2015 formulary/ formulario - molina healthcare · 2015-01-07 · 45376 marketplace ca formulary...

MolinaHealthcare.com/Marketplace

2015

Formulary/ Formulario(List of Covered Drugs)/(Lista de medicinas cubiertas)

California

MolinaHealthcare.com/Marketplace

45376CAMP0914

Product offered by Molina Healthcare of California, a wholly owned subsidiary of Molina Healthcare, Inc.

45376 Marketplace CA Formulary 2015.indd All Pages 9/23/14 8:04 AM

PA - Prior Authorization QL - Special Quantity Limit may apply ST - Step Therapy Age - Special Age Limit may apply Tier 0 = Preventative Services at $0 copay; Tier 1 = Formulary Generic Drugs Tier 2 = Formulary Preferred Brand Drugs; Tier 3 = Formulary Non-Preferred Brand Drugs Tier 4 = Specialty Drugs; DME = Coinsurance may apply

1

Molina California Marketplace (01/01/2015)

Drug Name Drug Tier Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS Amphetamines amphetamine cap 5mg er Tier 1 AGE

amphetamine cap 10mg er Tier 1 AGE





amphetamine tab 5mg Tier 1 AGE

amphetamine tab 7.5mg Tier 1 AGE


amphetamine tab 12.5mg Tier 1 AGE




dextroamphet cap 5mg er Tier 1 PA; AGE



dextroamphet tab 5mg Tier 1 AGE

dextroamphet tab 10mg Tier 1 AGE

methamphetam tab 5mg Tier 1 PA

zenzedi tab 5mg Tier 1 AGE

zenzedi tab 10mg Tier 1 AGE

Attention-Deficit/Hyperactivity Disorder (ADHD) Agents STRATTERA CAP 10MG Tier 2 AGE

STRATTERA CAP 18MG Tier 2 AGE






Stimulants - Misc. dexmethylph tab 2.5mg Tier 1 AGE

dexmethylph tab 5mg Tier 1 AGE

dexmethylph tab 10mg Tier 1 AGE

metadate tab 20mg er Tier 1 AGE

methylphenid cap 10mg Tier 1 AGE


methylphenid cap 20mg er Tier 1 PA; AGE


2








methylphenid sol 5mg/5ml Tier 1

methylphenid sol 10mg/5ml Tier 1

methylphenid tab 5mg Tier 1 AGE


methylphenid tab 10mg er Tier 1 AGE

methylphenid tab 18mg er Tier 1 PA; AGE


methylphenid tab 20mg er Tier 1 AGE




modafinil tab 100mg Tier 1 PA

NUVIGIL TAB 50MG Tier 2 PA



RITALIN LA CAP 10MG Tier 2 PA; AGE

ALTERNATIVE MEDICINES Alternative Medicine - M's melatonin cap 3mg Tier 1

melatonin cap 5mg Tier 1

MELATONIN LIQ 1MG/4ML Tier 2

melatonin tab 1mg Tier 1

melatonin tab 3mg TABS Tier 1

melatonin tab 5mg Tier 1

melatonin tab 10mg cr Tier 1

melatonin tab 300mcg Tier 1

Alternative Medicine Combinations melatin tab 3-1mg Tier 1

melatonin tab 3-2mg Tier 1

melatonin tr tab /vit-b6 Tier 1

AMINOGLYCOSIDES Aminoglycosides amikacin inj 1gm/4ml Tier 1

neomycin tab 500mg Tier 1

paromomycin cap 250mg Tier 1

streptomycin inj 1gm Tier 1

streptomycin via 1gm Tier 1


3


tobramycin neb 300/5ml Tier 4 PA

ANALGESICS - ANTI-INFLAMMATORY Anti-TNF-alpha - Monoclonoal Antibodies HUMIRA KIT 20MG/0.4 Tier 4 PA

HUMIRA KIT 40MG/0.8 Tier 4 PA

HUMIRA PEN KIT 40MG/0.8 Tier 4 PA

SIMPONI INJ 50MG Tier 4 PA, ST

SIMPONI INJ 100MG/ML Tier 4 PA, ST

Gold Compounds RIDAURA CAP 3MG Tier 3

Interleukin-6 Receptor Inhibitors ACTEMRA INJ 80MG/4ML Tier 4 PA, ST

ACTEMRA INJ 162/0.9 Tier 4 PA, ST

ACTEMRA INJ 200/10ML Tier 4 PA, ST

ACTEMRA INJ 400/20ML Tier 4 PA, ST

Nonsteroidal Anti-inflammatory Agents (NSAIDs) CELEBREX CAP 50MG Tier 3 PA

CELEBREX CAP 100MG Tier 3 PA



diclofen pot tab 50mg Tier 1

diclofenac tab 25mg dr Tier 1



etodolac tab 400mg Tier 1

etodolac tab 500mg Tier 1

flurbiprofen tab 50mg Tier 1

flurbiprofen tab 100mg Tier 1

ibu-drops dro 40mg/ml Tier 1

ibuprofen cap 200mg Tier 1

ibuprofen jr chw 100mg Tier 1

ibuprofen sus 100/5ml Tier 1

ibuprofen tab 200mg Tier 1




indomethacin cap 25mg Tier 1

indomethacin cap 50mg Tier 1

ketoprofen cap 50mg Tier 1

ketoprofen cap 75mg Tier 1

ketorolac tab 10mg Tier 1

meloxicam tab 7.5mg Tier 1

meloxicam tab 15mg Tier 1


4


nabumetone tab 500mg Tier 1

nabumetone tab 750mg Tier 1

naproxen dr tab 375mg Tier 1

naproxen dr tab 500mg Tier 1

naproxen sod tab 220mg Tier 1



naproxen sus 125/5ml Tier 1

naproxen tab 250mg Tier 1



oxaprozin tab 600mg Tier 1 PA

piroxicam cap 10mg Tier 1 PA

piroxicam cap 20mg Tier 1 PA

sm ibuprofen tab 100mg jr Tier 1

sulindac tab 150mg Tier 1

sulindac tab 200mg Tier 1

Pyrimidine Synthesis Inhibitors leflunomide tab 10mg Tier 1

leflunomide tab 20mg Tier 1

Soluble Tumor Necrosis Factor Receptor Agents ENBREL INJ 25/0.5ML Tier 4 PA

ENBREL INJ 25MG Tier 4 PA

ENBREL INJ 50MG/ML Tier 4 PA

ENBREL SRCLK INJ 50MG/ML Tier 4 PA

ANALGESICS - NonNarcotic Analgesic Combinations but/apap/caf cap Tier 1

but/apap/caf tab Tier 1

but/asa/caff cap Tier 1

but/asa/caff tab Tier 1

butal/apap tab 50-325mg Tier 1

Analgesics Other acetam melts tab 80mg Tier 1

acetamin cap 500mg Tier 1

acetamin jr tab 160mg rt Tier 1

acetamin liq 500/15ml Tier 1

acetamin sol 160/5ml Tier 1

acetamin sup 120mg Tier 1



acetamin tab 325mg Tier 1

acetamin tab 650mg Tier 1


5


acetaminophn sus 160/5ml Tier 1

acetaminophn tab 500mg Tier 1

APAP 500 LIQ 500/5ML Tier 2

apap chw 80mg Tier 1

apap dro 80/0.8ml Tier 1

apap infants dro 80/0.8ml Tier 1

apra elx 160/5ml Tier 1

asa free chw 160mg jr Tier 1

chld asafree elx 80/2.5ml Tier 1

FEVERALL INF SUP 80MG Tier 2

medi-tabs elx 80/2.5ml Tier 1

q-pap liq 160/5ml Tier 1

Salicylates aspirin 81 tab 81mg ec Tier 0

aspirin adlt tab 81mg Tier 0

aspirin chw 81mg Tier 0

ASPIRIN TAB 81MG Tier 0

aspirin tab 325mg Tier 0

aspirin tab 325mg ec Tier 0

salsalate tab 500mg Tier 1

salsalate tab 750mg Tier 1

ANALGESICS - OPIOID Opioid Agonists codeine sulf tab 15mg Tier 1

codeine sulf tab 30mg Tier 1

codeine sulf tab 60mg Tier 1

fentanyl dis 12mcg/hr Tier 1 PA




fentanyl dis 100mcg/h Tier 1 PA

hydromorphon tab 2mg Tier 1

hydromorphon tab 4mg Tier 1

meperidine sol 50mg/5ml Tier 1

meperidine tab 50mg Tier 1

meperidine tab 100mg Tier 1

methadone sol 5mg/5ml Tier 1

methadone sol 10mg/5ml Tier 1

methadone tab 5mg Tier 1

methadone tab 10mg Tier 1

morphine sul sol 10mg/5ml Tier 1 PA

morphine sul sol 20mg/5ml Tier 1 PA

morphine sul sol 20mg/ml Tier 1 PA


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morphine sul tab 15mg Tier 1

morphine sul tab 15mg er Tier 1

morphine sul tab 30mg Tier 1




NUCYNTA TAB 50MG Tier 3 PA



oxycodone tab 5mg Tier 1





oxymorphone tab hcl 5mg Tier 1 PA

oxymorphone tab hcl 10mg Tier 1 PA

tramadol hcl tab 50mg Tier 1

Opioid Combinations apap/codeine sol 120-12/5 Tier 1

apap/codeine tab 300-15mg Tier 1



but/apap/caf cap codeine Tier 1

hydroco/apap sol 7.5-325 Tier 1

hydroco/apap sol 7.5-500 Tier 1

hydroco/apap tab 2.5-500 Tier 1

hydroco/apap tab 5-325mg Tier 1









hydrogesic cap 5-500mg Tier 1

oxycod/apap tab 5-325mg Tier 1

oxycod/apap tab 10-325mg Tier 1

Opioid Partial Agonists buprenorphin sub 2mg Tier 1 PA

buprenorphin sub 8mg Tier 1 PA

BUTRANS DIS 10MCG/HR Tier 3 PA

ANDROGENS-ANABOLIC


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Anabolic Steroids oxandrolone tab 2.5mg Tier 1 PA

oxandrolone tab 10mg Tier 1 PA

Androgens ANDROXY TAB 10MG Tier 3

danazol cap 50mg Tier 1



METHITEST TAB 10MG Tier 2

testost cyp inj 100mg/ml Tier 1

testost cyp inj 200mg/ml Tier 1

testost enan inj 200mg/ml Tier 1

ANORECTAL AGENTS Rectal Combinations hc pramoxine cre 1-1% Tier 1

hc pramoxine cre 2.5-1% Tier 1

hemorrhoidal cre Tier 1

Rectal Local Anesthetics dibucaine oin 1% Tier 1

Rectal Steroids hydrocort ac sup 25mg Tier 1

proctosol hc cre 2.5% Tier 1

ANTACIDS Antacid Combinations acid gone chw 80-20mg Tier 1

acid gone sus Tier 1

alamag-plus chw Tier 1

almacone chw Tier 1

antacid chw dbl st Tier 1

antacid extr chw 675-135 Tier 1

antacid sus ultra st Tier 1

calcium rich sus antacid Tier 1

foam antacid chw 80-20mg Tier 1

foam antacid sus Tier 1

heartbrn ant chw 160-105 Tier 1

heartburn chw ex st Tier 1

maalox multi sus symp max Tier 1

maalox sus advanced Tier 1

maalox sus reg st Tier 1

mag-al plus liq Tier 1

mag-al plus liq xs Tier 1

mi-acid chw Tier 1


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mintox plus chw Tier 1

Antacids - Bicarbonate sodium bicar tab 10gr Tier 1

sodium bicar tab 325mg Tier 1

sodium bicar tab 650mg Tier 1

Antacids - Calcium Salts calc antacid chw 750mg Tier 1

calc antacid chw 1000mg Tier 1

calcium carb chw 500mg Tier 1

CALCIUM CARB TAB 648MG Tier 2

stomach rlf chw 400mg Tier 1

Antacids - Magnesium Salts mag oxide tab 250mg Tier 1

MAG OXIDE TAB 400MG 400mg Tier 1

mag oxide tab 420mg Tier 1

magnesium tab 250mg 250mg Tier 1

ANTHELMINTICS Anthelmintics ALBENZA TAB 200MG Tier 2

BILTRICIDE TAB 600MG Tier 3

pamix sus 50mg/ml Tier 1

PIN-X CHW 250MG Tier 2

pin-x sus 50mg/ml Tier 1

reeses med sus pinworm Tier 1

STROMECTOL TAB 3MG Tier 2

ANTI-INFECTIVE AGENTS - MISC. Anti-infective Agents - Misc. CAYSTON INH 75MG Tier 4 PA

metronidazol tab 250mg Tier 1

metronidazol tab 500mg Tier 1

NEBUPENT INH 300MG Tier 3

trimethoprim tab 100mg Tier 1

vancomycin cap 125mg Tier 1 PA

vancomycin cap 250mg Tier 1 PA

Anti-infective Misc. - Combinations e.s.p. sus 200-600 Tier 1

ees/sulfisox sus 200-600 Tier 1

smz-tmp sus 200-40/5 Tier 1

smz-tmp tab 400-80mg Tier 1

smz/tmp ds tab 800-160 Tier 1

sulfatrim pd sus 200-40/5 Tier 1

Antiprotozoal Agents


9


atovaquone sus 750/5ml Tier 1 PA

Carbapenems imipenem/cil inj 250mg Tier 3 PA

imipenem/cil inj 500mg Tier 3 PA

INVANZ INJ 1GM Tier 3 PA

meropenem inj 500mg Tier 3 PA

Leprostatics dapsone tab 25mg Tier 1

dapsone tab 100mg Tier 1

Lincosamides clindamycin cap 150mg Tier 1

clindamycin cap 300mg Tier 1

clindamycin sol 75mg/5ml Tier 1

Oxazolidinones ZYVOX SUS 100MG/5M Tier 2 PA

ZYVOX TAB 600MG Tier 2 PA

ANTIANGINAL AGENTS Antianginals-Other RANEXA TAB 500MG Tier 2 PA

RANEXA TAB 1000MG Tier 2 PA

Nitrates isosorb din sub 2.5mg Tier 1

isosorb din tab 5mg Tier 1




isosorb mono tab 10mg Tier 1

isosorb mono tab 20mg Tier 1

isosorb mono tab 30mg er Tier 1



nitroglycer cap 2.5mg er Tier 1

nitroglycer cap 6.5mg er Tier 1

nitroglycer cap 9mg er Tier 1

nitroglycer dis 0.2mg/hr Tier 1



NITROSTAT SUB 0.3MG Tier 2



ANTIANXIETY AGENTS Antianxiety Agents - Misc.


10


buspirone tab 5mg Tier 1

buspirone tab 7.5mg Tier 1



hydroxyz hcl syp 10mg/5ml Tier 1

hydroxyz hcl tab 10mg Tier 1



hydroxyz pam cap 25mg Tier 1



Benzodiazepines alprazolam tab 0.5mg Tier 1

alprazolam tab 0.25mg Tier 1

alprazolam tab 1mg Tier 1

alprazolam tab 2mg Tier 1

chlordiazep cap 5mg Tier 1



cloraz dipot tab 7.5mg Tier 1

DIAZEPAM CON 5MG/ML Tier 2 PA

diazepam sol 1mg/ml Tier 1

diazepam tab 2mg Tier 1



lorazepam con 2mg/ml Tier 1

lorazepam tab 0.5mg Tier 1

lorazepam tab 1mg Tier 1

lorazepam tab 2mg Tier 1

oxazepam cap 10mg Tier 1



ANTIARRHYTHMICS Antiarrhythmics Type I-A disopyramide cap 150mg Tier 1

quinidine su tab 300mg Tier 1

Antiarrhythmics Type I-B mexiletine cap 150mg Tier 1

mexiletine cap 200mg Tier 1

mexiletine cap 250mg Tier 1

Antiarrhythmics Type I-C flecainide tab 50mg Tier 1

flecainide tab 100mg Tier 1


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flecainide tab 150mg Tier 1

propafenone tab 150mg Tier 1



Antiarrhythmics Type III amiodarone tab 200mg Tier 1

MULTAQ TAB 400MG Tier 3

TIKOSYN CAP 125MCG Tier 3



ANTIASTHMATIC AND BRONCHODILATOR AGENTS Anti-Inflammatory Agents cromolyn sod neb 20mg/2ml Tier 1

Antiasthmatic - Monoclonal Antibodies XOLAIR SOL 150MG Tier 4 PA

Bronchodilators - Anticholinergics ATROVENT HFA AER 17MCG Tier 2

ipratropium sol 0.02%inh Tier 1

TUDORZA PRES AER 400/ACT Tier 2

Leukotriene Modulators montelukast chw 4mg Tier 1

montelukast chw 5mg Tier 1

montelukast tab 10mg Tier 1

Selective Phosphodiesterase 4 (PDE4) Inhibitors DALIRESP TAB 500MCG Tier 3 PA

Steroid Inhalants AEROSPAN AER 80MCG Tier 2

ASMANEX 7 AER 110MCG Tier 2






budesonide sus 0.5mg/2 Tier 1

budesonide sus 0.25mg/2 Tier 1

PULMICORT INH 90MCG Tier 2

PULMICORT INH 180MCG Tier 2

QVAR AER 40MCG Tier 2

QVAR AER 80MCG Tier 2

Sympathomimetics ADVAIR DISKU AER 100/50 Tier 2 ST

albuterol neb 0.5% Tier 1


12


albuterol neb 0.63mg/3 Tier 1

albuterol neb 0.083% Tier 1

albuterol neb 1.25mg/3 Tier 1

albuterol syp 2mg/5ml Tier 1

albuterol tab 4mg Tier 1

DULERA AER 100-5MCG Tier 2 ST

DULERA AER 200-5MCG Tier 2 ST

FORADIL CAP AEROLIZE Tier 2 ST

PROAIR HFA AER Tier 2

SEREVENT DIS AER 50MCG Tier 2 ST

SYMBICORT AER 80-4.5 Tier 2 ST

SYMBICORT AER 160-4.5 Tier 2 ST

terbutaline tab 2.5mg Tier 1

terbutaline tab 5mg Tier 1

VENTOLIN HFA AER Tier 3 ST

Xanthines aminophyllin inj 25mg/ml Tier 1

aminophyllin tab 100mg Tier 1

aminophyllin tab 200mg Tier 1

theophylline sol 80/15ml Tier 1

theophylline tab 100mg er Tier 1






ANTICOAGULANTS Coumarin Anticoagulants COUMADIN TAB 1MG Tier 2

COUMADIN TAB 2.5MG Tier 2

COUMADIN TAB 2MG Tier 2





COUMADIN TAB 7.5MG Tier 2


jantoven tab 1mg Tier 1

jantoven tab 2.5mg Tier 1






13



jantoven tab 7.5mg Tier 1


warfarin tab 1mg Tier 1

warfarin tab 2.5mg Tier 1






warfarin tab 7.5mg Tier 1


Direct Factor Xa Inhibitors XARELTO TAB 10MG Tier 3

XARELTO TAB 15MG Tier 3

XARELTO TAB 20MG Tier 3

Heparins And Heparinoid-Like Agents enoxaparin inj 30/0.3ml Tier 4 QL

enoxaparin inj 40/0.4ml Tier 4 QL



enoxaparin inj 100mg/ml Tier 4 QL

enoxaparin inj 120/0.8 Tier 4 QL

enoxaparin inj 150mg/ml Tier 4 QL

enoxaparin inj 300/3ml Tier 4 QL

fondaparinux sol 2.5/0.5 Tier 4 PA



fondaparinux sol 10/0.8 Tier 4 PA

FRAGMIN INJ 2500/0.2 Tier 4 PA



FRAGMIN INJ 10000/ML Tier 4 PA

FRAGMIN INJ 12500UNT Tier 4 PA



ANTICONVULSANTS Anticonvulsants - Benzodiazepines clonazepam tab 0.5mg Tier 1

clonazepam tab 1mg Tier 1

clonazepam tab 2mg Tier 1

diazepam gel 2.5mg Tier 1

diazepam gel 10mg Tier 1


14


diazepam gel 20mg Tier 1

ONFI TAB 5MG Tier 2 PA



Anticonvulsants - Misc. BANZEL SUS 40MG/ML Tier 2 PA

BANZEL TAB 200MG Tier 2 PA

BANZEL TAB 400MG Tier 2 PA

carbamazepin cap 100mg er Tier 1



carbamazepin chw 100mg Tier 1

carbamazepin sus 100/5ml Tier 1

carbamazepin tab 200mg Tier 1

carbamazepin tab 200mg er Tier 1

carbamazepin tab 400mg er Tier 1

gabapentin cap 100mg Tier 1



gabapentin sol 250/5ml Tier 1

gabapentin tab 600mg Tier 1

gabapentin tab 800mg Tier 1

lamotrigine chw 5mg Tier 1

lamotrigine chw 25mg Tier 1

lamotrigine tab 25mg Tier 1




levetiraceta sol 100mg/ml Tier 1

levetiraceta tab 250mg Tier 1




LYRICA CAP 25MG Tier 2 PA








oxcarbazepin sus 300mg/5m Tier 1

oxcarbazepin tab 150mg Tier 1


15




POTIGA TAB 50MG Tier 2 PA



primidone tab 50mg Tier 1

primidone tab 250mg Tier 1

TEGRETOL-XR TAB 100MG Tier 2

topiramate cap 15mg Tier 1

topiramate cap 25mg Tier 1

topiramate tab 25mg Tier 1




VIMPAT SOL 10MG/ML Tier 2 PA

VIMPAT TAB 50MG Tier 2 PA




zonisamide cap 25mg Tier 1



Carbamates felbamate sus 600/5ml Tier 1

felbamate tab 400mg Tier 1

felbamate tab 600mg Tier 1

GABA Modulators SABRIL POW 500MG Tier 4 PA

SABRIL TAB 500MG Tier 4 PA

tiagabine tab 2mg Tier 1 PA

tiagabine tab 4mg Tier 1 PA

Hydantoins DILANTIN CAP 30MG Tier 2

phenytoin chw 50mg Tier 1

phenytoin ex cap 100mg Tier 1



phenytoin sus 125/5ml Tier 1

Succinimides ethosuximide cap 250mg Tier 1

ethosuximide sol 250/5ml Tier 1

Valproic Acid divalproex cap 125mg Tier 1


16


divalproex tab 125mg dr Tier 1


divalproex tab 250mg er Tier 1


divalproex tab 500mg er Tier 1

valproic acd cap 250mg Tier 1

valproic acd sol 250/5ml Tier 1

ANTIDEPRESSANTS Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine tab 15mg Tier 1

mirtazapine tab 30mg Tier 1

mirtazapine tab 45mg Tier 1

Antidepressants - Misc. bupropion tab 75mg Tier 1

bupropion tab 100mg Tier 1

bupropion tab 100mg er Tier 1



bupropn hcl tab 150mg xl Tier 1

bupropn hcl tab 300mg xl Tier 1

maprotiline tab 50mg Tier 1

maprotiline tab 75mg Tier 1

Modified Cyclics trazodone tab 50mg Tier 1

trazodone tab 100mg Tier 1



Monoamine Oxidase Inhibitors (MAOIs) phenelzine tab 15mg Tier 1

tranylcyprom tab 10mg Tier 1

Selective Serotonin Reuptake Inhibitors (SSRIs) citalopram sol 10mg/5ml Tier 1

citalopram tab 10mg Tier 1



escitalopram sol 5mg/5ml Tier 1 PA

escitalopram tab 5mg Tier 1 PA



fluoxetine cap 10mg Tier 1

fluoxetine cap 20mg Tier 1

fluoxetine sol 20mg/5ml Tier 1


17


fluoxetine tab 10mg Tier 1

fluoxetine tab 20mg Tier 1

fluvoxamine tab 25mg Tier 1



paroxetine tab 10mg Tier 1




sertraline con 20mg/ml Tier 1

sertraline tab 25mg Tier 1



Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) duloxetine cap 20mg Tier 1 ST

duloxetine cap 30mg Tier 1 ST

duloxetine cap 60mg Tier 1 ST

venlafaxine cap 37.5 er Tier 1

venlafaxine cap 75mg er Tier 1

venlafaxine cap 150mg er Tier 1

venlafaxine tab 25mg Tier 1

venlafaxine tab 37.5mg Tier 1




Tricyclic Agents amitriptylin tab 10mg Tier 1

amitriptylin tab 25mg Tier 1





amoxapine tab 25mg Tier 1




clomipramine cap 25mg Tier 1



desipramine tab 10mg Tier 1





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doxepin hcl cap 10mg Tier 1






doxepin hcl con 10mg/ml Tier 1

imipram hcl tab 10mg Tier 1



nortriptylin cap 10mg Tier 1




protriptylin tab 5mg Tier 1

protriptylin tab 10mg Tier 1

ANTIDIABETICS Alpha-Glucosidase Inhibitors acarbose tab 25mg Tier 1

acarbose tab 50mg Tier 1

acarbose tab 100mg Tier 1

Antidiabetic Combinations glyb/metform tab 1.25-250 Tier 1

glyb/metform tab 2.5-500 Tier 1

glyb/metform tab 5-500mg Tier 1

JANUMET TAB 50-500MG Tier 2 PA

JANUMET TAB 50-1000 Tier 2 PA

JANUMET XR TAB 50-1000 Tier 2 PA

JANUMET XR TAB 100-1000 Tier 2 PA

JENTADUETO TAB 2.5-500 Tier 2 PA

KOMBIGLYZE TAB 2.5-1000 Tier 3 PA

KOMBIGLYZE TAB 5-500MG Tier 3 PA

KOMBIGLYZE TAB 5-1000MG Tier 3 PA

Biguanides metformin tab 500mg Tier 1

metformin tab 500mg er Tier 1

metformin tab 750mg er Tier 1

metformin tab 850mg Tier 1

metformin tab 1000mg Tier 1

Diabetic Other GLUCAGON KIT 1MG Tier 2


19


GLUCOSE-VITAMIN C CHEW TAB 4-0.006

GM

Tier 2

GNP GLUCOSE CHW RASPBERY Tier 2

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors JANUVIA TAB 25MG Tier 2 PA

JANUVIA TAB 50MG Tier 2 PA

JANUVIA TAB 100MG Tier 2 PA

ONGLYZA TAB 2.5MG Tier 3 PA

ONGLYZA TAB 5MG Tier 3 PA

TRADJENTA TAB 5MG Tier 2 PA

Incretin Mimetic Agents (GLP-1 Receptor Agonists) BYETTA INJ 5MCG Tier 2 PA

BYETTA INJ 10MCG Tier 2 PA

Insulin APIDRA INJ SOLOSTAR Tier 3 ST

APIDRA INJ U-100 Tier 3 ST

HUMALOG INJ 100/ML Tier 3 ST

HUMALOG KWIK INJ 100/ML Tier 3 ST

HUMALOG MIX INJ 50/50 Tier 3 ST

HUMALOG MIX INJ 50/50KWP Tier 3 ST

HUMALOG MIX INJ 75/25KWP Tier 3 ST

HUMALOG MIX SUS 75/25 Tier 3 ST

HUMULIN INJ 70/30 Tier 3 ST

HUMULIN INJ 70/30KWP Tier 3 ST

HUMULIN N INJ U-100 Tier 3 ST

HUMULIN N INJ U-100KWP Tier 3 ST

HUMULIN N PN INJ U-100 Tier 3 ST

HUMULIN PEN INJ 70/30 Tier 3 ST

HUMULIN R INJ U-100 Tier 3 ST

HUMULIN R INJ U-500 Tier 3 ST

LANTUS INJ 100/ML Tier 2

LANTUS INJ SOLOSTAR Tier 2

NOVOLIN INJ 70/30 Tier 2

NOVOLIN N INJ U-100 Tier 2

NOVOLIN R INJ PENFILL Tier 2

NOVOLIN R INJ U-100 Tier 2

NOVOLOG INJ 100/ML Tier 2

NOVOLOG INJ FLEXPEN Tier 2

NOVOLOG INJ PENFILL Tier 2

NOVOLOG MIX INJ 70/30 Tier 2

NOVOLOG MIX INJ FLEXPEN Tier 2

Insulin Sensitizing Agents pioglitazone tab 15mg Tier 1 ST


20


pioglitazone tab 30mg Tier 1 ST

pioglitazone tab 45mg Tier 1 ST

Meglitinide Analogues nateglinide tab 60mg Tier 1 PA

nateglinide tab 120mg Tier 1 PA

Sulfonylureas chlorpropam tab 100mg Tier 1

chlorpropam tab 250mg Tier 1

glimepiride tab 1mg Tier 1



glipizide er tab 2.5mg Tier 1

glipizide er tab 5mg Tier 1

glipizide er tab 10mg Tier 1

glipizide tab 5mg Tier 1

glipizide tab 10mg Tier 1

glipizide xl tab 2.5mg Tier 1

glipizide xl tab 5mg Tier 1

glipizide xl tab 10mg Tier 1

glyburid mcr tab 1.5mg Tier 1

glyburid mcr tab 3mg Tier 1

glyburid mcr tab 6mg Tier 1

glyburide tab 1.25mg Tier 1

glyburide tab 2.5mg Tier 1

glyburide tab 5mg Tier 1

tolbutamide tab 500mg Tier 1

ANTIDIARRHEALS Antidiarrheal Agents - Misc. bismatrol sus 262/15ml Tier 1

bismuth chw 262mg Tier 1

bismuth ms sus 525/15ml Tier 1

kaopectate sus 262/15ml Tier 1

pink bismuth tab 262mg Tier 1

Antiperistaltic Agents diphen/atrop liq 2.5/5 Tier 1

diphen/atrop tab 2.5mg Tier 1

loperamide cap 2mg Tier 1

loperamide liq 1mg/5ml Tier 1

loperamide sus 1mg/7.5 Tier 1

loperamide tab 2mg Tier 1

ANTIDOTES Antidotes - Chelating Agents


21


CHEMET CAP 100MG Tier 3

Opioid Antagonists naltrexone tab 50mg Tier 1

ANTIEMETICS 5-HT3 Receptor Antagonists granisetron tab 1mg Tier 1

ondansetron sol 4mg/5ml Tier 1 PA

ondansetron tab 4mg Tier 1

ondansetron tab 4mg odt Tier 1

ondansetron tab 8mg Tier 1

ondansetron tab 8mg odt Tier 1

Antiemetics - Anticholinergic dimenhydrin tab 50mg Tier 1

meclizine chw 25mg Tier 1

meclizine tab 12.5mg Tier 1

meclizine tab 25mg Tier 1

TRANSDERM-SC DIS 1.5MG Tier 2 PA

Antiemetics - Miscellaneous anti-nausea liq Tier 1

dronabinol cap 2.5mg Tier 1 PA

dronabinol cap 5mg Tier 1 PA

dronabinol cap 10mg Tier 1 PA

ANTIFUNGALS Antifungals griseofulvin sus 125/5ml Tier 1

nystatin tab 500000 Tier 1

terbinafine tab 250mg Tier 1

Imidazole-Related Antifungals fluconazole sus 10mg/ml Tier 1 PA

fluconazole sus 40mg/ml Tier 1 PA

fluconazole tab 50mg Tier 1




itraconazole cap 100mg Tier 1

ketoconazole tab 200mg Tier 1

ANTIHISTAMINES Antihistamines - Alkylamines aller-chlor syp 2mg/5ml Tier 1

chlorphenir tab 4mg Tier 1

chlorphenir tab 12mg cr Tier 1

Antihistamines - Ethanolamines


22


ALER-DRYL TAB 50MG Tier 2

allrgy melts tab 12.5mg Tier 1

allrgy relf tab 12.5mg Tier 1

carbinoxamin sol 4mg/5ml Tier 1

carbinoxamin tab 4mg Tier 1

child comple chw allergy Tier 1

clemastine syp 0.5/5ml Tier 1

clemastine tab 1.34mg Tier 1

clemastine tab 2.68mg Tier 1

cvs allergy chw 12.5mg Tier 1

diphedryl liq 12.5/5ml Tier 1

diphenhydram cap 25mg Tier 1

diphenhydram cap 50mg Tier 1

diphenhydram elx 12.5/5ml Tier 1

diphenhydram inj 50mg/ml Tier 1

diphenhydram tab 25mg Tier 1

dytuss syp 12.5/5ml Tier 1

wal-dryl alr tab 12.5mg Tier 1

Antihistamines - Non-Sedating ALLEGRA ALRG TAB 30MG TABS Tier 2 PA

cetirizine chw 5mg Tier 1

cetirizine chw 10mg Tier 1

cetirizine sol 1mg/ml Tier 1

cetirizine sol 5mg/5ml Tier 1

cetirizine syp 1mg/ml SYRP Tier 1

cetirizine syp 5mg/5ml Tier 1

cetirizine tab 5mg Tier 1

cetirizine tab 10mg Tier 1

fexofenadine tab 60mg Tier 1 PA

fexofenadine tab 180mg Tier 1 PA

loratadine sol 5mg/5ml Tier 1

loratadine syp 5mg/5ml Tier 1

loratadine tab 10mg Tier 1

Antihistamines - Phenothiazines promethazine inj 25mg/ml Tier 1

promethazine sol 6.25/5ml Tier 1

promethazine sup 12.5mg Tier 1

promethazine sup 25mg Tier 1

promethazine syp 6.25/5ml Tier 1

promethazine tab 12.5mg Tier 1

promethazine tab 25mg Tier 1

promethazine tab 50mg Tier 1

promethegan sup 50mg Tier 1 PA


23


Antihistamines - Piperidines cyproheptad syp 2mg/5ml Tier 1

cyproheptad tab 4mg Tier 1

ANTIHYPERLIPIDEMICS Bile Acid Sequestrants cholestyram pow 4gm POWD Tier 1

cholestyram pow 4gm lite POWD Tier 1

colestipol tab 1gm Tier 1

prevalite pow 4gm Tier 1

Fibric Acid Derivatives fenofibrate cap 67mg Tier 1

fenofibrate cap 134mg Tier 1

fenofibrate cap 200mg Tier 1

fenofibrate tab 48mg Tier 1



fenofibric tab 35mg Tier 1

gemfibrozil tab 600mg Tier 1

HMG CoA Reductase Inhibitors atorvastatin tab 10mg Tier 1 ST

atorvastatin tab 20mg Tier 1 ST



lovastatin tab 10mg Tier 1



pravastatin tab 10mg Tier 1




simvastatin tab 5mg Tier 1




Nicotinic Acid Derivatives niacor tab 500mg Tier 1

ANTIHYPERTENSIVES ACE Inhibitors benazepril tab 5mg Tier 1

benazepril tab 10mg Tier 1




24


captopril tab 12.5mg Tier 1

captopril tab 25mg Tier 1



enalapril tab 2.5mg Tier 1

enalapril tab 5mg Tier 1



fosinopril tab 10mg Tier 1



lisinopril tab 2.5mg Tier 1

lisinopril tab 5mg Tier 1





quinapril tab 5mg Tier 1




Agents for Pheochromocytoma DIBENZYLINE CAP 10MG Tier 2

Angiotensin II Receptor Antagonists irbesartan tab 75mg Tier 1 ST

irbesartan tab 150mg Tier 1 ST

irbesartan tab 300mg Tier 1 ST

losartan pot tab 25mg Tier 1 ST



Antiadrenergic Antihypertensives clonidine tab 0.1mg Tier 1

clonidine tab 0.2mg Tier 1

clonidine tab 0.3mg Tier 1

doxazosin tab 1mg Tier 1




guanfacine tab 1mg Tier 1

guanfacine tab 2mg Tier 1

methyldopa tab 250mg Tier 1

methyldopa tab 500mg Tier 1

prazosin hcl cap 1mg Tier 1


25




terazosin cap 1mg Tier 1




Antihypertensive Combinations atenol/chlor tab 50-25mg Tier 1

atenol/chlor tab 100-25mg Tier 1

benazep/hctz tab 10-12.5 Tier 1

benazep/hctz tab 20-12.5 Tier 1

benazep/hctz tab 20-25mg Tier 1

bisoprl/hctz tab 2.5/6.25 Tier 1

bisoprl/hctz tab 5-6.25mg Tier 1

bisoprl/hctz tab 10/6.25 Tier 1

captopr/hctz tab 25-15mg Tier 1




enalapr/hctz tab 5-12.5mg Tier 1

enalapr/hctz tab 10-25mg Tier 1

fosinop/hctz tab 10/12.5 Tier 1

irbesar/hctz tab 150-12.5 Tier 1 ST

irbesar/hctz tab 300-12.5 Tier 1 ST

lisinop/hctz tab 10-12.5 Tier 1

lisinop/hctz tab 20-12.5 Tier 1

lisinop/hctz tab 20-25mg Tier 1

losartan/hct tab 50-12.5 Tier 1 ST

losartan/hct tab 100-12.5 Tier 1 ST

losartan/hct tab 100-25 Tier 1 ST

Vasodilators hydralazine tab 10mg Tier 1

hydralazine tab 25mg Tier 1



minoxidil tab 2.5mg Tier 1

minoxidil tab 10mg Tier 1

ANTIMALARIALS Antimalarial Combinations atovaq/progu tab 62.5-25 Tier 1

atovaq/progu tab 250-100 Tier 1

COARTEM TAB 20-120MG Tier 3

Antimalarials


26


chloroquine tab 250mg Tier 1

chloroquine tab 500mg Tier 1

hydroxychlor tab 200mg Tier 1

mefloquine tab 250mg Tier 1

PRIMAQUINE TAB 26.3MG Tier 2

quinine sulf cap 324mg Tier 1

ANTIMYASTHENIC AGENTS Antimyasthenic Agents pyridostigm tab 60mg Tier 1

ANTIMYCOBACTERIAL AGENTS Anti TB Combinations isonarif cap Tier 1

Antimycobacterial Agents cycloserine cap 250mg Tier 1

ethambutol tab 100mg Tier 1

ethambutol tab 400mg Tier 1

isoniazid tab 100mg Tier 1

isoniazid tab 300mg Tier 1

PRIFTIN TAB 150MG Tier 2

pyrazinamide tab 500mg Tier 1

rifabutin cap 150mg Tier 1

rifampin cap 150mg Tier 1

rifampin cap 300mg Tier 1

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES Alkylating Agents ALKERAN INJ 50MG Tier 3 PA

ALKERAN TAB 2MG Tier 2

cyclophosph tab 25mg Tier 1

cyclophosph tab 50mg Tier 1

HEXALEN CAP 50MG Tier 4 PA

LEUKERAN TAB 2MG Tier 2

lomustine cap 10mg Tier 1



melphalan inj 50mg Tier 4 PA

temozolomide cap 5mg Tier 4 PA






Antimetabolites


27


capecitabine tab 150mg Tier 4 PA

capecitabine tab 500mg Tier 4 PA

fludarabine inj 50mg Tier 1 PA

mercaptopur tab 50mg Tier 1

methotrexate tab 2.5mg Tier 1

THIOGUANINE TAB 40MG Tier 3

Antineoplastic - Antibodies RITUXAN INJ 100MG Tier 4 PA

RITUXAN INJ 500MG Tier 4 PA

Antineoplastic - Hedgehog Pathway Inhibitors ERIVEDGE CAP 150MG Tier 4 PA

Antineoplastic - Hormonal and Related Agents anastrozole tab 1mg Tier 1

bicalutamide tab 50mg Tier 1

EMCYT CAP 140MG Tier 3

exemestane tab 25mg Tier 1

flutamide cap 125mg Tier 1

letrozole tab 2.5mg Tier 1

leuprolide inj 1mg/0.2 Tier 4 PA

LYSODREN TAB 500MG Tier 2

megestrol ac sus 40mg/ml Tier 1

megestrol ac tab 20mg Tier 1

megestrol ac tab 40mg Tier 1

tamoxifen tab 10mg Tier 1 $0 Copay for Breast

Cancer Prevention for Women age 35+

tamoxifen tab 20mg Tier 1 $0 Copay for Breast

Cancer Prevention for

Women age 35+

ZOLADEX IMP 3.6MG Tier 4 PA

ZOLADEX IMP 10.8MG Tier 4 PA

ZYTIGA TAB 250MG Tier 4 PA

Antineoplastic Antibiotics mitoxantron inj 2mg/ml Tier 4 PA

mitoxantron inj 20mg Tier 4 PA

Antineoplastic Enzyme Inhibitors AFINITOR DIS TAB 2MG Tier 4 PA

AFINITOR DIS TAB 3MG Tier 4 PA

AFINITOR DIS TAB 5MG Tier 4 PA

CAPRELSA TAB 100MG Tier 4 PA

CAPRELSA TAB 300MG Tier 4 PA

GLEEVEC TAB 100MG Tier 4 PA

GLEEVEC TAB 400MG Tier 4 PA


28


JAKAFI TAB 5MG Tier 4 PA





NEXAVAR TAB 200MG Tier 4 PA

SPRYCEL TAB 20MG Tier 4 PA





STIVARGA TAB 40MG Tier 4 PA

SUTENT CAP 12.5MG Tier 4 PA

SUTENT CAP 25MG Tier 4 PA

SUTENT CAP 50MG Tier 4 PA

TARCEVA TAB 25MG Tier 4 PA



TASIGNA CAP 150MG Tier 4 PA

TASIGNA CAP 200MG Tier 4 PA

TYKERB TAB 250MG Tier 4 PA

VOTRIENT TAB 200MG Tier 4 PA

Antineoplastics Misc. ACTIMMUNE INJ 2MU/0.5 Tier 4 PA

hydroxyurea cap 500mg Tier 1

INTRON-A INJ 10MU Tier 4 PA

INTRON-A INJ 25MU Tier 4 PA

MATULANE CAP 50MG Tier 2 PA

tretinoin cap 10mg Tier 1 PA

Chemotherapy Adjuncts KEPIVANCE INJ 6.25MG Tier 4 PA

Chemotherapy Rescue/Antidote Agents amifostine inj 500mg Tier 4 PA

leucovor ca tab 5mg Tier 1




Mitotic Inhibitors etoposide cap 50mg Tier 1 PA

etoposide inj 20mg/ml 20mg/ml,

100mg/5ml

Tier 4 PA

Topoisomerase I Inhibitors topotecan inj 4mg Tier 4 PA


29


ANTIPARKINSON AGENTS Antiparkinson Adjuvants carbidopa tab 25mg Tier 1

Antiparkinson Anticholinergics benztropine tab 0.5mg Tier 1

benztropine tab 1mg Tier 1

benztropine tab 2mg Tier 1

trihexyphen elx 0.4mg/ml Tier 1 PA

trihexyphen tab 2mg Tier 1

trihexyphen tab 5mg Tier 1

Antiparkinson COMT Inhibitors entacapone tab 200mg Tier 1

Antiparkinson Dopaminergics amantadine cap 100mg Tier 1

amantadine syp 50mg/5ml Tier 1

APOKYN INJ 10MG/ML Tier 4 PA

bromocriptin cap 5mg Tier 1

bromocriptin tab 2.5mg Tier 1

carb/levo er tab 25-100mg Tier 1

carb/levo er tab 50-200mg Tier 1

carb/levo tab 10-100mg TABS Tier 1



pramipexole tab 0.5mg Tier 1 ST





pramipexole tab 1mg Tier 1 ST

ropinirole tab 0.5mg Tier 1

ropinirole tab 0.25mg Tier 1

ropinirole tab 1mg Tier 1





Antiparkinson Monoamine Oxidase Inhibitors AZILECT TAB 0.5MG Tier 2

AZILECT TAB 1MG Tier 2

selegiline cap 5mg Tier 1

selegiline tab 5mg Tier 1

ANTIPSYCHOTICS/ANTIMANIC AGENTS


30


Antimanic Agents lithium carb cap 150mg Tier 1

lithium carb cap 300mg Tier 1

lithium carb cap 600mg Tier 1

lithium carb tab 300mg Tier 1

lithium carb tab 300mg er Tier 1

lithium carb tab 450mg er Tier 1

LITHIUM CITR SOL 8MEQ/5ML Tier 2

Antipsychotics - Misc. LATUDA TAB 20MG Tier 2 PA

LATUDA TAB 40MG Tier 2 PA



ziprasidone cap 20mg Tier 1 ST




Benzisoxazoles FANAPT PAK Tier 2 PA

FANAPT TAB 1MG Tier 2 PA







INVEGA SUST INJ 39/0.25 Tier 2 PA

INVEGA SUST INJ 78/0.5ML Tier 2 PA


INVEGA SUST INJ 156MG/ML Tier 2 PA


INVEGA TAB 1.5MG Tier 2 PA

INVEGA TAB 3MG Tier 2 PA



RISPERDAL INJ 12.5MG Tier 2 PA

RISPERDAL INJ 25MG Tier 2 PA

RISPERDAL INJ 37.5MG Tier 2 PA

RISPERDAL INJ 50MG Tier 2 PA

risperidone sol 1mg/ml Tier 1

risperidone tab 0.5mg Tier 1

risperidone tab 0.5mg od Tier 1

risperidone tab 0.25mg Tier 1


31


risperidone tab 1mg Tier 1

risperidone tab 1mg odt Tier 1







Butyrophenones haloper dec inj 50mg/ml Tier 1

haloper dec inj 100mg/ml Tier 1

haloper lac inj 5mg/ml Tier 1

haloperidol con 2mg/ml Tier 1

haloperidol tab 0.5mg Tier 1

haloperidol tab 1mg Tier 1





Dibenzapines clozapine tab 25mg Tier 1 ST

clozapine tab 50mg Tier 1 ST



loxapine cap 5mg Tier 1




olanzapine tab 2.5mg Tier 1 ST

olanzapine tab 5mg Tier 1 ST

olanzapine tab 7.5mg Tier 1 ST




quetiapine tab 25mg Tier 1 ST






SAPHRIS SUB 5MG Tier 2 PA

SAPHRIS SUB 10MG Tier 2 PA

SEROQUEL XR TAB 50MG Tier 2 PA


32






Phenothiazines chlorpromaz tab 10mg Tier 1

chlorpromaz tab 25mg Tier 1




fluphenaz de inj 25mg/ml Tier 1

fluphenazine inj 2.5mg/ml Tier 1

fluphenazine tab 1mg Tier 1

fluphenazine tab 2.5mg Tier 1



perphenazine tab 2mg Tier 1




prochlorper sup 25mg Tier 1

prochlorper tab 5mg Tier 1

prochlorper tab 10mg Tier 1

thioridazine tab 10mg Tier 1




trifluoperaz tab 1mg Tier 1




Quinolinone Derivatives ABILIFY DISC TAB 10MG Tier 2 PA

ABILIFY DISC TAB 15MG Tier 2 PA

ABILIFY MAIN INJ 300MG Tier 2 PA

ABILIFY MAIN INJ 400MG Tier 2 PA

ABILIFY SOL 1MG/ML Tier 2 PA

ABILIFY TAB 2MG Tier 2 PA







33


Thioxanthenes thiothixene cap 1mg Tier 1

thiothixene cap 2mg Tier 1



ANTISEPTICS DISINFECTANTS Chlorine Antiseptics betasept liq 4% Tier 1

PHISOHEX LIQ 3% Tier 2

ANTIVIRALS Antiretrovirals abacav/lamiv tab /zidovud Tier 1

abacavir tab 300mg Tier 1

APTIVUS CAP 250MG Tier 2

APTIVUS SOL Tier 2

ATRIPLA TAB Tier 2

COMPLERA TAB Tier 2

CRIXIVAN CAP 200MG Tier 2

CRIXIVAN CAP 400MG Tier 2

didanosine cap 125mg Tier 1



EDURANT TAB 25MG Tier 2

EMTRIVA CAP 200MG Tier 2

EMTRIVA SOL 10MG/ML Tier 2

EPIVIR SOL 10MG/ML Tier 2

EPZICOM TAB 600-300 Tier 2

FUZEON KIT Tier 4 PA

INTELENCE TAB 100MG Tier 4 PA

INTELENCE TAB 200MG Tier 4 PA

INVIRASE TAB 500MG Tier 2

ISENTRESS CHW 100MG Tier 2

ISENTRESS TAB 400MG Tier 2

KALETRA SOL Tier 2

KALETRA TAB 100-25MG Tier 2

KALETRA TAB 200-50MG Tier 2

lamivud/zido tab 150-300 Tier 1

lamivudine tab 100mg Tier 1



LEXIVA TAB 700MG Tier 2

nevirapine sus 50mg/5ml Tier 1

nevirapine tab 200mg Tier 1


34


nevirapine tab 400mg er Tier 1

NORVIR CAP 100MG Tier 2

NORVIR SOL 80MG/ML Tier 2

NORVIR TAB 100MG Tier 2

PREZISTA SUS 100MG/ML Tier 2

PREZISTA TAB 400MG Tier 2



RESCRIPTOR TAB 100 MG Tier 2

RESCRIPTOR TAB 100MG Tier 2

RESCRIPTOR TAB 200MG Tier 2

REYATAZ CAP 150MG Tier 2



SELZENTRY TAB 150MG Tier 2

SELZENTRY TAB 300MG Tier 2

stavudine cap 20mg Tier 1



STRIBILD TAB Tier 2 PA

SUSTIVA CAP 50MG Tier 2

SUSTIVA CAP 200MG Tier 2

SUSTIVA TAB 600MG Tier 2

TRIZIVIR TAB Tier 2

TRUVADA TAB 200-300 Tier 2

VIRACEPT TAB 250MG Tier 2

VIRACEPT TAB 625MG Tier 2

VIREAD TAB 150MG Tier 2

VIREAD TAB 300MG Tier 2

ZIAGEN SOL 20MG/ML Tier 2

zidovudine cap 100mg Tier 1

zidovudine syp 50mg/5ml Tier 1

zidovudine tab 300mg Tier 1

CMV Agents foscarnet inj 24mg/ml Tier 3 PA

VALCYTE SOL 50MG/ML Tier 2 PA

VALCYTE TAB 450MG Tier 2 PA

Hepatitis Agents adefov dipiv tab 10mg Tier 1

BARACLUDE SOL .05MG/ML Tier 2

BARACLUDE TAB 0.5MG Tier 2

BARACLUDE TAB 1MG Tier 2

INCIVEK TAB 375MG Tier 4 PA


35


INFERGEN INJ 15MCG Tier 4 PA

PEG-INTRON KIT 150MCG Tier 4 PA

PEGASYS INJ Tier 4 PA

PEGASYS INJ 180MCG/M Tier 4 PA

ribavirin cap 200mg Tier 4 PA

ribavirin tab 200mg Tier 4 PA

TYZEKA TAB 600MG Tier 3

VICTRELIS CAP 200MG Tier 4 PA

Herpes Agents acyclovir cap 200mg Tier 1

acyclovir sus 200/5ml Tier 1

acyclovir tab 400mg Tier 1

acyclovir tab 800mg Tier 1

famciclovir tab 125mg Tier 1



valacyclovir tab 1gm Tier 1

valacyclovir tab 500mg Tier 1

Influenza Agents RELENZA MIS DISKHALE Tier 2

rimantadine tab 100mg Tier 1

TAMIFLU CAP 30MG Tier 2



TAMIFLU SUS 6MG/ML Tier 2

ASSORTED CLASSES Chelating Agents CUPRIMINE CAP 250MG Tier 2

DEPEN TITRA TAB 250MG Tier 2

SYPRINE CAP 250MG Tier 3

Immunomodulators REVLIMID CAP 5MG Tier 4 PA

REVLIMID CAP 10MG Tier 4 PA



THALOMID CAP 100MG Tier 4 PA

Immunosuppressive Agents azathioprine tab 50mg Tier 1

cyclosporine cap 25mg Tier 1

cyclosporine cap 25mg mod Tier 1

cyclosporine cap 50mg mod Tier 1

cyclosporine cap 100mg Tier 1


36


cyclosporine cap 100mg md Tier 1

cyclosporine sol modified Tier 1

gengraf cap 25mg Tier 1

gengraf cap 100mg Tier 1

gengraf sol 100mg/ml Tier 1

hecoria cap 0.5mg Tier 1

hecoria cap 1mg Tier 1

mycophenolat cap 250mg Tier 1

mycophenolat tab 500mg Tier 1

mycophenolic tab 180mg dr Tier 1

mycophenolic tab 360mg dr Tier 1

NEORAL CAP 25MG Tier 2

NEORAL CAP 100MG Tier 2

NEORAL SOL 100MG/ML Tier 2

NULOJIX INJ 250MG Tier 3 PA

RAPAMUNE SOL 1MG/ML Tier 3

RAPAMUNE TAB 1MG Tier 3

RAPAMUNE TAB 2MG Tier 3

SANDIMMUNE CAP 25MG Tier 2

SANDIMMUNE CAP 100MG Tier 2

sirolimus tab 0.5mg Tier 1

tacrolimus cap 0.5mg Tier 1

tacrolimus cap 1mg Tier 1

ZORTRESS TAB 0.5MG Tier 4 PA



Irrigation Solutions physiosol sol irrigat Tier 1

steril water sol irrig Tier 1

Potassium Removing Resins sod poly sul pow Tier 1

BETA BLOCKERS Alpha-Beta Blockers carvedilol tab 3.125mg Tier 1

carvedilol tab 6.25mg Tier 1

carvedilol tab 12.5mg Tier 1

carvedilol tab 25mg Tier 1

labetalol tab 100mg Tier 1



Beta Blockers Cardio-Selective acebutolol cap 200mg Tier 1

acebutolol cap 400mg Tier 1


37


atenolol tab 25mg Tier 1



bisoprol fum tab 5mg Tier 1

bisoprol fum tab 10mg Tier 1

metoprol tar tab 25mg Tier 1



metoprolol tab 25mg er Tier 1




Beta Blockers Non-Selective nadolol tab 20mg Tier 1

nadolol tab 40mg Tier 1

nadolol tab 80mg Tier 1

propranolol cap 60mg er Tier 1




propranolol sol 20mg/5ml Tier 1

propranolol sol 40mg/5ml Tier 1

propranolol tab 10mg Tier 1





sotalol af tab 80mg Tier 1

sotalol af tab 120mg Tier 1

sotalol hcl tab 80mg Tier 1




timolol mal tab 5mg Tier 1



CALCIUM CHANNEL BLOCKERS Calcium Channel Blockers amlodipine tab 2.5mg Tier 1

amlodipine tab 5mg Tier 1

amlodipine tab 10mg Tier 1

diltiazem cap 120mg er CP24 Tier 1

diltiazem cap 120mg/24 Tier 1


38


diltiazem cap 180mg er Tier 1





diltiazem tab 30mg Tier 1




felodipine tab 5mg er Tier 1

felodipine tab 10mg er Tier 1

nicardipine cap 20mg Tier 1

nicardipine cap 30mg Tier 1

nifedipine cap 20mg Tier 1

nifedipine tab 30mg er Tier 1



verapamil cap 100mg er Tier 1





verapamil cap 360mg sr Tier 1

verapamil tab 40mg Tier 1



verapamil tab 120mg er Tier 1



CARDIOTONICS Cardiac Glycosides digoxin sol 50mcg/ml Tier 1

digoxin tab 0.25mg Tier 1

digoxin tab 0.125mg Tier 1

LANOXIN TAB 0.25MG Tier 2

LANOXIN TAB 0.125MG Tier 2

CARDIOVASCULAR AGENTS - MISC. Peripheral Vasodilators niacin cap 500mg Tier 1

Prostaglandin Vasodilators REMODULIN INJ 1MG/ML Tier 4 PA

REMODULIN INJ 2.5MG/ML Tier 4 PA

REMODULIN INJ 5MG/ML Tier 4 PA


39


Pulmonary Hypertension - Endothelin Receptor Antagonists TRACLEER TAB 62.5MG Tier 4 PA

TRACLEER TAB 125MG Tier 4 PA

Pulmonary Hypertension - Phosphodiesterase Inhibitors ADCIRCA TAB 20MG Tier 4 PA

sildenafil tab 20mg Tier 4 PA

CEPHALOSPORINS Cephalosporins - 1st Generation cefadroxil sus 250/5ml Tier 1

cefadroxil sus 500/5ml Tier 1

cefazolin inj 1gm Tier 1 PA

cefazolin inj 20gm Tier 1 PA

cefazolin inj 500mg Tier 1 PA

cephalexin cap 250mg Tier 1

cephalexin cap 500mg Tier 1

cephalexin sus 125/5ml Tier 1

cephalexin sus 250/5ml Tier 1

Cephalosporins - 2nd Generation cefaclor cap 250mg Tier 1

cefaclor sus 125/5ml Tier 1

cefaclor sus 250/5ml Tier 1

CEFOTAN INJ 1GM/10ML Tier 3 PA

CEFOTAN INJ 2GM/20ML Tier 3 PA

CEFOTAN INJ 10G/100M Tier 3 PA

CEFOTET/DEX INJ 1-3.58% Tier 3 PA

CEFOTET/DEX INJ 2-2.08% Tier 3 PA

CEFOTETAN INJ 1GM/10ML Tier 3 PA

CEFOTETAN INJ 2GM/20ML Tier 3 PA

CEFOTETAN INJ 10G Tier 3 PA

cefoxitin inj 1gm Tier 1 PA



cefprozil sus 125/5ml Tier 1

cefprozil sus 250/5ml Tier 1

cefuroxime tab 250mg Tier 1

cefuroxime tab 500mg Tier 1

Cephalosporins - 3rd Generation CEDAX CAP 400MG Tier 3 PA

cefdinir cap 300mg Tier 1 PA

cefdinir sus 125/5ml Tier 1

cefdinir sus 250/5ml Tier 1

cefditoren tab 200mg Tier 1 PA

cefditoren tab 400mg Tier 1 PA


40


cefotaxime inj 1gm Tier 1 PA



cefotaxime inj 500mg Tier 1 PA

cefpodo prox sus 50mg/5ml Tier 1

cefpodo prox sus 100/5ml Tier 1

cefpodoxime tab 100mg Tier 1

cefpodoxime tab 200mg Tier 1

CLAFORAN INJ 2GM Tier 2 PA

CLAFORAN/D5W INJ 1GM Tier 2 PA

SUPRAX SUS 100/5ML Tier 3

SUPRAX SUS 200/5ML Tier 3

SUPRAX TAB 400MG Tier 3

CONTRACEPTIVES Combination Contraceptives - Oral altavera tab Tier 0

alyacen tab 1/35 Tier 0

alyacen tab 7/7/7 Tier 0

amethyst tab 90-20mcg Tier 0

apri tab Tier 0

aranelle tab Tier 0

aubra tab 0.1-0.02 Tier 0

aviane tab Tier 0

azurette tab 28 day Tier 0

balziva tab Tier 0

briellyn tab Tier 0

caziant pak Tier 0

cesia pak Tier 0

chateal tab 0.15/30 Tier 0

cryselle-28 tab 28 tabs Tier 0

cyclafem tab 1/35 Tier 0

cyclafem tab 7/7/7 Tier 0

dasetta tab 1/35 Tier 0

dasetta tab 7/7/7 Tier 0

deso/ethinyl tab estradio Tier 0

drospir/ethi tab 3-0.03mg Tier 0

elinest tab Tier 0

emoquette tab Tier 0

enpresse-28 tab Tier 0

enskyce tab Tier 0

estarylla tab 0.25-35 Tier 0

falmina tab Tier 0

gianvi tab 3-0.02mg Tier 0


41


gildagia tab 0.4-35 Tier 0

gildess fe tab 1.5/30 Tier 0

gildess fe tab 1/20 Tier 0

gildess tab 1.5/30 Tier 0

gildess tab 1/20 Tier 0

junel 1.5/30 tab Tier 0

junel 1/20 tab Tier 0

junel fe tab 1.5/30 Tier 0

junel fe tab 1/20 Tier 0

kariva tab 28 day Tier 0

kelnor tab 1/35 Tier 0

kurvelo tab 0.15/30 Tier 0

larin fe tab 1.5/30 Tier 0

larin fe tab 1/20 Tier 0

leena tab Tier 0

lessina tab Tier 0

levonest tab Tier 0

levonor/ethi tab 0.1-0.02 Tier 0

levonor/ethi tab estradio Tier 0

levora-28 tab 0.15/30 Tier 0

loryna tab 3-0.02mg Tier 0

low-ogestrel tab Tier 0

lutera tab Tier 0

marlissa tab 0.15/30 Tier 0

microgestin tab 1.5/30 Tier 0

microgestin tab 1/20 Tier 0

microgestin tab fe1.5/30 Tier 0

microgestin tab fe 1/20 Tier 0

mono-linyah tab 0.25-35 Tier 0

mononessa tab Tier 0

myzilra tab Tier 0

necon tab 0.5/35 Tier 0

necon tab 1/35 Tier 0

necon tab 1/50-28 Tier 0

necon tab 7/7/7 Tier 0

norgest/eth tab estrad Tier 0

norgest/ethi tab 0.25/35 Tier 0

norgest/ethi tab estradio Tier 0

nortrel tab 0.5/35 Tier 0

nortrel tab 1/35 Tier 0

nortrel tab 7/7/7 Tier 0

ocella tab 3-0.03mg Tier 0

ogestrel tab Tier 0


42


orsythia tab Tier 0

philith tab 0.4-35 Tier 0

pimtrea tab Tier 0

pirmella tab 1/35 Tier 0

pirmella tab 7/7/7 Tier 0

portia-28 tab Tier 0

previfem tab Tier 0

reclipsen tab Tier 0

solia tab Tier 0

sprintec 28 tab 28 day Tier 0

sronyx tab Tier 0

syeda tab 3-0.03mg Tier 0

tilia fe tab Tier 0

tri-estaryll tab Tier 0

tri-legest tab fe Tier 0

tri-linyah tab Tier 0

tri-previfem tab Tier 0

tri-sprintec tab Tier 0

trinessa tab Tier 0

trivora-28 tab Tier 0

velivet pak Tier 0

vestura tab 3-0.02mg Tier 0

viorele tab Tier 0

vyfemla tab 0.4-35 Tier 0

wera tab 0.5/35 Tier 0

wymzya fe chw 0.4mg-35 Tier 0

zarah tab 3-0.03mg Tier 0

zenchent fe chw 0.4mg-35 Tier 0

zenchent tab Tier 0

zeosa chw Tier 0

zovia 1/35e tab Tier 0

zovia 1/50e tab Tier 0

Combination Contraceptives - Transdermal xulane dis 150-35 Tier 0

Combination Contraceptives - Vaginal NUVARING MIS Tier 0

Emergency Contraceptives ELLA TAB 30MG Tier 0

levonorgestr tab 0.75mg Tier 0

levonorgestr tab 1.5mg Tier 0

my way tab 1.5mg Tier 0

next choice tab 0.75mg Tier 0

next choice tab 1.5mg Tier 0


43


Progestin Contraceptives - IUD MIRENA IUD SYSTEM Tier 4 PA

Progestin Contraceptives - Injectable medroxypr ac inj 150mg/ml Tier 0

Progestin Contraceptives - Oral camila tab 0.35mg Tier 0

errin tab 0.35mg Tier 0

heather tab 0.35mg Tier 0

jencycla tab 0.35mg Tier 0

jolivette tab 0.35mg Tier 0

lyza tab 0.35mg Tier 0

nora-be tab 0.35mg Tier 0

norethindron tab 0.35mg Tier 0

CORTICOSTEROIDS Glucocorticosteroids budesonide cap 3mg/24hr Tier 1 PA

cortisone ac tab 25mg Tier 1

dexamethason elx 0.5/5ml Tier 1

dexamethason sol 0.5/5ml Tier 1

dexamethason tab 0.5mg Tier 1



dexamethason tab 1mg Tier 1




hydrocort tab 5mg Tier 1



methylpred pak 4mg Tier 1

methylpred tab 4mg Tier 1




pred sod pho sol 5mg/5ml Tier 1

pred sod pho sol 6.7/5ml Tier 1

prednisolone sol 15mg/5ml Tier 1

prednisolone sol 25mg/5ml Tier 1

prednisolone syp 15mg/5ml Tier 1

prednisone pak 5mg Tier 1

prednisone pak 10mg Tier 1

prednisone sol 5mg/5ml Tier 1

prednisone tab 1mg Tier 1


44


prednisone tab 2.5mg Tier 1





Mineralocorticoids fludrocort tab 0.1mg Tier 1

COUGH/COLD/ALLERGY Antitussives benzonatate cap 100mg Tier 1

benzonatate cap 200mg Tier 1

hydrocod/hom syp 5-1.5/5 Tier 1

robitussin syp 7.5/5ml Tier 1

st joseph co syp 7.5/5ml Tier 1

triaminic syp cough Tier 1

Cough/Cold/Allergy Combinations allergy-d tab 25-10mg Tier 1

brom/pse/dm syp Tier 1

bromfed dm syp Tier 1

brotapp dm liq 15-1-5/5 Tier 1

brotapp liq Tier 1

CAPMIST DM TAB Tier 2

cetiriz/pse tab 5-120mg Tier 1

cgh dm max liq 10-200 Tier 1

cheratussin sol dac Tier 1

cold & cough liq 6.25-2.5 Tier 1

cold/allergy elx children Tier 1

cold/cough elx children Tier 1

cold/cough elx dm Tier 1

cold/cough liq 6.25-2.5 Tier 1

cough dm syp 100-10/5 Tier 1

delsym night liq cgh/cold Tier 1

dimetane dx syp Tier 1

dimetapp liq nighttim Tier 1

dm/gg sol 10-100/5 Tier 1

eql triactin elx cld/cgh Tier 1

guaiatussin syp ac Tier 1

guaifenesin sol dac Tier 1

guaifenesin syp dm Tier 1

loratadine d tab 5-120mg Tier 1

loratadine-d tab 10-240mg Tier 1

MUCINEX D TAB 60-600MG Tier 2

mucus-dm tab 30-600mg Tier 1


45


mytussin dac sol Tier 1

night time liq cgh/cold Tier 1

PRO-CLEAR AC SYP Tier 2

prometh vc syp 6.25-5/5 Tier 1

prometh vc/ syp codeine Tier 1

prometh/cod syp 6.25-10 Tier 1

promethazine syp dm Tier 1

q-tapp dm elx Tier 1

q-tapp elx 1-15/5ml Tier 1

q-tussin dm syp 100-10/5 Tier 1

ra allergy tab sinus Tier 1

robitussin liq cgh/cong Tier 1

robitussin liq nighttim Tier 1

robitussin liq to go dm Tier 1

rynex pse liq Tier 1

triacting nt liq cold/cgh Tier 1

tussin dm liq 10-200/5 Tier 1

tussin dm liq 100-10/5 Tier 1

tussin dm syp 100-10/5 Tier 1

wal-dryl-d tab alrg/sin Tier 1

wal-tap dm elx cold/cgh Tier 1

wal-tap elx cld/alle Tier 1

Expectorants guaifenesin sol 100/5ml Tier 1

guaifenesin syp 100/5ml Tier 1

guaifenesin tab 200mg Tier 1

guaifenesin tab 400mg Tier 1

guaifenesin tab 600mg er Tier 1

Misc. Respiratory Inhalants sod chloride neb 0.9% Tier 1

sodium chlor neb 3% Tier 1

sodium chlor neb 7% Tier 1

Mucolytics acetylcyst sol 20% Tier 1

DERMATOLOGICALS Acne Products ACNE MEDICAT LOT 5% Tier 2

ACNE MEDICAT LOT 10% Tier 2

adapalene cre 0.1% Tier 1

adapalene gel 0.1% Tier 1

adapalene gel 0.3% Tier 1

amnesteem cap 10mg Tier 1 PA



46



benzoyl per gel 5% Tier 1

benzoyl per gel 10% Tier 1

bpo-5 wash liq 5% Tier 1

bpo-10 wash liq 10% Tier 1

claravis cap 10mg Tier 1 PA




CLEAN&CLEAR LOT EXFOLIAT Tier 2

clindamy/ben gel 1.2-5% Tier 1 PA

clindamycin gel 1% Tier 1

clindamycin lot 1% Tier 1

clindamycin sol 1% Tier 1

DIFFERIN LOT 0.1% Tier 3

erythromycin gel 2% Tier 1

erythromycin gel /benzoyl Tier 1

erythromycin sol 2% Tier 1

myorisan cap 10mg Tier 1 PA



tretinoin cre 0.1% Tier 1 PA; AGE

tretinoin cre 0.05% Tier 1 PA; AGE

tretinoin cre 0.025% Tier 1 AGE

tretinoin gel 0.01% Tier 1 PA; AGE

tretinoin gel 0.025% Tier 1 PA; AGE

zenatane cap 10mg Tier 1 PA



Anti-inflammatory Agents - Topical VOLTAREN GEL 1% Tier 2 PA

Antibiotics - Topical ALTABAX OIN 1% Tier 3 PA

bacitracin oin 500/gm Tier 1

gentamicin cre 0.1% Tier 1

gentamicin oin 0.1% Tier 1

mupirocin oin 2% Tier 1

poly bacitra oin Tier 1

triple antib oin Tier 1

triple antib oin plus Tier 1

Antifungals - Topical ciclodan cre 0.77% Tier 1

clotrim/beta cre diprop Tier 1


47


clotrim/beta lot diprop Tier 1

clotrimazole cre 1% 1% Tier 1

clotrimazole sol 1% Tier 1

dermafungal oin 2% Tier 1

econazole cre 1% Tier 1

ketoconazole cre 2% Tier 1

ketoconazole sha 2% Tier 1

miconazole aer 2% Tier 1

miconazole cre 2% 2% Tier 1

miconazorb pow af 2% Tier 1

nystat/triam cre Tier 1

nystat/triam oin Tier 1

nystatin cre 100000 Tier 1

nystatin oin 100000 Tier 1

nystatin pow 100000 Tier 1

terbinafine cre 1% Tier 1

tolnaftate aer 1% AERP Tier 1

tolnaftate cre 1% 1% Tier 1

tolnaftate pow 1% Tier 1

tolnaftate sol 1% Tier 1

Antihistamines-Topical allergy cre 2-0.1% Tier 1

Antineoplastic or Premalignant Lesion Agents - Topical fluorouracil cre 5% Tier 1

PANRETIN GEL 0.1% Tier 4 PA

Antipsoriatics calcipotrien oin 0.005% Tier 1 PA

calcipotrien sol 0.005% Tier 1 PA

DRITHO-CREME CRE HP 1% Tier 2

Antiseborrheic Products dandruff sha 1% Tier 1

selenium sul lot 2.5% Tier 1

selenium sul sha 2.5% Tier 1

Antivirals - Topical ABREVA CRE 10% Tier 2

acyclovir oin 5% Tier 1 PA

ZOVIRAX CRE 5% Tier 2 PA

Burn Products silver sulfa cre 1% Tier 1

SULFAMYLON CRE 85MG/GM Tier 3

SULFAMYLON PAK 5% Tier 3

Corticosteroids - Topical


48


alclometason cre 0.05% Tier 1

alclometason oin 0.05% Tier 1

aug betamet cre 0.05% Tier 1

betameth val cre 0.1% Tier 1

clobetasol cre 0.05% Tier 1

clobetasol gel 0.05% Tier 1

clobetasol oin 0.05% Tier 1

clobetasol sol 0.05% Tier 1

cortizone-10 gel 1% Tier 1

desonide cre 0.05% Tier 1

desonide oin 0.05% Tier 1

fluocin acet oil 0.01% sc Tier 1

fluocinonide cre 0.05% Tier 1

fluocinonide gel 0.05% Tier 1

fluocinonide oin 0.05% Tier 1

fluocinonide sol 0.05% Tier 1 PA

fluticasone cre 0.05% Tier 1

fluticasone oin 0.005% Tier 1

halobetasol cre 0.05% Tier 1 PA

halobetasol oin 0.05% Tier 1 PA

hc valerate cre 0.2% Tier 1

hc-1% hemorr oin 1% Tier 1

hc/aloe cre 0.5% Tier 1

hydrocort ac cre 0.5% Tier 1

hydrocort ac cre 1% Tier 1

hydrocort cre 0.5% Tier 1

hydrocort cre 1% Tier 1

hydrocort cre 2.5% Tier 1

hydrocort lot 1% Tier 1

hydrocort lot 2.5% Tier 1

hydrocort oin 0.5% Tier 1

hydrocort oin 1% Tier 1

hydrocort oin 2.5% Tier 1

hydrocort/ cre aloe 1% Tier 1

mometasone cre 0.1% Tier 1 PA

mometasone oin 0.1% Tier 1 PA

prednicarbat cre 0.1% Tier 1

prednicarbat oin 0.1% Tier 1

triamcinolon cre 0.1% Tier 1



triamcinolon lot 0.1% Tier 1

triamcinolon lot 0.025% Tier 1


49


triamcinolon oin 0.1% Tier 1



Emollients ammonium lac cre 12% Tier 1

ammonium lac lot 12% Tier 1

Immunomodulating Agents - Topical imiquimod cre 5% Tier 1 PA

Immunosuppressive Agents - Topical ELIDEL CRE 1% Tier 2 PA

PROTOPIC OIN 0.1% Tier 2 PA

PROTOPIC OIN 0.03% Tier 2 PA

Keratolytic/Antimitotic Agents podofilox sol 0.5% Tier 1

Local Anesthetics - Topical lido/prilocn cre 2.5-2.5% Tier 1

lidocaine gel 2% Tier 1

lidocaine oin 5% Tier 1

lidocaine pad 5% Tier 1 PA

lidocaine sol 4% Tier 1

Misc. Topical hypercare sol 20% Tier 1

ZINC-OXYDE OIN 0.44-20% Tier 2

Pigmenting-Depigmenting Agents OXSORALEN LOT 1% Tier 3 PA

Rosacea Agents FINACEA GEL 15% Tier 3

metronidazol cre 0.75% Tier 1

metronidazol gel 0.75% Tier 1

metronidazol lot 0.75% Tier 1

Scabicides Pediculicides eql lice kit solution Tier 1

EURAX CRE 10% Tier 2 ST

lice bedding aer 0.5% Tier 1

lice control aer 0.5% Tier 1

lice killing sha Tier 1

lice soln kit Tier 1

lice treatmt sha 0.33-4% Tier 1

lice trtmnt liq 1% Tier 1

licide aer 0.5% Tier 1

malathion lot 0.5% Tier 1 ST

permethrin cre 5% Tier 1


50


permethrin lot 1% Tier 1

ra lice kit solution Tier 1

spinosad sus 0.9% Tier 1 PA

tolnaftate cre 1% 1% Tier 1

ULESFIA LOT 5% Tier 2 ST

DIAGNOSTIC PRODUCTS Diagnostic Drugs THYROGEN INJ 1.1MG Tier 4 PA

Diagnostic Tests TRUETEST TES Tier 2

DIGESTIVE AIDS Digestive Enzymes CREON CAP 3000UNIT Tier 2

CREON CAP 6000UNIT Tier 2

CREON CAP 12000UNT Tier 2

CREON CAP 24000UNT Tier 2

pancrelipase cap 5000unit Tier 1

DIURETICS Carbonic Anhydrase Inhibitors acetazolamid cap 500mg er Tier 1

acetazolamid tab 125mg Tier 1

acetazolamid tab 250mg Tier 1

methazolamid tab 25mg Tier 1

methazolamid tab 50mg Tier 1

Diuretic Combinations ALDACTAZIDE TAB 50/50 Tier 2

amilor/hctz tab 5-50 Tier 1

spirono/hctz tab 25/25 Tier 1

triamt/hctz cap 37.5-25 Tier 1

triamt/hctz tab 37.5-25 Tier 1

triamt/hctz tab 75-50mg Tier 1

Loop Diuretics bumetanide tab 0.5mg Tier 1

bumetanide tab 1mg Tier 1

bumetanide tab 2mg Tier 1

FUROSEMIDE SOL 8MG/ML Tier 2

furosemide sol 10mg/ml Tier 1

furosemide tab 20mg Tier 1



torsemide tab 5mg Tier 1



51




Potassium Sparing Diuretics amiloride tab 5mg Tier 1

spironolact tab 25mg Tier 1



Thiazides and Thiazide-Like Diuretics chlorthalid tab 25mg Tier 1

chlorthalid tab 50mg Tier 1

hydrochlorot cap 12.5mg Tier 1

hydrochlorot tab 12.5mg Tier 1

hydrochlorot tab 25mg Tier 1

hydrochlorot tab 50mg Tier 1

indapamide tab 1.25mg Tier 1

indapamide tab 2.5mg Tier 1

metolazone tab 2.5mg Tier 1

metolazone tab 5mg Tier 1

metolazone tab 10mg Tier 1

ENDOCRINE AND METABOLIC AGENTS - MISC. Bone Density Regulators alendronate tab 5mg Tier 1

alendronate tab 10mg Tier 1




calcitonin spr 200/act Tier 1 PA

etidron disd tab 200mg Tier 1

etidron disd tab 400mg Tier 1

FORTEO SOL 600/2.4 Tier 4 PA

FOSAMAX + D TAB 70-2800 Tier 2

FOSAMAX + D TAB 70-5600 Tier 2

ibandronate tab 150mg Tier 1

Growth Hormones OMNITROPE INJ 5.8MG Tier 4

TEV-TROPIN INJ 5MG Tier 4 PA

Hormone Receptor Modulators raloxifene tab 60mg Tier 1 PA; $0 Copay for Breast

Cancer Prevention for

Women age 35+

Insulin-Like Growth Factors (Somatomedins) INCRELEX INJ 40MG/4ML Tier 4 PA


52


LHRH/GnRH Agonist Analog Pituitary Suppressants LUPR DEP-PED INJ 7.5MG Tier 4 PA

LUPR DEP-PED INJ 11.25MG Tier 4 PA

LUPR DEP-PED INJ 15MG Tier 4 PA

LUPR DEP-PED INJ 30MG Tier 4 PA

SYNAREL SOL 2MG/ML Tier 4 PA

Metabolic Modifiers BUPHENYL TAB 500MG Tier 4 PA

calcitriol cap 0.5mcg Tier 1

calcitriol cap 0.25mcg Tier 1

CYSTADANE POW Tier 3 PA

ELAPRASE INJ 6MG/3ML Tier 4 PA

FABRAZYME INJ 5MG Tier 4 PA

KUVAN TAB 100MG Tier 4 PA

levocarnitin sol 1gm/10ml Tier 1

levocarnitin tab 330mg Tier 1

ORFADIN CAP 2MG Tier 4 PA



phenylbutyra pow sodium Tier 4 PA

SENSIPAR TAB 30MG Tier 4 PA



Posterior Pituitary Hormones desmopressin spr 0.01% .1mg/ml Tier 1 PA

desmopressin tab 0.1mg Tier 1

desmopressin tab 0.2mg Tier 1

STIMATE SOL 1.5MG/ML Tier 4 PA

Prolactin Inhibitors cabergoline tab 0.5mg Tier 1

Somatostatic Agents octreotide inj 100mcg Tier 4 PA

SANDOSTATIN KIT LAR 20MG Tier 4 PA

SANDOSTATIN KIT LAR 30MG Tier 4 PA

ESTROGENS Estrogen Combinations essian h.s. tab Tier 1

essian tab Tier 1

est estrogen tab mtest Tier 1

est estrogen tab mtest hs Tier 1

FEMHRT TAB 0.5-2.5 Tier 2

mtest hs/est tab estrogen Tier 1


53


mtest/est tab estrogen Tier 1

PREMPHASE TAB Tier 2

PREMPRO TAB 0.3-1.5 Tier 2

PREMPRO TAB 0.45-1.5 Tier 2

PREMPRO TAB 0.625-5 Tier 2

PREMPRO TAB .625-2.5 Tier 2

Estrogens estradiol tab 0.5mg Tier 1

estradiol tab 1mg Tier 1

estradiol tab 2mg Tier 1

estropipate tab 0.75mg Tier 1

estropipate tab 1.5mg Tier 1

estropipate tab 3mg Tier 1

ortho-est tab 0.625 Tier 1

ortho-est tab 1.25 Tier 1

PREMARIN TAB 0.3MG Tier 2





FLUOROQUINOLONES Fluoroquinolones ciprofloxacn tab 250mg Tier 1

ciprofloxacn tab 500mg Tier 1

ciprofloxacn tab 750mg Tier 1

levofloxacin sol 25mg/ml Tier 1 PA

levofloxacin tab 250mg Tier 1 PA



NOROXIN TAB 400MG Tier 3

GASTROINTESTINAL AGENTS - MISC. Antiflatulents gas relief cap 125mg Tier 1

gas relief cap 180mg Tier 1

gas relief dro infants Tier 1

LITTLE TUMMY DRO 20/0.3ML Tier 1

simethicone chw 80mg Tier 1

simethicone chw 125mg Tier 1

simethicone dro 40/0.6ml Tier 1

Gallstone Solubilizing Agents ursodiol cap 300mg Tier 1

Gastrointestinal Chloride Channel Activators


54


AMITIZA CAP 8MCG Tier 3 PA

AMITIZA CAP 24MCG Tier 3 PA

Gastrointestinal Stimulants metoclopram sol 5mg/5ml Tier 1

metoclopram tab 5mg Tier 1

metoclopram tab 10mg Tier 1

Inflammatory Bowel Agents APRISO CAP 0.375GM Tier 2

ASACOL HD TAB 800MG Tier 3

ASACOL TAB 400MG DR Tier 3

balsalazide cap 750mg Tier 1

sulfasalazin tab 500mg Tier 1

sulfasalazin tab 500mg dr Tier 1

Intestinal Acidifiers lactulose sol 10gm/15 10gm/15ml Tier 1

Phosphate Binder Agents calc acetate cap 667mg Tier 1

RENVELA PAK 0.8GM Tier 3 ST

RENVELA PAK 2.4GM Tier 3 ST

RENVELA TAB 800MG Tier 3 ST

GENITOURINARY Miscellaneous bethanechol tab 5mg Tier 1

bethanechol tab 10mg Tier 1



Urinary Antispasmodics oxybutynin syp 5mg/5ml Tier 1

oxybutynin tab 5mg Tier 1

oxybutynin tab 5mg er Tier 1 ST



tolterodine tab 1mg Tier 1 ST

tolterodine tab 2mg Tier 1 ST

trospium cl tab 20mg Tier 1 ST

GENITOURINARY AGENTS - MISCELLANEOUS Alkalinizers citric acid/ sol sod citr Tier 1

cytra-2 sol Tier 1

cytra-k sol Tier 1

k citrate sol citr acd Tier 1

pot citrate tab 540mg Tier 1


55


pot citrate tab 1080mg Tier 1

Cystinosis Agents CYSTAGON CAP 50MG Tier 3 PA

CYSTAGON CAP 150MG Tier 3 PA

Genitourinary Irrigants acetic acid sol 0.25%irr Tier 1

sodium chlor sol 0.9% irr Tier 1

Interstitial Cystitis Agents ELMIRON CAP 100MG Tier 2

Prostatic Hypertrophy Agents alfuzosin tab 10mg Tier 1

finasteride tab 5mg Tier 1

tamsulosin cap 0.4mg Tier 1

Urinary Analgesics phenazopyrid tab 100mg Tier 1

phenazopyrid tab 200mg Tier 1

GOUT AGENTS Gout Agent Combinations proben/colch tab 500-0.5 Tier 1

Gout Agents allopurinol tab 100mg Tier 1

allopurinol tab 300mg Tier 1

COLCRYS TAB 0.6MG Tier 2 PA

Uricosurics probenecid tab 500mg Tier 1

HEMATOLOGICAL AGENTS - MISC. Antihemophilic Products ADVATE INJ 250UNIT Tier 4 PA

ADVATE INJ 500UNIT Tier 4 PA






BENEFIX INJ 250UNIT Tier 4 PA





HELIXATE FS INJ 250UNIT Tier 4 PA




56


HELIXATE FS SOL 250UNIT Tier 4 PA



HUMATE-P SOL 1200UNIT Tier 4 PA

HUMATE-P SOL 2400UNIT Tier 4 PA

KOGENATE FS INJ 250/BS Tier 4 PA

KOGENATE FS INJ 250UNIT Tier 4 PA





RIXUBIS INJ 250 UNIT Tier 4 PA

RIXUBIS INJ 500UNIT Tier 4 PA




Hematorheologic Agents pentoxifylli tab 400mg er Tier 1

Platelet Aggregation Inhibitors AGGRENOX CAP 25-200MG Tier 2 PA

cilostazol tab 50mg Tier 1

cilostazol tab 100mg Tier 1

clopidogrel tab 75mg Tier 1

dipyridamole tab 25mg Tier 1



EFFIENT TAB 5MG Tier 3 PA

EFFIENT TAB 10MG Tier 3 PA

ticlopidine tab 250mg Tier 1

HEMATOPOIETIC AGENTS Cobalamins vitamin b12 tab 1000 cr Tier 1

vitamin b-12 sub 500mcg Tier 1



vitamin b-12 tab 100mcg Tier 1




Folic Acid/Folates folic acid tab 1mg Tier 1

folic acid tab 400mcg Tier 0

folic acid tab 800mcg Tier 0


57


Hematopoietic Growth Factors ARANESP INJ 25MCG Tier 4 PA

ARANESP INJ 40MCG 40mcg/0.4ml Tier 4 PA

ARANESP INJ 60MCG Tier 4 PA






EPOGEN INJ 2000/ML Tier 4 PA




LEUKINE INJ 250MCG Tier 4 PA

NEULASTA INJ 6MG/0.6M Tier 4 PA

NEUPOGEN INJ 300/0.5 Tier 4 PA

NEUPOGEN INJ 300MCG Tier 4 PA

NEUPOGEN INJ 480/0.8 Tier 4 PA

NEUPOGEN INJ 480MCG Tier 4 PA

PROCRIT INJ 2000/ML Tier 4 PA





Hematopoietic Mixtures ferocon cap Tier 1

ferotrin cap Tier 1

ferotrinsic cap Tier 1

foltrin cap Tier 1

iron complex cap Tier 1

martinic cap Tier 1

polysacchari cap iron Tier 1

tl icon cap Tier 1

tricon cap Tier 1

Iron ferrous fum tab 324mg Tier 1

ferrous gluc tab 240mg Tier 1

ferrous gluc tab 324mg 324mg Tier 1

FERROUS GLUC TAB 324MG 324mg Tier 2

ferrous gluc tab 325mg Tier 1

FERROUS SUL LIQ 220/5ML Tier 2

ferrous sulf dro 15mg/ml Tier 0

ferrous sulf elx 220/5ml Tier 0


58


FERROUS SULF TAB 324MG EC Tier 2

ferrous sulf tab 325mg Tier 1

ferrous sulf tab 325mg ec Tier 1

ferus cap 150mg Tier 1

gnp iron tab 45mg Tier 1

hm iron tab 45mg Tier 1

iron chews chw pediatri Tier 1

iron slow tab 45mg Tier 1

iron tab 160mg cr Tier 1

iron therapy tab 200mg Tier 1

slow iron tab 50mg Tier 1

slow release tab 47.5mg Tier 1

sm iron tab 45mg Tier 1

wee care sus 15/1.25 Tier 0

HEMOSTATICS Hemostatics - Systemic tranex acid inj 100mg/ml Tier 1 PA

HYPNOTICS Antihistamine Hypnotics calcium rich sus antacid Tier 1

sleep aid tab 25mg Tier 1

sleep aid tab 50mg Tier 1

sleep tab 25mg Tier 1

Barbiturate Hypnotics phenobarb sol 20mg/5ml Tier 1

phenobarb tab 15mg Tier 1

phenobarb tab 16.2mg Tier 1







Non-Barbiturate Hypnotics chloral hydr syp 500/5ml Tier 1

estazolam tab 1mg Tier 1

estazolam tab 2mg Tier 1

flurazepam cap 15mg Tier 1

flurazepam cap 30mg Tier 1

temazepam cap 15mg Tier 1

temazepam cap 30mg Tier 1

triazolam tab 0.25mg Tier 1

triazolam tab 0.125mg Tier 1


59


zolpidem tab 5mg Tier 1

zolpidem tab 10mg Tier 1

LAXATIVES Bulk Laxatives best fiber pow Tier 1

clr soluble pow fiber Tier 1

eq fiber pow Tier 1

fiber cap 0.52gm Tier 1

fiber laxatv tab 625mg Tier 1

fiber laxtiv cap 0.52gm Tier 1

fiber powder pow Tier 1

fiber tab 625mg Tier 1

fiber therap cap 0.52gm Tier 1

fiber therap pow 28.3% Tier 1



fiber therap tab 500mg Tier 1

fiber therap tab 625mg Tier 1

fiber-caps tab 625mg Tier 1

fiber-lax tab 625mg Tier 1

fibergen tab 625mg Tier 1

fibertab tab 625mg Tier 1

gnp best pow fiber Tier 1

hm fiber tab 500mg Tier 1

KONSYL POW 28.3% Tier 2

KONSYL POW 100% PACK Tier 2

KONSYL-D POW 52.3% Tier 2

metafiber pow 30.9% Tier 1



METAMUCIL POW 28% Tier 2

metamucil pow 30.9% Tier 1

METAMUCIL POW 55.46% Tier 2

metamucil pow 58.6% Tier 1

METAMUCIL POW 58.12% Tier 2

METAMUCIL POW CLEAR Tier 2

METAMUCIL WAF Tier 2

NAT FIBER POW 58.6% Tier 2

psyllium pow 100% Tier 1

qc natural pow vegetabl Tier 1

ra fiber tab 500mg Tier 1

sb fib lax pow 33% Tier 1

sm fiber lax tab 500mg Tier 1


60


soluble fib tab therapy Tier 1

total fiber pow Tier 1

UNIFIBER POW Tier 2

veg fiber pow 63% Tier 1

Laxative Combinations gavilyte-c sol Tier 1

gavilyte-g sol Tier 1

GOLYTELY SOL Tier 2

HALFLYTELY KIT FLAV PKS Tier 2

peg 3350 sol electrol Tier 1

peg-3350 sol electrol Tier 1

peg-3350/kcl sol /sodium Tier 1

senna-s tab 8.6-50mg Tier 1

Laxatives - Miscellaneous glycerin sup 1.2gm Tier 1

glycerin sup 2.1gm Tier 1

glycerin sup 2gm Tier 1

glycerin sup 80.7% Tier 1

lactulose sol 10gm/15 10gm/15ml Tier 1

lactulose sol 20gm/30 Tier 1

polyeth glyc pow 3350 nf Tier 1

Lubricant Laxatives MINERAL OIL Tier 2

mineral oil ene Tier 1

Saline Laxatives disposable ene Tier 1

disposable ene single Tier 1

disposable ene twin pk Tier 1

enema ene double Tier 1

enema ene single Tier 1

enema ready- ene -to-use Tier 1

eq enema ene double Tier 1

mag citrate sol cherry Tier 1

mag citrate sol grape Tier 1

mag citrate sol lemon Tier 1

milk of magn sus Tier 1

MILK OF MAGN SUS 2400MG Tier 2

oral saline sol laxative Tier 1

OSMOPREP TAB 1.5GM Tier 3

phosphate sol laxative Tier 1

saline ene laxative Tier 1

VISICOL TAB 1.5GM Tier 3

Stimulant Laxatives


61


bisacodyl sup 10mg Tier 1

bisacodyl tab 5mg ec Tier 1

laxative chw 15mg Tier 1

senna syp 8.8mg/5 Tier 1

senna tab 8.6mg Tier 1

senna tab 25mg Tier 1

SENNA TAB 187MG Tier 2

VERACOLATE TAB Tier 1

Surfactant Laxatives docu soft cap 100mg Tier 1

docusate cal cap 240mg Tier 1

docusate sod cap 250mg Tier 1

docusate sod liq 50mg/5ml Tier 1

docusate sod syp 20mg/5ml Tier 1

docusate sod tab 100mg Tier 1

docusol plus ene 20-283 Tier 1

enemeez plus ene 20-283 Tier 1

PEDIA-LAX LIQ 50MG Tier 2

stool softnr cap 50mg Tier 1

vacuant plus ene 20-283 Tier 1

MACROLIDES Azithromycin azithromycin pow 1gm pak Tier 1

azithromycin sus 100/5ml Tier 1

azithromycin sus 200/5ml Tier 1

azithromycin tab 250mg Tier 1



Clarithromycin clarithromyc sus 125/5ml Tier 1

clarithromyc sus 250/5ml Tier 1

clarithromyc tab 250mg Tier 1

clarithromyc tab 500mg Tier 1

clarithromyc tab 500mg er Tier 1

Erythromycins e.e.s. 400 tab 400mg Tier 1

E.E.S. GRAN SUS 200/5ML Tier 2

ERY-TAB TAB 250MG EC Tier 2



ERYPED SUS 200/5ML Tier 2

erythrocin tab 250mg Tier 1

erythrom eth tab 400mg Tier 1


62


erythromycin tab 250mg bs Tier 1

erythromycin tab 500mg bs Tier 1

MEDICAL DEVICES Contraceptives CONDOMS Tier 2

FEMALE CONDOMS Tier 0

FEMCAP MIS 22MM Tier 0



OMNIFLEX DPR Tier 0

ORTHO COIL DPR KIT 50 Tier 0



ORTHO FLAT DPR KIT 55 Tier 0









ORTHO FLEX DPR 65MM Tier 0




PRENTIF MIS 22MM Tier 0




PRENTIF MIS FITTING Tier 0

TODAY SPONGE MIS Tier 0

TROJAN MIS NATULAMB Tier 2

WIDE-SEAL DPR KIT 60 Tier 0








Diabetic Supplies LANCETS DME


63


TRUERESULT KIT DME QL

Misc. Devices ALCOHOL SWABS Tier 2

Parenteral Therapy Supplies INSULIN PEN NEEDLES DME

INSULIN SYRINGES DME

Respiratory Therapy Supplies NEBULIZERS Tier 2

RESPIRATORY MASKS Tier 2

SPACERS Tier 2 QL

MIGRAINE PRODUCTS Migraine Combinations isometh/apap cap dichlor Tier 1 ST

Migraine Products dihydroergot inj 1mg/ml Tier 1

ERGOMAR SUB 2MG Tier 3

Serotonin Agonists naratriptan tab 1mg Tier 1 QL

naratriptan tab 2.5mg Tier 1 QL

rizatriptan tab 5mg Tier 1 ST; QL

rizatriptan tab 10mg Tier 1 ST; QL

sumatriptan tab 25mg Tier 1 QL



MINERALS ELECTROLYTES Calcium ca cit/vit d tab 315/200 Tier 1

ca cit/vit d tab 315/250 Tier 1

ca/mg/zn tab Tier 1

calc 600+d tab 600-800 Tier 1

calc cit+d3 tab 250-200 Tier 1

calc citr/d3 tab 200-250 Tier 1

calcitrate tab 950mg Tier 1

calcium 500 tab +d Tier 1

CALCIUM 600 CHW +D/MINER Tier 1

calcium 600 chw +d/mnrls Tier 1

calcium 600 chw w/vit d Tier 1

calcium + d3 tab 600mg Tier 1

calcium carb sus 1250/5ml Tier 1

calcium carb tab 600mg Tier 1

calcium carb tab 1250mg Tier 1

calcium chw 500mg Tier 1


64


calcium tab 600mg 1500mg Tier 1

calcium+d tab 600-400 Tier 1

CALCIUM/D3 TAB Tier 1

calcium/d3 tab 500-400 Tier 1

calcium/d cap 600mg Tier 1

calcium/d chw 500-400 Tier 1

calcium/d tab 250mg Tier 1

calcium/d tab 500-200 Tier 1

calcium/d tab 500/200 Tier 1





calcium/vitd tab 500-400 Tier 1

calcium/vt d tab 600-125 Tier 1

calvite p&d tab Tier 1

os-cal 500 chw Tier 1

oys shell+d tab 250-125 Tier 1

OYSCO 500+D CHW Tier 2

oyst shell/d tab 500mg Tier 1

oyster shell tab 500mg Tier 1

ra calcium+d tab 600mg Tier 1

Electrolyte Mixtures ped elctrlyt sol Tier 1

Fluoride fluoride chw 0.5mg f Tier 0

fluoride chw 0.25mg f Tier 0

fluoride chw 1mg f Tier 1

fluoritab dro 0.125mg Tier 0

flura-drops dro 0.25mg f Tier 0

sod fluoride dro 0.5mg/ml Tier 0

sod fluoride tab 0.5mg f Tier 0

Magnesium mag oxide tab 400mg 400mg Tier 1

mag-sr tab 535mg Tier 1

magnesium cap 500mg Tier 1

magnesium gl tab 500mg Tier 1

magnesium su inj 50% Tier 1

magnesium tab 200mg Tier 1

magnesium tab 250mg 250mg Tier 1

magnesium tab 500mg Tier 1

magnesium-ox tab 400mg Tier 1

Phosphate


65


phospha 250 tab neutral Tier 1

Potassium pot chloride cap 8meq er Tier 1

pot chloride cap 10meq er Tier 1

pot chloride liq 10% Tier 1

pot chloride liq 20% Tier 1

pot chloride tab 8meq er Tier 1

pot chloride tab 10meq er Tier 1

pot cl micro tab 10meq er Tier 1

pot cl micro tab 20meq er Tier 1

potassium tab 25meq ef Tier 1

Sodium sod chloride tab 1000mg Tier 1

Zinc zinc sulfate cap 220mg Tier 1

MOUTH/THROAT/DENTAL AGENTS Anesthetics Topical Oral lidocaine sol 2% visc Tier 1

Anti-infectives - Throat clotrimazole tro 10mg Tier 1

nystatin sus 100000 Tier 1

Antiseptics - Mouth/Throat paroex sol 0.12% Tier 1

periogard sol 0.12% Tier 1

Dental Products denta 5000 cre plus Tier 1

fluoridex gel 1.1% Tier 1

Steroids - Mouth/Throat triamcinolon pst 0.1% Tier 1

Throat Products - Misc. cevimeline cap 30mg Tier 1 PA

MULTIVITAMINS B-Complex w/ Folic Acid b complex tab vit c Tier 1

folbee plus tab Tier 1

rena-vite rx tab Tier 1

renal tab multivit Tier 1

reno cap Tier 1

virt-vite tab plus Tier 1

Multiple Vitamins w/ Iron multi-day tab /iron Tier 1


66


Multiple Vitamins w/ Minerals multi cap complete Tier 1

multi vitamn tab minerals Tier 1

multivitamin liq mineral Tier 1

Multivitamins mult vitamin tab daily Tier 1

multivitamin cap Tier 1

Ped MV w/ Fluoride mult-vit/fl chw 0.5mg Tier 1

multi-vit/fl chw 0.25mg Tier 1

multi-vit/fl chw 1mg Tier 1

multi-vit/fl dro 0.5mg/ml Tier 1

multi-vit/fl dro 0.25mg Tier 1

QUFLORA PED CHW 0.5MG Tier 1

QUFLORA PED CHW 0.25MG Tier 1

QUFLORA PED CHW 1MG Tier 1

tri-vit/fluo dro 0.5mg Tier 1

tri-vit/fluo dro 0.25mg Tier 1

Ped MV w/ Iron childrens chw /iron Tier 1

polyvitamin dro /iron Tier 1

Ped Multi Vitamins w/Fl FE multi-vit/fl dro /fe 0.25 Tier 2

tri-vit/fe dro /fl 0.25 Tier 1

Ped Multiple Vitamins w/ Minerals childrens chw gummies Tier 1

multivitamin dro pediatrc Tier 1

polyvitamin chw /iron Tier 1

Pediatric Multiple Vitamins kids vitamin chw extra c Tier 1

poly vitamin chw Tier 1

polyvitamin dro Tier 1

Pediatric Vitamins tri-vitamin dro Tier 1

Prenatal Vitamins CL PRENATAL TAB 28-0.8MG Tier 2

CO-NATAL FA TAB 29-1MG Tier 2

COMPLETENATE CHW Tier 2

CVS PRENATAL TAB Tier 2

CVS PRENATAL TAB 28-0.8MG Tier 2

EQL PRENATAL TAB FORMULA Tier 2

GNP PRENATAL TAB 28-0.8MG Tier 2


67


HM PRENATAL TAB Tier 2

inatal adv tab Tier 1

inatal gt tab Tier 1

inatal ultra tab Tier 1

KP PRENATAL TAB MULTIVIT Tier 2

M-VIT TAB 27-1MG Tier 2

MISSION PREN TAB /FA Tier 2

MISSION PREN TAB HP Tier 2

MULTI PRENAT TAB Tier 2

NATAL-V RX TAB 29-1MG Tier 2

PNV FOLIC AC TAB + IRON Tier 2

PRE-NATAL TAB FORMULA Tier 2

prenaplus tab Tier 1

prenatabs fa tab Tier 1

prenatabs rx tab Tier 1

prenatal 19 chw tab Tier 1

prenatal 19 tab Tier 1

prenatal ad tab Tier 1

PRENATAL ONE TAB DAILY Tier 2

PRENATAL TAB Tier 2

PRENATAL TAB 27-0.8MG Tier 2

PRENATAL TAB 27-1MG Tier 2

PRENATAL TAB 28-0.8MG Tier 2

PRENATAL TAB COMPLETE Tier 2

PRENATAL TAB FORMULA Tier 2

PRENATAL TAB FORTE Tier 2

PRENATAL TAB LOW IRON Tier 2

prenatal tab plus Tier 1

PRENATAL TAB PLUS Tier 2

prenatal tab plus fe Tier 1

PRENATAL TAB VITAMINS Tier 2

PRENATAL VIT TAB PLUS Tier 2

PRENATAL/FE TAB Tier 2

PX PRENATAL TAB MULTIVIT Tier 2

QC PRENATAL TAB 28-0.8MG Tier 2

RA PRENATAL TAB 28-0.8MG Tier 2

RA PRENATAL TAB FORMULA Tier 2

RIGHT STEP TAB PRENATAL Tier 2

SE-NATAL 19 CHW Tier 2

SE-NATAL ONE TAB Tier 2

SM PRENATAL TAB VITAMINS Tier 2

STUART PREN TAB Tier 2

TH PRENATAL TAB VITAMINS Tier 2


68


THERANATAL TAB 27-1 Tier 2

triadvance tab Tier 1

trinate tab Tier 1

ultra tabs tab Tier 1

VINATE ONE TAB Tier 2

VOL-PLUS TAB Tier 2

VOL-TAB RX TAB Tier 2

MUSCULOSKELETAL THERAPY AGENTS Central Muscle Relaxants baclofen tab 10mg Tier 1

baclofen tab 20mg Tier 1

carisoprodol tab 350mg Tier 1

chlorzoxazon tab 500mg Tier 1

cyclobenzapr tab 5mg Tier 1

cyclobenzapr tab 10mg Tier 1

methocarbam tab 500mg Tier 1

methocarbam tab 750mg Tier 1

orphenadrine tab 100mg er Tier 1

tizanidine tab 2mg Tier 1

tizanidine tab 4mg Tier 1

Direct Muscle Relaxants dantrolene cap 25mg Tier 1

dantrolene cap 50mg Tier 1

dantrolene cap 100mg Tier 1

Viscosupplements EUFLEXXA INJ 10MG/ML Tier 4 PA

NASAL AGENTS - SYSTEMIC AND TOPICAL Nasal Agents - Misc. saline nasal spr 0.65% Tier 1

Nasal Anti-infectives BACTROBAN OIN NASAL 2% Tier 2 PA

Nasal Antiallergy azelastine spr 0.1% Tier 1

cromolyn sod spr 5.2/act Tier 1

Nasal Anticholinergics ipratropium spr 0.03% Tier 1

ipratropium spr 0.06% Tier 1

Nasal Steroids flunisolide spr 0.025% Tier 1

flunisolide spr 29mcg Tier 1

fluticasone spr 50mcg Tier 1

Sympathomimetic Decongestants


69


child silfed liq 15mg/5ml Tier 1

chld decongs liq 15mg/5ml Tier 1

nasal decon liq 15mg/5ml Tier 1

NASAL DECONG LIQ 30MG/5ML Tier 1

nasal decong tab 10mg Tier 1

non-pseudo tab 10mg Tier 1

pseudoephedr syp 30mg/5ml Tier 1

pseudoephedr tab 30mg Tier 1

pseudoephedr tab 60mg Tier 1

pseudoephedr tab 120mg er Tier 1

sinus/conges tab 10mg Tier 1

SUDAFED PE SOL CHILDREN Tier 2

sudogest pe tab 10mg Tier 1

suphedrine tab 10mg Tier 1

suphedrine tab pe 10mg Tier 1

TYZINE PED DRO 0.05% Tier 3

TYZINE SOL 0.1% Tier 3

unifed liq 30mg/5ml Tier 1

NEUROMUSCULAR AGENTS ALS Agents riluzole tab 50mg Tier 1 PA

NUTRIENTS Misc. Nutritional Substances fish oil cap 300mg Tier 1

fish oil cap 500mg Tier 1

fish oil cap 1000mg Tier 1

fish oil cap 1200mg CPDR Tier 1

omega 3 cap 1000mg Tier 1

omega-3 cap 1200mg Tier 1

OPHTHALMIC AGENTS Artificial Tears and Lubricants artifi tears dro 1-0.3% Tier 1

artifi tears oin op Tier 1

artifi tears sol op Tier 1

artificial dro tears Tier 1

artificial sol tears Tier 1

artificial sol tears op Tier 1

LACRISERT MIS 5MG OP Tier 3 PA

lubricant dro 1.4% Tier 1

lubricating sol 0.5% Tier 1

lubricnt eye dro 0.4-0.3% Tier 1

lubricnt eye dro 0.5% op Tier 1

pure & gentl dro 0.3% Tier 1


70


Beta-blockers - Ophthalmic betaxolol sol 0.5% op Tier 1

carteolol sol 1% op Tier 1

dorzol/timol sol 2-0.5%op Tier 1

levobunolol sol 0.5% op Tier 1

levobunolol sol 0.25% op Tier 1

metipranolol sol 0.3% oph Tier 1

timolol gel sol 0.5% op Tier 1

timolol gel sol 0.25% op Tier 1

timolol mal sol 0.5% op Tier 1

timolol mal sol 0.25% op Tier 1

Cycloplegic Mydriatics atropine sul sol 1% op Tier 1

tropicamide sol 0.5% op Tier 1

tropicamide sol 1% op Tier 1

Miotics pilocarpine sol 1% op Tier 1

pilocarpine sol 2% op Tier 1

pilocarpine sol 4% op Tier 1

Ophthalmic Adrenergic Agents brimonidine sol 0.2% op Tier 1

brimonidine sol 0.15% Tier 1

Ophthalmic Anti-infectives bacit/polymy oin op Tier 1

bacitracin oin op Tier 1

BESIVANCE SUS 0.6% Tier 3

ciprofloxacn sol 0.3% op Tier 1

erythromycin oin 5mg/gm Tier 1

gentamicin oin 0.3% op Tier 1

gentamicin sol 0.3% op Tier 1

levofloxacin sol 0.5% Tier 1

neo/bac/poly oin op Tier 1

neo/poly/gra sol op Tier 1

ofloxacin dro 0.3% op Tier 1

sulfacet sod sol 10% op Tier 1

tobramycin sol 0.3% op Tier 1

trifluridine sol 1% op Tier 1

trimethoprim sol polymyxn Tier 1

ZIRGAN GEL 0.15% Tier 3 PA

Ophthalmic Decongestants naphazoline sol 0.1% op Tier 1

Ophthalmic Local Anesthetics


71


proparacaine sol 0.5% op Tier 1

Ophthalmic Steroids dexameth pho sol 0.1% op Tier 1

fluoromethol sus 0.1% op Tier 1

neo/poly/bac oin /hc 1%op Tier 1

neo/poly/dex oin 0.1% op Tier 1

neo/poly/dex sus 0.1% op Tier 1

prednisolone sus 1% op Tier 1

sulf/pred na sol op Tier 1

tobra/dexame sus 0.3-0.1% Tier 1

TOBRADEX OIN 0.3-0.1% Tier 2

Ophthalmics - Misc. azelastine dro 0.05% Tier 1 PA

cromolyn sod sol 4% op Tier 1

diclofenac sol 0.1% op Tier 1

dorzolamide sol 2% op Tier 1

epinastine dro 0.05% Tier 1

flurbiprofen sol 0.03% op Tier 1

ketorolac sol 0.4% Tier 1

ketorolac sol 0.5% Tier 1

ketotif fum dro 0.025%op Tier 1

sod chloride oin 5% op Tier 1

sod chloride sol 5% op Tier 1

Prostaglandins - Ophthalmic latanoprost sol 0.005% Tier 1

TRAVATAN Z DRO 0.004% Tier 2 ST

travoprost dro 0.004% Tier 1 ST

OTIC AGENTS Otic Agents - Miscellaneous acetic acid sol 2% otic Tier 1

ear drying dro 95-5% Tier 1

ear wax remv sol 6.5% ot Tier 1

Otic Anti-infectives ofloxacin dro 0.3%otic Tier 1

Otic Combinations antipy/benzo sol otic Tier 1

neo/poly/hc sol 1% otic Tier 1

neo/poly/hc sus 1% otic Tier 1

pramoxine-hc dro aq otic Tier 1

Otic Steroids hc/acet acid sol otic Tier 1

OXYTOCICS


72


Oxytocics methylergon tab 0.2mg Tier 1

PASSIVE IMMUNIZING AGENTS Immune Serums CARIMUNE INJ 12GM Tier 4 PA

CARIMUNE NF INJ 12GM Tier 4 PA

FLEBOGAMMA INJ 5% Tier 4 PA

FLEBOGAMMA INJ 10% Tier 4 PA

FLEBOGAMMA INJ DIF 5% .5gm/10ml, 5% Tier 4 PA

GAMASTAN S/D INJ Tier 4 PA

GAMMAGARD INJ 1GM/10ML Tier 4 PA

GAMMAGARD SD INJ 10GM HU Tier 4 PA

GAMMAKED INJ 1GM/10ML Tier 4 PA

GAMMAPLEX INJ 5GM Tier 4 PA

GAMUNEX INJ 10% Tier 4 PA

GAMUNEX-C INJ 1GM/10ML Tier 4 PA

HIZENTRA INJ 2GM/10ML Tier 4 PA

IMMUNE GLOBU INJ HUMAN Tier 4 PA

OCTAGAM INJ 5GM Tier 4 PA

PANGLOBULIN INJ 12GM Tier 4 PA

PANGLOBULIN SOL 12GM Tier 4 PA

POLYGAM S/D SOL 10GM Tier 4 PA

PRIVIGEN INJ 20GRAMS Tier 4 PA

RHOGAM PLUS INJ 300MCG Tier 4 PA

SANDOGLOBULI INJ IV 12GM Tier 4 PA

VENOGLOBUL-S INJ 10% Tier 4 PA

Monoclonal Antibodies SYNAGIS INJ 50MG Tier 4 PA

SYNAGIS INJ 100MG/ML Tier 4 PA

PENICILLINS Aminopenicillins amoxicillin cap 250mg Tier 1

amoxicillin cap 500mg Tier 1

amoxicillin chw 125mg Tier 1

amoxicillin chw 250mg Tier 1

amoxicillin sus 125/5ml Tier 1




amoxicillin tab 500mg Tier 1

amoxicillin tab 875mg Tier 1

ampicillin cap 250mg Tier 1

ampicillin cap 500mg Tier 1


73


ampicillin sus 125/5ml Tier 1

ampicillin sus 250/5ml Tier 1

Natural Penicillins pen g sod inj 5000000 Tier 1 PA

penicilln gk inj 20mu Tier 1 PA

penicilln vk sol 125/5ml Tier 1

penicilln vk sol 250/5ml Tier 1

penicilln vk tab 250mg Tier 1

penicilln vk tab 500mg Tier 1

pfizerpen g inj 20mu Tier 1 PA

pfizerpen-g inj 20mu Tier 1 PA

Penicillin Combinations amox/k clav chw 200mg Tier 1

amox/k clav chw 400mg Tier 1

amox/k clav sus 200/5ml Tier 1




amox/k clav tab 250mg Tier 1



amp-sulbacta inj 1-0.5gm Tier 1 PA

amp-sulbacta inj 1.5gm Tier 1 PA

amp-sulbacta inj 3gm Tier 1 PA

amp-sulbacta inj 10-5gm Tier 1 PA

amp-sulbacta inj 15gm Tier 1 PA

ampi/sulbact inj 1-0.5gm Tier 1 PA

AUGMENTIN SUS 125/5ML Tier 2

piper/tazoba inj 2-0.25gm Tier 1 PA

piper/tazoba inj 3-0.375g Tier 1 PA

piper/tazoba inj 4-0.5gm Tier 1 PA

TIMENTIN INJ 3.1GM SOLR Tier 3 PA

Penicillinase-Resistant Penicillins bactocill inj 2gm Tier 1 PA

bactocill inj 10gm Tier 1 PA

dicloxacill cap 250mg Tier 1

dicloxacill cap 500mg Tier 1

nafcillin inj 1gm Tier 1 PA

nafcillin inj 1gm pbk Tier 1 PA


nafcillin inj 2gm pbk Tier 1 PA


nallpen inj 1gm Tier 1 PA


74




oxacillin inj 2gm Tier 1 PA

oxacillin inj 10gm Tier 1 PA

PROGESTINS Progestins medroxypr ac tab 2.5mg Tier 1

medroxypr ac tab 5mg Tier 1

medroxypr ac tab 10mg Tier 1

norethin ace tab 5mg Tier 1

progesterone cap 100mg Tier 1

progesterone cap 200mg Tier 1

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC. Agents for Chemical Dependency CAMPRAL TAB 333MG Tier 3 PA

disulfiram tab 250mg Tier 1

disulfiram tab 500mg Tier 1

Anti-Cataplectic Agents XYREM SOL 500MG/ML Tier 2 PA

Antidementia Agents donepezil tab 5mg Tier 1

donepezil tab 5mg odt Tier 1

donepezil tab 10mg Tier 1

donepezil tab 10mg odt Tier 1

EXELON DIS 4.6MG/24 Tier 2 PA

EXELON DIS 9.5MG/24 Tier 2 PA

galantamine cap 8mg er Tier 1

galantamine cap 24mg er Tier 1

galantamine tab 4mg Tier 1



NAMENDA SOL 10MG/5ML Tier 2

NAMENDA TAB 5-10MG Tier 2

NAMENDA TAB 5MG Tier 2

NAMENDA TAB 10MG Tier 2

Multiple Sclerosis Agents AMPYRA TAB 10MG Tier 4 PA

AVONEX KIT 30MCG Tier 4 PA

AVONEX PEN KIT 30MCG Tier 4 PA

AVONEX PREFL KIT 30MCG Tier 4 PA

COPAXONE KIT 20MG/ML Tier 4 PA

EXTAVIA INJ 0.3MG Tier 4 PA


75


GILENYA CAP 0.5MG Tier 4 PA

TYSABRI INJ 300/15ML Tier 4 PA, ST

Psychotherapeutic and Neurological Agents - Misc. ergoloid mes tab 1mg oral Tier 1

ORAP TAB 1MG Tier 2

ORAP TAB 2MG Tier 2

Smoking Deterrents bupropion tab 150mg Tier 0 QL

CHANTIX PAK 0.5& 1MG Tier 0 QL

CHANTIX PAK 1MG Tier 0 QL

CHANTIX TAB 0.5MG Tier 0 QL

CHANTIX TAB 1MG Tier 0 QL

nicotine dis 7mg/24hr Tier 0 QL

nicotine dis 14mg/24h Tier 0 QL

nicotine dis 21mg/24h Tier 0 QL

nicotine lozenge 2 mg Tier 0 QL

nicotine lozenge 4 mg Tier 0 QL

nicotine pol gum 2mg Tier 0 QL

nicotine pol gum 4mg Tier 0 QL

NICOTROL INH Tier 0 QL

NICOTROL NS SPR 10MG/ML Tier 0 QL

RESPIRATORY AGENTS - MISC. Cystic Fibrosis Agents PULMOZYME SOL 1MG/ML Tier 4 PA

SULFONAMIDES Sulfonamides SULFADIAZINE TAB 500MG Tier 1

TETRACYCLINES Tetracyclines demeclocycl tab 150mg Tier 1

demeclocycl tab 300mg Tier 1

doxycyc mono cap 50mg Tier 1

doxycyc mono cap 100mg Tier 1

doxycyc mono tab 100mg Tier 1

minocycline cap 50mg Tier 1

minocycline cap 100mg Tier 1

tetracycline cap 250mg Tier 1

tetracycline cap 500mg Tier 1

THYROID AGENTS Antithyroid Agents methimazole tab 5mg Tier 1

methimazole tab 10mg Tier 1


76


propylthiour tab 50mg Tier 1

Thyroid Hormones ARMOUR THYRO TAB 15MG Tier 2

ARMOUR THYRO TAB 120MG Tier 2




levothroid tab 25mcg Tier 1












levothyroxin tab 25mcg Tier 1












levoxyl tab 25mcg Tier 1











liothyronine inj 10mcg/ml Tier 1


77


liothyronine tab 5mcg Tier 1



NATURE-THROI TAB 16.25MG Tier 2



NATURE-THROI TAB 65MG Tier 2




np thyroid tab 30mg Tier 1



SYNTHROID TAB 25MCG Tier 2












unith direct tab 25mcg Tier 1











unithroid tab 25mcg Tier 1








78







WESTHROID TAB 16.25MG Tier 2



WESTHROID TAB 65MG Tier 2




WESTHROID-P TAB 16.25MG Tier 2



WESTHROID-P TAB 65MG Tier 2


WESTHROID-P TAB 130MG Tier 2

WP THYROID TAB 16.25MG Tier 2



WP THYROID TAB 65MG Tier 2


WP THYROID TAB 130MG Tier 2

ULCER DRUGS Antispasmodics atropine sul inj 0.1mg/ml Tier 3

atropine sul inj 0.05mg/1 Tier 3

bella alk/pb tab 16.2mg Tier 1

CUVPOSA SOL 1MG/5ML Tier 2 PA

dicyclomine cap 10mg Tier 1

dicyclomine sol 10mg/5ml Tier 1

dicyclomine tab 20mg Tier 1

glycopyrrol tab 1mg Tier 1

glycopyrrol tab 2mg Tier 1

hyoscyamine dro 0.125/ml Tier 1

hyoscyamine sub 0.125mg Tier 1

hyoscyamine tab 0.125mg Tier 1

hyoscyamine tab 0.375 er Tier 1

hyosyne elx 0.125/5 Tier 1

quadrapax elx Tier 1

se-donna elx pb hyos Tier 1

H-2 Antagonists


79


cimetidine sol 300/5ml Tier 1

cimetidine tab 200mg Tier 1




famotidine tab 10mg Tier 1



nizatidine cap 150mg Tier 1 PA

nizatidine sol 15mg/ml Tier 1 PA

ranitidine syp 15mg/ml Tier 1

ranitidine tab 75mg Tier 1



Misc. Anti-Ulcer CARAFATE SUS 1GM/10ML Tier 2 PA

sucralfate tab 1gm Tier 1

Proton Pump Inhibitors FIRST-OMEPRA SUS 2MG/ML Tier 2 PA

lansoprazole cap 15mg dr Tier 1 PA

lansoprazole cap 30mg dr Tier 1 PA

NEXIUM 24HR CAP 20MG Tier 1

OMEPRAZOLE + SUS SYRSPEND Tier 2 PA

omeprazole cap 10mg Tier 1

omeprazole cap 20.6mgdr Tier 1

omeprazole cap 20mg Tier 1

OMEPRAZOLE TAB 20MG Tier 1

pantoprazole tab 20mg Tier 1 ST

pantoprazole tab 40mg Tier 1 ST

PRILOSEC OTC TAB 20MG Tier 1

Ulcer Drugs - Prostaglandins misoprostol tab 100mcg Tier 1

misoprostol tab 200mcg Tier 1

URINARY ANTI-INFECTIVES Urinary Anti-infectives methenam hip tab 1gm Tier 1

MONUROL PAK GRANULES Tier 3

nitrofur mac cap 50mg Tier 1

nitrofur mac cap 100mg Tier 1

nitrofurantn cap 100mg Tier 1

URINARY ANTISPASMODICS Beta-3 Adrenergic Agonists


80


MYRBETRIQ TAB 25MG Tier 3

MYRBETRIQ TAB 50MG Tier 3

Urinary Antispasmodics flavoxate tab 100mg Tier 1

VACCINES Viral Vaccines AFLURIA INJ Tier 0

AFLURIA INJ PF Tier 0

EZ USE FLU KIT Tier 0

FLUARIX INJ PF Tier 0

FLUARIX QUAD INJ Tier 0

FLULAVAL INJ Tier 0

FLUVIRIN INJ Tier 0

FLUVIRIN INJ PF Tier 0

FLUZONE INJ INTRADRM Tier 0

FLUZONE INJ PF Tier 0

FLUZONE PED/ INJ PF Tier 0

FLUZONE QUAD INJ Tier 0

FLUZONE SPLT INJ Tier 0

VAGINAL PRODUCTS Spermicides CONCEPTROL GEL 4% Tier 0

Vaginal Anti-infectives clindamycin cre 2% vag Tier 1

clotrimazole cre 1% 1% Tier 1

clotrimazole cre 2% Tier 1

metronidazol gel 0.75%vag Tier 1

miconazole 3 cre 4% Tier 1

miconazole 3 kit combo pk Tier 1

miconazole cre 2% 2% Tier 1

miconazole sup 100mg Tier 1

terconazole cre 0.4% Tier 1

terconazole cre 0.8% Tier 1

terconazole sup 80mg Tier 1

tioconazole oin 6.5% vag Tier 1

Vaginal Estrogens ESTRACE VAG CRE 0.1MG/GM Tier 2

PREMARIN VAG CRE 0.625MG Tier 2

VAGIFEM TAB 10MCG Tier 2

VASOPRESSORS Anaphylaxis Therapy Agents epinephrine inj 0.15mg Tier 1


81


EPIPEN 2-PAK INJ 0.3MG Tier 2

EPIPEN-JR INJ 2-PAK Tier 2

Vasopressors midodrine tab 2.5mg Tier 1

midodrine tab 5mg Tier 1

midodrine tab 10mg Tier 1

VITAMINS Oil Soluble Vitamins bio-d-mulsio liq 400unit Tier 0

ergocalcifer cap 50000unt Tier 1

MEPHYTON TAB 5MG Tier 2

vitamin d3 cap 2000unit Tier 1

vitamin d3 cap 5000unit Tier 1

vitamin d3 cap 10000unt Tier 1

vitamin d3 cap 50000unt Tier 1

vitamin d3 chw 400unit Tier 0

vitamin d3 chw 1000unit Tier 1

vitamin d3 dro 5000unit Tier 1

vitamin d3 tab 400unit Tier 0

vitamin d3 tab 1000unit Tier 1

vitamin d cap 1000unit Tier 1

vitamin d dro 400unit Tier 0

vitamin d-3 tab 2000unit Tier 1

vitamin d-3 tab 5000unit Tier 1

Water Soluble Vitamins niacin cap 250mg er Tier 1

niacin cap 500mg sr Tier 1

niacin tab 50mg Tier 1



niacin tab 250mg sr Tier 1


niacin tab 500mg er Tier 1

niacin tab 750mg tr Tier 1

niacinamide tab 500mg Tier 1

pyridoxine tab 25mg Tier 1



vitamin b-6 tab 200mg cr Tier 1

82

Index A abacav/lamiv tab /zidovud .................33 abacavir tab 300mg ..........................33

ABILIFY DISC TAB 10MG ....................32

ABILIFY DISC TAB 15MG ....................32

ABILIFY MAIN INJ 300MG ..................32 ABILIFY MAIN INJ 400MG ..................32

ABILIFY SOL 1MG/ML ........................32

ABILIFY TAB 10MG ............................32

ABILIFY TAB 15MG ............................32

ABILIFY TAB 20MG ............................32 ABILIFY TAB 2MG .............................32

ABILIFY TAB 30MG ............................32

ABILIFY TAB 5MG .............................32

ABREVA CRE 10% .............................47 acarbose tab 100mg..........................18

acarbose tab 25mg ...........................18

acarbose tab 50mg ...........................18

acebutolol cap 200mg .......................36 acebutolol cap 400mg .......................36

acetam melts tab 80mg ...................... 4

acetamin cap 500mg .......................... 4

acetamin jr tab 160mg rt .................... 4

acetamin liq 500/15ml ........................ 4 acetamin sol 160/5ml ......................... 4

acetamin sup 120mg .......................... 4

acetamin sup 325mg .......................... 4

acetamin sup 650mg .......................... 4 acetamin tab 325mg .......................... 4

acetamin tab 650mg .......................... 4

acetaminophn sus 160/5ml ................. 4

acetaminophn tab 500mg ................... 5 acetazolamid cap 500mg er................50

acetazolamid tab 125mg ....................50

acetazolamid tab 250mg ....................50

acetic acid sol 0.25%irr .....................55 acetic acid sol 2% otic .......................71

acetylcyst sol 20% ............................45

acid gone chw 80-20mg ...................... 7

acid gone sus .................................... 7

ACNE MEDICAT LOT 10% ...................45 ACNE MEDICAT LOT 5% ....................45

ACTEMRA INJ 162/0.9 ........................ 3

ACTEMRA INJ 200/10ML ..................... 3

ACTEMRA INJ 400/20ML ..................... 3 ACTEMRA INJ 80MG/4ML .................... 3

ACTIMMUNE INJ 2MU/0.5...................28

acyclovir cap 200mg ......................... 35

acyclovir oin 5% .............................. 47 acyclovir sus 200/5ml ....................... 35

acyclovir tab 400mg ......................... 35

acyclovir tab 800mg ......................... 35

adapalene cre 0.1% ......................... 45 adapalene gel 0.1% .......................... 45

adapalene gel 0.3% .......................... 45

ADCIRCA TAB 20MG ......................... 39

adefov dipiv tab 10mg ...................... 34

ADVAIR DISKU AER 100/50 ............... 11 ADVATE INJ 1000UNIT ...................... 55

ADVATE INJ 1500UNIT ...................... 55

ADVATE INJ 2000UNIT ...................... 55

ADVATE INJ 250UNIT ....................... 55 ADVATE INJ 3000UNIT ...................... 55

ADVATE INJ 4000UNIT ...................... 55

ADVATE INJ 500UNIT ....................... 55

AEROSPAN AER 80MCG ..................... 11 AFINITOR DIS TAB 2MG .................... 27

AFINITOR DIS TAB 3MG .................... 27

AFINITOR DIS TAB 5MG .................... 27

AFLURIA INJ .................................... 80

AFLURIA INJ PF ................................ 80 AGGRENOX CAP 25-200MG ............... 56

alamag-plus chw ................................ 7

ALBENZA TAB 200MG ......................... 8

albuterol neb 0.083% ....................... 12 albuterol neb 0.5% ........................... 11

albuterol neb 0.63mg/3 .................... 11

albuterol neb 1.25mg/3 .................... 12

albuterol syp 2mg/5ml ...................... 12 albuterol tab 4mg ............................. 12

alclometason cre 0.05% .................... 48

alclometason oin 0.05% .................... 48

ALCOHOL SWABS ............................. 63 ALDACTAZIDE TAB 50/50 .................. 50

alendronate tab 10mg....................... 51



alendronate tab 5mg ........................ 51 alendronate tab 70mg....................... 51

ALER-DRYL TAB 50MG ...................... 22

alfuzosin tab 10mg ........................... 55

ALKERAN INJ 50MG .......................... 26 ALKERAN TAB 2MG ........................... 26

ALLEGRA ALRG TAB 30MG ................. 22

83

aller-chlor syp 2mg/5ml .....................21

allergy cre 2-0.1% ............................47

allergy-d tab 25-10mg .......................44 allopurinol tab 100mg........................55

allopurinol tab 300mg........................55

allrgy melts tab 12.5mg .....................22

allrgy relf tab 12.5mg ........................22 almacone chw ................................... 7

alprazolam tab 0.25mg ......................10

alprazolam tab 0.5mg .......................10

alprazolam tab 1mg ..........................10 alprazolam tab 2mg ..........................10

ALTABAX OIN 1% .............................46

altavera tab .....................................40

alyacen tab 1/35 ...............................40 alyacen tab 7/7/7 .............................40

amantadine cap 100mg .....................29

amantadine syp 50mg/5ml.................29

amethyst tab 90-20mcg ....................40

amifostine inj 500mg.........................28 amikacin inj 1gm/4ml ......................... 2

amilor/hctz tab 5-50 .........................50

amiloride tab 5mg .............................51

aminophyllin inj 25mg/ml ..................12 aminophyllin tab 100mg ....................12

aminophyllin tab 200mg ....................12

amiodarone tab 200mg......................11

AMITIZA CAP 24MCG .........................54 AMITIZA CAP 8MCG ..........................54

amitriptylin tab 100mg ......................17

amitriptylin tab 10mg ........................17

amitriptylin tab 150mg ......................17

amitriptylin tab 25mg ........................17 amitriptylin tab 50mg ........................17

amitriptylin tab 75mg ........................17

amlodipine tab 10mg .........................37

amlodipine tab 2.5mg ........................37 amlodipine tab 5mg ..........................37

ammonium lac cre 12% .....................49

ammonium lac lot 12% ......................49

amnesteem cap 10mg .......................45 amnesteem cap 20mg .......................45

amnesteem cap 40mg .......................46

amox/k clav chw 200mg ....................73

amox/k clav chw 400mg ....................73 amox/k clav sus 200/5ml ...................73

amox/k clav sus 250/5ml ...................73

amox/k clav sus 400/5ml ...................73

amox/k clav sus 600/5ml .................. 73

amox/k clav tab 250mg .................... 73

amox/k clav tab 500mg .................... 73 amox/k clav tab 875mg .................... 73

amoxapine tab 100mg ...................... 17

amoxapine tab 150mg ...................... 17

amoxapine tab 25mg ........................ 17 amoxapine tab 50mg ........................ 17

amoxicillin cap 250mg ...................... 72

amoxicillin cap 500mg ...................... 72

amoxicillin chw 125mg ...................... 72 amoxicillin chw 250mg ...................... 72

amoxicillin sus 125/5ml .................... 72

amoxicillin sus 200/5ml .................... 72

amoxicillin sus 250/5ml .................... 72 amoxicillin sus 400/5ml .................... 72

amoxicillin tab 500mg ....................... 72

amoxicillin tab 875mg ....................... 72

amphetamine cap 10mg er .................. 1

amphetamine cap 15mg er .................. 1 amphetamine cap 20mg er .................. 1



amphetamine cap 5mg er .................... 1 amphetamine tab 10mg ...................... 1

amphetamine tab 12.5mg ................... 1

amphetamine tab 15mg ...................... 1

amphetamine tab 20mg ...................... 1 amphetamine tab 30mg ...................... 1

amphetamine tab 5mg ........................ 1

amphetamine tab 7.5mg ..................... 1

ampi/sulbact inj 1-0.5gm .................. 73

ampicillin cap 250mg ........................ 72 ampicillin cap 500mg ........................ 73

ampicillin sus 125/5ml ...................... 73

ampicillin sus 250/5ml ...................... 73

amp-sulbacta inj 1.5gm .................... 73 amp-sulbacta inj 1-0.5gm ................. 73

amp-sulbacta inj 10-5gm .................. 73

amp-sulbacta inj 15gm ..................... 73

amp-sulbacta inj 3gm ....................... 73 AMPYRA TAB 10MG ........................... 74

anastrozole tab 1mg ......................... 27

ANDROXY TAB 10MG .......................... 7

antacid chw dbl st .............................. 7 antacid extr chw 675-135 .................... 7

antacid sus ultra st ............................. 7

anti-nausea liq ................................. 21

84

antipy/benzo sol otic .........................71

APAP 500 LIQ 500/5ML ....................... 5

apap chw 80mg ................................. 5 apap dro 80/0.8ml ............................. 5

apap infants dro 80/0.8ml ................... 5

apap/codeine sol 120-12/5 ................. 6

apap/codeine tab 300-15mg ............... 6 apap/codeine tab 300-30mg ............... 6

apap/codeine tab 300-60mg ............... 6

APIDRA INJ SOLOSTAR ......................19

APIDRA INJ U-100 ............................19 APOKYN INJ 10MG/ML .......................29

apra elx 160/5ml ............................... 5

apri tab ...........................................40

APRISO CAP 0.375GM .......................54 APTIVUS CAP 250MG .........................33

APTIVUS SOL ...................................33

aranelle tab ......................................40

ARANESP INJ 100MCG .......................57

ARANESP INJ 150MCG .......................57 ARANESP INJ 200MCG .......................57

ARANESP INJ 25MCG .........................57

ARANESP INJ 300MCG .......................57

ARANESP INJ 40MCG .........................57 ARANESP INJ 500MCG .......................57

ARANESP INJ 60MCG .........................57

ARMOUR THYRO TAB 120MG ..............76

ARMOUR THYRO TAB 15MG ................76 ARMOUR THYRO TAB 180MG ..............76



artifi tears dro 1-0.3% .......................69

artifi tears oin op ..............................69 artifi tears sol op ..............................69

artificial dro tears..............................69

artificial sol tears ..............................69

artificial sol tears op ..........................69 asa free chw 160mg jr ........................ 5

ASACOL HD TAB 800MG ....................54

ASACOL TAB 400MG DR.....................54

ASMANEX 120 AER 220MCG ...............11 ASMANEX 14 AER 220MCG .................11

ASMANEX 30 AER 110MCG .................11

ASMANEX 30 AER 220MCG .................11

ASMANEX 60 AER 220MCG .................11 ASMANEX 7 AER 110MCG ..................11

aspirin 81 tab 81mg ec ....................... 5

aspirin adlt tab 81mg ......................... 5

aspirin chw 81mg ............................... 5

aspirin tab 325mg .............................. 5

aspirin tab 325mg ec .......................... 5 ASPIRIN TAB 81MG ............................ 5

atenol/chlor tab 100-25mg ................ 25

atenol/chlor tab 50-25mg .................. 25

atenolol tab 100mg .......................... 37 atenolol tab 25mg ............................ 37

atenolol tab 50mg ............................ 37

atorvastatin tab 10mg ...................... 23

atorvastatin tab 20mg ...................... 23 atorvastatin tab 40mg ...................... 23

atorvastatin tab 80mg ...................... 23

atovaq/progu tab 250-100 ................ 25

atovaq/progu tab 62.5-25 ................. 25 atovaquone sus 750/5ml ..................... 8

ATRIPLA TAB ................................... 33

atropine sul inj 0.05mg/1 .................. 78

atropine sul inj 0.1mg/ml .................. 78

atropine sul sol 1% op ...................... 70 ATROVENT HFA AER 17MCG .............. 11

aubra tab 0.1-0.02 ........................... 40

aug betamet cre 0.05% .................... 48

AUGMENTIN SUS 125/5ML ................ 73 aviane tab ....................................... 40

AVONEX KIT 30MCG ......................... 74

AVONEX PEN KIT 30MCG ................... 74

AVONEX PREFL KIT 30MCG ................ 74 azathioprine tab 50mg ...................... 35

azelastine dro 0.05% ........................ 71

azelastine spr 0.1% .......................... 68

AZILECT TAB 0.5MG ......................... 29

AZILECT TAB 1MG ............................ 29 azithromycin pow 1gm pak ................ 61

azithromycin sus 100/5ml ................. 61

azithromycin sus 200/5ml ................. 61

azithromycin tab 250mg ................... 61 azithromycin tab 500mg ................... 61

azithromycin tab 600mg ................... 61

azurette tab 28 day .......................... 40

B b complex tab vit c ........................... 65

bacit/polymy oin op .......................... 70

bacitracin oin 500/gm ....................... 46

bacitracin oin op .............................. 70 baclofen tab 10mg ........................... 68

baclofen tab 20mg ........................... 68

bactocill inj 10gm ............................. 73

85

bactocill inj 2gm ...............................73

BACTROBAN OIN NASAL 2% ..............68

balsalazide cap 750mg ......................54 balziva tab .......................................40

BANZEL SUS 40MG/ML ......................14

BANZEL TAB 200MG ..........................14

BANZEL TAB 400MG ..........................14 BARACLUDE SOL .05MG/ML ...............34

BARACLUDE TAB 0.5MG .....................34

BARACLUDE TAB 1MG .......................34

bella alk/pb tab 16.2mg .....................78 benazep/hctz tab 10-12.5 ..................25

benazep/hctz tab 20-12.5 ..................25

benazep/hctz tab 20-25mg ................25

benazepril tab 10mg .........................23 benazepril tab 20mg .........................23

benazepril tab 40mg .........................23

benazepril tab 5mg ...........................23

BENEFIX INJ 1000UNIT......................55

BENEFIX INJ 2000UNIT......................55 BENEFIX INJ 250UNIT .......................55

BENEFIX INJ 3000UNIT......................55

BENEFIX INJ 500UNIT .......................55

benzonatate cap 100mg ....................44 benzonatate cap 200mg ....................44

benzoyl per gel 10% .........................46

benzoyl per gel 5% ...........................46

benztropine tab 0.5mg ......................29 benztropine tab 1mg .........................29

benztropine tab 2mg .........................29

BESIVANCE SUS 0.6% .......................70

best fiber pow ..................................59

betameth val cre 0.1% ......................48 betasept liq 4% ................................33

betaxolol sol 0.5% op ........................70

bethanechol tab 10mg .......................54

bethanechol tab 25mg .......................54 bethanechol tab 50mg .......................54

bethanechol tab 5mg .........................54

bicalutamide tab 50mg ......................27

BILTRICIDE TAB 600MG...................... 8 bio-d-mulsio liq 400unit .....................81

bisacodyl sup 10mg ..........................61

bisacodyl tab 5mg ec .........................61

bismatrol sus 262/15ml .....................20 bismuth chw 262mg ..........................20

bismuth ms sus 525/15ml ..................20

bisoprl/hctz tab 10/6.25 ....................25

bisoprl/hctz tab 2.5/6.25 ................... 25

bisoprl/hctz tab 5-6.25mg ................. 25

bisoprol fum tab 10mg ...................... 37 bisoprol fum tab 5mg ....................... 37

bpo-10 wash liq 10% ........................ 46

bpo-5 wash liq 5% ........................... 46

briellyn tab ...................................... 40 brimonidine sol 0.15% ...................... 70

brimonidine sol 0.2% op ................... 70

brom/pse/dm syp ............................. 44

bromfed dm syp ............................... 44 bromocriptin cap 5mg ....................... 29

bromocriptin tab 2.5mg .................... 29

brotapp dm liq 15-1-5/5 ................... 44

brotapp liq ...................................... 44 budesonide cap 3mg/24hr ................. 43

budesonide sus 0.25mg/2 ................. 11

budesonide sus 0.5mg/2 ................... 11

bumetanide tab 0.5mg ...................... 50

bumetanide tab 1mg ........................ 50 bumetanide tab 2mg ........................ 50

BUPHENYL TAB 500MG ..................... 52

buprenorphin sub 2mg ........................ 6

buprenorphin sub 8mg ........................ 6 bupropion tab 100mg ....................... 16

bupropion tab 100mg er.................... 16

bupropion tab 150mg ....................... 75

bupropion tab 150mg er.................... 16 bupropion tab 200mg er.................... 16

bupropion tab 75mg ......................... 16

bupropn hcl tab 150mg xl ................. 16

bupropn hcl tab 300mg xl ................. 16

buspirone tab 10mg ......................... 10 buspirone tab 15mg ......................... 10

buspirone tab 5mg ............................. 9

buspirone tab 7.5mg ........................ 10

but/apap/caf cap ................................ 4 but/apap/caf cap codeine .................... 6

but/apap/caf tab ................................ 4

but/asa/caff cap ................................. 4

but/asa/caff tab ................................. 4 butal/apap tab 50-325mg ................... 4

BUTRANS DIS 10MCG/HR .................... 6

BYETTA INJ 10MCG .......................... 19

BYETTA INJ 5MCG ............................ 19 C ca cit/vit d tab 315/200 .................... 63

ca cit/vit d tab 315/250 .................... 63

86

ca/mg/zn tab ...................................63

cabergoline tab 0.5mg .......................52

calc 600+d tab 600-800 ....................63 calc acetate cap 667mg .....................54

calc antacid chw 1000mg .................... 8

calc antacid chw 750mg ...................... 8

calc cit+d3 tab 250-200.....................63 calc citr/d3 tab 200-250 ....................63

calcipotrien oin 0.005% .....................47

calcipotrien sol 0.005% .....................47

calcitonin spr 200/act ........................51 calcitrate tab 950mg .........................63

calcitriol cap 0.25mcg ........................52

calcitriol cap 0.5mcg .........................52

calcium + d3 tab 600mg ....................63 calcium 500 tab +d ...........................63

CALCIUM 600 CHW +D/MINER ...........63

calcium 600 chw +d/mnrls .................63

calcium 600 chw w/vit d ....................63

calcium carb chw 500mg .................... 8 calcium carb sus 1250/5ml ................63

calcium carb tab 1250mg ...................63

calcium carb tab 600mg ....................63

CALCIUM CARB TAB 648MG ................ 8 calcium chw 500mg ..........................63

calcium rich sus antacid ................. 7, 58

calcium tab 600mg ...........................64

calcium/d cap 600mg ........................64 calcium/d chw 500-400 .....................64

calcium/d tab 250mg ........................64

calcium/d tab 500/200 ......................64

calcium/d tab 500-200 ......................64

calcium/d tab 500mg ........................64 calcium/d tab 600-200 ......................64

calcium/d tab 600-400 ......................64

calcium/d tab 600mg ........................64

CALCIUM/D3 TAB ..............................64 calcium/d3 tab 500-400 .....................64

calcium/vitd tab 500-400 ...................64

calcium/vt d tab 600-125 ...................64

calcium+d tab 600-400 .....................64 calvite p&d tab .................................64

camila tab 0.35mg ............................43

CAMPRAL TAB 333MG ........................74

capecitabine tab 150mg .....................27 capecitabine tab 500mg .....................27

CAPMIST DM TAB ..............................44

CAPRELSA TAB 100MG ......................27

CAPRELSA TAB 300MG ...................... 27

captopr/hctz tab 25-15mg ................. 25

captopr/hctz tab 25-25mg ................. 25 captopr/hctz tab 50-15mg ................. 25

captopr/hctz tab 50-25mg ................. 25

captopril tab 100mg ......................... 24

captopril tab 12.5mg ........................ 24 captopril tab 25mg ........................... 24

captopril tab 50mg ........................... 24

CARAFATE SUS 1GM/10ML ................ 79

carb/levo er tab 25-100mg ................ 29 carb/levo er tab 50-200mg ................ 29

carb/levo tab 10-100mg.................... 29

carb/levo tab 25-100mg.................... 29

carb/levo tab 25-250mg.................... 29 carbamazepin cap 100mg er .............. 14

carbamazepin cap 200mg er .............. 14

carbamazepin cap 300mg er .............. 14

carbamazepin chw 100mg ................. 14

carbamazepin sus 100/5ml ................ 14 carbamazepin tab 200mg .................. 14

carbamazepin tab 200mg er .............. 14

carbamazepin tab 400mg er .............. 14

carbidopa tab 25mg.......................... 29 carbinoxamin sol 4mg/5ml ................ 22

carbinoxamin tab 4mg ...................... 22

CARIMUNE INJ 12GM ........................ 72

CARIMUNE NF INJ 12GM ................... 72 carisoprodol tab 350mg .................... 68

carteolol sol 1% op ........................... 70

carvedilol tab 12.5mg ....................... 36

carvedilol tab 25mg .......................... 36

carvedilol tab 3.125mg ..................... 36 carvedilol tab 6.25mg ....................... 36

CAYSTON INH 75MG ........................... 8

caziant pak ...................................... 40

CEDAX CAP 400MG ........................... 39 cefaclor cap 250mg .......................... 39

cefaclor sus 125/5ml ........................ 39

cefaclor sus 250/5ml ........................ 39

cefadroxil sus 250/5ml ...................... 39 cefadroxil sus 500/5ml ...................... 39

cefazolin inj 1gm .............................. 39

cefazolin inj 20gm ............................ 39

cefazolin inj 500mg .......................... 39 cefdinir cap 300mg ........................... 39

cefdinir sus 125/5ml ......................... 39

cefdinir sus 250/5ml ......................... 39

87

cefditoren tab 200mg ........................39

cefditoren tab 400mg ........................39

CEFOTAN INJ 10G/100M ....................39 CEFOTAN INJ 1GM/10ML ....................39

CEFOTAN INJ 2GM/20ML ....................39

cefotaxime inj 10gm..........................40

cefotaxime inj 1gm ...........................40 cefotaxime inj 2gm ...........................40

cefotaxime inj 500mg ........................40

CEFOTET/DEX INJ 1-3.58% ................39

CEFOTET/DEX INJ 2-2.08% ................39 CEFOTETAN INJ 10G .........................39

CEFOTETAN INJ 1GM/10ML ................39

CEFOTETAN INJ 2GM/20ML ................39

cefoxitin inj 10gm .............................39 cefoxitin inj 1gm ...............................39

cefoxitin inj 2gm ...............................39

cefpodo prox sus 100/5ml ..................40

cefpodo prox sus 50mg/5ml ...............40

cefpodoxime tab 100mg ....................40 cefpodoxime tab 200mg ....................40

cefprozil sus 125/5ml ........................39

cefprozil sus 250/5ml ........................39

cefuroxime tab 250mg.......................39 cefuroxime tab 500mg.......................39

CELEBREX CAP 100MG ....................... 3

CELEBREX CAP 200MG ....................... 3

CELEBREX CAP 400MG ....................... 3 CELEBREX CAP 50MG ......................... 3

cephalexin cap 250mg .......................39

cephalexin cap 500mg .......................39

cephalexin sus 125/5ml .....................39

cephalexin sus 250/5ml .....................39 cesia pak .........................................40

cetiriz/pse tab 5-120mg.....................44

cetirizine chw 10mg ..........................22

cetirizine chw 5mg ............................22 cetirizine sol 1mg/ml .........................22

cetirizine sol 5mg/5ml .......................22

cetirizine syp 1mg/ml ........................22

cetirizine syp 5mg/5ml ......................22 cetirizine tab 10mg ...........................22

cetirizine tab 5mg .............................22

cevimeline cap 30mg .........................65

cgh dm max liq 10-200 ......................44 CHANTIX PAK 0.5& 1MG ....................75

CHANTIX PAK 1MG ............................75

CHANTIX TAB 0.5MG .........................75

CHANTIX TAB 1MG ........................... 75

chateal tab 0.15/30 .......................... 40

CHEMET CAP 100MG ......................... 21 cheratussin sol dac ........................... 44

child comple chw allergy ................... 22

child silfed liq 15mg/5ml ................... 69

childrens chw /iron ........................... 66 childrens chw gummies ..................... 66

chld asafree elx 80/2.5ml .................... 5

chld decongs liq 15mg/5ml ................ 69

chloral hydr syp 500/5ml .................. 58 chlordiazep cap 10mg ....................... 10

chlordiazep cap 25mg ....................... 10

chlordiazep cap 5mg ......................... 10

chloroquine tab 250mg ..................... 26 chloroquine tab 500mg ..................... 26

chlorphenir tab 12mg cr .................... 21

chlorphenir tab 4mg ......................... 21

chlorpromaz tab 100mg .................... 32

chlorpromaz tab 10mg ...................... 32 chlorpromaz tab 200mg .................... 32

chlorpromaz tab 25mg ...................... 32

chlorpromaz tab 50mg ...................... 32

chlorpropam tab 100mg .................... 20 chlorpropam tab 250mg .................... 20

chlorthalid tab 25mg......................... 51

chlorthalid tab 50mg......................... 51

chlorzoxazon tab 500mg ................... 68 cholestyram pow 4gm ....................... 23

cholestyram pow 4gm lite ................. 23

ciclodan cre 0.77% ........................... 46

cilostazol tab 100mg ......................... 56

cilostazol tab 50mg .......................... 56 cimetidine sol 300/5ml ...................... 79

cimetidine tab 200mg ....................... 79

cimetidine tab 300mg ....................... 79

cimetidine tab 400mg ....................... 79 cimetidine tab 800mg ....................... 79

ciprofloxacn sol 0.3% op ................... 70

ciprofloxacn tab 250mg ..................... 53

ciprofloxacn tab 500mg ..................... 53 ciprofloxacn tab 750mg ..................... 53

citalopram sol 10mg/5ml................... 16

citalopram tab 10mg ........................ 16

citalopram tab 20mg ........................ 16 citalopram tab 40mg ........................ 16

citric acid/ sol sod citr ....................... 54

CL PRENATAL TAB 28-0.8MG ............. 66

88

CLAFORAN INJ 2GM ..........................40

CLAFORAN/D5W INJ 1GM ..................40

claravis cap 10mg .............................46 claravis cap 20mg .............................46

claravis cap 30mg .............................46

claravis cap 40mg .............................46

clarithromyc sus 125/5ml ..................61 clarithromyc sus 250/5ml ..................61

clarithromyc tab 250mg .....................61

clarithromyc tab 500mg .....................61

clarithromyc tab 500mg er .................61 CLEAN&CLEAR LOT EXFOLIAT .............46

clemastine syp 0.5/5ml .....................22

clemastine tab 1.34mg ......................22

clemastine tab 2.68mg ......................22 clindamy/ben gel 1.2-5% ...................46

clindamycin cap 150mg ...................... 9

clindamycin cap 300mg ...................... 9

clindamycin cre 2% vag .....................80

clindamycin gel 1% ...........................46 clindamycin lot 1%............................46

clindamycin sol 1% ...........................46

clindamycin sol 75mg/5ml .................. 9

clobetasol cre 0.05% .........................48 clobetasol gel 0.05% .........................48

clobetasol oin 0.05% .........................48

clobetasol sol 0.05% .........................48

clomipramine cap 25mg .....................17 clomipramine cap 50mg .....................17

clomipramine cap 75mg .....................17

clonazepam tab 0.5mg ......................13

clonazepam tab 1mg .........................13

clonazepam tab 2mg .........................13 clonidine tab 0.1mg ..........................24

clonidine tab 0.2mg ..........................24

clonidine tab 0.3mg ..........................24

clopidogrel tab 75mg .........................56 cloraz dipot tab 7.5mg .......................10

clotrim/beta cre diprop ......................46

clotrim/beta lot diprop .......................47

clotrimazole cre 1% .................... 47, 80 clotrimazole cre 2% ..........................80

clotrimazole sol 1% ...........................47

clotrimazole tro 10mg .......................65

clozapine tab 100mg .........................31 clozapine tab 200mg .........................31

clozapine tab 25mg ...........................31

clozapine tab 50mg ...........................31

clr soluble pow fiber ......................... 59

COARTEM TAB 20-120MG .................. 25

codeine sulf tab 15mg......................... 5 codeine sulf tab 30mg......................... 5

codeine sulf tab 60mg......................... 5

COLCRYS TAB 0.6MG ........................ 55

cold & cough liq 6.25-2.5 .................. 44 cold/allergy elx children .................... 44

cold/cough elx children ..................... 44

cold/cough elx dm ............................ 44

cold/cough liq 6.25-2.5 ..................... 44 colestipol tab 1gm ............................ 23

COMPLERA TAB ................................ 33

COMPLETENATE CHW ....................... 66

CO-NATAL FA TAB 29-1MG ................ 66 CONCEPTROL GEL 4% ...................... 80

CONDOMS ....................................... 62

COPAXONE KIT 20MG/ML .................. 74

cortisone ac tab 25mg ...................... 43

cortizone-10 gel 1% ......................... 48 cough dm syp 100-10/5 .................... 44

COUMADIN TAB 10MG ...................... 12

COUMADIN TAB 1MG ........................ 12

COUMADIN TAB 2.5MG ..................... 12 COUMADIN TAB 2MG ........................ 12

COUMADIN TAB 3MG ........................ 12

COUMADIN TAB 4MG ........................ 12

COUMADIN TAB 5MG ........................ 12 COUMADIN TAB 6MG ........................ 12

COUMADIN TAB 7.5MG ..................... 12

CREON CAP 12000UNT...................... 50

CREON CAP 24000UNT...................... 50

CREON CAP 3000UNIT ...................... 50 CREON CAP 6000UNIT ...................... 50

CRIXIVAN CAP 200MG ...................... 33

CRIXIVAN CAP 400MG ...................... 33

cromolyn sod neb 20mg/2ml ............. 11 cromolyn sod sol 4% op .................... 71

cromolyn sod spr 5.2/act .................. 68

cryselle-28 tab 28 tabs ..................... 40

CUPRIMINE CAP 250MG .................... 35 CUVPOSA SOL 1MG/5ML ................... 78

cvs allergy chw 12.5mg .................... 22

CVS PRENATAL TAB .......................... 66

CVS PRENATAL TAB 28-0.8MG ........... 66 cyclafem tab 1/35 ............................ 40

cyclafem tab 7/7/7 ........................... 40

cyclobenzapr tab 10mg ..................... 68

89

cyclobenzapr tab 5mg .......................68

cyclophosph tab 25mg .......................26

cyclophosph tab 50mg .......................26 cycloserine cap 250mg ......................26

cyclosporine cap 100mg ....................35

cyclosporine cap 100mg md ...............36

cyclosporine cap 25mg ......................35 cyclosporine cap 25mg mod ...............35

cyclosporine cap 50mg mod ...............35

cyclosporine sol modified ...................36

cyproheptad syp 2mg/5ml .................23 cyproheptad tab 4mg ........................23

CYSTADANE POW ..............................52

CYSTAGON CAP 150MG .....................55

CYSTAGON CAP 50MG .......................55 cytra-2 sol .......................................54

cytra-k sol .......................................54

D DALIRESP TAB 500MCG .....................11

danazol cap 100mg ............................ 7 danazol cap 200mg ............................ 7

danazol cap 50mg .............................. 7

dandruff sha 1% ...............................47

dantrolene cap 100mg .......................68 dantrolene cap 25mg ........................68

dantrolene cap 50mg ........................68

dapsone tab 100mg ........................... 9

dapsone tab 25mg ............................. 9 dasetta tab 1/35 ...............................40

dasetta tab 7/7/7 ..............................40

delsym night liq cgh/cold ...................44

demeclocycl tab 150mg .....................75

demeclocycl tab 300mg .....................75 denta 5000 cre plus ..........................65

DEPEN TITRA TAB 250MG ..................35

dermafungal oin 2% ..........................47

desipramine tab 100mg .....................17 desipramine tab 10mg .......................17

desipramine tab 150mg .....................18

desipramine tab 25mg .......................17

desipramine tab 50mg .......................17 desipramine tab 75mg .......................17

desmopressin spr 0.01% ...................52

desmopressin tab 0.1mg ....................52

desmopressin tab 0.2mg ....................52 deso/ethinyl tab estradio ...................40

desonide cre 0.05% ..........................48

desonide oin 0.05% ..........................48

dexameth pho sol 0.1% op ................ 71

dexamethason elx 0.5/5ml ................ 43

dexamethason sol 0.5/5ml ................ 43 dexamethason tab 0.5mg .................. 43

dexamethason tab 0.75mg ................ 43

dexamethason tab 1.5mg .................. 43

dexamethason tab 1mg .................... 43 dexamethason tab 2mg .................... 43

dexamethason tab 4mg .................... 43

dexamethason tab 6mg .................... 43

dexmethylph tab 10mg ....................... 1 dexmethylph tab 2.5mg ...................... 1

dexmethylph tab 5mg ......................... 1

dextroamphet cap 10mg er ................. 1

dextroamphet cap 15mg er ................. 1 dextroamphet cap 5mg er ................... 1

dextroamphet tab 10mg...................... 1

dextroamphet tab 5mg ....................... 1

DIAZEPAM CON 5MG/ML ................... 10

diazepam gel 10mg .......................... 13 diazepam gel 2.5mg ......................... 13

diazepam gel 20mg .......................... 13

diazepam sol 1mg/ml ....................... 10

diazepam tab 10mg .......................... 10 diazepam tab 2mg............................ 10

diazepam tab 5mg............................ 10

DIBENZYLINE CAP 10MG ................... 24

dibucaine oin 1% ............................... 7 diclofen pot tab 50mg ......................... 3

diclofenac sol 0.1% op ...................... 71

diclofenac tab 25mg dr ....................... 3

diclofenac tab 50mg dr ....................... 3

diclofenac tab 75mg dr ....................... 3 dicloxacill cap 250mg ........................ 73

dicloxacill cap 500mg ........................ 73

dicyclomine cap 10mg ...................... 78

dicyclomine sol 10mg/5ml ................. 78 dicyclomine tab 20mg ....................... 78

didanosine cap 125mg ...................... 33

didanosine cap 250mg ...................... 33

didanosine cap 400mg ...................... 33 DIFFERIN LOT 0.1% ......................... 46

digoxin sol 50mcg/ml ....................... 38

digoxin tab 0.125mg......................... 38

digoxin tab 0.25mg .......................... 38 dihydroergot inj 1mg/ml ................... 63

DILANTIN CAP 30MG ........................ 15

diltiazem cap 120mg er ..................... 37

90

diltiazem cap 120mg/24 ....................37

diltiazem cap 180mg er .....................38

diltiazem cap 180mg/24 ....................38 diltiazem cap 240mg er .....................38

diltiazem cap 240mg/24 ....................38

diltiazem cap 300mg er .....................38

diltiazem tab 120mg .........................38 diltiazem tab 30mg ...........................38

diltiazem tab 60mg ...........................38

diltiazem tab 90mg ...........................38

dimenhydrin tab 50mg ......................21 dimetane dx syp ...............................44

dimetapp liq nighttim ........................44

diphedryl liq 12.5/5ml .......................22

diphen/atrop liq 2.5/5 .......................20 diphen/atrop tab 2.5mg .....................20

diphenhydram cap 25mg ...................22

diphenhydram cap 50mg ...................22

diphenhydram elx 12.5/5ml ...............22

diphenhydram inj 50mg/ml ................22 diphenhydram tab 25mg ....................22

dipyridamole tab 25mg ......................56

dipyridamole tab 50mg ......................56

dipyridamole tab 75mg ......................56 disopyramide cap 150mg ...................10

disposable ene..................................60

disposable ene single ........................60

disposable ene twin pk ......................60 disulfiram tab 250mg ........................74

disulfiram tab 500mg ........................74

divalproex cap 125mg .......................15

divalproex tab 125mg dr ....................15

divalproex tab 250mg dr ....................16 divalproex tab 250mg er ....................16

divalproex tab 500mg dr ....................16

divalproex tab 500mg er ....................16

dm/gg sol 10-100/5 ..........................44 docu soft cap 100mg .........................61

docusate cal cap 240mg ....................61

docusate sod cap 250mg ...................61

docusate sod liq 50mg/5ml ................61 docusate sod syp 20mg/5ml ...............61

docusate sod tab 100mg ....................61

docusol plus ene 20-283 ....................61

donepezil tab 10mg ...........................74 donepezil tab 10mg odt .....................74

donepezil tab 5mg ............................74

donepezil tab 5mg odt .......................74

dorzol/timol sol 2-0.5%op ................. 70

dorzolamide sol 2% op...................... 71

doxazosin tab 1mg ........................... 24 doxazosin tab 2mg ........................... 24

doxazosin tab 4mg ........................... 24

doxazosin tab 8mg ........................... 24

doxepin hcl cap 100mg ..................... 18 doxepin hcl cap 10mg ....................... 18

doxepin hcl cap 150mg ..................... 18

doxepin hcl cap 25mg ....................... 18

doxepin hcl cap 50mg ....................... 18 doxepin hcl cap 75mg ....................... 18

doxepin hcl con 10mg/ml .................. 18

doxycyc mono cap 100mg ................. 75

doxycyc mono cap 50mg ................... 75 doxycyc mono tab 100mg ................. 75

DRITHO-CREME CRE HP 1% .............. 47

dronabinol cap 10mg ........................ 21

dronabinol cap 2.5mg ....................... 21

dronabinol cap 5mg .......................... 21 drospir/ethi tab 3-0.03mg ................. 40

DULERA AER 100-5MCG .................... 12

DULERA AER 200-5MCG .................... 12

duloxetine cap 20mg ........................ 17 duloxetine cap 30mg ........................ 17

duloxetine cap 60mg ........................ 17

dytuss syp 12.5/5ml ......................... 22

E e.e.s. 400 tab 400mg ....................... 61

E.E.S. GRAN SUS 200/5ML ................ 61

e.s.p. sus 200-600 ............................. 8

ear drying dro 95-5% ....................... 71

ear wax remv sol 6.5% ot ................. 71 econazole cre 1% ............................. 47

EDURANT TAB 25MG ........................ 33

ees/sulfisox sus 200-600 ..................... 8

EFFIENT TAB 10MG .......................... 56 EFFIENT TAB 5MG ............................ 56

ELAPRASE INJ 6MG/3ML.................... 52

ELIDEL CRE 1% ............................... 49

elinest tab ....................................... 40 ELLA TAB 30MG ............................... 42

ELMIRON CAP 100MG ....................... 55

EMCYT CAP 140MG ........................... 27

emoquette tab ................................. 40 EMTRIVA CAP 200MG ........................ 33

EMTRIVA SOL 10MG/ML .................... 33

enalapr/hctz tab 10-25mg ................. 25

91

enalapr/hctz tab 5-12.5mg.................25

enalapril tab 10mg ............................24

enalapril tab 2.5mg ...........................24 enalapril tab 20mg ............................24

enalapril tab 5mg ..............................24

ENBREL INJ 25/0.5ML......................... 4

ENBREL INJ 25MG .............................. 4 ENBREL INJ 50MG/ML ......................... 4

ENBREL SRCLK INJ 50MG/ML .............. 4

enema ene double ............................60

enema ene single ..............................60 enema ready- ene -to-use .................60

enemeez plus ene 20-283 ..................61

enoxaparin inj 100mg/ml ...................13

enoxaparin inj 120/0.8 ......................13 enoxaparin inj 150mg/ml ...................13

enoxaparin inj 30/0.3ml ....................13

enoxaparin inj 300/3ml .....................13

enoxaparin inj 40/0.4ml ....................13

enoxaparin inj 60/0.6ml ....................13 enoxaparin inj 80/0.8ml ....................13

enpresse-28 tab ...............................40

enskyce tab .....................................40

entacapone tab 200mg ......................29 epinastine dro 0.05% ........................71

epinephrine inj 0.15mg ......................81

EPIPEN 2-PAK INJ 0.3MG ...................81

EPIPEN-JR INJ 2-PAK .........................81 EPIVIR SOL 10MG/ML ........................33

EPOGEN INJ 10000/ML ......................57

EPOGEN INJ 2000/ML ........................57

EPOGEN INJ 20000/ML ......................57

EPOGEN INJ 4000/ML ........................57 EPZICOM TAB 600-300 ......................33

eq enema ene double ........................60

eq fiber pow .....................................59

eql lice kit solution ............................49 EQL PRENATAL TAB FORMULA ............66

eql triactin elx cld/cgh .......................44

ergocalcifer cap 50000unt ..................81

ergoloid mes tab 1mg oral .................75 ERGOMAR SUB 2MG ..........................63

ERIVEDGE CAP 150MG ......................27

errin tab 0.35mg ..............................43

ERYPED SUS 200/5ML .......................61 ERY-TAB TAB 250MG EC ....................61

ERY-TAB TAB 333MG EC ....................61

ERY-TAB TAB 500MG EC ....................61

erythrocin tab 250mg ....................... 61

erythrom eth tab 400mg ................... 61

erythromycin gel /benzoyl ................. 46 erythromycin gel 2% ........................ 46

erythromycin oin 5mg/gm ................. 70

erythromycin sol 2% ........................ 46

erythromycin tab 250mg bs ............... 62 erythromycin tab 500mg bs ............... 62

escitalopram sol 5mg/5ml ................. 16

escitalopram tab 10mg ..................... 16

escitalopram tab 20mg ..................... 16 escitalopram tab 5mg ....................... 16

essian h.s. tab ................................. 52

essian tab ....................................... 52

est estrogen tab mtest ...................... 52 est estrogen tab mtest hs.................. 52

estarylla tab 0.25-35 ........................ 40

estazolam tab 1mg ........................... 58

estazolam tab 2mg ........................... 58

ESTRACE VAG CRE 0.1MG/GM ........... 80 estradiol tab 0.5mg .......................... 53

estradiol tab 1mg ............................. 53

estradiol tab 2mg ............................. 53

estropipate tab 0.75mg ..................... 53 estropipate tab 1.5mg ...................... 53

estropipate tab 3mg ......................... 53

ethambutol tab 100mg ..................... 26

ethambutol tab 400mg ..................... 26 ethosuximide cap 250mg .................. 15

ethosuximide sol 250/5ml ................. 15

etidron disd tab 200mg ..................... 51

etidron disd tab 400mg ..................... 51

etodolac tab 400mg ............................ 3 etodolac tab 500mg ............................ 3

etoposide cap 50mg ......................... 28

etoposide inj 20mg/ml ...................... 28

EUFLEXXA INJ 10MG/ML.................... 68 EURAX CRE 10% .............................. 49

EXELON DIS 4.6MG/24 ..................... 74

EXELON DIS 9.5MG/24 ..................... 74

exemestane tab 25mg ...................... 27 EXTAVIA INJ 0.3MG .......................... 75

EZ USE FLU KIT ............................... 80

F FABRAZYME INJ 5MG ........................ 52 falmina tab ...................................... 40

famciclovir tab 125mg ...................... 35

famciclovir tab 250mg ...................... 35

92

famciclovir tab 500mg .......................35

famotidine tab 10mg .........................79

famotidine tab 20mg .........................79 famotidine tab 40mg .........................79

FANAPT PAK .....................................30

FANAPT TAB 10MG ............................30

FANAPT TAB 12MG ............................30 FANAPT TAB 1MG ..............................30

FANAPT TAB 2MG ..............................30

FANAPT TAB 4MG ..............................30

FANAPT TAB 6MG ..............................30 FANAPT TAB 8MG ..............................30

felbamate sus 600/5ml ......................15

felbamate tab 400mg ........................15

felbamate tab 600mg ........................15 felodipine tab 10mg er ......................38

felodipine tab 5mg er ........................38

FEMALE CONDOMS ............................62

FEMCAP MIS 22MM ...........................62

FEMCAP MIS 26MM ...........................62 FEMCAP MIS 30MM ...........................62

FEMHRT TAB 0.5-2.5 .........................52

fenofibrate cap 134mg.......................23

fenofibrate cap 200mg.......................23 fenofibrate cap 67mg ........................23

fenofibrate tab 160mg .......................23

fenofibrate tab 48mg .........................23

fenofibrate tab 54mg .........................23 fenofibric tab 35mg ...........................23

fentanyl dis 100mcg/h ........................ 5

fentanyl dis 12mcg/hr ........................ 5

fentanyl dis 25mcg/hr ........................ 5

fentanyl dis 50mcg/hr ........................ 5 fentanyl dis 75mcg/hr ........................ 5

ferocon cap ......................................57

ferotrin cap ......................................57

ferotrinsic cap ..................................57 ferrous fum tab 324mg ......................57

ferrous gluc tab 240mg .....................57

ferrous gluc tab 324mg .....................57

FERROUS GLUC TAB 324MG ...............57 ferrous gluc tab 325mg .....................57

FERROUS SUL LIQ 220/5ML ...............57

ferrous sulf dro 15mg/ml ...................57

ferrous sulf elx 220/5ml .....................57 FERROUS SULF TAB 324MG EC ...........58

ferrous sulf tab 325mg ......................58

ferrous sulf tab 325mg ec ..................58

ferus cap 150mg .............................. 58

FEVERALL INF SUP 80MG .................... 5

fexofenadine tab 180mg ................... 22 fexofenadine tab 60mg ..................... 22

fiber cap 0.52gm .............................. 59

fiber laxatv tab 625mg ...................... 59

fiber laxtiv cap 0.52gm ..................... 59 fiber powder pow ............................. 59

fiber tab 625mg ............................... 59

fiber therap cap 0.52gm .................... 59

fiber therap pow 28.3% .................... 59 fiber therap pow 48.57% .................. 59

fiber therap pow 58.6% .................... 59

fiber therap tab 500mg ..................... 59

fiber therap tab 625mg ..................... 59 fiber-caps tab 625mg ....................... 59

fibergen tab 625mg .......................... 59

fiber-lax tab 625mg .......................... 59

fibertab tab 625mg........................... 59

FINACEA GEL 15% ........................... 49 finasteride tab 5mg .......................... 55

FIRST-OMEPRA SUS 2MG/ML ............. 79

fish oil cap 1000mg .......................... 69

fish oil cap 1200mg .......................... 69 fish oil cap 300mg ............................ 69

fish oil cap 500mg ............................ 69

flavoxate tab 100mg ......................... 80

FLEBOGAMMA INJ 10% ..................... 72 FLEBOGAMMA INJ 5% ....................... 72

FLEBOGAMMA INJ DIF 5% ................. 72

flecainide tab 100mg ........................ 10

flecainide tab 150mg ........................ 10

flecainide tab 50mg .......................... 10 FLUARIX INJ PF ................................ 80

FLUARIX QUAD INJ ........................... 80

fluconazole sus 10mg/ml ................... 21

fluconazole sus 40mg/ml ................... 21 fluconazole tab 100mg ...................... 21

fluconazole tab 150mg ...................... 21

fluconazole tab 200mg ...................... 21

fluconazole tab 50mg........................ 21 fludarabine inj 50mg ........................ 27

fludrocort tab 0.1mg ......................... 44

FLULAVAL INJ .................................. 80

flunisolide spr 0.025% ...................... 68 flunisolide spr 29mcg ........................ 68

fluocin acet oil 0.01% sc ................... 48

fluocinonide cre 0.05% ..................... 48

93

fluocinonide gel 0.05% ......................48

fluocinonide oin 0.05% ......................48

fluocinonide sol 0.05% ......................48 fluoride chw 0.25mg f ........................64

fluoride chw 0.5mg f .........................64

fluoride chw 1mg f ............................64

fluoridex gel 1.1% ............................65 fluoritab dro 0.125mg........................64

fluoromethol sus 0.1% op ..................71

fluorouracil cre 5% ............................47

fluoxetine cap 10mg ..........................16 fluoxetine cap 20mg ..........................16

fluoxetine sol 20mg/5ml ....................16

fluoxetine tab 10mg ..........................16

fluoxetine tab 20mg ..........................17 fluphenaz de inj 25mg/ml ..................32

fluphenazine inj 2.5mg/ml .................32

fluphenazine tab 10mg ......................32

fluphenazine tab 1mg ........................32

fluphenazine tab 2.5mg .....................32 fluphenazine tab 5mg ........................32

flura-drops dro 0.25mg f ....................64

flurazepam cap 15mg ........................58

flurazepam cap 30mg ........................58 flurbiprofen sol 0.03% op ..................71

flurbiprofen tab 100mg ....................... 3

flurbiprofen tab 50mg ......................... 3

flutamide cap 125mg .........................27 fluticasone cre 0.05% ........................48

fluticasone oin 0.005% ......................48

fluticasone spr 50mcg .......................68

FLUVIRIN INJ ...................................80

FLUVIRIN INJ PF ...............................80 fluvoxamine tab 100mg .....................17

fluvoxamine tab 25mg .......................17

fluvoxamine tab 50mg .......................17

FLUZONE INJ INTRADRM ...................80 FLUZONE INJ PF ...............................80

FLUZONE PED/ INJ PF........................80

FLUZONE QUAD INJ ..........................80

FLUZONE SPLT INJ ............................80 foam antacid chw 80-20mg ................. 7

foam antacid sus ............................... 7

folbee plus tab ..................................65

folic acid tab 1mg .............................56 folic acid tab 400mcg ........................56

folic acid tab 800mcg ........................56

foltrin cap ........................................57

fondaparinux sol 10/0.8 .................... 13

fondaparinux sol 2.5/0.5 ................... 13

fondaparinux sol 5.0/0.4 ................... 13 fondaparinux sol 7.5/0.6 ................... 13

FORADIL CAP AEROLIZE ................... 12

FORTEO SOL 600/2.4 ....................... 51

FOSAMAX + D TAB 70-2800 .............. 51 FOSAMAX + D TAB 70-5600 .............. 51

foscarnet inj 24mg/ml ...................... 34

fosinop/hctz tab 10/12.5 ................... 25

fosinopril tab 10mg .......................... 24 fosinopril tab 20mg .......................... 24

fosinopril tab 40mg .......................... 24

FRAGMIN INJ 10000/ML .................... 13

FRAGMIN INJ 12500UNT ................... 13 FRAGMIN INJ 15000UNT ................... 13

FRAGMIN INJ 18000UNT ................... 13

FRAGMIN INJ 2500/0.2 ..................... 13

FRAGMIN INJ 5000/0.2 ..................... 13

FRAGMIN INJ 7500/0.3 ..................... 13 furosemide sol 10mg/ml ................... 50

FUROSEMIDE SOL 8MG/ML ................ 50

furosemide tab 20mg ........................ 50

furosemide tab 40mg ........................ 50 furosemide tab 80mg ........................ 50

FUZEON KIT .................................... 33

G gabapentin cap 100mg ..................... 14 gabapentin cap 300mg ..................... 14

gabapentin cap 400mg ..................... 14

gabapentin sol 250/5ml .................... 14

gabapentin tab 600mg ...................... 14

gabapentin tab 800mg ...................... 14 galantamine cap 24mg er .................. 74

galantamine cap 8mg er ................... 74

galantamine tab 12mg ...................... 74

galantamine tab 4mg ........................ 74 galantamine tab 8mg ........................ 74

GAMASTAN S/D INJ .......................... 72

GAMMAGARD INJ 1GM/10ML ............. 72

GAMMAGARD SD INJ 10GM HU .......... 72 GAMMAKED INJ 1GM/10ML ................ 72

GAMMAPLEX INJ 5GM ....................... 72

GAMUNEX INJ 10% .......................... 72

GAMUNEX-C INJ 1GM/10ML ............... 72 gas relief cap 125mg ........................ 53

gas relief cap 180mg ........................ 53

gas relief dro infants ......................... 53

94

gavilyte-c sol ....................................60

gavilyte-g sol ...................................60

gemfibrozil tab 600mg .......................23 gengraf cap 100mg ...........................36

gengraf cap 25mg .............................36

gengraf sol 100mg/ml .......................36

gentamicin cre 0.1% .........................46 gentamicin oin 0.1% .........................46

gentamicin oin 0.3% op .....................70

gentamicin sol 0.3% op .....................70

gianvi tab 3-0.02mg ..........................40 gildagia tab 0.4-35 ............................41

gildess fe tab 1.5/30 .........................41

gildess fe tab 1/20 ............................41

gildess tab 1.5/30 .............................41 gildess tab 1/20 ................................41

GILENYA CAP 0.5MG .........................75

GLEEVEC TAB 100MG ........................27

GLEEVEC TAB 400MG ........................27

glimepiride tab 1mg ..........................20 glimepiride tab 2mg ..........................20

glimepiride tab 4mg ..........................20

glipizide er tab 10mg .........................20

glipizide er tab 2.5mg ........................20 glipizide er tab 5mg ..........................20

glipizide tab 10mg ............................20

glipizide tab 5mg ..............................20

glipizide xl tab 10mg .........................20 glipizide xl tab 2.5mg ........................20

glipizide xl tab 5mg ...........................20

GLUCAGON KIT 1MG .........................18

GLUCOSE-VITAMIN C CHEW TAB 4-0.006

GM ..................................................19 glyb/metform tab 1.25-250 ................18

glyb/metform tab 2.5-500..................18

glyb/metform tab 5-500mg ................18

glyburid mcr tab 1.5mg .....................20 glyburid mcr tab 3mg ........................20

glyburid mcr tab 6mg ........................20

glyburide tab 1.25mg ........................20

glyburide tab 2.5mg ..........................20 glyburide tab 5mg .............................20

glycerin sup 1.2gm ...........................60

glycerin sup 2.1gm ...........................60

glycerin sup 2gm ..............................60 glycerin sup 80.7% ...........................60

glycopyrrol tab 1mg ..........................78

glycopyrrol tab 2mg ..........................78

gnp best pow fiber ........................... 59

GNP GLUCOSE CHW RASPBERY .......... 19

gnp iron tab 45mg............................ 58 GNP PRENATAL TAB 28-0.8MG ........... 66

GOLYTELY SOL ................................. 60

granisetron tab 1mg ......................... 21

griseofulvin sus 125/5ml ................... 21 guaiatussin syp ac ............................ 44

guaifenesin sol 100/5ml .................... 45

guaifenesin sol dac ........................... 44

guaifenesin syp 100/5ml ................... 45 guaifenesin syp dm .......................... 44

guaifenesin tab 200mg ..................... 45

guaifenesin tab 400mg ..................... 45

guaifenesin tab 600mg er .................. 45 guanfacine tab 1mg .......................... 24

guanfacine tab 2mg .......................... 24

H HALFLYTELY KIT FLAV PKS ................ 60

halobetasol cre 0.05% ...................... 48 halobetasol oin 0.05% ...................... 48

haloper dec inj 100mg/ml ................. 31

haloper dec inj 50mg/ml ................... 31

haloper lac inj 5mg/ml ...................... 31 haloperidol con 2mg/ml .................... 31

haloperidol tab 0.5mg ....................... 31

haloperidol tab 10mg ........................ 31

haloperidol tab 1mg.......................... 31 haloperidol tab 20mg ........................ 31

haloperidol tab 2mg.......................... 31

haloperidol tab 5mg.......................... 31

hc pramoxine cre 1-1%....................... 7

hc pramoxine cre 2.5-1% .................... 7 hc valerate cre 0.2% ........................ 48

hc/acet acid sol otic .......................... 71

hc/aloe cre 0.5%.............................. 48

hc-1% hemorr oin 1% ...................... 48 heartbrn ant chw 160-105 ................... 7

heartburn chw ex st ........................... 7

heather tab 0.35mg .......................... 43

hecoria cap 0.5mg ............................ 36 hecoria cap 1mg .............................. 36

HELIXATE FS INJ 1000UNIT ............... 55

HELIXATE FS INJ 250UNIT ................ 55

HELIXATE FS INJ 500UNIT ................ 55 HELIXATE FS SOL 1000UNIT .............. 56

HELIXATE FS SOL 250UNIT ............... 56

HELIXATE FS SOL 500UNIT ............... 56

95

hemorrhoidal cre ............................... 7

HEXALEN CAP 50MG ..........................26

HIZENTRA INJ 2GM/10ML ..................72 hm fiber tab 500mg ..........................59

hm iron tab 45mg .............................58

HM PRENATAL TAB ............................67

HUMALOG INJ 100/ML .......................19 HUMALOG KWIK INJ 100/ML ..............19

HUMALOG MIX INJ 50/50 ...................19

HUMALOG MIX INJ 50/50KWP ............19

HUMALOG MIX INJ 75/25KWP ............19 HUMALOG MIX SUS 75/25 .................19

HUMATE-P SOL 1200UNIT ..................56

HUMATE-P SOL 2400UNIT ..................56

HUMIRA KIT 20MG/0.4 ....................... 3 HUMIRA KIT 40MG/0.8 ....................... 3

HUMIRA PEN KIT 40MG/0.8 ................. 3

HUMULIN INJ 70/30 ..........................19

HUMULIN INJ 70/30KWP ....................19

HUMULIN N INJ U-100 .......................19 HUMULIN N INJ U-100KWP ................19

HUMULIN N PN INJ U-100 ..................19

HUMULIN PEN INJ 70/30 ....................19

HUMULIN R INJ U-100 .......................19 HUMULIN R INJ U-500 .......................19

hydralazine tab 100mg ......................25

hydralazine tab 10mg ........................25

hydralazine tab 25mg ........................25 hydralazine tab 50mg ........................25

hydrochlorot cap 12.5mg ...................51

hydrochlorot tab 12.5mg ...................51

hydrochlorot tab 25mg ......................51

hydrochlorot tab 50mg ......................51 hydroco/apap sol 7.5-325 ................... 6

hydroco/apap sol 7.5-500 ................... 6

hydroco/apap tab 10-325mg ............... 6

hydroco/apap tab 10-500mg ............... 6 hydroco/apap tab 10-650mg ............... 6

hydroco/apap tab 2.5-500 .................. 6

hydroco/apap tab 5-325mg ................. 6

hydroco/apap tab 5-500mg ................. 6 hydroco/apap tab 7.5-325 .................. 6

hydroco/apap tab 7.5-500 .................. 6

hydroco/apap tab 7.5-650 .................. 6

hydroco/apap tab 7.5-750 .................. 6 hydrocod/hom syp 5-1.5/5 .................44

hydrocort ac cre 0.5% .......................48

hydrocort ac cre 1% ..........................48

hydrocort ac sup 25mg ....................... 7

hydrocort cre 0.5% .......................... 48

hydrocort cre 1% ............................. 48 hydrocort cre 2.5% .......................... 48

hydrocort lot 1% .............................. 48

hydrocort lot 2.5% ........................... 48

hydrocort oin 0.5% .......................... 48 hydrocort oin 1% ............................. 48

hydrocort oin 2.5% .......................... 48

hydrocort tab 10mg .......................... 43

hydrocort tab 20mg .......................... 43 hydrocort tab 5mg ........................... 43

hydrocort/ cre aloe 1% ..................... 48

hydrogesic cap 5-500mg ..................... 6

hydromorphon tab 2mg ...................... 5 hydromorphon tab 4mg ...................... 5

hydroxychlor tab 200mg ................... 26

hydroxyurea cap 500mg ................... 28

hydroxyz hcl syp 10mg/5ml ............... 10

hydroxyz hcl tab 10mg ..................... 10 hydroxyz hcl tab 25mg ..................... 10

hydroxyz hcl tab 50mg ..................... 10

hydroxyz pam cap 100mg ................. 10

hydroxyz pam cap 25mg ................... 10 hydroxyz pam cap 50mg ................... 10

hyoscyamine dro 0.125/ml ................ 78

hyoscyamine sub 0.125mg ................ 78

hyoscyamine tab 0.125mg ................ 78 hyoscyamine tab 0.375 er ................. 78

hyosyne elx 0.125/5 ......................... 78

hypercare sol 20% ........................... 49

I ibandronate tab 150mg ..................... 51 ibu-drops dro 40mg/ml ....................... 3

ibuprofen cap 200mg .......................... 3

ibuprofen jr chw 100mg ...................... 3

ibuprofen sus 100/5ml ........................ 3 ibuprofen tab 200mg .......................... 3

ibuprofen tab 400mg .......................... 3

ibuprofen tab 600mg .......................... 3

ibuprofen tab 800mg .......................... 3 imipenem/cil inj 250mg ...................... 9

imipenem/cil inj 500mg ...................... 9

imipram hcl tab 10mg ....................... 18

imipram hcl tab 25mg ....................... 18 imipram hcl tab 50mg ....................... 18

imiquimod cre 5% ............................ 49

IMMUNE GLOBU INJ HUMAN .............. 72

96

inatal adv tab ...................................67

inatal gt tab .....................................67

inatal ultra tab ..................................67 INCIVEK TAB 375MG .........................34

INCRELEX INJ 40MG/4ML ...................51

indapamide tab 1.25mg .....................51

indapamide tab 2.5mg .......................51 indomethacin cap 25mg ...................... 3

indomethacin cap 50mg ...................... 3

INFERGEN INJ 15MCG .......................35

INSULIN PEN NEEDLES ......................63 INSULIN SYRINGES ...........................63

INTELENCE TAB 100MG .....................33

INTELENCE TAB 200MG .....................33

INTRON-A INJ 10MU..........................28 INTRON-A INJ 25MU..........................28

INVANZ INJ 1GM ............................... 9

INVEGA SUST INJ 117/0.75 ...............30

INVEGA SUST INJ 156MG/ML .............30

INVEGA SUST INJ 234/1.5 .................30 INVEGA SUST INJ 39/0.25 .................30

INVEGA SUST INJ 78/0.5ML ...............30

INVEGA TAB 1.5MG ...........................30

INVEGA TAB 3MG..............................30 INVEGA TAB 6MG..............................30

INVEGA TAB 9MG..............................30

INVIRASE TAB 500MG .......................33

ipratropium sol 0.02%inh...................11 ipratropium spr 0.03% ......................68

ipratropium spr 0.06% ......................68

irbesar/hctz tab 150-12.5 ..................25

irbesar/hctz tab 300-12.5 ..................25

irbesartan tab 150mg ........................24 irbesartan tab 300mg ........................24

irbesartan tab 75mg ..........................24

iron chews chw pediatri .....................58

iron complex cap ..............................57 iron slow tab 45mg ...........................58

iron tab 160mg cr .............................58

iron therapy tab 200mg .....................58

ISENTRESS CHW 100MG ....................33 ISENTRESS TAB 400MG .....................33

isometh/apap cap dichlor ...................63

isonarif cap ......................................26

isoniazid tab 100mg ..........................26 isoniazid tab 300mg ..........................26

isosorb din sub 2.5mg ........................ 9

isosorb din tab 10mg .......................... 9



isosorb din tab 5mg ............................ 9 isosorb mono tab 10mg ...................... 9

isosorb mono tab 120mg er ................. 9

isosorb mono tab 20mg ...................... 9

isosorb mono tab 30mg er................... 9 isosorb mono tab 60mg er................... 9

itraconazole cap 100mg .................... 21

J JAKAFI TAB 10MG ............................ 28 JAKAFI TAB 15MG ............................ 28

JAKAFI TAB 20MG ............................ 28

JAKAFI TAB 25MG ............................ 28

JAKAFI TAB 5MG .............................. 28 jantoven tab 10mg ........................... 13

jantoven tab 1mg ............................. 12

jantoven tab 2.5mg .......................... 12

jantoven tab 2mg ............................. 12

jantoven tab 3mg ............................. 12 jantoven tab 4mg ............................. 12

jantoven tab 5mg ............................. 12

jantoven tab 6mg ............................. 12

jantoven tab 7.5mg .......................... 13 JANUMET TAB 50-1000 ..................... 18

JANUMET TAB 50-500MG .................. 18

JANUMET XR TAB 100-1000............... 18

JANUMET XR TAB 50-1000 ................ 18 JANUVIA TAB 100MG ........................ 19

JANUVIA TAB 25MG .......................... 19

JANUVIA TAB 50MG .......................... 19

jencycla tab 0.35mg ......................... 43

JENTADUETO TAB 2.5-500 ................ 18 jolivette tab 0.35mg ......................... 43

junel 1.5/30 tab ............................... 41

junel 1/20 tab .................................. 41

junel fe tab 1.5/30 ........................... 41 junel fe tab 1/20 .............................. 41

K k citrate sol citr acd .......................... 54

KALETRA SOL .................................. 33 KALETRA TAB 100-25MG ................... 33

KALETRA TAB 200-50MG ................... 33

kaopectate sus 262/15ml .................. 20

kariva tab 28 day ............................. 41 kelnor tab 1/35 ................................ 41

KEPIVANCE INJ 6.25MG .................... 28

ketoconazole cre 2% ........................ 47

97

ketoconazole sha 2% ........................47

ketoconazole tab 200mg ....................21

ketoprofen cap 50mg ......................... 3 ketoprofen cap 75mg ......................... 3

ketorolac sol 0.4% ............................71

ketorolac sol 0.5% ............................71

ketorolac tab 10mg ............................ 3 ketotif fum dro 0.025%op ..................71

kids vitamin chw extra c ....................66

KOGENATE FS INJ 1000/BS ................56

KOGENATE FS INJ 1000UNIT ..............56 KOGENATE FS INJ 250/BS .................56

KOGENATE FS INJ 250UNIT................56

KOGENATE FS INJ 500/BS .................56

KOGENATE FS INJ 500UNIT................56 KOMBIGLYZE TAB 2.5-1000 ...............18

KOMBIGLYZE TAB 5-1000MG..............18

KOMBIGLYZE TAB 5-500MG ...............18

KONSYL POW 100% ..........................59

KONSYL POW 28.3% .........................59 KONSYL-D POW 52.3% ......................59

KP PRENATAL TAB MULTIVIT ..............67

kurvelo tab 0.15/30 ..........................41

KUVAN TAB 100MG ...........................52 L labetalol tab 100mg ..........................36

labetalol tab 200mg ..........................36

labetalol tab 300mg ..........................36 LACRISERT MIS 5MG OP ....................69

lactulose sol 10gm/15 ................. 54, 60

lactulose sol 20gm/30 .......................60

lamivud/zido tab 150-300 ..................33

lamivudine tab 100mg .......................33 lamivudine tab 150mg .......................33

lamivudine tab 300mg .......................33

lamotrigine chw 25mg .......................14

lamotrigine chw 5mg .........................14 lamotrigine tab 100mg ......................14

lamotrigine tab 150mg ......................14

lamotrigine tab 200mg ......................14

lamotrigine tab 25mg ........................14 LANCETS .........................................62

LANOXIN TAB 0.125MG .....................38

LANOXIN TAB 0.25MG .......................38

lansoprazole cap 15mg dr ..................79 lansoprazole cap 30mg dr ..................79

LANTUS INJ 100/ML ..........................19

LANTUS INJ SOLOSTAR .....................19

larin fe tab 1.5/30 ............................ 41

larin fe tab 1/20 ............................... 41

latanoprost sol 0.005% ..................... 71 LATUDA TAB 120MG ......................... 30

LATUDA TAB 20MG ........................... 30

LATUDA TAB 40MG ........................... 30

LATUDA TAB 80MG ........................... 30 laxative chw 15mg ........................... 61

leena tab ......................................... 41

leflunomide tab 10mg ......................... 4

leflunomide tab 20mg ......................... 4 lessina tab ....................................... 41

letrozole tab 2.5mg .......................... 27

leucovor ca tab 10mg ....................... 28

leucovor ca tab 15mg ....................... 28 leucovor ca tab 25mg ....................... 28

leucovor ca tab 5mg ......................... 28

LEUKERAN TAB 2MG ......................... 26

LEUKINE INJ 250MCG ....................... 57

leuprolide inj 1mg/0.2 ...................... 27 levetiraceta sol 100mg/ml ................. 14

levetiraceta tab 1000mg ................... 14

levetiraceta tab 250mg ..................... 14

levetiraceta tab 500mg ..................... 14 levetiraceta tab 750mg ..................... 14

levobunolol sol 0.25% op .................. 70

levobunolol sol 0.5% op .................... 70

levocarnitin sol 1gm/10ml ................. 52 levocarnitin tab 330mg ..................... 52

levofloxacin sol 0.5% ........................ 70

levofloxacin sol 25mg/ml................... 53

levofloxacin tab 250mg ..................... 53

levofloxacin tab 500mg ..................... 53 levofloxacin tab 750mg ..................... 53

levonest tab .................................... 41

levonor/ethi tab 0.1-0.02 .................. 41

levonor/ethi tab estradio ................... 41 levonorgestr tab 0.75mg ................... 42

levonorgestr tab 1.5mg ..................... 42

levora-28 tab 0.15/30 ....................... 41

levothroid tab 100mcg ...................... 76 levothroid tab 112mcg ...................... 76

levothroid tab 125mcg ...................... 76


levothroid tab 150mcg ...................... 76 levothroid tab 175mcg ...................... 76


levothroid tab 25mcg ........................ 76

98

levothroid tab 300mcg .......................76

levothroid tab 50mcg ........................76

levothroid tab 75mcg ........................76 levothroid tab 88mcg ........................76

levothyroxin tab 100mcg ...................76


levothyroxin tab 125mcg ...................76 levothyroxin tab 137mcg ...................76



levothyroxin tab 200mcg ...................76 levothyroxin tab 25mcg .....................76


levothyroxin tab 50mcg .....................76

levothyroxin tab 75mcg .....................76 levothyroxin tab 88mcg .....................76

levoxyl tab 100mcg ...........................76

levoxyl tab 112mcg ...........................76

levoxyl tab 125mcg ...........................76

levoxyl tab 137mcg ...........................76 levoxyl tab 150mcg ...........................76

levoxyl tab 175mcg ...........................76

levoxyl tab 200mcg ...........................76

levoxyl tab 25mcg.............................76 levoxyl tab 50mcg.............................76

levoxyl tab 75mcg.............................76

levoxyl tab 88mcg.............................76

LEXIVA TAB 700MG ...........................33 lice bedding aer 0.5%........................49

lice control aer 0.5% .........................49

lice killing sha ...................................49

lice soln kit ......................................49

lice treatmt sha 0.33-4% ...................49 lice trtmnt liq 1% ..............................49

licide aer 0.5% .................................49

lido/prilocn cre 2.5-2.5% ...................49

lidocaine gel 2% ...............................49 lidocaine oin 5% ...............................49

lidocaine pad 5% ..............................49

lidocaine sol 2% visc .........................65

lidocaine sol 4% ...............................49 liothyronine inj 10mcg/ml ..................77

liothyronine tab 25mcg ......................77

liothyronine tab 50mcg ......................77

liothyronine tab 5mcg ........................77 lisinop/hctz tab 10-12.5 .....................25

lisinop/hctz tab 20-12.5 .....................25

lisinop/hctz tab 20-25mg ...................25

lisinopril tab 10mg............................ 24

lisinopril tab 2.5mg .......................... 24

lisinopril tab 20mg............................ 24 lisinopril tab 30mg............................ 24

lisinopril tab 40mg............................ 24

lisinopril tab 5mg ............................. 24

lithium carb cap 150mg .................... 30 lithium carb cap 300mg .................... 30

lithium carb cap 600mg .................... 30

lithium carb tab 300mg ..................... 30

lithium carb tab 300mg er ................. 30 lithium carb tab 450mg er ................. 30

LITHIUM CITR SOL 8MEQ/5ML ........... 30

LITTLE TUMMY DRO 20/0.3ML............ 53

lomustine cap 100mg ....................... 26 lomustine cap 10mg ......................... 26

lomustine cap 40mg ......................... 26

loperamide cap 2mg ......................... 20

loperamide liq 1mg/5ml .................... 20

loperamide sus 1mg/7.5 ................... 20 loperamide tab 2mg ......................... 20

loratadine d tab 5-120mg .................. 44

loratadine sol 5mg/5ml ..................... 22

loratadine syp 5mg/5ml .................... 22 loratadine tab 10mg ......................... 22

loratadine-d tab 10-240mg ................ 44

lorazepam con 2mg/ml ..................... 10

lorazepam tab 0.5mg ........................ 10 lorazepam tab 1mg .......................... 10

lorazepam tab 2mg .......................... 10

loryna tab 3-0.02mg ......................... 41

losartan pot tab 100mg ..................... 24

losartan pot tab 25mg ...................... 24 losartan pot tab 50mg ...................... 24

losartan/hct tab 100-12.5 ................. 25

losartan/hct tab 100-25 .................... 25

losartan/hct tab 50-12.5 ................... 25 lovastatin tab 10mg.......................... 23

lovastatin tab 20mg.......................... 23

lovastatin tab 40mg.......................... 23

low-ogestrel tab ............................... 41 loxapine cap 10mg ........................... 31

loxapine cap 25mg ........................... 31

loxapine cap 50mg ........................... 31

loxapine cap 5mg ............................. 31 lubricant dro 1.4% ........................... 69

lubricating sol 0.5% ......................... 69

lubricnt eye dro 0.4-0.3% ................. 69

99

lubricnt eye dro 0.5% op ...................69

LUPR DEP-PED INJ 11.25MG ...............52

LUPR DEP-PED INJ 15MG ...................52 LUPR DEP-PED INJ 30MG ...................52

LUPR DEP-PED INJ 7.5MG ..................52

lutera tab .........................................41

LYRICA CAP 100MG ...........................14 LYRICA CAP 150MG ...........................14

LYRICA CAP 200MG ...........................14

LYRICA CAP 225MG ...........................14

LYRICA CAP 25MG.............................14 LYRICA CAP 300MG ...........................14

LYRICA CAP 50MG.............................14

LYRICA CAP 75MG.............................14

LYSODREN TAB 500MG ......................27 lyza tab 0.35mg ...............................43

M maalox multi sus symp max ................ 7

maalox sus advanced ......................... 7

maalox sus reg st .............................. 7 mag citrate sol cherry .......................60

mag citrate sol grape ........................60

mag citrate sol lemon ........................60

mag oxide tab 250mg ........................ 8 mag oxide tab 400mg .......................64

MAG OXIDE TAB 400MG ..................... 8

mag oxide tab 420mg ........................ 8

mag-al plus liq................................... 7 mag-al plus liq xs .............................. 7

magnesium cap 500mg .....................64

magnesium gl tab 500mg ..................64

magnesium su inj 50% ......................64

magnesium tab 200mg ......................64 magnesium tab 250mg .................. 8, 64

magnesium tab 500mg ......................64

magnesium-ox tab 400mg .................64

mag-sr tab 535mg ............................64 malathion lot 0.5% ...........................49

maprotiline tab 50mg ........................16

maprotiline tab 75mg ........................16

marlissa tab 0.15/30 .........................41 martinic cap .....................................57

MATULANE CAP 50MG .......................28

meclizine chw 25mg ..........................21

meclizine tab 12.5mg ........................21 meclizine tab 25mg ...........................21

medi-tabs elx 80/2.5ml ...................... 5

medroxypr ac inj 150mg/ml ...............43

medroxypr ac tab 10mg .................... 74

medroxypr ac tab 2.5mg ................... 74

medroxypr ac tab 5mg ...................... 74 mefloquine tab 250mg ...................... 26

megestrol ac sus 40mg/ml ................ 27

megestrol ac tab 20mg ..................... 27

megestrol ac tab 40mg ..................... 27 melatin tab 3-1mg ............................. 2

melatonin cap 3mg ............................. 2

melatonin cap 5mg ............................. 2

MELATONIN LIQ 1MG/4ML ................... 2 melatonin tab 10mg cr ........................ 2

melatonin tab 1mg ............................. 2

melatonin tab 300mcg ........................ 2

melatonin tab 3-2mg .......................... 2 melatonin tab 3mg ............................. 2

melatonin tab 5mg ............................. 2

melatonin tr tab /vit-b6 ...................... 2

meloxicam tab 15mg .......................... 3

meloxicam tab 7.5mg ......................... 3 melphalan inj 50mg .......................... 26

meperidine sol 50mg/5ml .................... 5

meperidine tab 100mg ........................ 5

meperidine tab 50mg.......................... 5 MEPHYTON TAB 5MG ........................ 81

mercaptopur tab 50mg ..................... 27

meropenem inj 500mg ........................ 9

metadate tab 20mg er ........................ 1 metafiber pow 30.9% ....................... 59

metafiber pow 48.57% ..................... 59

metafiber pow 58.6% ....................... 59

METAMUCIL POW 28% ...................... 59

metamucil pow 30.9% ...................... 59 METAMUCIL POW 55.46% ................. 59

METAMUCIL POW 58.12% ................. 59

metamucil pow 58.6% ...................... 59

METAMUCIL POW CLEAR ................... 59 METAMUCIL WAF .............................. 59

metformin tab 1000mg ..................... 18

metformin tab 500mg ....................... 18

metformin tab 500mg er ................... 18 metformin tab 750mg er ................... 18

metformin tab 850mg ....................... 18

methadone sol 10mg/5ml.................... 5

methadone sol 5mg/5ml ..................... 5 methadone tab 10mg ......................... 5

methadone tab 5mg ........................... 5

methamphetam tab 5mg ..................... 1

100

methazolamid tab 25mg ....................50

methazolamid tab 50mg ....................50

methenam hip tab 1gm .....................79 methimazole tab 10mg ......................76

methimazole tab 5mg ........................75

METHITEST TAB 10MG ........................ 7

methocarbam tab 500mg ...................68 methocarbam tab 750mg ...................68

methotrexate tab 2.5mg ....................27

methyldopa tab 250mg ......................24

methyldopa tab 500mg ......................24 methylergon tab 0.2mg .....................72

methylphenid cap 10mg ..................... 1


methylphenid cap 20mg er .................. 1 methylphenid cap 30mg ..................... 1

methylphenid cap 30mg er .................. 2


methylphenid cap 40mg er .................. 2

methylphenid cap 50mg ..................... 2 methylphenid cap 60mg ..................... 2

methylphenid sol 10mg/5ml ................ 2

methylphenid sol 5mg/5ml .................. 2

methylphenid tab 10mg ...................... 2 methylphenid tab 10mg er .................. 2

methylphenid tab 18mg er .................. 2

methylphenid tab 20mg ...................... 2

methylphenid tab 20mg er .................. 2 methylphenid tab 27mg er .................. 2



methylphenid tab 5mg........................ 2

methylpred pak 4mg .........................43 methylpred tab 16mg ........................43

methylpred tab 32mg ........................43

methylpred tab 4mg ..........................43

methylpred tab 8mg ..........................43 metipranolol sol 0.3% oph .................70

metoclopram sol 5mg/5ml .................54

metoclopram tab 10mg .....................54

metoclopram tab 5mg .......................54 metolazone tab 10mg ........................51

metolazone tab 2.5mg .......................51

metolazone tab 5mg .........................51

metoprol tar tab 100mg .....................37 metoprol tar tab 25mg ......................37

metoprol tar tab 50mg ......................37

metoprolol tab 100mg er ...................37

metoprolol tab 200mg er ................... 37

metoprolol tab 25mg er .................... 37

metoprolol tab 50mg er .................... 37 metronidazol cre 0.75% .................... 49

metronidazol gel 0.75% .................... 49

metronidazol gel 0.75%vag ............... 80

metronidazol lot 0.75% ..................... 49 metronidazol tab 250mg ..................... 8

metronidazol tab 500mg ..................... 8

mexiletine cap 150mg....................... 10

mexiletine cap 200mg....................... 10 mexiletine cap 250mg....................... 10

mi-acid chw ....................................... 7

miconazole 3 cre 4% ........................ 80

miconazole 3 kit combo pk ................ 80 miconazole aer 2% ........................... 47

miconazole cre 2% ...................... 47, 80

miconazole sup 100mg ..................... 80

miconazorb pow af 2% ..................... 47

microgestin tab 1.5/30...................... 41 microgestin tab 1/20 ........................ 41

microgestin tab fe 1/20 ..................... 41

microgestin tab fe1.5/30 ................... 41

midodrine tab 10mg ......................... 81 midodrine tab 2.5mg ........................ 81

midodrine tab 5mg ........................... 81

milk of magn sus .............................. 60

MILK OF MAGN SUS 2400MG ............. 60 MINERAL OIL ................................... 60

mineral oil ene ................................. 60

minocycline cap 100mg ..................... 75

minocycline cap 50mg ...................... 75

minoxidil tab 10mg........................... 25 minoxidil tab 2.5mg.......................... 25

mintox plus chw ................................. 7

MIRENA IUD SYSTEM ........................ 43

mirtazapine tab 15mg ....................... 16 mirtazapine tab 30mg ....................... 16

mirtazapine tab 45mg ....................... 16

misoprostol tab 100mcg .................... 79

misoprostol tab 200mcg .................... 79 MISSION PREN TAB /FA .................... 67

MISSION PREN TAB HP ..................... 67

mitoxantron inj 20mg ....................... 27

mitoxantron inj 2mg/ml .................... 27 modafinil tab 100mg........................... 2

mometasone cre 0.1% ...................... 48

mometasone oin 0.1% ...................... 48

101

mono-linyah tab 0.25-35 ...................41

mononessa tab .................................41

montelukast chw 4mg .......................11 montelukast chw 5mg .......................11

montelukast tab 10mg.......................11

MONUROL PAK GRANULES .................79

morphine sul sol 10mg/5ml ................. 5 morphine sul sol 20mg/5ml ................. 5

morphine sul sol 20mg/ml .................. 5

morphine sul tab 100mg er ................. 6

morphine sul tab 15mg ....................... 5 morphine sul tab 15mg er ................... 6

morphine sul tab 30mg ....................... 6

morphine sul tab 30mg er ................... 6

morphine sul tab 60mg er ................... 6 mtest hs/est tab estrogen ..................52

mtest/est tab estrogen ......................53

MUCINEX D TAB 60-600MG ................44

mucus-dm tab 30-600mg ..................44

mult vitamin tab daily........................66 MULTAQ TAB 400MG .........................11

multi cap complete ............................66

MULTI PRENAT TAB ...........................67

multi vitamn tab minerals ..................66 multi-day tab /iron ............................65

multi-vit/fl chw 0.25mg .....................66

multi-vit/fl chw 1mg ..........................66

multi-vit/fl dro /fe 0.25 ......................66 multi-vit/fl dro 0.25mg ......................66

multi-vit/fl dro 0.5mg/ml ...................66

multivitamin cap ...............................66

multivitamin dro pediatrc ...................66

multivitamin liq mineral .....................66 mult-vit/fl chw 0.5mg ........................66

mupirocin oin 2% .............................46

M-VIT TAB 27-1MG ...........................67

my way tab 1.5mg ............................42 mycophenolat cap 250mg ..................36

mycophenolat tab 500mg ..................36

mycophenolic tab 180mg dr ...............36

mycophenolic tab 360mg dr ...............36 myorisan cap 10mg ...........................46

myorisan cap 20mg ...........................46

myorisan cap 40mg ...........................46

MYRBETRIQ TAB 25MG ......................80 MYRBETRIQ TAB 50MG ......................80

mytussin dac sol ...............................45

myzilra tab.......................................41

N nabumetone tab 500mg ...................... 3

nabumetone tab 750mg ...................... 4 nadolol tab 20mg ............................. 37

nadolol tab 40mg ............................. 37

nadolol tab 80mg ............................. 37

nafcillin inj 10gm ............................. 73 nafcillin inj 1gm ............................... 73

nafcillin inj 1gm pbk ......................... 73

nafcillin inj 2gm ............................... 73

nafcillin inj 2gm pbk ......................... 73 nallpen inj 10gm .............................. 74

nallpen inj 1gm ................................ 74

nallpen inj 2gm ................................ 74

naltrexone tab 50mg ........................ 21 NAMENDA SOL 10MG/5ML ................. 74

NAMENDA TAB 10MG ........................ 74

NAMENDA TAB 5-10MG ..................... 74

NAMENDA TAB 5MG .......................... 74

naphazoline sol 0.1% op ................... 70 naproxen dr tab 375mg ...................... 4

naproxen dr tab 500mg ...................... 4

naproxen sod tab 220mg .................... 4

naproxen sod tab 275mg .................... 4 naproxen sod tab 550mg .................... 4

naproxen sus 125/5ml ........................ 4

naproxen tab 250mg .......................... 4

naproxen tab 375mg .......................... 4 naproxen tab 500mg .......................... 4

naratriptan tab 1mg ......................... 63

naratriptan tab 2.5mg....................... 63

nasal decon liq 15mg/5ml ................. 69

NASAL DECONG LIQ 30MG/5ML ......... 69 nasal decong tab 10mg ..................... 69

NAT FIBER POW 58.6% ..................... 59

NATAL-V RX TAB 29-1MG .................. 67

nateglinide tab 120mg ...................... 20 nateglinide tab 60mg ........................ 20

NATURE-THROI TAB 130MG............... 77

NATURE-THROI TAB 16.25MG ............ 77

NATURE-THROI TAB 195MG............... 77 NATURE-THROI TAB 32.5MG.............. 77

NATURE-THROI TAB 48.75MG ............ 77

NATURE-THROI TAB 65MG ................ 77

NATURE-THROI TAB 97.5MG.............. 77 NEBULIZERS.................................... 63

NEBUPENT INH 300MG ....................... 8

necon tab 0.5/35 ............................. 41

102

necon tab 1/35 .................................41

necon tab 1/50-28 ............................41

necon tab 7/7/7 ................................41 neo/bac/poly oin op ..........................70

neo/poly/bac oin /hc 1%op ................71

neo/poly/dex oin 0.1% op ..................71

neo/poly/dex sus 0.1% op .................71 neo/poly/gra sol op ...........................70

neo/poly/hc sol 1% otic .....................71

neo/poly/hc sus 1% otic ....................71

neomycin tab 500mg .......................... 2 NEORAL CAP 100MG..........................36

NEORAL CAP 25MG ...........................36

NEORAL SOL 100MG/ML ....................36

NEULASTA INJ 6MG/0.6M...................57 NEUPOGEN INJ 300/0.5 .....................57

NEUPOGEN INJ 300MCG ....................57

NEUPOGEN INJ 480/0.8 .....................57

NEUPOGEN INJ 480MCG ....................57

nevirapine sus 50mg/5ml ...................33 nevirapine tab 200mg .......................33

nevirapine tab 400mg er ....................34

NEXAVAR TAB 200MG ........................28

NEXIUM 24HR CAP 20MG ...................79 next choice tab 0.75mg .....................42

next choice tab 1.5mg .......................42

niacin cap 250mg er ..........................81

niacin cap 500mg..............................38 niacin cap 500mg sr ..........................81

niacin tab 100mg ..............................81

niacin tab 250mg ..............................81

niacin tab 250mg sr ..........................81

niacin tab 500mg ..............................81 niacin tab 500mg er ..........................81

niacin tab 50mg ................................81

niacin tab 750mg tr ...........................81

niacinamide tab 500mg .....................81 niacor tab 500mg..............................23

nicardipine cap 20mg ........................38

nicardipine cap 30mg ........................38

nicotine dis 14mg/24h .......................75 nicotine dis 21mg/24h .......................75

nicotine dis 7mg/24hr .......................75

nicotine lozenge 2 mg .......................75

nicotine lozenge 4 mg .......................75 nicotine pol gum 2mg ........................75

nicotine pol gum 4mg ........................75

NICOTROL INH .................................75

NICOTROL NS SPR 10MG/ML ............. 75

nifedipine cap 20mg ......................... 38

nifedipine tab 30mg er ...................... 38 nifedipine tab 60mg er ...................... 38

nifedipine tab 90mg er ...................... 38

night time liq cgh/cold ...................... 45

nitrofur mac cap 100mg .................... 79 nitrofur mac cap 50mg ...................... 79

nitrofurantn cap 100mg .................... 79

nitroglycer cap 2.5mg er ..................... 9

nitroglycer cap 6.5mg er ..................... 9 nitroglycer cap 9mg er ........................ 9

nitroglycer dis 0.2mg/hr ...................... 9

nitroglycer dis 0.4mg/hr ...................... 9

nitroglycer dis 0.6mg/hr ...................... 9 NITROSTAT SUB 0.3MG ...................... 9

NITROSTAT SUB 0.4MG ...................... 9

NITROSTAT SUB 0.6MG ...................... 9

nizatidine cap 150mg ........................ 79

nizatidine sol 15mg/ml ...................... 79 non-pseudo tab 10mg ....................... 69

nora-be tab 0.35mg ......................... 43

norethin ace tab 5mg ....................... 74

norethindron tab 0.35mg .................. 43 norgest/eth tab estrad ...................... 41

norgest/ethi tab 0.25/35 ................... 41

norgest/ethi tab estradio ................... 41

NOROXIN TAB 400MG ....................... 53 nortrel tab 0.5/35 ............................ 41

nortrel tab 1/35 ............................... 41

nortrel tab 7/7/7 .............................. 41

nortriptylin cap 10mg ....................... 18

nortriptylin cap 25mg ....................... 18 nortriptylin cap 50mg ....................... 18

nortriptylin cap 75mg ....................... 18

NORVIR CAP 100MG ......................... 34

NORVIR SOL 80MG/ML ...................... 34 NORVIR TAB 100MG ......................... 34

NOVOLIN INJ 70/30 .......................... 19

NOVOLIN N INJ U-100 ...................... 19

NOVOLIN R INJ PENFILL .................... 19 NOVOLIN R INJ U-100 ...................... 19

NOVOLOG INJ 100/ML ...................... 19

NOVOLOG INJ FLEXPEN..................... 19

NOVOLOG INJ PENFILL ..................... 19 NOVOLOG MIX INJ 70/30 .................. 19

NOVOLOG MIX INJ FLEXPEN .............. 19

np thyroid tab 30mg ......................... 77

103

np thyroid tab 60mg .........................77

np thyroid tab 90mg .........................77

NUCYNTA TAB 100MG ........................ 6 NUCYNTA TAB 50MG .......................... 6

NUCYNTA TAB 75MG .......................... 6

NULOJIX INJ 250MG ..........................36

NUVARING MIS .................................42 NUVIGIL TAB 150MG .......................... 2

NUVIGIL TAB 250MG .......................... 2

NUVIGIL TAB 50MG ............................ 2

nystat/triam cre................................47 nystat/triam oin ................................47

nystatin cre 100000 ..........................47

nystatin oin 100000 ..........................47

nystatin pow 100000 .........................47 nystatin sus 100000 ..........................65

nystatin tab 500000 ..........................21

O ocella tab 3-0.03mg ..........................41

OCTAGAM INJ 5GM ...........................72 octreotide inj 100mcg ........................52

ofloxacin dro 0.3% op .......................70

ofloxacin dro 0.3%otic .......................71

ogestrel tab......................................41 olanzapine tab 10mg .........................31

olanzapine tab 15mg .........................31

olanzapine tab 2.5mg ........................31

olanzapine tab 20mg .........................31 olanzapine tab 5mg ...........................31

olanzapine tab 7.5mg ........................31

omega 3 cap 1000mg ........................69

omega-3 cap 1200mg .......................69

OMEPRAZOLE + SUS SYRSPEND .........79 omeprazole cap 10mg .......................79

omeprazole cap 20.6mgdr ..................79

omeprazole cap 20mg .......................79

OMEPRAZOLE TAB 20MG....................79 OMNIFLEX DPR .................................62

OMNITROPE INJ 5.8MG ......................51

ondansetron sol 4mg/5ml ..................21

ondansetron tab 4mg ........................21 ondansetron tab 4mg odt ...................21

ondansetron tab 8mg ........................21

ondansetron tab 8mg odt ...................21

ONFI TAB 10MG ................................14 ONFI TAB 20MG ................................14

ONFI TAB 5MG .................................14

ONGLYZA TAB 2.5MG ........................19

ONGLYZA TAB 5MG .......................... 19

oral saline sol laxative ...................... 60

ORAP TAB 1MG ................................ 75 ORAP TAB 2MG ................................ 75

ORFADIN CAP 10MG ......................... 52

ORFADIN CAP 2MG ........................... 52

ORFADIN CAP 5MG ........................... 52 orphenadrine tab 100mg er ............... 68

orsythia tab ..................................... 42

ORTHO COIL DPR KIT 100 ................. 62

ORTHO COIL DPR KIT 105 ................. 62 ORTHO COIL DPR KIT 50 ................... 62

ORTHO FLAT DPR KIT 55 ................... 62


ORTHO FLAT DPR KIT 65 ................... 62 ORTHO FLAT DPR KIT 70 ................... 62




ORTHO FLAT DPR KIT 90 ................... 62 ORTHO FLAT DPR KIT 95 ................... 62

ORTHO FLEX DPR 65MM .................... 62

ORTHO FLEX DPR 70MM .................... 62

ORTHO FLEX DPR 75MM .................... 62 ORTHO FLEX DPR 80MM .................... 62

ortho-est tab 0.625 .......................... 53

ortho-est tab 1.25 ............................ 53

os-cal 500 chw................................. 64 OSMOPREP TAB 1.5GM ..................... 60

oxacillin inj 10gm ............................. 74

oxacillin inj 2gm ............................... 74

oxandrolone tab 10mg ........................ 7

oxandrolone tab 2.5mg ....................... 7 oxaprozin tab 600mg .......................... 4

oxazepam cap 10mg ......................... 10

oxazepam cap 15mg ......................... 10

oxazepam cap 30mg ......................... 10 oxcarbazepin sus 300mg/5m ............. 14

oxcarbazepin tab 150mg ................... 14

oxcarbazepin tab 300mg ................... 14

oxcarbazepin tab 600mg ................... 15 OXSORALEN LOT 1% ........................ 49

oxybutynin syp 5mg/5ml ................... 54

oxybutynin tab 10mg er .................... 54

oxybutynin tab 15mg er .................... 54 oxybutynin tab 5mg ......................... 54

oxybutynin tab 5mg er ...................... 54

oxycod/apap tab 10-325mg ................. 6

104

oxycod/apap tab 5-325mg .................. 6

oxycodone tab 10mg .......................... 6

oxycodone tab 15mg .......................... 6 oxycodone tab 20mg .......................... 6

oxycodone tab 30mg .......................... 6

oxycodone tab 5mg ............................ 6

oxymorphone tab hcl 10mg ................. 6 oxymorphone tab hcl 5mg .................. 6

oys shell+d tab 250-125 ....................64

OYSCO 500+D CHW ..........................64

oyst shell/d tab 500mg ......................64 oyster shell tab 500mg ......................64

P pamix sus 50mg/ml ........................... 8

pancrelipase cap 5000unit .................50 PANGLOBULIN INJ 12GM ...................72

PANGLOBULIN SOL 12GM ..................72

PANRETIN GEL 0.1% .........................47

pantoprazole tab 20mg ......................79

pantoprazole tab 40mg ......................79 paroex sol 0.12% .............................65

paromomycin cap 250mg .................... 2

paroxetine tab 10mg .........................17

paroxetine tab 20mg .........................17 paroxetine tab 30mg .........................17

paroxetine tab 40mg .........................17

ped elctrlyt sol ..................................64

PEDIA-LAX LIQ 50MG ........................61 peg 3350 sol electrol .........................60

peg-3350 sol electrol .........................60

peg-3350/kcl sol /sodium ..................60

PEGASYS INJ ....................................35

PEGASYS INJ 180MCG/M ...................35 PEG-INTRON KIT 150MCG ..................35

pen g sod inj 5000000 .......................73

penicilln gk inj 20mu .........................73

penicilln vk sol 125/5ml .....................73 penicilln vk sol 250/5ml .....................73

penicilln vk tab 250mg ......................73

penicilln vk tab 500mg ......................73

pentoxifylli tab 400mg er ...................56 periogard sol 0.12% ..........................65

permethrin cre 5% ............................49

permethrin lot 1% ............................50

perphenazine tab 16mg .....................32 perphenazine tab 2mg .......................32

perphenazine tab 4mg .......................32

perphenazine tab 8mg .......................32

pfizerpen g inj 20mu ........................ 73

pfizerpen-g inj 20mu ........................ 73

phenazopyrid tab 100mg ................... 55 phenazopyrid tab 200mg ................... 55

phenelzine tab 15mg ........................ 16

phenobarb sol 20mg/5ml .................. 58

phenobarb tab 100mg ...................... 58 phenobarb tab 15mg ........................ 58

phenobarb tab 16.2mg ..................... 58

phenobarb tab 30mg ........................ 58

phenobarb tab 32.4mg ..................... 58 phenobarb tab 60mg ........................ 58

phenobarb tab 64.8mg ..................... 58

phenobarb tab 97.2mg ..................... 58

phenylbutyra pow sodium ................. 52 phenytoin chw 50mg ........................ 15

phenytoin ex cap 100mg ................... 15



phenytoin sus 125/5ml ..................... 15 philith tab 0.4-35 ............................. 42

PHISOHEX LIQ 3% ........................... 33

phospha 250 tab neutral ................... 65

phosphate sol laxative ...................... 60 physiosol sol irrigat .......................... 36

pilocarpine sol 1% op ....................... 70

pilocarpine sol 2% op ....................... 70

pilocarpine sol 4% op ....................... 70 pimtrea tab ..................................... 42

pink bismuth tab 262mg ................... 20

PIN-X CHW 250MG ............................. 8

pin-x sus 50mg/ml ............................. 8

pioglitazone tab 15mg ...................... 19 pioglitazone tab 30mg ...................... 20

pioglitazone tab 45mg ...................... 20

piper/tazoba inj 2-0.25gm ................. 73

piper/tazoba inj 3-0.375g .................. 73 piper/tazoba inj 4-0.5gm .................. 73

pirmella tab 1/35 ............................. 42

pirmella tab 7/7/7 ............................ 42

piroxicam cap 10mg ........................... 4 piroxicam cap 20mg ........................... 4

PNV FOLIC AC TAB + IRON ................ 67

podofilox sol 0.5% ........................... 49

poly bacitra oin ................................ 46 poly vitamin chw .............................. 66

polyeth glyc pow 3350 nf .................. 60

POLYGAM S/D SOL 10GM .................. 72

105

polysacchari cap iron .........................57

polyvitamin chw /iron ........................66

polyvitamin dro ................................66 polyvitamin dro /iron .........................66

portia-28 tab ....................................42

pot chloride cap 10meq er .................65

pot chloride cap 8meq er ...................65 pot chloride liq 10% ..........................65

pot chloride liq 20% ..........................65

pot chloride tab 10meq er ..................65

pot chloride tab 8meq er ....................65 pot citrate tab 1080mg ......................55

pot citrate tab 540mg ........................54

pot cl micro tab 10meq er ..................65

pot cl micro tab 20meq er ..................65 potassium tab 25meq ef ....................65

POTIGA TAB 200MG ..........................15

POTIGA TAB 400MG ..........................15

POTIGA TAB 50MG ............................15

pramipexole tab 0.125mg ..................29 pramipexole tab 0.25mg ....................29

pramipexole tab 0.5mg ......................29

pramipexole tab 0.75mg ....................29

pramipexole tab 1.5mg ......................29 pramipexole tab 1mg ........................29

pramoxine-hc dro aq otic ...................71

pravastatin tab 10mg ........................23

pravastatin tab 20mg ........................23 pravastatin tab 40mg ........................23

pravastatin tab 80mg ........................23

prazosin hcl cap 1mg .........................24

prazosin hcl cap 2mg .........................25

prazosin hcl cap 5mg .........................25 pred sod pho sol 5mg/5ml .................43

pred sod pho sol 6.7/5ml ...................43

prednicarbat cre 0.1% .......................48

prednicarbat oin 0.1% .......................48 prednisolone sol 15mg/5ml ................43

prednisolone sol 25mg/5ml ................43

prednisolone sus 1% op .....................71

prednisolone syp 15mg/5ml ...............43 prednisone pak 10mg ........................43

prednisone pak 5mg ..........................43

prednisone sol 5mg/5ml ....................43

prednisone tab 10mg ........................44 prednisone tab 1mg ..........................43

prednisone tab 2.5mg .......................44

prednisone tab 20mg ........................44

prednisone tab 50mg ........................ 44

prednisone tab 5mg.......................... 44

PREMARIN TAB 0.3MG ...................... 53 PREMARIN TAB 0.45MG .................... 53

PREMARIN TAB 0.625MG ................... 53

PREMARIN TAB 0.9MG ...................... 53

PREMARIN TAB 1.25MG .................... 53 PREMARIN VAG CRE 0.625MG ............ 80

PREMPHASE TAB .............................. 53

PREMPRO TAB .625-2.5 .................... 53

PREMPRO TAB 0.3-1.5 ...................... 53 PREMPRO TAB 0.45-1.5 .................... 53

PREMPRO TAB 0.625-5 ..................... 53

prenaplus tab .................................. 67

prenatabs fa tab............................... 67 prenatabs rx tab .............................. 67

prenatal 19 chw tab .......................... 67

prenatal 19 tab ................................ 67

prenatal ad tab ................................ 67

PRENATAL ONE TAB DAILY ................ 67 PRENATAL TAB................................. 67

PRENATAL TAB 27-0.8MG .................. 67

PRENATAL TAB 27-1MG..................... 67

PRENATAL TAB 28-0.8MG .................. 67 PRENATAL TAB COMPLETE ................. 67

PRENATAL TAB FORMULA .................. 67

PRE-NATAL TAB FORMULA ................. 67

PRENATAL TAB FORTE ...................... 67 PRENATAL TAB LOW IRON ................. 67

prenatal tab plus .............................. 67

PRENATAL TAB PLUS ........................ 67

prenatal tab plus fe .......................... 67

PRENATAL TAB VITAMINS ................. 67 PRENATAL VIT TAB PLUS ................... 67

PRENATAL/FE TAB ............................ 67

PRENTIF MIS 22MM .......................... 62

PRENTIF MIS 25MM .......................... 62 PRENTIF MIS 28MM .......................... 62

PRENTIF MIS 31MM .......................... 62

PRENTIF MIS FITTING ....................... 62

prevalite pow 4gm............................ 23 previfem tab .................................... 42

PREZISTA SUS 100MG/ML ................. 34

PREZISTA TAB 400MG ...................... 34

PREZISTA TAB 600MG ...................... 34 PREZISTA TAB 800MG ...................... 34

PRIFTIN TAB 150MG ......................... 26

PRILOSEC OTC TAB 20MG ................. 79

106

PRIMAQUINE TAB 26.3MG ..................26

primidone tab 250mg ........................15

primidone tab 50mg ..........................15 PRIVIGEN INJ 20GRAMS ....................72

PROAIR HFA AER ..............................12

proben/colch tab 500-0.5...................55

probenecid tab 500mg .......................55 prochlorper sup 25mg .......................32

prochlorper tab 10mg ........................32

prochlorper tab 5mg..........................32

PRO-CLEAR AC SYP ...........................45 PROCRIT INJ 10000/ML .....................57

PROCRIT INJ 2000/ML .......................57

PROCRIT INJ 20000/ML .....................57

PROCRIT INJ 4000/ML .......................57 PROCRIT INJ 40000/ML .....................57

proctosol hc cre 2.5%......................... 7

progesterone cap 100mg ...................74

progesterone cap 200mg ...................74

prometh vc syp 6.25-5/5 ...................45 prometh vc/ syp codeine ....................45

prometh/cod syp 6.25-10 ..................45

promethazine inj 25mg/ml .................22

promethazine sol 6.25/5ml ................22 promethazine sup 12.5mg .................22

promethazine sup 25mg ....................22

promethazine syp 6.25/5ml................22

promethazine syp dm ........................45 promethazine tab 12.5mg ..................22

promethazine tab 25mg .....................22

promethazine tab 50mg .....................22

promethegan sup 50mg .....................22

propafenone tab 150mg.....................11 propafenone tab 225mg.....................11

propafenone tab 300mg.....................11

proparacaine sol 0.5% op ..................71

propranolol cap 120mg er ..................37 propranolol cap 160mg er ..................37

propranolol cap 60mg er ....................37

propranolol cap 80mg er ....................37

propranolol sol 20mg/5ml ..................37 propranolol sol 40mg/5ml ..................37

propranolol tab 10mg ........................37


propranolol tab 40mg ........................37 propranolol tab 60mg ........................37


propylthiour tab 50mg .......................76

PROTOPIC OIN 0.03% ...................... 49

PROTOPIC OIN 0.1% ........................ 49

protriptylin tab 10mg ........................ 18 protriptylin tab 5mg ......................... 18

pseudoephedr syp 30mg/5ml ............. 69

pseudoephedr tab 120mg er .............. 69

pseudoephedr tab 30mg ................... 69 pseudoephedr tab 60mg ................... 69

psyllium pow 100% .......................... 59

PULMICORT INH 180MCG .................. 11

PULMICORT INH 90MCG .................... 11 PULMOZYME SOL 1MG/ML ................. 75

pure & gentl dro 0.3% ...................... 69

PX PRENATAL TAB MULTIVIT ............. 67

pyrazinamide tab 500mg ................... 26 pyridostigm tab 60mg ....................... 26

pyridoxine tab 100mg ....................... 81

pyridoxine tab 25mg ......................... 81

pyridoxine tab 50mg ......................... 81

Q qc natural pow vegetabl .................... 59

QC PRENATAL TAB 28-0.8MG ............. 67

q-pap liq 160/5ml .............................. 5

q-tapp dm elx .................................. 45 q-tapp elx 1-15/5ml ......................... 45

q-tussin dm syp 100-10/5 ................. 45

quadrapax elx .................................. 78

quetiapine tab 100mg ....................... 31 quetiapine tab 200mg ....................... 31

quetiapine tab 25mg......................... 31

quetiapine tab 300mg ....................... 31

quetiapine tab 400mg ....................... 31

quetiapine tab 50mg......................... 31 QUFLORA PED CHW 0.25MG .............. 66

QUFLORA PED CHW 0.5MG ................ 66

QUFLORA PED CHW 1MG ................... 66

quinapril tab 10mg ........................... 24 quinapril tab 20mg ........................... 24

quinapril tab 40mg ........................... 24

quinapril tab 5mg ............................. 24

quinidine su tab 300mg..................... 10 quinine sulf cap 324mg ..................... 26

QVAR AER 40MCG ............................ 11

QVAR AER 80MCG ............................ 11

R ra allergy tab sinus ........................... 45

ra calcium+d tab 600mg ................... 64

ra fiber tab 500mg ........................... 59

107

ra lice kit solution .............................50

RA PRENATAL TAB 28-0.8MG ..............67

RA PRENATAL TAB FORMULA ..............67 raloxifene tab 60mg ..........................51

RANEXA TAB 1000MG ......................... 9

RANEXA TAB 500MG .......................... 9

ranitidine syp 15mg/ml ......................79 ranitidine tab 150mg .........................79

ranitidine tab 300mg .........................79

ranitidine tab 75mg ...........................79

RAPAMUNE SOL 1MG/ML ....................36 RAPAMUNE TAB 1MG .........................36

RAPAMUNE TAB 2MG .........................36

reclipsen tab ....................................42

reeses med sus pinworm .................... 8 RELENZA MIS DISKHALE....................35

REMODULIN INJ 1MG/ML ...................38

REMODULIN INJ 2.5MG/ML ................38

REMODULIN INJ 5MG/ML ...................38

renal tab multivit ..............................65 rena-vite rx tab ................................65

reno cap ..........................................65

RENVELA PAK 0.8GM .........................54

RENVELA PAK 2.4GM .........................54 RENVELA TAB 800MG ........................54

RESCRIPTOR TAB 100 MG ..................34

RESCRIPTOR TAB 100MG ...................34

RESCRIPTOR TAB 200MG ...................34 RESPIRATORY MASKS .......................63

REVLIMID CAP 10MG .........................35

REVLIMID CAP 15MG .........................35

REVLIMID CAP 25MG .........................35

REVLIMID CAP 5MG...........................35 REYATAZ CAP 150MG ........................34

REYATAZ CAP 200MG ........................34

REYATAZ CAP 300MG ........................34

RHOGAM PLUS INJ 300MCG ...............72 ribavirin cap 200mg ..........................35

ribavirin tab 200mg ...........................35

RIDAURA CAP 3MG ............................ 3

rifabutin cap 150mg ..........................26 rifampin cap 150mg ..........................26

rifampin cap 300mg ..........................26

RIGHT STEP TAB PRENATAL ...............67

riluzole tab 50mg ..............................69 rimantadine tab 100mg .....................35

RISPERDAL INJ 12.5MG .....................30

RISPERDAL INJ 25MG ........................30

RISPERDAL INJ 37.5MG .................... 30

RISPERDAL INJ 50MG ....................... 30

risperidone sol 1mg/ml ..................... 30 risperidone tab 0.25mg ..................... 30

risperidone tab 0.5mg ....................... 30

risperidone tab 0.5mg od .................. 30

risperidone tab 1mg ......................... 31 risperidone tab 1mg odt .................... 31

risperidone tab 2mg ......................... 31

risperidone tab 2mg odt .................... 31

risperidone tab 3mg ......................... 31 risperidone tab 3mg odt .................... 31

risperidone tab 4mg ......................... 31

risperidone tab 4mg odt .................... 31

RITALIN LA CAP 10MG ........................ 2 RITUXAN INJ 100MG......................... 27

RITUXAN INJ 500MG......................... 27

RIXUBIS INJ 1000UNIT ..................... 56

RIXUBIS INJ 2000UNIT ..................... 56

RIXUBIS INJ 250 UNIT ...................... 56 RIXUBIS INJ 3000UNIT ..................... 56

RIXUBIS INJ 500UNIT ....................... 56

rizatriptan tab 10mg ......................... 63

rizatriptan tab 5mg........................... 63 robitussin liq cgh/cong ...................... 45

robitussin liq nighttim ....................... 45

robitussin liq to go dm ...................... 45

robitussin syp 7.5/5ml ...................... 44 ropinirole tab 0.25mg ....................... 29

ropinirole tab 0.5mg ......................... 29

ropinirole tab 1mg ............................ 29


ropinirole tab 3mg ............................ 29 ropinirole tab 4mg ............................ 29


rynex pse liq .................................... 45

S SABRIL POW 500MG ......................... 15

SABRIL TAB 500MG .......................... 15

saline ene laxative ............................ 60

saline nasal spr 0.65% ...................... 68 salsalate tab 500mg ........................... 5

salsalate tab 750mg ........................... 5

SANDIMMUNE CAP 100MG................. 36

SANDIMMUNE CAP 25MG .................. 36 SANDOGLOBULI INJ IV 12GM ............ 72

SANDOSTATIN KIT LAR 20MG ............ 52

SANDOSTATIN KIT LAR 30MG ............ 52

108

SAPHRIS SUB 10MG ..........................31

SAPHRIS SUB 5MG ............................31

sb fib lax pow 33% ...........................59 se-donna elx pb hyos ........................78

selegiline cap 5mg ............................29

selegiline tab 5mg .............................29

selenium sul lot 2.5% ........................47 selenium sul sha 2.5% ......................47

SELZENTRY TAB 150MG .....................34

SELZENTRY TAB 300MG .....................34

SE-NATAL 19 CHW ............................67 SE-NATAL ONE TAB ...........................67

senna syp 8.8mg/5 ...........................61

SENNA TAB 187MG ...........................61

senna tab 25mg................................61 senna tab 8.6mg ..............................61

senna-s tab 8.6-50mg .......................60

SENSIPAR TAB 30MG ........................52

SENSIPAR TAB 60MG ........................52

SENSIPAR TAB 90MG ........................52 SEREVENT DIS AER 50MCG ................12

SEROQUEL XR TAB 150MG .................32

SEROQUEL XR TAB 200MG .................32

SEROQUEL XR TAB 300MG .................32 SEROQUEL XR TAB 400MG .................32

SEROQUEL XR TAB 50MG ...................31

sertraline con 20mg/ml .....................17

sertraline tab 100mg .........................17 sertraline tab 25mg ...........................17

sertraline tab 50mg ...........................17

sildenafil tab 20mg............................39

silver sulfa cre 1% ............................47

simethicone chw 125mg ....................53 simethicone chw 80mg ......................53

simethicone dro 40/0.6ml ..................53

SIMPONI INJ 100MG/ML ..................... 3

SIMPONI INJ 50MG ............................ 3 simvastatin tab 10mg ........................23

simvastatin tab 20mg ........................23

simvastatin tab 40mg ........................23

simvastatin tab 5mg..........................23 sinus/conges tab 10mg ......................69

sirolimus tab 0.5mg ..........................36

sleep aid tab 25mg ...........................58

sleep aid tab 50mg ...........................58 sleep tab 25mg.................................58

slow iron tab 50mg ...........................58

slow release tab 47.5mg ....................58

sm fiber lax tab 500mg ..................... 59

sm ibuprofen tab 100mg jr .................. 4

sm iron tab 45mg ............................. 58 SM PRENATAL TAB VITAMINS ............ 67

smz/tmp ds tab 800-160 ..................... 8

smz-tmp sus 200-40/5 ....................... 8

smz-tmp tab 400-80mg ...................... 8 sod chloride neb 0.9% ...................... 45

sod chloride oin 5% op ..................... 71

sod chloride sol 5% op ...................... 71

sod chloride tab 1000mg ................... 65 sod fluoride dro 0.5mg/ml ................. 64

sod fluoride tab 0.5mg f .................... 64

sod poly sul pow .............................. 36

sodium bicar tab 10gr ......................... 8 sodium bicar tab 325mg...................... 8

sodium bicar tab 650mg...................... 8

sodium chlor neb 3% ........................ 45

sodium chlor neb 7% ........................ 45

sodium chlor sol 0.9% irr .................. 55 solia tab .......................................... 42

soluble fib tab therapy ...................... 60

sotalol af tab 120mg ......................... 37

sotalol af tab 80mg .......................... 37 sotalol hcl tab 120mg ....................... 37

sotalol hcl tab 160mg ....................... 37

sotalol hcl tab 240mg ....................... 37

sotalol hcl tab 80mg ......................... 37 SPACERS......................................... 63

spinosad sus 0.9% ........................... 50

spirono/hctz tab 25/25 ..................... 50

spironolact tab 100mg ...................... 51

spironolact tab 25mg ........................ 51 spironolact tab 50mg ........................ 51

sprintec 28 tab 28 day ...................... 42

SPRYCEL TAB 100MG ........................ 28

SPRYCEL TAB 140MG ........................ 28 SPRYCEL TAB 20MG .......................... 28

SPRYCEL TAB 50MG .......................... 28

SPRYCEL TAB 70MG .......................... 28

sronyx tab ....................................... 42 st joseph co syp 7.5/5ml ................... 44

stavudine cap 20mg ......................... 34

stavudine cap 30mg ......................... 34

stavudine cap 40mg ......................... 34 steril water sol irrig .......................... 36

STIMATE SOL 1.5MG/ML ................... 52

STIVARGA TAB 40MG ....................... 28

109

stomach rlf chw 400mg ...................... 8

stool softnr cap 50mg ........................61

STRATTERA CAP 100MG ..................... 1 STRATTERA CAP 10MG ....................... 1

STRATTERA CAP 18MG ....................... 1

STRATTERA CAP 25MG ....................... 1

STRATTERA CAP 40MG ....................... 1 STRATTERA CAP 60MG ....................... 1

STRATTERA CAP 80MG ....................... 1

streptomycin inj 1gm ......................... 2

streptomycin via 1gm ......................... 2 STRIBILD TAB ..................................34

STROMECTOL TAB 3MG ...................... 8

STUART PREN TAB ............................67

sucralfate tab 1gm ............................79 SUDAFED PE SOL CHILDREN ..............69

sudogest pe tab 10mg .......................69

sulf/pred na sol op ............................71

sulfacet sod sol 10% op .....................70

SULFADIAZINE TAB 500MG ................75 SULFAMYLON CRE 85MG/GM ..............47

SULFAMYLON PAK 5% .......................47

sulfasalazin tab 500mg ......................54

sulfasalazin tab 500mg dr ..................54 sulfatrim pd sus 200-40/5 ................... 8

sulindac tab 150mg ............................ 4

sulindac tab 200mg ............................ 4

sumatriptan tab 100mg .....................63 sumatriptan tab 25mg .......................63

sumatriptan tab 50mg .......................63

suphedrine tab 10mg ........................69

suphedrine tab pe 10mg ....................69

SUPRAX SUS 100/5ML .......................40 SUPRAX SUS 200/5ML .......................40

SUPRAX TAB 400MG ..........................40

SUSTIVA CAP 200MG ........................34

SUSTIVA CAP 50MG ..........................34 SUSTIVA TAB 600MG ........................34

SUTENT CAP 12.5MG .........................28

SUTENT CAP 25MG............................28

SUTENT CAP 50MG............................28 syeda tab 3-0.03mg ..........................42

SYMBICORT AER 160-4.5 ...................12

SYMBICORT AER 80-4.5.....................12

SYNAGIS INJ 100MG/ML ....................72 SYNAGIS INJ 50MG ...........................72

SYNAREL SOL 2MG/ML ......................52

SYNTHROID TAB 100MCG ..................77

SYNTHROID TAB 112MCG ................. 77


SYNTHROID TAB 137MCG ................. 77 SYNTHROID TAB 150MCG ................. 77



SYNTHROID TAB 25MCG ................... 77 SYNTHROID TAB 300MCG ................. 77

SYNTHROID TAB 50MCG ................... 77

SYNTHROID TAB 75MCG ................... 77

SYNTHROID TAB 88MCG ................... 77 SYPRINE CAP 250MG ........................ 35

T tacrolimus cap 0.5mg ....................... 36

tacrolimus cap 1mg .......................... 36 TAMIFLU CAP 30MG .......................... 35

TAMIFLU CAP 45MG .......................... 35

TAMIFLU CAP 75MG .......................... 35

TAMIFLU SUS 6MG/ML ...................... 35

tamoxifen tab 10mg ......................... 27 tamoxifen tab 20mg ......................... 27

tamsulosin cap 0.4mg ....................... 55

TARCEVA TAB 100MG ....................... 28

TARCEVA TAB 150MG ....................... 28 TARCEVA TAB 25MG ......................... 28

TASIGNA CAP 150MG ....................... 28

TASIGNA CAP 200MG ....................... 28

TEGRETOL-XR TAB 100MG ................ 15 temazepam cap 15mg ...................... 58

temazepam cap 30mg ...................... 58

temozolomide cap 100mg ................. 26


temozolomide cap 180mg ................. 26 temozolomide cap 20mg ................... 26


temozolomide cap 5mg ..................... 26

terazosin cap 10mg .......................... 25 terazosin cap 1mg ............................ 25

terazosin cap 2mg ............................ 25

terazosin cap 5mg ............................ 25

terbinafine cre 1%............................ 47 terbinafine tab 250mg ...................... 21

terbutaline tab 2.5mg ....................... 12

terbutaline tab 5mg .......................... 12

terconazole cre 0.4% ........................ 80 terconazole cre 0.8% ........................ 80

terconazole sup 80mg ....................... 80

testost cyp inj 100mg/ml .................... 7

110

testost cyp inj 200mg/ml .................... 7

testost enan inj 200mg/ml .................. 7

tetracycline cap 250mg......................75 tetracycline cap 500mg......................75

TEV-TROPIN INJ 5MG ........................51

TH PRENATAL TAB VITAMINS .............67

THALOMID CAP 100MG ......................35 theophylline sol 80/15ml....................12

theophylline tab 100mg er .................12


theophylline tab 300mg er .................12 theophylline tab 400mg er .................12



THERANATAL TAB 27-1 ......................68 THIOGUANINE TAB 40MG ..................27

thioridazine tab 100mg ......................32

thioridazine tab 10mg........................32

thioridazine tab 25mg........................32

thioridazine tab 50mg........................32 thiothixene cap 10mg ........................33

thiothixene cap 1mg ..........................33

thiothixene cap 2mg ..........................33

thiothixene cap 5mg ..........................33 THYROGEN INJ 1.1MG .......................50

tiagabine tab 2mg .............................15

tiagabine tab 4mg .............................15

ticlopidine tab 250mg ........................56 TIKOSYN CAP 125MCG ......................11

TIKOSYN CAP 250MCG ......................11

TIKOSYN CAP 500MCG ......................11

tilia fe tab ........................................42

TIMENTIN INJ 3.1GM .........................73 timolol gel sol 0.25% op ....................70

timolol gel sol 0.5% op ......................70

timolol mal sol 0.25% op ...................70

timolol mal sol 0.5% op .....................70 timolol mal tab 10mg ........................37

timolol mal tab 20mg ........................37

timolol mal tab 5mg ..........................37

tioconazole oin 6.5% vag ...................80 tizanidine tab 2mg ............................68

tizanidine tab 4mg ............................68

tl icon cap ........................................57

tobra/dexame sus 0.3-0.1% ...............71 TOBRADEX OIN 0.3-0.1% ..................71

tobramycin neb 300/5ml ..................... 2

tobramycin sol 0.3% op .....................70

TODAY SPONGE MIS ......................... 62

tolbutamide tab 500mg ..................... 20

tolnaftate aer 1% ............................. 47 tolnaftate cre 1% ........................ 47, 50

tolnaftate pow 1% ............................ 47

tolnaftate sol 1% ............................. 47

tolterodine tab 1mg .......................... 54 tolterodine tab 2mg .......................... 54

topiramate cap 15mg........................ 15

topiramate cap 25mg........................ 15

topiramate tab 100mg ...................... 15 topiramate tab 200mg ...................... 15

topiramate tab 25mg ........................ 15

topiramate tab 50mg ........................ 15

topotecan inj 4mg ............................ 28 torsemide tab 100mg ....................... 51

torsemide tab 10mg ......................... 50

torsemide tab 20mg ......................... 51

torsemide tab 5mg ........................... 50

total fiber pow ................................. 60 TRACLEER TAB 125MG ...................... 39

TRACLEER TAB 62.5MG ..................... 39

TRADJENTA TAB 5MG ....................... 19

tramadol hcl tab 50mg ........................ 6 tranex acid inj 100mg/ml .................. 58

TRANSDERM-SC DIS 1.5MG............... 21

tranylcyprom tab 10mg ..................... 16

TRAVATAN Z DRO 0.004% ................ 71 travoprost dro 0.004% ..................... 71

trazodone tab 100mg ....................... 16

trazodone tab 150mg ....................... 16

trazodone tab 300mg ....................... 16

trazodone tab 50mg ......................... 16 tretinoin cap 10mg ........................... 28

tretinoin cre 0.025% ........................ 46

tretinoin cre 0.05% .......................... 46

tretinoin cre 0.1% ............................ 46 tretinoin gel 0.01% .......................... 46

tretinoin gel 0.025% ......................... 46

triacting nt liq cold/cgh ..................... 45

triadvance tab ................................. 68 triamcinolon cre 0.025% ................... 48

triamcinolon cre 0.1% ...................... 48

triamcinolon cre 0.5% ...................... 48

triamcinolon lot 0.025% .................... 48 triamcinolon lot 0.1% ....................... 48

triamcinolon oin 0.025% ................... 49

triamcinolon oin 0.1% ....................... 49

111

triamcinolon oin 0.5% .......................49

triamcinolon pst 0.1% .......................65

triaminic syp cough ...........................44 triamt/hctz cap 37.5-25 .....................50

triamt/hctz tab 37.5-25 .....................50

triamt/hctz tab 75-50mg ...................50

triazolam tab 0.125mg ......................58 triazolam tab 0.25mg ........................58

tricon cap ........................................57

tri-estaryll tab ..................................42

trifluoperaz tab 10mg ........................32 trifluoperaz tab 1mg ..........................32

trifluoperaz tab 2mg ..........................32

trifluoperaz tab 5mg ..........................32

trifluridine sol 1% op .........................70 trihexyphen elx 0.4mg/ml ..................29

trihexyphen tab 2mg .........................29

trihexyphen tab 5mg .........................29

tri-legest tab fe ................................42

tri-linyah tab ....................................42 trimethoprim sol polymyxn ................70

trimethoprim tab 100mg ..................... 8

trinate tab........................................68

trinessa tab ......................................42 triple antib oin ..................................46

triple antib oin plus ...........................46

tri-previfem tab ................................42

tri-sprintec tab .................................42 tri-vit/fe dro /fl 0.25 ..........................66

tri-vit/fluo dro 0.25mg .......................66

tri-vit/fluo dro 0.5mg ........................66

tri-vitamin dro ..................................66

trivora-28 tab ...................................42 TRIZIVIR TAB ...................................34

TROJAN MIS NATULAMB ....................62

tropicamide sol 0.5% op ....................70

tropicamide sol 1% op .......................70 trospium cl tab 20mg ........................54

TRUERESULT KIT ..............................63

TRUETEST TES .................................50

TRUVADA TAB 200-300 .....................34 TUDORZA PRES AER 400/ACT.............11

tussin dm liq 100-10/5 ......................45

tussin dm liq 10-200/5 ......................45

tussin dm syp 100-10/5 .....................45 TYKERB TAB 250MG ..........................28

TYSABRI INJ 300/15ML......................75

TYZEKA TAB 600MG ..........................35

TYZINE PED DRO 0.05% ................... 69

TYZINE SOL 0.1% ............................ 69

U ULESFIA LOT 5% ............................. 50

ultra tabs tab ................................... 68

unifed liq 30mg/5ml ......................... 69

UNIFIBER POW ................................ 60 unith direct tab 100mcg .................... 77

unith direct tab 112mcg .................... 77


unith direct tab 150mcg .................... 77 unith direct tab 175mcg .................... 77


unith direct tab 25mcg ...................... 77

unith direct tab 300mcg .................... 77 unith direct tab 50mcg ...................... 77



unithroid tab 100mcg ....................... 77

unithroid tab 112mcg ....................... 77 unithroid tab 125mcg ....................... 78



unithroid tab 175mcg ....................... 78 unithroid tab 200mcg ....................... 78

unithroid tab 25mcg ......................... 77


unithroid tab 50mcg ......................... 77 unithroid tab 75mcg ......................... 77

unithroid tab 88mcg ......................... 77

ursodiol cap 300mg .......................... 53

V vacuant plus ene 20-283 ................... 61 VAGIFEM TAB 10MCG ....................... 80

valacyclovir tab 1gm ......................... 35

valacyclovir tab 500mg ..................... 35

VALCYTE SOL 50MG/ML .................... 34 VALCYTE TAB 450MG ........................ 34

valproic acd cap 250mg .................... 16

valproic acd sol 250/5ml ................... 16

vancomycin cap 125mg ...................... 8 vancomycin cap 250mg ...................... 8

veg fiber pow 63% ........................... 60

velivet pak ...................................... 42

venlafaxine cap 150mg er ................. 17 venlafaxine cap 37.5 er ..................... 17

venlafaxine cap 75mg er ................... 17

venlafaxine tab 100mg ..................... 17

112

venlafaxine tab 25mg ........................17

venlafaxine tab 37.5mg .....................17

venlafaxine tab 50mg ........................17 venlafaxine tab 75mg ........................17

VENOGLOBUL-S INJ 10% ...................72

VENTOLIN HFA AER ...........................12

VERACOLATE TAB .............................61 verapamil cap 100mg er ....................38

verapamil cap 120mg er ....................38

verapamil cap 180mg er ....................38

verapamil cap 240mg er ....................38 verapamil cap 300mg er ....................38

verapamil cap 360mg sr ....................38

verapamil tab 120mg ........................38

verapamil tab 120mg er ....................38 verapamil tab 180mg er ....................38

verapamil tab 240mg er ....................38

verapamil tab 40mg ..........................38

verapamil tab 80mg ..........................38

vestura tab 3-0.02mg........................42 VICTRELIS CAP 200MG ......................35

VIMPAT SOL 10MG/ML .......................15

VIMPAT TAB 100MG ..........................15

VIMPAT TAB 150MG ..........................15 VIMPAT TAB 200MG ..........................15

VIMPAT TAB 50MG ............................15

VINATE ONE TAB ..............................68

viorele tab .......................................42 VIRACEPT TAB 250MG .......................34

VIRACEPT TAB 625MG .......................34

VIREAD TAB 150MG ..........................34

VIREAD TAB 300MG ..........................34

virt-vite tab plus ...............................65 VISICOL TAB 1.5GM ..........................60

vitamin b-12 sub 1000mcg ................56

vitamin b-12 sub 2500mcg ................56

vitamin b-12 sub 500mcg ..................56 vitamin b12 tab 1000 cr ....................56

vitamin b-12 tab 1000mcg .................56

vitamin b-12 tab 100mcg ...................56

vitamin b-12 tab 250mcg ...................56 vitamin b-12 tab 500mcg ...................56

vitamin b-6 tab 200mg cr ..................81

vitamin d cap 1000unit ......................81

vitamin d dro 400unit ........................81 vitamin d3 cap 10000unt ...................81

vitamin d3 cap 2000unit ....................81

vitamin d3 cap 50000unt ...................81

vitamin d3 cap 5000unit ................... 81

vitamin d3 chw 1000unit ................... 81

vitamin d3 chw 400unit ..................... 81 vitamin d3 dro 5000unit .................... 81

vitamin d3 tab 1000unit .................... 81

vitamin d-3 tab 2000unit................... 81

vitamin d3 tab 400unit...................... 81 vitamin d-3 tab 5000unit................... 81

VOL-PLUS TAB ................................. 68

VOL-TAB RX TAB .............................. 68

VOLTAREN GEL 1% .......................... 46 VOTRIENT TAB 200MG ...................... 28

vyfemla tab 0.4-35 ........................... 42

W wal-dryl alr tab 12.5mg .................... 22 wal-dryl-d tab alrg/sin ...................... 45

wal-tap dm elx cold/cgh .................... 45

wal-tap elx cld/alle ........................... 45

warfarin tab 10mg ............................ 13

warfarin tab 1mg ............................. 13 warfarin tab 2.5mg ........................... 13

warfarin tab 2mg ............................. 13

warfarin tab 3mg ............................. 13

warfarin tab 4mg ............................. 13 warfarin tab 5mg ............................. 13

warfarin tab 6mg ............................. 13

warfarin tab 7.5mg ........................... 13

wee care sus 15/1.25 ....................... 58 wera tab 0.5/35 ............................... 42

WESTHROID TAB 130MG ................... 78

WESTHROID TAB 16.25MG ................ 78

WESTHROID TAB 195MG ................... 78

WESTHROID TAB 32.5MG .................. 78 WESTHROID TAB 48.75MG ................ 78

WESTHROID TAB 65MG .................... 78

WESTHROID TAB 97.5MG .................. 78

WESTHROID-P TAB 130MG ................ 78 WESTHROID-P TAB 16.25MG ............. 78

WESTHROID-P TAB 32.5MG ............... 78

WESTHROID-P TAB 48.75MG ............. 78

WESTHROID-P TAB 65MG ................. 78 WESTHROID-P TAB 97.5MG ............... 78

WIDE-SEAL DPR KIT 60 .................... 62

WIDE-SEAL DPR KIT 65 .................... 62

WIDE-SEAL DPR KIT 70 .................... 62 WIDE-SEAL DPR KIT 75 .................... 62

WIDE-SEAL DPR KIT 80 .................... 62

WIDE-SEAL DPR KIT 85 .................... 62

113

WIDE-SEAL DPR KIT 90 .....................62

WIDE-SEAL DPR KIT 95 .....................62

WP THYROID TAB 130MG ...................78 WP THYROID TAB 16.25MG ................78

WP THYROID TAB 32.5MG ..................78

WP THYROID TAB 48.75MG ................78

WP THYROID TAB 65MG ....................78 WP THYROID TAB 97.5MG ..................78

wymzya fe chw 0.4mg-35 ..................42

X XARELTO TAB 10MG ..........................13 XARELTO TAB 15MG ..........................13

XARELTO TAB 20MG ..........................13

XOLAIR SOL 150MG ..........................11

xulane dis 150-35 .............................42 XYREM SOL 500MG/ML ......................74

Z zarah tab 3-0.03mg ..........................42

zenatane cap 10mg ...........................46

zenatane cap 20mg ...........................46 zenatane cap 40mg ...........................46

zenchent fe chw 0.4mg-35 .................42

zenchent tab ....................................42

zenzedi tab 10mg .............................. 1 zenzedi tab 5mg ................................ 1

zeosa chw ........................................42

ZIAGEN SOL 20MG/ML ......................34

zidovudine cap 100mg ...................... 34

zidovudine syp 50mg/5ml ................. 34

zidovudine tab 300mg ...................... 34 zinc sulfate cap 220mg ..................... 65

ZINC-OXYDE OIN 0.44-20% .............. 49

ziprasidone cap 20mg ....................... 30

ziprasidone cap 40mg ....................... 30 ziprasidone cap 60mg ....................... 30

ziprasidone cap 80mg ....................... 30

ZIRGAN GEL 0.15% .......................... 70

ZOLADEX IMP 10.8MG ...................... 27 ZOLADEX IMP 3.6MG ........................ 27

zolpidem tab 10mg ........................... 59

zolpidem tab 5mg ............................ 59

zonisamide cap 100mg ..................... 15 zonisamide cap 25mg ....................... 15

zonisamide cap 50mg ....................... 15

ZORTRESS TAB 0.25MG .................... 36

ZORTRESS TAB 0.5MG ...................... 36

ZORTRESS TAB 0.75MG .................... 36 zovia 1/35e tab ................................ 42

zovia 1/50e tab ................................ 42

ZOVIRAX CRE 5% ............................ 47

ZYTIGA TAB 250MG .......................... 27 ZYVOX SUS 100MG/5M ....................... 9

ZYVOX TAB 600MG ............................. 9

2015 formulary/ formulario - molina healthcare · 2015-01-07 · 45376 marketplace ca formulary...

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