Comprehensive Formulary 2018 (List of Covered Drugs) THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN Indiana University Health Plans Medicare Select Plus HMO 009-001 Indiana University Health Plans Medicare Select Plus HMO 009-002 Indiana University Health Plans Medicare Select Plus HMO 009-003 Indiana University Health Plans Medicare Choice HMO POS 004 950 N. Meridian St., Suite 400 Indianapolis, IN 46204-1202 This comprehensive formulary was updated on 09.01.2018. For more recent information or other questions, please contact us, IU Health Plans, Pharmacy Member Services, at 866.823.1016 or, for TTY users, 800.743.3333, Oct. 1 to Feb. 14 8 am to 8 pm, seven days a week; Feb. 15 to Sept. 30 8 am to 8 pm, Monday Friday, or visit iuhealthplans.org. Indiana University Health Plans is a Medicare Advantage organization with a Medicare contract. Enrollment in Indiana University Health Plans depends on contract renewal. Other pharmacies/physicians/providers are available in our network. Product types include HMO and HMO POS. 2017 IUHealth 8/17 IUH#25005 H7220_IUHMA18131 Accepted 8.4.2017
Indiana University Health Plans 2018 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved Formulary File Submission ID, 18425 Version Number 13.0 This formulary was updated on 09.01.2018. For more recent information or other questions, please contact us, IU Health Plans Pharmacy Member Services, at 844.432.0695 or, for TTY users, 800.743.3333, 24 hours a day, 7 days a week, or visit iuhealthplans.org. Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means IU Health Plans. When it refers to plan or our plan, it means IU Health Plans. This document includes a list of the drugs (formulary) for our plan which is current as of 09.01.2018. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2019, and from time to time during the year. Indiana University Health Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Indiana University Health Plans does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Indiana University Health Plans: 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) i
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 Allison Shelton If you believe that Indiana University Health Plans 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: Allison Shelton, Civil Rights Coordinator, Indiana University Health Plans, 950 N. Meridian St., Suite 400, Indianapolis, IN 46204, (317) 963-9788, TTY (800) 743-3333, (317) 963-9801, ashelton@iuhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Allison Shelton, 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. What is the IU Health Plans Formulary? A formulary is a list of covered drugs selected by IU Health Plans in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. IU Health Plans will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an IU Health Plans network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. ii
If we remove drugs from our formulary, or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 09.01.2018. To get updated information about the drugs covered by IU Health Plans, please contact us. Our contact information appears on the front and back cover pages. How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 131. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? IU Health Plans covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: IU Health Plans requires you [or your physician] to get prior authorization for certain drugs. This means that you will need to get approval from IU Health Plans before you fill your prescriptions. If you don t get approval, IU Health Plans may not cover the drug. iii
Quantity Limits: For certain drugs, IU Health Plans limits the amount of the drug that IU Health Plans will cover. For example, IU Health Plans provides 10 patches per prescription for fentanyl 50 mcg/hr patches. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, IU Health Plans requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, IU Health Plans may not cover Drug B unless you try Drug A first. If Drug A does not work for you, IU Health Plans will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask IU Health Plans to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the IU Health Plans formulary? on page V for information about how to request an exception. What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Pharmacy Member Services and ask if your drug is covered. If you learn that IU Health Plans does not cover your drug, you have two options: You can ask Pharmacy Member Services for a list of similar drugs that are covered by IU Health Plans. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by IU Health Plans. You can ask IU Health Plans to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the IU Health Plans Formulary? You can ask IU Health Plans to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. iv
You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level. You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, IU Health Plans limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, IU Health Plans will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you request a formulary or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with up to a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a v
31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception. For more information For more detailed information about your IU Health Plans prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about IU Health Plans, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800- MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov. IU Health Plans Formulary The formulary below provides coverage information about the drugs covered by IU Health Plans. If you have trouble finding your drug in the list, turn to the Index that begins on page 131. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., XARELTO) and generic drugs are listed in lower-case italics (e.g., amoxicillin). The information in the Requirements/Limits column tells you if IU Health Plans has any special requirements for coverage of your drug. IU Health Plans drug tiers and cost-sharing amounts after the annual deductible of $200 (excludes Tiers 1, 2, & 6) for 2018: IU Health Plans Choice Drug Tier 30 Day Copay 90 Day Copay 1 Preferred Generic drugs* $6 $18 2 Generic drugs $12 $36 3 Preferred Brand and some Generic drugs $45 $135 4 Non-Preferred Brand and some Generic drugs $100 $300 5 Specialty drugs 29% 29% (maximum 30- day supply) 6 Select Care Drugs $0 $0 * We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about NOTE: Drugs are provided in a Long-term Care Facility for up to a 31-day supply. vi
IU Health Plans drug tiers and cost-sharing amounts after the annual deductible of $200 (excludes Tiers 1, 2, & 6) for 2018: IU Health Plans Select Plus Drug Tier 30 Day Copay 90 Day Copay 1 Preferred Generic drugs $6 $18 2 Generic drugs $15 $45 3 Preferred Brand and some Generic drugs $47 $141 4 Non-Preferred Brand and some Generic drugs $100 $300 5 Specialty drugs 29% 29% (maximum 30- day supply) 6 Select Care Drugs $0 $0 NOTE: Drugs are provided in a Long-term Care Facility for up to a 31-day supply. List of Abbreviations GC: Gap Coverage*. We provide additional coverage of this prescription drug in the Coverage Gap. Please refer to our Evidence of Coverage for more information about B/D: This prescription may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, please call Customer Service. NM: Not Available at Mail-Order. This prescription drug is not available through our mail-order service. Consider using mail order for your long-term (maintenance) medications (such as high blood pressure medications). Retail network pharmacies may be more appropriate for short-term prescriptions (such as antibiotics). PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you don t get approval, we may not cover the drug. QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. vii
ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. DL: Day Supply Limit. For certain drugs, we will only cover up to a 30 day supply at a time. viii
ANALGESICS GOUT allopurinol sodium for inj 500 mg 2 allopurinol tab 100 mg 2 allopurinol tab 300 mg 2 colchicine w/ probenecid tab 0.5-500 mg 2 COLCRYS TAB 0.6MG 3 probenecid tab 500 mg 2 ULORIC TAB 40MG 3 QL (30 tabs / 30 days), ST ULORIC TAB 80MG 3 QL (30 tabs / 30 days), ST ZURAMPIC TAB 200MG 4 PA MISCELLANEOUS clonidine hcl inj (for epidural infusion) 100 2 B/D mcg/ml clonidine hcl inj (for epidural infusion) 500 2 B/D mcg/ml PRIALT INJ 25MCG/ML 4 NM PRIALT INJ 100MCG 4 NM NSAIDS celecoxib cap 50 mg 3 celecoxib cap 100 mg 3 celecoxib cap 200 mg 3 celecoxib cap 400 mg 3 diclofenac potassium tab 50 mg 2 diclofenac sodium tab delayed release 25 4 mg diclofenac sodium tab delayed release 50 2 mg diclofenac sodium tab delayed release 75 2 mg diclofenac sodium tab er 24hr 100 mg 2 diflunisal tab 500 mg 4 etodolac cap 200 mg 4 etodolac cap 300 mg 4 etodolac tab 400 mg 4 etodolac tab 500 mg 4 fenoprofen calcium tab 600 mg 2 1
flurbiprofen tab 50 mg 2 flurbiprofen tab 100 mg 2 ibu tab 600mg 1 GC ibu tab 800mg 1 GC ibuprofen susp 100 mg/5ml 1 GC ibuprofen tab 400 mg 1 GC ibuprofen tab 600 mg 1 GC ibuprofen tab 800 mg 1 GC ketoprofen cap 75 mg 2 meclofenamate sodium cap 50 mg 4 meclofenamate sodium cap 100 mg 4 meloxicam tab 7.5 mg 1 GC meloxicam tab 15 mg 1 GC nabumetone tab 500 mg 2 nabumetone tab 750 mg 2 naproxen dr tab 375mg 2 naproxen dr tab 500mg 2 naproxen sodium tab 275 mg 1 GC naproxen sodium tab 550 mg 1 GC naproxen susp 125 mg/5ml 1 GC naproxen tab 250 mg 1 GC naproxen tab 375 mg 1 GC naproxen tab 500 mg 1 GC piroxicam cap 10 mg 3 piroxicam cap 20 mg 3 salsalate tab 500 mg 2 salsalate tab 750 mg 2 sulindac tab 150 mg 2 sulindac tab 200 mg 2 tolmetin sodium cap 400 mg 4 tolmetin sodium tab 200 mg 2 tolmetin sodium tab 600 mg 4 OPIOID ANALGESICS acetaminophen w/ codeine soln 120-12 mg/5ml 2 QL (4500 ml / 30 days) acetaminophen w/ codeine tab 300-15 mg 2 QL (390 tabs / 30 days) acetaminophen w/ codeine tab 300-30 mg 2 QL (390 tabs / 30 days) acetaminophen w/ codeine tab 300-60 mg 2 QL (180 tabs / 30 days) ascomp/cod cap 30mg 4 QL (180 caps / 30 days) 2
butalbital-acetaminophen-caff w/ cod cap 4 QL (180 caps / 30 days) 50-325-40-30 mg butalbital-aspirin-caff w/ codeine cap 50-4 QL (180 caps / 30 days) 325-40-30 mg butorphanol tartrate inj 1 mg/ml 2 QL (720 ml / 30 days) butorphanol tartrate inj 2 mg/ml 2 QL (360 ml / 30 days) butorphanol tartrate nasal soln 10 mg/ml 4 QL (40 ml / 30 days) nalbuphine hcl inj 10 mg/ml 4 QL (200 ml / 30 days) nalbuphine hcl inj 20 mg/ml 4 QL (100 ml / 30 days) tramadol hcl tab 50 mg 2 QL (240 tabs / 30 days) tramadol-acetaminophen tab 37.5-325 mg 2 QL (40 tabs / 5 days) OPIOID ANALGESICS, CII ABSTRAL SUB 100MCG 5 QL (120 tabs / 30 days), PA; DL ABSTRAL SUB 200MCG 5 QL (120 tabs / 30 days), PA; DL ABSTRAL SUB 300MCG 5 QL (120 tabs / 30 days), PA; DL ABSTRAL SUB 400MCG 5 QL (116 tabs / 30 days), PA; DL ABSTRAL SUB 600MCG 5 QL (77 tabs / 30 days), PA; DL ABSTRAL SUB 800MCG 5 QL (58 tabs / 30 days), PA; DL codeine sulfate tab 15 mg 2 QL (180 tabs / 30 days) codeine sulfate tab 30 mg 2 QL (180 tabs / 30 days) codeine sulfate tab 60 mg 2 QL (180 tabs / 30 days) duramorph inj 0.5mg/ml 4 QL (400 ampules / 30 days) duramorph inj 1mg/ml 4 QL (200 ampules / 30 days) endocet tab 2.5-325 2 QL (360 tabs / 30 days) endocet tab 5-325mg 2 QL (360 tabs / 30 days) endocet tab 7.5-325 2 QL (360 tabs / 30 days) endocet tab 10-325mg 2 QL (360 tabs / 30 days) FENTANYL CIT INJ 100MCG 3 fentanyl citrate inj 0.05 mg/ml 3 fentanyl citrate lozenge on a handle 200 mcg 5 QL (120 lozenges / 30 days), PA; DL 3
fentanyl citrate lozenge on a handle 400 mcg 5 QL (116 lozenges / 30 days), PA; DL fentanyl citrate lozenge on a handle 600 mcg 5 QL (77 lozenges / 30 days), PA; DL fentanyl citrate lozenge on a handle 800 mcg 5 QL (58 lozenges / 30 days), PA; DL fentanyl citrate lozenge on a handle 1200 mcg 5 QL (39 lozenges / 30 days), PA; DL fentanyl citrate lozenge on a handle 1600 mcg 5 QL (29 lozenges / 30 days), PA; DL fentanyl citrate pf soln cartridge 100 3 mcg/2ml fentanyl citrate preservative free (pf) inj 3 100 mcg/2ml fentanyl td patch 72hr 12 mcg/hr 3 QL (10 patches / 30 days) fentanyl td patch 72hr 25 mcg/hr 3 QL (10 patches / 30 days) fentanyl td patch 72hr 50 mcg/hr 3 QL (10 patches / 30 days) fentanyl td patch 72hr 75 mcg/hr 3 QL (10 patches / 30 days) fentanyl td patch 72hr 100 mcg/hr 3 QL (10 patches / 30 days) FENTORA TAB 100MCG 5 QL (120 tabs / 30 days), PA; DL FENTORA TAB 200MCG 5 QL (120 tabs / 30 days), PA; DL FENTORA TAB 400MCG 5 QL (116 tabs / 30 days), PA; DL FENTORA TAB 600MCG 5 QL (77 tabs / 30 days), PA; DL FENTORA TAB 800MCG 5 QL (58 tabs / 30 days), PA; DL hydrocodone-acetaminophen soln 7.5-325 4 QL (3600 ml / 30 days) mg/15ml hydrocodone-acetaminophen soln 10-325 4 mg/15ml hydrocodone-acetaminophen tab 2.5-325 mg 2 QL (360 tabs / 30 days) hydrocodone-acetaminophen tab 5-300 mg 4 QL (390 tabs / 30 days) 4
hydrocodone-acetaminophen tab 5-325 mg 2 QL (360 tabs / 30 days) hydrocodone-acetaminophen tab 7.5-300 4 QL (390 tabs / 30 days) mg hydrocodone-acetaminophen tab 7.5-325 2 QL (360 tabs / 30 days) mg hydrocodone-acetaminophen tab 10-300 4 QL (390 tabs / 30 days) mg hydrocodone-acetaminophen tab 10-325 2 QL (360 tabs / 30 days) mg hydrocodone-ibuprofen tab 7.5-200 mg 2 QL (150 tabs / 30 days) hydromorphone hcl inj 1 mg/ml 4 hydromorphone hcl inj 2 mg/ml 4 QL (150 ml / 30 days) hydromorphone hcl inj 4 mg/ml 4 hydromorphone hcl preservative free (pf) 4 QL (150 vials / 30 days) inj 10 mg/ml hydromorphone hcl preservative free (pf) 4 QL (30 vials / 30 days) inj 10 mg/ml hydromorphone hcl tab 2 mg 2 QL (180 tabs / 30 days) hydromorphone hcl tab 4 mg 2 QL (180 tabs / 30 days) hydromorphone hcl tab 8 mg 4 QL (180 tabs / 30 days) LAZANDA SPR 100MCG 5 QL (45 units / 30 days), PA; DL LAZANDA SPR 300MCG 5 QL (16 units / 30 days), PA; DL LAZANDA SPR 400MCG 5 QL (30 units / 30 days), PA; DL levorphanol tartrate tab 2 mg 5 QL (240 tabs / 30 days); DL lorcet hd tab 10-325mg 2 QL (360 tabs / 30 days) lorcet plus tab 7.5-325 2 QL (360 tabs / 30 days) lorcet tab 5-325mg 2 QL (360 tabs / 30 days) methadone hcl conc 10 mg/ml 2 methadone hcl inj 10 mg/ml 2 QL (160 ml / 30 days) methadone hcl soln 5 mg/5ml 2 QL (2000 ml / 30 days) methadone hcl soln 10 mg/5ml 4 QL (1000 ml / 30 days) methadone hcl tab 5 mg 2 QL (90 tabs / 30 days) methadone hcl tab 10 mg 2 QL (200 tabs / 30 days) methadone hcl tab for oral susp 40 mg 2 METHADOSE CON 10MG/ML 2 MORPHINE SUL INJ 2MG/ML 2 QL (1000 ml / 30 days) 5
MORPHINE SUL INJ 4MG/ML 2 QL (500 ml / 30 days) MORPHINE SUL INJ 5MG/ML 2 QL (400 ml / 30 days) MORPHINE SUL INJ 150/30ML 2 morphine sulfate iv soln 1 mg/ml 2 morphine sulfate iv soln pf 10 mg/ml 2 morphine sulfate iv soln pf 15 mg/ml 2 morphine sulfate oral soln 10 mg/5ml 2 QL (900 ml / 30 days) morphine sulfate oral soln 20 mg/5ml 2 QL (900 ml / 30 days) morphine sulfate oral soln 100 mg/5ml (20 2 QL (300 ml / 30 days) mg/ml) morphine sulfate tab 15 mg 2 QL (180 tabs / 30 days) morphine sulfate tab 30 mg 2 QL (180 tabs / 30 days) morphine sulfate tab er 15 mg 2 QL (90 tabs / 30 days) morphine sulfate tab er 30 mg 2 QL (90 tabs / 30 days) morphine sulfate tab er 60 mg 2 QL (90 tabs / 30 days) morphine sulfate tab er 100 mg 2 QL (60 tabs / 30 days) morphine sulfate tab er 200 mg 2 QL (30 tabs / 30 days) oxycodone hcl cap 5 mg 2 QL (180 caps / 30 days) oxycodone hcl conc 100 mg/5ml (20 4 QL (180 ml / 30 days) mg/ml) oxycodone hcl soln 5 mg/5ml 2 QL (900 ml / 30 days) oxycodone hcl tab 5 mg 2 QL (180 tabs / 30 days) oxycodone hcl tab 10 mg 2 QL (180 tabs / 30 days) oxycodone hcl tab 15 mg 4 QL (180 tabs / 30 days) oxycodone hcl tab 20 mg 4 QL (180 tabs / 30 days) oxycodone hcl tab 30 mg 4 QL (134 tabs / 30 days) oxycodone w/ acetaminophen tab 2.5-325 2 QL (360 tabs / 30 days) mg oxycodone w/ acetaminophen tab 5-325 mg 2 QL (360 tabs / 30 days) oxycodone w/ acetaminophen tab 7.5-325 2 QL (360 tabs / 30 days) mg oxycodone w/ acetaminophen tab 10-325 2 QL (360 tabs / 30 days) mg oxycodone-aspirin tab 4.8355-325 mg 4 QL (360 tabs / 30 days) oxycodone-ibuprofen tab 5-400 mg 4 QL (120 tabs / 30 days) oxymorphone hcl tab 5 mg 4 QL (180 tabs / 30 days) oxymorphone hcl tab 10 mg 4 QL (180 tabs / 30 days) oxymorphone hcl tab er 12hr 5 mg 4 QL (60 tabs / 30 days) 6
oxymorphone hcl tab er 12hr 7.5 mg 4 QL (60 tabs / 30 days) oxymorphone hcl tab er 12hr 10 mg 4 QL (60 tabs / 30 days) oxymorphone hcl tab er 12hr 15 mg 4 QL (60 tabs / 30 days) oxymorphone hcl tab er 12hr 20 mg 4 QL (60 tabs / 30 days) oxymorphone hcl tab er 12hr 30 mg 4 QL (60 tabs / 30 days) oxymorphone hcl tab er 12hr 40 mg 4 QL (50 tabs / 30 days) SUBSYS SPR 100MCG 5 QL (120 sprays / 30 days), PA; DL SUBSYS SPR 200MCG 5 QL (120 sprays / 30 days), PA; DL SUBSYS SPR 400MCG 5 QL (84 sprays / 30 days), PA; DL SUBSYS SPR 600MCG 5 QL (56 sprays / 30 days), PA; DL SUBSYS SPR 800MCG 5 QL (42 sprays / 30 days), PA; DL SUBSYS SPR 1200MCG 5 QL (77 sprays / 30 days), PA; DL SUBSYS SPR 1600MCG 5 QL (58 sprays / 30 days), PA; DL PSYCHOTHERAPEUTIC-MISC buprenorphine hcl inj 0.3 mg/ml (base 4 QL (267 ml / 30 days) equiv) TALWIN INJ 30MG/ML 4 ANESTHETICS LOCAL ANESTHETICS lidocaine hcl local inj 1% 2 lidocaine hcl local inj 2% 2 lidocaine hcl local preservative free (pf) inj 2 0.5% lidocaine hcl local preservative free (pf) inj 2 1% lidocaine hcl local preservative free (pf) inj 2 1.5% lidocaine hcl local preservative free (pf) inj 2 2% lidocaine hcl local preservative free (pf) inj 2 4% ropivacaine hcl inj 2 mg/ml 2 ropivacaine hcl inj 5 mg/ml 2 7
ropivacaine hcl inj 7.5 mg/ml 2 ropivacaine hcl inj 10 mg/ml 2 ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate inj 1 gm/4ml (250 mg/ml) 3 amikacin sulfate inj 500 mg/2ml (250 3 mg/ml) BETHKIS NEB 300/4ML 5 B/D, NM; DL gentamicin in saline inj 0.8 mg/ml 2 gentamicin in saline inj 1 mg/ml 2 gentamicin in saline inj 1.2 mg/ml 2 gentamicin in saline inj 1.6 mg/ml 2 gentamicin sulfate inj 40 mg/ml 2 neomycin sulfate tab 500 mg 2 paromomycin sulfate cap 250 mg 2 streptomycin sulfate for inj 1 gm 4 SULFADIAZINE TAB 500MG 2 TOBI PODHALR CAP 28MG 5 QL (224 caps / 56 days), NM; DL tobramycin nebu soln 300 mg/5ml 5 B/D, NM; DL tobramycin sulfate inj 10 mg/ml (base 2 equivalent) tobramycin sulfate inj 80 mg/2ml (40 2 mg/ml) (base equiv) ANTI-INFECTIVES - MISCELLANEOUS ALBENZA TAB 200MG 3 ALINIA SUS 100/5ML 4 ALINIA TAB 500MG 5 QL (40 tabs / 30 days); DL atovaquone susp 750 mg/5ml 5 DL AZACTAM INJ 2GM 4 aztreonam for inj 1 gm 4 aztreonam for inj 2 gm 4 baciim inj 50000unt 2 bacitracin intramuscular for soln 50000 2 unit BILTRICIDE TAB 600MG 3 CAYSTON INH 75MG 5 QL (84 vials / 56 days), NM, LA; DL 8
chloramphenicol sodium succinate for iv inj 2 1 gm clindamycin hcl cap 75 mg 2 clindamycin hcl cap 150 mg 2 clindamycin hcl cap 300 mg 2 clindamycin palmitate hcl for soln 75 2 mg/5ml (base equiv) clindamycin phosphate in d5w iv soln 300 2 mg/50ml clindamycin phosphate in d5w iv soln 600 2 mg/50ml clindamycin phosphate in d5w iv soln 900 2 mg/50ml clindamycin phosphate iv soln 300 mg/2ml 2 clindamycin phosphate iv soln 900 mg/6ml 2 colistimethate sod for inj 150 mg (colistin 2 base activity) DALVANCE SOL 500MG 5 DL dapsone tab 25 mg 3 dapsone tab 100 mg 3 daptomycin for iv soln 500 mg 5 DL DARAPRIM TAB 25MG 4 doripenem for iv infusion 500 mg 4 imipenem-cilastatin intravenous for soln 2 250 mg imipenem-cilastatin intravenous for soln 2 500 mg INVANZ INJ 1GM 4 ivermectin tab 3 mg 2 LINCOCIN INJ 300MG/ML 4 lincomycin hcl inj 300 mg/ml 4 linezolid for susp 100 mg/5ml 5 DL linezolid iv soln 600 mg/300ml (2 mg/ml) 5 DL linezolid tab 600 mg 5 DL meropenem iv for soln 1 gm 2 meropenem iv for soln 500 mg 2 methenamine hippurate tab 1 gm 2 methenamine mandelate tab 0.5 gm 2 methenamine mandelate tab 1 gm 2 metronidazole cap 375 mg 3 9
metronidazole in nacl 0.79% iv soln 500 2 mg/100ml metronidazole tab 250 mg 2 metronidazole tab 500 mg 2 MONUROL PAK GRANULES 4 NEBUPENT INH 300MG 4 B/D nitrofurantoin macrocrystalline cap 50 mg 2 nitrofurantoin macrocrystalline cap 100 mg 2 nitrofurantoin monohydrate 2 macrocrystalline cap 100 mg ORBACTIV SOL 400MG 5 DL PENTAM 300 INJ 300MG 4 polymyxin b sulfate for inj 500000 unit 2 SIVEXTRO INJ 200MG 5 QL (6 vials / 30 days); DL SIVEXTRO TAB 200MG 5 QL (6 tabs / 30 days); DL sulfamethoxazole-trimethoprim iv soln 2 400-80 mg/5ml sulfamethoxazole-trimethoprim susp 200-1 GC 40 mg/5ml sulfamethoxazole-trimethoprim tab 400-80 1 GC mg sulfamethoxazole-trimethoprim tab 800-1 GC 160 mg SYNERCID INJ 500MG 5 DL tigecycline for iv soln 50 mg 5 DL tinidazole tab 250 mg 3 tinidazole tab 500 mg 3 trimethoprim tab 100 mg 2 vancomycin hcl cap 125 mg 5 DL vancomycin hcl cap 250 mg 5 DL vancomycin hcl for inj 10 gm 3 vancomycin hcl for inj 500 mg 3 vancomycin hcl for inj 1000 mg 3 XIFAXAN TAB 200MG 4 QL (9 tabs / 3 days) ANTIFUNGALS ABELCET INJ 5MG/ML 5 B/D; DL AMBISOME INJ 50MG 5 B/D; DL amphotericin b for inj 50 mg 4 B/D 10
caspofungin acetate for iv soln 50 mg 5 B/D; DL caspofungin acetate for iv soln 70 mg 5 B/D; DL CRESEMBA CAP 186 MG 5 DL CRESEMBA INJ 372MG 5 DL ERAXIS INJ 50MG 4 ERAXIS INJ 100MG 4 fluconazole for susp 10 mg/ml 2 fluconazole for susp 40 mg/ml 2 fluconazole in nacl 0.9% inj 200 mg/100ml 2 fluconazole in nacl 0.9% inj 400 mg/200ml 2 fluconazole tab 50 mg 2 fluconazole tab 100 mg 2 fluconazole tab 150 mg 2 fluconazole tab 200 mg 2 flucytosine cap 250 mg 5 DL flucytosine cap 500 mg 5 DL griseofulvin microsize susp 125 mg/5ml 4 griseofulvin microsize tab 500 mg 4 griseofulvin ultramicrosize tab 125 mg 4 griseofulvin ultramicrosize tab 250 mg 4 itraconazole cap 100 mg 4 QL (120 caps / 30 days), PA ketoconazole tab 200 mg 2 MYCAMINE INJ 50MG 5 DL MYCAMINE INJ 100MG 5 DL NOXAFIL SUS 40MG/ML 5 PA; DL NOXAFIL TAB 100MG 5 QL (93 tabs / 30 days), PA; DL nystatin tab 500000 unit 2 terbinafine hcl tab 250 mg 1 GC voriconazole for inj 200 mg 2 voriconazole for susp 40 mg/ml 5 DL voriconazole tab 50 mg 5 DL voriconazole tab 200 mg 5 DL ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg 2 atovaquone-proguanil hcl tab 250-100 mg 2 chloroquine phosphate tab 250 mg 2 chloroquine phosphate tab 500 mg 2 11
COARTEM TAB 20-120MG 3 mefloquine hcl tab 250 mg 2 PRIMAQUINE TAB 26.3MG 3 quinine sulfate cap 324 mg 2 PA ANTIRETROVIRAL AGENTS abacavir sulfate soln 20 mg/ml (base 4 equiv) abacavir sulfate tab 300 mg (base equiv) 2 APTIVUS CAP 250MG 5 DL APTIVUS SOL 5 DL atazanavir sulfate cap 150 mg (base equiv) 5 DL atazanavir sulfate cap 200 mg (base equiv) 5 DL atazanavir sulfate cap 300 mg (base equiv) 5 DL CRIXIVAN CAP 200MG 3 CRIXIVAN CAP 400MG 3 didanosine delayed release capsule 200 mg 2 didanosine delayed release capsule 250 mg 2 didanosine delayed release capsule 400 mg 2 EDURANT TAB 25MG 5 DL efavirenz cap 50 mg 4 efavirenz cap 200 mg 4 efavirenz tab 600 mg 5 DL EMTRIVA CAP 200MG 3 EMTRIVA SOL 10MG/ML 3 fosamprenavir calcium tab 700 mg (base 5 DL equiv) FUZEON INJ 90MG 5 NM; DL INTELENCE TAB 25MG 4 INTELENCE TAB 100MG 5 DL INTELENCE TAB 200MG 5 DL INVIRASE CAP 200MG 4 INVIRASE TAB 500MG 5 DL ISENTRESS CHW 25MG 3 ISENTRESS CHW 100MG 3 ISENTRESS HD TAB 600MG 5 DL ISENTRESS POW 100MG 3 ISENTRESS TAB 400MG 5 DL JULUCA TAB 50-25MG 5 QL (30 tabs / 30 days); DL 12
lamivudine oral soln 10 mg/ml 2 lamivudine tab 150 mg 2 lamivudine tab 300 mg 2 LEXIVA SUS 50MG/ML 4 nevirapine tab 200 mg 2 nevirapine tab er 24hr 100 mg 2 nevirapine tab er 24hr 400 mg 2 NORVIR CAP 100MG 4 NORVIR POW 100MG 4 NORVIR SOL 80MG/ML 4 NORVIR TAB 100MG 4 PREZISTA SUS 100MG/ML 4 PREZISTA TAB 75MG 4 PREZISTA TAB 150MG 4 PREZISTA TAB 600MG 5 DL PREZISTA TAB 800MG 5 DL RESCRIPTOR TAB 100 MG 4 RESCRIPTOR TAB 200MG 4 RETROVIR INJ 10MG/ML 4 REYATAZ CAP 150MG 5 DL REYATAZ CAP 200MG 5 DL REYATAZ CAP 300MG 5 DL REYATAZ POW 50MG 5 DL ritonavir tab 100 mg 4 SELZENTRY SOL 20MG/ML 5 DL SELZENTRY TAB 25MG 4 SELZENTRY TAB 75MG 5 DL SELZENTRY TAB 150MG 5 DL SELZENTRY TAB 300MG 5 DL stavudine cap 15 mg 2 stavudine cap 20 mg 2 stavudine cap 30 mg 2 stavudine cap 40 mg 2 SUSTIVA CAP 200MG 4 SUSTIVA TAB 600MG 5 DL tenofovir disoproxil fumarate tab 300 mg 5 DL TIVICAY TAB 10MG 4 TIVICAY TAB 25MG 5 DL TIVICAY TAB 50MG 5 DL 13
TYBOST TAB 150MG 3 VIDEX EC CAP 125MG 3 VIDEX SOL 4GM 4 VIRACEPT TAB 250MG 5 DL VIRACEPT TAB 625MG 5 DL VIRAMUNE SUS 50MG/5ML 4 VIREAD POW 40MG/GM 5 DL VIREAD TAB 150MG 5 DL VIREAD TAB 200MG 5 DL VIREAD TAB 250MG 5 DL VIREAD TAB 300MG 5 DL ZERIT SOL 1MG/ML 4 ZIAGEN SOL 20MG/ML 4 zidovudine cap 100 mg 2 zidovudine syrup 10 mg/ml 2 zidovudine tab 300 mg 2 ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine tab 600-300 mg 5 DL abacavir sulfate-lamivudine-zidovudine tab 5 DL 300-150-300 mg ATRIPLA TAB 5 DL BIKTARVY TAB 5 DL COMPLERA TAB 5 DL DESCOVY TAB 200/25 5 DL EVOTAZ TAB 300-150 5 DL GENVOYA TAB 5 DL KALETRA TAB 100-25MG 4 KALETRA TAB 200-50MG 5 DL lamivudine-zidovudine tab 150-300 mg 4 lopinavir-ritonavir soln 400-100 mg/5ml 4 (80-20 mg/ml) ODEFSEY TAB 5 DL PREZCOBIX TAB 800-150 5 DL STRIBILD TAB 5 DL SYMFI LO TAB 5 DL SYMFI TAB 5 DL TRIUMEQ TAB 5 DL TRUVADA TAB 100-150 5 DL 14
TRUVADA TAB 133-200 5 DL TRUVADA TAB 167-250 5 DL TRUVADA TAB 200-300 5 DL ANTITUBERCULAR AGENTS CAPASTAT SUL INJ 1GM 4 ethambutol hcl tab 100 mg 2 ethambutol hcl tab 400 mg 2 isoniazid inj 100 mg/ml 2 isoniazid syrup 50 mg/5ml 1 GC isoniazid tab 100 mg 1 GC isoniazid tab 300 mg 1 GC PASER GRA 4GM 4 PRIFTIN TAB 150MG 4 pyrazinamide tab 500 mg 2 rifabutin cap 150 mg 4 RIFAMATE CAP 4 rifampin cap 150 mg 2 rifampin cap 300 mg 2 rifampin for inj 600 mg 2 RIFATER TAB 4 SIRTURO TAB 100MG 5 LA, PA; DL TRECATOR TAB 250MG 4 ANTIVIRALS acyclovir cap 200 mg 1 GC acyclovir sodium iv soln 50 mg/ml 2 B/D acyclovir susp 200 mg/5ml 4 acyclovir tab 400 mg 2 acyclovir tab 800 mg 2 adefovir dipivoxil tab 10 mg 5 PA; DL BARACLUDE SOL.05MG/ML 4 PA cidofovir iv inj 75 mg/ml 5 B/D; DL entecavir tab 0.5 mg 5 PA; DL entecavir tab 1 mg 5 PA; DL EPCLUSA TAB 400-100 5 QL (28 tabs / 28 days), EPIVIR HBV SOL 5MG/ML 4 famciclovir tab 125 mg 2 famciclovir tab 250 mg 2 famciclovir tab 500 mg 2 15
foscarnet sodium inj 24 mg/ml 2 B/D ganciclovir sodium for inj 500 mg 2 B/D HARVONI TAB 90-400MG 5 QL (28 tabs / 28 days), lamivudine tab 100 mg (hbv) 2 MAVYRET TAB 100-40MG 5 QL (84 tabs / 28 days), MODERIBA PAK 800/DAY 5 NM; DL MODERIBA PAK 1200/DAY 5 NM; DL moderiba tab 200mg 2 NM MODERIBA TAB 600/DAY 5 NM; DL MODERIBA TAB 1000/DAY 5 NM; DL oseltamivir phosphate cap 30 mg (base 3 QL (84 caps / 180 days) equiv) oseltamivir phosphate cap 45 mg (base 3 QL (42 caps / 180 days) equiv) oseltamivir phosphate cap 75 mg (base 3 QL (42 caps / 180 days) equiv) oseltamivir phosphate for susp 6 mg/ml 3 QL (525 ml / 180 days) (base equiv) PEGASYS INJ 5 QL (4 injections / 28 days), NM; DL PEGASYS INJ 180MCG/M 5 QL (4 injections / 28 days), NM; DL PEGASYS INJ PROCLICK 5 QL (4 injections / 28 days), NM; DL REBETOL SOL 40MG/ML 5 NM; DL RELENZA MIS DISKHALE 3 QL (120 blisters / 365 days) ribasphere cap 200mg 2 NM ribasphere tab 200mg 4 NM ribasphere tab 400mg 4 NM ribasphere tab 600mg 5 NM; DL ribavirin cap 200 mg 2 NM ribavirin tab 200 mg 2 NM rimantadine hydrochloride tab 100 mg 2 SOVALDI TAB 400MG 5 QL (30 tabs / 30 days), valacyclovir hcl tab 1 gm 3 valacyclovir hcl tab 500 mg 3 16
valganciclovir hcl for soln 50 mg/ml (base 5 DL equiv) valganciclovir hcl tab 450 mg (base 5 DL equivalent) VEMLIDY TAB 25MG 5 PA; DL VOSEVI TAB 5 QL (28 tabs / 28 days), ZEPATIER TAB 50-100MG 5 QL (28 tabs / 28 days), CEPHALOSPORINS AVYCAZ INJ 2-0.5GM 5 DL cefaclor cap 250 mg 2 cefaclor cap 500 mg 2 CEFACLOR ER TAB 500MG 2 cefadroxil cap 500 mg 2 cefadroxil for susp 250 mg/5ml 2 cefadroxil for susp 500 mg/5ml 2 cefadroxil tab 1 gm 2 cefazolin sodium for inj 1 gm 2 cefazolin sodium for inj 10 gm 2 cefazolin sodium for inj 500 mg 2 cefdinir cap 300 mg 2 cefdinir for susp 125 mg/5ml 2 cefdinir for susp 250 mg/5ml 2 cefepime hcl for inj 1 gm 3 cefepime hcl for inj 2 gm 3 cefotaxime sodium for inj 1 gm 2 cefotaxime sodium for inj 2 gm 2 cefotaxime sodium for inj 10 gm 2 cefotaxime sodium for inj 500 mg 2 cefotetan disodium for inj 1 gm 2 cefotetan disodium for inj 2 gm 2 cefotetan disodium for inj 10 gm 2 cefoxitin sodium for inj 10 gm 2 cefoxitin sodium for iv soln 1 gm 2 cefoxitin sodium for iv soln 2 gm 2 cefpodoxime proxetil for susp 50 mg/5ml 4 cefpodoxime proxetil for susp 100 mg/5ml 4 cefpodoxime proxetil tab 100 mg 4 17
cefpodoxime proxetil tab 200 mg 4 cefprozil for susp 125 mg/5ml 2 cefprozil for susp 250 mg/5ml 2 cefprozil tab 250 mg 2 cefprozil tab 500 mg 2 ceftazidime for inj 1 gm 2 ceftazidime for inj 2 gm 2 ceftazidime for inj 6 gm 2 ceftibuten cap 400 mg 2 ceftibuten for susp 180 mg/5ml 2 ceftriaxone sodium for inj 1 gm 2 ceftriaxone sodium for inj 2 gm 2 ceftriaxone sodium for inj 10 gm 4 ceftriaxone sodium for inj 250 mg 2 ceftriaxone sodium for inj 500 mg 2 cefuroxime axetil tab 250 mg 2 cefuroxime axetil tab 500 mg 2 cefuroxime sodium for inj 750 mg 2 cefuroxime sodium for iv soln 1.5 gm 2 cephalexin cap 250 mg 1 GC cephalexin cap 500 mg 1 GC cephalexin cap 750 mg 4 cephalexin for susp 125 mg/5ml 1 GC cephalexin for susp 250 mg/5ml 1 GC cephalexin tab 250 mg 1 GC cephalexin tab 500 mg 1 GC SUPRAX CAP 400MG 4 SUPRAX CHW 100MG 4 SUPRAX CHW 200MG 4 TEFLARO INJ 400MG 4 TEFLARO INJ 600MG 5 DL ZERBAXA INJ 1.5GM 5 DL ERYTHROMYCINS/MACROLIDES azithromycin for susp 100 mg/5ml 2 azithromycin for susp 200 mg/5ml 2 azithromycin iv for soln 500 mg 2 azithromycin powd pack for susp 1 gm 2 azithromycin tab 250 mg 2 azithromycin tab 500 mg 2 18
azithromycin tab 600 mg 2 clarithromycin for susp 125 mg/5ml 3 clarithromycin for susp 250 mg/5ml 3 clarithromycin tab 250 mg 2 clarithromycin tab 500 mg 2 clarithromycin tab er 24hr 500 mg 2 DIFICID TAB 200MG 5 QL (20 tabs / 10 days), ST; DL e.e.s. 400 tab 400mg 4 E.E.S. GRAN SUS 200/5ML 4 ery-tab tab 250mg ec 4 ery-tab tab 333mg ec 4 ery-tab tab 500mg ec 4 ERYTHROCIN INJ 500MG 4 erythrocin tab 250mg 4 erythromycin ethylsuccinate for susp 200 4 mg/5ml erythromycin ethylsuccinate tab 400 mg 4 erythromycin tab 250 mg 4 erythromycin tab 500 mg 4 erythromycin w/ delayed release particles 2 cap 250 mg FLUOROQUINOLONES AVELOX INJ 4 ciprofloxacin 200 mg/100ml in d5w 2 ciprofloxacin 400 mg/200ml in d5w 2 ciprofloxacin hcl tab 100 mg (base equiv) 1 GC ciprofloxacin hcl tab 250 mg (base equiv) 1 GC ciprofloxacin hcl tab 500 mg (base equiv) 1 GC ciprofloxacin hcl tab 750 mg (base equiv) 1 GC ciprofloxacin iv soln 200 mg/20ml (1%) 2 ciprofloxacin-ciprofloxacin hcl tab er 24hr 2 QL (28 tabs / 30 days) 500 mg (base eq) ciprofloxacin-ciprofloxacin hcl tab er 24hr 2 QL (14 tabs / 30 days) 1000 mg(base eq) levofloxacin in d5w iv soln 250 mg/50ml 2 levofloxacin in d5w iv soln 500 mg/100ml 2 levofloxacin in d5w iv soln 750 mg/150ml 2 levofloxacin iv soln 25 mg/ml 2 19
levofloxacin oral soln 25 mg/ml 3 levofloxacin tab 250 mg 2 levofloxacin tab 500 mg 2 levofloxacin tab 750 mg 2 moxifloxacin hcl 400 mg/250ml in sodium 4 chloride 0.8% inj moxifloxacin hcl tab 400 mg (base equiv) 3 ofloxacin tab 300 mg 2 ofloxacin tab 400 mg 2 PENICILLINS amoxicillin & k clavulanate chew tab 200-2 28.5 mg amoxicillin & k clavulanate chew tab 400-2 57 mg amoxicillin & k clavulanate for susp 200-2 28.5 mg/5ml amoxicillin & k clavulanate for susp 250-4 62.5 mg/5ml amoxicillin & k clavulanate for susp 400-57 2 mg/5ml amoxicillin & k clavulanate for susp 600-2 42.9 mg/5ml amoxicillin & k clavulanate tab 250-125 mg 4 amoxicillin & k clavulanate tab 500-125 mg 2 amoxicillin & k clavulanate tab 875-125 mg 2 amoxicillin & k clavulanate tab er 12hr 4 1000-62.5 mg amoxicillin (trihydrate) cap 250 mg 1 GC amoxicillin (trihydrate) cap 500 mg 1 GC amoxicillin (trihydrate) chew tab 125 mg 1 GC amoxicillin (trihydrate) chew tab 250 mg 1 GC amoxicillin (trihydrate) for susp 125 1 GC mg/5ml amoxicillin (trihydrate) for susp 200 1 GC mg/5ml amoxicillin (trihydrate) for susp 250 1 GC mg/5ml amoxicillin (trihydrate) for susp 400 1 GC mg/5ml amoxicillin (trihydrate) tab 500 mg 1 GC 20
amoxicillin (trihydrate) tab 875 mg 1 GC ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm 2 ampicillin & sulbactam sodium for inj 3 (2-2 1) gm ampicillin & sulbactam sodium for inj 15 2 (10-5) gm ampicillin cap 500 mg 2 ampicillin sodium for inj 1 gm 2 ampicillin sodium for inj 2 gm 2 ampicillin sodium for inj 125 mg 2 ampicillin sodium for inj 250 mg 2 ampicillin sodium for inj 500 mg 2 ampicillin sodium for iv soln 2 gm 2 ampicillin sodium for iv soln 10 gm 2 BACTOCILL INJ DEX 1GM 2 BACTOCILL INJ DEX 2GM 5 DL BICILLIN C-R INJ 900/300 4 BICILLIN C-R INJ 1200000 4 BICILLIN L-A INJ 600000 4 BICILLIN L-A INJ 1200000 4 BICILLIN L-A INJ 2400000 4 dicloxacillin sodium cap 250 mg 2 dicloxacillin sodium cap 500 mg 2 nafcillin sodium for inj 1 gm 4 nafcillin sodium for inj 2 gm 4 nafcillin sodium for iv soln 2 gm 4 nafcillin sodium for iv soln 10 gm 5 DL oxacillin sodium for inj 1 gm (base 2 equivalent) oxacillin sodium for inj 2 gm (base 2 equivalent) oxacillin sodium for inj 10 gm (base 5 DL equivalent) PEN G PROC INJ 600000 2 PENICILL GK/ INJ DEX 2MU 4 PENICILL GK/ INJ DEX 3MU 4 penicillin g potassium for inj 20000000 unit 2 penicillin g sodium for inj 5000000 unit 5 DL 21
penicillin v potassium for soln 125 mg/5ml 1 GC penicillin v potassium for soln 250 mg/5ml 1 GC penicillin v potassium tab 250 mg 1 GC penicillin v potassium tab 500 mg 1 GC pfizerpen inj 20mu 2 piperacillin sod-tazobactam na for inj 3.3754 gm (3-0.375 gm) piperacillin sod-tazobactam sod for inj 2.25 4 gm (2-0.25 gm) piperacillin sod-tazobactam sod for inj 4.5 4 gm (4-0.5 gm) piperacillin sod-tazobactam sod for inj 40.5 4 gm (36-4.5 gm) ZOSYN SOL 2-0.25GM 4 ZOSYN SOL 3-0.375G 4 ZOSYN SOL 4-0.50GM 4 TETRACYCLINES doxy 100 inj 100mg 2 doxycycline hyclate cap 50 mg 3 doxycycline hyclate cap 100 mg 4 doxycycline hyclate tab 20 mg 2 doxycycline hyclate tab 100 mg 4 doxycycline monohydrate cap 50 mg 2 doxycycline monohydrate cap 100 mg 2 doxycycline monohydrate for susp 25 4 mg/5ml doxycycline monohydrate tab 50 mg 2 doxycycline monohydrate tab 75 mg 2 doxycycline monohydrate tab 100 mg 4 doxycycline monohydrate tab 150 mg 4 minocycline hcl cap 50 mg 2 minocycline hcl cap 75 mg 2 minocycline hcl cap 100 mg 2 morgidox cap 1x50mg 3 tetracycline hcl cap 250 mg 4 tetracycline hcl cap 500 mg 4 VIBRAMYCIN SYP 50MG/5ML 4 ANTINEOPLASTIC AGENTS ALKYLATING AGENTS 22
BENDEKA INJ 100/4ML 5 NM; DL BICNU INJ 100MG 4 busulfan inj 6 mg/ml 5 DL cyclophosphamide cap 25 mg 4 B/D cyclophosphamide cap 50 mg 4 B/D cyclophosphamide for inj 1 gm 4 B/D cyclophosphamide for inj 2 gm 4 B/D cyclophosphamide for inj 500 mg 4 B/D dacarbazine for inj 100 mg 2 dacarbazine for inj 200 mg 2 EMCYT CAP 140MG 4 PA GLEOSTINE CAP 10MG 4 PA GLEOSTINE CAP 40MG 4 PA GLEOSTINE CAP 100MG 4 PA HEXALEN CAP 50MG 5 DL ifosfamide for inj 1 gm 2 IFOSFAMIDE INJ 3GM 2 ifosfamide iv inj 1 gm/20ml (50 mg/ml) 2 ifosfamide iv inj 3 gm/60ml (50 mg/ml) 2 LEUKERAN TAB 2MG 4 melphalan hcl for inj 50 mg (base equiv) 5 DL MUSTARGEN INJ 10MG 4 TEMODAR INJ 100MG 5 NM; DL thiotepa for inj 15 mg 5 NM; DL TREANDA INJ 25MG 5 NM; DL TREANDA INJ 100MG 5 NM; DL ZANOSAR INJ 1GM 4 ANTHRACYCLINES adriamycin inj 20mg 2 doxorubicin hcl for inj 10 mg 2 doxorubicin hcl for inj 50 mg 2 doxorubicin hcl inj 2 mg/ml 2 doxorubicin hcl liposomal inj (for iv 5 DL infusion) 2 mg/ml epirubicin hcl iv soln 50 mg/25ml (2 2 mg/ml) epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) 2 ANTIBIOTICS 23
bleomycin sulfate for inj 15 unit 2 bleomycin sulfate for inj 30 unit 2 B/D dactinomycin for inj 0.5 mg 5 DL daunorubicin hcl inj 5 mg/ml (base equiv) 2 idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 5 DL mitomycin for iv soln 5 mg 5 DL mitomycin for iv soln 20 mg 5 DL mitomycin for iv soln 40 mg 5 DL VALSTAR SOL 40MG/ML 5 NM; DL ANTIMETABOLITES adrucil inj 500/10ml 2 B/D ALIMTA INJ 100MG 5 DL ALIMTA INJ 500MG 5 DL ARRANON INJ 5MG/ML 5 DL azacitidine for inj 100 mg 5 NM; DL cladribine iv soln 10 mg/10ml (1 mg/ml) 5 B/D; DL clofarabine iv soln 1 mg/ml 5 DL cytarabine inj 20 mg/ml 2 B/D cytarabine inj pf 20 mg/ml 2 B/D cytarabine inj pf 100 mg/ml 2 B/D decitabine for inj 50 mg 5 NM; DL floxuridine for inj 0.5 gm 2 fludarabine phosphate for inj 50 mg 2 fludarabine phosphate inj 25 mg/ml 2 fluorouracil iv soln 1 gm/20ml (50 mg/ml) 2 fluorouracil iv soln 5 gm/100ml (50 mg/ml) 2 B/D FOLOTYN INJ 40MG/2ML 5 NM; DL gemcitabine hcl for inj 1 gm 5 DL gemcitabine hcl for inj 2 gm 5 DL gemcitabine hcl for inj 200 mg 5 DL gemcitabine hcl inj 1 gm/26.3ml (38 5 DL mg/ml) (base equiv) gemcitabine hcl inj 2 gm/52.6ml (38 5 DL mg/ml) (base equiv) gemcitabine hcl inj 200 mg/5.26ml (38 5 DL mg/ml) (base equiv) mercaptopurine tab 50 mg 2 methotrexate sodium for inj 1 gm 2 B/D 24
methotrexate sodium inj 250 mg/10ml (25 2 B/D mg/ml) methotrexate sodium inj pf 50 mg/2ml (25 2 B/D mg/ml) methotrexate sodium inj pf 250 mg/10ml 2 B/D (25 mg/ml) NIPENT INJ 10MG 5 DL PURIXAN SUS 20MG/ML 5 TABLOID TAB 40MG 4 PA VYXEOS INJ 44-100MG 5 B/D, NM; DL ANTIMITOTIC, TAXOIDS ABRAXANE INJ 100MG 5 DL DOCETAXEL INJ 80MG/4ML 5 DL docetaxel soln for iv infusion 160 mg/16ml 5 DL JEVTANA INJ 60/1.5ML 5 NM; DL paclitaxel iv conc 100 mg/16.7ml (6 2 mg/ml) ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate inj 1 mg/ml 2 B/D vincasar pfs inj 1mg/ml 2 B/D vincristine sulfate iv soln 1 mg/ml 2 B/D vinorelbine tartrate inj 10 mg/ml (base 2 equiv) vinorelbine tartrate inj 50 mg/5ml (10 2 mg/ml) (base equiv) BIOLOGIC RESPONSE MODIFIERS ARZERRA CON 100/5ML 5 B/D, NM; DL AVASTIN INJ 5 NM; DL AVASTIN INJ 400/16ML 5 NM; DL BAVENCIO INJ 20MG/ML 5 BELEODAQ INJ 500MG 5 NM; DL BLINCYTO INJ 35MCG 5 NM; DL BORTEZOMIB INJ 3.5MG 5 NM; DL CAMPATH INJ 30MG/ML 5 DL CYRAMZA INJ 100/10ML 5 B/D, NM; DL CYRAMZA INJ 500/50ML 5 B/D, NM; DL DARZALEX SOL 100MG/5M 5 NM, LA; DL DARZALEX SOL 400MG/20 5 NM, LA; DL EMPLICITI INJ 300MG 5 B/D, NM; DL 25
EMPLICITI INJ 400MG 5 B/D, NM; DL ERBITUX INJ 100MG 5 NM; DL ERBITUX INJ 200MG 5 NM; DL ERIVEDGE CAP 150MG 5 QL (30 caps / 30 days), FARYDAK CAP 10MG 5 QL (12 caps / 21 days), FARYDAK CAP 15MG 5 QL (12 caps / 21 days), FARYDAK CAP 20MG 5 QL (6 caps / 21 days), GAZYVA INJ 25MG/ML 5 NM; DL HERCEPTIN INJ 150MG 5 NM; DL HERCEPTIN INJ 440MG 5 NM; DL IBRANCE CAP 75MG 5 QL (42 caps / 28 days), IBRANCE CAP 100MG 5 QL (42 caps / 28 days), IBRANCE CAP 125MG 5 QL (21 caps / 28 days), IDHIFA TAB 50MG 5 QL (30 tabs / 30 days), NM, LA, PA; DL IDHIFA TAB 100MG 5 QL (30 tabs / 30 days), NM, LA, PA; DL IMFINZI INJ 120/2.4 5 NM; DL IMFINZI INJ 500/10 5 NM; DL ISTODAX OVR INJ 10MG 5 NM; DL KADCYLA INJ 100MG 5 NM; DL KADCYLA INJ 160MG 5 NM; DL KEYTRUDA INJ 100MG/4M 5 NM; DL KISQALI 200 PAK FEMARA 5 QL (49 tabs / 28 days), KISQALI 400 PAK FEMARA 5 QL (70 tabs / 28 days), KISQALI 600 PAK FEMARA 5 QL (91 tabs / 28 days), KISQALI TAB 200DOSE 5 QL (63 tabs / 28 days), KISQALI TAB 400DOSE 5 QL (63 tabs / 28 days), 26
KISQALI TAB 600DOSE 5 QL (63 tabs / 28 days), KYPROLIS SOL 30MG 5 NM; DL KYPROLIS SOL 60MG 5 NM; DL LARTRUVO INJ 10MG/ML 5 NM, LA; DL LARTRUVO INJ 190/19ML 5 NM, LA; DL LYNPARZA CAP 50MG 5 QL (480 caps / 30 days), LYNPARZA TAB 100MG 5 QL (180 tabs / 30 days), NM, LA, PA; DL LYNPARZA TAB 150MG 5 QL (120 tabs / 30 days), NM, LA, PA; DL MYLOTARG INJ 4.5MG 5 NM, LA; DL NINLARO CAP 2.3MG 5 QL (6 caps / 28 days), NINLARO CAP 3MG 5 QL (6 caps / 28 days), NINLARO CAP 4MG 5 QL (3 caps / 28 days), ODOMZO CAP 200MG 5 QL (30 caps / 30 days), NM, LA, PA; DL OPDIVO INJ 40MG/4ML 5 NM; DL OPDIVO INJ 100MG/10 5 NM; DL PERJETA INJ 420/14ML 5 NM; DL PORTRAZZA INJ 800/50ML 5 B/D, NM; DL RITUXAN INJ 100MG 5 NM, LA, PA; DL RITUXAN INJ 500MG 5 RUBRACA TAB 200MG 5 NM, LA, PA; DL RUBRACA TAB 250MG 5 NM, LA, PA; DL RUBRACA TAB 300MG 5 NM, LA, PA; DL TECENTRIQ INJ 1200/20 5 NM, LA; DL TORISEL SOL 25MG/ML 5 NM; DL UNITUXIN INJ 5 NM; DL VECTIBIX INJ 100MG 5 B/D, NM; DL VECTIBIX INJ 400MG 5 B/D, NM; DL VELCADE INJ 3.5MG 5 NM; DL VENCLEXTA TAB 10MG 4 QL (1200 tabs / 30 days), NM, LA, PA VENCLEXTA TAB 50MG 4 QL (240 tabs / 30 days), NM, LA, PA 27
VENCLEXTA TAB 100MG 5 QL (120 tabs / 30 days), NM, LA, PA; DL VENCLEXTA TAB START PK 5 QL (42 tabs / 30 days), NM, LA, PA; DL VERZENIO TAB 50MG 5 QL (56 tabs / 28 days), NM, LA, PA; DL VERZENIO TAB 100MG 5 QL (56 tabs / 28 days), NM, LA, PA; DL VERZENIO TAB 150MG 5 QL (56 tabs / 28 days), NM, LA, PA; DL VERZENIO TAB 200MG 5 QL (56 tabs / 28 days), NM, LA, PA; DL YERVOY INJ 50MG 5 NM; DL YERVOY INJ 200MG 5 NM; DL ZALTRAP INJ 100/4ML 5 NM; DL ZALTRAP INJ 200/8ML 5 NM; DL ZEJULA CAP 100MG 5 QL (90 caps / 30 days), ZOLINZA CAP 100MG 5 QL (120 caps / 30 days), DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) methotrexate sodium inj 25 mg/ml 2 B/D HORMONAL ANTINEOPLASTIC AGENTS anastrozole tab 1 mg 2 bicalutamide tab 50 mg 2 DEPO-PROVERA INJ 400/ML 4 ELIGARD INJ 7.5MG 4 QL (1 kit / 28 days), NM, PA ELIGARD INJ 22.5MG 4 QL (1 kit / 84 days), NM, PA ELIGARD INJ 30MG 4 QL (1 kit / 112 days), NM, PA ELIGARD INJ 45MG 4 QL (1 kit / 168 days), NM, PA ERLEADA TAB 60MG 5 NM, LA, PA; DL exemestane tab 25 mg 4 FARESTON TAB 60MG 5 PA; DL FASLODEX INJ 250/5ML 5 DL FIRMAGON INJ 80MG 4 QL (12 vials / 28 days), NM, PA 28
FIRMAGON INJ 120MG 5 QL (4 vials / 365 days), flutamide cap 125 mg 2 hydroxyprogesterone caproate im in oil 5 PA; DL 1.25 gm/5ml letrozole tab 2.5 mg 2 leuprolide acetate inj kit 5 mg/ml 2 NM, PA LUPRON DEPOT INJ 3.75MG 5 QL (1 kit / 28 days), LUPRON DEPOT INJ 7.5MG 5 QL (1 kit / 28 days), LUPRON DEPOT INJ 11.25MG 5 QL (1 kit / 84 days), LUPRON DEPOT INJ 22.5MG 5 QL (1 kit / 84 days), LUPRON DEPOT INJ 30MG 5 QL (1 kit / 84 days), LUPRON DEPOT INJ 45MG 5 QL (1 kit / 168 days), LYSODREN TAB 500MG 5 DL megestrol acetate susp 40 mg/ml 3 PA megestrol acetate tab 20 mg 3 PA megestrol acetate tab 40 mg 3 PA nilutamide tab 150 mg 5 DL SOLTAMOX SOL 10MG/5ML 4 tamoxifen citrate tab 10 mg (base 2 equivalent) tamoxifen citrate tab 20 mg (base 2 equivalent) TRELSTAR MIX INJ 3.75MG 5 QL (1 injection / 28 days), TRELSTAR MIX INJ 11.25MG 5 QL (1 injection / 84 days), TRELSTAR MIX INJ 22.5MG 5 QL (1 injection / 168 days), XTANDI CAP 40MG 5 QL (120 caps / 30 days), ZYTIGA TAB 250MG 5 QL (120 tabs / 30 days), ZYTIGA TAB 500MG 5 QL (60 tabs / 30 days), NM, LA, PA; DL 29
IMMUNOMODULATORS POMALYST CAP 1MG 5 QL (84 caps / 28 days), POMALYST CAP 2MG 5 QL (42 caps / 28 days), POMALYST CAP 3MG 5 QL (42 caps / 28 days), POMALYST CAP 4MG 5 QL (21 caps / 28 days), REVLIMID CAP 2.5MG 5 QL (210 caps / 28 days), NM, LA, PA; DL REVLIMID CAP 5MG 5 QL (105 caps / 28 days), NM, LA, PA; DL REVLIMID CAP 10MG 5 QL (63 caps / 28 days), NM, LA, PA; DL REVLIMID CAP 15MG 5 QL (42 caps / 28 days), NM, LA, PA; DL REVLIMID CAP 20MG 5 QL (42 caps / 28 days), NM, LA, PA; DL REVLIMID CAP 25MG 5 QL (21 caps / 28 days), NM, LA, PA; DL SYLVANT SOL 100MG 5 SYLVANT SOL 400MG 5 THALOMID CAP 50MG 5 THALOMID CAP 100MG 5 THALOMID CAP 150MG 5 QL (90 caps / 30 days), THALOMID CAP 200MG 5 QL (60 caps / 30 days), KINASE INHIBITORS AFINITOR DIS TAB 2MG 5 AFINITOR DIS TAB 3MG 5 AFINITOR DIS TAB 5MG 5 AFINITOR TAB 2.5MG 5 QL (120 tabs / 30 days), AFINITOR TAB 5MG 5 QL (60 tabs / 30 days), AFINITOR TAB 7.5MG 5 QL (60 tabs / 30 days), 30
AFINITOR TAB 10MG 5 QL (30 tabs / 30 days), ALECENSA CAP 150MG 5 QL (240 caps / 30 days), ALIQOPA INJ 60MG 5 NM, LA; DL ALUNBRIG PAK 5 QL (60 tabs / 365 days), NM, LA, PA; DL ALUNBRIG TAB 30MG 5 QL (180 tabs / 30 days), ALUNBRIG TAB 90MG 5 QL (60 tabs / 30 days), NM, LA, PA; DL ALUNBRIG TAB 180MG 5 QL (30 tabs / 30 days), NM, LA, PA; DL BOSULIF TAB 100MG 5 QL (180 tabs / 30 days), BOSULIF TAB 400MG 5 QL (30 tabs / 30 days), BOSULIF TAB 500MG 5 QL (60 tabs / 30 days), CABOMETYX TAB 20MG 5 QL (90 tabs / 30 days), NM, LA, PA; DL CABOMETYX TAB 40MG 5 QL (60 tabs / 30 days), NM, LA, PA; DL CABOMETYX TAB 60MG 5 QL (30 tabs / 30 days), NM, LA, PA; DL CALQUENCE CAP 100MG 5 QL (60 caps / 30 days), NM, LA, PA; DL CAPRELSA TAB 100MG 3 QL (90 tabs / 30 days), NM, LA, PA CAPRELSA TAB 300MG 3 QL (30 tabs / 30 days), NM, LA, PA COMETRIQ KIT 60MG 5 QL (252 caps / 28 days), COMETRIQ KIT 100MG 5 QL (112 caps / 28 days), COMETRIQ KIT 140MG 5 QL (112 caps / 28 days), COTELLIC TAB 20MG 5 QL (63 tabs / 28 days), NM, LA, PA; DL GILOTRIF TAB 20MG 5 QL (60 tabs / 30 days), 31
GILOTRIF TAB 30MG 5 QL (60 tabs / 30 days), GILOTRIF TAB 40MG 5 QL (30 tabs / 30 days), ICLUSIG TAB 15MG 5 QL (90 tabs / 30 days), ICLUSIG TAB 45MG 5 QL (30 tabs / 30 days), imatinib mesylate tab 100 mg (base equivalent) 5 QL (240 tabs / 30 days), imatinib mesylate tab 400 mg (base equivalent) 5 QL (60 tabs / 30 days), IMBRUVICA CAP 70MG 5 QL (240 caps / 30 days), NM, LA, PA; DL IMBRUVICA CAP 140MG 5 QL (120 caps / 30 days), IMBRUVICA TAB 140MG 5 QL (120 tabs / 30 days), NM, LA, PA; DL IMBRUVICA TAB 280MG 5 QL (60 tabs / 30 days), NM, LA, PA; DL IMBRUVICA TAB 420MG 5 QL (30 tabs / 30 days), NM, LA, PA; DL IMBRUVICA TAB 560MG 5 QL (30 tabs / 30 days), NM, LA, PA; DL INLYTA TAB 1MG 5 QL (600 tabs / 30 days), INLYTA TAB 5MG 5 QL (120 tabs / 30 days), IRESSA TAB 250MG 5 QL (30 tabs / 30 days), JAKAFI TAB 5MG 5 QL (300 tabs / 30 days), JAKAFI TAB 10MG 5 QL (180 tabs / 30 days), JAKAFI TAB 15MG 5 QL (120 tabs / 30 days), JAKAFI TAB 20MG 5 QL (120 tabs / 30 days), JAKAFI TAB 25MG 5 QL (60 tabs / 30 days), 32
LENVIMA CAP 8 MG 5 QL (180 caps / 30 days), LENVIMA CAP 10 MG 5 QL (90 caps / 30 days), LENVIMA CAP 14 MG 5 QL (120 caps / 30 days), LENVIMA CAP 18 MG 5 QL (180 caps / 30 days), LENVIMA CAP 20 MG 5 QL (120 caps / 30 days), LENVIMA CAP 24 MG 5 QL (90 caps / 30 days), MEKINIST TAB 0.5MG 5 QL (120 tabs / 30 days), MEKINIST TAB 2MG 5 QL (30 tabs / 30 days), NERLYNX TAB 40MG 5 QL (180 tabs / 30 days), NM, LA, PA; DL NEXAVAR TAB 200MG 5 QL (120 tabs / 30 days), NM, LA, PA; DL RYDAPT CAP 25MG 5 QL (224 caps / 28 days), SPRYCEL TAB 20MG 5 QL (270 tabs / 30 days), SPRYCEL TAB 50MG 5 QL (120 tabs / 30 days), SPRYCEL TAB 70MG 5 QL (90 tabs / 30 days), SPRYCEL TAB 80MG 5 QL (90 tabs / 30 days), SPRYCEL TAB 100MG 5 QL (60 tabs / 30 days), SPRYCEL TAB 140MG 5 QL (60 tabs / 30 days), STIVARGA TAB 40MG 5 QL (84 tabs / 28 days), SUTENT CAP 12.5MG 5 QL (210 caps / 30 days), SUTENT CAP 25MG 5 QL (120 caps / 30 days), 33
SUTENT CAP 37.5MG 5 QL (90 caps / 30 days), SUTENT CAP 50MG 5 QL (60 caps / 30 days), TAFINLAR CAP 50MG 5 QL (180 caps / 30 days), TAFINLAR CAP 75MG 5 QL (120 caps / 30 days), TAGRISSO TAB 40MG 5 QL (60 tabs / 30 days), NM, LA, PA; DL TAGRISSO TAB 80MG 5 QL (30 tabs / 30 days), NM, LA, PA; DL TARCEVA TAB 25MG 5 TARCEVA TAB 100MG 5 QL (150 tabs / 30 days), TARCEVA TAB 150MG 5 QL (90 tabs / 30 days), TASIGNA CAP 50MG 5 QL (480 caps / 30 days), TASIGNA CAP 150MG 5 QL (180 caps / 30 days), TASIGNA CAP 200MG 5 QL (120 caps / 30 days), TYKERB TAB 250MG 5 QL (180 tabs / 30 days), NM, LA, PA; DL VOTRIENT TAB 200MG 5 QL (120 tabs / 30 days), XALKORI CAP 200MG 5 QL (90 caps / 30 days), XALKORI CAP 250MG 5 QL (60 caps / 30 days), ZELBORAF TAB 240MG 5 QL (240 tabs / 30 days), ZYDELIG TAB 100MG 5 QL (90 tabs / 30 days), ZYDELIG TAB 150MG 5 QL (60 tabs / 30 days), ZYKADIA CAP 150MG 5 QL (150 caps / 30 days), MISCELLANEOUS bexarotene cap 75 mg 5 34
ERWINAZE INJ 10000UNT 5 NM; DL HALAVEN INJ 1MG/2ML 5 NM; DL hydroxyurea cap 500 mg 2 IXEMPRA KIT INJ 15MG 5 NM; DL IXEMPRA KIT INJ 45MG 5 NM; DL LONSURF TAB 15-6.14 5 LONSURF TAB 20-8.19 5 MATULANE CAP 50MG 5 DL mitoxantrone hcl inj conc 25 mg/12.5ml (2 2 NM mg/ml) PROLEUKIN INJ 22MU 5 NM; DL SYLATRON KIT 200MCG 5 NM; DL SYLATRON KIT 300MCG 5 NM; DL SYLATRON KIT 600MCG 5 NM; DL SYNRIBO INJ 3.5MG 5 NM; DL THERACYS INJ 4 TICE BCG INJ 4 tretinoin cap 10 mg 5 DL TRISENOX INJ 12MG/6ML 5 DL YONDELIS INJ 1MG 5 NM; DL PLATINUM-BASED AGENTS carboplatin iv soln 150 mg/15ml 2 cisplatin inj 50 mg/50ml (1 mg/ml) 2 oxaliplatin for iv inj 50 mg 4 oxaliplatin for iv inj 100 mg 4 oxaliplatin iv soln 50 mg/10ml 4 oxaliplatin iv soln 100 mg/20ml 4 PROTECTIVE AGENTS dexrazoxane for inj 250 mg 5 DL dexrazoxane for inj 500 mg 5 DL ELITEK INJ 1.5MG 5 DL ELITEK INJ 7.5MG 5 DL FUSILEV INJ 50MG 5 NM; DL KEPIVANCE INJ 6.25MG 5 LA; DL leucovorin calcium for inj 100 mg 2 leucovorin calcium for inj 350 mg 2 leucovorin calcium tab 5 mg 2 leucovorin calcium tab 10 mg 2 leucovorin calcium tab 15 mg 2 35
leucovorin calcium tab 25 mg 2 levoleucovorin calcium for iv inj 50 mg (base equiv) 5 NM; DL levoleucovorin calcium inj 175 mg/17.5ml 5 NM; DL (base equiv) mesna inj 100 mg/ml 2 MESNEX TAB 400MG 4 ZINECARD INJ 250MG 5 DL TOPOISOMERASE INHIBITORS ETOPOPHOS INJ 100MG 4 etoposide inj 100 mg/5ml (20 mg/ml) 2 irinotecan hcl inj 40 mg/2ml (20 mg/ml) 3 irinotecan hcl inj 100 mg/5ml (20 mg/ml) 3 irinotecan hcl inj 500 mg/25ml (20 mg/ml) 3 toposar inj 1gm/50ml 2 topotecan hcl for inj 4 mg 5 DL CARDIOVASCULAR ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl cap 2.5-2 10 mg amlodipine besylate-benazepril hcl cap 5-2 10 mg amlodipine besylate-benazepril hcl cap 5-2 20 mg amlodipine besylate-benazepril hcl cap 5-2 40 mg amlodipine besylate-benazepril hcl cap 10-2 20 mg amlodipine besylate-benazepril hcl cap 10-2 40 mg benazepril & hydrochlorothiazide tab 5-2 6.25 mg benazepril & hydrochlorothiazide tab 10-2 12.5 mg benazepril & hydrochlorothiazide tab 20-2 12.5 mg benazepril & hydrochlorothiazide tab 20-25 2 mg captopril & hydrochlorothiazide tab 25-15 2 mg 36
captopril & hydrochlorothiazide tab 25-25 2 mg captopril & hydrochlorothiazide tab 50-15 2 mg captopril & hydrochlorothiazide tab 50-25 2 mg enalapril maleate & hydrochlorothiazide tab 6 5-12.5 mg enalapril maleate & hydrochlorothiazide tab 6 10-25 mg fosinopril sodium & hydrochlorothiazide tab 2 10-12.5 mg fosinopril sodium & hydrochlorothiazide tab 2 20-12.5 mg lisinopril & hydrochlorothiazide tab 10-12.5 6 mg lisinopril & hydrochlorothiazide tab 20-12.5 6 mg lisinopril & hydrochlorothiazide tab 20-25 6 mg moexipril-hydrochlorothiazide tab 7.5-12.5 2 mg moexipril-hydrochlorothiazide tab 15-12.5 2 mg moexipril-hydrochlorothiazide tab 15-25 2 mg quinapril-hydrochlorothiazide tab 10-12.5 1 GC mg quinapril-hydrochlorothiazide tab 20-12.5 mg 1 GC quinapril-hydrochlorothiazide tab 20-25 mg 1 GC ACE INHIBITORS benazepril hcl tab 5 mg 6 benazepril hcl tab 10 mg 6 benazepril hcl tab 20 mg 6 benazepril hcl tab 40 mg 6 captopril tab 12.5 mg 2 captopril tab 25 mg 2 captopril tab 50 mg 2 captopril tab 100 mg 2 37
enalapril maleate tab 2.5 mg 1 GC enalapril maleate tab 5 mg 1 GC enalapril maleate tab 10 mg 1 GC enalapril maleate tab 20 mg 1 GC fosinopril sodium tab 10 mg 6 fosinopril sodium tab 20 mg 6 fosinopril sodium tab 40 mg 6 lisinopril tab 2.5 mg 6 lisinopril tab 5 mg 6 lisinopril tab 10 mg 6 lisinopril tab 20 mg 6 lisinopril tab 30 mg 6 lisinopril tab 40 mg 6 moexipril hcl tab 7.5 mg 2 moexipril hcl tab 15 mg 2 perindopril erbumine tab 2 mg 2 perindopril erbumine tab 4 mg 2 perindopril erbumine tab 8 mg 2 quinapril hcl tab 5 mg 6 quinapril hcl tab 10 mg 6 quinapril hcl tab 20 mg 6 quinapril hcl tab 40 mg 6 ramipril cap 1.25 mg 6 ramipril cap 2.5 mg 6 ramipril cap 5 mg 6 ramipril cap 10 mg 6 trandolapril tab 1 mg 6 trandolapril tab 2 mg 6 trandolapril tab 4 mg 6 ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone tab 25 mg 4 eplerenone tab 50 mg 4 spironolactone tab 25 mg 1 GC spironolactone tab 50 mg 1 GC spironolactone tab 100 mg 1 GC ALPHA BLOCKERS doxazosin mesylate tab 1 mg 2 doxazosin mesylate tab 2 mg 2 38
doxazosin mesylate tab 4 mg 2 doxazosin mesylate tab 8 mg 2 prazosin hcl cap 1 mg 2 prazosin hcl cap 2 mg 2 prazosin hcl cap 5 mg 2 terazosin hcl cap 1 mg (base equivalent) 1 GC terazosin hcl cap 2 mg (base equivalent) 1 GC terazosin hcl cap 5 mg (base equivalent) 1 GC terazosin hcl cap 10 mg (base equivalent) 1 GC ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-valsartan tab 5-160 2 mg amlodipine besylate-valsartan tab 5-320 2 mg amlodipine besylate-valsartan tab 10-160 2 mg amlodipine besylate-valsartan tab 10-320 2 mg candesartan cilexetil-hydrochlorothiazide 4 tab 16-12.5 mg candesartan cilexetil-hydrochlorothiazide 4 tab 32-12.5 mg candesartan cilexetil-hydrochlorothiazide 4 tab 32-25 mg ENTRESTO TAB 24-26MG 3 QL (60 tabs / 30 days) ENTRESTO TAB 49-51MG 3 QL (60 tabs / 30 days) ENTRESTO TAB 97-103MG 3 QL (60 tabs / 30 days) irbesartan-hydrochlorothiazide tab 150-6 12.5 mg irbesartan-hydrochlorothiazide tab 300-6 12.5 mg losartan potassium & hydrochlorothiazide 6 tab 50-12.5 mg losartan potassium & hydrochlorothiazide 6 tab 100-12.5 mg losartan potassium & hydrochlorothiazide 6 tab 100-25 mg telmisartan-amlodipine tab 40-5 mg 4 telmisartan-amlodipine tab 40-10 mg 4 telmisartan-amlodipine tab 80-5 mg 4 39
telmisartan-amlodipine tab 80-10 mg 4 telmisartan-hydrochlorothiazide tab 40-4 12.5 mg telmisartan-hydrochlorothiazide tab 80-4 12.5 mg telmisartan-hydrochlorothiazide tab 80-25 4 mg valsartan-hydrochlorothiazide tab 80-12.5 2 mg valsartan-hydrochlorothiazide tab 160-12.52 mg valsartan-hydrochlorothiazide tab 160-25 2 mg valsartan-hydrochlorothiazide tab 320-12.52 mg valsartan-hydrochlorothiazide tab 320-25 2 mg ANGIOTENSIN II RECEPTOR ANTAGONISTS candesartan cilexetil tab 4 mg 4 candesartan cilexetil tab 8 mg 4 candesartan cilexetil tab 16 mg 4 candesartan cilexetil tab 32 mg 4 eprosartan mesylate tab 600 mg 4 irbesartan tab 75 mg 6 irbesartan tab 150 mg 6 irbesartan tab 300 mg 6 losartan potassium tab 25 mg 6 losartan potassium tab 50 mg 6 losartan potassium tab 100 mg 6 telmisartan tab 20 mg 2 telmisartan tab 40 mg 2 telmisartan tab 80 mg 2 valsartan tab 40 mg 2 valsartan tab 80 mg 2 valsartan tab 160 mg 2 valsartan tab 320 mg 2 ANTIARRHYTHMICS amiodarone hcl inj 150 mg/3ml (50 mg/ml) 2 B/D 40
amiodarone hcl tab 100 mg 2 amiodarone hcl tab 200 mg 2 amiodarone hcl tab 400 mg 4 disopyramide phosphate cap 100 mg 2 disopyramide phosphate cap 150 mg 2 dofetilide cap 125 mcg (0.125 mg) 3 NM dofetilide cap 250 mcg (0.25 mg) 3 NM dofetilide cap 500 mcg (0.5 mg) 3 NM flecainide acetate tab 50 mg 2 flecainide acetate tab 100 mg 2 flecainide acetate tab 150 mg 2 ibutilide fumarate inj 1 mg/10ml 2 lidocaine hcl iv inj 10 mg/ml 2 lidocaine hcl iv inj 20 mg/ml 2 lidocaine iv infusion in d5w inj 4 mg/ml 2 lidocaine iv infusion in d5w inj 8 mg/ml 2 mexiletine hcl cap 150 mg 2 mexiletine hcl cap 200 mg 2 mexiletine hcl cap 250 mg 2 MULTAQ TAB 400MG 3 pacerone tab 100mg 2 pacerone tab 200mg 2 pacerone tab 400mg 4 procainamide hcl inj 100 mg/ml 2 procainamide hcl inj 500 mg/ml 2 propafenone hcl cap er 12hr 225 mg 4 propafenone hcl cap er 12hr 325 mg 4 propafenone hcl cap er 12hr 425 mg 4 propafenone hcl tab 150 mg 2 propafenone hcl tab 225 mg 2 propafenone hcl tab 300 mg 2 QUINIDINE GL INJ 80MG/ML 2 quinidine sulfate tab 200 mg 2 quinidine sulfate tab 300 mg 2 sorine tab 80mg 2 sorine tab 120mg 2 sorine tab 160mg 2 sorine tab 240mg 2 sotalol hcl (afib/afl) tab 120 mg 2 41
sotalol hcl tab 80 mg 2 sotalol hcl tab 160 mg 2 sotalol hcl tab 240 mg 2 ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS atorvastatin calcium tab 10 mg (base 6 equivalent) atorvastatin calcium tab 20 mg (base 6 equivalent) atorvastatin calcium tab 40 mg (base 6 equivalent) atorvastatin calcium tab 80 mg (base 6 equivalent) fluvastatin sodium cap 20 mg 4 fluvastatin sodium cap 40 mg 4 lovastatin tab 10 mg 6 lovastatin tab 20 mg 6 lovastatin tab 40 mg 6 pravastatin sodium tab 10 mg 6 pravastatin sodium tab 20 mg 6 pravastatin sodium tab 40 mg 6 pravastatin sodium tab 80 mg 6 rosuvastatin calcium tab 5 mg 4 rosuvastatin calcium tab 10 mg 4 rosuvastatin calcium tab 20 mg 4 rosuvastatin calcium tab 40 mg 4 simvastatin tab 5 mg 6 simvastatin tab 10 mg 6 simvastatin tab 20 mg 6 simvastatin tab 40 mg 6 simvastatin tab 80 mg 6 ANTILIPEMICS, MISCELLANEOUS cholestyramine light powder 4 gm/dose 3 cholestyramine powder packets 4 gm 3 choline fenofibrate cap dr 45 mg (fenofibric 3 QL (30 caps / 30 days) acid equiv) choline fenofibrate cap dr 135 mg 4 QL (30 caps / 30 days) (fenofibric acid equiv) colestipol hcl granule packets 5 gm 3 colestipol hcl tab 1 gm 3 42
ezetimibe tab 10 mg 3 fenofibrate micronized cap 43 mg 3 QL (30 caps / 30 days) fenofibrate micronized cap 67 mg 2 QL (30 caps / 30 days) fenofibrate micronized cap 130 mg 4 QL (30 caps / 30 days) fenofibrate micronized cap 134 mg 3 QL (30 caps / 30 days) fenofibrate micronized cap 200 mg 4 QL (30 caps / 30 days) fenofibrate tab 48 mg 2 QL (30 tabs / 30 days) fenofibrate tab 54 mg 2 QL (30 tabs / 30 days) fenofibrate tab 145 mg 4 QL (30 tabs / 30 days) fenofibrate tab 160 mg 2 QL (30 tabs / 30 days) fenofibric acid tab 35 mg 2 fenofibric acid tab 105 mg 2 gemfibrozil tab 600 mg 2 JUXTAPID CAP 5MG 5 QL (30 caps / 30 days), NM, LA, PA; DL JUXTAPID CAP 10MG 5 QL (30 caps / 30 days), NM, LA, PA; DL JUXTAPID CAP 20MG 5 QL (30 caps / 30 days), NM, LA, PA; DL JUXTAPID CAP 30MG 5 QL (30 caps / 30 days), NM, LA, PA; DL JUXTAPID CAP 40MG 5 QL (30 caps / 30 days), NM, LA, PA; DL JUXTAPID CAP 60MG 5 QL (30 caps / 30 days), NM, LA, PA; DL KYNAMRO INJ 200MG/ML 5 QL (4 syringes / 28 days), NM, LA, PA; DL niacin tab er 500 mg (antihyperlipidemic) 4 niacin tab er 750 mg (antihyperlipidemic) 4 niacin tab er 1000 mg (antihyperlipidemic) 4 omega-3-acid ethyl esters cap 1 gm 3 PRALUENT INJ 75MG/ML 5 QL (2 pens / 28 days), PRALUENT INJ 150MG/ML 5 QL (2 pens / 28 days), prevalite pow 4gm pk 3 REPATHA INJ 140MG/ML 5 QL (3 syringes / 28 days), REPATHA PUSH INJ 420/3.5 5 QL (1 cartridge / 28 days), 43
REPATHA SURE INJ 140MG/ML 5 QL (3 pens / 28 days), VASCEPA CAP 0.5GM 3 VASCEPA CAP 1GM 3 WELCHOL PAK 3.75GM 3 WELCHOL TAB 625MG 3 BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone tab 50-25 mg 2 atenolol & chlorthalidone tab 100-25 mg 2 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg 1 GC bisoprolol & hydrochlorothiazide tab 5-6.25 1 GC mg bisoprolol & hydrochlorothiazide tab 10-1 GC 6.25 mg metoprolol & hydrochlorothiazide tab 50-3 25 mg metoprolol & hydrochlorothiazide tab 100-3 25 mg metoprolol & hydrochlorothiazide tab 100-50 mg 3 nadolol & bendroflumethiazide tab 40-5 mg 3 nadolol & bendroflumethiazide tab 80-5 mg 3 propranolol & hydrochlorothiazide tab 40-2 25 mg propranolol & hydrochlorothiazide tab 80-2 25 mg BETA-BLOCKERS acebutolol hcl cap 200 mg 2 acebutolol hcl cap 400 mg 2 atenolol tab 25 mg 1 GC atenolol tab 50 mg 1 GC atenolol tab 100 mg 1 GC betaxolol hcl tab 10 mg 2 betaxolol hcl tab 20 mg 2 bisoprolol fumarate tab 5 mg 2 bisoprolol fumarate tab 10 mg 2 carvedilol tab 3.125 mg 1 GC carvedilol tab 6.25 mg 1 GC 44
carvedilol tab 12.5 mg 1 GC carvedilol tab 25 mg 1 GC esmolol hcl inj 100 mg/10ml 2 labetalol hcl iv soln 5 mg/ml 2 labetalol hcl tab 100 mg 2 labetalol hcl tab 200 mg 2 labetalol hcl tab 300 mg 2 metoprolol succinate tab er 24hr 25 mg 2 (tartrate equiv) metoprolol succinate tab er 24hr 50 mg 2 (tartrate equiv) metoprolol succinate tab er 24hr 100 mg 2 (tartrate equiv) metoprolol succinate tab er 24hr 200 mg 2 (tartrate equiv) metoprolol tartrate iv soln 5 mg/5ml 2 metoprolol tartrate tab 25 mg 1 GC metoprolol tartrate tab 50 mg 1 GC metoprolol tartrate tab 100 mg 1 GC nadolol tab 20 mg 3 nadolol tab 40 mg 3 nadolol tab 80 mg 3 pindolol tab 5 mg 2 pindolol tab 10 mg 2 propranolol hcl cap er 24hr 60 mg 3 propranolol hcl cap er 24hr 80 mg 3 propranolol hcl cap er 24hr 120 mg 3 propranolol hcl cap er 24hr 160 mg 3 propranolol hcl inj 1 mg/ml 2 propranolol hcl oral soln 20 mg/5ml 2 propranolol hcl oral soln 40 mg/5ml 2 propranolol hcl tab 10 mg 1 GC propranolol hcl tab 20 mg 1 GC propranolol hcl tab 40 mg 1 GC propranolol hcl tab 60 mg 1 GC propranolol hcl tab 80 mg 1 GC timolol maleate tab 5 mg 2 timolol maleate tab 10 mg 2 timolol maleate tab 20 mg 2 45
CALCIUM CHANNEL BLOCKERS afeditab tab 30mg cr 2 afeditab tab 60mg cr 2 amlodipine besylate tab 2.5 mg (base 2 equivalent) amlodipine besylate tab 5 mg (base 2 equivalent) amlodipine besylate tab 10 mg (base 2 equivalent) CARDENE IV INJ 40/200ML 4 CARDENE IV SOL 20/200ML 4 cartia xt cap 120/24hr 2 cartia xt cap 180/24hr 2 cartia xt cap 240/24hr 2 cartia xt cap 300/24hr 2 dilt-xr cap 120mg 2 dilt-xr cap 180mg 2 dilt-xr cap 240mg 2 diltiazem hcl cap er 12hr 60 mg 2 diltiazem hcl cap er 12hr 90 mg 2 diltiazem hcl cap er 12hr 120 mg 2 diltiazem hcl coated beads cap er 24hr 120 2 mg diltiazem hcl coated beads cap er 24hr 180 2 mg diltiazem hcl coated beads cap er 24hr 240 2 mg diltiazem hcl coated beads cap er 24hr 300 2 mg diltiazem hcl extended release beads cap 4 er 24hr 360 mg diltiazem hcl extended release beads cap 2 er 24hr 420 mg diltiazem hcl iv soln 50 mg/10ml (5 2 mg/ml) diltiazem hcl tab 30 mg 1 GC diltiazem hcl tab 60 mg 1 GC diltiazem hcl tab 90 mg 1 GC diltiazem hcl tab 120 mg 1 GC DILTIAZEM INJ 100MG 2 46
felodipine tab er 24hr 2.5 mg 2 felodipine tab er 24hr 5 mg 2 felodipine tab er 24hr 10 mg 2 isradipine cap 2.5 mg 2 isradipine cap 5 mg 2 matzim la tab 180mg/24 4 matzim la tab 240mg/24 4 matzim la tab 300mg/24 4 matzim la tab 360mg/24 4 matzim la tab 420mg/24 4 nicardipine hcl cap 20 mg 2 nicardipine hcl cap 30 mg 2 nicardipine hcl iv soln 2.5 mg/ml 2 nifedipine tab er 24hr 30 mg 2 nifedipine tab er 24hr 60 mg 2 nifedipine tab er 24hr 90 mg 2 nifedipine tab er 24hr osmotic release 30 2 mg nifedipine tab er 24hr osmotic release 60 2 mg nifedipine tab er 24hr osmotic release 90 2 mg taztia xt cap 120mg/24 2 taztia xt cap 180mg/24 2 taztia xt cap 240mg/24 2 taztia xt cap 300mg/24 2 taztia xt cap 360mg/24 4 verapamil hcl cap er 24hr 100 mg 2 verapamil hcl cap er 24hr 120 mg 2 verapamil hcl cap er 24hr 180 mg 2 verapamil hcl cap er 24hr 200 mg 2 verapamil hcl cap er 24hr 240 mg 2 verapamil hcl cap er 24hr 300 mg 2 verapamil hcl cap er 24hr 360 mg 2 verapamil hcl iv soln 2.5 mg/ml 2 verapamil hcl tab 40 mg 1 GC verapamil hcl tab 80 mg 1 GC verapamil hcl tab 120 mg 1 GC verapamil hcl tab er 120 mg 2 47
verapamil hcl tab er 180 mg 2 verapamil hcl tab er 240 mg 2 DIGITALIS GLYCOSIDES digitek tab 0.25mg 2 digitek tab 0.125mg 2 digox tab 0.25mg 2 digox tab 0.125mg 2 digoxin inj 0.25 mg/ml 2 digoxin oral soln 0.05 mg/ml 2 digoxin tab 125 mcg (0.125 mg) 2 digoxin tab 250 mcg (0.25 mg) 2 DIRECT RENIN INHIBITORS/COMBINATIONS TEKTURNA HCT TAB 150-12.5 3 ST TEKTURNA HCT TAB 150-25MG 3 ST TEKTURNA HCT TAB 300-12.5 3 ST TEKTURNA HCT TAB 300-25MG 3 ST TEKTURNA TAB 150MG 3 ST TEKTURNA TAB 300MG 3 ST DIURETICS acetazolamide cap er 12hr 500 mg 2 acetazolamide sodium for inj 500 mg 2 acetazolamide tab 125 mg 2 acetazolamide tab 250 mg 2 amiloride & hydrochlorothiazide tab 5-50 2 mg amiloride hcl tab 5 mg 2 bumetanide inj 0.25 mg/ml 2 bumetanide tab 0.5 mg 2 bumetanide tab 1 mg 2 bumetanide tab 2 mg 2 chlorothiazide sodium for inj 500 mg 2 chlorothiazide tab 250 mg 2 chlorothiazide tab 500 mg 2 chlorthalidone tab 25 mg 2 chlorthalidone tab 50 mg 2 DIURIL SUS 250/5ML 4 furosemide inj 10 mg/ml 2 furosemide oral soln 8 mg/ml 2 48
furosemide oral soln 10 mg/ml 2 furosemide tab 20 mg 1 GC furosemide tab 40 mg 1 GC furosemide tab 80 mg 1 GC hydrochlorothiazide cap 12.5 mg 1 GC hydrochlorothiazide tab 12.5 mg 1 GC hydrochlorothiazide tab 25 mg 1 GC hydrochlorothiazide tab 50 mg 1 GC indapamide tab 1.25 mg 1 GC indapamide tab 2.5 mg 1 GC methazolamide tab 25 mg 4 methazolamide tab 50 mg 4 methyclothiazide tab 5 mg 2 metolazone tab 2.5 mg 2 metolazone tab 5 mg 2 metolazone tab 10 mg 2 spironolactone & hydrochlorothiazide tab 2 25-25 mg torsemide tab 5 mg 1 GC torsemide tab 10 mg 1 GC torsemide tab 20 mg 1 GC torsemide tab 100 mg 1 GC triamterene & hydrochlorothiazide cap 1 GC 37.5-25 mg triamterene & hydrochlorothiazide tab 1 GC 37.5-25 mg triamterene & hydrochlorothiazide tab 75-1 GC 50 mg MISCELLANEOUS clonidine hcl tab 0.1 mg 2 clonidine hcl tab 0.2 mg 2 clonidine hcl tab 0.3 mg 2 clonidine hcl td patch weekly 0.1 mg/24hr 2 clonidine hcl td patch weekly 0.2 mg/24hr 2 clonidine hcl td patch weekly 0.3 mg/24hr 2 CORLANOR TAB 5MG 4 QL (60 tabs / 30 days), PA CORLANOR TAB 7.5MG 4 QL (60 tabs / 30 days), PA 49
DEMSER CAP 250MG 5 PA; DL hydralazine hcl inj 20 mg/ml 2 hydralazine hcl tab 10 mg 2 hydralazine hcl tab 25 mg 2 hydralazine hcl tab 50 mg 2 hydralazine hcl tab 100 mg 2 KEVEYIS TAB 50MG 5 QL (120 tabs / 30 days), midodrine hcl tab 2.5 mg 3 midodrine hcl tab 5 mg 3 midodrine hcl tab 10 mg 3 minoxidil tab 2.5 mg 2 minoxidil tab 10 mg 2 NORTHERA CAP 100MG 5 QL (540 caps / 30 days), NORTHERA CAP 200MG 5 QL (360 caps / 30 days), NORTHERA CAP 300MG 5 QL (180 caps / 30 days), phenoxybenzamine hcl cap 10 mg 5 DL RANEXA TAB 500MG 3 QL (60 tabs / 30 days) RANEXA TAB 1000MG 3 QL (60 tabs / 30 days) VECAMYL TAB 2.5MG 5 PA; DL NITRATES isosorbide dinitrate tab 5 mg 3 isosorbide dinitrate tab 10 mg 3 isosorbide dinitrate tab 20 mg 3 isosorbide dinitrate tab 30 mg 3 isosorbide dinitrate tab er 40 mg 3 isosorbide mononitrate tab 10 mg 1 GC isosorbide mononitrate tab 20 mg 1 GC isosorbide mononitrate tab er 24hr 30 mg 2 isosorbide mononitrate tab er 24hr 60 mg 2 isosorbide mononitrate tab er 24hr 120 mg 2 NITRO-BID OIN 2% 2 NITRO-DUR DIS 0.3MG/HR 4 NITRO-DUR DIS 0.8MG/HR 4 NITROGLYCER INJ 5MG/ML 2 B/D nitroglycerin sl tab 0.3 mg 2 50
nitroglycerin sl tab 0.4 mg 2 nitroglycerin sl tab 0.6 mg 2 nitroglycerin td patch 24hr 0.1 mg/hr 2 nitroglycerin td patch 24hr 0.2 mg/hr 2 nitroglycerin td patch 24hr 0.4 mg/hr 2 nitroglycerin td patch 24hr 0.6 mg/hr 2 nitroglycerin tl soln 0.4 mg/spray (400 2 mcg/spray) PULMONARY ARTERIAL HYPERTENSION ADCIRCA TAB 20MG 5 QL (60 tabs / 30 days), ADEMPAS TAB 0.5MG 5 QL (90 tabs / 30 days), NM, LA, PA; DL ADEMPAS TAB 1.5MG 5 QL (90 tabs / 30 days), NM, LA, PA; DL ADEMPAS TAB 1MG 5 QL (90 tabs / 30 days), NM, LA, PA; DL ADEMPAS TAB 2.5MG 5 QL (90 tabs / 30 days), NM, LA, PA; DL ADEMPAS TAB 2MG 5 QL (90 tabs / 30 days), NM, LA, PA; DL epoprostenol sodium for inj 0.5 mg 5 B/D, NM; DL epoprostenol sodium for inj 1.5 mg 5 B/D, NM; DL LETAIRIS TAB 5MG 5 QL (30 tabs / 30 days), NM, LA, PA; DL LETAIRIS TAB 10MG 5 QL (30 tabs / 30 days), NM, LA, PA; DL OPSUMIT TAB 10MG 5 QL (30 tabs / 30 days), NM, LA, PA; DL REMODULIN INJ 1MG/ML 5 NM, LA, PA; DL REMODULIN INJ 2.5MG/ML 5 NM, LA, PA; DL REMODULIN INJ 5MG/ML 5 NM, LA, PA; DL REMODULIN INJ 10MG/ML 5 NM, LA, PA; DL REVATIO SUS 10MG/ML 5 QL (180 ml / 30 days), sildenafil citrate tab 20 mg 3 QL (90 tabs / 30 days), NM, PA TRACLEER TAB 32MG 5 QL (60 tabs / 30 days), NM, LA, PA; DL 51
TRACLEER TAB 62.5MG 5 QL (60 tabs / 30 days), NM, LA, PA; DL TRACLEER TAB 125MG 5 QL (60 tabs / 30 days), NM, LA, PA; DL UPTRAVI TAB 200/800 5 QL (400 tabs / year), NM, LA, PA; DL UPTRAVI TAB 200MCG 5 QL (60 tabs / 30 days), NM, LA, PA; DL UPTRAVI TAB 400MCG 5 QL (60 tabs / 30 days), NM, LA, PA; DL UPTRAVI TAB 600MCG 5 QL (60 tabs / 30 days), NM, LA, PA; DL UPTRAVI TAB 800MCG 5 QL (60 tabs / 30 days), NM, LA, PA; DL UPTRAVI TAB 1000MCG 5 QL (60 tabs / 30 days), NM, LA, PA; DL UPTRAVI TAB 1200MCG 5 QL (60 tabs / 30 days), NM, LA, PA; DL UPTRAVI TAB 1400MCG 5 QL (60 tabs / 30 days), NM, LA, PA; DL UPTRAVI TAB 1600MCG 5 QL (60 tabs / 30 days), NM, LA, PA; DL VELETRI INJ 0.5MG 5 B/D, NM; DL VELETRI INJ 1.5MG 5 B/D, NM; DL VENTAVIS SOL 10MCG/ML 5 VENTAVIS SOL 20MCG/ML 5 CENTRAL NERVOUS SYSTEM ANTIANXIETY alprazolam tab 0.5 mg 2 QL (90 tabs / 30 days) alprazolam tab 0.25 mg 2 QL (90 tabs / 30 days) alprazolam tab 1 mg 2 QL (90 tabs / 30 days) alprazolam tab 2 mg 2 QL (150 tabs / 30 days) alprazolam tab er 24hr 0.5 mg 2 QL (30 tabs / 30 days) alprazolam tab er 24hr 1 mg 2 QL (30 tabs / 30 days) alprazolam tab er 24hr 2 mg 2 QL (150 tabs / 30 days) alprazolam tab er 24hr 3 mg 2 QL (90 tabs / 30 days) buspirone hcl tab 5 mg 2 buspirone hcl tab 7.5 mg 2 buspirone hcl tab 10 mg 2 buspirone hcl tab 15 mg 2 52
buspirone hcl tab 30 mg 4 fluvoxamine maleate tab 25 mg 2 fluvoxamine maleate tab 50 mg 2 fluvoxamine maleate tab 100 mg 2 lorazepam con 2mg/ml 2 QL (150 ml / 30 days) lorazepam inj 2 mg/ml 2 lorazepam inj 4 mg/ml 2 lorazepam tab 0.5 mg 2 QL (600 tabs / 30 days) lorazepam tab 1 mg 2 QL (300 tabs / 30 days) lorazepam tab 2 mg 2 QL (150 tabs / 30 days) oxazepam cap 10 mg 2 QL (120 caps / 30 days) oxazepam cap 15 mg 2 QL (120 caps / 30 days) oxazepam cap 30 mg 2 QL (120 caps / 30 days) ANTICONVULSANTS APTIOM TAB 200MG 4 PA APTIOM TAB 400MG 5 PA; DL APTIOM TAB 600MG 5 PA; DL APTIOM TAB 800MG 5 PA; DL BANZEL SUS 40MG/ML 4 PA BANZEL TAB 200MG 4 PA BANZEL TAB 400MG 5 PA; DL BRIVIACT INJ 50MG/5ML 5 PA; DL BRIVIACT SOL 10MG/ML 5 PA; DL BRIVIACT TAB 10MG 5 PA; DL BRIVIACT TAB 25MG 5 PA; DL BRIVIACT TAB 50MG 5 PA; DL BRIVIACT TAB 75MG 5 PA; DL BRIVIACT TAB 100MG 5 PA; DL carbamazepine cap er 12hr 100 mg 2 carbamazepine cap er 12hr 200 mg 2 carbamazepine cap er 12hr 300 mg 2 carbamazepine chew tab 100 mg 2 carbamazepine susp 100 mg/5ml 2 carbamazepine tab 200 mg 2 carbamazepine tab er 12hr 100 mg 2 carbamazepine tab er 12hr 200 mg 2 carbamazepine tab er 12hr 400 mg 2 CELONTIN CAP 300MG 4 53
clonazepam orally disintegrating tab 0.5 mg 2 QL (1200 tabs / 30 days), ST clonazepam orally disintegrating tab 0.25 mg 2 QL (2400 tabs / 30 days), ST clonazepam orally disintegrating tab 0.125 2 QL (4800 tabs / 30 mg days), ST clonazepam orally disintegrating tab 1 mg 2 QL (600 tabs / 30 days), ST clonazepam orally disintegrating tab 2 mg 2 QL (300 tabs / 30 days), ST clonazepam tab 0.5 mg 2 QL (1200 tabs / 30 days) clonazepam tab 1 mg 2 QL (600 tabs / 30 days) clonazepam tab 2 mg 2 QL (300 tabs / 30 days) clorazepate dipotassium tab 3.75 mg 2 QL (720 tabs / 30 days) clorazepate dipotassium tab 7.5 mg 2 QL (360 tabs / 30 days) clorazepate dipotassium tab 15 mg 2 QL (180 tabs / 30 days) DIASTAT ACDL GEL 5-10MG 4 DIASTAT ACDL GEL 12.5-20 4 DIASTAT PED GEL 2.5M GEL 4 diazepam con 5mg/ml 2 QL (240 ml / 30 days) diazepam inj 5 mg/ml 2 diazepam oral soln 1 mg/ml 2 QL (1200 ml / 30 days) diazepam tab 2 mg 2 QL (600 tabs / 30 days) diazepam tab 5 mg 2 QL (240 tabs / 30 days) diazepam tab 10 mg 2 QL (120 tabs / 30 days) DILANTIN CAP 30MG 3 divalproex sodium cap delayed release sprinkle 125 mg 2 divalproex sodium tab delayed release 125 2 mg divalproex sodium tab delayed release 250 2 mg divalproex sodium tab delayed release 500 2 mg divalproex sodium tab er 24 hr 250 mg 3 divalproex sodium tab er 24 hr 500 mg 3 epitol tab 200mg 2 ethosuximide cap 250 mg 4 ethosuximide soln 250 mg/5ml 4 54
felbamate susp 600 mg/5ml 4 felbamate tab 400 mg 4 felbamate tab 600 mg 4 fosphenytoin sodium inj 100 mg/2ml 2 (phenytoin equiv) fosphenytoin sodium inj 500 mg/10ml 2 (phenytoin equiv) FYCOMPA SUS 0.5MG/ML 4 PA FYCOMPA TAB 2MG 4 PA FYCOMPA TAB 4MG 4 PA FYCOMPA TAB 6MG 4 PA FYCOMPA TAB 8MG 4 PA FYCOMPA TAB 10MG 4 PA FYCOMPA TAB 12MG 4 PA gabapentin cap 100 mg 2 gabapentin cap 300 mg 2 gabapentin cap 400 mg 2 gabapentin oral soln 250 mg/5ml 2 gabapentin tab 600 mg 2 gabapentin tab 800 mg 2 GABITRIL TAB 12MG 4 GABITRIL TAB 16MG 4 lamotrigine tab 25 mg 2 lamotrigine tab 25 mg (35) starter kit 2 lamotrigine tab 100 mg 2 lamotrigine tab 150 mg 2 lamotrigine tab 200 mg 2 lamotrigine tab chewable dispersible 5 mg 2 lamotrigine tab chewable dispersible 25 mg 2 levetiracetam in sodium chloride iv soln 4 500 mg/100ml levetiracetam in sodium chloride iv soln 4 1000 mg/100ml levetiracetam in sodium chloride iv soln 4 1500 mg/100ml levetiracetam inj 500 mg/5ml (100 mg/ml) 2 levetiracetam oral soln 100 mg/ml 4 levetiracetam tab 250 mg 2 levetiracetam tab 500 mg 2 55
levetiracetam tab 750 mg 2 levetiracetam tab 1000 mg 2 levetiracetam tab er 24hr 500 mg 2 levetiracetam tab er 24hr 750 mg 2 LYRICA CAP 25MG 4 QL (720 caps / 30 days), PA LYRICA CAP 50MG 4 QL (360 caps / 30 days), PA LYRICA CAP 75MG 4 QL (240 caps / 30 days), PA LYRICA CAP 100MG 4 QL (180 caps / 30 days), PA LYRICA CAP 150MG 4 QL (120 caps / 30 days), PA LYRICA CAP 200MG 4 QL (90 caps / 30 days), PA LYRICA CAP 225MG 4 QL (90 caps / 30 days), PA LYRICA CAP 300MG 4 QL (60 caps / 30 days), PA LYRICA SOL 20MG/ML 4 QL (900 ml / 30 days), PA ONFI SUS 2.5MG/ML 5 PA; DL ONFI TAB 10MG 5 PA; DL ONFI TAB 20MG 5 PA; DL oxcarbazepine susp 300 mg/5ml (60 4 mg/ml) oxcarbazepine tab 150 mg 2 oxcarbazepine tab 300 mg 2 oxcarbazepine tab 600 mg 2 PEGANONE TAB 250MG 4 PHENOBARB INJ 65MG/ML 3 PA phenobarbital elixir 20 mg/5ml 3 PA phenobarbital sodium inj 130 mg/ml 3 PA phenobarbital tab 15 mg 3 PA phenobarbital tab 16.2 mg 3 PA phenobarbital tab 30 mg 3 PA phenobarbital tab 32.4 mg 3 PA phenobarbital tab 60 mg 3 PA phenobarbital tab 64.8 mg 3 PA 56
phenobarbital tab 97.2 mg 3 PA phenobarbital tab 100 mg 3 PA phenytoin chew tab 50 mg 2 phenytoin sodium extended cap 100 mg 2 phenytoin sodium extended cap 200 mg 2 phenytoin sodium extended cap 300 mg 2 phenytoin sodium inj 50 mg/ml 2 phenytoin susp 125 mg/5ml 2 primidone tab 50 mg 2 primidone tab 250 mg 2 roweepra tab 500mg 2 roweepra tab 750mg 2 roweepra tab 1000mg 2 roweepra xr tab 500mg xr 2 roweepra xr tab 750mg xr 2 SABRIL TAB 500MG 5 QL (180 tabs / 30 days), NM, LA, PA; DL SPRITAM TAB 250MG 4 PA SPRITAM TAB 500MG 4 PA SPRITAM TAB 750MG 4 PA SPRITAM TAB 1000MG 4 PA tiagabine hcl tab 2 mg 4 tiagabine hcl tab 4 mg 4 tiagabine hcl tab 12 mg 4 tiagabine hcl tab 16 mg 4 topiramate sprinkle cap 15 mg 3 topiramate sprinkle cap 25 mg 3 topiramate tab 25 mg 2 topiramate tab 50 mg 2 topiramate tab 100 mg 2 topiramate tab 200 mg 2 valproate sodium inj 100 mg/ml 2 valproate sodium oral soln 250 mg/5ml 2 (base equiv) valproic acid cap 250 mg 2 vigabatrin powd pack 500 mg 5 QL (180 packets / 30 days), NM, LA, PA; DL VIMPAT INJ 200MG/20 5 PA; DL VIMPAT SOL 10MG/ML 4 PA 57
VIMPAT TAB 50MG 4 PA VIMPAT TAB 100MG 4 PA VIMPAT TAB 150MG 4 PA VIMPAT TAB 200MG 4 PA zonisamide cap 25 mg 2 zonisamide cap 50 mg 2 zonisamide cap 100 mg 2 ANTIDEMENTIA donepezil hydrochloride orally 2 disintegrating tab 5 mg donepezil hydrochloride orally 2 disintegrating tab 10 mg donepezil hydrochloride tab 5 mg 2 donepezil hydrochloride tab 10 mg 2 galantamine hydrobromide cap er 24hr 8 2 mg galantamine hydrobromide cap er 24hr 16 2 mg galantamine hydrobromide cap er 24hr 24 2 mg galantamine hydrobromide oral soln 4 2 mg/ml galantamine hydrobromide tab 4 mg 2 galantamine hydrobromide tab 8 mg 2 galantamine hydrobromide tab 12 mg 2 memantine hcl oral solution 2 mg/ml 2 PA memantine hcl tab 5 mg 2 QL (60 tabs / 30 days), PA memantine hcl tab 5 mg (28) & 10 mg 3 QL (49 tabs / 28 days), (21) titration pak PA memantine hcl tab 10 mg 2 QL (60 tabs / 30 days), PA rivastigmine tartrate cap 1.5 mg 3 rivastigmine tartrate cap 3 mg 3 rivastigmine tartrate cap 4.5 mg 3 rivastigmine tartrate cap 6 mg 3 rivastigmine td patch 24hr 4.6 mg/24hr 3 rivastigmine td patch 24hr 9.5 mg/24hr 3 rivastigmine td patch 24hr 13.3 mg/24hr 3 ANTIDEPRESSANTS 58
amitriptyline hcl tab 10 mg 2 PA amitriptyline hcl tab 25 mg 2 PA amitriptyline hcl tab 50 mg 2 PA amitriptyline hcl tab 75 mg 2 PA amitriptyline hcl tab 100 mg 2 PA amitriptyline hcl tab 150 mg 2 PA amoxapine tab 25 mg 2 amoxapine tab 50 mg 2 amoxapine tab 100 mg 2 amoxapine tab 150 mg 2 bupropion hcl tab 75 mg 2 bupropion hcl tab 100 mg 2 bupropion hcl tab er 12hr 100 mg 2 bupropion hcl tab er 12hr 150 mg 2 bupropion hcl tab er 12hr 200 mg 2 bupropion hcl tab er 24hr 150 mg 2 bupropion hcl tab er 24hr 300 mg 2 citalopram hydrobromide oral soln 10 1 GC, QL (600 ml / 30 mg/5ml days) citalopram hydrobromide tab 10 mg (base 1 GC, QL (120 tabs / 30 equiv) days) citalopram hydrobromide tab 20 mg (base 1 GC, QL (60 tabs / 30 equiv) days) citalopram hydrobromide tab 40 mg (base 1 GC, QL (30 tabs / 30 equiv) days) clomipramine hcl cap 25 mg 4 PA clomipramine hcl cap 50 mg 4 PA clomipramine hcl cap 75 mg 4 PA desipramine hcl tab 10 mg 2 desipramine hcl tab 25 mg 2 desipramine hcl tab 50 mg 2 desipramine hcl tab 75 mg 2 desipramine hcl tab 100 mg 2 desipramine hcl tab 150 mg 2 DESVENLAFAX TAB 50MG ER 4 QL (240 tabs / 30 days), ST DESVENLAFAX TAB 100MG ER 4 QL (120 tabs / 30 days), ST desvenlafaxine succinate tab er 24hr 25 4 QL (480 tabs / 30 days), mg (base equiv) ST 59
desvenlafaxine succinate tab er 24hr 50 mg (base equiv) 4 QL (240 tabs / 30 days), ST desvenlafaxine succinate tab er 24hr 100 mg (base equiv) 4 QL (120 tabs / 30 days), ST doxepin hcl cap 10 mg 2 PA doxepin hcl cap 25 mg 2 PA doxepin hcl cap 50 mg 2 PA doxepin hcl cap 75 mg 2 PA doxepin hcl cap 100 mg 2 PA doxepin hcl cap 150 mg 2 PA doxepin hcl conc 10 mg/ml 2 PA duloxetine hcl enteric coated pellets cap 20 2 QL (180 caps / 30 days) mg (base eq) duloxetine hcl enteric coated pellets cap 30 2 QL (120 caps / 30 days) mg (base eq) duloxetine hcl enteric coated pellets cap 40 4 QL (90 caps / 30 days) mg (base eq) duloxetine hcl enteric coated pellets cap 60 2 QL (60 caps / 30 days) mg (base eq) EMSAM DIS 6MG/24HR 5 DL EMSAM DIS 9MG/24HR 5 DL EMSAM DIS 12MG/24H 5 DL escitalopram oxalate soln 5 mg/5ml (base 4 QL (600 ml / 30 days) equiv) escitalopram oxalate tab 5 mg (base 2 QL (120 tabs / 30 days) equiv) escitalopram oxalate tab 10 mg (base 2 QL (60 tabs / 30 days) equiv) escitalopram oxalate tab 20 mg (base 2 QL (30 tabs / 30 days) equiv) FETZIMA CAP 20MG 4 QL (180 caps / 30 days), PA FETZIMA CAP 40MG 4 QL (90 caps / 30 days), PA FETZIMA CAP 80MG 4 QL (60 caps / 30 days), PA FETZIMA CAP 120MG 4 QL (30 caps / 30 days), PA FETZIMA CAP TITRATIO 4 QL (28 caps / 28 days), PA 60
fluoxetine hcl cap 10 mg 1 GC fluoxetine hcl cap 20 mg 1 GC fluoxetine hcl cap 40 mg 1 GC fluoxetine hcl solution 20 mg/5ml 1 GC fluoxetine hcl tab 10 mg 1 GC fluoxetine hcl tab 20 mg 1 GC imipramine hcl tab 10 mg 2 PA imipramine hcl tab 25 mg 2 PA imipramine hcl tab 50 mg 2 PA imipramine pamoate cap 75 mg 2 PA imipramine pamoate cap 100 mg 2 PA imipramine pamoate cap 125 mg 2 PA imipramine pamoate cap 150 mg 2 PA maprotiline hcl tab 25 mg 2 maprotiline hcl tab 50 mg 2 maprotiline hcl tab 75 mg 2 MARPLAN TAB 10MG 4 mirtazapine orally disintegrating tab 15 mg 2 mirtazapine orally disintegrating tab 30 mg 2 mirtazapine orally disintegrating tab 45 mg 2 mirtazapine tab 7.5 mg 2 mirtazapine tab 15 mg 2 mirtazapine tab 30 mg 2 mirtazapine tab 45 mg 2 nefazodone hcl tab 50 mg 4 nefazodone hcl tab 100 mg 4 nefazodone hcl tab 150 mg 4 nefazodone hcl tab 200 mg 4 nefazodone hcl tab 250 mg 4 nortriptyline hcl cap 10 mg 1 GC nortriptyline hcl cap 25 mg 1 GC nortriptyline hcl cap 50 mg 1 GC nortriptyline hcl cap 75 mg 1 GC nortriptyline hcl soln 10 mg/5ml 2 paroxetine hcl tab 10 mg 1 GC paroxetine hcl tab 20 mg 1 GC paroxetine hcl tab 30 mg 1 GC paroxetine hcl tab 40 mg 1 GC paroxetine hcl tab er 24hr 12.5 mg 4 61
paroxetine hcl tab er 24hr 25 mg 4 paroxetine hcl tab er 24hr 37.5 mg 4 PAXIL SUS 10MG/5ML 4 phenelzine sulfate tab 15 mg 2 protriptyline hcl tab 5 mg 3 protriptyline hcl tab 10 mg 3 sertraline hcl oral concentrate for solution 2 20 mg/ml sertraline hcl tab 25 mg 2 sertraline hcl tab 50 mg 2 sertraline hcl tab 100 mg 2 tranylcypromine sulfate tab 10 mg 4 trazodone hcl tab 50 mg 1 GC trazodone hcl tab 100 mg 1 GC trazodone hcl tab 150 mg 1 GC trazodone hcl tab 300 mg 4 trimipramine maleate cap 25 mg 2 PA trimipramine maleate cap 50 mg 2 PA trimipramine maleate cap 100 mg 2 PA TRINTELLIX TAB 5MG 4 QL (120 tabs / 30 days), PA TRINTELLIX TAB 10MG 4 QL (60 tabs / 30 days), PA TRINTELLIX TAB 20MG 4 QL (30 tabs / 30 days), PA venlafaxine hcl cap er 24hr 37.5 mg (base 2 QL (300 caps / 30 days) equivalent) venlafaxine hcl cap er 24hr 75 mg (base 2 QL (150 caps / 30 days) equivalent) venlafaxine hcl cap er 24hr 150 mg (base 2 QL (90 caps / 30 days) equivalent) venlafaxine hcl tab 25 mg 2 venlafaxine hcl tab 37.5 mg 2 venlafaxine hcl tab 50 mg 2 venlafaxine hcl tab 75 mg 2 venlafaxine hcl tab 100 mg 2 VIIBRYD KIT STARTER 4 QL (30 tabs / 30 days), PA VIIBRYD TAB 10MG 4 QL (120 tabs / 30 days), PA 62
VIIBRYD TAB 20MG 4 QL (60 tabs / 30 days), PA VIIBRYD TAB 40MG 4 QL (30 tabs / 30 days), PA ANTIPARKINSONIAN AGENTS amantadine hcl cap 100 mg 3 amantadine hcl syrup 50 mg/5ml 3 amantadine hcl tab 100 mg 3 APOKYN INJ 10MG/ML 5 QL (90 ml / 30 days), NM, LA, PA; DL benztropine mesylate inj 1 mg/ml 2 benztropine mesylate tab 0.5 mg 2 benztropine mesylate tab 1 mg 2 benztropine mesylate tab 2 mg 2 bromocriptine mesylate cap 5 mg (base 3 equivalent) bromocriptine mesylate tab 2.5 mg (base equivalent) 3 carbidopa & levodopa orally disintegrating 2 tab 10-100 mg carbidopa & levodopa orally disintegrating 2 tab 25-100 mg carbidopa & levodopa orally disintegrating 2 tab 25-250 mg carbidopa & levodopa tab 10-100 mg 2 carbidopa & levodopa tab 25-100 mg 2 carbidopa & levodopa tab 25-250 mg 2 carbidopa & levodopa tab er 25-100 mg 2 carbidopa & levodopa tab er 50-200 mg 2 carbidopa tab 25 mg 5 DL carbidopa-levodopa-entacapone tabs 12.5-3 50-200 mg carbidopa-levodopa-entacapone tabs 3 18.75-75-200 mg carbidopa-levodopa-entacapone tabs 25-3 100-200 mg carbidopa-levodopa-entacapone tabs 3 31.25-125-200 mg carbidopa-levodopa-entacapone tabs 37.5-3 150-200 mg 63
carbidopa-levodopa-entacapone tabs 50-3 200-200 mg DUOPA SUS 4.63-20 5 entacapone tab 200 mg 3 NEUPRO DIS 1MG/24HR 4 QL (30 patches / 30 days), PA NEUPRO DIS 2MG/24HR 4 QL (30 patches / 30 days), PA NEUPRO DIS 3MG/24HR 4 QL (30 patches / 30 days), PA NEUPRO DIS 4MG/24HR 4 QL (30 patches / 30 days), PA NEUPRO DIS 6MG/24HR 4 QL (30 patches / 30 days), PA NEUPRO DIS 8MG/24HR 4 QL (30 patches / 30 days), PA pramipexole dihydrochloride tab 0.5 mg 2 pramipexole dihydrochloride tab 0.25 mg 2 pramipexole dihydrochloride tab 0.75 mg 2 pramipexole dihydrochloride tab 0.125 mg 2 pramipexole dihydrochloride tab 1 mg 2 pramipexole dihydrochloride tab 1.5 mg 2 rasagiline mesylate tab 0.5 mg (base 3 equiv) rasagiline mesylate tab 1 mg (base equiv) 3 ropinirole hydrochloride tab 0.5 mg 2 ropinirole hydrochloride tab 0.25 mg 2 ropinirole hydrochloride tab 1 mg 2 ropinirole hydrochloride tab 2 mg 2 ropinirole hydrochloride tab 3 mg 2 ropinirole hydrochloride tab 4 mg 2 ropinirole hydrochloride tab 5 mg 2 selegiline hcl cap 5 mg 3 selegiline hcl tab 5 mg 3 trihexyphenidyl hcl elixir 0.4 mg/ml 2 trihexyphenidyl hcl tab 2 mg 2 trihexyphenidyl hcl tab 5 mg 2 ANTIPSYCHOTICS ABILIFY MAIN INJ 300MG 5 QL (2 injections / 28 days); DL 64
ABILIFY MAIN INJ 400MG 5 QL (1 injection / 28 days); DL aripiprazole oral solution 1 mg/ml 3 QL (900 ml / 30 days), PA aripiprazole orally disintegrating tab 10 mg 3 QL (90 tabs / 30 days), PA aripiprazole orally disintegrating tab 15 mg 3 QL (60 tabs / 30 days), PA aripiprazole tab 2 mg 3 QL (450 tabs / 30 days) aripiprazole tab 5 mg 3 QL (180 tabs / 30 days) aripiprazole tab 10 mg 3 QL (90 tabs / 30 days) aripiprazole tab 15 mg 3 QL (60 tabs / 30 days) aripiprazole tab 20 mg 3 QL (45 tabs / 30 days) aripiprazole tab 30 mg 3 QL (30 tabs / 30 days) ARISTADA INJ 441MG/1. 5 QL (2 injections / 28 days); DL ARISTADA INJ 662MG/2 5 QL (2 injections / 28 days); DL ARISTADA INJ 882MG/3 5 QL (1 injection / 28 days); DL ARISTADA INJ 1064MG 5 QL (1 injection / 56 days); DL CHLORPROMAZ INJ 50MG/2ML 2 chlorpromazine hcl tab 10 mg 2 chlorpromazine hcl tab 25 mg 2 chlorpromazine hcl tab 50 mg 2 chlorpromazine hcl tab 100 mg 2 chlorpromazine hcl tab 200 mg 2 clozapine orally disintegrating tab 12.5 mg 2 ST clozapine orally disintegrating tab 25 mg 2 ST clozapine orally disintegrating tab 100 mg 2 ST clozapine orally disintegrating tab 150 mg 4 QL (180 tabs / 30 days), ST clozapine orally disintegrating tab 200 mg 4 QL (150 tabs / 30 days), ST clozapine tab 25 mg 2 clozapine tab 50 mg 2 clozapine tab 100 mg 2 clozapine tab 200 mg 2 ergoloid mesylates tab 1 mg 3 65
FANAPT PAK 4 QL (8 tabs / 30 days), PA FANAPT TAB 1MG 4 QL (720 tabs / 30 days), PA FANAPT TAB 2MG 4 QL (360 tabs / 30 days), PA FANAPT TAB 4MG 4 QL (180 tabs / 30 days), PA FANAPT TAB 6MG 4 QL (120 tabs / 30 days), PA FANAPT TAB 8MG 4 QL (90 tabs / 30 days), PA FANAPT TAB 10MG 4 QL (90 tabs / 30 days), PA FANAPT TAB 12MG 4 QL (60 tabs / 30 days), PA fluphenazine decanoate inj 25 mg/ml 2 fluphenazine hcl elixir 2.5 mg/5ml 2 fluphenazine hcl inj 2.5 mg/ml 2 fluphenazine hcl oral conc 5 mg/ml 2 fluphenazine hcl tab 1 mg 2 fluphenazine hcl tab 2.5 mg 2 fluphenazine hcl tab 5 mg 2 fluphenazine hcl tab 10 mg 2 GEODON INJ 20MG 4 haloperidol decanoate im soln 50 mg/ml 2 haloperidol decanoate im soln 100 mg/ml 2 haloperidol lactate inj 5 mg/ml 2 haloperidol lactate oral conc 2 mg/ml 2 haloperidol tab 0.5 mg 1 GC haloperidol tab 1 mg 1 GC haloperidol tab 2 mg 1 GC haloperidol tab 5 mg 1 GC haloperidol tab 10 mg 1 GC haloperidol tab 20 mg 1 GC INVEGA SUST INJ 39/0.25 4 QL (6 injections / 28 days) INVEGA SUST INJ 78/0.5ML 5 QL (3 injections / 28 days); DL 66
INVEGA SUST INJ 117/0.75 5 QL (2 injections / 28 days); DL INVEGA SUST INJ 156MG/ML 5 QL (2 injections / 28 days); DL INVEGA SUST INJ 234/1.5 5 QL (1 injection / 28 days); DL INVEGA TRINZ INJ 273MG 5 QL (3 injections / 84 days); DL INVEGA TRINZ INJ 410MG 5 QL (2 injections / 84 days); DL INVEGA TRINZ INJ 546MG 5 QL (2 injections / 84 days); DL INVEGA TRINZ INJ 819MG 5 QL (1 injection / 84 days); DL LATUDA TAB 20MG 5 QL (240 tabs / 30 days); DL LATUDA TAB 40MG 5 QL (120 tabs / 30 days); DL LATUDA TAB 60MG 5 QL (90 tabs / 30 days); DL LATUDA TAB 80MG 5 QL (60 tabs / 30 days); DL LATUDA TAB 120MG 5 QL (60 tabs / 30 days); DL loxapine succinate cap 5 mg 2 loxapine succinate cap 10 mg 2 loxapine succinate cap 25 mg 2 loxapine succinate cap 50 mg 2 NUPLAZID TAB 17MG 5 QL (60 tabs / 30 days), olanzapine for im inj 10 mg 2 olanzapine orally disintegrating tab 5 mg 4 QL (120 tabs / 30 days) olanzapine orally disintegrating tab 10 mg 4 QL (60 tabs / 30 days) olanzapine orally disintegrating tab 15 mg 4 QL (60 tabs / 30 days) olanzapine orally disintegrating tab 20 mg 4 QL (30 tabs / 30 days) olanzapine tab 2.5 mg 2 QL (240 tabs / 30 days) olanzapine tab 5 mg 2 QL (120 tabs / 30 days) olanzapine tab 7.5 mg 2 QL (90 tabs / 30 days) olanzapine tab 10 mg 2 QL (60 tabs / 30 days) olanzapine tab 15 mg 2 QL (60 tabs / 30 days) 67
olanzapine tab 20 mg 2 QL (30 tabs / 30 days) paliperidone tab er 24hr 1.5 mg 5 QL (240 tabs / 30 days), PA; DL paliperidone tab er 24hr 3 mg 5 QL (120 tabs / 30 days), PA; DL paliperidone tab er 24hr 6 mg 5 QL (60 tabs / 30 days), PA; DL paliperidone tab er 24hr 9 mg 5 QL (60 tabs / 30 days), PA; DL perphenazine tab 2 mg 2 perphenazine tab 4 mg 2 perphenazine tab 8 mg 2 perphenazine tab 16 mg 2 pimozide tab 1 mg 2 pimozide tab 2 mg 2 quetiapine fumarate tab 25 mg 2 QL (960 tabs / 30 days), PA quetiapine fumarate tab 50 mg 2 QL (480 tabs / 30 days), PA quetiapine fumarate tab 100 mg 2 QL (240 tabs / 30 days) quetiapine fumarate tab 200 mg 2 QL (120 tabs / 30 days) quetiapine fumarate tab 300 mg 2 QL (90 tabs / 30 days) quetiapine fumarate tab 400 mg 2 QL (90 tabs / 30 days) quetiapine fumarate tab er 24hr 50 mg 4 PA quetiapine fumarate tab er 24hr 150 mg 4 PA quetiapine fumarate tab er 24hr 200 mg 4 PA quetiapine fumarate tab er 24hr 300 mg 4 PA quetiapine fumarate tab er 24hr 400 mg 4 PA REXULTI TAB 0.5MG 5 QL (240 tabs / 30 days), PA; DL REXULTI TAB 0.25MG 5 QL (480 tabs / 30 days), PA; DL REXULTI TAB 1MG 5 QL (120 tabs / 30 days), PA; DL REXULTI TAB 2MG 5 QL (60 tabs / 30 days), PA; DL REXULTI TAB 3MG 5 QL (45 tabs / 30 days), PA; DL REXULTI TAB 4MG 5 QL (30 tabs / 30 days), PA; DL 68
RISPERDAL INJ 12.5MG 4 QL (8 vials / 28 days) RISPERDAL INJ 25MG 4 QL (4 vials / 28 days) RISPERDAL INJ 37.5MG 5 QL (4 vials / 28 days); DL RISPERDAL INJ 50MG 5 QL (2 vials / 28 days); DL risperidone orally disintegrating tab 0.5 mg 4 QL (960 tabs / 30 days) risperidone orally disintegrating tab 0.25 mg 4 QL (1920 tabs / 30 days) risperidone orally disintegrating tab 1 mg 4 QL (480 tabs / 30 days) risperidone orally disintegrating tab 2 mg 4 QL (240 tabs / 30 days) risperidone orally disintegrating tab 3 mg 4 QL (180 tabs / 30 days) risperidone orally disintegrating tab 4 mg 4 QL (120 tabs / 30 days) risperidone soln 1 mg/ml 2 risperidone tab 0.5 mg 2 QL (960 tabs / 30 days) risperidone tab 0.25 mg 2 QL (1920 tabs / 30 days) risperidone tab 1 mg 2 QL (480 tabs / 30 days) risperidone tab 2 mg 2 QL (240 tabs / 30 days) risperidone tab 3 mg 2 QL (180 tabs / 30 days) risperidone tab 4 mg 2 QL (120 tabs / 30 days) SAPHRIS SUB 2.5MG 4 QL (240 tabs / 30 days), PA SAPHRIS SUB 5MG 4 QL (120 tabs / 30 days), PA SAPHRIS SUB 10MG 4 QL (60 tabs / 30 days), PA thioridazine hcl tab 10 mg 2 thioridazine hcl tab 25 mg 2 thioridazine hcl tab 50 mg 2 thioridazine hcl tab 100 mg 2 thiothixene cap 1 mg 2 thiothixene cap 2 mg 2 thiothixene cap 5 mg 2 thiothixene cap 10 mg 2 trifluoperazine hcl tab 1 mg (base 2 equivalent) trifluoperazine hcl tab 2 mg (base equivalent) 2 69
trifluoperazine hcl tab 5 mg (base 2 equivalent) trifluoperazine hcl tab 10 mg (base 2 equivalent) VERSACLOZ SUS 50MG/ML 5 QL (540 ml / 30 days), PA; DL VRAYLAR CAP 1.5-3MG 4 QL (7 caps / 30 days), PA VRAYLAR CAP 1.5MG 5 QL (120 caps / 30 days), PA; DL VRAYLAR CAP 3MG 5 QL (60 caps / 30 days), PA; DL VRAYLAR CAP 4.5MG 5 QL (60 caps / 30 days), PA; DL VRAYLAR CAP 6MG 5 QL (30 caps / 30 days), PA; DL ziprasidone hcl cap 20 mg 3 QL (300 caps / 30 days) ziprasidone hcl cap 40 mg 3 QL (150 caps / 30 days) ziprasidone hcl cap 60 mg 3 QL (120 caps / 30 days) ziprasidone hcl cap 80 mg 3 QL (90 caps / 30 days) ZYPREXA RELP INJ 210MG 4 QL (3 vials / 28 days) ZYPREXA RELP INJ 300MG 4 QL (3 vials / 28 days) ZYPREXA RELP INJ 405MG 4 QL (3 vials / 28 days) ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine-dextroamphetamine cap er 4 QL (30 caps / 30 days) 24hr 5 mg amphetamine-dextroamphetamine cap er 4 QL (30 caps / 30 days) 24hr 10 mg amphetamine-dextroamphetamine cap er 4 QL (30 caps / 30 days) 24hr 15 mg amphetamine-dextroamphetamine cap er 4 QL (60 caps / 30 days) 24hr 20 mg amphetamine-dextroamphetamine cap er 4 QL (60 caps / 30 days) 24hr 25 mg amphetamine-dextroamphetamine cap er 4 QL (60 caps / 30 days) 24hr 30 mg amphetamine-dextroamphetamine tab 5 mg 2 QL (90 tabs / 30 days) amphetamine-dextroamphetamine tab 7.5 2 QL (90 tabs / 30 days) mg 70
amphetamine-dextroamphetamine tab 10 2 QL (90 tabs / 30 days) mg amphetamine-dextroamphetamine tab 2 QL (90 tabs / 30 days) 12.5 mg amphetamine-dextroamphetamine tab 15 2 QL (60 tabs / 30 days) mg amphetamine-dextroamphetamine tab 20 2 QL (90 tabs / 30 days) mg amphetamine-dextroamphetamine tab 30 2 QL (60 tabs / 30 days) mg atomoxetine hcl cap 10 mg (base equiv) 4 QL (30 caps / 30 days) atomoxetine hcl cap 18 mg (base equiv) 4 QL (60 caps / 30 days) atomoxetine hcl cap 25 mg (base equiv) 4 QL (90 caps / 30 days) atomoxetine hcl cap 40 mg (base equiv) 4 QL (30 caps / 30 days) atomoxetine hcl cap 60 mg (base equiv) 4 QL (30 caps / 30 days) atomoxetine hcl cap 80 mg (base equiv) 4 QL (30 caps / 30 days) atomoxetine hcl cap 100 mg (base equiv) 4 QL (30 caps / 30 days) clonidine hcl tab er 12hr 0.1 mg 3 QL (120 tabs / 30 days), PA dextroamphetamine sulfate cap er 24hr 5 mg 4 QL (30 caps / 30 days) dextroamphetamine sulfate cap er 24hr 10 4 QL (120 caps / 30 days) mg dextroamphetamine sulfate cap er 24hr 15 4 QL (120 caps / 30 days) mg dextroamphetamine sulfate tab 5 mg 2 QL (180 tabs / 30 days) dextroamphetamine sulfate tab 10 mg 2 QL (180 tabs / 30 days) metadate tab 20mg er 4 QL (90 tabs / 30 days) methamphetamine hcl tab 5 mg 2 QL (150 tabs / 30 days), PA methylphenidate hcl cap er 10 mg (cd) 4 QL (30 caps / 30 days) methylphenidate hcl cap er 20 mg (cd) 4 QL (30 caps / 30 days) methylphenidate hcl cap er 24hr 60 mg 4 QL (30 caps / 30 days) (la) methylphenidate hcl cap er 30 mg (cd) 4 QL (30 caps / 30 days) methylphenidate hcl cap er 40 mg (cd) 4 QL (30 caps / 30 days) methylphenidate hcl cap er 50 mg (cd) 4 QL (30 caps / 30 days) methylphenidate hcl cap er 60 mg (cd) 4 QL (30 caps / 30 days) methylphenidate hcl soln 5 mg/5ml 2 QL (1800 ml / 30 days) methylphenidate hcl soln 10 mg/5ml 2 QL (900 ml / 30 days) 71
methylphenidate hcl tab 5 mg 2 QL (90 tabs / 30 days) methylphenidate hcl tab 10 mg 2 QL (90 tabs / 30 days) methylphenidate hcl tab 20 mg 2 QL (150 tabs / 30 days) methylphenidate hcl tab er 10 mg 4 QL (90 tabs / 30 days) methylphenidate hcl tab er 20 mg 4 QL (90 tabs / 30 days) methylphenidate hcl tab er osmotic release 4 QL (30 tabs / 30 days) (osm) 18 mg methylphenidate hcl tab er osmotic release 4 QL (30 tabs / 30 days) (osm) 27 mg methylphenidate hcl tab er osmotic release 4 QL (60 tabs / 30 days) (osm) 36 mg methylphenidate hcl tab er osmotic release 4 QL (30 tabs / 30 days) (osm) 54 mg methylphenidate hcl tab er osmotic release 4 QL (30 tabs / 30 days) (osm) 72 mg zenzedi tab 5mg 2 QL (180 tabs / 30 days) zenzedi tab 10mg 2 QL (180 tabs / 30 days) HYPNOTICS HETLIOZ CAP 20MG 5 QL (30 caps / 30 days), ROZEREM TAB 8MG 3 QL (30 tabs / 30 days) SILENOR TAB 3MG 4 QL (30 tabs / 30 days) SILENOR TAB 6MG 4 QL (30 tabs / 30 days) temazepam cap 7.5 mg 2 QL (30 caps / 30 days) temazepam cap 15 mg 2 QL (60 caps / 30 days) temazepam cap 22.5 mg 2 QL (30 caps / 30 days) temazepam cap 30 mg 2 QL (30 caps / 30 days) zaleplon cap 5 mg 2 QL (30 caps / 30 days), ST zaleplon cap 10 mg 2 QL (30 caps / 30 days), ST zolpidem tartrate tab 5 mg 2 QL (30 tabs / 30 days), ST zolpidem tartrate tab 10 mg 2 QL (30 tabs / 30 days), ST MIGRAINE dihydroergotamine mesylate inj 1 mg/ml 3 dihydroergotamine mesylate nasal spray 4 5 DL mg/ml migergot sup 2/100 5 DL 72
naratriptan hcl tab 1 mg (base equiv) 2 QL (9 tabs / 28 days) naratriptan hcl tab 2.5 mg (base equiv) 2 QL (9 tabs / 28 days) rizatriptan benzoate oral disintegrating tab 2 QL (24 tabs / 28 days) 5 mg (base eq) rizatriptan benzoate oral disintegrating tab 2 QL (12 tabs / 28 days) 10 mg (base eq) rizatriptan benzoate tab 5 mg (base 2 QL (24 tabs / 28 days) equivalent) rizatriptan benzoate tab 10 mg (base 2 QL (12 tabs / 28 days) equivalent) sumatriptan nasal spray 5 mg/act 4 QL (18 inhalers / 28 days) sumatriptan nasal spray 20 mg/act 4 QL (12 inhalers / 28 days) sumatriptan succinate inj 6 mg/0.5ml 4 QL (4 ml / 28 days) sumatriptan succinate solution autoinjector 4 QL (4 ml / 28 days) 4 mg/0.5ml sumatriptan succinate solution autoinjector 6 mg/0.5ml 4 QL (4 ml / 28 days) sumatriptan succinate solution cartridge 4 4 QL (4 ml / 28 days) mg/0.5ml sumatriptan succinate tab 25 mg 2 QL (9 tabs / 28 days) sumatriptan succinate tab 50 mg 2 QL (9 tabs / 28 days) sumatriptan succinate tab 100 mg 2 QL (9 tabs / 28 days) zolmitriptan orally disintegrating tab 2.5 mg 4 QL (6 tabs / 28 days) zolmitriptan orally disintegrating tab 5 mg 4 QL (6 tabs / 28 days) zolmitriptan tab 2.5 mg 4 QL (6 tabs / 28 days) zolmitriptan tab 5 mg 4 QL (6 tabs / 28 days) MISCELLANEOUS EQUETRO CAP 100MG 4 EQUETRO CAP 200MG 4 EQUETRO CAP 300MG 4 GRALISE STAR MIS 300/600 4 QL (156 tabs / 365 days), PA GRALISE TAB 300MG 4 QL (30 tabs / 30 days), PA GRALISE TAB 600MG 4 QL (90 tabs / 30 days), PA GUANIDINE TAB 125MG 2 73
HORIZANT TAB 300MG 4 QL (60 tabs / 30 days), PA HORIZANT TAB 600MG 4 QL (60 tabs / 30 days), PA lithium carbonate cap 150 mg 1 GC lithium carbonate cap 300 mg 1 GC lithium carbonate cap 600 mg 1 GC lithium carbonate tab 300 mg 1 GC lithium carbonate tab er 300 mg 2 lithium carbonate tab er 450 mg 2 LITHIUM SOL 8MEQ/5ML 2 MESTINON SYP 60MG/5ML 4 neostigmine methylsulfate iv soln 5 mg/10 2 ml (0.5 mg/ml) neostigmine methylsulfate iv soln 10 2 mg/10 ml (1 mg/ml) NUEDEXTA CAP 20-10MG 4 QL (60 caps / 30 days), PA pyridostigmine bromide tab 60 mg 2 REGONOL INJ 5MG/ML 2 riluzole tab 50 mg 3 SAVELLA MIS TITR PAK 4 QL (110 tabs / 365 days), PA SAVELLA TAB 12.5MG 4 QL (60 tabs / 30 days), PA SAVELLA TAB 25MG 4 QL (60 tabs / 30 days), PA SAVELLA TAB 50MG 4 QL (60 tabs / 30 days), PA SAVELLA TAB 100MG 4 QL (60 tabs / 30 days), PA tetrabenazine tab 12.5 mg 5 QL (240 tabs / 30 days), tetrabenazine tab 25 mg 5 QL (120 tabs / 30 days), MULTIPLE SCLEROSIS AGENTS AMPYRA TAB 10MG 5 QL (60 tabs / 30 days), NM, LA, PA; DL AUBAGIO TAB 7MG 5 QL (30 tabs / 30 days), 74
AUBAGIO TAB 14MG 5 QL (30 tabs / 30 days), BETASERON INJ 0.3MG 5 QL (14 injections / 28 days), COPAXONE INJ 40MG/ML 5 QL (12 syringes / 28 days), GILENYA CAP 0.5MG 5 QL (30 caps / 30 days), glatopa inj 20mg/ml 5 QL (30 syringes / 30 days), TYSABRI INJ 300/15ML 5 QL (15 ml / 28 days), NM, LA, PA; DL MUSCULOSKELETAL THERAPY AGENTS baclofen tab 5 mg 2 baclofen tab 10 mg 2 baclofen tab 20 mg 2 BOTOX INJ 100UNIT 4 QL (4 ml / 84 days), PA BOTOX INJ 200UNIT 4 QL (2 ml / 84 days), PA carisoprodol tab 350 mg 2 PA carisoprodol w/ aspirin & codeine tab 200-325-16 mg 4 QL (240 tabs / 30 days), PA carisoprodol w/ aspirin tab 200-325 mg 2 PA chlorzoxazone tab 500 mg 2 PA cyclobenzaprine hcl tab 5 mg 2 PA cyclobenzaprine hcl tab 10 mg 2 PA dantrolene sodium cap 25 mg 3 dantrolene sodium cap 50 mg 3 dantrolene sodium cap 100 mg 3 DYSPORT INJ 300UNIT 4 QL (3 ml / 84 days), PA DYSPORT INJ 500UNIT 4 QL (3 ml / 84 days), PA GABLOFEN INJ 20000/20 4 B/D LIORESAL INT INJ 10MG/5ML 5 B/D; DL LIORESAL INT INJ 10MG/20 4 B/D methocarbamol tab 500 mg 2 PA methocarbamol tab 750 mg 2 PA orphenadrine citrate inj 30 mg/ml 2 PA orphenadrine citrate tab er 12hr 100 mg 2 PA tizanidine hcl tab 2 mg (base equivalent) 2 tizanidine hcl tab 4 mg (base equivalent) 2 75
XEOMIN INJ 50 UNIT 4 QL (8 injections / 84 days), PA XEOMIN INJ 100UNIT 4 QL (8 injections / 84 days), PA NARCOLEPSY/CATAPLEXY armodafinil tab 50 mg 4 QL (30 tabs / 30 days), PA armodafinil tab 150 mg 4 QL (30 tabs / 30 days), PA armodafinil tab 200 mg 4 QL (30 tabs / 30 days), PA armodafinil tab 250 mg 4 QL (30 tabs / 30 days), PA dexmethylphenidate hcl tab 2.5 mg 2 QL (60 tabs / 30 days) dexmethylphenidate hcl tab 5 mg 2 QL (60 tabs / 30 days) dexmethylphenidate hcl tab 10 mg 2 QL (60 tabs / 30 days) modafinil tab 100 mg 3 QL (60 tabs / 30 days), PA modafinil tab 200 mg 3 QL (60 tabs / 30 days), PA XYREM SOL 500MG/ML 5 QL (540 ml / 30 days), NM, LA, PA; DL PSYCHOTHERAPEUTIC-MISC acamprosate calcium tab delayed release 333 mg 2 buprenorphine hcl sl tab 2 mg (base equiv) 2 QL (60 tabs / 30 days), PA buprenorphine hcl sl tab 8 mg (base equiv) 2 QL (60 tabs / 30 days), PA buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv) 3 QL (90 tabs / 30 days), PA buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv) 3 QL (90 tabs / 30 days), PA bupropion hcl (smoking deterrent) tab er 2 12hr 150 mg CHANTIX PAK 0.5& 1MG 4 QL (106 tabs / year) CHANTIX PAK 1MG 4 QL (336 tabs / year) CHANTIX TAB 0.5MG 4 QL (336 tabs / year) CHANTIX TAB 1MG 4 QL (336 tabs / year) 76
chlordiazepoxide-amitriptyline tab 5-12.5 2 mg chlordiazepoxide-amitriptyline tab 10-25 2 mg disulfiram tab 250 mg 2 disulfiram tab 500 mg 2 naloxone hcl inj 0.4 mg/ml 2 naloxone hcl inj 4 mg/10ml 2 naloxone hcl soln cartridge 0.4 mg/ml 2 naloxone hcl soln prefilled syringe 2 2 mg/2ml naltrexone hcl tab 50 mg 2 NICOTROL INH 4 NICOTROL NS SPR 10MG/ML 4 perphenazine-amitriptyline tab 2-10 mg 2 perphenazine-amitriptyline tab 2-25 mg 2 perphenazine-amitriptyline tab 4-10 mg 2 perphenazine-amitriptyline tab 4-25 mg 2 perphenazine-amitriptyline tab 4-50 mg 2 SUBOXONE MIS 2-0.5MG 4 QL (60 SL films / 30 days), PA SUBOXONE MIS 4-1MG 4 QL (60 SL films / 30 days), PA SUBOXONE MIS 8-2MG 4 QL (60 SL films / 30 days), PA SUBOXONE MIS 12-3MG 4 QL (60 SL films / 30 days), PA ENDOCRINE AND METABOLIC ANDROGENS ANADROL-50 TAB 50MG 5 PA; DL ANDRODERM DIS 2MG/24HR 4 PA ANDRODERM DIS 4MG/24HR 4 PA oxandrolone tab 2.5 mg 3 PA oxandrolone tab 10 mg 3 PA STRIANT MIS 30MG 4 PA testosterone cypionate im inj in oil 100 2 PA mg/ml testosterone cypionate im inj in oil 200 mg/ml 2 PA 77
testosterone enanthate im inj in oil 200 2 PA mg/ml testosterone td gel 12.5 mg/act (1%) 3 PA testosterone td gel 25 mg/2.5gm (1%) 3 PA testosterone td gel 50 mg/5gm (1%) 3 PA ANTIDIABETICS, INJECTABLE BYDUREON INJ 2MG 3 QL (4 vials / 28 days) BYDUREON INJ BCISE 3 QL (4 pens / 28 days) BYDUREON PEN INJ 2MG 3 QL (4 pens / 28 days) BYETTA INJ 5MCG 4 QL (1 pen / 28 days) BYETTA INJ 10MCG 4 QL (1 pen / 28 days) FIASP FLEX INJ TOUCH 3 QL (15 pens / 30 days) FIASP INJ 100/ML 3 QL (5 vials / 30 days) GAUZE PADS & DRESSINGS - PADS 2 X 2 3 HUMULIN R INJ U-500 3 QL (12 pens / 30 days) HUMULIN R INJ U-500 3 QL (40 ml / 30 days) INSULIN PEN NEEDLE 3 INSULIN SYRINGE (DISP) U-100 0.3 ML 3 INSULIN SYRINGE (DISP) U-100 1 ML 3 INSULIN SYRINGE (DISP) U-100 1/2 ML 3 ISOPROPYL ALCOHOL 0.7ML/ML 2 LANTUS INJ 100/ML 3 QL (50 ml / 30 days) LANTUS INJ SOLOSTAR 3 QL (45 ml / 30 days) LEVEMIR INJ 3 QL (50 ml / 30 days) LEVEMIR INJ FLEXTOUC 3 QL (15 pens / 30 days) NEEDLES, INSULIN DISP., SAFETY 3 NOVOLIN INJ 70/30 3 QL (50 ml / 30 days); (brand RELION not covered) NOVOLIN N INJ U-100 3 QL (50 ml / 30 days); (brand RELION not covered) NOVOLIN R INJ U-100 3 QL (50 ml / 30 days); (brand RELION not covered) NOVOLOG INJ 100/ML 3 QL (50 ml / 30 days) NOVOLOG INJ FLEXPEN 3 QL (15 pens / 30 days) NOVOLOG INJ PENFILL 3 QL (15 pens / 30 days) NOVOLOG MIX INJ 70/30 3 QL (50 ml / 30 days) 78
NOVOLOG MIX INJ FLEXPEN 3 QL (15 pens / 30 days) OZEMPIC INJ 2/1.5ML 3 QL (1 pen / 28 days); 0.25MG OR 0.5MG/DOSE OZEMPIC INJ 2/1.5ML 3 QL (2 pens / 28 days); 1MG/DOSE SYMLINPEN 60 INJ 1000MCG 3 QL (8 pens / 28 days), ST SYMLNPEN 120 INJ 1000MCG 3 QL (4 pens / 28 days), ST TOUJEO SOLO INJ 300IU/ML 3 QL (3 pens / 30 days) TOUJEO SOLO INJ 300IU/ML 3 QL (6 pens / 30 days) TRESIBA FLEX INJ 100UNIT 3 QL (15 pens / 30 days) TRESIBA FLEX INJ 200UNIT 3 QL (9 pens / 30 days) TRULICITY INJ 0.75/0.5 3 QL (4 pens / 28 days) TRULICITY INJ 1.5/0.5 3 QL (4 pens / 28 days) VICTOZA INJ 18MG/3ML 3 QL (3 pens / 30 days) XULTOPHY INJ 100/3.6 3 QL (5 pens / 30 days) ANTIDIABETICS, ORAL acarbose tab 25 mg 2 acarbose tab 50 mg 2 acarbose tab 100 mg 2 glimepiride tab 1 mg 6 QL (240 tabs / 30 days) glimepiride tab 2 mg 6 QL (120 tabs / 30 days) glimepiride tab 4 mg 6 QL (60 tabs / 30 days) glipizide tab 5 mg 6 QL (240 tabs / 30 days) glipizide tab 10 mg 6 QL (120 tabs / 30 days) glipizide tab er 24hr 2.5 mg 6 QL (240 tabs / 30 days) glipizide tab er 24hr 5 mg 6 QL (120 tabs / 30 days) glipizide tab er 24hr 10 mg 6 QL (60 tabs / 30 days) glipizide-metformin hcl tab 2.5-250 mg 2 QL (240 tabs / 30 days) glipizide-metformin hcl tab 2.5-500 mg 2 QL (120 tabs / 30 days) glipizide-metformin hcl tab 5-500 mg 2 QL (120 tabs / 30 days) INVOKAMET TAB 50-500MG 3 QL (120 tabs / 30 days) INVOKAMET TAB 50-1000 3 QL (60 tabs / 30 days) INVOKAMET TAB 150-500 3 QL (60 tabs / 30 days) INVOKAMET TAB 150-1000 3 QL (60 tabs / 30 days) INVOKAMET XR TAB 50-500MG 3 QL (120 tabs / 30 days) INVOKAMET XR TAB 50-1000 3 QL (60 tabs / 30 days) 79
INVOKAMET XR TAB 150-500 3 QL (60 tabs / 30 days) INVOKAMET XR TAB 150-1000 3 QL (60 tabs / 30 days) INVOKANA TAB 100MG 3 QL (30 tabs / 30 days) INVOKANA TAB 300MG 3 QL (30 tabs / 30 days) JANUMET TAB 50-500MG 3 JANUMET TAB 50-1000 3 JANUMET XR TAB 50-500MG 3 JANUMET XR TAB 50-1000 3 JANUMET XR TAB 100-1000 3 JANUVIA TAB 25MG 3 JANUVIA TAB 50MG 3 JANUVIA TAB 100MG 3 JARDIANCE TAB 10MG 3 QL (60 tabs / 30 days) JARDIANCE TAB 25MG 3 QL (30 tabs / 30 days) JENTADUETO TAB 2.5-500 3 JENTADUETO TAB 2.5-850 3 JENTADUETO TAB 2.5-1000 3 JENTADUETO TAB XR 3 metformin hcl tab 500 mg 6 QL (150 tabs / 30 days) metformin hcl tab 850 mg 6 QL (90 tabs / 30 days) metformin hcl tab 1000 mg 6 QL (75 tabs / 30 days) metformin hcl tab er 24hr 500 mg 6 metformin hcl tab er 24hr 750 mg 6 QL (60 tabs / 30 days) nateglinide tab 60 mg 2 nateglinide tab 120 mg 2 pioglitazone hcl tab 15 mg (base equiv) 6 QL (30 tabs / 30 days) pioglitazone hcl tab 30 mg (base equiv) 6 QL (30 tabs / 30 days) pioglitazone hcl tab 45 mg (base equiv) 6 QL (30 tabs / 30 days) pioglitazone hcl-metformin hcl tab 15-500 4 QL (90 tabs / 30 days) mg pioglitazone hcl-metformin hcl tab 15-850 4 QL (90 tabs / 30 days) mg repaglinide tab 0.5 mg 2 repaglinide tab 1 mg 2 repaglinide tab 2 mg 2 RIOMET SOL 4 QL (765 ml / 30 days) SYNJARDY TAB 3 QL (60 tabs / 30 days) SYNJARDY TAB 5-500MG 3 QL (60 tabs / 30 days) SYNJARDY TAB 5-1000MG 3 QL (60 tabs / 30 days) 80
SYNJARDY TAB 12.5-500 3 QL (60 tabs / 30 days) SYNJARDY XR TAB 3 QL (60 tabs / 30 days) SYNJARDY XR TAB 5-1000MG 3 QL (60 tabs / 30 days) SYNJARDY XR TAB 10-1000 3 QL (30 tabs / 30 days) SYNJARDY XR TAB 25-1000 3 QL (30 tabs / 30 days) tolazamide tab 250 mg 2 QL (120 tabs / 30 days) tolazamide tab 500 mg 2 QL (60 tabs / 30 days) tolbutamide tab 500 mg 2 QL (180 tabs / 30 days) TRADJENTA TAB 5MG 3 BISPHOSPHONATES alendronate sodium oral soln 70 mg/75ml 4 alendronate sodium tab 5 mg 1 GC alendronate sodium tab 10 mg 1 GC alendronate sodium tab 35 mg 1 GC alendronate sodium tab 40 mg 1 GC alendronate sodium tab 70 mg 1 GC etidronate disodium tab 200 mg 2 etidronate disodium tab 400 mg 2 ibandronate sodium iv soln 3 mg/3ml (base equivalent) 3 QL (1 injection / 90 days) ibandronate sodium tab 150 mg (base 3 QL (1 tab / 28 days) equivalent) pamidronate disodium for inj 30 mg 2 pamidronate disodium for inj 90 mg 2 pamidronate disodium iv soln 3 mg/ml 2 pamidronate disodium iv soln 9 mg/ml 2 PAMIDRONATE INJ 6MG/ML 2 risedronate sodium tab 150 mg 4 QL (1 tab / 28 days), ST risedronate sodium tab delayed release 35 4 QL (4 tabs / 28 days), mg ST risedronate tab 35mg 4 QL (12 tabs / 84 days) zoledronic acid inj conc for iv infusion 4 4 NM mg/5ml zoledronic acid iv soln 5 mg/100ml 2 QL (100 ml / year), NM ZOMETA INJ 4MG/100 5 NM; DL CALCIUM RECEPTOR AGONISTS SENSIPAR TAB 30MG 3 B/D, NM SENSIPAR TAB 60MG 5 B/D, NM; DL SENSIPAR TAB 90MG 5 B/D, NM; DL 81
CHELATING AGENTS CHEMET CAP 100MG 4 PA DEPEN TITRA TAB 250MG 5 PA; DL EXJADE TAB 125MG 5 NM, LA, PA; DL EXJADE TAB 250MG 5 NM, LA, PA; DL EXJADE TAB 500MG 5 NM, LA, PA; DL FERRIPROX SOL 100MG/ML 5 FERRIPROX TAB 500MG 5 JADENU SPRKL GRA 90MG 5 JADENU SPRKL GRA 180MG 5 JADENU SPRKL GRA 360MG 5 JADENU TAB 90MG 5 JADENU TAB 180MG 5 JADENU TAB 360MG 5 kionex sus 15gm/60 2 sodium polystyrene sulfonate powder 2 sps sus 15gm/60 2 SYPRINE CAP 250MG 5 PA; DL trientine hcl cap 250 mg 5 PA; DL VELTASSA POW 8.4GM 4 QL (30 packets / 30 days), PA VELTASSA POW 16.8GM 4 QL (30 packets / 30 days), PA VELTASSA POW 25.2GM 4 QL (30 packets / 30 days), PA CONTRACEPTIVES altavera tab 2 alyacen tab 1/35 2 alyacen tab 7/7/7 2 amethia lo tab 2 amethia tab 2 apri tab 2 aranelle tab 2 ashlyna tab 2 aubra tab 0.1-0.02 2 aviane tab 2 azurette tab 28 day 2 balziva tab 2 bekyree tab 2 82
blisovi 24 tab fe 1/20 2 blisovi fe tab 1.5/30 2 blisovi fe tab 1/20 2 briellyn tab 2 camila tab 0.35mg 2 camrese lo tab 2 camrese tab 2 caziant pak 2 chateal tab 0.15/30 2 cryselle-28 tab 28 tabs 2 cyclafem tab 1/35 2 cyclafem tab 7/7/7 2 cyred tab 2 dasetta tab 1/35 2 dasetta tab 7/7/7 2 daysee tab 2 deblitane tab 0.35mg 2 delyla tab 0.1-0.02 2 DEPO-SQ PROV INJ 104 4 QL (1 injection / 84 days) desogest-eth estrad & eth estrad tab 0.15-2 0.02/0.01 mg(21/5) desogestrel & ethinyl estradiol tab 0.15 2 mg-30 mcg drospirenone-ethinyl estradiol tab 3-0.02 2 mg drospirenone-ethinyl estradiol tab 3-0.03 2 mg elinest tab 2 ELLA TAB 30MG 3 emoquette tab 2 enpresse-28 tab 2 enskyce tab 2 errin tab 0.35mg 2 estarylla tab 0.25-35 2 ethynodiol diacetate & ethinyl estradiol tab 2 1 mg-35 mcg ethynodiol diacetate & ethinyl estradiol tab 2 1 mg-50 mcg falmina tab 2 83
femynor tab 0.25-35 2 gianvi tab 3-0.02mg 2 gildess fe tab 1.5/30 2 gildess fe tab 1/20 2 gildess tab 1/20 2 heather tab 0.35mg 2 introvale tab 2 isibloom tab 0.15-30 2 jencycla tab 0.35mg 2 jolessa tab 2 jolivette tab 0.35mg 2 juleber tab 2 junel 1.5/30 tab 2 junel 1/20 tab 2 junel fe 24 tab 1/20 2 junel fe tab 1.5/30 2 junel fe tab 1/20 2 kaitlib fe chw 2 kariva tab 28 day 2 kelnor 1/50 tab 2 kelnor tab 1/35 2 kimidess tab 2 kurvelo tab 0.15/30 2 larin 24 tab fe 1/20 2 larin fe tab 1.5/30 2 larin fe tab 1/20 2 larin tab 1.5/30 2 larin tab 1/20 2 larissia tab 2 layolis fe chw 2 leena tab 2 lessina tab 2 levonest tab 2 levonorg-eth est tab 0.1-0.02mg(84) & eth 2 est tab 0.01mg(7) levonorg-eth est tab 0.15-0.03mg(84) & 2 eth est tab 0.01mg(7) levonorgestrel & ethinyl estradiol (91-day) 2 tab 0.15-0.03 mg 84
levonorgestrel & ethinyl estradiol tab 0.1 2 mg-20 mcg levonorgestrel & ethinyl estradiol tab 0.15 2 mg-30 mcg levonorgestrel-eth estra tab 0.05-2 30/0.075-40/0.125-30mg-mcg levonorgestrel-ethinyl estradiol 2 (continuous) tab 90-20 mcg levora-28 tab 0.15/30 2 loryna tab 3-0.02mg 2 low-ogestrel tab 2 lutera tab 2 lyza tab 0.35mg 2 marlissa tab 0.15/30 2 medroxyprogesterone acetate im susp 150 2 QL (1 injection / 84 mg/ml days) medroxyprogesterone acetate im susp prefilled syr 150 mg/ml 2 QL (1 injection / 84 days) microgestin tab 1.5/30 2 microgestin tab 1/20 2 microgestin tab fe1.5/30 2 microgestin tab fe 1/20 2 mili tab 0.25/35 2 mono-linyah tab 0.25-35 2 mononessa tab 2 myzilra tab 2 necon tab 0.5/35 2 necon tab 7/7/7 2 nikki tab 3-0.02mg 2 nora-be tab 0.35mg 2 norethindrone & ethinyl estradiol-fe chew 2 tab 0.4 mg-35 mcg norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg 2 norethindrone ace & ethinyl estradiol tab 1 2 mg-20 mcg norethindrone ace & ethinyl estradiol-fe 2 tab 1 mg-20 mcg norethindrone ace-ethinyl estradiol-fe tab 2 1 mg-20 mcg (24) 85
norethindrone tab 0.35 mg 2 norgestimate & ethinyl estradiol tab 0.25 2 mg-35 mcg norgestimate-eth estrad tab 0.18-2 25/0.215-25/0.25-25 mg-mcg norgestimate-eth estrad tab 0.18-2 35/0.215-35/0.25-35 mg-mcg norlyroc tab 0.35mg 2 nortrel tab 0.5/35 2 nortrel tab 1/35 2 nortrel tab 7/7/7 2 NUVARING MIS 4 QL (1 ring / 28 days) ocella tab 3-0.03mg 2 ogestrel tab 2 orsythia tab 2 philith tab 0.4-35 2 pimtrea tab 2 pirmella tab 1/35 2 pirmella tab 7/7/7 2 portia-28 tab 2 previfem tab 2 quasense tab 2 reclipsen tab 2 setlakin tab 2 sharobel tab 0.35mg 2 sprintec 28 tab 28 day 2 sronyx tab 2 syeda tab 3-0.03mg 2 tarina fe tab 1/20 2 tilia fe tab 2 tri-estaryll tab 2 tri-legest tab fe 2 tri-linyah tab 2 tri-lo tab estaryll 2 tri-lo- tab marzia 2 tri-lo- tab sprintec 2 tri-mili tab 2 tri-previfem tab 2 tri-sprintec tab 2 86
tri-vylibra tab 2 trinessa lo tab 2 trinessa tab 2 trivora-28 tab 2 velivet pak 2 vestura tab 3-0.02mg 2 vienva tab 0.1-20 2 viorele tab 2 vyfemla tab 0.4-35 2 vylibra tab 0.25-35 2 wera tab 0.5/35 2 wymzya fe chw 0.4mg-35 2 xulane dis 150-35 4 QL (3 patches / 28 days) zarah tab 3-0.03mg 2 zenchent tab 2 zovia 1/35e tab 2 ENDOMETRIOSIS danazol cap 50 mg 2 danazol cap 100 mg 2 danazol cap 200 mg 2 LUPANETA KIT 3.75-5 5 QL (1 kit / 28 days), LUPANETA KIT 11.25-5 5 QL (1 kit / 84 days), methyltestosterone cap 10 mg 4 PA SYNAREL SOL 2MG/ML 5 PA; DL ENZYME REPLACEMENTS ADAGEN INJ 250/ML 5 NM, LA, PA; DL ALDURAZYME INJ 2.9MG/5M 5 NM, LA, PA; DL BUPHENYL TAB 500MG 5 CARBAGLU TAB 200MG 5 NM, LA, PA; DL CERDELGA CAP 84MG 5 QL (60 caps / 30 days), CEREZYME INJ 400UNIT 5 NM, LA, PA; DL CYSTADANE POW 5 NM; DL CYSTAGON CAP 50MG 3 NM, LA, PA CYSTAGON CAP 150MG 3 NM, LA, PA ELAPRASE INJ 6MG/3ML 5 NM, LA, PA; DL 87
ELELYSO INJ 200UNIT 5 FABRAZYME INJ 5MG 5 NM, LA, PA; DL FABRAZYME INJ 35MG 5 NM, LA, PA; DL KUVAN POW 100MG 5 KUVAN POW 500MG 5 KUVAN TAB 100MG 5 NM, LA, PA; DL levocarnitine inj 200 mg/ml 2 levocarnitine oral soln 1 gm/10ml (10%) 2 levocarnitine tab 330 mg 2 LUMIZYME INJ 50MG 5 miglustat cap 100 mg 5 NAGLAZYME INJ 1MG/ML 5 NM, LA, PA; DL ORFADIN CAP 2MG 5 NM, LA, PA; DL ORFADIN CAP 5MG 5 NM, LA, PA; DL ORFADIN CAP 10MG 5 NM, LA, PA; DL ORFADIN CAP 20MG 5 NM, LA, PA; DL ORFADIN SUS 4MG/ML 5 NM, LA, PA; DL RAVICTI LIQ 1.1GM/ML 5 QL (525 ml / 30 days), sodium phenylbutyrate oral powder 3 5 gm/teaspoonful sodium phenylbutyrate tab 500 mg 5 VPRIV INJ 400UNIT 5 ZAVESCA CAP 100MG 5 NM, LA, PA; DL ESTROGENS amabelz tab 0.5-0.1 2 amabelz tab 1-0.5mg 2 DEPO-ESTRADI INJ 5MG/ML 4 DIVIGEL GEL 1MG/GM 4 DUAVEE TAB 0.45-20 3 PA ESTRACE VAG CRE 0.01% 4 estradiol & norethindrone acetate tab 0.5-0.1 mg 2 estradiol & norethindrone acetate tab 1-0.52 mg estradiol tab 0.5 mg 2 estradiol tab 1 mg 2 estradiol tab 2 mg 2 88
estradiol td patch twice weekly 0.1 mg/24hr 2 QL (8 patches / 28 days) estradiol td patch twice weekly 0.05 mg/24hr 2 QL (8 patches / 28 days) estradiol td patch twice weekly 0.025 mg/24hr 2 QL (8 patches / 28 days) estradiol td patch twice weekly 0.075 mg/24hr 2 QL (8 patches / 28 days) estradiol td patch twice weekly 0.0375 mg/24hr 2 QL (8 patches / 28 days) estradiol td patch weekly 0.1 mg/24hr 2 QL (4 patches / 28 days) estradiol td patch weekly 0.05 mg/24hr 2 QL (4 patches / 28 days) estradiol td patch weekly 0.06 mg/24hr 2 QL (4 patches / 28 days) estradiol td patch weekly 0.025 mg/24hr 2 QL (4 patches / 28 days) estradiol td patch weekly 0.075 mg/24hr 2 QL (4 patches / 28 days) estradiol td patch weekly 0.0375 mg/24hr 2 QL (4 patches / 28 (37.5 mcg/24hr) days) estradiol vaginal tab 10 mcg 4 estradiol valerate im in oil 20 mg/ml 2 estradiol valerate im in oil 40 mg/ml 2 ESTRING MIS 2MG 4 estropipate tab 0.75 mg 2 estropipate tab 1.5 mg 2 FEMRING MIS 0.1MG/24 4 FEMRING MIS 0.05/24H 4 fyavolv tab 1-5 2 jinteli tab 1mg-5mcg 2 MENOSTAR DIS 14MCG 4 QL (4 patches / 28 days) mimvey lo tab 0.5-0.1 2 mimvey tab 1-0.5mg 2 norethindrone acetate-ethinyl estradiol tab 2 1 mg-5 mcg PREMARIN INJ 25MG 4 PREMARIN VAG CRE 0.625MG 3 89
yuvafem tab 10mcg 4 GLUCOCORTICOIDS betamethasone sod phosphate & acetate 2 inj susp 6 (3-3) mg/ml cortisone acetate tab 25 mg 2 DEPO-MEDROL INJ 20MG/ML 4 DEXAMETHASON CON 1MG/ML 2 dexamethasone elixir 0.5 mg/5ml 2 dexamethasone sodium phosphate inj 10 2 mg/ml dexamethasone sodium phosphate inj 120 2 mg/30ml dexamethasone tab 0.5 mg 1 GC dexamethasone tab 0.75 mg 1 GC dexamethasone tab 1 mg 1 GC dexamethasone tab 1.5 mg 1 GC dexamethasone tab 2 mg 1 GC dexamethasone tab 4 mg 1 GC dexamethasone tab 6 mg 1 GC fludrocortisone acetate tab 0.1 mg 2 hydrocortisone tab 5 mg 2 hydrocortisone tab 10 mg 2 hydrocortisone tab 20 mg 2 methylprednisolone acetate inj susp 40 2 mg/ml methylprednisolone acetate inj susp 80 mg/ml 2 methylprednisolone sod succ for inj 40 mg 2 (base equiv) methylprednisolone sod succ for inj 125 2 mg (base equiv) methylprednisolone sod succ for inj 1000 2 mg (base equiv) methylprednisolone tab 4 mg 2 methylprednisolone tab 8 mg 2 methylprednisolone tab 16 mg 2 methylprednisolone tab 32 mg 2 methylprednisolone tab therapy pack 4 mg 2 (21) 90
prednisolone sod phosph oral soln 6.7 2 mg/5ml (5 mg/5ml base) prednisolone sodium phosphate oral soln 2 25 mg/5ml (base eq) prednisolone syrup 15 mg/5ml (usp 2 solution equivalent) PREDNISONE CON 5MG/ML 2 prednisone oral soln 5 mg/5ml 1 GC prednisone tab 1 mg 1 GC prednisone tab 2.5 mg 1 GC prednisone tab 5 mg 1 GC prednisone tab 10 mg 1 GC prednisone tab 20 mg 1 GC prednisone tab 50 mg 1 GC prednisone tab therapy pack 5 mg (21) 1 GC prednisone tab therapy pack 5 mg (48) 1 GC prednisone tab therapy pack 10 mg (21) 1 GC prednisone tab therapy pack 10 mg (48) 1 GC SOLU-CORTEF INJ 100MG 4 SOLU-CORTEF INJ 250MG 4 SOLU-CORTEF INJ 500MG 4 SOLU-CORTEF INJ 1000MG 4 SOLU-MEDROL INJ 2GM 4 SOLU-MEDROL INJ 40MG 4 SOLU-MEDROL INJ 125MG 4 SOLU-MEDROL INJ 500MG 4 SOLU-MEDROL INJ 1000MG 4 GLUCOSE ELEVATING AGENTS GLUCAGEN INJ HYPOKIT 3 GLUCAGON KIT 1MG 4 PROGLYCEM SUS 50MG/ML 4 HUMAN GROWTH HORMONES GENOTROPIN INJ 0.2MG 3 NM, PA GENOTROPIN INJ 0.4MG 5 GENOTROPIN INJ 0.6MG 5 GENOTROPIN INJ 0.8MG 5 GENOTROPIN INJ 1.2MG 5 GENOTROPIN INJ 1.4MG 5 GENOTROPIN INJ 1.6MG 5 91
GENOTROPIN INJ 1.8MG 5 GENOTROPIN INJ 1MG 5 GENOTROPIN INJ 2MG 5 GENOTROPIN INJ 5MG 5 GENOTROPIN INJ 12MG 5 HUMATROPE INJ 5MG 5 HUMATROPE INJ 6MG 5 HUMATROPE INJ 12MG 5 HUMATROPE INJ 24MG 5 NORDITROPIN INJ 5/1.5ML 5 NORDITROPIN INJ 10/1.5ML 5 NORDITROPIN INJ 15/1.5ML 5 NORDITROPIN INJ 30/3ML 5 NUTROPIN AQ INJ 10MG/2ML 5 NUTROPIN AQ INJ 20MG/2ML 5 NUTROPIN AQ INJ NUSPIN 5 5 OMNITROPE INJ 5.8MG 5 OMNITROPE INJ 5/1.5ML 5 OMNITROPE INJ 10/1.5ML 5 SAIZEN INJ 5MG 5 SAIZEN INJ 8.8MG 5 SAIZENPREP INJ 8.8MG 5 SEROSTIM INJ 4MG 5 NM, LA, PA; DL SEROSTIM INJ 5MG 5 NM, LA, PA; DL SEROSTIM INJ 6MG 5 NM, LA, PA; DL ZOMACTON INJ 5MG 4 NM, PA ZOMACTON INJ 10MG 5 ZORBTIVE INJ 8.8MG 5 NM, LA, PA; DL MISCELLANEOUS acetylcysteine inj 200 mg/ml 2 cabergoline tab 0.5 mg 2 calcitonin (salmon) nasal soln 200 unit/act 3 CHOR GONADOT INJ 10000UNT 3 NM, PA deferoxamine mesylate for inj 2 gm 2 NM deferoxamine mesylate for inj 500 mg 2 NM EGRIFTA SOL 1MG 5 QL (60 vials / 30 days), fomepizole inj 1 gm/ml (for iv infusion) 2 92
FORTEO SOL 600/2.4 5 QL (2.4 ml / 28 days), NM, ST; DL H.P. ACTHAR INJ 80UNIT 5 QL (35 ml / 28 days), INCRELEX INJ 40MG/4ML 5 NM, LA, PA; DL KANUMA INJ 20/10ML 5 KORLYM TAB 300MG 5 QL (120 tabs / 30 days), LUPR DEP-PED INJ 3M 30MG 5 QL (1 kit / 84 days), LUPR DEP-PED INJ 11.25MG 5 QL (1 kit / 28 days), LUPR DEP-PED INJ 15MG 5 QL (1 kit / 28 days), methylergonovine maleate inj 0.2 mg/ml 2 MIACALCIN INJ 200/ML 4 MYALEPT INJ 11.3MG 5 QL (60 vials / 30 days), NM, LA, PA; DL NATPARA INJ 25MCG 5 QL (2 cartridges / 28 days), NM, LA, PA; DL NATPARA INJ 50MCG 5 QL (2 cartridges / 28 days), NM, LA, PA; DL NATPARA INJ 75MCG 5 QL (2 cartridges / 28 days), NM, LA, PA; DL NATPARA INJ 100MCG 5 QL (2 cartridges / 28 days), NM, LA, PA; DL octreotide acetate inj 50 mcg/ml (0.05 4 NM mg/ml) octreotide acetate inj 100 mcg/ml (0.1 4 NM mg/ml) octreotide acetate inj 200 mcg/ml (0.2 4 NM mg/ml) octreotide acetate inj 500 mcg/ml (0.5 5 NM; DL mg/ml) octreotide acetate inj 1000 mcg/ml (1 5 NM; DL mg/ml) oxytocin inj 10 unit/ml 2 PROLIA SOL 60MG/ML 4 QL (1 injection / 168 days), NM, PA raloxifene hcl tab 60 mg 3 93
SAMSCA TAB 15MG 5 QL (30 tabs / 30 days), SAMSCA TAB 30MG 5 QL (60 tabs / 30 days), SANDOSTATIN KIT LAR 10MG 5 SANDOSTATIN KIT LAR 20MG 5 SANDOSTATIN KIT LAR 30MG 5 SIGNIFOR INJ 0.3MG/ML 5 QL (60 ampules / 30 days), SIGNIFOR INJ 0.6MG/ML 5 QL (60 ampules / 30 days), SIGNIFOR INJ 0.9MG/ML 5 QL (60 ampules / 30 days), SIGNIFOR LAR INJ 20MG 5 QL (1 injection / 28 days), SIGNIFOR LAR INJ 40MG 5 QL (1 injection / 28 days), SIGNIFOR LAR INJ 60MG 5 QL (1 injection / 28 days), SOMATULINE INJ 60/0.2ML 5 QL (2 injections / 28 days), SOMATULINE INJ 90/0.3ML 5 QL (2 injections / 28 days), SOMATULINE INJ 120/.5ML 5 QL (1 injection / 28 days), SOMAVERT INJ 10MG 5 QL (30 vials / 30 days), SOMAVERT INJ 15MG 5 QL (30 vials / 30 days), SOMAVERT INJ 20MG 5 QL (30 vials / 30 days), SOMAVERT INJ 25MG 5 QL (30 vials / 30 days), SOMAVERT INJ 30MG 5 QL (30 vials / 30 days), STRENSIQ INJ 18/0.45 5 NM, LA, PA; DL STRENSIQ INJ 28/0.7ML 5 NM, LA, PA; DL STRENSIQ INJ 40MG/ML 5 NM, LA, PA; DL STRENSIQ INJ 80/0.8ML 5 NM, LA, PA; DL XGEVA INJ 5 QL (1 vial / 28 days), 94
PHOSPHATE BINDER AGENTS AURYXIA TAB 210MG 3 calcium acetate (phosphate binder) cap 2 667 mg (169 mg ca) calcium acetate (phosphate binder) tab 2 667 mg sevelamer carbonate packet 0.8 gm 3 sevelamer carbonate packet 2.4 gm 3 sevelamer carbonate tab 800 mg 3 PROGESTINS MAKENA INJ 250MG/ML 5 medroxyprogesterone acetate tab 2.5 mg 2 medroxyprogesterone acetate tab 5 mg 2 medroxyprogesterone acetate tab 10 mg 2 norethindrone acetate tab 5 mg 2 progesterone micronized cap 100 mg 2 progesterone micronized cap 200 mg 2 THYROID AGENTS levothyroxine sodium tab 25 mcg 2 levothyroxine sodium tab 50 mcg 2 levothyroxine sodium tab 75 mcg 2 levothyroxine sodium tab 88 mcg 2 levothyroxine sodium tab 100 mcg 2 levothyroxine sodium tab 112 mcg 2 levothyroxine sodium tab 125 mcg 2 levothyroxine sodium tab 137 mcg 2 levothyroxine sodium tab 150 mcg 2 levothyroxine sodium tab 175 mcg 2 levothyroxine sodium tab 200 mcg 2 levothyroxine sodium tab 300 mcg 2 liothyronine sodium iv soln 10 mcg/ml 2 liothyronine sodium tab 5 mcg 2 liothyronine sodium tab 25 mcg 2 liothyronine sodium tab 50 mcg 2 methimazole tab 5 mg 2 methimazole tab 10 mg 2 propylthiouracil tab 50 mg 2 SYNTHROID TAB 25MCG 4 SYNTHROID TAB 50MCG 4 95
SYNTHROID TAB 75MCG 4 SYNTHROID TAB 88MCG 4 SYNTHROID TAB 100MCG 4 SYNTHROID TAB 112MCG 4 SYNTHROID TAB 125MCG 4 SYNTHROID TAB 137MCG 4 SYNTHROID TAB 150MCG 4 SYNTHROID TAB 175MCG 4 SYNTHROID TAB 200MCG 4 SYNTHROID TAB 300MCG 4 unithroid tab 25mcg 3 unithroid tab 50mcg 3 unithroid tab 75mcg 3 unithroid tab 88mcg 3 unithroid tab 100mcg 3 unithroid tab 112mcg 3 unithroid tab 125mcg 3 unithroid tab 150mcg 3 unithroid tab 175mcg 3 unithroid tab 200mcg 3 unithroid tab 300mcg 3 VASOPRESSINS desmopressin acetate inj 4 mcg/ml 2 desmopressin acetate nasal spray soln 2 0.01% desmopressin acetate nasal spray soln 2 0.01% (refrigerated) desmopressin acetate tab 0.1 mg 2 desmopressin acetate tab 0.2 mg 2 STIMATE SOL 1.5MG/ML 4 NM GASTROINTESTINAL ANTIEMETICS ALOXI INJ 0.25MG/5 4 aprepitant capsule 40 mg 4 B/D aprepitant capsule 80 mg 4 B/D aprepitant capsule 125 mg 4 B/D aprepitant capsule therapy pack 80 & 125 4 B/D mg compro sup 25mg 2 96
dronabinol cap 2.5 mg 4 PA dronabinol cap 5 mg 4 PA dronabinol cap 10 mg 5 PA; DL EMEND SOL 150MG 4 EMEND SUS 125MG 4 B/D granisetron hcl inj 0.1 mg/ml 2 granisetron hcl inj 1 mg/ml 2 granisetron hcl inj 4 mg/4ml (1 mg/ml) 2 granisetron hcl tab 1 mg 4 B/D, ST meclizine hcl tab 12.5 mg 2 meclizine hcl tab 25 mg 2 metoclopramide hcl inj 5 mg/ml (base 2 equivalent) metoclopramide hcl soln 5 mg/5ml (10 1 GC mg/10ml) (base equiv) metoclopramide hcl tab 5 mg (base 1 GC equivalent) metoclopramide hcl tab 10 mg (base 1 GC equivalent) ondansetron hcl inj 4 mg/2ml (2 mg/ml) 2 ondansetron hcl oral soln 4 mg/5ml 2 B/D ondansetron hcl tab 4 mg 2 B/D ondansetron hcl tab 8 mg 2 B/D ondansetron hcl tab 24 mg 4 B/D ondansetron orally disintegrating tab 4 mg 2 B/D ondansetron orally disintegrating tab 8 mg 2 B/D palonosetron hcl iv soln 0.25 mg/5ml (base 4 equivalent) PALONOSETRON INJ 0.25/2ML 4 phenadoz sup 12.5mg 2 prochlorperazine edisylate inj 5 mg/ml 2 prochlorperazine maleate tab 5 mg (base 1 GC equivalent) prochlorperazine maleate tab 10 mg (base 1 GC equivalent) prochlorperazine suppos 25 mg 2 promethazine hcl inj 25 mg/ml 2 promethazine hcl inj 50 mg/ml 2 promethazine hcl suppos 12.5 mg 2 promethazine hcl suppos 25 mg 2 97
promethazine hcl suppos 50 mg 2 promethazine hcl syrup 6.25 mg/5ml 2 PA promethazine hcl tab 12.5 mg 2 PA promethazine hcl tab 25 mg 2 PA promethazine hcl tab 50 mg 2 PA promethegan sup 25mg 2 promethegan sup 50mg 2 SANCUSO DIS 3.1MG 5 QL (4 patches / 28 days), ST; DL scopolamine td patch 72hr 1 mg/3days 4 ANTISPASMODICS atropine sulfate soln prefill syr 0.25 2 mg/5ml (0.05 mg/ml) BENTYL INJ 10MG/ML 4 dicyclomine hcl cap 10 mg 2 dicyclomine hcl oral soln 10 mg/5ml 2 dicyclomine hcl tab 20 mg 2 glycopyrrolate inj 4 mg/20ml (0.2 mg/ml) 2 glycopyrrolate tab 1 mg 2 glycopyrrolate tab 2 mg 2 methscopolamine bromide tab 2.5 mg 2 methscopolamine bromide tab 5 mg 2 propantheline bromide tab 15 mg 2 H2-RECEPTOR ANTAGONISTS cimetidine hcl soln 300 mg/5ml 2 cimetidine tab 200 mg 2 cimetidine tab 300 mg 2 cimetidine tab 400 mg 2 cimetidine tab 800 mg 2 famotidine for susp 40 mg/5ml 4 famotidine in nacl 0.9% iv soln 20 4 mg/50ml famotidine inj 20 mg/2ml 2 famotidine tab 20 mg 2 famotidine tab 40 mg 2 nizatidine cap 150 mg 2 nizatidine cap 300 mg 4 nizatidine oral soln 15 mg/ml 2 ranitidine hcl cap 150 mg 3 98
ranitidine hcl cap 300 mg 3 ranitidine hcl inj 50 mg/2ml (25 mg/ml) 2 ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 4 ranitidine hcl tab 150 mg 1 GC ranitidine hcl tab 300 mg 1 GC INFLAMMATORY BOWEL DISEASE APRISO CAP 0.375GM 3 ARISTOSPAN INJ 5MG/ML 4 ARISTOSPAN INJ 20MG/ML 4 balsalazide disodium cap 750 mg 3 budesonide delayed release particles cap 3 5 DL mg CANASA SUP 1000MG 5 DL DELZICOL CAP 400MG 4 hydrocortisone enema 100 mg/60ml 2 mesalamine enema 4 gm 4 mesalamine tab delayed release 800 mg 3 sulfasalazine tab 500 mg 2 sulfasalazine tab delayed release 500 mg 2 triamcinolone acetonide inj susp 10 mg/ml 2 triamcinolone acetonide inj susp 40 mg/ml 2 LAXATIVES constulose sol 10gm/15 2 enulose sol 10gm/15 2 gavilyte-c sol 2 gavilyte-g sol 2 gavilyte-n sol flav pk 2 generlac sol 10gm/15 2 lactulose solution 10 gm/15ml 2 peg 3350-kcl-na bicarb-nacl-na sulfate for 2 soln 236 gm peg 3350-kcl-na bicarb-nacl-na sulfate for 2 soln 240 gm peg 3350-kcl-sod bicarb-nacl for soln 420 2 gm polyethylene glycol 3350 oral powder 2 SUPREP BOWEL SOL PREP KIT 3 trilyte sol 2 MISCELLANEOUS 99
alosetron hcl tab 0.5 mg (base equiv) 5 PA; DL alosetron hcl tab 1 mg (base equiv) 5 PA; DL AMITIZA CAP 8MCG 4 AMITIZA CAP 24MCG 4 CARAFATE SUS 1GM/10ML 4 cromolyn sodium oral conc 100 mg/5ml 2 diphenoxylate w/ atropine liq 2.5-0.025 2 mg/5ml diphenoxylate w/ atropine tab 2.5-0.025 2 mg GATTEX KIT 5MG 5 QL (30 kits / 30 days), LINZESS CAP 72MCG 3 QL (30 caps / 30 days) LINZESS CAP 145MCG 3 QL (30 caps / 30 days) LINZESS CAP 290MCG 3 QL (30 caps / 30 days) loperamide hcl cap 2 mg 2 misoprostol tab 100 mcg 2 misoprostol tab 200 mcg 3 MOVANTIK TAB 12.5MG 3 QL (30 tabs / 30 days) MOVANTIK TAB 25MG 3 QL (30 tabs / 30 days) MYTESI TAB 125MG 4 PA OCALIVA TAB 5MG 5 QL (30 tabs / 30 days), NM, LA, PA; DL OCALIVA TAB 10MG 5 QL (30 tabs / 30 days), NM, LA, PA; DL RELISTOR INJ 8/0.4ML 5 PA; DL RELISTOR INJ 12/0.6ML 5 PA; DL RELISTOR TAB 150MG 5 QL (90 tabs / 30 days), PA; DL SUCRAID SOL 8500/ML 5 PA; DL sucralfate tab 1 gm 2 ursodiol cap 300 mg 3 ursodiol tab 250 mg 3 ursodiol tab 500 mg 3 VIBERZI TAB 75MG 5 QL (60 tabs / 30 days), PA; DL VIBERZI TAB 100MG 5 QL (60 tabs / 30 days), PA; DL XERMELO TAB 250MG 5 QL (84 tabs / 28 days), 100
XIFAXAN TAB 550MG 5 QL (60 tabs / 30 days), PA; DL PANCREATIC ENZYMES CREON CAP 3000UNIT 3 CREON CAP 6000UNIT 3 CREON CAP 12000UNT 3 CREON CAP 24000UNT 3 CREON CAP 36000UNT 3 ZENPEP CAP 3000UNIT 4 (LIP-PROT-AMYL) 3000-10000-16000 UNIT ZENPEP CAP 5000UNIT 4 (LIP-PROT-AMYL) 5000-17000-24000 UNIT ZENPEP CAP 10000UNT 4 (LIP-PROT-AMYL) 10000-32000-42000 UNIT ZENPEP CAP 15000UNT 4 (LIP-PROT-AMYL) 15000-51000-82000 UNIT ZENPEP CAP 20000UNT 4 (LIP-PROT-AMYL) 20000-63000-84000 UNIT ZENPEP CAP 25000 4 (LIP-PROT-AMYL) 25000-79000-105000 UNIT ZENPEP CAP 25000UNT 4 (LIP-PROT-AMYL) 25000-85000-136000 UNIT ZENPEP CAP 40000 5 DL; (LIP-PROT-AMYL) 40000-126000-168000 UNIT PROTON PUMP INHIBITORS DEXILANT CAP 30MG DR 4 QL (30 caps / 30 days), ST DEXILANT CAP 60MG DR 4 QL (30 caps / 30 days), ST lansoprazole cap delayed release 15 mg 3 QL (30 caps / 30 days) lansoprazole cap delayed release 30 mg 3 QL (30 caps / 30 days) omeprazole cap delayed release 10 mg 2 QL (60 caps / 30 days) omeprazole cap delayed release 20 mg 2 QL (60 caps / 30 days) omeprazole cap delayed release 40 mg 2 QL (60 caps / 30 days) 101
pantoprazole sodium ec tab 20 mg (base 2 QL (60 tabs / 30 days) equiv) pantoprazole sodium ec tab 40 mg (base 2 QL (60 tabs / 30 days) equiv) pantoprazole sodium for iv soln 40 mg 4 (base equiv) GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl tab er 24hr 10 mg 2 dutasteride cap 0.5 mg 4 dutasteride-tamsulosin hcl cap 0.5-0.4 mg 4 finasteride tab 5 mg 1 GC tamsulosin hcl cap 0.4 mg 2 MISCELLANEOUS bethanechol chloride tab 5 mg 2 bethanechol chloride tab 10 mg 2 bethanechol chloride tab 25 mg 2 bethanechol chloride tab 50 mg 2 ELMIRON CAP 100MG 4 flavoxate hcl tab 100 mg 2 LITHOSTAT TAB 250MG 3 potassium citrate tab er 5 meq (540 mg) 4 potassium citrate tab er 10 meq (1080 mg) 4 potassium citrate tab er 15 meq (1620 mg) 4 THIOLA TAB 100MG 4 PA URINARY ANTISPASMODICS MYRBETRIQ TAB 25MG 4 QL (30 tabs / 30 days) MYRBETRIQ TAB 50MG 4 QL (30 tabs / 30 days) oxybutynin chloride syrup 5 mg/5ml 1 GC oxybutynin chloride tab 5 mg 1 GC oxybutynin chloride tab er 24hr 5 mg 2 oxybutynin chloride tab er 24hr 10 mg 2 oxybutynin chloride tab er 24hr 15 mg 2 tolterodine tartrate cap er 24hr 2 mg 3 tolterodine tartrate cap er 24hr 4 mg 3 tolterodine tartrate tab 1 mg 3 tolterodine tartrate tab 2 mg 3 trospium chloride cap er 24hr 60 mg 2 trospium chloride tab 20 mg 2 102
VESICARE TAB 5MG 3 VESICARE TAB 10MG 3 VAGINAL ANTI-INFECTIVES CLEOCIN SUP 100MG 4 clindamycin phosphate vaginal cream 2% 2 metronidazole vaginal gel 0.75% 2 miconazole 3 sup 200mg 2 terconazole vaginal cream 0.4% 2 terconazole vaginal cream 0.8% 2 terconazole vaginal suppos 80 mg 4 vandazole gel 0.75% 3 HEMATOLOGIC ANTICOAGULANTS ARGATROBAN INJ 125/125 5 DL argatroban inj 250 mg/2.5ml (concentrate 5 DL for iv infusion) ELIQUIS ST P TAB 5MG 3 QL (148 tabs / 365 days) ELIQUIS TAB 2.5MG 3 QL (60 tabs / 30 days) ELIQUIS TAB 5MG 3 QL (74 tabs / 30 days) enoxaparin sodium inj 30 mg/0.3ml 4 QL (36 ml / year) enoxaparin sodium inj 40 mg/0.4ml 4 QL (48 ml / year) enoxaparin sodium inj 60 mg/0.6ml 4 QL (72 ml / year) enoxaparin sodium inj 80 mg/0.8ml 4 QL (96 ml / year) enoxaparin sodium inj 100 mg/ml 4 QL (120 ml / year) enoxaparin sodium inj 120 mg/0.8ml 4 QL (96 ml / year) enoxaparin sodium inj 150 mg/ml 4 QL (120 ml / year) enoxaparin sodium inj 300 mg/3ml 4 QL (360 ml / year) fondaparinux sodium subcutaneous inj 2.5 4 QL (30 ml / year) mg/0.5ml fondaparinux sodium subcutaneous inj 5 mg/0.4ml 5 QL (24 ml / year); DL fondaparinux sodium subcutaneous inj 7.5 5 QL (36 ml / year); DL mg/0.6ml fondaparinux sodium subcutaneous inj 10 5 QL (48 ml / year); DL mg/0.8ml FRAGMIN INJ 2500/0.2 4 QL (6 ml / 30 days) FRAGMIN INJ 5000/0.2 4 QL (6 ml / 30 days) FRAGMIN INJ 7500/0.3 5 QL (9 ml / 30 days); DL 103
FRAGMIN INJ 10000/ML 5 QL (30 ml / 30 days); DL FRAGMIN INJ 12500UNT 5 QL (15 ml / 30 days); DL FRAGMIN INJ 15000UNT 5 QL (18 ml / 30 days); DL FRAGMIN INJ 18000UNT 5 QL (21.6 ml / 30 days); DL FRAGMIN INJ 95000UNT 5 QL (22.8 ml / 30 days); DL HEP SOD/D5W INJ 50UNT/ML 2 HEP SOD/NACL INJ 12500UNT 2 heparin sodium (porcine) 2 unit/ml in 2 sodium chloride 0.9% heparin sodium (porcine) 40 unit/ml in 2 d5w heparin sodium (porcine) 50 unit/ml in 2 d5w heparin sodium (porcine) 100 unit/ml in d5w 2 heparin sodium (porcine) inj 1000 unit/ml 2 heparin sodium (porcine) inj 5000 unit/ml 2 heparin sodium (porcine) inj 10000 unit/ml 2 heparin sodium (porcine) inj 20000 unit/ml 2 heparin sodium (porcine) pf inj 5000 2 unit/0.5ml jantoven tab 1mg 2 jantoven tab 2.5mg 2 jantoven tab 2mg 2 jantoven tab 3mg 2 jantoven tab 4mg 2 jantoven tab 5mg 2 jantoven tab 6mg 2 jantoven tab 7.5mg 2 jantoven tab 10mg 2 PRADAXA CAP 75MG 4 QL (60 caps / 30 days) PRADAXA CAP 110MG 4 QL (180 caps / year) PRADAXA CAP 150MG 4 QL (60 caps / 30 days) warfarin sodium tab 1 mg 1 GC warfarin sodium tab 2 mg 1 GC 104
warfarin sodium tab 2.5 mg 1 GC warfarin sodium tab 3 mg 1 GC warfarin sodium tab 4 mg 1 GC warfarin sodium tab 5 mg 1 GC warfarin sodium tab 6 mg 1 GC warfarin sodium tab 7.5 mg 1 GC warfarin sodium tab 10 mg 1 GC XARELTO STAR TAB 15/20MG 3 QL (51 tabs / 30 days) XARELTO TAB 10MG 3 QL (365 tabs / year) XARELTO TAB 15MG 3 QL (60 tabs / 30 days) XARELTO TAB 20MG 3 QL (30 tabs / 30 days) HEMATOPOIETIC GROWTH FACTORS ARANESP INJ 10MCG 4 NM, PA ARANESP INJ 25MCG 4 NM, PA ARANESP INJ 40MCG 4 NM, PA ARANESP INJ 60MCG 5 ARANESP INJ 100MCG 5 ARANESP INJ 150MCG 5 ARANESP INJ 200MCG 5 ARANESP INJ 300MCG 5 ARANESP INJ 500MCG 5 EPOGEN INJ 2000/ML 4 NM, PA EPOGEN INJ 3000/ML 4 NM, PA EPOGEN INJ 4000/ML 4 NM, PA EPOGEN INJ 10000/ML 4 NM, PA EPOGEN INJ 20000/ML 5 GRANIX INJ 300/0.5 5 GRANIX INJ 480/0.8 5 LEUKINE INJ 250MCG 5 MOZOBIL INJ 5 QL (9.6 ml / 4 days), NEULASTA INJ 6MG/0.6M 5 NEUPOGEN INJ 300/0.5 5 NEUPOGEN INJ 300MCG 5 NEUPOGEN INJ 480/0.8 5 NEUPOGEN INJ 480MCG 5 PROCRIT INJ 2000/ML 3 NM, PA PROCRIT INJ 3000/ML 3 NM, PA PROCRIT INJ 4000/ML 3 NM, PA 105
PROCRIT INJ 10000/ML 3 NM, PA PROCRIT INJ 20000/ML 5 PROCRIT INJ 40000/ML 5 ZARXIO INJ 300/0.5 5 ZARXIO INJ 480/0.8 5 MISCELLANEOUS aminocaproic acid inj 250 mg/ml 2 anagrelide hcl cap 0.5 mg 2 anagrelide hcl cap 1 mg 2 BERINERT INJ 500UNIT 5 cilostazol tab 50 mg 2 cilostazol tab 100 mg 2 CINRYZE SOL 500 UNIT 5 QL (20 ml / 30 days), FIRAZYR INJ 30MG/3ML 5 pentoxifylline tab er 400 mg 2 PROMACTA TAB 12.5MG 5 QL (30 tabs / 30 days), NM, LA, PA; DL PROMACTA TAB 25MG 5 QL (30 tabs / 30 days), NM, LA, PA; DL PROMACTA TAB 50MG 5 QL (60 tabs / 30 days), NM, LA, PA; DL PROMACTA TAB 75MG 5 QL (60 tabs / 30 days), NM, LA, PA; DL RUCONEST INJ 2100UNIT 5 tranexamic acid iv soln 1000 mg/10ml 2 (100 mg/ml) tranexamic acid tab 650 mg 3 QL (30 tabs / 28 days) PLATELET AGGREGATION INHIBITORS aspirin-dipyridamole cap er 12hr 25-200 3 mg BRILINTA TAB 60MG 3 QL (60 tabs / 30 days) BRILINTA TAB 90MG 3 QL (60 tabs / 30 days) clopidogrel bisulfate tab 75 mg (base 2 equiv) dipyridamole tab 25 mg 3 dipyridamole tab 50 mg 3 dipyridamole tab 75 mg 3 prasugrel hcl tab 5 mg (base equiv) 3 QL (30 tabs / 30 days) 106
prasugrel hcl tab 10 mg (base equiv) 3 QL (30 tabs / 30 days) ticlopidine hcl tab 250 mg 2 ZONTIVITY TAB 2.08MG 4 QL (30 tabs / 30 days), PA IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) ENBREL INJ 25/0.5ML 5 QL (16 injections / 28 days), ENBREL INJ 25MG 5 QL (16 injections / 28 days), ENBREL INJ 50MG/ML 5 QL (8 injections / 28 days), ENBREL SRCLK INJ 50MG/ML 5 QL (8 injections / 28 days), HUMIRA INJ 10/0.1ML 5 HUMIRA INJ 10MG/0.2 5 HUMIRA INJ 20/0.2ML 5 HUMIRA INJ 40/0.4ML 5 HUMIRA KIT 20MG/0.4 5 HUMIRA KIT 40MG/0.8 5 HUMIRA PEDIA INJ CROHNS 5 HUMIRA PEN INJ 40/0.4ML 5 HUMIRA PEN INJ 40MG/0.8 5 HUMIRA PEN INJ CD/UC/HS 5 HUMIRA PEN INJ PS/UV 5 hydroxychloroquine sulfate tab 200 mg 2 leflunomide tab 10 mg 2 leflunomide tab 20 mg 2 methotrexate sodium tab 2.5 mg (base 2 equiv) OTREXUP INJ 10MG 4 QL (1.6 ml / 28 days), NM, PA OTREXUP INJ 12.5/0.4 4 QL (1.6 ml / 28 days), NM, PA OTREXUP INJ 15MG 4 QL (1.6 ml / 28 days), NM, PA OTREXUP INJ 17.5/0.4 4 QL (1.6 ml / 28 days), NM, PA OTREXUP INJ 20MG 4 QL (1.6 ml / 28 days), NM, PA 107
OTREXUP INJ 22.5/0.4 4 QL (1.6 ml / 28 days), NM, PA OTREXUP INJ 25MG 4 QL (1.6 ml / 28 days), NM, PA RASUVO INJ 7.5MG 3 QL (0.6 ml / 28 days), NM, PA RASUVO INJ 10MG 3 QL (0.8 ml / 28 days), NM, PA RASUVO INJ 12.5MG 3 QL (1 ml / 28 days), NM, PA RASUVO INJ 15MG 3 QL (1.2 ml / 28 days), NM, PA RASUVO INJ 17.5MG 3 QL (1.4 ml / 28 days), NM, PA RASUVO INJ 20MG 3 QL (1.6 ml / 28 days), NM, PA RASUVO INJ 22.5MG 3 QL (1.8 ml / 28 days), NM, PA RASUVO INJ 25MG 3 QL (2 ml / 28 days), NM, PA RASUVO INJ 30MG 3 QL (2.4 ml / 28 days), NM, PA REMICADE INJ 100MG 5 RIDAURA CAP 3MG 5 DL XATMEP SOL 2.5MG/ML 4 B/D XELJANZ TAB 5MG 5 QL (60 tabs / 30 days), XELJANZ XR TAB 11MG 5 QL (30 tabs / 30 days), IMMUNOGLOBULINS BIVIGAM INJ 10% 5 CARIMUNE NF INJ 6GM 5 FLEBOGAMMA INJ 5GM/50ML 5 FLEBOGAMMA INJ 10/200ML 5 FLEBOGAMMA INJ 20/400ML 5 FLEBOGAMMA INJ DIF 5% 5 GAMASTAN S/D INJ 3 NM, PA GAMMAGARD INJ 2.5GM/25 5 GAMMAGARD SD INJ 5GM HU 5 GAMMAGARD SD INJ 10GM HU 5 108
GAMMAKED INJ 1GM/10ML 5 GAMMAPLEX INJ 5% 5 GAMMAPLEX INJ 10% 5 GAMUNEX-C INJ 1GM/10ML 5 HIZENTRA INJ 1GM/5ML 5 HIZENTRA INJ 2GM/10ML 5 HIZENTRA INJ 4GM/20ML 5 HIZENTRA INJ 10/50ML 5 IMOGAM RABIE INJ 300/2ML 3 OCTAGAM INJ 1GM 5 OCTAGAM INJ 2GM/20ML 5 PRIVIGEN INJ 20GRAMS 5 IMMUNOMODULATORS ACTIMMUNE INJ 2MU/0.5 5 NM, LA, PA; DL ARCALYST INJ 220MG 5 NM, LA, PA; DL ILARIS INJ 150MG/ML 5 QL (2 vials / 28 days), NM, LA, PA; DL INTRON A INJ 10MU 5 NM; DL INTRON A INJ 18MU 5 NM; DL INTRON A INJ 25MU 5 NM; DL INTRON A INJ 50MU 5 NM; DL ORALAIR SUB 300 IR 4 QL (30 tabs / 30 days), PA ZINPLAVA SOL 25MG/ML 5 PA; DL IMMUNOSUPPRESSANTS ATGAM INJ 250MG 5 B/D; DL AZATHIOPRINE INJ 100MG 2 B/D azathioprine tab 50 mg 2 B/D BENLYSTA INJ 120MG 5 BENLYSTA INJ 200MG/ML 5 BENLYSTA INJ 400MG 5 CELLCEPT IV INJ 500MG 4 B/D cyclosporine cap 25 mg 2 B/D cyclosporine cap 100 mg 2 B/D cyclosporine iv soln 50 mg/ml 2 B/D cyclosporine modified cap 25 mg 2 B/D cyclosporine modified cap 50 mg 2 B/D cyclosporine modified cap 100 mg 2 B/D cyclosporine modified oral soln 100 mg/ml 2 B/D 109
gengraf cap 25mg 2 B/D gengraf cap 100mg 2 B/D gengraf sol 100mg/ml 2 B/D mycophenolate mofetil cap 250 mg 2 B/D mycophenolate mofetil for oral susp 200 5 B/D; DL mg/ml mycophenolate mofetil hcl for iv soln 500 4 B/D mg (base equiv) mycophenolate mofetil tab 500 mg 2 B/D mycophenolate sodium tab dr 180 mg 4 B/D (mycophenolic acid equiv) mycophenolate sodium tab dr 360 mg 4 B/D (mycophenolic acid equiv) NULOJIX INJ 250MG 5 PA; DL PROGRAF INJ 5MG/ML 4 B/D RAPAMUNE SOL 1MG/ML 5 PA; DL SIMULECT INJ 10MG 4 B/D SIMULECT INJ 20MG 4 B/D sirolimus tab 0.5 mg 4 PA sirolimus tab 1 mg 4 PA sirolimus tab 2 mg 5 PA; DL tacrolimus cap 0.5 mg 2 B/D tacrolimus cap 1 mg 2 B/D tacrolimus cap 5 mg 4 B/D THYMOGLOBULN INJ 25MG 5 B/D; DL ZORTRESS TAB 0.5MG 5 PA; DL ZORTRESS TAB 0.25MG 4 PA ZORTRESS TAB 0.75MG 5 PA; DL VACCINES ACTHIB INJ 3 ADACEL INJ 3 BCG VACCINE INJ 4 BEXSERO INJ 3 BOOSTRIX INJ 3 DAPTACEL INJ 3 DIP/TET PED INJ 25-5LFU 3 ENGERIX-B INJ 10/0.5ML 3 B/D ENGERIX-B INJ 20MCG/ML 3 B/D GARDASIL 9 INJ 3 PA 110
HAVRIX INJ 720UNIT 3 HAVRIX INJ 1440UNIT 3 HIBERIX SOL 10MCG 3 IMOVAX RABIE INJ 2.5/ML 3 INFANRIX INJ 3 IPOL INJ INACTIVE 3 IXIARO INJ 3 KINRIX INJ 3 M-M-R II INJ 3 MENACTRA INJ 3 MENVEO INJ 3 PEDIARIX INJ 0.5ML 3 PEDVAX HIB INJ 3 PROQUAD INJ 3 QUADRACEL INJ 3 RABAVERT INJ 3 RECOMBIVA HB INJ 5MCG/0.5 3 B/D RECOMBIVA HB INJ 10MCG/ML 3 B/D RECOMBIVA-HB INJ 40MCG/ML 3 B/D ROTARIX SUS 3 ROTATEQ SOL 3 SHINGRIX INJ 50MCG 3 PA SYNAGIS INJ 50MG 5 NM, LA, PA; DL SYNAGIS INJ 100MG/ML 5 TENIVAC INJ 5-2LF 3 TET/DIP TOX INJ 2-2 LF 3 TRUMENBA INJ 3 TWINRIX INJ 3 TYPHIM VI INJ 3 VAQTA INJ 25/0.5ML 3 VAQTA INJ 50UNT/ML 3 VARIVAX INJ 3 YF-VAX INJ 3 ZOSTAVAX INJ 3 QL (1 vaccine / 365 days), PA NUTRITIONAL/SUPPLEMENTS ELECTROLYTES calcium gluconate inj 10% 2 fluoritab chw 0.5mg f 2 111
fluoritab chw 2.2mg 2 K-TAB TAB 8MEQ CR 2 k-vescent tab 25meq ef 2 klor-con 8 tab 8meq er 2 klor-con 10 tab 10meq er 2 klor-con m10 tab 10meq er 2 KLOR-CON M15 TAB 15MEQ ER 2 klor-con m20 tab 20meq er 2 klor-con pak 20meq 4 klor-con spr cap 8meq 2 klor-con spr cap 10meq 2 ludent chw 0.25mg f 2 MAGNESIUM SU INJ 2GM/50ML 2 MAGNESIUM SU INJ 4G/100ML 2 MAGNESIUM SU INJ 20/500ML 2 MAGNESIUM SU INJ 40G/1000 2 MAGNESIUM SU INJ 80MG/ML 2 magnesium sulfate inj 50% 2 MG SO4/D5W INJ 10MG/ML 4 multivit/fl chw 0.5mg 2 multivit/fl chw 0.25mg 2 multivit/fl chw 1mg 2 pediatric multiple vitamins w/ fl-fe drops 2 0.25-10 mg/ml pediatric multiple vitamins w/ fluoride soln 2 0.5 mg/ml pediatric multiple vitamins w/ fluoride soln 2 0.25 mg/ml pot chloride tab 25meq ef 2 potassium acetate inj 2 meq/ml 2 potassium chloride cap er 8 meq 2 potassium chloride cap er 10 meq 2 potassium chloride microencapsulated crys 2 er tab 10 meq potassium chloride microencapsulated crys 2 er tab 20 meq potassium chloride oral soln 10% (20 4 meq/15ml) potassium chloride oral soln 20% (40 3 meq/15ml) 112
potassium chloride powder packet 20 meq 2 potassium chloride tab er 8 meq (600 mg) 2 potassium chloride tab er 10 meq 2 potassium chloride tab er 20 meq (1500 2 mg) potassium phosphates inj 15 mm/5ml 2 (phos) 22 meq/5ml (k) potassium phosphates inj 45 mm/15ml 2 (phos) 66 meq/15ml (k) potassium phosphates inj 150 mm/50ml 2 (phos) 220 meq/50ml (k) SOD LACTATE INJ 5MEQ/ML 2 sodium acetate inj 2 meq/ml 2 sodium acetate inj 4 meq/ml 2 sodium bicarbonate inj 7.5% 2 sodium bicarbonate inj 8.4% 2 sodium chloride inj 2.5 meq/ml (14.6%) 2 sodium fluoride 2.2 mg 2 tpn electrol inj 3 tri-vit/fe dro /fl 0.25 2 tri-vit/fl dro 0.5mg 2 tri-vit/fl dro 0.25mg 2 IV NUTRITION amino acid infusion 6% 4 B/D AMINOSYN 7% INJ /LYTES 4 B/D AMINOSYN II INJ 8.5% 4 B/D aminosyn ii inj 8.5/lyte 4 B/D AMINOSYN II INJ 10% 4 B/D AMINOSYN II INJ 15% 3 B/D aminosyn inj 8.5/lyte 4 B/D AMINOSYN M INJ 3.5% 4 B/D AMINOSYN-HBC INJ 7% 4 B/D AMINOSYN-PF INJ 7% 4 B/D AMINOSYN-PF INJ 10% 4 B/D AMINOSYN-RF INJ 5.2% 4 B/D CLINIMIX E INJ 2.75/D5W 4 B/D CLINIMIX E INJ 2.75/D10 4 B/D CLINIMIX E INJ 4.25/D5W 4 B/D CLINIMIX E INJ 4.25/D10 4 B/D 113
CLINIMIX E INJ 4.25/D25 4 B/D CLINIMIX E INJ 5%/D15W 4 B/D CLINIMIX E INJ 5%/D20W 4 B/D CLINIMIX E INJ 5%/D25W 4 B/D CLINIMIX INJ 2.75/D5W 4 B/D CLINIMIX INJ 4.25/D5W 4 B/D CLINIMIX INJ 4.25/D10 4 B/D CLINIMIX INJ 4.25/D20 4 B/D CLINIMIX INJ 4.25/D25 4 B/D CLINIMIX INJ 5%/D15W 4 B/D CLINIMIX INJ 5%/D20W 4 B/D CLINIMIX INJ 5%/D25W 4 B/D clinisol sf inj 15% 3 B/D FREAMINE HBC INJ 6.9% 4 B/D hepatamine sol 8% 4 B/D intralipid inj 20% 2 B/D INTRALIPID INJ 30% 4 B/D KABIVEN EMU 4 B/D NEPHRAMINE INJ 5.4% 4 B/D PERIKABIVEN EMU 4 B/D plenamine inj 15% 3 B/D PREMASOL SOL 10% 4 B/D PROCALAMINE INJ 3% 4 B/D PROSOL INJ 20% 4 B/D TRAVASOL INJ 10% 4 B/D TROPHAMINE INJ 6% 4 B/D TROPHAMINE INJ 10% 4 B/D IV REPLACEMENT SOLUTIONS D5W/LYTES INJ #48 2 D10W/NACL INJ 0.2% 2 dextrose 2.5% w/ sodium chloride 0.45% 2 dextrose 5% in lactated ringers 2 dextrose 5% w/ sodium chloride 0.2% 2 dextrose 5% w/ sodium chloride 0.9% 2 dextrose 5% w/ sodium chloride 0.33% 2 dextrose 5% w/ sodium chloride 0.45% 2 dextrose 5% w/ sodium chloride 0.225% 2 dextrose 10% w/ sodium chloride 0.45% 2 dextrose inj 5% 2 114
dextrose inj 10% 2 DEXTROSE INJ 20% 2 dextrose inj 25% 2 dextrose inj 30% 2 DEXTROSE INJ 40% 2 dextrose inj 50% 2 dextrose inj 70% 2 IONOSOL-MB INJ /D5W 4 ISOLYTE-P INJ /D5W 4 ISOLYTE-S INJ 4 kcl 10 meq/l (0.075%) in dextrose 5% & 2 nacl 0.45% inj kcl 20 meq/l (0.15%) in dextrose 5% & 2 nacl 0.2% inj kcl 20 meq/l (0.15%) in dextrose 5% & 2 nacl 0.9% inj kcl 20 meq/l (0.15%) in dextrose 5% & 2 nacl 0.33% inj kcl 20 meq/l (0.15%) in dextrose 5% & 2 nacl 0.45% inj kcl 20 meq/l (0.15%) in nacl 0.9% inj 2 kcl 20 meq/l (0.15%) in nacl 0.45% inj 2 kcl 30 meq/l (0.224%) in dextrose 5% & 2 nacl 0.2% inj kcl 30 meq/l (0.224%) in dextrose 5% & 2 nacl 0.45% inj kcl 40 meq/l (0.3%) in dextrose 5% & nacl 2 0.2% inj kcl 40 meq/l (0.3%) in dextrose 5% & nacl 2 0.45% inj kcl 40 meq/l (0.3%) in nacl 0.9% inj 2 KCL/D5W/LACT INJ 20MEQ/L 2 KCL/D5W/NACL INJ 0.3/0.9% 2 lactated ringer's solution 2 NORMOSOL -M INJ /D5W 4 NORMOSOL -R INJ /D5W 4 NORMOSOL-R INJ PH 7.4 4 PLASMA-LYTE INJ -148 4 PLASMA-LYTE INJ -A 4 115
potassium chloride 20 meq/l (0.15%) in 2 dextrose 5% inj potassium chloride 30 meq/l (0.224%) in 2 dextrose 5% inj potassium chloride 40 meq/l (0.3%) in 2 dextrose 5% inj potassium chloride inj 2 meq/ml 4 potassium chloride inj 10 meq/100ml 2 potassium chloride inj 20 meq/100ml 2 potassium chloride inj 30 meq/100ml 2 potassium chloride inj 40 meq/100ml 2 ringer's solution 2 sodium chloride inj 0.45% 2 sodium chloride inj 3% 2 sodium chloride inj 4 meq/ml (23.4%) 2 sodium chloride inj 5% 2 sodium chloride iv soln 0.9% 2 VITAMINS ascorbic acid 80 mg / biotin 0.030 mg / 2 calcium carbonate 200 mg / cupric oxide 3 mg / ferrous fumarate 60 mg calcitriol cap 0.5 mcg 2 calcitriol cap 0.25 mcg 2 calcitriol inj 1 mcg/ml 2 calcitriol oral soln 1 mcg/ml 2 doxercalciferol cap 0.5 mcg 4 doxercalciferol cap 1 mcg 5 DL doxercalciferol cap 2.5 mcg 4 doxercalciferol inj 4 mcg/2ml (2 mcg/ml) 4 paricalcitol cap 1 mcg 2 paricalcitol cap 2 mcg 2 paricalcitol cap 4 mcg 2 paricalcitol iv soln 2 mcg/ml 4 paricalcitol iv soln 5 mcg/ml 4 ZEMPLAR INJ 2MCG/ML 4 ZEMPLAR INJ 5MCG/ML 4 OPHTHALMIC ANTI-INFECTIVE/ANTI-INFLAMMATORY 116
bacitracin-polymyxin-neomycin-hc ophth 1 GC oint 1% BLEPHAMIDE OIN S.O.P. 4 BLEPHAMIDE SUS OP 4 neomycin-polymyxin-dexamethasone 1 GC ophth oint 0.1% neomycin-polymyxin-dexamethasone 1 GC ophth susp 0.1% neomycin-polymyxin-hc ophth susp 2 PRED-G S.O.P OIN OP 4 PRED-G SUS OP 4 sulfacetamide sodium-prednisolone ophth 2 soln 10-0.23(0.25)% TOBRADEX OIN 0.3-0.1% 4 tobramycin-dexamethasone ophth susp 2 0.3-0.1% ZYLET SUS 0.5-0.3% 4 ANTI-INFECTIVES AZASITE SOL 1% 4 bacitracin ophth oint 500 unit/gm 2 bacitracin-polymyxin b ophth oint 2 BESIVANCE SUS 0.6% 4 CILOXAN OIN 0.3% OP 4 ciprofloxacin hcl ophth soln 0.3% 2 erythromycin ophth oint 5 mg/gm 1 GC gatifloxacin ophth soln 0.5% 4 gentak oin 0.3% op 2 gentamicin sulfate ophth soln 0.3% 1 GC levofloxacin ophth soln 0.5% 2 MOXEZA SOL 0.5% 4 moxifloxacin hcl ophth soln 0.5% (base 4 equiv) NATACYN SUS 5% OP 4 neomycin-bacitrac zn-polymyx 5(3.5)mg- 1 GC 400unt-10000unt op oin neomycin-polymy-gramicid op sol 1.75-1 GC 10000-0.025mg-unt-mg/ml ofloxacin ophth soln 0.3% 2 polymyxin b-trimethoprim ophth soln 1 GC 10000 unit/ml-0.1% 117
sulfacetamide sodium ophth oint 10% 2 sulfacetamide sodium ophth soln 10% 1 GC tobramycin ophth soln 0.3% 1 GC TOBREX OIN 0.3% OP 4 trifluridine ophth soln 1% 2 ZIRGAN GEL 0.15% 4 ANTI-INFLAMMATORIES ACUVAIL SOL 0.45% 4 ALREX SUS 0.2% 4 dexamethasone sodium phosphate ophth 2 soln 0.1% diclofenac sodium ophth soln 0.1% 2 DUREZOL EMU 0.05% 3 fluorometholone ophth susp 0.1% 2 flurbiprofen sodium ophth soln 0.03% 2 FML FORTE SUS 0.25% OP 4 FML OIN 0.1% OP 4 ketorolac tromethamine ophth soln 0.4% 2 ketorolac tromethamine ophth soln 0.5% 2 LOTEMAX GEL 0.5% 4 LOTEMAX OIN 0.5% 4 LOTEMAX SUS 0.5% 4 MAXIDEX SUS 0.1% OP 4 PRED MILD SUS 0.12% OP 4 PRED SOD PHO SOL 1% OP 2 prednisolone acetate ophth susp 1% 2 ANTIALLERGICS ALOCRIL SOL 2% 4 ALOMIDE SOL 0.1% OP 4 azelastine hcl ophth soln 0.05% 2 BEPREVE DRO 1.5% 4 cromolyn sodium ophth soln 4% 2 EMADINE SOL 0.05% OP 4 epinastine hcl ophth soln 0.05% 2 ANTIGLAUCOMA ALPHAGAN P SOL 0.1% 3 apraclonidine hcl ophth soln 0.5% (base 2 equivalent) betaxolol hcl ophth soln 0.5% 2 118
BETIMOL SOL 0.5% 4 BETIMOL SOL 0.25% 4 BETOPTIC-S SUS 0.25% OP 4 bimatoprost ophth soln 0.03% 3 ST brimonidine tartrate ophth soln 0.2% 2 brimonidine tartrate ophth soln 0.15% 2 carteolol hcl ophth soln 1% 2 COMBIGAN SOL 0.2/0.5% 3 dorzolamide hcl ophth soln 2% 2 dorzolamide hcl-timolol maleate ophth soln 2 22.3-6.8 mg/ml IOPIDINE SOL 1% OP 4 latanoprost ophth soln 0.005% 2 levobunolol hcl ophth soln 0.5% 1 GC LUMIGAN SOL 0.01% 3 metipranolol ophth soln 0.3% 2 PHOSPHOLINE SOL 0.125%OP 4 pilocarpine hcl ophth soln 1% 3 pilocarpine hcl ophth soln 2% 3 pilocarpine hcl ophth soln 4% 3 SIMBRINZA SUS 1-0.2% 3 timolol maleate ophth gel forming soln 3 0.5% timolol maleate ophth gel forming soln 3 0.25% timolol maleate ophth soln 0.5% 1 GC timolol maleate ophth soln 0.25% 1 GC TRAVATAN Z DRO 0.004% 4 ST ZIOPTAN DRO 0.0015% 4 ST MISCELLANEOUS atropine sulfate ophth soln 1% 2 CYSTARAN SOL 0.44% 5 RESTASIS EMU 0.05% 3 QL (60 vials / 30 days) RESPIRATORY ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPT AER 62.5-25 3 COMBIVENT AER 20-100 3 ipratropium-albuterol nebu soln 0.5-2.5(3) 2 B/D mg/3ml 119
STIOLTO AER 2.5-2.5 3 TRELEGY AER ELLIPTA 3 ANTICHOLINERGICS ATROVENT HFA AER 17MCG 4 INCRUSE ELPT INH 62.5MCG 3 ipratropium bromide inhal soln 0.02% 2 B/D ipratropium bromide nasal soln 0.03% (21 2 mcg/spray) ipratropium bromide nasal soln 0.06% (42 2 mcg/spray) SPIRIVA AER 1.25MCG 3 SPIRIVA CAP HANDIHLR 3 SPIRIVA SPR 2.5MCG 3 ANTIHISTAMINES azelastine hcl nasal spray 0.1% (137 2 mcg/spray) carbinoxamine maleate soln 4 mg/5ml 2 PA carbinoxamine maleate tab 4 mg 2 PA clemastine fumarate tab 2.68 mg 2 PA cyproheptadine hcl syrup 2 mg/5ml 2 PA cyproheptadine hcl tab 4 mg 2 PA desloratadine tab 5 mg 4 diphenhydramine hcl inj 50 mg/ml 2 hydroxyzine hcl im soln 25 mg/ml 4 hydroxyzine hcl im soln 50 mg/ml 4 hydroxyzine hcl syrup 10 mg/5ml 4 PA hydroxyzine hcl tab 10 mg 2 PA hydroxyzine hcl tab 25 mg 2 PA hydroxyzine hcl tab 50 mg 2 PA hydroxyzine pamoate cap 25 mg 2 PA hydroxyzine pamoate cap 50 mg 2 PA hydroxyzine pamoate cap 100 mg 2 PA levocetirizine dihydrochloride soln 2.5 4 mg/5ml (0.5 mg/ml) levocetirizine dihydrochloride tab 5 mg 2 BETA AGONISTS albuterol sulfate soln nebu 0.5% (5 mg/ml) 1 GC, B/D albuterol sulfate soln nebu 0.63 mg/3ml (base equiv) 1 GC, B/D 120
albuterol sulfate soln nebu 0.083% (2.5 1 GC, B/D mg/3ml) albuterol sulfate soln nebu 1.25 mg/3ml 1 GC, B/D (base equiv) albuterol sulfate syrup 2 mg/5ml 1 GC albuterol sulfate tab 2 mg 4 albuterol sulfate tab 4 mg 4 albuterol sulfate tab er 12hr 4 mg 4 albuterol sulfate tab er 12hr 8 mg 2 BROVANA NEB 15MCG 4 B/D ISUPREL INJ 0.2MG/ML 4 levalbuterol hcl soln nebu 0.31 mg/3ml 2 B/D (base equiv) levalbuterol hcl soln nebu 0.63 mg/3ml 2 B/D (base equiv) levalbuterol hcl soln nebu 1.25 mg/3ml 2 B/D (base equiv) levalbuterol hcl soln nebu conc 1.25 2 B/D mg/0.5ml (base equiv) levalbuterol tartrate inhal aerosol 45 mcg/act (base equiv) 4 QL (2 inhalers / 30 days) metaproterenol sulfate syrup 10 mg/5ml 2 metaproterenol sulfate tab 10 mg 2 metaproterenol sulfate tab 20 mg 2 PERFOROMIST NEB 20MCG 4 B/D SEREVENT DIS AER 50MCG 3 STRIVERDI AER 2.5MCG 4 terbutaline sulfate inj 1 mg/ml 2 terbutaline sulfate tab 2.5 mg 2 terbutaline sulfate tab 5 mg 2 VENTOLIN HFA AER 3 QL (2 inhalers / 30 days) LEUKOTRIENE MODULATORS montelukast sodium chew tab 4 mg (base 2 QL (30 tabs / 30 days) equiv) montelukast sodium chew tab 5 mg (base 2 QL (30 tabs / 30 days) equiv) montelukast sodium oral granules packet 4 2 QL (30 packets / 30 mg (base equiv) days) 121
montelukast sodium tab 10 mg (base 2 QL (30 tabs / 30 days) equiv) zafirlukast tab 10 mg 4 zafirlukast tab 20 mg 4 MAST CELL STABILIZERS cromolyn sodium soln nebu 20 mg/2ml 2 B/D MISCELLANEOUS acetylcysteine inhal soln 10% 2 B/D acetylcysteine inhal soln 20% 2 B/D ARALAST NP INJ 1000MG 5 NM, LA, PA; DL DALIRESP TAB 250MCG 4 PA DALIRESP TAB 500MCG 4 PA epinephrine solution auto-injector 0.15 2 mg/0.3ml (1:2000) EPIPEN 2-PAK INJ 0.3MG 3 EPIPEN-JR INJ 2-PAK 3 ESBRIET CAP 267MG 5 QL (270 caps / 30 days), ESBRIET TAB 267MG 5 QL (270 tabs / 30 days), ESBRIET TAB 801MG 5 QL (90 tabs / 30 days), GLASSIA INJ 5 NM, LA, PA; DL KALYDECO PAK 50MG 5 QL (56 packets / 28 days), KALYDECO PAK 75MG 5 QL (56 packets / 28 days), KALYDECO TAB 150MG 5 QL (60 tabs / 30 days), NUCALA INJ 100MG 5 QL (1 vial / 28 days), NM, LA, PA; DL OFEV CAP 100MG 5 QL (60 caps / 30 days), OFEV CAP 150MG 5 QL (60 caps / 30 days), ORKAMBI TAB 100-125 5 QL (112 tabs / 28 days), ORKAMBI TAB 200-125 5 QL (120 tabs / 30 days), PROLASTIN-C INJ 1000MG 5 NM, LA, PA; DL 122
PULMOZYME SOL 1MG/ML 5 QL (150 ml / 30 days), XOLAIR SOL 150MG 5 QL (6 vials / 28 days), NM, LA, PA; DL ZEMAIRA INJ 1000MG 5 NM, LA, PA; DL NASAL STEROIDS flunisolide nasal soln 25 mcg/act (0.025%) 2 fluticasone propionate nasal susp 50 2 mcg/act STEROID INHALANTS ARNUITY ELPT INH 50MCG 3 ARNUITY ELPT INH 100MCG 3 ARNUITY ELPT INH 200MCG 3 budesonide inhalation susp 0.5 mg/2ml 3 B/D budesonide inhalation susp 0.25 mg/2ml 3 B/D budesonide inhalation susp 1 mg/2ml 3 B/D FLOVENT DISK AER 50MCG 3 FLOVENT DISK AER 100MCG 3 FLOVENT DISK AER 250MCG 3 FLOVENT HFA AER 44MCG 3 FLOVENT HFA AER 110MCG 3 FLOVENT HFA AER 220MCG 3 PULMICORT INH 90MCG 3 PULMICORT INH 180MCG 3 STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKU AER 100/50 3 ADVAIR DISKU AER 250/50 3 ADVAIR DISKU AER 500/50 3 ADVAIR HFA AER 45/21 3 ADVAIR HFA AER 115/21 3 ADVAIR HFA AER 230/21 3 BREO ELLIPTA INH 100-25 3 BREO ELLIPTA INH 200-25 3 SYMBICORT AER 80-4.5 3 SYMBICORT AER 160-4.5 3 XANTHINES aminophylline inj 25 mg/ml 2 theophylline soln 80 mg/15ml 2 123
theophylline tab er 12hr 100 mg 2 theophylline tab er 12hr 200 mg 2 theophylline tab er 12hr 300 mg 2 theophylline tab er 24hr 400 mg 2 theophylline tab er 24hr 600 mg 2 TOPICAL DERMATOLOGY, ACNE adapalene cream 0.1% 4 PA adapalene gel 0.1% 4 PA amnesteem cap 10mg 4 amnesteem cap 20mg 4 amnesteem cap 40mg 4 avita cre 0.025% 3 PA benzoyl peroxide-erythromycin gel 5-3% 3 claravis cap 10mg 4 claravis cap 20mg 4 claravis cap 30mg 4 claravis cap 40mg 4 clindamycin phosphate gel 1% 2 clindamycin phosphate lotion 1% 2 clindamycin phosphate soln 1% 2 clindamycin phosphate swab 1% 2 ery pad 2% 2 ERYGEL GEL 2% 4 erythromycin gel 2% 4 erythromycin soln 2% 2 isotretinoin cap 10 mg 4 isotretinoin cap 20 mg 4 isotretinoin cap 30 mg 4 isotretinoin cap 40 mg 4 myorisan cap 10mg 4 myorisan cap 20mg 4 myorisan cap 30mg 4 myorisan cap 40mg 4 sulfacetamide sodium lotion 10% (acne) 2 tretinoin cream 0.1% 3 PA tretinoin cream 0.05% 3 PA tretinoin cream 0.025% 3 PA tretinoin gel 0.01% 3 PA 124
tretinoin gel 0.025% 3 PA zenatane cap 10mg 4 zenatane cap 20mg 4 zenatane cap 30mg 4 zenatane cap 40mg 4 DERMATOLOGY, ANTIBIOTICS BACTROBAN OIN NASAL 2% 4 gentamicin sulfate cream 0.1% 2 gentamicin sulfate oint 0.1% 2 mupirocin oint 2% 2 silver sulfadiazine cream 1% 2 ssd cre 1% 2 SULFAMYLON CRE 85MG/GM 4 DERMATOLOGY, ANTIFUNGAL clotrimazole w/ betamethasone cream 1-2 0.05% clotrimazole w/ betamethasone lotion 1-4 0.05% nystatin-triamcinolone cream 100000-0.1 4 unit/gm-% nystatin-triamcinolone oint 100000-0.1 4 unit/gm-% DERMATOLOGY, ANTIFUNGALS ciclodan cre 0.77% 2 ciclopirox gel 0.77% 4 ciclopirox olamine cream 0.77% (base 3 equiv) ciclopirox olamine susp 0.77% (base 2 equiv) ciclopirox solution 8% 2 clotrimazole cream 1% 2 clotrimazole soln 1% 2 econazole nitrate cream 1% 4 ketoconazole cream 2% 2 nyamyc pow 100000 2 nystatin cream 100000 unit/gm 1 GC nystatin oint 100000 unit/gm 1 GC nystatin topical powder 100000 unit/gm 2 nystop pow 100000 2 125
DERMATOLOGY, ANTIPSORIATICS acitretin cap 10 mg 5 PA; DL acitretin cap 17.5 mg 5 PA; DL acitretin cap 25 mg 5 PA; DL calcipotriene cream 0.005% 4 calcipotriene oint 0.005% 4 calcipotriene soln 0.005% (50 mcg/ml) 4 calcitriol oint 3 mcg/gm 4 QL (800gm / 28 days) methoxsalen rapid cap 10 mg 5 PA; DL tazarotene cream 0.1% 4 PA TAZORAC CRE 0.05% 4 PA TAZORAC GEL 0.1% 4 PA TAZORAC GEL 0.05% 4 PA DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo 2% 2 selenium sulfide lotion 2.5% 2 DERMATOLOGY, CORTICOSTEROIDS ala-cort cre 1% 1 GC ala-cort cre 2.5% 1 GC alclometasone dipropionate cream 0.05% 3 alclometasone dipropionate oint 0.05% 4 amcinonide cream 0.1% 4 amcinonide lotion 0.1% 2 AMCINONIDE OIN 0.1% 2 betamethasone dipropionate augmented 2 cream 0.05% betamethasone dipropionate augmented 4 gel 0.05% betamethasone dipropionate augmented 4 lotion 0.05% betamethasone dipropionate augmented 4 oint 0.05% betamethasone dipropionate cream 0.05% 4 betamethasone dipropionate lotion 0.05% 2 betamethasone dipropionate oint 0.05% 4 betamethasone valerate cream 0.1% (base 2 equivalent) betamethasone valerate lotion 0.1% (base 3 equivalent) 126
betamethasone valerate oint 0.1% (base 2 equivalent) clobetasol e cre 0.05% 4 clobetasol propionate cream 0.05% 4 clobetasol propionate gel 0.05% 4 clobetasol propionate oint 0.05% 4 clobetasol propionate soln 0.05% 2 desonide cream 0.05% 4 desonide lotion 0.05% 4 desonide oint 0.05% 4 desoximetasone cream 0.05% 4 desoximetasone cream 0.25% 4 desoximetasone gel 0.05% 4 desoximetasone oint 0.25% 4 diflorasone diacetate cream 0.05% 4 diflorasone diacetate oint 0.05% 4 fluocin acet oil scalp 4 fluocinolone acetonide cream 0.01% 4 fluocinolone acetonide cream 0.025% 4 fluocinolone acetonide oint 0.025% 4 fluocinolone acetonide soln 0.01% 4 fluocinonide cream 0.05% 3 fluocinonide emulsified base cream 0.05% 3 fluocinonide gel 0.05% 4 fluocinonide oint 0.05% 4 fluocinonide soln 0.05% 4 fluticasone propionate cream 0.05% 2 fluticasone propionate oint 0.005% 2 halobetasol propionate cream 0.05% 4 halobetasol propionate oint 0.05% 4 hydrocortisone butyrate oint 0.1% 4 hydrocortisone butyrate soln 0.1% 3 hydrocortisone cream 1% 1 GC hydrocortisone cream 2.5% 1 GC hydrocortisone lotion 2.5% 1 GC hydrocortisone oint 1% 1 GC hydrocortisone oint 2.5% 1 GC hydrocortisone valerate cream 0.2% 4 hydrocortisone valerate oint 0.2% 4 127
mometasone furoate cream 0.1% 2 mometasone furoate oint 0.1% 2 mometasone furoate solution 0.1% (lotion) 2 prednicarbate cream 0.1% 2 prednicarbate oint 0.1% 2 triamcinolone acetonide cream 0.1% 2 triamcinolone acetonide cream 0.5% 1 GC triamcinolone acetonide cream 0.025% 1 GC triamcinolone acetonide lotion 0.1% 2 triamcinolone acetonide lotion 0.025% 2 triamcinolone acetonide oint 0.1% 1 GC triamcinolone acetonide oint 0.5% 1 GC triamcinolone acetonide oint 0.025% 1 GC triderm cre 0.1% 2 DERMATOLOGY, LOCAL ANESTHETICS lidocaine hcl gel 2% 2 lidocaine hcl soln 4% 2 lidocaine oint 5% 4 lidocaine patch 5% 4 QL (90 patches / 30 days), PA lidocaine-prilocaine cream 2.5-2.5% 4 DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir oint 5% 2 CONDYLOX GEL 0.5% 4 DENAVIR CRE 1% 4 diclofenac sodium gel 1% 4 QL (1000gm / 30 days) ELIDEL CRE 1% 4 PA EUCRISA OIN 2% 4 PA fluorouracil cream 5% 3 fluorouracil soln 2% 3 fluorouracil soln 5% 3 imiquimod cream 5% 3 lactic acid (ammonium lactate) cream 12% 2 lactic acid (ammonium lactate) lotion 12% 2 metronidazole cream 0.75% 3 metronidazole gel 0.75% 3 metronidazole lotion 0.75% 3 PANRETIN GEL 0.1% 5 PA; DL PICATO GEL 0.05% 5 PA; DL 128
PICATO GEL 0.015% 5 PA; DL podofilox soln 0.5% 2 procto-med cre hc 2.5% 2 procto-pak cre 1% 2 proctosol hc cre 2.5% 2 proctozone cre -hc 2.5% 2 rosadan cre 0.75% 3 rosadan gel 0.75% 3 tacrolimus oint 0.1% 4 PA tacrolimus oint 0.03% 4 PA TARGRETIN GEL 1% 5 NM; DL VALCHLOR GEL 0.016% 5 DERMATOLOGY, SCABICIDES AND PEDICULIDES lindane shampoo 1% 4 malathion lotion 0.5% 4 permethrin cream 5% 3 DERMATOLOGY, WOUND CARE AGENTS acetic acid irrigation soln 0.25% 2 glycine irrigation soln 1.5% 2 lactated ringer's for irrigation 2 neomycin-polymyxin b gu irrigation soln 2 physiolyte sol 3 physiosol sol irrigat 3 REGRANEX GEL 0.01% 5 PA; DL ringer's solution for irrigation 2 SANTYL OIN 250/GM 4 sodium chloride irrigation soln 0.9% 2 water for irrigation, sterile irrigation soln 2 MOUTH/THROAT/DENTAL AGENTS cevimeline hcl cap 30 mg 4 chlorhexidine gluconate soln 0.12% 2 clotrimazole troche 10 mg 2 dentagel gel 1.1% 2 lidocaine hcl laryngotracheal soln 4% 2 lidocaine hcl viscous soln 2% 1 GC nystatin susp 100000 unit/ml 2 periogard sol 0.12% 2 periomed con 0.63% 2 129
pilocarpine hcl tab 5 mg 3 pilocarpine hcl tab 7.5 mg 3 sf 5000 plus cre 1.1% 2 triamcinolone acetonide dental paste 0.1% 2 OTIC acetic acid otic soln 2% 2 CIPRO HC SUS OTIC 4 CIPRODEX SUS 0.3-0.1% 4 ciprofloxacin hcl otic soln 0.2% (base 2 equivalent) COLY-MYCIN S SUS OTIC 4 FLOXIN SOL 0.3% 2 fluocinolone acetonide (otic) oil 0.01% 2 hydrocortisone w/ acetic acid otic soln 1-2 2% neomycin-polymyxin-hc otic soln 1% 2 neomycin-polymyxin-hc otic susp 3.5 2 mg/ml-10000 unit/ml-1% ofloxacin otic soln 0.3% 2 130
Index A abacavir sulfate soln 20 mg/ml (base equiv)... 12 abacavir sulfate tab 300 mg (base equiv)... 12 abacavir sulfate-lamivudine tab 600-300 mg... 14 abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg... 14 ABELCET INJ 5MG/ML... 10 ABILIFY MAIN INJ 300MG... 64 ABILIFY MAIN INJ 400MG... 65 ABRAXANE INJ 100MG... 25 ABSTRAL SUB 100MCG... 3 ABSTRAL SUB 200MCG... 3 ABSTRAL SUB 300MCG... 3 ABSTRAL SUB 400MCG... 3 ABSTRAL SUB 600MCG... 3 ABSTRAL SUB 800MCG... 3 acamprosate calcium tab delayed release 333 mg... 76 acarbose tab 100 mg... 79 acarbose tab 25 mg... 79 acarbose tab 50 mg... 79 acebutolol hcl cap 200 mg... 44 acebutolol hcl cap 400 mg... 44 acetaminophen w/ codeine soln 120-12 mg/5ml... 2 acetaminophen w/ codeine tab 300-15 mg... 2 acetaminophen w/ codeine tab 300-30 mg... 2 acetaminophen w/ codeine tab 300-60 mg... 2 acetazolamide cap er 12hr 500 mg... 48 acetazolamide sodium for inj 500 mg.. 48 acetazolamide tab 125 mg... 48 acetazolamide tab 250 mg... 48 acetic acid irrigation soln 0.25%... 129 acetic acid otic soln 2%... 130 acetylcysteine inhal soln 10%... 122 acetylcysteine inhal soln 20%... 122 acetylcysteine inj 200 mg/ml... 92 acitretin cap 10 mg... 126 acitretin cap 17.5 mg... 126 acitretin cap 25 mg... 126 ACTHIB INJ... 110 ACTIMMUNE INJ 2MU/0.5... 109 ACUVAIL SOL 0.45%... 118 acyclovir cap 200 mg... 15 acyclovir oint 5%... 128 acyclovir sodium iv soln 50 mg/ml... 15 acyclovir susp 200 mg/5ml... 15 acyclovir tab 400 mg... 15 acyclovir tab 800 mg... 15 ADACEL INJ... 110 ADAGEN INJ 250/ML... 87 adapalene cream 0.1%... 124 adapalene gel 0.1%... 124 ADCIRCA TAB 20MG... 51 adefovir dipivoxil tab 10 mg... 15 ADEMPAS TAB 0.5MG... 51 ADEMPAS TAB 1.5MG... 51 ADEMPAS TAB 1MG... 51 ADEMPAS TAB 2.5MG... 51 ADEMPAS TAB 2MG... 51 adriamycin inj 20mg... 23 adrucil inj 500/10ml... 24 ADVAIR DISKU AER 100/50... 123 ADVAIR DISKU AER 250/50... 123 ADVAIR DISKU AER 500/50... 123 ADVAIR HFA AER 115/21... 123 ADVAIR HFA AER 230/21... 123 ADVAIR HFA AER 45/21... 123 afeditab tab 30mg cr... 46 afeditab tab 60mg cr... 46 AFINITOR DIS TAB 2MG... 30 AFINITOR DIS TAB 3MG... 30 AFINITOR DIS TAB 5MG... 30 AFINITOR TAB 10MG... 31 AFINITOR TAB 2.5MG... 30 AFINITOR TAB 5MG... 30 AFINITOR TAB 7.5MG... 30 ala-cort cre 1%... 126 ala-cort cre 2.5%... 126 ALBENZA TAB 200MG... 8 albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)... 121 131
albuterol sulfate soln nebu 0.5% (5 mg/ml)... 121 albuterol sulfate soln nebu 0.63 mg/3ml (base equiv)... 121 albuterol sulfate soln nebu 1.25 mg/3ml (base equiv)... 121 albuterol sulfate syrup 2 mg/5ml... 121 albuterol sulfate tab 2 mg... 121 albuterol sulfate tab 4 mg... 121 albuterol sulfate tab er 12hr 4 mg... 121 albuterol sulfate tab er 12hr 8 mg... 121 alclometasone dipropionate cream 0.05%... 126 alclometasone dipropionate oint 0.05%... 126 ALDURAZYME INJ 2.9MG/5M... 87 ALECENSA CAP 150MG... 31 alendronate sodium oral soln 70 mg/75ml... 81 alendronate sodium tab 10 mg... 81 alendronate sodium tab 35 mg... 81 alendronate sodium tab 40 mg... 81 alendronate sodium tab 5 mg... 81 alendronate sodium tab 70 mg... 81 alfuzosin hcl tab er 24hr 10 mg... 102 ALIMTA INJ 100MG... 24 ALIMTA INJ 500MG... 24 ALINIA SUS 100/5ML... 8 ALINIA TAB 500MG... 8 ALIQOPA INJ 60MG... 31 allopurinol sodium for inj 500 mg... 1 allopurinol tab 100 mg... 1 allopurinol tab 300 mg... 1 ALOCRIL SOL 2%... 118 ALOMIDE SOL 0.1% OP... 118 alosetron hcl tab 0.5 mg (base equiv) 100 alosetron hcl tab 1 mg (base equiv).. 100 ALOXI INJ 0.25MG/5... 96 ALPHAGAN P SOL 0.1%... 118 alprazolam tab 0.25 mg... 52 alprazolam tab 0.5 mg... 52 alprazolam tab 1 mg... 52 alprazolam tab 2 mg... 52 alprazolam tab er 24hr 0.5 mg... 52 alprazolam tab er 24hr 1 mg... 52 alprazolam tab er 24hr 2 mg... 52 alprazolam tab er 24hr 3 mg... 52 ALREX SUS 0.2%... 118 altavera tab... 82 ALUNBRIG PAK... 31 ALUNBRIG TAB 180MG... 31 ALUNBRIG TAB 30MG... 31 ALUNBRIG TAB 90MG... 31 alyacen tab 1/35... 82 alyacen tab 7/7/7... 82 amabelz tab 0.5-0.1... 88 amabelz tab 1-0.5mg... 88 amantadine hcl cap 100 mg... 63 amantadine hcl syrup 50 mg/5ml... 63 amantadine hcl tab 100 mg... 63 AMBISOME INJ 50MG... 10 amcinonide cream 0.1%... 126 amcinonide lotion 0.1%... 126 AMCINONIDE OIN 0.1%... 126 amethia lo tab... 82 amethia tab... 82 amikacin sulfate inj 1 gm/4ml (250 mg/ml)... 8 amikacin sulfate inj 500 mg/2ml (250 mg/ml)... 8 amiloride & hydrochlorothiazide tab 5-50 mg... 48 amiloride hcl tab 5 mg... 48 amino acid infusion 6%... 113 aminocaproic acid inj 250 mg/ml... 106 aminophylline inj 25 mg/ml... 124 AMINOSYN 7% INJ /LYTES... 113 AMINOSYN II INJ 10%... 113 AMINOSYN II INJ 15%... 113 AMINOSYN II INJ 8.5%... 113 aminosyn ii inj 8.5/lyte... 113 aminosyn inj 8.5/lyte... 113 AMINOSYN M INJ 3.5%... 113 AMINOSYN-HBC INJ 7%... 113 AMINOSYN-PF INJ 10%... 113 AMINOSYN-PF INJ 7%... 113 AMINOSYN-RF INJ 5.2%... 113 amiodarone hcl inj 150 mg/3ml (50 mg/ml)... 40 amiodarone hcl tab 100 mg... 41 amiodarone hcl tab 200 mg... 41 amiodarone hcl tab 400 mg... 41 132
AMITIZA CAP 24MCG... 100 AMITIZA CAP 8MCG... 100 amitriptyline hcl tab 10 mg... 59 amitriptyline hcl tab 100 mg... 59 amitriptyline hcl tab 150 mg... 59 amitriptyline hcl tab 25 mg... 59 amitriptyline hcl tab 50 mg... 59 amitriptyline hcl tab 75 mg... 59 amlodipine besylate tab 10 mg (base equivalent)... 46 amlodipine besylate tab 2.5 mg (base equivalent)... 46 amlodipine besylate tab 5 mg (base equivalent)... 46 amlodipine besylate-benazepril hcl cap 10-20 mg... 36 amlodipine besylate-benazepril hcl cap 10-40 mg... 36 amlodipine besylate-benazepril hcl cap 2.5-10 mg... 36 amlodipine besylate-benazepril hcl cap 5-10 mg... 36 amlodipine besylate-benazepril hcl cap 5-20 mg... 36 amlodipine besylate-benazepril hcl cap 5-40 mg... 36 amlodipine besylate-valsartan tab 10-160 mg... 39 amlodipine besylate-valsartan tab 10-320 mg... 39 amlodipine besylate-valsartan tab 5-160 mg... 39 amlodipine besylate-valsartan tab 5-320 mg... 39 amnesteem cap 10mg... 124 amnesteem cap 20mg... 124 amnesteem cap 40mg... 124 amoxapine tab 100 mg... 59 amoxapine tab 150 mg... 59 amoxapine tab 25 mg... 59 amoxapine tab 50 mg... 59 amoxicillin & k clavulanate chew tab 200-28.5 mg... 20 amoxicillin & k clavulanate chew tab 400-57 mg... 20 amoxicillin & k clavulanate for susp 200-28.5 mg/5ml... 20 amoxicillin & k clavulanate for susp 250-62.5 mg/5ml... 20 amoxicillin & k clavulanate for susp 400-57 mg/5ml... 20 amoxicillin & k clavulanate for susp 600-42.9 mg/5ml... 20 amoxicillin & k clavulanate tab 250-125 mg... 20 amoxicillin & k clavulanate tab 500-125 mg... 20 amoxicillin & k clavulanate tab 875-125 mg... 20 amoxicillin & k clavulanate tab er 12hr 1000-62.5 mg... 20 amoxicillin (trihydrate) cap 250 mg... 20 amoxicillin (trihydrate) cap 500 mg... 20 amoxicillin (trihydrate) chew tab 125 mg... 20 amoxicillin (trihydrate) chew tab 250 mg... 20 amoxicillin (trihydrate) for susp 125 mg/5ml... 20 amoxicillin (trihydrate) for susp 200 mg/5ml... 20 amoxicillin (trihydrate) for susp 250 mg/5ml... 20 amoxicillin (trihydrate) for susp 400 mg/5ml... 20 amoxicillin (trihydrate) tab 500 mg... 20 amoxicillin (trihydrate) tab 875 mg... 21 amphetamine-dextroamphetamine cap er 24hr 10 mg... 70 amphetamine-dextroamphetamine cap er 24hr 15 mg... 70 amphetamine-dextroamphetamine cap er 24hr 20 mg... 70 amphetamine-dextroamphetamine cap er 24hr 25 mg... 70 amphetamine-dextroamphetamine cap er 24hr 30 mg... 70 amphetamine-dextroamphetamine cap er 24hr 5 mg... 70 amphetamine-dextroamphetamine tab 10 mg... 71 amphetamine-dextroamphetamine tab 133
12.5 mg... 71 amphetamine-dextroamphetamine tab 15 mg... 71 amphetamine-dextroamphetamine tab 20 mg... 71 amphetamine-dextroamphetamine tab 30 mg... 71 amphetamine-dextroamphetamine tab 5 mg... 70 amphetamine-dextroamphetamine tab 7.5 mg... 70 amphotericin b for inj 50 mg... 10 ampicillin & sulbactam sodium for inj 1.5 (1-0.5) gm... 21 ampicillin & sulbactam sodium for inj 15 (10-5) gm... 21 ampicillin & sulbactam sodium for inj 3 (2-1) gm... 21 ampicillin cap 500 mg... 21 ampicillin sodium for inj 1 gm... 21 ampicillin sodium for inj 125 mg... 21 ampicillin sodium for inj 2 gm... 21 ampicillin sodium for inj 250 mg... 21 ampicillin sodium for inj 500 mg... 21 ampicillin sodium for iv soln 10 gm... 21 ampicillin sodium for iv soln 2 gm... 21 AMPYRA TAB 10MG... 74 ANADROL-50 TAB 50MG... 77 anagrelide hcl cap 0.5 mg... 106 anagrelide hcl cap 1 mg... 106 anastrozole tab 1 mg... 28 ANDRODERM DIS 2MG/24HR... 77 ANDRODERM DIS 4MG/24HR... 77 ANORO ELLIPT AER 62.5-25... 119 APOKYN INJ 10MG/ML... 63 apraclonidine hcl ophth soln 0.5% (base equivalent)... 119 aprepitant capsule 125 mg... 96 aprepitant capsule 40 mg... 96 aprepitant capsule 80 mg... 96 aprepitant capsule therapy pack 80 & 125 mg... 96 apri tab... 82 APRISO CAP 0.375GM... 99 APTIOM TAB 200MG... 53 APTIOM TAB 400MG... 53 APTIOM TAB 600MG... 53 APTIOM TAB 800MG... 53 APTIVUS CAP 250MG... 12 APTIVUS SOL... 12 ARALAST NP INJ 1000MG... 122 aranelle tab... 82 ARANESP INJ 100MCG... 105 ARANESP INJ 10MCG... 105 ARANESP INJ 150MCG... 105 ARANESP INJ 200MCG... 105 ARANESP INJ 25MCG... 105 ARANESP INJ 300MCG... 105 ARANESP INJ 40MCG... 105 ARANESP INJ 500MCG... 105 ARANESP INJ 60MCG... 105 ARCALYST INJ 220MG... 109 ARGATROBAN INJ 125/125... 103 argatroban inj 250 mg/2.5ml (concentrate for iv infusion)... 103 aripiprazole oral solution 1 mg/ml... 65 aripiprazole orally disintegrating tab 10 mg... 65 aripiprazole orally disintegrating tab 15 mg... 65 aripiprazole tab 10 mg... 65 aripiprazole tab 15 mg... 65 aripiprazole tab 2 mg... 65 aripiprazole tab 20 mg... 65 aripiprazole tab 30 mg... 65 aripiprazole tab 5 mg... 65 ARISTADA INJ 1064MG... 65 ARISTADA INJ 441MG/1.... 65 ARISTADA INJ 662MG/2... 65 ARISTADA INJ 882MG/3... 65 ARISTOSPAN INJ 20MG/ML... 99 ARISTOSPAN INJ 5MG/ML... 99 armodafinil tab 150 mg... 76 armodafinil tab 200 mg... 76 armodafinil tab 250 mg... 76 armodafinil tab 50 mg... 76 ARNUITY ELPT INH 100MCG... 123 ARNUITY ELPT INH 200MCG... 123 ARNUITY ELPT INH 50MCG... 123 ARRANON INJ 5MG/ML... 24 ARZERRA CON 100/5ML... 25 ascomp/cod cap 30mg... 2 134
ascorbic acid 80 mg / biotin 0.030 mg / calcium carbonate 200 mg / cupric oxide 3 mg / ferrous fumarate 60 mg... 116 ashlyna tab... 82 aspirin-dipyridamole cap er 12hr 25-200 mg... 106 atazanavir sulfate cap 150 mg (base equiv)... 12 atazanavir sulfate cap 200 mg (base equiv)... 12 atazanavir sulfate cap 300 mg (base equiv)... 12 atenolol & chlorthalidone tab 100-25 mg... 44 atenolol & chlorthalidone tab 50-25 mg... 44 atenolol tab 100 mg... 44 atenolol tab 25 mg... 44 atenolol tab 50 mg... 44 ATGAM INJ 250MG... 109 atomoxetine hcl cap 10 mg (base equiv)... 71 atomoxetine hcl cap 100 mg (base equiv)... 71 atomoxetine hcl cap 18 mg (base equiv)... 71 atomoxetine hcl cap 25 mg (base equiv)... 71 atomoxetine hcl cap 40 mg (base equiv)... 71 atomoxetine hcl cap 60 mg (base equiv)... 71 atomoxetine hcl cap 80 mg (base equiv)... 71 atorvastatin calcium tab 10 mg (base equivalent)... 42 atorvastatin calcium tab 20 mg (base equivalent)... 42 atorvastatin calcium tab 40 mg (base equivalent)... 42 atorvastatin calcium tab 80 mg (base equivalent)... 42 atovaquone susp 750 mg/5ml... 8 atovaquone-proguanil hcl tab 250-100 mg... 11 atovaquone-proguanil hcl tab 62.5-25 mg... 11 ATRIPLA TAB... 14 atropine sulfate ophth soln 1%... 119 atropine sulfate soln prefill syr 0.25 mg/5ml (0.05 mg/ml)... 98 ATROVENT HFA AER 17MCG... 120 AUBAGIO TAB 14MG... 75 AUBAGIO TAB 7MG... 74 aubra tab 0.1-0.02... 82 AURYXIA TAB 210MG... 95 AVASTIN INJ... 25 AVASTIN INJ 400/16ML... 25 AVELOX INJ... 19 aviane tab... 82 avita cre 0.025%... 124 AVYCAZ INJ 2-0.5GM... 17 azacitidine for inj 100 mg... 24 AZACTAM INJ 2GM... 8 AZASITE SOL 1%... 117 AZATHIOPRINE INJ 100MG... 109 azathioprine tab 50 mg... 109 azelastine hcl nasal spray 0.1% (137 mcg/spray)... 120 azelastine hcl ophth soln 0.05%... 118 azithromycin for susp 100 mg/5ml... 18 azithromycin for susp 200 mg/5ml... 18 azithromycin iv for soln 500 mg... 18 azithromycin powd pack for susp 1 gm 18 azithromycin tab 250 mg... 18 azithromycin tab 500 mg... 18 azithromycin tab 600 mg... 19 aztreonam for inj 1 gm... 8 aztreonam for inj 2 gm... 8 azurette tab 28 day... 82 B baciim inj 50000unt... 8 bacitracin intramuscular for soln 50000 unit... 8 bacitracin ophth oint 500 unit/gm... 117 bacitracin-polymyxin b ophth oint... 117 bacitracin-polymyxin-neomycin-hc ophth oint 1%... 117 baclofen tab 10 mg... 75 baclofen tab 20 mg... 75 baclofen tab 5 mg... 75 BACTOCILL INJ DEX 1GM... 21 135
BACTOCILL INJ DEX 2GM... 21 BACTROBAN OIN NASAL 2%... 125 balsalazide disodium cap 750 mg... 99 balziva tab... 82 BANZEL SUS 40MG/ML... 53 BANZEL TAB 200MG... 53 BANZEL TAB 400MG... 53 BARACLUDE SOL.05MG/ML... 15 BAVENCIO INJ 20MG/ML... 25 BCG VACCINE INJ... 110 bekyree tab... 82 BELEODAQ INJ 500MG... 25 benazepril & hydrochlorothiazide tab 10-12.5 mg... 36 benazepril & hydrochlorothiazide tab 20-12.5 mg... 36 benazepril & hydrochlorothiazide tab 20-25 mg... 36 benazepril & hydrochlorothiazide tab 5-6.25 mg... 36 benazepril hcl tab 10 mg... 37 benazepril hcl tab 20 mg... 37 benazepril hcl tab 40 mg... 37 benazepril hcl tab 5 mg... 37 BENDEKA INJ 100/4ML... 23 BENLYSTA INJ 120MG... 109 BENLYSTA INJ 200MG/ML... 109 BENLYSTA INJ 400MG... 109 BENTYL INJ 10MG/ML... 98 benzoyl peroxide-erythromycin gel 5-3%... 124 benztropine mesylate inj 1 mg/ml... 63 benztropine mesylate tab 0.5 mg... 63 benztropine mesylate tab 1 mg... 63 benztropine mesylate tab 2 mg... 63 BEPREVE DRO 1.5%... 118 BERINERT INJ 500UNIT... 106 BESIVANCE SUS 0.6%... 117 betamethasone dipropionate augmented cream 0.05%... 126 betamethasone dipropionate augmented gel 0.05%... 126 betamethasone dipropionate augmented lotion 0.05%... 126 betamethasone dipropionate augmented oint 0.05%... 126 betamethasone dipropionate cream 0.05%... 126 betamethasone dipropionate lotion 0.05%... 126 betamethasone dipropionate oint 0.05%... 126 betamethasone sod phosphate & acetate inj susp 6 (3-3) mg/ml... 90 betamethasone valerate cream 0.1% (base equivalent)... 126 betamethasone valerate lotion 0.1% (base equivalent)... 127 betamethasone valerate oint 0.1% (base equivalent)... 127 BETASERON INJ 0.3MG... 75 betaxolol hcl ophth soln 0.5%... 119 betaxolol hcl tab 10 mg... 44 betaxolol hcl tab 20 mg... 44 bethanechol chloride tab 10 mg... 102 bethanechol chloride tab 25 mg... 102 bethanechol chloride tab 5 mg... 102 bethanechol chloride tab 50 mg... 102 BETHKIS NEB 300/4ML... 8 BETIMOL SOL 0.25%... 119 BETIMOL SOL 0.5%... 119 BETOPTIC-S SUS 0.25% OP... 119 bexarotene cap 75 mg... 34 BEXSERO INJ... 110 bicalutamide tab 50 mg... 28 BICILLIN C-R INJ 1200000... 21 BICILLIN C-R INJ 900/300... 21 BICILLIN L-A INJ 1200000... 21 BICILLIN L-A INJ 2400000... 21 BICILLIN L-A INJ 600000... 21 BICNU INJ 100MG... 23 BIKTARVY TAB... 14 BILTRICIDE TAB 600MG... 8 bimatoprost ophth soln 0.03%... 119 bisoprolol & hydrochlorothiazide tab 10-6.25 mg... 44 bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg... 44 bisoprolol & hydrochlorothiazide tab 5-6.25 mg... 44 bisoprolol fumarate tab 10 mg... 44 bisoprolol fumarate tab 5 mg... 44 136
BIVIGAM INJ 10%... 108 bleomycin sulfate for inj 15 unit... 24 bleomycin sulfate for inj 30 unit... 24 BLEPHAMIDE OIN S.O.P.... 117 BLEPHAMIDE SUS OP... 117 BLINCYTO INJ 35MCG... 25 blisovi 24 tab fe 1/20... 83 blisovi fe tab 1.5/30... 83 blisovi fe tab 1/20... 83 BOOSTRIX INJ... 110 BORTEZOMIB INJ 3.5MG... 25 BOSULIF TAB 100MG... 31 BOSULIF TAB 400MG... 31 BOSULIF TAB 500MG... 31 BOTOX INJ 100UNIT... 75 BOTOX INJ 200UNIT... 75 BREO ELLIPTA INH 100-25... 123 BREO ELLIPTA INH 200-25... 123 briellyn tab... 83 BRILINTA TAB 60MG... 106 BRILINTA TAB 90MG... 106 brimonidine tartrate ophth soln 0.15%... 119 brimonidine tartrate ophth soln 0.2% 119 BRIVIACT INJ 50MG/5ML... 53 BRIVIACT SOL 10MG/ML... 53 BRIVIACT TAB 100MG... 53 BRIVIACT TAB 10MG... 53 BRIVIACT TAB 25MG... 53 BRIVIACT TAB 50MG... 53 BRIVIACT TAB 75MG... 53 bromocriptine mesylate cap 5 mg (base equivalent)... 63 bromocriptine mesylate tab 2.5 mg (base equivalent)... 63 BROVANA NEB 15MCG... 121 budesonide delayed release particles cap 3 mg... 99 budesonide inhalation susp 0.25 mg/2ml... 123 budesonide inhalation susp 0.5 mg/2ml... 123 budesonide inhalation susp 1 mg/2ml 123 bumetanide inj 0.25 mg/ml... 48 bumetanide tab 0.5 mg... 48 bumetanide tab 1 mg... 48 bumetanide tab 2 mg... 48 BUPHENYL TAB 500MG... 87 buprenorphine hcl inj 0.3 mg/ml (base equiv)... 7 buprenorphine hcl sl tab 2 mg (base equiv)... 76 buprenorphine hcl sl tab 8 mg (base equiv)... 76 buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv)... 76 buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv)... 76 bupropion hcl (smoking deterrent) tab er 12hr 150 mg... 76 bupropion hcl tab 100 mg... 59 bupropion hcl tab 75 mg... 59 bupropion hcl tab er 12hr 100 mg... 59 bupropion hcl tab er 12hr 150 mg... 59 bupropion hcl tab er 12hr 200 mg... 59 bupropion hcl tab er 24hr 150 mg... 59 bupropion hcl tab er 24hr 300 mg... 59 buspirone hcl tab 10 mg... 52 buspirone hcl tab 15 mg... 52 buspirone hcl tab 30 mg... 53 buspirone hcl tab 5 mg... 52 buspirone hcl tab 7.5 mg... 52 busulfan inj 6 mg/ml... 23 butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg... 3 butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg... 3 butorphanol tartrate inj 1 mg/ml... 3 butorphanol tartrate inj 2 mg/ml... 3 butorphanol tartrate nasal soln 10 mg/ml... 3 BYDUREON INJ 2MG... 78 BYDUREON INJ BCISE... 78 BYDUREON PEN INJ 2MG... 78 BYETTA INJ 10MCG... 78 BYETTA INJ 5MCG... 78 C cabergoline tab 0.5 mg... 92 CABOMETYX TAB 20MG... 31 CABOMETYX TAB 40MG... 31 CABOMETYX TAB 60MG... 31 calcipotriene cream 0.005%... 126 137
calcipotriene oint 0.005%... 126 calcipotriene soln 0.005% (50 mcg/ml)... 126 calcitonin (salmon) nasal soln 200 unit/act... 92 calcitriol cap 0.25 mcg... 116 calcitriol cap 0.5 mcg... 116 calcitriol inj 1 mcg/ml... 116 calcitriol oint 3 mcg/gm... 126 calcitriol oral soln 1 mcg/ml... 116 calcium acetate (phosphate binder) cap 667 mg (169 mg ca)... 95 calcium acetate (phosphate binder) tab 667 mg... 95 calcium gluconate inj 10%... 112 CALQUENCE CAP 100MG... 31 camila tab 0.35mg... 83 CAMPATH INJ 30MG/ML... 25 camrese lo tab... 83 camrese tab... 83 CANASA SUP 1000MG... 99 candesartan cilexetil tab 16 mg... 40 candesartan cilexetil tab 32 mg... 40 candesartan cilexetil tab 4 mg... 40 candesartan cilexetil tab 8 mg... 40 candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg... 39 candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg... 39 candesartan cilexetil-hydrochlorothiazide tab 32-25 mg... 39 CAPASTAT SUL INJ 1GM... 15 CAPRELSA TAB 100MG... 31 CAPRELSA TAB 300MG... 31 captopril & hydrochlorothiazide tab 25-15 mg... 36 captopril & hydrochlorothiazide tab 25-25 mg... 37 captopril & hydrochlorothiazide tab 50-15 mg... 37 captopril & hydrochlorothiazide tab 50-25 mg... 37 captopril tab 100 mg... 37 captopril tab 12.5 mg... 37 captopril tab 25 mg... 37 captopril tab 50 mg... 37 CARAFATE SUS 1GM/10ML... 100 CARBAGLU TAB 200MG... 87 carbamazepine cap er 12hr 100 mg... 53 carbamazepine cap er 12hr 200 mg... 53 carbamazepine cap er 12hr 300 mg... 53 carbamazepine chew tab 100 mg... 53 carbamazepine susp 100 mg/5ml... 53 carbamazepine tab 200 mg... 53 carbamazepine tab er 12hr 100 mg... 53 carbamazepine tab er 12hr 200 mg... 53 carbamazepine tab er 12hr 400 mg... 53 carbidopa & levodopa orally disintegrating tab 10-100 mg... 63 carbidopa & levodopa orally disintegrating tab 25-100 mg... 63 carbidopa & levodopa orally disintegrating tab 25-250 mg... 63 carbidopa & levodopa tab 10-100 mg. 63 carbidopa & levodopa tab 25-100 mg. 63 carbidopa & levodopa tab 25-250 mg. 63 carbidopa & levodopa tab er 25-100 mg... 63 carbidopa & levodopa tab er 50-200 mg... 63 carbidopa tab 25 mg... 63 carbidopa-levodopa-entacapone tabs 12.5-50-200 mg... 63 carbidopa-levodopa-entacapone tabs 18.75-75-200 mg... 63 carbidopa-levodopa-entacapone tabs 25-100-200 mg... 63 carbidopa-levodopa-entacapone tabs 31.25-125-200 mg... 63 carbidopa-levodopa-entacapone tabs 37.5-150-200 mg... 63 carbidopa-levodopa-entacapone tabs 50-200-200 mg... 64 carbinoxamine maleate soln 4 mg/5ml... 120 carbinoxamine maleate tab 4 mg... 120 carboplatin iv soln 150 mg/15ml... 35 CARDENE IV INJ 40/200ML... 46 CARDENE IV SOL 20/200ML... 46 CARIMUNE NF INJ 6GM... 108 carisoprodol tab 350 mg... 75 carisoprodol w/ aspirin & codeine tab 138
200-325-16 mg... 75 carisoprodol w/ aspirin tab 200-325 mg... 75 carteolol hcl ophth soln 1%... 119 cartia xt cap 120/24hr... 46 cartia xt cap 180/24hr... 46 cartia xt cap 240/24hr... 46 cartia xt cap 300/24hr... 46 carvedilol tab 12.5 mg... 45 carvedilol tab 25 mg... 45 carvedilol tab 3.125 mg... 44 carvedilol tab 6.25 mg... 44 caspofungin acetate for iv soln 50 mg. 11 caspofungin acetate for iv soln 70 mg. 11 CAYSTON INH 75MG... 8 caziant pak... 83 cefaclor cap 250 mg... 17 cefaclor cap 500 mg... 17 CEFACLOR ER TAB 500MG... 17 cefadroxil cap 500 mg... 17 cefadroxil for susp 250 mg/5ml... 17 cefadroxil for susp 500 mg/5ml... 17 cefadroxil tab 1 gm... 17 cefazolin sodium for inj 1 gm... 17 cefazolin sodium for inj 10 gm... 17 cefazolin sodium for inj 500 mg... 17 cefdinir cap 300 mg... 17 cefdinir for susp 125 mg/5ml... 17 cefdinir for susp 250 mg/5ml... 17 cefepime hcl for inj 1 gm... 17 cefepime hcl for inj 2 gm... 17 cefotaxime sodium for inj 1 gm... 17 cefotaxime sodium for inj 10 gm... 17 cefotaxime sodium for inj 2 gm... 17 cefotaxime sodium for inj 500 mg... 17 cefotetan disodium for inj 1 gm... 17 cefotetan disodium for inj 10 gm... 17 cefotetan disodium for inj 2 gm... 17 cefoxitin sodium for inj 10 gm... 17 cefoxitin sodium for iv soln 1 gm... 17 cefoxitin sodium for iv soln 2 gm... 17 cefpodoxime proxetil for susp 100 mg/5ml... 17 cefpodoxime proxetil for susp 50 mg/5ml... 17 cefpodoxime proxetil tab 100 mg... 17 cefpodoxime proxetil tab 200 mg... 18 cefprozil for susp 125 mg/5ml... 18 cefprozil for susp 250 mg/5ml... 18 cefprozil tab 250 mg... 18 cefprozil tab 500 mg... 18 ceftazidime for inj 1 gm... 18 ceftazidime for inj 2 gm... 18 ceftazidime for inj 6 gm... 18 ceftibuten cap 400 mg... 18 ceftibuten for susp 180 mg/5ml... 18 ceftriaxone sodium for inj 1 gm... 18 ceftriaxone sodium for inj 10 gm... 18 ceftriaxone sodium for inj 2 gm... 18 ceftriaxone sodium for inj 250 mg... 18 ceftriaxone sodium for inj 500 mg... 18 cefuroxime axetil tab 250 mg... 18 cefuroxime axetil tab 500 mg... 18 cefuroxime sodium for inj 750 mg... 18 cefuroxime sodium for iv soln 1.5 gm. 18 celecoxib cap 100 mg... 1 celecoxib cap 200 mg... 1 celecoxib cap 400 mg... 1 celecoxib cap 50 mg... 1 CELLCEPT IV INJ 500MG... 109 CELONTIN CAP 300MG... 53 cephalexin cap 250 mg... 18 cephalexin cap 500 mg... 18 cephalexin cap 750 mg... 18 cephalexin for susp 125 mg/5ml... 18 cephalexin for susp 250 mg/5ml... 18 cephalexin tab 250 mg... 18 cephalexin tab 500 mg... 18 CERDELGA CAP 84MG... 87 CEREZYME INJ 400UNIT... 87 cevimeline hcl cap 30 mg... 129 CHANTIX PAK 0.5& 1MG... 76 CHANTIX PAK 1MG... 76 CHANTIX TAB 0.5MG... 76 CHANTIX TAB 1MG... 76 chateal tab 0.15/30... 83 CHEMET CAP 100MG... 82 chloramphenicol sodium succinate for iv inj 1 gm... 9 chlordiazepoxide-amitriptyline tab 10-25 mg... 77 chlordiazepoxide-amitriptyline tab 5-12.5 139
mg... 77 chlorhexidine gluconate soln 0.12%.. 129 chloroquine phosphate tab 250 mg... 11 chloroquine phosphate tab 500 mg... 11 chlorothiazide sodium for inj 500 mg... 48 chlorothiazide tab 250 mg... 48 chlorothiazide tab 500 mg... 48 CHLORPROMAZ INJ 50MG/2ML... 65 chlorpromazine hcl tab 10 mg... 65 chlorpromazine hcl tab 100 mg... 65 chlorpromazine hcl tab 200 mg... 65 chlorpromazine hcl tab 25 mg... 65 chlorpromazine hcl tab 50 mg... 65 chlorthalidone tab 25 mg... 48 chlorthalidone tab 50 mg... 48 chlorzoxazone tab 500 mg... 75 cholestyramine light powder 4 gm/dose... 42 cholestyramine powder packets 4 gm.. 42 choline fenofibrate cap dr 135 mg (fenofibric acid equiv)... 42 choline fenofibrate cap dr 45 mg (fenofibric acid equiv)... 42 CHOR GONADOT INJ 10000UNT... 92 ciclodan cre 0.77%... 125 ciclopirox gel 0.77%... 125 ciclopirox olamine cream 0.77% (base equiv)... 125 ciclopirox olamine susp 0.77% (base equiv)... 125 ciclopirox solution 8%... 125 cidofovir iv inj 75 mg/ml... 15 cilostazol tab 100 mg... 106 cilostazol tab 50 mg... 106 CILOXAN OIN 0.3% OP... 117 cimetidine hcl soln 300 mg/5ml... 98 cimetidine tab 200 mg... 98 cimetidine tab 300 mg... 98 cimetidine tab 400 mg... 98 cimetidine tab 800 mg... 98 CINRYZE SOL 500 UNIT... 106 CIPRO HC SUS OTIC... 130 CIPRODEX SUS 0.3-0.1%... 130 ciprofloxacin 200 mg/100ml in d5w... 19 ciprofloxacin 400 mg/200ml in d5w... 19 ciprofloxacin hcl ophth soln 0.3%... 117 ciprofloxacin hcl otic soln 0.2% (base equivalent)... 130 ciprofloxacin hcl tab 100 mg (base equiv)... 19 ciprofloxacin hcl tab 250 mg (base equiv)... 19 ciprofloxacin hcl tab 500 mg (base equiv)... 19 ciprofloxacin hcl tab 750 mg (base equiv)... 19 ciprofloxacin iv soln 200 mg/20ml (1%)... 19 ciprofloxacin-ciprofloxacin hcl tab er 24hr 1000 mg(base eq)... 19 ciprofloxacin-ciprofloxacin hcl tab er 24hr 500 mg (base eq)... 19 cisplatin inj 50 mg/50ml (1 mg/ml)... 35 citalopram hydrobromide oral soln 10 mg/5ml... 59 citalopram hydrobromide tab 10 mg (base equiv)... 59 citalopram hydrobromide tab 20 mg (base equiv)... 59 citalopram hydrobromide tab 40 mg (base equiv)... 59 cladribine iv soln 10 mg/10ml (1 mg/ml)... 24 claravis cap 10mg... 124 claravis cap 20mg... 124 claravis cap 30mg... 124 claravis cap 40mg... 124 clarithromycin for susp 125 mg/5ml... 19 clarithromycin for susp 250 mg/5ml... 19 clarithromycin tab 250 mg... 19 clarithromycin tab 500 mg... 19 clarithromycin tab er 24hr 500 mg... 19 clemastine fumarate tab 2.68 mg... 120 CLEOCIN SUP 100MG... 103 clindamycin hcl cap 150 mg... 9 clindamycin hcl cap 300 mg... 9 clindamycin hcl cap 75 mg... 9 clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)... 9 clindamycin phosphate gel 1%... 124 clindamycin phosphate in d5w iv soln 300 mg/50ml... 9 140
clindamycin phosphate in d5w iv soln 600 mg/50ml... 9 clindamycin phosphate in d5w iv soln 900 mg/50ml... 9 clindamycin phosphate iv soln 300 mg/2ml... 9 clindamycin phosphate iv soln 900 mg/6ml... 9 clindamycin phosphate lotion 1%... 124 clindamycin phosphate soln 1%... 124 clindamycin phosphate swab 1%... 124 clindamycin phosphate vaginal cream 2%... 103 CLINIMIX E INJ 2.75/D10... 114 CLINIMIX E INJ 2.75/D5W... 114 CLINIMIX E INJ 4.25/D10... 114 CLINIMIX E INJ 4.25/D25... 114 CLINIMIX E INJ 4.25/D5W... 114 CLINIMIX E INJ 5%/D15W... 114 CLINIMIX E INJ 5%/D20W... 114 CLINIMIX E INJ 5%/D25W... 114 CLINIMIX INJ 2.75/D5W... 114 CLINIMIX INJ 4.25/D10... 114 CLINIMIX INJ 4.25/D20... 114 CLINIMIX INJ 4.25/D25... 114 CLINIMIX INJ 4.25/D5W... 114 CLINIMIX INJ 5%/D15W... 114 CLINIMIX INJ 5%/D20W... 114 CLINIMIX INJ 5%/D25W... 114 clinisol sf inj 15%... 114 clobetasol e cre 0.05%... 127 clobetasol propionate cream 0.05%.. 127 clobetasol propionate gel 0.05%... 127 clobetasol propionate oint 0.05%... 127 clobetasol propionate soln 0.05%... 127 clofarabine iv soln 1 mg/ml... 24 clomipramine hcl cap 25 mg... 59 clomipramine hcl cap 50 mg... 59 clomipramine hcl cap 75 mg... 59 clonazepam orally disintegrating tab 0.125 mg... 54 clonazepam orally disintegrating tab 0.25 mg... 54 clonazepam orally disintegrating tab 0.5 mg... 54 clonazepam orally disintegrating tab 1 mg... 54 clonazepam orally disintegrating tab 2 mg... 54 clonazepam tab 0.5 mg... 54 clonazepam tab 1 mg... 54 clonazepam tab 2 mg... 54 clonidine hcl inj (for epidural infusion) 100 mcg/ml... 1 clonidine hcl inj (for epidural infusion) 500 mcg/ml... 1 clonidine hcl tab 0.1 mg... 49 clonidine hcl tab 0.2 mg... 49 clonidine hcl tab 0.3 mg... 49 clonidine hcl tab er 12hr 0.1 mg... 71 clonidine hcl td patch weekly 0.1 mg/24hr... 49 clonidine hcl td patch weekly 0.2 mg/24hr... 49 clonidine hcl td patch weekly 0.3 mg/24hr... 49 clopidogrel bisulfate tab 75 mg (base equiv)... 106 clorazepate dipotassium tab 15 mg... 54 clorazepate dipotassium tab 3.75 mg.. 54 clorazepate dipotassium tab 7.5 mg... 54 clotrimazole cream 1%... 125 clotrimazole soln 1%... 125 clotrimazole troche 10 mg... 129 clotrimazole w/ betamethasone cream 1-0.05%... 125 clotrimazole w/ betamethasone lotion 1-0.05%... 125 clozapine orally disintegrating tab 100 mg... 65 clozapine orally disintegrating tab 12.5 mg... 65 clozapine orally disintegrating tab 150 mg... 65 clozapine orally disintegrating tab 200 mg... 65 clozapine orally disintegrating tab 25 mg... 65 clozapine tab 100 mg... 65 clozapine tab 200 mg... 65 clozapine tab 25 mg... 65 clozapine tab 50 mg... 65 141
COARTEM TAB 20-120MG... 12 codeine sulfate tab 15 mg... 3 codeine sulfate tab 30 mg... 3 codeine sulfate tab 60 mg... 3 colchicine w/ probenecid tab 0.5-500 mg... 1 COLCRYS TAB 0.6MG... 1 colestipol hcl granule packets 5 gm... 42 colestipol hcl tab 1 gm... 42 colistimethate sod for inj 150 mg (colistin base activity)... 9 COLY-MYCIN S SUS OTIC... 130 COMBIGAN SOL 0.2/0.5%... 119 COMBIVENT AER 20-100... 120 COMETRIQ KIT 100MG... 31 COMETRIQ KIT 140MG... 31 COMETRIQ KIT 60MG... 31 COMPLERA TAB... 14 compro sup 25mg... 96 CONDYLOX GEL 0.5%... 128 constulose sol 10gm/15... 99 COPAXONE INJ 40MG/ML... 75 CORLANOR TAB 5MG... 49 CORLANOR TAB 7.5MG... 49 cortisone acetate tab 25 mg... 90 COTELLIC TAB 20MG... 31 CREON CAP 12000UNT... 101 CREON CAP 24000UNT... 101 CREON CAP 3000UNIT... 101 CREON CAP 36000UNT... 101 CREON CAP 6000UNIT... 101 CRESEMBA CAP 186 MG... 11 CRESEMBA INJ 372MG... 11 CRIXIVAN CAP 200MG... 12 CRIXIVAN CAP 400MG... 12 cromolyn sodium ophth soln 4%... 118 cromolyn sodium oral conc 100 mg/5ml... 100 cromolyn sodium soln nebu 20 mg/2ml... 122 cryselle-28 tab 28 tabs... 83 cyclafem tab 1/35... 83 cyclafem tab 7/7/7... 83 cyclobenzaprine hcl tab 10 mg... 75 cyclobenzaprine hcl tab 5 mg... 75 cyclophosphamide cap 25 mg... 23 cyclophosphamide cap 50 mg... 23 cyclophosphamide for inj 1 gm... 23 cyclophosphamide for inj 2 gm... 23 cyclophosphamide for inj 500 mg... 23 cyclosporine cap 100 mg... 109 cyclosporine cap 25 mg... 109 cyclosporine iv soln 50 mg/ml... 109 cyclosporine modified cap 100 mg... 110 cyclosporine modified cap 25 mg... 109 cyclosporine modified cap 50 mg... 109 cyclosporine modified oral soln 100 mg/ml... 110 cyproheptadine hcl syrup 2 mg/5ml.. 120 cyproheptadine hcl tab 4 mg... 120 CYRAMZA INJ 100/10ML... 25 CYRAMZA INJ 500/50ML... 25 cyred tab... 83 CYSTADANE POW... 87 CYSTAGON CAP 150MG... 87 CYSTAGON CAP 50MG... 87 CYSTARAN SOL 0.44%... 119 cytarabine inj 20 mg/ml... 24 cytarabine inj pf 100 mg/ml... 24 cytarabine inj pf 20 mg/ml... 24 D D10W/NACL INJ 0.2%... 114 D5W/LYTES INJ #48... 114 dacarbazine for inj 100 mg... 23 dacarbazine for inj 200 mg... 23 dactinomycin for inj 0.5 mg... 24 DALIRESP TAB 250MCG... 122 DALIRESP TAB 500MCG... 122 DALVANCE SOL 500MG... 9 danazol cap 100 mg... 87 danazol cap 200 mg... 87 danazol cap 50 mg... 87 dantrolene sodium cap 100 mg... 75 dantrolene sodium cap 25 mg... 75 dantrolene sodium cap 50 mg... 75 dapsone tab 100 mg... 9 dapsone tab 25 mg... 9 DAPTACEL INJ... 110 daptomycin for iv soln 500 mg... 9 DARAPRIM TAB 25MG... 9 DARZALEX SOL 100MG/5M... 25 DARZALEX SOL 400MG/20... 25 142
dasetta tab 1/35... 83 dasetta tab 7/7/7... 83 daunorubicin hcl inj 5 mg/ml (base equiv)... 24 daysee tab... 83 deblitane tab 0.35mg... 83 decitabine for inj 50 mg... 24 deferoxamine mesylate for inj 2 gm... 92 deferoxamine mesylate for inj 500 mg. 92 delyla tab 0.1-0.02... 83 DELZICOL CAP 400MG... 99 DEMSER CAP 250MG... 50 DENAVIR CRE 1%... 128 dentagel gel 1.1%... 129 DEPEN TITRA TAB 250MG... 82 DEPO-ESTRADI INJ 5MG/ML... 88 DEPO-MEDROL INJ 20MG/ML... 90 DEPO-PROVERA INJ 400/ML... 28 DEPO-SQ PROV INJ 104... 83 DESCOVY TAB 200/25... 14 desipramine hcl tab 10 mg... 59 desipramine hcl tab 100 mg... 59 desipramine hcl tab 150 mg... 59 desipramine hcl tab 25 mg... 59 desipramine hcl tab 50 mg... 59 desipramine hcl tab 75 mg... 59 desloratadine tab 5 mg... 120 desmopressin acetate inj 4 mcg/ml... 96 desmopressin acetate nasal spray soln 0.01%... 96 desmopressin acetate nasal spray soln 0.01% (refrigerated)... 96 desmopressin acetate tab 0.1 mg... 96 desmopressin acetate tab 0.2 mg... 96 desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5)... 83 desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg... 83 desonide cream 0.05%... 127 desonide lotion 0.05%... 127 desonide oint 0.05%... 127 desoximetasone cream 0.05%... 127 desoximetasone cream 0.25%... 127 desoximetasone gel 0.05%... 127 desoximetasone oint 0.25%... 127 DESVENLAFAX TAB 100MG ER... 59 DESVENLAFAX TAB 50MG ER... 59 desvenlafaxine succinate tab er 24hr 100 mg (base equiv)... 60 desvenlafaxine succinate tab er 24hr 25 mg (base equiv)... 59 desvenlafaxine succinate tab er 24hr 50 mg (base equiv)... 60 DEXAMETHASON CON 1MG/ML... 90 dexamethasone elixir 0.5 mg/5ml... 90 dexamethasone sodium phosphate inj 10 mg/ml... 90 dexamethasone sodium phosphate inj 120 mg/30ml... 90 dexamethasone sodium phosphate ophth soln 0.1%... 118 dexamethasone tab 0.5 mg... 90 dexamethasone tab 0.75 mg... 90 dexamethasone tab 1 mg... 90 dexamethasone tab 1.5 mg... 90 dexamethasone tab 2 mg... 90 dexamethasone tab 4 mg... 90 dexamethasone tab 6 mg... 90 DEXILANT CAP 30MG DR... 101 DEXILANT CAP 60MG DR... 101 dexmethylphenidate hcl tab 10 mg... 76 dexmethylphenidate hcl tab 2.5 mg... 76 dexmethylphenidate hcl tab 5 mg... 76 dexrazoxane for inj 250 mg... 35 dexrazoxane for inj 500 mg... 35 dextroamphetamine sulfate cap er 24hr 10 mg... 71 dextroamphetamine sulfate cap er 24hr 15 mg... 71 dextroamphetamine sulfate cap er 24hr 5 mg... 71 dextroamphetamine sulfate tab 10 mg 71 dextroamphetamine sulfate tab 5 mg. 71 dextrose 10% w/ sodium chloride 0.45%... 115 dextrose 2.5% w/ sodium chloride 0.45%... 114 dextrose 5% in lactated ringers... 114 dextrose 5% w/ sodium chloride 0.2%... 114 dextrose 5% w/ sodium chloride 0.225%... 115 143
dextrose 5% w/ sodium chloride 0.33%... 114 dextrose 5% w/ sodium chloride 0.45%... 115 dextrose 5% w/ sodium chloride 0.9%... 114 dextrose inj 10%... 115 DEXTROSE INJ 20%... 115 dextrose inj 25%... 115 dextrose inj 30%... 115 DEXTROSE INJ 40%... 115 dextrose inj 5%... 115 dextrose inj 50%... 115 dextrose inj 70%... 115 DIASTAT ACDL GEL 12.5-20... 54 DIASTAT ACDL GEL 5-10MG... 54 DIASTAT PED GEL 2.5M GEL... 54 diazepam con 5mg/ml... 54 diazepam inj 5 mg/ml... 54 diazepam oral soln 1 mg/ml... 54 diazepam tab 10 mg... 54 diazepam tab 2 mg... 54 diazepam tab 5 mg... 54 diclofenac potassium tab 50 mg... 1 diclofenac sodium gel 1%... 128 diclofenac sodium ophth soln 0.1%... 118 diclofenac sodium tab delayed release 25 mg... 1 diclofenac sodium tab delayed release 50 mg... 1 diclofenac sodium tab delayed release 75 mg... 1 diclofenac sodium tab er 24hr 100 mg.. 1 dicloxacillin sodium cap 250 mg... 21 dicloxacillin sodium cap 500 mg... 21 dicyclomine hcl cap 10 mg... 98 dicyclomine hcl oral soln 10 mg/5ml... 98 dicyclomine hcl tab 20 mg... 98 didanosine delayed release capsule 200 mg... 12 didanosine delayed release capsule 250 mg... 12 didanosine delayed release capsule 400 mg... 12 DIFICID TAB 200MG... 19 diflorasone diacetate cream 0.05%... 127 diflorasone diacetate oint 0.05%... 127 diflunisal tab 500 mg... 1 digitek tab 0.125mg... 48 digitek tab 0.25mg... 48 digox tab 0.125mg... 48 digox tab 0.25mg... 48 digoxin inj 0.25 mg/ml... 48 digoxin oral soln 0.05 mg/ml... 48 digoxin tab 125 mcg (0.125 mg)... 48 digoxin tab 250 mcg (0.25 mg)... 48 dihydroergotamine mesylate inj 1 mg/ml... 72 dihydroergotamine mesylate nasal spray 4 mg/ml... 72 DILANTIN CAP 30MG... 54 diltiazem hcl cap er 12hr 120 mg... 46 diltiazem hcl cap er 12hr 60 mg... 46 diltiazem hcl cap er 12hr 90 mg... 46 diltiazem hcl coated beads cap er 24hr 120 mg... 46 diltiazem hcl coated beads cap er 24hr 180 mg... 46 diltiazem hcl coated beads cap er 24hr 240 mg... 46 diltiazem hcl coated beads cap er 24hr 300 mg... 46 diltiazem hcl extended release beads cap er 24hr 360 mg... 46 diltiazem hcl extended release beads cap er 24hr 420 mg... 46 diltiazem hcl iv soln 50 mg/10ml (5 mg/ml)... 46 diltiazem hcl tab 120 mg... 46 diltiazem hcl tab 30 mg... 46 diltiazem hcl tab 60 mg... 46 diltiazem hcl tab 90 mg... 46 DILTIAZEM INJ 100MG... 46 dilt-xr cap 120mg... 46 dilt-xr cap 180mg... 46 dilt-xr cap 240mg... 46 DIP/TET PED INJ 25-5LFU... 110 diphenhydramine hcl inj 50 mg/ml... 120 diphenoxylate w/ atropine liq 2.5-0.025 mg/5ml... 100 diphenoxylate w/ atropine tab 2.5-0.025 mg... 100 144
dipyridamole tab 25 mg... 106 dipyridamole tab 50 mg... 106 dipyridamole tab 75 mg... 107 disopyramide phosphate cap 100 mg.. 41 disopyramide phosphate cap 150 mg.. 41 disulfiram tab 250 mg... 77 disulfiram tab 500 mg... 77 DIURIL SUS 250/5ML... 48 divalproex sodium cap delayed release sprinkle 125 mg... 54 divalproex sodium tab delayed release 125 mg... 54 divalproex sodium tab delayed release 250 mg... 54 divalproex sodium tab delayed release 500 mg... 54 divalproex sodium tab er 24 hr 250 mg... 54 divalproex sodium tab er 24 hr 500 mg... 54 DIVIGEL GEL 1MG/GM... 88 DOCETAXEL INJ 80MG/4ML... 25 docetaxel soln for iv infusion 160 mg/16ml... 25 dofetilide cap 125 mcg (0.125 mg)... 41 dofetilide cap 250 mcg (0.25 mg)... 41 dofetilide cap 500 mcg (0.5 mg)... 41 donepezil hydrochloride orally disintegrating tab 10 mg... 58 donepezil hydrochloride orally disintegrating tab 5 mg... 58 donepezil hydrochloride tab 10 mg... 58 donepezil hydrochloride tab 5 mg... 58 doripenem for iv infusion 500 mg... 9 dorzolamide hcl ophth soln 2%... 119 dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml... 119 doxazosin mesylate tab 1 mg... 38 doxazosin mesylate tab 2 mg... 38 doxazosin mesylate tab 4 mg... 39 doxazosin mesylate tab 8 mg... 39 doxepin hcl cap 10 mg... 60 doxepin hcl cap 100 mg... 60 doxepin hcl cap 150 mg... 60 doxepin hcl cap 25 mg... 60 doxepin hcl cap 50 mg... 60 doxepin hcl cap 75 mg... 60 doxepin hcl conc 10 mg/ml... 60 doxercalciferol cap 0.5 mcg... 116 doxercalciferol cap 1 mcg... 116 doxercalciferol cap 2.5 mcg... 116 doxercalciferol inj 4 mcg/2ml (2 mcg/ml)... 116 doxorubicin hcl for inj 10 mg... 23 doxorubicin hcl for inj 50 mg... 23 doxorubicin hcl inj 2 mg/ml... 23 doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml... 23 doxy 100 inj 100mg... 22 doxycycline hyclate cap 100 mg... 22 doxycycline hyclate cap 50 mg... 22 doxycycline hyclate tab 100 mg... 22 doxycycline hyclate tab 20 mg... 22 doxycycline monohydrate cap 100 mg 22 doxycycline monohydrate cap 50 mg.. 22 doxycycline monohydrate for susp 25 mg/5ml... 22 doxycycline monohydrate tab 100 mg. 22 doxycycline monohydrate tab 150 mg. 22 doxycycline monohydrate tab 50 mg.. 22 doxycycline monohydrate tab 75 mg.. 22 dronabinol cap 10 mg... 97 dronabinol cap 2.5 mg... 97 dronabinol cap 5 mg... 97 drospirenone-ethinyl estradiol tab 3-0.02 mg... 83 drospirenone-ethinyl estradiol tab 3-0.03 mg... 83 DUAVEE TAB 0.45-20... 88 duloxetine hcl enteric coated pellets cap 20 mg (base eq)... 60 duloxetine hcl enteric coated pellets cap 30 mg (base eq)... 60 duloxetine hcl enteric coated pellets cap 40 mg (base eq)... 60 duloxetine hcl enteric coated pellets cap 60 mg (base eq)... 60 DUOPA SUS 4.63-20... 64 duramorph inj 0.5mg/ml... 3 duramorph inj 1mg/ml... 3 DUREZOL EMU 0.05%... 118 dutasteride cap 0.5 mg... 102 145
dutasteride-tamsulosin hcl cap 0.5-0.4 mg... 102 DYSPORT INJ 300UNIT... 75 DYSPORT INJ 500UNIT... 75 E e.e.s. 400 tab 400mg... 19 E.E.S. GRAN SUS 200/5ML... 19 econazole nitrate cream 1%... 125 EDURANT TAB 25MG... 12 efavirenz cap 200 mg... 12 efavirenz cap 50 mg... 12 efavirenz tab 600 mg... 12 EGRIFTA SOL 1MG... 92 ELAPRASE INJ 6MG/3ML... 87 ELELYSO INJ 200UNIT... 88 ELIDEL CRE 1%... 128 ELIGARD INJ 22.5MG... 28 ELIGARD INJ 30MG... 28 ELIGARD INJ 45MG... 28 ELIGARD INJ 7.5MG... 28 elinest tab... 83 ELIQUIS ST P TAB 5MG... 103 ELIQUIS TAB 2.5MG... 103 ELIQUIS TAB 5MG... 103 ELITEK INJ 1.5MG... 35 ELITEK INJ 7.5MG... 35 ELLA TAB 30MG... 83 ELMIRON CAP 100MG... 102 EMADINE SOL 0.05% OP... 118 EMCYT CAP 140MG... 23 EMEND SOL 150MG... 97 EMEND SUS 125MG... 97 emoquette tab... 83 EMPLICITI INJ 300MG... 25 EMPLICITI INJ 400MG... 26 EMSAM DIS 12MG/24H... 60 EMSAM DIS 6MG/24HR... 60 EMSAM DIS 9MG/24HR... 60 EMTRIVA CAP 200MG... 12 EMTRIVA SOL 10MG/ML... 12 enalapril maleate & hydrochlorothiazide tab 10-25 mg... 37 enalapril maleate & hydrochlorothiazide tab 5-12.5 mg... 37 enalapril maleate tab 10 mg... 38 enalapril maleate tab 2.5 mg... 38 enalapril maleate tab 20 mg... 38 enalapril maleate tab 5 mg... 38 ENBREL INJ 25/0.5ML... 107 ENBREL INJ 25MG... 107 ENBREL INJ 50MG/ML... 107 ENBREL SRCLK INJ 50MG/ML... 107 endocet tab 10-325mg... 3 endocet tab 2.5-325... 3 endocet tab 5-325mg... 3 endocet tab 7.5-325... 3 ENGERIX-B INJ 10/0.5ML... 110 ENGERIX-B INJ 20MCG/ML... 111 enoxaparin sodium inj 100 mg/ml... 103 enoxaparin sodium inj 120 mg/0.8ml 103 enoxaparin sodium inj 150 mg/ml... 103 enoxaparin sodium inj 30 mg/0.3ml. 103 enoxaparin sodium inj 300 mg/3ml.. 103 enoxaparin sodium inj 40 mg/0.4ml. 103 enoxaparin sodium inj 60 mg/0.6ml. 103 enoxaparin sodium inj 80 mg/0.8ml. 103 enpresse-28 tab... 83 enskyce tab... 83 entacapone tab 200 mg... 64 entecavir tab 0.5 mg... 15 entecavir tab 1 mg... 15 ENTRESTO TAB 24-26MG... 39 ENTRESTO TAB 49-51MG... 39 ENTRESTO TAB 97-103MG... 39 enulose sol 10gm/15... 99 EPCLUSA TAB 400-100... 15 epinastine hcl ophth soln 0.05%... 118 epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000)... 122 EPIPEN 2-PAK INJ 0.3MG... 122 EPIPEN-JR INJ 2-PAK... 122 epirubicin hcl iv soln 200 mg/100ml (2 mg/ml)... 23 epirubicin hcl iv soln 50 mg/25ml (2 mg/ml)... 23 epitol tab 200mg... 54 EPIVIR HBV SOL 5MG/ML... 15 eplerenone tab 25 mg... 38 eplerenone tab 50 mg... 38 EPOGEN INJ 10000/ML... 105 EPOGEN INJ 2000/ML... 105 EPOGEN INJ 20000/ML... 105 146
EPOGEN INJ 3000/ML... 105 EPOGEN INJ 4000/ML... 105 epoprostenol sodium for inj 0.5 mg... 51 epoprostenol sodium for inj 1.5 mg... 51 eprosartan mesylate tab 600 mg... 40 EQUETRO CAP 100MG... 73 EQUETRO CAP 200MG... 73 EQUETRO CAP 300MG... 73 ERAXIS INJ 100MG... 11 ERAXIS INJ 50MG... 11 ERBITUX INJ 100MG... 26 ERBITUX INJ 200MG... 26 ergoloid mesylates tab 1 mg... 65 ERIVEDGE CAP 150MG... 26 ERLEADA TAB 60MG... 28 errin tab 0.35mg... 83 ERWINAZE INJ 10000UNT... 35 ery pad 2%... 124 ERYGEL GEL 2%... 124 ery-tab tab 250mg ec... 19 ery-tab tab 333mg ec... 19 ery-tab tab 500mg ec... 19 ERYTHROCIN INJ 500MG... 19 erythrocin tab 250mg... 19 erythromycin ethylsuccinate for susp 200 mg/5ml... 19 erythromycin ethylsuccinate tab 400 mg... 19 erythromycin gel 2%... 124 erythromycin ophth oint 5 mg/gm... 117 erythromycin soln 2%... 124 erythromycin tab 250 mg... 19 erythromycin tab 500 mg... 19 erythromycin w/ delayed release particles cap 250 mg... 19 ESBRIET CAP 267MG... 122 ESBRIET TAB 267MG... 122 ESBRIET TAB 801MG... 122 escitalopram oxalate soln 5 mg/5ml (base equiv)... 60 escitalopram oxalate tab 10 mg (base equiv)... 60 escitalopram oxalate tab 20 mg (base equiv)... 60 escitalopram oxalate tab 5 mg (base equiv)... 60 esmolol hcl inj 100 mg/10ml... 45 estarylla tab 0.25-35... 83 ESTRACE VAG CRE 0.01%... 88 estradiol & norethindrone acetate tab 0.5-0.1 mg... 88 estradiol & norethindrone acetate tab 1-0.5 mg... 88 estradiol tab 0.5 mg... 88 estradiol tab 1 mg... 88 estradiol tab 2 mg... 88 estradiol td patch twice weekly 0.025 mg/24hr... 89 estradiol td patch twice weekly 0.0375 mg/24hr... 89 estradiol td patch twice weekly 0.05 mg/24hr... 89 estradiol td patch twice weekly 0.075 mg/24hr... 89 estradiol td patch twice weekly 0.1 mg/24hr... 89 estradiol td patch weekly 0.025 mg/24hr... 89 estradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)... 89 estradiol td patch weekly 0.05 mg/24hr... 89 estradiol td patch weekly 0.06 mg/24hr... 89 estradiol td patch weekly 0.075 mg/24hr... 89 estradiol td patch weekly 0.1 mg/24hr 89 estradiol vaginal tab 10 mcg... 89 estradiol valerate im in oil 20 mg/ml.. 89 estradiol valerate im in oil 40 mg/ml.. 89 ESTRING MIS 2MG... 89 estropipate tab 0.75 mg... 89 estropipate tab 1.5 mg... 89 ethambutol hcl tab 100 mg... 15 ethambutol hcl tab 400 mg... 15 ethosuximide cap 250 mg... 54 ethosuximide soln 250 mg/5ml... 54 ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg... 83 ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg... 83 etidronate disodium tab 200 mg... 81 147
etidronate disodium tab 400 mg... 81 etodolac cap 200 mg... 1 etodolac cap 300 mg... 1 etodolac tab 400 mg... 1 etodolac tab 500 mg... 1 ETOPOPHOS INJ 100MG... 36 etoposide inj 100 mg/5ml (20 mg/ml). 36 EUCRISA OIN 2%... 128 EVOTAZ TAB 300-150... 14 exemestane tab 25 mg... 28 EXJADE TAB 125MG... 82 EXJADE TAB 250MG... 82 EXJADE TAB 500MG... 82 ezetimibe tab 10 mg... 43 F FABRAZYME INJ 35MG... 88 FABRAZYME INJ 5MG... 88 falmina tab... 83 famciclovir tab 125 mg... 15 famciclovir tab 250 mg... 15 famciclovir tab 500 mg... 15 famotidine for susp 40 mg/5ml... 98 famotidine in nacl 0.9% iv soln 20 mg/50ml... 98 famotidine inj 20 mg/2ml... 98 famotidine tab 20 mg... 98 famotidine tab 40 mg... 98 FANAPT PAK... 66 FANAPT TAB 10MG... 66 FANAPT TAB 12MG... 66 FANAPT TAB 1MG... 66 FANAPT TAB 2MG... 66 FANAPT TAB 4MG... 66 FANAPT TAB 6MG... 66 FANAPT TAB 8MG... 66 FARESTON TAB 60MG... 28 FARYDAK CAP 10MG... 26 FARYDAK CAP 15MG... 26 FARYDAK CAP 20MG... 26 FASLODEX INJ 250/5ML... 28 felbamate susp 600 mg/5ml... 55 felbamate tab 400 mg... 55 felbamate tab 600 mg... 55 felodipine tab er 24hr 10 mg... 47 felodipine tab er 24hr 2.5 mg... 47 felodipine tab er 24hr 5 mg... 47 FEMRING MIS 0.05/24H... 89 FEMRING MIS 0.1MG/24... 89 femynor tab 0.25-35... 84 fenofibrate micronized cap 130 mg... 43 fenofibrate micronized cap 134 mg... 43 fenofibrate micronized cap 200 mg... 43 fenofibrate micronized cap 43 mg... 43 fenofibrate micronized cap 67 mg... 43 fenofibrate tab 145 mg... 43 fenofibrate tab 160 mg... 43 fenofibrate tab 48 mg... 43 fenofibrate tab 54 mg... 43 fenofibric acid tab 105 mg... 43 fenofibric acid tab 35 mg... 43 fenoprofen calcium tab 600 mg... 1 FENTANYL CIT INJ 100MCG... 3 fentanyl citrate inj 0.05 mg/ml... 3 fentanyl citrate lozenge on a handle 1200 mcg... 4 fentanyl citrate lozenge on a handle 1600 mcg... 4 fentanyl citrate lozenge on a handle 200 mcg... 3 fentanyl citrate lozenge on a handle 400 mcg... 4 fentanyl citrate lozenge on a handle 600 mcg... 4 fentanyl citrate lozenge on a handle 800 mcg... 4 fentanyl citrate pf soln cartridge 100 mcg/2ml... 4 fentanyl citrate preservative free (pf) inj 100 mcg/2ml... 4 fentanyl td patch 72hr 100 mcg/hr... 4 fentanyl td patch 72hr 12 mcg/hr... 4 fentanyl td patch 72hr 25 mcg/hr... 4 fentanyl td patch 72hr 50 mcg/hr... 4 fentanyl td patch 72hr 75 mcg/hr... 4 FENTORA TAB 100MCG... 4 FENTORA TAB 200MCG... 4 FENTORA TAB 400MCG... 4 FENTORA TAB 600MCG... 4 FENTORA TAB 800MCG... 4 FERRIPROX SOL 100MG/ML... 82 FERRIPROX TAB 500MG... 82 FETZIMA CAP 120MG... 60 148
FETZIMA CAP 20MG... 60 FETZIMA CAP 40MG... 60 FETZIMA CAP 80MG... 60 FETZIMA CAP TITRATIO... 60 FIASP FLEX INJ TOUCH... 78 FIASP INJ 100/ML... 78 finasteride tab 5 mg... 102 FIRAZYR INJ 30MG/3ML... 106 FIRMAGON INJ 120MG... 29 FIRMAGON INJ 80MG... 28 flavoxate hcl tab 100 mg... 102 FLEBOGAMMA INJ 10/200ML... 108 FLEBOGAMMA INJ 20/400ML... 108 FLEBOGAMMA INJ 5GM/50ML... 108 FLEBOGAMMA INJ DIF 5%... 108 flecainide acetate tab 100 mg... 41 flecainide acetate tab 150 mg... 41 flecainide acetate tab 50 mg... 41 FLOVENT DISK AER 100MCG... 123 FLOVENT DISK AER 250MCG... 123 FLOVENT DISK AER 50MCG... 123 FLOVENT HFA AER 110MCG... 123 FLOVENT HFA AER 220MCG... 123 FLOVENT HFA AER 44MCG... 123 FLOXIN SOL 0.3%... 130 floxuridine for inj 0.5 gm... 24 fluconazole for susp 10 mg/ml... 11 fluconazole for susp 40 mg/ml... 11 fluconazole in nacl 0.9% inj 200 mg/100ml... 11 fluconazole in nacl 0.9% inj 400 mg/200ml... 11 fluconazole tab 100 mg... 11 fluconazole tab 150 mg... 11 fluconazole tab 200 mg... 11 fluconazole tab 50 mg... 11 flucytosine cap 250 mg... 11 flucytosine cap 500 mg... 11 fludarabine phosphate for inj 50 mg... 24 fludarabine phosphate inj 25 mg/ml... 24 fludrocortisone acetate tab 0.1 mg... 90 flunisolide nasal soln 25 mcg/act (0.025%)... 123 fluocin acet oil scalp... 127 fluocinolone acetonide (otic) oil 0.01%... 130 fluocinolone acetonide cream 0.01% 127 fluocinolone acetonide cream 0.025% 127 fluocinolone acetonide oint 0.025%.. 127 fluocinolone acetonide soln 0.01%... 127 fluocinonide cream 0.05%... 127 fluocinonide emulsified base cream 0.05%... 127 fluocinonide gel 0.05%... 127 fluocinonide oint 0.05%... 127 fluocinonide soln 0.05%... 127 fluoritab chw 0.5mg f... 112 fluoritab chw 2.2mg... 112 fluorometholone ophth susp 0.1%... 118 fluorouracil cream 5%... 128 fluorouracil iv soln 1 gm/20ml (50 mg/ml)... 24 fluorouracil iv soln 5 gm/100ml (50 mg/ml)... 24 fluorouracil soln 2%... 128 fluorouracil soln 5%... 128 fluoxetine hcl cap 10 mg... 61 fluoxetine hcl cap 20 mg... 61 fluoxetine hcl cap 40 mg... 61 fluoxetine hcl solution 20 mg/5ml... 61 fluoxetine hcl tab 10 mg... 61 fluoxetine hcl tab 20 mg... 61 fluphenazine decanoate inj 25 mg/ml. 66 fluphenazine hcl elixir 2.5 mg/5ml... 66 fluphenazine hcl inj 2.5 mg/ml... 66 fluphenazine hcl oral conc 5 mg/ml... 66 fluphenazine hcl tab 1 mg... 66 fluphenazine hcl tab 10 mg... 66 fluphenazine hcl tab 2.5 mg... 66 fluphenazine hcl tab 5 mg... 66 flurbiprofen sodium ophth soln 0.03%... 118 flurbiprofen tab 100 mg... 2 flurbiprofen tab 50 mg... 2 flutamide cap 125 mg... 29 fluticasone propionate cream 0.05%. 127 fluticasone propionate nasal susp 50 mcg/act... 123 fluticasone propionate oint 0.005%.. 127 fluvastatin sodium cap 20 mg... 42 fluvastatin sodium cap 40 mg... 42 fluvoxamine maleate tab 100 mg... 53 149
fluvoxamine maleate tab 25 mg... 53 fluvoxamine maleate tab 50 mg... 53 FML FORTE SUS 0.25% OP... 118 FML OIN 0.1% OP... 118 FOLOTYN INJ 40MG/2ML... 24 fomepizole inj 1 gm/ml (for iv infusion)... 92 fondaparinux sodium subcutaneous inj 10 mg/0.8ml... 103 fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml... 103 fondaparinux sodium subcutaneous inj 5 mg/0.4ml... 103 fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml... 103 FORTEO SOL 600/2.4... 93 fosamprenavir calcium tab 700 mg (base equiv)... 12 foscarnet sodium inj 24 mg/ml... 16 fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg... 37 fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg... 37 fosinopril sodium tab 10 mg... 38 fosinopril sodium tab 20 mg... 38 fosinopril sodium tab 40 mg... 38 fosphenytoin sodium inj 100 mg/2ml (phenytoin equiv)... 55 fosphenytoin sodium inj 500 mg/10ml (phenytoin equiv)... 55 FRAGMIN INJ 10000/ML... 104 FRAGMIN INJ 12500UNT... 104 FRAGMIN INJ 15000UNT... 104 FRAGMIN INJ 18000UNT... 104 FRAGMIN INJ 2500/0.2... 103 FRAGMIN INJ 5000/0.2... 104 FRAGMIN INJ 7500/0.3... 104 FRAGMIN INJ 95000UNT... 104 FREAMINE HBC INJ 6.9%... 114 furosemide inj 10 mg/ml... 48 furosemide oral soln 10 mg/ml... 49 furosemide oral soln 8 mg/ml... 48 furosemide tab 20 mg... 49 furosemide tab 40 mg... 49 furosemide tab 80 mg... 49 FUSILEV INJ 50MG... 35 FUZEON INJ 90MG... 12 fyavolv tab 1-5... 89 FYCOMPA SUS 0.5MG/ML... 55 FYCOMPA TAB 10MG... 55 FYCOMPA TAB 12MG... 55 FYCOMPA TAB 2MG... 55 FYCOMPA TAB 4MG... 55 FYCOMPA TAB 6MG... 55 FYCOMPA TAB 8MG... 55 G gabapentin cap 100 mg... 55 gabapentin cap 300 mg... 55 gabapentin cap 400 mg... 55 gabapentin oral soln 250 mg/5ml... 55 gabapentin tab 600 mg... 55 gabapentin tab 800 mg... 55 GABITRIL TAB 12MG... 55 GABITRIL TAB 16MG... 55 GABLOFEN INJ 20000/20... 75 galantamine hydrobromide cap er 24hr 16 mg... 58 galantamine hydrobromide cap er 24hr 24 mg... 58 galantamine hydrobromide cap er 24hr 8 mg... 58 galantamine hydrobromide oral soln 4 mg/ml... 58 galantamine hydrobromide tab 12 mg 58 galantamine hydrobromide tab 4 mg.. 58 galantamine hydrobromide tab 8 mg.. 58 GAMASTAN S/D INJ... 108 GAMMAGARD INJ 2.5GM/25... 108 GAMMAGARD SD INJ 10GM HU... 109 GAMMAGARD SD INJ 5GM HU... 109 GAMMAKED INJ 1GM/10ML... 109 GAMMAPLEX INJ 10%... 109 GAMMAPLEX INJ 5%... 109 GAMUNEX-C INJ 1GM/10ML... 109 ganciclovir sodium for inj 500 mg... 16 GARDASIL 9 INJ... 111 gatifloxacin ophth soln 0.5%... 117 GATTEX KIT 5MG... 100 GAUZE PADS & DRESSINGS - PADS 2 X 2... 78 gavilyte-c sol... 99 gavilyte-g sol... 99 150
gavilyte-n sol flav pk... 99 GAZYVA INJ 25MG/ML... 26 gemcitabine hcl for inj 1 gm... 24 gemcitabine hcl for inj 2 gm... 24 gemcitabine hcl for inj 200 mg... 24 gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml) (base equiv)... 24 gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml) (base equiv)... 24 gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml) (base equiv)... 24 gemfibrozil tab 600 mg... 43 generlac sol 10gm/15... 99 gengraf cap 100mg... 110 gengraf cap 25mg... 110 gengraf sol 100mg/ml... 110 GENOTROPIN INJ 0.2MG... 91 GENOTROPIN INJ 0.4MG... 91 GENOTROPIN INJ 0.6MG... 91 GENOTROPIN INJ 0.8MG... 91 GENOTROPIN INJ 1.2MG... 91 GENOTROPIN INJ 1.4MG... 91 GENOTROPIN INJ 1.6MG... 91 GENOTROPIN INJ 1.8MG... 92 GENOTROPIN INJ 12MG... 92 GENOTROPIN INJ 1MG... 92 GENOTROPIN INJ 2MG... 92 GENOTROPIN INJ 5MG... 92 gentak oin 0.3% op... 117 gentamicin in saline inj 0.8 mg/ml... 8 gentamicin in saline inj 1 mg/ml... 8 gentamicin in saline inj 1.2 mg/ml... 8 gentamicin in saline inj 1.6 mg/ml... 8 gentamicin sulfate cream 0.1%... 125 gentamicin sulfate inj 40 mg/ml... 8 gentamicin sulfate oint 0.1%... 125 gentamicin sulfate ophth soln 0.3%.. 117 GENVOYA TAB... 14 GEODON INJ 20MG... 66 gianvi tab 3-0.02mg... 84 gildess fe tab 1.5/30... 84 gildess fe tab 1/20... 84 gildess tab 1/20... 84 GILENYA CAP 0.5MG... 75 GILOTRIF TAB 20MG... 31 GILOTRIF TAB 30MG... 32 GILOTRIF TAB 40MG... 32 GLASSIA INJ... 122 glatopa inj 20mg/ml... 75 GLEOSTINE CAP 100MG... 23 GLEOSTINE CAP 10MG... 23 GLEOSTINE CAP 40MG... 23 glimepiride tab 1 mg... 79 glimepiride tab 2 mg... 79 glimepiride tab 4 mg... 79 glipizide tab 10 mg... 79 glipizide tab 5 mg... 79 glipizide tab er 24hr 10 mg... 79 glipizide tab er 24hr 2.5 mg... 79 glipizide tab er 24hr 5 mg... 79 glipizide-metformin hcl tab 2.5-250 mg... 79 glipizide-metformin hcl tab 2.5-500 mg... 79 glipizide-metformin hcl tab 5-500 mg. 79 GLUCAGEN INJ HYPOKIT... 91 GLUCAGON KIT 1MG... 91 glycine irrigation soln 1.5%... 129 glycopyrrolate inj 4 mg/20ml (0.2 mg/ml)... 98 glycopyrrolate tab 1 mg... 98 glycopyrrolate tab 2 mg... 98 GRALISE STAR MIS 300/600... 73 GRALISE TAB 300MG... 73 GRALISE TAB 600MG... 73 granisetron hcl inj 0.1 mg/ml... 97 granisetron hcl inj 1 mg/ml... 97 granisetron hcl inj 4 mg/4ml (1 mg/ml)... 97 granisetron hcl tab 1 mg... 97 GRANIX INJ 300/0.5... 105 GRANIX INJ 480/0.8... 105 griseofulvin microsize susp 125 mg/5ml... 11 griseofulvin microsize tab 500 mg... 11 griseofulvin ultramicrosize tab 125 mg 11 griseofulvin ultramicrosize tab 250 mg 11 GUANIDINE TAB 125MG... 73 H H.P. ACTHAR INJ 80UNIT... 93 HALAVEN INJ 1MG/2ML... 35 halobetasol propionate cream 0.05% 127 151
halobetasol propionate oint 0.05%... 127 haloperidol decanoate im soln 100 mg/ml... 66 haloperidol decanoate im soln 50 mg/ml... 66 haloperidol lactate inj 5 mg/ml... 66 haloperidol lactate oral conc 2 mg/ml.. 66 haloperidol tab 0.5 mg... 66 haloperidol tab 1 mg... 66 haloperidol tab 10 mg... 66 haloperidol tab 2 mg... 66 haloperidol tab 20 mg... 66 haloperidol tab 5 mg... 66 HARVONI TAB 90-400MG... 16 HAVRIX INJ 1440UNIT... 111 HAVRIX INJ 720UNIT... 111 heather tab 0.35mg... 84 HEP SOD/D5W INJ 50UNT/ML... 104 HEP SOD/NACL INJ 12500UNT... 104 heparin sodium (porcine) 100 unit/ml in d5w... 104 heparin sodium (porcine) 2 unit/ml in sodium chloride 0.9%... 104 heparin sodium (porcine) 40 unit/ml in d5w... 104 heparin sodium (porcine) 50 unit/ml in d5w... 104 heparin sodium (porcine) inj 1000 unit/ml... 104 heparin sodium (porcine) inj 10000 unit/ml... 104 heparin sodium (porcine) inj 20000 unit/ml... 104 heparin sodium (porcine) inj 5000 unit/ml... 104 heparin sodium (porcine) pf inj 5000 unit/0.5ml... 104 hepatamine sol 8%... 114 HERCEPTIN INJ 150MG... 26 HERCEPTIN INJ 440MG... 26 HETLIOZ CAP 20MG... 72 HEXALEN CAP 50MG... 23 HIBERIX SOL 10MCG... 111 HIZENTRA INJ 10/50ML... 109 HIZENTRA INJ 1GM/5ML... 109 HIZENTRA INJ 2GM/10ML... 109 HIZENTRA INJ 4GM/20ML... 109 HORIZANT TAB 300MG... 74 HORIZANT TAB 600MG... 74 HUMATROPE INJ 12MG... 92 HUMATROPE INJ 24MG... 92 HUMATROPE INJ 5MG... 92 HUMATROPE INJ 6MG... 92 HUMIRA INJ 10/0.1ML... 107 HUMIRA INJ 10MG/0.2... 107 HUMIRA INJ 20/0.2ML... 107 HUMIRA INJ 40/0.4ML... 107 HUMIRA KIT 20MG/0.4... 107 HUMIRA KIT 40MG/0.8... 107 HUMIRA PEDIA INJ CROHNS... 107 HUMIRA PEN INJ 40/0.4ML... 107 HUMIRA PEN INJ 40MG/0.8... 107 HUMIRA PEN INJ CD/UC/HS... 107 HUMIRA PEN INJ PS/UV... 107 HUMULIN R INJ U-500... 78 hydralazine hcl inj 20 mg/ml... 50 hydralazine hcl tab 10 mg... 50 hydralazine hcl tab 100 mg... 50 hydralazine hcl tab 25 mg... 50 hydralazine hcl tab 50 mg... 50 hydrochlorothiazide cap 12.5 mg... 49 hydrochlorothiazide tab 12.5 mg... 49 hydrochlorothiazide tab 25 mg... 49 hydrochlorothiazide tab 50 mg... 49 hydrocodone-acetaminophen soln 10-325 mg/15ml... 4 hydrocodone-acetaminophen soln 7.5-325 mg/15ml... 4 hydrocodone-acetaminophen tab 10-300 mg... 5 hydrocodone-acetaminophen tab 10-325 mg... 5 hydrocodone-acetaminophen tab 2.5-325 mg... 4 hydrocodone-acetaminophen tab 5-300 mg... 4 hydrocodone-acetaminophen tab 5-325 mg... 5 hydrocodone-acetaminophen tab 7.5-300 mg... 5 hydrocodone-acetaminophen tab 7.5-325 mg... 5 152
hydrocodone-ibuprofen tab 7.5-200 mg 5 hydrocortisone butyrate oint 0.1%... 127 hydrocortisone butyrate soln 0.1%... 127 hydrocortisone cream 1%... 127 hydrocortisone cream 2.5%... 127 hydrocortisone enema 100 mg/60ml... 99 hydrocortisone lotion 2.5%... 127 hydrocortisone oint 1%... 127 hydrocortisone oint 2.5%... 127 hydrocortisone tab 10 mg... 90 hydrocortisone tab 20 mg... 90 hydrocortisone tab 5 mg... 90 hydrocortisone valerate cream 0.2%. 128 hydrocortisone valerate oint 0.2%... 128 hydrocortisone w/ acetic acid otic soln 1-2%... 130 hydromorphone hcl inj 1 mg/ml... 5 hydromorphone hcl inj 2 mg/ml... 5 hydromorphone hcl inj 4 mg/ml... 5 hydromorphone hcl preservative free (pf) inj 10 mg/ml... 5 hydromorphone hcl tab 2 mg... 5 hydromorphone hcl tab 4 mg... 5 hydromorphone hcl tab 8 mg... 5 hydroxychloroquine sulfate tab 200 mg... 107 hydroxyprogesterone caproate im in oil 1.25 gm/5ml... 29 hydroxyurea cap 500 mg... 35 hydroxyzine hcl im soln 25 mg/ml... 120 hydroxyzine hcl im soln 50 mg/ml... 120 hydroxyzine hcl syrup 10 mg/5ml... 120 hydroxyzine hcl tab 10 mg... 120 hydroxyzine hcl tab 25 mg... 120 hydroxyzine hcl tab 50 mg... 120 hydroxyzine pamoate cap 100 mg... 120 hydroxyzine pamoate cap 25 mg... 120 hydroxyzine pamoate cap 50 mg... 120 I ibandronate sodium iv soln 3 mg/3ml (base equivalent)... 81 ibandronate sodium tab 150 mg (base equivalent)... 81 IBRANCE CAP 100MG... 26 IBRANCE CAP 125MG... 26 IBRANCE CAP 75MG... 26 ibu tab 600mg... 2 ibu tab 800mg... 2 ibuprofen susp 100 mg/5ml... 2 ibuprofen tab 400 mg... 2 ibuprofen tab 600 mg... 2 ibuprofen tab 800 mg... 2 ibutilide fumarate inj 1 mg/10ml... 41 ICLUSIG TAB 15MG... 32 ICLUSIG TAB 45MG... 32 idarubicin hcl iv inj 10 mg/10ml (1 mg/ml)... 24 IDHIFA TAB 100MG... 26 IDHIFA TAB 50MG... 26 ifosfamide for inj 1 gm... 23 IFOSFAMIDE INJ 3GM... 23 ifosfamide iv inj 1 gm/20ml (50 mg/ml)... 23 ifosfamide iv inj 3 gm/60ml (50 mg/ml)... 23 ILARIS INJ 150MG/ML... 109 imatinib mesylate tab 100 mg (base equivalent)... 32 imatinib mesylate tab 400 mg (base equivalent)... 32 IMBRUVICA CAP 140MG... 32 IMBRUVICA CAP 70MG... 32 IMBRUVICA TAB 140MG... 32 IMBRUVICA TAB 280MG... 32 IMBRUVICA TAB 420MG... 32 IMBRUVICA TAB 560MG... 32 IMFINZI INJ 120/2.4... 26 IMFINZI INJ 500/10... 26 imipenem-cilastatin intravenous for soln 250 mg... 9 imipenem-cilastatin intravenous for soln 500 mg... 9 imipramine hcl tab 10 mg... 61 imipramine hcl tab 25 mg... 61 imipramine hcl tab 50 mg... 61 imipramine pamoate cap 100 mg... 61 imipramine pamoate cap 125 mg... 61 imipramine pamoate cap 150 mg... 61 imipramine pamoate cap 75 mg... 61 imiquimod cream 5%... 128 IMOGAM RABIE INJ 300/2ML... 109 IMOVAX RABIE INJ 2.5/ML... 111 153
INCRELEX INJ 40MG/4ML... 93 INCRUSE ELPT INH 62.5MCG... 120 indapamide tab 1.25 mg... 49 indapamide tab 2.5 mg... 49 INFANRIX INJ... 111 INLYTA TAB 1MG... 32 INLYTA TAB 5MG... 32 INSULIN PEN NEEDLE... 78 INSULIN SYRINGE (DISP) U-100 0.3 ML... 78 INSULIN SYRINGE (DISP) U-100 1 ML. 78 INSULIN SYRINGE (DISP) U-100 1/2 ML... 78 INTELENCE TAB 100MG... 12 INTELENCE TAB 200MG... 12 INTELENCE TAB 25MG... 12 intralipid inj 20%... 114 INTRALIPID INJ 30%... 114 INTRON A INJ 10MU... 109 INTRON A INJ 18MU... 109 INTRON A INJ 25MU... 109 INTRON A INJ 50MU... 109 introvale tab... 84 INVANZ INJ 1GM... 9 INVEGA SUST INJ 117/0.75... 67 INVEGA SUST INJ 156MG/ML... 67 INVEGA SUST INJ 234/1.5... 67 INVEGA SUST INJ 39/0.25... 66 INVEGA SUST INJ 78/0.5ML... 66 INVEGA TRINZ INJ 273MG... 67 INVEGA TRINZ INJ 410MG... 67 INVEGA TRINZ INJ 546MG... 67 INVEGA TRINZ INJ 819MG... 67 INVIRASE CAP 200MG... 12 INVIRASE TAB 500MG... 12 INVOKAMET TAB 150-1000... 79 INVOKAMET TAB 150-500... 79 INVOKAMET TAB 50-1000... 79 INVOKAMET TAB 50-500MG... 79 INVOKAMET XR TAB 150-1000... 80 INVOKAMET XR TAB 150-500... 80 INVOKAMET XR TAB 50-1000... 79 INVOKAMET XR TAB 50-500MG... 79 INVOKANA TAB 100MG... 80 INVOKANA TAB 300MG... 80 IONOSOL-MB INJ /D5W... 115 IOPIDINE SOL 1% OP... 119 IPOL INJ INACTIVE... 111 ipratropium bromide inhal soln 0.02%... 120 ipratropium bromide nasal soln 0.03% (21 mcg/spray)... 120 ipratropium bromide nasal soln 0.06% (42 mcg/spray)... 120 ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml... 120 irbesartan tab 150 mg... 40 irbesartan tab 300 mg... 40 irbesartan tab 75 mg... 40 irbesartan-hydrochlorothiazide tab 150-12.5 mg... 39 irbesartan-hydrochlorothiazide tab 300-12.5 mg... 39 IRESSA TAB 250MG... 32 irinotecan hcl inj 100 mg/5ml (20 mg/ml)... 36 irinotecan hcl inj 40 mg/2ml (20 mg/ml)... 36 irinotecan hcl inj 500 mg/25ml (20 mg/ml)... 36 ISENTRESS CHW 100MG... 12 ISENTRESS CHW 25MG... 12 ISENTRESS HD TAB 600MG... 12 ISENTRESS POW 100MG... 12 ISENTRESS TAB 400MG... 12 isibloom tab 0.15-30... 84 ISOLYTE-P INJ /D5W... 115 ISOLYTE-S INJ... 115 isoniazid inj 100 mg/ml... 15 isoniazid syrup 50 mg/5ml... 15 isoniazid tab 100 mg... 15 isoniazid tab 300 mg... 15 ISOPROPYL ALCOHOL 0.7ML/ML... 78 isosorbide dinitrate tab 10 mg... 50 isosorbide dinitrate tab 20 mg... 50 isosorbide dinitrate tab 30 mg... 50 isosorbide dinitrate tab 5 mg... 50 isosorbide dinitrate tab er 40 mg... 50 isosorbide mononitrate tab 10 mg... 50 isosorbide mononitrate tab 20 mg... 50 isosorbide mononitrate tab er 24hr 120 mg... 50 154
isosorbide mononitrate tab er 24hr 30 mg... 50 isosorbide mononitrate tab er 24hr 60 mg... 50 isotretinoin cap 10 mg... 124 isotretinoin cap 20 mg... 124 isotretinoin cap 30 mg... 124 isotretinoin cap 40 mg... 124 isradipine cap 2.5 mg... 47 isradipine cap 5 mg... 47 ISTODAX OVR INJ 10MG... 26 ISUPREL INJ 0.2MG/ML... 121 itraconazole cap 100 mg... 11 ivermectin tab 3 mg... 9 IXEMPRA KIT INJ 15MG... 35 IXEMPRA KIT INJ 45MG... 35 IXIARO INJ... 111 J JADENU SPRKL GRA 180MG... 82 JADENU SPRKL GRA 360MG... 82 JADENU SPRKL GRA 90MG... 82 JADENU TAB 180MG... 82 JADENU TAB 360MG... 82 JADENU TAB 90MG... 82 JAKAFI TAB 10MG... 32 JAKAFI TAB 15MG... 32 JAKAFI TAB 20MG... 32 JAKAFI TAB 25MG... 32 JAKAFI TAB 5MG... 32 jantoven tab 10mg... 104 jantoven tab 1mg... 104 jantoven tab 2.5mg... 104 jantoven tab 2mg... 104 jantoven tab 3mg... 104 jantoven tab 4mg... 104 jantoven tab 5mg... 104 jantoven tab 6mg... 104 jantoven tab 7.5mg... 104 JANUMET TAB 50-1000... 80 JANUMET TAB 50-500MG... 80 JANUMET XR TAB 100-1000... 80 JANUMET XR TAB 50-1000... 80 JANUMET XR TAB 50-500MG... 80 JANUVIA TAB 100MG... 80 JANUVIA TAB 25MG... 80 JANUVIA TAB 50MG... 80 JARDIANCE TAB 10MG... 80 JARDIANCE TAB 25MG... 80 jencycla tab 0.35mg... 84 JENTADUETO TAB 2.5-1000... 80 JENTADUETO TAB 2.5-500... 80 JENTADUETO TAB 2.5-850... 80 JENTADUETO TAB XR... 80 JEVTANA INJ 60/1.5ML... 25 jinteli tab 1mg-5mcg... 89 jolessa tab... 84 jolivette tab 0.35mg... 84 juleber tab... 84 JULUCA TAB 50-25MG... 12 junel 1.5/30 tab... 84 junel 1/20 tab... 84 junel fe 24 tab 1/20... 84 junel fe tab 1.5/30... 84 junel fe tab 1/20... 84 JUXTAPID CAP 10MG... 43 JUXTAPID CAP 20MG... 43 JUXTAPID CAP 30MG... 43 JUXTAPID CAP 40MG... 43 JUXTAPID CAP 5MG... 43 JUXTAPID CAP 60MG... 43 K KABIVEN EMU... 114 KADCYLA INJ 100MG... 26 KADCYLA INJ 160MG... 26 kaitlib fe chw... 84 KALETRA TAB 100-25MG... 14 KALETRA TAB 200-50MG... 14 KALYDECO PAK 50MG... 122 KALYDECO PAK 75MG... 122 KALYDECO TAB 150MG... 122 KANUMA INJ 20/10ML... 93 kariva tab 28 day... 84 kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj... 115 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj... 115 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.33% inj... 115 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj... 115 kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.9% inj... 115 155
kcl 20 meq/l (0.15%) in nacl 0.45% inj... 115 kcl 20 meq/l (0.15%) in nacl 0.9% inj... 115 kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.2% inj... 115 kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj... 115 kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.2% inj... 115 kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45% inj... 115 kcl 40 meq/l (0.3%) in nacl 0.9% inj. 115 KCL/D5W/LACT INJ 20MEQ/L... 115 KCL/D5W/NACL INJ 0.3/0.9%... 115 kelnor 1/50 tab... 84 kelnor tab 1/35... 84 KEPIVANCE INJ 6.25MG... 35 ketoconazole cream 2%... 125 ketoconazole shampoo 2%... 126 ketoconazole tab 200 mg... 11 ketoprofen cap 75 mg... 2 ketorolac tromethamine ophth soln 0.4%... 118 ketorolac tromethamine ophth soln 0.5%... 118 KEVEYIS TAB 50MG... 50 KEYTRUDA INJ 100MG/4M... 26 kimidess tab... 84 KINRIX INJ... 111 kionex sus 15gm/60... 82 KISQALI 200 PAK FEMARA... 26 KISQALI 400 PAK FEMARA... 26 KISQALI 600 PAK FEMARA... 26 KISQALI TAB 200DOSE... 26 KISQALI TAB 400DOSE... 26 KISQALI TAB 600DOSE... 27 klor-con 10 tab 10meq er... 112 klor-con 8 tab 8meq er... 112 klor-con m10 tab 10meq er... 112 KLOR-CON M15 TAB 15MEQ ER... 112 klor-con m20 tab 20meq er... 112 klor-con pak 20meq... 112 klor-con spr cap 10meq... 112 klor-con spr cap 8meq... 112 KORLYM TAB 300MG... 93 K-TAB TAB 8MEQ CR... 112 kurvelo tab 0.15/30... 84 KUVAN POW 100MG... 88 KUVAN POW 500MG... 88 KUVAN TAB 100MG... 88 k-vescent tab 25meq ef... 112 KYNAMRO INJ 200MG/ML... 43 KYPROLIS SOL 30MG... 27 KYPROLIS SOL 60MG... 27 L labetalol hcl iv soln 5 mg/ml... 45 labetalol hcl tab 100 mg... 45 labetalol hcl tab 200 mg... 45 labetalol hcl tab 300 mg... 45 lactated ringer's for irrigation... 129 lactated ringer's solution... 115 lactic acid (ammonium lactate) cream 12%... 128 lactic acid (ammonium lactate) lotion 12%... 128 lactulose solution 10 gm/15ml... 99 lamivudine oral soln 10 mg/ml... 13 lamivudine tab 100 mg (hbv)... 16 lamivudine tab 150 mg... 13 lamivudine tab 300 mg... 13 lamivudine-zidovudine tab 150-300 mg... 14 lamotrigine tab 100 mg... 55 lamotrigine tab 150 mg... 55 lamotrigine tab 200 mg... 55 lamotrigine tab 25 mg... 55 lamotrigine tab 25 mg (35) starter kit. 55 lamotrigine tab chewable dispersible 25 mg... 55 lamotrigine tab chewable dispersible 5 mg... 55 lansoprazole cap delayed release 15 mg... 101 lansoprazole cap delayed release 30 mg... 101 LANTUS INJ 100/ML... 78 LANTUS INJ SOLOSTAR... 78 larin 24 tab fe 1/20... 84 larin fe tab 1.5/30... 84 larin fe tab 1/20... 84 larin tab 1.5/30... 84 156
larin tab 1/20... 84 larissia tab... 84 LARTRUVO INJ 10MG/ML... 27 LARTRUVO INJ 190/19ML... 27 latanoprost ophth soln 0.005%... 119 LATUDA TAB 120MG... 67 LATUDA TAB 20MG... 67 LATUDA TAB 40MG... 67 LATUDA TAB 60MG... 67 LATUDA TAB 80MG... 67 layolis fe chw... 84 LAZANDA SPR 100MCG... 5 LAZANDA SPR 300MCG... 5 LAZANDA SPR 400MCG... 5 leena tab... 84 leflunomide tab 10 mg... 107 leflunomide tab 20 mg... 107 LENVIMA CAP 10 MG... 33 LENVIMA CAP 14 MG... 33 LENVIMA CAP 18 MG... 33 LENVIMA CAP 20 MG... 33 LENVIMA CAP 24 MG... 33 LENVIMA CAP 8 MG... 33 lessina tab... 84 LETAIRIS TAB 10MG... 51 LETAIRIS TAB 5MG... 51 letrozole tab 2.5 mg... 29 leucovorin calcium for inj 100 mg... 35 leucovorin calcium for inj 350 mg... 35 leucovorin calcium tab 10 mg... 35 leucovorin calcium tab 15 mg... 35 leucovorin calcium tab 25 mg... 36 leucovorin calcium tab 5 mg... 35 LEUKERAN TAB 2MG... 23 LEUKINE INJ 250MCG... 105 leuprolide acetate inj kit 5 mg/ml... 29 levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)... 121 levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv)... 121 levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv)... 121 levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv)... 121 levalbuterol tartrate inhal aerosol 45 mcg/act (base equiv)... 121 LEVEMIR INJ... 78 LEVEMIR INJ FLEXTOUC... 78 levetiracetam in sodium chloride iv soln 1000 mg/100ml... 55 levetiracetam in sodium chloride iv soln 1500 mg/100ml... 55 levetiracetam in sodium chloride iv soln 500 mg/100ml... 55 levetiracetam inj 500 mg/5ml (100 mg/ml)... 55 levetiracetam oral soln 100 mg/ml... 55 levetiracetam tab 1000 mg... 56 levetiracetam tab 250 mg... 55 levetiracetam tab 500 mg... 55 levetiracetam tab 750 mg... 56 levetiracetam tab er 24hr 500 mg... 56 levetiracetam tab er 24hr 750 mg... 56 levobunolol hcl ophth soln 0.5%... 119 levocarnitine inj 200 mg/ml... 88 levocarnitine oral soln 1 gm/10ml (10%)... 88 levocarnitine tab 330 mg... 88 levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5 mg/ml)... 120 levocetirizine dihydrochloride tab 5 mg... 120 levofloxacin in d5w iv soln 250 mg/50ml... 19 levofloxacin in d5w iv soln 500 mg/100ml... 19 levofloxacin in d5w iv soln 750 mg/150ml... 19 levofloxacin iv soln 25 mg/ml... 19 levofloxacin ophth soln 0.5%... 117 levofloxacin oral soln 25 mg/ml... 20 levofloxacin tab 250 mg... 20 levofloxacin tab 500 mg... 20 levofloxacin tab 750 mg... 20 levoleucovorin calcium for iv inj 50 mg (base equiv)... 36 levoleucovorin calcium inj 175 mg/17.5ml (base equiv)... 36 levonest tab... 84 levonorgestrel & ethinyl estradiol (91- day) tab 0.15-0.03 mg... 84 levonorgestrel & ethinyl estradiol tab 0.1 157
mg-20 mcg... 85 levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg... 85 levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg... 85 levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg... 85 levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7)... 84 levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7)... 84 levora-28 tab 0.15/30... 85 levorphanol tartrate tab 2 mg... 5 levothyroxine sodium tab 100 mcg... 95 levothyroxine sodium tab 112 mcg... 95 levothyroxine sodium tab 125 mcg... 95 levothyroxine sodium tab 137 mcg... 95 levothyroxine sodium tab 150 mcg... 95 levothyroxine sodium tab 175 mcg... 95 levothyroxine sodium tab 200 mcg... 95 levothyroxine sodium tab 25 mcg... 95 levothyroxine sodium tab 300 mcg... 95 levothyroxine sodium tab 50 mcg... 95 levothyroxine sodium tab 75 mcg... 95 levothyroxine sodium tab 88 mcg... 95 LEXIVA SUS 50MG/ML... 13 lidocaine hcl gel 2%... 128 lidocaine hcl iv inj 10 mg/ml... 41 lidocaine hcl iv inj 20 mg/ml... 41 lidocaine hcl laryngotracheal soln 4% 129 lidocaine hcl local inj 1%... 7 lidocaine hcl local inj 2%... 7 lidocaine hcl local preservative free (pf) inj 0.5%... 7 lidocaine hcl local preservative free (pf) inj 1%... 7 lidocaine hcl local preservative free (pf) inj 1.5%... 7 lidocaine hcl local preservative free (pf) inj 2%... 7 lidocaine hcl local preservative free (pf) inj 4%... 7 lidocaine hcl soln 4%... 128 lidocaine hcl viscous soln 2%... 129 lidocaine iv infusion in d5w inj 4 mg/ml... 41 lidocaine iv infusion in d5w inj 8 mg/ml... 41 lidocaine oint 5%... 128 lidocaine patch 5%... 128 lidocaine-prilocaine cream 2.5-2.5%. 128 LINCOCIN INJ 300MG/ML... 9 lincomycin hcl inj 300 mg/ml... 9 lindane shampoo 1%... 129 linezolid for susp 100 mg/5ml... 9 linezolid iv soln 600 mg/300ml (2 mg/ml)... 9 linezolid tab 600 mg... 9 LINZESS CAP 145MCG... 100 LINZESS CAP 290MCG... 100 LINZESS CAP 72MCG... 100 LIORESAL INT INJ 10MG/20... 75 LIORESAL INT INJ 10MG/5ML... 75 liothyronine sodium iv soln 10 mcg/ml 95 liothyronine sodium tab 25 mcg... 95 liothyronine sodium tab 5 mcg... 95 liothyronine sodium tab 50 mcg... 95 lisinopril & hydrochlorothiazide tab 10-12.5 mg... 37 lisinopril & hydrochlorothiazide tab 20-12.5 mg... 37 lisinopril & hydrochlorothiazide tab 20-25 mg... 37 lisinopril tab 10 mg... 38 lisinopril tab 2.5 mg... 38 lisinopril tab 20 mg... 38 lisinopril tab 30 mg... 38 lisinopril tab 40 mg... 38 lisinopril tab 5 mg... 38 lithium carbonate cap 150 mg... 74 lithium carbonate cap 300 mg... 74 lithium carbonate cap 600 mg... 74 lithium carbonate tab 300 mg... 74 lithium carbonate tab er 300 mg... 74 lithium carbonate tab er 450 mg... 74 LITHIUM SOL 8MEQ/5ML... 74 LITHOSTAT TAB 250MG... 102 LONSURF TAB 15-6.14... 35 LONSURF TAB 20-8.19... 35 loperamide hcl cap 2 mg... 100 lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)... 14 158
lorazepam con 2mg/ml... 53 lorazepam inj 2 mg/ml... 53 lorazepam inj 4 mg/ml... 53 lorazepam tab 0.5 mg... 53 lorazepam tab 1 mg... 53 lorazepam tab 2 mg... 53 lorcet hd tab 10-325mg... 5 lorcet plus tab 7.5-325... 5 lorcet tab 5-325mg... 5 loryna tab 3-0.02mg... 85 losartan potassium & hydrochlorothiazide tab 100-12.5 mg... 39 losartan potassium & hydrochlorothiazide tab 100-25 mg... 39 losartan potassium & hydrochlorothiazide tab 50-12.5 mg... 39 losartan potassium tab 100 mg... 40 losartan potassium tab 25 mg... 40 losartan potassium tab 50 mg... 40 LOTEMAX GEL 0.5%... 118 LOTEMAX OIN 0.5%... 118 LOTEMAX SUS 0.5%... 118 lovastatin tab 10 mg... 42 lovastatin tab 20 mg... 42 lovastatin tab 40 mg... 42 low-ogestrel tab... 85 loxapine succinate cap 10 mg... 67 loxapine succinate cap 25 mg... 67 loxapine succinate cap 5 mg... 67 loxapine succinate cap 50 mg... 67 ludent chw 0.25mg f... 112 LUMIGAN SOL 0.01%... 119 LUMIZYME INJ 50MG... 88 LUPANETA KIT 11.25-5... 87 LUPANETA KIT 3.75-5... 87 LUPR DEP-PED INJ 11.25MG... 93 LUPR DEP-PED INJ 15MG... 93 LUPR DEP-PED INJ 3M 30MG... 93 LUPRON DEPOT INJ 11.25MG... 29 LUPRON DEPOT INJ 22.5MG... 29 LUPRON DEPOT INJ 3.75MG... 29 LUPRON DEPOT INJ 30MG... 29 LUPRON DEPOT INJ 45MG... 29 LUPRON DEPOT INJ 7.5MG... 29 lutera tab... 85 LYNPARZA CAP 50MG... 27 LYNPARZA TAB 100MG... 27 LYNPARZA TAB 150MG... 27 LYRICA CAP 100MG... 56 LYRICA CAP 150MG... 56 LYRICA CAP 200MG... 56 LYRICA CAP 225MG... 56 LYRICA CAP 25MG... 56 LYRICA CAP 300MG... 56 LYRICA CAP 50MG... 56 LYRICA CAP 75MG... 56 LYRICA SOL 20MG/ML... 56 LYSODREN TAB 500MG... 29 lyza tab 0.35mg... 85 M MAGNESIUM SU INJ 20/500ML... 112 MAGNESIUM SU INJ 2GM/50ML... 112 MAGNESIUM SU INJ 40G/1000... 112 MAGNESIUM SU INJ 4G/100ML... 112 MAGNESIUM SU INJ 80MG/ML... 112 magnesium sulfate inj 50%... 112 MAKENA INJ 250MG/ML... 95 malathion lotion 0.5%... 129 maprotiline hcl tab 25 mg... 61 maprotiline hcl tab 50 mg... 61 maprotiline hcl tab 75 mg... 61 marlissa tab 0.15/30... 85 MARPLAN TAB 10MG... 61 MATULANE CAP 50MG... 35 matzim la tab 180mg/24... 47 matzim la tab 240mg/24... 47 matzim la tab 300mg/24... 47 matzim la tab 360mg/24... 47 matzim la tab 420mg/24... 47 MAVYRET TAB 100-40MG... 16 MAXIDEX SUS 0.1% OP... 118 meclizine hcl tab 12.5 mg... 97 meclizine hcl tab 25 mg... 97 meclofenamate sodium cap 100 mg... 2 meclofenamate sodium cap 50 mg... 2 medroxyprogesterone acetate im susp 150 mg/ml... 85 medroxyprogesterone acetate im susp prefilled syr 150 mg/ml... 85 medroxyprogesterone acetate tab 10 mg... 95 medroxyprogesterone acetate tab 2.5 159
mg... 95 medroxyprogesterone acetate tab 5 mg... 95 mefloquine hcl tab 250 mg... 12 megestrol acetate susp 40 mg/ml... 29 megestrol acetate tab 20 mg... 29 megestrol acetate tab 40 mg... 29 MEKINIST TAB 0.5MG... 33 MEKINIST TAB 2MG... 33 meloxicam tab 15 mg... 2 meloxicam tab 7.5 mg... 2 melphalan hcl for inj 50 mg (base equiv)... 23 memantine hcl oral solution 2 mg/ml.. 58 memantine hcl tab 10 mg... 58 memantine hcl tab 5 mg... 58 memantine hcl tab 5 mg (28) & 10 mg (21) titration pak... 58 MENACTRA INJ... 111 MENOSTAR DIS 14MCG... 89 MENVEO INJ... 111 mercaptopurine tab 50 mg... 24 meropenem iv for soln 1 gm... 9 meropenem iv for soln 500 mg... 9 mesalamine enema 4 gm... 99 mesalamine tab delayed release 800 mg... 99 mesna inj 100 mg/ml... 36 MESNEX TAB 400MG... 36 MESTINON SYP 60MG/5ML... 74 metadate tab 20mg er... 71 metaproterenol sulfate syrup 10 mg/5ml... 121 metaproterenol sulfate tab 10 mg... 121 metaproterenol sulfate tab 20 mg... 121 metformin hcl tab 1000 mg... 80 metformin hcl tab 500 mg... 80 metformin hcl tab 850 mg... 80 metformin hcl tab er 24hr 500 mg... 80 metformin hcl tab er 24hr 750 mg... 80 methadone hcl conc 10 mg/ml... 5 methadone hcl inj 10 mg/ml... 5 methadone hcl soln 10 mg/5ml... 5 methadone hcl soln 5 mg/5ml... 5 methadone hcl tab 10 mg... 5 methadone hcl tab 5 mg... 5 methadone hcl tab for oral susp 40 mg. 5 METHADOSE CON 10MG/ML... 5 methamphetamine hcl tab 5 mg... 71 methazolamide tab 25 mg... 49 methazolamide tab 50 mg... 49 methenamine hippurate tab 1 gm... 9 methenamine mandelate tab 0.5 gm... 9 methenamine mandelate tab 1 gm... 9 methimazole tab 10 mg... 95 methimazole tab 5 mg... 95 methocarbamol tab 500 mg... 75 methocarbamol tab 750 mg... 75 methotrexate sodium for inj 1 gm... 24 methotrexate sodium inj 25 mg/ml... 28 methotrexate sodium inj 250 mg/10ml (25 mg/ml)... 25 methotrexate sodium inj pf 250 mg/10ml (25 mg/ml)... 25 methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)... 25 methotrexate sodium tab 2.5 mg (base equiv)... 107 methoxsalen rapid cap 10 mg... 126 methscopolamine bromide tab 2.5 mg 98 methscopolamine bromide tab 5 mg... 98 methyclothiazide tab 5 mg... 49 methylergonovine maleate inj 0.2 mg/ml... 93 methylphenidate hcl cap er 10 mg (cd) 71 methylphenidate hcl cap er 20 mg (cd) 71 methylphenidate hcl cap er 24hr 60 mg (la)... 71 methylphenidate hcl cap er 30 mg (cd) 71 methylphenidate hcl cap er 40 mg (cd) 71 methylphenidate hcl cap er 50 mg (cd) 71 methylphenidate hcl cap er 60 mg (cd) 71 methylphenidate hcl soln 10 mg/5ml.. 71 methylphenidate hcl soln 5 mg/5ml... 71 methylphenidate hcl tab 10 mg... 72 methylphenidate hcl tab 20 mg... 72 methylphenidate hcl tab 5 mg... 72 methylphenidate hcl tab er 10 mg... 72 methylphenidate hcl tab er 20 mg... 72 methylphenidate hcl tab er osmotic release (osm) 18 mg... 72 methylphenidate hcl tab er osmotic 160
release (osm) 27 mg... 72 methylphenidate hcl tab er osmotic release (osm) 36 mg... 72 methylphenidate hcl tab er osmotic release (osm) 54 mg... 72 methylphenidate hcl tab er osmotic release (osm) 72 mg... 72 methylprednisolone acetate inj susp 40 mg/ml... 90 methylprednisolone acetate inj susp 80 mg/ml... 90 methylprednisolone sod succ for inj 1000 mg (base equiv)... 90 methylprednisolone sod succ for inj 125 mg (base equiv)... 90 methylprednisolone sod succ for inj 40 mg (base equiv)... 90 methylprednisolone tab 16 mg... 90 methylprednisolone tab 32 mg... 90 methylprednisolone tab 4 mg... 90 methylprednisolone tab 8 mg... 90 methylprednisolone tab therapy pack 4 mg (21)... 90 methyltestosterone cap 10 mg... 87 metipranolol ophth soln 0.3%... 119 metoclopramide hcl inj 5 mg/ml (base equivalent)... 97 metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base equiv)... 97 metoclopramide hcl tab 10 mg (base equivalent)... 97 metoclopramide hcl tab 5 mg (base equivalent)... 97 metolazone tab 10 mg... 49 metolazone tab 2.5 mg... 49 metolazone tab 5 mg... 49 metoprolol & hydrochlorothiazide tab 100-25 mg... 44 metoprolol & hydrochlorothiazide tab 100-50 mg... 44 metoprolol & hydrochlorothiazide tab 50-25 mg... 44 metoprolol succinate tab er 24hr 100 mg (tartrate equiv)... 45 metoprolol succinate tab er 24hr 200 mg (tartrate equiv)... 45 metoprolol succinate tab er 24hr 25 mg (tartrate equiv)... 45 metoprolol succinate tab er 24hr 50 mg (tartrate equiv)... 45 metoprolol tartrate iv soln 5 mg/5ml.. 45 metoprolol tartrate tab 100 mg... 45 metoprolol tartrate tab 25 mg... 45 metoprolol tartrate tab 50 mg... 45 metronidazole cap 375 mg... 9 metronidazole cream 0.75%... 128 metronidazole gel 0.75%... 128 metronidazole in nacl 0.79% iv soln 500 mg/100ml... 10 metronidazole lotion 0.75%... 128 metronidazole tab 250 mg... 10 metronidazole tab 500 mg... 10 metronidazole vaginal gel 0.75%... 103 mexiletine hcl cap 150 mg... 41 mexiletine hcl cap 200 mg... 41 mexiletine hcl cap 250 mg... 41 MG SO4/D5W INJ 10MG/ML... 112 MIACALCIN INJ 200/ML... 93 miconazole 3 sup 200mg... 103 microgestin tab 1.5/30... 85 microgestin tab 1/20... 85 microgestin tab fe 1/20... 85 microgestin tab fe1.5/30... 85 midodrine hcl tab 10 mg... 50 midodrine hcl tab 2.5 mg... 50 midodrine hcl tab 5 mg... 50 migergot sup 2/100... 72 miglustat cap 100 mg... 88 mili tab 0.25/35... 85 mimvey lo tab 0.5-0.1... 89 mimvey tab 1-0.5mg... 89 minocycline hcl cap 100 mg... 22 minocycline hcl cap 50 mg... 22 minocycline hcl cap 75 mg... 22 minoxidil tab 10 mg... 50 minoxidil tab 2.5 mg... 50 mirtazapine orally disintegrating tab 15 mg... 61 mirtazapine orally disintegrating tab 30 mg... 61 mirtazapine orally disintegrating tab 45 mg... 61 161
mirtazapine tab 15 mg... 61 mirtazapine tab 30 mg... 61 mirtazapine tab 45 mg... 61 mirtazapine tab 7.5 mg... 61 misoprostol tab 100 mcg... 100 misoprostol tab 200 mcg... 100 mitomycin for iv soln 20 mg... 24 mitomycin for iv soln 40 mg... 24 mitomycin for iv soln 5 mg... 24 mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml)... 35 M-M-R II INJ... 111 modafinil tab 100 mg... 76 modafinil tab 200 mg... 76 MODERIBA PAK 1200/DAY... 16 MODERIBA PAK 800/DAY... 16 MODERIBA TAB 1000/DAY... 16 moderiba tab 200mg... 16 MODERIBA TAB 600/DAY... 16 moexipril hcl tab 15 mg... 38 moexipril hcl tab 7.5 mg... 38 moexipril-hydrochlorothiazide tab 15-12.5 mg... 37 moexipril-hydrochlorothiazide tab 15-25 mg... 37 moexipril-hydrochlorothiazide tab 7.5-12.5 mg... 37 mometasone furoate cream 0.1%... 128 mometasone furoate oint 0.1%... 128 mometasone furoate solution 0.1% (lotion)... 128 mono-linyah tab 0.25-35... 85 mononessa tab... 85 montelukast sodium chew tab 4 mg (base equiv)... 121 montelukast sodium chew tab 5 mg (base equiv)... 121 montelukast sodium oral granules packet 4 mg (base equiv)... 122 montelukast sodium tab 10 mg (base equiv)... 122 MONUROL PAK GRANULES... 10 morgidox cap 1x50mg... 22 MORPHINE SUL INJ 150/30ML... 6 MORPHINE SUL INJ 2MG/ML... 5 MORPHINE SUL INJ 4MG/ML... 6 MORPHINE SUL INJ 5MG/ML... 6 morphine sulfate iv soln 1 mg/ml... 6 morphine sulfate iv soln pf 10 mg/ml... 6 morphine sulfate iv soln pf 15 mg/ml... 6 morphine sulfate oral soln 10 mg/5ml... 6 morphine sulfate oral soln 100 mg/5ml (20 mg/ml)... 6 morphine sulfate oral soln 20 mg/5ml... 6 morphine sulfate tab 15 mg... 6 morphine sulfate tab 30 mg... 6 morphine sulfate tab er 100 mg... 6 morphine sulfate tab er 15 mg... 6 morphine sulfate tab er 200 mg... 6 morphine sulfate tab er 30 mg... 6 morphine sulfate tab er 60 mg... 6 MOVANTIK TAB 12.5MG... 100 MOVANTIK TAB 25MG... 100 MOXEZA SOL 0.5%... 117 moxifloxacin hcl 400 mg/250ml in sodium chloride 0.8% inj... 20 moxifloxacin hcl ophth soln 0.5% (base equiv)... 117 moxifloxacin hcl tab 400 mg (base equiv)... 20 MOZOBIL INJ... 105 MULTAQ TAB 400MG... 41 multivit/fl chw 0.25mg... 112 multivit/fl chw 0.5mg... 112 multivit/fl chw 1mg... 112 mupirocin oint 2%... 125 MUSTARGEN INJ 10MG... 23 MYALEPT INJ 11.3MG... 93 MYCAMINE INJ 100MG... 11 MYCAMINE INJ 50MG... 11 mycophenolate mofetil cap 250 mg.. 110 mycophenolate mofetil for oral susp 200 mg/ml... 110 mycophenolate mofetil hcl for iv soln 500 mg (base equiv)... 110 mycophenolate mofetil tab 500 mg... 110 mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv)... 110 mycophenolate sodium tab dr 360 mg (mycophenolic acid equiv)... 110 MYLOTARG INJ 4.5MG... 27 myorisan cap 10mg... 124 162
myorisan cap 20mg... 124 myorisan cap 30mg... 124 myorisan cap 40mg... 124 MYRBETRIQ TAB 25MG... 102 MYRBETRIQ TAB 50MG... 102 MYTESI TAB 125MG... 100 myzilra tab... 85 N nabumetone tab 500 mg... 2 nabumetone tab 750 mg... 2 nadolol & bendroflumethiazide tab 40-5 mg... 44 nadolol & bendroflumethiazide tab 80-5 mg... 44 nadolol tab 20 mg... 45 nadolol tab 40 mg... 45 nadolol tab 80 mg... 45 nafcillin sodium for inj 1 gm... 21 nafcillin sodium for inj 2 gm... 21 nafcillin sodium for iv soln 10 gm... 21 nafcillin sodium for iv soln 2 gm... 21 NAGLAZYME INJ 1MG/ML... 88 nalbuphine hcl inj 10 mg/ml... 3 nalbuphine hcl inj 20 mg/ml... 3 naloxone hcl inj 0.4 mg/ml... 77 naloxone hcl inj 4 mg/10ml... 77 naloxone hcl soln cartridge 0.4 mg/ml. 77 naloxone hcl soln prefilled syringe 2 mg/2ml... 77 naltrexone hcl tab 50 mg... 77 naproxen dr tab 375mg... 2 naproxen dr tab 500mg... 2 naproxen sodium tab 275 mg... 2 naproxen sodium tab 550 mg... 2 naproxen susp 125 mg/5ml... 2 naproxen tab 250 mg... 2 naproxen tab 375 mg... 2 naproxen tab 500 mg... 2 naratriptan hcl tab 1 mg (base equiv).. 73 naratriptan hcl tab 2.5 mg (base equiv)... 73 NATACYN SUS 5% OP... 117 nateglinide tab 120 mg... 80 nateglinide tab 60 mg... 80 NATPARA INJ 100MCG... 93 NATPARA INJ 25MCG... 93 NATPARA INJ 50MCG... 93 NATPARA INJ 75MCG... 93 NEBUPENT INH 300MG... 10 necon tab 0.5/35... 85 necon tab 7/7/7... 85 NEEDLES, INSULIN DISP., SAFETY... 78 nefazodone hcl tab 100 mg... 61 nefazodone hcl tab 150 mg... 61 nefazodone hcl tab 200 mg... 61 nefazodone hcl tab 250 mg... 61 nefazodone hcl tab 50 mg... 61 neomycin sulfate tab 500 mg... 8 neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin... 117 neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml... 117 neomycin-polymyxin b gu irrigation soln... 129 neomycin-polymyxin-dexamethasone ophth oint 0.1%... 117 neomycin-polymyxin-dexamethasone ophth susp 0.1%... 117 neomycin-polymyxin-hc ophth susp.. 117 neomycin-polymyxin-hc otic soln 1% 130 neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%... 130 neostigmine methylsulfate iv soln 10 mg/10 ml (1 mg/ml)... 74 neostigmine methylsulfate iv soln 5 mg/10 ml (0.5 mg/ml)... 74 NEPHRAMINE INJ 5.4%... 114 NERLYNX TAB 40MG... 33 NEULASTA INJ 6MG/0.6M... 105 NEUPOGEN INJ 300/0.5... 105 NEUPOGEN INJ 300MCG... 105 NEUPOGEN INJ 480/0.8... 105 NEUPOGEN INJ 480MCG... 105 NEUPRO DIS 1MG/24HR... 64 NEUPRO DIS 2MG/24HR... 64 NEUPRO DIS 3MG/24HR... 64 NEUPRO DIS 4MG/24HR... 64 NEUPRO DIS 6MG/24HR... 64 NEUPRO DIS 8MG/24HR... 64 nevirapine tab 200 mg... 13 nevirapine tab er 24hr 100 mg... 13 nevirapine tab er 24hr 400 mg... 13 163
NEXAVAR TAB 200MG... 33 niacin tab er 1000 mg (antihyperlipidemic)... 43 niacin tab er 500 mg (antihyperlipidemic)... 43 niacin tab er 750 mg (antihyperlipidemic)... 43 nicardipine hcl cap 20 mg... 47 nicardipine hcl cap 30 mg... 47 nicardipine hcl iv soln 2.5 mg/ml... 47 NICOTROL INH... 77 NICOTROL NS SPR 10MG/ML... 77 nifedipine tab er 24hr 30 mg... 47 nifedipine tab er 24hr 60 mg... 47 nifedipine tab er 24hr 90 mg... 47 nifedipine tab er 24hr osmotic release 30 mg... 47 nifedipine tab er 24hr osmotic release 60 mg... 47 nifedipine tab er 24hr osmotic release 90 mg... 47 nikki tab 3-0.02mg... 85 nilutamide tab 150 mg... 29 NINLARO CAP 2.3MG... 27 NINLARO CAP 3MG... 27 NINLARO CAP 4MG... 27 NIPENT INJ 10MG... 25 NITRO-BID OIN 2%... 50 NITRO-DUR DIS 0.3MG/HR... 50 NITRO-DUR DIS 0.8MG/HR... 50 nitrofurantoin macrocrystalline cap 100 mg... 10 nitrofurantoin macrocrystalline cap 50 mg... 10 nitrofurantoin monohydrate macrocrystalline cap 100 mg... 10 NITROGLYCER INJ 5MG/ML... 50 nitroglycerin sl tab 0.3 mg... 50 nitroglycerin sl tab 0.4 mg... 51 nitroglycerin sl tab 0.6 mg... 51 nitroglycerin td patch 24hr 0.1 mg/hr.. 51 nitroglycerin td patch 24hr 0.2 mg/hr.. 51 nitroglycerin td patch 24hr 0.4 mg/hr.. 51 nitroglycerin td patch 24hr 0.6 mg/hr.. 51 nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)... 51 nizatidine cap 150 mg... 98 nizatidine cap 300 mg... 98 nizatidine oral soln 15 mg/ml... 98 nora-be tab 0.35mg... 85 NORDITROPIN INJ 10/1.5ML... 92 NORDITROPIN INJ 15/1.5ML... 92 NORDITROPIN INJ 30/3ML... 92 NORDITROPIN INJ 5/1.5ML... 92 norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg... 85 norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg... 85 norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg... 85 norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg... 85 norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24)... 85 norethindrone acetate tab 5 mg... 95 norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg... 89 norethindrone tab 0.35 mg... 86 norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg... 86 norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg... 86 norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg... 86 norlyroc tab 0.35mg... 86 NORMOSOL -M INJ /D5W... 115 NORMOSOL -R INJ /D5W... 115 NORMOSOL-R INJ PH 7.4... 116 NORTHERA CAP 100MG... 50 NORTHERA CAP 200MG... 50 NORTHERA CAP 300MG... 50 nortrel tab 0.5/35... 86 nortrel tab 1/35... 86 nortrel tab 7/7/7... 86 nortriptyline hcl cap 10 mg... 61 nortriptyline hcl cap 25 mg... 61 nortriptyline hcl cap 50 mg... 61 nortriptyline hcl cap 75 mg... 61 nortriptyline hcl soln 10 mg/5ml... 61 NORVIR CAP 100MG... 13 NORVIR POW 100MG... 13 NORVIR SOL 80MG/ML... 13 164
NORVIR TAB 100MG... 13 NOVOLIN INJ 70/30... 78 NOVOLIN N INJ U-100... 78 NOVOLIN R INJ U-100... 78 NOVOLOG INJ 100/ML... 78 NOVOLOG INJ FLEXPEN... 78 NOVOLOG INJ PENFILL... 78 NOVOLOG MIX INJ 70/30... 78 NOVOLOG MIX INJ FLEXPEN... 79 NOXAFIL SUS 40MG/ML... 11 NOXAFIL TAB 100MG... 11 NUCALA INJ 100MG... 122 NUEDEXTA CAP 20-10MG... 74 NULOJIX INJ 250MG... 110 NUPLAZID TAB 17MG... 67 NUTROPIN AQ INJ 10MG/2ML... 92 NUTROPIN AQ INJ 20MG/2ML... 92 NUTROPIN AQ INJ NUSPIN 5... 92 NUVARING MIS... 86 nyamyc pow 100000... 125 nystatin cream 100000 unit/gm... 125 nystatin oint 100000 unit/gm... 125 nystatin susp 100000 unit/ml... 129 nystatin tab 500000 unit... 11 nystatin topical powder 100000 unit/gm... 126 nystatin-triamcinolone cream 100000-0.1 unit/gm-%... 125 nystatin-triamcinolone oint 100000-0.1 unit/gm-%... 125 nystop pow 100000... 126 O OCALIVA TAB 10MG... 100 OCALIVA TAB 5MG... 100 ocella tab 3-0.03mg... 86 OCTAGAM INJ 1GM... 109 OCTAGAM INJ 2GM/20ML... 109 octreotide acetate inj 100 mcg/ml (0.1 mg/ml)... 93 octreotide acetate inj 1000 mcg/ml (1 mg/ml)... 93 octreotide acetate inj 200 mcg/ml (0.2 mg/ml)... 93 octreotide acetate inj 50 mcg/ml (0.05 mg/ml)... 93 octreotide acetate inj 500 mcg/ml (0.5 mg/ml)... 93 ODEFSEY TAB... 14 ODOMZO CAP 200MG... 27 OFEV CAP 100MG... 122 OFEV CAP 150MG... 122 ofloxacin ophth soln 0.3%... 118 ofloxacin otic soln 0.3%... 130 ofloxacin tab 300 mg... 20 ofloxacin tab 400 mg... 20 ogestrel tab... 86 olanzapine for im inj 10 mg... 67 olanzapine orally disintegrating tab 10 mg... 67 olanzapine orally disintegrating tab 15 mg... 67 olanzapine orally disintegrating tab 20 mg... 67 olanzapine orally disintegrating tab 5 mg... 67 olanzapine tab 10 mg... 67 olanzapine tab 15 mg... 67 olanzapine tab 2.5 mg... 67 olanzapine tab 20 mg... 68 olanzapine tab 5 mg... 67 olanzapine tab 7.5 mg... 67 omega-3-acid ethyl esters cap 1 gm... 43 omeprazole cap delayed release 10 mg... 101 omeprazole cap delayed release 20 mg... 102 omeprazole cap delayed release 40 mg... 102 OMNITROPE INJ 10/1.5ML... 92 OMNITROPE INJ 5.8MG... 92 OMNITROPE INJ 5/1.5ML... 92 ondansetron hcl inj 4 mg/2ml (2 mg/ml)... 97 ondansetron hcl oral soln 4 mg/5ml... 97 ondansetron hcl tab 24 mg... 97 ondansetron hcl tab 4 mg... 97 ondansetron hcl tab 8 mg... 97 ondansetron orally disintegrating tab 4 mg... 97 ondansetron orally disintegrating tab 8 mg... 97 ONFI SUS 2.5MG/ML... 56 165
ONFI TAB 10MG... 56 ONFI TAB 20MG... 56 OPDIVO INJ 100MG/10... 27 OPDIVO INJ 40MG/4ML... 27 OPSUMIT TAB 10MG... 51 ORALAIR SUB 300 IR... 109 ORBACTIV SOL 400MG... 10 ORFADIN CAP 10MG... 88 ORFADIN CAP 20MG... 88 ORFADIN CAP 2MG... 88 ORFADIN CAP 5MG... 88 ORFADIN SUS 4MG/ML... 88 ORKAMBI TAB 100-125... 122 ORKAMBI TAB 200-125... 123 orphenadrine citrate inj 30 mg/ml... 75 orphenadrine citrate tab er 12hr 100 mg... 75 orsythia tab... 86 oseltamivir phosphate cap 30 mg (base equiv)... 16 oseltamivir phosphate cap 45 mg (base equiv)... 16 oseltamivir phosphate cap 75 mg (base equiv)... 16 oseltamivir phosphate for susp 6 mg/ml (base equiv)... 16 OTREXUP INJ 10MG... 107 OTREXUP INJ 12.5/0.4... 107 OTREXUP INJ 15MG... 107 OTREXUP INJ 17.5/0.4... 107 OTREXUP INJ 20MG... 108 OTREXUP INJ 22.5/0.4... 108 OTREXUP INJ 25MG... 108 oxacillin sodium for inj 1 gm (base equivalent)... 21 oxacillin sodium for inj 10 gm (base equivalent)... 21 oxacillin sodium for inj 2 gm (base equivalent)... 21 oxaliplatin for iv inj 100 mg... 35 oxaliplatin for iv inj 50 mg... 35 oxaliplatin iv soln 100 mg/20ml... 35 oxaliplatin iv soln 50 mg/10ml... 35 oxandrolone tab 10 mg... 77 oxandrolone tab 2.5 mg... 77 oxazepam cap 10 mg... 53 oxazepam cap 15 mg... 53 oxazepam cap 30 mg... 53 oxcarbazepine susp 300 mg/5ml (60 mg/ml)... 56 oxcarbazepine tab 150 mg... 56 oxcarbazepine tab 300 mg... 56 oxcarbazepine tab 600 mg... 56 oxybutynin chloride syrup 5 mg/5ml. 102 oxybutynin chloride tab 5 mg... 102 oxybutynin chloride tab er 24hr 10 mg... 102 oxybutynin chloride tab er 24hr 15 mg... 102 oxybutynin chloride tab er 24hr 5 mg 102 oxycodone hcl cap 5 mg... 6 oxycodone hcl conc 100 mg/5ml (20 mg/ml)... 6 oxycodone hcl soln 5 mg/5ml... 6 oxycodone hcl tab 10 mg... 6 oxycodone hcl tab 15 mg... 6 oxycodone hcl tab 20 mg... 6 oxycodone hcl tab 30 mg... 6 oxycodone hcl tab 5 mg... 6 oxycodone w/ acetaminophen tab 10-325 mg... 6 oxycodone w/ acetaminophen tab 2.5-325 mg... 6 oxycodone w/ acetaminophen tab 5-325 mg... 6 oxycodone w/ acetaminophen tab 7.5-325 mg... 6 oxycodone-aspirin tab 4.8355-325 mg.. 6 oxycodone-ibuprofen tab 5-400 mg... 6 oxymorphone hcl tab 10 mg... 6 oxymorphone hcl tab 5 mg... 6 oxymorphone hcl tab er 12hr 10 mg... 7 oxymorphone hcl tab er 12hr 15 mg... 7 oxymorphone hcl tab er 12hr 20 mg... 7 oxymorphone hcl tab er 12hr 30 mg... 7 oxymorphone hcl tab er 12hr 40 mg... 7 oxymorphone hcl tab er 12hr 5 mg... 6 oxymorphone hcl tab er 12hr 7.5 mg... 7 oxytocin inj 10 unit/ml... 93 OZEMPIC INJ 2/1.5ML... 79 P pacerone tab 100mg... 41 166
pacerone tab 200mg... 41 pacerone tab 400mg... 41 paclitaxel iv conc 100 mg/16.7ml (6 mg/ml)... 25 paliperidone tab er 24hr 1.5 mg... 68 paliperidone tab er 24hr 3 mg... 68 paliperidone tab er 24hr 6 mg... 68 paliperidone tab er 24hr 9 mg... 68 palonosetron hcl iv soln 0.25 mg/5ml (base equivalent)... 97 PALONOSETRON INJ 0.25/2ML... 97 pamidronate disodium for inj 30 mg... 81 pamidronate disodium for inj 90 mg... 81 pamidronate disodium iv soln 3 mg/ml 81 pamidronate disodium iv soln 9 mg/ml 81 PAMIDRONATE INJ 6MG/ML... 81 PANRETIN GEL 0.1%... 129 pantoprazole sodium ec tab 20 mg (base equiv)... 102 pantoprazole sodium ec tab 40 mg (base equiv)... 102 pantoprazole sodium for iv soln 40 mg (base equiv)... 102 paricalcitol cap 1 mcg... 116 paricalcitol cap 2 mcg... 116 paricalcitol cap 4 mcg... 116 paricalcitol iv soln 2 mcg/ml... 116 paricalcitol iv soln 5 mcg/ml... 116 paromomycin sulfate cap 250 mg... 8 paroxetine hcl tab 10 mg... 61 paroxetine hcl tab 20 mg... 61 paroxetine hcl tab 30 mg... 61 paroxetine hcl tab 40 mg... 61 paroxetine hcl tab er 24hr 12.5 mg... 61 paroxetine hcl tab er 24hr 25 mg... 62 paroxetine hcl tab er 24hr 37.5 mg... 62 PASER GRA 4GM... 15 PAXIL SUS 10MG/5ML... 62 PEDIARIX INJ 0.5ML... 111 pediatric multiple vitamins w/ fl-fe drops 0.25-10 mg/ml... 112 pediatric multiple vitamins w/ fluoride soln 0.25 mg/ml... 112 pediatric multiple vitamins w/ fluoride soln 0.5 mg/ml... 112 PEDVAX HIB INJ... 111 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm... 99 peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm... 99 peg 3350-kcl-sod bicarb-nacl for soln 420 gm... 99 PEGANONE TAB 250MG... 56 PEGASYS INJ... 16 PEGASYS INJ 180MCG/M... 16 PEGASYS INJ PROCLICK... 16 PEN G PROC INJ 600000... 21 PENICILL GK/ INJ DEX 2MU... 21 PENICILL GK/ INJ DEX 3MU... 21 penicillin g potassium for inj 20000000 unit... 21 penicillin g sodium for inj 5000000 unit... 21 penicillin v potassium for soln 125 mg/5ml... 22 penicillin v potassium for soln 250 mg/5ml... 22 penicillin v potassium tab 250 mg... 22 penicillin v potassium tab 500 mg... 22 PENTAM 300 INJ 300MG... 10 pentoxifylline tab er 400 mg... 106 PERFOROMIST NEB 20MCG... 121 PERIKABIVEN EMU... 114 perindopril erbumine tab 2 mg... 38 perindopril erbumine tab 4 mg... 38 perindopril erbumine tab 8 mg... 38 periogard sol 0.12%... 130 periomed con 0.63%... 130 PERJETA INJ 420/14ML... 27 permethrin cream 5%... 129 perphenazine tab 16 mg... 68 perphenazine tab 2 mg... 68 perphenazine tab 4 mg... 68 perphenazine tab 8 mg... 68 perphenazine-amitriptyline tab 2-10 mg... 77 perphenazine-amitriptyline tab 2-25 mg... 77 perphenazine-amitriptyline tab 4-10 mg... 77 perphenazine-amitriptyline tab 4-25 mg... 77 167
perphenazine-amitriptyline tab 4-50 mg... 77 pfizerpen inj 20mu... 22 phenadoz sup 12.5mg... 97 phenelzine sulfate tab 15 mg... 62 PHENOBARB INJ 65MG/ML... 56 phenobarbital elixir 20 mg/5ml... 56 phenobarbital sodium inj 130 mg/ml... 56 phenobarbital tab 100 mg... 57 phenobarbital tab 15 mg... 56 phenobarbital tab 16.2 mg... 56 phenobarbital tab 30 mg... 56 phenobarbital tab 32.4 mg... 56 phenobarbital tab 60 mg... 56 phenobarbital tab 64.8 mg... 56 phenobarbital tab 97.2 mg... 57 phenoxybenzamine hcl cap 10 mg... 50 phenytoin chew tab 50 mg... 57 phenytoin sodium extended cap 100 mg... 57 phenytoin sodium extended cap 200 mg... 57 phenytoin sodium extended cap 300 mg... 57 phenytoin sodium inj 50 mg/ml... 57 phenytoin susp 125 mg/5ml... 57 philith tab 0.4-35... 86 PHOSPHOLINE SOL 0.125%OP... 119 physiolyte sol... 129 physiosol sol irrigat... 129 PICATO GEL 0.015%... 129 PICATO GEL 0.05%... 129 pilocarpine hcl ophth soln 1%... 119 pilocarpine hcl ophth soln 2%... 119 pilocarpine hcl ophth soln 4%... 119 pilocarpine hcl tab 5 mg... 130 pilocarpine hcl tab 7.5 mg... 130 pimozide tab 1 mg... 68 pimozide tab 2 mg... 68 pimtrea tab... 86 pindolol tab 10 mg... 45 pindolol tab 5 mg... 45 pioglitazone hcl tab 15 mg (base equiv)... 80 pioglitazone hcl tab 30 mg (base equiv)... 80 pioglitazone hcl tab 45 mg (base equiv)... 80 pioglitazone hcl-metformin hcl tab 15-500 mg... 80 pioglitazone hcl-metformin hcl tab 15-850 mg... 80 piperacillin sod-tazobactam na for inj 3.375 gm (3-0.375 gm)... 22 piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm)... 22 piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm)... 22 piperacillin sod-tazobactam sod for inj 40.5 gm (36-4.5 gm)... 22 pirmella tab 1/35... 86 pirmella tab 7/7/7... 86 piroxicam cap 10 mg... 2 piroxicam cap 20 mg... 2 PLASMA-LYTE INJ -148... 116 PLASMA-LYTE INJ -A... 116 plenamine inj 15%... 114 podofilox soln 0.5%... 129 polyethylene glycol 3350 oral powder. 99 polymyxin b sulfate for inj 500000 unit 10 polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%... 118 POMALYST CAP 1MG... 30 POMALYST CAP 2MG... 30 POMALYST CAP 3MG... 30 POMALYST CAP 4MG... 30 portia-28 tab... 86 PORTRAZZA INJ 800/50ML... 27 pot chloride tab 25meq ef... 112 potassium acetate inj 2 meq/ml... 112 potassium chloride 20 meq/l (0.15%) in dextrose 5% inj... 116 potassium chloride 30 meq/l (0.224%) in dextrose 5% inj... 116 potassium chloride 40 meq/l (0.3%) in dextrose 5% inj... 116 potassium chloride cap er 10 meq... 112 potassium chloride cap er 8 meq... 112 potassium chloride inj 10 meq/100ml 116 potassium chloride inj 2 meq/ml... 116 potassium chloride inj 20 meq/100ml 116 potassium chloride inj 30 meq/100ml 116 168
potassium chloride inj 40 meq/100ml 116 potassium chloride microencapsulated crys er tab 10 meq... 112 potassium chloride microencapsulated crys er tab 20 meq... 112 potassium chloride oral soln 10% (20 meq/15ml)... 113 potassium chloride oral soln 20% (40 meq/15ml)... 113 potassium chloride powder packet 20 meq... 113 potassium chloride tab er 10 meq... 113 potassium chloride tab er 20 meq (1500 mg)... 113 potassium chloride tab er 8 meq (600 mg)... 113 potassium citrate tab er 10 meq (1080 mg)... 102 potassium citrate tab er 15 meq (1620 mg)... 102 potassium citrate tab er 5 meq (540 mg)... 102 potassium phosphates inj 15 mm/5ml (phos) 22 meq/5ml (k)... 113 potassium phosphates inj 150 mm/50ml (phos) 220 meq/50ml (k)... 113 potassium phosphates inj 45 mm/15ml (phos) 66 meq/15ml (k)... 113 PRADAXA CAP 110MG... 104 PRADAXA CAP 150MG... 104 PRADAXA CAP 75MG... 104 PRALUENT INJ 150MG/ML... 43 PRALUENT INJ 75MG/ML... 43 pramipexole dihydrochloride tab 0.125 mg... 64 pramipexole dihydrochloride tab 0.25 mg... 64 pramipexole dihydrochloride tab 0.5 mg... 64 pramipexole dihydrochloride tab 0.75 mg... 64 pramipexole dihydrochloride tab 1 mg. 64 pramipexole dihydrochloride tab 1.5 mg... 64 prasugrel hcl tab 10 mg (base equiv) 107 prasugrel hcl tab 5 mg (base equiv).. 107 pravastatin sodium tab 10 mg... 42 pravastatin sodium tab 20 mg... 42 pravastatin sodium tab 40 mg... 42 pravastatin sodium tab 80 mg... 42 prazosin hcl cap 1 mg... 39 prazosin hcl cap 2 mg... 39 prazosin hcl cap 5 mg... 39 PRED MILD SUS 0.12% OP... 118 PRED SOD PHO SOL 1% OP... 118 PRED-G S.O.P OIN OP... 117 PRED-G SUS OP... 117 prednicarbate cream 0.1%... 128 prednicarbate oint 0.1%... 128 prednisolone acetate ophth susp 1% 118 prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base)... 91 prednisolone sodium phosphate oral soln 25 mg/5ml (base eq)... 91 prednisolone syrup 15 mg/5ml (usp solution equivalent)... 91 PREDNISONE CON 5MG/ML... 91 prednisone oral soln 5 mg/5ml... 91 prednisone tab 1 mg... 91 prednisone tab 10 mg... 91 prednisone tab 2.5 mg... 91 prednisone tab 20 mg... 91 prednisone tab 5 mg... 91 prednisone tab 50 mg... 91 prednisone tab therapy pack 10 mg (21)... 91 prednisone tab therapy pack 10 mg (48)... 91 prednisone tab therapy pack 5 mg (21)... 91 prednisone tab therapy pack 5 mg (48)... 91 PREMARIN INJ 25MG... 89 PREMARIN VAG CRE 0.625MG... 89 PREMASOL SOL 10%... 114 prevalite pow 4gm pk... 43 previfem tab... 86 PREZCOBIX TAB 800-150... 14 PREZISTA SUS 100MG/ML... 13 PREZISTA TAB 150MG... 13 PREZISTA TAB 600MG... 13 PREZISTA TAB 75MG... 13 169
PREZISTA TAB 800MG... 13 PRIALT INJ 100MCG... 1 PRIALT INJ 25MCG/ML... 1 PRIFTIN TAB 150MG... 15 PRIMAQUINE TAB 26.3MG... 12 primidone tab 250 mg... 57 primidone tab 50 mg... 57 PRIVIGEN INJ 20GRAMS... 109 probenecid tab 500 mg... 1 procainamide hcl inj 100 mg/ml... 41 procainamide hcl inj 500 mg/ml... 41 PROCALAMINE INJ 3%... 114 prochlorperazine edisylate inj 5 mg/ml 97 prochlorperazine maleate tab 10 mg (base equivalent)... 97 prochlorperazine maleate tab 5 mg (base equivalent)... 97 prochlorperazine suppos 25 mg... 97 PROCRIT INJ 10000/ML... 106 PROCRIT INJ 2000/ML... 105 PROCRIT INJ 20000/ML... 106 PROCRIT INJ 3000/ML... 106 PROCRIT INJ 4000/ML... 106 PROCRIT INJ 40000/ML... 106 procto-med cre hc 2.5%... 129 procto-pak cre 1%... 129 proctosol hc cre 2.5%... 129 proctozone cre -hc 2.5%... 129 progesterone micronized cap 100 mg.. 95 progesterone micronized cap 200 mg.. 95 PROGLYCEM SUS 50MG/ML... 91 PROGRAF INJ 5MG/ML... 110 PROLASTIN-C INJ 1000MG... 123 PROLEUKIN INJ 22MU... 35 PROLIA SOL 60MG/ML... 93 PROMACTA TAB 12.5MG... 106 PROMACTA TAB 25MG... 106 PROMACTA TAB 50MG... 106 PROMACTA TAB 75MG... 106 promethazine hcl inj 25 mg/ml... 97 promethazine hcl inj 50 mg/ml... 97 promethazine hcl suppos 12.5 mg... 97 promethazine hcl suppos 25 mg... 97 promethazine hcl suppos 50 mg... 98 promethazine hcl syrup 6.25 mg/5ml.. 98 promethazine hcl tab 12.5 mg... 98 promethazine hcl tab 25 mg... 98 promethazine hcl tab 50 mg... 98 promethegan sup 25mg... 98 promethegan sup 50mg... 98 propafenone hcl cap er 12hr 225 mg.. 41 propafenone hcl cap er 12hr 325 mg.. 41 propafenone hcl cap er 12hr 425 mg.. 41 propafenone hcl tab 150 mg... 41 propafenone hcl tab 225 mg... 41 propafenone hcl tab 300 mg... 41 propantheline bromide tab 15 mg... 98 propranolol & hydrochlorothiazide tab 40-25 mg... 44 propranolol & hydrochlorothiazide tab 80-25 mg... 44 propranolol hcl cap er 24hr 120 mg... 45 propranolol hcl cap er 24hr 160 mg... 45 propranolol hcl cap er 24hr 60 mg... 45 propranolol hcl cap er 24hr 80 mg... 45 propranolol hcl inj 1 mg/ml... 45 propranolol hcl oral soln 20 mg/5ml... 45 propranolol hcl oral soln 40 mg/5ml... 45 propranolol hcl tab 10 mg... 45 propranolol hcl tab 20 mg... 45 propranolol hcl tab 40 mg... 45 propranolol hcl tab 60 mg... 45 propranolol hcl tab 80 mg... 45 propylthiouracil tab 50 mg... 95 PROQUAD INJ... 111 PROSOL INJ 20%... 114 protriptyline hcl tab 10 mg... 62 protriptyline hcl tab 5 mg... 62 PULMICORT INH 180MCG... 123 PULMICORT INH 90MCG... 123 PULMOZYME SOL 1MG/ML... 123 PURIXAN SUS 20MG/ML... 25 pyrazinamide tab 500 mg... 15 pyridostigmine bromide tab 60 mg... 74 Q QUADRACEL INJ... 111 quasense tab... 86 quetiapine fumarate tab 100 mg... 68 quetiapine fumarate tab 200 mg... 68 quetiapine fumarate tab 25 mg... 68 quetiapine fumarate tab 300 mg... 68 quetiapine fumarate tab 400 mg... 68 170
quetiapine fumarate tab 50 mg... 68 quetiapine fumarate tab er 24hr 150 mg... 68 quetiapine fumarate tab er 24hr 200 mg... 68 quetiapine fumarate tab er 24hr 300 mg... 68 quetiapine fumarate tab er 24hr 400 mg... 68 quetiapine fumarate tab er 24hr 50 mg... 68 quinapril hcl tab 10 mg... 38 quinapril hcl tab 20 mg... 38 quinapril hcl tab 40 mg... 38 quinapril hcl tab 5 mg... 38 quinapril-hydrochlorothiazide tab 10-12.5 mg... 37 quinapril-hydrochlorothiazide tab 20-12.5 mg... 37 quinapril-hydrochlorothiazide tab 20-25 mg... 37 QUINIDINE GL INJ 80MG/ML... 41 quinidine sulfate tab 200 mg... 41 quinidine sulfate tab 300 mg... 41 quinine sulfate cap 324 mg... 12 R RABAVERT INJ... 111 raloxifene hcl tab 60 mg... 93 ramipril cap 1.25 mg... 38 ramipril cap 10 mg... 38 ramipril cap 2.5 mg... 38 ramipril cap 5 mg... 38 RANEXA TAB 1000MG... 50 RANEXA TAB 500MG... 50 ranitidine hcl cap 150 mg... 98 ranitidine hcl cap 300 mg... 99 ranitidine hcl inj 50 mg/2ml (25 mg/ml)... 99 ranitidine hcl syrup 15 mg/ml (75 mg/5ml)... 99 ranitidine hcl tab 150 mg... 99 ranitidine hcl tab 300 mg... 99 RAPAMUNE SOL 1MG/ML... 110 rasagiline mesylate tab 0.5 mg (base equiv)... 64 rasagiline mesylate tab 1 mg (base equiv)... 64 RASUVO INJ 10MG... 108 RASUVO INJ 12.5MG... 108 RASUVO INJ 15MG... 108 RASUVO INJ 17.5MG... 108 RASUVO INJ 20MG... 108 RASUVO INJ 22.5MG... 108 RASUVO INJ 25MG... 108 RASUVO INJ 30MG... 108 RASUVO INJ 7.5MG... 108 RAVICTI LIQ 1.1GM/ML... 88 REBETOL SOL 40MG/ML... 16 reclipsen tab... 86 RECOMBIVA HB INJ 10MCG/ML... 111 RECOMBIVA HB INJ 5MCG/0.5... 111 RECOMBIVA-HB INJ 40MCG/ML... 111 REGONOL INJ 5MG/ML... 74 REGRANEX GEL 0.01%... 129 RELENZA MIS DISKHALE... 16 RELISTOR INJ 12/0.6ML... 100 RELISTOR INJ 8/0.4ML... 100 RELISTOR TAB 150MG... 100 REMICADE INJ 100MG... 108 REMODULIN INJ 10MG/ML... 51 REMODULIN INJ 1MG/ML... 51 REMODULIN INJ 2.5MG/ML... 51 REMODULIN INJ 5MG/ML... 51 repaglinide tab 0.5 mg... 80 repaglinide tab 1 mg... 80 repaglinide tab 2 mg... 80 REPATHA INJ 140MG/ML... 43 REPATHA PUSH INJ 420/3.5... 43 REPATHA SURE INJ 140MG/ML... 44 RESCRIPTOR TAB 100 MG... 13 RESCRIPTOR TAB 200MG... 13 RESTASIS EMU 0.05%... 119 RETROVIR INJ 10MG/ML... 13 REVATIO SUS 10MG/ML... 51 REVLIMID CAP 10MG... 30 REVLIMID CAP 15MG... 30 REVLIMID CAP 2.5MG... 30 REVLIMID CAP 20MG... 30 REVLIMID CAP 25MG... 30 REVLIMID CAP 5MG... 30 REXULTI TAB 0.25MG... 68 REXULTI TAB 0.5MG... 68 171
REXULTI TAB 1MG... 68 REXULTI TAB 2MG... 68 REXULTI TAB 3MG... 68 REXULTI TAB 4MG... 68 REYATAZ CAP 150MG... 13 REYATAZ CAP 200MG... 13 REYATAZ CAP 300MG... 13 REYATAZ POW 50MG... 13 ribasphere cap 200mg... 16 ribasphere tab 200mg... 16 ribasphere tab 400mg... 16 ribasphere tab 600mg... 16 ribavirin cap 200 mg... 16 ribavirin tab 200 mg... 16 RIDAURA CAP 3MG... 108 rifabutin cap 150 mg... 15 RIFAMATE CAP... 15 rifampin cap 150 mg... 15 rifampin cap 300 mg... 15 rifampin for inj 600 mg... 15 RIFATER TAB... 15 riluzole tab 50 mg... 74 rimantadine hydrochloride tab 100 mg 16 ringer's solution... 116 ringer's solution for irrigation... 129 RIOMET SOL... 80 risedronate sodium tab 150 mg... 81 risedronate sodium tab delayed release 35 mg... 81 risedronate tab 35mg... 81 RISPERDAL INJ 12.5MG... 69 RISPERDAL INJ 25MG... 69 RISPERDAL INJ 37.5MG... 69 RISPERDAL INJ 50MG... 69 risperidone orally disintegrating tab 0.25 mg... 69 risperidone orally disintegrating tab 0.5 mg... 69 risperidone orally disintegrating tab 1 mg... 69 risperidone orally disintegrating tab 2 mg... 69 risperidone orally disintegrating tab 3 mg... 69 risperidone orally disintegrating tab 4 mg... 69 risperidone soln 1 mg/ml... 69 risperidone tab 0.25 mg... 69 risperidone tab 0.5 mg... 69 risperidone tab 1 mg... 69 risperidone tab 2 mg... 69 risperidone tab 3 mg... 69 risperidone tab 4 mg... 69 ritonavir tab 100 mg... 13 RITUXAN INJ 100MG... 27 RITUXAN INJ 500MG... 27 rivastigmine tartrate cap 1.5 mg... 58 rivastigmine tartrate cap 3 mg... 58 rivastigmine tartrate cap 4.5 mg... 58 rivastigmine tartrate cap 6 mg... 58 rivastigmine td patch 24hr 13.3 mg/24hr... 58 rivastigmine td patch 24hr 4.6 mg/24hr... 58 rivastigmine td patch 24hr 9.5 mg/24hr... 58 rizatriptan benzoate oral disintegrating tab 10 mg (base eq)... 73 rizatriptan benzoate oral disintegrating tab 5 mg (base eq)... 73 rizatriptan benzoate tab 10 mg (base equivalent)... 73 rizatriptan benzoate tab 5 mg (base equivalent)... 73 ropinirole hydrochloride tab 0.25 mg.. 64 ropinirole hydrochloride tab 0.5 mg... 64 ropinirole hydrochloride tab 1 mg... 64 ropinirole hydrochloride tab 2 mg... 64 ropinirole hydrochloride tab 3 mg... 64 ropinirole hydrochloride tab 4 mg... 64 ropinirole hydrochloride tab 5 mg... 64 ropivacaine hcl inj 10 mg/ml... 8 ropivacaine hcl inj 2 mg/ml... 7 ropivacaine hcl inj 5 mg/ml... 7 ropivacaine hcl inj 7.5 mg/ml... 8 rosadan cre 0.75%... 129 rosadan gel 0.75%... 129 rosuvastatin calcium tab 10 mg... 42 rosuvastatin calcium tab 20 mg... 42 rosuvastatin calcium tab 40 mg... 42 rosuvastatin calcium tab 5 mg... 42 ROTARIX SUS... 111 172
ROTATEQ SOL... 111 roweepra tab 1000mg... 57 roweepra tab 500mg... 57 roweepra tab 750mg... 57 roweepra xr tab 500mg xr... 57 roweepra xr tab 750mg xr... 57 ROZEREM TAB 8MG... 72 RUBRACA TAB 200MG... 27 RUBRACA TAB 250MG... 27 RUBRACA TAB 300MG... 27 RUCONEST INJ 2100UNIT... 106 RYDAPT CAP 25MG... 33 S SABRIL TAB 500MG... 57 SAIZEN INJ 5MG... 92 SAIZEN INJ 8.8MG... 92 SAIZENPREP INJ 8.8MG... 92 salsalate tab 500 mg... 2 salsalate tab 750 mg... 2 SAMSCA TAB 15MG... 94 SAMSCA TAB 30MG... 94 SANCUSO DIS 3.1MG... 98 SANDOSTATIN KIT LAR 10MG... 94 SANDOSTATIN KIT LAR 20MG... 94 SANDOSTATIN KIT LAR 30MG... 94 SANTYL OIN 250/GM... 129 SAPHRIS SUB 10MG... 69 SAPHRIS SUB 2.5MG... 69 SAPHRIS SUB 5MG... 69 SAVELLA MIS TITR PAK... 74 SAVELLA TAB 100MG... 74 SAVELLA TAB 12.5MG... 74 SAVELLA TAB 25MG... 74 SAVELLA TAB 50MG... 74 scopolamine td patch 72hr 1 mg/3days... 98 selegiline hcl cap 5 mg... 64 selegiline hcl tab 5 mg... 64 selenium sulfide lotion 2.5%... 126 SELZENTRY SOL 20MG/ML... 13 SELZENTRY TAB 150MG... 13 SELZENTRY TAB 25MG... 13 SELZENTRY TAB 300MG... 13 SELZENTRY TAB 75MG... 13 SENSIPAR TAB 30MG... 81 SENSIPAR TAB 60MG... 81 SENSIPAR TAB 90MG... 81 SEREVENT DIS AER 50MCG... 121 SEROSTIM INJ 4MG... 92 SEROSTIM INJ 5MG... 92 SEROSTIM INJ 6MG... 92 sertraline hcl oral concentrate for solution 20 mg/ml... 62 sertraline hcl tab 100 mg... 62 sertraline hcl tab 25 mg... 62 sertraline hcl tab 50 mg... 62 setlakin tab... 86 sevelamer carbonate packet 0.8 gm... 95 sevelamer carbonate packet 2.4 gm... 95 sevelamer carbonate tab 800 mg... 95 sf 5000 plus cre 1.1%... 130 sharobel tab 0.35mg... 86 SHINGRIX INJ 50MCG... 111 SIGNIFOR INJ 0.3MG/ML... 94 SIGNIFOR INJ 0.6MG/ML... 94 SIGNIFOR INJ 0.9MG/ML... 94 SIGNIFOR LAR INJ 20MG... 94 SIGNIFOR LAR INJ 40MG... 94 SIGNIFOR LAR INJ 60MG... 94 sildenafil citrate tab 20 mg... 51 SILENOR TAB 3MG... 72 SILENOR TAB 6MG... 72 silver sulfadiazine cream 1%... 125 SIMBRINZA SUS 1-0.2%... 119 SIMULECT INJ 10MG... 110 SIMULECT INJ 20MG... 110 simvastatin tab 10 mg... 42 simvastatin tab 20 mg... 42 simvastatin tab 40 mg... 42 simvastatin tab 5 mg... 42 simvastatin tab 80 mg... 42 sirolimus tab 0.5 mg... 110 sirolimus tab 1 mg... 110 sirolimus tab 2 mg... 110 SIRTURO TAB 100MG... 15 SIVEXTRO INJ 200MG... 10 SIVEXTRO TAB 200MG... 10 SOD LACTATE INJ 5MEQ/ML... 113 sodium acetate inj 2 meq/ml... 113 sodium acetate inj 4 meq/ml... 113 sodium bicarbonate inj 7.5%... 113 sodium bicarbonate inj 8.4%... 113 173
sodium chloride inj 0.45%... 116 sodium chloride inj 2.5 meq/ml (14.6%)... 113 sodium chloride inj 3%... 116 sodium chloride inj 4 meq/ml (23.4%)... 116 sodium chloride inj 5%... 116 sodium chloride irrigation soln 0.9%. 129 sodium chloride iv soln 0.9%... 116 sodium fluoride 2.2 mg... 113 sodium phenylbutyrate oral powder 3 gm/teaspoonful... 88 sodium phenylbutyrate tab 500 mg... 88 sodium polystyrene sulfonate powder.. 82 SOLTAMOX SOL 10MG/5ML... 29 SOLU-CORTEF INJ 1000MG... 91 SOLU-CORTEF INJ 100MG... 91 SOLU-CORTEF INJ 250MG... 91 SOLU-CORTEF INJ 500MG... 91 SOLU-MEDROL INJ 1000MG... 91 SOLU-MEDROL INJ 125MG... 91 SOLU-MEDROL INJ 2GM... 91 SOLU-MEDROL INJ 40MG... 91 SOLU-MEDROL INJ 500MG... 91 SOMATULINE INJ 120/.5ML... 94 SOMATULINE INJ 60/0.2ML... 94 SOMATULINE INJ 90/0.3ML... 94 SOMAVERT INJ 10MG... 94 SOMAVERT INJ 15MG... 94 SOMAVERT INJ 20MG... 94 SOMAVERT INJ 25MG... 94 SOMAVERT INJ 30MG... 94 sorine tab 120mg... 41 sorine tab 160mg... 41 sorine tab 240mg... 41 sorine tab 80mg... 41 sotalol hcl (afib/afl) tab 120 mg... 41 sotalol hcl tab 160 mg... 42 sotalol hcl tab 240 mg... 42 sotalol hcl tab 80 mg... 42 SOVALDI TAB 400MG... 16 SPIRIVA AER 1.25MCG... 120 SPIRIVA CAP HANDIHLR... 120 SPIRIVA SPR 2.5MCG... 120 spironolactone & hydrochlorothiazide tab 25-25 mg... 49 spironolactone tab 100 mg... 38 spironolactone tab 25 mg... 38 spironolactone tab 50 mg... 38 sprintec 28 tab 28 day... 86 SPRITAM TAB 1000MG... 57 SPRITAM TAB 250MG... 57 SPRITAM TAB 500MG... 57 SPRITAM TAB 750MG... 57 SPRYCEL TAB 100MG... 33 SPRYCEL TAB 140MG... 33 SPRYCEL TAB 20MG... 33 SPRYCEL TAB 50MG... 33 SPRYCEL TAB 70MG... 33 SPRYCEL TAB 80MG... 33 sps sus 15gm/60... 82 sronyx tab... 86 ssd cre 1%... 125 stavudine cap 15 mg... 13 stavudine cap 20 mg... 13 stavudine cap 30 mg... 13 stavudine cap 40 mg... 13 STIMATE SOL 1.5MG/ML... 96 STIOLTO AER 2.5-2.5... 120 STIVARGA TAB 40MG... 33 STRENSIQ INJ 18/0.45... 94 STRENSIQ INJ 28/0.7ML... 94 STRENSIQ INJ 40MG/ML... 94 STRENSIQ INJ 80/0.8ML... 94 streptomycin sulfate for inj 1 gm... 8 STRIANT MIS 30MG... 77 STRIBILD TAB... 14 STRIVERDI AER 2.5MCG... 121 SUBOXONE MIS 12-3MG... 77 SUBOXONE MIS 2-0.5MG... 77 SUBOXONE MIS 4-1MG... 77 SUBOXONE MIS 8-2MG... 77 SUBSYS SPR 100MCG... 7 SUBSYS SPR 1200MCG... 7 SUBSYS SPR 1600MCG... 7 SUBSYS SPR 200MCG... 7 SUBSYS SPR 400MCG... 7 SUBSYS SPR 600MCG... 7 SUBSYS SPR 800MCG... 7 SUCRAID SOL 8500/ML... 100 sucralfate tab 1 gm... 100 sulfacetamide sodium lotion 10% (acne) 174
... 124 sulfacetamide sodium ophth oint 10%... 118 sulfacetamide sodium ophth soln 10%... 118 sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%... 117 SULFADIAZINE TAB 500MG... 8 sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml... 10 sulfamethoxazole-trimethoprim susp 200-40 mg/5ml... 10 sulfamethoxazole-trimethoprim tab 400-80 mg... 10 sulfamethoxazole-trimethoprim tab 800-160 mg... 10 SULFAMYLON CRE 85MG/GM... 125 sulfasalazine tab 500 mg... 99 sulfasalazine tab delayed release 500 mg... 99 sulindac tab 150 mg... 2 sulindac tab 200 mg... 2 sumatriptan nasal spray 20 mg/act... 73 sumatriptan nasal spray 5 mg/act... 73 sumatriptan succinate inj 6 mg/0.5ml. 73 sumatriptan succinate solution autoinjector 4 mg/0.5ml... 73 sumatriptan succinate solution autoinjector 6 mg/0.5ml... 73 sumatriptan succinate solution cartridge 4 mg/0.5ml... 73 sumatriptan succinate tab 100 mg... 73 sumatriptan succinate tab 25 mg... 73 sumatriptan succinate tab 50 mg... 73 SUPRAX CAP 400MG... 18 SUPRAX CHW 100MG... 18 SUPRAX CHW 200MG... 18 SUPREP BOWEL SOL PREP KIT... 99 SUSTIVA CAP 200MG... 13 SUSTIVA TAB 600MG... 13 SUTENT CAP 12.5MG... 33 SUTENT CAP 25MG... 33 SUTENT CAP 37.5MG... 34 SUTENT CAP 50MG... 34 syeda tab 3-0.03mg... 86 SYLATRON KIT 200MCG... 35 SYLATRON KIT 300MCG... 35 SYLATRON KIT 600MCG... 35 SYLVANT SOL 100MG... 30 SYLVANT SOL 400MG... 30 SYMBICORT AER 160-4.5... 123 SYMBICORT AER 80-4.5... 123 SYMFI LO TAB... 14 SYMFI TAB... 14 SYMLINPEN 60 INJ 1000MCG... 79 SYMLNPEN 120 INJ 1000MCG... 79 SYNAGIS INJ 100MG/ML... 111 SYNAGIS INJ 50MG... 111 SYNAREL SOL 2MG/ML... 87 SYNERCID INJ 500MG... 10 SYNJARDY TAB... 80 SYNJARDY TAB 12.5-500... 81 SYNJARDY TAB 5-1000MG... 80 SYNJARDY TAB 5-500MG... 80 SYNJARDY XR TAB... 81 SYNJARDY XR TAB 10-1000... 81 SYNJARDY XR TAB 25-1000... 81 SYNJARDY XR TAB 5-1000MG... 81 SYNRIBO INJ 3.5MG... 35 SYNTHROID TAB 100MCG... 96 SYNTHROID TAB 112MCG... 96 SYNTHROID TAB 125MCG... 96 SYNTHROID TAB 137MCG... 96 SYNTHROID TAB 150MCG... 96 SYNTHROID TAB 175MCG... 96 SYNTHROID TAB 200MCG... 96 SYNTHROID TAB 25MCG... 95 SYNTHROID TAB 300MCG... 96 SYNTHROID TAB 50MCG... 95 SYNTHROID TAB 75MCG... 96 SYNTHROID TAB 88MCG... 96 SYPRINE CAP 250MG... 82 T TABLOID TAB 40MG... 25 tacrolimus cap 0.5 mg... 110 tacrolimus cap 1 mg... 110 tacrolimus cap 5 mg... 110 tacrolimus oint 0.03%... 129 tacrolimus oint 0.1%... 129 TAFINLAR CAP 50MG... 34 TAFINLAR CAP 75MG... 34 TAGRISSO TAB 40MG... 34 175
TAGRISSO TAB 80MG... 34 TALWIN INJ 30MG/ML... 7 tamoxifen citrate tab 10 mg (base equivalent)... 29 tamoxifen citrate tab 20 mg (base equivalent)... 29 tamsulosin hcl cap 0.4 mg... 102 TARCEVA TAB 100MG... 34 TARCEVA TAB 150MG... 34 TARCEVA TAB 25MG... 34 TARGRETIN GEL 1%... 129 tarina fe tab 1/20... 86 TASIGNA CAP 150MG... 34 TASIGNA CAP 200MG... 34 TASIGNA CAP 50MG... 34 tazarotene cream 0.1%... 126 TAZORAC CRE 0.05%... 126 TAZORAC GEL 0.05%... 126 TAZORAC GEL 0.1%... 126 taztia xt cap 120mg/24... 47 taztia xt cap 180mg/24... 47 taztia xt cap 240mg/24... 47 taztia xt cap 300mg/24... 47 taztia xt cap 360mg/24... 47 TECENTRIQ INJ 1200/20... 27 TEFLARO INJ 400MG... 18 TEFLARO INJ 600MG... 18 TEKTURNA HCT TAB 150-12.5... 48 TEKTURNA HCT TAB 150-25MG... 48 TEKTURNA HCT TAB 300-12.5... 48 TEKTURNA HCT TAB 300-25MG... 48 TEKTURNA TAB 150MG... 48 TEKTURNA TAB 300MG... 48 telmisartan tab 20 mg... 40 telmisartan tab 40 mg... 40 telmisartan tab 80 mg... 40 telmisartan-amlodipine tab 40-10 mg.. 39 telmisartan-amlodipine tab 40-5 mg... 39 telmisartan-amlodipine tab 80-10 mg.. 40 telmisartan-amlodipine tab 80-5 mg... 39 telmisartan-hydrochlorothiazide tab 40-12.5 mg... 40 telmisartan-hydrochlorothiazide tab 80-12.5 mg... 40 telmisartan-hydrochlorothiazide tab 80-25 mg... 40 temazepam cap 15 mg... 72 temazepam cap 22.5 mg... 72 temazepam cap 30 mg... 72 temazepam cap 7.5 mg... 72 TEMODAR INJ 100MG... 23 TENIVAC INJ 5-2LF... 111 tenofovir disoproxil fumarate tab 300 mg... 13 terazosin hcl cap 1 mg (base equivalent)... 39 terazosin hcl cap 10 mg (base equivalent)... 39 terazosin hcl cap 2 mg (base equivalent)... 39 terazosin hcl cap 5 mg (base equivalent)... 39 terbinafine hcl tab 250 mg... 11 terbutaline sulfate inj 1 mg/ml... 121 terbutaline sulfate tab 2.5 mg... 121 terbutaline sulfate tab 5 mg... 121 terconazole vaginal cream 0.4%... 103 terconazole vaginal cream 0.8%... 103 terconazole vaginal suppos 80 mg... 103 testosterone cypionate im inj in oil 100 mg/ml... 77 testosterone cypionate im inj in oil 200 mg/ml... 77 testosterone enanthate im inj in oil 200 mg/ml... 78 testosterone td gel 12.5 mg/act (1%). 78 testosterone td gel 25 mg/2.5gm (1%)78 testosterone td gel 50 mg/5gm (1%).. 78 TET/DIP TOX INJ 2-2 LF... 111 tetrabenazine tab 12.5 mg... 74 tetrabenazine tab 25 mg... 74 tetracycline hcl cap 250 mg... 22 tetracycline hcl cap 500 mg... 22 THALOMID CAP 100MG... 30 THALOMID CAP 150MG... 30 THALOMID CAP 200MG... 30 THALOMID CAP 50MG... 30 theophylline soln 80 mg/15ml... 124 theophylline tab er 12hr 100 mg... 124 theophylline tab er 12hr 200 mg... 124 theophylline tab er 12hr 300 mg... 124 theophylline tab er 24hr 400 mg... 124 176
theophylline tab er 24hr 600 mg... 124 THERACYS INJ... 35 THIOLA TAB 100MG... 102 thioridazine hcl tab 10 mg... 69 thioridazine hcl tab 100 mg... 69 thioridazine hcl tab 25 mg... 69 thioridazine hcl tab 50 mg... 69 thiotepa for inj 15 mg... 23 thiothixene cap 1 mg... 69 thiothixene cap 10 mg... 69 thiothixene cap 2 mg... 69 thiothixene cap 5 mg... 69 THYMOGLOBULN INJ 25MG... 110 tiagabine hcl tab 12 mg... 57 tiagabine hcl tab 16 mg... 57 tiagabine hcl tab 2 mg... 57 tiagabine hcl tab 4 mg... 57 TICE BCG INJ... 35 ticlopidine hcl tab 250 mg... 107 tigecycline for iv soln 50 mg... 10 tilia fe tab... 86 timolol maleate ophth gel forming soln 0.25%... 119 timolol maleate ophth gel forming soln 0.5%... 119 timolol maleate ophth soln 0.25%... 119 timolol maleate ophth soln 0.5%... 119 timolol maleate tab 10 mg... 45 timolol maleate tab 20 mg... 45 timolol maleate tab 5 mg... 45 tinidazole tab 250 mg... 10 tinidazole tab 500 mg... 10 TIVICAY TAB 10MG... 13 TIVICAY TAB 25MG... 13 TIVICAY TAB 50MG... 13 tizanidine hcl tab 2 mg (base equivalent)... 75 tizanidine hcl tab 4 mg (base equivalent)... 75 TOBI PODHALR CAP 28MG... 8 TOBRADEX OIN 0.3-0.1%... 117 tobramycin nebu soln 300 mg/5ml... 8 tobramycin ophth soln 0.3%... 118 tobramycin sulfate inj 10 mg/ml (base equivalent)... 8 tobramycin sulfate inj 80 mg/2ml (40 mg/ml) (base equiv)... 8 tobramycin-dexamethasone ophth susp 0.3-0.1%... 117 TOBREX OIN 0.3% OP... 118 tolazamide tab 250 mg... 81 tolazamide tab 500 mg... 81 tolbutamide tab 500 mg... 81 tolmetin sodium cap 400 mg... 2 tolmetin sodium tab 200 mg... 2 tolmetin sodium tab 600 mg... 2 tolterodine tartrate cap er 24hr 2 mg 102 tolterodine tartrate cap er 24hr 4 mg 102 tolterodine tartrate tab 1 mg... 102 tolterodine tartrate tab 2 mg... 102 topiramate sprinkle cap 15 mg... 57 topiramate sprinkle cap 25 mg... 57 topiramate tab 100 mg... 57 topiramate tab 200 mg... 57 topiramate tab 25 mg... 57 topiramate tab 50 mg... 57 toposar inj 1gm/50ml... 36 topotecan hcl for inj 4 mg... 36 TORISEL SOL 25MG/ML... 27 torsemide tab 10 mg... 49 torsemide tab 100 mg... 49 torsemide tab 20 mg... 49 torsemide tab 5 mg... 49 TOUJEO SOLO INJ 300IU/ML... 79 tpn electrol inj... 113 TRACLEER TAB 125MG... 52 TRACLEER TAB 32MG... 51 TRACLEER TAB 62.5MG... 52 TRADJENTA TAB 5MG... 81 tramadol hcl tab 50 mg... 3 tramadol-acetaminophen tab 37.5-325 mg... 3 trandolapril tab 1 mg... 38 trandolapril tab 2 mg... 38 trandolapril tab 4 mg... 38 tranexamic acid iv soln 1000 mg/10ml (100 mg/ml)... 106 tranexamic acid tab 650 mg... 106 tranylcypromine sulfate tab 10 mg... 62 TRAVASOL INJ 10%... 114 TRAVATAN Z DRO 0.004%... 119 trazodone hcl tab 100 mg... 62 177
trazodone hcl tab 150 mg... 62 trazodone hcl tab 300 mg... 62 trazodone hcl tab 50 mg... 62 TREANDA INJ 100MG... 23 TREANDA INJ 25MG... 23 TRECATOR TAB 250MG... 15 TRELEGY AER ELLIPTA... 120 TRELSTAR MIX INJ 11.25MG... 29 TRELSTAR MIX INJ 22.5MG... 29 TRELSTAR MIX INJ 3.75MG... 29 TRESIBA FLEX INJ 100UNIT... 79 TRESIBA FLEX INJ 200UNIT... 79 tretinoin cap 10 mg... 35 tretinoin cream 0.025%... 125 tretinoin cream 0.05%... 124 tretinoin cream 0.1%... 124 tretinoin gel 0.01%... 125 tretinoin gel 0.025%... 125 triamcinolone acetonide cream 0.025%... 128 triamcinolone acetonide cream 0.1%. 128 triamcinolone acetonide cream 0.5%. 128 triamcinolone acetonide dental paste 0.1%... 130 triamcinolone acetonide inj susp 10 mg/ml... 99 triamcinolone acetonide inj susp 40 mg/ml... 99 triamcinolone acetonide lotion 0.025%... 128 triamcinolone acetonide lotion 0.1%.. 128 triamcinolone acetonide oint 0.025%. 128 triamcinolone acetonide oint 0.1%... 128 triamcinolone acetonide oint 0.5%... 128 triamterene & hydrochlorothiazide cap 37.5-25 mg... 49 triamterene & hydrochlorothiazide tab 37.5-25 mg... 49 triamterene & hydrochlorothiazide tab 75-50 mg... 49 triderm cre 0.1%... 128 trientine hcl cap 250 mg... 82 tri-estaryll tab... 86 trifluoperazine hcl tab 1 mg (base equivalent)... 69 trifluoperazine hcl tab 10 mg (base equivalent)... 70 trifluoperazine hcl tab 2 mg (base equivalent)... 69 trifluoperazine hcl tab 5 mg (base equivalent)... 70 trifluridine ophth soln 1%... 118 trihexyphenidyl hcl elixir 0.4 mg/ml... 64 trihexyphenidyl hcl tab 2 mg... 64 trihexyphenidyl hcl tab 5 mg... 64 tri-legest tab fe... 86 tri-linyah tab... 86 tri-lo tab estaryll... 86 tri-lo- tab marzia... 86 tri-lo- tab sprintec... 86 trilyte sol... 99 trimethoprim tab 100 mg... 10 tri-mili tab... 86 trimipramine maleate cap 100 mg... 62 trimipramine maleate cap 25 mg... 62 trimipramine maleate cap 50 mg... 62 trinessa lo tab... 87 trinessa tab... 87 TRINTELLIX TAB 10MG... 62 TRINTELLIX TAB 20MG... 62 TRINTELLIX TAB 5MG... 62 tri-previfem tab... 86 TRISENOX INJ 12MG/6ML... 35 tri-sprintec tab... 86 TRIUMEQ TAB... 14 tri-vit/fe dro /fl 0.25... 113 tri-vit/fl dro 0.25mg... 113 tri-vit/fl dro 0.5mg... 113 trivora-28 tab... 87 tri-vylibra tab... 87 TROPHAMINE INJ 10%... 114 TROPHAMINE INJ 6%... 114 trospium chloride cap er 24hr 60 mg 103 trospium chloride tab 20 mg... 103 TRULICITY INJ 0.75/0.5... 79 TRULICITY INJ 1.5/0.5... 79 TRUMENBA INJ... 111 TRUVADA TAB 100-150... 14 TRUVADA TAB 133-200... 15 TRUVADA TAB 167-250... 15 TRUVADA TAB 200-300... 15 TWINRIX INJ... 111 178
TYBOST TAB 150MG... 14 TYKERB TAB 250MG... 34 TYPHIM VI INJ... 111 TYSABRI INJ 300/15ML... 75 U ULORIC TAB 40MG... 1 ULORIC TAB 80MG... 1 unithroid tab 100mcg... 96 unithroid tab 112mcg... 96 unithroid tab 125mcg... 96 unithroid tab 150mcg... 96 unithroid tab 175mcg... 96 unithroid tab 200mcg... 96 unithroid tab 25mcg... 96 unithroid tab 300mcg... 96 unithroid tab 50mcg... 96 unithroid tab 75mcg... 96 unithroid tab 88mcg... 96 UNITUXIN INJ... 27 UPTRAVI TAB 1000MCG... 52 UPTRAVI TAB 1200MCG... 52 UPTRAVI TAB 1400MCG... 52 UPTRAVI TAB 1600MCG... 52 UPTRAVI TAB 200/800... 52 UPTRAVI TAB 200MCG... 52 UPTRAVI TAB 400MCG... 52 UPTRAVI TAB 600MCG... 52 UPTRAVI TAB 800MCG... 52 ursodiol cap 300 mg... 100 ursodiol tab 250 mg... 100 ursodiol tab 500 mg... 100 V valacyclovir hcl tab 1 gm... 16 valacyclovir hcl tab 500 mg... 16 VALCHLOR GEL 0.016%... 129 valganciclovir hcl for soln 50 mg/ml (base equiv)... 17 valganciclovir hcl tab 450 mg (base equivalent)... 17 valproate sodium inj 100 mg/ml... 57 valproate sodium oral soln 250 mg/5ml (base equiv)... 57 valproic acid cap 250 mg... 57 valsartan tab 160 mg... 40 valsartan tab 320 mg... 40 valsartan tab 40 mg... 40 valsartan tab 80 mg... 40 valsartan-hydrochlorothiazide tab 160-12.5 mg... 40 valsartan-hydrochlorothiazide tab 160-25 mg... 40 valsartan-hydrochlorothiazide tab 320-12.5 mg... 40 valsartan-hydrochlorothiazide tab 320-25 mg... 40 valsartan-hydrochlorothiazide tab 80-12.5 mg... 40 VALSTAR SOL 40MG/ML... 24 vancomycin hcl cap 125 mg... 10 vancomycin hcl cap 250 mg... 10 vancomycin hcl for inj 10 gm... 10 vancomycin hcl for inj 1000 mg... 10 vancomycin hcl for inj 500 mg... 10 vandazole gel 0.75%... 103 VAQTA INJ 25/0.5ML... 111 VAQTA INJ 50UNT/ML... 111 VARIVAX INJ... 111 VASCEPA CAP 0.5GM... 44 VASCEPA CAP 1GM... 44 VECAMYL TAB 2.5MG... 50 VECTIBIX INJ 100MG... 27 VECTIBIX INJ 400MG... 27 VELCADE INJ 3.5MG... 27 VELETRI INJ 0.5MG... 52 VELETRI INJ 1.5MG... 52 velivet pak... 87 VELTASSA POW 16.8GM... 82 VELTASSA POW 25.2GM... 82 VELTASSA POW 8.4GM... 82 VEMLIDY TAB 25MG... 17 VENCLEXTA TAB 100MG... 28 VENCLEXTA TAB 10MG... 27 VENCLEXTA TAB 50MG... 27 VENCLEXTA TAB START PK... 28 venlafaxine hcl cap er 24hr 150 mg (base equivalent)... 62 venlafaxine hcl cap er 24hr 37.5 mg (base equivalent)... 62 venlafaxine hcl cap er 24hr 75 mg (base equivalent)... 62 venlafaxine hcl tab 100 mg... 62 venlafaxine hcl tab 25 mg... 62 179
venlafaxine hcl tab 37.5 mg... 62 venlafaxine hcl tab 50 mg... 62 venlafaxine hcl tab 75 mg... 62 VENTAVIS SOL 10MCG/ML... 52 VENTAVIS SOL 20MCG/ML... 52 VENTOLIN HFA AER... 121 verapamil hcl cap er 24hr 100 mg... 47 verapamil hcl cap er 24hr 120 mg... 47 verapamil hcl cap er 24hr 180 mg... 47 verapamil hcl cap er 24hr 200 mg... 47 verapamil hcl cap er 24hr 240 mg... 47 verapamil hcl cap er 24hr 300 mg... 47 verapamil hcl cap er 24hr 360 mg... 47 verapamil hcl iv soln 2.5 mg/ml... 47 verapamil hcl tab 120 mg... 47 verapamil hcl tab 40 mg... 47 verapamil hcl tab 80 mg... 47 verapamil hcl tab er 120 mg... 47 verapamil hcl tab er 180 mg... 48 verapamil hcl tab er 240 mg... 48 VERSACLOZ SUS 50MG/ML... 70 VERZENIO TAB 100MG... 28 VERZENIO TAB 150MG... 28 VERZENIO TAB 200MG... 28 VERZENIO TAB 50MG... 28 VESICARE TAB 10MG... 103 VESICARE TAB 5MG... 103 vestura tab 3-0.02mg... 87 VIBERZI TAB 100MG... 100 VIBERZI TAB 75MG... 100 VIBRAMYCIN SYP 50MG/5ML... 22 VICTOZA INJ 18MG/3ML... 79 VIDEX EC CAP 125MG... 14 VIDEX SOL 4GM... 14 vienva tab 0.1-20... 87 vigabatrin powd pack 500 mg... 57 VIIBRYD KIT STARTER... 62 VIIBRYD TAB 10MG... 62 VIIBRYD TAB 20MG... 63 VIIBRYD TAB 40MG... 63 VIMPAT INJ 200MG/20... 57 VIMPAT SOL 10MG/ML... 57 VIMPAT TAB 100MG... 58 VIMPAT TAB 150MG... 58 VIMPAT TAB 200MG... 58 VIMPAT TAB 50MG... 58 vinblastine sulfate inj 1 mg/ml... 25 vincasar pfs inj 1mg/ml... 25 vincristine sulfate iv soln 1 mg/ml... 25 vinorelbine tartrate inj 10 mg/ml (base equiv)... 25 vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) (base equiv)... 25 viorele tab... 87 VIRACEPT TAB 250MG... 14 VIRACEPT TAB 625MG... 14 VIRAMUNE SUS 50MG/5ML... 14 VIREAD POW 40MG/GM... 14 VIREAD TAB 150MG... 14 VIREAD TAB 200MG... 14 VIREAD TAB 250MG... 14 VIREAD TAB 300MG... 14 voriconazole for inj 200 mg... 11 voriconazole for susp 40 mg/ml... 11 voriconazole tab 200 mg... 11 voriconazole tab 50 mg... 11 VOSEVI TAB... 17 VOTRIENT TAB 200MG... 34 VPRIV INJ 400UNIT... 88 VRAYLAR CAP 1.5-3MG... 70 VRAYLAR CAP 1.5MG... 70 VRAYLAR CAP 3MG... 70 VRAYLAR CAP 4.5MG... 70 VRAYLAR CAP 6MG... 70 vyfemla tab 0.4-35... 87 vylibra tab 0.25-35... 87 VYXEOS INJ 44-100MG... 25 W warfarin sodium tab 1 mg... 105 warfarin sodium tab 10 mg... 105 warfarin sodium tab 2 mg... 105 warfarin sodium tab 2.5 mg... 105 warfarin sodium tab 3 mg... 105 warfarin sodium tab 4 mg... 105 warfarin sodium tab 5 mg... 105 warfarin sodium tab 6 mg... 105 warfarin sodium tab 7.5 mg... 105 water for irrigation, sterile irrigation soln... 129 WELCHOL PAK 3.75GM... 44 WELCHOL TAB 625MG... 44 wera tab 0.5/35... 87 180
wymzya fe chw 0.4mg-35... 87 X XALKORI CAP 200MG... 34 XALKORI CAP 250MG... 34 XARELTO STAR TAB 15/20MG... 105 XARELTO TAB 10MG... 105 XARELTO TAB 15MG... 105 XARELTO TAB 20MG... 105 XATMEP SOL 2.5MG/ML... 108 XELJANZ TAB 5MG... 108 XELJANZ XR TAB 11MG... 108 XEOMIN INJ 100UNIT... 76 XEOMIN INJ 50 UNIT... 76 XERMELO TAB 250MG... 100 XGEVA INJ... 94 XIFAXAN TAB 200MG... 10 XIFAXAN TAB 550MG... 101 XOLAIR SOL 150MG... 123 XTANDI CAP 40MG... 29 xulane dis 150-35... 87 XULTOPHY INJ 100/3.6... 79 XYREM SOL 500MG/ML... 76 Y YERVOY INJ 200MG... 28 YERVOY INJ 50MG... 28 YF-VAX INJ... 111 YONDELIS INJ 1MG... 35 yuvafem tab 10mcg... 90 Z zafirlukast tab 10 mg... 122 zafirlukast tab 20 mg... 122 zaleplon cap 10 mg... 72 zaleplon cap 5 mg... 72 ZALTRAP INJ 100/4ML... 28 ZALTRAP INJ 200/8ML... 28 ZANOSAR INJ 1GM... 23 zarah tab 3-0.03mg... 87 ZARXIO INJ 300/0.5... 106 ZARXIO INJ 480/0.8... 106 ZAVESCA CAP 100MG... 88 ZEJULA CAP 100MG... 28 ZELBORAF TAB 240MG... 34 ZEMAIRA INJ 1000MG... 123 ZEMPLAR INJ 2MCG/ML... 116 ZEMPLAR INJ 5MCG/ML... 116 zenatane cap 10mg... 125 zenatane cap 20mg... 125 zenatane cap 30mg... 125 zenatane cap 40mg... 125 zenchent tab... 87 ZENPEP CAP 10000UNT... 101 ZENPEP CAP 15000UNT... 101 ZENPEP CAP 20000UNT... 101 ZENPEP CAP 25000... 101 ZENPEP CAP 25000UNT... 101 ZENPEP CAP 3000UNIT... 101 ZENPEP CAP 40000... 101 ZENPEP CAP 5000UNIT... 101 zenzedi tab 10mg... 72 zenzedi tab 5mg... 72 ZEPATIER TAB 50-100MG... 17 ZERBAXA INJ 1.5GM... 18 ZERIT SOL 1MG/ML... 14 ZIAGEN SOL 20MG/ML... 14 zidovudine cap 100 mg... 14 zidovudine syrup 10 mg/ml... 14 zidovudine tab 300 mg... 14 ZINECARD INJ 250MG... 36 ZINPLAVA SOL 25MG/ML... 109 ZIOPTAN DRO 0.0015%... 119 ziprasidone hcl cap 20 mg... 70 ziprasidone hcl cap 40 mg... 70 ziprasidone hcl cap 60 mg... 70 ziprasidone hcl cap 80 mg... 70 ZIRGAN GEL 0.15%... 118 zoledronic acid inj conc for iv infusion 4 mg/5ml... 81 zoledronic acid iv soln 5 mg/100ml... 81 ZOLINZA CAP 100MG... 28 zolmitriptan orally disintegrating tab 2.5 mg... 73 zolmitriptan orally disintegrating tab 5 mg... 73 zolmitriptan tab 2.5 mg... 73 zolmitriptan tab 5 mg... 73 zolpidem tartrate tab 10 mg... 72 zolpidem tartrate tab 5 mg... 72 ZOMACTON INJ 10MG... 92 ZOMACTON INJ 5MG... 92 ZOMETA INJ 4MG/100... 81 zonisamide cap 100 mg... 58 zonisamide cap 25 mg... 58 181
zonisamide cap 50 mg... 58 ZONTIVITY TAB 2.08MG... 107 ZORBTIVE INJ 8.8MG... 92 ZORTRESS TAB 0.25MG... 110 ZORTRESS TAB 0.5MG... 110 ZORTRESS TAB 0.75MG... 110 ZOSTAVAX INJ... 111 ZOSYN SOL 2-0.25GM... 22 ZOSYN SOL 3-0.375G... 22 ZOSYN SOL 4-0.50GM... 22 zovia 1/35e tab... 87 ZURAMPIC TAB 200MG... 1 ZYDELIG TAB 100MG... 34 ZYDELIG TAB 150MG... 34 ZYKADIA CAP 150MG... 34 ZYLET SUS 0.5-0.3%... 117 ZYPREXA RELP INJ 210MG... 70 ZYPREXA RELP INJ 300MG... 70 ZYPREXA RELP INJ 405MG... 70 ZYTIGA TAB 250MG... 29 ZYTIGA TAB 500MG... 29 182
950 N. Meridian St., Suite 400 Indianapolis, IN 46204-1202 iuhealthplans.org This comprehensive formulary was updated on 09.01.2018. For more recent information or other questions, please contact us, IU Health Plans, Pharmacy Member Services, at 866.823.1016 or, for TTY users, 800.743.3333, Oct. 1 to Feb. 14 8 am to 8 pm, seven days a week; Feb. 15 to Sept. 30 8 am to 8 pm, Monday Friday, or visit iuhealthplans.org. ATTENTION: Our Customer Solutions Center has free language interpreter services available for non-english speakers. Call 800.455.9776 (TTY: 800.743.3333). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 800.455.9776 (TTY: 800.743.3333). 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 800.455.9776 (TTY: 800.743.3333). IU Health Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. IU Health Plans cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. IU Health Plans 遵守適用的聯邦民權法律規定, 不因種族 膚色 民族血統 年齡 殘障或性別而歧視任何人