generics plus drug list · generics plus drug list in texas and oklahoma referred to as preferred...

4621 HCSC © Prime Therapeutics LLC 10/16

October 2016

Generics Plus Drug List In Texas and Oklahoma referred to as Preferred Drug List 2

Please consider talking to your doctor about prescribing preferred medications, which

may help reduce your out-of-pocket costs. This list may help guide you and your doctor in

selecting an appropriate medication for you.

The drug list, also known as a formulary, is regularly updated. You can view the most

up-to-date list, or the specialty drug list, at MyPrime.com.

Contents

Introduction ...................................................................... I

How drugs are selected ................................................... I

How member payment is determined .............................. I

How to use this list ........................................................... I

Generic drugs ................................................................. II

Coverage considerations ............................................... III

Specialty drugs .............................................................. IV

Abbreviation/acronym key .............................................. V

Therapeutic Class Drug List

Anti-Infective Agents ....................................................... 1

Cancer Drugs .................................................................. 7

Hormones, Diabetes and Related Drugs ........................ 8

Heart and Circulatory Drugs ......................................... 13

Respiratory Agents ....................................................... 22

Gastrointestinal Drugs .................................................. 24

Genitourinary Drugs ...................................................... 26

Central Nervous System Drugs .................................... 26

Pain Relief Drugs .......................................................... 33

Neuromuscular Drugs ................................................... 37

Supplements ................................................................. 40

Blood Modifying Drugs .................................................. 41

Topical Products ........................................................... 46

Miscellaneous Categories (includes Supplies

and Devices) ............................................................... 50

Index ............................................................................. 52

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.

For Texas Residents only -- Find and estimate prices for medicines on this formulary at:

https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXGENPLUS/en/find-medicine.html


Blue Cross and Blue Shield Generics Plus October 2016 Drug List I

Introduction

Blue Cross and Blue Shield Generics Plus is pleased to present the 2016 Drug List. This is a list of preferred

drugs which includes Brand drugs and a partial listing of generic drugs. Members are encouraged to show this

list to their physicians and pharmacists. Physicians are encouraged to prescribe drugs on this list, when

right for the member. However, decisions regarding therapy and treatment are always between members

and their physician.

Drug List updates – This list is regularly updated as generic drugs become available and changes take place in

the pharmaceuticals market. For the most up-to-date information, visit MyPrime.com and log in or call the

number on the back of your ID card.

How drugs are selected

Drugs on this list are selected based on the recommendations of a committee made up of physicians and

pharmacists from throughout the country. The committee, which includes at least one representative from your

health plan, reviews drugs regulated by the U.S. Food and Drug Administration (FDA).

Both drugs that are newly approved by the FDA as well as those that have been on the market for some time are

considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on

the list.

How member payment is determined

This list shows prescription drug products in tiers. Generally, each drug is placed into one of three or four member

payment tiers: generic, Preferred Brand or Non-Preferred Brand (not listed in this document). Specialty drugs can

either be within the previous three tiers or can be a separate fourth tier depending on your benefit design. To

verify your payment amount for a drug, visit MyPrime.com and log in or call the number on the back of your ID

card.

Your pharmacy benefit includes coverage for many prescription drugs, although some exclusions may

apply. For example, drugs indicated for cosmetic purposes, e.g., Propecia, for hair growth, may not be covered.

Prescription products that have over-the-counter (OTC) equivalents may not be covered. Drugs that are not FDA-

approved for self-administration may be available through your medical benefit.

How to use this list

Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand

drug in (parentheses). The reference brand drug is a non-preferred (NP) brand and is only included as

a reference to the brand. Some generic products have no reference brand.

Example: atorvastatin (Lipitor)

Brand drugs are listed in all CAPITAL letters.

Example: PROAIR HFA

Drugs used to treat multiple conditions

Some drugs in the same dosage form may be used to treat more than one medical condition. In these instances,

each medication is classified according to its first FDA-approved use. Please check the index if you do not find

your particular medication in the class/condition section that corresponds to your use.

For Texas Residents only -- Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXGENPLUS/en/find-medicine.html


Blue Cross and Blue Shield Generics Plus October 2016 Drug List II

Generic drugs

Using generic drugs, when right for you, can help you save on your out-of-pocket medication costs. Generic drugs

must be approved by the FDA just as brand drugs are, and must meet the same standards.

There are two types of generic drugs:

A generic equivalent is made with the same active ingredient(s) at the same dosage as the reference drug.

A generic alternative is a drug typically used to treat the same condition, but the active ingredient(s)

differs from the brand drug.

According to the FDA, compared to its brand counterpart, an FDA-approved generic drug:

Is chemically the same

Works just as well in the body

Is as safe and effective

Meets the same standards set by the FDA

The main difference between the reference brand drug and the generic equivalent is that the generic often costs

much less.

Preferred brand drugs typically move to a non-preferred brand tier after a generic equivalent becomes available.

You may be responsible for the brand member payment amount plus the difference in cost between the brand

and generic equivalent if you or your doctor requests the reference brand rather than the generic. Generic drugs

have the lowest member payment amount.

Consider talking to your doctor about generic drugs

If your doctor writes a prescription for a brand drug that does not have a generic equivalent, consider asking if an

appropriate generic alternative is available.

You can also let your pharmacist know that you would like a generic equivalent for a brand drug, whenever one is

available. Your pharmacist can usually substitute a generic equivalent for its brand counterpart without a new

prescription from your doctor.

Only your doctor can determine whether a generic alternative is right for you and must prescribe the medication.

For Texas Residents only – Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXGENPLUS/en/find-medicine.html


Blue Cross and Blue Shield Generics Plus October 2016 Drug List III

Coverage considerations

Most prescription drug benefit plans provide coverage for up to a 30-day supply of medication, with some

exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications.

Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood

pressure, diabetes or high cholesterol. Some plans may exclude coverage for certain agents or drug categories,

like those used for erectile dysfunction or weight loss.

Over-the-counter exclusions: Your benefit plan may not provide coverage for prescription medications that

have an over-the-counter version. You should refer to your benefit plan material for details about your particular

benefits.

Compounded medications: Your benefit plan may not provide coverage for compounded medications. Please

see your plan materials or call the number on the back of your ID card to determine whether compounded

medications are covered and/or verify your payment amount.

Repackaged medications: Repackaged versions of medications already available on the market are not covered.

Prior Authorization (PA): Your benefit plan may require prior authorization for certain drugs. This means that

your doctor will need to submit a prior authorization request for coverage of these medications, and the request

will need to be approved, before the medication will be covered under your plan. For the preferred medications

listed in this document, if a prior authorization is commonly required, it will generally be noted next to the

medication with a dot under the prior authorization column. Some plans may have prior authorization on additional

medications beyond those noted in this document. Refer to your benefit plan materials for details about your

particular benefits.

Step Therapy (ST): Your benefit plan may include a step therapy program. This means you may need to try

another proven, cost-effective medication before coverage may be available for the drug included in the program.

Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. For the

preferred medications listed in this document, if a step therapy is commonly required, it will generally be noted

next to the medication with a dot under the step therapy column. Some plans may have step therapy programs on

additional medications beyond those noted in this document. Refer to your benefit plan materials for details about

your particular benefits.

Dispensing Limits (DL): Drug Dispensing limits help encourage medication use as intended by the FDA.

Dispensing limits are placed on medications in certain drug categories. For the preferred medications listed in this

document, if a dispensing limit applies, it will generally be noted next to the medication with a dot under the

dispensing limits column. Limits may include: quantity of covered medication per prescription, quantity of covered

medication in a given time period, coverage only for members within a certain age range, and coverage only for

members of a specific gender. If your doctor prescribes a greater quantity of medication than what the dispensing

limit allows, you can still get the medication. However, you will be responsible for the full cost of the prescription

beyond what your coverage allows.* For a list of medications and their dispensing limits, visit myprime.com.

*Please note: For certain controlled substance medications, some state laws may not allow coverage by a health

benefit plan of such medication if dispensed in a quantity beyond what the dispensing limit allows. You will be

responsible for the full cost of the prescription with no benefits applied if the dispensed quantity exceeds the

dispensing limit.

Remember, medication decisions are between you and your doctor. Only you and your doctor can determine

which medication is right for you. Discuss any questions or concerns you have about medications you are taking

or are prescribed with your doctor. Blue Cross and Blue Shield Generics Plus does not provide health care

services and, therefore, cannot guarantee any results or outcomes.

For Texas Residents only – Find and estimate prices for medicines on this formulary at:



Blue Cross and Blue Shield Generics Plus October 2016 Drug List IV

Specialty drugs

Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis

and rheumatoid arthritis. Specialty drugs may be oral, topical or injectable medications that can either be

self-administered or administered by a health care professional. For a current list of specialty medications,

visit MyPrime.com.

Note that some drug classes may be excluded by some plans and therefore may not be covered under your

pharmacy benefit. Your plan may have a different coverage level for self-administered specialty drugs. If you

have questions about your coverage for specialty medications or your prescription drug benefit, call the

number on the back of your ID card.

Prime Therapeutics Specialty Pharmacy Program

Through Prime Therapeutics Specialty Pharmacy, members can have covered specialty medications delivered

directly to them or their doctor’s office. When you receive specialty medications through Prime, you also receive at

no additional charge the following services:

Coordination of coverage between you, your doctor and your health plan

Educational materials about your particular condition and information about managing potential

medication side effects

Syringes, sharps containers and other supplies with every shipment for self-injectables

24/7/365 phone access to a pharmacist for urgent medication issues

To order through Prime Therapeutics Specialty Pharmacy:

Have your doctor call or fax your prescription to Prime Therapeutics Specialty Pharmacy. Your doctor can

call 877-627-6337 or fax to 877-828-3939.

If you have an existing prescription for a covered specialty medication, you can call 877-627-6337 to

transfer your prescription.

A Prime Therapeutics coordinator will contact you to arrange delivery of your medication.

The prescription can be shipped directly to you or your prescribing doctor’s office. Each package is

individually marked for each member. Refrigerated drugs are shipped in temperature-controlled

packaging.

If you have questions, please contact Prime Therapeutics Specialty Pharmacy at 877-627-6337,

visit www.PrimeTherapeutics.com/specialty, or call the number on the back of your ID card.

* Blue Cross and Blue Shield of Illinois (BCBSIL), Blue Cross and Blue Shield of Montana (BCBSMT), Blue Cross and Blue Shield of

New Mexico (BCBSNM), Blue Cross and Blue Shield of Oklahoma (BCBSOK), and Blue Cross and Blue Shield of Texas (BCBSTX)

are Divisions of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and

Blue Shield Association. BCBSIL, BCBSMT, BCBSNM, BCBSOK, and BCBSTX contract with Prime Therapeutics to provide pharmacy

benefit management, home delivery pharmacy and specialty pharmacy services. BCBSIL, BCBSMT, BCBSNM, BCBSOK, and BCBSTX,

as well as several other independent Blue Cross and Blue Shield Plans, have an ownership interest in Prime Therapeutics LLC.

For Texas Residents only – Find and estimate prices for medicines on this formulary at:



Blue Cross and Blue Shield Generics Plus October 2016 Drug List V

Abbreviation/acronym key

caps .................................................................... 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 tablets

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

For Texas Residents only – Find and estimate prices for medicines on this formulary at: https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXGENPLUS/en/find-medicine.html


2016

for Texas Residents only -- Find and estimate prices for medicines on this formulary at:https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXGENPLUS/en/find-medicine.html

Blue Cross and Blue Shield Generics Plus October 2016 Drug Formulary 1

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

ANTI-INFECTIVE AGENTSPENICILLINSamoxicillin (trihydrate) cap 250 mgamoxicillin (trihydrate) cap 500 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 mgdicloxacillin sodium cap 250 mgdicloxacillin sodium cap 500 mgpenicillin v potassium for soln

125 mg/5ml

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

penicillin v potassium for soln250 mg/5ml

penicillin 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)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

ceftriaxone sodium for inj 2 gmcefuroxime axetil tab 250 mg (Ceftin)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/5mlMACROLIDESazithromycin 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)erythromycin 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 mg

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

doxycycline monohydrate cap 75 mg(Monodox)

•

doxycycline monohydrate cap100 mg (Monodox)

doxycycline monohydrate cap150 mg (Adoxa)

•

doxycycline monohydrate tab 50 mg(Adoxa)

doxycycline monohydrate tab 75 mg(Adoxa)

doxycycline monohydrate tab100 mg (Adoxa pak 1/100)

doxycycline monohydrate tab150 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 mgtetracycline hcl cap 250 mg

(Tetracycline hcl)tetracycline hcl cap 500 mg

(Tetracycline hcl)FLUOROQUINOLONESciprofloxacin for oral susp

250 mg/5ml (5%) (5 gm/100ml)(Cipro)

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

ciprofloxacin hcl tab 250 mg (baseequiv) (Cipro)

ciprofloxacin hcl tab 500 mg (baseequiv) (Cipro)

ciprofloxacin hcl tab 750 mg (baseequiv)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

ciprofloxacin-ciprofloxacin hcl tab sr24hr 500 mg (base eq) (Cipro xr)

ciprofloxacin-ciprofloxacin hcl tab sr24hr 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 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 INFECTIONSfluconazole 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)

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

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)NOXAFIL – posaconazole tab delayed

release 100 mg•

NOXAFIL – posaconazole susp 40 mg/ml

•

nystatin tab 500000 unitterbinafine 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/mlDAKLINZA – daclatasvir

dihydrochloride tab 30 mg (baseequivalent)

• •

DAKLINZA – daclatasvirdihydrochloride tab 60 mg (baseequivalent)

• •

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

DAKLINZA – daclatasvirdihydrochloride tab 90 mg (baseequivalent)

• •

entecavir tab 0.5 mg (Baraclude)entecavir tab 1 mg (Baraclude)HARVONI – ledipasvir-sofosbuvir tab

90-400 mg• •

lamivudine tab 100 mg (hbv) (Epivirhbv)

PEGASYS – peginterferon alfa-2a inj180 mcg/ml

• •

PEGASYS – peginterferon alfa-2a inj180 mcg/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)•

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg(Trizivir)

•

APTIVUS – tipranavir cap 250 mg •APTIVUS – tipranavir oral soln 100 mg/

ml•

ATRIPLA – efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg

•

CRIXIVAN – indinavir sulfate cap 200mg

•

CRIXIVAN – indinavir sulfate cap 400mg

•

didanosine delayed release capsule125 mg (Videx ec)

•


•


•


•

EMTRIVA – emtricitabine caps 200 mg •EMTRIVA – emtricitabine soln 10 mg/ml •EPZICOM – abacavir sulfate-

lamivudine tab 600-300 mg•

FUZEON – enfuvirtide for inj 90 mg • •INTELENCE – etravirine tab 25 mg •INTELENCE – etravirine tab 100 mg •INTELENCE – etravirine tab 200 mg •INVIRASE – saquinavir mesylate cap

200 mg•

INVIRASE – saquinavir mesylate tab500 mg

•

ISENTRESS – raltegravir potassiumtab 400 mg (base equiv)

•

ISENTRESS – raltegravir potassiumpacket for susp 100 mg (base equiv)

•

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

ISENTRESS – raltegravir potassiumchew tab 25 mg (base equiv)

•

ISENTRESS – raltegravir potassiumchew tab 100 mg (base equiv)

•

KALETRA – lopinavir-ritonavir soln400-100 mg/5ml (80-20 mg/ml)

•

KALETRA – lopinavir-ritonavir tab100-25 mg

•

KALETRA – lopinavir-ritonavir tab200-50 mg

•

lamivudine 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 tab700 mg (base equiv)

•

LEXIVA – fosamprenavir calcium susp50 mg/ml (base equiv)

•

nevirapine tab sr 24hr 100 mg(Viramune xr)

•

nevirapine tab sr 24hr 400 mg(Viramune xr)

•

nevirapine tab 200 mg (Viramune) •NORVIR – ritonavir cap 100 mg •NORVIR – ritonavir tab 100 mg •NORVIR – ritonavir oral soln 80 mg/ml •PREZISTA – darunavir ethanolate susp

100 mg/ml (base equiv)•

PREZISTA – darunavir ethanolate tab75 mg (base equiv)

•


•


•

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y


•

RESCRIPTOR – delavirdine mesylatetab 100 mg

•

RESCRIPTOR – delavirdine mesylatetab 200 mg

•

REYATAZ – atazanavir sulfate oralpowder packet 50 mg (base equiv)

•

REYATAZ – atazanavir sulfate cap 150mg (base equiv)

•


•


•

SELZENTRY – maraviroc tab 150 mg •SELZENTRY – maraviroc tab 300 mg •stavudine 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-cobic-emtricitab-tenofovdf tab 150-150-200-300 mg

•

SUSTIVA – efavirenz tab 600 mg •SUSTIVA – efavirenz cap 50 mg •SUSTIVA – efavirenz cap 200 mg •TIVICAY – dolutegravir sodium tab 10

mg (base equiv)•

TIVICAY – dolutegravir sodium tab 25mg (base equiv)

•

TIVICAY – dolutegravir sodium tab 50mg (base equiv)

•

TRUVADA – emtricitabine-tenofovirdisoproxil fumarate tab 100-150 mg

•

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y


•


•


•

VIDEX – didanosine for soln 2 gm •VIDEX – didanosine for soln 4 gm •VIRACEPT – nelfinavir mesylate tab

250 mg•

VIRACEPT – nelfinavir mesylate tab625 mg

•

VIRAMUNE – nevirapine susp 50mg/5ml

•

VIRAMUNE XR – nevirapine tab sr24hr 100 mg

•

VIREAD – tenofovir disoproxil fumarateoral powder 40 mg/gm

•

VIREAD – tenofovir disoproxil fumaratetab 150 mg

•


•


•


•

ZIAGEN – abacavir sulfate soln 20 mg/ml (base equiv)

•

zidovudine cap 100 mg (Retrovir) •zidovudine syrup 10 mg/ml (Retrovir) •zidovudine tab 300 mg •MALARIAatovaquone-proguanil hcl tab

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

250-100 mg (Malarone)

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

chloroquine phosphate tab 250 mgchloroquine phosphate tab 500 mg

(Aralen)DARAPRIM – 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 mgBILTRICIDE – 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) (Cleocinpediatric gr)

dapsone tab 25 mgdapsone tab 100 mgIMPAVIDO – miltefosine cap 50 mglinezolid for susp 100 mg/5ml (Zyvox) •linezolid tab 600 mg (Zyvox) •metronidazole tab 250 mg (Flagyl)metronidazole tab 500 mg (Flagyl)sulfamethoxazole-trimethoprim susp

200-40 mg/5mlsulfamethoxazole-trimethoprim tab

400-80 mg (Bactrim)sulfamethoxazole-trimethoprim tab

800-160 mg (Bactrim ds)trimethoprim tab 100 mg

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

vancomycin hcl cap 125 mg(Vancocin hcl)

vancomycin hcl cap 250 mg(Vancocin hcl)

XIFAXAN – rifaximin tab 550 mg •ZYVOX – linezolid for susp 100 mg/5ml •CANCER DRUGSACTIMMUNE – interferon gamma-1b

inj 100 mcg/0.5ml (2000000unit/0.5ml)

•

ALKERAN – melphalan tab 2 mganastrozole tab 1 mg (Arimidex)bexarotene cap 75 mg (Targretin) • • •bicalutamide tab 50 mg (Casodex)capecitabine tab 150 mg (Xeloda) • •capecitabine tab 500 mg (Xeloda) • •exemestane tab 25 mg (Aromasin)flutamide cap 125 mgGLEEVEC – imatinib mesylate tab 100

mg (base equivalent)• • •

GLEEVEC – imatinib mesylate tab 400mg (base equivalent)

• • •

hydroxyurea cap 500 mg (Hydrea)imatinib mesylate tab 100 mg (base

equivalent) (Gleevec)• • •

imatinib mesylate tab 400 mg (baseequivalent) (Gleevec)

• • •

letrozole tab 2.5 mg (Femara)LEUCOVORIN CALCIUM – leucovorin

calcium tab 10 mgLEUCOVORIN CALCIUM – leucovorin

calcium tab 15 mgleucovorin calcium tab 5 mgleucovorin calcium tab 25 mgLEUKERAN – chlorambucil tab 2 mg

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

megestrol acetate susp 40 mg/ml(Megace oral)

megestrol acetate tab 20 mgmegestrol acetate tab 40 mgMEKINIST – trametinib dimethyl

sulfoxide tab 0.5 mg (baseequivalent)

• •

MEKINIST – trametinib dimethylsulfoxide tab 2 mg (base equivalent)

• •

mercaptopurine tab 50 mg(Purinethol)

methotrexate sodium tab 2.5 mg(base equiv)

MYLERAN – busulfan tab 2 mgNEXAVAR – sorafenib tosylate tab 200

mg (base equivalent)• •

nilutamide tab 150 mg (Nilandron)SUTENT – sunitinib malate cap 12.5

mg (base equivalent)• •

SUTENT – sunitinib malate cap 25 mg(base equivalent)

• •

SUTENT – sunitinib malate cap 37.5mg (base equivalent)

• •

SUTENT – sunitinib malate cap 50 mg(base equivalent)

• •

SYLATRON – peginterferon alfa-2b forinj kit 200 mcg

• •


• •


• •

TAFINLAR – dabrafenib mesylate cap50 mg (base equivalent)

• •

TAFINLAR – dabrafenib mesylate cap75 mg (base equivalent)

• •

tamoxifen citrate tab 10 mg (baseequivalent)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

tamoxifen citrate tab 20 mg (baseequivalent)

TARCEVA – erlotinib hcl tab 25 mg(base equivalent)

• •


• •


• •

TASIGNA – nilotinib hcl cap 150 mg(base equivalent)

• •

TASIGNA – nilotinib hcl cap 200 mg(base equivalent)

• •

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 • •VOTRIENT – pazopanib hcl tab 200 mg

(base equiv)• •

XALKORI – crizotinib cap 200 mg • •XALKORI – crizotinib cap 250 mg • •ZELBORAF – vemurafenib tab 240 mg • •ZYTIGA – abiraterone acetate tab 250

mg• •

HORMONES, DIABETES AND RELATED DRUGSCORTICOSTEROIDSbudesonide delayed release

particles cap 3 mg (Entocort ec)CORTISONE ACETATE – cortisone

acetate tab 25 mgdexamethasone elixir 0.5 mg/5mldexamethasone tab 0.5 mgdexamethasone tab 0.75 mg

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

dexamethasone 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 therapy

pack 4 mg (21) (Medrol dosepak)methylprednisolone tab 4 mg

(Medrol)methylprednisolone tab 8 mg



(Medrol)prednisolone sod phosph oral

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

prednisolone sod phosphate oralsoln 15 mg/5ml (base equiv)

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

prednisone tab 1 mgprednisone tab 2.5 mgprednisone tab 5 mgprednisone tab 10 mgprednisone tab 20 mgMALE HORMONESANDROGEL – testosterone td gel

20.25 mg/1.25gm (1.62%)• •

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

• •

ANDROGEL PUMP – testosterone tdgel 20.25 mg/act (1.62%)

• •

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

ANDROXY – fluoxymesterone tab 10mg

•

danazol cap 50 mg •danazol cap 100 mg •danazol cap 200 mg •testosterone cypionate im inj in oil

100 mg/ml (Depo-testosterone)• •

testosterone cypionate im inj in oil200 mg/ml (Depo-testosterone)

• •

testosterone enanthate im inj in oil200 mg/ml

• •

testosterone td gel 25 mg/2.5gm (1%)(Androgel)

• •

testosterone td gel 50 mg/5gm (1%)(Androgel)

• •

testosterone td gel 12.5 mg/act (1%)(Androgel pump)

• •

ESTROGENSCOMBIPATCH – estradiol-

norethindrone ace td pttw 0.05-0.14mg/day

COMBIPATCH – estradiol-norethindrone ace td pttw 0.05-0.25mg/day

DIVIGEL – estradiol td gel 0.25mg/0.25gm (0.1%)

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

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

estradiol & norethindrone acetatetab 0.5-0.1 mg (Activella)

estradiol & norethindrone acetatetab 1-0.5 mg (Activella)

estradiol tab 0.5 mg (Estrace)estradiol tab 1 mg (Estrace)estradiol tab 2 mg (Estrace)

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

estradiol td patch twice weekly0.025 mg/24hr (Vivelle-dot)

•


•


•


•


•

estradiol td patch weekly0.025 mg/24hr (Climara)

•

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

•


•


•


•


•

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

norethindrone acetate-ethinylestradiol tab 1 mg-5 mcg

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)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

progesterone micronized cap 100 mg(Prometrium)

progesterone micronized cap 200 mg(Prometrium)

BIRTH CONTROLELLA – ulipristal acetate tab 30 mg •levonorgestrel tab 1.5 mg (Plan b

one-step)•

MIRENA – levonorgestrel releasing iud20 mcg/day (52 mg total)

NUVARING – etonogestrel-ethinylestradiol va ring 0.120-0.015 mg/24hr

•

oral contraceptives – all generics •SKYLA – levonorgestrel releasing iud

14 mcg/day (13.5 mg total)INFERTILITYchorionic gonadotropin for inj 10000

unit• •

clomiphene citrate tab 50 mg(Clomid)

FOLLISTIM AQ – follitropin beta inj 75unit/0.5ml

• •


• •


• •


• •

DIABETESacarbose tab 25 mg (Precose)acarbose tab 50 mg (Precose)acarbose tab 100 mg (Precose)glimepiride tab 1 mg (Amaryl)glimepiride tab 2 mg (Amaryl)glimepiride tab 4 mg (Amaryl)

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

glipizide tab sr 24hr 2.5 mg (Glucotrolxl)

glipizide tab sr 24hr 5 mg (Glucotrolxl)

glipizide tab sr 24hr 10 mg (Glucotrolxl)

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 mgglyburide 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)JARDIANCE – empagliflozin tab 10 mg •JARDIANCE – empagliflozin tab 25 mg •metformin hcl tab sr 24hr 500 mg

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

(Glucophage xr)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

metformin hcl tab 500 mg(Glucophage)



nateglinide tab 60 mg (Starlix)nateglinide tab 120 mg (Starlix)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/

ml•

NOVOLOG FLEXPEN – insulin aspartsoln pen-injector 100 unit/ml

•

NOVOLOG PENFILL – insulin aspartsoln cartridge 100 unit/ml

•

Short-Acting InsulinsNOVOLIN R – insulin regular (human)

inj 100 unit/ml•

Intermediate-Acting Insulins

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

NOVOLIN N – insulin nph (human)(isophane) inj 100 unit/ml

•

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

•

NOVOLOG MIX 70/30 – insulin aspartprot & 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/

ml•

LANTUS SOLOSTAR – insulin glarginesoln pen-injector 100 unit/ml

•

LEVEMIR – insulin detemir inj 100 unit/ml

•

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

•

TOUJEO SOLOSTAR – insulin glarginesoln pen-injector 300 unit/ml

•

THYROID REGULATIONlevothyroxine sodium tab 25 mcg

(Synthroid)levothyroxine sodium tab 50 mcg






(Synthroid)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

levothyroxine sodium tab 137 mcg(Synthroid)





liothyronine sodium tab 5 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 5.8mg

• •

OMNITROPE – somatropin inj 5mg/1.5ml

• •

OMNITROPE – somatropin inj 10mg/1.5ml

• •

OTHER HORMONES AND RELATED DRUGSalendronate sodium tab 5 mg •alendronate sodium tab 10 mg •alendronate sodium tab 35 mg •alendronate sodium tab 70 mg

(Fosamax)•

cabergoline tab 0.5 mg

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

calcitonin (salmon) nasal soln 200unit/act (Miacalcin)

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

(Rocaltrol)desmopressin acetate inj 4 mcg/ml

(Ddavp)desmopressin acetate nasal soln

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

soln 0.01% (Ddavp)desmopressin acetate nasal spray

soln 0.01% (refrigerated)desmopressin acetate tab 0.1 mg

(Ddavp)desmopressin acetate tab 0.2 mg

(Ddavp)ibandronate sodium tab 150 mg

(base equivalent) (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 susp 4 mg/ml •ORFADIN – nitisinone cap 2 mg •

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

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)raloxifene hcl tab 60 mg (Evista)risedronate sodium tab 5 mg

(Actonel)•

risedronate sodium tab 30 mg(Actonel)

•


•


•

SENSIPAR – cinacalcet hcl tab 30 mg(base equiv)



STIMATE – desmopressin acetatenasal soln 1.5 mg/ml

STRENSIQ – asfotase alfasubcutaneous inj 18 mg/0.45ml

•


•

STRENSIQ – asfotase alfasubcutaneous inj 40 mg/ml

•


•

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

5-6.25 mg

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

benazepril & hydrochlorothiazide tab10-12.5 mg (Lotensin hct)

benazepril & hydrochlorothiazide tab20-12.5 mg (Lotensin hct)

benazepril & hydrochlorothiazide tab20-25 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 tab 12.5 mgcaptopril tab 25 mgcaptopril tab 50 mgcaptopril tab 100 mgenalapril maleate &

hydrochlorothiazide tab 5-12.5 mgenalapril maleate &

hydrochlorothiazide tab 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)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

lisinopril & hydrochlorothiazide tab20-25 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 mgmoexipril-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)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)

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

trandolapril tab 1 mg (Mavik)trandolapril tab 2 mg (Mavik)trandolapril tab 4 mg (Mavik)ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS)AND COMBINATIONSamlodipine-valsartan-

hydrochlorothiazide tab5-160-12.5 mg (Exforge hct)

amlodipine-valsartan-hydrochlorothiazide tab5-160-25 mg (Exforge hct)

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



candesartan cilexetil tab 4 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)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

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 tab100-12.5 mg (Hyzaar)

losartan potassium &hydrochlorothiazide tab 100-25 mg(Hyzaar)

losartan potassium tab 25 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)valsartan tab 80 mg (Diovan)valsartan tab 160 mg (Diovan)valsartan tab 320 mg (Diovan)valsartan-hydrochlorothiazide tab

80-12.5 mg (Diovan hct)

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

valsartan-hydrochlorothiazide tab160-12.5 mg (Diovan hct)

valsartan-hydrochlorothiazide tab160-25 mg (Diovan hct)

valsartan-hydrochlorothiazide tab320-12.5 mg (Diovan hct)

valsartan-hydrochlorothiazide tab320-25 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)labetalol hcl tab 100 mg (Trandate)labetalol hcl tab 200 mg (Trandate)labetalol hcl tab 300 mg (Trandate)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

metoprolol & hydrochlorothiazidetab 50-25 mg (Lopressor hct)

metoprolol & hydrochlorothiazidetab 100-25 mg (Lopressor hct)

metoprolol & hydrochlorothiazidetab 100-50 mg

metoprolol succinate tab sr 24hr25 mg (tartrate equiv) (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 hcl cap sr 24hr 60 mg

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



(Inderal la)propranolol hcl tab 10 mgpropranolol hcl tab 20 mgpropranolol hcl tab 40 mgpropranolol hcl tab 60 mg

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

propranolol hcl tab 80 mgCALCIUM CHANNEL BLOCKERS ANDCOMBINATIONSamlodipine besylate tab 2.5 mg

(Norvasc)amlodipine besylate tab 5 mg

(Norvasc)amlodipine besylate tab 10 mg

(Norvasc)amlodipine besylate-atorvastatin

calcium tab 2.5-10 mg (Caduet)amlodipine besylate-atorvastatin



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







calcium tab 10-80 mg (Caduet)amlodipine besylate-benazepril hcl

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

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

cap 5-20 mg (Lotrel)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

amlodipine besylate-benazepril hclcap 5-40 mg (Lotrel)



amlodipine besylate-valsartan tab5-160 mg (Exforge)




diltiazem hcl cap sr 24hr 120 mgdiltiazem hcl cap sr 24hr 180 mgdiltiazem hcl cap sr 24hr 240 mgdiltiazem hcl coated beads cap sr

24hr 120 mg (Cardizem cd)diltiazem hcl coated beads cap sr




24hr 360 mg (Cardizem cd)diltiazem hcl extended release beads

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




cap sr 24hr 360 mg (Tiazac)

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

diltiazem hcl extended release beadscap sr 24hr 420 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)nifedipine tab sr 24hr osmotic

release 90 mg (Procardia xl)verapamil hcl cap sr 24hr 120 mg

(Verelan)verapamil hcl cap sr 24hr 180 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 40 mg

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

verapamil hcl tab 80 mg (Calan)verapamil hcl tab 120 mg (Calan)CHEST PAINisosorbide dinitrate tab 5 mg (Isordil

titradose)isosorbide dinitrate tab 10 mgisosorbide dinitrate tab 20 mgisosorbide dinitrate tab 30 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 mgnitroglycerin 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

mgNITROSTAT – 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)

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

atorvastatin calcium tab 40 mg (baseequivalent) (Lipitor)

atorvastatin calcium tab 80 mg (baseequivalent) (Lipitor)

cholestyramine light powder packets4 gm

cholestyramine light powder 4 gm/dose (Questran light)

cholestyramine powder packets4 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 (Colestidflavored)

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) •fenofibrate tab 54 mg (Lofibra) •

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

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)PRALUENT – alirocumab

subcutaneous soln pen-injector 75mg/ml

• • •

PRALUENT – alirocumabsubcutaneous soln pen-injector 150mg/ml

• • •

PRALUENT – alirocumabsubcutaneous soln prefilled syringe75 mg/ml

• • •

PRALUENT – alirocumabsubcutaneous soln prefilled syringe150 mg/ml

• • •

pravastatin sodium tab 10 mgpravastatin sodium tab 20 mg

(Pravachol)pravastatin sodium tab 40 mg

(Pravachol)pravastatin sodium tab 80 mg

(Pravachol)REPATHA – evolocumab subcutaneous

soln prefilled syringe 140 mg/ml• • •

REPATHA PUSHTRONEX SYSTEM– evolocumab subcutaneous solncartridge/infusor 420 mg/3.5ml

• • •

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

REPATHA SURECLICK – evolocumabsubcutaneous soln auto-injector 140mg/ml

• • •

rosuvastatin calcium tab 5 mg(Crestor)




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)FLUID 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 mgchlorthalidone tab 25 mgfurosemide 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 mg

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

hydrochlorothiazide 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 mgdisopyramide phosphate cap 100 mg

(Norpace)

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

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 mgpropafenone 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 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) • • •clonidine hcl tab 0.1 mg (Catapres)clonidine hcl tab 0.2 mg (Catapres)clonidine hcl tab 0.3 mg (Catapres)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

clonidine hcl td patch weekly0.1 mg/24hr (Catapres-tts-1)



DIBENZYLINE – phenoxybenzaminehcl cap 10 mg

digoxin tab 125 mcg (0.125 mg)(Lanoxin)

digoxin tab 250 mcg (0.25 mg)(Lanoxin)

doxazosin mesylate tab 1 mg(Cardura)




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 mgmethyldopa 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 mg

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

OPSUMIT – 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 • • •UPTRAVI – selexipag tab therapy pack

200 mcg (140) & 800 mcg (60)• • •

UPTRAVI – selexipag tab 200 mcg • • •UPTRAVI – selexipag tab 400 mcg • • •UPTRAVI – selexipag tab 600 mcg • • •UPTRAVI – selexipag tab 800 mcg • • •UPTRAVI – selexipag tab 1000 mcg • • •UPTRAVI – selexipag tab 1200 mcg • • •UPTRAVI – selexipag tab 1400 mcg • • •UPTRAVI – selexipag tab 1600 mcg • • •ERECTILE DYSFUNCTIONCIALIS – tadalafil tab 2.5 mg • •CIALIS – tadalafil tab 5 mg • •CIALIS – tadalafil tab 10 mg • •CIALIS – tadalafil tab 20 mg • •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)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

RESPIRATORY AGENTSANTIHISTAMINEScetirizine hcl oral soln 1 mg/ml

(5 mg/5ml)cyproheptadine hcl syrup 2 mg/5mlcyproheptadine hcl tab 4 mgdesloratadine 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 PRODUCTSazelastine hcl nasal spray 0.1%

(137 mcg/spray)•

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

•

flunisolide nasal soln 25 mcg/act(0.025%)

•

fluticasone propionate nasal susp50 mcg/act (Flonase)

•

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

•

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

•

mometasone furoate nasal susp50 mcg/act (Nasonex)

•

triamcinolone acetonide nasalaerosol suspension 55 mcg/act(Nasacort aq)

•

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

COUGH/COLD/ALLERGYacetylcysteine inhal soln 10%acetylcysteine inhal soln 20%ASTHMA/COPDalbuterol sulfate soln nebu 0.083%

(2.5 mg/3ml)•

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

•

albuterol sulfate soln nebu0.63 mg/3ml (base equiv)

•

albuterol sulfate soln nebu1.25 mg/3ml (base equiv)

•

albuterol sulfate syrup 2 mg/5mlalbuterol sulfate tab 2 mgalbuterol sulfate tab 4 mgARNUITY ELLIPTA – fluticasone

furoate aerosol powder breath activ100 mcg/act

•

ARNUITY ELLIPTA – fluticasonefuroate aerosol powder breath activ200 mcg/act

•

budesonide inhalation susp0.25 mg/2ml (Pulmicort)

•

budesonide inhalation susp0.5 mg/2ml (Pulmicort)

•

budesonide inhalation susp1 mg/2ml (Pulmicort)

•

FLOVENT DISKUS – fluticasonepropionate aer pow ba 50 mcg/blister

•


•


•

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

FLOVENT HFA – fluticasonepropionate hfa inhal aero 44 mcg/act(50/valve)

•

FLOVENT HFA – fluticasonepropionate hfa inhal aer 110 mcg/act(125/valve)

•

FLOVENT HFA – fluticasonepropionate hfa inhal aer 220 mcg/act(250/valve)

•

INCRUSE ELLIPTA – umeclidinium braero powd breath act 62.5 mcg/inh(base eq)

•

ipratropium bromide inhal soln0.02%

•

ipratropium-albuterol nebu soln0.5-2.5(3) mg/3ml (Duoneb)

•

levalbuterol hcl soln nebu conc1.25 mg/0.5ml (base equiv)

•

levalbuterol hcl soln nebu0.31 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 granulespacket 4 mg (base equiv) (Singulair)

montelukast sodium tab 10 mg (baseequiv) (Singulair)

PROAIR HFA – albuterol sulfate inhalaero 108 mcg/act (90mcg base equiv)

•

PROAIR RESPICLICK – albuterolsulfate aer pow ba 108 mcg/act (90mcg base equiv)

•

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

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

•

QVAR – beclomethasone diprop inhalaero soln 80 mcg/act (100/valve)

•

SEREVENT DISKUS – salmeterolxinafoate aer pow ba 50 mcg/dose(base equiv)

•

SPIRIVA HANDIHALER – tiotropiumbromide monohydrate inhal cap 18mcg (base equiv)

•

SPIRIVA RESPIMAT – tiotropiumbromide monohydrate inhal aerosol1.25 mcg/act

•

SPIRIVA RESPIMAT – tiotropiumbromide monohydrate inhal aerosol2.5 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 baseequiv)

•

zafirlukast tab 10 mg (Accolate)zafirlukast tab 20 mg (Accolate)OTHER RESPIRATORY DRUGSKALYDECO – ivacaftor tab 150 mg • • •

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

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)peg 3350-kcl-na bicarb-nacl-na

sulfate for soln 240 gm (Colyte-flavor packs)

ANTIDIARRHEALSdiphenoxylate w/ atropine tab

2.5-0.025 mg (Lomotil)loperamide hcl cap 2 mgULCER/GERDcimetidine 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 capdelayed release 40 mg (base eq)(Nexium)

•

famotidine tab 20 mg (Pepcid)

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

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)lansoprazole cap delayed release

15 mg (Prevacid)•

lansoprazole cap delayed release30 mg (Prevacid)

•

methscopolamine bromide tab2.5 mg (Pamine)

methscopolamine bromide tab 5 mg(Pamine forte)

misoprostol tab 100 mcg (Cytotec)misoprostol tab 200 mcg (Cytotec)omeprazole cap delayed release

10 mg (Prilosec)•

omeprazole cap delayed release20 mg (Prilosec)

•

omeprazole cap delayed release40 mg (Prilosec)

•

pantoprazole sodium ec tab 20 mg(base equiv) (Protonix)

•

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

•

ranitidine hcl cap 150 mg

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

ranitidine 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 VOMITINGEMEND – aprepitant for oral susp 125

mg (125 mg/5ml)•

EMEND – aprepitant capsule therapypack 80 & 125 mg

•

EMEND – aprepitant capsule 40 mg •EMEND – aprepitant capsule 80 mg •EMEND – aprepitant capsule 125 mg •granisetron hcl tab 1 mg •meclizine hcl tab 12.5 mgmeclizine hcl tab 25 mgondansetron hcl inj 4 mg/2ml (2 mg/

ml)•

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

•

ondansetron hcl oral soln 4 mg/5ml(Zofran)

•

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

4 mg (Zofran odt)•

ondansetron orally disintegrating tab8 mg (Zofran odt)

•

trimethobenzamide hcl cap 300 mg(Tigan)

DIGESTIVE ENZYMESZENPEP – pancrelipase (lip-prot-amyl)

dr cap 3000-10000-16000 unit

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

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






OTHER GASTROINTESTINAL DRUGSbalsalazide 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 •lactulose (encephalopathy) solution

10 gm/15mlmesalamine enema 4 gmmetoclopramide hcl soln 5 mg/5ml

(10 mg/10ml)metoclopramide hcl tab 5 mg

(Reglan)metoclopramide hcl tab 10 mg

(Reglan)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)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

ursodiol tab 500 mg (Urso forte)GENITOURINARY DRUGSURINARY TRACT INFECTIONSnitrofurantoin 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)VAGINAL PRODUCTSclindamycin phosphate vaginal

cream 2% (Cleocin)ESTRACE – estradiol vaginal cream

0.1 mg/gmmetronidazole vaginal gel 0.75%

(Metrogel-vaginal)

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

terconazole vaginal cream 0.4%(Terazol 7)

terconazole vaginal cream 0.8%(Terazol 3)

terconazole vaginal suppos 80 mgVAGIFEM – estradiol vaginal tab 10

mcgOTHER GENITOURINARY DRUGSalfuzosin hcl tab sr 24hr 10 mg

(Uroxatral)CYSTAGON – cysteamine bitartrate

cap 50 mg•

CYSTAGON – cysteamine bitartratecap 150 mg

•

dutasteride cap 0.5 mg (Avodart)finasteride tab 5 mg (Proscar)pot & 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 solutionmodi)

tamsulosin hcl cap 0.4 mg (Flomax)CENTRAL NERVOUS SYSTEM DRUGSANXIETYalprazolam tab sr 24hr 0.5 mg (Xanax

xr)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

alprazolam tab sr 24hr 1 mg (Xanaxxr)



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 tab 2 mg (Valium)diazepam tab 5 mg (Valium)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 mg

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

amitriptyline 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)citalopram hydrobromide tab 40 mg

(base equiv) (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)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

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 pelletscap 30 mg (Cymbalta)

•

duloxetine hcl enteric coated pelletscap 60 mg (Cymbalta)

•

escitalopram oxalate soln 5 mg/5ml(base equiv) (Lexapro)

escitalopram oxalate tab 5 mg (baseequiv) (Lexapro)

escitalopram oxalate tab 10 mg(base equiv) (Lexapro)

escitalopram oxalate tab 20 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 mgfluvoxamine 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)

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

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)venlafaxine hcl cap sr 24hr 75 mg

(base equivalent) (Effexor xr)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

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

venlafaxine hcl tab sr 24hr 37.5 mg(base equivalent) (Venlafaxine hcler)

venlafaxine hcl tab sr 24hr 75 mg(base equivalent) (Venlafaxine hcler)

venlafaxine hcl tab sr 24hr 150 mg(base equivalent) (Venlafaxine hcler)

venlafaxine hcl tab 25 mgvenlafaxine hcl tab 37.5 mgvenlafaxine hcl tab 50 mgvenlafaxine hcl tab 75 mgvenlafaxine hcl tab 100 mgPSYCHOTIC AND BIPOLAR DISORDERSaripiprazole tab 2 mg (Abilify) •aripiprazole tab 5 mg (Abilify) •aripiprazole tab 10 mg (Abilify) •aripiprazole tab 15 mg (Abilify) •aripiprazole tab 20 mg (Abilify) •aripiprazole tab 30 mg (Abilify) •chlorpromazine 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 mg •clozapine tab 100 mg (Clozaril) •clozapine tab 200 mg •fluphenazine decanoate inj 25 mg/mlFLUPHENAZINE HCL – fluphenazine

hcl elixir 2.5 mg/5ml

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

FLUPHENAZINE HCL – fluphenazinehcl oral conc 5 mg/ml

fluphenazine 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)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 mgloxapine 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 tab10 mg (Zyprexa zydis)

•

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y


•


•

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 mgperphenazine 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)

•


•


•


•


•

risperidone orally disintegrating tab0.25 mg

•

risperidone orally disintegrating tab0.5 mg (Risperdal m-tab)

•

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

risperidone orally disintegrating tab1 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 mg•

SEROQUEL XR – quetiapine fumaratetab sr 24hr 150 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) •

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

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)•

zolpidem tartrate tab cr 12.5 mg(Ambien cr)

•

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

cap sr 24hr 5 mg (Adderall xr)•

amphetamine-dextroamphetaminecap sr 24hr 10 mg (Adderall xr)

•


•


•


•

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y


•

amphetamine-dextroamphetaminetab 5 mg (Adderall)

•

amphetamine-dextroamphetaminetab 7.5 mg (Adderall)

•


•

amphetamine-dextroamphetaminetab 12.5 mg (Adderall)

•


•


•


•

caffeine citrate oral soln 60 mg/3ml(10 mg/ml base equiv) (Cafcit)

dexmethylphenidate hcl cap sr 24 hr5 mg (Focalin xr)

•


•


•


•


•


•

dextroamphetamine sulfate cap sr24hr 5 mg (Dexedrine)

•


•


•

dextroamphetamine sulfate tab 5 mg •

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

dextroamphetamine sulfate tab10 mg

•

guanfacine hcl tab sr 24hr 1 mg(base equiv) (Intuniv)

•


•


•


•

methylphenidate hcl tab cr 10 mg •methylphenidate hcl tab cr 20 mg

(Ritalin sr)•

methylphenidate hcl tab 5 mg(Ritalin)

•


•


•

modafinil tab 100 mg (Provigil) •modafinil tab 200 mg (Provigil) •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 prefilledsyringe 20 mg/ml (Copaxone)

• •

PLEGRIDY – peginterferon beta-1asoln pen-injector 125 mcg/0.5ml

• •

PLEGRIDY – peginterferon beta-1asoln prefilled syringe 125 mcg/0.5ml

• •

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

• •

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

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

• •

REBIF – interferon beta-1a soln pref syr22 mcg/0.5ml (12mu/ml)

• •

REBIF – interferon beta-1a soln pref syr44 mcg/0.5ml (24mu/ml)

• •

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

• •

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

• •

REBIF REBIDOSE TITRATION –interferon beta-1a auto-inj 6x8.8mcg/0.2ml & 6x22 mcg/0.5ml

• •

REBIF TITRATION PACK – interferonbeta-1a pref syr 6x8.8 mcg/0.2ml &6x22 mcg/0.5ml

• •

TECFIDERA – dimethyl fumaratecapsule delayed release 120 mg

• •

TECFIDERA – dimethyl fumaratecapsule delayed release 240 mg

• •

TECFIDERA STARTER PACK –dimethyl fumarate capsule dr starterpack 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 (baseequiv)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

CHANTIX STARTING MONTH PA –varenicline tartrate tab 0.5 mg x 11 &tab 1 mg 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 (Ariceptodt)

donepezil hydrochloride tab 5 mg(Aricept)

donepezil hydrochloride tab 10 mg(Aricept)

galantamine hydrobromide cap sr24hr 8 mg (Razadyne er)



galantamine hydrobromide tab 4 mg(Razadyne)

galantamine hydrobromide tab 8 mg(Razadyne)

galantamine hydrobromide tab12 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 titrationpa)

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

NICOTROL NS – nicotine nasal spray10 mg/ml (0.5 mg/spray)

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

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 mgbutalbital-acetaminophen-caffeine

cap 50-325-40 mgbutalbital-acetaminophen-caffeine

tab 50-325-40 mgbutalbital-aspirin-caffeine cap

50-325-40 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)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

buprenorphine hcl sl tab 2 mg (baseequiv)

• •

buprenorphine hcl sl tab 8 mg (baseequiv)

• •

butalbital-aspirin-caff w/ codeine cap50-325-40-30 mg (Fiorinal/codeine#3)

codeine sulfate tab 15 mg (Codeinesulfate)

codeine sulfate tab 30 mgcodeine sulfate tab 60 mgfentanyl citrate lozenge on a handle

200 mcg (Actiq)• •

fentanyl citrate lozenge on a handle400 mcg (Actiq)

• •


• •


• •


• •


• •

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

•


•


•


•


•

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

hydrocodone-acetaminophen tab10-325 mg (Norco)

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

hydrocodone-acetaminophen tab5-325 mg (Norco)

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

hydrocodone-ibuprofen tab 5-200 mg(Reprexain)

hydrocodone-ibuprofen tab7.5-200 mg (Vicoprofen)

hydrocodone-ibuprofen tab10-200 mg (Ibudone)

hydromorphone hcl liqd 1 mg/ml(Dilaudid)

hydromorphone hcl tab 2 mg(Dilaudid)



methadone hcl conc 10 mg/ml(Methadose)

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

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

methadone hcl tab for oral susp40 mg

methadone hcl tab 5 mg (Dolophinehcl)

methadone hcl tab 10 mg (Dolophine)MORPHINE SULFATE – morphine

sulfate tab 15 mgMORPHINE SULFATE – morphine

sulfate tab 30 mgMORPHINE SULFATE – morphine

sulfate suppos 5 mgMORPHINE SULFATE – morphine

sulfate suppos 10 mg

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

MORPHINE SULFATE – morphinesulfate suppos 20 mg

MORPHINE SULFATE – morphinesulfate suppos 30 mg

morphine sulfate oral soln 10 mg/5mlmorphine sulfate oral soln 20 mg/5mlmorphine sulfate oral soln

100 mg/5ml (20 mg/ml)morphine sulfate tab cr 15 mg (Ms

contin)•

morphine sulfate tab cr 30 mg (Mscontin)

•


•


•


•

oxycodone hcl cap 5 mgoxycodone hcl conc 100 mg/5ml

(20 mg/ml) (Oxycodone hcl)oxycodone hcl soln 5 mg/5ml

(Oxycodone hcl)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)

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

oxycodone-aspirin tab4.8355-325 mg (Percodan)

OXYCONTIN – oxycodone hcl tab er12hr deter 10 mg

•


•


•


•


•


•


•

tramadol hcl tab sr 24hr 100 mg(Ultram er)

•


•


•

tramadol hcl tab 50 mg (Ultram) •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 mg

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

diclofenac sodium tab delayedrelease 75 mg

diclofenac sodium tab sr 24hr100 mg (Voltaren-xr)

ENBREL – etanercept forsubcutaneous inj 25 mg

• • •

ENBREL – etanercept subcutaneoussoln prefilled syringe 25 mg/0.5ml

• • •

ENBREL – etanercept subcutaneoussoln prefilled syringe 50 mg/ml

• • •

ENBREL SURECLICK – etanerceptsubcutaneous solution auto-injector50 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• • •

HUMIRA – adalimumab prefilledsyringe kit 20 mg/0.4ml

• • •

HUMIRA – adalimumab prefilledsyringe kit 40 mg/0.8ml

• • •

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

• • •

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

• • •

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

• • •

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

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

• • •

ibuprofen susp 100 mg/5mlibuprofen tab 400 mgibuprofen tab 600 mgibuprofen tab 800 mgindomethacin 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 susp 125 mg/5ml

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

soln auto-injector 50 mg/0.5ml• • •

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

SIMPONI – golimumab subcutaneoussoln auto-injector 100 mg/ml

• • •

SIMPONI – golimumab subcutaneoussoln prefilled syringe 50 mg/0.5ml

• • •

SIMPONI – golimumab subcutaneoussoln prefilled syringe 100 mg/ml

• • •

sulindac tab 150 mgsulindac tab 200 mgMIGRAINE HEADACHESIMITREX – sumatriptan nasal spray 5

mg/act•

IMITREX – sumatriptan nasal spray 20mg/act

•

isometheptene-dichloral-acetaminophen cap 65-100-325 mg

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

•

naratriptan hcl tab 2.5 mg (baseequiv) (Amerge)

•

rizatriptan benzoate oraldisintegrating tab 5 mg (base eq)(Maxalt-mlt)

•

rizatriptan benzoate oraldisintegrating tab 10 mg (base eq)(Maxalt-mlt)

•

rizatriptan benzoate tab 5 mg (baseequivalent) (Maxalt)

•

rizatriptan benzoate tab 10 mg (baseequivalent) (Maxalt)

•

sumatriptan nasal spray 5 mg/act(Imitrex)

•

sumatriptan nasal spray 20 mg/act(Imitrex)

•

sumatriptan succinate inj 6 mg/0.5ml(Imitrex)

•

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

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

•

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

•

sumatriptan succinate solutioncartridge 4 mg/0.5ml (Imitrexstatdose ref)

•

sumatriptan succinate solutioncartridge 6 mg/0.5ml (Imitrexstatdose ref)

•

sumatriptan succinate tab 25 mg(Imitrex)

•


•


•

GOUTallopurinol tab 100 mg (Zyloprim)allopurinol tab 300 mg (Zyloprim)colchicine w/ probenecid tab

0.5-500 mgprobenecid tab 500 mgLOCAL ANESTHETICS INJECTABLElidocaine hcl local inj 1% (Xylocaine)lidocaine hcl local preservative free

(pf) inj 1% (Xylocaine-mpf)NEUROMUSCULAR DRUGSSEIZUREScarbamazepine cap sr 12hr 100 mg

(Carbatrol)carbamazepine cap sr 12hr 200 mg

(Carbatrol)carbamazepine cap sr 12hr 300 mg

(Carbatrol)carbamazepine chew tab 100 mg

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

carbamazepine susp 100 mg/5ml(Tegretol)

carbamazepine tab sr 12hr 100 mg(Tegretol-xr)



carbamazepine tab 200 mg (Tegretol)clonazepam tab 0.5 mg (Klonopin)clonazepam tab 1 mg (Klonopin)clonazepam tab 2 mg (Klonopin)DIASTAT ACUDIAL – diazepam rectal

gel delivery system 10 mgDIASTAT ACUDIAL – diazepam rectal

gel delivery system 20 mgDIASTAT PEDIATRIC – diazepam

rectal gel delivery system 2.5 mgdivalproex sodium cap delayed

release sprinkle 125 mg (Depakotesprinkles)

divalproex sodium tab delayedrelease 125 mg (Depakote)



divalproex sodium tab sr 24 hr250 mg (Depakote er)

divalproex sodium tab sr 24 hr500 mg (Depakote er)

ethosuximide cap 250 mg (Zarontin)ethosuximide soln 250 mg/5ml

(Zarontin)gabapentin cap 100 mg (Neurontin)gabapentin cap 300 mg (Neurontin)

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

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)levetiracetam oral soln 100 mg/ml

(Keppra)levetiracetam tab sr 24hr 500 mg

(Keppra xr)levetiracetam tab sr 24hr 750 mg

(Keppra xr)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)phenytoin chew tab 50 mg (Dilantin

infatabs)phenytoin sodium extended cap

100 mg (Dilantin)phenytoin sodium extended cap

200 mg (Phenytek)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

phenytoin sodium extended cap300 mg (Phenytek)

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 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)valproate sodium syrup 250 mg/5ml

(base equiv) (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/5mlbenztropine 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 mg

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

carbidopa & levodopa orallydisintegrating tab 25-250 mg

carbidopa & levodopa tab cr25-100 mg (Sinemet cr)

carbidopa & levodopa tab cr50-200 mg (Sinemet cr)

carbidopa & levodopa tab 10-100 mg(Sinemet)



entacapone tab 200 mg (Comtan)pramipexole dihydrochloride tab

0.125 mg (Mirapex)pramipexole dihydrochloride tab




1 mg (Mirapex)pramipexole dihydrochloride tab

1.5 mg (Mirapex)ropinirole hydrochloride tab 0.25 mg

(Requip)ropinirole hydrochloride tab 0.5 mg

(Requip)ropinirole hydrochloride tab 1 mg




(Requip)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

ropinirole hydrochloride tab 5 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 mgdantrolene sodium cap 25 mg

(Dantrium)dantrolene sodium cap 50 mg

(Dantrium)dantrolene sodium cap 100 mg

(Dantrolene sodium)metaxalone tab 800 mg (Skelaxin)methocarbamol tab 500 mg (Robaxin)methocarbamol tab 750 mg

(Robaxin-750)orphenadrine citrate tab sr 12hr

100 mgtizanidine hcl tab 2 mg (base

equivalent)•

tizanidine hcl tab 4 mg (baseequivalent) (Zanaflex)

•

OTHER NEUROMUSCULAR DRUGSpyridostigmine bromide tab 60 mg

(Mestinon)riluzole tab 50 mg (Rilutek)SUPPLEMENTS

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

VITAMINSergocalciferol cap 50000 unit

(Drisdol)MEPHYTON – phytonadione tab 5 mgMULTIVITAMINSpediatric multiple vitamins w/ fl-fe

drops 0.25-10 mg/mlpediatric multiple vitamins w/

fluoride chew tab 0.25 mgpediatric multiple vitamins w/

fluoride chew tab 0.5 mgpediatric multiple vitamins w/

fluoride chew tab 1 mgpediatric multiple vitamins w/

fluoride soln 0.25 mg/mlpediatric multiple vitamins w/

fluoride soln 0.5 mg/mlpediatric vitamins acd w/ fluoride

soln 0.25 mg/mlpediatric vitamins acd w/ fluoride

soln 0.5 mg/mlPRENATAL PLUS – prenatal vit w/ fe

fumarate-fa tab 27-1 mgPRENATAL VITAMINS PLUS LO –

prenatal vit w/ fe fumarate-fa tab 27-1mg

MINERALS AND ELECTROLYTESpot bicarbonate & chloride effer tab

25 meqpot phos monobasic w/sod phos di

& monobas tab 155-852-130mg (K-phos neutral)

potassium chloride cap cr 8 meq(Micro-k)

potassium chloride cap cr 10 meq(Micro-k)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

potassium chloridemicroencapsulated crys cr tab 10meq

potassium chloridemicroencapsulated crys cr tab 20meq

potassium chloride oral soln 10% (20meq/15ml)

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

potassium chloride powder packet20 meq

potassium chloride tab cr 8 meq(600 mg)

potassium chloride tab cr 10 meq (K-tab)

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 DRUGSADVATE – antihemophilic factor rahf-

pfm for inj 250 unit•

ADVATE – antihemophilic factor rahf-pfm for inj 500 unit

•


•


•


•

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y


•


•

ADYNOVATE – antihemophilic factorrecomb pegylated for inj 250 unit

•


•


•


•

AFSTYLA – antihemophilic fact rcmbsingle chain for inj kit 250 unit

•


•


•


•


•

ALPHANATE/VON WILLEBRAND –antihemophilic factor/vwf (human) forinj 250 unit

•


•


•


•


•

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

ALPHANINE SD – coagulation factor ixfor inj 500 unit

•


•


•

ALPROLIX – coagulation factor ix(recomb) (rfixfc) for inj 250 unit

•


•


•


•


•

anagrelide hcl cap 0.5 mg (Agrylin)anagrelide hcl cap 1 mgBEBULIN – factor ix complex for inj

200-1200 unit•

BENEFIX – coagulation factor ix(recombinant) for inj 250 unit

•


•


•


•


•

BRILINTA – ticagrelor tab 60 mgBRILINTA – ticagrelor tab 90 mgCEREZYME – imiglucerase for inj 400

unit•

cilostazol tab 50 mg (Pletal)cilostazol tab 100 mg (Pletal)

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

clopidogrel bisulfate tab 75 mg (baseequiv) (Plavix)

COAGADEX – coagulation factor x(human) for inj 250 unit

•

COAGADEX – coagulation factor x(human) for inj 500 unit

•

CORIFACT – factor xiii concentrate(human) for inj kit 1000-1600 unit

•

cyanocobalamin inj 1000 mcg/mldipyridamole tab 25 mg (Persantine)dipyridamole tab 50 mg (Persantine)dipyridamole tab 75 mg (Persantine)ELIQUIS – apixaban tab 2.5 mg •ELIQUIS – apixaban tab 5 mg •ELOCTATE – 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)

•


•


•


•

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

enoxaparin sodium inj 100 mg/ml(Lovenox)

•


•

enoxaparin sodium inj 150 mg/ml(Lovenox)

•

enoxaparin sodium inj 300 mg/3ml(Lovenox)

•

FEIBA – antiinhibitor coagulantcomplex for inj

•

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

• •

folic acid tab 1 mgHELIXATE FS – antihemophilic factor

(recombinant) for inj kit 250 unit•

HELIXATE FS – antihemophilic factor(recombinant) for inj kit 500 unit

•


•


•


•

HEMOFIL M – antihemophilic factor(human) for inj 250 unit

•


•


•


•

HUMATE-P – antihemophilic factor/vwf(human) for inj 250-600 unit

•


•


•

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

IDELVION – coagulation factor ix(recomb) (rix-fp) for inj 250 unit

•


•


•


•

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

•


•


•

KOATE-DVI – antihemophilic factor(human) for inj 250 unit

•


•


•

KOGENATE FS – antihemophilic factor(recombinant) for inj kit 250 unit

•


•


•


•


•

KOGENATE FS BIO-SET –antihemophilic factor (recombinant)for inj kit 250 unit

•


•

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y


•


•


•

KOVALTRY – antihemophilic factor(recombinant) for inj 250 unit

•


•


•


•


•

MONOCLATE-P – antihemophilic factor(human) for inj kit 250 unit

•


•


•

MONONINE – coagulation factor ix forinj 500 unit

•

MONONINE – coagulation factor ix forinj 1000 unit

•

NEUPOGEN – filgrastim soln prefilledsyringe 300 mcg/0.5ml

•

NEUPOGEN – filgrastim soln prefilledsyringe 480 mcg/0.8ml (600 mcg/ml)

•

NEUPOGEN – filgrastim inj 300 mcg/ml •NEUPOGEN – filgrastim inj 480

mcg/1.6ml (300 mcg/ml)•

NOVOEIGHT – antihemophilic factor(recombinant) for inj 250 unit

•

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y


•


•


•


•


•

NOVOSEVEN RT – coagulation factorviia (recomb) for inj 1 mg (1000 mcg)

•


•


•


•

NUWIQ – antihemophilic factor(recombinant) for inj 250 unit

•


•


•


•

NUWIQ – antihemophilic factor(recombinant) for inj kit 250 unit

•


•


•


•

OBIZUR – antihemophilic factor(recomb porc) rpfviii for inj 500 unit

•

pentoxifylline tab cr 400 mg

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

PROCRIT – epoetin alfa inj 2000 unit/ml

• •


• •


• •


• •


• •


• •

PROFILNINE – factor ix complex for inj500 unit

•


•


•

PROFILNINE SD – factor ix complexfor inj 500 unit

•


•


•

RECOMBINATE – antihemophilic factor(recombinant) for inj 220-400 unit

•


•


•


•


•

RIXUBIS – coagulation factor ix(recombinant) for inj 250 unit

•

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y


•


•


•


•

TRETTEN – coagulation factor xiii a-subunit for inj 2000-3125 unit

•

VONVENDI – von willebrand factor(recombinant) for inj 650 unit

•

VONVENDI – von willebrand factor(recombinant) for inj 1300 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)WILATE – antihemophilic factor/vwf

(human) for inj 500-500 unit kit•

WILATE – antihemophilic factor/vwf(human) for inj 1000-1000 unit kit

•

XYNTHA – antihemophilic factorrecombinant paf for inj kit 250 unit

•


•


•

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y


•

XYNTHA SOLOFUSE – antihemophilicfactor recombinant paf for inj kit 250unit

•


•


•


•


•

TOPICAL PRODUCTSEYEAnti-infectivesBACITRACIN – bacitracin ophth oint

500 unit/gmbacitracin-polymyxin b ophth ointciprofloxacin hcl ophth soln 0.3%

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

(Garamycin)NATACYN – natamycin ophth susp 5%neomycin-bacitrac zn-polymyx

5(3.5)mg-400unt-10000unt op oinneomycin-polymy-gramicid op sol

1.75-10000-0.025mg-unt-mg/ml(Neosporin)

ofloxacin ophth soln 0.3% (Ocuflox)

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

polymyxin b-trimethoprim ophthsoln 10000 unit/ml-0.1% (Polytrim)

sulfacetamide sodium ophth soln10% (Bleph-10)

tobramycin ophth soln 0.3% (Tobrex)trifluridine ophth soln 1% (Viroptic)Steroids and Combination Productsbacitracin-polymyxin-neomycin-hc

ophth oint 1%fluorometholone ophth susp 0.1%

(Fml liquifilm)neomycin-polymyxin-

dexamethasone ophth oint 0.1%(Maxitrol)

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

prednisolone acetate ophth susp 1%(Pred forte)

sulfacetamide sodium-prednisoloneophth soln 10-0.23(0.25)%

tobramycin-dexamethasone ophthsusp 0.3-0.1% (Tobradex)

Glaucomabrimonidine 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 0.5%(Betagan)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

pilocarpine hcl ophth soln 1% (Isoptocarpine)



timolol maleate ophth gel formingsoln 0.25% (Timoptic-xe)

timolol maleate ophth gel formingsoln 0.5% (Timoptic-xe)

timolol maleate ophth soln 0.25%(Timoptic)

timolol maleate ophth soln 0.5%(Timoptic)

Other Eye Productsatropine 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%flurbiprofen sodium ophth soln

0.03% (Ocufen)homatropine hbr ophth soln 5%

(Isopto homatropine)ketorolac tromethamine ophth soln

0.4% (Acular ls)ketorolac tromethamine ophth soln

0.5% (Acular)olopatadine hcl ophth soln 0.1%

(base equivalent) (Patanol)tropicamide ophth soln 0.5%tropicamide ophth soln 1%

(Mydriacyl)EAR

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

acetic acid otic soln 2%hydrocortisone w/ acetic acid otic

soln 1-2% (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 viscous soln 2%nystatin susp 100000 unit/mlpilocarpine 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/PRODUCTSAcne

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

adapalene 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-benzoylperoxide gel 1-5% (Benzaclin)

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)sulfacetamide sodium lotion 10%

(acne) (Klaron)

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

sulfacetamide sodium w/ sulfurcream 10-5%

sulfacetamide sodium w/ sulfuremulsion 10-5%

sulfacetamide sodium w/ sulfurlotion 10-5%

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)tretinoin microsphere gel 0.1%

(Retin-a micro)Anti-infectivesciclopirox gel 0.77% (Loprox) •ciclopirox olamine cream 0.77%

(base equiv)•

ciclopirox olamine susp 0.77% (baseequiv)

•

ciclopirox shampoo 1% (Loproxshampoo)

•

ciclopirox solution 8% (Penlac naillacquer)

•

diclofenac sodium gel 1% (Voltaren)econazole nitrate cream 1%ketoconazole cream 2%ketoconazole shampoo 2% (Nizoral)mupirocin calcium cream 2%

(Bactroban)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

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% (Diproleneaf)

betamethasone dipropionateaugmented gel 0.05%

betamethasone dipropionateaugmented lotion 0.05% (Diprolene)

betamethasone dipropionateaugmented oint 0.05% (Diprolene)

betamethasone dipropionate cream0.05%

betamethasone dipropionate lotion0.05%

betamethasone dipropionate oint0.05%

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)

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

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 0.25%

(Topicort)desoximetasone gel 0.05% (Topicort)desoximetasone oint 0.25% (Topicort)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%fluocinonide soln 0.05%fluticasone propionate cream 0.05%

(Cutivate)fluticasone propionate oint 0.005%

(Cutivate)halobetasol propionate cream 0.05%

(Ultravate)

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

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 0.025%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%

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

calcipotriene soln 0.005% (50 mcg/ml)

diclofenac sodium (actinickeratoses) gel 3% (Solaraze)

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)lindane shampoo 1%malathion lotion 0.5% (Ovide)permethrin cream 5% (Elimite)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)VALCHLOR – mechlorethamine hcl gel

0.016% (base equivalent)•

MISCELLANEOUS CATEGORIESDIABETIC SUPPLIESTEST STRIPS – BAYER ASCENSIA

AUTODISC, BREEZE 2, CONTOUR,CONTOUR NEXT

•

INSULIN PEN NEEDLES – VARIOUS •INSULIN SYRINGES – VARIOUSLANCETS – VARIOUSRESPIRATORY INHALER-ASSIST DEVICES

2016



Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

BREATHERITE – spacer/aerosol-holding chambers - device

MISCELLANEOUS DRUGSazathioprine tab 50 mg (Imuran)buprenorphine hcl-naloxone hcl sl

tab 2-0.5 mg (base equiv)• •

buprenorphine hcl-naloxone hcl sltab 8-2 mg (base equiv)

• •

CHEMET – succimer cap 100 mgCUPRIMINE – penicillamine cap 250

mg•

cyclosporine cap 25 mg(Sandimmune)

cyclosporine cap 100 mg(Sandimmune)

CYCLOSPORINE MODIFIED –cyclosporine modified cap 50 mg

cyclosporine modified cap 25 mg(Neoral)

cyclosporine modified cap 50 mg(Cyclosporine modifie)

cyclosporine modified cap 100 mg(Neoral)

cyclosporine modified oral soln100 mg/ml (Neoral)

DEPEN TITRATABS – penicillamine tab250 mg

•

mycophenolate mofetil cap 250 mg(Cellcept)

mycophenolate mofetil for oral susp200 mg/ml (Cellcept)

mycophenolate mofetil tab 500 mg(Cellcept)

mycophenolate sodium tab dr180 mg (mycophenolic acid equiv)(Myfortic)

Drug Name Spe

cial

ty

Prio

r Aut

horiz

atio

n

Dis

pens

ing

Lim

its

Ste

p Th

erap

y

mycophenolate sodium tab dr360 mg (mycophenolic acid equiv)(Myfortic)

naloxone hcl inj 0.4 mg/mlnaltrexone hcl tab 50 mg (Revia)NARCAN – naloxone hcl nasal spray 4

mg/0.1mlRAPAMUNE – 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)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 • •

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).......................................................................... 32

acarbose tab 25 mg (Precose)........................................ 10acarbose tab 50 mg (Precose)........................................ 10acarbose tab 100 mg (Precose)...................................... 10acebutolol hcl cap 200 mg (Sectral)...............................15acebutolol hcl cap 400 mg (Sectral)...............................15acetaminophen w/ codeine soln 120-12 mg/5ml........... 33acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine)............................................................................ 33

acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3).......................................................................33

acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4).......................................................................33

acetazolamide cap sr 12hr 500 mg (Diamox)................ 19acetazolamide tab 250 mg............................................... 19acetic acid otic soln 2%...................................................47acetylcysteine inhal soln 10%.........................................22acetylcysteine inhal soln 20%.........................................22acitretin cap 10 mg (Soriatane).......................................50acitretin cap 17.5 mg (Soriatane)....................................50acitretin cap 25 mg (Soriatane).......................................50ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml(2000000 unit/0.5ml)........................................................... 7

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).....................................48adapalene gel 0.1% (Differin).......................................... 48adapalene gel 0.3% (Differin).......................................... 48ADCIRCA – tadalafil tab 20 mg (pah)................................20adefovir dipivoxil tab 10 mg (Hepsera)............................3ADVATE – antihemophilic factor rahf-pfm for inj 250unit......................................................................................41

ADVATE – antihemophilic factor rahf-pfm for inj 500unit......................................................................................41






ADYNOVATE – antihemophilic factor recomb pegylated forinj 250 unit.........................................................................41

ADYNOVATE – antihemophilic factor recomb pegylated forinj 500 unit.........................................................................41

ADYNOVATE – antihemophilic factor recomb pegylated forinj 1000 unit.......................................................................41

ADYNOVATE – antihemophilic factor recomb pegylated forinj 2000 unit.......................................................................41

AFSTYLA – antihemophilic fact rcmb single chain for inj kit250 unit..............................................................................41

AFSTYLA – antihemophilic fact rcmb single chain for inj kit500 unit..............................................................................41

AFSTYLA – antihemophilic fact rcmb single chain for inj kit1000 unit............................................................................41



ALBENZA – albendazole tab 200 mg.................................. 6albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)..........22albuterol sulfate soln nebu 0.5% (5 mg/ml)...................22albuterol sulfate soln nebu 0.63 mg/3ml (baseequiv).................................................................................22

albuterol sulfate soln nebu 1.25 mg/3ml (baseequiv).................................................................................22

albuterol sulfate syrup 2 mg/5ml....................................22albuterol sulfate tab 2 mg................................................22albuterol sulfate tab 4 mg................................................22alclometasone dipropionate cream 0.05%(Aclovate)..........................................................................49

alclometasone dipropionate oint 0.05%.........................49alendronate sodium tab 5 mg......................................... 12alendronate sodium tab 10 mg....................................... 12alendronate sodium tab 35 mg....................................... 12alendronate sodium tab 70 mg (Fosamax).................... 12alfuzosin hcl tab sr 24hr 10 mg (Uroxatral)................... 26ALKERAN – melphalan tab 2 mg.........................................7allopurinol tab 100 mg (Zyloprim).................................. 37allopurinol tab 300 mg (Zyloprim).................................. 37ALPHANATE/VON WILLEBRAND – antihemophilic factor/vwf (human) for inj 250 unit..............................................41

ALPHANATE/VON WILLEBRAND – antihemophilic factor/vwf (human) for inj 500 unit..............................................41

ALPHANATE/VON WILLEBRAND – antihemophilic factor/vwf (human) for inj 1000 unit............................................41



ALPHANINE SD – coagulation factor ix for inj 500 unit.....42

2016



ALPHANINE SD – coagulation factor ix for inj 1000unit......................................................................................42

ALPHANINE SD – coagulation factor ix for inj 1500unit......................................................................................42

alprazolam tab 0.25 mg (Xanax)......................................27alprazolam tab 0.5 mg (Xanax)........................................27alprazolam tab 1 mg (Xanax)...........................................27alprazolam tab 2 mg (Xanax)...........................................27alprazolam tab sr 24hr 0.5 mg (Xanax xr)......................26alprazolam tab sr 24hr 1 mg (Xanax xr).........................27alprazolam tab sr 24hr 2 mg (Xanax xr).........................27alprazolam tab sr 24hr 3 mg (Xanax xr).........................27ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj250 unit..............................................................................42

ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj500 unit..............................................................................42

ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj1000 unit............................................................................42



amantadine hcl cap 100 mg............................................ 39amantadine hcl syrup 50 mg/5ml....................................39amiloride & hydrochlorothiazide tab 5-50 mg............... 19amiloride hcl tab 5 mg..................................................... 19amiodarone hcl tab 100 mg.............................................20amiodarone hcl tab 400 mg.............................................20amiodarone hcl tab 200 mg (Cordarone)....................... 20amitriptyline hcl tab 10 mg..............................................27amitriptyline hcl tab 25 mg..............................................27amitriptyline hcl tab 50 mg..............................................27amitriptyline hcl tab 75 mg..............................................27amitriptyline hcl tab 100 mg............................................27amitriptyline hcl tab 150 mg............................................27amlodipine besylate-atorvastatin calcium tab 2.5-10mg (Caduet)......................................................................16

amlodipine besylate-atorvastatin calcium tab 2.5-20mg (Caduet)......................................................................16

amlodipine besylate-atorvastatin calcium tab 2.5-40mg (Caduet)......................................................................16

amlodipine besylate-atorvastatin calcium tab 5-10 mg(Caduet).............................................................................16








amlodipine besylate-benazepril hcl cap 2.5-10 mg(Lotrel)...............................................................................16

amlodipine besylate-benazepril hcl cap 5-10 mg(Lotrel)...............................................................................16





amlodipine besylate tab 2.5 mg (Norvasc).................... 16amlodipine besylate tab 5 mg (Norvasc)....................... 16amlodipine besylate tab 10 mg (Norvasc)..................... 16amlodipine besylate-valsartan tab 5-160 mg(Exforge)........................................................................... 17

amlodipine besylate-valsartan tab 5-320 mg(Exforge)........................................................................... 17



amlodipine-valsartan-hydrochlorothiazide tab5-160-12.5 mg (Exforge hct)...........................................14

amlodipine-valsartan-hydrochlorothiazide tab 5-160-25mg (Exforge hct)..............................................................14

amlodipine-valsartan-hydrochlorothiazide tab10-160-12.5 mg (Exforge hct).........................................14

amlodipine-valsartan-hydrochlorothiazide tab10-160-25 mg (Exforge hct)............................................14

amlodipine-valsartan-hydrochlorothiazide tab10-320-25 mg (Exforge hct)............................................14

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..................................1

2016



amoxicillin (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)..................................................................... 31

amphetamine-dextroamphetamine cap sr 24hr 10 mg(Adderall xr)..................................................................... 31





amphetamine-dextroamphetamine tab 5 mg(Adderall).......................................................................... 31

amphetamine-dextroamphetamine tab 7.5 mg(Adderall).......................................................................... 31


amphetamine-dextroamphetamine tab 12.5 mg(Adderall).......................................................................... 31




ampicillin cap 250 mg........................................................ 1ampicillin cap 500 mg........................................................ 1anagrelide hcl cap 1 mg.................................................. 42anagrelide hcl cap 0.5 mg (Agrylin)............................... 42anastrozole tab 1 mg (Arimidex).......................................7ANDROGEL PUMP – testosterone td gel 20.25 mg/act(1.62%).................................................................................8

ANDROGEL – testosterone td gel 20.25 mg/1.25gm(1.62%).................................................................................8

ANDROGEL – testosterone td gel 40.5 mg/2.5gm(1.62%).................................................................................8

ANDROXY – fluoxymesterone tab 10 mg............................9APTIVUS – tipranavir cap 250 mg.......................................4APTIVUS – tipranavir oral soln 100 mg/ml.......................... 4aripiprazole tab 2 mg (Abilify).........................................29aripiprazole tab 5 mg (Abilify).........................................29aripiprazole tab 10 mg (Abilify).......................................29aripiprazole tab 15 mg (Abilify).......................................29aripiprazole tab 20 mg (Abilify).......................................29aripiprazole tab 30 mg (Abilify).......................................29

ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 100 mcg/act.................................................. 22

ARNUITY ELLIPTA – fluticasone furoate aerosol powderbreath activ 200 mcg/act.................................................. 22

atenolol & chlorthalidone tab 50-25 mg (Tenoretic50)...................................................................................... 15

atenolol & chlorthalidone tab 100-25 mg (Tenoretic100).................................................................................... 15

atenolol tab 25 mg (Tenormin)........................................ 15atenolol tab 50 mg (Tenormin)........................................ 15atenolol tab 100 mg (Tenormin)...................................... 15atorvastatin calcium tab 10 mg (base equivalent)(Lipitor)..............................................................................18

atorvastatin calcium tab 20 mg (base equivalent)(Lipitor)..............................................................................18



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 soln 1% (Isopto atropine)......... 47azathioprine tab 50 mg (Imuran).....................................51azelastine hcl nasal spray 0.1% (137 mcg/spray)......... 22azelastine hcl nasal spray 0.15% (205.5 mcg/spray)(Astepro)........................................................................... 22

azelastine hcl ophth soln 0.05% (Optivar)..................... 47azithromycin 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).............................. 2B

BACITRACIN – bacitracin ophth oint 500 unit/gm............. 46bacitracin-polymyxin b ophth oint..................................46bacitracin-polymyxin-neomycin-hc ophth oint 1%.......46baclofen tab 10 mg...........................................................40baclofen tab 20 mg...........................................................40balsalazide disodium cap 750 mg (Colazal).................. 25BARACLUDE – entecavir oral soln 0.05 mg/ml...................3BEBULIN – factor ix complex for inj 200-1200 unit............42benazepril & hydrochlorothiazide tab 5-6.25 mg.......... 13benazepril & hydrochlorothiazide tab 10-12.5 mg(Lotensin hct)...................................................................13

benazepril & hydrochlorothiazide tab 20-12.5 mg(Lotensin hct)...................................................................13

benazepril & hydrochlorothiazide tab 20-25 mg(Lotensin hct)...................................................................13

2016



benazepril hcl tab 5 mg................................................... 13benazepril hcl tab 10 mg (Lotensin)...............................13benazepril hcl tab 20 mg (Lotensin)...............................13benazepril hcl tab 40 mg (Lotensin)...............................13BENEFIX – coagulation factor ix (recombinant) for inj 250unit......................................................................................42

BENEFIX – coagulation factor ix (recombinant) for inj 500unit......................................................................................42




benzoyl peroxide-erythromycin gel 5-3%(Benzamycin)....................................................................48

benztropine mesylate tab 0.5 mg....................................39benztropine mesylate tab 1 mg.......................................39benztropine mesylate tab 2 mg.......................................39betamethasone dipropionate augmented cream 0.05%(Diprolene af)................................................................... 49

betamethasone dipropionate augmented gel0.05%................................................................................. 49

betamethasone dipropionate augmented lotion 0.05%(Diprolene)........................................................................ 49

betamethasone dipropionate augmented oint 0.05%(Diprolene)........................................................................ 49

betamethasone dipropionate cream 0.05%................... 49betamethasone dipropionate lotion 0.05%....................49betamethasone dipropionate oint 0.05%....................... 49betamethasone valerate cream 0.1%............................. 49betamethasone valerate lotion 0.1%.............................. 49betamethasone valerate oint 0.1%................................. 49BETASERON – interferon beta-1b for inj kit 0.3 mg.......... 32bexarotene cap 75 mg (Targretin).....................................7bicalutamide tab 50 mg (Casodex)...................................7BILTRICIDE – praziquantel tab 600 mg...............................6bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg(Ziac)..................................................................................15

bisoprolol & hydrochlorothiazide tab 5-6.25 mg(Ziac)..................................................................................15

bisoprolol & hydrochlorothiazide tab 10-6.25 mg(Ziac)..................................................................................15

bisoprolol fumarate tab 5 mg (Zebeta)...........................15bisoprolol fumarate tab 10 mg (Zebeta).........................15BREATHERITE – spacer/aerosol-holding chambers -device.................................................................................51

BRILINTA – ticagrelor tab 60 mg....................................... 42BRILINTA – ticagrelor tab 90 mg....................................... 42brimonidine tartrate ophth soln 0.2%.............................46brimonidine tartrate ophth soln 0.15% (Alphaganp)........................................................................................ 46

bromocriptine mesylate cap 5 mg (Parlodel)................ 39

bromocriptine mesylate tab 2.5 mg (Parlodel).............. 39budesonide delayed release particles cap 3 mg(Entocort ec)...................................................................... 8

budesonide inhalation susp 0.25 mg/2ml(Pulmicort)........................................................................ 22

budesonide inhalation susp 0.5 mg/2ml(Pulmicort)........................................................................ 22

budesonide inhalation susp 1 mg/2ml (Pulmicort).......22bumetanide tab 0.5 mg.................................................... 19bumetanide tab 1 mg........................................................19bumetanide tab 2 mg........................................................19buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (baseequiv).................................................................................51

buprenorphine hcl-naloxone hcl sl tab 8-2 mg (baseequiv).................................................................................51

buprenorphine hcl sl tab 2 mg (base equiv)................. 34buprenorphine hcl sl tab 8 mg (base equiv)................. 34bupropion hcl (smoking deterrent) tab sr 12hr 150 mg(Zyban).............................................................................. 32

bupropion hcl tab 75 mg (Wellbutrin)............................ 27bupropion hcl tab 100 mg (Wellbutrin).......................... 27bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr).........27bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr).........27bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr).........27bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl)......... 27bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl)......... 27buspirone hcl tab 5 mg....................................................27buspirone hcl tab 10 mg..................................................27buspirone hcl tab 15 mg..................................................27buspirone hcl tab 30 mg..................................................27butalbital-acetaminophen-caffeine cap 50-325-40mg...................................................................................... 33

butalbital-acetaminophen-caffeine tab 50-325-40mg...................................................................................... 33

butalbital-acetaminophen tab 50-325 mg.......................33butalbital-aspirin-caffeine cap 50-325-40 mg(Fiorinal)............................................................................33

butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg(Fiorinal/codeine #3)....................................................... 34C

cabergoline tab 0.5 mg.................................................... 12caffeine citrate oral soln 60 mg/3ml (10 mg/ml baseequiv) (Cafcit)...................................................................31

calcipotriene cream 0.005% (Dovonex)..........................50calcipotriene oint 0.005%.................................................50calcipotriene soln 0.005% (50 mcg/ml).......................... 50calcitonin (salmon) nasal soln 200 unit/act(Miacalcin)........................................................................ 12

calcitriol cap 0.25 mcg (Rocaltrol)..................................12calcitriol cap 0.5 mcg (Rocaltrol)....................................12calcitriol oral soln 1 mcg/ml (Rocaltrol).........................12

2016



calcium acetate (phosphate binder) cap 667 mg (169mg ca) (Phoslo)............................................................... 25

calcium acetate (phosphate binder) tab 667 mg(Eliphos)............................................................................25

CANASA – mesalamine suppos 1000 mg......................... 25candesartan cilexetil-hydrochlorothiazide tab 16-12.5mg (Atacand hct).............................................................14

candesartan cilexetil-hydrochlorothiazide tab 32-12.5mg (Atacand hct).............................................................14

candesartan cilexetil-hydrochlorothiazide tab 32-25mg (Atacand hct).............................................................14

candesartan cilexetil tab 4 mg (Atacand)...................... 14candesartan cilexetil tab 8 mg (Atacand)...................... 14candesartan cilexetil tab 16 mg (Atacand).................... 14candesartan cilexetil tab 32 mg (Atacand).................... 14capecitabine tab 150 mg (Xeloda).................................... 7capecitabine tab 500 mg (Xeloda).................................... 7captopril tab 12.5 mg........................................................13captopril tab 25 mg...........................................................13captopril tab 50 mg...........................................................13captopril tab 100 mg.........................................................13carbamazepine cap sr 12hr 100 mg (Carbatrol)............37carbamazepine cap sr 12hr 200 mg (Carbatrol)............37carbamazepine cap sr 12hr 300 mg (Carbatrol)............37carbamazepine chew tab 100 mg................................... 37carbamazepine susp 100 mg/5ml (Tegretol)..................38carbamazepine tab 200 mg (Tegretol)............................38carbamazepine tab sr 12hr 100 mg (Tegretol-xr).......... 38carbamazepine tab sr 12hr 200 mg (Tegretol-xr).......... 38carbamazepine tab sr 12hr 400 mg (Tegretol-xr).......... 38carbidopa & levodopa orally disintegrating tab 10-100mg...................................................................................... 39

carbidopa & levodopa orally disintegrating tab 25-100mg...................................................................................... 39

carbidopa & levodopa orally disintegrating tab 25-250mg...................................................................................... 39

carbidopa & levodopa tab cr 25-100 mg (Sinemetcr).......................................................................................39

carbidopa & levodopa tab cr 50-200 mg (Sinemetcr).......................................................................................39

carbidopa & levodopa tab 10-100 mg (Sinemet)...........39carbidopa & levodopa tab 25-100 mg (Sinemet)...........39carbidopa & levodopa tab 25-250 mg (Sinemet)...........39carteolol hcl ophth soln 1%............................................ 46carvedilol tab 3.125 mg (Coreg)......................................15carvedilol tab 6.25 mg (Coreg)........................................15carvedilol tab 12.5 mg (Coreg)........................................15carvedilol tab 25 mg (Coreg)...........................................15cefaclor cap 250 mg........................................................... 1cefaclor cap 500 mg........................................................... 1cefadroxil cap 500 mg........................................................1cefadroxil for susp 250 mg/5ml........................................ 1cefadroxil for susp 500 mg/5ml........................................ 1

cefadroxil 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..................................... 1cefprozil 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........................................2ceftriaxone 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).............................. 2cefuroxime axetil tab 500 mg (Ceftin).............................. 2celecoxib cap 50 mg (Celebrex)......................................35celecoxib cap 100 mg (Celebrex)....................................35celecoxib cap 200 mg (Celebrex)....................................35celecoxib cap 400 mg (Celebrex)....................................35cephalexin cap 250 mg (Keflex)........................................2cephalexin cap 500 mg (Keflex)........................................2cephalexin for susp 125 mg/5ml.......................................2cephalexin for susp 250 mg/5ml.......................................2CEREZYME – imiglucerase for inj 400 unit....................... 42cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)................... 22cevimeline hcl cap 30 mg (Evoxac)................................47CHANTIX CONTINUING MONTH – varenicline tartrate tab1 mg (base equiv).............................................................32

CHANTIX STARTING MONTH PA – varenicline tartratetab 0.5 mg x 11 & tab 1 mg x 42 pack............................. 33

CHANTIX – varenicline tartrate tab 0.5 mg (baseequiv)................................................................................. 32

CHANTIX – varenicline tartrate tab 1 mg (base equiv)......32CHEMET – succimer cap 100 mg......................................51CHENODAL – chenodiol tab 250 mg.................................25chlorhexidine gluconate soln 0.12% (Peridex)..............47chloroquine phosphate tab 250 mg..................................6chloroquine phosphate tab 500 mg (Aralen)...................6chlorothiazide tab 500 mg............................................... 19chlorpromazine hcl tab 10 mg........................................ 29chlorpromazine hcl tab 25 mg........................................ 29chlorpromazine hcl tab 50 mg........................................ 29chlorpromazine hcl tab 100 mg...................................... 29chlorpromazine hcl tab 200 mg...................................... 29chlorthalidone tab 25 mg.................................................19chlorzoxazone tab 500 mg (Parafon forte dsc)............. 40

2016



cholestyramine light powder 4 gm/dose (Questranlight)...................................................................................18

cholestyramine light powder packets 4 gm.................. 18cholestyramine powder 4 gm/dose (Questran).............18cholestyramine powder packets 4 gm (Questran)........18choline fenofibrate cap dr 45 mg (fenofibric acidequiv) (Trilipix).................................................................18

choline fenofibrate cap dr 135 mg (fenofibric acidequiv) (Trilipix).................................................................18

chorionic gonadotropin for inj 10000 unit..................... 10CIALIS – tadalafil tab 2.5 mg............................................. 21CIALIS – tadalafil tab 5 mg................................................ 21CIALIS – tadalafil tab 10 mg.............................................. 21CIALIS – tadalafil tab 20 mg.............................................. 21ciclopirox gel 0.77% (Loprox)......................................... 48ciclopirox olamine cream 0.77% (base equiv)...............48ciclopirox olamine susp 0.77% (base equiv).................48ciclopirox shampoo 1% (Loprox shampoo).................. 48ciclopirox solution 8% (Penlac nail lacquer).................48cilostazol tab 50 mg (Pletal)............................................42cilostazol tab 100 mg (Pletal)..........................................42cimetidine hcl soln 300 mg/5ml...................................... 24cimetidine tab 300 mg......................................................24cimetidine tab 400 mg......................................................24cimetidine tab 800 mg......................................................24ciprofloxacin-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)..............................................................2

ciprofloxacin for oral susp 500 mg/5ml (10%) (10gm/100ml) (Cipro)..............................................................2

ciprofloxacin hcl ophth soln 0.3% (Ciloxan)................. 46ciprofloxacin hcl tab 750 mg (base equiv).......................2ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)..........2ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)..........2citalopram hydrobromide oral soln 10 mg/5ml............. 27citalopram hydrobromide tab 10 mg (base equiv)(Celexa)............................................................................. 27

citalopram hydrobromide tab 20 mg (base equiv)(Celexa)............................................................................. 27

citalopram hydrobromide tab 40 mg (base equiv)(Celexa)............................................................................. 27

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)..........2clindamycin hcl cap 75 mg (Cleocin)...............................6clindamycin hcl cap 150 mg (Cleocin).............................6clindamycin hcl cap 300 mg (Cleocin).............................6

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

clindamycin phosphate-benzoyl peroxide gel 1-5%(Benzaclin)........................................................................48

clindamycin phosphate gel 1% (Cleocin-t)....................48clindamycin phosphate lotion 1% (Cleocin-t)............... 48clindamycin phosphate soln 1% (Cleocin-t)..................48clindamycin phosphate swab 1% (Cleocin-t)................ 48clindamycin phosphate vaginal cream 2%(Cleocin)............................................................................26

clindamycin phosph-benzoyl peroxide (refrig) gel 1.2(1)-5% (Duac)....................................................................48

clobetasol propionate cream 0.05% (Temovate)...........49clobetasol propionate emollient base cream 0.05%(Temovate e).....................................................................49

clobetasol propionate foam 0.05% (Olux)......................49clobetasol propionate gel 0.05% (Temovate)................ 49clobetasol propionate oint 0.05% (Temovate)...............49clobetasol propionate soln 0.05% (Temovate).............. 49clomiphene citrate tab 50 mg (Clomid)..........................10clomipramine hcl cap 25 mg (Anafranil)........................27clomipramine hcl cap 50 mg (Anafranil)........................27clomipramine hcl cap 75 mg (Anafranil)........................27clonazepam tab 0.5 mg (Klonopin).................................38clonazepam tab 1 mg (Klonopin)....................................38clonazepam tab 2 mg (Klonopin)....................................38clonidine hcl tab 0.1 mg (Catapres)............................... 20clonidine hcl tab 0.2 mg (Catapres)............................... 20clonidine hcl tab 0.3 mg (Catapres)............................... 20clonidine hcl td patch weekly 0.1 mg/24hr (Catapres-tts-1)...................................................................................21

clonidine hcl td patch weekly 0.2 mg/24hr (Catapres-tts-2)...................................................................................21

clonidine hcl td patch weekly 0.3 mg/24hr (Catapres-tts-3)...................................................................................21

clopidogrel bisulfate tab 75 mg (base equiv)(Plavix).............................................................................. 42

clotrimazole troche 10 mg............................................... 47clozapine tab 50 mg......................................................... 29clozapine tab 200 mg....................................................... 29clozapine tab 25 mg (Clozaril).........................................29clozapine tab 100 mg (Clozaril).......................................29COAGADEX – coagulation factor x (human) for inj 250unit......................................................................................42

COAGADEX – coagulation factor x (human) for inj 500unit......................................................................................42

codeine sulfate tab 30 mg............................................... 34codeine sulfate tab 60 mg............................................... 34codeine sulfate tab 15 mg (Codeine sulfate).................34colchicine w/ probenecid tab 0.5-500 mg...................... 37colestipol hcl granule packets 5 gm (Colestidflavored)............................................................................18

colestipol hcl granules 5 gm (Colestid flavored).......... 18

2016



colestipol hcl tab 1 gm (Colestid)...................................18COMBIPATCH – estradiol-norethindrone ace td pttw0.05-0.14 mg/day.................................................................9

COMBIPATCH – estradiol-norethindrone ace td pttw0.05-0.25 mg/day.................................................................9

COPAXONE – glatiramer acetate soln prefilled syringe 20mg/ml..................................................................................32

COPAXONE – glatiramer acetate soln prefilled syringe 40mg/ml..................................................................................32

CORIFACT – factor xiii concentrate (human) for inj kit1000-1600 unit...................................................................42

CORTIFOAM – hydrocortisone acetate rectal foam 10%(90 mg/dose)..................................................................... 47

CORTISONE ACETATE – cortisone acetate tab 25 mg...... 8CRESTOR – rosuvastatin calcium tab 5 mg......................18CRESTOR – rosuvastatin calcium tab 10 mg....................18CRESTOR – rosuvastatin calcium tab 20 mg....................18CRESTOR – rosuvastatin calcium tab 40 mg....................18CRIXIVAN – indinavir sulfate cap 200 mg........................... 4CRIXIVAN – indinavir sulfate cap 400 mg........................... 4cromolyn sodium ophth soln 4%....................................47CUPRIMINE – penicillamine cap 250 mg.......................... 51cyanocobalamin inj 1000 mcg/ml................................... 42cyclobenzaprine hcl tab 5 mg.........................................40cyclobenzaprine hcl tab 10 mg.......................................40cyclopentolate hcl ophth soln 1% (Cyclogyl)................47cyclosporine cap 25 mg (Sandimmune)........................ 51cyclosporine cap 100 mg (Sandimmune)...................... 51cyclosporine modified cap 50 mg (Cyclosporinemodifie)............................................................................. 51

cyclosporine modified cap 25 mg (Neoral)....................51cyclosporine modified cap 100 mg (Neoral)..................51CYCLOSPORINE MODIFIED – cyclosporine modified cap50 mg.................................................................................51

cyclosporine modified oral soln 100 mg/ml(Neoral)..............................................................................51

cyproheptadine hcl syrup 2 mg/5ml...............................22cyproheptadine hcl tab 4 mg.......................................... 22CYSTAGON – cysteamine bitartrate cap 50 mg................26CYSTAGON – cysteamine bitartrate cap 150 mg..............26

DDAKLINZA – daclatasvir dihydrochloride tab 30 mg (baseequivalent)............................................................................3

DAKLINZA – daclatasvir dihydrochloride tab 60 mg (baseequivalent)............................................................................3

DAKLINZA – daclatasvir dihydrochloride tab 90 mg (baseequivalent)............................................................................4

danazol cap 50 mg..............................................................9danazol cap 100 mg............................................................9danazol cap 200 mg............................................................9dantrolene sodium cap 25 mg (Dantrium)..................... 40dantrolene sodium cap 50 mg (Dantrium)..................... 40

dantrolene sodium cap 100 mg (Dantrolenesodium)............................................................................. 40

dapsone tab 25 mg.............................................................6dapsone tab 100 mg...........................................................6DARAPRIM – pyrimethamine tab 25 mg............................. 6demeclocycline hcl tab 150 mg........................................ 2demeclocycline hcl tab 300 mg........................................ 2DEPEN TITRATABS – penicillamine tab 250 mg.............. 51desipramine hcl tab 10 mg (Norpramin)........................ 27desipramine hcl tab 25 mg (Norpramin)........................ 27desipramine hcl tab 50 mg (Norpramin)........................ 27desipramine hcl tab 75 mg (Norpramin)........................ 27desipramine hcl tab 100 mg (Norpramin)...................... 28desipramine hcl tab 150 mg (Norpramin)...................... 28desloratadine tab 5 mg (Clarinex).................................. 22desmopressin acetate inj 4 mcg/ml (Ddavp).................12desmopressin acetate nasal soln 0.01% (refrigerated)(Ddavp)..............................................................................12

desmopressin acetate nasal spray soln 0.01%(Ddavp)..............................................................................12

desmopressin acetate nasal spray soln 0.01%(refrigerated).....................................................................12

desmopressin acetate tab 0.1 mg (Ddavp)....................12desmopressin acetate tab 0.2 mg (Ddavp)....................12desonide cream 0.05% (Desowen)................................. 49desonide lotion 0.05% (Desowen).................................. 49desonide oint 0.05% (Desowen)......................................49desoximetasone cream 0.25% (Topicort).......................49desoximetasone gel 0.05% (Topicort)............................ 49desoximetasone oint 0.25% (Topicort)...........................49dexamethasone elixir 0.5 mg/5ml..................................... 8dexamethasone tab 0.5 mg............................................... 8dexamethasone tab 0.75 mg............................................. 8dexamethasone tab 1.5 mg............................................... 8dexamethasone tab 4 mg.................................................. 8dexamethasone tab 6 mg.................................................. 8dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalinxr).......................................................................................31

dexmethylphenidate hcl cap sr 24 hr 10 mg (Focalinxr).......................................................................................31





dextroamphetamine sulfate cap sr 24hr 5 mg(Dexedrine)....................................................................... 31


2016




dextroamphetamine sulfate tab 5 mg.............................31dextroamphetamine sulfate tab 10 mg...........................32DIASTAT ACUDIAL – diazepam rectal gel delivery system10 mg.................................................................................38

DIASTAT ACUDIAL – diazepam rectal gel delivery system20 mg.................................................................................38

DIASTAT PEDIATRIC – diazepam rectal gel deliverysystem 2.5 mg...................................................................38

diazepam tab 2 mg (Valium)............................................27diazepam tab 5 mg (Valium)............................................27diazepam tab 10 mg (Valium)..........................................27DIBENZYLINE – phenoxybenzamine hcl cap 10 mg.........21diclofenac potassium tab 50 mg (Cataflam)..................35diclofenac sodium (actinic keratoses) gel 3%(Solaraze)..........................................................................50

diclofenac sodium gel 1% (Voltaren)..............................48diclofenac sodium ophth soln 0.1%...............................47diclofenac sodium tab delayed release 25 mg..............35diclofenac sodium tab delayed release 50 mg..............35diclofenac sodium tab delayed release 75 mg..............36diclofenac sodium tab sr 24hr 100 mg (Voltaren-xr).......................................................................................36

dicloxacillin sodium cap 250 mg...................................... 1dicloxacillin sodium cap 500 mg...................................... 1dicyclomine hcl cap 10 mg (Bentyl)...............................24dicyclomine hcl oral soln 10 mg/5ml............................. 24dicyclomine hcl tab 20 mg (Bentyl)................................24didanosine delayed release capsule 125 mg (Videxec)........................................................................................ 4

didanosine delayed release capsule 200 mg (Videxec)........................................................................................ 4



digoxin tab 125 mcg (0.125 mg) (Lanoxin).................... 21digoxin tab 250 mcg (0.25 mg) (Lanoxin)...................... 21diltiazem hcl cap sr 24hr 120 mg....................................17diltiazem hcl cap sr 24hr 180 mg....................................17diltiazem hcl cap sr 24hr 240 mg....................................17diltiazem hcl coated beads cap sr 24hr 120 mg(Cardizem cd)...................................................................17

diltiazem hcl coated beads cap sr 24hr 180 mg(Cardizem cd)...................................................................17




diltiazem hcl extended release beads cap sr 24hr 120mg (Tiazac).......................................................................17






diltiazem hcl tab 90 mg....................................................17diltiazem hcl tab 30 mg (Cardizem)................................17diltiazem hcl tab 60 mg (Cardizem)................................17diltiazem hcl tab 120 mg (Cardizem)..............................17diphenoxylate w/ atropine tab 2.5-0.025 mg(Lomotil)............................................................................24

dipyridamole tab 25 mg (Persantine)............................. 42dipyridamole tab 50 mg (Persantine)............................. 42dipyridamole tab 75 mg (Persantine)............................. 42disopyramide phosphate cap 100 mg (Norpace).......... 20disopyramide phosphate cap 150 mg (Norpace).......... 20disulfiram tab 250 mg (Antabuse).................................. 33disulfiram tab 500 mg (Antabuse).................................. 33divalproex sodium cap delayed release sprinkle 125mg (Depakote sprinkles)................................................ 38

divalproex sodium tab delayed release 125 mg(Depakote)........................................................................ 38



divalproex sodium tab sr 24 hr 250 mg (Depakoteer).......................................................................................38

divalproex sodium tab sr 24 hr 500 mg (Depakoteer).......................................................................................38

DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%).............9DIVIGEL – estradiol td gel 0.5 mg/0.5gm (0.1%).................9DIVIGEL – estradiol td gel 1 mg/gm (0.1%).........................9donepezil hydrochloride orally disintegrating tab 5 mg(Aricept odt)..................................................................... 33

donepezil hydrochloride orally disintegrating tab 10mg (Aricept odt).............................................................. 33

donepezil hydrochloride tab 5 mg (Aricept)..................33donepezil hydrochloride tab 10 mg (Aricept)................33DONNATAL – pb-hyoscy-atrop-scopol tab16.2-0.1037-0.0194-0.0065 mg........................................ 24

dorzolamide hcl ophth soln 2% (Trusopt)..................... 46dorzolamide hcl-timolol maleate ophth soln 22.3-6.8mg/ml (Cosopt)................................................................ 46

doxazosin mesylate tab 1 mg (Cardura)........................21doxazosin mesylate tab 2 mg (Cardura)........................21

2016



doxazosin mesylate tab 4 mg (Cardura)........................21doxazosin mesylate tab 8 mg (Cardura)........................21doxepin hcl cap 10 mg.....................................................28doxepin hcl cap 25 mg.....................................................28doxepin hcl cap 50 mg.....................................................28doxepin hcl cap 100 mg...................................................28doxepin hcl conc 10 mg/ml............................................. 28doxycycline 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

duloxetine hcl enteric coated pellets cap 20 mg(Cymbalta)........................................................................ 28



dutasteride cap 0.5 mg (Avodart)................................... 26E

econazole nitrate cream 1%............................................ 48ELIQUIS – apixaban tab 2.5 mg........................................ 42ELIQUIS – apixaban tab 5 mg........................................... 42ELLA – ulipristal acetate tab 30 mg...................................10ELOCTATE – antihemophilic factor (recomb) rfviiifc for inj250 unit..............................................................................42

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




EMEND – aprepitant capsule 40 mg..................................25EMEND – aprepitant capsule 80 mg..................................25EMEND – aprepitant capsule 125 mg................................25EMEND – aprepitant capsule therapy pack 80 & 125mg...................................................................................... 25

EMEND – aprepitant for oral susp 125 mg (125mg/5ml).............................................................................. 25

EMTRIVA – emtricitabine caps 200 mg............................... 4EMTRIVA – emtricitabine soln 10 mg/ml............................. 4enalapril maleate & hydrochlorothiazide tab 5-12.5mg...................................................................................... 13

enalapril maleate & hydrochlorothiazide tab 10-25 mg(Vaseretic).........................................................................13

enalapril maleate tab 2.5 mg (Vasotec)..........................13enalapril maleate tab 5 mg (Vasotec).............................13enalapril maleate tab 10 mg (Vasotec)...........................13enalapril maleate tab 20 mg (Vasotec)...........................13ENBREL – etanercept for subcutaneous inj 25 mg........... 36ENBREL – etanercept subcutaneous soln prefilled syringe25 mg/0.5ml.......................................................................36

ENBREL – etanercept subcutaneous soln prefilled syringe50 mg/ml............................................................................36

ENBREL SURECLICK – etanercept subcutaneoussolution auto-injector 50 mg/ml.........................................36

enoxaparin 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)................ 43enoxaparin sodium inj 120 mg/0.8ml (Lovenox)........... 43enoxaparin sodium inj 150 mg/ml (Lovenox)................ 43enoxaparin sodium inj 300 mg/3ml (Lovenox).............. 43entacapone tab 200 mg (Comtan)...................................39entecavir tab 0.5 mg (Baraclude)......................................4entecavir tab 1 mg (Baraclude).........................................4EPIPEN-JR 2-PAK – epinephrine solution auto-injector0.15 mg/0.3ml (1:2000).....................................................21

EPIPEN 2-PAK – epinephrine solution auto-injector 0.3mg/0.3ml (1:1000)............................................................. 21

eplerenone tab 25 mg (Inspra)........................................21eplerenone tab 50 mg (Inspra)........................................21EPZICOM – abacavir sulfate-lamivudine tab 600-300mg........................................................................................ 4

ergocalciferol cap 50000 unit (Drisdol)..........................40erythromycin gel 2% (Erygel)..........................................48erythromycin ophth oint 5 mg/gm..................................46erythromycin pads 2%..................................................... 48erythromycin soln 2%...................................................... 48erythromycin w/ delayed release particles cap 250mg........................................................................................ 2

escitalopram oxalate soln 5 mg/5ml (base equiv)(Lexapro)...........................................................................28

escitalopram oxalate tab 5 mg (base equiv)(Lexapro)...........................................................................28



2016



esomeprazole magnesium cap delayed release 20 mg(base eq) (Nexium)..........................................................24

esomeprazole magnesium cap delayed release 40 mg(base eq) (Nexium)..........................................................24

estazolam tab 1 mg.......................................................... 31estazolam tab 2 mg.......................................................... 31ESTRACE – estradiol vaginal cream 0.1 mg/gm...............26estradiol & norethindrone acetate tab 0.5-0.1 mg(Activella)............................................................................9

estradiol & norethindrone acetate tab 1-0.5 mg(Activella)............................................................................9

estradiol tab 0.5 mg (Estrace)...........................................9estradiol tab 1 mg (Estrace)..............................................9estradiol tab 2 mg (Estrace)..............................................9estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot).......................................................................................9

estradiol td patch twice weekly 0.0375 mg/24hr(Vivelle-dot).........................................................................9

estradiol td patch twice weekly 0.05 mg/24hr (Vivelle-dot).......................................................................................9



estradiol td patch weekly 0.025 mg/24hr (Climara).........9estradiol td patch weekly 0.05 mg/24hr (Climara)...........9estradiol td patch weekly 0.06 mg/24hr (Climara)...........9estradiol td patch weekly 0.075 mg/24hr (Climara).........9estradiol td patch weekly 0.1 mg/24hr (Climara).............9estradiol td patch weekly 0.0375 mg/24hr (37.5mcg/24hr) (Climara)...........................................................9

eszopiclone tab 1 mg (Lunesta)......................................31eszopiclone tab 2 mg (Lunesta)......................................31eszopiclone tab 3 mg (Lunesta)......................................31ethambutol hcl tab 100 mg (Myambutol)......................... 3ethambutol hcl tab 400 mg (Myambutol)......................... 3ethosuximide cap 250 mg (Zarontin)..............................38ethosuximide soln 250 mg/5ml (Zarontin)..................... 38etodolac cap 200 mg........................................................ 36etodolac cap 300 mg........................................................ 36etodolac tab 400 mg.........................................................36etodolac tab 500 mg.........................................................36etodolac tab sr 24hr 400 mg........................................... 36etodolac tab sr 24hr 500 mg........................................... 36etodolac tab sr 24hr 600 mg........................................... 36exemestane tab 25 mg (Aromasin)...................................7F

famciclovir tab 125 mg (Famvir)....................................... 4famciclovir tab 250 mg (Famvir)....................................... 4famciclovir tab 500 mg (Famvir)....................................... 4famotidine tab 20 mg (Pepcid)........................................24famotidine tab 40 mg (Pepcid)........................................24

FEIBA – antiinhibitor coagulant complex for inj................. 43felodipine tab sr 24hr 2.5 mg.......................................... 17felodipine tab sr 24hr 5 mg............................................. 17felodipine tab sr 24hr 10 mg........................................... 17fenofibrate micronized cap 67 mg (Lofibra).................. 18fenofibrate micronized cap 134 mg (Lofibra)................ 18fenofibrate micronized cap 200 mg (Lofibra)................ 18fenofibrate tab 54 mg (Lofibra)....................................... 18fenofibrate tab 160 mg (Lofibra)..................................... 19fenofibrate tab 48 mg (Tricor)......................................... 18fenofibrate tab 145 mg (Tricor)....................................... 19fentanyl citrate lozenge on a handle 200 mcg(Actiq)................................................................................34

fentanyl citrate lozenge on a handle 400 mcg(Actiq)................................................................................34





fentanyl td patch 72hr 12 mcg/hr (Duragesic)...............34fentanyl td patch 72hr 25 mcg/hr (Duragesic)...............34fentanyl td patch 72hr 50 mcg/hr (Duragesic)...............34fentanyl td patch 72hr 75 mcg/hr (Duragesic)...............34fentanyl td patch 72hr 100 mcg/hr (Duragesic).............34FINACEA – azelaic acid foam 15%................................... 48FINACEA – azelaic acid gel 15%.......................................48finasteride tab 5 mg (Proscar)........................................ 26FIRAZYR – icatibant acetate inj 30 mg/3ml (baseequivalent)......................................................................... 43

flecainide acetate tab 50 mg........................................... 20flecainide acetate tab 100 mg......................................... 20flecainide acetate tab 150 mg......................................... 20FLOVENT DISKUS – fluticasone propionate aer pow ba50 mcg/blister.................................................................... 22

FLOVENT DISKUS – fluticasone propionate aer pow ba100 mcg/blister.................................................................. 22

FLOVENT DISKUS – fluticasone propionate aer pow ba250 mcg/blister.................................................................. 22

FLOVENT HFA – fluticasone propionate hfa inhal aer 110mcg/act (125/valve)...........................................................23

FLOVENT HFA – fluticasone propionate hfa inhal aer 220mcg/act (250/valve)...........................................................23

FLOVENT HFA – fluticasone propionate hfa inhal aero 44mcg/act (50/valve)............................................................. 23

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)....................................3

2016



fluconazole tab 200 mg (Diflucan)....................................3flucytosine cap 250 mg (Ancobon)...................................3flucytosine cap 500 mg (Ancobon)...................................3fludrocortisone acetate tab 0.1 mg...................................8flunisolide nasal soln 25 mcg/act (0.025%)................... 22fluocinolone acetonide cream 0.01%............................. 49fluocinolone acetonide cream 0.025% (Synalar)...........49fluocinolone acetonide oil 0.01% (body oil) (Derma-smoothe/fs bod).............................................................. 49

fluocinolone acetonide oil 0.01% (scalp oil) (Derma-smoothe/fs sca)............................................................... 49

fluocinolone acetonide oint 0.025% (Synalar)...............49fluocinolone acetonide soln 0.01% (Synalar)................49fluocinonide cream 0.05%............................................... 49fluocinonide emulsified base cream 0.05%...................49fluocinonide gel 0.05%.....................................................49fluocinonide oint 0.05%....................................................49fluocinonide soln 0.05%...................................................49fluorometholone ophth susp 0.1% (Fml liquifilm)........ 46fluorouracil cream 5% (Efudex)...................................... 50fluorouracil soln 2%......................................................... 50fluorouracil soln 5%......................................................... 50fluoxetine hcl cap 10 mg (Prozac)..................................28fluoxetine hcl cap 20 mg (Prozac)..................................28fluoxetine hcl cap 40 mg (Prozac)..................................28fluoxetine hcl solution 20 mg/5ml.................................. 28fluoxetine hcl tab 10 mg.................................................. 28fluoxetine hcl tab 20 mg.................................................. 28fluphenazine decanoate inj 25 mg/ml.............................29FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5mg/5ml............................................................................... 29

FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ml........................................................................................29

fluphenazine hcl tab 1 mg............................................... 29fluphenazine hcl tab 2.5 mg............................................ 29fluphenazine hcl tab 5 mg............................................... 29fluphenazine hcl tab 10 mg............................................. 29flurbiprofen sodium ophth soln 0.03% (Ocufen)...........47flurbiprofen tab 50 mg......................................................36flurbiprofen tab 100 mg................................................... 36flutamide cap 125 mg.........................................................7fluticasone propionate cream 0.05% (Cutivate)............ 49fluticasone propionate nasal susp 50 mcg/act(Flonase)........................................................................... 22

fluticasone propionate oint 0.005% (Cutivate).............. 49fluvoxamine maleate tab 25 mg......................................28fluvoxamine maleate tab 50 mg......................................28fluvoxamine maleate tab 100 mg....................................28folic acid tab 1 mg............................................................43FOLLISTIM AQ – follitropin beta inj 75 unit/0.5ml..............10FOLLISTIM AQ – follitropin beta inj 300 unit/0.36ml..........10FOLLISTIM AQ – follitropin beta inj 600 unit/0.72ml..........10FOLLISTIM AQ – follitropin beta inj 900 unit/1.08ml..........10

fosinopril sodium & hydrochlorothiazide tab 10-12.5mg...................................................................................... 13

fosinopril sodium & hydrochlorothiazide tab 20-12.5mg...................................................................................... 13

fosinopril sodium tab 10 mg........................................... 13fosinopril sodium tab 20 mg........................................... 13fosinopril sodium tab 40 mg........................................... 13furosemide oral soln 10 mg/ml....................................... 19furosemide tab 20 mg (Lasix)......................................... 19furosemide tab 40 mg (Lasix)......................................... 19furosemide tab 80 mg (Lasix)......................................... 19FUZEON – enfuvirtide for inj 90 mg.....................................4

Ggabapentin cap 100 mg (Neurontin)...............................38gabapentin cap 300 mg (Neurontin)...............................38gabapentin cap 400 mg (Neurontin)...............................38gabapentin oral soln 250 mg/5ml (Neurontin)...............38gabapentin tab 600 mg (Neurontin)................................38gabapentin tab 800 mg (Neurontin)................................38galantamine hydrobromide cap sr 24hr 8 mg(Razadyne er)...................................................................33

galantamine hydrobromide cap sr 24hr 16 mg(Razadyne er)...................................................................33

galantamine hydrobromide cap sr 24hr 24 mg(Razadyne er)...................................................................33

galantamine hydrobromide tab 4 mg (Razadyne).........33galantamine hydrobromide tab 8 mg (Razadyne).........33galantamine hydrobromide tab 12 mg (Razadyne).......33gemfibrozil tab 600 mg (Lopid).......................................19gentamicin sulfate ophth oint 0.3%................................46gentamicin sulfate ophth soln 0.3% (Garamycin).........46glatiramer acetate soln prefilled syringe 20 mg/ml(Copaxone)....................................................................... 32

GLEEVEC – imatinib mesylate tab 100 mg (baseequivalent)............................................................................7

GLEEVEC – imatinib mesylate tab 400 mg (baseequivalent)............................................................................7

glimepiride tab 1 mg (Amaryl).........................................10glimepiride tab 2 mg (Amaryl).........................................10glimepiride tab 4 mg (Amaryl).........................................10glipizide-metformin hcl tab 2.5-250 mg..........................10glipizide-metformin hcl tab 2.5-500 mg..........................10glipizide-metformin hcl tab 5-500 mg.............................10glipizide tab 5 mg (Glucotrol)..........................................10glipizide tab 10 mg (Glucotrol)........................................10glipizide tab sr 24hr 2.5 mg (Glucotrol xl)..................... 10glipizide tab sr 24hr 5 mg (Glucotrol xl)........................ 10glipizide tab sr 24hr 10 mg (Glucotrol xl)...................... 10GLUCAGON EMERGENCY KIT – glucagon (rdna) for injkit 1 mg..............................................................................10

glyburide-metformin tab 1.25-250 mg(Glucovance).................................................................... 10

2016



glyburide-metformin tab 2.5-500 mg (Glucovance)...... 10glyburide-metformin tab 5-500 mg (Glucovance)......... 10glyburide micronized tab 1.5 mg (Glynase)...................10glyburide micronized tab 3 mg (Glynase)......................10glyburide micronized tab 6 mg (Glynase)......................10glyburide tab 1.25 mg.......................................................10glyburide tab 2.5 mg.........................................................10glyburide tab 5 mg............................................................10glycopyrrolate tab 1 mg (Robinul)..................................24glycopyrrolate tab 2 mg (Robinul forte).........................24granisetron hcl tab 1 mg................................................. 25griseofulvin microsize susp 125 mg/5ml......................... 3griseofulvin microsize tab 500 mg (Grifulvin v)..............3guanfacine hcl tab 1 mg (Tenex).................................... 21guanfacine hcl tab 2 mg (Tenex).................................... 21guanfacine hcl tab sr 24hr 1 mg (base equiv)(Intuniv).............................................................................32

guanfacine hcl tab sr 24hr 2 mg (base equiv)(Intuniv).............................................................................32

guanfacine hcl tab sr 24hr 3 mg (base equiv)(Intuniv).............................................................................32

guanfacine hcl tab sr 24hr 4 mg (base equiv)(Intuniv).............................................................................32H

halobetasol propionate cream 0.05% (Ultravate)..........49halobetasol propionate oint 0.05% (Ultravate)..............50haloperidol decanoate im soln 50 mg/ml (Haldoldecanoate 50)...................................................................29

haloperidol decanoate im soln 100 mg/ml (Haldoldecanoate 100).................................................................29

haloperidol lactate oral conc 2 mg/ml............................29haloperidol tab 0.5 mg..................................................... 29haloperidol tab 1 mg........................................................ 29haloperidol tab 2 mg........................................................ 29haloperidol tab 5 mg........................................................ 29haloperidol tab 10 mg...................................................... 29haloperidol tab 20 mg...................................................... 29HARVONI – ledipasvir-sofosbuvir tab 90-400 mg................4HELIXATE FS – antihemophilic factor (recombinant) for injkit 250 unit.........................................................................43

HELIXATE FS – antihemophilic factor (recombinant) for injkit 500 unit.........................................................................43

HELIXATE FS – antihemophilic factor (recombinant) for injkit 1000 unit.......................................................................43



HEMOFIL M – antihemophilic factor (human) for inj 250unit......................................................................................43




homatropine hbr ophth soln 5% (Isoptohomatropine)....................................................................47

HUMATE-P – antihemophilic factor/vwf (human) for inj250-600 unit.......................................................................43

HUMATE-P – antihemophilic factor/vwf (human) for inj500-1200 unit.....................................................................43

HUMATE-P – antihemophilic factor/vwf (human) for inj1000-2400 unit...................................................................43

HUMIRA – adalimumab prefilled syringe kit 10mg/0.2ml............................................................................ 36



HUMIRA PEDIATRIC CROHNS D – adalimumab prefilledsyringe kit 40 mg/0.8ml.....................................................36

HUMIRA PEN – adalimumab pen-injector kit 40mg/0.8ml............................................................................ 36

HUMIRA PEN-CROHNS DISEASE – adalimumab pen-injector kit 40 mg/0.8ml.....................................................36

HUMIRA PEN-PSORIASIS STAR – adalimumab pen-injector kit 40 mg/0.8ml.....................................................36

hydralazine hcl tab 10 mg............................................... 21hydralazine hcl tab 25 mg............................................... 21hydralazine hcl tab 50 mg............................................... 21hydralazine hcl tab 100 mg............................................. 21hydrochlorothiazide cap 12.5 mg (Microzide)............... 19hydrochlorothiazide tab 12.5 mg.................................... 19hydrochlorothiazide tab 25 mg....................................... 20hydrochlorothiazide tab 50 mg....................................... 20hydrocodone-acetaminophen soln 7.5-325 mg/15ml(Hycet)............................................................................... 34

hydrocodone-acetaminophen tab 7.5-325 mg(Norco).............................................................................. 34

hydrocodone-acetaminophen tab 5-325 mg(Norco).............................................................................. 34

hydrocodone-acetaminophen tab 10-325 mg(Norco).............................................................................. 34

hydrocodone-ibuprofen tab 10-200 mg (Ibudone)........ 34hydrocodone-ibuprofen tab 5-200 mg (Reprexain).......34hydrocodone-ibuprofen tab 7.5-200 mg(Vicoprofen)......................................................................34

hydrocortisone acetate suppos 25 mg (Anusol-hc)..... 47hydrocortisone acetate suppos 30 mg (Proctocort).....47hydrocortisone cream 2.5%.............................................50hydrocortisone enema 100 mg/60ml (Cortenema)........47hydrocortisone lotion 2.5%............................................. 50hydrocortisone oint 2.5%.................................................50hydrocortisone rectal cream 2.5% (Anusol-hc)............ 47

2016



hydrocortisone tab 5 mg (Cortef)..................................... 8hydrocortisone tab 10 mg (Cortef)................................... 8hydrocortisone tab 20 mg (Cortef)................................... 8hydrocortisone valerate cream 0.2%..............................50hydrocortisone valerate oint 0.2% (Westcort)...............50hydrocortisone w/ acetic acid otic soln 1-2% (Vosolhc)...................................................................................... 47

hydromorphone hcl liqd 1 mg/ml (Dilaudid)..................34hydromorphone hcl tab 2 mg (Dilaudid)........................34hydromorphone hcl tab 4 mg (Dilaudid)........................34hydromorphone hcl tab 8 mg (Dilaudid)........................34hydroxychloroquine sulfate tab 200 mg (Plaquenil).......6hydroxyurea cap 500 mg (Hydrea)................................... 7hydroxyzine hcl syrup 10 mg/5ml...................................27hydroxyzine hcl tab 10 mg.............................................. 27hydroxyzine hcl tab 25 mg.............................................. 27hydroxyzine hcl tab 50 mg.............................................. 27hydroxyzine pamoate cap 25 mg (Vistaril).................... 27hydroxyzine pamoate cap 50 mg (Vistaril).................... 27hyoscyamine sulfate elixir 0.125 mg/5ml.......................24hyoscyamine sulfate soln 0.125 mg/ml..........................24hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)...... 24hyoscyamine sulfate tab 0.125 mg (Levsin)..................24hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl)..........24hyoscyamine sulfate tab sr 12hr 0.375 mg (Levbid).....24I

ibandronate sodium tab 150 mg (base equivalent)(Boniva).............................................................................12

ibuprofen susp 100 mg/5ml.............................................36ibuprofen tab 400 mg....................................................... 36ibuprofen tab 600 mg....................................................... 36ibuprofen tab 800 mg....................................................... 36IDELVION – coagulation factor ix (recomb) (rix-fp) for inj250 unit..............................................................................43

IDELVION – coagulation factor ix (recomb) (rix-fp) for inj500 unit..............................................................................43

IDELVION – coagulation factor ix (recomb) (rix-fp) for inj1000 unit............................................................................43

IDELVION – coagulation factor ix (recomb) (rix-fp) for inj2000 unit............................................................................43

imatinib mesylate tab 100 mg (base equivalent)(Gleevec).............................................................................7

imatinib mesylate tab 400 mg (base equivalent)(Gleevec).............................................................................7

imipramine hcl tab 10 mg (Tofranil)............................... 28imipramine hcl tab 25 mg (Tofranil)............................... 28imipramine hcl tab 50 mg (Tofranil)............................... 28imiquimod cream 5% (Aldara).........................................50IMITREX – sumatriptan nasal spray 5 mg/act................... 37IMITREX – sumatriptan nasal spray 20 mg/act................. 37IMPAVIDO – miltefosine cap 50 mg.....................................6INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml).........12

INCRUSE ELLIPTA – umeclidinium br aero powd breathact 62.5 mcg/inh (base eq)...............................................23

indapamide tab 1.25 mg...................................................20indapamide tab 2.5 mg.....................................................20indomethacin cap 25 mg................................................. 36indomethacin cap 50 mg................................................. 36INSULIN PEN NEEDLES – VARIOUS...............................50INSULIN SYRINGES – VARIOUS......................................50INTELENCE – 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..................... 4ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml(Duoneb)........................................................................... 23

ipratropium bromide inhal soln 0.02%...........................23ipratropium bromide nasal soln 0.03% (21 mcg/spray)(Atrovent)..........................................................................22

ipratropium bromide nasal soln 0.06% (42 mcg/spray)(Atrovent)..........................................................................22

irbesartan-hydrochlorothiazide tab 150-12.5 mg(Avalide)............................................................................ 15

irbesartan-hydrochlorothiazide tab 300-12.5 mg(Avalide)............................................................................ 15

irbesartan tab 75 mg (Avapro)........................................ 14irbesartan tab 150 mg (Avapro)...................................... 15irbesartan tab 300 mg (Avapro)...................................... 15ISENTRESS – raltegravir potassium chew tab 25 mg(base equiv).........................................................................5

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

isometheptene-dichloral-acetaminophen cap65-100-325 mg..................................................................37

isoniazid tab 100 mg.......................................................... 3isoniazid tab 300 mg.......................................................... 3isosorbide dinitrate tab 10 mg........................................18isosorbide dinitrate tab 20 mg........................................18isosorbide dinitrate tab 30 mg........................................18isosorbide dinitrate tab 5 mg (Isordil titradose)........... 18isosorbide mononitrate tab 10 mg................................. 18isosorbide mononitrate tab 20 mg................................. 18isosorbide mononitrate tab sr 24hr 30 mg (Imdur).......18isosorbide mononitrate tab sr 24hr 60 mg (Imdur).......18isosorbide mononitrate tab sr 24hr 120 mg (Imdur).....18isotretinoin cap 10 mg..................................................... 48isotretinoin cap 20 mg..................................................... 48isotretinoin cap 40 mg..................................................... 48isotretinoin cap 30 mg (Claravis)....................................48itraconazole cap 100 mg (Sporanox)................................3

2016



ivermectin 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

JJARDIANCE – empagliflozin tab 10 mg.............................10JARDIANCE – empagliflozin tab 25 mg.............................10

KKALETRA – 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............................... 24KALYDECO – ivacaftor packet 75 mg............................... 24KALYDECO – ivacaftor tab 150 mg................................... 23ketoconazole cream 2%................................................... 48ketoconazole shampoo 2% (Nizoral)..............................48ketoprofen cap 50 mg...................................................... 36ketoprofen cap 75 mg...................................................... 36ketorolac tromethamine ophth soln 0.5% (Acular)....... 47ketorolac tromethamine ophth soln 0.4% (Acularls)....................................................................................... 47

KOATE-DVI – antihemophilic factor (human) for inj 250unit......................................................................................43



KOGENATE FS – antihemophilic factor (recombinant) forinj kit 250 unit....................................................................43

KOGENATE FS – antihemophilic factor (recombinant) forinj kit 500 unit....................................................................43

KOGENATE FS – antihemophilic factor (recombinant) forinj kit 1000 unit..................................................................43



KOGENATE FS BIO-SET – antihemophilic factor(recombinant) for inj kit 250 unit.......................................43

KOGENATE FS BIO-SET – antihemophilic factor(recombinant) for inj kit 500 unit.......................................43

KOGENATE FS BIO-SET – antihemophilic factor(recombinant) for inj kit 1000 unit.....................................44



KOVALTRY – antihemophilic factor (recombinant) for inj250 unit..............................................................................44

KOVALTRY – antihemophilic factor (recombinant) for inj500 unit..............................................................................44

KOVALTRY – antihemophilic factor (recombinant) for inj1000 unit............................................................................44



Llabetalol hcl tab 100 mg (Trandate)................................15labetalol hcl tab 200 mg (Trandate)................................15labetalol hcl tab 300 mg (Trandate)................................15lactulose (encephalopathy) solution 10 gm/15ml......... 25lactulose solution 10 gm/15ml........................................ 24lamivudine 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)..................................................................... 38

lamotrigine tab chewable dispersible 25 mg (Lamictalchewable di)..................................................................... 38

lamotrigine tab 25 mg (Lamictal)....................................38lamotrigine tab 100 mg (Lamictal)..................................38lamotrigine tab 150 mg (Lamictal)..................................38lamotrigine tab 200 mg (Lamictal)..................................38LANCETS – VARIOUS....................................................... 50lansoprazole cap delayed release 15 mg(Prevacid)..........................................................................24

lansoprazole cap delayed release 30 mg(Prevacid)..........................................................................24

LANTUS – insulin glargine inj 100 unit/ml......................... 11LANTUS SOLOSTAR – insulin glargine soln pen-injector100 unit/ml......................................................................... 11

latanoprost ophth soln 0.005% (Xalatan).......................46leflunomide tab 10 mg (Arava)........................................36leflunomide tab 20 mg (Arava)........................................36letrozole tab 2.5 mg (Femara)........................................... 7LEUCOVORIN CALCIUM – leucovorin calcium tab 10mg........................................................................................ 7

LEUCOVORIN CALCIUM – leucovorin calcium tab 15mg........................................................................................ 7

leucovorin calcium tab 5 mg.............................................7leucovorin calcium tab 25 mg...........................................7LEUKERAN – chlorambucil tab 2 mg.................................. 7levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (baseequiv).................................................................................23

levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)(Xopenex)..........................................................................23

2016





LEVEMIR FLEXTOUCH – insulin detemir soln pen-injector100 unit/ml......................................................................... 11

LEVEMIR – insulin detemir inj 100 unit/ml.........................11levetiracetam oral soln 100 mg/ml (Keppra)..................38levetiracetam tab 250 mg (Keppra).................................38levetiracetam tab 500 mg (Keppra).................................38levetiracetam tab 750 mg (Keppra).................................38levetiracetam tab 1000 mg (Keppra)...............................38levetiracetam tab sr 24hr 500 mg (Keppra xr)...............38levetiracetam tab sr 24hr 750 mg (Keppra xr)...............38levobunolol hcl ophth soln 0.5% (Betagan).................. 46levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... 12levocarnitine tab 330 mg (Carnitor)................................12levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml) (Xyzal).........................................................................22

levocetirizine dihydrochloride tab 5 mg (Xyzal)............22levofloxacin oral soln 25 mg/ml (Levaquin).................... 3levofloxacin tab 250 mg (Levaquin)................................. 3levofloxacin tab 500 mg (Levaquin)................................. 3levofloxacin tab 750 mg (Levaquin)................................. 3levonorgestrel tab 1.5 mg (Plan b one-step)................. 10levothyroxine sodium tab 25 mcg (Synthroid)..............11levothyroxine sodium tab 50 mcg (Synthroid)..............11levothyroxine sodium tab 75 mcg (Synthroid)..............11levothyroxine sodium tab 88 mcg (Synthroid)..............11levothyroxine sodium tab 100 mcg (Synthroid)............11levothyroxine sodium tab 112 mcg (Synthroid)............ 11levothyroxine sodium tab 125 mcg (Synthroid)............11levothyroxine sodium tab 137 mcg (Synthroid)............12levothyroxine sodium tab 150 mcg (Synthroid)............12levothyroxine sodium tab 175 mcg (Synthroid)............12levothyroxine sodium tab 200 mcg (Synthroid)............12levothyroxine sodium tab 300 mcg (Synthroid)............12LEXIVA – fosamprenavir calcium susp 50 mg/ml (baseequiv)....................................................................................5

LEXIVA – fosamprenavir calcium tab 700 mg (baseequiv)....................................................................................5

lidocaine hcl gel 2%......................................................... 50lidocaine hcl local inj 1% (Xylocaine)............................ 37lidocaine hcl local preservative free (pf) inj 1%(Xylocaine-mpf)................................................................37

lidocaine hcl soln 4% (Xylocaine)...................................50lidocaine hcl viscous soln 2%........................................ 47lidocaine oint 5%...............................................................50lidocaine patch 5% (Lidoderm)....................................... 50lindane shampoo 1%........................................................ 50linezolid for susp 100 mg/5ml (Zyvox)............................. 6linezolid tab 600 mg (Zyvox)............................................. 6liothyronine sodium tab 5 mcg (Cytomel)..................... 12

liothyronine sodium tab 25 mcg (Cytomel)................... 12liothyronine sodium tab 50 mcg (Cytomel)................... 12lisinopril & hydrochlorothiazide tab 10-12.5 mg(Zestoretic)....................................................................... 13

lisinopril & hydrochlorothiazide tab 20-12.5 mg(Zestoretic)....................................................................... 13

lisinopril & hydrochlorothiazide tab 20-25 mg(Zestoretic)....................................................................... 14

lisinopril tab 5 mg (Prinivil)............................................. 14lisinopril tab 10 mg (Prinivil)........................................... 14lisinopril tab 20 mg (Prinivil)........................................... 14lisinopril tab 2.5 mg (Zestril)........................................... 14lisinopril tab 30 mg (Zestril)............................................ 14lisinopril tab 40 mg (Zestril)............................................ 14lithium carbonate cap 300 mg.........................................29lithium carbonate cap 150 mg (Lithium carbonate)......29lithium carbonate cap 600 mg (Lithium carbonate)......29lithium carbonate tab cr 450 mg.....................................29lithium carbonate tab cr 300 mg (Lithobid)................... 29lithium carbonate tab 300 mg......................................... 29loperamide hcl cap 2 mg................................................. 24lorazepam conc 2 mg/ml (Lorazepam intensol)............ 27lorazepam tab 0.5 mg (Ativan)........................................ 27lorazepam tab 1 mg (Ativan)........................................... 27lorazepam tab 2 mg (Ativan)........................................... 27losartan potassium & hydrochlorothiazide tab 50-12.5mg (Hyzaar)...................................................................... 15

losartan potassium & hydrochlorothiazide tab 100-12.5mg (Hyzaar)...................................................................... 15

losartan potassium & hydrochlorothiazide tab 100-25mg (Hyzaar)...................................................................... 15

losartan potassium tab 25 mg (Cozaar).........................15losartan potassium tab 50 mg (Cozaar).........................15losartan potassium tab 100 mg (Cozaar).......................15lovastatin tab 10 mg.........................................................19lovastatin tab 20 mg (Mevacor).......................................19lovastatin tab 40 mg (Mevacor).......................................19loxapine succinate cap 10 mg........................................ 29loxapine succinate cap 25 mg........................................ 29loxapine succinate cap 50 mg........................................ 29loxapine succinate cap 5 mg (Loxitane)........................29M

malathion lotion 0.5% (Ovide).........................................50meclizine hcl tab 12.5 mg................................................ 25meclizine hcl tab 25 mg................................................... 25medroxyprogesterone acetate tab 2.5 mg (Provera)...... 9medroxyprogesterone acetate tab 5 mg (Provera).........9medroxyprogesterone acetate tab 10 mg (Provera).......9mefloquine hcl tab 250 mg................................................ 6megestrol acetate susp 40 mg/ml (Megace oral)............ 7megestrol acetate tab 20 mg.............................................7megestrol acetate tab 40 mg.............................................7

2016



MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg(base equivalent).................................................................7

MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (baseequivalent)............................................................................7

meloxicam tab 7.5 mg (Mobic)........................................36meloxicam tab 15 mg (Mobic).........................................36memantine hcl oral solution 2 mg/ml (Namenda)......... 33memantine hcl tab 5 mg (28) & 10 mg (21) titration pak(Namenda titration pa)....................................................33

memantine hcl tab 5 mg (Namenda).............................. 33memantine hcl tab 10 mg (Namenda)............................ 33MEPHYTON – phytonadione tab 5 mg.............................. 40mercaptopurine tab 50 mg (Purinethol)...........................7mesalamine enema 4 gm................................................. 25metaxalone tab 800 mg (Skelaxin)..................................40metformin hcl tab 500 mg (Glucophage)....................... 11metformin hcl tab 850 mg (Glucophage)....................... 11metformin hcl tab 1000 mg (Glucophage)..................... 11metformin hcl tab sr 24hr 500 mg (Glucophage xr)......10metformin hcl tab sr 24hr 750 mg (Glucophage xr)......10methadone hcl conc 10 mg/ml (Methadose)................. 34methadone hcl soln 5 mg/5ml (Methadone hcl)............34methadone hcl soln 10 mg/5ml (Methadone hcl).......... 34methadone hcl tab for oral susp 40 mg.........................34methadone hcl tab 10 mg (Dolophine)...........................34methadone hcl tab 5 mg (Dolophine hcl).......................34methazolamide tab 25 mg (Neptazane)..........................20methazolamide tab 50 mg (Neptazane)..........................20methimazole tab 5 mg (Tapazole)................................... 12methimazole tab 10 mg (Tapazole)................................. 12methocarbamol tab 750 mg (Robaxin-750)....................40methocarbamol tab 500 mg (Robaxin)...........................40methotrexate sodium tab 2.5 mg (base equiv)................7methscopolamine bromide tab 2.5 mg (Pamine).......... 24methscopolamine bromide tab 5 mg (Pamineforte).................................................................................. 24

methyldopa tab 250 mg................................................... 21methyldopa tab 500 mg................................................... 21methylergonovine maleate tab 0.2 mg...........................12methylphenidate hcl tab cr 10 mg..................................32methylphenidate hcl tab cr 20 mg (Ritalin sr)............... 32methylphenidate hcl tab 5 mg (Ritalin).......................... 32methylphenidate hcl tab 10 mg (Ritalin)........................ 32methylphenidate hcl tab 20 mg (Ritalin)........................ 32methylprednisolone tab 4 mg (Medrol)............................8methylprednisolone tab 8 mg (Medrol)............................8methylprednisolone tab 16 mg (Medrol)..........................8methylprednisolone tab 32 mg (Medrol)..........................8methylprednisolone tab therapy pack 4 mg (21)(Medrol dosepak)...............................................................8

metoclopramide hcl soln 5 mg/5ml (10 mg/10ml).........25metoclopramide hcl tab 5 mg (Reglan)..........................25metoclopramide hcl tab 10 mg (Reglan)........................25

metolazone tab 10 mg......................................................20metolazone tab 2.5 mg (Zaroxolyn)................................20metolazone tab 5 mg (Zaroxolyn)...................................20metoprolol & hydrochlorothiazide tab 100-50 mg........ 16metoprolol & hydrochlorothiazide tab 50-25 mg(Lopressor hct)................................................................ 16

metoprolol & hydrochlorothiazide tab 100-25 mg(Lopressor hct)................................................................ 16

metoprolol succinate tab sr 24hr 25 mg (tartrate equiv)(Toprol xl)......................................................................... 16

metoprolol succinate tab sr 24hr 50 mg (tartrate equiv)(Toprol xl)......................................................................... 16

metoprolol succinate tab sr 24hr 100 mg (tartrateequiv) (Toprol xl)............................................................. 16

metoprolol succinate tab sr 24hr 200 mg (tartrateequiv) (Toprol xl)............................................................. 16

metoprolol tartrate tab 25 mg......................................... 16metoprolol tartrate tab 50 mg (Lopressor).................... 16metoprolol tartrate tab 100 mg (Lopressor).................. 16metronidazole cream 0.75% (Metrocream).................... 48metronidazole gel 0.75%..................................................48metronidazole gel 1% (Metrogel).................................... 48metronidazole lotion 0.75% (Metrolotion)......................48metronidazole tab 250 mg (Flagyl)................................... 6metronidazole tab 500 mg (Flagyl)................................... 6metronidazole vaginal gel 0.75% (Metrogel-vaginal)..............................................................................26

mexiletine hcl cap 150 mg...............................................20mexiletine hcl cap 200 mg...............................................20mexiletine hcl cap 250 mg...............................................20midodrine hcl tab 2.5 mg.................................................21midodrine hcl tab 5 mg....................................................21midodrine hcl tab 10 mg..................................................21minocycline 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.........................................................21minoxidil tab 10 mg..........................................................21MIRENA – levonorgestrel releasing iud 20 mcg/day (52mg total).............................................................................10

mirtazapine tab 7.5 mg.....................................................28mirtazapine tab 15 mg (Remeron).................................. 28mirtazapine tab 30 mg (Remeron).................................. 28mirtazapine tab 45 mg (Remeron).................................. 28misoprostol tab 100 mcg (Cytotec)................................ 24misoprostol tab 200 mcg (Cytotec)................................ 24modafinil tab 100 mg (Provigil).......................................32modafinil tab 200 mg (Provigil).......................................32moexipril hcl tab 7.5 mg (Univasc).................................14moexipril hcl tab 15 mg (Univasc)..................................14

2016



moexipril-hydrochlorothiazide tab 7.5-12.5 mg.............14moexipril-hydrochlorothiazide tab 15-25 mg.................14moexipril-hydrochlorothiazide tab 15-12.5 mg(Uniretic)........................................................................... 14

mometasone furoate cream 0.1% (Elocon)................... 50mometasone furoate nasal susp 50 mcg/act(Nasonex)..........................................................................22

mometasone furoate oint 0.1% (Elocon)........................50mometasone furoate solution 0.1% (lotion)(Elocon).............................................................................50

MONOCLATE-P – antihemophilic factor (human) for inj kit250 unit..............................................................................44

MONOCLATE-P – antihemophilic factor (human) for inj kit1000 unit............................................................................44

MONOCLATE-P – antihemophilic factor (human) for inj kit1500 unit............................................................................44

MONONINE – coagulation factor ix for inj 500 unit........... 44MONONINE – coagulation factor ix for inj 1000 unit..........44montelukast sodium chew tab 4 mg (base equiv)(Singulair)......................................................................... 23

montelukast sodium chew tab 5 mg (base equiv)(Singulair)......................................................................... 23

montelukast sodium oral granules packet 4 mg (baseequiv) (Singulair)............................................................. 23

montelukast sodium tab 10 mg (base equiv)(Singulair)......................................................................... 23

MORPHINE SULFATE – morphine sulfate suppos 5mg...................................................................................... 34




MORPHINE SULFATE – morphine sulfate tab 15 mg....... 34MORPHINE SULFATE – morphine sulfate tab 30 mg....... 34morphine sulfate oral soln 10 mg/5ml........................... 35morphine sulfate oral soln 20 mg/5ml........................... 35morphine sulfate oral soln 100 mg/5ml (20 mg/ml)...... 35morphine sulfate tab cr 15 mg (Ms contin)................... 35morphine sulfate tab cr 30 mg (Ms contin)................... 35morphine sulfate tab cr 60 mg (Ms contin)................... 35morphine sulfate tab cr 100 mg (Ms contin)................. 35morphine sulfate tab cr 200 mg (Ms contin)................. 35mupirocin calcium cream 2% (Bactroban).................... 48mupirocin oint 2% (Bactroban).......................................49mycophenolate mofetil cap 250 mg (Cellcept)..............51mycophenolate mofetil for oral susp 200 mg/ml(Cellcept)...........................................................................51

mycophenolate mofetil tab 500 mg (Cellcept)...............51mycophenolate sodium tab dr 180 mg (mycophenolicacid equiv) (Myfortic)......................................................51

mycophenolate sodium tab dr 360 mg (mycophenolicacid equiv) (Myfortic)......................................................51

MYLERAN – busulfan tab 2 mg...........................................7

Nnabumetone tab 500 mg.................................................. 36nabumetone tab 750 mg.................................................. 36nadolol tab 20 mg (Corgard)........................................... 16nadolol tab 40 mg (Corgard)........................................... 16nadolol tab 80 mg (Corgard)........................................... 16naloxone hcl inj 0.4 mg/ml.............................................. 51naltrexone hcl tab 50 mg (Revia)....................................51naproxen sodium tab 275 mg (Anaprox)....................... 36naproxen sodium tab 550 mg (Anaprox ds)..................36naproxen susp 125 mg/5ml (Naprosyn).........................36naproxen tab ec 375 mg (Ec-naprosyn).........................36naproxen tab ec 500 mg (Ec-naprosyn).........................36naproxen tab 250 mg (Naprosyn)................................... 36naproxen tab 375 mg (Naprosyn)................................... 36naproxen tab 500 mg (Naprosyn)................................... 36naratriptan hcl tab 1 mg (base equiv) (Amerge)........... 37naratriptan hcl tab 2.5 mg (base equiv) (Amerge)........ 37NARCAN – naloxone hcl nasal spray 4 mg/0.1ml............. 51NATACYN – natamycin ophth susp 5%............................. 46nateglinide tab 60 mg (Starlix)........................................11nateglinide tab 120 mg (Starlix)......................................11neomycin-bacitrac zn-polymyx5(3.5)mg-400unt-10000unt op oin..................................46

neomycin-polymy-gramicid op sol1.75-10000-0.025mg-unt-mg/ml (Neosporin)................46

neomycin-polymyxin-dexamethasone ophth oint 0.1%(Maxitrol)...........................................................................46

neomycin-polymyxin-dexamethasone ophth susp0.1% (Maxitrol)................................................................. 46

neomycin-polymyxin-hc otic soln 1% (Cortisporin)..... 47neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000unit/ml-1%.........................................................................47

neomycin sulfate tab 500 mg............................................3NEUPOGEN – filgrastim inj 300 mcg/ml............................44NEUPOGEN – filgrastim inj 480 mcg/1.6ml (300 mcg/ml)...................................................................................... 44

NEUPOGEN – filgrastim soln prefilled syringe 300mcg/0.5ml...........................................................................44

NEUPOGEN – filgrastim soln prefilled syringe 480mcg/0.8ml (600 mcg/ml)................................................... 44

nevirapine tab 200 mg (Viramune)....................................5nevirapine tab sr 24hr 100 mg (Viramune xr)..................5nevirapine tab sr 24hr 400 mg (Viramune xr)..................5NEXAVAR – sorafenib tosylate tab 200 mg (baseequivalent)............................................................................7

niacin tab cr 500 mg (antihyperlipidemic)(Niaspan)...........................................................................19

2016





NICOTROL INHALER – nicotine inhaler system 10 mg (4mg delivered).....................................................................33

NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/spray)................................................................................. 33

nifedipine tab sr 24hr 30 mg (Adalat cc)........................17nifedipine tab sr 24hr 60 mg (Adalat cc)........................17nifedipine tab sr 24hr 90 mg (Adalat cc)........................17nifedipine tab sr 24hr osmotic release 30 mg(Procardia xl)....................................................................17

nifedipine tab sr 24hr osmotic release 60 mg(Procardia xl)....................................................................17

nifedipine tab sr 24hr osmotic release 90 mg(Procardia xl)....................................................................17

nilutamide tab 150 mg (Nilandron)................................... 7nitrofurantoin macrocrystalline cap 25 mg(Macrodantin)................................................................... 26

nitrofurantoin macrocrystalline cap 50 mg(Macrodantin)................................................................... 26

nitrofurantoin macrocrystalline cap 100 mg(Macrodantin)................................................................... 26

nitrofurantoin monohydrate macrocrystalline cap 100mg (Macrobid)..................................................................26

nitrofurantoin susp 25 mg/5ml (Furadantin)..................26nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)..........18nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)..........18nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)..........18nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)..........18NITROSTAT – nitroglycerin sl tab 0.3 mg.......................... 18NITROSTAT – nitroglycerin sl tab 0.4 mg.......................... 18NITROSTAT – nitroglycerin sl tab 0.6 mg.......................... 18norethindrone acetate-ethinyl estradiol tab 1 mg-5mcg...................................................................................... 9

norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5mcg (Femhrt low dose).................................................... 9

norethindrone acetate tab 5 mg (Aygestin).....................9nortriptyline hcl cap 10 mg (Pamelor)............................28nortriptyline hcl cap 25 mg (Pamelor)............................28nortriptyline hcl cap 50 mg (Pamelor)............................28nortriptyline hcl cap 75 mg (Pamelor)............................28NORVIR – ritonavir cap 100 mg.......................................... 5NORVIR – ritonavir oral soln 80 mg/ml................................5NORVIR – ritonavir tab 100 mg........................................... 5NOVOEIGHT – antihemophilic factor (recombinant) for inj250 unit..............................................................................44

NOVOEIGHT – antihemophilic factor (recombinant) for inj500 unit..............................................................................44

NOVOEIGHT – antihemophilic factor (recombinant) for inj1000 unit............................................................................44




NOVOLIN 70/30 – insulin nph isophane & regular humaninj 100 unit/ml (70-30).......................................................11

NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ml........................................................................................11

NOVOLIN R – insulin regular (human) inj 100 unit/ml....... 11NOVOLOG FLEXPEN – insulin aspart soln pen-injector100 unit/ml......................................................................... 11

NOVOLOG – insulin aspart inj 100 unit/ml........................ 11NOVOLOG MIX 70/30 – insulin aspart prot & aspart(human) inj 100 unit/ml (70-30)........................................ 11

NOVOLOG MIX 70/30 PREFILL – insulin aspart prot &aspart sus pen-inj 100 unit/ml (70-30)..............................11

NOVOLOG PENFILL – insulin aspart soln cartridge 100unit/ml.................................................................................11

NOVOSEVEN RT – coagulation factor viia (recomb) for inj1 mg (1000 mcg)...............................................................44




NOXAFIL – posaconazole susp 40 mg/ml...........................3NOXAFIL – posaconazole tab delayed release 100 mg......3NUEDEXTA – dextromethorphan hbr-quinidine sulfate cap20-10 mg............................................................................33

NUVARING – etonogestrel-ethinyl estradiol va ring0.120-0.015 mg/24hr.........................................................10

NUWIQ – antihemophilic factor (recombinant) for inj kit250 unit..............................................................................44

NUWIQ – antihemophilic factor (recombinant) for inj kit500 unit..............................................................................44

NUWIQ – antihemophilic factor (recombinant) for inj kit1000 unit............................................................................44

NUWIQ – antihemophilic factor (recombinant) for inj kit2000 unit............................................................................44

NUWIQ – antihemophilic factor (recombinant) for inj 250unit......................................................................................44




nystatin cream 100000 unit/gm.......................................49nystatin oint 100000 unit/gm........................................... 49nystatin susp 100000 unit/ml.......................................... 47

2016



nystatin tab 500000 unit.....................................................3nystatin topical powder....................................................49nystatin-triamcinolone cream 100000-0.1 unit/gm-%........................................................................................ 50

nystatin-triamcinolone oint 100000-0.1 unit/gm-%....... 50O

OBIZUR – antihemophilic factor (recomb porc) rpfviii for inj500 unit..............................................................................44

octreotide acetate inj 50 mcg/ml (0.05 mg/ml)(Sandostatin)....................................................................12




octreotide acetate inj 1000 mcg/ml (1 mg/ml)(Sandostatin)....................................................................12

ofloxacin ophth soln 0.3% (Ocuflox)..............................46ofloxacin otic soln 0.3%...................................................47olanzapine orally disintegrating tab 5 mg (Zyprexazydis)................................................................................. 29

olanzapine orally disintegrating tab 10 mg (Zyprexazydis)................................................................................. 29



olanzapine tab 2.5 mg (Zyprexa).....................................30olanzapine tab 5 mg (Zyprexa)........................................30olanzapine tab 7.5 mg (Zyprexa).....................................30olanzapine tab 10 mg (Zyprexa)......................................30olanzapine tab 15 mg (Zyprexa)......................................30olanzapine tab 20 mg (Zyprexa)......................................30olopatadine hcl ophth soln 0.1% (base equivalent)(Patanol)............................................................................47

omeprazole cap delayed release 10 mg (Prilosec)....... 24omeprazole cap delayed release 20 mg (Prilosec)....... 24omeprazole cap delayed release 40 mg (Prilosec)....... 24OMNITROPE – somatropin for inj 5.8 mg......................... 12OMNITROPE – somatropin inj 5 mg/1.5ml........................12OMNITROPE – somatropin inj 10 mg/1.5ml......................12ondansetron hcl inj 4 mg/2ml (2 mg/ml)........................ 25ondansetron hcl inj 40 mg/20ml (2 mg/ml) (Zofran)......25ondansetron hcl oral soln 4 mg/5ml (Zofran)................25ondansetron hcl tab 24 mg............................................. 25ondansetron hcl tab 4 mg (Zofran).................................25ondansetron hcl tab 8 mg (Zofran).................................25ondansetron orally disintegrating tab 4 mg (Zofranodt).....................................................................................25

ondansetron orally disintegrating tab 8 mg (Zofranodt).....................................................................................25

OPSUMIT – macitentan tab 10 mg....................................21oral contraceptives – all generics.......................................10ORFADIN – nitisinone cap 2 mg........................................12ORFADIN – nitisinone cap 5 mg........................................13ORFADIN – nitisinone cap 10 mg......................................13ORFADIN – nitisinone susp 4 mg/ml................................. 12orphenadrine citrate tab sr 12hr 100 mg....................... 40oxaprozin tab 600 mg (Daypro).......................................36oxcarbazepine susp 300 mg/5ml (60 mg/ml)(Trileptal)...........................................................................38

oxcarbazepine tab 150 mg (Trileptal)............................. 38oxcarbazepine tab 300 mg (Trileptal)............................. 38oxcarbazepine tab 600 mg (Trileptal)............................. 38oxybutynin chloride syrup 5 mg/5ml..............................26oxybutynin chloride tab 5 mg......................................... 26oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)......26oxybutynin chloride tab sr 24hr 10 mg (Ditropanxl)....................................................................................... 26

oxybutynin chloride tab sr 24hr 15 mg (Ditropanxl)....................................................................................... 26

oxycodone-aspirin tab 4.8355-325 mg (Percodan)....... 35oxycodone hcl cap 5 mg................................................. 35oxycodone hcl conc 100 mg/5ml (20 mg/ml)(Oxycodone hcl).............................................................. 35

oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)............35oxycodone hcl tab 10 mg................................................ 35oxycodone hcl tab 20 mg................................................ 35oxycodone hcl tab 5 mg (Roxicodone).......................... 35oxycodone hcl tab 15 mg (Roxicodone)........................ 35oxycodone hcl tab 30 mg (Roxicodone)........................ 35oxycodone w/ acetaminophen tab 5-325 mg(Percocet)......................................................................... 35

oxycodone w/ acetaminophen tab 7.5-325 mg(Percocet)......................................................................... 35

oxycodone w/ acetaminophen tab 10-325 mg(Percocet)......................................................................... 35

OXYCONTIN – oxycodone hcl tab er 12hr deter 10mg...................................................................................... 35







2016



Ppantoprazole sodium ec tab 20 mg (base equiv)(Protonix).......................................................................... 24

pantoprazole sodium ec tab 40 mg (base equiv)(Protonix).......................................................................... 24

paricalcitol cap 1 mcg (Zemplar).................................... 13paricalcitol cap 2 mcg (Zemplar).................................... 13paricalcitol cap 4 mcg (Zemplar).................................... 13paromomycin sulfate cap 250 mg.................................... 3paroxetine hcl tab 10 mg (Paxil).....................................28paroxetine hcl tab 20 mg (Paxil).....................................28paroxetine hcl tab 30 mg (Paxil).....................................28paroxetine hcl tab 40 mg (Paxil).....................................28paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)................ 28paroxetine hcl tab sr 24hr 25 mg (Paxil cr)................... 28paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)................ 28pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml....................................................................................... 40

pediatric multiple vitamins w/ fluoride chew tab 0.25mg...................................................................................... 40

pediatric multiple vitamins w/ fluoride chew tab 0.5mg...................................................................................... 40

pediatric multiple vitamins w/ fluoride chew tab 1mg...................................................................................... 40

pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml....................................................................................... 40

pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml....................................................................................... 40

pediatric vitamins acd w/ fluoride soln 0.25 mg/ml...... 40pediatric vitamins acd w/ fluoride soln 0.5 mg/ml........ 40PEGASYS – 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).......................................................24

peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm(Golytely)...........................................................................24

peg 3350-kcl-sod bicarb-nacl for soln 420 gm(Nulytely/flavor pack)......................................................24

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....................................1pentoxifylline tab cr 400 mg............................................44perindopril erbumine tab 2 mg....................................... 14perindopril erbumine tab 4 mg (Aceon).........................14perindopril erbumine tab 8 mg (Aceon).........................14permethrin cream 5% (Elimite)........................................50perphenazine tab 2 mg.................................................... 30

perphenazine tab 4 mg.................................................... 30perphenazine tab 8 mg.................................................... 30perphenazine tab 16 mg.................................................. 30phenelzine sulfate tab 15 mg (Nardil)............................ 28phenobarbital elixir 20 mg/5ml........................................31phenobarbital tab 16.2 mg...............................................31phenobarbital tab 32.4 mg...............................................31phenoxybenzamine hcl cap 10 mg (Dibenzyline)......... 21phenytoin chew tab 50 mg (Dilantin infatabs)...............38phenytoin sodium extended cap 100 mg (Dilantin)...... 38phenytoin sodium extended cap 200 mg(Phenytek).........................................................................38

phenytoin sodium extended cap 300 mg(Phenytek).........................................................................39

phenytoin susp 125 mg/5ml (Dilantin)........................... 39pilocarpine hcl ophth soln 1% (Isopto carpine)............ 47pilocarpine hcl ophth soln 2% (Isopto carpine)............ 47pilocarpine hcl ophth soln 4% (Isopto carpine)............ 47pilocarpine hcl tab 5 mg (Salagen).................................47pilocarpine hcl tab 7.5 mg (Salagen)..............................47pimozide tab 1 mg (Orap)................................................ 33pimozide tab 2 mg (Orap)................................................ 33pindolol tab 5 mg..............................................................16pindolol tab 10 mg............................................................16pioglitazone hcl-metformin hcl tab 15-500 mg(Actoplus met)................................................................. 11

pioglitazone hcl-metformin hcl tab 15-850 mg(Actoplus met)................................................................. 11

pioglitazone hcl tab 15 mg (base equiv) (Actos)...........11pioglitazone hcl tab 30 mg (base equiv) (Actos)...........11pioglitazone hcl tab 45 mg (base equiv) (Actos)...........11piroxicam cap 10 mg (Feldene).......................................36piroxicam cap 20 mg (Feldene).......................................36PLEGRIDY – peginterferon beta-1a soln pen-injector 125mcg/0.5ml...........................................................................32

PLEGRIDY – peginterferon beta-1a soln prefilled syringe125 mcg/0.5ml...................................................................32

PLEGRIDY STARTER PACK – peginterferon beta-1a solnpen-inj 63 & 94 mcg/0.5ml pack.......................................32

PLEGRIDY STARTER PACK – peginterferon beta-1a solnpref syr 63 & 94 mcg/0.5ml pack..................................... 32

podofilox soln 0.5% (Condylox)......................................50polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% (Polytrim)...........................................................46

pot & sod citrates w/ cit ac soln 550-500-334mg/5ml...............................................................................26

potassium chloride cap cr 8 meq (Micro-k)...................40potassium chloride cap cr 10 meq (Micro-k).................40potassium chloride microencapsulated crys cr tab 10meq....................................................................................41

potassium chloride microencapsulated crys cr tab 20meq....................................................................................41

potassium chloride oral soln 10% (20 meq/15ml).........41

2016



potassium chloride oral soln 20% (40 meq/15ml).........41potassium chloride powder packet 20 meq.................. 41potassium chloride tab cr 10 meq (K-tab)..................... 41potassium chloride tab cr 8 meq (600 mg)....................41potassium citrate & citric acid powder pack 3300-1002mg...................................................................................... 26

potassium citrate & citric acid soln 1100-334mg/5ml...............................................................................26

potassium citrate tab cr 5 meq (540 mg) (Urocit-k5)........................................................................................ 26

potassium citrate tab cr 10 meq (1080 mg) (Urocit-k10)...................................................................................... 26

potassium citrate tab cr 15 meq (1620 mg) (Urocit-k15)...................................................................................... 26

pot bicarbonate & chloride effer tab 25 meq.................40pot phos monobasic w/sod phos di & monobas tab155-852-130mg (K-phos neutral)................................... 40

PRALUENT – alirocumab subcutaneous soln pen-injector75 mg/ml............................................................................19

PRALUENT – alirocumab subcutaneous soln pen-injector150 mg/ml..........................................................................19

PRALUENT – alirocumab subcutaneous soln prefilledsyringe 75 mg/ml...............................................................19

PRALUENT – alirocumab subcutaneous soln prefilledsyringe 150 mg/ml.............................................................19

pramipexole dihydrochloride tab 0.125 mg(Mirapex)........................................................................... 39

pramipexole dihydrochloride tab 0.25 mg(Mirapex)........................................................................... 39

pramipexole dihydrochloride tab 0.5 mg (Mirapex)......39pramipexole dihydrochloride tab 0.75 mg(Mirapex)........................................................................... 39

pramipexole dihydrochloride tab 1 mg (Mirapex).........39pramipexole dihydrochloride tab 1.5 mg (Mirapex)......39pravastatin sodium tab 10 mg........................................ 19pravastatin sodium tab 20 mg (Pravachol)....................19pravastatin sodium tab 40 mg (Pravachol)....................19pravastatin sodium tab 80 mg (Pravachol)....................19prazosin hcl cap 1 mg (Minipress)................................. 21prazosin hcl cap 2 mg (Minipress)................................. 21prazosin hcl cap 5 mg (Minipress)................................. 21prednisolone acetate ophth susp 1% (Pred forte)........ 46prednisolone sod phosphate oral soln 15 mg/5ml(base equiv)........................................................................8

prednisolone sod phosph oral soln 6.7 mg/5ml (5mg/5ml base) (Pediapred)................................................ 8

prednisolone syrup 15 mg/5ml (usp solutionequivalent) (Prelone).........................................................8

prednisone tab 1 mg.......................................................... 8prednisone tab 2.5 mg....................................................... 8prednisone tab 5 mg.......................................................... 8prednisone tab 10 mg........................................................ 8prednisone tab 20 mg........................................................ 8

PRENATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1mg...................................................................................... 40

PRENATAL VITAMINS PLUS LO – prenatal vit w/ fefumarate-fa tab 27-1 mg................................................... 40

PREZISTA – 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

primidone tab 50 mg (Mysoline)..................................... 39primidone tab 250 mg (Mysoline)................................... 39PROAIR HFA – albuterol sulfate inhal aero 108 mcg/act(90mcg base equiv).......................................................... 23

PROAIR RESPICLICK – albuterol sulfate aer pow ba 108mcg/act (90 mcg base equiv)........................................... 23

probenecid tab 500 mg.................................................... 37prochlorperazine maleate tab 5 mg (base equivalent)(Compazine)..................................................................... 30

prochlorperazine maleate tab 10 mg (base equivalent)(Compazine)..................................................................... 30

prochlorperazine suppos 25 mg.....................................30PROCRIT – epoetin alfa inj 2000 unit/ml...........................45PROCRIT – epoetin alfa inj 3000 unit/ml...........................45PROCRIT – epoetin alfa inj 4000 unit/ml...........................45PROCRIT – epoetin alfa inj 10000 unit/ml.........................45PROCRIT – epoetin alfa inj 20000 unit/ml.........................45PROCRIT – epoetin alfa inj 40000 unit/ml.........................45PROFILNINE – factor ix complex for inj 500 unit...............45PROFILNINE – factor ix complex for inj 1000 unit.............45PROFILNINE – factor ix complex for inj 1500 unit.............45PROFILNINE SD – factor ix complex for inj 500 unit.........45PROFILNINE SD – factor ix complex for inj 1000 unit.......45PROFILNINE SD – factor ix complex for inj 1500 unit.......45progesterone micronized cap 100 mg(Prometrium).................................................................... 10

progesterone micronized cap 200 mg(Prometrium).................................................................... 10

promethazine hcl suppos 12.5 mg................................. 22promethazine hcl suppos 25 mg.................................... 22promethazine hcl suppos 50 mg.................................... 22promethazine hcl syrup 6.25 mg/5ml............................. 22promethazine hcl tab 12.5 mg.........................................22promethazine hcl tab 25 mg............................................22promethazine hcl tab 50 mg............................................22propafenone hcl cap sr 12hr 225 mg (Rythmol sr)....... 20

2016



propafenone hcl cap sr 12hr 325 mg (Rythmol sr)....... 20propafenone hcl cap sr 12hr 425 mg (Rythmol sr)....... 20propafenone hcl tab 300 mg........................................... 20propafenone hcl tab 150 mg (Rythmol)......................... 20propafenone hcl tab 225 mg (Rythmol)......................... 20propranolol hcl cap sr 24hr 60 mg (Inderal la)..............16propranolol hcl cap sr 24hr 80 mg (Inderal la)..............16propranolol hcl cap sr 24hr 120 mg (Inderal la)............16propranolol hcl cap sr 24hr 160 mg (Inderal la)............16propranolol hcl tab 10 mg............................................... 16propranolol hcl tab 20 mg............................................... 16propranolol hcl tab 40 mg............................................... 16propranolol hcl tab 60 mg............................................... 16propranolol hcl tab 80 mg............................................... 16propylthiouracil tab 50 mg.............................................. 12PULMOZYME – dornase alfa inhal soln 1 mg/ml.............. 24pyrazinamide tab 500 mg...................................................3pyridostigmine bromide tab 60 mg (Mestinon)............. 40Q

quetiapine fumarate tab 25 mg (Seroquel).................... 30quetiapine fumarate tab 50 mg (Seroquel).................... 30quetiapine fumarate tab 100 mg (Seroquel).................. 30quetiapine fumarate tab 200 mg (Seroquel).................. 30quetiapine fumarate tab 300 mg (Seroquel).................. 30quetiapine fumarate tab 400 mg (Seroquel).................. 30quinapril hcl tab 5 mg (Accupril).................................... 14quinapril hcl tab 10 mg (Accupril).................................. 14quinapril hcl tab 20 mg (Accupril).................................. 14quinapril hcl tab 40 mg (Accupril).................................. 14quinapril-hydrochlorothiazide tab 10-12.5 mg(Accuretic)........................................................................ 14

quinapril-hydrochlorothiazide tab 20-12.5 mg(Accuretic)........................................................................ 14

quinapril-hydrochlorothiazide tab 20-25 mg(Accuretic)........................................................................ 14

quinidine gluconate tab cr 324 mg.................................20QVAR – beclomethasone diprop inhal aero soln 40 mcg/act (50/valve).....................................................................23

QVAR – beclomethasone diprop inhal aero soln 80 mcg/act (100/valve)...................................................................23

Rraloxifene hcl tab 60 mg (Evista)....................................13ramipril cap 1.25 mg (Altace).......................................... 14ramipril cap 2.5 mg (Altace)............................................ 14ramipril cap 5 mg (Altace)............................................... 14ramipril cap 10 mg (Altace)............................................. 14ranitidine hcl cap 150 mg................................................ 24ranitidine hcl cap 300 mg................................................ 25ranitidine hcl syrup 15 mg/ml (75 mg/5ml).................... 25ranitidine hcl tab 150 mg (Zantac)..................................25ranitidine hcl tab 300 mg (Zantac)..................................25

RAPAMUNE – sirolimus oral soln 1 mg/ml........................ 51REBIF – interferon beta-1a soln pref syr 22 mcg/0.5ml(12mu/ml)...........................................................................32

REBIF – interferon beta-1a soln pref syr 44 mcg/0.5ml(24mu/ml)...........................................................................32

REBIF REBIDOSE – interferon beta-1a soln auto-inj 22mcg/0.5ml (12mu/ml).........................................................32

REBIF REBIDOSE – interferon beta-1a soln auto-inj 44mcg/0.5ml (24mu/ml).........................................................32

REBIF REBIDOSE TITRATION – interferon beta-1a auto-inj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml............................ 32

REBIF TITRATION PACK – interferon beta-1a pref syr6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml................................. 32

RECOMBINATE – antihemophilic factor (recombinant) forinj 220-400 unit..................................................................45

RECOMBINATE – antihemophilic factor (recombinant) forinj 401-800 unit..................................................................45

RECOMBINATE – antihemophilic factor (recombinant) forinj 801-1240 unit................................................................45

RECOMBINATE – antihemophilic factor (recombinant) forinj 1241-1800 unit..............................................................45

RECOMBINATE – antihemophilic factor (recombinant) forinj 1801-2400 unit..............................................................45

repaglinide tab 0.5 mg (Prandin).................................... 11repaglinide tab 1 mg (Prandin)....................................... 11repaglinide tab 2 mg (Prandin)....................................... 11REPATHA – evolocumab subcutaneous soln prefilledsyringe 140 mg/ml.............................................................19

REPATHA PUSHTRONEX SYSTEM – evolocumabsubcutaneous soln cartridge/infusor 420 mg/3.5ml..........19

REPATHA SURECLICK – evolocumab subcutaneous solnauto-injector 140 mg/ml.................................................... 19

RESCRIPTOR – delavirdine mesylate tab 100 mg..............5RESCRIPTOR – delavirdine mesylate tab 200 mg..............5REVLIMID – lenalidomide cap 5 mg..................................51REVLIMID – lenalidomide cap 10 mg................................51REVLIMID – lenalidomide cap 15 mg................................51REVLIMID – lenalidomide cap 20 mg................................51REVLIMID – lenalidomide cap 25 mg................................51REVLIMID – lenalidomide caps 2.5 mg............................. 51REYATAZ – 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)...........................................3

2016



riluzole tab 50 mg (Rilutek)............................................. 40risedronate sodium tab 5 mg (Actonel)......................... 13risedronate sodium tab 30 mg (Actonel)....................... 13risedronate sodium tab 35 mg (Actonel)....................... 13risedronate sodium tab 150 mg (Actonel)..................... 13risperidone orally disintegrating tab 0.25 mg............... 30risperidone orally disintegrating tab 0.5 mg (Risperdalm-tab)................................................................................ 30

risperidone orally disintegrating tab 1 mg (Risperdalm-tab)................................................................................ 30




risperidone soln 1 mg/ml (Risperdal).............................30risperidone tab 0.25 mg (Risperdal)...............................30risperidone tab 0.5 mg (Risperdal).................................30risperidone tab 1 mg (Risperdal)....................................30risperidone tab 2 mg (Risperdal)....................................30risperidone tab 3 mg (Risperdal)....................................30risperidone tab 4 mg (Risperdal)....................................30rivastigmine tartrate cap 1.5 mg (Exelon)......................33rivastigmine tartrate cap 3 mg (Exelon).........................33rivastigmine tartrate cap 4.5 mg (Exelon)......................33rivastigmine tartrate cap 6 mg (Exelon).........................33RIXUBIS – coagulation factor ix (recombinant) for inj 250unit......................................................................................45

RIXUBIS – coagulation factor ix (recombinant) for inj 500unit......................................................................................45




rizatriptan benzoate oral disintegrating tab 5 mg (baseeq) (Maxalt-mlt)................................................................37

rizatriptan benzoate oral disintegrating tab 10 mg(base eq) (Maxalt-mlt).....................................................37

rizatriptan benzoate tab 5 mg (base equivalent)(Maxalt)..............................................................................37

rizatriptan benzoate tab 10 mg (base equivalent)(Maxalt)..............................................................................37

ropinirole hydrochloride tab 0.25 mg (Requip)............. 39ropinirole hydrochloride tab 0.5 mg (Requip)............... 39ropinirole hydrochloride tab 1 mg (Requip).................. 39ropinirole hydrochloride tab 2 mg (Requip).................. 39ropinirole hydrochloride tab 3 mg (Requip).................. 39ropinirole hydrochloride tab 4 mg (Requip).................. 39ropinirole hydrochloride tab 5 mg (Requip).................. 40rosuvastatin calcium tab 5 mg (Crestor)....................... 19

rosuvastatin calcium tab 10 mg (Crestor)..................... 19rosuvastatin calcium tab 20 mg (Crestor)..................... 19rosuvastatin calcium tab 40 mg (Crestor)..................... 19S

SABRIL – vigabatrin powd pack 500 mg........................... 39SABRIL – vigabatrin tab 500 mg........................................39salsalate tab 500 mg.........................................................33salsalate tab 750 mg.........................................................33selegiline hcl cap 5 mg (Eldepryl).................................. 40selegiline hcl tab 5 mg.....................................................40selenium sulfide lotion 2.5%........................................... 50SELZENTRY – maraviroc tab 150 mg................................. 5SELZENTRY – maraviroc tab 300 mg................................. 5SENSIPAR – cinacalcet hcl tab 30 mg (base equiv)..........13SENSIPAR – cinacalcet hcl tab 60 mg (base equiv)..........13SENSIPAR – cinacalcet hcl tab 90 mg (base equiv)..........13SEREVENT DISKUS – salmeterol xinafoate aer pow ba50 mcg/dose (base equiv)................................................ 23

SEROQUEL XR – quetiapine fumarate tab sr 24hr 50mg...................................................................................... 30





sertraline hcl oral conc 20 mg/ml (Zoloft)......................28sertraline hcl tab 25 mg (Zoloft)..................................... 28sertraline hcl tab 50 mg (Zoloft)..................................... 28sertraline hcl tab 100 mg (Zoloft)................................... 28sildenafil citrate tab 20 mg (Revatio)............................. 21silver sulfadiazine cream 1% (Silvadene)...................... 49SIMPONI – golimumab subcutaneous soln auto-injector50 mg/0.5ml.......................................................................36

SIMPONI – golimumab subcutaneous soln auto-injector100 mg/ml..........................................................................37

SIMPONI – golimumab subcutaneous soln prefilledsyringe 50 mg/0.5ml..........................................................37

SIMPONI – golimumab subcutaneous soln prefilledsyringe 100 mg/ml.............................................................37

simvastatin tab 5 mg (Zocor).......................................... 19simvastatin tab 10 mg (Zocor)........................................ 19simvastatin tab 20 mg (Zocor)........................................ 19simvastatin tab 40 mg (Zocor)........................................ 19simvastatin tab 80 mg (Zocor)........................................ 19sirolimus tab 0.5 mg (Rapamune)...................................51sirolimus tab 1 mg (Rapamune)......................................51sirolimus tab 2 mg (Rapamune)......................................51SKYLA – levonorgestrel releasing iud 14 mcg/day (13.5mg total).............................................................................10

2016



sodium citrate & citric acid soln 500-334 mg/5ml(Shohls solution modi)................................................... 26

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)...... 47sodium fluoride gel 1.1% (0.5% f) (Previdentfluoride).............................................................................47

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).................................................................................. 51

sodium polystyrene sulfonate powder(Kayexalate)......................................................................51

sotalol hcl (afib/afl) tab 80 mg (Betapace af).................20sotalol hcl (afib/afl) tab 120 mg (Betapace af)...............20sotalol hcl (afib/afl) tab 160 mg (Betapace af)...............20sotalol hcl tab 240 mg......................................................20sotalol hcl tab 80 mg (Betapace)....................................20sotalol hcl tab 120 mg (Betapace)..................................20sotalol hcl tab 160 mg (Betapace)..................................20SOVALDI – sofosbuvir tab 400 mg...................................... 4SPIRIVA HANDIHALER – tiotropium bromidemonohydrate inhal cap 18 mcg (base equiv)................... 23

SPIRIVA RESPIMAT – tiotropium bromide monohydrateinhal aerosol 1.25 mcg/act................................................23

SPIRIVA RESPIMAT – tiotropium bromide monohydrateinhal aerosol 2.5 mcg/act..................................................23

spironolactone & hydrochlorothiazide tab 25-25 mg(Aldactazide).....................................................................20

spironolactone tab 25 mg (Aldactone)...........................20spironolactone tab 50 mg (Aldactone)...........................20spironolactone tab 100 mg (Aldactone).........................20stavudine 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............................................................................ 50

STELARA – ustekinumab soln prefilled syringe 90 mg/ml........................................................................................50

STIMATE – desmopressin acetate nasal soln 1.5 mg/ml........................................................................................13

STRENSIQ – asfotase alfa subcutaneous inj 18mg/0.45ml.......................................................................... 13

STRENSIQ – asfotase alfa subcutaneous inj 28mg/0.7ml............................................................................ 13

STRENSIQ – asfotase alfa subcutaneous inj 40 mg/ml........................................................................................13

STRENSIQ – asfotase alfa subcutaneous inj 80mg/0.8ml............................................................................ 13

STRIBILD – elvitegrav-cobic-emtricitab-tenofovdf tab150-150-200-300 mg...........................................................5

sucralfate tab 1 gm (Carafate).........................................25sulfacetamide sodium lotion 10% (acne) (Klaron)........48sulfacetamide sodium ophth soln 10% (Bleph-10)....... 46sulfacetamide sodium-prednisolone ophth soln10-0.23(0.25)%.................................................................. 46

sulfacetamide sodium w/ sulfur cream 10-5%.............. 48sulfacetamide sodium w/ sulfur emulsion 10-5%......... 48sulfacetamide sodium w/ sulfur lotion 10-5%............... 48sulfamethoxazole-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)............................................................................. 25

sulfasalazine tab 500 mg (Azulfidine)............................ 25sulindac tab 150 mg......................................................... 37sulindac tab 200 mg......................................................... 37sumatriptan nasal spray 5 mg/act (Imitrex)...................37sumatriptan nasal spray 20 mg/act (Imitrex).................37sumatriptan succinate inj 6 mg/0.5ml (Imitrex).............37sumatriptan succinate solution auto-injector 4mg/0.5ml (Imitrex statdose sys)....................................37

sumatriptan succinate solution auto-injector 6mg/0.5ml (Imitrex statdose sys)....................................37

sumatriptan succinate solution cartridge 4 mg/0.5ml(Imitrex statdose ref)...................................................... 37

sumatriptan succinate solution cartridge 6 mg/0.5ml(Imitrex statdose ref)...................................................... 37

sumatriptan succinate tab 25 mg (Imitrex)....................37sumatriptan succinate tab 50 mg (Imitrex)....................37sumatriptan succinate tab 100 mg (Imitrex)..................37SUSTIVA – efavirenz cap 50 mg......................................... 5SUSTIVA – efavirenz cap 200 mg....................................... 5SUSTIVA – efavirenz tab 600 mg........................................ 5SUTENT – sunitinib malate cap 12.5 mg (baseequivalent)............................................................................7

SUTENT – sunitinib malate cap 25 mg (baseequivalent)............................................................................7

SUTENT – sunitinib malate cap 37.5 mg (baseequivalent)............................................................................7

SUTENT – sunitinib malate cap 50 mg (baseequivalent)............................................................................7

SYLATRON – peginterferon alfa-2b for inj kit 200 mcg....... 7SYLATRON – peginterferon alfa-2b for inj kit 300 mcg....... 7SYLATRON – peginterferon alfa-2b for inj kit 600 mcg....... 7

2016



SYMBICORT – budesonide-formoterol fumarate dihydaerosol 80-4.5 mcg/act..................................................... 23

SYMBICORT – budesonide-formoterol fumarate dihydaerosol 160-4.5 mcg/act................................................... 23

Ttacrolimus cap 0.5 mg (Prograf)..................................... 51tacrolimus cap 1 mg (Prograf)........................................ 51tacrolimus cap 5 mg (Prograf)........................................ 51tacrolimus oint 0.03% (Protopic).................................... 50tacrolimus oint 0.1% (Protopic)...................................... 50TAFINLAR – dabrafenib mesylate cap 50 mg (baseequivalent)............................................................................7

TAFINLAR – dabrafenib mesylate cap 75 mg (baseequivalent)............................................................................7

tamoxifen citrate tab 10 mg (base equivalent)................7tamoxifen citrate tab 20 mg (base equivalent)................8tamsulosin hcl cap 0.4 mg (Flomax).............................. 26TARCEVA – erlotinib hcl tab 25 mg (base equivalent).........8TARCEVA – erlotinib hcl tab 100 mg (base equivalent).......8TARCEVA – erlotinib hcl tab 150 mg (base equivalent).......8TASIGNA – nilotinib hcl cap 150 mg (base equivalent)....... 8TASIGNA – nilotinib hcl cap 200 mg (base equivalent)....... 8TAZORAC – tazarotene cream 0.05%...............................48TAZORAC – tazarotene cream 0.1%.................................48TAZORAC – tazarotene gel 0.05%.................................... 48TAZORAC – tazarotene gel 0.1%...................................... 48TECFIDERA – dimethyl fumarate capsule delayed release120 mg...............................................................................32

TECFIDERA – dimethyl fumarate capsule delayed release240 mg...............................................................................32

TECFIDERA STARTER PACK – dimethyl fumaratecapsule dr starter pack 120 mg & 240 mg....................... 32

telmisartan-hydrochlorothiazide tab 40-12.5 mg(Micardis hct)................................................................... 15

telmisartan-hydrochlorothiazide tab 80-12.5 mg(Micardis hct)................................................................... 15

telmisartan-hydrochlorothiazide tab 80-25 mg(Micardis hct)................................................................... 15

telmisartan tab 20 mg (Micardis).................................... 15telmisartan tab 40 mg (Micardis).................................... 15telmisartan tab 80 mg (Micardis).................................... 15temazepam cap 7.5 mg (Restoril)................................... 31temazepam cap 15 mg (Restoril).................................... 31temazepam cap 22.5 mg (Restoril)................................. 31temazepam cap 30 mg (Restoril).................................... 31temozolomide cap 5 mg (Temodar).................................. 8temozolomide cap 20 mg (Temodar)................................ 8temozolomide cap 100 mg (Temodar)..............................8temozolomide cap 140 mg (Temodar)..............................8temozolomide cap 180 mg (Temodar)..............................8temozolomide cap 250 mg (Temodar)..............................8terazosin hcl cap 1 mg.....................................................21

terazosin hcl cap 2 mg.....................................................21terazosin hcl cap 5 mg.....................................................21terazosin hcl cap 10 mg...................................................21terbinafine hcl tab 250 mg (Lamisil).................................3terbutaline sulfate tab 2.5 mg......................................... 23terbutaline sulfate tab 5 mg............................................ 23terconazole vaginal cream 0.4% (Terazol 7).................. 26terconazole vaginal cream 0.8% (Terazol 3).................. 26terconazole vaginal suppos 80 mg.................................26testosterone cypionate im inj in oil 100 mg/ml (Depo-testosterone)...................................................................... 9

testosterone cypionate im inj in oil 200 mg/ml (Depo-testosterone)...................................................................... 9

testosterone enanthate im inj in oil 200 mg/ml...............9testosterone td gel 12.5 mg/act (1%) (Androgelpump).................................................................................. 9

testosterone td gel 25 mg/2.5gm (1%) (Androgel).......... 9testosterone td gel 50 mg/5gm (1%) (Androgel)............. 9TEST STRIPS – BAYER ASCENSIA AUTODISC,BREEZE 2, CONTOUR, CONTOUR NEXT..................... 50

tetrabenazine tab 12.5 mg (Xenazine)............................ 33tetrabenazine tab 25 mg (Xenazine)............................... 33tetracycline hcl cap 250 mg (Tetracycline hcl)................2tetracycline hcl cap 500 mg (Tetracycline hcl)................2THALOMID – thalidomide cap 50 mg................................ 51THALOMID – thalidomide cap 100 mg.............................. 51THALOMID – thalidomide cap 150 mg.............................. 51THALOMID – thalidomide cap 200 mg.............................. 51theophylline tab sr 12hr 100 mg.....................................23theophylline tab sr 12hr 200 mg.....................................23theophylline tab sr 12hr 300 mg.....................................23theophylline tab sr 12hr 450 mg.....................................23theophylline tab sr 24hr 400 mg.....................................23theophylline tab sr 24hr 600 mg.....................................23thiothixene cap 1 mg........................................................30thiothixene cap 2 mg........................................................30thiothixene cap 5 mg........................................................30thiothixene cap 10 mg......................................................30timolol maleate ophth gel forming soln 0.25%(Timoptic-xe).................................................................... 47

timolol maleate ophth gel forming soln 0.5%(Timoptic-xe).................................................................... 47

timolol maleate ophth soln 0.25% (Timoptic)................47timolol maleate ophth soln 0.5% (Timoptic)..................47TIVICAY – dolutegravir sodium tab 10 mg (base equiv)...... 5TIVICAY – dolutegravir sodium tab 25 mg (base equiv)...... 5TIVICAY – dolutegravir sodium tab 50 mg (base equiv)...... 5tizanidine hcl tab 2 mg (base equivalent)......................40tizanidine hcl tab 4 mg (base equivalent)(Zanaflex).......................................................................... 40

tobramycin-dexamethasone ophth susp 0.3-0.1%(Tobradex).........................................................................46

tobramycin nebu soln 300 mg/5ml (Tobi)........................ 3

2016



tobramycin ophth soln 0.3% (Tobrex)............................ 46tolterodine tartrate cap sr 24hr 2 mg (Detrol la)............26tolterodine tartrate cap sr 24hr 4 mg (Detrol la)............26tolterodine tartrate tab 1 mg (Detrol)............................. 26tolterodine tartrate tab 2 mg (Detrol)............................. 26topiramate 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).......................................20torsemide tab 10 mg (Demadex).....................................20torsemide tab 20 mg (Demadex).....................................20torsemide tab 100 mg (Demadex)...................................20TOUJEO SOLOSTAR – insulin glargine soln pen-injector300 unit/ml......................................................................... 11

TRACLEER – bosentan tab 62.5 mg.................................21TRACLEER – bosentan tab 125 mg..................................21tramadol-acetaminophen tab 37.5-325 mg(Ultracet)........................................................................... 35

tramadol hcl tab 50 mg (Ultram).....................................35tramadol hcl tab sr 24hr 100 mg (Ultram er)................. 35tramadol hcl tab sr 24hr 200 mg (Ultram er)................. 35tramadol hcl tab sr 24hr 300 mg (Ultram er)................. 35trandolapril tab 1 mg (Mavik).......................................... 14trandolapril tab 2 mg (Mavik).......................................... 14trandolapril tab 4 mg (Mavik).......................................... 14tranylcypromine sulfate tab 10 mg (Parnate)................28trazodone hcl tab 50 mg.................................................. 28trazodone hcl tab 100 mg................................................ 28trazodone hcl tab 150 mg................................................ 28trazodone hcl tab 300 mg................................................ 28tretinoin cap 10 mg.............................................................8tretinoin cream 0.025% (Retin-a).....................................48tretinoin cream 0.05% (Retin-a).......................................48tretinoin cream 0.1% (Retin-a).........................................48tretinoin gel 0.01% (Retin-a)............................................ 48tretinoin gel 0.025% (Retin-a)..........................................48tretinoin microsphere gel 0.04% (Retin-a micro).......... 48tretinoin microsphere gel 0.1% (Retin-a micro)............ 48TRETTEN – coagulation factor xiii a-subunit for inj2000-3125 unit...................................................................45

triamcinolone acetonide cream 0.025%......................... 50triamcinolone acetonide cream 0.1%............................. 50triamcinolone acetonide cream 0.5%............................. 50triamcinolone acetonide dental paste 0.1%.................. 47triamcinolone acetonide lotion 0.025%..........................50triamcinolone acetonide lotion 0.1%..............................50triamcinolone acetonide nasal aerosol suspension 55mcg/act (Nasacort aq).................................................... 22

triamcinolone acetonide oint 0.025%............................. 50triamcinolone acetonide oint 0.1%................................. 50

triamterene & hydrochlorothiazide cap 37.5-25 mg(Dyazide)........................................................................... 20

triamterene & hydrochlorothiazide tab 37.5-25 mg(Maxzide-25)..................................................................... 20

triamterene & hydrochlorothiazide tab 75-50 mg(Maxzide)...........................................................................20

trifluoperazine hcl tab 1 mg............................................ 30trifluoperazine hcl tab 2 mg............................................ 30trifluoperazine hcl tab 5 mg............................................ 30trifluoperazine hcl tab 10 mg.......................................... 30trifluridine ophth soln 1% (Viroptic)............................... 46trihexyphenidyl hcl elixir 0.4 mg/ml............................... 40trihexyphenidyl hcl tab 2 mg...........................................40trihexyphenidyl hcl tab 5 mg...........................................40trimethobenzamide hcl cap 300 mg (Tigan).................. 25trimethoprim tab 100 mg................................................... 6tropicamide ophth soln 0.5%.......................................... 47tropicamide ophth soln 1% (Mydriacyl)......................... 47TRUVADA – emtricitabine-tenofovir disoproxil fumaratetab 100-150 mg................................................................... 5

TRUVADA – emtricitabine-tenofovir disoproxil fumaratetab 133-200 mg................................................................... 6



UUPTRAVI – selexipag tab 200 mcg....................................21UPTRAVI – selexipag tab 400 mcg....................................21UPTRAVI – selexipag tab 600 mcg....................................21UPTRAVI – selexipag tab 800 mcg....................................21UPTRAVI – selexipag tab 1000 mcg..................................21UPTRAVI – selexipag tab 1200 mcg..................................21UPTRAVI – selexipag tab 1400 mcg..................................21UPTRAVI – selexipag tab 1600 mcg..................................21UPTRAVI – selexipag tab therapy pack 200 mcg (140) &800 mcg (60)..................................................................... 21

ursodiol cap 300 mg (Actigall)........................................25ursodiol tab 250 mg (Urso 250)...................................... 25ursodiol tab 500 mg (Urso forte).................................... 26V

VAGIFEM – estradiol vaginal tab 10 mcg.......................... 26valacyclovir hcl tab 1 gm (Valtrex)................................... 4valacyclovir hcl tab 500 mg (Valtrex)............................... 4VALCHLOR – mechlorethamine hcl gel 0.016% (baseequivalent)......................................................................... 50

VALCYTE – valganciclovir hcl for soln 50 mg/ml (baseequiv)....................................................................................3

valganciclovir hcl tab 450 mg (base equivalent)(Valcyte).............................................................................. 3

2016



valproate sodium syrup 250 mg/5ml (base equiv)(Depakene)........................................................................39

valproic acid cap 250 mg (Depakene)............................39valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovanhct).....................................................................................15

valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovanhct).....................................................................................15

valsartan-hydrochlorothiazide tab 160-25 mg (Diovanhct).....................................................................................15

valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovanhct).....................................................................................15

valsartan-hydrochlorothiazide tab 320-25 mg (Diovanhct).....................................................................................15

valsartan tab 40 mg (Diovan).......................................... 15valsartan tab 80 mg (Diovan).......................................... 15valsartan tab 160 mg (Diovan)........................................ 15valsartan tab 320 mg (Diovan)........................................ 15vancomycin hcl cap 125 mg (Vancocin hcl)....................7vancomycin hcl cap 250 mg (Vancocin hcl)....................7venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent)(Effexor xr)....................................................................... 28

venlafaxine hcl cap sr 24hr 75 mg (base equivalent)(Effexor xr)....................................................................... 28

venlafaxine hcl cap sr 24hr 150 mg (base equivalent)(Effexor xr)....................................................................... 29

venlafaxine hcl tab 25 mg................................................29venlafaxine hcl tab 37.5 mg.............................................29venlafaxine hcl tab 50 mg................................................29venlafaxine hcl tab 75 mg................................................29venlafaxine hcl tab 100 mg..............................................29venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent)(Venlafaxine hcl er)......................................................... 29

venlafaxine hcl tab sr 24hr 75 mg (base equivalent)(Venlafaxine hcl er)......................................................... 29

venlafaxine hcl tab sr 24hr 150 mg (base equivalent)(Venlafaxine hcl er)......................................................... 29

VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act(90mcg base equiv).......................................................... 23

verapamil hcl cap sr 24hr 120 mg (Verelan).................. 17verapamil hcl cap sr 24hr 180 mg (Verelan).................. 17verapamil hcl cap sr 24hr 240 mg (Verelan).................. 17verapamil hcl cap sr 24hr 360 mg (Verelan).................. 17verapamil hcl tab cr 120 mg (Calan sr)..........................17verapamil hcl tab cr 180 mg (Calan sr)..........................17verapamil hcl tab cr 240 mg (Calan sr)..........................17verapamil hcl tab 40 mg.................................................. 17verapamil hcl tab 80 mg (Calan).....................................18verapamil hcl tab 120 mg (Calan)...................................18VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ml)...................................................................................... 11

VIDEX – didanosine for soln 2 gm.......................................6VIDEX – didanosine for soln 4 gm.......................................6VIRACEPT – nelfinavir mesylate tab 250 mg...................... 6

VIRACEPT – nelfinavir mesylate tab 625 mg...................... 6VIRAMUNE – nevirapine susp 50 mg/5ml...........................6VIRAMUNE XR – nevirapine tab sr 24hr 100 mg................6VIREAD – tenofovir disoproxil fumarate oral powder 40mg/gm.................................................................................. 6

VIREAD – tenofovir disoproxil fumarate tab 150 mg........... 6VIREAD – tenofovir disoproxil fumarate tab 200 mg........... 6VIREAD – tenofovir disoproxil fumarate tab 250 mg........... 6VIREAD – tenofovir disoproxil fumarate tab 300 mg........... 6VONVENDI – von willebrand factor (recombinant) for inj650 unit..............................................................................45

VONVENDI – von willebrand factor (recombinant) for inj1300 unit............................................................................45

voriconazole for susp 40 mg/ml (Vfend)..........................3voriconazole tab 50 mg (Vfend)........................................3voriconazole tab 200 mg (Vfend)......................................3VOTRIENT – pazopanib hcl tab 200 mg (base equiv).........8

Wwarfarin sodium tab 1 mg (Coumadin).......................... 45warfarin sodium tab 2 mg (Coumadin).......................... 45warfarin sodium tab 2.5 mg (Coumadin)....................... 45warfarin sodium tab 3 mg (Coumadin).......................... 45warfarin sodium tab 4 mg (Coumadin).......................... 45warfarin sodium tab 5 mg (Coumadin).......................... 45warfarin sodium tab 6 mg (Coumadin).......................... 45warfarin sodium tab 7.5 mg (Coumadin)....................... 45warfarin sodium tab 10 mg (Coumadin)........................ 45WILATE – antihemophilic factor/vwf (human) for inj500-500 unit kit..................................................................45

WILATE – antihemophilic factor/vwf (human) for inj1000-1000 unit kit..............................................................45

XXALKORI – crizotinib cap 200 mg....................................... 8XALKORI – crizotinib cap 250 mg....................................... 8XIFAXAN – rifaximin tab 550 mg......................................... 7XYNTHA – antihemophilic factor recombinant paf for inj kit250 unit..............................................................................45

XYNTHA – antihemophilic factor recombinant paf for inj kit500 unit..............................................................................45

XYNTHA – antihemophilic factor recombinant paf for inj kit1000 unit............................................................................45

XYNTHA – antihemophilic factor recombinant paf for inj kit2000 unit............................................................................46

XYNTHA SOLOFUSE – antihemophilic factor recombinantpaf for inj kit 250 unit........................................................46

XYNTHA SOLOFUSE – antihemophilic factor recombinantpaf for inj kit 500 unit........................................................46

XYNTHA SOLOFUSE – antihemophilic factor recombinantpaf for inj kit 1000 unit......................................................46


2016




Y

Zzafirlukast tab 10 mg (Accolate)..................................... 23zafirlukast tab 20 mg (Accolate)..................................... 23zaleplon cap 5 mg (Sonata).............................................31zaleplon cap 10 mg (Sonata)...........................................31ZELBORAF – vemurafenib tab 240 mg............................... 8ZENPEP – pancrelipase (lip-prot-amyl) dr cap3000-10000-16000 unit..................................................... 25

ZENPEP – pancrelipase (lip-prot-amyl) dr cap5000-17000-27000 unit..................................................... 25

ZENPEP – pancrelipase (lip-prot-amyl) dr cap10000-34000-55000 unit...................................................25

ZENPEP – pancrelipase (lip-prot-amyl) dr cap15000-51000-82000 unit...................................................25

ZENPEP – pancrelipase (lip-prot-amyl) dr cap20000-68000-109000 unit.................................................25

ZENPEP – pancrelipase (lip-prot-amyl) dr cap25000-85000-136000 unit.................................................25

ZENPEP – pancrelipase (lip-prot-amyl) dr cap40000-136000-218000 unit...............................................25

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)............................. 30ziprasidone hcl cap 40 mg (Geodon)............................. 30ziprasidone hcl cap 60 mg (Geodon)............................. 31ziprasidone hcl cap 80 mg (Geodon)............................. 31zolpidem tartrate tab cr 6.25 mg (Ambien cr)................31zolpidem tartrate tab cr 12.5 mg (Ambien cr)................31zolpidem tartrate tab 5 mg (Ambien)..............................31zolpidem tartrate tab 10 mg (Ambien)............................31zonisamide cap 50 mg..................................................... 39zonisamide cap 25 mg (Zonegran)................................. 39zonisamide cap 100 mg (Zonegran)............................... 39ZYTIGA – abiraterone acetate tab 250 mg..........................8ZYVOX – linezolid for susp 100 mg/5ml.............................. 7

generics plus drug list · generics plus drug list in texas and oklahoma referred to as preferred...

Documents