2019 List of Covered Drugs (FORMULARY)Blue Cross Community MMAI 2019 LIST OF COVERED DRUGS If you...

Blue Cross Community MMAI (Medicare-Medicaid Plan)SM

2019 List of Covered Drugs (FORMULARY)

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

HPMS Approved Formulary File ID: 0019196

Effective January 2019

1-877-723-7702 (TTY/TDD: 711) We are available 24 hours a day, seven (7) days a week. The call is free.

For more information, visit http://www.bcbsil.com/mmai

H0927_BEN_IL_RX19a Approved 10032018

Updated 12/2019

234941.1219

http://www.bcbsil.com/mmai

Blue Cross Community MMAI 2019 LIST OF COVERED DRUGS

If you have questions, please call Blue Cross Community MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hours a day, seven (7) days a week. The call is free. For more information, visit http://www.bcbsil.com/mmai.

Blue Cross Community MMAISM | 2019 List of Covered Drugs (Formulary)

IntroductionThis document is called the List of Covered Drugs (also known as the Drug List). It tells you which prescription drugs and over-the-counter drugs and items are covered by Blue Cross Community MMAI. The Drug List also tells you if there are any special rules or restrictions on any drugs covered by Blue Cross Community MMAI. Key terms and their definitions appear in the last chapter of the Member Handbook.

Table of ContentsA. Disclaimers ................................................................................................................................................... i

B. Frequently Asked Questions (FAQ) ......................................................................................................... ivB1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered

Drugs the “Drug List” for short.) .............................................................................................................iv

B2. Does the Drug List ever change? ..........................................................................................................iv

B3. What happens when there is a change to the Drug List? ..................................................................... v

B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs? ........................................................................................................................................vi

B5. How will you know if the drug you want has limitations or if there are required actions to take to get the drug? ......................................................................................................................................vi

B6. What happens if we change our rules about some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)? ................................................................vi

B7. How can you find a drug on the Drug List? ...........................................................................................vi

B8. What if the drug you want to take is not on the Drug List? ...................................................................vii

B9. What if you are a new Blue Cross Community MMAI member and can’t find your drug on the Drug List or have a problem getting your drug? ...................................................................................vii

B10. Can you ask for an exception to cover your drug? ..............................................................................viii

B11. How can you ask for an exception? .......................................................................................................ix

B12. How long does it take to get an exception? ...........................................................................................ix

B13. What are generic drugs? .......................................................................................................................ix

B14. What are OTC drugs? ............................................................................................................................ix

B15. Does Blue Cross Community MMAI cover OTC non-drug products? ..................................................ix

B16. What is your copay? .............................................................................................................................. x


C. List of Covered Drugs ................................................................................................................................ xi

D. List of Drugs by Medical Condition .......................................................................................................xiv

E. Index of Covered Drugs ..........................................................................................................................114



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A. DisclaimersThis is a list of drugs that members can get in Blue Cross Community MMAI.

• Blue Cross Community MMAI is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees.

• The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.

• ATTENTION: If you speak Spanish, language assistance services, free of charge, are available to you. Call 1-877-723-7702 (TTY/TDD 711). We are available 24 hours a day, seven (7) days a week. The call is free.

• ATENCIÓN: Si habla español, los servicios de asistencia lingüística están a su disposición sin costo alguno para usted. Llame al 1-877-723-7702 (TTY/TDD:711). Estamos a su disposición las 24 horas del día, los siete (7) días de la semana. La llamada es gratuita.

• You can get this document for free in other formats, such as large print, braille, or audio. Call 1-877-723-7702(TTY/TDD 711). We are available 24 hours a day, seven (7) days a week. The call is free.

• You can request to always have your materials sent to you in the language and/or format (such as large print, braille, or audio) that you need. Call 1-877-723-7702 (TTY/TDD: 711). We are available 24 hours a day, seven (7) days a week. Once requested, Member Services will always send you materials in your chosen language and/or format until you request to have it changed. This service is free.


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Blue Cross and Blue Shield of Illinois complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield of Illinois does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Blue Cross and Blue Shield of Illinois:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as: ○ Qualified sign language interpreters

○ Written information in other formats (large print, audio, accessible electronic formats, other formats) • Provides free language services to people whose primary language is not English, such as: ○ Qualified interpreters ○ Information written in other languages If you need these services, contact Civil Rights Coordinator. If you believe that Blue Cross and Blue Shield of Illinois has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, Office of Civil Rights Coordinator, 300 E. Randolph St., 35th floor, Chicago, Illinois 60601, 1-855-664-7270, TTY/TDD: 1-855-661-6965, Fax: 1-855-661-6960, [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

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

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

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

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.


mailto:[email protected]

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html


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ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-877-723-7702 (TTY/TDD: 711).

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-723-7702 (TTY/TDD: 711).

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-877-723-7702 (TTY/TDD: 711).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-877-723-7702 （TTY/TDD：711

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.

1-877-723-7702 (TTY: TTY/TDD) 번으로 전화해 주십시오.

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-723-7702 (TTY/TDD: 711).

7702-723-877-1اللغوية تتوافر لك بالمجان. اتصل برقمملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة (.711)رقم هاتف الصم والبكم:

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-877-723-7702 (телетайп: 711).

સુચના: જો તમે ગુજરાતી બોલતા હો, તો નન:શુલક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે. ફોન કરો 1-877-723-7702 (TTY/TDD: 711).

خبردار: اگر آپ اردو بولتے ہیں، تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں ۔ کال کريں1-877-723-7702 (TTY/TDD: 711).

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-877-723-7702 (TTY/TDD: 711).

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-877-723-7702 (TTY/TDD: 711).

ध्यान दें: यदि आप हिंदी बोलते हंै तो आपके लिए मुफ्त मंे भाषा सहायता सेवाएं उपलब्ध हैं।

1-877-723-7702 (TTY/TDD: 711) पर कॉल करंे।

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-877-723-7702 (ATS: 711).

ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-877-723-7702 (TTY/TDD: 711).

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-723-7702 (TTY/TDD: 711).


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B. Frequently Asked Questions (FAQ)Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer.

B1. What prescription drugs are on the List of Covered Drugs? (We call the List of Covered Drugs the “Drug List” for short.)The drugs on the List of Covered Drugs that starts on page xi are the drugs covered by Blue Cross Community MMAI. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”

• Blue Cross Community MMAI will cover all medically necessary drugs on the Drug List if:

– your doctor or other prescriber says you need them to get better or stay healthy, and

– you fill the prescription at a Blue Cross Community MMAI network pharmacy.

• Blue Cross Community MMAI may have additional steps to access certain drugs (see question B4 below).

You can also see an up-to-date list of drugs that we cover on our website at http://www.bcbsil.com/mmai or call Member Services at 1-877-723-7702 (TTY/TDD 711). We are available 24 hours a day, seven (7) days a week. The call is free.

B2. Does the Drug List ever change?Yes. Blue Cross Community MMAI may add or remove drugs on the Drug List during the year. We may also change our rules about drugs. For example, we could:

• Decide to require or not require prior approval for a drug. (Prior approval is permission from Blue Cross Community MMAI before you can get a drug.)

Add or change the amount of a drug you can get (called quantity limits).

Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)

•

•

For more information on these drug rules, see question B4.

If you are taking a drug that was covered at the beginning of the year, we will generally not remove or change coverage of that drug during the rest of the year unless:

• a new, cheaper drug comes along that works as well as a drug on the Drug List now, orwe learn that a drug is not safe, ora drug is removed from the market.

•

•




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Questions B3 and B6 below have more information on what happens when the Drug List changes.• You can always check Blue Cross Community MMAI’s up to date Drug List online at

http://www.bcbsil.com/mmai.• You can also call Member Services to check the current Drug List at 1-877-723-7702 (TTY/TDD 711). We are

available 24 hours a day, seven (7) days a week. The call is free.

B3. What happens when there is a change to the Drug List?Some changes to the Drug List will happen immediately. For example:

• A new generic drug becomes available. Sometimes, a new and a cheaper drug comes along that works just as well, as a drug on the Drug List now. When that happens, we may remove the current drug, but your cost for the new drug will stay the same or will be lower. When we add the new generic drug, we may also decide to keep the current drug on the list but change its coverage rules or limits.

– We may not tell you before we make this change, but we will send you information about the specific change or changes we made.

– You or your provider can ask for an exception from these changes. We will send you a notice with the steps you can take to ask for an exception. Please see question B10 for more information on exceptions.

• A drug is taken off the market. If the Food and Drug Administration (FDA) says a drug you are taking is not safe, or the drug’s manufacturer takes a drug off the market, we will take it off the Drug List. If you are taking the drug, we will let you know.

We may make other changes that affect the drugs you take. We will tell you in advance about these other changes to the Drug List. These changes might happen if:

• The FDA provides new guidance or there are new clinical guidelines about a drug.

• We add a generic drug that is not new to the market and– Replace a brand name drug currently on the Drug List or

– Change the coverage rules or limits for the brand name drug.

When these changes happen, we will tell you at least 30 days before we make the change to the Drug List or when you ask for a refill. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Then you can:

• Get a 30-day supply of the drug before the change to the Drug List is made, or

• Ask for an exception from these changes. Please see question B10 for more information about exceptions.



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B4. Are there any restrictions or limits on drug coverage or any required actions to take to get certain drugs?Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases, you or your doctor or other prescriber must do something before you can get the drug. For example,

•

Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from Blue Cross Community MMAI before you fill your prescription. If you don’t get approval, Blue Cross Community MMAI may not cover the drug.

Quantity limits: Sometimes Blue Cross Community MMAI limits the amount of a drug you can get.

Step therapy: Sometimes Blue Cross Community MMAI requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second.

•

•

You can find out if your drug has any additional requirements or limits by looking in the tables on pages 1-113. You can also get more information by visiting our web site at http://www.bcbsil.com/mmai. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy.

You can ask for an “exception” from these limits.

This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Please see question B10-B12 for more information about exceptions.

B5. How will you know if the drug you want has limitations or if there are required actions to take to get the drug?The List of Covered Drugs on page xi has a column labeled “Necessary actions, restrictions, or limits on use.”

B6. What happens if we change our rules about some drugs (for example, prior authorization (approval), quantity limits, and/or step therapy restrictions)?In some cases, we will tell you in advance if we add or change prior approval, quantity limits, and/or step therapy restrictions on a drug. See question B3 for more information about this advance notice and situations where we may not be able to tell you in advance when our rules about the drugs on the Drug List change.

B7. How can you find a drug on the Drug List?There are two ways to find a drug:

• You can search alphabetically (if you know how to spell the drug), or• You can search by medical condition.

To search alphabetically, go to the Index of Covered Drugs Alphabetical Listing section. You can find it in the index that begins on Page 114.




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To search by medical condition, find the section labeled “List of drugs by medical condition” on page xv. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, cardiovascular agents. That is where you will find drugs that treat heart conditions.

B8. What if the drug you want to take is not on the Drug List?If you don’t see your drug on the Drug List, call Member Services at 1-877-723-7702 (TTY/TDD 711), 24 hours a day, (7) days a week, and ask about it. The call is free. If you learn that Blue Cross Community MMAI will not cover the drug, you can do one of these things:

•

Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or

• You can ask the health plan to make an exception to cover your drug. Please see question B10-B12 for more information about exceptions.

B9. What if you are a new Blue Cross Community MMAI member and can’t find your drug on the Drug List or have a problem getting your drug?We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of Blue Cross Community MMAI. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception.

If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication.

We will cover a 30-day supply of your drug if:• you are taking a drug that is not on our Drug List, or

health plan rules do not let you get the amount ordered by your prescriber, orthe drug requires prior approval by Blue Cross Community MMAI, or

•

•

• you are taking a drug that is part of a step therapy restriction.

If you are in a nursing home or other long-term care facility, and need a drug that is not on the Drug List or if you cannot easily get the drug you need, we can help. If you have been in the plan for more than 90 days, live in a long-term care facility, and need a supply right away:

• We will cover one 31-day supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new Blue Cross Community MMAI member.

• This is in addition to the temporary supply during the first 90 days you are a member of Blue Cross Community MMAI.


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Circumstances exist in which unplanned transitions for current members could arise and in which prescribed drug regimens may not be on the formulary. These circumstances usually involve level of care changes in which a member is changing from one treatment setting to another. For these unplanned transitions, you must use our exceptions and appeals process. Coverage determinations and redeterminations will be processed as expeditiously as your health condition requires.

In order to prevent a temporary gap in care when a member is discharged to go home, members are permitted to have a full outpatient supply available to continue therapy once their limited supply provided at discharge is exhausted. This outpatient supply is available in advance of discharge from a Part A stay.

When a member is admitted to or discharged from a long-term care facility, he or she does not have access to the remainder of the previously dispensed prescription. We will ensure you have a refill upon admission or discharge. A one-time override of the “refill too soon” edits are provided for each medication which would be impacted due to a member being admitted to or discharged from a long-term care facility. Early refill edits are not used to limit appropriate and necessary access to a member’s Part D benefit, and such members are allowed to access a refill upon admission or discharge.

To ask for a temporary supply, call Member Services. (Phone numbers are printed on the back cover of this booklet).

During the time when you are getting a temporary supply of a drug, you should talk with your provider to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug. The sections below tell you more about these options.

B10. Can you ask for an exception to cover your drug?Yes. You can ask Blue Cross Community MMAI to make an exception to cover a drug that is not on the Drug List.

You can also ask us to change the rules on your drug.• For example, Blue Cross Community MMAI may limit the amount of a drug we will cover. If your drug has a

limit, you can ask us to change the limit and cover more.

• Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.



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B11. How can you ask for an exception?To ask for an exception, call Member Services at 1-877-723-7702 (TTY/TDD 711). We are available 24 hours a day, seven (7) days a week. A Member Services representative will work with you and your provider to help you ask for an exception. You can also read Chapter 9 of the Member Handbook to learn more about exceptions.

B12. How long does it take to get an exception?First, we must get a statement from your prescriber supporting your ask for an exception. After we get the statement, we will give you a decision on your exception request within 72 hours.

If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of getting your prescriber’s supporting statement.

B13. What are generic drugs?Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA).

Blue Cross Community MMAI covers both brand name drugs and generic drugs.

B14. What are OTC drugs?OTC stands for “over-the-counter”. Blue Cross Community MMAI covers some OTC drugs when they are written as prescriptions by your provider.

You can read the Blue Cross Community MMAI Drug List to see what OTC drugs are covered.

B15. Does Blue Cross Community MMAI cover OTC non-drug products?Blue Cross Community MMAI covers some OTC non-drug products when they are written as prescriptions by your provider.

Examples of OTC non-drug products include syringes, pen needles, etc.

You can read the Blue Cross Community MMAI Drug List to see what OTC non-drug products are covered.


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B16. What is your copay?You can read the Blue Cross Community MMAI Drug List to learn about the copay for each drug. Blue Cross Community MMAI members living in nursing homes or other long-term care facilities will have no copays. Some members getting long-term care in the community will also have no copays.

Depending on your income and institutional status, you pay the following:

For generic drugs in tiers 1 and 2, either:• $0 copay, or

$1.25 copay, or

$3.40 copay.

•

•

For brand name drugs in tiers 1 and 2, either:• $0 copay, or

$3.80 copay, or

$8.50 copay.

•

•

For Non-Medicare Rx and Over-the-Counter Drugs in Tier 3, your copay is $0.



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C. List of Covered DrugsThe following list of covered drugs gives you information about the drugs covered by Blue Cross Community MMAI. If you have trouble finding your drug in the list, turn to the Index of Covered Drugs that begins on page 114. The index alphabetically lists all drugs covered by Blue Cross Community MMAI.

The first column of the chart lists the name of the drug. Brand name drugs are capitalized (e.g., MOXEZA) and generic drugs are listed in lower-case italics (e.g., hydroxychloroquine).

The information in the necessary actions, restrictions, or limits on use column tells you if Blue Cross Community MMAI has any rules for covering your drug.

KEYUppercase = BRAND NAME

Lowercase italics = generics

Tier 1 = Generic Drugs

Tier 2 = Brand Drugs

Tier 3 = Over the Counter Drugs

BD = Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance. These drugs require prior authorization to determine coverage under Part B or D. You can also read Chapter 6 of the Member Handbook to learn about prior authorizations.

PA = Prior Authorization

ST = Step Therapy

QL = Quantity limit restrictions apply.

MC = Medicaid Covered Drug; different appeal rules may apply

* - Limited distribution drug. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at 1-877-723-7702 (TTY/TDD 711). We are available 24 hours a day, seven (7) days a week.

# = High Risk Medication (HRM). Medicine that may be unsafe in patients greater than 65 years of age. Our formulary does not include coverage for some of these drugs, but alternatives may be found in lower co-pay tiers. Please discuss with your doctor if there are alternatives to these medications that would be appropriate for you to use.


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2019 DOSAGE FORM ABBREVIATIONS KEYact actuation

aepb aerosol powder blister

aer, aero aerosol

app applicator

ba, breath active breath activated

cap, caps capsules

cart cartridge

chew tab chewable tablets

conc concentrate

DR delayed-release

disintegr disintegrating

ec enteric coated

ER, extended extended-release

ext extract

g, gm gram

hr hour

IM intramuscular

inhal inhalation

inj injection

IR immediate-release

IV intravenous

liq, liqd liquid

lotn lotion

mcg microgram

mEq milliequivalentmg milligrammL milliliternebu nebulesODT orally disintegrating tabletsoint ointmentop, ophth ophthalmicosm osmoticpak packpf preservative-freepfu plaque forming unitspow, powd powderPref, prefill prefilledrecomb recombinationrefrig regigerateSL sublingualsoln solutionsupp, suppos suppositoriessusp suspensionsyr syringetab, tabs tabletstd transdermalunt unitsVac vaccine

Note: The “MC” next to a drug means the drug is not a “Part D drug.” The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage)

• In addition, if you are getting Extra Help to pay for your prescriptions, you will not get any Extra Help to pay for these drugs. For more information on Extra Help, please see the call-out box below.



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Extra Help is a Medicare program that helps people with limited incomes and resources reduce Medicare Part D prescription drug costs, such as premiums, deductibles, and copays. Extra Help is also called the “Low-Income Subsidy,” or “LIS.”

•

These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Medicaid.

• If you or your doctor disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call Member Services at 1-877-723-7702 (TTY/TDD: 711). We are available 24 hours a day, seven (7) days a week. The call is free. You can also read Chapter 9 of the Member Handbook to learn how to appeal a decision.


D. List of Drugs by Medical ConditionThe drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, cardiovascular agents. That is where you will find drugs that treat heart conditions.

Cardiovascular Agents

Name of drug Drug Tier LevelNecessary actions, restrictions, or limits on use

lisinopril tab 40 mg 1 PA

REPATHA - evolocumab subcutaneous soln prefilled syringe 140 mg/ml 2 PA, QL (3 syringes/30 days)

Here are the meanings of the codes used in the “Necessary actions, restrictions, or limits on use” column:

QL = Q uantity limit restrictions apply: you must have approval from the plan before you can get more than this quantity at a time.

PA = P rior authorization (approval): you must have approval from the plan before you can get this drug.

ST = St ep therapy: you must try another drug before you can get this one.

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2019

You can find information on what the symbols and abbreviations in this table mean by going to the List of CoveredDrugs section.

1

Name of DrugDrug Tier Level

Necessary actions,restrictions, or limits onuse

Analgesicsacetaminophen chew tab 80 mg 3 MCacetaminophen liquid 160 mg/5ml 3 MCacetaminophen soln 160 mg/5ml 3 MCacetaminophen suppos 120 mg 3 MCacetaminophen suppos 325 mg 3 MCacetaminophen susp 80 mg/0.8ml 3 MCacetaminophen susp 160 mg/5ml 3 MCacetaminophen tab 325 mg 3 MCacetaminophen tab 500 mg 3 MCacetaminophen w/ codeine soln 120-12 mg/5ml 2 QL (2700 mls/30 days)acetaminophen w/ codeine tab 300-15 mg 2 QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-30 mg 2 QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-60 mg 2 QL (180 tablets/30 days)aspirin buffered (ca carb-mg carb-mg ox) tab 325 mg 3 MCaspirin chew tab 81 mg 3 MCaspirin tab delayed release 81 mg 3 MCaspirin tab delayed release 325 mg 3 MCaspirin tab 325 mg 3 MCaspirin-acetaminophen-caffeine tab 250-250-65 mg 3 MCbutalbital-acetaminophen-caffeine tab 50-325-40 mg# 2 PA, QL (180 tablets/30 days)butalbital-aspirin-caffeine cap 50-325-40 mg# 2 PA, QL (180

capsules/30 days)BUTORPHANOL TARTRATE - butorphanol tartrate inj

1 mg/ml2

butorphanol tartrate inj 2 mg/ml 2celecoxib cap 50 mg 2 QL (60 capsules/30 days)celecoxib cap 100 mg 2 QL (60 capsules/30 days)celecoxib cap 200 mg 2 QL (60 capsules/30 days)celecoxib cap 400 mg 2 QL (30 capsules/30 days)diclofenac potassium tab 50 mg 1 QL (120 tablets/30 days)diclofenac sodium gel 1% 2 PAdiclofenac sodium tab delayed release 25 mg 1 QL (240 tablets/30 days)diclofenac sodium tab delayed release 50 mg 1 QL (120 tablets/30 days)diclofenac sodium tab delayed release 75 mg 1 QL (60 tablets/30 days)diclofenac sodium tab er 24hr 100 mg 1 QL (60 tablets/30 days)EC-NAPROXEN - naproxen tab ec 375 mg 1 QL (120 tablets/30 days)EC-NAPROXEN - naproxen tab ec 500 mg 1 QL (90 tablets/30 days)

2019

You can find information on what the symbols and abbreviations in this table mean by going to the List of CoveredDrugs section.2



etodolac cap 200 mg 1 QL (150 capsules/30 days)etodolac cap 300 mg 1 QL (90 capsules/30 days)etodolac tab 400 mg 1 QL (60 tablets/30 days)etodolac tab 500 mg 1 QL (60 tablets/30 days)EXCEDRIN EXTRA STRENGTH - aspirin-acetaminophen-

caffeine tab 250-250-65 mg3 MC

EXCEDRIN MIGRAINE - aspirin-acetaminophen-caffeinetab 250-250-65 mg

3 MC

fentanyl citrate lozenge on a handle 200 mcg 2 PA, QL (120lozenges/30 days)






fentanyl td patch 72hr 12 mcg/hr 2 PA, QL (15 patches/30 days)fentanyl td patch 72hr 25 mcg/hr 2 PA, QL (15 patches/30 days)fentanyl td patch 72hr 37.5 mcg/hr 2 PA, QL (15 patches/30 days)fentanyl td patch 72hr 50 mcg/hr 2 PA, QL (15 patches/30 days)fentanyl td patch 72hr 62.5 mcg/hr 2 PA, QL (15 patches/30 days)fentanyl td patch 72hr 75 mcg/hr 2 PA, QL (15 patches/30 days)fentanyl td patch 72hr 87.5 mcg/hr 2 PA, QL (15 patches/30 days)fentanyl td patch 72hr 100 mcg/hr 2 PA, QL (15 patches/30 days)FEVERALL INFANTS - acetaminophen suppos 80 mg 3 MChydrocodone-acetaminophen soln 7.5-325 mg/15ml 2 QL (3600 mls/30 days)hydrocodone-acetaminophen tab 10-325 mg 2 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 5-325 mg 2 QL (360 tablets/30 days)hydrocodone-acetaminophen tab 7.5-325 mg 2 QL (180 tablets/30 days)hydromorphone hcl inj 2 mg/ml 2 BDhydromorphone hcl liqd 1 mg/ml 2 QL (1440 mls/30 days)hydromorphone hcl preservative free inj 2 mg/ml 2 BDhydromorphone hcl preservative free inj 10 mg/ml 2 BDhydromorphone hcl tab 2 mg 2 QL (180 tablets/30 days)hydromorphone hcl tab 4 mg 2 QL (180 tablets/30 days)

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hydromorphone hcl tab 8 mg 2 QL (180 tablets/30 days)ibuprofen tab 200 mg 3 MCibuprofen tab 400 mg 1 QL (240 tablets/30 days)ibuprofen tab 600 mg 1 QL (150 tablets/30 days)ibuprofen tab 800 mg 1 QL (120 tablets/30 days)LAZANDA - fentanyl citrate nasal spray 100 mcg/act 2 PA, QL (30 bottles/30 days)LAZANDA - fentanyl citrate nasal spray 300 mcg/act 2 PA, QL (30 bottles/30 days)LAZANDA - fentanyl citrate nasal spray 400 mcg/act 2 PA, QL (30 bottles/30 days)meloxicam tab 7.5 mg 1 QL (60 tablets/30 days)meloxicam tab 15 mg 1 QL (30 tablets/30 days)methadone hcl tab 5 mg 2 QL (180 tablets/30 days)methadone hcl tab 10 mg 2 QL (360 tablets/30 days)morphine sulfate inj pf 0.5 mg/ml 2 BDmorphine sulfate inj pf 1 mg/ml 2 BDmorphine sulfate tab er 15 mg 2 PA, QL (90 tablets/30 days)morphine sulfate tab er 30 mg 2 PA, QL (90 tablets/30 days)morphine sulfate tab er 60 mg 2 PA, QL (90 tablets/30 days)morphine sulfate tab er 100 mg 2 PA, QL (90 tablets/30 days)morphine sulfate tab er 200 mg 2 PA, QL (90 tablets/30 days)morphine sulfate tab 15 mg 2 QL (240 tablets/30 days)morphine sulfate tab 30 mg 2 QL (180 tablets/30 days)nabumetone tab 500 mg 1 QL (120 tablets/30 days)nabumetone tab 750 mg 1 QL (60 tablets/30 days)naproxen sodium tab 220 mg 3 MCnaproxen sodium tab 275 mg 2 QL (150 tablets/30 days)naproxen sodium tab 550 mg 2 QL (90 tablets/30 days)naproxen susp 125 mg/5ml 2 QL (1800 mls/30 days)naproxen tab ec 375 mg 1 QL (120 tablets/30 days)naproxen tab ec 500 mg 1 QL (90 tablets/30 days)naproxen tab 250 mg 1 QL (180 tablets/30 days)naproxen tab 375 mg 1 QL (120 tablets/30 days)naproxen tab 500 mg 1 QL (90 tablets/30 days)NORTEMP INFANTS - acetaminophen susp 80 mg/0.8ml 3 MCoxycodone hcl tab 5 mg 2 QL (360 tablets/30 days)oxycodone hcl tab 10 mg 2 QL (180 tablets/30 days)oxycodone hcl tab 15 mg 2 QL (180 tablets/30 days)oxycodone hcl tab 20 mg 2 QL (180 tablets/30 days)oxycodone hcl tab 30 mg 2 QL (180 tablets/30 days)

2019




oxycodone w/ acetaminophen tab 2.5-325 mg 2 QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 5-325 mg 2 QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 7.5-325 mg 2 QL (240 tablets/30 days)oxycodone w/ acetaminophen tab 10-325 mg 2 QL (180 tablets/30 days)sulindac tab 150 mg 1 QL (60 tablets/30 days)sulindac tab 200 mg 1 QL (60 tablets/30 days)tramadol hcl tab 50 mg 1 QL (240 tablets/30 days)TYLENOL INFANTS PAIN+FEVER - acetaminophen susp

160 mg/5ml3 MC

Anestheticslidocaine hcl soln 4% 1 PA, QL (150 mls/30 days)lidocaine hcl urethral/mucosal gel prefilled syringe 2% 1 PA, QL (150 mls/30 days)lidocaine hcl urethral/mucosal gel 2% 1 PA, QL (150 mls/30 days)lidocaine hcl viscous soln 2% 1lidocaine patch 5% 2 PA, QL (90 patches/30 days)lidocaine-prilocaine cream 2.5-2.5% 2 PA, QL (60 grams/30 days)Anti-Addiction/Substance Abuse Treatment Agentsacamprosate calcium tab delayed release 333 mg 2BUNAVAIL - buprenorphine-naloxone buccal film

2.1-0.3 mg2 QL (330 films/30 days)

BUNAVAIL - buprenorphine-naloxone buccal film4.2-0.7 mg

2 QL (150 films/30 days)

BUNAVAIL - buprenorphine-naloxone buccal film 6.3-1 mg 2 QL (90 films/30 days)buprenorphine hcl sl tab 2 mg 1 QL (360 tablets/30 days)buprenorphine hcl sl tab 8 mg 1 QL (90 tablets/30 days)buprenorphine hcl-naloxone hcl sl film 2-0.5 mg 1 QL (360 films/30 days)buprenorphine hcl-naloxone hcl sl film 4-1 mg 1 QL (180 films/30 days)buprenorphine hcl-naloxone hcl sl film 8-2 mg 1 QL (90 films/30 days)buprenorphine hcl-naloxone hcl sl film 12-3 mg 1 QL (60 films/30 days)buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg 1 QL (360 tablets/30 days)buprenorphine hcl-naloxone hcl sl tab 8-2 mg 1 QL (90 tablets/30 days)bupropion hcl (smoking deterrent) tab er 12hr 150 mg 1CHANTIX - varenicline tartrate tab 0.5 mg 2CHANTIX - varenicline tartrate tab 1 mg 2CHANTIX CONTINUING MONTH PACK - varenicline

tartrate tab 1 mg2

CHANTIX STARTING MONTH PACK - varenicline tartratetab 0.5 mg x 11 & tab 1 mg x 42 pack

2

disulfiram tab 250 mg 1

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disulfiram tab 500 mg 1NALOXONE HCL - naloxone hcl soln cartridge 0.4 mg/ml 1NALOXONE HCL - naloxone hcl soln prefilled syringe

2 mg/2ml1

naloxone hcl inj 0.4 mg/ml 1naloxone hcl inj 4 mg/10ml 1naltrexone hcl tab 50 mg 1NARCAN - naloxone hcl nasal spray 4 mg/0.1ml 2NICODERM CQ - nicotine td patch 24hr 7 mg/24hr 3 MCNICODERM CQ - nicotine td patch 24hr 14 mg/24hr 3 MCNICODERM CQ - nicotine td patch 24hr 21 mg/24hr 3 MCNICORETTE - nicotine polacrilex gum 2 mg 3 MCNICORETTE - nicotine polacrilex gum 4 mg 3 MCNICORETTE - nicotine polacrilex lozenge 2 mg 3 MCNICORETTE - nicotine polacrilex lozenge 4 mg 3 MCNICORETTE MINI - nicotine polacrilex lozenge 2 mg 3 MCNICORETTE MINI - nicotine polacrilex lozenge 4 mg 3 MCNICORETTE STARTER KIT - nicotine polacrilex gum 2 mg 3 MCNICORETTE STARTER KIT - nicotine polacrilex gum 4 mg 3 MCnicotine polacrilex gum 2 mg 3 MCnicotine polacrilex gum 4 mg 3 MCnicotine polacrilex lozenge 2 mg 3 MCnicotine polacrilex lozenge 4 mg 3 MCnicotine td patch 24hr 7 mg/24hr 3 MCnicotine td patch 24hr 14 mg/24hr 3 MCnicotine td patch 24hr 21 mg/24hr 3 MCNICOTINE TRANSDERMAL SYSTEM - nicotine td patch

24 hr kit 21-14-7 mg/24hr3 MC

NICOTROL INHALER - nicotine inhaler system 10 mg(4 mg delivered)

2

NICOTROL NS - nicotine nasal spray 10 mg/ml (0.5 mg/spray)

2

SUBOXONE - buprenorphine hcl-naloxone hcl sl film2-0.5 mg


SUBOXONE - buprenorphine hcl-naloxone hcl sl film4-1 mg






2019




ZUBSOLV - buprenorphine hcl-naloxone hcl sl tab0.7-0.18 mg

2 QL (1020 tablets/30 days)











Antibacterialsamikacin sulfate inj 500 mg/2ml (250 mg/ml) 2amikacin sulfate inj 1 gm/4ml (250 mg/ml) 2AMOXICILLIN - amoxicillin (trihydrate) chew tab 125 mg 2AMOXICILLIN - amoxicillin (trihydrate) chew tab 250 mg 2amoxicillin (trihydrate) cap 250 mg 1amoxicillin (trihydrate) cap 500 mg 1amoxicillin (trihydrate) for susp 125 mg/5ml 1amoxicillin (trihydrate) for susp 200 mg/5ml 1amoxicillin (trihydrate) for susp 250 mg/5ml 1amoxicillin (trihydrate) for susp 400 mg/5ml 1amoxicillin (trihydrate) tab 500 mg 1amoxicillin (trihydrate) tab 875 mg 1amoxicillin & k clavulanate for susp 200-28.5 mg/5ml 2amoxicillin & k clavulanate for susp 250-62.5 mg/5ml 2amoxicillin & k clavulanate for susp 400-57 mg/5ml 2amoxicillin & k clavulanate for susp 600-42.9 mg/5ml 2amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg 2amoxicillin & k clavulanate tab 250-125 mg 2amoxicillin & k clavulanate tab 500-125 mg 2amoxicillin & k clavulanate tab 875-125 mg 2AMOXICILLIN/CLAVULANATE POTASSIUM - amoxicillin &

k clavulanate chew tab 200-28.5 mg2

AMOXICILLIN/CLAVULANATE POTASSIUM - amoxicillin &k clavulanate chew tab 400-57 mg

2

ampicillin & sulbactam sodium for inj 3 (2-1) gm 2ampicillin cap 500 mg 1AMPICILLIN SODIUM - ampicillin sodium for iv soln 1 gm 2

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ampicillin sodium for inj 250 mg 2ampicillin sodium for inj 500 mg 2ampicillin sodium for inj 1 gm 2ampicillin sodium for inj 2 gm 2ampicillin sodium for iv soln 2 gm 2AMPICILLIN-SULBACTAM - ampicillin & sulbactam sodium

for iv soln 3 (2-1) gm2

AZITHROMYCIN - azithromycin powd pack for susp 1 gm 2azithromycin for susp 100 mg/5ml 2azithromycin for susp 200 mg/5ml 2azithromycin iv for soln 500 mg 2azithromycin tab 250 mg 1azithromycin tab 500 mg 1azithromycin tab 600 mg 1aztreonam for inj 1 gm 2aztreonam for inj 2 gm 2BACTRIM - sulfamethoxazole-trimethoprim tab 400-80 mg 2BACTRIM DS - sulfamethoxazole-trimethoprim tab

800-160 mg2

BICILLIN L-A - penicillin g benzathine intramuscular susp600000 unit/ml

2

BICILLIN L-A - penicillin g benzathine intramuscular susp1200000 unit/2ml

2

BICILLIN L-A - penicillin g benzathine intramuscular susp2400000 unit/4ml

2

cefaclor cap 250 mg 2cefaclor cap 500 mg 2cefadroxil cap 500 mg 1cefazolin sodium for inj 500 mg 2cefazolin sodium for inj 1 gm 2cefazolin sodium for inj 10 gm 2cefdinir cap 300 mg 2cefdinir for susp 125 mg/5ml 2cefdinir for susp 250 mg/5ml 2cefepime hcl for inj 1 gm 2cefepime hcl for inj 2 gm 2cefixime cap 400 mg 2CEFOTAXIME SODIUM - cefotaxime sodium for inj 500 mg 2cefotaxime sodium for inj 1 gm 2

2019




cefoxitin sodium for iv soln 1 gm 2cefoxitin sodium for iv soln 2 gm 2cefpodoxime proxetil tab 100 mg 2cefpodoxime proxetil tab 200 mg 2cefprozil tab 250 mg 2cefprozil tab 500 mg 2ceftazidime for inj 1 gm 2ceftazidime for inj 2 gm 2ceftazidime for inj 6 gm 2ceftazidime for iv soln 2 gm 2CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE -

ceftriaxone sodium in dextrose inj 20 mg/ml2

CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE -ceftriaxone sodium in dextrose inj 40 mg/ml

2

ceftriaxone sodium for inj 250 mg 1ceftriaxone sodium for inj 500 mg 1ceftriaxone sodium for inj 1 gm 2ceftriaxone sodium for inj 2 gm 2ceftriaxone sodium for inj 10 gm 2ceftriaxone sodium for iv soln 1 gm 2ceftriaxone sodium for iv soln 2 gm 2CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv

soln 1 gm and dextrose 3.74%2

CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for ivsoln 2 gm and dextrose 2.22%

2

cefuroxime axetil tab 250 mg 2cefuroxime axetil tab 500 mg 2cefuroxime sodium for inj 750 mg 2cefuroxime sodium for inj 7.5 gm 2cefuroxime sodium for iv soln 1.5 gm 2cephalexin cap 250 mg 1cephalexin cap 500 mg 1cephalexin cap 750 mg 1cephalexin for susp 125 mg/5ml 2cephalexin for susp 250 mg/5ml 2CHLORAMPHENICOL SODIUM SUCCINATE -

chloramphenicol sodium succinate for iv inj 1 gm2

CIPRO - ciprofloxacin hcl tab 250 mg 2CIPRO - ciprofloxacin hcl tab 500 mg 2

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

2

CIPROFLOXACIN HCL - ciprofloxacin hcl tab 100 mg 2ciprofloxacin hcl tab 250 mg 1ciprofloxacin hcl tab 500 mg 1ciprofloxacin hcl tab 750 mg 1ciprofloxacin 200 mg/100ml in d5w 2ciprofloxacin 400 mg/200ml in d5w 2clarithromycin for susp 125 mg/5ml 2clarithromycin for susp 250 mg/5ml 2clarithromycin tab 250 mg 2clarithromycin tab 500 mg 2CLEOCIN - clindamycin phosphate vaginal cream 2% 2CLEOCIN - clindamycin hcl cap 75 mg 2CLEOCIN - clindamycin hcl cap 150 mg 2CLEOCIN - clindamycin hcl cap 300 mg 2CLEOCIN PHOSPHATE - clindamycin phosphate inj

900 mg/6ml2

clindamycin hcl cap 75 mg 1clindamycin hcl cap 150 mg 1clindamycin hcl cap 300 mg 1clindamycin palmitate hcl for soln 75 mg/5ml 2clindamycin phosphate gel 1% 2clindamycin phosphate inj 300 mg/2ml 2clindamycin phosphate inj 600 mg/4ml 2clindamycin phosphate inj 900 mg/6ml 2clindamycin phosphate inj 9 gm/60ml 2clindamycin phosphate iv soln 300 mg/2ml 2clindamycin phosphate iv soln 600 mg/4ml 2clindamycin phosphate iv soln 900 mg/6ml 2clindamycin phosphate lotion 1% 2clindamycin phosphate soln 1% 2clindamycin phosphate swab 1% 2clindamycin phosphate vaginal cream 2% 2colistimethate sod for inj 150 mg 2DALVANCE - dalbavancin hcl for iv soln 500 mg 2daptomycin for iv soln 500 mg 2demeclocycline hcl tab 150 mg 2

2019




demeclocycline hcl tab 300 mg 2dicloxacillin sodium cap 250 mg 2dicloxacillin sodium cap 500 mg 2DIFICID - fidaxomicin tab 200 mg 2doxycycline hyclate cap 50 mg 2doxycycline hyclate cap 100 mg 2doxycycline hyclate for inj 100 mg 2doxycycline hyclate tab 20 mg 2doxycycline hyclate tab 100 mg 2doxycycline monohydrate cap 50 mg 2doxycycline monohydrate cap 75 mg 2doxycycline monohydrate cap 100 mg 2doxycycline monohydrate cap 150 mg 2doxycycline monohydrate tab 50 mg 2doxycycline monohydrate tab 75 mg 2doxycycline monohydrate tab 100 mg 2doxycycline monohydrate tab 150 mg 2ERYPED 400 - erythromycin ethylsuccinate for susp

400 mg/5ml2

ERYTHROCIN LACTOBIONATE - erythromycinlactobionate for inj 500 mg

2

erythromycin ethylsuccinate for susp 400 mg/5ml 2erythromycin tab delayed release 250 mg 2erythromycin tab delayed release 333 mg 2erythromycin tab delayed release 500 mg 2erythromycin tab 250 mg 2erythromycin tab 500 mg 2erythromycin w/ delayed release particles cap 250 mg 2FLAGYL - metronidazole tab 250 mg 2FLAGYL - metronidazole tab 500 mg 2gentamicin sulfate inj 10 mg/ml 2gentamicin sulfate inj 40 mg/ml 2imipenem-cilastatin intravenous for soln 250 mg 2imipenem-cilastatin intravenous for soln 500 mg 2IMPAVIDO - miltefosine cap 50 mg 2INVANZ - ertapenem sodium for inj 1 gm 2INVANZ - ertapenem sodium for iv inj 1 gm 2LEVAQUIN - levofloxacin tab 500 mg 2

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LEVAQUIN - levofloxacin tab 750 mg 2levofloxacin in d5w iv soln 250 mg/50ml 2levofloxacin in d5w iv soln 500 mg/100ml 2levofloxacin in d5w iv soln 750 mg/150ml 2levofloxacin iv soln 25 mg/ml 2levofloxacin oral soln 25 mg/ml 1levofloxacin tab 250 mg 1levofloxacin tab 500 mg 1levofloxacin tab 750 mg 1LINEZOLID - linezolid in sodium chloride iv soln

600 mg/300ml-0.9%2

linezolid for susp 100 mg/5ml 2 PAlinezolid iv soln 600 mg/300ml (2 mg/ml) 2linezolid tab 600 mg 2 PAMAXIPIME - cefepime hcl for inj 1 gm 2MAXIPIME - cefepime hcl for inj 2 gm 2meropenem iv for soln 500 mg 2meropenem iv for soln 1 gm 2MERREM - meropenem iv for soln 500 mg 2methenamine hippurate tab 1 gm 2metronidazole in nacl 0.74% iv soln 500 mg/100ml 2metronidazole in nacl 0.79% iv soln 500 mg/100ml 2metronidazole iv soln 5 mg/ml 2metronidazole tab 250 mg 1metronidazole tab 500 mg 1metronidazole vaginal gel 0.75% 2MINOCIN - minocycline hcl cap 50 mg 2minocycline hcl cap 50 mg 2minocycline hcl cap 75 mg 2minocycline hcl cap 100 mg 2minocycline hcl tab 50 mg 2minocycline hcl tab 75 mg 2minocycline hcl tab 100 mg 2MOXIFLOXACIN HCL - moxifloxacin hcl iv solution

400 mg/250ml2

moxifloxacin hcl tab 400 mg 2moxifloxacin hcl 400 mg/250ml in sodium chloride 0.8% inj 2NAFCILLIN SODIUM - nafcillin sodium for iv soln 1 gm 2

2019




NAFCILLIN SODIUM - nafcillin sodium for iv soln 2 gm 2NAFCILLIN SODIUM - nafcillin sodium for inj 10 gm 2nafcillin sodium for inj 1 gm 2nafcillin sodium for inj 2 gm 2nafcillin sodium for iv soln 10 gm 2neomycin sulfate tab 500 mg 2nitrofurantoin macrocrystalline cap 50 mg# 2nitrofurantoin macrocrystalline cap 100 mg# 2nitrofurantoin monohydrate macrocrystalline cap 100 mg# 2ofloxacin tab 400 mg 2paromomycin sulfate cap 250 mg 2penicillin g potassium for inj 5000000 unit 2penicillin g potassium for inj 20000000 unit 2PENICILLIN G POTASSIUM IN DEXTROSE - penicillin g

potassium inj 20000 unit/ml in dextrose2

PENICILLIN G POTASSIUM IN DEXTROSE - penicillin gpotassium inj 40000 unit/ml in dextrose

2

PENICILLIN G POTASSIUM IN DEXTROSE - penicillin gpotassium inj 60000 unit/ml in dextrose

2

penicillin v potassium for soln 125 mg/5ml 1penicillin v potassium for soln 250 mg/5ml 1penicillin v potassium tab 250 mg 1penicillin v potassium tab 500 mg 1piperacillin sod-tazobactam na for inj 3.375 gm

(3-0.375 gm)2

piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm) 2piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) 2PRIMAXIN IV - imipenem-cilastatin intravenous for soln

500 mg2

SIVEXTRO - tedizolid phosphate tab 200 mg 2 PASIVEXTRO - tedizolid phosphate for iv soln 200 mg 2STREPTOMYCIN SULFATE - streptomycin sulfate for inj

1 gm2

sulfacetamide sodium lotion 10% 2SULFADIAZINE - sulfadiazine tab 500 mg 2sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml 2sulfamethoxazole-trimethoprim susp 200-40 mg/5ml 2sulfamethoxazole-trimethoprim tab 400-80 mg 1sulfamethoxazole-trimethoprim tab 800-160 mg 1

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SUPRAX - cefixime cap 400 mg 2SUPRAX - cefixime chew tab 100 mg 2SUPRAX - cefixime chew tab 200 mg 2SYNERCID - quinupristin-dalfopristin for inj 500 mg

(150-350 mg)2

TAZICEF - ceftazidime for iv soln 1 gm 2TEFLARO - ceftaroline fosamil for iv soln 400 mg 2TEFLARO - ceftaroline fosamil for iv soln 600 mg 2tetracycline hcl cap 250 mg 2tetracycline hcl cap 500 mg 2tigecycline for iv soln 50 mg 2TOBRAMYCIN SULFATE - tobramycin sulfate inj 10 mg/ml 2TOBRAMYCIN SULFATE - tobramycin sulfate inj

2 gm/50ml (40 mg/ml)2

tobramycin sulfate for inj 1.2 gm 2tobramycin sulfate inj 80 mg/2ml (40 mg/ml) 2tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) 2trimethoprim tab 100 mg 1TYGACIL - tigecycline for iv soln 50 mg 2UNASYN - ampicillin & sulbactam sodium for inj 3 (2-1) gm 2vancomycin hcl cap 125 mg 2vancomycin hcl cap 250 mg 2vancomycin hcl for iv soln 100 gm 2vancomycin hcl for iv soln 500 mg 2vancomycin hcl for iv soln 750 mg 2vancomycin hcl for iv soln 1 gm 2vancomycin hcl for iv soln 5 gm 2vancomycin hcl for iv soln 10 gm 2VANCOMYCIN HYDROCHLORIDE - vancomycin hcl for iv

soln 250 mg2

VANCOMYCIN HYDROCHLORIDE - vancomycin hcl for ivsoln 1.25 gm

2

VANCOMYCIN HYDROCHLORIDE - vancomycin hcl for ivsoln 1.5 gm

2

VIBRAMYCIN - doxycycline hyclate cap 100 mg 2ZITHROMAX - azithromycin iv for soln 500 mg 2ZITHROMAX - azithromycin tab 250 mg 2ZITHROMAX - azithromycin tab 500 mg 2ZITHROMAX - azithromycin tab 600 mg 2

2019




ZITHROMAX - azithromycin for susp 100 mg/5ml 2ZITHROMAX - azithromycin for susp 200 mg/5ml 2ZITHROMAX - azithromycin powd pack for susp 1 gm 2ZITHROMAX TRI-PAK - azithromycin tab 500 mg 2ZITHROMAX Z-PAK - azithromycin tab 250 mg 2ZOSYN - piperacillin sod-tazobactam sod in dex iv soln

2-0.25gm/50ml2

ZOSYN - piperacillin sod-tazobactam sod in dex iv soln4-0.5gm/100ml

2

ZOSYN - piperacillin sod-tazobactam sod in dex iv sol3-0.375gm/50ml

2

AnticonvulsantsAPTIOM - eslicarbazepine acetate tab 200 mg 2APTIOM - eslicarbazepine acetate tab 400 mg 2APTIOM - eslicarbazepine acetate tab 600 mg 2APTIOM - eslicarbazepine acetate tab 800 mg 2BANZEL - rufinamide susp 40 mg/ml 2BANZEL - rufinamide tab 200 mg 2BANZEL - rufinamide tab 400 mg 2BRIVIACT - brivaracetam tab 10 mg 2BRIVIACT - brivaracetam tab 25 mg 2BRIVIACT - brivaracetam tab 50 mg 2BRIVIACT - brivaracetam tab 75 mg 2BRIVIACT - brivaracetam tab 100 mg 2BRIVIACT - brivaracetam oral soln 10 mg/ml 2BRIVIACT - brivaracetam iv soln 50 mg/5ml 2carbamazepine cap er 12hr 100 mg 1carbamazepine cap er 12hr 200 mg 1carbamazepine cap er 12hr 300 mg 1carbamazepine chew tab 100 mg 1carbamazepine susp 100 mg/5ml 1carbamazepine tab er 12hr 100 mg 1carbamazepine tab er 12hr 200 mg 1carbamazepine tab er 12hr 400 mg 1carbamazepine tab 200 mg 1CELONTIN - methsuximide cap 300 mg 2clobazam suspension 2.5 mg/ml 2 PA, QL (480 mls/30 days)clobazam tab 10 mg 1 PA, QL (60 tablets/30 days)clobazam tab 20 mg 1 PA, QL (60 tablets/30 days)

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15



DIASTAT ACUDIAL - diazepam rectal gel delivery system10 mg

2 QL (5 twin pack(s)/30 days)

DIASTAT ACUDIAL - diazepam rectal gel delivery system20 mg


DIASTAT PEDIATRIC - diazepam rectal gel delivery system2.5 mg


DIAZEPAM - diazepam rectal gel delivery system 10 mg 2 QL (5 twin pack(s)/30 days)DIAZEPAM RECTAL GEL - diazepam rectal gel delivery

system 2.5 mg2 QL (5 twin pack(s)/30 days)

DIAZEPAM RECTAL GEL - diazepam rectal gel deliverysystem 10 mg


DIAZEPAM RECTAL GEL - diazepam rectal gel deliverysystem 20 mg


DILANTIN - phenytoin sodium extended cap 30 mg 2divalproex sodium cap delayed release sprinkle 125 mg 1divalproex sodium tab delayed release 125 mg 1divalproex sodium tab delayed release 250 mg 1divalproex sodium tab delayed release 500 mg 1divalproex sodium tab er 24 hr 250 mg 1divalproex sodium tab er 24 hr 500 mg 1EPIDIOLEX - cannabidiol soln 100 mg/ml 2 PAethosuximide cap 250 mg 1ethosuximide soln 250 mg/5ml 1felbamate susp 600 mg/5ml 2felbamate tab 400 mg 2felbamate tab 600 mg 2fosphenytoin sodium inj 100 mg/2ml 2fosphenytoin sodium inj 500 mg/10ml 2FYCOMPA - perampanel susp 0.5 mg/ml 2FYCOMPA - perampanel tab 2 mg 2FYCOMPA - perampanel tab 4 mg 2FYCOMPA - perampanel tab 6 mg 2FYCOMPA - perampanel tab 8 mg 2FYCOMPA - perampanel tab 10 mg 2FYCOMPA - perampanel tab 12 mg 2gabapentin cap 100 mg 1 QL (1080 capsules/30 days)gabapentin cap 300 mg 1 QL (360 capsules/30 days)gabapentin cap 400 mg 1 QL (270 capsules/30 days)gabapentin oral soln 250 mg/5ml 1 QL (2160 mls/30 days)

2019




gabapentin tab 600 mg 1 QL (180 tablets/30 days)gabapentin tab 800 mg 1 QL (135 tablets/30 days)lamotrigine tab chewable dispersible 5 mg 1lamotrigine tab chewable dispersible 25 mg 1lamotrigine tab 25 mg 1lamotrigine tab 100 mg 1lamotrigine tab 150 mg 1lamotrigine tab 200 mg 1levetiracetam inj 500 mg/5ml (100 mg/ml) 2levetiracetam oral soln 100 mg/ml 1levetiracetam tab 250 mg 1levetiracetam tab 500 mg 1levetiracetam tab 750 mg 1levetiracetam tab 1000 mg 1LYRICA - pregabalin soln 20 mg/ml 1 QL (900 mls/30 days)LYRICA - pregabalin cap 25 mg 1 QL (90 capsules/30 days)LYRICA - pregabalin cap 50 mg 1 QL (90 capsules/30 days)LYRICA - pregabalin cap 75 mg 1 QL (90 capsules/30 days)LYRICA - pregabalin cap 100 mg 1 QL (90 capsules/30 days)LYRICA - pregabalin cap 150 mg 1 QL (90 capsules/30 days)LYRICA - pregabalin cap 200 mg 1 QL (90 capsules/30 days)LYRICA - pregabalin cap 225 mg 1 QL (60 capsules/30 days)LYRICA - pregabalin cap 300 mg 1 QL (60 capsules/30 days)NAYZILAM - midazolam nasal spray soln 5 mg/0.1 ml 2 QL (10 bottles/30 days)ONFI - clobazam suspension 2.5 mg/ml 2 PA, QL (480 mls/30 days)ONFI - clobazam tab 10 mg 2 PA, QL (60 tablets/30 days)ONFI - clobazam tab 20 mg 2 PA, QL (60 tablets/30 days)oxcarbazepine susp 300 mg/5ml (60 mg/ml) 2oxcarbazepine tab 150 mg 1oxcarbazepine tab 300 mg 1oxcarbazepine tab 600 mg 1PEGANONE - ethotoin tab 250 mg 2phenobarbital elixir 20 mg/5ml# 2 PAPHENOBARBITAL SODIUM - phenobarbital sodium inj

65 mg/ml#2 PA

PHENOBARBITAL SODIUM - phenobarbital sodium inj130 mg/ml#

2 PA

phenobarbital tab 15 mg# 2 PA

2019


17



phenobarbital tab 16.2 mg# 2 PAphenobarbital tab 30 mg# 2 PAphenobarbital tab 32.4 mg# 2 PAphenobarbital tab 60 mg# 2 PAphenobarbital tab 64.8 mg# 2 PAphenobarbital tab 97.2 mg# 2 PAphenobarbital tab 100 mg# 2 PAphenytoin chew tab 50 mg 1phenytoin sodium extended cap 100 mg 1phenytoin sodium extended cap 200 mg 1phenytoin sodium extended cap 300 mg 1phenytoin susp 125 mg/5ml 1pregabalin cap 25 mg 1 QL (90 capsules/30 days)pregabalin cap 50 mg 1 QL (90 capsules/30 days)pregabalin cap 75 mg 1 QL (90 capsules/30 days)pregabalin cap 100 mg 1 QL (90 capsules/30 days)pregabalin cap 150 mg 1 QL (90 capsules/30 days)pregabalin cap 200 mg 1 QL (90 capsules/30 days)pregabalin cap 225 mg 1 QL (60 capsules/30 days)pregabalin cap 300 mg 1 QL (60 capsules/30 days)pregabalin soln 20 mg/ml 1 QL (900 mls/30 days)primidone tab 50 mg 1primidone tab 250 mg 1SABRIL - vigabatrin tab 500 mg* 2SPRITAM - levetiracetam tab disintegrating soluble 250 mg 2SPRITAM - levetiracetam tab disintegrating soluble 500 mg 2SPRITAM - levetiracetam tab disintegrating soluble 750 mg 2SPRITAM - levetiracetam tab disintegrating soluble

1000 mg2

SYMPAZAN - clobazam oral film 5 mg 2 PA, QL (240 films/30 days)SYMPAZAN - clobazam oral film 10 mg 2 PA, QL (60 films/30 days)SYMPAZAN - clobazam oral film 20 mg 2 PA, QL (60 films/30 days)tiagabine hcl tab 2 mg 2tiagabine hcl tab 4 mg 2tiagabine hcl tab 12 mg 2tiagabine hcl tab 16 mg 2topiramate sprinkle cap 15 mg 1topiramate sprinkle cap 25 mg 1

2019




topiramate tab 25 mg 1topiramate tab 50 mg 1topiramate tab 100 mg 1topiramate tab 200 mg 1valproate sodium inj 100 mg/ml 1valproate sodium oral soln 250 mg/5ml 2valproic acid cap 250 mg 1vigabatrin powd pack 500 mg* 2vigabatrin tab 500 mg* 2VIMPAT - lacosamide tab 50 mg 1VIMPAT - lacosamide tab 100 mg 1VIMPAT - lacosamide tab 150 mg 1VIMPAT - lacosamide tab 200 mg 1VIMPAT - lacosamide iv inj 200 mg/20ml (10 mg/ml) 1VIMPAT - lacosamide oral solution 10 mg/ml 1zonisamide cap 25 mg 1zonisamide cap 50 mg 1zonisamide cap 100 mg 1Antidementia Agentsdonepezil hydrochloride tab 5 mg 1donepezil hydrochloride tab 10 mg 1ERGOLOID MESYLATES - ergoloid mesylates tab 1 mg# 1 PAGALANTAMINE HYDROBROMIDE - galantamine

hydrobromide oral soln 4 mg/ml2

galantamine hydrobromide cap er 24hr 8 mg 1galantamine hydrobromide cap er 24hr 16 mg 1galantamine hydrobromide cap er 24hr 24 mg 1galantamine hydrobromide tab 4 mg 1galantamine hydrobromide tab 8 mg 1galantamine hydrobromide tab 12 mg 1memantine hcl oral solution 2 mg/ml 2 PAmemantine hcl tab 5 mg 1 PAmemantine hcl tab 10 mg 1 PAmemantine hcl tab 5 mg (28) & 10 mg (21) titration pak 1 PArivastigmine tartrate cap 1.5 mg 1rivastigmine tartrate cap 3 mg 1rivastigmine tartrate cap 4.5 mg 1rivastigmine tartrate cap 6 mg 1

2019


19



rivastigmine td patch 24hr 4.6 mg/24hr 2rivastigmine td patch 24hr 9.5 mg/24hr 2rivastigmine td patch 24hr 13.3 mg/24hr 2Antidepressantsamitriptyline hcl tab 10 mg# 2 PAamitriptyline hcl tab 25 mg# 2 PAamitriptyline hcl tab 50 mg# 2 PAamitriptyline hcl tab 75 mg# 2 PAamitriptyline hcl tab 100 mg# 2 PAamitriptyline hcl tab 150 mg# 2 PAAMOXAPINE - amoxapine tab 25 mg# 2 PAAMOXAPINE - amoxapine tab 50 mg# 2 PAAMOXAPINE - amoxapine tab 100 mg# 2 PAAMOXAPINE - amoxapine tab 150 mg# 2 PAbupropion hcl tab er 12hr 100 mg 1 QL (90 tablets/30 days)bupropion hcl tab er 12hr 150 mg 1 QL (60 tablets/30 days)bupropion hcl tab er 12hr 200 mg 1 QL (60 tablets/30 days)bupropion hcl tab er 24hr 150 mg 1 QL (90 tablets/30 days)bupropion hcl tab er 24hr 300 mg 1 QL (30 tablets/30 days)bupropion hcl tab 75 mg 1 QL (60 tablets/30 days)bupropion hcl tab 100 mg 1 QL (120 tablets/30 days)CELEXA - citalopram hydrobromide tab 10 mg 2 QL (45 tablets/30 days)CELEXA - citalopram hydrobromide tab 20 mg 2 QL (45 tablets/30 days)CELEXA - citalopram hydrobromide tab 40 mg 2 QL (30 tablets/30 days)citalopram hydrobromide oral soln 10 mg/5ml 2 QL (600 mls/30 days)citalopram hydrobromide tab 10 mg 1 QL (45 tablets/30 days)citalopram hydrobromide tab 20 mg 1 QL (45 tablets/30 days)citalopram hydrobromide tab 40 mg 1 QL (30 tablets/30 days)clomipramine hcl cap 25 mg# 2 PAclomipramine hcl cap 50 mg# 2 PAclomipramine hcl cap 75 mg# 2 PAdesipramine hcl tab 10 mg# 2 PAdesipramine hcl tab 25 mg# 2 PAdesipramine hcl tab 50 mg# 2 PAdesipramine hcl tab 75 mg# 2 PAdesipramine hcl tab 100 mg# 2 PAdesipramine hcl tab 150 mg# 2 PAdesvenlafaxine succinate tab er 24hr 25 mg 2 QL (30 tablets/30 days)

2019




desvenlafaxine succinate tab er 24hr 50 mg 2 QL (30 tablets/30 days)desvenlafaxine succinate tab er 24hr 100 mg 2 QL (30 tablets/30 days)doxepin hcl cap 150 mg# 2 PAdoxepin hcl cap 10 mg# 2 PAdoxepin hcl cap 25 mg# 2 PAdoxepin hcl cap 50 mg# 2 PAdoxepin hcl cap 75 mg# 2 PAdoxepin hcl cap 100 mg# 2 PAdoxepin hcl conc 10 mg/ml# 2 PAduloxetine hcl enteric coated pellets cap 20 mg 1 QL (60 capsules/30 days)duloxetine hcl enteric coated pellets cap 30 mg 1 QL (90 capsules/30 days)duloxetine hcl enteric coated pellets cap 60 mg 1 QL (60 capsules/30 days)EMSAM - selegiline td patch 24hr 6 mg/24hr 2EMSAM - selegiline td patch 24hr 9 mg/24hr 2EMSAM - selegiline td patch 24hr 12 mg/24hr 2escitalopram oxalate soln 5 mg/5ml 2 QL (600 mls/30 days)escitalopram oxalate tab 5 mg 1 QL (45 tablets/30 days)escitalopram oxalate tab 10 mg 1 QL (45 tablets/30 days)escitalopram oxalate tab 20 mg 1 QL (30 tablets/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 20 mg 2 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 40 mg 2 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 80 mg 2 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 120 mg 2 QL (30 capsules/30 days)FETZIMA TITRATION PACK - levomilnacipran hcl cap er

24hr 20 & 40 mg therapy pack2 QL (28 capsules/28 days)

fluoxetine hcl cap 10 mg 1 QL (90 capsules/30 days)fluoxetine hcl cap 20 mg 1 QL (120 capsules/30 days)fluoxetine hcl cap 40 mg 1 QL (60 capsules/30 days)fluoxetine hcl solution 20 mg/5ml 1 QL (600 mls/30 days)fluoxetine hcl tab 10 mg 1 QL (90 tablets/30 days)fluoxetine hcl tab 20 mg 1 QL (120 tablets/30 days)fluvoxamine maleate tab 25 mg 1 QL (30 tablets/30 days)fluvoxamine maleate tab 50 mg 1 QL (30 tablets/30 days)fluvoxamine maleate tab 100 mg 1 QL (90 tablets/30 days)imipramine hcl tab 10 mg# 2 PAimipramine hcl tab 25 mg# 2 PAimipramine hcl tab 50 mg# 2 PALEXAPRO - escitalopram oxalate tab 5 mg 2 QL (45 tablets/30 days)

2019


21



LEXAPRO - escitalopram oxalate tab 10 mg 2 QL (45 tablets/30 days)LEXAPRO - escitalopram oxalate tab 20 mg 2 QL (30 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 25 mg 2 QL (90 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 50 mg 2 QL (90 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 75 mg 2 QL (90 tablets/30 days)MARPLAN - isocarboxazid tab 10 mg 2mirtazapine orally disintegrating tab 15 mg 1 QL (30 tablets/30 days)mirtazapine orally disintegrating tab 30 mg 1 QL (30 tablets/30 days)mirtazapine orally disintegrating tab 45 mg 1 QL (30 tablets/30 days)mirtazapine tab 7.5 mg 1 QL (30 tablets/30 days)mirtazapine tab 15 mg 1 QL (45 tablets/30 days)mirtazapine tab 30 mg 1 QL (30 tablets/30 days)mirtazapine tab 45 mg 1 QL (30 tablets/30 days)NARDIL - phenelzine sulfate tab 15 mg 2NEFAZODONE HCL - nefazodone hcl tab 100 mg 2NEFAZODONE HCL - nefazodone hcl tab 150 mg 2nefazodone hcl tab 50 mg 1nefazodone hcl tab 250 mg 1NEFAZODONE HYDROCHLORIDE - nefazodone hcl tab

200 mg2

nortriptyline hcl cap 10 mg# 2 PAnortriptyline hcl cap 25 mg# 2 PAnortriptyline hcl cap 50 mg# 2 PAnortriptyline hcl cap 75 mg# 2 PAnortriptyline hcl soln 10 mg/5ml# 2 PAPARNATE - tranylcypromine sulfate tab 10 mg 2paroxetine hcl tab 10 mg# 2 PA, QL (45 tablets/30 days)paroxetine hcl tab 20 mg# 2 PA, QL (30 tablets/30 days)paroxetine hcl tab 30 mg# 2 PA, QL (60 tablets/30 days)paroxetine hcl tab 40 mg# 2 PA, QL (45 tablets/30 days)PAXIL - paroxetine hcl oral susp 10 mg/5ml# 2 PA, QL (900 mls/30 days)PAXIL - paroxetine hcl tab 10 mg# 2 PA, QL (45 tablets/30 days)PAXIL - paroxetine hcl tab 20 mg# 2 PA, QL (30 tablets/30 days)PAXIL - paroxetine hcl tab 30 mg# 2 PA, QL (60 tablets/30 days)PAXIL - paroxetine hcl tab 40 mg# 2 PA, QL (45 tablets/30 days)phenelzine sulfate tab 15 mg 2protriptyline hcl tab 5 mg# 2 PAprotriptyline hcl tab 10 mg# 2 PA

2019




PROZAC - fluoxetine hcl cap 10 mg 2 QL (90 capsules/30 days)PROZAC - fluoxetine hcl cap 20 mg 2 QL (120 capsules/30 days)PROZAC - fluoxetine hcl cap 40 mg 2 QL (60 capsules/30 days)REMERON - mirtazapine tab 15 mg 2 QL (45 tablets/30 days)REMERON - mirtazapine tab 30 mg 2 QL (30 tablets/30 days)REMERON SOLTAB - mirtazapine orally disintegrating tab

15 mg2 QL (30 tablets/30 days)

REMERON SOLTAB - mirtazapine orally disintegrating tab30 mg


REMERON SOLTAB - mirtazapine orally disintegrating tab45 mg


sertraline hcl oral concentrate for solution 20 mg/ml 1 QL (300 mls/30 days)sertraline hcl tab 25 mg 1 QL (45 tablets/30 days)sertraline hcl tab 50 mg 1 QL (45 tablets/30 days)sertraline hcl tab 100 mg 1 QL (60 tablets/30 days)SPRAVATO 56MG DOSE - esketamine hcl nasal soln

28 mg/device x 2 (56 mg dose pack)2 PA, QL (16 bottles/28 days)

SPRAVATO 84MG DOSE - esketamine hcl nasal soln28 mg/device x 3 (84 mg dose pack)

2 PA, QL (24 bottles/28 days)

tranylcypromine sulfate tab 10 mg 2trazodone hcl tab 50 mg 1trazodone hcl tab 100 mg 1trazodone hcl tab 150 mg 1trazodone hcl tab 300 mg 1trimipramine maleate cap 25 mg# 2 PAtrimipramine maleate cap 50 mg# 2 PAtrimipramine maleate cap 100 mg# 2 PATRINTELLIX - vortioxetine hbr tab 5 mg 2 QL (30 tablets/30 days)TRINTELLIX - vortioxetine hbr tab 10 mg 2 QL (30 tablets/30 days)TRINTELLIX - vortioxetine hbr tab 20 mg 2 QL (30 tablets/30 days)venlafaxine hcl cap er 24hr 37.5 mg 1 QL (60 capsules/30 days)venlafaxine hcl cap er 24hr 75 mg 1 QL (90 capsules/30 days)venlafaxine hcl cap er 24hr 150 mg 1 QL (30 capsules/30 days)venlafaxine hcl tab er 24hr 37.5 mg 2 QL (60 tablets/30 days)venlafaxine hcl tab er 24hr 75 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab er 24hr 150 mg 2 QL (30 tablets/30 days)venlafaxine hcl tab 25 mg 1 QL (90 tablets/30 days)venlafaxine hcl tab 37.5 mg 1 QL (90 tablets/30 days)venlafaxine hcl tab 50 mg 1 QL (90 tablets/30 days)

2019


23



venlafaxine hcl tab 75 mg 1 QL (90 tablets/30 days)venlafaxine hcl tab 100 mg 1 QL (90 tablets/30 days)VIIBRYD - vilazodone hcl tab 10 mg 2 QL (30 tablets/30 days)VIIBRYD - vilazodone hcl tab 20 mg 2 QL (30 tablets/30 days)VIIBRYD - vilazodone hcl tab 40 mg 2 QL (30 tablets/30 days)VIIBRYD STARTER PACK - vilazodone hcl tab starter kit 10

(7) & 20 (23) mg2 QL (1 kit/30 days)

ZOLOFT - sertraline hcl tab 25 mg 2 QL (45 tablets/30 days)ZOLOFT - sertraline hcl tab 50 mg 2 QL (45 tablets/30 days)ZOLOFT - sertraline hcl tab 100 mg 2 QL (60 tablets/30 days)Antiemeticsaprepitant capsule therapy pack 80 & 125 mg 2 BDaprepitant capsule 40 mg 2 BDaprepitant capsule 80 mg 2 BDaprepitant capsule 125 mg 2 BDCHLORPROMAZINE HCL - chlorpromazine hcl inj 25 mg/

ml2 PA

CHLORPROMAZINE HCL - chlorpromazine hcl inj50 mg/2ml

2 PA

chlorpromazine hcl tab 10 mg 2 PAchlorpromazine hcl tab 25 mg 2 PAchlorpromazine hcl tab 50 mg 2 PAchlorpromazine hcl tab 100 mg 2 PAchlorpromazine hcl tab 200 mg 2 PAdimenhydrinate tab 50 mg 3 MCdronabinol cap 2.5 mg 2 BDdronabinol cap 5 mg 2 BDdronabinol cap 10 mg 2 BDEMEND - fosaprepitant dimeglumine for iv infusion 150 mg 2fosaprepitant dimeglumine for iv infusion 150 mg 2fructose-dextrose-phosphoric acid oral soln 3 MCgranisetron hcl inj 1 mg/ml 2granisetron hcl inj 4 mg/4ml (1 mg/ml) 2meclizine hcl chew tab 25 mg 3 MCmeclizine hcl tab 12.5 mg# 2meclizine hcl tab 12.5 mg# 3 MCmeclizine hcl tab 25 mg# 3 MCondansetron hcl inj 4 mg/2ml (2 mg/ml) 2ondansetron hcl inj 40 mg/20ml (2 mg/ml) 2

2019




ondansetron hcl tab 4 mg 2 BDondansetron hcl tab 8 mg 2 BDondansetron hcl tab 24 mg 2 BDondansetron orally disintegrating tab 4 mg 1 BDondansetron orally disintegrating tab 8 mg 1 BDpalonosetron hcl iv soln pref syr 0.25 mg/5ml 2palonosetron hcl iv soln 0.25 mg/5ml 2PALONOSETRON HYDROCHLORIDE - palonosetron hcl

iv soln 0.25 mg/2ml2

perphenazine tab 2 mg 1 PAperphenazine tab 4 mg 1 PAperphenazine tab 8 mg 1 PAperphenazine tab 16 mg 1 PAprochlorperazine edisylate inj 10 mg/2ml 2prochlorperazine edisylate inj 50 mg/10ml 2prochlorperazine maleate tab 5 mg 1prochlorperazine maleate tab 10 mg 1prochlorperazine suppos 25 mg 2promethazine hcl syrup 6.25 mg/5ml# 2 PApromethazine hcl tab 25 mg# 2 PAAntifungalsAMBISOME - amphotericin b liposome iv for susp 50 mg 2 BDAMPHOTERICIN B - amphotericin b for iv soln 50 mg 2 BDCANCIDAS - caspofungin acetate for iv soln 70 mg 2caspofungin acetate for iv soln 50 mg 2caspofungin acetate for iv soln 70 mg 2ciclopirox olamine cream 0.77% 2ciclopirox solution 8% 1clotrimazole cream 1% 3 MCclotrimazole troche 10 mg 1clotrimazole vaginal cream 1% 3 MCclotrimazole vaginal cream 2% 3 MCCRESEMBA - isavuconazonium sulfate cap 186 mg 2 PACRESEMBA - isavuconazonium sulfate for iv soln 372 mg 2 PADIFLUCAN - fluconazole tab 50 mg 2DIFLUCAN - fluconazole tab 100 mg 2DIFLUCAN - fluconazole tab 150 mg 2DIFLUCAN - fluconazole tab 200 mg 2

2019


25



DIFLUCAN - fluconazole for susp 10 mg/ml 2DIFLUCAN - fluconazole for susp 40 mg/ml 2fluconazole for susp 10 mg/ml 2fluconazole for susp 40 mg/ml 2fluconazole in dextrose inj 200 mg/100ml 2fluconazole in dextrose inj 400 mg/200ml 2fluconazole in nacl 0.9% inj 200 mg/100ml 2fluconazole in nacl 0.9% inj 400 mg/200ml 2fluconazole tab 50 mg 1fluconazole tab 100 mg 1fluconazole tab 150 mg 1fluconazole tab 200 mg 1flucytosine cap 250 mg 2flucytosine cap 500 mg 2griseofulvin microsize susp 125 mg/5ml 2griseofulvin ultramicrosize tab 125 mg 2griseofulvin ultramicrosize tab 250 mg 2itraconazole cap 100 mg 2ketoconazole cream 2% 1ketoconazole shampoo 2% 1ketoconazole tab 200 mg 2LAMISIL AT - terbinafine hcl cream 1% 3 MCLAMISIL AT JOCK ITCH - terbinafine hcl cream 1% 3 MCLOPROX - ciclopirox olamine cream 0.77% 2miconazole nitrate vaginal app 200 mg & 2% cream 9 gm

kit3 MC

miconazole nitrate vaginal cream 2% 3 MCmiconazole nitrate vaginal cream 4% (200 mg/5gm) 3 MCmiconazole nitrate vaginal suppos 100 mg 3 MCmiconazole nitrate vaginal supp 200 mg & 2% cream 9 gm

kit3 MC

miconazole nitrate vaginal supp 1200 mg & 2% cream kit 3 MCMYCAMINE - micafungin sodium for iv soln 50 mg 2MYCAMINE - micafungin sodium for iv soln 100 mg 2naftifine hcl cream 2% 2naftifine hcl gel 1% 2NAFTIN - naftifine hcl cream 2% 2NAFTIN - naftifine hcl gel 1% 2

2019




NAFTIN - naftifine hcl gel 2% 2NIZORAL - ketoconazole shampoo 2% 2NOXAFIL - posaconazole tab delayed release 100 mg 2 PANOXAFIL - posaconazole susp 40 mg/ml 2 PANOXAFIL - posaconazole iv soln 300 mg/16.7ml (18 mg/ml) 2 PAnystatin cream 100000 unit/gm 1nystatin oint 100000 unit/gm 1nystatin susp 100000 unit/ml 1nystatin tab 500000 unit 2nystatin topical powder 100000 unit/gm 1posaconazole tab delayed release 100 mg 2 PAterbinafine hcl cream 1% 3 MCterbinafine hcl tab 250 mg 1terconazole vaginal cream 0.8% 2terconazole vaginal cream 0.4% 2tioconazole vaginal oint 6.5% 3 MCVFEND IV - voriconazole for inj 200 mg 2 PAvoriconazole for inj 200 mg 2 PAvoriconazole for susp 40 mg/ml 2 PAvoriconazole tab 50 mg 2 PAvoriconazole tab 200 mg 2 PAAntigout Agentsallopurinol tab 100 mg 1allopurinol tab 300 mg 1colchicine w/ probenecid tab 0.5-500 mg 1COLCRYS - colchicine tab 0.6 mg 1febuxostat tab 40 mg 2 STfebuxostat tab 80 mg 2 STprobenecid tab 500 mg 1ULORIC - febuxostat tab 40 mg 1 STULORIC - febuxostat tab 80 mg 1 STZYLOPRIM - allopurinol tab 100 mg 2ZYLOPRIM - allopurinol tab 300 mg 2Antimigraine AgentsAIMOVIG - erenumab-aooe subcutaneous soln auto-

injector 70 mg/ml1 PA, QL (2 pens/30 days)

AIMOVIG - erenumab-aooe subcutaneous soln auto-injector 140 mg/ml

1 PA, QL (1 pen/30 days)

AMERGE - naratriptan hcl tab 1 mg 2 QL (18 tablets/30 days)

2019


27



AMERGE - naratriptan hcl tab 2.5 mg 2 QL (18 tablets/30 days)EMGALITY - galcanezumab-gnlm subcutaneous soln auto-

injector 120 mg/ml1 PA, QL (2 pens/30 days)

EMGALITY - galcanezumab-gnlm subcutaneous solnprefilled syr 100 mg/ml

1 PA, QL (3 syringes/30 days)

EMGALITY - galcanezumab-gnlm subcutaneous solnprefilled syr 120 mg/ml


IMITREX - sumatriptan succinate inj 6 mg/0.5ml 2IMITREX - sumatriptan nasal spray 5 mg/act 2 QL (12 units (2

packages)/30 days)IMITREX - sumatriptan nasal spray 20 mg/act 2 QL (12 units (2

packages)/30 days)IMITREX - sumatriptan succinate tab 25 mg 2 QL (18 tablets/30 days)IMITREX - sumatriptan succinate tab 50 mg 2 QL (18 tablets/30 days)IMITREX - sumatriptan succinate tab 100 mg 2 QL (18 tablets/30 days)IMITREX STATDOSE REFILL - sumatriptan succinate

solution cartridge 4 mg/0.5ml2

IMITREX STATDOSE REFILL - sumatriptan succinatesolution cartridge 6 mg/0.5ml

2

IMITREX STATDOSE SYSTEM - sumatriptan succinatesolution auto-injector 4 mg/0.5ml

2

IMITREX STATDOSE SYSTEM - sumatriptan succinatesolution auto-injector 6 mg/0.5ml

2

MAXALT - rizatriptan benzoate tab 10 mg 2 QL (18 tablets/30 days)MAXALT-MLT - rizatriptan benzoate oral disintegrating tab

10 mg2 QL (18 tablets/30 days)

MIGERGOT - ergotamine w/ caffeine suppos 2-100 mg 2MIGRANAL - dihydroergotamine mesylate nasal spray

4 mg/ml1 QL (8 mls/28 days)

naratriptan hcl tab 1 mg 1 QL (18 tablets/30 days)naratriptan hcl tab 2.5 mg 1 QL (18 tablets/30 days)rizatriptan benzoate oral disintegrating tab 5 mg 1 QL (18 tablets/30 days)rizatriptan benzoate oral disintegrating tab 10 mg 1 QL (18 tablets/30 days)rizatriptan benzoate tab 5 mg 1 QL (18 tablets/30 days)rizatriptan benzoate tab 10 mg 1 QL (18 tablets/30 days)sumatriptan nasal spray 5 mg/act 2 QL (12 units (2

packages)/30 days)sumatriptan nasal spray 20 mg/act 2 QL (12 units (2

packages)/30 days)SUMATRIPTAN SUCCINATE - sumatriptan succinate

solution prefilled syringe 6 mg/0.5ml2

2019




sumatriptan succinate inj 6 mg/0.5ml 2sumatriptan succinate solution auto-injector 4 mg/0.5ml 2sumatriptan succinate solution auto-injector 6 mg/0.5ml 2sumatriptan succinate solution cartridge 4 mg/0.5ml 2sumatriptan succinate solution cartridge 6 mg/0.5ml 2sumatriptan succinate tab 25 mg 1 QL (18 tablets/30 days)sumatriptan succinate tab 50 mg 1 QL (18 tablets/30 days)sumatriptan succinate tab 100 mg 1 QL (18 tablets/30 days)Antimyasthenic AgentsGUANIDINE HCL - guanidine hcl tab 125 mg 2MESTINON - pyridostigmine bromide oral soln 60 mg/5ml 2pyridostigmine bromide oral soln 60 mg/5ml 2pyridostigmine bromide tab 60 mg 1AntimycobacterialsCAPASTAT SULFATE - capreomycin sulfate for inj 1 gm 2dapsone tab 25 mg 2dapsone tab 100 mg 2ethambutol hcl tab 100 mg 2ethambutol hcl tab 400 mg 2ISONIAZID - isoniazid inj 100 mg/ml 2isoniazid tab 100 mg 1isoniazid tab 300 mg 1MYAMBUTOL - ethambutol hcl tab 400 mg 2PASER - aminosalicylic acid er granules packet 4 gm 2PRIFTIN - rifapentine tab 150 mg 2pyrazinamide tab 500 mg 2rifabutin cap 150 mg 2RIFADIN - rifampin cap 150 mg 2rifampin cap 150 mg 2rifampin cap 300 mg 2rifampin for inj 600 mg 2SIRTURO - bedaquiline fumarate tab 100 mg 2TRECATOR - ethionamide tab 250 mg 2Antineoplasticsabiraterone acetate tab 250 mg 2 PA, QL (120 tablets/30 days)ABRAXANE - paclitaxel protein-bound particles for iv susp

100 mg2 PA

AFINITOR - everolimus tab 2.5 mg 2 PA, QL (30 tablets/30 days)

2019


29



AFINITOR - everolimus tab 5 mg 2 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 7.5 mg 2 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 10 mg 2 PA, QL (30 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 2 mg 2 PA, QL (60 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 3 mg 2 PA, QL (90 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 5 mg 2 PA, QL (60 tablets/30 days)ALECENSA - alectinib hcl cap 150 mg* 2 PA, QL (240

capsules/30 days)ALIMTA - pemetrexed disodium for iv soln 100 mg 2 PAALIMTA - pemetrexed disodium for iv soln 500 mg 2 PAALIQOPA - copanlisib hcl for iv soln 60 mg 2 PAALUNBRIG - brigatinib tab initiation therapy pack 90 mg &

180 mg2 PA, QL (30 tablets/30 days)

ALUNBRIG - brigatinib tab 30 mg 2 PA, QL (120 tablets/30 days)ALUNBRIG - brigatinib tab 90 mg 2 PA, QL (30 tablets/30 days)ALUNBRIG - brigatinib tab 180 mg 2 PA, QL (30 tablets/30 days)anastrozole tab 1 mg 1ARRANON - nelarabine iv soln 5 mg/ml 2arsenic trioxide iv soln 10 mg/10ml (1 mg/ml) 2arsenic trioxide iv soln 12 mg/6ml (2 mg/ml) 2ARZERRA - ofatumumab conc for iv infusion 100 mg/5ml* 2 PAARZERRA - ofatumumab conc for iv infusion

1000 mg/50ml*2 PA

AVASTIN - bevacizumab iv soln 100 mg/4ml (for infusion)* 2 PAAVASTIN - bevacizumab iv soln 400 mg/16ml (for infusion)* 2 PABALVERSA - erdafitinib tab 3 mg 2 PA, QL (90 tablets/30 days)BALVERSA - erdafitinib tab 4 mg 2 PA, QL (60 tablets/30 days)BALVERSA - erdafitinib tab 5 mg 2 PA, QL (30 tablets/30 days)BAVENCIO - avelumab soln for iv infusion 200 mg/10ml

(20 mg/ml)2 PA

BELEODAQ - belinostat for iv inj 500 mg* 2 PABENDEKA - bendamustine hcl iv soln 100 mg/4ml (25 mg/

ml)2

BESPONSA - inotuzumab ozogamicin for iv soln 0.9 mg 2 PAbexarotene cap 75 mg 2 PAbicalutamide tab 50 mg 2BICNU - carmustine for inj 100 mg 2bleomycin sulfate for inj 15 unit 2 BDbleomycin sulfate for inj 30 unit 2 BD

2019




BLINCYTO - blinatumomab for iv infusion 35 mcg* 2 BD, PABOSULIF - bosutinib tab 100 mg 2 PA, QL (180 tablets/30 days)BOSULIF - bosutinib tab 400 mg 2 PA, QL (30 tablets/30 days)BOSULIF - bosutinib tab 500 mg 2 PA, QL (30 tablets/30 days)BRAFTOVI - encorafenib cap 75 mg 2 PA, QL (180

capsules/30 days)busulfan inj 6 mg/ml 2CABOMETYX - cabozantinib s-malate tab 20 mg* 2 PA, QL (30 tablets/30 days)CABOMETYX - cabozantinib s-malate tab 40 mg* 2 PA, QL (30 tablets/30 days)CABOMETYX - cabozantinib s-malate tab 60 mg* 2 PA, QL (30 tablets/30 days)CALQUENCE - acalabrutinib cap 100 mg 2 PA, QL (60 capsules/30 days)CAMPTOSAR - irinotecan hcl inj 100 mg/5ml (20 mg/ml) 2CAPRELSA - vandetanib tab 100 mg* 2 PA, QL (60 tablets/30 days)CAPRELSA - vandetanib tab 300 mg* 2 PA, QL (30 tablets/30 days)carboplatin iv soln 50 mg/5ml 1carboplatin iv soln 150 mg/15ml 1carboplatin iv soln 450 mg/45ml 1carboplatin iv soln 600 mg/60ml 1carmustine for inj 100 mg 2CISPLATIN - cisplatin inj 200 mg/200ml (1 mg/ml) 1cisplatin inj 50 mg/50ml (1 mg/ml) 1cisplatin inj 100 mg/100ml (1 mg/ml) 1cladribine iv soln 10 mg/10ml (1 mg/ml) 2 BDclofarabine iv soln 1 mg/ml 2COMETRIQ - cabozantinib s-malate cap 3 x 20 mg (60 mg

dose) kit*2 PA, QL (84 capsules/28 days)

COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 1 x20 mg (100 dose) kit*

2 PA, QL (56 capsules/28 days)

COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 3 x20 mg (140 dose) kit*

2 PA, QL (112capsules/28 days)

COPIKTRA - duvelisib cap 15 mg 2 PA, QL (56 capsules/28 days)COPIKTRA - duvelisib cap 25 mg 2 PA, QL (56 capsules/28 days)COSMEGEN - dactinomycin for inj 0.5 mg 2COTELLIC - cobimetinib fumarate tab 20 mg* 2 PA, QL (63 tablets/28 days)cyclophosphamide cap 25 mg 2 BDcyclophosphamide cap 50 mg 2 BDcyclophosphamide for inj 500 mg 2cyclophosphamide for inj 1 gm 2cyclophosphamide for inj 2 gm 2

2019


31



CYRAMZA - ramucirumab iv soln 100 mg/10ml (forinfusion)*

2 PA

CYRAMZA - ramucirumab iv soln 500 mg/50ml (forinfusion)*

2 PA

CYTARABINE - cytarabine inj 20 mg/ml 1 BDcytarabine inj pf 20 mg/ml 1 BDcytarabine inj pf 100 mg/ml 1 BDDACARBAZINE - dacarbazine for inj 100 mg 2dacarbazine for inj 200 mg 1dactinomycin for inj 0.5 mg 2DARZALEX - daratumumab iv soln 100 mg/5ml* 2 PADARZALEX - daratumumab iv soln 400 mg/20ml* 2 PAdaunorubicin hcl iv soln 20 mg/4ml 1DAUNORUBICIN HYDROCHLORIDE - daunorubicin hcl iv

soln 50 mg/10ml1

DAURISMO - glasdegib maleate tab 25 mg 2 PA, QL (60 tablets/30 days)DAURISMO - glasdegib maleate tab 100 mg 2 PA, QL (30 tablets/30 days)decitabine for inj 50 mg 2dexrazoxane hcl for inj 250 mg 2dexrazoxane hcl for inj 500 mg 2DOCETAXEL - docetaxel for inj conc 200 mg/10ml (20 mg/

ml)2

docetaxel for inj conc 20 mg/ml 2docetaxel for inj conc 80 mg/4ml (20 mg/ml) 2docetaxel for inj conc 160 mg/8ml (20 mg/ml) 2docetaxel soln for iv infusion 20 mg/2ml 2docetaxel soln for iv infusion 80 mg/8ml 2docetaxel soln for iv infusion 160 mg/16ml 2doxorubicin hcl for inj 10 mg 2 BDdoxorubicin hcl for inj 50 mg 2 BDdoxorubicin hcl inj 2 mg/ml 1 BDdoxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml 2 BD, PAELITEK - rasburicase for iv soln 1.5 mg 2ELITEK - rasburicase for iv soln 7.5 mg 2ELLENCE - epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) 2EMCYT - estramustine phosphate sodium cap 140 mg 2EMPLICITI - elotuzumab for iv soln 300 mg 2 PAEMPLICITI - elotuzumab for iv soln 400 mg 2 PAepirubicin hcl iv soln 50 mg/25ml (2 mg/ml) 2

2019




epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) 2ERBITUX - cetuximab iv soln 100 mg/50ml (2 mg/ml) 2 PAERBITUX - cetuximab iv soln 200 mg/100ml (2 mg/ml) 2 PAERIVEDGE - vismodegib cap 150 mg* 2 PA, QL (30 capsules/30 days)ERLEADA - apalutamide tab 60 mg 2 PA, QL (120 tablets/30 days)erlotinib hcl tab 25 mg 2 PA, QL (60 tablets/30 days)erlotinib hcl tab 100 mg 2 PA, QL (30 tablets/30 days)erlotinib hcl tab 150 mg 2 PA, QL (30 tablets/30 days)ERWINAZE - asparaginase erwinia chrysanthemi for inj

10000 unit2

ETHYOL - amifostine for inj 500 mg 2ETOPOPHOS - etoposide phosphate iv for inj 100 mg 2etoposide inj 100 mg/5ml (20 mg/ml) 2etoposide inj 500 mg/25ml (20 mg/ml) 2etoposide inj 1 gm/50ml (20 mg/ml) 2EVOMELA - melphalan hcl for inj 50 mg* 2exemestane tab 25 mg 2FARESTON - toremifene citrate tab 60 mg 2FARYDAK - panobinostat lactate cap 10 mg* 2 PA, QL (6 capsules/21 days)FARYDAK - panobinostat lactate cap 15 mg* 2 PA, QL (6 capsules/21 days)FARYDAK - panobinostat lactate cap 20 mg* 2 PA, QL (6 capsules/21 days)FASLODEX - fulvestrant inj 250 mg/5ml 2fludarabine phosphate for inj 50 mg 1fludarabine phosphate inj 25 mg/ml 1fluorouracil iv soln 500 mg/10ml (50 mg/ml) 1 BDfluorouracil iv soln 1 gm/20ml (50 mg/ml) 1 BDfluorouracil iv soln 2.5 gm/50ml (50 mg/ml) 1 BDfluorouracil iv soln 5 gm/100ml (50 mg/ml) 1 BDflutamide cap 125 mg 2FOLOTYN - pralatrexate iv inj 20 mg/ml 2 PAFOLOTYN - pralatrexate iv inj 40 mg/2ml 2 PAfulvestrant inj 250 mg/5ml 2GAZYVA - obinutuzumab soln for iv infusion 1000 mg/40ml

(25 mg/ml)2 PA

gemcitabine hcl for inj 200 mg 2gemcitabine hcl for inj 1 gm 2gemcitabine hcl for inj 2 gm 2gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml) 2

2019


33



gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml) 2gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml) 2GILOTRIF - afatinib dimaleate tab 20 mg 2 PA, QL (30 tablets/30 days)GILOTRIF - afatinib dimaleate tab 30 mg 2 PA, QL (30 tablets/30 days)GILOTRIF - afatinib dimaleate tab 40 mg 2 PA, QL (30 tablets/30 days)GLEOSTINE - lomustine cap 10 mg 2GLEOSTINE - lomustine cap 40 mg 2GLEOSTINE - lomustine cap 100 mg 2HALAVEN - eribulin mesylate inj 1 mg/2ml (0.5 mg/ml) 2 PAHERCEPTIN - trastuzumab for iv soln 150 mg* 2 PAHERCEPTIN HYLECTA - trastuzumab-hyaluronidase-oysk

inj 600-10000 mg-unit/5ml*2 PA

hydroxyurea cap 500 mg 2IBRANCE - palbociclib cap 75 mg* 2 PA, QL (21 capsules/28 days)IBRANCE - palbociclib cap 100 mg* 2 PA, QL (21 capsules/28 days)IBRANCE - palbociclib cap 125 mg* 2 PA, QL (21 capsules/28 days)ICLUSIG - ponatinib hcl tab 15 mg 2 PA, QL (60 tablets/30 days)ICLUSIG - ponatinib hcl tab 45 mg 2 PA, QL (30 tablets/30 days)idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 2idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 2idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) 2IDHIFA - enasidenib mesylate tab 50 mg 2 PA, QL (30 tablets/30 days)IDHIFA - enasidenib mesylate tab 100 mg 2 PA, QL (30 tablets/30 days)IFEX - ifosfamide for inj 1 gm 2IFOSFAMIDE - ifosfamide for inj 3 gm 2ifosfamide for inj 1 gm 2imatinib mesylate tab 100 mg 2 PA, QL (90 tablets/30 days)imatinib mesylate tab 400 mg 2 PA, QL (60 tablets/30 days)IMBRUVICA - ibrutinib cap 70 mg 2 PA, QL (30 capsules/30 days)IMBRUVICA - ibrutinib cap 140 mg 2 PA, QL (120

capsules/30 days)IMBRUVICA - ibrutinib tab 140 mg 2 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 280 mg 2 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 420 mg 2 PA, QL (30 tablets/30 days)IMBRUVICA - ibrutinib tab 560 mg 2 PA, QL (30 tablets/30 days)IMFINZI - durvalumab soln for iv infusion 120 mg/2.4ml

(50 mg/ml)2 PA

IMFINZI - durvalumab soln for iv infusion 500 mg/10ml(50 mg/ml)

2 PA

2019




IMLYGIC - talimogene laherparepvec intralesional inj1000000 unit/ml*

2

IMLYGIC - talimogene laherparepvec intralesional inj100000000 unit/ml*

2

INLYTA - axitinib tab 1 mg* 2 PA, QL (180 tablets/30 days)INLYTA - axitinib tab 5 mg* 2 PA, QL (120 tablets/30 days)INREBIC - fedratinib hcl cap 100 mg 2 PA, QL (120

capsules/30 days)IRESSA - gefitinib tab 250 mg* 2 PA, QL (30 tablets/30 days)IRINOTECAN - irinotecan hcl inj 500 mg/25ml (20 mg/ml) 2irinotecan hcl inj 40 mg/2ml (20 mg/ml) 2irinotecan hcl inj 100 mg/5ml (20 mg/ml) 2ISTODAX (OVERFILL) - romidepsin for iv inj 10 mg 2 PAIXEMPRA KIT - ixabepilone for iv infusion 15 mg 2IXEMPRA KIT - ixabepilone for iv infusion 45 mg 2JAKAFI - ruxolitinib phosphate tab 5 mg* 2 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 10 mg* 2 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 15 mg* 2 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 20 mg* 2 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 25 mg* 2 PA, QL (60 tablets/30 days)JEVTANA - cabazitaxel inj 60 mg/1.5ml (for iv infusion) 2 PAKADCYLA - ado-trastuzumab emtansine for iv soln 100 mg 2 PAKADCYLA - ado-trastuzumab emtansine for iv soln 160 mg 2 PAKANJINTI - trastuzumab-anns for iv soln 420 mg 2 PAKEYTRUDA - pembrolizumab iv soln 100 mg/4ml (25 mg/

ml)*2 PA

KISQALI - ribociclib succinate tab pack 200 mg daily dose 2 PA, QL (63 tablets/28 days)KISQALI - ribociclib succinate tab pack 400 mg daily dose

(200 mg tab)2 PA, QL (63 tablets/28 days)

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

2 PA, QL (63 tablets/28 days)

KISQALI FEMARA 200 DOSE - ribociclib 200 mg dose(200 mg tab) & letrozole 2.5 mg tbpk






KYPROLIS - carfilzomib for inj 10 mg 2 PAKYPROLIS - carfilzomib for inj 30 mg 2 PAKYPROLIS - carfilzomib for inj 60 mg 2 PA

2019


35



LARTRUVO - olaratumab soln for iv infusion 190 mg/19ml(10 mg/ml)

2 PA

LARTRUVO - olaratumab soln for iv infusion 500 mg/50ml(10 mg/ml)

2 PA

LENVIMA 10 MG DAILY DOSE - lenvatinib cap therapypack 10 mg*


LENVIMA 12MG DAILY DOSE - lenvatinib cap therapypack 4 (3) mg*


LENVIMA 14 MG DAILY DOSE - lenvatinib cap therapypack 10 & 4 mg*


LENVIMA 18 MG DAILY DOSE - lenvatinib cap therapypack 10 & 4 (2) mg*


LENVIMA 20 MG DAILY DOSE - lenvatinib cap therapypack 10 (2) mg*


LENVIMA 24 MG DAILY DOSE - lenvatinib cap therapypack 10 (2) & 4 mg*


LENVIMA 4 MG DAILY DOSE - lenvatinib cap therapy pack4 mg*


LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack4 (2) mg*


letrozole tab 2.5 mg 1LEUCOVORIN CALCIUM - leucovorin calcium inj

100 mg/10ml (10 mg/ml)2

LEUCOVORIN CALCIUM - leucovorin calcium tab 10 mg 2LEUCOVORIN CALCIUM - leucovorin calcium tab 15 mg 2leucovorin calcium for inj 50 mg 2leucovorin calcium for inj 100 mg 2leucovorin calcium for inj 200 mg 2leucovorin calcium for inj 350 mg 2leucovorin calcium for inj 500 mg 2leucovorin calcium inj 500 mg/50ml (10 mg/ml) 2leucovorin calcium tab 5 mg 1leucovorin calcium tab 25 mg 2LEUKERAN - chlorambucil tab 2 mg 2LIBTAYO - cemiplimab-rwlc iv soln 350 mg/7ml (50 mg/ml) 2 PALONSURF - trifluridine-tipiracil tab 15-6.14 mg 2 PA, QL (100 tablets/28 days)LONSURF - trifluridine-tipiracil tab 20-8.19 mg 2 PA, QL (80 tablets/28 days)LORBRENA - lorlatinib tab 25 mg 2 PA, QL (90 tablets/30 days)LORBRENA - lorlatinib tab 100 mg 2 PA, QL (30 tablets/30 days)LUMOXITI - moxetumomab pasudotox-tdfk for iv soln 1 mg 2 PALYNPARZA - olaparib tab 100 mg* 2 PA, QL (120 tablets/30 days)

2019




LYNPARZA - olaparib tab 150 mg* 2 PA, QL (120 tablets/30 days)MARQIBO - vincristine sulfate liposome iv susp 5 mg/31ml

(0.16 mg/ml)2

MATULANE - procarbazine hcl cap 50 mg* 2 PAMEKINIST - trametinib dimethyl sulfoxide tab 0.5 mg* 2 PA, QL (90 tablets/30 days)MEKINIST - trametinib dimethyl sulfoxide tab 2 mg* 2 PA, QL (30 tablets/30 days)MEKTOVI - binimetinib tab 15 mg 2 PA, QL (180 tablets/30 days)melphalan hcl for inj 50 mg 2mercaptopurine tab 50 mg 2mesna inj 100 mg/ml 2MESNEX - mesna tab 400 mg 2MESNEX - mesna inj 100 mg/ml 2mitomycin for iv soln 5 mg 2mitomycin for iv soln 20 mg 2mitomycin for iv soln 40 mg 2mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml) 1mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) 1mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml) 1MVASI - bevacizumab-awwb iv soln 100 mg/4ml (for

infusion)2 PA

MVASI - bevacizumab-awwb iv soln 400 mg/16ml (forinfusion)

2 PA

MYLOTARG - gemtuzumab ozogamicin for iv soln 4.5 mg 2 PANERLYNX - neratinib maleate tab 40 mg 2 PA, QL (180 tablets/30 days)NEXAVAR - sorafenib tosylate tab 200 mg* 2 PA, QL (120 tablets/30 days)nilutamide tab 150 mg 2NINLARO - ixazomib citrate cap 2.3 mg 2 PA, QL (3 capsules/28 days)NINLARO - ixazomib citrate cap 3 mg 2 PA, QL (3 capsules/28 days)NINLARO - ixazomib citrate cap 4 mg 2 PA, QL (3 capsules/28 days)NIPENT - pentostatin for inj 10 mg 2NUBEQA - darolutamide tab 300 mg 2 PA, QL (120 tablets/30 days)ODOMZO - sonidegib phosphate cap 200 mg* 2 PA, QL (30 capsules/30 days)ONCASPAR - pegaspargase inj 750 unit/ml 2ONIVYDE - irinotecan hcl liposome iv inj 43 mg/10ml

(4.3 mg/ml)2 PA

OPDIVO - nivolumab iv soln 40 mg/4ml* 2 PAOPDIVO - nivolumab iv soln 100 mg/10ml* 2 PAOPDIVO - nivolumab iv soln 240 mg/24ml* 2 PAoxaliplatin for iv inj 50 mg 2

2019


37



oxaliplatin for iv inj 100 mg 2oxaliplatin iv soln 50 mg/10ml 2oxaliplatin iv soln 100 mg/20ml 2paclitaxel iv conc 30 mg/5ml (6 mg/ml) 2paclitaxel iv conc 100 mg/16.7ml (6 mg/ml) 2paclitaxel iv conc 300 mg/50ml (6 mg/ml) 2PANRETIN - alitretinoin gel 0.1% 2PERJETA - pertuzumab soln for iv infusion 420 mg/14ml

(30 mg/ml)*2 PA

PIQRAY 200MG DAILY DOSE - alpelisib tab therapy pack200 mg daily dose


PIQRAY 250MG DAILY DOSE - alpelisib tab pack 250 mgdaily dose (200 mg & 50 mg tabs)


PIQRAY 300MG DAILY DOSE - alpelisib tab pack 300 mgdaily dose (2x150 mg tab)


POLIVY - polatuzumab vedotin-piiq for iv solution 140 mg 2 PAPOMALYST - pomalidomide cap 1 mg* 2 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 2 mg* 2 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 3 mg* 2 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 4 mg* 2 PA, QL (21 capsules/28 days)PORTRAZZA - necitumumab iv soln 800 mg/50ml (16 mg/

ml)*2 PA

POTELIGEO - mogamulizumab-kpkc iv soln 20 mg/5ml(4 mg/ml)

2 PA

PROLEUKIN - aldesleukin for iv soln 22000000 unit 2PURIXAN - mercaptopurine susp 2000 mg/100ml (20 mg/

ml)*2

REVLIMID - lenalidomide caps 2.5 mg* 2 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 5 mg* 2 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 10 mg* 2 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 15 mg* 2 PA, QL (21 capsules/28 days)REVLIMID - lenalidomide cap 20 mg* 2 PA, QL (21 capsules/28 days)REVLIMID - lenalidomide cap 25 mg* 2 PA, QL (21 capsules/28 days)RITUXAN - rituximab iv soln 100 mg/10ml* 2 PARITUXAN - rituximab iv soln 500 mg/50ml* 2 PARITUXAN HYCELA - rituximab-hyaluronidase human inj

1400-23400 mg-unit/11.7ml2 PA

RITUXAN HYCELA - rituximab-hyaluronidase human inj1600-26800 mg-unit/13.4ml

2 PA

2019




ROZLYTREK - entrectinib cap 100 mg 2 PA, QL (150capsules/30 days)

ROZLYTREK - entrectinib cap 200 mg 2 PA, QL (90 capsules/30 days)RUBRACA - rucaparib camsylate tab 200 mg 2 PA, QL (120 tablets/30 days)RUBRACA - rucaparib camsylate tab 250 mg 2 PA, QL (120 tablets/30 days)RUBRACA - rucaparib camsylate tab 300 mg 2 PA, QL (120 tablets/30 days)RYDAPT - midostaurin cap 25 mg 2 PA, QL (240

capsules/30 days)SOLTAMOX - tamoxifen citrate oral soln 10 mg/5ml 2SPRYCEL - dasatinib tab 20 mg 2 PA, QL (90 tablets/30 days)SPRYCEL - dasatinib tab 50 mg 2 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 70 mg 2 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 80 mg 2 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 100 mg 2 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 140 mg 2 PA, QL (30 tablets/30 days)STIVARGA - regorafenib tab 40 mg* 2 PA, QL (84 tablets/28 days)SUTENT - sunitinib malate cap 12.5 mg 2 PA, QL (90 capsules/30 days)SUTENT - sunitinib malate cap 25 mg 2 PA, QL (30 capsules/30 days)SUTENT - sunitinib malate cap 37.5 mg 2 PA, QL (30 capsules/30 days)SUTENT - sunitinib malate cap 50 mg 2 PA, QL (30 capsules/30 days)SYNRIBO - omacetaxine mepesuccinate for inj 3.5 mg 2 PATABLOID - thioguanine tab 40 mg 2TAFINLAR - dabrafenib mesylate cap 50 mg* 2 PA, QL (120

capsules/30 days)TAFINLAR - dabrafenib mesylate cap 75 mg* 2 PA, QL (120

capsules/30 days)TAGRISSO - osimertinib mesylate tab 40 mg* 2 PA, QL (30 tablets/30 days)TAGRISSO - osimertinib mesylate tab 80 mg* 2 PA, QL (30 tablets/30 days)TALZENNA - talazoparib tosylate cap 0.25 mg 2 PA, QL (90 capsules/30 days)TALZENNA - talazoparib tosylate cap 1 mg 2 PA, QL (30 capsules/30 days)tamoxifen citrate tab 10 mg 1tamoxifen citrate tab 20 mg 1TARCEVA - erlotinib hcl tab 25 mg 2 PA, QL (60 tablets/30 days)TARCEVA - erlotinib hcl tab 100 mg 2 PA, QL (30 tablets/30 days)TARCEVA - erlotinib hcl tab 150 mg 2 PA, QL (30 tablets/30 days)TARGRETIN - bexarotene gel 1% 2TASIGNA - nilotinib hcl cap 50 mg 2 PA, QL (120

capsules/30 days)

2019


39



TASIGNA - nilotinib hcl cap 150 mg 2 PA, QL (120capsules/30 days)

TASIGNA - nilotinib hcl cap 200 mg 2 PA, QL (120capsules/30 days)

TECENTRIQ - atezolizumab iv soln 840 mg/14ml* 2 PATECENTRIQ - atezolizumab iv soln 1200 mg/20ml* 2 PATEMODAR - temozolomide for iv soln 100 mg 2temsirolimus soln for iv infusion 25 mg/ml 2THALOMID - thalidomide cap 50 mg 2 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 100 mg 2 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 150 mg 2 PA, QL (60 capsules/30 days)THALOMID - thalidomide cap 200 mg 2 PA, QL (60 capsules/30 days)thiotepa for inj 15 mg 2TIBSOVO - ivosidenib tab 250 mg 2 PA, QL (60 tablets/30 days)topotecan hcl for inj 4 mg 2toremifene citrate tab 60 mg 2TREANDA - bendamustine hcl for iv soln 25 mg 2TREANDA - bendamustine hcl for iv soln 100 mg 2tretinoin cap 10 mg 2 PATRISENOX - arsenic trioxide iv soln 12 mg/6ml (2 mg/ml) 2TURALIO - pexidartinib hcl cap 200 mg 2 PA, QL (120

capsules/30 days)TYKERB - lapatinib ditosylate tab 250 mg* 2 PA, QL (180 tablets/30 days)UNITUXIN - dinutuximab iv soln 17.5 mg/5ml (3.5 mg/ml)* 2 PAVALCHLOR - mechlorethamine hcl gel 0.016%* 2VECTIBIX - panitumumab iv soln 100 mg/5ml 2 PAVECTIBIX - panitumumab iv soln 400 mg/20ml 2 PAVELCADE - bortezomib for inj 3.5 mg 2 PAVENCLEXTA - venetoclax tab 10 mg* 1 PA, QL (60 tablets/30 days)VENCLEXTA - venetoclax tab 50 mg* 2 PA, QL (30 tablets/30 days)VENCLEXTA - venetoclax tab 100 mg* 2 PA, QL (180 tablets/30 days)VENCLEXTA STARTING PACK - venetoclax tab therapy

starter pack 10 & 50 & 100 mg*2 PA, QL (1 pack (42

tablets)/28 days)VERZENIO - abemaciclib tab 50 mg 2 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 100 mg 2 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 150 mg 2 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 200 mg 2 PA, QL (60 tablets/30 days)VINBLASTINE SULFATE - vinblastine sulfate inj 1 mg/ml 2 BD

2019




vincristine sulfate iv soln 1 mg/ml 1 BDvinorelbine tartrate inj 10 mg/ml 2vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) 2VITRAKVI - larotrectinib sulfate oral soln 20 mg/ml 2 PA, QL (300 mls/30 days)VITRAKVI - larotrectinib sulfate cap 25 mg 2 PA, QL (180

capsules/30 days)VITRAKVI - larotrectinib sulfate cap 100 mg 2 PA, QL (60 capsules/30 days)VIZIMPRO - dacomitinib tab 15 mg 2 PA, QL (30 tablets/30 days)VIZIMPRO - dacomitinib tab 30 mg 2 PA, QL (30 tablets/30 days)VIZIMPRO - dacomitinib tab 45 mg 2 PA, QL (30 tablets/30 days)VOTRIENT - pazopanib hcl tab 200 mg* 2 PA, QL (120 tablets/30 days)VYXEOS - daunorubicin-cytarabine liposome for iv inj

44-100 mg2 PA

XALKORI - crizotinib cap 200 mg* 2 PA, QL (60 capsules/30 days)XALKORI - crizotinib cap 250 mg* 2 PA, QL (60 capsules/30 days)XOSPATA - gilteritinib fumarate tablet 40 mg 2 PA, QL (90 tablets/30 days)XPOVIO 100 MG ONCE WEEKLY - selinexor tab therapy

pack 20 mg (100 mg once weekly)2 PA, QL (1 box/28 days)

XPOVIO 60 MG ONCE WEEKLY - selinexor tab therapypack 20 mg (60 mg once weekly)

2 PA, QL (1 box/28 days)

XPOVIO 80 MG ONCE WEEKLY - selinexor tab therapypack 20 mg (80 mg once weekly)


XPOVIO 80 MG TWICE WEEKLY - selinexor tab therapypack 20 mg (80 mg twice weekly)


XTANDI - enzalutamide cap 40 mg* 2 PA, QL (120capsules/30 days)

YERVOY - ipilimumab soln for iv infusion 50 mg/10ml(5 mg/ml)*

2 PA

YERVOY - ipilimumab soln for iv infusion 200 mg/40ml(5 mg/ml)*

2 PA

YONDELIS - trabectedin for inj 1 mg 2 PAYONSA - abiraterone acetate tab 125 mg* 2 PA, QL (120 tablets/30 days)ZALTRAP - ziv-aflibercept iv soln 100 mg/4ml (for infusion) 2 PAZALTRAP - ziv-aflibercept iv soln 200 mg/8ml (for infusion) 2 PAZANOSAR - streptozocin for inj 1 gm 2ZEJULA - niraparib tosylate cap 100 mg 2 PA, QL (90 capsules/30 days)ZELBORAF - vemurafenib tab 240 mg* 2 PA, QL (240 tablets/30 days)ZOLINZA - vorinostat cap 100 mg 2 PA, QL (120

capsules/30 days)ZYDELIG - idelalisib tab 100 mg* 2 PA, QL (60 tablets/30 days)

2019


41



ZYDELIG - idelalisib tab 150 mg* 2 PA, QL (60 tablets/30 days)ZYKADIA - ceritinib cap 150 mg* 2 PA, QL (90 capsules/30 days)ZYKADIA - ceritinib tab 150 mg* 2 PA, QL (90 tablets/30 days)ZYTIGA - abiraterone acetate tab 250 mg* 2 PA, QL (120 tablets/30 days)ZYTIGA - abiraterone acetate tab 500 mg* 2 PA, QL (60 tablets/30 days)Antiparasiticsalbendazole tab 200 mg 2ALBENZA - albendazole tab 200 mg 2ALINIA - nitazoxanide tab 500 mg 2ALINIA - nitazoxanide for susp 100 mg/5ml 2atovaquone susp 750 mg/5ml 2atovaquone-proguanil hcl tab 62.5-25 mg 2atovaquone-proguanil hcl tab 250-100 mg 2BENZNIDAZOLE - benznidazole tab 12.5 mg 2BENZNIDAZOLE - benznidazole tab 100 mg 2BILTRICIDE - praziquantel tab 600 mg 2CHLOROQUINE PHOSPHATE - chloroquine phosphate

tab 250 mg2

chloroquine phosphate tab 500 mg 2COARTEM - artemether-lumefantrine tab 20-120 mg 2DARAPRIM - pyrimethamine tab 25 mg 2hydroxychloroquine sulfate tab 200 mg 1ivermectin tab 3 mg 2malathion lotion 0.5% 2mefloquine hcl tab 250 mg 1NEBUPENT - pentamidine isethionate for nebulization soln

300 mg2 BD

PENTAM 300 - pentamidine isethionate for soln 300 mg 2pentamidine isethionate for soln 300 mg 2permethrin cream 5% 1permethrin creme rinse 1% 3 MCpermethrin lotion 1% 3 MCpraziquantel tab 600 mg 2primaquine phosphate tab 26.3 mg 2Antiparkinson Agentsamantadine hcl cap 100 mg 1amantadine hcl syrup 50 mg/5ml 1APOKYN - apomorphine hcl soln cartridge 30 mg/3ml* 2 PA, QL (60 mls/30 days)benztropine mesylate tab 0.5 mg# 1 PA

2019




benztropine mesylate tab 1 mg# 1 PAbenztropine mesylate tab 2 mg# 1 PAbromocriptine mesylate tab 2.5 mg 2carbidopa & levodopa orally disintegrating tab 10-100 mg 1carbidopa & levodopa orally disintegrating tab 25-100 mg 1carbidopa & levodopa orally disintegrating tab 25-250 mg 1carbidopa & levodopa tab er 25-100 mg 1carbidopa & levodopa tab er 50-200 mg 1carbidopa & levodopa tab 10-100 mg 1carbidopa & levodopa tab 25-100 mg 1carbidopa & levodopa tab 25-250 mg 1entacapone tab 200 mg 2INBRIJA - levodopa inhal powder cap 42 mg 2 PA, QL (300

capsules/30 days)pramipexole dihydrochloride tab 0.125 mg 1pramipexole dihydrochloride tab 0.25 mg 1pramipexole dihydrochloride tab 0.5 mg 1pramipexole dihydrochloride tab 0.75 mg 1pramipexole dihydrochloride tab 1 mg 1pramipexole dihydrochloride tab 1.5 mg 1rasagiline mesylate tab 0.5 mg 1rasagiline mesylate tab 1 mg 1ropinirole hydrochloride tab 0.25 mg 1ropinirole hydrochloride tab 0.5 mg 1ropinirole hydrochloride tab 1 mg 1ropinirole hydrochloride tab 2 mg 1ropinirole hydrochloride tab 3 mg 1ropinirole hydrochloride tab 4 mg 1ropinirole hydrochloride tab 5 mg 1selegiline hcl cap 5 mg 2selegiline hcl tab 5 mg 1AntipsychoticsADASUVE - loxapine aerosol powder breath activated

10 mg2 PA

aripiprazole oral solution 1 mg/ml 2 PA, QL (750 mls/30 days)aripiprazole orally disintegrating tab 10 mg 2 PA, QL (60 tablets/30 days)aripiprazole orally disintegrating tab 15 mg 2 PA, QL (60 tablets/30 days)aripiprazole tab 2 mg 2 PA, QL (45 tablets/30 days)

2019


43



aripiprazole tab 5 mg 2 PA, QL (45 tablets/30 days)aripiprazole tab 10 mg 2 PA, QL (30 tablets/30 days)aripiprazole tab 15 mg 2 PA, QL (30 tablets/30 days)aripiprazole tab 20 mg 2 PA, QL (30 tablets/30 days)aripiprazole tab 30 mg 2 PA, QL (30 tablets/30 days)ARISTADA - aripiprazole lauroxil im er susp prefilled syr

441 mg/1.6ml2 PA, QL (1 syringe/28 days)

ARISTADA - aripiprazole lauroxil im er susp prefilled syr662 mg/2.4ml

2 PA, QL (1 syringe/28 days)





ARISTADA INITIO - aripiprazole lauroxil im er susp prefilledsyr 675 mg/2.4ml


clozapine orally disintegrating tab 12.5 mg 2 PA, QL (90 tablets/30 days)clozapine orally disintegrating tab 25 mg 2 PA, QL (270 tablets/30 days)clozapine orally disintegrating tab 100 mg 2 PA, QL (270 tablets/30 days)clozapine tab 25 mg 1 PA, QL (90 tablets/30 days)clozapine tab 50 mg 1 PA, QL (90 tablets/30 days)clozapine tab 100 mg 1 PA, QL (270 tablets/30 days)clozapine tab 200 mg 1 PA, QL (120 tablets/30 days)FANAPT - iloperidone tab 1 mg 2 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 2 mg 2 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 4 mg 2 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 6 mg 2 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 8 mg 2 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 10 mg 2 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 12 mg 2 PA, QL (60 tablets/30 days)FANAPT TITRATION PACK - iloperidone tab 1 mg & 2 mg

& 4 mg & 6 mg titration pak2 PA, QL (7 packs (56

tablets)/28 days)fluphenazine decanoate inj 25 mg/ml 2 PAFLUPHENAZINE HCL - fluphenazine hcl oral conc 5 mg/ml 2 PAFLUPHENAZINE HCL - fluphenazine hcl inj 2.5 mg/ml 2 PAfluphenazine hcl tab 1 mg 2 PAfluphenazine hcl tab 2.5 mg 2 PAfluphenazine hcl tab 5 mg 2 PAfluphenazine hcl tab 10 mg 2 PAFLUPHENAZINE HYDROCHLORIDE - fluphenazine hcl

elixir 2.5 mg/5ml2 PA

2019




GEODON - ziprasidone mesylate for inj 20 mg 2 PA, QL (60 vials/30 days)haloperidol decanoate im soln 50 mg/ml 2 PAhaloperidol decanoate im soln 100 mg/ml 2 PAhaloperidol lactate inj 5 mg/ml 2 PAhaloperidol lactate oral conc 2 mg/ml 1 PAhaloperidol tab 0.5 mg 1 PAhaloperidol tab 1 mg 1 PAhaloperidol tab 2 mg 1 PAhaloperidol tab 5 mg 1 PAhaloperidol tab 10 mg 1 PAhaloperidol tab 20 mg 1 PAINVEGA SUSTENNA - paliperidone palmitate er susp pref

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

INVEGA SUSTENNA - paliperidone palmitate er susp prefsyr 78 mg/0.5ml

2 PA, QL (1 kit/28 days)



INVEGA SUSTENNA - paliperidone palmitate er susp prefsyr 156 mg/ml




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








LATUDA - lurasidone hcl tab 20 mg 2 PA, QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 40 mg 2 PA, QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 60 mg 2 PA, QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 80 mg 2 PA, QL (60 tablets/30 days)LATUDA - lurasidone hcl tab 120 mg 2 PA, QL (30 tablets/30 days)loxapine succinate cap 5 mg 1 PAloxapine succinate cap 10 mg 1 PAloxapine succinate cap 25 mg 1 PAloxapine succinate cap 50 mg 1 PAMOLINDONE HYDROCHLORIDE - molindone hcl tab 5 mg 2 PAMOLINDONE HYDROCHLORIDE - molindone hcl tab

10 mg2 PA

2019


45



MOLINDONE HYDROCHLORIDE - molindone hcl tab25 mg

2 PA

NUPLAZID - pimavanserin tartrate cap 34 mg* 2 PA, QL (30 capsules/30 days)NUPLAZID - pimavanserin tartrate tab 10 mg* 2 PA, QL (30 tablets/30 days)olanzapine for im inj 10 mg 2 PA, QL (90 vials/30 days)olanzapine orally disintegrating tab 5 mg 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 10 mg 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 15 mg 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 20 mg 2 PA, QL (30 tablets/30 days)olanzapine tab 2.5 mg 1 PA, QL (45 tablets/30 days)olanzapine tab 5 mg 1 PA, QL (45 tablets/30 days)olanzapine tab 7.5 mg 1 PA, QL (45 tablets/30 days)olanzapine tab 10 mg 1 PA, QL (45 tablets/30 days)olanzapine tab 15 mg 1 PA, QL (30 tablets/30 days)olanzapine tab 20 mg 1 PA, QL (30 tablets/30 days)paliperidone tab er 24hr 1.5 mg 2 PA, QL (30 tablets/30 days)paliperidone tab er 24hr 3 mg 2 PA, QL (30 tablets/30 days)paliperidone tab er 24hr 6 mg 2 PA, QL (60 tablets/30 days)paliperidone tab er 24hr 9 mg 2 PA, QL (30 tablets/30 days)PERSERIS - risperidone subcutaneous for er susp prefilled

syr 90 mg2 PA, QL (1 syringe/30 days)

PERSERIS - risperidone subcutaneous for er susp prefilledsyr 120 mg


pimozide tab 1 mg 1pimozide tab 2 mg 1quetiapine fumarate tab 25 mg 1 PA, QL (120 tablets/30 days)quetiapine fumarate tab 50 mg 1 PA, QL (120 tablets/30 days)quetiapine fumarate tab 100 mg 1 PA, QL (120 tablets/30 days)quetiapine fumarate tab 200 mg 1 PA, QL (120 tablets/30 days)quetiapine fumarate tab 300 mg 1 PA, QL (60 tablets/30 days)quetiapine fumarate tab 400 mg 1 PA, QL (60 tablets/30 days)REXULTI - brexpiprazole tab 0.25 mg 2 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 0.5 mg 2 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 1 mg 2 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 2 mg 2 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 3 mg 2 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 4 mg 2 PA, QL (30 tablets/30 days)RISPERDAL CONSTA - risperidone microspheres for im

extended rel susp 12.5 mg2 PA, QL (2 vials/28 days)

2019




RISPERDAL CONSTA - risperidone microspheres for imextended rel susp 25 mg

2 PA, QL (2 vials/28 days)

RISPERDAL CONSTA - risperidone microspheres for imextended rel susp 37.5 mg


RISPERDAL CONSTA - risperidone microspheres for imextended rel susp 50 mg


risperidone orally disintegrating tab 0.25 mg 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 0.5 mg 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 1 mg 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 2 mg 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 3 mg 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 4 mg 2 PA, QL (120 tablets/30 days)risperidone soln 1 mg/ml 1 PA, QL (480 mls/30 days)risperidone tab 0.25 mg 1 PA, QL (60 tablets/30 days)risperidone tab 0.5 mg 1 PA, QL (60 tablets/30 days)risperidone tab 1 mg 1 PA, QL (60 tablets/30 days)risperidone tab 2 mg 1 PA, QL (60 tablets/30 days)risperidone tab 3 mg 1 PA, QL (60 tablets/30 days)risperidone tab 4 mg 1 PA, QL (120 tablets/30 days)SAPHRIS - asenapine maleate sl tab 2.5 mg 2 PA, QL (60 tablets/30 days)SAPHRIS - asenapine maleate sl tab 5 mg 2 PA, QL (60 tablets/30 days)SAPHRIS - asenapine maleate sl tab 10 mg 2 PA, QL (60 tablets/30 days)thioridazine hcl tab 10 mg 2 PAthioridazine hcl tab 25 mg 2 PAthioridazine hcl tab 50 mg 2 PAthioridazine hcl tab 100 mg 2 PAthiothixene cap 1 mg 1 PAthiothixene cap 2 mg 1 PAthiothixene cap 5 mg 1 PAthiothixene cap 10 mg 1 PAtrifluoperazine hcl tab 1 mg 1 PAtrifluoperazine hcl tab 2 mg 1 PAtrifluoperazine hcl tab 5 mg 1 PAtrifluoperazine hcl tab 10 mg 1 PAVERSACLOZ - clozapine susp 50 mg/ml 2 PA, QL (540 mls/30 days)VRAYLAR - cariprazine hcl cap 1.5 mg 2 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 3 mg 2 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 4.5 mg 2 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 6 mg 2 PA, QL (30 capsules/30 days)

2019


47



ziprasidone hcl cap 20 mg 1 PA, QL (90 capsules/30 days)ziprasidone hcl cap 40 mg 1 PA, QL (90 capsules/30 days)ziprasidone hcl cap 60 mg 1 PA, QL (60 capsules/30 days)ziprasidone hcl cap 80 mg 1 PA, QL (60 capsules/30 days)ZYPREXA RELPREVV - olanzapine pamoate for extended

rel im susp 210 mg2 PA, QL (2 vials/28 days)

ZYPREXA RELPREVV - olanzapine pamoate for extendedrel im susp 300 mg


ZYPREXA RELPREVV - olanzapine pamoate for extendedrel im susp 405 mg

2 PA, QL (1 vial/28 days)

Antispasticity Agentsbaclofen tab 10 mg 1baclofen tab 20 mg 1tizanidine hcl tab 2 mg 1tizanidine hcl tab 4 mg 1Antiviralsabacavir sulfate soln 20 mg/ml 2 QL (960 mls/30 days)abacavir sulfate tab 300 mg 2 QL (60 tablets/30 days)abacavir sulfate-lamivudine tab 600-300 mg 2 QL (30 tablets/30 days)abacavir sulfate-lamivudine-zidovudine tab

300-150-300 mg2 QL (60 tablets/30 days)

acyclovir cap 200 mg 1acyclovir oint 5% 2acyclovir sodium iv soln 50 mg/ml 2 BDacyclovir susp 200 mg/5ml 2acyclovir tab 400 mg 1acyclovir tab 800 mg 1adefovir dipivoxil tab 10 mg 2APTIVUS - tipranavir cap 250 mg 2 QL (120 capsules/30 days)APTIVUS - tipranavir oral soln 100 mg/ml 2 QL (380 mls/30 days)atazanavir sulfate cap 150 mg 2 QL (30 capsules/30 days)atazanavir sulfate cap 200 mg 2 QL (60 capsules/30 days)atazanavir sulfate cap 300 mg 2 QL (30 capsules/30 days)ATRIPLA - efavirenz-emtricitabine-tenofovir df tab


BARACLUDE - entecavir oral soln 0.05 mg/ml 2BIKTARVY - bictegravir-emtricitabine-tenofovir af tab


CIMDUO - lamivudine-tenofovir disoproxil fumarate tab300-300 mg


2019




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


CRIXIVAN - indinavir sulfate cap 200 mg 1 QL (270 capsules/30 days)CRIXIVAN - indinavir sulfate cap 400 mg 1 QL (180 capsules/30 days)CYTOVENE - ganciclovir sodium for inj 500 mg 2 BDDELSTRIGO - doravirine-lamivudine-tenofovir df tab


DENAVIR - penciclovir cream 1% 2DESCOVY - emtricitabine-tenofovir alafenamide fumarate

tab 200-25 mg2 QL (30 tablets/30 days)

didanosine delayed release capsule 200 mg 2 QL (30 capsules/30 days)didanosine delayed release capsule 250 mg 2 QL (30 capsules/30 days)didanosine delayed release capsule 400 mg 2 QL (30 capsules/30 days)DOVATO - dolutegravir sodium-lamivudine tab 50-300 mg 2 QL (30 tablets/30 days)EDURANT - rilpivirine hcl tab 25 mg 2 QL (30 tablets/30 days)efavirenz cap 50 mg 2 QL (90 capsules/30 days)efavirenz cap 200 mg 2 QL (60 capsules/30 days)efavirenz tab 600 mg 2 QL (30 tablets/30 days)EMTRIVA - emtricitabine caps 200 mg 2 QL (30 capsules/30 days)EMTRIVA - emtricitabine soln 10 mg/ml 2 QL (850 mls/30 days)entecavir tab 0.5 mg 2entecavir tab 1 mg 2EPCLUSA - sofosbuvir-velpatasvir tab 400-100 mg 2 PAEPIVIR HBV - lamivudine oral soln 5 mg/ml (hbv) 2EVOTAZ - atazanavir sulfate-cobicistat tab 300-150 mg 2 QL (30 tablets/30 days)famciclovir tab 125 mg 2famciclovir tab 250 mg 2famciclovir tab 500 mg 2fosamprenavir calcium tab 700 mg 2 QL (120 tablets/30 days)FUZEON - enfuvirtide for inj 90 mg 2 QL (60 vials/30 days)ganciclovir sodium for inj 500 mg 2 BDGENVOYA - elvitegrav-cobic-emtricitab-tenofov af tab

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

HARVONI - ledipasvir-sofosbuvir tab 45-200 mg 2 PAHARVONI - ledipasvir-sofosbuvir tab 90-400 mg 2 PAINTELENCE - etravirine tab 25 mg 2 QL (120 tablets/30 days)INTELENCE - etravirine tab 100 mg 2 QL (60 tablets/30 days)INTELENCE - etravirine tab 200 mg 2 QL (60 tablets/30 days)INTRON A - interferon alfa-2b inj 6000000 unit/ml 2

2019


49



INTRON A - interferon alfa-2b inj 10000000 unit/ml 2INTRON A - interferon alfa-2b for inj 10000000 unit 2INTRON A - interferon alfa-2b for inj 18000000 unit 2INTRON A - interferon alfa-2b for inj 50000000 unit 2INTRON A W/DILUENT - interferon alfa-2b for inj

10000000 unit2

INTRON A W/DILUENT - interferon alfa-2b for inj18000000 unit

2

INTRON A W/DILUENT - interferon alfa-2b for inj50000000 unit

2

INVIRASE - saquinavir mesylate tab 500 mg 2 QL (120 tablets/30 days)ISENTRESS - raltegravir potassium packet for susp

100 mg2 QL (60 packets/30 days)

ISENTRESS - raltegravir potassium tab 400 mg 2 QL (60 tablets/30 days)ISENTRESS - raltegravir potassium chew tab 25 mg 1 QL (180 tablets/30 days)ISENTRESS - raltegravir potassium chew tab 100 mg 1 QL (180 tablets/30 days)ISENTRESS HD - raltegravir potassium tab 600 mg 2 QL (60 tablets/30 days)JULUCA - dolutegravir sodium-rilpivirine hcl tab 50-25 mg 2 QL (30 tablets/30 days)KALETRA - lopinavir-ritonavir tab 100-25 mg 2 QL (300 tablets/30 days)KALETRA - lopinavir-ritonavir tab 200-50 mg 2 QL (120 tablets/30 days)lamivudine oral soln 10 mg/ml 2 QL (960 mls/30 days)lamivudine tab 100 mg (hbv) 2lamivudine tab 150 mg 2 QL (60 tablets/30 days)lamivudine tab 300 mg 2 QL (30 tablets/30 days)lamivudine-zidovudine tab 150-300 mg 2 QL (60 tablets/30 days)LEXIVA - fosamprenavir calcium tab 700 mg 2 QL (120 tablets/30 days)LEXIVA - fosamprenavir calcium susp 50 mg/ml 2 QL (1800 mls/30 days)lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) 2 QL (480 mls/30 days)MAVYRET - glecaprevir-pibrentasvir tab 100-40 mg 2 PAnevirapine susp 50 mg/5ml 2 QL (1200 mls/30 days)nevirapine tab er 24hr 100 mg 2 QL (90 tablets/30 days)nevirapine tab er 24hr 400 mg 2 QL (30 tablets/30 days)nevirapine tab 200 mg 1 QL (60 tablets/30 days)NORVIR - ritonavir oral soln 80 mg/ml 2 QL (480 mls/30 days)NORVIR - ritonavir powder packet 100 mg 2 QL (360 packets/30 days)ODEFSEY - emtricitabine-rilpivirine-tenofovir af tab


oseltamivir phosphate cap 30 mg 2oseltamivir phosphate cap 45 mg 2

2019




oseltamivir phosphate cap 75 mg 2oseltamivir phosphate for susp 6 mg/ml 1PEGASYS - peginterferon alfa-2a inj 180 mcg/ml 2 PAPEGASYS - peginterferon alfa-2a inj 180 mcg/0.5ml 2 PAPEGASYS PROCLICK - peginterferon alfa-2a inj

180 mcg/0.5ml2 PA

PIFELTRO - doravirine tab 100 mg 2 QL (30 tablets/30 days)PREVYMIS - letermovir tab 240 mg 2PREVYMIS - letermovir tab 480 mg 2PREZCOBIX - darunavir-cobicistat tab 800-150 mg 2 QL (30 tablets/30 days)PREZISTA - darunavir ethanolate susp 100 mg/ml 2 QL (400 mls/30 days)PREZISTA - darunavir ethanolate tab 75 mg 2 QL (300 tablets/30 days)PREZISTA - darunavir ethanolate tab 150 mg 2 QL (180 tablets/30 days)PREZISTA - darunavir ethanolate tab 600 mg 2 QL (60 tablets/30 days)PREZISTA - darunavir ethanolate tab 800 mg 2 QL (30 tablets/30 days)RELENZA DISKHALER - zanamivir aero powder breath

activated 5 mg/blister2

RESCRIPTOR - delavirdine mesylate tab 200 mg 2 QL (180 tablets/30 days)RETROVIR IV INFUSION - zidovudine iv soln 10 mg/ml 2REYATAZ - atazanavir sulfate oral powder packet 50 mg 2 QL (240 packets/30 days)REYATAZ - atazanavir sulfate cap 150 mg 2 QL (30 capsules/30 days)REYATAZ - atazanavir sulfate cap 200 mg 2 QL (60 capsules/30 days)REYATAZ - atazanavir sulfate cap 300 mg 2 QL (30 capsules/30 days)ribavirin cap 200 mg 2ribavirin tab 200 mg 2ritonavir tab 100 mg 2 QL (360 tablets/30 days)SELZENTRY - maraviroc oral soln 20 mg/ml 2 QL (1840 mls/30 days)SELZENTRY - maraviroc tab 25 mg 2 QL (240 tablets/30 days)SELZENTRY - maraviroc tab 75 mg 2 QL (60 tablets/30 days)SELZENTRY - maraviroc tab 150 mg 2 QL (60 tablets/30 days)SELZENTRY - maraviroc tab 300 mg 2 QL (120 tablets/30 days)SOVALDI - sofosbuvir tab 400 mg 2 PAstavudine cap 15 mg 1 QL (60 capsules/30 days)stavudine cap 20 mg 1 QL (60 capsules/30 days)stavudine cap 30 mg 1 QL (60 capsules/30 days)stavudine cap 40 mg 1 QL (60 capsules/30 days)STRIBILD - elvitegrav-cobic-emtricitab-tenofovdf tab

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

SUSTIVA - efavirenz cap 50 mg 2 QL (90 capsules/30 days)

2019


51



SUSTIVA - efavirenz cap 200 mg 2 QL (60 capsules/30 days)SYLATRON - peginterferon alfa-2b for inj kit 200 mcg 2 PASYLATRON - peginterferon alfa-2b for inj kit 300 mcg 2 PASYLATRON - peginterferon alfa-2b for inj kit 600 mcg 2 PASYMFI - efavirenz-lamivudine-tenofovir df tab


SYMFI LO - efavirenz-lamivudine-tenofovir df tab400-300-300 mg


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


TAMIFLU - oseltamivir phosphate for susp 6 mg/ml 2tenofovir disoproxil fumarate tab 300 mg 2 QL (30 tablets/30 days)TIVICAY - dolutegravir sodium tab 10 mg 2 QL (60 tablets/30 days)TIVICAY - dolutegravir sodium tab 25 mg 2 QL (60 tablets/30 days)TIVICAY - dolutegravir sodium tab 50 mg 2 QL (60 tablets/30 days)TRIUMEQ - abacavir-dolutegravir-lamivudine tab


TROGARZO - ibalizumab-uiyk iv soln 200 mg/1.33ml(150 mg/ml)

2 QL (14 vials/28 days)

TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab100-150 mg








TYBOST - cobicistat tab 150 mg 1 QL (30 tablets/30 days)valacyclovir hcl tab 500 mg 1valacyclovir hcl tab 1 gm 1valganciclovir hcl for soln 50 mg/ml 2valganciclovir hcl tab 450 mg 2VALTREX - valacyclovir hcl tab 500 mg 2VALTREX - valacyclovir hcl tab 1 gm 2VIDEX - didanosine for soln 2 gm 2 QL (1200 mls/30 days)VIDEX - didanosine for soln 4 gm 2 QL (1200 mls/30 days)VIDEX EC - didanosine delayed release capsule 125 mg 2 QL (30 capsules/30 days)VIDEX EC - didanosine delayed release capsule 200 mg 2 QL (30 capsules/30 days)VIDEX EC - didanosine delayed release capsule 250 mg 2 QL (30 capsules/30 days)VIDEX EC - didanosine delayed release capsule 400 mg 2 QL (30 capsules/30 days)

2019




VIEKIRA PAK - ombitas-paritapre-riton & dasab tab pak12.5-75-50 & 250 mg

2 PA

VIRACEPT - nelfinavir mesylate tab 250 mg 2 QL (270 tablets/30 days)VIRACEPT - nelfinavir mesylate tab 625 mg 2 QL (120 tablets/30 days)VIRAMUNE - nevirapine susp 50 mg/5ml 2 QL (1200 mls/30 days)VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/

gm2 QL (240 grams/30 days)

VIREAD - tenofovir disoproxil fumarate tab 150 mg 2 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 200 mg 2 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 250 mg 2 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 300 mg 2 QL (30 tablets/30 days)VOSEVI - sofosbuvir-velpatasvir-voxilaprevir tab

400-100-100 mg2 PA

XOFLUZA - baloxavir marboxil tab therapy pack 20 (2) mg(40 mg dose)

2

XOFLUZA - baloxavir marboxil tab therapy pack 40 (2) mg(80 mg dose)

2

ZEPATIER - elbasvir-grazoprevir tab 50-100 mg 2 PAZIAGEN - abacavir sulfate soln 20 mg/ml 2 QL (960 mls/30 days)zidovudine cap 100 mg 2 QL (180 capsules/30 days)zidovudine syrup 10 mg/ml 2 QL (1920 mls/30 days)zidovudine tab 300 mg 2 QL (60 tablets/30 days)ZOVIRAX - acyclovir cap 200 mg 2ZOVIRAX - acyclovir susp 200 mg/5ml 2ZOVIRAX - acyclovir tab 400 mg 2ZOVIRAX - acyclovir tab 800 mg 2Anxiolyticsalprazolam tab 0.25 mg 2 QL (120 tablets/30 days)alprazolam tab 0.5 mg 2 QL (120 tablets/30 days)alprazolam tab 1 mg 2 QL (120 tablets/30 days)alprazolam tab 2 mg 2 QL (150 tablets/30 days)buspirone hcl tab 5 mg 1buspirone hcl tab 7.5 mg 1buspirone hcl tab 10 mg 1buspirone hcl tab 15 mg 1buspirone hcl tab 30 mg 1clonazepam orally disintegrating tab 0.125 mg 1 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.25 mg 1 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.5 mg 1 PA, QL (90 tablets/30 days)

2019


53



clonazepam orally disintegrating tab 1 mg 1 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 2 mg 1 PA, QL (300 tablets/30 days)clonazepam tab 0.5 mg 1 PA, QL (120 tablets/30 days)clonazepam tab 1 mg 1 PA, QL (120 tablets/30 days)clonazepam tab 2 mg 1 PA, QL (300 tablets/30 days)clorazepate dipotassium tab 3.75 mg 2 PA, QL (120 tablets/30 days)clorazepate dipotassium tab 7.5 mg 2 PA, QL (360 tablets/30 days)clorazepate dipotassium tab 15 mg 2 PA, QL (180 tablets/30 days)DIAZEPAM - diazepam oral soln 1 mg/ml 2 PA, QL (1200 mls/30 days)diazepam tab 2 mg 1 PA, QL (120 tablets/30 days)diazepam tab 5 mg 1 PA, QL (120 tablets/30 days)diazepam tab 10 mg 1 PA, QL (120 tablets/30 days)lorazepam tab 0.5 mg 1 PA, QL (120 tablets/30 days)lorazepam tab 1 mg 1 PA, QL (120 tablets/30 days)lorazepam tab 2 mg 1 PA, QL (150 tablets/30 days)Bipolar AgentsLITHIUM - lithium oral solution 8 meq/5ml 2lithium carbonate cap 150 mg 1lithium carbonate cap 300 mg 1lithium carbonate cap 600 mg 1lithium carbonate tab er 300 mg 1lithium carbonate tab er 450 mg 1lithium carbonate tab 300 mg 1Blood Glucose Regulatorsacarbose tab 25 mg 1 QL (360 tablets/30 days)acarbose tab 50 mg 1 QL (180 tablets/30 days)acarbose tab 100 mg 1 QL (90 tablets/30 days)ACTOS - pioglitazone hcl tab 15 mg 2 QL (90 tablets/30 days)ACTOS - pioglitazone hcl tab 30 mg 2 QL (30 tablets/30 days)ACTOS - pioglitazone hcl tab 45 mg 2 QL (30 tablets/30 days)ALCOHOL SWABS 1ALOGLIPTIN - alogliptin benzoate tab 6.25 mg 1 QL (120 tablets/30 days)ALOGLIPTIN - alogliptin benzoate tab 12.5 mg 1 QL (60 tablets/30 days)ALOGLIPTIN - alogliptin benzoate tab 25 mg 1 QL (30 tablets/30 days)ALOGLIPTIN/METFORMIN HCL - alogliptin-metformin hcl

tab 12.5-500 mg1 QL (60 tablets/30 days)

ALOGLIPTIN/METFORMIN HCL - alogliptin-metformin hcltab 12.5-1000 mg


2019




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






ALOGLIPTIN/PIOGLITAZONE - alogliptin-pioglitazone tab25-15 mg






AMARYL - glimepiride tab 1 mg 2 QL (240 tablets/30 days)AMARYL - glimepiride tab 2 mg 2 QL (120 tablets/30 days)AMARYL - glimepiride tab 4 mg 2 QL (60 tablets/30 days)ASSURE ID INSULIN SAFETY SYRINGE/

U-100/0.5ML/29G X 1/2"1

ASSURE ID INSULIN SAFETY SYRINGE/U-100/1ML/29GX 1/2"

1

ASSURE ID SAFETY PEN NEEDLES 31G X 5MM (1/5"OR 3/16")

1

BASAGLAR KWIKPEN - insulin glargine soln pen-injector100 unit/ml

1 QL (20 pens/30 days)

BD SAFETYGLIDE INSULIN SYRINGE 0.3ML/31G X15/64"

1

BD SAFETYGLIDE INSULIN SYRINGE 0.5ML/31G X15/64"

1

BD SAFETYGLIDE INSULIN SYRINGE 1ML/31G X 15/64" 1BYDUREON BCISE - exenatide extended release susp

auto-injector 2 mg/0.85ml1 QL (4 pens/28 days), ST

BYDUREON PEN - exenatide extended release for susppen-injector 2 mg

1 QL (4 pens/28 days), ST

CYCLOSET - bromocriptine mesylate tab 0.8 mg 2 QL (180 tablets/30 days)EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE

1ML/30G X 1/2"1

EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/0.5ML/29G X 1/2"

1

EASY TOUCH INSULIN SYRINGE/SAFETY/U-100/1ML/30G X 1/2"

1

EASY TOUCH SHEATHLOCK SAFETY INSULINSYRINGE 1ML/29G X 1/2"

1

EASY TOUCH SHEATHLOCK SAFETY SYRINGE1ML/30G X 1/2"

1

2019


55



GAUZE PADS 2" X 2" 1glimepiride tab 1 mg 1 QL (240 tablets/30 days)glimepiride tab 2 mg 1 QL (120 tablets/30 days)glimepiride tab 4 mg 1 QL (60 tablets/30 days)glipizide tab er 24hr 2.5 mg 1 QL (240 tablets/30 days)glipizide tab er 24hr 5 mg 1 QL (120 tablets/30 days)glipizide tab er 24hr 10 mg 1 QL (60 tablets/30 days)glipizide tab 5 mg 1 QL (240 tablets/30 days)glipizide tab 10 mg 1 QL (120 tablets/30 days)GLUCAGEN HYPOKIT - glucagon hcl (rdna) for inj 1 mg 2 QL (4 kits/30 days)GLUCOPHAGE - metformin hcl tab 500 mg 2 QL (150 tablets/30 days)GLUCOPHAGE - metformin hcl tab 850 mg 2 QL (90 tablets/30 days)GLUCOPHAGE - metformin hcl tab 1000 mg 2 QL (75 tablets/30 days)GLUCOPHAGE XR - metformin hcl tab er 24hr 500 mg 2 QL (120 tablets/30 days)GLUCOPHAGE XR - metformin hcl tab er 24hr 750 mg 2 QL (60 tablets/30 days)glucose gel 40% 3 MCGLUCOTROL - glipizide tab 5 mg 2 QL (240 tablets/30 days)GLUCOTROL - glipizide tab 10 mg 2 QL (120 tablets/30 days)GLUCOTROL XL - glipizide tab er 24hr 2.5 mg 2 QL (240 tablets/30 days)GLUCOTROL XL - glipizide tab er 24hr 5 mg 2 QL (120 tablets/30 days)GLUCOTROL XL - glipizide tab er 24hr 10 mg 2 QL (60 tablets/30 days)GLYXAMBI - empagliflozin-linagliptin tab 10-5 mg 2 QL (30 tablets/30 days)GLYXAMBI - empagliflozin-linagliptin tab 25-5 mg 2 QL (30 tablets/30 days)HUMALOG - insulin lispro soln cartridge 100 unit/ml 1 QL (20 cartridges/30 days)HUMALOG - insulin lispro inj 100 unit/ml 1 QL (60 mls/30 days)HUMALOG JUNIOR KWIKPEN - insulin lispro soln pen-

injector 100 unit/ml (0.5 unit dial)1 QL (20 pens/30 days)

HUMALOG KWIKPEN - insulin lispro soln pen-injector 100unit/ml (1 unit dial)


HUMALOG KWIKPEN - insulin lispro soln pen-injector 200unit/ml


HUMALOG MIX 50/50 - insulin lispro protamine & lispro inj100 unit/ml (50-50)


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


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


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


2019




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

1 QL (60 mls/30 days)

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


HUMULIN R - insulin regular (human) inj 100 unit/ml 1 QL (60 mls/30 days)HUMULIN R U-500 (CONCENTRATE) - insulin regular

(human) inj 500 unit/ml1 BD

HUMULIN R U-500 KWIKPEN - insulin regular (human)soln pen-injector 500 unit/ml


HUMULIN 70/30 - insulin nph isophane & regular human inj100 unit/ml (70-30)

1 QL (60 mls/30 days)

HUMULIN 70/30 KWIKPEN - insulin nph & regular susppen-inj 100 unit/ml (70-30)


INSULIN PEN NEEDLE 29G X 12.7MM (1/2") 1INSULIN PEN NEEDLE 29G X 5MM (1/5" OR 3/16") 1INSULIN PEN NEEDLE 29G X 8MM (1/3" OR 5/16") 1INSULIN PEN NEEDLE 30G X 5MM (1/5" OR 3/16") 1INSULIN PEN NEEDLE 30G X 8MM (1/3" OR 5/16") 1INSULIN PEN NEEDLE 31G X 4MM (1/6" OR 5/32") 1INSULIN PEN NEEDLE 32G X 5MM (1/5" OR 3/16") 1INSULIN PEN NEEDLE 33G X 4MM (1/6" OR 5/32") 1INSULIN PEN NEEDLE 33G X 5MM (1/5" OR 3/16") 1INSULIN PEN NEEDLE 33G X 6MM (1/4" OR 15/64") 1INSULIN PEN NEEDLE 33G X 8MM (1/3" OR 5/16") 1INSULIN SYRINGE (DISP) U-100/0.3ML 1INSULIN SYRINGE (DISP) U-100/0.5ML 1INSULIN SYRINGE (DISP) U-100/1ML 1INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X 15/64" 1INSULIN SYRINGE/NEEDLE U-100 0.5 ML 30 X 15/64" 1INSULIN SYRINGE/NEEDLE U-100 0.5 ML 32 X 5/16" 1INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X 15/64" 1INSULIN SYRINGE/NEEDLE U-100 1 ML 32 X 5/16" 1INSULIN SYRINGE/NEEDLE U-100/0.3ML/28G X 1/2" 1INSULIN SYRINGE/NEEDLE U-100/0.3ML/29G 1INSULIN SYRINGE/NEEDLE U-100/0.3ML/29G X 1" 1INSULIN SYRINGE/NEEDLE U-100/0.3ML/30G 1INSULIN SYRINGE/NEEDLE U-100/0.3ML/31G X

1/4" (6MM)1

INSULIN SYRINGE/NEEDLE U-100/0.5ML/27G X 1/2" 1INSULIN SYRINGE/NEEDLE U-100/0.5ML/28G X 5/16" 1

2019


57



INSULIN SYRINGE/NEEDLE U-100/0.5ML/29G 1INSULIN SYRINGE/NEEDLE U-100/0.5ML/29G X 5/16" 1INSULIN SYRINGE/NEEDLE U-100/0.5ML/30G 1INSULIN SYRINGE/NEEDLE U-100/0.5ML/30G X

3/16" (5MM)1

INSULIN SYRINGE/NEEDLE U-100/0.5ML/30G X 3/8" 1INSULIN SYRINGE/NEEDLE U-100/0.5ML/31G X

1/4" (6MM)1

INSULIN SYRINGE/NEEDLE U-100/1ML/25G X 1" 1INSULIN SYRINGE/NEEDLE U-100/1ML/25G X 5/8" 1INSULIN SYRINGE/NEEDLE U-100/1ML/26G X 1/2" 1INSULIN SYRINGE/NEEDLE U-100/1ML/27G X 1/2" 1INSULIN SYRINGE/NEEDLE U-100/1ML/27G X 5/8" 1INSULIN SYRINGE/NEEDLE U-100/1ML/28G X 5/16" 1INSULIN SYRINGE/NEEDLE U-100/1ML/29G X 5/16" 1INSULIN SYRINGE/NEEDLE U-100/1ML/30G 1INSULIN SYRINGE/NEEDLE U-100/1ML/30G X

3/16" (5MM)1

INSULIN SYRINGE/NEEDLE U-100/1ML/31G X1/4" (6MM)

1

INSULIN SYRINGE/NEEDLE U-100/2ML/27.5G X 5/8" 1INSULIN SYRINGE/NEEDLE U-40/1ML/25G X 5/8" 1INSULIN SYRINGE/NEEDLE U-500/0.5ML/31G X 6MM

(15/64")1

JARDIANCE - empagliflozin tab 10 mg 1 QL (60 tablets/30 days)JARDIANCE - empagliflozin tab 25 mg 1 QL (30 tablets/30 days)KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr

2.5-1000 mg1 QL (60 tablets/30 days)

KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr5-500 mg


KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr5-1000 mg


metformin hcl tab er 24hr 500 mg 1 QL (120 tablets/30 days)metformin hcl tab er 24hr 750 mg 1 QL (60 tablets/30 days)metformin hcl tab 500 mg 1 QL (150 tablets/30 days)metformin hcl tab 850 mg 1 QL (90 tablets/30 days)metformin hcl tab 1000 mg 1 QL (75 tablets/30 days)MONOJECT INSULIN SYRINGE/SAFETY/PERM

NEEDLE/0.3ML/29G X 1/2"1

MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/0.5ML/29G X 1/2"

1

2019




MONOJECT INSULIN SYRINGE/SAFETY/PERMNEEDLE/1ML/29G X 1/2"

1

nateglinide tab 60 mg 1 QL (180 tablets/30 days)nateglinide tab 120 mg 1 QL (90 tablets/30 days)ONGLYZA - saxagliptin hcl tab 2.5 mg 1 QL (60 tablets/30 days)ONGLYZA - saxagliptin hcl tab 5 mg 1 QL (30 tablets/30 days)OZEMPIC - semaglutide soln pen-inj 0.25 or 0.5 mg/dose

(2 mg/1.5ml)1 QL (1 pen/28 days), ST

OZEMPIC - semaglutide soln pen-inj 1 mg/dose(2 mg/1.5ml)

1 QL (2 pens/28 days), ST

pioglitazone hcl tab 15 mg 1 QL (90 tablets/30 days)pioglitazone hcl tab 30 mg 1 QL (30 tablets/30 days)pioglitazone hcl tab 45 mg 1 QL (30 tablets/30 days)PRECOSE - acarbose tab 25 mg 2 QL (360 tablets/30 days)PRECOSE - acarbose tab 50 mg 2 QL (180 tablets/30 days)PRECOSE - acarbose tab 100 mg 2 QL (90 tablets/30 days)PREVENT SAFETY PEN NEEDLE 31G X 1/4" 1PREVENT SAFETY PEN NEEDLE 31G X 5/16" 1PROGLYCEM - diazoxide susp 50 mg/ml 2SAFETY INSULIN SYRINGES 1ML/30G X 1/2" 1STARLIX - nateglinide tab 60 mg 2 QL (180 tablets/30 days)STARLIX - nateglinide tab 120 mg 2 QL (90 tablets/30 days)SYMLINPEN 120 - pramlintide acetate pen-inj

2700 mcg/2.7ml (1000 mcg/ml)2

SYMLINPEN 60 - pramlintide acetate pen-inj1500 mcg/1.5ml (1000 mcg/ml)

2

TECHLITE INSULIN SYRINGE U-100/0.3ML/29G X 1/2" 1TECHLITE INSULIN SYRINGE U-100/0.3ML/30G X 1/2" 1TECHLITE INSULIN SYRINGE U-100/0.3ML/30G X 5/16" 1TECHLITE INSULIN SYRINGE U-100/0.3ML/31G X 15/64" 1TECHLITE INSULIN SYRINGE U-100/0.3ML/31G X 5/16" 1TECHLITE INSULIN SYRINGE U-100/0.5ML/29G X 1/2" 1TECHLITE INSULIN SYRINGE U-100/0.5ML/30G X 1/2" 1TECHLITE INSULIN SYRINGE U-100/0.5ML/30G X 5/16" 1TECHLITE INSULIN SYRINGE U-100/0.5ML/31G X 15/64" 1TECHLITE INSULIN SYRINGE U-100/0.5ML/31G X 5/16" 1TECHLITE INSULIN SYRINGE U-100/1ML/29G X 1/2" 1TECHLITE INSULIN SYRINGE U-100/1ML/30G X 1/2" 1TECHLITE INSULIN SYRINGE U-100/1ML/30G X 5/16" 1

2019


59



TECHLITE INSULIN SYRINGE U-100/1ML/31G X 15/64" 1TECHLITE INSULIN SYRINGE U-100/1ML/31G X 5/16" 1TECHLITE PEN NEEDLES 29G X 10MM 1TECHLITE PEN NEEDLES 29G X 12MM 1TECHLITE PEN NEEDLES 31G X 5MM 1TECHLITE PEN NEEDLES/31G X 6MM 1TECHLITE PEN NEEDLES/31G X 8MM 1TECHLITE PEN NEEDLES/32G X 4MM 1TECHLITE PEN NEEDLES/32G X 6MM 1TECHLITE PEN NEEDLES/32G X 8MM 1TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/29G X 1/2" 1TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/30G X 5/16" 1TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/31G X 5/16" 1TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/28G X 1/2" 1TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/29G X 1/2" 1TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/30G X 5/16" 1TRUEPLUS INSULIN SYRINGE/U-100/0.5ML/31G X 5/16" 1TRUEPLUS INSULIN SYRINGE/U-100/1ML/28G X 1/2" 1TRUEPLUS INSULIN SYRINGE/U-100/1ML/29G X 1/2" 1TRUEPLUS INSULIN SYRINGE/U-100/1ML/30G X 5/16"TRUEPLUS INSULIN SYRINGE/U-100/1ML/31G X 5/16" 1

1

TRUEPLUS PEN NEEDLES 29G X 12MM 1TRUEPLUS PEN NEEDLES 31G X 5MM 1TRUEPLUS PEN NEEDLES 31G X 6MM 1TRUEPLUS PEN NEEDLES 31G X 8MM 1TRUEPLUS PEN NEEDLES 32G X 4MM 1TRUEPLUS 5-BEVEL PEN NEEDLES 31GX5MM 1TRUEPLUS 5-BEVEL PEN NEEDLES 31GX6MM 1TRUEPLUS 5-BEVEL PEN NEEDLES 31GX8MM 1TRUEPLUS 5-BEVEL PEN NEEDLES 32GX4MM 1ULTICARE INSULIN SAFETY SYRINGE/0.5ML/29G X 1/2" 1ULTICARE INSULIN SAFETY SYRINGE/1ML/29G X 1/2" 1VANISHPOINT INSULIN SYRINGE/0.5ML/30G X 1/2" 1VICTOZA - liraglutide soln pen-injector 18 mg/3ml (6 mg/

ml)1 QL (1 pack/30 days), ST

Blood Products/Modifiers/Volume Expandersanagrelide hcl cap 0.5 mg 2anagrelide hcl cap 1 mg 2

2019




aspirin-dipyridamole cap er 12hr 25-200 mg 2azacitidine for inj 100 mg 2BRILINTA - ticagrelor tab 60 mg 1BRILINTA - ticagrelor tab 90 mg 1cilostazol tab 50 mg 1cilostazol tab 100 mg 1clopidogrel bisulfate tab 75 mg 1ELIQUIS - apixaban tab 2.5 mg 1 QL (60 tablets/30 days)ELIQUIS - apixaban tab 5 mg 1 QL (74 tablets/30 days)ELIQUIS STARTER PACK - apixaban tab 5 mg 1 QL (74 tablets/30 days)enoxaparin sodium inj 30 mg/0.3ml 2 QL (30 syringes/90 days)enoxaparin sodium inj 40 mg/0.4ml 2 QL (30 syringes/90 days)enoxaparin sodium inj 60 mg/0.6ml 2 QL (30 syringes/90 days)enoxaparin sodium inj 80 mg/0.8ml 2 QL (30 syringes/90 days)enoxaparin sodium inj 100 mg/ml 2 QL (30 syringes/90 days)enoxaparin sodium inj 120 mg/0.8ml 2 QL (30 syringes/90 days)enoxaparin sodium inj 150 mg/ml 2 QL (30 syringes/90 days)enoxaparin sodium inj 300 mg/3ml 2 QL (10 vials/90 days)EPOGEN - epoetin alfa inj 2000 unit/ml 2 PAEPOGEN - epoetin alfa inj 3000 unit/ml 2 PAEPOGEN - epoetin alfa inj 4000 unit/ml 2 PAEPOGEN - epoetin alfa inj 10000 unit/ml 2 PAEPOGEN - epoetin alfa inj 20000 unit/ml 2 PAfondaparinux sodium subcutaneous inj 2.5 mg/0.5ml 2 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 5 mg/0.4ml 2 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml 2 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 10 mg/0.8ml 2 QL (30 syringes/90 days)HEPARIN SODIUM - heparin sodium (porcine) inj soln pref

syr 5000 unit/0.5ml1

HEPARIN SODIUM - heparin sodium (porcine) pf inj 5000unit/ml

1

heparin sodium (porcine) inj 1000 unit/ml 1heparin sodium (porcine) inj 5000 unit/ml 1heparin sodium (porcine) inj 10000 unit/ml 1heparin sodium (porcine) inj 20000 unit/ml 1heparin sodium (porcine) pf inj 5000 unit/0.5ml 1heparin sodium (porcine)-dextrose iv sol 20000

unit/500ml-5%2

PRADAXA - dabigatran etexilate mesylate cap 75 mg 2 QL (60 capsules/30 days)

2019


61



PRADAXA - dabigatran etexilate mesylate cap 110 mg 2 QL (71 capsules/90 days)PRADAXA - dabigatran etexilate mesylate cap 150 mg 2 QL (60 capsules/30 days)prasugrel hcl tab 5 mg 1prasugrel hcl tab 10 mg 1PROCRIT - epoetin alfa inj 2000 unit/ml 2 PAPROCRIT - epoetin alfa inj 3000 unit/ml 2 PAPROCRIT - epoetin alfa inj 4000 unit/ml 2 PAPROCRIT - epoetin alfa inj 10000 unit/ml 2 PAPROCRIT - epoetin alfa inj 20000 unit/ml 2 PAPROCRIT - epoetin alfa inj 40000 unit/ml 2 PAPROMACTA - eltrombopag olamine powder pack for susp

12.5 mg*2 PA

PROMACTA - eltrombopag olamine tab 12.5 mg* 2 PAPROMACTA - eltrombopag olamine tab 25 mg* 2 PAPROMACTA - eltrombopag olamine tab 50 mg* 2 PAPROMACTA - eltrombopag olamine tab 75 mg* 2 PARETACRIT - epoetin alfa-epbx inj 2000 unit/ml 2 PARETACRIT - epoetin alfa-epbx inj 3000 unit/ml 2 PARETACRIT - epoetin alfa-epbx inj 4000 unit/ml 2 PARETACRIT - epoetin alfa-epbx inj 10000 unit/ml 2 PARETACRIT - epoetin alfa-epbx inj 40000 unit/ml 2 PAtranexamic acid iv soln 1000 mg/10ml (100 mg/ml) 2tranexamic acid tab 650 mg 2warfarin sodium tab 1 mg 1warfarin sodium tab 2 mg 1warfarin sodium tab 2.5 mg 1warfarin sodium tab 3 mg 1warfarin sodium tab 4 mg 1warfarin sodium tab 5 mg 1warfarin sodium tab 6 mg 1warfarin sodium tab 7.5 mg 1warfarin sodium tab 10 mg 1ZARXIO - filgrastim-sndz soln prefilled syringe

300 mcg/0.5ml2

ZARXIO - filgrastim-sndz soln prefilled syringe480 mcg/0.8ml

2

Cardiovascular AgentsACCUPRIL - quinapril hcl tab 5 mg 2ACCUPRIL - quinapril hcl tab 10 mg 2

2019




ACCUPRIL - quinapril hcl tab 20 mg 2ACCUPRIL - quinapril hcl tab 40 mg 2acetazolamide cap er 12hr 500 mg 2acetazolamide tab 125 mg 2acetazolamide tab 250 mg 2ADALAT CC - nifedipine tab er 24hr 30 mg 2ADALAT CC - nifedipine tab er 24hr 60 mg 2ADALAT CC - nifedipine tab er 24hr 90 mg 2ALDACTONE - spironolactone tab 25 mg 2ALDACTONE - spironolactone tab 50 mg 2ALDACTONE - spironolactone tab 100 mg 2aliskiren fumarate tab 150 mg 1 QL (30 tablets/30 days)aliskiren fumarate tab 300 mg 1 QL (30 tablets/30 days)ALTACE - ramipril cap 1.25 mg 2ALTACE - ramipril cap 2.5 mg 2ALTACE - ramipril cap 5 mg 2ALTACE - ramipril cap 10 mg 2amiloride hcl tab 5 mg 1amiodarone hcl tab 200 mg 1amlodipine besylate tab 2.5 mg 1amlodipine besylate tab 5 mg 1amlodipine besylate tab 10 mg 1amlodipine besylate-benazepril hcl cap 2.5-10 mg 1amlodipine besylate-benazepril hcl cap 5-10 mg 1amlodipine besylate-benazepril hcl cap 5-20 mg 1amlodipine besylate-benazepril hcl cap 5-40 mg 1amlodipine besylate-benazepril hcl cap 10-20 mg 1amlodipine besylate-benazepril hcl cap 10-40 mg 1atenolol tab 25 mg 1atenolol tab 50 mg 1atenolol tab 100 mg 1atorvastatin calcium tab 10 mg 1 QL (45 tablets/30 days)atorvastatin calcium tab 20 mg 1 QL (45 tablets/30 days)atorvastatin calcium tab 40 mg 1 QL (45 tablets/30 days)atorvastatin calcium tab 80 mg 1 QL (30 tablets/30 days)AVALIDE - irbesartan-hydrochlorothiazide tab 150-12.5 mg 2 QL (30 tablets/30 days)AVALIDE - irbesartan-hydrochlorothiazide tab 300-12.5 mg 2 QL (30 tablets/30 days)AVAPRO - irbesartan tab 75 mg 2 QL (30 tablets/30 days)

2019


63



AVAPRO - irbesartan tab 150 mg 2 QL (60 tablets/30 days)AVAPRO - irbesartan tab 300 mg 2 QL (30 tablets/30 days)benazepril & hydrochlorothiazide tab 5-6.25 mg 1benazepril & hydrochlorothiazide tab 10-12.5 mg 1benazepril & hydrochlorothiazide tab 20-12.5 mg 1benazepril & hydrochlorothiazide tab 20-25 mg 1benazepril hcl tab 5 mg 1benazepril hcl tab 10 mg 1benazepril hcl tab 20 mg 1benazepril hcl tab 40 mg 1bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg 1bisoprolol & hydrochlorothiazide tab 5-6.25 mg 1bisoprolol & hydrochlorothiazide tab 10-6.25 mg 1bisoprolol fumarate tab 5 mg 1bisoprolol fumarate tab 10 mg 1bumetanide inj 0.25 mg/ml 2bumetanide tab 0.5 mg 1bumetanide tab 1 mg 1bumetanide tab 2 mg 1CALAN - verapamil hcl tab 120 mg 2CALAN SR - verapamil hcl tab er 120 mg 2CALAN SR - verapamil hcl tab er 240 mg 2captopril tab 12.5 mg 1captopril tab 25 mg 1captopril tab 50 mg 1captopril tab 100 mg 1CARDIZEM - diltiazem hcl tab 30 mg 2CARDIZEM - diltiazem hcl tab 60 mg 2CARDIZEM - diltiazem hcl tab 120 mg 2CARDIZEM CD - diltiazem hcl coated beads cap er 24hr

120 mg2

CARDIZEM CD - diltiazem hcl coated beads cap er 24hr180 mg

2


2


2


2

2019




CARDIZEM LA - diltiazem hcl coated beads tab er 24hr180 mg

2


2


2


2


2

carvedilol tab 3.125 mg 1carvedilol tab 6.25 mg 1carvedilol tab 12.5 mg 1carvedilol tab 25 mg 1chlorthalidone tab 25 mg 1chlorthalidone tab 50 mg 1cholestyramine light powder packets 4 gm 2cholestyramine light powder 4 gm/dose 2cholestyramine powder packets 4 gm 2cholestyramine powder 4 gm/dose 2clonidine hcl tab 0.1 mg 1clonidine hcl tab 0.2 mg 1clonidine hcl tab 0.3 mg 1clonidine td patch weekly 0.1 mg/24hr 2clonidine td patch weekly 0.2 mg/24hr 2clonidine td patch weekly 0.3 mg/24hr 2colestipol hcl granule packets 5 gm 1colestipol hcl granules 5 gm 1colestipol hcl tab 1 gm 1COREG - carvedilol tab 3.125 mg 2COREG - carvedilol tab 6.25 mg 2COREG - carvedilol tab 12.5 mg 2COREG - carvedilol tab 25 mg 2CORLANOR - ivabradine hcl oral soln 5 mg/5ml 1 PA, QL (600 mls/30 days)CORLANOR - ivabradine hcl tab 5 mg 1 PA, QL (60 tablets/30 days)CORLANOR - ivabradine hcl tab 7.5 mg 1 PA, QL (60 tablets/30 days)COZAAR - losartan potassium tab 25 mg 2 QL (60 tablets/30 days)COZAAR - losartan potassium tab 50 mg 2 QL (60 tablets/30 days)COZAAR - losartan potassium tab 100 mg 2 QL (30 tablets/30 days)

2019


65



DEMSER - metyrosine cap 250 mg 2digoxin oral soln 0.05 mg/ml# 2 QL (150 mls/30 days)digoxin tab 125 mcg (0.125 mg)# 1 QL (30 tablets/30 days)digoxin tab 250 mcg (0.25 mg)# 2 PA, QL (30 tablets/30 days)diltiazem hcl cap er 12hr 60 mg 1diltiazem hcl cap er 12hr 90 mg 1diltiazem hcl cap er 12hr 120 mg 1diltiazem hcl cap er 24hr 120 mg 1diltiazem hcl cap er 24hr 180 mg 1diltiazem hcl cap er 24hr 240 mg 1diltiazem hcl coated beads cap er 24hr 120 mg 1diltiazem hcl coated beads cap er 24hr 180 mg 1diltiazem hcl coated beads cap er 24hr 240 mg 1diltiazem hcl coated beads cap er 24hr 300 mg 1diltiazem hcl coated beads cap er 24hr 360 mg 1diltiazem hcl coated beads tab er 24hr 180 mg 2diltiazem hcl coated beads tab er 24hr 240 mg 2diltiazem hcl coated beads tab er 24hr 300 mg 2diltiazem hcl coated beads tab er 24hr 360 mg 2diltiazem hcl coated beads tab er 24hr 420 mg 2diltiazem hcl extended release beads cap er 24hr 120 mg 1diltiazem hcl extended release beads cap er 24hr 180 mg 1diltiazem hcl extended release beads cap er 24hr 240 mg 1diltiazem hcl extended release beads cap er 24hr 300 mg 1diltiazem hcl extended release beads cap er 24hr 360 mg 1diltiazem hcl extended release beads cap er 24hr 420 mg 1diltiazem hcl tab 30 mg 2diltiazem hcl tab 60 mg 2diltiazem hcl tab 90 mg 2diltiazem hcl tab 120 mg 2dofetilide cap 125 mcg (0.125 mg) 2dofetilide cap 250 mcg (0.25 mg) 2dofetilide cap 500 mcg (0.5 mg) 2doxazosin mesylate tab 1 mg 1 QL (60 tablets/30 days)doxazosin mesylate tab 2 mg 1 QL (60 tablets/30 days)doxazosin mesylate tab 4 mg 1 QL (60 tablets/30 days)doxazosin mesylate tab 8 mg 1 QL (60 tablets/30 days)enalapril maleate & hydrochlorothiazide tab 5-12.5 mg 1

2019




enalapril maleate & hydrochlorothiazide tab 10-25 mg 1enalapril maleate tab 2.5 mg 1enalapril maleate tab 5 mg 1enalapril maleate tab 10 mg 1enalapril maleate tab 20 mg 1ENTRESTO - sacubitril-valsartan tab 24-26 mg 1 QL (60 tablets/30 days)ENTRESTO - sacubitril-valsartan tab 49-51 mg 1 QL (60 tablets/30 days)ENTRESTO - sacubitril-valsartan tab 97-103 mg 1 QL (60 tablets/30 days)ezetimibe tab 10 mg 1 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-10 mg 1 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-20 mg 1 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-40 mg 1 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-80 mg 1 QL (30 tablets/30 days)felodipine tab er 24hr 2.5 mg 2felodipine tab er 24hr 5 mg 2felodipine tab er 24hr 10 mg 2fenofibrate micronized cap 67 mg 1 QL (30 capsules/30 days)fenofibrate micronized cap 134 mg 1 QL (30 capsules/30 days)fenofibrate micronized cap 200 mg 1 QL (30 capsules/30 days)fenofibrate tab 48 mg 1 QL (60 tablets/30 days)fenofibrate tab 54 mg 1 QL (60 tablets/30 days)fenofibrate tab 145 mg 1 QL (30 tablets/30 days)fenofibrate tab 160 mg 1 QL (30 tablets/30 days)flecainide acetate tab 50 mg 1flecainide acetate tab 100 mg 1flecainide acetate tab 150 mg 1fosinopril sodium tab 10 mg 1fosinopril sodium tab 20 mg 1fosinopril sodium tab 40 mg 1furosemide inj 10 mg/ml 2furosemide oral soln 10 mg/ml 1furosemide tab 20 mg 1furosemide tab 40 mg 1furosemide tab 80 mg 1gemfibrozil tab 600 mg 1 QL (60 tablets/30 days)hydralazine hcl tab 10 mg 1hydralazine hcl tab 25 mg 1hydralazine hcl tab 50 mg 1

2019


67



hydralazine hcl tab 100 mg 1hydrochlorothiazide cap 12.5 mg 1hydrochlorothiazide tab 12.5 mg 1hydrochlorothiazide tab 25 mg 1hydrochlorothiazide tab 50 mg 1HYZAAR - losartan potassium & hydrochlorothiazide tab

50-12.5 mg2 QL (30 tablets/30 days)

HYZAAR - losartan potassium & hydrochlorothiazide tab100-12.5 mg


HYZAAR - losartan potassium & hydrochlorothiazide tab100-25 mg


irbesartan tab 75 mg 1 QL (30 tablets/30 days)irbesartan tab 150 mg 1 QL (60 tablets/30 days)irbesartan tab 300 mg 1 QL (30 tablets/30 days)irbesartan-hydrochlorothiazide tab 150-12.5 mg 1 QL (30 tablets/30 days)irbesartan-hydrochlorothiazide tab 300-12.5 mg 1 QL (30 tablets/30 days)isosorbide dinitrate tab 5 mg 1isosorbide dinitrate tab 10 mg 1isosorbide dinitrate tab 20 mg 1isosorbide mononitrate tab er 24hr 30 mg 1isosorbide mononitrate tab er 24hr 60 mg 1isosorbide mononitrate tab er 24hr 120 mg 1labetalol hcl tab 100 mg 1labetalol hcl tab 200 mg 1labetalol hcl tab 300 mg 1LASIX - furosemide tab 20 mg 2LASIX - furosemide tab 40 mg 2LASIX - furosemide tab 80 mg 2LIPITOR - atorvastatin calcium tab 10 mg 2 QL (45 tablets/30 days)LIPITOR - atorvastatin calcium tab 20 mg 2 QL (45 tablets/30 days)LIPITOR - atorvastatin calcium tab 40 mg 2 QL (45 tablets/30 days)LIPITOR - atorvastatin calcium tab 80 mg 2 QL (30 tablets/30 days)lisinopril & hydrochlorothiazide tab 10-12.5 mg 1lisinopril & hydrochlorothiazide tab 20-12.5 mg 1lisinopril & hydrochlorothiazide tab 20-25 mg 1lisinopril tab 2.5 mg 1lisinopril tab 5 mg 1lisinopril tab 10 mg 1lisinopril tab 20 mg 1

2019




lisinopril tab 30 mg 1lisinopril tab 40 mg 1LOPRESSOR - metoprolol tartrate tab 50 mg 2LOPRESSOR - metoprolol tartrate tab 100 mg 2losartan potassium & hydrochlorothiazide tab 50-12.5 mg 1 QL (30 tablets/30 days)losartan potassium & hydrochlorothiazide tab 100-12.5 mg 1 QL (30 tablets/30 days)losartan potassium & hydrochlorothiazide tab 100-25 mg 1 QL (30 tablets/30 days)losartan potassium tab 25 mg 1 QL (60 tablets/30 days)losartan potassium tab 50 mg 1 QL (60 tablets/30 days)losartan potassium tab 100 mg 1 QL (30 tablets/30 days)LOTENSIN - benazepril hcl tab 10 mg 2LOTENSIN - benazepril hcl tab 20 mg 2LOTENSIN - benazepril hcl tab 40 mg 2lovastatin tab 10 mg 1 QL (60 tablets/30 days)lovastatin tab 20 mg 1 QL (60 tablets/30 days)lovastatin tab 40 mg 1 QL (60 tablets/30 days)methazolamide tab 25 mg 2methazolamide tab 50 mg 2metoprolol succinate tab er 24hr 25 mg 1metoprolol succinate tab er 24hr 50 mg 1metoprolol succinate tab er 24hr 100 mg 1metoprolol succinate tab er 24hr 200 mg 1metoprolol tartrate tab 25 mg 1metoprolol tartrate tab 50 mg 1metoprolol tartrate tab 100 mg 1mexiletine hcl cap 150 mg 2mexiletine hcl cap 200 mg 2mexiletine hcl cap 250 mg 2MICARDIS - telmisartan tab 20 mg 2 QL (30 tablets/30 days)MICARDIS - telmisartan tab 40 mg 2 QL (30 tablets/30 days)MICARDIS - telmisartan tab 80 mg 2 QL (30 tablets/30 days)MICARDIS HCT - telmisartan-hydrochlorothiazide tab

40-12.5 mg2 QL (30 tablets/30 days)

MICARDIS HCT - telmisartan-hydrochlorothiazide tab80-12.5 mg


MICARDIS HCT - telmisartan-hydrochlorothiazide tab80-25 mg


midodrine hcl tab 2.5 mg 2midodrine hcl tab 5 mg 2

2019


69



midodrine hcl tab 10 mg 2minoxidil tab 2.5 mg 1minoxidil tab 10 mg 1MULTAQ - dronedarone hcl tab 400 mg 1niacin tab er 500 mg 2 QL (30 tablets/30 days)niacin tab er 750 mg 2 QL (60 tablets/30 days)niacin tab er 1000 mg 2 QL (60 tablets/30 days)nifedipine tab er 24hr 30 mg 1nifedipine tab er 24hr 60 mg 1nifedipine tab er 24hr 90 mg 1nifedipine tab er 24hr osmotic release 30 mg 1nifedipine tab er 24hr osmotic release 60 mg 1nifedipine tab er 24hr osmotic release 90 mg 1nimodipine cap 30 mg 2NITRO-BID - nitroglycerin oint 2% 2nitroglycerin sl tab 0.3 mg 1nitroglycerin sl tab 0.4 mg 1nitroglycerin sl tab 0.6 mg 1nitroglycerin td patch 24hr 0.1 mg/hr 1nitroglycerin td patch 24hr 0.2 mg/hr 1nitroglycerin td patch 24hr 0.4 mg/hr 1nitroglycerin td patch 24hr 0.6 mg/hr 1NORTHERA - droxidopa cap 100 mg* 2 PANORTHERA - droxidopa cap 200 mg* 2 PANORTHERA - droxidopa cap 300 mg* 2 PANORVASC - amlodipine besylate tab 2.5 mg 2NORVASC - amlodipine besylate tab 5 mg 2NORVASC - amlodipine besylate tab 10 mg 2omega-3-acid ethyl esters cap 1 gm 1pentoxifylline tab er 400 mg 1phenoxybenzamine hcl cap 10 mg 2pindolol tab 5 mg 2pindolol tab 10 mg 2PRAVACHOL - pravastatin sodium tab 20 mg 2 QL (45 tablets/30 days)PRAVACHOL - pravastatin sodium tab 40 mg 2 QL (45 tablets/30 days)PRAVACHOL - pravastatin sodium tab 80 mg 2 QL (30 tablets/30 days)pravastatin sodium tab 10 mg 1 QL (45 tablets/30 days)pravastatin sodium tab 20 mg 1 QL (45 tablets/30 days)

2019




pravastatin sodium tab 40 mg 1 QL (45 tablets/30 days)pravastatin sodium tab 80 mg 1 QL (30 tablets/30 days)prazosin hcl cap 1 mg 1prazosin hcl cap 2 mg 1prazosin hcl cap 5 mg 1PRINIVIL - lisinopril tab 5 mg 2PRINIVIL - lisinopril tab 10 mg 2PRINIVIL - lisinopril tab 20 mg 2PROCARDIA XL - nifedipine tab er 24hr osmotic release

30 mg2

PROCARDIA XL - nifedipine tab er 24hr osmotic release60 mg

2

PROCARDIA XL - nifedipine tab er 24hr osmotic release90 mg

2

propafenone hcl cap er 12hr 225 mg 2propafenone hcl cap er 12hr 325 mg 2propafenone hcl cap er 12hr 425 mg 2propafenone hcl tab 150 mg 2propafenone hcl tab 225 mg 2propafenone hcl tab 300 mg 2propranolol hcl inj 1 mg/ml 1propranolol hcl tab 10 mg 1propranolol hcl tab 20 mg 1propranolol hcl tab 40 mg 1propranolol hcl tab 80 mg 1quinapril hcl tab 5 mg 1quinapril hcl tab 10 mg 1quinapril hcl tab 20 mg 1quinapril hcl tab 40 mg 1QUINIDINE SULFATE - quinidine sulfate tab 200 mg 2QUINIDINE SULFATE - quinidine sulfate tab 300 mg 2ramipril cap 1.25 mg 1ramipril cap 2.5 mg 1ramipril cap 5 mg 1ramipril cap 10 mg 1RANEXA - ranolazine tab er 12hr 500 mg 1 QL (60 tablets/30 days)RANEXA - ranolazine tab er 12hr 1000 mg 1 QL (60 tablets/30 days)ranolazine tab er 12hr 500 mg 1 QL (60 tablets/30 days)ranolazine tab er 12hr 1000 mg 1 QL (60 tablets/30 days)

2019


71



REPATHA - evolocumab subcutaneous soln prefilledsyringe 140 mg/ml


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

2 PA, QL (1 system/30 days)

REPATHA SURECLICK - evolocumab subcutaneous solnauto-injector 140 mg/ml

2 PA, QL (2 pens/28 days)

rosuvastatin calcium tab 5 mg 1 QL (45 tablets/30 days)rosuvastatin calcium tab 10 mg 1 QL (45 tablets/30 days)rosuvastatin calcium tab 20 mg 1 QL (45 tablets/30 days)rosuvastatin calcium tab 40 mg 1 QL (30 tablets/30 days)simvastatin tab 5 mg 1 QL (45 tablets/30 days)simvastatin tab 10 mg 1 QL (45 tablets/30 days)simvastatin tab 20 mg 1 QL (60 tablets/30 days)simvastatin tab 40 mg 1 QL (45 tablets/30 days)simvastatin tab 80 mg 1 QL (30 tablets/30 days)sotalol hcl (afib/afl) tab 80 mg 1sotalol hcl (afib/afl) tab 120 mg 1sotalol hcl (afib/afl) tab 160 mg 1sotalol hcl tab 80 mg 1sotalol hcl tab 120 mg 1sotalol hcl tab 160 mg 1sotalol hcl tab 240 mg 1spironolactone tab 25 mg 1spironolactone tab 50 mg 1spironolactone tab 100 mg 1SULAR - nisoldipine tab er 24hr 8.5 mg 2SULAR - nisoldipine tab er 24hr 17 mg 2SULAR - nisoldipine tab er 24hr 34 mg 2TEKTURNA - aliskiren fumarate tab 150 mg 1 QL (30 tablets/30 days)TEKTURNA - aliskiren fumarate tab 300 mg 1 QL (30 tablets/30 days)telmisartan tab 20 mg 1 QL (30 tablets/30 days)telmisartan tab 40 mg 1 QL (30 tablets/30 days)telmisartan tab 80 mg 1 QL (30 tablets/30 days)telmisartan-hydrochlorothiazide tab 40-12.5 mg 1 QL (30 tablets/30 days)telmisartan-hydrochlorothiazide tab 80-12.5 mg 1 QL (60 tablets/30 days)telmisartan-hydrochlorothiazide tab 80-25 mg 1 QL (30 tablets/30 days)terazosin hcl cap 1 mg 1 QL (90 capsules/30 days)terazosin hcl cap 2 mg 1 QL (60 capsules/30 days)terazosin hcl cap 5 mg 1 QL (60 capsules/30 days)

2019




terazosin hcl cap 10 mg 1 QL (60 capsules/30 days)TIAZAC - diltiazem hcl extended release beads cap er 24hr

120 mg2

TIAZAC - diltiazem hcl extended release beads cap er 24hr180 mg

2


2


2


2


2

torsemide tab 5 mg 1torsemide tab 10 mg 1torsemide tab 20 mg 1torsemide tab 100 mg 1triamterene & hydrochlorothiazide cap 37.5-25 mg 1triamterene & hydrochlorothiazide tab 37.5-25 mg 1triamterene & hydrochlorothiazide tab 75-50 mg 1VASERETIC - enalapril maleate & hydrochlorothiazide tab

10-25 mg2

VASOTEC - enalapril maleate tab 2.5 mg 2VASOTEC - enalapril maleate tab 5 mg 2VASOTEC - enalapril maleate tab 10 mg 2VASOTEC - enalapril maleate tab 20 mg 2verapamil hcl cap er 24hr 360 mg 2verapamil hcl cap er 24hr 100 mg 2verapamil hcl cap er 24hr 120 mg 2verapamil hcl cap er 24hr 180 mg 2verapamil hcl cap er 24hr 200 mg 2verapamil hcl cap er 24hr 240 mg 2verapamil hcl cap er 24hr 300 mg 2verapamil hcl tab er 120 mg 1verapamil hcl tab er 180 mg 1verapamil hcl tab er 240 mg 1verapamil hcl tab 40 mg 1verapamil hcl tab 80 mg 1verapamil hcl tab 120 mg 1VERELAN - verapamil hcl cap er 24hr 120 mg 2

2019


73



VERELAN - verapamil hcl cap er 24hr 180 mg 2VERELAN - verapamil hcl cap er 24hr 240 mg 2VERELAN - verapamil hcl cap er 24hr 360 mg 2VERELAN PM - verapamil hcl cap er 24hr 100 mg 2VERELAN PM - verapamil hcl cap er 24hr 200 mg 2VERELAN PM - verapamil hcl cap er 24hr 300 mg 2VYNDAMAX - tafamidis cap 61 mg 2 PA, QL (30 capsules/30 days)VYNDAQEL - tafamidis meglumine (cardiac) cap 20 mg 2 PA, QL (120

capsules/30 days)ZESTORETIC - lisinopril & hydrochlorothiazide tab

10-12.5 mg2

ZESTORETIC - lisinopril & hydrochlorothiazide tab20-12.5 mg

2

ZESTORETIC - lisinopril & hydrochlorothiazide tab20-25 mg

2

ZESTRIL - lisinopril tab 2.5 mg 2ZESTRIL - lisinopril tab 5 mg 2ZESTRIL - lisinopril tab 10 mg 2ZESTRIL - lisinopril tab 20 mg 2ZESTRIL - lisinopril tab 30 mg 2ZESTRIL - lisinopril tab 40 mg 2ZOCOR - simvastatin tab 10 mg 2 QL (45 tablets/30 days)ZOCOR - simvastatin tab 20 mg 2 QL (60 tablets/30 days)ZOCOR - simvastatin tab 40 mg 2 QL (45 tablets/30 days)ZOCOR - simvastatin tab 80 mg 2 QL (30 tablets/30 days)Central Nervous System Agentsamphetamine-dextroamphetamine cap er 24hr 5 mg 2 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 10 mg 2 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 15 mg 2 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 20 mg 2 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 25 mg 2 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 30 mg 2 QL (30 capsules/30 days)AMPYRA - dalfampridine tab er 12hr 10 mg* 2 PAatomoxetine hcl cap 10 mg 2 QL (60 capsules/30 days)atomoxetine hcl cap 18 mg 2 QL (60 capsules/30 days)atomoxetine hcl cap 25 mg 2 QL (60 capsules/30 days)atomoxetine hcl cap 40 mg 2 QL (60 capsules/30 days)atomoxetine hcl cap 60 mg 2 QL (30 capsules/30 days)atomoxetine hcl cap 80 mg 2 QL (30 capsules/30 days)

2019




atomoxetine hcl cap 100 mg 2 QL (30 capsules/30 days)AVONEX - interferon beta-1a im prefilled syringe kit

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

AVONEX PEN - interferon beta-1a im auto-injector kit30 mcg/0.5ml


BETASERON - interferon beta-1b for inj kit 0.3 mg 2 PA, QL (15 vials/syringes/30 days)

clonidine hcl tab er 12hr 0.1 mg 1 QL (120 tablets/30 days)dalfampridine tab er 12hr 10 mg 2 PAdexmethylphenidate hcl tab 2.5 mg 2 QL (60 tablets/30 days)dexmethylphenidate hcl tab 5 mg 2 QL (60 tablets/30 days)dexmethylphenidate hcl tab 10 mg 2 QL (60 tablets/30 days)dextroamphetamine sulfate tab 5 mg 2 QL (90 tablets/30 days)dextroamphetamine sulfate tab 10 mg 2 QL (180 tablets/30 days)glatiramer acetate soln prefilled syringe 20 mg/ml 2 PA, QL (30 syringes/30 days)glatiramer acetate soln prefilled syringe 40 mg/ml 2 PA, QL (12 syringes/28 days)MAYZENT - siponimod fumarate tab 0.25 mg 2 PA, QL (120 tablets/30 days)MAYZENT - siponimod fumarate tab 2 mg 2 PA, QL (30 tablets/30 days)methylphenidate hcl tab er 20 mg 2 QL (90 tablets/30 days)methylphenidate hcl tab 5 mg 2 QL (90 tablets/30 days)methylphenidate hcl tab 10 mg 2 QL (90 tablets/30 days)methylphenidate hcl tab 20 mg 2 QL (90 tablets/30 days)NUEDEXTA - dextromethorphan hbr-quinidine sulfate cap

20-10 mg1 PA, QL (60 capsules/30 days)

riluzole tab 50 mg 2TECFIDERA - dimethyl fumarate capsule delayed release

120 mg2 PA, QL (60 capsules/30 days)

TECFIDERA - dimethyl fumarate capsule delayed release240 mg


TECFIDERA STARTER PACK - dimethyl fumarate capsuledr starter pack 120 mg & 240 mg


tetrabenazine tab 12.5 mg 2 PA, QL (240 tablets/30 days)tetrabenazine tab 25 mg 2 PA, QL (120 tablets/30 days)Dental and Oral Agentschlorhexidine gluconate soln 0.12% 1KEPIVANCE - palifermin for iv inj 6.25 mg 2pilocarpine hcl tab 5 mg 2pilocarpine hcl tab 7.5 mg 2Dermatological Agentsacitretin cap 10 mg 2

2019


75



acitretin cap 17.5 mg 2acitretin cap 25 mg 2ACNE MEDICATION 10 - benzoyl peroxide lotion 10% 3 MCACNE MEDICATION 5 - benzoyl peroxide lotion 5% 3 MCALOE VESTA PROTECTIVE - skin protectants misc -

ointment3 MC

ARTHRITIS PAIN RELIEVING - capsaicin cream 0.075% 3 MCazelaic acid gel 15% 1bacitracin oint 500 unit/gm 3 MCbacitracin zinc oint 500 unit/gm 3 MCbacitracin-polymyxin b oint 3 MCBENZOYL PEROXIDE - benzoyl peroxide gel 2.5% 3 MCBENZOYL PEROXIDE CLEANSER - benzoyl peroxide liq

6%3 MC

benzoyl peroxide gel 5% 3 MCbenzoyl peroxide gel 10% 3 MCbenzoyl peroxide-erythromycin gel 5-3% 2BETADINE - povidone-iodine soln 5% 3 MCBETADINE - povidone-iodine soln 10% 3 MCBETADINE SURGICAL SCRUB - povidone-iodine soln

7.5%3 MC

BETADINE SWABSTICKS - povidone-iodine swabs 10% 3 MCbetamethasone dipropionate cream 0.05% 1betamethasone dipropionate lotion 0.05% 1betamethasone dipropionate oint 0.05% 1betamethasone valerate cream 0.1% 1betamethasone valerate lotion 0.1% 1betamethasone valerate oint 0.1% 1calcipotriene cream 0.005% 2calcipotriene soln 0.005% (50 mcg/ml) 2capsaicin cream 0.025% 3 MCCARAC - fluorouracil cream 0.5% 2chlorhexidine gluconate liquid 4% 3 MCchlorhexidine gluconate soln 4% 3 MCclobetasol propionate cream 0.05% 2clobetasol propionate emollient base cream 0.05% 2clobetasol propionate gel 0.05% 2clobetasol propionate oint 0.05% 2clobetasol propionate soln 0.05% 2

2019




clotrimazole w/ betamethasone cream 1-0.05% 1CONDYLOX - podofilox gel 0.5% 2CORTISPORIN - neomycin-polymyxin-hc crm 3.5 mg/

gm-10000 unt/gm-0.5%2

CORTISPORIN - bacitracin-polymyxin-neomycin hc oint 1% 2CRITIC-AID CLEAR MOISTUREBARRIER - skin

protectants misc - ointment3 MC

dibucaine rectal ointment 1% 3 MCELIDEL - pimecrolimus cream 1% 2 PAFINACEA - azelaic acid foam 15% 1FINACEA - azelaic acid gel 15% 1fluocinonide cream 0.05% 1fluocinonide emulsified base cream 0.05% 1fluocinonide gel 0.05% 1fluocinonide oint 0.05% 2fluocinonide soln 0.05% 2FLUOROURACIL - fluorouracil soln 2% 2FLUOROURACIL - fluorouracil soln 5% 2FLUOROURACIL - fluorouracil cream 0.5% 2fluorouracil cream 5% 2fluticasone propionate cream 0.05% 2fluticasone propionate oint 0.005% 2gentamicin sulfate cream 0.1% 2gentamicin sulfate oint 0.1% 2hydrocortisone cream 0.5% 3 MChydrocortisone cream 1% 1hydrocortisone cream 1% 3 MChydrocortisone cream 2.5% 1hydrocortisone lotion 1% 3 MChydrocortisone lotion 2.5% 1hydrocortisone oint 0.5% 3 MChydrocortisone oint 1% 1hydrocortisone oint 1% 3 MChydrocortisone oint 2.5% 1hydrocortisone-aloe vera cream 0.5% 3 MChydrocortisone-aloe vera cream 1% 3 MCimiquimod cream 5% 2 PAisotretinoin cap 10 mg 2

2019


77



isotretinoin cap 20 mg 2isotretinoin cap 30 mg 2isotretinoin cap 40 mg 2lactic acid (ammonium lactate) cream 12% 1lactic acid (ammonium lactate) lotion 12% 1lidocaine anorectal cream 5% 3 MCLOTRISONE - clotrimazole w/ betamethasone cream

1-0.05%2

metronidazole cream 0.75% 1metronidazole gel 0.75% 1metronidazole gel 1% 2metronidazole lotion 0.75% 1miconazole nitrate cream 2% 3 MCmometasone furoate cream 0.1% 2mometasone furoate oint 0.1% 2mometasone furoate solution 0.1% (lotion) 2mupirocin calcium cream 2% 2mupirocin oint 2% 1neomycin-bacitracin-polymyxin oint 3 MCneomycin-bacitracin-polymyxin-pramoxine oint 1% 3 MCphenylephrine in hard fat rectal suppos 0.25% 3 MCpimecrolimus cream 1% 2 PApodofilox soln 0.5% 1povidone-iodine oint 10% 3 MCpovidone-iodine soln 7.5% 3 MCpovidone-iodine soln 10% 3 MCpovidone-iodine swabs 10% 3 MCpramoxine hcl rectal foam 1% 3 MCprednicarbate cream 0.1% 2PROCTOFOAM - pramoxine hcl rectal foam 1% 3 MCPROSHIELD PLUS SKIN PROTECTANT - dimethicone

cream 1%3 MC

pyrantel pamoate susp 144 mg/ml 3 MCpyreth-piperonyl butox sham-permeth aero-nit remover gel

kit3 MC

pyrethrins-piperonyl butoxide shampoo 0.33-4% 3 MCREGRANEX - becaplermin gel 0.01% 2 PA, QL (15 grams/30 days)REMEDY NUTRASHIELD - dimethicone cream 1% 3 MCSANTYL - collagenase oint 250 unit/gm 1

2019




selenium sulfide lotion 2.5% 1SILVADENE - silver sulfadiazine cream 1% 2silver sulfadiazine cream 1% 2skin protectants misc - cream 3 MCSOOLANTRA - ivermectin cream 1% 1SWEEN CREAM - vitamins a & d cream 3 MCtacrolimus oint 0.03% 2 PAtacrolimus oint 0.1% 2 PAtazarotene cream 0.1% 2TAZORAC - tazarotene cream 0.05% 2TAZORAC - tazarotene gel 0.05% 2TAZORAC - tazarotene gel 0.1% 2tretinoin cream 0.025% 2tretinoin cream 0.05% 2tretinoin cream 0.1% 2tretinoin gel 0.01% 2tretinoin gel 0.025% 2triamcinolone acetonide cream 0.025% 1triamcinolone acetonide cream 0.1% 1triamcinolone acetonide cream 0.5% 1triamcinolone acetonide lotion 0.1% 2triamcinolone acetonide oint 0.025% 1triamcinolone acetonide oint 0.1% 1triamcinolone acetonide oint 0.5% 1vitamins a & d oint 3 MCzinc oxide oint 20% 3 MCElectrolytes/Minerals/Metals/Vitaminsamino acid infusion 6% 1 BDAMINOSYN II - amino acid infusion 10% 2 BDAMINOSYN-PF - amino acid infusion 10% 2 BDAMINOSYN-PF 7% - amino acid infusion 7% 2 BDcalcium acetate cap 667 mg 2calcium acetate tab 667 mg 2calcium carbonate-vitamin d tab 500 mg-200 unit 3 MCCALCIUM GLUCONATE - calcium gluconate tab 500 mg 3 MCCARBAGLU - carglumic acid tab 200 mg 2 PACHEMET - succimer cap 100 mg 2

2019


79



CLINIMIX E 2.75%/DEXTROSE 5% - amino acidelectrolyte w/cal infusion 2.75% in d5w

2 BD


2 BD


2 BD

CLINIMIX E 5%/DEXTROSE 15% - amino acid electrolytew/cal infusion 5% in d15w

2 BD

CLINIMIX E 5%/DEXTROSE 20% - amino acid electrolytew/cal infusion 5% in d20w

2 BD

CLINIMIX 4.25%/DEXTROSE 10% - amino acid infusion4.25% in d10w

2 BD


2 BD


2 BD

CLINIMIX 5%/DEXTROSE 15% - amino acid infusion 5% ind15w

2 BD


2 BD


2 BD

cyanocobalamin inj 1000 mcg/ml 3 MCdeferasirox tab for oral susp 125 mg 2 PAdeferasirox tab for oral susp 250 mg 2 PAdeferasirox tab for oral susp 500 mg 2 PAdextrose inj 5% 2dextrose inj 10% 2dextrose 2.5% w/ sodium chloride 0.45% 2dextrose 5% in lactated ringers 2dextrose 5% w/ sodium chloride 0.2% 2dextrose 5% w/ sodium chloride 0.33% 2dextrose 5% w/ sodium chloride 0.45% 2dextrose 5% w/ sodium chloride 0.9% 2ergocalciferol cap 1.25 mg (50000 unit) 3 MCergocalciferol soln 200 mcg/ml (8000 unit/ml) 3 MCEXJADE - deferasirox tab for oral susp 125 mg* 2 PAEXJADE - deferasirox tab for oral susp 250 mg* 2 PAEXJADE - deferasirox tab for oral susp 500 mg* 2 PAfat emulsion plant based iv emulsion 20% 2 BD

2019




FERAHEME - ferumoxytol inj 510 mg/17ml (30 mg/ml)(elemental fe)

3 MC

FERRLECIT - sod ferric gluc cmplx in sucrose iv soln12.5 mg/ml (fe eq)

3 MC

FERROUS SULFATE - ferrous sulfate tab ec 324 mg(65 mg fe equivalent)

3 MC

ferrous sulfate tab ec 325 mg (65 mg fe equivalent) 3 MCferrous sulfate tab 325 mg (65 mg elemental fe) 3 MCFOLIC ACID - folic acid inj 5 mg/ml 3 MCfolic acid tab 1 mg 3 MCFOSRENOL - lanthanum carbonate oral powder pack

750 mg2

FOSRENOL - lanthanum carbonate oral powder pack1000 mg

2

FREAMINE HBC 6.9% - amino acid infusion 6.9% 2 BDFREAMINE III - amino acid infusion 10% 2 BDGALZIN - zinc acetate cap 25 mg (elemental zinc) 3 MCGALZIN - zinc acetate cap 50 mg (elemental zinc) 3 MCHEPATAMINE - amino acid infusion 8% 2 BDHYDROXOCOBALAMIN - hydroxocobalamin acetate inj

1000 mcg/ml3 MC

INFED - iron dextran inj 50 mg/ml (elemental iron) 3 MCINFUVITE PEDIATRIC - pediatric multiple vitamins iv soln 3 MCINJECTAFER - ferric carboxymaltose iv soln 750 mg/15ml

(fe equivalent)3 MC

IONOSOL-MB/DEXTROSE 5% - electrolyte-mb in d5w soln 2irrigation solution, physiological 2ISOLYTE-P/DEXTROSE 5% - electrolyte-p in d5w soln 2ISOLYTE-S - electrolyte-s solution 2JADENU - deferasirox tab 90 mg 2 PAJADENU - deferasirox tab 180 mg 2 PAJADENU - deferasirox tab 360 mg 2 PAJADENU SPRINKLE - deferasirox granules packet 90 mg 2 PAJADENU SPRINKLE - deferasirox granules packet 180 mg 2 PAJADENU SPRINKLE - deferasirox granules packet 360 mg 2 PAkcl 20 meq/l (0.15%) in nacl 0.45% inj 2kcl 20 meq/l (0.15%) in nacl 0.9% inj 2kcl 40 meq/l (0.3%) in nacl 0.9% inj 2kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj 2kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj 2

2019


81



kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.33% inj 2kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj 2kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.9% inj 2kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj 2kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45% inj 2lactated ringer's for irrigation 2lactated ringer's solution 2lanthanum carbonate chew tab 500 mg 2lanthanum carbonate chew tab 750 mg 2lanthanum carbonate chew tab 1000 mg 2levocarnitine oral soln 1 gm/10ml (10%) 2levocarnitine tab 330 mg 2MAGNEBIND 300 - calcium carbonate-magnesium

carbonate tab 250-300 mg3 MC

magnesium sulfate inj 50% 1MEPHYTON - phytonadione tab 5 mg 3 MCNEPHRAMINE - amino acid infusion 5.4% 2 BDNORMOSOL-M IN D5W - electrolyte-m in d5w soln 2NORMOSOL-R - electrolyte-r (ph 7.4) solution 2NORMOSOL-R IN D5W - electrolyte-r in d5w soln 2parenteral electrolyte conc 2phytonadione inj 10 mg/ml 3 MCPLASMA-LYTE A - electrolyte-a solution 2PLASMA-LYTE-148 - electrolyte-148 solution 2potassium chloride cap er 8 meq 1potassium chloride cap er 10 meq 1potassium chloride inj 40 meq/100ml 2potassium chloride inj 2 meq/ml 1potassium chloride inj 10 meq/100ml 2potassium chloride inj 20 meq/100ml 2potassium chloride microencapsulated crys er tab 10 meq 1potassium chloride microencapsulated crys er tab 20 meq 1potassium chloride oral soln 10% (20 meq/15ml) 2potassium chloride tab er 8 meq (600 mg) 1potassium chloride tab er 10 meq 1potassium chloride 20 meq/l (0.15%) in dextrose 5% inj 2POTASSIUM CHLORIDE/DEXTROSE - potassium chloride

40 meq/l (0.3%) in dextrose 5% inj2

2019




POTASSIUM CHLORIDE/DEXTROSE/LACTATEDRINGERS - potassium chloride 20 meq/l (0.15%) in d5wlactated ringers

2

POTASSIUM CHLORIDE/DEXTROSE/LACTATEDRINGERS - potassium chloride 40 meq/l (0.3%) in d5wlactated ringers

2

potassium citrate tab er 5 meq (540 mg) 2potassium citrate tab er 10 meq (1080 mg) 2potassium citrate tab er 15 meq (1620 mg) 2PREMASOL - amino acid infusion 10% 2 BDPROCALAMINE - amino acid electrolyte infusion 3% 2 BDPROSOL - amino acid infusion 20% 2 BDpyridoxine hcl inj 100 mg/ml 3 MCringer's solution 2ringer's solution for irrigation 2sevelamer carbonate packet 0.8 gm 2sevelamer carbonate packet 2.4 gm 2sevelamer carbonate tab 800 mg 2sod ferric gluc cmplx in sucrose iv soln 12.5 mg/ml (fe eq) 3 MCsodium chloride inj 2.5 meq/ml (14.6%) 2sodium chloride irrigation soln 0.9% 2sodium chloride iv soln 0.45% 2sodium chloride iv soln 0.9% 2sodium chloride iv soln 3% 2sodium chloride iv soln 5% 2sodium polystyrene sulfonate oral susp 15 gm/60ml 1sodium polystyrene sulfonate powder 1sodium polystyrene sulfonate rectal susp 30 gm/120ml 1thiamine hcl inj 100 mg/ml 3 MCTRAVASOL - amino acid infusion 10% 2 BDtrientine hcl cap 250 mg 2 PA, QL (240

capsules/30 days)TRIFERIC - ferric pyrophosphate citrate pack 272 mg (fe

equiv)3 MC

TROPHAMINE - amino acid infusion 10% 2 BDVENOFER - iron sucrose inj 20 mg/ml (fe equiv) 3 MCwater for irrigation, sterile irrigation soln 2Gastrointestinal Agentsalosetron hcl tab 0.5 mg 2

2019


83



alosetron hcl tab 1 mg 2alum & mag hydroxide-simethicone chew tab

200-200-25 mg3 MC

alum & mag hydroxide-simethicone susp200-200-20 mg/5ml

3 MC

alum & mag hydroxide-simethicone susp400-400-40 mg/5ml

3 MC

ALUMINUM HYDROXIDE - aluminum hydroxide gel susp320 mg/5ml

3 MC

aluminum hydroxide-magnesium carbonate chew tab160-105 mg

3 MC

aluminum hydroxide-magnesium carbonate susp95-358 mg/15ml

3 MC

AMITIZA - lubiprostone cap 8 mcg 1 PAAMITIZA - lubiprostone cap 24 mcg 1 PAbisacodyl suppos 10 mg 3 MCbisacodyl tab delayed release 5 mg 3 MCbismuth subsalicylate chew tab 262 mg 3 MCbismuth subsalicylate susp 262 mg/15ml 3 MCbismuth subsalicylate susp 525 mg/15ml 3 MCbismuth subsalicylate tab 262 mg 3 MCcalcium carbonate (antacid) chew tab 500 mg 3 MCcalcium carbonate (antacid) chew tab 750 mg 3 MCcalcium carbonate (antacid) susp 1250 mg/5ml 3 MCcalcium carbonate tab 1250 mg (500 mg elemental ca) 3 MCcalcium polycarbophil tab 625 mg 3 MCCHENODAL - chenodiol tab 250 mg* 2 PACITRUCEL - methylcellulose tab 500 mg 3 MCCITRUCEL FIBER LAXATIVE - methylcellulose powder

laxative3 MC

COLACE - docusate sodium cap 100 mg 3 MCCOLACE CLEAR - docusate sodium cap 50 mg 3 MCCOLYTE-FLAVOR PACKS - peg 3350-kcl-na bicarb-nacl-

na sulfate for soln 240 gm2

dicyclomine hcl tab 20 mg# 2 PAdocusate calcium cap 240 mg 3 MCdocusate sodium cap 100 mg 3 MCdocusate sodium cap 250 mg 3 MCdocusate sodium enema 283 mg 3 MCdocusate sodium liquid 150 mg/15ml 3 MC

2019




docusate sodium syrup 60 mg/15ml 3 MCdocusate sodium tab 100 mg 3 MCDOCUSOL KIDS - docusate sodium enema 100 mg/5ml 3 MCDOCUSOL PLUS MINI-ENEMA - benzocaine-docusate

sodium rectal enema 20-283 mg3 MC

ENEMEEZ PLUS - benzocaine-docusate sodium rectalenema 20-283 mg

3 MC

esomeprazole magnesium cap delayed release 20 mg 2 QL (30 capsules/30 days)esomeprazole magnesium cap delayed release 40 mg 2 QL (30 capsules/30 days)EX-LAX - sennosides chew tab 15 mg 3 MCEX-LAX - sennosides tab 15 mg 3 MCEX-LAX MAXIMUM STRENGTH - sennosides tab 25 mg 3 MCfamotidine inj 20 mg/2ml 2famotidine inj 40 mg/4ml 2famotidine inj 200 mg/20ml 2famotidine tab 10 mg 3 MCfamotidine tab 20 mg 1famotidine tab 40 mg 1FIBERCON - calcium polycarbophil tab 625 mg 3 MCFLEET ENEMA - sodium phosphates - enema 3 MCFLEET LIQUID GLYCERIN SUPPOSITORIES - glycerin

enema adult 5.4 gm/average delivered dose3 MC

FLEET PEDIATRIC - sodium phosphates - enema(pediatric)

3 MC

GATTEX - teduglutide (rdna) for inj kit 5 mg* 2 PAGAVISCON - aluminum hydroxide-magnesium trisilicate

chew tab 80-14.2 mg3 MC

GAVISCON - aluminum hydroxide-magnesium carbonatesusp 95-358 mg/15ml

3 MC

GAVISCON EXTRA STRENGTH - aluminum hydroxide-magnesium carbonate chew tab 160-105 mg

3 MC

GAVISCON EXTRA STRENGTH - aluminum hydroxide-magnesium carbonate susp 508-475 mg/10ml

3 MC

GAVISCON EXTRA STRENGTH RELIEF FORMULA- aluminum hydroxide-magnesium carbonate susp508-475 mg/10ml

3 MC

GLYCERIN ADULT - glycerin suppos 2 gm 3 MCglycerin suppos 1.2 gm 3 MCglycerin suppos 2 gm 3 MCglycopyrrolate tab 1 mg 1

2019


85



glycopyrrolate tab 2 mg 1GOLYTELY - peg 3350-kcl-na bicarb-nacl-na sulfate for

soln 236 gm2

KAOPECTATE STOOL SOFTENER - docusate calcium cap240 mg

3 MC

KONSYL - psyllium powder 60.3% 3 MCKONSYL - psyllium powder 71.67% 3 MCKONSYL - psyllium powder packet 60.3% 3 MCKONSYL DAILY FIBER - psyllium powder 100% 3 MCKONSYL DAILY FIBER - psyllium powder packet 28.3% 3 MCKONSYL DAILY FIBER - psyllium powder packet 100% 3 MCKONSYL-D - psyllium powder 52.3% 3 MClactulose (encephalopathy) solution 10 gm/15ml 1lactulose solution 10 gm/15ml 1lansoprazole cap delayed release 15 mg 2 QL (30 capsules/30 days)lansoprazole cap delayed release 30 mg 2 QL (30 capsules/30 days)LINZESS - linaclotide cap 72 mcg 1 PALINZESS - linaclotide cap 145 mcg 1 PALINZESS - linaclotide cap 290 mcg 1 PAloperamide hcl cap 2 mg 1loperamide hcl cap 2 mg 3 MCloperamide hcl liq 1 mg/7.5ml 3 MCloperamide hcl liq 1 mg/5ml (0.2 mg/ml) 3 MCloperamide hcl tab 2 mg 3 MCmagnesium hydroxide susp 400 mg/5ml 3 MCmagnesium oxide tab 400 mg (241.3 mg elemental mg) 3 MCmagnesium oxide tab 400 mg 3 MCmagnesium oxide tab 420 mg 3 MCmethylcellulose powder laxative 3 MCmethylcellulose tab 500 mg 3 MCmetoclopramide hcl inj 5 mg/ml 2metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) 2metoclopramide hcl tab 5 mg 1metoclopramide hcl tab 10 mg 1MILK OF MAGNESIA CONCENTRATE- magnesium

hydroxide susp concentrate 2400 mg/10ml3 MC

misoprostol tab 100 mcg 2misoprostol tab 200 mcg 2

2019




MOVIPREP - peg 3350-kcl-nacl-na sulfate-na ascorbate-cfor soln 100 gm

2

MYALEPT - metreleptin for subcutaneous inj 11.3 mg* 2 PANULYTELY/FLAVOR PACKS - peg 3350-kcl-sod bicarb-

nacl for soln 420 gm2

omeprazole cap delayed release 10 mg 1 QL (30 capsules/30 days)omeprazole cap delayed release 20 mg 1 QL (60 capsules/30 days)omeprazole cap delayed release 40 mg 1 QL (60 capsules/30 days)pantoprazole sodium ec tab 20 mg 1 QL (30 tablets/30 days)pantoprazole sodium ec tab 40 mg 1 QL (60 tablets/30 days)pantoprazole sodium for iv soln 40 mg 2PEDIA-LAX - magnesium hydroxide chew tab 400 mg 3 MCPEDIA-LAX - docusate sodium liquid 50 mg/15ml 3 MCPEDIA-LAX - glycerin suppos 1 gm 3 MCPEDIA-LAX - glycerin liquid suppos 2.8 gm (2.7 ml) 3 MCpeg 3350-kcl-sod bicarb-nacl for soln 420 gm 2peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm 2peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm 1polyethylene glycol 3350 oral powder 3 MCpolyethylene glycol 3350 oral packet 3 MCpsyllium cap 0.52 gm 3 MCpsyllium powder 28.3% 3 MCpsyllium powder 30.9% 3 MCpsyllium powder 48.57% 3 MCpsyllium powder 58.6% 3 MCranitidine hcl syrup 15 mg/ml (75 mg/5ml) 1ranitidine hcl tab 75 mg 3 MCranitidine hcl tab 150 mg 1ranitidine hcl tab 300 mg 1RELISTOR - methylnaltrexone bromide tab 150 mg 2 PARELISTOR - methylnaltrexone bromide inj 8 mg/0.4ml

(20 mg/ml)2 PA

RELISTOR - methylnaltrexone bromide inj 12 mg/0.6ml(20 mg/ml)

2 PA

SENNA LEAVES - senna leaves 3 MCsennosides syrup 8.8 mg/5ml 3 MCsennosides tab 8.6 mg 3 MCsennosides tab 15 mg 3 MCsennosides tab 17.2 mg 3 MC

2019


87



sennosides tab 25 mg 3 MCsennosides-docusate sodium tab 8.6-50 mg 3 MCSENOKOT - sennosides tab 8.6 mg 3 MCSENOKOT S - sennosides-docusate sodium tab 8.6-50 mg 3 MCSODIUM BICARBONATE - sodium bicarbonate powder 3 MCsodium bicarbonate tab 325 mg 3 MCsodium bicarbonate tab 650 mg 3 MCsodium phosphates - enema 3 MCSORBITOL - sorbitol oral solution 70% 3 MCSORBITOL - sorbitol rectal solution 70% 3 MCsucralfate tab 1 gm 1SUPREP BOWEL PREP KIT - sod sulfate-pot sulf-mg sulf

oral sol 17.5-3.13-1.6 gm/177ml2

TUMS - calcium carbonate (antacid) chew tab 500 mg 3 MCTUMS CHEWY BITES - calcium carbonate (antacid) chew

tab 750 mg3 MC

TUMS E-X 750 - calcium carbonate (antacid) chew tab750 mg

3 MC

TUMS EXTRA STRENGTH 750 - calcium carbonate(antacid) chew tab 750 mg

3 MC

TUMS KIDS - calcium carbonate (antacid) chew tab750 mg

3 MC

TUMS SMOOTHIES - calcium carbonate (antacid) chewtab 750 mg

3 MC

ursodiol cap 300 mg 2ursodiol tab 250 mg 2ursodiol tab 500 mg 2XIFAXAN - rifaximin tab 550 mg 2ZANTAC 75 - ranitidine hcl tab 75 mg 3 MCGenetic or Enzyme Disorder: Replacement, Modifiers, TreatmentALDURAZYME - laronidase soln for iv infusion 2.9 mg/5ml

(500 unit/5ml)*2

CEREZYME - imiglucerase for inj 400 unit* 2 PACREON - pancrelipase (lip-prot-amyl) dr cap

3000-9500-15000 unit1

CREON - pancrelipase (lip-prot-amyl) dr cap6000-19000-30000 unit

1


1


1

2019





1

CRYSVITA - burosumab-twza inj 10 mg/ml 2 PACRYSVITA - burosumab-twza inj 20 mg/ml 2 PACRYSVITA - burosumab-twza inj 30 mg/ml 2 PACYSTADANE - betaine powder for oral solution 2CYSTAGON - cysteamine bitartrate cap 50 mg* 2 PACYSTAGON - cysteamine bitartrate cap 150 mg* 2 PAELAPRASE - idursulfase soln for iv infusion 6 mg/3ml

(2 mg/ml)*2

ELELYSO - taliglucerase alfa for inj 200 unit* 2 PAFABRAZYME - agalsidase beta for iv soln 5 mg* 2FABRAZYME - agalsidase beta for iv soln 35 mg* 2KUVAN - sapropterin dihydrochloride soluble tab 100 mg* 2 PAKUVAN - sapropterin dihydrochloride powder packet

100 mg*2 PA

KUVAN - sapropterin dihydrochloride powder packet500 mg*

2 PA

LUMIZYME - alglucosidase alfa for iv soln 50 mg 2miglustat cap 100 mg* 2 PA, QL (90 capsules/30 days)NAGLAZYME - galsulfase soln for iv infusion 1 mg/ml* 2nitisinone cap 2 mg* 2nitisinone cap 5 mg* 2nitisinone cap 10 mg* 2OCALIVA - obeticholic acid tab 5 mg* 2 PA, QL (30 tablets/30 days)OCALIVA - obeticholic acid tab 10 mg* 2 PA, QL (30 tablets/30 days)ORFADIN - nitisinone susp 4 mg/ml* 2ORFADIN - nitisinone cap 2 mg* 2ORFADIN - nitisinone cap 5 mg* 2ORFADIN - nitisinone cap 10 mg* 2ORFADIN - nitisinone cap 20 mg* 2PALYNZIQ - pegvaliase-pqpz subcutaneous soln pref

syringe 2.5 mg/0.5ml2 PA

PALYNZIQ - pegvaliase-pqpz subcutaneous soln prefsyringe 10 mg/0.5ml

2 PA

PALYNZIQ - pegvaliase-pqpz subcutaneous soln prefsyringe 20 mg/ml

2 PA

PROLASTIN-C - alpha1-proteinase inhibitor (human) inj1000 mg/20ml*

2 PA

2019


89



PROLASTIN-C - alpha1-proteinase inhibitor (human) for ivsoln 1000 mg*

2 PA

REVCOVI - elapegademase-lvlr im soln 2.4 mg/1.5ml(1.6 mg/ml)

2

sodium phenylbutyrate oral powder 3 gm/teaspoonful 2 PAsodium phenylbutyrate tab 500 mg 2 PASTRENSIQ - asfotase alfa subcutaneous inj 18 mg/0.45ml* 2 PASTRENSIQ - asfotase alfa subcutaneous inj 28 mg/0.7ml* 2 PASTRENSIQ - asfotase alfa subcutaneous inj 40 mg/ml* 2 PASTRENSIQ - asfotase alfa subcutaneous inj 80 mg/0.8ml* 2 PAVPRIV - velaglucerase alfa for inj 400 unit 2 PAZENPEP - pancrelipase (lip-prot-amyl) dr cap

3000-10000-14000 unit1

ZENPEP - pancrelipase (lip-prot-amyl) dr cap5000-17000-24000 unit

1


1


1


1


1


1

Genitourinary Agentsalfuzosin hcl tab er 24hr 10 mg 1 QL (30 tablets/30 days)AVODART - dutasteride cap 0.5 mg 2 QL (30 capsules/30 days)bethanechol chloride tab 5 mg 2bethanechol chloride tab 10 mg 2bethanechol chloride tab 25 mg 2bethanechol chloride tab 50 mg 2D-PENAMINE - penicillamine tab 125 mg 2DEPEN TITRATABS - penicillamine tab 250 mg 2dutasteride cap 0.5 mg 1 QL (30 capsules/30 days)finasteride tab 5 mg 1 QL (30 tablets/30 days)FLOMAX - tamsulosin hcl cap 0.4 mg 2 QL (60 capsules/30 days)methylergonovine maleate tab 0.2 mg 2MYRBETRIQ - mirabegron tab er 24 hr 25 mg 2 QL (30 tablets/30 days)MYRBETRIQ - mirabegron tab er 24 hr 50 mg 2 QL (30 tablets/30 days)

2019




oxybutynin chloride syrup 5 mg/5ml 1 QL (600 mls/30 days)oxybutynin chloride tab er 24hr 5 mg 2 QL (30 tablets/30 days)oxybutynin chloride tab er 24hr 10 mg 2 QL (90 tablets/30 days)oxybutynin chloride tab er 24hr 15 mg 2 QL (60 tablets/30 days)oxybutynin chloride tab 5 mg 1 QL (120 tablets/30 days)PROSCAR - finasteride tab 5 mg 2 QL (30 tablets/30 days)tamsulosin hcl cap 0.4 mg 1 QL (60 capsules/30 days)tolterodine tartrate cap er 24hr 2 mg 2 QL (30 capsules/30 days)tolterodine tartrate cap er 24hr 4 mg 2 QL (30 capsules/30 days)TOVIAZ - fesoterodine fumarate tab er 24hr 4 mg 1 QL (30 tablets/30 days)TOVIAZ - fesoterodine fumarate tab er 24hr 8 mg 1 QL (30 tablets/30 days)Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)CORTEF - hydrocortisone tab 10 mg 2CORTISONE ACETATE - cortisone acetate tab 25 mg 2DEXAMETHASONE - dexamethasone tab 1 mg 1DEXAMETHASONE - dexamethasone tab 2 mg 1dexamethasone elixir 0.5 mg/5ml 2dexamethasone sodium phosphate inj 4 mg/ml 2dexamethasone sodium phosphate inj 20 mg/5ml 2dexamethasone sodium phosphate inj 120 mg/30ml 2dexamethasone tab 0.5 mg 1dexamethasone tab 0.75 mg 1dexamethasone tab 1.5 mg 1dexamethasone tab 4 mg 1dexamethasone tab 6 mg 1fludrocortisone acetate tab 0.1 mg 1hydrocortisone tab 5 mg 2hydrocortisone tab 10 mg 2hydrocortisone tab 20 mg 2MEDROL - methylprednisolone tab 4 mg 2MEDROL - methylprednisolone tab 8 mg 2MEDROL - methylprednisolone tab 16 mg 2MEDROL - methylprednisolone tab 32 mg 2MEDROL DOSEPAK - methylprednisolone tab therapy

pack 4 mg (21)2

methylprednisolone sod succ for inj 40 mg 1methylprednisolone sod succ for inj 125 mg 1methylprednisolone sod succ for inj 500 mg 1

2019


91



methylprednisolone sod succ for inj 1000 mg 1methylprednisolone tab therapy pack 4 mg (21) 2methylprednisolone tab 4 mg 2methylprednisolone tab 8 mg 2methylprednisolone tab 16 mg 2methylprednisolone tab 32 mg 2prednisolone sod phosphate oral soln 15 mg/5ml 1prednisolone syrup 15 mg/5ml 1PREDNISONE - prednisone oral soln 5 mg/5ml 2prednisone tab therapy pack 5 mg (21) 1prednisone tab therapy pack 5 mg (48) 1prednisone tab therapy pack 10 mg (21) 1prednisone tab therapy pack 10 mg (48) 1prednisone tab 1 mg 1prednisone tab 2.5 mg 1prednisone tab 5 mg 1prednisone tab 10 mg 1prednisone tab 20 mg 1prednisone tab 50 mg 1SOLU-MEDROL - methylprednisolone sod succ for inj

40 mg2

SOLU-MEDROL - methylprednisolone sod succ for inj125 mg

2

SOLU-MEDROL - methylprednisolone sod succ for inj1000 mg

2

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)CHORIONIC GONADOTROPIN - chorionic gonadotropin

for im inj 10000 unit2 PA

DDAVP - desmopressin acetate nasal soln 0.01%(refrigerated)

2

DDAVP - desmopressin acetate inj 4 mcg/ml 2desmopressin acetate inj 4 mcg/ml 2desmopressin acetate tab 0.1 mg 2desmopressin acetate tab 0.2 mg 2INCRELEX - mecasermin inj 40 mg/4ml (10 mg/ml)* 2OMNITROPE - somatropin for inj 5.8 mg 2 PAOMNITROPE - somatropin inj 5 mg/1.5ml 2 PAOMNITROPE - somatropin inj 10 mg/1.5ml 2 PAPREGNYL W/DILUENT BENZYL ALCOHOL/NACL -

chorionic gonadotropin for im inj 10000 unit2 PA

2019




STIMATE - desmopressin acetate nasal soln 1.5 mg/ml 2Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)ANADROL-50 - oxymetholone tab 50 mg 2 PAANDRODERM - testosterone td patch 24hr 2 mg/24hr 1 PA, QL (30 patches/30 days)ANDRODERM - testosterone td patch 24hr 4 mg/24hr 1 PA, QL (30 patches/30 days)ANDROGEL - testosterone td gel 20.25 mg/1.25gm

(1.62%)1 PA, QL (30 packets/30 days)

ANDROGEL - testosterone td gel 40.5 mg/2.5gm (1.62%) 1 PA, QL (60 packets/30 days)ANDROGEL PUMP - testosterone td gel 20.25 mg/act

(1.62%)1 PA, QL (2 pump

bottles/30 days)COMBIPATCH - estradiol-norethindrone ace td pttw

0.05-0.14 mg/day#2

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

2

danazol cap 50 mg 2 PAdanazol cap 100 mg 2 PAdanazol cap 200 mg 2 PADEPO-PROVERA - medroxyprogesterone acetate im susp

400 mg/ml2

desogest-eth estrad & eth estrad tab0.15-0.02/0.01 mg(21/5)

1

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

1

desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg 1DIVIGEL - estradiol td gel 0.25 mg/0.25gm (0.1%)# 2DIVIGEL - estradiol td gel 0.5 mg/0.5gm (0.1%)# 2DIVIGEL - estradiol td gel 0.75 mg/0.75gm (0.1%)# 2DIVIGEL - estradiol td gel 1 mg/gm (0.1%)# 2drospirenone-ethinyl estrad-levomefolate tab

3-0.02-0.451 mg1

drospirenone-ethinyl estrad-levomefolate tab3-0.03-0.451 mg

2

drospirenone-ethinyl estradiol tab 3-0.02 mg 1drospirenone-ethinyl estradiol tab 3-0.03 mg 1DUAVEE - conjugated estrogens-bazedoxifene tab

0.45-20 mg#2

ELLA - ulipristal acetate tab 30 mg 1estradiol & norethindrone acetate tab 1-0.5 mg# 2estradiol tab 0.5 mg# 2estradiol tab 1 mg# 2estradiol tab 2 mg# 2

2019


93



estradiol td patch twice weekly 0.025 mg/24hr# 2estradiol td patch twice weekly 0.0375 mg/24hr# 2estradiol td patch twice weekly 0.05 mg/24hr# 2estradiol td patch twice weekly 0.075 mg/24hr# 2estradiol td patch twice weekly 0.1 mg/24hr# 2estradiol td patch weekly 0.025 mg/24hr# 2estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)# 2estradiol td patch weekly 0.05 mg/24hr# 2estradiol td patch weekly 0.06 mg/24hr# 2estradiol td patch weekly 0.075 mg/24hr# 2estradiol td patch weekly 0.1 mg/24hr# 2estradiol vaginal cream 0.1 mg/gm 2estradiol vaginal tab 10 mcg 1ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg 1ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg 1HYDROXYPROGESTERONE CAPROATE -

hydroxyprogesterone caproate im in oil 1.25 gm/5ml2

levonorg-eth est tab 0.1-0.02mg(84) & eth est tab0.01mg(7)

1

levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg 1levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg 1levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg 1levonorgestrel tab 1.5 mg 3 MClevonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-

mcg1

medroxyprogesterone acetate im susp prefilled syr 150 mg/ml

2

medroxyprogesterone acetate im susp 150 mg/ml 2medroxyprogesterone acetate tab 2.5 mg 1medroxyprogesterone acetate tab 5 mg 1medroxyprogesterone acetate tab 10 mg 1megestrol acetate susp 40 mg/ml# 2 PAmegestrol acetate tab 20 mg# 2 PAmegestrol acetate tab 40 mg# 2 PAnorethindrone & ethinyl estradiol tab 0.4 mg-35 mcg 1norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg 1norethindrone & ethinyl estradiol tab 1 mg-35 mcg 1norethindrone & ethinyl estradiol-fe chew tab

0.4 mg-35 mcg1

2019




norethindrone & ethinyl estradiol-fe chew tab0.8 mg-25 mcg

2

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

1

norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg 1norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg 1norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg 1norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg 1norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24) 1norethindrone acetate tab 5 mg 2norethindrone tab 0.35 mg 1norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-

mcg1

norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg 1norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg 1norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-

mcg1

norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg

1

norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg 1oxandrolone tab 2.5 mg 2 PAoxandrolone tab 10 mg 2 PAPLAN B ONE-STEP - levonorgestrel tab 1.5 mg 3 MCPREMARIN - estrogens, conjugated vaginal cream

0.625 mg/gm1

progesterone micronized cap 100 mg 1progesterone micronized cap 200 mg 1raloxifene hcl tab 60 mg 2testosterone cypionate im inj in oil 100 mg/ml 2 PAtestosterone cypionate im inj in oil 200 mg/ml 2 PAtestosterone td gel 25 mg/2.5gm (1%) 2 PA, QL (90 packets/30 days)testosterone td gel 50 mg/5gm (1%) 2 PA, QL (60 units/30 days)testosterone td gel 12.5 mg/act (1%) 2 PA, QL (4 pump

bottles/30 days)testosterone td gel 20.25 mg/1.25gm (1.62%) 1 PA, QL (30 packets/30 days)testosterone td gel 40.5 mg/2.5gm (1.62%) 1 PA, QL (60 packets/30 days)testosterone td gel 20.25 mg/act (1.62%) 1 PA, QL (2 pump

bottles/30 days)VAGIFEM - estradiol vaginal tab 10 mcg 2

2019


95



Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)levothyroxine sodium tab 25 mcg (levo-t, levoxyl, unithroid,

unithroid direct)1

levothyroxine sodium tab 50 mcg (levo-t, levoxyl, unithroid,unithroid direct)

1


1


1

levothyroxine sodium tab 100 mcg (levo-t, levoxyl,unithroid, unithroid direct)

1


1


1

levothyroxine sodium tab 137 mcg (levo-t, levoxyl,unithroid)

1


1


1


1

levothyroxine sodium tab 300 mcg (levo-t, unithroid,unithroid direct)

1

liothyronine sodium tab 5 mcg 1liothyronine sodium tab 25 mcg 1liothyronine sodium tab 50 mcg 1SYNTHROID - levothyroxine sodium tab 25 mcg 2SYNTHROID - levothyroxine sodium tab 50 mcg 2SYNTHROID - levothyroxine sodium tab 75 mcg 2SYNTHROID - levothyroxine sodium tab 88 mcg 2SYNTHROID - levothyroxine sodium tab 100 mcg 2SYNTHROID - levothyroxine sodium tab 112 mcg 2SYNTHROID - levothyroxine sodium tab 125 mcg 2SYNTHROID - levothyroxine sodium tab 137 mcg 2SYNTHROID - levothyroxine sodium tab 150 mcg 2SYNTHROID - levothyroxine sodium tab 175 mcg 2SYNTHROID - levothyroxine sodium tab 200 mcg 2SYNTHROID - levothyroxine sodium tab 300 mcg 2

2019




Hormonal Agents, Suppressant (Adrenal)KORLYM - mifepristone tab 300 mg* 2 PA, QL (120 tablets/30 days)LYSODREN - mitotane tab 500 mg 2Hormonal Agents, Suppressant (Pituitary)cabergoline tab 0.5 mg 2ELIGARD - leuprolide acetate for subcutaneous inj kit

7.5 mg2

ELIGARD - leuprolide acetate (3 month) for subcutaneousinj kit 22.5mg

2

ELIGARD - leuprolide acetate (4 month) for subcutaneousinj kit 30 mg

2

ELIGARD - leuprolide acetate (6 month) for subcutaneousinj kit 45 mg

2

FIRMAGON - degarelix acetate for inj 80 mg 2FIRMAGON - degarelix acetate for inj 120 mg 2leuprolide acetate inj kit 5 mg/ml 2LUPRON DEPOT (1-MONTH) - leuprolide acetate for inj kit

3.75 mg2

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

2

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

2

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

2

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

2

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

2

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate forinj pediatric kit 7.5 mg

2

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate forinj pediatric kit 11.25 mg

2

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate forinj pediatric kit 15 mg

2

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

2

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

2

octreotide acetate inj 50 mcg/ml (0.05 mg/ml) 2 PAoctreotide acetate inj 100 mcg/ml (0.1 mg/ml) 2 PAoctreotide acetate inj 200 mcg/ml (0.2 mg/ml) 2 PAoctreotide acetate inj 500 mcg/ml (0.5 mg/ml) 2 PA

2019


97



octreotide acetate inj 1000 mcg/ml (1 mg/ml) 2 PASANDOSTATIN - octreotide acetate inj 50 mcg/ml

(0.05 mg/ml)2 PA

SANDOSTATIN - octreotide acetate inj 100 mcg/ml(0.1 mg/ml)

2 PA

SANDOSTATIN - octreotide acetate inj 500 mcg/ml(0.5 mg/ml)

2 PA

SIGNIFOR - pasireotide diaspartate inj 0.3 mg/ml* 2 PASIGNIFOR - pasireotide diaspartate inj 0.6 mg/ml* 2 PASIGNIFOR - pasireotide diaspartate inj 0.9 mg/ml* 2 PASOMATULINE DEPOT - lanreotide acetate extended

release inj 60 mg/0.2ml2 PA

SOMATULINE DEPOT - lanreotide acetate extendedrelease inj 90 mg/0.3ml

2 PA

SOMATULINE DEPOT - lanreotide acetate extendedrelease inj 120 mg/0.5ml

2 PA

SOMAVERT - pegvisomant for inj 10 mg* 2 PASOMAVERT - pegvisomant for inj 15 mg* 2 PASOMAVERT - pegvisomant for inj 20 mg* 2 PASOMAVERT - pegvisomant for inj 25 mg* 2 PASOMAVERT - pegvisomant for inj 30 mg* 2 PASYNAREL - nafarelin acetate nasal soln 2 mg/ml (200 mcg/

act)2

TRELSTAR - triptorelin pamoate for im susp 3.75 mg 2 PATRELSTAR - triptorelin pamoate for im susp 11.25 mg 2 PATRELSTAR MIXJECT - triptorelin pamoate for im susp

3.75 mg2 PA

TRELSTAR MIXJECT - triptorelin pamoate for im susp11.25 mg

2 PA

TRELSTAR MIXJECT - triptorelin pamoate for im susp22.5 mg

2 PA

Hormonal Agents, Suppressant (Thyroid)methimazole tab 5 mg 1methimazole tab 10 mg 1propylthiouracil tab 50 mg 1Immunological AgentsACTHIB - haemophilus b polysaccharide conjugate vaccine

for inj2

ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml(2000000 unit/0.5ml)*

2 PA

ADACEL - tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml

2

2019




ARCALYST - rilonacept for inj 220 mg* 2 PAAZATHIOPRINE - azathioprine sodium for inj 100 mg 2 BDazathioprine tab 50 mg 1 BDBCG VACCINE - bcg vaccine inj 2BENLYSTA - belimumab subcutaneous solution auto-

injector 200 mg/ml2 PA

BENLYSTA - belimumab subcutaneous solution prefilledsyringe 200 mg/ml

2 PA

BENLYSTA - belimumab for iv soln 120 mg 2 PABENLYSTA - belimumab for iv soln 400 mg 2 PABEXSERO - meningococcal vac b (recomb omv adjuv) inj

prefilled syringe2

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

2

CINRYZE - c1 esterase inhibitor (human) for iv inj 500 unit* 2 PA, QL (20 vials/30 days)COSENTYX - secukinumab subcutaneous soln prefilled

syringe 150 mg/ml*2 PA

COSENTYX - secukinumab subcutaneous pref syr 150 mg/ml (300 mg dose)*

2 PA

COSENTYX SENSOREADY PEN - secukinumabsubcutaneous soln auto-injector 150 mg/ml*

2 PA

COSENTYX SENSOREADY PEN - secukinumabsubcutaneous auto-inj 150 mg/ml (300 mg dose)*

2 PA

cyclosporine cap 25 mg 2 BDcyclosporine cap 100 mg 2 BDcyclosporine iv soln 50 mg/ml 2 BDCYCLOSPORINE MODIFIED - cyclosporine modified cap

50 mg2 BD

cyclosporine modified cap 25 mg 2 BDcyclosporine modified cap 100 mg 2 BDcyclosporine modified oral soln 100 mg/ml 2 BDDAPTACEL - diph, acellular pert & tet tox inj 15 lf-23 mcg-5

lf/0.5ml2

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

2

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

2 BD

ENGERIX-B - hepatitis b vaccine (recombinant) susp20 mcg/ml

2 BD

FIRAZYR - icatibant acetate inj 30 mg/3ml 2 PA, QL (6 syringes/30 days)GAMMAGARD LIQUID - immune globulin (human) iv or

subcutaneous soln 1 gm/10ml2 BD, PA

2019


99



GAMMAGARD LIQUID - immune globulin (human) iv orsubcutaneous soln 2.5 gm/25ml

2 BD, PA

GAMMAGARD LIQUID - immune globulin (human) iv orsubcutaneous soln 5 gm/50ml

2 BD, PA


2 BD, PA


2 BD, PA


2 BD, PA

GAMMAGARD S/D - immune globulin (human) iv for soln5 gm

2 BD, PA

GAMMAGARD S/D - immune globulin (human) iv for soln10 gm

2 BD, PA

GAMMAPLEX - immune globulin (human) iv soln5 gm/100ml

2 BD, PA


2 BD, PA


2 BD, PA


2 BD, PA


2 BD, PA


2 BD, PA

GAMUNEX-C - immune globulin (human) iv orsubcutaneous soln 1 gm/10ml

2 BD, PA

GAMUNEX-C - immune globulin (human) iv orsubcutaneous soln 2.5 gm/25ml

2 BD, PA


2 BD, PA


2 BD, PA


2 BD, PA


2 BD, PA

GARDASIL 9 - human papillomavirus (hpv) 9-valentrecomb vac susp pref syr

2

GARDASIL 9 - human papillomavirus (hpv) 9-valentrecomb vac im susp

2

HAEGARDA - c1 esterase inhibitor (human) forsubcutaneous inj 2000 unit


2019




HAEGARDA - c1 esterase inhibitor (human) forsubcutaneous inj 3000 unit


HAVRIX - hepatitis a vaccine inj susp 720 el unit/0.5ml 2HAVRIX - hepatitis a vaccine inj susp 1440 el unit/ml 2HIBERIX - haemophilus b polysaccharide conjugate vac for

inj 10 mcg2

HUMIRA - adalimumab prefilled syringe kit 10 mg/0.1ml 2 PAHUMIRA - adalimumab prefilled syringe kit 10 mg/0.2ml 2 PAHUMIRA - adalimumab prefilled syringe kit 20 mg/0.2ml 2 PAHUMIRA - adalimumab prefilled syringe kit 20 mg/0.4ml 2 PAHUMIRA - adalimumab prefilled syringe kit 40 mg/0.8ml 2 PAHUMIRA - adalimumab prefilled syringe kit 40 mg/0.4ml 2 PAHUMIRA PEDIATRIC CROHNS DISEASE STARTER

PACK - adalimumab prefilled syringe kit 40 mg/0.8ml2 PA

HUMIRA PEDIATRIC CROHNS DISEASE STARTERPACK - adalimumab prefilled syringe kit 80 mg/0.8ml

2 PA

HUMIRA PEDIATRIC CROHNS DISEASE STARTERPACK - adalimumab prefilled syringe kit 80 mg/0.8ml &40 mg/0.4ml

2 PA

HUMIRA PEN - adalimumab pen-injector kit 40 mg/0.8ml 2 PAHUMIRA PEN - adalimumab pen-injector kit 40 mg/0.4ml 2 PAHUMIRA PEN-CD/UC/HS STARTER - adalimumab pen-

injector kit 40 mg/0.8ml2 PA

HUMIRA PEN-CD/UC/HS STARTER - adalimumab pen-injector kit 80 mg/0.8ml

2 PA

HUMIRA PEN-PS/UV STARTER - adalimumab pen-injectorkit 40 mg/0.8ml

2 PA

HUMIRA PEN-PS/UV STARTER - adalimumab pen-injectorkit 80 mg/0.8ml & 40 mg/0.4ml

2 PA

icatibant acetate inj 30 mg/3ml 2 PA, QL (6 syringes/30 days)ILARIS - canakinumab subcutaneous inj 150 mg/ml* 2 PAIMOVAX RABIES (H.D.C.V.) - rabies virus vaccine, hdc inj 2 BDINFANRIX - diph, acellular pert & tet tox inj 25 lf-58 mcg-10

lf/0.5ml2

IPOL INACTIVATED IPV - poliovirus vaccine, ipv injection 2IXIARO - japanese encephalitis vaccine inactivated

adsorbed inj2

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

2

leflunomide tab 10 mg 2leflunomide tab 20 mg 2

2019


101



M-M-R II - measles-mumps-rubella virus vaccines for injsoln

2

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

2

MENVEO - meningococcal (a, c, y, and w-135) oligo conjvac for inj

2

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

1

methotrexate sodium for inj 1 gm 1methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) 1methotrexate sodium inj pf 250 mg/10ml (25 mg/ml) 1methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) 1methotrexate sodium inj 50 mg/2ml (25 mg/ml) 1methotrexate sodium tab 2.5 mg 1mycophenolate mofetil cap 250 mg 1 BDmycophenolate mofetil for oral susp 200 mg/ml 2 BDmycophenolate mofetil hcl for iv soln 500 mg 2 BDmycophenolate mofetil tab 500 mg 1 BDNULOJIX - belatacept for iv infusion 250 mg 2 BDORENCIA - abatacept for iv soln 250 mg 2 PAORENCIA - abatacept subcutaneous soln prefilled syringe

50 mg/0.4ml2 PA

ORENCIA - abatacept subcutaneous soln prefilled syringe87.5 mg/0.7ml

2 PA

ORENCIA - abatacept subcutaneous soln prefilled syringe125 mg/ml

2 PA

ORENCIA CLICKJECT - abatacept subcutaneous solnauto-injector 125 mg/ml

2 PA

OTEZLA - apremilast tab starter therapy pack 10 mg &20 mg & 30 mg*

2 PA

OTEZLA - apremilast tab 30 mg* 2 PAPEDIARIX - diph-tetanus tox-acell pert-hepatitis b-polio ipv

vac inj2

PEDVAX HIB - haemophilus b polysaccharide conj vac imsusp 7.5 mcg/0.5 ml

2

PENTACEL - diph-ac per-tet tox ad-poliov-haemoph b polyvac for im susp

2

PROGRAF - tacrolimus inj 5 mg/ml 2 BDPROGRAF - tacrolimus packet for susp 0.2 mg 2 BDPROGRAF - tacrolimus packet for susp 1 mg 2 BD

2019




PROQUAD - measles-mumps-rubella-varicella virusvaccines for susp

2

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

2

RABAVERT - rabies vaccine, pcec for inj 2 BDRAPAMUNE - sirolimus oral soln 1 mg/ml 2 BDRECOMBIVAX HB - hepatitis b vaccine (recombinant) susp

5 mcg/0.5ml2 BD

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

2 BD

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

2 BD

RENFLEXIS - infliximab-abda for iv inj 100 mg 2 PAROTARIX - rotavirus vaccine, live for oral susp 2ROTATEQ - rotavirus vaccine, live oral pentavalent soln 2SANDIMMUNE - cyclosporine oral soln 100 mg/ml 2 BDSHINGRIX - zoster vac recombinant adjuvanted for im inj

50 mcg/0.5ml2 QL (2 vaccines/lifetime)

sirolimus oral soln 1 mg/ml 2 BDsirolimus tab 0.5 mg 2 BDsirolimus tab 1 mg 2 BDsirolimus tab 2 mg 2 BDSTAMARIL - yellow fever vaccine for inj suspension 2SYLVANT - siltuximab for iv infusion 100 mg 2SYLVANT - siltuximab for iv infusion 400 mg 2SYNAGIS - palivizumab im soln 50 mg/0.5ml* 2SYNAGIS - palivizumab im soln 100 mg/ml* 2tacrolimus cap 0.5 mg 2 BDtacrolimus cap 1 mg 2 BDtacrolimus cap 5 mg 2 BDTDVAX - tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml 1TENIVAC - tetanus-diphtheria toxoids (td) inj 5-2 lfu 2THYMOGLOBULIN - anti-thymocyte globulin for iv soln

25 mg (lymphocyte ig)2 BD

TRUMENBA - meningococcal group b vac (recomb) imsusp prefilled syr

2

TWINRIX - hep a-hep b vaccine susp pref syr 720-20 elu-mcg/ml

2

TYPHIM VI - typhoid vi polysaccharide intramuscular vacinj 25 mcg/0.5ml

2

VAQTA - hepatitis a vaccine inj susp 25 unit/0.5ml 2

2019


103



VAQTA - hepatitis a vaccine inj susp 50 unit/ml 2VARIVAX - varicella virus vac live for subcutaneous inj

1350 pfu/0.5ml2

XATMEP - methotrexate oral soln 2.5 mg/ml 2 BDXOLAIR - omalizumab for inj 150 mg* 2 PAXOLAIR - omalizumab subcutaneous soln prefilled syringe

75 mg/0.5ml*2 PA

XOLAIR - omalizumab subcutaneous soln prefilled syringe150 mg/ml*

2 PA

YF-VAX - yellow fever vaccine subcutaneous inj 2ZORTRESS - everolimus tab 0.25 mg 2 BDZORTRESS - everolimus tab 0.5 mg 2 BDZORTRESS - everolimus tab 0.75 mg 2 BDZORTRESS - everolimus tab 1 mg 2 BDZOSTAVAX - zoster vaccine live for subcutaneous susp

19400 unit/0.65ml2 QL (1 vaccine/lifetime)

Inflammatory Bowel Disease AgentsAPRISO - mesalamine cap er 24hr 0.375 gm 2ASACOL HD - mesalamine tab delayed release 800 mg 2balsalazide disodium cap 750 mg 2budesonide delayed release particles cap 3 mg 2CANASA - mesalamine suppos 1000 mg 2DIPENTUM - olsalazine sodium cap 250 mg 2hydrocortisone enema 100 mg/60ml 2hydrocortisone rectal cream 1% 1hydrocortisone rectal cream 2.5% 1mesalamine enema 4 gm 2mesalamine rectal enema 4 gm & cleanser wipe kit 2mesalamine suppos 1000 mg 2mesalamine tab delayed release 800 mg 2mesalamine tab delayed release 1.2 gm 1sulfasalazine tab delayed release 500 mg 2sulfasalazine tab 500 mg 1Metabolic Bone Disease Agentsalendronate sodium tab 5 mg 1 QL (30 tablets/30 days)alendronate sodium tab 10 mg 1 QL (120 tablets/30 days)alendronate sodium tab 35 mg 1 QL (4 tablets/28 days)alendronate sodium tab 70 mg 1 QL (4 tablets/28 days)calcitonin (salmon) nasal soln 200 unit/act 2

2019




calcitriol cap 0.25 mcg 1calcitriol cap 0.5 mcg 1calcitriol inj 1 mcg/ml 2calcitriol oral soln 1 mcg/ml 2cinacalcet hcl tab 30 mg 2 PAcinacalcet hcl tab 60 mg 2 PAcinacalcet hcl tab 90 mg 2 PAFORTEO - teriparatide (recombinant) inj 600 mcg/2.4ml 2 PAibandronate sodium tab 150 mg 1 QL (1 tablet/28 days)MIACALCIN - calcitonin (salmon) inj 200 unit/ml 2NATPARA - parathyroid hormone (recombinant) for inj

cartridge 25 mcg*2 PA, QL (2 cartridges/28 days)

NATPARA - parathyroid hormone (recombinant) for injcartridge 50 mcg*

2 PA, QL (2 cartridges/28 days)





paricalcitol cap 1 mcg 2paricalcitol cap 2 mcg 2paricalcitol cap 4 mcg 2paricalcitol iv soln 2 mcg/ml 2paricalcitol iv soln 5 mcg/ml 2PROLIA - denosumab inj soln prefilled syringe 60 mg/ml 2 PASENSIPAR - cinacalcet hcl tab 30 mg 2 PASENSIPAR - cinacalcet hcl tab 60 mg 2 PASENSIPAR - cinacalcet hcl tab 90 mg 2 PATYMLOS - abaloparatide subcutaneous soln pen-injector

3120 mcg/1.56ml2 PA

XGEVA - denosumab inj 120 mg/1.7ml 2 PAzoledronic acid inj conc for iv infusion 4 mg/5ml 2zoledronic acid iv soln 5 mg/100ml 2Ophthalmic AgentsACULAR - ketorolac tromethamine ophth soln 0.5% 2ACULAR LS - ketorolac tromethamine ophth soln 0.4% 2ACUVAIL - ketorolac tromethamine (pf) ophth soln 0.45% 2ALOCRIL - nedocromil sodium ophth soln 2% 2ALREX - loteprednol etabonate ophth susp 0.2% 2artificial tear ophth ointment 3 MC

2019


105



artificial tear ophth solution 3 MCazelastine hcl ophth soln 0.05% 1BACITRACIN - bacitracin ophth oint 500 unit/gm 2bacitracin-polymyxin b ophth oint 1BESIVANCE - besifloxacin hcl ophth susp 0.6% 2betaxolol hcl ophth soln 0.5% 1BLEPHAMIDE - sulfacetamide sodium-prednisolone ophth

susp 10-0.2%2

brimonidine tartrate ophth soln 0.15% 1brimonidine tartrate ophth soln 0.2% 1bromfenac sodium ophth soln 0.09% (once-daily) 2carteolol hcl ophth soln 1% 1CILOXAN - ciprofloxacin hcl ophth soln 0.3% 2ciprofloxacin hcl ophth soln 0.3% 1COSOPT - dorzolamide hcl-timolol maleate ophth soln

22.3-6.8 mg/ml2

cromolyn sodium ophth soln 4% 1CYSTARAN - cysteamine hcl ophth soln 0.44% 2DEXAMETHASONE SODIUM PHOSPHATE -

dexamethasone sodium phosphate ophth soln 0.1%2

dextran 70-hypromellose ophth soln 0.1-0.3% 3 MCdextran 70-hypromellose (pf) ophth soln 0.1-0.3% 3 MCdiclofenac sodium ophth soln 0.1% 1dorzolamide hcl ophth soln 2% 1dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml 1DUREZOL - difluprednate ophth emulsion 0.05% 2epinastine hcl ophth soln 0.05% 1erythromycin ophth oint 5 mg/gm 1FLAREX - fluorometholone acetate ophth susp 0.1% 2fluorometholone ophth susp 0.1% 2flurbiprofen sodium ophth soln 0.03% 1FML - fluorometholone ophth oint 0.1% 2FML FORTE - fluorometholone ophth susp 0.25% 2FML LIQUIFILM - fluorometholone ophth susp 0.1% 2gentamicin sulfate ophth oint 0.3% 1gentamicin sulfate ophth soln 0.3% 1ILEVRO - nepafenac ophth susp 0.3% 1ketorolac tromethamine ophth soln 0.4% 1ketorolac tromethamine ophth soln 0.5% 1

2019




LACRISERT - artificial tear ophth insert 2latanoprost ophth soln 0.005% 1levobunolol hcl ophth soln 0.5% 1MAXITROL - neomycin-polymyxin-dexamethasone ophth

susp 0.1%2

MAXITROL - neomycin-polymyxin-dexamethasone ophthoint 0.1%

2

MOXEZA - moxifloxacin hcl ophth soln 0.5% (2 times daily) 2moxifloxacin hcl ophth soln 0.5% 1MURO 128 - sodium chloride hypertonic ophth soln 2% 3 MCNATACYN - natamycin ophth susp 5% 2neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-

unt-mg/ml1

neomycin-polymyxin-dexamethasone ophth oint 0.1% 1neomycin-polymyxin-dexamethasone ophth susp 0.1% 1NEVANAC - nepafenac ophth susp 0.1% 2OCUFLOX - ofloxacin ophth soln 0.3% 2ofloxacin ophth soln 0.3% 1PATANOL - olopatadine hcl ophth soln 0.1% 2PHOSPHOLINE IODIDE - echothiophate iodide ophth for

soln 0.125%2

pilocarpine hcl ophth soln 1% 2pilocarpine hcl ophth soln 2% 2pilocarpine hcl ophth soln 4% 2polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% 1POLYTRIM - polymyxin b-trimethoprim ophth soln 10000

unit/ml-0.1%2

polyvinyl alcohol ophth soln 1.4% 3 MCpolyvinyl alcohol-povidone ophth soln 5-6 mg/ml (0.5-0.6%) 3 MCPRED FORTE - prednisolone acetate ophth susp 1% 2PRED MILD - prednisolone acetate ophth susp 0.12% 2PRED-G - gentamicin-prednisolone ace ophth susp 0.3-1% 2PRED-G S.O.P. - gentamicin-prednisolone ace ophth oint

0.3-0.6%2

prednisolone acetate ophth susp 1% 2PROLENSA - bromfenac sodium ophth soln 0.07% 2RESTASIS - cyclosporine (ophth) emulsion 0.05% 2 PA, QL (60 vials/30 days)RESTASIS MULTIDOSE - cyclosporine (ophth) emulsion

0.05%2 PA, QL (2 bottles/30 days)

sodium chloride hypertonic ophth oint 5% 3 MC

2019


107



sodium chloride hypertonic ophth soln 5% 3 MCsulfacetamide sodium ophth soln 10% 1sulfacetamide sodium-prednisolone ophth soln

10-0.23(0.25)%1

timolol maleate ophth gel forming soln 0.25% 1timolol maleate ophth gel forming soln 0.5% 1timolol maleate ophth soln 0.25% 1timolol maleate ophth soln 0.5% 1TIMOPTIC - timolol maleate ophth soln 0.25% 2TIMOPTIC - timolol maleate ophth soln 0.5% 2TIMOPTIC-XE - timolol maleate ophth gel forming soln

0.25%2

TOBRADEX - tobramycin-dexamethasone ophth susp0.3-0.1%

2

TOBRADEX ST - tobramycin-dexamethasone ophth susp0.3-0.05%

2

tobramycin ophth soln 0.3% 1tobramycin-dexamethasone ophth susp 0.3-0.1% 2TOBREX - tobramycin ophth soln 0.3% 2TRAVATAN Z - travoprost ophth soln 0.004% 1trifluridine ophth soln 1% 2white petrolatum-mineral oil ophth ointment 3 MCZYLET - loteprednol etabonate-tobramycin ophth susp

0.5-0.3%2

Otic Agentsacetic acid otic soln 2% 1carbamide peroxide 6.5% otic soln 3 MCCIPRO HC - ciprofloxacin-hydrocortisone otic susp 0.2-1% 2CIPRODEX - ciprofloxacin-dexamethasone otic susp

0.3-0.1%2

COLY-MYCIN S - neomycin-colistin-hc-thonzonium oticsusp 3.3-3-10-0.5 mg/ml

2

DEBROX - carbamide peroxide 6.5% otic soln 3 MCfluocinolone acetonide (otic) oil 0.01% 2hydrocortisone w/ acetic acid otic soln 1-2% 1neomycin-polymyxin-hc otic soln 1% 1neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/

ml-1%1

ofloxacin otic soln 0.3% 2

2019




OTOVEL - ciprofloxacin-fluocinolone aceton (pf) otic soln0.3-0.025%

2

SWIM EAR - isopropyl alcohol otic liquid 95% 3 MCRespiratory Tract/Pulmonary Agentsacetylcysteine inhal soln 10% 2 BDacetylcysteine inhal soln 20% 2 BDADCIRCA - tadalafil tab 20 mg (pah) 2 PA, QL (60 tablets/30 days)ADEMPAS - riociguat tab 0.5 mg 2 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 1 mg 2 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 1.5 mg 2 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 2 mg 2 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 2.5 mg 2 PA, QL (90 tablets/30 days)ADVAIR DISKUS - fluticasone-salmeterol aer powder ba

100-50 mcg/dose1 QL (1 inhaler/30 days)

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

1 QL (1 inhaler/30 days)

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


ADVAIR HFA - fluticasone-salmeterol inhal aerosol45-21 mcg/act

1 QL (1 canister/30 days)





albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) 1 BDalbuterol sulfate soln nebu 0.5% (5 mg/ml) 1 BDalbuterol sulfate soln nebu 0.63 mg/3ml 1 BDalbuterol sulfate soln nebu 1.25 mg/3ml 1 BDalbuterol sulfate syrup 2 mg/5ml 1albuterol sulfate tab 2 mg 2albuterol sulfate tab 4 mg 2ambrisentan tab 5 mg* 2 PA, QL (30 tablets/30 days)ambrisentan tab 10 mg* 2 PA, QL (30 tablets/30 days)ANORO ELLIPTA - umeclidinium-vilanterol aero powd ba

62.5-25 mcg/inh1 QL (1 package/30 days)

ARNUITY ELLIPTA - fluticasone furoate aerosol powderbreath activ 50 mcg/act

1 QL (30 blisters/30 days)





2019


109



ASMANEX HFA - mometasone furoate inhal aerosolsuspension 100 mcg/act


ASMANEX HFA - mometasone furoate inhal aerosolsuspension 200 mcg/act


ASMANEX TWISTHALER 120 METERED DOSES -mometasone furoate inhal powd 220 mcg/inh












ATROVENT HFA - ipratropium bromide hfa inhal aerosol17 mcg/act

2 QL (2 canisters/30 days)

azelastine hcl nasal spray 0.1% (137 mcg/spray) 2 QL (2 bottles/30 days)azelastine hcl nasal spray 0.15% (205.5 mcg/spray) 2 QL (2 bottles/30 days)bosentan tab 62.5 mg* 2 PA, QL (60 tablets/30 days)bosentan tab 125 mg* 2 PA, QL (60 tablets/30 days)BREO ELLIPTA - fluticasone furoate-vilanterol aero powd

ba 100-25 mcg/inh1 QL (1 package/30 days)

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

1 QL (1 package/30 days)

budesonide inhalation susp 0.25 mg/2ml 2 BDbudesonide inhalation susp 0.5 mg/2ml 2 BDbudesonide inhalation susp 1 mg/2ml 2 BDcaffeine citrate oral soln 60 mg/3ml 1cetirizine hcl chew tab 5 mg 3 MCcetirizine hcl chew tab 10 mg 3 MCcetirizine hcl oral soln 1 mg/ml (5 mg/5ml) 3 MCcetirizine hcl tab 5 mg 3 MCcetirizine hcl tab 10 mg 3 MCCLEMASTINE FUMARATE - clemastine fumarate tab

2.68 mg#2 PA

COMBIVENT RESPIMAT - ipratropium-albuterol inhalaerosol soln 20-100 mcg/act


cromolyn sodium soln nebu 20 mg/2ml 1 BDDALIRESP - roflumilast tab 250 mcg 2 PA, QL (30 tablets/30 days)

2019




DALIRESP - roflumilast tab 500 mcg 2 PA, QL (30 tablets/30 days)dextromethorphan-guaifenesin liquid 10-100 mg/5ml 3 MCdextromethorphan-guaifenesin liquid 10-200 mg/5ml 3 MCdextromethorphan-guaifenesin syrup 10-100 mg/5ml 3 MCdiphenhydramine hcl cap 25 mg# 3 MCdiphenhydramine hcl cap 50 mg# 3 MCdiphenhydramine hcl inj 50 mg/ml 2diphenhydramine hcl liquid 12.5 mg/5ml 3 MCdiphenhydramine hcl tab 25 mg 3 MCDULERA - mometasone furoate-formoterol fumarate

aerosol 100-5 mcg/act2 QL (1 canister/30 days)

DULERA - mometasone furoate-formoterol fumarateaerosol 200-5 mcg/act


epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000) 1epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)

(generic for EpiPen 2-Pak)1

ESBRIET - pirfenidone cap 267 mg* 2 PA, QL (270capsules/30 days)

ESBRIET - pirfenidone tab 267 mg* 2 PA, QL (270 tablets/30 days)ESBRIET - pirfenidone tab 801 mg* 2 PA, QL (90 tablets/30 days)FLOVENT DISKUS - fluticasone propionate aer pow ba

50 mcg/blister1 QL (1 inhaler/30 days)

FLOVENT DISKUS - fluticasone propionate aer pow ba100 mcg/blister


FLOVENT DISKUS - fluticasone propionate aer pow ba250 mcg/blister

1 QL (4 inhalers/30 days)

FLOVENT HFA - fluticasone propionate hfa inhal aero44 mcg/act (50/valve)


FLOVENT HFA - fluticasone propionate hfa inhal aer110 mcg/act (125/valve)


FLOVENT HFA - fluticasone propionate hfa inhal aer220 mcg/act (250/valve)


FLOWTUSS - hydrocodone-guaifenesin soln2.5-200 mg/5ml

3 MC

fluticasone propionate nasal susp 50 mcg/act 1 QL (1 bottle/30 days)FLUTICASONE PROPIONATE/SALMETEROL -

fluticasone-salmeterol aer powder ba 55-14 mcg/act1 QL (1 inhaler/30 days)

FLUTICASONE PROPIONATE/SALMETEROL -fluticasone-salmeterol aer powder ba 113-14 mcg/act


FLUTICASONE PROPIONATE/SALMETEROL -fluticasone-salmeterol aer powder ba 232-14 mcg/act


guaifenesin liquid 100 mg/5ml 3 MC

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111



guaifenesin syrup 100 mg/5ml 3 MCINCRUSE ELLIPTA - umeclidinium br aero powd breath act

62.5 mcg/inh1 QL (30 blisters/30 days)

ipratropium bromide inhal soln 0.02% 1 BDipratropium bromide nasal soln 0.03% (21 mcg/spray) 1 QL (2 bottles/30 days)ipratropium bromide nasal soln 0.06% (42 mcg/spray) 1 QL (3 bottles/30 days)KALYDECO - ivacaftor tab 150 mg 2 PA, QL (60 tablets/30 days)KALYDECO - ivacaftor packet 25 mg 2 PA, QL (60 packets/30 days)KALYDECO - ivacaftor packet 50 mg 2 PA, QL (60 packets/30 days)KALYDECO - ivacaftor packet 75 mg 2 PA, QL (60 packets/30 days)LETAIRIS - ambrisentan tab 5 mg* 2 PA, QL (30 tablets/30 days)LETAIRIS - ambrisentan tab 10 mg* 2 PA, QL (30 tablets/30 days)levocetirizine dihydrochloride tab 5 mg 1loratadine cap 10 mg 3 MCloratadine rapidly-disintegrating tab 10 mg 3 MCloratadine syrup 5 mg/5ml 3 MCloratadine tab 10 mg 3 MCmometasone furoate nasal susp 50 mcg/act 2 QL (2 bottles/30 days)montelukast sodium chew tab 4 mg 1montelukast sodium chew tab 5 mg 1montelukast sodium oral granules packet 4 mg 2montelukast sodium tab 10 mg 1OFEV - nintedanib esylate cap 100 mg* 2 PA, QL (60 capsules/30 days)OFEV - nintedanib esylate cap 150 mg* 2 PA, QL (60 capsules/30 days)OPSUMIT - macitentan tab 10 mg* 2 PA, QL (30 tablets/30 days)ORKAMBI - lumacaftor-ivacaftor tab 100-125 mg* 2 PA, QL (120 tablets/30 days)ORKAMBI - lumacaftor-ivacaftor tab 200-125 mg* 2 PA, QL (120 tablets/30 days)ORKAMBI - lumacaftor-ivacaftor granules packet

100-125 mg*2 PA, QL (60 packets/30 days)

ORKAMBI - lumacaftor-ivacaftor granules packet150-188 mg*

2 PA, QL (60 packets/30 days)

promethazine w/ codeine syrup 6.25-10 mg/5ml# 3 MCpromethazine-phenylephrine-codeine syrup

6.25-5-10 mg/5ml#3 MC

pseudoephedrine hcl tab 30 mg 3 MCPULMOZYME - dornase alfa inhal soln 1 mg/ml 2 BDREMODULIN - treprostinil inj soln 20 mg/20ml (1 mg/ml)* 2 BDREMODULIN - treprostinil inj soln 50 mg/20ml (2.5 mg/ml)* 2 BDREMODULIN - treprostinil inj soln 100 mg/20ml (5 mg/ml)* 2 BD

2019




REMODULIN - treprostinil inj soln 200 mg/20ml (10 mg/ml)* 2 BDribavirin for inhal soln 6 gm 2SEREVENT DISKUS - salmeterol xinafoate aer pow ba

50 mcg/dose1 QL (1 inhaler/30 days)

sildenafil citrate tab 20 mg 2 PA, QL (90 tablets/30 days)STIOLTO RESPIMAT - tiotropium br-olodaterol inhal aero

soln 2.5-2.5 mcg/act1 QL (1 canister/30 days)

STRIVERDI RESPIMAT - olodaterol hcl inhal aerosol soln2.5 mcg/act

1 QL (1 cartridge/30 days)

SYMBICORT - budesonide-formoterol fumarate dihydaerosol 80-4.5 mcg/act


SYMBICORT - budesonide-formoterol fumarate dihydaerosol 160-4.5 mcg/act


SYMDEKO - tezacaftor-ivacaftor 50-75 mg & ivacaftor75 mg tab tbpk


SYMDEKO - tezacaftor-ivacaftor 100-150 mg & ivacaftor150 mg tab tbpk


tadalafil tab 20 mg (pah) 2 PA, QL (60 tablets/30 days)terbutaline sulfate tab 2.5 mg 2terbutaline sulfate tab 5 mg 2theophylline tab er 12hr 300 mg 1theophylline tab er 12hr 450 mg 1theophylline tab er 24hr 400 mg 1theophylline tab er 24hr 600 mg 1tobramycin nebu soln 300 mg/5ml 2 BDTRACLEER - bosentan tab for oral susp 32 mg* 2 PA, QL (120 tablets/30 days)TRACLEER - bosentan tab 62.5 mg* 2 PA, QL (60 tablets/30 days)TRACLEER - bosentan tab 125 mg* 2 PA, QL (60 tablets/30 days)TRELEGY ELLIPTA - fluticasone-umeclidinium-vilanterol

aepb 100-62.5-25 mcg/inh1 QL (60 blisters/30 days)

treprostinil inj soln 20 mg/20ml (1 mg/ml)* 2 BDtreprostinil inj soln 50 mg/20ml (2.5 mg/ml)* 2 BDtreprostinil inj soln 100 mg/20ml (5 mg/ml)* 2 BDtreprostinil inj soln 200 mg/20ml (10 mg/ml)* 2 BDTUDORZA PRESSAIR - aclidinium bromide aerosol powd

breath activated 400 mcg/act1 QL (1 canister/30 days)

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

2 PA, QL (1 pack (200tablets)/28 days)

UPTRAVI - selexipag tab 200 mcg* 2 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 400 mcg* 2 PA, QL (60 tablets/30 days)

2019

113



UPTRAVI - selexipag tab 600 mcg* 2 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 800 mcg* 2 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1000 mcg* 2 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1200 mcg* 2 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1400 mcg* 2 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1600 mcg* 2 PA, QL (60 tablets/30 days)VANAMINE PD - diphenhydramine hcl liquid 6.25 mg/ml 3 MCVENTAVIS - iloprost inhalation solution 10 mcg/ml 2 BD, PA, QL (270 mls/30 days)VENTAVIS - iloprost inhalation solution 20 mcg/ml 2 BD, PA, QL (270 mls/30 days)VENTOLIN HFA - albuterol sulfate inhal aero 108 mcg/act 1 QL (36 grams/30 days)zafirlukast tab 10 mg 2zafirlukast tab 20 mg 2Skeletal Muscle Relaxantscyclobenzaprine hcl tab 5 mg# 2 PAcyclobenzaprine hcl tab 10 mg# 2 PAmethocarbamol tab 500 mg# 2 PAmethocarbamol tab 750 mg# 2 PASleep Disorder Agentsarmodafinil tab 50 mg 2 PA, QL (30 tablets/30 days)armodafinil tab 150 mg 2 PA, QL (30 tablets/30 days)armodafinil tab 200 mg 2 PA, QL (30 tablets/30 days)armodafinil tab 250 mg 2 PA, QL (30 tablets/30 days)HETLIOZ - tasimelteon capsule 20 mg* 2 PA, QL (30 capsules/30 days)modafinil tab 100 mg 2 PA, QL (30 tablets/30 days)modafinil tab 200 mg 2 PA, QL (30 tablets/30 days)SILENOR - doxepin hcl tab 3 mg 1 QL (30 tablets/30 days)SILENOR - doxepin hcl tab 6 mg 1 QL (30 tablets/30 days)temazepam cap 15 mg 2 QL (30 capsules/30 days)temazepam cap 30 mg 2 QL (30 capsules/30 days)XYREM - sodium oxybate oral solution 500 mg/ml* 2 PA, QL (540 mls/30 days)zaleplon cap 5 mg# 2 PAzaleplon cap 10 mg# 2 PAzolpidem tartrate tab 5 mg# 2 PAzolpidem tartrate tab 10 mg# 2 PA


2019

114

E. Index of Covered Drugs

Aabacavir sulfate-lamivudine tab 600-300 mg........... 47abacavir sulfate-lamivudine-zidovudine tab

300-150-300 mg........................................................47abacavir sulfate soln 20 mg/ml..................................47abacavir sulfate tab 300 mg.......................................47abiraterone acetate tab 250 mg................................ 28ABRAXANE...................................................................28acamprosate calcium tab delayed release 333

mg..................................................................................4acarbose tab 100 mg.................................................. 53acarbose tab 25 mg.................................................... 53acarbose tab 50 mg.................................................... 53ACCUPRIL.................................................................... 61ACCUPRIL.................................................................... 61ACCUPRIL.................................................................... 62ACCUPRIL.................................................................... 62acetaminophen chew tab 80 mg................................. 1acetaminophen liquid 160 mg/5ml...............................1acetaminophen soln 160 mg/5ml.................................1acetaminophen suppos 120 mg...................................1acetaminophen suppos 325 mg...................................1acetaminophen susp 160 mg/5ml................................1acetaminophen susp 80 mg/0.8ml.............................. 1acetaminophen tab 325 mg..........................................1acetaminophen tab 500 mg..........................................1acetaminophen w/ codeine soln 120-12 mg/5ml....... 1acetaminophen w/ codeine tab 300-15 mg................ 1acetaminophen w/ codeine tab 300-30 mg................ 1acetaminophen w/ codeine tab 300-60 mg................ 1acetazolamide cap er 12hr 500 mg.......................... 62acetazolamide tab 125 mg......................................... 62acetazolamide tab 250 mg......................................... 62acetic acid otic soln 2%............................................107acetylcysteine inhal soln 10%..................................108acetylcysteine inhal soln 20%..................................108acitretin cap 10 mg......................................................74acitretin cap 17.5 mg...................................................75acitretin cap 25 mg......................................................75ACNE MEDICATION 10..............................................75ACNE MEDICATION 5................................................75ACTHIB..........................................................................97ACTIMMUNE................................................................ 97ACTOS...........................................................................53ACTOS...........................................................................53ACTOS...........................................................................53ACULAR......................................................................104ACULAR LS................................................................104ACUVAIL..................................................................... 104

acyclovir cap 200 mg.................................................. 47acyclovir oint 5%..........................................................47acyclovir sodium iv soln 50 mg/ml............................ 47acyclovir susp 200 mg/5ml.........................................47acyclovir tab 400 mg...................................................47acyclovir tab 800 mg...................................................47ADACEL........................................................................ 97ADALAT CC..................................................................62ADALAT CC..................................................................62ADALAT CC..................................................................62ADASUVE..................................................................... 42ADCIRCA.................................................................... 108adefovir dipivoxil tab 10 mg....................................... 47ADEMPAS...................................................................108ADEMPAS...................................................................108ADEMPAS...................................................................108ADEMPAS...................................................................108ADEMPAS...................................................................108ADVAIR DISKUS....................................................... 108ADVAIR DISKUS....................................................... 108ADVAIR DISKUS....................................................... 108ADVAIR HFA.............................................................. 108ADVAIR HFA.............................................................. 108ADVAIR HFA.............................................................. 108AFINITOR......................................................................28AFINITOR......................................................................29AFINITOR......................................................................29AFINITOR......................................................................29AFINITOR DISPERZ................................................... 29AFINITOR DISPERZ................................................... 29AFINITOR DISPERZ................................................... 29AIMOVIG....................................................................... 26AIMOVIG....................................................................... 26albendazole tab 200 mg............................................. 41ALBENZA...................................................................... 41albuterol sulfate soln nebu 0.083% (2.5

mg/3ml).....................................................................108albuterol sulfate soln nebu 0.5% (5 mg/ml)........... 108albuterol sulfate soln nebu 0.63 mg/3ml................ 108albuterol sulfate soln nebu 1.25 mg/3ml................ 108albuterol sulfate syrup 2 mg/5ml............................. 108albuterol sulfate tab 2 mg.........................................108albuterol sulfate tab 4 mg.........................................108ALCOHOL SWABS......................................................53ALDACTONE................................................................ 62ALDACTONE................................................................ 62ALDACTONE................................................................ 62ALDURAZYME............................................................. 87ALECENSA................................................................... 29alendronate sodium tab 10 mg................................103alendronate sodium tab 35 mg................................103alendronate sodium tab 5 mg..................................103

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115

alendronate sodium tab 70 mg................................103alfuzosin hcl tab er 24hr 10 mg.................................89ALIMTA.......................................................................... 29ALIMTA.......................................................................... 29ALINIA............................................................................41ALINIA............................................................................41ALIQOPA....................................................................... 29aliskiren fumarate tab 150 mg................................... 62aliskiren fumarate tab 300 mg................................... 62allopurinol tab 100 mg................................................ 26allopurinol tab 300 mg................................................ 26ALOCRIL..................................................................... 104ALOE VESTA PROTECTIVE..................................... 75ALOGLIPTIN.................................................................53ALOGLIPTIN.................................................................53ALOGLIPTIN.................................................................53ALOGLIPTIN/METFORMIN HCL...............................53ALOGLIPTIN/METFORMIN HCL...............................53ALOGLIPTIN/PIOGLITAZONE...................................54ALOGLIPTIN/PIOGLITAZONE...................................54ALOGLIPTIN/PIOGLITAZONE...................................54ALOGLIPTIN/PIOGLITAZONE...................................54ALOGLIPTIN/PIOGLITAZONE...................................54ALOGLIPTIN/PIOGLITAZONE...................................54alosetron hcl tab 0.5 mg.............................................82alosetron hcl tab 1 mg................................................ 83alprazolam tab 0.25 mg..............................................52alprazolam tab 0.5 mg................................................ 52alprazolam tab 1 mg................................................... 52alprazolam tab 2 mg................................................... 52ALREX......................................................................... 104ALTACE......................................................................... 62ALTACE......................................................................... 62ALTACE......................................................................... 62ALTACE......................................................................... 62alum & mag hydroxide-simethicone chew tab

200-200-25 mg..........................................................83alum & mag hydroxide-simethicone susp 200-200-20

mg/5ml........................................................................ 83alum & mag hydroxide-simethicone susp 400-400-40

mg/5ml........................................................................ 83ALUMINUM HYDROXIDE.......................................... 83aluminum hydroxide-magnesium carbonate chew tab

160-105 mg............................................................... 83aluminum hydroxide-magnesium carbonate susp

95-358 mg/15ml........................................................ 83ALUNBRIG....................................................................29ALUNBRIG....................................................................29ALUNBRIG....................................................................29ALUNBRIG....................................................................29amantadine hcl cap 100 mg.......................................41amantadine hcl syrup 50 mg/5ml.............................. 41

AMARYL........................................................................ 54AMARYL........................................................................ 54AMARYL........................................................................ 54AMBISOME...................................................................24ambrisentan tab 10 mg.............................................108ambrisentan tab 5 mg...............................................108AMERGE....................................................................... 26AMERGE....................................................................... 27amikacin sulfate inj 1 gm/4ml (250 mg/ml).................6amikacin sulfate inj 500 mg/2ml (250 mg/ml).............6amiloride hcl tab 5 mg................................................ 62amino acid infusion 6%...............................................78AMINOSYN II............................................................... 78AMINOSYN-PF.............................................................78AMINOSYN-PF 7%......................................................78amiodarone hcl tab 200 mg....................................... 62AMITIZA.........................................................................83AMITIZA.........................................................................83amitriptyline hcl tab 100 mg....................................... 19amitriptyline hcl tab 10 mg......................................... 19amitriptyline hcl tab 150 mg....................................... 19amitriptyline hcl tab 25 mg......................................... 19amitriptyline hcl tab 50 mg......................................... 19amitriptyline hcl tab 75 mg......................................... 19amlodipine besylate-benazepril hcl cap 10-20

mg................................................................................62amlodipine besylate-benazepril hcl cap 10-40

mg................................................................................62amlodipine besylate-benazepril hcl cap 2.5-10




mg................................................................................62amlodipine besylate tab 10 mg..................................62amlodipine besylate tab 2.5 mg.................................62amlodipine besylate tab 5 mg....................................62AMOXAPINE.................................................................19AMOXAPINE.................................................................19AMOXAPINE.................................................................19AMOXAPINE.................................................................19AMOXICILLIN................................................................. 6AMOXICILLIN................................................................. 6AMOXICILLIN/CLAVULANATE POTASSIUM............6AMOXICILLIN/CLAVULANATE POTASSIUM............6amoxicillin (trihydrate) cap 250 mg............................. 6amoxicillin (trihydrate) cap 500 mg............................. 6amoxicillin (trihydrate) for susp 125 mg/5ml...............6amoxicillin (trihydrate) for susp 200 mg/5ml...............6amoxicillin (trihydrate) for susp 250 mg/5ml...............6

2019

116

amoxicillin (trihydrate) for susp 400 mg/5ml...............6amoxicillin (trihydrate) tab 500 mg.............................. 6amoxicillin (trihydrate) tab 875 mg.............................. 6amoxicillin & k clavulanate for susp 200-28.5

mg/5ml.......................................................................... 6amoxicillin & k clavulanate for susp 250-62.5

mg/5ml.......................................................................... 6amoxicillin & k clavulanate for susp 400-57

mg/5ml.......................................................................... 6amoxicillin & k clavulanate for susp 600-42.9

mg/5ml.......................................................................... 6amoxicillin & k clavulanate tab 250-125 mg...............6amoxicillin & k clavulanate tab 500-125 mg...............6amoxicillin & k clavulanate tab 875-125 mg...............6amoxicillin & k clavulanate tab er 12hr 1000-62.5

mg..................................................................................6amphetamine-dextroamphetamine cap er 24hr 10

mg................................................................................73amphetamine-dextroamphetamine cap er 24hr 15





mg................................................................................73AMPHOTERICIN B......................................................24ampicillin & sulbactam sodium for inj 3 (2-1) gm.......6ampicillin cap 500 mg................................................... 6AMPICILLIN SODIUM................................................... 6ampicillin sodium for inj 1 gm...................................... 7ampicillin sodium for inj 250 mg.................................. 7ampicillin sodium for inj 2 gm...................................... 7ampicillin sodium for inj 500 mg.................................. 7ampicillin sodium for iv soln 2 gm............................... 7AMPICILLIN-SULBACTAM........................................... 7AMPYRA........................................................................73ANADROL-50............................................................... 92anagrelide hcl cap 0.5 mg..........................................59anagrelide hcl cap 1 mg............................................. 59anastrozole tab 1 mg.................................................. 29ANDRODERM.............................................................. 92ANDRODERM.............................................................. 92ANDROGEL..................................................................92ANDROGEL..................................................................92ANDROGEL PUMP..................................................... 92ANORO ELLIPTA.......................................................108APOKYN........................................................................41aprepitant capsule 125 mg.........................................23aprepitant capsule 40 mg...........................................23

aprepitant capsule 80 mg...........................................23aprepitant capsule therapy pack 80 & 125 mg........ 23APRISO....................................................................... 103APTIOM......................................................................... 14APTIOM......................................................................... 14APTIOM......................................................................... 14APTIOM......................................................................... 14APTIVUS....................................................................... 47APTIVUS....................................................................... 47ARCALYST....................................................................98aripiprazole orally disintegrating tab 10 mg............. 42aripiprazole orally disintegrating tab 15 mg............. 42aripiprazole oral solution 1 mg/ml............................. 42aripiprazole tab 10 mg................................................ 43aripiprazole tab 15 mg................................................ 43aripiprazole tab 20 mg................................................ 43aripiprazole tab 2 mg.................................................. 42aripiprazole tab 30 mg................................................ 43aripiprazole tab 5 mg.................................................. 43ARISTADA.....................................................................43ARISTADA.....................................................................43ARISTADA.....................................................................43ARISTADA.....................................................................43ARISTADA INITIO........................................................43armodafinil tab 150 mg.............................................113armodafinil tab 200 mg.............................................113armodafinil tab 250 mg.............................................113armodafinil tab 50 mg............................................... 113ARNUITY ELLIPTA....................................................108ARNUITY ELLIPTA....................................................108ARNUITY ELLIPTA....................................................108ARRANON.................................................................... 29arsenic trioxide iv soln 10 mg/10ml (1 mg/ml)......... 29arsenic trioxide iv soln 12 mg/6ml (2 mg/ml)........... 29ARTHRITIS PAIN RELIEVING...................................75artificial tear ophth ointment.....................................104artificial tear ophth solution...................................... 105ARZERRA..................................................................... 29ARZERRA..................................................................... 29ASACOL HD...............................................................103ASMANEX HFA..........................................................109ASMANEX HFA..........................................................109ASMANEX TWISTHALER 120 METERED

DOSES.....................................................................109ASMANEX TWISTHALER 14 METERED




DOSES.....................................................................109

2019

117

ASMANEX TWISTHALER 7 METEREDDOSES.....................................................................109

aspirin-acetaminophen-caffeine tab 250-250-65mg..................................................................................1

aspirin buffered (ca carb-mg carb-mg ox) tab 325mg..................................................................................1

aspirin chew tab 81 mg.................................................1aspirin-dipyridamole cap er 12hr 25-200 mg........... 60aspirin tab 325 mg.........................................................1aspirin tab delayed release 325 mg............................1aspirin tab delayed release 81 mg.............................. 1ASSURE ID INSULIN SAFETY SYRINGE/

U-100/0.5ML/29G X 1/2"......................................... 54ASSURE ID INSULIN SAFETY SYRINGE/

U-100/1ML/29G X 1/2".............................................54ASSURE ID SAFETY PEN NEEDLES 31G X 5MM

(1/5" OR 3/16")..........................................................54atazanavir sulfate cap 150 mg...................................47atazanavir sulfate cap 200 mg...................................47atazanavir sulfate cap 300 mg...................................47atenolol tab 100 mg.....................................................62atenolol tab 25 mg.......................................................62atenolol tab 50 mg.......................................................62atomoxetine hcl cap 100 mg......................................74atomoxetine hcl cap 10 mg........................................73atomoxetine hcl cap 18 mg........................................73atomoxetine hcl cap 25 mg........................................73atomoxetine hcl cap 40 mg........................................73atomoxetine hcl cap 60 mg........................................73atomoxetine hcl cap 80 mg........................................73atorvastatin calcium tab 10 mg..................................62atorvastatin calcium tab 20 mg..................................62atorvastatin calcium tab 40 mg..................................62atorvastatin calcium tab 80 mg..................................62atovaquone-proguanil hcl tab 250-100 mg...............41atovaquone-proguanil hcl tab 62.5-25 mg................41atovaquone susp 750 mg/5ml....................................41ATRIPLA........................................................................ 47ATROVENT HFA........................................................109AVALIDE........................................................................ 62AVALIDE........................................................................ 62AVAPRO........................................................................ 62AVAPRO........................................................................ 63AVAPRO........................................................................ 63AVASTIN........................................................................29AVASTIN........................................................................29AVODART..................................................................... 89AVONEX........................................................................ 74AVONEX PEN.............................................................. 74azacitidine for inj 100 mg........................................... 60AZATHIOPRINE........................................................... 98azathioprine tab 50 mg............................................... 98

azelaic acid gel 15%................................................... 75azelastine hcl nasal spray 0.1% (137 mcg/

spray)........................................................................109azelastine hcl nasal spray 0.15% (205.5 mcg/

spray)........................................................................109azelastine hcl ophth soln 0.05%..............................105AZITHROMYCIN............................................................ 7azithromycin for susp 100 mg/5ml.............................. 7azithromycin for susp 200 mg/5ml.............................. 7azithromycin iv for soln 500 mg...................................7azithromycin tab 250 mg.............................................. 7azithromycin tab 500 mg.............................................. 7azithromycin tab 600 mg.............................................. 7aztreonam for inj 1 gm..................................................7aztreonam for inj 2 gm..................................................7BBACITRACIN.............................................................. 105bacitracin oint 500 unit/gm......................................... 75bacitracin-polymyxin b oint......................................... 75bacitracin-polymyxin b ophth oint............................105bacitracin zinc oint 500 unit/gm................................. 75baclofen tab 10 mg......................................................47baclofen tab 20 mg......................................................47BACTRIM.........................................................................7BACTRIM DS..................................................................7balsalazide disodium cap 750 mg...........................103BALVERSA....................................................................29BALVERSA....................................................................29BALVERSA....................................................................29BANZEL.........................................................................14BANZEL.........................................................................14BANZEL.........................................................................14BARACLUDE................................................................ 47BASAGLAR KWIKPEN............................................... 54BAVENCIO.................................................................... 29BCG VACCINE.............................................................98BD SAFETYGLIDE INSULIN SYRINGE 0.3ML/31G

X 15/64"......................................................................54BD SAFETYGLIDE INSULIN SYRINGE 0.5ML/31G

X 15/64"......................................................................54BD SAFETYGLIDE INSULIN SYRINGE 1ML/31G X

15/64"..........................................................................54BELEODAQ.................................................................. 29benazepril & hydrochlorothiazide tab 10-12.5

mg................................................................................63benazepril & hydrochlorothiazide tab 20-12.5

mg................................................................................63benazepril & hydrochlorothiazide tab 20-25 mg...... 63benazepril & hydrochlorothiazide tab 5-6.25 mg..... 63benazepril hcl tab 10 mg............................................ 63benazepril hcl tab 20 mg............................................ 63

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benazepril hcl tab 40 mg............................................ 63benazepril hcl tab 5 mg.............................................. 63BENDEKA..................................................................... 29BENLYSTA.................................................................... 98BENLYSTA.................................................................... 98BENLYSTA.................................................................... 98BENLYSTA.................................................................... 98BENZNIDAZOLE..........................................................41BENZNIDAZOLE..........................................................41BENZOYL PEROXIDE................................................75BENZOYL PEROXIDE CLEANSER......................... 75benzoyl peroxide-erythromycin gel 5-3%................. 75benzoyl peroxide gel 10%.......................................... 75benzoyl peroxide gel 5%............................................ 75benztropine mesylate tab 0.5 mg.............................. 41benztropine mesylate tab 1 mg................................. 42benztropine mesylate tab 2 mg................................. 42BESIVANCE................................................................105BESPONSA.................................................................. 29BETADINE.....................................................................75BETADINE.....................................................................75BETADINE SURGICAL SCRUB................................75BETADINE SWABSTICKS..........................................75betamethasone dipropionate cream 0.05%............. 75betamethasone dipropionate lotion 0.05%...............75betamethasone dipropionate oint 0.05%..................75betamethasone valerate cream 0.1%....................... 75betamethasone valerate lotion 0.1%.........................75betamethasone valerate oint 0.1%............................75BETASERON................................................................ 74betaxolol hcl ophth soln 0.5%..................................105bethanechol chloride tab 10 mg................................ 89bethanechol chloride tab 25 mg................................ 89bethanechol chloride tab 50 mg................................ 89bethanechol chloride tab 5 mg.................................. 89bexarotene cap 75 mg................................................29BEXSERO..................................................................... 98bicalutamide tab 50 mg.............................................. 29BICILLIN L-A...................................................................7BICILLIN L-A...................................................................7BICILLIN L-A...................................................................7BICNU............................................................................29BIKTARVY..................................................................... 47BILTRICIDE...................................................................41bisacodyl suppos 10 mg.............................................83bisacodyl tab delayed release 5 mg......................... 83bismuth subsalicylate chew tab 262 mg...................83bismuth subsalicylate susp 262 mg/15ml.................83bismuth subsalicylate susp 525 mg/15ml.................83bismuth subsalicylate tab 262 mg.............................83bisoprolol & hydrochlorothiazide tab 10-6.25

mg................................................................................63

bisoprolol & hydrochlorothiazide tab 2.5-6.25mg................................................................................63

bisoprolol & hydrochlorothiazide tab 5-6.25 mg...... 63bisoprolol fumarate tab 10 mg...................................63bisoprolol fumarate tab 5 mg..................................... 63bleomycin sulfate for inj 15 unit.................................29bleomycin sulfate for inj 30 unit.................................29BLEPHAMIDE.............................................................105BLINCYTO.....................................................................30BOOSTRIX....................................................................98bosentan tab 125 mg................................................109bosentan tab 62.5 mg...............................................109BOSULIF....................................................................... 30BOSULIF....................................................................... 30BOSULIF....................................................................... 30BRAFTOVI.....................................................................30BREO ELLIPTA..........................................................109BREO ELLIPTA..........................................................109BRILINTA.......................................................................60BRILINTA.......................................................................60brimonidine tartrate ophth soln 0.15%....................105brimonidine tartrate ophth soln 0.2%......................105BRIVIACT......................................................................14BRIVIACT......................................................................14BRIVIACT......................................................................14BRIVIACT......................................................................14BRIVIACT......................................................................14BRIVIACT......................................................................14BRIVIACT......................................................................14bromfenac sodium ophth soln 0.09% (once-

daily)......................................................................... 105bromocriptine mesylate tab 2.5 mg...........................42budesonide delayed release particles cap 3

mg............................................................................. 103budesonide inhalation susp 0.25 mg/2ml...............109budesonide inhalation susp 0.5 mg/2ml.................109budesonide inhalation susp 1 mg/2ml.................... 109bumetanide inj 0.25 mg/ml......................................... 63bumetanide tab 0.5 mg...............................................63bumetanide tab 1 mg.................................................. 63bumetanide tab 2 mg.................................................. 63BUNAVAIL....................................................................... 4BUNAVAIL....................................................................... 4BUNAVAIL....................................................................... 4buprenorphine hcl-naloxone hcl sl film 12-3 mg........ 4buprenorphine hcl-naloxone hcl sl film 2-0.5 mg.......4buprenorphine hcl-naloxone hcl sl film 4-1 mg.......... 4buprenorphine hcl-naloxone hcl sl film 8-2 mg.......... 4buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg........4buprenorphine hcl-naloxone hcl sl tab 8-2 mg...........4buprenorphine hcl sl tab 2 mg..................................... 4buprenorphine hcl sl tab 8 mg..................................... 4

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bupropion hcl (smoking deterrent) tab er 12hr 150mg..................................................................................4

bupropion hcl tab 100 mg...........................................19bupropion hcl tab 75 mg.............................................19bupropion hcl tab er 12hr 100 mg.............................19bupropion hcl tab er 12hr 150 mg.............................19bupropion hcl tab er 12hr 200 mg.............................19bupropion hcl tab er 24hr 150 mg.............................19bupropion hcl tab er 24hr 300 mg.............................19buspirone hcl tab 10 mg.............................................52buspirone hcl tab 15 mg.............................................52buspirone hcl tab 30 mg.............................................52buspirone hcl tab 5 mg............................................... 52buspirone hcl tab 7.5 mg............................................52busulfan inj 6 mg/ml.................................................... 30butalbital-acetaminophen-caffeine tab 50-325-40

mg..................................................................................1butalbital-aspirin-caffeine cap 50-325-40 mg.............1BUTORPHANOL TARTRATE.......................................1butorphanol tartrate inj 2 mg/ml...................................1BYDUREON BCISE.................................................... 54BYDUREON PEN........................................................ 54Ccabergoline tab 0.5 mg............................................... 96CABOMETYX............................................................... 30CABOMETYX............................................................... 30CABOMETYX............................................................... 30caffeine citrate oral soln 60 mg/3ml........................109CALAN........................................................................... 63CALAN SR.................................................................... 63CALAN SR.................................................................... 63calcipotriene cream 0.005%.......................................75calcipotriene soln 0.005% (50 mcg/ml).....................75calcitonin (salmon) nasal soln 200 unit/act............ 103calcitriol cap 0.25 mcg..............................................104calcitriol cap 0.5 mcg................................................ 104calcitriol inj 1 mcg/ml.................................................104calcitriol oral soln 1 mcg/ml......................................104calcium acetate cap 667 mg......................................78calcium acetate tab 667 mg.......................................78calcium carbonate (antacid) chew tab 500 mg........ 83calcium carbonate (antacid) chew tab 750 mg........ 83calcium carbonate (antacid) susp 1250 mg/5ml......83calcium carbonate tab 1250 mg (500 mg elemental

ca)................................................................................83calcium carbonate-vitamin d tab 500 mg-200

unit...............................................................................78CALCIUM GLUCONATE.............................................78calcium polycarbophil tab 625 mg.............................83CALQUENCE................................................................30CAMPTOSAR............................................................... 30

CANASA......................................................................103CANCIDAS....................................................................24CAPASTAT SULFATE..................................................28CAPRELSA................................................................... 30CAPRELSA................................................................... 30capsaicin cream 0.025%.............................................75captopril tab 100 mg................................................... 63captopril tab 12.5 mg.................................................. 63captopril tab 25 mg......................................................63captopril tab 50 mg......................................................63CARAC.......................................................................... 75CARBAGLU.................................................................. 78carbamazepine cap er 12hr 100 mg.........................14carbamazepine cap er 12hr 200 mg.........................14carbamazepine cap er 12hr 300 mg.........................14carbamazepine chew tab 100 mg............................. 14carbamazepine susp 100 mg/5ml............................. 14carbamazepine tab 200 mg........................................14carbamazepine tab er 12hr 100 mg..........................14carbamazepine tab er 12hr 200 mg..........................14carbamazepine tab er 12hr 400 mg..........................14carbamide peroxide 6.5% otic soln.........................107carbidopa & levodopa orally disintegrating tab

10-100 mg..................................................................42carbidopa & levodopa orally disintegrating tab

25-100 mg..................................................................42carbidopa & levodopa orally disintegrating tab

25-250 mg..................................................................42carbidopa & levodopa tab 10-100 mg.......................42carbidopa & levodopa tab 25-100 mg.......................42carbidopa & levodopa tab 25-250 mg.......................42carbidopa & levodopa tab er 25-100 mg.................. 42carbidopa & levodopa tab er 50-200 mg.................. 42carboplatin iv soln 150 mg/15ml................................30carboplatin iv soln 450 mg/45ml................................30carboplatin iv soln 50 mg/5ml.................................... 30carboplatin iv soln 600 mg/60ml................................30CARDIZEM....................................................................63CARDIZEM....................................................................63CARDIZEM....................................................................63CARDIZEM CD............................................................ 63CARDIZEM CD............................................................ 63CARDIZEM CD............................................................ 63CARDIZEM CD............................................................ 63CARDIZEM CD............................................................ 63CARDIZEM LA............................................................. 64CARDIZEM LA............................................................. 64CARDIZEM LA............................................................. 64CARDIZEM LA............................................................. 64CARDIZEM LA............................................................. 64carmustine for inj 100 mg...........................................30carteolol hcl ophth soln 1%......................................105

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carvedilol tab 12.5 mg.................................................64carvedilol tab 25 mg....................................................64carvedilol tab 3.125 mg.............................................. 64carvedilol tab 6.25 mg.................................................64caspofungin acetate for iv soln 50 mg......................24caspofungin acetate for iv soln 70 mg......................24cefaclor cap 250 mg......................................................7cefaclor cap 500 mg......................................................7cefadroxil cap 500 mg...................................................7cefazolin sodium for inj 10 gm.....................................7cefazolin sodium for inj 1 gm....................................... 7cefazolin sodium for inj 500 mg...................................7cefdinir cap 300 mg.......................................................7cefdinir for susp 125 mg/5ml........................................7cefdinir for susp 250 mg/5ml........................................7cefepime hcl for inj 1 gm.............................................. 7cefepime hcl for inj 2 gm.............................................. 7cefixime cap 400 mg..................................................... 7CEFOTAXIME SODIUM................................................7cefotaxime sodium for inj 1 gm....................................7cefoxitin sodium for iv soln 1 gm.................................8cefoxitin sodium for iv soln 2 gm.................................8cefpodoxime proxetil tab 100 mg................................ 8cefpodoxime proxetil tab 200 mg................................ 8cefprozil tab 250 mg......................................................8cefprozil tab 500 mg......................................................8ceftazidime for inj 1 gm.................................................8ceftazidime for inj 2 gm.................................................8ceftazidime for inj 6 gm.................................................8ceftazidime for iv soln 2 gm......................................... 8CEFTRIAXONE/DEXTROSE....................................... 8CEFTRIAXONE/DEXTROSE....................................... 8CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE.......8CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE.......8ceftriaxone sodium for inj 10 gm................................. 8ceftriaxone sodium for inj 1 gm................................... 8ceftriaxone sodium for inj 250 mg............................... 8ceftriaxone sodium for inj 2 gm................................... 8ceftriaxone sodium for inj 500 mg............................... 8ceftriaxone sodium for iv soln 1 gm............................ 8ceftriaxone sodium for iv soln 2 gm............................ 8cefuroxime axetil tab 250 mg.......................................8cefuroxime axetil tab 500 mg.......................................8cefuroxime sodium for inj 7.5 gm................................ 8cefuroxime sodium for inj 750 mg............................... 8cefuroxime sodium for iv soln 1.5 gm......................... 8celecoxib cap 100 mg................................................... 1celecoxib cap 200 mg................................................... 1celecoxib cap 400 mg................................................... 1celecoxib cap 50 mg..................................................... 1CELEXA.........................................................................19CELEXA.........................................................................19

CELEXA.........................................................................19CELONTIN.................................................................... 14cephalexin cap 250 mg.................................................8cephalexin cap 500 mg.................................................8cephalexin cap 750 mg.................................................8cephalexin for susp 125 mg/5ml..................................8cephalexin for susp 250 mg/5ml..................................8CEREZYME.................................................................. 87cetirizine hcl chew tab 10 mg.................................. 109cetirizine hcl chew tab 5 mg.................................... 109cetirizine hcl oral soln 1 mg/ml (5 mg/5ml).............109cetirizine hcl tab 10 mg............................................ 109cetirizine hcl tab 5 mg...............................................109CHANTIX......................................................................... 4CHANTIX......................................................................... 4CHANTIX CONTINUING MONTH PACK................... 4CHANTIX STARTING MONTH PACK.........................4CHEMET........................................................................78CHENODAL.................................................................. 83CHLORAMPHENICOL SODIUM SUCCINATE..........8chlorhexidine gluconate liquid 4%.............................75chlorhexidine gluconate soln 0.12%......................... 74chlorhexidine gluconate soln 4%...............................75CHLOROQUINE PHOSPHATE................................. 41chloroquine phosphate tab 500 mg...........................41CHLORPROMAZINE HCL..........................................23CHLORPROMAZINE HCL..........................................23chlorpromazine hcl tab 100 mg................................. 23chlorpromazine hcl tab 10 mg................................... 23chlorpromazine hcl tab 200 mg................................. 23chlorpromazine hcl tab 25 mg................................... 23chlorpromazine hcl tab 50 mg................................... 23chlorthalidone tab 25 mg............................................ 64chlorthalidone tab 50 mg............................................ 64cholestyramine light powder 4 gm/dose................... 64cholestyramine light powder packets 4 gm.............. 64cholestyramine powder 4 gm/dose........................... 64cholestyramine powder packets 4 gm...................... 64CHORIONIC GONADOTROPIN................................91ciclopirox olamine cream 0.77%................................24ciclopirox solution 8%..................................................24cilostazol tab 100 mg.................................................. 60cilostazol tab 50 mg.................................................... 60CILOXAN.....................................................................105CIMDUO........................................................................ 47cinacalcet hcl tab 30 mg...........................................104cinacalcet hcl tab 60 mg...........................................104cinacalcet hcl tab 90 mg...........................................104CINRYZE.......................................................................98CIPRO..............................................................................8CIPRO..............................................................................8CIPRODEX................................................................. 107

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ciprofloxacin 200 mg/100ml in d5w.............................9ciprofloxacin 400 mg/200ml in d5w.............................9ciprofloxacin for oral susp 500 mg/5ml (10%) (10

gm/100ml).....................................................................9CIPROFLOXACIN HCL.................................................9ciprofloxacin hcl ophth soln 0.3%............................105ciprofloxacin hcl tab 250 mg........................................ 9ciprofloxacin hcl tab 500 mg........................................ 9ciprofloxacin hcl tab 750 mg........................................ 9CIPRO HC.................................................................. 107CISPLATIN.................................................................... 30cisplatin inj 100 mg/100ml (1 mg/ml)........................ 30cisplatin inj 50 mg/50ml (1 mg/ml)............................ 30citalopram hydrobromide oral soln 10 mg/5ml.........19citalopram hydrobromide tab 10 mg......................... 19citalopram hydrobromide tab 20 mg......................... 19citalopram hydrobromide tab 40 mg......................... 19CITRUCEL.................................................................... 83CITRUCEL FIBER LAXATIVE....................................83cladribine iv soln 10 mg/10ml (1 mg/ml)...................30clarithromycin for susp 125 mg/5ml............................ 9clarithromycin for susp 250 mg/5ml............................ 9clarithromycin tab 250 mg............................................ 9clarithromycin tab 500 mg............................................ 9CLEMASTINE FUMARATE......................................109CLEOCIN.........................................................................9CLEOCIN.........................................................................9CLEOCIN.........................................................................9CLEOCIN.........................................................................9CLEOCIN PHOSPHATE............................................... 9clindamycin hcl cap 150 mg.........................................9clindamycin hcl cap 300 mg.........................................9clindamycin hcl cap 75 mg...........................................9clindamycin palmitate hcl for soln 75 mg/5ml............ 9clindamycin phosphate gel 1%.................................... 9clindamycin phosphate inj 300 mg/2ml.......................9clindamycin phosphate inj 600 mg/4ml.......................9clindamycin phosphate inj 900 mg/6ml.......................9clindamycin phosphate inj 9 gm/60ml.........................9clindamycin phosphate iv soln 300 mg/2ml................9clindamycin phosphate iv soln 600 mg/4ml................9clindamycin phosphate iv soln 900 mg/6ml................9clindamycin phosphate lotion 1%................................ 9clindamycin phosphate soln 1%.................................. 9clindamycin phosphate swab 1%................................ 9clindamycin phosphate vaginal cream 2%................. 9CLINIMIX 4.25%/DEXTROSE 10%.......................... 79CLINIMIX 4.25%/DEXTROSE 25%.......................... 79CLINIMIX 4.25%/DEXTROSE 5%.............................79CLINIMIX 5%/DEXTROSE 15%................................79CLINIMIX 5%/DEXTROSE 20%................................79CLINIMIX 5%/DEXTROSE 25%................................79

CLINIMIX E 2.75%/DEXTROSE 5%.........................79CLINIMIX E 4.25%/DEXTROSE 10%.......................79CLINIMIX E 4.25%/DEXTROSE 5%.........................79CLINIMIX E 5%/DEXTROSE 15%............................ 79CLINIMIX E 5%/DEXTROSE 20%............................ 79clobazam suspension 2.5 mg/ml............................... 14clobazam tab 10 mg....................................................14clobazam tab 20 mg....................................................14clobetasol propionate cream 0.05%..........................75clobetasol propionate emollient base cream

0.05%..........................................................................75clobetasol propionate gel 0.05%............................... 75clobetasol propionate oint 0.05%.............................. 75clobetasol propionate soln 0.05%............................. 75clofarabine iv soln 1 mg/ml........................................ 30clomipramine hcl cap 25 mg......................................19clomipramine hcl cap 50 mg......................................19clomipramine hcl cap 75 mg......................................19clonazepam orally disintegrating tab 0.125 mg....... 52clonazepam orally disintegrating tab 0.25 mg......... 52clonazepam orally disintegrating tab 0.5 mg............52clonazepam orally disintegrating tab 1 mg...............53clonazepam orally disintegrating tab 2 mg...............53clonazepam tab 0.5 mg.............................................. 53clonazepam tab 1 mg................................................. 53clonazepam tab 2 mg................................................. 53clonidine hcl tab 0.1 mg..............................................64clonidine hcl tab 0.2 mg..............................................64clonidine hcl tab 0.3 mg..............................................64clonidine hcl tab er 12hr 0.1 mg................................74clonidine td patch weekly 0.1 mg/24hr..................... 64clonidine td patch weekly 0.2 mg/24hr..................... 64clonidine td patch weekly 0.3 mg/24hr..................... 64clopidogrel bisulfate tab 75 mg..................................60clorazepate dipotassium tab 15 mg.......................... 53clorazepate dipotassium tab 3.75 mg.......................53clorazepate dipotassium tab 7.5 mg......................... 53clotrimazole cream 1%................................................24clotrimazole troche 10 mg.......................................... 24clotrimazole vaginal cream 1%..................................24clotrimazole vaginal cream 2%..................................24clotrimazole w/ betamethasone cream 1-0.05%......76clozapine orally disintegrating tab 100 mg...............43clozapine orally disintegrating tab 12.5 mg..............43clozapine orally disintegrating tab 25 mg................. 43clozapine tab 100 mg..................................................43clozapine tab 200 mg..................................................43clozapine tab 25 mg....................................................43clozapine tab 50 mg....................................................43COARTEM.....................................................................41COLACE........................................................................83COLACE CLEAR......................................................... 83

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colchicine w/ probenecid tab 0.5-500 mg.................26COLCRYS..................................................................... 26colestipol hcl granule packets 5 gm..........................64colestipol hcl granules 5 gm...................................... 64colestipol hcl tab 1 gm................................................64colistimethate sod for inj 150 mg.................................9COLY-MYCIN S......................................................... 107COLYTE-FLAVOR PACKS......................................... 83COMBIPATCH.............................................................. 92COMBIPATCH.............................................................. 92COMBIVENT RESPIMAT......................................... 109COMETRIQ...................................................................30COMETRIQ...................................................................30COMETRIQ...................................................................30COMPLERA..................................................................48CONDYLOX..................................................................76COPIKTRA....................................................................30COPIKTRA....................................................................30COREG..........................................................................64COREG..........................................................................64COREG..........................................................................64COREG..........................................................................64CORLANOR..................................................................64CORLANOR..................................................................64CORLANOR..................................................................64CORTEF........................................................................ 90CORTISONE ACETATE..............................................90CORTISPORIN.............................................................76CORTISPORIN.............................................................76COSENTYX.................................................................. 98COSENTYX.................................................................. 98COSENTYX SENSOREADY PEN............................ 98COSENTYX SENSOREADY PEN............................ 98COSMEGEN................................................................. 30COSOPT..................................................................... 105COTELLIC.....................................................................30COZAAR........................................................................64COZAAR........................................................................64COZAAR........................................................................64CREON..........................................................................87CREON..........................................................................87CREON..........................................................................87CREON..........................................................................87CREON..........................................................................88CRESEMBA.................................................................. 24CRESEMBA.................................................................. 24CRITIC-AID CLEAR MOISTUREBARRIER.............76CRIXIVAN......................................................................48CRIXIVAN......................................................................48cromolyn sodium ophth soln 4%............................. 105cromolyn sodium soln nebu 20 mg/2ml..................109CRYSVITA.....................................................................88

CRYSVITA.....................................................................88CRYSVITA.....................................................................88cyanocobalamin inj 1000 mcg/ml.............................. 79cyclobenzaprine hcl tab 10 mg................................113cyclobenzaprine hcl tab 5 mg..................................113cyclophosphamide cap 25 mg................................... 30cyclophosphamide cap 50 mg................................... 30cyclophosphamide for inj 1 gm..................................30cyclophosphamide for inj 2 gm..................................30cyclophosphamide for inj 500 mg..............................30CYCLOSET...................................................................54cyclosporine cap 100 mg............................................98cyclosporine cap 25 mg..............................................98cyclosporine iv soln 50 mg/ml....................................98CYCLOSPORINE MODIFIED.................................... 98cyclosporine modified cap 100 mg............................98cyclosporine modified cap 25 mg..............................98cyclosporine modified oral soln 100 mg/ml.............. 98CYRAMZA.....................................................................31CYRAMZA.....................................................................31CYSTADANE................................................................ 88CYSTAGON.................................................................. 88CYSTAGON.................................................................. 88CYSTARAN.................................................................105CYTARABINE............................................................... 31cytarabine inj pf 100 mg/ml........................................31cytarabine inj pf 20 mg/ml.......................................... 31CYTOVENE...................................................................48DDACARBAZINE............................................................ 31dacarbazine for inj 200 mg.........................................31dactinomycin for inj 0.5 mg........................................ 31dalfampridine tab er 12hr 10 mg............................... 74DALIRESP.................................................................. 109DALIRESP.................................................................. 110DALVANCE......................................................................9danazol cap 100 mg....................................................92danazol cap 200 mg....................................................92danazol cap 50 mg......................................................92dapsone tab 100 mg................................................... 28dapsone tab 25 mg..................................................... 28DAPTACEL....................................................................98daptomycin for iv soln 500 mg.....................................9DARAPRIM................................................................... 41DARZALEX................................................................... 31DARZALEX................................................................... 31daunorubicin hcl iv soln 20 mg/4ml...........................31DAUNORUBICIN HYDROCHLORIDE......................31DAURISMO...................................................................31DAURISMO...................................................................31DDAVP...........................................................................91

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DDAVP...........................................................................91DEBROX..................................................................... 107decitabine for inj 50 mg.............................................. 31deferasirox tab for oral susp 125 mg........................79deferasirox tab for oral susp 250 mg........................79deferasirox tab for oral susp 500 mg........................79DELSTRIGO................................................................. 48demeclocycline hcl tab 150 mg................................... 9demeclocycline hcl tab 300 mg................................. 10DEMSER....................................................................... 65DENAVIR.......................................................................48DEPEN TITRATABS....................................................89DEPO-PROVERA........................................................ 92DESCOVY.....................................................................48desipramine hcl tab 100 mg.......................................19desipramine hcl tab 10 mg.........................................19desipramine hcl tab 150 mg.......................................19desipramine hcl tab 25 mg.........................................19desipramine hcl tab 50 mg.........................................19desipramine hcl tab 75 mg.........................................19desmopressin acetate inj 4 mcg/ml...........................91desmopressin acetate tab 0.1 mg.............................91desmopressin acetate tab 0.2 mg.............................91desogest-eth estrad & eth estrad tab 0.15-0.02/0.01

mg(21/5)..................................................................... 92desogest-ethin est tab

0.1-0.025/0.125-0.025/0.15-0.025mg-mg..............92desogestrel & ethinyl estradiol tab 0.15 mg-30

mcg..............................................................................92desvenlafaxine succinate tab er 24hr 100 mg......... 20desvenlafaxine succinate tab er 24hr 25 mg........... 19desvenlafaxine succinate tab er 24hr 50 mg........... 20DEXAMETHASONE.................................................... 90DEXAMETHASONE.................................................... 90dexamethasone elixir 0.5 mg/5ml..............................90DEXAMETHASONE SODIUM PHOSPHATE........105dexamethasone sodium phosphate inj 120

mg/30ml......................................................................90dexamethasone sodium phosphate inj 20

mg/5ml........................................................................ 90dexamethasone sodium phosphate inj 4 mg/ml...... 90dexamethasone tab 0.5 mg........................................90dexamethasone tab 0.75 mg..................................... 90dexamethasone tab 1.5 mg........................................90dexamethasone tab 4 mg...........................................90dexamethasone tab 6 mg...........................................90dexmethylphenidate hcl tab 10 mg........................... 74dexmethylphenidate hcl tab 2.5 mg.......................... 74dexmethylphenidate hcl tab 5 mg............................. 74dexrazoxane hcl for inj 250 mg................................. 31dexrazoxane hcl for inj 500 mg................................. 31

dextran 70-hypromellose (pf) ophth soln0.1-0.3%...................................................................105

dextran 70-hypromellose ophth soln 0.1-0.3%......105dextroamphetamine sulfate tab 10 mg..................... 74dextroamphetamine sulfate tab 5 mg....................... 74dextromethorphan-guaifenesin liquid 10-100

mg/5ml......................................................................110dextromethorphan-guaifenesin liquid 10-200

mg/5ml......................................................................110dextromethorphan-guaifenesin syrup 10-100

mg/5ml......................................................................110dextrose 2.5% w/ sodium chloride 0.45%................ 79dextrose 5% in lactated ringers................................. 79dextrose 5% w/ sodium chloride 0.2%......................79dextrose 5% w/ sodium chloride 0.33%................... 79dextrose 5% w/ sodium chloride 0.45%................... 79dextrose 5% w/ sodium chloride 0.9%......................79dextrose inj 10%.......................................................... 79dextrose inj 5%............................................................ 79DIASTAT ACUDIAL......................................................15DIASTAT ACUDIAL......................................................15DIASTAT PEDIATRIC..................................................15DIAZEPAM.................................................................... 15DIAZEPAM.................................................................... 53DIAZEPAM RECTAL GEL.......................................... 15DIAZEPAM RECTAL GEL.......................................... 15DIAZEPAM RECTAL GEL.......................................... 15diazepam tab 10 mg................................................... 53diazepam tab 2 mg......................................................53diazepam tab 5 mg......................................................53dibucaine rectal ointment 1%.....................................76diclofenac potassium tab 50 mg..................................1diclofenac sodium gel 1%.............................................1diclofenac sodium ophth soln 0.1%........................ 105diclofenac sodium tab delayed release 25 mg...........1diclofenac sodium tab delayed release 50 mg...........1diclofenac sodium tab delayed release 75 mg...........1diclofenac sodium tab er 24hr 100 mg....................... 1dicloxacillin sodium cap 250 mg................................10dicloxacillin sodium cap 500 mg................................10dicyclomine hcl tab 20 mg..........................................83didanosine delayed release capsule 200 mg...........48didanosine delayed release capsule 250 mg...........48didanosine delayed release capsule 400 mg...........48DIFICID..........................................................................10DIFLUCAN.................................................................... 24DIFLUCAN.................................................................... 24DIFLUCAN.................................................................... 24DIFLUCAN.................................................................... 24DIFLUCAN.................................................................... 25DIFLUCAN.................................................................... 25digoxin oral soln 0.05 mg/ml......................................65

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digoxin tab 125 mcg (0.125 mg)................................65digoxin tab 250 mcg (0.25 mg)..................................65DILANTIN...................................................................... 15diltiazem hcl cap er 12hr 120 mg..............................65diltiazem hcl cap er 12hr 60 mg................................ 65diltiazem hcl cap er 12hr 90 mg................................ 65diltiazem hcl cap er 24hr 120 mg..............................65diltiazem hcl cap er 24hr 180 mg..............................65diltiazem hcl cap er 24hr 240 mg..............................65diltiazem hcl coated beads cap er 24hr 120 mg......65diltiazem hcl coated beads cap er 24hr 180 mg......65diltiazem hcl coated beads cap er 24hr 240 mg......65diltiazem hcl coated beads cap er 24hr 300 mg......65diltiazem hcl coated beads cap er 24hr 360 mg......65diltiazem hcl coated beads tab er 24hr 180 mg.......65diltiazem hcl coated beads tab er 24hr 240 mg.......65diltiazem hcl coated beads tab er 24hr 300 mg.......65diltiazem hcl coated beads tab er 24hr 360 mg.......65diltiazem hcl coated beads tab er 24hr 420 mg.......65diltiazem hcl extended release beads cap er 24hr

120 mg....................................................................... 65diltiazem hcl extended release beads cap er 24hr





420 mg....................................................................... 65diltiazem hcl tab 120 mg............................................ 65diltiazem hcl tab 30 mg...............................................65diltiazem hcl tab 60 mg...............................................65diltiazem hcl tab 90 mg...............................................65dimenhydrinate tab 50 mg..........................................23DIPENTUM................................................................. 103diphenhydramine hcl cap 25 mg............................. 110diphenhydramine hcl cap 50 mg............................. 110diphenhydramine hcl inj 50 mg/ml.......................... 110diphenhydramine hcl liquid 12.5 mg/5ml................110diphenhydramine hcl tab 25 mg.............................. 110DIPHTHERIA/TETANUS TOXOIDS

ADSORBED...............................................................98disulfiram tab 250 mg....................................................4disulfiram tab 500 mg....................................................5divalproex sodium cap delayed release sprinkle 125

mg................................................................................15divalproex sodium tab delayed release 125 mg...... 15divalproex sodium tab delayed release 250 mg...... 15divalproex sodium tab delayed release 500 mg...... 15divalproex sodium tab er 24 hr 250 mg....................15

divalproex sodium tab er 24 hr 500 mg....................15DIVIGEL.........................................................................92DIVIGEL.........................................................................92DIVIGEL.........................................................................92DIVIGEL.........................................................................92DOCETAXEL.................................................................31docetaxel for inj conc 160 mg/8ml (20 mg/ml).........31docetaxel for inj conc 20 mg/ml.................................31docetaxel for inj conc 80 mg/4ml (20 mg/ml)........... 31docetaxel soln for iv infusion 160 mg/16ml.............. 31docetaxel soln for iv infusion 20 mg/2ml.................. 31docetaxel soln for iv infusion 80 mg/8ml.................. 31docusate calcium cap 240 mg...................................83docusate sodium cap 100 mg....................................83docusate sodium cap 250 mg....................................83docusate sodium enema 283 mg.............................. 83docusate sodium liquid 150 mg/15ml....................... 83docusate sodium syrup 60 mg/15ml......................... 84docusate sodium tab 100 mg.....................................84DOCUSOL KIDS..........................................................84DOCUSOL PLUS MINI-ENEMA................................84dofetilide cap 125 mcg (0.125 mg)............................65dofetilide cap 250 mcg (0.25 mg)..............................65dofetilide cap 500 mcg (0.5 mg)................................65donepezil hydrochloride tab 10 mg........................... 18donepezil hydrochloride tab 5 mg............................. 18dorzolamide hcl ophth soln 2%............................... 105dorzolamide hcl-timolol maleate ophth soln 22.3-6.8

mg/ml........................................................................ 105DOVATO........................................................................ 48doxazosin mesylate tab 1 mg.................................... 65doxazosin mesylate tab 2 mg.................................... 65doxazosin mesylate tab 4 mg.................................... 65doxazosin mesylate tab 8 mg.................................... 65doxepin hcl cap 100 mg............................................. 20doxepin hcl cap 10 mg............................................... 20doxepin hcl cap 150 mg............................................. 20doxepin hcl cap 25 mg............................................... 20doxepin hcl cap 50 mg............................................... 20doxepin hcl cap 75 mg............................................... 20doxepin hcl conc 10 mg/ml........................................ 20doxorubicin hcl for inj 10 mg......................................31doxorubicin hcl for inj 50 mg......................................31doxorubicin hcl inj 2 mg/ml.........................................31doxorubicin hcl liposomal inj (for iv infusion) 2 mg/

ml.................................................................................31doxycycline hyclate cap 100 mg................................10doxycycline hyclate cap 50 mg..................................10doxycycline hyclate for inj 100 mg............................ 10doxycycline hyclate tab 100 mg................................ 10doxycycline hyclate tab 20 mg...................................10doxycycline monohydrate cap 100 mg..................... 10

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doxycycline monohydrate cap 150 mg..................... 10doxycycline monohydrate cap 50 mg....................... 10doxycycline monohydrate cap 75 mg....................... 10doxycycline monohydrate tab 100 mg...................... 10doxycycline monohydrate tab 150 mg...................... 10doxycycline monohydrate tab 50 mg........................ 10doxycycline monohydrate tab 75 mg........................ 10D-PENAMINE............................................................... 89dronabinol cap 10 mg................................................. 23dronabinol cap 2.5 mg................................................ 23dronabinol cap 5 mg................................................... 23drospirenone-ethinyl estradiol tab 3-0.02 mg.......... 92drospirenone-ethinyl estradiol tab 3-0.03 mg.......... 92drospirenone-ethinyl estrad-levomefolate tab

3-0.02-0.451 mg........................................................92drospirenone-ethinyl estrad-levomefolate tab

3-0.03-0.451 mg........................................................92DUAVEE........................................................................ 92DULERA......................................................................110DULERA......................................................................110duloxetine hcl enteric coated pellets cap 20 mg......20duloxetine hcl enteric coated pellets cap 30 mg......20duloxetine hcl enteric coated pellets cap 60 mg......20DUREZOL................................................................... 105dutasteride cap 0.5 mg............................................... 89EEASY TOUCH FLIPLOCK SAFETY INSULIN

SYRINGE 1ML/30G X 1/2"..................................... 54EASY TOUCH INSULIN SYRINGE/SAFETY/

U-100/0.5ML/29G X 1/2"......................................... 54EASY TOUCH INSULIN SYRINGE/SAFETY/

U-100/1ML/30G X 1/2".............................................54EASY TOUCH SHEATHLOCK SAFETY INSULIN

SYRINGE 1ML/29G X 1/2"..................................... 54EASY TOUCH SHEATHLOCK SAFETY SYRINGE

1ML/30G X 1/2"........................................................ 54EC-NAPROXEN............................................................. 1EC-NAPROXEN............................................................. 1EDURANT..................................................................... 48efavirenz cap 200 mg................................................. 48efavirenz cap 50 mg....................................................48efavirenz tab 600 mg.................................................. 48ELAPRASE................................................................... 88ELELYSO.......................................................................88ELIDEL...........................................................................76ELIGARD.......................................................................96ELIGARD.......................................................................96ELIGARD.......................................................................96ELIGARD.......................................................................96ELIQUIS.........................................................................60ELIQUIS.........................................................................60

ELIQUIS STARTER PACK......................................... 60ELITEK...........................................................................31ELITEK...........................................................................31ELLA...............................................................................92ELLENCE...................................................................... 31EMCYT.......................................................................... 31EMEND..........................................................................23EMGALITY.................................................................... 27EMGALITY.................................................................... 27EMGALITY.................................................................... 27EMPLICITI.....................................................................31EMPLICITI.....................................................................31EMSAM..........................................................................20EMSAM..........................................................................20EMSAM..........................................................................20EMTRIVA.......................................................................48EMTRIVA.......................................................................48enalapril maleate & hydrochlorothiazide tab 10-25

mg................................................................................66enalapril maleate & hydrochlorothiazide tab 5-12.5

mg................................................................................65enalapril maleate tab 10 mg...................................... 66enalapril maleate tab 2.5 mg..................................... 66enalapril maleate tab 20 mg...................................... 66enalapril maleate tab 5 mg.........................................66ENEMEEZ PLUS......................................................... 84ENGERIX-B.................................................................. 98ENGERIX-B.................................................................. 98enoxaparin sodium inj 100 mg/ml............................. 60enoxaparin sodium inj 120 mg/0.8ml........................ 60enoxaparin sodium inj 150 mg/ml............................. 60enoxaparin sodium inj 300 mg/3ml........................... 60enoxaparin sodium inj 30 mg/0.3ml.......................... 60enoxaparin sodium inj 40 mg/0.4ml.......................... 60enoxaparin sodium inj 60 mg/0.6ml.......................... 60enoxaparin sodium inj 80 mg/0.8ml.......................... 60entacapone tab 200 mg..............................................42entecavir tab 0.5 mg................................................... 48entecavir tab 1 mg.......................................................48ENTRESTO...................................................................66ENTRESTO...................................................................66ENTRESTO...................................................................66EPCLUSA......................................................................48EPIDIOLEX................................................................... 15epinastine hcl ophth soln 0.05%............................. 105epinephrine solution auto-injector 0.15 mg/0.3ml

(1:2000).................................................................... 110epinephrine solution auto-injector 0.3 mg/0.3ml

(1:1000) (generic for EpiPen 2-Pak)....................110epirubicin hcl iv soln 200 mg/100ml (2 mg/ml)........ 32epirubicin hcl iv soln 50 mg/25ml (2 mg/ml).............31EPIVIR HBV..................................................................48

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EPOGEN....................................................................... 60EPOGEN....................................................................... 60EPOGEN....................................................................... 60EPOGEN....................................................................... 60EPOGEN....................................................................... 60ERBITUX....................................................................... 32ERBITUX....................................................................... 32ergocalciferol cap 1.25 mg (50000 unit)...................79ergocalciferol soln 200 mcg/ml (8000 unit/ml)......... 79ERGOLOID MESYLATES.......................................... 18ERIVEDGE....................................................................32ERLEADA......................................................................32erlotinib hcl tab 100 mg.............................................. 32erlotinib hcl tab 150 mg.............................................. 32erlotinib hcl tab 25 mg................................................ 32ERWINAZE................................................................... 32ERYPED 400................................................................10ERYTHROCIN LACTOBIONATE...............................10erythromycin ethylsuccinate for susp 400

mg/5ml........................................................................ 10erythromycin ophth oint 5 mg/gm............................105erythromycin tab 250 mg............................................10erythromycin tab 500 mg............................................10erythromycin tab delayed release 250 mg............... 10erythromycin tab delayed release 333 mg............... 10erythromycin tab delayed release 500 mg............... 10erythromycin w/ delayed release particles cap 250

mg................................................................................10ESBRIET..................................................................... 110ESBRIET..................................................................... 110ESBRIET..................................................................... 110escitalopram oxalate soln 5 mg/5ml..........................20escitalopram oxalate tab 10 mg................................ 20escitalopram oxalate tab 20 mg................................ 20escitalopram oxalate tab 5 mg...................................20esomeprazole magnesium cap delayed release 20

mg................................................................................84esomeprazole magnesium cap delayed release 40

mg................................................................................84estradiol & norethindrone acetate tab 1-0.5 mg...... 92estradiol tab 0.5 mg.....................................................92estradiol tab 1 mg........................................................92estradiol tab 2 mg........................................................92estradiol td patch twice weekly 0.025 mg/24hr........93estradiol td patch twice weekly 0.0375 mg/24hr......93estradiol td patch twice weekly 0.05 mg/24hr..........93estradiol td patch twice weekly 0.075 mg/24hr........93estradiol td patch twice weekly 0.1 mg/24hr............ 93estradiol td patch weekly 0.025 mg/24hr..................93estradiol td patch weekly 0.0375 mg/24hr (37.5

mcg/24hr)................................................................... 93estradiol td patch weekly 0.05 mg/24hr....................93

estradiol td patch weekly 0.06 mg/24hr....................93estradiol td patch weekly 0.075 mg/24hr..................93estradiol td patch weekly 0.1 mg/24hr......................93estradiol vaginal cream 0.1 mg/gm........................... 93estradiol vaginal tab 10 mcg......................................93ethambutol hcl tab 100 mg.........................................28ethambutol hcl tab 400 mg.........................................28ethosuximide cap 250 mg.......................................... 15ethosuximide soln 250 mg/5ml.................................. 15ethynodiol diacetate & ethinyl estradiol tab 1 mg-35

mcg..............................................................................93ethynodiol diacetate & ethinyl estradiol tab 1 mg-50

mcg..............................................................................93ETHYOL........................................................................ 32etodolac cap 200 mg.....................................................2etodolac cap 300 mg.....................................................2etodolac tab 400 mg......................................................2etodolac tab 500 mg......................................................2ETOPOPHOS............................................................... 32etoposide inj 100 mg/5ml (20 mg/ml)....................... 32etoposide inj 1 gm/50ml (20 mg/ml)..........................32etoposide inj 500 mg/25ml (20 mg/ml)..................... 32EVOMELA..................................................................... 32EVOTAZ.........................................................................48EXCEDRIN EXTRA STRENGTH................................ 2EXCEDRIN MIGRAINE.................................................2exemestane tab 25 mg............................................... 32EXJADE.........................................................................79EXJADE.........................................................................79EXJADE.........................................................................79EX-LAX.......................................................................... 84EX-LAX.......................................................................... 84EX-LAX MAXIMUM STRENGTH...............................84ezetimibe-simvastatin tab 10-10 mg......................... 66ezetimibe-simvastatin tab 10-20 mg......................... 66ezetimibe-simvastatin tab 10-40 mg......................... 66ezetimibe-simvastatin tab 10-80 mg......................... 66ezetimibe tab 10 mg....................................................66FFABRAZYME................................................................ 88FABRAZYME................................................................ 88famciclovir tab 125 mg................................................48famciclovir tab 250 mg................................................48famciclovir tab 500 mg................................................48famotidine inj 200 mg/20ml........................................ 84famotidine inj 20 mg/2ml.............................................84famotidine inj 40 mg/4ml.............................................84famotidine tab 10 mg.................................................. 84famotidine tab 20 mg.................................................. 84famotidine tab 40 mg.................................................. 84FANAPT.........................................................................43

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FANAPT.........................................................................43FANAPT.........................................................................43FANAPT.........................................................................43FANAPT.........................................................................43FANAPT.........................................................................43FANAPT.........................................................................43FANAPT TITRATION PACK....................................... 43FARESTON...................................................................32FARYDAK......................................................................32FARYDAK......................................................................32FARYDAK......................................................................32FASLODEX................................................................... 32fat emulsion plant based iv emulsion 20%...............79febuxostat tab 40 mg.................................................. 26febuxostat tab 80 mg.................................................. 26felbamate susp 600 mg/5ml.......................................15felbamate tab 400 mg................................................. 15felbamate tab 600 mg................................................. 15felodipine tab er 24hr 10 mg......................................66felodipine tab er 24hr 2.5 mg.....................................66felodipine tab er 24hr 5 mg........................................66fenofibrate micronized cap 134 mg...........................66fenofibrate micronized cap 200 mg...........................66fenofibrate micronized cap 67 mg.............................66fenofibrate tab 145 mg................................................66fenofibrate tab 160 mg................................................66fenofibrate tab 48 mg..................................................66fenofibrate tab 54 mg..................................................66fentanyl citrate lozenge on a handle 1200 mcg......... 2fentanyl citrate lozenge on a handle 1600 mcg......... 2fentanyl citrate lozenge on a handle 200 mcg........... 2fentanyl citrate lozenge on a handle 400 mcg........... 2fentanyl citrate lozenge on a handle 600 mcg........... 2fentanyl citrate lozenge on a handle 800 mcg........... 2fentanyl td patch 72hr 100 mcg/hr...............................2fentanyl td patch 72hr 12 mcg/hr.................................2fentanyl td patch 72hr 25 mcg/hr.................................2fentanyl td patch 72hr 37.5 mcg/hr............................. 2fentanyl td patch 72hr 50 mcg/hr.................................2fentanyl td patch 72hr 62.5 mcg/hr............................. 2fentanyl td patch 72hr 75 mcg/hr.................................2fentanyl td patch 72hr 87.5 mcg/hr............................. 2FERAHEME.................................................................. 80FERRLECIT.................................................................. 80FERROUS SULFATE.................................................. 80ferrous sulfate tab 325 mg (65 mg elemental fe).....80ferrous sulfate tab ec 325 mg (65 mg fe

equivalent)..................................................................80FETZIMA....................................................................... 20FETZIMA....................................................................... 20FETZIMA....................................................................... 20FETZIMA....................................................................... 20

FETZIMA TITRATION PACK......................................20FEVERALL INFANTS.................................................... 2FIBERCON....................................................................84FINACEA....................................................................... 76FINACEA....................................................................... 76finasteride tab 5 mg.....................................................89FIRAZYR....................................................................... 98FIRMAGON...................................................................96FIRMAGON...................................................................96FLAGYL......................................................................... 10FLAGYL......................................................................... 10FLAREX.......................................................................105flecainide acetate tab 100 mg....................................66flecainide acetate tab 150 mg....................................66flecainide acetate tab 50 mg......................................66FLEET ENEMA............................................................ 84FLEET LIQUID GLYCERIN SUPPOSITORIES....... 84FLEET PEDIATRIC......................................................84FLOMAX........................................................................89FLOVENT DISKUS....................................................110FLOVENT DISKUS....................................................110FLOVENT DISKUS....................................................110FLOVENT HFA...........................................................110FLOVENT HFA...........................................................110FLOVENT HFA...........................................................110FLOWTUSS................................................................ 110fluconazole for susp 10 mg/ml...................................25fluconazole for susp 40 mg/ml...................................25fluconazole in dextrose inj 200 mg/100ml................25fluconazole in dextrose inj 400 mg/200ml................25fluconazole in nacl 0.9% inj 200 mg/100ml..............25fluconazole in nacl 0.9% inj 400 mg/200ml..............25fluconazole tab 100 mg.............................................. 25fluconazole tab 150 mg.............................................. 25fluconazole tab 200 mg.............................................. 25fluconazole tab 50 mg.................................................25flucytosine cap 250 mg...............................................25flucytosine cap 500 mg...............................................25fludarabine phosphate for inj 50 mg......................... 32fludarabine phosphate inj 25 mg/ml..........................32fludrocortisone acetate tab 0.1 mg............................90fluocinolone acetonide (otic) oil 0.01%...................107fluocinonide cream 0.05%.......................................... 76fluocinonide emulsified base cream 0.05%..............76fluocinonide gel 0.05%................................................76fluocinonide oint 0.05%...............................................76fluocinonide soln 0.05%..............................................76fluorometholone ophth susp 0.1%...........................105FLUOROURACIL......................................................... 76FLUOROURACIL......................................................... 76FLUOROURACIL......................................................... 76fluorouracil cream 5%................................................. 76

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fluorouracil iv soln 1 gm/20ml (50 mg/ml)

110

................ 32fluorouracil iv soln 2.5 gm/50ml (50 mg/ml)............. 32fluorouracil iv soln 500 mg/10ml (50 mg/ml)............ 32fluorouracil iv soln 5 gm/100ml (50 mg/ml).............. 32fluoxetine hcl cap 10 mg............................................ 20fluoxetine hcl cap 20 mg............................................ 20fluoxetine hcl cap 40 mg............................................ 20fluoxetine hcl solution 20 mg/5ml.............................. 20fluoxetine hcl tab 10 mg............................................. 20fluoxetine hcl tab 20 mg............................................. 20fluphenazine decanoate inj 25 mg/ml....................... 43FLUPHENAZINE HCL.................................................43FLUPHENAZINE HCL.................................................43fluphenazine hcl tab 10 mg........................................43fluphenazine hcl tab 1 mg.......................................... 43fluphenazine hcl tab 2.5 mg.......................................43fluphenazine hcl tab 5 mg.......................................... 43FLUPHENAZINE HYDROCHLORIDE...................... 43flurbiprofen sodium ophth soln 0.03%.................... 105flutamide cap 125 mg................................................. 32FLUTICASONE PROPIONATE/

SALMETEROL........................................................ 110FLUTICASONE PROPIONATE/

SALMETEROL........................................................ 110FLUTICASONE PROPIONATE/

SALMETEROL........................................................fluticasone propionate cream 0.05%.........................76fluticasone propionate nasal susp 50 mcg/act.......110fluticasone propionate oint 0.005%...........................76fluvoxamine maleate tab 100 mg.............................. 20fluvoxamine maleate tab 25 mg................................ 20fluvoxamine maleate tab 50 mg................................ 20FML.............................................................................. 105FML FORTE............................................................... 105FML LIQUIFILM......................................................... 105FOLIC ACID..................................................................80folic acid tab 1 mg.......................................................80FOLOTYN......................................................................32FOLOTYN......................................................................32fondaparinux sodium subcutaneous inj 10

mg/0.8ml.....................................................................60fondaparinux sodium subcutaneous inj 2.5

mg/0.5ml.....................................................................60fondaparinux sodium subcutaneous inj 5

mg/0.4ml.....................................................................60fondaparinux sodium subcutaneous inj 7.5

mg/0.6ml.....................................................................60FORTEO......................................................................104fosamprenavir calcium tab 700 mg........................... 48fosaprepitant dimeglumine for iv infusion 150

mg................................................................................23fosinopril sodium tab 10 mg.......................................66

fosinopril sodium tab 20 mg.......................................66fosinopril sodium tab 40 mg.......................................66fosphenytoin sodium inj 100 mg/2ml........................ 15fosphenytoin sodium inj 500 mg/10ml...................... 15FOSRENOL.................................................................. 80FOSRENOL.................................................................. 80FREAMINE HBC 6.9%................................................80FREAMINE III...............................................................80fructose-dextrose-phosphoric acid oral soln............ 23fulvestrant inj 250 mg/5ml.......................................... 32furosemide inj 10 mg/ml............................................. 66furosemide oral soln 10 mg/ml.................................. 66furosemide tab 20 mg................................................. 66furosemide tab 40 mg................................................. 66furosemide tab 80 mg................................................. 66FUZEON........................................................................48FYCOMPA.....................................................................15FYCOMPA.....................................................................15FYCOMPA.....................................................................15FYCOMPA.....................................................................15FYCOMPA.....................................................................15FYCOMPA.....................................................................15FYCOMPA.....................................................................15Ggabapentin cap 100 mg..............................................15gabapentin cap 300 mg..............................................15gabapentin cap 400 mg..............................................15gabapentin oral soln 250 mg/5ml.............................. 15gabapentin tab 600 mg...............................................16gabapentin tab 800 mg...............................................16GALANTAMINE HYDROBROMIDE.......................... 18galantamine hydrobromide cap er 24hr 16 mg........18galantamine hydrobromide cap er 24hr 24 mg........18galantamine hydrobromide cap er 24hr 8 mg..........18galantamine hydrobromide tab 12 mg...................... 18galantamine hydrobromide tab 4 mg........................ 18galantamine hydrobromide tab 8 mg........................ 18GALZIN..........................................................................80GALZIN..........................................................................80GAMMAGARD LIQUID............................................... 98GAMMAGARD LIQUID............................................... 99GAMMAGARD LIQUID............................................... 99GAMMAGARD LIQUID............................................... 99GAMMAGARD LIQUID............................................... 99GAMMAGARD LIQUID............................................... 99GAMMAGARD S/D......................................................99GAMMAGARD S/D......................................................99GAMMAPLEX............................................................... 99GAMMAPLEX............................................................... 99GAMMAPLEX............................................................... 99GAMMAPLEX............................................................... 99

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GAMMAPLEX............................................................... 99GAMMAPLEX............................................................... 99GAMUNEX-C................................................................ 99GAMUNEX-C................................................................ 99GAMUNEX-C................................................................ 99GAMUNEX-C................................................................ 99GAMUNEX-C................................................................ 99GAMUNEX-C................................................................ 99ganciclovir sodium for inj 500 mg..............................48GARDASIL 9.................................................................99GARDASIL 9.................................................................99GATTEX.........................................................................84GAUZE PADS 2" X 2".................................................55GAVISCON....................................................................84GAVISCON....................................................................84GAVISCON EXTRA STRENGTH.............................. 84GAVISCON EXTRA STRENGTH.............................. 84GAVISCON EXTRA STRENGTH RELIEF

FORMULA..................................................................84GAZYVA.........................................................................32gemcitabine hcl for inj 1 gm.......................................32gemcitabine hcl for inj 200 mg...................................32gemcitabine hcl for inj 2 gm.......................................32gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml)............ 33gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml)........ 32gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml)............ 33gemfibrozil tab 600 mg............................................... 66gentamicin sulfate cream 0.1%................................. 76gentamicin sulfate inj 10 mg/ml................................. 10gentamicin sulfate inj 40 mg/ml................................. 10gentamicin sulfate oint 0.1%......................................76gentamicin sulfate ophth oint 0.3%.........................105gentamicin sulfate ophth soln 0.3%........................ 105GENVOYA.....................................................................48GEODON.......................................................................44GILOTRIF......................................................................33GILOTRIF......................................................................33GILOTRIF......................................................................33glatiramer acetate soln prefilled syringe 20 mg/

ml.................................................................................74glatiramer acetate soln prefilled syringe 40 mg/

ml.................................................................................74GLEOSTINE..................................................................33GLEOSTINE..................................................................33GLEOSTINE..................................................................33glimepiride tab 1 mg....................................................55glimepiride tab 2 mg....................................................55glimepiride tab 4 mg....................................................55glipizide tab 10 mg...................................................... 55glipizide tab 5 mg........................................................ 55glipizide tab er 24hr 10 mg........................................ 55glipizide tab er 24hr 2.5 mg....................................... 55

glipizide tab er 24hr 5 mg...........................................55GLUCAGEN HYPOKIT............................................... 55GLUCOPHAGE............................................................ 55GLUCOPHAGE............................................................ 55GLUCOPHAGE............................................................ 55GLUCOPHAGE XR..................................................... 55GLUCOPHAGE XR..................................................... 55glucose gel 40%.......................................................... 55GLUCOTROL................................................................55GLUCOTROL................................................................55GLUCOTROL XL......................................................... 55GLUCOTROL XL......................................................... 55GLUCOTROL XL......................................................... 55GLYCERIN ADULT...................................................... 84glycerin suppos 1.2 gm...............................................84glycerin suppos 2 gm..................................................84glycopyrrolate tab 1 mg.............................................. 84glycopyrrolate tab 2 mg.............................................. 85GLYXAMBI.................................................................... 55GLYXAMBI.................................................................... 55GOLYTELY....................................................................85granisetron hcl inj 1 mg/ml......................................... 23granisetron hcl inj 4 mg/4ml (1 mg/ml)..................... 23griseofulvin microsize susp 125 mg/5ml...................25griseofulvin ultramicrosize tab 125 mg..................... 25griseofulvin ultramicrosize tab 250 mg..................... 25guaifenesin liquid 100 mg/5ml................................. 110guaifenesin syrup 100 mg/5ml.................................111GUANIDINE HCL.........................................................28HHAEGARDA.................................................................. 99HAEGARDA................................................................100HALAVEN...................................................................... 33haloperidol decanoate im soln 100 mg/ml................44haloperidol decanoate im soln 50 mg/ml..................44haloperidol lactate inj 5 mg/ml...................................44haloperidol lactate oral conc 2 mg/ml....................... 44haloperidol tab 0.5 mg................................................ 44haloperidol tab 10 mg................................................. 44haloperidol tab 1 mg................................................... 44haloperidol tab 20 mg................................................. 44haloperidol tab 2 mg................................................... 44haloperidol tab 5 mg................................................... 44HARVONI...................................................................... 48HARVONI...................................................................... 48HAVRIX........................................................................100HAVRIX........................................................................100HEPARIN SODIUM......................................................60HEPARIN SODIUM......................................................60heparin sodium (porcine)-dextrose iv sol 20000

unit/500ml-5%............................................................60

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heparin sodium (porcine) inj 10000 unit/ml.............. 60heparin sodium (porcine) inj 1000 unit/ml................ 60heparin sodium (porcine) inj 20000 unit/ml.............. 60heparin sodium (porcine) inj 5000 unit/ml................ 60heparin sodium (porcine) pf inj 5000 unit/0.5ml.......60HEPATAMINE............................................................... 80HERCEPTIN................................................................. 33HERCEPTIN HYLECTA..............................................33HETLIOZ..................................................................... 113HIBERIX...................................................................... 100HUMALOG.................................................................... 55HUMALOG.................................................................... 55HUMALOG JUNIOR KWIKPEN.................................55HUMALOG KWIKPEN.................................................55HUMALOG KWIKPEN.................................................55HUMALOG MIX 50/50................................................ 55HUMALOG MIX 50/50 KWIKPEN............................. 55HUMALOG MIX 75/25................................................ 55HUMALOG MIX 75/25 KWIKPEN............................. 55HUMIRA...................................................................... 100HUMIRA...................................................................... 100HUMIRA...................................................................... 100HUMIRA...................................................................... 100HUMIRA...................................................................... 100HUMIRA...................................................................... 100HUMIRA PEDIATRIC CROHNS DISEASE

STARTER PACK.....................................................100HUMIRA PEDIATRIC CROHNS DISEASE

STARTER PACK.....................................................100HUMIRA PEDIATRIC CROHNS DISEASE

STARTER PACK.....................................................100HUMIRA PEN.............................................................100HUMIRA PEN.............................................................100HUMIRA PEN-CD/UC/HS STARTER..................... 100HUMIRA PEN-CD/UC/HS STARTER..................... 100HUMIRA PEN-PS/UV STARTER............................ 100HUMIRA PEN-PS/UV STARTER............................ 100HUMULIN 70/30...........................................................56HUMULIN 70/30 KWIKPEN....................................... 56HUMULIN N..................................................................56HUMULIN N KWIKPEN.............................................. 56HUMULIN R..................................................................56HUMULIN R U-500 (CONCENTRATE).................... 56HUMULIN R U-500 KWIKPEN.................................. 56hydralazine hcl tab 100 mg........................................67hydralazine hcl tab 10 mg.......................................... 66hydralazine hcl tab 25 mg.......................................... 66hydralazine hcl tab 50 mg.......................................... 66hydrochlorothiazide cap 12.5 mg.............................. 67hydrochlorothiazide tab 12.5 mg............................... 67hydrochlorothiazide tab 25 mg...................................67hydrochlorothiazide tab 50 mg...................................67

hydrocodone-acetaminophen soln 7.5-325mg/15ml........................................................................ 2

hydrocodone-acetaminophen tab 10-325 mg............ 2hydrocodone-acetaminophen tab 5-325 mg.............. 2hydrocodone-acetaminophen tab 7.5-325 mg........... 2hydrocortisone-aloe vera cream 0.5%......................76hydrocortisone-aloe vera cream 1%......................... 76hydrocortisone cream 0.5%........................................76hydrocortisone cream 1%...........................................76hydrocortisone cream 1%...........................................76hydrocortisone cream 2.5%........................................76hydrocortisone enema 100 mg/60ml...................... 103hydrocortisone lotion 1%............................................ 76hydrocortisone lotion 2.5%......................................... 76hydrocortisone oint 0.5%............................................ 76hydrocortisone oint 1%............................................... 76hydrocortisone oint 1%............................................... 76hydrocortisone oint 2.5%............................................ 76hydrocortisone rectal cream 1%..............................103hydrocortisone rectal cream 2.5%...........................103hydrocortisone tab 10 mg...........................................90hydrocortisone tab 20 mg...........................................90hydrocortisone tab 5 mg.............................................90hydrocortisone w/ acetic acid otic soln 1-2%.........107hydromorphone hcl inj 2 mg/ml................................... 2hydromorphone hcl liqd 1 mg/ml................................. 2hydromorphone hcl preservative free inj 10 mg/

ml................................................................................... 2hydromorphone hcl preservative free inj 2 mg/ml......2hydromorphone hcl tab 2 mg....................................... 2hydromorphone hcl tab 4 mg....................................... 2hydromorphone hcl tab 8 mg....................................... 3HYDROXOCOBALAMIN.............................................80hydroxychloroquine sulfate tab 200 mg....................41HYDROXYPROGESTERONE CAPROATE............ 93hydroxyurea cap 500 mg............................................33HYZAAR........................................................................ 67HYZAAR........................................................................ 67HYZAAR........................................................................ 67Iibandronate sodium tab 150 mg..............................104IBRANCE.......................................................................33IBRANCE.......................................................................33IBRANCE.......................................................................33ibuprofen tab 200 mg.................................................... 3ibuprofen tab 400 mg.................................................... 3ibuprofen tab 600 mg.................................................... 3ibuprofen tab 800 mg.................................................... 3icatibant acetate inj 30 mg/3ml................................100ICLUSIG........................................................................ 33ICLUSIG........................................................................ 33

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idarubicin hcl iv inj 10 mg/10ml (1 mg/ml)................33idarubicin hcl iv inj 20 mg/20ml (1 mg/ml)................33idarubicin hcl iv inj 5 mg/5ml (1 mg/ml).................... 33IDHIFA............................................................................33IDHIFA............................................................................33IFEX............................................................................... 33IFOSFAMIDE................................................................ 33ifosfamide for inj 1 gm................................................ 33ILARIS..........................................................................100ILEVRO........................................................................105imatinib mesylate tab 100 mg....................................33imatinib mesylate tab 400 mg....................................33IMBRUVICA.................................................................. 33IMBRUVICA.................................................................. 33IMBRUVICA.................................................................. 33IMBRUVICA.................................................................. 33IMBRUVICA.................................................................. 33IMBRUVICA.................................................................. 33IMFINZI..........................................................................33IMFINZI..........................................................................33imipenem-cilastatin intravenous for soln 250

mg................................................................................10imipenem-cilastatin intravenous for soln 500

mg................................................................................10imipramine hcl tab 10 mg...........................................20imipramine hcl tab 25 mg...........................................20imipramine hcl tab 50 mg...........................................20imiquimod cream 5%...................................................76IMITREX........................................................................ 27IMITREX........................................................................ 27IMITREX........................................................................ 27IMITREX........................................................................ 27IMITREX........................................................................ 27IMITREX........................................................................ 27IMITREX STATDOSE REFILL................................... 27IMITREX STATDOSE REFILL................................... 27IMITREX STATDOSE SYSTEM.................................27IMITREX STATDOSE SYSTEM.................................27IMLYGIC........................................................................ 34IMLYGIC........................................................................ 34IMOVAX RABIES (H.D.C.V.)....................................100IMPAVIDO..................................................................... 10INBRIJA......................................................................... 42INCRELEX.................................................................... 91INCRUSE ELLIPTA................................................... 111INFANRIX....................................................................100INFED............................................................................ 80INFUVITE PEDIATRIC................................................80INJECTAFER................................................................ 80INLYTA...........................................................................34INLYTA...........................................................................34INREBIC........................................................................ 34

INSULIN PEN NEEDLE 29G X 12.7MM (1/2")........56INSULIN PEN NEEDLE 29G X 5MM (1/5" OR

3/16")...........................................................................56INSULIN PEN NEEDLE 29G X 8MM (1/3" OR








15/64")........................................................................ 56INSULIN PEN NEEDLE 33G X 8MM (1/3" OR

5/16")...........................................................................56INSULIN SYRINGE/NEEDLE U-100/0.3ML/28G X

1/2".............................................................................. 56INSULIN SYRINGE/NEEDLE

U-100/0.3ML/29G......................................................56INSULIN SYRINGE/NEEDLE U-100/0.3ML/29G X

1"................................................................................. 56INSULIN SYRINGE/NEEDLE


1/4" (6MM)..................................................................56INSULIN SYRINGE/NEEDLE U-100/0.5ML/27G X

1/2".............................................................................. 56INSULIN SYRINGE/NEEDLE U-100/0.5ML/28G X

5/16"............................................................................56INSULIN SYRINGE/NEEDLE


5/16"............................................................................57INSULIN SYRINGE/NEEDLE


3/16" (5MM)............................................................... 57INSULIN SYRINGE/NEEDLE U-100/0.5ML/30G X


1/4" (6MM)..................................................................57INSULIN SYRINGE/NEEDLE U-100/1ML/25G X

1"................................................................................. 57INSULIN SYRINGE/NEEDLE U-100/1ML/25G X

5/8".............................................................................. 57

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INSULIN SYRINGE/NEEDLE U-100/1ML/26G X1/2".............................................................................. 57



INSULIN SYRINGE/NEEDLE U-100/1ML/28G X5/16"............................................................................57

INSULIN SYRINGE/NEEDLE U-100/1ML/29G X5/16"............................................................................57

INSULIN SYRINGE/NEEDLE U-100/1ML/30G....... 57INSULIN SYRINGE/NEEDLE U-100/1ML/30G X

3/16" (5MM)............................................................... 57INSULIN SYRINGE/NEEDLE U-100/1ML/31G X

1/4" (6MM)..................................................................57INSULIN SYRINGE/NEEDLE U-100/2ML/27.5G X

5/8".............................................................................. 57INSULIN SYRINGE/NEEDLE U-100 0.3 ML 30 X

15/64"..........................................................................56INSULIN SYRINGE/NEEDLE U-100 0.5 ML 30 X

15/64"..........................................................................56INSULIN SYRINGE/NEEDLE U-100 0.5 ML 32 X

5/16"............................................................................56INSULIN SYRINGE/NEEDLE U-100 1 ML 30 X

15/64"..........................................................................56INSULIN SYRINGE/NEEDLE U-100 1 ML 32 X

5/16"............................................................................56INSULIN SYRINGE/NEEDLE U-40/1ML/25G X


6MM (15/64").............................................................57INSULIN SYRINGE (DISP) U-100/0.3ML................ 56INSULIN SYRINGE (DISP) U-100/0.5ML................ 56INSULIN SYRINGE (DISP) U-100/1ML....................56INTELENCE.................................................................. 48INTELENCE.................................................................. 48INTELENCE.................................................................. 48INTRON A.....................................................................48INTRON A.....................................................................49INTRON A.....................................................................49INTRON A.....................................................................49INTRON A.....................................................................49INTRON A W/DILUENT..............................................49INTRON A W/DILUENT..............................................49INTRON A W/DILUENT..............................................49INVANZ.......................................................................... 10INVANZ.......................................................................... 10INVEGA SUSTENNA.................................................. 44INVEGA SUSTENNA.................................................. 44INVEGA SUSTENNA.................................................. 44INVEGA SUSTENNA.................................................. 44INVEGA SUSTENNA.................................................. 44

INVEGA TRINZA..........................................................44INVEGA TRINZA..........................................................44INVEGA TRINZA..........................................................44INVEGA TRINZA..........................................................44INVIRASE......................................................................49IONOSOL-MB/DEXTROSE 5%.................................80IPOL INACTIVATED IPV.......................................... 100ipratropium bromide inhal soln 0.02%.................... 111ipratropium bromide nasal soln 0.03% (21 mcg/

spray)........................................................................111ipratropium bromide nasal soln 0.06% (42 mcg/

spray)........................................................................111irbesartan-hydrochlorothiazide tab 150-12.5 mg.....67irbesartan-hydrochlorothiazide tab 300-12.5 mg.....67irbesartan tab 150 mg.................................................67irbesartan tab 300 mg.................................................67irbesartan tab 75 mg...................................................67IRESSA..........................................................................34IRINOTECAN................................................................34irinotecan hcl inj 100 mg/5ml (20 mg/ml)................. 34irinotecan hcl inj 40 mg/2ml (20 mg/ml)....................34irrigation solution, physiological.................................80ISENTRESS..................................................................49ISENTRESS..................................................................49ISENTRESS..................................................................49ISENTRESS..................................................................49ISENTRESS HD...........................................................49ISOLYTE-P/DEXTROSE 5%......................................80ISOLYTE-S....................................................................80ISONIAZID.................................................................... 28isoniazid tab 100 mg...................................................28isoniazid tab 300 mg...................................................28isosorbide dinitrate tab 10 mg................................... 67isosorbide dinitrate tab 20 mg................................... 67isosorbide dinitrate tab 5 mg......................................67isosorbide mononitrate tab er 24hr 120 mg............. 67isosorbide mononitrate tab er 24hr 30 mg............... 67isosorbide mononitrate tab er 24hr 60 mg............... 67isotretinoin cap 10 mg.................................................76isotretinoin cap 20 mg.................................................77isotretinoin cap 30 mg.................................................77isotretinoin cap 40 mg.................................................77ISTODAX (OVERFILL)................................................34itraconazole cap 100 mg............................................ 25ivermectin tab 3 mg.....................................................41IXEMPRA KIT...............................................................34IXEMPRA KIT...............................................................34IXIARO.........................................................................100JJADENU........................................................................ 80JADENU........................................................................ 80

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JADENU........................................................................ 80JADENU SPRINKLE................................................... 80JADENU SPRINKLE................................................... 80JADENU SPRINKLE................................................... 80JAKAFI...........................................................................34JAKAFI...........................................................................34JAKAFI...........................................................................34JAKAFI...........................................................................34JAKAFI...........................................................................34JARDIANCE..................................................................57JARDIANCE..................................................................57JEVTANA.......................................................................34JULUCA.........................................................................49KKADCYLA......................................................................34KADCYLA......................................................................34KALETRA...................................................................... 49KALETRA...................................................................... 49KALYDECO.................................................................111KALYDECO.................................................................111KALYDECO.................................................................111KALYDECO.................................................................111KANJINTI.......................................................................34KAOPECTATE STOOL SOFTENER.........................85kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45%

inj................................................................................. 80kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2%




inj................................................................................. 81kcl 20 meq/l (0.15%) in nacl 0.45% inj..................... 80kcl 20 meq/l (0.15%) in nacl 0.9% inj....................... 80kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45%


inj................................................................................. 81kcl 40 meq/l (0.3%) in nacl 0.9% inj..........................80KEPIVANCE..................................................................74ketoconazole cream 2%............................................. 25ketoconazole shampoo 2%........................................ 25ketoconazole tab 200 mg........................................... 25ketorolac tromethamine ophth soln 0.4%...............105ketorolac tromethamine ophth soln 0.5%...............105KEYTRUDA...................................................................34KINRIX.........................................................................100KISQALI.........................................................................34KISQALI.........................................................................34KISQALI.........................................................................34

KISQALI FEMARA 200 DOSE...................................34KISQALI FEMARA 400 DOSE...................................34KISQALI FEMARA 600 DOSE...................................34KOMBIGLYZE XR........................................................57KOMBIGLYZE XR........................................................57KOMBIGLYZE XR........................................................57KONSYL........................................................................ 85KONSYL........................................................................ 85KONSYL........................................................................ 85KONSYL-D....................................................................85KONSYL DAILY FIBER...............................................85KONSYL DAILY FIBER...............................................85KONSYL DAILY FIBER...............................................85KORLYM........................................................................96KUVAN...........................................................................88KUVAN...........................................................................88KUVAN...........................................................................88KYPROLIS.................................................................... 34KYPROLIS.................................................................... 34KYPROLIS.................................................................... 34Llabetalol hcl tab 100 mg............................................. 67labetalol hcl tab 200 mg............................................. 67labetalol hcl tab 300 mg............................................. 67LACRISERT................................................................106lactated ringer's for irrigation......................................81lactated ringer's solution............................................. 81lactic acid (ammonium lactate) cream 12%............. 77lactic acid (ammonium lactate) lotion 12%...............77lactulose (encephalopathy) solution 10

gm/15ml......................................................................85lactulose solution 10 gm/15ml................................... 85LAMISIL AT...................................................................25LAMISIL AT JOCK ITCH............................................ 25lamivudine oral soln 10 mg/ml...................................49lamivudine tab 100 mg (hbv)..................................... 49lamivudine tab 150 mg................................................49lamivudine tab 300 mg................................................49lamivudine-zidovudine tab 150-300 mg....................49lamotrigine tab 100 mg............................................... 16lamotrigine tab 150 mg............................................... 16lamotrigine tab 200 mg............................................... 16lamotrigine tab 25 mg................................................. 16lamotrigine tab chewable dispersible 25 mg............16lamotrigine tab chewable dispersible 5 mg.............. 16lansoprazole cap delayed release 15 mg.................85lansoprazole cap delayed release 30 mg.................85lanthanum carbonate chew tab 1000 mg................. 81lanthanum carbonate chew tab 500 mg................... 81lanthanum carbonate chew tab 750 mg................... 81LARTRUVO...................................................................35

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LARTRUVO...................................................................35LASIX............................................................................. 67LASIX............................................................................. 67LASIX............................................................................. 67latanoprost ophth soln 0.005%................................106LATUDA.........................................................................44LATUDA.........................................................................44LATUDA.........................................................................44LATUDA.........................................................................44LATUDA.........................................................................44LAZANDA........................................................................ 3LAZANDA........................................................................ 3LAZANDA........................................................................ 3leflunomide tab 10 mg.............................................. 100leflunomide tab 20 mg.............................................. 100LENVIMA 10 MG DAILY DOSE.................................35LENVIMA 12MG DAILY DOSE..................................35LENVIMA 14 MG DAILY DOSE.................................35LENVIMA 18 MG DAILY DOSE.................................35LENVIMA 20 MG DAILY DOSE.................................35LENVIMA 24 MG DAILY DOSE.................................35LENVIMA 4 MG DAILY DOSE...................................35LENVIMA 8 MG DAILY DOSE...................................35LETAIRIS.....................................................................111LETAIRIS.....................................................................111letrozole tab 2.5 mg.....................................................35LEUCOVORIN CALCIUM...........................................35LEUCOVORIN CALCIUM...........................................35LEUCOVORIN CALCIUM...........................................35leucovorin calcium for inj 100 mg..............................35leucovorin calcium for inj 200 mg..............................35leucovorin calcium for inj 350 mg..............................35leucovorin calcium for inj 500 mg..............................35leucovorin calcium for inj 50 mg................................35leucovorin calcium inj 500 mg/50ml (10 mg/ml)...... 35leucovorin calcium tab 25 mg.................................... 35leucovorin calcium tab 5 mg...................................... 35LEUKERAN...................................................................35leuprolide acetate inj kit 5 mg/ml...............................96LEVAQUIN.....................................................................10LEVAQUIN.....................................................................11levetiracetam inj 500 mg/5ml (100 mg/ml)............... 16levetiracetam oral soln 100 mg/ml............................ 16levetiracetam tab 1000 mg.........................................16levetiracetam tab 250 mg...........................................16levetiracetam tab 500 mg...........................................16levetiracetam tab 750 mg...........................................16levobunolol hcl ophth soln 0.5%..............................106levocarnitine oral soln 1 gm/10ml (10%).................. 81levocarnitine tab 330 mg............................................ 81levocetirizine dihydrochloride tab 5 mg.................. 111levofloxacin in d5w iv soln 250 mg/50ml.................. 11

levofloxacin in d5w iv soln 500 mg/100ml................11levofloxacin in d5w iv soln 750 mg/150ml................11levofloxacin iv soln 25 mg/ml.....................................11levofloxacin oral soln 25 mg/ml................................. 11levofloxacin tab 250 mg..............................................11levofloxacin tab 500 mg..............................................11levofloxacin tab 750 mg..............................................11levonorgestrel & ethinyl estradiol (91-day) tab

0.15-0.03 mg............................................................. 93levonorgestrel & ethinyl estradiol tab 0.15 mg-30

mcg..............................................................................93levonorgestrel & ethinyl estradiol tab 0.1 mg-20

mcg..............................................................................93levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg........................93levonorgestrel tab 1.5 mg...........................................93levonorg-eth est tab 0.1-0.02mg(84) & eth est tab

0.01mg(7)...................................................................93levothyroxine sodium tab 100 mcg (levo-t, levoxyl,

unithroid, unithroid direct)........................................95levothyroxine sodium tab 112 mcg (levo-t, levoxyl,



unithroid).....................................................................95levothyroxine sodium tab 150 mcg (levo-t, levoxyl,




unithroid, unithroid direct)........................................95levothyroxine sodium tab 300 mcg (levo-t, unithroid,

unithroid direct)......................................................... 95levothyroxine sodium tab 50 mcg (levo-t, levoxyl,



unithroid, unithroid direct)........................................95LEXAPRO......................................................................20LEXAPRO......................................................................21LEXAPRO......................................................................21LEXIVA...........................................................................49LEXIVA...........................................................................49LIBTAYO........................................................................ 35lidocaine anorectal cream 5%....................................77lidocaine hcl soln 4%.....................................................4lidocaine hcl urethral/mucosal gel 2%........................ 4

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lidocaine hcl urethral/mucosal gel prefilled syringe2%..................................................................................4

lidocaine hcl viscous soln 2%...................................... 4lidocaine patch 5%.........................................................4lidocaine-prilocaine cream 2.5-2.5%........................... 4LINEZOLID....................................................................11linezolid for susp 100 mg/5ml.................................... 11linezolid iv soln 600 mg/300ml (2 mg/ml).................11linezolid tab 600 mg.................................................... 11LINZESS........................................................................85LINZESS........................................................................85LINZESS........................................................................85liothyronine sodium tab 25 mcg.................................95liothyronine sodium tab 50 mcg.................................95liothyronine sodium tab 5 mcg...................................95LIPITOR.........................................................................67LIPITOR.........................................................................67LIPITOR.........................................................................67LIPITOR.........................................................................67lisinopril & hydrochlorothiazide tab 10-12.5 mg.......67lisinopril & hydrochlorothiazide tab 20-12.5 mg.......67lisinopril & hydrochlorothiazide tab 20-25 mg..........67lisinopril tab 10 mg...................................................... 67lisinopril tab 2.5 mg..................................................... 67lisinopril tab 20 mg...................................................... 67lisinopril tab 30 mg...................................................... 68lisinopril tab 40 mg...................................................... 68lisinopril tab 5 mg........................................................ 67LITHIUM........................................................................ 53lithium carbonate cap 150 mg................................... 53lithium carbonate cap 300 mg................................... 53lithium carbonate cap 600 mg................................... 53lithium carbonate tab 300 mg.................................... 53lithium carbonate tab er 300 mg................................53lithium carbonate tab er 450 mg................................53LONSURF..................................................................... 35LONSURF..................................................................... 35loperamide hcl cap 2 mg............................................ 85loperamide hcl cap 2 mg............................................ 85loperamide hcl liq 1 mg/5ml (0.2 mg/ml).................. 85loperamide hcl liq 1 mg/7.5ml....................................85loperamide hcl tab 2 mg.............................................85lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/

ml)................................................................................49LOPRESSOR................................................................68LOPRESSOR................................................................68LOPROX........................................................................25loratadine cap 10 mg................................................ 111loratadine rapidly-disintegrating tab 10 mg............111loratadine syrup 5 mg/5ml........................................111loratadine tab 10 mg................................................. 111lorazepam tab 0.5 mg................................................. 53

lorazepam tab 1 mg.................................................... 53lorazepam tab 2 mg.................................................... 53LORBRENA.................................................................. 35LORBRENA.................................................................. 35losartan potassium & hydrochlorothiazide tab

100-12.5 mg.............................................................. 68losartan potassium & hydrochlorothiazide tab 100-25

mg................................................................................68losartan potassium & hydrochlorothiazide tab

50-12.5 mg.................................................................68losartan potassium tab 100 mg................................. 68losartan potassium tab 25 mg................................... 68losartan potassium tab 50 mg................................... 68LOTENSIN.................................................................... 68LOTENSIN.................................................................... 68LOTENSIN.................................................................... 68LOTRISONE................................................................. 77lovastatin tab 10 mg....................................................68lovastatin tab 20 mg....................................................68lovastatin tab 40 mg....................................................68loxapine succinate cap 10 mg................................... 44loxapine succinate cap 25 mg................................... 44loxapine succinate cap 50 mg................................... 44loxapine succinate cap 5 mg..................................... 44LUMIZYME....................................................................88LUMOXITI......................................................................35LUPRON DEPOT (1-MONTH)...................................96LUPRON DEPOT (1-MONTH)...................................96LUPRON DEPOT (3-MONTH)...................................96LUPRON DEPOT (3-MONTH)...................................96LUPRON DEPOT (4-MONTH)...................................96LUPRON DEPOT (6-MONTH)...................................96LUPRON DEPOT-PED (1-MONTH)......................... 96LUPRON DEPOT-PED (1-MONTH)......................... 96LUPRON DEPOT-PED (1-MONTH)......................... 96LUPRON DEPOT-PED (3-MONTH)......................... 96LUPRON DEPOT-PED (3-MONTH)......................... 96LYNPARZA....................................................................35LYNPARZA....................................................................36LYRICA.......................................................................... 16LYRICA.......................................................................... 16LYRICA.......................................................................... 16LYRICA.......................................................................... 16LYRICA.......................................................................... 16LYRICA.......................................................................... 16LYRICA.......................................................................... 16LYRICA.......................................................................... 16LYRICA.......................................................................... 16LYSODREN...................................................................96MMAGNEBIND 300........................................................ 81magnesium hydroxide susp 400 mg/5ml..................85

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magnesium oxide tab 400 mg................................... 85magnesium oxide tab 400 mg (241.3 mg elemental

mg).............................................................................. 85magnesium oxide tab 420 mg................................... 85magnesium sulfate inj 50%........................................ 81malathion lotion 0.5%..................................................41MAPROTILINE HCL.................................................... 21MAPROTILINE HCL.................................................... 21MAPROTILINE HCL.................................................... 21MARPLAN..................................................................... 21MARQIBO......................................................................36MATULANE...................................................................36MAVYRET..................................................................... 49MAXALT.........................................................................27MAXALT-MLT................................................................27MAXIPIME.....................................................................11MAXIPIME.....................................................................11MAXITROL..................................................................106MAXITROL..................................................................106MAYZENT......................................................................74MAYZENT......................................................................74meclizine hcl chew tab 25 mg................................... 23meclizine hcl tab 12.5 mg...........................................23meclizine hcl tab 12.5 mg...........................................23meclizine hcl tab 25 mg..............................................23MEDROL....................................................................... 90MEDROL....................................................................... 90MEDROL....................................................................... 90MEDROL....................................................................... 90MEDROL DOSEPAK................................................... 90medroxyprogesterone acetate im susp 150 mg/

ml.................................................................................93medroxyprogesterone acetate im susp prefilled syr

150 mg/ml.................................................................. 93medroxyprogesterone acetate tab 10 mg.................93medroxyprogesterone acetate tab 2.5 mg............... 93medroxyprogesterone acetate tab 5 mg...................93mefloquine hcl tab 250 mg.........................................41megestrol acetate susp 40 mg/ml............................. 93megestrol acetate tab 20 mg..................................... 93megestrol acetate tab 40 mg..................................... 93MEKINIST......................................................................36MEKINIST......................................................................36MEKTOVI.......................................................................36meloxicam tab 15 mg....................................................3meloxicam tab 7.5 mg...................................................3melphalan hcl for inj 50 mg........................................36memantine hcl oral solution 2 mg/ml........................ 18memantine hcl tab 10 mg...........................................18memantine hcl tab 5 mg.............................................18memantine hcl tab 5 mg (28) & 10 mg (21) titration

pak...............................................................................18

MENACTRA................................................................101MENVEO.....................................................................101MEPHYTON..................................................................81mercaptopurine tab 50 mg......................................... 36meropenem iv for soln 1 gm......................................11meropenem iv for soln 500 mg..................................11MERREM.......................................................................11mesalamine enema 4 gm.........................................103mesalamine rectal enema 4 gm & cleanser wipe

kit...............................................................................103mesalamine suppos 1000 mg..................................103mesalamine tab delayed release 1.2 gm............... 103mesalamine tab delayed release 800 mg.............. 103mesna inj 100 mg/ml...................................................36MESNEX........................................................................36MESNEX........................................................................36MESTINON................................................................... 28metformin hcl tab 1000 mg........................................ 57metformin hcl tab 500 mg...........................................57metformin hcl tab 850 mg...........................................57metformin hcl tab er 24hr 500 mg.............................57metformin hcl tab er 24hr 750 mg.............................57methadone hcl tab 10 mg.............................................3methadone hcl tab 5 mg...............................................3methazolamide tab 25 mg..........................................68methazolamide tab 50 mg..........................................68methenamine hippurate tab 1 gm............................. 11methimazole tab 10 mg.............................................. 97methimazole tab 5 mg................................................ 97methocarbamol tab 500 mg..................................... 113methocarbamol tab 750 mg..................................... 113METHOTREXATE SODIUM.....................................101methotrexate sodium for inj 1 gm............................101methotrexate sodium inj 50 mg/2ml (25 mg/

ml)............................................................................. 101methotrexate sodium inj pf 1000 mg/40ml (25 mg/



ml)............................................................................. 101methotrexate sodium tab 2.5 mg.............................101methylcellulose powder laxative................................ 85methylcellulose tab 500 mg........................................85methylergonovine maleate tab 0.2 mg..................... 89methylphenidate hcl tab 10 mg................................. 74methylphenidate hcl tab 20 mg................................. 74methylphenidate hcl tab 5 mg....................................74methylphenidate hcl tab er 20 mg.............................74methylprednisolone sod succ for inj 1000 mg..........91methylprednisolone sod succ for inj 125 mg............90methylprednisolone sod succ for inj 40 mg..............90

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methylprednisolone sod succ for inj 500 mg............90methylprednisolone tab 16 mg...................................91methylprednisolone tab 32 mg...................................91methylprednisolone tab 4 mg.....................................91methylprednisolone tab 8 mg.....................................91methylprednisolone tab therapy pack 4 mg (21)..... 91metoclopramide hcl inj 5 mg/ml.................................85metoclopramide hcl soln 5 mg/5ml (10

mg/10ml).....................................................................85metoclopramide hcl tab 10 mg.................................. 85metoclopramide hcl tab 5 mg.....................................85metoprolol succinate tab er 24hr 100 mg.................68metoprolol succinate tab er 24hr 200 mg.................68metoprolol succinate tab er 24hr 25 mg...................68metoprolol succinate tab er 24hr 50 mg...................68metoprolol tartrate tab 100 mg.................................. 68metoprolol tartrate tab 25 mg.....................................68metoprolol tartrate tab 50 mg.....................................68metronidazole cream 0.75%...................................... 77metronidazole gel 0.75%............................................ 77metronidazole gel 1%..................................................77metronidazole in nacl 0.74% iv soln 500

mg/100ml....................................................................11metronidazole in nacl 0.79% iv soln 500

mg/100ml....................................................................11metronidazole iv soln 5 mg/ml...................................11metronidazole lotion 0.75%........................................77metronidazole tab 250 mg..........................................11metronidazole tab 500 mg..........................................11metronidazole vaginal gel 0.75%.............................. 11mexiletine hcl cap 150 mg......................................... 68mexiletine hcl cap 200 mg......................................... 68mexiletine hcl cap 250 mg......................................... 68MIACALCIN................................................................ 104MICARDIS.....................................................................68MICARDIS.....................................................................68MICARDIS.....................................................................68MICARDIS HCT........................................................... 68MICARDIS HCT........................................................... 68MICARDIS HCT........................................................... 68miconazole nitrate cream 2%.................................... 77miconazole nitrate vaginal app 200 mg & 2% cream

9 gm kit...................................................................... 25miconazole nitrate vaginal cream 2%.......................25miconazole nitrate vaginal cream 4% (200

mg/5gm)..................................................................... 25miconazole nitrate vaginal supp 1200 mg & 2%

cream kit.....................................................................25miconazole nitrate vaginal supp 200 mg & 2% cream

9 gm kit...................................................................... 25miconazole nitrate vaginal suppos 100 mg..............25midodrine hcl tab 10 mg.............................................69

midodrine hcl tab 2.5 mg............................................68midodrine hcl tab 5 mg............................................... 68MIGERGOT...................................................................27miglustat cap 100 mg..................................................88MIGRANAL....................................................................27MILK OF MAGNESIA CONCENTRATE................... 85MINOCIN....................................................................... 11minocycline hcl cap 100 mg.......................................11minocycline hcl cap 50 mg.........................................11minocycline hcl cap 75 mg.........................................11minocycline hcl tab 100 mg........................................11minocycline hcl tab 50 mg..........................................11minocycline hcl tab 75 mg..........................................11minoxidil tab 10 mg..................................................... 69minoxidil tab 2.5 mg.................................................... 69mirtazapine orally disintegrating tab 15 mg............. 21mirtazapine orally disintegrating tab 30 mg............. 21mirtazapine orally disintegrating tab 45 mg............. 21mirtazapine tab 15 mg................................................ 21mirtazapine tab 30 mg................................................ 21mirtazapine tab 45 mg................................................ 21mirtazapine tab 7.5 mg............................................... 21misoprostol tab 100 mcg............................................ 85misoprostol tab 200 mcg............................................ 85mitomycin for iv soln 20 mg....................................... 36mitomycin for iv soln 40 mg....................................... 36mitomycin for iv soln 5 mg......................................... 36mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml).....36mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/

ml)................................................................................36mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml).....36M-M-R II...................................................................... 101modafinil tab 100 mg................................................ 113modafinil tab 200 mg................................................ 113MOLINDONE HYDROCHLORIDE............................ 44MOLINDONE HYDROCHLORIDE............................ 44MOLINDONE HYDROCHLORIDE............................ 45mometasone furoate cream 0.1%............................. 77mometasone furoate nasal susp 50 mcg/act.........111mometasone furoate oint 0.1%..................................77mometasone furoate solution 0.1% (lotion)..............77MONOJECT INSULIN SYRINGE/SAFETY/PERM

NEEDLE/0.3ML/29G X 1/2".................................... 57MONOJECT INSULIN SYRINGE/SAFETY/PERM

NEEDLE/0.5ML/29G X 1/2".................................... 57MONOJECT INSULIN SYRINGE/SAFETY/PERM

NEEDLE/1ML/29G X 1/2"........................................58montelukast sodium chew tab 4 mg....................... 111montelukast sodium chew tab 5 mg....................... 111montelukast sodium oral granules packet 4

mg............................................................................. 111montelukast sodium tab 10 mg............................... 111

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morphine sulfate inj pf 0.5 mg/ml................................ 3morphine sulfate inj pf 1 mg/ml................................... 3morphine sulfate tab 15 mg......................................... 3morphine sulfate tab 30 mg......................................... 3morphine sulfate tab er 100 mg...................................3morphine sulfate tab er 15 mg.....................................3morphine sulfate tab er 200 mg...................................3morphine sulfate tab er 30 mg.....................................3morphine sulfate tab er 60 mg.....................................3MOVIPREP................................................................... 86MOXEZA..................................................................... 106MOXIFLOXACIN HCL.................................................11moxifloxacin hcl 400 mg/250ml in sodium chloride

0.8% inj.......................................................................11moxifloxacin hcl ophth soln 0.5%............................106moxifloxacin hcl tab 400 mg...................................... 11MULTAQ........................................................................ 69mupirocin calcium cream 2%.....................................77mupirocin oint 2%........................................................ 77MURO 128..................................................................106MVASI............................................................................ 36MVASI............................................................................ 36MYALEPT...................................................................... 86MYAMBUTOL................................................................28MYCAMINE...................................................................25MYCAMINE...................................................................25mycophenolate mofetil cap 250 mg........................ 101mycophenolate mofetil for oral susp 200 mg/

ml...............................................................................101mycophenolate mofetil hcl for iv soln 500 mg........101mycophenolate mofetil tab 500 mg.........................101MYLOTARG.................................................................. 36MYRBETRIQ.................................................................89MYRBETRIQ.................................................................89Nnabumetone tab 500 mg...............................................3nabumetone tab 750 mg...............................................3NAFCILLIN SODIUM...................................................11NAFCILLIN SODIUM...................................................12NAFCILLIN SODIUM...................................................12nafcillin sodium for inj 1 gm....................................... 12nafcillin sodium for inj 2 gm....................................... 12nafcillin sodium for iv soln 10 gm..............................12naftifine hcl cream 2%................................................ 25naftifine hcl gel 1%...................................................... 25NAFTIN..........................................................................25NAFTIN..........................................................................25NAFTIN..........................................................................26NAGLAZYME................................................................88NALOXONE HCL........................................................... 5NALOXONE HCL........................................................... 5

naloxone hcl inj 0.4 mg/ml............................................5naloxone hcl inj 4 mg/10ml...........................................5naltrexone hcl tab 50 mg..............................................5naproxen sodium tab 220 mg...................................... 3naproxen sodium tab 275 mg...................................... 3naproxen sodium tab 550 mg...................................... 3naproxen susp 125 mg/5ml..........................................3naproxen tab 250 mg.................................................... 3naproxen tab 375 mg.................................................... 3naproxen tab 500 mg.................................................... 3naproxen tab ec 375 mg...............................................3naproxen tab ec 500 mg...............................................3naratriptan hcl tab 1 mg..............................................27naratriptan hcl tab 2.5 mg.......................................... 27NARCAN..........................................................................5NARDIL..........................................................................21NATACYN....................................................................106nateglinide tab 120 mg............................................... 58nateglinide tab 60 mg................................................. 58NATPARA....................................................................104NATPARA....................................................................104NATPARA....................................................................104NATPARA....................................................................104NAYZILAM.....................................................................16NEBUPENT...................................................................41NEFAZODONE HCL....................................................21NEFAZODONE HCL....................................................21nefazodone hcl tab 250 mg........................................21nefazodone hcl tab 50 mg..........................................21NEFAZODONE HYDROCHLORIDE.........................21neomycin-bacitracin-polymyxin oint.......................... 77neomycin-bacitracin-polymyxin-pramoxine oint

1%............................................................................... 77neomycin-polymy-gramicid op sol

1.75-10000-0.025mg-unt-mg/ml...........................106neomycin-polymyxin-dexamethasone ophth oint

0.1%..........................................................................106neomycin-polymyxin-dexamethasone ophth susp

0.1%..........................................................................106neomycin-polymyxin-hc otic soln 1%......................107neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000

unit/ml-1%................................................................ 107neomycin sulfate tab 500 mg.....................................12NEPHRAMINE..............................................................81NERLYNX......................................................................36NEVANAC................................................................... 106nevirapine susp 50 mg/5ml........................................ 49nevirapine tab 200 mg................................................ 49nevirapine tab er 24hr 100 mg.................................. 49nevirapine tab er 24hr 400 mg.................................. 49NEXAVAR......................................................................36niacin tab er 1000 mg.................................................69

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niacin tab er 500 mg................................................... 69niacin tab er 750 mg................................................... 69NICODERM CQ............................................................. 5NICODERM CQ............................................................. 5NICODERM CQ............................................................. 5NICORETTE....................................................................5NICORETTE....................................................................5NICORETTE....................................................................5NICORETTE....................................................................5NICORETTE MINI..........................................................5NICORETTE MINI..........................................................5NICORETTE STARTER KIT.........................................5NICORETTE STARTER KIT.........................................5nicotine polacrilex gum 2 mg....................................... 5nicotine polacrilex gum 4 mg....................................... 5nicotine polacrilex lozenge 2 mg................................. 5nicotine polacrilex lozenge 4 mg................................. 5nicotine td patch 24hr 14 mg/24hr...............................5nicotine td patch 24hr 21 mg/24hr...............................5nicotine td patch 24hr 7 mg/24hr.................................5NICOTINE TRANSDERMAL SYSTEM.......................5NICOTROL INHALER................................................... 5NICOTROL NS...............................................................5nifedipine tab er 24hr 30 mg......................................69nifedipine tab er 24hr 60 mg......................................69nifedipine tab er 24hr 90 mg......................................69nifedipine tab er 24hr osmotic release 30 mg..........69nifedipine tab er 24hr osmotic release 60 mg..........69nifedipine tab er 24hr osmotic release 90 mg..........69nilutamide tab 150 mg................................................ 36nimodipine cap 30 mg.................................................69NINLARO.......................................................................36NINLARO.......................................................................36NINLARO.......................................................................36NIPENT..........................................................................36nitisinone cap 10 mg...................................................88nitisinone cap 2 mg..................................................... 88nitisinone cap 5 mg..................................................... 88NITRO-BID....................................................................69nitrofurantoin macrocrystalline cap 100 mg............. 12nitrofurantoin macrocrystalline cap 50 mg............... 12nitrofurantoin monohydrate macrocrystalline cap 100

mg................................................................................12nitroglycerin sl tab 0.3 mg.......................................... 69nitroglycerin sl tab 0.4 mg.......................................... 69nitroglycerin sl tab 0.6 mg.......................................... 69nitroglycerin td patch 24hr 0.1 mg/hr........................ 69nitroglycerin td patch 24hr 0.2 mg/hr........................ 69nitroglycerin td patch 24hr 0.4 mg/hr........................ 69nitroglycerin td patch 24hr 0.6 mg/hr........................ 69NIZORAL....................................................................... 26

norethindrone & ethinyl estradiol-fe chew tab 0.4mg-35 mcg.................................................................93

norethindrone & ethinyl estradiol-fe chew tab 0.8mg-25 mcg.................................................................94

norethindrone & ethinyl estradiol tab 0.4 mg-35mcg..............................................................................93

norethindrone & ethinyl estradiol tab 0.5 mg-35mcg..............................................................................93

norethindrone & ethinyl estradiol tab 1 mg-35mcg..............................................................................93

norethindrone ace & ethinyl estradiol-fe tab 1.5mg-30 mcg.................................................................94

norethindrone ace & ethinyl estradiol-fe tab 1 mg-20mcg..............................................................................94

norethindrone ace & ethinyl estradiol tab 1.5 mg-30mcg..............................................................................94

norethindrone ace & ethinyl estradiol tab 1 mg-20mcg..............................................................................94

norethindrone ace-ethinyl estradiol-fe tab 1 mg-20mcg (24).....................................................................94

norethindrone acetate tab 5 mg................................ 94norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35

mg-mcg.......................................................................94norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35

mg-mcg.......................................................................94norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35

mg-mcg.......................................................................94norethindrone tab 0.35 mg......................................... 94norgestimate & ethinyl estradiol tab 0.25 mg-35

mcg..............................................................................94norgestimate-eth estrad tab

0.18-25/0.215-25/0.25-25 mg-mcg.........................94norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mg-mcg.........................94norgestrel & ethinyl estradiol tab 0.3 mg-30

mcg..............................................................................94NORMOSOL-M IN D5W.............................................81NORMOSOL-R.............................................................81NORMOSOL-R IN D5W............................................. 81NORTEMP INFANTS.....................................................3NORTHERA.................................................................. 69NORTHERA.................................................................. 69NORTHERA.................................................................. 69nortriptyline hcl cap 10 mg......................................... 21nortriptyline hcl cap 25 mg......................................... 21nortriptyline hcl cap 50 mg......................................... 21nortriptyline hcl cap 75 mg......................................... 21nortriptyline hcl soln 10 mg/5ml.................................21NORVASC..................................................................... 69NORVASC..................................................................... 69NORVASC..................................................................... 69NORVIR.........................................................................49

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NORVIR.........................................................................49NOXAFIL....................................................................... 26NOXAFIL....................................................................... 26NOXAFIL....................................................................... 26NUBEQA........................................................................36NUEDEXTA...................................................................74NULOJIX..................................................................... 101NULYTELY/FLAVOR PACKS..................................... 86NUPLAZID.....................................................................45NUPLAZID.....................................................................45nystatin cream 100000 unit/gm................................. 26nystatin oint 100000 unit/gm......................................26nystatin susp 100000 unit/ml..................................... 26nystatin tab 500000 unit............................................. 26nystatin topical powder 100000 unit/gm................... 26OOCALIVA....................................................................... 88OCALIVA....................................................................... 88octreotide acetate inj 1000 mcg/ml (1 mg/ml)..........97octreotide acetate inj 100 mcg/ml (0.1 mg/ml).........96octreotide acetate inj 200 mcg/ml (0.2 mg/ml).........96octreotide acetate inj 500 mcg/ml (0.5 mg/ml).........96octreotide acetate inj 50 mcg/ml (0.05 mg/ml).........96OCUFLOX...................................................................106ODEFSEY..................................................................... 49ODOMZO...................................................................... 36OFEV........................................................................... 111OFEV........................................................................... 111ofloxacin ophth soln 0.3%........................................ 106ofloxacin otic soln 0.3%............................................107ofloxacin tab 400 mg...................................................12olanzapine for im inj 10 mg........................................45olanzapine orally disintegrating tab 10 mg...............45olanzapine orally disintegrating tab 15 mg...............45olanzapine orally disintegrating tab 20 mg...............45olanzapine orally disintegrating tab 5 mg.................45olanzapine tab 10 mg................................................. 45olanzapine tab 15 mg................................................. 45olanzapine tab 2.5 mg................................................ 45olanzapine tab 20 mg................................................. 45olanzapine tab 5 mg....................................................45olanzapine tab 7.5 mg................................................ 45omega-3-acid ethyl esters cap 1 gm.........................69omeprazole cap delayed release 10 mg.................. 86omeprazole cap delayed release 20 mg.................. 86omeprazole cap delayed release 40 mg.................. 86OMNITROPE................................................................ 91OMNITROPE................................................................ 91OMNITROPE................................................................ 91ONCASPAR.................................................................. 36ondansetron hcl inj 40 mg/20ml (2 mg/ml)...............23

ondansetron hcl inj 4 mg/2ml (2 mg/ml)................... 23ondansetron hcl tab 24 mg........................................ 24ondansetron hcl tab 4 mg...........................................24ondansetron hcl tab 8 mg...........................................24ondansetron orally disintegrating tab 4 mg.............. 24ondansetron orally disintegrating tab 8 mg.............. 24ONFI...............................................................................16ONFI...............................................................................16ONFI...............................................................................16ONGLYZA......................................................................58ONGLYZA......................................................................58ONIVYDE...................................................................... 36OPDIVO.........................................................................36OPDIVO.........................................................................36OPDIVO.........................................................................36OPSUMIT....................................................................111ORENCIA....................................................................101ORENCIA....................................................................101ORENCIA....................................................................101ORENCIA....................................................................101ORENCIA CLICKJECT............................................. 101ORFADIN.......................................................................88ORFADIN.......................................................................88ORFADIN.......................................................................88ORFADIN.......................................................................88ORFADIN.......................................................................88ORKAMBI....................................................................111ORKAMBI....................................................................111ORKAMBI....................................................................111ORKAMBI....................................................................111oseltamivir phosphate cap 30 mg............................. 49oseltamivir phosphate cap 45 mg............................. 49oseltamivir phosphate cap 75 mg............................. 50oseltamivir phosphate for susp 6 mg/ml...................50OTEZLA.......................................................................101OTEZLA.......................................................................101OTOVEL...................................................................... 108oxaliplatin for iv inj 100 mg........................................ 37oxaliplatin for iv inj 50 mg...........................................36oxaliplatin iv soln 100 mg/20ml..................................37oxaliplatin iv soln 50 mg/10ml....................................37oxandrolone tab 10 mg...............................................94oxandrolone tab 2.5 mg..............................................94oxcarbazepine susp 300 mg/5ml (60 mg/ml)...........16oxcarbazepine tab 150 mg.........................................16oxcarbazepine tab 300 mg.........................................16oxcarbazepine tab 600 mg.........................................16oxybutynin chloride syrup 5 mg/5ml..........................90oxybutynin chloride tab 5 mg.....................................90oxybutynin chloride tab er 24hr 10 mg..................... 90oxybutynin chloride tab er 24hr 15 mg..................... 90oxybutynin chloride tab er 24hr 5 mg....................... 90

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oxycodone hcl tab 10 mg............................................. 3oxycodone hcl tab 15 mg............................................. 3oxycodone hcl tab 20 mg............................................. 3oxycodone hcl tab 30 mg............................................. 3oxycodone hcl tab 5 mg............................................... 3oxycodone w/ acetaminophen tab 10-325 mg........... 4oxycodone w/ acetaminophen tab 2.5-325 mg..........4oxycodone w/ acetaminophen tab 5-325 mg............. 4oxycodone w/ acetaminophen tab 7.5-325 mg..........4OZEMPIC...................................................................... 58OZEMPIC...................................................................... 58Ppaclitaxel iv conc 100 mg/16.7ml (6 mg/ml).............37paclitaxel iv conc 300 mg/50ml (6 mg/ml)................37paclitaxel iv conc 30 mg/5ml (6 mg/ml).................... 37paliperidone tab er 24hr 1.5 mg................................ 45paliperidone tab er 24hr 3 mg................................... 45paliperidone tab er 24hr 6 mg................................... 45paliperidone tab er 24hr 9 mg................................... 45palonosetron hcl iv soln 0.25 mg/5ml....................... 24palonosetron hcl iv soln pref syr 0.25 mg/5ml......... 24PALONOSETRON HYDROCHLORIDE................... 24PALYNZIQ..................................................................... 88PALYNZIQ..................................................................... 88PALYNZIQ..................................................................... 88PANRETIN.....................................................................37pantoprazole sodium ec tab 20 mg...........................86pantoprazole sodium ec tab 40 mg...........................86pantoprazole sodium for iv soln 40 mg.....................86parenteral electrolyte conc......................................... 81paricalcitol cap 1 mcg............................................... 104paricalcitol cap 2 mcg............................................... 104paricalcitol cap 4 mcg............................................... 104paricalcitol iv soln 2 mcg/ml.....................................104paricalcitol iv soln 5 mcg/ml.....................................104PARNATE...................................................................... 21paromomycin sulfate cap 250 mg............................. 12paroxetine hcl tab 10 mg............................................21paroxetine hcl tab 20 mg............................................21paroxetine hcl tab 30 mg............................................21paroxetine hcl tab 40 mg............................................21PASER........................................................................... 28PATANOL.................................................................... 106PAXIL............................................................................. 21PAXIL............................................................................. 21PAXIL............................................................................. 21PAXIL............................................................................. 21PAXIL............................................................................. 21PEDIA-LAX....................................................................86PEDIA-LAX....................................................................86PEDIA-LAX....................................................................86

PEDIA-LAX....................................................................86PEDIARIX....................................................................101PEDVAX HIB.............................................................. 101peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236

gm................................................................................86peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240

gm................................................................................86peg 3350-kcl-sod bicarb-nacl for soln 420 gm.........86PEGANONE..................................................................16PEGASYS..................................................................... 50PEGASYS..................................................................... 50PEGASYS PROCLICK................................................50penicillin g potassium for inj 20000000 unit............. 12penicillin g potassium for inj 5000000 unit............... 12PENICILLIN G POTASSIUM IN DEXTROSE.......... 12PENICILLIN G POTASSIUM IN DEXTROSE.......... 12PENICILLIN G POTASSIUM IN DEXTROSE.......... 12penicillin v potassium for soln 125 mg/5ml.............. 12penicillin v potassium for soln 250 mg/5ml.............. 12penicillin v potassium tab 250 mg............................. 12penicillin v potassium tab 500 mg............................. 12PENTACEL................................................................. 101PENTAM 300................................................................41pentamidine isethionate for soln 300 mg..................41pentoxifylline tab er 400 mg.......................................69PERJETA.......................................................................37permethrin cream 5%..................................................41permethrin creme rinse 1%........................................41permethrin lotion 1%................................................... 41perphenazine tab 16 mg.............................................24perphenazine tab 2 mg...............................................24perphenazine tab 4 mg...............................................24perphenazine tab 8 mg...............................................24PERSERIS.................................................................... 45PERSERIS.................................................................... 45phenelzine sulfate tab 15 mg.....................................21phenobarbital elixir 20 mg/5ml...................................16PHENOBARBITAL SODIUM...................................... 16PHENOBARBITAL SODIUM...................................... 16phenobarbital tab 100 mg...........................................17phenobarbital tab 15 mg.............................................16phenobarbital tab 16.2 mg......................................... 17phenobarbital tab 30 mg.............................................17phenobarbital tab 32.4 mg......................................... 17phenobarbital tab 60 mg.............................................17phenobarbital tab 64.8 mg......................................... 17phenobarbital tab 97.2 mg......................................... 17phenoxybenzamine hcl cap 10 mg........................... 69phenylephrine in hard fat rectal suppos 0.25%....... 77phenytoin chew tab 50 mg.........................................17phenytoin sodium extended cap 100 mg................. 17phenytoin sodium extended cap 200 mg................. 17

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phenytoin sodium extended cap 300 mg................. 17phenytoin susp 125 mg/5ml....................................... 17PHOSPHOLINE IODIDE.......................................... 106phytonadione inj 10 mg/ml......................................... 81PIFELTRO..................................................................... 50pilocarpine hcl ophth soln 1%..................................106pilocarpine hcl ophth soln 2%..................................106pilocarpine hcl ophth soln 4%..................................106pilocarpine hcl tab 5 mg............................................. 74pilocarpine hcl tab 7.5 mg.......................................... 74pimecrolimus cream 1%............................................. 77pimozide tab 1 mg.......................................................45pimozide tab 2 mg.......................................................45pindolol tab 10 mg.......................................................69pindolol tab 5 mg......................................................... 69pioglitazone hcl tab 15 mg......................................... 58pioglitazone hcl tab 30 mg......................................... 58pioglitazone hcl tab 45 mg......................................... 58piperacillin sod-tazobactam na for inj 3.375 gm

(3-0.375 gm)..............................................................12piperacillin sod-tazobactam sod for inj 2.25 gm

(2-0.25 gm)................................................................ 12piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5

gm).............................................................................. 12PIQRAY 200MG DAILY DOSE.................................. 37PIQRAY 250MG DAILY DOSE.................................. 37PIQRAY 300MG DAILY DOSE.................................. 37PLAN B ONE-STEP.................................................... 94PLASMA-LYTE-148..................................................... 81PLASMA-LYTE A......................................................... 81podofilox soln 0.5%..................................................... 77POLIVY..........................................................................37polyethylene glycol 3350 oral packet........................86polyethylene glycol 3350 oral powder.......................86polymyxin b-trimethoprim ophth soln 10000 unit/

ml-0.1%.................................................................... 106POLYTRIM.................................................................. 106polyvinyl alcohol ophth soln 1.4%........................... 106polyvinyl alcohol-povidone ophth soln 5-6 mg/ml

(0.5-0.6%)................................................................ 106POMALYST...................................................................37POMALYST...................................................................37POMALYST...................................................................37POMALYST...................................................................37PORTRAZZA................................................................ 37posaconazole tab delayed release 100 mg............. 26POTASSIUM CHLORIDE/DEXTROSE.....................81POTASSIUM CHLORIDE/DEXTROSE/LACTATED

RINGERS...................................................................82POTASSIUM CHLORIDE/DEXTROSE/LACTATED

RINGERS...................................................................82

potassium chloride 20 meq/l (0.15%) in dextrose 5%inj................................................................................. 81

potassium chloride cap er 10 meq............................81potassium chloride cap er 8 meq.............................. 81potassium chloride inj 10 meq/100ml....................... 81potassium chloride inj 20 meq/100ml....................... 81potassium chloride inj 2 meq/ml................................81potassium chloride inj 40 meq/100ml....................... 81potassium chloride microencapsulated crys er tab 10

meq............................................................................. 81potassium chloride microencapsulated crys er tab 20

meq............................................................................. 81potassium chloride oral soln 10% (20

meq/15ml).................................................................. 81potassium chloride tab er 10 meq.............................81potassium chloride tab er 8 meq (600 mg).............. 81potassium citrate tab er 10 meq (1080 mg)............. 82potassium citrate tab er 15 meq (1620 mg)............. 82potassium citrate tab er 5 meq (540 mg)................. 82POTELIGEO................................................................. 37povidone-iodine oint 10%........................................... 77povidone-iodine soln 10%.......................................... 77povidone-iodine soln 7.5%......................................... 77povidone-iodine swabs 10%...................................... 77PRADAXA..................................................................... 60PRADAXA..................................................................... 61PRADAXA..................................................................... 61pramipexole dihydrochloride tab 0.125 mg.............. 42pramipexole dihydrochloride tab 0.25 mg................ 42pramipexole dihydrochloride tab 0.5 mg.................. 42pramipexole dihydrochloride tab 0.75 mg................ 42pramipexole dihydrochloride tab 1.5 mg.................. 42pramipexole dihydrochloride tab 1 mg......................42pramoxine hcl rectal foam 1%................................... 77prasugrel hcl tab 10 mg..............................................61prasugrel hcl tab 5 mg................................................61PRAVACHOL................................................................ 69PRAVACHOL................................................................ 69PRAVACHOL................................................................ 69pravastatin sodium tab 10 mg................................... 69pravastatin sodium tab 20 mg................................... 69pravastatin sodium tab 40 mg................................... 70pravastatin sodium tab 80 mg................................... 70praziquantel tab 600 mg.............................................41prazosin hcl cap 1 mg.................................................70prazosin hcl cap 2 mg.................................................70prazosin hcl cap 5 mg.................................................70PRECOSE.....................................................................58PRECOSE.....................................................................58PRECOSE.....................................................................58PRED FORTE............................................................ 106PRED-G.......................................................................106

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PRED-G S.O.P........................................................... 106PRED MILD................................................................ 106prednicarbate cream 0.1%......................................... 77prednisolone acetate ophth susp 1%..................... 106prednisolone sod phosphate oral soln 15

mg/5ml........................................................................ 91prednisolone syrup 15 mg/5ml...................................91PREDNISONE.............................................................. 91prednisone tab 10 mg................................................. 91prednisone tab 1 mg................................................... 91prednisone tab 2.5 mg................................................91prednisone tab 20 mg................................................. 91prednisone tab 50 mg................................................. 91prednisone tab 5 mg................................................... 91prednisone tab therapy pack 10 mg (21)................. 91prednisone tab therapy pack 10 mg (48)................. 91prednisone tab therapy pack 5 mg (21)....................91prednisone tab therapy pack 5 mg (48)....................91pregabalin cap 100 mg............................................... 17pregabalin cap 150 mg............................................... 17pregabalin cap 200 mg............................................... 17pregabalin cap 225 mg............................................... 17pregabalin cap 25 mg................................................. 17pregabalin cap 300 mg............................................... 17pregabalin cap 50 mg................................................. 17pregabalin cap 75 mg................................................. 17pregabalin soln 20 mg/ml........................................... 17PREGNYL W/DILUENT BENZYL ALCOHOL/

NACL.......................................................................... 91PREMARIN................................................................... 94PREMASOL.................................................................. 82PREVENT SAFETY PEN NEEDLE 31G X 1/4"...... 58PREVENT SAFETY PEN NEEDLE 31G X

5/16"............................................................................58PREVYMIS....................................................................50PREVYMIS....................................................................50PREZCOBIX................................................................. 50PREZISTA..................................................................... 50PREZISTA..................................................................... 50PREZISTA..................................................................... 50PREZISTA..................................................................... 50PREZISTA..................................................................... 50PRIFTIN.........................................................................28primaquine phosphate tab 26.3 mg.......................... 41PRIMAXIN IV................................................................12primidone tab 250 mg................................................. 17primidone tab 50 mg................................................... 17PRINIVIL........................................................................70PRINIVIL........................................................................70PRINIVIL........................................................................70probenecid tab 500 mg...............................................26PROCALAMINE........................................................... 82

PROCARDIA XL.......................................................... 70PROCARDIA XL.......................................................... 70PROCARDIA XL.......................................................... 70prochlorperazine edisylate inj 10 mg/2ml.................24prochlorperazine edisylate inj 50 mg/10ml...............24prochlorperazine maleate tab 10 mg........................ 24prochlorperazine maleate tab 5 mg.......................... 24prochlorperazine suppos 25 mg................................ 24PROCRIT...................................................................... 61PROCRIT...................................................................... 61PROCRIT...................................................................... 61PROCRIT...................................................................... 61PROCRIT...................................................................... 61PROCRIT...................................................................... 61PROCTOFOAM............................................................77progesterone micronized cap 100 mg...................... 94progesterone micronized cap 200 mg...................... 94PROGLYCEM............................................................... 58PROGRAF.................................................................. 101PROGRAF.................................................................. 101PROGRAF.................................................................. 101PROLASTIN-C..............................................................88PROLASTIN-C..............................................................89PROLENSA................................................................ 106PROLEUKIN................................................................. 37PROLIA........................................................................104PROMACTA.................................................................. 61PROMACTA.................................................................. 61PROMACTA.................................................................. 61PROMACTA.................................................................. 61PROMACTA.................................................................. 61promethazine hcl syrup 6.25 mg/5ml........................24promethazine hcl tab 25 mg...................................... 24promethazine-phenylephrine-codeine syrup

6.25-5-10 mg/5ml................................................... 111promethazine w/ codeine syrup 6.25-10

mg/5ml......................................................................111propafenone hcl cap er 12hr 225 mg........................70propafenone hcl cap er 12hr 325 mg........................70propafenone hcl cap er 12hr 425 mg........................70propafenone hcl tab 150 mg......................................70propafenone hcl tab 225 mg......................................70propafenone hcl tab 300 mg......................................70propranolol hcl inj 1 mg/ml......................................... 70propranolol hcl tab 10 mg...........................................70propranolol hcl tab 20 mg...........................................70propranolol hcl tab 40 mg...........................................70propranolol hcl tab 80 mg...........................................70propylthiouracil tab 50 mg.......................................... 97PROQUAD..................................................................102PROSCAR.....................................................................90PROSHIELD PLUS SKIN PROTECTANT................77

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PROSOL........................................................................82protriptyline hcl tab 10 mg..........................................21protriptyline hcl tab 5 mg............................................ 21PROZAC........................................................................22PROZAC........................................................................22PROZAC........................................................................22pseudoephedrine hcl tab 30 mg..............................111psyllium cap 0.52 gm.................................................. 86psyllium powder 28.3%...............................................86psyllium powder 30.9%...............................................86psyllium powder 48.57%.............................................86psyllium powder 58.6%...............................................86PULMOZYME.............................................................111PURIXAN.......................................................................37pyrantel pamoate susp 144 mg/ml............................77pyrazinamide tab 500 mg...........................................28pyreth-piperonyl butox sham-permeth aero-nit

remover gel kit.......................................................... 77pyrethrins-piperonyl butoxide shampoo

0.33-4%...................................................................... 77pyridostigmine bromide oral soln 60 mg/5ml........... 28pyridostigmine bromide tab 60 mg............................28pyridoxine hcl inj 100 mg/ml...................................... 82QQUADRACEL............................................................. 102quetiapine fumarate tab 100 mg................................45quetiapine fumarate tab 200 mg................................45quetiapine fumarate tab 25 mg..................................45quetiapine fumarate tab 300 mg................................45quetiapine fumarate tab 400 mg................................45quetiapine fumarate tab 50 mg..................................45quinapril hcl tab 10 mg............................................... 70quinapril hcl tab 20 mg............................................... 70quinapril hcl tab 40 mg............................................... 70quinapril hcl tab 5 mg................................................. 70QUINIDINE SULFATE................................................. 70QUINIDINE SULFATE................................................. 70RRABAVERT................................................................. 102raloxifene hcl tab 60 mg............................................. 94ramipril cap 1.25 mg................................................... 70ramipril cap 10 mg.......................................................70ramipril cap 2.5 mg......................................................70ramipril cap 5 mg.........................................................70RANEXA........................................................................70RANEXA........................................................................70ranitidine hcl syrup 15 mg/ml (75 mg/5ml)............... 86ranitidine hcl tab 150 mg............................................ 86ranitidine hcl tab 300 mg............................................ 86ranitidine hcl tab 75 mg.............................................. 86ranolazine tab er 12hr 1000 mg................................ 70

ranolazine tab er 12hr 500 mg.................................. 70RAPAMUNE................................................................102rasagiline mesylate tab 0.5 mg..................................42rasagiline mesylate tab 1 mg.....................................42RECOMBIVAX HB.....................................................102RECOMBIVAX HB.....................................................102RECOMBIVAX HB.....................................................102REGRANEX.................................................................. 77RELENZA DISKHALER.............................................. 50RELISTOR.....................................................................86RELISTOR.....................................................................86RELISTOR.....................................................................86REMEDY NUTRASHIELD..........................................77REMERON....................................................................22REMERON....................................................................22REMERON SOLTAB....................................................22REMERON SOLTAB....................................................22REMERON SOLTAB....................................................22REMODULIN.............................................................. 111REMODULIN.............................................................. 111REMODULIN.............................................................. 111REMODULIN.............................................................. 112RENFLEXIS................................................................ 102REPATHA...................................................................... 71REPATHA PUSHTRONEX SYSTEM........................71REPATHA SURECLICK.............................................. 71RESCRIPTOR.............................................................. 50RESTASIS...................................................................106RESTASIS MULTIDOSE...........................................106RETACRIT.....................................................................61RETACRIT.....................................................................61RETACRIT.....................................................................61RETACRIT.....................................................................61RETACRIT.....................................................................61RETROVIR IV INFUSION.......................................... 50REVCOVI...................................................................... 89REVLIMID......................................................................37REVLIMID......................................................................37REVLIMID......................................................................37REVLIMID......................................................................37REVLIMID......................................................................37REVLIMID......................................................................37REXULTI........................................................................45REXULTI........................................................................45REXULTI........................................................................45REXULTI........................................................................45REXULTI........................................................................45REXULTI........................................................................45REYATAZ.......................................................................50REYATAZ.......................................................................50REYATAZ.......................................................................50REYATAZ.......................................................................50

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ribavirin cap 200 mg....................................................50ribavirin for inhal soln 6 gm......................................112ribavirin tab 200 mg.....................................................50rifabutin cap 150 mg................................................... 28RIFADIN.........................................................................28rifampin cap 150 mg................................................... 28rifampin cap 300 mg................................................... 28rifampin for inj 600 mg................................................28riluzole tab 50 mg........................................................74ringer's solution............................................................ 82ringer's solution for irrigation......................................82RISPERDAL CONSTA................................................ 45RISPERDAL CONSTA................................................ 46RISPERDAL CONSTA................................................ 46RISPERDAL CONSTA................................................ 46risperidone orally disintegrating tab 0.25 mg........... 46risperidone orally disintegrating tab 0.5 mg............. 46risperidone orally disintegrating tab 1 mg................ 46risperidone orally disintegrating tab 2 mg................ 46risperidone orally disintegrating tab 3 mg................ 46risperidone orally disintegrating tab 4 mg................ 46risperidone soln 1 mg/ml............................................ 46risperidone tab 0.25 mg..............................................46risperidone tab 0.5 mg................................................46risperidone tab 1 mg................................................... 46risperidone tab 2 mg................................................... 46risperidone tab 3 mg................................................... 46risperidone tab 4 mg................................................... 46ritonavir tab 100 mg.................................................... 50RITUXAN.......................................................................37RITUXAN.......................................................................37RITUXAN HYCELA......................................................37RITUXAN HYCELA......................................................37rivastigmine tartrate cap 1.5 mg................................18rivastigmine tartrate cap 3 mg................................... 18rivastigmine tartrate cap 4.5 mg................................18rivastigmine tartrate cap 6 mg................................... 18rivastigmine td patch 24hr 13.3 mg/24hr..................19rivastigmine td patch 24hr 4.6 mg/24hr.................... 19rivastigmine td patch 24hr 9.5 mg/24hr.................... 19rizatriptan benzoate oral disintegrating tab 10

mg................................................................................27rizatriptan benzoate oral disintegrating tab 5

mg................................................................................27rizatriptan benzoate tab 10 mg..................................27rizatriptan benzoate tab 5 mg.................................... 27ropinirole hydrochloride tab 0.25 mg........................ 42ropinirole hydrochloride tab 0.5 mg...........................42ropinirole hydrochloride tab 1 mg..............................42ropinirole hydrochloride tab 2 mg..............................42ropinirole hydrochloride tab 3 mg..............................42ropinirole hydrochloride tab 4 mg..............................42

ropinirole hydrochloride tab 5 mg..............................42rosuvastatin calcium tab 10 mg.................................71rosuvastatin calcium tab 20 mg.................................71rosuvastatin calcium tab 40 mg.................................71rosuvastatin calcium tab 5 mg...................................71ROTARIX.....................................................................102ROTATEQ....................................................................102ROZLYTREK.................................................................38ROZLYTREK.................................................................38RUBRACA.....................................................................38RUBRACA.....................................................................38RUBRACA.....................................................................38RYDAPT........................................................................ 38SSABRIL.......................................................................... 17SAFETY INSULIN SYRINGES 1ML/30G X 1/2"..... 58SANDIMMUNE...........................................................102SANDOSTATIN.............................................................97SANDOSTATIN.............................................................97SANDOSTATIN.............................................................97SANTYL.........................................................................77SAPHRIS.......................................................................46SAPHRIS.......................................................................46SAPHRIS.......................................................................46selegiline hcl cap 5 mg............................................... 42selegiline hcl tab 5 mg................................................42selenium sulfide lotion 2.5%...................................... 78SELZENTRY.................................................................50SELZENTRY.................................................................50SELZENTRY.................................................................50SELZENTRY.................................................................50SELZENTRY.................................................................50SENNA LEAVES.......................................................... 86sennosides-docusate sodium tab 8.6-50 mg........... 87sennosides syrup 8.8 mg/5ml.................................... 86sennosides tab 15 mg.................................................86sennosides tab 17.2 mg............................................. 86sennosides tab 25 mg.................................................87sennosides tab 8.6 mg................................................86SENOKOT.....................................................................87SENOKOT S.................................................................87SENSIPAR.................................................................. 104SENSIPAR.................................................................. 104SENSIPAR.................................................................. 104SEREVENT DISKUS.................................................112sertraline hcl oral concentrate for solution 20 mg/

ml.................................................................................22sertraline hcl tab 100 mg............................................22sertraline hcl tab 25 mg..............................................22sertraline hcl tab 50 mg..............................................22sevelamer carbonate packet 0.8 gm.........................82

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sevelamer carbonate packet 2.4 gm.........................82sevelamer carbonate tab 800 mg..............................82SHINGRIX...................................................................102SIGNIFOR..................................................................... 97SIGNIFOR..................................................................... 97SIGNIFOR..................................................................... 97sildenafil citrate tab 20 mg....................................... 112SILENOR.....................................................................113SILENOR.....................................................................113SILVADENE...................................................................78silver sulfadiazine cream 1%..................................... 78simvastatin tab 10 mg.................................................71simvastatin tab 20 mg.................................................71simvastatin tab 40 mg.................................................71simvastatin tab 5 mg...................................................71simvastatin tab 80 mg.................................................71sirolimus oral soln 1 mg/ml...................................... 102sirolimus tab 0.5 mg..................................................102sirolimus tab 1 mg.....................................................102sirolimus tab 2 mg.....................................................102SIRTURO.......................................................................28SIVEXTRO.................................................................... 12SIVEXTRO.................................................................... 12skin protectants misc - cream....................................78sod ferric gluc cmplx in sucrose iv soln 12.5 mg/ml

(fe eq)......................................................................... 82SODIUM BICARBONATE...........................................87sodium bicarbonate tab 325 mg................................87sodium bicarbonate tab 650 mg................................87sodium chloride hypertonic ophth oint 5%............. 106sodium chloride hypertonic ophth soln 5%............ 107sodium chloride inj 2.5 meq/ml (14.6%)................... 82sodium chloride irrigation soln 0.9%......................... 82sodium chloride iv soln 0.45%...................................82sodium chloride iv soln 0.9%..................................... 82sodium chloride iv soln 3%........................................ 82sodium chloride iv soln 5%........................................ 82sodium phenylbutyrate oral powder 3 gm/

teaspoonful.................................................................89sodium phenylbutyrate tab 500 mg...........................89sodium phosphates - enema......................................87sodium polystyrene sulfonate oral susp 15

gm/60ml......................................................................82sodium polystyrene sulfonate powder...................... 82sodium polystyrene sulfonate rectal susp 30

gm/120ml....................................................................82SOLTAMOX...................................................................38SOLU-MEDROL........................................................... 91SOLU-MEDROL........................................................... 91SOLU-MEDROL........................................................... 91SOMATULINE DEPOT................................................97SOMATULINE DEPOT................................................97

SOMATULINE DEPOT................................................97SOMAVERT.................................................................. 97SOMAVERT.................................................................. 97SOMAVERT.................................................................. 97SOMAVERT.................................................................. 97SOMAVERT.................................................................. 97SOOLANTRA................................................................78SORBITOL.................................................................... 87SORBITOL.................................................................... 87sotalol hcl (afib/afl) tab 120 mg................................. 71sotalol hcl (afib/afl) tab 160 mg................................. 71sotalol hcl (afib/afl) tab 80 mg................................... 71sotalol hcl tab 120 mg.................................................71sotalol hcl tab 160 mg.................................................71sotalol hcl tab 240 mg.................................................71sotalol hcl tab 80 mg...................................................71SOVALDI....................................................................... 50spironolactone tab 100 mg.........................................71spironolactone tab 25 mg...........................................71spironolactone tab 50 mg...........................................71SPRAVATO 56MG DOSE...........................................22SPRAVATO 84MG DOSE...........................................22SPRITAM.......................................................................17SPRITAM.......................................................................17SPRITAM.......................................................................17SPRITAM.......................................................................17SPRYCEL......................................................................38SPRYCEL......................................................................38SPRYCEL......................................................................38SPRYCEL......................................................................38SPRYCEL......................................................................38SPRYCEL......................................................................38STAMARIL...................................................................102STARLIX........................................................................ 58STARLIX........................................................................ 58stavudine cap 15 mg...................................................50stavudine cap 20 mg...................................................50stavudine cap 30 mg...................................................50stavudine cap 40 mg...................................................50STIMATE....................................................................... 92STIOLTO RESPIMAT................................................ 112STIVARGA.....................................................................38STRENSIQ....................................................................89STRENSIQ....................................................................89STRENSIQ....................................................................89STRENSIQ....................................................................89STREPTOMYCIN SULFATE...................................... 12STRIBILD...................................................................... 50STRIVERDI RESPIMAT............................................112SUBOXONE....................................................................5SUBOXONE....................................................................5SUBOXONE....................................................................5

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SUBOXONE....................................................................5sucralfate tab 1 gm......................................................87SULAR........................................................................... 71SULAR........................................................................... 71SULAR........................................................................... 71sulfacetamide sodium lotion 10%..............................12sulfacetamide sodium ophth soln 10%...................107sulfacetamide sodium-prednisolone ophth soln

10-0.23(0.25)%....................................................... 107SULFADIAZINE............................................................ 12sulfamethoxazole-trimethoprim iv soln 400-80

mg/5ml........................................................................ 12sulfamethoxazole-trimethoprim susp 200-40

mg/5ml........................................................................ 12sulfamethoxazole-trimethoprim tab 400-80 mg....... 12sulfamethoxazole-trimethoprim tab 800-160 mg..... 12sulfasalazine tab 500 mg......................................... 103sulfasalazine tab delayed release 500 mg.............103sulindac tab 150 mg......................................................4sulindac tab 200 mg......................................................4sumatriptan nasal spray 20 mg/act........................... 27sumatriptan nasal spray 5 mg/act............................. 27SUMATRIPTAN SUCCINATE.....................................27sumatriptan succinate inj 6 mg/0.5ml....................... 28sumatriptan succinate solution auto-injector 4

mg/0.5ml.....................................................................28sumatriptan succinate solution auto-injector 6

mg/0.5ml.....................................................................28sumatriptan succinate solution cartridge 4

mg/0.5ml.....................................................................28sumatriptan succinate solution cartridge 6

mg/0.5ml.....................................................................28sumatriptan succinate tab 100 mg............................ 28sumatriptan succinate tab 25 mg.............................. 28sumatriptan succinate tab 50 mg.............................. 28SUPRAX........................................................................13SUPRAX........................................................................13SUPRAX........................................................................13SUPREP BOWEL PREP KIT.....................................87SUSTIVA........................................................................50SUSTIVA........................................................................51SUTENT........................................................................ 38SUTENT........................................................................ 38SUTENT........................................................................ 38SUTENT........................................................................ 38SWEEN CREAM..........................................................78SWIM EAR..................................................................108SYLATRON................................................................... 51SYLATRON................................................................... 51SYLATRON................................................................... 51SYLVANT.....................................................................102SYLVANT.....................................................................102

SYMBICORT...............................................................112SYMBICORT...............................................................112SYMDEKO.................................................................. 112SYMDEKO.................................................................. 112SYMFI............................................................................ 51SYMFI LO..................................................................... 51SYMLINPEN 120......................................................... 58SYMLINPEN 60........................................................... 58SYMPAZAN...................................................................17SYMPAZAN...................................................................17SYMPAZAN...................................................................17SYMTUZA..................................................................... 51SYNAGIS.................................................................... 102SYNAGIS.................................................................... 102SYNAREL......................................................................97SYNERCID....................................................................13SYNRIBO...................................................................... 38SYNTHROID.................................................................95SYNTHROID.................................................................95SYNTHROID.................................................................95SYNTHROID.................................................................95SYNTHROID.................................................................95SYNTHROID.................................................................95SYNTHROID.................................................................95SYNTHROID.................................................................95SYNTHROID.................................................................95SYNTHROID.................................................................95SYNTHROID.................................................................95SYNTHROID.................................................................95TTABLOID........................................................................38tacrolimus cap 0.5 mg.............................................. 102tacrolimus cap 1 mg..................................................102tacrolimus cap 5 mg..................................................102tacrolimus oint 0.03%..................................................78tacrolimus oint 0.1%....................................................78tadalafil tab 20 mg (pah).......................................... 112TAFINLAR..................................................................... 38TAFINLAR..................................................................... 38TAGRISSO.................................................................... 38TAGRISSO.................................................................... 38TALZENNA....................................................................38TALZENNA....................................................................38TAMIFLU........................................................................51tamoxifen citrate tab 10 mg........................................38tamoxifen citrate tab 20 mg........................................38tamsulosin hcl cap 0.4 mg......................................... 90TARCEVA...................................................................... 38TARCEVA...................................................................... 38TARCEVA...................................................................... 38TARGRETIN..................................................................38TASIGNA....................................................................... 38

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TASIGNA....................................................................... 39TASIGNA....................................................................... 39tazarotene cream 0.1%...............................................78TAZICEF........................................................................ 13TAZORAC......................................................................78TAZORAC......................................................................78TAZORAC......................................................................78TDVAX......................................................................... 102TECENTRIQ................................................................. 39TECENTRIQ................................................................. 39TECFIDERA..................................................................74TECFIDERA..................................................................74TECFIDERA STARTER PACK...................................74TECHLITE INSULIN SYRINGE U-100/0.3ML/29G X

1/2".............................................................................. 58TECHLITE INSULIN SYRINGE U-100/0.3ML/30G X


5/16"............................................................................58TECHLITE INSULIN SYRINGE U-100/0.3ML/31G X

15/64"..........................................................................58TECHLITE INSULIN SYRINGE U-100/0.3ML/31G X





15/64"..........................................................................58TECHLITE INSULIN SYRINGE U-100/0.5ML/31G X

5/16"............................................................................58TECHLITE INSULIN SYRINGE U-100/1ML/29G X

1/2".............................................................................. 58TECHLITE INSULIN SYRINGE U-100/1ML/30G X

1/2".............................................................................. 58TECHLITE INSULIN SYRINGE U-100/1ML/30G X

5/16"............................................................................58TECHLITE INSULIN SYRINGE U-100/1ML/31G X

15/64"..........................................................................59TECHLITE INSULIN SYRINGE U-100/1ML/31G X

5/16"............................................................................59TECHLITE PEN NEEDLES/31G X 6MM..................59TECHLITE PEN NEEDLES/31G X 8MM..................59TECHLITE PEN NEEDLES/32G X 4MM..................59TECHLITE PEN NEEDLES/32G X 6MM..................59TECHLITE PEN NEEDLES/32G X 8MM..................59TECHLITE PEN NEEDLES 29G X 10MM............... 59TECHLITE PEN NEEDLES 29G X 12MM............... 59TECHLITE PEN NEEDLES 31G X 5MM..................59TEFLARO......................................................................13

TEFLARO......................................................................13TEKTURNA...................................................................71TEKTURNA...................................................................71telmisartan-hydrochlorothiazide tab 40-12.5 mg..... 71telmisartan-hydrochlorothiazide tab 80-12.5 mg..... 71telmisartan-hydrochlorothiazide tab 80-25 mg.........71telmisartan tab 20 mg................................................. 71telmisartan tab 40 mg................................................. 71telmisartan tab 80 mg................................................. 71temazepam cap 15 mg.............................................113temazepam cap 30 mg.............................................113TEMODAR.................................................................... 39temsirolimus soln for iv infusion 25 mg/ml............... 39TENIVAC..................................................................... 102tenofovir disoproxil fumarate tab 300 mg................. 51terazosin hcl cap 10 mg............................................. 72terazosin hcl cap 1 mg............................................... 71terazosin hcl cap 2 mg............................................... 71terazosin hcl cap 5 mg............................................... 71terbinafine hcl cream 1%............................................26terbinafine hcl tab 250 mg..........................................26terbutaline sulfate tab 2.5 mg.................................. 112terbutaline sulfate tab 5 mg..................................... 112terconazole vaginal cream 0.4%............................... 26terconazole vaginal cream 0.8%............................... 26testosterone cypionate im inj in oil 100 mg/ml.........94testosterone cypionate im inj in oil 200 mg/ml.........94testosterone td gel 12.5 mg/act (1%)........................94testosterone td gel 20.25 mg/1.25gm (1.62%).........94testosterone td gel 20.25 mg/act (1.62%)................ 94testosterone td gel 25 mg/2.5gm (1%)..................... 94testosterone td gel 40.5 mg/2.5gm (1.62%).............94testosterone td gel 50 mg/5gm (1%).........................94tetrabenazine tab 12.5 mg......................................... 74tetrabenazine tab 25 mg.............................................74tetracycline hcl cap 250 mg....................................... 13tetracycline hcl cap 500 mg....................................... 13THALOMID....................................................................39THALOMID....................................................................39THALOMID....................................................................39THALOMID....................................................................39theophylline tab er 12hr 300 mg............................. 112theophylline tab er 12hr 450 mg............................. 112theophylline tab er 24hr 400 mg............................. 112theophylline tab er 24hr 600 mg............................. 112thiamine hcl inj 100 mg/ml......................................... 82thioridazine hcl tab 100 mg........................................46thioridazine hcl tab 10 mg.......................................... 46thioridazine hcl tab 25 mg.......................................... 46thioridazine hcl tab 50 mg.......................................... 46thiotepa for inj 15 mg.................................................. 39thiothixene cap 10 mg.................................................46

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thiothixene cap 1 mg...................................................46thiothixene cap 2 mg...................................................46thiothixene cap 5 mg...................................................46THYMOGLOBULIN....................................................102tiagabine hcl tab 12 mg.............................................. 17tiagabine hcl tab 16 mg.............................................. 17tiagabine hcl tab 2 mg................................................ 17tiagabine hcl tab 4 mg................................................ 17TIAZAC.......................................................................... 72TIAZAC.......................................................................... 72TIAZAC.......................................................................... 72TIAZAC.......................................................................... 72TIAZAC.......................................................................... 72TIAZAC.......................................................................... 72TIBSOVO.......................................................................39tigecycline for iv soln 50 mg...................................... 13timolol maleate ophth gel forming soln 0.25%.......107timolol maleate ophth gel forming soln 0.5%.........107timolol maleate ophth soln 0.25%........................... 107timolol maleate ophth soln 0.5%............................. 107TIMOPTIC................................................................... 107TIMOPTIC................................................................... 107TIMOPTIC-XE.............................................................107tioconazole vaginal oint 6.5%.................................... 26TIVICAY......................................................................... 51TIVICAY......................................................................... 51TIVICAY......................................................................... 51tizanidine hcl tab 2 mg................................................47tizanidine hcl tab 4 mg................................................47TOBRADEX................................................................ 107TOBRADEX ST..........................................................107tobramycin-dexamethasone ophth susp

0.3-0.1%...................................................................107tobramycin nebu soln 300 mg/5ml..........................112tobramycin ophth soln 0.3%.................................... 107TOBRAMYCIN SULFATE........................................... 13TOBRAMYCIN SULFATE........................................... 13tobramycin sulfate for inj 1.2 gm............................... 13tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml)........13tobramycin sulfate inj 80 mg/2ml (40 mg/ml)........... 13TOBREX......................................................................107tolterodine tartrate cap er 24hr 2 mg........................ 90tolterodine tartrate cap er 24hr 4 mg........................ 90topiramate sprinkle cap 15 mg.................................. 17topiramate sprinkle cap 25 mg.................................. 17topiramate tab 100 mg................................................18topiramate tab 200 mg................................................18topiramate tab 25 mg..................................................18topiramate tab 50 mg..................................................18topotecan hcl for inj 4 mg...........................................39toremifene citrate tab 60 mg...................................... 39torsemide tab 100 mg................................................. 72

torsemide tab 10 mg................................................... 72torsemide tab 20 mg................................................... 72torsemide tab 5 mg..................................................... 72TOVIAZ.......................................................................... 90TOVIAZ.......................................................................... 90TRACLEER.................................................................112TRACLEER.................................................................112TRACLEER.................................................................112tramadol hcl tab 50 mg.................................................4tranexamic acid iv soln 1000 mg/10ml (100 mg/

ml)................................................................................61tranexamic acid tab 650 mg.......................................61tranylcypromine sulfate tab 10 mg............................ 22TRAVASOL....................................................................82TRAVATAN Z.............................................................. 107trazodone hcl tab 100 mg...........................................22trazodone hcl tab 150 mg...........................................22trazodone hcl tab 300 mg...........................................22trazodone hcl tab 50 mg.............................................22TREANDA..................................................................... 39TREANDA..................................................................... 39TRECATOR...................................................................28TRELEGY ELLIPTA...................................................112TRELSTAR....................................................................97TRELSTAR....................................................................97TRELSTAR MIXJECT..................................................97TRELSTAR MIXJECT..................................................97TRELSTAR MIXJECT..................................................97treprostinil inj soln 100 mg/20ml (5 mg/ml)............ 112treprostinil inj soln 200 mg/20ml (10 mg/ml)..........112treprostinil inj soln 20 mg/20ml (1 mg/ml).............. 112treprostinil inj soln 50 mg/20ml (2.5 mg/ml)........... 112tretinoin cap 10 mg......................................................39tretinoin cream 0.025%...............................................78tretinoin cream 0.05%................................................. 78tretinoin cream 0.1%................................................... 78tretinoin gel 0.01%.......................................................78tretinoin gel 0.025%.....................................................78triamcinolone acetonide cream 0.025%................... 78triamcinolone acetonide cream 0.1%........................78triamcinolone acetonide cream 0.5%........................78triamcinolone acetonide lotion 0.1%......................... 78triamcinolone acetonide oint 0.025%........................78triamcinolone acetonide oint 0.1%............................ 78triamcinolone acetonide oint 0.5%............................ 78triamterene & hydrochlorothiazide cap 37.5-25

mg................................................................................72triamterene & hydrochlorothiazide tab 37.5-25

mg................................................................................72triamterene & hydrochlorothiazide tab 75-50

mg................................................................................72trientine hcl cap 250 mg............................................. 82

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TRIFERIC......................................................................82trifluoperazine hcl tab 10 mg......................................46trifluoperazine hcl tab 1 mg........................................46trifluoperazine hcl tab 2 mg........................................46trifluoperazine hcl tab 5 mg........................................46trifluridine ophth soln 1%..........................................107trimethoprim tab 100 mg.............................................13trimipramine maleate cap 100 mg.............................22trimipramine maleate cap 25 mg...............................22trimipramine maleate cap 50 mg...............................22TRINTELLIX..................................................................22TRINTELLIX..................................................................22TRINTELLIX..................................................................22TRISENOX....................................................................39TRIUMEQ......................................................................51TROGARZO..................................................................51TROPHAMINE..............................................................82TRUEPLUS 5-BEVEL PEN NEEDLES

31GX5MM.................................................................. 59TRUEPLUS 5-BEVEL PEN NEEDLES



32GX4MM.................................................................. 59TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/29G

X 1/2"..........................................................................59TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/30G

X 5/16"........................................................................59TRUEPLUS INSULIN SYRINGE/U-100/0.3ML/31G





X 5/16"........................................................................59TRUEPLUS INSULIN SYRINGE/U-100/1ML/28G X

1/2".............................................................................. 59TRUEPLUS INSULIN SYRINGE/U-100/1ML/29G X

1/2".............................................................................. 59TRUEPLUS INSULIN SYRINGE/U-100/1ML/30G X

5/16"............................................................................59TRUEPLUS INSULIN SYRINGE/U-100/1ML/31G X

5/16"............................................................................59TRUEPLUS PEN NEEDLES 29G X 12MM............. 59TRUEPLUS PEN NEEDLES 31G X 5MM................59TRUEPLUS PEN NEEDLES 31G X 6MM................59TRUEPLUS PEN NEEDLES 31G X 8MM................59TRUEPLUS PEN NEEDLES 32G X 4MM................59

TRUMENBA................................................................102TRUVADA......................................................................51TRUVADA......................................................................51TRUVADA......................................................................51TRUVADA......................................................................51TUDORZA PRESSAIR............................................. 112TUMS............................................................................. 87TUMS CHEWY BITES................................................ 87TUMS E-X 750.............................................................87TUMS EXTRA STRENGTH 750................................87TUMS KIDS.................................................................. 87TUMS SMOOTHIES....................................................87TURALIO....................................................................... 39TWINRIX..................................................................... 102TYBOST........................................................................ 51TYGACIL....................................................................... 13TYKERB........................................................................ 39TYLENOL INFANTS PAIN+FEVER.............................4TYMLOS......................................................................104TYPHIM VI..................................................................102UULORIC......................................................................... 26ULORIC......................................................................... 26ULTICARE INSULIN SAFETY SYRINGE/0.5ML/29G

X 1/2"..........................................................................59ULTICARE INSULIN SAFETY SYRINGE/1ML/29G X

1/2".............................................................................. 59UNASYN........................................................................13UNITUXIN......................................................................39UPTRAVI..................................................................... 112UPTRAVI..................................................................... 112UPTRAVI..................................................................... 112UPTRAVI..................................................................... 113UPTRAVI..................................................................... 113UPTRAVI..................................................................... 113UPTRAVI..................................................................... 113UPTRAVI..................................................................... 113UPTRAVI..................................................................... 113ursodiol cap 300 mg....................................................87ursodiol tab 250 mg.....................................................87ursodiol tab 500 mg.....................................................87VVAGIFEM.......................................................................94valacyclovir hcl tab 1 gm............................................ 51valacyclovir hcl tab 500 mg........................................51VALCHLOR................................................................... 39valganciclovir hcl for soln 50 mg/ml.......................... 51valganciclovir hcl tab 450 mg.....................................51valproate sodium inj 100 mg/ml.................................18valproate sodium oral soln 250 mg/5ml....................18valproic acid cap 250 mg........................................... 18

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VALTREX.......................................................................51VALTREX.......................................................................51VANAMINE PD...........................................................113vancomycin hcl cap 125 mg...................................... 13vancomycin hcl cap 250 mg...................................... 13vancomycin hcl for iv soln 100 gm............................13vancomycin hcl for iv soln 10 gm..............................13vancomycin hcl for iv soln 1 gm................................ 13vancomycin hcl for iv soln 500 mg............................13vancomycin hcl for iv soln 5 gm................................ 13vancomycin hcl for iv soln 750 mg............................13VANCOMYCIN HYDROCHLORIDE..........................13VANCOMYCIN HYDROCHLORIDE..........................13VANCOMYCIN HYDROCHLORIDE..........................13VANISHPOINT INSULIN SYRINGE/0.5ML/30G X

1/2".............................................................................. 59VAQTA......................................................................... 102VAQTA......................................................................... 103VARIVAX..................................................................... 103VASERETIC.................................................................. 72VASOTEC......................................................................72VASOTEC......................................................................72VASOTEC......................................................................72VASOTEC......................................................................72VECTIBIX...................................................................... 39VECTIBIX...................................................................... 39VELCADE......................................................................39VENCLEXTA.................................................................39VENCLEXTA.................................................................39VENCLEXTA.................................................................39VENCLEXTA STARTING PACK................................ 39venlafaxine hcl cap er 24hr 150 mg..........................22venlafaxine hcl cap er 24hr 37.5 mg.........................22venlafaxine hcl cap er 24hr 75 mg............................22venlafaxine hcl tab 100 mg........................................ 23venlafaxine hcl tab 25 mg.......................................... 22venlafaxine hcl tab 37.5 mg....................................... 22venlafaxine hcl tab 50 mg.......................................... 22venlafaxine hcl tab 75 mg.......................................... 23venlafaxine hcl tab er 24hr 150 mg...........................22venlafaxine hcl tab er 24hr 37.5 mg......................... 22venlafaxine hcl tab er 24hr 75 mg.............................22VENOFER..................................................................... 82VENTAVIS................................................................... 113VENTAVIS................................................................... 113VENTOLIN HFA......................................................... 113verapamil hcl cap er 24hr 100 mg............................ 72verapamil hcl cap er 24hr 120 mg............................ 72verapamil hcl cap er 24hr 180 mg............................ 72verapamil hcl cap er 24hr 200 mg............................ 72verapamil hcl cap er 24hr 240 mg............................ 72verapamil hcl cap er 24hr 300 mg............................ 72

verapamil hcl cap er 24hr 360 mg............................ 72verapamil hcl tab 120 mg...........................................72verapamil hcl tab 40 mg............................................. 72verapamil hcl tab 80 mg............................................. 72verapamil hcl tab er 120 mg...................................... 72verapamil hcl tab er 180 mg...................................... 72verapamil hcl tab er 240 mg...................................... 72VERELAN......................................................................72VERELAN......................................................................73VERELAN......................................................................73VERELAN......................................................................73VERELAN PM.............................................................. 73VERELAN PM.............................................................. 73VERELAN PM.............................................................. 73VERSACLOZ................................................................ 46VERZENIO....................................................................39VERZENIO....................................................................39VERZENIO....................................................................39VERZENIO....................................................................39VFEND IV......................................................................26VIBRAMYCIN................................................................13VICTOZA....................................................................... 59VIDEX............................................................................ 51VIDEX............................................................................ 51VIDEX EC..................................................................... 51VIDEX EC..................................................................... 51VIDEX EC..................................................................... 51VIDEX EC..................................................................... 51VIEKIRA PAK................................................................52vigabatrin powd pack 500 mg....................................18vigabatrin tab 500 mg................................................. 18VIIBRYD.........................................................................23VIIBRYD.........................................................................23VIIBRYD.........................................................................23VIIBRYD STARTER PACK......................................... 23VIMPAT.......................................................................... 18VIMPAT.......................................................................... 18VIMPAT.......................................................................... 18VIMPAT.......................................................................... 18VIMPAT.......................................................................... 18VIMPAT.......................................................................... 18VINBLASTINE SULFATE............................................39vincristine sulfate iv soln 1 mg/ml............................. 40vinorelbine tartrate inj 10 mg/ml................................ 40vinorelbine tartrate inj 50 mg/5ml (10 mg/ml).......... 40VIRACEPT.................................................................... 52VIRACEPT.................................................................... 52VIRAMUNE................................................................... 52VIREAD..........................................................................52VIREAD..........................................................................52VIREAD..........................................................................52VIREAD..........................................................................52

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152

VIREAD..........................................................................52vitamins a & d oint.......................................................78VITRAKVI...................................................................... 40VITRAKVI...................................................................... 40VITRAKVI...................................................................... 40VIZIMPRO..................................................................... 40VIZIMPRO..................................................................... 40VIZIMPRO..................................................................... 40voriconazole for inj 200 mg........................................26voriconazole for susp 40 mg/ml.................................26voriconazole tab 200 mg............................................ 26voriconazole tab 50 mg.............................................. 26VOSEVI..........................................................................52VOTRIENT.................................................................... 40VPRIV............................................................................ 89VRAYLAR...................................................................... 46VRAYLAR...................................................................... 46VRAYLAR...................................................................... 46VRAYLAR...................................................................... 46VYNDAMAX.................................................................. 73VYNDAQEL...................................................................73VYXEOS........................................................................40Wwarfarin sodium tab 10 mg.........................................61warfarin sodium tab 1 mg...........................................61warfarin sodium tab 2.5 mg........................................61warfarin sodium tab 2 mg...........................................61warfarin sodium tab 3 mg...........................................61warfarin sodium tab 4 mg...........................................61warfarin sodium tab 5 mg...........................................61warfarin sodium tab 6 mg...........................................61warfarin sodium tab 7.5 mg........................................61water for irrigation, sterile irrigation soln...................82white petrolatum-mineral oil ophth ointment.......... 107XXALKORI....................................................................... 40XALKORI....................................................................... 40XATMEP...................................................................... 103XGEVA.........................................................................104XIFAXAN........................................................................87XOFLUZA......................................................................52XOFLUZA......................................................................52XOLAIR........................................................................103XOLAIR........................................................................103XOLAIR........................................................................103XOSPATA...................................................................... 40XPOVIO 100 MG ONCE WEEKLY........................... 40XPOVIO 60 MG ONCE WEEKLY..............................40XPOVIO 80 MG ONCE WEEKLY..............................40XPOVIO 80 MG TWICE WEEKLY............................ 40XTANDI.......................................................................... 40

XYREM........................................................................113YYERVOY........................................................................40YERVOY........................................................................40YF-VAX........................................................................ 103YONDELIS.................................................................... 40YONSA.......................................................................... 40Zzafirlukast tab 10 mg.................................................113zafirlukast tab 20 mg.................................................113zaleplon cap 10 mg...................................................113zaleplon cap 5 mg.....................................................113ZALTRAP.......................................................................40ZALTRAP.......................................................................40ZANOSAR..................................................................... 40ZANTAC 75...................................................................87ZARXIO..........................................................................61ZARXIO..........................................................................61ZEJULA..........................................................................40ZELBORAF................................................................... 40ZENPEP........................................................................ 89ZENPEP........................................................................ 89ZENPEP........................................................................ 89ZENPEP........................................................................ 89ZENPEP........................................................................ 89ZENPEP........................................................................ 89ZENPEP........................................................................ 89ZEPATIER..................................................................... 52ZESTORETIC............................................................... 73ZESTORETIC............................................................... 73ZESTORETIC............................................................... 73ZESTRIL........................................................................73ZESTRIL........................................................................73ZESTRIL........................................................................73ZESTRIL........................................................................73ZESTRIL........................................................................73ZESTRIL........................................................................73ZIAGEN..........................................................................52zidovudine cap 100 mg...............................................52zidovudine syrup 10 mg/ml........................................ 52zidovudine tab 300 mg................................................52zinc oxide oint 20%..................................................... 78ziprasidone hcl cap 20 mg......................................... 47ziprasidone hcl cap 40 mg......................................... 47ziprasidone hcl cap 60 mg......................................... 47ziprasidone hcl cap 80 mg......................................... 47ZITHROMAX.................................................................13ZITHROMAX.................................................................13ZITHROMAX.................................................................13ZITHROMAX.................................................................13ZITHROMAX.................................................................14

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ZITHROMAX.................................................................14ZITHROMAX.................................................................14ZITHROMAX TRI-PAK................................................ 14ZITHROMAX Z-PAK.................................................... 14ZOCOR..........................................................................73ZOCOR..........................................................................73ZOCOR..........................................................................73ZOCOR..........................................................................73zoledronic acid inj conc for iv infusion 4

mg/5ml......................................................................104zoledronic acid iv soln 5 mg/100ml.........................104ZOLINZA........................................................................40ZOLOFT.........................................................................23ZOLOFT.........................................................................23ZOLOFT.........................................................................23zolpidem tartrate tab 10 mg.....................................113zolpidem tartrate tab 5 mg....................................... 113zonisamide cap 100 mg..............................................18zonisamide cap 25 mg................................................18zonisamide cap 50 mg................................................18ZORTRESS.................................................................103ZORTRESS.................................................................103ZORTRESS.................................................................103ZORTRESS.................................................................103ZOSTAVAX..................................................................103ZOSYN...........................................................................14ZOSYN...........................................................................14ZOSYN...........................................................................14ZOVIRAX.......................................................................52ZOVIRAX.......................................................................52ZOVIRAX.......................................................................52ZOVIRAX.......................................................................52ZUBSOLV........................................................................ 6ZUBSOLV........................................................................ 6ZUBSOLV........................................................................ 6ZUBSOLV........................................................................ 6ZUBSOLV........................................................................ 6ZUBSOLV........................................................................ 6ZYDELIG....................................................................... 40ZYDELIG....................................................................... 41ZYKADIA....................................................................... 41ZYKADIA....................................................................... 41ZYLET..........................................................................107ZYLOPRIM....................................................................26ZYLOPRIM....................................................................26ZYPREXA RELPREVV............................................... 47ZYPREXA RELPREVV............................................... 47ZYPREXA RELPREVV............................................... 47ZYTIGA..........................................................................41ZYTIGA..........................................................................41

Note to existing enrollees: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

If you have questions, please call Blue Cross Community MMAI at 1-877-723-7702 (TTY/TTD 711). We are available 24 hours a day, seven (7) days a week. The call is free. For more information, visit http://www.bcbsil.com/mmai.For questions about enrolling call: Illinois Client Enrollment Services 1-877-912-8880, Monday through Friday from 8 a.m. to 7 p.m.

(TTY: 1-866-565-8576)

Website: enrollhfs.illinois.govThis formulary was updated on 12/2019

Medicare-Medicaid Plan provided by Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an Independent Licensee of the Blue Cross and Blue Shield Association. HCSC is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees. Enrollment in HCSC’s plan depends on contract renewal.

https://enrollhfs.illinois.gov

https://www.bcbsil.com/mmai/

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