Drugs That Have Quantitiy Limits (QL)

Similar documents
ABILIFY ABILIFY DISCMELT ACTONEL ACTOPLUS MET ACTOPLUS MET XR ACTOS ADCIRCA ADVAIR DISKUS ADVAIR HFA

2014 Quantity Limits (QL) Criteria

Quantity limits on medications are established to maximize the dosing regimen and decrease cost.

Drug Quantity Limits Quantity limits (QL) on medications are established to maximize the dosing regimen and decrease cost

STEP THERAPY ALGORITHMS PUP Select Formulary

VIVA Health, Inc. Part D Cumulative Formulary Changes for 2009

National Preferred Formulary Quantity Limits Drug List Helpful Tip: To search for a specific drug, use the find feature (Ctrl + F)

Generics. Lead with. Prescription Step Therapy Program

How do I request an exception to the Liberty Health Advantage s Formulary?

RxBlue 2010 ST Criteria

Michigan Department of Community Health Co-pay and Quantity Limitations

Quantity per Dispensing Level Limits/Allowances

Generics. Lead with. P r e s c r i p t i o n S t e p T h e r a p y P r o g r a m

Quantity Limits 2016 Paramount Medicare Formulary Formulary ID: Version 26 Updated: 11/1/2016

Michigan Department of Community Health Quantity Limitations

Anthem Prescription Management s Clinical Connections Program

PDP Classic Formulary Addendum

Medication and Dose 10/04/ /05/2016 Total % Change Since 10/2012 ABILIFY 10 MG TABLET $18.76 $ %

Responsible Quantity Program Effective 4/1/10. Abilify oral solution

ANTICHOLINERGIC BRONCHODILATORS ANTICHOLINERGIC BETA-AGONIST COMBO'S CORTICOSTEROID / BRONCHODILATOR COMBO'S NASAL STEROIDS LEUKOTRIENE MODIFIERS

THERAPEUTIC AREA NAME STRENGTH DOSAGE FORM

Relative Cost/Month. Less than $10. Loratadine Liquid* $10-$15 Cetirizine liquid 1mg/mL*

Michigan Department of Health & Human Services Quantity Limitations

2013 Quantity Level Limits (QLL) Criteria

2013 Preferred Drug List An evidence-based pharmacy program that works for you

2013 Preferred Drug List An evidence-based pharmacy program that works for you

2013 Preferred Drug List An evidence-based pharmacy program that works for you

Step Therapy Medications

Alaska Medicaid 90 Day** Generic Prescription Medication List

2010 Prescription Drug Guide

2014 Step Therapy Criteria (List of Step Therapy Criteria)

Drug / Pregnancy Conflicts Excessive Daily Doses Ingredient Duplication Insufficient Daily Doses

PDL DOSAGE CONSOLIDATION LIST

Performance Drug List

Primary/Preferred Drug List

Primary/Preferred Drug List

Michigan Department of Health & Human Services Quantity Limitations

Three-Tier Prescription Drug Benefit Rider A

Prescription Drug Benefit Rider

Three-Tier Prescription Drug Benefits Rider

AGGRENOX. Products Affected. Details. First Health Part D Value Plus (PDP) Last Updated: 10/01/2017. Aggrenox

THERAPEUTIC AREA NAME STRENGTH DOSAGE FORM

+-Quantity per Dispensing Level Limits/Allowances

2013 Step Therapy (ST) Criteria

PDF created with pdffactory trial version

Cost Effectiveness Recommendations For Kentucky Retirement Systems MTM Plan 2011

ARBS MEDICATION(S) SUBJECT TO STEP THERAPY DIOVAN HCT MG TAB, DIOVAN HCT MG TABLET

AGGRENOX. Products Affected. Details. GRP B2 Last Updated: 09/01/2018. Aggrenox

Medicare Part D 2012 Formulary Changes Service To Senior and Total Fit

Pharmacy Costs: Can I Make a Difference?

2013 Quantity Level Limits (QLL) Criteria

STATE OF NEW YORK DEPARTMENT OF HEALTH

Data Class: Internal. 1 inhaler (30 blisters OR 14 blisters institutional pack) per presciption

Blue Medicare HMO Essential 2015 Quantity Limit List Blue Medicare Rx Standard 2015 Quantity Limit List

STATE OF NEW YORK DEPARTMENT OF HEALTH

Save on your drugs with HealthyRx

Step Therapy Criteria 2019

WellCare Classic Formulary Addendum

Before a Step 2 medication is covered You get a prescription

U T I L I Z A T I O N E D I T S

2014 Preferred Drug List An evidence-based pharmacy program that works for you

FirstCarolinaCare Insurance Company Step Therapy Requirements

Amitriptyline Hydrochloride Heart Health & BP Amlodipine Besylate 5mg Norvasc Antibiotics Amoxicillin 500 mg Amoxil

ADHD STIMULANTS-S(SHC)

Table 1: Price increases for Brand Name Drugs with Generic Equivalents

Amitriptyline Hydrochloride Heart Health & BP Amlodipine Besylate 5mg Norvasc Antibiotics Amoxicillin 500 mg Amoxil

Step Therapy. Here s how it works:

Blue Cross KeyRx TK Preventive RX Pack Drug List Large Group Effective January 1, 2019

Preferred Covered Brands (may have a reduced copay)

CARDIOVASCULAR ACE INHIBITORS fosinopril lisinopril quinapril ramipril ACE INHIBITOR / DIURETIC COMBINATIONS fosinoprilhydrochlorothiazide

CRITERIA Trial of two generic formulary products from the following: atomoxetine or ADHD stimulant medication.

Primary/Preferred Drug List

Step Therapy Requirements. Effective: 12/01/2016

Value-Based Drug List for ABCs of Diabetes

Additional Standard Generics HSA Preventive Drug List Effective January 1, 2019

TRICARE Uniform Formulary. Pre-Authorization Requirements

Plan Year CCHP Senior Program (HMO) Step Therapy Criteria (ST)

Alprazolam 0.25mg, 0.5mg, 1mg tablets

Inhaled bronchodilators relax constricted airways and treat the noisy part of asthma: coughing, wheezing, choking and shortness of breath.

Blue Cross and Blue Shield of Minnesota GenRx Formulary Updates

ANGIOTENSIN RECEPTOR BLOCKERS

These medications will require preauthorization (PA) for HMSA Medicare Part D members.

RXSelect SM Preventive Drug List

Pequot Health Care Smart Quantity Program*

Beneficiary Advisory Panel Handout Uniform Formulary Decisions 23 June 2011

SOLID DOSAGE FORMULATIONS

WellCare Signature (PDP) and WellCare Classic (PDP) Formulary Addendum

Aetna Better Health FIDA Plan

HDHP EHB. Effective January 1, 2014

SelectHealth Advantage 2018 Step Therapy Criteria. Previous trial on at least ONE: Generic topical acne treatment. Previous trial on: alendronate

2015 Chinese Community Health Plan Senior Program (HMO) Step Therapy Criteria Last Updated 11/1/2015

Performance Drug List

Network Health Insurance Corporation Upcoming Negative Changes to the Medicare Part D Formulary

BB&T Drug Quantity Program List

5-ASA. Products Affected Dipentum 250 mg capsule. Details. Lialda 1.2 gram tablet,delayed release

ANTIDEPRESSANTS - BUPROPION

5-ASA. Products Affected DIPENTUM 250 MG CAPSULE LIALDA 1.2 GRAM TABLET,DELAYED RELEASE. Details

Transcription:

Drugs That Have Quantitiy Limits (QL) There are Quantity Limits set by your UA Medicare Group Part D Prescription Drug Plan for the drugs listed below. The UA Medicare Group Part D Prescription Drug Plan will only provide coverage up to the limits specified in the chart below. If you require a quantity more than what is specified, then you, your appointed representative, or your prescriber can request review by calling Customer Service toll-free at 1-866-524-4199, 8:00 a.m. to 8:00 p.m., in your local time zone, Monday through Friday. Customer Service is available in English and other languages. TTY/TDD users should call 1-866-524-4170. Drug Name Dosage Form Strength Tier Level Value Quantity Limit Amount Quantity Limit Days ABILIFY TABS 10MG 3 270 90 ABILIFY TABS 15MG 3 180 90 ABILIFY TABS 20MG 3 90 90 ABILIFY TABS 2MG 3 90 90 ABILIFY TABS 30MG 3 90 90 ABILIFY TABS 5MG 3 90 90 ABILIFY DISCMELT TBDP 10MG 3 270 90 ABILIFY DISCMELT TBDP 15MG 3 180 90 ACARBOSE TABS 100MG 1 270 90 ACARBOSE TABS 25MG 1 270 90 ACARBOSE TABS 50MG 1 270 90 ACCOLATE TABS 10MG 3 180 90 ACCOLATE TABS 20MG 3 180 90 ACEON TABS 2MG 2 180 90 ACEON TABS 4MG 2 180 90 ACEON TABS 8MG 2 180 90 ACTOPLUS MET TABS 500MG; 15MG 2 270 90 ACTOPLUS MET TABS 850MG; 15MG 2 270 90 ACTOS TABS 15MG 2 90 90 ACTOS TABS 30MG 2 90 90 ACTOS TABS 45MG 2 90 90 ADVAIR DISKUS MISC 100MCG/DOSE; 2 180 90 50MCG/DOSE ADVAIR DISKUS MISC 250MCG/DOSE; 2 180 90 ADVAIR DISKUS MISC 500MCG/DOSE; 50MCG/DOSE 2 180 90 ADVAIR HFA AERO 115MCG/ACT; 21MCG/ACT 2 36 90 1 Date of Last Update: 9/1/09

ADVAIR HFA AERO 230MCG/ACT; 21MCG/ACT 2 36 90 ADVAIR HFA AERO 45MCG/ACT; 21MCG/ACT 2 36 90 AFINITOR TABS 10MG 4 180 90 AFINITOR TABS 5MG 4 90 90 AGGRENOX CP12 25MG; 200MG 2 180 90 ALLEGRA-D 12 HOUR TB12 60MG; 120MG 3 180 90 ALLEGRA-D 24 HOUR TB24 180MG; 240MG 3 90 90 AMERGE TABS 1MG 2 36 90 AMERGE TABS 2.5MG 2 24 90 AMLODIPINE BESYLATE/BENAZEPRIL CAPS 10MG; 20MG 1 90 90 HYDROCHLORIDE AMLODIPINE BESYLATE/BENAZEPRIL CAPS 2.5MG; 10MG 1 90 90 HYDROCHLORIDE AMLODIPINE BESYLATE/BENAZEPRIL CAPS 5MG; 10MG 1 90 90 HYDROCHLORIDE AMLODIPINE BESYLATE/BENAZEPRIL CAPS 5MG; 20MG 1 90 90 HYDROCHLORIDE ANDRODERM PT24 2.5MG/24HR 2 60 30 ANDRODERM PT24 5MG/24HR 2 60 30 ARANESP ALBUMIN FREE SOLN 100MCG/ML 2 12 90 ARANESP ALBUMIN FREE SOLN 100MCG/0.5ML 2 6 90 ARANESP ALBUMIN FREE SOLN 150MCG/0.3ML 2 3.6 90 ARANESP ALBUMIN FREE SOLN 200MCG/0.4ML 2 4.8 90 ARANESP ALBUMIN FREE SOLN 200MCG/ML 2 12 90 ARANESP ALBUMIN FREE SOLN 25MCG/ML 2 24 90 ARANESP ALBUMIN FREE SOLN 25MCG/0.42ML 2 10.08 90 ARANESP ALBUMIN FREE SOLN 300MCG/ML 2 12 90 ARANESP ALBUMIN FREE SOLN 300MCG/0.6ML 2 7.2 90 ARANESP ALBUMIN FREE SOLN 40MCG/ML 2 24 90 ARANESP ALBUMIN FREE SOLN 40MCG/0.4ML 2 9.6 90 ARANESP ALBUMIN FREE SOLN 500MCG/ML 2 3 90 ARANESP ALBUMIN FREE SOLN 60MCG/ML 2 24 90 ARANESP ALBUMIN FREE SOLN 60MCG/0.3ML 2 7.2 90 ARICEPT TABS 10MG 2 90 90 ARICEPT TABS 5MG 2 90 90 ARICEPT ODT TBDP 10MG 2 90 90 ARICEPT ODT TBDP 5MG 2 90 90 ASMANEX 120 METERED DOSES AEPB 220MCG/INH 2 3 90 2 Date of Last Update: 9/1/09

ASMANEX 14 METERED DOSES AEPB 220MCG/INH 2 3 90 ASMANEX 30 METERED DOSES AEPB 220MCG/INH 2 3 90 ASMANEX 60 METERED DOSES AEPB 220MCG/INH 2 3 90 ATACAND TABS 16MG 2 180 90 ATACAND TABS 32MG 2 90 90 ATACAND TABS 4MG 2 90 90 ATACAND TABS 8MG 2 90 90 ATACAND HCT TABS 16MG; 12.5MG 2 90 90 ATACAND HCT TABS 32MG; 12.5MG 2 90 90 ATACAND HCT TABS 32MG; 25MG 2 90 90 ATROVENT HFA AERS 17MCG/ACT 2 77.4 90 AVALIDE TABS 12.5MG; 150MG 2 90 90 AVALIDE TABS 12.5MG; 300MG 2 90 90 AVALIDE TABS 25MG; 300MG 2 90 90 AVANDAMET TABS 1000MG; 2MG 2 180 90 AVANDAMET TABS 500MG; 2MG 2 180 90 AVANDAMET TABS 1000MG; 4MG 2 180 90 AVANDAMET TABS 500MG; 4MG 2 180 90 AVANDARYL TABS 1MG; 4MG 2 180 90 AVANDARYL TABS 2MG; 4MG 2 180 90 AVANDARYL TABS 4MG; 4MG 2 90 90 AVANDARYL TABS 2MG; 8MG 2 90 90 AVANDARYL TABS 4MG; 8MG 2 90 90 AVANDIA TABS 2MG 2 180 90 AVANDIA TABS 4MG 2 180 90 AVANDIA TABS 8MG 2 90 90 AVAPRO TABS 150MG 2 90 90 AVAPRO TABS 300MG 2 90 90 AVAPRO TABS 75MG 2 90 90 AVODART CAPS 0.5MG 2 90 90 AVONEX KIT 30MCG/VIAL 4 12 90 AVONEX KIT 30MCG/0.5ML 4 12 90 AZMACORT AERS 75MCG/ACT 3 120 90 BARACLUDE SOLN 0.05MG/ML 2 1890 90 BARACLUDE TABS 0.5MG 4 90 90 BARACLUDE TABS 1MG 4 90 90 BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE TABS 10MG; 12.5MG 1 720 90 BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE TABS 20MG; 12.5MG 1 360 90 3 Date of Last Update: 9/1/09

BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE TABS 20MG; 25MG 1 360 90 BENAZEPRIL HCL/HYDROCHLOROTHIAZIDE TABS 5MG; 6.25MG 1 1440 90 BETASERON SOLR 0.3MG 4 45 90 BIDIL TABS 37.5MG; 20MG 2 540 90 BROVANA NEBU 15MCG/2ML 3 360 90 BUDEPRION SR TB12 100MG 1 180 90 BUDEPRION SR TB12 150MG 1 180 90 BUDEPRION XL TB24 150MG 1 90 90 BUDEPRION XL TB24 300MG 1 90 90 BUPROBAN TB12 150MG 1 180 90 BUPROPION HCL SR TB12 100MG 1 180 90 BUPROPION HCL SR TB12 200MG 1 180 90 BUPROPION HCL SR TB12 150MG 1 180 90 BUTORPHANOL TARTRATE SOLN 10MG/ML 1 30 90 BYETTA SOLN 10MCG/0.04ML 3 7.2 90 CABERGOLINE TABS 0.5MG 1 48 90 CADUET TABS 10MG; 10MG 2 90 90 CADUET TABS 10MG; 20MG 2 90 90 CADUET TABS 10MG; 40MG 2 90 90 CADUET TABS 10MG; 80MG 2 90 90 CADUET TABS 2.5MG; 10MG 2 90 90 CADUET TABS 2.5MG; 20MG 2 90 90 CADUET TABS 2.5MG; 40MG 2 90 90 CADUET TABS 5MG; 10MG 2 90 90 CADUET TABS 5MG; 20MG 2 90 90 CADUET TABS 5MG; 40MG 2 90 90 CADUET TABS 5MG; 80MG 2 90 90 CALCITONIN-SALMON SOLN 200UNIT/ACT 1 12 90 CAMPRAL TBEC 333MG 2 540 90 CAPTOPRIL /HYDROCHLOROTHIAZIDE TABS 25MG; 15MG 1 90 90 CAPTOPRIL /HYDROCHLOROTHIAZIDE TABS 25MG; 25MG 1 90 90 CAPTOPRIL /HYDROCHLOROTHIAZIDE TABS 50MG; 15MG 1 90 90 CAPTOPRIL /HYDROCHLOROTHIAZIDE TABS 50MG; 25MG 1 270 90 CELEBREX CAPS 100MG 2 180 90 CELEBREX CAPS 200MG 2 180 90 CELEBREX CAPS 400MG 2 180 90 CELEBREX CAPS 50MG 2 180 90 CENESTIN TABS 0.3MG 2 90 90 4 Date of Last Update: 9/1/09

CENESTIN TABS 0.45MG 2 90 90 CENESTIN TABS 0.625MG 2 90 90 CENESTIN TABS 0.9MG 2 90 90 CENESTIN TABS 1.25MG 2 90 90 CILOSTAZOL TABS 100MG 1 180 90 CILOSTAZOL TABS 50MG 1 180 90 CITALOPRAM HYDROBROMIDE TABS 10MG 1 180 90 CITALOPRAM HYDROBROMIDE TABS 20MG 1 270 90 CITALOPRAM HYDROBROMIDE TABS 40MG 1 90 90 CLARINEX TABS 5MG 2 90 90 CLARINEX REDITABS TBDP 2.5MG 2 90 90 CLARINEX REDITABS TBDP 5MG 2 90 90 CLARINEX-D 12 HOUR TB12 2.5MG; 120MG 2 180 90 CLARINEX-D 24 HOUR TB24 5MG; 240MG 2 90 90 COMBIVENT AERO 103MCG/ACT; 18MCG/ACT 2 88.2 90 COPAXONE KIT 20MG/ML 4 90 90 COZAAR TABS 100MG 2 90 90 COZAAR TABS 25MG 2 180 90 COZAAR TABS 50MG 2 180 90 CRESTOR TABS 10MG 2 90 90 CRESTOR TABS 20MG 2 90 90 CRESTOR TABS 40MG 2 90 90 CRESTOR TABS 5MG 2 90 90 CYMBALTA CPEP 20MG 2 180 90 CYMBALTA CPEP 30MG 2 180 90 CYMBALTA CPEP 60MG 2 90 90 DETROL TABS 1MG 2 180 90 DETROL TABS 2MG 2 180 90 DETROL LA CP24 2MG 2 90 90 DETROL LA CP24 4MG 2 90 90 DIOVAN TABS 160MG 2 180 90 DIOVAN TABS 320MG 2 90 90 DIOVAN TABS 40MG 2 180 90 DIOVAN TABS 80MG 2 180 90 DIOVAN HCT TABS 12.5MG; 160MG 2 90 90 DIOVAN HCT TABS 25MG; 160MG 2 90 90 5 Date of Last Update: 9/1/09

DIOVAN HCT TABS 12.5MG; 320MG 2 90 90 DIOVAN HCT TABS 25MG; 320MG 2 90 90 DIOVAN HCT TABS 12.5MG; 80MG 2 90 90 DOXAZOSIN MESYLATE TABS 1MG 1 180 90 DOXAZOSIN MESYLATE TABS 2MG 1 180 90 DOXAZOSIN MESYLATE TABS 4MG 1 180 90 DOXAZOSIN MESYLATE TABS 8MG 1 180 90 DUETACT TABS 2MG; 30MG 2 30 30 DUETACT TABS 4MG; 30MG 2 30 30 EFFEXOR XR CP24 150MG 3 90 90 EFFEXOR XR CP24 37.5MG 3 90 90 EFFEXOR XR CP24 75MG 3 90 90 EMEND CAPS 125MG 2 6 90 EMEND CAPS 40MG 2 3 90 EMEND MISC 0 2 18 90 EMEND CAPS 80MG 2 24 90 EMSAM PT24 6MG/24HR 3 90 90 EMSAM PT24 9MG/24HR 3 90 90 EMSAM PT24 12MG/24HR 3 90 90 ENABLEX TB24 15MG 2 90 90 ENABLEX TB24 7.5MG 2 90 90 ENALAPRIL TABS 10MG; 25MG 1 180 90 MALEATE/HYDROCHLOROTHIAZIDE ENALAPRIL TABS 5MG; 12.5MG 1 90 90 MALEATE/HYDROCHLOROTHIAZIDE ENBREL KIT 25MG 4 24 90 ENBREL SOLN 50MG/ML 4 24 90 ENBREL SURECLICK SOLN 50MG/ML 4 24 90 ENJUVIA TABS 0.3MG 2 90 90 ENJUVIA TABS 0.45MG 2 90 90 ENJUVIA TABS 0.625MG 2 90 90 ENJUVIA TABS 0.9MG 2 90 90 ENJUVIA TABS 1.25MG 2 90 90 6 Date of Last Update: 9/1/09

EPOGEN SOLN 10000UNIT/ML 3 72 90 EPOGEN SOLN 2000UNIT/ML 3 36 90 EPOGEN SOLN 20000UNIT/ML 3 36 90 EPOGEN SOLN 3000UNIT/ML 3 36 90 EPOGEN SOLN 4000UNIT/ML 3 36 90 EPOGEN SOLN 40000UNIT/ML 3 12 90 EVISTA TABS 60MG 2 90 90 EXELON CAPS 1.5MG 2 180 90 EXELON CAPS 3MG 2 180 90 EXELON CAPS 4.5MG 2 180 90 EXELON CAPS 6MG 2 180 90 EXELON PT24 4.6MG/24HR 2 90 90 EXELON PT24 9.5MG/24HR 2 90 90 EXFORGE TABS 10MG; 160MG 2 90 90 EXFORGE TABS 10MG; 320MG 2 90 90 EXFORGE TABS 5MG; 160MG 2 90 90 EXFORGE TABS 5MG; 320MG 2 90 90 EXFORGE HCT TABS 5MG; 12.5MG; 160MG 2 90 90 EXFORGE HCT TABS 5MG; 25MG; 160MG 2 90 90 EXFORGE HCT TABS 10MG; 12.5MG; 160MG 2 90 90 EXFORGE HCT TABS 10MG; 25MG; 160MG 2 90 90 EXFORGE HCT TABS 10MG; 25MG; 320MG 2 90 90 FENTANYL CITRATE ORAL TRANSMUCOSAL LPOP 1200MCG 1 360 90 FENTANYL CITRATE ORAL TRANSMUCOSAL LPOP 1600MCG 1 360 90 FENTANYL CITRATE ORAL TRANSMUCOSAL LPOP 200MCG 1 360 90 FENTANYL CITRATE ORAL TRANSMUCOSAL LPOP 400MCG 1 360 90 FENTANYL CITRATE ORAL TRANSMUCOSAL LPOP 600MCG 1 360 90 7 Date of Last Update: 9/1/09

FENTANYL CITRATE ORAL TRANSMUCOSAL LPOP 800MCG 1 360 90 FEXOFENADINE HCL TABS 180MG 1 90 90 FEXOFENADINE HCL TABS 30MG 1 180 90 FEXOFENADINE HCL TABS 60MG 1 180 90 FINASTERIDE TABS 5MG 1 90 90 FLOMAX CP24 0.4MG 2 180 90 FLOVENT DISKUS AEPB 100MCG/BLIST 2 180 90 FLOVENT DISKUS AEPB 250MCG/BLIST 2 180 90 FLOVENT DISKUS AEPB 50MCG/BLIST 2 180 90 FLOVENT HFA AERO 110MCG/ACT 2 72 90 FLOVENT HFA AERO 220MCG/ACT 2 72 90 FLOVENT HFA AERO 44MCG/ACT 2 72 90 FLUOXETINE HCL CAPS 10MG 1 720 90 FLUOXETINE HCL CAPS 20MG 1 360 90 FLUOXETINE HCL CAPS 40MG 1 180 90 FLUOXETINE HCL TABS 10MG 1 720 90 FLUOXETINE HCL TABS 20MG 1 360 90 FLUVOXAMINE MALEATE TABS 100MG 1 270 90 FLUVOXAMINE MALEATE TABS 25MG 1 270 90 FLUVOXAMINE MALEATE TABS 50MG 1 270 90 FORADIL AEROLIZER CAPS 12MCG 2 180 90 FORTAMET TB24 1000MG 2 180 90 FORTAMET TB24 500MG 2 450 90 FORTEO SOLN 600MCG/2.4ML 2 7.2 90 FORTICAL SOLN 200UNIT/ACT 1 12 90 FOSINOPRIL TABS 10MG; 12.5MG 1 90 90 SODIUM/HYDROCHLOROTHIAZIDE FOSINOPRIL SODIUM/HYDROCHLOROTHIAZIDE TABS 20MG; 12.5MG 1 360 90 8 Date of Last Update: 9/1/09

GALANTAMINE HYDROBROMIDE CP24 16MG 1 90 90 GALANTAMINE HYDROBROMIDE CP24 24MG 1 90 90 GALANTAMINE HYDROBROMIDE CP24 8MG 1 90 90 GALANTAMINE HYDROBROMIDE TABS 12MG 1 180 90 GALANTAMINE HYDROBROMIDE TABS 4MG 1 180 90 GALANTAMINE HYDROBROMIDE TABS 8MG 1 180 90 GEODON CAPS 20MG 2 180 90 GEODON CAPS 40MG 2 180 90 GEODON CAPS 60MG 2 180 90 GEODON CAPS 80MG 2 180 90 GLIMEPIRIDE TABS 1MG 1 90 90 GLIMEPIRIDE TABS 2MG 1 90 90 GLIMEPIRIDE TABS 4MG 1 180 90 GLIPIZIDE TABS 10MG 1 360 90 GLIPIZIDE TABS 5MG 1 720 90 GLIPIZIDE ER TB24 2.5MG 1 90 90 GLIPIZIDE XL TB24 10MG 1 180 90 GLIPIZIDE XL TB24 5MG 1 90 90 GLIPIZIDE/METFORMIN HCL TABS 2.5MG; 250MG 1 360 90 GLIPIZIDE/METFORMIN HCL TABS 2.5MG; 500MG 1 360 90 GLIPIZIDE/METFORMIN HCL TABS 5MG; 500MG 1 360 90 GLYBURIDE MICRONIZED TABS 1.5MG 1 90 90 GLYBURIDE MICRONIZED TABS 3MG 1 90 90 GLYBURIDE MICRONIZED TABS 6MG 1 180 90 GLYBURIDE/METFORMIN HCL TABS 1.25MG; 250MG 1 180 90 GLYBURIDE/METFORMIN HCL TABS 2.5MG; 500MG 1 180 90 GLYBURIDE/METFORMIN HCL TABS 5MG; 500MG 1 360 90 GRANISETRON HCL SOLN 0.1MG/ML 1 42 90 GRANISETRON HCL SOLN 1MG/ML 1 42 90 GRANISETRON HCL TABS 1MG 1 180 90 HEPSERA TABS 10MG 4 90 90 9 Date of Last Update: 9/1/09

HUMIRA KIT 40MG/0.8ML 4 9.6 90 HYZAAR TABS 12.5MG; 100MG 2 90 90 HYZAAR TABS 25MG; 100MG 2 90 90 HYZAAR TABS 12.5MG; 50MG 2 90 90 IMITREX SOLN 6MG/0.5ML 2 12 90 INTAL INHALER AERS 800MCG/ACT 2 85.2 90 ITRACONAZOLE CAPS 100MG 1 360 90 JANUMET TABS 1000MG; 50MG 2 180 90 JANUMET TABS 500MG; 50MG 2 180 90 JANUVIA TABS 100MG 2 90 90 JANUVIA TABS 25MG 2 90 90 JANUVIA TABS 50MG 2 90 90 KAPIDEX CPDR 30MG 3 90 90 KAPIDEX CPDR 60MG 3 90 90 KETEK TABS 300MG 2 20 30 KETEK TABS 400MG 2 20 30 LEFLUNOMIDE TABS 10MG 1 90 90 LEFLUNOMIDE TABS 20MG 1 90 90 LEXAPRO TABS 10MG 2 90 90 LEXAPRO TABS 20MG 2 90 90 LEXAPRO TABS 5MG 2 90 90 LIPITOR TABS 10MG 2 90 90 LIPITOR TABS 20MG 2 90 90 LIPITOR TABS 40MG 2 90 90 LIPITOR TABS 80MG 2 90 90 LISINOPRIL /HYDROCHLOROTHIAZIDE TABS 12.5MG; 10MG 1 90 90 LISINOPRIL /HYDROCHLOROTHIAZIDE TABS 12.5MG; 20MG 1 90 90 LISINOPRIL /HYDROCHLOROTHIAZIDE TABS 25MG; 20MG 1 360 90 LOTREL CAPS 10MG; 40MG 2 90 90 LOTREL CAPS 5MG; 40MG 2 90 90 LOTRONEX TABS 0.5MG 2 180 90 LOTRONEX TABS 1MG 2 180 90 LOVASTATIN TABS 10MG 1 90 90 LOVASTATIN TABS 20MG 1 180 90 LOVASTATIN TABS 40MG 1 180 90 LYRICA CAPS 100MG 2 270 90 LYRICA CAPS 150MG 2 270 90 LYRICA CAPS 200MG 2 270 90 10 Date of Last Update: 9/1/09

LYRICA CAPS 225MG 2 180 90 LYRICA CAPS 25MG 2 270 90 LYRICA CAPS 300MG 2 180 90 LYRICA CAPS 50MG 2 270 90 LYRICA CAPS 75MG 2 180 90 MAXALT TABS 10MG 2 36 90 MAXALT TABS 5MG 2 36 90 MAXALT-MLT TBDP 10MG 2 36 90 MAXALT-MLT TBDP 5MG 2 36 90 METFORMIN HCL TABS 1000MG 1 180 90 METFORMIN HCL TABS 500MG 1 360 90 METFORMIN HCL TABS 850MG 1 270 90 METFORMIN HCL ER TB24 500MG 1 360 90 METFORMIN HCL ER TB24 750MG 1 270 90 MICARDIS TABS 20MG 2 90 90 MICARDIS TABS 40MG 2 90 90 MICARDIS TABS 80MG 2 90 90 MICARDIS HCT TABS 12.5MG; 40MG 2 90 90 MICARDIS HCT TABS 12.5MG; 80MG 2 90 90 MICARDIS HCT TABS 25MG; 80MG 2 90 90 MIGRANAL SOLN 4MG/ML 3 24 90 MIRTAZAPINE TABS 15MG 1 90 90 MIRTAZAPINE TBDP 15MG 1 90 90 MIRTAZAPINE TABS 30MG 1 90 90 MIRTAZAPINE TABS 45MG 1 90 90 MIRTAZAPINE TABS 7.5MG 1 90 90 MIRTAZAPINE ODT TBDP 30MG 1 90 90 MIRTAZAPINE ODT TBDP 45MG 1 90 90 MOEXIPRIL /HYDROCHLOROTHIAZIDE TABS 12.5MG; 15MG 1 90 90 MOEXIPRIL /HYDROCHLOROTHIAZIDE TABS 25MG; 15MG 1 180 90 MOEXIPRIL /HYDROCHLOROTHIAZIDE TABS 12.5MG; 7.5MG 1 90 90 NAMENDA TABS 10MG 3 180 90 NAMENDA TABS 5MG 3 270 90 NEFAZODONE HCL TABS 100MG 1 180 90 NEFAZODONE HCL TABS 150MG 1 180 90 NEFAZODONE HCL TABS 200MG 1 180 90 NEFAZODONE HCL TABS 250MG 1 180 90 NEFAZODONE HCL TABS 50MG 1 180 90 11 Date of Last Update: 9/1/09

NEULASTA SOLN 6MG/0.6ML 3 3.6 90 NEUMEGA SOLR 5MG 4 63 90 NEUPOGEN SOLN 300MCG/0.5ML 4 21 90 NEUPOGEN SOLN 480MCG/0.8ML 4 33.6 90 NEUPOGEN SOLN 480MCG/1.6ML 4 67.2 90 NEXAVAR TABS 200MG 4 360 90 NEXIUM CPDR 20MG 2 90 90 NEXIUM CPDR 40MG 2 90 90 NEXIUM PACK 10MG 2 90 90 NEXIUM PACK 20MG 2 90 90 NEXIUM PACK 40MG 2 90 90 NICOTROL INHALER INHA 10MG 3 504 90 OMEPRAZOLE CPDR 10MG 1 180 90 OMEPRAZOLE CPDR 20MG 1 180 90 OMEPRAZOLE CPDR 40MG 1 90 90 ONDANSETRON HCL TABS 24MG 1 21 90 ONDANSETRON HCL TABS 4MG 1 135 90 ONDANSETRON HCL TABS 8MG 1 135 90 ONDANSETRON ODT TBDP 4MG 1 135 90 ONDANSETRON ODT TBDP 8MG 1 135 90 OXYBUTYNIN CHLORIDE ER TB24 10MG 1 180 90 OXYBUTYNIN CHLORIDE ER TB24 15MG 1 180 90 OXYBUTYNIN CHLORIDE ER TB24 5MG 1 90 90 OXYTROL PTTW 3.9MG/24HR 2 32 90 PANTOPRAZOLE SODIUM TBEC 20MG 1 180 90 PANTOPRAZOLE SODIUM TBEC 40MG 1 180 90 PAROXETINE HCL TABS 10MG 1 180 90 PAROXETINE HCL TABS 20MG 1 90 90 PAROXETINE HCL TABS 30MG 1 180 90 PAROXETINE HCL TABS 40MG 1 90 90 PAROXETINE HCL ER TB24 12.5MG 1 180 90 PAROXETINE HCL ER TB24 25MG 1 270 90 PEGASYS KIT 180MCG/0.5ML 4 6 90 PEG-INTRON KIT 50MCG/0.5ML 4 12 90 PEG-INTRON REDIPEN KIT 120MCG/0.5ML 4 12 90 PEG-INTRON REDIPEN KIT 150MCG/0.5ML 4 12 90 PEG-INTRON REDIPEN KIT 50MCG/0.5ML 4 12 90 PEG-INTRON REDIPEN KIT 80MCG/0.5ML 4 12 90 12 Date of Last Update: 9/1/09

PEG-INTRON REDIPEN PAK 4 KIT 120MCG/0.5ML 4 12 90 PEG-INTRON REDIPEN PAK 4 KIT 150MCG/0.5ML 4 12 90 PEG-INTRON REDIPEN PAK 4 KIT 80MCG/0.5ML 4 12 90 PRANDIN TABS 0.5MG 2 360 90 PRANDIN TABS 1MG 2 360 90 PRANDIN TABS 2MG 2 720 90 PRAVASTATIN SODIUM TABS 10MG 1 90 90 PRAVASTATIN SODIUM TABS 20MG 1 90 90 PRAVASTATIN SODIUM TABS 40MG 1 180 90 PRAVASTATIN SODIUM TABS 80MG 1 90 90 PRAZOSIN HCL CAPS 1MG 1 360 90 PRAZOSIN HCL CAPS 2MG 1 360 90 PRAZOSIN HCL CAPS 5MG 1 360 90 PREVACID CPDR 15MG 2 180 90 PREVACID CPDR 30MG 2 180 90 PREVACID SOLUTAB TBDP 15MG 2 180 90 PREVACID SOLUTAB TBDP 30MG 2 180 90 PRISTIQ TB24 100MG 2 90 90 PRISTIQ TB24 50MG 2 90 90 PROAIR HFA AERS 108MCG/ACT 2 51 90 PROCRIT SOLN 10000UNIT/ML 2 36 90 PROCRIT SOLN 2000UNIT/ML 2 36 90 PROCRIT SOLN 20000UNIT/ML 2 36 90 PROCRIT SOLN 3000UNIT/ML 2 36 90 PROCRIT SOLN 4000UNIT/ML 2 36 90 PROCRIT SOLN 40000UNIT/ML 2 12 90 PROMACTA TABS 25MG 4 270 90 PROMACTA TABS 50MG 4 90 90 PROVENTIL HFA AERS 108MCG/ACT 2 41 90 PROVIGIL TABS 100MG 2 90 90 PROVIGIL TABS 200MG 2 90 90 PULMICORT FLEXHALER AEPB 180MCG/ACT 2 6 90 PULMICORT FLEXHALER AEPB 90MCG/ACT 2 6 90 QUINAPRIL /HYDROCHLOROTHIAZIDE TABS 12.5MG; 10MG 1 90 90 QUINAPRIL /HYDROCHLOROTHIAZIDE TABS 12.5MG; 20MG 1 90 90 QUINAPRIL /HYDROCHLOROTHIAZIDE TABS 25MG; 20MG 1 90 90 QUINARETIC TABS 12.5MG; 10MG 1 90 90 QUINARETIC TABS 12.5MG; 20MG 1 90 90 13 Date of Last Update: 9/1/09

QUINARETIC TABS 25MG; 20MG 1 90 90 QVAR AERS 40MCG/ACT 2 66 90 QVAR AERS 80MCG/ACT 2 66 90 REBIF SOLN 22MCG/0.5ML 4 18 90 REBIF SOLN 44MCG/0.5ML 4 18 90 RELENZA DISKHALER AEPB 5MG/BLISTER 2 280 365 RELPAX TABS 20MG 2 36 90 RELPAX TABS 40MG 2 36 90 REVATIO TABS 20MG 4 270 90 RISPERDAL M-TAB TBDP 1MG 2 180 90 RISPERIDONE TABS 0.25MG 1 180 90 RISPERIDONE TABS 0.5MG 1 180 90 RISPERIDONE TABS 1MG 1 180 90 RISPERIDONE TABS 2MG 1 180 90 RISPERIDONE TABS 3MG 1 180 90 RISPERIDONE TABS 4MG 1 180 90 RISPERIDONE ODT TBDP 0.25MG 1 180 90 RISPERIDONE ODT TBDP 0.5MG 1 180 90 RISPERIDONE ODT TBDP 2MG 1 180 90 RISPERIDONE ODT TBDP 3MG 1 180 90 RISPERIDONE ODT TBDP 4MG 1 180 90 SANCTURA TABS 20MG 2 180 90 SANCTURA XR CP24 60MG 2 90 90 SELFEMRA CAPS 10MG 1 720 90 SELFEMRA CAPS 20MG 1 360 90 SEREVENT DISKUS AEPB 50MCG/DOSE 2 180 90 SEROQUEL TABS 100MG 2 270 90 SEROQUEL TABS 200MG 2 270 90 SEROQUEL TABS 25MG 2 180 90 SEROQUEL TABS 300MG 2 180 90 SEROQUEL TABS 400MG 2 180 90 SEROQUEL TABS 50MG 2 270 90 SEROQUEL XR TB24 150MG 2 180 90 SEROQUEL XR TB24 200MG 2 270 90 SEROQUEL XR TB24 300MG 2 180 90 14 Date of Last Update: 9/1/09

SEROQUEL XR TB24 400MG 2 180 90 SEROQUEL XR TB24 50MG 2 270 90 SERTRALINE HCL TABS 100MG 1 180 90 SERTRALINE HCL TABS 25MG 1 180 90 SERTRALINE HCL TABS 50MG 1 270 90 SIMVASTATIN TABS 10MG 1 90 90 SIMVASTATIN TABS 20MG 1 90 90 SIMVASTATIN TABS 40MG 1 90 90 SIMVASTATIN TABS 5MG 1 90 90 SIMVASTATIN TABS 80MG 1 90 90 SINGULAIR CHEW 4MG 2 90 90 SINGULAIR CHEW 5MG 2 90 90 SINGULAIR PACK 4MG 2 90 90 SINGULAIR TABS 10MG 2 90 90 SKELID TABS 240MG 3 180 90 SOMAVERT SOLR 10MG 2 90 90 SOMAVERT SOLR 15MG 2 90 90 SOMAVERT SOLR 20MG 2 90 90 SPIRIVA HANDIHALER CAPS 18MCG 2 90 90 SPRYCEL TABS 100MG 4 180 90 SPRYCEL TABS 20MG 4 360 90 SPRYCEL TABS 50MG 4 270 90 SPRYCEL TABS 70MG 4 180 90 STARLIX TABS 120MG 2 270 90 STARLIX TABS 60MG 2 270 90 SUMATRIPTAN SUCCINATE SOLN 6MG/0.5ML 1 12 90 SUMATRIPTAN SUCCINATE TABS 25MG 1 54 90 SUMATRIPTAN SUCCINATE TABS 50MG 1 54 90 SUMATRIPTAN SUCCINATE TABS 100MG 1 27 90 SUTENT CAPS 12.5MG 4 360 90 SUTENT CAPS 25MG 4 180 90 SUTENT CAPS 50MG 4 90 90 SYMBICORT AERO 160MCG/ACT; 4.5MCG/ACT 2 30.6 90 SYMBICORT AERO 80MCG/ACT; 4.5MCG/ACT 2 30.6 90 SYMBYAX CAPS 25MG; 12MG 3 90 90 SYMBYAX CAPS 50MG; 12MG 3 90 90 15 Date of Last Update: 9/1/09

SYMBYAX CAPS 25MG; 3MG 3 90 90 SYMBYAX CAPS 25MG; 6MG 3 90 90 SYMBYAX CAPS 50MG; 6MG 3 90 90 SYMLIN SOLN 600MCG/ML 3 60 90 SYMLINPEN 60 SOLN 1000MCG/ML 3 33 90 TAMIFLU CAPS 30MG 2 20 365 TAMIFLU CAPS 45MG 2 20 365 TAMIFLU CAPS 75MG 2 56 365 TARCEVA TABS 100MG 4 90 90 TARCEVA TABS 150MG 4 90 90 TARCEVA TABS 25MG 4 180 90 TEKTURNA TABS 150MG 2 90 90 TEKTURNA TABS 300MG 2 90 90 TEKTURNA HCT TABS 150MG; 12.5MG 2 90 90 TEKTURNA HCT TABS 150MG; 25MG 2 90 90 TEKTURNA HCT TABS 300MG; 12.5MG 2 90 90 TEKTURNA HCT TABS 300MG; 25MG 2 90 90 TERAZOSIN HCL CAPS 10MG 1 180 90 TERAZOSIN HCL CAPS 1MG 1 180 90 TERAZOSIN HCL CAPS 2MG 1 180 90 TERAZOSIN HCL CAPS 5MG 1 180 90 TERBINAFINE HCL TABS 250MG 1 90 90 TICLOPIDINE HCL TABS 250MG 1 180 90 TYKERB TABS 250MG 4 450 90 TYZEKA TABS 600MG 4 90 90 UROXATRAL TB24 10MG 2 90 90 VALTREX TABS 1GM 2 90 90 VALTREX TABS 500MG 2 180 90 VENLAFAXINE HCL TABS 100MG 1 270 90 VENLAFAXINE HCL TABS 25MG 1 270 90 VENLAFAXINE HCL TABS 37.5MG 1 270 90 VENLAFAXINE HCL TABS 50MG 1 270 90 VENLAFAXINE HCL TABS 75MG 1 270 90 VENTOLIN HFA AERS 108MCG/ACT 2 108 90 VESICARE TABS 10MG 2 90 90 VESICARE TABS 5MG 2 90 90 VFEND SUSR 40MG/ML 2 900 90 VFEND TABS 200MG 2 180 90 16 Date of Last Update: 9/1/09

VFEND TABS 50MG 2 360 90 VIDAZA SUSR 100MG 4 4200 90 VYTORIN TABS 10MG; 10MG 2 90 90 VYTORIN TABS 10MG; 20MG 2 90 90 VYTORIN TABS 10MG; 40MG 2 90 90 VYTORIN TABS 10MG; 80MG 2 90 90 XIFAXAN TABS 200MG 3 9 30 ZETIA TABS 10MG 2 90 90 ZOMIG SOLN 5MG 2 36 90 ZOMIG TABS 2.5MG 2 36 90 ZOMIG TABS 5MG 2 27 90 ZOMIG ZMT TBDP 2.5MG 2 36 90 ZOMIG ZMT TBDP 5MG 2 27 90 ZYFLO CR TB12 600MG 3 360 90 ZYPREXA TABS 10MG 2 90 90 ZYPREXA TABS 15MG 2 90 90 ZYPREXA TABS 2.5MG 2 90 90 ZYPREXA TABS 20MG 2 90 90 ZYPREXA TABS 5MG 2 90 90 ZYPREXA TABS 7.5MG 2 90 90 ZYPREXA ZYDIS TBDP 10MG 2 90 90 ZYPREXA ZYDIS TBDP 15MG 2 90 90 ZYPREXA ZYDIS TBDP 20MG 2 90 90 ZYPREXA ZYDIS TBDP 5MG 2 90 90 ZYVOX SUSR 100MG/5ML 2 1800 30 ZYVOX TABS 600MG 2 56 30 17 Date of Last Update: 9/1/09

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback