Drug List Bcbs2017

Blue Cross and Blue Shield of Illinois
Family Health Plan

2017 Drug List
PLEASE READ:
THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
This formulary is up-to-date through its
publication date, 10/1/2017. Please notify
Blue Cross Community Family Health Plan
at ilmedicaidoperations@bcbsil.com or
1-877-860-2837 TTY/TDD 711 with any
mistakes in the formulary.
IL_FHP_RX 229793.1017
Blue Cross and Blue Shield of Illinois complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield
of Illinois does not exclude people or treat them differently because of race, color, national origin, age,
disability, or sex.
Blue Cross and Blue Shield of Illinois:

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

200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
i
ATTENTION: If you speak English, language assistance services, free of charge, are available to you.
Call 1-855-710-6984 (TTY: 711).
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.

Llame al 1-855-710-6984 (TTY: 711).
UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej.

Zadzwoń pod numer 1-855-710-6984 (TTY: 711).
注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-855-710-6984
（TTY：711）。
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다.

1-855-710-6984 (TTY: 711) 번으로 전화해 주십시오.
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang
walang bayad. Tumawag sa 1-855-710-6984 (TTY: 711).
1-855-710-6984 ‫ اتصل برقم‬.‫ فإن خدمات المساعدة اللغوية تتوافر لك بالمجان‬،‫ إذا كنت تتحدث اذكر اللغة‬:‫ملحوظة‬
.)711:‫(رقم هاتف الصم والبكم‬
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода.
Звоните 1-855-710-6984 (телетайп: 711).
સુચના: જો તમે ગુજરાતી બોલતા હો, તો નન:શુલક ભાષા સહાય સેવાઓ તમારા માટે ઉપલબ્ધ છે . ફોન કરો
1-855-710-6984 (TTY: 711).
‫ تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں ۔ کال کريں‬،‫ اگر آپ اردو بولتے ہیں‬:‫خبردار‬
1-855-710-6984 (TTY: 711).
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn.
Gọi số 1-855-710-6984 (TTY: 711).
ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti.
Chiamare il numero 1-855-710-6984 (TTY: 711).
ध्यान दें: यदि आप हिंदी बोलते हैं तो आपके लिए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं।
1-855-710-6984 (TTY: 711) पर कॉल करें।
ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement.
Appelez le 1-855-710-6984 (ATS: 711).
ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες
παρέχονται δωρεάν. Καλέστε 1-855-710-6984 (TTY: 711).
ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur
Verfügung. Rufnummer: 1-855-710-6984 (TTY: 711).
ii
What is the Blue Cross Community Family –– The information in the “Necessary
Health Plan (the “plan”) drug list? actions, restrictions, or limits on use”
column tells you if Blue Cross
The drug list (sometimes called a formulary) is a list Community Family Health Plan has any
showing the drugs that can be covered by the plan. rules for covering your drug.
The drugs listed will be covered as long as you:
• The drugs are listed in categories, or
• have a medical need for them groups, based on the type of medical
• fill the medication orders at an conditions they treat. (For example, drugs
in-network pharmacy used to treat a heart condition are listed
under Cardiovascular Agents).
• follow the other plan rules
• If you know what your drug is used for,
For more information on how to fill your
look for the group in the drug list.
medication orders, please review your
Member Handbook. • Then, look under that group for your drug.
2. Alphabetical Listing
What will I pay? • Look for your drug in the at the back
You do not pay for covered drugs. of this book.
• Next to your drug, you will see the
Can the drug list change? page number where you can find
Yes, it can change. coverage information.
Coverage may change if: What are generic drugs?
• a new, less expensive generic drug A generic drug is approved by the Food and
becomes available
Drug List
Drug Administration (FDA) as having the same
• new information about a drug shows it to active ingredient as the brand name drug, but
be unsafe or less effective often costs less. The plan covers both brand
name drugs and generic drugs.
You will be told in writing when the drug list
does change.
Are there any limits on my coverage?
How do I use the drug list? Added conditions or limits on some covered
drugs may include:
There are two ways to find your drug in the list
• Prior Authorization: You or your doctor may
beginning on page 1.
need to get approval before you fill your
1. Category medication orders. If you do not get approval,
• The list of covered drugs that begins on the plan may not cover the drug.
page 1 gives you information about the • Quantity Limits: For certain drugs, the plan
drugs covered by Blue Cross Community limits the amount that will be covered.
Family Health Plan. If you have trouble
• Step Therapy: In some cases, the plan
finding your drug in the list, turn to the
requires you to first try certain drugs before
Index that begins at the back of this book. another drug can be covered. For example, if
• The first column of the chart has the name Drug A and Drug B both treat your medical
of the drug. Brand name drugs are condition, the plan may not cover Drug B
capitalized (e.g., CIPRO) and generic drugs unless you try Drug A first. If Drug A does not
are listed in lower-case italics (e.g., ). work for you, the plan will then cover Drug B.
iii
You can find out if your drug has any added Which drug categories are not covered by
conditions or limits by looking at the list that the plan drug list?
begins on page 1. You will find our contact
The following drug categories are not covered by
information below, and the date we last updated
your plan:
the list, on the front and back cover pages.
–– Anorexia, weight loss, or weight
Does the plan pay for over-the-counter gain drugs
(OTC) drugs? –– Bulk chemicals
Yes, the plan pays for certain OTC drugs with –– Cosmetic enhancing drugs
a valid medication order from your doctor, and –– Diagnostic agents
you may get those at no cost. Generic products
–– Drug Efficacy Study Implementation
are to be prescribed and given out when a
(DESI) that are classified as ineffective
vailable. These products are to be filled at a plan
network pharmacy and for quantities up to a –– Experimental and investigational drugs
30-day supply. –– Erectile dysfunction drugs prescribed to
treat impotence
What if my drug is not on the drug list? –– Fertility drugs
Contact Member Services and ask if your drug is –– General anesthetic drugs
covered. If you learn that the plan does not cover
–– Over-the-counter products not
your drug, you have two options:
otherwise included on the plan’s
• Talk to your doctor to decide if you should drug list
first try a different drug on our list before you
–– Surgical supply/medical devices
request an exception.
Drug List
• Ask Member Services about making an For more Information

exception to cover your drug. Send in a
For more details about your plan’s drug
statement from your doctor backing your
coverage, please review your Member Handbook
request. We must decide within 24 hours of
and other plan materials.
getting your doctor’s statement.
If you have any questions, please call Member
We usually only approve requests for exceptions
Services at: 1-877-723-7702 (TTY/TDD 711). We
if the other drugs included on our list or the
are available 24 hours a day, seven (7) days a
added use limits would make your treatment less
week. The call is free.
effective and/or would be harmful to your
health.
iv
Language Assistance
Interpreter Services
We can arrange for someone to help you speak
with us in any language. These services are free.
If your doctor does not speak your language, we
can arrange for a translator to help you. Please
call Member Services at the number above.
Hearing and Vision Problems
For our members with hearing problems, we offer
TTY/TDD service free of charge. The line is open
24 hours a day/seven day a week at 711.
Other Languages and Formats: You can get this
document in Spanish, or speak with someone
about this information in other languages for
free. Call 1-877-860-2837 (TTY/TDD: 711). The
call is free. You can also call Member Services,
toll-free, to request this information in other
alternative formats such as Braille, large print and
other forms. Call Toll Free: 1-877-860-2837
(TTY/TDD: 711). We are available 24 hours a day,
seven (7) days a week. The call is free.
Drug List
v
2017
What the drug Necessary actions,

will cost you restrictions, or limits on
(tier level) use
Name of Drug
ANTI-INFECTIVE DRUGS
PENICILLINS
AMOXICILLIN – amoxicillin (trihydrate) chew tab 125 mg $0 (2)
AMOXICILLIN – amoxicillin (trihydrate) chew tab 250 mg $0 (2)
amoxicillin (trihydrate) cap 250 mg $0 (1)
amoxicillin (trihydrate) cap 500 mg $0 (1)
amoxicillin (trihydrate) for susp 125 mg/5ml $0 (1)
amoxicillin (trihydrate) tab 875 mg $0 (1)
amoxicillin & k clavulanate for susp 200-28.5 mg/5ml $0 (1)
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml $0 (1)
(Augmentin)
amoxicillin & k clavulanate for susp 400-57 mg/5ml $0 (1)
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin $0 (1)
es-600)
amoxicillin & k clavulanate tab 250-125 mg $0 (1)
amoxicillin & k clavulanate tab 500-125 mg (Augmentin) $0 (1)
amoxicillin & k clavulanate tab 875-125 mg (Augmentin) $0 (1)
ampicillin cap 500 mg $0 (1)
dicloxacillin sodium cap 250 mg $0 (1)
dicloxacillin sodium cap 500 mg $0 (1)
penicillin v potassium for soln 125 mg/5ml $0 (1)
penicillin v potassium for soln 250 mg/5ml $0 (1)
penicillin v potassium tab 250 mg $0 (1)
penicillin v potassium tab 500 mg $0 (1)
CEPHALOSPORINS
cefaclor cap 250 mg $0 (1)
cefaclor cap 500 mg $0 (1)
cefadroxil cap 500 mg $0 (1)
cefadroxil for susp 250 mg/5ml $0 (1)
cefadroxil for susp 500 mg/5ml $0 (1)
cefadroxil tab 1 gm $0 (1)
cefdinir cap 300 mg $0 (1)
1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

order
2 = Brand Drugs PA = Prior Authorization QL = Quantity Limits SP = Specialty
3 = Over the Counter Drugs ST = Step Therapy
1
2017

(tier level) use
Name of Drug
cefdinir for susp 125 mg/5ml $0 (1)
cefdinir for susp 250 mg/5ml $0 (1)
cefprozil for susp 125 mg/5ml $0 (1)
cefprozil for susp 250 mg/5ml $0 (1)
cefprozil tab 250 mg $0 (1)
cefprozil tab 500 mg $0 (1)
ceftriaxone sodium for inj 250 mg $0 (1)
ceftriaxone sodium for inj 500 mg $0 (1)
ceftriaxone sodium for inj 1 gm $0 (1)
ceftriaxone sodium for inj 2 gm $0 (1)
cefuroxime axetil tab 250 mg $0 (1)
cefuroxime axetil tab 500 mg $0 (1)
cephalexin cap 250 mg (Keflex) $0 (1)
cephalexin cap 500 mg (Keflex) $0 (1)
cephalexin for susp 125 mg/5ml $0 (1)
cephalexin for susp 250 mg/5ml $0 (1)
MACROLIDES
azithromycin for susp 100 mg/5ml (Zithromax) $0 (1)
azithromycin for susp 200 mg/5ml (Zithromax) $0 (1)
azithromycin tab 250 mg (Zithromax) $0 (1) QL (60 tablets/180 days)
clarithromycin for susp 125 mg/5ml $0 (1)
clarithromycin for susp 250 mg/5ml $0 (1)
clarithromycin tab 250 mg $0 (1)
clarithromycin tab 500 mg (Biaxin) $0 (1)
TETRACYCLINES
demeclocycline hcl tab 150 mg $0 (1)
doxycycline hyclate cap 50 mg $0 (1)
doxycycline hyclate cap 100 mg (Vibramycin) $0 (1)
doxycycline hyclate tab 20 mg $0 (1)
doxycycline hyclate tab 100 mg $0 (1)
doxycycline monohydrate cap 50 mg $0 (1)
doxycycline monohydrate cap 100 mg (Monodox) $0 (1)
doxycycline monohydrate for susp 25 mg/5ml (Vibramycin) $0 (1)

order
2
2017

(tier level) use
Name of Drug
doxycycline monohydrate tab 50 mg $0 (1)
minocycline hcl cap 50 mg (Minocin) $0 (1)
minocycline hcl cap 75 mg $0 (1)
minocycline hcl cap 100 mg (Minocin) $0 (1)
minocycline hcl tab 50 mg $0 (1)
FLUOROQUINOLONES
ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) (Cipro) $0 (1)
ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) $0 (1)
(Cipro)
ciprofloxacin hcl tab 250 mg (base equiv) (Cipro) $0 (1)
ciprofloxacin hcl tab 500 mg (base equiv) (Cipro) $0 (1)
ciprofloxacin hcl tab 750 mg (base equiv) $0 (1)
LEVOFLOXACIN – levofloxacin oral soln 25 mg/ml $0 (2)
levofloxacin tab 250 mg (Levaquin) $0 (1)
SULFADIAZINE – sulfadiazine tab 500 mg $0 (1)
AMINOGLYCOSIDES
neomycin sulfate tab 500 mg $0 (1)
paromomycin sulfate cap 250 mg $0 (1)
tobramycin nebu soln 300 mg/5ml (Tobi) $0 (1) QL (56 ampules/56 days), SP
TUBERCULOSIS
ethambutol hcl tab 100 mg (Myambutol) $0 (1)
ethambutol hcl tab 400 mg (Myambutol) $0 (1)
isoniazid tab 100 mg $0 (1) 90
isoniazid tab 300 mg $0 (1) 90
PRIFTIN – rifapentine tab 150 mg $0 (2)
pyrazinamide tab 500 mg $0 (1)
rifabutin cap 150 mg (Mycobutin) $0 (1)
rifampin cap 150 mg (Rifadin) $0 (1)
rifampin cap 300 mg $0 (1)

order
3
2017

(tier level) use
Name of Drug
FUNGAL INFECTIONS
fluconazole for susp 10 mg/ml (Diflucan) $0 (1)
fluconazole for susp 40 mg/ml (Diflucan) $0 (1)
fluconazole tab 50 mg (Diflucan) $0 (1)
flucytosine cap 250 mg (Ancobon) $0 (1)
flucytosine cap 500 mg (Ancobon) $0 (1)
griseofulvin microsize susp 125 mg/5ml $0 (1)
griseofulvin microsize tab 500 mg $0 (1)
griseofulvin ultramicrosize tab 125 mg (Gris-peg) $0 (1)
griseofulvin ultramicrosize tab 250 mg (Gris-peg) $0 (1)
itraconazole cap 100 mg (Sporanox) $0 (1) QL (120 capsules/30 days)
ketoconazole tab 200 mg $0 (1)
NOXAFIL – posaconazole tab delayed release 100 mg $0 (2) PA, 90
NOXAFIL – posaconazole susp 40 mg/ml $0 (2) PA, 90
nystatin tab 500000 unit $0 (1)
terbinafine hcl tab 250 mg (Lamisil) $0 (1)
voriconazole for susp 40 mg/ml (Vfend) $0 (1) PA
voriconazole tab 50 mg (Vfend) $0 (1) PA
voriconazole tab 200 mg (Vfend) $0 (1) PA
VIRAL INFECTIONS
Cytomegalovirus
valganciclovir hcl tab 450 mg (base equivalent) (Valcyte) $0 (1) 90
Hepatitis
BARACLUDE – entecavir oral soln 0.05 mg/ml $0 (2) 90
entecavir tab 0.5 mg (Baraclude) $0 (1) 90
entecavir tab 1 mg (Baraclude) $0 (1) 90
EPCLUSA – sofosbuvir-velpatasvir tab 400-100 mg $0 (2) PA, SP
lamivudine tab 100 mg (hbv) (Epivir hbv) $0 (1) 90
MAVYRET – glecaprevir-pibrentasvir tab 100-40 mg $0 (1) PA, SP
ribavirin cap 200 mg (Rebetol) $0 (1) SP
SOVALDI – sofosbuvir tab 400 mg $0 (2) PA, SP
ZEPATIER – elbasvir-grazoprevir tab 50-100 mg $0 (2) PA, SP

order
4
2017

(tier level) use
Name of Drug
Herpes
acyclovir cap 200 mg (Zovirax) $0 (1)
acyclovir susp 200 mg/5ml (Zovirax) $0 (1)
acyclovir tab 400 mg (Zovirax) $0 (1)
acyclovir tab 800 mg (Zovirax) $0 (1)
valacyclovir hcl tab 500 mg (Valtrex) $0 (1)
valacyclovir hcl tab 1 gm (Valtrex) $0 (1)
HIV/AIDS
abacavir sulfate tab 300 mg (base equiv) (Ziagen) $0 (1) QL (60 tablets/30 days)
abacavir sulfate-lamivudine tab 600-300 mg (Epzicom) $0 (1) QL (30 tablets/30 days)
abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg $0 (1) QL (60 tablets/30 days)
(Trizivir)
APTIVUS – tipranavir cap 250 mg $0 (2) QL (120 capsules/30 days)
APTIVUS – tipranavir oral soln 100 mg/ml $0 (2) QL (4 bottles/30 days)
ATRIPLA – efavirenz-emtricitabine-tenofovir df tab $0 (2) QL (30 tablets/30 days)
600-200-300 mg
CRIXIVAN – indinavir sulfate cap 200 mg $0 (2) QL (270 capsules/30 days)
CRIXIVAN – indinavir sulfate cap 400 mg $0 (2) QL (180 capsules/30 days)
DESCOVY – emtricitabine-tenofovir alafenamide fumarate tab $0 (2) QL (30 tablets/30 days)
200-25 mg
didanosine delayed release capsule 125 mg (Videx ec) $0 (1) QL (30 capsules/30 days)
EDURANT – rilpivirine hcl tab 25 mg (base equivalent) $0 (2) QL (30 tablets/30 days)
EMTRIVA – emtricitabine caps 200 mg $0 (2) QL (30 capsules/30 days)
EMTRIVA – emtricitabine soln 10 mg/ml $0 (2) QL (720 mls/30 days)
GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab $0 (2) QL (30 tablets/30 days)
150-150-200-10 mg
INTELENCE – etravirine tab 25 mg $0 (2) QL (120 tablets/30 days)
INVIRASE – saquinavir mesylate cap 200 mg $0 (2) QL (300 capsules/30 days)
INVIRASE – saquinavir mesylate tab 500 mg $0 (2) QL (120 tablets/30 days)
ISENTRESS – raltegravir potassium packet for susp 100 mg $0 (2) QL (60 packets/30 days)
(base equiv)
ISENTRESS – raltegravir potassium tab 400 mg (base equiv) $0 (2) QL (60 tablets/30 days)

order
5
2017

(tier level) use
Name of Drug
ISENTRESS – raltegravir potassium chew tab 25 mg (base $0 (2) QL (180 tablets/30 days)
equiv)
ISENTRESS – raltegravir potassium chew tab 100 mg (base $0 (2) QL (180 tablets/30 days)
equiv)
ISENTRESS HD – raltegravir potassium tab 600 mg (base equiv) $0 (2) QL (60 tablets/30 days)
KALETRA – lopinavir-ritonavir tab 100-25 mg $0 (2) QL (180 tablets/30 days)
KALETRA – lopinavir-ritonavir tab 200-50 mg $0 (2) QL (120 tablets/30 days)
lamivudine oral soln 10 mg/ml (Epivir) $0 (1) QL (4 bottles/30 days)
lamivudine tab 150 mg (Epivir) $0 (1) QL (30 tablets/30 days)
lamivudine tab 300 mg (Epivir) $0 (1) QL (30 tablets/30 days)
lamivudine-zidovudine tab 150-300 mg (Combivir) $0 (1) QL (60 tablets/30 days)
LEXIVA – fosamprenavir calcium tab 700 mg (base equiv) $0 (2) QL (120 tablets/30 days)
LEXIVA – fosamprenavir calcium susp 50 mg/ml (base equiv) $0 (2) QL (8 bottles/30 days)
lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) (Kaletra) $0 (1) QL (480 mls/30 days)
nevirapine tab er 24hr 100 mg (Viramune xr) $0 (1) QL (90 tablets/30 days)
nevirapine tab er 24hr 400 mg (Viramune xr) $0 (1) QL (30 tablets/30 days)
nevirapine tab 200 mg (Viramune) $0 (1) QL (60 tablets/30 days)
NORVIR – ritonavir cap 100 mg $0 (2) QL (360 capsules/30 days)
NORVIR – ritonavir tab 100 mg $0 (2) QL (360 tablets/30 days)
NORVIR – ritonavir oral soln 80 mg/ml $0 (2) QL (2 bottles/30 days)
PREZISTA – darunavir ethanolate susp 100 mg/ml (base equiv) $0 (2) QL (2 bottles/30 days)
PREZISTA – darunavir ethanolate tab 75 mg (base equiv) $0 (2) QL (300 tablets/30 days)
RESCRIPTOR – delavirdine mesylate tab 100 mg $0 (2) QL (90 tablets/30 days)
RESCRIPTOR – delavirdine mesylate tab 200 mg $0 (2) QL (180 tablets/30 days)
REYATAZ – atazanavir sulfate oral powder packet 50 mg (base $0 (2) QL (240 packets/30 days)
equiv)
REYATAZ – atazanavir sulfate cap 150 mg (base equiv) $0 (2) QL (30 capsules/30 days)
SELZENTRY – maraviroc tab 25 mg $0 (2) QL (240 tablets/30 days)
stavudine cap 15 mg (Zerit) $0 (1) QL (60 capsules/30 days)

order
6
2017

(tier level) use
Name of Drug
SUSTIVA – efavirenz tab 600 mg $0 (2) QL (30 tablets/30 days)
SUSTIVA – efavirenz cap 50 mg $0 (2) QL (90 tablets/30 days)
SUSTIVA – efavirenz cap 200 mg $0 (2) QL (60 tablets/30 days)
TIVICAY – dolutegravir sodium tab 10 mg (base equiv) $0 (2) QL (60 tablets/30 days)
TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab $0 (2) QL (30 tablets/30 days)
100-150 mg
133-200 mg
167-250 mg
200-300 mg
VIDEX – didanosine for soln 2 gm $0 (2) QL (1200 mls/30 days)
VIDEX – didanosine for soln 4 gm $0 (2) QL (1200 mls/30 days)
VIRACEPT – nelfinavir mesylate tab 250 mg $0 (2) QL (270 tablets/30 days)
VIRACEPT – nelfinavir mesylate tab 625 mg $0 (2) QL (120 tablets/30 days)
VIRAMUNE – nevirapine susp 50 mg/5ml $0 (2) QL (5 bottles/30 days)
VIREAD – tenofovir disoproxil fumarate oral powder 40 mg/gm $0 (2) QL (4 bottles/30 days)
VIREAD – tenofovir disoproxil fumarate tab 150 mg $0 (2) QL (30 tablets/30 days)
ZIAGEN – abacavir sulfate soln 20 mg/ml (base equiv) $0 (2) QL (4 bottles/30 days)
zidovudine cap 100 mg (Retrovir) $0 (1) QL (180 capsules/30 days)
zidovudine syrup 10 mg/ml (Retrovir) $0 (1) QL (8 bottles/30 days)
zidovudine tab 300 mg $0 (1) QL (60 tablets/30 days)
Influenza
oseltamivir phosphate cap 30 mg (base equiv) (Tamiflu) $0 (1) QL (40 capsules/120 days)
RELENZA DISKHALER – zanamivir aero powder breath $0 (2) QL (20 disks/120 days)
activated 5 mg/blister

order
7
2017

(tier level) use
Name of Drug
TAMIFLU – oseltamivir phosphate for susp 6 mg/ml (base equiv) $0 (2) QL (360 mls/120 days)
MALARIA
atovaquone-proguanil hcl tab 62.5-25 mg (Malarone) $0 (1)
atovaquone-proguanil hcl tab 250-100 mg (Malarone) $0 (1)
CHLOROQUINE PHOSPHATE – chloroquine phosphate tab $0 (2) 90
250 mg
chloroquine phosphate tab 500 mg $0 (1) 90
DARAPRIM – pyrimethamine tab 25 mg $0 (2)
hydroxychloroquine sulfate tab 200 mg (Plaquenil) $0 (1) 90
mefloquine hcl tab 250 mg $0 (1) 90
PRIMAQUINE PHOSPHATE – primaquine phosphate tab $0 (2)
26.3 mg (15 mg base)
WORM INFECTIONS
ALBENZA – albendazole tab 200 mg $0 (2)
BILTRICIDE – praziquantel tab 600 mg $0 (2)
ivermectin tab 3 mg (Stromectol) $0 (1)
OTHER ANTI-INFECTIVES
atovaquone susp 750 mg/5ml (Mepron) $0 (1)
clindamycin hcl cap 75 mg (Cleocin) $0 (1)
clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) $0 (1)
(Cleocin pediatric gr)
dapsone tab 25 mg $0 (1) 90
dapsone tab 100 mg $0 (1) 90
linezolid for susp 100 mg/5ml (Zyvox) $0 (1) QL (600 mls/180 days)
linezolid tab 600 mg (Zyvox) $0 (1) QL (56 tablets/180 days)
metronidazole cap 375 mg (Flagyl) $0 (1)
metronidazole tab 250 mg (Flagyl) $0 (1)
metronidazole tab 500 mg (Flagyl) $0 (1)
sulfamethoxazole-trimethoprim susp 200-40 mg/5ml $0 (1)
sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim) $0 (1)
sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds) $0 (1)
trimethoprim tab 100 mg $0 (1)
vancomycin hcl cap 125 mg (Vancocin hcl) $0 (1)
vancomycin hcl cap 250 mg (Vancocin hcl) $0 (1)

order
8
2017

(tier level) use
Name of Drug
XIFAXAN – rifaximin tab 200 mg $0 (2) PA, QL (9 tablets/30 days)
XIFAXAN – rifaximin tab 550 mg $0 (2) PA, QL (60 tablets/30
days), 90
ZYVOX – linezolid for susp 100 mg/5ml $0 (2) QL (4 bottles/180 days)
IMMUNIZING AGENTS
AFLURIA PF 2015-2016 – influenza virus vaccine split pf susp $0 (2)
pref syringe 0.5 ml
pref syringe 0.5 ml
pref syringe 0.5 ml
AFLURIA QUADRIVALENT 2016 – influenza virus vac split $0 (2)
quadrivalent susp pref syr 0.5ml
AFLURIA QUADRIVALENT 2017 – influenza virus vac split $0 (2)
AFLURIA QUADRIVALENT 2017 – influenza virus vaccine split $0 (2)
quadrivalent im inj
AFLURIA 2015-2016 – influenza virus vaccine split im susp $0 (2)
FLUAD 2016-2017 – influenza vac type a&b surface ant adj susp $0 (2)
pref syr 0.5 ml
FLUARIX QUADRIVALENT 2015 – influenza virus vac split $0 (2)
FLUCELVAX QUADRIVALENT 20 – influenza vac tiss-cult subunt $0 (2)
quad susp pref syr 0.5 ml
FLUCELVAX QUADRIVALENT 20 – influenza vac tissue-cultured $0 (1)
subunit quadrivalent im susp
FLULAVAL QUADRIVALENT 201 – influenza virus vac split $0 (2)
FLULAVAL QUADRIVALENT 201 – influenza virus vaccine split $0 (2)
quadrivalent im inj
FLULAVAL 2014-2015 – influenza virus vaccine split im susp $0 (2)
FLUVIRIN 2015-2016 – influenza vac type a&b surface antigen $0 (2)
susp pref syr 0.5 ml
FLUVIRIN 2015-2016 – influenza virus vaccine types a & b $0 (2)
surface antigen im susp

order
9
2017

(tier level) use
Name of Drug
FLUZONE HIGH-DOSE PF 2015 – influenza virus vac split high- $0 (2) AL
dose pf susp pref syr 0.5ml
FLUZONE QUADRIVALENT 2015 – influenza virus vac split $0 (2)
FLUZONE QUADRIVALENT 2015 – influenza virus vaccine split $0 (2)
quadrivalent im inj
quadrivalent im inj
quadrivalent inj 0.5 ml
quadrivalent im inj
FLUZONE SPLIT 2015-2016 – influenza virus vaccine split im $0 (2)
susp
SYNAGIS – palivizumab im soln 50 mg/0.5ml $0 (1) PA, SP
SYNAGIS – palivizumab im soln 100 mg/ml $0 (1) PA, SP
CANCER DRUGS
ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml $0 (2) PA, QL (12 vials/28 days), SP
(2000000 unit/0.5ml)
AFINITOR – everolimus tab 2.5 mg $0 (2) PA, QL (30 tablets/30
days), SP
AFINITOR – everolimus tab 5 mg $0 (2) PA, QL (30 tablets/30
days), SP
AFINITOR – everolimus tab 7.5 mg $0 (2) PA, QL (30 tablets/30
days), SP

order
10
2017

(tier level) use
Name of Drug
AFINITOR – everolimus tab 10 mg $0 (2) PA, QL (30 tablets/30
days), SP
AFINITOR DISPERZ – everolimus tab for oral susp 2 mg $0 (2) PA, QL (60 tablets/30
days), SP
days), SP
days), SP
ALKERAN – melphalan tab 2 mg $0 (2)
anastrozole tab 1 mg (Arimidex) $0 (1) 90
bexarotene cap 75 mg (Targretin) $0 (1) PA, SP
bicalutamide tab 50 mg (Casodex) $0 (1)
capecitabine tab 150 mg (Xeloda) $0 (1) PA, SP
capecitabine tab 500 mg (Xeloda) $0 (1) PA, SP
COTELLIC – cobimetinib fumarate tab 20 mg (base equivalent) $0 (2) PA, QL (63 tablets/28 days)
CYCLOPHOSPHAMIDE – cyclophosphamide cap 25 mg $0 (2)
CYCLOPHOSPHAMIDE – cyclophosphamide cap 50 mg $0 (2)
CYTARABINE – cytarabine inj 20 mg/ml $0 (2)
exemestane tab 25 mg (Aromasin) $0 (1) 90
flutamide cap 125 mg $0 (1)
hydroxyurea cap 500 mg (Hydrea) $0 (1)
IBRANCE – palbociclib cap 75 mg $0 (2) PA, QL (21 capsules/28
days), SP
days), SP
days), SP
imatinib mesylate tab 100 mg (base equivalent) (Gleevec) $0 (1) PA, QL (90 tablets/30), SP
imatinib mesylate tab 400 mg (base equivalent) (Gleevec) $0 (1) PA, QL (60 tablets/30
days), SP
KISQALI – ribociclib succinate tab 200 mg (base equiv) $0 (2) PA, QL (63 tablets/28 days)
KISQALI FEMARA 200 DOSE – ribociclib tab 200 mg & letrozole $0 (1) PA, QL (91 tablets/28 days)
tab 2.5 mg therapy pack

order
11
2017

(tier level) use
Name of Drug
LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapy pack $0 (2) PA, QL (30 capsules/30
10 mg (10 mg daily dose) days), SP
LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapy pack 10 $0 (2) PA, QL (60 capsules/30
& 4 mg (14 mg daily dose) days), SP
LENVIMA 18 MG DAILY DOSE – lenvatinib cap therapy pack 10 $0 (2) PA, QL (90 capsules/30 days)
& 4 (2) mg (18 mg daily dose)
(2) mg (20 mg daily dose) days), SP
(2) & 4 mg (24 mg daily dose) days), SP
LENVIMA 8 MG DAILY DOSE – lenvatinib cap therapy pack 4 $0 (2) PA, QL (60 capsules/30 days)
(2) mg (8 mg daily dose)
letrozole tab 2.5 mg (Femara) $0 (1) 90
LEUCOVORIN CALCIUM – leucovorin calcium tab 10 mg $0 (2)
LEUCOVORIN CALCIUM – leucovorin calcium tab 15 mg $0 (2)
leucovorin calcium tab 5 mg $0 (1)
leucovorin calcium tab 25 mg $0 (1)
LEUKERAN – chlorambucil tab 2 mg $0 (2)
LYNPARZA – olaparib cap 50 mg $0 (2) PA, QL (480
capsules/30 days), SP
megestrol acetate susp 40 mg/ml $0 (1)
megestrol acetate tab 20 mg $0 (1)
megestrol acetate tab 40 mg $0 (1)
MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg (base $0 (2) PA, QL (90 tablets/30
equivalent) days), SP
MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base $0 (2) PA, QL (30 tablets/30
equivalent) days), SP
melphalan tab 2 mg (Alkeran) $0 (1)
mercaptopurine tab 50 mg $0 (1)
METHOTREXATE SODIUM – methotrexate sodium inj $0 (2)
250 mg/10ml (25 mg/ml)
methotrexate sodium tab 2.5 mg (base equiv) $0 (1)
MYLERAN – busulfan tab 2 mg $0 (2)
NEXAVAR – sorafenib tosylate tab 200 mg (base equivalent) $0 (2) PA, QL (120
tablets/30 days), SP
RUBRACA – rucaparib camsylate tab 200 mg (base equivalent) $0 (2) PA, QL (120 tablets/30 days)

order
12
2017

(tier level) use
Name of Drug
RYDAPT – midostaurin cap 25 mg $0 (1) PA, QL (240
capsules/30 days)
SPRYCEL – dasatinib tab 20 mg $0 (2) PA, QL (60 tablets/30
days), SP
days), SP
days), SP
days), SP
days), SP
days), SP
STIVARGA – regorafenib tab 40 mg $0 (2) PA, QL (84 tablets/28
days), SP
SUTENT – sunitinib malate cap 12.5 mg (base equivalent) $0 (2) PA, QL (90 capsules/30
days), SP
SUTENT – sunitinib malate cap 25 mg (base equivalent) $0 (2) PA, QL (30 capsules/30
days), SP
SUTENT – sunitinib malate cap 37.5 mg (base equivalent) $0 (2) PA, QL (30 capsules/30
days), SP
SUTENT – sunitinib malate cap 50 mg (base equivalent) $0 (2) PA, QL (30 capsules/30
days), SP
tamoxifen citrate tab 10 mg (base equivalent) $0 (1) 90
tamoxifen citrate tab 20 mg (base equivalent) $0 (1) 90
TARCEVA – erlotinib hcl tab 25 mg (base equivalent) $0 (2) PA, QL (60 tablets/30
days), SP
days), SP
days), SP
TASIGNA – nilotinib hcl cap 150 mg (base equivalent) $0 (2) PA, QL (120
TASIGNA – nilotinib hcl cap 200 mg (base equivalent) $0 (2) PA, QL (120
temozolomide cap 5 mg (Temodar) $0 (1) PA, SP

order
13
2017

(tier level) use
Name of Drug
tretinoin cap 10 mg $0 (1) PA, SP
VOTRIENT – pazopanib hcl tab 200 mg (base equiv) $0 (2) PA, QL (120
XALKORI – crizotinib cap 200 mg $0 (2) PA, QL (60 capsules/30
days), SP
XALKORI – crizotinib cap 250 mg $0 (2) PA, QL (60 capsules/30
days), SP
XTANDI – enzalutamide cap 40 mg $0 (2) PA, QL (120
ZELBORAF – vemurafenib tab 240 mg $0 (2) PA, QL (240
ZYTIGA – abiraterone acetate tab 250 mg $0 (2) PA, QL (120
ZYTIGA – abiraterone acetate tab 500 mg $0 (2) PA, QL (60 tablets/30 days)
HORMONES, DIABETES AND RELATED DRUGS
CORTICOSTEROIDS
budesonide delayed release particles cap 3 mg (Entocort ec) $0 (1)
CORTISONE ACETATE – cortisone acetate tab 25 mg $0 (2)
DEXAMETHASONE – dexamethasone soln 0.5 mg/5ml $0 (2)
dexamethasone elixir 0.5 mg/5ml $0 (1)
dexamethasone tab 0.5 mg $0 (1)
dexamethasone tab 4 mg $0 (1)
dexamethasone tab 6 mg $0 (1)
fludrocortisone acetate tab 0.1 mg $0 (1) 90
hydrocortisone tab 5 mg (Cortef) $0 (1)
methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak) $0 (1)
methylprednisolone tab 4 mg (Medrol) $0 (1)

order
14
2017

(tier level) use
Name of Drug
prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) $0 (1)
(Pediapred)
prednisolone sod phosphate oral soln 15 mg/5ml (base equiv) $0 (1)
prednisolone syrup 15 mg/5ml (usp solution equivalent) $0 (1)
PREDNISONE – prednisone tab 50 mg $0 (2)
PREDNISONE – prednisone oral soln 5 mg/5ml $0 (2)
prednisone tab 1 mg $0 (1)
prednisone tab 2.5 mg $0 (1)
MALE HORMONES
danazol cap 50 mg $0 (1)
testosterone cypionate im inj in oil 100 mg/ml (Depo- $0 (1) QL (10 mls/28 days)
testosterone)
testosterone cypionate im inj in oil 200 mg/ml (Depo- $0 (1) QL (10 mls/28 days)
testosterone)
testosterone enanthate im inj in oil 200 mg/ml $0 (1) QL (1 vial/28 days)
ESTROGENS
COMBIPATCH – estradiol-norethindrone ace td pttw $0 (2) 90
0.05-0.14 mg/day
COMBIPATCH – estradiol-norethindrone ace td pttw $0 (2) 90
0.05-0.25 mg/day
estradiol & norethindrone acetate tab 0.5-0.1 mg (Activella) $0 (1) 90
estradiol & norethindrone acetate tab 1-0.5 mg (Activella) $0 (1) 90
estradiol tab 0.5 mg (Estrace) $0 (1) 90
estradiol tab 1 mg (Estrace) $0 (1) 90
estradiol tab 2 mg (Estrace) $0 (1) 90
estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-dot) $0 (1) QL (8 patches/30 days), 90

order
15
2017

(tier level) use
Name of Drug
estradiol td patch weekly 0.025 mg/24hr (Climara) $0 (1) QL (4 patches/30 days), 90
estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr) $0 (1) QL (4 patches/30 days), 90
(Climara)
ESTROPIPATE – estropipate tab 0.75 mg $0 (2) 90
ESTROPIPATE – estropipate tab 1.5 mg $0 (2) 90
ESTROPIPATE – estropipate tab 3 mg $0 (2) 90
norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg $0 (1) 90
PREMPRO – conjugated estrogen-medroxyprogest acetate tab $0 (2) 90
0.3-1.5 mg
0.45-1.5 mg
0.625-5 mg
PROGESTINS
medroxyprogesterone acetate tab 2.5 mg (Provera) $0 (1) 90
medroxyprogesterone acetate tab 5 mg (Provera) $0 (1) 90
medroxyprogesterone acetate tab 10 mg (Provera) $0 (1) 90
megestrol acetate susp 625 mg/5ml (Megace es) $0 (1) 90
norethindrone acetate tab 5 mg (Aygestin) $0 (1) 90
progesterone im in oil 50 mg/ml $0 (1)
progesterone micronized cap 100 mg (Prometrium) $0 (1) 90
progesterone micronized cap 200 mg (Prometrium) $0 (1) 90
BIRTH CONTROL
CONDOMS - various $0 (3)
DEPO-PROVERA CONTRACEPTIV – medroxyprogesterone $0 (2) 90
acetate im susp 150 mg/ml
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) $0 (1) QL (28 tablets/21 days), 90
(Mircette)
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg (Desogen) $0 (1) QL (28 tablets/21 days), 90
DIAPHRAGMS - various $0 (2)
drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin 28) $0 (1) QL (28 tablets/21 days), 90
ELLA – ulipristal acetate tab 30 mg $0 (2) QL (3 tablets/365 days)
ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg $0 (1) QL (28 tablets/21 days), 90

order
16
2017

(tier level) use
Name of Drug
KYLEENA – levonorgestrel releasing iud 17.5 mcg/day (19.5 mg $0 (2)
total)
levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg $0 (1) QL (28 tablets/21 days), 90
levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg $0 (1) QL (28 tablets/21 days), 90
levonorgestrel tab 1.5 mg $0 (3) QL (3 tablets/365 days)
levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg $0 (1) QL (28 tablets/21 days), 90
medroxyprogesterone acetate im susp 150 mg/ml (Depo-provera $0 (1) 90
contrac)
MIRENA – levonorgestrel releasing iud 20 mcg/day (52 mg total) $0 (2) 90
NECON 10/11-28 – norethindrone-eth estradiol tab $0 (2) QL (28 tablets/21 days), 90
0.5-35/1-35 mg-mcg (10/11)
NEXPLANON – etonogestrel subdermal implant 68 mg $0 (2) 90
norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg (Loestrin $0 (1) QL (28 tablets/21 days), 90
1/20-21)
norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg $0 (1) QL (28 tablets/21 days), 90
(Loestrin 1.5/30-21)
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg $0 (1) QL (28 tablets/21 days), 90
(Loestrin fe 1/20)
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg (Ortho- $0 (1) QL (28 tablets/21 days), 90
cyclen)
norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg $0 (1) QL (28 tablets/21 days), 90
(Ortho tri-cyclen lo)
norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg $0 (1) QL (28 tablets/21 days), 90
(Ortho tri-cyclen)
NUVARING – etonogestrel-ethinyl estradiol va ring $0 (2) QL (1 ring/21 days), 90
0.120-0.015 mg/24hr
PARAGARD INTRAUTERINE COP – copper iud $0 (2) 90
PLAN B ONE-STEP – levonorgestrel tab 1.5 mg $0 (3) QL (3 tablets/365 days)
SKYLA – levonorgestrel releasing iud 14 mcg/day (13.5 mg total) $0 (2) 90
XULANE – norelgestromin-ethinyl estradiol td ptwk $0 (2) QL (4 patches/21 days), 90
150-35 mcg/24hr
DIABETES
acarbose tab 25 mg (Precose) $0 (1) QL (180 tablets/30 days), 90
ALOGLIPTIN – alogliptin benzoate tab 6.25 mg (base equiv) $0 (2) QL (30 tablets/30
days), ST, 90
ALOGLIPTIN – alogliptin benzoate tab 12.5 mg (base equiv) $0 (2) QL (30 tablets/30
days), ST, 90

order
17
2017

(tier level) use
Name of Drug
ALOGLIPTIN – alogliptin benzoate tab 25 mg (base equiv) $0 (2) QL (30 tablets/30
days), ST, 90
ALOGLIPTIN/METFORMIN HCL – alogliptin-metformin hcl tab $0 (2) QL (60 tablets/30
12.5-500 mg days), ST, 90
ALOGLIPTIN/METFORMIN HCL – alogliptin-metformin hcl tab $0 (2) QL (60 tablets/30
12.5-1000 mg days), ST, 90
ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab $0 (2) QL (30 tablets/30
12.5-15 mg days), ST, 90
12.5-30 mg days), ST, 90
12.5-45 mg days), ST, 90
25-15 mg days), ST, 90
25-30 mg days), ST, 90
25-45 mg days), ST, 90
glimepiride tab 1 mg (Amaryl) $0 (1) QL (60 tablets/30 days), 90
glipizide tab er 24hr 2.5 mg (Glucotrol xl) $0 (1) QL (60 tablets/30 days), 90
glipizide tab er 24hr 5 mg (Glucotrol xl) $0 (1) QL (90 tablets/30 days), 90
glipizide tab er 24hr 10 mg (Glucotrol xl) $0 (1) QL (60 tablets/30 days), 90
glipizide tab 5 mg (Glucotrol) $0 (1) QL (120 tablets/30 days), 90
glipizide tab 10 mg (Glucotrol) $0 (1) QL (120 tablets/30 days), 90
GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj kit 1 mg $0 (2) QL (6 pens/365 days)
glyburide micronized tab 1.5 mg (Glynase) $0 (1) QL (120 tablets/30 days), 90
glyburide micronized tab 3 mg (Glynase) $0 (1) QL (60 tablets/30 days), 90
glyburide micronized tab 6 mg (Glynase) $0 (1) QL (60 tablets/30 days), 90
glyburide tab 1.25 mg $0 (1) QL (60 tablets/30 days), 90
glyburide tab 2.5 mg $0 (1) QL (60 tablets/30 days), 90
glyburide tab 5 mg $0 (1) QL (120 tablets/30 days), 90
glyburide-metformin tab 1.25-250 mg $0 (1) QL (120 tablets/30 days), 90
glyburide-metformin tab 2.5-500 mg (Glucovance) $0 (1) QL (120 tablets/30 days), 90
glyburide-metformin tab 5-500 mg (Glucovance) $0 (1) QL (120 tablets/30 days), 90
metformin hcl tab er 24hr 500 mg (Glucophage xr) $0 (1) QL (120 tablets/30 days), 90

order
18
2017

(tier level) use
Name of Drug
metformin hcl tab er 24hr 750 mg (Glucophage xr) $0 (1) QL (60 tablets/30 days), 90
metformin hcl tab 500 mg (Glucophage) $0 (1) QL (120 tablets/30 days), 90
nateglinide tab 60 mg (Starlix) $0 (1) QL (120 tablets/30 days), 90
nateglinide tab 120 mg (Starlix) $0 (1) QL (90 tablets/30 days), 90
pioglitazone hcl tab 15 mg (base equiv) (Actos) $0 (1) QL (30 tablets/30 days), 90
TOLAZAMIDE – tolazamide tab 250 mg $0 (2) QL (90 tablets/30 days), 90
VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) $0 (2) QL (3 pens/30 days), ST, 90
DIABETES - INSULINS
Rapid-Acting Insulins
HUMALOG – insulin lispro soln cartridge 100 unit/ml $0 (2) QL (45 mls/30 days), 90
HUMALOG – insulin lispro inj 100 unit/ml $0 (2) QL (45 mls/30 days), 90
HUMALOG JUNIOR KWIKPEN – insulin lispro soln pen-injector $0 (2) QL (45 mls/30 days), 90
100 unit/ml
HUMALOG KWIKPEN – insulin lispro soln pen-injector 100 unit/ $0 (2) QL (45 mls/30 days), 90
ml
HUMALOG KWIKPEN – insulin lispro soln pen-injector 200 unit/ $0 (2) QL (24 mls/30 days), 90
ml
NOVOLOG – insulin aspart inj 100 unit/ml $0 (2) QL (45 mls/30 days), 90
NOVOLOG FLEXPEN – insulin aspart soln pen-injector 100 unit/ $0 (2) QL (45 mls/30 days), 90
ml
NOVOLOG PENFILL – insulin aspart soln cartridge 100 unit/ml $0 (2) QL (45 mls/30 days), 90
Short-Acting Insulins
HUMULIN R – insulin regular (human) inj 100 unit/ml $0 (3) QL (45 mls/30 days), 90
NOVOLIN R – insulin regular (human) inj 100 unit/ml $0 (3) QL (45 mls/30 days), 90
NOVOLIN R RELION – insulin regular (human) inj 100 unit/ml $0 (3) QL (45 mls/30 days), 90
Intermediate-Acting Insulins
HUMALOG MIX 50/50 – insulin lispro protamine & lispro inj 100 $0 (2) QL (45 mls/30 days), 90
unit/ml (50-50)
HUMALOG MIX 50/50 KWIKPEN – insulin lispro prot & lispro sus $0 (2) QL (45 mls/30 days), 90
pen-inj 100 unit/ml (50-50)
HUMALOG MIX 75/25 – insulin lispro prot & lispro inj 100 unit/ml $0 (2) QL (45 mls/30 days), 90
(75-25)
HUMALOG MIX 75/25 KWIKPEN – insulin lispro prot & lispro sus $0 (2) QL (45 mls/30 days), 90
pen-inj 100 unit/ml (75-25)

order
19
2017

(tier level) use
Name of Drug
HUMULIN N – insulin nph (human) (isophane) inj 100 unit/ml $0 (3) QL (45 mls/30 days), 90
HUMULIN N KWIKPEN – insulin nph (human) (isophane) susp $0 (3) QL (45 mls/30 days), 90
pen-injector 100 unit/ml
HUMULIN 70/30 – insulin nph isophane & regular human inj 100 $0 (3) QL (45 mls/30 days), 90
unit/ml (70-30)
HUMULIN 70/30 KWIKPEN – insulin nph & regular susp pen-inj $0 (3) QL (45 mls/30 days), 90
100 unit/ml (70-30)
NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ml $0 (3) QL (45 mls/30 days), 90
NOVOLIN N RELION – insulin nph (human) (isophane) inj 100 $0 (3) QL (45 mls/30 days), 90
unit/ml
NOVOLIN 70/30 – insulin nph isophane & regular human inj 100 $0 (3) QL (45 mls/30 days), 90
unit/ml (70-30)
NOVOLIN 70/30 RELION – insulin nph isophane & regular $0 (3) QL (45 mls/30 days), 90
human inj 100 unit/ml (70-30)
NOVOLOG MIX 70/30 – insulin aspart prot & aspart (human) inj $0 (2) QL (45 mls/30 days), 90
100 unit/ml (70-30)
NOVOLOG MIX 70/30 PREFILL – insulin aspart prot & aspart $0 (2) QL (45 mls/30 days), 90
sus pen-inj 100 unit/ml (70-30)
Basal Insulins
BASAGLAR KWIKPEN – insulin glargine soln pen-injector 100 $0 (2) QL (45 mls/30 days), 90
unit/ml
THYROID REGULATION
levothyroxine sodium tab 25 mcg (Synthroid) $0 (1) 90
liothyronine sodium tab 5 mcg (Cytomel) $0 (1) 90
methimazole tab 5 mg (Tapazole) $0 (1) 90

order
20
2017

(tier level) use
Name of Drug
methimazole tab 10 mg (Tapazole) $0 (1) 90
propylthiouracil tab 50 mg $0 (1) 90
thyroid tab 30 mg (1/2 grain) (Armour thyroid) $0 (1) 90
thyroid tab 60 mg (1 grain) (Armour thyroid) $0 (1) 90
thyroid tab 90 mg (1 1/2 grain) (Armour thyroid) $0 (1) 90
GROWTH HORMONE
OMNITROPE – somatropin for inj 5.8 mg $0 (2) PA, SP
OTHER HORMONES AND RELATED DRUGS
ALENDRONATE SODIUM – alendronate sodium tab 40 mg $0 (2) QL (30 tablets/30 days)
alendronate sodium tab 5 mg $0 (1) QL (30 tablets/30 days), 90
alendronate sodium tab 70 mg (Fosamax) $0 (1) QL (4 tablets/28 days), 90
cabergoline tab 0.5 mg $0 (1)
calcitonin (salmon) nasal soln 200 unit/act $0 (1) 90
calcitriol cap 0.25 mcg (Rocaltrol) $0 (1) 90
calcitriol cap 0.5 mcg (Rocaltrol) $0 (1) 90
calcitriol oral soln 1 mcg/ml (Rocaltrol) $0 (1) 90
desmopressin acetate nasal soln 0.01% (refrigerated) (Ddavp) $0 (1) 90
desmopressin acetate nasal spray soln 0.01% (Ddavp) $0 (1) 90
desmopressin acetate nasal spray soln 0.01% (refrigerated) $0 (1) 90
desmopressin acetate tab 0.1 mg (Ddavp) $0 (1) 90
desmopressin acetate tab 0.2 mg (Ddavp) $0 (1) 90
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor) $0 (1) 90
levocarnitine tab 330 mg (Carnitor) $0 (1) 90
METHERGINE – methylergonovine maleate tab 0.2 mg $0 (2)
octreotide acetate inj 50 mcg/ml (0.05 mg/ml) (Sandostatin) $0 (1) PA, QL (90 mls/30
days), SP, 90
days), SP, 90
days), SP, 90
octreotide acetate inj 500 mcg/ml (0.5 mg/ml) (Sandostatin) $0 (1) PA, QL (30 vials/30 days), SP
octreotide acetate inj 1000 mcg/ml (1 mg/ml) (Sandostatin) $0 (1) PA, QL (30 vials/30 days), SP
raloxifene hcl tab 60 mg (Evista) $0 (1) 90

order
21
2017

(tier level) use
Name of Drug
STIMATE – desmopressin acetate nasal soln 1.5 mg/ml $0 (2) 90
TYMLOS – abaloparatide subcutaneous soln pen-injector $0 (1) PA, QL (1 pen/30 days), 90
3120 mcg/1.56ml
HEART AND CIRCULATORY DRUGS
ANGIOTENSIN CONVERTING ENZYME (ACE) INHIBITORS AND COMBINATIONS
benazepril & hydrochlorothiazide tab 5-6.25 mg $0 (1) 90
benazepril & hydrochlorothiazide tab 10-12.5 mg (Lotensin hct) $0 (1) 90
benazepril & hydrochlorothiazide tab 20-12.5 mg (Lotensin hct) $0 (1) 90
benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin hct) $0 (1) 90
benazepril hcl tab 5 mg $0 (1) 90
benazepril hcl tab 10 mg $0 (1) 90
benazepril hcl tab 20 mg (Lotensin) $0 (1) 90
benazepril hcl tab 40 mg (Lotensin) $0 (1) 90
captopril tab 12.5 mg $0 (1) 90
captopril tab 25 mg $0 (1) 90
CAPTOPRIL/HYDROCHLOROTHIA – captopril & $0 (2) 90
hydrochlorothiazide tab 25-15 mg
enalapril maleate & hydrochlorothiazide tab 5-12.5 mg $0 (1) 90
enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic) $0 (1) 90
enalapril maleate tab 2.5 mg (Vasotec) $0 (1) 90
enalapril maleate tab 5 mg (Vasotec) $0 (1) 90
fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg $0 (1) 90
fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg $0 (1) 90
fosinopril sodium tab 10 mg $0 (1) 90
lisinopril & hydrochlorothiazide tab 10-12.5 mg (Zestoretic) $0 (1) 90

order
22
2017

(tier level) use
Name of Drug
lisinopril & hydrochlorothiazide tab 20-12.5 mg (Zestoretic) $0 (1) 90
lisinopril & hydrochlorothiazide tab 20-25 mg (Zestoretic) $0 (1) 90
lisinopril tab 2.5 mg (Zestril) $0 (1) 90
lisinopril tab 5 mg (Prinivil) $0 (1) 90
lisinopril tab 30 mg (Zestril) $0 (1) 90
lisinopril tab 40 mg (Zestril) $0 (1) 90
moexipril hcl tab 7.5 mg $0 (1) 90
moexipril hcl tab 15 mg $0 (1) 90
moexipril-hydrochlorothiazide tab 7.5-12.5 mg $0 (1) 90
moexipril-hydrochlorothiazide tab 15-12.5 mg $0 (1) 90
moexipril-hydrochlorothiazide tab 15-25 mg $0 (1) 90
perindopril erbumine tab 2 mg $0 (1) 90
perindopril erbumine tab 4 mg (Aceon) $0 (1) 90
perindopril erbumine tab 8 mg (Aceon) $0 (1) 90
quinapril hcl tab 5 mg (Accupril) $0 (1) 90
quinapril-hydrochlorothiazide tab 10-12.5 mg (Accuretic) $0 (1) 90
quinapril-hydrochlorothiazide tab 20-12.5 mg (Accuretic) $0 (1) 90
quinapril-hydrochlorothiazide tab 20-25 mg (Accuretic) $0 (1) 90
ramipril cap 1.25 mg (Altace) $0 (1) 90
ramipril cap 2.5 mg (Altace) $0 (1) 90
ramipril cap 5 mg (Altace) $0 (1) 90
ramipril cap 10 mg (Altace) $0 (1) 90
trandolapril tab 1 mg $0 (1) 90
trandolapril tab 2 mg (Mavik) $0 (1) 90
trandolapril tab 4 mg $0 (1) 90
ANGIOTENSIN II RECEPTOR ANTAGONISTS (ARBS) AND COMBINATIONS
irbesartan tab 75 mg (Avapro) $0 (1) QL (30 tablets/30 days), 90
irbesartan-hydrochlorothiazide tab 150-12.5 mg (Avalide) $0 (1) QL (30 tablets/30 days), 90

order
23
2017

(tier level) use
Name of Drug
irbesartan-hydrochlorothiazide tab 300-12.5 mg (Avalide) $0 (1) QL (30 tablets/30 days), 90
losartan potassium & hydrochlorothiazide tab 50-12.5 mg $0 (1) QL (30 tablets/30 days), 90
(Hyzaar)
losartan potassium & hydrochlorothiazide tab 100-12.5 mg $0 (1) QL (30 tablets/30 days), 90
(Hyzaar)
losartan potassium & hydrochlorothiazide tab 100-25 mg $0 (1) QL (30 tablets/30 days), 90
(Hyzaar)
losartan potassium tab 25 mg (Cozaar) $0 (1) QL (60 tablets/30 days), 90
valsartan tab 40 mg (Diovan) $0 (1) QL (60 tablets/30 days), 90
valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan hct) $0 (1) QL (30 tablets/30 days), 90
valsartan-hydrochlorothiazide tab 160-25 mg (Diovan hct) $0 (1) QL (30 tablets/30 days), 90
valsartan-hydrochlorothiazide tab 320-25 mg (Diovan hct) $0 (1) QL (30 tablets/30 days), 90
BETA BLOCKERS AND COMBINATIONS
acebutolol hcl cap 200 mg $0 (1) 90
acebutolol hcl cap 400 mg $0 (1) 90
atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50) $0 (1) 90
atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100) $0 (1) 90
atenolol tab 25 mg (Tenormin) $0 (1) 90
betaxolol hcl tab 10 mg $0 (1) 90
betaxolol hcl tab 20 mg $0 (1) 90
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg (Ziac) $0 (1) 90
bisoprolol & hydrochlorothiazide tab 5-6.25 mg (Ziac) $0 (1) 90
bisoprolol & hydrochlorothiazide tab 10-6.25 mg (Ziac) $0 (1) 90
bisoprolol fumarate tab 5 mg $0 (1) 90
bisoprolol fumarate tab 10 mg $0 (1) 90
carvedilol tab 3.125 mg (Coreg) $0 (1) 90

order
24
2017

(tier level) use
Name of Drug
carvedilol tab 25 mg (Coreg) $0 (1) 90
labetalol hcl tab 100 mg $0 (1) 90
metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct) $0 (1) 90
metoprolol & hydrochlorothiazide tab 100-25 mg $0 (1) 90
metoprolol succinate tab er 24hr 25 mg (tartrate equiv) (Toprol xl) $0 (1) 90
metoprolol succinate tab er 24hr 50 mg (tartrate equiv) (Toprol xl) $0 (1) 90
metoprolol succinate tab er 24hr 100 mg (tartrate equiv) (Toprol $0 (1) 90
xl)
metoprolol succinate tab er 24hr 200 mg (tartrate equiv) (Toprol $0 (1) 90
xl)
metoprolol tartrate tab 25 mg $0 (1) 90
metoprolol tartrate tab 50 mg (Lopressor) $0 (1) 90
metoprolol tartrate tab 100 mg (Lopressor) $0 (1) 90
METOPROLOL/HYDROCHLOROTHI – metoprolol & $0 (2) 90
nadolol tab 20 mg (Corgard) $0 (1) 90
propranolol hcl tab 10 mg $0 (1) 90
PROPRANOLOL/HYDROCHLOROTH – propranolol & $0 (2) 90
CALCIUM CHANNEL BLOCKERS AND COMBINATIONS
amlodipine besylate tab 2.5 mg (Norvasc) $0 (1) 90
amlodipine besylate tab 5 mg (Norvasc) $0 (1) 90
amlodipine besylate tab 10 mg (Norvasc) $0 (1) 90
amlodipine besylate-benazepril hcl cap 2.5-10 mg $0 (1) 90
amlodipine besylate-benazepril hcl cap 5-10 mg (Lotrel) $0 (1) 90
amlodipine besylate-benazepril hcl cap 5-40 mg $0 (1) 90

order
25
2017

(tier level) use
Name of Drug
amlodipine besylate-valsartan tab 5-160 mg (Exforge) $0 (1) QL (30 tablets/30 days), 90
diltiazem hcl cap er 12hr 60 mg $0 (1) 90
diltiazem hcl coated beads cap er 24hr 120 mg (Cardizem cd) $0 (1) 90
diltiazem hcl coated beads cap er 24hr 300 mg $0 (1) 90
diltiazem hcl extended release beads cap er 24hr 120 mg $0 (1) 90
(Tiazac)
(Tiazac)
(Tiazac)
(Tiazac)
(Tiazac)
(Tiazac)
diltiazem hcl tab 30 mg (Cardizem) $0 (1) 90
diltiazem hcl tab 90 mg $0 (1) 90
felodipine tab er 24hr 2.5 mg $0 (1) 90
felodipine tab er 24hr 5 mg $0 (1) 90
felodipine tab er 24hr 10 mg $0 (1) 90
nifedipine cap 10 mg (Procardia) $0 (1) 90
nifedipine tab er 24hr 30 mg (Adalat cc) $0 (1) 90

order
26
2017

(tier level) use
Name of Drug
nifedipine tab er 24hr osmotic release 30 mg (Procardia xl) $0 (1) 90
verapamil hcl cap er 24hr 100 mg (Verelan pm) $0 (1) 90
verapamil hcl cap er 24hr 120 mg (Verelan) $0 (1) 90
verapamil hcl tab er 120 mg (Calan sr) $0 (1) 90
verapamil hcl tab 40 mg $0 (1) 90
verapamil hcl tab 80 mg (Calan) $0 (1) 90
verapamil hcl tab 120 mg (Calan) $0 (1) 90
CHEST PAIN
ISOSORBIDE DINITRATE ER – isosorbide dinitrate tab er 40 mg $0 (2) 90
isosorbide dinitrate tab 5 mg (Isordil titradose) $0 (1) 90
isosorbide dinitrate tab 10 mg $0 (1) 90
isosorbide mononitrate tab er 24hr 30 mg $0 (1) 90
isosorbide mononitrate tab 10 mg $0 (1) 90
isosorbide mononitrate tab 20 mg $0 (1) 90
nitroglycerin cap er 2.5 mg $0 (1) 90
nitroglycerin cap er 6.5 mg $0 (1) 90
nitroglycerin cap er 9 mg $0 (1) 90
nitroglycerin sl tab 0.3 mg (Nitrostat) $0 (1) 90
nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur) $0 (1) 90

order
27
2017

(tier level) use
Name of Drug
CHOLESTEROL LOWERING
atorvastatin calcium tab 10 mg (base equivalent) (Lipitor) $0 (1) QL (30 tablets/30 days), 90
cholestyramine light powder packets 4 gm $0 (1) 90
cholestyramine light powder 4 gm/dose (Questran light) $0 (1) 90
cholestyramine powder packets 4 gm (Questran) $0 (1) 90
cholestyramine powder 4 gm/dose (Questran) $0 (1) 90
choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix) $0 (1) QL (60 tablets/30 days), 90
choline fenofibrate cap dr 135 mg (fenofibric acid equiv) (Trilipix) $0 (1) QL (30 tablets/30 days), 90
colestipol hcl granule packets 5 gm (Colestid flavored) $0 (1) 90
colestipol hcl granules 5 gm (Colestid) $0 (1) 90
colestipol hcl tab 1 gm (Colestid) $0 (1) 90
fenofibrate micronized cap 43 mg $0 (1) QL (60 capsules/30 days), 90
fenofibrate micronized cap 67 mg (Lofibra) $0 (1) QL (30 capsules/30 days), 90
fenofibrate tab 48 mg (Tricor) $0 (1) QL (60 tablets/30 days), 90
fenofibrate tab 54 mg (Lofibra) $0 (1) QL (60 tablets/30 days), 90
fenofibrate tab 145 mg (Tricor) $0 (1) QL (30 tablets/30 days), 90
fenofibrate tab 160 mg $0 (1) QL (30 tablets/30 days), 90
gemfibrozil tab 600 mg (Lopid) $0 (1) QL (60 tablets/30 days), 90
lovastatin tab 10 mg $0 (1) QL (60 tablets/30 days), 90
PRALUENT – alirocumab subcutaneous soln pen-injector 75 mg/ $0 (2) PA, QL (2 pens/28 days), SP
ml
PRALUENT – alirocumab subcutaneous soln pen-injector $0 (2) PA, QL (2 pens/28 days), SP
150 mg/ml
pravastatin sodium tab 10 mg $0 (1) QL (45 tablets/30 days), 90
pravastatin sodium tab 20 mg (Pravachol) $0 (1) QL (45 tablets/30 days), 90

order
28
2017

(tier level) use
Name of Drug
REPATHA – evolocumab subcutaneous soln prefilled syringe $0 (2) PA, QL (2 syringes/28
140 mg/ml days), SP
REPATHA SURECLICK – evolocumab subcutaneous soln auto- $0 (2) PA, QL (2 syringes/28
injector 140 mg/ml days), SP
rosuvastatin calcium tab 5 mg (Crestor) $0 (1) QL (30 tablets/30 days), 90
simvastatin tab 5 mg (Zocor) $0 (1) QL (30 tablets/30 days), 90
FLUID RETENTION
acetazolamide cap er 12hr 500 mg (Diamox) $0 (1) 90
acetazolamide tab 125 mg $0 (1) 90
acetazolamide tab 250 mg $0 (1) 90
amiloride & hydrochlorothiazide tab 5-50 mg $0 (1) 90
amiloride hcl tab 5 mg $0 (1) 90
bumetanide tab 0.5 mg (Bumex) $0 (1) 90
bumetanide tab 1 mg (Bumex) $0 (1) 90
bumetanide tab 2 mg (Bumex) $0 (1) 90
CHLOROTHIAZIDE – chlorothiazide tab 250 mg $0 (2) 90
chlorothiazide tab 500 mg $0 (1) 90
chlorthalidone tab 25 mg $0 (1) 90
chlorthalidone tab 50 mg $0 (1) 90
furosemide oral soln 10 mg/ml $0 (1) 90
furosemide tab 20 mg (Lasix) $0 (1) 90
hydrochlorothiazide cap 12.5 mg (Microzide) $0 (1) 90
hydrochlorothiazide tab 12.5 mg $0 (1) 90
hydrochlorothiazide tab 25 mg $0 (1) 90
hydrochlorothiazide tab 50 mg $0 (1) 90
indapamide tab 1.25 mg $0 (1) 90
indapamide tab 2.5 mg $0 (1) 90

order
29
2017

(tier level) use
Name of Drug
metolazone tab 2.5 mg $0 (1) 90
metolazone tab 5 mg $0 (1) 90
metolazone tab 10 mg $0 (1) 90
spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide) $0 (1) 90
spironolactone tab 25 mg (Aldactone) $0 (1) 90
torsemide tab 5 mg $0 (1) 90
torsemide tab 10 mg (Demadex) $0 (1) 90
torsemide tab 20 mg (Demadex) $0 (1) 90
torsemide tab 100 mg $0 (1) 90
triamterene & hydrochlorothiazide cap 37.5-25 mg (Dyazide) $0 (1) 90
triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25) $0 (1) 90
triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide) $0 (1) 90
HEART RHYTHM
amiodarone hcl tab 200 mg $0 (1) 90
disopyramide phosphate cap 100 mg (Norpace) $0 (1) 90
disopyramide phosphate cap 150 mg (Norpace) $0 (1) 90
dofetilide cap 125 mcg (0.125 mg) (Tikosyn) $0 (1) 90
flecainide acetate tab 50 mg $0 (1) 90
mexiletine hcl cap 150 mg $0 (1) 90
propafenone hcl tab 150 mg $0 (1) 90
quinidine gluconate tab er 324 mg $0 (1) 90
QUINIDINE SULFATE – quinidine sulfate tab 200 mg $0 (2) 90
QUINIDINE SULFATE – quinidine sulfate tab 300 mg $0 (2) 90
sotalol hcl tab 80 mg (Betapace) $0 (1) 90

order
30
2017

(tier level) use
Name of Drug
sotalol hcl tab 240 mg $0 (1) 90
OTHER HEART RELATED DRUGS
ADCIRCA – tadalafil tab 20 mg (pah) $0 (2) PA, QL (60 tablets/30
days), SP
clonidine hcl tab 0.1 mg (Catapres) $0 (1) 90
clonidine hcl td patch weekly 0.1 mg/24hr (Catapres-tts-1) $0 (1) 90
DIGOXIN – digoxin oral soln 0.05 mg/ml $0 (2) 90
digoxin tab 125 mcg (0.125 mg) (Lanoxin) $0 (1) 90
digoxin tab 250 mcg (0.25 mg) (Lanoxin) $0 (1) 90
doxazosin mesylate tab 1 mg (Cardura) $0 (1) QL (30 tablets/30 days), 90
ENTRESTO – sacubitril-valsartan tab 24-26 mg $0 (2) PA, QL (60 tablets/30
days), 90
days), 90
days), 90
guanfacine hcl tab 1 mg $0 (1) 90
guanfacine hcl tab 2 mg $0 (1) 90
hydralazine hcl tab 10 mg $0 (1) 90
methyldopa tab 250 mg $0 (1) 90
methyldopa tab 500 mg $0 (1) 90
midodrine hcl tab 2.5 mg $0 (1)
midodrine hcl tab 5 mg $0 (1)
midodrine hcl tab 10 mg $0 (1)
minoxidil tab 2.5 mg $0 (1) 90

order
31
2017

(tier level) use
Name of Drug
minoxidil tab 10 mg $0 (1) 90
PAPAVERINE HCL – papaverine hcl inj 30 mg/ml $0 (1)
phenoxybenzamine hcl cap 10 mg (Dibenzyline) $0 (1)
prazosin hcl cap 1 mg (Minipress) $0 (1) 90
sildenafil citrate tab 20 mg (Revatio) $0 (1) PA, QL (90 tablets/30
days), SP, 90
terazosin hcl cap 1 mg $0 (1) QL (30 capsules/30 days), 90
TRACLEER – bosentan tab 62.5 mg $0 (2) PA, QL (60 tablets/30
days), SP
TRACLEER – bosentan tab 125 mg $0 (2) PA, QL (60 tablets/30
days), SP
ANAPHYLAXIS
EPINEPHRINE – epinephrine solution auto-injector $0 (2) QL (4 pens/1 prescription)
0.15 mg/0.3ml (1:2000)
EPINEPHRINE – epinephrine solution auto-injector 0.3 mg/0.3ml $0 (2) QL (4 pens/1 prescription)
(1:1000)
RESPIRATORY AGENTS
ANTIHISTAMINES
carbinoxamine maleate soln 4 mg/5ml $0 (1)
carbinoxamine maleate tab 4 mg $0 (1)
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml) $0 (1)
cetirizine hcl tab 5 mg $0 (3)
cetirizine hcl tab 10 mg $0 (3)
chlorpheniramine maleate tab 4 mg $0 (3)
clemastine fumarate tab 1.34 mg (1 mg base equiv) $0 (3)
cyproheptadine hcl syrup 2 mg/5ml $0 (1)
cyproheptadine hcl tab 4 mg $0 (1)
desloratadine tab 5 mg (Clarinex) $0 (1)
diphenhydramine hcl cap 25 mg $0 (3)
diphenhydramine hcl cap 50 mg $0 (1)
diphenhydramine hcl liquid 12.5 mg/5ml $0 (3)

order
32
2017

(tier level) use
Name of Drug
diphenhydramine hcl tab 25 mg $0 (3)
fexofenadine hcl susp 30 mg/5ml (6 mg/ml) $0 (3)
fexofenadine hcl tab 60 mg $0 (3)
fexofenadine hcl tab 180 mg $0 (3)
levocetirizine dihydrochloride tab 5 mg $0 (1)
loratadine syrup 5 mg/5ml $0 (3)
loratadine tab 10 mg $0 (3)
promethazine hcl suppos 12.5 mg $0 (1)
promethazine hcl suppos 25 mg $0 (1)
promethazine hcl syrup 6.25 mg/5ml $0 (1)
promethazine hcl tab 12.5 mg $0 (1)
promethazine hcl tab 25 mg $0 (1)
promethazine hcl tab 50 mg $0 (1)
NASAL PRODUCTS
azelastine hcl nasal spray 0.1% (137 mcg/spray) $0 (1) QL (2 bottles/30 days)
FLUNISOLIDE – flunisolide nasal soln 25 mcg/act (0.025%) $0 (1) QL (3 bottles/30 days)
fluticasone propionate nasal susp 50 mcg/act $0 (1) QL (1 inhaler/30 days)
phenylephrine hcl tab 10 mg $0 (3)
saline nasal spray 0.65% $0 (3)
COUGH/COLD/ALLERGY
acetylcysteine inhal soln 10% $0 (1)
acetylcysteine inhal soln 20% $0 (1)
BROHIST D – brompheniramine & phenylephrine tab 4-10 mg $0 (3)
brompheniramine & phenylephrine elixir 1-2.5 mg/5ml $0 (3)
dextromethorphan-guaifenesin liquid 10-100 mg/5ml $0 (3)
diphenhydramine-phenylephrine liq 6.25-2.5 mg/5ml $0 (3)
guaifenesin liquid 100 mg/5ml $0 (3)
guaifenesin-codeine soln 100-10 mg/5ml $0 (3) ME
phenylephrine w/ dm-gg liqd 5-10-200 mg/5ml $0 (3)
phenylephrine-guaifenesin tab 10-400 mg $0 (3)
PHENYLEPHRINE/GUAIFENESIN – phenylephrine-guaifenesin $0 (2)
liqd 7.5-100 mg/5ml (1.5-20 mg/ml)
promethazine w/ codeine syrup 6.25-10 mg/5ml $0 (1) ME
RELHIST BP – brompheniramine & phenylephrine tab 4-10 mg $0 (3)
RU-HIST D – brompheniramine & phenylephrine tab 4-10 mg $0 (3)

order
33
2017

(tier level) use
Name of Drug
sodium chloride soln nebu 0.9% $0 (1)
sodium chloride soln nebu 3% $0 (1)
sodium chloride soln nebu 7% (Hyper-sal) $0 (1)
sodium chloride soln nebu 10% $0 (1)
TRIAMINIC NIGHT TIME COLD – diphenhydramine- $0 (3)
phenylephrine syrup 6.25-2.5 mg/5ml
ASTHMA/COPD
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) $0 (1) QL (125 containers/30
days), 90
albuterol sulfate soln nebu 0.5% (5 mg/ml) $0 (1) QL (60 mls/30 days), 90
albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) $0 (1) QL (125 containers/30
days), 90
albuterol sulfate soln nebu 1.25 mg/3ml (base equiv) $0 (1) QL (125 containers/30
days), 90
albuterol sulfate syrup 2 mg/5ml $0 (1) 90
ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath $0 (2) QL (30 blisters/30 days), 90
activ 100 mcg/act
ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath $0 (2) QL (30 blisters/30 days), 90
activ 200 mcg/act
ATROVENT HFA – ipratropium bromide hfa inhal aerosol $0 (2) QL (2 inhalers/30 days), 90
17 mcg/act
budesonide inhalation susp 0.25 mg/2ml (Pulmicort) $0 (1) QL (2 packages/30 days), 90
budesonide inhalation susp 0.5 mg/2ml (Pulmicort) $0 (1) QL (2 packages/30 days), 90
budesonide inhalation susp 1 mg/2ml (Pulmicort) $0 (1) QL (60 mls/30 days), 90
COMBIVENT RESPIMAT – ipratropium-albuterol inhal aerosol $0 (2) QL (2 inhalers/30 days), 90
soln 20-100 mcg/act
CROMOLYN SODIUM – cromolyn sodium soln nebu 20 mg/2ml $0 (2) QL (120 containers/30
days), 90
FLOVENT DISKUS – fluticasone propionate aer pow ba 50 mcg/ $0 (2) AL, QL (1 inhaler/30 days), 90
blister
FLOVENT DISKUS – fluticasone propionate aer pow ba $0 (2) AL, QL (1 inhaler/30 days), 90
100 mcg/blister
FLOVENT DISKUS – fluticasone propionate aer pow ba $0 (2) AL, QL (4 inhalers/30
250 mcg/blister days), 90
FLOVENT HFA – fluticasone propionate hfa inhal aero 44 mcg/ $0 (2) AL, QL (1 inhaler/30 days), 90
act (50/valve)
FLOVENT HFA – fluticasone propionate hfa inhal aer 110 mcg/ $0 (2) AL, QL (1 inhaler/30 days), 90
act (125/valve)
FLOVENT HFA – fluticasone propionate hfa inhal aer 220 mcg/ $0 (2) AL, QL (2 inhalers/30
act (250/valve) days), 90

order
34
2017

(tier level) use
Name of Drug
FLUTICASONE PROPIONATE/SA – fluticasone-salmeterol aer $0 (2) QL (1 inhaler/30 days), 90
powder ba 55-14 mcg/act
ipratropium bromide inhal soln 0.02% $0 (1) QL (150 vials/30 days), 90
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml $0 (1) QL (180 containers/30
days), 90
montelukast sodium chew tab 4 mg (base equiv) (Singulair) $0 (1) QL (30 tablets/30 days), 90
montelukast sodium chew tab 5 mg (base equiv) (Singulair) $0 (1) QL (30 tablets/30 days), 90
montelukast sodium oral granules packet 4 mg (base equiv) $0 (1) QL (30 packets/30 days), 90
(Singulair)
montelukast sodium tab 10 mg (base equiv) (Singulair) $0 (1) QL (30 tablets/30 days), 90
QVAR – beclomethasone diprop inhal aero soln 40 mcg/act (50/ $0 (2) AL, QL (2 containers/30
valve) days), 90
QVAR – beclomethasone diprop inhal aero soln 80 mcg/act (100/ $0 (2) AL, QL (2 containers/30
valve) days), 90
SEREVENT DISKUS – salmeterol xinafoate aer pow ba 50 mcg/ $0 (2) QL (60 blisters/30 days), 90
dose (base equiv)
SPIRIVA HANDIHALER – tiotropium bromide monohydrate inhal $0 (2) QL (30 capsules/30 days), 90
cap 18 mcg (base equiv)
SYMBICORT – budesonide-formoterol fumarate dihyd aerosol $0 (2) AL, QL (1 inhaler/30 days), 90
80-4.5 mcg/act
SYMBICORT – budesonide-formoterol fumarate dihyd aerosol $0 (2) AL, QL (1 inhaler/30 days), 90
160-4.5 mcg/act
terbutaline sulfate tab 2.5 mg $0 (1) 90
terbutaline sulfate tab 5 mg $0 (1) 90
theophylline soln 80 mg/15ml $0 (1) 90
theophylline tab er 12hr 100 mg $0 (1) 90
VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act $0 (2) QL (3 inhalers/30 days), 90
(90mcg base equiv)
OTHER RESPIRATORY DRUGS

order
35
2017

(tier level) use
Name of Drug
KALYDECO – ivacaftor tab 150 mg $0 (2) PA, QL (60 tablets/30
days), SP
KALYDECO – ivacaftor packet 50 mg $0 (2) PA, QL (56 packets/28
days), SP
KALYDECO – ivacaftor packet 75 mg $0 (2) PA, QL (56 packets/28
days), SP
PULMOZYME – dornase alfa inhal soln 1 mg/ml $0 (2) SP
GASTROINTESTINAL DRUGS
LAXATIVES
bisacodyl tab delayed release 5 mg $0 (3)
docusate sodium cap 100 mg $0 (3)
docusate sodium cap 250 mg $0 (3)
docusate sodium liquid 150 mg/15ml $0 (3)
FLEET LIQUID GLYCERIN SUP – glycerin enema adult 5.4 gm/ $0 (3)
average delivered dose
glycerin suppos 1 gm $0 (3)
glycerin suppos 2 gm $0 (3)
KONSYL – psyllium powder 60.3% $0 (3)
KONSYL – psyllium powder 71.67% $0 (3)
KONSYL-D – psyllium powder 52.3% $0 (3)
lactulose solution 10 gm/15ml $0 (1) 90
magnesium citrate soln $0 (3)
METAMUCIL MULTIHEALTH FIB – psyllium powder 55.46% $0 (3)
METAMUCIL MULTIHEALTH FIB – psyllium powder 63% $0 (3)
METAMUCIL SMOOTH TEXTURE – psyllium powder 63% $0 (3)
PEDIA-LAX – glycerin liquid suppos 2.8 gm (2.7 ml) $0 (3)
peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor $0 (1)
pack)
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely) $0 (1)
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm (Colyte- $0 (1)
flavor packs)
polyethylene glycol 3350 oral powder $0 (1)
psyllium powder 28.3% $0 (3)
psyllium powder 30% $0 (3)

order
36
2017

(tier level) use
Name of Drug
psyllium powder 95% $0 (3)
sennosides tab 8.6 mg $0 (3)
ANTIDIARRHEALS
bismuth subsalicylate susp 262 mg/15ml $0 (3)
diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil) $0 (1)
loperamide hcl cap 2 mg $0 (1)
loperamide hcl liq 1 mg/5ml (0.2 mg/ml) $0 (3)
loperamide hcl tab 2 mg $0 (3)
ANTACIDS
alum & mag hydroxide-simethicone susp 200-200-20 mg/5ml $0 (3)
alum & mag hydroxide-simethicone susp 400-400-40 mg/5ml $0 (3)
calcium carbonate (antacid) chew tab 500 mg $0 (3)
magnesium oxide tab 400 mg $0 (3)
ULCER/GERD
cimetidine hcl soln 300 mg/5ml $0 (1) 90
cimetidine tab 200 mg $0 (1) 90
dicyclomine hcl cap 10 mg (Bentyl) $0 (1) 90
dicyclomine hcl oral soln 10 mg/5ml $0 (1) 90
dicyclomine hcl tab 20 mg $0 (1) 90
famotidine for susp 40 mg/5ml (Pepcid) $0 (1) 90
famotidine tab 10 mg $0 (3) 90
famotidine tab 20 mg (Pepcid) $0 (1) 90
famotidine tab 40 mg (Pepcid) $0 (1) 90
glycopyrrolate tab 1 mg (Robinul) $0 (1) 90
glycopyrrolate tab 2 mg (Robinul forte) $0 (1) 90
hyoscyamine sulfate elixir 0.125 mg/5ml $0 (1) 90
hyoscyamine sulfate soln 0.125 mg/ml $0 (1) 90
hyoscyamine sulfate tab disint 0.125 mg (Anaspaz) $0 (1) 90
hyoscyamine sulfate tab er 12hr 0.375 mg (Levbid) $0 (1) 90
hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl) $0 (1) 90

order
37
2017

(tier level) use
Name of Drug
hyoscyamine sulfate tab 0.125 mg (Levsin) $0 (1) 90
lansoprazole cap delayed release 15 mg (Prevacid) $0 (1) QL (60 Capsules/30
days; 120 Days
Supply/365 Days), 90
lansoprazole cap delayed release 30 mg (Prevacid) $0 (1) QL (60 Capsules/30
days; 120 Days
misoprostol tab 100 mcg (Cytotec) $0 (1) 90
misoprostol tab 200 mcg (Cytotec) $0 (1) 90
NIZATIDINE – nizatidine oral soln 15 mg/ml $0 (2) 90
nizatidine cap 150 mg $0 (1) 90
nizatidine cap 300 mg $0 (1) 90
omeprazole cap delayed release 20 mg $0 (1) QL (60 Capsules/30
days; 120 Days
omeprazole cap delayed release 40 mg $0 (1) QL (60 Capsules/30
days; 120 Days
pantoprazole sodium ec tab 20 mg (base equiv) (Protonix) $0 (1) QL (60 Tablets/30 days; 120
Days Supply/365 Days), 90
pantoprazole sodium ec tab 40 mg (base equiv) (Protonix) $0 (1) QL (60 Tablets/30 days; 120
Days Supply/365 Days), 90
ranitidine hcl syrup 15 mg/ml (75 mg/5ml) $0 (1) 90
ranitidine hcl tab 75 mg $0 (3) 90
ranitidine hcl tab 150 mg (Zantac) $0 (1) 90
ranitidine hcl tab 300 mg (Zantac) $0 (1) 90
sucralfate tab 1 gm (Carafate) $0 (1) 90
NAUSEA AND VOMITING
fructose-dextrose-phosphoric acid oral soln $0 (3)
meclizine hcl tab 12.5 mg $0 (1)
meclizine hcl tab 25 mg $0 (1)
ondansetron hcl oral soln 4 mg/5ml (Zofran) $0 (1) QL (300 mls/30 days)
ondansetron hcl tab 4 mg (Zofran) $0 (1) QL (30 tablets/30 days)
ondansetron hcl tab 8 mg (Zofran) $0 (1) QL (30 tablets/30 days)
ondansetron hcl tab 24 mg $0 (1) QL (1 tablet/30 days)
ondansetron orally disintegrating tab 4 mg (Zofran odt) $0 (1) QL (30 tablets/30 days)
ondansetron orally disintegrating tab 8 mg (Zofran odt) $0 (1) QL (30 tablets/30 days)

order
38
2017

(tier level) use
Name of Drug
prochlorperazine maleate tab 5 mg (base equivalent) $0 (1) 90
prochlorperazine maleate tab 10 mg (base equivalent) $0 (1) 90
prochlorperazine suppos 25 mg $0 (1)
DIGESTIVE ENZYMES
CREON – pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 $0 (2) 90
unit
CREON – pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000 $0 (2) 90
unit
CREON – pancrelipase (lip-prot-amyl) dr cap $0 (2) 90
12000-38000-60000 unit
24000-76000-120000 unit
36000-114000-180000 unit
ZENPEP – pancrelipase (lip-prot-amyl) dr cap $0 (2) 90
3000-10000-16000 unit
5000-17000-27000 unit
10000-34000-55000 unit
15000-51000-82000 unit
20000-68000-109000 unit
25000-85000-136000 unit
40000-136000-218000 unit
OTHER GASTROINTESTINAL DRUGS
balsalazide disodium cap 750 mg (Colazal) $0 (1)
calcium acetate (phosphate binder) cap 667 mg (169 mg ca) $0 (1) 90
calcium acetate (phosphate binder) tab 667 mg (Eliphos) $0 (1) 90
CANASA – mesalamine suppos 1000 mg $0 (2)
cromolyn sodium oral conc 100 mg/5ml (Gastrocrom) $0 (1) 90
lactulose (encephalopathy) solution 10 gm/15ml $0 (1) 90
MESALAMINE DR – mesalamine tab delayed release 800 mg $0 (2)
mesalamine enema 4 gm $0 (1)
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) $0 (1)
metoclopramide hcl tab 5 mg (Reglan) $0 (1)

order
39
2017

(tier level) use
Name of Drug
metoclopramide hcl tab 10 mg (Reglan) $0 (1) 90
simethicone chew tab 80 mg $0 (3)
simethicone susp 40 mg/0.6ml $0 (3)
sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs) $0 (1) 90
sulfasalazine tab 500 mg (Azulfidine) $0 (1) 90
ursodiol cap 300 mg (Actigall) $0 (1) 90
ursodiol tab 250 mg (Urso 250) $0 (1) 90
ursodiol tab 500 mg (Urso forte) $0 (1) 90
GENITOURINARY DRUGS
URINARY TRACT INFECTIONS
nitrofurantoin macrocrystalline cap 25 mg (Macrodantin) $0 (1)
nitrofurantoin monohydrate macrocrystalline cap 100 mg $0 (1)
(Macrobid)
nitrofurantoin susp 25 mg/5ml (Furadantin) $0 (1)
URINARY TRACT SPASMS
bethanechol chloride tab 5 mg (Urecholine) $0 (1)
oxybutynin chloride syrup 5 mg/5ml $0 (1) QL (600 mls/30 days), 90
oxybutynin chloride tab er 24hr 5 mg (Ditropan xl) $0 (1) QL (30 tablets/30 days), 90
oxybutynin chloride tab 5 mg $0 (1) QL (120 tablets/30 days), 90
VAGINAL PRODUCTS
clindamycin phosphate vaginal cream 2% (Cleocin) $0 (1)
clotrimazole vaginal cream 2% $0 (3)
estradiol vaginal tab 10 mcg (Vagifem) $0 (1) 90
metronidazole vaginal gel 0.75% (Metrogel-vaginal) $0 (1)
miconazole nitrate vaginal cream 2% $0 (3)
terconazole vaginal cream 0.4% (Terazol 7) $0 (1)
terconazole vaginal cream 0.8% $0 (1)
terconazole vaginal suppos 80 mg $0 (1)

order
40
2017

(tier level) use
Name of Drug
tioconazole vaginal oint 6.5% $0 (3)
OTHER GENITOURINARY DRUGS
alfuzosin hcl tab er 24hr 10 mg (Uroxatral) $0 (1) QL (30 tablets/30 days), 90
finasteride tab 5 mg (Proscar) $0 (1) QL (30 tablets/30 days), 90
phenazopyridine hcl tab 100 mg (Pyridium) $0 (1)
phenazopyridine hcl tab 200 mg (Pyridium) $0 (1)
pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml $0 (1)
potassium citrate & citric acid powder pack 3300-1002 mg $0 (1)
potassium citrate & citric acid soln 1100-334 mg/5ml $0 (1)
potassium citrate tab er 5 meq (540 mg) (Urocit-k 5) $0 (1)
sodium chloride irrigation soln 0.9% $0 (1)
sodium citrate & citric acid soln 500-334 mg/5ml (Shohls solution $0 (1)
modi)
tamsulosin hcl cap 0.4 mg (Flomax) $0 (1) QL (60 capsules/30 days), 90
CENTRAL NERVOUS SYSTEM DRUGS
ANXIETY
alprazolam tab 0.25 mg (Xanax) $0 (1) QL (120 tablets/30 days)
alprazolam tab 0.5 mg (Xanax) $0 (1) QL (120 tablets/30 days)
alprazolam tab 1 mg (Xanax) $0 (1) QL (120 tablets/30 days)
alprazolam tab 2 mg (Xanax) $0 (1) QL (90 tablets/30 days)
buspirone hcl tab 5 mg $0 (1)
chlordiazepoxide hcl cap 5 mg $0 (1) QL (120 capsules/30 days)
clorazepate dipotassium tab 3.75 mg $0 (1) QL (90 tablets/30 days)
clorazepate dipotassium tab 7.5 mg (Tranxene t) $0 (1) QL (90 tablets/30 days)
clorazepate dipotassium tab 15 mg $0 (1) QL (120 tablets/30 days)
diazepam conc 5 mg/ml $0 (1) QL (240 mls/30 days)
diazepam tab 2 mg (Valium) $0 (1) QL (120 tablets/30 days)

order
41
2017

(tier level) use
Name of Drug
HYDROXYZINE HCL – hydroxyzine hcl im soln 25 mg/ml $0 (2)
hydroxyzine hcl syrup 10 mg/5ml $0 (1)
hydroxyzine hcl tab 10 mg $0 (1)
hydroxyzine pamoate cap 25 mg (Vistaril) $0 (1)
hydroxyzine pamoate cap 50 mg (Vistaril) $0 (1)
lorazepam conc 2 mg/ml $0 (1) QL (150 mls/30 days)
lorazepam tab 0.5 mg (Ativan) $0 (1) QL (90 tablets/30 days)
lorazepam tab 1 mg (Ativan) $0 (1) QL (90 tablets/30 days)
lorazepam tab 2 mg (Ativan) $0 (1) QL (150 tablets/30 days)
DEPRESSION
amitriptyline hcl tab 10 mg $0 (1) 90
amitriptyline hcl tab 25 mg (Elavil) $0 (1) 90
bupropion hcl tab er 12hr 100 mg (Wellbutrin sr) $0 (1) QL (60 tablets/30 days), 90
bupropion hcl tab er 24hr 150 mg (Wellbutrin xl) $0 (1) QL (30 tablets/30 days), 90
bupropion hcl tab er 24hr 300 mg (Wellbutrin xl) $0 (1) QL (30 tablets/30 days), 90
bupropion hcl tab 75 mg $0 (1) QL (60 tablets/30 days), 90
bupropion hcl tab 100 mg $0 (1) QL (120 tablets/30 days), 90
citalopram hydrobromide oral soln 10 mg/5ml $0 (1) QL (600 mls/30 days), 90
citalopram hydrobromide tab 10 mg (base equiv) (Celexa) $0 (1) QL (30 tablets/30 days), 90
DOXEPIN HCL – doxepin hcl cap 75 mg $0 (2) 90
doxepin hcl cap 10 mg $0 (1) 90

order
42
2017

(tier level) use
Name of Drug
doxepin hcl conc 10 mg/ml $0 (1) 90
duloxetine hcl enteric coated pellets cap 20 mg (Cymbalta) $0 (1) QL (60 capsules/30 days), 90
escitalopram oxalate soln 5 mg/5ml (base equiv) $0 (1) QL (600 mls/30 days), 90
escitalopram oxalate tab 5 mg (base equiv) (Lexapro) $0 (1) QL (30 tablets/30 days), 90
fluoxetine hcl cap 10 mg (Prozac) $0 (1) QL (30 capsules/30 days), 90
fluoxetine hcl cap 20 mg (Prozac) $0 (1) QL (120 capsules/30
days), 90
fluoxetine hcl solution 20 mg/5ml $0 (1) QL (600 mls/30 days), 90
fluvoxamine maleate tab 25 mg $0 (1) QL (30 tablets/30 days), 90
imipramine hcl tab 10 mg (Tofranil) $0 (1) 90
mirtazapine orally disintegrating tab 15 mg (Remeron soltab) $0 (1) QL (30 tablets/30 days), 90
mirtazapine tab 15 mg (Remeron) $0 (1) QL (30 tablets/30 days), 90
nortriptyline hcl cap 10 mg (Pamelor) $0 (1) 90
paroxetine hcl tab 10 mg (Paxil) $0 (1) QL (30 tablets/30 days), 90
sertraline hcl oral conc 20 mg/ml (Zoloft) $0 (1) QL (300 mls/30 days), 90
sertraline hcl tab 25 mg (Zoloft) $0 (1) QL (30 tablets/30 days), 90

order
43
2017

(tier level) use
Name of Drug
trazodone hcl tab 50 mg $0 (1) 90
venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) (Effexor $0 (1) QL (30 capsules/30 days), 90
xr)
venlafaxine hcl cap er 24hr 75 mg (base equivalent) (Effexor xr) $0 (1) QL (90 capsules/30 days), 90
venlafaxine hcl cap er 24hr 150 mg (base equivalent) (Effexor xr) $0 (1) QL (30 capsules/30 days), 90
venlafaxine hcl tab 25 mg $0 (1) QL (90 tablets/30 days), 90
venlafaxine hcl tab 37.5 mg $0 (1) QL (90 tablets/30 days), 90
PSYCHOTIC AND BIPOLAR DISORDERS
ABILIFY MAINTENA – aripiprazole im for extended release susp $0 (2) QL (1 syringe/28
300 mg days), ST, 90
ABILIFY MAINTENA – aripiprazole im for extended release susp $0 (2) QL (1 syringe/28
400 mg days), ST, 90
aripiprazole oral solution 1 mg/ml $0 (1) QL (150 mls/30 days), 90
aripiprazole tab 2 mg (Abilify) $0 (1) QL (30 tablets/30 days), 90
ARISTADA – aripiprazole lauroxil im er susp prefilled syr $0 (2) QL (1 syringe/28
441 mg/1.6ml days), ST, 90
662 mg/2.4ml days), ST, 90
882 mg/3.2ml days), ST, 90
1064 mg/3.9ml days), ST, 90
clozapine orally disintegrating tab 25 mg (Fazaclo) $0 (1) QL (60 tablets/30 days)
clozapine orally disintegrating tab 100 mg (Fazaclo) $0 (1) QL (60 tablets/30 days)

order
44
2017

(tier level) use
Name of Drug
clozapine tab 25 mg (Clozaril) $0 (1) QL (90 tablets/30 days)
clozapine tab 50 mg $0 (1) QL (90 tablets/30 days)
clozapine tab 100 mg (Clozaril) $0 (1) QL (270 tablets/30 days)
clozapine tab 200 mg $0 (1) QL (120 tablets/30 days)
fluphenazine decanoate inj 25 mg/ml $0 (1)
FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5 mg/5ml $0 (2) 90
FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ml $0 (2) 90
fluphenazine hcl tab 1 mg $0 (1) 90
fluphenazine hcl tab 2.5 mg $0 (1) 90
haloperidol decanoate im soln 50 mg/ml (Haldol decanoate 50) $0 (1)
haloperidol decanoate im soln 100 mg/ml (Haldol decanoate 100) $0 (1)
haloperidol lactate oral conc 2 mg/ml $0 (1) 90
haloperidol tab 0.5 mg $0 (1) 90
haloperidol tab 1 mg $0 (1) 90
INVEGA SUSTENNA – paliperidone palmitate im extended- $0 (2) QL (1 kit/28 days), ST
release susp 39 mg/0.25ml
INVEGA SUSTENNA – paliperidone palmitate im extend-release $0 (2) QL (1 kit/28 days), ST
susp 117 mg/0.75ml
release susp 156 mg/ml
LATUDA – lurasidone hcl tab 20 mg $0 (2) QL (30 tablets/30
days), ST, 90
days), ST, 90
days), ST, 90
days), ST, 90

order
45
2017

(tier level) use
Name of Drug
days), ST, 90
LITHIUM – lithium oral solution 8 meq/5ml $0 (2) 90
lithium carbonate cap 150 mg (Lithium carbonate) $0 (1) 90
lithium carbonate cap 300 mg $0 (1) 90
lithium carbonate cap 600 mg (Lithium carbonate) $0 (1) 90
lithium carbonate tab er 300 mg (Lithobid) $0 (1) 90
lithium carbonate tab er 450 mg $0 (1) 90
lithium carbonate tab 300 mg $0 (1) 90
loxapine succinate cap 5 mg $0 (1) 90
olanzapine for im inj 10 mg (Zyprexa) $0 (1) QL (90 vials/30 days), 90
olanzapine orally disintegrating tab 5 mg (Zyprexa zydis) $0 (1) QL (30 tablets/30 days), 90
olanzapine tab 2.5 mg (Zyprexa) $0 (1) QL (30 tablets/30 days), 90
olanzapine tab 5 mg (Zyprexa) $0 (1) QL (30 tablets/30 days), 90
olanzapine tab 7.5 mg (Zyprexa) $0 (1) QL (30 tablets/30 days), 90
perphenazine tab 2 mg $0 (1) 90
quetiapine fumarate tab 25 mg (Seroquel) $0 (1) QL (90 tablets/30 days), 90
risperidone orally disintegrating tab 0.25 mg $0 (1) QL (60 tablets/30 days), 90

order
46
2017

(tier level) use
Name of Drug
risperidone orally disintegrating tab 0.5 mg (Risperdal m-tab) $0 (1) QL (60 tablets/30 days), 90
risperidone orally disintegrating tab 1 mg (Risperdal m-tab) $0 (1) QL (60 tablets/30 days), 90
risperidone soln 1 mg/ml (Risperdal) $0 (1) QL (480 mls/30 days), 90
risperidone tab 0.25 mg (Risperdal) $0 (1) QL (120 tablets/30 days), 90
risperidone tab 0.5 mg (Risperdal) $0 (1) QL (120 tablets/30 days), 90
risperidone tab 1 mg (Risperdal) $0 (1) QL (120 tablets/30 days), 90
thioridazine hcl tab 10 mg $0 (1) 90
thiothixene cap 1 mg $0 (1) 90
trifluoperazine hcl tab 1 mg $0 (1) 90
ziprasidone hcl cap 20 mg (Geodon) $0 (1) QL (60 capsules/30 days), 90
SLEEP AIDS
estazolam tab 1 mg $0 (1) QL (30 tablets/30 days)
estazolam tab 2 mg $0 (1) QL (30 tablets/30 days)
eszopiclone tab 1 mg (Lunesta) $0 (1) QL (30 tablets/30 days)
PHENOBARBITAL – phenobarbital tab 15 mg $0 (2) 90

order
47
2017

(tier level) use
Name of Drug
phenobarbital elixir 20 mg/5ml $0 (1) 90
phenobarbital tab 16.2 mg $0 (1) 90
temazepam cap 15 mg (Restoril) $0 (1) QL (30 capsules/30 days)
temazepam cap 30 mg (Restoril) $0 (1) QL (30 capsules/30 days)
zaleplon cap 5 mg (Sonata) $0 (1) QL (30 capsules/30 days)
zaleplon cap 10 mg (Sonata) $0 (1) QL (30 capsules/30 days)
zolpidem tartrate tab 5 mg (Ambien) $0 (1) QL (30 tablets/30 days)
zolpidem tartrate tab 10 mg (Ambien) $0 (1) QL (30 tablets/30 days)
HYPERACTIVITY/NARCOLEPSY
amphetamine-dextroamphetamine cap er 24hr 5 mg (Adderall xr) $0 (1) AL, QL (30 capsules/30 days)
amphetamine-dextroamphetamine cap er 24hr 10 mg (Adderall $0 (1) AL, QL (30 capsules/30 days)
xr)
xr)
xr)
xr)
xr)
amphetamine-dextroamphetamine tab 5 mg (Adderall) $0 (1) AL, QL (60 tablets/30 days)
amphetamine-dextroamphetamine tab 7.5 mg (Adderall) $0 (1) AL, QL (60 tablets/30 days)
amphetamine-dextroamphetamine tab 12.5 mg (Adderall) $0 (1) AL, QL (60 tablets/30 days)
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv) $0 (1)
dexmethylphenidate hcl cap er 24 hr 5 mg (Focalin xr) $0 (1) AL, QL (30 capsules/30 days)

order
48
2017

(tier level) use
Name of Drug
dexmethylphenidate hcl tab 2.5 mg (Focalin) $0 (1) AL, QL (60 tablets/30 days)
dexmethylphenidate hcl tab 5 mg (Focalin) $0 (1) AL, QL (60 tablets/30 days)
dexmethylphenidate hcl tab 10 mg (Focalin) $0 (1) AL, QL (60 tablets/30 days)
guanfacine hcl tab er 24hr 1 mg (base equiv) (Intuniv) $0 (1) QL (30 tablets/30 days)
methylphenidate hcl cap er 10 mg (cd) $0 (1) AL, QL (30 capsules/30 days)
methylphenidate hcl cap er 24hr 20 mg (la) (Ritalin la) $0 (1) AL, QL (30 capsules/30 days)
METHYLPHENIDATE HCL ER – methylphenidate hcl tab er 24hr $0 (2) AL, QL (30 tablets/30 days)
18 mg
27 mg
36 mg
54 mg
methylphenidate hcl tab er osmotic release (osm) 18 mg $0 (1) AL, QL (30 tablets/30 days)
(Concerta)
(Concerta)
(Concerta)
(Concerta)
methylphenidate hcl tab er 10 mg $0 (1) AL, QL (90 tablets/30 days)
methylphenidate hcl tab 5 mg (Ritalin) $0 (1) AL, QL (90 tablets/30 days)

order
49
2017

(tier level) use
Name of Drug
modafinil tab 100 mg (Provigil) $0 (1) PA, QL (30 tablets/30 days)
modafinil tab 200 mg (Provigil) $0 (1) PA, QL (30 tablets/30 days)
MULTIPLE SCLEROSIS
AMPYRA – dalfampridine tab er 12hr 10 mg $0 (2) PA, QL (60 tablets/30
days), SP
AUBAGIO – teriflunomide tab 7 mg $0 (2) PA, QL (30 tablets/30
days), SP
AUBAGIO – teriflunomide tab 14 mg $0 (2) PA, QL (30 tablets/30
days), SP
AVONEX – interferon beta-1a im prefilled syringe kit $0 (2) PA, QL (1 kit/28 days), SP
30 mcg/0.5ml
AVONEX – interferon beta-1a for im inj kit 30mcg (33mcg(6.6 $0 (2) PA, QL (4 vials/28 days), SP
mu)/vial)
AVONEX PEN – interferon beta-1a im auto-injector kit $0 (2) PA, QL (1 kit/28 days), SP
30 mcg/0.5ml
EXTAVIA – interferon beta-1b for inj kit 0.3 mg $0 (2) PA, QL (14 vials/28 days), SP
glatiramer acetate soln prefilled syringe 20 mg/ml (Copaxone) $0 (1) PA, QL (30 syringes/30
days), SP
OTHER CENTRAL NERVOUS SYSTEM DRUGS
acamprosate calcium tab delayed release 333 mg $0 (1) 90
bupropion hcl (smoking deterrent) tab er 12hr 150 mg (Zyban) $0 (1) QL (180 days/365 days)
CHANTIX – varenicline tartrate tab 0.5 mg (base equiv) $0 (2) QL (180 days/365 days)
CHANTIX – varenicline tartrate tab 1 mg (base equiv) $0 (2) QL (180 days/365 days)
CHANTIX CONTINUING MONTH – varenicline tartrate tab 1 mg $0 (2) QL (180 days/365 days)
(base equiv)
CHANTIX STARTING MONTH PA – varenicline tartrate tab $0 (2) QL (180 days/365 days)
0.5 mg x 11 & tab 1 mg x 42 pack
disulfiram tab 250 mg (Antabuse) $0 (1) 90
disulfiram tab 500 mg (Antabuse) $0 (1) 90
donepezil hydrochloride orally disintegrating tab 5 mg $0 (1) QL (30 tablets/30 days), 90
donepezil hydrochloride orally disintegrating tab 10 mg $0 (1) QL (30 tablets/30 days), 90
donepezil hydrochloride tab 5 mg (Aricept) $0 (1) QL (30 tablets/30 days), 90
donepezil hydrochloride tab 10 mg (Aricept) $0 (1) QL (30 tablets/30 days), 90
naltrexone hcl tab 50 mg $0 (1)
nicotine polacrilex gum 2 mg $0 (3) QL (180 days/365 days)
nicotine polacrilex gum 4 mg $0 (3) QL (180 days/365 days)

order
50
2017

(tier level) use
Name of Drug
nicotine td patch 24hr 7 mg/24hr $0 (3) QL (180 days/365 days)
pimozide tab 1 mg (Orap) $0 (1) 90
pimozide tab 2 mg (Orap) $0 (1) 90
VIVITROL – naltrexone for im extended release susp 380 mg $0 (2) SP
XYREM – sodium oxybate oral solution 500 mg/ml $0 (2) PA, QL (3 bottles/30
days), SP
PAIN RELIEF DRUGS
NON-NARCOTIC DRUGS
acetaminophen cap 500 mg $0 (3)
acetaminophen chew tab 80 mg $0 (3)
acetaminophen chew tab 160 mg $0 (3)
acetaminophen disintegrating tab 80 mg $0 (3)
acetaminophen liquid 160 mg/5ml $0 (3)
acetaminophen soln 160 mg/5ml $0 (3)
acetaminophen suppos 120 mg $0 (3)
acetaminophen susp 80 mg/0.8ml $0 (3)
acetaminophen susp 160 mg/5ml $0 (3)
acetaminophen tab 325 mg $0 (3)
acetaminophen tab 500 mg $0 (3)
aspirin chew tab 81 mg $0 (3) 90
aspirin tab delayed release 81 mg $0 (3) 90
aspirin tab delayed release 325 mg $0 (3) 90
aspirin tab 325 mg $0 (3) 90
butalbital-acetaminophen tab 50-325 mg $0 (1) QL (180 tablets/30 days)
butalbital-acetaminophen-caffeine cap 50-300-40 mg (Fioricet) $0 (1) QL (180 capsules/30 days)
butalbital-acetaminophen-caffeine cap 50-325-40 mg $0 (1) QL (180 capsules/30 days)
butalbital-acetaminophen-caffeine tab 50-325-40 mg (Esgic) $0 (1) QL (180 tablets/30 days)
butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal) $0 (1) QL (180 capsules/30 days)
salsalate tab 500 mg $0 (1) 90
salsalate tab 750 mg $0 (1) 90
NARCOTIC DRUGS
acetaminophen w/ codeine soln 120-12 mg/5ml $0 (1) ME, QL (2700 mls/30 days)
acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine) $0 (1) ME, QL (360 tablets/30 days)

order
51
2017

(tier level) use
Name of Drug
acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3) $0 (1) ME, QL (360 tablets/30 days)
acetaminophen w/ codeine tab 300-60 mg (Tylenol/codeine #4) $0 (1) ME, QL (180 tablets/30 days)
ACETAMINOPHEN/CAFFEINE/DI – acetaminophen-caffeine- $0 (2) ME, QL (300
dihydrocodeine cap 320.5-30-16 mg capsules/30 days)
BUNAVAIL – buprenorphine-naloxone buccal film 2.1-0.3 mg $0 (2) QL (60 films/30 days)
(base equiv)
BUNAVAIL – buprenorphine-naloxone buccal film 4.2-0.7 mg $0 (2) QL (60 films/30 days)
(base equiv)
BUNAVAIL – buprenorphine-naloxone buccal film 6.3-1 mg (base $0 (2) QL (60 films/30 days)
equiv)
buprenorphine hcl sl tab 2 mg (base equiv) $0 (1) QL (15 tablets/90 days)
buprenorphine hcl sl tab 8 mg (base equiv) $0 (1) QL (15 tablets/90 days)
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) $0 (1) QL (60 tablets/30 days)
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) $0 (1) QL (60 tablets/30 days)
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg $0 (1) ME, QL (180
capsules/30 days)
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg (Fiorinal/ $0 (1) ME, QL (180
codeine #3) capsules/30 days)
codeine sulfate tab 15 mg (Codeine sulfate) $0 (1) ME, QL (180 tablets/30 days)
fentanyl td patch 72hr 12 mcg/hr (Duragesic) $0 (1) ME, QL (15 patches/30 days)
hydrocodone-acetaminophen soln 7.5-325 mg/15ml (Hycet) $0 (1) ME, QL (3600 mls/30 days)
hydrocodone-acetaminophen tab 2.5-325 mg $0 (1) ME, QL (360 tablets/30 days)
hydrocodone-acetaminophen tab 10-325 mg (Norco) $0 (1) ME, QL (180 tablets/30 days)
hydrocodone-acetaminophen tab 5-325 mg (Norco) $0 (1) ME, QL (360 tablets/30 days)
hydrocodone-acetaminophen tab 7.5-325 mg (Norco) $0 (1) ME, QL (180 tablets/30 days)
hydromorphone hcl liqd 1 mg/ml (Dilaudid) $0 (1) ME, QL (1440 mls/30 days)
hydromorphone hcl tab 2 mg (Dilaudid) $0 (1) ME, QL (180 tablets/30 days)
meperidine hcl tab 50 mg $0 (1) ME, QL (240 tablets/30 days)
meperidine hcl tab 100 mg (Demerol) $0 (1) ME, QL (240 tablets/30 days)

order
52
2017

(tier level) use
Name of Drug
MORPHINE SULFATE – morphine sulfate tab 15 mg $0 (2) ME, QL (240 tablets/30 days)
MORPHINE SULFATE – morphine sulfate tab 30 mg $0 (2) ME, QL (180 tablets/30 days)
MORPHINE SULFATE – morphine sulfate suppos 5 mg $0 (2) ME
morphine sulfate oral soln 10 mg/5ml $0 (1) ME, QL (2700 mls/30 days)
morphine sulfate oral soln 20 mg/5ml $0 (1) ME, QL (1350 mls/30 days)
morphine sulfate oral soln 100 mg/5ml (20 mg/ml) $0 (1) ME, QL (270 mls/30 days)
oxycodone hcl conc 100 mg/5ml (20 mg/ml) $0 (1) ME, QL (270 mls/30 days)
oxycodone hcl soln 5 mg/5ml $0 (1) ME, QL (5400 mls/30 days)
oxycodone hcl tab 5 mg (Roxicodone) $0 (1) ME, QL (360 tablets/30 days)
oxycodone hcl tab 10 mg $0 (1) ME, QL (180 tablets/30 days)
oxycodone hcl tab 20 mg $0 (1) ME, QL (180 tablets/30 days)
oxycodone w/ acetaminophen tab 5-325 mg (Percocet) $0 (1) ME, QL (360 tablets/30 days)
oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet) $0 (1) ME, QL (240 tablets/30 days)
oxycodone w/ acetaminophen tab 10-325 mg (Percocet) $0 (1) ME, QL (180 tablets/30 days)
oxycodone-aspirin tab 4.8355-325 mg $0 (1) ME, QL (360 tablets/30 days)
OXYCODONE/ACETAMINOPHEN – oxycodone w/ $0 (2) ME, QL (1800 mls/30 days)
acetaminophen soln 5-325 mg/5ml
PROBUPHINE IMPLANT KIT – buprenorphine hcl subdermal $0 (2)
implant 74.2 mg (base equiv)
SUBOXONE – buprenorphine hcl-naloxone hcl sl film 2-0.5 mg $0 (2) QL (60 films/30 days)
(base equiv)
SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1 mg $0 (2) QL (60 films/30 days)
(base equiv)
(base equiv)
(base equiv)
tramadol hcl tab 50 mg (Ultram) $0 (1) ME, QL (240 tablets/30 days)
ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab 1.4-0.36 mg $0 (2) QL (60 tablets/30 days)
(base eq)
(base eq)

order
53
2017

(tier level) use
Name of Drug
(base eq)
(base eq)
(base eq)
RHEUMATOID AND OSTEOARTHRITIS
celecoxib cap 50 mg (Celebrex) $0 (1) AL, QL (60 capsules/30
days), ST, 90
days), ST, 90
days), ST, 90
days), ST, 90
diclofenac potassium tab 50 mg $0 (1) QL (120 tablets/30 days), 90
diclofenac sodium gel 1% (Voltaren) $0 (1) QL (200 grams/30 days)
diclofenac sodium tab delayed release 50 mg $0 (1) QL (120 tablets/30 days), 90
diclofenac sodium tab delayed release 75 mg $0 (1) QL (60 tablets/30 days), 90
diclofenac sodium tab er 24hr 100 mg $0 (1) QL (60 tablets/30 days), 90
ENBREL – etanercept for subcutaneous inj 25 mg $0 (2) PA, QL (8 vials/28 days), 90
ENBREL – etanercept subcutaneous soln prefilled syringe $0 (2) PA, QL (8 syringes/28
25 mg/0.5ml days), SP, 90
ENBREL – etanercept subcutaneous soln prefilled syringe $0 (2) PA, QL (4 syringes/28
50 mg/ml days), SP, 90
ENBREL SURECLICK – etanercept subcutaneous solution auto- $0 (2) PA, QL (4 syringes/28
injector 50 mg/ml days), SP, 90
flurbiprofen tab 50 mg $0 (1) QL (180 tablets/30 days), 90
flurbiprofen tab 100 mg $0 (1) QL (90 tablets/30 days), 90
HUMIRA – adalimumab prefilled syringe kit 10 mg/0.2ml $0 (2) PA, QL (2 syringes/28
days), SP
days), SP
days), SP
HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled syringe $0 (2) PA, QL (3 syringes/180
kit 40 mg/0.8ml days), SP
HUMIRA PEN – adalimumab pen-injector kit 40 mg/0.8ml $0 (2) PA, QL (2 pens/180 days), SP

order
54
2017

(tier level) use
Name of Drug
HUMIRA PEN-CROHNS DISEASE – adalimumab pen-injector kit $0 (2) PA, QL (6 pens/180 days), SP
40 mg/0.8ml
HUMIRA PEN-PSORIASIS STAR – adalimumab pen-injector kit $0 (2) PA, QL (4 pens/28 days), SP
40 mg/0.8ml
ibuprofen cap 200 mg $0 (3) 90
ibuprofen susp 100 mg/5ml $0 (1) QL (1000 mls/30 days)
ibuprofen tab 200 mg $0 (3) 90
ibuprofen tab 400 mg $0 (1) QL (120 tablets/30 days), 90
indomethacin cap er 75 mg $0 (1) QL (60 capsules/30 days), 90
indomethacin cap 25 mg $0 (1) QL (90 capsules/30 days), 90
indomethacin cap 50 mg $0 (1) QL (60 capsules/30 days), 90
ketoprofen cap 50 mg $0 (1) QL (180 capsules/30
days), 90
ketoprofen cap 75 mg $0 (1) QL (120 capsules/30
days), 90
ketorolac tromethamine tab 10 mg $0 (1) QL (20 tablets/30 days)
leflunomide tab 10 mg (Arava) $0 (1) 90
leflunomide tab 20 mg (Arava) $0 (1) 90
meloxicam tab 7.5 mg (Mobic) $0 (1) QL (60 tablets/30 days), 90
meloxicam tab 15 mg (Mobic) $0 (1) QL (30 tablets/30 days), 90
nabumetone tab 500 mg $0 (1) QL (120 tablets/30 days), 90
nabumetone tab 750 mg $0 (1) QL (60 tablets/30 days), 90
naproxen sodium tab 220 mg $0 (3) 90
naproxen sodium tab 275 mg $0 (1) QL (150 tablets/30 days), 90
naproxen sodium tab 550 mg (Anaprox ds) $0 (1) QL (90 tablets/30 days), 90
naproxen tab ec 375 mg (Ec-naprosyn) $0 (1) QL (120 tablets/30 days), 90
naproxen tab ec 500 mg (Ec-naprosyn) $0 (1) QL (90 tablets/30 days), 90
naproxen tab 250 mg $0 (1) QL (150 tablets/30 days), 90
naproxen tab 375 mg $0 (1) QL (120 tablets/30 days), 90
naproxen tab 500 mg (Naprosyn) $0 (1) QL (90 tablets/30 days), 90
piroxicam cap 10 mg (Feldene) $0 (1) QL (60 capsules/30 days), 90
piroxicam cap 20 mg (Feldene) $0 (1) QL (30 capsules/30 days), 90
sulindac tab 150 mg $0 (1) QL (60 tablets/30 days), 90
sulindac tab 200 mg $0 (1) QL (60 tablets/30 days), 90

order
55
2017

(tier level) use
Name of Drug
MIGRAINE HEADACHES
rizatriptan benzoate oral disintegrating tab 5 mg (base eq) $0 (1) QL (18 tablets/30 days)
(Maxalt-mlt)
rizatriptan benzoate oral disintegrating tab 10 mg (base eq) $0 (1) QL (18 tablets/30 days)
(Maxalt-mlt)
rizatriptan benzoate tab 5 mg (base equivalent) (Maxalt) $0 (1) QL (18 tablets/30 days)
rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt) $0 (1) QL (18 tablets/30 days)
sumatriptan succinate inj 6 mg/0.5ml (Imitrex) $0 (1) QL (12 vials/30 days)
sumatriptan succinate solution cartridge 6 mg/0.5ml (Imitrex $0 (1) QL (6 packages/30 days)
statdose ref)
sumatriptan succinate tab 25 mg (Imitrex) $0 (1) QL (18 tablets/30 days)
GOUT
allopurinol tab 100 mg (Zyloprim) $0 (1) 90
allopurinol tab 300 mg (Zyloprim) $0 (1) 90
colchicine w/ probenecid tab 0.5-500 mg $0 (1) 90
probenecid tab 500 mg $0 (1) 90
NEUROMUSCULAR DRUGS
SEIZURES
carbamazepine chew tab 100 mg $0 (1) 90
carbamazepine susp 100 mg/5ml (Tegretol) $0 (1) 90
carbamazepine tab er 12hr 100 mg (Tegretol-xr) $0 (1) 90
carbamazepine tab 200 mg (Tegretol) $0 (1) 90
clonazepam orally disintegrating tab 0.125 mg $0 (1) QL (90 tablets/30 days), 90
clonazepam orally disintegrating tab 1 mg $0 (1) QL (90 tablets/30 days), 90
clonazepam orally disintegrating tab 2 mg $0 (1) QL (60 tablets/30 days), 90
clonazepam tab 0.5 mg (Klonopin) $0 (1) QL (90 tablets/30 days), 90
clonazepam tab 1 mg (Klonopin) $0 (1) QL (90 tablets/30 days), 90
clonazepam tab 2 mg (Klonopin) $0 (1) QL (60 tablets/30 days), 90
DIAZEPAM RECTAL GEL – diazepam rectal gel delivery system $0 (2) QL (2 packs/30 days)
2.5 mg

order
56
2017

(tier level) use
Name of Drug
10 mg
20 mg
DILANTIN – phenytoin sodium extended cap 30 mg $0 (2) 90
divalproex sodium cap delayed release sprinkle 125 mg $0 (1) 90
(Depakote sprinkles)
divalproex sodium tab delayed release 125 mg (Depakote) $0 (1) 90
divalproex sodium tab er 24 hr 250 mg (Depakote er) $0 (1) 90
divalproex sodium tab er 24 hr 500 mg (Depakote er) $0 (1) 90
ethosuximide cap 250 mg (Zarontin) $0 (1) 90
ethosuximide soln 250 mg/5ml (Zarontin) $0 (1) 90
gabapentin cap 100 mg (Neurontin) $0 (1) QL (720 capsules/30
days), 90
days), 90
days), 90
gabapentin oral soln 250 mg/5ml (Neurontin) $0 (1) QL (1500 mls/30 days), 90
gabapentin tab 600 mg (Neurontin) $0 (1) QL (120 tablets/30 days), 90
gabapentin tab 800 mg (Neurontin) $0 (1) QL (90 tablets/30 days), 90
lamotrigine tab chewable dispersible 5 mg (Lamictal chewable di) $0 (1) 90
lamotrigine tab chewable dispersible 25 mg (Lamictal chewable $0 (1) 90
di)
lamotrigine tab 25 mg (Lamictal) $0 (1) 90
levetiracetam oral soln 100 mg/ml (Keppra) $0 (1) 90
levetiracetam tab er 24hr 500 mg (Keppra xr) $0 (1) 90
levetiracetam tab er 24hr 750 mg (Keppra xr) $0 (1) 90
levetiracetam tab 250 mg (Keppra) $0 (1) 90

order
57
2017

(tier level) use
Name of Drug
oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal) $0 (1) 90
oxcarbazepine tab 150 mg (Trileptal) $0 (1) 90
phenytoin chew tab 50 mg (Dilantin infatabs) $0 (1) 90
phenytoin sodium extended cap 100 mg (Dilantin) $0 (1) 90
phenytoin sodium extended cap 200 mg (Phenytek) $0 (1) 90
phenytoin sodium extended cap 300 mg (Phenytek) $0 (1) 90
phenytoin susp 125 mg/5ml (Dilantin-125) $0 (1) 90
primidone tab 50 mg (Mysoline) $0 (1) 90
primidone tab 250 mg (Mysoline) $0 (1) 90
topiramate sprinkle cap 15 mg (Topamax sprinkle) $0 (1) 90
topiramate sprinkle cap 25 mg (Topamax sprinkle) $0 (1) 90
topiramate tab 25 mg (Topamax) $0 (1) 90
valproate sodium oral soln 250 mg/5ml (base equiv) (Depakene) $0 (1) 90
valproic acid cap 250 mg (Depakene) $0 (1) 90
zonisamide cap 25 mg (Zonegran) $0 (1) 90
zonisamide cap 50 mg $0 (1) 90
zonisamide cap 100 mg (Zonegran) $0 (1) 90
PARKINSON'S DISEASE
amantadine hcl cap 100 mg $0 (1) 90
amantadine hcl syrup 50 mg/5ml $0 (1) 90
benztropine mesylate tab 0.5 mg $0 (1) 90
benztropine mesylate tab 1 mg $0 (1) 90
benztropine mesylate tab 2 mg $0 (1) 90
bromocriptine mesylate tab 2.5 mg (base equivalent) (Parlodel) $0 (1) 90
carbidopa & levodopa tab er 25-100 mg (Sinemet cr) $0 (1) 90
carbidopa & levodopa tab er 50-200 mg (Sinemet cr) $0 (1) 90
carbidopa & levodopa tab 10-100 mg (Sinemet) $0 (1) 90
carbidopa tab 25 mg (Lodosyn) $0 (1) 90

order
58
2017

(tier level) use
Name of Drug
entacapone tab 200 mg (Comtan) $0 (1) 90
pramipexole dihydrochloride tab 0.125 mg (Mirapex) $0 (1) 90
pramipexole dihydrochloride tab 1 mg (Mirapex) $0 (1) 90
ropinirole hydrochloride tab 0.25 mg (Requip) $0 (1) 90
ropinirole hydrochloride tab 0.5 mg (Requip) $0 (1) 90
ropinirole hydrochloride tab 1 mg (Requip) $0 (1) 90
selegiline hcl cap 5 mg (Eldepryl) $0 (1) 90
selegiline hcl tab 5 mg $0 (1) 90
trihexyphenidyl hcl elixir 0.4 mg/ml $0 (1) 90
trihexyphenidyl hcl tab 2 mg $0 (1) 90
trihexyphenidyl hcl tab 5 mg $0 (1) 90
MUSCLE RELAXANTS
baclofen tab 10 mg $0 (1) 90
baclofen tab 20 mg $0 (1) 90
chlorzoxazone tab 500 mg (Parafon forte dsc) $0 (1)
cyclobenzaprine hcl tab 5 mg $0 (1)
cyclobenzaprine hcl tab 10 mg $0 (1)
dantrolene sodium cap 25 mg (Dantrium) $0 (1)
dantrolene sodium cap 50 mg (Dantrium) $0 (1)
dantrolene sodium cap 100 mg $0 (1)
methocarbamol tab 500 mg (Robaxin) $0 (1)
methocarbamol tab 750 mg (Robaxin-750) $0 (1)
orphenadrine citrate tab er 12hr 100 mg $0 (1)
tizanidine hcl tab 2 mg (base equivalent) $0 (1) QL (180 tablets/30 days), 90
tizanidine hcl tab 4 mg (base equivalent) (Zanaflex) $0 (1) QL (180 tablets/30 days), 90
OTHER NEUROMUSCULAR DRUGS
pyridostigmine bromide tab 60 mg (Mestinon) $0 (1)

order
59
2017

(tier level) use
Name of Drug
riluzole tab 50 mg (Rilutek) $0 (1) 90
SUPPLEMENTS
VITAMINS
ascorbic acid tab 500 mg $0 (3)
cholecalciferol cap 1000 unit $0 (3)
cholecalciferol oral liquid 400 unit/ml $0 (3)
cholecalciferol tab 400 unit $0 (3)
DECARA – cholecalciferol cap 25000 unit $0 (3)
ergocalciferol cap 50000 unit $0 (1) 90
MEPHYTON – phytonadione tab 5 mg $0 (2)
niacin cap er 250 mg $0 (3)
niacin cap er 500 mg $0 (3)
niacin tab er 250 mg $0 (3)
niacin tab 100 mg $0 (3)
niacin tab 500 mg $0 (3)
NIACIN TR – niacin tab er 1000 mg $0 (3)
thiamine hcl tab 50 mg $0 (3)
thiamine hcl tab 100 mg $0 (3)
MULTIVITAMINS
b-complex w/ c & folic acid cap 1 mg (Nephrocaps) $0 (1)
b-complex w/ c & folic acid tab $0 (1)
b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx) $0 (1)
b-complex w/ c & folic acid tab 5 mg $0 (1)
EQ MULTIVITAMINS ADULT GU – multiple vitamins w/ minerals $0 (3)
chew tab

order
60
2017

(tier level) use
Name of Drug
FOLBEE PLUS CZ – b-complex w/ c-biotin-minerals & folic acid $0 (2)
tab 5 mg
multiple vitamin tab $0 (3)
multiple vitamins w/ iron tab $0 (3)
multiple vitamins w/ minerals & fa tab 1.25 mg (Corvite) $0 (1)
multiple vitamins w/ minerals cap $0 (1)
multiple vitamins w/ minerals tab (Strovite forte) $0 (1)
pediatric multiple vitamin w/ c & fa chew tab $0 (3)
pediatric multiple vitamin w/ minerals & c drops 45 mg/ml $0 (3)
PRENATAL VITAMINS - various $0 (2)
PRESERVISION AREDS 2 + MU – multiple vitamins w/ minerals $0 (3)
cap
TRI-VI-SOL – pediatric vitamins adc drops 750 unit-400 $0 (3)
unit-35 mg/ml
MINERALS AND ELECTROLYTES
calcium carbonate tab 1250 mg (500 mg elemental ca) $0 (3)
calcium carbonate-cholecalciferol tab 500 mg-200 unit $0 (3)
calcium carbonate-cholecalciferol tab 600 mg-400 unit $0 (3)
calcium carbonate-vitamin d tab 250 mg-125 unit $0 (3)
calcium citrate tab 950 mg (200 mg elemental ca) $0 (3)
K-PHOS – potassium phosphate monobasic tab 500 mg $0 (2) 90
magnesium oxide tab 400 mg (241.3 mg elemental mg) $0 (1)
oral electrolyte solution $0 (3)
pot bicarbonate & chloride effer tab 25 meq $0 (1) 90
pot phos monobasic w/sod phos di & monobas tab $0 (1) 90
155-852-130mg (K-phos neutral)
potassium bicarbonate effer tab 25 meq $0 (1) 90
POTASSIUM CHLORIDE – potassium chloride oral soln 20% (40 $0 (2) 90
meq/15ml)
potassium chloride cap er 8 meq (Micro-k) $0 (1) 90
potassium chloride cap er 10 meq (Micro-k) $0 (1) 90
POTASSIUM CHLORIDE ER – potassium chloride tab er 8 meq $0 (2) 90
(600 mg)
potassium chloride microencapsulated crys er tab 10 meq $0 (1) 90
potassium chloride microencapsulated crys er tab 20 meq $0 (1) 90

order
61
2017

(tier level) use
Name of Drug
potassium chloride oral soln 10% (20 meq/15ml) $0 (1) 90
potassium chloride powder packet 20 meq $0 (1) 90
potassium chloride tab er 8 meq (600 mg) $0 (1) 90
potassium chloride tab er 10 meq (K-tab) $0 (1) 90
SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from 2.2 mg $0 (2) 90
naf)
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf) $0 (1) 90
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf) $0 (1) 90
sodium fluoride chew tab 1 mg f (from 2.2 mg naf) $0 (1) 90
sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop naf) $0 (1) 90
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf) $0 (1) 90
OTHER SUPPLEMENTS
FALESSA – levomefolate glucosamine tab 1 mg (folate $0 (2)
equivalent)
FISH OIL ULTRA – omega-3 fatty acids cap 1400 mg $0 (3)
OCEAN BLUE MINICAPS OMEGA – omega-3 fatty acids cap $0 (3)
350 mg
OMEGA POWER – omega-3 fatty acids cap 1050 mg $0 (3)
OMEGA-3 – omega-3 fatty acids cap 1400 mg $0 (3)
OMEGA-3 IQ – omega-3 fatty acids chew tab 240 mg $0 (3)
OMEGA-3 2100 – omega-3 fatty acids cap 1050 mg $0 (3)
omega-3 fatty acids cap 500 mg $0 (3)
omega-3 fatty acids cap delayed release 1000 mg $0 (3)
omega-3 fatty acids cap delayed release 1200 mg $0 (3)
PRO NUTRIENTS OMEGA 3 – omega-3 fatty acids cap delayed $0 (3)
release 332.5 mg
BLOOD MODIFYING DRUGS
ADVATE – antihemophilic factor rahf-pfm for inj 250 unit $0 (2) SP

order
62
2017

(tier level) use
Name of Drug
ADYNOVATE – antihemophilic factor recomb pegylated for inj $0 (2) SP
250 unit
500 unit
750 unit
1000 unit
1500 unit
2000 unit
3000 unit
ALPHANATE/VON WILLEBRAND – antihemophilic factor/vwf $0 (2) SP
(human) for inj 250 unit
ALPHANINE SD – coagulation factor ix for inj 500 unit $0 (2) SP
anagrelide hcl cap 0.5 mg (Agrylin) $0 (1) 90
anagrelide hcl cap 1 mg $0 (1) 90
ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled $0 (2) PA, SP
syringe 10 mcg/0.4ml

order
63
2017

(tier level) use
Name of Drug
syringe 500 mcg/ml
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25 mcg/ $0 (2) PA, SP
ml
ml
ml
ml
ml
ml
aspirin-dipyridamole cap er 12hr 25-200 mg (Aggrenox) $0 (1) 90
BEBULIN – factor ix complex for inj 200-1200 unit $0 (2) SP
BENEFIX – coagulation factor ix (recombinant) for inj kit 250 unit $0 (2) SP
BENEFIX – coagulation factor ix (recombinant) for inj kit 500 unit $0 (2) SP
BENEFIX – coagulation factor ix (recombinant) for inj kit 1000 $0 (2) SP
unit
unit
unit
BRILINTA – ticagrelor tab 60 mg $0 (2) PA, QL (60 tablets/30
days), 90
BRILINTA – ticagrelor tab 90 mg $0 (2) PA, QL (60 tablets/30
days), 90
cilostazol tab 50 mg $0 (1) 90
cilostazol tab 100 mg $0 (1) 90
clopidogrel bisulfate tab 75 mg (base equiv) (Plavix) $0 (1) 90
clopidogrel bisulfate tab 300 mg (base equiv) (Plavix) $0 (1)
COAGADEX – coagulation factor x (human) for inj 250 unit $0 (2) SP
COAGADEX – coagulation factor x (human) for inj 500 unit $0 (2) SP
cyanocobalamin inj 1000 mcg/ml $0 (1)
cyanocobalamin tab er 1000 mcg $0 (3)

order
64
2017

(tier level) use
Name of Drug
cyanocobalamin tab 100 mcg $0 (3)
dipyridamole tab 25 mg $0 (1) 90
ELIQUIS – apixaban tab 2.5 mg $0 (2) PA, QL (60 tablets/30
days), 90
ELIQUIS – apixaban tab 5 mg $0 (2) PA, QL (120
tablets/30 days), 90
enoxaparin sodium inj 30 mg/0.3ml (Lovenox) $0 (1) QL (30 syringes/365 days)
enoxaparin sodium inj 100 mg/ml (Lovenox) $0 (1) QL (30 syringes/365 days)
enoxaparin sodium inj 150 mg/ml (Lovenox) $0 (1) QL (30 syringes/365 days)
enoxaparin sodium inj 300 mg/3ml (Lovenox) $0 (1) QL (30 vials/365 days)
fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap $0 (1)
(Tandem plus)
fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 mg $0 (1)
fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 mg $0 (1)
ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1 mg $0 (1)
ferrous fumarate-folic acid tab 324-1 mg $0 (1)
ferrous sulfate tab ec 325 mg (65 mg fe equivalent) $0 (3)
ferrous sulfate tab 325 mg (65 mg elemental fe) $0 (3)
FIRAZYR – icatibant acetate inj 30 mg/3ml (base equivalent) $0 (2) PA, QL (6 syringes/30
days), SP
folic acid tab 400 mcg $0 (3)
folic acid tab 800 mcg $0 (3) 90
folic acid tab 1 mg $0 (1) 90
folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg $0 (1)
folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard rx) $0 (1)
folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg $0 (1)

order
65
2017

(tier level) use
Name of Drug
HELIXATE FS – antihemophilic factor (recombinant) for inj kit $0 (1) SP
250 unit
500 unit
1000 unit
2000 unit
3000 unit
HEMOFIL M – antihemophilic factor (human) for inj 250 unit $0 (2) SP
HUMATE-P – antihemophilic factor/vwf (human) for inj 500-1200 $0 (2) SP
unit
HUMATE-P – antihemophilic factor/vwf (human) for inj $0 (2) SP
1000-2400 unit
iron combination cap $0 (1)
iron polysacch complex-vit b12-fa cap 150-0.025-1 mg $0 (1)
iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg $0 (1)
(Hematron-af)
iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg (Corvite $0 (1)
150)
IXINITY – coagulation factor ix (recombinant) for inj 500 unit $0 (2) SP
KOATE – antihemophilic factor (human) for inj 250 unit $0 (2) SP
KOATE-DVI – antihemophilic factor (human) for inj 250 unit $0 (2) SP
KOGENATE FS – antihemophilic factor (recombinant) for inj kit $0 (1) SP
250 unit
500 unit
1000 unit

order
66
2017

(tier level) use
Name of Drug
2000 unit
3000 unit
KOGENATE FS BIO-SET – antihemophilic factor (recombinant) $0 (1) SP
for inj kit 250 unit
LMD 10% DEXTROSE 5% – dextran 40 inj 10% in d5w $0 (2)
MONOCLATE-P – antihemophilic factor (human) for inj kit 1000 $0 (2) SP
unit
MONOCLATE-P – antihemophilic factor (human) for inj kit 1500 $0 (2) SP
unit
MONONINE – coagulation factor ix for inj 1000 unit $0 (2) SP
NEUPOGEN – filgrastim soln prefilled syringe 300 mcg/0.5ml $0 (2) SP
NEUPOGEN – filgrastim soln prefilled syringe 480 mcg/0.8ml $0 (2) SP
(600 mcg/ml)
NEUPOGEN – filgrastim inj 300 mcg/ml $0 (2) SP
NEUPOGEN – filgrastim inj 480 mcg/1.6ml (300 mcg/ml) $0 (2) SP
pentoxifylline tab er 400 mg $0 (1) 90
PROFILNINE – factor ix complex for inj 500 unit $0 (2) SP
PROFILNINE SD – factor ix complex for inj 500 unit $0 (2) SP
RECOMBINATE – antihemophilic factor (recombinant) for inj $0 (2) SP
220-400 unit
401-800 unit
801-1240 unit
1241-1800 unit

order
67
2017

(tier level) use
Name of Drug
1801-2400 unit
RIXUBIS – coagulation factor ix (recombinant) for inj 250 unit $0 (2) SP
tranexamic acid tab 650 mg (Lysteda) $0 (1)
warfarin sodium tab 1 mg (Coumadin) $0 (1) 90
warfarin sodium tab 2.5 mg (Coumadin) $0 (1) 90
warfarin sodium tab 7.5 mg (Coumadin) $0 (1) 90
XARELTO – rivaroxaban tab 10 mg $0 (2) QL (35 tablets/365 days), 90
XARELTO – rivaroxaban tab 15 mg $0 (2) PA, QL (60 tablets/30
days), 90
XARELTO – rivaroxaban tab 20 mg $0 (2) PA, QL (30 tablets/30
days), 90
XARELTO STARTER PACK – rivaroxaban tab starter therapy $0 (2) PA, QL (51 tablets/30 days)
pack 15 mg & 20 mg
XYNTHA – antihemophilic factor recombinant paf for inj kit 250 $0 (2) SP
unit
unit
unit
unit
XYNTHA SOLOFUSE – antihemophilic factor recombinant paf for $0 (2) SP
inj kit 250 unit
inj kit 500 unit
inj kit 1000 unit

order
68
2017

(tier level) use
Name of Drug
inj kit 2000 unit
inj kit 3000 unit
ZARXIO – filgrastim-sndz soln prefilled syringe 300 mcg/0.5ml $0 (2) SP
ZARXIO – filgrastim-sndz soln prefilled syringe 480 mcg/0.8ml $0 (2) SP
TOPICAL DRUGS
EYE
Anti-infectives
BACITRACIN – bacitracin ophth oint 500 unit/gm $0 (2)
bacitracin-polymyxin b ophth oint $0 (1)
ciprofloxacin hcl ophth soln 0.3% (Ciloxan) $0 (1)
erythromycin ophth oint 5 mg/gm $0 (1)
GENTAK – gentamicin sulfate ophth oint 0.3% $0 (1)
gentamicin sulfate ophth soln 0.3% $0 (1)
levofloxacin ophth soln 0.5% $0 (1)
NATACYN – natamycin ophth susp 5% $0 (2)
neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin $0 (1)
neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ $0 (1)
ml (Neosporin)
ofloxacin ophth soln 0.3% (Ocuflox) $0 (1)
polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% $0 (1)
(Polytrim)
sulfacetamide sodium ophth soln 10% (Bleph-10) $0 (1)
tobramycin ophth soln 0.3% (Tobrex) $0 (1)
trifluridine ophth soln 1% (Viroptic) $0 (1)
Steroids and Combination Products
bacitracin-polymyxin-neomycin-hc ophth oint 1% $0 (1)
DEXAMETHASONE SODIUM PHOS – dexamethasone sodium $0 (2)
phosphate ophth soln 0.1%
fluorometholone ophth susp 0.1% (Fml liquifilm) $0 (1)
neomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol) $0 (1)
neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol) $0 (1)
prednisolone acetate ophth susp 1% (Pred forte) $0 (1)
PREDNISOLONE SODIUM PHOSP – prednisolone sodium $0 (2)
phosphate ophth soln 1%
sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% $0 (1)

order
69
2017

(tier level) use
Name of Drug
tobramycin-dexamethasone ophth susp 0.3-0.1% (Tobradex) $0 (1)
Glaucoma
ALPHAGAN P – brimonidine tartrate ophth soln 0.1% $0 (2) 90
apraclonidine hcl ophth soln 0.5% (base equivalent) (Iopidine) $0 (1)
betaxolol hcl ophth soln 0.5% $0 (1) 90
brimonidine tartrate ophth soln 0.2% $0 (1) 90
carteolol hcl ophth soln 1% $0 (1) 90
dorzolamide hcl ophth soln 2% (Trusopt) $0 (1) 90
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml $0 (1) 90
(Cosopt)
latanoprost ophth soln 0.005% (Xalatan) $0 (1) QL (1 bottle/30 days), 90
levobunolol hcl ophth soln 0.5% (Betagan) $0 (1) 90
pilocarpine hcl ophth soln 1% (Isopto carpine) $0 (1) 90
timolol maleate ophth soln 0.25% (Timoptic) $0 (1) 90
timolol maleate ophth soln 0.5% (Timoptic) $0 (1) 90
Other Eye Products
artificial tear ophth solution $0 (3)
ATROPINE SULFATE – atropine sulfate ophth soln 1% $0 (2) 90
ATROPINE SULFATE – atropine sulfate ophth oint 1% $0 (2) 90
azelastine hcl ophth soln 0.05% $0 (1)
cromolyn sodium ophth soln 4% $0 (1)
cyclopentolate hcl ophth soln 0.5% (Cyclogyl) $0 (1) 90
cyclopentolate hcl ophth soln 1% (Cyclogyl) $0 (1) 90
cyclopentolate hcl ophth soln 2% (Cyclogyl) $0 (1) 90
diclofenac sodium ophth soln 0.1% $0 (1)
flurbiprofen sodium ophth soln 0.03% (Ocufen) $0 (1)
ketorolac tromethamine ophth soln 0.4% (Acular ls) $0 (1)
ketorolac tromethamine ophth soln 0.5% (Acular) $0 (1)
ketotifen fumarate ophth soln 0.025% (base equiv) $0 (3)
proparacaine hcl ophth soln 0.5% $0 (1)
tetracaine hcl ophth soln 0.5% $0 (1)
tetrahydroz-dextran-peg-povidone ophth soln 0.05-0.1-1-1% $0 (3)
EAR

order
70
2017

(tier level) use
Name of Drug
acetic acid otic soln 2% $0 (1)
carbamide peroxide 6.5% otic soln $0 (3)
hydrocortisone w/ acetic acid otic soln 1-2% $0 (1)
neomycin-polymyxin-hc otic soln 1% $0 (1)
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% $0 (1)
ofloxacin otic soln 0.3% (Floxin otic) $0 (1)
MOUTH AND THROAT (local)
chlorhexidine gluconate soln 0.12% (Peridex) $0 (1)
clotrimazole troche 10 mg $0 (1)
lidocaine hcl viscous soln 2% $0 (1)
nystatin susp 100000 unit/ml $0 (1)
pilocarpine hcl tab 5 mg (Salagen) $0 (1) 90
pilocarpine hcl tab 7.5 mg (Salagen) $0 (1) 90
sodium fluoride cream 1.1% (Prevident 5000 plus) $0 (1) 90
sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride) $0 (1) 90
sodium fluoride rinse 0.2% $0 (1) 90
triamcinolone acetonide dental paste 0.1% $0 (1)
ANORECTAL AGENTS
hydrocortisone enema 100 mg/60ml (Cortenema) $0 (1)
hydrocortisone rectal cream 1% (Proctocort) $0 (1)
hydrocortisone rectal cream 2.5% (Anusol-hc) $0 (1)
SKIN CONDITIONS/PRODUCTS
Acne
benzoyl peroxide liq 10% $0 (1) AL
benzoyl peroxide lotion 6% $0 (1) AL
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5% $0 (1) AL
(Duac)
clindamycin phosphate gel 1% (Cleocin-t) $0 (1) AL
clindamycin phosphate lotion 1% (Cleocin-t) $0 (1) AL
clindamycin phosphate soln 1% (Cleocin-t) $0 (1) AL
clindamycin phosphate swab 1% (Cleocin-t) $0 (1) AL
DIFFERIN – adapalene gel 0.1% $0 (3) AL
erythromycin gel 2% (Erygel) $0 (1) AL
erythromycin pads 2% $0 (1) AL
erythromycin soln 2% $0 (1) AL

order
71
2017

(tier level) use
Name of Drug
isotretinoin cap 10 mg $0 (1) AL
isotretinoin cap 20 mg $0 (1) AL
metronidazole cream 0.75% (Metrocream) $0 (1) AL
metronidazole gel 0.75% $0 (1) AL
metronidazole gel 1% (Metrogel) $0 (1) AL
sulfacetamide sodium w/ sulfur emulsion 10-1% $0 (1) AL
sulfacetamide sodium w/ sulfur emulsion 10-5% $0 (1) AL
tazarotene cream 0.1% (Tazorac) $0 (1) AL
TAZORAC – tazarotene gel 0.05% $0 (2) AL
TAZORAC – tazarotene gel 0.1% $0 (2) AL
tretinoin cream 0.025% (Retin-a) $0 (1) AL
tretinoin gel 0.01% (Retin-a) $0 (1) AL
tretinoin gel 0.025% (Retin-a) $0 (1) AL
Anti-infectives
bacitracin oint 500 unit/gm $0 (3)
bacitracin zinc oint 500 unit/gm $0 (3)
bacitracin-polymyxin b oint $0 (3)
ciclopirox olamine cream 0.77% (base equiv) (Loprox) $0 (1)
clotrimazole cream 1% $0 (1)
clotrimazole soln 1% $0 (1)
clotrimazole w/ betamethasone cream 1-0.05% (Lotrisone) $0 (1)
diclofenac sodium gel 1% (Voltaren) $0 (1) QL (200 grams/30 days)
econazole nitrate cream 1% $0 (1)
GENTAMICIN SULFATE – gentamicin sulfate oint 0.1% $0 (2)
gentamicin sulfate cream 0.1% $0 (1)
ketoconazole cream 2% $0 (1)
ketoconazole shampoo 2% (Nizoral) $0 (1)
miconazole nitrate aerosol pow 2% $0 (3)
miconazole nitrate cream 2% $0 (3)
mupirocin oint 2% $0 (1)
neomycin-bacitracin-polymyxin oint $0 (3)
nystatin cream 100000 unit/gm $0 (1)
nystatin oint 100000 unit/gm $0 (1)

order
72
2017

(tier level) use
Name of Drug
nystatin topical powder 100000 unit/gm $0 (1)
silver sulfadiazine cream 1% (Silvadene) $0 (1)
tolnaftate aerosol 1% $0 (3)
Corticosteroids
alclometasone dipropionate cream 0.05% $0 (1)
alclometasone dipropionate oint 0.05% $0 (1)
AUGMENTED BETAMETHASONE D – betamethasone $0 (2)
dipropionate augmented gel 0.05%
betamethasone dipropionate augmented cream 0.05% $0 (1)
(Diprolene af)
betamethasone dipropionate augmented lotion 0.05% (Diprolene) $0 (1)
betamethasone dipropionate augmented oint 0.05% (Diprolene) $0 (1)
betamethasone dipropionate cream 0.05% $0 (1)
betamethasone dipropionate lotion 0.05% $0 (1)
betamethasone dipropionate oint 0.05% $0 (1)
betamethasone valerate cream 0.1% $0 (1)
betamethasone valerate lotion 0.1% $0 (1)
betamethasone valerate oint 0.1% $0 (1)
clobetasol propionate cream 0.05% (Temovate) $0 (1)
clobetasol propionate emollient base cream 0.05% $0 (1)
clobetasol propionate gel 0.05% (Temovate) $0 (1)
clobetasol propionate oint 0.05% (Temovate) $0 (1)
clobetasol propionate soln 0.05% (Temovate) $0 (1)
desoximetasone cream 0.25% (Topicort) $0 (1)
fluocinolone acetonide cream 0.01% $0 (1)
fluocinolone acetonide cream 0.025% (Synalar) $0 (1)
fluocinolone acetonide oint 0.025% (Synalar) $0 (1)
fluocinolone acetonide soln 0.01% (Synalar) $0 (1)
fluocinonide cream 0.05% $0 (1)
fluocinonide emulsified base cream 0.05% $0 (1)
fluocinonide gel 0.05% $0 (1)
fluocinonide oint 0.05% $0 (1)
fluocinonide soln 0.05% $0 (1)
fluticasone propionate cream 0.05% (Cutivate) $0 (1)
fluticasone propionate oint 0.005% $0 (1)
halobetasol propionate cream 0.05% (Ultravate) $0 (1)

order
73
2017

(tier level) use
Name of Drug
halobetasol propionate oint 0.05% (Ultravate) $0 (1)
hydrocortisone butyrate oint 0.1% (Locoid) $0 (1)
hydrocortisone cream 0.5% $0 (3)
hydrocortisone cream 1% $0 (1)
hydrocortisone cream 2.5% $0 (1)
hydrocortisone lotion 2.5% $0 (1)
hydrocortisone oint 0.5% $0 (3)
hydrocortisone oint 1% $0 (1)
hydrocortisone oint 2.5% $0 (1)
hydrocortisone valerate cream 0.2% $0 (1)
hydrocortisone valerate oint 0.2% (Westcort) $0 (1)
mometasone furoate cream 0.1% (Elocon) $0 (1)
mometasone furoate oint 0.1% (Elocon) $0 (1)
mometasone furoate solution 0.1% (lotion) $0 (1)
prednicarbate cream 0.1% (Dermatop) $0 (1)
prednicarbate oint 0.1% (Dermatop) $0 (1)
triamcinolone acetonide cream 0.025% $0 (1)
triamcinolone acetonide lotion 0.025% $0 (1)
triamcinolone acetonide lotion 0.1% $0 (1)
triamcinolone acetonide oint 0.025% $0 (1)
triamcinolone acetonide oint 0.1% $0 (1)
Other Skin Products
calcipotriene cream 0.005% (Dovonex) $0 (1)
calcipotriene oint 0.005% $0 (1)
calcipotriene soln 0.005% (50 mcg/ml) $0 (1)
ELIDEL – pimecrolimus cream 1% $0 (2) ST
fluorouracil cream 5% (Efudex) $0 (1) QL (240 grams/180 days)
imiquimod cream 5% (Aldara) $0 (1) QL (48 packs/180 days)
lactic acid (ammonium lactate) lotion 12% (Lac-hydrin) $0 (3)
lidocaine hcl cream 3% $0 (1) QL (120 grams/30 days)
lidocaine hcl gel 2% $0 (1) QL (120 grams/30 days)
lidocaine hcl soln 4% (Xylocaine) $0 (1) QL (120 grams/30 days)
lidocaine oint 5% $0 (1) PA, QL (120 grams/30 days)

order
74
2017

(tier level) use
Name of Drug
lidocaine patch 5% (Lidoderm) $0 (1) PA, QL (120 patches/30 days)
lidocaine-prilocaine cream kit 2.5-2.5% $0 (1)
lidocaine-prilocaine cream 2.5-2.5% $0 (1)
methoxsalen rapid cap 10 mg (Oxsoralen ultra) $0 (1)
permethrin cream 5% (Elimite) $0 (1)
permethrin creme rinse 1% $0 (3)
podofilox soln 0.5% $0 (1)
QC CALAMINE – calamine lotion $0 (3)
selenium sulfide lotion 2.5% $0 (1)
tacrolimus oint 0.03% (Protopic) $0 (1) ST
tacrolimus oint 0.1% (Protopic) $0 (1) ST
VALCHLOR – mechlorethamine hcl gel 0.016% (base equivalent) $0 (2) SP
vitamins a & d oint $0 (3)
zinc oxide oint 20% $0 (3)
zinc oxide oint 10% $0 (3)
ZYCLARA – imiquimod cream 3.75% $0 (2) PA, QL (56 packets/180 days)
ZYCLARA PUMP – imiquimod cream 2.5% $0 (2) PA, QL (15 grams/180 days)
ZYCLARA PUMP – imiquimod cream 3.75% $0 (2) PA, QL (15 grams/180 days)
MISCELLANEOUS CATEGORIES (includes supplies and devices)
DIABETIC SUPPLIES
GLUCOSE METERS - BAYER ASCENCIA $0 (3)
TEST STRIPS - BAYER ASCENCIA $0 (3) QL (204 strips/30
days), ST, 90
ALCOHOL PREP PADS, SWABS - various $0 (3) QL (200 swabs/30 days), 90
INSULIN PEN NEEDLES - TECHLITE and TRUEPLUS $0 (3) QL (200 insulin pen
needles/30 days), 90
INSULIN SYRINGES - TECHLITE and TRUEPLUS $0 (3) QL (200 syringes/30
days), 90
LANCETS - BAYER ASCENCIA $0 (3) QL (200 units/30 days), 90
RESPIRATORY INHALER-ASSIST DEVICES
RESPIRATORY THERAPY SUPPLIES - various $0 (3)
SPACER/AEROSOL - HOLDING CHAMBERS - various $0 (2)
MISCELLANEOUS DRUGS
azathioprine tab 50 mg (Imuran) $0 (1) 90
CHEMET – succimer cap 100 mg $0 (2)

order
75
2017

(tier level) use
Name of Drug
cyclosporine cap 25 mg (Sandimmune) $0 (1) 90
cyclosporine cap 100 mg (Sandimmune) $0 (1) 90
CYCLOSPORINE MODIFIED – cyclosporine modified cap 50 mg $0 (2) 90
cyclosporine modified cap 25 mg (Neoral) $0 (1) 90
cyclosporine modified cap 50 mg (Cyclosporine modifie) $0 (1) 90
cyclosporine modified cap 100 mg (Neoral) $0 (1) 90
cyclosporine modified oral soln 100 mg/ml (Neoral) $0 (1) 90
DEPEN TITRATABS – penicillamine tab 250 mg $0 (2) SP
irrigation solution, physiological $0 (1)
lactated ringer's for irrigation $0 (1)
mycophenolate mofetil cap 250 mg (Cellcept) $0 (1) 90
mycophenolate mofetil for oral susp 200 mg/ml (Cellcept) $0 (1) 90
mycophenolate mofetil tab 500 mg (Cellcept) $0 (1) 90
mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv) $0 (1) 90
(Myfortic)
mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv) $0 (1) 90
(Myfortic)
NALOXONE HCL – naloxone hcl soln cartridge 0.4 mg/ml $0 (2)
NALOXONE HCL – naloxone hcl soln prefilled syringe 2 mg/2ml $0 (2)
NARCAN – naloxone hcl nasal spray 4 mg/0.1ml $0 (2)
REVLIMID – lenalidomide caps 2.5 mg $0 (2) PA, QL (30 capsules/30
days), SP
REVLIMID – lenalidomide cap 5 mg $0 (2) PA, QL (30 capsules/30
days), SP
days), SP
days), SP
days), SP
days), SP
ringer's solution for irrigation $0 (1)
sirolimus tab 0.5 mg (Rapamune) $0 (1) 90
sirolimus tab 1 mg (Rapamune) $0 (1) 90
sirolimus tab 2 mg (Rapamune) $0 (1) 90
sodium polystyrene sulfonate oral susp 15 gm/60ml $0 (1)

order
76
2017

(tier level) use
Name of Drug
sodium polystyrene sulfonate powder $0 (1)
sodium polystyrene sulfonate rectal susp 30 gm/120ml $0 (1)
tacrolimus cap 0.5 mg (Prograf) $0 (1) 90
tacrolimus cap 1 mg (Prograf) $0 (1) 90
tacrolimus cap 5 mg (Prograf) $0 (1) 90
THALOMID – thalidomide cap 50 mg $0 (2) PA, QL (30 capsules/30
days), SP
days), SP
days), SP
water for irrigation, sterile irrigation soln $0 (1)
ZORTRESS – everolimus tab 0.25 mg $0 (2) 90

order
77
2017
ADVATE – antihemophilic factor rahf-pfm for inj 1000
INDEX unit................................................................................
A unit................................................................................
abacavir sulfate-lamivudine tab 600-300 mg
unit................................................................................
(Epzicom).....................................................................
abacavir sulfate-lamivudine-zidovudine tab 300-150-300
unit................................................................................
mg (Trizivir)..................................................................
abacavir sulfate tab 300 mg (base equiv) (Ziagen)......
unit................................................................................
ABILIFY MAINTENA – aripiprazole im for extended
ADYNOVATE – antihemophilic factor recomb pegylated
release susp 300 mg..................................................
for inj 250 unit.............................................................
ABILIFY MAINTENA – aripiprazole im for extended
release susp 400 mg..................................................
for inj 500 unit.............................................................
acamprosate calcium tab delayed release 333 mg......
acarbose tab 25 mg (Precose).....................................
for inj 750 unit.............................................................
acarbose tab 50 mg (Precose).....................................
acarbose tab 100 mg (Precose)...................................
for inj 1000 unit...........................................................
acebutolol hcl cap 200 mg............................................
acebutolol hcl cap 400 mg............................................
for inj 1500 unit...........................................................
ACETAMINOPHEN/CAFFEINE/DI – acetaminophen-
caffeine-dihydrocodeine cap 320.5-30-16 mg............
for inj 2000 unit...........................................................
acetaminophen cap 500 mg.........................................
acetaminophen chew tab 80 mg..................................
for inj 3000 unit...........................................................
acetaminophen chew tab 160 mg................................
AEROCHAMBER MINI AEROSOL..............................
acetaminophen disintegrating tab 80 mg.....................
AFINITOR DISPERZ – everolimus tab for oral susp 2
acetaminophen liquid 160 mg/5ml................................
mg................................................................................
acetaminophen soln 160 mg/5ml.................................
acetaminophen suppos 120 mg...................................
mg................................................................................
acetaminophen susp 80 mg/0.8ml...............................
acetaminophen susp 160 mg/5ml................................
mg................................................................................
acetaminophen tab 325 mg..........................................
AFINITOR – everolimus tab 2.5 mg.............................
acetaminophen tab 500 mg..........................................
AFINITOR – everolimus tab 5 mg................................
acetaminophen w/ codeine soln 120-12 mg/5ml..........
AFINITOR – everolimus tab 7.5 mg.............................
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
AFINITOR – everolimus tab 10 mg..............................
codeine).......................................................................
AFLURIA 2015-2016 – influenza virus vaccine split im
susp..............................................................................
codeine #3)..................................................................
susp..............................................................................
codeine #4)..................................................................
acetazolamide cap er 12hr 500 mg (Diamox)..............
susp..............................................................................
acetazolamide tab 125 mg...........................................
AFLURIA PF 2015-2016 – influenza virus vaccine split pf
acetazolamide tab 250 mg...........................................
susp pref syringe 0.5 ml.............................................
acetic acid otic soln 2%................................................
acetylcysteine inhal soln 10%.......................................
acetylcysteine inhal soln 20%.......................................
ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)...................................................
AFLURIA QUADRIVALENT 2017 – influenza virus
acyclovir cap 200 mg (Zovirax)....................................
vaccine split quadrivalent im inj..................................
acyclovir susp 200 mg/5ml (Zovirax)............................
AFLURIA QUADRIVALENT 2016 – influenza virus vac
acyclovir tab 400 mg (Zovirax).....................................
split quadrivalent susp pref syr 0.5ml.........................
acyclovir tab 800 mg (Zovirax).....................................
AFLURIA QUADRIVALENT 2017 – influenza virus vac
ADCIRCA – tadalafil tab 20 mg (pah)..........................
split quadrivalent susp pref syr 0.5ml.........................
ALBENZA – albendazole tab 200 mg..........................
unit................................................................................
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml).........
albuterol sulfate soln nebu 0.5% (5 mg/ml)..................
unit................................................................................
78
2017
albuterol sulfate soln nebu 0.63 mg/3ml (base ALPHANINE SD – coagulation factor ix for inj 1500
equiv)............................................................................ unit................................................................................
albuterol sulfate soln nebu 1.25 mg/3ml (base alprazolam tab 0.25 mg (Xanax)..................................
equiv)............................................................................ alprazolam tab 0.5 mg (Xanax)....................................
albuterol sulfate syrup 2 mg/5ml.................................. alprazolam tab 1 mg (Xanax).......................................
alclometasone dipropionate cream 0.05%................... alprazolam tab 2 mg (Xanax).......................................
alclometasone dipropionate oint 0.05%....................... alum & mag hydroxide-simethicone susp 200-200-20
ALCOHOL PREP PADS, SWABS - various................. mg/5ml..........................................................................
ALENDRONATE SODIUM – alendronate sodium tab 40 alum & mag hydroxide-simethicone susp 400-400-40
mg................................................................................ mg/5ml..........................................................................
alendronate sodium tab 5 mg....................................... amantadine hcl cap 100 mg.........................................
alendronate sodium tab 10 mg..................................... amantadine hcl syrup 50 mg/5ml.................................
alendronate sodium tab 35 mg..................................... amiloride & hydrochlorothiazide tab 5-50 mg...............
alendronate sodium tab 70 mg (Fosamax).................. amiloride hcl tab 5 mg..................................................
alfuzosin hcl tab er 24hr 10 mg (Uroxatral).................. amiodarone hcl tab 200 mg..........................................
ALKERAN – melphalan tab 2 mg................................. amitriptyline hcl tab 10 mg............................................
allopurinol tab 100 mg (Zyloprim)................................. amitriptyline hcl tab 50 mg............................................
allopurinol tab 300 mg (Zyloprim)................................. amitriptyline hcl tab 75 mg............................................
ALOGLIPTIN/METFORMIN HCL – alogliptin-metformin amitriptyline hcl tab 100 mg..........................................
hcl tab 12.5-500 mg.................................................... amitriptyline hcl tab 150 mg..........................................
ALOGLIPTIN/METFORMIN HCL – alogliptin-metformin amitriptyline hcl tab 25 mg (Elavil)...............................
hcl tab 12.5-1000 mg.................................................. amlodipine besylate-benazepril hcl cap 2.5-10 mg......
ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone amlodipine besylate-benazepril hcl cap 5-40 mg.........
tab 12.5-15 mg............................................................ amlodipine besylate-benazepril hcl cap 5-10 mg
ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone (Lotrel)..........................................................................
tab 25-15 mg............................................................... amlodipine besylate-benazepril hcl cap 10-40 mg
tab 25-30 mg............................................................... amlodipine besylate tab 2.5 mg (Norvasc)...................
ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone amlodipine besylate tab 5 mg (Norvasc)......................
tab 25-45 mg............................................................... amlodipine besylate tab 10 mg (Norvasc)....................
ALOGLIPTIN – alogliptin benzoate tab 6.25 mg (base amlodipine besylate-valsartan tab 5-160 mg
equiv)............................................................................ (Exforge)......................................................................
ALOGLIPTIN – alogliptin benzoate tab 12.5 mg (base amlodipine besylate-valsartan tab 5-320 mg
equiv)............................................................................ (Exforge)......................................................................
ALOGLIPTIN – alogliptin benzoate tab 25 mg (base amlodipine besylate-valsartan tab 10-160 mg
equiv)............................................................................ (Exforge)......................................................................
ALPHAGAN P – brimonidine tartrate ophth soln amlodipine besylate-valsartan tab 10-320 mg
0.1%............................................................................. (Exforge)......................................................................
ALPHANATE/VON WILLEBRAND – antihemophilic factor/ amoxicillin & k clavulanate for susp 200-28.5
vwf (human) for inj 250 unit........................................ mg/5ml..........................................................................
ALPHANATE/VON WILLEBRAND – antihemophilic factor/ amoxicillin & k clavulanate for susp 400-57
vwf (human) for inj 500 unit........................................ mg/5ml..........................................................................
ALPHANATE/VON WILLEBRAND – antihemophilic factor/ amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
vwf (human) for inj 1000 unit...................................... (Augmentin).................................................................
ALPHANATE/VON WILLEBRAND – antihemophilic factor/ amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
vwf (human) for inj 1500 unit...................................... (Augmentin es-600).....................................................
ALPHANATE/VON WILLEBRAND – antihemophilic factor/ amoxicillin & k clavulanate tab 250-125 mg.................
vwf (human) for inj 2000 unit...................................... amoxicillin & k clavulanate tab 500-125 mg
ALPHANINE SD – coagulation factor ix for inj 500 (Augmentin).................................................................
unit................................................................................ amoxicillin & k clavulanate tab 875-125 mg
ALPHANINE SD – coagulation factor ix for inj 1000 (Augmentin).................................................................
unit................................................................................
79
2017
AMOXICILLIN – amoxicillin (trihydrate) chew tab 125 ARANESP ALBUMIN FREE – darbepoetin alfa soln inj
mg................................................................................ 300 mcg/ml..................................................................
AMOXICILLIN – amoxicillin (trihydrate) chew tab 250 ARANESP ALBUMIN FREE – darbepoetin alfa soln
mg................................................................................ prefilled syringe 10 mcg/0.4ml....................................
amoxicillin (trihydrate) cap 250 mg............................... ARANESP ALBUMIN FREE – darbepoetin alfa soln
amoxicillin (trihydrate) cap 500 mg............................... prefilled syringe 25 mcg/0.42ml..................................
amoxicillin (trihydrate) for susp 125 mg/5ml................. ARANESP ALBUMIN FREE – darbepoetin alfa soln
amoxicillin (trihydrate) for susp 200 mg/5ml................. prefilled syringe 40 mcg/0.4ml....................................
amoxicillin (trihydrate) for susp 250 mg/5ml................. ARANESP ALBUMIN FREE – darbepoetin alfa soln
amoxicillin (trihydrate) for susp 400 mg/5ml................. prefilled syringe 60 mcg/0.3ml....................................
amoxicillin (trihydrate) tab 875 mg............................... ARANESP ALBUMIN FREE – darbepoetin alfa soln
amphetamine-dextroamphetamine cap er 24hr 5 mg prefilled syringe 100 mcg/0.5ml..................................
(Adderall xr)................................................................. ARANESP ALBUMIN FREE – darbepoetin alfa soln
amphetamine-dextroamphetamine cap er 24hr 25 mg prefilled syringe 500 mcg/ml.......................................
(Adderall xr)................................................................. aripiprazole oral solution 1 mg/ml.................................
amphetamine-dextroamphetamine cap er 24hr 30 mg aripiprazole tab 2 mg (Abilify).......................................
(Adderall xr)................................................................. aripiprazole tab 5 mg (Abilify).......................................
amphetamine-dextroamphetamine tab 5 mg aripiprazole tab 10 mg (Abilify).....................................
(Adderall)...................................................................... aripiprazole tab 15 mg (Abilify).....................................
amphetamine-dextroamphetamine tab 7.5 mg aripiprazole tab 20 mg (Abilify).....................................
(Adderall)...................................................................... aripiprazole tab 30 mg (Abilify).....................................
amphetamine-dextroamphetamine tab 10 mg ARISTADA – aripiprazole lauroxil im er susp prefilled syr
(Adderall)...................................................................... 441 mg/1.6ml...............................................................
amphetamine-dextroamphetamine tab 12.5 mg ARISTADA – aripiprazole lauroxil im er susp prefilled syr
(Adderall)...................................................................... 662 mg/2.4ml...............................................................
(Adderall)...................................................................... 882 mg/3.2ml...............................................................
(Adderall)...................................................................... 1064 mg/3.9ml.............................................................
amphetamine-dextroamphetamine tab 30 mg ARNUITY ELLIPTA – fluticasone furoate aerosol powder
(Adderall)...................................................................... breath activ 100 mcg/act.............................................
ampicillin cap 500 mg................................................... ARNUITY ELLIPTA – fluticasone furoate aerosol powder
AMPYRA – dalfampridine tab er 12hr 10 mg............... breath activ 200 mcg/act.............................................
anagrelide hcl cap 1 mg............................................... artificial tear ophth solution...........................................
anagrelide hcl cap 0.5 mg (Agrylin).............................. ascorbic acid tab 500 mg.............................................
anastrozole tab 1 mg (Arimidex).................................. aspirin chew tab 81 mg................................................
apraclonidine hcl ophth soln 0.5% (base equivalent) aspirin-dipyridamole cap er 12hr 25-200 mg
(Iopidine)...................................................................... (Aggrenox)...................................................................
APTIVUS – tipranavir cap 250 mg............................... aspirin tab delayed release 81 mg...............................
APTIVUS – tipranavir oral soln 100 mg/ml................... aspirin tab delayed release 325 mg.............................
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25 aspirin tab 325 mg........................................................
mcg/ml.......................................................................... atenolol & chlorthalidone tab 50-25 mg (Tenoretic
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 40 50)................................................................................
mcg/ml.......................................................................... atenolol & chlorthalidone tab 100-25 mg (Tenoretic
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 60 100)..............................................................................
mcg/ml.......................................................................... atenolol tab 25 mg (Tenormin).....................................
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj atenolol tab 50 mg (Tenormin).....................................
100 mcg/ml.................................................................. atenolol tab 100 mg (Tenormin)...................................
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj atorvastatin calcium tab 10 mg (base equivalent)
200 mcg/ml.................................................................. (Lipitor).........................................................................
80
2017
atorvastatin calcium tab 20 mg (base equivalent) b-complex w/ c & folic acid tab 5 mg...........................
(Lipitor)......................................................................... b-complex w/ c & folic acid tab 1 mg (Nephro-vite
atorvastatin calcium tab 40 mg (base equivalent) rx).................................................................................
(Lipitor)......................................................................... BEBULIN – factor ix complex for inj 200-1200 unit......
atorvastatin calcium tab 80 mg (base equivalent) benazepril & hydrochlorothiazide tab 5-6.25 mg..........
(Lipitor)......................................................................... benazepril & hydrochlorothiazide tab 10-12.5 mg
atovaquone-proguanil hcl tab 62.5-25 mg (Lotensin hct)...............................................................
(Malarone).................................................................... benazepril & hydrochlorothiazide tab 20-12.5 mg
atovaquone-proguanil hcl tab 250-100 mg (Lotensin hct)...............................................................
(Malarone).................................................................... benazepril & hydrochlorothiazide tab 20-25 mg (Lotensin
atovaquone susp 750 mg/5ml (Mepron)...................... hct)...............................................................................
ATRIPLA – efavirenz-emtricitabine-tenofovir df tab benazepril hcl tab 5 mg................................................
600-200-300 mg.......................................................... benazepril hcl tab 10 mg..............................................
ATROPINE SULFATE – atropine sulfate ophth oint benazepril hcl tab 20 mg (Lotensin).............................
1%................................................................................ benazepril hcl tab 40 mg (Lotensin).............................
ATROPINE SULFATE – atropine sulfate ophth soln BENEFIX – coagulation factor ix (recombinant) for inj kit
1%................................................................................ 250 unit........................................................................
ATROVENT HFA – ipratropium bromide hfa inhal aerosol BENEFIX – coagulation factor ix (recombinant) for inj kit
17 mcg/act................................................................... 500 unit........................................................................
AUBAGIO – teriflunomide tab 7 mg............................. BENEFIX – coagulation factor ix (recombinant) for inj kit
AUBAGIO – teriflunomide tab 14 mg........................... 1000 unit......................................................................
AUGMENTED BETAMETHASONE D – betamethasone BENEFIX – coagulation factor ix (recombinant) for inj kit
dipropionate augmented gel 0.05%............................ 2000 unit......................................................................
AVONEX – interferon beta-1a for im inj kit 30mcg BENEFIX – coagulation factor ix (recombinant) for inj kit
(33mcg(6.6 mu)/vial)................................................... 3000 unit......................................................................
AVONEX – interferon beta-1a im prefilled syringe kit 30 benzoyl peroxide liq 10%..............................................
mcg/0.5ml..................................................................... benzoyl peroxide lotion 6%...........................................
AVONEX PEN – interferon beta-1a im auto-injector kit 30 benztropine mesylate tab 0.5 mg.................................
mcg/0.5ml..................................................................... benztropine mesylate tab 1 mg....................................
azathioprine tab 50 mg (Imuran).................................. benztropine mesylate tab 2 mg....................................
azelastine hcl nasal spray 0.1% (137 mcg/spray)........ betamethasone dipropionate augmented cream 0.05%
azelastine hcl ophth soln 0.05%................................... (Diprolene af)...............................................................
azithromycin for susp 100 mg/5ml (Zithromax)............ betamethasone dipropionate augmented lotion 0.05%
azithromycin for susp 200 mg/5ml (Zithromax)............ (Diprolene)...................................................................
azithromycin tab 250 mg (Zithromax)........................... betamethasone dipropionate augmented oint 0.05%
azithromycin tab 500 mg (Zithromax)........................... (Diprolene)...................................................................
azithromycin tab 600 mg (Zithromax)........................... betamethasone dipropionate cream 0.05%..................
B betamethasone dipropionate lotion 0.05%...................
betamethasone dipropionate oint 0.05%......................
BACITRACIN – bacitracin ophth oint 500 unit/gm....... betamethasone valerate cream 0.1%...........................
bacitracin oint 500 unit/gm............................................ betamethasone valerate lotion 0.1%............................
bacitracin-polymyxin b oint........................................... betamethasone valerate oint 0.1%...............................
bacitracin-polymyxin b ophth oint................................. betaxolol hcl ophth soln 0.5%.......................................
bacitracin-polymyxin-neomycin-hc ophth oint 1%........ betaxolol hcl tab 10 mg................................................
bacitracin zinc oint 500 unit/gm.................................... betaxolol hcl tab 20 mg................................................
baclofen tab 10 mg....................................................... bethanechol chloride tab 5 mg (Urecholine)................
baclofen tab 20 mg....................................................... bethanechol chloride tab 10 mg (Urecholine)..............
balsalazide disodium cap 750 mg (Colazal)................. bethanechol chloride tab 25 mg (Urecholine)..............
BARACLUDE – entecavir oral soln 0.05 mg/ml........... bethanechol chloride tab 50 mg (Urecholine)..............
BASAGLAR KWIKPEN – insulin glargine soln pen-injector bexarotene cap 75 mg (Targretin)................................
100 unit/ml................................................................... bicalutamide tab 50 mg (Casodex)...............................
BAYER CONTOUR BLOOD GLUCO........................... BILTRICIDE – praziquantel tab 600 mg.......................
BAYER MICROLET LANCETS..................................... bisacodyl tab delayed release 5 mg.............................
b-complex w/ c & folic acid cap 1 mg bismuth subsalicylate susp 262 mg/15ml.....................
(Nephrocaps)............................................................... bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
b-complex w/ c & folic acid tab..................................... (Ziac)............................................................................
81
2017
bisoprolol & hydrochlorothiazide tab 5-6.25 mg butalbital-acetaminophen-caff w/ cod cap 50-325-40-30
(Ziac)............................................................................ mg................................................................................
bisoprolol & hydrochlorothiazide tab 10-6.25 mg butalbital-acetaminophen tab 50-325 mg.....................
(Ziac)............................................................................ butalbital-aspirin-caffeine cap 50-325-40 mg
bisoprolol fumarate tab 5 mg........................................ (Fiorinal).......................................................................
bisoprolol fumarate tab 10 mg...................................... butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
BRILINTA – ticagrelor tab 60 mg................................. (Fiorinal/codeine #3)....................................................
BRILINTA – ticagrelor tab 90 mg................................. C
brimonidine tartrate ophth soln 0.2%............................
BROHIST D – brompheniramine & phenylephrine tab 4-10 cabergoline tab 0.5 mg.................................................
mg................................................................................ caffeine citrate oral soln 60 mg/3ml (10 mg/ml base
bromocriptine mesylate tab 2.5 mg (base equivalent) equiv)............................................................................
(Parlodel)...................................................................... calcipotriene cream 0.005% (Dovonex).......................
brompheniramine & phenylephrine elixir 1-2.5 calcipotriene oint 0.005%..............................................
mg/5ml.......................................................................... calcipotriene soln 0.005% (50 mcg/ml)........................
budesonide delayed release particles cap 3 mg (Entocort calcitonin (salmon) nasal soln 200 unit/act..................
ec)................................................................................ calcitriol cap 0.25 mcg (Rocaltrol)................................
budesonide inhalation susp 0.25 mg/2ml calcitriol cap 0.5 mcg (Rocaltrol)..................................
(Pulmicort).................................................................... calcitriol oral soln 1 mcg/ml (Rocaltrol)........................
budesonide inhalation susp 0.5 mg/2ml calcium acetate (phosphate binder) cap 667 mg (169 mg
(Pulmicort).................................................................... ca)................................................................................
budesonide inhalation susp 1 mg/2ml (Pulmicort)....... calcium acetate (phosphate binder) tab 667 mg
bumetanide tab 0.5 mg (Bumex).................................. (Eliphos).......................................................................
bumetanide tab 1 mg (Bumex)..................................... calcium carbonate (antacid) chew tab 500 mg.............
bumetanide tab 2 mg (Bumex)..................................... calcium carbonate (antacid) chew tab 750 mg.............
BUNAVAIL – buprenorphine-naloxone buccal film 2.1-0.3 calcium carbonate (antacid) chew tab 1000 mg...........
mg (base equiv).......................................................... calcium carbonate-cholecalciferol tab 500 mg-200
BUNAVAIL – buprenorphine-naloxone buccal film 4.2-0.7 unit................................................................................
mg (base equiv).......................................................... calcium carbonate-cholecalciferol tab 600 mg-400
BUNAVAIL – buprenorphine-naloxone buccal film 6.3-1 unit................................................................................
mg (base equiv).......................................................... calcium carbonate tab 1250 mg (500 mg elemental
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base ca)................................................................................
equiv)............................................................................ calcium carbonate-vitamin d tab 250 mg-125 unit.......
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base calcium carbonate-vitamin d tab 500 mg-200 unit.......
equiv)............................................................................ calcium carbonate-vitamin d tab 600 mg-400 unit.......
buprenorphine hcl sl tab 2 mg (base equiv)................. calcium citrate tab 950 mg (200 mg elemental ca)......
buprenorphine hcl sl tab 8 mg (base equiv)................. CANASA – mesalamine suppos 1000 mg...................
bupropion hcl (smoking deterrent) tab er 12hr 150 mg capecitabine tab 150 mg (Xeloda)................................
(Zyban)......................................................................... capecitabine tab 500 mg (Xeloda)................................
bupropion hcl tab er 12hr 100 mg (Wellbutrin sr)......... CAPTOPRIL/HYDROCHLOROTHIA – captopril &
bupropion hcl tab er 12hr 150 mg (Wellbutrin sr)......... hydrochlorothiazide tab 25-15 mg..............................
bupropion hcl tab er 12hr 200 mg (Wellbutrin sr)......... CAPTOPRIL/HYDROCHLOROTHIA – captopril &
bupropion hcl tab er 24hr 150 mg (Wellbutrin xl)......... hydrochlorothiazide tab 25-25 mg..............................
bupropion hcl tab er 24hr 300 mg (Wellbutrin xl)......... CAPTOPRIL/HYDROCHLOROTHIA – captopril &
bupropion hcl tab 75 mg............................................... hydrochlorothiazide tab 50-15 mg..............................
bupropion hcl tab 100 mg............................................. CAPTOPRIL/HYDROCHLOROTHIA – captopril &
buspirone hcl tab 5 mg................................................. hydrochlorothiazide tab 50-25 mg..............................
buspirone hcl tab 10 mg............................................... captopril tab 12.5 mg....................................................
buspirone hcl tab 15 mg............................................... captopril tab 25 mg.......................................................
buspirone hcl tab 30 mg............................................... captopril tab 50 mg.......................................................
butalbital-acetaminophen-caffeine cap 50-325-40 captopril tab 100 mg.....................................................
mg................................................................................ carbamazepine chew tab 100 mg................................
butalbital-acetaminophen-caffeine cap 50-300-40 mg carbamazepine susp 100 mg/5ml (Tegretol)................
(Fioricet)....................................................................... carbamazepine tab er 12hr 100 mg (Tegretol-xr).........
butalbital-acetaminophen-caffeine tab 50-325-40 mg carbamazepine tab er 12hr 200 mg (Tegretol-xr).........
(Esgic).......................................................................... carbamazepine tab er 12hr 400 mg (Tegretol-xr).........
82
2017
carbamazepine tab 200 mg (Tegretol)......................... chlordiazepoxide hcl cap 5 mg.....................................
carbamide peroxide 6.5% otic soln.............................. chlordiazepoxide hcl cap 10 mg...................................
carbidopa & levodopa tab er 25-100 mg (Sinemet chlordiazepoxide hcl cap 25 mg...................................
cr)................................................................................. chlorhexidine gluconate soln 0.12% (Peridex).............
carbidopa & levodopa tab er 50-200 mg (Sinemet CHLOROQUINE PHOSPHATE – chloroquine phosphate
cr)................................................................................. tab 250 mg..................................................................
carbidopa & levodopa tab 10-100 mg (Sinemet).......... chloroquine phosphate tab 500 mg..............................
carbidopa & levodopa tab 25-100 mg (Sinemet).......... CHLOROTHIAZIDE – chlorothiazide tab 250 mg........
carbidopa & levodopa tab 25-250 mg (Sinemet).......... chlorothiazide tab 500 mg............................................
carbidopa tab 25 mg (Lodosyn).................................... chlorpheniramine maleate tab 4 mg.............................
carbinoxamine maleate soln 4 mg/5ml......................... chlorthalidone tab 25 mg..............................................
carbinoxamine maleate tab 4 mg................................. chlorthalidone tab 50 mg..............................................
carteolol hcl ophth soln 1%.......................................... chlorzoxazone tab 500 mg (Parafon forte dsc)............
carvedilol tab 3.125 mg (Coreg)................................... cholecalciferol cap 1000 unit........................................
carvedilol tab 6.25 mg (Coreg)..................................... cholecalciferol cap 2000 unit........................................
carvedilol tab 12.5 mg (Coreg)..................................... cholecalciferol cap 5000 unit........................................
carvedilol tab 25 mg (Coreg)........................................ cholecalciferol cap 10000 unit......................................
cefaclor cap 250 mg..................................................... cholecalciferol cap 50000 unit......................................
cefaclor cap 500 mg..................................................... cholecalciferol oral liquid 400 unit/ml............................
cefadroxil cap 500 mg.................................................. cholecalciferol tab 400 unit...........................................
cefadroxil for susp 250 mg/5ml.................................... cholecalciferol tab 1000 unit.........................................
cefadroxil for susp 500 mg/5ml.................................... cholecalciferol tab 2000 unit.........................................
cefadroxil tab 1 gm....................................................... cholecalciferol tab 50000 unit.......................................
cefdinir cap 300 mg...................................................... cholestyramine light powder 4 gm/dose (Questran
cefdinir for susp 125 mg/5ml........................................ light)..............................................................................
cefdinir for susp 250 mg/5ml........................................ cholestyramine light powder packets 4 gm..................
cefprozil for susp 125 mg/5ml...................................... cholestyramine powder 4 gm/dose (Questran)............
cefprozil for susp 250 mg/5ml...................................... cholestyramine powder packets 4 gm (Questran)........
cefprozil tab 250 mg..................................................... choline fenofibrate cap dr 45 mg (fenofibric acid equiv)
cefprozil tab 500 mg..................................................... (Trilipix).........................................................................
ceftriaxone sodium for inj 1 gm.................................... choline fenofibrate cap dr 135 mg (fenofibric acid equiv)
ceftriaxone sodium for inj 2 gm.................................... (Trilipix).........................................................................
ceftriaxone sodium for inj 250 mg................................ ciclopirox olamine cream 0.77% (base equiv)
ceftriaxone sodium for inj 500 mg................................ (Loprox)........................................................................
cefuroxime axetil tab 250 mg....................................... cilostazol tab 50 mg......................................................
cefuroxime axetil tab 500 mg....................................... cilostazol tab 100 mg....................................................
celecoxib cap 50 mg (Celebrex)................................... cimetidine hcl soln 300 mg/5ml....................................
celecoxib cap 100 mg (Celebrex)................................. cimetidine tab 200 mg..................................................
cephalexin cap 250 mg (Keflex)................................... cimetidine tab 800 mg..................................................
cephalexin cap 500 mg (Keflex)................................... ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml)
cephalexin for susp 125 mg/5ml................................... (Cipro)..........................................................................
cephalexin for susp 250 mg/5ml................................... ciprofloxacin for oral susp 500 mg/5ml (10%) (10
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)................... gm/100ml) (Cipro)........................................................
cetirizine hcl tab 5 mg................................................... ciprofloxacin hcl ophth soln 0.3% (Ciloxan).................
cetirizine hcl tab 10 mg................................................. ciprofloxacin hcl tab 750 mg (base equiv)....................
CHANTIX CONTINUING MONTH – varenicline tartrate ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)........
tab 1 mg (base equiv)................................................. ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)........
CHANTIX STARTING MONTH PA – varenicline tartrate citalopram hydrobromide oral soln 10 mg/5ml.............
tab 0.5 mg x 11 & tab 1 mg x 42 pack....................... citalopram hydrobromide tab 10 mg (base equiv)
CHANTIX – varenicline tartrate tab 0.5 mg (base (Celexa)........................................................................
equiv)............................................................................ citalopram hydrobromide tab 20 mg (base equiv)
CHANTIX – varenicline tartrate tab 1 mg (base (Celexa)........................................................................
equiv)............................................................................ citalopram hydrobromide tab 40 mg (base equiv)
CHEMET – succimer cap 100 mg................................ (Celexa)........................................................................
83
2017
clarithromycin for susp 125 mg/5ml.............................. clozapine orally disintegrating tab 100 mg
clarithromycin for susp 250 mg/5ml.............................. (Fazaclo)......................................................................
clarithromycin tab 250 mg............................................ clozapine tab 50 mg.....................................................
clarithromycin tab 500 mg (Biaxin)............................... clozapine tab 200 mg...................................................
clemastine fumarate tab 1.34 mg (1 mg base clozapine tab 25 mg (Clozaril)......................................
equiv)............................................................................ clozapine tab 100 mg (Clozaril)....................................
clindamycin hcl cap 75 mg (Cleocin)............................ COAGADEX – coagulation factor x (human) for inj 250
clindamycin hcl cap 150 mg (Cleocin).......................... unit................................................................................
clindamycin hcl cap 300 mg (Cleocin).......................... COAGADEX – coagulation factor x (human) for inj 500
clindamycin palmitate hcl for soln 75 mg/5ml (base equiv) unit................................................................................
(Cleocin pediatric gr)................................................... codeine sulfate tab 15 mg (Codeine sulfate)................
clindamycin phosphate gel 1% (Cleocin-t)................... codeine sulfate tab 30 mg (Codeine sulfate)................
clindamycin phosphate lotion 1% (Cleocin-t)............... codeine sulfate tab 60 mg (Codeine sulfate)................
clindamycin phosphate soln 1% (Cleocin-t)................. colchicine w/ probenecid tab 0.5-500 mg.....................
clindamycin phosphate swab 1% (Cleocin-t)............... colestipol hcl granule packets 5 gm (Colestid
clindamycin phosphate vaginal cream 2% flavored).......................................................................
(Cleocin)....................................................................... colestipol hcl granules 5 gm (Colestid)........................
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 colestipol hcl tab 1 gm (Colestid).................................
(1)-5% (Duac).............................................................. COMBIPATCH – estradiol-norethindrone ace td pttw
clobetasol propionate cream 0.05% (Temovate).......... 0.05-0.14 mg/day.........................................................
clobetasol propionate emollient base cream COMBIPATCH – estradiol-norethindrone ace td pttw
0.05%........................................................................... 0.05-0.25 mg/day.........................................................
clobetasol propionate gel 0.05% (Temovate)............... COMBIVENT RESPIMAT – ipratropium-albuterol inhal
clobetasol propionate oint 0.05% (Temovate).............. aerosol soln 20-100 mcg/act.......................................
clobetasol propionate soln 0.05% (Temovate)............. CONDOMS....................................................................
clonazepam orally disintegrating tab 0.125 mg............ CORTISONE ACETATE – cortisone acetate tab 25
clonazepam orally disintegrating tab 0.25 mg.............. mg................................................................................
clonazepam orally disintegrating tab 0.5 mg................ COTELLIC – cobimetinib fumarate tab 20 mg (base
clonazepam orally disintegrating tab 1 mg................... equivalent)....................................................................
clonazepam orally disintegrating tab 2 mg................... CREON – pancrelipase (lip-prot-amyl) dr cap
clonazepam tab 0.5 mg (Klonopin)............................... 3000-9500-15000 unit.................................................
clonazepam tab 1 mg (Klonopin).................................. CREON – pancrelipase (lip-prot-amyl) dr cap
clonazepam tab 2 mg (Klonopin).................................. 6000-19000-30000 unit...............................................
clonidine hcl tab 0.1 mg (Catapres)............................. CREON – pancrelipase (lip-prot-amyl) dr cap
clonidine hcl tab 0.2 mg (Catapres)............................. 12000-38000-60000 unit.............................................
clonidine hcl tab 0.3 mg (Catapres)............................. CREON – pancrelipase (lip-prot-amyl) dr cap
clonidine hcl td patch weekly 0.1 mg/24hr (Catapres- 24000-76000-120000 unit...........................................
tts-1)............................................................................. CREON – pancrelipase (lip-prot-amyl) dr cap
clonidine hcl td patch weekly 0.2 mg/24hr (Catapres- 36000-114000-180000 unit.........................................
tts-2)............................................................................. CRIXIVAN – indinavir sulfate cap 200 mg....................
clonidine hcl td patch weekly 0.3 mg/24hr (Catapres- CRIXIVAN – indinavir sulfate cap 400 mg....................
tts-3)............................................................................. CROMOLYN SODIUM – cromolyn sodium soln nebu 20
clopidogrel bisulfate tab 75 mg (base equiv) mg/2ml..........................................................................
(Plavix)......................................................................... cromolyn sodium ophth soln 4%..................................
clopidogrel bisulfate tab 300 mg (base equiv) cromolyn sodium oral conc 100 mg/5ml
(Plavix)......................................................................... (Gastrocrom)................................................................
clorazepate dipotassium tab 3.75 mg.......................... cyanocobalamin inj 1000 mcg/ml.................................
clorazepate dipotassium tab 15 mg.............................. cyanocobalamin tab er 1000 mcg................................
clorazepate dipotassium tab 7.5 mg (Tranxene t)........ cyanocobalamin tab 100 mcg.......................................
clotrimazole cream 1%.................................................. cyanocobalamin tab 250 mcg.......................................
clotrimazole soln 1%..................................................... cyanocobalamin tab 500 mcg.......................................
clotrimazole troche 10 mg............................................ cyanocobalamin tab 1000 mcg.....................................
clotrimazole vaginal cream 2%..................................... cyclobenzaprine hcl tab 5 mg.......................................
clotrimazole w/ betamethasone cream 1-0.05% cyclobenzaprine hcl tab 10 mg.....................................
(Lotrisone).................................................................... cyclopentolate hcl ophth soln 0.5% (Cyclogyl).............
clozapine orally disintegrating tab 25 mg (Fazaclo)..... cyclopentolate hcl ophth soln 1% (Cyclogyl)................
84
2017
cyclopentolate hcl ophth soln 2% (Cyclogyl)................ dexamethasone tab 0.5 mg..........................................
CYCLOPHOSPHAMIDE – cyclophosphamide cap 25 dexamethasone tab 0.75 mg........................................
mg................................................................................ dexamethasone tab 1.5 mg..........................................
CYCLOPHOSPHAMIDE – cyclophosphamide cap 50 dexamethasone tab 4 mg.............................................
mg................................................................................ dexamethasone tab 6 mg.............................................
cyclosporine cap 25 mg (Sandimmune)....................... dexmethylphenidate hcl cap er 24 hr 5 mg (Focalin
cyclosporine cap 100 mg (Sandimmune)..................... xr).................................................................................
cyclosporine modified cap 50 mg (Cyclosporine dexmethylphenidate hcl cap er 24 hr 10 mg (Focalin
modifie)........................................................................ xr).................................................................................
cyclosporine modified cap 25 mg (Neoral)................... dexmethylphenidate hcl cap er 24 hr 15 mg (Focalin
cyclosporine modified cap 100 mg (Neoral)................. xr).................................................................................
CYCLOSPORINE MODIFIED – cyclosporine modified cap dexmethylphenidate hcl cap er 24 hr 20 mg (Focalin
50 mg........................................................................... xr).................................................................................
cyclosporine modified oral soln 100 mg/ml dexmethylphenidate hcl cap er 24 hr 30 mg (Focalin
(Neoral)........................................................................ xr).................................................................................
cyproheptadine hcl syrup 2 mg/5ml.............................. dexmethylphenidate hcl cap er 24 hr 40 mg (Focalin
cyproheptadine hcl tab 4 mg........................................ xr).................................................................................
CYTARABINE – cytarabine inj 20 mg/ml..................... dexmethylphenidate hcl tab 2.5 mg (Focalin)..............
D dexmethylphenidate hcl tab 5 mg (Focalin).................
dexmethylphenidate hcl tab 10 mg (Focalin)...............
danazol cap 50 mg....................................................... dextromethorphan-guaifenesin liquid 10-100
danazol cap 100 mg..................................................... mg/5ml..........................................................................
danazol cap 200 mg..................................................... diazepam conc 5 mg/ml................................................
dantrolene sodium cap 100 mg.................................... DIAZEPAM RECTAL GEL – diazepam rectal gel delivery
dantrolene sodium cap 25 mg (Dantrium).................... system 2.5 mg.............................................................
dantrolene sodium cap 50 mg (Dantrium).................... DIAZEPAM RECTAL GEL – diazepam rectal gel delivery
dapsone tab 25 mg....................................................... system 10 mg..............................................................
dapsone tab 100 mg..................................................... DIAZEPAM RECTAL GEL – diazepam rectal gel delivery
DARAPRIM – pyrimethamine tab 25 mg...................... system 20 mg..............................................................
DECARA – cholecalciferol cap 25000 unit................... diazepam tab 2 mg (Valium)........................................
demeclocycline hcl tab 150 mg.................................... diazepam tab 5 mg (Valium)........................................
DEPEN TITRATABS – penicillamine tab 250 mg......... diazepam tab 10 mg (Valium)......................................
DEPO-PROVERA CONTRACEPTIV – diclofenac potassium tab 50 mg...................................
medroxyprogesterone acetate im susp 150 mg/ diclofenac sodium gel 1% (Voltaren).................. ,
ml.................................................................................. diclofenac sodium ophth soln 0.1%..............................
DESCOVY – emtricitabine-tenofovir alafenamide fumarate diclofenac sodium tab delayed release 50 mg.............
tab 200-25 mg............................................................. diclofenac sodium tab delayed release 75 mg.............
desloratadine tab 5 mg (Clarinex)................................ diclofenac sodium tab er 24hr 100 mg.........................
desmopressin acetate nasal soln 0.01% (refrigerated) dicloxacillin sodium cap 250 mg...................................
(Ddavp)........................................................................ dicloxacillin sodium cap 500 mg...................................
desmopressin acetate nasal spray soln 0.01% dicyclomine hcl cap 10 mg (Bentyl)..............................
(Ddavp)........................................................................ dicyclomine hcl oral soln 10 mg/5ml............................
desmopressin acetate nasal spray soln 0.01% dicyclomine hcl tab 20 mg............................................
(refrigerated)................................................................ didanosine delayed release capsule 125 mg (Videx
desmopressin acetate tab 0.1 mg (Ddavp).................. ec)................................................................................
desmopressin acetate tab 0.2 mg (Ddavp).................. didanosine delayed release capsule 200 mg (Videx
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 ec)................................................................................
mg(21/5) (Mircette)...................................................... didanosine delayed release capsule 250 mg (Videx
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg ec)................................................................................
(Desogen).................................................................... didanosine delayed release capsule 400 mg (Videx
desoximetasone cream 0.25% (Topicort)..................... ec)................................................................................
DEXAMETHASONE – dexamethasone soln 0.5 DIFFERIN – adapalene gel 0.1%.................................
mg/5ml.......................................................................... DIGOXIN – digoxin oral soln 0.05 mg/ml.....................
dexamethasone elixir 0.5 mg/5ml................................. digoxin tab 125 mcg (0.125 mg) (Lanoxin)..................
DEXAMETHASONE SODIUM PHOS – dexamethasone digoxin tab 250 mcg (0.25 mg) (Lanoxin)....................
sodium phosphate ophth soln 0.1%...........................
85
2017
DILANTIN – phenytoin sodium extended cap 30 docusate sodium cap 100 mg......................................
mg................................................................................ docusate sodium cap 250 mg......................................
diltiazem hcl cap er 12hr 60 mg................................... docusate sodium liquid 150 mg/15ml...........................
diltiazem hcl cap er 24hr 120 mg................................. dofetilide cap 125 mcg (0.125 mg) (Tikosyn)...............
diltiazem hcl cap er 24hr 180 mg................................. dofetilide cap 250 mcg (0.25 mg) (Tikosyn).................
diltiazem hcl cap er 24hr 240 mg................................. dofetilide cap 500 mcg (0.5 mg) (Tikosyn)...................
diltiazem hcl coated beads cap er 24hr 300 mg.......... donepezil hydrochloride orally disintegrating tab 5
diltiazem hcl coated beads cap er 24hr 120 mg (Cardizem mg................................................................................
cd)................................................................................ donepezil hydrochloride orally disintegrating tab 10
diltiazem hcl coated beads cap er 24hr 180 mg (Cardizem mg................................................................................
cd)................................................................................ donepezil hydrochloride tab 5 mg (Aricept)..................
diltiazem hcl coated beads cap er 24hr 240 mg (Cardizem donepezil hydrochloride tab 10 mg (Aricept)................
cd)................................................................................ dorzolamide hcl ophth soln 2% (Trusopt).....................
diltiazem hcl extended release beads cap er 24hr 120 mg dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/
(Tiazac)........................................................................ ml (Cosopt)..................................................................
diltiazem hcl extended release beads cap er 24hr 180 mg doxazosin mesylate tab 1 mg (Cardura)......................
(Tiazac)........................................................................ doxazosin mesylate tab 2 mg (Cardura)......................
diltiazem hcl extended release beads cap er 24hr 240 mg doxazosin mesylate tab 4 mg (Cardura)......................
(Tiazac)........................................................................ doxazosin mesylate tab 8 mg (Cardura)......................
diltiazem hcl extended release beads cap er 24hr 300 mg doxepin hcl cap 10 mg.................................................
(Tiazac)........................................................................ doxepin hcl cap 25 mg.................................................
diltiazem hcl extended release beads cap er 24hr 360 mg doxepin hcl cap 50 mg.................................................
(Tiazac)........................................................................ doxepin hcl cap 100 mg...............................................
diltiazem hcl extended release beads cap er 24hr 420 mg doxepin hcl cap 150 mg...............................................
(Tiazac)........................................................................ doxepin hcl conc 10 mg/ml...........................................
diltiazem hcl tab 90 mg................................................. DOXEPIN HCL – doxepin hcl cap 75 mg.....................
diltiazem hcl tab 30 mg (Cardizem).............................. doxycycline hyclate cap 50 mg.....................................
diltiazem hcl tab 60 mg (Cardizem).............................. doxycycline hyclate cap 100 mg (Vibramycin).............
diltiazem hcl tab 120 mg (Cardizem)............................ doxycycline hyclate tab 20 mg.....................................
diphenhydramine hcl cap 25 mg.................................. doxycycline hyclate tab 100 mg...................................
diphenhydramine hcl cap 50 mg.................................. doxycycline monohydrate cap 50 mg...........................
diphenhydramine hcl liquid 12.5 mg/5ml...................... doxycycline monohydrate cap 100 mg (Monodox).......
diphenhydramine hcl tab 25 mg................................... doxycycline monohydrate for susp 25 mg/5ml
diphenhydramine-phenylephrine liq 6.25-2.5 (Vibramycin).................................................................
mg/5ml.......................................................................... doxycycline monohydrate tab 50 mg............................
diphenoxylate w/ atropine tab 2.5-0.025 mg doxycycline monohydrate tab 75 mg............................
(Lomotil)....................................................................... doxycycline monohydrate tab 100 mg..........................
dipyridamole tab 25 mg................................................ drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin
dipyridamole tab 50 mg................................................ 28)................................................................................
dipyridamole tab 75 mg................................................ duloxetine hcl enteric coated pellets cap 20 mg
disopyramide phosphate cap 100 mg (Norpace)......... (Cymbalta)....................................................................
disopyramide phosphate cap 150 mg (Norpace)......... duloxetine hcl enteric coated pellets cap 30 mg
disulfiram tab 250 mg (Antabuse)................................ (Cymbalta)....................................................................
disulfiram tab 500 mg (Antabuse)................................ duloxetine hcl enteric coated pellets cap 60 mg
divalproex sodium cap delayed release sprinkle 125 mg (Cymbalta)....................................................................
(Depakote sprinkles)...................................................
E
divalproex sodium tab delayed release 125 mg
(Depakote)................................................................... econazole nitrate cream 1%.........................................
divalproex sodium tab delayed release 250 mg EDURANT – rilpivirine hcl tab 25 mg (base
(Depakote)................................................................... equivalent)....................................................................
divalproex sodium tab delayed release 500 mg ELIDEL – pimecrolimus cream 1%...............................
(Depakote)................................................................... ELIQUIS – apixaban tab 2.5 mg..................................
divalproex sodium tab er 24 hr 250 mg (Depakote ELIQUIS – apixaban tab 5 mg.....................................
er)................................................................................. ELLA – ulipristal acetate tab 30 mg.............................
divalproex sodium tab er 24 hr 500 mg (Depakote EMTRIVA – emtricitabine caps 200 mg.......................
er)................................................................................. EMTRIVA – emtricitabine soln 10 mg/ml......................
86
2017
enalapril maleate & hydrochlorothiazide tab 5-12.5 estradiol tab 1 mg (Estrace).........................................
mg................................................................................ estradiol tab 2 mg (Estrace).........................................
enalapril maleate & hydrochlorothiazide tab 10-25 mg estradiol td patch twice weekly 0.025 mg/24hr (Vivelle-
(Vaseretic).................................................................... dot)...............................................................................
enalapril maleate tab 2.5 mg (Vasotec)........................ estradiol td patch twice weekly 0.0375 mg/24hr (Vivelle-
enalapril maleate tab 5 mg (Vasotec)........................... dot)...............................................................................
enalapril maleate tab 10 mg (Vasotec)......................... estradiol td patch twice weekly 0.05 mg/24hr (Vivelle-
enalapril maleate tab 20 mg (Vasotec)......................... dot)...............................................................................
ENBREL – etanercept for subcutaneous inj 25 mg...... estradiol td patch twice weekly 0.075 mg/24hr (Vivelle-
ENBREL – etanercept subcutaneous soln prefilled syringe dot)...............................................................................
25 mg/0.5ml................................................................. estradiol td patch twice weekly 0.1 mg/24hr (Vivelle-
ENBREL – etanercept subcutaneous soln prefilled syringe dot)...............................................................................
50 mg/ml...................................................................... estradiol td patch weekly 0.025 mg/24hr (Climara)......
ENBREL SURECLICK – etanercept subcutaneous estradiol td patch weekly 0.05 mg/24hr (Climara)........
solution auto-injector 50 mg/ml................................... estradiol td patch weekly 0.06 mg/24hr (Climara)........
enoxaparin sodium inj 30 mg/0.3ml (Lovenox)............ estradiol td patch weekly 0.075 mg/24hr (Climara)......
enoxaparin sodium inj 40 mg/0.4ml (Lovenox)............ estradiol td patch weekly 0.1 mg/24hr (Climara)..........
enoxaparin sodium inj 60 mg/0.6ml (Lovenox)............ estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)
enoxaparin sodium inj 80 mg/0.8ml (Lovenox)............ (Climara)......................................................................
enoxaparin sodium inj 100 mg/ml (Lovenox)............... estradiol vaginal tab 10 mcg (Vagifem)........................
enoxaparin sodium inj 120 mg/0.8ml (Lovenox).......... ESTROPIPATE – estropipate tab 0.75 mg...................
enoxaparin sodium inj 150 mg/ml (Lovenox)............... ESTROPIPATE – estropipate tab 1.5 mg.....................
enoxaparin sodium inj 300 mg/3ml (Lovenox)............. ESTROPIPATE – estropipate tab 3 mg........................
entacapone tab 200 mg (Comtan)................................ eszopiclone tab 1 mg (Lunesta)...................................
entecavir tab 0.5 mg (Baraclude)................................. eszopiclone tab 2 mg (Lunesta)...................................
entecavir tab 1 mg (Baraclude).................................... eszopiclone tab 3 mg (Lunesta)...................................
ENTRESTO – sacubitril-valsartan tab 24-26 mg......... ethambutol hcl tab 100 mg (Myambutol)......................
ENTRESTO – sacubitril-valsartan tab 49-51 mg......... ethambutol hcl tab 400 mg (Myambutol)......................
ENTRESTO – sacubitril-valsartan tab 97-103 mg....... ethosuximide cap 250 mg (Zarontin)............................
EPCLUSA – sofosbuvir-velpatasvir tab 400-100 ethosuximide soln 250 mg/5ml (Zarontin)....................
mg................................................................................ ethynodiol diacetate & ethinyl estradiol tab 1 mg-50
EPINEPHRINE – epinephrine solution auto-injector 0.15 mcg...............................................................................
mg/0.3ml (1:2000)....................................................... exemestane tab 25 mg (Aromasin)..............................
EPINEPHRINE – epinephrine solution auto-injector 0.3 EXTAVIA – interferon beta-1b for inj kit 0.3 mg............
mg/0.3ml (1:1000).......................................................
F
EQ MULTIVITAMINS ADULT GU – multiple vitamins w/
minerals chew tab....................................................... FALESSA – levomefolate glucosamine tab 1 mg (folate
ergocalciferol cap 50000 unit........................................ equivalent)....................................................................
erythromycin gel 2% (Erygel)....................................... famotidine for susp 40 mg/5ml (Pepcid).......................
erythromycin ophth oint 5 mg/gm................................. famotidine tab 10 mg....................................................
erythromycin pads 2%.................................................. famotidine tab 20 mg (Pepcid).....................................
erythromycin soln 2%.................................................... famotidine tab 40 mg (Pepcid).....................................
escitalopram oxalate soln 5 mg/5ml (base equiv)........ fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1
escitalopram oxalate tab 5 mg (base equiv) mg................................................................................
(Lexapro)...................................................................... fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240
escitalopram oxalate tab 10 mg (base equiv) mg................................................................................
(Lexapro)...................................................................... fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap
escitalopram oxalate tab 20 mg (base equiv) (Tandem plus)..............................................................
(Lexapro)...................................................................... felodipine tab er 24hr 2.5 mg.......................................
estazolam tab 1 mg...................................................... felodipine tab er 24hr 5 mg..........................................
estazolam tab 2 mg...................................................... felodipine tab er 24hr 10 mg........................................
estradiol & norethindrone acetate tab 0.5-0.1 mg fenofibrate micronized cap 43 mg................................
(Activella)..................................................................... fenofibrate micronized cap 67 mg (Lofibra)..................
estradiol & norethindrone acetate tab 1-0.5 mg fenofibrate micronized cap 134 mg (Lofibra)................
(Activella)..................................................................... fenofibrate micronized cap 200 mg (Lofibra)................
estradiol tab 0.5 mg (Estrace)...................................... fenofibrate tab 160 mg..................................................
87
2017
fenofibrate tab 54 mg (Lofibra)..................................... fluconazole tab 200 mg (Diflucan)................................
fenofibrate tab 48 mg (Tricor)....................................... flucytosine cap 250 mg (Ancobon)...............................
fenofibrate tab 145 mg (Tricor)..................................... flucytosine cap 500 mg (Ancobon)...............................
fentanyl td patch 72hr 12 mcg/hr (Duragesic).............. fludrocortisone acetate tab 0.1 mg...............................
fentanyl td patch 72hr 25 mcg/hr (Duragesic).............. FLULAVAL 2014-2015 – influenza virus vaccine split im
fentanyl td patch 72hr 50 mcg/hr (Duragesic).............. susp..............................................................................
fentanyl td patch 72hr 75 mcg/hr (Duragesic).............. FLULAVAL QUADRIVALENT 201 – influenza virus
fentanyl td patch 72hr 100 mcg/hr (Duragesic)............ vaccine split quadrivalent im inj..................................
ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1 FLULAVAL QUADRIVALENT 201 – influenza virus vac
mg................................................................................ split quadrivalent susp pref syr 0.5ml.........................
ferrous fumarate-folic acid tab 324-1 mg..................... FLUNISOLIDE – flunisolide nasal soln 25 mcg/act
ferrous sulfate tab ec 325 mg (65 mg fe (0.025%).......................................................................
equivalent).................................................................... fluocinolone acetonide cream 0.01%...........................
ferrous sulfate tab 325 mg (65 mg elemental fe)......... fluocinolone acetonide cream 0.025% (Synalar)..........
fexofenadine hcl susp 30 mg/5ml (6 mg/ml)................ fluocinolone acetonide oint 0.025% (Synalar)..............
fexofenadine hcl tab 60 mg.......................................... fluocinolone acetonide soln 0.01% (Synalar)...............
fexofenadine hcl tab 180 mg........................................ fluocinonide cream 0.05%............................................
finasteride tab 5 mg (Proscar)...................................... fluocinonide emulsified base cream 0.05%..................
FIRAZYR – icatibant acetate inj 30 mg/3ml (base fluocinonide gel 0.05%..................................................
equivalent).................................................................... fluocinonide oint 0.05%.................................................
FISH OIL ULTRA – omega-3 fatty acids cap 1400 fluocinonide soln 0.05%................................................
mg................................................................................ fluorometholone ophth susp 0.1% (Fml liquifilm).........
flecainide acetate tab 50 mg........................................ fluorouracil cream 5% (Efudex)....................................
flecainide acetate tab 100 mg...................................... fluoxetine hcl cap 10 mg (Prozac)................................
flecainide acetate tab 150 mg...................................... fluoxetine hcl cap 20 mg (Prozac)................................
FLEET LIQUID GLYCERIN SUP – glycerin enema adult fluoxetine hcl solution 20 mg/5ml.................................
5.4 gm/average delivered dose.................................. fluphenazine decanoate inj 25 mg/ml...........................
FLOVENT DISKUS – fluticasone propionate aer pow ba FLUPHENAZINE HCL – fluphenazine hcl elixir 2.5
50 mcg/blister.............................................................. mg/5ml..........................................................................
FLOVENT DISKUS – fluticasone propionate aer pow ba FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/
100 mcg/blister............................................................ ml..................................................................................
FLOVENT DISKUS – fluticasone propionate aer pow ba fluphenazine hcl tab 1 mg............................................
250 mcg/blister............................................................ fluphenazine hcl tab 2.5 mg.........................................
FLOVENT HFA – fluticasone propionate hfa inhal aer 110 fluphenazine hcl tab 5 mg............................................
mcg/act (125/valve)..................................................... fluphenazine hcl tab 10 mg..........................................
FLOVENT HFA – fluticasone propionate hfa inhal aer 220 flurbiprofen sodium ophth soln 0.03% (Ocufen)...........
mcg/act (250/valve)..................................................... flurbiprofen tab 50 mg...................................................
FLOVENT HFA – fluticasone propionate hfa inhal aero 44 flurbiprofen tab 100 mg.................................................
mcg/act (50/valve)....................................................... flutamide cap 125 mg...................................................
FLUAD 2016-2017 – influenza vac type a&b surface ant FLUTICASONE PROPIONATE/SA – fluticasone-
adj susp pref syr 0.5 ml.............................................. salmeterol aer powder ba 55-14 mcg/act...................
FLUARIX QUADRIVALENT 2015 – influenza virus vac FLUTICASONE PROPIONATE/SA – fluticasone-
split quadrivalent susp pref syr 0.5ml......................... salmeterol aer powder ba 113-14 mcg/act.................
FLUARIX QUADRIVALENT 2016 – influenza virus vac FLUTICASONE PROPIONATE/SA – fluticasone-
split quadrivalent susp pref syr 0.5ml......................... salmeterol aer powder ba 232-14 mcg/act.................
FLUARIX QUADRIVALENT 2017 – influenza virus vac fluticasone propionate cream 0.05% (Cutivate)...........
split quadrivalent susp pref syr 0.5ml......................... fluticasone propionate nasal susp 50 mcg/act.............
FLUCELVAX QUADRIVALENT 20 – influenza vac tiss-cult fluticasone propionate oint 0.005%..............................
subunt quad susp pref syr 0.5 ml............................... FLUVIRIN 2015-2016 – influenza vac type a&b surface
FLUCELVAX QUADRIVALENT 20 – influenza vac tissue- antigen susp pref syr 0.5 ml.......................................
cultured subunit quadrivalent im susp........................ FLUVIRIN 2016-2017 – influenza vac type a&b surface
fluconazole for susp 10 mg/ml (Diflucan)..................... antigen susp pref syr 0.5 ml.......................................
fluconazole for susp 40 mg/ml (Diflucan)..................... FLUVIRIN 2017-2018 – influenza vac type a&b surface
fluconazole tab 50 mg (Diflucan).................................. antigen susp pref syr 0.5 ml.......................................
fluconazole tab 100 mg (Diflucan)................................ FLUVIRIN 2015-2016 – influenza virus vaccine types a &
fluconazole tab 150 mg (Diflucan)................................ b surface antigen im susp...........................................
88
2017
FLUVIRIN 2016-2017 – influenza virus vaccine types a & gabapentin oral soln 250 mg/5ml (Neurontin)..............
b surface antigen im susp........................................... gabapentin tab 600 mg (Neurontin)..............................
FLUVIRIN 2017-2018 – influenza virus vaccine types a & gabapentin tab 800 mg (Neurontin)..............................
b surface antigen im susp........................................... gemfibrozil tab 600 mg (Lopid).....................................
fluvoxamine maleate tab 25 mg................................... GENTAK – gentamicin sulfate ophth oint 0.3%............
fluvoxamine maleate tab 50 mg................................... gentamicin sulfate cream 0.1%....................................
fluvoxamine maleate tab 100 mg................................. GENTAMICIN SULFATE – gentamicin sulfate oint
FLUZONE HIGH-DOSE PF 2015 – influenza virus vac 0.1%.............................................................................
split high-dose pf susp pref syr 0.5ml......................... gentamicin sulfate ophth soln 0.3%..............................
FLUZONE HIGH-DOSE PF 2016 – influenza virus vac GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab
split high-dose pf susp pref syr 0.5ml......................... 150-150-200-10 mg.....................................................
FLUZONE HIGH-DOSE PF 2017 – influenza virus vac glatiramer acetate soln prefilled syringe 20 mg/ml
split high-dose pf susp pref syr 0.5ml......................... (Copaxone)..................................................................
FLUZONE QUADRIVALENT 2015 – influenza virus glimepiride tab 1 mg (Amaryl)......................................
vaccine split quadrivalent im inj.................................. glimepiride tab 2 mg (Amaryl)......................................
FLUZONE QUADRIVALENT 2016 – influenza virus glimepiride tab 4 mg (Amaryl)......................................
vaccine split quadrivalent im inj.................................. glipizide tab er 24hr 2.5 mg (Glucotrol xl)....................
FLUZONE QUADRIVALENT 2017 – influenza virus glipizide tab er 24hr 5 mg (Glucotrol xl).......................
vaccine split quadrivalent im inj.................................. glipizide tab er 24hr 10 mg (Glucotrol xl).....................
FLUZONE QUADRIVALENT 2016 – influenza virus glipizide tab 5 mg (Glucotrol)........................................
vaccine split quadrivalent inj 0.5 ml............................ glipizide tab 10 mg (Glucotrol)......................................
FLUZONE QUADRIVALENT 2015 – influenza virus vac GLUCAGON EMERGENCY KIT – glucagon (rdna) for inj
split quadrivalent susp pref syr 0.5ml......................... kit 1 mg........................................................................
FLUZONE QUADRIVALENT 2016 – influenza virus vac glyburide-metformin tab 1.25-250 mg..........................
split quadrivalent susp pref syr 0.5ml......................... glyburide-metformin tab 2.5-500 mg (Glucovance)......
FLUZONE QUADRIVALENT 2017 – influenza virus vac glyburide-metformin tab 5-500 mg (Glucovance).........
split quadrivalent susp pref syr 0.5ml......................... glyburide micronized tab 1.5 mg (Glynase)..................
FLUZONE SPLIT 2015-2016 – influenza virus vaccine glyburide micronized tab 3 mg (Glynase).....................
split im susp................................................................. glyburide micronized tab 6 mg (Glynase).....................
FOLBEE PLUS CZ – b-complex w/ c-biotin-minerals & glyburide tab 1.25 mg...................................................
folic acid tab 5 mg....................................................... glyburide tab 2.5 mg.....................................................
folic acid tab 400 mcg................................................... glyburide tab 5 mg........................................................
folic acid tab 800 mcg................................................... glycerin suppos 1 gm....................................................
folic acid tab 1 mg........................................................ glycerin suppos 2 gm....................................................
folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 glycopyrrolate tab 1 mg (Robinul)................................
mg................................................................................ glycopyrrolate tab 2 mg (Robinul forte)........................
folic acid-vitamin b6-vitamin b12 tab 2.5-25-1 mg........ griseofulvin microsize susp 125 mg/5ml......................
folic acid-vitamin b6-vitamin b12 tab 2.2-25-1 mg (Folgard griseofulvin microsize tab 500 mg................................
rx)................................................................................. griseofulvin ultramicrosize tab 125 mg (Gris-peg)........
fosinopril sodium & hydrochlorothiazide tab 10-12.5 griseofulvin ultramicrosize tab 250 mg (Gris-peg)........
mg................................................................................ guaifenesin-codeine soln 100-10 mg/5ml.....................
fosinopril sodium & hydrochlorothiazide tab 20-12.5 guaifenesin liquid 100 mg/5ml......................................
mg................................................................................ guanfacine hcl tab er 24hr 1 mg (base equiv)
fosinopril sodium tab 10 mg......................................... (Intuniv)........................................................................
fosinopril sodium tab 20 mg......................................... guanfacine hcl tab er 24hr 2 mg (base equiv)
fosinopril sodium tab 40 mg......................................... (Intuniv)........................................................................
fructose-dextrose-phosphoric acid oral soln................. guanfacine hcl tab er 24hr 3 mg (base equiv)
furosemide oral soln 10 mg/ml..................................... (Intuniv)........................................................................
furosemide tab 20 mg (Lasix)....................................... guanfacine hcl tab er 24hr 4 mg (base equiv)
furosemide tab 40 mg (Lasix)....................................... (Intuniv)........................................................................
furosemide tab 80 mg (Lasix)....................................... guanfacine hcl tab 1 mg...............................................
G guanfacine hcl tab 2 mg...............................................
gabapentin cap 100 mg (Neurontin)............................. H

gabapentin cap 300 mg (Neurontin)............................. halobetasol propionate cream 0.05% (Ultravate).........
gabapentin cap 400 mg (Neurontin)............................. halobetasol propionate oint 0.05% (Ultravate).............
89
2017
haloperidol decanoate im soln 50 mg/ml (Haldol HUMIRA PEDIATRIC CROHNS D – adalimumab prefilled
decanoate 50).............................................................. syringe kit 40 mg/0.8ml...............................................
haloperidol decanoate im soln 100 mg/ml (Haldol HUMIRA PEN – adalimumab pen-injector kit 40
decanoate 100)............................................................ mg/0.8ml......................................................................
haloperidol lactate oral conc 2 mg/ml........................... HUMIRA PEN-CROHNS DISEASE – adalimumab pen-
haloperidol tab 0.5 mg.................................................. injector kit 40 mg/0.8ml...............................................
haloperidol tab 1 mg..................................................... HUMIRA PEN-PSORIASIS STAR – adalimumab pen-
haloperidol tab 2 mg..................................................... injector kit 40 mg/0.8ml...............................................
haloperidol tab 5 mg..................................................... HUMULIN 70/30 – insulin nph isophane & regular human
haloperidol tab 10 mg................................................... inj 100 unit/ml (70-30).................................................
haloperidol tab 20 mg................................................... HUMULIN 70/30 KWIKPEN – insulin nph & regular susp
HELIXATE FS – antihemophilic factor (recombinant) for inj pen-inj 100 unit/ml (70-30)..........................................
kit 250 unit................................................................... HUMULIN N – insulin nph (human) (isophane) inj 100
HELIXATE FS – antihemophilic factor (recombinant) for inj unit/ml...........................................................................
kit 500 unit................................................................... HUMULIN N KWIKPEN – insulin nph (human) (isophane)
HELIXATE FS – antihemophilic factor (recombinant) for inj susp pen-injector 100 unit/ml......................................
kit 1000 unit................................................................. HUMULIN R – insulin regular (human) inj 100 unit/
HELIXATE FS – antihemophilic factor (recombinant) for inj ml..................................................................................
kit 2000 unit................................................................. hydralazine hcl tab 10 mg............................................
HELIXATE FS – antihemophilic factor (recombinant) for inj hydralazine hcl tab 25 mg............................................
kit 3000 unit................................................................. hydralazine hcl tab 50 mg............................................
HEMOFIL M – antihemophilic factor (human) for inj 250 hydralazine hcl tab 100 mg..........................................
unit................................................................................ hydrochlorothiazide cap 12.5 mg (Microzide)..............
HEMOFIL M – antihemophilic factor (human) for inj 500 hydrochlorothiazide tab 12.5 mg..................................
unit................................................................................ hydrochlorothiazide tab 25 mg.....................................
HEMOFIL M – antihemophilic factor (human) for inj 1000 hydrochlorothiazide tab 50 mg.....................................
unit................................................................................ hydrocodone-acetaminophen soln 7.5-325 mg/15ml
HEMOFIL M – antihemophilic factor (human) for inj 1700 (Hycet)..........................................................................
unit................................................................................ hydrocodone-acetaminophen tab 2.5-325 mg.............
HUMALOG – insulin lispro inj 100 unit/ml.................... hydrocodone-acetaminophen tab 7.5-325 mg
HUMALOG – insulin lispro soln cartridge 100 unit/ (Norco).........................................................................
ml.................................................................................. hydrocodone-acetaminophen tab 5-325 mg
HUMALOG JUNIOR KWIKPEN – insulin lispro soln pen- (Norco).........................................................................
injector 100 unit/ml...................................................... hydrocodone-acetaminophen tab 10-325 mg
HUMALOG KWIKPEN – insulin lispro soln pen-injector (Norco).........................................................................
100 unit/ml................................................................... hydrocortisone butyrate oint 0.1% (Locoid)..................
HUMALOG KWIKPEN – insulin lispro soln pen-injector hydrocortisone cream 0.5%..........................................
200 unit/ml................................................................... hydrocortisone cream 1%.............................................
HUMALOG MIX 75/25 – insulin lispro prot & lispro inj 100 hydrocortisone cream 2.5%..........................................
unit/ml (75-25)............................................................. hydrocortisone enema 100 mg/60ml (Cortenema).......
HUMALOG MIX 50/50 – insulin lispro protamine & lispro hydrocortisone lotion 2.5%...........................................
inj 100 unit/ml (50-50)................................................. hydrocortisone oint 0.5%..............................................
HUMALOG MIX 50/50 KWIKPEN – insulin lispro prot & hydrocortisone oint 1%.................................................
lispro sus pen-inj 100 unit/ml (50-50)......................... hydrocortisone oint 2.5%..............................................
HUMALOG MIX 75/25 KWIKPEN – insulin lispro prot & hydrocortisone rectal cream 2.5% (Anusol-hc)............
lispro sus pen-inj 100 unit/ml (75-25)......................... hydrocortisone rectal cream 1% (Proctocort)...............
HUMATE-P – antihemophilic factor/vwf (human) for inj hydrocortisone tab 5 mg (Cortef)..................................
500-1200 unit............................................................... hydrocortisone tab 10 mg (Cortef)................................
HUMATE-P – antihemophilic factor/vwf (human) for inj hydrocortisone tab 20 mg (Cortef)................................
1000-2400 unit............................................................. hydrocortisone valerate cream 0.2%............................
HUMIRA – adalimumab prefilled syringe kit 10 hydrocortisone valerate oint 0.2% (Westcort)..............
mg/0.2ml...................................................................... hydrocortisone w/ acetic acid otic soln 1-2%...............
HUMIRA – adalimumab prefilled syringe kit 20 hydromorphone hcl liqd 1 mg/ml (Dilaudid)..................
mg/0.4ml...................................................................... hydromorphone hcl tab 2 mg (Dilaudid).......................
HUMIRA – adalimumab prefilled syringe kit 40 hydromorphone hcl tab 4 mg (Dilaudid).......................
mg/0.8ml...................................................................... hydromorphone hcl tab 8 mg (Dilaudid).......................
90
2017
hydroxychloroquine sulfate tab 200 mg (Plaquenil)..... INVIRASE – saquinavir mesylate cap 200 mg.............
hydroxyurea cap 500 mg (Hydrea)............................... INVIRASE – saquinavir mesylate tab 500 mg..............
HYDROXYZINE HCL – hydroxyzine hcl im soln 25 mg/ ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml......
ml.................................................................................. ipratropium bromide inhal soln 0.02%..........................
hydroxyzine hcl syrup 10 mg/5ml................................. irbesartan-hydrochlorothiazide tab 150-12.5 mg
hydroxyzine hcl tab 10 mg............................................ (Avalide).......................................................................
hydroxyzine hcl tab 25 mg............................................ irbesartan-hydrochlorothiazide tab 300-12.5 mg
hydroxyzine hcl tab 50 mg............................................ (Avalide).......................................................................
hydroxyzine pamoate cap 25 mg (Vistaril)................... irbesartan tab 75 mg (Avapro)......................................
hydroxyzine pamoate cap 50 mg (Vistaril)................... irbesartan tab 150 mg (Avapro)....................................
hyoscyamine sulfate elixir 0.125 mg/5ml..................... irbesartan tab 300 mg (Avapro)....................................
hyoscyamine sulfate soln 0.125 mg/ml........................ iron combination cap.....................................................
hyoscyamine sulfate tab disint 0.125 mg iron-docusate-b12-folic acid-c-e-cu-biotin tab 150-1 mg
(Anaspaz)..................................................................... (Hematron-af)...............................................................
hyoscyamine sulfate tab er 12hr 0.375 mg iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg
(Levbid)........................................................................ (Corvite 150)................................................................
hyoscyamine sulfate tab 0.125 mg (Levsin)................. iron polysacch complex-vit b12-fa cap 150-0.025-1
hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl).......... mg................................................................................
I irrigation solution, physiological....................................
ISENTRESS HD – raltegravir potassium tab 600 mg
IBRANCE – palbociclib cap 75 mg............................... (base equiv).................................................................
IBRANCE – palbociclib cap 100 mg............................. ISENTRESS – raltegravir potassium chew tab 25 mg
IBRANCE – palbociclib cap 125 mg............................. (base equiv).................................................................
ibuprofen cap 200 mg................................................... ISENTRESS – raltegravir potassium chew tab 100 mg
ibuprofen susp 100 mg/5ml.......................................... (base equiv).................................................................
ibuprofen tab 200 mg.................................................... ISENTRESS – raltegravir potassium packet for susp 100
ibuprofen tab 400 mg.................................................... mg (base equiv)..........................................................
ibuprofen tab 600 mg.................................................... ISENTRESS – raltegravir potassium tab 400 mg (base
ibuprofen tab 800 mg.................................................... equiv)............................................................................
imatinib mesylate tab 100 mg (base equivalent) isoniazid tab 100 mg.....................................................
(Gleevec)...................................................................... isoniazid tab 300 mg.....................................................
imatinib mesylate tab 400 mg (base equivalent) ISOSORBIDE DINITRATE ER – isosorbide dinitrate tab er
(Gleevec)...................................................................... 40 mg...........................................................................
imipramine hcl tab 10 mg (Tofranil).............................. isosorbide dinitrate tab 10 mg......................................
imiquimod cream 5% (Aldara)...................................... isosorbide dinitrate tab 5 mg (Isordil titradose)............
indapamide tab 1.25 mg............................................... isosorbide mononitrate tab er 24hr 30 mg...................
indapamide tab 2.5 mg................................................. isosorbide mononitrate tab er 24hr 60 mg...................
indomethacin cap er 75 mg.......................................... isosorbide mononitrate tab er 24hr 120 mg.................
indomethacin cap 25 mg.............................................. isosorbide mononitrate tab 10 mg................................
indomethacin cap 50 mg.............................................. isosorbide mononitrate tab 20 mg................................
INSULIN SYRINGE/0.5ML/30G.................................... isotretinoin cap 10 mg..................................................
INTELENCE – etravirine tab 25 mg............................. isotretinoin cap 20 mg..................................................
INTELENCE – etravirine tab 100 mg........................... itraconazole cap 100 mg (Sporanox)...........................
INTELENCE – etravirine tab 200 mg........................... ivermectin tab 3 mg (Stromectol).................................
INVEGA SUSTENNA – paliperidone palmitate im IXINITY – coagulation factor ix (recombinant) for inj 500
extended-release susp 39 mg/0.25ml........................ unit................................................................................
extended-release susp 78 mg/0.5ml.......................... unit................................................................................
extended-release susp 156 mg/ml............................. unit................................................................................
INVEGA SUSTENNA – paliperidone palmitate im
extended-release susp 234 mg/1.5ml........................
INVEGA SUSTENNA – paliperidone palmitate im extend-
release susp 117 mg/0.75ml.......................................
91
2017
J KOGENATE FS BIO-SET – antihemophilic factor

(recombinant) for inj kit 3000 unit...............................
K KONSYL-D – psyllium powder 52.3%..........................
KONSYL – psyllium powder 60.3%..............................
KALETRA – lopinavir-ritonavir tab 100-25 mg............. KONSYL – psyllium powder 71.67%............................
KALETRA – lopinavir-ritonavir tab 200-50 mg............. K-PHOS – potassium phosphate monobasic tab 500
KALYDECO – ivacaftor packet 50 mg.......................... mg................................................................................
KALYDECO – ivacaftor packet 75 mg.......................... KYLEENA – levonorgestrel releasing iud 17.5 mcg/day
KALYDECO – ivacaftor tab 150 mg............................. (19.5 mg total).............................................................
ketoconazole cream 2%...............................................
ketoconazole shampoo 2% (Nizoral)............................ L
ketoconazole tab 200 mg............................................. labetalol hcl tab 100 mg...............................................
ketoprofen cap 50 mg................................................... labetalol hcl tab 200 mg...............................................
ketoprofen cap 75 mg................................................... labetalol hcl tab 300 mg...............................................
ketorolac tromethamine ophth soln 0.5% (Acular)....... lactated ringer's for irrigation........................................
ketorolac tromethamine ophth soln 0.4% (Acular lactic acid (ammonium lactate) lotion 12% (Lac-
ls).................................................................................. hydrin)..........................................................................
ketorolac tromethamine tab 10 mg............................... lactulose (encephalopathy) solution 10 gm/15ml.........
ketotifen fumarate ophth soln 0.025% (base equiv)..... lactulose solution 10 gm/15ml......................................
KISQALI FEMARA 200 DOSE – ribociclib tab 200 mg & lamivudine oral soln 10 mg/ml (Epivir).........................
letrozole tab 2.5 mg therapy pack.............................. lamivudine tab 150 mg (Epivir).....................................
KISQALI FEMARA 400 DOSE – ribociclib tab 200 mg & lamivudine tab 300 mg (Epivir).....................................
letrozole tab 2.5 mg therapy pack.............................. lamivudine tab 100 mg (hbv) (Epivir hbv)....................
KISQALI FEMARA 600 DOSE – ribociclib tab 200 mg & lamivudine-zidovudine tab 150-300 mg (Combivir)......
letrozole tab 2.5 mg therapy pack.............................. lamotrigine tab chewable dispersible 5 mg (Lamictal
KISQALI – ribociclib succinate tab 200 mg (base chewable di).................................................................
equiv)............................................................................ lamotrigine tab chewable dispersible 25 mg (Lamictal
KOATE – antihemophilic factor (human) for inj 250 chewable di).................................................................
unit................................................................................ lamotrigine tab 25 mg (Lamictal)..................................
KOATE – antihemophilic factor (human) for inj 500 lamotrigine tab 100 mg (Lamictal)................................
unit................................................................................ lamotrigine tab 150 mg (Lamictal)................................
KOATE – antihemophilic factor (human) for inj 1000 lamotrigine tab 200 mg (Lamictal)................................
unit................................................................................ lansoprazole cap delayed release 15 mg
KOATE-DVI – antihemophilic factor (human) for inj 250 (Prevacid).....................................................................
unit................................................................................ lansoprazole cap delayed release 30 mg
KOATE-DVI – antihemophilic factor (human) for inj 500 (Prevacid).....................................................................
unit................................................................................ latanoprost ophth soln 0.005% (Xalatan).....................
KOATE-DVI – antihemophilic factor (human) for inj 1000 LATUDA – lurasidone hcl tab 20 mg............................
unit................................................................................ LATUDA – lurasidone hcl tab 40 mg............................
KOGENATE FS – antihemophilic factor (recombinant) for LATUDA – lurasidone hcl tab 60 mg............................
inj kit 250 unit.............................................................. LATUDA – lurasidone hcl tab 80 mg............................
KOGENATE FS – antihemophilic factor (recombinant) for LATUDA – lurasidone hcl tab 120 mg..........................
inj kit 500 unit.............................................................. leflunomide tab 10 mg (Arava).....................................
KOGENATE FS – antihemophilic factor (recombinant) for leflunomide tab 20 mg (Arava).....................................
inj kit 1000 unit............................................................ LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapy
KOGENATE FS – antihemophilic factor (recombinant) for pack 10 & 4 mg (14 mg daily dose)...........................
KOGENATE FS – antihemophilic factor (recombinant) for pack 10 & 4 (2) mg (18 mg daily dose)......................
KOGENATE FS BIO-SET – antihemophilic factor pack 10 (2) & 4 mg (24 mg daily dose)......................
(recombinant) for inj kit 250 unit................................. LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapy
KOGENATE FS BIO-SET – antihemophilic factor pack 10 mg (10 mg daily dose)..................................
(recombinant) for inj kit 500 unit................................. LENVIMA 20 MG DAILY DOSE – lenvatinib cap therapy
KOGENATE FS BIO-SET – antihemophilic factor pack 10 (2) mg (20 mg daily dose).............................
(recombinant) for inj kit 1000 unit............................... LENVIMA 8 MG DAILY DOSE – lenvatinib cap therapy
KOGENATE FS BIO-SET – antihemophilic factor pack 4 (2) mg (8 mg daily dose).................................
(recombinant) for inj kit 2000 unit...............................
92
2017
letrozole tab 2.5 mg (Femara)...................................... linezolid for susp 100 mg/5ml (Zyvox)..........................
LEUCOVORIN CALCIUM – leucovorin calcium tab 10 linezolid tab 600 mg (Zyvox)........................................
mg................................................................................ liothyronine sodium tab 5 mcg (Cytomel).....................
LEUCOVORIN CALCIUM – leucovorin calcium tab 15 liothyronine sodium tab 25 mcg (Cytomel)...................
mg................................................................................ liothyronine sodium tab 50 mcg (Cytomel)...................
leucovorin calcium tab 5 mg......................................... lisinopril & hydrochlorothiazide tab 10-12.5 mg
leucovorin calcium tab 25 mg....................................... (Zestoretic)...................................................................
LEUKERAN – chlorambucil tab 2 mg........................... lisinopril & hydrochlorothiazide tab 20-12.5 mg
levetiracetam oral soln 100 mg/ml (Keppra)................ (Zestoretic)...................................................................
levetiracetam tab er 24hr 500 mg (Keppra xr)............. lisinopril & hydrochlorothiazide tab 20-25 mg
levetiracetam tab er 24hr 750 mg (Keppra xr)............. (Zestoretic)...................................................................
levetiracetam tab 250 mg (Keppra).............................. lisinopril tab 5 mg (Prinivil)...........................................
levetiracetam tab 500 mg (Keppra).............................. lisinopril tab 10 mg (Prinivil).........................................
levetiracetam tab 750 mg (Keppra).............................. lisinopril tab 20 mg (Prinivil).........................................
levetiracetam tab 1000 mg (Keppra)............................ lisinopril tab 2.5 mg (Zestril).........................................
levobunolol hcl ophth soln 0.5% (Betagan).................. lisinopril tab 30 mg (Zestril)..........................................
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)...... lisinopril tab 40 mg (Zestril)..........................................
levocarnitine tab 330 mg (Carnitor).............................. lithium carbonate cap 300 mg......................................
levocetirizine dihydrochloride tab 5 mg........................ lithium carbonate cap 150 mg (Lithium carbonate)......
LEVOFLOXACIN – levofloxacin oral soln 25 mg/ lithium carbonate cap 600 mg (Lithium carbonate)......
ml.................................................................................. lithium carbonate tab er 450 mg...................................
levofloxacin ophth soln 0.5%........................................ lithium carbonate tab er 300 mg (Lithobid)...................
levofloxacin tab 250 mg (Levaquin).............................. lithium carbonate tab 300 mg.......................................
levofloxacin tab 500 mg (Levaquin).............................. LITHIUM – lithium oral solution 8 meq/5ml..................
levofloxacin tab 750 mg (Levaquin).............................. LMD 10% DEXTROSE 5% – dextran 40 inj 10% in
levonorgestrel & ethinyl estradiol tab 0.1 mg-20 d5w...............................................................................
mcg............................................................................... loperamide hcl cap 2 mg..............................................
levonorgestrel & ethinyl estradiol tab 0.15 mg-30 loperamide hcl liq 1 mg/5ml (0.2 mg/ml)......................
mcg............................................................................... loperamide hcl tab 2 mg...............................................
levonorgestrel-eth estra tab lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)
0.05-30/0.075-40/0.125-30mg-mcg............................ (Kaletra).......................................................................
levonorgestrel tab 1.5 mg............................................. loratadine syrup 5 mg/5ml............................................
levothyroxine sodium tab 25 mcg (Synthroid).............. loratadine tab 10 mg.....................................................
levothyroxine sodium tab 50 mcg (Synthroid).............. lorazepam conc 2 mg/ml..............................................
levothyroxine sodium tab 75 mcg (Synthroid).............. lorazepam tab 0.5 mg (Ativan).....................................
levothyroxine sodium tab 88 mcg (Synthroid).............. lorazepam tab 1 mg (Ativan)........................................
levothyroxine sodium tab 100 mcg (Synthroid)............ lorazepam tab 2 mg (Ativan)........................................
levothyroxine sodium tab 112 mcg (Synthroid)............ losartan potassium & hydrochlorothiazide tab 50-12.5 mg
levothyroxine sodium tab 125 mcg (Synthroid)............ (Hyzaar).......................................................................
levothyroxine sodium tab 137 mcg (Synthroid)............ losartan potassium & hydrochlorothiazide tab 100-12.5
levothyroxine sodium tab 150 mcg (Synthroid)............ mg (Hyzaar).................................................................
levothyroxine sodium tab 175 mcg (Synthroid)............ losartan potassium & hydrochlorothiazide tab 100-25 mg
levothyroxine sodium tab 200 mcg (Synthroid)............ (Hyzaar).......................................................................
levothyroxine sodium tab 300 mcg (Synthroid)............ losartan potassium tab 25 mg (Cozaar).......................
LEXIVA – fosamprenavir calcium susp 50 mg/ml (base losartan potassium tab 50 mg (Cozaar).......................
equiv)............................................................................ losartan potassium tab 100 mg (Cozaar).....................
LEXIVA – fosamprenavir calcium tab 700 mg (base lovastatin tab 10 mg.....................................................
equiv)............................................................................ lovastatin tab 20 mg.....................................................
lidocaine hcl cream 3%................................................. lovastatin tab 40 mg.....................................................
lidocaine hcl gel 2%...................................................... loxapine succinate cap 5 mg........................................
lidocaine hcl soln 4% (Xylocaine)................................. loxapine succinate cap 10 mg......................................
lidocaine hcl viscous soln 2%....................................... loxapine succinate cap 25 mg......................................
lidocaine oint 5%........................................................... loxapine succinate cap 50 mg......................................
lidocaine patch 5% (Lidoderm)..................................... LYNPARZA – olaparib cap 50 mg................................
lidocaine-prilocaine cream 2.5-2.5%............................
lidocaine-prilocaine cream kit 2.5-2.5%........................
93
2017
M methotrexate sodium tab 2.5 mg (base equiv).............

methoxsalen rapid cap 10 mg (Oxsoralen ultra)..........
magnesium citrate soln................................................. methyldopa tab 250 mg................................................
magnesium oxide tab 400 mg...................................... methyldopa tab 500 mg................................................
magnesium oxide tab 400 mg (241.3 mg elemental methylphenidate hcl cap er 24hr 20 mg (la) (Ritalin
mg)............................................................................... la)..................................................................................
MASK VORTEX/CHILD/FROG..................................... methylphenidate hcl cap er 24hr 30 mg (la) (Ritalin
MAVYRET – glecaprevir-pibrentasvir tab 100-40 la)..................................................................................
mg................................................................................ methylphenidate hcl cap er 24hr 40 mg (la) (Ritalin
meclizine hcl tab 12.5 mg............................................. la)..................................................................................
meclizine hcl tab 25 mg................................................ methylphenidate hcl cap er 10 mg (cd)........................
medroxyprogesterone acetate im susp 150 mg/ml (Depo- methylphenidate hcl cap er 20 mg (cd)........................
provera contrac).......................................................... methylphenidate hcl cap er 30 mg (cd)........................
medroxyprogesterone acetate tab 2.5 mg methylphenidate hcl cap er 40 mg (cd)........................
(Provera)...................................................................... methylphenidate hcl cap er 50 mg (cd)........................
medroxyprogesterone acetate tab 5 mg (Provera)...... methylphenidate hcl cap er 60 mg (cd)........................
medroxyprogesterone acetate tab 10 mg METHYLPHENIDATE HCL ER – methylphenidate hcl tab
(Provera)...................................................................... er 24hr 18 mg..............................................................
mefloquine hcl tab 250 mg........................................... METHYLPHENIDATE HCL ER – methylphenidate hcl tab
megestrol acetate susp 40 mg/ml................................ er 24hr 27 mg..............................................................
megestrol acetate susp 625 mg/5ml (Megace es)....... METHYLPHENIDATE HCL ER – methylphenidate hcl tab
megestrol acetate tab 20 mg........................................ er 24hr 36 mg..............................................................
megestrol acetate tab 40 mg........................................ METHYLPHENIDATE HCL ER – methylphenidate hcl tab
MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg er 24hr 54 mg..............................................................
(base equivalent)......................................................... methylphenidate hcl tab er 10 mg................................
MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base methylphenidate hcl tab er osmotic release (osm) 18 mg
equivalent).................................................................... (Concerta)....................................................................
meloxicam tab 7.5 mg (Mobic)..................................... methylphenidate hcl tab er osmotic release (osm) 27 mg
meloxicam tab 15 mg (Mobic)...................................... (Concerta)....................................................................
melphalan tab 2 mg (Alkeran)...................................... methylphenidate hcl tab er osmotic release (osm) 36 mg
meperidine hcl tab 50 mg............................................. (Concerta)....................................................................
meperidine hcl tab 100 mg (Demerol).......................... methylphenidate hcl tab er osmotic release (osm) 54 mg
MEPHYTON – phytonadione tab 5 mg........................ (Concerta)....................................................................
mercaptopurine tab 50 mg............................................ methylphenidate hcl tab 5 mg (Ritalin).........................
MESALAMINE DR – mesalamine tab delayed release 800 methylphenidate hcl tab 10 mg (Ritalin).......................
mg................................................................................ methylphenidate hcl tab 20 mg (Ritalin).......................
mesalamine enema 4 gm............................................. methylprednisolone tab 4 mg (Medrol).........................
METAMUCIL MULTIHEALTH FIB – psyllium powder methylprednisolone tab 8 mg (Medrol).........................
55.46%......................................................................... methylprednisolone tab 16 mg (Medrol).......................
METAMUCIL MULTIHEALTH FIB – psyllium powder methylprednisolone tab 32 mg (Medrol).......................
63%.............................................................................. methylprednisolone tab therapy pack 4 mg (21) (Medrol
METAMUCIL SMOOTH TEXTURE – psyllium powder dosepak)......................................................................
63%.............................................................................. metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)........
metformin hcl tab er 24hr 500 mg (Glucophage xr)..... metoclopramide hcl tab 5 mg (Reglan)........................
metformin hcl tab er 24hr 750 mg (Glucophage xr)..... metoclopramide hcl tab 10 mg (Reglan)......................
metformin hcl tab 500 mg (Glucophage)...................... metolazone tab 2.5 mg.................................................
metformin hcl tab 850 mg (Glucophage)...................... metolazone tab 5 mg....................................................
metformin hcl tab 1000 mg (Glucophage).................... metolazone tab 10 mg..................................................
METHERGINE – methylergonovine maleate tab 0.2 METOPROLOL/HYDROCHLOROTHI – metoprolol &
mg................................................................................ hydrochlorothiazide tab 100-50 mg............................
methimazole tab 5 mg (Tapazole)................................ metoprolol & hydrochlorothiazide tab 100-25 mg.........
methimazole tab 10 mg (Tapazole).............................. metoprolol & hydrochlorothiazide tab 50-25 mg
methocarbamol tab 750 mg (Robaxin-750).................. (Lopressor hct)............................................................
methocarbamol tab 500 mg (Robaxin)......................... metoprolol succinate tab er 24hr 25 mg (tartrate equiv)
METHOTREXATE SODIUM – methotrexate sodium inj (Toprol xl).....................................................................
250 mg/10ml (25 mg/ml).............................................
94
2017
metoprolol succinate tab er 24hr 50 mg (tartrate equiv) mometasone furoate solution 0.1% (lotion)..................
(Toprol xl)..................................................................... MONOCLATE-P – antihemophilic factor (human) for inj kit
metoprolol succinate tab er 24hr 100 mg (tartrate equiv) 1000 unit......................................................................
(Toprol xl)..................................................................... MONOCLATE-P – antihemophilic factor (human) for inj kit
metoprolol succinate tab er 24hr 200 mg (tartrate equiv) 1500 unit......................................................................
(Toprol xl)..................................................................... MONONINE – coagulation factor ix for inj 1000
metoprolol tartrate tab 25 mg....................................... unit................................................................................
metoprolol tartrate tab 50 mg (Lopressor).................... montelukast sodium chew tab 4 mg (base equiv)
metoprolol tartrate tab 100 mg (Lopressor).................. (Singulair).....................................................................
metronidazole cap 375 mg (Flagyl).............................. montelukast sodium chew tab 5 mg (base equiv)
metronidazole cream 0.75% (Metrocream).................. (Singulair).....................................................................
metronidazole gel 0.75%.............................................. montelukast sodium oral granules packet 4 mg (base
metronidazole gel 1% (Metrogel)................................. equiv) (Singulair).........................................................
metronidazole tab 250 mg (Flagyl)............................... montelukast sodium tab 10 mg (base equiv)
metronidazole tab 500 mg (Flagyl)............................... (Singulair).....................................................................
metronidazole vaginal gel 0.75% (Metrogel- MORPHINE SULFATE – morphine sulfate suppos 5
vaginal)......................................................................... mg................................................................................
mexiletine hcl cap 150 mg............................................ MORPHINE SULFATE – morphine sulfate suppos 10
mexiletine hcl cap 200 mg............................................ mg................................................................................
mexiletine hcl cap 250 mg............................................ MORPHINE SULFATE – morphine sulfate suppos 20
miconazole nitrate aerosol pow 2%.............................. mg................................................................................
miconazole nitrate cream 2%....................................... MORPHINE SULFATE – morphine sulfate suppos 30
miconazole nitrate vaginal cream 2%.......................... mg................................................................................
midodrine hcl tab 2.5 mg.............................................. MORPHINE SULFATE – morphine sulfate tab 15
midodrine hcl tab 5 mg................................................. mg................................................................................
midodrine hcl tab 10 mg............................................... MORPHINE SULFATE – morphine sulfate tab 30
minocycline hcl cap 75 mg........................................... mg................................................................................
minocycline hcl cap 50 mg (Minocin)........................... morphine sulfate oral soln 10 mg/5ml..........................
minocycline hcl cap 100 mg (Minocin)......................... morphine sulfate oral soln 20 mg/5ml..........................
minocycline hcl tab 50 mg............................................ morphine sulfate oral soln 100 mg/5ml (20 mg/ml)......
minocycline hcl tab 75 mg............................................ multiple vitamins w/ iron tab.........................................
minocycline hcl tab 100 mg.......................................... multiple vitamins w/ minerals & fa tab 1.25 mg
minoxidil tab 2.5 mg...................................................... (Corvite).......................................................................
minoxidil tab 10 mg....................................................... multiple vitamins w/ minerals cap.................................
MIRENA – levonorgestrel releasing iud 20 mcg/day (52 multiple vitamins w/ minerals tab (Strovite forte)..........
mg total)....................................................................... multiple vitamin tab.......................................................
mirtazapine orally disintegrating tab 15 mg (Remeron mupirocin oint 2%.........................................................
soltab)........................................................................... mycophenolate mofetil cap 250 mg (Cellcept).............
mirtazapine orally disintegrating tab 30 mg (Remeron mycophenolate mofetil for oral susp 200 mg/ml
soltab)........................................................................... (Cellcept)......................................................................
mirtazapine orally disintegrating tab 45 mg (Remeron mycophenolate mofetil tab 500 mg (Cellcept)..............
soltab)........................................................................... mycophenolate sodium tab dr 180 mg (mycophenolic acid
mirtazapine tab 15 mg (Remeron)................................ equiv) (Myfortic)...........................................................
mirtazapine tab 30 mg (Remeron)................................ mycophenolate sodium tab dr 360 mg (mycophenolic acid
mirtazapine tab 45 mg (Remeron)................................ equiv) (Myfortic)...........................................................
misoprostol tab 100 mcg (Cytotec)............................... MYLERAN – busulfan tab 2 mg...................................
misoprostol tab 200 mcg (Cytotec)............................... N
modafinil tab 100 mg (Provigil).....................................
modafinil tab 200 mg (Provigil)..................................... nabumetone tab 500 mg...............................................
moexipril hcl tab 7.5 mg............................................... nabumetone tab 750 mg...............................................
moexipril hcl tab 15 mg................................................ nadolol tab 20 mg (Corgard)........................................
moexipril-hydrochlorothiazide tab 7.5-12.5 mg............ nadolol tab 40 mg (Corgard)........................................
moexipril-hydrochlorothiazide tab 15-12.5 mg............. nadolol tab 80 mg (Corgard)........................................
moexipril-hydrochlorothiazide tab 15-25 mg................ NALOXONE HCL – naloxone hcl soln cartridge 0.4 mg/
mometasone furoate cream 0.1% (Elocon).................. ml..................................................................................
mometasone furoate oint 0.1% (Elocon)......................
95
2017
NALOXONE HCL – naloxone hcl soln prefilled syringe 2 nicotine td patch 24hr 21 mg/24hr................................
mg/2ml.......................................................................... nifedipine cap 10 mg (Procardia).................................
naltrexone hcl tab 50 mg.............................................. nifedipine tab er 24hr 30 mg (Adalat cc)......................
naproxen sodium tab 220 mg....................................... nifedipine tab er 24hr 60 mg (Adalat cc)......................
naproxen sodium tab 275 mg....................................... nifedipine tab er 24hr 90 mg (Adalat cc)......................
naproxen sodium tab 550 mg (Anaprox ds)................. nifedipine tab er 24hr osmotic release 30 mg (Procardia
naproxen tab ec 375 mg (Ec-naprosyn)....................... xl)..................................................................................
naproxen tab ec 500 mg (Ec-naprosyn)....................... nifedipine tab er 24hr osmotic release 60 mg (Procardia
naproxen tab 250 mg.................................................... xl)..................................................................................
naproxen tab 375 mg.................................................... nifedipine tab er 24hr osmotic release 90 mg (Procardia
naproxen tab 500 mg (Naprosyn)................................. xl)..................................................................................
NARCAN – naloxone hcl nasal spray 4 mg/0.1ml........ nitrofurantoin macrocrystalline cap 25 mg
NATACYN – natamycin ophth susp 5%....................... (Macrodantin)...............................................................
nateglinide tab 60 mg (Starlix)...................................... nitrofurantoin macrocrystalline cap 50 mg
nateglinide tab 120 mg (Starlix).................................... (Macrodantin)...............................................................
NECON 10/11-28 – norethindrone-eth estradiol tab nitrofurantoin macrocrystalline cap 100 mg
0.5-35/1-35 mg-mcg (10/11)....................................... (Macrodantin)...............................................................
neomycin-bacitracin-polymyxin oint.............................. nitrofurantoin monohydrate macrocrystalline cap 100 mg
neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt (Macrobid)....................................................................
op oin........................................................................... nitrofurantoin susp 25 mg/5ml (Furadantin).................
neomycin-polymy-gramicid op sol 1.75-10000-0.025mg- nitroglycerin cap er 2.5 mg...........................................
unt-mg/ml (Neosporin)................................................. nitroglycerin cap er 6.5 mg...........................................
neomycin-polymyxin-dexamethasone ophth oint 0.1% nitroglycerin cap er 9 mg..............................................
(Maxitrol)...................................................................... nitroglycerin sl tab 0.3 mg (Nitrostat)...........................
neomycin-polymyxin-dexamethasone ophth susp 0.1% nitroglycerin sl tab 0.4 mg (Nitrostat)...........................
(Maxitrol)...................................................................... nitroglycerin sl tab 0.6 mg (Nitrostat)...........................
neomycin-polymyxin-hc otic soln 1%........................... nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)..........
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)..........
ml-1%........................................................................... nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)..........
neomycin sulfate tab 500 mg....................................... nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)..........
NEUPOGEN – filgrastim inj 300 mcg/ml...................... nizatidine cap 150 mg...................................................
NEUPOGEN – filgrastim inj 480 mcg/1.6ml (300 mcg/ nizatidine cap 300 mg...................................................
ml)................................................................................ NIZATIDINE – nizatidine oral soln 15 mg/ml................
NEUPOGEN – filgrastim soln prefilled syringe 300 norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg
mcg/0.5ml..................................................................... (Loestrin fe 1/20).........................................................
NEUPOGEN – filgrastim soln prefilled syringe 480 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg
mcg/0.8ml (600 mcg/ml)............................................. (Loestrin 1/20-21)........................................................
nevirapine tab er 24hr 100 mg (Viramune xr).............. norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg
nevirapine tab er 24hr 400 mg (Viramune xr).............. (Loestrin 1.5/30-21).....................................................
nevirapine tab 200 mg (Viramune)............................... norethindrone acetate-ethinyl estradiol tab 1 mg-5
NEXAVAR – sorafenib tosylate tab 200 mg (base mcg...............................................................................
equivalent).................................................................... norethindrone acetate tab 5 mg (Aygestin)..................
NEXPLANON – etonogestrel subdermal implant 68 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg
mg................................................................................ (Ortho-cyclen)..............................................................
niacin cap er 250 mg.................................................... norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35
niacin cap er 500 mg.................................................... mg-mcg (Ortho tri-cyclen)...........................................
niacin tab er 250 mg..................................................... norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25
niacin tab er 500 mg..................................................... mg-mcg (Ortho tri-cyclen lo).......................................
niacin tab er 750 mg..................................................... nortriptyline hcl cap 10 mg (Pamelor)..........................
niacin tab 100 mg......................................................... nortriptyline hcl cap 25 mg (Pamelor)..........................
niacin tab 500 mg......................................................... nortriptyline hcl cap 50 mg (Pamelor)..........................
NIACIN TR – niacin tab er 1000 mg............................ nortriptyline hcl cap 75 mg (Pamelor)..........................
nicotine polacrilex gum 2 mg........................................ NORVIR – ritonavir cap 100 mg...................................
nicotine polacrilex gum 4 mg........................................ NORVIR – ritonavir oral soln 80 mg/ml........................
nicotine td patch 24hr 7 mg/24hr.................................. NORVIR – ritonavir tab 100 mg...................................
nicotine td patch 24hr 14 mg/24hr................................
96
2017
NOVOLIN 70/30 – insulin nph isophane & regular human olanzapine tab 2.5 mg (Zyprexa)..................................
inj 100 unit/ml (70-30)................................................. olanzapine tab 5 mg (Zyprexa).....................................
NOVOLIN 70/30 RELION – insulin nph isophane & olanzapine tab 7.5 mg (Zyprexa)..................................
regular human inj 100 unit/ml (70-30)........................ olanzapine tab 10 mg (Zyprexa)...................................
NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ olanzapine tab 15 mg (Zyprexa)...................................
ml.................................................................................. olanzapine tab 20 mg (Zyprexa)...................................
NOVOLIN N RELION – insulin nph (human) (isophane) inj omega-3 fatty acids cap delayed release 1000 mg......
100 unit/ml................................................................... omega-3 fatty acids cap delayed release 1200 mg......
NOVOLIN R – insulin regular (human) inj 100 unit/ omega-3 fatty acids cap 500 mg..................................
ml.................................................................................. omega-3 fatty acids cap 435 mg..................................
NOVOLIN R RELION – insulin regular (human) inj 100 omega-3 fatty acids cap 1000 mg................................
unit/ml........................................................................... omega-3 fatty acids cap 1200 mg................................
NOVOLOG FLEXPEN – insulin aspart soln pen-injector OMEGA-3 IQ – omega-3 fatty acids chew tab 240
100 unit/ml................................................................... mg................................................................................
NOVOLOG – insulin aspart inj 100 unit/ml................... OMEGA-3 – omega-3 fatty acids cap 1400 mg...........
NOVOLOG MIX 70/30 – insulin aspart prot & aspart OMEGA-3 2100 – omega-3 fatty acids cap 1050
(human) inj 100 unit/ml (70-30).................................. mg................................................................................
NOVOLOG MIX 70/30 PREFILL – insulin aspart prot & OMEGA POWER – omega-3 fatty acids cap 1050
aspart sus pen-inj 100 unit/ml (70-30)........................ mg................................................................................
NOVOLOG PENFILL – insulin aspart soln cartridge 100 omeprazole cap delayed release 20 mg......................
unit/ml........................................................................... omeprazole cap delayed release 40 mg......................
NOXAFIL – posaconazole susp 40 mg/ml................... OMNIFLEX DIAPHRAGM.............................................
NOXAFIL – posaconazole tab delayed release 100 OMNITROPE – somatropin for inj 5.8 mg....................
mg................................................................................ ondansetron hcl oral soln 4 mg/5ml (Zofran)...............
NUVARING – etonogestrel-ethinyl estradiol va ring ondansetron hcl tab 24 mg...........................................
0.120-0.015 mg/24hr................................................... ondansetron hcl tab 4 mg (Zofran)...............................
nystatin cream 100000 unit/gm.................................... ondansetron hcl tab 8 mg (Zofran)...............................
nystatin oint 100000 unit/gm......................................... ondansetron orally disintegrating tab 4 mg (Zofran
nystatin susp 100000 unit/ml........................................ odt)...............................................................................
nystatin tab 500000 unit............................................... ondansetron orally disintegrating tab 8 mg (Zofran
nystatin topical powder 100000 unit/gm....................... odt)...............................................................................
O oral electrolyte solution.................................................
orphenadrine citrate tab er 12hr 100 mg......................
OCEAN BLUE MINICAPS OMEGA – omega-3 fatty acids oseltamivir phosphate cap 30 mg (base equiv)
cap 350 mg.................................................................. (Tamiflu).......................................................................
octreotide acetate inj 50 mcg/ml (0.05 mg/ml) oseltamivir phosphate cap 45 mg (base equiv)
(Sandostatin)................................................................ (Tamiflu).......................................................................
octreotide acetate inj 100 mcg/ml (0.1 mg/ml) oseltamivir phosphate cap 75 mg (base equiv)
(Sandostatin)................................................................ (Tamiflu).......................................................................
octreotide acetate inj 200 mcg/ml (0.2 mg/ml) oxcarbazepine susp 300 mg/5ml (60 mg/ml)
(Sandostatin)................................................................ (Trileptal)......................................................................
octreotide acetate inj 500 mcg/ml (0.5 mg/ml) oxcarbazepine tab 150 mg (Trileptal)...........................
(Sandostatin)................................................................ oxcarbazepine tab 300 mg (Trileptal)...........................
octreotide acetate inj 1000 mcg/ml (1 mg/ml) oxcarbazepine tab 600 mg (Trileptal)...........................
(Sandostatin)................................................................ oxybutynin chloride syrup 5 mg/5ml.............................
ofloxacin ophth soln 0.3% (Ocuflox)............................. oxybutynin chloride tab er 24hr 5 mg (Ditropan xl)......
ofloxacin otic soln 0.3% (Floxin otic)............................ oxybutynin chloride tab er 24hr 10 mg (Ditropan
olanzapine for im inj 10 mg (Zyprexa).......................... xl)..................................................................................
olanzapine orally disintegrating tab 5 mg (Zyprexa oxybutynin chloride tab er 24hr 15 mg (Ditropan
zydis)............................................................................ xl)..................................................................................
olanzapine orally disintegrating tab 10 mg (Zyprexa oxybutynin chloride tab 5 mg........................................
zydis)............................................................................ OXYCODONE/ACETAMINOPHEN – oxycodone w/
olanzapine orally disintegrating tab 15 mg (Zyprexa acetaminophen soln 5-325 mg/5ml............................
zydis)............................................................................ oxycodone-aspirin tab 4.8355-325 mg.........................
olanzapine orally disintegrating tab 20 mg (Zyprexa oxycodone hcl conc 100 mg/5ml (20 mg/ml)................
zydis)............................................................................ oxycodone hcl soln 5 mg/5ml.......................................
97
2017
oxycodone hcl tab 10 mg............................................. phenobarbital tab 16.2 mg............................................
oxycodone hcl tab 20 mg............................................. phenobarbital tab 32.4 mg............................................
oxycodone hcl tab 5 mg (Roxicodone)......................... phenobarbital tab 64.8 mg............................................
oxycodone hcl tab 15 mg (Roxicodone)....................... phenobarbital tab 97.2 mg............................................
oxycodone hcl tab 30 mg (Roxicodone)....................... phenoxybenzamine hcl cap 10 mg (Dibenzyline).........
oxycodone w/ acetaminophen tab 5-325 mg PHENYLEPHRINE/GUAIFENESIN – phenylephrine-
(Percocet)..................................................................... guaifenesin liqd 7.5-100 mg/5ml (1.5-20 mg/ml)........
oxycodone w/ acetaminophen tab 7.5-325 mg phenylephrine-guaifenesin tab 10-400 mg...................
(Percocet)..................................................................... phenylephrine hcl tab 10 mg........................................
oxycodone w/ acetaminophen tab 10-325 mg phenylephrine w/ dm-gg liqd 5-10-200 mg/5ml............
(Percocet)..................................................................... phenytoin chew tab 50 mg (Dilantin infatabs)..............
P phenytoin sodium extended cap 100 mg (Dilantin)......
phenytoin sodium extended cap 200 mg
pantoprazole sodium ec tab 20 mg (base equiv) (Phenytek)....................................................................
(Protonix)...................................................................... phenytoin sodium extended cap 300 mg
pantoprazole sodium ec tab 40 mg (base equiv) (Phenytek)....................................................................
(Protonix)...................................................................... phenytoin susp 125 mg/5ml (Dilantin-125)...................
PAPAVERINE HCL – papaverine hcl inj 30 mg/ml....... pilocarpine hcl ophth soln 1% (Isopto carpine)............
PARAGARD INTRAUTERINE COP – copper iud........ pilocarpine hcl ophth soln 2% (Isopto carpine)............
paromomycin sulfate cap 250 mg................................ pilocarpine hcl ophth soln 4% (Isopto carpine)............
paroxetine hcl tab 10 mg (Paxil)................................... pilocarpine hcl tab 5 mg (Salagen)...............................
paroxetine hcl tab 20 mg (Paxil)................................... pilocarpine hcl tab 7.5 mg (Salagen)............................
paroxetine hcl tab 30 mg (Paxil)................................... pimozide tab 1 mg (Orap).............................................
paroxetine hcl tab 40 mg (Paxil)................................... pimozide tab 2 mg (Orap).............................................
PEDIA-LAX – glycerin liquid suppos 2.8 gm (2.7 pioglitazone hcl tab 15 mg (base equiv) (Actos)..........
ml)................................................................................ pioglitazone hcl tab 30 mg (base equiv) (Actos)..........
pediatric multiple vitamin w/ c & fa chew tab............... pioglitazone hcl tab 45 mg (base equiv) (Actos)..........
pediatric multiple vitamin w/ minerals & c drops 45 mg/ piroxicam cap 10 mg (Feldene)....................................
ml.................................................................................. piroxicam cap 20 mg (Feldene)....................................
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm PLAN B ONE-STEP – levonorgestrel tab 1.5 mg........
(Colyte-flavor packs)................................................... PNV TABS 29-1............................................................
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm podofilox soln 0.5%.......................................................
(Golytely)...................................................................... polyethylene glycol 3350 oral powder..........................
peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/ polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%
flavor pack).................................................................. (Polytrim)......................................................................
penicillin v potassium for soln 125 mg/5ml................... pot & sod citrates w/ cit ac soln 550-500-334
penicillin v potassium for soln 250 mg/5ml................... mg/5ml..........................................................................
penicillin v potassium tab 250 mg................................ potassium bicarbonate effer tab 25 meq......................
penicillin v potassium tab 500 mg................................ potassium chloride cap er 8 meq (Micro-k)..................
pentoxifylline tab er 400 mg......................................... potassium chloride cap er 10 meq (Micro-k)................
perindopril erbumine tab 2 mg...................................... POTASSIUM CHLORIDE ER – potassium chloride tab er
perindopril erbumine tab 4 mg (Aceon)........................ 8 meq (600 mg)...........................................................
perindopril erbumine tab 8 mg (Aceon)........................ potassium chloride microencapsulated crys er tab 10
permethrin cream 5% (Elimite)..................................... meq..............................................................................
permethrin creme rinse 1%.......................................... potassium chloride microencapsulated crys er tab 20
perphenazine tab 2 mg................................................. meq..............................................................................
perphenazine tab 4 mg................................................. potassium chloride oral soln 10% (20 meq/15ml)........
perphenazine tab 8 mg................................................. POTASSIUM CHLORIDE – potassium chloride oral soln
perphenazine tab 16 mg............................................... 20% (40 meq/15ml).....................................................
phenazopyridine hcl tab 100 mg (Pyridium)................. potassium chloride powder packet 20 meq..................
phenazopyridine hcl tab 200 mg (Pyridium)................. potassium chloride tab er 10 meq (K-tab)....................
phenobarbital elixir 20 mg/5ml...................................... potassium chloride tab er 8 meq (600 mg)..................
PHENOBARBITAL – phenobarbital tab 15 mg............ potassium citrate & citric acid powder pack 3300-1002
PHENOBARBITAL – phenobarbital tab 30 mg............ mg................................................................................
PHENOBARBITAL – phenobarbital tab 60 mg............ potassium citrate & citric acid soln 1100-334
PHENOBARBITAL – phenobarbital tab 100 mg.......... mg/5ml..........................................................................
98
2017
potassium citrate tab er 5 meq (540 mg) (Urocit-k PREZISTA – darunavir ethanolate susp 100 mg/ml (base
5).................................................................................. equiv)............................................................................
potassium citrate tab er 10 meq (1080 mg) (Urocit-k PREZISTA – darunavir ethanolate tab 75 mg (base
10)................................................................................ equiv)............................................................................
potassium citrate tab er 15 meq (1620 mg) (Urocit-k PREZISTA – darunavir ethanolate tab 150 mg (base
15)................................................................................ equiv)............................................................................
pot bicarbonate & chloride effer tab 25 meq................ PREZISTA – darunavir ethanolate tab 600 mg (base
pot phos monobasic w/sod phos di & monobas tab equiv)............................................................................
155-852-130mg (K-phos neutral)................................ PREZISTA – darunavir ethanolate tab 800 mg (base
PRALUENT – alirocumab subcutaneous soln pen-injector equiv)............................................................................
75 mg/ml...................................................................... PRIFTIN – rifapentine tab 150 mg...............................
PRALUENT – alirocumab subcutaneous soln pen-injector PRIMAQUINE PHOSPHATE – primaquine phosphate tab
150 mg/ml.................................................................... 26.3 mg (15 mg base)................................................
pramipexole dihydrochloride tab 0.125 mg primidone tab 50 mg (Mysoline)...................................
(Mirapex)...................................................................... primidone tab 250 mg (Mysoline).................................
pramipexole dihydrochloride tab 0.25 mg probenecid tab 500 mg.................................................
(Mirapex)...................................................................... PROBUPHINE IMPLANT KIT – buprenorphine hcl
pramipexole dihydrochloride tab 0.5 mg (Mirapex)...... subdermal implant 74.2 mg (base equiv)...................
pramipexole dihydrochloride tab 0.75 mg prochlorperazine maleate tab 5 mg (base
(Mirapex)...................................................................... equivalent)....................................................................
pramipexole dihydrochloride tab 1 mg (Mirapex)......... prochlorperazine maleate tab 10 mg (base
pramipexole dihydrochloride tab 1.5 mg (Mirapex)...... equivalent)....................................................................
pravastatin sodium tab 10 mg...................................... prochlorperazine suppos 25 mg...................................
pravastatin sodium tab 20 mg (Pravachol)................... PROFILNINE – factor ix complex for inj 500 unit.........
pravastatin sodium tab 40 mg (Pravachol)................... PROFILNINE – factor ix complex for inj 1000 unit.......
pravastatin sodium tab 80 mg (Pravachol)................... PROFILNINE – factor ix complex for inj 1500 unit.......
prazosin hcl cap 1 mg (Minipress)............................... PROFILNINE SD – factor ix complex for inj 500
prazosin hcl cap 2 mg (Minipress)............................... unit................................................................................
prazosin hcl cap 5 mg (Minipress)............................... PROFILNINE SD – factor ix complex for inj 1000
prednicarbate cream 0.1% (Dermatop)........................ unit................................................................................
prednicarbate oint 0.1% (Dermatop)............................ PROFILNINE SD – factor ix complex for inj 1500
prednisolone acetate ophth susp 1% (Pred forte)........ unit................................................................................
PREDNISOLONE SODIUM PHOSP – prednisolone progesterone im in oil 50 mg/ml...................................
sodium phosphate ophth soln 1%.............................. progesterone micronized cap 100 mg
prednisolone sod phosphate oral soln 15 mg/5ml (base (Prometrium)................................................................
equiv)............................................................................ progesterone micronized cap 200 mg
prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml (Prometrium)................................................................
base) (Pediapred)........................................................ promethazine hcl suppos 12.5 mg...............................
prednisolone syrup 15 mg/5ml (usp solution promethazine hcl suppos 25 mg..................................
equivalent).................................................................... promethazine hcl syrup 6.25 mg/5ml...........................
PREDNISONE – prednisone oral soln 5 mg/5ml......... promethazine hcl tab 12.5 mg......................................
PREDNISONE – prednisone tab 50 mg....................... promethazine hcl tab 25 mg.........................................
prednisone tab 1 mg..................................................... promethazine hcl tab 50 mg.........................................
prednisone tab 2.5 mg.................................................. promethazine w/ codeine syrup 6.25-10 mg/5ml.........
prednisone tab 5 mg..................................................... PRO NUTRIENTS OMEGA 3 – omega-3 fatty acids cap
prednisone tab 10 mg................................................... delayed release 332.5 mg..........................................
prednisone tab 20 mg................................................... propafenone hcl tab 150 mg.........................................
PREMPRO – conjugated estrogen-medroxyprogest propafenone hcl tab 225 mg.........................................
acetate tab 0.3-1.5 mg................................................ propafenone hcl tab 300 mg.........................................
PREMPRO – conjugated estrogen-medroxyprogest proparacaine hcl ophth soln 0.5%................................
acetate tab 0.45-1.5 mg.............................................. PROPRANOLOL/HYDROCHLOROTH – propranolol &
PREMPRO – conjugated estrogen-medroxyprogest hydrochlorothiazide tab 40-25 mg..............................
acetate tab 0.625-5 mg............................................... propranolol hcl tab 10 mg.............................................
PRESERVISION AREDS 2 + MU – multiple vitamins w/ propranolol hcl tab 20 mg.............................................
minerals cap................................................................ propranolol hcl tab 40 mg.............................................
propranolol hcl tab 60 mg.............................................
99
2017
propranolol hcl tab 80 mg............................................. RECOMBINATE – antihemophilic factor (recombinant) for
propylthiouracil tab 50 mg............................................ inj 1241-1800 unit........................................................
psyllium powder 28.3%................................................. RECOMBINATE – antihemophilic factor (recombinant) for
psyllium powder 30%.................................................... inj 1801-2400 unit........................................................
psyllium powder 30.9%................................................. RELENZA DISKHALER – zanamivir aero powder breath
psyllium powder 48.57%............................................... activated 5 mg/blister..................................................
psyllium powder 58.6%................................................. RELHIST BP – brompheniramine & phenylephrine tab
psyllium powder 95%.................................................... 4-10 mg........................................................................
PULMOZYME – dornase alfa inhal soln 1 mg/ml......... REPATHA – evolocumab subcutaneous soln prefilled
pyrazinamide tab 500 mg............................................. syringe 140 mg/ml.......................................................
pyridostigmine bromide tab 60 mg (Mestinon)............. REPATHA SURECLICK – evolocumab subcutaneous soln
auto-injector 140 mg/ml...............................................
Q
RESCRIPTOR – delavirdine mesylate tab 100 mg......
QC CALAMINE – calamine lotion................................. RESCRIPTOR – delavirdine mesylate tab 200 mg......
quetiapine fumarate tab 25 mg (Seroquel)................... REVLIMID – lenalidomide cap 5 mg............................
quetiapine fumarate tab 50 mg (Seroquel)................... REVLIMID – lenalidomide cap 10 mg..........................
quetiapine fumarate tab 100 mg (Seroquel)................. REVLIMID – lenalidomide cap 15 mg..........................
quetiapine fumarate tab 400 mg (Seroquel)................. REVLIMID – lenalidomide caps 2.5 mg.......................
quinapril hcl tab 5 mg (Accupril)................................... REYATAZ – atazanavir sulfate cap 150 mg (base
quinapril hcl tab 10 mg (Accupril)................................. equiv)............................................................................
quinapril hcl tab 20 mg (Accupril)................................. REYATAZ – atazanavir sulfate cap 200 mg (base
quinapril hcl tab 40 mg (Accupril)................................. equiv)............................................................................
quinapril-hydrochlorothiazide tab 10-12.5 mg REYATAZ – atazanavir sulfate cap 300 mg (base
(Accuretic).................................................................... equiv)............................................................................
quinapril-hydrochlorothiazide tab 20-12.5 mg REYATAZ – atazanavir sulfate oral powder packet 50 mg
(Accuretic).................................................................... (base equiv).................................................................
quinapril-hydrochlorothiazide tab 20-25 mg ribavirin cap 200 mg (Rebetol).....................................
(Accuretic).................................................................... rifabutin cap 150 mg (Mycobutin).................................
quinidine gluconate tab er 324 mg............................... rifampin cap 300 mg.....................................................
QUINIDINE SULFATE – quinidine sulfate tab 200 rifampin cap 150 mg (Rifadin)......................................
mg................................................................................ riluzole tab 50 mg (Rilutek)...........................................
QUINIDINE SULFATE – quinidine sulfate tab 300 ringer's solution for irrigation........................................
mg................................................................................ risperidone orally disintegrating tab 0.25 mg...............
QVAR – beclomethasone diprop inhal aero soln 40 mcg/ risperidone orally disintegrating tab 0.5 mg (Risperdal m-
act (50/valve)............................................................... tab)...............................................................................
QVAR – beclomethasone diprop inhal aero soln 80 mcg/ risperidone orally disintegrating tab 1 mg (Risperdal m-
act (100/valve)............................................................. tab)...............................................................................
R risperidone orally disintegrating tab 2 mg (Risperdal m-
tab)...............................................................................
raloxifene hcl tab 60 mg (Evista).................................. risperidone orally disintegrating tab 3 mg (Risperdal m-
ramipril cap 1.25 mg (Altace)....................................... tab)...............................................................................
ramipril cap 2.5 mg (Altace)......................................... risperidone orally disintegrating tab 4 mg (Risperdal m-
ramipril cap 5 mg (Altace)............................................ tab)...............................................................................
ramipril cap 10 mg (Altace).......................................... risperidone soln 1 mg/ml (Risperdal)............................
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)................... risperidone tab 0.25 mg (Risperdal).............................
ranitidine hcl tab 75 mg................................................ risperidone tab 0.5 mg (Risperdal)...............................
ranitidine hcl tab 150 mg (Zantac)................................ risperidone tab 1 mg (Risperdal)..................................
ranitidine hcl tab 300 mg (Zantac)................................ risperidone tab 2 mg (Risperdal)..................................
RECOMBINATE – antihemophilic factor (recombinant) for risperidone tab 3 mg (Risperdal)..................................
inj 220-400 unit............................................................ risperidone tab 4 mg (Risperdal)..................................
RECOMBINATE – antihemophilic factor (recombinant) for RIXUBIS – coagulation factor ix (recombinant) for inj 250
inj 401-800 unit............................................................ unit................................................................................
RECOMBINATE – antihemophilic factor (recombinant) for RIXUBIS – coagulation factor ix (recombinant) for inj 500
inj 801-1240 unit.......................................................... unit................................................................................
100
2017
RIXUBIS – coagulation factor ix (recombinant) for inj 1000 simvastatin tab 5 mg (Zocor)........................................
unit................................................................................ simvastatin tab 10 mg (Zocor)......................................
RIXUBIS – coagulation factor ix (recombinant) for inj 2000 simvastatin tab 20 mg (Zocor)......................................
unit................................................................................ simvastatin tab 40 mg (Zocor)......................................
RIXUBIS – coagulation factor ix (recombinant) for inj 3000 sirolimus tab 0.5 mg (Rapamune)................................
unit................................................................................ sirolimus tab 1 mg (Rapamune)...................................
rizatriptan benzoate oral disintegrating tab 5 mg (base eq) sirolimus tab 2 mg (Rapamune)...................................
(Maxalt-mlt).................................................................. SKYLA – levonorgestrel releasing iud 14 mcg/day (13.5
rizatriptan benzoate oral disintegrating tab 10 mg (base mg total).......................................................................
eq) (Maxalt-mlt)........................................................... sodium chloride irrigation soln 0.9%.............................
rizatriptan benzoate tab 5 mg (base equivalent) sodium chloride soln nebu 0.9%..................................
(Maxalt)........................................................................ sodium chloride soln nebu 3%.....................................
rizatriptan benzoate tab 10 mg (base equivalent) sodium chloride soln nebu 10%...................................
(Maxalt)........................................................................ sodium chloride soln nebu 7% (Hyper-sal)..................
ropinirole hydrochloride tab 0.25 mg (Requip)............. sodium citrate & citric acid soln 500-334 mg/5ml (Shohls
ropinirole hydrochloride tab 0.5 mg (Requip)............... solution modi)..............................................................
ropinirole hydrochloride tab 1 mg (Requip).................. sodium fluoride chew tab 0.25 mg f (from 0.55 mg
ropinirole hydrochloride tab 2 mg (Requip).................. naf)...............................................................................
ropinirole hydrochloride tab 3 mg (Requip).................. sodium fluoride chew tab 0.5 mg f (from 1.1 mg
ropinirole hydrochloride tab 4 mg (Requip).................. naf)...............................................................................
ropinirole hydrochloride tab 5 mg (Requip).................. sodium fluoride chew tab 1 mg f (from 2.2 mg naf)......
rosuvastatin calcium tab 5 mg (Crestor)...................... sodium fluoride cream 1.1% (Prevident 5000 plus).....
rosuvastatin calcium tab 10 mg (Crestor).................... sodium fluoride gel 1.1% (0.5% f) (Prevident
rosuvastatin calcium tab 20 mg (Crestor).................... fluoride)........................................................................
rosuvastatin calcium tab 40 mg (Crestor).................... sodium fluoride rinse 0.2%...........................................
RUBRACA – rucaparib camsylate tab 200 mg (base SODIUM FLUORIDE – sodium fluoride tab 1 mg f (from
equivalent).................................................................... 2.2 mg naf)..................................................................
RUBRACA – rucaparib camsylate tab 250 mg (base sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop
equivalent).................................................................... naf)...............................................................................
RUBRACA – rucaparib camsylate tab 300 mg (base sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml
equivalent).................................................................... naf)...............................................................................
RU-HIST D – brompheniramine & phenylephrine tab 4-10 sodium polystyrene sulfonate oral susp 15
mg................................................................................ gm/60ml.......................................................................
RYDAPT – midostaurin cap 25 mg.............................. sodium polystyrene sulfonate powder..........................
S sodium polystyrene sulfonate rectal susp 30
gm/120ml.....................................................................
saline nasal spray 0.65%.............................................. sotalol hcl tab 240 mg..................................................
salsalate tab 500 mg.................................................... sotalol hcl tab 80 mg (Betapace)..................................
salsalate tab 750 mg.................................................... sotalol hcl tab 120 mg (Betapace)................................
selegiline hcl cap 5 mg (Eldepryl)................................ sotalol hcl tab 160 mg (Betapace)................................
selegiline hcl tab 5 mg.................................................. SOVALDI – sofosbuvir tab 400 mg..............................
selenium sulfide lotion 2.5%......................................... SPIRIVA HANDIHALER – tiotropium bromide
SELZENTRY – maraviroc tab 25 mg........................... monohydrate inhal cap 18 mcg (base equiv).............
SELZENTRY – maraviroc tab 75 mg........................... spironolactone & hydrochlorothiazide tab 25-25 mg
SELZENTRY – maraviroc tab 300 mg......................... (Aldactazide)................................................................
sennosides tab 8.6 mg................................................. spironolactone tab 25 mg (Aldactone).........................
SEREVENT DISKUS – salmeterol xinafoate aer pow ba spironolactone tab 50 mg (Aldactone).........................
50 mcg/dose (base equiv).......................................... spironolactone tab 100 mg (Aldactone).......................
sertraline hcl oral conc 20 mg/ml (Zoloft)..................... SPRYCEL – dasatinib tab 20 mg.................................
sertraline hcl tab 25 mg (Zoloft)................................... SPRYCEL – dasatinib tab 50 mg.................................
sertraline hcl tab 50 mg (Zoloft)................................... SPRYCEL – dasatinib tab 70 mg.................................
sertraline hcl tab 100 mg (Zoloft)................................. SPRYCEL – dasatinib tab 80 mg.................................
sildenafil citrate tab 20 mg (Revatio)............................ SPRYCEL – dasatinib tab 100 mg...............................
silver sulfadiazine cream 1% (Silvadene).................... SPRYCEL – dasatinib tab 140 mg...............................
simethicone chew tab 80 mg........................................ stavudine cap 15 mg (Zerit)..........................................
simethicone susp 40 mg/0.6ml..................................... stavudine cap 20 mg (Zerit)..........................................
101
2017
stavudine cap 30 mg (Zerit).......................................... T
stavudine cap 40 mg (Zerit)..........................................
STIMATE – desmopressin acetate nasal soln 1.5 mg/ tacrolimus cap 0.5 mg (Prograf)...................................
ml.................................................................................. tacrolimus cap 1 mg (Prograf)......................................
STIVARGA – regorafenib tab 40 mg............................ tacrolimus cap 5 mg (Prograf)......................................
SUBOXONE – buprenorphine hcl-naloxone hcl sl film tacrolimus oint 0.03% (Protopic)...................................
2-0.5 mg (base equiv)................................................. tacrolimus oint 0.1% (Protopic).....................................
SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1 TAMIFLU – oseltamivir phosphate for susp 6 mg/ml (base
mg (base equiv).......................................................... equiv)............................................................................
SUBOXONE – buprenorphine hcl-naloxone hcl sl film 8-2 tamoxifen citrate tab 10 mg (base equivalent).............
mg (base equiv).......................................................... tamoxifen citrate tab 20 mg (base equivalent).............
SUBOXONE – buprenorphine hcl-naloxone hcl sl film tamsulosin hcl cap 0.4 mg (Flomax)............................
12-3 mg (base equiv).................................................. TARCEVA – erlotinib hcl tab 25 mg (base
sucralfate tab 1 gm (Carafate)...................................... equivalent)....................................................................
sulfacetamide sodium ophth soln 10% (Bleph-10)....... TARCEVA – erlotinib hcl tab 100 mg (base
sulfacetamide sodium-prednisolone ophth soln equivalent)....................................................................
10-0.23(0.25)%............................................................ TARCEVA – erlotinib hcl tab 150 mg (base
sulfacetamide sodium w/ sulfur emulsion 10-1%......... equivalent)....................................................................
sulfacetamide sodium w/ sulfur emulsion 10-5%......... TASIGNA – nilotinib hcl cap 150 mg (base
SULFADIAZINE – sulfadiazine tab 500 mg.................. equivalent)....................................................................
sulfamethoxazole-trimethoprim susp 200-40 TASIGNA – nilotinib hcl cap 200 mg (base
mg/5ml.......................................................................... equivalent)....................................................................
sulfamethoxazole-trimethoprim tab 400-80 mg tazarotene cream 0.1% (Tazorac)................................
(Bactrim)....................................................................... TAZORAC – tazarotene gel 0.05%..............................
sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim TAZORAC – tazarotene gel 0.1%................................
ds)................................................................................ TECHLITE PEN NEEDLES 29G..................................
sulfasalazine tab delayed release 500 mg (Azulfidine en- temazepam cap 15 mg (Restoril).................................
tabs)............................................................................. temazepam cap 30 mg (Restoril).................................
sulfasalazine tab 500 mg (Azulfidine).......................... temozolomide cap 5 mg (Temodar)..............................
sulindac tab 150 mg..................................................... temozolomide cap 20 mg (Temodar)............................
sulindac tab 200 mg..................................................... temozolomide cap 100 mg (Temodar)..........................
sumatriptan succinate inj 6 mg/0.5ml (Imitrex)............. temozolomide cap 140 mg (Temodar)..........................
sumatriptan succinate solution cartridge 6 mg/0.5ml temozolomide cap 180 mg (Temodar)..........................
(Imitrex statdose ref)................................................... temozolomide cap 250 mg (Temodar)..........................
sumatriptan succinate tab 25 mg (Imitrex)................... terazosin hcl cap 1 mg.................................................
sumatriptan succinate tab 50 mg (Imitrex)................... terazosin hcl cap 2 mg.................................................
sumatriptan succinate tab 100 mg (Imitrex)................. terazosin hcl cap 5 mg.................................................
SUSTIVA – efavirenz cap 50 mg.................................. terazosin hcl cap 10 mg...............................................
SUSTIVA – efavirenz cap 200 mg................................ terbinafine hcl tab 250 mg (Lamisil).............................
SUSTIVA – efavirenz tab 600 mg................................ terbutaline sulfate tab 2.5 mg.......................................
SUTENT – sunitinib malate cap 12.5 mg (base terbutaline sulfate tab 5 mg..........................................
equivalent).................................................................... terconazole vaginal cream 0.8%..................................
SUTENT – sunitinib malate cap 25 mg (base terconazole vaginal cream 0.4% (Terazol 7)................
equivalent).................................................................... terconazole vaginal suppos 80 mg...............................
SUTENT – sunitinib malate cap 37.5 mg (base testosterone cypionate im inj in oil 100 mg/ml (Depo-
equivalent).................................................................... testosterone)................................................................
SUTENT – sunitinib malate cap 50 mg (base testosterone cypionate im inj in oil 200 mg/ml (Depo-
equivalent).................................................................... testosterone)................................................................
SYMBICORT – budesonide-formoterol fumarate dihyd testosterone enanthate im inj in oil 200 mg/ml.............
aerosol 80-4.5 mcg/act................................................ tetracaine hcl ophth soln 0.5%.....................................
SYMBICORT – budesonide-formoterol fumarate dihyd tetrahydroz-dextran-peg-povidone ophth soln
aerosol 160-4.5 mcg/act............................................. 0.05-0.1-1-1%..............................................................
SYNAGIS – palivizumab im soln 50 mg/0.5ml............. THALOMID – thalidomide cap 50 mg..........................
SYNAGIS – palivizumab im soln 100 mg/ml................ THALOMID – thalidomide cap 100 mg........................
THALOMID – thalidomide cap 150 mg........................
theophylline soln 80 mg/15ml.......................................
102
2017
theophylline tab er 12hr 100 mg................................... trazodone hcl tab 150 mg.............................................
theophylline tab er 12hr 200 mg................................... tretinoin cap 10 mg.......................................................
theophylline tab er 12hr 300 mg................................... tretinoin cream 0.025% (Retin-a).................................
theophylline tab er 12hr 450 mg................................... tretinoin cream 0.05% (Retin-a)....................................
theophylline tab er 24hr 400 mg................................... tretinoin cream 0.1% (Retin-a)......................................
theophylline tab er 24hr 600 mg................................... tretinoin gel 0.01% (Retin-a).........................................
thiamine hcl tab 50 mg................................................. tretinoin gel 0.025% (Retin-a).......................................
thiamine hcl tab 100 mg............................................... triamcinolone acetonide cream 0.025%.......................
thioridazine hcl tab 10 mg............................................ triamcinolone acetonide cream 0.1%...........................
thioridazine hcl tab 25 mg............................................ triamcinolone acetonide cream 0.5%...........................
thioridazine hcl tab 50 mg............................................ triamcinolone acetonide dental paste 0.1%.................
thioridazine hcl tab 100 mg.......................................... triamcinolone acetonide lotion 0.025%.........................
thiothixene cap 1 mg.................................................... triamcinolone acetonide lotion 0.1%.............................
thiothixene cap 2 mg.................................................... triamcinolone acetonide oint 0.025%...........................
thiothixene cap 5 mg.................................................... triamcinolone acetonide oint 0.1%...............................
thiothixene cap 10 mg.................................................. TRIAMINIC NIGHT TIME COLD – diphenhydramine-
thyroid tab 30 mg (1/2 grain) (Armour thyroid)............. phenylephrine syrup 6.25-2.5 mg/5ml........................
thyroid tab 90 mg (1 1/2 grain) (Armour thyroid).......... triamterene & hydrochlorothiazide cap 37.5-25 mg
thyroid tab 60 mg (1 grain) (Armour thyroid)................ (Dyazide)......................................................................
timolol maleate ophth soln 0.25% (Timoptic)............... triamterene & hydrochlorothiazide tab 37.5-25 mg
timolol maleate ophth soln 0.5% (Timoptic)................. (Maxzide-25)................................................................
tioconazole vaginal oint 6.5%....................................... triamterene & hydrochlorothiazide tab 75-50 mg
TIVICAY – dolutegravir sodium tab 10 mg (base (Maxzide).....................................................................
equiv)............................................................................ trifluoperazine hcl tab 1 mg..........................................
TIVICAY – dolutegravir sodium tab 25 mg (base trifluoperazine hcl tab 2 mg..........................................
equiv)............................................................................ trifluoperazine hcl tab 5 mg..........................................
TIVICAY – dolutegravir sodium tab 50 mg (base trifluoperazine hcl tab 10 mg........................................
equiv)............................................................................ trifluridine ophth soln 1% (Viroptic)...............................
tizanidine hcl tab 2 mg (base equivalent)..................... trihexyphenidyl hcl elixir 0.4 mg/ml...............................
tizanidine hcl tab 4 mg (base equivalent) trihexyphenidyl hcl tab 2 mg.........................................
(Zanaflex)..................................................................... trihexyphenidyl hcl tab 5 mg.........................................
tobramycin-dexamethasone ophth susp 0.3-0.1% trimethoprim tab 100 mg...............................................
(Tobradex).................................................................... TRI-VI-SOL – pediatric vitamins adc drops 750 unit-400
tobramycin nebu soln 300 mg/5ml (Tobi)..................... unit-35 mg/ml...............................................................
tobramycin ophth soln 0.3% (Tobrex)........................... TRUVADA – emtricitabine-tenofovir disoproxil fumarate
TOLAZAMIDE – tolazamide tab 250 mg...................... tab 100-150 mg...........................................................
tolnaftate aerosol 1%.................................................... TRUVADA – emtricitabine-tenofovir disoproxil fumarate
topiramate sprinkle cap 15 mg (Topamax sprinkle)...... tab 133-200 mg...........................................................
topiramate sprinkle cap 25 mg (Topamax sprinkle)...... TRUVADA – emtricitabine-tenofovir disoproxil fumarate
topiramate tab 25 mg (Topamax)................................. tab 167-250 mg...........................................................
topiramate tab 50 mg (Topamax)................................. TRUVADA – emtricitabine-tenofovir disoproxil fumarate
topiramate tab 100 mg (Topamax)............................... tab 200-300 mg...........................................................
topiramate tab 200 mg (Topamax)............................... TYMLOS – abaloparatide subcutaneous soln pen-injector
torsemide tab 5 mg....................................................... 3120 mcg/1.56ml.........................................................
torsemide tab 100 mg................................................... U
torsemide tab 10 mg (Demadex)..................................
torsemide tab 20 mg (Demadex).................................. ursodiol cap 300 mg (Actigall)......................................
TRACLEER – bosentan tab 62.5 mg........................... ursodiol tab 250 mg (Urso 250)....................................
TRACLEER – bosentan tab 125 mg............................ ursodiol tab 500 mg (Urso forte)..................................
tramadol hcl tab 50 mg (Ultram)................................... V
trandolapril tab 1 mg.....................................................
trandolapril tab 4 mg..................................................... valacyclovir hcl tab 1 gm (Valtrex)................................
trandolapril tab 2 mg (Mavik)........................................ valacyclovir hcl tab 500 mg (Valtrex)............................
tranexamic acid tab 650 mg (Lysteda)......................... VALCHLOR – mechlorethamine hcl gel 0.016% (base
trazodone hcl tab 50 mg............................................... equivalent)....................................................................
trazodone hcl tab 100 mg.............................................
103
2017
valganciclovir hcl tab 450 mg (base equivalent) VIREAD – tenofovir disoproxil fumarate tab 150
(Valcyte)....................................................................... mg................................................................................
valproate sodium oral soln 250 mg/5ml (base equiv) VIREAD – tenofovir disoproxil fumarate tab 200
(Depakene).................................................................. mg................................................................................
valproic acid cap 250 mg (Depakene).......................... VIREAD – tenofovir disoproxil fumarate tab 250
valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan mg................................................................................
hct)............................................................................... VIREAD – tenofovir disoproxil fumarate tab 300
valsartan-hydrochlorothiazide tab 160-12.5 mg (Diovan mg................................................................................
hct)............................................................................... vitamins a & d oint........................................................
valsartan-hydrochlorothiazide tab 160-25 mg (Diovan VIVITROL – naltrexone for im extended release susp 380
hct)............................................................................... mg................................................................................
valsartan-hydrochlorothiazide tab 320-12.5 mg (Diovan voriconazole for susp 40 mg/ml (Vfend).......................
hct)............................................................................... voriconazole tab 50 mg (Vfend)...................................
valsartan-hydrochlorothiazide tab 320-25 mg (Diovan voriconazole tab 200 mg (Vfend).................................
hct)............................................................................... VOTRIENT – pazopanib hcl tab 200 mg (base
valsartan tab 40 mg (Diovan)....................................... equiv)............................................................................
valsartan tab 80 mg (Diovan)....................................... W
valsartan tab 160 mg (Diovan).....................................
valsartan tab 320 mg (Diovan)..................................... warfarin sodium tab 1 mg (Coumadin).........................
vancomycin hcl cap 125 mg (Vancocin hcl)................. warfarin sodium tab 2 mg (Coumadin).........................
vancomycin hcl cap 250 mg (Vancocin hcl)................. warfarin sodium tab 2.5 mg (Coumadin)......................
venlafaxine hcl cap er 24hr 37.5 mg (base equivalent) warfarin sodium tab 3 mg (Coumadin).........................
(Effexor xr)................................................................... warfarin sodium tab 4 mg (Coumadin).........................
venlafaxine hcl cap er 24hr 75 mg (base equivalent) warfarin sodium tab 5 mg (Coumadin).........................
(Effexor xr)................................................................... warfarin sodium tab 6 mg (Coumadin).........................
venlafaxine hcl cap er 24hr 150 mg (base equivalent) warfarin sodium tab 7.5 mg (Coumadin)......................
(Effexor xr)................................................................... warfarin sodium tab 10 mg (Coumadin).......................
venlafaxine hcl tab 25 mg............................................. water for irrigation, sterile irrigation soln......................
venlafaxine hcl tab 37.5 mg.......................................... X
venlafaxine hcl tab 50 mg.............................................
venlafaxine hcl tab 75 mg............................................. XALKORI – crizotinib cap 200 mg................................
venlafaxine hcl tab 100 mg........................................... XALKORI – crizotinib cap 250 mg................................
VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act XARELTO – rivaroxaban tab 10 mg.............................
(90mcg base equiv)..................................................... XARELTO – rivaroxaban tab 15 mg.............................
verapamil hcl cap er 24hr 120 mg (Verelan)................ XARELTO – rivaroxaban tab 20 mg.............................
verapamil hcl cap er 24hr 180 mg (Verelan)................ XARELTO STARTER PACK – rivaroxaban tab starter
verapamil hcl cap er 24hr 240 mg (Verelan)................ therapy pack 15 mg & 20 mg.....................................
verapamil hcl cap er 24hr 360 mg (Verelan)................ XIFAXAN – rifaximin tab 200 mg..................................
verapamil hcl cap er 24hr 100 mg (Verelan pm).......... XIFAXAN – rifaximin tab 550 mg..................................
verapamil hcl cap er 24hr 200 mg (Verelan pm).......... XTANDI – enzalutamide cap 40 mg.............................
verapamil hcl cap er 24hr 300 mg (Verelan pm).......... XULANE – norelgestromin-ethinyl estradiol td ptwk
verapamil hcl tab er 120 mg (Calan sr)........................ 150-35 mcg/24hr.........................................................
verapamil hcl tab er 180 mg (Calan sr)........................ XYNTHA – antihemophilic factor recombinant paf for inj kit
250 unit........................................................................
verapamil hcl tab er 240 mg (Calan sr)........................
XYNTHA – antihemophilic factor recombinant paf for inj kit
verapamil hcl tab 40 mg...............................................
500 unit........................................................................
verapamil hcl tab 80 mg (Calan)..................................
verapamil hcl tab 120 mg (Calan)................................
1000 unit......................................................................
VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/
ml)................................................................................
2000 unit......................................................................
VIDEX – didanosine for soln 2 gm...............................
XYNTHA SOLOFUSE – antihemophilic factor
VIDEX – didanosine for soln 4 gm...............................
recombinant paf for inj kit 250 unit.............................
VIRACEPT – nelfinavir mesylate tab 250 mg..............
VIRACEPT – nelfinavir mesylate tab 625 mg..............
recombinant paf for inj kit 500 unit.............................
VIRAMUNE – nevirapine susp 50 mg/5ml...................
VIREAD – tenofovir disoproxil fumarate oral powder 40
recombinant paf for inj kit 1000 unit...........................
mg/gm..........................................................................
104
2017
XYNTHA SOLOFUSE – antihemophilic factor ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab 8.6-2.1
recombinant paf for inj kit 2000 unit........................... mg (base eq)...............................................................
XYNTHA SOLOFUSE – antihemophilic factor ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab
recombinant paf for inj kit 3000 unit........................... 11.4-2.9 mg (base eq).................................................
XYREM – sodium oxybate oral solution 500 mg/ml..... ZYCLARA – imiquimod cream 3.75%..........................
Y ZYCLARA PUMP – imiquimod cream 2.5%.................
ZYCLARA PUMP – imiquimod cream 3.75%...............
Z ZYTIGA – abiraterone acetate tab 250 mg..................
ZYTIGA – abiraterone acetate tab 500 mg..................
zaleplon cap 5 mg (Sonata)......................................... ZYVOX – linezolid for susp 100 mg/5ml......................
zaleplon cap 10 mg (Sonata).......................................
ZARXIO – filgrastim-sndz soln prefilled syringe 300
mcg/0.5ml.....................................................................
ZARXIO – filgrastim-sndz soln prefilled syringe 480
mcg/0.8ml.....................................................................
ZELBORAF – vemurafenib tab 240 mg.......................
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
3000-10000-16000 unit...............................................
5000-17000-27000 unit...............................................
10000-34000-55000 unit.............................................
15000-51000-82000 unit.............................................
20000-68000-109000 unit...........................................
25000-85000-136000 unit...........................................
40000-136000-218000 unit.........................................
ZEPATIER – elbasvir-grazoprevir tab 50-100 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.................................................
zinc oxide oint 10%.......................................................
zinc oxide oint 20%.......................................................
ziprasidone hcl cap 20 mg (Geodon)...........................
zolpidem tartrate tab 5 mg (Ambien)............................
zolpidem tartrate tab 10 mg (Ambien)..........................
zonisamide cap 50 mg..................................................
zonisamide cap 25 mg (Zonegran)...............................
zonisamide cap 100 mg (Zonegran)............................
ZORTRESS – everolimus tab 0.25 mg........................
ZORTRESS – everolimus tab 0.5 mg..........................
ZORTRESS – everolimus tab 0.75 mg........................
ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab
1.4-0.36 mg (base eq)................................................
ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab
2.9-0.71 mg (base eq)................................................
ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab 5.7-1.4
mg (base eq)...............................................................
105
This formulary was updated on 10/1/2017.
Blue Cross Community Family Health Plan is provided

by Blue Cross and Blue Shield of Illinois, a Division
of Health Care Service Corporation, a Mutual Legal
Reserve Company (HCSC), an Independent Licensee
of the Blue Cross and Blue Shield Association.

Drug List Bcbs2017

Hochgeladen von

Dokumentinformationen

Copyright

Verfügbare Formate

Dieses Dokument teilen

Dokument teilen oder einbetten

Freigabeoptionen

Stufen Sie dieses Dokument als nützlich ein?

Sind diese Inhalte unangemessen?

Copyright:

Verfügbare Formate

Drug List Bcbs2017

Hochgeladen von

Copyright:

Verfügbare Formate

Blue Cross and Blue Shield of Illinois

Family Health Plan

Blue Cross and Blue Shield of Illinois:

If you need these services, contact Civil Rights Coordinator.

U.S. Department of Health and Human Services

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

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej.

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

• Ask Member Services about making an For more Information

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail

What the drug Necessary actions,

1 = Generic Drugs AL = Age Limit ME = Morphine Equivalent 90 = 90 days available at mail