-1.4-200 mg
w/fefum-methfol-fa-dha cap VITATRUE - prenat w/o a w/fe 4
27-0.6-0.4-300 mg chel-fa tab 30-1.4 mg & dha
cap 300mg pk
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
VIVA DHA - prenatal vit w/ 4 FLORIVA - sodium fluoride- 4
fe fum-fa-omega 3 cap vitamin d liqd drops 0.25 mg/
28-1-200 mg ml-400 unit/ml
VOL-NATE - prenatal vit w/ fe 4 FLUOR-A-DAY - sodium 4
fumarate-fa tab 28-1 mg fluoride-xylitol chew tab 0.55
VOL-PLUS - prenatal vit w/ fe 4 (0.25 mg f)-236.79 mg
fumarate-fa tab 27-1 mg FLUOR-A-DAY - sodium 4
VOL-TAB RX - prenatal vit w/ 4 fluoride-xylitol chew tab 2.2
iron carbonyl-fa tab 29-1 mg (1 mg f)-236.79 mg
VP-CH PLUS - prenatal w/o 4 FLUORABON - sodium fluoride 4

a w/fe cbn-dss-fa-dha cap soln 0.25 mg/0.6ml (from
29-1-265 mg 0.55 mg/0.6ml naf)
VP-CH-PNV - prenatal w/o vit 4 FLURA-DROPS - sodium 4

a w/ fe cbn-dss-fa-dha cap fluoride soln 0.25 mg/drop f
30-1-260 mg (from 0.55 mg/drop naf)
4 GALZIN - zinc acetate cap 25 4
VP-GGR-B6 PRENATAL -
prenatal w/ calcium-vit b6-fa- mg (elemental zinc)
ginger tab 1.2 mg GALZIN - zinc acetate cap 50 4
VP-HEME OB - prenat vit-fe 4 mg (elemental zinc)
poly cmplx-fe heme poly-fa K-TAB - potassium chloride tab 4
tab 28-6-1 mg er 8 meq (600 mg)
VP-HEME OB + DHA - prenat- 4 K-TAB - potassium chloride tab 4
fe poly cmplx-fe heme poly- er 20 meq (1500 mg)
fa tab & omega 3 cap pck KLOR-CON M15 - potassium 4
VP-HEME ONE - prenat-fe poly 4 chloride microencapsulated
cmplx-fe heme poly-fa-dha crys er tab 15 meq
cap 22-6-1-200 mg LOZI-FLUR - sodium fluoride 4
VP-PNV-DHA - prenatal vit 4 lozenge 1 mg f (from 2.2 mg
w/ fe fum-fa-omega 3 cap naf)
28-1-215.8 mg MONOCAL - sodium A
ZATEAN-PN DHA - prenat w/ 4 monofluorophosphate-
o a w/fefum-methfol-fa-dha calcium carb tab 22.75-625
cap 27-0.6-0.4-300 mg mg
ZATEAN-PN PLUS - prenat 4 POTASSIUM CHLORIDE - 2
w/o a w/ fe fumerate- potassium chloride oral soln
methylfolate-fa-omega 3 cap 20% (40 meq/15ml)
MINERALS and ELECTROLYTES potassium chloride cap er 8 2
FLORICAL - sodium fluoride w/ A meq (Micro-k)
calcium carb cap 8.3-364 mg potassium chloride cap er 2
FLORICAL - sodium fluoride w/ A 10 meq (Micro-k)
calcium carb tab 8.3-364 mg
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
POTASSIUM CHLORIDE ER - 4 ADD-INS COMPLETE - amino 4
potassium chloride tab er 8 acids pack
meq (600 mg) amino acids cap 2
POTASSIUM CHLORIDE ER - 4 2
amino acids tab
potassium chloride tab er 20
ARGIMENT - amino acids pack 4
meq (1500 mg)
1 ARGIMENT AT - amino acids 4
potassium chloride
microencapsulated crys er pack
tab 10 meq COMPLETE AMINO ACID 4
potassium chloride 1 MIX - amino acids oral
microencapsulated crys er powder
tab 20 meq COMPLEX ESSENTIAL MSD - 4
potassium chloride oral soln 2 amino acids oral powder
10% (20 meq/15ml) COMPLEX JUNIOR MSD - 4
potassium chloride powder 2 amino acids oral powder
packet 20 meq COMPLEX MSUD - amino 4
potassium chloride tab er 8 1 acids oral powder
meq (600 mg) COMPLEX MSUD AMINO 4
potassium chloride tab er 10 1 ACID B - amino acids bar
meq (K-tab) DEQUASINE - amino acids tab 4
SODIUM FLUORIDE - sodium 4 ESSENTIAL AMINO ACID 4
fluoride tab 0.5 mg f (from MIX - amino acids oral
1.1 mg naf) powder
SODIUM FLUORIDE - sodium 4 G-PREPROTEIN - amino acids 4
fluoride tab 1 mg f (from 2.2 oral liquid
mg naf) GLUTARADE AMINO ACID 4
sodium fluoride chew tab 1 BLEN - amino acids oral
0.25 mg f (from 0.55 mg powder
naf) (Luride) GLUTARADE ESSENTIAL 4
sodium fluoride chew tab 1 GA-1 - amino acids oral
0.5 mg f (from 1.1 mg naf) powder
(Luride) GLUTARADE JUNIOR GA-1 - 4
sodium fluoride chew tab 1 amino acids oral powder
1 mg f (from 2.2 mg naf) HEPAMENT - amino acids 4
(Luride) pack
sodium fluoride soln 2 LIQUACEL - amino acids oral 4
0.125 mg/drop f (0.275 mg/ liquid
drop naf)
LIQUACEL PUMP + GO - 4
sodium fluoride soln 0.5 mg/ 1 amino acids oral liquid
ml f (from 1.1 mg/ml naf)
NUTRASENTIALS - amino 4
(Luride)
acids oral powder
NUTRIENTS
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
NUTRESTORE - glutamine 4 ALITRAQ - nutritional 4
powd pack 5 gm supplement pack
PERIFLEX LQ PKU - amino 4 ARGINAID - nutritional 4
acids oral liquid supplement pack
PHENYLADE - amino acids 4 ARGINAID EXTRA - nutritional 4
oral powder supplement liquid
PHENYLADE AMINO ACID - 4 BALANCE TOTAL 4
amino acids bar NUTRITIONAL - nutritional
PHENYLADE AMINO ACID 4 supplement liquid
BLEN - amino acids pack BALANCED NUTRITIONAL 4
PHENYLADE MTE - amino 4 DRIN - nutritional supplement
acids oral powder liquid
4 BALANCED NUTRITIONAL 4
PHENYLADE MTE AMINO
ACID - amino acids pack SHAK - nutritional
supplement liquid
PHENYLADE PHEBLOC - 4
BCAD 1 - nutritional 4
amino acids oral powder
supplement powder
PHENYLADE PHEBLOC - 4
BCAD 2 - nutritional 4
amino acids tab
supplement powder
PHENYLADE40 DRINK MIX - 4
BEEF/POTATOES/PEAS - 4
amino acids pack
nutritional supplement liquid
PHLEXY-10 - amino acids cap 4
BENECALORIE - nutritional 4
PREPROTEIN - amino acids 4
supplement liquid
oral liquid
BOOST - nutritional 4
PREPROTEIN 20 - amino 4
supplement liquid
acids oral liquid
BOOST BREEZE - nutritional 4
SOLVIL - amino acids pack 4
supplement liquid
SUPER-AMINO 1600 - amino 4 4
BOOST CALORIE SMART -
acids tab nutritional supplement liquid
TRIAMINO - amino acids tab 4
BOOST COMPACT - nutritional 4
XPHE MAXAMUM - amino 4 supplement liquid
acids oral powder BOOST GLUCOSE 4
XPHE MAXAMUM - amino 4 CONTROL - nutritional
acids pack supplement liquid
DIETARY PRODUCTS BOOST HIGH PROTEIN - 4
A-SOY - nutritional supplement 4 nutritional supplement liquid
liquid BOOST HIGH PROTEIN - 4
ACERFLEX - nutritional 4 nutritional supplement
supplement powder powder
ADVERA - nutritional 4
supplement liquid
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
BOOST KID ESSENTIALS 4 CARNATION BREAKFAST 4
1.0 - nutritional supplement ESSEN - nutritional
liquid supplement pack
BOOST KID ESSENTIALS 4 CARNATION INSTANT 4
1.5 - nutritional supplement BREAKFA - nutritional
liquid supplement liquid
BOOST KIDS ESSENTIALS - 4 CHOICE DM - nutritional 4
nutritional supplement liquid supplement liquid
BOOST PLUS - nutritional 4 CHOICE DM TF - nutritional 4
supplement liquid supplement liquid
BOOST PUDDING - nutritional 4 CHOLEXTRA - nutritional 4
supplement pudding supplement powder
BOOST SMOOTHIE - 4 CLICK ESPRESSO PROTEIN 4
nutritional supplement liquid DR - nutritional supplement
BOOST VHC - nutritional 4 powder
supplement liquid COMPLEAT - nutritional 4
BOOST 100 CALORIE 4 supplement liquid
SMART - nutritional COMPLEAT CLOSED 4
supplement liquid SYSTEM - nutritional
BOOST/BENEFIBER - 4 supplement liquid
nutritional supplement liquid COMPLEAT PEDIATRIC - 4
CALCILO XD - infant foods 4 nutritional supplement liquid
powder COMPLEAT PEDIATRIC 4
CAMINO PRO BETTERMILK/ 4 REDUCE - nutritional
GLY - nutritional supplement supplement liquid
pack COMPLETE NUTRITION - 4
CAMINO PRO COMPLETE/ 4 nutritional supplement liquid
GLYTA - nutritional COMPLETE NUTRITION 4
supplement bar PLUS - nutritional
CAMINO PRO PKU - nutritional 4 supplement liquid
supplement liquid COMPLETE PROTEIN 4
CAMINO PRO RESTORE/ 4 & VITAMI - nutritional
GLYTAC - nutritional supplement powder
supplement liquid CRITICARE HN - nutritional 4
CAMINO PRO SWIRL - 4 supplement liquid
nutritional supplement pack CRUCIAL - nutritional 4
CAMINO PRO 15PE - 4 supplement liquid
nutritional supplement liquid CVS NUTRITION LIQUID - 4
CARNATION BREAKFAST 4 nutritional supplement liquid
ESSEN - nutritional CVS NUTRITION PLUS - 4
supplement liquid nutritional supplement liquid
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
CVS NUTRITIONAL SHAKE - 4 ENSURE ACTIVE - nutritional 4
CYCLINEX-1 - nutritional 4 ENSURE ACTIVE HEART 4
supplement powder HEALT - nutritional
CYCLINEX-2 - nutritional 4 supplement liquid
supplement powder ENSURE ACTIVE HIGH 4
DIABETIC TF - nutritional 4 PROTEI - nutritional
4 ENSURE ACTIVE LIGHT - 4
DIABETISHIELD - nutritional
4 ENSURE BONE HEALTH 4
DIABETISOURCE - nutritional
supplement liquid REVIGO - nutritional
supplement liquid
DIABETISOURCE AC - 4
ENSURE CLEAR - nutritional 4
supplement liquid
DIARESQ - nutritional 4
ENSURE CLINICAL 4
supplement pack
STRENGTH - nutritional
DIARESQ CHILDRENS - 4
supplement liquid
nutritional supplement pack
ENSURE COMPACT - 4
DUOCAL - nutritional 4
supplement powder
ENSURE COMPLETE - 4
EAA SUPPLEMENT - 4
ENSURE COMPLETE 4
EGG/PRO - nutritional 4
NUTRITION - nutritional
supplement powder supplement liquid
ELECARE - nutritional 4 4
ENSURE ENLIVE - nutritional
ELECARE JR - nutritional 4 4
ENSURE HEALTHY MOM -
supplement powder nutritional supplement bar
ELECARE/DHA/ARA - 4 4
ENSURE HEALTHY MOM -
nutritional supplement nutritional supplement liquid
powder
ENSURE HIGH CALCIUM - 4
ENLIVE - nutritional 4
supplement liquid
ENSURE HIGH PROTEIN - 4
ENSURE - nutritional 4
supplement bar
ENSURE HIGH PROTEIN - 4
ENSURE - nutritional 4
nutritional supplement
supplement liquid powder
ENSURE - nutritional 4 4
ENSURE IMMUNE HEALTH -
supplement powder nutritional supplement liquid
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
ENSURE MUSCLE HEALTH 4 FIBER FLOW - nutritional 4
REVI - nutritional supplement supplement liquid
liquid FIBER-STAT - nutritional 4
ENSURE NUTRA SHAKE HI- 4 supplement liquid
CAL - nutritional supplement FIBERSOURCE CLOSED 4
liquid SYSTEM - nutritional
ENSURE NUTRITION 4 supplement liquid
SHAKE - nutritional FIBERSOURCE HN - 4
ENSURE PLUS - nutritional 4 4
FIBERSOURCE HN CLOSED
supplement liquid SYS - nutritional supplement
ENSURE PLUS HN - nutritional 4 liquid
supplement liquid FLAVOR PACKETS - nutritional 4
ENSURE PRE-SURGERY - 4 supplement flavor pack
nutritional supplement liquid FLAVOUR PAC - nutritional 4
ENSURE PUDDING - 4 supplement flavor pack
nutritional supplement FORTA DRINK - nutritional 4
pudding supplement powder
ENSURE SURGERY 4 4
FORTA SHAKE - nutritional
IMMUNONUTR - nutritional supplement powder
supplement liquid
FRUITIVITS - nutritional 4
ENSURE/FIBER - nutritional 4
supplement pack
supplement liquid
GA - nutritional supplement 4
ENU NUTRITIONAL SHAKE - 4
powder
GA EXPRESS15 - nutritional 4
EO28 SPLASH - nutritional 4
supplement pack
supplement liquid
GA GEL - nutritional 4
EQ NUTRITIONAL SHAKE - 4
supplement pack
GA-1 ANAMIX EARLY 4
EQ NUTRITIONAL SHAKE 4
YEARS - nutritional
PLUS - nutritional supplement powder
supplement liquid
GLUCERNA - nutritional 4
EQ WEIGHT LOSS 4
supplement bar
SHAKE ULTR - nutritional
GLUCERNA - nutritional 4
supplement liquid
supplement liquid
EQUATE - nutritional 4
GLUCERNA ADVANCE 4
supplement liquid
SHAKE - nutritional
EQUATE PLUS - nutritional 4
supplement liquid
supplement liquid
GLUCERNA CARBSTEADY - 4
F.A.A. - nutritional supplement 4
liquid
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
GLUCERNA CEREAL 4 GLUCERNA 1.5 CAL - 4
CRUNCHY F - nutritional nutritional supplement liquid
supplement misc GLUCO BURST - nutritional 4
GLUCERNA CRISPY 4 supplement liquid
DELIGHTS - nutritional GLUTAREX-1 - nutritional 4
supplement bar supplement powder
GLUCERNA HUNGER 4 4
GLUTAREX-2 - nutritional
SMART SHA - nutritional supplement powder
supplement liquid
GLYCOSADE - nutritional 4
GLUCERNA MEAL - nutritional 4
supplement pack
supplement bar
GLYTACTIN BETTERMILK 4
GLUCERNA MEAL 4
DE-L - nutritional supplement
REPLACEMENT - nutritional pack
supplement bar
GLYTACTIN BETTERMILK 15 - 4
GLUCERNA MINI SNACK - 4
nutritional supplement bar
GLYTACTIN BUILD 10PE - 4
GLUCERNA MINI SNACKS - 4
nutritional supplement bar
GLYTACTIN COMPLETE 4
GLUCERNA OS - nutritional 4
10PE - nutritional supplement
supplement liquid bar
GLUCERNA SELECT - 4 4
GLYTACTIN RESTORE LITE
nutritional supplement liquid 10 - nutritional supplement
GLUCERNA SHAKE - 4 liquid
nutritional supplement liquid GLYTACTIN RESTORE LITE 4
GLUCERNA SNACK - 4 10 - nutritional supplement
nutritional supplement bar pack
GLUCERNA SNACK SHAKE - 4 GLYTACTIN RESTORE 10 - 4
nutritional supplement liquid nutritional supplement liquid
GLUCERNA WEIGHT 4 GLYTACTIN RESTORE 5 - 4
LOSS SHAK - nutritional nutritional supplement pack
supplement liquid GLYTACTIN RTD 10 - 4
GLUCERNA 1.0 CAL - 4 nutritional supplement liquid
nutritional supplement liquid GLYTACTIN RTD 15 - 4
GLUCERNA 1.0 CAL/FIBER - 4 nutritional supplement liquid
nutritional supplement liquid GLYTROL - nutritional 4
GLUCERNA 1.0 WITH 4 supplement liquid
CARBSTE - nutritional GLYTROL PREBIO1 - 4
GLUCERNA 1.2 CAL - 4 4
GNP NUTRITIONAL DRINK -
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
GNP NUTRITIONAL DRINK 4 HIGH-PROTEIN 4
PLU - nutritional supplement NUTRITIONAL - nutritional
GOAT MILK - nutritional 4 HM NUTRISURE - nutritional 4
HAELAN HTPI FERMENTED 4 HM NUTRISURE PLUS - 4
ORG - nutritional supplement nutritional supplement liquid
liquid HOM 2 - nutritional supplement 4
HAELAN 951 FERMENTED 4 powder
ORGA - nutritional HOMACTIN AA PLUS - 4
HCU ANAMIX EARLY YEARS - 4 HOMINEX-1 - nutritional 4
nutritional supplement supplement powder
powder
HOMINEX-2 - nutritional 4
HCU ANAMIX NEXT - 4
supplement powder
I-VALEX-1 - nutritional 4
powder
supplement powder
HCU COOLER - nutritional 4
I-VALEX-2 - nutritional 4
supplement liquid
supplement powder
HCU EXPRESS - nutritional 4
IMMULIFE - nutritional 4
supplement pack
supplement powder
HCU EXPRESS20 - nutritional 4
IMMUNOPRO RX - nutritional 4
supplement pack
supplement powder
HCU GEL - nutritional 4
IMPACT - nutritional 4
supplement pack
supplement liquid
HCU LOPHLEX LQ - nutritional 4
IMPACT ADVANCED 4
supplement liquid
RECOVERY - nutritional
HCY 1 - nutritional supplement 4 supplement liquid
powder
IMPACT GLUTAMINE - 4
HCY 2 - nutritional supplement 4 nutritional supplement liquid
powder
IMPACT PEPTIDE 1.5 - 4
HEALTH SOURCE SOY 4
PROTEIN - nutritional
IMPACT 1.5 - nutritional 4
supplement powder
supplement liquid
HEALTHY ACCENTS NUTRA 4
IMPACT/FIBER - nutritional 4
FIT - nutritional supplement
4 IMUPLUS - nutritional 4
HEARTBAR - nutritional
supplement bar supplement pack
INNOVACIN - nutritional 4
HI-CAL - nutritional supplement 4
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
INTROLITE - nutritional 4 JUVEN - nutritional supplement 4
supplement liquid pack
ISOCAL - nutritional 4 JUVEN - nutritional supplement 4
ISOCAL HN - nutritional 4 JUVEN NUTRIVIGOR - 4
supplement liquid nutritional supplement pack
ISOCAL HN PLUS - nutritional 4 JUVEN REVIGOR - nutritional 4
supplement liquid supplement pack
ISOSOURCE - nutritional 4 K-PAX IMMUNE BOOSTER 4
supplement liquid PROT - nutritional
ISOSOURCE CLOSED 4 supplement powder
SYSTEM - nutritional KATE FARMS CORE 4
supplement liquid ESSENTIAL - nutritional
ISOSOURCE HN - nutritional 4 supplement liquid
supplement liquid KETOCAL 3:1 - nutritional 4
ISOSOURCE VHN - nutritional 4 supplement powder
supplement liquid KETOCAL 4:1 - nutritional 4
ISOSOURCE 1.5 CAL - 4 supplement liquid
nutritional supplement liquid KETOCAL 4:1 - nutritional 4
ISOVACTIN AA PLUS - 4 supplement powder
nutritional supplement liquid KETOCAL 4:1 LQ MULTI 4
IVA ANAMIX EARLY YEARS - 4 FIBE - nutritional supplement
powder KETOGEN - nutritional 4
IVA ANAMIX NEXT - nutritional 4 supplement powder
supplement powder KETONEX-1 - nutritional 4
JEVITY 1 CAL - nutritional 4 supplement powder
supplement liquid KETONEX-2 - nutritional 4
JEVITY 1 CAL/FIBER - 4 supplement powder
nutritional supplement liquid KETOVIE - nutritional 4
JEVITY 1.2 CAL - nutritional 4 supplement liquid
supplement liquid KETOVIE PEPTIDE - 4
JEVITY 1.2 CAL/FIBER - 4 nutritional supplement liquid
nutritional supplement liquid KETOVOLVE 4:1 - nutritional 4
JEVITY 1.5 CAL - nutritional 4 supplement powder
supplement liquid KIDS PROTEIN ORGANIC 4
JEVITY 1.5 CAL/FIBER - 4 NUTR - nutritional
JUICE PLUS FIBRE - 4 KINRAY PREFERRED PLUS - 4

2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
LANAFLEX - nutritional 4 MODULEN IBD - nutritional 4
supplement pack supplement powder
LEU-FREE COOLER - 4 MONOGEN - nutritional 4
nutritional supplement liquid supplement powder
LIPISTART - nutritional 4 MSUD AID - nutritional 4
supplement powder supplement powder
LIQUID HOPE - nutritional 4 MSUD ANAMIX EARLY 4
supplement liquid YEARS - nutritional
LMD - nutritional supplement 4 supplement powder
powder MSUD COOLER - nutritional 4
LOPHLEX - nutritional 4 supplement liquid
supplement pack MSUD EXPRESS - nutritional 4
LOPHLEX LQ 20 - nutritional 4 supplement pack
supplement liquid MSUD EXPRESS20 - 4
LPS CRITICAL CARE SUGAR 4 nutritional supplement pack
F - nutritional supplement MSUD GEL - nutritional 4
LPS SUGAR FREE - nutritional 4 MSUD LOPHLEX LQ - 4
MCT PRO-CAL - nutritional 4 MSUD MAXAMAID - nutritional 4
supplement pack supplement powder
MCT PROCAL - nutritional 4 MSUD MAXAMUM - nutritional 4
MERITENE - nutritional 4 MSUD 2 - nutritional 4
METAFORM - nutritional 4 NEOCATE INFANT DHA/ 4
supplement pack ARA - nutritional supplement
METHIONAID - nutritional 4 powder
supplement powder NEOCATE JUNIOR - nutritional 4
MMA/PA ANAMIX EARLY 4 supplement powder
YEARS - nutritional NEOCATE JUNIOR/ 4
supplement powder PREBIOTICS - nutritional
MMA/PA ANAMIX NEXT - 4 supplement powder
nutritional supplement NEOCATE NUTRA - nutritional 4
powder supplement powder
MMA/PA COOLER - nutritional 4 NEOCATE SPLASH - 4
MMA/PA COOLER15 - 4 NEPRO - nutritional 4
MMA/PA GEL - nutritional 4
supplement pack
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
NEPRO WITH CARB 4 NUTRA/SHAKE - nutritional 4
STEADY - nutritional supplement liquid (frozen)
supplement liquid NUTRA/SHAKE FRUIT PLUS - 4
NEPRO WITH 4 nutritional supplement liquid
CARBSTEADY - nutritional (frozen)
supplement liquid NUTRA/SHAKE SUPREME - 4
NESTLE FLAVOR - nutritional 4 nutritional supplement liquid
supplement flavor pack (frozen)
NESTLE FLAVOR EXTRA 4 NUTRA/SHAKE SUPREME - 4
STREN - nutritional nutritional supplement liquid
supplement flavor pack NUTRAMENT - nutritional 4
NESTLE FLAVOR FOR KIDS - 4 supplement liquid
nutritional supplement flavor NUTRAMINE - nutritional 4
pack supplement pack
NOURISH - nutritional 4 4
NUTRAMINE APPLE AMINO
supplement liquid BIT - nutritional supplement
NOVASOURCE 4 pack
PULMONARY - nutritional NUTRAMINE BANANA 4
supplement liquid AMINO B - nutritional
NOVASOURCE RENAL - 4 supplement pack
nutritional supplement liquid NUTRAMINE CHOCOLATE 4
NUTRA BALANCE DIABETIC 4 AMINO - nutritional
NU - nutritional supplement supplement pack
bar NUTRAMINE MANGO AMINO 4
NUTRA BALANCE FIBER 4 BI - nutritional supplement
COOKI - nutritional pack
supplement misc NUTRAMINE MIXED 4
NUTRA BALANCE PROTEIN 4 FLAVORS A - nutritional
FOR - nutritional supplement supplement pack
misc NUTRAMINE PEACHES 4
NUTRA SHAKE - nutritional 4 & CREAM - nutritional
supplement liquid (frozen) supplement pack
NUTRA SHAKE/SUPREME - 4 NUTRAMINE PINEAPPLE 4
nutritional supplement liquid AMINO - nutritional
(frozen) supplement pack
NUTRA/BALANCE RE/GEN - 4 NUTREN JR - nutritional 4
(frozen) NUTREN JR FIBER - 4
NUTRA/BALANCE RE/ 4 nutritional supplement liquid
GEN FREE - nutritional NUTREN JUNIOR - nutritional 4
supplement liquid (frozen) supplement liquid
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
NUTREN JUNIOR 1.0 - 4 NUTRITIONAL DRINK MIX - 4
nutritional supplement liquid nutritional supplement
NUTREN JUNIOR/FIBER - 4 powder
nutritional supplement liquid NUTRITIONAL DRINK PLUS - 4
NUTREN PULMONARY - 4 nutritional supplement liquid
nutritional supplement liquid NUTRITIONAL DRINK SHAKE 4
NUTREN RENAL - nutritional 4 M - nutritional supplement
4 NUTRITIONAL SHAKE - 4
NUTREN 1.0 - nutritional
4 NUTRITIONAL SHAKE 4
NUTREN 1.0 CAL - nutritional
supplement liquid COMPLET - nutritional
supplement liquid
NUTREN 1.0/FIBER - 4
NUTRITIONAL SHAKE PLUS - 4
NUTREN 1.0/FIBER/ 4
NUTRITIONAL SHAKE PLUS 4
ULTRAPAK - nutritional
supplement liquid PR - nutritional supplement
liquid
NUTREN 1.5 - nutritional 4
NUTRITIONAL 4
supplement liquid
SUPPLEMENT - nutritional
NUTREN 1.5 CAL - nutritional 4
supplement liquid
supplement liquid
nutritional supplement liquid 2
NUTREN 1.5 FIBER - 4
NUTRITIONAL SUPPLEMENT 4
PL - nutritional supplement
NUTREN 2.0 - nutritional 4
liquid
supplement liquid
NUTRIVENT - nutritional 4
NUTREN 2.0 CAL - nutritional 4
supplement liquid
supplement liquid
NUTRIVENT 1.5 - nutritional 4
NUTRICIA PREOP - nutritional 4
supplement liquid
supplement pack
NUTRIVIR - nutritional 4
NUTRIFOCUS - nutritional 4
supplement powder
supplement liquid
NUTRIVIR NSA - nutritional 4
NUTRIHEAL - nutritional 4
supplement powder
supplement liquid
OA 1 - nutritional supplement 4
NUTRIHEP 1.5 CAL - 4
powder
OA 2 - nutritional supplement 4
NUTRIRENAL - nutritional 4
powder
supplement liquid
OPTICLEANSE GHI - 4
NUTRITIONAL DRINK - 4
nutritional supplement liquid powder
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
OPTIMENTAL - nutritional 4 PEDIASURE ENTERAL 4
supplement liquid FORMULA - nutritional
OPTISOURCE VERY 4 supplement liquid
HIGH PROT - nutritional PEDIASURE GROW & GAIN - 4
ORANGE CHICKEN/ 4 PEDIASURE NUTRIPALS - 4
CARROTS/BR - nutritional nutritional supplement bar
supplement liquid PEDIASURE NUTRIPALS - 4
ORGANIC NUTRITION 4 nutritional supplement liquid
COMPLET - nutritional PEDIASURE PEDIATRIC - 4
ORGANIC NUTRITION 4 4
PEDIASURE PEPTIDE 1.0
PLANT B - nutritional CAL - nutritional supplement
supplement liquid liquid
ORGANIC NUTRITION 4 4
PEDIASURE PEPTIDE 1.5
VEGAN-A - nutritional CAL - nutritional supplement
supplement liquid liquid
ORGANIC PEDIA SMART - 4 4
PEDIASURE SHAKE MIX -
nutritional supplement nutritional supplement
powder powder
OS 2 - nutritional supplement 4 4
PEDIASURE SHAKE WITH
powder FIBE - nutritional supplement
OSMOLITE - nutritional 4 liquid
supplement liquid PEDIASURE SIDEKICKS - 4
OSMOLITE HN - nutritional 4 nutritional supplement liquid
supplement liquid PEDIASURE SIDEKICKS - 4
OSMOLITE 1 CAL - nutritional 4 nutritional supplement
OSMOLITE 1.0 CAL - 4 PEDIASURE SIDEKICKS 4
nutritional supplement liquid CLEAR - nutritional
OSMOLITE 1.2 CAL - 4 supplement liquid
nutritional supplement liquid PEDIASURE SIDEKICKS 4
OSMOLITE 1.5 CAL - 4 SHAKE - nutritional
4 PEDIASURE WITH FIBER - 4
OXEPA - nutritional
4 PEDIASURE 1.0 CAL/FIBER - 4
OXEPA 1.5 - nutritional
4 PEDIASURE 1.5 CAL - 4
PEDIASURE - nutritional
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
PEDIASURE 1.5 CAL WITH 4 PEPTAMEN OS - nutritional 4
FI - nutritional supplement supplement liquid
liquid PEPTAMEN OS 1.5 - nutritional 4
PEDIASURE 1.5 CAL/FIBER - 4 supplement liquid
nutritional supplement liquid PEPTAMEN VHP - nutritional 4
PEDIATRIC DRINK - nutritional 4 supplement liquid
supplement liquid PEPTAMEN 1 CAL - nutritional 4
PEDIATRIC PEPTINEX DT - 4 supplement liquid
nutritional supplement liquid PEPTAMEN 1 CAL/PREBIO1 - 4
PEDIATRIC PEPTINEX DT/ 4 nutritional supplement liquid
FIB - nutritional supplement PEPTAMEN 1.5 - nutritional 4
PEPDITE JUNIOR - nutritional 4 4
PEPTAMEN 1.5 CAL -
supplement pack nutritional supplement liquid
PEPTAMEN - nutritional 4 4
PEPTAMEN 1.5 CAL/
supplement liquid PREBIO1 - nutritional
PEPTAMEN AF - nutritional 4 supplement liquid
supplement liquid PEPTAMEN/PREBIO1 - 4
PEPTAMEN BARIATRIC - 4 nutritional supplement liquid
nutritional supplement liquid PEPTINEX DT - nutritional 4
PEPTAMEN INTENSE VHP - 4 supplement liquid
nutritional supplement liquid PEPTINEX DT WITH 4
PEPTAMEN JUNIOR - 4 PREBIOTI - nutritional
PEPTAMEN JUNIOR - 4 PEPTINEX 1.0 - nutritional 4
nutritional supplement supplement liquid
powder PEPTINEX 1.5 - nutritional 4
PEPTAMEN JUNIOR FIBER - 4 supplement liquid
nutritional supplement liquid PERATIVE - nutritional 4
PEPTAMEN JUNIOR HP - 4 supplement liquid
nutritional supplement liquid PERATIVE 1.3 CAL - nutritional 4
PEPTAMEN JUNIOR 1 CAL - 4 supplement liquid
nutritional supplement liquid PERIFLEX ADVANCE - 4
PEPTAMEN JUNIOR 1 CAL/ 4 nutritional supplement
PRE - nutritional supplement powder
liquid PERIFLEX JUNIOR - 4
PEPTAMEN JUNIOR 1.5 CAL - 4 nutritional supplement
PEPTAMEN JUNIOR/ 4 PFD 1 - nutritional supplement 4
PREBIO1 - nutritional powder
supplement liquid
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
PFD 2 - nutritional supplement 4 PKU COOLER 10 - nutritional 4
powder supplement liquid
PHENACTIN AA PLUS - 4 PKU COOLER 15 - nutritional 4
PHENEX-1 - nutritional 4 PKU COOLER 20 - nutritional 4
PHENEX-2 - nutritional 4 PKU EXPRESS - nutritional 4
supplement powder supplement pack
PHENYL-FREE 2 - nutritional 4 PKU EXPRESS20 - nutritional 4
PHENYL-FREE 2HP - 4 PKU GEL - nutritional 4
nutritional supplement supplement pack
powder PKU LOPHLEX LQ 20 - 4
PHENYLADE DRINK MIX - 4 nutritional supplement liquid
nutritional supplement PKU PERIFLEX EARLY 4
powder YEARS - nutritional
PHENYLADE ESSENTIAL 4 supplement powder
DRINK - nutritional PKU PERIFLEX JUNIOR 4
supplement pack PLUS - nutritional
PHENYLADE ESSENTIAL 4 supplement powder
DRINK - nutritional PKU SPHERE 15 - nutritional 4
PHENYLADE GMP - nutritional 4 4
PKU SPHERE 20 - nutritional
supplement pack supplement pack
PHENYLADE GMP - nutritional 4 4
PKU TRIO - nutritional
PHENYLADE GMP MIX-IN - 4 4
PKU 2 - nutritional supplement
nutritional supplement pack powder
PHENYLADE RTD PKU 10 - 4 4
PKU 3 - nutritional supplement
PHENYLADE60 DRINK MIX - 4 4
POLYCAL - nutritional
nutritional supplement pack supplement powder
PHENYLADE60 DRINK MIX - 4 4
PORTAGEN - nutritional
nutritional supplement supplement powder
powder
PPA/MMA EXPRESS - 4
PHLEXY-10 - nutritional 4
supplement pack
PRO-CAL - nutritional 4
PHYTOFUSION - nutritional 4
supplement pack
supplement pack
PRO-CAL - nutritional 4
PIVOT 1.5 CAL - nutritional 4
supplement powder
supplement liquid
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
PRO-PHREE - nutritional 4 PROTEIN FORTIFIED 4
supplement powder COOKIE - nutritional
PROBALANCE - nutritional 4 supplement misc
supplement liquid PROVIMIN - nutritional 4
PROMACTIN AA PLUS - 4 supplement powder
nutritional supplement liquid PULMOCARE - nutritional 4
PROMOD - nutritional 4 supplement liquid
supplement liquid PULMOCARE 1.5 - nutritional 4
PROMOD - nutritional 4 supplement liquid
supplement powder PX VANILLA PLUS - nutritional 4
PROMOTE - nutritional 4 supplement liquid
supplement liquid QUINOA KALE & HEMP - 4
PROMOTE WITH FIBER - 4 nutritional supplement liquid
nutritional supplement liquid RA BALANCED 4
PROMOTE 1.0 - nutritional 4 NUTRITIONAL - nutritional
4 RA BALANCED 4
PROMOTE 1.0 WITH FIBER -
nutritional supplement liquid NUTRITIONAL P - nutritional
supplement liquid
PROMOTE/FIBER - nutritional 4
RA NUTRITIONAL 4
supplement liquid
SUPPLEMENT - nutritional
PROPIMEX-1 - nutritional 4
supplement liquid
supplement powder
RA NUTRITIONAL SUPPORT - 4
PROPIMEX-2 - nutritional 4
PROSOURCE - nutritional 4 4
RA PEDIATRIC
supplement liquid NUTRITIONAL - nutritional
PROSOURCE - nutritional 4 supplement liquid
supplement powder RE/GEN PROTEIN 4
PROSOURCE NO CARB - 4 FORTIFIED - nutritional
nutritional supplement liquid supplement misc
PROSOURCE PLUS - 4 RE/NEPH - nutritional 4
PROSOURCE TF - nutritional 4 RE/NEPH HP/HC - nutritional 4
supplement liquid supplement liquid (frozen)
PROSOURCE ZAC - nutritional 4 RE/NEPH LP/HC - nutritional 4
PROSURE - nutritional 4 RE/NEPH REDUCED 4
supplement liquid SUGAR - nutritional
PROTAIN XL - nutritional 4 supplement liquid
supplement liquid
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
RENALCAL - nutritional 4 RESURGEX - nutritional 4
RENASTART - nutritional 4 RESURGEX PLUS - nutritional 4
REPLETE - nutritional 4 RESURGEX SELECT - 4
REPLETE FIBER - nutritional 4 S.O.S. 15 - nutritional 4
REPLETE FIBER 1 CAL - 4 S.O.S. 20 - nutritional 4
nutritional supplement liquid supplement pack
REPLETE/FIBER/ULTRAPAK - 4 S.O.S. 25 - nutritional 4
nutritional supplement liquid supplement pack
RESOURCE ARGINAID - 4 SALMON/OATS/SQUASH - 4
nutritional supplement pack nutritional supplement liquid
RESOURCE DAIRY 4 SB COMPLETE NUTRITION - 4
THICK HONE - nutritional nutritional supplement liquid
supplement liquid SB COMPLETE NUTRITION 4
RESOURCE DIABETIC TF - 4 PLU - nutritional supplement
nutritional supplement liquid liquid
RESOURCE JUICE DRINK - 4 SCANDICAL - nutritional 4
(frozen) SCANDISHAKE - nutritional 4
RESOURCE JUST FOR 4 supplement misc
KIDS - nutritional supplement SCANDISHAKE - nutritional 4
RESOURCE JUST FOR KIDS 4 4
SCANDISHAKE - nutritional
WI - nutritional supplement supplement powder
liquid
SM NUTRI-DRINK - nutritional 4
RESOURCE JUST FOR KIDS 4
supplement liquid
1. - nutritional supplement
SM NUTRI-DRINK + - 4
liquid
RESOURCE SUPPORT - 4
SOL CARB - nutritional 4
supplement powder
RESOURCE THICKENUP 4
SOURCE COOKIE BAR - 4
THICKE - nutritional
supplement liquid nutritional supplement bar
4 SOY PROTEIN SHAKE - 4
RESOURCE 2.0 - nutritional
supplement liquid nutritional supplement
powder
RESPALOR - nutritional 4
SUBDUE - nutritional 4
supplement liquid
supplement liquid
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
SUBDUE PLUS - nutritional 4 TYLACTIN RESTORE 10 - 4
SUPLENA - nutritional 4 TYLACTIN RESTORE 5PE - 4
SUPLENA RTU - nutritional 4 TYLACTIN RTD 15 - nutritional 4
SUPLENA WITH CARB 4 TYR ANAMIX EARLY YEARS - 4
STEADY - nutritional nutritional supplement
SUPLENA 1.8 WITH 4 TYR ANAMIX NEXT - 4
CARBSTEA - nutritional nutritional supplement
THICK-IT BEEF LASAGNA 4 TYR COOLER - nutritional 4
PUR - nutritional supplement supplement liquid
misc TYR COOLER20 - nutritional 4
THICK-IT CHICKEN A LA KIN - 4 supplement liquid
nutritional supplement misc TYR EXPRESS - nutritional 4
THICK-IT MAPLE CINNAMON 4 supplement pack
F - nutritional supplement TYR EXPRESS20 - nutritional 4
misc supplement pack
THICK-IT MIXED FRUIT AND - 4 TYR GEL - nutritional 4
nutritional supplement misc supplement pack
THICK-IT SEASONED 4 4
TYR LOPHLEX LQ - nutritional
CHICKEN - nutritional supplement liquid
supplement misc
TYREX-1 - nutritional 4
THICK-IT SWEET CORN 4
supplement powder
PUREE - nutritional
TYREX-2 - nutritional 4
supplement misc
supplement powder
THICK-IT THICKENED 4
TYROS 1 - nutritional 4
CRANBE - nutritional
supplement liquid supplement powder
4 TYROS 2 - nutritional 4
THRIVACIN DETOX -
4 UCD ANAMIX JUNIOR - 4
THRIVACIN 30 - nutritional
supplement liquid nutritional supplement
powder
TOLEREX - nutritional 4
UCD TRIO - nutritional 4
supplement pack
supplement powder
TWOCAL HN - nutritional 4
UCD 2 - nutritional supplement 4
supplement liquid
powder
TWOCAL HN 2.0 - nutritional 4
ULTRACAL - nutritional 4
supplement liquid
supplement liquid
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
ULTRACAL HN PLUS - 4 VIVONEX RTF - nutritional 4
ULTRAMINO SOY PROTEIN - 4 VIVONEX T.E.N. - nutritional 4
nutritional supplement supplement pack
powder WELLNESS ESSENTIALS - 4
UTYMAX - nutritional 4 nutritional supplement kit
supplement pack WELLNESS ESSENTIALS AI - 4
VHC 2.25 - nutritional 4 nutritional supplement kit
supplement liquid WELLNESS ESSENTIALS 4
VILACTIN AA PLUS - 4 BLOOD - nutritional
nutritional supplement liquid supplement kit
VITAJOULE - nutritional 4 WELLNESS ESSENTIALS 4
supplement powder FOR J - nutritional
VITAL AF 1.2 CAL - nutritional 4 supplement kit
VITAL AF 1.2 CAL 4 FOR M - nutritional
ADVANCED - nutritional supplement kit
VITAL HIGH PROTEIN - 4 FOR P - nutritional
nutritional supplement liquid supplement kit
4 WELLNESS ESSENTIALS 4
VITAL HN - nutritional
supplement pack FOR W - nutritional
supplement kit
VITAL HP 1.0 CAL - nutritional 4
WND 1 - nutritional supplement 4
supplement liquid
powder
VITAL JR - nutritional 4
WND 2 - nutritional supplement 4
supplement liquid
powder
VITAL PEPTIDE 1.5 CAL - 4
XLEU MAXAMAID - nutritional 4
supplement powder
VITAL 1.0 CAL - nutritional 4
XLEU MAXAMUM - nutritional 4
supplement liquid
supplement powder
VITAL 1.5 CAL - nutritional 4
XLYS-XTRP MAXAMAID - 4
supplement liquid
VITAPRO - nutritional 4
powder
supplement powder
XLYS-XTRP MAXAMUM - 4
VITAQUICK - nutritional 4
VIVONEX PEDIATRIC - 4 4
XMET MAXAMAID - nutritional
nutritional supplement pack supplement powder
VIVONEX PLUS - nutritional 4 4
XMET MAXAMUM - nutritional
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
XMTVI MAXAMAID - nutritional 4 ARANESP ALBUMIN 5
supplement powder FREE - darbepoetin alfa
XMTVI MAXAMUM - nutritional 4 soln prefilled syringe 40
supplement powder mcg/0.4ml
XPHE MAXAMAID - nutritional 4 ARANESP ALBUMIN 5

supplement powder FREE - darbepoetin alfa
soln prefilled syringe 60
XPHE-XTYR MAXAMAID - 4
mcg/0.3ml
powder ARANESP ALBUMIN FREE - 5
darbepoetin alfa soln
XTRACAL PLUS - nutritional 4
prefilled syringe 100
supplement liquid mcg/0.5ml
HEMATOLOGICAL AGENTS ARANESP ALBUMIN FREE - 5
HEMATOPOIETIC AGENTS darbepoetin alfa soln
ARANESP ALBUMIN FREE - 5 prefilled syringe 150
darbepoetin alfa soln inj 25 mcg/0.3ml
mcg/ml ARANESP ALBUMIN FREE - 5
ARANESP ALBUMIN FREE - 5 darbepoetin alfa soln
darbepoetin alfa soln inj 40 prefilled syringe 200
mcg/ml mcg/0.4ml
ARANESP ALBUMIN FREE - 5 ARANESP ALBUMIN FREE - 5

darbepoetin alfa soln inj 60 darbepoetin alfa soln
mcg/ml prefilled syringe 300
mcg/0.6ml
ARANESP ALBUMIN FREE - 5
darbepoetin alfa soln inj 100 ARANESP ALBUMIN FREE - 5
mcg/ml darbepoetin alfa soln
prefilled syringe 500 mcg/ml
darbepoetin alfa soln inj 200 carbonyl iron susp A
mcg/ml 15 mg/1.25ml (elemental
iron)
darbepoetin alfa soln inj 300 CERDELGA - eliglustat tartrate 5
mcg/ml cap 84 mg (base equivalent)
1
ARANESP ALBUMIN 5 cyanocobalamin inj
FREE - darbepoetin alfa 1000 mcg/ml
soln prefilled syringe 10 DROXIA - hydroxyurea cap 4
mcg/0.4ml 200 mg
ARANESP ALBUMIN 5 DROXIA - hydroxyurea cap 4
FREE - darbepoetin alfa 300 mg
soln prefilled syringe 25 DROXIA - hydroxyurea cap 4
mcg/0.42ml 400 mg
EPOGEN - epoetin alfa inj 5
2000 unit/ml
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
EPOGEN - epoetin alfa inj 5 LEUKINE - sargramostim 5
3000 unit/ml lyophilized for inj 250 mcg
EPOGEN - epoetin alfa inj 5 MIRCERA - methoxy peg- 4
4000 unit/ml epoetin beta soln prefilled
EPOGEN - epoetin alfa inj 5 syr 30 mcg/0.3ml
10000 unit/ml MIRCERA - methoxy peg- 4
EPOGEN - epoetin alfa inj 5 epoetin beta soln prefilled
20000 unit/ml syr 50 mcg/0.3ml
FER-IN-SOL - ferrous sulfate A MIRCERA - methoxy peg- 4

soln 75 mg/ml (15 mg/ml epoetin beta soln prefilled
elemental fe) syr 75 mcg/0.3ml
FERRETTS CHEWABLE A MIRCERA - methoxy peg- 4

IRON - carbonyl iron chew epoetin beta soln prefilled
tab 18 mg (elemental iron) syr 100 mcg/0.3ml
FERROUS SULFATE - ferrous A MIRCERA - methoxy peg- 4

sulfate liquid 220 mg/5ml (44 epoetin beta soln prefilled
mg/5ml elemental fe) syr 150 mcg/0.3ml
FERROUS SULFATE - ferrous A MIRCERA - methoxy peg- 4

sulfate syrup 300 mg/5ml epoetin beta soln prefilled
(60 mg/5ml elemental fe) syr 200 mcg/0.3ml
4
ferrous sulfate elixir A NASCOBAL - cyanocobalamin
220 mg/5ml (44 mg/5ml nasal spray 500 mcg/0.1ml
elemental fe) NEULASTA - pegfilgrastim soln 5
ferrous sulfate soln 75 mg/ A prefilled syringe 6 mg/0.6ml
ml (15 mg/ml elemental fe) NEULASTA ONPRO KIT - 5
folic acid cap 0.8 mg A pegfilgrastim soln prefilled
syringe kit 6 mg/0.6ml
folic acid tab 400 mcg A
NEUPOGEN - filgrastim inj 300 5
folic acid tab 800 mcg A mcg/ml
folic acid tab 1 mg 1 5
NEUPOGEN - filgrastim inj 480
GRANIX - tbo-filgrastim 5 mcg/1.6ml (300 mcg/ml)
soln prefilled syringe 300 NEUPOGEN - filgrastim 5
mcg/0.5ml soln prefilled syringe 300
GRANIX - tbo-filgrastim 5 mcg/0.5ml
soln prefilled syringe 480 NEUPOGEN - filgrastim 5
mcg/0.8ml soln prefilled syringe 480
ICAR PEDIATRIC - carbonyl A mcg/0.8ml (600 mcg/ml)
iron susp 15 mg/1.25ml PROCRIT - epoetin alfa inj 5
(elemental iron) 2000 unit/ml
IRON CHEWS PEDIATRIC - A PROCRIT - epoetin alfa inj 5
carbonyl iron chew tab 15 3000 unit/ml
mg (elemental iron)
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
PROCRIT - epoetin alfa inj 5 COUMADIN - warfarin sodium 4
4000 unit/ml tab 6 mg
10000 unit/ml tab 7.5 mg
20000 unit/ml tab 10 mg
PROCRIT - epoetin alfa inj 5 ELIQUIS - apixaban tab 2.5 mg 3
40000 unit/ml ELIQUIS - apixaban tab 5 mg 3
PROMACTA - eltrombopag 5 enoxaparin sodium inj 2
olamine tab 12.5 mg (base 30 mg/0.3ml (Lovenox)
equiv)
enoxaparin sodium inj 2
PROMACTA - eltrombopag 5 40 mg/0.4ml (Lovenox)
olamine tab 25 mg (base
equiv) enoxaparin sodium inj 2
60 mg/0.6ml (Lovenox)
PROMACTA - eltrombopag 5
olamine tab 50 mg (base enoxaparin sodium inj 2
equiv) 80 mg/0.8ml (Lovenox)
PROMACTA - eltrombopag 5 enoxaparin sodium inj 2
olamine tab 75 mg (base 100 mg/ml (Lovenox)
equiv) enoxaparin sodium inj 2
ZARXIO - filgrastim-sndz 5 120 mg/0.8ml (Lovenox)
soln prefilled syringe 300 enoxaparin sodium inj 2
mcg/0.5ml 150 mg/ml (Lovenox)
ZARXIO - filgrastim-sndz 5 enoxaparin sodium inj 2
soln prefilled syringe 480 300 mg/3ml (Lovenox)
mcg/0.8ml fondaparinux sodium 2
ZAVESCA - miglustat cap 100 5 subcutaneous inj
mg 2.5 mg/0.5ml (Arixtra)
ANTICOAGULANTS fondaparinux sodium 2
COUMADIN - warfarin sodium 4 subcutaneous inj
tab 1 mg 5 mg/0.4ml (Arixtra)
COUMADIN - warfarin sodium 4 fondaparinux sodium 2
tab 2 mg subcutaneous inj
7.5 mg/0.6ml (Arixtra)
COUMADIN - warfarin sodium 4
tab 2.5 mg fondaparinux sodium 2
subcutaneous inj
COUMADIN - warfarin sodium 4
10 mg/0.8ml (Arixtra)
tab 3 mg
4
FRAGMIN - dalteparin sodium 4
COUMADIN - warfarin sodium inj 10000 unit/ml
tab 4 mg
4
FRAGMIN - dalteparin sodium 4
COUMADIN - warfarin sodium inj 2500 unit/0.2ml
tab 5 mg
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
FRAGMIN - dalteparin sodium 4 warfarin sodium tab 2.5 mg 1
inj 5000 unit/0.2ml (Coumadin)
FRAGMIN - dalteparin sodium 4 warfarin sodium tab 3 mg 1
FRAGMIN - dalteparin sodium 4 warfarin sodium tab 7.5 mg 1
heparin sodium (porcine) inj 2 warfarin sodium tab 10 mg 1
1000 unit/ml (Coumadin)
heparin sodium (porcine) inj 2 XARELTO - rivaroxaban tab 10 3
5000 unit/ml mg
10000 unit/ml mg
20000 unit/ml mg
heparin sodium (porcine) pf 2 XARELTO STARTER PACK - 3
inj 5000 unit/0.5ml rivaroxaban tab starter
PRADAXA - dabigatran 4 therapy pack 15 mg & 20 mg
etexilate mesylate cap 75 HEMOSTATICS
mg (etexilate base eq) AMICAR - aminocaproic acid 4
PRADAXA - dabigatran 4 oral soln 0.25 gm/ml
etexilate mesylate cap 110 AMICAR - aminocaproic acid 4
mg (etexilate base eq) tab 500 mg
PRADAXA - dabigatran 4 AMICAR - aminocaproic acid 4
etexilate mesylate cap 150 tab 1000 mg
mg (etexilate base eq)
tranexamic acid tab 650 mg 2
SAVAYSA - edoxaban tosylate 4 (Lysteda)
HEMATOLOGICAL AGENTS - MISC.
SAVAYSA - edoxaban tosylate 4
tab 30 mg (base equivalent) ADVATE - antihemophilic factor 5
rahf-pfm for inj 250 unit
SAVAYSA - edoxaban tosylate 4
tab 60 mg (base equivalent) ADVATE - antihemophilic factor 5
warfarin sodium tab 1 mg 1
(Coumadin) ADVATE - antihemophilic factor 5
warfarin sodium tab 2 mg 1
(Coumadin)
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
ADVATE - antihemophilic factor 5 ALPHANATE/VON 5
rahf-pfm for inj 1500 unit WILLEBRAND -
ADVATE - antihemophilic factor 5 antihemophilic factor/vwf
rahf-pfm for inj 2000 unit (human) for inj 1000 unit
ADVATE - antihemophilic factor 5 ALPHANATE/VON 5

rahf-pfm for inj 3000 unit WILLEBRAND -
antihemophilic factor/vwf
ADVATE - antihemophilic factor 5 (human) for inj 1500 unit
ALPHANATE/VON 5
ADYNOVATE - antihemophilic 5 WILLEBRAND -
factor recomb pegylated for antihemophilic factor/vwf
inj 250 unit (human) for inj 2000 unit
ADYNOVATE - antihemophilic 5 ALPHANINE SD - coagulation 5
factor recomb pegylated for factor ix for inj 500 unit
inj 500 unit
ALPHANINE SD - coagulation 5
ADYNOVATE - antihemophilic 5 factor ix for inj 1000 unit
factor recomb pegylated for
inj 750 unit ALPHANINE SD - coagulation 5
factor ix for inj 1500 unit
ADYNOVATE - antihemophilic 5
factor recomb pegylated for ALPROLIX - coagulation factor 5
inj 1000 unit ix (recomb) (rfixfc) for inj 250
unit
inj 1500 unit ix (recomb) (rfixfc) for inj 500
unit
inj 2000 unit ix (recomb) (rfixfc) for inj
1000 unit
inj 3000 unit ix (recomb) (rfixfc) for inj
2000 unit
AGGRENOX - aspirin- 4
dipyridamole cap er 12hr ALPROLIX - coagulation factor 5
25-200 mg ix (recomb) (rfixfc) for inj
3000 unit
ALPHANATE/VON 5
WILLEBRAND - ALPROLIX - coagulation factor 5
antihemophilic factor/vwf ix (recomb) (rfixfc) for inj
(human) for inj 250 unit 4000 unit
2
ALPHANATE/VON 5 anagrelide hcl cap 0.5 mg
WILLEBRAND - (Agrylin)
antihemophilic factor/vwf anagrelide hcl cap 1 mg 2
(human) for inj 500 unit aspirin-dipyridamole cap er 2
12hr 25-200 mg (Aggrenox)
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
BEBULIN - factor ix complex 5 dipyridamole tab 25 mg 1
for inj 200-1200 unit (Persantine)
BENEFIX - coagulation factor 5 dipyridamole tab 50 mg 2
ix (recombinant) for inj kit (Persantine)
250 unit dipyridamole tab 75 mg 2
BENEFIX - coagulation factor 5 (Persantine)
ix (recombinant) for inj kit EFFIENT - prasugrel hcl tab 5 4
500 unit mg (base equiv)
BENEFIX - coagulation factor 5 EFFIENT - prasugrel hcl tab 10 4
ix (recombinant) for inj kit mg (base equiv)
1000 unit
ELOCTATE - antihemophilic 5
BENEFIX - coagulation factor 5 factor (recomb) rfviiifc for inj
ix (recombinant) for inj kit 250 unit
2000 unit
BENEFIX - coagulation factor 5 factor (recomb) rfviiifc for inj
ix (recombinant) for inj kit 500 unit
3000 unit
BERINERT - c1 esterase 5 factor (recomb) rfviiifc for inj
inhibitor (human) for iv inj kit 750 unit
500 unit
3
BRILINTA - ticagrelor tab 60 factor (recomb) rfviiifc for inj
mg 1000 unit
3
BRILINTA - ticagrelor tab 90 ELOCTATE - antihemophilic 5
mg factor (recomb) rfviiifc for inj
cilostazol tab 50 mg (Pletal) 1 1500 unit
cilostazol tab 100 mg (Pletal) 1 ELOCTATE - antihemophilic 5
clopidogrel bisulfate tab 1 factor (recomb) rfviiifc for inj
75 mg (base equiv) (Plavix) 2000 unit
clopidogrel bisulfate tab 2 ELOCTATE - antihemophilic 5

300 mg (base equiv) factor (recomb) rfviiifc for inj
(Plavix) 3000 unit
COAGADEX - coagulation 5 ELOCTATE - antihemophilic 5

factor x (human) for inj 250 factor (recomb) rfviiifc for inj
unit 4000 unit
COAGADEX - coagulation 5 ELOCTATE - antihemophilic 5

factor x (human) for inj 500 factor (recomb) rfviiifc for inj
unit 5000 unit
CORIFACT - factor xiii 5 ELOCTATE - antihemophilic 5

concentrate (human) for inj factor (recomb) rfviiifc for inj
kit 1000-1600 unit 6000 unit
FEIBA - antiinhibitor coagulant 5
complex for inj
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
FIRAZYR - icatibant acetate inj 5 IDELVION - coagulation factor 5
30 mg/3ml (base equivalent) ix (recomb) (rix-fp) for inj 500
HELIXATE FS - antihemophilic 5 unit
factor (recombinant) for inj IDELVION - coagulation factor 5
kit 250 unit ix (recomb) (rix-fp) for inj
HELIXATE FS - antihemophilic 5 1000 unit
factor (recombinant) for inj IDELVION - coagulation factor 5
kit 500 unit ix (recomb) (rix-fp) for inj
HELIXATE FS - antihemophilic 5 2000 unit
factor (recombinant) for inj IXINITY - coagulation factor ix 5
kit 1000 unit (recombinant) for inj 250 unit
HELIXATE FS - antihemophilic 5 IXINITY - coagulation factor ix 5
factor (recombinant) for inj (recombinant) for inj 500 unit
kit 2000 unit IXINITY - coagulation factor ix 5
HELIXATE FS - antihemophilic 5 (recombinant) for inj 1000
factor (recombinant) for inj unit
kit 3000 unit IXINITY - coagulation factor ix 5
HEMOFIL M - antihemophilic 5 (recombinant) for inj 1500
factor (human) for inj 250 unit
unit IXINITY - coagulation factor ix 5
unit IXINITY - coagulation factor ix 5
unit KCENTRA - prothrombin 4
HEMOFIL M - antihemophilic 5 complex conc human for inj
factor (human) for inj 1700 kit 500 unit
unit KCENTRA - prothrombin 4
HUMATE-P - antihemophilic 5 complex conc human for inj
factor/vwf (human) for inj kit 1000 unit
250-600 unit KOATE - antihemophilic factor 5
HUMATE-P - antihemophilic 5 (human) for inj 250 unit
factor/vwf (human) for inj KOATE - antihemophilic factor 5
500-1200 unit (human) for inj 500 unit
HUMATE-P - antihemophilic 5 KOATE - antihemophilic factor 5
factor/vwf (human) for inj (human) for inj 1000 unit
1000-2400 unit
KOATE-DVI - antihemophilic 5
IDELVION - coagulation factor 5 factor (human) for inj 250
ix (recomb) (rix-fp) for inj 250 unit
unit
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
KOATE-DVI - antihemophilic 5 KOGENATE FS BIO-SET - 5
factor (human) for inj 500 antihemophilic factor
unit (recombinant) for inj kit 3000
KOATE-DVI - antihemophilic 5 unit
factor (human) for inj 1000 KOVALTRY - antihemophilic 5
unit factor (recombinant) for inj
KOGENATE FS - 5 250 unit
antihemophilic factor KOVALTRY - antihemophilic 5
(recombinant) for inj kit 250 factor (recombinant) for inj
unit 500 unit
KOGENATE FS - 5 KOVALTRY - antihemophilic 5
antihemophilic factor factor (recombinant) for inj
(recombinant) for inj kit 500 1000 unit
unit KOVALTRY - antihemophilic 5
KOGENATE FS - 5 factor (recombinant) for inj
antihemophilic factor 2000 unit
(recombinant) for inj kit 1000 KOVALTRY - antihemophilic 5
KOGENATE FS - 5 3000 unit
antihemophilic factor MONOCLATE-P - 5
(recombinant) for inj kit 2000 antihemophilic factor
unit (human) for inj kit 1000 unit
KOGENATE FS - 5 MONOCLATE-P - 5
antihemophilic factor antihemophilic factor
(recombinant) for inj kit 3000 (human) for inj kit 1500 unit
unit
MONONINE - coagulation 5
KOGENATE FS BIO-SET - 5 factor ix for inj 1000 unit
antihemophilic factor
(recombinant) for inj kit 250 NOVOEIGHT - antihemophilic 5
250 unit
KOGENATE FS BIO-SET - 5
antihemophilic factor NOVOEIGHT - antihemophilic 5
(recombinant) for inj kit 500 factor (recombinant) for inj
unit 500 unit
KOGENATE FS BIO-SET - 5 NOVOEIGHT - antihemophilic 5
antihemophilic factor factor (recombinant) for inj
(recombinant) for inj kit 1000 1000 unit
unit NOVOEIGHT - antihemophilic 5
KOGENATE FS BIO-SET - 5 factor (recombinant) for inj
antihemophilic factor 1500 unit
(recombinant) for inj kit 2000 NOVOEIGHT - antihemophilic 5
2000 unit
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
NOVOEIGHT - antihemophilic 5 PROFILNINE - factor ix 5
factor (recombinant) for inj complex for inj 1000 unit
3000 unit PROFILNINE - factor ix 5
NOVOSEVEN RT - coagulation 5 complex for inj 1500 unit
factor viia (recomb) for inj 1 PROFILNINE SD - factor ix 5
mg (1000 mcg) complex for inj 500 unit
NOVOSEVEN RT - coagulation 5 PROFILNINE SD - factor ix 5
factor viia (recomb) for inj 2 complex for inj 1000 unit
mg (2000 mcg)
PROFILNINE SD - factor ix 5
NOVOSEVEN RT - coagulation 5 complex for inj 1500 unit
factor viia (recomb) for inj 5
mg (5000 mcg) RECOMBINATE - 5
NOVOSEVEN RT - coagulation 5 (recombinant) for inj 220-400
factor viia (recomb) for inj 8 unit
mg (8000 mcg)
RECOMBINATE - 5
NUWIQ - antihemophilic factor 5 antihemophilic factor
(bdd-rfviii) for inj kit 250 unit (recombinant) for inj 401-800
NUWIQ - antihemophilic factor 5 unit
(bdd-rfviii) for inj kit 500 unit RECOMBINATE - 5
(bdd-rfviii) for inj kit 1000 unit (recombinant) for inj
NUWIQ - antihemophilic factor 5 801-1240 unit
(bdd-rfviii) for inj kit 2000 unit RECOMBINATE - 5
(bdd-rfviii) for inj 250 unit (recombinant) for inj
1241-1800 unit
NUWIQ - antihemophilic factor 5
(bdd-rfviii) for inj 500 unit RECOMBINATE - 5
NUWIQ - antihemophilic factor 5 (recombinant) for inj
(bdd-rfviii) for inj 1000 unit 1801-2400 unit
NUWIQ - antihemophilic factor 5 RIASTAP - fibrinogen conc 4
(bdd-rfviii) for inj 2000 unit (human) inj approximately 1
OBIZUR - antihemophilic factor 5 gm (900-1300 mg)
(recomb porc) rpfviii for inj RIXUBIS - coagulation factor ix 5
500 unit (recombinant) for inj 250 unit
pentoxifylline tab er 400 mg 1 5
RIXUBIS - coagulation factor ix
prasugrel hcl tab 5 mg (base 2 (recombinant) for inj 500 unit
equiv) (Effient) RIXUBIS - coagulation factor 5
prasugrel hcl tab 10 mg 2 ix (recombinant) for inj 1000
(base equiv) (Effient) unit
PROFILNINE - factor ix 5
complex for inj 500 unit
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
RIXUBIS - coagulation factor 5 XYNTHA SOLOFUSE - 5
ix (recombinant) for inj 2000 antihemophilic factor
unit recombinant paf for inj kit
RIXUBIS - coagulation factor 5 2000 unit
ix (recombinant) for inj 3000 XYNTHA SOLOFUSE - 5
unit antihemophilic factor
RUCONEST - c1 esterase 5 recombinant paf for inj kit
inhibitor (recombinant) for iv 3000 unit
inj 2100 unit ZONTIVITY - vorapaxar 4
TRETTEN - coagulation 5 sulfate tab 2.08 mg (base
factor xiii a-subunit for inj equivalent)
2000-3125 unit TOPICAL PRODUCTS
WILATE - antihemophilic factor/ 5 OPHTHALMIC AGENTS
vwf (human) for inj 500-500 ACUVAIL - ketorolac 4
unit kit tromethamine ophth soln
WILATE - antihemophilic 5 0.45%
factor/vwf (human) for inj AKTEN - lidocaine hcl ophth 4
1000-1000 unit kit gel 3.5%
XYNTHA - antihemophilic 5 ALOCRIL - nedocromil sodium 4
factor recombinant paf for inj ophth soln 2%
kit 250 unit
ALOMIDE - lodoxamide 4
XYNTHA - antihemophilic 5 tromethamine ophth soln
factor recombinant paf for inj 0.1%
kit 500 unit
ALPHAGAN P - brimonidine 4
XYNTHA - antihemophilic 5 tartrate ophth soln 0.1%
factor recombinant paf for inj
ALREX - loteprednol etabonate 4
kit 1000 unit
ophth susp 0.2%
XYNTHA - antihemophilic 5 2
factor recombinant paf for inj apraclonidine hcl ophth soln
kit 2000 unit 0.5% (base equivalent)
(Iopidine)
XYNTHA SOLOFUSE - 5 1
antihemophilic factor ATROPINE SULFATE -
recombinant paf for inj kit atropine sulfate ophth soln
250 unit 1%
5 AZASITE - azithromycin ophth 4
XYNTHA SOLOFUSE -
antihemophilic factor soln 1%
recombinant paf for inj kit azelastine hcl ophth soln 2
500 unit 0.05%
XYNTHA SOLOFUSE - 5 AZOPT - brinzolamide ophth 4
antihemophilic factor susp 1%
recombinant paf for inj kit BACITRACIN - bacitracin ophth 3
1000 unit oint 500 unit/gm
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
bacitracin-polymyxin b 1 CILOXAN - ciprofloxacin hcl 4
ophth oint ophth oint 0.3%
bacitracin-polymyxin- 2 ciprofloxacin hcl ophth soln 1
neomycin-hc ophth oint 0.3% (Ciloxan)
1% COMBIGAN - brimonidine 4
BEPREVE - bepotastine 4 tartrate-timolol maleate
besilate ophth soln 1.5% ophth soln 0.2-0.5%
BESIVANCE - besifloxacin 4 COSOPT PF - dorzolamide hcl- 4
hcl ophth susp 0.6% (base timolol maleate ophth sol
equiv) 22.3-6.8 mg/ml pf
BETADINE OPHTHALMIC 4 cromolyn sodium ophth soln 1
PREP - povidone-iodine 4%
ophth soln 5% CYCLOGYL - cyclopentolate 4
betaxolol hcl ophth soln 2 hcl ophth soln 0.5%
0.5% CYCLOMYDRIL - 4
BETIMOL - timolol ophth soln 4 cyclopentolate w/
0.25% phenylephrine ophth soln
BETIMOL - timolol ophth soln 4 0.2-1%
0.5% cyclopentolate hcl ophth 2
BETOPTIC-S - betaxolol hcl 4 soln 0.5% (Cyclogyl)
ophth susp 0.25% cyclopentolate hcl ophth 1
BIMATOPROST - bimatoprost 4 soln 1% (Cyclogyl)
ophth soln 0.03% cyclopentolate hcl ophth 2
BLEPHAMIDE - sulfacetamide 4 soln 2% (Cyclogyl)
sodium-prednisolone ophth CYSTARAN - cysteamine hcl 5
susp 10-0.2% ophth soln 0.44% (base
BLEPHAMIDE S.O.P. - 4 equivalent)
sulfacetamide sodium- DEXAMETHASONE SODIUM 4
prednisolone ophth oint PHOS - dexamethasone
10-0.2% sodium phosphate ophth
brimonidine tartrate ophth 2 soln 0.1%
soln 0.15% (Alphagan p) diclofenac sodium ophth 1
brimonidine tartrate ophth 1 soln 0.1%
soln 0.2% dorzolamide hcl ophth soln 1
BROMFENAC - bromfenac 4 2% (Trusopt)
sodium ophth soln 0.09% dorzolamide hcl-timolol 1
(base equivalent) maleate ophth soln
bromfenac sodium ophth 2 22.3-6.8 mg/ml (Cosopt)
soln 0.09% (base equiv) DUREZOL - difluprednate 4
(once-daily) ophth emulsion 0.05%
carteolol hcl ophth soln 1% 1
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
EMADINE - emedastine 4 levobunolol hcl ophth soln 1
difumarate ophth soln 0.05% 0.5% (Betagan)
(base equiv) levofloxacin ophth soln 0.5% 2
epinastine hcl ophth soln 2 4
LOTEMAX - loteprednol
0.05% (Elestat) etabonate ophth gel 0.5%
erythromycin ophth oint 1 4
5 mg/gm etabonate ophth oint 0.5%
FLAREX - fluorometholone 4 4
acetate ophth susp 0.1% etabonate ophth susp 0.5%
2
fluorometholone ophth susp LUMIGAN - bimatoprost ophth 4
0.1% (Fml liquifilm) soln 0.01%
flurbiprofen sodium ophth 1 4
MAXIDEX - dexamethasone
soln 0.03% (Ocufen) ophth susp 0.1%
FML - fluorometholone ophth 4 4
METIPRANOLOL -
oint 0.1% metipranolol ophth soln
FML FORTE - fluorometholone 4 0.3%
ophth susp 0.25% MITOSOL - mitomycin for 4
gatifloxacin ophth soln 0.5% 2 ophth soln kit 0.2 mg
(Zymaxid) MOXEZA - moxifloxacin hcl 4
GENTAK - gentamicin sulfate 1 ophth soln 0.5% (base eq) (2
ophth oint 0.3% times daily)
gentamicin sulfate ophth 1 moxifloxacin hcl ophth 2
soln 0.3% (Garamycin) soln 0.5% (base equiv)
ILEVRO - nepafenac ophth 4 (Vigamox)
susp 0.3% NATACYN - natamycin ophth 3
IOPIDINE - apraclonidine 4 susp 5%
hcl ophth soln 1% (base neomycin-bacitrac 2
equivalent) zn-polymyx
ISTALOL - timolol maleate 4 5(3.5)mg-400unt-10000unt
ophth soln 0.5% (once-daily) op oin
2 neomycin-polymy- 2
ketorolac tromethamine
ophth soln 0.4% (Acular ls) gramicid op sol
1.75-10000-0.025mg-unt-
ketorolac tromethamine 1
mg/ml (Neosporin)
ophth soln 0.5% (Acular)
neomycin-polymyxin- 1
LACRISERT - artificial tear 4
dexamethasone ophth oint
ophth insert 0.1% (Maxitrol)
LASTACAFT - alcaftadine 4 1
neomycin-polymyxin-
ophth soln 0.25% dexamethasone ophth
latanoprost ophth soln 1 susp 0.1% (Maxitrol)
0.005% (Xalatan)
2017
Prior Authorization
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Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
NEOMYCIN/POLYMYXIN/ 4 PREDNISOLONE SODIUM 4
HYDROC - neomycin- PHOSP - prednisolone
polymyxin-hc ophth susp sodium phosphate ophth
NEVANAC - nepafenac ophth 4 soln 1%
susp 0.1% PROLENSA - bromfenac 4
ofloxacin ophth soln 0.3% 2 sodium ophth soln 0.07%
(Ocuflox) (base equivalent)
2 proparacaine hcl ophth soln 2
olopatadine hcl ophth soln
0.1% (base equivalent) 0.5% (Alcaine)
(Patanol) RESCULA - unoprostone 4
olopatadine hcl ophth soln 2 isopropyl ophth soln 0.15%
0.2% (base equivalent) RESTASIS - cyclosporine 4
(Pataday) (ophth) emulsion 0.05%
PATADAY - olopatadine hcl 4 RESTASIS MULTIDOSE - 4
ophth soln 0.2% (base cyclosporine (ophth)
equivalent) emulsion 0.05%
phenylephrine hcl ophth 2 SIMBRINZA - brinzolamide- 3
soln 2.5% brimonidine tartrate ophth
phenylephrine hcl ophth 2 susp 1-0.2%
soln 10% SULFACETAMIDE SODIUM - 4
pilocarpine hcl ophth soln 2 sulfacetamide sodium ophth
1% (Isopto carpine) oint 10%
2 sulfacetamide sodium ophth 2
pilocarpine hcl ophth soln
2% (Isopto carpine) soln 10% (Bleph-10)
2 sulfacetamide sodium- 1
pilocarpine hcl ophth soln
4% (Isopto carpine) prednisolone ophth soln
10-0.23(0.25)%
polymyxin b-trimethoprim 1
tetracaine hcl ophth soln 2
ophth soln 10000 unit/
ml-0.1% (Polytrim) 0.5%
4 timolol maleate ophth gel 2
PRED MILD - prednisolone
acetate ophth susp 0.12% forming soln 0.25%
(Timoptic-xe)
PRED-G - gentamicin- 4
timolol maleate ophth gel 2
prednisolone ace ophth susp
0.3-1% forming soln 0.5%
(Timoptic-xe)
PRED-G S.O.P. - gentamicin- 4
timolol maleate ophth soln 1
prednisolone ace ophth oint
0.3-0.6% 0.25% (Timoptic)
2 timolol maleate ophth soln 1
prednisolone acetate ophth
susp 1% (Pred forte) 0.5% (Timoptic)
TIMOPTIC OCUDOSE - timolol 4
maleate preservative free
ophth soln 0.25%
2017
Prior Authorization
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Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
TIMOPTIC OCUDOSE - timolol 4 CIPRO HC - ciprofloxacin- 4
maleate preservative free hydrocortisone otic susp
ophth soln 0.5% 0.2-1%
TOBRADEX - tobramycin- 4 CIPRODEX - ciprofloxacin- 4
dexamethasone ophth oint dexamethasone otic susp
0.3-0.1% 0.3-0.1%
TOBRADEX ST - tobramycin- 4 CIPROFLOXACIN - 4
dexamethasone ophth susp ciprofloxacin hcl otic soln
0.3-0.05% 0.2% (base equivalent)
tobramycin ophth soln 0.3% 1 COLY-MYCIN S - neomycin- 4
(Tobrex) colistin-hc-thonzonium otic
tobramycin-dexamethasone 2 susp 3.3-3-10-0.5 mg/ml
ophth susp 0.3-0.1% fluocinolone acetonide (otic) 2
(Tobradex) oil 0.01% (Dermotic)
TOBREX - tobramycin ophth 4 hydrocortisone w/ acetic 2
oint 0.3% acid otic soln 1-2%
TRAVATAN Z - travoprost 4 neomycin-polymyxin-hc otic 2
ophth soln 0.004% soln 1% (Cortisporin)
(benzalkonium free) (bak neomycin-polymyxin-hc otic 2
free) susp 3.5 mg/ml-10000 unit/
trifluridine ophth soln 1% 2 ml-1%
(Viroptic) ofloxacin otic soln 0.3% 2
VIGAMOX - moxifloxacin hcl 4
MOUTH/THROAT/DENTAL AGENTS
ophth soln 0.5% (base
equiv) ACT TOTAL CARE DRY A
MOUTH - sodium fluoride
XIIDRA - lifitegrast ophth soln 4 rinse 0.02%
5%
cevimeline hcl cap 30 mg 2
ZIOPTAN - tafluprost ophth 4 (Evoxac)
soln 0.0015%
chlorhexidine gluconate 1
ZIRGAN - ganciclovir ophth gel 4
soln 0.12% (Peridex)
0.15%
clotrimazole troche 10 mg 2
ZYLET - loteprednol etabonate- 4
tobramycin ophth susp COLGATE DRY MOUTH A
0.5-0.3% RELIEF - sodium fluoride
mouthwash 2.1 mg/10ml
OTIC AGENTS
2
CREST COMPLETE - sodium A
acetic acid otic soln 2% fluoride paste 0.243%
CETRAXAL - ciprofloxacin 4 4
DEBACTEROL - sulfuric acid-
hcl otic soln 0.2% (base sulfonated phenolics soln
equivalent) 30-50%
2017
Prior Authorization
Prior Authorization
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Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
EQL DENTAL TRAVEL PACK - 4 NAFRINSE DAILY/ 4
sodium fluoride paste ACIDULATED - sodium
0.243% & mouthwash kit fluoride-phosphoric acid for
EQL TRAVEL TOOTHBRUSH/ A soln 1 mg/5ml (f equiv)
TOO - sodium NAFRINSE DAILY/NEUTRAL - 4
monofluorophosphate paste sodium fluoride for soln rinse
0.15% 0.05%
GEL-KAM - stannous fluoride A NAFRINSE WEEKLY - sodium 4
gel 0.4% fluoride for soln rinse 0.2%
GEL-KAM ORAL CARE 4 nystatin susp 100000 unit/ml 2
RINSE - stannous fluoride OMNI GEL - stannous fluoride A
conc 0.63% gel 0.4%
LIDOCAINE HCL - lidocaine 4 4
ORAVIG - miconazole buccal
hcl laryngotracheal soln 4% tab 50 mg (mouth-throat)
1
lidocaine hcl viscous soln PARODONTAX - stannous A
2% fluoride paste 0.454%
LISTERINE ESSENTIAL A PHOS FLUR - sodium fluoride A
CARE - sod rinse 0.044%
monofluorophosph-eucal-
men-methyl sal-thymol gel PHOS-FLUR ORTHO A
0.76% DEFENSE - sodium fluoride
rinse 0.044%
LISTERINE NATURALS WITH 4 2
F - sodium fluoride rinse pilocarpine hcl tab 5 mg
0.02% (Salagen)
A pilocarpine hcl tab 7.5 mg 2
LISTERINE RESTORING -
sodium fluoride rinse (Salagen)
0.0221% (0.01% f) PREVIDENT FLUORIDE - 4
LISTERINE SMART RINSE - A sodium fluoride gel 1.1%
sodium fluoride rinse (0.5% f)
0.0221% (0.01% f) PREVIDENT 5000 BOOSTER - 4
LISTERINE TOTAL CARE - A sodium fluoride paste 1.1%
sodium fluoride rinse PREVIDENT 5000 BOOSTER 4
0.0221% (0.01% f) PL - sodium fluoride paste
LISTERINE TOTAL CARE A 1.1%
PLUS - sodium fluoride rinse PREVIDENT 5000 DRY 4
0.0221% (0.01% f) MOUTH - sodium fluoride gel
LISTERINE TOTAL CARE A 1.1% (0.5% f)
ZERO - sodium fluoride rinse PREVIDENT 5000 ENAMEL 4
0.02% PRO - sodium fluoride-
LISTERINE WHITENING/ A potassium nitrate paste
RESTO - sodium fluoride 1.1-5%
rinse 0.0221% (0.01% f)
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
PREVIDENT 5000 PLUS - 4 CORTIFOAM - hydrocortisone 3
sodium fluoride cream 1.1% acetate rectal foam 10% (90
PREVIDENT 5000 4 mg/dose)
SENSITIVE - sodium hydrocortisone acetate w/ 2
fluoride-potassium nitrate pramoxine rectal cream
paste 1.1-5% 1-1% (Analpram-hc)
REMBRANDT DEEPLY A hydrocortisone enema 2
WHITE+PE - sodium 100 mg/60ml (Cortenema)
monofluorophosphate paste hydrocortisone rectal cream 2
0.884% 1% (Proctocort)
SENSODYNE REPAIR & A hydrocortisone rectal cream 2
PROTEC - stannous fluoride 2.5% (Anusol-hc)
paste 0.454%
PROCTOFOAM HC - 4
sodium fluoride cream 1.1% 1 hydrocortisone acetate w/
(Prevident 5000 plus) pramoxine rectal foam 1-1%
sodium fluoride gel 1.1% 1 RECTIV - nitroglycerin oint 4
(0.5% f) (Prevident fluoride) 0.4%
sodium fluoride paste 1.1% 1 UCERIS - budesonide rectal 4
(Prevident 5000 boost) foam 2 mg/act
sodium fluoride rinse A DERMATOLOGICALS
0.0221% (0.01% f)
acitretin cap 10 mg 2
sodium fluoride rinse 0.05% A (Soriatane)
Sodium fluoride rinse 0.2% 1 acitretin cap 17.5 mg 2
(Prevident) (Soriatane)
sodium fluoride-potassium 1 acitretin cap 25 mg 2
nitrate paste 1.1-5% (Soriatane)
(Prevident 5000 sensi)
acyclovir oint 5% (Zovirax) 2
stannous fluoride conc A 2
0.63% (Gel-kam oral care ri) adapalene cream 0.1%
(Differin)
stannous fluoride gel 0.4% A 2
adapalene gel 0.1% (Differin)
STANNOUS FLUORIDE A 2
RINSE - stannous fluoride liq adapalene gel 0.3% (Differin)
0.1% alclometasone dipropionate 2
THERA-FLUR-N - sodium 4 cream 0.05% (Aclovate)
fluoride gel 1.1% (0.5% f) alclometasone dipropionate 2
triamcinolone acetonide 2 oint 0.05%
dental paste 0.1% ALTABAX - retapamulin oint 4
ANORECTAL AGENTS 1%
4 AMCINONIDE - amcinonide 4
ANALPRAM-HC -
hydrocortisone acetate w/ cream 0.1%
pramoxine rectal lotn 2.5-1%
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
AMCINONIDE - amcinonide 4 calcipotriene- 2
lotion 0.1% betamethasone
AMCINONIDE - amcinonide 4 dipropionate oint
oint 0.1% 0.005-0.064% (Taclonex)
ASTERO - lidocaine hcl gel 4% 4 CARAC - fluorouracil cream 4

0.5%
AUGMENTED 2
CENTANY - mupirocin oint 2% 4
BETAMETHASONE D -
betamethasone dipropionate ciclopirox gel 0.77% 2
augmented gel 0.05% ciclopirox olamine cream 2
benzoyl peroxide- 2 0.77% (base equiv)
erythromycin gel 5-3% ciclopirox olamine susp 2
(Benzamycin) 0.77% (base equiv)
betamethasone dipropionate 2 2
ciclopirox shampoo 1%
augmented cream 0.05% (Loprox shampoo)
(Diprolene af)
2
ciclopirox solution 8% 2
betamethasone dipropionate (Penlac Nail Lacquer)
augmented lotion 0.05%
clindamycin phosph-benzoyl 2
(Diprolene)
peroxide (refrig) gel 1.2
betamethasone dipropionate 2
(1)-5% (Duac)
augmented oint 0.05%
clindamycin phosphate 2
(Diprolene)
foam 1% (Evoclin)
clindamycin phosphate gel 2
cream 0.05%
1% (Cleocin-t)
lotion 0.05%
lotion 1% (Cleocin-t)
clindamycin phosphate soln 2
oint 0.05%
1% (Cleocin-t)
betamethasone valerate 2
aerosol foam 0.12% (Luxiq)
swab 1% (Cleocin-t)
clindamycin phosphate- 2
cream 0.1%
benzoyl peroxide gel 1-5%
(Benzaclin)
lotion 0.1%
clindamycin phosphate- 2
betamethasone valerate oint 2
tretinoin gel 1.2-0.025%
0.1% (Ziana)
calcipotriene cream 0.005% 2 2
clobetasol propionate cream
(Dovonex) 0.05% (Temovate)
calcipotriene oint 0.005% 2 2
clobetasol propionate
calcipotriene soln 0.005% 2 emollient base cream
(50 mcg/ml) 0.05% (Temovate e)
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
clobetasol propionate gel 2 desonide cream 0.05% 2
0.05% (Temovate) (Desowen)
clobetasol propionate lotion 2 desonide lotion 0.05% 2
0.05% (Clobex) (Desowen)
clobetasol propionate oint 2 desonide oint 0.05% 2
0.05% (Temovate) (Desowen)
clobetasol propionate 2 desoximetasone cream 2
shampoo 0.05% (Clobex) 0.25% (Topicort)
clobetasol propionate soln 2 desoximetasone gel 0.05% 2
0.05% (Temovate) (Topicort)
CLOCORTOLONE PIVALATE - 4 desoximetasone oint 0.25% 2
clocortolone pivalate cream (Topicort)
0.1% diclofenac sodium (actinic 2
CLOCORTOLONE PIVALATE 4 keratoses) gel 3%
PUM - clocortolone pivalate (Solaraze)
cream 0.1% diclofenac sodium gel 1% 2
clotrimazole w/ 2 (Voltaren)
betamethasone cream diclofenac sodium soln 1.5% 2
1-0.05% (Lotrisone) (Pennsaid)
clotrimazole w/ 2 4
DIFLORASONE DIACETATE -
betamethasone lotion diflorasone diacetate oint
1-0.05% 0.05%
CONDYLOX - podofilox gel 4 4
DOXEPIN
0.5% HYDROCHLORIDE -
CORDRAN - flurandrenolide 4 doxepin hcl cream 5%
tape 4 mcg/sqcm econazole nitrate cream 1% 2
CORTISPORIN - bacitracin- 4 4
ECOZA - econazole nitrate
polymyxin-neomycin hc oint foam 1%
1%
4
ELIDEL - pimecrolimus cream 4
CORTISPORIN - neomycin- 1%
polymyxin-hc crm 3.5 mg/
ENSTILAR - calcipotriene- 3
gm-10000 unt/gm-0.5%
betamethasone dipropionate
COSENTYX - secukinumab 5 foam 0.005-0.064%
ERTACZO - sertaconazole 4
syringe 150 mg/ml
nitrate cream 2%
COSENTYX SENSOREADY 5 2
PEN - secukinumab erythromycin gel 2% (Erygel)
subcutaneous soln auto- erythromycin pads 2% 2
injector 150 mg/ml erythromycin soln 2% 2
DENAVIR - penciclovir cream 4 4
EURAX - crotamiton cream
1% 10%
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
EURAX - crotamiton lotion 10% 4 flurandrenolide lotion 0.05% 2
EXELDERM - sulconazole 4 (Cordran)
nitrate cream 1% fluticasone propionate 2
EXELDERM - sulconazole 4 cream 0.05% (Cutivate)
nitrate solution 1% fluticasone propionate oint 2
FINACEA - azelaic acid foam 3 0.005%
15% GENTAMICIN SULFATE - 4
FINACEA - azelaic acid gel 3 gentamicin sulfate oint 0.1%
15% gentamicin sulfate cream 2
fluocinolone acetonide 2 0.1%
cream 0.01% halobetasol propionate 2
fluocinolone acetonide 2 cream 0.05% (Ultravate)
cream 0.025% (Synalar) halobetasol propionate oint 2
fluocinolone acetonide oil 2 0.05% (Ultravate)
0.01% (body oil) (Derma- HALOG - halcinonide oint 0.1% 4
smoothe/fs bod) hydrocortisone butyrate 2
fluocinolone acetonide oil 2 cream 0.1% (Locoid)
0.01% (scalp oil) (Derma- hydrocortisone butyrate oint 2
smoothe/fs sca) 0.1% (Locoid)
fluocinolone acetonide oint 2 2
hydrocortisone butyrate
0.025% (Synalar) soln 0.1% (Locoid)
fluocinolone acetonide soln 2 1
hydrocortisone cream 2.5%
0.01% (Synalar)
hydrocortisone lotion 2.5% 1
fluocinonide cream 0.05% 2
hydrocortisone oint 2.5% 1
fluocinonide emulsified base 2
hydrocortisone valerate 2
cream 0.05%
cream 0.2%
fluocinonide gel 0.05% 2
hydrocortisone valerate oint 2
fluocinonide oint 0.05% 2
0.2% (Westcort)
2
fluocinonide soln 0.05% imiquimod cream 5% 2
FLUOROPLEX - fluorouracil 4 (Aldara)
cream 1% isotretinoin cap 10 mg 2
FLUOROURACIL - fluorouracil 4 isotretinoin cap 20 mg 2
cream 0.5%
2
isotretinoin cap 30 mg 2
FLUOROURACIL - fluorouracil
soln 2% isotretinoin cap 40 mg 2
FLUOROURACIL - fluorouracil 2 JUBLIA - efinaconazole soln 4
soln 5% 10%
fluorouracil cream 5% 2 KERYDIN - tavaborole soln 5% 4
(Efudex) ketoconazole cream 2% 2
flurandrenolide cream 0.05% 2
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
ketoconazole shampoo 2% 1 mupirocin calcium cream 2
(Nizoral) 2% (Bactroban)
lactic acid (ammonium 2 mupirocin oint 2% 1
lactate) lotion 12% (Lac- (Bactroban)
hydrin) naftifine hcl cream 1% 2
LEVULAN KERASTICK - 4 2
naftifine hcl cream 2%
aminolevulinic acid hcl for (Naftin)
soln 20% (stick applicator)
NAFTIN - naftifine hcl cream 4
lidocaine hcl gel 2% 1 2%
lidocaine hcl soln 4% 1 NAFTIN - naftifine hcl gel 1% 4
(Xylocaine)
NAFTIN - naftifine hcl gel 2% 4
lidocaine patch 5% 2 4
(Lidoderm) NATROBA - spinosad susp
0.9%
lidocaine-prilocaine cream 2
NEO-SYNALAR - neomycin 4
kit 2.5-2.5%
sulfate-fluocinolone
lidocaine-prilocaine cream 2
acetonide cream 0.5-0.025%
2.5-2.5% (Emla)
nystatin cream 100000 unit/ 1
LINDANE - lindane shampoo 2
gm
1%
nystatin oint 100000 unit/gm 2
LUZU - luliconazole cream 1% 4
nystatin topical powder 2
malathion lotion 0.5% 2
100000 unit/gm
(Ovide)
nystatin-triamcinolone 2
MENTAX - butenafine hcl 4
cream 100000-0.1 unit/gm-
cream 1% %
methoxsalen rapid cap 2 2
nystatin-triamcinolone oint
10 mg (Oxsoralen ultra) 100000-0.1 unit/gm-%
metronidazole cream 0.75% 2 2
oxiconazole nitrate cream
(Metrocream) 1% (Oxistat)
metronidazole gel 0.75% 2 4
OXISTAT - oxiconazole nitrate
metronidazole gel 1% 2 cream 1%
(Metrogel) OXISTAT - oxiconazole nitrate 4
metronidazole lotion 0.75% 2 lotion 1%
(Metrolotion) PANRETIN - alitretinoin gel 4
mometasone furoate cream 1 0.1%
0.1% (Elocon) permethrin cream 5% 2
mometasone furoate oint 1 (Elimite)
0.1% (Elocon) PICATO - ingenol mebutate gel 4
mometasone furoate 1 0.015%
solution 0.1% (lotion) PICATO - ingenol mebutate gel 4
(Elocon) 0.05%
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
PLIAGLIS - lidocaine-tetracaine 4 tacrolimus oint 0.1% 2
cream 7-7% (Protopic)
podofilox soln 0.5% 2 TARGRETIN - bexarotene gel 5
(Condylox) 1%
prednicarbate cream 0.1% 2 tazarotene cream 0.1% 2
(Dermatop) (Tazorac)
prednicarbate oint 0.1% 2 TAZORAC - tazarotene cream 3
(Dermatop) 0.05%
PRUDOXIN - doxepin hcl 4 TAZORAC - tazarotene cream 3
cream 5% 0.1%
REGRANEX - becaplermin gel 4 TAZORAC - tazarotene gel 3
0.01% 0.05%
SANTYL - collagenase oint 250 4 TAZORAC - tazarotene gel 3
unit/gm 0.1%
selenium sulfide lotion 2.5% 1 TOLAK - fluorouracil cream 4% 4
silver sulfadiazine cream 1% 1 tretinoin cream 0.025% 2
(Silvadene) (Retin-a)
SKLICE - ivermectin lotion 4 tretinoin cream 0.05% (Retin- 2
0.5% a)
SOOLANTRA - ivermectin 3 tretinoin cream 0.1% (Retin- 2
cream 1% a)
SPINOSAD - spinosad susp 4 tretinoin gel 0.01% (Retin-a) 2
0.9% tretinoin gel 0.025% (Retin-a) 2
STELARA - ustekinumab inj 45 5 tretinoin gel 0.05% (Atralin) 2
mg/0.5ml
tretinoin microsphere gel 2
STELARA - ustekinumab soln 5 0.04% (Retin-a micro)
prefilled syringe 45 mg/0.5ml
tretinoin microsphere gel 2
STELARA - ustekinumab soln 5 0.1% (Retin-a micro pump)
prefilled syringe 90 mg/ml
triamcinolone acetonide 2
sulfacetamide sodium lotion 2
aerosol soln 0.147 mg/gm
10% (acne) (Klaron) (Kenalog)
SULFAMYLON - mafenide 4 1
triamcinolone acetonide
acetate cream 85 mg/gm cream 0.025%
SYNERA - lidocaine-tetracaine 4 1
topical patch 70-70 mg cream 0.1%
TACLONEX - calcipotriene- 4 1
betamethasone dipropionate cream 0.5%
susp 0.005-0.064%
triamcinolone acetonide 2
tacrolimus oint 0.03% 2 lotion 0.025%
(Protopic)
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
triamcinolone acetonide 2 EVZIO - naloxone hcl solution 4
lotion 0.1% auto-injector 2 mg/0.4ml
triamcinolone acetonide oint 1 EXJADE - deferasirox tab for 5
0.025% oral susp 125 mg
triamcinolone acetonide oint 1 EXJADE - deferasirox tab for 5
TRIDESILON - desonide cream 2 EXJADE - deferasirox tab for 5
ULESFIA - benzyl alcohol 4 FERRIPROX - deferiprone oral 5
lotion 5% soln 100 mg/ml
VALCHLOR - mechlorethamine 5 FERRIPROX - deferiprone tab 5
hcl gel 0.016% (base 500 mg
equivalent) JADENU - deferasirox tab 90 5
VEREGEN - sinecatechins oint 4 mg
15% JADENU - deferasirox tab 180 5
VOLTAREN - diclofenac 3 mg
sodium gel 1% JADENU - deferasirox tab 360 5
VUSION - miconazole-zinc 4 mg
oxide-white petrolatum oint NALOXONE HCL - naloxone 4
0.25-15-81.35% hcl soln prefilled syringe 2
XOLEGEL - ketoconazole gel 4 mg/2ml
2% naloxone hcl inj 0.4 mg/ml 2
ZONALON - doxepin hcl cream 4 naltrexone hcl tab 50 mg 2
5% (Revia)
ZYCLARA - imiquimod cream 4 NARCAN - naloxone hcl nasal 3
3.75% spray 4 mg/0.1ml
ZYCLARA PUMP - imiquimod 4 RADIOGARDASE - prussian 4
cream 2.5% blue insoluble cap 0.5 gm
ZYCLARA PUMP - imiquimod 4 DIAGNOSTIC PRODUCTS
cream 3.75%
BAYER BREEZE 2 TEST 2
MISCELLANEOUS PRODUCTS DISC - glucose blood test
ANTIDOTES disk
CETYLEV - acetylcysteine 4 BAYER CONTOUR BLOOD 2
effervescent tab 500 mg GLUCO - glucose blood test
CETYLEV - acetylcysteine 4 strip
effervescent tab 2.5 gm BAYER CONTOUR NEXT 2
CHEMET - succimer cap 100 3 BLOOD - glucose blood test
mg strip
EVZIO - naloxone hcl solution 4 MEDICAL DEVICES

auto-injector 0.4 mg/0.4ml
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
BREATHERITE - spacer/ 3 WIDE-SEAL SILICONE A
aerosol-holding chambers - DIAPHR - diaphragm wide
device seal 60 mm
BREATHERITE 3 WIDE-SEAL SILICONE A
COLLAPSIBLE - spacer/ DIAPHR - diaphragm wide
aerosol-holding chambers - seal 65 mm
device WIDE-SEAL SILICONE A
BREATHERITE RIGID 3 DIAPHR - diaphragm wide
SPACER - spacer/aerosol- seal 70 mm
holding chambers - device WIDE-SEAL SILICONE A
BREATHERITE W/LARGE 3 DIAPHR - diaphragm wide
MASK - spacer/aerosol- seal 75 mm
BREATHERITE W/MEDIUM 3 DIAPHR - diaphragm wide
BREATHERITE W/SMALL 3 DIAPHR - diaphragm wide
CAYA - diaphragm arc-spring A DIAPHR - diaphragm wide
FC FEMALE CONDOM - A seal 90 mm
condoms - female WIDE-SEAL SILICONE A
FC2 FEMALE CONDOM - A DIAPHR - diaphragm wide
condoms - female seal 95 mm
FEMCAP - cervical cap 22 mm A ASSORTED CLASSES
FEMCAP - cervical cap 26 mm A ASTAGRAF XL - tacrolimus 4

cap er 24hr 0.5 mg
FEMCAP - cervical cap 30 mm A
4
ASTAGRAF XL - tacrolimus 4
HURRISEAL - dental cap er 24hr 1 mg
desensitizing product -
solution ASTAGRAF XL - tacrolimus 4
cap er 24hr 5 mg
INSULIN PEN NEEDLES- 3 4
VARIOUS ATGAM - lymphocyte immune
globulin anti-thymocyte g inj
INSULIN SYRINGES- 3 50 mg/ml(eq)
VARIOUS
AZASAN - azathioprine tab 75 4
LANCETS-VARIOUS 3
mg
LANCING DEVICE-VARIOUS 4
AZASAN - azathioprine tab 100 4
OMNIFLEX DIAPHRAGM - A mg
diaphragms azathioprine tab 50 mg 2
SPACERS-VARIOUS 4 (Imuran)
2017
Prior Authorization
Prior Authorization
Dispensing Limits
Dispensing Limits
Step Therapy
Step Therapy
Drug Tier
Drug Tier
ACA
ACA
Drug Name Drug Name
CUPRIMINE - penicillamine 5 NEORAL - cyclosporine 4
cap 250 mg modified cap 100 mg
cyclosporine cap 25 mg 2 NEORAL - cyclosporine 4
(Sandimmune) modified oral soln 100 mg/ml
cyclosporine cap 100 mg 2 PROGRAF - tacrolimus cap 0.5 4
(Sandimmune) mg
CYCLOSPORINE MODIFIED - 3 PROGRAF - tacrolimus cap 1 4
cyclosporine modified cap mg
50 mg PROGRAF - tacrolimus cap 5 4
cyclosporine modified cap 2 mg
25 mg (Neoral) RAPAMUNE - sirolimus oral 3
cyclosporine modified 2 soln 1 mg/ml
cap 50 mg (Cyclosporine REVLIMID - lenalidomide caps 5
modifie) 2.5 mg
2
cyclosporine modified cap REVLIMID - lenalidomide cap 5 5
100 mg (Neoral) mg
2
cyclosporine modified oral REVLIMID - lenalidomide cap 5
soln 100 mg/ml (Neoral) 10 mg
DEPEN TITRATABS - 5 REVLIMID - lenalidomide cap 5
penicillamine tab 250 mg 15 mg
4
ENVARSUS XR - tacrolimus REVLIMID - lenalidomide cap 5
tab er 24hr 0.75 mg 20 mg
4
ENVARSUS XR - tacrolimus REVLIMID - lenalidomide cap 5
tab er 24hr 1 mg 25 mg
ENVARSUS XR - tacrolimus 4 4
SANDIMMUNE - cyclosporine
tab er 24hr 4 mg cap 25 mg
mycophenolate mofetil cap 2 4
250 mg (Cellcept) cap 100 mg
mycophenolate mofetil 2 4
for oral susp 200 mg/ml oral soln 100 mg/ml
(Cellcept)
sirolimus tab 0.5 mg 2
mycophenolate mofetil tab 2
(Rapamune)
500 mg (Cellcept)
sirolimus tab 1 mg 2
mycophenolate sodium tab 2
(Rapamune)
dr 180 mg (mycophenolic
sirolimus tab 2 mg 2
acid equiv) (Myfortic)
(Rapamune)
mycophenolate sodium tab 2
sodium polystyrene 2
dr 360 mg (mycophenolic
acid equiv) (Myfortic) sulfonate oral susp
15 gm/60ml (Sps)
NEORAL - cyclosporine 4
modified cap 25 mg
2017
Prior Authorization
Dispensing Limits
Step Therapy
Drug Tier
ACA
Drug Name
sulfonate powder
(Kayexalate)
sulfonate rectal susp
30 gm/120ml
SYPRINE - trientine hcl cap 5
250 mg
tacrolimus cap 0.5 mg 2
(Prograf)
tacrolimus cap 1 mg 2
(Prograf)
tacrolimus cap 5 mg 2
(Prograf)
THALOMID - thalidomide cap 5
50 mg
100 mg
150 mg
200 mg
VELTASSA - patiromer sorbitex 4
calcium for susp packet 8.4
gm (base eq)
gm (base eq)
gm (base eq)
ZORTRESS - everolimus tab 4
0.25 mg
0.5 mg
0.75 mg
2017
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab
INDEX er 24hr 30-1000 mg........................................................ 26
ACT TOTAL CARE DRY MOUTH -sodium fluoride rinse
A 0.02%.............................................................................138
ACUVAIL -ketorolac tromethamine ophth soln
abacavir sulfate-lamivudine tab 600-300 mg
0.45%.............................................................................134
(Epzicom)......................................................................... 6
acyclovir cap 200 mg (Zovirax)........................................ 6
abacavir sulfate-lamivudine-zidovudine tab
acyclovir oint 5% (Zovirax)........................................... 140
300-150-300 mg (Trizivir)................................................ 6
acyclovir susp 200 mg/5ml (Zovirax).............................. 6
abacavir sulfate tab 300 mg (base equiv) (Ziagen)........ 6
acyclovir tab 400 mg (Zovirax)........................................ 6
ABSTRAL -fentanyl citrate sl tab 100 mcg (base
acyclovir tab 800 mg (Zovirax)........................................ 6
equiv)............................................................................... 80
ADACEL -tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-
mcg/0.5ml........................................................................ 13
equiv)............................................................................... 80
adapalene cream 0.1% (Differin).................................. 140
adapalene gel 0.1% (Differin)....................................... 140
equiv)............................................................................... 80
adapalene gel 0.3% (Differin)....................................... 140
ADASUVE -loxapine aerosol powder breath activated 10
equiv)............................................................................... 80
mg.................................................................................... 68
ADCIRCA -tadalafil tab 20 mg (pah)................................. 50
equiv)............................................................................... 80
ADDERALL XR -amphetamine-dextroamphetamine cap
er 24hr 5 mg................................................................... 72
equiv)............................................................................... 80
acamprosate calcium tab delayed release 333 mg...... 76
er 24hr 10 mg................................................................. 72
acarbose tab 25 mg (Precose)....................................... 26
acarbose tab 50 mg (Precose)....................................... 26
er 24hr 15 mg................................................................. 72
acarbose tab 100 mg (Precose)..................................... 26
acebutolol hcl cap 200 mg (Sectral).............................. 38
er 24hr 20 mg................................................................. 73
acebutolol hcl cap 400 mg (Sectral).............................. 38
ACERFLEX -nutritional supplement powder................... 108
er 24hr 25 mg................................................................. 73
ACETAMINOPHEN/CAFFEINE/DI -acetaminophen-
caffeine-dihydrocodeine cap 320.5-30-16 mg................81
er 24hr 30 mg................................................................. 73
acetaminophen w/ codeine soln 120-12 mg/5ml.......... 80
ADD-INS COMPLETE -amino acids pack...................... 107
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
adefovir dipivoxil tab 10 mg (Hepsera)........................... 6
codeine).......................................................................... 80
ADEMPAS -riociguat tab 0.5 mg....................................... 50
ADEMPAS -riociguat tab 1 mg.......................................... 50
codeine #3).................................................................... 80
ADEMPAS -riociguat tab 2 mg.......................................... 50
codeine #4).................................................................... 81
acetazolamide cap er 12hr 500 mg (Diamox)............... 46
ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
acetazolamide tab 125 mg.............................................. 46
100-50 mcg/dose............................................................ 53
acetazolamide tab 250 mg.............................................. 46
acetic acid otic soln 2%................................................ 138
250-50 mcg/dose............................................................ 53
acetylcysteine inhal soln 10%........................................ 52
acetylcysteine inhal soln 20%........................................ 52
500-50 mcg/dose............................................................ 53
acitretin cap 10 mg (Soriatane).................................... 140
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 45-21
acitretin cap 17.5 mg (Soriatane)................................. 140
mcg/act............................................................................ 53
acitretin cap 25 mg (Soriatane).................................... 140
ACTEMRA -tocilizumab subcutaneous soln prefilled
mcg/act............................................................................ 53
syringe 162 mg/0.9ml..................................................... 87
ACTIMMUNE -interferon gamma-1b inj 100 mcg/0.5ml
mcg/act............................................................................ 53
(2000000 unit/0.5ml)....................................................... 14
ADVATE -antihemophilic factor rahf-pfm for inj 250
ACTIVE OB -prenatal w/o a w/fe cbn-fa-dha cap 20-1-320
unit................................................................................. 128
mg.................................................................................... 99
ADVATE -antihemophilic factor rahf-pfm for inj 500
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab
unit................................................................................. 128
er 24hr 15-1000 mg........................................................ 26
2017
ADVATE -antihemophilic factor rahf-pfm for inj 1000 AFREZZA -insulin regular (human) inhal powd 4 (60) & 8
unit................................................................................. 128 (30) unit/cart.................................................................... 31
ADVATE -antihemophilic factor rahf-pfm for inj 1500 AFREZZA -insulin regular (human) inhal powd 4 (90) & 8
unit................................................................................. 129 (90) unit/cart.................................................................... 31
ADVATE -antihemophilic factor rahf-pfm for inj 2000 AFREZZA -insulin regular (human) inh powd 4 & 8 & 12
unit................................................................................. 129 unit/cart (60).................................................................... 31
ADVATE -antihemophilic factor rahf-pfm for inj 3000 AFREZZA -insulin regular (human) inh powd 8 (60) & 12
unit................................................................................. 129 (30) unit/cart.................................................................... 31
ADVATE -antihemophilic factor rahf-pfm for inj 4000 AGGRENOX -aspirin-dipyridamole cap er 12hr 25-200
unit................................................................................. 129 mg.................................................................................. 129
ADVERA -nutritional supplement liquid...........................108 AKTEN -lidocaine hcl ophth gel 3.5%............................. 134
ADYNOVATE -antihemophilic factor recomb pegylated for AKYNZEO -netupitant-palonosetron cap 300-0.5 mg....... 58
inj 250 unit.................................................................... 129 ALBENZA -albendazole tab 200 mg................................. 11
ADYNOVATE -antihemophilic factor recomb pegylated for albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)......... 53
inj 500 unit.................................................................... 129 albuterol sulfate soln nebu 0.5% (5 mg/ml).................. 53
ADYNOVATE -antihemophilic factor recomb pegylated for albuterol sulfate soln nebu 0.63 mg/3ml (base
inj 750 unit.................................................................... 129 equiv).............................................................................. 53
ADYNOVATE -antihemophilic factor recomb pegylated for albuterol sulfate soln nebu 1.25 mg/3ml (base
inj 1000 unit.................................................................. 129 equiv).............................................................................. 53
ADYNOVATE -antihemophilic factor recomb pegylated for albuterol sulfate syrup 2 mg/5ml................................... 53
inj 1500 unit.................................................................. 129 albuterol sulfate tab er 12hr 4 mg (Vospire er)............ 53
ADYNOVATE -antihemophilic factor recomb pegylated for albuterol sulfate tab er 12hr 8 mg (Vospire er)............ 53
inj 2000 unit.................................................................. 129 albuterol sulfate tab 2 mg...............................................53
ADYNOVATE -antihemophilic factor recomb pegylated for albuterol sulfate tab 4 mg...............................................53
inj 3000 unit.................................................................. 129 alclometasone dipropionate cream 0.05%
AFINITOR DISPERZ -everolimus tab for oral susp 2 (Aclovate)..................................................................... 140
mg.................................................................................... 14 alclometasone dipropionate oint 0.05%......................140
AFINITOR DISPERZ -everolimus tab for oral susp 3 ALDACTAZIDE -spironolactone & hydrochlorothiazide tab
mg.................................................................................... 14 50-50 mg......................................................................... 47
AFINITOR DISPERZ -everolimus tab for oral susp 5 ALECENSA -alectinib hcl cap 150 mg (base
mg.................................................................................... 14 equivalent)....................................................................... 14
AFINITOR -everolimus tab 2.5 mg.................................... 14 ALENDRONATE SODIUM -alendronate sodium tab 40
AFINITOR -everolimus tab 5 mg....................................... 14 mg.................................................................................... 34
AFINITOR -everolimus tab 7.5 mg.................................... 14 alendronate sodium tab 5 mg........................................ 34
AFINITOR -everolimus tab 10 mg..................................... 14 alendronate sodium tab 10 mg...................................... 34
AFLURIA 2015-2016 -influenza virus vaccine split im alendronate sodium tab 35 mg...................................... 34
susp................................................................................. 12 alendronate sodium tab 70 mg (Fosamax)................... 34
AFLURIA 2017-2018 -influenza virus vaccine split im alfuzosin hcl tab er 24hr 10 mg (Uroxatral).................. 63
susp................................................................................. 12 ALINIA -nitazoxanide for susp 100 mg/5ml.......................11
AFLURIA PF 2015-2016 -influenza virus vaccine split pf ALINIA -nitazoxanide tab 500 mg..................................... 11
susp pref syringe 0.5 ml................................................. 12 ALITRAQ -nutritional supplement pack........................... 108
AFLURIA PF 2017-2018 -influenza virus vaccine split pf ALKERAN -melphalan tab 2 mg....................................... 14
susp pref syringe 0.5 ml................................................. 12 allopurinol tab 100 mg (Zyloprim)................................. 91
AFLURIA QUADRIVALENT 2017 -influenza virus vaccine allopurinol tab 300 mg (Zyloprim)................................. 91
split quadrivalent im inj................................................... 12 almotriptan malate tab 6.25 mg (Axert).........................90
AFLURIA QUADRIVALENT 2017 -influenza virus vac split almotriptan malate tab 12.5 mg (Axert).........................90
quadrivalent susp pref syr 0.5ml.................................... 12 ALOCRIL -nedocromil sodium ophth soln 2%................ 134
AFREZZA -insulin regular (human) inhalation powder 4 ALOGLIPTIN/METFORMIN HCL -alogliptin-metformin hcl
unit/cartridge.................................................................... 31 tab 12.5-500 mg............................................................. 26
AFREZZA -insulin regular (human) inhalation powder 8 ALOGLIPTIN/METFORMIN HCL -alogliptin-metformin hcl
unit/cartridge.................................................................... 31 tab 12.5-1000 mg........................................................... 26
AFREZZA -insulin regular (human) inhalation powder 12 ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab
unit/cartridge.................................................................... 31 12.5-15 mg...................................................................... 26
AFREZZA -insulin regular (human) inhal powd 4 (30) & 8 ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab
(60) unit/cart.................................................................... 31 12.5-30 mg...................................................................... 26
2017
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab alprazolam tab 2 mg (Xanax)..........................................64
12.5-45 mg...................................................................... 26 ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab 250 unit......................................................................... 129
25-15 mg......................................................................... 26 ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab 500 unit......................................................................... 129
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab 1000 unit....................................................................... 129
ALOGLIPTIN -alogliptin benzoate tab 6.25 mg (base 2000 unit....................................................................... 129
equiv)............................................................................... 26 ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
ALOGLIPTIN -alogliptin benzoate tab 12.5 mg (base 3000 unit....................................................................... 129
equiv)............................................................................... 26 ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
ALOGLIPTIN -alogliptin benzoate tab 25 mg (base 4000 unit....................................................................... 129
equiv)............................................................................... 26 ALREX -loteprednol etabonate ophth susp 0.2%........... 134
ALOMIDE -lodoxamide tromethamine ophth soln ALTABAX -retapamulin oint 1%.......................................140
0.1%...............................................................................134 ALUNBRIG -brigatinib tab 30 mg...................................... 14
ALORA -estradiol td patch twice weekly 0.025 amantadine hcl cap 100 mg........................................... 96
mg/24hr........................................................................... 22 amantadine hcl syrup 50 mg/5ml.................................. 96
ALORA -estradiol td patch twice weekly 0.05 mg/24hr..... 22 amantadine hcl tab 100 mg............................................ 96
ALORA -estradiol td patch twice weekly 0.075 AMCINONIDE -amcinonide cream 0.1%........................ 140
mg/24hr........................................................................... 22 AMCINONIDE -amcinonide lotion 0.1%.......................... 141
ALORA -estradiol td patch twice weekly 0.1 mg/24hr....... 22 AMCINONIDE -amcinonide oint 0.1%.............................141
alosetron hcl tab 0.5 mg (base equiv) (Lotronex)........ 60 AMICAR -aminocaproic acid oral soln 0.25 gm/ml......... 128
alosetron hcl tab 1 mg (base equiv) (Lotronex)........... 60 AMICAR -aminocaproic acid tab 500 mg........................ 128
ALPHAGAN P -brimonidine tartrate ophth soln 0.1%..... 134 AMICAR -aminocaproic acid tab 1000 mg...................... 128
ALPHANATE/VON WILLEBRAND -antihemophilic factor/ amiloride & hydrochlorothiazide tab 5-50 mg.............. 47
vwf (human) for inj 250 unit......................................... 129 amiloride hcl tab 5 mg.................................................... 47
ALPHANATE/VON WILLEBRAND -antihemophilic factor/ amino acids cap............................................................. 107
vwf (human) for inj 500 unit......................................... 129 amino acids tab.............................................................. 107
ALPHANATE/VON WILLEBRAND -antihemophilic factor/ amiodarone hcl tab 100 mg............................................ 41
vwf (human) for inj 1000 unit....................................... 129 amiodarone hcl tab 400 mg............................................ 41
ALPHANATE/VON WILLEBRAND -antihemophilic factor/ amiodarone hcl tab 200 mg (Cordarone)...................... 41
vwf (human) for inj 1500 unit....................................... 129 amitriptyline hcl tab 10 mg............................................. 65
ALPHANATE/VON WILLEBRAND -antihemophilic factor/ amitriptyline hcl tab 25 mg............................................. 65
vwf (human) for inj 2000 unit....................................... 129 amitriptyline hcl tab 50 mg............................................. 65
ALPHANINE SD -coagulation factor ix for inj 500 amitriptyline hcl tab 75 mg............................................. 65
unit................................................................................. 129 amitriptyline hcl tab 100 mg........................................... 65
ALPHANINE SD -coagulation factor ix for inj 1000 amitriptyline hcl tab 150 mg........................................... 65
unit................................................................................. 129 amlodipine besylate-benazepril hcl cap 2.5-10 mg
ALPHANINE SD -coagulation factor ix for inj 1500 (Lotrel)............................................................................ 42
unit................................................................................. 129 amlodipine besylate-benazepril hcl cap 5-10 mg
ALPRAZOLAM INTENSOL -alprazolam conc 1 mg/ (Lotrel)............................................................................ 42
ml..................................................................................... 64 amlodipine besylate-benazepril hcl cap 5-20 mg
alprazolam orally disintegrating tab 0.5 mg................. 64 (Lotrel)............................................................................ 42
alprazolam orally disintegrating tab 1 mg.................... 64 amlodipine besylate-benazepril hcl cap 5-40 mg
alprazolam orally disintegrating tab 2 mg.................... 64 (Lotrel)............................................................................ 42
alprazolam orally disintegrating tab 0.25 mg amlodipine besylate-benazepril hcl cap 10-20 mg
(Niravam)........................................................................ 64 (Lotrel)............................................................................ 42
alprazolam tab er 24hr 0.5 mg (Xanax xr)..................... 64 amlodipine besylate-benazepril hcl cap 10-40 mg
alprazolam tab er 24hr 1 mg (Xanax xr)........................ 64 (Lotrel)............................................................................ 42
alprazolam tab er 24hr 2 mg (Xanax xr)........................ 64 amlodipine besylate tab 2.5 mg (Norvasc)................... 39
alprazolam tab er 24hr 3 mg (Xanax xr)........................ 64 amlodipine besylate tab 5 mg (Norvasc)...................... 39
alprazolam tab 0.25 mg (Xanax).................................... 64 amlodipine besylate tab 10 mg (Norvasc).................... 39
alprazolam tab 0.5 mg (Xanax)...................................... 64 amlodipine besylate-valsartan tab 5-160 mg
alprazolam tab 1 mg (Xanax)..........................................64 (Exforge)......................................................................... 42
2017
amlodipine besylate-valsartan tab 5-320 mg amphetamine-dextroamphetamine cap er 24hr 15 mg
(Exforge)......................................................................... 42 (Adderall xr)................................................................... 73
amlodipine-valsartan-hydrochlorothiazide tab amphetamine-dextroamphetamine cap er 24hr 30 mg
5-160-12.5 mg (Exforge hct)........................................ 42 (Adderall xr)................................................................... 73
amlodipine-valsartan-hydrochlorothiazide tab amphetamine-dextroamphetamine tab 5 mg
5-160-25 mg (Exforge hct)........................................... 42 (Adderall)........................................................................ 73
amlodipine-valsartan-hydrochlorothiazide tab amphetamine-dextroamphetamine tab 7.5 mg
10-160-12.5 mg (Exforge hct)...................................... 42 (Adderall)........................................................................ 73
amlodipine-valsartan-hydrochlorothiazide tab amphetamine-dextroamphetamine tab 10 mg
10-160-25 mg (Exforge hct)......................................... 42 (Adderall)........................................................................ 73
amlodipine-valsartan-hydrochlorothiazide tab amphetamine-dextroamphetamine tab 12.5 mg
10-320-25 mg (Exforge hct)......................................... 42 (Adderall)........................................................................ 73
AMOXAPINE -amoxapine tab 25 mg................................ 65 amphetamine-dextroamphetamine tab 15 mg
AMOXAPINE -amoxapine tab 50 mg................................ 65 (Adderall)........................................................................ 73
AMOXAPINE -amoxapine tab 100 mg.............................. 65 amphetamine-dextroamphetamine tab 20 mg
AMOXAPINE -amoxapine tab 150 mg.............................. 65 (Adderall)........................................................................ 73
AMOXICILLIN/CLAVULANATE P -amoxicillin & k amphetamine-dextroamphetamine tab 30 mg
clavulanate chew tab 200-28.5 mg.................................. 1 (Adderall)........................................................................ 73
AMOXICILLIN/CLAVULANATE P -amoxicillin & k ampicillin cap 500 mg....................................................... 1
clavulanate chew tab 400-57 mg..................................... 1 AMPYRA -dalfampridine tab er 12hr 10 mg..................... 76
amoxicillin & k clavulanate for susp 200-28.5 ANADROL-50 -oxymetholone tab 50 mg.......................... 21
mg/5ml.............................................................................. 1 anagrelide hcl cap 1 mg............................................... 129
amoxicillin & k clavulanate for susp 400-57 mg/5ml..... 1 anagrelide hcl cap 0.5 mg (Agrylin)............................ 129
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml ANALPRAM-HC -hydrocortisone acetate w/ pramoxine
(Augmentin)..................................................................... 1 rectal lotn 2.5-1%..........................................................140
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml anastrozole tab 1 mg (Arimidex)................................... 14
(Augmentin es-600)........................................................ 1 ANDRODERM -testosterone td patch 24hr 2 mg/24hr..... 21
amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg ANDRODERM -testosterone td patch 24hr 4 mg/24hr..... 21
(Augmentin xr)................................................................ 1 ANDROGEL PUMP -testosterone td gel 20.25 mg/act
amoxicillin & k clavulanate tab 250-125 mg................... 1 (1.62%)............................................................................ 21
amoxicillin & k clavulanate tab 500-125 mg ANDROGEL -testosterone td gel 20.25 mg/1.25gm
(Augmentin)..................................................................... 1 (1.62%)............................................................................ 21
amoxicillin & k clavulanate tab 875-125 mg ANDROGEL -testosterone td gel 40.5 mg/2.5gm
(Augmentin)..................................................................... 1 (1.62%)............................................................................ 21
AMOXICILLIN -amoxicillin (trihydrate) chew tab 125 ANDROXY -fluoxymesterone tab 10 mg........................... 21
mg...................................................................................... 1 ANGELIQ -drospirenone-estradiol tab 0.25-0.5 mg.......... 22
AMOXICILLIN -amoxicillin (trihydrate) chew tab 250 ANGELIQ -drospirenone-estradiol tab 0.5-1 mg............... 22
mg...................................................................................... 1 ANORO ELLIPTA -umeclidinium-vilanterol aero powd ba
amoxicillin (trihydrate) cap 250 mg................................. 1 62.5-25 mcg/inh.............................................................. 53
amoxicillin (trihydrate) cap 500 mg................................. 1 ANZEMET -dolasetron mesylate tab 50 mg..................... 58
amoxicillin (trihydrate) for susp 125 mg/5ml..................1 ANZEMET -dolasetron mesylate tab 100 mg................... 58
amoxicillin (trihydrate) for susp 200 mg/5ml..................1 APIDRA -insulin glulisine inj 100 unit/ml........................... 30
amoxicillin (trihydrate) for susp 250 mg/5ml..................1 APIDRA SOLOSTAR -insulin glulisine soln pen-injector inj
amoxicillin (trihydrate) for susp 400 mg/5ml..................1 100 unit/ml.......................................................................30
amoxicillin (trihydrate) tab 500 mg.................................. 1 APOKYN -apomorphine hcl soln cartridge 30 mg/3ml...... 96
amoxicillin (trihydrate) tab 875 mg.................................. 1 apraclonidine hcl ophth soln 0.5% (base equivalent)
amphetamine-dextroamphetamine cap er 24hr 5 mg (Iopidine)...................................................................... 134
(Adderall xr)................................................................... 73 aprepitant capsule 80 mg (Emend)............................... 58
amphetamine-dextroamphetamine cap er 24hr 10 mg aprepitant capsule therapy pack 80 & 125 mg
(Adderall xr)................................................................... 73 (Emend).......................................................................... 58
APRISO -mesalamine cap er 24hr 0.375 gm................... 60
2017
APTENSIO XR -methylphenidate hcl cap er 24hr 10 mg ARGINAID EXTRA -nutritional supplement liquid........... 108
(xr)................................................................................... 73 ARGINAID -nutritional supplement pack......................... 108
APTENSIO XR -methylphenidate hcl cap er 24hr 15 mg aripiprazole orally disintegrating tab 10 mg.................68
(xr)................................................................................... 73 aripiprazole orally disintegrating tab 15 mg.................68
APTENSIO XR -methylphenidate hcl cap er 24hr 20 mg aripiprazole oral solution 1 mg/ml................................. 68
(xr)................................................................................... 73 aripiprazole tab 2 mg (Abilify)........................................ 68
APTENSIO XR -methylphenidate hcl cap er 24hr 30 mg aripiprazole tab 5 mg (Abilify)........................................ 68
(xr)................................................................................... 73 aripiprazole tab 10 mg (Abilify)...................................... 68
APTENSIO XR -methylphenidate hcl cap er 24hr 40 mg aripiprazole tab 15 mg (Abilify)...................................... 68
(xr)................................................................................... 73 aripiprazole tab 20 mg (Abilify)...................................... 68
APTENSIO XR -methylphenidate hcl cap er 24hr 50 mg aripiprazole tab 30 mg (Abilify)...................................... 68
(xr)................................................................................... 73 armodafinil tab 50 mg (Nuvigil)......................................73
APTENSIO XR -methylphenidate hcl cap er 24hr 60 mg armodafinil tab 150 mg (Nuvigil)................................... 73
(xr)................................................................................... 73 armodafinil tab 200 mg (Nuvigil)................................... 73
APTIOM -eslicarbazepine acetate tab 200 mg................. 91 armodafinil tab 250 mg (Nuvigil)................................... 73
APTIOM -eslicarbazepine acetate tab 400 mg................. 91 ARMOUR THYROID -thyroid tab 15 mg (1/4 grain)......... 32
APTIOM -eslicarbazepine acetate tab 600 mg................. 91 ARMOUR THYROID -thyroid tab 120 mg (2 grain).......... 32
APTIOM -eslicarbazepine acetate tab 800 mg................. 91 ARMOUR THYROID -thyroid tab 180 mg (3 grain).......... 32
APTIVUS -tipranavir cap 250 mg........................................ 6 ARMOUR THYROID -thyroid tab 240 mg (4 grain).......... 32
APTIVUS -tipranavir oral soln 100 mg/ml........................... 6 ARMOUR THYROID -thyroid tab 300 mg (5 grain).......... 32
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 25 ARNUITY ELLIPTA -fluticasone furoate aerosol powder
mcg/ml........................................................................... 125 breath activ 100 mcg/act................................................ 53
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 40 ARNUITY ELLIPTA -fluticasone furoate aerosol powder
mcg/ml........................................................................... 125 breath activ 200 mcg/act................................................ 53
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 60 ASACOL HD -mesalamine tab delayed release 800
mcg/ml........................................................................... 125 mg.................................................................................... 60
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 100 ASMANEX HFA -mometasone furoate inhal aerosol
mcg/ml........................................................................... 125 suspension 100 mcg/act................................................. 53
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 200 ASMANEX HFA -mometasone furoate inhal aerosol
mcg/ml........................................................................... 125 suspension 200 mcg/act................................................. 53
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 300 ASMANEX TWISTHALER 120 ME -mometasone furoate
mcg/ml........................................................................... 125 inhal powd 220 mcg/inh (breath activated).................... 53
ARANESP ALBUMIN FREE -darbepoetin alfa soln ASMANEX TWISTHALER 30 MET -mometasone furoate
prefilled syringe 10 mcg/0.4ml..................................... 125 inhal powd 110 mcg/inh (breath activated).................... 54
prefilled syringe 25 mcg/0.42ml................................... 125 inhal powd 220 mcg/inh (breath activated).................... 54
prefilled syringe 40 mcg/0.4ml..................................... 125 inhal powd 220 mcg/inh (breath activated).................... 54
ARANESP ALBUMIN FREE -darbepoetin alfa soln A-SOY -nutritional supplement liquid.............................. 108
prefilled syringe 60 mcg/0.3ml..................................... 125 aspirin chew tab 81 mg...................................................80
ARANESP ALBUMIN FREE -darbepoetin alfa soln aspirin-dipyridamole cap er 12hr 25-200 mg
prefilled syringe 100 mcg/0.5ml................................... 125 (Aggrenox)................................................................... 129
ARANESP ALBUMIN FREE -darbepoetin alfa soln aspirin tab delayed release 81 mg.................................80
prefilled syringe 150 mcg/0.3ml................................... 125 ASTAGRAF XL -tacrolimus cap er 24hr 0.5 mg..............147
ARANESP ALBUMIN FREE -darbepoetin alfa soln ASTAGRAF XL -tacrolimus cap er 24hr 1 mg................ 147
prefilled syringe 200 mcg/0.4ml................................... 125 ASTAGRAF XL -tacrolimus cap er 24hr 5 mg................ 147
ARANESP ALBUMIN FREE -darbepoetin alfa soln ASTERO -lidocaine hcl gel 4%....................................... 141
prefilled syringe 300 mcg/0.6ml................................... 125 atenolol & chlorthalidone tab 50-25 mg (Tenoretic
ARANESP ALBUMIN FREE -darbepoetin alfa soln 50).................................................................................... 42
prefilled syringe 500 mcg/ml........................................ 125 atenolol & chlorthalidone tab 100-25 mg (Tenoretic
ARCALYST -rilonacept for inj 220 mg...............................87 100).................................................................................. 42
ARCAPTA NEOHALER -indacaterol maleate inhal powder atenolol tab 25 mg (Tenormin)....................................... 38
cap 75 mcg (base equiv)................................................53 atenolol tab 50 mg (Tenormin)....................................... 38
ARGIMENT -amino acids pack....................................... 107 atenolol tab 100 mg (Tenormin)..................................... 38
ARGIMENT AT -amino acids pack.................................. 107
2017
ATGAM -lymphocyte immune globulin anti-thymocyte g inj AVONEX PEN -interferon beta-1a im auto-injector kit 30
50 mg/ml(eq)................................................................. 147 mcg/0.5ml........................................................................ 76
atomoxetine hcl cap 10 mg (base equiv) AXIRON -testosterone td soln 30 mg/act.......................... 21
(Strattera)....................................................................... 73 AZASAN -azathioprine tab 75 mg................................... 147
atomoxetine hcl cap 18 mg (base equiv) AZASAN -azathioprine tab 100 mg................................. 147
(Strattera)....................................................................... 73 AZASITE -azithromycin ophth soln 1%........................... 134
atomoxetine hcl cap 25 mg (base equiv) azathioprine tab 50 mg (Imuran).................................. 147
(Strattera)....................................................................... 74 azelastine hcl nasal spray 0.1% (137 mcg/spray)........ 51
atomoxetine hcl cap 40 mg (base equiv) azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
(Strattera)....................................................................... 74 (Astepro).........................................................................52
atomoxetine hcl cap 60 mg (base equiv) azelastine hcl ophth soln 0.05%.................................. 134
(Strattera)....................................................................... 74 AZILECT -rasagiline mesylate tab 0.5 mg (base
atomoxetine hcl cap 80 mg (base equiv) equiv)............................................................................... 96
(Strattera)....................................................................... 74 AZILECT -rasagiline mesylate tab 1 mg (base equiv)...... 96
atomoxetine hcl cap 100 mg (base equiv) AZITHROMYCIN -azithromycin powd pack for susp 1
(Strattera)....................................................................... 74 gm...................................................................................... 3
atorvastatin calcium tab 10 mg (base equivalent) azithromycin for susp 100 mg/5ml (Zithromax)............. 3
(Lipitor)........................................................................... 48 azithromycin for susp 200 mg/5ml (Zithromax)............. 3
atorvastatin calcium tab 20 mg (base equivalent) azithromycin tab 250 mg (Zithromax)............................. 3
(Lipitor)........................................................................... 48 azithromycin tab 500 mg (Zithromax)............................. 3
atorvastatin calcium tab 40 mg (base equivalent) azithromycin tab 600 mg (Zithromax)............................. 3
(Lipitor)........................................................................... 48 AZOPT -brinzolamide ophth susp 1%............................. 134
atorvastatin calcium tab 80 mg (base equivalent) B
(Lipitor)........................................................................... 48
atovaquone-proguanil hcl tab 62.5-25 mg BABY DDROPS -cholecalciferol drops 400 unit/0.03ml
(Malarone)...................................................................... 10 (per drop)........................................................................ 99
atovaquone-proguanil hcl tab 250-100 mg BACITRACIN -bacitracin ophth oint 500 unit/gm............ 134
(Malarone)...................................................................... 10 bacitracin-polymyxin b ophth oint.............................. 135
atovaquone susp 750 mg/5ml (Mepron)....................... 11 bacitracin-polymyxin-neomycin-hc ophth oint
ATRIPLA -efavirenz-emtricitabine-tenofovir df tab 1%.................................................................................. 135
600-200-300 mg................................................................6 baclofen tab 10 mg.......................................................... 98
ATROPINE SULFATE -atropine sulfate ophth soln baclofen tab 20 mg.......................................................... 98
1%.................................................................................. 134 BACTROBAN NASAL -mupirocin calcium nasal oint
ATROVENT HFA -ipratropium bromide hfa inhal aerosol 2%.................................................................................... 52
17 mcg/act.......................................................................54 BALANCED NUTRITIONAL DRIN -nutritional supplement
AUBAGIO -teriflunomide tab 7 mg.................................... 76 liquid.............................................................................. 108
AUBAGIO -teriflunomide tab 14 mg.................................. 76 BALANCED NUTRITIONAL SHAK -nutritional
AUGMENTED BETAMETHASONE D -betamethasone supplement liquid.......................................................... 108
dipropionate augmented gel 0.05%............................. 141 BALANCE TOTAL NUTRITIONAL -nutritional supplement
AUGMENTIN -amoxicillin & k clavulanate for susp liquid.............................................................................. 108
125-31.25 mg/5ml............................................................. 1 BAL-CARE DHA -prenat w/fe poly-na fered-fa tab 27-1 &
AURYXIA -ferric citrate tab 1 gm (210 mg ferric iron)....... 60 omega cap dr 430mg..................................................... 99
AUSTEDO -deutetrabenazine tab 6 mg............................ 76 balsalazide disodium cap 750 mg (Colazal)................. 60
AUSTEDO -deutetrabenazine tab 9 mg............................ 76 BANZEL -rufinamide susp 40 mg/ml................................. 91
AUSTEDO -deutetrabenazine tab 12 mg.......................... 76 BANZEL -rufinamide tab 200 mg...................................... 91
AVANDIA -rosiglitazone maleate tab 2 mg (base BANZEL -rufinamide tab 400 mg...................................... 91
equiv)............................................................................... 26 BARACLUDE -entecavir oral soln 0.05 mg/ml.................... 6
AVANDIA -rosiglitazone maleate tab 4 mg (base BAYER BREEZE 2 TEST DISC -glucose blood test
equiv)............................................................................... 27 disk................................................................................ 146
AVC -sulfanilamide vaginal cream 15%............................ 63 BAYER CONTOUR BLOOD GLUCO -glucose blood test
AVONEX -interferon beta-1a for im inj kit 30mcg strip................................................................................ 146
(33mcg(6.6 mu)/vial)....................................................... 76 BAYER CONTOUR NEXT BLOOD -glucose blood test
AVONEX -interferon beta-1a im prefilled syringe kit 30 strip................................................................................ 146
mcg/0.5ml........................................................................ 76 BCAD 1 -nutritional supplement powder......................... 108
BCAD 2 -nutritional supplement powder......................... 108
BEBULIN -factor ix complex for inj 200-1200 unit.......... 130
2017
BEEF/POTATOES/PEAS -nutritional supplement betamethasone dipropionate augmented lotion 0.05%
liquid.............................................................................. 108 (Diprolene)................................................................... 141
BELBUCA -buprenorphine hcl buccal film 75 mcg (base betamethasone dipropionate augmented oint 0.05%
equivalent)....................................................................... 81 (Diprolene)................................................................... 141
BELBUCA -buprenorphine hcl buccal film 150 mcg (base betamethasone dipropionate cream 0.05%................ 141
equivalent)....................................................................... 81 betamethasone dipropionate lotion 0.05%................. 141
BELBUCA -buprenorphine hcl buccal film 300 mcg (base betamethasone dipropionate oint 0.05%.................... 141
equivalent)....................................................................... 81 betamethasone valerate aerosol foam 0.12%
BELBUCA -buprenorphine hcl buccal film 750 mcg (base (Luxiq)........................................................................... 141
equivalent)....................................................................... 81 betamethasone valerate cream 0.1%.......................... 141
BELBUCA -buprenorphine hcl buccal film 900 mcg (base betamethasone valerate lotion 0.1%........................... 141
equivalent)....................................................................... 81 betamethasone valerate oint 0.1%.............................. 141
benazepril & hydrochlorothiazide tab 5-6.25 mg......... 42 BETASERON -interferon beta-1b for inj kit 0.3 mg........... 76
benazepril & hydrochlorothiazide tab 10-12.5 mg betaxolol hcl ophth soln 0.5%......................................135
(Lotensin hct)................................................................ 43 betaxolol hcl tab 10 mg (Kerlone)................................. 38
benazepril & hydrochlorothiazide tab 20-12.5 mg betaxolol hcl tab 20 mg (Kerlone)................................. 38
(Lotensin hct)................................................................ 43 bethanechol chloride tab 5 mg (Urecholine)................ 62
benazepril & hydrochlorothiazide tab 20-25 mg bethanechol chloride tab 10 mg (Urecholine).............. 62
(Lotensin hct)................................................................ 43 bethanechol chloride tab 25 mg (Urecholine).............. 62
benazepril hcl tab 5 mg.................................................. 43 bethanechol chloride tab 50 mg (Urecholine).............. 62
benazepril hcl tab 10 mg (Lotensin).............................. 43 BETHKIS -tobramycin nebu soln 300 mg/4ml.................... 5
benazepril hcl tab 20 mg (Lotensin).............................. 43 BETIMOL -timolol ophth soln 0.25%............................... 135
benazepril hcl tab 40 mg (Lotensin).............................. 43 BETIMOL -timolol ophth soln 0.5%................................. 135
BENECALORIE -nutritional supplement liquid................ 108 BETOPTIC-S -betaxolol hcl ophth susp 0.25%.............. 135
BENEFIX -coagulation factor ix (recombinant) for inj kit bexarotene cap 75 mg (Targretin)..................................15
250 unit......................................................................... 130 BEYAZ -drospirenone-ethinyl estrad-levomefolate tab
BENEFIX -coagulation factor ix (recombinant) for inj kit 3-0.02-0.451 mg..............................................................23
500 unit......................................................................... 130 bicalutamide tab 50 mg (Casodex)................................ 15
BENEFIX -coagulation factor ix (recombinant) for inj kit BIDIL -isosorbide dinitrate-hydralazine hcl tab 20-37.5
1000 unit....................................................................... 130 mg.................................................................................... 50
BENEFIX -coagulation factor ix (recombinant) for inj kit BILTRICIDE -praziquantel tab 600 mg.............................. 11
2000 unit....................................................................... 130 BIMATOPROST -bimatoprost ophth soln 0.03%............ 135
BENEFIX -coagulation factor ix (recombinant) for inj kit bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln
3000 unit....................................................................... 130 kit..................................................................................... 56
BENICAR -olmesartan medoxomil tab 5 mg.....................43 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
BENICAR -olmesartan medoxomil tab 20 mg...................43 (Ziac)............................................................................... 43
BENICAR -olmesartan medoxomil tab 40 mg...................43 bisoprolol & hydrochlorothiazide tab 5-6.25 mg
benzonatate cap 150 mg................................................. 52 (Ziac)............................................................................... 43
benzonatate cap 200 mg................................................. 52 bisoprolol & hydrochlorothiazide tab 10-6.25 mg
benzonatate cap 100 mg (Tessalon perles).................. 52 (Ziac)............................................................................... 43
benzoyl peroxide-erythromycin gel 5-3% bisoprolol fumarate tab 5 mg (Zebeta)..........................38
(Benzamycin)............................................................... 141 bisoprolol fumarate tab 10 mg (Zebeta)........................38
benztropine mesylate tab 0.5 mg.................................. 96 BLEPHAMIDE S.O.P. -sulfacetamide sodium-
benztropine mesylate tab 1 mg..................................... 96 prednisolone ophth oint 10-0.2%................................. 135
benztropine mesylate tab 2 mg..................................... 96 BLEPHAMIDE -sulfacetamide sodium-prednisolone ophth
BEPREVE -bepotastine besilate ophth soln 1.5%.......... 135 susp 10-0.2%................................................................ 135
BERINERT -c1 esterase inhibitor (human) for iv inj kit 500 BOOST/BENEFIBER -nutritional supplement liquid....... 109
unit................................................................................. 130 BOOST BREEZE -nutritional supplement liquid............. 108
BESIVANCE -besifloxacin hcl ophth susp 0.6% (base BOOST CALORIE SMART -nutritional supplement
equiv)............................................................................. 135 liquid.............................................................................. 108
BETADINE OPHTHALMIC PREP -povidone-iodine ophth BOOST 100 CALORIE SMART -nutritional supplement
soln 5%......................................................................... 135 liquid.............................................................................. 109
betamethasone dipropionate augmented cream 0.05% BOOST COMPACT -nutritional supplement liquid.......... 108
(Diprolene af)............................................................... 141 BOOST GLUCOSE CONTROL -nutritional supplement
liquid.............................................................................. 108
2017
BOOST HIGH PROTEIN -nutritional supplement bromfenac sodium ophth soln 0.09% (base equiv)
liquid.............................................................................. 108 (once-daily).................................................................. 135
BOOST HIGH PROTEIN -nutritional supplement bromocriptine mesylate cap 5 mg (base equivalent)
powder........................................................................... 108 (Parlodel)........................................................................ 96
BOOST KID ESSENTIALS 1.0 -nutritional supplement bromocriptine mesylate tab 2.5 mg (base equivalent)
liquid.............................................................................. 109 (Parlodel)........................................................................ 96
BOOST KID ESSENTIALS 1.5 -nutritional supplement BROVANA -arformoterol tartrate soln nebu 15 mcg/2ml
liquid.............................................................................. 109 (base equiv).................................................................... 54
BOOST KIDS ESSENTIALS -nutritional supplement budesonide delayed release particles cap 3 mg
liquid.............................................................................. 109 (Entocort ec).................................................................. 20
BOOST -nutritional supplement liquid............................. 108 budesonide inhalation susp 0.25 mg/2ml
BOOST PLUS -nutritional supplement liquid.................. 109 (Pulmicort)......................................................................54
BOOST PUDDING -nutritional supplement pudding.......109 budesonide inhalation susp 0.5 mg/2ml
BOOSTRIX -tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf- (Pulmicort)......................................................................54
lf-mcg/0.5ml..................................................................... 13 budesonide inhalation susp 1 mg/2ml (Pulmicort)...... 54
BOOST SMOOTHIE -nutritional supplement liquid........ 109 budesonide nasal susp 32 mcg/act (Rhinocort
BOOST VHC -nutritional supplement liquid.................... 109 aqua)............................................................................... 52
BOSULIF -bosutinib tab 100 mg....................................... 15 bumetanide tab 0.5 mg................................................... 47
BOSULIF -bosutinib tab 500 mg....................................... 15 bumetanide tab 1 mg...................................................... 47
BP FOLINATAL PLUS B -prenatal w/ calcium carbonate- bumetanide tab 2 mg...................................................... 47
b6-b12-fa tab 1 mg......................................................... 99 BUNAVAIL -buprenorphine-naloxone buccal film 2.1-0.3
BP MULTINATAL PLUS -prenatal w/o a vit w/ fe fumarate- mg (base equiv).............................................................. 81
fa tab 30-1 mg................................................................ 99 BUNAVAIL -buprenorphine-naloxone buccal film 4.2-0.7
BP MULTINATAL PLUS -prenatal w/o a vit w/ fe fum-fa mg (base equiv).............................................................. 81
tab chew 40-1 mg........................................................... 99 BUNAVAIL -buprenorphine-naloxone buccal film 6.3-1 mg
BRAVELLE -urofollitropin purified for inj 75 unit............... 34 (base equiv).................................................................... 81
BREATHERITE COLLAPSIBLE -spacer/aerosol-holding BUPHENYL -sodium phenylbutyrate tab 500 mg............. 34
chambers - device........................................................ 147 BUPRENORPHINE -buprenorphine td patch weekly 5
BREATHERITE RIGID SPACER -spacer/aerosol-holding mcg/hr.............................................................................. 81
chambers - device........................................................ 147 BUPRENORPHINE -buprenorphine td patch weekly 7.5
BREATHERITE -spacer/aerosol-holding chambers - mcg/hr.............................................................................. 81
device............................................................................ 147 BUPRENORPHINE -buprenorphine td patch weekly 10
BREATHERITE W/LARGE MASK -spacer/aerosol-holding mcg/hr.............................................................................. 81
chambers - device........................................................ 147 BUPRENORPHINE -buprenorphine td patch weekly 15
BREATHERITE W/MEDIUM MASK -spacer/aerosol- mcg/hr.............................................................................. 81
holding chambers - device........................................... 147 BUPRENORPHINE -buprenorphine td patch weekly 20
BREATHERITE W/SMALL MASK -spacer/aerosol-holding mcg/hr.............................................................................. 81
chambers - device........................................................ 147 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base
BREO ELLIPTA -fluticasone furoate-vilanterol aero powd equiv).............................................................................. 81
ba 100-25 mcg/inh.......................................................... 54 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
BREO ELLIPTA -fluticasone furoate-vilanterol aero powd equiv).............................................................................. 81
ba 200-25 mcg/inh.......................................................... 54 buprenorphine hcl sl tab 2 mg (base equiv)................ 81
BRILINTA -ticagrelor tab 60 mg...................................... 130 buprenorphine hcl sl tab 8 mg (base equiv)................ 81
BRILINTA -ticagrelor tab 90 mg...................................... 130 bupropion hcl (smoking deterrent) tab er 12hr 150 mg
brimonidine tartrate ophth soln 0.2%......................... 135 (Zyban)............................................................................ 76
brimonidine tartrate ophth soln 0.15% (Alphagan bupropion hcl tab er 12hr 100 mg (Wellbutrin sr)........ 65
p)................................................................................... 135 bupropion hcl tab er 12hr 150 mg (Wellbutrin sr)........ 65
BRIVIACT -brivaracetam oral soln 10 mg/ml.................... 91 bupropion hcl tab er 12hr 200 mg (Wellbutrin sr)........ 65
BRIVIACT -brivaracetam tab 10 mg................................. 91 bupropion hcl tab er 24hr 150 mg (Wellbutrin xl)........ 65
BRIVIACT -brivaracetam tab 25 mg................................. 91 bupropion hcl tab er 24hr 300 mg (Wellbutrin xl)........ 65
BRIVIACT -brivaracetam tab 50 mg................................. 91 bupropion hcl tab 75 mg (Wellbutrin)........................... 65
BRIVIACT -brivaracetam tab 75 mg................................. 91 bupropion hcl tab 100 mg (Wellbutrin)......................... 65
BRIVIACT -brivaracetam tab 100 mg............................... 91 buspirone hcl tab 5 mg................................................... 64
BROMFENAC -bromfenac sodium ophth soln 0.09% buspirone hcl tab 7.5 mg................................................ 64
(base equivalent).......................................................... 135 buspirone hcl tab 10 mg................................................. 64
2017
buspirone hcl tab 15 mg................................................. 64 calcipotriene cream 0.005% (Dovonex).......................141
buspirone hcl tab 30 mg................................................. 64 calcipotriene oint 0.005%..............................................141
BUTALBITAL/ASPIRIN/CAFFEI -butalbital-aspirin-caffeine calcipotriene soln 0.005% (50 mcg/ml)....................... 141
tab 50-325-40 mg........................................................... 80 calcitonin (salmon) nasal soln 200 unit/act
butalbital-acetaminophen-caffeine cap 50-325-40 (Miacalcin)...................................................................... 34
mg................................................................................... 80 calcitriol cap 0.25 mcg (Rocaltrol)................................. 34
butalbital-acetaminophen-caffeine cap 50-300-40 mg calcitriol cap 0.5 mcg (Rocaltrol)................................... 34
(Fioricet)......................................................................... 80 calcitriol oral soln 1 mcg/ml (Rocaltrol)........................34
butalbital-acetaminophen-caffeine tab 50-325-40 mg calcium acetate (phosphate binder) cap 667 mg (169
(Esgic)............................................................................. 80 mg ca) (Phoslo)............................................................. 60
butalbital-acetaminophen-caff w/ cod cap calcium acetate (phosphate binder) tab 667 mg
50-325-40-30 mg............................................................ 81 (Eliphos)......................................................................... 60
butalbital-acetaminophen-caff w/ cod cap CALCIUM PNV -prenatal w/o vit a w/ fe fum-fa-omega 3
50-300-40-30 mg (Fioricet/codeine)............................ 81 cap 28-1-250 mg............................................................ 99
butalbital-acetaminophen tab 50-325 mg......................80 CAMINO PRO BETTERMILK/GLY -nutritional supplement
butalbital-aspirin-caffeine cap 50-325-40 mg pack............................................................................... 109
(Fiorinal)......................................................................... 80 CAMINO PRO COMPLETE/GLYTA -nutritional
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg supplement bar............................................................. 109
(Fiorinal/codeine #3)..................................................... 81 CAMINO PRO 15PE -nutritional supplement liquid........ 109
butorphanol tartrate nasal soln 10 mg/ml.................... 81 CAMINO PRO PKU -nutritional supplement liquid..........109
BUTRANS -buprenorphine td patch weekly 5 mcg/hr.......81 CAMINO PRO RESTORE/GLYTAC -nutritional
BUTRANS -buprenorphine td patch weekly 7.5 mcg/ supplement liquid.......................................................... 109
hr...................................................................................... 81 CAMINO PRO SWIRL -nutritional supplement pack...... 109
BUTRANS -buprenorphine td patch weekly 10 mcg/ CANASA -mesalamine suppos 1000 mg.......................... 60
hr...................................................................................... 81 candesartan cilexetil-hydrochlorothiazide tab 16-12.5
BUTRANS -buprenorphine td patch weekly 15 mcg/ mg (Atacand hct).......................................................... 43
hr...................................................................................... 81 candesartan cilexetil-hydrochlorothiazide tab 32-12.5
BUTRANS -buprenorphine td patch weekly 20 mcg/ mg (Atacand hct).......................................................... 43
hr...................................................................................... 81 candesartan cilexetil-hydrochlorothiazide tab 32-25
BYDUREON -exenatide for inj extended release susp 2 mg (Atacand hct).......................................................... 43
mg.................................................................................... 27 candesartan cilexetil tab 4 mg (Atacand)..................... 43
BYDUREON PEN -exenatide extended release for susp candesartan cilexetil tab 8 mg (Atacand)..................... 43
pen-injector 2 mg............................................................ 27 candesartan cilexetil tab 16 mg (Atacand)................... 43
BYETTA -exenatide soln pen-injector 5 mcg/0.02ml........ 27 candesartan cilexetil tab 32 mg (Atacand)................... 43
BYETTA -exenatide soln pen-injector 10 mcg/0.04ml...... 27 CAPCOF -phenylephrine-chlorphen w/ codeine syrup
BYSTOLIC -nebivolol hcl tab 2.5 mg (base 5-2-10 mg/5ml................................................................. 52
equivalent)....................................................................... 38 capecitabine tab 150 mg (Xeloda)................................. 15
BYSTOLIC -nebivolol hcl tab 5 mg (base equivalent).......38 capecitabine tab 500 mg (Xeloda)................................. 15
BYSTOLIC -nebivolol hcl tab 10 mg (base CAPRELSA -vandetanib tab 100 mg................................ 15
equivalent)....................................................................... 38 CAPRELSA -vandetanib tab 300 mg................................ 15
BYSTOLIC -nebivolol hcl tab 20 mg (base captopril tab 12.5 mg...................................................... 43
equivalent)....................................................................... 38 captopril tab 25 mg......................................................... 43
C captopril tab 50 mg......................................................... 43
captopril tab 100 mg....................................................... 43
cabergoline tab 0.5 mg................................................... 34 CARAC -fluorouracil cream 0.5%.................................... 141
CABOMETYX -cabozantinib s-malate tab 20 mg (base CARAFATE -sucralfate susp 1 gm/10ml........................... 57
equivalent)....................................................................... 15 CARBAGLU -carglumic acid tab 200 mg.......................... 34
CABOMETYX -cabozantinib s-malate tab 40 mg (base carbamazepine cap er 12hr 100 mg (Carbatrol)........... 91
equivalent)....................................................................... 15 carbamazepine cap er 12hr 200 mg (Carbatrol)........... 91
CABOMETYX -cabozantinib s-malate tab 60 mg (base carbamazepine cap er 12hr 300 mg (Carbatrol)........... 91
equivalent)....................................................................... 15 carbamazepine chew tab 100 mg.................................. 91
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base carbamazepine susp 100 mg/5ml (Tegretol)................. 91
equiv).............................................................................. 74 carbamazepine tab er 12hr 100 mg (Tegretol-xr)......... 91
CALCILO XD -infant foods powder................................. 109 carbamazepine tab er 12hr 200 mg (Tegretol-xr)......... 91
calcipotriene-betamethasone dipropionate oint carbamazepine tab er 12hr 400 mg (Tegretol-xr)......... 91
0.005-0.064% (Taclonex)............................................ 141
2017
carbamazepine tab 200 mg (Tegretol)........................... 91 cefaclor cap 250 mg.......................................................... 2
CARBATROL -carbamazepine cap er 12hr 100 mg......... 91 cefaclor cap 500 mg.......................................................... 2
CARBATROL -carbamazepine cap er 12hr 200 mg......... 91 CEFACLOR -cefaclor for susp 125 mg/5ml........................ 1
CARBATROL -carbamazepine cap er 12hr 300 mg......... 91 CEFACLOR -cefaclor for susp 250 mg/5ml........................ 1
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopa- CEFACLOR -cefaclor for susp 375 mg/5ml........................ 1
entacapone tabs 12.5-50-200 mg.................................. 96 CEFACLOR ER -cefaclor monohydrate tab er 12hr 500
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopa- mg...................................................................................... 2
entacapone tabs 18.75-75-200 mg................................ 96 cefadroxil cap 500 mg....................................................... 2
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopa- cefadroxil for susp 250 mg/5ml....................................... 2
entacapone tabs 25-100-200 mg................................... 96 cefadroxil for susp 500 mg/5ml....................................... 2
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopa- cefadroxil tab 1 gm............................................................ 2
entacapone tabs 31.25-125-200 mg.............................. 96 cefdinir cap 300 mg........................................................... 2
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopa- cefdinir for susp 125 mg/5ml........................................... 2
entacapone tabs 37.5-150-200 mg................................ 96 cefdinir for susp 250 mg/5ml........................................... 2
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopa- CEFDITOREN PIVOXIL -cefditoren pivoxil tab 200 mg
entacapone tabs 50-200-200 mg................................... 96 (base equivalent).............................................................. 2
carbidopa & levodopa orally disintegrating tab 10-100 CEFDITOREN PIVOXIL -cefditoren pivoxil tab 400 mg
mg................................................................................... 96 (base equivalent).............................................................. 2
carbidopa & levodopa orally disintegrating tab 25-100 cefixime for susp 100 mg/5ml (Suprax).......................... 2
mg................................................................................... 96 cefixime for susp 200 mg/5ml (Suprax).......................... 2
carbidopa & levodopa orally disintegrating tab 25-250 cefpodoxime proxetil for susp 50 mg/5ml...................... 2
mg................................................................................... 96 cefpodoxime proxetil for susp 100 mg/5ml.................... 2
carbidopa & levodopa tab er 25-100 mg (Sinemet cefpodoxime proxetil tab 100 mg.................................... 2
cr).................................................................................... 96 cefpodoxime proxetil tab 200 mg.................................... 2
carbidopa & levodopa tab er 50-200 mg (Sinemet cefprozil for susp 125 mg/5ml..........................................2
cr).................................................................................... 96 cefprozil for susp 250 mg/5ml..........................................2
carbidopa & levodopa tab 10-100 mg (Sinemet).......... 96 cefprozil tab 250 mg.......................................................... 2
carbidopa & levodopa tab 25-100 mg (Sinemet).......... 96 cefprozil tab 500 mg.......................................................... 2
carbidopa & levodopa tab 25-250 mg (Sinemet).......... 96 CEFTIBUTEN -ceftibuten cap 400 mg................................ 2
carbidopa tab 25 mg (Lodosyn)..................................... 96 CEFTIBUTEN -ceftibuten for susp 180 mg/5ml.................. 2
carbinoxamine maleate soln 4 mg/5ml......................... 51 CEFTIN -cefuroxime axetil for susp 125 mg/5ml................ 2
carbinoxamine maleate tab 4 mg.................................. 51 CEFTIN -cefuroxime axetil for susp 250 mg/5ml................ 2
carbonyl iron susp 15 mg/1.25ml (elemental cefuroxime axetil tab 250 mg (Ceftin)............................. 2
iron)............................................................................... 125 cefuroxime axetil tab 500 mg (Ceftin)............................. 2
CARDIZEM LA -diltiazem hcl coated beads tab er 24hr celecoxib cap 50 mg (Celebrex).................................... 87
120 mg............................................................................ 39 celecoxib cap 100 mg (Celebrex).................................. 87
carisoprodol tab 250 mg (Soma)................................... 98 celecoxib cap 200 mg (Celebrex).................................. 87
carisoprodol tab 350 mg (Soma)................................... 98 celecoxib cap 400 mg (Celebrex).................................. 87
CARNATION BREAKFAST ESSEN -nutritional CELONTIN -methsuximide cap 300 mg............................ 92
supplement liquid.......................................................... 109 CENTANY -mupirocin oint 2%.........................................141
CARNATION BREAKFAST ESSEN -nutritional cephalexin cap 250 mg (Keflex)....................................... 2
supplement pack........................................................... 109 cephalexin cap 500 mg (Keflex)....................................... 2
CARNATION INSTANT BREAKFA -nutritional supplement cephalexin cap 750 mg (Keflex)....................................... 2
liquid.............................................................................. 109 CEPHALEXIN -cephalexin tab 250 mg............................... 2
carteolol hcl ophth soln 1%......................................... 135 CEPHALEXIN -cephalexin tab 500 mg............................... 2
carvedilol tab 3.125 mg (Coreg)..................................... 38 cephalexin for susp 125 mg/5ml...................................... 2
carvedilol tab 6.25 mg (Coreg)....................................... 38 cephalexin for susp 250 mg/5ml...................................... 2
carvedilol tab 12.5 mg (Coreg)....................................... 38 CERDELGA -eliglustat tartrate cap 84 mg (base
carvedilol tab 25 mg (Coreg).......................................... 38 equivalent)..................................................................... 125
CAYA -diaphragm arc-spring........................................... 147 CERVIDIL -dinoprostone vaginal inserts 10 mg............... 34
CAYSTON -aztreonam lysine for inhal soln 75 mg (base CESAMET -nabilone cap 1 mg......................................... 58
equivalent)....................................................................... 11 CETRAXAL -ciprofloxacin hcl otic soln 0.2% (base
C-BUFF -multiple vitamins w/ minerals powder................ 99 equivalent)..................................................................... 138
CEDAX -ceftibuten cap 400 mg.......................................... 1 CETROTIDE -cetrorelix acetate for inj kit 0.25 mg........... 34
CEDAX -ceftibuten for susp 180 mg/5ml............................ 1 CETYLEV -acetylcysteine effervescent tab 2.5 gm........ 146
2017
CETYLEV -acetylcysteine effervescent tab 500 mg....... 146 CHOLEXTRA -nutritional supplement powder................ 109
cevimeline hcl cap 30 mg (Evoxac)............................. 138 choline fenofibrate cap dr 45 mg (fenofibric acid
CHANTIX CONTINUING MONTH -varenicline tartrate tab equiv) (Trilipix).............................................................. 48
1 mg (base equiv).......................................................... 76 choline fenofibrate cap dr 135 mg (fenofibric acid
CHANTIX STARTING MONTH PA -varenicline tartrate tab equiv) (Trilipix).............................................................. 48
0.5 mg x 11 & tab 1 mg x 42 pack.................................76 CHORIONIC GONADOTROPIN -chorionic gonadotropin
CHANTIX -varenicline tartrate tab 0.5 mg (base for inj 10000 unit............................................................. 34
equiv)............................................................................... 76 CIALIS -tadalafil tab 2.5 mg......................................... 50,51
CHANTIX -varenicline tartrate tab 1 mg (base equiv).......76 CIALIS -tadalafil tab 5 mg............................................ 50,51
CHEMET -succimer cap 100 mg.................................... 146 CIALIS -tadalafil tab 10 mg.......................................... 50,51
CHENODAL -chenodiol tab 250 mg................................. 60 CIALIS -tadalafil tab 20 mg.......................................... 50,51
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxide- ciclopirox gel 0.77%...................................................... 141
amitriptyline tab 5-12.5 mg............................................. 76 ciclopirox olamine cream 0.77% (base equiv)............141
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxide- ciclopirox olamine susp 0.77% (base equiv).............. 141
amitriptyline tab 10-25 mg.............................................. 77 ciclopirox shampoo 1% (Loprox shampoo)............... 141
chlordiazepoxide hcl cap 5 mg...................................... 64 ciclopirox solution 8% (Penlac Nail Lacquer)............ 141
chlordiazepoxide hcl cap 10 mg.................................... 64 cilostazol tab 50 mg (Pletal)......................................... 130
chlordiazepoxide hcl cap 25 mg.................................... 64 cilostazol tab 100 mg (Pletal)....................................... 130
chlorhexidine gluconate soln 0.12% (Peridex)...........138 CILOXAN -ciprofloxacin hcl ophth oint 0.3%.................. 135
CHLOROQUINE PHOSPHATE -chloroquine phosphate cimetidine hcl soln 300 mg/5ml..................................... 57
tab 250 mg...................................................................... 10 cimetidine tab 300 mg..................................................... 57
chloroquine phosphate tab 500 mg (Aralen)................ 10 cimetidine tab 400 mg..................................................... 57
CHLOROTHIAZIDE -chlorothiazide tab 250 mg............... 47 cimetidine tab 800 mg..................................................... 57
chlorothiazide tab 500 mg.............................................. 47 CIMZIA -certolizumab pegol inj kit 2 x 200 mg/ml............ 60
chlorpromazine hcl tab 10 mg....................................... 68 CIMZIA STARTER KIT -certolizumab pegol inj kit 6 x 200
chlorpromazine hcl tab 25 mg....................................... 68 mg/ml............................................................................... 60
chlorpromazine hcl tab 50 mg....................................... 68 CIPRODEX -ciprofloxacin-dexamethasone otic susp
chlorpromazine hcl tab 100 mg..................................... 68 0.3-0.1%........................................................................ 138
chlorpromazine hcl tab 200 mg..................................... 68 CIPROFLOXACIN -ciprofloxacin hcl otic soln 0.2% (base
CHLORPROPAMIDE -chlorpropamide tab 100 mg.......... 27 equivalent)..................................................................... 138
CHLORPROPAMIDE -chlorpropamide tab 250 mg.......... 27 ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000
chlorthalidone tab 25 mg................................................ 47 mg(base eq) (Cipro xr)................................................... 4
chlorthalidone tab 50 mg................................................ 47 ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 mg
chlorzoxazone tab 500 mg (Parafon forte dsc)............ 98 (base eq) (Cipro xr)........................................................ 4
CHOICE DM -nutritional supplement liquid.....................109 ciprofloxacin for oral susp 250 mg/5ml (5%) (5
CHOICE DM TF -nutritional supplement liquid............... 109 gm/100ml) (Cipro)........................................................... 4
CHOLBAM -cholic acid cap 50 mg................................... 60 ciprofloxacin for oral susp 500 mg/5ml (10%) (10
CHOLBAM -cholic acid cap 250 mg................................. 60 gm/100ml) (Cipro)........................................................... 4
cholecalciferol cap 400 unit........................................... 99 CIPROFLOXACIN HCL -ciprofloxacin hcl tab 100 mg
cholecalciferol cap 1000 unit......................................... 99 (base equiv)...................................................................... 4
cholecalciferol cap 50000 unit....................................... 99 ciprofloxacin hcl ophth soln 0.3% (Ciloxan).............. 135
cholecalciferol chew tab 400 unit.................................. 99 ciprofloxacin hcl tab 750 mg (base equiv)..................... 4
cholecalciferol chew tab 1000 unit................................ 99 ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)......... 4
cholecalciferol drops 400 unit/0.03ml (per drop)......... 99 ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)......... 4
cholecalciferol drops 5000 unit/ml (1000 CIPRO HC -ciprofloxacin-hydrocortisone otic susp
unit/0.2ml).......................................................................99 0.2-1%........................................................................... 138
cholecalciferol oral liquid 400 unit/ml........................... 99 citalopram hydrobromide oral soln 10 mg/5ml............ 65
cholecalciferol tab 400 unit............................................ 99 citalopram hydrobromide tab 10 mg (base equiv)
cholecalciferol tab 1000 unit.......................................... 99 (Celexa)........................................................................... 65
cholecalciferol tab 50000 unit........................................ 99 citalopram hydrobromide tab 20 mg (base equiv)
cholestyramine light powder 4 gm/dose (Questran (Celexa)........................................................................... 65
light)................................................................................ 48 citalopram hydrobromide tab 40 mg (base equiv)
cholestyramine light powder packets 4 gm................. 48 (Celexa)........................................................................... 65
cholestyramine powder 4 gm/dose (Questran)............ 48 CITRANATAL ASSURE -prenat w/o a w/fecbn-fegl-dss-fa
cholestyramine powder packets 4 gm (Questran)....... 48 tab & dha cap 300 mg pack......................................... 100
2017
CITRANATAL B-CALM -prenat w/o a w/fecbn-feglu-fa tab CLOMIPHENE CITRATE -clomiphene citrate tab 50
20-1 mg & vit b6 tab pak............................................. 100 mg.................................................................................... 34
CITRANATAL DHA -prenat w/o a w/fecbn-fegl-dss-fa tab clomipramine hcl cap 25 mg (Anafranil)....................... 65
& dha cap 250 mg pack............................................... 100 clomipramine hcl cap 50 mg (Anafranil)....................... 65
CITRANATAL 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa clomipramine hcl cap 75 mg (Anafranil)....................... 65
tab 90 &dha cap 300mg pak........................................ 100 clonazepam orally disintegrating tab 0.125 mg........... 92
CITRANATAL HARMONY -prenat w/o a w/fe fum-fe cbn- clonazepam orally disintegrating tab 0.25 mg............. 92
dss-fa-dha cap 27-1-260 mg........................................ 100 clonazepam orally disintegrating tab 0.5 mg............... 92
CITRANATAL RX -prenatal w/o a w/ fe carbonyl-fe gluc- clonazepam orally disintegrating tab 1 mg.................. 92
dss-fa tab 27-1mg.........................................................100 clonazepam orally disintegrating tab 2 mg.................. 92
clarithromycin for susp 125 mg/5ml............................... 3 clonazepam tab 0.5 mg (Klonopin)................................ 92
clarithromycin for susp 250 mg/5ml (Biaxin)................. 3 clonazepam tab 1 mg (Klonopin)................................... 92
clarithromycin tab er 24hr 500 mg.................................. 3 clonazepam tab 2 mg (Klonopin)................................... 92
clarithromycin tab 250 mg (Biaxin)................................. 3 clonidine hcl tab er 12hr 0.1 mg (Kapvay).................... 74
clarithromycin tab 500 mg (Biaxin)................................. 3 clonidine hcl tab 0.1 mg (Catapres).............................. 43
CLEMASTINE FUMARATE -clemastine fumarate tab 2.68 clonidine hcl tab 0.2 mg (Catapres).............................. 43
mg.................................................................................... 51 clonidine hcl tab 0.3 mg (Catapres).............................. 43
CLEOCIN -clindamycin phosphate vaginal suppos 100 clonidine hcl td patch weekly 0.1 mg/24hr (Catapres-
mg.................................................................................... 63 tts-1)................................................................................ 43
CLICK ESPRESSO PROTEIN DR -nutritional supplement clonidine hcl td patch weekly 0.2 mg/24hr (Catapres-
powder........................................................................... 109 tts-2)................................................................................ 43
CLIMARA PRO -estradiol-levonorgestrel td patch weekly clonidine hcl td patch weekly 0.3 mg/24hr (Catapres-
0.045-0.015 mg/day........................................................ 22 tts-3)................................................................................ 43
clindamycin hcl cap 75 mg (Cleocin)............................ 11 clopidogrel bisulfate tab 75 mg (base equiv)
clindamycin hcl cap 150 mg (Cleocin).......................... 11 (Plavix).......................................................................... 130
clindamycin hcl cap 300 mg (Cleocin).......................... 11 clopidogrel bisulfate tab 300 mg (base equiv)
clindamycin palmitate hcl for soln 75 mg/5ml (base (Plavix).......................................................................... 130
equiv) (Cleocin pediatric gr)........................................11 clorazepate dipotassium tab 3.75 mg (Tranxene t)...... 64
clindamycin phosphate-benzoyl peroxide gel 1-5% clorazepate dipotassium tab 7.5 mg (Tranxene t)........ 64
(Benzaclin)................................................................... 141 clorazepate dipotassium tab 15 mg (Tranxene t)......... 64
clindamycin phosphate foam 1% (Evoclin)................ 141 clotrimazole troche 10 mg............................................ 138
clindamycin phosphate gel 1% (Cleocin-t)................. 141 clotrimazole w/ betamethasone cream 1-0.05%
clindamycin phosphate lotion 1% (Cleocin-t)............ 141 (Lotrisone).................................................................... 142
clindamycin phosphate soln 1% (Cleocin-t)............... 141 clotrimazole w/ betamethasone lotion 1-0.05%..........142
clindamycin phosphate swab 1% (Cleocin-t)............. 141 CLOZAPINE ODT -clozapine orally disintegrating tab 12.5
clindamycin phosphate-tretinoin gel 1.2-0.025% mg.................................................................................... 68
(Ziana)........................................................................... 141 CLOZAPINE ODT -clozapine orally disintegrating tab 150
clindamycin phosphate vaginal cream 2% mg.................................................................................... 68
(Cleocin)......................................................................... 63 CLOZAPINE ODT -clozapine orally disintegrating tab 200
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 mg.................................................................................... 68
(1)-5% (Duac)............................................................... 141 clozapine orally disintegrating tab 25 mg
CLINDESSE -clindamycin phosphate (one dose) vaginal (Fazaclo)......................................................................... 68
cream 2%........................................................................ 63 clozapine orally disintegrating tab 100 mg
clobetasol propionate cream 0.05% (Temovate)........ 141 (Fazaclo)......................................................................... 69
clobetasol propionate emollient base cream 0.05% clozapine tab 50 mg........................................................ 69
(Temovate e)................................................................ 141 clozapine tab 200 mg...................................................... 69
clobetasol propionate gel 0.05% (Temovate)............. 142 clozapine tab 25 mg (Clozaril)........................................69
clobetasol propionate lotion 0.05% (Clobex)............. 142 clozapine tab 100 mg (Clozaril)..................................... 69
clobetasol propionate oint 0.05% (Temovate)............ 142 C-NATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap
clobetasol propionate shampoo 0.05% (Clobex)....... 142 28-1-200 mg.................................................................... 99
clobetasol propionate soln 0.05% (Temovate)........... 142 COAGADEX -coagulation factor x (human) for inj 250
CLOCORTOLONE PIVALATE -clocortolone pivalate unit................................................................................. 130
cream 0.1%................................................................... 142 COAGADEX -coagulation factor x (human) for inj 500
CLOCORTOLONE PIVALATE PUM -clocortolone pivalate unit................................................................................. 130
cream 0.1%................................................................... 142 COARTEM -artemether-lumefantrine tab 20-120 mg....... 10
2017
codeine sulfate tab 15 mg (Codeine sulfate)................ 81 COMPLEX MSUD AMINO ACID B -amino acids bar..... 107
codeine sulfate tab 30 mg (Codeine sulfate)................ 82 COMPLEX MSUD -amino acids oral powder..................107
codeine sulfate tab 60 mg (Codeine sulfate)................ 82 CO-NATAL FA -prenatal vit w/ fe fumarate-fa tab 29-1
COLCHICINE -colchicine cap 0.6 mg............................... 91 mg.................................................................................. 100
COLCHICINE -colchicine tab 0.6 mg................................ 91 CONCEPT DHA -prenatal w/fe fum-fe poly -fa-omega 3
colchicine w/ probenecid tab 0.5-500 mg..................... 91 cap 53.5-38-1 mg......................................................... 100
COLCRYS -colchicine tab 0.6 mg..................................... 91 CONCEPT OB -prenatal w/o a w/fe fum-fe poly-fa cap
colestipol hcl granule packets 5 gm (Colestid 130-92.4-1 mg...............................................................100
flavored)......................................................................... 48 CONCERTA -methylphenidate hcl tab er osmotic release
colestipol hcl granules 5 gm (Colestid flavored)......... 48 (osm) 18 mg....................................................................74
colestipol hcl tab 1 gm (Colestid)..................................48 CONCERTA -methylphenidate hcl tab er osmotic release
COLGATE DRY MOUTH RELIEF -sodium fluoride (osm) 27 mg....................................................................74
mouthwash 2.1 mg/10ml.............................................. 138 CONCERTA -methylphenidate hcl tab er osmotic release
COLY-MYCIN S -neomycin-colistin-hc-thonzonium otic (osm) 36 mg....................................................................74
susp 3.3-3-10-0.5 mg/ml.............................................. 138 CONCERTA -methylphenidate hcl tab er osmotic release
COMBIGAN -brimonidine tartrate-timolol maleate ophth (osm) 54 mg....................................................................74
soln 0.2-0.5%................................................................ 135 CONDYLOX -podofilox gel 0.5%.................................... 142
COMBIPATCH -estradiol-norethindrone ace td pttw COPAXONE -glatiramer acetate soln prefilled syringe 20
0.05-0.14 mg/day............................................................ 22 mg/ml............................................................................... 77
COMBIPATCH -estradiol-norethindrone ace td pttw COPAXONE -glatiramer acetate soln prefilled syringe 40
0.05-0.25 mg/day............................................................ 22 mg/ml............................................................................... 77
COMBIVENT RESPIMAT -ipratropium-albuterol inhal CORDRAN -flurandrenolide tape 4 mcg/sqcm............... 142
aerosol soln 20-100 mcg/act.......................................... 54 COREG CR -carvedilol phosphate cap er 24hr 10 mg..... 38
COMETRIQ -cabozantinib s-malate cap 3 x 20 mg (60 mg COREG CR -carvedilol phosphate cap er 24hr 20 mg..... 38
dose) kit........................................................................... 15 COREG CR -carvedilol phosphate cap er 24hr 40 mg..... 38
COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 1 x 20 COREG CR -carvedilol phosphate cap er 24hr 80 mg..... 38
mg (100 dose) kit............................................................15 CORIFACT -factor xiii concentrate (human) for inj kit
COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 3 x 20 1000-1600 unit.............................................................. 130
mg (140 dose) kit............................................................15 CORLANOR -ivabradine hcl tab 5 mg (base equiv)......... 50
COMMIT -nicotine polacrilex lozenge 2 mg...................... 77 CORLANOR -ivabradine hcl tab 7.5 mg (base equiv)...... 50
COMMIT -nicotine polacrilex lozenge 4 mg...................... 77 CORTIFOAM -hydrocortisone acetate rectal foam 10%
COMPLEAT CLOSED SYSTEM -nutritional supplement (90 mg/dose)................................................................. 140
liquid.............................................................................. 109 CORTISONE ACETATE -cortisone acetate tab 25 mg..... 20
COMPLEAT -nutritional supplement liquid...................... 109 CORTISPORIN -bacitracin-polymyxin-neomycin hc oint
COMPLEAT PEDIATRIC -nutritional supplement 1%.................................................................................. 142
liquid.............................................................................. 109 CORTISPORIN -neomycin-polymyxin-hc crm 3.5 mg/
COMPLEAT PEDIATRIC REDUCE -nutritional gm-10000 unt/gm-0.5%................................................ 142
supplement liquid.......................................................... 109 COSENTYX -secukinumab subcutaneous soln prefilled
COMPLERA -emtricitabine-rilpivirine-tenofovir df tab syringe 150 mg/ml........................................................ 142
200-25-300 mg.................................................................. 6 COSENTYX SENSOREADY PEN -secukinumab
COMPLETE AMINO ACID MIX -amino acids oral subcutaneous soln auto-injector 150 mg/ml................ 142
powder........................................................................... 107 COSOPT PF -dorzolamide hcl-timolol maleate ophth sol
COMPLETE NATAL DHA -prenat-fe bis-fe prot succ-fa-ca 22.3-6.8 mg/ml pf..........................................................135
tab & omega 3 cap 250 pk.......................................... 100 COTELLIC -cobimetinib fumarate tab 20 mg (base
COMPLETENATE -prenatal vit w/ fe fumarate-fa chew tab equivalent)....................................................................... 15
29-1 mg......................................................................... 100 COUMADIN -warfarin sodium tab 1 mg.......................... 127
COMPLETE NUTRITION -nutritional supplement COUMADIN -warfarin sodium tab 2 mg.......................... 127
liquid.............................................................................. 109 COUMADIN -warfarin sodium tab 2.5 mg....................... 127
COMPLETE NUTRITION PLUS -nutritional supplement COUMADIN -warfarin sodium tab 3 mg.......................... 127
liquid.............................................................................. 109 COUMADIN -warfarin sodium tab 4 mg.......................... 127
COMPLETE PROTEIN & VITAMI -nutritional supplement COUMADIN -warfarin sodium tab 5 mg.......................... 127
powder........................................................................... 109 COUMADIN -warfarin sodium tab 6 mg.......................... 127
COMPLEX ESSENTIAL MSD -amino acids oral COUMADIN -warfarin sodium tab 7.5 mg....................... 127
powder........................................................................... 107 COUMADIN -warfarin sodium tab 10 mg........................ 127
COMPLEX JUNIOR MSD -amino acids oral powder...... 107
2017
CREON -pancrelipase (lip-prot-amyl) dr cap CYCLOSERINE -cycloserine cap 250 mg.......................... 5
3000-9500-15000 unit.....................................................59 CYCLOSET -bromocriptine mesylate tab 0.8 mg (base
CREON -pancrelipase (lip-prot-amyl) dr cap equivalent)....................................................................... 27
6000-19000-30000 unit...................................................59 cyclosporine cap 25 mg (Sandimmune)..................... 148
CREON -pancrelipase (lip-prot-amyl) dr cap cyclosporine cap 100 mg (Sandimmune)................... 148
12000-38000-60000 unit................................................ 59 cyclosporine modified cap 50 mg (Cyclosporine
CREON -pancrelipase (lip-prot-amyl) dr cap modifie)......................................................................... 148
24000-76000-120000 unit.............................................. 59 cyclosporine modified cap 25 mg (Neoral).................148
CREON -pancrelipase (lip-prot-amyl) dr cap cyclosporine modified cap 100 mg (Neoral)...............148
36000-114000-180000 unit............................................. 59 CYCLOSPORINE MODIFIED -cyclosporine modified cap
CRESEMBA -isavuconazonium sulfate cap 186 mg.......... 5 50 mg............................................................................ 148
CREST COMPLETE -sodium fluoride paste 0.243%..... 138 cyclosporine modified oral soln 100 mg/ml
CRESTOR -rosuvastatin calcium tab 5 mg.......................48 (Neoral)......................................................................... 148
CRESTOR -rosuvastatin calcium tab 10 mg.....................48 cyproheptadine hcl syrup 2 mg/5ml.............................. 51
CRESTOR -rosuvastatin calcium tab 20 mg.....................48 cyproheptadine hcl tab 4 mg......................................... 51
CRESTOR -rosuvastatin calcium tab 40 mg.....................48 CYSTADANE -betaine powder for oral solution................ 34
CRINONE -progesterone vaginal gel 4%.......................... 63 CYSTAGON -cysteamine bitartrate cap 50 mg.................63
CRINONE -progesterone vaginal gel 8%.......................... 63 CYSTAGON -cysteamine bitartrate cap 150 mg...............63
CRITICARE HN -nutritional supplement liquid................109 CYSTARAN -cysteamine hcl ophth soln 0.44% (base
CRIXIVAN -indinavir sulfate cap 200 mg............................ 6 equivalent)..................................................................... 135
CRIXIVAN -indinavir sulfate cap 400 mg............................ 6 D
CROMOLYN SODIUM -cromolyn sodium soln nebu 20
mg/2ml............................................................................. 54 DAKLINZA -daclatasvir dihydrochloride tab 30 mg (base
cromolyn sodium ophth soln 4%................................ 135 equivalent)......................................................................... 6
cromolyn sodium oral conc 100 mg/5ml DAKLINZA -daclatasvir dihydrochloride tab 60 mg (base
(Gastrocrom).................................................................. 60 equivalent)......................................................................... 6
CRUCIAL -nutritional supplement liquid..........................109 DAKLINZA -daclatasvir dihydrochloride tab 90 mg (base
CUPRIMINE -penicillamine cap 250 mg......................... 148 equivalent)......................................................................... 6
CUROSURF -poractant alfa intratracheal susp 120 DALIRESP -roflumilast tab 500 mcg................................. 54
mg/1.5ml.......................................................................... 56 danazol cap 50 mg.......................................................... 21
CUROSURF -poractant alfa intratracheal susp 240 danazol cap 100 mg........................................................ 21
mg/3ml............................................................................. 56 danazol cap 200 mg........................................................ 21
CUVPOSA -glycopyrrolate oral soln 1 mg/5ml................. 57 dantrolene sodium cap 100 mg..................................... 98
CVS NUTRITIONAL SHAKE -nutritional supplement dantrolene sodium cap 25 mg (Dantrium).................... 98
liquid.............................................................................. 110 dantrolene sodium cap 50 mg (Dantrium).................... 98
CVS NUTRITION LIQUID -nutritional supplement dapsone tab 25 mg.......................................................... 11
liquid.............................................................................. 109 dapsone tab 100 mg........................................................ 11
CVS NUTRITION PLUS -nutritional supplement DAPTACEL -diph, acellular pert & tet tox inj 15 lf-10
liquid.............................................................................. 109 mcg-5 lf/0.5ml................................................................. 13
cyanocobalamin inj 1000 mcg/ml................................ 125 DARAPRIM -pyrimethamine tab 25 mg............................ 11
CYCLINEX-1 -nutritional supplement powder................. 110 darifenacin hydrobromide tab er 24hr 7.5 mg (base
CYCLINEX-2 -nutritional supplement powder................. 110 equiv) (Enablex)............................................................ 62
cyclobenzaprine hcl tab 5 mg........................................ 98 darifenacin hydrobromide tab er 24hr 15 mg (base
cyclobenzaprine hcl tab 10 mg...................................... 98 equiv) (Enablex)............................................................ 62
cyclobenzaprine hcl tab 7.5 mg (Fexmid)..................... 98 DDROPS -cholecalciferol drops 1000 unit/0.03ml (per
CYCLOGYL -cyclopentolate hcl ophth soln 0.5%........... 135 drop)................................................................................ 99
CYCLOMYDRIL -cyclopentolate w/ phenylephrine ophth DEBACTEROL -sulfuric acid-sulfonated phenolics soln
soln 0.2-1%................................................................... 135 30-50%.......................................................................... 138
cyclopentolate hcl ophth soln 0.5% (Cyclogyl)..........135 DELZICOL -mesalamine cap dr 400 mg........................... 60
cyclopentolate hcl ophth soln 1% (Cyclogyl).............135 demeclocycline hcl tab 150 mg....................................... 3
cyclopentolate hcl ophth soln 2% (Cyclogyl).............135 demeclocycline hcl tab 300 mg....................................... 3
CYCLOPHOSPHAMIDE -cyclophosphamide cap 25 DEMSER -metyrosine cap 250 mg................................... 43
mg.................................................................................... 15 DENAVIR -penciclovir cream 1%.................................... 142
CYCLOPHOSPHAMIDE -cyclophosphamide cap 50 DEPAKENE -valproate sodium oral soln 250 mg/5ml
mg.................................................................................... 15 (base equiv).................................................................... 92
DEPAKENE -valproic acid cap 250 mg.............................92
2017
DEPEN TITRATABS -penicillamine tab 250 mg............. 148 DEXAMETHASONE -dexamethasone soln 0.5
DEPO-PROVERA CONTRACEPTIV - mg/5ml............................................................................. 20
medroxyprogesterone acetate im susp 150 mg/ml........ 24 DEXAMETHASONE -dexamethasone tab 1 mg...............20
DEPO-PROVERA CONTRACEPTIV - DEXAMETHASONE -dexamethasone tab 2 mg...............20
medroxyprogesterone acetate im susp prefilled syr 150 dexamethasone elixir 0.5 mg/5ml.................................. 20
mg/ml............................................................................... 24 DEXAMETHASONE INTENSOL -dexamethasone conc 1
DEPO-SUBQ PROVERA 104 -medroxyprogesterone mg/ml............................................................................... 20
acetate susp pref syr 104 mg/0.65ml.............................24 DEXAMETHASONE SODIUM PHOS -dexamethasone
DEPO-TESTOSTERONE -testosterone cypionate im inj in sodium phosphate ophth soln 0.1%............................. 135
oil 100 mg/ml.................................................................. 21 dexamethasone tab 0.5 mg............................................ 20
DEPO-TESTOSTERONE -testosterone cypionate im inj in dexamethasone tab 0.75 mg.......................................... 20
oil 200 mg/ml.................................................................. 21 dexamethasone tab 1.5 mg............................................ 20
DEQUASINE -amino acids tab........................................ 107 dexamethasone tab 4 mg............................................... 20
DESCOVY -emtricitabine-tenofovir alafenamide fumarate dexamethasone tab 6 mg............................................... 20
tab 200-25 mg...................................................................6 DEXILANT -dexlansoprazole cap delayed release 30
desipramine hcl tab 10 mg (Norpramin)....................... 65 mg.................................................................................... 57
desipramine hcl tab 25 mg (Norpramin)....................... 65 DEXILANT -dexlansoprazole cap delayed release 60
desipramine hcl tab 50 mg (Norpramin)....................... 65 mg.................................................................................... 57
desipramine hcl tab 75 mg (Norpramin)....................... 65 dexmethylphenidate hcl cap er 24 hr 5 mg (Focalin
desipramine hcl tab 100 mg (Norpramin)..................... 65 xr).................................................................................... 74
desipramine hcl tab 150 mg (Norpramin)..................... 65 dexmethylphenidate hcl cap er 24 hr 10 mg (Focalin
DESLORATADINE ODT -desloratadine tab orally xr).................................................................................... 74
disintegrating 2.5 mg...................................................... 51 dexmethylphenidate hcl cap er 24 hr 15 mg (Focalin
DESLORATADINE ODT -desloratadine tab orally xr).................................................................................... 74
disintegrating 5 mg......................................................... 51 dexmethylphenidate hcl cap er 24 hr 20 mg (Focalin
desloratadine tab 5 mg (Clarinex)................................. 51 xr).................................................................................... 74
desmopressin acetate inj 4 mcg/ml (Ddavp)................ 34 dexmethylphenidate hcl cap er 24 hr 25 mg (Focalin
desmopressin acetate nasal soln 0.01% (refrigerated) xr).................................................................................... 74
(Ddavp)........................................................................... 34 dexmethylphenidate hcl cap er 24 hr 30 mg (Focalin
desmopressin acetate nasal spray soln 0.01% xr).................................................................................... 74
(Ddavp)........................................................................... 34 dexmethylphenidate hcl cap er 24 hr 35 mg (Focalin
desmopressin acetate nasal spray soln 0.01% xr).................................................................................... 74
(refrigerated).................................................................. 35 dexmethylphenidate hcl cap er 24 hr 40 mg (Focalin
desmopressin acetate tab 0.1 mg (Ddavp)................... 35 xr).................................................................................... 74
desmopressin acetate tab 0.2 mg (Ddavp)................... 35 dexmethylphenidate hcl tab 2.5 mg (Focalin).............. 74
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 dexmethylphenidate hcl tab 5 mg (Focalin)................. 74
mg(21/5) (Mircette)........................................................ 24 dexmethylphenidate hcl tab 10 mg (Focalin)............... 74
desogest-ethin est tab DEX4 QUICK DISSOLVE GLUCO -glucose chew tab 4
0.1-0.025/0.125-0.025/0.15-0.025mg-mg gm.................................................................................... 27
(Cyclessa).......................................................................24 dextroamphetamine sulfate cap er 24hr 5 mg
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Dexedrine)..................................................................... 74
(Desogen)....................................................................... 24 dextroamphetamine sulfate cap er 24hr 10 mg
desonide cream 0.05% (Desowen).............................. 142 (Dexedrine)..................................................................... 74
desonide lotion 0.05% (Desowen)............................... 142 dextroamphetamine sulfate cap er 24hr 15 mg
desonide oint 0.05% (Desowen).................................. 142 (Dexedrine)..................................................................... 74
desoximetasone cream 0.25% (Topicort)....................142 dextroamphetamine sulfate oral solution 5 mg/5ml
desoximetasone gel 0.05% (Topicort)......................... 142 (Procentra)..................................................................... 74
desoximetasone oint 0.25% (Topicort)........................ 142 dextroamphetamine sulfate tab 5 mg........................... 74
desvenlafaxine succinate tab er 24hr 25 mg (base dextroamphetamine sulfate tab 10 mg......................... 74
equiv) (Pristiq)............................................................... 65 DIABETIC TF -nutritional supplement liquid................... 110
desvenlafaxine succinate tab er 24hr 50 mg (base DIABETISHIELD -nutritional supplement liquid.............. 110
equiv) (Pristiq)............................................................... 65 DIABETISOURCE AC -nutritional supplement liquid...... 110
desvenlafaxine succinate tab er 24hr 100 mg (base DIABETISOURCE -nutritional supplement liquid............ 110
equiv) (Pristiq)............................................................... 66 DIARESQ CHILDRENS -nutritional supplement
pack............................................................................... 110
2017
DIARESQ -nutritional supplement pack.......................... 110 diltiazem hcl cap er 12hr 60 mg.....................................39
DIASTAT ACUDIAL -diazepam rectal gel delivery system diltiazem hcl cap er 12hr 90 mg.....................................39
10 mg.............................................................................. 92 diltiazem hcl cap er 12hr 120 mg...................................39
DIASTAT ACUDIAL -diazepam rectal gel delivery system diltiazem hcl cap er 24hr 120 mg...................................39
20 mg.............................................................................. 92 diltiazem hcl cap er 24hr 180 mg...................................39
DIASTAT PEDIATRIC -diazepam rectal gel delivery diltiazem hcl cap er 24hr 240 mg...................................40
system 2.5 mg................................................................ 92 diltiazem hcl coated beads cap er 24hr 300 mg........... 40
diazepam conc 5 mg/ml.................................................. 64 diltiazem hcl coated beads cap er 24hr 120 mg
DIAZEPAM -diazepam oral soln 1 mg/ml..........................64 (Cardizem cd)................................................................ 40
diazepam tab 2 mg (Valium)........................................... 64 diltiazem hcl coated beads cap er 24hr 180 mg
diazepam tab 5 mg (Valium)........................................... 64 (Cardizem cd)................................................................ 40
diazepam tab 10 mg (Valium)......................................... 64 diltiazem hcl coated beads cap er 24hr 240 mg
DICLEGIS -doxylamine-pyridoxine tab delayed release (Cardizem cd)................................................................ 40
10-10 mg......................................................................... 58 diltiazem hcl coated beads cap er 24hr 360 mg
diclofenac potassium tab 50 mg................................... 87 (Cardizem cd)................................................................ 40
diclofenac sodium (actinic keratoses) gel 3% diltiazem hcl coated beads tab er 24hr 180 mg
(Solaraze)..................................................................... 142 (Cardizem la)................................................................. 40
diclofenac sodium gel 1% (Voltaren)...........................142 diltiazem hcl coated beads tab er 24hr 240 mg
diclofenac sodium ophth soln 0.1%............................ 135 (Cardizem la)................................................................. 40
diclofenac sodium soln 1.5% (Pennsaid)................... 142 diltiazem hcl coated beads tab er 24hr 300 mg
diclofenac sodium tab delayed release 25 mg............. 87 (Cardizem la)................................................................. 40
diclofenac sodium tab delayed release 50 mg............. 87 diltiazem hcl coated beads tab er 24hr 360 mg
diclofenac sodium tab delayed release 75 mg............. 87 (Cardizem la)................................................................. 40
diclofenac sodium tab er 24hr 100 mg......................... 87 diltiazem hcl coated beads tab er 24hr 420 mg
diclofenac w/ misoprostol tab delayed release 50-0.2 (Cardizem la)................................................................. 40
mg (Arthrotec 50)..........................................................87 diltiazem hcl extended release beads cap er 24hr 120
diclofenac w/ misoprostol tab delayed release 75-0.2 mg (Tiazac).................................................................... 40
mg (Arthrotec 75)..........................................................87 diltiazem hcl extended release beads cap er 24hr 180
dicloxacillin sodium cap 250 mg..................................... 1 mg (Tiazac).................................................................... 40
dicloxacillin sodium cap 500 mg..................................... 1 diltiazem hcl extended release beads cap er 24hr 240
dicyclomine hcl cap 10 mg (Bentyl).............................. 57 mg (Tiazac).................................................................... 40
dicyclomine hcl oral soln 10 mg/5ml............................ 57 diltiazem hcl extended release beads cap er 24hr 300
dicyclomine hcl tab 20 mg (Bentyl)............................... 57 mg (Tiazac).................................................................... 40
didanosine delayed release capsule 125 mg (Videx diltiazem hcl extended release beads cap er 24hr 360
ec)...................................................................................... 6 mg (Tiazac).................................................................... 40
didanosine delayed release capsule 200 mg (Videx diltiazem hcl extended release beads cap er 24hr 420
ec)...................................................................................... 6 mg (Tiazac).................................................................... 40
didanosine delayed release capsule 250 mg (Videx diltiazem hcl tab 90 mg................................................... 40
ec)...................................................................................... 6 diltiazem hcl tab 30 mg (Cardizem)............................... 40
didanosine delayed release capsule 400 mg (Videx diltiazem hcl tab 60 mg (Cardizem)............................... 40
ec)...................................................................................... 6 diltiazem hcl tab 120 mg (Cardizem)............................. 40
DIFICID -fidaxomicin tab 200 mg........................................ 3 DIPENTUM -olsalazine sodium cap 250 mg.....................60
DIFLORASONE DIACETATE -diflorasone diacetate oint DIPHENOXYLATE/ATROPINE -diphenoxylate w/ atropine
0.05%.............................................................................142 liq 2.5-0.025 mg/5ml....................................................... 57
diflunisal tab 500 mg....................................................... 80 diphenoxylate w/ atropine tab 2.5-0.025 mg
DIGOXIN -digoxin oral soln 0.05 mg/ml............................ 37 (Lomotil)......................................................................... 57
digoxin tab 125 mcg (0.125 mg) (Lanoxin)................... 37 DIPHTHERIA/TETANUS TOXOID -diphtheria-tetanus tox
digoxin tab 250 mcg (0.25 mg) (Lanoxin)..................... 37 adsorbed (dt) im inj 25-5 unit/0.5ml............................... 14
dihydroergotamine mesylate inj 1 mg/ml (D.h.e. dipyridamole tab 25 mg (Persantine).......................... 130
45).................................................................................... 90 dipyridamole tab 50 mg (Persantine).......................... 130
DILANTIN INFATABS -phenytoin chew tab 50 mg........... 92 dipyridamole tab 75 mg (Persantine).......................... 130
DILANTIN -phenytoin sodium extended cap 30 mg......... 92 disopyramide phosphate cap 100 mg (Norpace)......... 41
DILANTIN -phenytoin sodium extended cap 100 mg........92 disopyramide phosphate cap 150 mg (Norpace)......... 41
DILANTIN-125 -phenytoin susp 125 mg/5ml.................... 92 disulfiram tab 250 mg (Antabuse)................................. 77
DILATRATE SR -isosorbide dinitrate cap er 40 mg.......... 37 disulfiram tab 500 mg (Antabuse)................................. 77
2017
DIURIL -chlorothiazide susp 250 mg/5ml......................... 47 doxycycline monohydrate cap 100 mg (Monodox)........4
divalproex sodium cap delayed release sprinkle 125 doxycycline monohydrate for susp 25 mg/5ml
mg (Depakote sprinkles).............................................. 92 (Vibramycin)..................................................................... 4
divalproex sodium tab delayed release 125 mg doxycycline monohydrate tab 50 mg (Adoxa)............... 4
(Depakote)...................................................................... 92 doxycycline monohydrate tab 75 mg (Adoxa)............... 4
divalproex sodium tab delayed release 250 mg doxycycline monohydrate tab 100 mg (Adoxa pak
(Depakote)...................................................................... 92 1/100)................................................................................. 4
divalproex sodium tab delayed release 500 mg doxycycline monohydrate tab 150 mg (Adoxa pak
(Depakote)...................................................................... 92 1/150)................................................................................. 4
divalproex sodium tab er 24 hr 250 mg (Depakote dronabinol cap 2.5 mg (Marinol).................................... 58
er).................................................................................... 92 dronabinol cap 5 mg (Marinol)....................................... 58
divalproex sodium tab er 24 hr 500 mg (Depakote dronabinol cap 10 mg (Marinol)..................................... 58
er).................................................................................... 92 drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin
DIVIGEL -estradiol td gel 0.25 mg/0.25gm (0.1%)........... 22 28).................................................................................... 24
DIVIGEL -estradiol td gel 0.5 mg/0.5gm (0.1%)............... 22 drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)..... 24
DIVIGEL -estradiol td gel 1 mg/gm (0.1%)....................... 22 drospirenone-ethinyl estrad-levomefolate tab
dofetilide cap 125 mcg (0.125 mg) (Tikosyn)................41 3-0.02-0.451 mg (Beyaz)............................................... 24
dofetilide cap 250 mcg (0.25 mg) (Tikosyn)..................41 DROXIA -hydroxyurea cap 200 mg................................ 125
dofetilide cap 500 mcg (0.5 mg) (Tikosyn)....................41 DROXIA -hydroxyurea cap 300 mg................................ 125
donepezil hydrochloride orally disintegrating tab 5 DROXIA -hydroxyurea cap 400 mg................................ 125
mg................................................................................... 77 DUAVEE -conjugated estrogens-bazedoxifene tab
donepezil hydrochloride orally disintegrating tab 10 0.45-20 mg...................................................................... 22
mg................................................................................... 77 DUET DHA BALANCED -prenat w/fe poly-na fered-fa tab
donepezil hydrochloride tab 5 mg (Aricept)................. 77 25-1 & omega cap 267 mg.......................................... 100
donepezil hydrochloride tab 10 mg (Aricept)............... 77 DUET DHA 400 -prenat w/fe poly-na fered-fa tab 25-1 &
donepezil hydrochloride tab 23 mg (Aricept)............... 77 omega cap 400 mg...................................................... 100
DORAL -quazepam tab 15 mg.......................................... 72 DULERA -mometasone furoate-formoterol fumarate
dorzolamide hcl ophth soln 2% (Trusopt).................. 135 aerosol 100-5 mcg/act.................................................... 54
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 DULERA -mometasone furoate-formoterol fumarate
mg/ml (Cosopt)............................................................135 aerosol 200-5 mcg/act.................................................... 54
DOTHELLE DHA -prenatal w/fe fum-fe poly -fa-omega 3 DULOXETINE HCL -duloxetine hcl enteric coated pellets
cap 53.5-38-1 mg......................................................... 100 cap 40 mg....................................................................... 66
doxazosin mesylate tab 1 mg (Cardura)....................... 43 duloxetine hcl enteric coated pellets cap 20 mg
doxazosin mesylate tab 2 mg (Cardura)....................... 43 (Cymbalta)...................................................................... 66
doxazosin mesylate tab 4 mg (Cardura)....................... 43 duloxetine hcl enteric coated pellets cap 30 mg
doxazosin mesylate tab 8 mg (Cardura)....................... 43 (Cymbalta)...................................................................... 66
doxepin hcl cap 10 mg....................................................66 duloxetine hcl enteric coated pellets cap 60 mg
doxepin hcl cap 25 mg....................................................66 (Cymbalta)...................................................................... 66
doxepin hcl cap 50 mg....................................................66 DUOCAL -nutritional supplement powder....................... 110
doxepin hcl cap 100 mg..................................................66 DUOPA -carbidopa-levodopa enteral susp 4.63-20 mg/
doxepin hcl cap 150 mg..................................................66 ml..................................................................................... 96
doxepin hcl conc 10 mg/ml............................................ 66 DUREZOL -difluprednate ophth emulsion 0.05%........... 135
DOXEPIN HCL -doxepin hcl cap 75 mg........................... 66 dutasteride cap 0.5 mg (Avodart).................................. 63
DOXEPIN HYDROCHLORIDE -doxepin hcl cream dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn)...... 63
5%.................................................................................. 142 D-VI-SOL -cholecalciferol oral liquid 400 unit/ml.............. 99
doxercalciferol cap 0.5 mcg (Hectorol)......................... 35 DYRENIUM -triamterene cap 50 mg................................. 47
doxercalciferol cap 1 mcg (Hectorol)............................ 35 DYRENIUM -triamterene cap 100 mg............................... 47
doxercalciferol cap 2.5 mcg (Hectorol)......................... 35 E
doxycycline hyclate cap 50 mg....................................... 3
doxycycline hyclate cap 100 mg (Vibramycin)...............3 EAA SUPPLEMENT -nutritional supplement pack......... 110
doxycycline hyclate tab 20 mg........................................ 4 econazole nitrate cream 1%......................................... 142
doxycycline hyclate tab 100 mg...................................... 4 ECOZA -econazole nitrate foam 1%............................... 142
doxycycline monohydrate cap 50 mg............................. 4 EDARBI -azilsartan medoxomil tab 40 mg........................43
doxycycline monohydrate cap 150 mg (Adoxa).............4 EDARBI -azilsartan medoxomil tab 80 mg........................44
doxycycline monohydrate cap 75 mg (Monodox)..........4 EDECRIN -ethacrynic acid tab 25 mg.............................. 47
EDURANT -rilpivirine hcl tab 25 mg (base equivalent)....... 6
2017
E.E.S. 400 -erythromycin ethylsuccinate tab 400 mg......... 3 EMADINE -emedastine difumarate ophth soln 0.05%
E.E.S. GRANULES -erythromycin ethylsuccinate for susp (base equiv).................................................................. 136
200 mg/5ml....................................................................... 3 EMBEDA -morphine-naltrexone cap er 20-0.8 mg........... 82
EFFIENT -prasugrel hcl tab 5 mg (base equiv).............. 130 EMBEDA -morphine-naltrexone cap er 30-1.2 mg........... 82
EFFIENT -prasugrel hcl tab 10 mg (base equiv)............ 130 EMBEDA -morphine-naltrexone cap er 50-2 mg.............. 82
EGG/PRO -nutritional supplement powder..................... 110 EMBEDA -morphine-naltrexone cap er 60-2.4 mg........... 82
EGRIFTA -tesamorelin acetate for inj 1 mg (base EMBEDA -morphine-naltrexone cap er 80-3.2 mg........... 82
equiv)............................................................................... 35 EMBEDA -morphine-naltrexone cap er 100-4 mg............ 82
ELECARE/DHA/ARA -nutritional supplement EMCYT -estramustine phosphate sodium cap 140
powder........................................................................... 110 mg.................................................................................... 15
ELECARE JR -nutritional supplement powder................110 EMEND -aprepitant capsule 40 mg.................................. 58
ELECARE -nutritional supplement powder..................... 110 EMEND -aprepitant capsule 80 mg.................................. 58
ELESTRIN -estradiol gel 0.06% (0.52 mg/0.87 gm EMEND -aprepitant capsule 125 mg................................ 58
metered-dose pump)...................................................... 22 EMEND -aprepitant for oral susp 125 mg (125
eletriptan hydrobromide tab 20 mg (base equivalent) mg/5ml)............................................................................ 58
(Relpax).......................................................................... 90 EMEND TRIPACK -aprepitant capsule therapy pack 80 &
eletriptan hydrobromide tab 40 mg (base equivalent) 125 mg............................................................................ 59
(Relpax).......................................................................... 90 EMSAM -selegiline td patch 24hr 6 mg/24hr.................... 66
ELIDEL -pimecrolimus cream 1%................................... 142 EMSAM -selegiline td patch 24hr 9 mg/24hr.................... 66
ELIGARD -leuprolide acetate for subcutaneous inj kit 7.5 EMSAM -selegiline td patch 24hr 12 mg/24hr.................. 66
mg.................................................................................... 15 EMTRIVA -emtricitabine caps 200 mg................................ 6
ELIGARD -leuprolide acetate (3 month) for subcutaneous EMTRIVA -emtricitabine soln 10 mg/ml.............................. 7
inj kit 22.5mg...................................................................15 EMVERM -mebendazole chew tab 100 mg...................... 11
ELIGARD -leuprolide acetate (4 month) for subcutaneous ENABLEX -darifenacin hydrobromide tab er 24hr 7.5 mg
inj kit 30 mg.................................................................... 15 (base equiv).................................................................... 62
ELIGARD -leuprolide acetate (6 month) for subcutaneous ENABLEX -darifenacin hydrobromide tab er 24hr 15 mg
inj kit 45 mg.................................................................... 15 (base equiv).................................................................... 62
ELIQUIS -apixaban tab 2.5 mg....................................... 127 enalapril maleate & hydrochlorothiazide tab 5-12.5
ELIQUIS -apixaban tab 5 mg.......................................... 127 mg................................................................................... 44
ELITE-OB -prenatal vit w/ iron carbonyl-fa tab 50-1.25 enalapril maleate & hydrochlorothiazide tab 10-25 mg
mg.................................................................................. 100 (Vaseretic)...................................................................... 44
ELIXOPHYLLIN -theophylline elixir 80 mg/15ml............... 54 enalapril maleate tab 2.5 mg (Vasotec)......................... 44
ELLA -ulipristal acetate tab 30 mg.................................... 24 enalapril maleate tab 5 mg (Vasotec)............................ 44
ELMIRON -pentosan polysulfate sodium caps 100 enalapril maleate tab 10 mg (Vasotec).......................... 44
mg.................................................................................... 63 enalapril maleate tab 20 mg (Vasotec).......................... 44
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj ENBRACE HR -prenatal vit w/ fe gly cys-fa-omega 3 fatty
250 unit......................................................................... 130 acids cap....................................................................... 100
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj ENBREL -etanercept for subcutaneous inj 25 mg............ 87
500 unit......................................................................... 130 ENBREL -etanercept subcutaneous soln prefilled syringe
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 25 mg/0.5ml.................................................................... 87
750 unit......................................................................... 130 ENBREL -etanercept subcutaneous soln prefilled syringe
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj 50 mg/ml......................................................................... 87
1000 unit....................................................................... 130 ENBREL SURECLICK -etanercept subcutaneous solution
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj auto-injector 50 mg/ml.................................................... 87
1500 unit....................................................................... 130 ENCARE -nonoxynol-9 vaginal suppos 100 mg............... 63
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj END FATIGUE DAILY ENERGY -multiple vitamins w/
2000 unit....................................................................... 130 minerals powder............................................................100
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj ENDOMETRIN -progesterone vaginal insert 100 mg....... 63
3000 unit....................................................................... 130 ENGERIX-B -hepatitis b vaccine (recombinant) 10
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj mcg/0.5ml........................................................................ 12
4000 unit....................................................................... 130 ENGERIX-B -hepatitis b vaccine (recombinant) 20 mcg/
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj ml..................................................................................... 12
5000 unit....................................................................... 130 ENGERIX-B -hepatitis b vaccine (recombinant) susp 10
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj mcg/0.5ml........................................................................ 12
6000 unit....................................................................... 130
2017
ENGERIX-B -hepatitis b vaccine (recombinant) susp 20 ENSURE PRE-SURGERY -nutritional supplement
mcg/ml............................................................................. 12 liquid.............................................................................. 111
ENLIVE -nutritional supplement liquid.............................110 ENSURE PUDDING -nutritional supplement
enoxaparin sodium inj 30 mg/0.3ml (Lovenox).......... 127 pudding.......................................................................... 111
enoxaparin sodium inj 40 mg/0.4ml (Lovenox).......... 127 ENSURE SURGERY IMMUNONUTR -nutritional
enoxaparin sodium inj 60 mg/0.6ml (Lovenox).......... 127 supplement liquid.......................................................... 111
enoxaparin sodium inj 80 mg/0.8ml (Lovenox).......... 127 entacapone tab 200 mg (Comtan)................................. 96
enoxaparin sodium inj 100 mg/ml (Lovenox)............. 127 entecavir tab 0.5 mg (Baraclude)..................................... 7
enoxaparin sodium inj 120 mg/0.8ml (Lovenox)........ 127 entecavir tab 1 mg (Baraclude)........................................ 7
enoxaparin sodium inj 150 mg/ml (Lovenox)............. 127 ENTEREG -alvimopan cap 12 mg.................................... 60
enoxaparin sodium inj 300 mg/3ml (Lovenox)........... 127 ENTRESTO -sacubitril-valsartan tab 24-26 mg................ 50
ENSTILAR -calcipotriene-betamethasone dipropionate ENTRESTO -sacubitril-valsartan tab 49-51 mg................ 50
foam 0.005-0.064%...................................................... 142 ENTRESTO -sacubitril-valsartan tab 97-103 mg.............. 50
ENSURE/FIBER -nutritional supplement liquid............... 111 ENU NUTRITIONAL SHAKE -nutritional supplement
ENSURE ACTIVE HEART HEALT -nutritional supplement liquid.............................................................................. 111
liquid.............................................................................. 110 ENVARSUS XR -tacrolimus tab er 24hr 0.75 mg........... 148
ENSURE ACTIVE HIGH PROTEI -nutritional supplement ENVARSUS XR -tacrolimus tab er 24hr 1 mg................ 148
liquid.............................................................................. 110 ENVARSUS XR -tacrolimus tab er 24hr 4 mg................ 148
ENSURE ACTIVE LIGHT -nutritional supplement EO28 SPLASH -nutritional supplement liquid................. 111
liquid.............................................................................. 110 EPCLUSA -sofosbuvir-velpatasvir tab 400-100 mg............ 7
ENSURE ACTIVE -nutritional supplement liquid............ 110 epinastine hcl ophth soln 0.05% (Elestat).................. 136
ENSURE BONE HEALTH REVIGO -nutritional EPINEPHRINE - AUTHORIZED GENERIC TO EPIPEN
supplement liquid.......................................................... 110 -epinephrine solution auto-injector 0.15 mg/0.3ml
ENSURE CLEAR -nutritional supplement liquid............. 110 (1:2000)........................................................................... 48
ENSURE CLINICAL STRENGTH -nutritional supplement EPINEPHRINE - AUTHORIZED GENERIC TO EPIPEN
liquid.............................................................................. 110 -epinephrine solution auto-injector 0.3 mg/0.3ml
ENSURE COMPACT -nutritional supplement liquid....... 110 (1:1000)........................................................................... 48
ENSURE COMPLETE -nutritional supplement liquid..... 110 EPINEPHRINE -epinephrine solution auto-injector 0.15
ENSURE COMPLETE NUTRITION -nutritional mg/0.15ml (1:1000)......................................................... 48
supplement liquid.......................................................... 110 EPINEPHRINE -epinephrine solution auto-injector 0.3
ENSURE ENLIVE -nutritional supplement liquid............ 110 mg/0.3ml (1:1000)........................................................... 48
ENSURE HEALTHY MOM -nutritional supplement EPIPEN-JR 2-PAK -epinephrine solution auto-injector
bar.................................................................................. 110 0.15 mg/0.3ml (1:2000).................................................. 48
ENSURE HEALTHY MOM -nutritional supplement EPIPEN 2-PAK -epinephrine solution auto-injector 0.3
liquid.............................................................................. 110 mg/0.3ml (1:1000)........................................................... 48
ENSURE HIGH CALCIUM -nutritional supplement EPIVIR HBV -lamivudine oral soln 5 mg/ml (hbv)............... 7
liquid.............................................................................. 110 eplerenone tab 25 mg (Inspra)....................................... 44
ENSURE HIGH PROTEIN -nutritional supplement eplerenone tab 50 mg (Inspra)....................................... 44
liquid.............................................................................. 110 EPOGEN -epoetin alfa inj 2000 unit/ml...........................125
ENSURE HIGH PROTEIN -nutritional supplement EPOGEN -epoetin alfa inj 3000 unit/ml...........................126
powder........................................................................... 110 EPOGEN -epoetin alfa inj 4000 unit/ml...........................126
ENSURE IMMUNE HEALTH -nutritional supplement EPOGEN -epoetin alfa inj 10000 unit/ml.........................126
liquid.............................................................................. 110 EPOGEN -epoetin alfa inj 20000 unit/ml.........................126
ENSURE MUSCLE HEALTH REVI -nutritional EPROSARTAN MESYLATE -eprosartan mesylate tab 600
supplement liquid.......................................................... 111 mg.................................................................................... 44
ENSURE NUTRA SHAKE HI-CAL -nutritional supplement EPZICOM -abacavir sulfate-lamivudine tab 600-300
liquid.............................................................................. 111 mg...................................................................................... 7
ENSURE -nutritional supplement bar..............................110 EQL DENTAL TRAVEL PACK -sodium fluoride paste
ENSURE -nutritional supplement liquid.......................... 110 0.243% & mouthwash kit..............................................139
ENSURE -nutritional supplement powder....................... 110 EQL TRAVEL TOOTHBRUSH/TOO -sodium
ENSURE NUTRITION SHAKE -nutritional supplement monofluorophosphate paste 0.15%............................. 139
liquid.............................................................................. 111 EQ NUTRITIONAL SHAKE -nutritional supplement
ENSURE PLUS HN -nutritional supplement liquid..........111 liquid.............................................................................. 111
ENSURE PLUS -nutritional supplement liquid................ 111 EQ NUTRITIONAL SHAKE PLUS -nutritional supplement
liquid.............................................................................. 111
2017
EQUATE -nutritional supplement liquid........................... 111 estazolam tab 1 mg......................................................... 72
EQUATE PLUS -nutritional supplement liquid................ 111 estazolam tab 2 mg......................................................... 72
EQUETRO -carbamazepine (antipsychotic) cap er 12hr ESTRACE -estradiol vaginal cream 0.1 mg/gm................ 63
100 mg............................................................................ 69 estradiol & norethindrone acetate tab 0.5-0.1 mg
EQUETRO -carbamazepine (antipsychotic) cap er 12hr (Activella)....................................................................... 22
200 mg............................................................................ 69 estradiol & norethindrone acetate tab 1-0.5 mg
EQUETRO -carbamazepine (antipsychotic) cap er 12hr (Activella)....................................................................... 22
300 mg............................................................................ 69 estradiol tab 0.5 mg (Estrace)........................................ 22
EQ WEIGHT LOSS SHAKE ULTR -nutritional supplement estradiol tab 1 mg (Estrace)........................................... 22
liquid.............................................................................. 111 estradiol tab 2 mg (Estrace)........................................... 22
ergocalciferol cap 50000 unit (Drisdol)......................... 99 estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-
ERGOLOID MESYLATES -ergoloid mesylates tab 1 dot).................................................................................. 22
mg.................................................................................... 77 estradiol td patch twice weekly 0.0375 mg/24hr
ERGOMAR -ergotamine tartrate sl tab 2 mg.................... 90 (Vivelle-dot).................................................................... 22
ergotamine w/ caffeine tab 1-100 mg (Cafergot).......... 90 estradiol td patch twice weekly 0.05 mg/24hr (Vivelle-
ERIVEDGE -vismodegib cap 150 mg............................... 15 dot).................................................................................. 22
ERTACZO -sertaconazole nitrate cream 2%.................. 142 estradiol td patch twice weekly 0.075 mg/24hr (Vivelle-
ERYPED 200 -erythromycin ethylsuccinate for susp 200 dot).................................................................................. 22
mg/5ml............................................................................... 3 estradiol td patch twice weekly 0.1 mg/24hr (Vivelle-
ERYPED 400 -erythromycin ethylsuccinate for susp 400 dot).................................................................................. 22
mg/5ml............................................................................... 3 estradiol td patch weekly 0.025 mg/24hr (Climara)......22
ERY-TAB -erythromycin tab delayed release 250 mg........ 3 estradiol td patch weekly 0.05 mg/24hr (Climara)........22
ERY-TAB -erythromycin tab delayed release 333 mg........ 3 estradiol td patch weekly 0.06 mg/24hr (Climara)........23
ERY-TAB -erythromycin tab delayed release 500 mg........ 3 estradiol td patch weekly 0.075 mg/24hr (Climara)......23
ERYTHROCIN STEARATE -erythromycin stearate tab estradiol td patch weekly 0.1 mg/24hr (Climara)..........23
250 mg.............................................................................. 3 estradiol td patch weekly 0.0375 mg/24hr (37.5
ERYTHROMYCIN BASE -erythromycin tab 250 mg.......... 3 mcg/24hr) (Climara)...................................................... 22
ERYTHROMYCIN BASE -erythromycin tab 500 mg.......... 3 estradiol vaginal tab 10 mcg (Vagifem).........................63
ERYTHROMYCIN ETHYLSUCCINA -erythromycin estradiol valerate im in oil 20 mg/ml (Delestrogen)..... 23
ethylsuccinate tab 400 mg............................................... 3 estradiol valerate im in oil 40 mg/ml (Delestrogen)..... 23
erythromycin ethylsuccinate for susp 200 mg/5ml ESTRING -estradiol vaginal ring 2 mg (7.5
(E.e.s. granules).............................................................. 3 mcg/24hrs).......................................................................63
erythromycin gel 2% (Erygel)....................................... 142 ESTROGEL -estradiol gel 0.06% (0.75 mg/1.25 gm
erythromycin ophth oint 5 mg/gm............................... 136 metered-dose pump)...................................................... 23
erythromycin pads 2%.................................................. 142 ESTROPIPATE -estropipate tab 0.75 mg......................... 23
erythromycin soln 2%................................................... 142 ESTROPIPATE -estropipate tab 1.5 mg........................... 23
erythromycin w/ delayed release particles cap 250 ESTROPIPATE -estropipate tab 3 mg.............................. 23
mg......................................................................................3 eszopiclone tab 1 mg (Lunesta).................................... 72
ESBRIET -pirfenidone cap 267 mg................................... 56 eszopiclone tab 2 mg (Lunesta).................................... 72
ESBRIET -pirfenidone tab 267 mg.................................... 56 eszopiclone tab 3 mg (Lunesta).................................... 72
ESBRIET -pirfenidone tab 801 mg.................................... 56 ethacrynic acid tab 25 mg.............................................. 47
escitalopram oxalate soln 5 mg/5ml (base equiv) ethambutol hcl tab 100 mg (Myambutol)........................ 5
(Lexapro)........................................................................ 66 ethambutol hcl tab 400 mg (Myambutol)........................ 5
escitalopram oxalate tab 5 mg (base equiv) ethosuximide cap 250 mg (Zarontin)............................ 92
(Lexapro)........................................................................ 66 ethosuximide soln 250 mg/5ml (Zarontin).................... 92
escitalopram oxalate tab 10 mg (base equiv) ethynodiol diacetate & ethinyl estradiol tab 1 mg-35
(Lexapro)........................................................................ 66 mcg................................................................................. 24
escitalopram oxalate tab 20 mg (base equiv) ethynodiol diacetate & ethinyl estradiol tab 1 mg-50
(Lexapro)........................................................................ 66 mcg (Zovia 1/50e)......................................................... 24
esomeprazole magnesium cap delayed release 20 mg ETIDRONATE DISODIUM -etidronate disodium tab 200
(base eq) (Nexium)....................................................... 57 mg.................................................................................... 35
esomeprazole magnesium cap delayed release 40 mg etodolac cap 200 mg....................................................... 87
(base eq) (Nexium)....................................................... 57 etodolac cap 300 mg....................................................... 87
ESSENTIAL AMINO ACID MIX -amino acids oral etodolac tab er 24hr 400 mg.......................................... 87
powder........................................................................... 107 etodolac tab er 24hr 500 mg.......................................... 87
2017
etodolac tab er 24hr 600 mg.......................................... 87 FARYDAK -panobinostat lactate cap 20 mg (base
etodolac tab 400 mg........................................................ 87 equivalent)....................................................................... 15
etodolac tab 500 mg........................................................ 87 FAZACLO -clozapine orally disintegrating tab 12.5
ETOPOSIDE -etoposide cap 50 mg..................................15 mg.................................................................................... 69
EURAX -crotamiton cream 10%...................................... 142 FAZACLO -clozapine orally disintegrating tab 150 mg..... 69
EURAX -crotamiton lotion 10%....................................... 143 FAZACLO -clozapine orally disintegrating tab 200 mg..... 69
EVAMIST -estradiol transdermal spray 1.53 mg/spray..... 23 FC FEMALE CONDOM -condoms - female....................147
EVOTAZ -atazanavir sulfate-cobicistat tab 300-150 mg FC2 FEMALE CONDOM -condoms - female..................147
(base equiv)...................................................................... 7 FEIBA -antiinhibitor coagulant complex for inj................ 130
EVZIO -naloxone hcl solution auto-injector 0.4 felbamate susp 600 mg/5ml (Felbatol).......................... 92
mg/0.4ml........................................................................ 146 felbamate tab 400 mg (Felbatol).................................... 92
EVZIO -naloxone hcl solution auto-injector 2 felbamate tab 600 mg (Felbatol).................................... 92
mg/0.4ml........................................................................ 146 felodipine tab er 24hr 2.5 mg......................................... 40
EXALGO -hydromorphone hcl tab er 24hr deter 32 felodipine tab er 24hr 5 mg............................................ 40
mg.................................................................................... 82 felodipine tab er 24hr 10 mg.......................................... 40
EXELDERM -sulconazole nitrate cream 1%................... 143 FEMCAP -cervical cap 22 mm........................................ 147
EXELDERM -sulconazole nitrate solution 1%................ 143 FEMCAP -cervical cap 26 mm........................................ 147
exemestane tab 25 mg (Aromasin)................................ 15 FEMCAP -cervical cap 30 mm........................................ 147
EXJADE -deferasirox tab for oral susp 125 mg.............. 146 FEMRING -estradiol acetate vaginal ring 0.05
EXJADE -deferasirox tab for oral susp 250 mg.............. 146 mg/24hr........................................................................... 63
EXJADE -deferasirox tab for oral susp 500 mg.............. 146 FEMRING -estradiol acetate vaginal ring 0.1 mg/24hr..... 63
EXTAVIA -interferon beta-1b for inj kit 0.3 mg.................. 77 fenofibrate micronized cap 43 mg................................. 48
EXTRA-VIRT PLUS DHA -prenatal w/o vit a w/ fe fum- fenofibrate micronized cap 130 mg............................... 48
doc-fa-dha cap 29-1.25-350 mg................................... 100 fenofibrate micronized cap 67 mg (Lofibra)................. 48
ezetimibe tab 10 mg (Zetia)............................................ 48 fenofibrate micronized cap 134 mg (Lofibra)............... 48
F fenofibrate tab 54 mg (Lofibra)...................................... 48
fenofibrate tab 160 mg (Lofibra).................................... 49
F.A.A. -nutritional supplement liquid................................ 111 fenofibrate tab 48 mg (Tricor)........................................ 48
FACTIVE -gemifloxacin mesylate tab 320 mg (base fenofibrate tab 145 mg (Tricor)...................................... 49
equiv)................................................................................. 4 FENOPROFEN CALCIUM -fenoprofen calcium cap 200
FALESSA -levonorgest-eth estrad tab 0.1 mg-20 mcg & fa mg.................................................................................... 87
tab 1 mg kit..................................................................... 24 FENOPROFEN CALCIUM -fenoprofen calcium cap 400
famciclovir tab 125 mg (Famvir)...................................... 7 mg.................................................................................... 87
famciclovir tab 250 mg (Famvir)...................................... 7 FENOPROFEN CALCIUM -fenoprofen calcium tab 600
famciclovir tab 500 mg (Famvir)...................................... 7 mg.................................................................................... 88
famotidine for susp 40 mg/5ml (Pepcid)....................... 57 fentanyl citrate lozenge on a handle 200 mcg
famotidine tab 40 mg (Pepcid)....................................... 57 (Actiq)............................................................................. 82
FANAPT -iloperidone tab 1 mg......................................... 69 fentanyl citrate lozenge on a handle 400 mcg
FANAPT -iloperidone tab 2 mg......................................... 69 (Actiq)............................................................................. 82
FANAPT -iloperidone tab 6 mg......................................... 69 (Actiq)............................................................................. 82
FANAPT -iloperidone tab 10 mg....................................... 69 (Actiq)............................................................................. 82
FANAPT -iloperidone tab 12 mg....................................... 69 fentanyl citrate lozenge on a handle 1200 mcg
FANAPT TITRATION PACK -iloperidone tab 1 mg & 2 mg (Actiq)............................................................................. 82
& 4 mg & 6 mg titration pak........................................... 69 fentanyl citrate lozenge on a handle 1600 mcg
FARESTON -toremifene citrate tab 60 mg (base (Actiq)............................................................................. 82
equivalent)....................................................................... 15 FENTANYL -fentanyl td patch 72hr 37.5 mcg/hr...............82
FARXIGA -dapagliflozin propanediol tab 5 mg (base FENTANYL -fentanyl td patch 72hr 62.5 mcg/hr...............82
equivalent)....................................................................... 27 FENTANYL -fentanyl td patch 72hr 87.5 mcg/hr...............82
FARXIGA -dapagliflozin propanediol tab 10 mg (base fentanyl td patch 72hr 12 mcg/hr (Duragesic).............. 82
equivalent)....................................................................... 27 fentanyl td patch 72hr 25 mcg/hr (Duragesic).............. 82
FARYDAK -panobinostat lactate cap 10 mg (base fentanyl td patch 72hr 50 mcg/hr (Duragesic).............. 82
equivalent)....................................................................... 15 fentanyl td patch 72hr 75 mcg/hr (Duragesic).............. 82
FARYDAK -panobinostat lactate cap 15 mg (base fentanyl td patch 72hr 100 mcg/hr (Duragesic)............ 82
equivalent)....................................................................... 15
2017
FENTORA -fentanyl citrate buccal tab 100 mcg (base FLOVENT DISKUS -fluticasone propionate aer pow ba
equiv)............................................................................... 82 250 mcg/blister................................................................ 54
FENTORA -fentanyl citrate buccal tab 200 mcg (base FLOVENT HFA -fluticasone propionate hfa inhal aer 110
equiv)............................................................................... 82 mcg/act (125/valve)........................................................ 54
FENTORA -fentanyl citrate buccal tab 400 mcg (base FLOVENT HFA -fluticasone propionate hfa inhal aer 220
equiv)............................................................................... 82 mcg/act (250/valve)........................................................ 54
FENTORA -fentanyl citrate buccal tab 600 mcg (base FLOVENT HFA -fluticasone propionate hfa inhal aero 44
equiv)............................................................................... 82 mcg/act (50/valve)...........................................................54
FENTORA -fentanyl citrate buccal tab 800 mcg (base FLUAD 2016-2017 -influenza vac type a&b surface ant
equiv)............................................................................... 82 adj susp pref syr 0.5 ml................................................. 12
FER-IN-SOL -ferrous sulfate soln 75 mg/ml (15 mg/ml FLUAD 2017-2018 -influenza vac type a&b surface ant
elemental fe)................................................................. 126 adj susp pref syr 0.5 ml................................................. 12
FERRETTS CHEWABLE IRON -carbonyl iron chew tab FLUARIX QUADRIVALENT 2017 -influenza virus vac split
18 mg (elemental iron)................................................. 126 quadrivalent susp pref syr 0.5ml.................................... 12
FERRIPROX -deferiprone oral soln 100 mg/ml.............. 146 FLUBLOK 2015-2016 -influenza virus vac recombinant
FERRIPROX -deferiprone tab 500 mg............................ 146 hemagglutinin (ha) inj..................................................... 12
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental FLUBLOK 2017-2018 -influenza virus vac recombinant
fe).................................................................................. 126 hemagglutinin (ha) inj..................................................... 12
FERROUS SULFATE -ferrous sulfate liquid 220 mg/5ml FLUBLOK QUADRIVALENT 2017 -influenza vac recomb
(44 mg/5ml elemental fe)............................................. 126 ha quad pf soln pref syr 0.5 ml...................................... 12
FERROUS SULFATE -ferrous sulfate syrup 300 mg/5ml FLUCELVAX QUADRIVALENT 20 -influenza vac tiss-cult
(60 mg/5ml elemental fe)............................................. 126 subunt quad susp pref syr 0.5 ml.................................. 12
ferrous sulfate soln 75 mg/ml (15 mg/ml elemental FLUCELVAX QUADRIVALENT 20 -influenza vac tissue-
fe).................................................................................. 126 cultured subunit quadrivalent im susp........................... 12
FIBER FLOW -nutritional supplement liquid................... 111 fluconazole for susp 10 mg/ml (Diflucan)....................... 5
FIBERSOURCE CLOSED SYSTEM -nutritional fluconazole for susp 40 mg/ml (Diflucan)....................... 5
supplement liquid.......................................................... 111 fluconazole tab 50 mg (Diflucan)..................................... 5
FIBERSOURCE HN CLOSED SYS -nutritional fluconazole tab 100 mg (Diflucan)................................... 5
supplement liquid.......................................................... 111 fluconazole tab 150 mg (Diflucan)................................... 5
FIBERSOURCE HN -nutritional supplement liquid......... 111 fluconazole tab 200 mg (Diflucan)................................... 5
FIBER-STAT -nutritional supplement liquid..................... 111 flucytosine cap 250 mg (Ancobon)................................. 5
FINACEA -azelaic acid foam 15%.................................. 143 flucytosine cap 500 mg (Ancobon)................................. 5
FINACEA -azelaic acid gel 15%..................................... 143 fludrocortisone acetate tab 0.1 mg............................... 20
finasteride tab 5 mg (Proscar)....................................... 63 FLULAVAL QUADRIVALENT 201 -influenza virus vaccine
FIRAZYR -icatibant acetate inj 30 mg/3ml (base split quadrivalent im inj................................................... 12
equivalent)..................................................................... 131 FLULAVAL QUADRIVALENT 201 -influenza virus vac split
FLAREX -fluorometholone acetate ophth susp 0.1%..... 136 quadrivalent susp pref syr 0.5ml.................................... 12
FLAVOR PACKETS -nutritional supplement flavor FLUNISOLIDE -flunisolide nasal soln 25 mcg/act
pack............................................................................... 111 (0.025%).......................................................................... 52
FLAVOUR PAC -nutritional supplement flavor pack....... 111 fluocinolone acetonide cream 0.01%.......................... 143
flavoxate hcl tab 100 mg.................................................62 fluocinolone acetonide cream 0.025% (Synalar)........143
flecainide acetate tab 50 mg.......................................... 41 fluocinolone acetonide oil 0.01% (body oil) (Derma-
flecainide acetate tab 100 mg........................................ 41 smoothe/fs bod).......................................................... 143
flecainide acetate tab 150 mg........................................ 41 fluocinolone acetonide oil 0.01% (scalp oil) (Derma-
FLORICAL -sodium fluoride w/ calcium carb cap 8.3-364 smoothe/fs sca)...........................................................143
mg.................................................................................. 106 fluocinolone acetonide oint 0.025% (Synalar)............ 143
FLORICAL -sodium fluoride w/ calcium carb tab 8.3-364 fluocinolone acetonide (otic) oil 0.01%
mg.................................................................................. 106 (Dermotic).................................................................... 138
FLORIVA -sodium fluoride-vitamin d liqd drops 0.25 mg/ fluocinolone acetonide soln 0.01% (Synalar)............. 143
ml-400 unit/ml............................................................... 106 fluocinonide cream 0.05%............................................ 143
FLOVENT DISKUS -fluticasone propionate aer pow ba 50 fluocinonide emulsified base cream 0.05%................ 143
mcg/blister....................................................................... 54 fluocinonide gel 0.05%.................................................. 143
FLOVENT DISKUS -fluticasone propionate aer pow ba fluocinonide oint 0.05%................................................ 143
100 mcg/blister................................................................ 54 fluocinonide soln 0.05%................................................ 143
2017
FLUORABON -sodium fluoride soln 0.25 mg/0.6ml (from FLUVIRIN 2016-2017 -influenza vac type a&b surface
0.55 mg/0.6ml naf)........................................................106 antigen susp pref syr 0.5 ml...........................................12
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 0.55 FLUVIRIN 2017-2018 -influenza vac type a&b surface
(0.25 mg f)-236.79 mg..................................................106 antigen susp pref syr 0.5 ml...........................................13
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 2.2 (1 mg FLUVIRIN 2015-2016 -influenza virus vaccine types a & b
f)-236.79 mg.................................................................. 106 surface antigen im susp................................................. 12
fluorometholone ophth susp 0.1% (Fml liquifilm)..... 136 FLUVIRIN 2016-2017 -influenza virus vaccine types a & b
FLUOROPLEX -fluorouracil cream 1%........................... 143 surface antigen im susp................................................. 13
fluorouracil cream 5% (Efudex)................................... 143 FLUVIRIN 2017-2018 -influenza virus vaccine types a & b
FLUOROURACIL -fluorouracil cream 0.5%.................... 143 surface antigen im susp................................................. 13
FLUOROURACIL -fluorouracil soln 2%.......................... 143 fluvoxamine maleate tab 25 mg..................................... 66
FLUOROURACIL -fluorouracil soln 5%.......................... 143 fluvoxamine maleate tab 50 mg..................................... 66
FLUOXETINE DR -fluoxetine hcl cap delayed release 90 fluvoxamine maleate tab 100 mg................................... 66
mg.................................................................................... 66 FLUZONE HIGH-DOSE PF 2017 -influenza virus vac split
FLUOXETINE -fluoxetine hcl (pmdd) cap 10 mg.............. 77 high-dose pf susp pref syr 0.5ml....................................13
FLUOXETINE -fluoxetine hcl (pmdd) cap 20 mg.............. 77 FLUZONE INTRADERMAL QUADR -influenza virus vac
fluoxetine hcl cap 10 mg (Prozac)................................. 66 split quad intradermal pen 9 mcg/strain......................... 13
fluoxetine hcl cap 20 mg (Prozac)................................. 66 FLUZONE QUADRIVALENT 2017 -influenza virus
fluoxetine hcl cap 40 mg (Prozac)................................. 66 vaccine split quadrivalent im inj..................................... 13
fluoxetine hcl solution 20 mg/5ml................................. 66 FLUZONE QUADRIVALENT 2017 -influenza virus vac
fluoxetine hcl tab 10 mg................................................. 66 split quadrivalent susp pref syr 0.25 ml......................... 13
fluoxetine hcl tab 20 mg................................................. 66 FLUZONE QUADRIVALENT 2017 -influenza virus vac
FLUPHENAZINE HCL -fluphenazine hcl elixir 2.5 split quadrivalent susp pref syr 0.5ml............................ 13
mg/5ml............................................................................. 69 FML -fluorometholone ophth oint 0.1%........................... 136
FLUPHENAZINE HCL -fluphenazine hcl oral conc 5 mg/ FML FORTE -fluorometholone ophth susp 0.25%.......... 136
ml..................................................................................... 69 FOCALGIN CA -prenat w/o a w/fecbn-fegl-dss-fa tab &
fluphenazine hcl tab 1 mg.............................................. 69 dha cap 300 mg pack...................................................100
fluphenazine hcl tab 2.5 mg........................................... 69 FOCALGIN 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa tab
fluphenazine hcl tab 5 mg.............................................. 69 90 &dha cap 300mg pak.............................................. 100
fluphenazine hcl tab 10 mg............................................ 69 FOCALIN XR -dexmethylphenidate hcl cap er 24 hr 25
FLURA-DROPS -sodium fluoride soln 0.25 mg/drop f mg.................................................................................... 74
(from 0.55 mg/drop naf)............................................... 106 FOCALIN XR -dexmethylphenidate hcl cap er 24 hr 35
flurandrenolide cream 0.05%....................................... 143 mg.................................................................................... 74
flurandrenolide lotion 0.05% (Cordran).......................143 FOLCAL DHA -prenatal w/o vit a w/ fe fum-dss-fa-dha
FLURAZEPAM HCL -flurazepam hcl cap 15 mg.............. 72 cap 27-1.25-300 mg..................................................... 100
FLURAZEPAM HCL -flurazepam hcl cap 30 mg.............. 72 FOLCAPS OMEGA 3 -prenatal vit w/ fe cbn-fe asp glyc-
flurbiprofen sodium ophth soln 0.03% (Ocufen)........136 fa-omega 3 cap 27-1mg............................................... 100
flurbiprofen tab 50 mg.................................................... 88 FOLET DHA -prenat w/fecbn-bisg-methylf-dss tab dr &
flurbiprofen tab 100 mg.................................................. 88 dha cap pak.................................................................. 100
flutamide cap 125 mg...................................................... 15 FOLET ONE -prenat w/o a w/fecbn-bisg-methylf-dss-dha
FLUTICASONE PROPIONATE/SA -fluticasone-salmeterol cap 38-1-225 mg.......................................................... 100
aer powder ba 55-14 mcg/act........................................ 54 folic acid cap 0.8 mg..................................................... 126
FLUTICASONE PROPIONATE/SA -fluticasone-salmeterol folic acid tab 400 mcg................................................... 126
aer powder ba 113-14 mcg/act...................................... 54 folic acid tab 800 mcg................................................... 126
FLUTICASONE PROPIONATE/SA -fluticasone-salmeterol folic acid tab 1 mg......................................................... 126
aer powder ba 232-14 mcg/act...................................... 54 FOLIVANE-OB -prenatal w/o a w/fe fum-fe poly-fa cap
fluticasone propionate cream 0.05% (Cutivate)......... 143 130-92.4-1 mg...............................................................100
fluticasone propionate nasal susp 50 mcg/act............ 52 FOLLISTIM AQ -follitropin beta inj 75 unit/0.5ml.............. 35
fluticasone propionate oint 0.005%............................. 143 FOLLISTIM AQ -follitropin beta inj 300 unit/0.36ml.......... 35
fluvastatin sodium cap 20 mg (Lescol)......................... 49 FOLLISTIM AQ -follitropin beta inj 600 unit/0.72ml.......... 35
fluvastatin sodium cap 40 mg (Lescol)......................... 49 FOLLISTIM AQ -follitropin beta inj 900 unit/1.08ml.......... 35
fluvastatin sodium tab er 24 hr 80 mg (Lescol xl)........49 fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml
FLUVIRIN 2015-2016 -influenza vac type a&b surface (Arixtra).........................................................................127
antigen susp pref syr 0.5 ml...........................................12 fondaparinux sodium subcutaneous inj 5 mg/0.4ml
(Arixtra).........................................................................127
2017
fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml G
(Arixtra).........................................................................127
fondaparinux sodium subcutaneous inj 10 mg/0.8ml GA-1 ANAMIX EARLY YEARS -nutritional supplement
(Arixtra).........................................................................127 powder........................................................................... 111
FORTA DRINK -nutritional supplement powder.............. 111 gabapentin cap 100 mg (Neurontin).............................. 93
FORTA SHAKE -nutritional supplement powder............. 111 gabapentin cap 300 mg (Neurontin).............................. 93
FORTEO -teriparatide (recombinant) inj 600 gabapentin cap 400 mg (Neurontin).............................. 93
mcg/2.4ml........................................................................ 35 gabapentin oral soln 250 mg/5ml (Neurontin).............. 93
FOSAMAX PLUS D -alendronate sodium-cholecalciferol gabapentin tab 600 mg (Neurontin)............................... 93
tab 70-2800 mg-unit....................................................... 35 gabapentin tab 800 mg (Neurontin)............................... 93
FOSAMAX PLUS D -alendronate sodium-cholecalciferol GABITRIL -tiagabine hcl tab 12 mg.................................. 93
tab 70-5600 mg-unit....................................................... 35 GABITRIL -tiagabine hcl tab 16 mg.................................. 93
fosinopril sodium & hydrochlorothiazide tab 10-12.5 GA EXPRESS15 -nutritional supplement pack............... 111
mg................................................................................... 44 GA GEL -nutritional supplement pack............................. 111
fosinopril sodium & hydrochlorothiazide tab 20-12.5 galantamine hydrobromide cap er 24hr 8 mg
mg................................................................................... 44 (Razadyne er)................................................................ 77
fosinopril sodium tab 10 mg.......................................... 44 galantamine hydrobromide cap er 24hr 16 mg
fosinopril sodium tab 20 mg.......................................... 44 (Razadyne er)................................................................ 77
fosinopril sodium tab 40 mg.......................................... 44 galantamine hydrobromide cap er 24hr 24 mg
FOSRENOL -lanthanum carbonate chew tab 500 mg (Razadyne er)................................................................ 77
(elemental).......................................................................60 GALANTAMINE HYDROBROMIDE -galantamine
FOSRENOL -lanthanum carbonate chew tab 750 mg hydrobromide oral soln 4 mg/ml.................................... 77
(elemental).......................................................................60 galantamine hydrobromide tab 4 mg (Razadyne)........ 77
FOSRENOL -lanthanum carbonate chew tab 1000 mg galantamine hydrobromide tab 8 mg (Razadyne)........ 77
(elemental).......................................................................60 galantamine hydrobromide tab 12 mg (Razadyne)...... 77
FOSRENOL -lanthanum carbonate oral powder pack 750 GALZIN -zinc acetate cap 25 mg (elemental zinc)......... 106
mg (elemental)................................................................ 60 GALZIN -zinc acetate cap 50 mg (elemental zinc)......... 106
FOSRENOL -lanthanum carbonate oral powder pack GANIRELIX ACETATE -ganirelix acetate inj 250
1000 mg (elemental).......................................................60 mcg/0.5ml........................................................................ 35
FRAGMIN -dalteparin sodium inj 10000 unit/ml..............127 GA -nutritional supplement powder................................. 111
FRAGMIN -dalteparin sodium inj 2500 unit/0.2ml...........127 gatifloxacin ophth soln 0.5% (Zymaxid)..................... 136
FRAGMIN -dalteparin sodium inj 5000 unit/0.2ml...........128 GATTEX -teduglutide (rdna) for inj kit 5 mg...................... 60
FRAGMIN -dalteparin sodium inj 7500 unit/0.3ml...........128 GEL-KAM ORAL CARE RINSE -stannous fluoride conc
FRAGMIN -dalteparin sodium inj 12500 unit/0.5ml.........128 0.63%.............................................................................139
FRAGMIN -dalteparin sodium inj 15000 unit/0.6ml.........128 GEL-KAM -stannous fluoride gel 0.4%........................... 139
FRAGMIN -dalteparin sodium inj 18000 unit/0.72ml.......128 gemfibrozil tab 600 mg (Lopid)...................................... 49
FRAGMIN -dalteparin sodium inj 95000 unit/3.8ml.........128 GENERESS FE -norethindrone & ethinyl estradiol-fe
FROVA -frovatriptan succinate tab 2.5 mg (base chew tab 0.8 mg-25 mcg................................................24
equivalent)....................................................................... 90 GENTAK -gentamicin sulfate ophth oint 0.3%................ 136
frovatriptan succinate tab 2.5 mg (base equivalent) gentamicin sulfate cream 0.1%.................................... 143
(Frova).............................................................................90 GENTAMICIN SULFATE -gentamicin sulfate oint
FRUITIVITS -nutritional supplement pack.......................111 0.1%...............................................................................143
furosemide oral soln 10 mg/ml...................................... 47 gentamicin sulfate ophth soln 0.3% (Garamycin)...... 136
furosemide tab 20 mg (Lasix)........................................ 47 GENVOYA -elvitegrav-cobic-emtricitab-tenofov af tab
furosemide tab 40 mg (Lasix)........................................ 47 150-150-200-10 mg.......................................................... 7
furosemide tab 80 mg (Lasix)........................................ 47 GIALAX -polyethylene glycol 3350 - kit............................ 56
FUZEON -enfuvirtide for inj 90 mg..................................... 7 GIAZO -balsalazide disodium tab 1.1 gm......................... 60
FYCOMPA -perampanel susp 0.5 mg/ml.......................... 92 GILENYA -fingolimod hcl cap 0.5 mg (base equiv)........... 77
FYCOMPA -perampanel tab 2 mg.................................... 92 GILOTRIF -afatinib dimaleate tab 20 mg (base
FYCOMPA -perampanel tab 4 mg.................................... 92 equivalent)....................................................................... 15
FYCOMPA -perampanel tab 6 mg.................................... 92 GILOTRIF -afatinib dimaleate tab 30 mg (base
FYCOMPA -perampanel tab 8 mg.................................... 92 equivalent)....................................................................... 15
FYCOMPA -perampanel tab 10 mg.................................. 92 GILOTRIF -afatinib dimaleate tab 40 mg (base
FYCOMPA -perampanel tab 12 mg.................................. 92 equivalent)....................................................................... 16
glatiramer acetate soln prefilled syringe 20 mg/ml
(Copaxone)..................................................................... 77
2017
GLEEVEC -imatinib mesylate tab 100 mg (base GLUCERNA 1.0 WITH CARBSTE -nutritional supplement
equivalent)....................................................................... 16 liquid.............................................................................. 112
GLEEVEC -imatinib mesylate tab 400 mg (base GLUCO BURST -nutritional supplement liquid............... 112
equivalent)....................................................................... 16 GLUMETZA -metformin hcl tab er 24hr modified release
GLEOSTINE -lomustine cap 5 mg.................................... 16 500 mg............................................................................ 27
GLEOSTINE -lomustine cap 10 mg.................................. 16 GLUMETZA -metformin hcl tab er 24hr modified release
GLEOSTINE -lomustine cap 40 mg.................................. 16 1000 mg.......................................................................... 27
GLEOSTINE -lomustine cap 100 mg................................ 16 GLUTARADE AMINO ACID BLEN -amino acids oral
glimepiride tab 1 mg (Amaryl)........................................27 powder........................................................................... 107
glimepiride tab 2 mg (Amaryl)........................................27 GLUTARADE ESSENTIAL GA-1 -amino acids oral
glimepiride tab 4 mg (Amaryl)........................................27 powder........................................................................... 107
glipizide-metformin hcl tab 2.5-250 mg......................... 27 GLUTARADE JUNIOR GA-1 -amino acids oral
glipizide-metformin hcl tab 2.5-500 mg......................... 27 powder........................................................................... 107
glipizide-metformin hcl tab 5-500 mg............................ 27 GLUTAREX-1 -nutritional supplement powder................112
glipizide tab er 24hr 2.5 mg (Glucotrol xl).................... 27 GLUTAREX-2 -nutritional supplement powder................112
glipizide tab er 24hr 5 mg (Glucotrol xl)....................... 27 glyburide-metformin tab 1.25-250 mg
glipizide tab er 24hr 10 mg (Glucotrol xl)..................... 27 (Glucovance).................................................................. 27
glipizide tab 5 mg (Glucotrol).........................................27 glyburide-metformin tab 2.5-500 mg (Glucovance)..... 27
glipizide tab 10 mg (Glucotrol).......................................27 glyburide-metformin tab 5-500 mg (Glucovance)........ 27
GLUCAGEN HYPOKIT -glucagon hcl (rdna) for inj 1 mg glyburide micronized tab 1.5 mg (Glynase)..................27
(base equiv).................................................................... 27 glyburide micronized tab 3 mg (Glynase).....................27
GLUCAGON EMERGENCY KIT -glucagon (rdna) for inj glyburide micronized tab 6 mg (Glynase).....................27
kit 1 mg........................................................................... 27 glyburide tab 1.25 mg..................................................... 27
GLUCERNA ADVANCE SHAKE -nutritional supplement glyburide tab 2.5 mg....................................................... 27
liquid.............................................................................. 111 glyburide tab 5 mg.......................................................... 27
GLUCERNA 1.0 CAL/FIBER -nutritional supplement glycopyrrolate tab 1 mg (Robinul)................................. 57
liquid.............................................................................. 112 glycopyrrolate tab 2 mg (Robinul forte)........................57
GLUCERNA 1.0 CAL -nutritional supplement liquid....... 112 GLYCOSADE -nutritional supplement pack.................... 112
GLUCERNA 1.2 CAL -nutritional supplement liquid....... 112 GLYSET -miglitol tab 25 mg.............................................. 27
GLUCERNA 1.5 CAL -nutritional supplement liquid....... 112 GLYSET -miglitol tab 50 mg.............................................. 27
GLUCERNA CARBSTEADY -nutritional supplement GLYSET -miglitol tab 100 mg............................................ 27
liquid.............................................................................. 111 GLYTACTIN BETTERMILK DE-L -nutritional supplement
GLUCERNA CEREAL CRUNCHY F -nutritional pack............................................................................... 112
supplement misc........................................................... 112 GLYTACTIN BETTERMILK 15 -nutritional supplement
GLUCERNA CRISPY DELIGHTS -nutritional supplement pack............................................................................... 112
bar.................................................................................. 112 GLYTACTIN BUILD 10PE -nutritional supplement
GLUCERNA HUNGER SMART SHA -nutritional pack............................................................................... 112
supplement liquid.......................................................... 112 GLYTACTIN COMPLETE 10PE -nutritional supplement
GLUCERNA MEAL -nutritional supplement bar..............112 bar.................................................................................. 112
GLUCERNA MEAL REPLACEMENT -nutritional GLYTACTIN RESTORE LITE 10 -nutritional supplement
supplement bar............................................................. 112 liquid.............................................................................. 112
GLUCERNA MINI SNACK -nutritional supplement GLYTACTIN RESTORE LITE 10 -nutritional supplement
bar.................................................................................. 112 pack............................................................................... 112
GLUCERNA MINI SNACKS -nutritional supplement GLYTACTIN RESTORE 10 -nutritional supplement
bar.................................................................................. 112 liquid.............................................................................. 112
GLUCERNA -nutritional supplement bar.........................111 GLYTACTIN RESTORE 5 -nutritional supplement
GLUCERNA -nutritional supplement liquid..................... 111 pack............................................................................... 112
GLUCERNA OS -nutritional supplement liquid............... 112 GLYTACTIN RTD 10 -nutritional supplement liquid........ 112
GLUCERNA SELECT -nutritional supplement liquid...... 112 GLYTACTIN RTD 15 -nutritional supplement liquid........ 112
GLUCERNA SHAKE -nutritional supplement liquid........ 112 GLYTROL -nutritional supplement liquid......................... 112
GLUCERNA SNACK -nutritional supplement bar........... 112 GLYTROL PREBIO1 -nutritional supplement liquid........ 112
GLUCERNA SNACK SHAKE -nutritional supplement GLYXAMBI -empagliflozin-linagliptin tab 10-5 mg............ 27
liquid.............................................................................. 112 GLYXAMBI -empagliflozin-linagliptin tab 25-5 mg............ 28
GLUCERNA WEIGHT LOSS SHAK -nutritional GNP NUTRITIONAL DRINK -nutritional supplement
supplement liquid.......................................................... 112 liquid.............................................................................. 112
2017
GNP NUTRITIONAL DRINK PLU -nutritional supplement haloperidol tab 0.5 mg.................................................... 69
liquid.............................................................................. 113 haloperidol tab 1 mg....................................................... 69
GOAT MILK -nutritional supplement powder.................. 113 haloperidol tab 2 mg....................................................... 69
GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate haloperidol tab 5 mg....................................................... 69
packet 227.1 gm............................................................. 56 haloperidol tab 10 mg..................................................... 69
GONAL-F -follitropin alfa for inj 450 unit........................... 35 haloperidol tab 20 mg..................................................... 69
GONAL-F -follitropin alfa for inj 1050 unit......................... 35 HARVONI -ledipasvir-sofosbuvir tab 90-400 mg................ 7
GONAL-F RFF -follitropin alfa for inj 75 unit..................... 35 HCU ANAMIX EARLY YEARS -nutritional supplement
GONAL-F RFF REDIJECT -follitropin alfa inj 300 powder........................................................................... 113
unit/0.5ml......................................................................... 35 HCU ANAMIX NEXT -nutritional supplement
GONAL-F RFF REDIJECT -follitropin alfa inj 450 powder........................................................................... 113
unit/0.75ml....................................................................... 35 HCU COOLER -nutritional supplement liquid................. 113
GONAL-F RFF REDIJECT -follitropin alfa inj 900 HCU EXPRESS -nutritional supplement pack................ 113
unit/1.5ml......................................................................... 35 HCU EXPRESS20 -nutritional supplement pack............ 113
G-PREPROTEIN -amino acids oral liquid....................... 107 HCU GEL -nutritional supplement pack.......................... 113
GRALISE -gabapentin (once-daily) tab 300 mg................77 HCU LOPHLEX LQ -nutritional supplement liquid.......... 113
GRALISE -gabapentin (once-daily) tab 600 mg................77 HCY 1 -nutritional supplement powder........................... 113
GRALISE STARTER -gabapentin (once-daily) tab pack HCY 2 -nutritional supplement powder........................... 113
300 mg (9) & 600 mg (69)............................................. 77 HEALTH SOURCE SOY PROTEIN -nutritional
granisetron hcl tab 1 mg................................................ 59 supplement powder...................................................... 113
GRANIX -tbo-filgrastim soln prefilled syringe 300 HEALTHY ACCENTS NUTRA FIT -nutritional supplement
mcg/0.5ml...................................................................... 126 liquid.............................................................................. 113
GRANIX -tbo-filgrastim soln prefilled syringe 480 HEARTBAR -nutritional supplement bar......................... 113
mcg/0.8ml...................................................................... 126 HELIXATE FS -antihemophilic factor (recombinant) for inj
GRASTEK -timothy grass pollen allergen ext tab sl 2800 kit 250 unit.................................................................... 131
bau................................................................................... 14 HELIXATE FS -antihemophilic factor (recombinant) for inj
griseofulvin microsize susp 125 mg/5ml........................ 5 kit 500 unit.................................................................... 131
griseofulvin microsize tab 500 mg (Grifulvin v)............. 5 HELIXATE FS -antihemophilic factor (recombinant) for inj
griseofulvin ultramicrosize tab 125 mg (Gris-peg)........ 6 kit 1000 unit.................................................................. 131
griseofulvin ultramicrosize tab 250 mg (Gris-peg)........ 6 HELIXATE FS -antihemophilic factor (recombinant) for inj
guaifenesin-codeine liquid 225-7.5 mg/5ml.................. 52 kit 2000 unit.................................................................. 131
guaifenesin-codeine soln 100-6.3 mg/5ml.................... 52 HELIXATE FS -antihemophilic factor (recombinant) for inj
guaifenesin-codeine soln 100-10 mg/5ml..................... 52 kit 3000 unit.................................................................. 131
guanfacine hcl tab er 24hr 1 mg (base equiv) HEMENATAL OB + DHA -prenat-fe poly cmplx-fe heme
(Intuniv).......................................................................... 74 poly-fa tab & omega 3 cap pck.................................... 100
guanfacine hcl tab er 24hr 2 mg (base equiv) HEMENATAL OB -prenat vit-fe poly cmplx-fe heme poly-
(Intuniv).......................................................................... 74 fa tab 28-6-1 mg........................................................... 100
guanfacine hcl tab er 24hr 3 mg (base equiv) HEMOFIL M -antihemophilic factor (human) for inj 250
(Intuniv).......................................................................... 74 unit................................................................................. 131
guanfacine hcl tab er 24hr 4 mg (base equiv) HEMOFIL M -antihemophilic factor (human) for inj 500
(Intuniv).......................................................................... 74 unit................................................................................. 131
guanfacine hcl tab 1 mg (Tenex)................................... 44 HEMOFIL M -antihemophilic factor (human) for inj 1000
guanfacine hcl tab 2 mg (Tenex)................................... 44 unit................................................................................. 131
GUANIDINE HCL -guanidine hcl tab 125 mg................... 98 HEMOFIL M -antihemophilic factor (human) for inj 1700
GYNAZOLE-1 -butoconazole nitrate (one dose) vaginal unit................................................................................. 131
cream 2%........................................................................ 63 HEPAMENT -amino acids pack.......................................107
H heparin sodium (porcine) inj 1000 unit/ml.................. 128
heparin sodium (porcine) inj 5000 unit/ml.................. 128
HAELAN 951 FERMENTED ORGA -nutritional heparin sodium (porcine) inj 10000 unit/ml................ 128
supplement liquid.......................................................... 113 heparin sodium (porcine) inj 20000 unit/ml................ 128
HAELAN HTPI FERMENTED ORG -nutritional heparin sodium (porcine) pf inj 5000 unit/0.5ml........ 128
supplement liquid.......................................................... 113 HETLIOZ -tasimelteon capsule 20 mg.............................. 72
halobetasol propionate cream 0.05% (Ultravate)....... 143 HEXALEN -altretamine cap 50 mg................................... 16
halobetasol propionate oint 0.05% (Ultravate)........... 143 HI-CAL -nutritional supplement liquid..............................113
HALOG -halcinonide oint 0.1%....................................... 143
haloperidol lactate oral conc 2 mg/ml...........................69
2017
HIGH-PROTEIN NUTRITIONAL -nutritional supplement HUMULIN N KWIKPEN -insulin nph (human) (isophane)
liquid.............................................................................. 113 susp pen-injector 100 unit/ml......................................... 31
HISTEX-AC -phenylephrine-triprolidine-codeine syrup HUMULIN R -insulin regular (human) inj 100 unit/ml........ 31
10-2.5-10 mg/5ml............................................................ 52 HUMULIN R U-500 (CONCENTR -insulin regular (human)
HM NUTRISURE -nutritional supplement liquid..............113 inj 500 unit/ml..................................................................31
HM NUTRISURE PLUS -nutritional supplement HUMULIN R U-500 KWIKPEN -insulin regular (human)
liquid.............................................................................. 113 soln pen-injector 500 unit/ml.......................................... 31
HOMACTIN AA PLUS -nutritional supplement liquid...... 113 HURRISEAL -dental desensitizing product - solution..... 147
HOMINEX-1 -nutritional supplement powder.................. 113 HYCAMTIN -topotecan hcl cap 0.25 mg (base equiv)...... 16
HOMINEX-2 -nutritional supplement powder.................. 113 HYCAMTIN -topotecan hcl cap 1 mg (base equiv)........... 16
HOM 2 -nutritional supplement powder.......................... 113 hydralazine hcl tab 10 mg.............................................. 44
HORIZANT -gabapentin enacarbil tab er 300 mg............. 77 hydralazine hcl tab 25 mg.............................................. 44
HORIZANT -gabapentin enacarbil tab er 600 mg............. 77 hydralazine hcl tab 50 mg.............................................. 44
H.P. ACTHAR -corticotropin inj gel 80 unit/ml................... 35 hydralazine hcl tab 100 mg............................................ 44
HUMALOG -insulin lispro inj 100 unit/ml...........................30 hydrochlorothiazide cap 12.5 mg (Microzide).............. 47
HUMALOG -insulin lispro soln cartridge 100 unit/ml.........30 hydrochlorothiazide tab 12.5 mg................................... 47
HUMALOG KWIKPEN -insulin lispro soln pen-injector 100 hydrochlorothiazide tab 25 mg...................................... 47
unit/ml.............................................................................. 30 hydrochlorothiazide tab 50 mg...................................... 47
HUMALOG KWIKPEN -insulin lispro soln pen-injector 200 hydrocodone-acetaminophen soln 7.5-325 mg/15ml
unit/ml.............................................................................. 30 (Hycet).............................................................................82
HUMALOG MIX 75/25 -insulin lispro prot & lispro inj 100 hydrocodone-acetaminophen tab 2.5-325 mg.............. 82
unit/ml (75-25)................................................................. 31 hydrocodone-acetaminophen tab 7.5-325 mg
HUMALOG MIX 50/50 -insulin lispro protamine & lispro inj (Norco)............................................................................ 82
100 unit/ml (50-50)......................................................... 31 hydrocodone-acetaminophen tab 5-325 mg
HUMALOG MIX 50/50 KWIKPEN -insulin lispro prot & (Norco)............................................................................ 82
lispro sus pen-inj 100 unit/ml (50-50).............................31 hydrocodone-acetaminophen tab 10-325 mg
HUMALOG MIX 75/25 KWIKPEN -insulin lispro prot & (Norco)............................................................................ 82
lispro sus pen-inj 100 unit/ml (75-25).............................31 hydrocodone-acetaminophen tab 7.5-300 mg
HUMATE-P -antihemophilic factor/vwf (human) for inj (Xodol)............................................................................ 82
250-600 unit.................................................................. 131 hydrocodone-acetaminophen tab 5-300 mg
500-1200 unit................................................................ 131 hydrocodone-acetaminophen tab 10-300 mg
1000-2400 unit.............................................................. 131 hydrocodone-ibuprofen tab 10-200 mg (Ibudone)....... 83
HUMIRA -adalimumab prefilled syringe kit 10 hydrocodone-ibuprofen tab 5-200 mg (Reprexain)......83
mg/0.2ml.......................................................................... 88 hydrocodone-ibuprofen tab 7.5-200 mg
HUMIRA -adalimumab prefilled syringe kit 20 (Vicoprofen)................................................................... 83
mg/0.4ml.......................................................................... 88 hydrocodone w/ homatropine syrup 5-1.5 mg/5ml...... 52
HUMIRA -adalimumab prefilled syringe kit 40 hydrocodone w/ homatropine tab 5-1.5 mg..................52
mg/0.8ml.......................................................................... 88 hydrocod polst-chlorphen polst er susp 10-8 mg/5ml
HUMIRA PEDIATRIC CROHNS D -adalimumab prefilled (Tussionex pennkineti)................................................. 52
syringe kit 40 mg/0.8ml.................................................. 88 hydrocortisone acetate w/ pramoxine rectal cream
HUMIRA PEN -adalimumab pen-injector kit 40 1-1% (Analpram-hc).................................................... 140
mg/0.8ml.......................................................................... 88 hydrocortisone butyrate cream 0.1% (Locoid)...........143
HUMIRA PEN-CROHNS DISEASE -adalimumab pen- hydrocortisone butyrate oint 0.1% (Locoid)............... 143
injector kit 40 mg/0.8ml.................................................. 88 hydrocortisone butyrate soln 0.1% (Locoid).............. 143
HUMIRA PEN-PSORIASIS STAR -adalimumab pen- hydrocortisone cream 2.5%..........................................143
injector kit 40 mg/0.8ml.................................................. 88 hydrocortisone enema 100 mg/60ml
HUMULIN 70/30 -insulin nph isophane & regular human (Cortenema)................................................................. 140
inj 100 unit/ml (70-30).................................................... 31 hydrocortisone lotion 2.5%.......................................... 143
HUMULIN 70/30 KWIKPEN -insulin nph & regular susp hydrocortisone oint 2.5%..............................................143
pen-inj 100 unit/ml (70-30)............................................. 31 hydrocortisone rectal cream 2.5% (Anusol-hc)......... 140
HUMULIN N -insulin nph (human) (isophane) inj 100 unit/ hydrocortisone rectal cream 1% (Proctocort)............ 140
ml..................................................................................... 31 hydrocortisone tab 5 mg (Cortef).................................. 20
hydrocortisone tab 10 mg (Cortef)................................ 20
2017
hydrocortisone tab 20 mg (Cortef)................................ 20 IBRANCE -palbociclib cap 100 mg................................... 16
hydrocortisone valerate cream 0.2%...........................143 IBRANCE -palbociclib cap 125 mg................................... 16
hydrocortisone valerate oint 0.2% (Westcort)............ 143 ibuprofen tab 400 mg...................................................... 88
hydrocortisone w/ acetic acid otic soln 1-2%............ 138 ibuprofen tab 600 mg...................................................... 88
hydromorphone hcl liqd 1 mg/ml (Dilaudid).................83 ibuprofen tab 800 mg...................................................... 88
hydromorphone hcl tab er 24hr deter 8 mg ICAR PEDIATRIC -carbonyl iron susp 15 mg/1.25ml
(Exalgo).......................................................................... 83 (elemental iron)............................................................. 126
hydromorphone hcl tab er 24hr deter 12 mg ICLUSIG -ponatinib hcl tab 15 mg (base equiv)............... 16
(Exalgo).......................................................................... 83 ICLUSIG -ponatinib hcl tab 45 mg (base equiv)............... 16
hydromorphone hcl tab er 24hr deter 16 mg IDELVION -coagulation factor ix (recomb) (rix-fp) for inj
(Exalgo).......................................................................... 83 250 unit......................................................................... 131
hydromorphone hcl tab er 24hr deter 32 mg IDELVION -coagulation factor ix (recomb) (rix-fp) for inj
(Exalgo).......................................................................... 83 500 unit......................................................................... 131
hydromorphone hcl tab 2 mg (Dilaudid)....................... 83 IDELVION -coagulation factor ix (recomb) (rix-fp) for inj
hydromorphone hcl tab 4 mg (Dilaudid)....................... 83 1000 unit....................................................................... 131
hydromorphone hcl tab 8 mg (Dilaudid)....................... 83 IDELVION -coagulation factor ix (recomb) (rix-fp) for inj
hydroxychloroquine sulfate tab 200 mg 2000 unit....................................................................... 131
(Plaquenil)...................................................................... 11 ILEVRO -nepafenac ophth susp 0.3%............................ 136
hydroxyurea cap 500 mg (Hydrea)................................ 16 imatinib mesylate tab 100 mg (base equivalent)
hydroxyzine hcl syrup 10 mg/5ml................................. 64 (Gleevec)........................................................................ 16
hydroxyzine hcl tab 10 mg............................................. 64 imatinib mesylate tab 400 mg (base equivalent)
hydroxyzine hcl tab 25 mg............................................. 64 (Gleevec)........................................................................ 16
hydroxyzine hcl tab 50 mg............................................. 64 IMBRUVICA -ibrutinib cap 140 mg................................... 16
hydroxyzine pamoate cap 25 mg (Vistaril)................... 65 imipramine hcl tab 10 mg (Tofranil).............................. 66
hydroxyzine pamoate cap 50 mg (Vistaril)................... 65 imipramine hcl tab 25 mg (Tofranil).............................. 66
HYDROXYZINE PAMOATE -hydroxyzine pamoate cap imipramine hcl tab 50 mg (Tofranil).............................. 66
100 mg............................................................................ 64 imipramine pamoate cap 75 mg (Tofranil-pm)............. 66
HYQVIA -immun glob inj 2.5 gm/25ml-hyaluron inj 200 imipramine pamoate cap 100 mg (Tofranil-pm)........... 66
unt/1.25 ml kit................................................................. 14 imipramine pamoate cap 125 mg (Tofranil-pm)........... 66
HYQVIA -immun glob inj 5 gm/50ml-hyaluron inj 400 imipramine pamoate cap 150 mg (Tofranil-pm)........... 66
unt/2.5 ml kit................................................................... 14 imiquimod cream 5% (Aldara)...................................... 143
HYQVIA -immun glob inj 10 gm/100ml-hyaluron inj 800 IMMULIFE -nutritional supplement powder..................... 113
unt/5 ml kit...................................................................... 14 IMMUNOPRO RX -nutritional supplement powder......... 113
HYQVIA -immun glob inj 20 gm/200ml-hyaluron inj 1600 IMOVAX RABIES (H.D.C.V.) -rabies virus vaccine, hdc
unt/10 ml kit.................................................................... 14 inj..................................................................................... 13
HYQVIA -immun glob inj 30 gm/300ml-hyaluron inj 2400 IMPACT/FIBER -nutritional supplement liquid................ 113
unt/15 ml kit.................................................................... 14 IMPACT ADVANCED RECOVERY -nutritional
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter supplement liquid.......................................................... 113
20 mg.............................................................................. 83 IMPACT GLUTAMINE -nutritional supplement liquid...... 113
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter IMPACT -nutritional supplement liquid............................ 113
30 mg.............................................................................. 83 IMPACT 1.5 -nutritional supplement liquid...................... 113
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter IMPACT PEPTIDE 1.5 -nutritional supplement liquid..... 113
40 mg.............................................................................. 83 IMPAVIDO -miltefosine cap 50 mg.................................... 11
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter IMUPLUS -nutritional supplement pack.......................... 113
60 mg.............................................................................. 83 INATAL ADVANCE -prenatal vit w/ dss-iron carbonyl-fa
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter tab 90-1 mg...................................................................101
80 mg.............................................................................. 83 INATAL GT -prenatal vit w/ dss-iron carbonyl-fa tab 90-1
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter mg.................................................................................. 101
100 mg............................................................................ 83 INATAL ULTRA -prenatal vit w/ dss-iron carbonyl-fa tab
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter 90-1 mg......................................................................... 101
120 mg............................................................................ 83 INCRELEX -mecasermin inj 40 mg/4ml (10 mg/ml)..........35
I INCRUSE ELLIPTA -umeclidinium br aero powd breath
act 62.5 mcg/inh (base eq)............................................ 54
ibandronate sodium tab 150 mg (base equivalent) indapamide tab 1.25 mg..................................................47
(Boniva).......................................................................... 35 indapamide tab 2.5 mg.................................................... 47
IBRANCE -palbociclib cap 75 mg..................................... 16
2017
indomethacin cap er 75 mg............................................ 88 IOPIDINE -apraclonidine hcl ophth soln 1% (base
indomethacin cap 25 mg................................................ 88 equivalent)..................................................................... 136
indomethacin cap 50 mg................................................ 88 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml..... 54
INFANATE BALANCE -prenatal w/o a w/fe cbn-dss-fa-dha ipratropium bromide inhal soln 0.02%.......................... 54
cap 29-1-265 mg.......................................................... 101 ipratropium bromide nasal soln 0.03% (21 mcg/spray)
INFANRIX -diph, acellular pert & tet tox inj 25 lf-58 (Atrovent)....................................................................... 52
mcg-10 lf/0.5ml............................................................... 14 ipratropium bromide nasal soln 0.06% (42 mcg/spray)
INFASURF -calfactant in nacl 0.9% intratracheal susp 35 (Atrovent)....................................................................... 52
mg/ml............................................................................... 56 irbesartan-hydrochlorothiazide tab 150-12.5 mg
INGREZZA -valbenazine tosylate cap 40 mg (base (Avalide)..........................................................................44
equiv)............................................................................... 77 irbesartan-hydrochlorothiazide tab 300-12.5 mg
INLYTA -axitinib tab 1 mg.................................................. 16 (Avalide)..........................................................................44
INLYTA -axitinib tab 5 mg.................................................. 16 irbesartan tab 75 mg (Avapro)....................................... 44
INNOVACIN -nutritional supplement liquid......................113 irbesartan tab 150 mg (Avapro)..................................... 44
INSULIN PEN NEEDLES-VARIOUS............................... 147 irbesartan tab 300 mg (Avapro)..................................... 44
INSULIN SYRINGES-VARIOUS...................................... 147 IRESSA -gefitinib tab 250 mg........................................... 16
INTELENCE -etravirine tab 25 mg...................................... 7 IRON CHEWS PEDIATRIC -carbonyl iron chew tab 15 mg
INTELENCE -etravirine tab 100 mg.................................... 7 (elemental iron)............................................................. 126
INTELENCE -etravirine tab 200 mg.................................... 7 ISENTRESS HD -raltegravir potassium tab 600 mg (base
INTERARTICULAR JOINT KIT -triamcinolone inj 40 mg/ equiv)................................................................................. 7
ml & lidocaine 1% & ammonia inh kit............................ 20 ISENTRESS -raltegravir potassium chew tab 25 mg (base
INTROLITE -nutritional supplement liquid.......................114 equiv)................................................................................. 7
INTRON A -interferon alfa-2b for inj 10000000 unit.......... 16 ISENTRESS -raltegravir potassium chew tab 100 mg
INTRON A -interferon alfa-2b for inj 18000000 unit.......... 16 (base equiv)...................................................................... 7
INTRON A -interferon alfa-2b for inj 50000000 unit.......... 16 ISENTRESS -raltegravir potassium packet for susp 100
INTRON A -interferon alfa-2b inj 6000000 unit/ml............ 16 mg (base equiv)................................................................ 7
INTRON A -interferon alfa-2b inj 10000000 unit/ml.......... 16 ISENTRESS -raltegravir potassium tab 400 mg (base
INTRON A W/DILUENT -interferon alfa-2b for inj equiv)................................................................................. 7
10000000 unit................................................................. 16 ISOCAL HN -nutritional supplement liquid...................... 114
INTRON A W/DILUENT -interferon alfa-2b for inj ISOCAL HN PLUS -nutritional supplement liquid........... 114
18000000 unit................................................................. 16 ISOCAL -nutritional supplement liquid............................ 114
INTRON A W/DILUENT -interferon alfa-2b for inj ISONIAZID -isoniazid syrup 50 mg/5ml.............................. 5
50000000 unit................................................................. 16 isoniazid tab 100 mg......................................................... 5
INVIRASE -saquinavir mesylate cap 200 mg..................... 7 isoniazid tab 300 mg......................................................... 5
INVIRASE -saquinavir mesylate tab 500 mg...................... 7 ISORDIL TITRADOSE -isosorbide dinitrate tab 40
INVOKAMET -canagliflozin-metformin hcl tab 50-500 mg.................................................................................... 37
mg.................................................................................... 28 ISOSORBIDE DINITRATE ER -isosorbide dinitrate tab er
INVOKAMET -canagliflozin-metformin hcl tab 150-500 40 mg.............................................................................. 37
mg.................................................................................... 28 isosorbide dinitrate tab 10 mg....................................... 37
INVOKAMET -canagliflozin-metformin hcl tab 50-1000 isosorbide dinitrate tab 20 mg....................................... 37
mg.................................................................................... 28 isosorbide dinitrate tab 30 mg....................................... 37
INVOKAMET -canagliflozin-metformin hcl tab 150-1000 isosorbide dinitrate tab 5 mg (Isordil titradose).......... 37
mg.................................................................................... 28 isosorbide mononitrate tab er 24hr 30 mg................... 37
INVOKAMET XR -canagliflozin-metformin hcl tab er 24hr isosorbide mononitrate tab er 24hr 60 mg................... 37
50-500 mg....................................................................... 28 isosorbide mononitrate tab er 24hr 120 mg................. 37
INVOKAMET XR -canagliflozin-metformin hcl tab er 24hr isosorbide mononitrate tab 10 mg................................ 37
50-1000 mg..................................................................... 28 isosorbide mononitrate tab 20 mg................................ 37
INVOKAMET XR -canagliflozin-metformin hcl tab er 24hr ISOSOURCE 1.5 CAL -nutritional supplement liquid......114
150-500 mg..................................................................... 28 ISOSOURCE CLOSED SYSTEM -nutritional supplement
INVOKAMET XR -canagliflozin-metformin hcl tab er 24hr liquid.............................................................................. 114
150-1000 mg................................................................... 28 ISOSOURCE HN -nutritional supplement liquid............. 114
INVOKANA -canagliflozin tab 100 mg.............................. 28 ISOSOURCE -nutritional supplement liquid.................... 114
INVOKANA -canagliflozin tab 300 mg.............................. 28 ISOSOURCE VHN -nutritional supplement liquid........... 114
IONSYS -fentanyl hcl iontophoretic td system 40 mcg/act isotretinoin cap 10 mg.................................................. 143
(base equiv).................................................................... 83 isotretinoin cap 20 mg.................................................. 143
2017
isotretinoin cap 30 mg.................................................. 143 JARDIANCE -empagliflozin tab 25 mg............................. 28
isotretinoin cap 40 mg.................................................. 143 JENTADUETO -linagliptin-metformin hcl tab 2.5-1000
ISOVACTIN AA PLUS -nutritional supplement liquid...... 114 mg.................................................................................... 28
isradipine cap 2.5 mg...................................................... 40 JENTADUETO -linagliptin-metformin hcl tab 2.5-500
isradipine cap 5 mg......................................................... 40 mg.................................................................................... 28
ISTALOL -timolol maleate ophth soln 0.5% (once- JENTADUETO -linagliptin-metformin hcl tab 2.5-850
daily).............................................................................. 136 mg.................................................................................... 28
itraconazole cap 100 mg (Sporanox).............................. 6 JENTADUETO XR -linagliptin-metformin hcl tab er 24hr
IVA ANAMIX EARLY YEARS -nutritional supplement 2.5-1000 mg.................................................................... 28
powder........................................................................... 114 JENTADUETO XR -linagliptin-metformin hcl tab er 24hr
IVA ANAMIX NEXT -nutritional supplement powder....... 114 5-1000 mg....................................................................... 28
I-VALEX-1 -nutritional supplement powder..................... 113 JEVITY 1 CAL/FIBER -nutritional supplement liquid...... 114
I-VALEX-2 -nutritional supplement powder..................... 113 JEVITY 1.2 CAL/FIBER -nutritional supplement
ivermectin tab 3 mg (Stromectol).................................. 11 liquid.............................................................................. 114
IXINITY -coagulation factor ix (recombinant) for inj 250 JEVITY 1.5 CAL/FIBER -nutritional supplement
unit................................................................................. 131 liquid.............................................................................. 114
IXINITY -coagulation factor ix (recombinant) for inj 500 JEVITY 1 CAL -nutritional supplement liquid.................. 114
unit................................................................................. 131 JEVITY 1.2 CAL -nutritional supplement liquid............... 114
IXINITY -coagulation factor ix (recombinant) for inj 1000 JEVITY 1.5 CAL -nutritional supplement liquid............... 114
unit................................................................................. 131 JTT PHYSICIANS KIT -triamcinolone inj 40 mg/ml &
IXINITY -coagulation factor ix (recombinant) for inj 1500 lidocaine 1% & ammonia inh kit..................................... 20
unit................................................................................. 131 JUBLIA -efinaconazole soln 10%.................................... 143
IXINITY -coagulation factor ix (recombinant) for inj 2000 JUICE PLUS FIBRE -nutritional supplement liquid......... 114
unit................................................................................. 131 JUVEN -nutritional supplement pack.............................. 114
IXINITY -coagulation factor ix (recombinant) for inj 3000 JUVEN -nutritional supplement powder.......................... 114
unit................................................................................. 131 JUVEN NUTRIVIGOR -nutritional supplement pack.......114
J JUVEN REVIGOR -nutritional supplement pack.............114
JUXTAPID -lomitapide mesylate cap 5 mg (base
JADENU -deferasirox tab 90 mg..................................... 146 equiv)............................................................................... 49
JADENU -deferasirox tab 180 mg................................... 146 JUXTAPID -lomitapide mesylate cap 10 mg (base
JADENU -deferasirox tab 360 mg................................... 146 equiv)............................................................................... 49
JAKAFI -ruxolitinib phosphate tab 5 mg (base JUXTAPID -lomitapide mesylate cap 20 mg (base
equivalent)....................................................................... 16 equiv)............................................................................... 49
JAKAFI -ruxolitinib phosphate tab 25 mg (base
equivalent)....................................................................... 16 K
JANUMET -sitagliptin-metformin hcl tab 50-500 mg......... 28 KALETRA -lopinavir-ritonavir soln 400-100 mg/5ml (80-20
JANUMET -sitagliptin-metformin hcl tab 50-1000 mg....... 28 mg/ml)................................................................................ 7
JANUMET XR -sitagliptin-metformin hcl tab er 24hr KALETRA -lopinavir-ritonavir tab 100-25 mg...................... 7
50-500 mg....................................................................... 28 KALETRA -lopinavir-ritonavir tab 200-50 mg...................... 7
JANUMET XR -sitagliptin-metformin hcl tab er 24hr KALYDECO -ivacaftor packet 50 mg................................ 56
50-1000 mg..................................................................... 28 KALYDECO -ivacaftor packet 75 mg................................ 56
JANUMET XR -sitagliptin-metformin hcl tab er 24hr KALYDECO -ivacaftor tab 150 mg.................................... 56
100-1000 mg................................................................... 28 KARBINAL ER -carbinoxamine maleate extended release
JANUVIA -sitagliptin phosphate tab 25 mg (base susp 4 mg/5ml................................................................ 51
equiv)............................................................................... 28 KATE FARMS CORE ESSENTIAL -nutritional supplement
JANUVIA -sitagliptin phosphate tab 50 mg (base liquid.............................................................................. 114
equiv)............................................................................... 28 KAZANO -alogliptin-metformin hcl tab 12.5-1000 mg....... 28
JANUVIA -sitagliptin phosphate tab 100 mg (base KAZANO -alogliptin-metformin hcl tab 12.5-500 mg......... 28
equiv)............................................................................... 28 KCENTRA -prothrombin complex conc human for inj kit
JARDIANCE -empagliflozin tab 10 mg............................. 28 500 unit......................................................................... 131
2017
KCENTRA -prothrombin complex conc human for inj kit KOGENATE FS -antihemophilic factor (recombinant) for
1000 unit....................................................................... 131 inj kit 250 unit............................................................... 132
KERYDIN -tavaborole soln 5%........................................143 KOGENATE FS -antihemophilic factor (recombinant) for
KETOCAL 4:1 LQ MULTI FIBE -nutritional supplement inj kit 500 unit............................................................... 132
liquid.............................................................................. 114 KOGENATE FS -antihemophilic factor (recombinant) for
KETOCAL 4:1 -nutritional supplement liquid.................. 114 inj kit 1000 unit............................................................. 132
KETOCAL 3:1 -nutritional supplement powder............... 114 KOGENATE FS -antihemophilic factor (recombinant) for
KETOCAL 4:1 -nutritional supplement powder............... 114 inj kit 2000 unit............................................................. 132
ketoconazole cream 2%................................................ 143 KOGENATE FS -antihemophilic factor (recombinant) for
ketoconazole shampoo 2% (Nizoral)........................... 144 inj kit 3000 unit............................................................. 132
KETOGEN -nutritional supplement powder.................... 114 KOGENATE FS BIO-SET -antihemophilic factor
KETONEX-1 -nutritional supplement powder..................114 (recombinant) for inj kit 250 unit.................................. 132
KETONEX-2 -nutritional supplement powder..................114 KOGENATE FS BIO-SET -antihemophilic factor
ketoprofen cap 50 mg..................................................... 88 (recombinant) for inj kit 500 unit.................................. 132
ketoprofen cap 75 mg..................................................... 88 KOGENATE FS BIO-SET -antihemophilic factor
ketorolac tromethamine ophth soln 0.5% (recombinant) for inj kit 1000 unit................................ 132
(Acular)......................................................................... 136 KOGENATE FS BIO-SET -antihemophilic factor
ketorolac tromethamine ophth soln 0.4% (Acular (recombinant) for inj kit 2000 unit................................ 132
ls)................................................................................... 136 KOGENATE FS BIO-SET -antihemophilic factor
ketorolac tromethamine tab 10 mg............................... 88 (recombinant) for inj kit 3000 unit................................ 132
KETOVIE -nutritional supplement liquid.......................... 114 KOMBIGLYZE XR -saxagliptin-metformin hcl tab er 24hr
KETOVIE PEPTIDE -nutritional supplement liquid......... 114 2.5-1000 mg.................................................................... 28
KETOVOLVE 4:1 -nutritional supplement powder.......... 114 KOMBIGLYZE XR -saxagliptin-metformin hcl tab er 24hr
KIDS PROTEIN ORGANIC NUTR -nutritional supplement 5-500 mg......................................................................... 28
liquid.............................................................................. 114 KOMBIGLYZE XR -saxagliptin-metformin hcl tab er 24hr
KINERET -anakinra subcutaneous soln prefilled syringe 5-1000 mg....................................................................... 29
100 mg/0.67ml................................................................ 88 KORLYM -mifepristone tab 300 mg.................................. 29
KINRAY PREFERRED PLUS -nutritional supplement KOVALTRY -antihemophilic factor (recombinant) for inj
liquid.............................................................................. 114 250 unit......................................................................... 132
KINRIX -diph-tetanus tox ad-acell pert & polio virus, ipv KOVALTRY -antihemophilic factor (recombinant) for inj
vac inj.............................................................................. 14 500 unit......................................................................... 132
KISQALI FEMARA 200 DOSE -ribociclib tab 200 mg & KOVALTRY -antihemophilic factor (recombinant) for inj
letrozole tab 2.5 mg therapy pack..................................16 1000 unit....................................................................... 132
KISQALI -ribociclib succinate tab 200 mg (base K-PAX IMMUNE BOOSTER PROT -nutritional
equiv)............................................................................... 16 supplement powder...................................................... 114
KITABIS PAK -tobramycin nebu soln 300 mg/5ml.............. 5 KRISTALOSE -lactulose oral crystal packet 10 gm.......... 56
KLOR-CON M15 -potassium chloride microencapsulated KRISTALOSE -lactulose oral crystal packet 20 gm.......... 56
crys er tab 15 meq....................................................... 106 K-TAB -potassium chloride tab er 8 meq (600 mg)......... 106
KOATE -antihemophilic factor (human) for inj 250 K-TAB -potassium chloride tab er 20 meq (1500 mg)..... 106
unit................................................................................. 131 KUVAN -sapropterin dihydrochloride powder packet 100
KOATE -antihemophilic factor (human) for inj 500 mg.................................................................................... 35
unit................................................................................. 131 KUVAN -sapropterin dihydrochloride powder packet 500
KOATE -antihemophilic factor (human) for inj 1000 mg.................................................................................... 35
unit................................................................................. 131 KUVAN -sapropterin dihydrochloride soluble tab 100
KOATE-DVI -antihemophilic factor (human) for inj 250 mg.................................................................................... 35
unit................................................................................. 131 KYNAMRO -mipomersen sodium soln prefilled syringe
KOATE-DVI -antihemophilic factor (human) for inj 500 200 mg/ml....................................................................... 49
unit................................................................................. 132 L
KOATE-DVI -antihemophilic factor (human) for inj 1000
unit................................................................................. 132 labetalol hcl tab 100 mg (Trandate)............................... 38
labetalol hcl tab 200 mg (Trandate)............................... 39
labetalol hcl tab 300 mg (Trandate)............................... 39
2017
LACRISERT -artificial tear ophth insert...........................136 LANOXIN -digoxin tab 187.5 mcg (0.1875 mg)................ 37
lactic acid (ammonium lactate) lotion 12% (Lac- LANOXIN -digoxin tab 250 mcg (0.25 mg)....................... 37
hydrin).......................................................................... 144 lansoprazole cap delayed release 15 mg
lactulose (encephalopathy) solution 10 gm/15ml........ 60 (Prevacid)....................................................................... 57
lactulose solution 10 gm/15ml....................................... 56 lansoprazole cap delayed release 30 mg
LAMICTAL STARTER/NOT TAKI -lamotrigine tab 25 mg (Prevacid)....................................................................... 57
(42) & 100 mg (7) starter kit...........................................93 LANTUS -insulin glargine inj 100 unit/ml.......................... 32
LAMICTAL STARTER/TAKING C -lamotrigine tab 25 mg LANTUS SOLOSTAR -insulin glargine soln pen-injector
(84) & 100 mg (14) starter kit.........................................93 100 unit/ml.......................................................................32
LAMICTAL STARTER/TAKING V -lamotrigine tab 25 mg LASTACAFT -alcaftadine ophth soln 0.25%................... 136
(35) starter kit..................................................................93 latanoprost ophth soln 0.005% (Xalatan).................... 136
LAMICTAL XR -lamotrigine tab er 24hr 25 (14) & 50 mg LATUDA -lurasidone hcl tab 20 mg...................................69
(14) & 100 mg(7) kit....................................................... 93 LATUDA -lurasidone hcl tab 40 mg...................................69
LAMICTAL XR -lamotrigine tab er 24hr 50 (14) & 100 LATUDA -lurasidone hcl tab 60 mg...................................69
mg(14) & 200 mg(7) kit.................................................. 93 LATUDA -lurasidone hcl tab 80 mg...................................69
LAMICTAL XR -lamotrigine tab er 24hr 25 mg (21) & 50 LATUDA -lurasidone hcl tab 120 mg.................................69
mg (7) titration kit............................................................93 LAZANDA -fentanyl citrate nasal spray 100 mcg/act (base
lamivudine oral soln 10 mg/ml (Epivir)........................... 7 equiv)............................................................................... 83
lamivudine tab 150 mg (Epivir)........................................ 7 LAZANDA -fentanyl citrate nasal spray 300 mcg/act (base
lamivudine tab 300 mg (Epivir)........................................ 7 equiv)............................................................................... 83
lamivudine tab 100 mg (hbv) (Epivir hbv)....................... 7 LAZANDA -fentanyl citrate nasal spray 400 mcg/act (base
lamivudine-zidovudine tab 150-300 mg (Combivir)....... 7 equiv)............................................................................... 83
lamotrigine orally disintegrating tab 25 mg (Lamictal leflunomide tab 10 mg (Arava)....................................... 88
odt).................................................................................. 93 leflunomide tab 20 mg (Arava)....................................... 88
lamotrigine orally disintegrating tab 50 mg (Lamictal LENVIMA 14 MG DAILY DOSE -lenvatinib cap therapy
odt).................................................................................. 93 pack 10 & 4 mg (14 mg daily dose)............................... 17
odt).................................................................................. 93 pack 10 & 4 (2) mg (18 mg daily dose)......................... 17
odt).................................................................................. 93 pack 10 (2) & 4 mg (24 mg daily dose)......................... 17
lamotrigine tab chewable dispersible 5 mg (Lamictal LENVIMA 10 MG DAILY DOSE -lenvatinib cap therapy
chewable di).................................................................. 93 pack 10 mg (10 mg daily dose)..................................... 17
lamotrigine tab chewable dispersible 25 mg (Lamictal LENVIMA 20 MG DAILY DOSE -lenvatinib cap therapy
chewable di).................................................................. 93 pack 10 (2) mg (20 mg daily dose)................................ 17
lamotrigine tab disint 25 (14) & 50 mg (14) & 100 mg LENVIMA 8 MG DAILY DOSE -lenvatinib cap therapy
(7) kit (Lamictal odt)..................................................... 93 pack 4 (2) mg (8 mg daily dose).................................... 17
lamotrigine tab disint 25 mg (21) & 50 mg (7) titration LETAIRIS -ambrisentan tab 5 mg..................................... 50
kit (Lamictal odt)........................................................... 93 LETAIRIS -ambrisentan tab 10 mg................................... 50
lamotrigine tab disint 50 mg (42)- 100 mg(14) titration letrozole tab 2.5 mg (Femara)........................................ 17
kit (Lamictal odt)........................................................... 93 LEUCOVORIN CALCIUM -leucovorin calcium tab 10
lamotrigine tab er 24hr 25 mg (Lamictal xr)................. 93 mg.................................................................................... 17
lamotrigine tab er 24hr 50 mg (Lamictal xr)................. 93 LEUCOVORIN CALCIUM -leucovorin calcium tab 15
lamotrigine tab er 24hr 100 mg (Lamictal xr)............... 93 mg.................................................................................... 17
lamotrigine tab er 24hr 200 mg (Lamictal xr)............... 93 leucovorin calcium tab 5 mg.......................................... 17
lamotrigine tab er 24hr 250 mg (Lamictal xr)............... 93 leucovorin calcium tab 25 mg........................................ 17
lamotrigine tab er 24hr 300 mg (Lamictal xr)............... 93 LEU-FREE COOLER -nutritional supplement liquid....... 115
lamotrigine tab 25 mg (Lamictal)................................... 93 LEUKERAN -chlorambucil tab 2 mg................................. 17
lamotrigine tab 100 mg (Lamictal)................................. 93 LEUKINE -sargramostim lyophilized for inj 250 mcg...... 126
lamotrigine tab 150 mg (Lamictal)................................. 93 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base
lamotrigine tab 200 mg (Lamictal)................................. 93 equiv) (Xopenex concentrate)..................................... 55
LANAFLEX -nutritional supplement pack........................ 115 levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
LANCETS-VARIOUS........................................................147 (Xopenex)....................................................................... 55
LANCING DEVICE-VARIOUS......................................... 147 levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv)
LANOXIN -digoxin tab 62.5 mcg (0.0625 mg).................. 37 (Xopenex)....................................................................... 55
LANOXIN -digoxin tab 125 mcg (0.125 mg)..................... 37
2017
levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv) LEVULAN KERASTICK -aminolevulinic acid hcl for soln
(Xopenex)....................................................................... 55 20% (stick applicator)................................................... 144
LEVEMIR FLEXTOUCH -insulin detemir soln pen-injector LEXIVA -fosamprenavir calcium susp 50 mg/ml (base
100 unit/ml.......................................................................32 equiv)................................................................................. 7
LEVEMIR -insulin detemir inj 100 unit/ml..........................32 LEXIVA -fosamprenavir calcium tab 700 mg (base
levetiracetam oral soln 100 mg/ml (Keppra).................94 equiv)................................................................................. 7
levetiracetam tab er 24hr 500 mg (Keppra xr).............. 94 LIALDA -mesalamine tab delayed release 1.2 gm........... 60
levetiracetam tab er 24hr 750 mg (Keppra xr).............. 94 lidocaine hcl gel 2%...................................................... 144
levetiracetam tab 250 mg (Keppra)............................... 94 LIDOCAINE HCL -lidocaine hcl laryngotracheal soln
levetiracetam tab 500 mg (Keppra)............................... 94 4%.................................................................................. 139
levetiracetam tab 750 mg (Keppra)............................... 94 lidocaine hcl soln 4% (Xylocaine)............................... 144
levetiracetam tab 1000 mg (Keppra)............................. 94 lidocaine hcl viscous soln 2%..................................... 139
levobunolol hcl ophth soln 0.5% (Betagan)............... 136 lidocaine patch 5% (Lidoderm).................................... 144
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)..... 35 lidocaine-prilocaine cream 2.5-2.5% (Emla)............... 144
levocarnitine tab 330 mg (Carnitor)............................... 35 lidocaine-prilocaine cream kit 2.5-2.5%...................... 144
levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 LINDANE -lindane shampoo 1%..................................... 144
mg/ml) (Xyzal)................................................................ 51 linezolid for susp 100 mg/5ml (Zyvox).......................... 11
levocetirizine dihydrochloride tab 5 mg (Xyzal)...........51 linezolid tab 600 mg (Zyvox).......................................... 11
LEVOFLOXACIN -levofloxacin oral soln 25 mg/ml............. 4 LINZESS -linaclotide cap 72 mcg..................................... 61
levofloxacin ophth soln 0.5%....................................... 136 LINZESS -linaclotide cap 145 mcg................................... 61
levofloxacin tab 250 mg (Levaquin)................................ 4 LINZESS -linaclotide cap 290 mcg................................... 61
levofloxacin tab 500 mg (Levaquin)................................ 4 liothyronine sodium tab 5 mcg (Cytomel).................... 32
levofloxacin tab 750 mg (Levaquin)................................ 5 liothyronine sodium tab 25 mcg (Cytomel).................. 32
levonor-eth est tab 0.15-0.02/0.025/0.03 mg &eth est liothyronine sodium tab 50 mcg (Cytomel).................. 32
0.01 mg (Quartette)....................................................... 24 LIPISTART -nutritional supplement powder.................... 115
levonorgestrel & ethinyl estradiol (91-day) tab LIQUACEL -amino acids oral liquid................................ 107
0.15-0.03 mg.................................................................. 24 LIQUACEL PUMP + GO -amino acids oral liquid........... 107
levonorgestrel & ethinyl estradiol tab 0.1 mg-20 LIQUID HOPE -nutritional supplement liquid.................. 115
mcg................................................................................. 24 lisinopril & hydrochlorothiazide tab 10-12.5 mg
levonorgestrel & ethinyl estradiol tab 0.15 mg-30 (Zestoretic)..................................................................... 44
mcg................................................................................. 24 lisinopril & hydrochlorothiazide tab 20-12.5 mg
LEVONORGESTREL AND ETHINY -levonorgestrel- (Zestoretic)..................................................................... 44
ethinyl estradiol (continuous) tab 90-20 mcg................. 24 lisinopril & hydrochlorothiazide tab 20-25 mg
levonorgestrel-eth estra tab (Zestoretic)..................................................................... 44
0.05-30/0.075-40/0.125-30mg-mcg............................... 24 lisinopril tab 5 mg (Prinivil)............................................ 44
levonorgestrel tab 1.5 mg............................................... 24 lisinopril tab 10 mg (Prinivil).......................................... 44
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab lisinopril tab 20 mg (Prinivil).......................................... 44
0.01mg(7) (Loseasonique)........................................... 24 lisinopril tab 2.5 mg (Zestril).......................................... 44
levonorg-eth est tab 0.15-0.03mg(84) & eth est tab lisinopril tab 30 mg (Zestril)........................................... 44
0.01mg(7) (Seasonique)............................................... 24 lisinopril tab 40 mg (Zestril)........................................... 44
LEVORPHANOL TARTRATE -levorphanol tartrate tab 2 LISTERINE ESSENTIAL CARE -sod monofluorophosph-
mg.................................................................................... 83 eucal-men-methyl sal-thymol gel 0.76%...................... 139
levothyroxine sodium tab 25 mcg (Synthroid)............. 32 LISTERINE NATURALS WITH F -sodium fluoride rinse
levothyroxine sodium tab 50 mcg (Synthroid)............. 32 0.02%.............................................................................139
levothyroxine sodium tab 75 mcg (Synthroid)............. 32 LISTERINE RESTORING -sodium fluoride rinse 0.0221%
levothyroxine sodium tab 88 mcg (Synthroid)............. 32 (0.01% f)........................................................................139
levothyroxine sodium tab 100 mcg (Synthroid)........... 32 LISTERINE SMART RINSE -sodium fluoride rinse
levothyroxine sodium tab 112 mcg (Synthroid)........... 32 0.0221% (0.01% f)........................................................ 139
levothyroxine sodium tab 125 mcg (Synthroid)........... 32 LISTERINE TOTAL CARE PLUS -sodium fluoride rinse
levothyroxine sodium tab 137 mcg (Synthroid)........... 32 0.0221% (0.01% f)........................................................ 139
levothyroxine sodium tab 150 mcg (Synthroid)........... 32 LISTERINE TOTAL CARE -sodium fluoride rinse 0.0221%
levothyroxine sodium tab 175 mcg (Synthroid)........... 32 (0.01% f)........................................................................139
levothyroxine sodium tab 200 mcg (Synthroid)........... 32 LISTERINE TOTAL CARE ZERO -sodium fluoride rinse
levothyroxine sodium tab 300 mcg (Synthroid)........... 32 0.02%.............................................................................139
2017
LISTERINE WHITENING/RESTO -sodium fluoride rinse LUMIGAN -bimatoprost ophth soln 0.01%...................... 136
0.0221% (0.01% f)........................................................ 139 LUZU -luliconazole cream 1%......................................... 144
lithium carbonate cap 300 mg....................................... 69 LYNPARZA -olaparib cap 50 mg....................................... 17
lithium carbonate cap 150 mg (Lithium carbonate)..... 69 LYRICA -pregabalin cap 25 mg.........................................94
lithium carbonate cap 600 mg (Lithium carbonate)..... 69 LYRICA -pregabalin cap 50 mg.........................................94
LITHIUM CARBONATE -lithium carbonate cap 150 LYRICA -pregabalin cap 75 mg.........................................94
mg.................................................................................... 69 LYRICA -pregabalin cap 100 mg.......................................94
LITHIUM CARBONATE -lithium carbonate cap 600 LYRICA -pregabalin cap 150 mg.......................................94
mg.................................................................................... 69 LYRICA -pregabalin cap 200 mg.......................................94
lithium carbonate tab er 450 mg.................................... 70 LYRICA -pregabalin cap 225 mg.......................................94
lithium carbonate tab er 300 mg (Lithobid).................. 70 LYRICA -pregabalin cap 300 mg.......................................94
lithium carbonate tab 300 mg........................................ 70 LYRICA -pregabalin soln 20 mg/ml................................... 94
LITHIUM -lithium oral solution 8 meq/5ml......................... 69 LYSODREN -mitotane tab 500 mg....................................17
LITHOBID -lithium carbonate tab er 300 mg.................... 70 M
LITHOSTAT -acetohydroxamic acid tab 250 mg............... 64
LIVALO -pitavastatin calcium tab 1 mg (base equiv)........ 49 malathion lotion 0.5% (Ovide)...................................... 144
LIVALO -pitavastatin calcium tab 2 mg (base equiv)........ 49 MAPROTILINE HCL -maprotiline hcl tab 25 mg............... 66
LIVALO -pitavastatin calcium tab 4 mg (base equiv)........ 49 MAPROTILINE HCL -maprotiline hcl tab 50 mg............... 66
LMD -nutritional supplement powder.............................. 115 MAPROTILINE HCL -maprotiline hcl tab 75 mg............... 66
LO LOESTRIN FE -norethin-eth estradiol-fe tab 1 mg-10 MAR-COF BP -pseudoephedrine-bromphen-codeine liqd
mcg (24)/10 mcg (2)....................................................... 24 30-2-7.5 mg/5ml.............................................................. 52
LONSURF -trifluridine-tipiracil tab 15-6.14 mg................. 17 MARNATAL-F -prenatal w/o vit a w/ fe polysac cmplx-fa
LONSURF -trifluridine-tipiracil tab 20-8.19 mg................. 17 cap 60-1 mg.................................................................. 101
LOPHLEX LQ 20 -nutritional supplement liquid.............. 115 MARPLAN -isocarboxazid tab 10 mg............................... 67
LOPHLEX -nutritional supplement pack..........................115 MATULANE -procarbazine hcl cap 50 mg........................ 17
lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) MAXIDEX -dexamethasone ophth susp 0.1%................ 136
(Kaletra)............................................................................ 7 MCT PRO-CAL -nutritional supplement pack................. 115
lorazepam conc 2 mg/ml (Lorazepam intensol)........... 65 MCT PROCAL -nutritional supplement powder.............. 115
lorazepam tab 0.5 mg (Ativan)....................................... 65 MECLOFENAMATE SODIUM -meclofenamate sodium
lorazepam tab 1 mg (Ativan).......................................... 65 cap 50 mg....................................................................... 88
lorazepam tab 2 mg (Ativan).......................................... 65 MECLOFENAMATE SODIUM -meclofenamate sodium
losartan potassium & hydrochlorothiazide tab 50-12.5 cap 100 mg..................................................................... 88
mg (Hyzaar)....................................................................44 MEDICAL PROVIDER SINGLE U -influenza virus vaccine
losartan potassium & hydrochlorothiazide tab split pf susp pref syr kit 0.5 ml....................................... 13
100-12.5 mg (Hyzaar).................................................... 44 MEDICAL PROVIDER SINGLE U -influenza virus vac
losartan potassium & hydrochlorothiazide tab 100-25 split quad inj prefilled syr kit 0.25 ml.............................. 13
mg (Hyzaar)....................................................................44 MEDICAL PROVIDER SINGLE U -influenza virus vac
losartan potassium tab 25 mg (Cozaar)........................ 44 types a & b pf pref syringe kit 0.5 ml............................. 13
losartan potassium tab 50 mg (Cozaar)........................ 44 MEDROL -methylprednisolone tab 2 mg.......................... 20
losartan potassium tab 100 mg (Cozaar)...................... 45 medroxyprogesterone acetate im susp 150 mg/ml
LOTEMAX -loteprednol etabonate ophth gel 0.5%......... 136 (Depo-provera contrac)................................................ 24
LOTEMAX -loteprednol etabonate ophth oint 0.5%........ 136 medroxyprogesterone acetate im susp prefilled syr
LOTEMAX -loteprednol etabonate ophth susp 0.5%...... 136 150 mg/ml (Depo-provera contrac)............................. 24
lovastatin tab 10 mg........................................................ 49 medroxyprogesterone acetate tab 2.5 mg
lovastatin tab 20 mg........................................................ 49 (Provera)......................................................................... 26
lovastatin tab 40 mg (Mevacor)..................................... 49 medroxyprogesterone acetate tab 5 mg (Provera)...... 26
loxapine succinate cap 5 mg......................................... 70 medroxyprogesterone acetate tab 10 mg
loxapine succinate cap 10 mg....................................... 70 (Provera)......................................................................... 26
loxapine succinate cap 25 mg....................................... 70 mefenamic acid cap 250 mg (Ponstel).......................... 88
loxapine succinate cap 50 mg....................................... 70 mefloquine hcl tab 250 mg............................................. 11
LOZI-FLUR -sodium fluoride lozenge 1 mg f (from 2.2 mg MEGA MULTIVITAMIN -multiple vitamins w/ minerals
naf)................................................................................. 106 powder........................................................................... 101
LPS CRITICAL CARE SUGAR F -nutritional supplement megestrol acetate susp 625 mg/5ml (Megace es)........ 26
liquid.............................................................................. 115 megestrol acetate susp 40 mg/ml (Megace oral)......... 17
LPS SUGAR FREE -nutritional supplement liquid.......... 115 megestrol acetate tab 20 mg.......................................... 17
megestrol acetate tab 40 mg.......................................... 17
2017
MEKINIST -trametinib dimethyl sulfoxide tab 0.5 mg methadone hcl conc 10 mg/ml (Methadose)................ 83
(base equivalent)............................................................ 17 methadone hcl soln 5 mg/5ml (Methadone hcl)........... 83
MEKINIST -trametinib dimethyl sulfoxide tab 2 mg (base methadone hcl soln 10 mg/5ml (Methadone hcl)......... 83
equivalent)....................................................................... 17 methadone hcl tab for oral susp 40 mg........................ 83
meloxicam tab 7.5 mg (Mobic)....................................... 88 methadone hcl tab 10 mg (Dolophine).......................... 83
meloxicam tab 15 mg (Mobic)........................................ 88 methadone hcl tab 5 mg (Dolophine hcl)..................... 83
melphalan tab 2 mg (Alkeran)........................................ 17 methamphetamine hcl tab 5 mg (Desoxyn).................. 74
memantine hcl oral solution 2 mg/ml (Namenda)........ 77 methazolamide tab 25 mg (Neptazane)......................... 47
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak methazolamide tab 50 mg (Neptazane)......................... 47
(Namenda titration pa)................................................. 78 methenamine hippurate tab 1 gm (Hiprex)................... 62
memantine hcl tab 5 mg (Namenda)............................. 78 METHERGINE -methylergonovine maleate tab 0.2
memantine hcl tab 10 mg (Namenda)........................... 78 mg.................................................................................... 34
M-END PE -phenylephrine-bromphen w/ codeine liqd methimazole tab 5 mg (Tapazole).................................. 32
3.33-1.33-6.33 mg/5ml....................................................52 methimazole tab 10 mg (Tapazole)................................ 32
MENEST -esterified estrogens tab 0.3 mg....................... 23 METHIONAID -nutritional supplement powder............... 115
MENEST -esterified estrogens tab 0.625 mg................... 23 METHITEST -methyltestosterone oral tab 10 mg............. 21
MENEST -esterified estrogens tab 1.25 mg..................... 23 methocarbamol tab 750 mg (Robaxin-750)................... 98
MENOPUR -menotropins for subcutaneous inj 75 methocarbamol tab 500 mg (Robaxin).......................... 98
unit................................................................................... 35 methotrexate sodium for inj 1 gm................................. 17
MENOSTAR -estradiol td patch weekly 14 mcg/24hr....... 23 methotrexate sodium inj 50 mg/2ml (25 mg/ml)........... 17
MENTAX -butenafine hcl cream 1%................................144 methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)...... 17
MEPERIDINE HCL -meperidine hcl oral soln 50 methotrexate sodium inj pf 100 mg/4ml (25 mg/
mg/5ml............................................................................. 83 ml)................................................................................... 17
MEPHYTON -phytonadione tab 5 mg............................... 99 methotrexate sodium inj pf 200 mg/8ml (25 mg/
meprobamate tab 200 mg............................................... 65 ml)................................................................................... 17
meprobamate tab 400 mg............................................... 65 methotrexate sodium inj pf 250 mg/10ml (25 mg/
mercaptopurine tab 50 mg............................................. 17 ml)................................................................................... 17
MERITENE -nutritional supplement powder................... 115 methotrexate sodium inj pf 1000 mg/40ml (25 mg/
MESALAMINE DR -mesalamine tab delayed release 800 ml)................................................................................... 17
mg.................................................................................... 61 METHOTREXATE SODIUM -methotrexate sodium inj 250
mesalamine enema 4 gm................................................ 61 mg/10ml (25 mg/ml)........................................................17
mesalamine tab delayed release 1.2 gm (Lialda)......... 61 methotrexate sodium tab 2.5 mg (base equiv)............. 18
MESNEX -mesna tab 400 mg........................................... 17 methoxsalen rapid cap 10 mg (Oxsoralen ultra)........ 144
MESTINON -pyridostigmine bromide syrup 60 methscopolamine bromide tab 2.5 mg (Pamine)......... 57
mg/5ml............................................................................. 99 methscopolamine bromide tab 5 mg (Pamine
METAFORM -nutritional supplement pack...................... 115 forte)................................................................................58
METAPROTERENOL SULFATE -metaproterenol sulfate METHYCLOTHIAZIDE -methyclothiazide tab 5 mg..........47
syrup 10 mg/5ml............................................................. 55 methyldopa tab 250 mg.................................................. 45
METAPROTERENOL SULFATE -metaproterenol sulfate methyldopa tab 500 mg.................................................. 45
tab 20 mg........................................................................ 55 methylphenidate hcl cap er 24hr 20 mg (la) (Ritalin
METAXALONE -metaxalone tab 400 mg.......................... 98 la)..................................................................................... 75
metaxalone tab 800 mg (Skelaxin)................................ 98 methylphenidate hcl cap er 24hr 30 mg (la) (Ritalin
metformin hcl tab er 24hr 500 mg (Glucophage xr)..... 29 la)..................................................................................... 75
metformin hcl tab er 24hr 750 mg (Glucophage xr)..... 29 methylphenidate hcl cap er 24hr 40 mg (la) (Ritalin
metformin hcl tab er 24hr modified release 500 mg la)..................................................................................... 75
(Glumetza)...................................................................... 29 methylphenidate hcl cap er 10 mg (cd)........................ 75
metformin hcl tab er 24hr modified release 1000 mg methylphenidate hcl cap er 20 mg (cd)........................ 75
(Glumetza)...................................................................... 29 methylphenidate hcl cap er 30 mg (cd)........................ 75
metformin hcl tab er 24hr osmotic 500 mg methylphenidate hcl cap er 40 mg (cd)........................ 75
(Fortamet)....................................................................... 29 methylphenidate hcl cap er 50 mg (cd)........................ 75
metformin hcl tab er 24hr osmotic 1000 mg methylphenidate hcl cap er 60 mg (cd)........................ 75
(Fortamet)....................................................................... 29 METHYLPHENIDATE HCL ER -methylphenidate hcl tab
metformin hcl tab 500 mg (Glucophage)...................... 29 er 24hr 18 mg................................................................. 75
metformin hcl tab 850 mg (Glucophage)...................... 29 METHYLPHENIDATE HCL ER -methylphenidate hcl tab
metformin hcl tab 1000 mg (Glucophage).................... 29 er 24hr 27 mg................................................................. 75
2017
METHYLPHENIDATE HCL ER -methylphenidate hcl tab metoprolol succinate tab er 24hr 200 mg (tartrate
er 24hr 36 mg................................................................. 75 equiv) (Toprol xl)........................................................... 39
METHYLPHENIDATE HCL ER -methylphenidate hcl tab metoprolol tartrate tab 25 mg........................................ 39
er 24hr 54 mg................................................................. 75 metoprolol tartrate tab 50 mg (Lopressor)................... 39
METHYLPHENIDATE HCL -methylphenidate hcl chew metoprolol tartrate tab 100 mg (Lopressor)................. 39
tab 2.5 mg....................................................................... 75 metronidazole cap 375 mg (Flagyl)............................... 11
METHYLPHENIDATE HCL -methylphenidate hcl chew metronidazole cream 0.75% (Metrocream)................. 144
tab 5 mg.......................................................................... 75 metronidazole gel 0.75%............................................... 144
METHYLPHENIDATE HCL -methylphenidate hcl chew metronidazole gel 1% (Metrogel)................................. 144
tab 10 mg........................................................................ 75 metronidazole lotion 0.75% (Metrolotion)................... 144
methylphenidate hcl soln 5 mg/5ml (Methylin)............ 75 metronidazole tab 250 mg (Flagyl)................................ 11
methylphenidate hcl soln 10 mg/5ml (Methylin).......... 75 metronidazole tab 500 mg (Flagyl)................................ 11
methylphenidate hcl tab er 10 mg................................. 75 metronidazole vaginal gel 0.75% (Metrogel-
methylphenidate hcl tab er 20 mg................................. 75 vaginal)........................................................................... 63
methylphenidate hcl tab er osmotic release (osm) 18 mexiletine hcl cap 150 mg.............................................. 41
mg (Concerta)................................................................ 75 mexiletine hcl cap 200 mg.............................................. 41
methylphenidate hcl tab er osmotic release (osm) 27 mexiletine hcl cap 250 mg.............................................. 41
mg (Concerta)................................................................ 75 MICONAZOLE 3 -miconazole nitrate vaginal suppos 200
methylphenidate hcl tab er osmotic release (osm) 36 mg.................................................................................... 63
mg (Concerta)................................................................ 75 midodrine hcl tab 2.5 mg................................................ 48
methylphenidate hcl tab er osmotic release (osm) 54 midodrine hcl tab 5 mg................................................... 48
mg (Concerta)................................................................ 75 midodrine hcl tab 10 mg................................................. 48
methylphenidate hcl tab 5 mg (Ritalin)......................... 75 miglitol tab 25 mg (Glyset)............................................. 29
methylphenidate hcl tab 10 mg (Ritalin)....................... 75 miglitol tab 50 mg (Glyset)............................................. 29
methylphenidate hcl tab 20 mg (Ritalin)....................... 75 miglitol tab 100 mg (Glyset)........................................... 29
methylprednisolone tab 4 mg (Medrol)......................... 20 MIGRANAL -dihydroergotamine mesylate nasal spray 4
methylprednisolone tab 8 mg (Medrol)......................... 20 mg/ml............................................................................... 90
methylprednisolone tab 16 mg (Medrol)....................... 20 MILLIPRED DP -prednisolone tab therapy pack 5 mg
methylprednisolone tab 32 mg (Medrol)....................... 20 (21).................................................................................. 20
methylprednisolone tab therapy pack 4 mg (21) MILLIPRED DP -prednisolone tab therapy pack 5 mg
(Medrol dosepak).......................................................... 20 (48).................................................................................. 20
methyltestosterone cap 10 mg (Testred)...................... 21 MILLIPRED -prednisolone sod phosphate oral soln 10
METIPRANOLOL -metipranolol ophth soln 0.3%........... 136 mg/5ml (base equiv)....................................................... 20
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)........ 61 MILLIPRED -prednisolone tab 5 mg................................. 20
metoclopramide hcl tab 5 mg (Reglan)......................... 61 MINASTRIN 24 FE -norethindrone ace-eth estradiol-fe
metoclopramide hcl tab 10 mg (Reglan)....................... 61 chew tab 1 mg-20 mcg (24)........................................... 25
METOCLOPRAMIDE ODT -metoclopramide hcl orally MINIVELLE -estradiol td patch twice weekly 0.025
disintegrating tab 5 mg................................................... 61 mg/24hr........................................................................... 23
METOCLOPRAMIDE ODT -metoclopramide hcl orally MINIVELLE -estradiol td patch twice weekly 0.0375
disintegrating tab 10 mg................................................. 61 mg/24hr........................................................................... 23
metolazone tab 2.5 mg.................................................... 47 MINIVELLE -estradiol td patch twice weekly 0.05
metolazone tab 5 mg....................................................... 47 mg/24hr........................................................................... 23
metolazone tab 10 mg..................................................... 47 MINIVELLE -estradiol td patch twice weekly 0.075
METOPROLOL/HYDROCHLOROTHI -metoprolol & mg/24hr........................................................................... 23
hydrochlorothiazide tab 100-50 mg................................ 45 MINIVELLE -estradiol td patch twice weekly 0.1
metoprolol & hydrochlorothiazide tab 50-25 mg mg/24hr........................................................................... 23
(Lopressor hct)..............................................................45 minocycline hcl cap 50 mg (Minocin)............................. 4
metoprolol & hydrochlorothiazide tab 100-25 mg minocycline hcl cap 75 mg (Minocin)............................. 4
(Lopressor hct)..............................................................45 minocycline hcl cap 100 mg (Minocin)........................... 4
metoprolol succinate tab er 24hr 25 mg (tartrate MINOCYCLINE HCL ER -minocycline hcl tab er 24hr 45
equiv) (Toprol xl)........................................................... 39 mg...................................................................................... 4
metoprolol succinate tab er 24hr 50 mg (tartrate minocycline hcl tab er 24hr 90 mg.................................. 4
equiv) (Toprol xl)........................................................... 39 minocycline hcl tab er 24hr 135 mg................................ 4
metoprolol succinate tab er 24hr 100 mg (tartrate minocycline hcl tab 50 mg............................................... 4
equiv) (Toprol xl)........................................................... 39 minocycline hcl tab 75 mg............................................... 4
2017
minocycline hcl tab 100 mg............................................. 4 mometasone furoate solution 0.1% (lotion)
minoxidil tab 2.5 mg........................................................ 45 (Elocon)........................................................................ 144
minoxidil tab 10 mg......................................................... 45 MONOCAL -sodium monofluorophosphate-calcium carb
MIRCERA -methoxy peg-epoetin beta soln prefilled syr 30 tab 22.75-625 mg......................................................... 106
mcg/0.3ml...................................................................... 126 MONOCLATE-P -antihemophilic factor (human) for inj kit
MIRCERA -methoxy peg-epoetin beta soln prefilled syr 50 1000 unit....................................................................... 132
mcg/0.3ml...................................................................... 126 MONOCLATE-P -antihemophilic factor (human) for inj kit
MIRCERA -methoxy peg-epoetin beta soln prefilled syr 75 1500 unit....................................................................... 132
mcg/0.3ml...................................................................... 126 MONOGEN -nutritional supplement powder................... 115
MIRCERA -methoxy peg-epoetin beta soln prefilled syr MONONINE -coagulation factor ix for inj 1000 unit........ 132
100 mcg/0.3ml.............................................................. 126 montelukast sodium chew tab 4 mg (base equiv)
MIRCERA -methoxy peg-epoetin beta soln prefilled syr (Singulair)....................................................................... 55
150 mcg/0.3ml.............................................................. 126 montelukast sodium chew tab 5 mg (base equiv)
MIRCERA -methoxy peg-epoetin beta soln prefilled syr (Singulair)....................................................................... 55
200 mcg/0.3ml.............................................................. 126 montelukast sodium tab 10 mg (base equiv)
mirtazapine orally disintegrating tab 15 mg (Remeron (Singulair)....................................................................... 55
soltab)............................................................................. 67 MONUROL -fosfomycin tromethamine powd pack 3 gm
mirtazapine orally disintegrating tab 30 mg (Remeron (base equivalent)............................................................ 62
soltab)............................................................................. 67 morphine sulfate cap er 24hr 10 mg (Kadian).............. 83
mirtazapine orally disintegrating tab 45 mg (Remeron morphine sulfate cap er 24hr 20 mg (Kadian).............. 84
soltab)............................................................................. 67 morphine sulfate cap er 24hr 30 mg (Kadian).............. 84
mirtazapine tab 7.5 mg....................................................67 morphine sulfate cap er 24hr 50 mg (Kadian).............. 84
mirtazapine tab 15 mg (Remeron)................................. 67 morphine sulfate cap er 24hr 60 mg (Kadian).............. 84
mirtazapine tab 30 mg (Remeron)................................. 67 morphine sulfate cap er 24hr 80 mg (Kadian).............. 84
mirtazapine tab 45 mg (Remeron)................................. 67 morphine sulfate cap er 24hr 100 mg (Kadian)............ 84
misoprostol tab 100 mcg (Cytotec)............................... 58 MORPHINE SULFATE ER -morphine sulfate beads cap
misoprostol tab 200 mcg (Cytotec)............................... 58 er 24hr 30 mg................................................................. 84
MITIGARE -colchicine cap 0.6 mg.................................... 91 MORPHINE SULFATE ER -morphine sulfate beads cap
MITOSOL -mitomycin for ophth soln kit 0.2 mg.............. 136 er 24hr 45 mg................................................................. 84
MMA/PA ANAMIX EARLY YEARS -nutritional supplement MORPHINE SULFATE ER -morphine sulfate beads cap
powder........................................................................... 115 er 24hr 60 mg................................................................. 84
MMA/PA ANAMIX NEXT -nutritional supplement MORPHINE SULFATE ER -morphine sulfate beads cap
powder........................................................................... 115 er 24hr 75 mg................................................................. 84
MMA/PA COOLER -nutritional supplement liquid........... 115 MORPHINE SULFATE ER -morphine sulfate beads cap
MMA/PA COOLER15 -nutritional supplement liquid....... 115 er 24hr 90 mg................................................................. 84
MMA/PA GEL -nutritional supplement pack.................... 115 MORPHINE SULFATE ER -morphine sulfate beads cap
modafinil tab 100 mg (Provigil)...................................... 75 er 24hr 120 mg............................................................... 84
modafinil tab 200 mg (Provigil)...................................... 75 MORPHINE SULFATE -morphine sulfate tab 15 mg........ 83
MODERIBA 1200 DOSE PACK -ribavirin tab 600 mg........ 8 MORPHINE SULFATE -morphine sulfate tab 30 mg........ 83
MODERIBA 800 DOSE PACK -ribavirin tab 400 mg.......... 8 morphine sulfate oral soln 10 mg/5ml.......................... 84
MODERIBA -ribavirin tab 200 mg & ribavirin tab 400 mg morphine sulfate oral soln 20 mg/5ml.......................... 84
dose pack.......................................................................... 7 morphine sulfate oral soln 100 mg/5ml (20 mg/ml)..... 84
MODERIBA -ribavirin tab 400 mg & ribavirin tab 600 mg morphine sulfate tab er 15 mg (Ms contin).................. 84
dose pack.......................................................................... 8 morphine sulfate tab er 30 mg (Ms contin).................. 84
MODULEN IBD -nutritional supplement powder............. 115 morphine sulfate tab er 60 mg (Ms contin).................. 84
moexipril hcl tab 7.5 mg................................................. 45 morphine sulfate tab er 100 mg (Ms contin)................ 84
moexipril hcl tab 15 mg.................................................. 45 morphine sulfate tab er 200 mg (Ms contin)................ 84
moexipril-hydrochlorothiazide tab 7.5-12.5 mg........... 45 MOTOFEN -difenoxin w/ atropine tab 1-0.025 mg............57
moexipril-hydrochlorothiazide tab 15-12.5 mg............ 45 MOVANTIK -naloxegol oxalate tab 12.5 mg (base
moexipril-hydrochlorothiazide tab 15-25 mg............... 45 equivalent)....................................................................... 61
mometasone furoate cream 0.1% (Elocon)................ 144 MOVANTIK -naloxegol oxalate tab 25 mg (base
mometasone furoate nasal susp 50 mcg/act equivalent)....................................................................... 61
(Nasonex)....................................................................... 52 MOVIPREP -peg 3350-kcl-nacl-na sulfate-na ascorbate-c
mometasone furoate oint 0.1% (Elocon).................... 144 for soln 100 gm...............................................................57
MOXATAG -amoxicillin (trihydrate) tab er 24hr 775 mg...... 1
2017
MOXEZA -moxifloxacin hcl ophth soln 0.5% (base eq) (2 nadolol tab 80 mg (Corgard).......................................... 39
times daily).................................................................... 136 NAFRINSE DAILY/ACIDULATED -sodium fluoride-
moxifloxacin hcl ophth soln 0.5% (base equiv) phosphoric acid for soln 1 mg/5ml (f equiv)................. 139
(Vigamox)..................................................................... 136 NAFRINSE DAILY/NEUTRAL -sodium fluoride for soln
moxifloxacin hcl tab 400 mg (base equiv) (Avelox)....... 5 rinse 0.05%................................................................... 139
MSUD AID -nutritional supplement powder.................... 115 NAFRINSE WEEKLY -sodium fluoride for soln rinse
MSUD ANAMIX EARLY YEARS -nutritional supplement 0.2%...............................................................................139
powder........................................................................... 115 naftifine hcl cream 1%.................................................. 144
MSUD COOLER -nutritional supplement liquid.............. 115 naftifine hcl cream 2% (Naftin).................................... 144
MSUD EXPRESS -nutritional supplement pack............. 115 NAFTIN -naftifine hcl cream 2%..................................... 144
MSUD EXPRESS20 -nutritional supplement pack......... 115 NAFTIN -naftifine hcl gel 1%........................................... 144
MSUD GEL -nutritional supplement pack....................... 115 NAFTIN -naftifine hcl gel 2%........................................... 144
MSUD LOPHLEX LQ -nutritional supplement liquid....... 115 naloxone hcl inj 0.4 mg/ml........................................... 146
MSUD MAXAMAID -nutritional supplement powder....... 115 NALOXONE HCL -naloxone hcl soln prefilled syringe 2
MSUD MAXAMUM -nutritional supplement powder....... 115 mg/2ml........................................................................... 146
MSUD 2 -nutritional supplement powder........................ 115 naltrexone hcl tab 50 mg (Revia)................................. 146
MULTAQ -dronedarone hcl tab 400 mg (base NAMENDA XR -memantine hcl cap er 24hr 7 mg............ 78
equivalent)....................................................................... 41 NAMENDA XR -memantine hcl cap er 24hr 14 mg.......... 78
mupirocin calcium cream 2% (Bactroban)................. 144 NAMENDA XR -memantine hcl cap er 24hr 21 mg.......... 78
mupirocin oint 2% (Bactroban).................................... 144 NAMENDA XR -memantine hcl cap er 24hr 28 mg.......... 78
M-VIT -prenatal vit w/ fe fumarate-fa tab 27-1 mg.......... 101 NAMENDA XR TITRATION PACK -memantine hcl cap er
MYALEPT -metreleptin for subcutaneous inj 11.3 mg...... 35 24hr 7 mg & 14 mg & 21 mg & 28 mg pack.................. 78
mycophenolate mofetil cap 250 mg (Cellcept)........... 148 NAMZARIC -memantine-donepezil cap er 24hr 7 & 14 &
mycophenolate mofetil for oral susp 200 mg/ml 21 & 28-10 mg pack....................................................... 78
(Cellcept)...................................................................... 148 NAMZARIC -memantine hcl-donepezil hcl cap er 24hr
mycophenolate mofetil tab 500 mg (Cellcept)............148 7-10 mg........................................................................... 78
mycophenolate sodium tab dr 180 mg (mycophenolic NAMZARIC -memantine hcl-donepezil hcl cap er 24hr
acid equiv) (Myfortic)................................................. 148 14-10 mg......................................................................... 78
mycophenolate sodium tab dr 360 mg (mycophenolic NAMZARIC -memantine hcl-donepezil hcl cap er 24hr
acid equiv) (Myfortic)................................................. 148 21-10 mg......................................................................... 78
MYLERAN -busulfan tab 2 mg.......................................... 18 NAMZARIC -memantine hcl-donepezil hcl cap er 24hr
MYNATAL ADVANCE -prenatal vit w/ dss-iron carbonyl-fa 28-10 mg......................................................................... 78
tab 90-1 mg...................................................................101 naproxen sodium tab er 24hr 375 mg (base equiv)
MYNATAL PLUS -prenatal vit w/ fe fumarate-fa tab 65-1 (Naprelan)....................................................................... 88
mg.................................................................................. 101 naproxen sodium tab er 24hr 500 mg (base equiv)
MYNATAL -prenatal multivitamins & minerals w/ iron & fa (Naprelan)....................................................................... 88
cap 1 mg....................................................................... 101 naproxen sodium tab 275 mg (Anaprox)...................... 88
MYNATAL ULTRACAPLET -prenatal vit w/ dss-iron naproxen sodium tab 550 mg (Anaprox ds)................. 88
carbonyl-fa tab 90-1 mg............................................... 101 naproxen susp 125 mg/5ml............................................ 88
MYNATAL-Z -prenatal vit w/ fe fumarate-fa tab 65-1 naproxen tab ec 375 mg (Ec-naprosyn)........................ 88
mg.................................................................................. 101 naproxen tab ec 500 mg (Ec-naprosyn)........................ 88
MYNATE 90 PLUS -prenatal vit w/ dss-fe fumarate-fa tab naproxen tab 250 mg (Naprosyn).................................. 88
er 90-1 mg.................................................................... 101 naproxen tab 375 mg (Naprosyn).................................. 88
MYRBETRIQ -mirabegron tab er 24 hr 25 mg..................62 naproxen tab 500 mg (Naprosyn).................................. 88
MYRBETRIQ -mirabegron tab er 24 hr 50 mg..................62 naratriptan hcl tab 1 mg (base equiv) (Amerge).......... 90
MYTESI -crofelemer tab delayed release 125 mg............ 57 naratriptan hcl tab 2.5 mg (base equiv) (Amerge)....... 90
N NARCAN -naloxone hcl nasal spray 4 mg/0.1ml............ 146
NASCOBAL -cyanocobalamin nasal spray 500
nabumetone tab 500 mg................................................. 88 mcg/0.1ml...................................................................... 126
nabumetone tab 750 mg................................................. 88 NATACHEW -prenatal vit w/ fe fum-fe bisglycin-fa chew
nadolol & bendroflumethiazide tab 40-5 mg tab 28-1 mg...................................................................101
(Corzide)......................................................................... 45 NATACYN -natamycin ophth susp 5%............................ 136
nadolol & bendroflumethiazide tab 80-5 mg NATALVIT -prenatal vit w/ fe fumarate-fa tab 75-1
(Corzide)......................................................................... 45 mg.................................................................................. 101
nadolol tab 20 mg (Corgard).......................................... 39
nadolol tab 40 mg (Corgard).......................................... 39
2017
NATAZIA -estradiol valerate-dienogest tab 3 mg /2-2 NEORAL -cyclosporine modified oral soln 100 mg/
mg/2-3 mg/1 mg............................................................. 25 ml................................................................................... 148
nateglinide tab 60 mg (Starlix)....................................... 29 NEO-SYNALAR -neomycin sulfate-fluocinolone acetonide
nateglinide tab 120 mg (Starlix)..................................... 29 cream 0.5-0.025%........................................................ 144
NATELLE ONE -prenatal w/o vit a w/ fe fum-fa-omega 3 NEPRO -nutritional supplement liquid.............................115
cap 28-1-250 mg.......................................................... 101 NEPRO WITH CARBSTEADY -nutritional supplement
NATROBA -spinosad susp 0.9%..................................... 144 liquid.............................................................................. 116
NATURE-THROID -thyroid tab 16.25 mg..........................32 NEPRO WITH CARB STEADY -nutritional supplement
NATURE-THROID -thyroid tab 32.5 mg............................32 liquid.............................................................................. 116
NATURE-THROID -thyroid tab 65 mg...............................32 NESINA -alogliptin benzoate tab 6.25 mg (base
NATURE-THROID -thyroid tab 81.25 mg..........................33 equiv)............................................................................... 29
NATURE-THROID -thyroid tab 97.5 mg............................33 NESINA -alogliptin benzoate tab 12.5 mg (base
NATURE-THROID -thyroid tab 113.75 mg........................ 33 equiv)............................................................................... 29
NATURE-THROID -thyroid tab 130 mg.............................33 NESINA -alogliptin benzoate tab 25 mg (base equiv).......29
NATURE-THROID -thyroid tab 146.25 mg....................... 33 NESTABS ABC -prenatal w/o vit a w/fe polysac-fa-ca tab
NATURE-THROID -thyroid tab 195 mg.............................33 & omega 3 cap............................................................. 101
NATURE-THROID -thyroid tab 260 mg.............................33 NESTABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg
NATURE-THROID -thyroid tab 48.75 mg (3/4 grain)........ 32 & omega cap pack....................................................... 101
NATURE-THROID -thyroid tab 325 mg (5 grain).............. 33 NESTABS -prenatal vit w/o vit a w/ fe bisglycinate-fa tab
NEBUPENT -pentamidine isethionate for nebulization 32-1 mg......................................................................... 101
soln 300 mg.................................................................... 11 NESTLE FLAVOR EXTRA STREN -nutritional
NECON 1/50-28 -norethindrone & mestranol tab 1 mg-50 supplement flavor pack................................................ 116
mcg.................................................................................. 25 NESTLE FLAVOR FOR KIDS -nutritional supplement
NEEVO DHA -prenat w/o a w/fefum-methylfol-omegas flavor pack..................................................................... 116
cap 27-1.13 mg............................................................. 101 NESTLE FLAVOR -nutritional supplement flavor
NEFAZODONE HCL -nefazodone hcl tab 100 mg........... 67 pack............................................................................... 116
NEFAZODONE HCL -nefazodone hcl tab 150 mg........... 67 NEULASTA ONPRO KIT -pegfilgrastim soln prefilled
NEFAZODONE HCL -nefazodone hcl tab 200 mg........... 67 syringe kit 6 mg/0.6ml.................................................. 126
nefazodone hcl tab 50 mg.............................................. 67 NEULASTA -pegfilgrastim soln prefilled syringe 6
nefazodone hcl tab 250 mg............................................ 67 mg/0.6ml........................................................................ 126
NEOCATE INFANT DHA/ARA -nutritional supplement NEUPOGEN -filgrastim inj 300 mcg/ml........................... 126
powder........................................................................... 115 NEUPOGEN -filgrastim inj 480 mcg/1.6ml (300 mcg/
NEOCATE JUNIOR/PREBIOTICS -nutritional supplement ml).................................................................................. 126
powder........................................................................... 115 NEUPOGEN -filgrastim soln prefilled syringe 300
NEOCATE JUNIOR -nutritional supplement powder...... 115 mcg/0.5ml...................................................................... 126
NEOCATE NUTRA -nutritional supplement powder....... 115 NEUPOGEN -filgrastim soln prefilled syringe 480
NEOCATE SPLASH -nutritional supplement liquid......... 115 mcg/0.8ml (600 mcg/ml)............................................... 126
NEOMYCIN/POLYMYXIN/HYDROC -neomycin- NEUPRO -rotigotine td patch 24hr 1 mg/24hr.................. 96
polymyxin-hc ophth susp.............................................. 137 NEUPRO -rotigotine td patch 24hr 2 mg/24hr.................. 96
neomycin-bacitrac zn-polymyx NEUPRO -rotigotine td patch 24hr 3 mg/24hr.................. 96
5(3.5)mg-400unt-10000unt op oin............................. 136 NEUPRO -rotigotine td patch 24hr 4 mg/24hr.................. 96
neomycin-polymy-gramicid op sol NEUPRO -rotigotine td patch 24hr 6 mg/24hr.................. 96
1.75-10000-0.025mg-unt-mg/ml (Neosporin)........... 136 NEUPRO -rotigotine td patch 24hr 8 mg/24hr.................. 97
neomycin-polymyxin-dexamethasone ophth oint 0.1% NEVANAC -nepafenac ophth susp 0.1%........................ 137
(Maxitrol)...................................................................... 136 nevirapine tab er 24hr 100 mg (Viramune xr)................. 8
neomycin-polymyxin-dexamethasone ophth susp nevirapine tab er 24hr 400 mg (Viramune xr)................. 8
0.1% (Maxitrol).............................................................136 nevirapine tab 200 mg (Viramune)...................................8
neomycin-polymyxin-hc otic soln 1% NEWGEN -prenatal vit w/o vit a w/ fe bisglycinate-fa tab
(Cortisporin).................................................................138 32-1 mg......................................................................... 101
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 NEXA PLUS -prenatal w/o vit a w/ fe fum-doc-fa-dha cap
unit/ml-1%.................................................................... 138 29-1.25-350 mg.............................................................101
neomycin sulfate tab 500 mg........................................... 5 NEXAVAR -sorafenib tosylate tab 200 mg (base
NEORAL -cyclosporine modified cap 25 mg...................148 equivalent)....................................................................... 18
NEORAL -cyclosporine modified cap 100 mg.................148 NEXIUM -esomeprazole magnesium for delayed release
susp packet 5 mg........................................................... 58
2017
NEXIUM -esomeprazole magnesium for delayed release nimodipine cap 30 mg..................................................... 41
susp packet 10 mg......................................................... 58 NINJACOF-XG -guaifenesin-codeine liquid 200-8
NEXIUM -esomeprazole magnesium for delayed release mg/5ml............................................................................. 52
susp packet 20 mg......................................................... 58 NINLARO -ixazomib citrate cap 2.3 mg (base
NEXIUM -esomeprazole magnesium for delayed release equivalent)....................................................................... 18
susp packet 40 mg......................................................... 58 NINLARO -ixazomib citrate cap 3 mg (base
NEXIUM -esomeprazole magnesium for delayed release equivalent)....................................................................... 18
susp pack 2.5 mg........................................................... 58 NINLARO -ixazomib citrate cap 4 mg (base
niacin tab er 500 mg (antihyperlipidemic) equivalent)....................................................................... 18
(Niaspan)........................................................................ 49 NISOLDIPINE ER -nisoldipine tab er 24hr 20 mg............ 41
niacin tab er 750 mg (antihyperlipidemic) NISOLDIPINE ER -nisoldipine tab er 24hr 25.5 mg......... 41
(Niaspan)........................................................................ 49 NISOLDIPINE ER -nisoldipine tab er 24hr 30 mg............ 41
niacin tab er 1000 mg (antihyperlipidemic) NISOLDIPINE ER -nisoldipine tab er 24hr 40 mg............ 41
(Niaspan)........................................................................ 49 nisoldipine tab er 24hr 8.5 mg (Sular)........................... 41
nicardipine hcl cap 20 mg.............................................. 40 nisoldipine tab er 24hr 17 mg (Sular)............................41
nicardipine hcl cap 30 mg.............................................. 40 nisoldipine tab er 24hr 34 mg (Sular)............................41
NICODERM CQ -nicotine td patch 24hr 7 mg/24hr.......... 78 NITRO-BID -nitroglycerin oint 2%..................................... 37
NICODERM CQ -nicotine td patch 24hr 14 mg/24hr........ 78 NITRO-DUR -nitroglycerin td patch 24hr 0.3 mg/hr.......... 37
NICODERM CQ -nicotine td patch 24hr 21 mg/24hr........ 78 NITRO-DUR -nitroglycerin td patch 24hr 0.8 mg/hr.......... 37
NICORETTE MINI -nicotine polacrilex lozenge 2 mg....... 78 nitrofurantoin macrocrystalline cap 25 mg
NICORETTE MINI -nicotine polacrilex lozenge 4 mg....... 78 (Macrodantin).................................................................62
NICORETTE -nicotine polacrilex gum 2 mg..................... 78 nitrofurantoin macrocrystalline cap 50 mg
NICORETTE -nicotine polacrilex gum 4 mg..................... 78 (Macrodantin).................................................................62
NICORETTE -nicotine polacrilex lozenge 2 mg................ 78 nitrofurantoin macrocrystalline cap 100 mg
NICORETTE -nicotine polacrilex lozenge 4 mg................ 78 (Macrodantin).................................................................62
NICORETTE STARTER KIT -nicotine polacrilex gum 2 nitrofurantoin monohydrate macrocrystalline cap 100
mg.................................................................................... 78 mg (Macrobid)............................................................... 62
NICORETTE STARTER KIT -nicotine polacrilex gum 4 nitrofurantoin susp 25 mg/5ml (Furadantin)................ 62
mg.................................................................................... 78 nitroglycerin cap er 2.5 mg............................................ 37
nicotine polacrilex gum 2 mg.........................................78 nitroglycerin cap er 6.5 mg............................................ 37
nicotine polacrilex gum 4 mg.........................................78 nitroglycerin cap er 9 mg............................................... 37
nicotine polacrilex lozenge 2 mg................................... 78 NITROGLYCERIN LINGUAL -nitroglycerin lingual aerosol
nicotine polacrilex lozenge 4 mg................................... 78 400 mcg/spray................................................................ 38
nicotine td patch 24hr 7 mg/24hr...................................78 nitroglycerin sl tab 0.3 mg (Nitrostat)........................... 38
nicotine td patch 24hr 14 mg/24hr.................................78 nitroglycerin sl tab 0.4 mg (Nitrostat)........................... 38
nicotine td patch 24hr 21 mg/24hr.................................78 nitroglycerin sl tab 0.6 mg (Nitrostat)........................... 38
NICOTINE TRANSDERMAL SYST -nicotine td patch 24 nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)......... 38
hr kit 21-14-7 mg/24hr.................................................... 78 nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)......... 38
NICOTROL INHALER -nicotine inhaler system 10 mg (4 nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)......... 38
mg delivered).................................................................. 78 nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)......... 38
NICOTROL NS -nicotine nasal spray 10 mg/ml (0.5 mg/ nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)
spray)............................................................................... 78 (Nitrolingual pumpspr)................................................. 38
nifedipine cap 20 mg....................................................... 40 NITROMIST -nitroglycerin lingual aerosol 400 mcg/
nifedipine cap 10 mg (Procardia).................................. 40 spray................................................................................ 38
nifedipine tab er 24hr 30 mg (Adalat cc).......................40 NITROSTAT -nitroglycerin sl tab 0.3 mg........................... 38
nifedipine tab er 24hr osmotic release 30 mg NIVA-PLUS -prenatal vit w/ fe fumarate-fa tab 27-1
(Procardia xl)................................................................. 40 mg.................................................................................. 101
nifedipine tab er 24hr osmotic release 60 mg nizatidine cap 150 mg..................................................... 58
(Procardia xl)................................................................. 40 nizatidine cap 300 mg (Axid).......................................... 58
nifedipine tab er 24hr osmotic release 90 mg NIZATIDINE -nizatidine oral soln 15 mg/ml...................... 58
(Procardia xl)................................................................. 41 nonoxynol-9 gel 4%......................................................... 63
NILANDRON -nilutamide tab 150 mg............................... 18 norethindrone & ethinyl estradiol-fe chew tab 0.4
nilutamide tab 150 mg (Nilandron)................................ 18 mg-35 mcg (Femcon fe)............................................... 25
2017
norethindrone & ethinyl estradiol-fe chew tab 0.8 NOVAREL -chorionic gonadotropin for inj 10000 unit....... 36
mg-25 mcg (Generess fe)............................................ 25 NOVASOURCE PULMONARY -nutritional supplement
norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg liquid.............................................................................. 116
(Brevicon-28)................................................................. 25 NOVASOURCE RENAL -nutritional supplement
norethindrone & ethinyl estradiol tab 1 mg-35 mcg liquid.............................................................................. 116
(Norinyl 1+35)................................................................ 25 NOVOEIGHT -antihemophilic factor (recombinant) for inj
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg 250 unit......................................................................... 132
(Ovcon-35)...................................................................... 25 NOVOEIGHT -antihemophilic factor (recombinant) for inj
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 500 unit......................................................................... 132
mcg (Loestrin fe 1/20).................................................. 25 NOVOEIGHT -antihemophilic factor (recombinant) for inj
norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 1000 unit....................................................................... 132
mcg (Loestrin fe 1.5/30)............................................... 25 NOVOEIGHT -antihemophilic factor (recombinant) for inj
norethindrone ace & ethinyl estradiol tab 1 mg-20 1500 unit....................................................................... 132
mcg (Loestrin 1/20-21)................................................. 25 NOVOEIGHT -antihemophilic factor (recombinant) for inj
norethindrone ace & ethinyl estradiol tab 1.5 mg-30 2000 unit....................................................................... 132
mcg (Loestrin 1.5/30-21).............................................. 25 NOVOEIGHT -antihemophilic factor (recombinant) for inj
norethindrone ace-eth estradiol-fe chew tab 1 mg-20 3000 unit....................................................................... 133
mcg (24) (Minastrin 24 fe)............................................25 NOVOLIN 70/30 -insulin nph isophane & regular human
norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 inj 100 unit/ml (70-30).................................................... 31
mcg (24)......................................................................... 25 NOVOLIN 70/30 RELION -insulin nph isophane & regular
norethindrone acetate-ethinyl estradiol tab 1 mg-5 human inj 100 unit/ml (70-30)........................................ 31
mcg................................................................................. 23 NOVOLIN N -insulin nph (human) (isophane) inj 100 unit/
norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 ml..................................................................................... 31
mcg (Femhrt low dose)................................................ 23 NOVOLIN N RELION -insulin nph (human) (isophane) inj
norethindrone acetate tab 5 mg (Aygestin).................. 26 100 unit/ml.......................................................................31
norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 NOVOLIN R -insulin regular (human) inj 100 unit/ml........ 31
mg-mcg (Estrostep fe)................................................. 25 NOVOLIN R RELION -insulin regular (human) inj 100
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 unit/ml.............................................................................. 31
mg-mcg (Ortho-novum 7/7/7)...................................... 25 NOVOLOG FLEXPEN -insulin aspart soln pen-injector
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg- 100 unit/ml.......................................................................30
mcg (Tri-norinyl 28)...................................................... 25 NOVOLOG -insulin aspart inj 100 unit/ml......................... 30
norethindrone tab 0.35 mg (Nor-qd).............................. 25 NOVOLOG MIX 70/30 -insulin aspart prot & aspart
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (human) inj 100 unit/ml (70-30)...................................... 32
(Ortho-cyclen)................................................................ 25 NOVOLOG MIX 70/30 PREFILL -insulin aspart prot &
norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 aspart sus pen-inj 100 unit/ml (70-30)........................... 32
mg-mcg (Ortho tri-cyclen)........................................... 25 NOVOLOG PENFILL -insulin aspart soln cartridge 100
norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 unit/ml.............................................................................. 31
mg-mcg (Ortho tri-cyclen lo)....................................... 25 NOVOSEVEN RT -coagulation factor viia (recomb) for inj
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg........ 25 1 mg (1000 mcg).......................................................... 133
NORPACE CR -disopyramide phosphate cap er 12hr 100 NOVOSEVEN RT -coagulation factor viia (recomb) for inj
mg.................................................................................... 41 2 mg (2000 mcg).......................................................... 133
NORPACE CR -disopyramide phosphate cap er 12hr 150 NOVOSEVEN RT -coagulation factor viia (recomb) for inj
mg.................................................................................... 42 5 mg (5000 mcg).......................................................... 133
NORPACE -disopyramide phosphate cap 100 mg........... 41 NOVOSEVEN RT -coagulation factor viia (recomb) for inj
NORPACE -disopyramide phosphate cap 150 mg........... 41 8 mg (8000 mcg).......................................................... 133
nortriptyline hcl cap 10 mg (Pamelor)...........................67 NOXAFIL -posaconazole susp 40 mg/ml............................ 6
nortriptyline hcl cap 25 mg (Pamelor)...........................67 NOXAFIL -posaconazole tab delayed release 100 mg....... 6
nortriptyline hcl cap 50 mg (Pamelor)...........................67 NUCALA -mepolizumab for inj 100 mg............................. 55
nortriptyline hcl cap 75 mg (Pamelor)...........................67 NUEDEXTA -dextromethorphan hbr-quinidine sulfate cap
NORTRIPTYLINE HCL -nortriptyline hcl soln 10 20-10 mg......................................................................... 79
mg/5ml............................................................................. 67 NUPLAZID -pimavanserin tartrate tab 17 mg (base
NORVIR -ritonavir cap 100 mg........................................... 8 equivalent)....................................................................... 70
NORVIR -ritonavir oral soln 80 mg/ml.................................8 NUTRA/BALANCE RE/GEN FREE -nutritional
NORVIR -ritonavir tab 100 mg............................................ 8 supplement liquid (frozen)............................................ 116
NOURISH -nutritional supplement liquid......................... 116
2017
NUTRA/BALANCE RE/GEN -nutritional supplement liquid NUTREN RENAL -nutritional supplement liquid............. 117
(frozen).......................................................................... 116 NUTRESTORE -glutamine powd pack 5 gm.................. 108
NUTRA/SHAKE FRUIT PLUS -nutritional supplement NUTRICIA PREOP -nutritional supplement pack........... 117
liquid (frozen)................................................................ 116 NUTRIFOCUS -nutritional supplement liquid.................. 117
NUTRA/SHAKE -nutritional supplement liquid NUTRIHEAL -nutritional supplement liquid..................... 117
(frozen).......................................................................... 116 NUTRIHEP 1.5 CAL -nutritional supplement liquid......... 117
NUTRA/SHAKE SUPREME -nutritional supplement NUTRIRENAL -nutritional supplement liquid.................. 117
liquid.............................................................................. 116 NUTRITIONAL DRINK MIX -nutritional supplement
NUTRA/SHAKE SUPREME -nutritional supplement liquid powder........................................................................... 117
(frozen).......................................................................... 116 NUTRITIONAL DRINK -nutritional supplement liquid..... 117
NUTRA BALANCE DIABETIC NU -nutritional supplement NUTRITIONAL DRINK PLUS -nutritional supplement
bar.................................................................................. 116 liquid.............................................................................. 117
NUTRA BALANCE FIBER COOKI -nutritional supplement NUTRITIONAL DRINK SHAKE M -nutritional supplement
misc............................................................................... 116 powder........................................................................... 117
NUTRA BALANCE PROTEIN FOR -nutritional NUTRITIONAL SHAKE COMPLET -nutritional
supplement misc........................................................... 116 supplement liquid.......................................................... 117
NUTRAMENT -nutritional supplement liquid................... 116 NUTRITIONAL SHAKE -nutritional supplement
NUTRAMINE APPLE AMINO BIT -nutritional supplement liquid.............................................................................. 117
pack............................................................................... 116 NUTRITIONAL SHAKE PLUS -nutritional supplement
NUTRAMINE BANANA AMINO B -nutritional supplement liquid.............................................................................. 117
pack............................................................................... 116 NUTRITIONAL SHAKE PLUS PR -nutritional supplement
NUTRAMINE CHOCOLATE AMINO -nutritional liquid.............................................................................. 117
supplement pack........................................................... 116 nutritional supplement liquid....................................... 117
NUTRAMINE MANGO AMINO BI -nutritional supplement NUTRITIONAL SUPPLEMENT -nutritional supplement
pack............................................................................... 116 liquid.............................................................................. 117
NUTRAMINE MIXED FLAVORS A -nutritional supplement NUTRITIONAL SUPPLEMENT PL -nutritional supplement
pack............................................................................... 116 liquid.............................................................................. 117
NUTRAMINE -nutritional supplement pack..................... 116 NUTRIVENT -nutritional supplement liquid..................... 117
NUTRAMINE PEACHES & CREAM -nutritional NUTRIVENT 1.5 -nutritional supplement liquid...............117
supplement pack........................................................... 116 NUTRIVIR NSA -nutritional supplement powder............ 117
NUTRAMINE PINEAPPLE AMINO -nutritional NUTRIVIR -nutritional supplement powder..................... 117
supplement pack........................................................... 116 NUVARING -etonogestrel-ethinyl estradiol va ring
NUTRASENTIALS -amino acids oral powder................. 107 0.120-0.015 mg/24hr...................................................... 25
NUTRA SHAKE/SUPREME -nutritional supplement liquid NUVESSA -metronidazole vaginal gel 1.3%.....................63
(frozen).......................................................................... 116 NUVIGIL -armodafinil tab 50 mg....................................... 75
NUTRA SHAKE -nutritional supplement liquid NUVIGIL -armodafinil tab 150 mg..................................... 75
(frozen).......................................................................... 116 NUVIGIL -armodafinil tab 200 mg..................................... 75
NUTREN 1.0/FIBER/ULTRAPAK -nutritional supplement NUVIGIL -armodafinil tab 250 mg..................................... 75
liquid.............................................................................. 117 NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 250
NUTREN 1.0/FIBER -nutritional supplement liquid.........117 unit................................................................................. 133
NUTREN 1.0 CAL -nutritional supplement liquid............ 117 NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 500
NUTREN 1.5 CAL -nutritional supplement liquid............ 117 unit................................................................................. 133
NUTREN 2.0 CAL -nutritional supplement liquid............ 117 NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 1000
NUTREN 1.5 FIBER -nutritional supplement liquid.........117 unit................................................................................. 133
NUTREN JR FIBER -nutritional supplement liquid......... 116 NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 2000
NUTREN JR -nutritional supplement liquid..................... 116 unit................................................................................. 133
NUTREN JUNIOR/FIBER -nutritional supplement NUWIQ -antihemophilic factor (bdd-rfviii) for inj 250
liquid.............................................................................. 117 unit................................................................................. 133
NUTREN JUNIOR -nutritional supplement liquid............ 116 NUWIQ -antihemophilic factor (bdd-rfviii) for inj 500
NUTREN JUNIOR 1.0 -nutritional supplement liquid...... 117 unit................................................................................. 133
NUTREN 1.0 -nutritional supplement liquid.................... 117 NUWIQ -antihemophilic factor (bdd-rfviii) for inj 1000
NUTREN 1.5 -nutritional supplement liquid.................... 117 unit................................................................................. 133
NUTREN 2.0 -nutritional supplement liquid.................... 117 NUWIQ -antihemophilic factor (bdd-rfviii) for inj 2000
NUTREN PULMONARY -nutritional supplement unit................................................................................. 133
liquid.............................................................................. 117 NYMALIZE -nimodipine oral soln 60 mg/20ml.................. 41
2017
nystatin cream 100000 unit/gm.................................... 144 OFEV -nintedanib esylate cap 150 mg (base
nystatin oint 100000 unit/gm........................................ 144 equivalent)....................................................................... 56
nystatin susp 100000 unit/ml....................................... 139 OFLOXACIN -ofloxacin tab 300 mg.................................... 5
nystatin tab 500000 unit....................................................6 ofloxacin ophth soln 0.3% (Ocuflox)........................... 137
nystatin topical powder 100000 unit/gm..................... 144 ofloxacin otic soln 0.3%................................................138
nystatin-triamcinolone cream 100000-0.1 unit/gm- ofloxacin tab 400 mg......................................................... 5
%.................................................................................... 144 OGESTREL -norgestrel & ethinyl estradiol tab 0.5 mg-50
nystatin-triamcinolone oint 100000-0.1 unit/gm- mcg.................................................................................. 25
%.................................................................................... 144 olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax)...... 79
O olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax)...... 79
olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax)...... 79
OA 1 -nutritional supplement powder.............................. 117 olanzapine-fluoxetine hcl cap 12-25 mg
OA 2 -nutritional supplement powder.............................. 117 (Symbyax)...................................................................... 79
OB COMPLETE/DHA -prenat w/ iron cbn-fe asp glyc-fa- olanzapine-fluoxetine hcl cap 12-50 mg
omega cap 30-10-1-200 mg......................................... 102 (Symbyax)...................................................................... 79
OB COMPLETE GOLD -prenat w/o a w/fecbn-methfol-fa- olanzapine orally disintegrating tab 5 mg (Zyprexa
dha cap 27.5-1-200 mg................................................ 101 zydis)...............................................................................70
OB COMPLETE ONE -prenatal w/o a w/fecbn-fe asp olanzapine orally disintegrating tab 10 mg (Zyprexa
glyc-fa-fish cap 50-1-476 mg........................................101 zydis)...............................................................................70
OB COMPLETE PETITE -prenat w/o a w/fecbn- olanzapine orally disintegrating tab 15 mg (Zyprexa
feaspglyc-fa-omega cap 35-5-1-200 mg...................... 101 zydis)...............................................................................70
OB COMPLETE PREMIER -prenatal vit w/ fe cbn-fe asp olanzapine orally disintegrating tab 20 mg (Zyprexa
glyc-fa tab 30-20-1 mg................................................. 102 zydis)...............................................................................70
OB COMPLETE -prenatal vit w/ iron carbonyl-fa tab olanzapine tab 2.5 mg (Zyprexa)................................... 70
50-1.25 mg.................................................................... 101 olanzapine tab 5 mg (Zyprexa)...................................... 70
OBIZUR -antihemophilic factor (recomb porc) rpfviii for inj olanzapine tab 7.5 mg (Zyprexa)................................... 70
500 unit......................................................................... 133 olanzapine tab 10 mg (Zyprexa).................................... 70
OBSTETRIX DHA -prenat w/fecbn-fa-dss tab 29-1 mg & olanzapine tab 15 mg (Zyprexa).................................... 70
omega 3 cap 387 mg pak............................................ 102 olanzapine tab 20 mg (Zyprexa).................................... 70
OBSTETRIX EC -prenatal vit w/ dss-iron carbonyl-fa tab olmesartan medoxomil tab 5 mg (Benicar).................. 45
29-1 mg......................................................................... 102 olmesartan medoxomil tab 20 mg (Benicar)................ 45
OBSTETRIX ONE -prenat w/o a w/fecbn-bisg-methylf- olmesartan medoxomil tab 40 mg (Benicar)................ 45
dss-dha cap 38-1-225 mg............................................ 102 olopatadine hcl nasal soln 0.6% (Patanase).................52
O-CAL FA -prenatal vit w/ fe fumarate-fa tab 27-1 olopatadine hcl ophth soln 0.2% (base equivalent)
mg.................................................................................. 101 (Pataday)...................................................................... 137
OCALIVA -obeticholic acid tab 5 mg................................. 61 olopatadine hcl ophth soln 0.1% (base equivalent)
OCALIVA -obeticholic acid tab 10 mg............................... 61 (Patanol)....................................................................... 137
O-CAL PRENATAL -prenatal vit w/ fe fumarate-fa tab 15-1 OLYSIO -simeprevir sodium cap 150 mg (base
mg.................................................................................. 101 equivalent)......................................................................... 8
octreotide acetate inj 50 mcg/ml (0.05 mg/ml) omeprazole cap delayed release 10 mg (Prilosec)...... 58
(Sandostatin)................................................................. 36 omeprazole cap delayed release 20 mg (Prilosec)...... 58
octreotide acetate inj 100 mcg/ml (0.1 mg/ml) omeprazole cap delayed release 40 mg (Prilosec)...... 58
(Sandostatin)................................................................. 36 OMNARIS -ciclesonide nasal susp 50 mcg/act................ 52
octreotide acetate inj 200 mcg/ml (0.2 mg/ml) OMNIFLEX DIAPHRAGM -diaphragms.......................... 147
(Sandostatin)................................................................. 36 OMNI GEL -stannous fluoride gel 0.4%.......................... 139
octreotide acetate inj 500 mcg/ml (0.5 mg/ml) OMNITROPE -somatropin for inj 5.8 mg.......................... 36
(Sandostatin)................................................................. 36 OMNITROPE -somatropin inj 5 mg/1.5ml......................... 36
octreotide acetate inj 1000 mcg/ml (1 mg/ml) OMNITROPE -somatropin inj 10 mg/1.5ml....................... 36
(Sandostatin)................................................................. 36 ondansetron hcl oral soln 4 mg/5ml (Zofran)............... 59
ODEFSEY -emtricitabine-rilpivirine-tenofovir af tab ondansetron hcl tab 24 mg............................................ 59
200-25-25 mg.................................................................... 8 ondansetron hcl tab 4 mg (Zofran)................................59
ODOMZO -sonidegib phosphate cap 200 mg (base ondansetron hcl tab 8 mg (Zofran)................................59
equivalent)....................................................................... 18 ondansetron orally disintegrating tab 4 mg (Zofran
OFEV -nintedanib esylate cap 100 mg (base odt).................................................................................. 59
equivalent)....................................................................... 56
2017
ondansetron orally disintegrating tab 8 mg (Zofran ORFADIN -nitisinone cap 10 mg....................................... 36
odt).................................................................................. 59 ORFADIN -nitisinone cap 20 mg....................................... 36
ONFI -clobazam suspension 2.5 mg/ml............................ 94 ORFADIN -nitisinone susp 4 mg/ml.................................. 36
ONFI -clobazam tab 10 mg............................................... 94 ORGANIC NUTRITION COMPLET -nutritional
ONFI -clobazam tab 20 mg............................................... 94 supplement liquid.......................................................... 118
ONGLYZA -saxagliptin hcl tab 2.5 mg (base equiv)......... 29 ORGANIC NUTRITION PLANT B -nutritional supplement
ONGLYZA -saxagliptin hcl tab 5 mg (base equiv)............ 29 liquid.............................................................................. 118
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab ORGANIC NUTRITION VEGAN-A -nutritional supplement
er 12hr deter 5 mg......................................................... 84 liquid.............................................................................. 118
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab ORGANIC PEDIA SMART -nutritional supplement
er 12hr deter 7.5 mg...................................................... 84 powder........................................................................... 118
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab ORKAMBI -lumacaftor-ivacaftor tab 100-125 mg............. 56
er 12hr deter 10 mg....................................................... 84 ORKAMBI -lumacaftor-ivacaftor tab 200-125 mg............. 56
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab orphenadrine citrate tab er 12hr 100 mg...................... 98
er 12hr deter 15 mg....................................................... 84 ORTHO TRI-CYCLEN LO -norgestimate-eth estrad tab
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab 0.18-25/0.215-25/0.25-25 mg-mcg................................. 25
er 12hr deter 20 mg....................................................... 84 oseltamivir phosphate cap 30 mg (base equiv)
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab (Tamiflu)............................................................................ 8
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab (Tamiflu)............................................................................ 8
OPSUMIT -macitentan tab 10 mg..................................... 50 (Tamiflu)............................................................................ 8
OPTICLEANSE GHI -nutritional supplement powder..... 117 OSENI -alogliptin-pioglitazone tab 12.5-15 mg................. 29
OPTIMENTAL -nutritional supplement liquid...................118 OSENI -alogliptin-pioglitazone tab 12.5-30 mg................. 29
OPTIONS GYNOL II VAGINAL -nonoxynol-9 gel 3%....... 63 OSENI -alogliptin-pioglitazone tab 12.5-45 mg................. 29
OPTISOURCE VERY HIGH PROT -nutritional OSENI -alogliptin-pioglitazone tab 25-15 mg.................... 29
supplement liquid.......................................................... 118 OSENI -alogliptin-pioglitazone tab 25-30 mg.................... 29
ORALAIR -grass mixed pollen ext tab sl 300 ir (index of OSENI -alogliptin-pioglitazone tab 25-45 mg.................... 29
reactivity)......................................................................... 14 OSMOLITE 1 CAL -nutritional supplement liquid............118
ORANGE CHICKEN/CARROTS/BR -nutritional OSMOLITE 1.0 CAL -nutritional supplement liquid.........118
supplement liquid.......................................................... 118 OSMOLITE 1.2 CAL -nutritional supplement liquid.........118
ORAP -pimozide tab 1 mg................................................ 79 OSMOLITE 1.5 CAL -nutritional supplement liquid.........118
ORAP -pimozide tab 2 mg................................................ 79 OSMOLITE HN -nutritional supplement liquid................ 118
ORAVIG -miconazole buccal tab 50 mg (mouth- OSMOLITE -nutritional supplement liquid....................... 118
throat)............................................................................ 139 OSMOPREP -sod phos mono-sod phos di tabs
ORENCIA -abatacept subcutaneous soln prefilled syringe 1.102-0.398 gm(1.5gm na phos).................................... 57
50 mg/0.4ml.................................................................... 89 OS 2 -nutritional supplement powder.............................. 118
ORENCIA -abatacept subcutaneous soln prefilled syringe OTEZLA -apremilast tab 30 mg........................................ 89
87.5 mg/0.7ml................................................................. 89 OTEZLA -apremilast tab starter therapy pack 10 mg & 20
ORENCIA -abatacept subcutaneous soln prefilled syringe mg & 30 mg.................................................................... 89
125 mg/ml....................................................................... 89 OTREXUP -methotrexate soln pf auto-injector 10
ORENCIA CLICKJECT -abatacept subcutaneous soln mg/0.4ml.......................................................................... 89
auto-injector 125 mg/ml.................................................. 89 OTREXUP -methotrexate soln pf auto-injector 12.5
ORENITRAM -treprostinil diolamine tab er 0.125 mg mg/0.4ml.......................................................................... 89
(base equiv).................................................................... 50 OTREXUP -methotrexate soln pf auto-injector 15
ORENITRAM -treprostinil diolamine tab er 0.25 mg (base mg/0.4ml.......................................................................... 89
equiv)............................................................................... 50 OTREXUP -methotrexate soln pf auto-injector 17.5
ORENITRAM -treprostinil diolamine tab er 1 mg (base mg/0.4ml.......................................................................... 89
equiv)............................................................................... 50 OTREXUP -methotrexate soln pf auto-injector 20
ORENITRAM -treprostinil diolamine tab er 2.5 mg (base mg/0.4ml.......................................................................... 89
equiv)............................................................................... 50 OTREXUP -methotrexate soln pf auto-injector 22.5
ORENITRAM -treprostinil diolamine tab er 5 mg (base mg/0.4ml.......................................................................... 89
equiv)............................................................................... 50 OTREXUP -methotrexate soln pf auto-injector 25
ORFADIN -nitisinone cap 2 mg......................................... 36 mg/0.4ml.......................................................................... 89
ORFADIN -nitisinone cap 5 mg......................................... 36 OVIDREL -choriogonadotropin alfa inj 250 mcg/0.5ml..... 36
2017
oxandrolone tab 2.5 mg (Oxandrin).............................. 21 oxycodone hcl tab 30 mg (Roxicodone)....................... 85
oxandrolone tab 10 mg (Oxandrin)............................... 21 oxycodone w/ acetaminophen tab 2.5-325 mg
oxaprozin tab 600 mg (Daypro)..................................... 89 (Percocet)....................................................................... 85
OXAYDO -oxycodone hcl tab abuse deter 5 mg.............. 84 oxycodone w/ acetaminophen tab 5-325 mg
OXAYDO -oxycodone hcl tab abuse deter 7.5 mg............84 (Percocet)....................................................................... 85
oxazepam cap 10 mg...................................................... 65 oxycodone w/ acetaminophen tab 7.5-325 mg
oxazepam cap 15 mg...................................................... 65 (Percocet)....................................................................... 85
oxazepam cap 30 mg...................................................... 65 oxycodone w/ acetaminophen tab 10-325 mg
oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Percocet)....................................................................... 85
(Trileptal)........................................................................ 94 OXYCONTIN -oxycodone hcl tab er 12hr deter 10 mg..... 85
oxcarbazepine tab 150 mg (Trileptal)............................ 94 OXYCONTIN -oxycodone hcl tab er 12hr deter 15 mg..... 85
OXEPA -nutritional supplement liquid............................. 118 OXYCONTIN -oxycodone hcl tab er 12hr deter 40 mg..... 85
OXEPA 1.5 -nutritional supplement liquid....................... 118 OXYCONTIN -oxycodone hcl tab er 12hr deter 60 mg..... 85
oxiconazole nitrate cream 1% (Oxistat)...................... 144 OXYCONTIN -oxycodone hcl tab er 12hr deter 80 mg..... 85
OXISTAT -oxiconazole nitrate cream 1%........................ 144 oxymorphone hcl tab 5 mg (Opana)..............................85
OXISTAT -oxiconazole nitrate lotion 1%......................... 144 oxymorphone hcl tab 10 mg (Opana)............................85
OXTELLAR XR -oxcarbazepine tab er 24hr 150 mg........ 94 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
OXTELLAR XR -oxcarbazepine tab er 24hr 300 mg........ 94 tab er 12hr 5 mg.............................................................85
OXTELLAR XR -oxcarbazepine tab er 24hr 600 mg........ 94 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
oxybutynin chloride syrup 5 mg/5ml............................ 62 tab er 12hr 7.5 mg..........................................................85
oxybutynin chloride tab er 24hr 5 mg (Ditropan xl)..... 62 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
oxybutynin chloride tab er 24hr 10 mg (Ditropan tab er 12hr 10 mg...........................................................85
xl)..................................................................................... 62 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
oxybutynin chloride tab er 24hr 15 mg (Ditropan tab er 12hr 15 mg...........................................................85
xl)..................................................................................... 62 OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
oxybutynin chloride tab 5 mg........................................ 62 tab er 12hr 20 mg...........................................................86
OXYCODONE/ACETAMINOPHEN -oxycodone w/ OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
acetaminophen soln 5-325 mg/5ml................................ 85 tab er 12hr 30 mg...........................................................86
OXYCODONE/IBUPROFEN -oxycodone-ibuprofen tab OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
5-400 mg......................................................................... 85 tab er 12hr 40 mg...........................................................86
oxycodone-aspirin tab 4.8355-325 mg (Percodan)...... 85 P
oxycodone hcl cap 5 mg................................................ 84
oxycodone hcl conc 100 mg/5ml (20 mg/ml) paliperidone tab er 24hr 1.5 mg (Invega)...................... 70
(Oxycodone hcl)............................................................ 84 paliperidone tab er 24hr 3 mg (Invega)......................... 70
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter paliperidone tab er 24hr 6 mg (Invega)......................... 70
10 mg.............................................................................. 84 paliperidone tab er 24hr 9 mg (Invega)......................... 70
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
15 mg.............................................................................. 84 2600-6200-10850 unit.....................................................59
20 mg.............................................................................. 85 4200-14200-24600 unit...................................................59
30 mg.............................................................................. 85 10500-35500-61500 unit................................................ 59
40 mg.............................................................................. 85 16800-56800-98400 unit................................................ 59
60 mg.............................................................................. 85 21000-54700-83900 unit................................................ 59
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter PANRETIN -alitretinoin gel 0.1%..................................... 144
80 mg.............................................................................. 85 pantoprazole sodium ec tab 20 mg (base equiv)
oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)...........85 (Protonix)........................................................................58
oxycodone hcl tab 10 mg............................................... 85 pantoprazole sodium ec tab 40 mg (base equiv)
oxycodone hcl tab 20 mg............................................... 85 (Protonix)........................................................................58
oxycodone hcl tab 5 mg (Roxicodone)......................... 85 PARAGARD INTRAUTERINE COP -copper iud............... 26
oxycodone hcl tab 15 mg (Roxicodone)....................... 85 paricalcitol cap 4 mcg..................................................... 36
paricalcitol cap 1 mcg (Zemplar)................................... 36
2017
paricalcitol cap 2 mcg (Zemplar)................................... 36 PEDIATRIC DRINK -nutritional supplement liquid.......... 119
PARODONTAX -stannous fluoride paste 0.454%........... 139 PEDIATRIC PEPTINEX DT/FIB -nutritional supplement
paromomycin sulfate cap 250 mg................................... 5 liquid.............................................................................. 119
paroxetine hcl tab er 24hr 25 mg (Paxil cr).................. 67 PEDIATRIC PEPTINEX DT -nutritional supplement
paroxetine hcl tab 10 mg (Paxil).................................... 67 liquid.............................................................................. 119
paroxetine hcl tab 20 mg (Paxil).................................... 67 PEGANONE -ethotoin tab 250 mg.................................... 94
paroxetine hcl tab 30 mg (Paxil).................................... 67 PEGASYS -peginterferon alfa-2a inj 180 mcg/ml............... 8
paroxetine hcl tab 40 mg (Paxil).................................... 67 PEGASYS -peginterferon alfa-2a inj 180 mcg/0.5ml.......... 8
PASER -aminosalicylic acid er granules packet 4 gm........ 5 PEGASYS PROCLICK -peginterferon alfa-2a inj 135
PATADAY -olopatadine hcl ophth soln 0.2% (base mcg/0.5ml.......................................................................... 8
equivalent)..................................................................... 137 PEGASYS PROCLICK -peginterferon alfa-2a inj 180
PCE -erythromycin w/ enteric coated particles tab 333 mcg/0.5ml.......................................................................... 8
mg...................................................................................... 3 PEGINTRON -peginterferon alfa-2b for inj kit 50
PCE -erythromycin w/ enteric coated particles tab 500 mcg/0.5ml.......................................................................... 8
mg...................................................................................... 3 PEGINTRON -peginterferon alfa-2b for inj kit 80
PCP 100 -mag cit-bisacodyl-petrolat-peg- mcg/0.5ml.......................................................................... 8
metoclopramide-electrol kit............................................. 57 PEGINTRON -peginterferon alfa-2b for inj kit 120
PEDIARIX -diph-tetanus tox-acell pert-hepatitis b-polio ipv mcg/0.5ml.......................................................................... 8
vac inj.............................................................................. 14 PEGINTRON -peginterferon alfa-2b for inj kit 150
PEDIASURE 1.0 CAL/FIBER -nutritional supplement mcg/0.5ml.......................................................................... 8
liquid.............................................................................. 118 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240
PEDIASURE 1.5 CAL/FIBER -nutritional supplement gm (Colyte-flavor packs)............................................. 57
liquid.............................................................................. 119 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236
PEDIASURE 1.5 CAL -nutritional supplement liquid...... 118 gm (Golytely)................................................................. 57
PEDIASURE 1.5 CAL WITH FI -nutritional supplement peg 3350-kcl-sod bicarb-nacl for soln 420 gm
liquid.............................................................................. 119 (Nulytely/flavor pack)................................................... 57
PEDIASURE ENTERAL FORMULA -nutritional penicillin v potassium for soln 125 mg/5ml................... 1
supplement liquid.......................................................... 118 penicillin v potassium for soln 250 mg/5ml................... 1
PEDIASURE GROW & GAIN -nutritional supplement penicillin v potassium tab 250 mg...................................1
liquid.............................................................................. 118 penicillin v potassium tab 500 mg...................................1
PEDIASURE NUTRIPALS -nutritional supplement PENTACEL -diph-ac per-tet tox ad-poliov-haemoph b poly
bar.................................................................................. 118 vac for im susp............................................................... 14
PEDIASURE NUTRIPALS -nutritional supplement PENTASA -mesalamine cap er 250 mg............................ 61
liquid.............................................................................. 118 PENTASA -mesalamine cap er 500 mg............................ 61
PEDIASURE -nutritional supplement liquid.................... 118 pentoxifylline tab er 400 mg......................................... 133
PEDIASURE PEDIATRIC -nutritional supplement PEPDITE JUNIOR -nutritional supplement pack............ 119
liquid.............................................................................. 118 PEPTAMEN/PREBIO1 -nutritional supplement liquid..... 119
PEDIASURE PEPTIDE 1.0 CAL -nutritional supplement PEPTAMEN AF -nutritional supplement liquid................ 119
liquid.............................................................................. 118 PEPTAMEN BARIATRIC -nutritional supplement
PEDIASURE PEPTIDE 1.5 CAL -nutritional supplement liquid.............................................................................. 119
liquid.............................................................................. 118 PEPTAMEN 1 CAL/PREBIO1 -nutritional supplement
PEDIASURE SHAKE MIX -nutritional supplement liquid.............................................................................. 119
powder........................................................................... 118 PEPTAMEN 1.5 CAL/PREBIO1 -nutritional supplement
PEDIASURE SHAKE WITH FIBE -nutritional supplement liquid.............................................................................. 119
liquid.............................................................................. 118 PEPTAMEN 1 CAL -nutritional supplement liquid...........119
PEDIASURE SIDEKICKS CLEAR -nutritional supplement PEPTAMEN 1.5 CAL -nutritional supplement liquid........119
liquid.............................................................................. 118 PEPTAMEN INTENSE VHP -nutritional supplement
PEDIASURE SIDEKICKS -nutritional supplement liquid.............................................................................. 119
liquid.............................................................................. 118 PEPTAMEN JUNIOR/PREBIO1 -nutritional supplement
PEDIASURE SIDEKICKS -nutritional supplement liquid.............................................................................. 119
powder........................................................................... 118 PEPTAMEN JUNIOR 1 CAL/PRE -nutritional supplement
PEDIASURE SIDEKICKS SHAKE -nutritional supplement liquid.............................................................................. 119
liquid.............................................................................. 118 PEPTAMEN JUNIOR 1 CAL -nutritional supplement
PEDIASURE WITH FIBER -nutritional supplement liquid.............................................................................. 119
liquid.............................................................................. 118
2017
PEPTAMEN JUNIOR 1.5 CAL -nutritional supplement PHENACTIN AA PLUS -nutritional supplement
liquid.............................................................................. 119 liquid.............................................................................. 120
PEPTAMEN JUNIOR FIBER -nutritional supplement phenelzine sulfate tab 15 mg (Nardil)........................... 67
liquid.............................................................................. 119 PHENEX-1 -nutritional supplement powder.................... 120
PEPTAMEN JUNIOR HP -nutritional supplement PHENEX-2 -nutritional supplement powder.................... 120
liquid.............................................................................. 119 phenobarbital elixir 20 mg/5ml...................................... 72
PEPTAMEN JUNIOR -nutritional supplement liquid....... 119 PHENOBARBITAL -phenobarbital tab 15 mg................... 72
PEPTAMEN JUNIOR -nutritional supplement PHENOBARBITAL -phenobarbital tab 30 mg................... 72
powder........................................................................... 119 PHENOBARBITAL -phenobarbital tab 60 mg................... 72
PEPTAMEN -nutritional supplement liquid...................... 119 PHENOBARBITAL -phenobarbital tab 100 mg................. 72
PEPTAMEN 1.5 -nutritional supplement liquid................ 119 phenobarbital tab 16.2 mg.............................................. 72
PEPTAMEN OS -nutritional supplement liquid............... 119 phenobarbital tab 32.4 mg.............................................. 72
PEPTAMEN OS 1.5 -nutritional supplement liquid......... 119 phenobarbital tab 64.8 mg.............................................. 72
PEPTAMEN VHP -nutritional supplement liquid............. 119 phenobarbital tab 97.2 mg.............................................. 72
PEPTINEX DT -nutritional supplement liquid..................119 phenoxybenzamine hcl cap 10 mg (Dibenzyline)........ 45
PEPTINEX DT WITH PREBIOTI -nutritional supplement PHENYLADE AMINO ACID -amino acids bar................ 108
liquid.............................................................................. 119 PHENYLADE AMINO ACID BLEN -amino acids
PEPTINEX 1.0 -nutritional supplement liquid................. 119 pack............................................................................... 108
PEPTINEX 1.5 -nutritional supplement liquid................. 119 PHENYLADE -amino acids oral powder......................... 108
PERATIVE 1.3 CAL -nutritional supplement liquid..........119 PHENYLADE40 DRINK MIX -amino acids pack.............108
PERATIVE -nutritional supplement liquid........................ 119 PHENYLADE60 DRINK MIX -nutritional supplement
PERFOROMIST -formoterol fumarate soln nebu 20 pack............................................................................... 120
mcg/2ml........................................................................... 55 PHENYLADE DRINK MIX -nutritional supplement
PERIFLEX ADVANCE -nutritional supplement powder........................................................................... 120
powder........................................................................... 119 PHENYLADE60 DRINK MIX -nutritional supplement
PERIFLEX JUNIOR -nutritional supplement powder...... 119 powder........................................................................... 120
PERIFLEX LQ PKU -amino acids oral liquid.................. 108 PHENYLADE ESSENTIAL DRINK -nutritional supplement
perindopril erbumine tab 2 mg...................................... 45 pack............................................................................... 120
perindopril erbumine tab 4 mg (Aceon)........................ 45 PHENYLADE ESSENTIAL DRINK -nutritional supplement
perindopril erbumine tab 8 mg (Aceon)........................ 45 powder........................................................................... 120
permethrin cream 5% (Elimite).................................... 144 PHENYLADE GMP MIX-IN -nutritional supplement
PERPHENAZINE/AMITRIPTYLIN -perphenazine- pack............................................................................... 120
amitriptyline tab 2-10 mg................................................ 79 PHENYLADE GMP -nutritional supplement pack........... 120
PERPHENAZINE/AMITRIPTYLIN -perphenazine- PHENYLADE GMP -nutritional supplement powder....... 120
amitriptyline tab 2-25 mg................................................ 79 PHENYLADE MTE AMINO ACID -amino acids pack..... 108
PERPHENAZINE/AMITRIPTYLIN -perphenazine- PHENYLADE MTE -amino acids oral powder................ 108
amitriptyline tab 4-10 mg................................................ 79 PHENYLADE PHEBLOC -amino acids oral powder....... 108
PERPHENAZINE/AMITRIPTYLIN -perphenazine- PHENYLADE PHEBLOC -amino acids tab..................... 108
amitriptyline tab 4-25 mg................................................ 79 PHENYLADE RTD PKU 10 -nutritional supplement
PERPHENAZINE/AMITRIPTYLIN -perphenazine- liquid.............................................................................. 120
amitriptyline tab 4-50 mg................................................ 79 phenylephrine hcl ophth soln 2.5%............................. 137
perphenazine tab 2 mg................................................... 70 phenylephrine hcl ophth soln 10%.............................. 137
perphenazine tab 4 mg................................................... 70 PHENYL-FREE 2HP -nutritional supplement
perphenazine tab 8 mg................................................... 70 powder........................................................................... 120
perphenazine tab 16 mg................................................. 70 PHENYL-FREE 2 -nutritional supplement powder..........120
PERTZYE -pancrelipase (lip-prot-amyl) dr cap PHENYTEK -phenytoin sodium extended cap 200
4000-14375-15125 unit...................................................59 mg.................................................................................... 94
PERTZYE -pancrelipase (lip-prot-amyl) dr cap PHENYTEK -phenytoin sodium extended cap 300
8000-28750-30250 unit...................................................59 mg.................................................................................... 94
PERTZYE -pancrelipase (lip-prot-amyl) dr cap phenytoin chew tab 50 mg (Dilantin infatabs)..............94
16000-57500-60500 unit................................................ 59 phenytoin sodium extended cap 100 mg (Dilantin)..... 94
PERTZYE -pancrelipase (lip-prot-amyl) dr cap phenytoin sodium extended cap 200 mg
24000-86250-90750 unit................................................ 59 (Phenytek)...................................................................... 94
PFD 1 -nutritional supplement powder............................ 119 phenytoin sodium extended cap 300 mg
PFD 2 -nutritional supplement powder............................ 120 (Phenytek)...................................................................... 94
2017
phenytoin susp 125 mg/5ml (Dilantin-125)................... 94 PLEGRIDY STARTER PACK -peginterferon beta-1a soln
PHLEXY-10 -amino acids cap......................................... 108 pen-inj 63 & 94 mcg/0.5ml pack.................................... 79
PHLEXY-10 -nutritional supplement pack....................... 120 PLEGRIDY STARTER PACK -peginterferon beta-1a soln
PHLEXY-VITS -multiple vitamins w/ minerals pref syr 63 & 94 mcg/0.5ml pack................................... 79
powder........................................................................... 102 PLIAGLIS -lidocaine-tetracaine cream 7-7%.................. 145
PHOS-FLUR ORTHO DEFENSE -sodium fluoride rinse PNEUMOVAX 23/1 DOSE -pneumococcal vaccine
0.044%.......................................................................... 139 polyvalent inj 25 mcg/0.5ml............................................ 13
PHOS FLUR -sodium fluoride rinse 0.044%................... 139 PNEUMOVAX 23 -pneumococcal vaccine polyvalent inj
PHOSLYRA -calcium acetate (phosphate binder) oral soln 25 mcg/0.5ml.................................................................. 13
667 mg/5ml..................................................................... 61 PNV-DHA+DOCUSATE -prenatal w/o vit a w/ fe fum-dss-
PHYSICIANS EZ USE JOINT T -triamcinolone inj 40 mg/ fa-dha cap 27-1.25-300 mg.......................................... 102
ml & lidocaine 1% & ammonia inh kit............................ 20 PNV-DHA -prenat w/o a w/fefum-methfol-fa-dha cap
PHYTOFUSION -nutritional supplement pack................ 120 27-0.6-0.4-300 mg........................................................ 102
phytonadione inj 1 mg/0.5ml (2 mg/ml).........................99 PNV FERROUS FUMARATE/DOCU -prenatal vit w/ dss-
PICATO -ingenol mebutate gel 0.015%.......................... 144 fe fumarate-fa tab 29-1 mg.......................................... 102
PICATO -ingenol mebutate gel 0.05%............................ 144 PNV OB+DHA -prenat w/o a w/fecbn-fegl-dss-fa tab &
pilocarpine hcl ophth soln 1% (Isopto carpine)......... 137 dha cap 250 mg pack...................................................102
pilocarpine hcl ophth soln 2% (Isopto carpine)......... 137 PNV-OMEGA -prenat w/o a w/ fe fumerate-methylfolate-
pilocarpine hcl ophth soln 4% (Isopto carpine)......... 137 fa-omega 3 cap............................................................. 102
pilocarpine hcl tab 5 mg (Salagen)..............................139 PNV PRENATAL PLUS MULTIVI -prenatal vit w/ fe
pilocarpine hcl tab 7.5 mg (Salagen)...........................139 fumarate-fa tab 27-1 mg...............................................102
pimozide tab 1 mg (Orap)............................................... 79 PNV-SELECT -prenatal vit w/ fe fum-methylfolate-fa tab
pimozide tab 2 mg (Orap)............................................... 79 27-0.6-0.4 mg................................................................ 102
pindolol tab 5 mg............................................................. 39 PNV TABS 29-1 -prenatal vit w/ iron carbonyl-fa tab 29-1
pindolol tab 10 mg........................................................... 39 mg.................................................................................. 102
pioglitazone hcl-metformin hcl tab 15-500 mg PNV-TOTAL -prenat w/ fe cbn-fe bisglyc-fa-fish oil cap
(Actoplus met)............................................................... 29 35-5-1.2 mg................................................................... 102
pioglitazone hcl-metformin hcl tab 15-850 mg PNV-VP-U -prenatal w/o a vit w/ fe fumarate-fa cap
(Actoplus met)............................................................... 29 106.5-1 mg.................................................................... 102
pioglitazone hcl tab 15 mg (base equiv) (Actos)..........29 podofilox soln 0.5% (Condylox)................................... 145
pioglitazone hcl tab 30 mg (base equiv) (Actos)..........29 POLYCAL -nutritional supplement powder......................120
pioglitazone hcl tab 45 mg (base equiv) (Actos)..........29 polyethylene glycol 3350 oral packet............................ 57
piroxicam cap 10 mg (Feldene)..................................... 89 polyethylene glycol 3350 oral powder.......................... 57
piroxicam cap 20 mg (Feldene)..................................... 89 polymyxin b-trimethoprim ophth soln 10000 unit/
PIVOT 1.5 CAL -nutritional supplement liquid................ 120 ml-0.1% (Polytrim)...................................................... 137
PKU COOLER 10 -nutritional supplement liquid.............120 POLY-TUSSIN AC -phenylephrine-bromphen w/ codeine
PKU COOLER 15 -nutritional supplement liquid.............120 liquid 10-4-10 mg/5ml..................................................... 52
PKU COOLER 20 -nutritional supplement liquid.............120 POMALYST -pomalidomide cap 1 mg.............................. 18
PKU EXPRESS -nutritional supplement pack.................120 POMALYST -pomalidomide cap 2 mg.............................. 18
PKU EXPRESS20 -nutritional supplement pack.............120 POMALYST -pomalidomide cap 3 mg.............................. 18
PKU GEL -nutritional supplement pack.......................... 120 POMALYST -pomalidomide cap 4 mg.............................. 18
PKU LOPHLEX LQ 20 -nutritional supplement liquid..... 120 PORTAGEN -nutritional supplement powder.................. 120
PKU 2 -nutritional supplement powder........................... 120 potassium chloride cap er 8 meq (Micro-k)................ 106
PKU 3 -nutritional supplement powder........................... 120 potassium chloride cap er 10 meq (Micro-k).............. 106
PKU PERIFLEX EARLY YEARS -nutritional supplement POTASSIUM CHLORIDE ER -potassium chloride tab er 8
powder........................................................................... 120 meq (600 mg)............................................................... 107
PKU PERIFLEX JUNIOR PLUS -nutritional supplement POTASSIUM CHLORIDE ER -potassium chloride tab er
powder........................................................................... 120 20 meq (1500 mg)........................................................ 107
PKU SPHERE 15 -nutritional supplement pack.............. 120 potassium chloride microencapsulated crys er tab 10
PKU SPHERE 20 -nutritional supplement pack.............. 120 meq............................................................................... 107
PKU TRIO -nutritional supplement powder..................... 120 potassium chloride microencapsulated crys er tab 20
PLEGRIDY -peginterferon beta-1a soln pen-injector 125 meq............................................................................... 107
mcg/0.5ml........................................................................ 79 potassium chloride oral soln 10% (20 meq/15ml)...... 107
PLEGRIDY -peginterferon beta-1a soln prefilled syringe POTASSIUM CHLORIDE -potassium chloride oral soln
125 mcg/0.5ml................................................................ 79 20% (40 meq/15ml)...................................................... 106
2017
potassium chloride powder packet 20 meq............... 107 PRED-G S.O.P. -gentamicin-prednisolone ace ophth oint
potassium chloride tab er 10 meq (K-tab).................. 107 0.3-0.6%........................................................................ 137
potassium chloride tab er 8 meq (600 mg)................. 107 PRED MILD -prednisolone acetate ophth susp
potassium citrate tab er 5 meq (540 mg) (Urocit-k 0.12%.............................................................................137
5)...................................................................................... 64 prednicarbate cream 0.1% (Dermatop)....................... 145
potassium citrate tab er 10 meq (1080 mg) (Urocit-k prednicarbate oint 0.1% (Dermatop)........................... 145
10).................................................................................... 64 prednisolone acetate ophth susp 1% (Pred forte)..... 137
potassium citrate tab er 15 meq (1620 mg) (Urocit-k PREDNISOLONE SODIUM PHOSP -prednisolone
15).................................................................................... 64 sodium phosphate ophth soln 1%................................ 137
PPA/MMA EXPRESS -nutritional supplement pack........ 120 PREDNISOLONE SODIUM PHOSP -prednisolone
PRADAXA -dabigatran etexilate mesylate cap 75 mg sodium phosphate oral soln 25 mg/5ml (base eq)......... 21
(etexilate base eq)........................................................ 128 prednisolone sod phos orally disintegr tab 10 mg
PRADAXA -dabigatran etexilate mesylate cap 110 mg (base eq) (Orapred odt)............................................... 20
PRADAXA -dabigatran etexilate mesylate cap 150 mg (base eq) (Orapred odt)............................................... 20
PRALUENT -alirocumab subcutaneous soln pen-injector (base eq) (Orapred odt)............................................... 20
75 mg/ml......................................................................... 49 prednisolone sod phosphate oral soln 15 mg/5ml
PRALUENT -alirocumab subcutaneous soln pen-injector (base equiv)................................................................... 21
150 mg/ml....................................................................... 49 prednisolone sod phosphate oral soln 10 mg/5ml
pramipexole dihydrochloride tab er 24hr 0.375 mg (base equiv) (Millipred)................................................ 21
(Mirapex er).................................................................... 97 prednisolone sod phosphate oral soln 20 mg/5ml
pramipexole dihydrochloride tab er 24hr 0.75 mg (base equiv) (Veripred 20)........................................... 21
(Mirapex er).................................................................... 97 prednisolone sod phosph oral soln 6.7 mg/5ml (5
pramipexole dihydrochloride tab er 24hr 1.5 mg mg/5ml base) (Pediapred)............................................21
(Mirapex er).................................................................... 97 prednisolone syrup 15 mg/5ml (usp solution
pramipexole dihydrochloride tab er 24hr 2.25 mg equivalent)......................................................................21
(Mirapex er).................................................................... 97 PREDNISONE INTENSOL -prednisone conc 5 mg/ml..... 21
pramipexole dihydrochloride tab er 24hr 3 mg PREDNISONE -prednisone oral soln 5 mg/5ml................ 21
(Mirapex er).................................................................... 97 PREDNISONE -prednisone tab 50 mg............................. 21
pramipexole dihydrochloride tab er 24hr 3.75 mg PREDNISONE -prednisone tab therapy pack 5 mg
(Mirapex er).................................................................... 97 (21).................................................................................. 21
pramipexole dihydrochloride tab er 24hr 4.5 mg PREDNISONE -prednisone tab therapy pack 5 mg
(Mirapex er).................................................................... 97 (48).................................................................................. 21
pramipexole dihydrochloride tab 0.125 mg PREDNISONE -prednisone tab therapy pack 10 mg
(Mirapex).........................................................................97 (21).................................................................................. 21
pramipexole dihydrochloride tab 0.25 mg PREDNISONE -prednisone tab therapy pack 10 mg
(Mirapex).........................................................................97 (48).................................................................................. 21
pramipexole dihydrochloride tab 0.5 mg (Mirapex)..... 97 prednisone tab 1 mg....................................................... 21
pramipexole dihydrochloride tab 0.75 mg prednisone tab 2.5 mg.................................................... 21
(Mirapex).........................................................................97 prednisone tab 5 mg....................................................... 21
pramipexole dihydrochloride tab 1 mg (Mirapex)........ 97 prednisone tab 10 mg..................................................... 21
pramipexole dihydrochloride tab 1.5 mg (Mirapex)..... 97 prednisone tab 20 mg..................................................... 21
prasugrel hcl tab 5 mg (base equiv) (Effient)............. 133 PREFERAOB +DHA -prenat-fe poly cmplx 28mg-fe heme
prasugrel hcl tab 10 mg (base equiv) (Effient)........... 133 poly-fa tab&dha cap pack.............................................102
pravastatin sodium tab 10 mg....................................... 49 PREFERAOB ONE -prenat-fe poly cmplx-fe heme poly-
pravastatin sodium tab 20 mg (Pravachol)...................49 fa-dha cap 22-6-1-200 mg............................................102
pravastatin sodium tab 40 mg (Pravachol)...................49 PREFERA OB -prenat vit-fe poly cmplx-fe heme poly-fa
pravastatin sodium tab 80 mg (Pravachol)...................49 tab 34-1 mg...................................................................102
prazosin hcl cap 1 mg (Minipress)................................ 45 PREFEST -estradiol tab 1 mg(15)/estrad-norgestimate
prazosin hcl cap 2 mg (Minipress)................................ 45 tab 1-0.09mg(15)............................................................ 23
prazosin hcl cap 5 mg (Minipress)................................ 45 PREGNYL W/DILUENT BENZYL -chorionic gonadotropin
PRED-G -gentamicin-prednisolone ace ophth susp for inj 10000 unit............................................................. 36
0.3-1%........................................................................... 137 PREMARIN -estrogens, conjugated tab 0.3 mg............... 23
PREMARIN -estrogens, conjugated tab 0.45 mg............. 23
2017
PREMARIN -estrogens, conjugated tab 0.625 mg........... 23 PRENATE ELITE -prenatal w/ fe asp gly-l methylfol-fa tab
PREMARIN -estrogens, conjugated tab 0.9 mg............... 23 20-0.6-0.4 mg................................................................ 103
PREMARIN -estrogens, conjugated tab 1.25 mg............. 23 PRENATE ENHANCE -prenat w/o a w/fefum-methfol-fa-
PREMARIN -estrogens, conjugated vaginal cream 0.625 dha cap 28-0.6-0.4-400 mg.......................................... 103
mg/gm.............................................................................. 63 PRENATE ESSENTIAL -prenat w/o a w/feaspg-methfol-
PREMPHASE -conj est 0.625(14)/conj est-medroxypro ac fa-dha cap 18-0.6-0.4-300 mg..................................... 103
tab 0.625-5mg(14).......................................................... 23 PRENATE ESSENTIAL -prenat w/o a w/feasp-methylf-fa-
PREMPRO -conjugated estrogen-medroxyprogest omeg cap 29-0.6-0.4-340 mg....................................... 103
acetate tab 0.3-1.5 mg................................................... 23 PRENATE MINI -prenat w/oa w/fecb-feasp-meth-fa-dha
PREMPRO -conjugated estrogen-medroxyprogest cap 18-0.6-0.4-350 mg................................................. 103
acetate tab 0.45-1.5 mg................................................. 23 PRENATE MINI -prenat w/o a w/fecbn-methylf-fa-dha cap
PREMPRO -conjugated estrogen-medroxyprogest 29-0.6-0.4-350 mg........................................................ 103
acetate tab 0.625-2.5 mg............................................... 23 PRENATE PIXIE -prenat w/o a w/feaspg-methfol-fa-dha
PREMPRO -conjugated estrogen-medroxyprogest cap 10-0.6-0.4-200 mg................................................. 103
acetate tab 0.625-5 mg.................................................. 23 PRENATE -prenat mv & min w/ l-methylfolate-fa chew tab
PRENA1 CHEW -prenat w/ b2-b6-b12-d3-folic acid chew 0.6-0.4 mg..................................................................... 103
tab 1.4 mg..................................................................... 103 PRENATE RESTORE -prenat w/o a w/fefum-methfol-fa-
PRENAISSANCE BALANCE -prenatal w/o vit a w/ fe cbn- dha cap 27-0.6-0.4-400 mg.......................................... 103
dss-fa-dha cap 30-1-260 mg........................................ 102 PREPIDIL -dinoprostone cervical gel 0.5 mg/3gm............34
PRENAISSANCE HARMONY DHA -prenat w/fe poly-na PREPLUS -prenatal vit w/ fe fumarate-fa tab 27-1
fered-fa tab 27-1 & omega cap dr 380mg....................102 mg.................................................................................. 103
PRENAISSANCE NEXT-B -prenatal w/ calcium-vit b6-fa- PREPOPIK -sod picosulfate-mg oxide-citric acid pack 10
ginger tab 1.22 mg....................................................... 102 mg-3.5 gm-12 gm........................................................... 57
PRENAISSANCE NEXT -prenatal w/ calcium-vit b6-fa- PREPROTEIN -amino acids oral liquid........................... 108
ginger tab 1.2 mg......................................................... 102 PREPROTEIN 20 -amino acids oral liquid...................... 108
PRENAISSANCE PLUS -prenatal w/o a w/fe cbn-dss-fa- PRETAB -prenatal vit w/ fe fumarate-fa tab 29-1 mg...... 103
dha cap 28-1-250 mg................................................... 103 PREVIDENT 5000 BOOSTER PL -sodium fluoride paste
PRENAISSANCE -prenatal w/o vit a w/ fe fum-dss-fa-dha 1.1%...............................................................................139
cap 29-1.25-325 mg..................................................... 102 PREVIDENT 5000 BOOSTER -sodium fluoride paste
PRENA1 PEARL -prenat w/oa w/fefum-na fered-fa-dha 1.1%...............................................................................139
cap er 30-1.4-200 mg................................................... 103 PREVIDENT 5000 DRY MOUTH -sodium fluoride gel
PRENATABS RX -prenatal vit w/ iron carbonyl-fa tab 29-1 1.1% (0.5% f)................................................................ 139
mg.................................................................................. 103 PREVIDENT 5000 ENAMEL PRO -sodium fluoride-
PRENATAL PLUS IRON -prenatal vit w/ iron carbonyl-fa potassium nitrate paste 1.1-5%................................... 139
tab 29-1 mg...................................................................103 PREVIDENT FLUORIDE -sodium fluoride gel 1.1% (0.5%
PRENATAL PLUS -prenatal vit w/ fe fumarate-fa tab 27-1 f)..................................................................................... 139
mg.................................................................................. 103 PREVIDENT 5000 PLUS -sodium fluoride cream
PRENATAL 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1 1.1%...............................................................................140
mg.................................................................................. 103 PREVIDENT 5000 SENSITIVE -sodium fluoride-
PRENATAL 19 -prenatal vit w/ fe fumarate-fa chew tab potassium nitrate paste 1.1-5%................................... 140
29-1 mg......................................................................... 103 PREVNAR 13 -pneumococcal 13-valent conjugate
PRENATAL -prenatal vit w/ fe fumarate-fa tab 27-1 vaccine inj....................................................................... 13
mg.................................................................................. 103 PREZCOBIX -darunavir-cobicistat tab 800-150 mg............8
PRENATAL-U -prenatal w/o a vit w/ fe fumarate-fa cap PREZISTA -darunavir ethanolate susp 100 mg/ml (base
106.5-1 mg.................................................................... 103 equiv)................................................................................. 8
PRENATAL VITAMINS PLUS LO -prenatal vit w/ fe PREZISTA -darunavir ethanolate tab 75 mg (base
fumarate-fa tab 27-1 mg...............................................103 equiv)................................................................................. 8
PRENATE AM -prenatal w/ calcium-vit b6-vit b12-fa- PREZISTA -darunavir ethanolate tab 150 mg (base
ginger tab 1 mg............................................................ 103 equiv)................................................................................. 8
PRENATE DHA -prenat w/o a w/feaspg-methfol-fa-dha PREZISTA -darunavir ethanolate tab 600 mg (base
cap 18-0.6-0.4-300 mg................................................. 103 equiv)................................................................................. 8
PRENATE DHA -prenat w/o a w/fefum-methfol-fa-dha cap PREZISTA -darunavir ethanolate tab 800 mg (base
28-0.6-0.4-300 mg........................................................ 103 equiv)................................................................................. 8
PRENATE ELITE -prenatal vit w/ fe fum-methylfolate-fa PRIFTIN -rifapentine tab 150 mg........................................ 5
tab 26-0.6-0.4 mg......................................................... 103
2017
PRIMAQUINE PHOSPHATE -primaquine phosphate tab progesterone micronized cap 100 mg
26.3 mg (15 mg base).................................................... 11 (Prometrium).................................................................. 26
primidone tab 50 mg (Mysoline).................................... 94 progesterone micronized cap 200 mg
primidone tab 250 mg (Mysoline).................................. 94 (Prometrium).................................................................. 26
PRIMSOL -trimethoprim hcl oral soln 50 mg/5ml (base PROGLYCEM -diazoxide susp 50 mg/ml......................... 29
equiv)............................................................................... 11 PROGRAF -tacrolimus cap 0.5 mg................................. 148
PRISTIQ -desvenlafaxine succinate tab er 24hr 25 mg PROGRAF -tacrolimus cap 1 mg.................................... 148
(base equiv).................................................................... 67 PROGRAF -tacrolimus cap 5 mg.................................... 148
PRISTIQ -desvenlafaxine succinate tab er 24hr 50 mg PROLENSA -bromfenac sodium ophth soln 0.07% (base
(base equiv).................................................................... 67 equivalent)..................................................................... 137
PRISTIQ -desvenlafaxine succinate tab er 24hr 100 mg PROMACTA -eltrombopag olamine tab 12.5 mg (base
(base equiv).................................................................... 67 equiv)............................................................................. 127
PR NATAL 400 EC -prenat-fe bis-fe prot succ-fa-ca tab & PROMACTA -eltrombopag olamine tab 25 mg (base
omega cap dr 400 pk................................................... 102 equiv)............................................................................. 127
PR NATAL 430 EC -prenat-fe bis-fe prot succ-fa-ca tab & PROMACTA -eltrombopag olamine tab 50 mg (base
omega cap dr 430 pk................................................... 102 equiv)............................................................................. 127
PR NATAL 400 -prenat-fe bis-fe prot succ-fa-ca tab & PROMACTA -eltrombopag olamine tab 75 mg (base
omega 3 cap 400 pk.................................................... 102 equiv)............................................................................. 127
PR NATAL 430 -prenat-fe bis-fe prot succ-fa-ca tab & PROMACTIN AA PLUS -nutritional supplement
omega 3 cap 430 pk.................................................... 102 liquid.............................................................................. 121
PROAIR HFA -albuterol sulfate inhal aero 108 mcg/act promethazine & phenylephrine syrup 6.25-5
(90mcg base equiv)........................................................ 55 mg/5ml............................................................................ 52
PROAIR RESPICLICK -albuterol sulfate aer pow ba 108 promethazine-dm syrup 6.25-15 mg/5ml.......................53
mcg/act (90 mcg base equiv)......................................... 55 promethazine hcl suppos 12.5 mg................................ 51
PROBALANCE -nutritional supplement liquid................. 121 promethazine hcl suppos 25 mg................................... 51
probenecid tab 500 mg................................................... 91 promethazine hcl suppos 50 mg................................... 51
PRO-CAL -nutritional supplement pack.......................... 120 promethazine hcl syrup 6.25 mg/5ml............................ 51
PRO-CAL -nutritional supplement powder...................... 120 promethazine hcl tab 12.5 mg........................................ 51
prochlorperazine maleate tab 5 mg (base equivalent) promethazine hcl tab 25 mg........................................... 51
(Compazine)................................................................... 70 promethazine hcl tab 50 mg........................................... 51
prochlorperazine maleate tab 10 mg (base equivalent) promethazine-phenylephrine-codeine syrup 6.25-5-10
(Compazine)................................................................... 70 mg/5ml............................................................................ 53
prochlorperazine suppos 25 mg.................................... 70 promethazine w/ codeine syrup 6.25-10 mg/5ml..........52
PRO-CLEAR AC -codeine-pyrilamine syrup 9-8.33 PROMOD -nutritional supplement liquid......................... 121
mg/5ml............................................................................. 52 PROMOD -nutritional supplement powder...................... 121
PROCRIT -epoetin alfa inj 2000 unit/ml.......................... 126 PROMOTE/FIBER -nutritional supplement liquid........... 121
PROCRIT -epoetin alfa inj 3000 unit/ml.......................... 126 PROMOTE -nutritional supplement liquid....................... 121
PROCRIT -epoetin alfa inj 4000 unit/ml.......................... 127 PROMOTE 1.0 -nutritional supplement liquid................. 121
PROCRIT -epoetin alfa inj 10000 unit/ml........................ 127 PROMOTE WITH FIBER -nutritional supplement
PROCRIT -epoetin alfa inj 20000 unit/ml........................ 127 liquid.............................................................................. 121
PROCRIT -epoetin alfa inj 40000 unit/ml........................ 127 PROMOTE 1.0 WITH FIBER -nutritional supplement
PROCTOFOAM HC -hydrocortisone acetate w/ liquid.............................................................................. 121
pramoxine rectal foam 1-1%........................................ 140 propafenone hcl cap er 12hr 225 mg (Rythmol sr)...... 42
PROCYSBI -cysteamine bitartrate cap delayed release 25 propafenone hcl cap er 12hr 325 mg (Rythmol sr)...... 42
mg (base equiv).............................................................. 64 propafenone hcl cap er 12hr 425 mg (Rythmol sr)...... 42
PROCYSBI -cysteamine bitartrate cap delayed release 75 propafenone hcl tab 300 mg.......................................... 42
mg (base equiv).............................................................. 64 propafenone hcl tab 150 mg (Rythmol)........................ 42
PROFILNINE -factor ix complex for inj 500 unit............. 133 propafenone hcl tab 225 mg (Rythmol)........................ 42
PROFILNINE -factor ix complex for inj 1000 unit........... 133 PROPANTHELINE BROMIDE -propantheline bromide tab
PROFILNINE -factor ix complex for inj 1500 unit........... 133 15 mg.............................................................................. 58
PROFILNINE SD -factor ix complex for inj 500 unit........133 proparacaine hcl ophth soln 0.5% (Alcaine).............. 137
PROFILNINE SD -factor ix complex for inj 1000 unit......133 PRO-PHREE -nutritional supplement powder................ 121
PROFILNINE SD -factor ix complex for inj 1500 unit......133 PROPIMEX-1 -nutritional supplement powder................ 121
progesterone im in oil 50 mg/ml.................................... 26 PROPIMEX-2 -nutritional supplement powder................ 121
propranolol hcl cap er 24hr 60 mg (Inderal la)............. 39
2017
propranolol hcl cap er 24hr 80 mg (Inderal la)............. 39 QUDEXY XR -topiramate cap er 24hr sprinkle 25 mg...... 94
propranolol hcl cap er 24hr 120 mg (Inderal la)........... 39 QUDEXY XR -topiramate cap er 24hr sprinkle 50 mg...... 94
propranolol hcl cap er 24hr 160 mg (Inderal la)........... 39 QUDEXY XR -topiramate cap er 24hr sprinkle 100
propranolol hcl tab 10 mg.............................................. 39 mg.................................................................................... 95
propranolol hcl tab 20 mg.............................................. 39 QUDEXY XR -topiramate cap er 24hr sprinkle 150
propranolol hcl tab 60 mg.............................................. 39 QUDEXY XR -topiramate cap er 24hr sprinkle 200
propylthiouracil tab 50 mg............................................. 33 quetiapine fumarate tab er 24hr 50 mg (Seroquel
PRO-RED AC -phenylephrine-dexchlorphenir-codeine xr).................................................................................... 70
syrup 5-1-9 mg/5ml.........................................................52 quetiapine fumarate tab er 24hr 150 mg (Seroquel
PROSOURCE NO CARB -nutritional supplement xr).................................................................................... 70
liquid.............................................................................. 121 quetiapine fumarate tab er 24hr 200 mg (Seroquel
PROSOURCE -nutritional supplement liquid.................. 121 xr).................................................................................... 70
PROSOURCE -nutritional supplement powder............... 121 quetiapine fumarate tab er 24hr 300 mg (Seroquel
PROSOURCE PLUS -nutritional supplement liquid........121 xr).................................................................................... 70
PROSOURCE TF -nutritional supplement liquid.............121 quetiapine fumarate tab er 24hr 400 mg (Seroquel
PROSOURCE ZAC -nutritional supplement liquid.......... 121 xr).................................................................................... 70
PROSTIN E2 -dinoprostone vaginal suppos 20 mg......... 34 quetiapine fumarate tab 25 mg (Seroquel)................... 70
PROSURE -nutritional supplement liquid........................121 quetiapine fumarate tab 50 mg (Seroquel)................... 70
PROTAIN XL -nutritional supplement liquid.................... 121 quetiapine fumarate tab 100 mg (Seroquel)................. 70
PROTEIN FORTIFIED COOKIE -nutritional supplement quetiapine fumarate tab 200 mg (Seroquel)................. 70
misc............................................................................... 121 quetiapine fumarate tab 300 mg (Seroquel)................. 71
protriptyline hcl tab 5 mg............................................... 67 quetiapine fumarate tab 400 mg (Seroquel)................. 71
protriptyline hcl tab 10 mg............................................. 67 quinapril hcl tab 5 mg (Accupril)................................... 45
PROVIDA DHA -prenat w/o a w/fe fum-fe poly-fa-dha cap quinapril hcl tab 10 mg (Accupril)................................. 45
16-16-1.25-110 mg........................................................103 quinapril hcl tab 20 mg (Accupril)................................. 45
PROVIDA OB -prenatal w/o a w/fe fum-fe poly-fa cap quinapril hcl tab 40 mg (Accupril)................................. 45
20-20-1.25 mg...............................................................103 quinapril-hydrochlorothiazide tab 10-12.5 mg
PROVIMIN -nutritional supplement powder.................... 121 (Accuretic)...................................................................... 45
PRUDOXIN -doxepin hcl cream 5%............................... 145 quinapril-hydrochlorothiazide tab 20-12.5 mg
pseudoeph-chlorphen w/ hydrocodone soln 60-4-5 (Accuretic)...................................................................... 45
mg/5ml (Zutripro).......................................................... 53 quinapril-hydrochlorothiazide tab 20-25 mg
pseudoephed-bromphen-dm syrup 30-2-10 (Accuretic)...................................................................... 45
mg/5ml............................................................................ 53 quinidine gluconate tab er 324 mg................................ 42
pseudoephedrine w/ cod-gg soln 30-10-100 QUINIDINE SULFATE -quinidine sulfate tab 200 mg....... 42
mg/5ml............................................................................ 53 QUINIDINE SULFATE -quinidine sulfate tab 300 mg....... 42
PULMOCARE -nutritional supplement liquid.................. 121 quinine sulfate cap 324 mg (Qualaquin)....................... 11
PULMOCARE 1.5 -nutritional supplement liquid............ 121 QUINOA KALE & HEMP -nutritional supplement
PULMOZYME -dornase alfa inhal soln 1 mg/ml............... 56 liquid.............................................................................. 121
PUREFE OB PLUS -prenatal w/o a w/fe fum-fe poly-fa QVAR -beclomethasone diprop inhal aero soln 40 mcg/act
cap 162.115.2-1 mg...................................................... 104 (50/valve)......................................................................... 55
PURIXAN -mercaptopurine susp 2000 mg/100ml (20 mg/ QVAR -beclomethasone diprop inhal aero soln 80 mcg/act
ml).................................................................................... 18 (100/valve)....................................................................... 55
PX VANILLA PLUS -nutritional supplement liquid.......... 121 R
pyrazinamide tab 500 mg..................................................5
pyridostigmine bromide tab er 180 mg (Mestinon RA BALANCED NUTRITIONAL -nutritional supplement
timespan)........................................................................99 liquid.............................................................................. 121
pyridostigmine bromide tab 60 mg (Mestinon)............ 99 RA BALANCED NUTRITIONAL P -nutritional supplement
liquid.............................................................................. 121
Q RABAVERT -rabies vaccine, pcec for inj.......................... 13
QUADRACEL -diph-tetanus tox ad-acell pert & polio rabeprazole sodium ec tab 20 mg (Aciphex)................ 58
virus, ipv vac inj.............................................................. 14 RADIOGARDASE -prussian blue insoluble cap 0.5
QUARTETTE -levonor-eth est tab 0.15-0.02/0.025/0.03 gm.................................................................................. 146
mg &eth est 0.01 mg...................................................... 26 RAGWITEK -short ragweed pollen allergen extract tab sl
QUAZEPAM -quazepam tab 15 mg.................................. 72 12 amb a 1-u.................................................................. 14
2017
raloxifene hcl tab 60 mg (Evista)................................... 36 REBIF -interferon beta-1a soln pref syr 44 mcg/0.5ml
ramipril cap 1.25 mg (Altace)......................................... 45 (24mu/ml)........................................................................ 79
ramipril cap 2.5 mg (Altace)........................................... 45 REBIF REBIDOSE -interferon beta-1a soln auto-inj 22
ramipril cap 5 mg (Altace).............................................. 45 mcg/0.5ml (12mu/ml)...................................................... 79
ramipril cap 10 mg (Altace)............................................ 45 REBIF REBIDOSE -interferon beta-1a soln auto-inj 44
RANEXA -ranolazine tab er 12hr 500 mg......................... 38 mcg/0.5ml (24mu/ml)...................................................... 79
RANEXA -ranolazine tab er 12hr 1000 mg....................... 38 REBIF REBIDOSE TITRATION -interferon beta-1a auto-
ranitidine hcl cap 150 mg............................................... 58 inj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml.......................... 79
ranitidine hcl cap 300 mg............................................... 58 REBIF TITRATION PACK -interferon beta-1a pref syr
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)................... 58 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml............................... 79
ranitidine hcl tab 300 mg (Zantac)................................. 58 RECOMBINATE -antihemophilic factor (recombinant) for
RA NUTRITIONAL SUPPLEMENT -nutritional inj 220-400 unit............................................................. 133
supplement liquid.......................................................... 121 RECOMBINATE -antihemophilic factor (recombinant) for
RA NUTRITIONAL SUPPORT -nutritional supplement inj 401-800 unit............................................................. 133
powder........................................................................... 121 RECOMBINATE -antihemophilic factor (recombinant) for
RAPAFLO -silodosin cap 4 mg..........................................64 inj 801-1240 unit........................................................... 133
RAPAFLO -silodosin cap 8 mg..........................................64 RECOMBINATE -antihemophilic factor (recombinant) for
RAPAMUNE -sirolimus oral soln 1 mg/ml....................... 148 inj 1241-1800 unit......................................................... 133
RA PEDIATRIC NUTRITIONAL -nutritional supplement RECOMBINATE -antihemophilic factor (recombinant) for
liquid.............................................................................. 121 inj 1801-2400 unit......................................................... 133
rasagiline mesylate tab 0.5 mg (base equiv) RECOMBIVAX HB -hepatitis b vaccine (recombinant)
(Azilect)........................................................................... 97 susp 5 mcg/0.5ml........................................................... 13
rasagiline mesylate tab 1 mg (base equiv) RECOMBIVAX HB -hepatitis b vaccine (recombinant)
(Azilect)........................................................................... 97 susp 10 mcg/ml.............................................................. 13
RASUVO -methotrexate soln pf auto-injector 7.5 RECOMBIVAX HB -hepatitis b vaccine (recombinant)
mg/0.15ml........................................................................ 89 susp 40 mcg/ml.............................................................. 13
RASUVO -methotrexate soln pf auto-injector 10 RECTIV -nitroglycerin oint 0.4%..................................... 140
mg/0.2ml.......................................................................... 89 REGRANEX -becaplermin gel 0.01%............................. 145
RASUVO -methotrexate soln pf auto-injector 12.5 RELENZA DISKHALER -zanamivir aero powder breath
mg/0.25ml........................................................................ 89 activated 5 mg/blister........................................................8
RASUVO -methotrexate soln pf auto-injector 15 RELION R -insulin regular (human) inj 100 unit/ml........... 31
mg/0.3ml.......................................................................... 89 RELNATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap
RASUVO -methotrexate soln pf auto-injector 17.5 28-1-200 mg.................................................................. 104
mg/0.35ml........................................................................ 89 RELPAX -eletriptan hydrobromide tab 20 mg (base
RASUVO -methotrexate soln pf auto-injector 20 equivalent)....................................................................... 90
mg/0.4ml.......................................................................... 89 RELPAX -eletriptan hydrobromide tab 40 mg (base
RASUVO -methotrexate soln pf auto-injector 22.5 equivalent)....................................................................... 90
mg/0.45ml........................................................................ 89 REMBRANDT DEEPLY WHITE+PE -sodium
RASUVO -methotrexate soln pf auto-injector 25 monofluorophosphate paste 0.884%........................... 140
mg/0.5ml.......................................................................... 89 RENAGEL -sevelamer hcl tab 400 mg............................. 61
RASUVO -methotrexate soln pf auto-injector 30 RENAGEL -sevelamer hcl tab 800 mg............................. 61
mg/0.6ml.......................................................................... 89 RENALCAL -nutritional supplement liquid...................... 122
RAVICTI -glycerol phenylbutyrate liquid 1.1 gm/ml...........36 RENASTART -nutritional supplement powder................ 122
RE/GEN PROTEIN FORTIFIED -nutritional supplement RENVELA -sevelamer carbonate packet 0.8 gm.............. 61
misc............................................................................... 121 RENVELA -sevelamer carbonate packet 2.4 gm.............. 61
RE/NEPH HP/HC -nutritional supplement liquid RENVELA -sevelamer carbonate tab 800 mg.................. 61
(frozen).......................................................................... 121 REPAGLINIDE/METFORMIN HYD -repaglinide-metformin
RE/NEPH LP/HC -nutritional supplement liquid..............121 hcl tab 1-500 mg.............................................................29
RE/NEPH -nutritional supplement liquid......................... 121 REPAGLINIDE/METFORMIN HYD -repaglinide-metformin
RE/NEPH REDUCED SUGAR -nutritional supplement hcl tab 2-500 mg.............................................................30
liquid.............................................................................. 121 repaglinide tab 0.5 mg (Prandin)................................... 29
REBETOL -ribavirin soln 40 mg/ml..................................... 8 repaglinide tab 1 mg (Prandin)...................................... 29
REBIF -interferon beta-1a soln pref syr 22 mcg/0.5ml repaglinide tab 2 mg (Prandin)...................................... 29
(12mu/ml)........................................................................ 79 REPATHA -evolocumab subcutaneous soln prefilled
syringe 140 mg/ml.......................................................... 49
2017
REPATHA PUSHTRONEX SYSTEM -evolocumab REYATAZ -atazanavir sulfate cap 300 mg (base equiv)..... 9
subcutaneous soln cartridge/infusor 420 mg/3.5ml....... 49 REYATAZ -atazanavir sulfate oral powder packet 50 mg
REPATHA SURECLICK -evolocumab subcutaneous soln (base equiv)...................................................................... 9
auto-injector 140 mg/ml.................................................. 49 RIASTAP -fibrinogen conc (human) inj approximately 1
REPLETE/FIBER/ULTRAPAK -nutritional supplement gm (900-1300 mg)........................................................ 133
liquid.............................................................................. 122 RIBASPHERE RIBAPAK -ribavirin tab 400 mg................... 9
REPLETE FIBER 1 CAL -nutritional supplement RIBASPHERE RIBAPAK -ribavirin tab 600 mg................... 9
liquid.............................................................................. 122 RIBASPHERE RIBAPAK -ribavirin tab 200 mg & ribavirin
REPLETE FIBER -nutritional supplement liquid............. 122 tab 400 mg dose pack......................................................9
REPLETE -nutritional supplement liquid......................... 122 RIBASPHERE RIBAPAK -ribavirin tab 400 mg & ribavirin
RESCRIPTOR -delavirdine mesylate tab 100 mg.............. 8 tab 600 mg dose pack......................................................9
RESCRIPTOR -delavirdine mesylate tab 200 mg.............. 8 RIBASPHERE -ribavirin tab 400 mg................................... 9
RESCULA -unoprostone isopropyl ophth soln RIBASPHERE -ribavirin tab 600 mg................................... 9
0.15%.............................................................................137 ribavirin cap 200 mg (Rebetol)......................................... 9
RESOURCE ARGINAID -nutritional supplement ribavirin for inhal soln 6 gm (Virazole)........................... 9
pack............................................................................... 122 ribavirin tab 200 mg (Copegus)....................................... 9
RESOURCE DAIRY THICK HONE -nutritional RIDAURA -auranofin cap 3 mg......................................... 89
supplement liquid.......................................................... 122 rifabutin cap 150 mg (Mycobutin).................................... 5
RESOURCE DIABETIC TF -nutritional supplement RIFAMATE -isoniazid & rifampin cap 150-300 mg.............. 5
liquid.............................................................................. 122 rifampin cap 150 mg (Rifadin).......................................... 5
RESOURCE JUICE DRINK -nutritional supplement liquid rifampin cap 300 mg (Rifadin).......................................... 5
(frozen).......................................................................... 122 RIFATER -isoniazid-rifampin w/ pyrazinamide tab
RESOURCE JUST FOR KIDS -nutritional supplement 50-120-300 mg.................................................................. 5
liquid.............................................................................. 122 riluzole tab 50 mg (Rilutek)............................................ 98
RESOURCE JUST FOR KIDS 1. -nutritional supplement rimantadine hydrochloride tab 100 mg (Flumadine)..... 9
liquid.............................................................................. 122 RIOMET -metformin hcl oral soln 500 mg/5ml.................. 30
RESOURCE JUST FOR KIDS WI -nutritional supplement risedronate sodium tab delayed release 35 mg
liquid.............................................................................. 122 (Atelvia).......................................................................... 36
RESOURCE 2.0 -nutritional supplement liquid............... 122 risedronate sodium tab 5 mg (Actonel)........................ 36
RESOURCE SUPPORT -nutritional supplement risedronate sodium tab 30 mg (Actonel)...................... 36
liquid.............................................................................. 122 risedronate sodium tab 35 mg (Actonel)...................... 36
RESOURCE THICKENUP THICKE -nutritional risedronate sodium tab 150 mg (Actonel).................... 36
supplement liquid.......................................................... 122 risperidone orally disintegrating tab 0.25 mg.............. 71
RESPALOR -nutritional supplement liquid...................... 122 risperidone orally disintegrating tab 0.5 mg (Risperdal
RESTASIS -cyclosporine (ophth) emulsion 0.05%......... 137 m-tab).............................................................................. 71
RESTASIS MULTIDOSE -cyclosporine (ophth) emulsion risperidone orally disintegrating tab 1 mg (Risperdal
0.05%.............................................................................137 m-tab).............................................................................. 71
RESURGEX -nutritional supplement pack...................... 122 risperidone orally disintegrating tab 2 mg (Risperdal
RESURGEX PLUS -nutritional supplement pack........... 122 m-tab).............................................................................. 71
RESURGEX SELECT -nutritional supplement pack....... 122 risperidone orally disintegrating tab 3 mg (Risperdal
REVATIO -sildenafil citrate for suspension 10 mg/ml....... 50 m-tab).............................................................................. 71
REVLIMID -lenalidomide cap 5 mg................................. 148 risperidone orally disintegrating tab 4 mg (Risperdal
REVLIMID -lenalidomide cap 10 mg............................... 148 m-tab).............................................................................. 71
REVLIMID -lenalidomide cap 15 mg............................... 148 risperidone soln 1 mg/ml (Risperdal)............................ 71
REVLIMID -lenalidomide cap 20 mg............................... 148 risperidone tab 0.25 mg (Risperdal).............................. 71
REVLIMID -lenalidomide cap 25 mg............................... 148 risperidone tab 0.5 mg (Risperdal)................................ 71
REVLIMID -lenalidomide caps 2.5 mg............................ 148 risperidone tab 1 mg (Risperdal)................................... 71
REXULTI -brexpiprazole tab 0.25 mg............................... 71 risperidone tab 2 mg (Risperdal)................................... 71
REXULTI -brexpiprazole tab 0.5 mg................................. 71 risperidone tab 3 mg (Risperdal)................................... 71
REXULTI -brexpiprazole tab 1 mg.................................... 71 risperidone tab 4 mg (Risperdal)................................... 71
REXULTI -brexpiprazole tab 2 mg.................................... 71 rivastigmine tartrate cap 1.5 mg (Exelon).....................79
REXULTI -brexpiprazole tab 3 mg.................................... 71 rivastigmine tartrate cap 3 mg (Exelon)........................79
REXULTI -brexpiprazole tab 4 mg.................................... 71 rivastigmine tartrate cap 4.5 mg (Exelon).....................79
REYATAZ -atazanavir sulfate cap 150 mg (base equiv)..... 9 rivastigmine tartrate cap 6 mg (Exelon)........................79
REYATAZ -atazanavir sulfate cap 200 mg (base equiv)..... 9 rivastigmine td patch 24hr 4.6 mg/24hr (Exelon)......... 79
2017
rivastigmine td patch 24hr 9.5 mg/24hr (Exelon)......... 80 RYTARY -carbidopa & levodopa cap er 36.25-145
rivastigmine td patch 24hr 13.3 mg/24hr (Exelon)....... 80 mg.................................................................................... 97
RIXUBIS -coagulation factor ix (recombinant) for inj 250 RYTARY -carbidopa & levodopa cap er 48.75-195
unit................................................................................. 133 mg.................................................................................... 97
RIXUBIS -coagulation factor ix (recombinant) for inj 500 RYTARY -carbidopa & levodopa cap er 61.25-245
unit................................................................................. 133 mg.................................................................................... 97
RIXUBIS -coagulation factor ix (recombinant) for inj 1000 S
unit................................................................................. 133
RIXUBIS -coagulation factor ix (recombinant) for inj 2000 SABRIL -vigabatrin powd pack 500 mg............................ 95
unit................................................................................. 134 SABRIL -vigabatrin tab 500 mg........................................ 95
RIXUBIS -coagulation factor ix (recombinant) for inj 3000 SAFYRAL -drospirenone-ethinyl estrad-levomefolate tab
unit................................................................................. 134 3-0.03-0.451 mg..............................................................26
rizatriptan benzoate oral disintegrating tab 5 mg (base SALMON/OATS/SQUASH -nutritional supplement
eq) (Maxalt-mlt)............................................................. 90 liquid.............................................................................. 122
rizatriptan benzoate oral disintegrating tab 10 mg SAMSCA -tolvaptan tab 15 mg......................................... 36
(base eq) (Maxalt-mlt).................................................. 90 SAMSCA -tolvaptan tab 30 mg......................................... 36
rizatriptan benzoate tab 5 mg (base equivalent) SANDIMMUNE -cyclosporine cap 25 mg....................... 148
(Maxalt)........................................................................... 90 SANDIMMUNE -cyclosporine cap 100 mg..................... 148
rizatriptan benzoate tab 10 mg (base equivalent) SANDIMMUNE -cyclosporine oral soln 100 mg/ml......... 148
(Maxalt)........................................................................... 90 SANTYL -collagenase oint 250 unit/gm.......................... 145
R-NATAL OB -prenatal w/o a w/fe cbn-fa-dha cap SAPHRIS -asenapine maleate sl tab 2.5 mg (base
20-1-320 mg.................................................................. 104 equiv)............................................................................... 71
ropinirole hydrochloride tab er 24hr 2 mg (base SAPHRIS -asenapine maleate sl tab 5 mg (base
equivalent) (Requip xl)................................................. 97 equiv)............................................................................... 71
ropinirole hydrochloride tab er 24hr 4 mg (base SAPHRIS -asenapine maleate sl tab 10 mg (base
equivalent) (Requip xl)................................................. 97 equiv)............................................................................... 71
ropinirole hydrochloride tab er 24hr 6 mg (base SAVAYSA -edoxaban tosylate tab 15 mg (base
equivalent) (Requip xl)................................................. 97 equivalent)..................................................................... 128
ropinirole hydrochloride tab 0.25 mg (Requip)............ 97 SAVELLA -milnacipran hcl tab 12.5 mg............................ 80
ropinirole hydrochloride tab 0.5 mg (Requip).............. 97 SAVELLA -milnacipran hcl tab 25 mg............................... 80
ropinirole hydrochloride tab 1 mg (Requip)................. 97 SAVELLA -milnacipran hcl tab 50 mg............................... 80
ropinirole hydrochloride tab 2 mg (Requip)................. 97 SAVELLA -milnacipran hcl tab 100 mg............................. 80
ropinirole hydrochloride tab 3 mg (Requip)................. 97 SAVELLA TITRATION PACK -milnacipran hcl tab 12.5 mg
ropinirole hydrochloride tab 4 mg (Requip)................. 97 (5) & 25 mg (8) & 50 mg (42) pak................................. 80
ropinirole hydrochloride tab 5 mg (Requip)................. 97 SB COMPLETE NUTRITION -nutritional supplement
rosuvastatin calcium tab 5 mg (Crestor)...................... 49 liquid.............................................................................. 122
rosuvastatin calcium tab 10 mg (Crestor).................... 49 SB COMPLETE NUTRITION PLU -nutritional supplement
rosuvastatin calcium tab 20 mg (Crestor).................... 49 liquid.............................................................................. 122
rosuvastatin calcium tab 40 mg (Crestor).................... 50 SCANDICAL -nutritional supplement powder................. 122
ROZEREM -ramelteon tab 8 mg....................................... 72 SCANDISHAKE -nutritional supplement misc................ 122
RUBRACA -rucaparib camsylate tab 200 mg (base SCANDISHAKE -nutritional supplement pack................ 122
equivalent)....................................................................... 18 SCANDISHAKE -nutritional supplement powder............ 122
RUBRACA -rucaparib camsylate tab 250 mg (base scopolamine td patch 72hr 1 mg/3days (Transderm-
equivalent)....................................................................... 18 scop)............................................................................... 59
RUBRACA -rucaparib camsylate tab 300 mg (base SELECT-OB -prenatal vit w/ fe polysac cmplx-fa chew tab
equivalent)....................................................................... 18 29-1 mg......................................................................... 104
RUCONEST -c1 esterase inhibitor (recombinant) for iv inj SELECT-OB -prenat w/ fepolycmplx-methylfol-fa chew
2100 unit....................................................................... 134 tab 29-0.6-0.4 mg......................................................... 104
RYDAPT -midostaurin cap 25 mg..................................... 18 selegiline hcl cap 5 mg (Eldepryl)................................. 98
RYTARY -carbidopa & levodopa cap er 23.75-95 mg.......97 selegiline hcl tab 5 mg.................................................... 98
selenium sulfide lotion 2.5%........................................ 145
SELZENTRY -maraviroc oral soln 20 mg/ml...................... 9
2017
SELZENTRY -maraviroc tab 25 mg.................................... 9 simvastatin tab 20 mg (Zocor)....................................... 50
SELZENTRY -maraviroc tab 75 mg.................................... 9 simvastatin tab 40 mg (Zocor)....................................... 50
SELZENTRY -maraviroc tab 150 mg.................................. 9 simvastatin tab 80 mg (Zocor)....................................... 50
SELZENTRY -maraviroc tab 300 mg.................................. 9 sirolimus tab 0.5 mg (Rapamune)............................... 148
SE-NATAL 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1 sirolimus tab 1 mg (Rapamune).................................. 148
mg.................................................................................. 104 sirolimus tab 2 mg (Rapamune).................................. 148
SE-NATAL 19 -prenatal vit w/ fe fumarate-fa chew tab SIRTURO -bedaquiline fumarate tab 100 mg (base
29-1 mg......................................................................... 104 equiv)................................................................................. 5
SENSIPAR -cinacalcet hcl tab 30 mg (base equiv).......... 36 SITAVIG -acyclovir buccal tab 50 mg.................................. 9
SENSIPAR -cinacalcet hcl tab 60 mg (base equiv).......... 36 SIVEXTRO -tedizolid phosphate tab 200 mg....................11
SENSIPAR -cinacalcet hcl tab 90 mg (base equiv).......... 36 SKLICE -ivermectin lotion 0.5%...................................... 145
SENSODYNE REPAIR & PROTEC -stannous fluoride SM NUTRI-DRINK + -nutritional supplement liquid........ 122
paste 0.454%................................................................ 140 SM NUTRI-DRINK -nutritional supplement liquid........... 122
SEREVENT DISKUS -salmeterol xinafoate aer pow ba 50 sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)
mcg/dose (base equiv)................................................... 55 (Luride)......................................................................... 107
SEROQUEL XR -quetiapine fumarate tab er 24hr 50 sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)
mg.................................................................................... 71 (Luride)......................................................................... 107
SEROQUEL XR -quetiapine fumarate tab er 24hr 150 sodium fluoride chew tab 1 mg f (from 2.2 mg naf)
mg.................................................................................... 71 (Luride)......................................................................... 107
SEROQUEL XR -quetiapine fumarate tab er 24hr 200 sodium fluoride cream 1.1% (Prevident 5000
mg.................................................................................... 71 plus).............................................................................. 140
SEROQUEL XR -quetiapine fumarate tab er 24hr 300 sodium fluoride gel 1.1% (0.5% f) (Prevident
mg.................................................................................... 71 fluoride)........................................................................ 140
SEROQUEL XR -quetiapine fumarate tab er 24hr 400 sodium fluoride paste 1.1% (Prevident 5000
mg.................................................................................... 71 boost)............................................................................ 140
sertraline hcl oral conc 20 mg/ml (Zoloft).................... 67 sodium fluoride-potassium nitrate paste 1.1-5%
sertraline hcl tab 25 mg (Zoloft).................................... 67 (Prevident 5000 sensi)............................................... 140
sertraline hcl tab 50 mg (Zoloft).................................... 67 sodium fluoride rinse 0.05%.........................................140
sertraline hcl tab 100 mg (Zoloft).................................. 67 sodium fluoride rinse 0.0221% (0.01% f).................... 140
sevelamer carbonate packet 0.8 gm (Renvela)............ 61 sodium fluoride rinse 0.2% (Prevident)...................... 140
sevelamer carbonate packet 2.4 gm (Renvela)............ 61 SODIUM FLUORIDE -sodium fluoride tab 0.5 mg f (from
sevelamer carbonate tab 800 mg (Renvela)................. 61 1.1 mg naf)....................................................................107
SFROWASA -mesalamine sulfite-free (sf) enema 4 SODIUM FLUORIDE -sodium fluoride tab 1 mg f (from
gm/60ml........................................................................... 61 2.2 mg naf)....................................................................107
SHUR-SEAL -nonoxynol-9 gel 2%.................................... 63 sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop
SIGNIFOR -pasireotide diaspartate inj 0.3 mg/ml (base naf)................................................................................ 107
equiv)............................................................................... 36 sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)
SIGNIFOR -pasireotide diaspartate inj 0.6 mg/ml (base (Luride)......................................................................... 107
equiv)............................................................................... 36 sodium phenylbutyrate oral powder 3 gm/teaspoonful
SIGNIFOR -pasireotide diaspartate inj 0.9 mg/ml (base (Buphenyl)...................................................................... 36
equiv)............................................................................... 36 sodium polystyrene sulfonate oral susp 15 gm/60ml
sildenafil citrate tab 20 mg (Revatio)............................ 50 (Sps).............................................................................. 148
silver sulfadiazine cream 1% (Silvadene)................... 145 sodium polystyrene sulfonate powder
SIMBRINZA -brinzolamide-brimonidine tartrate ophth (Kayexalate)................................................................. 149
susp 1-0.2%.................................................................. 137 sodium polystyrene sulfonate rectal susp 30
SIMPONI -golimumab subcutaneous soln auto-injector 50 gm/120ml...................................................................... 149
mg/0.5ml.......................................................................... 89 SOL CARB -nutritional supplement powder....................122
SIMPONI -golimumab subcutaneous soln auto-injector SOLTAMOX -tamoxifen citrate oral soln 10 mg/5ml (base
100 mg/ml....................................................................... 89 equivalent)....................................................................... 18
SIMPONI -golimumab subcutaneous soln prefilled syringe SOLVIL -amino acids pack.............................................. 108
50 mg/0.5ml.................................................................... 89 SOMAVERT -pegvisomant for inj 10 mg (as protein)....... 37
SIMPONI -golimumab subcutaneous soln prefilled syringe SOMAVERT -pegvisomant for inj 15 mg (as protein)....... 37
100 mg/ml....................................................................... 89 SOMAVERT -pegvisomant for inj 20 mg (as protein)....... 37
simvastatin tab 5 mg (Zocor)......................................... 50 SOMAVERT -pegvisomant for inj 25 mg (as protein)....... 37
simvastatin tab 10 mg (Zocor)....................................... 50 SOMAVERT -pegvisomant for inj 30 mg (as protein)....... 37
2017
SOOLANTRA -ivermectin cream 1%.............................. 145 stavudine cap 20 mg (Zerit)..............................................9
S.O.S. 15 -nutritional supplement pack.......................... 122 stavudine cap 30 mg (Zerit)..............................................9
S.O.S. 20 -nutritional supplement pack.......................... 122 stavudine cap 40 mg (Zerit)..............................................9
S.O.S. 25 -nutritional supplement pack.......................... 122 STELARA -ustekinumab inj 45 mg/0.5ml........................ 145
sotalol hcl (afib/afl) tab 80 mg (Betapace af)................ 39 STELARA -ustekinumab soln prefilled syringe 45
sotalol hcl (afib/afl) tab 120 mg (Betapace af).............. 39 mg/0.5ml........................................................................ 145
sotalol hcl (afib/afl) tab 160 mg (Betapace af).............. 39 STELARA -ustekinumab soln prefilled syringe 90 mg/
sotalol hcl tab 240 mg.....................................................39 ml................................................................................... 145
sotalol hcl tab 80 mg (Betapace)................................... 39 STIMATE -desmopressin acetate nasal soln 1.5 mg/
sotalol hcl tab 120 mg (Betapace)................................. 39 ml..................................................................................... 37
sotalol hcl tab 160 mg (Betapace)................................. 39 STIOLTO RESPIMAT -tiotropium br-olodaterol inhal aero
SOURCE COOKIE BAR -nutritional supplement bar......122 soln 2.5-2.5 mcg/act....................................................... 55
SOVALDI -sofosbuvir tab 400 mg....................................... 9 STIVARGA -regorafenib tab 40 mg................................... 18
SOY PROTEIN SHAKE -nutritional supplement STRATTERA -atomoxetine hcl cap 10 mg (base
powder........................................................................... 122 equiv)............................................................................... 75
SPACERS-VARIOUS....................................................... 147 STRATTERA -atomoxetine hcl cap 18 mg (base
SPECTRACEF -cefditoren pivoxil tab 400 mg (base equiv)............................................................................... 75
equivalent)......................................................................... 2 STRATTERA -atomoxetine hcl cap 25 mg (base
SPINOSAD -spinosad susp 0.9%................................... 145 equiv)............................................................................... 76
SPIRIVA HANDIHALER -tiotropium bromide monohydrate STRATTERA -atomoxetine hcl cap 40 mg (base
inhal cap 18 mcg (base equiv)....................................... 55 equiv)............................................................................... 76
SPIRIVA RESPIMAT -tiotropium bromide monohydrate STRATTERA -atomoxetine hcl cap 60 mg (base
inhal aerosol 1.25 mcg/act............................................. 55 equiv)............................................................................... 76
SPIRIVA RESPIMAT -tiotropium bromide monohydrate STRATTERA -atomoxetine hcl cap 80 mg (base
inhal aerosol 2.5 mcg/act............................................... 55 equiv)............................................................................... 76
spironolactone & hydrochlorothiazide tab 25-25 mg STRATTERA -atomoxetine hcl cap 100 mg (base
(Aldactazide).................................................................. 47 equiv)............................................................................... 76
spironolactone tab 25 mg (Aldactone).......................... 47 STRENSIQ -asfotase alfa subcutaneous inj 18
spironolactone tab 50 mg (Aldactone).......................... 47 mg/0.45ml........................................................................ 37
spironolactone tab 100 mg (Aldactone)........................ 47 STRENSIQ -asfotase alfa subcutaneous inj 28
SPORANOX -itraconazole oral soln 10 mg/ml....................6 mg/0.7ml.......................................................................... 37
SPRYCEL -dasatinib tab 20 mg........................................ 18 STRENSIQ -asfotase alfa subcutaneous inj 40 mg/ml..... 37
SPRYCEL -dasatinib tab 50 mg........................................ 18 STRENSIQ -asfotase alfa subcutaneous inj 80
SPRYCEL -dasatinib tab 70 mg........................................ 18 mg/0.8ml.......................................................................... 37
SPRYCEL -dasatinib tab 80 mg........................................ 18 STRIBILD -elvitegrav-cobic-emtricitab-tenofovdf tab
SPRYCEL -dasatinib tab 100 mg...................................... 18 150-150-200-300 mg........................................................ 9
SPRYCEL -dasatinib tab 140 mg...................................... 18 STRIVERDI RESPIMAT -olodaterol hcl inhal aerosol soln
STALEVO 100 -carbidopa-levodopa-entacapone tabs 2.5 mcg/act (base equiv)................................................ 55
25-100-200 mg................................................................98 SUBDUE -nutritional supplement liquid.......................... 122
STALEVO 125 -carbidopa-levodopa-entacapone tabs SUBDUE PLUS -nutritional supplement liquid................ 123
31.25-125-200 mg.......................................................... 98 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 2-0.5
STALEVO 150 -carbidopa-levodopa-entacapone tabs mg (base equiv).............................................................. 86
37.5-150-200 mg.............................................................98 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 4-1
50-200-200 mg................................................................98 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 8-2
12.5-50-200 mg...............................................................98 SUBOXONE -buprenorphine hcl-naloxone hcl sl film 12-3
18.75-75-200 mg.............................................................98 SUBSYS -fentanyl sublingual spray 100 mcg................... 86
stannous fluoride conc 0.63% (Gel-kam oral care SUBSYS -fentanyl sublingual spray 200 mcg................... 86
ri)................................................................................... 140 SUBSYS -fentanyl sublingual spray 400 mcg................... 86
stannous fluoride gel 0.4%........................................... 140 SUBSYS -fentanyl sublingual spray 600 mcg................... 86
STANNOUS FLUORIDE RINSE -stannous fluoride liq SUBSYS -fentanyl sublingual spray 800 mcg................... 86
0.1%...............................................................................140 SUBSYS -fentanyl sublingual spray 1200 mcg (600 mcg x
stavudine cap 15 mg (Zerit)..............................................9 2)...................................................................................... 86
2017
SUBSYS -fentanyl sublingual spray 1600 mcg (800 mcg x SUPREP BOWEL PREP KIT -sodium sulfate-potassium
2)...................................................................................... 86 sulfate-magnesium sulfate oral soln.............................. 57
SUCRAID -sacrosidase soln 8500 unit/ml........................ 59 SURMONTIL -trimipramine maleate cap 25 mg............... 67
sucralfate tab 1 gm (Carafate)....................................... 58 SURMONTIL -trimipramine maleate cap 50 mg............... 67
sulfacetamide sodium lotion 10% (acne) (Klaron)..... 145 SURMONTIL -trimipramine maleate cap 100 mg............. 67
sulfacetamide sodium ophth soln 10% SURVANTA INTRATRACHEAL -beractant in nacl 0.9%
(Bleph-10)..................................................................... 137 intratracheal susp 25 mg/ml........................................... 56
sulfacetamide sodium-prednisolone ophth soln SUSTIVA -efavirenz cap 50 mg.......................................... 9
10-0.23(0.25)%............................................................. 137 SUSTIVA -efavirenz cap 200 mg........................................ 9
SULFACETAMIDE SODIUM -sulfacetamide sodium ophth SUSTIVA -efavirenz tab 600 mg......................................... 9
oint 10%........................................................................ 137 SUTENT -sunitinib malate cap 12.5 mg (base
SULFADIAZINE -sulfadiazine tab 500 mg.......................... 5 equivalent)....................................................................... 18
sulfamethoxazole-trimethoprim susp 200-40 SUTENT -sunitinib malate cap 25 mg (base
mg/5ml............................................................................ 11 equivalent)....................................................................... 18
sulfamethoxazole-trimethoprim tab 400-80 mg SUTENT -sunitinib malate cap 37.5 mg (base
(Bactrim)......................................................................... 11 equivalent)....................................................................... 18
sulfamethoxazole-trimethoprim tab 800-160 mg SUTENT -sunitinib malate cap 50 mg (base
(Bactrim ds)................................................................... 11 equivalent)....................................................................... 18
SULFAMYLON -mafenide acetate cream 85 mg/gm...... 145 SYLATRON -peginterferon alfa-2b for inj kit 200 mcg...... 18
sulfasalazine tab delayed release 500 mg (Azulfidine SYLATRON -peginterferon alfa-2b for inj kit 300 mcg...... 18
en-tabs)........................................................................... 61 SYLATRON -peginterferon alfa-2b for inj kit 600 mcg...... 18
sulfasalazine tab 500 mg (Azulfidine)........................... 61 SYMBICORT -budesonide-formoterol fumarate dihyd
sulindac tab 150 mg........................................................ 89 aerosol 80-4.5 mcg/act................................................... 55
sulindac tab 200 mg........................................................ 89 SYMBICORT -budesonide-formoterol fumarate dihyd
sumatriptan nasal spray 5 mg/act (Imitrex).................. 90 aerosol 160-4.5 mcg/act................................................. 55
sumatriptan nasal spray 20 mg/act (Imitrex)................ 90 SYNAREL -nafarelin acetate nasal soln 2 mg/ml (200
sumatriptan succinate inj 6 mg/0.5ml (Imitrex)............ 90 mcg/act) (base eq)..........................................................37
sumatriptan succinate solution auto-injector 4 SYNERA -lidocaine-tetracaine topical patch 70-70
mg/0.5ml (Imitrex statdose sys)................................. 90 mg.................................................................................. 145
sumatriptan succinate solution auto-injector 6 SYNJARDY -empagliflozin-metformin hcl tab 12.5-1000
mg/0.5ml (Imitrex statdose sys)................................. 90 mg.................................................................................... 30
sumatriptan succinate solution cartridge 4 mg/0.5ml SYNJARDY -empagliflozin-metformin hcl tab 12.5-500
(Imitrex statdose ref).................................................... 90 mg.................................................................................... 30
sumatriptan succinate solution cartridge 6 mg/0.5ml SYNJARDY -empagliflozin-metformin hcl tab 5-500
(Imitrex statdose ref).................................................... 90 mg.................................................................................... 30
sumatriptan succinate tab 25 mg (Imitrex)................... 90 SYNJARDY -empagliflozin-metformin hcl tab 5-1000
sumatriptan succinate tab 50 mg (Imitrex)................... 90 mg.................................................................................... 30
sumatriptan succinate tab 100 mg (Imitrex)................. 90 SYNJARDY XR -empagliflozin-metformin hcl tab er 24hr
SUPER-AMINO 1600 -amino acids tab.......................... 108 5-1000 mg....................................................................... 30
SUPER DAILY D3 -cholecalciferol drops 1000 unit/0.03ml SYNJARDY XR -empagliflozin-metformin hcl tab er 24hr
(per drop)........................................................................ 99 10-1000 mg..................................................................... 30
SUPER NU-THERA -multiple vitamins w/ minerals SYNJARDY XR -empagliflozin-metformin hcl tab er 24hr
powder........................................................................... 104 12.5-1000 mg.................................................................. 30
SUPLENA -nutritional supplement liquid.........................123 SYNJARDY XR -empagliflozin-metformin hcl tab er 24hr
SUPLENA RTU -nutritional supplement liquid................ 123 25-1000 mg..................................................................... 30
SUPLENA WITH CARB STEADY -nutritional supplement SYNTHROID -levothyroxine sodium tab 25 mcg.............. 33
liquid.............................................................................. 123 SYNTHROID -levothyroxine sodium tab 50 mcg.............. 33
SUPLENA 1.8 WITH CARBSTEA -nutritional supplement SYNTHROID -levothyroxine sodium tab 75 mcg.............. 33
liquid.............................................................................. 123 SYNTHROID -levothyroxine sodium tab 88 mcg.............. 33
SUPRAX -cefixime cap 400 mg.......................................... 2 SYNTHROID -levothyroxine sodium tab 100 mcg............ 33
SUPRAX -cefixime chew tab 100 mg................................. 2 SYNTHROID -levothyroxine sodium tab 112 mcg............ 33
SUPRAX -cefixime chew tab 200 mg................................. 2 SYNTHROID -levothyroxine sodium tab 125 mcg............ 33
SUPRAX -cefixime for susp 100 mg/5ml............................ 2 SYNTHROID -levothyroxine sodium tab 137 mcg............ 33
2017
SYNTHROID -levothyroxine sodium tab 200 mcg............ 33 TECFIDERA -dimethyl fumarate capsule delayed release
SYNTHROID -levothyroxine sodium tab 300 mcg............ 33 240 mg............................................................................ 80
SYPRINE -trientine hcl cap 250 mg................................ 149 TECFIDERA STARTER PACK -dimethyl fumarate
T capsule dr starter pack 120 mg & 240 mg..................... 80
TECHNIVIE -ombitasvir-paritaprevir-ritonavir tab
TABLOID -thioguanine tab 40 mg..................................... 18 12.5-75-50 mg................................................................... 9
TACLONEX -calcipotriene-betamethasone dipropionate TEGRETOL -carbamazepine susp 100 mg/5ml............... 95
susp 0.005-0.064%....................................................... 145 TEGRETOL -carbamazepine tab 200 mg......................... 95
tacrolimus cap 0.5 mg (Prograf).................................. 149 TEGRETOL-XR -carbamazepine tab er 12hr 100 mg...... 95
tacrolimus cap 1 mg (Prograf)..................................... 149 TEGRETOL-XR -carbamazepine tab er 12hr 200 mg...... 95
tacrolimus cap 5 mg (Prograf)..................................... 149 TEGRETOL-XR -carbamazepine tab er 12hr 400 mg...... 95
tacrolimus oint 0.03% (Protopic)................................. 145 TEKTURNA -aliskiren fumarate tab 150 mg (base
tacrolimus oint 0.1% (Protopic)................................... 145 equivalent)....................................................................... 45
TAFINLAR -dabrafenib mesylate cap 50 mg (base TEKTURNA -aliskiren fumarate tab 300 mg (base
equivalent)....................................................................... 18 equivalent)....................................................................... 46
TAFINLAR -dabrafenib mesylate cap 75 mg (base TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
equivalent)....................................................................... 18 150-12.5 mg.................................................................... 46
TAGRISSO -osimertinib mesylate tab 40 mg (base TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
equivalent)....................................................................... 19 150-25 mg....................................................................... 46
TAGRISSO -osimertinib mesylate tab 80 mg (base TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
equivalent)....................................................................... 19 300-12.5 mg.................................................................... 46
TAMIFLU -oseltamivir phosphate cap 30 mg (base TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
equiv)................................................................................. 9 300-25 mg....................................................................... 46
TAMIFLU -oseltamivir phosphate cap 45 mg (base telmisartan-amlodipine tab 40-5 mg (Twynsta)............ 46
equiv)................................................................................. 9 telmisartan-amlodipine tab 80-5 mg (Twynsta)............ 46
TAMIFLU -oseltamivir phosphate cap 75 mg (base telmisartan-amlodipine tab 40-10 mg (Twynsta).......... 46
equiv)................................................................................. 9 telmisartan-amlodipine tab 80-10 mg (Twynsta).......... 46
TAMIFLU -oseltamivir phosphate for susp 6 mg/ml (base telmisartan-hydrochlorothiazide tab 40-12.5 mg
equiv)................................................................................. 9 (Micardis hct)................................................................. 46
tamoxifen citrate tab 10 mg (base equivalent)............. 19 telmisartan-hydrochlorothiazide tab 80-12.5 mg
tamoxifen citrate tab 20 mg (base equivalent)............. 19 (Micardis hct)................................................................. 46
tamsulosin hcl cap 0.4 mg (Flomax)............................. 64 telmisartan-hydrochlorothiazide tab 80-25 mg
TANZEUM -albiglutide for soln pen-injector 30 mg........... 30 (Micardis hct)................................................................. 46
TANZEUM -albiglutide for soln pen-injector 50 mg........... 30 telmisartan tab 20 mg (Micardis)................................... 46
TARCEVA -erlotinib hcl tab 25 mg (base equivalent)....... 19 telmisartan tab 40 mg (Micardis)................................... 46
TARCEVA -erlotinib hcl tab 100 mg (base equivalent)..... 19 telmisartan tab 80 mg (Micardis)................................... 46
TARCEVA -erlotinib hcl tab 150 mg (base equivalent)..... 19 temazepam cap 7.5 mg (Restoril).................................. 72
TARGRETIN -bexarotene gel 1%....................................145 temazepam cap 15 mg (Restoril)................................... 72
TARON-BC -prenat w/o a w/ fe cbnyl-fa tab 20-1 mg & vit temazepam cap 22.5 mg (Restoril)................................ 72
b6 tab pak..................................................................... 104 temazepam cap 30 mg (Restoril)................................... 72
TARON-C DHA -prenatal w/fe fum-fe poly -fa-omega 3 temozolomide cap 5 mg (Temodar)............................... 19
cap 53.5-38-1 mg......................................................... 104 temozolomide cap 20 mg (Temodar)............................. 19
TARON-PREX -prenatal w/o vit a w/ fe fum-dss-fa-dha temozolomide cap 100 mg (Temodar)........................... 19
cap 30-1.2-265 mg....................................................... 104 temozolomide cap 140 mg (Temodar)........................... 19
TASIGNA -nilotinib hcl cap 150 mg (base equivalent)...... 19 temozolomide cap 180 mg (Temodar)........................... 19
TASIGNA -nilotinib hcl cap 200 mg (base equivalent)...... 19 temozolomide cap 250 mg (Temodar)........................... 19
TASMAR -tolcapone tab 100 mg.......................................98 TENCON -butalbital-acetaminophen tab 50-325 mg........ 80
TAYTULLA -norethindrone ace-ethinyl estradiol-fe cap 1 TENIVAC -tetanus-diphtheria toxoids (td) inj 5-2 lfu......... 14
mg-20 mcg (24).............................................................. 26 terazosin hcl cap 1 mg....................................................46
tazarotene cream 0.1% (Tazorac)................................. 145 terazosin hcl cap 2 mg....................................................46
TAZORAC -tazarotene cream 0.05%.............................. 145 terazosin hcl cap 5 mg....................................................46
TAZORAC -tazarotene cream 0.1%................................ 145 terazosin hcl cap 10 mg..................................................46
TAZORAC -tazarotene gel 0.05%................................... 145 terbinafine hcl tab 250 mg (Lamisil)................................ 6
TAZORAC -tazarotene gel 0.1%..................................... 145 terbutaline sulfate tab 2.5 mg........................................ 55
TECFIDERA -dimethyl fumarate capsule delayed release terbutaline sulfate tab 5 mg........................................... 55
120 mg............................................................................ 80
2017
terconazole vaginal cream 0.4% (Terazol 7)................. 63 thioridazine hcl tab 50 mg.............................................. 71
terconazole vaginal cream 0.8% (Terazol 3)................. 63 thioridazine hcl tab 100 mg............................................ 71
terconazole vaginal suppos 80 mg............................... 63 thiothixene cap 1 mg....................................................... 71
testosterone cypionate im inj in oil 100 mg/ml (Depo- thiothixene cap 2 mg....................................................... 71
testosterone).................................................................. 22 thiothixene cap 5 mg....................................................... 71
testosterone cypionate im inj in oil 200 mg/ml (Depo- thiothixene cap 10 mg..................................................... 71
testosterone).................................................................. 22 THRIVACIN DETOX -nutritional supplement liquid......... 123
testosterone enanthate im inj in oil 200 mg/ml............ 22 THRIVACIN 30 -nutritional supplement liquid................. 123
testosterone td gel 12.5 mg/act (1%) (Androgel THRIVITE 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1
pump).............................................................................. 22 mg.................................................................................. 104
testosterone td gel 25 mg/2.5gm (1%) (Androgel)....... 22 THRIVITE RX -prenatal vit w/ iron carbonyl-fa tab 29-1
testosterone td gel 50 mg/5gm (1%) (Androgel).......... 22 mg.................................................................................. 104
testosterone td soln 30 mg/act (Axiron)....................... 22 thyroid tab 30 mg (1/2 grain) (Armour thyroid)............ 33
TETANUS/DIPHTHERIA TOXOID -tetanus-diphtheria thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)......... 33
toxoids (td) inj 2-2 lf/0.5ml.............................................. 14 thyroid tab 60 mg (1 grain) (Armour thyroid)............... 33
tetrabenazine tab 12.5 mg (Xenazine)........................... 80 thyroid tab 120 mg (2 grain) (Armour thyroid)............. 33
tetrabenazine tab 25 mg (Xenazine).............................. 80 THYROLAR-1/2 -liotrix (t3-t4) tab 30 mg (6.25-25
tetracaine hcl ophth soln 0.5%.................................... 137 mcg)................................................................................. 33
tetracycline hcl cap 250 mg (Tetracycline hcl)............... 4 THYROLAR-1/4 -liotrix (t3-t4) tab 15 mg (3.1-12.5
tetracycline hcl cap 500 mg (Tetracycline hcl)............... 4 mcg)................................................................................. 33
TETRACYCLINE HCL -tetracycline hcl cap 250 mg...........4 THYROLAR-1 -liotrix (t3-t4) tab 60 mg (12.5-50 mcg)......33
TETRACYCLINE HCL -tetracycline hcl cap 500 mg...........4 THYROLAR-2 -liotrix (t3-t4) tab 120 mg (25-100
THALOMID -thalidomide cap 50 mg............................... 149 mcg)................................................................................. 33
THALOMID -thalidomide cap 100 mg............................. 149 THYROLAR-3 -liotrix (t3-t4) tab 180 mg (37.5-150
THALOMID -thalidomide cap 150 mg............................. 149 mcg)................................................................................. 33
THALOMID -thalidomide cap 200 mg............................. 149 tiagabine hcl tab 2 mg (Gabitril).................................... 95
theophylline soln 80 mg/15ml........................................ 56 tiagabine hcl tab 4 mg (Gabitril).................................... 95
theophylline tab er 12hr 100 mg.................................... 56 TIKOSYN -dofetilide cap 125 mcg (0.125 mg)................. 42
theophylline tab er 12hr 200 mg.................................... 56 TIKOSYN -dofetilide cap 250 mcg (0.25 mg)................... 42
theophylline tab er 12hr 300 mg.................................... 56 TIKOSYN -dofetilide cap 500 mcg (0.5 mg)..................... 42
theophylline tab er 12hr 450 mg.................................... 56 timolol maleate ophth gel forming soln 0.25%
theophylline tab er 24hr 400 mg.................................... 56 (Timoptic-xe)................................................................ 137
theophylline tab er 24hr 600 mg.................................... 56 timolol maleate ophth gel forming soln 0.5%
THEO-24 -theophylline cap er 24hr 100 mg..................... 55 (Timoptic-xe)................................................................ 137
THEO-24 -theophylline cap er 24hr 200 mg..................... 55 timolol maleate ophth soln 0.25% (Timoptic)............. 137
THEO-24 -theophylline cap er 24hr 300 mg..................... 55 timolol maleate ophth soln 0.5% (Timoptic)............... 137
THEO-24 -theophylline cap er 24hr 400 mg..................... 56 TIMOLOL MALEATE -timolol maleate tab 5 mg............... 39
THERA-FLUR-N -sodium fluoride gel 1.1% (0.5% f)...... 140 TIMOLOL MALEATE -timolol maleate tab 10 mg............. 39
THICK-IT BEEF LASAGNA PUR -nutritional supplement TIMOLOL MALEATE -timolol maleate tab 20 mg............. 39
misc............................................................................... 123 TIMOPTIC OCUDOSE -timolol maleate preservative free
THICK-IT CHICKEN A LA KIN -nutritional supplement ophth soln 0.25%.......................................................... 137
misc............................................................................... 123 TIMOPTIC OCUDOSE -timolol maleate preservative free
THICK-IT MAPLE CINNAMON F -nutritional supplement ophth soln 0.5%............................................................ 138
misc............................................................................... 123 tinidazole tab 250 mg (Tindamax)..................................11
THICK-IT MIXED FRUIT AND -nutritional supplement tinidazole tab 500 mg (Tindamax)..................................11
misc............................................................................... 123 TIROSINT -levothyroxine sodium cap 13 mcg..................33
THICK-IT SEASONED CHICKEN -nutritional supplement TIROSINT -levothyroxine sodium cap 25 mcg..................33
THICK-IT SWEET CORN PUREE -nutritional supplement TIROSINT -levothyroxine sodium cap 75 mcg..................33
THICK-IT THICKENED CRANBE -nutritional supplement TIROSINT -levothyroxine sodium cap 100 mcg................33
liquid.............................................................................. 123 TIROSINT -levothyroxine sodium cap 112 mcg................ 33
THIOLA -tiopronin tab 100 mg.......................................... 64 TIROSINT -levothyroxine sodium cap 125 mcg................33
thioridazine hcl tab 10 mg.............................................. 71 TIROSINT -levothyroxine sodium cap 137 mcg................33
thioridazine hcl tab 25 mg.............................................. 71 TIROSINT -levothyroxine sodium cap 150 mcg................33
2017
TIVICAY -dolutegravir sodium tab 10 mg (base equiv)....... 9 topiramate sprinkle cap 25 mg (Topamax
TIVICAY -dolutegravir sodium tab 25 mg (base equiv)....... 9 sprinkle).......................................................................... 95
TIVICAY -dolutegravir sodium tab 50 mg (base equiv)....... 9 topiramate tab 25 mg (Topamax)................................... 95
tizanidine hcl cap 2 mg (base equivalent) topiramate tab 50 mg (Topamax)................................... 95
(Zanaflex)........................................................................98 topiramate tab 100 mg (Topamax)................................. 95
tizanidine hcl cap 4 mg (base equivalent) topiramate tab 200 mg (Topamax)................................. 95
(Zanaflex)........................................................................98 torsemide tab 5 mg (Demadex)...................................... 47
tizanidine hcl cap 6 mg (base equivalent) torsemide tab 10 mg (Demadex).................................... 47
(Zanaflex)........................................................................98 torsemide tab 20 mg (Demadex).................................... 47
tizanidine hcl tab 2 mg (base equivalent)..................... 98 torsemide tab 100 mg (Demadex).................................. 47
tizanidine hcl tab 4 mg (base equivalent) TOUJEO SOLOSTAR -insulin glargine soln pen-injector
(Zanaflex)........................................................................98 300 unit/ml.......................................................................32
TL-CARE DHA -prenatal w/fe fumarate-fa-dss-fish oil cap TOVIAZ -fesoterodine fumarate tab er 24hr 4 mg............ 62
27-1-500 mg.................................................................. 104 TOVIAZ -fesoterodine fumarate tab er 24hr 8 mg............ 62
TL FOLATE -prenatal vit w/ fe fum-methylfolate-fa tab TRACLEER -bosentan tab 62.5 mg.................................. 50
27-0.5-0.5 mg................................................................ 104 TRACLEER -bosentan tab 125 mg................................... 50
TL-SELECT -prenatal w/o vit a w/ fe fum-dss-fa-dha cap TRADJENTA -linagliptin tab 5 mg..................................... 30
29-1.25-325 mg.............................................................104 tramadol-acetaminophen tab 37.5-325 mg
TOBI PODHALER -tobramycin inhal cap 28 mg.................5 (Ultracet)......................................................................... 86
TOBRADEX ST -tobramycin-dexamethasone ophth susp tramadol hcl tab er 24hr biphasic release 100 mg....... 86
0.3-0.05%...................................................................... 138 tramadol hcl tab er 24hr biphasic release 200 mg....... 86
TOBRADEX -tobramycin-dexamethasone ophth oint tramadol hcl tab er 24hr biphasic release 300 mg....... 86
0.3-0.1%........................................................................ 138 tramadol hcl tab er 24hr 100 mg....................................86
tobramycin-dexamethasone ophth susp 0.3-0.1% tramadol hcl tab er 24hr 200 mg....................................86
(Tobradex).................................................................... 138 tramadol hcl tab er 24hr 300 mg....................................86
tobramycin nebu soln 300 mg/5ml (Tobi)....................... 5 tramadol hcl tab 50 mg (Ultram).................................... 86
tobramycin ophth soln 0.3% (Tobrex)......................... 138 trandolapril tab 1 mg (Mavik)......................................... 46
TOBRAMYCIN -tobramycin nebu soln 300 mg/5ml............ 5 trandolapril tab 2 mg (Mavik)......................................... 46
TOBREX -tobramycin ophth oint 0.3%........................... 138 trandolapril tab 4 mg (Mavik)......................................... 46
TODAY SPONGE -nonoxynol-9 vaginal sponge 1000 trandolapril-verapamil hcl tab er 1-240 mg (Tarka)...... 46
mg.................................................................................... 63 trandolapril-verapamil hcl tab er 2-180 mg (Tarka)...... 46
TOLAK -fluorouracil cream 4%........................................145 trandolapril-verapamil hcl tab er 2-240 mg (Tarka)...... 46
TOLAZAMIDE -tolazamide tab 250 mg.............................30 trandolapril-verapamil hcl tab er 4-240 mg (Tarka)...... 46
TOLAZAMIDE -tolazamide tab 500 mg.............................30 tranexamic acid tab 650 mg (Lysteda)........................ 128
TOLBUTAMIDE -tolbutamide tab 500 mg......................... 30 TRANSDERM-SCOP -scopolamine td patch 72hr 1
tolcapone tab 100 mg (Tasmar)..................................... 98 mg/3days......................................................................... 59
TOLEREX -nutritional supplement pack......................... 123 tranylcypromine sulfate tab 10 mg (Parnate)............... 67
TOLMETIN SODIUM -tolmetin sodium cap 400 mg......... 89 TRAVATAN Z -travoprost ophth soln 0.004%
tolterodine tartrate cap er 24hr 2 mg (Detrol la).......... 62 (benzalkonium free) (bak free)..................................... 138
tolterodine tartrate cap er 24hr 4 mg (Detrol la).......... 62 trazodone hcl tab 50 mg................................................. 67
tolterodine tartrate tab 1 mg (Detrol)............................ 62 trazodone hcl tab 100 mg............................................... 67
tolterodine tartrate tab 2 mg (Detrol)............................ 62 trazodone hcl tab 150 mg............................................... 67
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 25 trazodone hcl tab 300 mg............................................... 68
mg.................................................................................... 95 TRECATOR -ethionamide tab 250 mg................................ 5
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 50 TRESIBA FLEXTOUCH -insulin degludec soln pen-
mg.................................................................................... 95 injector 100 unit/ml......................................................... 32
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 100 TRESIBA FLEXTOUCH -insulin degludec soln pen-
mg.................................................................................... 95 injector 200 unit/ml......................................................... 32
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 150 tretinoin cap 10 mg......................................................... 19
mg.................................................................................... 95 tretinoin cream 0.025% (Retin-a)................................. 145
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 200 tretinoin cream 0.05% (Retin-a)................................... 145
mg.................................................................................... 95 tretinoin cream 0.1% (Retin-a)..................................... 145
topiramate sprinkle cap 15 mg (Topamax tretinoin gel 0.05% (Atralin).......................................... 145
sprinkle).......................................................................... 95 tretinoin gel 0.01% (Retin-a)......................................... 145
tretinoin gel 0.025% (Retin-a)....................................... 145
2017
tretinoin microsphere gel 0.04% (Retin-a micro)....... 145 trimipramine maleate cap 25 mg (Surmontil)............... 68
tretinoin microsphere gel 0.1% (Retin-a micro trimipramine maleate cap 50 mg (Surmontil)............... 68
pump)............................................................................ 145 trimipramine maleate cap 100 mg (Surmontil)............. 68
TRETTEN -coagulation factor xiii a-subunit for inj TRINATAL GT -prenatal vit w/ dss-iron carbonyl-fa tab
2000-3125 unit.............................................................. 134 90-1 mg......................................................................... 104
TREXALL -methotrexate sodium tab 5 mg (base TRINATAL RX 1 -prenatal vit w/ fe fumarate-fa tab 60-1
equiv)............................................................................... 19 mg.................................................................................. 104
TREXALL -methotrexate sodium tab 7.5 mg (base TRINATE -prenatal vit w/ fe fumarate-fa tab 28-1 mg..... 104
equiv)............................................................................... 19 TRISTART DHA -prenat w/o a w/fecbn-methylf-fa-dha cap
TREXALL -methotrexate sodium tab 10 mg (base 31-0.6-0.4-200 mg........................................................ 104
equiv)............................................................................... 19 TRI-TABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg
TREXALL -methotrexate sodium tab 15 mg (base & omega cap pack....................................................... 104
equiv)............................................................................... 19 TRIUMEQ -abacavir-dolutegravir-lamivudine tab
TRIADVANCE -prenatal vit w/ dss-iron carbonyl-fa tab 600-50-300 mg................................................................10
90-1 mg......................................................................... 104 TRIVEEN-DUO DHA -prenat-fe bis-fe prot succ-fa-ca tab
triamcinolone acetonide aerosol soln 0.147 mg/gm & omega 3 cap 400 pk................................................. 104
(Kenalog)...................................................................... 145 TRIVEEN-PRX RNF -prenatal w/o vit a w/ fe fum-dss-fa-
triamcinolone acetonide cream 0.025%...................... 145 dha cap 26-1.2-300 mg................................................ 104
triamcinolone acetonide cream 0.1%.......................... 145 TROKENDI XR -topiramate cap er 24hr 25 mg................ 95
triamcinolone acetonide cream 0.5%.......................... 145 TROKENDI XR -topiramate cap er 24hr 50 mg................ 95
triamcinolone acetonide dental paste 0.1%............... 140 TROKENDI XR -topiramate cap er 24hr 100 mg.............. 95
triamcinolone acetonide lotion 0.025%....................... 145 TROKENDI XR -topiramate cap er 24hr 200 mg.............. 95
triamcinolone acetonide lotion 0.1%........................... 146 trospium chloride cap er 24hr 60 mg............................ 62
triamcinolone acetonide nasal aerosol suspension 55 trospium chloride tab 20 mg.......................................... 62
mcg/act........................................................................... 52 TRULANCE -plecanatide tab 3 mg................................... 61
triamcinolone acetonide oint 0.025%.......................... 146 TRULICITY -dulaglutide soln pen-injector 0.75
triamcinolone acetonide oint 0.1%.............................. 146 mg/0.5ml.......................................................................... 30
TRIAMINO -amino acids tab........................................... 108 TRULICITY -dulaglutide soln pen-injector 1.5
TRIAMTERENE/HYDROCHLOROTH -triamterene & mg/0.5ml.......................................................................... 30
hydrochlorothiazide cap 50-25 mg................................. 47 TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab
triamterene & hydrochlorothiazide cap 37.5-25 mg 100-150 mg..................................................................... 10
(Dyazide).........................................................................47 TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab
triamterene & hydrochlorothiazide tab 37.5-25 mg 133-200 mg..................................................................... 10
(Maxzide-25)................................................................... 47 TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab
triamterene & hydrochlorothiazide tab 75-50 mg 167-250 mg..................................................................... 10
(Maxzide)........................................................................ 47 TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab
TRICARE PRENATAL COMPLEAT -prenat w/o a fefum-fa 200-300 mg..................................................................... 10
tab 27-1 mg & fish oil chew cap pak............................104 TUSNEL C -pseudoephedrine w/ cod-gg syrup 30-10-100
TRICARE PRENATAL DHA ONE -prenatal w/fe fumarate- mg/5ml............................................................................. 53
fa-dss-fish oil cap 27-1-500 mg................................... 104 TWOCAL HN -nutritional supplement liquid....................123
TRICARE PRENATAL -prenat w/o vit a w/ fe pyrophos- TWOCAL HN 2.0 -nutritional supplement liquid..............123
methylf chew tab 4.5-1 mg........................................... 104 TYBOST -cobicistat tab 150 mg....................................... 10
TRICARE -prenatal vit w/ fe fumarate-fa tab 27-1 TYKERB -lapatinib ditosylate tab 250 mg (base
mg.................................................................................. 104 equiv)............................................................................... 19
TRIDESILON -desonide cream 0.05%............................146 TYLACTIN RESTORE 10 -nutritional supplement
trifluoperazine hcl tab 1 mg........................................... 71 liquid.............................................................................. 123
trifluoperazine hcl tab 2 mg........................................... 71 TYLACTIN RESTORE 5PE -nutritional supplement
trifluoperazine hcl tab 5 mg........................................... 71 pack............................................................................... 123
trifluoperazine hcl tab 10 mg......................................... 71 TYLACTIN RTD 15 -nutritional supplement liquid.......... 123
trifluridine ophth soln 1% (Viroptic)............................ 138 TYMLOS -abaloparatide subcutaneous soln pen-injector
trihexyphenidyl hcl elixir 0.4 mg/ml.............................. 98 3120 mcg/1.56ml............................................................ 37
trihexyphenidyl hcl tab 2 mg..........................................98 TYR ANAMIX EARLY YEARS -nutritional supplement
trihexyphenidyl hcl tab 5 mg..........................................98 powder........................................................................... 123
trimethobenzamide hcl cap 300 mg (Tigan)................. 59 TYR ANAMIX NEXT -nutritional supplement powder..... 123
trimethoprim tab 100 mg................................................ 11 TYR COOLER -nutritional supplement liquid.................. 123
2017
TYR COOLER20 -nutritional supplement liquid.............. 123 valganciclovir hcl for soln 50 mg/ml (base equiv)
TYREX-1 -nutritional supplement powder....................... 123 (Valcyte).......................................................................... 10
TYREX-2 -nutritional supplement powder....................... 123 valganciclovir hcl tab 450 mg (base equivalent)
TYR EXPRESS -nutritional supplement pack................. 123 (Valcyte).......................................................................... 10
TYR EXPRESS20 -nutritional supplement pack............. 123 valproate sodium oral soln 250 mg/5ml (base equiv)
TYR GEL -nutritional supplement pack........................... 123 (Depakene)..................................................................... 95
TYR LOPHLEX LQ -nutritional supplement liquid...........123 valproic acid cap 250 mg (Depakene)........................... 95
TYROS 1 -nutritional supplement powder...................... 123 valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan
TYROS 2 -nutritional supplement powder...................... 123 hct).................................................................................. 46
TYVASO REFILL -treprostinil inhalation solution 0.6 mg/ valsartan-hydrochlorothiazide tab 160-12.5 mg
ml..................................................................................... 51 (Diovan hct)................................................................... 46
TYVASO STARTER -treprostinil inhalation solution 0.6 valsartan-hydrochlorothiazide tab 160-25 mg (Diovan
mg/ml............................................................................... 51 hct).................................................................................. 46
TYVASO -treprostinil inhalation solution 0.6 mg/ml.......... 50 valsartan-hydrochlorothiazide tab 320-12.5 mg
U (Diovan hct)................................................................... 46
valsartan-hydrochlorothiazide tab 320-25 mg (Diovan
UCD ANAMIX JUNIOR -nutritional supplement hct).................................................................................. 46
powder........................................................................... 123 valsartan tab 40 mg (Diovan)......................................... 46
UCD 2 -nutritional supplement powder........................... 123 valsartan tab 80 mg (Diovan)......................................... 46
UCD TRIO -nutritional supplement powder.................... 123 valsartan tab 160 mg (Diovan)....................................... 46
UCERIS -budesonide rectal foam 2 mg/act.................... 140 valsartan tab 320 mg (Diovan)....................................... 46
UCERIS -budesonide tab er 24hr 9 mg............................ 21 vancomycin hcl cap 125 mg (Vancocin hcl)................. 11
ULESFIA -benzyl alcohol lotion 5%................................ 146 vancomycin hcl cap 250 mg (Vancocin hcl)................. 11
ULORIC -febuxostat tab 40 mg......................................... 91 VARUBI -rolapitant hcl tab 90 mg (base equiv)................ 59
ULORIC -febuxostat tab 80 mg......................................... 91 VASCEPA -icosapent ethyl cap 0.5 gm............................ 50
ULTIMATECARE ONE NF -prenatal w/fe cbnyl-fe asp VASCEPA -icosapent ethyl cap 1 gm............................... 50
glyc-fa-dss-omega cap 20-7-1 mg............................... 105 VCF VAGINAL CONTRACEPTIVE -nonoxynol-9 film
ULTIMATECARE ONE -prenatal vit w/ fe cbn-fe asp glyc- 28%.................................................................................. 63
fa-omega 3 cap 27-1mg............................................... 105 VCF VAGINAL CONTRACEPTIVE -nonoxynol-9 foam
ULTRACAL HN PLUS -nutritional supplement liquid...... 124 12.5%...............................................................................63
ULTRACAL -nutritional supplement liquid....................... 123 VECAMYL -mecamylamine hcl tab 2.5 mg....................... 46
ULTRAMINO SOY PROTEIN -nutritional supplement VELPHORO -sucroferric oxyhydroxide chew tab 500
powder........................................................................... 124 mg.................................................................................... 61
UPTRAVI -selexipag tab 200 mcg.....................................51 VELTASSA -patiromer sorbitex calcium for susp packet
UPTRAVI -selexipag tab 400 mcg.....................................51 8.4 gm (base eq).......................................................... 149
UPTRAVI -selexipag tab 600 mcg.....................................51 VELTASSA -patiromer sorbitex calcium for susp packet
UPTRAVI -selexipag tab 800 mcg.....................................51 16.8 gm (base eq)........................................................ 149
UPTRAVI -selexipag tab 1000 mcg...................................51 VELTASSA -patiromer sorbitex calcium for susp packet
UPTRAVI -selexipag tab 1200 mcg...................................51 25.2 gm (base eq)........................................................ 149
UPTRAVI -selexipag tab 1400 mcg...................................51 VEMAVITE-PRX 2 -prenatal w/o vit a w/ fe fum-dss-fa-
UPTRAVI -selexipag tab 1600 mcg...................................51 dha cap 27-1.25-300 mg.............................................. 105
UPTRAVI -selexipag tab therapy pack 200 mcg (140) & VENA-BAL DHA -prenat w/fe poly-na fered-fa tab 27-1 &
800 mcg (60)...................................................................51 omega cap dr 430mg................................................... 105
ursodiol cap 300 mg (Actigall)....................................... 61 VENCLEXTA STARTING PACK -venetoclax tab therapy
ursodiol tab 250 mg (Urso 250)..................................... 61 starter pack 10 & 50 & 100 mg...................................... 19
ursodiol tab 500 mg (Urso forte)................................... 61 VENCLEXTA -venetoclax tab 10 mg.................................19
UTYMAX -nutritional supplement pack........................... 124 VENCLEXTA -venetoclax tab 50 mg.................................19
V VENCLEXTA -venetoclax tab 100 mg...............................19
venlafaxine hcl cap er 24hr 37.5 mg (base equivalent)
VAGIFEM -estradiol vaginal tab 10 mcg........................... 63 (Effexor xr)..................................................................... 68
valacyclovir hcl tab 1 gm (Valtrex)................................ 10 venlafaxine hcl cap er 24hr 75 mg (base equivalent)
valacyclovir hcl tab 500 mg (Valtrex)............................ 10 (Effexor xr)..................................................................... 68
VALCHLOR -mechlorethamine hcl gel 0.016% (base venlafaxine hcl cap er 24hr 150 mg (base equivalent)
equivalent)..................................................................... 146 (Effexor xr)..................................................................... 68
VALCYTE -valganciclovir hcl for soln 50 mg/ml (base
equiv)............................................................................... 10
2017
venlafaxine hcl tab er 24hr 37.5 mg (base equivalent) VIMPAT -lacosamide tab 100 mg...................................... 95
(Venlafaxine hcl er)....................................................... 68 VIMPAT -lacosamide tab 150 mg...................................... 95
venlafaxine hcl tab er 24hr 75 mg (base equivalent) VIMPAT -lacosamide tab 200 mg...................................... 95
(Venlafaxine hcl er)....................................................... 68 VINATE DHA RF -prenat w/o a w/fefum-methylfol-omegas
venlafaxine hcl tab er 24hr 150 mg (base equivalent) cap 27-1.13 mg............................................................. 105
(Venlafaxine hcl er)....................................................... 68 VINATE II -prenatal vit w/ fe bisglycinate chelate-fa tab
venlafaxine hcl tab 25 mg...............................................68 29-1 mg......................................................................... 105
venlafaxine hcl tab 37.5 mg............................................68 VINATE M -prenatal vit w/ sel-fe fumarate-fa tab 27-1
venlafaxine hcl tab 50 mg...............................................68 mg.................................................................................. 105
venlafaxine hcl tab 75 mg...............................................68 VINATE ONE -prenatal vit w/ fe fumarate-fa tab 60-1
venlafaxine hcl tab 100 mg.............................................68 mg.................................................................................. 105
VENTAVIS -iloprost inhalation solution 10 mcg/ml........... 51 VIOKACE -pancrelipase (lip-prot-amyl) tab
VENTAVIS -iloprost inhalation solution 20 mcg/ml........... 51 10440-39150-39150 unit................................................ 59
VENTOLIN HFA -albuterol sulfate inhal aero 108 mcg/act VIOKACE -pancrelipase (lip-prot-amyl) tab
(90mcg base equiv)........................................................ 56 20880-78300-78300 unit................................................ 59
verapamil hcl cap er 24hr 120 mg (Verelan)................. 41 VIRACEPT -nelfinavir mesylate tab 250 mg..................... 10
verapamil hcl cap er 24hr 180 mg (Verelan)................. 41 VIRACEPT -nelfinavir mesylate tab 625 mg..................... 10
verapamil hcl cap er 24hr 240 mg (Verelan)................. 41 VIRAMUNE -nevirapine susp 50 mg/5ml.......................... 10
verapamil hcl cap er 24hr 360 mg (Verelan)................. 41 VIRAZOLE -ribavirin for inhal soln 6 gm........................... 10
verapamil hcl cap er 24hr 100 mg (Verelan pm)........... 41 VIREAD -tenofovir disoproxil fumarate oral powder 40
verapamil hcl cap er 24hr 200 mg (Verelan pm)........... 41 mg/gm.............................................................................. 10
verapamil hcl cap er 24hr 300 mg (Verelan pm)........... 41 VIREAD -tenofovir disoproxil fumarate tab 150 mg.......... 10
verapamil hcl tab er 120 mg (Calan sr)......................... 41 VIREAD -tenofovir disoproxil fumarate tab 200 mg.......... 10
verapamil hcl tab 40 mg................................................. 41 VIRT-ADVANCE -prenatal vit w/ dss-iron carbonyl-fa tab
verapamil hcl tab 80 mg (Calan).................................... 41 90-1 mg......................................................................... 105
verapamil hcl tab 120 mg (Calan).................................. 41 VIRT-C DHA -prenatal w/fe fum-fe poly -fa-omega 3 cap
VEREGEN -sinecatechins oint 15%................................146 53.5-38-1 mg................................................................. 105
VERIPRED 20 -prednisolone sod phosphate oral soln 20 VIRT-NATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap
mg/5ml (base equiv)....................................................... 21 28-1-200 mg.................................................................. 105
VERSACLOZ -clozapine susp 50 mg/ml.......................... 71 VIRT NATE -prenatal vit w/ fe fumarate-fa tab 28-1
VESICARE -solifenacin succinate tab 5 mg..................... 62 mg.................................................................................. 105
VESICARE -solifenacin succinate tab 10 mg................... 62 VIRT-PN DHA -prenat w/o a w/fefum-methfol-fa-dha cap
VHC 2.25 -nutritional supplement liquid.......................... 124 27-0.6-0.4-300 mg........................................................ 105
VIBERZI -eluxadoline tab 75 mg....................................... 61 VIRT-PN PLUS -prenat w/o a w/ fe fumerate-methylfolate-
VIBERZI -eluxadoline tab 100 mg..................................... 61 fa-omega 3 cap............................................................. 105
VICTOZA -liraglutide soln pen-injector 18 mg/3ml (6 mg/ VIRT-PN -prenatal vit w/ fe fum-methylfolate-fa tab
ml).................................................................................... 30 27-0.6-0.4 mg................................................................ 105
VIDEX -didanosine for soln 2 gm...................................... 10 VIRTPREX -prenatal w/o vit a w/ fe fum-dss-fa-dha cap
VIDEX -didanosine for soln 4 gm...................................... 10 26-1.2-300 mg...............................................................105
VIEKIRA PAK -ombitas-paritapre-riton & dasab tab pak VIRT-SELECT -prenatal w/o vit a w/ fe fum-dss-fa-dha
12.5-75-50 & 250 mg..................................................... 10 cap 29-1.25-325 mg..................................................... 105
VIEKIRA XR -dasab-ombit-paritap-riton tab er 24hr VIRT-VITE GT -prenatal vit w/ dss-iron carbonyl-fa tab
200-8.33-50-33.33 mg.................................................... 10 90-1 mg......................................................................... 105
VIGAMOX -moxifloxacin hcl ophth soln 0.5% (base VITAFOL FE+ -prenat-fepoly-methol-fa-dha cap 90-1-200
equiv)............................................................................. 138 mg & dss 50mg cap..................................................... 105
VIIBRYD STARTER PACK -vilazodone hcl tab starter kit VITAFOL-NANO -prenatal w/o a w/ fefum-l methylfol-fa
10 (7) & 20 (23) mg....................................................... 68 tab 18-0.6-0.4 mg......................................................... 105
VIIBRYD -vilazodone hcl tab 10 mg..................................68 VITAFOL-OB+DHA -prenatal mv w/fe fum-fa tab 65-1 mg
VIIBRYD -vilazodone hcl tab 20 mg..................................68 & dha cap 250 mg pack............................................... 105
VIIBRYD -vilazodone hcl tab 40 mg..................................68 VITAFOL-OB -prenatal vit w/ fe fumarate-fa tab 65-1
VILACTIN AA PLUS -nutritional supplement liquid......... 124 mg.................................................................................. 105
VIMPAT -lacosamide oral solution 10 mg/ml.................... 95 VITAFOL-ONE -prenatal mv w/ fe polysac cmplx-fa-dha
VIMPAT -lacosamide tab 50 mg........................................ 95 cap 29-1-200 mg.......................................................... 105
2017
VITAJOULE -nutritional supplement powder...................124 VP-GGR-B6 PRENATAL -prenatal w/ calcium-vit b6-fa-
VITAL AF 1.2 CAL ADVANCED -nutritional supplement ginger tab 1.2 mg......................................................... 106
liquid.............................................................................. 124 VP-HEME OB + DHA -prenat-fe poly cmplx-fe heme poly-
VITAL AF 1.2 CAL -nutritional supplement liquid............ 124 fa tab & omega 3 cap pck............................................ 106
VITAL 1.0 CAL -nutritional supplement liquid................. 124 VP-HEME OB -prenat vit-fe poly cmplx-fe heme poly-fa
VITAL 1.5 CAL -nutritional supplement liquid................. 124 tab 28-6-1 mg............................................................... 106
VITAL HIGH PROTEIN -nutritional supplement VP-HEME ONE -prenat-fe poly cmplx-fe heme poly-fa-
liquid.............................................................................. 124 dha cap 22-6-1-200 mg................................................ 106
VITAL HN -nutritional supplement pack.......................... 124 VP-PNV-DHA -prenatal vit w/ fe fum-fa-omega 3 cap
VITAL HP 1.0 CAL -nutritional supplement liquid........... 124 28-1-215.8 mg...............................................................106
VITAL JR -nutritional supplement liquid.......................... 124 VUSION -miconazole-zinc oxide-white petrolatum oint
VITAL PEPTIDE 1.5 CAL -nutritional supplement 0.25-15-81.35%............................................................. 146
liquid.............................................................................. 124 VYVANSE -lisdexamfetamine dimesylate cap 10 mg....... 76
VITAMEDMD ONE RX/QUATREFO -prenat w/o a w/ VYVANSE -lisdexamfetamine dimesylate cap 20 mg....... 76
fefum-methfol-fa-dha cap 30-0.6-0.4-200 mg.............. 105 VYVANSE -lisdexamfetamine dimesylate cap 30 mg....... 76
VITAMEDMD REDICHEW RX -prenat w/ b2-b6-b12-d3- VYVANSE -lisdexamfetamine dimesylate cap 40 mg....... 76
folic acid chew tab 1.4 mg........................................... 105 VYVANSE -lisdexamfetamine dimesylate cap 50 mg....... 76
VITAMELTS VITAMIN D -cholecalciferol orally VYVANSE -lisdexamfetamine dimesylate cap 60 mg....... 76
disintegrating tab 1000 unit............................................ 99 VYVANSE -lisdexamfetamine dimesylate cap 70 mg....... 76
VITAMIN D3 -cholecalciferol oral liquid 1200 VYVANSE -lisdexamfetamine dimesylate chew tab 10
unit/15ml.......................................................................... 99 mg.................................................................................... 76
VITAMIN D3 -cholecalciferol spray 1000 unit/spray..........99 VYVANSE -lisdexamfetamine dimesylate chew tab 20
VITAMIN D2 -ergocalciferol tab 400 unit...........................99 mg.................................................................................... 76
VITAPEARL -prenat w/oa w/fefum-na fered-fa-dha cap er VYVANSE -lisdexamfetamine dimesylate chew tab 30
30-1.4-200 mg...............................................................105 mg.................................................................................... 76
VITA-PREN -prenatal vit w/ docusate-iron-fa tab 65-1 VYVANSE -lisdexamfetamine dimesylate chew tab 40
mg.................................................................................. 105 mg.................................................................................... 76
VITAPRO -nutritional supplement powder...................... 124 VYVANSE -lisdexamfetamine dimesylate chew tab 50
VITAQUICK -nutritional supplement powder................... 124 mg.................................................................................... 76
VITATRUE -prenat w/o a w/fe chel-fa tab 30-1.4 mg & dha VYVANSE -lisdexamfetamine dimesylate chew tab 60
cap 300mg pk............................................................... 105 mg.................................................................................... 76
VITUZ -hydrocodone-chlorpheniramine soln 5-4 W
mg/5ml............................................................................. 53
VIVA DHA -prenatal vit w/ fe fum-fa-omega 3 cap WALGREENS GLUCOSE -glucose chew tab 4 gm......... 30
28-1-200 mg.................................................................. 106 warfarin sodium tab 1 mg (Coumadin)....................... 128
VIVONEX PEDIATRIC -nutritional supplement pack...... 124 warfarin sodium tab 2 mg (Coumadin)....................... 128
VIVONEX PLUS -nutritional supplement powder........... 124 warfarin sodium tab 2.5 mg (Coumadin).................... 128
VIVONEX RTF -nutritional supplement liquid................. 124 warfarin sodium tab 3 mg (Coumadin)....................... 128
VIVONEX T.E.N. -nutritional supplement pack............... 124 warfarin sodium tab 4 mg (Coumadin)....................... 128
VIVOTIF -typhoid vaccine cap delayed release................ 13 warfarin sodium tab 5 mg (Coumadin)....................... 128
VOL-NATE -prenatal vit w/ fe fumarate-fa tab 28-1 warfarin sodium tab 6 mg (Coumadin)....................... 128
mg.................................................................................. 106 warfarin sodium tab 7.5 mg (Coumadin).................... 128
VOL-PLUS -prenatal vit w/ fe fumarate-fa tab 27-1 warfarin sodium tab 10 mg (Coumadin)..................... 128
mg.................................................................................. 106 WELCHOL -colesevelam hcl packet for susp 3.75 gm..... 50
VOL-TAB RX -prenatal vit w/ iron carbonyl-fa tab 29-1 WELCHOL -colesevelam hcl tab 625 mg......................... 50
mg.................................................................................. 106 WELLESSE VITAMIN D3 -cholecalciferol oral liquid 1000
VOLTAREN -diclofenac sodium gel 1%.......................... 146 unit/10ml.......................................................................... 99
voriconazole for susp 40 mg/ml (Vfend)......................... 6 WELLNESS ESSENTIALS AI -nutritional supplement
voriconazole tab 50 mg (Vfend)....................................... 6 kit................................................................................... 124
voriconazole tab 200 mg (Vfend)..................................... 6 WELLNESS ESSENTIALS BLOOD -nutritional
VOTRIENT -pazopanib hcl tab 200 mg (base equiv)....... 19 supplement kit............................................................... 124
VP-CH PLUS -prenatal w/o a w/fe cbn-dss-fa-dha cap WELLNESS ESSENTIALS FOR J -nutritional supplement
29-1-265 mg.................................................................. 106 kit................................................................................... 124
VP-CH-PNV -prenatal w/o vit a w/ fe cbn-dss-fa-dha cap WELLNESS ESSENTIALS FOR M -nutritional
30-1-260 mg.................................................................. 106 supplement kit............................................................... 124
2017
WELLNESS ESSENTIALS FOR P -nutritional supplement XIFAXAN -rifaximin tab 200 mg........................................ 11
kit................................................................................... 124 XIFAXAN -rifaximin tab 550 mg........................................ 11
WELLNESS ESSENTIALS FOR W -nutritional XIGDUO XR -dapagliflozin-metformin hcl tab er 24hr
supplement kit............................................................... 124 5-500 mg......................................................................... 30
WELLNESS ESSENTIALS -nutritional supplement XIGDUO XR -dapagliflozin-metformin hcl tab er 24hr
kit................................................................................... 124 5-1000 mg....................................................................... 30
WESTHROID -thyroid tab 32.5 mg................................... 34 XIGDUO XR -dapagliflozin-metformin hcl tab er 24hr
WESTHROID -thyroid tab 65 mg...................................... 34 10-500 mg....................................................................... 30
WESTHROID -thyroid tab 97.5 mg................................... 34 XIGDUO XR -dapagliflozin-metformin hcl tab er 24hr
WESTHROID -thyroid tab 130 mg.................................... 34 10-1000 mg..................................................................... 30
WESTHROID -thyroid tab 195 mg.................................... 34 XIIDRA -lifitegrast ophth soln 5%.................................... 138
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 60 XLEU MAXAMAID -nutritional supplement powder........ 124
mm................................................................................. 147 XLEU MAXAMUM -nutritional supplement powder.........124
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 65 XLYS-XTRP MAXAMAID -nutritional supplement
mm................................................................................. 147 powder........................................................................... 124
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 70 XLYS-XTRP MAXAMUM -nutritional supplement
mm................................................................................. 147 powder........................................................................... 124
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 75 XMET MAXAMAID -nutritional supplement powder........124
mm................................................................................. 147 XMET MAXAMUM -nutritional supplement powder........ 124
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 80 XMTVI MAXAMAID -nutritional supplement powder.......125
mm................................................................................. 147 XMTVI MAXAMUM -nutritional supplement powder....... 125
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 85 XOLEGEL -ketoconazole gel 2%.................................... 146
mm................................................................................. 147 XPHE MAXAMAID -nutritional supplement powder........ 125
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 90 XPHE MAXAMUM -amino acids oral powder................. 108
mm................................................................................. 147 XPHE MAXAMUM -amino acids pack............................ 108
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 95 XPHE-XTYR MAXAMAID -nutritional supplement
mm................................................................................. 147 powder........................................................................... 125
WILATE -antihemophilic factor/vwf (human) for inj XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent 9
500-500 unit kit............................................................. 134 mg.................................................................................... 86
WILATE -antihemophilic factor/vwf (human) for inj XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent
1000-1000 unit kit......................................................... 134 13.5 mg........................................................................... 86
WND 1 -nutritional supplement powder.......................... 124 XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent
WND 2 -nutritional supplement powder.......................... 124 18 mg.............................................................................. 86
WP THYROID -thyroid tab 16.25 mg................................ 34 XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent
WP THYROID -thyroid tab 32.5 mg.................................. 34 27 mg.............................................................................. 86
WP THYROID -thyroid tab 65 mg..................................... 34 XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent
WP THYROID -thyroid tab 81.25 mg................................ 34 36 mg.............................................................................. 86
WP THYROID -thyroid tab 97.5 mg.................................. 34 XTANDI -enzalutamide cap 40 mg.................................... 19
WP THYROID -thyroid tab 113.75 mg.............................. 34 XTRACAL PLUS -nutritional supplement liquid.............. 125
WP THYROID -thyroid tab 130 mg................................... 34 XULANE -norelgestromin-ethinyl estradiol td ptwk 150-35
WP THYROID -thyroid tab 48.75 mg (3/4 grain).............. 34 mcg/24hr.......................................................................... 26
X XYNTHA -antihemophilic factor recombinant paf for inj kit
250 unit......................................................................... 134
XALKORI -crizotinib cap 200 mg...................................... 19 XYNTHA -antihemophilic factor recombinant paf for inj kit
XALKORI -crizotinib cap 250 mg...................................... 19 500 unit......................................................................... 134
XARELTO -rivaroxaban tab 10 mg..................................128 XYNTHA -antihemophilic factor recombinant paf for inj kit
XARELTO -rivaroxaban tab 15 mg..................................128 1000 unit....................................................................... 134
XARELTO -rivaroxaban tab 20 mg..................................128 XYNTHA -antihemophilic factor recombinant paf for inj kit
XARELTO STARTER PACK -rivaroxaban tab starter 2000 unit....................................................................... 134
therapy pack 15 mg & 20 mg.......................................128 XYNTHA SOLOFUSE -antihemophilic factor recombinant
XELJANZ -tofacitinib citrate tab 5 mg (base paf for inj kit 250 unit................................................... 134
equivalent)....................................................................... 89 XYNTHA SOLOFUSE -antihemophilic factor recombinant
XELJANZ XR -tofacitinib citrate tab er 24hr 11 mg (base paf for inj kit 500 unit................................................... 134
equivalent)....................................................................... 90 XYNTHA SOLOFUSE -antihemophilic factor recombinant
XERMELO -telotristat etiprate tab 250 mg (telotristat ethyl paf for inj kit 1000 unit................................................. 134
equiv)............................................................................... 62
2017
XYNTHA SOLOFUSE -antihemophilic factor recombinant ZIRGAN -ganciclovir ophth gel 0.15%............................ 138
paf for inj kit 2000 unit................................................. 134 ZITHROMAX -azithromycin powd pack for susp 1 gm....... 3
XYNTHA SOLOFUSE -antihemophilic factor recombinant ZMAX -azithromycin extended release for oral susp 2
paf for inj kit 3000 unit................................................. 134 gm...................................................................................... 3
XYREM -sodium oxybate oral solution 500 mg/ml........... 80 ZOHYDRO ER -hydrocodone bitartrate cap er 12hr
Y abuse-deterrent 10 mg................................................... 86
ZOHYDRO ER -hydrocodone bitartrate cap er 12hr
Z abuse-deterrent 15 mg................................................... 86
ZOHYDRO ER -hydrocodone bitartrate cap er 12hr
zafirlukast tab 10 mg (Accolate).................................... 56 abuse-deterrent 20 mg................................................... 86
zafirlukast tab 20 mg (Accolate).................................... 56 ZOHYDRO ER -hydrocodone bitartrate cap er 12hr
zaleplon cap 5 mg (Sonata)............................................ 72 abuse-deterrent 30 mg................................................... 86
zaleplon cap 10 mg (Sonata).......................................... 72 ZOHYDRO ER -hydrocodone bitartrate cap er 12hr
ZARONTIN -ethosuximide cap 250 mg............................ 95 abuse-deterrent 40 mg................................................... 87
ZARONTIN -ethosuximide soln 250 mg/5ml..................... 95 ZOHYDRO ER -hydrocodone bitartrate cap er 12hr
ZARXIO -filgrastim-sndz soln prefilled syringe 300 abuse-deterrent 50 mg................................................... 87
mcg/0.5ml...................................................................... 127 ZOLINZA -vorinostat cap 100 mg..................................... 19
ZARXIO -filgrastim-sndz soln prefilled syringe 480 zolmitriptan orally disintegrating tab 2.5 mg (Zomig
mcg/0.8ml...................................................................... 127 zmt)................................................................................. 90
ZATEAN-PN DHA -prenat w/o a w/fefum-methfol-fa-dha zolmitriptan orally disintegrating tab 5 mg (Zomig
cap 27-0.6-0.4-300 mg................................................. 106 zmt)................................................................................. 91
ZATEAN-PN PLUS -prenat w/o a w/ fe fumerate- zolmitriptan tab 2.5 mg (Zomig)..................................... 91
methylfolate-fa-omega 3 cap........................................ 106 zolmitriptan tab 5 mg (Zomig)........................................ 91
ZAVESCA -miglustat cap 100 mg................................... 127 zolpidem tartrate sl tab 1.75 mg (Intermezzo).............. 72
ZEJULA -niraparib tosylate cap 100 mg (base zolpidem tartrate sl tab 3.5 mg (Intermezzo)................ 72
equivalent)....................................................................... 19 zolpidem tartrate tab er 6.25 mg (Ambien cr)............... 72
ZELAPAR -selegiline hcl orally disintegrating tab 1.25 zolpidem tartrate tab er 12.5 mg (Ambien cr)............... 72
mg.................................................................................... 98 zolpidem tartrate tab 5 mg (Ambien).............................72
ZELBORAF -vemurafenib tab 240 mg.............................. 19 zolpidem tartrate tab 10 mg (Ambien)...........................72
ZENPEP -pancrelipase (lip-prot-amyl) dr cap ZOMIG -zolmitriptan nasal spray 2.5 mg/spray unit..........91
3000-10000-16000 unit...................................................59 ZONALON -doxepin hcl cream 5%................................. 146
ZENPEP -pancrelipase (lip-prot-amyl) dr cap zonisamide cap 50 mg.................................................... 95
5000-17000-27000 unit...................................................60 zonisamide cap 25 mg (Zonegran)................................ 95
ZENPEP -pancrelipase (lip-prot-amyl) dr cap zonisamide cap 100 mg (Zonegran).............................. 95
10000-34000-55000 unit................................................ 60 ZONTIVITY -vorapaxar sulfate tab 2.08 mg (base
ZENPEP -pancrelipase (lip-prot-amyl) dr cap equivalent)..................................................................... 134
15000-51000-82000 unit................................................ 60 ZORTRESS -everolimus tab 0.25 mg............................. 149
ZENPEP -pancrelipase (lip-prot-amyl) dr cap ZORTRESS -everolimus tab 0.5 mg............................... 149
20000-68000-109000 unit.............................................. 60 ZORTRESS -everolimus tab 0.75 mg............................. 149
ZENPEP -pancrelipase (lip-prot-amyl) dr cap ZOSTAVAX -zoster vaccine live for subcutaneous susp
25000-85000-136000 unit.............................................. 60 19400 unit/0.65ml........................................................... 13
ZENPEP -pancrelipase (lip-prot-amyl) dr cap Z-TUSS AC -chlorpheniramine w/ codeine liquid 2-9
40000-136000-218000 unit............................................ 60 mg/5ml............................................................................. 53
ZEPATIER -elbasvir-grazoprevir tab 50-100 mg............... 10 ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab
ZERIT -stavudine for oral soln 1 mg/ml............................ 10 0.7-0.18 mg (base eq).................................................... 87
ZETIA -ezetimibe tab 10 mg............................................. 50 ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab
ZIAGEN -abacavir sulfate soln 20 mg/ml (base equiv)..... 10 1.4-0.36 mg (base eq).................................................... 87
zidovudine cap 100 mg (Retrovir)................................. 10 ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab
zidovudine syrup 10 mg/ml (Retrovir)........................... 10 2.9-0.71 mg (base eq).................................................... 87
zidovudine tab 300 mg.................................................... 10 ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 5.7-1.4
zileuton tab er 12hr 600 mg (Zyflo cr)........................... 56 mg (base eq)...................................................................87
ZIOPTAN -tafluprost ophth soln 0.0015%....................... 138 ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 8.6-2.1
ziprasidone hcl cap 20 mg (Geodon)............................ 71 mg (base eq)...................................................................87
ziprasidone hcl cap 40 mg (Geodon)............................ 72 ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 11.4-2.9
ziprasidone hcl cap 60 mg (Geodon)............................ 72 mg (base eq)...................................................................87
ziprasidone hcl cap 80 mg (Geodon)............................ 72
2017
ZYBAN -bupropion hcl (smoking deterrent) tab er 12hr
150 mg............................................................................ 80
ZYCLARA -imiquimod cream 3.75%............................... 146
ZYCLARA PUMP -imiquimod cream 2.5%..................... 146
ZYCLARA PUMP -imiquimod cream 3.75%................... 146
ZYDELIG -idelalisib tab 100 mg........................................ 19
ZYDELIG -idelalisib tab 150 mg........................................ 19
ZYFLO CR -zileuton tab er 12hr 600 mg.......................... 56
ZYFLO -zileuton tab 600 mg............................................. 56
ZYKADIA -ceritinib cap 150 mg........................................ 19
ZYLET -loteprednol etabonate-tobramycin ophth susp
0.5-0.3%........................................................................ 138
ZYTIGA -abiraterone acetate tab 250 mg......................... 19
ZYTIGA -abiraterone acetate tab 500 mg......................... 20

Health Insurance Marketplace 5 Tier Drug List

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Health Insurance Marketplace 5 Tier Drug List

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October 2017

Health Insurance Marketplace 5 Tier Drug List

To find a contracting pharmacy, please access the link below:

Contents Therapeutic Class Drug List

2656-G IL HIM Prime Therapeutics LLC 10/17

How drugs are selected

How member payment is determined

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 I

Drugs used to treat multiple conditions

There are two types of generic drugs:

Consider talking to your doctor about generic drugs

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 II

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 IV

Prime Specialty by AllianceRx Walgreens Prime

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 V

cap ...................................................................... capsules odt ............................................. orally disintegrating tabs

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 VI

To receive language or communication assistance free of charge, please call us at 855-710-6984.

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 1

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 2

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 3

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 4

TOBI PODHALER - tobramycin 5 ANTIFUNGALS

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 5

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 6

EPCLUSA - sofosbuvir- 5 ISENTRESS - raltegravir 3

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 7

nevirapine tab er 24hr 2 PEGINTRON - peginterferon 5

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 8

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 9

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 10

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 11

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 12

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 13

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 14

BOSULIF - bosutinib tab 500 5 ELIGARD - leuprolide acetate 5

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 15

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 16

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 17

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 18

TASIGNA - nilotinib hcl cap 200 5 VOTRIENT - pazopanib hcl tab 5

temozolomide cap 5 mg 5 XALKORI - crizotinib cap 200 5

temozolomide cap 20 mg 5 XALKORI - crizotinib cap 250 5

temozolomide cap 100 mg 5 XTANDI - enzalutamide cap 40 5

temozolomide cap 140 mg 5 ZEJULA - niraparib tosylate 5

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 19

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 20

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 21

ANGELIQ - drospirenone- 4 estradiol td patch twice 2

COMBIPATCH - estradiol- 3 estradiol td patch 2

DIVIGEL - estradiol td gel 0.25 3 estradiol td patch weekly 2

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 22

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 23

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 24

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 25

acarbose tab 50 mg 2 ALOGLIPTIN/ 4

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 26

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 27

JANUMET - sitagliptin- 3 KAZANO - alogliptin-metformin 4

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 28

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 29

BCBSIL Health Insurance Marketplace 5 Tier Drug List October 2017 30

HUMULIN R U-500 3 NOVOLIN N - insulin nph 2