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2296 NE © Prime Therapeutics LLC 01/16

January 2016

Blue Cross and Blue Shield of Nebraska Preferred Drug List

Contents

Drug Formulary .............................................................. I At your health care professional’s office ...................... I At the pharmacy ........................................................... I Specialty drugs ............................................................. I For more information .................................................... I How to use this list ...................................................... II

Therapeutic Class Drug List ........................................ 1 Anti-Infective Drugs ..................................................... 1 Immunizing Agents ...................................................... 6 Cancer Drugs .............................................................. 6 Hormones, Diabetes and Related Drugs .................... 9 Heart and Circulatory Drugs ...................................... 15 Respiratory Agents .................................................... 23 Gastrointestinal Drugs ............................................... 25 Genitourinary Drugs .................................................. 27 Central Nervous System Drugs ................................. 28 Pain Relief Drugs ...................................................... 34 Neuromuscular Drugs ............................................... 38 Supplements ............................................................. 41 Blood Modifying Drugs .............................................. 41 Topical Drugs ............................................................ 43 Miscellaneous Categories ......................................... 48

Index ............................................................................ 50

Key

cap ...................................................................... capsules chew .................................................................. chewable conc .............................................................. concentrate cr .......................................................... controlled release dr ............................................................. delayed release ec ................................................................enteric coated effe ................................................................. effervescent equiv ................................................................. equivalent er ...........................................................extended release inhal ................................................................... inhalation inj ......................................................................... injection liq .............................................................................. liquid lotn ........................................................................... lotion nebu ................................................................... nebulizer odt ............................................. orally disintegrating tabs oint ..................................................................... ointment ophth ............................................................... ophthalmic osm .......................................................... osmotic release powd ..................................................................... powder sa ............................................................ sustained action sl ...................................................................... sublingual soln ....................................................................... solution sr .......................................................... sustained release suppos ........................................................ suppositories susp ................................................................ suspension tab ........................................................................... tablets td ................................................................... transdermal

To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking for and click on Search.

Blue Cross and Blue Shield of Nebraska is an independent licensee of the Blue Cross and Blue Shield Association. BLUE CROSS®, BLUE SHIELD®, and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Prime Therapeutics LLC is an independent company providing pharmacy benefit management services.

I Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2016

Drug formulary

This Patient Medication List, also called a formulary, is a list of medications included in most prescription drug benefits. Coverage of formulary and non-formulary (NF) drugs is subject to your prescription benefit plan design.

A Pharmacy and Therapeutics Committee reviewed and approved this medication list. All medications on the list were selected after consideration of safety, effectiveness, uniqueness and cost. The Committee includes practicing physicians and pharmacists dedicated to providing patients with high-quality, cost-effective drug therapy. The Committee meets periodically to consider updates to the formulary.

Medications listed in this booklet are formulary drugs. Drugs not listed are NF.

At your health care professional’s office:

• Show this booklet to your health care professional each time a prescription is written

• Ask your health care professional if there are appropriate generic drugs to treat your condition

At the pharmacy:

• Bring this booklet to the pharmacy each time you have a prescription filled

• Ask the pharmacist to fill your prescriptions with generic drugs, when appropriate

Generic drugs are as safe and effective as their brand counterparts, and generally have a lower copay or co-insurance than brand drugs. To encourage the use of generic drugs, brand formulary drugs usually move to non-formulary (NF) status after a generic version becomes available. Formulary drugs are subject to annual review. Drug additions/removals may occur quarterly. However, the formulary may be updated at any time without notice.

Specialty drugs

Some Blue Cross and Blue Shield of Nebraska groups offer specific benefits for specialty drug products. Please refer to your Certificate of Coverage and/or Schedule of Benefits to determine the specific quantities allowed under your group’s benefit. Specialty products are typically injectable drugs that can be self administered by a patient or family member and are used to treat serious or chronic medical conditions such as multiple sclerosis, hemophilia, hepatitis and rheumatoid arthritis.

For more information

To access a searchable version of the Blue Cross and Blue Shield of Nebraska Drug formulary, visit our website at www.nebraskablue.com. If you have questions about your prescription benefit or how to use this booklet, please call the number on the back of your member ID card.

Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2016 II

How to use this list

This list is organized into broad therapeutic categories. For example, Anti-infective Drugs is a broad category. Within most categories, drugs are sub-grouped based upon drug class, for example under Anti-infective Drugs you will find Penicillins. All drugs listed, whether generic or brand, are formulary drugs. The graphic below shows the information that is provided in each column of the medication list and is an example only.

The first column of the chart lists the drug name. Generic drugs are shown in lower-case boldface type.

Formulary brand drugs are listed in all CAPITAL letters.

The second column indicates if the drug is a specialty drug. Note: Additional information about specialty drugs can be found in this document under the header for Specialty Drugs.

The remaining columns indicate the Utilization Management (UM) program(s) that apply to the prescription drug (e.g., Maximum Monthly Quantity). If an indicator is present in the column(s), then the UM program noted is possibly applied to your benefit. Some plans may have UM on additional medications beyond those noted in this document.

2016

Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2016 1

Drug Name Spe

cial

ty

Max

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Mon

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Qua

ntity

ANTI-INFECTIVE DRUGSPENICILLINSamoxicillin (trihydrate) cap 250 mgamoxicillin (trihydrate) cap 500 mgamoxicillin (trihydrate) chew tab 125 mgamoxicillin (trihydrate) chew tab 250 mgamoxicillin (trihydrate) for susp

125 mg/5mlamoxicillin (trihydrate) for susp



400 mg/5mlamoxicillin (trihydrate) tab 500 mgamoxicillin (trihydrate) tab 875 mgamoxicillin & k clavulanate for susp

200-28.5 mg/5mlamoxicillin & k clavulanate for susp

250-62.5 mg/5ml (Augmentin)amoxicillin & k clavulanate for susp

400-57 mg/5mlamoxicillin & k clavulanate for susp

600-42.9 mg/5ml (Augmentin es-600)amoxicillin & k clavulanate tab sr 12hr

1000-62.5 mg (Augmentin xr)amoxicillin & k clavulanate tab

250-125 mgamoxicillin & k clavulanate tab

500-125 mg (Augmentin)amoxicillin & k clavulanate tab

875-125 mg (Augmentin)ampicillin cap 250 mgampicillin cap 500 mgampicillin for susp 125 mg/5mlampicillin for susp 250 mg/5mlAUGMENTIN – amoxicillin & k clavulanate

for susp 125-31.25 mg/5ml

Drug Name Spe

cial

ty

Max

imum

Mon

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Qua

ntity

dicloxacillin sodium cap 250 mgdicloxacillin sodium cap 500 mgpenicillin v potassium for soln

125 mg/5mlpenicillin v potassium for soln

250 mg/5mlpenicillin v potassium tab 250 mgpenicillin v potassium tab 500 mgCEPHALOSPORINScefaclor cap 250 mgcefaclor cap 500 mgcefadroxil cap 500 mgcefadroxil for susp 250 mg/5mlcefadroxil for susp 500 mg/5mlcefadroxil tab 1 gmcefdinir cap 300 mgcefdinir for susp 125 mg/5mlcefdinir for susp 250 mg/5mlcefixime for susp 100 mg/5ml (Suprax)cefixime for susp 200 mg/5ml (Suprax)cefpodoxime proxetil for susp 50 mg/5mlcefpodoxime proxetil for susp 100 mg/5mlcefpodoxime proxetil tab 100 mgcefpodoxime proxetil tab 200 mgcefprozil for susp 125 mg/5mlcefprozil for susp 250 mg/5mlcefprozil tab 250 mgcefprozil tab 500 mgCEFTIN – cefuroxime axetil for susp 125

mg/5mlceftriaxone sodium for inj 250 mgceftriaxone sodium for inj 500 mg

(Rocephin)ceftriaxone sodium for inj 1 gm (Rocephin)ceftriaxone sodium for inj 2 gmcefuroxime axetil tab 250 mg (Ceftin)

2016

2 Blue Cross and Blue Shield of Nebraska Drug Formulary, January 2016

Drug Name Spe

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Max

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Mon

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Qua

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cefuroxime axetil tab 500 mg (Ceftin)cephalexin cap 250 mg (Keflex)cephalexin cap 500 mg (Keflex)cephalexin for susp 125 mg/5mlcephalexin for susp 250 mg/5mlSUPRAX – cefixime cap 400 mgSUPRAX – cefixime chew tab 100 mgSUPRAX – cefixime chew tab 200 mgSUPRAX – cefixime for susp 100 mg/5mlSUPRAX – cefixime for susp 200 mg/5mlSUPRAX – cefixime for susp 500 mg/5mlMACROLIDESAZITHROMYCIN – azithromycin powd pack

for susp 1 gmazithromycin for susp 100 mg/5ml

(Zithromax)azithromycin for susp 200 mg/5ml

(Zithromax)azithromycin tab 250 mg (Zithromax)azithromycin tab 500 mg (Zithromax)azithromycin tab 600 mg (Zithromax)clarithromycin for susp 125 mg/5mlclarithromycin for susp 250 mg/5ml

(Biaxin)clarithromycin tab sr 24hr 500 mg (Biaxin

xl pac)clarithromycin tab 250 mg (Biaxin)clarithromycin tab 500 mg (Biaxin)E.E.S. 400 – erythromycin ethylsuccinate tab

400 mgERY-TAB – erythromycin tab delayed

release 250 mgERY-TAB – erythromycin tab delayed

release 333 mgERY-TAB – erythromycin tab delayed

release 500 mg

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

ERYTHROCIN STEARATE – erythromycinstearate tab 250 mg

ERYTHROMYCIN BASE – erythromycin tab250 mg

ERYTHROMYCIN BASE – erythromycin tab500 mg

erythromycin ethylsuccinate tab 400 mgerythromycin w/ delayed release particles

cap 250 mgTETRACYCLINESdemeclocycline hcl tab 150 mgdemeclocycline hcl tab 300 mgdoxycycline hyclate cap 50 mgdoxycycline hyclate cap 100 mg

(Vibramycin)doxycycline hyclate tab 20 mgdoxycycline hyclate tab 100 mgdoxycycline monohydrate cap 50 mgdoxycycline monohydrate cap 75 mg

(Monodox)doxycycline monohydrate cap 100 mg

(Monodox)doxycycline monohydrate cap 150 mg

(Adoxa)doxycycline monohydrate tab 50 mg



(Adoxa pak 1/100)doxycycline monohydrate tab 150 mg

(Adoxa pak 1/150)minocycline hcl cap 50 mg (Minocin)minocycline hcl cap 75 mg (Minocin)minocycline hcl cap 100 mg (Minocin)minocycline hcl tab 50 mgminocycline hcl tab 75 mgminocycline hcl tab 100 mg

2016


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Max

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Mon

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tetracycline hcl cap 250 mgtetracycline hcl cap 500 mgFLUOROQUINOLONESciprofloxacin for oral susp 250 mg/5ml

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

(10%) (10 gm/100ml) (Cipro)ciprofloxacin hcl tab 250 mg (base equiv)

(Cipro)ciprofloxacin hcl tab 500 mg (base equiv)

(Cipro)ciprofloxacin hcl tab 750 mg (base equiv)ciprofloxacin-ciprofloxacin hcl tab sr 24hr

500 mg (base eq) (Cipro xr)ciprofloxacin-ciprofloxacin hcl tab sr 24hr

1000 mg(base eq) (Cipro xr)levofloxacin oral soln 25 mg/ml (Levaquin)levofloxacin tab 250 mg (Levaquin)levofloxacin tab 500 mg (Levaquin)levofloxacin tab 750 mg (Levaquin)AMINOGLYCOSIDESneomycin sulfate tab 500 mgparomomycin sulfate cap 250 mgtobramycin nebu soln 300 mg/5ml (Tobi) •TUBERCULOSISethambutol hcl tab 100 mg (Myambutol)ethambutol hcl tab 400 mg (Myambutol)ISONIAZID – isoniazid syrup 50 mg/5mlisoniazid tab 100 mgisoniazid tab 300 mgPRIFTIN – rifapentine tab 150 mgpyrazinamide tab 500 mgrifabutin cap 150 mg (Mycobutin)rifampin cap 150 mg (Rifadin)rifampin cap 300 mg (Rifadin)FUNGAL INFECTIONS

Drug Name Spe

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ty

Max

imum

Mon

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Qua

ntity

fluconazole for susp 10 mg/ml (Diflucan)fluconazole for susp 40 mg/ml (Diflucan)fluconazole tab 50 mg (Diflucan)fluconazole tab 100 mg (Diflucan)fluconazole tab 150 mg (Diflucan)fluconazole tab 200 mg (Diflucan)flucytosine cap 250 mg (Ancobon)flucytosine cap 500 mg (Ancobon)griseofulvin microsize susp 125 mg/5mlgriseofulvin microsize tab 500 mg

(Grifulvin v)itraconazole cap 100 mg (Sporanox)LAMISIL – terbinafine hcl oral granules

packet 125 mgLAMISIL – terbinafine hcl oral granules

packet 187.5 mgNOXAFIL – posaconazole tab delayed

release 100 mgNOXAFIL – posaconazole susp 40 mg/mlnystatin tab 500000 unitSPORANOX – itraconazole oral soln 10 mg/

mlterbinafine hcl tab 250 mg (Lamisil)voriconazole for susp 40 mg/ml (Vfend)voriconazole tab 50 mg (Vfend)voriconazole tab 200 mg (Vfend)VIRAL INFECTIONSCytomegalovirusVALCYTE – valganciclovir hcl for soln 50

mg/ml (base equiv)valganciclovir hcl tab 450 mg (base

equivalent) (Valcyte)Hepatitisadefovir dipivoxil tab 10 mg (Hepsera)BARACLUDE – entecavir oral soln 0.05 mg/

ml

2016


Drug Name Spe

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ty

Max

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Mon

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Qua

ntity

DAKLINZA – daclatasvir dihydrochloride tab30 mg (base equivalent)

•

DAKLINZA – daclatasvir dihydrochloride tab60 mg (base equivalent)

•

entecavir tab 0.5 mg (Baraclude)entecavir tab 1 mg (Baraclude)EPIVIR HBV – lamivudine oral soln 5 mg/ml

(hbv)HARVONI – ledipasvir-sofosbuvir tab 90-400

mg•

lamivudine tab 100 mg (hbv) (Epivir hbv)PEGASYS – peginterferon alfa-2a inj 180

mcg/ml•

PEGASYS – peginterferon alfa-2a inj 180mcg/0.5ml

•

PEGASYS PROCLICK – peginterferonalfa-2a inj 135 mcg/0.5ml

•

PEGASYS PROCLICK – peginterferonalfa-2a inj 180 mcg/0.5ml

•

ribavirin cap 200 mg (Rebetol) •ribavirin tab 200 mg (Copegus) •SOVALDI – sofosbuvir tab 400 mg •Herpesacyclovir cap 200 mg (Zovirax)acyclovir susp 200 mg/5ml (Zovirax)acyclovir tab 400 mg (Zovirax)acyclovir tab 800 mg (Zovirax)famciclovir tab 125 mg (Famvir)famciclovir tab 250 mg (Famvir)famciclovir tab 500 mg (Famvir)valacyclovir hcl tab 500 mg (Valtrex)valacyclovir hcl tab 1 gm (Valtrex)HIV/AIDSabacavir sulfate tab 300 mg (base equiv)

(Ziagen)abacavir sulfate-lamivudine-zidovudine

tab 300-150-300 mg (Trizivir)

Drug Name Spe

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ty

Max

imum

Mon

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Qua

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APTIVUS – tipranavir cap 250 mgAPTIVUS – tipranavir oral soln 100 mg/mlATRIPLA – efavirenz-emtricitabine-tenofovir

df tab 600-200-300 mgCOMPLERA – emtricitabine-rilpivirine-

tenofovir df tab 200-25-300 mgCRIXIVAN – indinavir sulfate cap 200 mgCRIXIVAN – indinavir sulfate cap 400 mgdidanosine delayed release capsule

125 mg (Videx ec)didanosine delayed release capsule



400 mg (Videx ec)EDURANT – rilpivirine hcl tab 25 mg (base

equivalent)EMTRIVA – emtricitabine caps 200 mgEMTRIVA – emtricitabine soln 10 mg/mlEPZICOM – abacavir sulfate-lamivudine tab

600-300 mgEVOTAZ – atazanavir sulfate-cobicistat tab

300-150 mg (base equiv)FUZEON – enfuvirtide for inj 90 mg •INTELENCE – etravirine tab 25 mgINTELENCE – etravirine tab 100 mgINTELENCE – etravirine tab 200 mgINVIRASE – saquinavir mesylate cap 200

mgINVIRASE – saquinavir mesylate tab 500 mgISENTRESS – raltegravir potassium tab 400

mg (base equiv)ISENTRESS – raltegravir potassium packet

for susp 100 mg (base equiv)ISENTRESS – raltegravir potassium chew

tab 25 mg (base equiv)

2016


Drug Name Spe

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ty

Max

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Mon

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ISENTRESS – raltegravir potassium chewtab 100 mg (base equiv)

KALETRA – lopinavir-ritonavir soln 400-100mg/5ml (80-20 mg/ml)

KALETRA – lopinavir-ritonavir tab 100-25 mgKALETRA – lopinavir-ritonavir tab 200-50 mglamivudine oral soln 10 mg/ml (Epivir)lamivudine tab 150 mg (Epivir)lamivudine tab 300 mg (Epivir)lamivudine-zidovudine tab 150-300 mg

(Combivir)LEXIVA – fosamprenavir calcium tab 700 mg

(base equiv)LEXIVA – fosamprenavir calcium susp 50

mg/ml (base equiv)nevirapine tab sr 24hr 400 mg (Viramune

xr)nevirapine tab 200 mg (Viramune)NORVIR – ritonavir cap 100 mgNORVIR – ritonavir tab 100 mgNORVIR – ritonavir oral soln 80 mg/mlPREZCOBIX – darunavir-cobicistat tab

800-150 mgPREZISTA – darunavir ethanolate susp 100

mg/ml (base equiv)PREZISTA – darunavir ethanolate tab 75 mg

(base equiv)PREZISTA – darunavir ethanolate tab 150

mg (base equiv)PREZISTA – darunavir ethanolate tab 600

mg (base equiv)PREZISTA – darunavir ethanolate tab 800

mg (base equiv)RESCRIPTOR – delavirdine mesylate tab

100 mgRESCRIPTOR – delavirdine mesylate tab

200 mgREYATAZ – atazanavir sulfate oral powder

packet 50 mg (base equiv)

Drug Name Spe

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ty

Max

imum

Mon

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Qua

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REYATAZ – atazanavir sulfate cap 150 mg(base equiv)



SELZENTRY – maraviroc tab 150 mgSELZENTRY – maraviroc tab 300 mgstavudine cap 15 mg (Zerit)stavudine cap 20 mg (Zerit)stavudine cap 30 mg (Zerit)stavudine cap 40 mg (Zerit)stavudine for oral soln 1 mg/ml (Zerit)STRIBILD – elvitegrav-cobicis-emtricitab-

tenofov tab 150-150-200-300 mgSUSTIVA – efavirenz tab 600 mgSUSTIVA – efavirenz cap 50 mgSUSTIVA – efavirenz cap 200 mgTIVICAY – dolutegravir sodium tab 50 mg

(base equiv)TRIUMEQ – abacavir-dolutegravir-

lamivudine tab 600-50-300 mgTRUVADA – emtricitabine-tenofovir

disoproxil fumarate tab 200-300 mgTYBOST – cobicistat tab 150 mgVIDEX – didanosine for soln 2 gmVIDEX – didanosine for soln 4 gmVIRACEPT – nelfinavir mesylate tab 250 mgVIRACEPT – nelfinavir mesylate tab 625 mgVIRAMUNE – nevirapine susp 50 mg/5mlVIRAMUNE XR – nevirapine tab sr 24hr 100

mgVIREAD – tenofovir disoproxil fumarate oral

powder 40 mg/gmVIREAD – tenofovir disoproxil fumarate tab

150 mgVIREAD – tenofovir disoproxil fumarate tab

200 mg

2016


Drug Name Spe

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Max

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Mon

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VIREAD – tenofovir disoproxil fumarate tab250 mg

VIREAD – tenofovir disoproxil fumarate tab300 mg

VITEKTA – elvitegravir tab 85 mgVITEKTA – elvitegravir tab 150 mgZIAGEN – abacavir sulfate soln 20 mg/ml

(base equiv)zidovudine cap 100 mg (Retrovir)zidovudine syrup 10 mg/ml (Retrovir)zidovudine tab 300 mgInfluenzaTAMIFLU – oseltamivir phosphate for susp 6

mg/ml (base equiv)TAMIFLU – oseltamivir phosphate cap 30 mg

(base equiv)TAMIFLU – oseltamivir phosphate cap 45 mg

(base equiv)TAMIFLU – oseltamivir phosphate cap 75 mg

(base equiv)MALARIAatovaquone-proguanil hcl tab 62.5-25 mg

(Malarone)atovaquone-proguanil hcl tab 250-100 mg

(Malarone)chloroquine phosphate tab 250 mgchloroquine phosphate tab 500 mg

(Aralen)COARTEM – artemether-lumefantrine tab

20-120 mgDARAPRIM – pyrimethamine tab 25 mghydroxychloroquine sulfate tab 200 mg

(Plaquenil)mefloquine hcl tab 250 mgPRIMAQUINE PHOSPHATE – primaquine

phosphate tab 26.3 mg (15 mg base)WORM INFECTIONSALBENZA – albendazole tab 200 mg

Drug Name Spe

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ty

Max

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Mon

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BILTRICIDE – praziquantel tab 600 mgivermectin tab 3 mg (Stromectol)OTHER ANTI-INFECTIVESclindamycin hcl cap 75 mg (Cleocin)clindamycin hcl cap 150 mg (Cleocin)clindamycin hcl cap 300 mg (Cleocin)clindamycin palmitate hcl for soln

75 mg/5ml (base equiv) (Cleocin pediatricgr)

dapsone tab 100 mgdapsone tab 25 mglinezolid tab 600 mg (Zyvox)metronidazole tab 250 mg (Flagyl)metronidazole tab 500 mg (Flagyl)NEBUPENT – pentamidine isethionate for

nebulization soln 300 mgSIVEXTRO – tedizolid phosphate tab 200

mgsulfamethoxazole-trimethoprim susp

200-40 mg/5mlsulfamethoxazole-trimethoprim tab

400-80 mg (Bactrim)sulfamethoxazole-trimethoprim tab

800-160 mg (Bactrim ds)trimethoprim tab 100 mgvancomycin hcl cap 125 mg (Vancocin hcl)vancomycin hcl cap 250 mg (Vancocin hcl)XIFAXAN – rifaximin tab 550 mgZYVOX – linezolid for susp 100 mg/5mlIMMUNIZING AGENTSSYNAGIS – palivizumab im soln 50

mg/0.5ml•

SYNAGIS – palivizumab im soln 100 mg/ml •CANCER DRUGSACTIMMUNE – interferon gamma-1b inj 100

mcg/0.5ml (2000000 unit/0.5ml)•

AFINITOR – everolimus tab 2.5 mg •

2016


Drug Name Spe

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Mon

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AFINITOR – everolimus tab 5 mg •AFINITOR – everolimus tab 7.5 mg •AFINITOR – everolimus tab 10 mg •AFINITOR DISPERZ – everolimus tab for

oral susp 2 mg•

AFINITOR DISPERZ – everolimus tab fororal susp 3 mg

•

AFINITOR DISPERZ – everolimus tab fororal susp 5 mg

•

ALKERAN – melphalan tab 2 mganastrozole tab 1 mg (Arimidex)bexarotene cap 75 mg (Targretin) •bicalutamide tab 50 mg (Casodex)BOSULIF – bosutinib tab 100 mg •BOSULIF – bosutinib tab 500 mg •capecitabine tab 150 mg (Xeloda) •capecitabine tab 500 mg (Xeloda) •CAPRELSA – vandetanib tab 100 mg •CAPRELSA – vandetanib tab 300 mg •COMETRIQ – cabozantinib s-malate cap 3 x

20 mg (60 mg dose) kit•

COMETRIQ – cabozantinib s-mal cap 1 x 80mg & 1 x 20 mg (100 dose) kit

•

COMETRIQ – cabozantinib s-mal cap 1 x 80mg & 3 x 20 mg (140 dose) kit

•

CYCLOPHOSPHAMIDE –cyclophosphamide cap 25 mg

CYCLOPHOSPHAMIDE –cyclophosphamide cap 50 mg

EMCYT – estramustine phosphate sodiumcap 140 mg

ERIVEDGE – vismodegib cap 150 mg •etoposide cap 50 mgexemestane tab 25 mg (Aromasin)FARESTON – toremifene citrate tab 60 mg

(base equivalent)FARYDAK – panobinostat lactate cap 10 mg

(base equivalent)•

Drug Name Spe

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ty

Max

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Mon

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FARYDAK – panobinostat lactate cap 15 mg(base equivalent)

•

FARYDAK – panobinostat lactate cap 20 mg(base equivalent)

•

flutamide cap 125 mgGILOTRIF – afatinib dimaleate tab 20 mg


GILOTRIF – afatinib dimaleate tab 30 mg(base equivalent)

•

GILOTRIF – afatinib dimaleate tab 40 mg(base equivalent)

•

GLEEVEC – imatinib mesylate tab 100 mg(base equivalent)

•

GLEEVEC – imatinib mesylate tab 400 mg(base equivalent)

•

GLEOSTINE – lomustine cap 5 mgGLEOSTINE – lomustine cap 10 mgGLEOSTINE – lomustine cap 40 mgGLEOSTINE – lomustine cap 100 mgHEXALEN – altretamine cap 50 mg •HYCAMTIN – topotecan hcl cap 0.25 mg

(base equiv)•

HYCAMTIN – topotecan hcl cap 1 mg (baseequiv)

•

hydroxyurea cap 500 mg (Hydrea)IBRANCE – palbociclib cap 75 mgIBRANCE – palbociclib cap 100 mgIBRANCE – palbociclib cap 125 mgICLUSIG – ponatinib hcl tab 15 mg (base

equiv)•

ICLUSIG – ponatinib hcl tab 45 mg (baseequiv)

•

IMBRUVICA – ibrutinib cap 140 mg •INLYTA – axitinib tab 1 mg •INLYTA – axitinib tab 5 mg •IRESSA – gefitinib tab 250 mg •JAKAFI – ruxolitinib phosphate tab 5 mg


2016


Drug Name Spe

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Mon

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JAKAFI – ruxolitinib phosphate tab 10 mg(base equivalent)

•


•


•


•

LENVIMA 10MG DAILY DOSE – lenvatinibcap therapy pack 10 mg (10 mg dailydose)

•

LENVIMA 14MG DAILY DOSE – lenvatinibcap therapy pack 10 & 4 mg (14 mg dailydose)

•

LENVIMA 20MG DAILY DOSE – lenvatinibcap therapy pack 10 (2) mg (20 mg dailydose)

•

LENVIMA 24MG DAILY DOSE – lenvatinibcap therapy pack 10 (2) & 4 mg (24 mgdaily dose)

•

letrozole tab 2.5 mg (Femara)leucovorin calcium tab 10 mgleucovorin calcium tab 15 mgleucovorin calcium tab 5 mgleucovorin calcium tab 25 mgLEUKERAN – chlorambucil tab 2 mgLOMUSTINE – lomustine cap 10 mgLOMUSTINE – lomustine cap 40 mgLOMUSTINE – lomustine cap 100 mgLONSURF – trifluridine-tipiracil tab 15-6.14

mg•

LONSURF – trifluridine-tipiracil tab 20-8.19mg

•

LYNPARZA – olaparib cap 50 mgLYSODREN – mitotane tab 500 mg •MATULANE – procarbazine hcl cap 50 mg •megestrol acetate susp 40 mg/ml (Megace

oral)megestrol acetate tab 20 mg

Drug Name Spe

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ty

Max

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Mon

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megestrol acetate tab 40 mgMEKINIST – trametinib dimethyl sulfoxide

tab 0.5 mg (base equivalent)•

MEKINIST – trametinib dimethyl sulfoxidetab 2 mg (base equivalent)

•

mercaptopurine tab 50 mg (Purinethol)MESNEX – mesna tab 400 mgmethotrexate sodium tab 2.5 mg (base

equiv)MYLERAN – busulfan tab 2 mgNEXAVAR – sorafenib tosylate tab 200 mg


NILANDRON – nilutamide tab 150 mgODOMZO – sonidegib phosphate cap 200

mg (base equivalent)•

POMALYST – pomalidomide cap 1 mg •POMALYST – pomalidomide cap 2 mg •POMALYST – pomalidomide cap 3 mg •POMALYST – pomalidomide cap 4 mg •PURIXAN – mercaptopurine susp 2000

mg/100ml (20 mg/ml)SOLTAMOX – tamoxifen citrate oral soln 10

mg/5ml (base equivalent)SPRYCEL – dasatinib tab 20 mg •SPRYCEL – dasatinib tab 50 mg •SPRYCEL – dasatinib tab 70 mg •SPRYCEL – dasatinib tab 80 mg •SPRYCEL – dasatinib tab 100 mg •SPRYCEL – dasatinib tab 140 mg •STIVARGA – regorafenib tab 40 mg •SUTENT – sunitinib malate cap 12.5 mg


SUTENT – sunitinib malate cap 25 mg (baseequivalent)

•

SUTENT – sunitinib malate cap 37.5 mg(base equivalent)

•

SUTENT – sunitinib malate cap 50 mg (baseequivalent)

•

2016


Drug Name Spe

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Max

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ntity

SYLATRON – peginterferon alfa-2b for inj kit200 mcg

•


•


•

TABLOID – thioguanine tab 40 mgTAFINLAR – dabrafenib mesylate cap 50 mg


TAFINLAR – dabrafenib mesylate cap 75 mg(base equivalent)

•

tamoxifen citrate tab 10 mg (baseequivalent)

tamoxifen citrate tab 20 mg (baseequivalent)

TARCEVA – erlotinib hcl tab 25 mg (baseequivalent)

•


•


•

TASIGNA – nilotinib hcl cap 150 mg (baseequivalent)

•

TASIGNA – nilotinib hcl cap 200 mg (baseequivalent)

•

temozolomide cap 5 mg (Temodar) •temozolomide cap 20 mg (Temodar) •temozolomide cap 100 mg (Temodar) •temozolomide cap 140 mg (Temodar) •temozolomide cap 180 mg (Temodar) •temozolomide cap 250 mg (Temodar) •tretinoin cap 10 mg •TYKERB – lapatinib ditosylate tab 250 mg

(base equiv)•

VOTRIENT – pazopanib hcl tab 200 mg(base equiv)

•

XALKORI – crizotinib cap 200 mg •XALKORI – crizotinib cap 250 mg •

Drug Name Spe

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ty

Max

imum

Mon

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Qua

ntity

XTANDI – enzalutamide cap 40 mg •ZELBORAF – vemurafenib tab 240 mg •ZOLINZA – vorinostat cap 100 mg •ZYDELIG – idelalisib tab 100 mg •ZYDELIG – idelalisib tab 150 mg •ZYKADIA – ceritinib cap 150 mg •ZYTIGA – abiraterone acetate tab 250 mg •HORMONES, DIABETES AND RELATED DRUGSCORTICOSTEROIDSbudesonide cap sr 24hr 3 mg (Entocort ec)cortisone acetate tab 25 mgdexamethasone elixir 0.5 mg/5mlDEXAMETHASONE INTENSOL –

dexamethasone conc 1 mg/mldexamethasone soln 0.5 mg/5mldexamethasone tab 1 mgdexamethasone tab 2 mgdexamethasone tab 0.5 mgdexamethasone tab 0.75 mgdexamethasone tab 1.5 mgdexamethasone tab 4 mgdexamethasone tab 6 mgfludrocortisone acetate tab 0.1 mghydrocortisone tab 5 mg (Cortef)hydrocortisone tab 10 mg (Cortef)hydrocortisone tab 20 mg (Cortef)methylprednisolone tab 4 mg dose pack

(Medrol dosepak)methylprednisolone tab 4 mg (Medrol)methylprednisolone tab 8 mg (Medrol)methylprednisolone tab 16 mg (Medrol)methylprednisolone tab 32 mg (Medrol)MILLIPRED – prednisolone tab 5 mgprednisolone sod phosph oral soln

6.7 mg/5ml (5 mg/5ml base) (Pediapred)

2016


Drug Name Spe

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ty

Max

imum

Mon

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Qua

ntity

prednisolone sod phosphate oral soln15 mg/5ml (base equiv) (Orapred)

prednisolone syrup 15 mg/5ml (uspsolution equivalent) (Prelone)

PREDNISONE – prednisone tab 50 mgPREDNISONE – prednisone oral soln 5

mg/5mlprednisone tab 1 mgprednisone tab 2.5 mgprednisone tab 5 mgprednisone tab 10 mgprednisone tab 20 mgMALE HORMONESANDRODERM – testosterone td patch 24hr

2 mg/24hrANDRODERM – testosterone td patch 24hr

4 mg/24hrANDROGEL – testosterone td gel 20.25

mg/1.25gm (1.62%)ANDROGEL – testosterone td gel 40.5

mg/2.5gm (1.62%)ANDROGEL PUMP – testosterone td gel

20.25 mg/act (1.62%)ANDROXY – fluoxymesterone tab 10 mgdanazol cap 50 mgdanazol cap 100 mgdanazol cap 200 mgtestosterone cypionate im inj in oil

100 mg/ml (Depo-testosterone)testosterone cypionate im inj in oil

200 mg/ml (Depo-testosterone)testosterone enanthate im inj in oil

200 mg/mlESTROGENSCLIMARA PRO – estradiol-levonorgestrel td

patch weekly 0.045-0.015 mg/dayDIVIGEL – estradiol td gel 0.25 mg/0.25gm

(0.1%)

Drug Name Spe

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ty

Max

imum

Mon

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Qua

ntity

DIVIGEL – estradiol td gel 0.5 mg/0.5gm(0.1%)

DIVIGEL – estradiol td gel 1 mg/gm (0.1%)estradiol & norethindrone acetate tab

0.5-0.1 mg (Activella)estradiol & norethindrone acetate tab

1-0.5 mg (Activella)estradiol tab 0.5 mg (Estrace)estradiol tab 1 mg (Estrace)estradiol tab 2 mg (Estrace)estradiol td patch twice weekly

0.025 mg/24hr (Vivelle-dot)estradiol td patch twice weekly




0.1 mg/24hr (Vivelle-dot)estradiol td patch weekly 0.025 mg/24hr

(Climara)estradiol td patch weekly 0.0375 mg/24hr

(37.5 mcg/24hr) (Climara)estradiol td patch weekly 0.05 mg/24hr




(Climara)estropipate tab 0.75 mgestropipate tab 1.5 mgnorethindrone acetate-ethinyl estradiol

tab 0.5 mg-2.5 mcg (Femhrt low dose)norethindrone acetate-ethinyl estradiol

tab 1 mg-5 mcg

2016


Drug Name Spe

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ty

Max

imum

Mon

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Qua

ntity

PREMARIN – estrogens, conjugated tab 0.3mg

PREMARIN – estrogens, conjugated tab0.45 mg


PREMARIN – estrogens, conjugated tab 0.9mg


PREMPHASE – conj est 0.625(14)/conj est-medroxypro ac tab 0.625-5mg(14)

PREMPRO – conjugated estrogen-medroxyprogest acetate tab 0.3-1.5 mg



PREMPRO – conjugated estrogen-medroxyprogest acetate tab 0.625-5 mg

PROGESTINSmedroxyprogesterone acetate tab 2.5 mg

(Provera)medroxyprogesterone acetate tab 5 mg

(Provera)medroxyprogesterone acetate tab 10 mg

(Provera)norethindrone acetate tab 5 mg (Aygestin)progesterone micronized cap 100 mg

(Prometrium)progesterone micronized cap 200 mg

(Prometrium)BIRTH CONTROLdesogest-eth estrad & eth estrad tab

0.15-0.02/0.01 mg(21/5) (kimidess)desogest-ethin est tab

0.1-0.025/0.125-0.025/0.15-0.025mg-mg(Cyclessa)

desogestrel & ethinyl estradiol tab0.15 mg-30 mcg (Desogen)

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

drospirenone-ethinyl estradiol tab3-0.02 mg (Yaz)

drospirenone-ethinyl estradiol tab3-0.03 mg (Yasmin 28)

ELLA – ulipristal acetate tab 30 mgethynodiol diacetate & ethinyl estradiol

tab 1 mg-35 mcgFC FEMALE CONDOM – condoms - femaleFC2 FEMALE CONDOM – condoms -

femalelevonorg-eth est tab 0.1-0.02mg(84) & eth

est tab 0.01mg(7) (Loseasonique)levonorg-eth est tab 0.15-0.03mg(84) &

eth est tab 0.01mg(7) (Seasonique)levonorgestrel & ethinyl estradiol (91-

day) tab 0.15-0.03 mg (introvale, jolessa,quasense)

levonorgestrel & ethinyl estradiol tab0.1 mg-20 mcg (delyla)

levonorgestrel & ethinyl estradiol tab0.15 mg-30 mcg

levonorgestrel tab 1.5 mg (aftera, econtraez, fallback solo, my way, next choiceone dose, opcicon one-step, takeaction)

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

medroxyprogesterone acetate im susp150 mg/ml (Depo-provera contrac)

norethindrone & ethinyl estradiol tab0.4 mg-35 mcg (Ovcon-35)

norethindrone & ethinyl estradiol tab0.5 mg-35 mcg (Brevicon-28)

norethindrone & ethinyl estradiol tab1 mg-35 mcg (Norinyl 1+35)

norethindrone & ethinyl estradiol-fe chewtab 0.4 mg-35 mcg (Femcon fe)

norethindrone ac-ethinyl estrad-fe tab1-20/1-30/1-35 mg-mcg (Estrostep fe)

2016


Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

norethindrone ace & ethinyl estradiol tab1 mg-20 mcg (Loestrin 1/20-21)

norethindrone ace & ethinyl estradiol tab1.5 mg-30 mcg (Loestrin 1.5/30-21)

norethindrone ace & ethinyl estradiol-fetab 1 mg-20 mcg (Loestrin fe 1/20)

norethindrone ace & ethinyl estradiol-fetab 1.5 mg-30 mcg (Loestrin fe 1.5/30)

norethindrone tab 0.35 mg (deblitane,norlyroc, sharobel)

norethindrone-eth estradiol tab0.5-35/0.75-35/1-35 mg-mcg (Ortho-novum 7/7/7)

norethindrone-eth estradiol tab0.5-35/1-35/0.5-35 mg-mcg (Tri-norinyl 28)

norgestimate & ethinyl estradiol tab0.25 mg-35 mcg (Ortho-cyclen)

norgestimate-eth estrad tab0.18-35/0.215-35/0.25-35 mg-mcg (Orthotri-cyclen)

norgestrel & ethinyl estradiol tab0.3 mg-30 mcg

NUVARING – etonogestrel-ethinyl estradiolva ring 0.120-0.015 mg/24hr

XULANE – norelgestromin-ethinyl estradioltd ptwk 150-35 mcg/24hr

INFERTILITYCETROTIDE – cetrorelix acetate for inj kit

0.25 mg•

chorionic gonadotropin for inj 10000 unit •clomiphene citrate tab 50 mg (Clomid)GONAL-F – follitropin alfa for inj 450 unit •GONAL-F – follitropin alfa for inj 1050 unit •GONAL-F RFF – follitropin alfa for inj 75 unit •GONAL-F RFF PEN – follitropin alfa inj 300

unit/0.5ml•

GONAL-F RFF PEN – follitropin alfa inj 450unit/0.75ml

•

GONAL-F RFF PEN – follitropin alfa inj 900unit/1.5ml

•

Drug Name Spe

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ty

Max

imum

Mon

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Qua

ntity

GONAL-F RFF REDIJECT – follitropin alfainj 300 unit/0.5ml

•


•


•

REPRONEX – menotropins for inj 75 unit •DIABETESacarbose tab 25 mg (Precose)acarbose tab 50 mg (Precose)acarbose tab 100 mg (Precose)BYDUREON – exenatide extended release

for susp pen-injector 2 mgBYDUREON – exenatide extended release

for inj susp 2 mgBYETTA – exenatide soln pen-injector 5

mcg/0.02mlBYETTA – exenatide soln pen-injector 10

mcg/0.04mlglimepiride tab 1 mg (Amaryl)glimepiride tab 2 mg (Amaryl)glimepiride tab 4 mg (Amaryl)glipizide tab sr 24hr 2.5 mg (Glucotrol xl)glipizide tab sr 24hr 5 mg (Glucotrol xl)glipizide tab sr 24hr 10 mg (Glucotrol xl)glipizide tab 5 mg (Glucotrol)glipizide tab 10 mg (Glucotrol)glipizide-metformin hcl tab 2.5-250 mgglipizide-metformin hcl tab 2.5-500 mgglipizide-metformin hcl tab 5-500 mgGLUCAGON EMERGENCY KIT – glucagon

(rdna) for inj kit 1 mgglyburide micronized tab 1.5 mg (Glynase)glyburide micronized tab 3 mg (Glynase)glyburide micronized tab 6 mg (Glynase)glyburide tab 1.25 mgglyburide tab 2.5 mg

2016


Drug Name Spe

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ty

Max

imum

Mon

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Qua

ntity

glyburide tab 5 mgglyburide-metformin tab 1.25-250 mg

(Glucovance)glyburide-metformin tab 2.5-500 mg

(Glucovance)glyburide-metformin tab 5-500 mg

(Glucovance)INVOKAMET – canagliflozin-metformin hcl

tab 50-500 mgINVOKAMET – canagliflozin-metformin hcl



tab 150-1000 mgINVOKANA – canagliflozin tab 100 mgINVOKANA – canagliflozin tab 300 mgJANUMET – sitagliptin-metformin hcl tab

50-500 mgJANUMET – sitagliptin-metformin hcl tab

50-1000 mgJANUMET XR – sitagliptin-metformin hcl tab

sr 24hr 50-500 mgJANUMET XR – sitagliptin-metformin hcl tab

sr 24hr 50-1000 mgJANUMET XR – sitagliptin-metformin hcl tab

sr 24hr 100-1000 mgJANUVIA – sitagliptin phosphate tab 25 mg

(base equiv)JANUVIA – sitagliptin phosphate tab 50 mg

(base equiv)JANUVIA – sitagliptin phosphate tab 100 mg

(base equiv)JARDIANCE – empagliflozin tab 10 mgJARDIANCE – empagliflozin tab 25 mgKOMBIGLYZE XR – saxagliptin-metformin

hcl tab sr 24hr 2.5-1000 mgKOMBIGLYZE XR – saxagliptin-metformin

hcl tab sr 24hr 5-500 mg

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

KOMBIGLYZE XR – saxagliptin-metforminhcl tab sr 24hr 5-1000 mg

metformin hcl tab sr 24hr 500 mg(Glucophage xr)

metformin hcl tab sr 24hr 750 mg(Glucophage xr)

metformin hcl tab 500 mg (Glucophage)metformin hcl tab 850 mg (Glucophage)metformin hcl tab 1000 mg (Glucophage)nateglinide tab 60 mg (Starlix)nateglinide tab 120 mg (Starlix)ONGLYZA – saxagliptin hcl tab 2.5 mg (base

equiv)ONGLYZA – saxagliptin hcl tab 5 mg (base

equiv)pioglitazone hcl tab 15 mg (base equiv)

(Actos)pioglitazone hcl tab 30 mg (base equiv)

(Actos)pioglitazone hcl tab 45 mg (base equiv)

(Actos)pioglitazone hcl-metformin hcl tab

15-500 mg (Actoplus met)pioglitazone hcl-metformin hcl tab

15-850 mg (Actoplus met)repaglinide tab 0.5 mg (Prandin)repaglinide tab 1 mg (Prandin)repaglinide tab 2 mg (Prandin)VICTOZA – liraglutide soln pen-injector 18

mg/3ml (6 mg/ml)DIABETES - INSULINSRapid-Acting InsulinsNOVOLOG – insulin aspart inj 100 unit/mlNOVOLOG FLEXPEN – insulin aspart soln

pen-injector 100 unit/mlNOVOLOG PENFILL – insulin aspart soln

cartridge 100 unit/ml

2016


Drug Name Spe

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ty

Max

imum

Mon

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Qua

ntity

NOVOLOG PENFILL – insulin aspart inj 100unit/ml

Short-Acting InsulinsHUMULIN R U-500 (CONCENTR – insulin

regular (human) inj 500 unit/mlNOVOLIN R – insulin regular (human) inj

100 unit/mlIntermediate-Acting InsulinsNOVOLIN N – insulin nph (human)

(isophane) inj 100 unit/mlNOVOLIN 70/30 – insulin nph isophane &

regular human inj 100 unit/ml (70-30)NOVOLOG MIX 70/30 – insulin aspart prot &

aspart (human) inj 100 unit/ml (70-30)NOVOLOG MIX 70/30 PREFILL – insulin

aspart prot & aspart sus pen-inj 100 unit/ml(70-30)

Basal InsulinsLANTUS – insulin glargine inj 100 unit/mlLANTUS SOLOSTAR – insulin glargine soln

pen-injector 100 unit/mlLEVEMIR – insulin detemir inj 100 unit/mlLEVEMIR FLEXPEN – insulin detemir soln

pen-injector 100 unit/mlLEVEMIR FLEXTOUCH – insulin detemir

soln pen-injector 100 unit/mlTOUJEO SOLOSTAR – insulin glargine soln

pen-injector 300 unit/mlTHYROID REGULATIONlevothyroxine sodium tab 25 mcg

(Synthroid)levothyroxine sodium tab 50 mcg




(Synthroid)

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

levothyroxine sodium tab 112 mcg(Synthroid)







liothyronine sodium tab 5 mcg (Cytomel)liothyronine sodium tab 25 mcg (Cytomel)liothyronine sodium tab 50 mcg (Cytomel)methimazole tab 5 mg (Tapazole)methimazole tab 10 mg (Tapazole)propylthiouracil tab 50 mgGROWTH HORMONEINCRELEX – mecasermin inj 40 mg/4ml (10

mg/ml)•

OMNITROPE – somatropin for inj 5.8 mg •OMNITROPE – somatropin inj 5 mg/1.5ml •OMNITROPE – somatropin inj 10 mg/1.5ml •OTHER HORMONES AND RELATED DRUGSalendronate sodium tab 5 mgalendronate sodium tab 10 mgalendronate sodium tab 35 mgalendronate sodium tab 70 mg (Fosamax)cabergoline tab 0.5 mgcalcitonin (salmon) nasal soln 200 unit/

act (Miacalcin)calcitriol cap 0.25 mcg (Rocaltrol)calcitriol cap 0.5 mcg (Rocaltrol)calcitriol oral soln 1 mcg/ml (Rocaltrol)

2016


Drug Name Spe

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ty

Max

imum

Mon

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Qua

ntity

desmopressin acetate nasal soln 0.01%(refrigerated) (Ddavp)

desmopressin acetate nasal spray soln0.01% (Ddavp)

desmopressin acetate nasal spray soln0.01% (refrigerated)

desmopressin acetate tab 0.1 mg (Ddavp)desmopressin acetate tab 0.2 mg (Ddavp)FABRAZYME – agalsidase beta for iv soln 5

mg•

FABRAZYME – agalsidase beta for iv soln35 mg

•

ibandronate sodium tab 150 mg (baseequivalent) (Boniva)

levocarnitine oral soln 1 gm/10ml (10%)(Carnitor)

levocarnitine tab 330 mg (Carnitor)methylergonovine maleate tab 0.2 mgoctreotide acetate inj 50 mcg/ml (0.05 mg/

ml) (Sandostatin)•

octreotide acetate inj 100 mcg/ml (0.1 mg/ml) (Sandostatin)

•


•


•

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

•

ORFADIN – nitisinone cap 2 mg •ORFADIN – nitisinone cap 5 mg •ORFADIN – nitisinone cap 10 mg •paricalcitol cap 1 mcg (Zemplar)paricalcitol cap 2 mcg (Zemplar)paricalcitol cap 4 mcg (Zemplar)PROLIA – denosumab inj 60 mg/mlraloxifene hcl tab 60 mg (Evista)risedronate sodium tab 5 mg (Actonel)risedronate sodium tab 30 mg (Actonel)

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

risedronate sodium tab 35 mg (Actonel)risedronate sodium tab 150 mg (Actonel)SANDOSTATIN LAR DEPOT – octreotide

acetate for im inj kit 10 mg•

SANDOSTATIN LAR DEPOT – octreotideacetate for im inj kit 20 mg

•

SANDOSTATIN LAR DEPOT – octreotideacetate for im inj kit 30 mg

•

SENSIPAR – cinacalcet hcl tab 30 mg (baseequiv)



HEART AND CIRCULATORY DRUGSANGIOTENSIN CONVERTING ENZYME (ACE)INHIBITORS AND COMBINATIONSbenazepril & hydrochlorothiazide tab

5-6.25 mgbenazepril & hydrochlorothiazide tab

10-12.5 mg (Lotensin hct)benazepril & hydrochlorothiazide tab

20-12.5 mg (Lotensin hct)benazepril & hydrochlorothiazide tab

20-25 mg (Lotensin hct)benazepril hcl tab 5 mgbenazepril hcl tab 10 mg (Lotensin)benazepril hcl tab 20 mg (Lotensin)benazepril hcl tab 40 mg (Lotensin)captopril & hydrochlorothiazide tab 25-15 mgcaptopril & hydrochlorothiazide tab 50-15 mgcaptopril tab 12.5 mgcaptopril tab 25 mgcaptopril tab 50 mgcaptopril tab 100 mgenalapril maleate & hydrochlorothiazide

tab 5-12.5 mg

2016


Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

enalapril maleate & hydrochlorothiazidetab 10-25 mg (Vaseretic)

enalapril maleate tab 2.5 mg (Vasotec)enalapril maleate tab 5 mg (Vasotec)enalapril maleate tab 10 mg (Vasotec)enalapril maleate tab 20 mg (Vasotec)fosinopril sodium & hydrochlorothiazide

tab 10-12.5 mgfosinopril sodium & hydrochlorothiazide

tab 20-12.5 mgfosinopril sodium tab 10 mgfosinopril sodium tab 20 mgfosinopril sodium tab 40 mglisinopril & hydrochlorothiazide tab

10-12.5 mg (Zestoretic)lisinopril & hydrochlorothiazide tab

20-12.5 mg (Zestoretic)lisinopril & hydrochlorothiazide tab

20-25 mg (Zestoretic)lisinopril tab 2.5 mg (Zestril)lisinopril tab 5 mg (Prinivil)lisinopril tab 10 mg (Prinivil)lisinopril tab 20 mg (Prinivil)lisinopril tab 30 mg (Zestril)lisinopril tab 40 mg (Zestril)moexipril hcl tab 7.5 mg (Univasc)moexipril hcl tab 15 mg (Univasc)moexipril-hydrochlorothiazide tab

7.5-12.5 mg (Uniretic)moexipril-hydrochlorothiazide tab

15-12.5 mg (Uniretic)moexipril-hydrochlorothiazide tab

15-25 mgperindopril erbumine tab 2 mgperindopril erbumine tab 4 mg (Aceon)perindopril erbumine tab 8 mg (Aceon)quinapril hcl tab 5 mg (Accupril)

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

quinapril hcl tab 10 mg (Accupril)quinapril hcl tab 20 mg (Accupril)quinapril hcl tab 40 mg (Accupril)quinapril-hydrochlorothiazide tab

10-12.5 mg (Accuretic)quinapril-hydrochlorothiazide tab

20-12.5 mg (Accuretic)quinapril-hydrochlorothiazide tab

20-25 mg (Accuretic)ramipril cap 1.25 mg (Altace)ramipril cap 2.5 mg (Altace)ramipril cap 5 mg (Altace)ramipril cap 10 mg (Altace)trandolapril tab 1 mg (Mavik)trandolapril tab 2 mg (Mavik)trandolapril tab 4 mg (Mavik)ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS)AND COMBINATIONSamlodipine-valsartan-hydrochlorothiazide

tab 5-160-12.5 mg (Exforge hct)amlodipine-valsartan-hydrochlorothiazide

tab 5-160-25 mg (Exforge hct)amlodipine-valsartan-hydrochlorothiazide

tab 10-160-12.5 mg (Exforge hct)amlodipine-valsartan-hydrochlorothiazide

tab 10-160-25 mg (Exforge hct)amlodipine-valsartan-hydrochlorothiazide

tab 10-320-25 mg (Exforge hct)BENICAR – olmesartan medoxomil tab 5 mgBENICAR – olmesartan medoxomil tab 20

mgBENICAR – olmesartan medoxomil tab 40

mgBENICAR HCT – olmesartan medoxomil-

hydrochlorothiazide tab 20-12.5 mgBENICAR HCT – olmesartan medoxomil-

hydrochlorothiazide tab 40-12.5 mg

2016


Drug Name Spe

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ty

Max

imum

Mon

thly

Qua

ntity

BENICAR HCT – olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg

candesartan cilexetil tab 4 mg (Atacand)candesartan cilexetil tab 8 mg (Atacand)candesartan cilexetil tab 16 mg (Atacand)candesartan cilexetil tab 32 mg (Atacand)candesartan cilexetil-hydrochlorothiazide

tab 16-12.5 mg (Atacand hct)candesartan cilexetil-hydrochlorothiazide

tab 32-12.5 mg (Atacand hct)candesartan cilexetil-hydrochlorothiazide

tab 32-25 mg (Atacand hct)irbesartan tab 75 mg (Avapro)irbesartan tab 150 mg (Avapro)irbesartan tab 300 mg (Avapro)irbesartan-hydrochlorothiazide tab

150-12.5 mg (Avalide)irbesartan-hydrochlorothiazide tab

300-12.5 mg (Avalide)losartan potassium & hydrochlorothiazide

tab 50-12.5 mg (Hyzaar)losartan potassium & hydrochlorothiazide

tab 100-12.5 mg (Hyzaar)losartan potassium & hydrochlorothiazide

tab 100-25 mg (Hyzaar)losartan potassium tab 25 mg (Cozaar)losartan potassium tab 50 mg (Cozaar)losartan potassium tab 100 mg (Cozaar)telmisartan tab 20 mg (Micardis)telmisartan tab 40 mg (Micardis)telmisartan tab 80 mg (Micardis)telmisartan-hydrochlorothiazide tab

40-12.5 mg (Micardis hct)telmisartan-hydrochlorothiazide tab

80-12.5 mg (Micardis hct)telmisartan-hydrochlorothiazide tab

80-25 mg (Micardis hct)valsartan tab 40 mg (Diovan)

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

valsartan tab 80 mg (Diovan)valsartan tab 160 mg (Diovan)valsartan tab 320 mg (Diovan)valsartan-hydrochlorothiazide tab

80-12.5 mg (Diovan hct)valsartan-hydrochlorothiazide tab


160-25 mg (Diovan hct)valsartan-hydrochlorothiazide tab


320-25 mg (Diovan hct)BETA BLOCKERS AND COMBINATIONSacebutolol hcl cap 200 mg (Sectral)acebutolol hcl cap 400 mg (Sectral)atenolol & chlorthalidone tab 50-25 mg

(Tenoretic 50)atenolol & chlorthalidone tab 100-25 mg

(Tenoretic 100)atenolol tab 25 mg (Tenormin)atenolol tab 50 mg (Tenormin)atenolol tab 100 mg (Tenormin)bisoprolol & hydrochlorothiazide tab

2.5-6.25 mg (Ziac)bisoprolol & hydrochlorothiazide tab

5-6.25 mg (Ziac)bisoprolol & hydrochlorothiazide tab

10-6.25 mg (Ziac)bisoprolol fumarate tab 5 mg (Zebeta)bisoprolol fumarate tab 10 mg (Zebeta)carvedilol tab 3.125 mg (Coreg)carvedilol tab 6.25 mg (Coreg)carvedilol tab 12.5 mg (Coreg)carvedilol tab 25 mg (Coreg)DUTOPROL – metoprolol &

hydrochlorothiazide tab sr 24hr 25-12.5 mg

2016


Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

DUTOPROL – metoprolol &hydrochlorothiazide tab sr 24hr 50-12.5 mg

DUTOPROL – metoprolol &hydrochlorothiazide tab sr 24hr 100-12.5mg

labetalol hcl tab 100 mg (Trandate)labetalol hcl tab 200 mg (Trandate)labetalol hcl tab 300 mg (Trandate)metoprolol succinate tab sr 24hr 25 mg

(Toprol xl)metoprolol succinate tab sr 24hr 50 mg



(Toprol xl)metoprolol tartrate tab 25 mgmetoprolol tartrate tab 50 mg (Lopressor)metoprolol tartrate tab 100 mg (Lopressor)nadolol tab 20 mg (Corgard)nadolol tab 40 mg (Corgard)nadolol tab 80 mg (Corgard)pindolol tab 5 mgpindolol tab 10 mgpropranolol & hydrochlorothiazide tab

40-25 mgpropranolol & hydrochlorothiazide tab

80-25 mgPROPRANOLOL HCL – propranolol hcl oral

soln 20 mg/5mlPROPRANOLOL HCL – propranolol hcl oral

soln 40 mg/5mlpropranolol hcl cap sr 24hr 60 mg (Inderal

la)propranolol hcl cap sr 24hr 80 mg (Inderal

la)propranolol hcl cap sr 24hr 120 mg

(Inderal la)

Drug Name Spe

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ty

Max

imum

Mon

thly

Qua

ntity

propranolol hcl cap sr 24hr 160 mg(Inderal la)

propranolol hcl tab 10 mgpropranolol hcl tab 20 mgpropranolol hcl tab 40 mgpropranolol hcl tab 60 mgpropranolol hcl tab 80 mgtimolol maleate tab 10 mgtimolol maleate tab 20 mgtimolol maleate tab 5 mgCALCIUM CHANNEL BLOCKERS ANDCOMBINATIONSamlodipine besylate tab 2.5 mg (Norvasc)amlodipine besylate tab 5 mg (Norvasc)amlodipine besylate tab 10 mg (Norvasc)amlodipine besylate-benazepril hcl cap

2.5-10 mg (Lotrel)amlodipine besylate-benazepril hcl cap

5-10 mg (Lotrel)amlodipine besylate-benazepril hcl cap




10-40 mg (Lotrel)amlodipine besylate-valsartan tab

5-160 mg (Exforge)amlodipine besylate-valsartan tab



10-320 mg (Exforge)diltiazem hcl cap sr 24hr 120 mgdiltiazem hcl cap sr 24hr 180 mg

2016


Drug Name Spe

cial

ty

Max

imum

Mon

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Qua

ntity

diltiazem hcl cap sr 24hr 240 mg (Dilacorxr)

diltiazem hcl coated beads cap sr 24hr120 mg (Cardizem cd)





diltiazem hcl extended release beads capsr 24hr 120 mg (Tiazac)






diltiazem hcl tab 30 mg (Cardizem)diltiazem hcl tab 60 mg (Cardizem)diltiazem hcl tab 90 mgdiltiazem hcl tab 120 mg (Cardizem)felodipine tab sr 24hr 2.5 mgfelodipine tab sr 24hr 5 mgfelodipine tab sr 24hr 10 mgnifedipine tab sr 24hr 30 mg (Adalat cc)nifedipine tab sr 24hr 60 mg (Adalat cc)nifedipine tab sr 24hr 90 mg (Adalat cc)nifedipine tab sr 24hr osmotic release

30 mg (Procardia xl)nifedipine tab sr 24hr osmotic release

60 mg (Procardia xl)

Drug Name Spe

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ty

Max

imum

Mon

thly

Qua

ntity

nifedipine tab sr 24hr osmotic release90 mg (Procardia xl)

verapamil hcl cap sr 24hr 120 mg(Verelan)




verapamil hcl tab cr 120 mg (Calan sr)verapamil hcl tab cr 180 mg (Calan sr)verapamil hcl tab cr 240 mg (Calan sr)verapamil hcl tab 80 mg (Calan)verapamil hcl tab 120 mg (Calan)CHEST PAIN (ANGINA)isosorbide dinitrate tab 5 mg (Isordil

titradose)isosorbide dinitrate tab 10 mgisosorbide dinitrate tab 20 mgisosorbide mononitrate tab sr 24hr 30 mg

(Imdur)isosorbide mononitrate tab sr 24hr 60 mg

(Imdur)isosorbide mononitrate tab sr 24hr

120 mg (Imdur)isosorbide mononitrate tab 10 mgisosorbide mononitrate tab 20 mgNITRO-BID – nitroglycerin oint 2%nitroglycerin td patch 24hr 0.1 mg/hr

(Nitro-dur)nitroglycerin td patch 24hr 0.2 mg/hr



(Nitro-dur)NITROSTAT – nitroglycerin sl tab 0.3 mg

2016


Drug Name Spe

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ty

Max

imum

Mon

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Qua

ntity

NITROSTAT – nitroglycerin sl tab 0.4 mgNITROSTAT – nitroglycerin sl tab 0.6 mgCHOLESTEROL LOWERINGatorvastatin calcium tab 10 mg (base

equivalent) (Lipitor)atorvastatin calcium tab 20 mg (base



equivalent) (Lipitor)cholestyramine light powder packets

4 gmcholestyramine light powder 4 gm/dose

(Questran light)cholestyramine powder packets 4 gm

(Questran)cholestyramine powder 4 gm/dose

(Questran)choline fenofibrate cap dr 45 mg

(fenofibric acid equiv) (Trilipix)choline fenofibrate cap dr 135 mg

(fenofibric acid equiv) (Trilipix)colestipol hcl granule packets 5 gm

(Colestid flavored)colestipol hcl granules 5 gm (Colestid

flavored)colestipol hcl tab 1 gm (Colestid)CRESTOR – rosuvastatin calcium tab 5 mgCRESTOR – rosuvastatin calcium tab 10 mgCRESTOR – rosuvastatin calcium tab 20 mgCRESTOR – rosuvastatin calcium tab 40 mgfenofibrate micronized cap 67 mg (Lofibra)fenofibrate micronized cap 134 mg

(Lofibra)fenofibrate micronized cap 200 mg

(Lofibra)fenofibrate tab 48 mg (Tricor)

Drug Name Spe

cial

ty

Max

imum

Mon

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Qua

ntity

fenofibrate tab 54 mg (Lofibra)fenofibrate tab 145 mg (Tricor)fenofibrate tab 160 mg (Lofibra)gemfibrozil tab 600 mg (Lopid)lovastatin tab 10 mglovastatin tab 20 mg (Mevacor)lovastatin tab 40 mg (Mevacor)niacin tab cr 500 mg (antihyperlipidemic)

(Niaspan)niacin tab cr 750 mg (antihyperlipidemic)

(Niaspan)niacin tab cr 1000 mg (antihyperlipidemic)

(Niaspan)pravastatin sodium tab 10 mgpravastatin sodium tab 20 mg (Pravachol)pravastatin sodium tab 40 mg (Pravachol)pravastatin sodium tab 80 mg (Pravachol)simvastatin tab 5 mg (Zocor)simvastatin tab 10 mg (Zocor)simvastatin tab 20 mg (Zocor)simvastatin tab 40 mg (Zocor)simvastatin tab 80 mg (Zocor)WELCHOL – colesevelam hcl tab 625 mgWELCHOL – colesevelam hcl packet for

susp 3.75 gmFLUID RETENTIONacetazolamide cap sr 12hr 500 mg

(Diamox)acetazolamide tab 250 mgamiloride & hydrochlorothiazide tab

5-50 mgamiloride hcl tab 5 mgbumetanide tab 0.5 mgbumetanide tab 1 mgbumetanide tab 2 mgchlorothiazide tab 500 mg

2016


Drug Name Spe

cial

ty

Max

imum

Mon

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Qua

ntity

furosemide oral soln 10 mg/mlfurosemide tab 20 mg (Lasix)furosemide tab 40 mg (Lasix)furosemide tab 80 mg (Lasix)hydrochlorothiazide cap 12.5 mg

(Microzide)hydrochlorothiazide tab 12.5 mghydrochlorothiazide tab 25 mghydrochlorothiazide tab 50 mgindapamide tab 1.25 mgindapamide tab 2.5 mgmethazolamide tab 25 mg (Neptazane)methazolamide tab 50 mg (Neptazane)metolazone tab 2.5 mg (Zaroxolyn)metolazone tab 5 mg (Zaroxolyn)metolazone tab 10 mgspironolactone & hydrochlorothiazide tab

25-25 mg (Aldactazide)spironolactone tab 25 mg (Aldactone)spironolactone tab 50 mg (Aldactone)spironolactone tab 100 mg (Aldactone)torsemide tab 5 mg (Demadex)torsemide tab 10 mg (Demadex)torsemide tab 20 mg (Demadex)torsemide tab 100 mg (Demadex)triamterene & hydrochlorothiazide cap

37.5-25 mg (Dyazide)triamterene & hydrochlorothiazide tab

37.5-25 mg (Maxzide-25)triamterene & hydrochlorothiazide tab

75-50 mg (Maxzide)HEART RHYTHMamiodarone hcl tab 100 mgamiodarone hcl tab 200 mg (Cordarone)amiodarone hcl tab 400 mg

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

disopyramide phosphate cap 100 mg(Norpace)

disopyramide phosphate cap 150 mg(Norpace)

flecainide acetate tab 50 mgflecainide acetate tab 100 mgflecainide acetate tab 150 mgmexiletine hcl cap 150 mgmexiletine hcl cap 200 mgmexiletine hcl cap 250 mgMULTAQ – dronedarone hcl tab 400 mg

(base equivalent)propafenone hcl cap sr 12hr 225 mg

(Rythmol sr)propafenone hcl cap sr 12hr 325 mg

(Rythmol sr)propafenone hcl cap sr 12hr 425 mg

(Rythmol sr)propafenone hcl tab 150 mg (Rythmol)propafenone hcl tab 225 mg (Rythmol)propafenone hcl tab 300 mgquinidine gluconate tab cr 324 mgQUINIDINE SULFATE ER – quinidine sulfate

tab cr 300 mgquinidine sulfate tab 300 mgsotalol hcl (afib/afl) tab 80 mg (Betapace

af)sotalol hcl (afib/afl) tab 120 mg (Betapace

af)sotalol hcl (afib/afl) tab 160 mg (Betapace

af)sotalol hcl tab 80 mg (Betapace)sotalol hcl tab 120 mg (Betapace)sotalol hcl tab 160 mg (Betapace)sotalol hcl tab 240 mgOTHER HEART RELATED DRUGSADCIRCA – tadalafil tab 20 mg (pah) •

2016


Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

amlodipine besylate-atorvastatin calciumtab 2.5-10 mg (Caduet)



amlodipine besylate-atorvastatin calciumtab 5-10 mg (Caduet)








clonidine hcl tab 0.1 mg (Catapres)clonidine hcl tab 0.2 mg (Catapres)clonidine hcl tab 0.3 mg (Catapres)clonidine hcl td patch weekly 0.1 mg/24hr

(Catapres-tts-1)clonidine hcl td patch weekly 0.2 mg/24hr

(Catapres-tts-2)clonidine hcl td patch weekly 0.3 mg/24hr

(Catapres-tts-3)digoxin oral soln 0.05 mg/mldigoxin tab 125 mcg (0.125 mg) (Lanoxin)digoxin tab 250 mcg (0.25 mg) (Lanoxin)doxazosin mesylate tab 1 mg (Cardura)doxazosin mesylate tab 2 mg (Cardura)doxazosin mesylate tab 4 mg (Cardura)doxazosin mesylate tab 8 mg (Cardura)

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

eplerenone tab 25 mg (Inspra)eplerenone tab 50 mg (Inspra)guanfacine hcl tab 1 mg (Tenex)guanfacine hcl tab 2 mg (Tenex)hydralazine hcl tab 10 mghydralazine hcl tab 25 mghydralazine hcl tab 50 mghydralazine hcl tab 100 mgLETAIRIS – ambrisentan tab 5 mg •LETAIRIS – ambrisentan tab 10 mg •methyldopa tab 250 mgmethyldopa tab 500 mgmidodrine hcl tab 2.5 mgmidodrine hcl tab 5 mgmidodrine hcl tab 10 mgminoxidil tab 2.5 mgminoxidil tab 10 mgOPSUMIT – macitentan tab 10 mg •phenoxybenzamine hcl cap 10 mg

(Dibenzyline)prazosin hcl cap 1 mg (Minipress)prazosin hcl cap 2 mg (Minipress)prazosin hcl cap 5 mg (Minipress)sildenafil citrate tab 20 mg (Revatio) •terazosin hcl cap 1 mgterazosin hcl cap 2 mgterazosin hcl cap 5 mgterazosin hcl cap 10 mgTRACLEER – bosentan tab 62.5 mg •TRACLEER – bosentan tab 125 mg •ERECTILE DYSFUNCTIONCIALIS – tadalafil tab 2.5 mgCIALIS – tadalafil tab 5 mgCIALIS – tadalafil tab 10 mgCIALIS – tadalafil tab 20 mg

2016


Drug Name Spe

cial

ty

Max

imum

Mon

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Qua

ntity

BEE STING KITSEPIPEN 2-PAK – epinephrine solution auto-

injector 0.3 mg/0.3ml (1:1000)EPIPEN-JR 2-PAK – epinephrine solution

auto-injector 0.15 mg/0.3ml (1:2000)RESPIRATORY AGENTSANTIHISTAMINEScetirizine hcl oral soln 1 mg/ml (5 mg/5ml)cyproheptadine hcl syrup 2 mg/5mlcyproheptadine hcl tab 4 mgdesloratadine tab orally disintegrating

2.5 mg (Clarinex reditabs)desloratadine tab orally disintegrating

5 mg (Clarinex reditabs)desloratadine tab 5 mg (Clarinex)levocetirizine dihydrochloride soln

2.5 mg/5ml (0.5 mg/ml) (Xyzal)levocetirizine dihydrochloride tab 5 mg

(Xyzal)promethazine hcl suppos 12.5 mgpromethazine hcl suppos 25 mgpromethazine hcl suppos 50 mgpromethazine hcl syrup 6.25 mg/5mlpromethazine hcl tab 12.5 mgpromethazine hcl tab 25 mgpromethazine hcl tab 50 mgNASAL PRODUCTSASTEPRO – azelastine hcl nasal spray

0.15% (205.5 mcg/spray)azelastine hcl nasal spray 0.1% (137 mcg/

spray)azelastine hcl nasal spray 0.15%

(205.5 mcg/spray) (Astepro)BACTROBAN NASAL – mupirocin calcium

nasal oint 2%flunisolide nasal soln 25 mcg/act (0.025%)

(Flunisolide)

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

fluticasone propionate nasal susp50 mcg/act (Flonase)

ipratropium bromide nasal soln 0.03%(21 mcg/spray) (Atrovent)

ipratropium bromide nasal soln 0.06%(42 mcg/spray) (Atrovent)

NASONEX – mometasone furoate nasalsusp 50 mcg/act

triamcinolone acetonide nasal aerosolsuspension 55 mcg/act (Nasacort aq)

COUGH/COLD/ALLERGYacetylcysteine inhal soln 10%acetylcysteine inhal soln 20%SSKI – potassium iodide soln 1 gm/mlASTHMA/COPDADVAIR DISKUS – fluticasone-salmeterol

aer powder ba 100-50 mcg/doseADVAIR DISKUS – fluticasone-salmeterol

aer powder ba 250-50 mcg/doseADVAIR DISKUS – fluticasone-salmeterol

aer powder ba 500-50 mcg/doseADVAIR HFA – fluticasone-salmeterol inhal

aerosol 45-21 mcg/actADVAIR HFA – fluticasone-salmeterol inhal

aerosol 115-21 mcg/actADVAIR HFA – fluticasone-salmeterol inhal

aerosol 230-21 mcg/actalbuterol sulfate soln nebu 0.083%

(2.5 mg/3ml)albuterol sulfate soln nebu 0.5% (5 mg/ml)albuterol sulfate soln nebu 0.63 mg/3ml

(base equiv)albuterol sulfate soln nebu 1.25 mg/3ml

(base equiv)albuterol sulfate syrup 2 mg/5mlalbuterol sulfate tab 2 mgalbuterol sulfate tab 4 mgANORO ELLIPTA – umeclidinium-vilanterol

aero powd ba 62.5-25 mcg/inh

2016


Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

ARNUITY ELLIPTA – fluticasone furoateaerosol powder breath activ 100 mcg/act

ARNUITY ELLIPTA – fluticasone furoateaerosol powder breath activ 200 mcg/act

ASMANEX HFA – mometasone furoate inhalaerosol suspension 100 mcg/act

ASMANEX HFA – mometasone furoate inhalaerosol suspension 200 mcg/act

ASMANEX TWISTHALER 120 ME –mometasone furoate inhal powd 220 mcg/inh (breath activated)

ASMANEX TWISTHALER 14 MET –mometasone furoate inhal powd 220 mcg/inh (breath activated)




ATROVENT HFA – ipratropium bromide hfainhal aerosol 17 mcg/act

BREO ELLIPTA – fluticasone furoate-vilanterol aero powd ba 100-25 mcg/inh

BREO ELLIPTA – fluticasone furoate-vilanterol aero powd ba 200-25 mcg/inh

budesonide inhalation susp 0.25 mg/2ml(Pulmicort)

budesonide inhalation susp 0.5 mg/2ml(Pulmicort)

budesonide inhalation susp 1 mg/2ml(Pulmicort)

COMBIVENT RESPIMAT – ipratropium-albuterol inhal aerosol soln 20-100 mcg/act

DULERA – mometasone furoate-formoterolfumarate aerosol 100-5 mcg/act

DULERA – mometasone furoate-formoterolfumarate aerosol 200-5 mcg/act

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

FLOVENT DISKUS – fluticasone propionateaer pow ba 50 mcg/blister



FLOVENT HFA – fluticasone propionate hfainhal aero 44 mcg/act (50/valve)

FLOVENT HFA – fluticasone propionate hfainhal aer 110 mcg/act (125/valve)

FLOVENT HFA – fluticasone propionate hfainhal aer 220 mcg/act (250/valve)

FORADIL AEROLIZER – formoterolfumarate inhal cap 12 mcg

INCRUSE ELLIPTA – umeclidinium br aeropowd breath act 62.5 mcg/inh (base eq)

ipratropium bromide inhal soln 0.02%ipratropium-albuterol nebu soln

0.5-2.5(3) mg/3ml (Duoneb)levalbuterol hcl soln nebu 0.31 mg/3ml

(base equiv) (Xopenex)levalbuterol hcl soln nebu 0.63 mg/3ml

(base equiv) (Xopenex)levalbuterol hcl soln nebu 1.25 mg/3ml

(base equiv) (Xopenex)montelukast sodium chew tab 4 mg (base

equiv) (Singulair)montelukast sodium chew tab 5 mg (base

equiv) (Singulair)montelukast sodium oral granules packet

4 mg (base equiv) (Singulair)montelukast sodium tab 10 mg (base

equiv) (Singulair)PROAIR HFA – albuterol sulfate inhal aero

108 mcg/act (90mcg base equiv)QVAR – beclomethasone diprop inhal aero

soln 40 mcg/act (50/valve)QVAR – beclomethasone diprop inhal aero

soln 80 mcg/act (100/valve)

2016


Drug Name Spe

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Mon

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ntity

SEREVENT DISKUS – salmeterol xinafoateaer pow ba 50 mcg/dose (base equiv)

SPIRIVA HANDIHALER – tiotropium bromidemonohydrate inhal cap 18 mcg (baseequiv)

SPIRIVA RESPIMAT – tiotropium bromidemonohydrate inhal aerosol 1.25 mcg/act

SPIRIVA RESPIMAT – tiotropium bromidemonohydrate inhal aerosol 2.5 mcg/act

SYMBICORT – budesonide-formoterolfumarate dihyd aerosol 80-4.5 mcg/act

SYMBICORT – budesonide-formoterolfumarate dihyd aerosol 160-4.5 mcg/act

terbutaline sulfate tab 2.5 mgterbutaline sulfate tab 5 mgtheophylline tab sr 12hr 100 mgtheophylline tab sr 12hr 200 mgtheophylline tab sr 12hr 300 mgtheophylline tab sr 12hr 450 mgtheophylline tab sr 24hr 400 mgtheophylline tab sr 24hr 600 mgVENTOLIN HFA – albuterol sulfate inhal

aero 108 mcg/act (90mcg base equiv)zafirlukast tab 10 mg (Accolate)zafirlukast tab 20 mg (Accolate)OTHER RESPIRATORY DRUGSKALYDECO – ivacaftor tab 150 mg •KALYDECO – ivacaftor packet 50 mg •KALYDECO – ivacaftor packet 75 mg •PULMOZYME – dornase alfa inhal soln 1

mg/ml•

GASTROINTESTINAL DRUGSLAXATIVESlactulose solution 10 gm/15mlpeg 3350-kcl-sod bicarb-nacl for soln

420 gm (Nulytely/flavor pack)peg 3350-kcl-na bicarb-nacl-na sulfate for

soln 236 gm (Golytely)

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

peg 3350-kcl-na bicarb-nacl-na sulfate forsoln 240 gm (Colyte-flavor packs)

ANTIDIARRHEALSdiphenoxylate w/ atropine liq

2.5-0.025 mg/5mldiphenoxylate w/ atropine tab

2.5-0.025 mg (Lomotil)loperamide hcl cap 2 mgULCER/GERDCARAFATE – sucralfate susp 1 gm/10mlcimetidine hcl soln 300 mg/5mlcimetidine tab 300 mgcimetidine tab 400 mgcimetidine tab 800 mgdicyclomine hcl cap 10 mg (Bentyl)dicyclomine hcl oral soln 10 mg/5mldicyclomine hcl tab 20 mg (Bentyl)DONNATAL – pb-hyoscy-atrop-scopol tab

16.2-0.1037-0.0194-0.0065 mgesomeprazole magnesium cap delayed

release 20 mg (base eq) (Nexium)esomeprazole magnesium cap delayed

release 40 mg (base eq) (Nexium)famotidine tab 20 mg (Pepcid)famotidine tab 40 mg (Pepcid)glycopyrrolate tab 1 mg (Robinul)glycopyrrolate tab 2 mg (Robinul forte)hyoscyamine sulfate elixir 0.125 mg/5mlhyoscyamine sulfate soln 0.125 mg/mlhyoscyamine sulfate tab disp 0.125 mg

(Anaspaz)hyoscyamine sulfate tab sl 0.125 mg

(Levsin/sl)hyoscyamine sulfate tab sr 12hr 0.375 mg

(Levbid)hyoscyamine sulfate tab 0.125 mg (Levsin)

2016


Drug Name Spe

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ty

Max

imum

Mon

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ntity

lansoprazole cap delayed release 15 mg(Prevacid)

lansoprazole cap delayed release 30 mg(Prevacid)

methscopolamine bromide tab 2.5 mg(Pamine)

methscopolamine bromide tab 5 mg(Pamine forte)

misoprostol tab 100 mcg (Cytotec)misoprostol tab 200 mcg (Cytotec)NEXIUM – esomeprazole magnesium for

delayed release susp pack 2.5 mgNEXIUM – esomeprazole magnesium for

delayed release susp packet 5 mgNEXIUM – esomeprazole magnesium for



delayed release susp packet 40 mgomeprazole cap delayed release 10 mg

(Prilosec)omeprazole cap delayed release 20 mg

(Prilosec)omeprazole cap delayed release 40 mg

(Prilosec)pantoprazole sodium ec tab 20 mg (base

equiv) (Protonix)pantoprazole sodium ec tab 40 mg (base

equiv) (Protonix)PROPANTHELINE BROMIDE –

propantheline bromide tab 15 mgranitidine hcl cap 150 mgranitidine hcl cap 300 mgranitidine hcl syrup 15 mg/ml (75 mg/5ml)ranitidine hcl tab 150 mg (Zantac)ranitidine hcl tab 300 mg (Zantac)sucralfate tab 1 gm (Carafate)NAUSEA AND VOMITING

Drug Name Spe

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ty

Max

imum

Mon

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Qua

ntity

EMEND – aprepitant capsule therapy pack80 & 125 mg

EMEND – aprepitant capsule 40 mgEMEND – aprepitant capsule 80 mgEMEND – aprepitant capsule 125 mggranisetron hcl tab 1 mgmeclizine hcl tab 12.5 mgmeclizine hcl tab 25 mgondansetron hcl oral soln 4 mg/5ml

(Zofran)ondansetron hcl tab 4 mg (Zofran)ondansetron hcl tab 8 mg (Zofran)ondansetron hcl tab 24 mgondansetron orally disintegrating tab

4 mg (Zofran odt)ondansetron orally disintegrating tab

8 mg (Zofran odt)trimethobenzamide hcl cap 300 mg (Tigan)DIGESTIVE ENZYMESCREON – pancrelipase (lip-prot-amyl) dr cap

3000-9500-15000 unitCREON – pancrelipase (lip-prot-amyl) dr cap




36000-114000-180000 unitZENPEP – pancrelipase (lip-prot-amyl) dr

cap 3000-10000-16000 unitZENPEP – pancrelipase (lip-prot-amyl) dr



cap 15000-51000-82000 unit

2016


Drug Name Spe

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ty

Max

imum

Mon

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Qua

ntity

ZENPEP – pancrelipase (lip-prot-amyl) drcap 20000-68000-109000 unit



OTHER GASTROINTESTINAL DRUGSASACOL HD – mesalamine tab delayed

release 800 mgbalsalazide disodium cap 750 mg

(Colazal)calcium acetate (phosphate binder) cap

667 mg (169 mg ca) (Phoslo)calcium acetate (phosphate binder) tab

667 mg (Eliphos)CANASA – mesalamine suppos 1000 mgCHENODAL – chenodiol tab 250 mg •DELZICOL – mesalamine cap dr 400 mglactulose (encephalopathy) solution

10 gm/15mlLIALDA – mesalamine tab delayed release

1.2 gmLINZESS – linaclotide cap 145 mcgLINZESS – linaclotide cap 290 mcgmesalamine enema 4 gmmetoclopramide hcl soln 5 mg/5ml

(10 mg/10ml)metoclopramide hcl tab 5 mg (Reglan)metoclopramide hcl tab 10 mg (Reglan)PENTASA – mesalamine cap cr 250 mgPENTASA – mesalamine cap cr 500 mgRENVELA – sevelamer carbonate tab 800

mgRENVELA – sevelamer carbonate packet 0.8

gmRENVELA – sevelamer carbonate packet 2.4

gm

Drug Name Spe

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ty

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imum

Mon

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sulfasalazine tab delayed release 500 mg(Azulfidine en-tabs)

sulfasalazine tab 500 mg (Azulfidine)ursodiol cap 300 mg (Actigall)ursodiol tab 250 mg (Urso 250)ursodiol tab 500 mg (Urso forte)GENITOURINARY DRUGSURINARY TRACT INFECTIONSMACRODANTIN – nitrofurantoin

macrocrystalline cap 25 mgnitrofurantoin macrocrystalline cap 25 mg

(Macrodantin)nitrofurantoin macrocrystalline cap 50 mg

(Macrodantin)nitrofurantoin macrocrystalline cap

100 mg (Macrodantin)nitrofurantoin monohydrate

macrocrystalline cap 100 mg (Macrobid)nitrofurantoin susp 25 mg/5ml

(Furadantin)URINARY TRACT SPASMSoxybutynin chloride syrup 5 mg/5mloxybutynin chloride tab sr 24hr 5 mg

(Ditropan xl)oxybutynin chloride tab sr 24hr 10 mg

(Ditropan xl)oxybutynin chloride tab sr 24hr 15 mg

(Ditropan xl)oxybutynin chloride tab 5 mgtolterodine tartrate cap sr 24hr 2 mg

(Detrol la)tolterodine tartrate cap sr 24hr 4 mg

(Detrol la)tolterodine tartrate tab 1 mg (Detrol)tolterodine tartrate tab 2 mg (Detrol)VESICARE – solifenacin succinate tab 5 mgVESICARE – solifenacin succinate tab 10

mg

2016


Drug Name Spe

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Mon

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VAGINAL PRODUCTSCLEOCIN – clindamycin phosphate vaginal

suppos 100 mgclindamycin phosphate vaginal cream 2%

(Cleocin)ENCARE – nonoxynol-9 vaginal suppos 100

mgESTRACE – estradiol vaginal cream 0.1 mg/

gmmetronidazole vaginal gel 0.75%

(Metrogel-vaginal)nonoxynol-9 gel 4% (Options Conceptrol

Vaginal)OPTIONS GYNOL II VAGINAL –

nonoxynol-9 gel 3%SHUR-SEAL – nonoxynol-9 gel 2%terconazole vaginal cream 0.4% (Terazol

7)terconazole vaginal cream 0.8% (Terazol

3)terconazole vaginal suppos 80 mg

(Terazol 3)TODAY SPONGE – nonoxynol-9 vaginal

sponge 1000 mgVAGIFEM – estradiol vaginal tab 10 mcgVCF VAGINAL CONTRACEPTIVE –

nonoxynol-9 foam 12.5%VCF VAGINAL CONTRACEPTIVE –

nonoxynol-9 film 28%OTHER GENITOURINARY DRUGSalfuzosin hcl tab sr 24hr 10 mg (Uroxatral)AVODART – dutasteride cap 0.5 mgCYSTAGON – cysteamine bitartrate cap 50

mgCYSTAGON – cysteamine bitartrate cap 150

mgCYTRA-3 – pot & sod citrates w/ cit ac syrup

550-500-334 mg/5mldutasteride cap 0.5 mg (Avodart)

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

finasteride tab 5 mg (Proscar)K-PHOS NO 2 – potassium & sodium acid

phosphates tab 305-700 mgpot & sod citrates w/ cit ac soln

550-500-334 mg/5mlpotassium citrate & citric acid powder

pack 3300-1002 mgpotassium citrate & citric acid soln

1100-334 mg/5mlpotassium citrate tab cr 5 meq (540 mg)

(Urocit-k 5)potassium citrate tab cr 10 meq (1080 mg)

(Urocit-k 10)potassium citrate tab cr 15 meq (1620 mg)

(Urocit-k 15)sodium citrate & citric acid soln

500-334 mg/5ml (Shohls solution modi)tamsulosin hcl cap 0.4 mg (Flomax)CENTRAL NERVOUS SYSTEM DRUGSANXIETYALPRAZOLAM INTENSOL – alprazolam

conc 1 mg/mlalprazolam tab sr 24hr 0.5 mg (Xanax xr)alprazolam tab sr 24hr 1 mg (Xanax xr)alprazolam tab sr 24hr 2 mg (Xanax xr)alprazolam tab sr 24hr 3 mg (Xanax xr)alprazolam tab 0.25 mg (Xanax)alprazolam tab 0.5 mg (Xanax)alprazolam tab 1 mg (Xanax)alprazolam tab 2 mg (Xanax)buspirone hcl tab 5 mgbuspirone hcl tab 10 mgbuspirone hcl tab 15 mgbuspirone hcl tab 30 mgdiazepam soln 1 mg/mldiazepam tab 2 mg (Valium)diazepam tab 5 mg (Valium)

2016


Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

diazepam tab 10 mg (Valium)hydroxyzine hcl syrup 10 mg/5mlhydroxyzine hcl tab 10 mghydroxyzine hcl tab 25 mghydroxyzine hcl tab 50 mghydroxyzine pamoate cap 25 mg (Vistaril)hydroxyzine pamoate cap 50 mg (Vistaril)lorazepam conc 2 mg/ml (Lorazepam

intensol)lorazepam tab 0.5 mg (Ativan)lorazepam tab 1 mg (Ativan)lorazepam tab 2 mg (Ativan)DEPRESSIONamitriptyline hcl tab 10 mgamitriptyline hcl tab 25 mgamitriptyline hcl tab 50 mgamitriptyline hcl tab 75 mgamitriptyline hcl tab 100 mgamitriptyline hcl tab 150 mgbupropion hcl tab sr 12hr 100 mg

(Wellbutrin sr)bupropion hcl tab sr 12hr 150 mg



(Wellbutrin xl)bupropion hcl tab sr 24hr 300 mg

(Wellbutrin xl)bupropion hcl tab 75 mg (Wellbutrin)bupropion hcl tab 100 mg (Wellbutrin)citalopram hydrobromide oral soln

10 mg/5mlcitalopram hydrobromide tab 10 mg (base

equiv) (Celexa)citalopram hydrobromide tab 20 mg (base

equiv) (Celexa)

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

citalopram hydrobromide tab 40 mg (baseequiv) (Celexa)

clomipramine hcl cap 25 mg (Anafranil)clomipramine hcl cap 50 mg (Anafranil)clomipramine hcl cap 75 mg (Anafranil)desipramine hcl tab 10 mg (Norpramin)desipramine hcl tab 25 mg (Norpramin)desipramine hcl tab 50 mg (Norpramin)desipramine hcl tab 75 mg (Norpramin)desipramine hcl tab 100 mg (Norpramin)desipramine hcl tab 150 mg (Norpramin)doxepin hcl cap 10 mgdoxepin hcl cap 25 mgdoxepin hcl cap 50 mgdoxepin hcl cap 100 mgdoxepin hcl conc 10 mg/mlduloxetine hcl enteric coated pellets cap

20 mg (Cymbalta)duloxetine hcl enteric coated pellets cap

30 mg (Cymbalta)duloxetine hcl enteric coated pellets cap

60 mg (Cymbalta)escitalopram oxalate soln 5 mg/5ml (base

equiv) (Lexapro)escitalopram oxalate tab 5 mg (base



equiv) (Lexapro)fluoxetine hcl cap 10 mg (Prozac)fluoxetine hcl cap 20 mg (Prozac)fluoxetine hcl cap 40 mg (Prozac)fluoxetine hcl solution 20 mg/5mlfluoxetine hcl tab 10 mgfluoxetine hcl tab 20 mgfluvoxamine maleate tab 25 mg

2016


Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

fluvoxamine maleate tab 50 mgfluvoxamine maleate tab 100 mgimipramine hcl tab 10 mg (Tofranil)imipramine hcl tab 25 mg (Tofranil)imipramine hcl tab 50 mg (Tofranil)mirtazapine tab 7.5 mgmirtazapine tab 15 mg (Remeron)mirtazapine tab 30 mg (Remeron)mirtazapine tab 45 mg (Remeron)nortriptyline hcl cap 10 mg (Pamelor)nortriptyline hcl cap 25 mg (Pamelor)nortriptyline hcl cap 50 mg (Pamelor)nortriptyline hcl cap 75 mg (Pamelor)paroxetine hcl tab sr 24hr 12.5 mg (Paxil

cr)paroxetine hcl tab sr 24hr 25 mg (Paxil cr)paroxetine hcl tab sr 24hr 37.5 mg (Paxil

cr)paroxetine hcl tab 10 mg (Paxil)paroxetine hcl tab 20 mg (Paxil)paroxetine hcl tab 30 mg (Paxil)paroxetine hcl tab 40 mg (Paxil)phenelzine sulfate tab 15 mg (Nardil)sertraline hcl oral conc 20 mg/ml (Zoloft)sertraline hcl tab 25 mg (Zoloft)sertraline hcl tab 50 mg (Zoloft)sertraline hcl tab 100 mg (Zoloft)tranylcypromine sulfate tab 10 mg

(Parnate)trazodone hcl tab 50 mgtrazodone hcl tab 100 mgtrazodone hcl tab 150 mgtrazodone hcl tab 300 mgvenlafaxine hcl cap sr 24hr 37.5 mg (base

equivalent) (Effexor xr)

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

venlafaxine hcl cap sr 24hr 75 mg (baseequivalent) (Effexor xr)

venlafaxine hcl cap sr 24hr 150 mg (baseequivalent) (Effexor xr)

venlafaxine hcl tab sr 24hr 37.5 mg (baseequivalent) (Venlafaxine hcl er)

venlafaxine hcl tab sr 24hr 75 mg (baseequivalent) (Venlafaxine hcl er)

venlafaxine hcl tab sr 24hr 150 mg (baseequivalent) (Venlafaxine hcl er)

venlafaxine hcl tab 25 mgvenlafaxine hcl tab 37.5 mgvenlafaxine hcl tab 50 mgvenlafaxine hcl tab 75 mgvenlafaxine hcl tab 100 mgPSYCHOTIC AND BIPOLAR DISORDERSchlorpromazine hcl tab 10 mgchlorpromazine hcl tab 25 mgchlorpromazine hcl tab 50 mgchlorpromazine hcl tab 100 mgchlorpromazine hcl tab 200 mgclozapine tab 25 mg (Clozaril)clozapine tab 50 mgclozapine tab 100 mg (Clozaril)clozapine tab 200 mgfluphenazine decanoate inj 25 mg/mlFLUPHENAZINE HCL – fluphenazine hcl

elixir 2.5 mg/5mlFLUPHENAZINE HCL – fluphenazine hcl

oral conc 5 mg/mlfluphenazine hcl tab 1 mgfluphenazine hcl tab 2.5 mgfluphenazine hcl tab 5 mgfluphenazine hcl tab 10 mghaloperidol decanoate im soln 50 mg/ml

(Haldol decanoate 50)

2016


Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

haloperidol decanoate im soln 100 mg/ml(Haldol decanoate 100)

haloperidol lactate oral conc 2 mg/mlhaloperidol tab 0.5 mghaloperidol tab 1 mghaloperidol tab 2 mghaloperidol tab 5 mghaloperidol tab 10 mghaloperidol tab 20 mglithium carbonate cap 150 mg (Lithium

carbonate)lithium carbonate cap 300 mglithium carbonate cap 600 mg (Lithium

carbonate)lithium carbonate tab cr 300 mg (Lithobid)lithium carbonate tab cr 450 mglithium carbonate tab 300 mglithium oral solution 8 meq/5mlloxapine succinate cap 5 mg (Loxitane)loxapine succinate cap 10 mgloxapine succinate cap 25 mgloxapine succinate cap 50 mgolanzapine orally disintegrating tab 5 mg

(Zyprexa zydis)olanzapine orally disintegrating tab 10 mg



(Zyprexa zydis)olanzapine tab 2.5 mg (Zyprexa)olanzapine tab 5 mg (Zyprexa)olanzapine tab 7.5 mg (Zyprexa)olanzapine tab 10 mg (Zyprexa)olanzapine tab 15 mg (Zyprexa)olanzapine tab 20 mg (Zyprexa)perphenazine tab 2 mg

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

perphenazine tab 4 mgperphenazine tab 8 mgperphenazine tab 16 mgprochlorperazine maleate tab 5 mg (base

equivalent) (Compazine)prochlorperazine maleate tab 10 mg (base

equivalent) (Compazine)prochlorperazine suppos 25 mgquetiapine fumarate tab 25 mg (Seroquel)quetiapine fumarate tab 50 mg (Seroquel)quetiapine fumarate tab 100 mg (Seroquel)quetiapine fumarate tab 200 mg (Seroquel)quetiapine fumarate tab 300 mg (Seroquel)quetiapine fumarate tab 400 mg (Seroquel)risperidone orally disintegrating tab

0.25 mgrisperidone orally disintegrating tab

0.5 mg (Risperdal m-tab)risperidone orally disintegrating tab 1 mg

(Risperdal m-tab)risperidone orally disintegrating tab 2 mg



(Risperdal m-tab)risperidone soln 1 mg/ml (Risperdal)risperidone tab 0.25 mg (Risperdal)risperidone tab 0.5 mg (Risperdal)risperidone tab 1 mg (Risperdal)risperidone tab 2 mg (Risperdal)risperidone tab 3 mg (Risperdal)risperidone tab 4 mg (Risperdal)SEROQUEL XR – quetiapine fumarate tab sr

24hr 50 mgSEROQUEL XR – quetiapine fumarate tab sr

24hr 150 mg

2016


Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

SEROQUEL XR – quetiapine fumarate tab sr24hr 200 mg



thiothixene cap 1 mgthiothixene cap 2 mgthiothixene cap 5 mgthiothixene cap 10 mgtrifluoperazine hcl tab 1 mgtrifluoperazine hcl tab 2 mgtrifluoperazine hcl tab 5 mgtrifluoperazine hcl tab 10 mgziprasidone hcl cap 20 mg (Geodon)ziprasidone hcl cap 40 mg (Geodon)ziprasidone hcl cap 60 mg (Geodon)ziprasidone hcl cap 80 mg (Geodon)SLEEP AIDSestazolam tab 1 mgestazolam tab 2 mgeszopiclone tab 1 mg (Lunesta)eszopiclone tab 2 mg (Lunesta)eszopiclone tab 3 mg (Lunesta)phenobarbital elixir 20 mg/5mlphenobarbital tab 16.2 mgphenobarbital tab 32.4 mgtemazepam cap 7.5 mg (Restoril)temazepam cap 15 mg (Restoril)temazepam cap 22.5 mg (Restoril)temazepam cap 30 mg (Restoril)zaleplon cap 5 mg (Sonata)zaleplon cap 10 mg (Sonata)zolpidem tartrate tab cr 6.25 mg (Ambien

cr)

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

zolpidem tartrate tab cr 12.5 mg (Ambiencr)

zolpidem tartrate tab 5 mg (Ambien)zolpidem tartrate tab 10 mg (Ambien)HYPERACTIVITY/NARCOLEPSYamphetamine-dextroamphetamine cap sr

24hr 5 mg (Adderall xr)amphetamine-dextroamphetamine cap sr





24hr 30 mg (Adderall xr)amphetamine-dextroamphetamine tab

5 mg (Adderall)amphetamine-dextroamphetamine tab

7.5 mg (Adderall)amphetamine-dextroamphetamine tab


12.5 mg (Adderall)amphetamine-dextroamphetamine tab



30 mg (Adderall)caffeine citrate oral soln 60 mg/3ml

(10 mg/ml base equiv) (Cafcit)dextroamphetamine sulfate cap sr 24hr

5 mg (Dexedrine)dextroamphetamine sulfate cap sr 24hr

10 mg (Dexedrine)dextroamphetamine sulfate cap sr 24hr

15 mg (Dexedrine)dextroamphetamine sulfate tab 5 mg

2016


Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

guanfacine hcl tab sr 24hr 1 mg (baseequiv) (Intuniv)




METHYLPHENIDATE HCL ER –methylphenidate hcl tab sa osm 18 mg




METHYLPHENIDATE HCL ER –methylphenidate hcl tab sr 24hr 18 mg




methylphenidate hcl tab cr 10 mgmethylphenidate hcl tab cr 20 mg (Ritalin

sr)methylphenidate hcl tab 5 mg (Ritalin)methylphenidate hcl tab 10 mg (Ritalin)methylphenidate hcl tab 20 mg (Ritalin)modafinil tab 100 mg (Provigil)modafinil tab 200 mg (Provigil)VYVANSE – lisdexamfetamine dimesylate

cap 10 mgVYVANSE – lisdexamfetamine dimesylate

cap 20 mgVYVANSE – lisdexamfetamine dimesylate

cap 30 mg

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

VYVANSE – lisdexamfetamine dimesylatecap 40 mg




MULTIPLE SCLEROSISBETASERON – interferon beta-1b for inj kit

0.3 mg• •

COPAXONE – glatiramer acetate solnprefilled syringe 20 mg/ml

• •

COPAXONE – glatiramer acetate solnprefilled syringe 40 mg/ml

• •

glatiramer acetate soln prefilled syringe20 mg/ml (Copaxone)

• •

PLEGRIDY – peginterferon beta-1a solnpen-injector 125 mcg/0.5ml

• •

PLEGRIDY – peginterferon beta-1a solnprefilled syringe 125 mcg/0.5ml

• •

PLEGRIDY STARTER PACK – peginterferonbeta-1a soln pen-inj 63 & 94 mcg/0.5mlpack

• •

PLEGRIDY STARTER PACK – peginterferonbeta-1a soln pref syr 63 & 94 mcg/0.5mlpack

• •

REBIF – interferon beta-1a soln pref syr 22mcg/0.5ml (12mu/ml)

• •

REBIF – interferon beta-1a soln pref syr 44mcg/0.5ml (24mu/ml)

• •

REBIF REBIDOSE – interferon beta-1a solnauto-inj 22 mcg/0.5ml (12mu/ml)

• •

REBIF REBIDOSE – interferon beta-1a solnauto-inj 44 mcg/0.5ml (24mu/ml)

• •

REBIF REBIDOSE TITRATION – interferonbeta-1a auto-inj 6x8.8 mcg/0.2ml & 6x22mcg/0.5ml

• •

REBIF TITRATION PACK – interferonbeta-1a pref syr 6x8.8 mcg/0.2ml & 6x22mcg/0.5ml

• •

2016


Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

TECFIDERA – dimethyl fumarate capsuledelayed release 120 mg

• •

TECFIDERA – dimethyl fumarate capsuledelayed release 240 mg

• •

TECFIDERA STARTER PACK – dimethylfumarate capsule dr starter pack 120 mg &240 mg

• •

OTHER CENTRAL NERVOUS SYSTEM DRUGSacamprosate calcium tab delayed release

333 mg (Campral)bupropion hcl (smoking deterrent) tab sr

12hr 150 mg (Zyban)CHANTIX – varenicline tartrate tab 0.5 mg

(base equiv)CHANTIX – varenicline tartrate tab 1 mg

(base equiv)CHANTIX CONTINUING MONTH –

varenicline tartrate tab 1 mg (base equiv)CHANTIX STARTING MONTH PA –

varenicline tartrate tab 0.5 mg x 11 & tab 1mg x 42 pack

disulfiram tab 250 mg (Antabuse)disulfiram tab 500 mg (Antabuse)donepezil hydrochloride orally

disintegrating tab 5 mg (Aricept odt)donepezil hydrochloride orally

disintegrating tab 10 mg (Aricept odt)donepezil hydrochloride tab 5 mg (Aricept)donepezil hydrochloride tab 10 mg

(Aricept)galantamine hydrobromide cap sr 24hr

8 mg (Razadyne er)galantamine hydrobromide cap sr 24hr

16 mg (Razadyne er)galantamine hydrobromide cap sr 24hr

24 mg (Razadyne er)galantamine hydrobromide tab 4 mg

(Razadyne)galantamine hydrobromide tab 8 mg

(Razadyne)

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

galantamine hydrobromide tab 12 mg(Razadyne)

memantine hcl oral solution 2 mg/ml(Namenda)

memantine hcl tab 5 mg (Namenda)memantine hcl tab 10 mg (Namenda)memantine hcl tab 5 mg (28) & 10 mg (21)

titration pak (Namenda titration pa)NAMENDA – memantine hcl oral solution 2

mg/mlNAMENDA XR – memantine hcl cap sr 24hr

7 mgNAMENDA XR – memantine hcl cap sr 24hr



28 mgNAMENDA XR TITRATION PACK –

memantine hcl cap sr 24hr 7 mg & 14 mg& 21 mg & 28 mg pack

NICOTROL INHALER – nicotine inhalersystem 10 mg (4 mg delivered)

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

NUEDEXTA – dextromethorphan hbr-quinidine sulfate cap 20-10 mg

pimozide tab 1 mg (Orap)pimozide tab 2 mg (Orap)rivastigmine tartrate cap 1.5 mg (Exelon)rivastigmine tartrate cap 3 mg (Exelon)rivastigmine tartrate cap 4.5 mg (Exelon)rivastigmine tartrate cap 6 mg (Exelon)tetrabenazine tab 12.5 mg (Xenazine) •tetrabenazine tab 25 mg (Xenazine) •PAIN RELIEF DRUGSNON-NARCOTIC DRUGSbutalbital-acetaminophen tab 50-325 mg

2016


Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

butalbital-acetaminophen-caffeine cap50-325-40 mg (Esgic)

butalbital-acetaminophen-caffeine tab50-325-40 mg (Esgic)

butalbital-aspirin-caffeine cap50-325-40 mg (Fiorinal)

salsalate tab 500 mgsalsalate tab 750 mgNARCOTIC DRUGSacetaminophen w/ codeine soln

120-12 mg/5mlacetaminophen w/ codeine tab 300-15 mg

(Tylenol/codeine)acetaminophen w/ codeine tab 300-30 mg

(Tylenol/codeine #3)acetaminophen w/ codeine tab 300-60 mg

(Tylenol/codeine #4)buprenorphine hcl sl tab 2 mg (base

equiv)buprenorphine hcl sl tab 8 mg (base

equiv)butalbital-aspirin-caff w/ codeine cap

50-325-40-30 mg (Fiorinal/codeine #3)codeine sulfate tab 15 mg (Codeine

sulfate)codeine sulfate tab 30 mgcodeine sulfate tab 60 mgDILAUDID – hydromorphone hcl

preservative free (pf) inj 2 mg/mlDILAUDID – hydromorphone hcl

preservative free (pf) inj 4 mg/mlfentanyl citrate lozenge on a handle

200 mcg (Actiq)•

fentanyl citrate lozenge on a handle400 mcg (Actiq)

•


•


•

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity


•


•

fentanyl td patch 72hr 12 mcg/hr(Duragesic)





hydrocodone-acetaminophen soln7.5-325 mg/15ml (Hycet)

hydrocodone-acetaminophen tab10-325 mg (Norco)

hydrocodone-acetaminophen tab5-325 mg (Norco)

hydrocodone-acetaminophen tab7.5-325 mg (Norco)

hydrocodone-ibuprofen tab 5-200 mg(Reprexain)

hydrocodone-ibuprofen tab 7.5-200 mg(Vicoprofen)

hydrocodone-ibuprofen tab 10-200 mg(Ibudone)

hydromorphone hcl liqd 1 mg/ml(Dilaudid)

hydromorphone hcl suppos 3 mghydromorphone hcl tab 2 mg (Dilaudid)hydromorphone hcl tab 4 mg (Dilaudid)hydromorphone hcl tab 8 mg (Dilaudid)KADIAN – morphine sulfate cap sr 24hr 10

mgKADIAN – morphine sulfate cap sr 24hr 40

mgKADIAN – morphine sulfate cap sr 24hr 200

mg

2016


Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

methadone hcl conc 10 mg/ml(Methadose)

methadone hcl soln 5 mg/5ml (Methadonehcl)

methadone hcl soln 10 mg/5ml(Methadone hcl)

methadone hcl tab for oral susp 40 mgmethadone hcl tab 5 mg (Dolophine hcl)methadone hcl tab 10 mg (Dolophine)morphine sulfate oral soln 10 mg/5mlmorphine sulfate oral soln 20 mg/5mlmorphine sulfate oral soln 100 mg/5ml

(20 mg/ml)morphine sulfate suppos 10 mgmorphine sulfate suppos 20 mgmorphine sulfate suppos 30 mgmorphine sulfate suppos 5 mgmorphine sulfate tab cr 15 mg (Ms contin)morphine sulfate tab cr 30 mg (Ms contin)morphine sulfate tab cr 60 mg (Ms contin)morphine sulfate tab cr 100 mg (Ms contin)morphine sulfate tab cr 200 mg (Ms contin)morphine sulfate tab 15 mgmorphine sulfate tab 30 mgNUCYNTA ER – tapentadol hcl tab sr 12hr

50 mgNUCYNTA ER – tapentadol hcl tab sr 12hr




250 mgoxycodone hcl cap 5 mgoxycodone hcl conc 100 mg/5ml (20 mg/

ml) (Oxycodone hcl)

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

oxycodone hcl soln 5 mg/5ml (Oxycodonehcl)

oxycodone hcl tab 5 mg (Roxicodone)oxycodone hcl tab 10 mgoxycodone hcl tab 15 mg (Roxicodone)oxycodone hcl tab 20 mgoxycodone hcl tab 30 mg (Roxicodone)oxycodone w/ acetaminophen tab

5-325 mg (Percocet)oxycodone w/ acetaminophen tab

7.5-325 mg (Percocet)oxycodone w/ acetaminophen tab

10-325 mg (Percocet)oxycodone-aspirin tab 4.8355-325 mg

(Percodan)OXYCONTIN – oxycodone hcl tab er 12hr

deter 10 mg•

OXYCONTIN – oxycodone hcl tab er 12hrdeter 15 mg

•


•


•


•


•


•

ROXICET – oxycodone w/ acetaminophensoln 5-325 mg/5ml

tramadol hcl tab sr 24hr 100 mg (Ultramer)



tramadol hcl tab 50 mg (Ultram)

2016


Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

tramadol-acetaminophen tab 37.5-325 mg(Ultracet)

RHEUMATOID AND OSTEOARTHRITIScelecoxib cap 50 mg (Celebrex)celecoxib cap 100 mg (Celebrex)celecoxib cap 200 mg (Celebrex)celecoxib cap 400 mg (Celebrex)diclofenac potassium tab 50 mg

(Cataflam)diclofenac sodium tab delayed release

25 mgdiclofenac sodium tab delayed release

50 mgdiclofenac sodium tab delayed release

75 mgdiclofenac sodium tab sr 24hr 100 mg

(Voltaren-xr)ENBREL – etanercept for subcutaneous inj

kit 25 mg• •

ENBREL – etanercept subcutaneous solnprefilled syringe 25 mg/0.5ml

• •

ENBREL – etanercept subcutaneous solnprefilled syringe 50 mg/ml

• •

ENBREL SURECLICK – etanerceptsubcutaneous solution auto-injector 50 mg/ml

• •

etodolac cap 200 mgetodolac cap 300 mgetodolac tab sr 24hr 400 mgetodolac tab sr 24hr 500 mgetodolac tab sr 24hr 600 mgetodolac tab 400 mgetodolac tab 500 mgflurbiprofen tab 50 mgflurbiprofen tab 100 mgHUMIRA – adalimumab prefilled syringe kit

10 mg/0.2ml• •

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

HUMIRA – adalimumab prefilled syringe kit20 mg/0.4ml

• •

HUMIRA – adalimumab prefilled syringe kit40 mg/0.8ml

• •

HUMIRA PEDIATRIC CROHNS D –adalimumab prefilled syringe kit 40mg/0.8ml

• •

HUMIRA PEN – adalimumab pen-injector kit40 mg/0.8ml

• •

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

• •

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

• •

ibuprofen susp 100 mg/5mlibuprofen tab 400 mgibuprofen tab 600 mgibuprofen tab 800 mgILARIS – canakinumab for inj 180 mg •indomethacin cap 25 mgindomethacin cap 50 mgketoprofen cap 50 mgketoprofen cap 75 mgleflunomide tab 10 mg (Arava)leflunomide tab 20 mg (Arava)meloxicam tab 7.5 mg (Mobic)meloxicam tab 15 mg (Mobic)nabumetone tab 500 mgnabumetone tab 750 mgnaproxen sodium tab 275 mg (Anaprox)naproxen sodium tab 550 mg (Anaprox ds)naproxen tab ec 375 mg (Ec-naprosyn)naproxen tab ec 500 mg (Ec-naprosyn)naproxen tab 250 mg (Naprosyn)naproxen tab 375 mg (Naprosyn)naproxen tab 500 mg (Naprosyn)oxaprozin tab 600 mg (Daypro)piroxicam cap 10 mg (Feldene)

2016


Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

piroxicam cap 20 mg (Feldene)SIMPONI – golimumab subcutaneous soln

auto-injector 50 mg/0.5ml• •

SIMPONI – golimumab subcutaneous solnauto-injector 100 mg/ml

• •

SIMPONI – golimumab subcutaneous solnprefilled syringe 50 mg/0.5ml

• •

SIMPONI – golimumab subcutaneous solnprefilled syringe 100 mg/ml

• •

sulindac tab 150 mgsulindac tab 200 mgMIGRAINE HEADACHESacetaminophen-isometheptene-dichloral

cap 325-65-100 mgMIGRANAL – dihydroergotamine mesylate

nasal spray 4 mg/ml•

naratriptan hcl tab 1 mg (base equiv)(Amerge)

•

naratriptan hcl tab 2.5 mg (base equiv)(Amerge)

•

rizatriptan benzoate orally disintegratingtab 5 mg (Maxalt-mlt)

•

rizatriptan benzoate orally disintegratingtab 10 mg (Maxalt-mlt)

•

rizatriptan benzoate tab 5 mg (Maxalt) •rizatriptan benzoate tab 10 mg (Maxalt) •SUMATRIPTAN – sumatriptan nasal spray 5

mg/act•

SUMATRIPTAN – sumatriptan nasal spray20 mg/act

•

sumatriptan succinate inj 6 mg/0.5ml(Imitrex statdose ref)

•

sumatriptan succinate solution auto-injector 4 mg/0.5ml (Imitrex statdose sys)

•

sumatriptan succinate solution auto-injector 6 mg/0.5ml (Imitrex statdose sys)

•

sumatriptan succinate solution cartridge4 mg/0.5ml (Imitrex statdose ref)

•

Drug Name Spe

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sumatriptan succinate solution cartridge6 mg/0.5ml (Imitrex statdose ref)

•

sumatriptan succinate tab 25 mg (Imitrex) •sumatriptan succinate tab 50 mg (Imitrex) •sumatriptan succinate tab 100 mg

(Imitrex)•

GOUTallopurinol tab 100 mg (Zyloprim)allopurinol tab 300 mg (Zyloprim)colchicine w/ probenecid tab 0.5-500 mgprobenecid tab 500 mgNEUROMUSCULAR DRUGSSEIZURESBANZEL – rufinamide susp 40 mg/mlBANZEL – rufinamide tab 200 mgBANZEL – rufinamide tab 400 mgcarbamazepine cap sr 12hr 100 mg

(Carbatrol)carbamazepine cap sr 12hr 200 mg

(Carbatrol)carbamazepine cap sr 12hr 300 mg

(Carbatrol)carbamazepine chew tab 100 mgcarbamazepine susp 100 mg/5ml

(Tegretol)carbamazepine tab sr 12hr 200 mg

(Tegretol-xr)carbamazepine tab sr 12hr 400 mg

(Tegretol-xr)carbamazepine tab 200 mg (Tegretol)CELONTIN – methsuximide cap 300 mgclonazepam tab 0.5 mg (Klonopin)clonazepam tab 1 mg (Klonopin)clonazepam tab 2 mg (Klonopin)DIASTAT ACUDIAL – diazepam rectal gel

delivery system 10 mg

2016


Drug Name Spe

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ty

Max

imum

Mon

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Qua

ntity

DIASTAT ACUDIAL – diazepam rectal geldelivery system 20 mg

DIASTAT PEDIATRIC – diazepam rectal geldelivery system 2.5 mg

DILANTIN – phenytoin sodium extended cap30 mg

DILANTIN – phenytoin sodium extended cap100 mg

DILANTIN-125 – phenytoin susp 125 mg/5mldivalproex sodium cap sprinkle 125 mg

(Depakote sprinkles)divalproex sodium tab delayed release

125 mg (Depakote)divalproex sodium tab delayed release

250 mg (Depakote)divalproex sodium tab delayed release

500 mg (Depakote)divalproex sodium tab sr 24 hr 250 mg

(Depakote er)divalproex sodium tab sr 24 hr 500 mg

(Depakote er)ethosuximide cap 250 mg (Zarontin)ethosuximide soln 250 mg/5ml (Zarontin)gabapentin cap 100 mg (Neurontin)gabapentin cap 300 mg (Neurontin)gabapentin cap 400 mg (Neurontin)gabapentin oral soln 250 mg/5ml

(Neurontin)gabapentin tab 600 mg (Neurontin)gabapentin tab 800 mg (Neurontin)lamotrigine tab chewable dispersible

5 mg (Lamictal chewable di)lamotrigine tab chewable dispersible

25 mg (Lamictal chewable di)lamotrigine tab 25 mg (Lamictal)lamotrigine tab 100 mg (Lamictal)lamotrigine tab 150 mg (Lamictal)lamotrigine tab 200 mg (Lamictal)

Drug Name Spe

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ty

Max

imum

Mon

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Qua

ntity

levetiracetam oral soln 100 mg/ml(Keppra)

levetiracetam tab sr 24hr 500 mg (Keppraxr)

levetiracetam tab sr 24hr 750 mg (Keppraxr)

levetiracetam tab 250 mg (Keppra)levetiracetam tab 500 mg (Keppra)levetiracetam tab 750 mg (Keppra)levetiracetam tab 1000 mg (Keppra)oxcarbazepine susp 300 mg/5ml (60 mg/

ml) (Trileptal)oxcarbazepine tab 150 mg (Trileptal)oxcarbazepine tab 300 mg (Trileptal)oxcarbazepine tab 600 mg (Trileptal)PHENYTEK – phenytoin sodium extended

cap 200 mgPHENYTEK – phenytoin sodium extended

cap 300 mgphenytoin chew tab 50 mg (Dilantin

infatabs)phenytoin sodium extended cap 100 mg

(Dilantin)phenytoin susp 125 mg/5ml (Dilantin)primidone tab 50 mg (Mysoline)primidone tab 250 mg (Mysoline)SABRIL – vigabatrin tab 500 mgSABRIL – vigabatrin powd pack 500 mgTEGRETOL-XR – carbamazepine tab sr

12hr 100 mgtopiramate sprinkle cap 15 mg (Topamax

sprinkle)topiramate sprinkle cap 25 mg (Topamax

sprinkle)topiramate tab 25 mg (Topamax)topiramate tab 50 mg (Topamax)topiramate tab 100 mg (Topamax)topiramate tab 200 mg (Topamax)

2016


Drug Name Spe

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ty

Max

imum

Mon

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Qua

ntity

valproate sodium syrup 250 mg/5ml (baseequiv) (Depakene)

valproic acid cap 250 mg (Depakene)zonisamide cap 25 mg (Zonegran)zonisamide cap 50 mgzonisamide cap 100 mg (Zonegran)PARKINSON'S DISEASEamantadine hcl cap 100 mgamantadine hcl syrup 50 mg/5mlAZILECT – rasagiline mesylate tab 0.5 mg

(base equiv)AZILECT – rasagiline mesylate tab 1 mg

(base equiv)benztropine mesylate tab 0.5 mgbenztropine mesylate tab 1 mgbenztropine mesylate tab 2 mgbromocriptine mesylate cap 5 mg

(Parlodel)bromocriptine mesylate tab 2.5 mg

(Parlodel)carbidopa & levodopa orally

disintegrating tab 10-100 mgcarbidopa & levodopa orally

disintegrating tab 25-100 mgcarbidopa & levodopa orally

disintegrating tab 25-250 mgcarbidopa & levodopa tab cr 25-100 mg

(Sinemet cr)carbidopa & levodopa tab cr 50-200 mg

(Sinemet cr)carbidopa & levodopa tab 10-100 mg

(Sinemet)carbidopa & levodopa tab 25-100 mg

(Sinemet)carbidopa & levodopa tab 25-250 mg

(Sinemet)entacapone tab 200 mg (Comtan)

Drug Name Spe

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ty

Max

imum

Mon

thly

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ntity

pramipexole dihydrochloride tab0.125 mg (Mirapex)

pramipexole dihydrochloride tab 0.25 mg(Mirapex)



pramipexole dihydrochloride tab 1 mg(Mirapex)


ropinirole hydrochloride tab 0.25 mg(Requip)

ropinirole hydrochloride tab 0.5 mg(Requip)

ropinirole hydrochloride tab 1 mg(Requip)





selegiline hcl cap 5 mg (Eldepryl)selegiline hcl tab 5 mgtrihexyphenidyl hcl elixir 0.4 mg/mltrihexyphenidyl hcl tab 2 mgtrihexyphenidyl hcl tab 5 mgMUSCLE RELAXANTSbaclofen tab 10 mgbaclofen tab 20 mgchlorzoxazone tab 500 mg (Parafon forte

dsc)cyclobenzaprine hcl tab 5 mgcyclobenzaprine hcl tab 10 mg

2016


Drug Name Spe

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ty

Max

imum

Mon

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Qua

ntity

dantrolene sodium cap 25 mg (Dantrium)dantrolene sodium cap 50 mg (Dantrium)metaxalone tab 800 mg (Skelaxin)methocarbamol tab 500 mg (Robaxin)methocarbamol tab 750 mg (Robaxin-750)orphenadrine citrate tab sr 12hr 100 mgorphenadrine w/ aspirin & caffeine tab

25-385-30 mgtizanidine hcl tab 2 mg (base equivalent)tizanidine hcl tab 4 mg (base equivalent)

(Zanaflex)OTHER NEUROMUSCULAR DRUGSpyridostigmine bromide tab 60 mg

(Mestinon)riluzole tab 50 mg (Rilutek)SUPPLEMENTSVITAMINSergocalciferol cap 50000 unit (Drisdol)MEPHYTON – phytonadione tab 5 mgMULTIVITAMINSpediatric multivitaminspediatric vitamins ADCPRENATAL VITAMINSMINERALS AND ELECTROLYTESFLUOR-A-DAY – sodium fluoride-xylitol

chew tab 0.55 (0.25 mg f)-236.79 mgFLUOR-A-DAY – sodium fluoride-xylitol

chew tab 1.1 (0.5 mg f)-236.79 mgFLUOR-A-DAY – sodium fluoride-xylitol

chew tab 2.2 (1 mg f)-236.79 mgFLURA-DROPS – sodium fluoride soln 0.25

mg/drop f (from 0.55 mg/drop naf)K-PHOS – potassium phosphate monobasic

tab 500 mgpot bicarbonate & chloride effer tab 25

meq

Drug Name Spe

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ty

Max

imum

Mon

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Qua

ntity

pot phos monobasic w/sod phos di &monobas tab 155-852-130mg (K-phosneutral)

potassium chloride cap cr 8 meq (Micro-k)potassium chloride cap cr 10 meq (Micro-

k)potassium chloride microencapsulated

crys cr tab 10 meqpotassium chloride microencapsulated

crys cr tab 20 meqpotassium chloride oral soln 10% (20

meq/15ml)potassium chloride oral soln 20% (40

meq/15ml)potassium chloride powder packet 20

meq (K-lor hospital pack)potassium chloride tab cr 8 meq (600 mg)potassium chloride tab cr 10 meq (K-tabs)SODIUM FLUORIDE – sodium fluoride tab

0.5 mg f (from 1.1 mg naf)sodium fluoride chew tab 0.25 mg f (from

0.55 mg naf) (Luride)sodium fluoride chew tab 0.5 mg f (from

1.1 mg naf) (Luride)sodium fluoride chew tab 1 mg f (from

2.2 mg naf) (Luride)sodium fluoride soln 0.125 mg/drop f

(0.275 mg/drop naf)sodium fluoride soln 0.5 mg/ml f (from

1.1 mg/ml naf) (Luride)BLOOD MODIFYING DRUGSALPROLIX – coagulation factor ix (recomb)

(rfixfc) for inj 500 unit•

ALPROLIX – coagulation factor ix (recomb)(rfixfc) for inj 1000 unit

•


•


•

AMICAR – aminocaproic acid tab 500 mg

2016


Drug Name Spe

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ty

Max

imum

Mon

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Qua

ntity

AMICAR – aminocaproic acid syrup 25%anagrelide hcl cap 0.5 mg (Agrylin)anagrelide hcl cap 1 mgARANESP ALBUMIN FREE – darbepoetin

alfa soln prefilled syringe 10 mcg/0.4ml•

ARANESP ALBUMIN FREE – darbepoetinalfa soln prefilled syringe 25 mcg/0.42ml

•


•


•


•


•


•


•

ARANESP ALBUMIN FREE – darbepoetinalfa soln prefilled syringe 500 mcg/ml

•

ARANESP ALBUMIN FREE – darbepoetinalfa soln inj 25 mcg/ml

•


•


•


•


•


•

cilostazol tab 50 mg (Pletal)cilostazol tab 100 mg (Pletal)CINRYZE – c1 esterase inhibitor (human) for

iv inj 500 unit•

clopidogrel bisulfate tab 75 mg (baseequiv) (Plavix)

Drug Name Spe

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ty

Max

imum

Mon

thly

Qua

ntity

cyanocobalamin inj 1000 mcg/mldipyridamole tab 25 mg (Persantine)dipyridamole tab 50 mg (Persantine)dipyridamole tab 75 mg (Persantine)ELIQUIS – apixaban tab 2.5 mgELIQUIS – apixaban tab 5 mgELOCTATE – antihemophilic factor (recomb)

rfviiifc for inj 250 unit•

ELOCTATE – antihemophilic factor (recomb)rfviiifc for inj 500 unit

•


•


•


•


•


•

enoxaparin sodium inj 30 mg/0.3ml(Lovenox)




enoxaparin sodium inj 100 mg/ml(Lovenox)


enoxaparin sodium inj 150 mg/ml(Lovenox)

enoxaparin sodium inj 300 mg/3ml(Lovenox)

FIRAZYR – icatibant acetate inj 30 mg/3ml(base equivalent)

•

folic acid tab 1 mg

2016


Drug Name Spe

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ty

Max

imum

Mon

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Qua

ntity

GRANIX – tbo-filgrastim soln prefilledsyringe 300 mcg/0.5ml

GRANIX – tbo-filgrastim soln prefilledsyringe 480 mcg/0.8ml

IXINITY – coagulation factor ix (recombinant)for inj 500 unit

•


•


•

NEULASTA – pegfilgrastim soln prefilledsyringe 6 mg/0.6ml

•

NEULASTA DELIVERY KIT – pegfilgrastimsoln prefilled syringe kit 6 mg/0.6ml

•

NOVOEIGHT – antihemophilic factor(recombinant) for inj 250 unit

•


•


•


•


•


•

OBIZUR – antihemophilic factor (recombporc) rpfviii for inj 500 unit

•

pentoxifylline tab cr 400 mgPRADAXA – dabigatran etexilate mesylate

cap 75 mg (etexilate base eq)PRADAXA – dabigatran etexilate mesylate

cap 150 mg (etexilate base eq)PROCRIT – epoetin alfa inj 2000 unit/ml •PROCRIT – epoetin alfa inj 3000 unit/ml •PROCRIT – epoetin alfa inj 4000 unit/ml •PROCRIT – epoetin alfa inj 10000 unit/ml •PROCRIT – epoetin alfa inj 20000 unit/ml •PROCRIT – epoetin alfa inj 40000 unit/ml •

Drug Name Spe

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ty

Max

imum

Mon

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ntity

SOLIRIS – eculizumab iv soln 10 mg/ml (forinfusion)

•

TRETTEN – coagulation factor xiii a-subunitfor inj 2000-3125 unit

•

warfarin sodium tab 1 mg (Coumadin)warfarin sodium tab 2 mg (Coumadin)warfarin sodium tab 2.5 mg (Coumadin)warfarin sodium tab 3 mg (Coumadin)warfarin sodium tab 4 mg (Coumadin)warfarin sodium tab 5 mg (Coumadin)warfarin sodium tab 6 mg (Coumadin)warfarin sodium tab 7.5 mg (Coumadin)warfarin sodium tab 10 mg (Coumadin)XARELTO – rivaroxaban tab 10 mgXARELTO – rivaroxaban tab 15 mgXARELTO – rivaroxaban tab 20 mgXARELTO STARTER PACK – rivaroxaban

tab starter therapy pack 15 mg & 20 mgTOPICAL DRUGSEYEAnti-infectivesBACITRACIN – bacitracin ophth oint 500

unit/gmbacitracin-polymyxin b ophth ointCILOXAN – ciprofloxacin hcl ophth oint 0.3%ciprofloxacin hcl ophth soln 0.3%

(Ciloxan)erythromycin ophth oint 5 mg/gmgentamicin sulfate ophth oint 0.3%gentamicin sulfate ophth soln 0.3%

(Garamycin)MOXEZA – moxifloxacin hcl ophth soln 0.5%

(base eq) (2 times daily)NATACYN – natamycin ophth susp 5%neomycin-bacitrac zn-polymyx

5(3.5)mg-400unt-10000unt op oin

2016


Drug Name Spe

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ty

Max

imum

Mon

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Qua

ntity

neomycin-polymy-gramicid op sol1.75-10000-0.025mg-unt-mg/ml(Neosporin)

ofloxacin ophth soln 0.3% (Ocuflox)polymyxin b-trimethoprim ophth soln

10000 unit/ml-0.1% (Polytrim)sulfacetamide sodium ophth soln 10%

(Bleph-10)tobramycin ophth soln 0.3% (Tobrex)trifluridine ophth soln 1% (Viroptic)VIGAMOX – moxifloxacin hcl ophth soln

0.5% (base equiv)Steroids and Combination Productsbacitracin-polymyxin-neomycin-hc ophth

oint 1%fluorometholone ophth susp 0.1% (Fml

liquifilm)LOTEMAX – loteprednol etabonate ophth

susp 0.5%LOTEMAX – loteprednol etabonate ophth gel

0.5%LOTEMAX – loteprednol etabonate ophth

oint 0.5%neomycin-polymyxin-dexamethasone

ophth oint 0.1% (Maxitrol)neomycin-polymyxin-dexamethasone

ophth susp 0.1% (Maxitrol)prednisolone acetate ophth susp 1%

(Pred forte)prednisolone sodium phosphate ophth soln

1%sulfacetamide sodium-prednisolone

ophth soln 10-0.23(0.25)%tobramycin-dexamethasone ophth susp

0.3-0.1% (Tobradex)ZYLET – loteprednol etabonate-tobramycin

ophth susp 0.5-0.3%GlaucomaAZOPT – brinzolamide ophth susp 1%

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

brimonidine tartrate ophth soln 0.15%(Alphagan p)

brimonidine tartrate ophth soln 0.2%carteolol hcl ophth soln 1%dorzolamide hcl ophth soln 2% (Trusopt)dorzolamide hcl-timolol maleate ophth

soln 22.3-6.8 mg/ml (Cosopt)latanoprost ophth soln 0.005% (Xalatan)levobunolol hcl ophth soln 0.25%levobunolol hcl ophth soln 0.5% (Betagan)LUMIGAN – bimatoprost ophth soln 0.01%pilocarpine hcl ophth soln 1% (Isopto

carpine)pilocarpine hcl ophth soln 2% (Isopto

carpine)pilocarpine hcl ophth soln 4% (Isopto

carpine)SIMBRINZA – brinzolamide-brimonidine

tartrate ophth susp 1-0.2%timolol maleate ophth gel forming soln

0.25% (Timoptic-xe)timolol maleate ophth gel forming soln

0.5% (Timoptic-xe)timolol maleate ophth soln 0.25%

(Timoptic)timolol maleate ophth soln 0.5% (Timoptic)TRAVATAN Z – travoprost ophth soln

0.004% (benzalkonium free) (bak free)Other Eye Productsatropine sulfate ophth oint 1%atropine sulfate ophth soln 1% (Isopto

atropine)azelastine hcl ophth soln 0.05% (Optivar)cromolyn sodium ophth soln 4%cyclopentolate hcl ophth soln 1%

(Cyclogyl)diclofenac sodium ophth soln 0.1%

2016


Drug Name Spe

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ty

Max

imum

Mon

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Qua

ntity

flurbiprofen sodium ophth soln 0.03%(Ocufen)

homatropine hbr ophth soln 5% (Isoptohomatropine)

ketorolac tromethamine ophth soln 0.4%(Acular ls)

ketorolac tromethamine ophth soln 0.5%(Acular)

PATADAY – olopatadine hcl ophth soln 0.2%(base equivalent)

PAZEO – olopatadine hcl ophth soln 0.7%(base equivalent)

tropicamide ophth soln 0.5%tropicamide ophth soln 1% (Mydriacyl)EARacetic acid otic soln 2%antipyrine-benzocaine otic soln 54-14 mg/

ml (5.4-1.4%)CIPRODEX – ciprofloxacin-dexamethasone

otic susp 0.3-0.1%CORTANE-B AQUEOUS – pramoxine-hc-

chloroxylenol aqueous otic soln 10-10-1mg/ml

hydrocortisone w/ acetic acid otic soln1-2% (Vosol hc)

neomycin-polymyxin-hc otic soln 1%(Cortisporin)

neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%

ofloxacin otic soln 0.3%MOUTH AND THROAT (local)cevimeline hcl cap 30 mg (Evoxac)chlorhexidine gluconate soln 0.12%

(Peridex)clotrimazole troche 10 mglidocaine hcl laryngotracheal soln 4% (Lta

360 kit)lidocaine hcl viscous soln 2%nystatin susp 100000 unit/ml

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

pilocarpine hcl tab 5 mg (Salagen)pilocarpine hcl tab 7.5 mg (Salagen)sodium fluoride cream 1.1% (Prevident

5000 plus)sodium fluoride gel 1.1% (0.5% f)

(Prevident fluoride)triamcinolone acetonide dental paste

0.1%ANORECTAL AGENTSCORTIFOAM – hydrocortisone acetate rectal

foam 10% (90 mg/dose)hydrocortisone acetate suppos 25 mg

(Anusol-hc)hydrocortisone acetate suppos 30 mg

(Proctocort)hydrocortisone enema 100 mg/60ml

(Cortenema)hydrocortisone rectal cream 2.5% (Anusol-

hc)SKIN CONDITIONS/PRODUCTSAcneadapalene cream 0.1% (Differin)adapalene gel 0.1% (Differin)adapalene gel 0.3% (Differin)benzoyl peroxide-erythromycin gel 5-3%

(Benzamycin)clindamycin phosph-benzoyl peroxide

(refrig) gel 1.2 (1)-5% (Duac)clindamycin phosphate gel 1% (Cleocin-t)clindamycin phosphate lotion 1%

(Cleocin-t)clindamycin phosphate soln 1% (Cleocin-

t)clindamycin phosphate swab 1% (Cleocin-

t)clindamycin phosphate-benzoyl

peroxide gel 1-5% (Benzaclin)EPIDUO – adapalene-benzoyl peroxide gel

0.1-2.5%

2016


Drug Name Spe

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ty

Max

imum

Mon

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ntity

EPIDUO FORTE – adapalene-benzoylperoxide gel 0.3-2.5%

erythromycin gel 2% (Erygel)erythromycin pads 2%erythromycin soln 2%FINACEA – azelaic acid foam 15%FINACEA – azelaic acid gel 15%isotretinoin cap 10 mgisotretinoin cap 20 mgisotretinoin cap 30 mg (Claravis)isotretinoin cap 40 mgmetronidazole cream 0.75% (Metrocream)metronidazole gel 0.75%metronidazole gel 1% (Metrogel)metronidazole lotion 0.75% (Metrolotion)SODIUM SULFACETAMIDE/SULF –

sulfacetamide sodium w/ sulfur susp10-5%

sulfacetamide sodium lotion 10% (acne)(Klaron)

sulfacetamide sodium w/ sulfur cream10-5%

sulfacetamide sodium w/ sulfur emulsion10-5%

sulfacetamide sodium w/ sulfur lotion10-5%

TAZORAC – tazarotene cream 0.05%TAZORAC – tazarotene cream 0.1%TAZORAC – tazarotene gel 0.05%TAZORAC – tazarotene gel 0.1%tretinoin cream 0.025% (Retin-a)tretinoin cream 0.05% (Retin-a)tretinoin cream 0.1% (Retin-a)tretinoin gel 0.01% (Retin-a)tretinoin gel 0.025% (Retin-a)tretinoin microsphere gel 0.04% (Retin-a

micro)

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

tretinoin microsphere gel 0.1% (Retin-amicro)

Anti-infectivesciclopirox gel 0.77% (Loprox)ciclopirox olamine cream 0.77% (base

equiv)ciclopirox olamine susp 0.77% (base

equiv)ciclopirox shampoo 1% (Loprox shampoo)ciclopirox solution 8% (Penlac nail lacquer)DENAVIR – penciclovir cream 1%econazole nitrate cream 1%gentamicin sulfate cream 0.1%gentamicin sulfate oint 0.1%ketoconazole cream 2%ketoconazole shampoo 2% (Nizoral)mupirocin calcium cream 2% (Bactroban)mupirocin oint 2% (Bactroban)nystatin cream 100000 unit/gmnystatin oint 100000 unit/gmnystatin topical powdersilver sulfadiazine cream 1% (Silvadene)Corticosteroidsalclometasone dipropionate cream 0.05%

(Aclovate)alclometasone dipropionate oint 0.05%betamethasone dipropionate augmented

cream 0.05% (Diprolene af)betamethasone dipropionate

augmented gel 0.05%betamethasone dipropionate augmented

lotion 0.05% (Diprolene)betamethasone dipropionate augmented

oint 0.05% (Diprolene)betamethasone dipropionate cream 0.05%betamethasone dipropionate lotion 0.05%betamethasone dipropionate oint 0.05%

2016


Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

betamethasone valerate cream 0.1%betamethasone valerate lotion 0.1%betamethasone valerate oint 0.1%clobetasol propionate cream 0.05%

(Temovate)clobetasol propionate emollient base

cream 0.05% (Temovate e)clobetasol propionate foam 0.05% (Olux)clobetasol propionate gel 0.05%

(Temovate)clobetasol propionate oint 0.05%

(Temovate)clobetasol propionate soln 0.05%

(Temovate)desonide cream 0.05% (Desowen)desonide lotion 0.05% (Desowen)desonide oint 0.05% (Desowen)desoximetasone cream 0.05%desoximetasone cream 0.25% (Topicort)desoximetasone gel 0.05% (Topicort)desoximetasone oint 0.25% (Topicort)diflorasone diacetate cream 0.05%fluocinolone acetonide cream 0.01%fluocinolone acetonide cream 0.025%

(Synalar)fluocinolone acetonide oil 0.01% (body

oil) (Derma-smoothe/fs bod)fluocinolone acetonide oil 0.01% (scalp

oil) (Derma-smoothe/fs sca)fluocinolone acetonide oint 0.025%

(Synalar)fluocinolone acetonide soln 0.01%

(Synalar)fluocinonide cream 0.05%fluocinonide emulsified base cream

0.05%fluocinonide gel 0.05%fluocinonide oint 0.05%

Drug Name Spe

cial

ty

Max

imum

Mon

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Qua

ntity

fluocinonide soln 0.05%fluticasone propionate cream 0.05%

(Cutivate)fluticasone propionate oint 0.005%

(Cutivate)halobetasol propionate cream 0.05%

(Ultravate)halobetasol propionate oint 0.05%

(Ultravate)hydrocortisone cream 2.5%hydrocortisone lotion 2.5%hydrocortisone oint 2.5%hydrocortisone valerate cream 0.2%hydrocortisone valerate oint 0.2%

(Westcort)mometasone furoate cream 0.1% (Elocon)mometasone furoate oint 0.1% (Elocon)mometasone furoate solution 0.1%

(lotion) (Elocon)nystatin-triamcinolone cream 100000-0.1

unit/gm-%nystatin-triamcinolone oint 100000-0.1

unit/gm-%triamcinolone acetonide cream 0.025%triamcinolone acetonide cream 0.1%triamcinolone acetonide cream 0.5%triamcinolone acetonide lotion 0.025%triamcinolone acetonide lotion 0.1%triamcinolone acetonide oint 0.5%triamcinolone acetonide oint 0.025%triamcinolone acetonide oint 0.1%Other Skin Productsacitretin cap 10 mg (Soriatane)acitretin cap 17.5 mg (Soriatane)acitretin cap 25 mg (Soriatane)calcipotriene cream 0.005% (Dovonex)calcipotriene oint 0.005%

2016


Drug Name Spe

cial

ty

Max

imum

Mon

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Qua

ntity

calcipotriene soln 0.005% (50 mcg/ml)CARAC – fluorouracil cream 0.5%diclofenac sodium (actinic keratoses) gel

3% (Solaraze)DRYSOL – aluminum chloride soln 20%ELIDEL – pimecrolimus cream 1%fluorouracil cream 5% (Efudex)fluorouracil soln 2%fluorouracil soln 5%imiquimod cream 5% (Aldara)lidocaine hcl gel 2%lidocaine hcl soln 4% (Xylocaine)lidocaine oint 5%lidocaine patch 5% (Lidoderm)lidocaine-prilocaine cream 2.5-2.5%

(Emla)lidocaine-prilocaine kit 2.5-2.5%lindane lotion 1%lindane shampoo 1%malathion lotion 0.5% (Ovide)permethrin cream 5% (Elimite)PICATO – ingenol mebutate gel 0.015%PICATO – ingenol mebutate gel 0.05%podofilox soln 0.5% (Condylox)selenium sulfide lotion 2.5%STELARA – ustekinumab soln prefilled

syringe 45 mg/0.5ml• •

STELARA – ustekinumab soln prefilledsyringe 90 mg/ml

• •

tacrolimus oint 0.03% (Protopic)tacrolimus oint 0.1% (Protopic)ULESFIA – benzyl alcohol lotion 5%VALCHLOR – mechlorethamine hcl gel

0.016% (base equivalent)•

VOLTAREN – diclofenac sodium gel 1%ZYCLARA – imiquimod cream 3.75%

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

ZYCLARA PUMP – imiquimod cream 2.5%ZYCLARA PUMP – imiquimod cream 3.75%MISCELLANEOUS CATEGORIES (includes suppliesand devices)DIABETIC SUPPLIESBLOOD GLUCOSE METER – BAYER

BREEZE 2, CONTOUR, CONTOUR LINK,CONTOUR NEXT EZ, CONTOUR NEXTLINK, DIDGET

BLOOD GLUCOSE METER – ROCHEACCU-CHEK AVIVA CONNECT, AVIVAPLUS, COMPACT PLUS, NANOSMARTVIEW

CALIBRATION LIQUID – BAYER ASCENSIAAUTODISC, BREEZE 2, CONTOUR,CONTOUR NEXT

CALIBRATION LIQUID – ROCHE ACCU-CHEK ACTIVE, AVIVA, COMPACTBLUE, COMPACT PLUS, INSTANT,SMARTVIEW; ACCUTREND

INSULIN ADMINISTRATION/INSULINPUMP SUPPLIES – VARIOUS

INSULIN PEN NEEDLES – VARIOUSINSULIN SYRINGES – VARIOUSLANCETS – BAYER, ROCHE, VARIOUSTEST STRIPS – BAYER ASCENSIA

AUTODISC, BREEZE 2, CONTOUR,CONTOUR NEXT

TEST STRIPS – ROCHE ACCU-CHEKACTIVE, AVIVA, AVIVA PLUS, COMPACT,COMPACT PLUS, SMARTVIEW;ACCUTREND

MEDICAL DEVICESINHALER ASSIST DEVICES - SPACERSMISCELLANEOUS DRUGSazathioprine tab 50 mg (Imuran)buprenorphine hcl-naloxone hcl sl tab

2-0.5 mg (base equiv)buprenorphine hcl-naloxone hcl sl tab

8-2 mg (base equiv)

2016


Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

CHEMET – succimer cap 100 mgCUPRIMINE – penicillamine cap 250 mgcyclosporine cap 25 mg (Sandimmune)cyclosporine cap 100 mg (Sandimmune)CYCLOSPORINE MODIFIED – cyclosporine

modified cap 50 mgcyclosporine modified cap 25 mg (Neoral)cyclosporine modified cap 100 mg

(Neoral)cyclosporine modified oral soln 100 mg/

ml (Neoral)mycophenolate mofetil cap 250 mg

(Cellcept)mycophenolate mofetil for oral susp

200 mg/ml (Cellcept)mycophenolate mofetil tab 500 mg

(Cellcept)mycophenolate sodium tab dr 180 mg

(mycophenolic acid equiv) (Myfortic)mycophenolate sodium tab dr 360 mg

(mycophenolic acid equiv) (Myfortic)naloxone hcl inj 0.4 mg/mlnaltrexone hcl tab 50 mg (Revia)RAPAMUNE – sirolimus oral soln 1 mg/mlREVLIMID – lenalidomide caps 2.5 mg •REVLIMID – lenalidomide cap 5 mg •REVLIMID – lenalidomide cap 10 mg •REVLIMID – lenalidomide cap 15 mg •REVLIMID – lenalidomide cap 20 mg •REVLIMID – lenalidomide cap 25 mg •sirolimus tab 0.5 mg (Rapamune)sirolimus tab 1 mg (Rapamune)sirolimus tab 2 mg (Rapamune)sodium polystyrene sulfonate oral susp

15 gm/60ml (Sps)sodium polystyrene sulfonate powder

(Kayexalate)

Drug Name Spe

cial

ty

Max

imum

Mon

thly

Qua

ntity

SUBOXONE – buprenorphine hcl-naloxonehcl sl film 2-0.5 mg (base equiv)

SUBOXONE – buprenorphine hcl-naloxonehcl sl film 4-1 mg (base equiv)



tacrolimus cap 0.5 mg (Prograf)tacrolimus cap 1 mg (Prograf)tacrolimus cap 5 mg (Prograf)THALOMID – thalidomide cap 50 mg •THALOMID – thalidomide cap 100 mg •THALOMID – thalidomide cap 150 mg •THALOMID – thalidomide cap 200 mg •ZORTRESS – everolimus tab 0.25 mgZORTRESS – everolimus tab 0.5 mgZORTRESS – everolimus tab 0.75 mg

2016


INDEX

Aabacavir sulfate-lamivudine-zidovudine tab300-150-300 mg (Trizivir).................................................. 4

abacavir sulfate tab 300 mg (base equiv) (Ziagen).........4acamprosate calcium tab delayed release 333 mg(Campral).......................................................................... 34

acarbose tab 25 mg (Precose)........................................ 12acarbose tab 50 mg (Precose)........................................ 12acarbose tab 100 mg (Precose)...................................... 12ACCU-CHEK ACTIVE STRIPS ACTIVE, AVIVA, AVIVAPLUS, COMPACT, COMPLAT PLUS, SMARTVIEW;ACCUTREND.................................................................... 48

acebutolol hcl cap 200 mg (Sectral)...............................17acebutolol hcl cap 400 mg (Sectral)...............................17acetaminophen-isometheptene-dichloral cap325-65-100 mg..................................................................38

acetaminophen w/ codeine soln 120-12 mg/5ml........... 35acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine)............................................................................ 35

acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3).......................................................................35

acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4).......................................................................35

acetazolamide cap sr 12hr 500 mg (Diamox)................ 20acetazolamide tab 250 mg............................................... 20acetic acid otic soln 2%...................................................45acetylcysteine inhal soln 10%.........................................23acetylcysteine inhal soln 20%.........................................23acitretin cap 10 mg (Soriatane).......................................47acitretin cap 17.5 mg (Soriatane)....................................47acitretin cap 25 mg (Soriatane).......................................47ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml(2000000 unit/0.5ml)........................................................... 6

acyclovir cap 200 mg (Zovirax).........................................4acyclovir susp 200 mg/5ml (Zovirax)............................... 4acyclovir tab 400 mg (Zovirax)..........................................4acyclovir tab 800 mg (Zovirax)..........................................4adapalene cream 0.1% (Differin).....................................45adapalene gel 0.1% (Differin).......................................... 45adapalene gel 0.3% (Differin).......................................... 45ADCIRCA – tadalafil tab 20 mg (pah)................................21adefovir dipivoxil tab 10 mg (Hepsera)............................3ADVAIR DISKUS – fluticasone-salmeterol aer powder ba100-50 mcg/dose...............................................................23

ADVAIR DISKUS – fluticasone-salmeterol aer powder ba250-50 mcg/dose...............................................................23

ADVAIR DISKUS – fluticasone-salmeterol aer powder ba500-50 mcg/dose...............................................................23

ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21mcg/act...............................................................................23

ADVAIR HFA – fluticasone-salmeterol inhal aerosol 115-21mcg/act...............................................................................23

ADVAIR HFA – fluticasone-salmeterol inhal aerosol230-21 mcg/act..................................................................23

AFINITOR DISPERZ – everolimus tab for oral susp 2mg........................................................................................ 7



AFINITOR – everolimus tab 2.5 mg.....................................6AFINITOR – everolimus tab 5 mg........................................7AFINITOR – everolimus tab 7.5 mg.....................................7AFINITOR – everolimus tab 10 mg......................................7ALBENZA – albendazole tab 200 mg.................................. 6albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)..........23albuterol sulfate soln nebu 0.5% (5 mg/ml)...................23albuterol sulfate soln nebu 0.63 mg/3ml (baseequiv).................................................................................23

albuterol sulfate soln nebu 1.25 mg/3ml (baseequiv).................................................................................23

albuterol sulfate syrup 2 mg/5ml....................................23albuterol sulfate tab 2 mg................................................23albuterol sulfate tab 4 mg................................................23alclometasone dipropionate cream 0.05%(Aclovate)..........................................................................46

alclometasone dipropionate oint 0.05%.........................46alendronate sodium tab 5 mg......................................... 14alendronate sodium tab 10 mg....................................... 14alendronate sodium tab 35 mg....................................... 14alendronate sodium tab 70 mg (Fosamax).................... 14alfuzosin hcl tab sr 24hr 10 mg (Uroxatral)................... 28ALKERAN – melphalan tab 2 mg.........................................7allopurinol tab 100 mg (Zyloprim).................................. 38allopurinol tab 300 mg (Zyloprim).................................. 38ALPRAZOLAM INTENSOL – alprazolam conc 1 mg/ml........................................................................................28

alprazolam tab 0.25 mg (Xanax)......................................28alprazolam tab 0.5 mg (Xanax)........................................28alprazolam tab 1 mg (Xanax)...........................................28alprazolam tab 2 mg (Xanax)...........................................28alprazolam tab sr 24hr 0.5 mg (Xanax xr)......................28alprazolam tab sr 24hr 1 mg (Xanax xr).........................28alprazolam tab sr 24hr 2 mg (Xanax xr).........................28alprazolam tab sr 24hr 3 mg (Xanax xr).........................28ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj500 unit..............................................................................41

ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj1000 unit............................................................................41



amantadine hcl cap 100 mg............................................ 40amantadine hcl syrup 50 mg/5ml....................................40AMICAR – aminocaproic acid syrup 25%..........................42AMICAR – aminocaproic acid tab 500 mg.........................41amiloride & hydrochlorothiazide tab 5-50 mg............... 20

2016


amiloride hcl tab 5 mg..................................................... 20amiodarone hcl tab 100 mg.............................................21amiodarone hcl tab 400 mg.............................................21amiodarone hcl tab 200 mg (Cordarone)....................... 21amitriptyline hcl tab 10 mg..............................................29amitriptyline hcl tab 25 mg..............................................29amitriptyline hcl tab 50 mg..............................................29amitriptyline hcl tab 75 mg..............................................29amitriptyline hcl tab 100 mg............................................29amitriptyline hcl tab 150 mg............................................29amlodipine besylate-atorvastatin calcium tab 2.5-10mg (Caduet)......................................................................22

amlodipine besylate-atorvastatin calcium tab 2.5-20mg (Caduet)......................................................................22

amlodipine besylate-atorvastatin calcium tab 2.5-40mg (Caduet)......................................................................22

amlodipine besylate-atorvastatin calcium tab 5-10 mg(Caduet).............................................................................22








amlodipine besylate-benazepril hcl cap 2.5-10 mg(Lotrel)...............................................................................18

amlodipine besylate-benazepril hcl cap 5-10 mg(Lotrel)...............................................................................18





amlodipine besylate tab 2.5 mg (Norvasc).................... 18amlodipine besylate tab 5 mg (Norvasc)....................... 18amlodipine besylate tab 10 mg (Norvasc)..................... 18amlodipine besylate-valsartan tab 5-160 mg(Exforge)........................................................................... 18

amlodipine besylate-valsartan tab 5-320 mg(Exforge)........................................................................... 18



amlodipine-valsartan-hydrochlorothiazide tab5-160-12.5 mg (Exforge hct)...........................................16

amlodipine-valsartan-hydrochlorothiazide tab 5-160-25mg (Exforge hct)..............................................................16

amlodipine-valsartan-hydrochlorothiazide tab10-160-12.5 mg (Exforge hct).........................................16

amlodipine-valsartan-hydrochlorothiazide tab10-160-25 mg (Exforge hct)............................................16

amlodipine-valsartan-hydrochlorothiazide tab10-320-25 mg (Exforge hct)............................................16

amoxicillin & k clavulanate for susp 200-28.5mg/5ml.................................................................................1

amoxicillin & k clavulanate for susp 400-57 mg/5ml...... 1amoxicillin & k clavulanate for susp 250-62.5 mg/5ml(Augmentin)........................................................................1

amoxicillin & k clavulanate for susp 600-42.9 mg/5ml(Augmentin es-600)...........................................................1

amoxicillin & k clavulanate tab 250-125 mg.................... 1amoxicillin & k clavulanate tab 500-125 mg(Augmentin)........................................................................1

amoxicillin & k clavulanate tab 875-125 mg(Augmentin)........................................................................1

amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg(Augmentin xr)...................................................................1

amoxicillin (trihydrate) cap 250 mg..................................1amoxicillin (trihydrate) cap 500 mg..................................1amoxicillin (trihydrate) chew tab 125 mg..............................1amoxicillin (trihydrate) chew tab 250 mg..............................1amoxicillin (trihydrate) for susp 125 mg/5ml...................1amoxicillin (trihydrate) for susp 200 mg/5ml...................1amoxicillin (trihydrate) for susp 250 mg/5ml...................1amoxicillin (trihydrate) for susp 400 mg/5ml...................1amoxicillin (trihydrate) tab 500 mg...................................1amoxicillin (trihydrate) tab 875 mg...................................1amphetamine-dextroamphetamine cap sr 24hr 5 mg(Adderall xr)..................................................................... 32

amphetamine-dextroamphetamine cap sr 24hr 10 mg(Adderall xr)..................................................................... 32





amphetamine-dextroamphetamine tab 5 mg(Adderall).......................................................................... 32

amphetamine-dextroamphetamine tab 7.5 mg(Adderall).......................................................................... 32


amphetamine-dextroamphetamine tab 12.5 mg(Adderall).......................................................................... 32


2016




ampicillin cap 250 mg........................................................ 1ampicillin cap 500 mg........................................................ 1ampicillin for susp 125 mg/5ml.............................................1ampicillin for susp 250 mg/5ml.............................................1anagrelide hcl cap 1 mg.................................................. 42anagrelide hcl cap 0.5 mg (Agrylin)............................... 42anastrozole tab 1 mg (Arimidex).......................................7ANDRODERM – testosterone td patch 24hr 2mg/24hr..............................................................................10

ANDRODERM – testosterone td patch 24hr 4mg/24hr..............................................................................10

ANDROGEL PUMP – testosterone td gel 20.25 mg/act(1.62%)...............................................................................10

ANDROGEL – testosterone td gel 20.25 mg/1.25gm(1.62%)...............................................................................10

ANDROGEL – testosterone td gel 40.5 mg/2.5gm(1.62%)...............................................................................10

ANDROXY – fluoxymesterone tab 10 mg..........................10ANORO ELLIPTA – umeclidinium-vilanterol aero powd ba62.5-25 mcg/inh.................................................................23

antipyrine-benzocaine otic soln 54-14 mg/ml(5.4-1.4%).......................................................................... 45

APTIVUS – tipranavir cap 250 mg.......................................4APTIVUS – tipranavir oral soln 100 mg/ml.......................... 4ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25mcg/ml................................................................................42

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 40mcg/ml................................................................................42

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 60mcg/ml................................................................................42

ARANESP ALBUMIN FREE – darbepoetin alfa soln inj100 mcg/ml........................................................................ 42



ARANESP ALBUMIN FREE – darbepoetin alfa solnprefilled syringe 10 mcg/0.4ml..........................................42

ARANESP ALBUMIN FREE – darbepoetin alfa solnprefilled syringe 25 mcg/0.42ml........................................42







ARANESP ALBUMIN FREE – darbepoetin alfa solnprefilled syringe 500 mcg/ml.............................................42

ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 100 mcg/act.................................................. 24

ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 200 mcg/act.................................................. 24

ASACOL HD – mesalamine tab delayed release 800mg...................................................................................... 27

ASMANEX HFA – mometasone furoate inhal aerosolsuspension 100 mcg/act................................................... 24

ASMANEX HFA – mometasone furoate inhal aerosolsuspension 200 mcg/act................................................... 24

ASMANEX TWISTHALER 120 ME – mometasone furoateinhal powd 220 mcg/inh (breath activated)...................... 24

ASMANEX TWISTHALER 14 MET – mometasone furoateinhal powd 220 mcg/inh (breath activated)...................... 24

ASMANEX TWISTHALER 30 MET – mometasone furoateinhal powd 110 mcg/inh (breath activated).......................24



ASTEPRO – azelastine hcl nasal spray 0.15% (205.5 mcg/spray)................................................................................. 23

atenolol & chlorthalidone tab 50-25 mg (Tenoretic50)...................................................................................... 17

atenolol & chlorthalidone tab 100-25 mg (Tenoretic100).................................................................................... 17

atenolol tab 25 mg (Tenormin)........................................ 17atenolol tab 50 mg (Tenormin)........................................ 17atenolol tab 100 mg (Tenormin)...................................... 17atorvastatin calcium tab 10 mg (base equivalent)(Lipitor)..............................................................................20

atorvastatin calcium tab 20 mg (base equivalent)(Lipitor)..............................................................................20



atovaquone-proguanil hcl tab 62.5-25 mg(Malarone)...........................................................................6

atovaquone-proguanil hcl tab 250-100 mg(Malarone)...........................................................................6

ATRIPLA – efavirenz-emtricitabine-tenofovir df tab600-200-300 mg.................................................................. 4

atropine sulfate ophth oint 1%............................................44atropine sulfate ophth soln 1% (Isopto atropine)......... 44ATROVENT HFA – ipratropium bromide hfa inhal aerosol17 mcg/act......................................................................... 24

AUGMENTIN – amoxicillin & k clavulanate for susp125-31.25 mg/5ml............................................................... 1

AVODART – dutasteride cap 0.5 mg................................. 28azathioprine tab 50 mg (Imuran).....................................48azelastine hcl nasal spray 0.1% (137 mcg/spray)......... 23azelastine hcl nasal spray 0.15% (205.5 mcg/spray)(Astepro)........................................................................... 23

2016


azelastine hcl ophth soln 0.05% (Optivar)..................... 44AZILECT – rasagiline mesylate tab 0.5 mg (baseequiv)................................................................................. 40

AZILECT – rasagiline mesylate tab 1 mg (base equiv)......40AZITHROMYCIN – azithromycin powd pack for susp 1gm........................................................................................ 2

azithromycin for susp 100 mg/5ml (Zithromax).............. 2azithromycin for susp 200 mg/5ml (Zithromax).............. 2azithromycin tab 250 mg (Zithromax).............................. 2azithromycin tab 500 mg (Zithromax).............................. 2azithromycin tab 600 mg (Zithromax).............................. 2AZOPT – brinzolamide ophth susp 1%..............................44

BBACITRACIN – bacitracin ophth oint 500 unit/gm............. 43bacitracin-polymyxin b ophth oint..................................43bacitracin-polymyxin-neomycin-hc ophth oint 1%.......44baclofen tab 10 mg...........................................................40baclofen tab 20 mg...........................................................40BACTROBAN NASAL – mupirocin calcium nasal oint2%...................................................................................... 23

balsalazide disodium cap 750 mg (Colazal).................. 27BANZEL – rufinamide susp 40 mg/ml................................38BANZEL – rufinamide tab 200 mg..................................... 38BANZEL – rufinamide tab 400 mg..................................... 38BARACLUDE – entecavir oral soln 0.05 mg/ml...................3benazepril & hydrochlorothiazide tab 5-6.25 mg.......... 15benazepril & hydrochlorothiazide tab 10-12.5 mg(Lotensin hct)...................................................................15

benazepril & hydrochlorothiazide tab 20-12.5 mg(Lotensin hct)...................................................................15

benazepril & hydrochlorothiazide tab 20-25 mg(Lotensin hct)...................................................................15

benazepril hcl tab 5 mg................................................... 15benazepril hcl tab 10 mg (Lotensin)...............................15benazepril hcl tab 20 mg (Lotensin)...............................15benazepril hcl tab 40 mg (Lotensin)...............................15BENICAR HCT – olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg................................. 16

BENICAR HCT – olmesartan medoxomil-hydrochlorothiazide tab 40-12.5 mg................................. 16

BENICAR HCT – olmesartan medoxomil-hydrochlorothiazide tab 40-25 mg.................................... 17

BENICAR – olmesartan medoxomil tab 5 mg....................16BENICAR – olmesartan medoxomil tab 20 mg..................16BENICAR – olmesartan medoxomil tab 40 mg..................16benzoyl peroxide-erythromycin gel 5-3%(Benzamycin)....................................................................45

benztropine mesylate tab 0.5 mg....................................40benztropine mesylate tab 1 mg.......................................40benztropine mesylate tab 2 mg.......................................40betamethasone dipropionate augmented cream 0.05%(Diprolene af)................................................................... 46

betamethasone dipropionate augmented gel0.05%................................................................................. 46

betamethasone dipropionate augmented lotion 0.05%(Diprolene)........................................................................ 46

betamethasone dipropionate augmented oint 0.05%(Diprolene)........................................................................ 46

betamethasone dipropionate cream 0.05%................... 46betamethasone dipropionate lotion 0.05%....................46betamethasone dipropionate oint 0.05%....................... 46betamethasone valerate cream 0.1%............................. 47betamethasone valerate lotion 0.1%.............................. 47betamethasone valerate oint 0.1%................................. 47BETASERON – interferon beta-1b for inj kit 0.3 mg.......... 33bexarotene cap 75 mg (Targretin).....................................7bicalutamide tab 50 mg (Casodex)...................................7BILTRICIDE – praziquantel tab 600 mg...............................6bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg(Ziac)..................................................................................17

bisoprolol & hydrochlorothiazide tab 5-6.25 mg(Ziac)..................................................................................17

bisoprolol & hydrochlorothiazide tab 10-6.25 mg(Ziac)..................................................................................17

bisoprolol fumarate tab 5 mg (Zebeta)...........................17bisoprolol fumarate tab 10 mg (Zebeta).........................17BLOOD GLUCOSE METER – BAYER BREEZE 2,CONTOUR, CONTOUR LINK, CONTOUR NEXT EZ,CONTOUR NEXT LINK, DIDGET.................................... 48

BLOOD GLUCOSE METER – ROCHE ACCU-CHEKAVIVA CONNECT, AVIVA PLUS, COMPACT PLUS,NANO SMARTVIEW......................................................... 48

BOSULIF – bosutinib tab 100 mg........................................ 7BOSULIF – bosutinib tab 500 mg........................................ 7BREO ELLIPTA – fluticasone furoate-vilanterol aero powdba 100-25 mcg/inh............................................................ 24

BREO ELLIPTA – fluticasone furoate-vilanterol aero powdba 200-25 mcg/inh............................................................ 24

brimonidine tartrate ophth soln 0.2%.............................44brimonidine tartrate ophth soln 0.15% (Alphaganp)........................................................................................ 44

bromocriptine mesylate cap 5 mg (Parlodel)................ 40bromocriptine mesylate tab 2.5 mg (Parlodel).............. 40budesonide cap sr 24hr 3 mg (Entocort ec)....................9budesonide inhalation susp 0.25 mg/2ml(Pulmicort)........................................................................ 24

budesonide inhalation susp 0.5 mg/2ml(Pulmicort)........................................................................ 24

budesonide inhalation susp 1 mg/2ml (Pulmicort).......24bumetanide tab 0.5 mg.................................................... 20bumetanide tab 1 mg........................................................20bumetanide tab 2 mg........................................................20buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (baseequiv).................................................................................48

buprenorphine hcl-naloxone hcl sl tab 8-2 mg (baseequiv).................................................................................48

buprenorphine hcl sl tab 2 mg (base equiv)................. 35buprenorphine hcl sl tab 8 mg (base equiv)................. 35bupropion hcl (smoking deterrent) tab sr 12hr 150 mg(Zyban).............................................................................. 34

2016


bupropion hcl tab 75 mg (Wellbutrin)............................ 29bupropion hcl tab 100 mg (Wellbutrin).......................... 29bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr).........29bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr).........29bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr).........29bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl)......... 29bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl)......... 29buspirone hcl tab 5 mg....................................................28buspirone hcl tab 10 mg..................................................28buspirone hcl tab 15 mg..................................................28buspirone hcl tab 30 mg..................................................28butalbital-acetaminophen-caffeine cap 50-325-40 mg(Esgic)............................................................................... 35

butalbital-acetaminophen-caffeine tab 50-325-40 mg(Esgic)............................................................................... 35

butalbital-acetaminophen tab 50-325 mg.......................34butalbital-aspirin-caffeine cap 50-325-40 mg(Fiorinal)............................................................................35

butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg(Fiorinal/codeine #3)....................................................... 35

BYDUREON – exenatide extended release for inj susp 2mg...................................................................................... 12

BYDUREON – exenatide extended release for susp pen-injector 2 mg......................................................................12

BYETTA – exenatide soln pen-injector 5 mcg/0.02ml........12BYETTA – exenatide soln pen-injector 10 mcg/0.04ml......12

Ccabergoline tab 0.5 mg.................................................... 14caffeine citrate oral soln 60 mg/3ml (10 mg/ml baseequiv) (Cafcit)...................................................................32

calcipotriene cream 0.005% (Dovonex)..........................47calcipotriene oint 0.005%.................................................47calcipotriene soln 0.005% (50 mcg/ml).......................... 48calcitonin (salmon) nasal soln 200 unit/act(Miacalcin)........................................................................ 14

calcitriol cap 0.25 mcg (Rocaltrol)..................................14calcitriol cap 0.5 mcg (Rocaltrol)....................................14calcitriol oral soln 1 mcg/ml (Rocaltrol).........................14calcium acetate (phosphate binder) cap 667 mg (169mg ca) (Phoslo)............................................................... 27

calcium acetate (phosphate binder) tab 667 mg(Eliphos)............................................................................27

CALIBRATION LIQUID – ASCENSIA AUTODISC,BREEZE 2, CONTOUR, CONTOUR NEXT..................... 48

CALIBRATION LIQUID – ROCHE ACCU-CHEK ACTIVE,AVIVA, COMPACT BLUE, COMPACT PLUS, INSTANT,SMARTVIEW; ACCUTREND............................................48

CANASA – mesalamine suppos 1000 mg......................... 27candesartan cilexetil-hydrochlorothiazide tab 16-12.5mg (Atacand hct).............................................................17

candesartan cilexetil-hydrochlorothiazide tab 32-12.5mg (Atacand hct).............................................................17

candesartan cilexetil-hydrochlorothiazide tab 32-25mg (Atacand hct).............................................................17

candesartan cilexetil tab 4 mg (Atacand)...................... 17

candesartan cilexetil tab 8 mg (Atacand)...................... 17candesartan cilexetil tab 16 mg (Atacand).................... 17candesartan cilexetil tab 32 mg (Atacand).................... 17capecitabine tab 150 mg (Xeloda).................................... 7capecitabine tab 500 mg (Xeloda).................................... 7CAPRELSA – vandetanib tab 100 mg................................. 7CAPRELSA – vandetanib tab 300 mg................................. 7captopril & hydrochlorothiazide tab 25-15 mg....................15captopril & hydrochlorothiazide tab 50-15 mg....................15captopril tab 12.5 mg........................................................15captopril tab 25 mg...........................................................15captopril tab 50 mg...........................................................15captopril tab 100 mg.........................................................15CARAC – fluorouracil cream 0.5%.....................................48CARAFATE – sucralfate susp 1 gm/10ml.......................... 25carbamazepine cap sr 12hr 100 mg (Carbatrol)............38carbamazepine cap sr 12hr 200 mg (Carbatrol)............38carbamazepine cap sr 12hr 300 mg (Carbatrol)............38carbamazepine chew tab 100 mg................................... 38carbamazepine susp 100 mg/5ml (Tegretol)..................38carbamazepine tab 200 mg (Tegretol)............................38carbamazepine tab sr 12hr 200 mg (Tegretol-xr).......... 38carbamazepine tab sr 12hr 400 mg (Tegretol-xr).......... 38carbidopa & levodopa orally disintegrating tab 10-100mg...................................................................................... 40

carbidopa & levodopa orally disintegrating tab 25-100mg...................................................................................... 40

carbidopa & levodopa orally disintegrating tab 25-250mg...................................................................................... 40

carbidopa & levodopa tab cr 25-100 mg (Sinemetcr).......................................................................................40

carbidopa & levodopa tab cr 50-200 mg (Sinemetcr).......................................................................................40

carbidopa & levodopa tab 10-100 mg (Sinemet)...........40carbidopa & levodopa tab 25-100 mg (Sinemet)...........40carbidopa & levodopa tab 25-250 mg (Sinemet)...........40carteolol hcl ophth soln 1%............................................ 44carvedilol tab 3.125 mg (Coreg)......................................17carvedilol tab 6.25 mg (Coreg)........................................17carvedilol tab 12.5 mg (Coreg)........................................17carvedilol tab 25 mg (Coreg)...........................................17cefaclor cap 250 mg........................................................... 1cefaclor cap 500 mg........................................................... 1cefadroxil cap 500 mg........................................................1cefadroxil for susp 250 mg/5ml........................................ 1cefadroxil for susp 500 mg/5ml........................................ 1cefadroxil tab 1 gm.............................................................1cefdinir cap 300 mg............................................................1cefdinir for susp 125 mg/5ml............................................ 1cefdinir for susp 250 mg/5ml............................................ 1cefixime for susp 100 mg/5ml (Suprax)........................... 1cefixime for susp 200 mg/5ml (Suprax)........................... 1cefpodoxime proxetil for susp 50 mg/5ml....................... 1cefpodoxime proxetil for susp 100 mg/5ml..................... 1cefpodoxime proxetil tab 100 mg..................................... 1cefpodoxime proxetil tab 200 mg..................................... 1

2016


cefprozil for susp 125 mg/5ml...........................................1cefprozil for susp 250 mg/5ml...........................................1cefprozil tab 250 mg...........................................................1cefprozil tab 500 mg...........................................................1CEFTIN – cefuroxime axetil for susp 125 mg/5ml............... 1ceftriaxone sodium for inj 2 gm........................................1ceftriaxone sodium for inj 1 gm (Rocephin)....................1ceftriaxone sodium for inj 250 mg....................................1ceftriaxone sodium for inj 500 mg (Rocephin)................1cefuroxime axetil tab 250 mg (Ceftin).............................. 1cefuroxime axetil tab 500 mg (Ceftin).............................. 2celecoxib cap 50 mg (Celebrex)......................................37celecoxib cap 100 mg (Celebrex)....................................37celecoxib cap 200 mg (Celebrex)....................................37celecoxib cap 400 mg (Celebrex)....................................37CELONTIN – methsuximide cap 300 mg...........................38cephalexin cap 250 mg (Keflex)........................................2cephalexin cap 500 mg (Keflex)........................................2cephalexin for susp 125 mg/5ml.......................................2cephalexin for susp 250 mg/5ml.......................................2cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)................... 23CETROTIDE – cetrorelix acetate for inj kit 0.25 mg.......... 12cevimeline hcl cap 30 mg (Evoxac)................................45CHANTIX CONTINUING MONTH – varenicline tartrate tab1 mg (base equiv).............................................................34

CHANTIX STARTING MONTH PA – varenicline tartratetab 0.5 mg x 11 & tab 1 mg x 42 pack............................. 34

CHANTIX – varenicline tartrate tab 0.5 mg (baseequiv)................................................................................. 34

CHANTIX – varenicline tartrate tab 1 mg (base equiv)......34CHEMET – succimer cap 100 mg......................................49CHENODAL – chenodiol tab 250 mg.................................27chlorhexidine gluconate soln 0.12% (Peridex)..............45chloroquine phosphate tab 250 mg..................................6chloroquine phosphate tab 500 mg (Aralen)...................6chlorothiazide tab 500 mg............................................... 20chlorpromazine hcl tab 10 mg........................................ 30chlorpromazine hcl tab 25 mg........................................ 30chlorpromazine hcl tab 50 mg........................................ 30chlorpromazine hcl tab 100 mg...................................... 30chlorpromazine hcl tab 200 mg...................................... 30chlorzoxazone tab 500 mg (Parafon forte dsc)............. 40cholestyramine light powder 4 gm/dose (Questranlight)...................................................................................20

cholestyramine light powder packets 4 gm.................. 20cholestyramine powder 4 gm/dose (Questran).............20cholestyramine powder packets 4 gm (Questran)........20choline fenofibrate cap dr 45 mg (fenofibric acidequiv) (Trilipix).................................................................20

choline fenofibrate cap dr 135 mg (fenofibric acidequiv) (Trilipix).................................................................20

chorionic gonadotropin for inj 10000 unit..................... 12CIALIS – tadalafil tab 2.5 mg............................................. 22CIALIS – tadalafil tab 5 mg................................................ 22CIALIS – tadalafil tab 10 mg.............................................. 22CIALIS – tadalafil tab 20 mg.............................................. 22

ciclopirox gel 0.77% (Loprox)......................................... 46ciclopirox olamine cream 0.77% (base equiv)...............46ciclopirox olamine susp 0.77% (base equiv).................46ciclopirox shampoo 1% (Loprox shampoo).................. 46ciclopirox solution 8% (Penlac nail lacquer).................46cilostazol tab 50 mg (Pletal)............................................42cilostazol tab 100 mg (Pletal)..........................................42CILOXAN – ciprofloxacin hcl ophth oint 0.3%................... 43cimetidine hcl soln 300 mg/5ml...................................... 25cimetidine tab 300 mg......................................................25cimetidine tab 400 mg......................................................25cimetidine tab 800 mg......................................................25CINRYZE – c1 esterase inhibitor (human) for iv inj 500unit......................................................................................42

CIPRODEX – ciprofloxacin-dexamethasone otic susp0.3-0.1%.............................................................................45

ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000mg(base eq) (Cipro xr)..................................................... 3

ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg(base eq) (Cipro xr)...........................................................3

ciprofloxacin for oral susp 250 mg/5ml (5%) (5gm/100ml) (Cipro)..............................................................3

ciprofloxacin for oral susp 500 mg/5ml (10%) (10gm/100ml) (Cipro)..............................................................3

ciprofloxacin hcl ophth soln 0.3% (Ciloxan)................. 43ciprofloxacin hcl tab 750 mg (base equiv).......................3ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)..........3ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)..........3citalopram hydrobromide oral soln 10 mg/5ml............. 29citalopram hydrobromide tab 10 mg (base equiv)(Celexa)............................................................................. 29

citalopram hydrobromide tab 20 mg (base equiv)(Celexa)............................................................................. 29

citalopram hydrobromide tab 40 mg (base equiv)(Celexa)............................................................................. 29

clarithromycin for susp 125 mg/5ml.................................2clarithromycin for susp 250 mg/5ml (Biaxin).................. 2clarithromycin tab 250 mg (Biaxin).................................. 2clarithromycin tab 500 mg (Biaxin).................................. 2clarithromycin tab sr 24hr 500 mg (Biaxin xl pac)..........2CLEOCIN – clindamycin phosphate vaginal suppos 100mg...................................................................................... 28

CLIMARA PRO – estradiol-levonorgestrel td patch weekly0.045-0.015 mg/day.......................................................... 10

clindamycin hcl cap 75 mg (Cleocin)...............................6clindamycin hcl cap 150 mg (Cleocin).............................6clindamycin hcl cap 300 mg (Cleocin).............................6clindamycin palmitate hcl for soln 75 mg/5ml (baseequiv) (Cleocin pediatric gr)............................................ 6

clindamycin phosphate-benzoyl peroxide gel 1-5%(Benzaclin)........................................................................45

clindamycin phosphate gel 1% (Cleocin-t)....................45clindamycin phosphate lotion 1% (Cleocin-t)............... 45clindamycin phosphate soln 1% (Cleocin-t)..................45clindamycin phosphate swab 1% (Cleocin-t)................ 45

2016


clindamycin phosphate vaginal cream 2%(Cleocin)............................................................................28

clindamycin phosph-benzoyl peroxide (refrig) gel 1.2(1)-5% (Duac)....................................................................45

clobetasol propionate cream 0.05% (Temovate)...........47clobetasol propionate emollient base cream 0.05%(Temovate e).....................................................................47

clobetasol propionate foam 0.05% (Olux)......................47clobetasol propionate gel 0.05% (Temovate)................ 47clobetasol propionate oint 0.05% (Temovate)...............47clobetasol propionate soln 0.05% (Temovate).............. 47clomiphene citrate tab 50 mg (Clomid)..........................12clomipramine hcl cap 25 mg (Anafranil)........................29clomipramine hcl cap 50 mg (Anafranil)........................29clomipramine hcl cap 75 mg (Anafranil)........................29clonazepam tab 0.5 mg (Klonopin).................................38clonazepam tab 1 mg (Klonopin)....................................38clonazepam tab 2 mg (Klonopin)....................................38clonidine hcl tab 0.1 mg (Catapres)............................... 22clonidine hcl tab 0.2 mg (Catapres)............................... 22clonidine hcl tab 0.3 mg (Catapres)............................... 22clonidine hcl td patch weekly 0.1 mg/24hr (Catapres-tts-1)...................................................................................22

clonidine hcl td patch weekly 0.2 mg/24hr (Catapres-tts-2)...................................................................................22

clonidine hcl td patch weekly 0.3 mg/24hr (Catapres-tts-3)...................................................................................22

clopidogrel bisulfate tab 75 mg (base equiv)(Plavix).............................................................................. 42

clotrimazole troche 10 mg............................................... 45clozapine tab 50 mg......................................................... 30clozapine tab 200 mg....................................................... 30clozapine tab 25 mg (Clozaril).........................................30clozapine tab 100 mg (Clozaril).......................................30COARTEM – artemether-lumefantrine tab 20-120 mg........ 6codeine sulfate tab 30 mg............................................... 35codeine sulfate tab 60 mg............................................... 35codeine sulfate tab 15 mg (Codeine sulfate).................35colchicine w/ probenecid tab 0.5-500 mg...................... 38colestipol hcl granule packets 5 gm (Colestidflavored)............................................................................20

colestipol hcl granules 5 gm (Colestid flavored).......... 20colestipol hcl tab 1 gm (Colestid)...................................20COMBIVENT RESPIMAT – ipratropium-albuterol inhalaerosol soln 20-100 mcg/act............................................ 24

COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60mg dose) kit.........................................................................7

COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20mg (100 dose) kit................................................................ 7

COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20mg (140 dose) kit................................................................ 7

COMPLERA – emtricitabine-rilpivirine-tenofovir df tab200-25-300 mg.................................................................... 4

COPAXONE – glatiramer acetate soln prefilled syringe 20mg/ml..................................................................................33

COPAXONE – glatiramer acetate soln prefilled syringe 40mg/ml..................................................................................33

CORTANE-B AQUEOUS – pramoxine-hc-chloroxylenolaqueous otic soln 10-10-1 mg/ml..................................... 45

CORTIFOAM – hydrocortisone acetate rectal foam 10%(90 mg/dose)..................................................................... 45

cortisone acetate tab 25 mg.................................................9CREON – pancrelipase (lip-prot-amyl) dr cap3000-9500-15000 unit....................................................... 26

CREON – pancrelipase (lip-prot-amyl) dr cap6000-19000-30000 unit..................................................... 26

CREON – pancrelipase (lip-prot-amyl) dr cap12000-38000-60000 unit...................................................26

CREON – pancrelipase (lip-prot-amyl) dr cap24000-76000-120000 unit.................................................26

CREON – pancrelipase (lip-prot-amyl) dr cap36000-114000-180000 unit............................................... 26

CRESTOR – rosuvastatin calcium tab 5 mg......................20CRESTOR – rosuvastatin calcium tab 10 mg....................20CRESTOR – rosuvastatin calcium tab 20 mg....................20CRESTOR – rosuvastatin calcium tab 40 mg....................20CRIXIVAN – indinavir sulfate cap 200 mg........................... 4CRIXIVAN – indinavir sulfate cap 400 mg........................... 4cromolyn sodium ophth soln 4%....................................44CUPRIMINE – penicillamine cap 250 mg.......................... 49cyanocobalamin inj 1000 mcg/ml................................... 42cyclobenzaprine hcl tab 5 mg.........................................40cyclobenzaprine hcl tab 10 mg.......................................40cyclopentolate hcl ophth soln 1% (Cyclogyl)................44CYCLOPHOSPHAMIDE – cyclophosphamide cap 25mg........................................................................................ 7

CYCLOPHOSPHAMIDE – cyclophosphamide cap 50mg........................................................................................ 7

cyclosporine cap 25 mg (Sandimmune)........................ 49cyclosporine cap 100 mg (Sandimmune)...................... 49cyclosporine modified cap 25 mg (Neoral)....................49cyclosporine modified cap 100 mg (Neoral)..................49CYCLOSPORINE MODIFIED – cyclosporine modified cap50 mg.................................................................................49

cyclosporine modified oral soln 100 mg/ml(Neoral)..............................................................................49

cyproheptadine hcl syrup 2 mg/5ml...............................23cyproheptadine hcl tab 4 mg.......................................... 23CYSTAGON – cysteamine bitartrate cap 50 mg................28CYSTAGON – cysteamine bitartrate cap 150 mg..............28CYTRA-3 – pot & sod citrates w/ cit ac syrup 550-500-334mg/5ml............................................................................... 28

DDAKLINZA – daclatasvir dihydrochloride tab 30 mg (baseequivalent)............................................................................4

DAKLINZA – daclatasvir dihydrochloride tab 60 mg (baseequivalent)............................................................................4

danazol cap 50 mg............................................................10danazol cap 100 mg..........................................................10danazol cap 200 mg..........................................................10

2016


dantrolene sodium cap 25 mg (Dantrium)..................... 41dantrolene sodium cap 50 mg (Dantrium)..................... 41dapsone tab 25 mg...............................................................6dapsone tab 100 mg.............................................................6DARAPRIM – pyrimethamine tab 25 mg............................. 6DELZICOL – mesalamine cap dr 400 mg..........................27demeclocycline hcl tab 150 mg........................................ 2demeclocycline hcl tab 300 mg........................................ 2DENAVIR – penciclovir cream 1%..................................... 46desipramine hcl tab 10 mg (Norpramin)........................ 29desipramine hcl tab 25 mg (Norpramin)........................ 29desipramine hcl tab 50 mg (Norpramin)........................ 29desipramine hcl tab 75 mg (Norpramin)........................ 29desipramine hcl tab 100 mg (Norpramin)...................... 29desipramine hcl tab 150 mg (Norpramin)...................... 29desloratadine tab 5 mg (Clarinex).................................. 23desloratadine tab orally disintegrating 2.5 mg(Clarinex reditabs)...........................................................23

desloratadine tab orally disintegrating 5 mg (Clarinexreditabs)............................................................................23

desmopressin acetate nasal soln 0.01% (refrigerated)(Ddavp)..............................................................................15

desmopressin acetate nasal spray soln 0.01%(Ddavp)..............................................................................15

desmopressin acetate nasal spray soln 0.01%(refrigerated).....................................................................15

desmopressin acetate tab 0.1 mg (Ddavp)....................15desmopressin acetate tab 0.2 mg (Ddavp)....................15desogest-eth estrad & eth estrad tab 0.15-0.02/0.01mg(21/5) (kimidess).........................................................11

desogest-ethin est tab0.1-0.025/0.125-0.025/0.15-0.025mg-mg (Cyclessa).....11

desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg(Desogen)......................................................................... 11

desonide cream 0.05% (Desowen)................................. 47desonide lotion 0.05% (Desowen).................................. 47desonide oint 0.05% (Desowen)......................................47desoximetasone cream 0.05%........................................... 47desoximetasone cream 0.25% (Topicort).......................47desoximetasone gel 0.05% (Topicort)............................ 47desoximetasone oint 0.25% (Topicort)...........................47dexamethasone elixir 0.5 mg/5ml..................................... 9DEXAMETHASONE INTENSOL – dexamethasone conc 1mg/ml....................................................................................9

dexamethasone soln 0.5 mg/5ml......................................... 9dexamethasone tab 0.5 mg............................................... 9dexamethasone tab 0.75 mg............................................. 9dexamethasone tab 1 mg.....................................................9dexamethasone tab 1.5 mg............................................... 9dexamethasone tab 2 mg.....................................................9dexamethasone tab 4 mg.................................................. 9dexamethasone tab 6 mg.................................................. 9dextroamphetamine sulfate cap sr 24hr 5 mg(Dexedrine)....................................................................... 32

dextroamphetamine sulfate cap sr 24hr 10 mg(Dexedrine)....................................................................... 32

dextroamphetamine sulfate cap sr 24hr 15 mg(Dexedrine)....................................................................... 32

dextroamphetamine sulfate tab 5 mg.............................32DIASTAT ACUDIAL – diazepam rectal gel delivery system10 mg.................................................................................38

DIASTAT ACUDIAL – diazepam rectal gel delivery system20 mg.................................................................................39

DIASTAT PEDIATRIC – diazepam rectal gel deliverysystem 2.5 mg...................................................................39

diazepam soln 1 mg/ml...................................................... 28diazepam tab 2 mg (Valium)............................................28diazepam tab 5 mg (Valium)............................................28diazepam tab 10 mg (Valium)..........................................29diclofenac potassium tab 50 mg (Cataflam)..................37diclofenac sodium (actinic keratoses) gel 3%(Solaraze)..........................................................................48

diclofenac sodium ophth soln 0.1%...............................44diclofenac sodium tab delayed release 25 mg..............37diclofenac sodium tab delayed release 50 mg..............37diclofenac sodium tab delayed release 75 mg..............37diclofenac sodium tab sr 24hr 100 mg (Voltaren-xr).......................................................................................37

dicloxacillin sodium cap 250 mg...................................... 1dicloxacillin sodium cap 500 mg...................................... 1dicyclomine hcl cap 10 mg (Bentyl)...............................25dicyclomine hcl oral soln 10 mg/5ml............................. 25dicyclomine hcl tab 20 mg (Bentyl)................................25didanosine delayed release capsule 125 mg (Videxec)........................................................................................ 4

didanosine delayed release capsule 200 mg (Videxec)........................................................................................ 4



diflorasone diacetate cream 0.05%....................................47digoxin oral soln 0.05 mg/ml.............................................. 22digoxin tab 125 mcg (0.125 mg) (Lanoxin).................... 22digoxin tab 250 mcg (0.25 mg) (Lanoxin)...................... 22DILANTIN – phenytoin sodium extended cap 30 mg.........39DILANTIN – phenytoin sodium extended cap 100 mg.......39DILANTIN-125 – phenytoin susp 125 mg/5ml................... 39DILAUDID – hydromorphone hcl preservative free (pf) inj 2mg/ml..................................................................................35

DILAUDID – hydromorphone hcl preservative free (pf) inj 4mg/ml..................................................................................35

diltiazem hcl cap sr 24hr 120 mg....................................18diltiazem hcl cap sr 24hr 180 mg....................................18diltiazem hcl cap sr 24hr 240 mg (Dilacor xr)................19diltiazem hcl coated beads cap sr 24hr 120 mg(Cardizem cd)...................................................................19

diltiazem hcl coated beads cap sr 24hr 180 mg(Cardizem cd)...................................................................19


2016




diltiazem hcl extended release beads cap sr 24hr 120mg (Tiazac).......................................................................19






diltiazem hcl tab 90 mg....................................................19diltiazem hcl tab 30 mg (Cardizem)................................19diltiazem hcl tab 60 mg (Cardizem)................................19diltiazem hcl tab 120 mg (Cardizem)..............................19diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml.................25diphenoxylate w/ atropine tab 2.5-0.025 mg(Lomotil)............................................................................25

dipyridamole tab 25 mg (Persantine)............................. 42dipyridamole tab 50 mg (Persantine)............................. 42dipyridamole tab 75 mg (Persantine)............................. 42disopyramide phosphate cap 100 mg (Norpace).......... 21disopyramide phosphate cap 150 mg (Norpace).......... 21disulfiram tab 250 mg (Antabuse).................................. 34disulfiram tab 500 mg (Antabuse).................................. 34divalproex sodium cap sprinkle 125 mg (Depakotesprinkles).......................................................................... 39

divalproex sodium tab delayed release 125 mg(Depakote)........................................................................ 39



divalproex sodium tab sr 24 hr 250 mg (Depakoteer).......................................................................................39

divalproex sodium tab sr 24 hr 500 mg (Depakoteer).......................................................................................39

DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%)...........10DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%)...............10DIVIGEL – estradiol td gel 1 mg/gm (0.1%).......................10donepezil hydrochloride orally disintegrating tab 5 mg(Aricept odt)..................................................................... 34

donepezil hydrochloride orally disintegrating tab 10mg (Aricept odt).............................................................. 34

donepezil hydrochloride tab 5 mg (Aricept)..................34donepezil hydrochloride tab 10 mg (Aricept)................34DONNATAL – pb-hyoscy-atrop-scopol tab16.2-0.1037-0.0194-0.0065 mg........................................ 25

dorzolamide hcl ophth soln 2% (Trusopt)..................... 44dorzolamide hcl-timolol maleate ophth soln 22.3-6.8mg/ml (Cosopt)................................................................ 44

doxazosin mesylate tab 1 mg (Cardura)........................22doxazosin mesylate tab 2 mg (Cardura)........................22doxazosin mesylate tab 4 mg (Cardura)........................22doxazosin mesylate tab 8 mg (Cardura)........................22doxepin hcl cap 10 mg.....................................................29doxepin hcl cap 25 mg.....................................................29doxepin hcl cap 50 mg.....................................................29doxepin hcl cap 100 mg...................................................29doxepin hcl conc 10 mg/ml............................................. 29doxycycline hyclate cap 50 mg.........................................2doxycycline hyclate cap 100 mg (Vibramycin)................2doxycycline hyclate tab 20 mg......................................... 2doxycycline hyclate tab 100 mg....................................... 2doxycycline monohydrate cap 50 mg.............................. 2doxycycline monohydrate cap 150 mg (Adoxa)..............2doxycycline monohydrate cap 75 mg (Monodox)...........2doxycycline monohydrate cap 100 mg (Monodox).........2doxycycline monohydrate tab 50 mg (Adoxa)................ 2doxycycline monohydrate tab 75 mg (Adoxa)................ 2doxycycline monohydrate tab 100 mg (Adoxa pak1/100)................................................................................... 2

doxycycline monohydrate tab 150 mg (Adoxa pak1/150)................................................................................... 2

drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin28)...................................................................................... 11

drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)......11DRYSOL – aluminum chloride soln 20%........................... 48DULERA – mometasone furoate-formoterol fumarateaerosol 100-5 mcg/act...................................................... 24

DULERA – mometasone furoate-formoterol fumarateaerosol 200-5 mcg/act...................................................... 24

duloxetine hcl enteric coated pellets cap 20 mg(Cymbalta)........................................................................ 29



dutasteride cap 0.5 mg (Avodart)................................... 28DUTOPROL – metoprolol & hydrochlorothiazide tab sr24hr 25-12.5 mg................................................................17

DUTOPROL – metoprolol & hydrochlorothiazide tab sr24hr 50-12.5 mg................................................................18

DUTOPROL – metoprolol & hydrochlorothiazide tab sr24hr 100-12.5 mg..............................................................18

Eeconazole nitrate cream 1%............................................ 46EDURANT – rilpivirine hcl tab 25 mg (base equivalent)...... 4E.E.S. 400 – erythromycin ethylsuccinate tab 400 mg........ 2ELIDEL – pimecrolimus cream 1%.................................... 48ELIQUIS – apixaban tab 2.5 mg........................................ 42ELIQUIS – apixaban tab 5 mg........................................... 42ELLA – ulipristal acetate tab 30 mg...................................11ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj250 unit..............................................................................42

2016


ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj500 unit..............................................................................42

ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj750 unit..............................................................................42

ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj1000 unit............................................................................42




EMCYT – estramustine phosphate sodium cap 140 mg......7EMEND – aprepitant capsule 40 mg..................................26EMEND – aprepitant capsule 80 mg..................................26EMEND – aprepitant capsule 125 mg................................26EMEND – aprepitant capsule therapy pack 80 & 125mg...................................................................................... 26

EMTRIVA – emtricitabine caps 200 mg............................... 4EMTRIVA – emtricitabine soln 10 mg/ml............................. 4enalapril maleate & hydrochlorothiazide tab 5-12.5mg...................................................................................... 15

enalapril maleate & hydrochlorothiazide tab 10-25 mg(Vaseretic).........................................................................16

enalapril maleate tab 2.5 mg (Vasotec)..........................16enalapril maleate tab 5 mg (Vasotec).............................16enalapril maleate tab 10 mg (Vasotec)...........................16enalapril maleate tab 20 mg (Vasotec)...........................16ENBREL – etanercept for subcutaneous inj kit 25 mg.......37ENBREL – etanercept subcutaneous soln prefilled syringe25 mg/0.5ml.......................................................................37

ENBREL – etanercept subcutaneous soln prefilled syringe50 mg/ml............................................................................37

ENBREL SURECLICK – etanercept subcutaneoussolution auto-injector 50 mg/ml.........................................37

ENCARE – nonoxynol-9 vaginal suppos 100 mg.............. 28enoxaparin sodium inj 30 mg/0.3ml (Lovenox)............. 42enoxaparin sodium inj 40 mg/0.4ml (Lovenox)............. 42enoxaparin sodium inj 60 mg/0.6ml (Lovenox)............. 42enoxaparin sodium inj 80 mg/0.8ml (Lovenox)............. 42enoxaparin sodium inj 100 mg/ml (Lovenox)................ 42enoxaparin sodium inj 120 mg/0.8ml (Lovenox)........... 42enoxaparin sodium inj 150 mg/ml (Lovenox)................ 42enoxaparin sodium inj 300 mg/3ml (Lovenox).............. 42entacapone tab 200 mg (Comtan)...................................40entecavir tab 0.5 mg (Baraclude)......................................4entecavir tab 1 mg (Baraclude).........................................4EPIDUO – adapalene-benzoyl peroxide gel 0.1-2.5%.......45EPIDUO FORTE – adapalene-benzoyl peroxide gel0.3-2.5%.............................................................................46

EPIPEN-JR 2-PAK – epinephrine solution auto-injector0.15 mg/0.3ml (1:2000).....................................................23

EPIPEN 2-PAK – epinephrine solution auto-injector 0.3mg/0.3ml (1:1000)............................................................. 23

EPIVIR HBV – lamivudine oral soln 5 mg/ml (hbv)..............4eplerenone tab 25 mg (Inspra)........................................22

eplerenone tab 50 mg (Inspra)........................................22EPZICOM – abacavir sulfate-lamivudine tab 600-300mg........................................................................................ 4

ergocalciferol cap 50000 unit (Drisdol)..........................41ERIVEDGE – vismodegib cap 150 mg................................ 7ERY-TAB – erythromycin tab delayed release 250 mg........2ERY-TAB – erythromycin tab delayed release 333 mg........2ERY-TAB – erythromycin tab delayed release 500 mg........2ERYTHROCIN STEARATE – erythromycin stearate tab250 mg.................................................................................2

ERYTHROMYCIN BASE – erythromycin tab 250 mg..........2ERYTHROMYCIN BASE – erythromycin tab 500 mg..........2erythromycin ethylsuccinate tab 400 mg..............................2erythromycin gel 2% (Erygel)..........................................46erythromycin ophth oint 5 mg/gm..................................43erythromycin pads 2%..................................................... 46erythromycin soln 2%...................................................... 46erythromycin w/ delayed release particles cap 250mg........................................................................................ 2

escitalopram oxalate soln 5 mg/5ml (base equiv)(Lexapro)...........................................................................29

escitalopram oxalate tab 5 mg (base equiv)(Lexapro)...........................................................................29



esomeprazole magnesium cap delayed release 20 mg(base eq) (Nexium)..........................................................25

esomeprazole magnesium cap delayed release 40 mg(base eq) (Nexium)..........................................................25

estazolam tab 1 mg.......................................................... 32estazolam tab 2 mg.......................................................... 32ESTRACE – estradiol vaginal cream 0.1 mg/gm...............28estradiol & norethindrone acetate tab 0.5-0.1 mg(Activella)..........................................................................10

estradiol & norethindrone acetate tab 1-0.5 mg(Activella)..........................................................................10

estradiol tab 0.5 mg (Estrace).........................................10estradiol tab 1 mg (Estrace)............................................10estradiol tab 2 mg (Estrace)............................................10estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot).....................................................................................10

estradiol td patch twice weekly 0.0375 mg/24hr(Vivelle-dot)...................................................................... 10

estradiol td patch twice weekly 0.05 mg/24hr (Vivelle-dot).....................................................................................10



estradiol td patch weekly 0.025 mg/24hr (Climara).......10estradiol td patch weekly 0.05 mg/24hr (Climara).........10estradiol td patch weekly 0.06 mg/24hr (Climara).........10estradiol td patch weekly 0.075 mg/24hr (Climara).......10estradiol td patch weekly 0.1 mg/24hr (Climara)...........10

2016


estradiol td patch weekly 0.0375 mg/24hr (37.5mcg/24hr) (Climara).........................................................10

estropipate tab 0.75 mg................................................... 10estropipate tab 1.5 mg..................................................... 10eszopiclone tab 1 mg (Lunesta)......................................32eszopiclone tab 2 mg (Lunesta)......................................32eszopiclone tab 3 mg (Lunesta)......................................32ethambutol hcl tab 100 mg (Myambutol)......................... 3ethambutol hcl tab 400 mg (Myambutol)......................... 3ethosuximide cap 250 mg (Zarontin)..............................39ethosuximide soln 250 mg/5ml (Zarontin)..................... 39ethynodiol diacetate & ethinyl estradiol tab 1 mg-35mcg....................................................................................11

etodolac cap 200 mg........................................................ 37etodolac cap 300 mg........................................................ 37etodolac tab 400 mg.........................................................37etodolac tab 500 mg.........................................................37etodolac tab sr 24hr 400 mg........................................... 37etodolac tab sr 24hr 500 mg........................................... 37etodolac tab sr 24hr 600 mg........................................... 37etoposide cap 50 mg............................................................ 7EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg(base equiv).........................................................................4

exemestane tab 25 mg (Aromasin)...................................7F

FABRAZYME – agalsidase beta for iv soln 5 mg.............. 15FABRAZYME – agalsidase beta for iv soln 35 mg............ 15famciclovir tab 125 mg (Famvir)....................................... 4famciclovir tab 250 mg (Famvir)....................................... 4famciclovir tab 500 mg (Famvir)....................................... 4famotidine tab 20 mg (Pepcid)........................................25famotidine tab 40 mg (Pepcid)........................................25FARESTON – toremifene citrate tab 60 mg (baseequivalent)............................................................................7

FARYDAK – panobinostat lactate cap 10 mg (baseequivalent)............................................................................7



FC FEMALE CONDOM – condoms - female.....................11FC2 FEMALE CONDOM – condoms - female...................11felodipine tab sr 24hr 2.5 mg.......................................... 19felodipine tab sr 24hr 5 mg............................................. 19felodipine tab sr 24hr 10 mg........................................... 19fenofibrate micronized cap 67 mg (Lofibra).................. 20fenofibrate micronized cap 134 mg (Lofibra)................ 20fenofibrate micronized cap 200 mg (Lofibra)................ 20fenofibrate tab 54 mg (Lofibra)....................................... 20fenofibrate tab 160 mg (Lofibra)..................................... 20fenofibrate tab 48 mg (Tricor)......................................... 20fenofibrate tab 145 mg (Tricor)....................................... 20fentanyl citrate lozenge on a handle 200 mcg(Actiq)................................................................................35

fentanyl citrate lozenge on a handle 400 mcg(Actiq)................................................................................35





fentanyl td patch 72hr 12 mcg/hr (Duragesic)...............35fentanyl td patch 72hr 25 mcg/hr (Duragesic)...............35fentanyl td patch 72hr 50 mcg/hr (Duragesic)...............35fentanyl td patch 72hr 75 mcg/hr (Duragesic)...............35fentanyl td patch 72hr 100 mcg/hr (Duragesic).............35FINACEA – azelaic acid foam 15%................................... 46FINACEA – azelaic acid gel 15%.......................................46finasteride tab 5 mg (Proscar)........................................ 28FIRAZYR – icatibant acetate inj 30 mg/3ml (baseequivalent)......................................................................... 42

flecainide acetate tab 50 mg........................................... 21flecainide acetate tab 100 mg......................................... 21flecainide acetate tab 150 mg......................................... 21FLOVENT DISKUS – fluticasone propionate aer pow ba50 mcg/blister.................................................................... 24

FLOVENT DISKUS – fluticasone propionate aer pow ba100 mcg/blister.................................................................. 24

FLOVENT DISKUS – fluticasone propionate aer pow ba250 mcg/blister.................................................................. 24

FLOVENT HFA – fluticasone propionate hfa inhal aer 110mcg/act (125/valve)...........................................................24

FLOVENT HFA – fluticasone propionate hfa inhal aer 220mcg/act (250/valve)...........................................................24

FLOVENT HFA – fluticasone propionate hfa inhal aero 44mcg/act (50/valve)............................................................. 24

fluconazole for susp 10 mg/ml (Diflucan)........................3fluconazole for susp 40 mg/ml (Diflucan)........................3fluconazole tab 50 mg (Diflucan)......................................3fluconazole tab 100 mg (Diflucan)....................................3fluconazole tab 150 mg (Diflucan)....................................3fluconazole tab 200 mg (Diflucan)....................................3flucytosine cap 250 mg (Ancobon)...................................3flucytosine cap 500 mg (Ancobon)...................................3fludrocortisone acetate tab 0.1 mg...................................9flunisolide nasal soln 25 mcg/act (0.025%)(Flunisolide)......................................................................23

fluocinolone acetonide cream 0.01%............................. 47fluocinolone acetonide cream 0.025% (Synalar)...........47fluocinolone acetonide oil 0.01% (body oil) (Derma-smoothe/fs bod).............................................................. 47

fluocinolone acetonide oil 0.01% (scalp oil) (Derma-smoothe/fs sca)............................................................... 47

fluocinolone acetonide oint 0.025% (Synalar)...............47fluocinolone acetonide soln 0.01% (Synalar)................47fluocinonide cream 0.05%............................................... 47fluocinonide emulsified base cream 0.05%...................47

2016


fluocinonide gel 0.05%.....................................................47fluocinonide oint 0.05%....................................................47fluocinonide soln 0.05%...................................................47FLUOR-A-DAY – sodium fluoride-xylitol chew tab 0.55(0.25 mg f)-236.79 mg...................................................... 41

FLUOR-A-DAY – sodium fluoride-xylitol chew tab 1.1 (0.5mg f)-236.79 mg................................................................41

FLUOR-A-DAY – sodium fluoride-xylitol chew tab 2.2 (1mg f)-236.79 mg................................................................41

fluorometholone ophth susp 0.1% (Fml liquifilm)........ 44fluorouracil cream 5% (Efudex)...................................... 48fluorouracil soln 2%......................................................... 48fluorouracil soln 5%......................................................... 48fluoxetine hcl cap 10 mg (Prozac)..................................29fluoxetine hcl cap 20 mg (Prozac)..................................29fluoxetine hcl cap 40 mg (Prozac)..................................29fluoxetine hcl solution 20 mg/5ml.................................. 29fluoxetine hcl tab 10 mg.................................................. 29fluoxetine hcl tab 20 mg.................................................. 29fluphenazine decanoate inj 25 mg/ml.............................30FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5mg/5ml............................................................................... 30

FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ml........................................................................................30

fluphenazine hcl tab 1 mg............................................... 30fluphenazine hcl tab 2.5 mg............................................ 30fluphenazine hcl tab 5 mg............................................... 30fluphenazine hcl tab 10 mg............................................. 30FLURA-DROPS – sodium fluoride soln 0.25 mg/drop f(from 0.55 mg/drop naf)....................................................41

flurbiprofen sodium ophth soln 0.03% (Ocufen)...........45flurbiprofen tab 50 mg......................................................37flurbiprofen tab 100 mg................................................... 37flutamide cap 125 mg.........................................................7fluticasone propionate cream 0.05% (Cutivate)............ 47fluticasone propionate nasal susp 50 mcg/act(Flonase)........................................................................... 23

fluticasone propionate oint 0.005% (Cutivate).............. 47fluvoxamine maleate tab 25 mg......................................29fluvoxamine maleate tab 50 mg......................................30fluvoxamine maleate tab 100 mg....................................30folic acid tab 1 mg............................................................42FORADIL AEROLIZER – formoterol fumarate inhal cap 12mcg.....................................................................................24

fosinopril sodium & hydrochlorothiazide tab 10-12.5mg...................................................................................... 16

fosinopril sodium & hydrochlorothiazide tab 20-12.5mg...................................................................................... 16

fosinopril sodium tab 10 mg........................................... 16fosinopril sodium tab 20 mg........................................... 16fosinopril sodium tab 40 mg........................................... 16furosemide oral soln 10 mg/ml....................................... 21furosemide tab 20 mg (Lasix)......................................... 21furosemide tab 40 mg (Lasix)......................................... 21furosemide tab 80 mg (Lasix)......................................... 21FUZEON – enfuvirtide for inj 90 mg.....................................4

Ggabapentin cap 100 mg (Neurontin)...............................39gabapentin cap 300 mg (Neurontin)...............................39gabapentin cap 400 mg (Neurontin)...............................39gabapentin oral soln 250 mg/5ml (Neurontin)...............39gabapentin tab 600 mg (Neurontin)................................39gabapentin tab 800 mg (Neurontin)................................39galantamine hydrobromide cap sr 24hr 8 mg(Razadyne er)...................................................................34

galantamine hydrobromide cap sr 24hr 16 mg(Razadyne er)...................................................................34

galantamine hydrobromide cap sr 24hr 24 mg(Razadyne er)...................................................................34

galantamine hydrobromide tab 4 mg (Razadyne).........34galantamine hydrobromide tab 8 mg (Razadyne).........34galantamine hydrobromide tab 12 mg (Razadyne).......34gemfibrozil tab 600 mg (Lopid).......................................20gentamicin sulfate cream 0.1%.......................................... 46gentamicin sulfate oint 0.1%.............................................. 46gentamicin sulfate ophth oint 0.3%................................43gentamicin sulfate ophth soln 0.3% (Garamycin).........43GILOTRIF – afatinib dimaleate tab 20 mg (baseequivalent)............................................................................7

GILOTRIF – afatinib dimaleate tab 30 mg (baseequivalent)............................................................................7

GILOTRIF – afatinib dimaleate tab 40 mg (baseequivalent)............................................................................7

glatiramer acetate soln prefilled syringe 20 mg/ml(Copaxone)....................................................................... 33

GLEEVEC – imatinib mesylate tab 100 mg (baseequivalent)............................................................................7

GLEEVEC – imatinib mesylate tab 400 mg (baseequivalent)............................................................................7

GLEOSTINE – lomustine cap 5 mg..................................... 7GLEOSTINE – lomustine cap 10 mg................................... 7GLEOSTINE – lomustine cap 40 mg................................... 7GLEOSTINE – lomustine cap 100 mg................................. 7glimepiride tab 1 mg (Amaryl).........................................12glimepiride tab 2 mg (Amaryl).........................................12glimepiride tab 4 mg (Amaryl).........................................12glipizide-metformin hcl tab 2.5-250 mg..........................12glipizide-metformin hcl tab 2.5-500 mg..........................12glipizide-metformin hcl tab 5-500 mg.............................12glipizide tab 5 mg (Glucotrol)..........................................12glipizide tab 10 mg (Glucotrol)........................................12glipizide tab sr 24hr 2.5 mg (Glucotrol xl)..................... 12glipizide tab sr 24hr 5 mg (Glucotrol xl)........................ 12glipizide tab sr 24hr 10 mg (Glucotrol xl)...................... 12GLUCAGON EMERGENCY KIT – glucagon (rdna) for injkit 1 mg..............................................................................12

glyburide-metformin tab 1.25-250 mg(Glucovance).................................................................... 13

glyburide-metformin tab 2.5-500 mg (Glucovance)...... 13glyburide-metformin tab 5-500 mg (Glucovance)......... 13glyburide micronized tab 1.5 mg (Glynase)...................12

2016


glyburide micronized tab 3 mg (Glynase)......................12glyburide micronized tab 6 mg (Glynase)......................12glyburide tab 1.25 mg.......................................................12glyburide tab 2.5 mg.........................................................12glyburide tab 5 mg............................................................13glycopyrrolate tab 1 mg (Robinul)..................................25glycopyrrolate tab 2 mg (Robinul forte).........................25GONAL-F – follitropin alfa for inj 450 unit..........................12GONAL-F – follitropin alfa for inj 1050 unit........................12GONAL-F RFF – follitropin alfa for inj 75 unit....................12GONAL-F RFF PEN – follitropin alfa inj 300 unit/0.5ml..... 12GONAL-F RFF PEN – follitropin alfa inj 450unit/0.75ml......................................................................... 12

GONAL-F RFF PEN – follitropin alfa inj 900 unit/1.5ml..... 12GONAL-F RFF REDIJECT – follitropin alfa inj 300unit/0.5ml............................................................................12

GONAL-F RFF REDIJECT – follitropin alfa inj 450unit/0.75ml......................................................................... 12

GONAL-F RFF REDIJECT – follitropin alfa inj 900unit/1.5ml............................................................................12

granisetron hcl tab 1 mg................................................. 26GRANIX – tbo-filgrastim soln prefilled syringe 300mcg/0.5ml...........................................................................43

GRANIX – tbo-filgrastim soln prefilled syringe 480mcg/0.8ml...........................................................................43

griseofulvin microsize susp 125 mg/5ml......................... 3griseofulvin microsize tab 500 mg (Grifulvin v)..............3guanfacine hcl tab 1 mg (Tenex).................................... 22guanfacine hcl tab 2 mg (Tenex).................................... 22guanfacine hcl tab sr 24hr 1 mg (base equiv)(Intuniv).............................................................................33

guanfacine hcl tab sr 24hr 2 mg (base equiv)(Intuniv).............................................................................33

guanfacine hcl tab sr 24hr 3 mg (base equiv)(Intuniv).............................................................................33

guanfacine hcl tab sr 24hr 4 mg (base equiv)(Intuniv).............................................................................33H

halobetasol propionate cream 0.05% (Ultravate)..........47halobetasol propionate oint 0.05% (Ultravate)..............47haloperidol decanoate im soln 50 mg/ml (Haldoldecanoate 50)...................................................................30

haloperidol decanoate im soln 100 mg/ml (Haldoldecanoate 100).................................................................31

haloperidol lactate oral conc 2 mg/ml............................31haloperidol tab 0.5 mg..................................................... 31haloperidol tab 1 mg........................................................ 31haloperidol tab 2 mg........................................................ 31haloperidol tab 5 mg........................................................ 31haloperidol tab 10 mg...................................................... 31haloperidol tab 20 mg...................................................... 31HARVONI – ledipasvir-sofosbuvir tab 90-400 mg................4HEXALEN – altretamine cap 50 mg.....................................7homatropine hbr ophth soln 5% (Isoptohomatropine)....................................................................45

HUMIRA – adalimumab prefilled syringe kit 10mg/0.2ml............................................................................ 37



HUMIRA PEDIATRIC CROHNS D – adalimumab prefilledsyringe kit 40 mg/0.8ml.....................................................37

HUMIRA PEN – adalimumab pen-injector kit 40mg/0.8ml............................................................................ 37

HUMIRA PEN-CROHNS DISEASE – adalimumab pen-injector kit 40 mg/0.8ml.....................................................37

HUMIRA PEN-PSORIASIS STAR – adalimumab pen-injector kit 40 mg/0.8ml.....................................................37

HUMULIN R U-500 (CONCENTR – insulin regular(human) inj 500 unit/ml..................................................... 14

HYCAMTIN – topotecan hcl cap 0.25 mg (base equiv)....... 7HYCAMTIN – topotecan hcl cap 1 mg (base equiv)............ 7hydralazine hcl tab 10 mg............................................... 22hydralazine hcl tab 25 mg............................................... 22hydralazine hcl tab 50 mg............................................... 22hydralazine hcl tab 100 mg............................................. 22hydrochlorothiazide cap 12.5 mg (Microzide)............... 21hydrochlorothiazide tab 12.5 mg.................................... 21hydrochlorothiazide tab 25 mg....................................... 21hydrochlorothiazide tab 50 mg....................................... 21hydrocodone-acetaminophen soln 7.5-325 mg/15ml(Hycet)............................................................................... 35

hydrocodone-acetaminophen tab 7.5-325 mg(Norco).............................................................................. 35

hydrocodone-acetaminophen tab 5-325 mg(Norco).............................................................................. 35

hydrocodone-acetaminophen tab 10-325 mg(Norco).............................................................................. 35

hydrocodone-ibuprofen tab 10-200 mg (Ibudone)........ 35hydrocodone-ibuprofen tab 5-200 mg (Reprexain).......35hydrocodone-ibuprofen tab 7.5-200 mg(Vicoprofen)......................................................................35

hydrocortisone acetate suppos 25 mg (Anusol-hc)..... 45hydrocortisone acetate suppos 30 mg (Proctocort).....45hydrocortisone cream 2.5%.............................................47hydrocortisone enema 100 mg/60ml (Cortenema)........45hydrocortisone lotion 2.5%............................................. 47hydrocortisone oint 2.5%.................................................47hydrocortisone rectal cream 2.5% (Anusol-hc)............ 45hydrocortisone tab 5 mg (Cortef)..................................... 9hydrocortisone tab 10 mg (Cortef)................................... 9hydrocortisone tab 20 mg (Cortef)................................... 9hydrocortisone valerate cream 0.2%..............................47hydrocortisone valerate oint 0.2% (Westcort)...............47hydrocortisone w/ acetic acid otic soln 1-2% (Vosolhc)...................................................................................... 45

hydromorphone hcl liqd 1 mg/ml (Dilaudid)..................35hydromorphone hcl suppos 3 mg.......................................35hydromorphone hcl tab 2 mg (Dilaudid)........................35hydromorphone hcl tab 4 mg (Dilaudid)........................35

2016


hydromorphone hcl tab 8 mg (Dilaudid)........................35hydroxychloroquine sulfate tab 200 mg (Plaquenil).......6hydroxyurea cap 500 mg (Hydrea)................................... 7hydroxyzine hcl syrup 10 mg/5ml...................................29hydroxyzine hcl tab 10 mg.............................................. 29hydroxyzine hcl tab 25 mg.............................................. 29hydroxyzine hcl tab 50 mg.............................................. 29hydroxyzine pamoate cap 25 mg (Vistaril).................... 29hydroxyzine pamoate cap 50 mg (Vistaril).................... 29hyoscyamine sulfate elixir 0.125 mg/5ml.......................25hyoscyamine sulfate soln 0.125 mg/ml..........................25hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)...... 25hyoscyamine sulfate tab 0.125 mg (Levsin)..................25hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl)..........25hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid).....25I

ibandronate sodium tab 150 mg (base equivalent)(Boniva).............................................................................15

IBRANCE – palbociclib cap 75 mg...................................... 7IBRANCE – palbociclib cap 100 mg.................................... 7IBRANCE – palbociclib cap 125 mg.................................... 7ibuprofen susp 100 mg/5ml.............................................37ibuprofen tab 400 mg....................................................... 37ibuprofen tab 600 mg....................................................... 37ibuprofen tab 800 mg....................................................... 37ICLUSIG – ponatinib hcl tab 15 mg (base equiv)................ 7ICLUSIG – ponatinib hcl tab 45 mg (base equiv)................ 7ILARIS – canakinumab for inj 180 mg............................... 37IMBRUVICA – ibrutinib cap 140 mg.....................................7imipramine hcl tab 10 mg (Tofranil)............................... 30imipramine hcl tab 25 mg (Tofranil)............................... 30imipramine hcl tab 50 mg (Tofranil)............................... 30imiquimod cream 5% (Aldara).........................................48INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml).........14INCRUSE ELLIPTA – umeclidinium br aero powd breathact 62.5 mcg/inh (base eq)...............................................24

indapamide tab 1.25 mg...................................................21indapamide tab 2.5 mg.....................................................21indomethacin cap 25 mg................................................. 37indomethacin cap 50 mg................................................. 37INHALER ASSIST DEVICES - SPACERS.........................48INLYTA – axitinib tab 1 mg...................................................7INLYTA – axitinib tab 5 mg...................................................7INSULIN ADMINISTRATION/INSULIN PUMP SUPPLIES– VARIOUS........................................................................48

INSULIN PEN NEEDLES – VARIOUS...............................48INSULIN SYRINGES – VARIOUS......................................48INTELENCE – etravirine tab 25 mg.....................................4INTELENCE – etravirine tab 100 mg...................................4INTELENCE – etravirine tab 200 mg...................................4INVIRASE – saquinavir mesylate cap 200 mg.................... 4INVIRASE – saquinavir mesylate tab 500 mg..................... 4INVOKAMET – canagliflozin-metformin hcl tab 50-500mg...................................................................................... 13

INVOKAMET – canagliflozin-metformin hcl tab 50-1000mg...................................................................................... 13



INVOKANA – canagliflozin tab 100 mg..............................13INVOKANA – canagliflozin tab 300 mg..............................13ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml(Duoneb)........................................................................... 24

ipratropium bromide inhal soln 0.02%...........................24ipratropium bromide nasal soln 0.03% (21 mcg/spray)(Atrovent)..........................................................................23

ipratropium bromide nasal soln 0.06% (42 mcg/spray)(Atrovent)..........................................................................23

irbesartan-hydrochlorothiazide tab 150-12.5 mg(Avalide)............................................................................ 17

irbesartan-hydrochlorothiazide tab 300-12.5 mg(Avalide)............................................................................ 17

irbesartan tab 75 mg (Avapro)........................................ 17irbesartan tab 150 mg (Avapro)...................................... 17irbesartan tab 300 mg (Avapro)...................................... 17IRESSA – gefitinib tab 250 mg............................................ 7ISENTRESS – raltegravir potassium chew tab 25 mg(base equiv).........................................................................4

ISENTRESS – raltegravir potassium chew tab 100 mg(base equiv).........................................................................5

ISENTRESS – raltegravir potassium packet for susp 100mg (base equiv).................................................................. 4

ISENTRESS – raltegravir potassium tab 400 mg (baseequiv)....................................................................................4

ISONIAZID – isoniazid syrup 50 mg/5ml............................. 3isoniazid tab 100 mg.......................................................... 3isoniazid tab 300 mg.......................................................... 3isosorbide dinitrate tab 10 mg........................................19isosorbide dinitrate tab 20 mg........................................19isosorbide dinitrate tab 5 mg (Isordil titradose)........... 19isosorbide mononitrate tab 10 mg................................. 19isosorbide mononitrate tab 20 mg................................. 19isosorbide mononitrate tab sr 24hr 30 mg (Imdur).......19isosorbide mononitrate tab sr 24hr 60 mg (Imdur).......19isosorbide mononitrate tab sr 24hr 120 mg (Imdur).....19isotretinoin cap 10 mg..................................................... 46isotretinoin cap 20 mg..................................................... 46isotretinoin cap 40 mg..................................................... 46isotretinoin cap 30 mg (Claravis)....................................46itraconazole cap 100 mg (Sporanox)................................3ivermectin tab 3 mg (Stromectol)..................................... 6IXINITY – coagulation factor ix (recombinant) for inj 500unit......................................................................................43

IXINITY – coagulation factor ix (recombinant) for inj 1000unit......................................................................................43

IXINITY – coagulation factor ix (recombinant) for inj 1500unit......................................................................................43

2016


JJAKAFI – ruxolitinib phosphate tab 5 mg (baseequivalent)............................................................................7

JAKAFI – ruxolitinib phosphate tab 10 mg (baseequivalent)............................................................................8




JANUMET – sitagliptin-metformin hcl tab 50-500 mg........13JANUMET – sitagliptin-metformin hcl tab 50-1000 mg......13JANUMET XR – sitagliptin-metformin hcl tab sr 24hr50-500 mg......................................................................... 13

JANUMET XR – sitagliptin-metformin hcl tab sr 24hr50-1000 mg....................................................................... 13

JANUMET XR – sitagliptin-metformin hcl tab sr 24hr100-1000 mg..................................................................... 13

JANUVIA – sitagliptin phosphate tab 25 mg (baseequiv)................................................................................. 13



JARDIANCE – empagliflozin tab 10 mg.............................13JARDIANCE – empagliflozin tab 25 mg.............................13

KKADIAN – morphine sulfate cap sr 24hr 10 mg.................35KADIAN – morphine sulfate cap sr 24hr 40 mg.................35KADIAN – morphine sulfate cap sr 24hr 200 mg...............35KALETRA – lopinavir-ritonavir soln 400-100 mg/5ml(80-20 mg/ml)...................................................................... 5

KALETRA – lopinavir-ritonavir tab 100-25 mg.....................5KALETRA – lopinavir-ritonavir tab 200-50 mg.....................5KALYDECO – ivacaftor packet 50 mg............................... 25KALYDECO – ivacaftor packet 75 mg............................... 25KALYDECO – ivacaftor tab 150 mg................................... 25ketoconazole cream 2%................................................... 46ketoconazole shampoo 2% (Nizoral)..............................46ketoprofen cap 50 mg...................................................... 37ketoprofen cap 75 mg...................................................... 37ketorolac tromethamine ophth soln 0.5% (Acular)....... 45ketorolac tromethamine ophth soln 0.4% (Acularls)....................................................................................... 45

KOMBIGLYZE XR – saxagliptin-metformin hcl tab sr 24hr2.5-1000 mg...................................................................... 13

KOMBIGLYZE XR – saxagliptin-metformin hcl tab sr 24hr5-500 mg............................................................................13

KOMBIGLYZE XR – saxagliptin-metformin hcl tab sr 24hr5-1000 mg......................................................................... 13

K-PHOS NO 2 – potassium & sodium acid phosphates tab305-700 mg....................................................................... 28

K-PHOS – potassium phosphate monobasic tab 500mg...................................................................................... 41

Llabetalol hcl tab 100 mg (Trandate)................................18labetalol hcl tab 200 mg (Trandate)................................18labetalol hcl tab 300 mg (Trandate)................................18lactulose (encephalopathy) solution 10 gm/15ml......... 27lactulose solution 10 gm/15ml........................................ 25LAMISIL – terbinafine hcl oral granules packet 125 mg...... 3LAMISIL – terbinafine hcl oral granules packet 187.5mg........................................................................................ 3

lamivudine oral soln 10 mg/ml (Epivir)............................ 5lamivudine tab 150 mg (Epivir)......................................... 5lamivudine tab 300 mg (Epivir)......................................... 5lamivudine tab 100 mg (hbv) (Epivir hbv)........................4lamivudine-zidovudine tab 150-300 mg (Combivir)........ 5lamotrigine tab chewable dispersible 5 mg (Lamictalchewable di)..................................................................... 39

lamotrigine tab chewable dispersible 25 mg (Lamictalchewable di)..................................................................... 39

lamotrigine tab 25 mg (Lamictal)....................................39lamotrigine tab 100 mg (Lamictal)..................................39lamotrigine tab 150 mg (Lamictal)..................................39lamotrigine tab 200 mg (Lamictal)..................................39LANCETS – BAYER, ROCHE, VARIOUS..........................48lansoprazole cap delayed release 15 mg(Prevacid)..........................................................................26

lansoprazole cap delayed release 30 mg(Prevacid)..........................................................................26

LANTUS – insulin glargine inj 100 unit/ml......................... 14LANTUS SOLOSTAR – insulin glargine soln pen-injector100 unit/ml......................................................................... 14

latanoprost ophth soln 0.005% (Xalatan).......................44leflunomide tab 10 mg (Arava)........................................37leflunomide tab 20 mg (Arava)........................................37LENVIMA 14MG DAILY DOSE – lenvatinib cap therapypack 10 & 4 mg (14 mg daily dose)................................... 8

LENVIMA 24MG DAILY DOSE – lenvatinib cap therapypack 10 (2) & 4 mg (24 mg daily dose)..............................8

LENVIMA 10MG DAILY DOSE – lenvatinib cap therapypack 10 mg (10 mg daily dose)..........................................8

LENVIMA 20MG DAILY DOSE – lenvatinib cap therapypack 10 (2) mg (20 mg daily dose).................................... 8

LETAIRIS – ambrisentan tab 5 mg.................................... 22LETAIRIS – ambrisentan tab 10 mg.................................. 22letrozole tab 2.5 mg (Femara)........................................... 8leucovorin calcium tab 5 mg.............................................8leucovorin calcium tab 10 mg...............................................8leucovorin calcium tab 15 mg...............................................8leucovorin calcium tab 25 mg...........................................8LEUKERAN – chlorambucil tab 2 mg.................................. 8levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)(Xopenex)..........................................................................24

levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv)(Xopenex)..........................................................................24

2016


levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv)(Xopenex)..........................................................................24

LEVEMIR FLEXPEN – insulin detemir soln pen-injector100 unit/ml......................................................................... 14

LEVEMIR FLEXTOUCH – insulin detemir soln pen-injector100 unit/ml......................................................................... 14

LEVEMIR – insulin detemir inj 100 unit/ml.........................14levetiracetam oral soln 100 mg/ml (Keppra)..................39levetiracetam tab 250 mg (Keppra).................................39levetiracetam tab 500 mg (Keppra).................................39levetiracetam tab 750 mg (Keppra).................................39levetiracetam tab 1000 mg (Keppra)...............................39levetiracetam tab sr 24hr 500 mg (Keppra xr)...............39levetiracetam tab sr 24hr 750 mg (Keppra xr)...............39levobunolol hcl ophth soln 0.25%.......................................44levobunolol hcl ophth soln 0.5% (Betagan).................. 44levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 15levocarnitine tab 330 mg (Carnitor)................................15levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) (Xyzal).........................................................................23

levocetirizine dihydrochloride tab 5 mg (Xyzal)............23levofloxacin oral soln 25 mg/ml (Levaquin).................... 3levofloxacin tab 250 mg (Levaquin)................................. 3levofloxacin tab 500 mg (Levaquin)................................. 3levofloxacin tab 750 mg (Levaquin)................................. 3levonorgestrel & ethinyl estradiol (91-day) tab0.15-0.03 mg (introvale, jolessa, quasense).................11

levonorgestrel & ethinyl estradiol tab 0.15 mg-30mcg....................................................................................11

levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg(delyla)...............................................................................11

levonorgestrel-eth estra tab0.05-30/0.075-40/0.125-30mg-mcg................................. 11

levonorgestrel tab 1.5 mg (aftera, econtra ez, fallbacksolo, my way, next choice one dose, opcicon one-step, take action).............................................................11

levonorg-eth est tab 0.1-0.02mg(84) & eth est tab0.01mg(7) (Loseasonique)..............................................11

levonorg-eth est tab 0.15-0.03mg(84) & eth est tab0.01mg(7) (Seasonique)..................................................11

levothyroxine sodium tab 25 mcg (Synthroid)..............14levothyroxine sodium tab 50 mcg (Synthroid)..............14levothyroxine sodium tab 75 mcg (Synthroid)..............14levothyroxine sodium tab 88 mcg (Synthroid)..............14levothyroxine sodium tab 100 mcg (Synthroid)............14levothyroxine sodium tab 112 mcg (Synthroid)............ 14levothyroxine sodium tab 125 mcg (Synthroid)............14levothyroxine sodium tab 137 mcg (Synthroid)............14levothyroxine sodium tab 150 mcg (Synthroid)............14levothyroxine sodium tab 175 mcg (Synthroid)............14levothyroxine sodium tab 200 mcg (Synthroid)............14levothyroxine sodium tab 300 mcg (Synthroid)............14LEXIVA – fosamprenavir calcium susp 50 mg/ml (baseequiv)....................................................................................5

LEXIVA – fosamprenavir calcium tab 700 mg (baseequiv)....................................................................................5

LIALDA – mesalamine tab delayed release 1.2 gm...........27lidocaine hcl gel 2%......................................................... 48lidocaine hcl laryngotracheal soln 4% (Lta 360 kit)......45lidocaine hcl soln 4% (Xylocaine)...................................48lidocaine hcl viscous soln 2%........................................ 45lidocaine oint 5%...............................................................48lidocaine patch 5% (Lidoderm)....................................... 48lidocaine-prilocaine cream 2.5-2.5% (Emla).................. 48lidocaine-prilocaine kit 2.5-2.5%..................................... 48lindane lotion 1%.............................................................. 48lindane shampoo 1%........................................................ 48linezolid tab 600 mg (Zyvox)............................................. 6LINZESS – linaclotide cap 145 mcg.................................. 27LINZESS – linaclotide cap 290 mcg.................................. 27liothyronine sodium tab 5 mcg (Cytomel)..................... 14liothyronine sodium tab 25 mcg (Cytomel)................... 14liothyronine sodium tab 50 mcg (Cytomel)................... 14lisinopril & hydrochlorothiazide tab 10-12.5 mg(Zestoretic)....................................................................... 16

lisinopril & hydrochlorothiazide tab 20-12.5 mg(Zestoretic)....................................................................... 16

lisinopril & hydrochlorothiazide tab 20-25 mg(Zestoretic)....................................................................... 16

lisinopril tab 5 mg (Prinivil)............................................. 16lisinopril tab 10 mg (Prinivil)........................................... 16lisinopril tab 20 mg (Prinivil)........................................... 16lisinopril tab 2.5 mg (Zestril)........................................... 16lisinopril tab 30 mg (Zestril)............................................ 16lisinopril tab 40 mg (Zestril)............................................ 16lithium carbonate cap 300 mg.........................................31lithium carbonate cap 150 mg (Lithium carbonate)......31lithium carbonate cap 600 mg (Lithium carbonate)......31lithium carbonate tab cr 450 mg.....................................31lithium carbonate tab cr 300 mg (Lithobid)................... 31lithium carbonate tab 300 mg......................................... 31lithium oral solution 8 meq/5ml...........................................31LOMUSTINE – lomustine cap 10 mg...................................8LOMUSTINE – lomustine cap 40 mg...................................8LOMUSTINE – lomustine cap 100 mg.................................8LONSURF – trifluridine-tipiracil tab 15-6.14 mg...................8LONSURF – trifluridine-tipiracil tab 20-8.19 mg...................8loperamide hcl cap 2 mg................................................. 25lorazepam conc 2 mg/ml (Lorazepam intensol)............ 29lorazepam tab 0.5 mg (Ativan)........................................ 29lorazepam tab 1 mg (Ativan)........................................... 29lorazepam tab 2 mg (Ativan)........................................... 29losartan potassium & hydrochlorothiazide tab 50-12.5mg (Hyzaar)...................................................................... 17

losartan potassium & hydrochlorothiazide tab 100-12.5mg (Hyzaar)...................................................................... 17

losartan potassium & hydrochlorothiazide tab 100-25mg (Hyzaar)...................................................................... 17

losartan potassium tab 25 mg (Cozaar).........................17losartan potassium tab 50 mg (Cozaar).........................17losartan potassium tab 100 mg (Cozaar).......................17LOTEMAX – loteprednol etabonate ophth gel 0.5%..........44

2016


LOTEMAX – loteprednol etabonate ophth oint 0.5%.........44LOTEMAX – loteprednol etabonate ophth susp 0.5%....... 44lovastatin tab 10 mg.........................................................20lovastatin tab 20 mg (Mevacor).......................................20lovastatin tab 40 mg (Mevacor).......................................20loxapine succinate cap 10 mg........................................ 31loxapine succinate cap 25 mg........................................ 31loxapine succinate cap 50 mg........................................ 31loxapine succinate cap 5 mg (Loxitane)........................31LUMIGAN – bimatoprost ophth soln 0.01%.......................44LYNPARZA – olaparib cap 50 mg........................................8LYSODREN – mitotane tab 500 mg.....................................8

MMACRODANTIN – nitrofurantoin macrocrystalline cap 25mg...................................................................................... 27

malathion lotion 0.5% (Ovide).........................................48MATULANE – procarbazine hcl cap 50 mg......................... 8meclizine hcl tab 12.5 mg................................................ 26meclizine hcl tab 25 mg................................................... 26medroxyprogesterone acetate im susp 150 mg/ml(Depo-provera contrac).................................................. 11

medroxyprogesterone acetate tab 2.5 mg(Provera)........................................................................... 11

medroxyprogesterone acetate tab 5 mg (Provera).......11medroxyprogesterone acetate tab 10 mg (Provera).....11mefloquine hcl tab 250 mg................................................ 6megestrol acetate susp 40 mg/ml (Megace oral)............ 8megestrol acetate tab 20 mg.............................................8megestrol acetate tab 40 mg.............................................8MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg(base equivalent).................................................................8

MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (baseequivalent)............................................................................8

meloxicam tab 7.5 mg (Mobic)........................................37meloxicam tab 15 mg (Mobic).........................................37memantine hcl oral solution 2 mg/ml (Namenda)......... 34memantine hcl tab 5 mg (28) & 10 mg (21) titration pak(Namenda titration pa)....................................................34

memantine hcl tab 5 mg (Namenda).............................. 34memantine hcl tab 10 mg (Namenda)............................ 34MEPHYTON – phytonadione tab 5 mg.............................. 41mercaptopurine tab 50 mg (Purinethol)...........................8mesalamine enema 4 gm................................................. 27MESNEX – mesna tab 400 mg............................................8metaxalone tab 800 mg (Skelaxin)..................................41metformin hcl tab 500 mg (Glucophage)....................... 13metformin hcl tab 850 mg (Glucophage)....................... 13metformin hcl tab 1000 mg (Glucophage)..................... 13metformin hcl tab sr 24hr 500 mg (Glucophage xr)......13metformin hcl tab sr 24hr 750 mg (Glucophage xr)......13methadone hcl conc 10 mg/ml (Methadose)................. 36methadone hcl soln 5 mg/5ml (Methadone hcl)............36methadone hcl soln 10 mg/5ml (Methadone hcl).......... 36methadone hcl tab for oral susp 40 mg.........................36methadone hcl tab 10 mg (Dolophine)...........................36

methadone hcl tab 5 mg (Dolophine hcl).......................36methazolamide tab 25 mg (Neptazane)..........................21methazolamide tab 50 mg (Neptazane)..........................21methimazole tab 5 mg (Tapazole)................................... 14methimazole tab 10 mg (Tapazole)................................. 14methocarbamol tab 750 mg (Robaxin-750)....................41methocarbamol tab 500 mg (Robaxin)...........................41methotrexate sodium tab 2.5 mg (base equiv)................8methscopolamine bromide tab 2.5 mg (Pamine).......... 26methscopolamine bromide tab 5 mg (Pamineforte).................................................................................. 26

methyldopa tab 250 mg................................................... 22methyldopa tab 500 mg................................................... 22methylergonovine maleate tab 0.2 mg...........................15METHYLPHENIDATE HCL ER – methylphenidate hcl tabsa osm 18 mg................................................................... 33

METHYLPHENIDATE HCL ER – methylphenidate hcl tabsa osm 27 mg................................................................... 33



METHYLPHENIDATE HCL ER – methylphenidate hcl tabsr 24hr 18 mg....................................................................33




methylphenidate hcl tab cr 10 mg..................................33methylphenidate hcl tab cr 20 mg (Ritalin sr)............... 33methylphenidate hcl tab 5 mg (Ritalin).......................... 33methylphenidate hcl tab 10 mg (Ritalin)........................ 33methylphenidate hcl tab 20 mg (Ritalin)........................ 33methylprednisolone tab 4 mg dose pack (Medroldosepak)............................................................................. 9

methylprednisolone tab 4 mg (Medrol)............................9methylprednisolone tab 8 mg (Medrol)............................9methylprednisolone tab 16 mg (Medrol)..........................9methylprednisolone tab 32 mg (Medrol)..........................9metoclopramide hcl soln 5 mg/5ml (10 mg/10ml).........27metoclopramide hcl tab 5 mg (Reglan)..........................27metoclopramide hcl tab 10 mg (Reglan)........................27metolazone tab 10 mg......................................................21metolazone tab 2.5 mg (Zaroxolyn)................................21metolazone tab 5 mg (Zaroxolyn)...................................21metoprolol succinate tab sr 24hr 25 mg (Toprol xl)......18metoprolol succinate tab sr 24hr 50 mg (Toprol xl)......18metoprolol succinate tab sr 24hr 100 mg (Toprolxl)....................................................................................... 18

metoprolol succinate tab sr 24hr 200 mg (Toprolxl)....................................................................................... 18

metoprolol tartrate tab 25 mg......................................... 18metoprolol tartrate tab 50 mg (Lopressor).................... 18metoprolol tartrate tab 100 mg (Lopressor).................. 18

2016


metronidazole cream 0.75% (Metrocream).................... 46metronidazole gel 0.75%..................................................46metronidazole gel 1% (Metrogel).................................... 46metronidazole lotion 0.75% (Metrolotion)......................46metronidazole tab 250 mg (Flagyl)................................... 6metronidazole tab 500 mg (Flagyl)................................... 6metronidazole vaginal gel 0.75% (Metrogel-vaginal)..............................................................................28

mexiletine hcl cap 150 mg...............................................21mexiletine hcl cap 200 mg...............................................21mexiletine hcl cap 250 mg...............................................21midodrine hcl tab 2.5 mg.................................................22midodrine hcl tab 5 mg....................................................22midodrine hcl tab 10 mg..................................................22MIGRANAL – dihydroergotamine mesylate nasal spray 4mg/ml..................................................................................38

MILLIPRED – prednisolone tab 5 mg.................................. 9minocycline hcl cap 50 mg (Minocin).............................. 2minocycline hcl cap 75 mg (Minocin).............................. 2minocycline hcl cap 100 mg (Minocin)............................ 2minocycline hcl tab 50 mg................................................ 2minocycline hcl tab 75 mg................................................ 2minocycline hcl tab 100 mg.............................................. 2minoxidil tab 2.5 mg.........................................................22minoxidil tab 10 mg..........................................................22mirtazapine tab 7.5 mg.....................................................30mirtazapine tab 15 mg (Remeron).................................. 30mirtazapine tab 30 mg (Remeron).................................. 30mirtazapine tab 45 mg (Remeron).................................. 30misoprostol tab 100 mcg (Cytotec)................................ 26misoprostol tab 200 mcg (Cytotec)................................ 26modafinil tab 100 mg (Provigil).......................................33modafinil tab 200 mg (Provigil).......................................33moexipril hcl tab 7.5 mg (Univasc).................................16moexipril hcl tab 15 mg (Univasc)..................................16moexipril-hydrochlorothiazide tab 15-25 mg.................16moexipril-hydrochlorothiazide tab 7.5-12.5 mg(Uniretic)........................................................................... 16

moexipril-hydrochlorothiazide tab 15-12.5 mg(Uniretic)........................................................................... 16

mometasone furoate cream 0.1% (Elocon)................... 47mometasone furoate oint 0.1% (Elocon)........................47mometasone furoate solution 0.1% (lotion)(Elocon).............................................................................47

montelukast sodium chew tab 4 mg (base equiv)(Singulair)......................................................................... 24

montelukast sodium chew tab 5 mg (base equiv)(Singulair)......................................................................... 24

montelukast sodium oral granules packet 4 mg (baseequiv) (Singulair)............................................................. 24

montelukast sodium tab 10 mg (base equiv)(Singulair)......................................................................... 24

morphine sulfate oral soln 10 mg/5ml........................... 36morphine sulfate oral soln 20 mg/5ml........................... 36morphine sulfate oral soln 100 mg/5ml (20 mg/ml)...... 36morphine sulfate suppos 5 mg...........................................36

morphine sulfate suppos 10 mg.........................................36morphine sulfate suppos 20 mg.........................................36morphine sulfate suppos 30 mg.........................................36morphine sulfate tab cr 15 mg (Ms contin)................... 36morphine sulfate tab cr 30 mg (Ms contin)................... 36morphine sulfate tab cr 60 mg (Ms contin)................... 36morphine sulfate tab cr 100 mg (Ms contin)................. 36morphine sulfate tab cr 200 mg (Ms contin)................. 36morphine sulfate tab 15 mg................................................36morphine sulfate tab 30 mg................................................36MOXEZA – moxifloxacin hcl ophth soln 0.5% (base eq) (2times daily)........................................................................ 43

MULTAQ – dronedarone hcl tab 400 mg (baseequivalent)......................................................................... 21

mupirocin calcium cream 2% (Bactroban).................... 46mupirocin oint 2% (Bactroban).......................................46mycophenolate mofetil cap 250 mg (Cellcept)..............49mycophenolate mofetil for oral susp 200 mg/ml(Cellcept)...........................................................................49

mycophenolate mofetil tab 500 mg (Cellcept)...............49mycophenolate sodium tab dr 180 mg (mycophenolicacid equiv) (Myfortic)......................................................49

mycophenolate sodium tab dr 360 mg (mycophenolicacid equiv) (Myfortic)......................................................49

MYLERAN – busulfan tab 2 mg...........................................8

Nnabumetone tab 500 mg.................................................. 37nabumetone tab 750 mg.................................................. 37nadolol tab 20 mg (Corgard)........................................... 18nadolol tab 40 mg (Corgard)........................................... 18nadolol tab 80 mg (Corgard)........................................... 18naloxone hcl inj 0.4 mg/ml.............................................. 49naltrexone hcl tab 50 mg (Revia)....................................49NAMENDA – memantine hcl oral solution 2 mg/ml........... 34NAMENDA XR – memantine hcl cap sr 24hr 7 mg........... 34NAMENDA XR – memantine hcl cap sr 24hr 14 mg......... 34NAMENDA XR – memantine hcl cap sr 24hr 21 mg......... 34NAMENDA XR – memantine hcl cap sr 24hr 28 mg......... 34NAMENDA XR TITRATION PACK – memantine hcl cap sr24hr 7 mg & 14 mg & 21 mg & 28 mg pack.....................34

naproxen sodium tab 275 mg (Anaprox)....................... 37naproxen sodium tab 550 mg (Anaprox ds)..................37naproxen tab ec 375 mg (Ec-naprosyn).........................37naproxen tab ec 500 mg (Ec-naprosyn).........................37naproxen tab 250 mg (Naprosyn)................................... 37naproxen tab 375 mg (Naprosyn)................................... 37naproxen tab 500 mg (Naprosyn)................................... 37naratriptan hcl tab 1 mg (base equiv) (Amerge)........... 38naratriptan hcl tab 2.5 mg (base equiv) (Amerge)........ 38NASONEX – mometasone furoate nasal susp 50 mcg/act.......................................................................................23

NATACYN – natamycin ophth susp 5%............................. 43nateglinide tab 60 mg (Starlix)........................................13nateglinide tab 120 mg (Starlix)......................................13

2016


NEBUPENT – pentamidine isethionate for nebulizationsoln 300 mg.........................................................................6

neomycin-bacitrac zn-polymyx5(3.5)mg-400unt-10000unt op oin..................................43

neomycin-polymy-gramicid op sol1.75-10000-0.025mg-unt-mg/ml (Neosporin)................44

neomycin-polymyxin-dexamethasone ophth oint 0.1%(Maxitrol)...........................................................................44

neomycin-polymyxin-dexamethasone ophth susp0.1% (Maxitrol)................................................................. 44

neomycin-polymyxin-hc otic soln 1% (Cortisporin)..... 45neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000unit/ml-1%.........................................................................45

neomycin sulfate tab 500 mg............................................3NEULASTA DELIVERY KIT – pegfilgrastim soln prefilledsyringe kit 6 mg/0.6ml.......................................................43

NEULASTA – pegfilgrastim soln prefilled syringe 6mg/0.6ml............................................................................ 43

nevirapine tab 200 mg (Viramune)....................................5nevirapine tab sr 24hr 400 mg (Viramune xr)..................5NEXAVAR – sorafenib tosylate tab 200 mg (baseequivalent)............................................................................8

NEXIUM – esomeprazole magnesium for delayed releasesusp packet 5 mg..............................................................26

NEXIUM – esomeprazole magnesium for delayed releasesusp packet 10 mg............................................................26



NEXIUM – esomeprazole magnesium for delayed releasesusp pack 2.5 mg..............................................................26

niacin tab cr 500 mg (antihyperlipidemic)(Niaspan)...........................................................................20



NICOTROL INHALER – nicotine inhaler system 10 mg (4mg delivered).....................................................................34

NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/spray)................................................................................. 34

nifedipine tab sr 24hr 30 mg (Adalat cc)........................19nifedipine tab sr 24hr 60 mg (Adalat cc)........................19nifedipine tab sr 24hr 90 mg (Adalat cc)........................19nifedipine tab sr 24hr osmotic release 30 mg(Procardia xl)....................................................................19

nifedipine tab sr 24hr osmotic release 60 mg(Procardia xl)....................................................................19

nifedipine tab sr 24hr osmotic release 90 mg(Procardia xl)....................................................................19

NILANDRON – nilutamide tab 150 mg................................ 8NITRO-BID – nitroglycerin oint 2%.................................... 19nitrofurantoin macrocrystalline cap 25 mg(Macrodantin)................................................................... 27

nitrofurantoin macrocrystalline cap 50 mg(Macrodantin)................................................................... 27

nitrofurantoin macrocrystalline cap 100 mg(Macrodantin)................................................................... 27

nitrofurantoin monohydrate macrocrystalline cap 100mg (Macrobid)..................................................................27

nitrofurantoin susp 25 mg/5ml (Furadantin)..................27nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)..........19nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)..........19nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)..........19nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)..........19NITROSTAT – nitroglycerin sl tab 0.3 mg.......................... 19NITROSTAT – nitroglycerin sl tab 0.4 mg.......................... 20NITROSTAT – nitroglycerin sl tab 0.6 mg.......................... 20nonoxynol-9 gel 4% (Options Conceptrol Vaginal).......28norethindrone & ethinyl estradiol-fe chew tab 0.4mg-35 mcg (Femcon fe)................................................. 11

norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg(Brevicon-28)....................................................................11

norethindrone & ethinyl estradiol tab 1 mg-35 mcg(Norinyl 1+35)...................................................................11

norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg(Ovcon-35)........................................................................ 11

norethindrone ace & ethinyl estradiol-fe tab 1 mg-20mcg (Loestrin fe 1/20).....................................................12

norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30mcg (Loestrin fe 1.5/30)..................................................12

norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg(Loestrin 1/20-21).............................................................12

norethindrone ace & ethinyl estradiol tab 1.5 mg-30mcg (Loestrin 1.5/30-21).................................................12

norethindrone acetate-ethinyl estradiol tab 1 mg-5mcg....................................................................................10

norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5mcg (Femhrt low dose).................................................. 10

norethindrone acetate tab 5 mg (Aygestin)...................11norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35mg-mcg (Estrostep fe)....................................................11

norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg (Ortho-novum 7/7/7)............................................... 12

norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg (Tri-norinyl 28).........................................................12

norethindrone tab 0.35 mg (deblitane, norlyroc,sharobel)...........................................................................12

norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg(Ortho-cyclen).................................................................. 12

norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35mg-mcg (Ortho tri-cyclen)..............................................12

norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg.........12nortriptyline hcl cap 10 mg (Pamelor)............................30nortriptyline hcl cap 25 mg (Pamelor)............................30nortriptyline hcl cap 50 mg (Pamelor)............................30nortriptyline hcl cap 75 mg (Pamelor)............................30NORVIR – ritonavir cap 100 mg.......................................... 5NORVIR – ritonavir oral soln 80 mg/ml................................5NORVIR – ritonavir tab 100 mg........................................... 5

2016


NOVOEIGHT – antihemophilic factor (recombinant) for inj250 unit..............................................................................43

NOVOEIGHT – antihemophilic factor (recombinant) for inj500 unit..............................................................................43

NOVOEIGHT – antihemophilic factor (recombinant) for inj1000 unit............................................................................43




NOVOLIN 70/30 – insulin nph isophane & regular humaninj 100 unit/ml (70-30).......................................................14

NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ml........................................................................................14

NOVOLIN R – insulin regular (human) inj 100 unit/ml....... 14NOVOLOG FLEXPEN – insulin aspart soln pen-injector100 unit/ml......................................................................... 13

NOVOLOG – insulin aspart inj 100 unit/ml........................ 13NOVOLOG MIX 70/30 – insulin aspart prot & aspart(human) inj 100 unit/ml (70-30)........................................ 14

NOVOLOG MIX 70/30 PREFILL – insulin aspart prot &aspart sus pen-inj 100 unit/ml (70-30)..............................14

NOVOLOG PENFILL – insulin aspart inj 100 unit/ml.........14NOVOLOG PENFILL – insulin aspart soln cartridge 100unit/ml.................................................................................13

NOXAFIL – posaconazole susp 40 mg/ml...........................3NOXAFIL – posaconazole tab delayed release 100 mg......3NUCYNTA ER – tapentadol hcl tab sr 12hr 50 mg............ 36NUCYNTA ER – tapentadol hcl tab sr 12hr 100 mg.......... 36NUCYNTA ER – tapentadol hcl tab sr 12hr 150 mg.......... 36NUCYNTA ER – tapentadol hcl tab sr 12hr 200 mg.......... 36NUCYNTA ER – tapentadol hcl tab sr 12hr 250 mg.......... 36NUEDEXTA – dextromethorphan hbr-quinidine sulfate cap20-10 mg............................................................................34

NUVARING – etonogestrel-ethinyl estradiol va ring0.120-0.015 mg/24hr.........................................................12

nystatin cream 100000 unit/gm.......................................46nystatin oint 100000 unit/gm........................................... 46nystatin susp 100000 unit/ml.......................................... 45nystatin tab 500000 unit.....................................................3nystatin topical powder....................................................46nystatin-triamcinolone cream 100000-0.1 unit/gm-%........................................................................................ 47

nystatin-triamcinolone oint 100000-0.1 unit/gm-%....... 47O

OBIZUR – antihemophilic factor (recomb porc) rpfviii for inj500 unit..............................................................................43

octreotide acetate inj 50 mcg/ml (0.05 mg/ml)(Sandostatin)....................................................................15




octreotide acetate inj 1000 mcg/ml (1 mg/ml)(Sandostatin)....................................................................15

ODOMZO – sonidegib phosphate cap 200 mg (baseequivalent)............................................................................8

ofloxacin ophth soln 0.3% (Ocuflox)..............................44ofloxacin otic soln 0.3%...................................................45olanzapine orally disintegrating tab 5 mg (Zyprexazydis)................................................................................. 31

olanzapine orally disintegrating tab 10 mg (Zyprexazydis)................................................................................. 31



olanzapine tab 2.5 mg (Zyprexa).....................................31olanzapine tab 5 mg (Zyprexa)........................................31olanzapine tab 7.5 mg (Zyprexa).....................................31olanzapine tab 10 mg (Zyprexa)......................................31olanzapine tab 15 mg (Zyprexa)......................................31olanzapine tab 20 mg (Zyprexa)......................................31omeprazole cap delayed release 10 mg (Prilosec)....... 26omeprazole cap delayed release 20 mg (Prilosec)....... 26omeprazole cap delayed release 40 mg (Prilosec)....... 26OMNITROPE – somatropin for inj 5.8 mg......................... 14OMNITROPE – somatropin inj 5 mg/1.5ml........................14OMNITROPE – somatropin inj 10 mg/1.5ml......................14ondansetron hcl oral soln 4 mg/5ml (Zofran)................26ondansetron hcl tab 24 mg............................................. 26ondansetron hcl tab 4 mg (Zofran).................................26ondansetron hcl tab 8 mg (Zofran).................................26ondansetron orally disintegrating tab 4 mg (Zofranodt).....................................................................................26

ondansetron orally disintegrating tab 8 mg (Zofranodt).....................................................................................26

ONGLYZA – saxagliptin hcl tab 2.5 mg (base equiv).........13ONGLYZA – saxagliptin hcl tab 5 mg (base equiv)............13OPSUMIT – macitentan tab 10 mg....................................22OPTIONS GYNOL II VAGINAL – nonoxynol-9 gel 3%...... 28ORFADIN – nitisinone cap 2 mg........................................15ORFADIN – nitisinone cap 5 mg........................................15ORFADIN – nitisinone cap 10 mg......................................15orphenadrine citrate tab sr 12hr 100 mg....................... 41orphenadrine w/ aspirin & caffeine tab 25-385-30mg...................................................................................... 41

oxaprozin tab 600 mg (Daypro).......................................37oxcarbazepine susp 300 mg/5ml (60 mg/ml)(Trileptal)...........................................................................39

oxcarbazepine tab 150 mg (Trileptal)............................. 39oxcarbazepine tab 300 mg (Trileptal)............................. 39oxcarbazepine tab 600 mg (Trileptal)............................. 39oxybutynin chloride syrup 5 mg/5ml..............................27oxybutynin chloride tab 5 mg......................................... 27oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)......27

2016


oxybutynin chloride tab sr 24hr 10 mg (Ditropanxl)....................................................................................... 27

oxybutynin chloride tab sr 24hr 15 mg (Ditropanxl)....................................................................................... 27

oxycodone-aspirin tab 4.8355-325 mg (Percodan)....... 36oxycodone hcl cap 5 mg................................................. 36oxycodone hcl conc 100 mg/5ml (20 mg/ml)(Oxycodone hcl).............................................................. 36

oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)............36oxycodone hcl tab 10 mg................................................ 36oxycodone hcl tab 20 mg................................................ 36oxycodone hcl tab 5 mg (Roxicodone).......................... 36oxycodone hcl tab 15 mg (Roxicodone)........................ 36oxycodone hcl tab 30 mg (Roxicodone)........................ 36oxycodone w/ acetaminophen tab 5-325 mg(Percocet)......................................................................... 36

oxycodone w/ acetaminophen tab 7.5-325 mg(Percocet)......................................................................... 36

oxycodone w/ acetaminophen tab 10-325 mg(Percocet)......................................................................... 36

OXYCONTIN – oxycodone hcl tab er 12hr deter 10mg...................................................................................... 36







Ppantoprazole sodium ec tab 20 mg (base equiv)(Protonix).......................................................................... 26

pantoprazole sodium ec tab 40 mg (base equiv)(Protonix).......................................................................... 26

paricalcitol cap 1 mcg (Zemplar).................................... 15paricalcitol cap 2 mcg (Zemplar).................................... 15paricalcitol cap 4 mcg (Zemplar).................................... 15paromomycin sulfate cap 250 mg.................................... 3paroxetine hcl tab 10 mg (Paxil).....................................30paroxetine hcl tab 20 mg (Paxil).....................................30paroxetine hcl tab 30 mg (Paxil).....................................30paroxetine hcl tab 40 mg (Paxil).....................................30paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)................ 30paroxetine hcl tab sr 24hr 25 mg (Paxil cr)................... 30paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)................ 30PATADAY – olopatadine hcl ophth soln 0.2% (baseequivalent)......................................................................... 45

PAZEO – olopatadine hcl ophth soln 0.7% (baseequivalent)......................................................................... 45

pediatric multivitamins.....................................................41

pediatric vitamins ADC.................................................... 41PEGASYS – peginterferon alfa-2a inj 180 mcg/ml.............. 4PEGASYS – peginterferon alfa-2a inj 180 mcg/0.5ml......... 4PEGASYS PROCLICK – peginterferon alfa-2a inj 135mcg/0.5ml.............................................................................4

PEGASYS PROCLICK – peginterferon alfa-2a inj 180mcg/0.5ml.............................................................................4

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm(Colyte-flavor packs).......................................................25

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm(Golytely)...........................................................................25

peg 3350-kcl-sod bicarb-nacl for soln 420 gm(Nulytely/flavor pack)......................................................25

penicillin v potassium for soln 125 mg/5ml.....................1penicillin v potassium for soln 250 mg/5ml.....................1penicillin v potassium tab 250 mg....................................1penicillin v potassium tab 500 mg....................................1PENTASA – mesalamine cap cr 250 mg........................... 27PENTASA – mesalamine cap cr 500 mg........................... 27pentoxifylline tab cr 400 mg............................................43perindopril erbumine tab 2 mg....................................... 16perindopril erbumine tab 4 mg (Aceon).........................16perindopril erbumine tab 8 mg (Aceon).........................16permethrin cream 5% (Elimite)........................................48perphenazine tab 2 mg.................................................... 31perphenazine tab 4 mg.................................................... 31perphenazine tab 8 mg.................................................... 31perphenazine tab 16 mg.................................................. 31phenelzine sulfate tab 15 mg (Nardil)............................ 30phenobarbital elixir 20 mg/5ml........................................32phenobarbital tab 16.2 mg...............................................32phenobarbital tab 32.4 mg...............................................32phenoxybenzamine hcl cap 10 mg (Dibenzyline)......... 22PHENYTEK – phenytoin sodium extended cap 200mg...................................................................................... 39

PHENYTEK – phenytoin sodium extended cap 300mg...................................................................................... 39

phenytoin chew tab 50 mg (Dilantin infatabs)...............39phenytoin sodium extended cap 100 mg (Dilantin)...... 39phenytoin susp 125 mg/5ml (Dilantin)........................... 39PICATO – ingenol mebutate gel 0.015%........................... 48PICATO – ingenol mebutate gel 0.05%............................. 48pilocarpine hcl ophth soln 1% (Isopto carpine)............ 44pilocarpine hcl ophth soln 2% (Isopto carpine)............ 44pilocarpine hcl ophth soln 4% (Isopto carpine)............ 44pilocarpine hcl tab 5 mg (Salagen).................................45pilocarpine hcl tab 7.5 mg (Salagen)..............................45pimozide tab 1 mg (Orap)................................................ 34pimozide tab 2 mg (Orap)................................................ 34pindolol tab 5 mg..............................................................18pindolol tab 10 mg............................................................18pioglitazone hcl-metformin hcl tab 15-500 mg(Actoplus met)................................................................. 13

pioglitazone hcl-metformin hcl tab 15-850 mg(Actoplus met)................................................................. 13

pioglitazone hcl tab 15 mg (base equiv) (Actos)...........13

2016


pioglitazone hcl tab 30 mg (base equiv) (Actos)...........13pioglitazone hcl tab 45 mg (base equiv) (Actos)...........13piroxicam cap 10 mg (Feldene).......................................37piroxicam cap 20 mg (Feldene).......................................38PLEGRIDY – peginterferon beta-1a soln pen-injector 125mcg/0.5ml...........................................................................33

PLEGRIDY – peginterferon beta-1a soln prefilled syringe125 mcg/0.5ml...................................................................33

PLEGRIDY STARTER PACK – peginterferon beta-1a solnpen-inj 63 & 94 mcg/0.5ml pack.......................................33

PLEGRIDY STARTER PACK – peginterferon beta-1a solnpref syr 63 & 94 mcg/0.5ml pack..................................... 33

podofilox soln 0.5% (Condylox)......................................48polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% (Polytrim)...........................................................44

POMALYST – pomalidomide cap 1 mg............................... 8POMALYST – pomalidomide cap 2 mg............................... 8POMALYST – pomalidomide cap 3 mg............................... 8POMALYST – pomalidomide cap 4 mg............................... 8pot & sod citrates w/ cit ac soln 550-500-334mg/5ml...............................................................................28

potassium chloride cap cr 8 meq (Micro-k)...................41potassium chloride cap cr 10 meq (Micro-k).................41potassium chloride microencapsulated crys cr tab 10meq....................................................................................41

potassium chloride microencapsulated crys cr tab 20meq....................................................................................41

potassium chloride oral soln 10% (20 meq/15ml).........41potassium chloride oral soln 20% (40 meq/15ml).........41potassium chloride powder packet 20 meq (K-lorhospital pack).................................................................. 41

potassium chloride tab cr 10 meq (K-tabs)................... 41potassium chloride tab cr 8 meq (600 mg)....................41potassium citrate & citric acid powder pack 3300-1002mg...................................................................................... 28

potassium citrate & citric acid soln 1100-334mg/5ml...............................................................................28

potassium citrate tab cr 5 meq (540 mg) (Urocit-k5)........................................................................................ 28

potassium citrate tab cr 10 meq (1080 mg) (Urocit-k10)...................................................................................... 28

potassium citrate tab cr 15 meq (1620 mg) (Urocit-k15)...................................................................................... 28

pot bicarbonate & chloride effer tab 25 meq.................41pot phos monobasic w/sod phos di & monobas tab155-852-130mg (K-phos neutral)................................... 41

PRADAXA – dabigatran etexilate mesylate cap 75 mg(etexilate base eq).............................................................43

PRADAXA – dabigatran etexilate mesylate cap 150 mg(etexilate base eq).............................................................43

pramipexole dihydrochloride tab 0.125 mg(Mirapex)........................................................................... 40


pramipexole dihydrochloride tab 0.5 mg (Mirapex)......40


pramipexole dihydrochloride tab 1 mg (Mirapex).........40pramipexole dihydrochloride tab 1.5 mg (Mirapex)......40pravastatin sodium tab 10 mg........................................ 20pravastatin sodium tab 20 mg (Pravachol)....................20pravastatin sodium tab 40 mg (Pravachol)....................20pravastatin sodium tab 80 mg (Pravachol)....................20prazosin hcl cap 1 mg (Minipress)................................. 22prazosin hcl cap 2 mg (Minipress)................................. 22prazosin hcl cap 5 mg (Minipress)................................. 22prednisolone acetate ophth susp 1% (Pred forte)........ 44prednisolone sodium phosphate ophth soln 1%................ 44prednisolone sod phosphate oral soln 15 mg/5ml(base equiv) (Orapred)....................................................10

prednisolone sod phosph oral soln 6.7 mg/5ml (5mg/5ml base) (Pediapred)................................................ 9

prednisolone syrup 15 mg/5ml (usp solutionequivalent) (Prelone).......................................................10

PREDNISONE – prednisone oral soln 5 mg/5ml...............10PREDNISONE – prednisone tab 50 mg............................ 10prednisone tab 1 mg........................................................ 10prednisone tab 2.5 mg..................................................... 10prednisone tab 5 mg........................................................ 10prednisone tab 10 mg...................................................... 10prednisone tab 20 mg...................................................... 10PREMARIN – estrogens, conjugated tab 0.3 mg...............11PREMARIN – estrogens, conjugated tab 0.45 mg.............11PREMARIN – estrogens, conjugated tab 0.625 mg...........11PREMARIN – estrogens, conjugated tab 0.9 mg...............11PREMARIN – estrogens, conjugated tab 1.25 mg.............11PREMPHASE – conj est 0.625(14)/conj est-medroxyproac tab 0.625-5mg(14)........................................................11

PREMPRO – conjugated estrogen-medroxyprogestacetate tab 0.3-1.5 mg......................................................11

PREMPRO – conjugated estrogen-medroxyprogestacetate tab 0.45-1.5 mg....................................................11

PREMPRO – conjugated estrogen-medroxyprogestacetate tab 0.625-2.5 mg..................................................11

PREMPRO – conjugated estrogen-medroxyprogestacetate tab 0.625-5 mg.....................................................11

PRENATAL VITAMINS........................................................41PREZCOBIX – darunavir-cobicistat tab 800-150 mg...........5PREZISTA – darunavir ethanolate susp 100 mg/ml (baseequiv)....................................................................................5

PREZISTA – darunavir ethanolate tab 75 mg (baseequiv)....................................................................................5




PRIFTIN – rifapentine tab 150 mg....................................... 3PRIMAQUINE PHOSPHATE – primaquine phosphate tab26.3 mg (15 mg base)........................................................ 6

2016


primidone tab 50 mg (Mysoline)..................................... 39primidone tab 250 mg (Mysoline)................................... 39PROAIR HFA – albuterol sulfate inhal aero 108 mcg/act(90mcg base equiv).......................................................... 24

probenecid tab 500 mg.................................................... 38prochlorperazine maleate tab 5 mg (base equivalent)(Compazine)..................................................................... 31

prochlorperazine maleate tab 10 mg (base equivalent)(Compazine)..................................................................... 31

prochlorperazine suppos 25 mg.....................................31PROCRIT – epoetin alfa inj 2000 unit/ml...........................43PROCRIT – epoetin alfa inj 3000 unit/ml...........................43PROCRIT – epoetin alfa inj 4000 unit/ml...........................43PROCRIT – epoetin alfa inj 10000 unit/ml.........................43PROCRIT – epoetin alfa inj 20000 unit/ml.........................43PROCRIT – epoetin alfa inj 40000 unit/ml.........................43progesterone micronized cap 100 mg(Prometrium).................................................................... 11

progesterone micronized cap 200 mg(Prometrium).................................................................... 11

PROLIA – denosumab inj 60 mg/ml...................................15promethazine hcl suppos 12.5 mg................................. 23promethazine hcl suppos 25 mg.................................... 23promethazine hcl suppos 50 mg.................................... 23promethazine hcl syrup 6.25 mg/5ml............................. 23promethazine hcl tab 12.5 mg.........................................23promethazine hcl tab 25 mg............................................23promethazine hcl tab 50 mg............................................23propafenone hcl cap sr 12hr 225 mg (Rythmol sr)....... 21propafenone hcl cap sr 12hr 325 mg (Rythmol sr)....... 21propafenone hcl cap sr 12hr 425 mg (Rythmol sr)....... 21propafenone hcl tab 300 mg........................................... 21propafenone hcl tab 150 mg (Rythmol)......................... 21propafenone hcl tab 225 mg (Rythmol)......................... 21PROPANTHELINE BROMIDE – propantheline bromidetab 15 mg.......................................................................... 26

propranolol & hydrochlorothiazide tab 40-25 mg............... 18propranolol & hydrochlorothiazide tab 80-25 mg............... 18propranolol hcl cap sr 24hr 60 mg (Inderal la)..............18propranolol hcl cap sr 24hr 80 mg (Inderal la)..............18propranolol hcl cap sr 24hr 120 mg (Inderal la)............18propranolol hcl cap sr 24hr 160 mg (Inderal la)............18PROPRANOLOL HCL – propranolol hcl oral soln 20mg/5ml............................................................................... 18

PROPRANOLOL HCL – propranolol hcl oral soln 40mg/5ml............................................................................... 18

propranolol hcl tab 10 mg............................................... 18propranolol hcl tab 20 mg............................................... 18propranolol hcl tab 40 mg............................................... 18propranolol hcl tab 60 mg............................................... 18propranolol hcl tab 80 mg............................................... 18propylthiouracil tab 50 mg.............................................. 14PULMOZYME – dornase alfa inhal soln 1 mg/ml.............. 25PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/ml)........................................................................................ 8

pyrazinamide tab 500 mg...................................................3

pyridostigmine bromide tab 60 mg (Mestinon)............. 41Q

quetiapine fumarate tab 25 mg (Seroquel).................... 31quetiapine fumarate tab 50 mg (Seroquel).................... 31quetiapine fumarate tab 100 mg (Seroquel).................. 31quetiapine fumarate tab 200 mg (Seroquel).................. 31quetiapine fumarate tab 300 mg (Seroquel).................. 31quetiapine fumarate tab 400 mg (Seroquel).................. 31quinapril hcl tab 5 mg (Accupril).................................... 16quinapril hcl tab 10 mg (Accupril).................................. 16quinapril hcl tab 20 mg (Accupril).................................. 16quinapril hcl tab 40 mg (Accupril).................................. 16quinapril-hydrochlorothiazide tab 10-12.5 mg(Accuretic)........................................................................ 16

quinapril-hydrochlorothiazide tab 20-12.5 mg(Accuretic)........................................................................ 16

quinapril-hydrochlorothiazide tab 20-25 mg(Accuretic)........................................................................ 16

quinidine gluconate tab cr 324 mg.................................21QUINIDINE SULFATE ER – quinidine sulfate tab cr 300mg...................................................................................... 21

quinidine sulfate tab 300 mg...........................................21QVAR – beclomethasone diprop inhal aero soln 40 mcg/act (50/valve).....................................................................24

QVAR – beclomethasone diprop inhal aero soln 80 mcg/act (100/valve)...................................................................24

Rraloxifene hcl tab 60 mg (Evista)....................................15ramipril cap 1.25 mg (Altace).......................................... 16ramipril cap 2.5 mg (Altace)............................................ 16ramipril cap 5 mg (Altace)............................................... 16ramipril cap 10 mg (Altace)............................................. 16ranitidine hcl cap 150 mg................................................ 26ranitidine hcl cap 300 mg................................................ 26ranitidine hcl syrup 15 mg/ml (75 mg/5ml).................... 26ranitidine hcl tab 150 mg (Zantac)..................................26ranitidine hcl tab 300 mg (Zantac)..................................26RAPAMUNE – sirolimus oral soln 1 mg/ml........................ 49REBIF – interferon beta-1a soln pref syr 22 mcg/0.5ml(12mu/ml)...........................................................................33

REBIF – interferon beta-1a soln pref syr 44 mcg/0.5ml(24mu/ml)...........................................................................33

REBIF REBIDOSE – interferon beta-1a soln auto-inj 22mcg/0.5ml (12mu/ml).........................................................33

REBIF REBIDOSE – interferon beta-1a soln auto-inj 44mcg/0.5ml (24mu/ml).........................................................33

REBIF REBIDOSE TITRATION – interferon beta-1a auto-inj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml............................ 33

REBIF TITRATION PACK – interferon beta-1a pref syr6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml................................. 33

RENVELA – sevelamer carbonate packet 0.8 gm.............27RENVELA – sevelamer carbonate packet 2.4 gm.............27RENVELA – sevelamer carbonate tab 800 mg..................27repaglinide tab 0.5 mg (Prandin).................................... 13

2016


repaglinide tab 1 mg (Prandin)....................................... 13repaglinide tab 2 mg (Prandin)....................................... 13REPRONEX – menotropins for inj 75 unit......................... 12RESCRIPTOR – delavirdine mesylate tab 100 mg..............5RESCRIPTOR – delavirdine mesylate tab 200 mg..............5REVLIMID – lenalidomide cap 5 mg..................................49REVLIMID – lenalidomide cap 10 mg................................49REVLIMID – lenalidomide cap 15 mg................................49REVLIMID – lenalidomide cap 20 mg................................49REVLIMID – lenalidomide cap 25 mg................................49REVLIMID – lenalidomide caps 2.5 mg............................. 49REYATAZ – atazanavir sulfate cap 150 mg (baseequiv)....................................................................................5

REYATAZ – atazanavir sulfate cap 200 mg (baseequiv)....................................................................................5

REYATAZ – atazanavir sulfate cap 300 mg (baseequiv)....................................................................................5

REYATAZ – atazanavir sulfate oral powder packet 50 mg(base equiv).........................................................................5

ribavirin cap 200 mg (Rebetol)..........................................4ribavirin tab 200 mg (Copegus)........................................ 4rifabutin cap 150 mg (Mycobutin).....................................3rifampin cap 150 mg (Rifadin)...........................................3rifampin cap 300 mg (Rifadin)...........................................3riluzole tab 50 mg (Rilutek)............................................. 41risedronate sodium tab 5 mg (Actonel)......................... 15risedronate sodium tab 30 mg (Actonel)....................... 15risedronate sodium tab 35 mg (Actonel)....................... 15risedronate sodium tab 150 mg (Actonel)..................... 15risperidone orally disintegrating tab 0.25 mg............... 31risperidone orally disintegrating tab 0.5 mg (Risperdalm-tab)................................................................................ 31

risperidone orally disintegrating tab 1 mg (Risperdalm-tab)................................................................................ 31




risperidone soln 1 mg/ml (Risperdal).............................31risperidone tab 0.25 mg (Risperdal)...............................31risperidone tab 0.5 mg (Risperdal).................................31risperidone tab 1 mg (Risperdal)....................................31risperidone tab 2 mg (Risperdal)....................................31risperidone tab 3 mg (Risperdal)....................................31risperidone tab 4 mg (Risperdal)....................................31rivastigmine tartrate cap 1.5 mg (Exelon)......................34rivastigmine tartrate cap 3 mg (Exelon).........................34rivastigmine tartrate cap 4.5 mg (Exelon)......................34rivastigmine tartrate cap 6 mg (Exelon).........................34rizatriptan benzoate orally disintegrating tab 5 mg(Maxalt-mlt).......................................................................38

rizatriptan benzoate orally disintegrating tab 10 mg(Maxalt-mlt).......................................................................38

rizatriptan benzoate tab 5 mg (Maxalt)...........................38

rizatriptan benzoate tab 10 mg (Maxalt).........................38ropinirole hydrochloride tab 0.25 mg (Requip)............. 40ropinirole hydrochloride tab 0.5 mg (Requip)............... 40ropinirole hydrochloride tab 1 mg (Requip).................. 40ropinirole hydrochloride tab 2 mg (Requip).................. 40ropinirole hydrochloride tab 3 mg (Requip).................. 40ropinirole hydrochloride tab 4 mg (Requip).................. 40ropinirole hydrochloride tab 5 mg (Requip).................. 40ROXICET – oxycodone w/ acetaminophen soln 5-325mg/5ml............................................................................... 36

SSABRIL – vigabatrin powd pack 500 mg........................... 39SABRIL – vigabatrin tab 500 mg........................................39salsalate tab 500 mg.........................................................35salsalate tab 750 mg.........................................................35SANDOSTATIN LAR DEPOT – octreotide acetate for iminj kit 10 mg.......................................................................15

SANDOSTATIN LAR DEPOT – octreotide acetate for iminj kit 20 mg.......................................................................15

SANDOSTATIN LAR DEPOT – octreotide acetate for iminj kit 30 mg.......................................................................15

selegiline hcl cap 5 mg (Eldepryl).................................. 40selegiline hcl tab 5 mg.....................................................40selenium sulfide lotion 2.5%........................................... 48SELZENTRY – maraviroc tab 150 mg................................. 5SELZENTRY – maraviroc tab 300 mg................................. 5SENSIPAR – cinacalcet hcl tab 30 mg (base equiv)..........15SENSIPAR – cinacalcet hcl tab 60 mg (base equiv)..........15SENSIPAR – cinacalcet hcl tab 90 mg (base equiv)..........15SEREVENT DISKUS – salmeterol xinafoate aer pow ba50 mcg/dose (base equiv)................................................ 25

SEROQUEL XR – quetiapine fumarate tab sr 24hr 50mg...................................................................................... 31





sertraline hcl oral conc 20 mg/ml (Zoloft)......................30sertraline hcl tab 25 mg (Zoloft)..................................... 30sertraline hcl tab 50 mg (Zoloft)..................................... 30sertraline hcl tab 100 mg (Zoloft)................................... 30SHUR-SEAL – nonoxynol-9 gel 2%...................................28sildenafil citrate tab 20 mg (Revatio)............................. 22silver sulfadiazine cream 1% (Silvadene)...................... 46SIMBRINZA – brinzolamide-brimonidine tartrate ophthsusp 1-0.2%.......................................................................44

SIMPONI – golimumab subcutaneous soln auto-injector50 mg/0.5ml.......................................................................38

SIMPONI – golimumab subcutaneous soln auto-injector100 mg/ml..........................................................................38

2016


SIMPONI – golimumab subcutaneous soln prefilledsyringe 50 mg/0.5ml..........................................................38

SIMPONI – golimumab subcutaneous soln prefilledsyringe 100 mg/ml.............................................................38

simvastatin tab 5 mg (Zocor).......................................... 20simvastatin tab 10 mg (Zocor)........................................ 20simvastatin tab 20 mg (Zocor)........................................ 20simvastatin tab 40 mg (Zocor)........................................ 20simvastatin tab 80 mg (Zocor)........................................ 20sirolimus tab 0.5 mg (Rapamune)...................................49sirolimus tab 1 mg (Rapamune)......................................49sirolimus tab 2 mg (Rapamune)......................................49SIVEXTRO – tedizolid phosphate tab 200 mg.....................6sodium citrate & citric acid soln 500-334 mg/5ml(Shohls solution modi)................................................... 28

sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)(Luride)..............................................................................41

sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)(Luride)..............................................................................41

sodium fluoride chew tab 1 mg f (from 2.2 mg naf)(Luride)..............................................................................41

sodium fluoride cream 1.1% (Prevident 5000 plus)...... 45sodium fluoride gel 1.1% (0.5% f) (Previdentfluoride).............................................................................45

SODIUM FLUORIDE – sodium fluoride tab 0.5 mg f (from1.1 mg naf)........................................................................ 41

sodium fluoride soln 0.125 mg/drop f (0.275 mg/dropnaf).....................................................................................41

sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)(Luride)..............................................................................41

sodium polystyrene sulfonate oral susp 15 gm/60ml(Sps).................................................................................. 49

sodium polystyrene sulfonate powder(Kayexalate)......................................................................49

SODIUM SULFACETAMIDE/SULF – sulfacetamidesodium w/ sulfur susp 10-5%........................................... 46

SOLIRIS – eculizumab iv soln 10 mg/ml (for infusion).......43SOLTAMOX – tamoxifen citrate oral soln 10 mg/5ml (baseequivalent)............................................................................8

sotalol hcl (afib/afl) tab 80 mg (Betapace af).................21sotalol hcl (afib/afl) tab 120 mg (Betapace af)...............21sotalol hcl (afib/afl) tab 160 mg (Betapace af)...............21sotalol hcl tab 240 mg......................................................21sotalol hcl tab 80 mg (Betapace)....................................21sotalol hcl tab 120 mg (Betapace)..................................21sotalol hcl tab 160 mg (Betapace)..................................21SOVALDI – sofosbuvir tab 400 mg...................................... 4SPIRIVA HANDIHALER – tiotropium bromidemonohydrate inhal cap 18 mcg (base equiv)................... 25

SPIRIVA RESPIMAT – tiotropium bromide monohydrateinhal aerosol 1.25 mcg/act................................................25

SPIRIVA RESPIMAT – tiotropium bromide monohydrateinhal aerosol 2.5 mcg/act..................................................25

spironolactone & hydrochlorothiazide tab 25-25 mg(Aldactazide).....................................................................21

spironolactone tab 25 mg (Aldactone)...........................21

spironolactone tab 50 mg (Aldactone)...........................21spironolactone tab 100 mg (Aldactone).........................21SPORANOX – itraconazole oral soln 10 mg/ml...................3SPRYCEL – dasatinib tab 20 mg.........................................8SPRYCEL – dasatinib tab 50 mg.........................................8SPRYCEL – dasatinib tab 70 mg.........................................8SPRYCEL – dasatinib tab 80 mg.........................................8SPRYCEL – dasatinib tab 100 mg.......................................8SPRYCEL – dasatinib tab 140 mg.......................................8SSKI – potassium iodide soln 1 gm/ml.............................. 23stavudine cap 15 mg (Zerit)...............................................5stavudine cap 20 mg (Zerit)...............................................5stavudine cap 30 mg (Zerit)...............................................5stavudine cap 40 mg (Zerit)...............................................5stavudine for oral soln 1 mg/ml (Zerit)............................ 5STELARA – ustekinumab soln prefilled syringe 45mg/0.5ml............................................................................ 48

STELARA – ustekinumab soln prefilled syringe 90 mg/ml........................................................................................48

STIVARGA – regorafenib tab 40 mg....................................8STRIBILD – elvitegrav-cobicis-emtricitab-tenofov tab150-150-200-300 mg...........................................................5

SUBOXONE – buprenorphine hcl-naloxone hcl sl film2-0.5 mg (base equiv).......................................................49

SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1mg (base equiv)................................................................ 49



sucralfate tab 1 gm (Carafate).........................................26sulfacetamide sodium lotion 10% (acne) (Klaron)........46sulfacetamide sodium ophth soln 10% (Bleph-10)....... 44sulfacetamide sodium-prednisolone ophth soln10-0.23(0.25)%.................................................................. 44

sulfacetamide sodium w/ sulfur cream 10-5%.............. 46sulfacetamide sodium w/ sulfur emulsion 10-5%......... 46sulfacetamide sodium w/ sulfur lotion 10-5%............... 46sulfamethoxazole-trimethoprim susp 200-40mg/5ml.................................................................................6

sulfamethoxazole-trimethoprim tab 400-80 mg(Bactrim)............................................................................. 6

sulfamethoxazole-trimethoprim tab 800-160 mg(Bactrim ds)........................................................................6

sulfasalazine tab delayed release 500 mg (Azulfidineen-tabs)............................................................................. 27

sulfasalazine tab 500 mg (Azulfidine)............................ 27sulindac tab 150 mg......................................................... 38sulindac tab 200 mg......................................................... 38sumatriptan succinate inj 6 mg/0.5ml (Imitrex statdoseref)......................................................................................38

sumatriptan succinate solution auto-injector 4mg/0.5ml (Imitrex statdose sys)....................................38

sumatriptan succinate solution auto-injector 6mg/0.5ml (Imitrex statdose sys)....................................38

2016


sumatriptan succinate solution cartridge 4 mg/0.5ml(Imitrex statdose ref)...................................................... 38

sumatriptan succinate solution cartridge 6 mg/0.5ml(Imitrex statdose ref)...................................................... 38

sumatriptan succinate tab 25 mg (Imitrex)....................38sumatriptan succinate tab 50 mg (Imitrex)....................38sumatriptan succinate tab 100 mg (Imitrex)..................38SUMATRIPTAN – sumatriptan nasal spray 5 mg/act.........38SUMATRIPTAN – sumatriptan nasal spray 20 mg/act.......38SUPRAX – cefixime cap 400 mg......................................... 2SUPRAX – cefixime chew tab 100 mg................................ 2SUPRAX – cefixime chew tab 200 mg................................ 2SUPRAX – cefixime for susp 100 mg/5ml........................... 2SUPRAX – cefixime for susp 200 mg/5ml........................... 2SUPRAX – cefixime for susp 500 mg/5ml........................... 2SUSTIVA – efavirenz cap 50 mg......................................... 5SUSTIVA – efavirenz cap 200 mg....................................... 5SUSTIVA – efavirenz tab 600 mg........................................ 5SUTENT – sunitinib malate cap 12.5 mg (baseequivalent)............................................................................8

SUTENT – sunitinib malate cap 25 mg (baseequivalent)............................................................................8

SUTENT – sunitinib malate cap 37.5 mg (baseequivalent)............................................................................8

SUTENT – sunitinib malate cap 50 mg (baseequivalent)............................................................................8

SYLATRON – peginterferon alfa-2b for inj kit 200 mcg....... 9SYLATRON – peginterferon alfa-2b for inj kit 300 mcg....... 9SYLATRON – peginterferon alfa-2b for inj kit 600 mcg....... 9SYMBICORT – budesonide-formoterol fumarate dihydaerosol 80-4.5 mcg/act..................................................... 25

SYMBICORT – budesonide-formoterol fumarate dihydaerosol 160-4.5 mcg/act................................................... 25

SYNAGIS – palivizumab im soln 50 mg/0.5ml.....................6SYNAGIS – palivizumab im soln 100 mg/ml........................6

TTABLOID – thioguanine tab 40 mg...................................... 9tacrolimus cap 0.5 mg (Prograf)..................................... 49tacrolimus cap 1 mg (Prograf)........................................ 49tacrolimus cap 5 mg (Prograf)........................................ 49tacrolimus oint 0.03% (Protopic).................................... 48tacrolimus oint 0.1% (Protopic)...................................... 48TAFINLAR – dabrafenib mesylate cap 50 mg (baseequivalent)............................................................................9

TAFINLAR – dabrafenib mesylate cap 75 mg (baseequivalent)............................................................................9

TAMIFLU – oseltamivir phosphate cap 30 mg (baseequiv)....................................................................................6



TAMIFLU – oseltamivir phosphate for susp 6 mg/ml (baseequiv)....................................................................................6

tamoxifen citrate tab 10 mg (base equivalent)................9

tamoxifen citrate tab 20 mg (base equivalent)................9tamsulosin hcl cap 0.4 mg (Flomax).............................. 28TARCEVA – erlotinib hcl tab 25 mg (base equivalent).........9TARCEVA – erlotinib hcl tab 100 mg (base equivalent).......9TARCEVA – erlotinib hcl tab 150 mg (base equivalent).......9TASIGNA – nilotinib hcl cap 150 mg (base equivalent)....... 9TASIGNA – nilotinib hcl cap 200 mg (base equivalent)....... 9TAZORAC – tazarotene cream 0.05%...............................46TAZORAC – tazarotene cream 0.1%.................................46TAZORAC – tazarotene gel 0.05%.................................... 46TAZORAC – tazarotene gel 0.1%...................................... 46TECFIDERA – dimethyl fumarate capsule delayed release120 mg...............................................................................34

TECFIDERA – dimethyl fumarate capsule delayed release240 mg...............................................................................34

TECFIDERA STARTER PACK – dimethyl fumaratecapsule dr starter pack 120 mg & 240 mg....................... 34

TEGRETOL-XR – carbamazepine tab sr 12hr 100 mg......39telmisartan-hydrochlorothiazide tab 40-12.5 mg(Micardis hct)................................................................... 17

telmisartan-hydrochlorothiazide tab 80-12.5 mg(Micardis hct)................................................................... 17

telmisartan-hydrochlorothiazide tab 80-25 mg(Micardis hct)................................................................... 17

telmisartan tab 20 mg (Micardis).................................... 17telmisartan tab 40 mg (Micardis).................................... 17telmisartan tab 80 mg (Micardis).................................... 17temazepam cap 7.5 mg (Restoril)................................... 32temazepam cap 15 mg (Restoril).................................... 32temazepam cap 22.5 mg (Restoril)................................. 32temazepam cap 30 mg (Restoril).................................... 32temozolomide cap 5 mg (Temodar).................................. 9temozolomide cap 20 mg (Temodar)................................ 9temozolomide cap 100 mg (Temodar)..............................9temozolomide cap 140 mg (Temodar)..............................9temozolomide cap 180 mg (Temodar)..............................9temozolomide cap 250 mg (Temodar)..............................9terazosin hcl cap 1 mg.....................................................22terazosin hcl cap 2 mg.....................................................22terazosin hcl cap 5 mg.....................................................22terazosin hcl cap 10 mg...................................................22terbinafine hcl tab 250 mg (Lamisil).................................3terbutaline sulfate tab 2.5 mg......................................... 25terbutaline sulfate tab 5 mg............................................ 25terconazole vaginal cream 0.4% (Terazol 7).................. 28terconazole vaginal cream 0.8% (Terazol 3).................. 28terconazole vaginal suppos 80 mg (Terazol 3)..............28testosterone cypionate im inj in oil 100 mg/ml (Depo-testosterone).................................................................... 10

testosterone cypionate im inj in oil 200 mg/ml (Depo-testosterone).................................................................... 10

testosterone enanthate im inj in oil 200 mg/ml.............10TEST STRIPS – BAYER ASCENSIA AUTODISC,BREEZE 2, CONTOUR, CONTOUR NEXT..................... 48

tetrabenazine tab 12.5 mg (Xenazine)............................ 34tetrabenazine tab 25 mg (Xenazine)............................... 34

2016


tetracycline hcl cap 250 mg..................................................3tetracycline hcl cap 500 mg..................................................3THALOMID – thalidomide cap 50 mg................................ 49THALOMID – thalidomide cap 100 mg.............................. 49THALOMID – thalidomide cap 150 mg.............................. 49THALOMID – thalidomide cap 200 mg.............................. 49theophylline tab sr 12hr 100 mg.....................................25theophylline tab sr 12hr 200 mg.....................................25theophylline tab sr 12hr 300 mg.....................................25theophylline tab sr 12hr 450 mg.....................................25theophylline tab sr 24hr 400 mg.....................................25theophylline tab sr 24hr 600 mg.....................................25thiothixene cap 1 mg........................................................32thiothixene cap 2 mg........................................................32thiothixene cap 5 mg........................................................32thiothixene cap 10 mg......................................................32timolol maleate ophth gel forming soln 0.25%(Timoptic-xe).................................................................... 44

timolol maleate ophth gel forming soln 0.5%(Timoptic-xe).................................................................... 44

timolol maleate ophth soln 0.25% (Timoptic)................44timolol maleate ophth soln 0.5% (Timoptic)..................44timolol maleate tab 5 mg.................................................... 18timolol maleate tab 10 mg..................................................18timolol maleate tab 20 mg..................................................18TIVICAY – dolutegravir sodium tab 50 mg (base equiv)...... 5tizanidine hcl tab 2 mg (base equivalent)......................41tizanidine hcl tab 4 mg (base equivalent)(Zanaflex).......................................................................... 41

tobramycin-dexamethasone ophth susp 0.3-0.1%(Tobradex).........................................................................44

tobramycin nebu soln 300 mg/5ml (Tobi)........................ 3tobramycin ophth soln 0.3% (Tobrex)............................ 44TODAY SPONGE – nonoxynol-9 vaginal sponge 1000mg...................................................................................... 28

tolterodine tartrate cap sr 24hr 2 mg (Detrol la)............27tolterodine tartrate cap sr 24hr 4 mg (Detrol la)............27tolterodine tartrate tab 1 mg (Detrol)............................. 27tolterodine tartrate tab 2 mg (Detrol)............................. 27topiramate sprinkle cap 15 mg (Topamax sprinkle)..... 39topiramate sprinkle cap 25 mg (Topamax sprinkle)..... 39topiramate tab 25 mg (Topamax).................................... 39topiramate tab 50 mg (Topamax).................................... 39topiramate tab 100 mg (Topamax).................................. 39topiramate tab 200 mg (Topamax).................................. 39torsemide tab 5 mg (Demadex).......................................21torsemide tab 10 mg (Demadex).....................................21torsemide tab 20 mg (Demadex).....................................21torsemide tab 100 mg (Demadex)...................................21TOUJEO SOLOSTAR – insulin glargine soln pen-injector300 unit/ml......................................................................... 14

TRACLEER – bosentan tab 62.5 mg.................................22TRACLEER – bosentan tab 125 mg..................................22tramadol-acetaminophen tab 37.5-325 mg(Ultracet)........................................................................... 37

tramadol hcl tab 50 mg (Ultram).....................................36

tramadol hcl tab sr 24hr 100 mg (Ultram er)................. 36tramadol hcl tab sr 24hr 200 mg (Ultram er)................. 36tramadol hcl tab sr 24hr 300 mg (Ultram er)................. 36trandolapril tab 1 mg (Mavik).......................................... 16trandolapril tab 2 mg (Mavik).......................................... 16trandolapril tab 4 mg (Mavik).......................................... 16tranylcypromine sulfate tab 10 mg (Parnate)................30TRAVATAN Z – travoprost ophth soln 0.004%(benzalkonium free) (bak free)......................................... 44

trazodone hcl tab 50 mg.................................................. 30trazodone hcl tab 100 mg................................................ 30trazodone hcl tab 150 mg................................................ 30trazodone hcl tab 300 mg................................................ 30tretinoin cap 10 mg.............................................................9tretinoin cream 0.025% (Retin-a).....................................46tretinoin cream 0.05% (Retin-a).......................................46tretinoin cream 0.1% (Retin-a).........................................46tretinoin gel 0.01% (Retin-a)............................................ 46tretinoin gel 0.025% (Retin-a)..........................................46tretinoin microsphere gel 0.04% (Retin-a micro).......... 46tretinoin microsphere gel 0.1% (Retin-a micro)............ 46TRETTEN – coagulation factor xiii a-subunit for inj2000-3125 unit...................................................................43

triamcinolone acetonide cream 0.025%......................... 47triamcinolone acetonide cream 0.1%............................. 47triamcinolone acetonide cream 0.5%............................. 47triamcinolone acetonide dental paste 0.1%.................. 45triamcinolone acetonide lotion 0.025%..........................47triamcinolone acetonide lotion 0.1%..............................47triamcinolone acetonide nasal aerosol suspension 55mcg/act (Nasacort aq).................................................... 23

triamcinolone acetonide oint 0.025%............................. 47triamcinolone acetonide oint 0.1%................................. 47triamcinolone acetonide oint 0.5%..................................... 47triamterene & hydrochlorothiazide cap 37.5-25 mg(Dyazide)........................................................................... 21

triamterene & hydrochlorothiazide tab 37.5-25 mg(Maxzide-25)..................................................................... 21

triamterene & hydrochlorothiazide tab 75-50 mg(Maxzide)...........................................................................21

trifluoperazine hcl tab 1 mg............................................ 32trifluoperazine hcl tab 2 mg............................................ 32trifluoperazine hcl tab 5 mg............................................ 32trifluoperazine hcl tab 10 mg.......................................... 32trifluridine ophth soln 1% (Viroptic)............................... 44trihexyphenidyl hcl elixir 0.4 mg/ml............................... 40trihexyphenidyl hcl tab 2 mg...........................................40trihexyphenidyl hcl tab 5 mg...........................................40trimethobenzamide hcl cap 300 mg (Tigan).................. 26trimethoprim tab 100 mg................................................... 6TRIUMEQ – abacavir-dolutegravir-lamivudine tab600-50-300 mg.................................................................... 5

tropicamide ophth soln 0.5%.......................................... 45tropicamide ophth soln 1% (Mydriacyl)......................... 45TRUVADA – emtricitabine-tenofovir disoproxil fumaratetab 200-300 mg................................................................... 5

2016


TYBOST – cobicistat tab 150 mg.........................................5TYKERB – lapatinib ditosylate tab 250 mg (base equiv)..... 9

UULESFIA – benzyl alcohol lotion 5%................................. 48ursodiol cap 300 mg (Actigall)........................................27ursodiol tab 250 mg (Urso 250)...................................... 27ursodiol tab 500 mg (Urso forte).................................... 27V

VAGIFEM – estradiol vaginal tab 10 mcg.......................... 28valacyclovir hcl tab 1 gm (Valtrex)................................... 4valacyclovir hcl tab 500 mg (Valtrex)............................... 4VALCHLOR – mechlorethamine hcl gel 0.016% (baseequivalent)......................................................................... 48

VALCYTE – valganciclovir hcl for soln 50 mg/ml (baseequiv)....................................................................................3

valganciclovir hcl tab 450 mg (base equivalent)(Valcyte).............................................................................. 3

valproate sodium syrup 250 mg/5ml (base equiv)(Depakene)........................................................................40

valproic acid cap 250 mg (Depakene)............................40valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovanhct).....................................................................................17

valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovanhct).....................................................................................17

valsartan-hydrochlorothiazide tab 160-25 mg (Diovanhct).....................................................................................17

valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovanhct).....................................................................................17

valsartan-hydrochlorothiazide tab 320-25 mg (Diovanhct).....................................................................................17

valsartan tab 40 mg (Diovan).......................................... 17valsartan tab 80 mg (Diovan).......................................... 17valsartan tab 160 mg (Diovan)........................................ 17valsartan tab 320 mg (Diovan)........................................ 17vancomycin hcl cap 125 mg (Vancocin hcl)....................6vancomycin hcl cap 250 mg (Vancocin hcl)....................6VCF VAGINAL CONTRACEPTIVE – nonoxynol-9 film28%.................................................................................... 28

VCF VAGINAL CONTRACEPTIVE – nonoxynol-9 foam12.5%................................................................................. 28

venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent)(Effexor xr)....................................................................... 30

venlafaxine hcl cap sr 24hr 75 mg (base equivalent)(Effexor xr)....................................................................... 30

venlafaxine hcl cap sr 24hr 150 mg (base equivalent)(Effexor xr)....................................................................... 30

venlafaxine hcl tab 25 mg................................................30venlafaxine hcl tab 37.5 mg.............................................30venlafaxine hcl tab 50 mg................................................30venlafaxine hcl tab 75 mg................................................30venlafaxine hcl tab 100 mg..............................................30venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent)(Venlafaxine hcl er)......................................................... 30

venlafaxine hcl tab sr 24hr 75 mg (base equivalent)(Venlafaxine hcl er)......................................................... 30

venlafaxine hcl tab sr 24hr 150 mg (base equivalent)(Venlafaxine hcl er)......................................................... 30

VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act(90mcg base equiv).......................................................... 25

verapamil hcl cap sr 24hr 120 mg (Verelan).................. 19verapamil hcl cap sr 24hr 180 mg (Verelan).................. 19verapamil hcl cap sr 24hr 240 mg (Verelan).................. 19verapamil hcl cap sr 24hr 360 mg (Verelan).................. 19verapamil hcl tab cr 120 mg (Calan sr)..........................19verapamil hcl tab cr 180 mg (Calan sr)..........................19verapamil hcl tab cr 240 mg (Calan sr)..........................19verapamil hcl tab 80 mg (Calan).....................................19verapamil hcl tab 120 mg (Calan)...................................19VESICARE – solifenacin succinate tab 5 mg.................... 27VESICARE – solifenacin succinate tab 10 mg...................27VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ml)...................................................................................... 13

VIDEX – didanosine for soln 2 gm.......................................5VIDEX – didanosine for soln 4 gm.......................................5VIGAMOX – moxifloxacin hcl ophth soln 0.5% (baseequiv)................................................................................. 44

VIRACEPT – nelfinavir mesylate tab 250 mg...................... 5VIRACEPT – nelfinavir mesylate tab 625 mg...................... 5VIRAMUNE – nevirapine susp 50 mg/5ml...........................5VIRAMUNE XR – nevirapine tab sr 24hr 100 mg................5VIREAD – tenofovir disoproxil fumarate oral powder 40mg/gm.................................................................................. 5

VIREAD – tenofovir disoproxil fumarate tab 150 mg........... 5VIREAD – tenofovir disoproxil fumarate tab 200 mg........... 5VIREAD – tenofovir disoproxil fumarate tab 250 mg........... 6VIREAD – tenofovir disoproxil fumarate tab 300 mg........... 6VITEKTA – elvitegravir tab 85 mg........................................6VITEKTA – elvitegravir tab 150 mg......................................6VOLTAREN – diclofenac sodium gel 1%........................... 48voriconazole for susp 40 mg/ml (Vfend)..........................3voriconazole tab 50 mg (Vfend)........................................3voriconazole tab 200 mg (Vfend)......................................3VOTRIENT – pazopanib hcl tab 200 mg (base equiv).........9VYVANSE – lisdexamfetamine dimesylate cap 10 mg...... 33VYVANSE – lisdexamfetamine dimesylate cap 20 mg...... 33VYVANSE – lisdexamfetamine dimesylate cap 30 mg...... 33VYVANSE – lisdexamfetamine dimesylate cap 40 mg...... 33VYVANSE – lisdexamfetamine dimesylate cap 50 mg...... 33VYVANSE – lisdexamfetamine dimesylate cap 60 mg...... 33VYVANSE – lisdexamfetamine dimesylate cap 70 mg...... 33

Wwarfarin sodium tab 1 mg (Coumadin).......................... 43warfarin sodium tab 2 mg (Coumadin).......................... 43warfarin sodium tab 2.5 mg (Coumadin)....................... 43warfarin sodium tab 3 mg (Coumadin).......................... 43warfarin sodium tab 4 mg (Coumadin).......................... 43warfarin sodium tab 5 mg (Coumadin).......................... 43warfarin sodium tab 6 mg (Coumadin).......................... 43

2016


warfarin sodium tab 7.5 mg (Coumadin)....................... 43warfarin sodium tab 10 mg (Coumadin)........................ 43WELCHOL – colesevelam hcl packet for susp 3.75gm...................................................................................... 20

WELCHOL – colesevelam hcl tab 625 mg........................ 20

XXALKORI – crizotinib cap 200 mg....................................... 9XALKORI – crizotinib cap 250 mg....................................... 9XARELTO – rivaroxaban tab 10 mg...................................43XARELTO – rivaroxaban tab 15 mg...................................43XARELTO – rivaroxaban tab 20 mg...................................43XARELTO STARTER PACK – rivaroxaban tab startertherapy pack 15 mg & 20 mg...........................................43

XIFAXAN – rifaximin tab 550 mg......................................... 6XTANDI – enzalutamide cap 40 mg.....................................9XULANE – norelgestromin-ethinyl estradiol td ptwk 150-35mcg/24hr............................................................................ 12

Y

Zzafirlukast tab 10 mg (Accolate)..................................... 25zafirlukast tab 20 mg (Accolate)..................................... 25zaleplon cap 5 mg (Sonata).............................................32zaleplon cap 10 mg (Sonata)...........................................32ZELBORAF – vemurafenib tab 240 mg............................... 9ZENPEP – pancrelipase (lip-prot-amyl) dr cap3000-10000-16000 unit..................................................... 26

ZENPEP – pancrelipase (lip-prot-amyl) dr cap5000-17000-27000 unit..................................................... 26

ZENPEP – pancrelipase (lip-prot-amyl) dr cap10000-34000-55000 unit...................................................26

ZENPEP – pancrelipase (lip-prot-amyl) dr cap15000-51000-82000 unit...................................................26

ZENPEP – pancrelipase (lip-prot-amyl) dr cap20000-68000-109000 unit.................................................27

ZENPEP – pancrelipase (lip-prot-amyl) dr cap25000-85000-136000 unit.................................................27

ZENPEP – pancrelipase (lip-prot-amyl) dr cap40000-136000-218000 unit...............................................27

ZIAGEN – abacavir sulfate soln 20 mg/ml (base equiv)...... 6zidovudine cap 100 mg (Retrovir).....................................6zidovudine syrup 10 mg/ml (Retrovir)..............................6zidovudine tab 300 mg.......................................................6ziprasidone hcl cap 20 mg (Geodon)............................. 32ziprasidone hcl cap 40 mg (Geodon)............................. 32ziprasidone hcl cap 60 mg (Geodon)............................. 32ziprasidone hcl cap 80 mg (Geodon)............................. 32ZOLINZA – vorinostat cap 100 mg...................................... 9zolpidem tartrate tab cr 6.25 mg (Ambien cr)................32zolpidem tartrate tab cr 12.5 mg (Ambien cr)................32zolpidem tartrate tab 5 mg (Ambien)..............................32zolpidem tartrate tab 10 mg (Ambien)............................32zonisamide cap 50 mg..................................................... 40zonisamide cap 25 mg (Zonegran)................................. 40

zonisamide cap 100 mg (Zonegran)............................... 40ZORTRESS – everolimus tab 0.25 mg.............................. 49ZORTRESS – everolimus tab 0.5 mg................................ 49ZORTRESS – everolimus tab 0.75 mg.............................. 49ZYCLARA – imiquimod cream 3.75%................................48ZYCLARA PUMP – imiquimod cream 2.5%...................... 48ZYCLARA PUMP – imiquimod cream 3.75%.................... 48ZYDELIG – idelalisib tab 100 mg.........................................9ZYDELIG – idelalisib tab 150 mg.........................................9ZYKADIA – ceritinib cap 150 mg......................................... 9ZYLET – loteprednol etabonate-tobramycin ophth susp0.5-0.3%.............................................................................44

ZYTIGA – abiraterone acetate tab 250 mg..........................9ZYVOX – linezolid for susp 100 mg/5ml.............................. 6

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