2015 formulary (list of covered drugs) - blue cross … formulary (list of covered drugs) drug list...

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Y0096_MRK_IL_MAFRMLRY15a Accepted 10012014

This formulary was updated on 11/20/2015. For more recent information or other questions, please contact Blue Cross Medicare AdvantageSM Customer Service, at 1-877-774-8592 or, for TTY/TDD users, 711, 8 a.m. - 8 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on weekends and holidays, or visit www.getblueil.com/mapd/druglist.

Note to existing members: This formulary has changed since last year. Please review this document to make sure it still contains the drugs you take.

850970.1115

Blue Cross Medicare Advantage (HMO)SM Blue Cross Medicare Advantage (HMO-POS)SM

Blue Cross Medicare Advantage (PPO)SM

2015 Formulary (List of Covered Drugs)PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

HPMS Approved Formulary File ID: 00015390, Version 14

This information is available for free in other languages. Please call our Customer Service number at 1-877-774-8592. (TTY/TDD users should call 711). We are open between 8 a.m. and 8 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on the weekends and holidays.

Esta información está disponible en otros idiomas de forma gratuita. Comuníquese a nuestro número de Servicio al cliente al 1-877-774-8592 (los usuarios de TTY/TDD deben llamar al 711). Nuestro horario es de 8 a.m. a 8 p.m., hora local, los 7 días de la semana. Si usted llama del 15 de febrero al 30 de septiembre, durante los fines de semana y feriados, se usarán tecnologías alternas (por ejemplo, correo de voz).

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

Note to existing members: This formulary has changed since last year. Please review this document to make sure it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Blue Cross and Blue Shield of Illinois. When it refers to “plan” or “our plan,” it means Blue Cross Medicare Advantage.

This document includes a list of the drugs (formulary) for our plan which is current as of November 2015. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2015, and from time to time during the year.

Blue Cross Medicare Advantage2015 Formulary

(List of Covered Drugs)

Drug List

iii

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

Can the Formulary (drug list) change?Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of November 20, 2015. To get updated information about the drugs covered by Blue Cross Medicare Advantage, please contact us. Our contact information appears on the front and back cover pages.

How do I use the Formulary? There are two ways to find your drug within the formulary:

Medical Condition

The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that begins on page 135. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

Drug

List

iv

What are generic drugs? Blue Cross Medicare Advantage covers both brand name drugs and generic drugs. A generic drug is

approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Are there any restrictions on my coverage?Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

• Prior Authorization: Blue Cross Medicare Advantage requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Blue Cross Medicare Advantage before you fill your prescriptions. If you don’t get approval, Blue Cross Medicare Advantage may not cover the drug.

• Quantity Limits: For certain drugs, Blue Cross Medicare Advantage limits the amount of the drug that Blue Cross Medicare Advantage will cover. For example, Blue Cross Medicare Advantage provides 30 tablets per prescription for alfuzosin ER. This may be in addition to a standard one-month or three-month supply.

• Step Therapy: In some cases, Blue Cross Medicare Advantage requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Blue Cross Medicare Advantage may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Blue Cross Medicare Advantage will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask Blue Cross Medicare Advantage to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the Blue Cross Medicare Advantage’s formulary?” on page v for information about how to request an exception.

Drug List

v

What if my drug is not on the Formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered.

If you learn that Blue Cross Medicare Advantage does not cover your drug, you have two options:

• You can ask Customer Service for a list of similar drugs that are covered by Blue Cross Medicare Advantage. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Blue Cross Medicare Advantage.

• You can ask Blue Cross Medicare Advantage to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the Blue Cross Medicare Advantage’s Formulary?You can ask Blue Cross Medicare Advantage to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Blue Cross Medicare Advantage limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, Blue Cross Medicare Advantage will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

Drug

List

vi

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with 91 to 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

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

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

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

Drug List

vii

For more informationFor more detailed information about your Blue Cross Medicare Advantage prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Blue Cross Medicare Advantage, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

Blue Cross Medicare Advantage’s FormularyThe formulary that begins on the next page provides coverage information about the drugs covered by Blue Cross Medicare Advantage. If you have trouble finding your drug in the list, turn to the Index that begins on page 135.

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

The information in the Requirements/Limits column tells you if Blue Cross Medicare Advantage has any special requirements for coverage of your drug.

KEY Uppercase = BRAND-NAME

Lower case italics = generics

Tier 1 = Preferred Generic Drugs

Tier 2 = Non-Preferred Generic Drugs

Tier 3 = Preferred Brand Drugs

Tier 4 = Non-Preferred Brand Drugs

Tier 5 = Specialty Drugs

X = Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance

• = Utilization Management: Prior Authorization, Quantity Limits, Step Therapy

* = Limited distribution drug. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Customer Service at 1-877-774-8592, hours of operation. TTY/TDD users should call 711.

† = Quantity limit restrictions apply. Restriction amounts are listed beginning on page 109.

# = High Risk Medication (HRM). Medicine that may be unsafe in patients greater than 65 years of age. Our formulary does include coverage for some of these drugs, but alternatives may be found in lower copay tiers. Please discuss with your doctor if there are alternatives to these medications that would be appropriate for you to use.

= We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence of Coverage for more information about this coverage.

The last three columns, Prior Authorization, Quantity Limit and Step Therapy, indicate if Blue Cross Medicare Advantage has any special requirements for coverage of that drug.

Drug

List

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KEYcaps capsules lotn lotion

chew tabs chewable tablets mcg microgram

conc concentrate mEq milliequivalent

crm cream mg milligram

DR delayed-release mL milliliter

ER extended-release NF non-formulary

g gram ODT orally disintegrating tablets

hr hour oint ointment

IM intramuscular SL sublingual

inhal inhalation soln solution

inj injection supp suppositories

IR immediate-release susp suspension

IV intravenous tabs tablets

liq liquid

Drug List

Copayment and Coinsurance Amounts:Tier 1 - Preferred Generic Drugs: $0/$0

Tier 2 - Non-Preferred Generic Drugs: $6/$18

Tier 3 - Preferred Brand Drugs: $39/$117

Tier 4 - Non-Preferred Brand Drugs: $85/$255

Tier 5 - Specialty Drugs: 33%

You must continue to pay your Medicare Part B premium. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year.

Below is the key for abbreviations used within the drug list.

2015

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.1 = Preferred Generic Drugs 2 = Non-Preferred Generic Drugs 3 = Preferred Brand Drugs4 = Non-Preferred Brand Drugs 5 = Specialty Drugs • = Utilization Management (UM)X = Drugs that may be covered by Medicare Part B or Medicare Part D depending on the circumstance† = Quantity limit restrictions for these drugs are listed beginning on page 109* = Limited Distribution Drug # = High Risk Medication (HRM)^ = We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidenceof Coverage for more information about this coverage.

1

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

AnalgesicsABSTRAL - fentanyl citrate sl tab

100 mcg5 • •

ABSTRAL - fentanyl citrate sl tab200 mcg

5 • •


5 • •


5 • •


5 • •


5 • •

acetaminophen w/ codeine soln120-12 mg/5ml^

2 •

acetaminophen w/ codeine tab300-15 mg^

2 •


2 •


2 •

butorphanol tartrate inj 1 mg/ml^ 2butorphanol tartrate inj 2 mg/ml^ 2butorphanol tartrate nasal soln

10 mg/ml^2

CELEBREX - celecoxib cap50 mg

3 •


3 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


3 •


3 •

celecoxib cap 50 mg^ 2 •celecoxib cap 100 mg^ 2 •celecoxib cap 200 mg^ 2 •celecoxib cap 400 mg^ 2 •codeine sulfate tab 15 mg^ 2 •codeine sulfate tab 30 mg^ 2 •codeine sulfate tab 60 mg^ 2 •diclofenac potassium tab 50 mg^ 2diclofenac sodium tab delayed

release 25 mg^2

diclofenac sodium tab delayedrelease 50 mg^

2


2

diclofenac sodium tab sr 24hr100 mg^

2

diclofenac w/ misoprostol tabdelayed release 50-0.2 mg^

2


2

etodolac cap 200 mg^ 2etodolac cap 300 mg^ 2etodolac tab sr 24hr 400 mg^ 2etodolac tab sr 24hr 500 mg^ 2etodolac tab sr 24hr 600 mg^ 2

2015


2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

etodolac tab 400 mg^ 2etodolac tab 500 mg^ 2fentanyl citrate lozenge on a

handle 200 mcg5 • •

fentanyl citrate lozenge on ahandle 400 mcg

5 • •


5 • •


5 • •


5 • •


5 • •

fentanyl td patch 72hr 12 mcg/hr^ 2 •fentanyl td patch 72hr 25 mcg/hr^ 2 •fentanyl td patch 72hr 50 mcg/hr^ 2 •fentanyl td patch 72hr 75 mcg/hr^ 2 •fentanyl td patch 72hr 100 mcg/

hr^2 •

flurbiprofen tab 50 mg^ 2flurbiprofen tab 100 mg^ 2hydrocodone-acetaminophen soln

7.5-325 mg/15ml^2 •

hydrocodone-acetaminophen tab10-325 mg^

2 •


2 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

hydrocodone-acetaminophen tab7.5-300 mg^

2 •


2 •

hydrocodone-acetaminophen tab7.5-325 mg^

2 •


2 •

hydrocodone-ibuprofen tab2.5-200 mg^

2 •

hydrocodone-ibuprofen tab5-200 mg^

2 •

hydrocodone-ibuprofen tab7.5-200 mg^

2 •

hydrocodone-ibuprofen tab10-200 mg^

2 •

hydromorphone hcl liqd 1 mg/ml^ 2 •hydromorphone hcl preservative

free (pf) inj 10 mg/ml^2 X

hydromorphone hcl tab 2 mg^ 2 •hydromorphone hcl tab 4 mg^ 2 •hydromorphone hcl tab 8 mg^ 2 •ibuprofen susp 100 mg/5ml^ 2ibuprofen tab 400 mg^ 2ibuprofen tab 600 mg^ 2ibuprofen tab 800 mg^ 2ketoprofen cap 50 mg^ 2ketoprofen cap 75 mg^ 2

2015


3

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

ketorolac tromethamine tab10 mg#

4 •

LAZANDA - fentanyl citrate nasalspray 100 mcg/act

5 • •

LAZANDA - fentanyl citrate nasalspray 400 mcg/act

5 • •

LEVORPHANOL TARTRATE -levorphanol tartrate tab 2 mg

4 •

meloxicam tab 7.5 mg^ 2meloxicam tab 15 mg^ 2methadone hcl tab 5 mg^ 2 •methadone hcl tab 10 mg^ 2 •MORPHINE SULFATE - morphine

sulfate tab 15 mg4 •

MORPHINE SULFATE - morphinesulfate tab 30 mg

4 •

morphine sulfate cap sr 24hr10 mg^

2 •

morphine sulfate inj pf 0.5 mg/ml^ 2 Xmorphine sulfate inj pf 1 mg/ml^ 2 Xmorphine sulfate oral soln

10 mg/5ml^2 •

morphine sulfate oral soln20 mg/5ml^

2 •

morphine sulfate oral soln100 mg/5ml (20 mg/ml)^

2 •

morphine sulfate tab cr 15 mg^ 2 •morphine sulfate tab cr 30 mg^ 2 •morphine sulfate tab cr 60 mg^ 2 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

morphine sulfate tab cr 100 mg^ 2 •morphine sulfate tab cr 200 mg^ 2 •nabumetone tab 500 mg^ 2nabumetone tab 750 mg^ 2naproxen sodium tab 275 mg^ 2naproxen sodium tab 550 mg^ 2naproxen susp 125 mg/5ml^ 2naproxen tab ec 375 mg^ 2naproxen tab ec 500 mg^ 2naproxen tab 250 mg^ 2naproxen tab 375 mg^ 2naproxen tab 500 mg^ 2NUCYNTA ER - tapentadol hcl

tab sr 12hr 50 mg3 •

NUCYNTA ER - tapentadol hcltab sr 12hr 100 mg

3 •


3 •


3 •


3 •

OPANA ER (CRUSHRESISTANT) - oxymorphonehcl tab er 12hr deter 5 mg

3 •

OPANA ER (CRUSHRESISTANT) - oxymorphonehcl tab er 12hr deter 7.5 mg

3 •

2015


4

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


3 •


3 •


3 •


3 •


3 •

oxaprozin tab 600 mg^ 2oxycodone hcl tab 5 mg^ 2 •oxycodone hcl tab 10 mg^ 2 •oxycodone hcl tab 15 mg^ 2 •oxycodone hcl tab 20 mg^ 2 •oxycodone hcl tab 30 mg^ 2 •oxycodone w/ acetaminophen tab

2.5-325 mg^2 •

oxycodone w/ acetaminophen tab5-325 mg^

2 •

oxycodone w/ acetaminophen tab7.5-325 mg^

2 •

oxycodone w/ acetaminophen tab10-325 mg^

2 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

oxycodone-aspirin tab4.8355-325 mg^

2 •

OXYCONTIN - oxycodone hcl taber 12hr deter 10 mg

3 •


3 •


3 •


3 •


3 •


3 •


3 •

piroxicam cap 10 mg^ 2piroxicam cap 20 mg^ 2SUBSYS - fentanyl sublingual

spray 100 mcg5 • •

SUBSYS - fentanyl sublingualspray 200 mcg

5 • •


5 • •


5 • •


5 • •

SUBSYS - fentanyl sublingualspray 1200 mcg (600 mcg x 2)

5 • •

2015


5

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

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y

SUBSYS - fentanyl sublingualspray 1600 mcg (800 mcg x 2)

5 • •

sulindac tab 150 mg^ 2sulindac tab 200 mg^ 2tolmetin sodium cap 400 mg^ 2tramadol hcl tab sr 24hr 100 mg^ 2 •tramadol hcl tab sr 24hr 200 mg^ 2 •tramadol hcl tab sr 24hr 300 mg^ 2 •tramadol hcl tab 50 mg^ 2 •tramadol-acetaminophen tab

37.5-325 mg^2 •

VOLTAREN - diclofenacsodium gel 1%

3 •

ZOHYDRO ER - hydrocodonebitartrate cap sr 12hr abuse-deterrent 10 mg

4 • •


4 • •


4 • •


4 • •


4 • •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


4 • •

ZOHYDRO ER - hydrocodonebitartrate cap sr 12hr 10 mg

4 • •


4 • •


4 • •


4 • •


4 • •


4 • •Anestheticslidocaine hcl gel 2%^ 2lidocaine hcl local inj 1%^ 2lidocaine hcl local preservative

free (pf) inj 1%^2

lidocaine hcl soln 4%^ 2lidocaine hcl viscous soln 2%^ 2lidocaine oint 5%^ 2lidocaine patch 5%^ 2 •lidocaine-prilocaine cream

2.5-2.5%^2

Anti-Addiction/Substance Abuse Treatment Agentsacamprosate calcium tab delayed

release 333 mg^2

buprenorphine hcl sl tab 2 mg^ 2 •

2015


6

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

buprenorphine hcl sl tab 8 mg^ 2 •buprenorphine hcl-naloxone hcl sl

tab 2-0.5 mg^2 •

buprenorphine hcl-naloxone hcl sltab 8-2 mg^

2 •

bupropion hcl (smoking deterrent)tab sr 12hr 150 mg^

2

BUTRANS - buprenorphine tdpatch weekly 5 mcg/hr

3 •

BUTRANS - buprenorphine tdpatch weekly 7.5 mcg/hr

3 •


3 •


3 •


3 •

CHANTIX - varenicline tartratetab 0.5 mg

3 •

CHANTIX - varenicline tartratetab 1 mg

3 •

CHANTIX CONTINUING MONTH- varenicline tartrate tab 1 mg

3 •

CHANTIX STARTING MONTHPACK - varenicline tartrate tab0.5 mg x 11 & tab 1 mg x 42pack

3 •

disulfiram tab 250 mg^ 2disulfiram tab 500 mg^ 2naloxone hcl inj 0.4 mg/ml^ 2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

naloxone hcl inj 1 mg/ml^ 2naltrexone hcl tab 50 mg^ 2NICOTROL INHALER - nicotine

inhaler system 10 mg (4 mgdelivered)

4

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

4

SUBOXONE - buprenorphine hcl-naloxone hcl sl film 2-0.5 mg

4 •

SUBOXONE - buprenorphine hcl-naloxone hcl sl film 4-1 mg

4 •


4 •


4 •

VIVITROL - naltrexone for imextended release susp 380 mg

5

Antibacterialsamikacin sulfate inj 500 mg/2ml

(250 mg/ml)^2

amikacin sulfate inj 1 gm/4ml(250 mg/ml)^

2

amoxicillin (trihydrate) cap250 mg^

2

amoxicillin (trihydrate) cap500 mg^

2

amoxicillin (trihydrate) for susp125 mg/5ml^

2


2

2015


7

Requirements/Limits

Drug Name Dru

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B o

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Prio

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horiz

atio

n

Qua

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Lim

its †

Ste

p Th

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y


2


2

amoxicillin (trihydrate) tab500 mg^

2

amoxicillin (trihydrate) tab875 mg^

2

amoxicillin & k clavulanate chewtab 200-28.5 mg^

2

amoxicillin & k clavulanate chewtab 400-57 mg^

2

amoxicillin & k clavulanate forsusp 200-28.5 mg/5ml^

2

amoxicillin & k clavulanate forsusp 400-57 mg/5ml^

2

amoxicillin & k clavulanate forsusp 600-42.9 mg/5ml^

2

amoxicillin & k clavulanate tab250-125 mg^

2


2


2

AMPICILLIN - ampicillin for susp125 mg/5ml

4

AMPICILLIN - ampicillin for susp250 mg/5ml

4

ampicillin & sulbactam sodium forinj 2-1 gm^

2

ampicillin cap 250 mg^ 2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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Prio

r Aut

horiz

atio

n

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ntity

Lim

its †

Ste

p Th

erap

y

ampicillin cap 500 mg^ 2AMPICILLIN SODIUM - ampicillin

sodium for iv soln 1 gm4

AMPICILLIN SODIUM - ampicillinsodium for iv soln 2 gm

4

ampicillin sodium for inj 250 mg^ 2ampicillin sodium for inj 500 mg^ 2ampicillin sodium for inj 1 gm^ 2ampicillin sodium for inj 2 gm^ 2ampicillin sodium for iv soln

10 gm^2

AVELOX - moxifloxacin hcl400 mg/250ml in sodiumchloride 0.8% inj

3

AZACTAM - aztreonam indextrose inj 1 gm/50 ml

4

AZACTAM - aztreonam indextrose inj 2 gm/50 ml

4

AZITHROMYCIN - azithromycinpowd pack for susp 1 gm

4

azithromycin for susp100 mg/5ml^

2

azithromycin for susp200 mg/5ml^

2

azithromycin iv for soln 500 mg^ 2azithromycin tab 250 mg^ 2azithromycin tab 500 mg^ 2azithromycin tab 600 mg^ 2aztreonam for inj 1 gm^ 2

2015


8

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

aztreonam for inj 2 gm^ 2BICILLIN L-A - penicillin g

benzathine intramuscular susp600000 unit/ml

4

BICILLIN L-A - penicillin gbenzathine intramuscular susp1200000 unit/2ml

4

BICILLIN L-A - penicillin gbenzathine intramuscular susp2400000 unit/4ml

4

cefaclor cap 250 mg^ 2cefaclor cap 500 mg^ 2cefadroxil cap 500 mg^ 2cefadroxil for susp 250 mg/5ml^ 2cefadroxil for susp 500 mg/5ml^ 2cefadroxil tab 1 gm^ 2cefazolin sodium for inj 500 mg^ 2cefazolin sodium for inj 1 gm^ 2cefazolin sodium for inj 10 gm^ 2cefazolin sodium for inj 20 gm^ 2cefdinir cap 300 mg^ 2cefdinir for susp 125 mg/5ml^ 2cefdinir for susp 250 mg/5ml^ 2cefepime hcl for inj 1 gm^ 2cefepime hcl for inj 2 gm^ 2cefotaxime sodium for inj

500 mg^2

cefotaxime sodium for inj 1 gm^ 2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

cefotaxime sodium for inj 2 gm^ 2cefotaxime sodium for inj 10 gm^ 2cefoxitin sodium for inj 10 gm^ 2cefoxitin sodium for iv soln 1 gm^ 2cefoxitin sodium for iv soln 2 gm^ 2cefpodoxime proxetil for susp

50 mg/5ml^2

cefpodoxime proxetil for susp100 mg/5ml^

2

cefpodoxime proxetil tab 100 mg^ 2cefpodoxime proxetil tab 200 mg^ 2cefprozil for susp 125 mg/5ml^ 2cefprozil for susp 250 mg/5ml^ 2cefprozil tab 250 mg^ 2cefprozil tab 500 mg^ 2ceftazidime for inj 1 gm^ 2ceftazidime for inj 2 gm^ 2ceftazidime for inj 6 gm^ 2ceftazidime for iv soln 1 gm^ 2ceftazidime for iv soln 2 gm^ 2CEFTRIAXONE IN ISO-

OSMOTIC - ceftriaxone sodiumin dextrose inj 20 mg/ml

4

CEFTRIAXONE IN ISO-OSMOTIC - ceftriaxone sodiumin dextrose inj 40 mg/ml

4

ceftriaxone sodium for inj250 mg^

2

2015


9

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

ceftriaxone sodium for inj500 mg^

2

ceftriaxone sodium for inj 1 gm^ 2ceftriaxone sodium for inj 2 gm^ 2ceftriaxone sodium for inj 10 gm^ 2ceftriaxone sodium for iv soln

1 gm^2

ceftriaxone sodium for iv soln2 gm^

2

CEFTRIAXONE/DEXTROSE -ceftriaxone sodium for iv soln1 gm and dextrose 3.74%

4

CEFTRIAXONE/DEXTROSE -ceftriaxone sodium for iv soln2 gm and dextrose 2.22%

4

cefuroxime axetil tab 250 mg^ 2cefuroxime axetil tab 500 mg^ 2cefuroxime sodium for inj

750 mg^2

cefuroxime sodium for inj 1.5 gm^ 2cefuroxime sodium for inj 7.5 gm^ 2cefuroxime sodium for iv soln

1.5 gm^2

cephalexin cap 250 mg^ 2cephalexin cap 500 mg^ 2cephalexin cap 750 mg^ 2cephalexin for susp 125 mg/5ml^ 2cephalexin for susp 250 mg/5ml^ 2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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horiz

atio

n

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ntity

Lim

its †

Ste

p Th

erap

y

CHLORAMPHENICOL SODIUMSUCCINATE - chloramphenicolsodium succinate for iv inj 1 gm

4

CIPRO - ciprofloxacin fororal susp 250 mg/5ml (5%)(5 gm/100ml)

4

CIPRO - ciprofloxacin for oralsusp 500 mg/5ml (10%)(10 gm/100ml)

4

ciprofloxacin for oral susp250 mg/5ml (5%) (5 gm/100ml)^

2

ciprofloxacin for oral susp500 mg/5ml (10%)(10 gm/100ml)^

2

ciprofloxacin hcl tab 100 mg^ 2ciprofloxacin hcl tab 250 mg^ 2ciprofloxacin hcl tab 500 mg^ 2ciprofloxacin hcl tab 750 mg^ 2ciprofloxacin iv soln 200 mg/20ml

(1%)^2

ciprofloxacin iv soln 400 mg/40ml(1%)^

2

ciprofloxacin-ciprofloxacin hcl tabsr 24hr 500 mg^

2

ciprofloxacin-ciprofloxacin hcl tabsr 24hr 1000 mg^

2

ciprofloxacin 200 mg/100ml ind5w^

2

ciprofloxacin 400 mg/200ml ind5w^

2

2015


10

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

CLAFORAN/D5W - cefotaximesodium in d5w iv soln1 gm/50ml

4

CLAFORAN/D5W - cefotaximesodium in d5w iv soln2 gm/50ml

4

clarithromycin for susp125 mg/5ml^

2

clarithromycin for susp250 mg/5ml^

2

clarithromycin tab sr 24hr500 mg^

2

clarithromycin tab 250 mg^ 2clarithromycin tab 500 mg^ 2clindamycin hcl cap 75 mg^ 2clindamycin hcl cap 150 mg^ 2clindamycin hcl cap 300 mg^ 2clindamycin phosphate in d5w iv

soln 300 mg/50ml^2

clindamycin phosphate in d5w ivsoln 600 mg/50ml^

2

clindamycin phosphate in d5w ivsoln 900 mg/50ml^

2

clindamycin phosphate inj300 mg/2ml^

2


2


2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

clindamycin phosphate inj9 gm/60ml^

2

clindamycin phosphate iv soln600 mg/4ml^

2

clindamycin phosphate iv soln900 mg/6ml^

2

clindamycin phosphate vaginalcream 2%^

2

colistimethate sodium for inj150 mg^

2

CUBICIN - daptomycin for iv soln500 mg

5

DALVANCE - dalbavancin hcl foriv soln 500 mg

5

demeclocycline hcl tab 150 mg^ 2demeclocycline hcl tab 300 mg^ 2dicloxacillin sodium cap 250 mg^ 2dicloxacillin sodium cap 500 mg^ 2DIFICID - fidaxomicin tab 200 mg 5doxycycline hyclate cap 50 mg^ 2doxycycline hyclate cap 100 mg^ 2doxycycline hyclate for inj

100 mg^2

doxycycline hyclate tab 20 mg^ 2doxycycline hyclate tab 100 mg^ 2doxycycline monohydrate cap

50 mg^2

doxycycline monohydrate cap75 mg^

2

2015


11

Requirements/Limits

Drug Name Dru

g Ti

er

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horiz

atio

n

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ntity

Lim

its †

Ste

p Th

erap

y


2


2

doxycycline monohydrate tab50 mg^

2


2


2


2

E.E.S. GRANULES -erythromycin ethylsuccinate forsusp 200 mg/5ml

4

ERY-TAB - erythromycin tabdelayed release 250 mg

4


4


4

ERYPED 200 - erythromycinethylsuccinate for susp200 mg/5ml

4

ERYPED 400 - erythromycinethylsuccinate for susp400 mg/5ml

4

ERYTHROCIN LACTOBIONATE -erythromycin lactobionate for inj500 mg

4

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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horiz

atio

n

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ntity

Lim

its †

Ste

p Th

erap

y

ERYTHROCIN LACTOBIONATE -erythromycin lactobionate for inj1000 mg

4

ERYTHROCIN STEARATE -erythromycin stearate tab250 mg

4

ERYTHROMYCIN BASE -erythromycin tab 250 mg

4

ERYTHROMYCIN BASE -erythromycin tab 500 mg

4

FORTAZ - ceftazidime for inj500 mg

4

FORTAZ - ceftazidime sodium ind5w inj 1 gm/50ml

4

FORTAZ - ceftazidime sodium ind5w inj 2 gm/50ml

4

gentamicin in saline inj 0.8 mg/ml^

2

gentamicin in saline inj 1 mg/ml^ 2gentamicin in saline inj 1.2 mg/

ml^2

gentamicin in saline inj 1.6 mg/ml^

2

gentamicin sulfate inj 10 mg/ml^ 2gentamicin sulfate inj 40 mg/ml^ 2gentamicin sulfate iv soln 10 mg/

ml^2

GENTAMICIN SULFATE/0.9%SODIUM CHLORIDE- gentamicin in saline inj 0.9 mg/ml

4

2015


12

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

GENTAMICIN SULFATE/0.9%SODIUM CHLORIDE- gentamicin in saline inj 1.4 mg/ml

4

imipenem-cilastatin intravenousfor soln 250 mg^

2

imipenem-cilastatin intravenousfor soln 500 mg^

2

INVANZ - ertapenem sodium forinj 1 gm

4

INVANZ - ertapenem sodium foriv inj 1 gm

4

KANAMYCIN SULFATE -kanamycin sulfate inj 333 mg/ml

4

levofloxacin in d5w iv soln250 mg/50ml^

2


2


2

levofloxacin iv soln 25 mg/ml^ 2levofloxacin oral soln 25 mg/ml^ 2levofloxacin tab 250 mg^ 2levofloxacin tab 500 mg^ 2levofloxacin tab 750 mg^ 2linezolid iv soln 2 mg/ml 5linezolid tab 600 mg 5 •MEFOXIN - cefoxitin sodium iv

soln 1 gm/50ml in dextrose2 gm/50ml

4

Requirements/Limits

Drug Name Dru

g Ti

er

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atio

n

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ntity

Lim

its †

Ste

p Th

erap

y

MEFOXIN - cefoxitin sodium ivsoln 2 gm/50ml in dextrose1.1 gm/50ml

4

meropenem iv for soln 500 mg^ 2meropenem iv for soln 1 gm^ 2methenamine hippurate tab

1 gm^2

METRO IV - metronidazolein nacl 0.74% iv soln500 mg/100ml

4

metronidazole cap 375 mg^ 2metronidazole in nacl 0.79% iv

soln 500 mg/100ml^2

metronidazole tab 250 mg^ 2metronidazole tab 500 mg^ 2metronidazole vaginal gel 0.75%^ 2minocycline hcl cap 50 mg^ 2minocycline hcl cap 75 mg^ 2minocycline hcl cap 100 mg^ 2minocycline hcl tab 50 mg^ 2minocycline hcl tab 75 mg^ 2minocycline hcl tab 100 mg^ 2moxifloxacin hcl tab 400 mg^ 2NAFCILLIN SODIUM - nafcillin

sodium for iv soln 1 gm4

NAFCILLIN SODIUM - nafcillinsodium for iv soln 2 gm

4

nafcillin sodium for inj 1 gm^ 2

2015


13

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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horiz

atio

n

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ntity

Lim

its †

Ste

p Th

erap

y

nafcillin sodium for inj 2 gm^ 2nafcillin sodium for inj 10 gm^ 2neomycin sulfate tab 500 mg^ 2neomycin-polymyxin b gu

irrigation soln^2

nitrofurantoin macrocrystallinecap 50 mg#

4 •

nitrofurantoin macrocrystallinecap 100 mg#

4 •

nitrofurantoin monohydratemacrocrystalline cap 100 mg#

4 •

nitrofurantoin susp 25 mg/5ml# 4 •ofloxacin tab 400 mg^ 2paromomycin sulfate cap

250 mg^2

penicillin g potassium for inj5000000 unit^

2

penicillin g potassium for inj20000000 unit^

2

PENICILLIN G POTASSIUMIN DEXTROSE - penicillin gpotassium inj 20000 unit/ml indextrose

4

PENICILLIN G POTASSIUMIN DEXTROSE - penicillin gpotassium inj 40000 unit/ml indextrose

4

PENICILLIN G POTASSIUMIN DEXTROSE - penicillin g

4

Requirements/Limits

Drug Name Dru

g Ti

er

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horiz

atio

n

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ntity

Lim

its †

Ste

p Th

erap

y

potassium inj 60000 unit/ml indextrose

PENICILLIN G SODIUM -penicillin g sodium for inj5000000 unit

4

penicillin v potassium for soln125 mg/5ml^

2

penicillin v potassium for soln250 mg/5ml^

2

penicillin v potassium tab250 mg^

2

penicillin v potassium tab500 mg^

2

piperacillin sodium-tazobactamsodium for inj 2-0.25 gm^

2


2


2

SIVEXTRO - tedizolid phosphatetab 200 mg

5 •

SIVEXTRO - tedizolid phosphatefor iv soln 200 mg

5

STREPTOMYCIN SULFATE -streptomycin sulfate for inj 1 gm

4

SULFADIAZINE - sulfadiazine tab500 mg

4

sulfamethoxazole-trimethoprimsusp 200-40 mg/5ml^

2

sulfamethoxazole-trimethoprimtab 400-80 mg^

2

2015


14

Requirements/Limits

Drug Name Dru

g Ti

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horiz

atio

n

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ntity

Lim

its †

Ste

p Th

erap

y

sulfamethoxazole-trimethoprimtab 800-160 mg^

2

SULFAMETHOXAZOLE/TRIMETHOPRIM -sulfamethoxazole-trimethoprimiv soln 400-80 mg/5ml

4

SUPRAX - cefixime cap 400 mg 4SUPRAX - cefixime chew tab

100 mg4

SUPRAX - cefixime chew tab200 mg

4

SYNERCID - quinupristin-dalfopristin for inj 500 mg(150-350 mg)

5

TEFLARO - ceftaroline fosamil foriv soln 400 mg

4

TEFLARO - ceftaroline fosamil foriv soln 600 mg

4

TETRACYCLINE HCL -tetracycline hcl cap 250 mg

4

TETRACYCLINE HCL -tetracycline hcl cap 500 mg

4

tobramycin sulfate for inj 1.2 gm^ 2tobramycin sulfate inj 10 mg/ml^ 2tobramycin sulfate inj 80 mg/2ml

(40 mg/ml)^2

tobramycin sulfate inj1.2 gm/30ml (40 mg/ml)^

2

tobramycin sulfate inj 2 gm/50ml(40 mg/ml)^

2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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horiz

atio

n

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ntity

Lim

its †

Ste

p Th

erap

y

TOBRAMYCIN SULFATE/SODIUM - tobramycin sulfate inj0.8 mg/ml in saline

4

trimethoprim tab 100 mg^ 2TYGACIL - tigecycline for iv soln

50 mg4

vancomycin hcl cap 125 mg 5vancomycin hcl cap 250 mg 5vancomycin hcl for inj 500 mg^ 2vancomycin hcl for inj 1000 mg^ 2vancomycin hcl for inj 5000 mg^ 2vancomycin hcl for inj 10 gm^ 2VANCOMYCIN HCL IN

DEXTROSE - vancomycin hcl indextrose inj 500 mg/100ml

4

VANCOMYCIN HCL INDEXTROSE - vancomycin hcl indextrose inj 750 mg/150ml

4

VANCOMYCIN HCL INDEXTROSE - vancomycin hcl indextrose inj 1 gm/200ml

4

XIFAXAN - rifaximin tab 550 mg 5ZINACEF - cefuroxime in sterile

water inj 1.5 gm/50ml4

ZOSYN - piperacillin sod-tazobactam sod in dex iv soln2-0.25gm/50ml

4

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

4

2015


15

Requirements/Limits

Drug Name Dru

g Ti

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n

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ntity

Lim

its †

Ste

p Th

erap

y

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

4

ZYVOX - linezolid tab 600 mg 5 •ZYVOX - linezolid for susp

100 mg/5ml5 •

ZYVOX - linezolid iv soln 2 mg/ml 5AnticonvulsantsAPTIOM - eslicarbazepine

acetate tab 200 mg4

APTIOM - eslicarbazepineacetate tab 400 mg

4


4


4

BANZEL - rufinamide susp40 mg/ml

5

BANZEL - rufinamide tab 200 mg 4BANZEL - rufinamide tab 400 mg 5carbamazepine cap sr 12hr

100 mg^2

carbamazepine cap sr 12hr200 mg^

2

carbamazepine cap sr 12hr300 mg^

2

carbamazepine chew tab100 mg^

2

carbamazepine susp100 mg/5ml^

2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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horiz

atio

n

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ntity

Lim

its †

Ste

p Th

erap

y

carbamazepine tab sr 12hr200 mg^

2

carbamazepine tab sr 12hr400 mg^

2

carbamazepine tab 200 mg^ 2CELONTIN - methsuximide cap

300 mg4

clonazepam orally disintegratingtab 0.125 mg^

2 • •


2 • •


2 • •

clonazepam orally disintegratingtab 1 mg^

2 • •


2 • •

clonazepam tab 0.5 mg^ 2 • •clonazepam tab 1 mg^ 2 • •clonazepam tab 2 mg^ 2 • •clorazepate dipotassium tab

3.75 mg^2 • •

clorazepate dipotassium tab7.5 mg^

2 • •

clorazepate dipotassium tab15 mg^

2 • •

DIASTAT ACUDIAL - diazepamrectal gel delivery system 10 mg

4 •

DIASTAT ACUDIAL - diazepamrectal gel delivery system 20 mg

4 •

2015


16

Requirements/Limits

Drug Name Dru

g Ti

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horiz

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Lim

its †

Ste

p Th

erap

y

DIASTAT PEDIATRIC - diazepamrectal gel delivery system2.5 mg

4 •

DIAZEPAM - diazepam soln1 mg/ml

4 • •

DIAZEPAM - diazepam rectal geldelivery system 2.5 mg

4 •

DIAZEPAM - diazepam rectal geldelivery system 10 mg

4 •

DIAZEPAM - diazepam rectal geldelivery system 20 mg

4 •

diazepam conc 5 mg/ml^ 2 • •diazepam tab 2 mg^ 2 • •diazepam tab 5 mg^ 2 • •diazepam tab 10 mg^ 2 • •DILANTIN - phenytoin sodium

extended cap 30 mg4

divalproex sodium cap sprinkle125 mg^

2

divalproex sodium tab delayedrelease 125 mg^

2


2


2

divalproex sodium tab sr 24 hr250 mg^

2


2

ethosuximide cap 250 mg^ 2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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horiz

atio

n

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ntity

Lim

its †

Ste

p Th

erap

y

ethosuximide soln 250 mg/5ml^ 2felbamate susp 600 mg/5ml^ 2felbamate tab 400 mg^ 2felbamate tab 600 mg^ 2fosphenytoin sodium inj

100 mg/2ml^2

fosphenytoin sodium inj500 mg/10ml^

2

FYCOMPA - perampanel tab2 mg

4


4


4


4


4


4

gabapentin cap 100 mg^ 2gabapentin cap 300 mg^ 2gabapentin cap 400 mg^ 2gabapentin oral soln 250 mg/5ml^ 2gabapentin tab 600 mg^ 2gabapentin tab 800 mg^ 2GABITRIL - tiagabine hcl tab

12 mg4

2015


17

Requirements/Limits

Drug Name Dru

g Ti

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horiz

atio

n

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ntity

Lim

its †

Ste

p Th

erap

y

GABITRIL - tiagabine hcl tab16 mg

4

LAMICTAL ODT - lamotrigineorally disintegrating tab 25 mg

4


4


4


4

lamotrigine orally disintegratingtab 25 mg^

2


2


2


2

lamotrigine tab chewabledispersible 5 mg^

2


2

lamotrigine tab 25 mg^ 2lamotrigine tab 100 mg^ 2lamotrigine tab 150 mg^ 2lamotrigine tab 200 mg^ 2LEVETIRACETAM - levetiracetam

in sodium chloride iv soln500 mg/100ml

4

Requirements/Limits

Drug Name Dru

g Ti

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horiz

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n

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ntity

Lim

its †

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p Th

erap

y

LEVETIRACETAM - levetiracetamin sodium chloride iv soln1000 mg/100ml

4

LEVETIRACETAM - levetiracetamin sodium chloride iv soln1500 mg/100ml

4

levetiracetam inj 500 mg/5ml(100 mg/ml)^

2

levetiracetam oral soln 100 mg/ml^

2

levetiracetam tab 250 mg^ 2levetiracetam tab 500 mg^ 2levetiracetam tab 750 mg^ 2levetiracetam tab 1000 mg^ 2LYRICA - pregabalin soln 20 mg/

ml3

LYRICA - pregabalin cap 25 mg 3LYRICA - pregabalin cap 50 mg 3LYRICA - pregabalin cap 75 mg 3LYRICA - pregabalin cap 100 mg 3LYRICA - pregabalin cap 150 mg 3LYRICA - pregabalin cap 200 mg 3LYRICA - pregabalin cap 225 mg 3LYRICA - pregabalin cap 300 mg 3ONFI - clobazam suspension

2.5 mg/ml4 • •

ONFI - clobazam tab 5 mg 4 • •ONFI - clobazam tab 10 mg 4 • •

2015


18

Requirements/Limits

Drug Name Dru

g Ti

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n

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its †

Ste

p Th

erap

y

ONFI - clobazam tab 20 mg 4 • •oxcarbazepine susp 300 mg/5ml

(60 mg/ml)^2

oxcarbazepine tab 150 mg^ 2oxcarbazepine tab 300 mg^ 2oxcarbazepine tab 600 mg^ 2PEGANONE - ethotoin tab

250 mg4

PHENOBARBITAL -phenobarbital tab 15 mg#

4 •


4 •


4 •


4 •

phenobarbital elixir 20 mg/5ml# 4 •PHENOBARBITAL SODIUM -

phenobarbital sodium inj 65 mg/ml#

4 •

phenobarbital sodium inj 130 mg/ml#

4 •

phenobarbital tab 16.2 mg# 4 •phenobarbital tab 32.4 mg# 4 •phenobarbital tab 64.8 mg# 4 •phenobarbital tab 97.2 mg# 4 •phenytoin chew tab 50 mg^ 2phenytoin sodium extended cap

100 mg^2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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horiz

atio

n

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ntity

Lim

its †

Ste

p Th

erap

y

phenytoin sodium extended cap200 mg^

2

phenytoin sodium extended cap300 mg^

2

phenytoin susp 125 mg/5ml^ 2POTIGA - ezogabine tab 50 mg 4POTIGA - ezogabine tab 200 mg 4POTIGA - ezogabine tab 300 mg 4POTIGA - ezogabine tab 400 mg 4primidone tab 50 mg^ 2primidone tab 250 mg^ 2SABRIL - vigabatrin tab 500 mg 4SABRIL - vigabatrin powd pack

500 mg4

TEGRETOL-XR - carbamazepinetab sr 12hr 100 mg

4

tiagabine hcl tab 2 mg^ 2tiagabine hcl tab 4 mg^ 2topiramate sprinkle cap 15 mg^ 2topiramate sprinkle cap 25 mg^ 2topiramate tab 25 mg^ 2topiramate tab 50 mg^ 2topiramate tab 100 mg^ 2topiramate tab 200 mg^ 2valproate sodium inj 100 mg/ml^ 2valproate sodium syrup

250 mg/5ml^2

valproic acid cap 250 mg^ 2

2015


19

Requirements/Limits

Drug Name Dru

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horiz

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its †

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p Th

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y

VIMPAT - lacosamide tab 50 mg 3VIMPAT - lacosamide tab 100 mg 3VIMPAT - lacosamide tab 150 mg 3VIMPAT - lacosamide tab 200 mg 3VIMPAT - lacosamide iv inj

200 mg/20ml (10 mg/ml)3

VIMPAT - lacosamide oralsolution 10 mg/ml

3

zonisamide cap 25 mg^ 2zonisamide cap 50 mg^ 2zonisamide cap 100 mg^ 2Antidementia Agentsdonepezil hydrochloride orally

disintegrating tab 5 mg^2

donepezil hydrochloride orallydisintegrating tab 10 mg^

2

donepezil hydrochloride tab5 mg^

2


2


2

ergoloid mesylates tab 1 mg# 3 •EXELON - rivastigmine td patch

24hr 4.6 mg/24hr3

EXELON - rivastigmine td patch24hr 9.5 mg/24hr

3

EXELON - rivastigmine td patch24hr 13.3 mg/24hr

3

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

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horiz

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n

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ntity

Lim

its †

Ste

p Th

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y

galantamine hydrobromide cap sr24hr 8 mg^

2


2


2

galantamine hydrobromide oralsoln 4 mg/ml^

2

galantamine hydrobromide tab4 mg^

2


2


2

memantine hcl oral solution 2 mg/ml^

2

memantine hcl tab 5 mg^ 2memantine hcl tab 10 mg^ 2memantine hcl tab 5 mg (28) &

10 mg (21) titration pak^2

NAMENDA - memantine hcl oralsolution 2 mg/ml

3

NAMENDA - memantine hcl tab5 mg

3

NAMENDA - memantine hcl tab10 mg

3

NAMENDA TITRATION PAK -memantine hcl tab 5 mg (28) &10 mg (21) titration pak

3

NAMENDA XR - memantine hclcap sr 24hr 7 mg

3

2015


20

Requirements/Limits

Drug Name Dru

g Ti

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B o

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Lim

its †

Ste

p Th

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y


3


3


3

NAMENDA XR TITRATION PACK- memantine hcl cap sr 24hr7 mg & 14 mg & 21 mg & 28 mgpack

3

rivastigmine tartrate cap 1.5 mg^ 2rivastigmine tartrate cap 3 mg^ 2rivastigmine tartrate cap 4.5 mg^ 2rivastigmine tartrate cap 6 mg^ 2rivastigmine td patch 24hr

4.6 mg/24hr^2

rivastigmine td patch 24hr9.5 mg/24hr^

2

rivastigmine td patch 24hr13.3 mg/24hr^

2

AntidepressantsABILIFY - aripiprazole tab 2 mg 5 •ABILIFY - aripiprazole tab 5 mg 5 •ABILIFY - aripiprazole tab 10 mg 5 •ABILIFY - aripiprazole tab 15 mg 5 •ABILIFY - aripiprazole tab 20 mg 5 •ABILIFY - aripiprazole tab 30 mg 5 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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n

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Lim

its †

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y

ABILIFY MAINTENA -aripiprazole im for extendedrelease susp 300 mg

5 •


5 •

amitriptyline hcl tab 10 mg# 4 •amitriptyline hcl tab 25 mg# 4 •amitriptyline hcl tab 50 mg# 4 •amitriptyline hcl tab 75 mg# 4 •amitriptyline hcl tab 100 mg# 4 •amitriptyline hcl tab 150 mg# 4 •AMOXAPINE - amoxapine tab

25 mg4

AMOXAPINE - amoxapine tab50 mg

4


4


4

ARIPIPRAZOLE ODT -aripiprazole orally disintegratingtab 10 mg

5 •


5 •

aripiprazole oral solution 1 mg/ml 5 •aripiprazole tab 2 mg 5 •aripiprazole tab 5 mg 5 •

2015


21

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

aripiprazole tab 10 mg 5 •aripiprazole tab 15 mg 5 •aripiprazole tab 20 mg 5 •aripiprazole tab 30 mg 5 •BRINTELLIX - vortioxetine hbr tab

5 mg4 •

BRINTELLIX - vortioxetine hbr tab10 mg

4 •

BRINTELLIX - vortioxetine hbr tab20 mg

4 •

bupropion hcl tab sr 12hr100 mg^

2 •


2 •


2 •


2 •


2 •

bupropion hcl tab 75 mg^ 2 •bupropion hcl tab 100 mg^ 2 •citalopram hydrobromide oral soln

10 mg/5ml^1 •

citalopram hydrobromide tab10 mg^

1 •


1 •


1 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

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y

clomipramine hcl cap 25 mg# 4 •clomipramine hcl cap 50 mg# 4 •clomipramine hcl cap 75 mg# 4 •desipramine hcl tab 10 mg^ 2desipramine hcl tab 25 mg^ 2desipramine hcl tab 50 mg^ 2desipramine hcl tab 75 mg^ 2desipramine hcl tab 100 mg^ 2desipramine hcl tab 150 mg^ 2DOXEPIN HCL - doxepin hcl cap

75 mg#4 •

doxepin hcl cap 10 mg# 4 •doxepin hcl cap 25 mg# 4 •doxepin hcl cap 50 mg# 4 •doxepin hcl cap 100 mg# 4 •doxepin hcl cap 150 mg# 4 •doxepin hcl conc 10 mg/ml# 4 •duloxetine hcl enteric coated

pellets cap 20 mg^2 •

duloxetine hcl enteric coatedpellets cap 30 mg^

2 •


2 •

EMSAM - selegiline td patch 24hr6 mg/24hr

5


5

2015


22

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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Prio

r Aut

horiz

atio

n

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ntity

Lim

its †

Ste

p Th

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y


5

escitalopram oxalate soln5 mg/5ml^

2 •

escitalopram oxalate tab 5 mg^ 2 •escitalopram oxalate tab 10 mg^ 2 •escitalopram oxalate tab 20 mg^ 2 •FETZIMA - levomilnacipran hcl

cap sr 24hr 20 mg4 •

FETZIMA - levomilnacipran hclcap sr 24hr 40 mg

4 •


4 •


4 •

FETZIMA TITRATION PACK -levomilnacipran hcl cap sr 24hr20 & 40 mg therapy pack

4 •

fluoxetine hcl cap delayed release90 mg^

2 •

fluoxetine hcl cap 10 mg^ 2 •fluoxetine hcl cap 20 mg^ 2 •fluoxetine hcl cap 40 mg^ 2 •fluoxetine hcl solution 20 mg/5ml^ 2 •fluoxetine hcl tab 10 mg^ 2 •fluoxetine hcl tab 20 mg^ 2 •fluvoxamine maleate tab 25 mg^ 2 •fluvoxamine maleate tab 50 mg^ 2 •fluvoxamine maleate tab 100 mg^ 2 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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Prio

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horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

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y

imipramine hcl tab 10 mg# 4 •imipramine hcl tab 25 mg# 4 •imipramine hcl tab 50 mg# 4 •MAPROTILINE HCL - maprotiline

hcl tab 25 mg4 •

MAPROTILINE HCL - maprotilinehcl tab 50 mg

4 •

MAPROTILINE HCL - maprotilinehcl tab 75 mg

4 •

MARPLAN - isocarboxazid tab10 mg

4

mirtazapine orally disintegratingtab 15 mg^

2 •


2 •


2 •

mirtazapine tab 7.5 mg^ 2 •mirtazapine tab 15 mg^ 2 •mirtazapine tab 30 mg^ 2 •mirtazapine tab 45 mg^ 2 •NEFAZODONE HCL -

nefazodone hcl tab 100 mg4

NEFAZODONE HCL -nefazodone hcl tab 150 mg

4

NEFAZODONE HCL -nefazodone hcl tab 200 mg

4

nefazodone hcl tab 50 mg^ 2nefazodone hcl tab 250 mg^ 2

2015


23

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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Prio

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horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

NORTRIPTYLINE HCL -nortriptyline hcl soln 10 mg/5ml

4

nortriptyline hcl cap 10 mg^ 2nortriptyline hcl cap 25 mg^ 2nortriptyline hcl cap 50 mg^ 2nortriptyline hcl cap 75 mg^ 2OLEPTRO - trazodone hcl tab sr

24hr 150 mg4 •

OLEPTRO - trazodone hcl tab sr24hr 300 mg

4 •

paroxetine hcl tab sr 24hr12.5 mg^

2 •

paroxetine hcl tab sr 24hr 25 mg^ 2 •paroxetine hcl tab sr 24hr

37.5 mg^2 •

paroxetine hcl tab 10 mg^ 2 •paroxetine hcl tab 20 mg^ 2 •paroxetine hcl tab 30 mg^ 2 •paroxetine hcl tab 40 mg^ 2 •PAXIL - paroxetine hcl oral susp

10 mg/5ml4 •

phenelzine sulfate tab 15 mg^ 2PRISTIQ - desvenlafaxine

succinate tab sr 24hr 25 mg4 •

PRISTIQ - desvenlafaxinesuccinate tab sr 24hr 50 mg

4 •

PRISTIQ - desvenlafaxinesuccinate tab sr 24hr 100 mg

4 •

protriptyline hcl tab 5 mg^ 2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

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y

protriptyline hcl tab 10 mg^ 2quetiapine fumarate tab 25 mg^ 2 •quetiapine fumarate tab 50 mg^ 2 •quetiapine fumarate tab 100 mg^ 2 •quetiapine fumarate tab 200 mg^ 2 •quetiapine fumarate tab 300 mg^ 2 •quetiapine fumarate tab 400 mg^ 2 •REXULTI - brexpiprazole tab

0.25 mg5 •

REXULTI - brexpiprazole tab0.5 mg

5 •

REXULTI - brexpiprazole tab1 mg

5 •


5 •


5 •


5 •

SEROQUEL XR - quetiapinefumarate tab sr 24hr 50 mg

3 •


3 •


3 •


3 •


3 •

2015


24

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

sertraline hcl oral conc 20 mg/ml^ 2 •sertraline hcl tab 25 mg^ 1 •sertraline hcl tab 50 mg^ 1 •sertraline hcl tab 100 mg^ 1 •SURMONTIL - trimipramine

maleate cap 25 mg#4 •

SURMONTIL - trimipraminemaleate cap 50 mg#

4 •

SURMONTIL - trimipraminemaleate cap 100 mg#

4 •

tranylcypromine sulfate tab10 mg^

2

trazodone hcl tab 50 mg^ 2trazodone hcl tab 100 mg^ 2trazodone hcl tab 150 mg^ 2trazodone hcl tab 300 mg^ 2trimipramine maleate cap 25 mg# 4 •trimipramine maleate cap 50 mg# 4 •trimipramine maleate cap

100 mg#4 •

venlafaxine hcl cap sr 24hr37.5 mg^

2 •

venlafaxine hcl cap sr 24hr75 mg^

2 •


2 •

venlafaxine hcl tab sr 24hr37.5 mg^

2 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

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horiz

atio

n

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ntity

Lim

its †

Ste

p Th

erap

y

venlafaxine hcl tab sr 24hr75 mg^

2 •


2 •

venlafaxine hcl tab 25 mg^ 2 •venlafaxine hcl tab 37.5 mg^ 2 •venlafaxine hcl tab 50 mg^ 2 •venlafaxine hcl tab 75 mg^ 2 •venlafaxine hcl tab 100 mg^ 2 •VIIBRYD - vilazodone hcl tab

10 mg4 •

VIIBRYD - vilazodone hcl tab20 mg

4 •

VIIBRYD - vilazodone hcl tab40 mg

4 •

VIIBRYD - vilazodone hcl tabstarter kit 10 (7) & 20 (7) & 40(16) mg

4 •

VIIBRYD STARTER PACK -vilazodone hcl tab starter kit 10(7) & 20 (23) mg

4 •

AntiemeticsALOXI - palonosetron hcl iv soln

0.25 mg/5ml4

CHLORPROMAZINE HCL -chlorpromazine hcl inj 25 mg/ml

4

CHLORPROMAZINE HCL- chlorpromazine hcl inj50 mg/2ml

4

chlorpromazine hcl tab 10 mg^ 2

2015


25

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

chlorpromazine hcl tab 25 mg^ 2chlorpromazine hcl tab 50 mg^ 2chlorpromazine hcl tab 100 mg^ 2chlorpromazine hcl tab 200 mg^ 2diphenhydramine hcl inj 50 mg/

ml^2

dronabinol cap 2.5 mg^ 2 Xdronabinol cap 5 mg^ 2 Xdronabinol cap 10 mg^ 2 XEMEND - aprepitant capsule

therapy pack 80 & 125 mg3 X

EMEND - fosaprepitantdimeglumine for iv infusion150 mg

4

EMEND - aprepitant capsule40 mg

3 X


3 X


3 X

granisetron hcl tab 1 mg^ 2 Xhydroxyzine hcl syrup 10 mg/5ml# 4 •hydroxyzine hcl tab 10 mg# 4 •hydroxyzine hcl tab 25 mg# 4 •hydroxyzine hcl tab 50 mg# 4 •meclizine hcl tab 12.5 mg^ 2meclizine hcl tab 25 mg^ 2metoclopramide hcl soln

5 mg/5ml (10 mg/10ml)^2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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Prio

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horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

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y

metoclopramide hcl tab 5 mg^ 2metoclopramide hcl tab 10 mg^ 2ondansetron hcl inj 4 mg/2ml

(2 mg/ml)^2

ondansetron hcl inj 40 mg/20ml(2 mg/ml)^

2

ondansetron hcl oral soln4 mg/5ml^

2 X

ondansetron hcl tab 4 mg^ 2 Xondansetron hcl tab 8 mg^ 2 Xondansetron hcl tab 24 mg^ 2 Xondansetron orally disintegrating

tab 4 mg^2 X

ondansetron orally disintegratingtab 8 mg^

2 X

perphenazine tab 2 mg^ 2perphenazine tab 4 mg^ 2perphenazine tab 8 mg^ 2perphenazine tab 16 mg^ 2prochlorperazine edisylate inj

5 mg/ml^2

prochlorperazine maleate tab5 mg^

2


2

prochlorperazine suppos 25 mg^ 2promethazine hcl suppos

12.5 mg#4 •

promethazine hcl suppos 25 mg# 4 •

2015


26

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

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y

promethazine hcl syrup6.25 mg/5ml#

4 •

promethazine hcl tab 12.5 mg# 4 •promethazine hcl tab 25 mg# 4 •promethazine hcl tab 50 mg# 4 •SANCUSO - granisetron td patch

3.1 mg/24hr (contains 34.3 mg)4 •

AntifungalsAMBISOME - amphotericin b

liposome iv for susp 50 mg5 X

AMPHOTERICIN B -amphotericin b for inj 50 mg

4 X

CANCIDAS - caspofungin acetatefor iv soln 50 mg

5

CANCIDAS - caspofungin acetatefor iv soln 70 mg

5

clotrimazole troche 10 mg^ 2CRESEMBA - isavuconazonium

sulfate cap 186 mg5 •

CRESEMBA - isavuconazoniumsulfate for iv soln 372 mg

5 •

fluconazole for susp 10 mg/ml^ 2fluconazole for susp 40 mg/ml^ 2fluconazole in dextrose inj

200 mg/100ml^2

fluconazole in dextrose inj400 mg/200ml^

2

FLUCONAZOLE IN NACL -fluconazole in nacl 0.9% inj100 mg/50ml

4

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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Prio

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horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

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y

fluconazole in nacl 0.9% inj200 mg/100ml^

2

fluconazole in nacl 0.9% inj400 mg/200ml^

2

fluconazole tab 50 mg^ 2fluconazole tab 100 mg^ 2fluconazole tab 150 mg^ 2fluconazole tab 200 mg^ 2flucytosine cap 250 mg 5flucytosine cap 500 mg 5griseofulvin microsize susp

125 mg/5ml^2

griseofulvin ultramicrosize tab125 mg^

2

griseofulvin ultramicrosize tab250 mg^

2

itraconazole cap 100 mg^ 2ketoconazole tab 200 mg^ 2MYCAMINE - micafungin sodium

for iv soln 50 mg4

MYCAMINE - micafungin sodiumfor iv soln 100 mg

5

NOXAFIL - posaconazole susp40 mg/ml

5 •

NOXAFIL - posaconazole iv soln300 mg/16.7ml (18 mg/ml)

4 •

nystatin susp 100000 unit/ml^ 2nystatin tab 500000 unit^ 2terbinafine hcl tab 250 mg^ 2

2015


27

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

terconazole vaginal cream 0.4%^ 2terconazole vaginal cream 0.8%^ 2terconazole vaginal suppos

80 mg^2

voriconazole for inj 200 mg^ 2 •voriconazole for susp 40 mg/ml 5 •voriconazole tab 50 mg 5 •voriconazole tab 200 mg 5 •Antigout Agentsallopurinol tab 100 mg^ 2allopurinol tab 300 mg^ 2ALOPRIM - allopurinol sodium for

inj 500 mg4

colchicine w/ probenecid tab0.5-500 mg^

2

COLCRYS - colchicine tab 0.6 mg 3probenecid tab 500 mg^ 2ULORIC - febuxostat tab 40 mg 3ULORIC - febuxostat tab 80 mg 3Anti-Inflammatory AgentsCELEBREX - celecoxib cap

50 mg3 •


3 •


3 •


3 •

celecoxib cap 50 mg^ 2 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

celecoxib cap 100 mg^ 2 •celecoxib cap 200 mg^ 2 •celecoxib cap 400 mg^ 2 •diclofenac potassium tab 50 mg^ 2diclofenac sodium tab delayed

release 25 mg^2


2


2

diclofenac sodium tab sr 24hr100 mg^

2


2


2

etodolac cap 200 mg^ 2etodolac cap 300 mg^ 2etodolac tab sr 24hr 400 mg^ 2etodolac tab sr 24hr 500 mg^ 2etodolac tab sr 24hr 600 mg^ 2etodolac tab 400 mg^ 2etodolac tab 500 mg^ 2flurbiprofen tab 50 mg^ 2flurbiprofen tab 100 mg^ 2ibuprofen susp 100 mg/5ml^ 2ibuprofen tab 400 mg^ 2ibuprofen tab 600 mg^ 2

2015


28

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

ibuprofen tab 800 mg^ 2ketoprofen cap 50 mg^ 2ketoprofen cap 75 mg^ 2meloxicam tab 7.5 mg^ 2meloxicam tab 15 mg^ 2nabumetone tab 500 mg^ 2nabumetone tab 750 mg^ 2naproxen sodium tab 275 mg^ 2naproxen sodium tab 550 mg^ 2naproxen susp 125 mg/5ml^ 2naproxen tab ec 375 mg^ 2naproxen tab ec 500 mg^ 2naproxen tab 250 mg^ 2naproxen tab 375 mg^ 2naproxen tab 500 mg^ 2oxaprozin tab 600 mg^ 2piroxicam cap 10 mg^ 2piroxicam cap 20 mg^ 2sulindac tab 150 mg^ 2sulindac tab 200 mg^ 2tolmetin sodium cap 400 mg^ 2VOLTAREN - diclofenac

sodium gel 1%3 •

Antimigraine Agentsbutalbital-acetaminophen-caff w/

cod cap 50-300-40-30 mg#4 • •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

butalbital-acetaminophen-caff w/cod cap 50-325-40-30 mg#

4 • •

butalbital-aspirin-caff w/ codeinecap 50-325-40-30 mg#

4 • •

divalproex sodium cap sprinkle125 mg^

2


2


2


2


2


2

MIGERGOT - ergotamine w/caffeine suppos 2-100 mg

4

MIGRANAL - dihydroergotaminemesylate nasal spray 4 mg/ml

3

naratriptan hcl tab 1 mg^ 2 •naratriptan hcl tab 2.5 mg^ 2 •propranolol hcl cap sr 24hr

60 mg^2

propranolol hcl cap sr 24hr80 mg^

2


2


2

2015


29

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

propranolol hcl inj 1 mg/ml^ 2propranolol hcl tab 10 mg^ 2propranolol hcl tab 20 mg^ 2propranolol hcl tab 40 mg^ 2propranolol hcl tab 60 mg^ 2propranolol hcl tab 80 mg^ 2rizatriptan benzoate orally

disintegrating tab 5 mg^2 •

rizatriptan benzoate orallydisintegrating tab 10 mg^

2 •

rizatriptan benzoate tab 5 mg^ 2 •rizatriptan benzoate tab 10 mg^ 2 •SUMATRIPTAN - sumatriptan

nasal spray 5 mg/act4 •

SUMATRIPTAN - sumatriptannasal spray 20 mg/act

4 •

SUMATRIPTAN SUCCINATE -sumatriptan succinate solutionprefilled syringe 6 mg/0.5ml^

2

sumatriptan succinate inj6 mg/0.5ml^

2

sumatriptan succinate solutionauto-injector 4 mg/0.5ml^

2

sumatriptan succinate solutionauto-injector 6 mg/0.5ml^

2

sumatriptan succinate solutioncartridge 4 mg/0.5ml^

2

sumatriptan succinate solutioncartridge 6 mg/0.5ml^

2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

sumatriptan succinate tab 25 mg^ 2 •sumatriptan succinate tab 50 mg^ 2 •sumatriptan succinate tab

100 mg^2 •

TIMOLOL MALEATE - timololmaleate tab 5 mg

4


4


4

topiramate sprinkle cap 15 mg^ 2topiramate sprinkle cap 25 mg^ 2topiramate tab 25 mg^ 2topiramate tab 50 mg^ 2topiramate tab 100 mg^ 2topiramate tab 200 mg^ 2Antimyasthenic AgentsGUANIDINE HCL - guanidine hcl

tab 125 mg4

MESTINON - pyridostigminebromide syrup 60 mg/5ml

4

MESTINON TIMESPAN -pyridostigmine bromide tab cr180 mg

3

pyridostigmine bromide tab cr180 mg^

2

pyridostigmine bromide tab60 mg^

2

2015


30

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

AntimycobacterialsCAPASTAT SULFATE -

capreomycin sulfate for inj 1 gm4

CYCLOSERINE - cycloserine cap250 mg

4

DAPSONE - dapsone tab 25 mg^ 2DAPSONE - dapsone tab

100 mg^2

ethambutol hcl tab 100 mg^ 2ethambutol hcl tab 400 mg^ 2ISONIAZID - isoniazid inj 100 mg/

ml4

isoniazid tab 100 mg^ 2isoniazid tab 300 mg^ 2PASER - aminosalicylic acid

cr granules packet 4 gm4

PRIFTIN - rifapentine tab 150 mg 4pyrazinamide tab 500 mg^ 2rifabutin cap 150 mg^ 2rifampin cap 150 mg^ 2rifampin cap 300 mg^ 2rifampin for inj 600 mg^ 2SEROMYCIN - cycloserine cap

250 mg4

TRECATOR - ethionamide tab250 mg

4

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

AntineoplasticsABRAXANE - paclitaxel protein-

bound particles for iv susp100 mg

5

AFINITOR - everolimus tab2.5 mg

5 • •

AFINITOR - everolimus tab 5 mg 5 • •AFINITOR - everolimus tab

7.5 mg5 • •

AFINITOR - everolimus tab 10 mg 5 • •AFINITOR DISPERZ - everolimus

tab for oral susp 2 mg5 • •

AFINITOR DISPERZ - everolimustab for oral susp 3 mg

5 • •

AFINITOR DISPERZ - everolimustab for oral susp 5 mg

5 • •

ALIMTA - pemetrexed disodiumfor iv soln 100 mg

5

ALIMTA - pemetrexed disodiumfor iv soln 500 mg

5

amifostine crystalline for inj500 mg

5

anastrozole tab 1 mg^ 2ARRANON - nelarabine iv soln

5 mg/ml5

ARZERRA - ofatumumab conc foriv infusion 100 mg/5ml*

5

ARZERRA - ofatumumab conc foriv infusion 1000 mg/50ml*

5

2015


31

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

AVASTIN - bevacizumab iv soln100 mg/4ml (for infusion)*

5

AVASTIN - bevacizumab iv soln400 mg/16ml (for infusion)*

5

azacitidine for inj 100 mg 5BELEODAQ - belinostat for iv inj

500 mg5

bexarotene cap 75 mg 5 •bicalutamide tab 50 mg^ 2BICNU - carmustine for inj

100 mg4

bleomycin sulfate for inj 15 unit^ 2 Xbleomycin sulfate for inj 30 unit^ 2 XBLINCYTO - blinatumomab for iv

infusion 35 mcg5

BOSULIF - bosutinib tab 100 mg 5 • •BOSULIF - bosutinib tab 500 mg 5 • •BUSULFEX - busulfan inj 6 mg/ml 5CAPRELSA - vandetanib tab

100 mg*5 • •

CAPRELSA - vandetanib tab300 mg*

5 • •

carboplatin iv soln 50 mg/5ml^ 2carboplatin iv soln 150 mg/15ml^ 2carboplatin iv soln 450 mg/45ml^ 2carboplatin iv soln 600 mg/60ml^ 2CISPLATIN - cisplatin inj

200 mg/200ml (1 mg/ml)^2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

cisplatin inj 50 mg/50ml (1 mg/ml)^

2

cisplatin inj 100 mg/100ml (1 mg/ml)^

2

cladribine inj 1 mg/ml 5 XCLOLAR - clofarabine iv soln

1 mg/ml5

COMETRIQ - cabozantinib s-malate cap 3 x 20 mg (60 mgdose) kit*

5 • •

COMETRIQ - cabozantinib s-malcap 1 x 80 mg & 1 x 20 mg (100dose) kit*

5 • •

COMETRIQ - cabozantinib s-malcap 1 x 80 mg & 3 x 20 mg (140dose) kit*

5 • •

COSMEGEN - dactinomycin forinj 0.5 mg

5

CYCLOPHOSPHAMIDE -cyclophosphamide cap 25 mg

4 X

CYCLOPHOSPHAMIDE -cyclophosphamide cap 50 mg

4 X

cyclophosphamide for inj 500 mg^ 2cyclophosphamide for inj 1 gm^ 2cyclophosphamide for inj 2 gm^ 2CYRAMZA - ramucirumab iv soln

100 mg/10ml (for infusion)5

CYRAMZA - ramucirumab iv soln500 mg/50ml (for infusion)

5

cytarabine inj pf 20 mg/ml^ 2 X

2015


32

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

cytarabine inj pf 100 mg/ml^ 2 Xcytarabine inj 20 mg/ml^ 2 XDACARBAZINE - dacarbazine for

inj 100 mg4

dacarbazine for inj 200 mg^ 2daunorubicin hcl for inj 20 mg^ 2daunorubicin hcl inj 5 mg/ml^ 2DAUNOXOME - daunorubicin

citrate liposome inj 2 mg/ml5

decitabine for inj 50 mg 5dexrazoxane for inj 250 mg 5dexrazoxane for inj 500 mg 5DOCEFREZ - docetaxel for inj

20 mg5

DOCEFREZ - docetaxel for inj80 mg

5

DOCETAXEL - docetaxel for injconc 20 mg/ml

5

DOCETAXEL - docetaxel for injconc 80 mg/4ml (20 mg/ml)

5

DOCETAXEL - docetaxel for injconc 140 mg/7ml (20 mg/ml)

5

DOCETAXEL - docetaxel soln foriv infusion 20 mg/2ml

5


5


5

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


5

docetaxel for inj conc 20 mg/ml 5docetaxel for inj conc 80 mg/4ml

(20 mg/ml)5

DOXIL - doxorubicin hcl liposomalinj (for iv infusion) 2 mg/ml

4 X

doxorubicin hcl for inj 10 mg^ 2 Xdoxorubicin hcl for inj 50 mg^ 2 Xdoxorubicin hcl inj 2 mg/ml^ 2 Xdoxorubicin hcl liposomal inj (for

iv infusion) 2 mg/ml^2 X

ELITEK - rasburicase for iv soln1.5 mg

5

ELITEK - rasburicase for iv soln7.5 mg

5

EMCYT - estramustine phosphatesodium cap 140 mg

4

epirubicin hcl iv soln 50 mg/25ml(2 mg/ml)^

2

epirubicin hcl iv soln200 mg/100ml (2 mg/ml)^

2

ERBITUX - cetuximab iv soln100 mg/50ml (2 mg/ml)

5

ERBITUX - cetuximab iv soln200 mg/100ml (2 mg/ml)

5

ERIVEDGE - vismodegib cap150 mg*

5 • •

2015


33

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

ERWINAZE - asparaginaseerwinia chrysanthemi for inj10000 unit

5

ETOPOPHOS - etoposidephosphate iv for inj 100 mg

4

etoposide inj 100 mg/5ml (20 mg/ml)^

2

etoposide inj 500 mg/25ml(20 mg/ml)^

2

etoposide inj 1 gm/50ml (20 mg/ml)^

2

exemestane tab 25 mg^ 2FARESTON - toremifene citrate

tab 60 mg5

FARYDAK - panobinostat lactatecap 10 mg

5 • •


5 • •


5 • •

FASLODEX - fulvestrant inj250 mg/5ml

5

FLUDARABINE PHOSPHATE- fludarabine phosphate inj25 mg/ml^

2

fludarabine phosphate for inj50 mg^

2

fludarabine phosphate inj 25 mg/ml^

2

fluorouracil inj 500 mg/10ml(50 mg/ml)^

2 X

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

fluorouracil inj 1 gm/20ml (50 mg/ml)^

2 X

fluorouracil inj 2.5 gm/50ml(50 mg/ml)^

2 X

fluorouracil inj 5 gm/100ml(50 mg/ml)^

2 X

flutamide cap 125 mg^ 2FOLOTYN - pralatrexate iv inj

20 mg/ml5

FOLOTYN - pralatrexate iv inj40 mg/2ml

5

GAZYVA - obinutuzumab solnfor iv infusion 1000 mg/40ml(25 mg/ml)

5

GEMCITABINE - gemcitabine hclinj 200 mg/5.26ml (38 mg/ml)

5

GEMCITABINE - gemcitabine hclinj 1 gm/26.3ml (38 mg/ml)

5

GEMCITABINE - gemcitabine hclinj 2 gm/52.6ml (38 mg/ml)

5

gemcitabine hcl for inj 200 mg 5gemcitabine hcl for inj 1 gm 5gemcitabine hcl for inj 2 gm 5GILOTRIF - afatinib dimaleate tab

20 mg5 • •

GILOTRIF - afatinib dimaleate tab30 mg

5 • •

GILOTRIF - afatinib dimaleate tab40 mg

5 • •

2015


34

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

GLEEVEC - imatinib mesylate tab100 mg

5 • •

GLEEVEC - imatinib mesylate tab400 mg

5 • •

GLEOSTINE - lomustine cap10 mg

4


4


4

HALAVEN - eribulin mesylate inj1 mg/2ml (0.5 mg/ml)

5

HERCEPTIN - trastuzumab for ivsoln 440 mg

5

HEXALEN - altretamine cap50 mg

5 •

hydroxyurea cap 500 mg^ 2IBRANCE - palbociclib cap 75 mg 5 • •IBRANCE - palbociclib cap

100 mg5 • •

IBRANCE - palbociclib cap125 mg

5 • •

ICLUSIG - ponatinib hcl tab15 mg

5 • •

ICLUSIG - ponatinib hcl tab45 mg

5 • •

idarubicin hcl iv inj 5 mg/5ml(1 mg/ml)

5


5

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


5

IFEX - ifosfamide for inj 3 gm 4IFOSFAMIDE - ifosfamide iv inj

1 gm/20ml (50 mg/ml)^2

IFOSFAMIDE - ifosfamide iv inj3 gm/60ml (50 mg/ml)^

2

IFOSFAMIDE - ifosfamide for inj3 gm

4

ifosfamide for inj 1 gm^ 2ifosfamide iv inj 1 gm/20ml

(50 mg/ml)^2

ifosfamide iv inj 3 gm/60ml(50 mg/ml)^

2

IMBRUVICA - ibrutinib cap140 mg

5 • •

INLYTA - axitinib tab 1 mg* 5 • •INLYTA - axitinib tab 5 mg* 5 • •IRESSA - gefitinib tab 250 mg 5 • •IRINOTECAN - irinotecan hcl inj

500 mg/25ml (20 mg/ml)^2

irinotecan hcl inj 40 mg/2ml(20 mg/ml)^

2

irinotecan hcl inj 100 mg/5ml(20 mg/ml)^

2

ISTODAX - romidepsin for iv inj10 mg

5

IXEMPRA KIT - ixabepilone for ivinfusion 15 mg

5

2015


35

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

IXEMPRA KIT - ixabepilone for ivinfusion 45 mg

5

JAKAFI - ruxolitinib phosphate tab5 mg*

5 • •


5 • •


5 • •


5 • •


5 • •

JEVTANA - cabazitaxel inj60 mg/1.5ml (for iv infusion)

5

KADCYLA - ado-trastuzumabemtansine for iv soln 100 mg

5

KADCYLA - ado-trastuzumabemtansine for iv soln 160 mg

5

KEYTRUDA - pembrolizumab ivsoln 100 mg/4ml (25 mg/ml)

5

KEYTRUDA - pembrolizumab foriv soln 50 mg

5

LENVIMA 10MG DAILY DOSE- lenvatinib cap therapy pack10 mg

5 • •

LENVIMA 14MG DAILY DOSE -lenvatinib cap therapy pack 10& 4 mg

5 • •

LENVIMA 20MG DAILY DOSE -lenvatinib cap therapy pack 10(2) mg

5 • •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

LENVIMA 24MG DAILY DOSE -lenvatinib cap therapy pack 10(2) & 4 mg

5 • •

letrozole tab 2.5 mg^ 2LEUCOVORIN CALCIUM -

leucovorin calcium tab 10 mg4

LEUCOVORIN CALCIUM -leucovorin calcium tab 15 mg

4

LEUCOVORIN CALCIUM -leucovorin calcium for inj500 mg

4

leucovorin calcium for inj 50 mg^ 2leucovorin calcium for inj 100 mg^ 2leucovorin calcium for inj 200 mg^ 2leucovorin calcium for inj 350 mg^ 2leucovorin calcium tab 5 mg^ 2leucovorin calcium tab 25 mg^ 2LEUKERAN - chlorambucil tab

2 mg3

LOMUSTINE - lomustine cap10 mg

4


4


4

LONSURF - trifluridine-tipiracil tab15-6.14 mg

5 • •

LONSURF - trifluridine-tipiracil tab20-8.19 mg

5 • •

LYNPARZA - olaparib cap 50 mg 5 • •

2015


36

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

MATULANE - procarbazine hclcap 50 mg*

5 •

MEKINIST - trametinib dimethylsulfoxide tab 0.5 mg

5 • •

MEKINIST - trametinib dimethylsulfoxide tab 2 mg

5 • •

melphalan hcl for inj 50 mg 5mercaptopurine tab 50 mg^ 2mesna inj 100 mg/ml^ 2MESNEX - mesna tab 400 mg 4methotrexate sodium for inj 1 gm^ 2methotrexate sodium inj pf 25 mg/

ml^2

methotrexate sodium inj 25 mg/ml^

2

methotrexate sodium tab 2.5 mg^ 2 Xmitomycin for iv soln 5 mg^ 2mitomycin for iv soln 20 mg^ 2mitomycin for iv soln 40 mg^ 2mitoxantrone hcl inj conc

20 mg/10ml (2 mg/ml)^2

mitoxantrone hcl inj conc25 mg/12.5ml (2 mg/ml)^

2

mitoxantrone hcl inj conc30 mg/15ml (2 mg/ml)^

2

MUSTARGEN - mechlorethaminehcl for inj 10 mg

4

NEXAVAR - sorafenib tosylate tab200 mg*

5 • •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

NILANDRON - nilutamide tab150 mg

4

NIPENT - pentostatin for inj10 mg

5

ODOMZO - sonidegib phosphatecap 200 mg

5 • •

ONCASPAR - pegaspargase inj750 unit/ml

5

OPDIVO - nivolumab iv soln40 mg/4ml

5

OPDIVO - nivolumab iv soln100 mg/10ml

5

oxaliplatin iv soln 50 mg/10ml 5oxaliplatin iv soln 100 mg/20ml 5oxaliplatin for iv inj 50 mg 5oxaliplatin for iv inj 100 mg 5paclitaxel iv conc 30 mg/5ml

(6 mg/ml)^2

paclitaxel iv conc 100 mg/16.7ml(6 mg/ml)^

2

paclitaxel iv conc 300 mg/50ml(6 mg/ml)^

2

PANRETIN - alitretinoin gel 0.1% 5PERJETA - pertuzumab soln for

iv infusion 420 mg/14ml (30 mg/ml)*

5

POMALYST - pomalidomide cap1 mg*

5 • •


5 • •

2015


37

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


5 • •


5 • •

PROLEUKIN - aldesleukin for ivsoln 22000000 unit

5

PURIXAN - mercaptopurine susp2000 mg/100ml (20 mg/ml)

5

REVLIMID - lenalidomide caps2.5 mg*

5 • •

REVLIMID - lenalidomide cap5 mg*

5 • •


5 • •


5 • •


5 • •


5 • •

RITUXAN - rituximab iv soln100 mg/10ml*

5 •

RITUXAN - rituximab iv soln500 mg/50ml*

5 •

SOLTAMOX - tamoxifen citrateoral soln 10 mg/5ml

4

SPRYCEL - dasatinib tab 20 mg 5 • •SPRYCEL - dasatinib tab 50 mg 5 • •SPRYCEL - dasatinib tab 70 mg 5 • •SPRYCEL - dasatinib tab 80 mg 5 • •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

SPRYCEL - dasatinib tab 100 mg 5 • •SPRYCEL - dasatinib tab 140 mg 5 • •STIVARGA - regorafenib tab

40 mg*5 • •

SUTENT - sunitinib malate cap12.5 mg

5 • •

SUTENT - sunitinib malate cap25 mg

5 • •

SUTENT - sunitinib malate cap37.5 mg

5 • •

SUTENT - sunitinib malate cap50 mg

5 • •

SYLATRON - peginterferonalfa-2b for inj kit 200 mcg

5 •


5 •


5 •

SYLATRON - peginterferonalfa-2b for inj kit 4 x 200 mcg

5 •


5 •


5 •

SYLVANT - siltuximab for ivinfusion 100 mg

5

SYLVANT - siltuximab for ivinfusion 400 mg

5

SYNRIBO - omacetaxinemepesuccinate for inj 3.5 mg

5

2015


38

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

TABLOID - thioguanine tab 40 mg 4TAFINLAR - dabrafenib mesylate

cap 50 mg5 • •

TAFINLAR - dabrafenib mesylatecap 75 mg

5 • •

tamoxifen citrate tab 10 mg^ 2tamoxifen citrate tab 20 mg^ 2TARCEVA - erlotinib hcl tab

25 mg5 • •

TARCEVA - erlotinib hcl tab100 mg

5 • •

TARCEVA - erlotinib hcl tab150 mg

5 • •

TARGRETIN - bexarotene cap75 mg

5 •

TARGRETIN - bexarotene gel 1% 5TASIGNA - nilotinib hcl cap

150 mg5 • •

TASIGNA - nilotinib hcl cap200 mg

5 • •

TAXOTERE - docetaxel for injconc 20 mg/ml

5

TAXOTERE - docetaxel for injconc 80 mg/4ml (20 mg/ml)

5

TEMODAR - temozolomide for ivsoln 100 mg

5

THALOMID - thalidomide cap50 mg

5 • •


5 • •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


5 • •


5 • •

THIOTEPA - thiotepa for inj15 mg

5

TOPOTECAN HCL - topotecanhcl inj 4 mg/4ml (for infusion)

5

topotecan hcl for inj 4 mg 5TORISEL - temsirolimus soln for

iv infusion 25 mg/ml5

TREANDA - bendamustine hcl ivsoln 45 mg/0.5ml (90 mg/ml)

5

TREANDA - bendamustine hcl ivsoln 180 mg/2ml (90 mg/ml)

5

TREANDA - bendamustine hcl foriv soln 25 mg

5

TREANDA - bendamustine hcl foriv soln 100 mg

5

tretinoin cap 10 mg 5 •TRISENOX - arsenic trioxide inj

10 mg/10ml (1 mg/ml)4

TYKERB - lapatinib ditosylate tab250 mg*

5 • •

UNITUXIN - dinutuximab iv soln17.5 mg/5ml (3.5 mg/ml)

5

UVADEX - methoxsalen soln20 mcg/ml

4

VECTIBIX - panitumumab iv soln100 mg/5ml

5

2015


39

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

VECTIBIX - panitumumab iv soln400 mg/20ml

5

VELCADE - bortezomib for inj3.5 mg

5

VINBLASTINE SULFATE -vinblastine sulfate inj 1 mg/ml

4 X

vincristine sulfate iv soln 1 mg/ml^ 2vinorelbine tartrate inj 10 mg/ml^ 2vinorelbine tartrate inj 50 mg/5ml

(10 mg/ml)^2

VOTRIENT - pazopanib hcl tab200 mg*

5 • •

XALKORI - crizotinib cap 200 mg* 5 • •XALKORI - crizotinib cap 250 mg* 5 • •XTANDI - enzalutamide cap

40 mg*5 • •

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

5

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

5

ZALTRAP - ziv-aflibercept iv soln100 mg/4ml (for infusion)

5

ZALTRAP - ziv-aflibercept iv soln200 mg/8ml (for infusion)

5

ZANOSAR - streptozocin for inj1 gm

4

ZELBORAF - vemurafenib tab240 mg*

5 • •

ZOLINZA - vorinostat cap 100 mg 5 • •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

ZYDELIG - idelalisib tab 100 mg 5 • •ZYDELIG - idelalisib tab 150 mg 5 • •ZYKADIA - ceritinib cap 150 mg 5 • •ZYTIGA - abiraterone acetate tab

250 mg*5 • •

AntiparasiticsALBENZA - albendazole tab

200 mg4

ALINIA - nitazoxanide tab 500 mg 4ALINIA - nitazoxanide for susp

100 mg/5ml4

atovaquone susp 750 mg/5ml 5atovaquone-proguanil hcl tab

62.5-25 mg^2

atovaquone-proguanil hcl tab250-100 mg^

2

BILTRICIDE - praziquantel tab600 mg

4

chloroquine phosphate tab250 mg^

2

chloroquine phosphate tab500 mg^

2

COARTEM - artemether-lumefantrine tab 20-120 mg

4

DARAPRIM - pyrimethamine tab25 mg

4

hydroxychloroquine sulfate tab200 mg^

2

ivermectin tab 3 mg^ 2lindane lotion 1%^ 2

2015


40

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

lindane shampoo 1%^ 2MALARONE - atovaquone-

proguanil hcl tab 62.5-25 mg4

malathion lotion 0.5%^ 2mefloquine hcl tab 250 mg^ 2NEBUPENT - pentamidine

isethionate for nebulization soln300 mg

4 X

PENTAM 300 - pentamidineisethionate for soln 300 mg

4 X

permethrin cream 5%^ 2PRIMAQUINE PHOSPHATE

- primaquine phosphate tab26.3 mg

4

STROMECTOL - ivermectin tab3 mg

3

Antiparkinson AgentsAMANTADINE HCL - amantadine

hcl tab 100 mg4

amantadine hcl cap 100 mg^ 2amantadine hcl syrup 50 mg/5ml^ 2APOKYN - apomorphine

hydrochloride inj 10 mg/ml*5

AZILECT - rasagiline mesylatetab 0.5 mg

3

AZILECT - rasagiline mesylatetab 1 mg

3

benztropine mesylate tab 0.5 mg# 4 •benztropine mesylate tab 1 mg# 4 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

benztropine mesylate tab 2 mg# 4 •bromocriptine mesylate cap

5 mg^2

bromocriptine mesylate tab2.5 mg^

2

carbidopa & levodopa orallydisintegrating tab 10-100 mg^

2


2


2

carbidopa & levodopa tab cr25-100 mg^

2

carbidopa & levodopa tab cr50-200 mg^

2

carbidopa & levodopa tab10-100 mg^

2


2


2

carbidopa tab 25 mg^ 2CARBIDOPA/LEVODOPA/

ENTACAPONE - carbidopa-levodopa-entacapone tabs12.5-50-200 mg^

2

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs18.75-75-200 mg^

2

2015


41

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs25-100-200 mg^

2


2


2

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs50-200-200 mg^

2

diphenhydramine hcl inj 50 mg/ml^

2

entacapone tab 200 mg^ 2NEUPRO - rotigotine td patch

24hr 1 mg/24hr3

NEUPRO - rotigotine td patch24hr 2 mg/24hr

3


3


3


3


3

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

pramipexole dihydrochloride tab0.125 mg^

2


2


2


2

pramipexole dihydrochloride tab1 mg^

2


2

ropinirole hydrochloride tab0.25 mg^

2

ropinirole hydrochloride tab0.5 mg^

2

ropinirole hydrochloride tab 1 mg^ 2ropinirole hydrochloride tab 2 mg^ 2ropinirole hydrochloride tab 3 mg^ 2ropinirole hydrochloride tab 4 mg^ 2ropinirole hydrochloride tab 5 mg^ 2selegiline hcl cap 5 mg^ 2selegiline hcl tab 5 mg^ 2TASMAR - tolcapone tab 100 mg 5tolcapone tab 100 mg 5AntipsychoticsABILIFY - aripiprazole tab 2 mg 5 •ABILIFY - aripiprazole tab 5 mg 5 •ABILIFY - aripiprazole tab 10 mg 5 •

2015


42

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

ABILIFY - aripiprazole tab 15 mg 5 •ABILIFY - aripiprazole tab 20 mg 5 •ABILIFY - aripiprazole tab 30 mg 5 •ABILIFY MAINTENA -

aripiprazole im for extendedrelease susp 300 mg

5 •


5 •

ADASUVE - loxapine aerosolpowder breath activated 10 mg

4


5 •


5 •

aripiprazole oral solution 1 mg/ml 5 •aripiprazole tab 2 mg 5 •aripiprazole tab 5 mg 5 •aripiprazole tab 10 mg 5 •aripiprazole tab 15 mg 5 •aripiprazole tab 20 mg 5 •aripiprazole tab 30 mg 5 •CHLORPROMAZINE HCL -

chlorpromazine hcl inj 25 mg/ml4

CHLORPROMAZINE HCL- chlorpromazine hcl inj50 mg/2ml

4

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

chlorpromazine hcl tab 10 mg^ 2chlorpromazine hcl tab 25 mg^ 2chlorpromazine hcl tab 50 mg^ 2chlorpromazine hcl tab 100 mg^ 2chlorpromazine hcl tab 200 mg^ 2clozapine tab 25 mg^ 2 •clozapine tab 50 mg^ 2 •clozapine tab 100 mg^ 2 •clozapine tab 200 mg^ 2 •FANAPT - iloperidone tab 1 mg 4 •FANAPT - iloperidone tab 2 mg 4 •FANAPT - iloperidone tab 4 mg 4 •FANAPT - iloperidone tab 6 mg 4 •FANAPT - iloperidone tab 8 mg 4 •FANAPT - iloperidone tab 10 mg 4 •FANAPT - iloperidone tab 12 mg 4 •FANAPT TITRATION PACK -

iloperidone tab 1 mg & 2 mg &4 mg & 6 mg titration pak

4 •

FAZACLO - clozapine orallydisintegrating tab 12.5 mg

4 •

FAZACLO - clozapine orallydisintegrating tab 25 mg

4 •


4 •


4 •

2015


43

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


4 •

fluphenazine decanoate inj25 mg/ml^

2

FLUPHENAZINE HCL -fluphenazine hcl elixir2.5 mg/5ml

4

FLUPHENAZINE HCL -fluphenazine hcl oral conc5 mg/ml

4

FLUPHENAZINE HCL -fluphenazine hcl inj 2.5 mg/ml

4

fluphenazine hcl tab 1 mg^ 2fluphenazine hcl tab 2.5 mg^ 2fluphenazine hcl tab 5 mg^ 2fluphenazine hcl tab 10 mg^ 2GEODON - ziprasidone mesylate

for inj 20 mg4 •

haloperidol decanoate im soln50 mg/ml^

2

haloperidol decanoate im soln100 mg/ml^

2

haloperidol lactate inj 5 mg/ml^ 2haloperidol lactate oral conc

2 mg/ml^2

haloperidol tab 0.5 mg^ 2haloperidol tab 1 mg^ 2haloperidol tab 2 mg^ 2haloperidol tab 5 mg^ 2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

haloperidol tab 10 mg^ 2haloperidol tab 20 mg^ 2INVEGA - paliperidone tab sr

24hr 1.5 mg4 •

INVEGA - paliperidone tab sr24hr 3 mg

4 •


4 •


5 •

INVEGA SUSTENNA -paliperidone palmitate imextended-release susp39 mg/0.25ml

4 •


4 •

INVEGA SUSTENNA -paliperidone palmitateim extend-release susp117 mg/0.75ml

5 •

INVEGA SUSTENNA -paliperidone palmitate imextended-release susp 156 mg/ml

5 •


5 •

2015


44

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

INVEGA TRINZA - paliperidonepalmitate im extend-releasesusp 273 mg/0.875ml

5 •


5 •


5 •


5 •

LATUDA - lurasidone hcl tab20 mg

4 •


4 •


4 •


4 •


4 •

loxapine succinate cap 5 mg^ 2loxapine succinate cap 10 mg^ 2loxapine succinate cap 25 mg^ 2loxapine succinate cap 50 mg^ 2olanzapine for im inj 10 mg^ 2 •olanzapine orally disintegrating

tab 5 mg^2 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

olanzapine orally disintegratingtab 10 mg^

2 •


2 •


2 •

olanzapine tab 2.5 mg^ 2 •olanzapine tab 5 mg^ 2 •olanzapine tab 7.5 mg^ 2 •olanzapine tab 10 mg^ 2 •olanzapine tab 15 mg^ 2 •olanzapine tab 20 mg^ 2 •ORAP - pimozide tab 1 mg 4ORAP - pimozide tab 2 mg 4paliperidone tab sr 24hr 1.5 mg 5 •paliperidone tab sr 24hr 3 mg 5 •paliperidone tab sr 24hr 6 mg 5 •paliperidone tab sr 24hr 9 mg 5 •perphenazine tab 2 mg^ 2perphenazine tab 4 mg^ 2perphenazine tab 8 mg^ 2perphenazine tab 16 mg^ 2pimozide tab 1 mg^ 2pimozide tab 2 mg^ 2prochlorperazine edisylate inj

5 mg/ml^2


2

2015


45

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


2

prochlorperazine suppos 25 mg^ 2quetiapine fumarate tab 25 mg^ 2 •quetiapine fumarate tab 50 mg^ 2 •quetiapine fumarate tab 100 mg^ 2 •quetiapine fumarate tab 200 mg^ 2 •quetiapine fumarate tab 300 mg^ 2 •quetiapine fumarate tab 400 mg^ 2 •REXULTI - brexpiprazole tab

0.25 mg5 •

REXULTI - brexpiprazole tab0.5 mg

5 •


5 •


5 •


5 •


5 •

RISPERDAL CONSTA -risperidone microspheres for inj12.5 mg

4 •

RISPERDAL CONSTA -risperidone microspheres for inj25 mg

4 •


5 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


5 •

risperidone orally disintegratingtab 0.25 mg^

2 •


2 •

risperidone orally disintegratingtab 1 mg^

2 •


2 •


2 •


2 •

risperidone soln 1 mg/ml^ 2 •risperidone tab 0.25 mg^ 2 •risperidone tab 0.5 mg^ 2 •risperidone tab 1 mg^ 2 •risperidone tab 2 mg^ 2 •risperidone tab 3 mg^ 2 •risperidone tab 4 mg^ 2 •SAPHRIS - asenapine maleate sl

tab 2.5 mg4 •

SAPHRIS - asenapine maleate sltab 5 mg

4 •

SAPHRIS - asenapine maleate sltab 10 mg

4 •


3 •

2015


46

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


3 •


3 •


3 •


3 •

thioridazine hcl tab 10 mg# 4 •thioridazine hcl tab 25 mg# 4 •thioridazine hcl tab 50 mg# 4 •thioridazine hcl tab 100 mg# 4 •thiothixene cap 1 mg^ 2thiothixene cap 2 mg^ 2thiothixene cap 5 mg^ 2thiothixene cap 10 mg^ 2trifluoperazine hcl tab 1 mg^ 2trifluoperazine hcl tab 2 mg^ 2trifluoperazine hcl tab 5 mg^ 2trifluoperazine hcl tab 10 mg^ 2VERSACLOZ - clozapine susp

50 mg/ml5 •

ziprasidone hcl cap 20 mg^ 2 •ziprasidone hcl cap 40 mg^ 2 •ziprasidone hcl cap 60 mg^ 2 •ziprasidone hcl cap 80 mg^ 2 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

ZYPREXA RELPREVV -olanzapine pamoate forextended rel im susp 210 mg

5 •


5 •


5 •

Antispasticity Agentsbaclofen tab 10 mg^ 2baclofen tab 20 mg^ 2dantrolene sodium cap 100 mg^ 2dantrolene sodium cap 25 mg^ 2dantrolene sodium cap 50 mg^ 2tizanidine hcl cap 2 mg^ 2tizanidine hcl cap 4 mg^ 2tizanidine hcl cap 6 mg^ 2tizanidine hcl tab 2 mg^ 2tizanidine hcl tab 4 mg^ 2Antiviralsabacavir sulfate tab 300 mg^ 2 •abacavir sulfate-lamivudine-

zidovudine tab 300-150-300 mg5 •

acyclovir cap 200 mg^ 2ACYCLOVIR SODIUM - acyclovir

sodium for inj 1000 mg4 X

acyclovir sodium for inj 500 mg^ 2 X

2015


47

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

acyclovir sodium iv soln 50 mg/ml^

2 X

acyclovir susp 200 mg/5ml^ 2acyclovir tab 400 mg^ 2acyclovir tab 800 mg^ 2adefovir dipivoxil tab 10 mg 5AMANTADINE HCL - amantadine

hcl tab 100 mg4

amantadine hcl cap 100 mg^ 2amantadine hcl syrup 50 mg/5ml^ 2APTIVUS - tipranavir cap 250 mg 5 •APTIVUS - tipranavir oral soln

100 mg/ml5 •

ATRIPLA - efavirenz-emtricitabine-tenofovir df tab600-200-300 mg

5 •

BARACLUDE - entecavir oral soln0.05 mg/ml

4

BARACLUDE - entecavir tab0.5 mg

5

BARACLUDE - entecavir tab1 mg

5

cidofovir iv inj 75 mg/ml^ 2COMPLERA - emtricitabine-

rilpivirine-tenofovir df tab200-25-300 mg

5 •

CRIXIVAN - indinavir sulfate cap200 mg

3 •

CRIXIVAN - indinavir sulfate cap400 mg

3 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

DAKLINZA - daclatasvirdihydrochloride tab 30 mg

5 •

DAKLINZA - daclatasvirdihydrochloride tab 60 mg

5 •

didanosine delayed releasecapsule 125 mg^

2 •


2 •


2 •


2 •

EDURANT - rilpivirine hcl tab25 mg

5 •

EMTRIVA - emtricitabine caps200 mg

4 •

EMTRIVA - emtricitabine soln10 mg/ml

4 •

entecavir tab 0.5 mg 5entecavir tab 1 mg 5EPIVIR - lamivudine oral soln

10 mg/ml3 •

EPIVIR HBV - lamivudine oralsoln 5 mg/ml (hbv)

3

EPZICOM - abacavir sulfate-lamivudine tab 600-300 mg

5 •

EVOTAZ - atazanavir sulfate-cobicistat tab 300-150 mg

5 •

famciclovir tab 125 mg^ 2famciclovir tab 250 mg^ 2

2015


48

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

famciclovir tab 500 mg^ 2FUZEON - enfuvirtide for inj

90 mg5 •

ganciclovir sodium for inj 500 mg^ 2 XHARVONI - ledipasvir-sofosbuvir

tab 90-400 mg5 •

INTELENCE - etravirine tab25 mg

4 •


5 •


5 •

INTRON A - interferon alfa-2b inj6000000 unit/ml

5

INTRON A - interferon alfa-2b inj10000000 unit/ml

5

INTRON A W/DILUENT -interferon alfa-2b for inj10000000 unit

5


5


5

INVIRASE - saquinavir mesylatecap 200 mg

5 •

INVIRASE - saquinavir mesylatetab 500 mg

5 •

ISENTRESS - raltegravirpotassium tab 400 mg

5 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

ISENTRESS - raltegravirpotassium packet for susp100 mg

4 •

ISENTRESS - raltegravirpotassium chew tab 25 mg

3 •

ISENTRESS - raltegravirpotassium chew tab 100 mg

3 •

KALETRA - lopinavir-ritonavirsoln 400-100 mg/5ml(80-20 mg/ml)

5 •

KALETRA - lopinavir-ritonavir tab100-25 mg

4 •

KALETRA - lopinavir-ritonavir tab200-50 mg

5 •

lamivudine oral soln 10 mg/ml^ 2 •lamivudine tab 100 mg (hbv)^ 2lamivudine tab 150 mg^ 2 •lamivudine tab 300 mg^ 2 •lamivudine-zidovudine tab

150-300 mg5 •

LEXIVA - fosamprenavir calciumtab 700 mg

5 •

LEXIVA - fosamprenavir calciumsusp 50 mg/ml

4 •

NEVIRAPINE - nevirapine susp50 mg/5ml

4 •

nevirapine tab sr 24hr 400 mg^ 2 •nevirapine tab 200 mg^ 2 •NORVIR - ritonavir cap 100 mg 4 •NORVIR - ritonavir tab 100 mg 4 •

2015


49

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

NORVIR - ritonavir oral soln80 mg/ml

4 •

OLYSIO - simeprevir sodium cap150 mg

5 •

PEG-INTRON - peginterferonalfa-2b for inj kit 50 mcg/0.5ml

5 •


5 •


5 •


5 •

PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit50 mcg/0.5ml

5 •


5 •


5 •


5 •

PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for inj kit50 mcg/0.5ml

5 •


5 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


5 •


5 •

PEGASYS - peginterferon alfa-2ainj 180 mcg/ml

5 •

PEGASYS - peginterferon alfa-2ainj 180 mcg/0.5ml

5 •

PEGASYS PROCLICK -peginterferon alfa-2a inj135 mcg/0.5ml

5 •

PEGASYS PROCLICK -peginterferon alfa-2a inj180 mcg/0.5ml

5 •

PREZCOBIX - darunavir-cobicistat tab 800-150 mg

5 •

PREZISTA - darunavir ethanolatesusp 100 mg/ml

5 •

PREZISTA - darunavir ethanolatetab 75 mg

4 •


4 •


5 •


5 •

REBETOL - ribavirin soln 40 mg/ml

4

2015


50

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

RESCRIPTOR - delavirdinemesylate tab 100 mg

4 •

RESCRIPTOR - delavirdinemesylate tab 200 mg

4 •

RETROVIR IV INFUSION -zidovudine iv soln 10 mg/ml

4

REYATAZ - atazanavir sulfate oralpowder packet 50 mg

5 •

REYATAZ - atazanavir sulfate cap100 mg

4 •


5 •


5 •


5 •

RIBASPHERE - ribavirin tab400 mg

4

RIBASPHERE - ribavirin tab600 mg

5

RIBASPHERE RIBAPAK -ribavirin tab 400 mg

5

RIBASPHERE RIBAPAK -ribavirin tab 600 mg

5

ribavirin cap 200 mg^ 2ribavirin tab 200 mg^ 2rimantadine hydrochloride tab

100 mg^2

SELZENTRY - maraviroc tab150 mg

5 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

SELZENTRY - maraviroc tab300 mg

5 •

SOVALDI - sofosbuvir tab 400 mg 5 •stavudine cap 15 mg^ 2 •stavudine cap 20 mg^ 2 •stavudine cap 30 mg^ 2 •stavudine cap 40 mg^ 2 •stavudine for oral soln 1 mg/ml^ 2 •STRIBILD - elvitegrav-cobicis-

emtricitab-tenofov tab150-150-200-300 mg

5 •

SUSTIVA - efavirenz tab 600 mg 3 •SUSTIVA - efavirenz cap 50 mg 3 •SUSTIVA - efavirenz cap 200 mg 3 •SYLATRON - peginterferon

alfa-2b for inj kit 200 mcg5 •


5 •


5 •


5 •


5 •


5 •

TAMIFLU - oseltamivir phosphatefor susp 6 mg/ml

4

2015


51

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

TAMIFLU - oseltamivir phosphatecap 30 mg

4


4


4

TECHNIVIE - ombitasvir-paritaprevir-ritonavir tab12.5-75-50 mg

5 •

TIVICAY - dolutegravir sodium tab50 mg

5 •

TRIUMEQ - abacavir-dolutegravir-lamivudine tab600-50-300 mg

5 •

TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab200-300 mg

5 •

TYBOST - cobicistat tab 150 mg 4 •TYZEKA - telbivudine tab 600 mg 4valacyclovir hcl tab 500 mg^ 2valacyclovir hcl tab 1 gm^ 2VALCYTE - valganciclovir hcl tab

450 mg5

VALCYTE - valganciclovir hcl forsoln 50 mg/ml

5

valganciclovir hcl tab 450 mg 5VIDEX - didanosine for soln 2 gm 4 •VIDEX - didanosine for soln 4 gm 4 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

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

5 •

VIRACEPT - nelfinavir mesylatetab 250 mg

5 •

VIRACEPT - nelfinavir mesylatetab 625 mg

5 •

VIRAMUNE - nevirapine susp50 mg/5ml

4 •

VIRAMUNE XR - nevirapine tabsr 24hr 100 mg

4 •

VIRAZOLE - ribavirin for inhalsoln 6 gm

5

VIREAD - tenofovir disoproxilfumarate oral powder 40 mg/gm

5 •

VIREAD - tenofovir disoproxilfumarate tab 150 mg

5 •


5 •


5 •


5 •

VITEKTA - elvitegravir tab 85 mg 5 •VITEKTA - elvitegravir tab 150 mg 5 •ZIAGEN - abacavir sulfate soln

20 mg/ml4 •

zidovudine cap 100 mg^ 2 •zidovudine syrup 10 mg/ml^ 2 •zidovudine tab 300 mg^ 2 •

2015


52

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

Anxiolyticsbuspirone hcl tab 5 mg^ 2buspirone hcl tab 7.5 mg^ 2buspirone hcl tab 10 mg^ 2buspirone hcl tab 15 mg^ 2buspirone hcl tab 30 mg^ 2clonazepam orally disintegrating

tab 0.125 mg^2 • •


2 • •


2 • •


2 • •


2 • •

clonazepam tab 0.5 mg^ 2 • •clonazepam tab 1 mg^ 2 • •clonazepam tab 2 mg^ 2 • •clorazepate dipotassium tab

3.75 mg^2 • •

clorazepate dipotassium tab7.5 mg^

2 • •

clorazepate dipotassium tab15 mg^

2 • •

DIAZEPAM - diazepam soln1 mg/ml

4 • •

diazepam conc 5 mg/ml^ 2 • •diazepam tab 2 mg^ 2 • •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

diazepam tab 5 mg^ 2 • •diazepam tab 10 mg^ 2 • •DOXEPIN HCL - doxepin hcl cap

75 mg#4 •

doxepin hcl cap 10 mg# 4 •doxepin hcl cap 25 mg# 4 •doxepin hcl cap 50 mg# 4 •doxepin hcl cap 100 mg# 4 •doxepin hcl cap 150 mg# 4 •doxepin hcl conc 10 mg/ml# 4 •duloxetine hcl enteric coated

pellets cap 20 mg^2 •


2 •


2 •

escitalopram oxalate soln5 mg/5ml^

2 •

escitalopram oxalate tab 5 mg^ 2 •escitalopram oxalate tab 10 mg^ 2 •escitalopram oxalate tab 20 mg^ 2 •hydroxyzine hcl syrup 10 mg/5ml# 4 •hydroxyzine hcl tab 10 mg# 4 •hydroxyzine hcl tab 25 mg# 4 •hydroxyzine hcl tab 50 mg# 4 •lorazepam tab 0.5 mg^ 2 • •lorazepam tab 1 mg^ 2 • •lorazepam tab 2 mg^ 2 • •

2015


53

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

paroxetine hcl tab sr 24hr12.5 mg^

2 •

paroxetine hcl tab sr 24hr 25 mg^ 2 •paroxetine hcl tab sr 24hr

37.5 mg^2 •

paroxetine hcl tab 10 mg^ 2 •paroxetine hcl tab 20 mg^ 2 •paroxetine hcl tab 30 mg^ 2 •paroxetine hcl tab 40 mg^ 2 •PAXIL - paroxetine hcl oral susp

10 mg/5ml4 •

sertraline hcl oral conc 20 mg/ml^ 2 •sertraline hcl tab 25 mg^ 1 •sertraline hcl tab 50 mg^ 1 •sertraline hcl tab 100 mg^ 1 •venlafaxine hcl cap sr 24hr

37.5 mg^2 •


2 •


2 •

venlafaxine hcl tab sr 24hr37.5 mg^

2 •


2 •


2 •

venlafaxine hcl tab 25 mg^ 2 •venlafaxine hcl tab 37.5 mg^ 2 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

venlafaxine hcl tab 50 mg^ 2 •venlafaxine hcl tab 75 mg^ 2 •venlafaxine hcl tab 100 mg^ 2 •Bipolar AgentsABILIFY - aripiprazole tab 2 mg 5 •ABILIFY - aripiprazole tab 5 mg 5 •ABILIFY - aripiprazole tab 10 mg 5 •ABILIFY - aripiprazole tab 15 mg 5 •ABILIFY - aripiprazole tab 20 mg 5 •ABILIFY - aripiprazole tab 30 mg 5 •ABILIFY MAINTENA -

aripiprazole im for extendedrelease susp 300 mg

5 •


5 •


5 •


5 •

aripiprazole oral solution 1 mg/ml 5 •aripiprazole tab 2 mg 5 •aripiprazole tab 5 mg 5 •aripiprazole tab 10 mg 5 •aripiprazole tab 15 mg 5 •aripiprazole tab 20 mg 5 •

2015


54

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

aripiprazole tab 30 mg 5 •divalproex sodium cap sprinkle

125 mg^2


2


2


2


2


2

EQUETRO - carbamazepine capsr 12hr 100 mg

4


4


4


4


4


4


4


2


2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


2


2


2


2

lamotrigine tab 25 mg^ 2lamotrigine tab 100 mg^ 2lamotrigine tab 150 mg^ 2lamotrigine tab 200 mg^ 2LITHIUM - lithium oral solution 8

meq/5ml4

lithium carbonate cap 150 mg^ 2lithium carbonate cap 300 mg^ 2lithium carbonate cap 600 mg^ 2lithium carbonate tab cr 300 mg^ 2lithium carbonate tab cr 450 mg^ 2lithium carbonate tab 300 mg^ 2olanzapine for im inj 10 mg^ 2 •olanzapine orally disintegrating

tab 5 mg^2 •


2 •


2 •


2 •

2015


55

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

olanzapine tab 2.5 mg^ 2 •olanzapine tab 5 mg^ 2 •olanzapine tab 7.5 mg^ 2 •olanzapine tab 10 mg^ 2 •olanzapine tab 15 mg^ 2 •olanzapine tab 20 mg^ 2 •quetiapine fumarate tab 25 mg^ 2 •quetiapine fumarate tab 50 mg^ 2 •quetiapine fumarate tab 100 mg^ 2 •quetiapine fumarate tab 200 mg^ 2 •quetiapine fumarate tab 300 mg^ 2 •quetiapine fumarate tab 400 mg^ 2 •RISPERDAL CONSTA -

risperidone microspheres for inj12.5 mg

4 •


4 •


5 •


5 •


2 •


2 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


2 •


2 •


2 •


2 •

risperidone soln 1 mg/ml^ 2 •risperidone tab 0.25 mg^ 2 •risperidone tab 0.5 mg^ 2 •risperidone tab 1 mg^ 2 •risperidone tab 2 mg^ 2 •risperidone tab 3 mg^ 2 •risperidone tab 4 mg^ 2 •SEROQUEL XR - quetiapine

fumarate tab sr 24hr 50 mg3 •


3 •


3 •


3 •


3 •

valproic acid cap 250 mg^ 2ziprasidone hcl cap 20 mg^ 2 •ziprasidone hcl cap 40 mg^ 2 •ziprasidone hcl cap 60 mg^ 2 •

2015


56

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

ziprasidone hcl cap 80 mg^ 2 •Blood Glucose Regulatorsacarbose tab 25 mg^ 2 •acarbose tab 50 mg^ 2 •acarbose tab 100 mg^ 2 •ALCOHOL SWABS 3BYDUREON - exenatide

extended release for susp pen-injector 2 mg

3 •

BYDUREON - exenatideextended release for inj susp2 mg

3 •

CYCLOSET - bromocriptinemesylate tab 0.8 mg

4 •

GAUZE PADS 2" X 2" 3glimepiride tab 1 mg^ 1 •glimepiride tab 2 mg^ 1 •glimepiride tab 4 mg^ 1 •glipizide tab sr 24hr 2.5 mg^ 1 •glipizide tab sr 24hr 5 mg^ 1 •glipizide tab sr 24hr 10 mg^ 1 •glipizide tab 5 mg^ 1 •glipizide tab 10 mg^ 1 •glipizide-metformin hcl tab

2.5-250 mg^2 •

glipizide-metformin hcl tab2.5-500 mg^

2 •

glipizide-metformin hcl tab5-500 mg^

2 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

GLUCAGEN HYPOKIT- glucagon hcl (rdna) for inj1 mg

3

GLUCAGON EMERGENCY KIT- glucagon (rdna) for inj kit 1 mg

3

GLYBURIDE - glyburide tab1.25 mg#

4 • •

GLYBURIDE - glyburide tab2.5 mg#

4 • •

GLYBURIDE - glyburide tab5 mg#

4 • •

glyburide micronized tab 1.5 mg# 4 • •glyburide micronized tab 3 mg# 4 • •glyburide micronized tab 6 mg# 4 • •glyburide tab 1.25 mg# 4 • •glyburide tab 2.5 mg# 4 • •glyburide tab 5 mg# 4 • •glyburide-metformin tab

1.25-250 mg#4 • •

glyburide-metformin tab2.5-500 mg#

4 • •

glyburide-metformin tab5-500 mg#

4 • •

HUMALOG - insulin lispro(human) soln cartridge 100 unit/ml

3

HUMALOG - insulin lispro(human) inj 100 unit/ml

3

2015


57

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

HUMALOG KWIKPEN - insulinlispro (human) soln pen-injector100 unit/ml

3

HUMALOG KWIKPEN - insulinlispro (human) soln pen-injector200 unit/ml

3

HUMALOG MIX 50/50 - insulinlispro prot & lispro (human) inj100 unit/ml (50-50)

3

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

3

HUMALOG MIX 75/25 - insulinlispro prot & lispro (human) inj100 unit/ml (75-25)

3

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

3

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

2

HUMULIN N KWIKPEN - insulinnph (human)(isophane) susppen-injector 100 unit/ml

3

HUMULIN N U-100 PEN - insulinnph (human)(isophane) susppen-injector 100 unit/ml

3

HUMULIN R - insulin regular(human) inj 100 unit/ml^

2

HUMULIN R U-500(CONCENTRATE) - insulinregular (human) inj 500 unit/ml^

2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

HUMULIN 70/30 - insulin nphisophane & regular human inj100 unit/ml (70-30)^

2

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

3

HUMULIN 70/30 PEN - insulinnph & regular susp pen-inj 100unit/ml (70-30)

3

INSULIN INJECTION DEVICE 3INSULIN SYRINGE/NEEDLE 3INVOKAMET - canagliflozin-

metformin hcl tab 50-500 mg3 •

INVOKAMET - canagliflozin-metformin hcl tab 50-1000 mg

3 •


3 •


3 •

INVOKANA - canagliflozin tab100 mg

3 •

INVOKANA - canagliflozin tab300 mg

3 •

JANUMET - sitagliptin-metforminhcl tab 50-500 mg

3 •

JANUMET - sitagliptin-metforminhcl tab 50-1000 mg

3 •

JANUMET XR - sitagliptin-metformin hcl tab sr 24hr50-500 mg

3 •

2015


58

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


3 •


3 •

JANUVIA - sitagliptin phosphatetab 25 mg

3 •


3 •


3 •

JARDIANCE - empagliflozin tab10 mg

4 •

JARDIANCE - empagliflozin tab25 mg

4 •

JENTADUETO - linagliptin-metformin hcl tab 2.5-500 mg

4 •


4 •


4 •

KOMBIGLYZE XR - saxagliptin-metformin hcl tab sr 24hr2.5-1000 mg

3 •

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

3 •

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

3 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

LANTUS - insulin glargine inj 100unit/ml

3

LANTUS SOLOSTAR -insulin glargine soln pen-injector100 unit/ml

3

LEVEMIR - insulin detemir inj 100unit/ml

3

LEVEMIR FLEXPEN - insulindetemir soln pen-injector 100unit/ml

3

LEVEMIR FLEXTOUCH - insulindetemir soln pen-injector 100unit/ml

3

metformin hcl tab sr 24hr500 mg^

1 •

metformin hcl tab sr 24hr750 mg^

1 •

metformin hcl tab 500 mg^ 1 •metformin hcl tab 850 mg^ 1 •metformin hcl tab 1000 mg^ 1 •nateglinide tab 60 mg^ 2 •nateglinide tab 120 mg^ 2 •ONGLYZA - saxagliptin hcl tab

2.5 mg3 •

ONGLYZA - saxagliptin hcl tab5 mg

3 •

pioglitazone hcl tab 15 mg^ 2 •pioglitazone hcl tab 30 mg^ 2 •pioglitazone hcl tab 45 mg^ 2 •

2015


59

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

pioglitazone hcl-glimepiride tab30-2 mg^

2 •

pioglitazone hcl-glimepiride tab30-4 mg^

2 •

pioglitazone hcl-metformin hcl tab15-500 mg^

2 •

pioglitazone hcl-metformin hcl tab15-850 mg^

2 •

PROGLYCEM - diazoxide susp50 mg/ml

4

repaglinide tab 0.5 mg^ 2 •repaglinide tab 1 mg^ 2 •repaglinide tab 2 mg^ 2 •SYMLINPEN 120 - pramlintide

acetate pen-inj 2700 mcg/2.7ml(1000 mcg/ml)

3

SYMLINPEN 60 - pramlintideacetate pen-inj 1500 mcg/1.5ml(1000 mcg/ml)

3

TOUJEO SOLOSTAR -insulin glargine soln pen-injector300 unit/ml

3

TRADJENTA - linagliptin tab 5 mg 4 •VICTOZA - liraglutide soln pen-

injector 18 mg/3ml (6 mg/ml)3 •

WELCHOL - colesevelam hcl tab625 mg

3

WELCHOL - colesevelam hclpacket for susp 3.75 gm

3

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

Blood Products/Modifiers/Volume ExpandersAGGRENOX - aspirin-

dipyridamole cap sr 12hr25-200 mg

4

anagrelide hcl cap 0.5 mg^ 2anagrelide hcl cap 1 mg^ 2ARANESP ALBUMIN FREE -

darbepoetin alfa soln prefilledsyringe 10 mcg/0.4ml

3 •

ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilledsyringe 25 mcg/0.42ml

3 •


3 •


3 •


5 •


5 •


5 •


5 •

2015


60

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

ARANESP ALBUMIN FREE -darbepoetin alfa soln prefilledsyringe 500 mcg/ml

5 •

ARANESP ALBUMIN FREE- darbepoetin alfa soln inj25 mcg/ml

3 •


3 •


3 •


5 •


5 •


5 •

BRILINTA - ticagrelor tab 60 mg 3BRILINTA - ticagrelor tab 90 mg 3cilostazol tab 50 mg^ 2cilostazol tab 100 mg^ 2clopidogrel bisulfate tab 75 mg^ 2COUMADIN - warfarin sodium tab

1 mg4

COUMADIN - warfarin sodium tab2 mg

4

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

COUMADIN - warfarin sodium tab2.5 mg

4


4


4


4


4

COUMADIN - warfarin sodium tab7.5 mg

4


4

dipyridamole tab 25 mg# 4dipyridamole tab 50 mg# 4dipyridamole tab 75 mg# 4EFFIENT - prasugrel hcl tab 5 mg 3EFFIENT - prasugrel hcl tab

10 mg3

ELIQUIS - apixaban tab 2.5 mg 4 •ELIQUIS - apixaban tab 5 mg 4 •enoxaparin sodium inj

30 mg/0.3ml^2 •

enoxaparin sodium inj40 mg/0.4ml^

2 •


2 •


2 •

2015


61

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

enoxaparin sodium inj 100 mg/ml^

2 •


2 •

enoxaparin sodium inj 150 mg/ml^

2 •

enoxaparin sodium inj300 mg/3ml^

2 •

EPOGEN - epoetin alfa inj 2000unit/ml

4 •


4 •


4 •


4 •


4 •

fondaparinux sodiumsubcutaneous inj 2.5 mg/0.5ml^

2 •

fondaparinux sodiumsubcutaneous inj 5 mg/0.4ml

5 •

fondaparinux sodiumsubcutaneous inj 7.5 mg/0.6ml

5 •

fondaparinux sodiumsubcutaneous inj 10 mg/0.8ml

5 •

GRANIX - tbo-filgrastim solnprefilled syringe 300 mcg/0.5ml

5

GRANIX - tbo-filgrastim solnprefilled syringe 480 mcg/0.8ml

5

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

heparin sodium (porcine) inj 1000unit/ml^

2

heparin sodium (porcine) inj 5000unit/ml^

2

heparin sodium (porcine) inj10000 unit/ml^

2

heparin sodium (porcine) inj20000 unit/ml^

2

heparin sodium (porcine) pf inj5000 unit/0.5ml^

2

heparin sodium (porcine) 40 unit/ml in d5w^

2

LEUKINE - sargramostimlyophilized for inj 250 mcg

5

MOZOBIL - plerixaforsubcutaneous inj 24 mg/1.2ml(20 mg/ml)

5

NEULASTA - pegfilgrastim solnprefilled syringe 6 mg/0.6ml

5

NEULASTA DELIVERY KIT -pegfilgrastim soln prefilledsyringe kit 6 mg/0.6ml

5

NEUMEGA - oprelvekin for inj5 mg

5

PRADAXA - dabigatran etexilatemesylate cap 75 mg

3 •

PRADAXA - dabigatran etexilatemesylate cap 150 mg

3 •

PROCRIT - epoetin alfa inj 2000unit/ml

4 •

2015


62

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


4 •


4 •


4 •


5 •


5 •

PROMACTA - eltrombopagolamine tab 12.5 mg*

5 •

PROMACTA - eltrombopagolamine tab 25 mg*

5 •


5 •


5 •

tranexamic acid inj 100 mg/ml^ 2tranexamic acid tab 650 mg^ 2warfarin sodium tab 1 mg^ 2warfarin sodium tab 2 mg^ 2warfarin sodium tab 2.5 mg^ 2warfarin sodium tab 3 mg^ 2warfarin sodium tab 4 mg^ 2warfarin sodium tab 5 mg^ 2warfarin sodium tab 6 mg^ 2warfarin sodium tab 7.5 mg^ 2warfarin sodium tab 10 mg^ 2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

XARELTO - rivaroxaban tab10 mg

3 •


3 •


3 •

XARELTO STARTER PACK -rivaroxaban tab starter therapypack 15 mg & 20 mg

3 •

ZONTIVITY - vorapaxar sulfatetab 2.08 mg

4

Cardiovascular Agentsacebutolol hcl cap 200 mg^ 2acebutolol hcl cap 400 mg^ 2ACETAZOLAMIDE -

acetazolamide tab 125 mg4

acetazolamide cap sr 12hr500 mg^

2

acetazolamide tab 250 mg^ 2amiloride & hydrochlorothiazide

tab 5-50 mg^2

amiloride hcl tab 5 mg^ 2amiodarone hcl tab 200 mg^ 2amiodarone hcl tab 400 mg^ 2amlodipine besylate tab 2.5 mg^ 2amlodipine besylate tab 5 mg^ 2amlodipine besylate tab 10 mg^ 2amlodipine besylate-atorvastatin

calcium tab 2.5-10 mg^2

2015


63

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

amlodipine besylate-atorvastatincalcium tab 2.5-20 mg^

2

amlodipine besylate-atorvastatincalcium tab 2.5-40 mg^

2

amlodipine besylate-atorvastatincalcium tab 5-10 mg^

2


2


2


2


2


2


2


2

amlodipine besylate-benazeprilhcl cap 2.5-10 mg^

2

amlodipine besylate-benazeprilhcl cap 5-10 mg^

2


2


2


2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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horiz

atio

n

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ntity

Lim

its †

Ste

p Th

erap

y


2

amlodipine besylate-valsartan tab5-160 mg^

2 •


2 •


2 •


2 •

amlodipine-valsartan-hydrochlorothiazide tab5-160-12.5 mg^

2 •

amlodipine-valsartan-hydrochlorothiazide tab5-160-25 mg^

2 •

amlodipine-valsartan-hydrochlorothiazide tab10-160-12.5 mg^

2 •


2 •


2 •

atenolol & chlorthalidone tab50-25 mg^

2

atenolol & chlorthalidone tab100-25 mg^

2

atenolol tab 25 mg^ 1atenolol tab 50 mg^ 1

2015


64

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

atenolol tab 100 mg^ 1atorvastatin calcium tab 10 mg^ 2 •atorvastatin calcium tab 20 mg^ 2 •atorvastatin calcium tab 40 mg^ 2 •atorvastatin calcium tab 80 mg^ 2 •AZOR - amlodipine besylate-

olmesartan medoxomil tab5-20 mg

3 •

AZOR - amlodipine besylate-olmesartan medoxomil tab5-40 mg

3 •


3 •


3 •

benazepril & hydrochlorothiazidetab 5-6.25 mg^

1


1


1

benazepril & hydrochlorothiazidetab 20-25 mg^

1

benazepril hcl tab 5 mg^ 1benazepril hcl tab 10 mg^ 1benazepril hcl tab 20 mg^ 1benazepril hcl tab 40 mg^ 1

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

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horiz

atio

n

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ntity

Lim

its †

Ste

p Th

erap

y

BENICAR - olmesartanmedoxomil tab 5 mg

3 •


3 •


3 •

BENICAR HCT - olmesartanmedoxomil-hydrochlorothiazidetab 20-12.5 mg

3 •

BENICAR HCT - olmesartanmedoxomil-hydrochlorothiazidetab 40-12.5 mg

3 •

BENICAR HCT - olmesartanmedoxomil-hydrochlorothiazidetab 40-25 mg

3 •

betaxolol hcl tab 10 mg^ 2betaxolol hcl tab 20 mg^ 2bisoprolol & hydrochlorothiazide

tab 2.5-6.25 mg^2

bisoprolol & hydrochlorothiazidetab 5-6.25 mg^

2

bisoprolol & hydrochlorothiazidetab 10-6.25 mg^

2

bisoprolol fumarate tab 5 mg^ 2bisoprolol fumarate tab 10 mg^ 2bumetanide inj 0.25 mg/ml^ 2bumetanide tab 0.5 mg^ 2bumetanide tab 1 mg^ 2bumetanide tab 2 mg^ 2

2015


65

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

BYSTOLIC - nebivolol hcl tab2.5 mg

4

BYSTOLIC - nebivolol hcl tab5 mg

4


4


4

candesartan cilexetil tab 4 mg^ 2 •candesartan cilexetil tab 8 mg^ 2 •candesartan cilexetil tab 16 mg^ 2 •candesartan cilexetil tab 32 mg^ 2 •candesartan cilexetil-

hydrochlorothiazide tab16-12.5 mg^

2 •

candesartan cilexetil-hydrochlorothiazide tab32-12.5 mg^

2 •

candesartan cilexetil-hydrochlorothiazide tab32-25 mg^

2 •

captopril tab 12.5 mg^ 1captopril tab 25 mg^ 1captopril tab 50 mg^ 1captopril tab 100 mg^ 1carvedilol tab 3.125 mg^ 2carvedilol tab 6.25 mg^ 2carvedilol tab 12.5 mg^ 2carvedilol tab 25 mg^ 2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

CHLOROTHIAZIDE -chlorothiazide tab 250 mg

4

chlorothiazide tab 500 mg^ 2CHLORTHALIDONE -

chlorthalidone tab 25 mg4

CHLORTHALIDONE -chlorthalidone tab 50 mg

4

cholestyramine light powderpackets 4 gm^

2

cholestyramine light powder4 gm/dose^

2

cholestyramine powder packets4 gm^

2

cholestyramine powder 4 gm/dose^

2

choline fenofibrate cap dr 45 mg^ 2 •choline fenofibrate cap dr

135 mg^2 •

clonidine hcl tab 0.1 mg^ 2clonidine hcl tab 0.2 mg^ 2clonidine hcl tab 0.3 mg^ 2clonidine hcl td patch weekly

0.1 mg/24hr^2

clonidine hcl td patch weekly0.2 mg/24hr^

2

clonidine hcl td patch weekly0.3 mg/24hr^

2

colestipol hcl granule packets5 gm^

2

colestipol hcl granules 5 gm^ 2

2015


66

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

colestipol hcl tab 1 gm^ 2CORLANOR - ivabradine hcl tab

5 mg4 • •

CORLANOR - ivabradine hcl tab7.5 mg

4 • •

CRESTOR - rosuvastatin calciumtab 5 mg

3 •


3 •


3 •


3 •

DEMSER - metyrosine cap250 mg

5

DIBENZYLINE -phenoxybenzamine hcl cap10 mg

4

DIGOXIN - digoxin oral soln0.05 mg/ml#

4 •

digoxin tab 125 mcg (0.125 mg)^# 2 •digoxin tab 250 mcg (0.25 mg)# 4 • •diltiazem hcl cap sr 12hr 60 mg^ 2diltiazem hcl cap sr 12hr 90 mg^ 2diltiazem hcl cap sr 12hr 120 mg^ 2diltiazem hcl cap sr 24hr 120 mg^ 2diltiazem hcl cap sr 24hr 180 mg^ 2diltiazem hcl cap sr 24hr 240 mg^ 2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

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r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

diltiazem hcl coated beads cap sr24hr 120 mg^

2


2


2


2


2

diltiazem hcl coated beads tab sr24hr 180 mg^

2


2


2


2


2

diltiazem hcl extended releasebeads cap sr 24hr 120 mg^

2


2


2


2


2

2015


67

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

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r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


2

diltiazem hcl tab 30 mg^ 2diltiazem hcl tab 60 mg^ 2diltiazem hcl tab 90 mg^ 2diltiazem hcl tab 120 mg^ 2doxazosin mesylate tab 1 mg^ 2 •doxazosin mesylate tab 2 mg^ 2 •doxazosin mesylate tab 4 mg^ 2 •doxazosin mesylate tab 8 mg^ 2 •enalapril maleate &


1

enalapril maleate &hydrochlorothiazide tab10-25 mg^

1

enalapril maleate tab 2.5 mg^ 1enalapril maleate tab 5 mg^ 1enalapril maleate tab 10 mg^ 1enalapril maleate tab 20 mg^ 1eplerenone tab 25 mg^ 2eplerenone tab 50 mg^ 2eprosartan mesylate tab 600 mg^ 2 •EXFORGE - amlodipine besylate-

valsartan tab 5-160 mg3 •

EXFORGE - amlodipine besylate-valsartan tab 5-320 mg

3 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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horiz

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n

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ntity

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its †

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p Th

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y


3 •


3 •

EXFORGE HCT - amlodipine-valsartan-hydrochlorothiazidetab 5-160-12.5 mg

3 •

EXFORGE HCT - amlodipine-valsartan-hydrochlorothiazidetab 5-160-25 mg

3 •

EXFORGE HCT - amlodipine-valsartan-hydrochlorothiazidetab 10-160-12.5 mg

3 •


3 •


3 •

felodipine tab sr 24hr 2.5 mg^ 2felodipine tab sr 24hr 5 mg^ 2felodipine tab sr 24hr 10 mg^ 2fenofibrate micronized cap

67 mg^2 •

fenofibrate micronized cap134 mg^

2 •

fenofibrate micronized cap200 mg^

2 •

fenofibrate tab 48 mg^ 2 •fenofibrate tab 54 mg^ 2 •

2015


68

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

fenofibrate tab 145 mg^ 2 •fenofibrate tab 160 mg^ 2 •flecainide acetate tab 50 mg^ 2flecainide acetate tab 100 mg^ 2flecainide acetate tab 150 mg^ 2fosinopril sodium &


2

fosinopril sodium &hydrochlorothiazide tab20-12.5 mg^

2

fosinopril sodium tab 10 mg^ 2fosinopril sodium tab 20 mg^ 2fosinopril sodium tab 40 mg^ 2furosemide inj 10 mg/ml^ 2furosemide oral soln 10 mg/ml^ 2furosemide tab 20 mg^ 2furosemide tab 40 mg^ 2furosemide tab 80 mg^ 2gemfibrozil tab 600 mg^ 2 •hydralazine hcl tab 10 mg^ 2hydralazine hcl tab 25 mg^ 2hydralazine hcl tab 50 mg^ 2hydralazine hcl tab 100 mg^ 2hydrochlorothiazide cap 12.5 mg^ 2hydrochlorothiazide tab 12.5 mg^ 2hydrochlorothiazide tab 25 mg^ 2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

hydrochlorothiazide tab 50 mg^ 2indapamide tab 1.25 mg^ 2indapamide tab 2.5 mg^ 2irbesartan tab 75 mg^ 1 •irbesartan tab 150 mg^ 1 •irbesartan tab 300 mg^ 1 •irbesartan-hydrochlorothiazide tab

150-12.5 mg^1 •

irbesartan-hydrochlorothiazide tab300-12.5 mg^

1 •

ISOSORBIDE DINITRATE -isosorbide dinitrate tab 30 mg

4

ISOSORBIDE DINITRATE -isosorbide dinitrate sl tab2.5 mg

4

isosorbide dinitrate tab cr 40 mg^ 2isosorbide dinitrate tab 5 mg^ 2isosorbide dinitrate tab 10 mg^ 2isosorbide dinitrate tab 20 mg^ 2isosorbide mononitrate tab sr

24hr 30 mg^2

isosorbide mononitrate tab sr24hr 60 mg^

2

isosorbide mononitrate tab sr24hr 120 mg^

2

isosorbide mononitrate tab10 mg^

2

isosorbide mononitrate tab20 mg^

2

2015


69

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

isradipine cap 2.5 mg^ 2isradipine cap 5 mg^ 2JUXTAPID - lomitapide mesylate

cap 5 mg*5 •

JUXTAPID - lomitapide mesylatecap 10 mg*

5 •


5 •


5 •


5 •


5 •

KYNAMRO - mipomersen sodiumsoln prefilled syringe 200 mg/ml*

5 •

labetalol hcl tab 100 mg^ 2labetalol hcl tab 200 mg^ 2labetalol hcl tab 300 mg^ 2LIDOCAINE HCL - lidocaine hcl iv

inj 10 mg/ml4

lisinopril & hydrochlorothiazidetab 10-12.5 mg^

1

lisinopril & hydrochlorothiazidetab 20-12.5 mg^

1

lisinopril & hydrochlorothiazidetab 20-25 mg^

1

lisinopril tab 2.5 mg^ 1lisinopril tab 5 mg^ 1

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

lisinopril tab 10 mg^ 1lisinopril tab 20 mg^ 1lisinopril tab 30 mg^ 1lisinopril tab 40 mg^ 1LIVALO - pitavastatin calcium tab

1 mg4 •

LIVALO - pitavastatin calcium tab2 mg

4 •

LIVALO - pitavastatin calcium tab4 mg

4 •

losartan potassium &hydrochlorothiazide tab50-12.5 mg^

1 •

losartan potassium &hydrochlorothiazide tab100-12.5 mg^

1 •

losartan potassium &hydrochlorothiazide tab100-25 mg^

1 •

losartan potassium tab 25 mg^ 1 •losartan potassium tab 50 mg^ 1 •losartan potassium tab 100 mg^ 1 •lovastatin tab 10 mg^ 1 •lovastatin tab 20 mg^ 1 •lovastatin tab 40 mg^ 1 •LOVAZA - omega-3-acid ethyl

esters cap 1 gm3

methazolamide tab 25 mg^ 2methazolamide tab 50 mg^ 2

2015


70

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

metolazone tab 2.5 mg^ 2metolazone tab 5 mg^ 2metolazone tab 10 mg^ 2metoprolol & hydrochlorothiazide

tab 50-25 mg^2

metoprolol & hydrochlorothiazidetab 100-25 mg^

2

metoprolol succinate tab sr 24hr25 mg^

2


2


2


2

metoprolol tartrate tab 25 mg^ 1metoprolol tartrate tab 50 mg^ 1metoprolol tartrate tab 100 mg^ 1mexiletine hcl cap 150 mg^ 2mexiletine hcl cap 200 mg^ 2mexiletine hcl cap 250 mg^ 2midodrine hcl tab 2.5 mg^ 2midodrine hcl tab 5 mg^ 2midodrine hcl tab 10 mg^ 2minoxidil tab 2.5 mg^ 2minoxidil tab 10 mg^ 2moexipril hcl tab 7.5 mg^ 2moexipril hcl tab 15 mg^ 2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

moexipril-hydrochlorothiazide tab7.5-12.5 mg^

2

moexipril-hydrochlorothiazide tab15-12.5 mg^

2

moexipril-hydrochlorothiazide tab15-25 mg^

2

MULTAQ - dronedarone hcl tab400 mg

3

nadolol tab 20 mg^ 2nadolol tab 40 mg^ 2nadolol tab 80 mg^ 2niacin tab cr 500 mg^ 2 •niacin tab cr 750 mg^ 2 •niacin tab cr 1000 mg^ 2 •nicardipine hcl cap 20 mg^ 2nicardipine hcl cap 30 mg^ 2nifedipine tab sr 24hr 30 mg^ 2nifedipine tab sr 24hr 60 mg^ 2nifedipine tab sr 24hr 90 mg^ 2nifedipine tab sr 24hr osmotic

release 30 mg^2

nifedipine tab sr 24hr osmoticrelease 60 mg^

2

nifedipine tab sr 24hr osmoticrelease 90 mg^

2

NISOLDIPINE ER - nisoldipinetab sr 24hr 25.5 mg

4

nisoldipine tab sr 24hr 8.5 mg^ 2nisoldipine tab sr 24hr 17 mg^ 2

2015


71

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

nisoldipine tab sr 24hr 34 mg^ 2NITRO-BID - nitroglycerin oint 2% 4nitroglycerin td patch 24hr 0.1 mg/

hr^2

nitroglycerin td patch 24hr 0.2 mg/hr^

2


2


2

nitroglycerin tl soln 0.4 mg/spray(400 mcg/spray)^

2

NITROSTAT - nitroglycerin sl tab0.3 mg

3


3


3

NORTHERA - droxidopa cap100 mg

5 •


5 •


5 •

omega-3-acid ethyl esters cap1 gm^

2

pentoxifylline tab cr 400 mg^ 2perindopril erbumine tab 2 mg^ 2perindopril erbumine tab 4 mg^ 2perindopril erbumine tab 8 mg^ 2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

phenoxybenzamine hcl cap10 mg^

2

pindolol tab 5 mg^ 2pindolol tab 10 mg^ 2pravastatin sodium tab 10 mg^ 1 •pravastatin sodium tab 20 mg^ 1 •pravastatin sodium tab 40 mg^ 1 •pravastatin sodium tab 80 mg^ 1 •prazosin hcl cap 1 mg^ 2prazosin hcl cap 2 mg^ 2prazosin hcl cap 5 mg^ 2propafenone hcl cap sr 12hr

225 mg^2

propafenone hcl cap sr 12hr325 mg^

2

propafenone hcl cap sr 12hr425 mg^

2

propafenone hcl tab 150 mg^ 2propafenone hcl tab 225 mg^ 2propafenone hcl tab 300 mg^ 2propranolol hcl cap sr 24hr

60 mg^2


2


2


2

propranolol hcl inj 1 mg/ml^ 2

2015


72

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

propranolol hcl tab 10 mg^ 2propranolol hcl tab 20 mg^ 2propranolol hcl tab 40 mg^ 2propranolol hcl tab 60 mg^ 2propranolol hcl tab 80 mg^ 2quinapril hcl tab 5 mg^ 2quinapril hcl tab 10 mg^ 2quinapril hcl tab 20 mg^ 2quinapril hcl tab 40 mg^ 2quinapril-hydrochlorothiazide tab

10-12.5 mg^2

quinapril-hydrochlorothiazide tab20-12.5 mg^

2

quinapril-hydrochlorothiazide tab20-25 mg^

2

quinidine gluconate tab cr324 mg^

2

QUINIDINE SULFATE - quinidinesulfate tab 200 mg

4

quinidine sulfate tab 300 mg^ 2ramipril cap 1.25 mg^ 2ramipril cap 2.5 mg^ 2ramipril cap 5 mg^ 2ramipril cap 10 mg^ 2RANEXA - ranolazine tab sr 12hr

500 mg3

RANEXA - ranolazine tab sr 12hr1000 mg

3

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

SIMCOR - niacin-simvastatin tabsr 24hr 500-20 mg

3 •


3 •


3 •


3 •


3 •

simvastatin tab 5 mg^ 1 •simvastatin tab 10 mg^ 1 •simvastatin tab 20 mg^ 1 •simvastatin tab 40 mg^ 1 •simvastatin tab 80 mg^ 1 •sotalol hcl (afib/afl) tab 80 mg^ 2sotalol hcl (afib/afl) tab 120 mg^ 2sotalol hcl (afib/afl) tab 160 mg^ 2sotalol hcl tab 80 mg^ 2sotalol hcl tab 120 mg^ 2sotalol hcl tab 160 mg^ 2sotalol hcl tab 240 mg^ 2spironolactone &

hydrochlorothiazide tab25-25 mg^

2

spironolactone tab 25 mg^ 2spironolactone tab 50 mg^ 2spironolactone tab 100 mg^ 2

2015


73

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

TEKTURNA - aliskiren fumaratetab 150 mg

3 •

TEKTURNA - aliskiren fumaratetab 300 mg

3 •

TEKTURNA HCT - aliskiren-hydrochlorothiazide tab150-12.5 mg

3 •

TEKTURNA HCT - aliskiren-hydrochlorothiazide tab150-25 mg

3 •

TEKTURNA HCT - aliskiren-hydrochlorothiazide tab300-12.5 mg

3 •

TEKTURNA HCT - aliskiren-hydrochlorothiazide tab300-25 mg

3 •

telmisartan tab 20 mg^ 2 •telmisartan tab 40 mg^ 2 •telmisartan tab 80 mg^ 2 •telmisartan-hydrochlorothiazide

tab 40-12.5 mg^2 •

telmisartan-hydrochlorothiazidetab 80-12.5 mg^

2 •

telmisartan-hydrochlorothiazidetab 80-25 mg^

2 •

terazosin hcl cap 1 mg^ 2 •terazosin hcl cap 2 mg^ 2 •terazosin hcl cap 5 mg^ 2 •terazosin hcl cap 10 mg^ 2 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

TIKOSYN - dofetilide cap125 mcg (0.125 mg)

4


4


4


4


4


4

torsemide tab 5 mg^ 2torsemide tab 10 mg^ 2torsemide tab 20 mg^ 2torsemide tab 100 mg^ 2trandolapril tab 1 mg^ 2trandolapril tab 2 mg^ 2trandolapril tab 4 mg^ 2triamterene & hydrochlorothiazide

cap 37.5-25 mg^2

triamterene & hydrochlorothiazidetab 37.5-25 mg^

2

triamterene & hydrochlorothiazidetab 75-50 mg^

2

TRIBENZOR - olmesartan-amlodipine-hydrochlorothiazidetab 20-5-12.5 mg

3 •

2015


74

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


3 •

TRIBENZOR - olmesartan-amlodipine-hydrochlorothiazidetab 40-5-25 mg

3 •


3 •

TRIBENZOR - olmesartan-amlodipine-hydrochlorothiazidetab 40-10-25 mg

3 •

valsartan tab 40 mg^ 2 •valsartan tab 80 mg^ 2 •valsartan tab 160 mg^ 2 •valsartan tab 320 mg^ 2 •valsartan-hydrochlorothiazide tab

80-12.5 mg^2 •

valsartan-hydrochlorothiazide tab160-12.5 mg^

2 •

valsartan-hydrochlorothiazide tab160-25 mg^

2 •

valsartan-hydrochlorothiazide tab320-12.5 mg^

2 •

valsartan-hydrochlorothiazide tab320-25 mg^

2 •

VASCEPA - icosapent ethyl cap1 gm

3

VERAPAMIL HCL - verapamil hcltab 40 mg

4

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

verapamil hcl cap sr 24hr100 mg^

2


2


2


2


2


2


2

verapamil hcl tab cr 120 mg^ 2verapamil hcl tab cr 180 mg^ 2verapamil hcl tab cr 240 mg^ 2verapamil hcl tab 80 mg^ 2verapamil hcl tab 120 mg^ 2VYTORIN - ezetimibe-simvastatin

tab 10-10 mg3 •

VYTORIN - ezetimibe-simvastatintab 10-20 mg

3 •


3 •


3 •

WELCHOL - colesevelam hcl tab625 mg

3

2015


75

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

WELCHOL - colesevelam hclpacket for susp 3.75 gm

3

ZETIA - ezetimibe tab 10 mg 3 •Central Nervous System Agentsamphetamine-

dextroamphetamine cap sr 24hr5 mg^

2 •

amphetamine-dextroamphetamine cap sr 24hr10 mg^

2 •


2 •


2 •


2 •


2 •

AMPYRA - dalfampridine tab sr12hr 10 mg*

5 •

AVONEX - interferon beta-1aim prefilled syringe kit30 mcg/0.5ml

5 • •

AVONEX - interferon beta-1a forim inj kit 30mcg (33mcg(6.6mu)/vial)

5 • •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

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

5 • •

BETASERON - interferon beta-1bfor inj kit 0.3 mg

5 • •

clonidine hcl tab sr 12hr 0.1 mg^ 2 •COPAXONE - glatiramer acetate

soln prefilled syringe 20 mg/ml5 • •

COPAXONE - glatiramer acetatesoln prefilled syringe 40 mg/ml

5 • •

dexmethylphenidate hcl tab2.5 mg^

2 •

dexmethylphenidate hcl tab5 mg^

2 •

dexmethylphenidate hcl tab10 mg^

2 •

dextroamphetamine sulfate cap sr24hr 5 mg^

2 •


2 •


2 •

dextroamphetamine sulfate tab5 mg^

2 •

dextroamphetamine sulfate tab10 mg^

2 •


2 •


2 •

2015


76

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


2 •

Glatopa - glatiramer acetate solnprefilled syringe 20 mg/ml

5 • •

LYRICA - pregabalin soln 20 mg/ml

3

LYRICA - pregabalin cap 25 mg 3LYRICA - pregabalin cap 50 mg 3LYRICA - pregabalin cap 75 mg 3LYRICA - pregabalin cap 100 mg 3LYRICA - pregabalin cap 150 mg 3LYRICA - pregabalin cap 200 mg 3LYRICA - pregabalin cap 225 mg 3LYRICA - pregabalin cap 300 mg 3methylphenidate hcl tab cr

20 mg^2 •

methylphenidate hcl tab 5 mg^ 2 •methylphenidate hcl tab 10 mg^ 2 •methylphenidate hcl tab 20 mg^ 2 •mitoxantrone hcl inj conc

20 mg/10ml (2 mg/ml)^2

mitoxantrone hcl inj conc25 mg/12.5ml (2 mg/ml)^

2

mitoxantrone hcl inj conc30 mg/15ml (2 mg/ml)^

2

NUEDEXTA - dextromethorphanhbr-quinidine sulfate cap20-10 mg

3

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

PLEGRIDY - peginterferonbeta-1a soln pen-injector125 mcg/0.5ml

5 • •

PLEGRIDY - peginterferonbeta-1a soln prefilled syringe125 mcg/0.5ml

5 • •

PLEGRIDY STARTER PACK -peginterferon beta-1a soln pen-inj 63 & 94 mcg/0.5ml pack

5 • •

PLEGRIDY STARTER PACK -peginterferon beta-1a soln prefsyr 63 & 94 mcg/0.5ml pack

5 • •

riluzole tab 50 mg 5STRATTERA - atomoxetine hcl

cap 10 mg4 •

STRATTERA - atomoxetine hclcap 18 mg

4 •


4 •


4 •


4 •


4 •


4 •

TECFIDERA - dimethyl fumaratecapsule delayed release120 mg

5 • •

2015


77

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

TECFIDERA - dimethyl fumaratecapsule delayed release240 mg

5 • •

TECFIDERA STARTER PACK -dimethyl fumarate capsule drstarter pack 120 mg & 240 mg

5 • •

tetrabenazine tab 12.5 mg* 5 • •tetrabenazine tab 25 mg* 5 • •TYSABRI - natalizumab for iv inj

conc 300 mg/15ml*5 •

XENAZINE - tetrabenazine tab12.5 mg*

5 • •

XENAZINE - tetrabenazine tab25 mg*

5 • •Dental and Oral Agentschlorhexidine gluconate soln

0.12%^2

doxycycline hyclate cap 50 mg^ 2doxycycline hyclate cap 100 mg^ 2doxycycline hyclate for inj

100 mg^2

doxycycline hyclate tab 20 mg^ 2doxycycline hyclate tab 100 mg^ 2KEPIVANCE - palifermin for iv inj

6.25 mg5

pilocarpine hcl tab 5 mg^ 2pilocarpine hcl tab 7.5 mg^ 2triamcinolone acetonide dental

paste 0.1%^2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

Dermatological Agentsacitretin cap 10 mg 5acitretin cap 17.5 mg 5acitretin cap 25 mg 5acyclovir oint 5%^ 2alclometasone dipropionate

cream 0.05%^2

alclometasone dipropionate oint0.05%^

2

amcinonide cream 0.1%^ 2AZELEX - azelaic acid cream

20%4

benzoyl peroxide-erythromycin gel 5-3%^

2

betamethasone dipropionateaugmented cream 0.05%^

2

betamethasone dipropionateaugmented gel 0.05%^

2

betamethasone dipropionateaugmented lotion 0.05%^

2

betamethasone dipropionateaugmented oint 0.05%^

2

betamethasone dipropionatecream 0.05%^

2

betamethasone dipropionatelotion 0.05%^

2

betamethasone dipropionate oint0.05%^

2

betamethasone valerate cream0.1%^

2

2015


78

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

betamethasone valerate lotion0.1%^

2

betamethasone valerate oint0.1%^

2

calcipotriene cream 0.005%^ 2calcipotriene oint 0.005%^ 2calcipotriene soln 0.005%

(50 mcg/ml)^2

CARAC - fluorouracil cream 0.5% 4ciclopirox gel 0.77%^ 2ciclopirox olamine cream 0.77%^ 2ciclopirox olamine susp 0.77%^ 2ciclopirox shampoo 1%^ 2ciclopirox solution 8%^ 2clindamycin phosphate gel 1%^ 2clindamycin phosphate lotion 1%^ 2clindamycin phosphate soln 1%^ 2clindamycin phosphate swab 1%^ 2clindamycin phosphate-benzoyl

peroxide gel 1-5%^2

clobetasol propionate cream0.05%^

2

clobetasol propionate emollientbase cream 0.05%^

2

clobetasol propionate gel 0.05%^ 2clobetasol propionate oint 0.05%^ 2clobetasol propionate soln

0.05%^2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

clotrimazole cream 1%^ 2clotrimazole w/ betamethasone

cream 1-0.05%^2

clotrimazole w/ betamethasonelotion 1-0.05%^

2

DENAVIR - penciclovir cream 1% 4desonide cream 0.05%^ 2desonide lotion 0.05%^ 2desonide oint 0.05%^ 2DESOXIMETASONE -

desoximetasone cream 0.05%4

desoximetasone cream 0.25%^ 2desoximetasone gel 0.05%^ 2desoximetasone oint 0.25%^ 2diclofenac sodium gel 3% 5diflorasone diacetate oint 0.05%^ 2econazole nitrate cream 1%^ 2ELIDEL - pimecrolimus cream 1% 4 •erythromycin pads 2%^ 2erythromycin soln 2%^ 2FINACEA - azelaic acid foam

15%4

FINACEA - azelaic acid gel 15% 4fluocinolone acetonide cream

0.01%^2

fluocinonide cream 0.05%^ 2fluocinonide emulsified base

cream 0.05%^2

2015


79

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

fluocinonide gel 0.05%^ 2fluocinonide oint 0.05%^ 2fluocinonide soln 0.05%^ 2fluorouracil cream 5%^ 2fluorouracil soln 2%^ 2fluorouracil soln 5%^ 2fluticasone propionate cream

0.05%^2

fluticasone propionate oint0.005%^

2

GENTAMICIN SULFATE- gentamicin sulfate cream 0.1%

4

GENTAMICIN SULFATE- gentamicin sulfate oint 0.1%

4

halobetasol propionate cream0.05%^

2

halobetasol propionate oint0.05%^

2

hydrocortisone butyrate cream0.1%^

2

hydrocortisone butyrate oint0.1%^

2

hydrocortisone butyrate soln0.1%^

2

hydrocortisone cream 1%^ 2hydrocortisone cream 2.5%^ 2hydrocortisone lotion 2.5%^ 2hydrocortisone oint 1%^ 2hydrocortisone oint 2.5%^ 2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

hydrocortisone valerate cream0.2%^

2

hydrocortisone valerate oint0.2%^

2

imiquimod cream 5%^ 2 •isotretinoin cap 10 mg^ 2isotretinoin cap 20 mg^ 2isotretinoin cap 30 mg^ 2isotretinoin cap 40 mg^ 2ketoconazole cream 2%^ 2ketoconazole shampoo 2%^ 2lactic acid (ammonium lactate)

cream 12%^2

lactic acid (ammonium lactate)lotion 12%^

2

methoxsalen rapid cap 10 mg 5metronidazole cream 0.75%^ 2metronidazole gel 0.75%^ 2metronidazole gel 1%^ 2metronidazole lotion 0.75%^ 2mometasone furoate cream

0.1%^2

mometasone furoate oint 0.1%^ 2mometasone furoate solution

0.1% (lotion)^2

mupirocin oint 2%^ 2nystatin cream 100000 unit/gm^ 2nystatin oint 100000 unit/gm^ 2

2015


80

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

nystatin topical powder^ 2nystatin-triamcinolone cream

100000-0.1 unit/gm-%^2

nystatin-triamcinolone oint100000-0.1 unit/gm-%^

2

ORACEA - doxycycline capdelayed release 40 mg

4

OXSORALEN ULTRA -methoxsalen rapid cap 10 mg

5

PICATO - ingenol mebutate gel0.015%

3 •

PICATO - ingenol mebutate gel0.05%

3 •

podofilox soln 0.5%^ 2prednicarbate cream 0.1%^ 2prednicarbate oint 0.1%^ 2SANTYL - collagenase oint 250

unit/gm3

selenium sulfide lotion 2.5%^ 2silver sulfadiazine cream 1%^ 2sulfacetamide sodium lotion 10%^ 2tacrolimus oint 0.03%^ 2 •tacrolimus oint 0.1%^ 2 •TAZORAC - tazarotene cream

0.05%4

TAZORAC - tazarotene cream0.1%

4

TAZORAC - tazarotene gel 0.05% 4TAZORAC - tazarotene gel 0.1% 4

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

tretinoin cream 0.025%^ 2tretinoin cream 0.05%^ 2tretinoin cream 0.1%^ 2tretinoin gel 0.01%^ 2tretinoin gel 0.025%^ 2TRIAMCINOLONE ACETONIDE

- triamcinolone acetonide oint0.5%

4

triamcinolone acetonide cream0.025%^

2


2


2

triamcinolone acetonide lotion0.025%^

2

triamcinolone acetonide lotion0.1%^

2

triamcinolone acetonide oint0.025%^

2

triamcinolone acetonide oint0.1%^

2

UVADEX - methoxsalen soln20 mcg/ml

4

VALCHLOR - mechlorethaminehcl gel 0.016%*

5

VECTICAL - calcitriol oint 3 mcg/gm

3

VOLTAREN - diclofenacsodium gel 1%

3 •

2015


81

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

Enzyme Replacements/ModifiersADAGEN - pegademase bovine

inj 250 unit/ml*5

ALDURAZYME - laronidase solnfor iv infusion 2.9 mg/5ml (500unit/5ml)*

5

BUPHENYL - sodiumphenylbutyrate tab 500 mg

5

CEREZYME - imiglucerase for inj400 unit*

5

CREON - pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000unit

3

CREON - pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000unit

3

CREON - pancrelipase(lip-prot-amyl) dr cap12000-38000-60000 unit

3


3


3

CYSTADANE - betaine powderfor oral solution

5

CYSTAGON - cysteaminebitartrate cap 50 mg*

4

CYSTAGON - cysteaminebitartrate cap 150 mg*

4

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

ELAPRASE - idursulfase soln foriv infusion 6 mg/3ml (2 mg/ml)

5

ELELYSO - taliglucerase alfa forinj 200 unit*

5

FABRAZYME - agalsidase betafor iv soln 5 mg*

5

FABRAZYME - agalsidase betafor iv soln 35 mg*

5

KUVAN - sapropterindihydrochloride soluble tab100 mg*

5 •

KUVAN - sapropterindihydrochloride powder packet100 mg*

5 •

KUVAN - sapropterindihydrochloride powder packet500 mg*

5 •

MYOZYME - alglucosidase alfafor iv soln 50 mg

5

NAGLAZYME - galsulfase soln foriv infusion 1 mg/ml*

5

ORFADIN - nitisinone cap 2 mg* 5ORFADIN - nitisinone cap 5 mg* 5ORFADIN - nitisinone cap 10 mg* 5sodium phenylbutyrate oral

powder 3 gm/teaspoonful5

VIOKACE - pancrelipase (lip-prot-amyl) tab 10440-39150-39150unit

4

2015


82

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

VIOKACE - pancrelipase (lip-prot-amyl) tab 20880-78300-78300unit

4

VPRIV - velaglucerase alfa for inj400 unit

5

ZAVESCA - miglustat cap100 mg*

5

ZENPEP - pancrelipase (lip-prot-amyl) dr cap 3000-10000-16000unit

3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap 5000-17000-27000unit

3

ZENPEP - pancrelipase(lip-prot-amyl) dr cap10000-34000-55000 unit

3


3


3


3


3

Gastrointestinal Agentsalosetron hcl tab 0.5 mg 5alosetron hcl tab 1 mg 5

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

AMITIZA - lubiprostone cap8 mcg

3 •

AMITIZA - lubiprostone cap24 mcg

3 •

CHENODAL - chenodiol tab250 mg*

5

cimetidine hcl soln 300 mg/5ml^ 2cimetidine tab 200 mg^ 2cimetidine tab 300 mg^ 2cimetidine tab 400 mg^ 2cimetidine tab 800 mg^ 2cromolyn sodium oral conc

100 mg/5ml5

DEXILANT - dexlansoprazole capdelayed release 30 mg

4 •

DEXILANT - dexlansoprazole capdelayed release 60 mg

4 •

dicyclomine hcl tab 20 mg^ 2esomeprazole sodium for

intravenous soln 20 mg^2

esomeprazole sodium forintravenous soln 40 mg^

2

famotidine for susp 40 mg/5ml^ 2famotidine inj 20 mg/2ml^ 2famotidine inj 40 mg/4ml^ 2famotidine inj 200 mg/20ml^ 2famotidine tab 20 mg^ 2famotidine tab 40 mg^ 2

2015


83

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

GATTEX - teduglutide (rdna) forinj kit 5 mg*

5 •

glycopyrrolate tab 1 mg^ 2glycopyrrolate tab 2 mg^ 2lactulose (encephalopathy)

solution 10 gm/15ml^2

lactulose solution 10 gm/15ml^ 2lansoprazole cap delayed release

15 mg^2 •

lansoprazole cap delayed release30 mg^

2 •

LINZESS - linaclotide cap145 mcg

3 •

LINZESS - linaclotide cap290 mcg

3 •

loperamide hcl cap 2 mg^ 2LOTRONEX - alosetron hcl tab

0.5 mg5

LOTRONEX - alosetron hcl tab1 mg

5

methscopolamine bromide tab2.5 mg^

2

methscopolamine bromide tab5 mg^

2

metoclopramide hcl soln5 mg/5ml (10 mg/10ml)^

2

metoclopramide hcl tab 5 mg^ 2metoclopramide hcl tab 10 mg^ 2misoprostol tab 100 mcg^ 2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

misoprostol tab 200 mcg^ 2MOVIPREP - peg 3350-kcl-nacl-

na sulfate-na ascorbate-c forsoln 100 gm

4

NEXIUM - esomeprazolemagnesium for delayed releasesusp pack 2.5 mg

3 •

NEXIUM - esomeprazolemagnesium for delayed releasesusp packet 5 mg

3 •


3 •


3 •


3 •

NEXIUM - esomeprazolemagnesium cap delayedrelease 20 mg

3 •

NEXIUM - esomeprazolemagnesium cap delayedrelease 40 mg

3 •

nizatidine cap 150 mg^ 2nizatidine cap 300 mg^ 2omeprazole cap delayed release

10 mg^2 •

omeprazole cap delayed release20 mg^

2 •

2015


84

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

omeprazole cap delayed release40 mg^

2 •

pantoprazole sodium ec tab20 mg^

2 •

pantoprazole sodium ec tab40 mg^

2 •

peg 3350-kcl-sod bicarb-nacl forsoln 420 gm^

2

peg 3350-kcl-na bicarb-nacl-nasulfate for soln 236 gm^

2

peg 3350-kcl-na bicarb-nacl-nasulfate for soln 240 gm^

2

polyethylene glycol 3350 oralpacket^

2

polyethylene glycol 3350 oralpowder^

2

PYLERA - bismuth subcit-metronidazole-tetracycline cap140-125-125 mg

3

rabeprazole sodium ec tab20 mg^

2 •

ranitidine hcl cap 150 mg^ 2ranitidine hcl cap 300 mg^ 2ranitidine hcl syrup 15 mg/ml

(75 mg/5ml)^2

ranitidine hcl tab 150 mg^ 2ranitidine hcl tab 300 mg^ 2RELISTOR - methylnaltrexone

bromide inj kit 12 mg/0.6ml4 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

RELISTOR - methylnaltrexonebromide inj 8 mg/0.4ml (20 mg/ml)

4 •

RELISTOR - methylnaltrexonebromide inj 12 mg/0.6ml(20 mg/ml)

4 •

sucralfate tab 1 gm^ 2SUPREP BOWEL PREP - sodium

sulfate-potassium sulfate-magnesium sulfate oral soln

3

ursodiol cap 300 mg^ 2XIFAXAN - rifaximin tab 550 mg 5Genitourinary Agentsalfuzosin hcl tab sr 24hr 10 mg^ 2 •AVODART - dutasteride cap

0.5 mg3 •

bethanechol chloride tab 5 mg^ 2bethanechol chloride tab 10 mg^ 2bethanechol chloride tab 25 mg^ 2bethanechol chloride tab 50 mg^ 2calcium acetate cap 667 mg^ 2calcium acetate tab 667 mg^ 2CUPRIMINE - penicillamine cap

250 mg3

DEPEN TITRATABS -penicillamine tab 250 mg

4

doxazosin mesylate tab 1 mg^ 2 •doxazosin mesylate tab 2 mg^ 2 •doxazosin mesylate tab 4 mg^ 2 •

2015


85

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

doxazosin mesylate tab 8 mg^ 2 •dutasteride cap 0.5 mg^ 2 •finasteride tab 5 mg^ 2 •FOSRENOL - lanthanum

carbonate chew tab 500 mg3

FOSRENOL - lanthanumcarbonate chew tab 750 mg

3

FOSRENOL - lanthanumcarbonate chew tab 1000 mg

3

FOSRENOL - lanthanumcarbonate oral powder pack750 mg

3

FOSRENOL - lanthanumcarbonate oral powder pack1000 mg

3

JALYN - dutasteride-tamsulosinhcl cap 0.5-0.4 mg

3 •

methylergonovine maleate tab0.2 mg^

2

MYRBETRIQ - mirabegron tab sr24 hr 25 mg

3 •

MYRBETRIQ - mirabegron tab sr24 hr 50 mg

3 •

neomycin-polymyxin b guirrigation soln^

2

oxybutynin chloride syrup5 mg/5ml^

2 •

oxybutynin chloride tab sr 24hr5 mg^

2 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


2 •


2 •

oxybutynin chloride tab 5 mg^ 2 •PHOSLYRA - calcium acetate

oral soln 667 mg/5ml3

prazosin hcl cap 1 mg^ 2prazosin hcl cap 2 mg^ 2prazosin hcl cap 5 mg^ 2RAPAFLO - silodosin cap 4 mg 3 •RAPAFLO - silodosin cap 8 mg 3 •RENVELA - sevelamer carbonate

tab 800 mg4

RENVELA - sevelamer carbonatepacket 0.8 gm

4

RENVELA - sevelamer carbonatepacket 2.4 gm

4

tamsulosin hcl cap 0.4 mg^ 2 •terazosin hcl cap 1 mg^ 2 •terazosin hcl cap 2 mg^ 2 •terazosin hcl cap 5 mg^ 2 •terazosin hcl cap 10 mg^ 2 •tolterodine tartrate cap sr 24hr

2 mg^2 •

tolterodine tartrate cap sr 24hr4 mg^

2 •

tolterodine tartrate tab 1 mg^ 2 •tolterodine tartrate tab 2 mg^ 2 •

2015


86

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

TOVIAZ - fesoterodine fumaratetab sr 24hr 4 mg

3 •

TOVIAZ - fesoterodine fumaratetab sr 24hr 8 mg

3 •

trospium chloride cap sr 24hr60 mg^

2 •

trospium chloride tab 20 mg^ 2 •VESICARE - solifenacin

succinate tab 5 mg3 •

VESICARE - solifenacinsuccinate tab 10 mg

3 •Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)CORTISONE ACETATE -

cortisone acetate tab 25 mg4

DEXAMETHASONE -dexamethasone tab 1 mg

4

DEXAMETHASONE -dexamethasone tab 2 mg

4

dexamethasone elixir0.5 mg/5ml^

2

dexamethasone sodiumphosphate inj 4 mg/ml^

2

dexamethasone sodiumphosphate inj 20 mg/5ml^

2

dexamethasone sodiumphosphate inj 120 mg/30ml^

2

dexamethasone tab 0.5 mg^ 2dexamethasone tab 0.75 mg^ 2dexamethasone tab 1.5 mg^ 2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

dexamethasone tab 4 mg^ 2dexamethasone tab 6 mg^ 2fludrocortisone acetate tab

0.1 mg^2

H.P. ACTHAR - corticotropininj gel 80 unit/ml*

5 •

hydrocortisone tab 5 mg^ 2hydrocortisone tab 10 mg^ 2hydrocortisone tab 20 mg^ 2methylprednisolone sodium

succinate for inj 40 mg^2

methylprednisolone sodiumsuccinate for inj 125 mg^

2

methylprednisolone sodiumsuccinate for inj 1000 mg^

2

methylprednisolone tab 4 mgdose pack^

2

methylprednisolone tab 4 mg^ 2 Xmethylprednisolone tab 8 mg^ 2 Xmethylprednisolone tab 16 mg^ 2 Xmethylprednisolone tab 32 mg^ 2 XMYALEPT - metreleptin for

subcutaneous inj 11.3 mg5 •

prednisolone sod phosph oralsoln 6.7 mg/5ml (5 mg/5mlbase)^

2 X

prednisolone sod phosphate oralsoln 15 mg/5ml^

2 X

prednisolone syrup 15 mg/5ml^ 2 X

2015


87

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

PREDNISONE - prednisone tab50 mg

4 X

PREDNISONE - prednisone oralsoln 5 mg/5ml

4 X

PREDNISONE - prednisone tab5 mg dose pack^

2

PREDNISONE - prednisone tab10 mg dose pack^

2

prednisone tab 1 mg^ 2 Xprednisone tab 2.5 mg^ 2 Xprednisone tab 5 mg^ 2 Xprednisone tab 10 mg^ 2 Xprednisone tab 20 mg^ 2 XHormonal Agents, Stimulant/Replacement/Modifying (Pituitary)chorionic gonadotropin for inj

10000 unit^2

desmopressin acetate inj 4 mcg/ml^

2

desmopressin acetate nasal soln0.01% (refrigerated)^

2

desmopressin acetate nasalspray soln 0.01%^

2

desmopressin acetate nasalspray soln 0.01% (refrigerated)^

2

desmopressin acetate tab0.1 mg^

2

desmopressin acetate tab0.2 mg^

2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

EGRIFTA - tesamorelin acetatefor inj 1 mg*

5 •

EGRIFTA - tesamorelin acetatefor inj 2 mg*

5 •

INCRELEX - mecasermin inj40 mg/4ml (10 mg/ml)*

5

OMNITROPE - somatropin for inj5.8 mg

3 •

OMNITROPE - somatropin inj5 mg/1.5ml

5 •

OMNITROPE - somatropin inj10 mg/1.5ml

5 •

STIMATE - desmopressin acetatenasal soln 1.5 mg/ml

4

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)ANADROL-50 - oxymetholone tab

50 mg5 •

ANDRODERM - testosterone tdpatch 24hr 2 mg/24hr

3 • •

ANDRODERM - testosterone tdpatch 24hr 4 mg/24hr

3 • •

ANDROGEL - testosterone td gel25 mg/2.5gm (1%)

3 • •

ANDROGEL - testosterone td gel50 mg/5gm (1%)

3 • •

ANDROGEL - testosterone td gel20.25 mg/1.25gm (1.62%)

3 • •

ANDROGEL - testosterone td gel40.5 mg/2.5gm (1.62%)

3 • •

2015


88

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

ANDROGEL PUMP -testosterone td gel 12.5 mg/act(1%)

3 • •

ANDROGEL PUMP -testosterone td gel 20.25 mg/act(1.62%)

3 • •

ANDROID - methyltestosteronecap 10 mg

4 •

ANDROXY - fluoxymesterone tab10 mg

4 •

AXIRON - testosterone td soln30 mg/act

4 • •

danazol cap 50 mg^ 2 •danazol cap 100 mg^ 2 •danazol cap 200 mg^ 2 •DEPO-PROVERA -

medroxyprogesterone acetateim susp 400 mg/ml

4

desogest-eth estrad & eth estradtab 0.15-0.02/0.01 mg(21/5)^

2

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

2

desogestrel & ethinyl estradiol tab0.15 mg-30 mcg^

2

DIVIGEL - estradiol td gel0.25 mg/0.25gm (0.1%)#

4 •

DIVIGEL - estradiol td gel0.5 mg/0.5gm (0.1%)#

4 •

DIVIGEL - estradiol td gel 1 mg/gm (0.1%)#

4 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

drospirenone-ethinyl estradiol tab3-0.02 mg^

2

drospirenone-ethinyl estradiol tab3-0.03 mg^

2

ELLA - ulipristal acetate tab30 mg

3

ESTRACE - estradiol vaginalcream 0.1 mg/gm

4

estradiol & norethindrone acetatetab 0.5-0.1 mg#

4 •

estradiol & norethindrone acetatetab 1-0.5 mg#

4 •

estradiol tab 0.5 mg# 4 •estradiol tab 1 mg# 4 •estradiol tab 2 mg# 4 •estradiol td patch weekly

0.025 mg/24hr#4 •

estradiol td patch weekly0.0375 mg/24hr(37.5 mcg/24hr)#

4 •

estradiol td patch weekly0.05 mg/24hr#

4 •


4 •


4 •


4 •

ESTROPIPATE - estropipate tab3 mg#

4 •

2015


89

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

estropipate tab 0.75 mg# 4 •estropipate tab 1.5 mg# 4 •ethynodiol diacetate & ethinyl

estradiol tab 1 mg-35 mcg^2

levonorg-eth est tab0.1-0.02mg(84) & eth est tab0.01mg(7)^

2

levonorg-eth est tab0.15-0.03mg(84) & eth est tab0.01mg(7)^

2

levonorgestrel & ethinyl estradiol(91-day) tab 0.15-0.03 mg^

2

levonorgestrel & ethinyl estradioltab 0.1 mg-20 mcg^

2

levonorgestrel & ethinyl estradioltab 0.15 mg-30 mcg^

2

levonorgestrel-eth estra tab0.05-30/0.075-40/0.125-30mg-mcg^

2

levonorgestrel-ethinyl estradiol(continuous) tab 90-20 mcg^

2

medroxyprogesterone acetate imsusp 150 mg/ml^

2

medroxyprogesterone acetate tab2.5 mg^

2

medroxyprogesterone acetate tab5 mg^

2

medroxyprogesterone acetate tab10 mg^

2

megestrol acetate susp 40 mg/ml#

4 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

megestrol acetate tab 20 mg# 4 •megestrol acetate tab 40 mg# 4 •MENEST - esterified estrogens

tab 0.3 mg#4 •

MENEST - esterified estrogenstab 0.625 mg#

4 •


4 •


4 •

methyltestosterone cap 10 mg^ 2 •norethindrone & ethinyl estradiol

tab 0.4 mg-35 mcg^2

norethindrone & ethinyl estradioltab 0.5 mg-35 mcg^

2

norethindrone & ethinyl estradioltab 1 mg-35 mcg^

2

norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg^

2

norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg^

2

norethindrone ac-ethinyl estrad-fetab 1-20/1-30/1-35 mg-mcg^

2

norethindrone ace & ethinylestradiol tab 1 mg-20 mcg^

2

norethindrone ace & ethinylestradiol tab 1.5 mg-30 mcg^

2

norethindrone ace & ethinylestradiol-fe tab 1 mg-20 mcg^

2

2015


90

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

norethindrone ace & ethinylestradiol-fe tab 1.5 mg-30 mcg^

2

norethindrone ace-ethinylestradiol-fe tab 1 mg-20 mcg(24)^

2

norethindrone acetate tab 5 mg^ 2norethindrone tab 0.35 mg^ 2norethindrone-eth estradiol tab

0.5-35/0.75-35/1-35 mg-mcg^2

norethindrone-eth estradiol tab0.5-35/1-35/0.5-35 mg-mcg^

2

norgestimate & ethinyl estradioltab 0.25 mg-35 mcg^

2

norgestimate-eth estrad tab0.18-35/0.215-35/0.25-35 mg-mcg^

2

norgestrel & ethinyl estradiol tab0.3 mg-30 mcg^

2

oxandrolone tab 2.5 mg^ 2 •oxandrolone tab 10 mg 5 •PREMARIN - estrogens,

conjugated vaginal cream0.625 mg/gm

3

PREMARIN - estrogens,conjugated tab 0.3 mg#

4 •


4 •


4 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


4 •


4 •

PREMPHASE - conj est0.625(14)/conj est-medroxyproac tab 0.625-5mg(14)#

4 •

PREMPRO - conjugatedestrogen-medroxyprogestacetate tab 0.3-1.5 mg#

4 •


4 •


4 •

PREMPRO - conjugatedestrogen-medroxyprogestacetate tab 0.625-5 mg#

4 •

raloxifene hcl tab 60 mg^ 2testosterone cypionate im inj in oil

100 mg/ml^2 •

testosterone cypionate im inj in oil200 mg/ml^

2 •

testosterone enanthate im inj inoil 200 mg/ml^

2 •

VAGIFEM - estradiol vaginal tab10 mcg

3

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)levothyroxine sodium tab 25 mcg^ 2

2015


91

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

levothyroxine sodium tab 50 mcg^ 2levothyroxine sodium tab 75 mcg^ 2levothyroxine sodium tab 88 mcg^ 2levothyroxine sodium tab

100 mcg^2

levothyroxine sodium tab112 mcg^

2


2


2


2


2


2


2

liothyronine sodium tab 5 mcg^ 2liothyronine sodium tab 25 mcg^ 2liothyronine sodium tab 50 mcg^ 2SYNTHROID - levothyroxine

sodium tab 25 mcg4

SYNTHROID - levothyroxinesodium tab 50 mcg

4


4


4

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


4


4


4


4


4


4


4


4

Hormonal Agents, Suppressant (Adrenal)LYSODREN - mitotane tab

500 mg3

Hormonal Agents, Suppressant (Parathyroid)SENSIPAR - cinacalcet hcl tab

30 mg3 •

SENSIPAR - cinacalcet hcl tab60 mg

3 •

SENSIPAR - cinacalcet hcl tab90 mg

3 •Hormonal Agents, Suppressant (Pituitary)bromocriptine mesylate cap

5 mg^2

bromocriptine mesylate tab2.5 mg^

2

2015


92

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

cabergoline tab 0.5 mg^ 2ELIGARD - leuprolide acetate for

subcutaneous inj kit 7.5 mg4

ELIGARD - leuprolide acetate (3month) for subcutaneous inj kit22.5mg

4

ELIGARD - leuprolide acetate (4month) for subcutaneous inj kit30 mg

4

ELIGARD - leuprolide acetate (6month) for subcutaneous inj kit45 mg

5

FIRMAGON - degarelix acetatefor inj 80 mg

4

FIRMAGON - degarelix acetatefor inj 120 mg

5

leuprolide acetate inj kit 5 mg/ml^ 2LUPRON DEPOT - leuprolide

acetate for inj kit 3.75 mg5

LUPRON DEPOT - leuprolideacetate for inj kit 7.5 mg

5

LUPRON DEPOT - leuprolideacetate (3 month) for inj kit11.25 mg

5

LUPRON DEPOT - leuprolideacetate (3 month) for inj kit22.5 mg

5

LUPRON DEPOT - leuprolideacetate (4 month) for inj kit30 mg

5

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

LUPRON DEPOT - leuprolideacetate (6 month) for inj kit45 mg

5

LUPRON DEPOT-PED -leuprolide acetate for injpediatric kit 7.5 mg

5

LUPRON DEPOT-PED -leuprolide acetate for injpediatric kit 11.25 mg

5

LUPRON DEPOT-PED -leuprolide acetate for injpediatric kit 15 mg

5

LUPRON DEPOT-PED -leuprolide acetate (3 month) forinj pediatric kit 11.25 mg

5

LUPRON DEPOT-PED -leuprolide acetate (3 month) forinj pediatric kit 30 mg

5

octreotide acetate inj 50 mcg/ml(0.05 mg/ml)^

2 •


2 •


2 •

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

5 •

octreotide acetate inj 1000 mcg/ml (1 mg/ml)

5 •

SIGNIFOR LAR - pasireotidepamoate for im er susp 20 mg*

5 •

2015


93

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


5 •


5 •

SIGNIFOR - pasireotidediaspartate inj 0.3 mg/ml*

5 •


5 •


5 •

SOMATULINE DEPOT -lanreotide acetate extendedrelease inj 60 mg/0.2ml

5 •


5 •


5 •

SOMAVERT - pegvisomant for inj10 mg*

5 •


5 •


5 •


5 •


5 •

SYNAREL - nafarelin acetatenasal soln 2 mg/ml

5

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

TRELSTAR - triptorelin pamoatefor im susp 3.75 mg

5

TRELSTAR - triptorelin pamoatefor im susp 11.25 mg

5

TRELSTAR MIXJECT - triptorelinpamoate for im susp 3.75 mg

5


5


5

Hormonal Agents, Suppressant (Thyroid)methimazole tab 5 mg^ 2methimazole tab 10 mg^ 2propylthiouracil tab 50 mg^ 2Immunological AgentsACTHIB - haemophilus b

polysaccharide conjugatevaccine for inj

4

ACTIMMUNE -interferon gamma-1b inj100 mcg/0.5ml (2000000unit/0.5ml)*

5

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

4

ARCALYST - rilonacept for inj220 mg*

5 •

ATGAM - lymphocyteimmune globulin anti-thymocyte g inj 50 mg/ml(eq)

5 X

AZASAN - azathioprine tab 75 mg 4 X

2015


94

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

AZASAN - azathioprine tab100 mg

4 X

azathioprine tab 50 mg^ 2 XBCG VACCINE - bcg vaccine inj 4BEXSERO - meningococcal vac b

(recomb adsorbed) inj prefilledsyringe

4

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

4

CELLCEPT - mycophenolatemofetil for oral susp 200 mg/ml

5 X

CELLCEPT INTRAVENOUS -mycophenolate mofetil hcl for ivsoln 500 mg

4 X

CERVARIX - humanpapillomavirus (hpv) bival (type16, 18) recmb vac inj

4

CINRYZE - c1 esterase inhibitor(human) for iv inj 500 unit*

5 • •

COMVAX - haemophilus bpolysac conj-hepatitis b(recomb) vac im susp

4

CUPRIMINE - penicillamine cap250 mg

3

cyclosporine cap 25 mg^ 2 Xcyclosporine cap 100 mg^ 2 Xcyclosporine iv soln 50 mg/ml^ 2 X

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

CYCLOSPORINE MODIFIED- cyclosporine modified cap50 mg

4 X

cyclosporine modified cap 25 mg^ 2 Xcyclosporine modified cap

100 mg^2 X

cyclosporine modified oral soln100 mg/ml^

2 X

DAPTACEL - diph, acellular pert& tet tox inj 15 lf-10 mcg-5lf/0.5ml

4


4

DIPHTHERIA/TETANUSTOXOID - diphtheria-tetanustox adsorbed (dt) im inj 25-5unit/0.5ml

4

ELIDEL - pimecrolimus cream 1% 4 •ENBREL - etanercept for

subcutaneous inj kit 25 mg5 •

ENBREL - etanerceptsubcutaneous soln prefilledsyringe 25 mg/0.5ml

5 •

ENBREL - etanerceptsubcutaneous soln prefilledsyringe 50 mg/ml

5 •

ENBREL SURECLICK -etanercept subcutaneoussolution auto-injector 50 mg/ml

5 •

2015


95

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

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

4 X

ENGERIX-B - hepatitis b vaccine(recombinant) susp 20 mcg/ml

4 X

FIRAZYR - icatibant acetate inj30 mg/3ml

5 • •

GAMMAPLEX - immune globulin(human) iv soln 2.5 gm/50ml

5 X •

GAMMAPLEX - immune globulin(human) iv soln 5 gm/100ml

5 X •


5 X •


5 X •

GAMUNEX-C - immune globulin(human) iv or subcutaneoussoln 1 gm/10ml

3 X •

GAMUNEX-C - immune globulin(human) iv or subcutaneoussoln 2.5 gm/25ml

3 X •


3 X •


3 X •


3 X •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y


3 X •

GARDASIL - humanpapillomavirus (hpv)quadrivalent recombinant vacinj

4

GARDASIL 9 - humanpapillomavirus (hpv) 9-valentrecomb vac susp pref syr

4

GARDASIL 9 - humanpapillomavirus (hpv) 9-valentrecomb vac im susp

4

HAVRIX - hepatitis a vaccine injsusp 720 el unit/0.5ml

4

HAVRIX - hepatitis a vaccine injsusp 1440 el unit/ml

4

HIBERIX - haemophilus bpolysaccharide conjugate vacfor inj 10 mcg

4

HUMIRA - adalimumab prefilledsyringe kit 10 mg/0.2ml

5 •


5 •


5 •

HUMIRA PEDIATRIC CROHNSDISEASE STARTER PACK -adalimumab prefilled syringe kit40 mg/0.8ml

5 •

2015


96

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

HUMIRA PEN - adalimumab pen-injector kit 40 mg/0.8ml

5 •

HUMIRA PEN-CROHNSDISEASE STARTER -adalimumab pen-injector kit40 mg/0.8ml

5 •

HUMIRA PEN-PSORIASISSTARTER - adalimumab pen-injector kit 40 mg/0.8ml

5 •

ILARIS - canakinumab for inj180 mg*

5 •

IMOVAX RABIES (H.D.C.V.) -rabies virus vaccine, hdc inj

3 X

INFANRIX - diph, acellular pert& tet tox inj 25 lf-58 mcg-10lf/0.5ml

4

IPOL INACTIVATED IPV -poliovirus vaccine, ipv injection

4

IXIARO - japanese encephalitisvaccine inactivated adsorbed inj

4

KINERET - anakinrasubcutaneous soln prefilledsyringe 100 mg/0.67ml

5 •

KINRIX - diph-tetanus tox ad-acellpert & polio virus, ipv vac inj

4

leflunomide tab 10 mg^ 2leflunomide tab 20 mg^ 2M-M-R II - measles, mumps &

rubella virus vaccines for inj4

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

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

4

MENOMUNE-A/C/Y/W-135 -meningococcal vaccine a, c, y,and w-135 inj

4

MENVEO - meningococcal (a, c,y, and w-135) oligo conj vac forinj

4

methotrexate sodium for inj 1 gm^ 2methotrexate sodium inj pf 25 mg/

ml^2

methotrexate sodium inj 25 mg/ml^

2

methotrexate sodium tab 2.5 mg^ 2 Xmycophenolate mofetil cap

250 mg^2 X

mycophenolate mofetil for oralsusp 200 mg/ml

5 X

mycophenolate mofetil tab500 mg^

2 X

mycophenolate sodium tab dr180 mg^

2 X

mycophenolate sodium tab dr360 mg^

2 X

NULOJIX - belatacept for ivinfusion 250 mg

5 X

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

4

2015


97

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

PENTACEL - diph-ac per-tet toxad-poliov-haemoph b poly vacfor im susp

4

PROGRAF - tacrolimus inj 5 mg/ml

4 X

PROQUAD - measles-mumps-rubella-varicella virus vaccinesfor inj

4

QUADRACEL - diph-tetanus toxad-acell pert & polio virus, ipvvac inj

4

RABAVERT - rabies vaccine,pcec for inj

4 X

RAPAMUNE - sirolimus oral soln1 mg/ml

5 X

RECOMBIVAX HB - hepatitis bvaccine (recombinant) susp5 mcg/0.5ml

4 X

RECOMBIVAX HB - hepatitis bvaccine (recombinant) susp10 mcg/ml

4 X

RECOMBIVAX HB - hepatitis bvaccine (recombinant) susp40 mcg/ml

4 X

REMICADE - infliximab for iv inj100 mg

5 •

RIDAURA - auranofin cap 3 mg 4ROTARIX - rotavirus vaccine, live

for oral susp4

ROTATEQ - rotavirus vaccine, liveoral pentavalent soln

4

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

SANDIMMUNE - cyclosporineoral soln 100 mg/ml

4 X

SIMULECT - basiliximab for ivsoln 10 mg

5 X

SIMULECT - basiliximab for ivsoln 20 mg

5 X

sirolimus tab 0.5 mg^ 2 Xsirolimus tab 1 mg^ 2 Xsirolimus tab 2 mg 5 XSYNAGIS - palivizumab im soln

50 mg/0.5ml5

SYNAGIS - palivizumab im soln100 mg/ml

5

tacrolimus cap 0.5 mg^ 2 Xtacrolimus cap 1 mg^ 2 Xtacrolimus cap 5 mg^ 2 XTENIVAC - tetanus-diphtheria

toxoids (td) inj 5-2 lfu3

TETANUS/DIPHTHERIA TOXOID- tetanus-diphtheria toxoids (td)inj 2-2 lf/0.5ml

3


5 • •


5 • •


5 • •


5 • •

2015


98

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

THYMOGLOBULIN - anti-thymocyte globulin for iv soln25 mg (lymphocyte ig)

5 X

TRUMENBA -meningococcal group b vaccineim susp prefilled syringe

4

TWINRIX - hepatitis a (inact)-hepb (recomb) vac inj 720-20 elu-mcg/ml

4

TYPHIM VI - typhoid vipolysaccharide intramuscularvac inj 25 mcg/0.5ml

4

TYSABRI - natalizumab for iv injconc 300 mg/15ml*

5 •

VAQTA - hepatitis a vaccine injsusp 25 unit/0.5ml

4

VAQTA - hepatitis a vaccine injsusp 50 unit/ml

4

VARIVAX - varicella virus vaclive for subcutaneous inj 1350pfu/0.5ml

4

YF-VAX - yellow fever vaccinesubcutaneous inj

4

ZORTRESS - everolimus tab0.25 mg

4 X


5 X


5 X

ZOSTAVAX - zoster vaccine livefor inj 19400 unit/0.65ml

4 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

Inflammatory Bowel Disease AgentsAPRISO - mesalamine cap sr

24hr 0.375 gm4

ASACOL HD - mesalamine tabdelayed release 800 mg

3

balsalazide disodium cap750 mg^

2

budesonide cap sr 24hr 3 mg 5CANASA - mesalamine suppos

1000 mg3

CORTIFOAM - hydrocortisoneacetate rectal foam 10%(90 mg/dose)

4

DELZICOL - mesalamine cap dr400 mg

3

DIPENTUM - olsalazine sodiumcap 250 mg

4

hydrocortisone enema100 mg/60ml^

2

hydrocortisone rectal cream 1%^ 2hydrocortisone rectal cream

2.5%^2

LIALDA - mesalamine tabdelayed release 1.2 gm

4

mesalamine enema 4 gm^ 2PENTASA - mesalamine cap cr

250 mg4

PENTASA - mesalamine cap cr500 mg

4

2015


99

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

sulfasalazine tab delayed release500 mg^

2

sulfasalazine tab 500 mg^ 2Metabolic Bone Disease Agentsalendronate sodium tab 5 mg^ 1 •alendronate sodium tab 10 mg^ 1 •alendronate sodium tab 35 mg^ 1 •alendronate sodium tab 70 mg^ 1 •ATELVIA - risedronate sodium tab

delayed release 35 mg3 •

calcitonin (salmon) nasal soln 200unit/act^

2

calcitriol cap 0.25 mcg^ 2calcitriol cap 0.5 mcg^ 2calcitriol inj 1 mcg/ml^ 2calcitriol oral soln 1 mcg/ml^ 2ETIDRONATE DISODIUM -

etidronate disodium tab 200 mg4

ETIDRONATE DISODIUM -etidronate disodium tab 400 mg

4

FORTEO - teriparatide(recombinant) inj 600 mcg/2.4ml

5 •

FORTICAL - calcitonin (salmon)nasal soln 200 unit/act

4

ibandronate sodium iv soln3 mg/3ml^

2

ibandronate sodium tab 150 mg^ 2 •MIACALCIN - calcitonin (salmon)

inj 200 unit/ml4

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

paricalcitol cap 1 mcg^ 2paricalcitol cap 2 mcg^ 2paricalcitol cap 4 mcg^ 2paricalcitol iv soln 2 mcg/ml^ 2paricalcitol iv soln 5 mcg/ml^ 2PROLIA - denosumab inj 60 mg/

ml4 •

risedronate sodium tab delayedrelease 35 mg^

2 •

risedronate sodium tab 5 mg^ 2 •risedronate sodium tab 30 mg^ 2 •risedronate sodium tab 35 mg^ 2 •risedronate sodium tab 150 mg^ 2 •XGEVA - denosumab inj

120 mg/1.7ml5

ZEMPLAR - paricalcitol iv soln2 mcg/ml

3

ZEMPLAR - paricalcitol iv soln5 mcg/ml

3

zoledronic acid inj conc for ivinfusion 4 mg/5ml^

2

zoledronic acid iv soln5 mg/100ml^

2

ZOMETA - zoledronic acid iv soln4 mg/100ml

5

Ophthalmic AgentsALPHAGAN P - brimonidine

tartrate ophth soln 0.1%4

azelastine hcl ophth soln 0.05%^ 2

2015


100

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

AZOPT - brinzolamide ophth susp1%

4

BACITRACIN - bacitracin ophthoint 500 unit/gm

4

bacitracin-polymyxin b ophth oint^ 2bacitracin-polymyxin-neomycin-hc

ophth oint 1%^2

BESIVANCE - besifloxacin hclophth susp 0.6%

4

betaxolol hcl ophth soln 0.5%^ 2BETOPTIC-S - betaxolol hcl

ophth susp 0.25%4

brimonidine tartrate ophth soln0.15%^

2

brimonidine tartrate ophth soln0.2%^

2

bromfenac sodium ophth soln0.09% (once-daily)^

2

carteolol hcl ophth soln 1%^ 2ciprofloxacin hcl ophth soln 0.3%^ 2COMBIGAN - brimonidine

tartrate-timolol maleate ophthsoln 0.2-0.5%

3

cromolyn sodium ophth soln 4%^ 2dexamethasone sodium

phosphate ophth soln 0.1%^2

diclofenac sodium ophth soln0.1%^

2

dorzolamide hcl ophth soln 2%^ 2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

dorzolamide hcl-timolol maleateophth soln 22.3-6.8 mg/ml^

2

DUREZOL - difluprednate ophthemulsion 0.05%

3

epinastine hcl ophth soln 0.05%^ 2erythromycin ophth oint 5 mg/gm^ 2fluorometholone ophth susp

0.1%^2

flurbiprofen sodium ophth soln0.03%^

2

gentamicin sulfate ophth oint0.3%^

2

gentamicin sulfate ophth soln0.3%^

2

ILEVRO - nepafenac ophth susp0.3%

3

ISTALOL - timolol maleate ophthsoln 0.5% (once-daily)

4

ketorolac tromethamine ophthsoln 0.4%^

2

ketorolac tromethamine ophthsoln 0.5%^

2

LACRISERT - artificial tear ophthinsert

4

latanoprost ophth soln 0.005%^ 2LEVOBUNOLOL HCL -

levobunolol hcl ophth soln0.25%

4

levobunolol hcl ophth soln 0.5%^ 2

2015


101

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

LOTEMAX - loteprednoletabonate ophth susp 0.5%

3

LOTEMAX - loteprednoletabonate ophth gel 0.5%

3

LOTEMAX - loteprednoletabonate ophth oint 0.5%

3

LUMIGAN - bimatoprost ophthsoln 0.01%

3

MOXEZA - moxifloxacin hcl ophthsoln 0.5% (2 times daily)

4

NAPHAZOLINE HCL -naphazoline hcl ophth soln0.1%

4

NATACYN - natamycin ophthsusp 5%

4

neomycin-bacitrac zn-polymyx5(3.5)mg-400unt-10000unt opoin^

2

neomycin-polymy-gramicid op sol1.75-10000-0.025mg-unt-mg/ml^

2

neomycin-polymyxin-dexamethasone ophth oint0.1%^

2

neomycin-polymyxin-dexamethasone ophth susp0.1%^

2

NEVANAC - nepafenac ophthsusp 0.1%

3

ofloxacin ophth soln 0.3%^ 2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

PATADAY - olopatadine hcl ophthsoln 0.2%

3

PATANOL - olopatadine hcl ophthsoln 0.1%

4

PHOSPHOLINE IODIDE -echothiophate iodide ophth forsoln 0.125%

4

pilocarpine hcl ophth soln 1%^ 2pilocarpine hcl ophth soln 2%^ 2pilocarpine hcl ophth soln 4%^ 2polymyxin b-trimethoprim ophth

soln 10000 unit/ml-0.1%^2

prednisolone acetate ophth susp1%^

2

PROLENSA - bromfenac sodiumophth soln 0.07%

4

RESTASIS - cyclosporine (ophth)emulsion 0.05%

3

SIMBRINZA - brinzolamide-brimonidine tartrate ophth susp1-0.2%

3

sulfacetamide sodium ophth soln10%^

2

sulfacetamide sodium-prednisolone ophth soln10-0.23(0.25)%^

2

timolol maleate ophth gel formingsoln 0.25%^

2

timolol maleate ophth gel formingsoln 0.5%^

2

2015


102

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

timolol maleate ophth soln0.25%^

2

timolol maleate ophth soln 0.5%^ 2TOBRADEX - tobramycin-

dexamethasone ophth oint0.3-0.1%

4

tobramycin ophth soln 0.3%^ 2tobramycin-dexamethasone ophth

susp 0.3-0.1%^2

TRAVATAN Z - travoprost ophthsoln 0.004%

3

trifluridine ophth soln 1%^ 2VIGAMOX - moxifloxacin hcl

ophth soln 0.5%3

Otic Agentsacetic acid otic soln 2%^ 2ACETIC ACID/ALUMINUM

ACETATE - acetic acid 2% inaluminum acetate otic soln

4

CIPRODEX - ciprofloxacin-dexamethasone otic susp0.3-0.1%

4

fluocinolone acetonide (otic) oil0.01%^

2

hydrocortisone w/ acetic acid oticsoln 1-2%^

2

neomycin-polymyxin-hc otic soln1%^

2

neomycin-polymyxin-hc otic susp3.5 mg/ml-10000 unit/ml-1%^

2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

ofloxacin otic soln 0.3%^ 2Respiratory Tract/Pulmonary Agentsacetylcysteine inhal soln 10%^ 2 Xacetylcysteine inhal soln 20%^ 2 XADCIRCA - tadalafil tab 20 mg 5 • •ADVAIR DISKUS - fluticasone-

salmeterol aer powder ba100-50 mcg/dose

3 •

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

3 •

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

3 •

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

3 •


3 •


3 •

albuterol sulfate soln nebu0.083% (2.5 mg/3ml)^

2 X

albuterol sulfate soln nebu 0.5%(5 mg/ml)^

2 X

albuterol sulfate soln nebu0.63 mg/3ml^

2 X

albuterol sulfate soln nebu1.25 mg/3ml^

2 X

2015


103

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

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y

albuterol sulfate syrup 2 mg/5ml^ 2albuterol sulfate tab sr 12hr 4 mg^ 2albuterol sulfate tab sr 12hr 8 mg^ 2albuterol sulfate tab 2 mg^ 2albuterol sulfate tab 4 mg^ 2ANORO ELLIPTA - umeclidinium-

vilanterol aero powd ba62.5-25 mcg/inh

3 •

ARNUITY ELLIPTA - fluticasonefuroate aerosol powder breathactiv 100 mcg/act

3 •

ARNUITY ELLIPTA - fluticasonefuroate aerosol powder breathactiv 200 mcg/act

3 •

ASMANEX HFA - mometasonefuroate inhal aerosolsuspension 100 mcg/act

3 •

ASMANEX HFA - mometasonefuroate inhal aerosolsuspension 200 mcg/act

3 •

ASMANEX TWISTHALER120 METERED DOSES -mometasone furoate inhal powd220 mcg/inh

3 •


3 •

ASMANEX TWISTHALER30 METERED DOSES -

3 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

mometasone furoate inhal powd110 mcg/inh


3 •


3 •


3 •

ASTEPRO - azelastine hcl nasalspray 0.15% (205.5 mcg/spray)

3 •

ATROVENT HFA - ipratropiumbromide hfa inhal aerosol17 mcg/act

4 •

azelastine hcl nasal spray 0.1%(137 mcg/spray)^

2 •

azelastine hcl nasal spray 0.15%(205.5 mcg/spray)^

2 •

BREO ELLIPTA - fluticasonefuroate-vilanterol aero powd ba100-25 mcg/inh

3 •

BREO ELLIPTA - fluticasonefuroate-vilanterol aero powd ba200-25 mcg/inh

3 •

caffeine citrate oral soln60 mg/3ml^

2

2015


104

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

clemastine fumarate tab 2.68 mg# 4 •COMBIVENT RESPIMAT -

ipratropium-albuterol inhalaerosol soln 20-100 mcg/act

4 •

cromolyn sodium soln nebu20 mg/2ml^

2 X

DALIRESP - roflumilast tab500 mcg

4 •

DULERA - mometasone furoate-formoterol fumarate aerosol100-5 mcg/act

4 •

DULERA - mometasone furoate-formoterol fumarate aerosol200-5 mcg/act

4 •

EPIPEN 2-PAK - epinephrinesolution auto-injector0.3 mg/0.3ml (1:1000)

3

EPIPEN-JR 2-PAK - epinephrinesolution auto-injector0.15 mg/0.3ml (1:2000)

3

ESBRIET - pirfenidone cap267 mg

5 • •

FLOVENT DISKUS - fluticasonepropionate aer pow ba 50 mcg/blister

3 •

FLOVENT DISKUS - fluticasonepropionate aer pow ba100 mcg/blister

3 •

FLOVENT DISKUS - fluticasonepropionate aer pow ba250 mcg/blister

3 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

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

3 •

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

3 •

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

3 •

fluticasone propionate nasal susp50 mcg/act^

2 •

FORADIL AEROLIZER -formoterol fumarate inhal cap12 mcg

3 •

GRASTEK - timothy grass pollenallergen ext tab sl 2800 bau

4 • •

hydroxyzine hcl syrup 10 mg/5ml# 4 •hydroxyzine hcl tab 10 mg# 4 •hydroxyzine hcl tab 25 mg# 4 •hydroxyzine hcl tab 50 mg# 4 •INCRUSE ELLIPTA -

umeclidinium br aero powdbreath act 62.5 mcg/inh

3 •

ipratropium bromide nasal soln0.03% (21 mcg/spray)^

2 •

ipratropium bromide nasal soln0.06% (42 mcg/spray)^

2 •

KALYDECO - ivacaftor tab150 mg

5 •

2015


105

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

erap

y

KALYDECO - ivacaftor packet50 mg

5 •

KALYDECO - ivacaftor packet75 mg

5 •

LETAIRIS - ambrisentan tab5 mg*

5 • •

LETAIRIS - ambrisentan tab10 mg*

5 • •

levocetirizine dihydrochloride tab5 mg^

2

montelukast sodium chew tab4 mg^

2

montelukast sodium chew tab5 mg^

2

montelukast sodium oral granulespacket 4 mg^

2

montelukast sodium tab 10 mg^ 2NASONEX - mometasone furoate

nasal susp 50 mcg/act3 •

OFEV - nintedanib esylate cap100 mg

5 • •

OFEV - nintedanib esylate cap150 mg

5 • •

olopatadine hcl nasal soln 0.6%^ 2 •OPSUMIT - macitentan tab

10 mg*5 • •

ORKAMBI - lumacaftor-ivacaftortab 200-125 mg

5 • •

PATANASE - olopatadine hclnasal soln 0.6%

4 •

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

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y

PROAIR HFA - albuterol sulfateinhal aero 108 mcg/act

3 •

PROAIR RESPICLICK - albuterolsulfate aer pow ba 108 mcg/act

3 •

PROLASTIN-C - alpha1-proteinase inhibitor (human) foriv soln 1000 mg*

5

promethazine hcl suppos12.5 mg#

4 •

promethazine hcl suppos 25 mg# 4 •promethazine hcl syrup

6.25 mg/5ml#4 •

promethazine hcl tab 12.5 mg# 4 •promethazine hcl tab 25 mg# 4 •promethazine hcl tab 50 mg# 4 •PULMOZYME - dornase alfa inhal

soln 1 mg/ml5 X

QVAR - beclomethasone dipropinhal aero soln 40 mcg/act (50/valve)

3 •

QVAR - beclomethasone dipropinhal aero soln 80 mcg/act (100/valve)

3 •

RAGWITEK - short ragweedpollen allergen extract tab sl 12amb a 1-u

4 • •

REMODULIN - treprostinil sodiuminj 1 mg/ml*

5 X

REMODULIN - treprostinil sodiuminj 2.5 mg/ml*

5 X

2015


106

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

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ntity

Lim

its †

Ste

p Th

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y


5 X


5 X

SEREVENT DISKUS - salmeterolxinafoate aer pow ba 50 mcg/dose

3 •

sildenafil citrate tab 20 mg^ 2 • •SPIRIVA HANDIHALER

- tiotropium bromidemonohydrate inhal cap 18 mcg

3 •

SPIRIVA RESPIMAT - tiotropiumbromide monohydrate inhalaerosol 2.5 mcg/act

3 •

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

3 •

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

3 •

terbutaline sulfate tab 2.5 mg^ 2terbutaline sulfate tab 5 mg^ 2theophylline tab sr 12hr 100 mg^ 2theophylline tab sr 12hr 200 mg^ 2theophylline tab sr 12hr 300 mg^ 2theophylline tab sr 12hr 450 mg^ 2theophylline tab sr 24hr 400 mg^ 2theophylline tab sr 24hr 600 mg^ 2tobramycin nebu soln 300 mg/5ml 5 X

Requirements/Limits

Drug Name Dru

g Ti

er

B o

r D

Prio

r Aut

horiz

atio

n

Qua

ntity

Lim

its †

Ste

p Th

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y

TRACLEER - bosentan tab62.5 mg*

5 • •

TRACLEER - bosentan tab125 mg*

5 • •

triamcinolone acetonide nasalaerosol suspension 55 mcg/act^

2 •

TYZINE PEDIATRIC NASALDROPS - tetrahydrozoline hclnasal soln 0.05%

4

VENTOLIN HFA - albuterolsulfate inhal aero 108 mcg/act

3 •

XOLAIR - omalizumab for inj150 mg*

5 •

XOPENEX HFA - levalbuteroltartrate inhal aerosol 45 mcg/act

4 •

zafirlukast tab 10 mg^ 2zafirlukast tab 20 mg^ 2Skeletal Muscle Relaxantscyclobenzaprine hcl tab 5 mg# 4 •cyclobenzaprine hcl tab 7.5 mg# 4 •cyclobenzaprine hcl tab 10 mg# 4 •methocarbamol tab 500 mg# 4 •methocarbamol tab 750 mg# 4 •Sleep Disorder AgentsHETLIOZ - tasimelteon capsule

20 mg5 • •

modafinil tab 100 mg^ 2 • •modafinil tab 200 mg 5 • •NUVIGIL - armodafinil tab 50 mg 4 • •

2015


107

Requirements/Limits

Drug Name Dru

g Ti

er

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horiz

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n

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Lim

its †

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y

NUVIGIL - armodafinil tab 150 mg 4 • •NUVIGIL - armodafinil tab 200 mg 4 • •NUVIGIL - armodafinil tab 250 mg 4 • •SILENOR - doxepin hcl tab 3 mg 3 •SILENOR - doxepin hcl tab 6 mg 3 •XYREM - sodium oxybate oral

solution 500 mg/ml*5 • •

zaleplon cap 5 mg# 3 •zaleplon cap 10 mg# 3 •zolpidem tartrate tab 5 mg# 4 •zolpidem tartrate tab 10 mg# 4 •Therapeutic Nutrients/Minerals/Electrolytesamino acid infusion 6%^ 2 Xamino acid infusion 8%^ 2 Xamino acid infusion 15%^ 2 XCHEMET - succimer cap 100 mg 4CUPRIMINE - penicillamine cap

250 mg3


4

dextrose inj 5%^ 2dextrose inj 10%^ 2dextrose 5% in lactated ringers^ 2dextrose 2.5% w/ sodium chloride

0.45%^2

dextrose 5% w/ sodium chloride0.2%^

2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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n

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ntity

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its †

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p Th

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y


2


2


2

electrolyte-m in d5w soln^ 2EXJADE - deferasirox tab for oral

susp 125 mg*5

EXJADE - deferasirox tab for oralsusp 250 mg*

5

EXJADE - deferasirox tab for oralsusp 500 mg*

5

fat emulsion iv soln 20%^ 2 Xfomepizole inj 1 gm/ml (for iv

infusion)5

JADENU - deferasirox tab 90 mg 5JADENU - deferasirox tab 180 mg 5JADENU - deferasirox tab 360 mg 5KCL 0.15%/D5W/LR - potassium

chloride 20 meq/l (0.15%) ind5w lactated ringers

4

KCL 0.3%/D5W/LR IV LAC RI- potassium chloride 40 meq/l(0.3%) in d5w lactated ringers

4

kcl 10 meq/l (0.075%) in dextrose5% & nacl 0.45% inj^

2


2

2015


108

Requirements/Limits

Drug Name Dru

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n

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y


2


2


2


2

lactated ringer's solution^ 2levocarnitine oral soln 1 gm/10ml

(10%)^2

levocarnitine tab 330 mg^ 2potassium chloride cap cr 8 meq^ 2potassium chloride cap cr 10

meq^2

potassium chloridemicroencapsulated crys cr tab10 meq^

2

potassium chloridemicroencapsulated crys cr tab20 meq^

2

potassium chloride tab cr 8 meq(600 mg)^

2

potassium chloride tab cr 10meq^

2

potassium chloride 20 meq/l(0.15%) in dextrose 5% inj^

2

potassium chloride 40 meq/l(0.3%) in dextrose 5% inj^

2

Requirements/Limits

Drug Name Dru

g Ti

er

B o

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horiz

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n

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its †

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y

potassium citrate tab cr 5 meq(540 mg)^

2


2


2

SAMSCA - tolvaptan tab 15 mg 5 •SAMSCA - tolvaptan tab 30 mg 5 •sodium chloride inj 0.45%^ 2sodium chloride irrigation soln

0.9%^2

sodium chloride iv soln 0.9%^ 2sodium polystyrene sulfonate oral

susp 15 gm/60ml^2

sodium polystyrene sulfonatepowder^

2

sodium polystyrene sulfonaterectal susp 30 gm/120ml^

2

SYPRINE - trientine hcl cap250 mg

5

water for irrigation, sterileirrigation soln^

2

2015

< Applies to members age 65 and over. 109

2015 Quantity Limits

Drug NameMonthly Limit(unless otherwise noted)

abacavir 300 mg 60 tabletsabacavir/lamivudine/zidovudine 300-150-300 mg 60 tabletsABILIFY MAINTENA 300 mg 1 syringe or 1 vialABILIFY MAINTENA 400 mg 1 vialABILIFY 10 mg 30 tabletsABILIFY 15 mg 30 tabletsABILIFY 2 mg 30 tabletsABILIFY 20 mg 30 tabletsABILIFY 30 mg 30 tabletsABILIFY 5 mg 30 tabletsABSTRAL SUB 100 mcg 120 tabletsABSTRAL SUB 200 mcg 120 tabletsABSTRAL SUB 300 mcg 120 tabletsABSTRAL SUB 400 mcg 120 tabletsABSTRAL SUB 600 mcg 120 tabletsABSTRAL SUB 800 mcg 120 tabletsacarbose 100 mg 90 tabletsacarbose 25 mg 360 tabletsacarbose 50 mg 180 tabletsacetaminophen/codeine 120-12 mg/5 mL soln 2700 mLacetaminophen/codeine 300-15 mg 360 tabletsacetaminophen/codeine 300-30 mg 360 tabletsacetaminophen/codeine 300-60 mg 180 tabletsADCIRCA 20 mg 60 tabletsADVAIR DISKUS 100/50 1 package of 60ADVAIR DISKUS 250/50 1 package of 60ADVAIR DISKUS 500/50 1 package of 60ADVAIR HFA 115/21 1 canisterADVAIR HFA 230/21 1 canisterADVAIR HFA 45/21 1 canisterAFINITOR DISPERZ 2 mg 60 tabletsAFINITOR DISPERZ 3 mg 90 tabletsAFINITOR DISPERZ 5 mg 60 tabletsAFINITOR 10 mg 30 tabletsAFINITOR 2.5 mg 30 tabletsAFINITOR 5 mg 30 tabletsAFINITOR 7.5 mg 30 tabletsalendronate 10 mg 120 tablets

2015

110 < Applies to members age 65 and over.


alendronate 35 mg 4 tablets per 28 daysalendronate 5 mg 30 tabletsalendronate 70 mg 4 tablets per 28 daysalfuzosin 10 mg 30 tabletsamlodipine besylate/valsartan 10-160 mg 30 tabletsamlodipine besylate/valsartan 10-320 mg 30 tabletsamlodipine besylate/valsartan 5-160 mg 30 tabletsamlodipine besylate/valsartan 5-320 mg 30 tabletsamlodipine/valsartan/hydrochlorothiazide 10-160-12.5 mg 30 tabletsamlodipine/valsartan/hydrochlorothiazide 10-160-25 mg 30 tabletsamlodipine/valsartan/hydrochlorothiazide 10-320-25 mg 30 tabletsamlodipine/valsartan/hydrochlorothiazide 5-160-12.5 mg 30 tabletsamlodipine/valsartan/hydrochlorothiazide 5-160-25 mg 30 tabletsamphetamine/dextroamphetamine ER 10 mg 30 capsulesamphetamine/dextroamphetamine ER 15 mg 30 capsulesamphetamine/dextroamphetamine ER 20 mg 30 capsulesamphetamine/dextroamphetamine ER 25 mg 30 capsulesamphetamine/dextroamphetamine ER 30 mg 30 capsulesamphetamine/dextroamphetamine ER 5 mg 30 capsulesANDRODERM 2 mg/24 hour 30 patchesANDRODERM 4 mg/24 hour 30 patchesANDROGEL PUMP 1.62% 2 pump bottlesANDROGEL PUMP 1% 4 pump bottlesANDROGEL 1.62% (20.25 mg/ 1.25 gm) 30 packetsANDROGEL 1.62% (40.5 mg/ 2.5 gm) 60 packetsANDROGEL 1% (25 mg/ 2.5 gm) 60 packetsANDROGEL 1% (50 mg/ 5 gm) 60 packetsANORO ELLIPTA 1 packageAPTIVUS 100 mg/mL soln 380 mLAPTIVUS 250 mg 120 capsulesARIPIPRAZOLE ODT 10 mg 60 tabletsARIPIPRAZOLE ODT 15 mg 60 tabletsaripiprazole 1 mg/mL oral soln 750 mLaripiprazole 10 mg 30 tabletsaripiprazole 15 mg 30 tabletsaripiprazole 2 mg 30 tabletsaripiprazole 20 mg 30 tabletsaripiprazole 30 mg 30 tabletsaripiprazole 5 mg 30 tabletsARNUITY ELLIPTA inh 100 mcg 30 blisters

2015



ARNUITY ELLIPTA inh 200 mcg 30 blistersascomp/codeine 30 mg 180 capsulesASMANEX HFA 100 mcg/act 1 canisterASMANEX HFA 200 mcg/act 1 canisterASMANEX TWISTHALER 120 (220 mcg) 1 canisterASMANEX TWISTHALER 14 (220 mcg) 1 canisterASMANEX TWISTHALER 30 (110 mcg) 1 canisterASMANEX TWISTHALER 30 (220 mcg) 1 canisterASMANEX TWISTHALER 60 (220 mcg) 1 canisterASMANEX TWISTHALER 7 (110 mcg) 1 canisterASTEPRO 0.15% 2 bottlesATELVIA 35 mg 4 tablets per 28 daysatorvastatin 10 mg 45 tabletsatorvastatin 20 mg 45 tabletsatorvastatin 40 mg 45 tabletsatorvastatin 80 mg 30 tabletsATRIPLA 600-200-300 mg 30 tabletsATROVENT HFA 17 mcg 2 canistersAVODART 0.5 mg 30 capsulesAVONEX KIT 30 mcg 1 kit per 28 daysAVONEX PEN KIT 30 mcg 1 kit per 28 daysAXIRON soln 30 mg/act 2 pump bottlesazelastine 0.1% nasal spray 2 bottlesazelastine 0.15% nasal spray 2 bottlesAZOR 10-20 mg 30 tabletsAZOR 10-40 mg 30 tabletsAZOR 5-20 mg 30 tabletsAZOR 5-40 mg 30 tabletsBENICAR HCT 20-12.5 mg 30 tabletsBENICAR HCT 40-12.5 mg 30 tabletsBENICAR HCT 40-25 mg 30 tabletsBENICAR 20 mg 30 tabletsBENICAR 40 mg 30 tabletsBENICAR 5 mg 60 tabletsBETASERON 0.3 mg 15 vials/syringesBOSULIF 100 mg 120 tabletsBOSULIF 500 mg 30 tabletsBREO ELLIPTA 100-25 mcg/inh 1 packageBREO ELLIPTA 200-25 mcg/inh 1 package

2015



BRINTELLIX 10 mg 30 tabletsBRINTELLIX 20 mg 30 tabletsBRINTELLIX 5 mg 30 tabletsbudeprion SR 150 mg 60 tabletsbupropion ER 100 mg 60 tabletsbupropion ER 150 mg 60 tabletsbupropion ER 200 mg 60 tabletsbupropion SR 100 mg 60 tabletsbupropion SR 150 mg 60 tabletsbupropion SR 200 mg 60 tabletsbupropion XL 150 mg 30 tabletsbupropion XL 300 mg 30 tabletsbupropion 100 mg 120 tabletsbupropion 75 mg 60 tabletsbutalbital/acetaminophen/caffeine w/ codeine 50-300-40-30 mg 180 capsulesbutalbital/acetaminophen/caffeine w/ codeine 50-325-40-30 mg 180 capsulesbutalbital/aspirin/caffeine w/ codeine 50-325-40-30 mg 180 capsulesBUTRANS 10 mcg/hr 4 patches per 28 daysBUTRANS 15 mcg/hr 4 patches per 28 daysBUTRANS 20 mcg/hr 4 patches per 28 daysBUTRANS 5 mcg/hr 4 patches per 28 daysBUTRANS 7.5 mcg/hr 4 patches per 28 daysBYDUREON PEN 2 mg 4 vials per 28 daysBYDUREON 2 mg 4 vials per 28 dayscandesartan 16 mg 60 tabletscandesartan 32 mg 30 tabletscandesartan 4 mg 60 tabletscandesartan 8 mg 60 tabletscandesartan/hydrochlorothiazide 16-12.5 mg 30 tabletscandesartan/hydrochlorothiazide 32-12.5 mg 30 tabletscandesartan/hydrochlorothiazide 32-25 mg 30 tabletsCAPRELSA 100 mg 60 tabletsCAPRELSA 300 mg 30 tabletsCELEBREX 100 mg 60 capsulesCELEBREX 200 mg 60 capsulesCELEBREX 400 mg 30 capsulesCELEBREX 50 mg 60 capsulescelecoxib 100 mg 60 capsulescelecoxib 200 mg 60 capsulescelecoxib 400 mg 30 capsules

2015



celecoxib 50 mg 60 capsulesCHANTIX PAK 0.5 mg & 1 mg 336 tablets or amount dispensed

up to 168 days of therapy per 365days

CHANTIX PAK 1 mg 336 tablets or amount dispensedup to 168 days of therapy per 365days

CHANTIX 0.5 mg 336 tablets or amount dispensedup to 168 days of therapy per 365days

CHANTIX 1 mg 336 tablets or amount dispensedup to 168 days of therapy per 365days

CINRYZE 20 vials or 100 mLcitalopram 10 mg 30 tabletscitalopram 10 mg/5 mL soln 600 mLcitalopram 20 mg 30 tabletscitalopram 40 mg 30 tabletsclonazepam ODT 0.125 mg 90 tabletsclonazepam ODT 0.25 mg 90 tabletsclonazepam ODT 0.5 mg 90 tabletsclonazepam ODT 1 mg 90 tabletsclonazepam ODT 2 mg 300 tabletsclonazepam 0.5 mg 90 tabletsclonazepam 1 mg 90 tabletsclonazepam 2 mg 300 tabletsclonidine ER 0.1 mg 120 tabletsclorazepate dipotassium 15 mg 180 tabletsclorazepate dipotassium 3.75 mg 90 tabletsclorazepate dipotassium 7.5 mg 90 tabletsclozapine 100 mg 270 tabletsclozapine 200 mg 120 tabletsclozapine 25 mg 90 tabletsclozapine 50 mg 90 tabletscodeine sulfate 15 mg 180 tabletscodeine sulfate 30 mg 180 tabletscodeine sulfate 60 mg 180 tabletsCOMBIVENT RESPIMAT 2 canistersCOMETRIQ KIT 100 mg 56 capsules per 28 daysCOMETRIQ KIT 140 mg 112 capsules per 28 daysCOMETRIQ KIT 60 mg 84 capsules per 28 days

2015



COMPLERA 200-25-300 mg 30 tabletsCOPAXONE soln prefilled syringe 20 mg/mL 30 syringesCOPAXONE soln prefilled syringe 40 mg/mL 12 syringes per 28 daysCORLANOR 5 mg 60 tabletsCORLANOR 7.5 mg 60 tabletsCRESTOR 10 mg 45 tabletsCRESTOR 20 mg 45 tabletsCRESTOR 40 mg 30 tabletsCRESTOR 5 mg 45 tabletsCRIXIVAN 200 mg 270 capsulesCRIXIVAN 400 mg 180 capsulesCYCLOSET 0.8 mg 180 tabletsDALIRESP 500 mcg 30 tabletsdexedrine 10 mg 180 tabletsdexedrine 5 mg 90 tabletsDEXILANT 30 mg 30 capsulesDEXILANT 60 mg 30 capsulesdexmethylphenidate 10 mg 60 tabletsdexmethylphenidate 2.5 mg 60 tabletsdexmethylphenidate 5 mg 60 tabletsdextroamphetamine ER 10 mg 120 capsulesdextroamphetamine ER 15 mg 120 capsulesdextroamphetamine ER 5 mg 90 capsulesdextroamphetamine 10 mg 180 tabletsdextroamphetamine 5 mg 90 tabletsDIASTAT ACUDIAL 12.5-20 mg 5 twin packsDIASTAT ACUDIAL 5-10 mg 5 twin packsDIASTAT PEDIATRIC 2.5 mg 5 twin packsDIAZEPAM 1 mg/mL soln 1200 mLdiazepam 10 mg 120 tabletsDIAZEPAM 10 mg gel 5 twin packsdiazepam 2 mg 120 tabletsDIAZEPAM 2.5 mg gel 5 twin packsDIAZEPAM 20 mg gel 5 twin packsdiazepam 5 mg 120 tabletsdiazepam 5 mg/mL conc 240 mLdidanosine 125 mg 30 capsulesdidanosine 200 mg 30 capsulesdidanosine 250 mg 30 capsulesdidanosine 400 mg 30 capsules

2015



digox 0.125 mg 30 tabletsdigox 0.25 mg 30 tabletsdigoxin 0.125 mg 30 tabletsdigoxin 0.25 mg 30 tabletsDIGOXIN 50 mcg/mL soln 75 mLdoxazosin 1 mg 30 tabletsdoxazosin 2 mg 30 tabletsdoxazosin 4 mg 30 tabletsdoxazosin 8 mg 60 tabletsDULERA 100-5 mcg 1 canisterDULERA 200-5 mcg 1 canisterduloxetine 20 mg 60 capsulesduloxetine 30 mg 60 capsulesduloxetine 60 mg 60 capsulesdutasteride 0.5 mg 30 capsulesEDURANT 25 mg 30 tabletsELIQUIS 2.5 mg 60 tabletsELIQUIS 5 mg 120 tabletsEMTRIVA 10 mg/mL soln 850 mLEMTRIVA 200 mg 30 capsulesendocet 10-325 mg 180 tabletsendocet 2.5-325 mg 360 tabletsendocet 5-325 mg 360 tabletsendocet 7.5-325 mg 240 tabletsendodan 4.8355-325 mg 360 tabletsenoxaparin 100 mg/mL 30 syringes per 90 daysenoxaparin 120 mg/0.8 mL 30 syringes per 90 daysenoxaparin 150 mg/mL 30 syringes per 90 daysenoxaparin 30 mg/0.3 mL 30 syringes per 90 daysenoxaparin 300 mg/3 mL 10 vials per 90 daysenoxaparin 40 mg/0.4 mL 30 syringes per 90 daysenoxaparin 60 mg/0.6 mL 30 syringes per 90 daysenoxaparin 80 mg/0.8 mL 30 syringes per 90 daysEPIVIR 10 mg/mL soln 960 mLeprosartan mesylate 600 mg 30 tabletsEPZICOM 600-300 mg 30 tabletsERIVEDGE 150 mg 30 capsulesESBRIET 267 mg 270 capsulesescitalopram 10 mg 30 tablets

2015



escitalopram 20 mg 30 tabletsescitalopram 5 mg 30 tabletsescitalopram 5 mg/5 mL soln 600 mLEVOTAZ 300-150 mg 30 tabletsEXFORGE HCT 10-160-12.5 mg 30 tabletsEXFORGE HCT 10-160-25 mg 30 tabletsEXFORGE HCT 10-320-25 mg 30 tabletsEXFORGE HCT 5-160-12.5 mg 30 tabletsEXFORGE HCT 5-160-25 mg 30 tabletsEXFORGE 10-160 mg 30 tabletsEXFORGE 10-320 mg 30 tabletsEXFORGE 5-160 mg 30 tabletsEXFORGE 5-320 mg 30 tabletsFANAPT PAK 7 packs (56 tablets) per 28 daysFANAPT 1 mg 60 tabletsFANAPT 10 mg 60 tabletsFANAPT 12 mg 60 tabletsFANAPT 2 mg 60 tabletsFANAPT 4 mg 60 tabletsFANAPT 6 mg 60 tabletsFANAPT 8 mg 60 tabletsFARYDAK 10 mg 6 capsules per 21 daysFARYDAK 15 mg 6 capsules per 21 daysFARYDAK 20 mg 6 capsules per 21 daysFAZACLO ODT 100 mg 90 tabletsFAZACLO ODT 12.5 mg 90 tabletsFAZACLO ODT 150 mg 180 tabletsFAZACLO ODT 200 mg 120 tabletsFAZACLO ODT 25 mg 270 tabletsfenofibrate 134 mg 30 capsulesfenofibrate 145 mg 30 tabletsfenofibrate 160 mg 30 tabletsfenofibrate 200 mg 30 capsulesfenofibrate 48 mg 60 tabletsfenofibrate 54 mg 60 tabletsfenofibrate 67 mg 30 capsulesfenofibric acid DR 135 mg 30 capsulesfenofibric acid DR 45 mg 60 capsulesfentanyl 100 mcg/hr transdermal patch 15 patchesfentanyl 12 mcg/hr transdermal patch 15 patches

2015



fentanyl 1200 mcg lozenge on a handle 120 lozengesfentanyl 1600 mcg lozenge on a handle 120 lozengesfentanyl 200 mcg lozenge on a handle 120 lozengesfentanyl 25 mcg/hr transdermal patch 15 patchesfentanyl 400 mcg lozenge on a handle 120 lozengesfentanyl 50 mcg/hr transdermal patch 15 patchesfentanyl 600 mcg lozenge on a handle 120 lozengesfentanyl 75 mcg/hr transdermal patch 15 patchesfentanyl 800 mcg lozenge on a handle 120 lozengesFETZIMA TITRATION PACK 28 capsules per 28 daysFETZIMA 120 mg 30 capsulesFETZIMA 20 mg 30 capsulesFETZIMA 40 mg 30 capsulesFETZIMA 80 mg 30 capsulesfinasteride 5 mg 30 tabletsFIRAZYR 30 mg/3 mL 6 syringesFLOVENT DISKUS 100 mcg 1 inhalerFLOVENT DISKUS 250 mcg 4 inhalersFLOVENT DISKUS 50 mcg 1 inhalerFLOVENT HFA 110 mcg 1 canisterFLOVENT HFA 220 mcg 2 canistersFLOVENT HFA 44 mcg 1 canisterfluoxetine DR 90 mg capsule 4 capsules per 28 daysfluoxetine 10 mg capsule 30 capsulesfluoxetine 10 mg tablet 30 tabletsfluoxetine 20 mg capsule 120 capsulesfluoxetine 20 mg tablet 120 tabletsfluoxetine 20 mg/5 mL soln 600 mLfluoxetine 40 mg capsule 60 capsulesfluticasone 50 mcg nasal spray 1 bottlefluvoxamine 100 mg 90 tabletsfluvoxamine 25 mg 30 tabletsfluvoxamine 50 mg 30 tabletsfondaparinux sodium subcutaneous inj 10 mg/0.8 mL 30 syringes per 90 daysfondaparinux sodium subcutaneous inj 2.5 mg/0.5 mL 30 syringes per 90 daysfondaparinux sodium subcutaneous inj 5 mg/0.4 mL 30 syringes per 90 daysfondaparinux sodium subcutaneous inj 7.5 mg/0.6 mL 30 syringes per 90 daysFORADIL 1 package of 60FUZEON 90 mg inj 60 vials

2015



gemfibrozil 600 mg 60 tabletsGEODON 20 mg inj 60 vialsGILOTRIF 20 mg 30 tabletsGILOTRIF 30 mg 30 tabletsGILOTRIF 40 mg 30 tabletsglatopa 20 mg/mL inj 30 syringesGLEEVEC 100 mg 90 tabletsGLEEVEC 400 mg 60 tabletsglimepiride 1 mg 240 tabletsglimepiride 2 mg 120 tabletsglimepiride 4 mg 60 tabletsglipizide ER 10 mg 60 tabletsglipizide ER 2.5 mg 240 tabletsglipizide ER 5 mg 120 tabletsglipizide XL 10 mg 60 tabletsglipizide XL 2.5 mg 240 tabletsglipizide XL 5 mg 120 tabletsglipizide 10 mg 120 tabletsglipizide 5 mg 240 tabletsglipizide/metformin 2.5-250 mg 240 tabletsglipizide/metformin 2.5-500 mg 120 tabletsglipizide/metformin 5-500 mg 120 tabletsglyburide micronized 1.5 mg 240 tabletsglyburide micronized 3 mg 120 tabletsglyburide micronized 6 mg 60 tabletsglyburide 1.25 mg 480 tabletsGLYBURIDE 1.25 mg 480 tabletsGLYBURIDE 2.5 mg 240 tabletsglyburide 2.5 mg 240 tabletsGLYBURIDE 5 mg 120 tabletsglyburide 5 mg 120 tabletsglyburide/metformin 1.25-250 mg 240 tabletsglyburide/metformin 2.5-500 mg 120 tabletsglyburide/metformin 5-500 mg 120 tabletsGRASTEK 30 tabletsHETLIOZ 20 mg 30 capsuleshydrocodone/acetaminophen 10-300 mg 180 tabletshydrocodone/acetaminophen 10-325 mg 180 tabletshydrocodone/acetaminophen 5-300 mg 360 tabletshydrocodone/acetaminophen 5-325 mg 360 tablets

2015



hydrocodone/acetaminophen 7.5-300 mg 180 tabletshydrocodone/acetaminophen 7.5-325 mg 180 tabletshydrocodone/acetaminophen 7.5-325 mg soln 3600 mLhydrocodone/ibuprofen 10-200 mg 150 tabletshydrocodone/ibuprofen 2.5-200 mg 150 tabletshydrocodone/ibuprofen 5-200 mg 150 tabletshydrocodone/ibuprofen 7.5-200 mg 150 tabletshydromorphone 1 mg/mL liquid 1440 mLhydromorphone 2 mg 180 tabletshydromorphone 4 mg 180 tabletshydromorphone 8 mg 180 tabletsibandronate 150 mg 1 tablet per 28 daysIBRANCE 100 mg 21 capsules per 28 daysIBRANCE 125 mg 21 capsules per 28 daysIBRANCE 75 mg 21 capsules per 28 daysibudone 5-200 mg 150 tabletsICLUSIG 15 mg 60 tabletsICLUSIG 45 mg 30 tabletsIMBRUVICA 140 mg 120 capsulesINCRUSE ELLIPTA 30 blistersINLYTA 1 mg 180 tabletsINLYTA 5 mg 120 tabletsINTELENCE 100 mg 60 tabletsINTELENCE 200 mg 60 tabletsINTELENCE 25 mg 120 tabletsINVEGA SUSTENNA 117 mg/0.75 mL 1 kitINVEGA SUSTENNA 156 mg/mL 1 kitINVEGA SUSTENNA 234 mg/1.5 mL 1 kitINVEGA SUSTENNA 39 mg/0.25 mL 1 kitINVEGA SUSTENNA 78 mg/0.5 mL 1 kitINVEGA TRINZA 273 mg 1 kit per 90 daysINVEGA TRINZA 410 mg 1 kit per 90 daysINVEGA TRINZA 546 mg 1 kit per 90 daysINVEGA TRINZA 819 mg 1 kit per 90 daysINVEGA 1.5 mg 30 tabletsINVEGA 3 mg 30 tabletsINVEGA 6 mg 60 tabletsINVEGA 9 mg 30 tabletsINVIRASE 200 mg 300 capsules

2015



INVIRASE 500 mg 120 tabletsINVOKAMET 150-1000 mg 60 tabletsINVOKAMET 150-500 mg 60 tabletsINVOKAMET 50-1000 mg 60 tabletsINVOKAMET 50-500 mg 120 tabletsINVOKANA 100 mg 90 tabletsINVOKANA 300 mg 30 tabletsipratropium 0.03% nasal spray 2 bottlesipratropium 0.06% nasal spray 3 bottlesirbesartan 150 mg 30 tabletsirbesartan 300 mg 30 tabletsirbesartan 75 mg 30 tabletsirbesartan/hydrochlorothiazide 150-12.5 mg 30 tabletsirbesartan/hydrochlorothiazide 300-12.5 mg 30 tabletsIRESSA 250 mg 30 tabletsISENTRESS 100 mg chewable tablet 180 tabletsISENTRESS 100 mg packet 60 packetsISENTRESS 25 mg chewable tablet 180 tabletsISENTRESS 400 mg tablet 60 tabletsJAKAFI 10 mg 60 tabletsJAKAFI 15 mg 60 tabletsJAKAFI 20 mg 60 tabletsJAKAFI 25 mg 60 tabletsJAKAFI 5 mg 60 tabletsJALYN 0.5-0.4 mg 30 capsulesJANUMET XR 100-1000 mg 30 tabletsJANUMET XR 50-1000 mg 60 tabletsJANUMET XR 50-500 mg 60 tabletsJANUMET 50-1000 mg 60 tabletsJANUMET 50-500 mg 60 tabletsJANUVIA 100 mg 30 tabletsJANUVIA 25 mg 120 tabletsJANUVIA 50 mg 60 tabletsJARDIANCE 10 mg 60 tabletsJARDIANCE 25 mg 30 tabletsJENTADUETO 2.5-1000 mg 60 tabletsJENTADUETO 2.5-500 mg 60 tabletsJENTADUETO 2.5-850 mg 60 tabletsKALETRA soln 320 mLKALETRA 100-25 mg 300 tablets

2015



KALETRA 200-50 mg 120 tabletsKALYDECO packet 50 mg 60 packetsKALYDECO packet 75 mg 60 packetsKALYDECO 150 mg 60 tabletsKOMBIGLYZE XR 2.5-1000 mg 60 tabletsKOMBIGLYZE XR 5-1000 mg 30 tabletsKOMBIGLYZE XR 5-500 mg 30 tabletslamivudine 10 mg/mL oral solution 960 mLlamivudine 150 mg 60 tabletslamivudine 300 mg 30 tabletslamivudine/zidovudine 150-300 mg 60 tabletslansoprazole DR 15 mg 30 capsuleslansoprazole DR 30 mg 30 capsulesLATUDA 120 mg 30 tabletsLATUDA 20 mg 30 tabletsLATUDA 40 mg 30 tabletsLATUDA 60 mg 30 tabletsLATUDA 80 mg 60 tabletsLAZANDA 100 mcg nasal spray 30 bottlesLAZANDA 400 mcg nasal spray 30 bottlesLENVIMA 10 mg DAILY DOSE 30 capsulesLENVIMA 14 mg DAILY DOSE 60 capsulesLENVIMA 20 mg DAILY DOSE 60 capsulesLENVIMA 24 mg DAILY DOSE 90 capsulesLETAIRIS 10 mg 30 tabletsLETAIRIS 5 mg 30 tabletsLEVORPHANOL 2 mg 120 tabletsLEXIVA 50 mg/mL susp 1800 mLLEXIVA 700 mg 120 tabletsLIVALO 1 mg 45 tabletsLIVALO 2 mg 45 tabletsLIVALO 4 mg 30 tabletsLONSURF 15-6.14 mg 40 tablets per 28 daysLONSURF 20-8.19 mg 80 tablets per 28 dayslorazepam 0.5 mg 90 tabletslorazepam 1 mg 90 tabletslorazepam 2 mg 150 tabletslorcet hd 10-325 mg 180 tabletslorcet plus 7.5-325 mg 180 tablets

2015



lorcet 5-325 mg 360 tabletslortab 10-325 mg 180 tabletslortab 5-325 mg 360 tabletslortab 7.5-325 mg 180 tabletslosartan 100 mg 30 tabletslosartan 25 mg 60 tabletslosartan 50 mg 60 tabletslosartan/hydrochlorothiazide 100-12.5 mg 30 tabletslosartan/hydrochlorothiazide 100-25 mg 30 tabletslosartan/hydrochlorothiazide 50-12.5 mg 30 tabletslovastatin 10 mg 60 tabletslovastatin 20 mg 60 tabletslovastatin 40 mg 60 tabletsLYNPARZA 50 mg 480 capsulesMAPROTILINE 25 mg 90 tabletsMAPROTILINE 50 mg 90 tabletsMAPROTILINE 75 mg 90 tabletsMEKINIST 0.5 mg 90 tabletsMEKINIST 2 mg 30 tabletsmetadate ER 20 mg 90 tabletsmetformin ER 500 mg 120 tabletsmetformin ER 750 mg 60 tabletsmetformin 1000 mg 75 tabletsmetformin 500 mg 150 tabletsmetformin 850 mg 90 tabletsmethadone 10 mg 360 tabletsmethadone 5 mg 180 tabletsmethadose 10 mg 360 tabletsmethylphenidate ER 20 mg 90 tabletsmethylphenidate SR 20 mg 90 tabletsmethylphenidate 10 mg 90 tabletsmethylphenidate 20 mg 90 tabletsmethylphenidate 5 mg 90 tabletsmirtazapine ODT 15 mg 30 tabletsmirtazapine ODT 30 mg 30 tabletsmirtazapine ODT 45 mg 30 tabletsmirtazapine 15 mg 30 tabletsmirtazapine 30 mg 30 tabletsmirtazapine 45 mg 30 tabletsmirtazapine 7.5 mg 30 tablets

2015



modafinil 100 mg 30 tabletsmodafinil 200 mg 30 tabletsmorphine sulfate ER 10 mg capsule 60 capsulesmorphine sulfate ER 100 mg tablet 90 tabletsmorphine sulfate ER 15 mg tablet 90 tabletsmorphine sulfate ER 200 mg tablet 90 tabletsmorphine sulfate ER 30 mg tablet 90 tabletsmorphine sulfate ER 60 mg tablet 90 tabletsmorphine sulfate 10 mg/5 mL soln 2700 mLmorphine sulfate 100 mg/5 mL soln 270 mLMORPHINE SULFATE 15 mg tablet 240 tabletsmorphine sulfate 20 mg/mL soln 270 mLmorphine sulfate 20 mg/5 mL soln 1350 mLMORPHINE SULFATE 30 mg tablet 180 tabletsMYRBETRIQ 25 mg 30 tabletsMYRBETRIQ 50 mg 30 tabletsnaratriptan 1 mg 18 tabletsnaratriptan 2.5 mg 18 tabletsNASONEX 2 bottlesnateglinide 120 mg 90 tabletsnateglinide 60 mg 180 tabletsnevirapine ER 400 mg 30 tabletsnevirapine 200 mg 60 tabletsnevirapine 50 mg/5 mL susp 1200 mLNEXAVAR 200 mg 120 tabletsNEXIUM 10 mg susp packet 30 packetsNEXIUM 2.5 mg susp packet 30 packetsNEXIUM 20 mg 30 capsulesNEXIUM 20 mg susp packet 30 packetsNEXIUM 40 mg 30 capsulesNEXIUM 40 mg susp packet 30 packetsNEXIUM 5 mg susp packet 30 packetsniacin ER 1000 mg 60 tabletsniacin ER 500 mg 30 tabletsniacin ER 750 mg 60 tabletsnitrofurantoin macrocrystalline 100 mg< 360 capsules or amount dispensed

up to 90 days of therapy per 365days

2015



nitrofurantoin macrocrystalline 50 mg< 360 capsules or amount dispensedup to 90 days of therapy per 365days

nitrofurantoin monohydrate 100 mg< 180 capsules or amount dispensedup to 90 days of therapy per 365days

nitrofurantoin 25 mg/5 mL susp< 7200 mL or amount dispensed up to90 days of therapy per 365 days

NORVIR 100 mg capsule 360 capsulesNORVIR 100 mg tablet 360 tabletsNORVIR 80 mg/mL soln 480 mLNUCYNTA ER 100 mg 60 tabletsNUCYNTA ER 150 mg 60 tabletsNUCYNTA ER 200 mg 60 tabletsNUCYNTA ER 250 mg 60 tabletsNUCYNTA ER 50 mg 60 tabletsNUVIGIL 150 mg 30 tabletsNUVIGIL 200 mg 30 tabletsNUVIGIL 250 mg 30 tabletsNUVIGIL 50 mg 30 tabletsODOMZO 200 mg 30 capsulesOFEV 100 mg 60 capsulesOFEV 150 mg 60 capsulesolanzapine ODT 10 mg 30 tabletsolanzapine ODT 15 mg 30 tabletsolanzapine ODT 20 mg 30 tabletsolanzapine ODT 5 mg 30 tabletsolanzapine 10 mg 30 tabletsolanzapine 10 mg inj 90 vialsolanzapine 15 mg 30 tabletsolanzapine 2.5 mg 30 tabletsolanzapine 20 mg 30 tabletsolanzapine 5 mg 30 tabletsolanzapine 7.5 mg 30 tabletsOLEPTRO 150 mg 45 tabletsOLEPTRO 300 mg 30 tabletsolopatadine 0.6% nasal soln 1 bottleomeprazole 10 mg 30 capsulesomeprazole 20 mg 30 capsulesomeprazole 40 mg 30 capsulesONFI 10 mg 60 tablets

2015



ONFI 2.5 mg/mL susp 480 mLONFI 20 mg 60 tabletsONFI 5 mg 60 tabletsONGLYZA 2.5 mg 60 tabletsONGLYZA 5 mg 30 tabletsOPANA ER 10 mg 60 tabletsOPANA ER 15 mg 60 tabletsOPANA ER 20 mg 60 tabletsOPANA ER 30 mg 60 tabletsOPANA ER 40 mg 60 tabletsOPANA ER 5 mg 60 tabletsOPANA ER 7.5 mg 60 tabletsOPSUMIT 10 mg 30 tabletsORKAMBI 200-125 mg 120 tabletsoxybutynin ER 10 mg 60 tabletsoxybutynin ER 15 mg 60 tabletsoxybutynin ER 5 mg 30 tabletsoxybutynin 5 mg 120 tabletsoxybutynin 5 mg/5 mL syrup 600 mLoxycodone 10 mg 180 tabletsoxycodone 15 mg 180 tabletsoxycodone 20 mg 180 tabletsoxycodone 30 mg 180 tabletsoxycodone 5 mg 360 tabletsoxycodone/acetaminophen 10-325 mg 180 tabletsoxycodone/acetaminophen 2.5-325 mg 360 tabletsoxycodone/acetaminophen 5-325 mg 360 tabletsoxycodone/acetaminophen 7.5-325 mg 240 tabletsoxycodone/aspirin 4.8355-325 mg 360 tabletsOXYCONTIN 10 mg 60 tabletsOXYCONTIN 15 mg 60 tabletsOXYCONTIN 20 mg 60 tabletsOXYCONTIN 30 mg 60 tabletsOXYCONTIN 40 mg 60 tabletsOXYCONTIN 60 mg 120 tabletsOXYCONTIN 80 mg 120 tabletspaliperidone sr 24hr 1.5 mg 30 tabletspaliperidone sr 24hr 3 mg 30 tabletspaliperidone sr 24hr 6 mg 60 tablets

2015



paliperidone sr 24hr 9 mg 30 tabletspantoprazole 20 mg 30 tabletspantoprazole 40 mg 30 tabletsparoxetine ER 12.5 mg 30 tabletsparoxetine ER 25 mg 60 tabletsparoxetine ER 37.5 mg 60 tabletsparoxetine 10 mg 30 tabletsparoxetine 20 mg 30 tabletsparoxetine 30 mg 60 tabletsparoxetine 40 mg 30 tabletsPATANASE 0.6% nasal soln 1 bottlePAXIL 10 mg/5 mL susp 900 mLPICATO 0.015% gel 3 tubesPICATO 0.05% gel 2 tubespioglitazone 15 mg 90 tabletspioglitazone 30 mg 30 tabletspioglitazone 45 mg 30 tabletspioglitazone/glimepiride 30-2 mg 30 tabletspioglitazone/glimepiride 30-4 mg 30 tabletspioglitazone/metformin 15-500 mg 90 tabletspioglitazone/metformin 15-850 mg 90 tabletsPLEGRIDY inj 2 syringes per 28 daysPLEGRIDY inj STARTER PACK 2 syringes per 28 daysPLEGRIDY PEN 2 syringes per 28 daysPLEGRIDY PEN STARTER PACK 2 syringes per 28 daysPOMALYST 1 mg 21 capsules per 28 daysPOMALYST 2 mg 21 capsules per 28 daysPOMALYST 3 mg 21 capsules per 28 daysPOMALYST 4 mg 21 capsules per 28 daysPRADAXA 150 mg 60 capsulesPRADAXA 75 mg 60 capsulespravastatin 10 mg 45 tabletspravastatin 20 mg 45 tabletspravastatin 40 mg 45 tabletspravastatin 80 mg 30 tabletsPREZCOBIX 800-150 mg 30 tabletsPREZISTA 100 mg/mL susp 400 mLPREZISTA 150 mg 180 tabletsPREZISTA 600 mg 60 tabletsPREZISTA 75 mg 300 tablets

2015



PREZISTA 800 mg 30 tabletsPRISTIQ 100 mg 30 tabletsPRISTIQ 25 mg 30 tabletsPRISTIQ 50 mg 30 tabletsPROAIR HFA 2 canistersPROAIR RESPICLICK 2 canistersquetiapine 100 mg 90 tabletsquetiapine 200 mg 90 tabletsquetiapine 25 mg 90 tabletsquetiapine 300 mg 60 tabletsquetiapine 400 mg 60 tabletsquetiapine 50 mg 90 tabletsQVAR 40 mcg 1 canisterQVAR 80 mcg 2 canistersrabeprazole 20 mg 30 tabletsRAGWITEK 30 tabletsRAPAFLO 4 mg 30 capsulesRAPAFLO 8 mg 30 capsulesrepaglinide 0.5 mg 960 tabletsrepaglinide 1 mg 480 tabletsrepaglinide 2 mg 240 tabletsreprexain 10-200 mg 150 tabletsRESCRIPTOR 100 mg 360 tabletsRESCRIPTOR 200 mg 180 tabletsREVLIMID 10 mg 30 capsulesREVLIMID 15 mg 21 capsules per 28 daysREVLIMID 2.5 mg 30 capsulesREVLIMID 20 mg 21 capsules per 28 daysREVLIMID 25 mg 21 capsules per 28 daysREVLIMID 5 mg 30 capsulesREXULTI 0.25 mg 30 tabletsREXULTI 0.5 mg 30 tabletsREXULTI 1 mg 30 tabletsREXULTI 2 mg 30 tabletsREXULTI 3 mg 30 tabletsREXULTI 4 mg 30 tabletsREYATAZ 100 mg 30 capsulesREYATAZ 150 mg 30 capsulesREYATAZ 200 mg 60 capsules

2015



REYATAZ 300 mg 30 capsulesREYATAZ 50 mg powder 150 packetsrisedronate delayed release 35 mg 4 tablets per 28 daysrisedronate 150 mg 1 tablet per 28 daysrisedronate 30 mg 30 tabletsrisedronate 35 mg 4 tablets per 28 daysrisedronate 5 mg 30 tabletsRISPERDAL 12.5 mg inj 2 vials per 28 daysRISPERDAL 25 mg inj 2 vials per 28 daysRISPERDAL 37.5 mg inj 2 vials per 28 daysRISPERDAL 50 mg inj 2 vials per 28 daysrisperidone ODT 0.25 mg 60 tabletsrisperidone ODT 0.5 mg 60 tabletsrisperidone ODT 1 mg 60 tabletsrisperidone ODT 2 mg 60 tabletsrisperidone ODT 3 mg 60 tabletsrisperidone ODT 4 mg 120 tabletsrisperidone 0.25 mg 60 tabletsrisperidone 0.5 mg 60 tabletsrisperidone 1 mg 60 tabletsrisperidone 1 mg/mL soln 480 mLrisperidone 2 mg 60 tabletsrisperidone 3 mg 60 tabletsrisperidone 4 mg 120 tabletsrizatriptan ODT 10 mg 18 tabletsrizatriptan ODT 5 mg 18 tabletsrizatriptan 10 mg 18 tabletsrizatriptan 5 mg 18 tabletsroxicet 5-325 mg 360 tabletsSANCUSO 3.1 mg transdermal patch 4 patches per 28 daysSAPHRIS 10 mg 60 tabletsSAPHRIS 2.5 mg 60 tabletsSAPHRIS 5 mg 60 tabletsSELZENTRY 150 mg 60 tabletsSELZENTRY 300 mg 120 tabletsSEREVENT DISKUS 50 mcg 1 package of 60SEROQUEL XR 150 mg 30 tabletsSEROQUEL XR 200 mg 30 tabletsSEROQUEL XR 300 mg 60 tabletsSEROQUEL XR 400 mg 60 tablets

2015



SEROQUEL XR 50 mg 60 tabletssertraline 100 mg 60 tabletssertraline 20 mg/mL conc 300 mLsertraline 25 mg 30 tabletssertraline 50 mg 30 tabletssildenafil 20 mg 90 tabletsSILENOR 3 mg 30 tabletsSILENOR 6 mg 30 tabletsSIMCOR 1000-20 mg 60 tabletsSIMCOR 1000-40 mg 30 tabletsSIMCOR 500-20 mg 30 tabletsSIMCOR 500-40 mg 30 tabletsSIMCOR 750-20 mg 60 tabletssimvastatin 10 mg 45 tabletssimvastatin 20 mg 60 tabletssimvastatin 40 mg 45 tabletssimvastatin 5 mg 45 tabletssimvastatin 80 mg 30 tabletsSPIRIVA HANDIHALER 30 capsulesSPIRIVA RESPIMAT 2.5 mcg/act 1 canisterSPRYCEL 100 mg 30 tabletsSPRYCEL 140 mg 30 tabletsSPRYCEL 20 mg 60 tabletsSPRYCEL 50 mg 30 tabletsSPRYCEL 70 mg 30 tabletsSPRYCEL 80 mg 30 tabletsstavudine 1 mg/mL soln 2400 mLstavudine 15 mg 60 capsulesstavudine 20 mg 60 capsulesstavudine 30 mg 60 capsulesstavudine 40 mg 60 capsulesSTIVARGA 40 mg 84 tablets per 28 daysSTRATTERA 10 mg 60 capsulesSTRATTERA 100 mg 30 capsulesSTRATTERA 18 mg 60 capsulesSTRATTERA 25 mg 60 capsulesSTRATTERA 40 mg 60 capsulesSTRATTERA 60 mg 30 capsulesSTRATTERA 80 mg 30 capsules

2015



STRIBILD 150-150-200-300 mg 30 tabletsSUBSYS 100 mcg 120 spray unitsSUBSYS 1200 mcg 240 spray unitsSUBSYS 1600 mcg 240 spray unitsSUBSYS 200 mcg 120 spray unitsSUBSYS 400 mcg 120 spray unitsSUBSYS 600 mcg 120 spray unitsSUBSYS 800 mcg 120 spray unitssumatriptan 100 mg 18 tabletsSUMATRIPTAN 20 mg/act nasal spray 12 units/2 packagessumatriptan 25 mg 18 tabletsSUMATRIPTAN 5 mg/act nasal spray 12 units/2 packagessumatriptan 50 mg 18 tabletsSUSTIVA 200 mg capsule 60 capsulesSUSTIVA 50 mg capsule 90 capsulesSUSTIVA 600 mg tablet 30 tabletsSUTENT 12.5 mg 90 capsulesSUTENT 25 mg 30 capsulesSUTENT 37.5 mg 30 capsulesSUTENT 50 mg 30 capsulesSYMBICORT 160-4.5 mcg/act 1 canisterSYMBICORT 80-4.5 mcg/act 1 canisterTAFINLAR 50 mg 120 capsulesTAFINLAR 75 mg 120 capsulestamsulosin 0.4 mg 60 capsulesTARCEVA 100 mg 30 tabletsTARCEVA 150 mg 30 tabletsTARCEVA 25 mg 60 tabletsTASIGNA 150 mg 120 capsulesTASIGNA 200 mg 120 capsulesTECFIDERA STARTER KIT 60 capsulesTECFIDERA 120 mg 60 capsulesTECFIDERA 240 mg 60 capsulesTEKTURNA HCT 150-12.5 mg 30 tabletsTEKTURNA HCT 150-25 mg 30 tabletsTEKTURNA HCT 300-12.5 mg 30 tabletsTEKTURNA HCT 300-25 mg 30 tabletsTEKTURNA 150 mg 30 tabletsTEKTURNA 300 mg 30 tabletstelmisartan 20 mg 30 tablets

2015



telmisartan 40 mg 30 tabletstelmisartan 80 mg 30 tabletstelmisartan/hydrochlorothiazide 40-12.5 mg 30 tabletstelmisartan/hydrochlorothiazide 80-12.5 mg 60 tabletstelmisartan/hydrochlorothiazide 80-25 mg 30 tabletsterazosin 1 mg 30 capsulesterazosin 10 mg 60 capsulesterazosin 2 mg 30 capsulesterazosin 5 mg 30 capsulestetrabenazine 12.5 mg 240 tabletstetrabenazine 25 mg 120 tabletsTHALOMID 100 mg 30 capsulesTHALOMID 150 mg 60 capsulesTHALOMID 200 mg 60 capsulesTHALOMID 50 mg 30 capsulesTIVICAY 50 mg 60 tabletstolterodine ER 2 mg 30 capsulestolterodine ER 4 mg 30 capsulestolterodine 1 mg 60 tabletstolterodine 2 mg 60 tabletsTOVIAZ 4 mg 30 tabletsTOVIAZ 8 mg 30 tabletsTRACLEER 125 mg 60 tabletsTRACLEER 62.5 mg 60 tabletsTRADJENTA 5 mg 30 tabletstramadol ER 100 mg 30 tabletstramadol ER 200 mg 30 tabletstramadol ER 300 mg 30 tabletstramadol 50 mg 240 tabletstramadol/acetaminophen 37.5-325 mg 240 tabletstriamcinolone acetonide nasal aerosol suspension 55 mcg/act 1 bottleTRIBENZOR 20-5-12.5 mg 30 tabletsTRIBENZOR 40-10-12.5 mg 30 tabletsTRIBENZOR 40-10-25 mg 30 tabletsTRIBENZOR 40-5-12.5 mg 30 tabletsTRIBENZOR 40-5-25 mg 30 tabletsTRIUMEQ 600-50-300 mg 30 tabletstrospium ER 60 mg 30 capsulestrospium 20 mg 60 tablets

2015



TRUVADA 200-300 mg 30 tabletsTYBOST 150 mg 30 tabletsTYKERB 250 mg 180 tabletsvalsartan 160 mg 60 tabletsvalsartan 320 mg 30 tabletsvalsartan 40 mg 60 tabletsvalsartan 80 mg 60 tabletsvalsartan/hydrochlorothiazide 160-12.5 mg 30 tabletsvalsartan/hydrochlorothiazide 160-25 mg 30 tabletsvalsartan/hydrochlorothiazide 320-12.5 mg 30 tabletsvalsartan/hydrochlorothiazide 320-25 mg 30 tabletsvalsartan/hydrochlorothiazide 80-12.5 mg 30 tabletsvenlafaxine ER 150 mg capsule 30 capsulesvenlafaxine ER 150 mg tablet 30 tabletsVENLAFAXINE ER 150 mg tablet 30 tabletsvenlafaxine ER 37.5 mg capsule 30 capsulesvenlafaxine ER 37.5 mg tablet 30 tabletsVENLAFAXINE ER 37.5 mg tablet 30 tabletsvenlafaxine ER 75 mg capsule 90 capsulesvenlafaxine ER 75 mg tablet 90 tabletsVENLAFAXINE ER 75 mg tablet 90 tabletsvenlafaxine 100 mg tablet 90 tabletsvenlafaxine 25 mg tablet 90 tabletsvenlafaxine 37.5 mg tablet 90 tabletsvenlafaxine 50 mg tablet 90 tabletsvenlafaxine 75 mg tablet 90 tabletsVENTOLIN HFA (18 grams) 2 canistersVENTOLIN HFA (8 grams) 2 canistersVERSACLOZ 50 mg/mL susp 540 mLVESICARE 10 mg 30 tabletsVESICARE 5 mg 30 tabletsvicodin ES 7.5-300 mg 180 tabletsvicodin HP 10-300 mg 180 tabletsvicodin 5-300 mg 360 tabletsVICTOZA 18 mg/3 mL inj 1 package of 3 pensVIDEX 2 gm soln 1200 mLVIDEX 4 gm soln 1200 mLVIIBRYD KIT 1 kit per 30 daysVIIBRYD STARTER PACK 1 kit per 30 daysVIIBRYD 10 mg 30 tablets

2015



VIIBRYD 20 mg 30 tabletsVIIBRYD 40 mg 30 tabletsVIRACEPT 250 mg 270 tabletsVIRACEPT 625 mg 120 tabletsVIRAMUNE XR 100 mg 120 tabletsVIRAMUNE 50 mg/5 mL susp 1200 mLVIREAD 150 mg 30 tabletsVIREAD 200 mg 30 tabletsVIREAD 250 mg 30 tabletsVIREAD 300 mg 30 tabletsVIREAD 40 mg/gm oral powder 240 gramsVITEKTA 150 mg 30 tabletsVITEKTA 85 mg 30 tabletsVOTRIENT 200 mg 120 tabletsVYTORIN 10-10 mg 30 tabletsVYTORIN 10-20 mg 30 tabletsVYTORIN 10-40 mg 30 tabletsVYTORIN 10-80 mg 30 tabletsXALKORI 200 mg 60 capsulesXALKORI 250 mg 60 capsulesXARELTO STARTER PACK 51 tabletsXARELTO 10 mg 35 tablets per 90 daysXARELTO 15 mg 60 tabletsXARELTO 20 mg 30 tabletsXENAZINE 12.5 mg 240 tabletsXENAZINE 25 mg 120 tabletsXOPENEX HFA 2 canistersXTANDI 40 mg 120 capsulesxylon 10-200 mg 150 tabletsXYREM 500 mg/mL soln 540 mLzaleplon 10 mg< 90 capsules or amount dispensed up

to 90 days of therapy per 365 dayszaleplon 5 mg< 90 capsules or amount dispensed up

to 90 days of therapy per 365 daysZELBORAF 240 mg 240 tabletszenzedi 10 mg 180 tabletszenzedi 5 mg 90 tabletsZETIA 10 mg 30 tabletsZIAGEN 20 mg/mL soln 960 mLzidovudine 100 mg capsule 180 capsules

2015



zidovudine 300 mg tablet 60 tabletszidovudine 50 mg/mL syrup 1920 mLziprasidone 20 mg 60 capsulesziprasidone 40 mg 60 capsulesziprasidone 60 mg 60 capsulesziprasidone 80 mg 60 capsulesZOHYDRO ER abuse-deterrent 10 mg 60 capsulesZOHYDRO ER abuse-deterrent 15 mg 60 capsulesZOHYDRO ER abuse-deterrent 20 mg 60 capsulesZOHYDRO ER abuse-deterrent 30 mg 60 capsulesZOHYDRO ER abuse-deterrent 40 mg 60 capsulesZOHYDRO ER abuse-deterrent 50 mg 60 capsulesZOHYDRO ER 10 mg 60 capsulesZOHYDRO ER 15 mg 60 capsulesZOHYDRO ER 20 mg 60 capsulesZOHYDRO ER 30 mg 60 capsulesZOHYDRO ER 40 mg 60 capsulesZOHYDRO ER 50 mg 60 capsulesZOLINZA 100 mg 120 capsuleszolpidem 10 mg< 90 tablets or amount dispensed up

to 90 days of therapy per 365 dayszolpidem 5 mg< 90 tablets or amount dispensed up

to 90 days of therapy per 365 daysZOSTAVAX inj 1 vaccine per lifetimeZYDELIG 100 mg 60 tabletsZYDELIG 150 mg 60 tabletsZYKADIA 150 mg 150 capsulesZYPREXA RELPREVV 210 mg 2 vials per 28 daysZYPREXA RELPREVV 300 mg 2 vials per 28 daysZYPREXA RELPREVV 405 mg 1 vial per 28 daysZYTIGA 250 mg 120 tablets

2015

135

INDEX

Aabacavir sulfate-lamivudine-zidovudine tab

300-150-300 mg........................................................46abacavir sulfate tab 300 mg.......................................46ABILIFY..........................................................................20ABILIFY..........................................................................20ABILIFY..........................................................................20ABILIFY..........................................................................20ABILIFY..........................................................................20ABILIFY..........................................................................20ABILIFY..........................................................................41ABILIFY..........................................................................41ABILIFY..........................................................................41ABILIFY..........................................................................42ABILIFY..........................................................................42ABILIFY..........................................................................42ABILIFY..........................................................................53ABILIFY..........................................................................53ABILIFY..........................................................................53ABILIFY..........................................................................53ABILIFY..........................................................................53ABILIFY..........................................................................53ABILIFY MAINTENA....................................................20ABILIFY MAINTENA....................................................20ABILIFY MAINTENA....................................................42ABILIFY MAINTENA....................................................42ABILIFY MAINTENA....................................................53ABILIFY MAINTENA....................................................53ABRAXANE...................................................................30ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1acamprosate calcium tab delayed release 333

mg..................................................................................5acarbose tab 100 mg.................................................. 56acarbose tab 25 mg.................................................... 56acarbose tab 50 mg.................................................... 56acebutolol hcl cap 200 mg..........................................62acebutolol hcl cap 400 mg..........................................62acetaminophen w/ codeine soln 120-12

mg/5ml.......................................................................... 1acetaminophen w/ codeine tab 300-15

mg..................................................................................1acetaminophen w/ codeine tab 300-30

mg..................................................................................1

acetaminophen w/ codeine tab 300-60mg..................................................................................1

ACETAZOLAMIDE....................................................... 62acetazolamide cap sr 12hr 500 mg........................... 62acetazolamide tab 250 mg......................................... 62ACETIC ACID/ALUMINUM

ACETATE................................................................. 102acetic acid otic soln 2%............................................ 102acetylcysteine inhal soln 10%..................................102acetylcysteine inhal soln 20%..................................102acitretin cap 10 mg......................................................77acitretin cap 17.5 mg...................................................77acitretin cap 25 mg......................................................77ACTHIB..........................................................................93ACTIMMUNE*...............................................................93acyclovir cap 200 mg.................................................. 46acyclovir oint 5%..........................................................77ACYCLOVIR SODIUM................................................ 46acyclovir sodium for inj 500 mg................................. 46acyclovir sodium iv soln 50 mg/ml.............................47acyclovir susp 200 mg/5ml......................................... 47acyclovir tab 400 mg................................................... 47acyclovir tab 800 mg................................................... 47ADACEL........................................................................ 93ADAGEN*......................................................................81ADASUVE..................................................................... 42ADCIRCA.................................................................... 102adefovir dipivoxil tab 10 mg........................................47ADVAIR DISKUS....................................................... 102ADVAIR DISKUS....................................................... 102ADVAIR DISKUS....................................................... 102ADVAIR HFA.............................................................. 102ADVAIR HFA.............................................................. 102ADVAIR HFA.............................................................. 102AFINITOR......................................................................30AFINITOR......................................................................30AFINITOR......................................................................30AFINITOR......................................................................30AFINITOR DISPERZ................................................... 30AFINITOR DISPERZ................................................... 30AFINITOR DISPERZ................................................... 30AGGRENOX................................................................. 59ALBENZA...................................................................... 39albuterol sulfate soln nebu 0.083% (2.5

mg/3ml).....................................................................102albuterol sulfate soln nebu 0.5% (5 mg/

ml)............................................................................. 102albuterol sulfate soln nebu 0.63

mg/3ml......................................................................102albuterol sulfate soln nebu 1.25

mg/3ml......................................................................102albuterol sulfate syrup 2 mg/5ml..............................103

2015

136

albuterol sulfate tab 2 mg.........................................103albuterol sulfate tab 4 mg.........................................103albuterol sulfate tab sr 12hr 4 mg............................103albuterol sulfate tab sr 12hr 8 mg............................103alclometasone dipropionate cream

0.05%..........................................................................77alclometasone dipropionate oint

0.05%..........................................................................77ALCOHOL SWABS......................................................56ALDURAZYME*............................................................81alendronate sodium tab 10 mg.................................. 99alendronate sodium tab 35 mg.................................. 99alendronate sodium tab 5 mg.................................... 99alendronate sodium tab 70 mg.................................. 99alfuzosin hcl tab sr 24hr 10 mg..................................84ALIMTA.......................................................................... 30ALIMTA.......................................................................... 30ALINIA............................................................................39ALINIA............................................................................39allopurinol tab 100 mg.................................................27allopurinol tab 300 mg.................................................27ALOPRIM...................................................................... 27alosetron hcl tab 0.5 mg............................................. 82alosetron hcl tab 1 mg................................................ 82ALOXI.............................................................................24ALPHAGAN P...............................................................99AMANTADINE HCL..................................................... 40AMANTADINE HCL..................................................... 47amantadine hcl cap 100 mg.......................................40amantadine hcl cap 100 mg.......................................47amantadine hcl syrup 50 mg/5ml...............................40amantadine hcl syrup 50 mg/5ml...............................47AMBISOME...................................................................26amcinonide cream 0.1%............................................. 77amifostine crystalline for inj 500 mg.......................... 30amikacin sulfate inj 1 gm/4ml (250 mg/

ml)..................................................................................6amikacin sulfate inj 500 mg/2ml (250 mg/

ml)..................................................................................6amiloride & hydrochlorothiazide tab 5-50

mg................................................................................62amiloride hcl tab 5 mg.................................................62amino acid infusion 15%...........................................107amino acid infusion 6%.............................................107amino acid infusion 8%.............................................107amiodarone hcl tab 200 mg........................................62amiodarone hcl tab 400 mg........................................62AMITIZA.........................................................................82AMITIZA.........................................................................82amitriptyline hcl tab 100 mg....................................... 20amitriptyline hcl tab 10 mg..........................................20amitriptyline hcl tab 150 mg....................................... 20

amitriptyline hcl tab 25 mg..........................................20amitriptyline hcl tab 50 mg..........................................20amitriptyline hcl tab 75 mg..........................................20amlodipine besylate-atorvastatin calcium tab 10-10

mg................................................................................63amlodipine besylate-atorvastatin calcium tab 10-20



mg................................................................................63amlodipine besylate-atorvastatin calcium tab 2.5-10







mg................................................................................63amlodipine besylate-benazepril hcl cap 10-20


mg................................................................................63amlodipine besylate-benazepril hcl cap 2.5-10




mg................................................................................63amlodipine besylate tab 10 mg..................................62amlodipine besylate tab 2.5 mg.................................62amlodipine besylate tab 5 mg.................................... 62amlodipine besylate-valsartan tab 10-160

mg................................................................................63amlodipine besylate-valsartan tab 10-320



mg................................................................................63amlodipine-valsartan-hydrochlorothiazide tab

10-160-12.5 mg.........................................................63amlodipine-valsartan-hydrochlorothiazide tab

10-160-25 mg............................................................63

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amlodipine-valsartan-hydrochlorothiazide tab10-320-25 mg............................................................63

amlodipine-valsartan-hydrochlorothiazide tab5-160-12.5 mg...........................................................63

amlodipine-valsartan-hydrochlorothiazide tab5-160-25 mg.............................................................. 63

AMOXAPINE.................................................................20AMOXAPINE.................................................................20AMOXAPINE.................................................................20AMOXAPINE.................................................................20amoxicillin (trihydrate) cap 250 mg..............................6amoxicillin (trihydrate) cap 500 mg..............................6amoxicillin (trihydrate) for susp 125

mg/5ml.......................................................................... 6amoxicillin (trihydrate) for susp 200



mg/5ml.......................................................................... 7amoxicillin (trihydrate) tab 500 mg...............................7amoxicillin (trihydrate) tab 875 mg...............................7amoxicillin & k clavulanate chew tab 200-28.5

mg..................................................................................7amoxicillin & k clavulanate chew tab 400-57

mg..................................................................................7amoxicillin & k clavulanate for susp 200-28.5

mg/5ml.......................................................................... 7amoxicillin & k clavulanate for susp 400-57

mg/5ml.......................................................................... 7amoxicillin & k clavulanate for susp 600-42.9

mg/5ml.......................................................................... 7amoxicillin & k clavulanate tab 250-125

mg..................................................................................7amoxicillin & k clavulanate tab 500-125

mg..................................................................................7amoxicillin & k clavulanate tab 875-125

mg..................................................................................7amphetamine-dextroamphetamine cap sr 24hr 10

mg................................................................................75amphetamine-dextroamphetamine cap sr 24hr 15





mg................................................................................75AMPHOTERICIN B......................................................26AMPICILLIN.................................................................... 7

AMPICILLIN.................................................................... 7ampicillin & sulbactam sodium for inj 2-1

gm..................................................................................7ampicillin cap 250 mg....................................................7ampicillin cap 500 mg....................................................7AMPICILLIN SODIUM................................................... 7AMPICILLIN SODIUM................................................... 7ampicillin sodium for inj 1 gm.......................................7ampicillin sodium for inj 250 mg...................................7ampicillin sodium for inj 2 gm.......................................7ampicillin sodium for inj 500 mg...................................7ampicillin sodium for iv soln 10 gm..............................7AMPYRA*......................................................................75ANADROL-50............................................................... 87anagrelide hcl cap 0.5 mg.......................................... 59anagrelide hcl cap 1 mg............................................. 59anastrozole tab 1 mg...................................................30ANDRODERM.............................................................. 87ANDRODERM.............................................................. 87ANDROGEL.................................................................. 87ANDROGEL.................................................................. 87ANDROGEL.................................................................. 87ANDROGEL.................................................................. 87ANDROGEL PUMP..................................................... 88ANDROGEL PUMP..................................................... 88ANDROID......................................................................88ANDROXY.....................................................................88ANORO ELLIPTA.......................................................103APOKYN*...................................................................... 40APRISO......................................................................... 98APTIOM......................................................................... 15APTIOM......................................................................... 15APTIOM......................................................................... 15APTIOM......................................................................... 15APTIVUS....................................................................... 47APTIVUS....................................................................... 47ARANESP ALBUMIN FREE.......................................59ARANESP ALBUMIN FREE.......................................59ARANESP ALBUMIN FREE.......................................59ARANESP ALBUMIN FREE.......................................59ARANESP ALBUMIN FREE.......................................59ARANESP ALBUMIN FREE.......................................59ARANESP ALBUMIN FREE.......................................59ARANESP ALBUMIN FREE.......................................59ARANESP ALBUMIN FREE.......................................60ARANESP ALBUMIN FREE.......................................60ARANESP ALBUMIN FREE.......................................60ARANESP ALBUMIN FREE.......................................60ARANESP ALBUMIN FREE.......................................60ARANESP ALBUMIN FREE.......................................60ARANESP ALBUMIN FREE.......................................60ARCALYST*.................................................................. 93

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ARIPIPRAZOLE ODT..................................................20ARIPIPRAZOLE ODT..................................................20ARIPIPRAZOLE ODT..................................................42ARIPIPRAZOLE ODT..................................................42ARIPIPRAZOLE ODT..................................................53ARIPIPRAZOLE ODT..................................................53aripiprazole oral solution 1 mg/ml..............................20aripiprazole oral solution 1 mg/ml..............................42aripiprazole oral solution 1 mg/ml..............................53aripiprazole tab 10 mg................................................ 21aripiprazole tab 10 mg................................................ 42aripiprazole tab 10 mg................................................ 53aripiprazole tab 15 mg................................................ 21aripiprazole tab 15 mg................................................ 42aripiprazole tab 15 mg................................................ 53aripiprazole tab 20 mg................................................ 21aripiprazole tab 20 mg................................................ 42aripiprazole tab 20 mg................................................ 53aripiprazole tab 2 mg...................................................20aripiprazole tab 2 mg...................................................42aripiprazole tab 2 mg...................................................53aripiprazole tab 30 mg................................................ 21aripiprazole tab 30 mg................................................ 42aripiprazole tab 30 mg................................................ 54aripiprazole tab 5 mg...................................................20aripiprazole tab 5 mg...................................................42aripiprazole tab 5 mg...................................................53ARNUITY ELLIPTA....................................................103ARNUITY ELLIPTA....................................................103ARRANON.................................................................... 30ARZERRA*....................................................................30ARZERRA*....................................................................30ASACOL HD.................................................................98ASMANEX HFA..........................................................103ASMANEX HFA..........................................................103ASMANEX TWISTHALER 120 METERED

DOSES.....................................................................103ASMANEX TWISTHALER 14 METERED





DOSES.....................................................................103ASTEPRO................................................................... 103ATELVIA.........................................................................99atenolol & chlorthalidone tab 100-25

mg................................................................................63atenolol & chlorthalidone tab 50-25 mg.................... 63

atenolol tab 100 mg.....................................................64atenolol tab 25 mg.......................................................63atenolol tab 50 mg.......................................................63ATGAM.......................................................................... 93atorvastatin calcium tab 10 mg.................................. 64atorvastatin calcium tab 20 mg.................................. 64atorvastatin calcium tab 40 mg.................................. 64atorvastatin calcium tab 80 mg.................................. 64atovaquone-proguanil hcl tab 250-100

mg................................................................................39atovaquone-proguanil hcl tab 62.5-25

mg................................................................................39atovaquone susp 750 mg/5ml....................................39ATRIPLA........................................................................ 47ATROVENT HFA........................................................103AVASTIN*...................................................................... 31AVASTIN*...................................................................... 31AVELOX...........................................................................7AVODART..................................................................... 84AVONEX........................................................................ 75AVONEX........................................................................ 75AVONEX PEN.............................................................. 75AXIRON......................................................................... 88azacitidine for inj 100 mg............................................31AZACTAM........................................................................7AZACTAM........................................................................7AZASAN........................................................................ 93AZASAN........................................................................ 94azathioprine tab 50 mg............................................... 94azelastine hcl nasal spray 0.1% (137 mcg/

spray)........................................................................103azelastine hcl nasal spray 0.15% (205.5 mcg/

spray)........................................................................103azelastine hcl ophth soln 0.05%................................ 99AZELEX......................................................................... 77AZILECT........................................................................40AZILECT........................................................................40AZITHROMYCIN............................................................ 7azithromycin for susp 100 mg/5ml...............................7azithromycin for susp 200 mg/5ml...............................7azithromycin iv for soln 500 mg................................... 7azithromycin tab 250 mg...............................................7azithromycin tab 500 mg...............................................7azithromycin tab 600 mg...............................................7AZOPT.........................................................................100AZOR............................................................................. 64AZOR............................................................................. 64AZOR............................................................................. 64AZOR............................................................................. 64aztreonam for inj 1 gm.................................................. 7aztreonam for inj 2 gm.................................................. 8

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BBACITRACIN.............................................................. 100bacitracin-polymyxin b ophth oint............................ 100bacitracin-polymyxin-neomycin-hc ophth oint

1%............................................................................. 100baclofen tab 10 mg......................................................46baclofen tab 20 mg......................................................46balsalazide disodium cap 750 mg............................. 98BANZEL.........................................................................15BANZEL.........................................................................15BANZEL.........................................................................15BARACLUDE................................................................ 47BARACLUDE................................................................ 47BARACLUDE................................................................ 47BCG VACCINE.............................................................94BELEODAQ.................................................................. 31benazepril & hydrochlorothiazide tab 10-12.5

mg................................................................................64benazepril & hydrochlorothiazide tab 20-12.5

mg................................................................................64benazepril & hydrochlorothiazide tab 20-25

mg................................................................................64benazepril & hydrochlorothiazide tab 5-6.25

mg................................................................................64benazepril hcl tab 10 mg............................................ 64benazepril hcl tab 20 mg............................................ 64benazepril hcl tab 40 mg............................................ 64benazepril hcl tab 5 mg.............................................. 64BENICAR.......................................................................64BENICAR.......................................................................64BENICAR.......................................................................64BENICAR HCT............................................................. 64BENICAR HCT............................................................. 64BENICAR HCT............................................................. 64benzoyl peroxide-erythromycin gel

5-3%............................................................................77benztropine mesylate tab 0.5 mg.............................. 40benztropine mesylate tab 1 mg..................................40benztropine mesylate tab 2 mg..................................40BESIVANCE................................................................100betamethasone dipropionate augmented cream

0.05%..........................................................................77betamethasone dipropionate augmented gel

0.05%..........................................................................77betamethasone dipropionate augmented lotion

0.05%..........................................................................77betamethasone dipropionate augmented oint

0.05%..........................................................................77betamethasone dipropionate cream

0.05%..........................................................................77

betamethasone dipropionate lotion0.05%..........................................................................77

betamethasone dipropionate oint0.05%..........................................................................77

betamethasone valerate cream 0.1%....................... 77betamethasone valerate lotion 0.1%.........................78betamethasone valerate oint 0.1%............................78BETASERON................................................................ 75betaxolol hcl ophth soln 0.5%..................................100betaxolol hcl tab 10 mg...............................................64betaxolol hcl tab 20 mg...............................................64bethanechol chloride tab 10 mg.................................84bethanechol chloride tab 25 mg.................................84bethanechol chloride tab 50 mg.................................84bethanechol chloride tab 5 mg...................................84BETOPTIC-S.............................................................. 100bexarotene cap 75 mg................................................ 31BEXSERO..................................................................... 94bicalutamide tab 50 mg...............................................31BICILLIN L-A...................................................................8BICILLIN L-A...................................................................8BICILLIN L-A...................................................................8BICNU............................................................................31BILTRICIDE...................................................................39bisoprolol & hydrochlorothiazide tab 10-6.25

mg................................................................................64bisoprolol & hydrochlorothiazide tab 2.5-6.25

mg................................................................................64bisoprolol & hydrochlorothiazide tab 5-6.25

mg................................................................................64bisoprolol fumarate tab 10 mg................................... 64bisoprolol fumarate tab 5 mg..................................... 64bleomycin sulfate for inj 15 unit................................. 31bleomycin sulfate for inj 30 unit................................. 31BLINCYTO.....................................................................31BOOSTRIX....................................................................94BOSULIF....................................................................... 31BOSULIF....................................................................... 31BREO ELLIPTA..........................................................103BREO ELLIPTA..........................................................103BRILINTA.......................................................................60BRILINTA.......................................................................60brimonidine tartrate ophth soln 0.15%.................... 100brimonidine tartrate ophth soln 0.2%...................... 100BRINTELLIX..................................................................21BRINTELLIX..................................................................21BRINTELLIX..................................................................21bromfenac sodium ophth soln 0.09% (once-

daily)......................................................................... 100bromocriptine mesylate cap 5 mg..............................40bromocriptine mesylate cap 5 mg..............................91bromocriptine mesylate tab 2.5 mg........................... 40

2015

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bromocriptine mesylate tab 2.5 mg........................... 91budesonide cap sr 24hr 3 mg.................................... 98bumetanide inj 0.25 mg/ml......................................... 64bumetanide tab 0.5 mg............................................... 64bumetanide tab 1 mg.................................................. 64bumetanide tab 2 mg.................................................. 64BUPHENYL...................................................................81buprenorphine hcl-naloxone hcl sl tab 2-0.5

mg..................................................................................6buprenorphine hcl-naloxone hcl sl tab 8-2

mg..................................................................................6buprenorphine hcl sl tab 2 mg......................................5buprenorphine hcl sl tab 8 mg......................................6bupropion hcl (smoking deterrent) tab sr 12hr 150

mg..................................................................................6bupropion hcl tab 100 mg...........................................21bupropion hcl tab 75 mg.............................................21bupropion hcl tab sr 12hr 100 mg..............................21bupropion hcl tab sr 12hr 150 mg..............................21bupropion hcl tab sr 12hr 200 mg..............................21bupropion hcl tab sr 24hr 150 mg..............................21bupropion hcl tab sr 24hr 300 mg..............................21buspirone hcl tab 10 mg............................................. 52buspirone hcl tab 15 mg............................................. 52buspirone hcl tab 30 mg............................................. 52buspirone hcl tab 5 mg............................................... 52buspirone hcl tab 7.5 mg............................................ 52BUSULFEX................................................................... 31butalbital-acetaminophen-caff w/ cod cap

50-300-40-30 mg...................................................... 28butalbital-acetaminophen-caff w/ cod cap

50-325-40-30 mg...................................................... 28butalbital-aspirin-caff w/ codeine cap 50-325-40-30

mg................................................................................28butorphanol tartrate inj 1 mg/ml................................... 1butorphanol tartrate inj 2 mg/ml................................... 1butorphanol tartrate nasal soln 10 mg/

ml................................................................................... 1BUTRANS........................................................................6BUTRANS........................................................................6BUTRANS........................................................................6BUTRANS........................................................................6BUTRANS........................................................................6BYDUREON..................................................................56BYDUREON..................................................................56BYSTOLIC.....................................................................65BYSTOLIC.....................................................................65BYSTOLIC.....................................................................65BYSTOLIC.....................................................................65Ccabergoline tab 0.5 mg............................................... 92

caffeine citrate oral soln 60 mg/3ml........................ 103calcipotriene cream 0.005%.......................................78calcipotriene oint 0.005%............................................78calcipotriene soln 0.005% (50 mcg/ml).....................78calcitonin (salmon) nasal soln 200 unit/

act................................................................................99calcitriol cap 0.25 mcg................................................ 99calcitriol cap 0.5 mcg...................................................99calcitriol inj 1 mcg/ml...................................................99calcitriol oral soln 1 mcg/ml........................................99calcium acetate cap 667 mg...................................... 84calcium acetate tab 667 mg....................................... 84CANASA........................................................................98CANCIDAS....................................................................26CANCIDAS....................................................................26candesartan cilexetil-hydrochlorothiazide tab 16-12.5

mg................................................................................65candesartan cilexetil-hydrochlorothiazide tab 32-12.5

mg................................................................................65candesartan cilexetil-hydrochlorothiazide tab 32-25

mg................................................................................65candesartan cilexetil tab 16 mg................................. 65candesartan cilexetil tab 32 mg................................. 65candesartan cilexetil tab 4 mg................................... 65candesartan cilexetil tab 8 mg................................... 65CAPASTAT SULFATE..................................................30CAPRELSA*..................................................................31CAPRELSA*..................................................................31captopril tab 100 mg....................................................65captopril tab 12.5 mg...................................................65captopril tab 25 mg......................................................65captopril tab 50 mg......................................................65CARAC.......................................................................... 78carbamazepine cap sr 12hr 100 mg..........................15carbamazepine cap sr 12hr 200 mg..........................15carbamazepine cap sr 12hr 300 mg..........................15carbamazepine chew tab 100 mg..............................15carbamazepine susp 100 mg/5ml..............................15carbamazepine tab 200 mg........................................15carbamazepine tab sr 12hr 200 mg.......................... 15carbamazepine tab sr 12hr 400 mg.......................... 15CARBIDOPA/LEVODOPA/

ENTACAPONE..........................................................40CARBIDOPA/LEVODOPA/




ENTACAPONE..........................................................41

2015

141

CARBIDOPA/LEVODOPA/ENTACAPONE..........................................................41

carbidopa & levodopa orally disintegrating tab10-100 mg..................................................................40



carbidopa & levodopa tab 10-100 mg....................... 40carbidopa & levodopa tab 25-100 mg....................... 40carbidopa & levodopa tab 25-250 mg....................... 40carbidopa & levodopa tab cr 25-100

mg................................................................................40carbidopa & levodopa tab cr 50-200

mg................................................................................40carbidopa tab 25 mg................................................... 40carboplatin iv soln 150 mg/15ml................................ 31carboplatin iv soln 450 mg/45ml................................ 31carboplatin iv soln 50 mg/5ml.................................... 31carboplatin iv soln 600 mg/60ml................................ 31carteolol hcl ophth soln 1%...................................... 100carvedilol tab 12.5 mg.................................................65carvedilol tab 25 mg....................................................65carvedilol tab 3.125 mg...............................................65carvedilol tab 6.25 mg.................................................65cefaclor cap 250 mg......................................................8cefaclor cap 500 mg......................................................8cefadroxil cap 500 mg...................................................8cefadroxil for susp 250 mg/5ml....................................8cefadroxil for susp 500 mg/5ml....................................8cefadroxil tab 1 gm........................................................ 8cefazolin sodium for inj 10 gm..................................... 8cefazolin sodium for inj 1 gm....................................... 8cefazolin sodium for inj 20 gm..................................... 8cefazolin sodium for inj 500 mg................................... 8cefdinir cap 300 mg....................................................... 8cefdinir for susp 125 mg/5ml........................................8cefdinir for susp 250 mg/5ml........................................8cefepime hcl for inj 1 gm.............................................. 8cefepime hcl for inj 2 gm.............................................. 8cefotaxime sodium for inj 10 gm..................................8cefotaxime sodium for inj 1 gm.................................... 8cefotaxime sodium for inj 2 gm.................................... 8cefotaxime sodium for inj 500 mg................................8cefoxitin sodium for inj 10 gm...................................... 8cefoxitin sodium for iv soln 1 gm................................. 8cefoxitin sodium for iv soln 2 gm................................. 8cefpodoxime proxetil for susp 100

mg/5ml.......................................................................... 8cefpodoxime proxetil for susp 50

mg/5ml.......................................................................... 8cefpodoxime proxetil tab 100 mg.................................8

cefpodoxime proxetil tab 200 mg.................................8cefprozil for susp 125 mg/5ml...................................... 8cefprozil for susp 250 mg/5ml...................................... 8cefprozil tab 250 mg......................................................8cefprozil tab 500 mg......................................................8ceftazidime for inj 1 gm.................................................8ceftazidime for inj 2 gm.................................................8ceftazidime for inj 6 gm.................................................8ceftazidime for iv soln 1 gm..........................................8ceftazidime for iv soln 2 gm..........................................8CEFTRIAXONE/DEXTROSE....................................... 9CEFTRIAXONE/DEXTROSE....................................... 9CEFTRIAXONE IN ISO-OSMOTIC............................. 8CEFTRIAXONE IN ISO-OSMOTIC............................. 8ceftriaxone sodium for inj 10 gm..................................9ceftriaxone sodium for inj 1 gm....................................9ceftriaxone sodium for inj 250 mg................................8ceftriaxone sodium for inj 2 gm....................................9ceftriaxone sodium for inj 500 mg................................9ceftriaxone sodium for iv soln 1 gm.............................9ceftriaxone sodium for iv soln 2 gm.............................9cefuroxime axetil tab 250 mg....................................... 9cefuroxime axetil tab 500 mg....................................... 9cefuroxime sodium for inj 1.5 gm.................................9cefuroxime sodium for inj 7.5 gm.................................9cefuroxime sodium for inj 750 mg................................9cefuroxime sodium for iv soln 1.5 gm..........................9CELEBREX..................................................................... 1CELEBREX..................................................................... 1CELEBREX..................................................................... 1CELEBREX..................................................................... 1CELEBREX................................................................... 27CELEBREX................................................................... 27CELEBREX................................................................... 27CELEBREX................................................................... 27celecoxib cap 100 mg................................................... 1celecoxib cap 100 mg................................................. 27celecoxib cap 200 mg................................................... 1celecoxib cap 200 mg................................................. 27celecoxib cap 400 mg................................................... 1celecoxib cap 400 mg................................................. 27celecoxib cap 50 mg......................................................1celecoxib cap 50 mg................................................... 27CELLCEPT....................................................................94CELLCEPT INTRAVENOUS...................................... 94CELONTIN.................................................................... 15cephalexin cap 250 mg.................................................9cephalexin cap 500 mg.................................................9cephalexin cap 750 mg.................................................9cephalexin for susp 125 mg/5ml..................................9cephalexin for susp 250 mg/5ml..................................9CEREZYME*.................................................................81

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CERVARIX.................................................................... 94CHANTIX......................................................................... 6CHANTIX......................................................................... 6CHANTIX CONTINUING MONTH............................... 6CHANTIX STARTING MONTH PACK.........................6CHEMET..................................................................... 107CHENODAL*.................................................................82CHLORAMPHENICOL SODIUM

SUCCINATE.................................................................9chlorhexidine gluconate soln 0.12%..........................77chloroquine phosphate tab 250 mg...........................39chloroquine phosphate tab 500 mg...........................39CHLOROTHIAZIDE..................................................... 65chlorothiazide tab 500 mg.......................................... 65CHLORPROMAZINE HCL..........................................24CHLORPROMAZINE HCL..........................................24CHLORPROMAZINE HCL..........................................42CHLORPROMAZINE HCL..........................................42chlorpromazine hcl tab 100 mg..................................25chlorpromazine hcl tab 100 mg..................................42chlorpromazine hcl tab 10 mg....................................24chlorpromazine hcl tab 10 mg....................................42chlorpromazine hcl tab 200 mg..................................25chlorpromazine hcl tab 200 mg..................................42chlorpromazine hcl tab 25 mg....................................25chlorpromazine hcl tab 25 mg....................................42chlorpromazine hcl tab 50 mg....................................25chlorpromazine hcl tab 50 mg....................................42CHLORTHALIDONE....................................................65CHLORTHALIDONE....................................................65cholestyramine light powder 4 gm/

dose............................................................................ 65cholestyramine light powder packets 4

gm................................................................................65cholestyramine powder 4 gm/dose............................65cholestyramine powder packets 4 gm.......................65choline fenofibrate cap dr 135 mg............................. 65choline fenofibrate cap dr 45 mg............................... 65chorionic gonadotropin for inj 10000

unit...............................................................................87ciclopirox gel 0.77%.................................................... 78ciclopirox olamine cream 0.77%................................78ciclopirox olamine susp 0.77%...................................78ciclopirox shampoo 1%............................................... 78ciclopirox solution 8%..................................................78cidofovir iv inj 75 mg/ml.............................................. 47cilostazol tab 100 mg.................................................. 60cilostazol tab 50 mg.................................................... 60cimetidine hcl soln 300 mg/5ml..................................82cimetidine tab 200 mg.................................................82cimetidine tab 300 mg.................................................82cimetidine tab 400 mg.................................................82

cimetidine tab 800 mg.................................................82CINRYZE*..................................................................... 94CIPRO..............................................................................9CIPRO..............................................................................9CIPRODEX................................................................. 102ciprofloxacin 200 mg/100ml in d5w............................. 9ciprofloxacin 400 mg/200ml in d5w............................. 9ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000

mg..................................................................................9ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500

mg..................................................................................9ciprofloxacin for oral susp 250 mg/5ml (5%) (5

gm/100ml).....................................................................9ciprofloxacin for oral susp 500 mg/5ml (10%) (10

gm/100ml).....................................................................9ciprofloxacin hcl ophth soln 0.3%............................ 100ciprofloxacin hcl tab 100 mg.........................................9ciprofloxacin hcl tab 250 mg.........................................9ciprofloxacin hcl tab 500 mg.........................................9ciprofloxacin hcl tab 750 mg.........................................9ciprofloxacin iv soln 200 mg/20ml (1%)...................... 9ciprofloxacin iv soln 400 mg/40ml (1%)...................... 9CISPLATIN.................................................................... 31cisplatin inj 100 mg/100ml (1 mg/ml).........................31cisplatin inj 50 mg/50ml (1 mg/ml).............................31citalopram hydrobromide oral soln 10

mg/5ml........................................................................ 21citalopram hydrobromide tab 10 mg..........................21citalopram hydrobromide tab 20 mg..........................21citalopram hydrobromide tab 40 mg..........................21cladribine inj 1 mg/ml.................................................. 31CLAFORAN/D5W.........................................................10CLAFORAN/D5W.........................................................10clarithromycin for susp 125 mg/5ml...........................10clarithromycin for susp 250 mg/5ml...........................10clarithromycin tab 250 mg.......................................... 10clarithromycin tab 500 mg.......................................... 10clarithromycin tab sr 24hr 500 mg............................. 10clemastine fumarate tab 2.68 mg............................ 104clindamycin hcl cap 150 mg.......................................10clindamycin hcl cap 300 mg.......................................10clindamycin hcl cap 75 mg......................................... 10clindamycin phosphate-benzoyl peroxide gel

1-5%............................................................................78clindamycin phosphate gel 1%.................................. 78clindamycin phosphate in d5w iv soln 300

mg/50ml......................................................................10clindamycin phosphate in d5w iv soln 600

mg/50ml......................................................................10clindamycin phosphate in d5w iv soln 900

mg/50ml......................................................................10clindamycin phosphate inj 300 mg/2ml.....................10

2015

143

clindamycin phosphate inj 600 mg/4ml.....................10clindamycin phosphate inj 900 mg/6ml.....................10clindamycin phosphate inj 9 gm/60ml....................... 10clindamycin phosphate iv soln 600

mg/4ml........................................................................ 10clindamycin phosphate iv soln 900

mg/6ml........................................................................ 10clindamycin phosphate lotion 1%.............................. 78clindamycin phosphate soln 1%................................ 78clindamycin phosphate swab 1%.............................. 78clindamycin phosphate vaginal cream

2%............................................................................... 10clobetasol propionate cream 0.05%..........................78clobetasol propionate emollient base cream

0.05%..........................................................................78clobetasol propionate gel 0.05%................................78clobetasol propionate oint 0.05%.............................. 78clobetasol propionate soln 0.05%..............................78CLOLAR........................................................................ 31clomipramine hcl cap 25 mg...................................... 21clomipramine hcl cap 50 mg...................................... 21clomipramine hcl cap 75 mg...................................... 21clonazepam orally disintegrating tab 0.125

mg................................................................................15clonazepam orally disintegrating tab 0.125





mg................................................................................52clonazepam orally disintegrating tab 1




mg................................................................................52clonazepam tab 0.5 mg.............................................. 15clonazepam tab 0.5 mg.............................................. 52clonazepam tab 1 mg..................................................15clonazepam tab 1 mg..................................................52clonazepam tab 2 mg..................................................15clonazepam tab 2 mg..................................................52clonidine hcl tab 0.1 mg..............................................65clonidine hcl tab 0.2 mg..............................................65clonidine hcl tab 0.3 mg..............................................65clonidine hcl tab sr 12hr 0.1 mg.................................75

clonidine hcl td patch weekly 0.1mg/24hr...................................................................... 65



clopidogrel bisulfate tab 75 mg..................................60clorazepate dipotassium tab 15 mg...........................15clorazepate dipotassium tab 15 mg...........................52clorazepate dipotassium tab 3.75 mg....................... 15clorazepate dipotassium tab 3.75 mg....................... 52clorazepate dipotassium tab 7.5 mg......................... 15clorazepate dipotassium tab 7.5 mg......................... 52clotrimazole cream 1%................................................78clotrimazole troche 10 mg.......................................... 26clotrimazole w/ betamethasone cream

1-0.05%...................................................................... 78clotrimazole w/ betamethasone lotion

1-0.05%...................................................................... 78clozapine tab 100 mg..................................................42clozapine tab 200 mg..................................................42clozapine tab 25 mg....................................................42clozapine tab 50 mg....................................................42COARTEM.....................................................................39codeine sulfate tab 15 mg............................................ 1codeine sulfate tab 30 mg............................................ 1codeine sulfate tab 60 mg............................................ 1colchicine w/ probenecid tab 0.5-500

mg................................................................................27COLCRYS..................................................................... 27colestipol hcl granule packets 5 gm.......................... 65colestipol hcl granules 5 gm.......................................65colestipol hcl tab 1 gm................................................ 66colistimethate sodium for inj 150 mg.........................10COMBIGAN................................................................ 100COMBIVENT RESPIMAT......................................... 104COMETRIQ*................................................................. 31COMETRIQ*................................................................. 31COMETRIQ*................................................................. 31COMPLERA.................................................................. 47COMVAX....................................................................... 94COPAXONE.................................................................. 75COPAXONE.................................................................. 75CORLANOR..................................................................66CORLANOR..................................................................66CORTIFOAM.................................................................98CORTISONE ACETATE..............................................86COSMEGEN................................................................. 31COUMADIN...................................................................60COUMADIN...................................................................60COUMADIN...................................................................60COUMADIN...................................................................60

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COUMADIN...................................................................60COUMADIN...................................................................60COUMADIN...................................................................60COUMADIN...................................................................60COUMADIN...................................................................60CREON..........................................................................81CREON..........................................................................81CREON..........................................................................81CREON..........................................................................81CREON..........................................................................81CRESEMBA.................................................................. 26CRESEMBA.................................................................. 26CRESTOR.....................................................................66CRESTOR.....................................................................66CRESTOR.....................................................................66CRESTOR.....................................................................66CRIXIVAN......................................................................47CRIXIVAN......................................................................47cromolyn sodium ophth soln 4%..............................100cromolyn sodium oral conc 100

mg/5ml........................................................................ 82cromolyn sodium soln nebu 20

mg/2ml......................................................................104CUBICIN........................................................................10CUPRIMINE.................................................................. 84CUPRIMINE.................................................................. 94CUPRIMINE................................................................107cyclobenzaprine hcl tab 10 mg................................ 106cyclobenzaprine hcl tab 5 mg.................................. 106cyclobenzaprine hcl tab 7.5 mg...............................106CYCLOPHOSPHAMIDE............................................. 31CYCLOPHOSPHAMIDE............................................. 31cyclophosphamide for inj 1 gm.................................. 31cyclophosphamide for inj 2 gm.................................. 31cyclophosphamide for inj 500 mg..............................31CYCLOSERINE............................................................30CYCLOSET...................................................................56cyclosporine cap 100 mg............................................94cyclosporine cap 25 mg..............................................94cyclosporine iv soln 50 mg/ml....................................94CYCLOSPORINE MODIFIED.................................... 94cyclosporine modified cap 100 mg............................ 94cyclosporine modified cap 25 mg.............................. 94cyclosporine modified oral soln 100 mg/

ml.................................................................................94CYRAMZA.....................................................................31CYRAMZA.....................................................................31CYSTADANE................................................................ 81CYSTAGON*.................................................................81CYSTAGON*.................................................................81cytarabine inj 20 mg/ml...............................................32cytarabine inj pf 100 mg/ml........................................ 32

cytarabine inj pf 20 mg/ml.......................................... 31DDACARBAZINE............................................................ 32dacarbazine for inj 200 mg.........................................32DAKLINZA.....................................................................47DAKLINZA.....................................................................47DALIRESP.................................................................. 104DALVANCE................................................................... 10danazol cap 100 mg....................................................88danazol cap 200 mg....................................................88danazol cap 50 mg......................................................88dantrolene sodium cap 100 mg................................. 46dantrolene sodium cap 25 mg....................................46dantrolene sodium cap 50 mg....................................46DAPSONE.....................................................................30DAPSONE.....................................................................30DAPTACEL....................................................................94DARAPRIM................................................................... 39daunorubicin hcl for inj 20 mg....................................32daunorubicin hcl inj 5 mg/ml.......................................32DAUNOXOME.............................................................. 32decitabine for inj 50 mg.............................................. 32DELZICOL.....................................................................98demeclocycline hcl tab 150 mg..................................10demeclocycline hcl tab 300 mg..................................10DEMSER....................................................................... 66DENAVIR.......................................................................78DEPEN TITRATABS.................................................... 84DEPEN TITRATABS.................................................... 94DEPEN TITRATABS..................................................107DEPO-PROVERA........................................................ 88desipramine hcl tab 100 mg.......................................21desipramine hcl tab 10 mg......................................... 21desipramine hcl tab 150 mg.......................................21desipramine hcl tab 25 mg......................................... 21desipramine hcl tab 50 mg......................................... 21desipramine hcl tab 75 mg......................................... 21desmopressin acetate inj 4 mcg/ml...........................87desmopressin acetate nasal soln 0.01%

(refrigerated).............................................................. 87desmopressin acetate nasal spray soln

0.01%..........................................................................87desmopressin acetate nasal spray soln 0.01%

(refrigerated).............................................................. 87desmopressin acetate tab 0.1 mg............................. 87desmopressin acetate tab 0.2 mg............................. 87desogest-eth estrad & eth estrad tab 0.15-0.02/0.01

mg(21/5)..................................................................... 88desogest-ethin est tab

0.1-0.025/0.125-0.025/0.15-0.025mg-mg................................................................................88

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desogestrel & ethinyl estradiol tab 0.15 mg-30mcg..............................................................................88

desonide cream 0.05%............................................... 78desonide lotion 0.05%.................................................78desonide oint 0.05%....................................................78DESOXIMETASONE................................................... 78desoximetasone cream 0.25%...................................78desoximetasone gel 0.05%........................................ 78desoximetasone oint 0.25%....................................... 78DEXAMETHASONE.................................................... 86DEXAMETHASONE.................................................... 86dexamethasone elixir 0.5 mg/5ml..............................86dexamethasone sodium phosphate inj 120

mg/30ml......................................................................86dexamethasone sodium phosphate inj 20

mg/5ml........................................................................ 86dexamethasone sodium phosphate inj 4 mg/

ml.................................................................................86dexamethasone sodium phosphate ophth soln

0.1%..........................................................................100dexamethasone tab 0.5 mg........................................86dexamethasone tab 0.75 mg......................................86dexamethasone tab 1.5 mg........................................86dexamethasone tab 4 mg...........................................86dexamethasone tab 6 mg...........................................86DEXILANT.....................................................................82DEXILANT.....................................................................82dexmethylphenidate hcl tab 10 mg............................75dexmethylphenidate hcl tab 2.5 mg...........................75dexmethylphenidate hcl tab 5 mg..............................75dexrazoxane for inj 250 mg........................................32dexrazoxane for inj 500 mg........................................32dextroamphetamine sulfate cap sr 24hr 10

mg................................................................................75dextroamphetamine sulfate cap sr 24hr 15

mg................................................................................75dextroamphetamine sulfate cap sr 24hr 5

mg................................................................................75dextroamphetamine sulfate tab 10 mg......................75dextroamphetamine sulfate tab 5 mg........................75dextrose 2.5% w/ sodium chloride

0.45%........................................................................107dextrose 5% in lactated ringers............................... 107dextrose 5% w/ sodium chloride

0.2%..........................................................................107dextrose 5% w/ sodium chloride

0.33%........................................................................107dextrose 5% w/ sodium chloride

0.45%........................................................................107dextrose 5% w/ sodium chloride

0.9%..........................................................................107dextrose inj 10%........................................................ 107

dextrose inj 5%.......................................................... 107DIASTAT ACUDIAL......................................................15DIASTAT ACUDIAL......................................................15DIASTAT PEDIATRIC..................................................16DIAZEPAM.................................................................... 16DIAZEPAM.................................................................... 16DIAZEPAM.................................................................... 16DIAZEPAM.................................................................... 16DIAZEPAM.................................................................... 52diazepam conc 5 mg/ml..............................................16diazepam conc 5 mg/ml..............................................52diazepam tab 10 mg....................................................16diazepam tab 10 mg....................................................52diazepam tab 2 mg......................................................16diazepam tab 2 mg......................................................52diazepam tab 5 mg......................................................16diazepam tab 5 mg......................................................52DIBENZYLINE.............................................................. 66diclofenac potassium tab 50 mg.................................. 1diclofenac potassium tab 50 mg................................ 27diclofenac sodium gel 3%...........................................78diclofenac sodium ophth soln 0.1%.........................100diclofenac sodium tab delayed release 25

mg..................................................................................1diclofenac sodium tab delayed release 25

mg................................................................................27diclofenac sodium tab delayed release 50


mg................................................................................27diclofenac sodium tab delayed release 75


mg................................................................................27diclofenac sodium tab sr 24hr 100 mg........................ 1diclofenac sodium tab sr 24hr 100 mg......................27diclofenac w/ misoprostol tab delayed release 50-0.2

mg..................................................................................1diclofenac w/ misoprostol tab delayed release 50-0.2

mg................................................................................27diclofenac w/ misoprostol tab delayed release 75-0.2

mg..................................................................................1diclofenac w/ misoprostol tab delayed release 75-0.2

mg................................................................................27dicloxacillin sodium cap 250 mg................................ 10dicloxacillin sodium cap 500 mg................................ 10dicyclomine hcl tab 20 mg..........................................82didanosine delayed release capsule 125

mg................................................................................47didanosine delayed release capsule 200

mg................................................................................47

2015

146

didanosine delayed release capsule 250mg................................................................................47

didanosine delayed release capsule 400mg................................................................................47

DIFICID..........................................................................10diflorasone diacetate oint 0.05%................................78DIGOXIN........................................................................66digoxin tab 125 mcg (0.125 mg)................................66digoxin tab 250 mcg (0.25 mg).................................. 66DILANTIN...................................................................... 16diltiazem hcl cap sr 12hr 120 mg...............................66diltiazem hcl cap sr 12hr 60 mg.................................66diltiazem hcl cap sr 12hr 90 mg.................................66diltiazem hcl cap sr 24hr 120 mg...............................66diltiazem hcl cap sr 24hr 180 mg...............................66diltiazem hcl cap sr 24hr 240 mg...............................66diltiazem hcl coated beads cap sr 24hr 120

mg................................................................................66diltiazem hcl coated beads cap sr 24hr 180




mg................................................................................66diltiazem hcl coated beads tab sr 24hr 180





mg................................................................................66diltiazem hcl extended release beads cap sr 24hr

120 mg....................................................................... 66diltiazem hcl extended release beads cap sr 24hr





420 mg....................................................................... 67diltiazem hcl tab 120 mg.............................................67diltiazem hcl tab 30 mg...............................................67diltiazem hcl tab 60 mg...............................................67diltiazem hcl tab 90 mg...............................................67

DIPENTUM....................................................................98diphenhydramine hcl inj 50 mg/ml.............................25diphenhydramine hcl inj 50 mg/ml.............................41DIPHTHERIA/TETANUS TOXOID.............................94dipyridamole tab 25 mg.............................................. 60dipyridamole tab 50 mg.............................................. 60dipyridamole tab 75 mg.............................................. 60disulfiram tab 250 mg....................................................6disulfiram tab 500 mg....................................................6divalproex sodium cap sprinkle 125

mg................................................................................16divalproex sodium cap sprinkle 125

mg................................................................................28divalproex sodium cap sprinkle 125

mg................................................................................54divalproex sodium tab delayed release 125









mg................................................................................54divalproex sodium tab sr 24 hr 250 mg.....................16divalproex sodium tab sr 24 hr 250 mg.....................28divalproex sodium tab sr 24 hr 250 mg.....................54divalproex sodium tab sr 24 hr 500 mg.....................16divalproex sodium tab sr 24 hr 500 mg.....................28divalproex sodium tab sr 24 hr 500 mg.....................54DIVIGEL.........................................................................88DIVIGEL.........................................................................88DIVIGEL.........................................................................88DOCEFREZ.................................................................. 32DOCEFREZ.................................................................. 32DOCETAXEL.................................................................32DOCETAXEL.................................................................32DOCETAXEL.................................................................32DOCETAXEL.................................................................32DOCETAXEL.................................................................32DOCETAXEL.................................................................32DOCETAXEL.................................................................32docetaxel for inj conc 20 mg/ml................................. 32

2015

147

docetaxel for inj conc 80 mg/4ml (20 mg/ml)................................................................................32

donepezil hydrochloride orally disintegrating tab 10mg................................................................................19

donepezil hydrochloride orally disintegrating tab 5mg................................................................................19

donepezil hydrochloride tab 10 mg........................... 19donepezil hydrochloride tab 23 mg........................... 19donepezil hydrochloride tab 5 mg..............................19dorzolamide hcl ophth soln 2%................................100dorzolamide hcl-timolol maleate ophth soln 22.3-6.8

mg/ml........................................................................ 100doxazosin mesylate tab 1 mg.................................... 67doxazosin mesylate tab 1 mg.................................... 84doxazosin mesylate tab 2 mg.................................... 67doxazosin mesylate tab 2 mg.................................... 84doxazosin mesylate tab 4 mg.................................... 67doxazosin mesylate tab 4 mg.................................... 84doxazosin mesylate tab 8 mg.................................... 67doxazosin mesylate tab 8 mg.................................... 85DOXEPIN HCL............................................................. 21DOXEPIN HCL............................................................. 52doxepin hcl cap 100 mg..............................................21doxepin hcl cap 100 mg..............................................52doxepin hcl cap 10 mg................................................21doxepin hcl cap 10 mg................................................52doxepin hcl cap 150 mg..............................................21doxepin hcl cap 150 mg..............................................52doxepin hcl cap 25 mg................................................21doxepin hcl cap 25 mg................................................52doxepin hcl cap 50 mg................................................21doxepin hcl cap 50 mg................................................52doxepin hcl conc 10 mg/ml.........................................21doxepin hcl conc 10 mg/ml.........................................52DOXIL............................................................................ 32doxorubicin hcl for inj 10 mg...................................... 32doxorubicin hcl for inj 50 mg...................................... 32doxorubicin hcl inj 2 mg/ml.........................................32doxorubicin hcl liposomal inj (for iv infusion) 2 mg/

ml.................................................................................32doxycycline hyclate cap 100 mg................................10doxycycline hyclate cap 100 mg................................77doxycycline hyclate cap 50 mg..................................10doxycycline hyclate cap 50 mg..................................77doxycycline hyclate for inj 100 mg.............................10doxycycline hyclate for inj 100 mg.............................77doxycycline hyclate tab 100 mg.................................10doxycycline hyclate tab 100 mg.................................77doxycycline hyclate tab 20 mg...................................10doxycycline hyclate tab 20 mg...................................77doxycycline monohydrate cap 100 mg......................11doxycycline monohydrate cap 150 mg......................11

doxycycline monohydrate cap 50 mg........................10doxycycline monohydrate cap 75 mg........................10doxycycline monohydrate tab 100 mg...................... 11doxycycline monohydrate tab 150 mg...................... 11doxycycline monohydrate tab 50 mg.........................11doxycycline monohydrate tab 75 mg.........................11dronabinol cap 10 mg................................................. 25dronabinol cap 2.5 mg................................................ 25dronabinol cap 5 mg....................................................25drospirenone-ethinyl estradiol tab 3-0.02

mg................................................................................88drospirenone-ethinyl estradiol tab 3-0.03

mg................................................................................88DULERA......................................................................104DULERA......................................................................104duloxetine hcl enteric coated pellets cap 20

mg................................................................................21duloxetine hcl enteric coated pellets cap 20








mg................................................................................76DUREZOL................................................................... 100dutasteride cap 0.5 mg............................................... 85EE.E.S. GRANULES......................................................11econazole nitrate cream 1%.......................................78EDURANT..................................................................... 47EFFIENT........................................................................60EFFIENT........................................................................60EGRIFTA*......................................................................87EGRIFTA*......................................................................87ELAPRASE................................................................... 81electrolyte-m in d5w soln..........................................107ELELYSO*.....................................................................81ELIDEL...........................................................................78ELIDEL...........................................................................94ELIGARD.......................................................................92ELIGARD.......................................................................92ELIGARD.......................................................................92

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ELIGARD.......................................................................92ELIQUIS.........................................................................60ELIQUIS.........................................................................60ELITEK...........................................................................32ELITEK...........................................................................32ELLA...............................................................................88EMCYT.......................................................................... 32EMEND..........................................................................25EMEND..........................................................................25EMEND..........................................................................25EMEND..........................................................................25EMEND..........................................................................25EMSAM..........................................................................21EMSAM..........................................................................21EMSAM..........................................................................22EMTRIVA.......................................................................47EMTRIVA.......................................................................47enalapril maleate & hydrochlorothiazide tab 10-25

mg................................................................................67enalapril maleate & hydrochlorothiazide tab 5-12.5

mg................................................................................67enalapril maleate tab 10 mg.......................................67enalapril maleate tab 2.5 mg......................................67enalapril maleate tab 20 mg.......................................67enalapril maleate tab 5 mg.........................................67ENBREL........................................................................ 94ENBREL........................................................................ 94ENBREL........................................................................ 94ENBREL SURECLICK................................................ 94ENGERIX-B.................................................................. 95ENGERIX-B.................................................................. 95enoxaparin sodium inj 100 mg/ml..............................61enoxaparin sodium inj 120 mg/0.8ml........................ 61enoxaparin sodium inj 150 mg/ml..............................61enoxaparin sodium inj 300 mg/3ml............................61enoxaparin sodium inj 30 mg/0.3ml...........................60enoxaparin sodium inj 40 mg/0.4ml...........................60enoxaparin sodium inj 60 mg/0.6ml...........................60enoxaparin sodium inj 80 mg/0.8ml...........................60entacapone tab 200 mg..............................................41entecavir tab 0.5 mg....................................................47entecavir tab 1 mg.......................................................47epinastine hcl ophth soln 0.05%..............................100EPIPEN 2-PAK...........................................................104EPIPEN-JR 2-PAK.....................................................104epirubicin hcl iv soln 200 mg/100ml (2 mg/

ml)................................................................................32epirubicin hcl iv soln 50 mg/25ml (2 mg/

ml)................................................................................32EPIVIR........................................................................... 47EPIVIR HBV..................................................................47eplerenone tab 25 mg.................................................67

eplerenone tab 50 mg.................................................67EPOGEN....................................................................... 61EPOGEN....................................................................... 61EPOGEN....................................................................... 61EPOGEN....................................................................... 61EPOGEN....................................................................... 61eprosartan mesylate tab 600 mg............................... 67EPZICOM...................................................................... 47EQUETRO.....................................................................54EQUETRO.....................................................................54EQUETRO.....................................................................54ERBITUX....................................................................... 32ERBITUX....................................................................... 32ergoloid mesylates tab 1 mg...................................... 19ERIVEDGE*.................................................................. 32ERWINAZE................................................................... 33ERYPED 200................................................................11ERYPED 400................................................................11ERY-TAB....................................................................... 11ERY-TAB....................................................................... 11ERY-TAB....................................................................... 11ERYTHROCIN LACTOBIONATE...............................11ERYTHROCIN LACTOBIONATE...............................11ERYTHROCIN STEARATE........................................ 11ERYTHROMYCIN BASE............................................ 11ERYTHROMYCIN BASE............................................ 11erythromycin ophth oint 5 mg/gm............................ 100erythromycin pads 2%.................................................78erythromycin soln 2%..................................................78ESBRIET..................................................................... 104escitalopram oxalate soln 5 mg/5ml..........................22escitalopram oxalate soln 5 mg/5ml..........................52escitalopram oxalate tab 10 mg.................................22escitalopram oxalate tab 10 mg.................................52escitalopram oxalate tab 20 mg.................................22escitalopram oxalate tab 20 mg.................................52escitalopram oxalate tab 5 mg...................................22escitalopram oxalate tab 5 mg...................................52esomeprazole sodium for intravenous soln 20

mg................................................................................82esomeprazole sodium for intravenous soln 40

mg................................................................................82ESTRACE......................................................................88estradiol & norethindrone acetate tab 0.5-0.1

mg................................................................................88estradiol & norethindrone acetate tab 1-0.5

mg................................................................................88estradiol tab 0.5 mg.....................................................88estradiol tab 1 mg........................................................88estradiol tab 2 mg........................................................88estradiol td patch weekly 0.025

mg/24hr...................................................................... 88

2015

149

estradiol td patch weekly 0.0375 mg/24hr (37.5mcg/24hr)................................................................... 88

estradiol td patch weekly 0.05 mg/24hr.................... 88estradiol td patch weekly 0.06 mg/24hr.................... 88estradiol td patch weekly 0.075

mg/24hr...................................................................... 88estradiol td patch weekly 0.1 mg/24hr...................... 88ESTROPIPATE............................................................. 88estropipate tab 0.75 mg..............................................89estropipate tab 1.5 mg................................................ 89ethambutol hcl tab 100 mg.........................................30ethambutol hcl tab 400 mg.........................................30ethosuximide cap 250 mg...........................................16ethosuximide soln 250 mg/5ml.................................. 16ethynodiol diacetate & ethinyl estradiol tab 1 mg-35

mcg..............................................................................89ETIDRONATE DISODIUM..........................................99ETIDRONATE DISODIUM..........................................99etodolac cap 200 mg.....................................................1etodolac cap 200 mg...................................................27etodolac cap 300 mg.....................................................1etodolac cap 300 mg...................................................27etodolac tab 400 mg......................................................2etodolac tab 400 mg....................................................27etodolac tab 500 mg......................................................2etodolac tab 500 mg....................................................27etodolac tab sr 24hr 400 mg........................................ 1etodolac tab sr 24hr 400 mg...................................... 27etodolac tab sr 24hr 500 mg........................................ 1etodolac tab sr 24hr 500 mg...................................... 27etodolac tab sr 24hr 600 mg........................................ 1etodolac tab sr 24hr 600 mg...................................... 27ETOPOPHOS............................................................... 33etoposide inj 100 mg/5ml (20 mg/ml)........................33etoposide inj 1 gm/50ml (20 mg/ml).......................... 33etoposide inj 500 mg/25ml (20 mg/ml)......................33EVOTAZ.........................................................................47EXELON........................................................................ 19EXELON........................................................................ 19EXELON........................................................................ 19exemestane tab 25 mg............................................... 33EXFORGE.....................................................................67EXFORGE.....................................................................67EXFORGE.....................................................................67EXFORGE.....................................................................67EXFORGE HCT........................................................... 67EXFORGE HCT........................................................... 67EXFORGE HCT........................................................... 67EXFORGE HCT........................................................... 67EXFORGE HCT........................................................... 67EXJADE*..................................................................... 107EXJADE*..................................................................... 107

EXJADE*..................................................................... 107FFABRAZYME*...............................................................81FABRAZYME*...............................................................81famciclovir tab 125 mg................................................47famciclovir tab 250 mg................................................47famciclovir tab 500 mg................................................48famotidine for susp 40 mg/5ml...................................82famotidine inj 200 mg/20ml........................................ 82famotidine inj 20 mg/2ml.............................................82famotidine inj 40 mg/4ml.............................................82famotidine tab 20 mg...................................................82famotidine tab 40 mg...................................................82FANAPT.........................................................................42FANAPT.........................................................................42FANAPT.........................................................................42FANAPT.........................................................................42FANAPT.........................................................................42FANAPT.........................................................................42FANAPT.........................................................................42FANAPT TITRATION PACK....................................... 42FARESTON...................................................................33FARYDAK......................................................................33FARYDAK......................................................................33FARYDAK......................................................................33FASLODEX................................................................... 33fat emulsion iv soln 20%...........................................107FAZACLO...................................................................... 42FAZACLO...................................................................... 42FAZACLO...................................................................... 42FAZACLO...................................................................... 42FAZACLO...................................................................... 43felbamate susp 600 mg/5ml....................................... 16felbamate tab 400 mg................................................. 16felbamate tab 600 mg................................................. 16felodipine tab sr 24hr 10 mg...................................... 67felodipine tab sr 24hr 2.5 mg..................................... 67felodipine tab sr 24hr 5 mg........................................ 67fenofibrate micronized cap 134 mg........................... 67fenofibrate micronized cap 200 mg........................... 67fenofibrate micronized cap 67 mg............................. 67fenofibrate tab 145 mg................................................68fenofibrate tab 160 mg................................................68fenofibrate tab 48 mg.................................................. 67fenofibrate tab 54 mg.................................................. 67fentanyl citrate lozenge on a handle 1200

mcg................................................................................2fentanyl citrate lozenge on a handle 1600

mcg................................................................................2fentanyl citrate lozenge on a handle 200

mcg................................................................................2

2015

150

fentanyl citrate lozenge on a handle 400mcg................................................................................2



fentanyl td patch 72hr 100 mcg/hr...............................2fentanyl td patch 72hr 12 mcg/hr................................. 2fentanyl td patch 72hr 25 mcg/hr................................. 2fentanyl td patch 72hr 50 mcg/hr................................. 2fentanyl td patch 72hr 75 mcg/hr................................. 2FETZIMA....................................................................... 22FETZIMA....................................................................... 22FETZIMA....................................................................... 22FETZIMA....................................................................... 22FETZIMA TITRATION PACK......................................22FINACEA....................................................................... 78FINACEA....................................................................... 78finasteride tab 5 mg.....................................................85FIRAZYR....................................................................... 95FIRMAGON...................................................................92FIRMAGON...................................................................92flecainide acetate tab 100 mg....................................68flecainide acetate tab 150 mg....................................68flecainide acetate tab 50 mg...................................... 68FLOVENT DISKUS....................................................104FLOVENT DISKUS....................................................104FLOVENT DISKUS....................................................104FLOVENT HFA...........................................................104FLOVENT HFA...........................................................104FLOVENT HFA...........................................................104fluconazole for susp 10 mg/ml................................... 26fluconazole for susp 40 mg/ml................................... 26fluconazole in dextrose inj 200

mg/100ml....................................................................26fluconazole in dextrose inj 400

mg/200ml....................................................................26FLUCONAZOLE IN NACL..........................................26fluconazole in nacl 0.9% inj 200

mg/100ml....................................................................26fluconazole in nacl 0.9% inj 400

mg/200ml....................................................................26fluconazole tab 100 mg...............................................26fluconazole tab 150 mg...............................................26fluconazole tab 200 mg...............................................26fluconazole tab 50 mg.................................................26flucytosine cap 250 mg............................................... 26flucytosine cap 500 mg............................................... 26FLUDARABINE PHOSPHATE................................... 33fludarabine phosphate for inj 50 mg..........................33fludarabine phosphate inj 25 mg/ml.......................... 33fludrocortisone acetate tab 0.1 mg............................ 86

fluocinolone acetonide (otic) oil0.01%........................................................................102

fluocinolone acetonide cream 0.01%........................ 78fluocinonide cream 0.05%.......................................... 78fluocinonide emulsified base cream

0.05%..........................................................................78fluocinonide gel 0.05%................................................79fluocinonide oint 0.05%...............................................79fluocinonide soln 0.05%..............................................79fluorometholone ophth susp 0.1%...........................100fluorouracil cream 5%................................................. 79fluorouracil inj 1 gm/20ml (50 mg/ml)........................33fluorouracil inj 2.5 gm/50ml (50 mg/ml).....................33fluorouracil inj 500 mg/10ml (50 mg/

ml)................................................................................33fluorouracil inj 5 gm/100ml (50 mg/ml)......................33fluorouracil soln 2%..................................................... 79fluorouracil soln 5%..................................................... 79fluoxetine hcl cap 10 mg.............................................22fluoxetine hcl cap 20 mg.............................................22fluoxetine hcl cap 40 mg.............................................22fluoxetine hcl cap delayed release 90

mg................................................................................22fluoxetine hcl solution 20 mg/5ml.............................. 22fluoxetine hcl tab 10 mg..............................................22fluoxetine hcl tab 20 mg..............................................22fluphenazine decanoate inj 25 mg/ml........................43FLUPHENAZINE HCL.................................................43FLUPHENAZINE HCL.................................................43FLUPHENAZINE HCL.................................................43fluphenazine hcl tab 10 mg........................................ 43fluphenazine hcl tab 1 mg.......................................... 43fluphenazine hcl tab 2.5 mg....................................... 43fluphenazine hcl tab 5 mg.......................................... 43flurbiprofen sodium ophth soln 0.03%.....................100flurbiprofen tab 100 mg.................................................2flurbiprofen tab 100 mg...............................................27flurbiprofen tab 50 mg................................................... 2flurbiprofen tab 50 mg.................................................27flutamide cap 125 mg..................................................33fluticasone propionate cream 0.05%.........................79fluticasone propionate nasal susp 50 mcg/

act..............................................................................104fluticasone propionate oint 0.005%........................... 79fluvoxamine maleate tab 100 mg...............................22fluvoxamine maleate tab 25 mg.................................22fluvoxamine maleate tab 50 mg.................................22FOLOTYN......................................................................33FOLOTYN......................................................................33fomepizole inj 1 gm/ml (for iv

infusion)....................................................................107

2015

151

fondaparinux sodium subcutaneous inj 10mg/0.8ml.....................................................................61

fondaparinux sodium subcutaneous inj 2.5mg/0.5ml.....................................................................61

fondaparinux sodium subcutaneous inj 5mg/0.4ml.....................................................................61

fondaparinux sodium subcutaneous inj 7.5mg/0.6ml.....................................................................61

FORADIL AEROLIZER............................................. 104FORTAZ.........................................................................11FORTAZ.........................................................................11FORTAZ.........................................................................11FORTEO........................................................................99FORTICAL.....................................................................99fosinopril sodium & hydrochlorothiazide tab 10-12.5

mg................................................................................68fosinopril sodium & hydrochlorothiazide tab 20-12.5

mg................................................................................68fosinopril sodium tab 10 mg....................................... 68fosinopril sodium tab 20 mg....................................... 68fosinopril sodium tab 40 mg....................................... 68fosphenytoin sodium inj 100 mg/2ml.........................16fosphenytoin sodium inj 500 mg/10ml.......................16FOSRENOL.................................................................. 85FOSRENOL.................................................................. 85FOSRENOL.................................................................. 85FOSRENOL.................................................................. 85FOSRENOL.................................................................. 85furosemide inj 10 mg/ml..............................................68furosemide oral soln 10 mg/ml...................................68furosemide tab 20 mg................................................. 68furosemide tab 40 mg................................................. 68furosemide tab 80 mg................................................. 68FUZEON........................................................................48FYCOMPA.....................................................................16FYCOMPA.....................................................................16FYCOMPA.....................................................................16FYCOMPA.....................................................................16FYCOMPA.....................................................................16FYCOMPA.....................................................................16Ggabapentin cap 100 mg.............................................. 16gabapentin cap 300 mg.............................................. 16gabapentin cap 400 mg.............................................. 16gabapentin oral soln 250 mg/5ml.............................. 16gabapentin tab 600 mg............................................... 16gabapentin tab 800 mg............................................... 16GABITRIL...................................................................... 16GABITRIL...................................................................... 17galantamine hydrobromide cap sr 24hr 16

mg................................................................................19

galantamine hydrobromide cap sr 24hr 24mg................................................................................19

galantamine hydrobromide cap sr 24hr 8mg................................................................................19

galantamine hydrobromide oral soln 4 mg/ml.................................................................................19

galantamine hydrobromide tab 12 mg...................... 19galantamine hydrobromide tab 4 mg.........................19galantamine hydrobromide tab 8 mg.........................19GAMMAPLEX............................................................... 95GAMMAPLEX............................................................... 95GAMMAPLEX............................................................... 95GAMMAPLEX............................................................... 95GAMUNEX-C................................................................ 95GAMUNEX-C................................................................ 95GAMUNEX-C................................................................ 95GAMUNEX-C................................................................ 95GAMUNEX-C................................................................ 95GAMUNEX-C................................................................ 95ganciclovir sodium for inj 500 mg.............................. 48GARDASIL.................................................................... 95GARDASIL 9.................................................................95GARDASIL 9.................................................................95GATTEX*....................................................................... 83GAUZE PADS 2" X 2".................................................56GAZYVA.........................................................................33GEMCITABINE............................................................. 33GEMCITABINE............................................................. 33GEMCITABINE............................................................. 33gemcitabine hcl for inj 1 gm....................................... 33gemcitabine hcl for inj 200 mg...................................33gemcitabine hcl for inj 2 gm....................................... 33gemfibrozil tab 600 mg............................................... 68gentamicin in saline inj 0.8 mg/ml............................. 11gentamicin in saline inj 1.2 mg/ml............................. 11gentamicin in saline inj 1.6 mg/ml............................. 11gentamicin in saline inj 1 mg/ml.................................11GENTAMICIN SULFATE............................................. 79GENTAMICIN SULFATE............................................. 79GENTAMICIN SULFATE/0.9% SODIUM

CHLORIDE.................................................................11GENTAMICIN SULFATE/0.9% SODIUM

CHLORIDE.................................................................12gentamicin sulfate inj 10 mg/ml................................. 11gentamicin sulfate inj 40 mg/ml................................. 11gentamicin sulfate iv soln 10 mg/ml.......................... 11gentamicin sulfate ophth oint 0.3%......................... 100gentamicin sulfate ophth soln 0.3%........................ 100GEODON.......................................................................43GILOTRIF......................................................................33GILOTRIF......................................................................33GILOTRIF......................................................................33

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Glatopa - glatiramer acetate soln prefilled syringe 20mg/ml.......................................................................... 76

GLEEVEC......................................................................34GLEEVEC......................................................................34GLEOSTINE..................................................................34GLEOSTINE..................................................................34GLEOSTINE..................................................................34glimepiride tab 1 mg....................................................56glimepiride tab 2 mg....................................................56glimepiride tab 4 mg....................................................56glipizide-metformin hcl tab 2.5-250 mg.....................56glipizide-metformin hcl tab 2.5-500 mg.....................56glipizide-metformin hcl tab 5-500 mg........................ 56glipizide tab 10 mg...................................................... 56glipizide tab 5 mg.........................................................56glipizide tab sr 24hr 10 mg.........................................56glipizide tab sr 24hr 2.5 mg........................................56glipizide tab sr 24hr 5 mg........................................... 56GLUCAGEN HYPOKIT............................................... 56GLUCAGON EMERGENCY KIT............................... 56GLYBURIDE..................................................................56GLYBURIDE..................................................................56GLYBURIDE..................................................................56glyburide-metformin tab 1.25-250 mg....................... 56glyburide-metformin tab 2.5-500 mg......................... 56glyburide-metformin tab 5-500 mg.............................56glyburide micronized tab 1.5 mg................................56glyburide micronized tab 3 mg...................................56glyburide micronized tab 6 mg...................................56glyburide tab 1.25 mg................................................. 56glyburide tab 2.5 mg....................................................56glyburide tab 5 mg.......................................................56glycopyrrolate tab 1 mg.............................................. 83glycopyrrolate tab 2 mg.............................................. 83granisetron hcl tab 1 mg.............................................25GRANIX......................................................................... 61GRANIX......................................................................... 61GRASTEK................................................................... 104griseofulvin microsize susp 125

mg/5ml........................................................................ 26griseofulvin ultramicrosize tab 125 mg......................26griseofulvin ultramicrosize tab 250 mg......................26GUANIDINE HCL.........................................................29HH.P. ACTHAR*..............................................................86HALAVEN...................................................................... 34halobetasol propionate cream 0.05%........................79halobetasol propionate oint 0.05%............................ 79haloperidol decanoate im soln 100 mg/

ml.................................................................................43

haloperidol decanoate im soln 50 mg/ml.................................................................................43

haloperidol lactate inj 5 mg/ml................................... 43haloperidol lactate oral conc 2 mg/ml........................43haloperidol tab 0.5 mg................................................ 43haloperidol tab 10 mg................................................. 43haloperidol tab 1 mg....................................................43haloperidol tab 20 mg................................................. 43haloperidol tab 2 mg....................................................43haloperidol tab 5 mg....................................................43HARVONI...................................................................... 48HAVRIX..........................................................................95HAVRIX..........................................................................95heparin sodium (porcine) 40 unit/ml in

d5w..............................................................................61heparin sodium (porcine) inj 10000 unit/

ml.................................................................................61heparin sodium (porcine) inj 1000 unit/



ml.................................................................................61heparin sodium (porcine) pf inj 5000

unit/0.5ml....................................................................61HERCEPTIN................................................................. 34HETLIOZ..................................................................... 106HEXALEN......................................................................34HIBERIX........................................................................ 95HUMALOG.................................................................... 56HUMALOG.................................................................... 56HUMALOG KWIKPEN.................................................57HUMALOG KWIKPEN.................................................57HUMALOG MIX 50/50.................................................57HUMALOG MIX 50/50 KWIKPEN............................. 57HUMALOG MIX 75/25.................................................57HUMALOG MIX 75/25 KWIKPEN............................. 57HUMIRA.........................................................................95HUMIRA.........................................................................95HUMIRA.........................................................................95HUMIRA PEDIATRIC CROHNS DISEASE

STARTER PACK.......................................................95HUMIRA PEN............................................................... 96HUMIRA PEN-CROHNS DISEASE

STARTER...................................................................96HUMIRA PEN-PSORIASIS STARTER..................... 96HUMULIN 70/30...........................................................57HUMULIN 70/30 KWIKPEN....................................... 57HUMULIN 70/30 PEN................................................. 57HUMULIN N..................................................................57HUMULIN N KWIKPEN.............................................. 57HUMULIN N U-100 PEN............................................ 57

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HUMULIN R..................................................................57HUMULIN R U-500 (CONCENTRATE).....................57hydralazine hcl tab 100 mg........................................ 68hydralazine hcl tab 10 mg.......................................... 68hydralazine hcl tab 25 mg.......................................... 68hydralazine hcl tab 50 mg.......................................... 68hydrochlorothiazide cap 12.5 mg...............................68hydrochlorothiazide tab 12.5 mg................................68hydrochlorothiazide tab 25 mg...................................68hydrochlorothiazide tab 50 mg...................................68hydrocodone-acetaminophen soln 7.5-325

mg/15ml........................................................................ 2hydrocodone-acetaminophen tab 10-300

mg..................................................................................2hydrocodone-acetaminophen tab 10-325



mg..................................................................................2hydrocodone-acetaminophen tab 7.5-300

mg..................................................................................2hydrocodone-acetaminophen tab 7.5-325

mg..................................................................................2hydrocodone-ibuprofen tab 10-200 mg.......................2hydrocodone-ibuprofen tab 2.5-200 mg......................2hydrocodone-ibuprofen tab 5-200 mg......................... 2hydrocodone-ibuprofen tab 7.5-200 mg......................2hydrocortisone butyrate cream 0.1%........................ 79hydrocortisone butyrate oint 0.1%.............................79hydrocortisone butyrate soln 0.1%............................ 79hydrocortisone cream 1%...........................................79hydrocortisone cream 2.5%........................................79hydrocortisone enema 100 mg/60ml.........................98hydrocortisone lotion 2.5%......................................... 79hydrocortisone oint 1%............................................... 79hydrocortisone oint 2.5%............................................ 79hydrocortisone rectal cream 1%................................ 98hydrocortisone rectal cream 2.5%.............................98hydrocortisone tab 10 mg...........................................86hydrocortisone tab 20 mg...........................................86hydrocortisone tab 5 mg............................................. 86hydrocortisone valerate cream 0.2%.........................79hydrocortisone valerate oint 0.2%............................. 79hydrocortisone w/ acetic acid otic soln

1-2%..........................................................................102hydromorphone hcl liqd 1 mg/ml..................................2hydromorphone hcl preservative free (pf) inj 10 mg/

ml................................................................................... 2hydromorphone hcl tab 2 mg....................................... 2hydromorphone hcl tab 4 mg....................................... 2hydromorphone hcl tab 8 mg....................................... 2

hydroxychloroquine sulfate tab 200 mg.................... 39hydroxyurea cap 500 mg............................................ 34hydroxyzine hcl syrup 10 mg/5ml.............................. 25hydroxyzine hcl syrup 10 mg/5ml.............................. 52hydroxyzine hcl syrup 10 mg/5ml............................ 104hydroxyzine hcl tab 10 mg..........................................25hydroxyzine hcl tab 10 mg..........................................52hydroxyzine hcl tab 10 mg....................................... 104hydroxyzine hcl tab 25 mg..........................................25hydroxyzine hcl tab 25 mg..........................................52hydroxyzine hcl tab 25 mg....................................... 104hydroxyzine hcl tab 50 mg..........................................25hydroxyzine hcl tab 50 mg..........................................52hydroxyzine hcl tab 50 mg....................................... 104Iibandronate sodium iv soln 3 mg/3ml........................99ibandronate sodium tab 150 mg................................ 99IBRANCE.......................................................................34IBRANCE.......................................................................34IBRANCE.......................................................................34ibuprofen susp 100 mg/5ml.......................................... 2ibuprofen susp 100 mg/5ml........................................27ibuprofen tab 400 mg.................................................... 2ibuprofen tab 400 mg.................................................. 27ibuprofen tab 600 mg.................................................... 2ibuprofen tab 600 mg.................................................. 27ibuprofen tab 800 mg.................................................... 2ibuprofen tab 800 mg.................................................. 28ICLUSIG........................................................................ 34ICLUSIG........................................................................ 34idarubicin hcl iv inj 10 mg/10ml (1 mg/

ml)................................................................................34idarubicin hcl iv inj 20 mg/20ml (1 mg/

ml)................................................................................34idarubicin hcl iv inj 5 mg/5ml (1 mg/ml).....................34IFEX............................................................................... 34IFOSFAMIDE................................................................ 34IFOSFAMIDE................................................................ 34IFOSFAMIDE................................................................ 34ifosfamide for inj 1 gm.................................................34ifosfamide iv inj 1 gm/20ml (50 mg/ml)..................... 34ifosfamide iv inj 3 gm/60ml (50 mg/ml)..................... 34ILARIS*.......................................................................... 96ILEVRO........................................................................100IMBRUVICA.................................................................. 34imipenem-cilastatin intravenous for soln 250

mg................................................................................12imipenem-cilastatin intravenous for soln 500

mg................................................................................12imipramine hcl tab 10 mg........................................... 22imipramine hcl tab 25 mg........................................... 22

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154

imipramine hcl tab 50 mg........................................... 22imiquimod cream 5%...................................................79IMOVAX RABIES (H.D.C.V.)...................................... 96INCRELEX*...................................................................87INCRUSE ELLIPTA................................................... 104indapamide tab 1.25 mg............................................. 68indapamide tab 2.5 mg............................................... 68INFANRIX......................................................................96INLYTA*......................................................................... 34INLYTA*......................................................................... 34INSULIN INJECTION DEVICE...................................57INSULIN SYRINGE/NEEDLE.....................................57INTELENCE.................................................................. 48INTELENCE.................................................................. 48INTELENCE.................................................................. 48INTRON A.....................................................................48INTRON A.....................................................................48INTRON A W/DILUENT..............................................48INTRON A W/DILUENT..............................................48INTRON A W/DILUENT..............................................48INVANZ.......................................................................... 12INVANZ.......................................................................... 12INVEGA......................................................................... 43INVEGA......................................................................... 43INVEGA......................................................................... 43INVEGA......................................................................... 43INVEGA SUSTENNA.................................................. 43INVEGA SUSTENNA.................................................. 43INVEGA SUSTENNA.................................................. 43INVEGA SUSTENNA.................................................. 43INVEGA SUSTENNA.................................................. 43INVEGA TRINZA..........................................................44INVEGA TRINZA..........................................................44INVEGA TRINZA..........................................................44INVEGA TRINZA..........................................................44INVIRASE......................................................................48INVIRASE......................................................................48INVOKAMET.................................................................57INVOKAMET.................................................................57INVOKAMET.................................................................57INVOKAMET.................................................................57INVOKANA....................................................................57INVOKANA....................................................................57IPOL INACTIVATED IPV.............................................96ipratropium bromide nasal soln 0.03% (21 mcg/

spray)........................................................................104ipratropium bromide nasal soln 0.06% (42 mcg/

spray)........................................................................104irbesartan-hydrochlorothiazide tab 150-12.5

mg................................................................................68irbesartan-hydrochlorothiazide tab 300-12.5

mg................................................................................68

irbesartan tab 150 mg.................................................68irbesartan tab 300 mg.................................................68irbesartan tab 75 mg................................................... 68IRESSA..........................................................................34IRINOTECAN................................................................34irinotecan hcl inj 100 mg/5ml (20 mg/

ml)................................................................................34irinotecan hcl inj 40 mg/2ml (20 mg/ml).................... 34ISENTRESS..................................................................48ISENTRESS..................................................................48ISENTRESS..................................................................48ISENTRESS..................................................................48ISONIAZID.................................................................... 30isoniazid tab 100 mg................................................... 30isoniazid tab 300 mg................................................... 30ISOSORBIDE DINITRATE..........................................68ISOSORBIDE DINITRATE..........................................68isosorbide dinitrate tab 10 mg....................................68isosorbide dinitrate tab 20 mg....................................68isosorbide dinitrate tab 5 mg......................................68isosorbide dinitrate tab cr 40 mg............................... 68isosorbide mononitrate tab 10 mg............................. 68isosorbide mononitrate tab 20 mg............................. 68isosorbide mononitrate tab sr 24hr 120

mg................................................................................68isosorbide mononitrate tab sr 24hr 30

mg................................................................................68isosorbide mononitrate tab sr 24hr 60

mg................................................................................68isotretinoin cap 10 mg.................................................79isotretinoin cap 20 mg.................................................79isotretinoin cap 30 mg.................................................79isotretinoin cap 40 mg.................................................79isradipine cap 2.5 mg..................................................69isradipine cap 5 mg..................................................... 69ISTALOL...................................................................... 100ISTODAX.......................................................................34itraconazole cap 100 mg............................................ 26ivermectin tab 3 mg.....................................................39IXEMPRA KIT...............................................................34IXEMPRA KIT...............................................................35IXIARO...........................................................................96JJADENU...................................................................... 107JADENU...................................................................... 107JADENU...................................................................... 107JAKAFI*......................................................................... 35JAKAFI*......................................................................... 35JAKAFI*......................................................................... 35JAKAFI*......................................................................... 35JAKAFI*......................................................................... 35

2015

155

JALYN............................................................................ 85JANUMET......................................................................57JANUMET......................................................................57JANUMET XR...............................................................57JANUMET XR...............................................................58JANUMET XR...............................................................58JANUVIA........................................................................58JANUVIA........................................................................58JANUVIA........................................................................58JARDIANCE..................................................................58JARDIANCE..................................................................58JENTADUETO.............................................................. 58JENTADUETO.............................................................. 58JENTADUETO.............................................................. 58JEVTANA.......................................................................35JUXTAPID*....................................................................69JUXTAPID*....................................................................69JUXTAPID*....................................................................69JUXTAPID*....................................................................69JUXTAPID*....................................................................69JUXTAPID*....................................................................69KKADCYLA......................................................................35KADCYLA......................................................................35KALETRA...................................................................... 48KALETRA...................................................................... 48KALETRA...................................................................... 48KALYDECO.................................................................104KALYDECO.................................................................105KALYDECO.................................................................105KANAMYCIN SULFATE.............................................. 12KCL 0.15%/D5W/LR..................................................107KCL 0.3%/D5W/LR IV LAC RI.................................107kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45%

inj...............................................................................107kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2%





inj...............................................................................108KEPIVANCE..................................................................77ketoconazole cream 2%..............................................79ketoconazole shampoo 2%........................................ 79ketoconazole tab 200 mg........................................... 26ketoprofen cap 50 mg................................................... 2ketoprofen cap 50 mg................................................. 28ketoprofen cap 75 mg................................................... 2

ketoprofen cap 75 mg................................................. 28ketorolac tromethamine ophth soln

0.4%..........................................................................100ketorolac tromethamine ophth soln

0.5%..........................................................................100ketorolac tromethamine tab 10 mg..............................3KEYTRUDA...................................................................35KEYTRUDA...................................................................35KINERET....................................................................... 96KINRIX........................................................................... 96KOMBIGLYZE XR........................................................58KOMBIGLYZE XR........................................................58KOMBIGLYZE XR........................................................58KUVAN*......................................................................... 81KUVAN*......................................................................... 81KUVAN*......................................................................... 81KYNAMRO*...................................................................69Llabetalol hcl tab 100 mg..............................................69labetalol hcl tab 200 mg..............................................69labetalol hcl tab 300 mg..............................................69LACRISERT................................................................100lactated ringer's solution........................................... 108lactic acid (ammonium lactate) cream

12%............................................................................. 79lactic acid (ammonium lactate) lotion

12%............................................................................. 79lactulose (encephalopathy) solution 10

gm/15ml......................................................................83lactulose solution 10 gm/15ml....................................83LAMICTAL ODT........................................................... 17LAMICTAL ODT........................................................... 17LAMICTAL ODT........................................................... 17LAMICTAL ODT........................................................... 17LAMICTAL ODT........................................................... 54LAMICTAL ODT........................................................... 54LAMICTAL ODT........................................................... 54LAMICTAL ODT........................................................... 54lamivudine oral soln 10 mg/ml................................... 48lamivudine tab 100 mg (hbv)......................................48lamivudine tab 150 mg................................................48lamivudine tab 300 mg................................................48lamivudine-zidovudine tab 150-300 mg.................... 48lamotrigine orally disintegrating tab 100

mg................................................................................17lamotrigine orally disintegrating tab 100



mg................................................................................54

2015

156

lamotrigine orally disintegrating tab 25mg................................................................................17




lamotrigine tab 100 mg............................................... 17lamotrigine tab 100 mg............................................... 54lamotrigine tab 150 mg............................................... 17lamotrigine tab 150 mg............................................... 54lamotrigine tab 200 mg............................................... 17lamotrigine tab 200 mg............................................... 54lamotrigine tab 25 mg................................................. 17lamotrigine tab 25 mg................................................. 54lamotrigine tab chewable dispersible 25

mg................................................................................17lamotrigine tab chewable dispersible 25



mg................................................................................54lansoprazole cap delayed release 15

mg................................................................................83lansoprazole cap delayed release 30

mg................................................................................83LANTUS.........................................................................58LANTUS SOLOSTAR..................................................58latanoprost ophth soln 0.005%................................ 100LATUDA.........................................................................44LATUDA.........................................................................44LATUDA.........................................................................44LATUDA.........................................................................44LATUDA.........................................................................44LAZANDA........................................................................ 3LAZANDA........................................................................ 3leflunomide tab 10 mg.................................................96leflunomide tab 20 mg.................................................96LENVIMA 10MG DAILY DOSE..................................35LENVIMA 14MG DAILY DOSE..................................35LENVIMA 20MG DAILY DOSE..................................35LENVIMA 24MG DAILY DOSE..................................35LETAIRIS*................................................................... 105LETAIRIS*................................................................... 105letrozole tab 2.5 mg.....................................................35LEUCOVORIN CALCIUM...........................................35LEUCOVORIN CALCIUM...........................................35LEUCOVORIN CALCIUM...........................................35leucovorin calcium for inj 100 mg.............................. 35leucovorin calcium for inj 200 mg.............................. 35

leucovorin calcium for inj 350 mg.............................. 35leucovorin calcium for inj 50 mg................................ 35leucovorin calcium tab 25 mg.................................... 35leucovorin calcium tab 5 mg.......................................35LEUKERAN...................................................................35LEUKINE....................................................................... 61leuprolide acetate inj kit 5 mg/ml............................... 92LEVEMIR.......................................................................58LEVEMIR FLEXPEN................................................... 58LEVEMIR FLEXTOUCH..............................................58LEVETIRACETAM........................................................17LEVETIRACETAM........................................................17LEVETIRACETAM........................................................17levetiracetam inj 500 mg/5ml (100 mg/

ml)................................................................................17levetiracetam oral soln 100 mg/ml.............................17levetiracetam tab 1000 mg......................................... 17levetiracetam tab 250 mg........................................... 17levetiracetam tab 500 mg........................................... 17levetiracetam tab 750 mg........................................... 17LEVOBUNOLOL HCL............................................... 100levobunolol hcl ophth soln 0.5%..............................100levocarnitine oral soln 1 gm/10ml

(10%)........................................................................ 108levocarnitine tab 330 mg.......................................... 108levocetirizine dihydrochloride tab 5

mg............................................................................. 105levofloxacin in d5w iv soln 250

mg/50ml......................................................................12levofloxacin in d5w iv soln 500

mg/100ml....................................................................12levofloxacin in d5w iv soln 750

mg/150ml....................................................................12levofloxacin iv soln 25 mg/ml..................................... 12levofloxacin oral soln 25 mg/ml..................................12levofloxacin tab 250 mg..............................................12levofloxacin tab 500 mg..............................................12levofloxacin tab 750 mg..............................................12levonorgestrel & ethinyl estradiol (91-day) tab

0.15-0.03 mg............................................................. 89levonorgestrel & ethinyl estradiol tab 0.15 mg-30

mcg..............................................................................89levonorgestrel & ethinyl estradiol tab 0.1 mg-20

mcg..............................................................................89levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg........................89levonorgestrel-ethinyl estradiol (continuous) tab

90-20 mcg..................................................................89levonorg-eth est tab 0.1-0.02mg(84) & eth est tab

0.01mg(7)...................................................................89levonorg-eth est tab 0.15-0.03mg(84) & eth est tab

0.01mg(7)...................................................................89

2015

157

LEVORPHANOL TARTRATE....................................... 3levothyroxine sodium tab 100 mcg............................91levothyroxine sodium tab 112 mcg............................ 91levothyroxine sodium tab 125 mcg............................91levothyroxine sodium tab 137 mcg............................91levothyroxine sodium tab 150 mcg............................91levothyroxine sodium tab 175 mcg............................91levothyroxine sodium tab 200 mcg............................91levothyroxine sodium tab 25 mcg..............................90levothyroxine sodium tab 300 mcg............................91levothyroxine sodium tab 50 mcg..............................91levothyroxine sodium tab 75 mcg..............................91levothyroxine sodium tab 88 mcg..............................91LEXIVA...........................................................................48LEXIVA...........................................................................48LIALDA...........................................................................98LIDOCAINE HCL..........................................................69lidocaine hcl gel 2%.......................................................5lidocaine hcl local inj 1%...............................................5lidocaine hcl local preservative free (pf) inj

1%..................................................................................5lidocaine hcl soln 4%.....................................................5lidocaine hcl viscous soln 2%.......................................5lidocaine oint 5%............................................................5lidocaine patch 5%.........................................................5lidocaine-prilocaine cream 2.5-2.5%........................... 5lindane lotion 1%......................................................... 39lindane shampoo 1%...................................................40linezolid iv soln 2 mg/ml..............................................12linezolid tab 600 mg.................................................... 12LINZESS........................................................................83LINZESS........................................................................83liothyronine sodium tab 25 mcg.................................91liothyronine sodium tab 50 mcg.................................91liothyronine sodium tab 5 mcg................................... 91lisinopril & hydrochlorothiazide tab 10-12.5

mg................................................................................69lisinopril & hydrochlorothiazide tab 20-12.5

mg................................................................................69lisinopril & hydrochlorothiazide tab 20-25

mg................................................................................69lisinopril tab 10 mg...................................................... 69lisinopril tab 2.5 mg..................................................... 69lisinopril tab 20 mg...................................................... 69lisinopril tab 30 mg...................................................... 69lisinopril tab 40 mg...................................................... 69lisinopril tab 5 mg.........................................................69LITHIUM........................................................................ 54lithium carbonate cap 150 mg....................................54lithium carbonate cap 300 mg....................................54lithium carbonate cap 600 mg....................................54lithium carbonate tab 300 mg.....................................54

lithium carbonate tab cr 300 mg................................ 54lithium carbonate tab cr 450 mg................................ 54LIVALO...........................................................................69LIVALO...........................................................................69LIVALO...........................................................................69LOMUSTINE................................................................. 35LOMUSTINE................................................................. 35LOMUSTINE................................................................. 35LONSURF..................................................................... 35LONSURF..................................................................... 35loperamide hcl cap 2 mg............................................ 83lorazepam tab 0.5 mg................................................. 52lorazepam tab 1 mg.................................................... 52lorazepam tab 2 mg.................................................... 52losartan potassium & hydrochlorothiazide tab

100-12.5 mg.............................................................. 69losartan potassium & hydrochlorothiazide tab 100-25

mg................................................................................69losartan potassium & hydrochlorothiazide tab

50-12.5 mg.................................................................69losartan potassium tab 100 mg..................................69losartan potassium tab 25 mg....................................69losartan potassium tab 50 mg....................................69LOTEMAX................................................................... 101LOTEMAX................................................................... 101LOTEMAX................................................................... 101LOTRONEX.................................................................. 83LOTRONEX.................................................................. 83lovastatin tab 10 mg....................................................69lovastatin tab 20 mg....................................................69lovastatin tab 40 mg....................................................69LOVAZA.........................................................................69loxapine succinate cap 10 mg....................................44loxapine succinate cap 25 mg....................................44loxapine succinate cap 50 mg....................................44loxapine succinate cap 5 mg......................................44LUMIGAN....................................................................101LUPRON DEPOT.........................................................92LUPRON DEPOT.........................................................92LUPRON DEPOT.........................................................92LUPRON DEPOT.........................................................92LUPRON DEPOT.........................................................92LUPRON DEPOT.........................................................92LUPRON DEPOT-PED............................................... 92LUPRON DEPOT-PED............................................... 92LUPRON DEPOT-PED............................................... 92LUPRON DEPOT-PED............................................... 92LUPRON DEPOT-PED............................................... 92LYNPARZA....................................................................35LYRICA.......................................................................... 17LYRICA.......................................................................... 17LYRICA.......................................................................... 17

2015

158

LYRICA.......................................................................... 17LYRICA.......................................................................... 17LYRICA.......................................................................... 17LYRICA.......................................................................... 17LYRICA.......................................................................... 17LYRICA.......................................................................... 17LYRICA.......................................................................... 76LYRICA.......................................................................... 76LYRICA.......................................................................... 76LYRICA.......................................................................... 76LYRICA.......................................................................... 76LYRICA.......................................................................... 76LYRICA.......................................................................... 76LYRICA.......................................................................... 76LYRICA.......................................................................... 76LYSODREN...................................................................91MMALARONE.................................................................. 40malathion lotion 0.5%..................................................40MAPROTILINE HCL.................................................... 22MAPROTILINE HCL.................................................... 22MAPROTILINE HCL.................................................... 22MARPLAN..................................................................... 22MATULANE*................................................................. 36meclizine hcl tab 12.5 mg...........................................25meclizine hcl tab 25 mg..............................................25medroxyprogesterone acetate im susp 150 mg/

ml.................................................................................89medroxyprogesterone acetate tab 10

mg................................................................................89medroxyprogesterone acetate tab 2.5

mg................................................................................89medroxyprogesterone acetate tab 5

mg................................................................................89mefloquine hcl tab 250 mg......................................... 40MEFOXIN...................................................................... 12MEFOXIN...................................................................... 12megestrol acetate susp 40 mg/ml..............................89megestrol acetate tab 20 mg..................................... 89megestrol acetate tab 40 mg..................................... 89MEKINIST......................................................................36MEKINIST......................................................................36meloxicam tab 15 mg....................................................3meloxicam tab 15 mg..................................................28meloxicam tab 7.5 mg...................................................3meloxicam tab 7.5 mg.................................................28melphalan hcl for inj 50 mg........................................ 36memantine hcl oral solution 2 mg/ml.........................19memantine hcl tab 10 mg...........................................19memantine hcl tab 5 mg............................................. 19

memantine hcl tab 5 mg (28) & 10 mg (21) titrationpak...............................................................................19

MENACTRA.................................................................. 96MENEST........................................................................89MENEST........................................................................89MENEST........................................................................89MENEST........................................................................89MENOMUNE-A/C/Y/W-135........................................ 96MENVEO....................................................................... 96mercaptopurine tab 50 mg......................................... 36meropenem iv for soln 1 gm...................................... 12meropenem iv for soln 500 mg.................................. 12mesalamine enema 4 gm........................................... 98mesna inj 100 mg/ml...................................................36MESNEX........................................................................36MESTINON................................................................... 29MESTINON TIMESPAN.............................................. 29metformin hcl tab 1000 mg.........................................58metformin hcl tab 500 mg...........................................58metformin hcl tab 850 mg...........................................58metformin hcl tab sr 24hr 500 mg..............................58metformin hcl tab sr 24hr 750 mg..............................58methadone hcl tab 10 mg.............................................3methadone hcl tab 5 mg............................................... 3methazolamide tab 25 mg.......................................... 69methazolamide tab 50 mg.......................................... 69methenamine hippurate tab 1 gm..............................12methimazole tab 10 mg.............................................. 93methimazole tab 5 mg.................................................93methocarbamol tab 500 mg..................................... 106methocarbamol tab 750 mg..................................... 106methotrexate sodium for inj 1 gm.............................. 36methotrexate sodium for inj 1 gm.............................. 96methotrexate sodium inj 25 mg/ml............................ 36methotrexate sodium inj 25 mg/ml............................ 96methotrexate sodium inj pf 25 mg/ml........................ 36methotrexate sodium inj pf 25 mg/ml........................ 96methotrexate sodium tab 2.5 mg............................... 36methotrexate sodium tab 2.5 mg............................... 96methoxsalen rapid cap 10 mg....................................79methscopolamine bromide tab 2.5 mg......................83methscopolamine bromide tab 5 mg......................... 83methylergonovine maleate tab 0.2 mg......................85methylphenidate hcl tab 10 mg..................................76methylphenidate hcl tab 20 mg..................................76methylphenidate hcl tab 5 mg....................................76methylphenidate hcl tab cr 20 mg............................. 76methylprednisolone sodium succinate for inj 1000

mg................................................................................86methylprednisolone sodium succinate for inj 125

mg................................................................................86

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methylprednisolone sodium succinate for inj 40mg................................................................................86

methylprednisolone tab 16 mg...................................86methylprednisolone tab 32 mg...................................86methylprednisolone tab 4 mg.....................................86methylprednisolone tab 4 mg dose

pack.............................................................................86methylprednisolone tab 8 mg.....................................86methyltestosterone cap 10 mg...................................89metoclopramide hcl soln 5 mg/5ml (10

mg/10ml).....................................................................25metoclopramide hcl soln 5 mg/5ml (10

mg/10ml).....................................................................83metoclopramide hcl tab 10 mg...................................25metoclopramide hcl tab 10 mg...................................83metoclopramide hcl tab 5 mg.....................................25metoclopramide hcl tab 5 mg.....................................83metolazone tab 10 mg................................................ 70metolazone tab 2.5 mg............................................... 70metolazone tab 5 mg...................................................70metoprolol & hydrochlorothiazide tab 100-25

mg................................................................................70metoprolol & hydrochlorothiazide tab 50-25

mg................................................................................70metoprolol succinate tab sr 24hr 100




mg................................................................................70metoprolol tartrate tab 100 mg...................................70metoprolol tartrate tab 25 mg.....................................70metoprolol tartrate tab 50 mg.....................................70METRO IV.....................................................................12metronidazole cap 375 mg.........................................12metronidazole cream 0.75%.......................................79metronidazole gel 0.75%............................................ 79metronidazole gel 1%..................................................79metronidazole in nacl 0.79% iv soln 500

mg/100ml....................................................................12metronidazole lotion 0.75%........................................ 79metronidazole tab 250 mg..........................................12metronidazole tab 500 mg..........................................12metronidazole vaginal gel 0.75%...............................12mexiletine hcl cap 150 mg..........................................70mexiletine hcl cap 200 mg..........................................70mexiletine hcl cap 250 mg..........................................70MIACALCIN...................................................................99midodrine hcl tab 10 mg............................................. 70midodrine hcl tab 2.5 mg............................................ 70

midodrine hcl tab 5 mg............................................... 70MIGERGOT...................................................................28MIGRANAL....................................................................28minocycline hcl cap 100 mg.......................................12minocycline hcl cap 50 mg......................................... 12minocycline hcl cap 75 mg......................................... 12minocycline hcl tab 100 mg........................................12minocycline hcl tab 50 mg..........................................12minocycline hcl tab 75 mg..........................................12minoxidil tab 10 mg..................................................... 70minoxidil tab 2.5 mg.................................................... 70mirtazapine orally disintegrating tab 15

mg................................................................................22mirtazapine orally disintegrating tab 30

mg................................................................................22mirtazapine orally disintegrating tab 45

mg................................................................................22mirtazapine tab 15 mg................................................ 22mirtazapine tab 30 mg................................................ 22mirtazapine tab 45 mg................................................ 22mirtazapine tab 7.5 mg............................................... 22misoprostol tab 100 mcg............................................ 83misoprostol tab 200 mcg............................................ 83mitomycin for iv soln 20 mg....................................... 36mitomycin for iv soln 40 mg....................................... 36mitomycin for iv soln 5 mg..........................................36mitoxantrone hcl inj conc 20 mg/10ml (2 mg/

ml)................................................................................36mitoxantrone hcl inj conc 20 mg/10ml (2 mg/

ml)................................................................................76mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/

ml)................................................................................36mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/



ml)................................................................................76M-M-R II........................................................................ 96modafinil tab 100 mg.................................................106modafinil tab 200 mg.................................................106moexipril hcl tab 15 mg...............................................70moexipril hcl tab 7.5 mg..............................................70moexipril-hydrochlorothiazide tab 15-12.5

mg................................................................................70moexipril-hydrochlorothiazide tab 15-25

mg................................................................................70moexipril-hydrochlorothiazide tab 7.5-12.5

mg................................................................................70mometasone furoate cream 0.1%............................. 79mometasone furoate oint 0.1%..................................79

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160

mometasone furoate solution 0.1%(lotion).........................................................................79

montelukast sodium chew tab 4 mg........................105montelukast sodium chew tab 5 mg........................105montelukast sodium oral granules packet 4

mg............................................................................. 105montelukast sodium tab 10 mg................................105MORPHINE SULFATE.................................................. 3MORPHINE SULFATE.................................................. 3morphine sulfate cap sr 24hr 10 mg............................3morphine sulfate inj pf 0.5 mg/ml.................................3morphine sulfate inj pf 1 mg/ml....................................3morphine sulfate oral soln 100 mg/5ml (20 mg/

ml)..................................................................................3morphine sulfate oral soln 10 mg/5ml......................... 3morphine sulfate oral soln 20 mg/5ml......................... 3morphine sulfate tab cr 100 mg................................... 3morphine sulfate tab cr 15 mg..................................... 3morphine sulfate tab cr 200 mg................................... 3morphine sulfate tab cr 30 mg..................................... 3morphine sulfate tab cr 60 mg..................................... 3MOVIPREP................................................................... 83MOXEZA..................................................................... 101moxifloxacin hcl tab 400 mg.......................................12MOZOBIL...................................................................... 61MULTAQ........................................................................ 70mupirocin oint 2%........................................................ 79MUSTARGEN............................................................... 36MYALEPT...................................................................... 86MYCAMINE...................................................................26MYCAMINE...................................................................26mycophenolate mofetil cap 250 mg...........................96mycophenolate mofetil for oral susp 200 mg/

ml.................................................................................96mycophenolate mofetil tab 500 mg........................... 96mycophenolate sodium tab dr 180 mg......................96mycophenolate sodium tab dr 360 mg......................96MYOZYME.................................................................... 81MYRBETRIQ.................................................................85MYRBETRIQ.................................................................85Nnabumetone tab 500 mg...............................................3nabumetone tab 500 mg.............................................28nabumetone tab 750 mg...............................................3nabumetone tab 750 mg.............................................28nadolol tab 20 mg........................................................70nadolol tab 40 mg........................................................70nadolol tab 80 mg........................................................70NAFCILLIN SODIUM...................................................12NAFCILLIN SODIUM...................................................12nafcillin sodium for inj 10 gm......................................13

nafcillin sodium for inj 1 gm........................................12nafcillin sodium for inj 2 gm........................................13NAGLAZYME*.............................................................. 81naloxone hcl inj 0.4 mg/ml............................................6naloxone hcl inj 1 mg/ml............................................... 6naltrexone hcl tab 50 mg.............................................. 6NAMENDA.................................................................... 19NAMENDA.................................................................... 19NAMENDA.................................................................... 19NAMENDA TITRATION PAK......................................19NAMENDA XR..............................................................19NAMENDA XR..............................................................20NAMENDA XR..............................................................20NAMENDA XR..............................................................20NAMENDA XR TITRATION PACK............................ 20NAPHAZOLINE HCL.................................................101naproxen sodium tab 275 mg.......................................3naproxen sodium tab 275 mg.................................... 28naproxen sodium tab 550 mg.......................................3naproxen sodium tab 550 mg.................................... 28naproxen susp 125 mg/5ml.......................................... 3naproxen susp 125 mg/5ml........................................28naproxen tab 250 mg.................................................... 3naproxen tab 250 mg.................................................. 28naproxen tab 375 mg.................................................... 3naproxen tab 375 mg.................................................. 28naproxen tab 500 mg.................................................... 3naproxen tab 500 mg.................................................. 28naproxen tab ec 375 mg...............................................3naproxen tab ec 375 mg.............................................28naproxen tab ec 500 mg...............................................3naproxen tab ec 500 mg.............................................28naratriptan hcl tab 1 mg..............................................28naratriptan hcl tab 2.5 mg...........................................28NASONEX...................................................................105NATACYN....................................................................101nateglinide tab 120 mg............................................... 58nateglinide tab 60 mg..................................................58NEBUPENT...................................................................40NEFAZODONE HCL....................................................22NEFAZODONE HCL....................................................22NEFAZODONE HCL....................................................22nefazodone hcl tab 250 mg........................................22nefazodone hcl tab 50 mg..........................................22neomycin-bacitrac zn-polymyx

5(3.5)mg-400unt-10000unt op oin........................101neomycin-polymy-gramicid op sol

1.75-10000-0.025mg-unt-mg/ml...........................101neomycin-polymyxin b gu irrigation

soln..............................................................................13neomycin-polymyxin b gu irrigation

soln..............................................................................85

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161

neomycin-polymyxin-dexamethasone ophth oint0.1%..........................................................................101

neomycin-polymyxin-dexamethasone ophth susp0.1%..........................................................................101

neomycin-polymyxin-hc otic soln 1%...................... 102neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000

unit/ml-1%................................................................ 102neomycin sulfate tab 500 mg.....................................13NEULASTA....................................................................61NEULASTA DELIVERY KIT....................................... 61NEUMEGA.................................................................... 61NEUPRO....................................................................... 41NEUPRO....................................................................... 41NEUPRO....................................................................... 41NEUPRO....................................................................... 41NEUPRO....................................................................... 41NEUPRO....................................................................... 41NEVANAC................................................................... 101NEVIRAPINE................................................................ 48nevirapine tab 200 mg................................................ 48nevirapine tab sr 24hr 400 mg...................................48NEXAVAR*.................................................................... 36NEXIUM.........................................................................83NEXIUM.........................................................................83NEXIUM.........................................................................83NEXIUM.........................................................................83NEXIUM.........................................................................83NEXIUM.........................................................................83NEXIUM.........................................................................83niacin tab cr 1000 mg................................................. 70niacin tab cr 500 mg....................................................70niacin tab cr 750 mg....................................................70nicardipine hcl cap 20 mg...........................................70nicardipine hcl cap 30 mg...........................................70NICOTROL INHALER................................................... 6NICOTROL NS............................................................... 6nifedipine tab sr 24hr 30 mg...................................... 70nifedipine tab sr 24hr 60 mg...................................... 70nifedipine tab sr 24hr 90 mg...................................... 70nifedipine tab sr 24hr osmotic release 30

mg................................................................................70nifedipine tab sr 24hr osmotic release 60

mg................................................................................70nifedipine tab sr 24hr osmotic release 90

mg................................................................................70NILANDRON.................................................................36NIPENT..........................................................................36NISOLDIPINE ER........................................................ 70nisoldipine tab sr 24hr 17 mg.....................................70nisoldipine tab sr 24hr 34 mg.....................................71nisoldipine tab sr 24hr 8.5 mg....................................70NITRO-BID....................................................................71

nitrofurantoin macrocrystalline cap 100mg................................................................................13

nitrofurantoin macrocrystalline cap 50mg................................................................................13

nitrofurantoin monohydrate macrocrystalline cap 100mg................................................................................13

nitrofurantoin susp 25 mg/5ml....................................13nitroglycerin td patch 24hr 0.1 mg/hr.........................71nitroglycerin td patch 24hr 0.2 mg/hr.........................71nitroglycerin td patch 24hr 0.4 mg/hr.........................71nitroglycerin td patch 24hr 0.6 mg/hr.........................71nitroglycerin tl soln 0.4 mg/spray (400 mcg/

spray)..........................................................................71NITROSTAT.................................................................. 71NITROSTAT.................................................................. 71NITROSTAT.................................................................. 71nizatidine cap 150 mg.................................................83nizatidine cap 300 mg.................................................83norethindrone & ethinyl estradiol-fe chew tab 0.4

mg-35 mcg.................................................................89norethindrone & ethinyl estradiol-fe chew tab 0.8

mg-25 mcg.................................................................89norethindrone & ethinyl estradiol tab 0.4 mg-35

mcg..............................................................................89norethindrone & ethinyl estradiol tab 0.5 mg-35

mcg..............................................................................89norethindrone & ethinyl estradiol tab 1 mg-35

mcg..............................................................................89norethindrone ace & ethinyl estradiol-fe tab 1.5

mg-30 mcg.................................................................90norethindrone ace & ethinyl estradiol-fe tab 1 mg-20

mcg..............................................................................89norethindrone ace & ethinyl estradiol tab 1.5 mg-30

mcg..............................................................................89norethindrone ace & ethinyl estradiol tab 1 mg-20

mcg..............................................................................89norethindrone ace-ethinyl estradiol-fe tab 1 mg-20

mcg (24).....................................................................90norethindrone acetate tab 5 mg.................................90norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35

mg-mcg.......................................................................89norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35

mg-mcg.......................................................................90norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35

mg-mcg.......................................................................90norethindrone tab 0.35 mg......................................... 90norgestimate & ethinyl estradiol tab 0.25 mg-35

mcg..............................................................................90norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mg-mcg.........................90norgestrel & ethinyl estradiol tab 0.3 mg-30

mcg..............................................................................90

2015

162

NORTHERA.................................................................. 71NORTHERA.................................................................. 71NORTHERA.................................................................. 71NORTRIPTYLINE HCL............................................... 23nortriptyline hcl cap 10 mg......................................... 23nortriptyline hcl cap 25 mg......................................... 23nortriptyline hcl cap 50 mg......................................... 23nortriptyline hcl cap 75 mg......................................... 23NORVIR.........................................................................48NORVIR.........................................................................48NORVIR.........................................................................49NOXAFIL....................................................................... 26NOXAFIL....................................................................... 26NUCYNTA ER.................................................................3NUCYNTA ER.................................................................3NUCYNTA ER.................................................................3NUCYNTA ER.................................................................3NUCYNTA ER.................................................................3NUEDEXTA...................................................................76NULOJIX........................................................................96NUVIGIL...................................................................... 106NUVIGIL...................................................................... 107NUVIGIL...................................................................... 107NUVIGIL...................................................................... 107nystatin cream 100000 unit/gm..................................79nystatin oint 100000 unit/gm...................................... 79nystatin susp 100000 unit/ml......................................26nystatin tab 500000 unit..............................................26nystatin topical powder............................................... 80nystatin-triamcinolone cream 100000-0.1 unit/gm-

%..................................................................................80nystatin-triamcinolone oint 100000-0.1 unit/gm-

%..................................................................................80Ooctreotide acetate inj 1000 mcg/ml (1 mg/

ml)................................................................................92octreotide acetate inj 100 mcg/ml (0.1 mg/




ml)................................................................................92ODOMZO...................................................................... 36OFEV........................................................................... 105OFEV........................................................................... 105ofloxacin ophth soln 0.3%........................................ 101ofloxacin otic soln 0.3%............................................ 102ofloxacin tab 400 mg...................................................13olanzapine for im inj 10 mg........................................ 44

olanzapine for im inj 10 mg........................................ 54olanzapine orally disintegrating tab 10

mg................................................................................44olanzapine orally disintegrating tab 10







mg................................................................................54olanzapine tab 10 mg..................................................44olanzapine tab 10 mg..................................................55olanzapine tab 15 mg..................................................44olanzapine tab 15 mg..................................................55olanzapine tab 2.5 mg.................................................44olanzapine tab 2.5 mg.................................................55olanzapine tab 20 mg..................................................44olanzapine tab 20 mg..................................................55olanzapine tab 5 mg....................................................44olanzapine tab 5 mg....................................................55olanzapine tab 7.5 mg.................................................44olanzapine tab 7.5 mg.................................................55OLEPTRO..................................................................... 23OLEPTRO..................................................................... 23olopatadine hcl nasal soln 0.6%..............................105OLYSIO..........................................................................49omega-3-acid ethyl esters cap 1 gm.........................71omeprazole cap delayed release 10

mg................................................................................83omeprazole cap delayed release 20

mg................................................................................83omeprazole cap delayed release 40

mg................................................................................84OMNITROPE................................................................ 87OMNITROPE................................................................ 87OMNITROPE................................................................ 87ONCASPAR.................................................................. 36ondansetron hcl inj 40 mg/20ml (2 mg/

ml)................................................................................25ondansetron hcl inj 4 mg/2ml (2 mg/

ml)................................................................................25ondansetron hcl oral soln 4 mg/5ml.......................... 25ondansetron hcl tab 24 mg.........................................25ondansetron hcl tab 4 mg...........................................25ondansetron hcl tab 8 mg...........................................25

2015

163

ondansetron orally disintegrating tab 4mg................................................................................25

ondansetron orally disintegrating tab 8mg................................................................................25

ONFI...............................................................................17ONFI...............................................................................17ONFI...............................................................................17ONFI...............................................................................18ONGLYZA......................................................................58ONGLYZA......................................................................58OPANA ER (CRUSH RESISTANT)............................. 3OPANA ER (CRUSH RESISTANT)............................. 3OPANA ER (CRUSH RESISTANT)............................. 4OPANA ER (CRUSH RESISTANT)............................. 4OPANA ER (CRUSH RESISTANT)............................. 4OPANA ER (CRUSH RESISTANT)............................. 4OPANA ER (CRUSH RESISTANT)............................. 4OPDIVO.........................................................................36OPDIVO.........................................................................36OPSUMIT*.................................................................. 105ORACEA........................................................................80ORAP............................................................................. 44ORAP............................................................................. 44ORFADIN*..................................................................... 81ORFADIN*..................................................................... 81ORFADIN*..................................................................... 81ORKAMBI....................................................................105oxaliplatin for iv inj 100 mg.........................................36oxaliplatin for iv inj 50 mg...........................................36oxaliplatin iv soln 100 mg/20ml..................................36oxaliplatin iv soln 50 mg/10ml....................................36oxandrolone tab 10 mg............................................... 90oxandrolone tab 2.5 mg..............................................90oxaprozin tab 600 mg....................................................4oxaprozin tab 600 mg................................................. 28oxcarbazepine susp 300 mg/5ml (60 mg/

ml)................................................................................18oxcarbazepine tab 150 mg.........................................18oxcarbazepine tab 300 mg.........................................18oxcarbazepine tab 600 mg.........................................18OXSORALEN ULTRA..................................................80oxybutynin chloride syrup 5 mg/5ml..........................85oxybutynin chloride tab 5 mg..................................... 85oxybutynin chloride tab sr 24hr 10 mg......................85oxybutynin chloride tab sr 24hr 15 mg......................85oxybutynin chloride tab sr 24hr 5 mg........................ 85oxycodone-aspirin tab 4.8355-325 mg........................4oxycodone hcl tab 10 mg..............................................4oxycodone hcl tab 15 mg..............................................4oxycodone hcl tab 20 mg..............................................4oxycodone hcl tab 30 mg..............................................4oxycodone hcl tab 5 mg................................................4

oxycodone w/ acetaminophen tab 10-325mg..................................................................................4

oxycodone w/ acetaminophen tab 2.5-325mg..................................................................................4

oxycodone w/ acetaminophen tab 5-325mg..................................................................................4

oxycodone w/ acetaminophen tab 7.5-325mg..................................................................................4

OXYCONTIN...................................................................4OXYCONTIN...................................................................4OXYCONTIN...................................................................4OXYCONTIN...................................................................4OXYCONTIN...................................................................4OXYCONTIN...................................................................4OXYCONTIN...................................................................4Ppaclitaxel iv conc 100 mg/16.7ml (6 mg/

ml)................................................................................36paclitaxel iv conc 300 mg/50ml (6 mg/

ml)................................................................................36paclitaxel iv conc 30 mg/5ml (6 mg/ml).....................36paliperidone tab sr 24hr 1.5 mg.................................44paliperidone tab sr 24hr 3 mg.................................... 44paliperidone tab sr 24hr 6 mg.................................... 44paliperidone tab sr 24hr 9 mg.................................... 44PANRETIN.....................................................................36pantoprazole sodium ec tab 20 mg........................... 84pantoprazole sodium ec tab 40 mg........................... 84paricalcitol cap 1 mcg................................................. 99paricalcitol cap 2 mcg................................................. 99paricalcitol cap 4 mcg................................................. 99paricalcitol iv soln 2 mcg/ml....................................... 99paricalcitol iv soln 5 mcg/ml....................................... 99paromomycin sulfate cap 250 mg..............................13paroxetine hcl tab 10 mg............................................ 23paroxetine hcl tab 10 mg............................................ 53paroxetine hcl tab 20 mg............................................ 23paroxetine hcl tab 20 mg............................................ 53paroxetine hcl tab 30 mg............................................ 23paroxetine hcl tab 30 mg............................................ 53paroxetine hcl tab 40 mg............................................ 23paroxetine hcl tab 40 mg............................................ 53paroxetine hcl tab sr 24hr 12.5 mg............................23paroxetine hcl tab sr 24hr 12.5 mg............................53paroxetine hcl tab sr 24hr 25 mg...............................23paroxetine hcl tab sr 24hr 25 mg...............................53paroxetine hcl tab sr 24hr 37.5 mg............................23paroxetine hcl tab sr 24hr 37.5 mg............................53PASER........................................................................... 30PATADAY.....................................................................101PATANASE..................................................................105

2015

164

PATANOL.................................................................... 101PAXIL............................................................................. 23PAXIL............................................................................. 53PEDVAX HIB................................................................ 96peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236

gm................................................................................84peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240

gm................................................................................84peg 3350-kcl-sod bicarb-nacl for soln 420

gm................................................................................84PEGANONE..................................................................18PEGASYS..................................................................... 49PEGASYS..................................................................... 49PEGASYS PROCLICK................................................49PEGASYS PROCLICK................................................49PEG-INTRON............................................................... 49PEG-INTRON............................................................... 49PEG-INTRON............................................................... 49PEG-INTRON............................................................... 49PEG-INTRON REDIPEN............................................ 49PEG-INTRON REDIPEN............................................ 49PEG-INTRON REDIPEN............................................ 49PEG-INTRON REDIPEN............................................ 49PEG-INTRON REDIPEN PAK 4................................ 49PEG-INTRON REDIPEN PAK 4................................ 49PEG-INTRON REDIPEN PAK 4................................ 49PEG-INTRON REDIPEN PAK 4................................ 49penicillin g potassium for inj 20000000

unit...............................................................................13penicillin g potassium for inj 5000000

unit...............................................................................13PENICILLIN G POTASSIUM IN

DEXTROSE............................................................... 13PENICILLIN G POTASSIUM IN

DEXTROSE............................................................... 13PENICILLIN G POTASSIUM IN

DEXTROSE............................................................... 13PENICILLIN G SODIUM............................................. 13penicillin v potassium for soln 125

mg/5ml........................................................................ 13penicillin v potassium for soln 250

mg/5ml........................................................................ 13penicillin v potassium tab 250 mg............................. 13penicillin v potassium tab 500 mg............................. 13PENTACEL....................................................................97PENTAM 300................................................................40PENTASA...................................................................... 98PENTASA...................................................................... 98pentoxifylline tab cr 400 mg....................................... 71perindopril erbumine tab 2 mg................................... 71perindopril erbumine tab 4 mg................................... 71perindopril erbumine tab 8 mg................................... 71

PERJETA*..................................................................... 36permethrin cream 5%..................................................40perphenazine tab 16 mg.............................................25perphenazine tab 16 mg.............................................44perphenazine tab 2 mg............................................... 25perphenazine tab 2 mg............................................... 44perphenazine tab 4 mg............................................... 25perphenazine tab 4 mg............................................... 44perphenazine tab 8 mg............................................... 25perphenazine tab 8 mg............................................... 44phenelzine sulfate tab 15 mg.....................................23PHENOBARBITAL....................................................... 18PHENOBARBITAL....................................................... 18PHENOBARBITAL....................................................... 18PHENOBARBITAL....................................................... 18phenobarbital elixir 20 mg/5ml...................................18PHENOBARBITAL SODIUM...................................... 18phenobarbital sodium inj 130 mg/ml......................... 18phenobarbital tab 16.2 mg..........................................18phenobarbital tab 32.4 mg..........................................18phenobarbital tab 64.8 mg..........................................18phenobarbital tab 97.2 mg..........................................18phenoxybenzamine hcl cap 10 mg............................71phenytoin chew tab 50 mg......................................... 18phenytoin sodium extended cap 100

mg................................................................................18phenytoin sodium extended cap 200

mg................................................................................18phenytoin sodium extended cap 300

mg................................................................................18phenytoin susp 125 mg/5ml....................................... 18PHOSLYRA...................................................................85PHOSPHOLINE IODIDE.......................................... 101PICATO..........................................................................80PICATO..........................................................................80pilocarpine hcl ophth soln 1%..................................101pilocarpine hcl ophth soln 2%..................................101pilocarpine hcl ophth soln 4%..................................101pilocarpine hcl tab 5 mg..............................................77pilocarpine hcl tab 7.5 mg.......................................... 77pimozide tab 1 mg....................................................... 44pimozide tab 2 mg....................................................... 44pindolol tab 10 mg....................................................... 71pindolol tab 5 mg......................................................... 71pioglitazone hcl-glimepiride tab 30-2

mg................................................................................59pioglitazone hcl-glimepiride tab 30-4

mg................................................................................59pioglitazone hcl-metformin hcl tab 15-500

mg................................................................................59pioglitazone hcl-metformin hcl tab 15-850

mg................................................................................59

2015

165

pioglitazone hcl tab 15 mg..........................................58pioglitazone hcl tab 30 mg..........................................58pioglitazone hcl tab 45 mg..........................................58piperacillin sodium-tazobactam sodium for inj 2-0.25

gm................................................................................13piperacillin sodium-tazobactam sodium for inj

3-0.375 gm.................................................................13piperacillin sodium-tazobactam sodium for inj 4-0.5

gm................................................................................13piroxicam cap 10 mg..................................................... 4piroxicam cap 10 mg...................................................28piroxicam cap 20 mg..................................................... 4piroxicam cap 20 mg...................................................28PLEGRIDY.................................................................... 76PLEGRIDY.................................................................... 76PLEGRIDY STARTER PACK..................................... 76PLEGRIDY STARTER PACK..................................... 76podofilox soln 0.5%..................................................... 80polyethylene glycol 3350 oral packet........................ 84polyethylene glycol 3350 oral powder.......................84polymyxin b-trimethoprim ophth soln 10000 unit/

ml-0.1%.................................................................... 101POMALYST*................................................................. 36POMALYST*................................................................. 36POMALYST*................................................................. 37POMALYST*................................................................. 37potassium chloride 20 meq/l (0.15%) in dextrose 5%

inj...............................................................................108potassium chloride 40 meq/l (0.3%) in dextrose 5%

inj...............................................................................108potassium chloride cap cr 10 meq.......................... 108potassium chloride cap cr 8 meq.............................108potassium chloride microencapsulated crys cr tab 10

meq........................................................................... 108potassium chloride microencapsulated crys cr tab 20

meq........................................................................... 108potassium chloride tab cr 10 meq........................... 108potassium chloride tab cr 8 meq (600

mg)............................................................................108potassium citrate tab cr 10 meq (1080



mg)............................................................................108POTIGA......................................................................... 18POTIGA......................................................................... 18POTIGA......................................................................... 18POTIGA......................................................................... 18PRADAXA..................................................................... 61PRADAXA..................................................................... 61

pramipexole dihydrochloride tab 0.125mg................................................................................41





pramipexole dihydrochloride tab 1 mg...................... 41pravastatin sodium tab 10 mg....................................71pravastatin sodium tab 20 mg....................................71pravastatin sodium tab 40 mg....................................71pravastatin sodium tab 80 mg....................................71prazosin hcl cap 1 mg.................................................71prazosin hcl cap 1 mg.................................................85prazosin hcl cap 2 mg.................................................71prazosin hcl cap 2 mg.................................................85prazosin hcl cap 5 mg.................................................71prazosin hcl cap 5 mg.................................................85prednicarbate cream 0.1%......................................... 80prednicarbate oint 0.1%..............................................80prednisolone acetate ophth susp 1%......................101prednisolone sod phosphate oral soln 15

mg/5ml........................................................................ 86prednisolone sod phosph oral soln 6.7 mg/5ml (5

mg/5ml base).............................................................86prednisolone syrup 15 mg/5ml...................................86PREDNISONE.............................................................. 87PREDNISONE.............................................................. 87PREDNISONE.............................................................. 87PREDNISONE.............................................................. 87prednisone tab 10 mg................................................. 87prednisone tab 1 mg................................................... 87prednisone tab 2.5 mg................................................ 87prednisone tab 20 mg................................................. 87prednisone tab 5 mg................................................... 87PREMARIN................................................................... 90PREMARIN................................................................... 90PREMARIN................................................................... 90PREMARIN................................................................... 90PREMARIN................................................................... 90PREMARIN................................................................... 90PREMPHASE............................................................... 90PREMPRO.................................................................... 90PREMPRO.................................................................... 90PREMPRO.................................................................... 90PREMPRO.................................................................... 90PREZCOBIX................................................................. 49PREZISTA..................................................................... 49PREZISTA..................................................................... 49

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PREZISTA..................................................................... 49PREZISTA..................................................................... 49PREZISTA..................................................................... 49PRIFTIN.........................................................................30PRIMAQUINE PHOSPHATE......................................40primidone tab 250 mg................................................. 18primidone tab 50 mg................................................... 18PRISTIQ........................................................................ 23PRISTIQ........................................................................ 23PRISTIQ........................................................................ 23PROAIR HFA..............................................................105PROAIR RESPICLICK..............................................105probenecid tab 500 mg............................................... 27prochlorperazine edisylate inj 5 mg/ml......................25prochlorperazine edisylate inj 5 mg/ml......................44prochlorperazine maleate tab 10 mg.........................25prochlorperazine maleate tab 10 mg.........................45prochlorperazine maleate tab 5 mg...........................25prochlorperazine maleate tab 5 mg...........................44prochlorperazine suppos 25 mg................................ 25prochlorperazine suppos 25 mg................................ 45PROCRIT...................................................................... 61PROCRIT...................................................................... 62PROCRIT...................................................................... 62PROCRIT...................................................................... 62PROCRIT...................................................................... 62PROCRIT...................................................................... 62PROGLYCEM............................................................... 59PROGRAF.....................................................................97PROLASTIN-C*..........................................................105PROLENSA................................................................ 101PROLEUKIN................................................................. 37PROLIA..........................................................................99PROMACTA*.................................................................62PROMACTA*.................................................................62PROMACTA*.................................................................62PROMACTA*.................................................................62promethazine hcl suppos 12.5 mg............................ 25promethazine hcl suppos 12.5 mg.......................... 105promethazine hcl suppos 25 mg................................25promethazine hcl suppos 25 mg..............................105promethazine hcl syrup 6.25 mg/5ml........................ 26promethazine hcl syrup 6.25 mg/5ml...................... 105promethazine hcl tab 12.5 mg....................................26promethazine hcl tab 12.5 mg................................. 105promethazine hcl tab 25 mg.......................................26promethazine hcl tab 25 mg.....................................105promethazine hcl tab 50 mg.......................................26promethazine hcl tab 50 mg.....................................105propafenone hcl cap sr 12hr 225 mg........................ 71propafenone hcl cap sr 12hr 325 mg........................ 71propafenone hcl cap sr 12hr 425 mg........................ 71

propafenone hcl tab 150 mg...................................... 71propafenone hcl tab 225 mg...................................... 71propafenone hcl tab 300 mg...................................... 71propranolol hcl cap sr 24hr 120 mg...........................28propranolol hcl cap sr 24hr 120 mg...........................71propranolol hcl cap sr 24hr 160 mg...........................28propranolol hcl cap sr 24hr 160 mg...........................71propranolol hcl cap sr 24hr 60 mg.............................28propranolol hcl cap sr 24hr 60 mg.............................71propranolol hcl cap sr 24hr 80 mg.............................28propranolol hcl cap sr 24hr 80 mg.............................71propranolol hcl inj 1 mg/ml......................................... 29propranolol hcl inj 1 mg/ml......................................... 71propranolol hcl tab 10 mg...........................................29propranolol hcl tab 10 mg...........................................72propranolol hcl tab 20 mg...........................................29propranolol hcl tab 20 mg...........................................72propranolol hcl tab 40 mg...........................................29propranolol hcl tab 40 mg...........................................72propranolol hcl tab 60 mg...........................................29propranolol hcl tab 60 mg...........................................72propranolol hcl tab 80 mg...........................................29propranolol hcl tab 80 mg...........................................72propylthiouracil tab 50 mg.......................................... 93PROQUAD.................................................................... 97protriptyline hcl tab 10 mg.......................................... 23protriptyline hcl tab 5 mg............................................ 23PULMOZYME.............................................................105PURIXAN.......................................................................37PYLERA.........................................................................84pyrazinamide tab 500 mg........................................... 30pyridostigmine bromide tab 60 mg............................ 29pyridostigmine bromide tab cr 180 mg......................29QQUADRACEL................................................................97quetiapine fumarate tab 100 mg................................23quetiapine fumarate tab 100 mg................................45quetiapine fumarate tab 100 mg................................55quetiapine fumarate tab 200 mg................................23quetiapine fumarate tab 200 mg................................45quetiapine fumarate tab 200 mg................................55quetiapine fumarate tab 25 mg..................................23quetiapine fumarate tab 25 mg..................................45quetiapine fumarate tab 25 mg..................................55quetiapine fumarate tab 300 mg................................23quetiapine fumarate tab 300 mg................................45quetiapine fumarate tab 300 mg................................55quetiapine fumarate tab 400 mg................................23quetiapine fumarate tab 400 mg................................45quetiapine fumarate tab 400 mg................................55quetiapine fumarate tab 50 mg..................................23

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quetiapine fumarate tab 50 mg..................................45quetiapine fumarate tab 50 mg..................................55quinapril hcl tab 10 mg............................................... 72quinapril hcl tab 20 mg............................................... 72quinapril hcl tab 40 mg............................................... 72quinapril hcl tab 5 mg..................................................72quinapril-hydrochlorothiazide tab 10-12.5

mg................................................................................72quinapril-hydrochlorothiazide tab 20-12.5

mg................................................................................72quinapril-hydrochlorothiazide tab 20-25

mg................................................................................72quinidine gluconate tab cr 324 mg............................ 72QUINIDINE SULFATE................................................. 72quinidine sulfate tab 300 mg...................................... 72QVAR........................................................................... 105QVAR........................................................................... 105RRABAVERT................................................................... 97rabeprazole sodium ec tab 20 mg............................. 84RAGWITEK.................................................................105raloxifene hcl tab 60 mg............................................. 90ramipril cap 1.25 mg....................................................72ramipril cap 10 mg.......................................................72ramipril cap 2.5 mg......................................................72ramipril cap 5 mg.........................................................72RANEXA........................................................................72RANEXA........................................................................72ranitidine hcl cap 150 mg........................................... 84ranitidine hcl cap 300 mg........................................... 84ranitidine hcl syrup 15 mg/ml (75

mg/5ml).......................................................................84ranitidine hcl tab 150 mg............................................ 84ranitidine hcl tab 300 mg............................................ 84RAPAFLO...................................................................... 85RAPAFLO...................................................................... 85RAPAMUNE.................................................................. 97REBETOL......................................................................49RECOMBIVAX HB....................................................... 97RECOMBIVAX HB....................................................... 97RECOMBIVAX HB....................................................... 97RELISTOR.....................................................................84RELISTOR.....................................................................84RELISTOR.....................................................................84REMICADE................................................................... 97REMODULIN*.............................................................105REMODULIN*.............................................................105REMODULIN*.............................................................106REMODULIN*.............................................................106RENVELA......................................................................85RENVELA......................................................................85

RENVELA......................................................................85repaglinide tab 0.5 mg................................................ 59repaglinide tab 1 mg....................................................59repaglinide tab 2 mg....................................................59RESCRIPTOR.............................................................. 50RESCRIPTOR.............................................................. 50RESTASIS...................................................................101RETROVIR IV INFUSION...........................................50REVLIMID*....................................................................37REVLIMID*....................................................................37REVLIMID*....................................................................37REVLIMID*....................................................................37REVLIMID*....................................................................37REVLIMID*....................................................................37REXULTI........................................................................23REXULTI........................................................................23REXULTI........................................................................23REXULTI........................................................................23REXULTI........................................................................23REXULTI........................................................................23REXULTI........................................................................45REXULTI........................................................................45REXULTI........................................................................45REXULTI........................................................................45REXULTI........................................................................45REXULTI........................................................................45REYATAZ.......................................................................50REYATAZ.......................................................................50REYATAZ.......................................................................50REYATAZ.......................................................................50REYATAZ.......................................................................50RIBASPHERE...............................................................50RIBASPHERE...............................................................50RIBASPHERE RIBAPAK.............................................50RIBASPHERE RIBAPAK.............................................50ribavirin cap 200 mg....................................................50ribavirin tab 200 mg.....................................................50RIDAURA...................................................................... 97rifabutin cap 150 mg....................................................30rifampin cap 150 mg....................................................30rifampin cap 300 mg....................................................30rifampin for inj 600 mg................................................ 30riluzole tab 50 mg........................................................ 76rimantadine hydrochloride tab 100 mg......................50risedronate sodium tab 150 mg................................. 99risedronate sodium tab 30 mg................................... 99risedronate sodium tab 35 mg................................... 99risedronate sodium tab 5 mg..................................... 99risedronate sodium tab delayed release 35

mg................................................................................99RISPERDAL CONSTA................................................ 45RISPERDAL CONSTA................................................ 45

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RISPERDAL CONSTA................................................ 45RISPERDAL CONSTA................................................ 45RISPERDAL CONSTA................................................ 55RISPERDAL CONSTA................................................ 55RISPERDAL CONSTA................................................ 55RISPERDAL CONSTA................................................ 55risperidone orally disintegrating tab 0.25

mg................................................................................45risperidone orally disintegrating tab 0.25



mg................................................................................55risperidone orally disintegrating tab 1








mg................................................................................55risperidone soln 1 mg/ml............................................ 45risperidone soln 1 mg/ml............................................ 55risperidone tab 0.25 mg..............................................45risperidone tab 0.25 mg..............................................55risperidone tab 0.5 mg................................................ 45risperidone tab 0.5 mg................................................ 55risperidone tab 1 mg................................................... 45risperidone tab 1 mg................................................... 55risperidone tab 2 mg................................................... 45risperidone tab 2 mg................................................... 55risperidone tab 3 mg................................................... 45risperidone tab 3 mg................................................... 55risperidone tab 4 mg................................................... 45risperidone tab 4 mg................................................... 55RITUXAN*..................................................................... 37RITUXAN*..................................................................... 37rivastigmine tartrate cap 1.5 mg................................ 20rivastigmine tartrate cap 3 mg....................................20rivastigmine tartrate cap 4.5 mg................................ 20rivastigmine tartrate cap 6 mg....................................20rivastigmine td patch 24hr 13.3

mg/24hr...................................................................... 20

rivastigmine td patch 24hr 4.6 mg/24hr.....................20rivastigmine td patch 24hr 9.5 mg/24hr.....................20rizatriptan benzoate orally disintegrating tab 10

mg................................................................................29rizatriptan benzoate orally disintegrating tab 5

mg................................................................................29rizatriptan benzoate tab 10 mg.................................. 29rizatriptan benzoate tab 5 mg.................................... 29ropinirole hydrochloride tab 0.25 mg.........................41ropinirole hydrochloride tab 0.5 mg...........................41ropinirole hydrochloride tab 1 mg.............................. 41ropinirole hydrochloride tab 2 mg.............................. 41ropinirole hydrochloride tab 3 mg.............................. 41ropinirole hydrochloride tab 4 mg.............................. 41ropinirole hydrochloride tab 5 mg.............................. 41ROTARIX.......................................................................97ROTATEQ......................................................................97SSABRIL.......................................................................... 18SABRIL.......................................................................... 18SAMSCA..................................................................... 108SAMSCA..................................................................... 108SANCUSO.....................................................................26SANDIMMUNE............................................................. 97SANTYL.........................................................................80SAPHRIS.......................................................................45SAPHRIS.......................................................................45SAPHRIS.......................................................................45selegiline hcl cap 5 mg............................................... 41selegiline hcl tab 5 mg................................................ 41selenium sulfide lotion 2.5%.......................................80SELZENTRY.................................................................50SELZENTRY.................................................................50SENSIPAR.....................................................................91SENSIPAR.....................................................................91SENSIPAR.....................................................................91SEREVENT DISKUS.................................................106SEROMYCIN................................................................ 30SEROQUEL XR........................................................... 23SEROQUEL XR........................................................... 23SEROQUEL XR........................................................... 23SEROQUEL XR........................................................... 23SEROQUEL XR........................................................... 23SEROQUEL XR........................................................... 45SEROQUEL XR........................................................... 46SEROQUEL XR........................................................... 46SEROQUEL XR........................................................... 46SEROQUEL XR........................................................... 46SEROQUEL XR........................................................... 55SEROQUEL XR........................................................... 55SEROQUEL XR........................................................... 55SEROQUEL XR........................................................... 55

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SEROQUEL XR........................................................... 55sertraline hcl oral conc 20 mg/ml...............................24sertraline hcl oral conc 20 mg/ml...............................53sertraline hcl tab 100 mg............................................ 24sertraline hcl tab 100 mg............................................ 53sertraline hcl tab 25 mg.............................................. 24sertraline hcl tab 25 mg.............................................. 53sertraline hcl tab 50 mg.............................................. 24sertraline hcl tab 50 mg.............................................. 53SIGNIFOR*....................................................................93SIGNIFOR*....................................................................93SIGNIFOR*....................................................................93SIGNIFOR LAR*.......................................................... 92SIGNIFOR LAR*.......................................................... 93SIGNIFOR LAR*.......................................................... 93sildenafil citrate tab 20 mg....................................... 106SILENOR.....................................................................107SILENOR.....................................................................107silver sulfadiazine cream 1%......................................80SIMBRINZA................................................................ 101SIMCOR........................................................................ 72SIMCOR........................................................................ 72SIMCOR........................................................................ 72SIMCOR........................................................................ 72SIMCOR........................................................................ 72SIMULECT.................................................................... 97SIMULECT.................................................................... 97simvastatin tab 10 mg.................................................72simvastatin tab 20 mg.................................................72simvastatin tab 40 mg.................................................72simvastatin tab 5 mg................................................... 72simvastatin tab 80 mg.................................................72sirolimus tab 0.5 mg.................................................... 97sirolimus tab 1 mg....................................................... 97sirolimus tab 2 mg....................................................... 97SIVEXTRO.................................................................... 13SIVEXTRO.................................................................... 13sodium chloride inj 0.45%........................................ 108sodium chloride irrigation soln 0.9%....................... 108sodium chloride iv soln 0.9%................................... 108sodium phenylbutyrate oral powder 3 gm/

teaspoonful.................................................................81sodium polystyrene sulfonate oral susp 15

gm/60ml....................................................................108sodium polystyrene sulfonate powder.....................108sodium polystyrene sulfonate rectal susp 30

gm/120ml................................................................. 108SOLTAMOX...................................................................37SOMATULINE DEPOT................................................93SOMATULINE DEPOT................................................93SOMATULINE DEPOT................................................93SOMAVERT*.................................................................93

SOMAVERT*.................................................................93SOMAVERT*.................................................................93SOMAVERT*.................................................................93SOMAVERT*.................................................................93sotalol hcl (afib/afl) tab 120 mg..................................72sotalol hcl (afib/afl) tab 160 mg..................................72sotalol hcl (afib/afl) tab 80 mg....................................72sotalol hcl tab 120 mg.................................................72sotalol hcl tab 160 mg.................................................72sotalol hcl tab 240 mg.................................................72sotalol hcl tab 80 mg...................................................72SOVALDI....................................................................... 50SPIRIVA HANDIHALER............................................106SPIRIVA RESPIMAT................................................. 106spironolactone & hydrochlorothiazide tab 25-25

mg................................................................................72spironolactone tab 100 mg.........................................72spironolactone tab 25 mg........................................... 72spironolactone tab 50 mg........................................... 72SPRYCEL......................................................................37SPRYCEL......................................................................37SPRYCEL......................................................................37SPRYCEL......................................................................37SPRYCEL......................................................................37SPRYCEL......................................................................37stavudine cap 15 mg...................................................50stavudine cap 20 mg...................................................50stavudine cap 30 mg...................................................50stavudine cap 40 mg...................................................50stavudine for oral soln 1 mg/ml..................................50STIMATE....................................................................... 87STIVARGA*...................................................................37STRATTERA.................................................................76STRATTERA.................................................................76STRATTERA.................................................................76STRATTERA.................................................................76STRATTERA.................................................................76STRATTERA.................................................................76STRATTERA.................................................................76STREPTOMYCIN SULFATE...................................... 13STRIBILD...................................................................... 50STROMECTOL.............................................................40SUBOXONE....................................................................6SUBOXONE....................................................................6SUBOXONE....................................................................6SUBOXONE....................................................................6SUBSYS.......................................................................... 4SUBSYS.......................................................................... 4SUBSYS.......................................................................... 4SUBSYS.......................................................................... 4SUBSYS.......................................................................... 4SUBSYS.......................................................................... 4

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SUBSYS.......................................................................... 5sucralfate tab 1 gm......................................................84sulfacetamide sodium lotion 10%.............................. 80sulfacetamide sodium ophth soln

10%...........................................................................101sulfacetamide sodium-prednisolone ophth soln

10-0.23(0.25)%....................................................... 101SULFADIAZINE............................................................ 13SULFAMETHOXAZOLE/

TRIMETHOPRIM...................................................... 14sulfamethoxazole-trimethoprim susp 200-40

mg/5ml........................................................................ 13sulfamethoxazole-trimethoprim tab 400-80

mg................................................................................13sulfamethoxazole-trimethoprim tab 800-160

mg................................................................................14sulfasalazine tab 500 mg............................................99sulfasalazine tab delayed release 500

mg................................................................................99sulindac tab 150 mg...................................................... 5sulindac tab 150 mg....................................................28sulindac tab 200 mg...................................................... 5sulindac tab 200 mg....................................................28SUMATRIPTAN............................................................ 29SUMATRIPTAN............................................................ 29SUMATRIPTAN SUCCINATE.....................................29sumatriptan succinate inj 6 mg/0.5ml........................29sumatriptan succinate solution auto-injector 4

mg/0.5ml.....................................................................29sumatriptan succinate solution auto-injector 6

mg/0.5ml.....................................................................29sumatriptan succinate solution cartridge 4

mg/0.5ml.....................................................................29sumatriptan succinate solution cartridge 6

mg/0.5ml.....................................................................29sumatriptan succinate tab 100 mg............................ 29sumatriptan succinate tab 25 mg...............................29sumatriptan succinate tab 50 mg...............................29SUPRAX........................................................................14SUPRAX........................................................................14SUPRAX........................................................................14SUPREP BOWEL PREP............................................ 84SURMONTIL.................................................................24SURMONTIL.................................................................24SURMONTIL.................................................................24SUSTIVA........................................................................50SUSTIVA........................................................................50SUSTIVA........................................................................50SUTENT........................................................................ 37SUTENT........................................................................ 37SUTENT........................................................................ 37SUTENT........................................................................ 37

SYLATRON................................................................... 37SYLATRON................................................................... 37SYLATRON................................................................... 37SYLATRON................................................................... 37SYLATRON................................................................... 37SYLATRON................................................................... 37SYLATRON................................................................... 50SYLATRON................................................................... 50SYLATRON................................................................... 50SYLATRON................................................................... 50SYLATRON................................................................... 50SYLATRON................................................................... 50SYLVANT.......................................................................37SYLVANT.......................................................................37SYMBICORT...............................................................106SYMBICORT...............................................................106SYMLINPEN 120......................................................... 59SYMLINPEN 60............................................................59SYNAGIS.......................................................................97SYNAGIS.......................................................................97SYNAREL......................................................................93SYNERCID....................................................................14SYNRIBO...................................................................... 37SYNTHROID.................................................................91SYNTHROID.................................................................91SYNTHROID.................................................................91SYNTHROID.................................................................91SYNTHROID.................................................................91SYNTHROID.................................................................91SYNTHROID.................................................................91SYNTHROID.................................................................91SYNTHROID.................................................................91SYNTHROID.................................................................91SYNTHROID.................................................................91SYNTHROID.................................................................91SYPRINE.....................................................................108TTABLOID........................................................................38tacrolimus cap 0.5 mg.................................................97tacrolimus cap 1 mg....................................................97tacrolimus cap 5 mg....................................................97tacrolimus oint 0.03%..................................................80tacrolimus oint 0.1%.................................................... 80TAFINLAR..................................................................... 38TAFINLAR..................................................................... 38TAMIFLU........................................................................50TAMIFLU........................................................................51TAMIFLU........................................................................51TAMIFLU........................................................................51tamoxifen citrate tab 10 mg........................................38tamoxifen citrate tab 20 mg........................................38tamsulosin hcl cap 0.4 mg..........................................85

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TARCEVA...................................................................... 38TARCEVA...................................................................... 38TARCEVA...................................................................... 38TARGRETIN..................................................................38TARGRETIN..................................................................38TASIGNA....................................................................... 38TASIGNA....................................................................... 38TASMAR........................................................................ 41TAXOTERE................................................................... 38TAXOTERE................................................................... 38TAZORAC......................................................................80TAZORAC......................................................................80TAZORAC......................................................................80TAZORAC......................................................................80TECFIDERA..................................................................76TECFIDERA..................................................................77TECFIDERA STARTER PACK...................................77TECHNIVIE................................................................... 51TEFLARO......................................................................14TEFLARO......................................................................14TEGRETOL-XR............................................................ 18TEKTURNA...................................................................73TEKTURNA...................................................................73TEKTURNA HCT......................................................... 73TEKTURNA HCT......................................................... 73TEKTURNA HCT......................................................... 73TEKTURNA HCT......................................................... 73telmisartan-hydrochlorothiazide tab 40-12.5

mg................................................................................73telmisartan-hydrochlorothiazide tab 80-12.5

mg................................................................................73telmisartan-hydrochlorothiazide tab 80-25

mg................................................................................73telmisartan tab 20 mg................................................. 73telmisartan tab 40 mg................................................. 73telmisartan tab 80 mg................................................. 73TEMODAR.................................................................... 38TENIVAC....................................................................... 97terazosin hcl cap 10 mg..............................................73terazosin hcl cap 10 mg..............................................85terazosin hcl cap 1 mg................................................73terazosin hcl cap 1 mg................................................85terazosin hcl cap 2 mg................................................73terazosin hcl cap 2 mg................................................85terazosin hcl cap 5 mg................................................73terazosin hcl cap 5 mg................................................85terbinafine hcl tab 250 mg..........................................26terbutaline sulfate tab 2.5 mg.................................. 106terbutaline sulfate tab 5 mg......................................106terconazole vaginal cream 0.4%................................27terconazole vaginal cream 0.8%................................27terconazole vaginal suppos 80 mg............................27

testosterone cypionate im inj in oil 100 mg/ml.................................................................................90

testosterone cypionate im inj in oil 200 mg/ml.................................................................................90

testosterone enanthate im inj in oil 200 mg/ml.................................................................................90

TETANUS/DIPHTHERIA TOXOID.............................97tetrabenazine tab 12.5 mg*........................................ 77tetrabenazine tab 25 mg*........................................... 77TETRACYCLINE HCL.................................................14TETRACYCLINE HCL.................................................14THALOMID....................................................................38THALOMID....................................................................38THALOMID....................................................................38THALOMID....................................................................38THALOMID....................................................................97THALOMID....................................................................97THALOMID....................................................................97THALOMID....................................................................97theophylline tab sr 12hr 100 mg.............................. 106theophylline tab sr 12hr 200 mg.............................. 106theophylline tab sr 12hr 300 mg.............................. 106theophylline tab sr 12hr 450 mg.............................. 106theophylline tab sr 24hr 400 mg.............................. 106theophylline tab sr 24hr 600 mg.............................. 106thioridazine hcl tab 100 mg........................................ 46thioridazine hcl tab 10 mg.......................................... 46thioridazine hcl tab 25 mg.......................................... 46thioridazine hcl tab 50 mg.......................................... 46THIOTEPA.....................................................................38thiothixene cap 10 mg.................................................46thiothixene cap 1 mg...................................................46thiothixene cap 2 mg...................................................46thiothixene cap 5 mg...................................................46THYMOGLOBULIN......................................................98tiagabine hcl tab 2 mg.................................................18tiagabine hcl tab 4 mg.................................................18TIKOSYN.......................................................................73TIKOSYN.......................................................................73TIKOSYN.......................................................................73TIMOLOL MALEATE................................................... 29TIMOLOL MALEATE................................................... 29TIMOLOL MALEATE................................................... 29TIMOLOL MALEATE................................................... 73TIMOLOL MALEATE................................................... 73TIMOLOL MALEATE................................................... 73timolol maleate ophth gel forming soln

0.25%........................................................................101timolol maleate ophth gel forming soln

0.5%..........................................................................101timolol maleate ophth soln 0.25%........................... 102timolol maleate ophth soln 0.5%..............................102

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TIVICAY......................................................................... 51tizanidine hcl cap 2 mg............................................... 46tizanidine hcl cap 4 mg............................................... 46tizanidine hcl cap 6 mg............................................... 46tizanidine hcl tab 2 mg................................................46tizanidine hcl tab 4 mg................................................46TOBRADEX................................................................ 102tobramycin-dexamethasone ophth susp

0.3-0.1%...................................................................102tobramycin nebu soln 300 mg/5ml.......................... 106tobramycin ophth soln 0.3%.....................................102TOBRAMYCIN SULFATE/SODIUM.......................... 14tobramycin sulfate for inj 1.2 gm................................14tobramycin sulfate inj 1.2 gm/30ml (40 mg/

ml)................................................................................14tobramycin sulfate inj 10 mg/ml................................. 14tobramycin sulfate inj 2 gm/50ml (40 mg/

ml)................................................................................14tobramycin sulfate inj 80 mg/2ml (40 mg/

ml)................................................................................14tolcapone tab 100 mg................................................. 41tolmetin sodium cap 400 mg........................................ 5tolmetin sodium cap 400 mg...................................... 28tolterodine tartrate cap sr 24hr 2 mg.........................85tolterodine tartrate cap sr 24hr 4 mg.........................85tolterodine tartrate tab 1 mg.......................................85tolterodine tartrate tab 2 mg.......................................85topiramate sprinkle cap 15 mg...................................18topiramate sprinkle cap 15 mg...................................29topiramate sprinkle cap 25 mg...................................18topiramate sprinkle cap 25 mg...................................29topiramate tab 100 mg................................................18topiramate tab 100 mg................................................29topiramate tab 200 mg................................................18topiramate tab 200 mg................................................29topiramate tab 25 mg.................................................. 18topiramate tab 25 mg.................................................. 29topiramate tab 50 mg.................................................. 18topiramate tab 50 mg.................................................. 29TOPOTECAN HCL...................................................... 38topotecan hcl for inj 4 mg........................................... 38TORISEL....................................................................... 38torsemide tab 100 mg................................................. 73torsemide tab 10 mg................................................... 73torsemide tab 20 mg................................................... 73torsemide tab 5 mg......................................................73TOUJEO SOLOSTAR..................................................59TOVIAZ.......................................................................... 86TOVIAZ.......................................................................... 86TRACLEER*............................................................... 106TRACLEER*............................................................... 106TRADJENTA................................................................. 59

tramadol-acetaminophen tab 37.5-325mg..................................................................................5

tramadol hcl tab 50 mg................................................. 5tramadol hcl tab sr 24hr 100 mg..................................5tramadol hcl tab sr 24hr 200 mg..................................5tramadol hcl tab sr 24hr 300 mg..................................5trandolapril tab 1 mg................................................... 73trandolapril tab 2 mg................................................... 73trandolapril tab 4 mg................................................... 73tranexamic acid inj 100 mg/ml................................... 62tranexamic acid tab 650 mg.......................................62tranylcypromine sulfate tab 10 mg............................ 24TRAVATAN Z.............................................................. 102trazodone hcl tab 100 mg...........................................24trazodone hcl tab 150 mg...........................................24trazodone hcl tab 300 mg...........................................24trazodone hcl tab 50 mg.............................................24TREANDA..................................................................... 38TREANDA..................................................................... 38TREANDA..................................................................... 38TREANDA..................................................................... 38TRECATOR...................................................................30TRELSTAR....................................................................93TRELSTAR....................................................................93TRELSTAR MIXJECT..................................................93TRELSTAR MIXJECT..................................................93TRELSTAR MIXJECT..................................................93tretinoin cap 10 mg......................................................38tretinoin cream 0.025%............................................... 80tretinoin cream 0.05%................................................. 80tretinoin cream 0.1%................................................... 80tretinoin gel 0.01%.......................................................80tretinoin gel 0.025%.....................................................80TRIAMCINOLONE ACETONIDE...............................80triamcinolone acetonide cream

0.025%........................................................................80triamcinolone acetonide cream 0.1%........................80triamcinolone acetonide cream 0.5%........................80triamcinolone acetonide dental paste

0.1%............................................................................77triamcinolone acetonide lotion 0.025%..................... 80triamcinolone acetonide lotion 0.1%..........................80triamcinolone acetonide nasal aerosol suspension

55 mcg/act............................................................... 106triamcinolone acetonide oint 0.025%........................ 80triamcinolone acetonide oint 0.1%.............................80triamterene & hydrochlorothiazide cap 37.5-25

mg................................................................................73triamterene & hydrochlorothiazide tab 37.5-25

mg................................................................................73triamterene & hydrochlorothiazide tab 75-50

mg................................................................................73

2015

173

TRIBENZOR................................................................. 73TRIBENZOR................................................................. 74TRIBENZOR................................................................. 74TRIBENZOR................................................................. 74TRIBENZOR................................................................. 74trifluoperazine hcl tab 10 mg......................................46trifluoperazine hcl tab 1 mg........................................46trifluoperazine hcl tab 2 mg........................................46trifluoperazine hcl tab 5 mg........................................46trifluridine ophth soln 1%.......................................... 102trimethoprim tab 100 mg.............................................14trimipramine maleate cap 100 mg............................. 24trimipramine maleate cap 25 mg............................... 24trimipramine maleate cap 50 mg............................... 24TRISENOX....................................................................38TRIUMEQ......................................................................51trospium chloride cap sr 24hr 60 mg.........................86trospium chloride tab 20 mg.......................................86TRUMENBA.................................................................. 98TRUVADA......................................................................51TWINRIX........................................................................98TYBOST........................................................................ 51TYGACIL....................................................................... 14TYKERB*.......................................................................38TYPHIM VI.................................................................... 98TYSABRI*......................................................................77TYSABRI*......................................................................98TYZEKA.........................................................................51TYZINE PEDIATRIC NASAL DROPS.....................106UULORIC......................................................................... 27ULORIC......................................................................... 27UNITUXIN......................................................................38ursodiol cap 300 mg....................................................84UVADEX........................................................................ 38UVADEX........................................................................ 80VVAGIFEM.......................................................................90valacyclovir hcl tab 1 gm............................................ 51valacyclovir hcl tab 500 mg........................................51VALCHLOR*..................................................................80VALCYTE.......................................................................51VALCYTE.......................................................................51valganciclovir hcl tab 450 mg.....................................51valproate sodium inj 100 mg/ml.................................18valproate sodium syrup 250 mg/5ml......................... 18valproic acid cap 250 mg............................................18valproic acid cap 250 mg............................................55valsartan-hydrochlorothiazide tab 160-12.5

mg................................................................................74

valsartan-hydrochlorothiazide tab 160-25mg................................................................................74

valsartan-hydrochlorothiazide tab 320-12.5mg................................................................................74

valsartan-hydrochlorothiazide tab 320-25mg................................................................................74

valsartan-hydrochlorothiazide tab 80-12.5mg................................................................................74

valsartan tab 160 mg...................................................74valsartan tab 320 mg...................................................74valsartan tab 40 mg.....................................................74valsartan tab 80 mg.....................................................74vancomycin hcl cap 125 mg.......................................14vancomycin hcl cap 250 mg.......................................14vancomycin hcl for inj 1000 mg................................. 14vancomycin hcl for inj 10 gm......................................14vancomycin hcl for inj 5000 mg................................. 14vancomycin hcl for inj 500 mg................................... 14VANCOMYCIN HCL IN DEXTROSE.........................14VANCOMYCIN HCL IN DEXTROSE.........................14VANCOMYCIN HCL IN DEXTROSE.........................14VAQTA........................................................................... 98VAQTA........................................................................... 98VARIVAX........................................................................98VASCEPA...................................................................... 74VECTIBIX...................................................................... 38VECTIBIX...................................................................... 39VECTICAL.....................................................................80VELCADE......................................................................39venlafaxine hcl cap sr 24hr 150 mg.......................... 24venlafaxine hcl cap sr 24hr 150 mg.......................... 53venlafaxine hcl cap sr 24hr 37.5 mg......................... 24venlafaxine hcl cap sr 24hr 37.5 mg......................... 53venlafaxine hcl cap sr 24hr 75 mg.............................24venlafaxine hcl cap sr 24hr 75 mg.............................53venlafaxine hcl tab 100 mg........................................ 24venlafaxine hcl tab 100 mg........................................ 53venlafaxine hcl tab 25 mg...........................................24venlafaxine hcl tab 25 mg...........................................53venlafaxine hcl tab 37.5 mg....................................... 24venlafaxine hcl tab 37.5 mg....................................... 53venlafaxine hcl tab 50 mg...........................................24venlafaxine hcl tab 50 mg...........................................53venlafaxine hcl tab 75 mg...........................................24venlafaxine hcl tab 75 mg...........................................53venlafaxine hcl tab sr 24hr 150 mg........................... 24venlafaxine hcl tab sr 24hr 150 mg........................... 53venlafaxine hcl tab sr 24hr 37.5 mg.......................... 24venlafaxine hcl tab sr 24hr 37.5 mg.......................... 53venlafaxine hcl tab sr 24hr 75 mg............................. 24venlafaxine hcl tab sr 24hr 75 mg............................. 53VENTOLIN HFA......................................................... 106

2015

174

VERAPAMIL HCL.........................................................74verapamil hcl cap sr 24hr 100 mg............................. 74verapamil hcl cap sr 24hr 120 mg............................. 74verapamil hcl cap sr 24hr 180 mg............................. 74verapamil hcl cap sr 24hr 200 mg............................. 74verapamil hcl cap sr 24hr 240 mg............................. 74verapamil hcl cap sr 24hr 300 mg............................. 74verapamil hcl cap sr 24hr 360 mg............................. 74verapamil hcl tab 120 mg........................................... 74verapamil hcl tab 80 mg............................................. 74verapamil hcl tab cr 120 mg.......................................74verapamil hcl tab cr 180 mg.......................................74verapamil hcl tab cr 240 mg.......................................74VERSACLOZ................................................................ 46VESICARE.................................................................... 86VESICARE.................................................................... 86VICTOZA....................................................................... 59VIDEX............................................................................ 51VIDEX............................................................................ 51VIEKIRA PAK................................................................51VIGAMOX....................................................................102VIIBRYD.........................................................................24VIIBRYD.........................................................................24VIIBRYD.........................................................................24VIIBRYD.........................................................................24VIIBRYD STARTER PACK......................................... 24VIMPAT.......................................................................... 19VIMPAT.......................................................................... 19VIMPAT.......................................................................... 19VIMPAT.......................................................................... 19VIMPAT.......................................................................... 19VIMPAT.......................................................................... 19VINBLASTINE SULFATE............................................39vincristine sulfate iv soln 1 mg/ml..............................39vinorelbine tartrate inj 10 mg/ml.................................39vinorelbine tartrate inj 50 mg/5ml (10 mg/

ml)................................................................................39VIOKACE.......................................................................81VIOKACE.......................................................................82VIRACEPT.................................................................... 51VIRACEPT.................................................................... 51VIRAMUNE................................................................... 51VIRAMUNE XR............................................................ 51VIRAZOLE.....................................................................51VIREAD..........................................................................51VIREAD..........................................................................51VIREAD..........................................................................51VIREAD..........................................................................51VIREAD..........................................................................51VITEKTA........................................................................ 51VITEKTA........................................................................ 51VIVITROL........................................................................ 6

VOLTAREN......................................................................5VOLTAREN....................................................................28VOLTAREN....................................................................80voriconazole for inj 200 mg........................................ 27voriconazole for susp 40 mg/ml.................................27voriconazole tab 200 mg............................................ 27voriconazole tab 50 mg...............................................27VOTRIENT*...................................................................39VPRIV............................................................................ 82VYTORIN.......................................................................74VYTORIN.......................................................................74VYTORIN.......................................................................74VYTORIN.......................................................................74Wwarfarin sodium tab 10 mg.........................................62warfarin sodium tab 1 mg...........................................62warfarin sodium tab 2.5 mg........................................62warfarin sodium tab 2 mg...........................................62warfarin sodium tab 3 mg...........................................62warfarin sodium tab 4 mg...........................................62warfarin sodium tab 5 mg...........................................62warfarin sodium tab 6 mg...........................................62warfarin sodium tab 7.5 mg........................................62water for irrigation, sterile irrigation

soln............................................................................108WELCHOL.....................................................................59WELCHOL.....................................................................59WELCHOL.....................................................................74WELCHOL.....................................................................75XXALKORI*......................................................................39XALKORI*......................................................................39XARELTO...................................................................... 62XARELTO...................................................................... 62XARELTO...................................................................... 62XARELTO STARTER PACK.......................................62XENAZINE*...................................................................77XENAZINE*...................................................................77XGEVA...........................................................................99XIFAXAN........................................................................14XIFAXAN........................................................................84XOLAIR*......................................................................106XOPENEX HFA..........................................................106XTANDI*.........................................................................39XYREM*...................................................................... 107YYERVOY*...................................................................... 39YERVOY*...................................................................... 39YF-VAX.......................................................................... 98

2015

175

Zzafirlukast tab 10 mg.................................................106zafirlukast tab 20 mg.................................................106zaleplon cap 10 mg...................................................107zaleplon cap 5 mg..................................................... 107ZALTRAP.......................................................................39ZALTRAP.......................................................................39ZANOSAR..................................................................... 39ZAVESCA*.....................................................................82ZELBORAF*..................................................................39ZEMPLAR......................................................................99ZEMPLAR......................................................................99ZENPEP........................................................................ 82ZENPEP........................................................................ 82ZENPEP........................................................................ 82ZENPEP........................................................................ 82ZENPEP........................................................................ 82ZENPEP........................................................................ 82ZENPEP........................................................................ 82ZETIA............................................................................. 75ZIAGEN..........................................................................51zidovudine cap 100 mg...............................................51zidovudine syrup 10 mg/ml.........................................51zidovudine tab 300 mg................................................51ZINACEF....................................................................... 14ziprasidone hcl cap 20 mg..........................................46ziprasidone hcl cap 20 mg..........................................55ziprasidone hcl cap 40 mg..........................................46ziprasidone hcl cap 40 mg..........................................55ziprasidone hcl cap 60 mg..........................................46ziprasidone hcl cap 60 mg..........................................55ziprasidone hcl cap 80 mg..........................................46ziprasidone hcl cap 80 mg..........................................56ZOHYDRO ER................................................................5ZOHYDRO ER................................................................5ZOHYDRO ER................................................................5ZOHYDRO ER................................................................5ZOHYDRO ER................................................................5ZOHYDRO ER................................................................5ZOHYDRO ER................................................................5ZOHYDRO ER................................................................5ZOHYDRO ER................................................................5ZOHYDRO ER................................................................5ZOHYDRO ER................................................................5ZOHYDRO ER................................................................5zoledronic acid inj conc for iv infusion 4

mg/5ml........................................................................ 99zoledronic acid iv soln 5 mg/100ml........................... 99ZOLINZA........................................................................39zolpidem tartrate tab 10 mg..................................... 107zolpidem tartrate tab 5 mg....................................... 107

ZOMETA........................................................................ 99zonisamide cap 100 mg..............................................19zonisamide cap 25 mg................................................19zonisamide cap 50 mg................................................19ZONTIVITY....................................................................62ZORTRESS...................................................................98ZORTRESS...................................................................98ZORTRESS...................................................................98ZOSTAVAX....................................................................98ZOSYN...........................................................................14ZOSYN...........................................................................14ZOSYN...........................................................................15ZYDELIG....................................................................... 39ZYDELIG....................................................................... 39ZYKADIA....................................................................... 39ZYPREXA RELPREVV............................................... 46ZYPREXA RELPREVV............................................... 46ZYPREXA RELPREVV............................................... 46ZYTIGA*........................................................................ 39ZYVOX...........................................................................15ZYVOX...........................................................................15ZYVOX...........................................................................15

ix

HMO, HMO-POS and PPO plans are provided by Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC), an Independent Licensee of the Blue Cross and Blue Shield Association. HCSC is a Medicare Advantage organization with a Medicare contract. Enrollment in HCSC’s plans depends on contract renewal.

This formulary was updated on 11/20/2015. For more recent information or other questions, please contact Blue Cross Medicare Advantage Customer Service, at 1-877-774-8592 or, for TTY/TDD users, 711, 8 a.m. - 8 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on weekends and holidays, or visit www.getblueil.com/mapd/druglist.

2015 formulary (list of covered drugs) - blue cross … formulary (list of covered drugs) drug list...

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