Download Prime Therapeutics NetResults F-Series July 2017 Prescription

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July 2017
NetResults™ F-Series Prescription Drug Guide
Please consider talking to your doctor about prescribing covered medications where noncovered (NC) medications are listed. Preferred medications (p or P) will help reduce your
out-of-pocket costs compared to non-preferred medications (NP). This list may help guide
you and your doctor in selecting an appropriate medication for you.
The drug list, also known as a formulary, is regularly updated. This list is subject to change.
Contents
Therapeutic Class Drug List
Introduction ...................................................................... I
Anti-Infective Agents ....................................................... 1
Coverage considerations ................................................. I
Biologicals ..................................................................... 10
Prior Authorization ........................................................... I
Antineoplastic Agents ................................................... 12
Step Therapy .................................................................. II
Endocrine and Metabolic Drugs .................................... 16
Dispensing Limits............................................................ II
Cardiovascular Agents .................................................. 32
Specialty Drugs ............................................................... II
Respiratory Agents ....................................................... 45
Non-Covered Drugs ........................................................ II
Gastrointestinal Agents ................................................. 50
Notice .............................................................................. II
Genitourinary Agents .................................................... 55
Abbreviation/acronym key .............................................. II
Central Nervous System Drugs .................................... 57
Analgesics and Anesthetics .......................................... 72
Neuromuscular Drugs ................................................... 82
Nutritional Products....................................................... 89
Hematological Agents ................................................... 96
Topical Products ......................................................... 104
Miscellaneous Products .............................................. 114
Index ........................................................................... 125
To search for a drug name within this PDF document, use the Control and F keys on your keyboard, or
go to Edit in the drop-down menu and select Find/Search. Type in the word or phrase you are looking
for and click on Search.
2060-J © Prime Therapeutics LLC 07/17
Introduction
The Prime Therapeutics NetResults F-Series Prescription Drug Guide contains covered drugs for a broad range
of diseases.
Generics drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand
drug in (parentheses). Some generic products have no reference brand.
Brand prescription drugs are shown in capital letters followed by the generic name.
The Prime Therapeutics NetResults F-Series Prescription Drug Guide is organized into broad categories (e.g.
Anti-Infective drugs). Within most categories, drugs are sub-grouped by drug class (e.g. Penicillins) or by use for
a specific medical condition (e.g. Diabetes).
To save the most money on prescription drugs, take this drug list with you each time you visit your physician.
Consider asking your physician to prescribe generic (p or np) and preferred (P) formulary medications, if
appropriate. Decisions about the need for a prescription drug and dosage of a prescription drug must be made
solely by you and your physician in accordance with the patient/physician relationship.
p = preferred generics
np = non-preferred generics
P = preferred brands
NP = non-preferred brands
NC = non-covered drugs
Coverage considerations
Most prescription drug benefit plans provide coverage for up to a 30-day supply of medication, with some
exceptions. Your plan may also provide coverage for up to a 90-day supply of maintenance medications.
Maintenance medications are those drugs you may take on an ongoing basis for conditions such as high blood
pressure, diabetes or high cholesterol. Some plans may exclude coverage for certain agents or drug categories,
like those used for erectile dysfunction, weight loss or infertility.
Over-the-counter exclusions: The NetResults Formulary may not provide coverage for prescription medications
that have an over-the-counter version. You should refer to your benefit plan material for details about your
particular benefits.
Compounded medications: Your benefit plan may not provide coverage for compounded medications. Please
see your plan materials or call the number on the back of your ID card to determine whether compounded
medications are covered and/or verify your payment amount.
Repackaged medications: Repackaged versions of medications already available on the market are not
covered.
Prior Authorization
Some drugs require prior authorization (PA) to ensure appropriate use. This means that your doctor will need to
submit a PA request for coverage. Coverage may be approved after certain criteria are met. If a PA is required for
a drug listed in this document, it will be noted next to the drug with a dot under the PA column.
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
I
Step Therapy
A step therapy (ST) program means you may need to try an alternative drug before coverage may be available for
the requested drug included in the ST program. ST programs help redirect members to safe, effective and less
expensive alternatives. If a ST is required for a drug listed in this document, it will be noted next to the drug with a
dot under the ST column.
Dispensing Limits
Dispensing limits (DL) help encourage drug use as intended by the Food and Drug Administration. The DL is the
maximum quantity that can be dispensed over a given period of time. These limits help encourage safe and
proper use. If a DL is required for a drug listed in this document, it will be noted next to the drug with a dot under
the DL column.
Specialty Drugs
Specialty drugs require special handling, patient monitoring, and unique education prior to use.
Non-Covered Drug
Certain drugs are non-covered (NC) on NetResults. If you fill a prescription for a NC drug, you will likely pay full
retail price. Please talk to your physician about prescribing a preferred alternative. If a drug is NC, it will be noted
under the Tier Designation column as NC.
Notice
The purpose of the Prime Therapeutics NetResults Prescription Drug List is to provide a guide to coverage.
Decisions about the need for a prescription drug and dosage of a prescription drug must be made solely by you
and your physician in accordance with the patient/physician relationship.
Abbreviation/acronym key
caps .................................................................... capsules odt .......................................... orally disintegrating tablets
chew .................................................................. chewable oint ...................................................................... ointment
conc .............................................................. concentrate ophth .............................................................. ophthalmic
cr .......................................................... controlled release osm ..........................................................osmotic release
dr ............................................................. delayed release powd ..................................................................... powder
ec ................................................................enteric coated sa ............................................................ sustained action
effe................................................................. effervescent sl ...................................................................... sublingual
equiv ................................................................ equivalent soln ...................................................................... solution
er ...........................................................extended release sr ..........................................................sustained release
inhal................................................................... inhalation suppos.........................................................suppositories
inj ......................................................................... injection susp ................................................................suspension
liq .............................................................................. liquid tab .......................................................................... tablets
lotn ........................................................................... lotion td ................................................................... transdermal
nebu ................................................................... nebulizer
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
II
ANTI-INFECTIVE AGENTS
PENICILLINS
AMPICILLIN- ampicillin for susp
125 mg/5ml
NP
NP
AMOXICILLIN- amoxicillin (trihydrate)
chew tab 125 mg
NP
AMPICILLIN- ampicillin for susp
250 mg/5ml
AMOXICILLIN- amoxicillin (trihydrate)
chew tab 250 mg
NP
ampicillin cap 250 mg
amoxicillin (trihydrate) cap 250 mg
p
amoxicillin (trihydrate) cap 500 mg
amoxicillin (trihydrate) for susp
125 mg/5ml
amoxicillin (trihydrate) for susp
200 mg/5ml
amoxicillin (trihydrate) for susp
250 mg/5ml
amoxicillin (trihydrate) for susp
400 mg/5ml
amoxicillin (trihydrate) tab 500 mg
amoxicillin (trihydrate) tab 875 mg
amoxicillin & k clavulanate for susp
200-28.5 mg/5ml
p
p
ampicillin cap 500 mg
AUGMENTIN- amoxicillin
& k clavulanate for susp
125-31.25 mg/5ml
dicloxacillin sodium cap 250 mg
p
p
p
penicillin v potassium tab 500 mg
p
p
amoxicillin & k clavulanate for susp np
250-62.5 mg/5ml (Augmentin)
amoxicillin & k clavulanate for susp p
400-57 mg/5ml
amoxicillin & k clavulanate for susp p
600-42.9 mg/5ml (Augmentin
es-600)
np
amoxicillin & k clavulanate tab sr
12hr 1000-62.5 mg (Augmentin xr)
np
amoxicillin & k clavulanate tab
250-125 mg
p
amoxicillin & k clavulanate tab
500-125 mg (Augmentin)
p
amoxicillin & k clavulanate tab
875-125 mg (Augmentin)
NP
AMOXICILLIN/CLAVULANATE Pamoxicillin & k clavulanate chew tab
200-28.5 mg
NP
AMOXICILLIN/CLAVULANATE Pamoxicillin & k clavulanate chew tab
400-57 mg
CEPHALOSPORINS
CEDAX- ceftibuten cap 400 mg
NP
CEDAX- ceftibuten for susp
180 mg/5ml
NP
CEFACLOR- cefaclor for susp
125 mg/5ml
NC
CEFACLOR- cefaclor for susp
250 mg/5ml
NC
CEFACLOR- cefaclor for susp
375 mg/5ml
NC
cefaclor cap 250 mg
np
cefaclor cap 500 mg
CEFACLOR ER- cefaclor
monohydrate tab sr 12hr 500 mg
cefadroxil cap 500 mg
cefadroxil for susp 250 mg/5ml
cefadroxil for susp 500 mg/5ml
cefadroxil tab 1 gm
cefdinir cap 300 mg
cefdinir for susp 125 mg/5ml
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
NP
MOXATAG- amoxicillin (trihydrate) tab NP
sr 24hr 775 mg
p
penicillin v potassium for soln
125 mg/5ml
p
penicillin v potassium for soln
250 mg/5ml
p
penicillin v potassium tab 250 mg
p
Step Therapy
p
np
p
Prior Authorization
p
dicloxacillin sodium cap 500 mg
p
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
np
NC
p
np
np
np
np
np
1
SUPRAX- cefixime for susp
500 mg/5ml
NC
SUPRAX- cefixime chew tab 100 mg
NC
SUPRAX- cefixime chew tab 200 mg
NC
cefpodoxime proxetil tab 200 mg
azithromycin tab 500 mg
(Zithromax)
cefprozil for susp 125 mg/5ml
cefprozil for susp 250 mg/5ml
np
np
np
MACROLIDES
AZITHROMYCIN- azithromycin powd
pack for susp 1 gm
P
azithromycin for susp 100 mg/5ml
(Zithromax)
np
azithromycin for susp 200 mg/5ml
(Zithromax)
azithromycin tab 250 mg
(Zithromax)
np
azithromycin tab 600 mg
(Zithromax)
np
clarithromycin for susp 125 mg/5ml
CEFTIBUTEN- ceftibuten cap 400 mg
NP
clarithromycin for susp 250 mg/5ml
CEFTIBUTEN- ceftibuten for susp
180 mg/5ml
NP
clarithromycin tab sr 24hr 500 mg
CEFTIN- cefuroxime axetil for susp
125 mg/5ml
P
CEFTIN- cefuroxime axetil for susp
250 mg/5ml
P
cefuroxime axetil tab 250 mg
np
cefprozil tab 250 mg
cefprozil tab 500 mg
clarithromycin tab 250 mg
clarithromycin tab 500 mg (Biaxin)
np
p
p
np
np
np
np
np
np
DIFICID- fidaxomicin tab 200 mg
NP
E.E.S. 400- erythromycin
ethylsuccinate tab 400 mg
NP
np
ERY-TAB- erythromycin tab delayed
release 250 mg
NP
CEPHALEXIN- cephalexin tab 250 mg NC
CEPHALEXIN- cephalexin tab 500 mg NC
ERY-TAB- erythromycin tab delayed
release 333 mg
NP
ERY-TAB- erythromycin tab delayed
release 500 mg
NP
ERYPED 400- erythromycin
ethylsuccinate for susp 400 mg/5ml
NP
cefuroxime axetil tab 500 mg
cephalexin cap 250 mg (Keflex)
cephalexin cap 500 mg (Keflex)
cephalexin cap 750 mg (Keflex)
cephalexin for susp 125 mg/5ml
cephalexin for susp 250 mg/5ml
p
p
np
np
np
DAXBIA- cephalexin cap 333 mg
NC
SPECTRACEF- cefditoren pivoxil tab
400 mg (base equivalent)
NC
ERYTHROCIN STEARATEerythromycin stearate tab 250 mg
P
ERYTHROMYCIN BASEerythromycin tab 250 mg
NP
ERYTHROMYCIN BASEerythromycin tab 500 mg
NP
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
NC
CEFDITOREN PIVOXIL- cefditoren
pivoxil tab 200 mg (base equivalent)
NC
CEFDITOREN PIVOXIL- cefditoren
pivoxil tab 400 mg (base equivalent)
np
cefixime for susp 100 mg/5ml
(Suprax)
np
cefixime for susp 200 mg/5ml
(Suprax)
np
cefpodoxime proxetil for susp
50 mg/5ml
np
cefpodoxime proxetil for susp
100 mg/5ml
np
cefpodoxime proxetil tab 100 mg
Step Therapy
NP
Prior Authorization
SUPRAX- cefixime cap 400 mg
Specialty
Tier Designation
Dispensing Limits
np
Step Therapy
cefdinir for susp 250 mg/5ml
Prior Authorization
Drug Name
Specialty
Drug Name
Tier Designation
2017
2
ERYTHROMYCIN ETHYLSUCCINAerythromycin ethylsuccinate tab
400 mg
NP
erythromycin ethylsuccinate for
susp 200 mg/5ml (E.e.s. granules)
np
doxycycline monohydrate cap
75 mg (Monodox)
np
doxycycline monohydrate cap
100 mg (Monodox)
PCE- erythromycin w/ enteric coated
particles tab 333 mg
NP
doxycycline monohydrate cap
150 mg (Adoxa)
PCE- erythromycin w/ enteric coated
particles tab 500 mg
NP
doxycycline monohydrate for susp
25 mg/5ml (Vibramycin)
ZITHROMAX- azithromycin powd
pack for susp 1 gm
NP
doxycycline monohydrate tab
50 mg
erythromycin w/ delayed release
particles cap 250 mg
ZMAX- azithromycin extended release NP
for oral susp 2 gm
TETRACYCLINES
ACTICLATE- doxycycline hyclate tab
75 mg
NC
ACTICLATE- doxycycline hyclate tab
150 mg
NC
demeclocycline hcl tab 150 mg
np
demeclocycline hcl tab 300 mg
np
DORYX MPC- doxycycline hyclate tab NC
delayed release 120 mg
np
doxycycline hyclate cap 50 mg
doxycycline hyclate cap 100 mg
(Vibramycin)
doxycycline hyclate tab delayed
release 50 mg (Doryx)
doxycycline hyclate tab delayed
release 75 mg
doxycycline hyclate tab delayed
release 100 mg
doxycycline hyclate tab delayed
release 150 mg
doxycycline hyclate tab delayed
release 200 mg (Doryx)
doxycycline hyclate tab 20 mg
doxycycline hyclate tab 100 mg
np
NC
NC
NC
NC
NC
np
np
doxycycline monohydrate cap
50 mg
doxycycline monohydrate tab
75 mg
doxycycline monohydrate tab
100 mg
doxycycline monohydrate tab
150 mg
minocycline hcl cap 50 mg
(Minocin)
minocycline hcl cap 75 mg
(Minocin)
minocycline hcl cap 100 mg
(Minocin)
np
p
np
np
np
np
np
np
p
np
np
np
•
minocycline hcl tab sr 24hr 90 mg
np
•
•
minocycline hcl tab 50 mg
minocycline hcl tab 75 mg
minocycline hcl tab 100 mg
np
np
np
np
SOLODYN- minocycline hcl tab sr
24hr 55 mg
NC
SOLODYN- minocycline hcl tab sr
24hr 65 mg
NC
SOLODYN- minocycline hcl tab sr
24hr 80 mg
NC
SOLODYN- minocycline hcl tab sr
24hr 105 mg
NC
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
p
MINOCYCLINE HCL ER- minocycline
hcl tab sr 24hr 45 mg
minocycline hcl tab sr 24hr 135 mg
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
3
NC
TARGADOX- doxycycline hyclate tab
50 mg
NC
tetracycline hcl cap 250 mg
(Tetracycline hcl)
np
tetracycline hcl cap 500 mg
(Tetracycline hcl)
VIBRAMYCIN- doxycycline calcium
syrup 50 mg/5ml
np
NC
AMINOGLYCOSIDES
BETHKIS- tobramycin nebu soln
300 mg/4ml
NP
•
KITABIS PAK- tobramycin nebu soln
300 mg/5ml
NP
•
neomycin sulfate tab 500 mg
paromomycin sulfate cap 250 mg
np
•
•
np
TOBRAMYCIN- tobramycin nebu soln NP
300 mg/5ml
np
tobramycin nebu soln 300 mg/5ml
(Tobi)
CIPROFLOXACIN HCL- ciprofloxacin
hcl tab 100 mg (base equiv)
NP
SULFADIAZINE- sulfadiazine tab
500 mg
ciprofloxacin hcl tab 250 mg (base
equiv) (Cipro)
p
FLUOROQUINOLONES
ciprofloxacin for oral susp
250 mg/5ml (5%) (5 gm/100ml)
(Cipro)
ciprofloxacin for oral susp
500 mg/5ml (10%) (10 gm/100ml)
(Cipro)
ciprofloxacin hcl tab 500 mg (base
equiv) (Cipro)
ciprofloxacin hcl tab 750 mg (base
equiv)
ciprofloxacin-ciprofloxacin hcl tab
sr 24hr 500 mg (base eq) (Cipro
xr)
ciprofloxacin-ciprofloxacin hcl tab
sr 24hr 1000 mg(base eq) (Cipro
xr)
np
p
p
np
np
SULFONAMIDES
ANTIMYCOBACTERIAL AGENTS
NP
ethambutol hcl tab 100 mg
(Myambutol)
np
ISONIAZID- isoniazid syrup
50 mg/5ml
isoniazid tab 100 mg
isoniazid tab 300 mg
np
NP
p
p
NP
FACTIVE- gemifloxacin mesylate tab
320 mg (base equiv)
NP
PASER- aminosalicylic acid
cr granules packet 4 gm
PRIFTIN- rifapentine tab 150 mg
P
LEVOFLOXACIN- levofloxacin oral
soln 25 mg/ml
np
pyrazinamide tab 500 mg
np
levofloxacin tab 250 mg (Levaquin)
p
levofloxacin tab 500 mg (Levaquin)
levofloxacin tab 750 mg (Levaquin)
moxifloxacin hcl tab 400 mg (base
equiv) (Avelox)
OFLOXACIN- ofloxacin tab 300 mg
rifabutin cap 150 mg (Mycobutin)
np
NP
p
RIFAMATE- isoniazid & rifampin cap
150-300 mg
p
rifampin cap 150 mg (Rifadin)
np
np
rifampin cap 300 mg
P
RIFATER- isoniazid-rifampin w/
pyrazinamide tab 50-120-300 mg
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
•
NP
CYCLOSERINE- cycloserine cap
250 mg
ethambutol hcl tab 400 mg
(Myambutol)
Dispensing Limits
p
NP
TOBI PODHALER- tobramycin inhal
cap 28 mg
Step Therapy
np
Prior Authorization
ofloxacin tab 400 mg
Specialty
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Tier Designation
SOLODYN- minocycline hcl tab sr
24hr 115 mg
Specialty
Drug Name
Tier Designation
2017
np
NP
4
SIRTURO- bedaquiline fumarate tab
100 mg (base equiv)
NP
ANTIVIRALS
abacavir sulfate tab 300 mg (base
equiv) (Ziagen)
TRECATOR- ethionamide tab 250 mg NP
ANTIFUNGALS
abacavir sulfate-lamivudine tab
600-300 mg (Epzicom)
•
CRESEMBA- isavuconazonium
sulfate cap 186 mg
NP
fluconazole for susp 10 mg/ml
(Diflucan)
np
abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg
(Trizivir)
np
acyclovir cap 200 mg (Zovirax)
p
acyclovir susp 200 mg/5ml
(Zovirax)
p
acyclovir tab 400 mg (Zovirax)
p
acyclovir tab 800 mg (Zovirax)
np
adefovir dipivoxil tab 10 mg
(Hepsera)
fluconazole for susp 40 mg/ml
(Diflucan)
fluconazole tab 50 mg (Diflucan)
fluconazole tab 100 mg (Diflucan)
fluconazole tab 150 mg (Diflucan)
fluconazole tab 200 mg (Diflucan)
flucytosine cap 250 mg (Ancobon)
flucytosine cap 500 mg (Ancobon)
griseofulvin microsize susp
125 mg/5ml
griseofulvin microsize tab 500 mg
griseofulvin ultramicrosize tab
125 mg (Gris-peg)
griseofulvin ultramicrosize tab
250 mg (Gris-peg)
itraconazole cap 100 mg
(Sporanox)
ketoconazole tab 200 mg
np
APTIVUS- tipranavir cap 250 mg
np
np
np
np
np
np
NC
•
NOXAFIL- posaconazole tab delayed
release 100 mg
P
•
NOXAFIL- posaconazole susp 40 mg/
ml
P
•
nystatin tab 500000 unit
np
•
ONMEL- itraconazole tab 200 mg
NC
SPORANOX- itraconazole oral soln
10 mg/ml
NP
•
•
p
•
•
•
terbinafine hcl tab 250 mg (Lamisil)
voriconazole for susp 40 mg/ml
(Vfend)
voriconazole tab 50 mg (Vfend)
voriconazole tab 200 mg (Vfend)
np
np
np
•
•
Dispensing Limits
Step Therapy
Prior Authorization
np
•
np
•
np
•
p
np
p
p
np
NP
APTIVUS- tipranavir oral soln 100 mg/ NP
ml
P
ATRIPLA- efavirenz-emtricitabinetenofovir df tab 600-200-300 mg
P
BARACLUDE- entecavir oral soln
0.05 mg/ml
P
COMPLERA- emtricitabine-rilpivirinetenofovir df tab 200-25-300 mg
NP
CRIXIVAN- indinavir sulfate cap
200 mg
NP
CRIXIVAN- indinavir sulfate cap
400 mg
NC
DAKLINZA- daclatasvir
dihydrochloride tab 30 mg (base
equivalent)
NC
DAKLINZA- daclatasvir
dihydrochloride tab 60 mg (base
equivalent)
NC
DAKLINZA- daclatasvir
dihydrochloride tab 90 mg (base
equivalent)
P
DESCOVY- emtricitabine-tenofovir
alafenamide fumarate tab
200-25 mg
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
•
•
•
•
•
•
•
5
didanosine delayed release capsule np
125 mg (Videx ec)
didanosine delayed release capsule np
200 mg (Videx ec)
didanosine delayed release capsule np
250 mg (Videx ec)
didanosine delayed release capsule np
400 mg (Videx ec)
NP
EDURANT- rilpivirine hcl tab 25 mg
(base equivalent)
EMTRIVA- emtricitabine caps 200 mg NP
•
•
•
•
•
•
ISENTRESS- raltegravir potassium
chew tab 25 mg (base equiv)
P
•
ISENTRESS- raltegravir potassium
chew tab 100 mg (base equiv)
P
•
KALETRA- lopinavir-ritonavir tab
100-25 mg
P
•
KALETRA- lopinavir-ritonavir tab
200-50 mg
P
•
lamivudine oral soln 10 mg/ml
(Epivir)
np
•
entecavir tab 0.5 mg (Baraclude)
np
np
lamivudine tab 150 mg (Epivir)
EPIVIR HBV- lamivudine oral soln
5 mg/ml (hbv)
P
famciclovir tab 125 mg
np
famciclovir tab 500 mg
FUZEON- enfuvirtide for inj 90 mg
np
np
NP
GENVOYA- elvitegrav-cobicemtricitab-tenofov af tab
150-150-200-10 mg
P
HARVONI- ledipasvir-sofosbuvir tab
90-400 mg
P
INTELENCE- etravirine tab 25 mg
P
INTELENCE- etravirine tab 100 mg
P
INTELENCE- etravirine tab 200 mg
P
INVIRASE- saquinavir mesylate cap
200 mg
NP
INVIRASE- saquinavir mesylate tab
500 mg
NP
ISENTRESS- raltegravir potassium
tab 400 mg (base equiv)
P
•
np
LEXIVA- fosamprenavir calcium tab
700 mg (base equiv)
NP
•
LEXIVA- fosamprenavir calcium susp
50 mg/ml (base equiv)
NP
•
lopinavir-ritonavir soln
400-100 mg/5ml (80-20 mg/ml)
(Kaletra)
np
•
lamivudine-zidovudine tab
150-300 mg (Combivir)
•
•
•
• •
•
•
•
•
•
•
np
•
•
•
lamivudine tab 300 mg (Epivir)
NP
EVOTAZ- atazanavir sulfate-cobicistat
tab 300-150 mg (base equiv)
famciclovir tab 250 mg
• •
Dispensing Limits
•
lamivudine tab 100 mg (hbv) (Epivir
hbv)
P
Step Therapy
P
NP
EPCLUSA- sofosbuvir-velpatasvir tab
400-100 mg
Prior Authorization
ISENTRESS- raltegravir potassium
packet for susp 100 mg (base equiv)
EMTRIVA- emtricitabine soln 10 mg/
ml
entecavir tab 1 mg (Baraclude)
Specialty
•
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
np
np
MODERIBA- ribavirin tab 200 mg &
ribavirin tab 400 mg dose pack
NP
•
MODERIBA- ribavirin tab 400 mg &
ribavirin tab 600 mg dose pack
NP
•
MODERIBA 1200 DOSE PACKribavirin tab 600 mg
NP
•
MODERIBA 800 DOSE PACKribavirin tab 400 mg
NP
•
NEVIRAPINE- nevirapine susp
50 mg/5ml
NP
•
nevirapine tab sr 24hr 100 mg
(Viramune xr)
np
•
np
•
p
•
•
nevirapine tab sr 24hr 400 mg
(Viramune xr)
nevirapine tab 200 mg (Viramune)
NORVIR- ritonavir cap 100 mg
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
NP
6
NORVIR- ritonavir tab 100 mg
P
NORVIR- ritonavir oral soln 80 mg/ml
P
ODEFSEY- emtricitabine-rilpivirinetenofovir af tab 200-25-25 mg
P
• •
PEGINTRON- peginterferon alfa-2b
for inj kit 150 mcg/0.5ml
NP
Dispensing Limits
• •
Step Therapy
Prior Authorization
Specialty
•
•
•
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
PREZCOBIX- darunavir-cobicistat tab
800-150 mg
P
•
PREZISTA- darunavir ethanolate susp
100 mg/ml (base equiv)
P
•
OLYSIO- simeprevir sodium cap
150 mg (base equivalent)
NP
oseltamivir phosphate cap 30 mg
(base equiv) (Tamiflu)
np
•
PREZISTA- darunavir ethanolate tab
75 mg (base equiv)
P
•
np
•
PREZISTA- darunavir ethanolate tab
150 mg (base equiv)
P
•
np
•
PREZISTA- darunavir ethanolate tab
600 mg (base equiv)
P
•
PREZISTA- darunavir ethanolate tab
800 mg (base equiv)
P
•
oseltamivir phosphate cap 45 mg
(base equiv) (Tamiflu)
oseltamivir phosphate cap 75 mg
(base equiv) (Tamiflu)
• •
PEG-INTRON REDIPENpeginterferon alfa-2b for inj kit
50 mcg/0.5ml
NP
PEG-INTRON REDIPENpeginterferon alfa-2b for inj kit
80 mcg/0.5ml
NP
• •
PEG-INTRON REDIPENpeginterferon alfa-2b for inj kit
120 mcg/0.5ml
NP
• •
PEG-INTRON REDIPENpeginterferon alfa-2b for inj kit
150 mcg/0.5ml
NP
• •
PEG-INTRON REDIPEN PAK 4peginterferon alfa-2b for inj kit
120 mcg/0.5ml
NP
• •
PEGASYS- peginterferon alfa-2a inj
180 mcg/ml
P
PEGASYS- peginterferon alfa-2a inj
180 mcg/0.5ml
•
REBETOL- ribavirin soln 40 mg/ml
NP
RELENZA DISKHALER- zanamivir
aero powder breath activated 5 mg/
blister
NP
•
RESCRIPTOR- delavirdine mesylate
tab 100 mg
NP
•
RESCRIPTOR- delavirdine mesylate
tab 200 mg
NP
•
REYATAZ- atazanavir sulfate oral
powder packet 50 mg (base equiv)
NP
•
REYATAZ- atazanavir sulfate cap
150 mg (base equiv)
P
•
• •
REYATAZ- atazanavir sulfate cap
200 mg (base equiv)
P
•
P
• •
REYATAZ- atazanavir sulfate cap
300 mg (base equiv)
P
•
PEGASYS PROCLICK- peginterferon
alfa-2a inj 135 mcg/0.5ml
P
• •
RIBASPHERE- ribavirin tab 400 mg
NP
RIBASPHERE- ribavirin tab 600 mg
NP
PEGASYS PROCLICK- peginterferon
alfa-2a inj 180 mcg/0.5ml
P
• •
PEGINTRON- peginterferon alfa-2b
for inj kit 50 mcg/0.5ml
NP
• •
PEGINTRON- peginterferon alfa-2b
for inj kit 80 mcg/0.5ml
NP
• •
PEGINTRON- peginterferon alfa-2b
for inj kit 120 mcg/0.5ml
NP
• •
RIBASPHERE RIBAPAK- ribavirin tab NP
400 mg
RIBASPHERE RIBAPAK- ribavirin tab NP
600 mg
RIBASPHERE RIBAPAK- ribavirin tab NP
200 mg & ribavirin tab 400 mg dose
pack
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
•
•
•
•
•
7
RIBASPHERE RIBAPAK- ribavirin tab NP
400 mg & ribavirin tab 600 mg dose
pack
np
ribavirin cap 200 mg (Rebetol)
ribavirin for inhal soln 6 gm
(Virazole)
ribavirin tab 200 mg (Copegus)
rimantadine hydrochloride tab
100 mg (Flumadine)
np
SELZENTRY- maraviroc tab 75 mg
NP
SELZENTRY- maraviroc tab 150 mg
NP
SELZENTRY- maraviroc tab 300 mg
NP
SITAVIG- acyclovir buccal tab 50 mg
NC
SOVALDI- sofosbuvir tab 400 mg
P
stavudine cap 15 mg (Zerit)
np
stavudine cap 40 mg (Zerit)
•
np
np
np
STRIBILD- elvitegrav-cobic-emtricitabtenofovdf tab 150-150-200-300 mg
P
SUSTIVA- efavirenz tab 600 mg
P
SUSTIVA- efavirenz cap 50 mg
P
SUSTIVA- efavirenz cap 200 mg
P
TAMIFLU- oseltamivir phosphate for
susp 6 mg/ml (base equiv)
NP
TECHNIVIE- ombitasvir-paritaprevirritonavir tab 12.5-75-50 mg
NC
•
•
•
•
•
•
•
•
•
TIVICAY- dolutegravir sodium tab
10 mg (base equiv)
P
•
TIVICAY- dolutegravir sodium tab
25 mg (base equiv)
P
•
TIVICAY- dolutegravir sodium tab
50 mg (base equiv)
P
•
TRIUMEQ- abacavir-dolutegravirlamivudine tab 600-50-300 mg
P
•
TRUVADA- emtricitabine-tenofovir
disoproxil fumarate tab 100-150 mg
P
•
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
TRUVADA- emtricitabine-tenofovir
disoproxil fumarate tab 133-200 mg
P
•
TRUVADA- emtricitabine-tenofovir
disoproxil fumarate tab 167-250 mg
P
•
TRUVADA- emtricitabine-tenofovir
disoproxil fumarate tab 200-300 mg
P
•
NP
•
TYBOST- cobicistat tab 150 mg
•
•
•
•
• •
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
•
np
NP
stavudine cap 30 mg (Zerit)
•
np
SELZENTRY- maraviroc tab 25 mg
stavudine cap 20 mg (Zerit)
Specialty
Drug Name
Tier Designation
2017
valacyclovir hcl tab 500 mg
(Valtrex)
valacyclovir hcl tab 1 gm (Valtrex)
p
np
valganciclovir hcl for soln 50 mg/ml np
(base equiv) (Valcyte)
valganciclovir hcl tab 450 mg (base np
equivalent) (Valcyte)
NC
VEMLIDY- tenofovir alafenamide
fumarate tab 25 mg
P
VIDEX- didanosine for soln 2 gm
VIDEX- didanosine for soln 4 gm
P
•
•
VIEKIRA PAK- ombitas-paritapreriton & dasab tab pak 12.5-75-50 &
250 mg
NC
VIEKIRA XR- dasab-ombitparitap-riton tab sr 24hr
200-8.33-50-33.33 mg
NC
VIRACEPT- nelfinavir mesylate tab
250 mg
NP
•
VIRACEPT- nelfinavir mesylate tab
625 mg
NP
•
VIRAMUNE- nevirapine susp
50 mg/5ml
P
•
VIREAD- tenofovir disoproxil fumarate
oral powder 40 mg/gm
P
•
VIREAD- tenofovir disoproxil fumarate
tab 150 mg
P
•
VIREAD- tenofovir disoproxil fumarate
tab 200 mg
P
•
VIREAD- tenofovir disoproxil fumarate
tab 250 mg
P
•
VIREAD- tenofovir disoproxil fumarate
tab 300 mg
P
•
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
8
ZEPATIER- elbasvir-grazoprevir tab
50-100 mg
NC
ZERIT- stavudine for oral soln 1 mg/
ml
NP
•
ZIAGEN- abacavir sulfate soln 20 mg/
ml (base equiv)
P
•
zidovudine cap 100 mg (Retrovir)
np
np
•
•
np
•
zidovudine syrup 10 mg/ml
(Retrovir)
zidovudine tab 300 mg
ANTIMALARIALS
atovaquone-proguanil hcl tab
62.5-25 mg (Malarone)
atovaquone-proguanil hcl tab
250-100 mg (Malarone)
np
np
atovaquone susp 750 mg/5ml
(Mepron)
np
dapsone tab 100 mg
np
CAYSTON- aztreonam lysine for inhal NP
soln 75 mg (base equivalent)
np
clindamycin hcl cap 75 mg
(Cleocin)
p
clindamycin hcl cap 150 mg
(Cleocin)
p
clindamycin hcl cap 300 mg
(Cleocin)
np
clindamycin palmitate hcl for soln
75 mg/5ml (base equiv) (Cleocin
pediatric gr)
np
dapsone tab 25 mg
CHLOROQUINE PHOSPHATEchloroquine phosphate tab 250 mg
NP
IMPAVIDO- miltefosine cap 50 mg
P
np
chloroquine phosphate tab 500 mg
np
linezolid for susp 100 mg/5ml
(Zyvox)
NP
linezolid tab 600 mg (Zyvox)
COARTEM- artemether-lumefantrine
tab 20-120 mg
DARAPRIM- pyrimethamine tab
25 mg
P
hydroxychloroquine sulfate tab
200 mg (Plaquenil)
np
mefloquine hcl tab 250 mg
np
PRIMAQUINE PHOSPHATEprimaquine phosphate tab 26.3 mg
(15 mg base)
P
quinine sulfate cap 324 mg
(Qualaquin)
np
ANTHELMINTICS
ALBENZA- albendazole tab 200 mg
P
BILTRICIDE- praziquantel tab 600 mg
P
EMVERM- mebendazole chew tab
100 mg
NC
ivermectin tab 3 mg (Stromectol)
np
ANTI-INFECTIVE AGENTS - MISC.
ALINIA- nitazoxanide tab 500 mg
NP
ALINIA- nitazoxanide for susp
100 mg/5ml
NP
metronidazole cap 375 mg (Flagyl)
metronidazole tab 250 mg (Flagyl)
metronidazole tab 500 mg (Flagyl)
SIVEXTRO- tedizolid phosphate tab
200 mg
NP
sulfamethoxazole-trimethoprim
susp 200-40 mg/5ml
np
trimethoprim tab 100 mg
vancomycin hcl cap 125 mg
(Vancocin hcl)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
p
NP
tinidazole tab 500 mg (Tindamax)
Step Therapy
p
PRIMSOL- trimethoprim hcl oral soln
50 mg/5ml (base equiv)
tinidazole tab 250 mg
Prior Authorization
np
NP
sulfamethoxazole-trimethoprim tab
800-160 mg (Bactrim ds)
•
np
NEBUPENT- pentamidine isethionate
for nebulization soln 300 mg
sulfamethoxazole-trimethoprim tab
400-80 mg (Bactrim)
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
p
p
np
np
p
np
9
vancomycin hcl cap 250 mg
(Vancocin hcl)
np
XIFAXAN- rifaximin tab 200 mg
NP
XIFAXAN- rifaximin tab 550 mg
P
BIOLOGICALS
VACCINES
FLUBLOK 2016-2017- influenza virus
vac recombinant hemagglutinin (ha)
inj
P
FLUCELVAX QUADRIVALENT 20influenza vac tiss-cult subunt quad
susp pref syr 0.5 ml
P
P
FLULAVAL QUADRIVALENT 201influenza virus vac split quadrivalent
susp pref syr 0.5ml
P
ACTHIB- haemophilus b
polysaccharide conjugate vaccine
for inj
FLULAVAL QUADRIVALENT 201influenza virus vaccine split
quadrivalent im inj
P
AFLURIA PF 2015-2016- influenza
virus vaccine split pf susp pref
syringe 0.5 ml
P
FLUMIST QUADRIVALENT- influenza
virus vaccine live quadrivalent
intranasal susp
P
AFLURIA PF 2016-2017- influenza
virus vaccine split pf susp pref
syringe 0.5 ml
P
P
P
AFLURIA QUADRIVALENT 2016influenza virus vac split quadrivalent
susp pref syr 0.5ml
FLUVIRIN 2015-2016- influenza vac
type a&b surface antigen susp pref
syr 0.5 ml
FLUVIRIN 2015-2016- influenza virus
vaccine types a & b surface antigen
im susp
P
AFLURIA 2015-2016- influenza virus
vaccine split im susp
P
AFLURIA 2016-2017- influenza virus
vaccine split im susp
P
P
BEXSERO- meningococcal vac b
(recomb omv adjuv) inj prefilled
syringe
P
FLUVIRIN 2016-2017- influenza vac
type a&b surface antigen susp pref
syr 0.5 ml
P
ENGERIX-B- hepatitis b vaccine
(recombinant) susp 10 mcg/0.5ml
P
FLUVIRIN 2016-2017- influenza virus
vaccine types a & b surface antigen
im susp
P
ENGERIX-B- hepatitis b vaccine
(recombinant) susp 20 mcg/ml
P
FLUZONE HIGH-DOSE PF 2016influenza virus vac split high-dose pf
susp pref syr 0.5ml
ENGERIX-B- hepatitis b vaccine
(recombinant) 10 mcg/0.5ml
P
P
ENGERIX-B- hepatitis b vaccine
(recombinant) 20 mcg/ml
P
FLUZONE INTRADERMAL QUADRinfluenza virus vac split quad
intradermal pen 9 mcg/strain
P
FLUAD 2016-2017- influenza vac type
a&b surface ant adj susp pref syr
0.5 ml
P
FLUZONE QUADRIVALENT 2016influenza virus vac split quadrivalent
susp pref syr 0.25 ml
P
FLUARIX QUADRIVALENT 2016influenza virus vac split quadrivalent
susp pref syr 0.5ml
P
FLUZONE QUADRIVALENT 2016influenza virus vac split quadrivalent
susp pref syr 0.5ml
P
FLUBLOK 2015-2016- influenza virus
vac recombinant hemagglutinin (ha)
inj
P
FLUZONE QUADRIVALENT 2016influenza virus vaccine split
quadrivalent im inj
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
10
FLUZONE QUADRIVALENT 2016influenza virus vaccine split
quadrivalent inj 0.5 ml
P
PREVNAR 13- pneumococcal 13valent conjugate vaccine inj
P
GARDASIL- human papillomavirus
(hpv) quadrivalent recombinant vac
inj
P
PROQUAD- measles-mumps-rubellavaricella virus vaccines for inj
P
RABAVERT- rabies vaccine, pcec for
inj
P
GARDASIL 9- human papillomavirus
(hpv) 9-valent recomb vac susp pref
syr
P
GARDASIL 9- human papillomavirus
(hpv) 9-valent recomb vac im susp
P
HAVRIX- hepatitis a vaccine inj susp
720 el unit/0.5ml
P
HAVRIX- hepatitis a vaccine inj susp
1440 el unit/ml
P
HIBERIX- haemophilus b
polysaccharide conjugate vac for inj
10 mcg
P
IMOVAX RABIES (H.D.C.V.)- rabies
virus vaccine, hdc inj
P
IPOL INACTIVATED IPV- poliovirus
vaccine, ipv injection
P
M-M-R II- measles, mumps & rubella
virus vaccines for inj
P
MENACTRA- meningococcal (a, c, y,
and w-135) conjugate vaccine inj
P
MENHIBRIX- meningococcal (c & y)haemophilus b tet tox conj vac for inj
P
MENVEO- meningococcal (a, c, y, and
w-135) oligo conj vac for inj
P
PEDVAX HIB- haemophilus b
polysaccharide conj vac im susp
7.5 mcg/0.5 ml
P
PNEUMOVAX 23- pneumococcal
vaccine polyvalent inj 25 mcg/0.5ml
P
ADACEL- tet tox-diph-acell pertuss ad
inj 5-2-15.5 lf-lf-mcg/0.5ml
P
PNEUMOVAX 23/1 DOSEpneumococcal vaccine polyvalent inj
25 mcg/0.5ml
P
BOOSTRIX- tet tox-diph-acell pertuss
ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml
P
P
PNEUMOVAX 23/5 DOSEpneumococcal vaccine polyvalent inj
25 mcg/0.5ml
P
DAPTACEL- diph, acellular pert & tet
tox inj 15 lf-10 mcg-5 lf/0.5ml
DIPHTHERIA/TETANUS TOXOIDdiphtheria-tetanus tox adsorbed (dt)
im inj 25-5 unit/0.5ml
P
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
RECOMBIVAX HB- hepatitis b vaccine P
(recombinant) susp 5 mcg/0.5ml
RECOMBIVAX HB- hepatitis b vaccine P
(recombinant) susp 10 mcg/ml
RECOMBIVAX HB- hepatitis b vaccine P
(recombinant) susp 40 mcg/ml
P
ROTARIX- rotavirus vaccine, live for
oral susp
ROTATEQ- rotavirus vaccine, live oral P
pentavalent soln
P
TRUMENBA- meningococcal group b
vac (recomb) im susp prefilled syr
P
TWINRIX- hepatitis a (inact)-hep b
(recomb) vac inj 720-20 elu-mcg/ml
P
VAQTA- hepatitis a vaccine inj susp
25 unit/0.5ml
P
VAQTA- hepatitis a vaccine inj susp
50 unit/ml
P
VARIVAX- varicella virus vac live for
subcutaneous inj 1350 pfu/0.5ml
VIVOTIF- typhoid vaccine cap delayed NP
release
P
ZOSTAVAX- zoster vaccine live
for subcutaneous susp 19400
unit/0.65ml
TOXOIDS
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
11
Dispensing Limits
AFINITOR- everolimus tab 5 mg
P
AFINITOR- everolimus tab 7.5 mg
P
AFINITOR- everolimus tab 10 mg
P
P
AFINITOR DISPERZ- everolimus tab
for oral susp 2 mg
P
•
•
•
•
PENTACEL- diph-ac per-tet tox adpoliov-haemoph b poly vac for im
susp
P
AFINITOR DISPERZ- everolimus tab
for oral susp 3 mg
P
• •
•
P
• •
•
QUADRACEL- diph-tetanus tox adacell pert & polio virus, ipv vac inj
P
AFINITOR DISPERZ- everolimus tab
for oral susp 5 mg
P
• •
•
TENIVAC- tetanus-diphtheria toxoids
(td) inj 5-2 lfu
P
ALECENSA- alectinib hcl cap 150 mg
(base equivalent)
ALKERAN- melphalan tab 2 mg
P
TETANUS/DIPHTHERIA TOXOIDtetanus-diphtheria toxoids (td) inj
2-2 lf/0.5ml
P
anastrozole tab 1 mg (Arimidex)
p
INFANRIX- diph, acellular pert & tet
tox inj 25 lf-58 mcg-10 lf/0.5ml
P
KINRIX- diph-tetanus tox ad-acell pert
& polio virus, ipv vac inj
P
PEDIARIX- diph-tetanus tox-acell
pert-hepatitis b-polio ipv vac inj
BIOLOGICALS MISC
bexarotene cap 75 mg (Targretin)
bicalutamide tab 50 mg (Casodex)
NP
CABOMETYX- cabozantinib s-malate
tab 40 mg (base equivalent)
NP
• •
•
CABOMETYX- cabozantinib s-malate
tab 60 mg (base equivalent)
NP
• •
•
capecitabine tab 150 mg (Xeloda)
np
•
•
•
•
•
•
•
•
BOSULIF- bosutinib tab 500 mg
P
•
ORALAIR- grass mixed pollen ext tab
sl 300 ir (index of reactivity)
NP
•
•
CABOMETYX- cabozantinib s-malate
tab 20 mg (base equivalent)
ORALAIR ADULT SAMPLE KIT- grass NP
mixed pollen ext tab sl 300 ir (index
of reactivity)
NP
ORALAIR ADULT STARTER
PAC- grass mixed pollen ext tab sl
300 ir (index of reactivity)
NP
ORALAIR CHILDREN/
ADOLESCE- grass mixed pollen tab
sl therpak 100 (3) ir & 300 (6) ir
NP
ORALAIR CHILDREN/
ADOLESCE- grass mixed pollen ext
tab sl 100 ir (index of reactivity)
NP
RAGWITEK- short ragweed pollen
allergen extract tab sl 12 amb a 1-u
•
•
•
•
ANTINEOPLASTIC AGENTS
ANTINEOPLASTICS
CAPRELSA- vandetanib tab 100 mg
P
CAPRELSA- vandetanib tab 300 mg
P
COMETRIQ- cabozantinib s-malate
cap 3 x 20 mg (60 mg dose) kit
P
•
•
•
•
•
COMETRIQ- cabozantinib s-mal cap 1
x 80 mg & 1 x 20 mg (100 dose) kit
P
• •
•
COMETRIQ- cabozantinib s-mal cap 1
x 80 mg & 3 x 20 mg (140 dose) kit
P
• •
•
COTELLIC- cobimetinib fumarate tab
20 mg (base equivalent)
P
• •
•
CYCLOPHOSPHAMIDEcyclophosphamide cap 25 mg
P
CYCLOPHOSPHAMIDEcyclophosphamide cap 50 mg
P
capecitabine tab 500 mg (Xeloda)
•
ACTIMMUNE- interferon gamma-1b
inj 100 mcg/0.5ml (2000000
unit/0.5ml)
P
•
AFINITOR- everolimus tab 2.5 mg
P
• •
•
• •
•
•
•
•
•
•
•
•
•
• •
• •
• •
P
NP
•
p
BOSULIF- bosutinib tab 100 mg
GRASTEK- timothy grass pollen
allergen ext tab sl 2800 bau
•
np
•
•
•
•
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
np
12
ELIGARD- leuprolide acetate (6
month) for subcutaneous inj kit
45 mg
NP
EMCYT- estramustine phosphate
sodium cap 140 mg
P
ERIVEDGE- vismodegib cap 150 mg
P
ETOPOSIDE- etoposide cap 50 mg
P
exemestane tab 25 mg (Aromasin)
np
•
•
• •
•
FARESTON- toremifene citrate tab
60 mg (base equivalent)
P
FARYDAK- panobinostat lactate cap
10 mg (base equivalent)
P
• •
•
FARYDAK- panobinostat lactate cap
15 mg (base equivalent)
P
• •
•
FARYDAK- panobinostat lactate cap
20 mg (base equivalent)
P
• •
•
flutamide cap 125 mg
np
• •
•
• •
•
• •
•
P
•
•
•
•
•
•
•
•
ICLUSIG- ponatinib hcl tab 45 mg
(base equiv)
P
• •
•
imatinib mesylate tab 100 mg (base
equivalent) (Gleevec)
np
• •
•
np
• •
•
IMBRUVICA- ibrutinib cap 140 mg
P
INLYTA- axitinib tab 1 mg
P
INLYTA- axitinib tab 5 mg
P
•
•
•
INTRON A- interferon alfa-2b inj
6000000 unit/ml
P
• •
• •
• •
•
INTRON A- interferon alfa-2b inj
10000000 unit/ml
P
•
INTRON A- interferon alfa-2b for inj
10000000 unit
P
•
INTRON A- interferon alfa-2b for inj
18000000 unit
P
•
INTRON A- interferon alfa-2b for inj
50000000 unit
P
•
INTRON A W/DILUENT- interferon
alfa-2b for inj 10000000 unit
P
•
INTRON A W/DILUENT- interferon
alfa-2b for inj 18000000 unit
P
•
P
•
•
•
np
IBRANCE- palbociclib cap 75 mg
P
IBRANCE- palbociclib cap 100 mg
P
IBRANCE- palbociclib cap 125 mg
P
ICLUSIG- ponatinib hcl tab 15 mg
(base equiv)
imatinib mesylate tab 400 mg (base
equivalent) (Gleevec)
Dispensing Limits
NP
•
•
•
•
hydroxyurea cap 500 mg (Hydrea)
Step Therapy
ELIGARD- leuprolide acetate (4
month) for subcutaneous inj kit
30 mg
Prior Authorization
•
Specialty
ELIGARD- leuprolide acetate (3
month) for subcutaneous inj kit
22.5mg
NP
Drug Name
Tier Designation
•
Dispensing Limits
NP
Step Therapy
ELIGARD- leuprolide acetate for
subcutaneous inj kit 7.5 mg
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
GILOTRIF- afatinib dimaleate tab
20 mg (base equivalent)
P
GILOTRIF- afatinib dimaleate tab
30 mg (base equivalent)
P
GILOTRIF- afatinib dimaleate tab
40 mg (base equivalent)
P
GLEOSTINE- lomustine cap 5 mg
P
INTRON A W/DILUENT- interferon
alfa-2b for inj 50000000 unit
GLEOSTINE- lomustine cap 10 mg
P
IRESSA- gefitinib tab 250 mg
P
GLEOSTINE- lomustine cap 40 mg
P
P
GLEOSTINE- lomustine cap 100 mg
P
JAKAFI- ruxolitinib phosphate tab
5 mg (base equivalent)
• •
• •
HEXALEN- altretamine cap 50 mg
P
• •
•
P
JAKAFI- ruxolitinib phosphate tab
10 mg (base equivalent)
P
HYCAMTIN- topotecan hcl cap
0.25 mg (base equiv)
• •
• •
P
• •
•
HYCAMTIN- topotecan hcl cap 1 mg
(base equiv)
P
• •
JAKAFI- ruxolitinib phosphate tab
15 mg (base equivalent)
JAKAFI- ruxolitinib phosphate tab
20 mg (base equivalent)
P
• •
•
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
13
• •
•
LENVIMA 10 MG DAILY DOSElenvatinib cap therapy pack 10 mg
(10 mg daily dose)
P
• •
•
LENVIMA 14 MG DAILY DOSElenvatinib cap therapy pack 10 &
4 mg (14 mg daily dose)
P
LENVIMA 18 MG DAILY DOSElenvatinib cap therapy pack 10 & 4
(2) mg (18 mg daily dose)
P
• •
LENVIMA 20 MG DAILY DOSElenvatinib cap therapy pack 10
(2) mg (20 mg daily dose)
P
LENVIMA 24 MG DAILY DOSElenvatinib cap therapy pack 10 (2) &
4 mg (24 mg daily dose)
•
megestrol acetate tab 20 mg
megestrol acetate tab 40 mg
p
p
MEKINIST- trametinib dimethyl
sulfoxide tab 0.5 mg (base
equivalent)
P
• •
•
MEKINIST- trametinib dimethyl
sulfoxide tab 2 mg (base equivalent)
P
• •
•
mercaptopurine tab 50 mg
np
• •
•
MESNEX- mesna tab 400 mg
P
•
METHOTREXATE SODIUMmethotrexate sodium inj
250 mg/10ml (25 mg/ml)
NP
• •
•
methotrexate sodium for inj 1 gm
np
P
• •
•
LENVIMA 8 MG DAILY DOSElenvatinib cap therapy pack 4 (2) mg
(8 mg daily dose)
P
• •
•
letrozole tab 2.5 mg (Femara)
p
methotrexate sodium inj pf
50 mg/2ml (25 mg/ml)
methotrexate sodium inj pf
100 mg/4ml (25 mg/ml)
methotrexate sodium inj pf
200 mg/8ml (25 mg/ml)
methotrexate sodium inj pf
250 mg/10ml (25 mg/ml)
LEUCOVORIN CALCIUM- leucovorin
calcium tab 10 mg
P
methotrexate sodium inj pf
1000 mg/40ml (25 mg/ml)
LEUCOVORIN CALCIUM- leucovorin
calcium tab 15 mg
P
methotrexate sodium inj 50 mg/2ml
(25 mg/ml)
leucovorin calcium tab 5 mg
np
methotrexate sodium tab 2.5 mg
(base equiv)
leucovorin calcium tab 25 mg
np
LEUKERAN- chlorambucil tab 2 mg
P
leuprolide acetate inj kit 5 mg/ml
np
LONSURF- trifluridine-tipiracil tab
15-6.14 mg
P
LONSURF- trifluridine-tipiracil tab
20-8.19 mg
P
LYNPARZA- olaparib cap 50 mg
P
LYSODREN- mitotane tab 500 mg
P
MATULANE- procarbazine hcl cap
50 mg
P
megestrol acetate susp 40 mg/ml
(Megace oral)
np
•
• •
•
• •
•
• •
• •
• •
•
Dispensing Limits
KISQALI- ribociclib succinate tab
200 mg (base equiv)
P
• •
•
Step Therapy
• •
Prior Authorization
P
Specialty
JAKAFI- ruxolitinib phosphate tab
25 mg (base equivalent)
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
p
np
np
p
np
p
np
MYLERAN- busulfan tab 2 mg
P
NEXAVAR- sorafenib tosylate tab
200 mg (base equivalent)
P
nilutamide tab 150 mg (Nilandron)
np
NINLARO- ixazomib citrate cap
2.3 mg (base equivalent)
P
• •
•
NINLARO- ixazomib citrate cap 3 mg
(base equivalent)
P
• •
•
NINLARO- ixazomib citrate cap 4 mg
(base equivalent)
P
• •
•
ODOMZO- sonidegib phosphate cap
200 mg (base equivalent)
P
• •
•
POMALYST- pomalidomide cap 1 mg
P
• •
•
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
14
P
POMALYST- pomalidomide cap 4 mg
P
PURIXAN- mercaptopurine susp
2000 mg/100ml (20 mg/ml)
P
RUBRACA- rucaparib camsylate tab
200 mg (base equivalent)
NP
• •
•
RUBRACA- rucaparib camsylate tab
300 mg (base equivalent)
NP
• •
•
SOLTAMOX- tamoxifen citrate oral
soln 10 mg/5ml (base equivalent)
NP
P
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
SUTENT- sunitinib malate cap 25 mg
(base equivalent)
P
• •
•
SUTENT- sunitinib malate cap
37.5 mg (base equivalent)
P
• •
•
SUTENT- sunitinib malate cap 50 mg
(base equivalent)
P
• •
•
SYLATRON- peginterferon alfa-2b for
inj kit 200 mcg
P
• •
SYLATRON- peginterferon alfa-2b for
inj kit 300 mcg
P
• •
SYLATRON- peginterferon alfa-2b for
inj kit 600 mcg
P
• •
SYNRIBO- omacetaxine
mepesuccinate for inj 3.5 mg
P
•
TABLOID- thioguanine tab 40 mg
P
TAFINLAR- dabrafenib mesylate cap
50 mg (base equivalent)
P
TAFINLAR- dabrafenib mesylate cap
75 mg (base equivalent)
P
SPRYCEL- dasatinib tab 20 mg
P
SPRYCEL- dasatinib tab 50 mg
P
SPRYCEL- dasatinib tab 70 mg
P
SPRYCEL- dasatinib tab 80 mg
P
SPRYCEL- dasatinib tab 100 mg
P
SPRYCEL- dasatinib tab 140 mg
P
STIVARGA- regorafenib tab 40 mg
P
SUTENT- sunitinib malate cap
12.5 mg (base equivalent)
• •
•
• •
•
Dispensing Limits
•
•
•
Step Therapy
POMALYST- pomalidomide cap 3 mg
• •
• •
• •
•
Prior Authorization
P
Specialty
POMALYST- pomalidomide cap 2 mg
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
TAGRISSO- osimertinib mesylate tab
40 mg (base equivalent)
P
• •
TAGRISSO- osimertinib mesylate tab
80 mg (base equivalent)
P
• •
•
tamoxifen citrate tab 10 mg (base
equivalent)
p
tamoxifen citrate tab 20 mg (base
equivalent)
•
p
TARCEVA- erlotinib hcl tab 25 mg
(base equivalent)
P
• •
•
TARCEVA- erlotinib hcl tab 100 mg
(base equivalent)
P
• •
•
TARCEVA- erlotinib hcl tab 150 mg
(base equivalent)
P
• •
•
TASIGNA- nilotinib hcl cap 150 mg
(base equivalent)
P
• •
•
TASIGNA- nilotinib hcl cap 200 mg
(base equivalent)
P
• •
•
temozolomide cap 5 mg (Temodar)
np
• •
• •
• •
temozolomide cap 20 mg (Temodar) np
np
temozolomide cap 100 mg
(Temodar)
np
temozolomide cap 140 mg
(Temodar)
np
temozolomide cap 180 mg
(Temodar)
np
temozolomide cap 250 mg
(Temodar)
np
tretinoin cap 10 mg
TREXALL- methotrexate sodium tab
5 mg (base equiv)
NP
TREXALL- methotrexate sodium tab
7.5 mg (base equiv)
NP
TREXALL- methotrexate sodium tab
10 mg (base equiv)
NP
TREXALL- methotrexate sodium tab
15 mg (base equiv)
NP
TYKERB- lapatinib ditosylate tab
250 mg (base equiv)
VENCLEXTA- venetoclax tab 10 mg
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
• •
• •
• •
• •
P
• •
•
NP
• •
•
15
VOTRIENT- pazopanib hcl tab
200 mg (base equiv)
P
• •
•
XALKORI- crizotinib cap 200 mg
P
XALKORI- crizotinib cap 250 mg
P
XTANDI- enzalutamide cap 40 mg
P
ZELBORAF- vemurafenib tab 240 mg
P
ZOLINZA- vorinostat cap 100 mg
P
ZYDELIG- idelalisib tab 100 mg
P
ZYDELIG- idelalisib tab 150 mg
P
ZYKADIA- ceritinib cap 150 mg
P
ZYTIGA- abiraterone acetate tab
250 mg
P
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
ZYTIGA- abiraterone acetate tab
500 mg
P
• •
•
ENDOCRINE AND METABOLIC DRUGS
CORTICOSTEROIDS
budesonide delayed release
particles cap 3 mg (Entocort ec)
CORTISONE ACETATE- cortisone
acetate tab 25 mg
np
P
DEXAMETHASONE- dexamethasone NP
soln 0.5 mg/5ml
DEXAMETHASONE- dexamethasone NP
tab 1 mg
DEXAMETHASONE- dexamethasone NP
tab 2 mg
np
dexamethasone elixir 0.5 mg/5ml
DEXAMETHASONE INTENSOLdexamethasone conc 1 mg/ml
dexamethasone tab 0.5 mg
dexamethasone tab 0.75 mg
dexamethasone tab 1.5 mg
dexamethasone tab 4 mg
dexamethasone tab 6 mg
NP
p
p
p
p
p
Dispensing Limits
NP
Step Therapy
VENCLEXTA STARTING PACKvenetoclax tab therapy starter pack
10 & 50 & 100 mg
Prior Authorization
NP
•
•
•
Specialty
VENCLEXTA- venetoclax tab 100 mg
• •
• •
• •
Drug Name
Tier Designation
Dispensing Limits
NP
Step Therapy
VENCLEXTA- venetoclax tab 50 mg
Specialty
Drug Name
Tier Designation
Prior Authorization
2017
DEXPAK 10 DAY- dexamethasone tab NC
therapy pack 1.5 mg (35)
DEXPAK 13 DAY- dexamethasone tab NC
therapy pack 1.5 mg (51)
DEXPAK 6 DAY- dexamethasone tab NC
therapy pack 1.5 mg (21)
NC
EMFLAZA- deflazacort susp
22.75 mg/ml
NC
EMFLAZA- deflazacort tab 6 mg
EMFLAZA- deflazacort tab 18 mg
NC
EMFLAZA- deflazacort tab 30 mg
NC
EMFLAZA- deflazacort tab 36 mg
NC
fludrocortisone acetate tab 0.1 mg
hydrocortisone tab 5 mg (Cortef)
hydrocortisone tab 10 mg (Cortef)
hydrocortisone tab 20 mg (Cortef)
p
np
np
np
LOCORT 11-DAY- dexamethasone
tab therapy pack 1.5 mg (41)
NC
LOCORT 7-DAY- dexamethasone tab
therapy pack 1.5 mg (27)
NC
MEDROL- methylprednisolone tab
2 mg
NP
methylprednisolone tab therapy
pack 4 mg (21) (Medrol dosepak)
methylprednisolone tab 4 mg
(Medrol)
methylprednisolone tab 8 mg
(Medrol)
methylprednisolone tab 16 mg
(Medrol)
methylprednisolone tab 32 mg
(Medrol)
p
np
np
np
p
MILLIPRED- prednisolone tab 5 mg
NP
MILLIPRED- prednisolone sod
phosphate oral soln 10 mg/5ml
(base equiv)
NP
MILLIPRED DP- prednisolone tab
therapy pack 5 mg (21)
NP
MILLIPRED DP- prednisolone tab
therapy pack 5 mg (48)
NP
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
16
prednisolone sod phos orally
disintegr tab 10 mg (base eq)
(Orapred odt)
prednisolone sod phos orally
disintegr tab 15 mg (base eq)
(Orapred odt)
prednisolone sod phos orally
disintegr tab 30 mg (base eq)
(Orapred odt)
prednisolone sod phosph oral
soln 6.7 mg/5ml (5 mg/5ml base)
(Pediapred)
prednisolone sod phosphate oral
soln 15 mg/5ml (base equiv)
prednisolone sod phosphate oral
soln 10 mg/5ml (base equiv)
(Millipred)
prednisolone sod phosphate oral
soln 20 mg/5ml (base equiv)
(Veripred 20)
np
prednisone tab 10 mg
RAYOS- prednisone tab delayed
release 2 mg
NC
RAYOS- prednisone tab delayed
release 5 mg
NC
np
UCERIS- budesonide tab sr 24hr
9 mg
NC
NP
p
VERIPRED 20- prednisolone sod
phosphate oral soln 20 mg/5ml
(base equiv)
np
np
p
PREDNISONE- prednisone tab 50 mg NP
P
PREDNISONE- prednisone oral soln
5 mg/5ml
NP
PREDNISONE- prednisone tab
therapy pack 5 mg (21)
NP
PREDNISONE- prednisone tab
therapy pack 5 mg (48)
NP
PREDNISONE- prednisone tab
therapy pack 10 mg (21)
NP
PREDNISONE- prednisone tab
therapy pack 10 mg (48)
NP
PREDNISONE INTENSOLprednisone conc 5 mg/ml
p
prednisone tab 1 mg
p
p
Dispensing Limits
Step Therapy
ZONACORT 11 DAY- dexamethasone NC
tab therapy pack 1.5 mg (41)
ZONACORT 7 DAY- dexamethasone NC
tab therapy pack 1.5 mg (27)
ANDROGEN-ANABOLIC
prednisolone syrup 15 mg/5ml (usp
solution equivalent)
Prior Authorization
p
NC
np
Specialty
Dispensing Limits
Step Therapy
Prior Authorization
Tier Designation
p
RAYOS- prednisone tab delayed
release 1 mg
np
PREDNISOLONE SODIUM PHOSPprednisolone sodium phosphate oral
soln 25 mg/5ml (base eq)
prednisone tab 5 mg
Drug Name
prednisone tab 20 mg
NP
prednisone tab 2.5 mg
Specialty
Drug Name
Tier Designation
2017
ANADROL-50- oxymetholone tab
50 mg
NP
ANDRODERM- testosterone td patch
24hr 2 mg/24hr
NC
ANDRODERM- testosterone td patch
24hr 4 mg/24hr
NC
•
ANDROGEL- testosterone td gel
20.25 mg/1.25gm (1.62%)
P
•
•
ANDROGEL- testosterone td gel
40.5 mg/2.5gm (1.62%)
P
•
•
ANDROGEL PUMP- testosterone
td gel 20.25 mg/act (1.62%)
P
•
•
ANDROXY- fluoxymesterone tab
10 mg
P
•
AVEED- testosterone undecanoate im NC
inj in oil 750 mg/3ml (250mg/ml)
P
AXIRON- testosterone td soln 30 mg/
act
np
danazol cap 50 mg
danazol cap 100 mg
danazol cap 200 mg
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
np
np
•
•
•
•
•
17
FORTESTA- testosterone td gel
10mg/act (2%)
NC
METHITEST- methyltestosterone oral
tab 10 mg
NP
•
methyltestosterone cap 10 mg
(Testred)
np
•
NATESTO- testosterone nasal gel
5.5 mg/act
NC
oxandrolone tab 2.5 mg (Oxandrin)
np
oxandrolone tab 10 mg (Oxandrin)
np
STRIANT- testosterone buccal
mucoadhesive system 30 mg
NC
TESTIM- testosterone td gel
50 mg/5gm (1%)
NC
TESTOSTERONE- testosterone td gel NC
25 mg/2.5gm (1%)
TESTOSTERONE- testosterone td gel NC
50 mg/5gm (1%)
TESTOSTERONE- testosterone td gel NC
10mg/act (2%)
p
testosterone cypionate im inj in oil
100 mg/ml (Depo-testosterone)
testosterone cypionate im inj in oil np
200 mg/ml (Depo-testosterone)
testosterone enanthate im inj in oil np
200 mg/ml
NC
TESTOSTERONE PUMPtestosterone td gel 12.5 mg/act (1%)
np
testosterone td gel 25 mg/2.5gm
(1%) (Androgel)
testosterone td gel 50 mg/5gm (1%) np
(Androgel)
testosterone td gel 12.5 mg/act (1%) np
•
•
ALORA- estradiol td patch twice
weekly 0.05 mg/24hr
NP
ALORA- estradiol td patch twice
weekly 0.075 mg/24hr
NP
ALORA- estradiol td patch twice
weekly 0.1 mg/24hr
NP
ANGELIQ- drospirenone-estradiol tab
0.25-0.5 mg
NP
ANGELIQ- drospirenone-estradiol tab
0.5-1 mg
NP
CLIMARA PRO- estradiollevonorgestrel td patch weekly
0.045-0.015 mg/day
•
•
•
•
•
•
•
•
•
•
•
•
COMBIPATCH- estradiolnorethindrone ace td pttw
0.05-0.14 mg/day
NP
COMBIPATCH- estradiolnorethindrone ace td pttw
0.05-0.25 mg/day
NP
DELESTROGEN- estradiol valerate
im in oil 10 mg/ml
NP
DEPO-ESTRADIOL- estradiol
cypionate im in oil 5 mg/ml
NP
DIVIGEL- estradiol td gel
0.25 mg/0.25gm (0.1%)
P
DIVIGEL- estradiol td gel
0.5 mg/0.5gm (0.1%)
P
DIVIGEL- estradiol td gel 1 mg/gm
(0.1%)
P
NP
ELESTRIN- estradiol gel 0.06%
(0.52 mg/0.87 gm metered-dose
pump)
NP
NC
estradiol & norethindrone acetate
tab 0.5-0.1 mg (Activella)
np
VOGELXO PUMP- testosterone td gel NC
12.5 mg/act (1%)
estradiol & norethindrone acetate
tab 1-0.5 mg (Activella)
ESTROGENS
estradiol tab 0.5 mg (Estrace)
ALORA- estradiol td patch twice
weekly 0.025 mg/24hr
NP
estradiol tab 1 mg (Estrace)
estradiol tab 2 mg (Estrace)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
Step Therapy
Prior Authorization
P
DUAVEE- conjugated estrogensbazedoxifene tab 0.45-20 mg
VOGELXO- testosterone td gel
50 mg/5gm (1%)
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
np
p
p
p
18
estradiol td patch twice weekly
0.025 mg/24hr (Vivelle-dot)
estradiol td patch twice weekly
0.0375 mg/24hr (Vivelle-dot)
estradiol td patch twice weekly
0.05 mg/24hr (Vivelle-dot)
estradiol td patch twice weekly
0.075 mg/24hr (Vivelle-dot)
estradiol td patch twice weekly
0.1 mg/24hr (Vivelle-dot)
estradiol td patch weekly
0.025 mg/24hr (Climara)
estradiol td patch weekly
0.0375 mg/24hr (37.5 mcg/24hr)
(Climara)
estradiol td patch weekly
0.05 mg/24hr (Climara)
estradiol td patch weekly
0.06 mg/24hr (Climara)
estradiol td patch weekly
0.075 mg/24hr (Climara)
estradiol td patch weekly
0.1 mg/24hr (Climara)
np
MENEST- esterified estrogens tab
1.25 mg
NP
np
MENOSTAR- estradiol td patch
weekly 14 mcg/24hr
NP
np
MINIVELLE- estradiol td patch twice
weekly 0.025 mg/24hr
NP
np
MINIVELLE- estradiol td patch twice
weekly 0.0375 mg/24hr
NP
np
MINIVELLE- estradiol td patch twice
weekly 0.05 mg/24hr
NP
np
MINIVELLE- estradiol td patch twice
weekly 0.075 mg/24hr
NP
np
MINIVELLE- estradiol td patch twice
weekly 0.1 mg/24hr
NP
norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg
(Femhrt low dose)
np
np
np
np
np
estradiol valerate im in oil 20 mg/ml np
(Delestrogen)
estradiol valerate im in oil 40 mg/ml np
(Delestrogen)
P
ESTROGEL- estradiol gel 0.06%
(0.75 mg/1.25 gm metered-dose
pump)
NP
ESTROPIPATE- estropipate tab
0.75 mg
NP
ESTROPIPATE- estropipate tab
1.5 mg
ESTROPIPATE- estropipate tab 3 mg NP
EVAMIST- estradiol transdermal spray NP
1.53 mg/spray
NP
MENEST- esterified estrogens tab
0.3 mg
NP
MENEST- esterified estrogens tab
0.625 mg
norethindrone acetate-ethinyl
estradiol tab 1 mg-5 mcg
Dispensing Limits
Step Therapy
Prior Authorization
np
PREFEST- estradiol tab 1 mg(15)/
estrad-norgestimate tab
1-0.09mg(15)
NP
PREMARIN- estrogens, conjugated
tab 0.3 mg
NP
PREMARIN- estrogens, conjugated
tab 0.45 mg
NP
PREMARIN- estrogens, conjugated
tab 0.625 mg
NP
PREMARIN- estrogens, conjugated
tab 0.9 mg
NP
PREMARIN- estrogens, conjugated
tab 1.25 mg
NP
PREMPHASE- conj est 0.625(14)/
conj est-medroxypro ac tab
0.625-5mg(14)
NP
PREMPRO- conjugated estrogenmedroxyprogest acetate tab
0.3-1.5 mg
NP
PREMPRO- conjugated estrogenmedroxyprogest acetate tab
0.45-1.5 mg
NP
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
19
PREMPRO- conjugated estrogenmedroxyprogest acetate tab
0.625-2.5 mg
NP
PREMPRO- conjugated estrogenmedroxyprogest acetate tab
0.625-5 mg
NP
CONTRACEPTIVES
NP
desogest-eth estrad & eth estrad
tab 0.15-0.02/0.01 mg(21/5)
(Mircette)
np
np
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg (Cyclessa)
p
desogestrel & ethinyl estradiol tab
0.15 mg-30 mcg (Desogen)
np
drospirenone-ethinyl estradlevomefolate tab 3-0.02-0.451 mg
(Beyaz)
np
drospirenone-ethinyl estradiol tab
3-0.02 mg (Yaz)
np
drospirenone-ethinyl estradiol tab
3-0.03 mg (Yasmin 28)
P
ELLA- ulipristal acetate tab 30 mg
ethynodiol diacetate & ethinyl
estradiol tab 1 mg-50 mcg
np
np
FALESSA- levonorgest-eth estrad tab
0.1 mg-20 mcg & fa tab 1 mg kit
NP
levonor-eth est tab
0.15-0.02/0.025/0.03 mg &eth est
0.01 mg (Quartette)
np
levonorg-eth est tab 0.1-0.02mg(84)
& eth est tab 0.01mg(7)
(Loseasonique)
levonorg-eth est tab
0.15-0.03mg(84) & eth est tab
0.01mg(7) (Seasonique)
levonorgestrel & ethinyl estradiol
(91-day) tab 0.15-0.03 mg
levonorgestrel & ethinyl estradiol
tab 0.1 mg-20 mcg
np
np
Dispensing Limits
p
levonorgestrel tab 1.5 mg
np
p
LO LOESTRIN FE- norethin-eth
estradiol-fe tab 1 mg-10 mcg
(24)/10 mcg (2)
NP
medroxyprogesterone acetate im
susp prefilled syr 150 mg/ml
(Depo-provera contrac)
np
MINASTRIN 24 FE- norethindrone
ace-eth estradiol-fe chew tab
1 mg-20 mcg (24)
Step Therapy
p
np
medroxyprogesterone acetate im
susp 150 mg/ml (Depo-provera
contrac)
Prior Authorization
np
LEVONORGESTREL AND ETHINYlevonorgestrel-ethinyl estradiol
(continuous) tab 90-20 mcg
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg
Specialty
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
levonorgestrel & ethinyl estradiol
tab 0.15 mg-30 mcg
DEPO-SUBQ PROVERA 104medroxyprogesterone acetate susp
pref syr 104 mg/0.65ml
ethynodiol diacetate & ethinyl
estradiol tab 1 mg-35 mcg
Specialty
Drug Name
Tier Designation
2017
np
NP
NATAZIA- estradiol valerate-dienogest NP
tab 3 mg /2-2 mg/2-3 mg/1 mg
P
NECON 1/50-28- norethindrone &
mestranol tab 1 mg-50 mcg
P
NECON 10/11-28- norethindrone-eth
estradiol tab 0.5-35/1-35 mg-mcg
(10/11)
np
norethindrone & ethinyl estradiol
tab 0.4 mg-35 mcg (Ovcon-35)
p
norethindrone & ethinyl estradiol
tab 0.5 mg-35 mcg (Brevicon-28)
p
norethindrone & ethinyl estradiol
tab 1 mg-35 mcg (Norinyl 1+35)
norethindrone & ethinyl estradiol-fe np
chew tab 0.4 mg-35 mcg (Femcon
fe)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
20
norethindrone & ethinyl estradiolfe chew tab 0.8 mg-25 mcg
(Generess fe)
norethindrone ac-ethinyl estradfe tab 1-20/1-30/1-35 mg-mcg
(Estrostep fe)
norethindrone ace & ethinyl
estradiol tab 1 mg-20 mcg
(Loestrin 1/20-21)
norethindrone ace & ethinyl
estradiol tab 1.5 mg-30 mcg
(Loestrin 1.5/30-21)
norethindrone ace & ethinyl
estradiol-fe tab 1 mg-20 mcg
(Loestrin fe 1/20)
norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg
(Loestrin fe 1.5/30)
norethindrone ace-eth estradiolfe chew tab 1 mg-20 mcg (24)
(Minastrin 24 fe)
np
NUVARING- etonogestrelethinyl estradiol va ring
0.120-0.015 mg/24hr
P
np
OGESTREL- norgestrel & ethinyl
estradiol tab 0.5 mg-50 mcg
P
p
QUARTETTE- levonor-eth est tab
0.15-0.02/0.025/0.03 mg &eth est
0.01 mg
NP
np
SAFYRAL- drospirenoneethinyl estrad-levomefolate tab
3-0.03-0.451 mg
NP
p
p
np
norethindrone ace-ethinyl estradiol- np
fe tab 1 mg-20 mcg (24)
p
norethindrone tab 0.35 mg (Ortho
micronor)
np
norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg
(Ortho-novum 7/7/7)
np
norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg (Trinorinyl 28)
norgestimate & ethinyl estradiol tab p
0.25 mg-35 mcg (Ortho-cyclen)
np
norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg
(Ortho tri-cyclen lo)
p
norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg
(Ortho tri-cyclen)
p
norgestrel & ethinyl estradiol tab
0.3 mg-30 mcg
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
TAYTULLA- norethindrone ace-ethinyl NC
estradiol-fe cap 1 mg-20 mcg (24)
P
XULANE- norelgestromin-ethinyl
estradiol td ptwk 150-35 mcg/24hr
PROGESTINS
medroxyprogesterone acetate tab
2.5 mg (Provera)
medroxyprogesterone acetate tab
5 mg (Provera)
medroxyprogesterone acetate tab
10 mg (Provera)
megestrol acetate susp 625 mg/5ml
(Megace es)
norethindrone acetate tab 5 mg
(Aygestin)
progesterone im in oil 50 mg/ml
progesterone micronized cap
100 mg (Prometrium)
progesterone micronized cap
200 mg (Prometrium)
p
p
p
np
np
np
np
np
ANTIDIABETICS
Antidiabetics
acarbose tab 25 mg (Precose)
acarbose tab 50 mg (Precose)
acarbose tab 100 mg (Precose)
ACTOPLUS MET XR- pioglitazone
hcl-metformin hcl tab sr 24hr
15-1000 mg
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
np
np
np
NP
21
ACTOPLUS MET XR- pioglitazone
hcl-metformin hcl tab sr 24hr
30-1000 mg
NP
BYDUREON PEN- exenatide
extended release for susp peninjector 2 mg
NP
ADLYXIN- lixisenatide soln peninjector 20 mcg/0.2ml (100 mcg/ml)
NC
BYETTA- exenatide soln pen-injector
5 mcg/0.02ml
NC
ADLYXIN STARTER PACKlixisenatide pen-inj starter kit
10 mcg/0.2ml & 20 mcg/0.2ml
NC
BYETTA- exenatide soln pen-injector
10 mcg/0.04ml
NC
ALOGLIPTIN- alogliptin benzoate tab
6.25 mg (base equiv)
NC
ALOGLIPTIN- alogliptin benzoate tab
12.5 mg (base equiv)
NC
ALOGLIPTIN- alogliptin benzoate tab
25 mg (base equiv)
NC
ALOGLIPTIN/METFORMIN HCLalogliptin-metformin hcl tab
12.5-500 mg
NC
ALOGLIPTIN/METFORMIN HCLalogliptin-metformin hcl tab
12.5-1000 mg
NC
ALOGLIPTIN/PIOGLITAZONEalogliptin-pioglitazone tab
12.5-15 mg
NC
ALOGLIPTIN/PIOGLITAZONEalogliptin-pioglitazone tab
12.5-30 mg
NC
ALOGLIPTIN/PIOGLITAZONEalogliptin-pioglitazone tab
12.5-45 mg
NC
ALOGLIPTIN/PIOGLITAZONEalogliptin-pioglitazone tab 25-15 mg
NC
ALOGLIPTIN/PIOGLITAZONEalogliptin-pioglitazone tab 25-30 mg
NC
ALOGLIPTIN/PIOGLITAZONEalogliptin-pioglitazone tab 25-45 mg
NC
AVANDIA- rosiglitazone maleate tab
2 mg (base equiv)
NC
AVANDIA- rosiglitazone maleate tab
4 mg (base equiv)
NC
BYDUREON- exenatide for inj
extended release susp 2 mg
NP
CHLORPROPAMIDE- chlorpropamide NP
tab 100 mg
CHLORPROPAMIDE- chlorpropamide NP
tab 250 mg
CYCLOSET- bromocriptine mesylate NC
tab 0.8 mg (base equivalent)
NP
FARXIGA- dapagliflozin propanediol
tab 5 mg (base equivalent)
NP
FARXIGA- dapagliflozin propanediol
tab 10 mg (base equivalent)
p
glimepiride tab 1 mg (Amaryl)
glimepiride tab 2 mg (Amaryl)
glimepiride tab 4 mg (Amaryl)
glipizide tab sr 24hr 2.5 mg
(Glucotrol xl)
glipizide tab sr 24hr 5 mg (Glucotrol
xl)
glipizide tab sr 24hr 10 mg
(Glucotrol xl)
glipizide tab 5 mg (Glucotrol)
glipizide tab 10 mg (Glucotrol)
glipizide-metformin hcl tab
2.5-250 mg
glipizide-metformin hcl tab
2.5-500 mg
glipizide-metformin hcl tab
5-500 mg
•
Dispensing Limits
Step Therapy
Prior Authorization
•
•
•
p
p
p
p
p
p
p
np
np
np
GLUCAGEN HYPOKIT- glucagon hcl
(rdna) for inj 1 mg (base equiv)
NP
GLUCAGON EMERGENCY
KIT- glucagon (rdna) for inj kit 1 mg
P
glyburide micronized tab 1.5 mg
(Glynase)
p
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
22
glyburide micronized tab 3 mg
(Glynase)
glyburide micronized tab 6 mg
(Glynase)
glyburide tab 1.25 mg
glyburide tab 2.5 mg
glyburide tab 5 mg
glyburide-metformin tab
1.25-250 mg
glyburide-metformin tab 2.5-500 mg
(Glucovance)
glyburide-metformin tab 5-500 mg
(Glucovance)
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
p
JANUMET- sitagliptin-metformin hcl
tab 50-1000 mg
P
•
p
JANUMET XR- sitagliptin-metformin
hcl tab sr 24hr 50-500 mg
P
•
p
JANUMET XR- sitagliptin-metformin
hcl tab sr 24hr 50-1000 mg
P
•
JANUMET XR- sitagliptin-metformin
hcl tab sr 24hr 100-1000 mg
P
•
JANUVIA- sitagliptin phosphate tab
25 mg (base equiv)
P
•
JANUVIA- sitagliptin phosphate tab
50 mg (base equiv)
P
•
JANUVIA- sitagliptin phosphate tab
100 mg (base equiv)
P
•
JARDIANCE- empagliflozin tab 10 mg
P
JARDIANCE- empagliflozin tab 25 mg
P
p
p
p
p
p
GLYXAMBI- empagliflozin-linagliptin
tab 10-5 mg
NC
GLYXAMBI- empagliflozin-linagliptin
tab 25-5 mg
NC
•
INVOKAMET- canagliflozin-metformin
hcl tab 50-500 mg
P
INVOKAMET- canagliflozin-metformin
hcl tab 50-1000 mg
P
INVOKAMET- canagliflozin-metformin
hcl tab 150-500 mg
P
INVOKAMET- canagliflozin-metformin
hcl tab 150-1000 mg
P
•
INVOKAMET XR- canagliflozinmetformin hcl tab sr 24hr 50-500 mg
P
•
INVOKAMET XR- canagliflozinmetformin hcl tab sr 24hr
50-1000 mg
P
•
INVOKAMET XR- canagliflozinmetformin hcl tab sr 24hr
150-500 mg
P
•
INVOKAMET XR- canagliflozinmetformin hcl tab sr 24hr
150-1000 mg
P
•
INVOKANA- canagliflozin tab 100 mg
P
INVOKANA- canagliflozin tab 300 mg
P
JANUMET- sitagliptin-metformin hcl
tab 50-500 mg
P
•
•
•
•
•
JENTADUETO- linagliptin-metformin
hcl tab 2.5-500 mg
NP
•
•
•
JENTADUETO- linagliptin-metformin
hcl tab 2.5-850 mg
NP
•
JENTADUETO- linagliptin-metformin
hcl tab 2.5-1000 mg
NP
•
JENTADUETO XR- linagliptinmetformin hcl tab sr 24hr
2.5-1000 mg
NP
•
NP
JENTADUETO XR- linagliptinmetformin hcl tab sr 24hr 5-1000 mg
KAZANO- alogliptin-metformin hcl tab NC
12.5-500 mg
KAZANO- alogliptin-metformin hcl tab NC
12.5-1000 mg
P
KOMBIGLYZE XR- saxagliptinmetformin hcl tab sr 24hr
2.5-1000 mg
P
KOMBIGLYZE XR- saxagliptinmetformin hcl tab sr 24hr 5-500 mg
P
KOMBIGLYZE XR- saxagliptinmetformin hcl tab sr 24hr 5-1000 mg
NP
KORLYM- mifepristone tab 300 mg
•
metformin hcl tab sr 24hr 500 mg
(Glucophage xr)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
p
•
•
•
• •
•
•
23
metformin hcl tab sr 24hr 750 mg
(Glucophage xr)
metformin hcl tab sr 24hr osmotic
500 mg (Fortamet)
metformin hcl tab sr 24hr osmotic
1000 mg (Fortamet)
metformin hcl tab sr 24hr modified
release 500 mg (Glumetza)
metformin hcl tab sr 24hr modified
release 1000 mg (Glumetza)
metformin hcl tab 500 mg
(Glucophage)
metformin hcl tab 850 mg
(Glucophage)
metformin hcl tab 1000 mg
(Glucophage)
miglitol tab 25 mg (Glyset)
miglitol tab 50 mg (Glyset)
miglitol tab 100 mg (Glyset)
nateglinide tab 60 mg (Starlix)
nateglinide tab 120 mg (Starlix)
np
•
NC
pioglitazone hcl-glimepiride tab
30-4 mg (Duetact)
p
pioglitazone hcl-metformin hcl tab
15-500 mg (Actoplus met)
np
np
np
np
NESINA- alogliptin benzoate tab
25 mg (base equiv)
NC
p
p
NC
NC
np
pioglitazone hcl-metformin hcl tab
15-850 mg (Actoplus met)
np
repaglinide tab 1 mg (Prandin)
np
PROGLYCEM- diazoxide susp 50 mg/ NP
ml
np
repaglinide tab 0.5 mg
np
NC
p
pioglitazone hcl-glimepiride tab
30-2 mg (Duetact)
p
NESINA- alogliptin benzoate tab
12.5 mg (base equiv)
pioglitazone hcl tab 15 mg (base
equiv) (Actos)
pioglitazone hcl tab 45 mg (base
equiv) (Actos)
p
NC
NC
pioglitazone hcl tab 30 mg (base
equiv) (Actos)
NC
NESINA- alogliptin benzoate tab
6.25 mg (base equiv)
OSENI- alogliptin-pioglitazone tab
25-45 mg
repaglinide tab 2 mg (Prandin)
np
REPAGLINIDE/METFORMIN HYDrepaglinide-metformin hcl tab
1-500 mg
NP
NP
ONGLYZA- saxagliptin hcl tab 2.5 mg
(base equiv)
P
•
REPAGLINIDE/METFORMIN HYDrepaglinide-metformin hcl tab
2-500 mg
ONGLYZA- saxagliptin hcl tab 5 mg
(base equiv)
P
•
RIOMET- metformin hcl oral soln
500 mg/5ml
NC
SOLIQUA 100/33- insulin glarginelixisenatide sol pen-inj 100-33 unitmcg/ml
NC
OSENI- alogliptin-pioglitazone tab
12.5-15 mg
NC
OSENI- alogliptin-pioglitazone tab
12.5-30 mg
NC
OSENI- alogliptin-pioglitazone tab
12.5-45 mg
NC
OSENI- alogliptin-pioglitazone tab
25-15 mg
NC
Dispensing Limits
•
NC
Step Therapy
np
OSENI- alogliptin-pioglitazone tab
25-30 mg
Prior Authorization
•
Specialty
p
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
SYMLINPEN 120- pramlintide acetate NP
pen-inj 2700 mcg/2.7ml (1000 mcg/
ml)
NP
SYMLINPEN 60- pramlintide acetate
pen-inj 1500 mcg/1.5ml (1000 mcg/
ml)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
24
P
•
SYNJARDY- empagliflozin-metformin
hcl tab 12.5-500 mg
P
•
SYNJARDY- empagliflozin-metformin
hcl tab 12.5-1000 mg
P
•
TANZEUM- albiglutide for soln peninjector 30 mg
NP
•
TANZEUM- albiglutide for soln peninjector 50 mg
NP
•
TOLAZAMIDE- tolazamide tab 250 mg NP
TOLAZAMIDE- tolazamide tab 500 mg NP
NC
HUMALOG KWIKPEN- insulin lispro
soln pen-injector 100 unit/ml
NC
HUMALOG KWIKPEN- insulin lispro
soln pen-injector 200 unit/ml
NC
NOVOLOG- insulin aspart inj 100 unit/
ml
P
•
NOVOLOG FLEXPEN- insulin aspart
soln pen-injector 100 unit/ml
P
•
NOVOLOG PENFILL- insulin aspart
soln cartridge 100 unit/ml
P
•
Short-Acting Insulins
NC
TOLBUTAMIDE- tolbutamide tab
500 mg
NP
AFREZZA- insulin regular (human)
inhalation powder 4 unit/cartridge
NP
TRULICITY- dulaglutide soln peninjector 0.75 mg/0.5ml
P
•
•
NC
TRADJENTA- linagliptin tab 5 mg
AFREZZA- insulin regular (human)
inhal powd 4 (30) & 8 (60) unit/cart
AFREZZA- insulin regular (human)
inhal powd 4 (60) & 8 (30) unit/cart
NC
TRULICITY- dulaglutide soln peninjector 1.5 mg/0.5ml
P
•
AFREZZA- insulin regular (human)
inhal powd 4 (90) & 8 (90) unit/cart
NC
VICTOZA- liraglutide soln pen-injector
18 mg/3ml (6 mg/ml)
P
•
XIGDUO XR- dapagliflozin-metformin
hcl tab sr 24hr 5-500 mg
NP
•
XIGDUO XR- dapagliflozin-metformin
hcl tab sr 24hr 5-1000 mg
NP
•
XIGDUO XR- dapagliflozin-metformin
hcl tab sr 24hr 10-500 mg
NP
•
XIGDUO XR- dapagliflozin-metformin
hcl tab sr 24hr 10-1000 mg
NP
•
AFREZZA- insulin regular (human) inh NC
powd 8 (60) & 12 (30) unit/cart
AFREZZA- insulin regular (human) inh NC
powd 4 & 8 & 12 unit/cart (60)
HUMULIN R- insulin regular (human) NC
inj 100 unit/ml
P
HUMULIN R U-500 (CONCENTRinsulin regular (human) inj 500 unit/
ml
HUMULIN R U-500 KWIKPEN- insulin P
regular (human) soln pen-injector
500 unit/ml
P
NOVOLIN R- insulin regular (human)
inj 100 unit/ml
P
NOVOLIN R RELION- insulin regular
(human) inj 100 unit/ml
XULTOPHY 100/3.6- insulin degludec- NC
liraglutide sol pen-inj 100-3.6 unitmg/ml
Rapid-Acting Insulins
APIDRA- insulin glulisine inj 100 unit/
ml
NC
APIDRA SOLOSTAR- insulin glulisine NC
soln pen-injector inj 100 unit/ml
NC
HUMALOG- insulin lispro soln
cartridge 100 unit/ml
Dispensing Limits
SYNJARDY- empagliflozin-metformin
hcl tab 5-1000 mg
HUMALOG- insulin lispro inj 100 unit/
ml
Step Therapy
•
Prior Authorization
P
Specialty
SYNJARDY- empagliflozin-metformin
hcl tab 5-500 mg
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
Intermediate-Acting Insulins
HUMALOG MIX 50/50- insulin lispro
protamine & lispro inj 100 unit/ml
(50-50)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
•
•
•
•
NC
25
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
LANTUS SOLOSTAR- insulin glargine
soln pen-injector 100 unit/ml
P
•
LEVEMIR- insulin detemir inj 100 unit/
ml
P
HUMALOG MIX 75/25- insulin lispro
prot & lispro inj 100 unit/ml (75-25)
NC
•
LEVEMIR FLEXTOUCH- insulin
detemir soln pen-injector 100 unit/ml
P
HUMALOG MIX 75/25 KWIKPENinsulin lispro prot & lispro sus peninj 100 unit/ml (75-25)
NC
•
P
•
HUMULIN N- insulin nph (human)
(isophane) inj 100 unit/ml
NC
TOUJEO SOLOSTAR- insulin glargine
soln pen-injector 300 unit/ml
P
•
HUMULIN N KWIKPEN- insulin nph
(human) (isophane) susp peninjector 100 unit/ml
NC
TRESIBA FLEXTOUCH- insulin
degludec soln pen-injector 100 unit/
ml
TRESIBA FLEXTOUCH- insulin
degludec soln pen-injector 200 unit/
ml
P
•
HUMALOG MIX 50/50 KWIKPENinsulin lispro prot & lispro sus peninj 100 unit/ml (50-50)
NC
HUMULIN 70/30- insulin nph isophane NC
& regular human inj 100 unit/ml
(70-30)
NC
HUMULIN 70/30 KWIKPEN- insulin
nph & regular susp pen-inj 100 unit/
ml (70-30)
P
NOVOLIN N- insulin nph (human)
(isophane) inj 100 unit/ml
P
NOVOLIN N RELION- insulin nph
(human) (isophane) inj 100 unit/ml
NOVOLIN 70/30- insulin nph isophane P
& regular human inj 100 unit/ml
(70-30)
NOVOLIN 70/30 RELION- insulin nph P
isophane & regular human inj 100
unit/ml (70-30)
P
NOVOLOG MIX 70/30- insulin aspart
prot & aspart (human) inj 100 unit/ml
(70-30)
P
NOVOLOG MIX 70/30 PREFILLinsulin aspart prot & aspart sus peninj 100 unit/ml (70-30)
Basal Insulins
BASAGLAR KWIKPENinsulin glargine soln pen-injector
100 unit/ml
LANTUS- insulin glargine inj 100 unit/
ml
THYROID AGENTS
•
•
•
•
•
•
NP
ARMOUR THYROID- thyroid tab
30 mg (1/2 grain)
NP
ARMOUR THYROID- thyroid tab
60 mg (1 grain)
NP
ARMOUR THYROID- thyroid tab
90 mg (1 1/2 grain)
NP
ARMOUR THYROID- thyroid tab
120 mg (2 grain)
NP
ARMOUR THYROID- thyroid tab
180 mg (3 grain)
NP
ARMOUR THYROID- thyroid tab
240 mg (4 grain)
NP
ARMOUR THYROID- thyroid tab
300 mg (5 grain)
NP
levothyroxine sodium tab 25 mcg
(Synthroid)
levothyroxine sodium tab 50 mcg
(Synthroid)
NC
P
ARMOUR THYROID- thyroid tab
15 mg (1/4 grain)
levothyroxine sodium tab 75 mcg
(Synthroid)
•
levothyroxine sodium tab 88 mcg
(Synthroid)
levothyroxine sodium tab 100 mcg
(Synthroid)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
p
p
p
p
p
26
levothyroxine sodium tab 112 mcg
(Synthroid)
levothyroxine sodium tab 125 mcg
(Synthroid)
levothyroxine sodium tab 137 mcg
(Synthroid)
levothyroxine sodium tab 150 mcg
(Synthroid)
levothyroxine sodium tab 175 mcg
(Synthroid)
levothyroxine sodium tab 200 mcg
(Synthroid)
levothyroxine sodium tab 300 mcg
(Synthroid)
liothyronine sodium tab 5 mcg
(Cytomel)
liothyronine sodium tab 25 mcg
(Cytomel)
liothyronine sodium tab 50 mcg
(Cytomel)
methimazole tab 5 mg (Tapazole)
methimazole tab 10 mg (Tapazole)
p
NATURE-THROID- thyroid tab
146.25 mg
p
p
NATURE-THROID NT-2.5- thyroid tab NP
162.5 mg (2 1/2 grain)
np
propylthiouracil tab 50 mg
p
SYNTHROID- levothyroxine sodium
tab 25 mcg
NP
p
SYNTHROID- levothyroxine sodium
tab 50 mcg
NP
p
SYNTHROID- levothyroxine sodium
tab 75 mcg
NP
np
SYNTHROID- levothyroxine sodium
tab 88 mcg
NP
np
SYNTHROID- levothyroxine sodium
tab 100 mcg
NP
np
SYNTHROID- levothyroxine sodium
tab 112 mcg
NP
np
SYNTHROID- levothyroxine sodium
tab 125 mcg
NP
p
SYNTHROID- levothyroxine sodium
tab 137 mcg
NP
NP
p
NATURE-THROID- thyroid tab
16.25 mg
NP
NP
NATURE-THROID- thyroid tab
32.5 mg
NP
SYNTHROID- levothyroxine sodium
tab 175 mcg
NP
NATURE-THROID- thyroid tab
48.75 mg (3/4 grain)
NP
SYNTHROID- levothyroxine sodium
tab 200 mcg
NP
NATURE-THROID- thyroid tab 65 mg
NP
SYNTHROID- levothyroxine sodium
tab 300 mcg
NATURE-THROID- thyroid tab
81.25 mg
NP
thyroid tab 15 mg (1/4 grain)
(Armour thyroid)
np
NATURE-THROID- thyroid tab
97.5 mg
NP
thyroid tab 30 mg (1/2 grain)
(Armour thyroid)
NATURE-THROID- thyroid tab
113.75 mg
NP
thyroid tab 60 mg (1 grain) (Armour
thyroid)
NATURE-THROID- thyroid tab 260 mg NP
NATURE-THROID- thyroid tab 325 mg NP
(5 grain)
thyroid tab 90 mg (1 1/2 grain)
(Armour thyroid)
Dispensing Limits
Step Therapy
Prior Authorization
NP
SYNTHROID- levothyroxine sodium
tab 150 mcg
NATURE-THROID- thyroid tab 130 mg NP
NATURE-THROID- thyroid tab 195 mg NP
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
p
p
p
THYROLAR-1- liotrix (t3-t4) tab 60 mg NP
(12.5-50 mcg)
NP
THYROLAR-1/2- liotrix (t3-t4) tab
30 mg (6.25-25 mcg)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
27
THYROLAR-1/4- liotrix (t3-t4) tab
15 mg (3.1-12.5 mcg)
NP
THYROLAR-2- liotrix (t3-t4) tab
120 mg (25-100 mcg)
NP
THYROLAR-3- liotrix (t3-t4) tab
180 mg (37.5-150 mcg)
NP
TIROSINT- levothyroxine sodium cap
13 mcg
NP
TIROSINT- levothyroxine sodium cap
25 mcg
NP
TIROSINT- levothyroxine sodium cap
50 mcg
NP
TIROSINT- levothyroxine sodium cap
75 mcg
NP
TIROSINT- levothyroxine sodium cap
88 mcg
NP
TIROSINT- levothyroxine sodium cap
100 mcg
NP
TIROSINT- levothyroxine sodium cap
112 mcg
NP
TIROSINT- levothyroxine sodium cap
125 mcg
NP
alendronate sodium tab 70 mg
(Fosamax)
TIROSINT- levothyroxine sodium cap
137 mcg
NP
BINOSTO- alendronate sodium
effervescent tab 70 mg
NC
TIROSINT- levothyroxine sodium cap
150 mcg
NP
BRAVELLE- urofollitropin purified for
inj 75 unit
NC
WESTHROID- thyroid tab 32.5 mg
NP
NP
WESTHROID- thyroid tab 65 mg
NP
BUPHENYL- sodium phenylbutyrate
tab 500 mg
WESTHROID- thyroid tab 97.5 mg
NP
cabergoline tab 0.5 mg
np
WESTHROID- thyroid tab 130 mg
NP
WESTHROID- thyroid tab 195 mg
NP
WP THYROID- thyroid tab 16.25 mg
NP
WP THYROID- thyroid tab 32.5 mg
NP
WP THYROID- thyroid tab 48.75 mg
(3/4 grain)
NP
calcitriol oral soln 1 mcg/ml
(Rocaltrol)
CARBAGLU- carglumic acid tab
200 mg
NP
WP THYROID- thyroid tab 65 mg
NP
• •
WP THYROID- thyroid tab 81.25 mg
NP
NP
•
WP THYROID- thyroid tab 97.5 mg
NP
CETROTIDE- cetrorelix acetate for inj
kit 0.25 mg
WP THYROID- thyroid tab 113.75 mg
NP
chorionic gonadotropin for inj
10000 unit
NC
OXYTOCICS
CERVIDIL- dinoprostone vaginal
inserts 10 mg
NP
METHERGINE- methylergonovine
maleate tab 0.2 mg
NP
PREPIDIL- dinoprostone cervical gel
0.5 mg/3gm
NP
PROSTIN E2- dinoprostone vaginal
suppos 20 mg
NP
Dispensing Limits
Step Therapy
NP
Prior Authorization
WP THYROID- thyroid tab 130 mg
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
ENDOCRINE and METABOLIC AGENTS - MISC.
NP
ALENDRONATE SODIUMalendronate sodium tab 40 mg
NP
ALENDRONATE SODIUMalendronate sodium oral soln
70 mg/75ml
p
alendronate sodium tab 5 mg
alendronate sodium tab 10 mg
alendronate sodium tab 35 mg
calcitonin (salmon) nasal soln 200
unit/act
calcitriol cap 0.25 mcg (Rocaltrol)
calcitriol cap 0.5 mcg (Rocaltrol)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
p
p
p
• •
np
p
np
np
28
CLOMIPHENE CITRATE- clomiphene
citrate tab 50 mg
p
CYSTADANE- betaine powder for oral NP
solution
desmopressin acetate inj 4 mcg/ml np
(Ddavp)
np
desmopressin acetate nasal soln
0.01% (refrigerated) (Ddavp)
np
desmopressin acetate nasal spray
soln 0.01% (Ddavp)
np
desmopressin acetate nasal spray
soln 0.01% (refrigerated)
np
desmopressin acetate tab 0.1 mg
(Ddavp)
np
desmopressin acetate tab 0.2 mg
(Ddavp)
np
doxercalciferol cap 0.5 mcg
(Hectorol)
np
doxercalciferol cap 1 mcg
(Hectorol)
np
doxercalciferol cap 2.5 mcg
(Hectorol)
EGRIFTA- tesamorelin acetate for inj NP
1 mg (base equiv)
EGRIFTA- tesamorelin acetate for inj NP
2 mg (base equiv)
ETIDRONATE DISODIUM- etidronate NC
disodium tab 200 mg
ETIDRONATE DISODIUM- etidronate NC
disodium tab 400 mg
P
FOLLISTIM AQ- follitropin beta inj 75
unit/0.5ml
FOLLISTIM AQ- follitropin beta inj 300 P
unit/0.36ml
FOLLISTIM AQ- follitropin beta inj 600 P
unit/0.72ml
FOLLISTIM AQ- follitropin beta inj 900 P
unit/1.08ml
NP
FORTEO- teriparatide (recombinant)
inj 600 mcg/2.4ml
FOSAMAX PLUS D- alendronate
sodium-cholecalciferol tab
70-2800 mg-unit
NC
FOSAMAX PLUS D- alendronate
sodium-cholecalciferol tab
70-5600 mg-unit
NC
GANIRELIX ACETATE- ganirelix
acetate inj 250 mcg/0.5ml
NP
GENOTROPIN- somatropin for
subcutaneous inj 5 mg
NC
GENOTROPIN- somatropin for inj
12 mg (13.8 mg overfill)
NC
GENOTROPIN MINIQUICKsomatropin for inj 0.2 mg
NC
GENOTROPIN MINIQUICKsomatropin for inj 0.4 mg
NC
GENOTROPIN MINIQUICKsomatropin for inj 0.6 mg
NC
GENOTROPIN MINIQUICKsomatropin for inj 0.8 mg
NC
GENOTROPIN MINIQUICKsomatropin for inj 1 mg
NC
• •
GENOTROPIN MINIQUICKsomatropin for inj 1.2 mg
NC
• •
GENOTROPIN MINIQUICKsomatropin for inj 1.4 mg
NC
GENOTROPIN MINIQUICKsomatropin for inj 1.6 mg
NC
GENOTROPIN MINIQUICKsomatropin for inj 1.8 mg
NC
•
GENOTROPIN MINIQUICKsomatropin for inj 2 mg
NC
•
GONAL-F- follitropin alfa for inj 450
unit
NC
•
GONAL-F- follitropin alfa for inj 1050
unit
NC
•
GONAL-F RFF- follitropin alfa for inj
75 unit
NC
GONAL-F RFF REDIJECT- follitropin
alfa inj 300 unit/0.5ml
NC
• •
•
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
•
29
GONAL-F RFF REDIJECT- follitropin
alfa inj 450 unit/0.75ml
NC
GONAL-F RFF REDIJECT- follitropin
alfa inj 900 unit/1.5ml
NC
H.P. ACTHAR- corticotropin inj gel 80
unit/ml
NP
HUMATROPE- somatropin for inj 5 mg NC
HUMATROPE- somatropin for inj 6 mg NC
(18 unit)
NC
HUMATROPE- somatropin for inj
12 mg (36 unit)
NC
HUMATROPE- somatropin for inj
24 mg
NC
HUMATROPE COMBO PACKsomatropin for inj 5 mg
np
ibandronate sodium tab 150 mg
(base equivalent) (Boniva)
P
INCRELEX- mecasermin inj
40 mg/4ml (10 mg/ml)
NP
KUVAN- sapropterin dihydrochloride
soluble tab 100 mg
NP
KUVAN- sapropterin dihydrochloride
powder packet 100 mg
NP
KUVAN- sapropterin dihydrochloride
powder packet 500 mg
np
levocarnitine oral soln 1 gm/10ml
(10%) (Carnitor)
levocarnitine tab 330 mg (Carnitor) np
• •
•
• •
• •
NATPARA- parathyroid hormone
(recombinant) for inj cartridge
100 mcg
NP
• •
NORDITROPIN FLEXPROsomatropin inj 5 mg/1.5ml
NC
NORDITROPIN FLEXPROsomatropin inj 10 mg/1.5ml
NC
NORDITROPIN FLEXPROsomatropin inj 15 mg/1.5ml
NC
NORDITROPIN FLEXPROsomatropin inj 30 mg/3ml
NC
NUTROPIN AQ NUSPIN 10somatropin inj 10 mg/2ml
NC
NUTROPIN AQ NUSPIN 20somatropin inj 20 mg/2ml
NC
NUTROPIN AQ NUSPIN 5somatropin inj 5 mg/2ml
NC
octreotide acetate inj 50 mcg/ml
(0.05 mg/ml) (Sandostatin)
np
•
np
•
np
•
np
•
np
•
OMNITROPE- somatropin inj
5 mg/1.5ml
P
• •
OMNITROPE- somatropin inj
10 mg/1.5ml
P
• •
OMNITROPE- somatropin for inj
5.8 mg
P
• •
ORFADIN- nitisinone susp 4 mg/ml
P
ORFADIN- nitisinone cap 2 mg
P
ORFADIN- nitisinone cap 5 mg
P
ORFADIN- nitisinone cap 10 mg
P
ORFADIN- nitisinone cap 20 mg
P
•
•
•
•
•
octreotide acetate inj 200 mcg/ml
(0.2 mg/ml) (Sandostatin)
octreotide acetate inj 1000 mcg/ml
(1 mg/ml) (Sandostatin)
•
NP
MIACALCIN- calcitonin (salmon) inj
200 unit/ml
NP
MYALEPT- metreleptin for
subcutaneous inj 11.3 mg
NP
• •
NATPARA- parathyroid hormone
(recombinant) for inj cartridge
25 mcg
NP
• •
NATPARA- parathyroid hormone
(recombinant) for inj cartridge
50 mcg
NP
• •
•
•
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
• •
Step Therapy
NP
octreotide acetate inj 500 mcg/ml
(0.5 mg/ml) (Sandostatin)
MENOPUR- menotropins for
subcutaneous inj 75 unit
Prior Authorization
NATPARA- parathyroid hormone
(recombinant) for inj cartridge
75 mcg
octreotide acetate inj 100 mcg/ml
(0.1 mg/ml) (Sandostatin)
• •
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
•
•
30
OVIDREL- choriogonadotropin alfa inj
250 mcg/0.5ml
P
paricalcitol cap 1 mcg (Zemplar)
np
paricalcitol cap 2 mcg (Zemplar)
paricalcitol cap 4 mcg
raloxifene hcl tab 60 mg (Evista)
RAVICTI- glycerol phenylbutyrate
liquid 1.1 gm/ml
np
np
np
NP
RAYALDEE- calcifediol cap cr 30 mcg NC
np
risedronate sodium tab delayed
release 35 mg (Atelvia)
np
risedronate sodium tab 5 mg
(Actonel)
np
risedronate sodium tab 30 mg
(Actonel)
np
risedronate sodium tab 35 mg
(Actonel)
np
risedronate sodium tab 150 mg
(Actonel)
NC
SAIZEN- somatropin (nonrefrigerated) for inj 5 mg
NC
SAIZEN- somatropin (nonrefrigerated) for inj 8.8 mg
NC
SAIZEN CLICK.EASY- somatropin
(non-refrigerated) for inj 8.8 mg
NC
SAIZENPREP RECONSTITUTIONsomatropin (non-refrigerated) for inj
8.8 mg
NP
SAMSCA- tolvaptan tab 15 mg
SAMSCA- tolvaptan tab 30 mg
NP
SENSIPAR- cinacalcet hcl tab 30 mg
(base equiv)
P
SENSIPAR- cinacalcet hcl tab 60 mg
(base equiv)
P
SENSIPAR- cinacalcet hcl tab 90 mg
(base equiv)
P
SEROSTIM- somatropin (nonrefrigerated) for subcutaneous inj
4 mg
•
NC
• •
•
•
SEROSTIM- somatropin (nonrefrigerated) for subcutaneous inj
5 mg
NC
SEROSTIM- somatropin (nonrefrigerated) for subcutaneous inj
6 mg
NC
SIGNIFOR- pasireotide diaspartate inj NP
0.3 mg/ml (base equiv)
SIGNIFOR- pasireotide diaspartate inj NP
0.6 mg/ml (base equiv)
SIGNIFOR- pasireotide diaspartate inj NP
0.9 mg/ml (base equiv)
sodium phenylbutyrate oral powder np
3 gm/teaspoonful (Buphenyl)
NP
SOMAVERT- pegvisomant for inj
10 mg (as protein)
NP
SOMAVERT- pegvisomant for inj
15 mg (as protein)
NP
SOMAVERT- pegvisomant for inj
20 mg (as protein)
NP
SOMAVERT- pegvisomant for inj
25 mg (as protein)
NP
SOMAVERT- pegvisomant for inj
30 mg (as protein)
P
STIMATE- desmopressin acetate
nasal soln 1.5 mg/ml
P
STRENSIQ- asfotase alfa
subcutaneous inj 18 mg/0.45ml
P
STRENSIQ- asfotase alfa
subcutaneous inj 28 mg/0.7ml
P
STRENSIQ- asfotase alfa
subcutaneous inj 40 mg/ml
P
STRENSIQ- asfotase alfa
subcutaneous inj 80 mg/0.8ml
NP
SYNAREL- nafarelin acetate nasal
soln 2 mg/ml (200 mcg/act) (base
eq)
NC
XURIDEN- uridine triacetate
oral granules packet 2 gm
NC
ZOMACTON- somatropin for
subcutaneous inj 5 mg
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
NC
Prior Authorization
OSPHENA- ospemifene tab 60 mg
Specialty
Drug Name
Tier Designation
2017
•
•
•
• •
•
•
•
•
•
• •
• •
• •
• •
31
ZOMACTON- somatropin for inj 10 mg NC
NC
ZORBTIVE- somatropin (nonrefrigerated) for subcutaneous inj
8.8 mg
CARDIOVASCULAR AGENTS
CARDIOTONICS
DIGOXIN- digoxin oral soln 0.05 mg/
ml
NP
digoxin tab 125 mcg (0.125 mg)
(Lanoxin)
np
digoxin tab 250 mcg (0.25 mg)
(Lanoxin)
np
isosorbide mononitrate tab 10 mg
isosorbide mononitrate tab 20 mg
NITRO-DUR- nitroglycerin td patch
24hr 0.3 mg/hr
NP
NITRO-DUR- nitroglycerin td patch
24hr 0.8 mg/hr
NP
nitroglycerin cap cr 2.5 mg
np
nitroglycerin cap cr 9 mg
np
NP
nitroglycerin sl tab 0.3 mg
(Nitrostat)
LANOXIN- digoxin tab 187.5 mcg
(0.1875 mg)
NP
nitroglycerin sl tab 0.4 mg
(Nitrostat)
LANOXIN- digoxin tab 250 mcg
(0.25 mg)
NP
nitroglycerin sl tab 0.6 mg
(Nitrostat)
nitroglycerin td patch 24hr 0.1 mg/
hr (Nitro-dur)
np
np
np
DILATRATE SR- isosorbide dinitrate
cap cr 40 mg
NP
GONITRO- nitroglycerin sublingual
powder packet 400 mcg
NC
ISORDIL TITRADOSE- isosorbide
dinitrate tab 40 mg
NP
ISOSORBIDE DINITRATE ERisosorbide dinitrate tab cr 40 mg
NP
isosorbide dinitrate tab 5 mg
(Isordil titradose)
np
nitroglycerin tl soln 0.4 mg/spray
(400 mcg/spray) (Nitrolingual
pumpspr)
np
NITROMIST- nitroglycerin lingual
aerosol 400 mcg/spray
NP
RANEXA- ranolazine tab sr 12hr
500 mg
NP
p
RANEXA- ranolazine tab sr 12hr
1000 mg
NP
p
BETA BLOCKERS
isosorbide dinitrate tab 10 mg
isosorbide dinitrate tab 20 mg
isosorbide dinitrate tab 30 mg
isosorbide mononitrate tab sr 24hr
30 mg
isosorbide mononitrate tab sr 24hr
60 mg
isosorbide mononitrate tab sr 24hr
120 mg
np
np
np
nitroglycerin td patch 24hr 0.2 mg/
hr (Nitro-dur)
nitroglycerin td patch 24hr 0.4 mg/
hr (Nitro-dur)
nitroglycerin td patch 24hr 0.6 mg/
hr (Nitro-dur)
acebutolol hcl cap 200 mg
acebutolol hcl cap 400 mg
atenolol tab 25 mg (Tenormin)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
np
NP
LANOXIN- digoxin tab 125 mcg
(0.125 mg)
Step Therapy
np
NITROGLYCERIN LINGUALnitroglycerin lingual aerosol
400 mcg/spray
NP
Prior Authorization
p
NP
LANOXIN- digoxin tab 62.5 mcg
(0.0625 mg)
ANTIANGINAL AGENTS
p
NITRO-BID- nitroglycerin oint 2%
nitroglycerin cap cr 6.5 mg
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
p
np
np
np
p
p
p
32
atenolol tab 50 mg (Tenormin)
atenolol tab 100 mg (Tenormin)
betaxolol hcl tab 10 mg
betaxolol hcl tab 20 mg
bisoprolol fumarate tab 5 mg
bisoprolol fumarate tab 10 mg
p
p
np
np
p
p
labetalol hcl tab 200 mg
labetalol hcl tab 300 mg
NC
metoprolol succinate tab sr 24hr
25 mg (tartrate equiv) (Toprol xl)
BYSTOLIC- nebivolol hcl tab 5 mg
(base equivalent)
NC
metoprolol succinate tab sr 24hr
50 mg (tartrate equiv) (Toprol xl)
BYSTOLIC- nebivolol hcl tab 10 mg
(base equivalent)
NC
metoprolol succinate tab sr 24hr
100 mg (tartrate equiv) (Toprol xl)
BYSTOLIC- nebivolol hcl tab 20 mg
(base equivalent)
NC
metoprolol succinate tab sr 24hr
200 mg (tartrate equiv) (Toprol xl)
carvedilol tab 6.25 mg (Coreg)
carvedilol tab 12.5 mg (Coreg)
carvedilol tab 25 mg (Coreg)
p
p
np
np
p
METOPROLOL TARTRATEmetoprolol tartrate tab 75 mg
NP
p
metoprolol tartrate tab 25 mg
p
COREG CR- carvedilol phosphate cap NP
sr 24hr 10 mg
COREG CR- carvedilol phosphate cap NP
sr 24hr 20 mg
COREG CR- carvedilol phosphate cap NP
sr 24hr 40 mg
COREG CR- carvedilol phosphate cap NP
sr 24hr 80 mg
NC
HEMANGEOL- propranolol hcl oral
soln 4.28 mg/ml (3.75 mg/ml base
equiv)
NC
INDERAL XL- propranolol hcl
sustained-release beads cap sr 24hr
80 mg
NC
INDERAL XL- propranolol hcl
sustained-release beads cap sr 24hr
120 mg
NC
INNOPRAN XL- propranolol hcl
sustained-release beads cap sr 24hr
80 mg
Dispensing Limits
np
NP
p
Step Therapy
np
METOPROLOL TARTRATEmetoprolol tartrate tab 37.5 mg
p
Prior Authorization
NC
INNOPRAN XL- propranolol hcl
sustained-release beads cap sr 24hr
120 mg
p
labetalol hcl tab 100 mg
BYSTOLIC- nebivolol hcl tab 2.5 mg
(base equivalent)
carvedilol tab 3.125 mg (Coreg)
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
metoprolol tartrate tab 50 mg
(Lopressor)
metoprolol tartrate tab 100 mg
(Lopressor)
nadolol tab 20 mg (Corgard)
nadolol tab 40 mg (Corgard)
nadolol tab 80 mg (Corgard)
pindolol tab 5 mg
pindolol tab 10 mg
p
p
np
np
np
np
np
PROPRANOLOL HCL- propranolol hcl
oral soln 20 mg/5ml
P
PROPRANOLOL HCL- propranolol hcl
oral soln 40 mg/5ml
P
propranolol hcl cap sr 24hr 60 mg
(Inderal la)
np
propranolol hcl cap sr 24hr 80 mg
(Inderal la)
propranolol hcl cap sr 24hr 120 mg
(Inderal la)
propranolol hcl cap sr 24hr 160 mg
(Inderal la)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
np
np
np
33
propranolol hcl tab 10 mg
propranolol hcl tab 20 mg
propranolol hcl tab 40 mg
propranolol hcl tab 60 mg
propranolol hcl tab 80 mg
sotalol hcl (afib/afl) tab 80 mg
(Betapace af)
sotalol hcl (afib/afl) tab 120 mg
(Betapace af)
sotalol hcl (afib/afl) tab 160 mg
(Betapace af)
sotalol hcl tab 80 mg (Betapace)
sotalol hcl tab 120 mg (Betapace)
sotalol hcl tab 160 mg (Betapace)
sotalol hcl tab 240 mg
p
p
np
np
np
np
np
np
p
p
p
np
diltiazem hcl coated beads cap sr
24hr 120 mg (Cardizem cd)
diltiazem hcl coated beads cap sr
24hr 180 mg (Cardizem cd)
diltiazem hcl coated beads cap sr
24hr 240 mg (Cardizem cd)
diltiazem hcl coated beads cap sr
24hr 300 mg
diltiazem hcl coated beads cap sr
24hr 360 mg (Cardizem cd)
diltiazem hcl coated beads tab sr
24hr 180 mg (Cardizem la)
diltiazem hcl coated beads tab sr
24hr 240 mg (Cardizem la)
diltiazem hcl coated beads tab sr
24hr 300 mg (Cardizem la)
np
np
np
np
np
np
TIMOLOL MALEATE- timolol maleate
tab 5 mg
NC
diltiazem hcl coated beads tab sr
24hr 420 mg (Cardizem la)
TIMOLOL MALEATE- timolol maleate
tab 10 mg
NC
diltiazem hcl extended release
beads cap sr 24hr 120 mg (Tiazac)
p
TIMOLOL MALEATE- timolol maleate
tab 20 mg
NC
p
amlodipine besylate tab 5 mg
(Norvasc)
amlodipine besylate tab 10 mg
(Norvasc)
p
p
np
np
diltiazem hcl extended release
beads cap sr 24hr 180 mg (Tiazac)
np
diltiazem hcl extended release
beads cap sr 24hr 240 mg (Tiazac)
np
diltiazem hcl extended release
beads cap sr 24hr 300 mg (Tiazac)
np
diltiazem hcl extended release
beads cap sr 24hr 360 mg (Tiazac)
np
diltiazem hcl extended release
beads cap sr 24hr 420 mg (Tiazac)
p
diltiazem hcl tab 30 mg (Cardizem)
CARDIZEM LA- diltiazem hcl coated
beads tab sr 24hr 120 mg
NP
diltiazem hcl cap sr 12hr 60 mg
np
diltiazem hcl tab 60 mg (Cardizem)
np
diltiazem hcl tab 90 mg
p
p
diltiazem hcl tab 120 mg (Cardizem) np
p
felodipine tab sr 24hr 2.5 mg
np
felodipine tab sr 24hr 5 mg
p
np
felodipine tab sr 24hr 10 mg
diltiazem hcl cap sr 12hr 90 mg
diltiazem hcl cap sr 12hr 120 mg
diltiazem hcl cap sr 24hr 120 mg
diltiazem hcl cap sr 24hr 180 mg
diltiazem hcl cap sr 24hr 240 mg
np
Dispensing Limits
p
diltiazem hcl coated beads tab sr
24hr 360 mg (Cardizem la)
p
Step Therapy
p
NC
amlodipine besylate tab 2.5 mg
(Norvasc)
Prior Authorization
p
SOTYLIZE- sotalol hcl oral solution
5 mg/ml
CALCIUM CHANNEL BLOCKERS
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
isradipine cap 2.5 mg
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
p
np
34
nicardipine hcl cap 20 mg
nicardipine hcl cap 30 mg
nifedipine cap 10 mg (Procardia)
nifedipine cap 20 mg
nifedipine tab sr 24hr 30 mg (Adalat
cc)
np
np
np
np
p
nifedipine tab sr 24hr 60 mg (Adalat np
cc)
nifedipine tab sr 24hr 90 mg (Adalat np
cc)
p
nifedipine tab sr 24hr osmotic
release 30 mg (Procardia xl)
p
nifedipine tab sr 24hr osmotic
release 60 mg (Procardia xl)
np
nifedipine tab sr 24hr osmotic
release 90 mg (Procardia xl)
np
nimodipine cap 30 mg
verapamil hcl cap sr 24hr 200 mg
(Verelan pm)
verapamil hcl cap sr 24hr 240 mg
(Verelan)
verapamil hcl cap sr 24hr 300 mg
(Verelan pm)
verapamil hcl cap sr 24hr 360 mg
(Verelan)
verapamil hcl tab cr 120 mg (Calan
sr)
verapamil hcl tab cr 180 mg (Calan
sr)
verapamil hcl tab cr 240 mg (Calan
sr)
verapamil hcl tab 40 mg
verapamil hcl tab 80 mg (Calan)
verapamil hcl tab 120 mg (Calan)
ANTIARRHYTHMICS
amiodarone hcl tab 100 mg
NISOLDIPINE ER- nisoldipine tab sr
24hr 20 mg
NP
NISOLDIPINE ER- nisoldipine tab sr
24hr 25.5 mg
NP
NISOLDIPINE ER- nisoldipine tab sr
24hr 30 mg
NP
disopyramide phosphate cap
100 mg (Norpace)
NISOLDIPINE ER- nisoldipine tab sr
24hr 40 mg
NP
disopyramide phosphate cap
150 mg (Norpace)
nisoldipine tab sr 24hr 8.5 mg
(Sular)
NC
dofetilide cap 125 mcg (0.125 mg)
(Tikosyn)
NC
dofetilide cap 250 mcg (0.25 mg)
(Tikosyn)
NC
dofetilide cap 500 mcg (0.5 mg)
(Tikosyn)
nisoldipine tab sr 24hr 17 mg
(Sular)
nisoldipine tab sr 24hr 34 mg
(Sular)
amiodarone hcl tab 200 mg
amiodarone hcl tab 400 mg
flecainide acetate tab 50 mg
NYMALIZE- nimodipine oral soln
60 mg/20ml
NP
verapamil hcl cap sr 24hr 100 mg
(Verelan pm)
np
flecainide acetate tab 150 mg
np
mexiletine hcl cap 200 mg
verapamil hcl cap sr 24hr 120 mg
(Verelan)
verapamil hcl cap sr 24hr 180 mg
(Verelan)
np
flecainide acetate tab 100 mg
mexiletine hcl cap 150 mg
mexiletine hcl cap 250 mg
MULTAQ- dronedarone hcl tab
400 mg (base equivalent)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
np
Prior Authorization
isradipine cap 5 mg
Specialty
Drug Name
Tier Designation
2017
np
np
np
np
p
p
p
p
p
p
np
p
np
np
np
np
np
np
p
np
np
np
np
np
P
35
NORPACE- disopyramide phosphate
cap 100 mg
NP
NORPACE- disopyramide phosphate
cap 150 mg
NP
NORPACE CR- disopyramide
phosphate cap sr 12hr 100 mg
NP
NORPACE CR- disopyramide
phosphate cap sr 12hr 150 mg
NP
propafenone hcl cap sr 12hr
225 mg (Rythmol sr)
np
propafenone hcl cap sr 12hr
325 mg (Rythmol sr)
propafenone hcl cap sr 12hr
425 mg (Rythmol sr)
propafenone hcl tab 150 mg
propafenone hcl tab 225 mg
propafenone hcl tab 300 mg
quinidine gluconate tab cr 324 mg
np
np
p
np
np
np
amlodipine besylate-olmesartan
medoxomil tab 10-20 mg (Azor)
amlodipine besylate-olmesartan
medoxomil tab 10-40 mg (Azor)
amlodipine besylate-valsartan tab
5-160 mg (Exforge)
amlodipine besylate-valsartan tab
5-320 mg (Exforge)
amlodipine besylate-valsartan tab
10-160 mg (Exforge)
amlodipine besylate-valsartan tab
10-320 mg (Exforge)
amlodipine-valsartanhydrochlorothiazide tab
5-160-12.5 mg (Exforge hct)
amlodipine-valsartanhydrochlorothiazide tab
5-160-25 mg (Exforge hct)
amlodipine-valsartanhydrochlorothiazide tab
10-160-12.5 mg (Exforge hct)
QUINIDINE SULFATE- quinidine
sulfate tab 200 mg
P
QUINIDINE SULFATE- quinidine
sulfate tab 300 mg
P
amlodipine-valsartanhydrochlorothiazide tab
10-160-25 mg (Exforge hct)
np
amlodipine-valsartanhydrochlorothiazide tab
10-320-25 mg (Exforge hct)
ANTIHYPERTENSIVES
amlodipine besylate-benazepril hcl
cap 2.5-10 mg
amlodipine besylate-benazepril hcl
cap 5-10 mg (Lotrel)
amlodipine besylate-benazepril hcl
cap 5-20 mg (Lotrel)
amlodipine besylate-benazepril hcl
cap 5-40 mg
amlodipine besylate-benazepril hcl
cap 10-20 mg (Lotrel)
amlodipine besylate-benazepril hcl
cap 10-40 mg (Lotrel)
amlodipine besylate-olmesartan
medoxomil tab 5-20 mg (Azor)
amlodipine besylate-olmesartan
medoxomil tab 5-40 mg (Azor)
p
p
p
p
p
NC
NC
atenolol & chlorthalidone tab
50-25 mg (Tenoretic 50)
atenolol & chlorthalidone tab
100-25 mg (Tenoretic 100)
benazepril & hydrochlorothiazide
tab 5-6.25 mg
benazepril & hydrochlorothiazide
tab 10-12.5 mg (Lotensin hct)
benazepril & hydrochlorothiazide
tab 20-12.5 mg (Lotensin hct)
benazepril & hydrochlorothiazide
tab 20-25 mg (Lotensin hct)
benazepril hcl tab 5 mg
benazepril hcl tab 10 mg
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
NC
NC
p
np
np
np
np
np
np
np
np
p
p
np
np
np
np
p
p
36
benazepril hcl tab 20 mg (Lotensin)
benazepril hcl tab 40 mg (Lotensin)
bisoprolol & hydrochlorothiazide
tab 2.5-6.25 mg (Ziac)
bisoprolol & hydrochlorothiazide
tab 5-6.25 mg (Ziac)
bisoprolol & hydrochlorothiazide
tab 10-6.25 mg (Ziac)
p
p
p
p
p
BYVALSON- nebivolol-valsartan tab
5-80 mg
NC
candesartan cilexetil tab 4 mg
(Atacand)
np
candesartan cilexetil tab 8 mg
(Atacand)
candesartan cilexetil tab 16 mg
(Atacand)
candesartan cilexetil tab 32 mg
(Atacand)
candesartan cilexetilhydrochlorothiazide tab
16-12.5 mg (Atacand hct)
candesartan cilexetilhydrochlorothiazide tab
32-12.5 mg (Atacand hct)
candesartan cilexetilhydrochlorothiazide tab 32-25 mg
(Atacand hct)
captopril tab 12.5 mg
captopril tab 25 mg
captopril tab 50 mg
captopril tab 100 mg
np
CAPTOPRIL/HYDROCHLOROTHIAcaptopril & hydrochlorothiazide tab
50-25 mg
NC
clonidine hcl tab 0.1 mg (Catapres)
p
clonidine hcl tab 0.2 mg (Catapres)
clonidine hcl tab 0.3 mg (Catapres)
clonidine hcl td patch weekly
0.1 mg/24hr (Catapres-tts-1)
clonidine hcl td patch weekly
0.2 mg/24hr (Catapres-tts-2)
clonidine hcl td patch weekly
0.3 mg/24hr (Catapres-tts-3)
np
np
CLORPRES- clonidine &
chlorthalidone tab 0.2-15 mg
NC
np
CLORPRES- clonidine &
chlorthalidone tab 0.3-15 mg
NC
np
DEMSER- metyrosine cap 250 mg
NC
np
np
np
np
np
doxazosin mesylate tab 4 mg
(Cardura)
doxazosin mesylate tab 8 mg
(Cardura)
p
p
p
p
DUTOPROL- metoprolol &
hydrochlorothiazide tab sr 24hr
25-12.5 mg
NC
NC
CAPTOPRIL/HYDROCHLOROTHIAcaptopril & hydrochlorothiazide tab
25-15 mg
NC
DUTOPROL- metoprolol &
hydrochlorothiazide tab sr 24hr
50-12.5 mg
NC
CAPTOPRIL/HYDROCHLOROTHIAcaptopril & hydrochlorothiazide tab
25-25 mg
NC
DUTOPROL- metoprolol &
hydrochlorothiazide tab sr 24hr
100-12.5 mg
NC
CAPTOPRIL/HYDROCHLOROTHIAcaptopril & hydrochlorothiazide tab
50-15 mg
NC
EDARBI- azilsartan medoxomil tab
40 mg
EDARBI- azilsartan medoxomil tab
80 mg
NC
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
np
np
doxazosin mesylate tab 2 mg
(Cardura)
Step Therapy
p
NC
np
Prior Authorization
p
CLORPRES- clonidine &
chlorthalidone tab 0.1-15 mg
doxazosin mesylate tab 1 mg
(Cardura)
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
37
EDARBYCLOR- azilsartan
medoxomil-chlorthalidone tab
40-12.5 mg
NC
EDARBYCLOR- azilsartan
medoxomil-chlorthalidone tab
40-25 mg
NC
enalapril maleate &
hydrochlorothiazide tab 5-12.5 mg
enalapril maleate &
hydrochlorothiazide tab 10-25 mg
(Vaseretic)
enalapril maleate tab 2.5 mg
(Vasotec)
enalapril maleate tab 5 mg
(Vasotec)
enalapril maleate tab 10 mg
(Vasotec)
enalapril maleate tab 20 mg
(Vasotec)
irbesartan tab 75 mg (Avapro)
irbesartan tab 300 mg (Avapro)
irbesartan-hydrochlorothiazide tab
150-12.5 mg (Avalide)
p
irbesartan-hydrochlorothiazide tab
300-12.5 mg (Avalide)
p
lisinopril & hydrochlorothiazide tab
10-12.5 mg (Zestoretic)
p
lisinopril & hydrochlorothiazide tab
20-12.5 mg (Zestoretic)
p
lisinopril & hydrochlorothiazide tab
20-25 mg (Zestoretic)
p
np
NP
eplerenone tab 25 mg (Inspra)
np
np
lisinopril tab 2.5 mg (Zestril)
lisinopril tab 5 mg (Prinivil)
lisinopril tab 10 mg (Prinivil)
lisinopril tab 20 mg (Prinivil)
lisinopril tab 30 mg (Zestril)
lisinopril tab 40 mg (Zestril)
losartan potassium &
hydrochlorothiazide tab
50-12.5 mg (Hyzaar)
EPROSARTAN MESYLATEeprosartan mesylate tab 600 mg
NC
fosinopril sodium &
hydrochlorothiazide tab
10-12.5 mg
np
losartan potassium &
hydrochlorothiazide tab
100-12.5 mg (Hyzaar)
np
losartan potassium &
hydrochlorothiazide tab
100-25 mg (Hyzaar)
fosinopril sodium &
hydrochlorothiazide tab
20-12.5 mg
fosinopril sodium tab 10 mg
fosinopril sodium tab 20 mg
fosinopril sodium tab 40 mg
guanfacine hcl tab 1 mg
guanfacine hcl tab 2 mg
hydralazine hcl tab 10 mg
hydralazine hcl tab 25 mg
hydralazine hcl tab 50 mg
hydralazine hcl tab 100 mg
p
p
p
losartan potassium tab 25 mg
(Cozaar)
losartan potassium tab 50 mg
(Cozaar)
p
losartan potassium tab 100 mg
(Cozaar)
p
methyldopa tab 250 mg
p
methyldopa tab 500 mg
p
p
p
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
irbesartan tab 150 mg (Avapro)
EPANED- enalapril maleate oral soln
1 mg/ml
eplerenone tab 50 mg (Inspra)
Specialty
Drug Name
Tier Designation
2017
p
p
p
p
p
p
p
p
p
p
p
p
p
p
p
p
p
p
p
p
p
np
METHYLDOPA/HYDROCHLOROTHI- NC
methyldopa & hydrochlorothiazide
tab 250-15 mg
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
38
METHYLDOPA/HYDROCHLOROTHI- NC
methyldopa & hydrochlorothiazide
tab 250-25 mg
np
metoprolol & hydrochlorothiazide
tab 50-25 mg (Lopressor hct)
np
metoprolol & hydrochlorothiazide
tab 100-25 mg
np
metoprolol & hydrochlorothiazide
tab 100-50 mg
NC
METOPROLOL SUCCINATE ER/Hmetoprolol & hydrochlorothiazide
tab sr 24hr 25-12.5 mg
NC
METOPROLOL SUCCINATE ER/Hmetoprolol & hydrochlorothiazide
tab sr 24hr 50-12.5 mg
NC
METOPROLOL SUCCINATE ER/Hmetoprolol & hydrochlorothiazide
tab sr 24hr 100-12.5 mg
p
minoxidil tab 2.5 mg
minoxidil tab 10 mg
moexipril hcl tab 7.5 mg
moexipril hcl tab 15 mg
moexipril-hydrochlorothiazide tab
7.5-12.5 mg
moexipril-hydrochlorothiazide tab
15-12.5 mg
moexipril-hydrochlorothiazide tab
15-25 mg
nadolol & bendroflumethiazide tab
40-5 mg (Corzide)
nadolol & bendroflumethiazide tab
80-5 mg (Corzide)
olmesartan medoxomil tab 5 mg
(Benicar)
olmesartan medoxomil tab 20 mg
(Benicar)
olmesartan medoxomil tab 40 mg
(Benicar)
olmesartan medoxomilhydrochlorothiazide tab
20-12.5 mg (Benicar hct)
p
np
np
olmesartan medoxomilhydrochlorothiazide tab
40-12.5 mg (Benicar hct)
perindopril erbumine tab 4 mg
(Aceon)
np
perindopril erbumine tab 8 mg
(Aceon)
np
phenoxybenzamine hcl cap 10 mg
(Dibenzyline)
np
NC
NC
NC
NC
Dispensing Limits
Step Therapy
Prior Authorization
NC
NC
olmesartan medoxomilhydrochlorothiazide tab 40-25 mg
(Benicar hct)
NC
olmesartan-amlodipinehydrochlorothiazide tab
20-5-12.5 mg (Tribenzor)
NC
olmesartan-amlodipinehydrochlorothiazide tab
40-5-12.5 mg (Tribenzor)
NC
olmesartan-amlodipinehydrochlorothiazide tab
40-5-25 mg (Tribenzor)
NC
olmesartan-amlodipinehydrochlorothiazide tab
40-10-12.5 mg (Tribenzor)
NC
olmesartan-amlodipinehydrochlorothiazide tab
40-10-25 mg (Tribenzor)
p
perindopril erbumine tab 2 mg
np
np
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
prazosin hcl cap 1 mg (Minipress)
prazosin hcl cap 2 mg (Minipress)
prazosin hcl cap 5 mg (Minipress)
p
np
np
np
np
np
PRESTALIA- perindopril arginineamlodipine besylate tab 3.5-2.5 mg
NC
PRESTALIA- perindopril arginineamlodipine besylate tab 7-5 mg
NC
PRESTALIA- perindopril arginineamlodipine besylate tab 14-10 mg
NC
PROPRANOLOL/
HYDROCHLOROTH- propranolol &
hydrochlorothiazide tab 40-25 mg
NP
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
39
PROPRANOLOL/
HYDROCHLOROTH- propranolol &
hydrochlorothiazide tab 80-25 mg
NP
QBRELIS- lisinopril oral soln 1 mg/ml
NP
quinapril hcl tab 5 mg (Accupril)
quinapril hcl tab 10 mg (Accupril)
quinapril hcl tab 20 mg (Accupril)
quinapril hcl tab 40 mg (Accupril)
quinapril-hydrochlorothiazide tab
10-12.5 mg (Accuretic)
quinapril-hydrochlorothiazide tab
20-12.5 mg (Accuretic)
quinapril-hydrochlorothiazide tab
20-25 mg (Accuretic)
ramipril cap 1.25 mg (Altace)
ramipril cap 2.5 mg (Altace)
ramipril cap 5 mg (Altace)
ramipril cap 10 mg (Altace)
p
p
p
p
p
np
p
p
p
p
p
telmisartan-amlodipine tab 80-5 mg
(Twynsta)
np
terazosin hcl cap 2 mg
p
terazosin hcl cap 5 mg
terazosin hcl cap 10 mg
trandolapril tab 1 mg (Mavik)
trandolapril tab 2 mg (Mavik)
trandolapril tab 4 mg
NC
TEKTURNA- aliskiren fumarate tab
300 mg (base equivalent)
NC
trandolapril-verapamil hcl tab cr
2-180 mg (Tarka)
TEKTURNA HCT- aliskirenhydrochlorothiazide tab
150-12.5 mg
NC
trandolapril-verapamil hcl tab cr
2-240 mg (Tarka)
TEKTURNA HCT- aliskirenhydrochlorothiazide tab 150-25 mg
NC
TEKTURNA HCT- aliskirenhydrochlorothiazide tab
300-12.5 mg
NC
TEKTURNA HCT- aliskirenhydrochlorothiazide tab 300-25 mg
NC
valsartan-hydrochlorothiazide tab
80-12.5 mg (Diovan hct)
telmisartan tab 20 mg (Micardis)
np
valsartan-hydrochlorothiazide tab
160-12.5 mg (Diovan hct)
telmisartan tab 80 mg (Micardis)
telmisartan-amlodipine tab 40-5 mg
(Twynsta)
telmisartan-amlodipine tab
40-10 mg (Twynsta)
trandolapril-verapamil hcl tab cr
4-240 mg (Tarka)
valsartan tab 40 mg (Diovan)
valsartan tab 80 mg (Diovan)
valsartan tab 160 mg (Diovan)
valsartan tab 320 mg (Diovan)
np
np
np
Dispensing Limits
Step Therapy
Prior Authorization
telmisartan-hydrochlorothiazide tab np
40-12.5 mg (Micardis hct)
telmisartan-hydrochlorothiazide tab np
80-12.5 mg (Micardis hct)
telmisartan-hydrochlorothiazide tab np
80-25 mg (Micardis hct)
p
terazosin hcl cap 1 mg
TEKTURNA- aliskiren fumarate tab
150 mg (base equivalent)
np
np
telmisartan-amlodipine tab
80-10 mg (Twynsta)
trandolapril-verapamil hcl tab cr
1-240 mg (Tarka)
telmisartan tab 40 mg (Micardis)
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
valsartan-hydrochlorothiazide tab
160-25 mg (Diovan hct)
valsartan-hydrochlorothiazide tab
320-12.5 mg (Diovan hct)
valsartan-hydrochlorothiazide tab
320-25 mg (Diovan hct)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
p
p
p
p
p
np
np
np
np
p
p
p
p
p
p
p
p
p
40
VECAMYL- mecamylamine hcl tab
2.5 mg
DIURETICS
acetazolamide cap sr 12hr 500 mg
(Diamox)
acetazolamide tab 125 mg
acetazolamide tab 250 mg
ALDACTAZIDE- spironolactone &
hydrochlorothiazide tab 50-50 mg
amiloride & hydrochlorothiazide tab
5-50 mg
amiloride hcl tab 5 mg
bumetanide tab 0.5 mg (Bumex)
bumetanide tab 1 mg (Bumex)
bumetanide tab 2 mg (Bumex)
NP
KEVEYIS- dichlorphenamide tab
50 mg
NC
np
np
methazolamide tab 25 mg
(Neptazane)
np
methazolamide tab 50 mg
(Neptazane)
np
NP
p
np
np
np
np
CHLOROTHIAZIDE- chlorothiazide
tab 250 mg
NP
chlorothiazide tab 500 mg
np
NP
metolazone tab 2.5 mg
np
metolazone tab 10 mg
spironolactone &
hydrochlorothiazide tab 25-25 mg
(Aldactazide)
spironolactone tab 25 mg
(Aldactone)
spironolactone tab 50 mg
(Aldactone)
np
spironolactone tab 100 mg
(Aldactone)
np
torsemide tab 5 mg
DIURIL- chlorothiazide susp
250 mg/5ml
NP
torsemide tab 10 mg (Demadex)
DYRENIUM- triamterene cap 50 mg
NP
DYRENIUM- triamterene cap 100 mg
NP
chlorthalidone tab 25 mg
chlorthalidone tab 50 mg
ethacrynic acid tab 25 mg (Edecrin) NC
FUROSEMIDE- furosemide oral soln NC
8 mg/ml
p
furosemide oral soln 10 mg/ml
furosemide tab 20 mg (Lasix)
furosemide tab 40 mg (Lasix)
furosemide tab 80 mg (Lasix)
hydrochlorothiazide cap 12.5 mg
(Microzide)
hydrochlorothiazide tab 12.5 mg
hydrochlorothiazide tab 25 mg
hydrochlorothiazide tab 50 mg
indapamide tab 1.25 mg
indapamide tab 2.5 mg
p
p
p
p
p
p
p
torsemide tab 20 mg (Demadex)
torsemide tab 100 mg
triamterene & hydrochlorothiazide
cap 37.5-25 mg (Dyazide)
triamterene & hydrochlorothiazide
tab 37.5-25 mg (Maxzide-25)
triamterene & hydrochlorothiazide
tab 75-50 mg (Maxzide)
Dispensing Limits
Step Therapy
Prior Authorization
np
METHYCLOTHIAZIDEmethyclothiazide tab 5 mg
metolazone tab 5 mg
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
np
np
np
p
p
p
p
p
p
p
p
p
p
TRIAMTERENE/HYDROCHLOROTH- NP
triamterene & hydrochlorothiazide
cap 50-25 mg
VASOPRESSORS
AUVI-Q- epinephrine solution autoinjector 0.15 mg/0.15ml (1:1000)
NC
AUVI-Q- epinephrine solution autoinjector 0.3 mg/0.3ml (1:1000)
NC
p
p
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
41
EPINEPHRINE(Mylan Products)epinephrine solution auto-injector
0.15 mg/0.3ml (1:2000)
np
EPINEPHRINE(Mylan Products)epinephrine solution auto-injector
0.3 mg/0.3ml (1:1000)
np
EPINEPHRINE- epinephrine solution
auto-injector 0.15 mg/0.15ml
(1:1000)
NC
EPINEPHRINE- epinephrine solution
auto-injector 0.3 mg/0.3ml (1:1000)
NC
choline fenofibrate cap dr 45 mg
(fenofibric acid equiv) (Trilipix)
EPIPEN 2-PAK- epinephrine solution
auto-injector 0.3 mg/0.3ml (1:1000)
NC
choline fenofibrate cap dr 135 mg
(fenofibric acid equiv) (Trilipix)
np
ezetimibe tab 10 mg (Zetia)
NC
fenofibrate micronized cap 67 mg
(Lofibra)
np
NC
EPIPEN-JR 2-PAK- epinephrine
solution auto-injector 0.15 mg/0.3ml
(1:2000)
np
midodrine hcl tab 2.5 mg
midodrine hcl tab 5 mg
midodrine hcl tab 10 mg
np
np
NORTHERA- droxidopa cap 100 mg
NC
NORTHERA- droxidopa cap 200 mg
NC
NORTHERA- droxidopa cap 300 mg
NC
ANTIHYPERLIPIDEMICS
ALTOPREV- lovastatin tab sr 24hr
20 mg
NC
ALTOPREV- lovastatin tab sr 24hr
40 mg
NC
ALTOPREV- lovastatin tab sr 24hr
60 mg
NC
ANTARA- fenofibrate micronized cap
30 mg
NC
ANTARA- fenofibrate micronized cap
90 mg
NC
atorvastatin calcium tab 10 mg
(base equivalent) (Lipitor)
atorvastatin calcium tab 20 mg
(base equivalent) (Lipitor)
atorvastatin calcium tab 40 mg
(base equivalent) (Lipitor)
atorvastatin calcium tab 80 mg
(base equivalent) (Lipitor)
p
cholestyramine light powder
packets 4 gm
cholestyramine light powder 4 gm/
dose (Questran light)
cholestyramine powder packets
4 gm (Questran)
cholestyramine powder 4 gm/dose
(Questran)
Dispensing Limits
Step Therapy
Prior Authorization
np
np
np
np
np
colestipol hcl granule packets 5 gm np
(Colestid flavored)
np
colestipol hcl granules 5 gm
(Colestid)
np
colestipol hcl tab 1 gm (Colestid)
ezetimibe-simvastatin tab 10-10 mg NC
(Vytorin)
ezetimibe-simvastatin tab 10-20 mg NC
(Vytorin)
ezetimibe-simvastatin tab 10-40 mg NC
(Vytorin)
ezetimibe-simvastatin tab 10-80 mg NC
(Vytorin)
NC
FENOFIBRATE- fenofibrate cap
50 mg
NC
FENOFIBRATE- fenofibrate cap
150 mg
np
fenofibrate micronized cap 43 mg
fenofibrate micronized cap 130 mg
p
fenofibrate micronized cap 134 mg
(Lofibra)
p
fenofibrate micronized cap 200 mg
(Lofibra)
p
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
fenofibrate tab 40 mg (Fenoglide)
fenofibrate tab 48 mg (Tricor)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
np
np
np
np
np
42
fenofibrate tab 54 mg (Lofibra)
fenofibrate tab 120 mg (Fenoglide)
fenofibrate tab 145 mg (Tricor)
fenofibrate tab 160 mg (Lofibra)
p
lovastatin tab 40 mg
np
niacin tab cr 500 mg
(antihyperlipidemic) (Niaspan)
np
niacin tab cr 750 mg
(antihyperlipidemic) (Niaspan)
np
FENOFIBRIC ACID- fenofibric acid
tab 35 mg
NC
FENOFIBRIC ACID- fenofibric acid
tab 105 mg
NC
FIBRICOR- fenofibric acid tab 35 mg
NC
niacin tab cr 1000 mg
(antihyperlipidemic) (Niaspan)
NIACOR- niacin (antihyperlipidemic)
tab 500 mg
FIBRICOR- fenofibric acid tab 105 mg NC
np
fluvastatin sodium cap 20 mg
fluvastatin sodium cap 40 mg
fluvastatin sodium tab sr 24 hr
80 mg (Lescol xl)
gemfibrozil tab 600 mg (Lopid)
np
np
p
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
p
np
np
np
NC
omega-3-acid ethyl esters cap 1 gm NC
(Lovaza)
P
PRALUENT- alirocumab
subcutaneous soln pen-injector
75 mg/ml
P
PRALUENT- alirocumab
subcutaneous soln pen-injector
150 mg/ml
p
pravastatin sodium tab 10 mg
• •
•
• •
•
JUXTAPID- lomitapide mesylate cap
5 mg (base equiv)
NP
• •
•
JUXTAPID- lomitapide mesylate cap
10 mg (base equiv)
NP
• •
•
pravastatin sodium tab 20 mg
(Pravachol)
JUXTAPID- lomitapide mesylate cap
20 mg (base equiv)
NP
• •
•
pravastatin sodium tab 40 mg
(Pravachol)
JUXTAPID- lomitapide mesylate cap
30 mg (base equiv)
NP
• •
•
pravastatin sodium tab 80 mg
(Pravachol)
JUXTAPID- lomitapide mesylate cap
40 mg (base equiv)
NP
• •
•
REPATHA- evolocumab subcutaneous
soln prefilled syringe 140 mg/ml
P
• •
•
JUXTAPID- lomitapide mesylate cap
60 mg (base equiv)
NP
• •
•
P
• •
•
KYNAMRO- mipomersen sodium soln NP
prefilled syringe 200 mg/ml
NC
LIPOFEN- fenofibrate cap 50 mg
• •
•
REPATHA PUSHTRONEX SYSTEMevolocumab subcutaneous soln
cartridge/infusor 420 mg/3.5ml
REPATHA SURECLICK- evolocumab
subcutaneous soln auto-injector
140 mg/ml
P
• •
•
rosuvastatin calcium tab 5 mg
(Crestor)
np
LIPOFEN- fenofibrate cap 150 mg
NC
LIVALO- pitavastatin calcium tab 1 mg NC
(base equiv)
LIVALO- pitavastatin calcium tab 2 mg NC
(base equiv)
LIVALO- pitavastatin calcium tab 4 mg NC
(base equiv)
p
lovastatin tab 10 mg
lovastatin tab 20 mg
p
rosuvastatin calcium tab 10 mg
(Crestor)
rosuvastatin calcium tab 20 mg
(Crestor)
rosuvastatin calcium tab 40 mg
(Crestor)
simvastatin tab 5 mg (Zocor)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
p
p
p
np
np
np
p
43
simvastatin tab 10 mg (Zocor)
simvastatin tab 20 mg (Zocor)
simvastatin tab 40 mg (Zocor)
simvastatin tab 80 mg (Zocor)
TRIGLIDE- fenofibrate tab 160 mg
p
amlodipine besylate-atorvastatin
calcium tab 5-80 mg (Caduet)
p
amlodipine besylate-atorvastatin
calcium tab 10-10 mg (Caduet)
p
p
amlodipine besylate-atorvastatin
calcium tab 10-20 mg (Caduet)
NC
VASCEPA- icosapent ethyl cap 0.5 gm NC
VASCEPA- icosapent ethyl cap 1 gm NC
VYTORIN- ezetimibe-simvastatin tab
10-10 mg
NC
VYTORIN- ezetimibe-simvastatin tab
10-20 mg
NC
VYTORIN- ezetimibe-simvastatin tab
10-40 mg
NC
VYTORIN- ezetimibe-simvastatin tab
10-80 mg
NC
WELCHOL- colesevelam hcl tab
625 mg
P
WELCHOL- colesevelam hcl packet
for susp 3.75 gm
P
ZETIA- ezetimibe tab 10 mg
np
CARDIOVASCULAR AGENTS - MISC.
ADCIRCA- tadalafil tab 20 mg (pah)
NP
ADEMPAS- riociguat tab 0.5 mg
NP
ADEMPAS- riociguat tab 1 mg
NP
ADEMPAS- riociguat tab 1.5 mg
NP
ADEMPAS- riociguat tab 2 mg
NP
ADEMPAS- riociguat tab 2.5 mg
NP
amlodipine besylate-atorvastatin
calcium tab 2.5-10 mg
np
amlodipine besylate-atorvastatin
calcium tab 2.5-20 mg
amlodipine besylate-atorvastatin
calcium tab 2.5-40 mg
amlodipine besylate-atorvastatin
calcium tab 5-10 mg (Caduet)
amlodipine besylate-atorvastatin
calcium tab 5-20 mg (Caduet)
amlodipine besylate-atorvastatin
calcium tab 5-40 mg (Caduet)
np
np
np
np
np
amlodipine besylate-atorvastatin
calcium tab 10-40 mg (Caduet)
amlodipine besylate-atorvastatin
calcium tab 10-80 mg (Caduet)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
np
np
np
np
np
BIDIL- isosorbide dinitrate-hydralazine NP
hcl tab 20-37.5 mg
CORLANOR- ivabradine hcl tab 5 mg NP
(base equiv)
NP
CORLANOR- ivabradine hcl tab
7.5 mg (base equiv)
P
ENTRESTO- sacubitril-valsartan tab
24-26 mg
P
ENTRESTO- sacubitril-valsartan tab
49-51 mg
P
ENTRESTO- sacubitril-valsartan tab
97-103 mg
P
LETAIRIS- ambrisentan tab 5 mg
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
ORENITRAM- treprostinil diolamine
tab cr 0.125 mg (base equiv)
NP
•
•
•
•
ORENITRAM- treprostinil diolamine
tab cr 0.25 mg (base equiv)
NP
• •
ORENITRAM- treprostinil diolamine
tab cr 1 mg (base equiv)
NP
• •
ORENITRAM- treprostinil diolamine
tab cr 2.5 mg (base equiv)
NP
• •
REVATIO- sildenafil citrate for
suspension 10 mg/ml
NP
• •
•
sildenafil citrate tab 20 mg
(Revatio)
np
• •
•
TRACLEER- bosentan tab 62.5 mg
P
TRACLEER- bosentan tab 125 mg
P
• •
• •
•
•
LETAIRIS- ambrisentan tab 10 mg
P
OPSUMIT- macitentan tab 10 mg
P
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
44
• •
•
TYVASO STARTER- treprostinil
inhalation solution 0.6 mg/ml
NP
• •
•
UPTRAVI- selexipag tab therapy pack
200 mcg (140) & 800 mcg (60)
P
• •
•
UPTRAVI- selexipag tab 200 mcg
P
UPTRAVI- selexipag tab 400 mcg
P
UPTRAVI- selexipag tab 600 mcg
P
UPTRAVI- selexipag tab 800 mcg
P
UPTRAVI- selexipag tab 1000 mcg
P
UPTRAVI- selexipag tab 1200 mcg
P
UPTRAVI- selexipag tab 1400 mcg
P
UPTRAVI- selexipag tab 1600 mcg
P
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
• •
•
ERECTILE DYSFUNCTION
CAVERJECT- alprostadil for inj
20 mcg
NP
CAVERJECT- alprostadil for inj
40 mcg
NP
CAVERJECT IMPULSE- alprostadil
for inj kit 10 mcg
NP
CAVERJECT IMPULSE- alprostadil
for inj kit 20 mcg
NP
CIALIS- tadalafil tab 2.5 mg
P
CIALIS- tadalafil tab 5 mg
P
CIALIS- tadalafil tab 10 mg
P
CIALIS- tadalafil tab 20 mg
P
EDEX- alprostadil for inj kit 10 mcg
NP
EDEX- alprostadil for inj kit 20 mcg
NP
EDEX- alprostadil for inj kit 40 mcg
NP
LEVITRA- vardenafil hcl tab 2.5 mg
NP
LEVITRA- vardenafil hcl tab 5 mg
NP
LEVITRA- vardenafil hcl tab 10 mg
NP
LEVITRA- vardenafil hcl tab 20 mg
NP
MUSE- alprostadil urethral pellet
125 mcg
NP
MUSE- alprostadil urethral pellet
250 mcg
NP
MUSE- alprostadil urethral pellet
500 mcg
NP
MUSE- alprostadil urethral pellet
1000 mcg
NP
STAXYN- vardenafil hcl orally
disintegrating tab 10 mg
NP
•
STENDRA- avanafil tab 50 mg
NP
STENDRA- avanafil tab 100 mg
NP
STENDRA- avanafil tab 200 mg
NP
•
•
•
•
•
•
VIAGRA- sildenafil citrate tab 25 mg
P
VIAGRA- sildenafil citrate tab 50 mg
P
VIAGRA- sildenafil citrate tab 100 mg
P
carbinoxamine maleate soln
4 mg/5ml
carbinoxamine maleate tab 4 mg
cetirizine hcl oral soln 1 mg/ml
(5 mg/5ml)
•
•
•
•
RESPIRATORY AGENTS
ANTIHISTAMINES
•
•
•
•
Dispensing Limits
TYVASO REFILL- treprostinil
inhalation solution 0.6 mg/ml
NP
VENTAVIS- iloprost inhalation solution NP
10 mcg/ml
VENTAVIS- iloprost inhalation solution NP
20 mcg/ml
•
Step Therapy
• •
Prior Authorization
NP
Specialty
TYVASO- treprostinil inhalation
solution 0.6 mg/ml
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
p
np
NC
CLARINEX- desloratadine syrup
0.5 mg/ml
NC
CLEMASTINE FUMARATEclemastine fumarate tab 2.68 mg
NP
cyproheptadine hcl syrup 2 mg/5ml
np
cyproheptadine hcl tab 4 mg
np
DESLORATADINE ODTdesloratadine tab orally
disintegrating 2.5 mg
NC
DESLORATADINE ODTdesloratadine tab orally
disintegrating 5 mg
NC
desloratadine tab 5 mg (Clarinex)
NC
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
45
diphenhydramine hcl elixir
12.5 mg/5ml
NC
ipratropium bromide nasal soln
0.06% (42 mcg/spray)
np
KARBINAL ER- carbinoxamine
maleate extended release susp
4 mg/5ml
NC
levocetirizine dihydrochloride soln
2.5 mg/5ml (0.5 mg/ml) (Xyzal)
NC
olopatadine hcl nasal soln 0.6%
(Patanase)
NC
OMNARIS- ciclesonide nasal susp
50 mcg/act
NC
np
QNASL- beclomethasone
dipropionate nasal aerosol 80 mcg/
act
NC
QNASL CHILDRENSbeclomethasone dipropionate nasal
aerosol 40 mcg/act
NC
triamcinolone acetonide nasal
aerosol suspension 55 mcg/act
NC
levocetirizine dihydrochloride tab
5 mg (Xyzal)
promethazine hcl suppos 12.5 mg
promethazine hcl suppos 25 mg
promethazine hcl suppos 50 mg
promethazine hcl syrup
6.25 mg/5ml
promethazine hcl tab 12.5 mg
promethazine hcl tab 25 mg
promethazine hcl tab 50 mg
RYVENT- carbinoxamine maleate tab
6 mg
mometasone furoate nasal susp
50 mcg/act (Nasonex)
np
np
p
p
p
ZETONNA- ciclesonide nasal aerosol
soln 37 mcg/act (50 mcg/valve)
p
NC
NASAL AGENTS - SYSTEMIC and TOPICAL
np
azelastine hcl nasal spray 0.1%
(137 mcg/spray)
NC
azelastine hcl nasal spray 0.15%
(205.5 mcg/spray) (Astepro)
NP
BACTROBAN NASAL- mupirocin
calcium nasal oint 2%
NC
BECONASE AQ- beclomethasone
dipropionate monohyd nasal susp
42 mcg/spray
budesonide nasal susp 32 mcg/act NC
(Rhinocort aqua)
NC
DYMISTA- azelastine hcl-fluticasone
prop nasal spray 137-50 mcg/act
NC
flunisolide nasal soln 25 mcg/act
(0.025%)
p
fluticasone propionate nasal susp
50 mcg/act
np
ipratropium bromide nasal soln
0.03% (21 mcg/spray)
COUGH/COLD/ALLERGY
acetylcysteine inhal soln 10%
•
acetylcysteine inhal soln 20%
BENZONATATE- benzonatate cap
150 mg
benzonatate cap 100 mg (Tessalon
perles)
benzonatate cap 200 mg
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
•
NC
NC
NC
np
np
NP
p
p
CAPCOF- phenylephrine-chlorphen w/ NP
codeine syrup 5-2-10 mg/5ml
NC
CLARINEX-D 12 HOURdesloratadine & pseudoephedrine
tab sr 12hr 2.5-120 mg
NP
CODITUSSIN AC- guaifenesincodeine liquid 200-10 mg/5ml
CODITUSSIN DAC- pseudoephedrine NP
w/ cod-gg liquid 30-10-200 mg/5ml
NC
FLOWTUSS- hydrocodoneguaifenesin soln 2.5-200 mg/5ml
np
guaifenesin-codeine liquid
225-7.5 mg/5ml
p
guaifenesin-codeine soln
100-6.3 mg/5ml
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
46
guaifenesin-codeine soln
100-10 mg/5ml
p
promethazine-dm syrup
6.25-15 mg/5ml
HISTEX-AC- phenylephrinetriprolidine-codeine syrup
10-2.5-10 mg/5ml
NP
HYCOFENIX- pseudoephedrine
w/ hydrocodone-gg soln
30-2.5-200 mg/5ml
NC
pseudoeph-chlorphen w/
hydrocodone soln 60-4-5 mg/5ml
(Zutripro)
hydrocod polst-chlorphen polst
er susp 10-8 mg/5ml (Tussionex
pennkineti)
np
pseudoephed-bromphen-dm syrup
30-2-10 mg/5ml
hydrocodone w/ homatropine syrup np
5-1.5 mg/5ml
np
hydrocodone w/ homatropine tab
5-1.5 mg
NP
LORTUSS EX- pseudoephedrine w/
cod-gg liquid 30-10-100 mg/5ml
NP
M-END PE- phenylephrinebromphen w/ codeine liqd
3.33-1.33-6.33 mg/5ml
NP
MAR-COF BP- pseudoephedrinebromphen-codeine liqd
30-2-7.5 mg/5ml
NINJACOF-XG- guaifenesin-codeine NP
liquid 200-8 mg/5ml
OBREDON- hydrocodone-guaifenesin NC
soln 2.5-200 mg/5ml
NP
PHENYLHISTINE DHpseudoephedrine-chlorphen w/
codeine liq 30-2-10 mg/5ml
NP
POLY-TUSSIN AC- phenylephrinebromphen w/ codeine liquid
10-4-10 mg/5ml
PRO-CLEAR AC- codeine-pyrilamine NP
syrup 9-8.33 mg/5ml
NP
PRO-RED AC- phenylephrinedexchlorphenir-codeine syrup
5-1-9 mg/5ml
np
promethazine & phenylephrine
syrup 6.25-5 mg/5ml
p
promethazine w/ codeine syrup
6.25-10 mg/5ml
promethazine-phenylephrinecodeine syrup 6.25-5-10 mg/5ml
pseudoephedrine w/ cod-gg soln
30-10-100 mg/5ml
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
p
np
np
NC
np
REZIRA- pseudoephedrine w/
hydrocodone soln 60-5 mg/5ml
NC
SEMPREX-D- acrivastine &
pseudoephedrine cap 8-60 mg
NC
TUSNEL C- pseudoephedrine w/ cod- NP
gg syrup 30-10-100 mg/5ml
NC
TUSSICAPS- hydrocod polstchlorphen polst cap sr 12hr 5-4 mg
NC
TUSSICAPS- hydrocod polstchlorphen polst cap sr 12hr 10-8 mg
NC
TUZISTRA XR- codeine polistchlorphen polist er susp
14.7-2.8 mg/5ml
NC
VITUZ- hydrocodonechlorpheniramine soln 5-4 mg/5ml
NP
Z-TUSS AC- chlorpheniramine w/
codeine liquid 2-9 mg/5ml
ANTIASTHMATIC and BRONCHODILATOR AGENTS
P
ADVAIR DISKUS- fluticasonesalmeterol aer powder ba
100-50 mcg/dose
P
ADVAIR DISKUS- fluticasonesalmeterol aer powder ba
250-50 mcg/dose
P
ADVAIR DISKUS- fluticasonesalmeterol aer powder ba
500-50 mcg/dose
P
ADVAIR HFA- fluticasone-salmeterol
inhal aerosol 45-21 mcg/act
P
ADVAIR HFA- fluticasone-salmeterol
inhal aerosol 115-21 mcg/act
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
•
•
•
•
•
47
ADVAIR HFA- fluticasone-salmeterol
inhal aerosol 230-21 mcg/act
AEROSPAN- flunisolide hfa inhal
aerosol 80 mcg/act
albuterol sulfate soln nebu 0.083%
(2.5 mg/3ml)
albuterol sulfate soln nebu 0.5%
(5 mg/ml)
albuterol sulfate soln nebu
0.63 mg/3ml (base equiv)
albuterol sulfate soln nebu
1.25 mg/3ml (base equiv)
albuterol sulfate syrup 2 mg/5ml
albuterol sulfate tab sr 12hr 4 mg
(Vospire er)
albuterol sulfate tab sr 12hr 8 mg
(Vospire er)
albuterol sulfate tab 2 mg
albuterol sulfate tab 4 mg
P
NC
p
np
np
np
p
np
np
np
np
ALVESCO- ciclesonide inhal aerosol
80 mcg/act
NC
ALVESCO- ciclesonide inhal aerosol
160 mcg/act
NC
P
•
NP
•
ARNUITY ELLIPTA- fluticasone
furoate aerosol powder breath activ
100 mcg/act
P
•
ARNUITY ELLIPTA- fluticasone
furoate aerosol powder breath activ
200 mcg/act
P
•
ASMANEX HFA- mometasone furoate
inhal aerosol suspension 100 mcg/
act
P
•
ASMANEX HFA- mometasone furoate
inhal aerosol suspension 200 mcg/
act
P
•
ANORO ELLIPTA- umeclidiniumvilanterol aero powd ba
62.5-25 mcg/inh
ARCAPTA NEOHALER- indacaterol
maleate inhal powder cap 75 mcg
(base equiv)
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
•
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
ASMANEX TWISTHALER 120 MEmometasone furoate inhal powd
220 mcg/inh (breath activated)
P
•
ASMANEX TWISTHALER 30 METmometasone furoate inhal powd
110 mcg/inh (breath activated)
P
•
ASMANEX TWISTHALER 30 METmometasone furoate inhal powd
220 mcg/inh (breath activated)
P
•
ASMANEX TWISTHALER 60 METmometasone furoate inhal powd
220 mcg/inh (breath activated)
P
•
ATROVENT HFA- ipratropium bromide NP
hfa inhal aerosol 17 mcg/act
NC
BEVESPI
AEROSPHERE- glycopyrrolateformoterol fumarate aerosol
9-4.8 mcg/act
P
BREO ELLIPTA- fluticasone furoatevilanterol aero powd ba 100-25 mcg/
inh
P
BREO ELLIPTA- fluticasone furoatevilanterol aero powd ba 200-25 mcg/
inh
BROVANA- arformoterol tartrate soln NP
nebu 15 mcg/2ml (base equiv)
np
budesonide inhalation susp
0.25 mg/2ml (Pulmicort)
np
budesonide inhalation susp
0.5 mg/2ml (Pulmicort)
np
budesonide inhalation susp
1 mg/2ml (Pulmicort)
NP
COMBIVENT RESPIMATipratropium-albuterol inhal aerosol
soln 20-100 mcg/act
NP
CROMOLYN SODIUM- cromolyn
sodium soln nebu 20 mg/2ml
NP
DALIRESP- roflumilast tab 500 mcg
DULERA- mometasone furoateformoterol fumarate aerosol
100-5 mcg/act
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
P
•
•
•
•
•
48
DULERA- mometasone furoateformoterol fumarate aerosol
200-5 mcg/act
ELIXOPHYLLIN- theophylline elixir
80 mg/15ml
P
NP
•
LEVALBUTEROL TARTRATE HFAlevalbuterol tartrate inhal aerosol
45 mcg/act (base equiv)
NC
METAPROTERENOL SULFATEmetaproterenol sulfate syrup
10 mg/5ml
NC
METAPROTERENOL SULFATEmetaproterenol sulfate tab 10 mg
NC
METAPROTERENOL SULFATEmetaproterenol sulfate tab 20 mg
NC
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
•
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
FLOVENT DISKUS- fluticasone
propionate aer pow ba 50 mcg/
blister
P
FLOVENT DISKUS- fluticasone
propionate aer pow ba 100 mcg/
blister
P
•
FLOVENT DISKUS- fluticasone
propionate aer pow ba 250 mcg/
blister
P
•
FLOVENT HFA- fluticasone
propionate hfa inhal aero 44 mcg/
act (50/valve)
P
•
FLOVENT HFA- fluticasone
propionate hfa inhal aer 110 mcg/act
(125/valve)
P
•
FLOVENT HFA- fluticasone
propionate hfa inhal aer 220 mcg/
act (250/valve)
P
•
PERFOROMIST- formoterol fumarate
soln nebu 20 mcg/2ml
NP
P
•
INCRUSE ELLIPTA- umeclidinium br
aero powd breath act 62.5 mcg/inh
(base eq)
P
•
PROAIR HFA- albuterol sulfate inhal
aero 108 mcg/act (90mcg base
equiv)
P
•
ipratropium bromide inhal soln
0.02%
p
PROAIR RESPICLICK- albuterol
sulfate aer pow ba 108 mcg/act
(90 mcg base equiv)
ipratropium-albuterol nebu soln
0.5-2.5(3) mg/3ml
levalbuterol hcl soln nebu conc
1.25 mg/0.5ml (base equiv)
(Xopenex concentrate)
levalbuterol hcl soln nebu
0.31 mg/3ml (base equiv)
(Xopenex)
levalbuterol hcl soln nebu
0.63 mg/3ml (base equiv)
(Xopenex)
levalbuterol hcl soln nebu
1.25 mg/3ml (base equiv)
(Xopenex)
p
np
np
np
np
montelukast sodium chew tab 4 mg
(base equiv) (Singulair)
montelukast sodium chew tab 5 mg
(base equiv) (Singulair)
montelukast sodium oral granules
packet 4 mg (base equiv)
(Singulair)
montelukast sodium tab 10 mg
(base equiv) (Singulair)
p
•
p
•
NC
p
NC
PROVENTIL HFA- albuterol sulfate
inhal aero 108 mcg/act (90mcg base
equiv)
NC
PULMICORT FLEXHALERbudesonide inhal aero powd
90 mcg/act (breath activated)
NC
PULMICORT FLEXHALERbudesonide inhal aero powd
180 mcg/act (breath activated)
P
QVAR- beclomethasone diprop inhal
aero soln 40 mcg/act (50/valve)
P
QVAR- beclomethasone diprop inhal
aero soln 80 mcg/act (100/valve)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
•
•
•
49
P
•
SPIRIVA RESPIMAT- tiotropium
bromide monohydrate inhal aerosol
1.25 mcg/act
P
•
SPIRIVA RESPIMAT- tiotropium
bromide monohydrate inhal aerosol
2.5 mcg/act
P
•
STIOLTO RESPIMAT- tiotropium
br-olodaterol inhal aero soln
2.5-2.5 mcg/act
P
•
STRIVERDI RESPIMAT- olodaterol
hcl inhal aerosol soln 2.5 mcg/act
(base equiv)
P
SYMBICORT- budesonide-formoterol
fumarate dihyd aerosol 80-4.5 mcg/
act
P
•
SYMBICORT- budesonideformoterol fumarate dihyd aerosol
160-4.5 mcg/act
P
•
terbutaline sulfate tab 2.5 mg
np
terbutaline sulfate tab 5 mg
NC
UTIBRON NEOHALER- indacaterolglycopyrrolate inhal cap
27.5-15.6 mcg
NC
VENTOLIN HFA- albuterol sulfate
inhal aero 108 mcg/act (90mcg base
equiv)
NC
zafirlukast tab 10 mg (Accolate)
np
zafirlukast tab 20 mg (Accolate)
np
THEO-24- theophylline cap sr 24hr
100 mg
NP
THEO-24- theophylline cap sr 24hr
200 mg
•
zileuton tab sr 12hr 600 mg (Zyflo
cr)
NC
NC
ZYFLO CR- zileuton tab sr 12hr
600 mg
NC
ESBRIET- pirfenidone cap 267 mg
NP
ESBRIET- pirfenidone tab 267 mg
NP
ESBRIET- pirfenidone tab 801 mg
NP
GLASSIA- alpha1-proteinase inhibitor
(human) inj 1000 mg/50ml
NP
KALYDECO- ivacaftor tab 150 mg
P
NP
KALYDECO- ivacaftor packet 50 mg
P
KALYDECO- ivacaftor packet 75 mg
P
THEO-24- theophylline cap sr 24hr
300 mg
NP
THEO-24- theophylline cap sr 24hr
400 mg
NP
theophylline soln 80 mg/15ml
np
OFEV- nintedanib esylate cap 100 mg NP
(base equivalent)
OFEV- nintedanib esylate cap 150 mg NP
(base equivalent)
NP
ORKAMBI- lumacaftor-ivacaftor tab
100-125 mg
NP
ORKAMBI- lumacaftor-ivacaftor tab
200-125 mg
PULMOZYME- dornase alfa inhal soln P
1 mg/ml
theophylline tab sr 12hr 100 mg
theophylline tab sr 12hr 200 mg
theophylline tab sr 12hr 300 mg
theophylline tab sr 12hr 450 mg
theophylline tab sr 24hr 400 mg
theophylline tab sr 24hr 600 mg
p
np
np
np
np
np
•
•
np
ZYFLO- zileuton tab 600 mg
RESPIRATORY AGENTS - MISC.
•
P
XOPENEX HFA- levalbuterol tartrate
inhal aerosol 45 mcg/act (base
equiv)
Dispensing Limits
SPIRIVA HANDIHALER- tiotropium
bromide monohydrate inhal cap
18 mcg (base equiv)
TUDORZA PRESSAIR- aclidinium
bromide aerosol powd breath
activated 400 mcg/act
Step Therapy
•
Prior Authorization
P
Specialty
SEREVENT DISKUS- salmeterol
xinafoate aer pow ba 50 mcg/dose
(base equiv)
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
• •
• •
• •
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
• •
•
• •
•
• •
•
•
GASTROINTESTINAL AGENTS
LAXATIVES
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
50
np
GIALAX- polyethylene glycol 3350 - kit NC
GOLYTELY- peg 3350-kcl-na bicarb- NC
nacl-na sulfate packet 227.1 gm
NC
KRISTALOSE- lactulose oral crystal
packet 10 gm
NC
KRISTALOSE- lactulose oral crystal
packet 20 gm
p
lactulose solution 10 gm/15ml
MOVIPREP- peg 3350-kcl-nacl-na
sulfate-na ascorbate-c for soln
100 gm
NC
OSMOPREP- sod phos mono-sod
phos di tabs 1.102-0.398 gm(1.5gm
na phos)
NC
PCP 100- mag cit-bisacodyl-petrolatpeg-metoclopramide-electrol kit
NC
peg 3350-kcl-sod bicarb-nacl for
soln 420 gm (Nulytely/flavor pack)
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 236 gm (Golytely)
peg 3350-kcl-na bicarb-nacl-na
sulfate for soln 240 gm (Colyteflavor packs)
polyethylene glycol 3350 oral
packet
polyethylene glycol 3350 oral
powder
p
MOTOFEN- difenoxin w/ atropine tab
1-0.025 mg
NP
MYTESI- crofelemer tab delayed
release 125 mg
NP
ULCER DRUGS
ACIPHEX SPRINKLE- rabeprazole
sodium capsule sprinkle dr 5 mg
NC
ACIPHEX SPRINKLE- rabeprazole
sodium capsule sprinkle dr 10 mg
NC
amoxicillin cap-clarithro tablansopraz cap dr therapy pack
(Prevpac)
NC
CARAFATE- sucralfate susp
1 gm/10ml
NP
chlordiazepoxide hcl-clidinium
bromide cap 5-2.5 mg (Librax)
NC
cimetidine hcl soln 300 mg/5ml
cimetidine tab 200 mg
cimetidine tab 800 mg
NC
NC
NP
np
NP
cimetidine tab 400 mg
NC
NC
NC
DEXILANT- dexlansoprazole cap
delayed release 60 mg
NC
p
np
p
DONNATAL- pb-hyoscy-atrop-scopol
tab 16.2-0.1037-0.0194-0.0065 mg
NC
DONNATAL- pb-hyoscyatrop-scopol elix
16.2-0.1037-0.0194-0.0065 mg/5ml
NC
esomeprazole magnesium cap
delayed release 20 mg (base eq)
(Nexium)
NC
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
NC
DEXILANT- dexlansoprazole cap
delayed release 30 mg
dicyclomine hcl tab 20 mg
Step Therapy
NC
NP
dicyclomine hcl oral soln
10 mg/5ml
Prior Authorization
NC
CUVPOSA- glycopyrrolate oral soln
1 mg/5ml
dicyclomine hcl cap 10 mg (Bentyl)
Specialty
Dispensing Limits
Step Therapy
Prior Authorization
p
SUPREP BOWEL PREP KITsodium sulfate-potassium sulfatemagnesium sulfate oral soln
DIPHENOXYLATE/ATROPINEdiphenoxylate w/ atropine liq
2.5-0.025 mg/5ml
NC
cimetidine tab 300 mg
NC
diphenoxylate w/ atropine tab
2.5-0.025 mg (Lomotil)
loperamide hcl cap 2 mg
p
PREPOPIK- sod picosulfatemg oxide-citric acid pack
10 mg-3.5 gm-12 gm
ANTIDIARRHEALS
Drug Name
Tier Designation
bisacodyl tab & peg 3350-kcl-sod
bicarb-nacl for soln kit
Specialty
Drug Name
Tier Designation
2017
51
NC
NEXIUM- esomeprazole magnesium
for delayed release susp packet
40 mg
ESOMEPRAZOLE STRONTIUMesomeprazole strontium cap
delayed release 24.65 mg
NC
NIZATIDINE- nizatidine oral soln
15 mg/ml
NC
NC
NC
ESOMEPRAZOLE STRONTIUMesomeprazole strontium cap
delayed release 49.3 mg
nizatidine cap 150 mg
famotidine for susp 40 mg/5ml
(Pepcid)
NC
esomeprazole magnesium cap
delayed release 40 mg (base eq)
(Nexium)
famotidine tab 20 mg (Pepcid)
famotidine tab 40 mg (Pepcid)
glycopyrrolate tab 1 mg (Robinul)
glycopyrrolate tab 2 mg (Robinul
forte)
lansoprazole cap delayed release
15 mg (Prevacid)
lansoprazole cap delayed release
30 mg (Prevacid)
omeprazole cap delayed release
20 mg
np
np
omeprazole cap delayed release
40 mg
NC
omeprazole-sodium bicarbonate
cap 20-1100 mg (Zegerid)
NC
methscopolamine bromide tab
2.5 mg (Pamine)
np
misoprostol tab 200 mcg (Cytotec)
omeprazole cap delayed release
10 mg
p
NC
misoprostol tab 100 mcg (Cytotec)
OMECLAMOX-PAK- amoxicillin capclarithro tab w/ omepraz cap dr
therapy pack
NC
LIBRAX- chlordiazepoxide hclclidinium bromide cap 5-2.5 mg
methscopolamine bromide tab
5 mg (Pamine forte)
nizatidine cap 300 mg
omeprazole-sodium bicarbonate
cap 40-1100 mg (Zegerid)
omeprazole-sodium bicarbonate
powd pack for susp 20-1680 mg
(Zegerid)
np
omeprazole-sodium bicarbonate
powd pack for susp 40-1680 mg
(Zegerid)
p
pantoprazole sodium ec tab 20 mg
(base equiv) (Protonix)
p
NEXIUM- esomeprazole magnesium
for delayed release susp pack
2.5 mg
P
NEXIUM- esomeprazole magnesium
for delayed release susp packet
5 mg
P
NEXIUM- esomeprazole magnesium
for delayed release susp packet
10 mg
P
NEXIUM- esomeprazole magnesium
for delayed release susp packet
20 mg
P
P
Dispensing Limits
Step Therapy
Prior Authorization
• •
NC
NC
p
•
p
•
p
•
NC
NC
NC
NC
p
•
p
•
• •
pantoprazole sodium ec tab 40 mg
(base equiv) (Protonix)
NC
• •
PREVACID SOLUTAB- lansoprazole
tab delayed release orally
disintegrating 15 mg
NC
• •
PREVACID SOLUTAB- lansoprazole
tab delayed release orally
disintegrating 30 mg
NC
• •
PRILOSEC- omeprazole magnesium
for delayed release susp packet
2.5 mg
PRILOSEC- omeprazole magnesium
for delayed release susp packet
10 mg
NC
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
52
PROPANTHELINE BROMIDEpropantheline bromide tab 15 mg
NP
PROTONIX- pantoprazole sodium for
delayed release susp packet 40 mg
NC
PYLERA- bismuth subcitmetronidazole-tetracycline cap
140-125-125 mg
NC
rabeprazole sodium ec tab 20 mg
(Aciphex)
NC
ranitidine hcl cap 150 mg
ranitidine hcl cap 300 mg
ranitidine hcl syrup 15 mg/ml
(75 mg/5ml)
ranitidine hcl tab 150 mg (Zantac)
ranitidine hcl tab 300 mg (Zantac)
sucralfate tab 1 gm (Carafate)
ANTIEMETICS
ondansetron hcl tab 4 mg (Zofran)
ondansetron hcl tab 8 mg (Zofran)
ondansetron hcl tab 24 mg
ondansetron orally disintegrating
tab 4 mg (Zofran odt)
ondansetron orally disintegrating
tab 8 mg (Zofran odt)
SANCUSO- granisetron td patch
3.1 mg/24hr (contains 34.3 mg)
NC
NC
NC
NC
p
np
AKYNZEO- netupitant-palonosetron
cap 300-0.5 mg
NP
•
ANZEMET- dolasetron mesylate tab
50 mg
NP
•
ANZEMET- dolasetron mesylate tab
100 mg
NP
aprepitant capsule therapy pack 80
& 125 mg (Emend)
np
aprepitant capsule 80 mg (Emend)
CESAMET- nabilone cap 1 mg
np
NP
•
•
•
•
DICLEGIS- doxylamine-pyridoxine tab NP
delayed release 10-10 mg
np
dronabinol cap 2.5 mg (Marinol)
dronabinol cap 5 mg (Marinol)
dronabinol cap 10 mg (Marinol)
np
np
EMEND- aprepitant for oral susp
125 mg (125 mg/5ml)
P
•
granisetron hcl tab 1 mg
np
•
meclizine hcl tab 12.5 mg
meclizine hcl tab 25 mg
ondansetron hcl oral soln 4 mg/5ml
(Zofran)
NC
NC
np
•
Dispensing Limits
Step Therapy
Prior Authorization
p
•
•
•
•
p
•
p
p
np
NC
TRANSDERM-SCOP- scopolamine td NP
patch 72hr 1 mg/3days
trimethobenzamide hcl cap 300 mg np
(Tigan)
NP
VARUBI- rolapitant hcl tab 90 mg
(base equiv)
NC
ZUPLENZ- ondansetron oral soluble
film 4 mg
NC
ZUPLENZ- ondansetron oral soluble
film 8 mg
DIGESTIVE AIDS
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
CREON- pancrelipase (lip-prot-amyl)
dr cap 3000-9500-15000 unit
P
CREON- pancrelipase (lip-prot-amyl)
dr cap 6000-19000-30000 unit
P
CREON- pancrelipase (lip-prot-amyl)
dr cap 12000-38000-60000 unit
P
CREON- pancrelipase (lip-prot-amyl)
dr cap 24000-76000-120000 unit
P
CREON- pancrelipase (lip-prot-amyl)
dr cap 36000-114000-180000 unit
P
PANCREAZE- pancrelipase (lip-protamyl) dr cap 2600-6200-10850 unit
NC
•
PANCREAZE- pancrelipase (lip-prot- NC
amyl) dr cap 4200-14200-24600 unit
PANCREAZE- pancrelipase (lip-prot- NC
amyl) dr cap 10500-35500-61500
unit
PANCREAZE- pancrelipase (lip-prot- NC
amyl) dr cap 16800-56800-98400
unit
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
53
PANCREAZE- pancrelipase (lip-protamyl) dr cap 21000-54700-83900
unit
NC
AURYXIA- ferric citrate tab 1 gm
(210 mg ferric iron)
NP
balsalazide disodium cap 750 mg
(Colazal)
np
PERTZYE- pancrelipase (lip-protamyl) dr cap 4000-14375-15125 unit
NC
PERTZYE- pancrelipase (lip-protamyl) dr cap 8000-28750-30250 unit
NC
calcium acetate (phosphate binder)
cap 667 mg (169 mg ca)
PERTZYE- pancrelipase (lip-protamyl) dr cap 16000-57500-60500
unit
NC
SUCRAID- sacrosidase soln 8500
unit/ml
NP
VIOKACE- pancrelipase (lip-protamyl) tab 10440-39150-39150 unit
NC
VIOKACE- pancrelipase (lip-protamyl) tab 20880-78300-78300 unit
•
calcium acetate (phosphate binder) NC
tab 667 mg (Eliphos)
P
CANASA- mesalamine suppos
1000 mg
P
CHENODAL- chenodiol tab 250 mg
NP
CHOLBAM- cholic acid cap 250 mg
NP
NC
CIMZIA- certolizumab pegol for inj kit
2 x 200 mg
NC
ZENPEP- pancrelipase (lip-prot-amyl)
dr cap 3000-10000-16000 unit
P
CIMZIA- certolizumab pegol inj kit 2 x
200 mg/ml
NC
ZENPEP- pancrelipase (lip-prot-amyl)
dr cap 5000-17000-27000 unit
P
CIMZIA STARTER KIT- certolizumab
pegol inj kit 6 x 200 mg/ml
NC
ZENPEP- pancrelipase (lip-prot-amyl)
dr cap 10000-34000-55000 unit
P
cromolyn sodium oral conc
100 mg/5ml (Gastrocrom)
np
ZENPEP- pancrelipase (lip-prot-amyl)
dr cap 15000-51000-82000 unit
P
DELZICOL- mesalamine cap dr
400 mg
ZENPEP- pancrelipase (lip-prot-amyl)
dr cap 20000-68000-109000 unit
P
DIPENTUM- olsalazine sodium cap
250 mg
NC
ZENPEP- pancrelipase (lip-prot-amyl)
dr cap 25000-85000-136000 unit
P
FOSRENOL- lanthanum carbonate
chew tab 500 mg (elemental)
NP
ZENPEP- pancrelipase (lip-prot-amyl)
dr cap 40000-136000-218000 unit
P
FOSRENOL- lanthanum carbonate
chew tab 750 mg (elemental)
NP
FOSRENOL- lanthanum carbonate
chew tab 1000 mg (elemental)
NP
FOSRENOL- lanthanum carbonate
oral powder pack 750 mg
(elemental)
NP
FOSRENOL- lanthanum carbonate
oral powder pack 1000 mg
(elemental)
NP
GATTEX- teduglutide (rdna) for inj kit
5 mg
NP
GIAZO- balsalazide disodium tab
1.1 gm
NC
AMITIZA- lubiprostone cap 24 mcg
NP
APRISO- mesalamine cap sr 24hr
0.375 gm
NC
ASACOL HD- mesalamine tab
delayed release 800 mg
P
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
Step Therapy
Prior Authorization
np
CHOLBAM- cholic acid cap 50 mg
GASTROINTESTINAL AGENTS- MISC.
NC
alosetron hcl tab 0.5 mg (base
equiv) (Lotronex)
alosetron hcl tab 1 mg (base equiv) NC
(Lotronex)
NP
AMITIZA- lubiprostone cap 8 mcg
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
•
•
•
P
• •
54
lactulose (encephalopathy) solution
10 gm/15ml
P
LINZESS- linaclotide cap 72 mcg
P
LINZESS- linaclotide cap 145 mcg
P
LINZESS- linaclotide cap 290 mcg
P
MESALAMINE DR- mesalamine tab
delayed release 800 mg
mesalamine enema 4 gm
metoclopramide hcl tab 5 mg
(Reglan)
metoclopramide hcl tab 10 mg
(Reglan)
P
RENVELA- sevelamer carbonate
packet 0.8 gm
P
P
P
RENVELA- sevelamer carbonate
packet 2.4 gm
NP
np
SFROWASA- mesalamine sulfite-free
(sf) enema 4 gm/60ml
p
sulfasalazine tab delayed release
500 mg (Azulfidine en-tabs)
np
p
sulfasalazine tab 500 mg
(Azulfidine)
p
TRULANCE- plecanatide tab 3 mg
NC
ursodiol cap 300 mg (Actigall)
np
NP
METOCLOPRAMIDE ODTmetoclopramide hcl orally
disintegrating tab 10 mg
NP
MOVANTIK- naloxegol oxalate tab
12.5 mg (base equivalent)
NP
MOVANTIK- naloxegol oxalate tab
25 mg (base equivalent)
NP
OCALIVA- obeticholic acid tab 5 mg
NP
OCALIVA- obeticholic acid tab 10 mg
NP
ursodiol tab 250 mg (Urso 250)
ursodiol tab 500 mg (Urso forte)
PENTASA- mesalamine cap cr
250 mg
P
PENTASA- mesalamine cap cr
500 mg
P
PHOSLYRA- calcium acetate
(phosphate binder) oral soln
667 mg/5ml
NP
RELISTOR- methylnaltrexone bromide NC
tab 150 mg
RELISTOR- methylnaltrexone bromide NC
inj 8 mg/0.4ml (20 mg/ml)
RELISTOR- methylnaltrexone bromide NC
inj 12 mg/0.6ml (20 mg/ml)
Dispensing Limits
Step Therapy
Prior Authorization
RENAGEL- sevelamer hcl tab 400 mg NP
RENAGEL- sevelamer hcl tab 800 mg NP
RENVELA- sevelamer carbonate tab
800 mg
METOCLOPRAMIDE ODTmetoclopramide hcl orally
disintegrating tab 5 mg
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
p
LIALDA- mesalamine tab delayed
release 1.2 gm
metoclopramide hcl soln 5 mg/5ml
(10 mg/10ml)
Specialty
Drug Name
Tier Designation
2017
VELPHORO- sucroferric oxyhydroxide
chew tab 500 mg
np
np
np
P
VIBERZI- eluxadoline tab 75 mg
NC
VIBERZI- eluxadoline tab 100 mg
NC
GENITOURINARY AGENTS
URINARY ANTI-INFECTIVES
• •
• •
•
•
methenamine hippurate tab 1 gm
(Hiprex)
np
MONUROL- fosfomycin tromethamine NP
powd pack 3 gm (base equivalent)
nitrofurantoin macrocrystalline cap np
25 mg (Macrodantin)
nitrofurantoin macrocrystalline cap np
50 mg (Macrodantin)
nitrofurantoin macrocrystalline cap np
100 mg (Macrodantin)
np
nitrofurantoin monohydrate
macrocrystalline cap 100 mg
(Macrobid)
np
nitrofurantoin susp 25 mg/5ml
(Furadantin)
URINARY ANTISPASMODICS
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
55
bethanechol chloride tab 5 mg
(Urecholine)
bethanechol chloride tab 10 mg
(Urecholine)
bethanechol chloride tab 25 mg
(Urecholine)
bethanechol chloride tab 50 mg
(Urecholine)
darifenacin hydrobromide tab
sr 24hr 7.5 mg (base equiv)
(Enablex)
np
np
TOVIAZ- fesoterodine fumarate tab sr NC
24hr 4 mg
TOVIAZ- fesoterodine fumarate tab sr NC
24hr 8 mg
np
trospium chloride cap sr 24hr
60 mg
np
trospium chloride tab 20 mg
NC
VESICARE- solifenacin succinate tab
5 mg
P
VESICARE- solifenacin succinate tab
10 mg
P
np
np
NC
darifenacin hydrobromide tab sr
24hr 15 mg (base equiv) (Enablex)
NC
flavoxate hcl tab 100 mg
GELNIQUE- oxybutynin chloride td gel NC
10%
NC
GELNIQUE PUMP- oxybutynin
chloride td gel 10%
MYRBETRIQ- mirabegron tab sr 24 hr P
25 mg
MYRBETRIQ- mirabegron tab sr 24 hr P
50 mg
p
oxybutynin chloride syrup
5 mg/5ml
np
oxybutynin chloride tab sr 24hr
5 mg (Ditropan xl)
np
oxybutynin chloride tab sr 24hr
10 mg (Ditropan xl)
np
oxybutynin chloride tab sr 24hr
15 mg (Ditropan xl)
np
oxybutynin chloride tab 5 mg
VAGINAL PRODUCTS
AVC- sulfanilamide vaginal cream
15%
NP
CLEOCIN- clindamycin phosphate
vaginal suppos 100 mg
NP
clindamycin phosphate vaginal
cream 2% (Cleocin)
np
CLINDESSE- clindamycin phosphate
(one dose) vaginal cream 2%
NP
CRINONE- progesterone vaginal gel
4%
P
CRINONE- progesterone vaginal gel
8%
P
ENCARE- nonoxynol-9 vaginal
suppos 100 mg
P
ENDOMETRIN- progesterone vaginal
insert 100 mg
ESTRACE- estradiol vaginal cream
0.1 mg/gm
np
NP
tolterodine tartrate cap sr 24hr
2 mg (Detrol la)
ESTRING- estradiol vaginal ring 2 mg
(7.5 mcg/24hrs)
np
FEMRING- estradiol acetate vaginal
ring 0.05 mg/24hr
NP
np
FEMRING- estradiol acetate vaginal
ring 0.1 mg/24hr
NP
np
GYNAZOLE-1- butoconazole nitrate
(one dose) vaginal cream 2%
NP
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
NC
OXYTROL- oxybutynin td patch twice
weekly 3.9 mg/24hr
tolterodine tartrate tab 2 mg
(Detrol)
Step Therapy
P
estradiol vaginal tab 10 mcg
(Vagifem)
tolterodine tartrate tab 1 mg
(Detrol)
Prior Authorization
NC
NC
tolterodine tartrate cap sr 24hr
4 mg (Detrol la)
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
56
np
finasteride tab 5 mg (Proscar)
LITHOSTAT- acetohydroxamic acid
tab 250 mg
NP
MICONAZOLE 3- miconazole nitrate
vaginal suppos 200 mg
NP
potassium citrate tab cr 5 meq
(540 mg) (Urocit-k 5)
np
nonoxynol-9 gel 4%
np
metronidazole vaginal gel 0.75%
(Metrogel-vaginal)
NUVESSA- metronidazole vaginal gel
1.3%
OPTIONS GYNOL II VAGINALnonoxynol-9 gel 3%
PREMARIN- estrogens, conjugated
vaginal cream 0.625 mg/gm
NP
P
P
terconazole vaginal cream 0.4%
(Terazol 7)
np
terconazole vaginal suppos 80 mg
potassium citrate tab cr 15 meq
(1620 mg) (Urocit-k 15)
NP
SHUR-SEAL- nonoxynol-9 gel 2%
terconazole vaginal cream 0.8%
potassium citrate tab cr 10 meq
(1080 mg) (Urocit-k 10)
RAPAFLO- silodosin cap 8 mg
np
tamsulosin hcl cap 0.4 mg (Flomax)
VCF VAGINAL CONTRACEPTIVEnonoxynol-9 foam 12.5%
P
ALPRAZOLAM INTENSOLalprazolam conc 1 mg/ml
NP
VCF VAGINAL CONTRACEPTIVEnonoxynol-9 film 28%
P
alprazolam orally disintegrating tab
0.25 mg
np
ANTIANXIETY AGENTS
alprazolam orally disintegrating tab
0.5 mg
p
alprazolam orally disintegrating tab
1 mg
NC
CARDURA XL- doxazosin mesylate
tab sr 24 hr 8 mg (base equiv)
NC
CYSTAGON- cysteamine bitartrate
cap 50 mg
P
•
CYSTAGON- cysteamine bitartrate
cap 150 mg
P
•
dutasteride cap 0.5 mg (Avodart)
np
ELMIRON- pentosan polysulfate
sodium caps 100 mg
NP
NP
CENTRAL NERVOUS SYSTEM DRUGS
CARDURA XL- doxazosin mesylate
tab sr 24 hr 4 mg (base equiv)
dutasteride-tamsulosin hcl cap
0.5-0.4 mg (Jalyn)
•
p
np
np
•
NC
VAGIFEM- estradiol vaginal tab
10 mcg
alfuzosin hcl tab sr 24hr 10 mg
(Uroxatral)
Dispensing Limits
np
P
GENITOURINARY AGENTS - MISC.
Step Therapy
np
TODAY SPONGE- nonoxynol-9
vaginal sponge 1000 mg
THIOLA- tiopronin tab 100 mg
Prior Authorization
p
PROCYSBI- cysteamine bitartrate cap NP
delayed release 25 mg (base equiv)
PROCYSBI- cysteamine bitartrate cap NP
delayed release 75 mg (base equiv)
NC
RAPAFLO- silodosin cap 4 mg
np
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
alprazolam orally disintegrating tab
2 mg
alprazolam tab sr 24hr 0.5 mg
(Xanax xr)
alprazolam tab sr 24hr 1 mg (Xanax
xr)
alprazolam tab sr 24hr 2 mg (Xanax
xr)
alprazolam tab sr 24hr 3 mg (Xanax
xr)
alprazolam tab 0.25 mg (Xanax)
alprazolam tab 0.5 mg (Xanax)
alprazolam tab 1 mg (Xanax)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
np
np
np
p
p
np
np
p
p
p
57
buspirone hcl tab 5 mg
buspirone hcl tab 7.5 mg
buspirone hcl tab 10 mg
buspirone hcl tab 15 mg
buspirone hcl tab 30 mg
chlordiazepoxide hcl cap 5 mg
chlordiazepoxide hcl cap 10 mg
chlordiazepoxide hcl cap 25 mg
clorazepate dipotassium tab
3.75 mg
clorazepate dipotassium tab 7.5 mg
(Tranxene t)
clorazepate dipotassium tab 15 mg
p
p
np
p
p
np
p
p
p
p
p
np
DIAZEPAM- diazepam oral soln 1 mg/
ml
P
diazepam conc 5 mg/ml
np
diazepam tab 2 mg (Valium)
diazepam tab 5 mg (Valium)
diazepam tab 10 mg (Valium)
hydroxyzine hcl syrup 10 mg/5ml
hydroxyzine hcl tab 10 mg
hydroxyzine hcl tab 25 mg
hydroxyzine hcl tab 50 mg
p
p
p
p
p
p
p
HYDROXYZINE PAMOATEhydroxyzine pamoate cap 100 mg
NP
hydroxyzine pamoate cap 25 mg
(Vistaril)
p
hydroxyzine pamoate cap 50 mg
(Vistaril)
lorazepam conc 2 mg/ml
lorazepam tab 0.5 mg (Ativan)
lorazepam tab 1 mg (Ativan)
lorazepam tab 2 mg (Ativan)
meprobamate tab 200 mg
meprobamate tab 400 mg
oxazepam cap 10 mg
p
np
p
p
p
NC
NC
np
oxazepam cap 30 mg
ANTIDEPRESSANTS
amitriptyline hcl tab 10 mg
amitriptyline hcl tab 25 mg (Elavil)
amitriptyline hcl tab 50 mg
amitriptyline hcl tab 75 mg
amitriptyline hcl tab 100 mg
amitriptyline hcl tab 150 mg
Dispensing Limits
Step Therapy
np
Prior Authorization
oxazepam cap 15 mg
Specialty
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Tier Designation
alprazolam tab 2 mg (Xanax)
Specialty
Drug Name
Tier Designation
2017
np
p
p
p
np
np
np
AMOXAPINE- amoxapine tab 25 mg
NC
AMOXAPINE- amoxapine tab 50 mg
NC
AMOXAPINE- amoxapine tab 100 mg NC
AMOXAPINE- amoxapine tab 150 mg NC
APLENZIN- bupropion hbr tab sr 24hr NC
174 mg
APLENZIN- bupropion hbr tab sr 24hr NC
348 mg
APLENZIN- bupropion hbr tab sr 24hr NC
522 mg
p
bupropion hcl tab sr 12hr 100 mg
(Wellbutrin sr)
p
bupropion hcl tab sr 12hr 150 mg
(Wellbutrin sr)
np
bupropion hcl tab sr 12hr 200 mg
(Wellbutrin sr)
np
bupropion hcl tab sr 24hr 150 mg
(Wellbutrin xl)
np
bupropion hcl tab sr 24hr 300 mg
(Wellbutrin xl)
np
bupropion hcl tab 75 mg
bupropion hcl tab 100 mg
citalopram hydrobromide oral soln
10 mg/5ml
citalopram hydrobromide tab 10 mg
(base equiv) (Celexa)
citalopram hydrobromide tab 20 mg
(base equiv) (Celexa)
citalopram hydrobromide tab 40 mg
(base equiv) (Celexa)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
•
•
•
•
•
np
•
•
•
p
•
p
•
p
•
np
58
clomipramine hcl cap 25 mg
(Anafranil)
clomipramine hcl cap 50 mg
(Anafranil)
clomipramine hcl cap 75 mg
(Anafranil)
desipramine hcl tab 10 mg
(Norpramin)
desipramine hcl tab 25 mg
(Norpramin)
desipramine hcl tab 50 mg
desipramine hcl tab 75 mg
desipramine hcl tab 100 mg
desipramine hcl tab 150 mg
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
np
EMSAM- selegiline td patch 24hr
6 mg/24hr
NP
np
EMSAM- selegiline td patch 24hr
9 mg/24hr
NP
np
EMSAM- selegiline td patch 24hr
12 mg/24hr
NP
np
escitalopram oxalate soln 5 mg/5ml
(base equiv)
np
•
p
•
p
•
p
•
np
escitalopram oxalate tab 5 mg
(base equiv) (Lexapro)
np
escitalopram oxalate tab 10 mg
(base equiv) (Lexapro)
np
escitalopram oxalate tab 20 mg
(base equiv) (Lexapro)
np
np
DESVENLAFAXINE ERdesvenlafaxine tab sr 24hr 50 mg
NP
• •
FETZIMA- levomilnacipran hcl cap sr
24hr 20 mg (base equivalent)
NP
• •
DESVENLAFAXINE ERdesvenlafaxine tab sr 24hr 100 mg
NP
• •
FETZIMA- levomilnacipran hcl cap sr
24hr 40 mg (base equivalent)
NP
• •
desvenlafaxine succinate tab sr
24hr 25 mg (base equiv) (Pristiq)
np
•
FETZIMA- levomilnacipran hcl cap sr
24hr 80 mg (base equivalent)
NP
• •
np
•
FETZIMA- levomilnacipran hcl cap sr
24hr 120 mg (base equivalent)
NP
• •
np
desvenlafaxine succinate tab sr
24hr 100 mg (base equiv) (Pristiq)
NP
DOXEPIN HCL- doxepin hcl cap
75 mg
p
doxepin hcl cap 10 mg
•
• •
np
NP
FETZIMA TITRATION PACKlevomilnacipran hcl cap sr 24hr 20 &
40 mg therapy pack
np
FLUOXETINE DR- fluoxetine hcl cap
delayed release 90 mg
FLUOXETINE HCL- fluoxetine hcl tab NC
60 mg
p
fluoxetine hcl cap 10 mg (Prozac)
np
fluoxetine hcl cap 20 mg (Prozac)
np
fluoxetine hcl cap 40 mg (Prozac)
p
fluoxetine hcl solution 20 mg/5ml
desvenlafaxine succinate tab sr
24hr 50 mg (base equiv) (Pristiq)
doxepin hcl cap 25 mg
doxepin hcl cap 50 mg
doxepin hcl cap 100 mg
doxepin hcl cap 150 mg
doxepin hcl conc 10 mg/ml
np
DULOXETINE HCL- duloxetine hcl
enteric coated pellets cap 40 mg
NC
duloxetine hcl enteric coated
pellets cap 20 mg (Cymbalta)
np
•
np
•
np
•
duloxetine hcl enteric coated
pellets cap 30 mg (Cymbalta)
duloxetine hcl enteric coated
pellets cap 60 mg (Cymbalta)
fluoxetine hcl tab 10 mg
fluoxetine hcl tab 20 mg
fluvoxamine maleate cap sr 24hr
100 mg
fluvoxamine maleate cap sr 24hr
150 mg
fluvoxamine maleate tab 25 mg
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
p
p
p
np
np
• •
•
•
•
•
•
•
NC
NC
p
•
59
fluvoxamine maleate tab 100 mg
FORFIVO XL- bupropion hcl tab sr
24hr 450 mg
imipramine hcl tab 10 mg (Tofranil)
imipramine hcl tab 25 mg (Tofranil)
imipramine hcl tab 50 mg (Tofranil)
imipramine pamoate cap 75 mg
imipramine pamoate cap 100 mg
imipramine pamoate cap 125 mg
p
p
NC
NORTRIPTYLINE HCL- nortriptyline
hcl soln 10 mg/5ml
nortriptyline hcl cap 10 mg
(Pamelor)
p
nortriptyline hcl cap 25 mg
(Pamelor)
p
p
nortriptyline hcl cap 50 mg
(Pamelor)
np
np
nortriptyline hcl cap 75 mg
(Pamelor)
np
np
KHEDEZLA- desvenlafaxine tab sr
24hr 50 mg
NC
paroxetine hcl tab sr 24hr 12.5 mg
(Paxil cr)
KHEDEZLA- desvenlafaxine tab sr
24hr 100 mg
NC
paroxetine hcl tab sr 24hr 25 mg
(Paxil cr)
MAPROTILINE HCL- maprotiline hcl
tab 25 mg
NC
paroxetine hcl tab sr 24hr 37.5 mg
(Paxil cr)
MAPROTILINE HCL- maprotiline hcl
tab 50 mg
NC
MAPROTILINE HCL- maprotiline hcl
tab 75 mg
NC
MARPLAN- isocarboxazid tab 10 mg
NP
mirtazapine orally disintegrating
tab 15 mg (Remeron soltab)
np
•
np
•
np
•
np
•
•
•
•
imipramine pamoate cap 150 mg
mirtazapine orally disintegrating
tab 30 mg (Remeron soltab)
mirtazapine orally disintegrating
tab 45 mg (Remeron soltab)
mirtazapine tab 7.5 mg
mirtazapine tab 15 mg (Remeron)
mirtazapine tab 30 mg (Remeron)
mirtazapine tab 45 mg (Remeron)
paroxetine hcl tab 10 mg (Paxil)
p
p
p
paroxetine hcl tab 20 mg (Paxil)
paroxetine hcl tab 30 mg (Paxil)
paroxetine hcl tab 40 mg (Paxil)
Dispensing Limits
Step Therapy
NC
Prior Authorization
nefazodone hcl tab 250 mg
Specialty
Dispensing Limits
Step Therapy
Prior Authorization
•
•
Drug Name
Tier Designation
fluvoxamine maleate tab 50 mg
Specialty
Drug Name
Tier Designation
2017
NP
p
p
p
p
NC
NC
NC
p
p
p
p
PAXIL- paroxetine hcl oral susp
10 mg/5ml (base equiv)
NC
PEXEVA- paroxetine mesylate tab
10 mg (base equiv)
NC
PEXEVA- paroxetine mesylate tab
20 mg (base equiv)
NC
PEXEVA- paroxetine mesylate tab
30 mg (base equiv)
NC
PEXEVA- paroxetine mesylate tab
40 mg (base equiv)
NC
phenelzine sulfate tab 15 mg
(Nardil)
np
•
•
•
•
NEFAZODONE HCL- nefazodone hcl
tab 100 mg
NC
PRISTIQ- desvenlafaxine succinate
tab sr 24hr 25 mg (base equiv)
NP
• •
NEFAZODONE HCL- nefazodone hcl
tab 150 mg
NC
PRISTIQ- desvenlafaxine succinate
tab sr 24hr 50 mg (base equiv)
NP
• •
NEFAZODONE HCL- nefazodone hcl
tab 200 mg
NC
PRISTIQ- desvenlafaxine succinate
tab sr 24hr 100 mg (base equiv)
NP
• •
nefazodone hcl tab 50 mg
NC
protriptyline hcl tab 5 mg
np
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
60
sertraline hcl tab 50 mg (Zoloft)
sertraline hcl tab 100 mg (Zoloft)
tranylcypromine sulfate tab 10 mg
(Parnate)
trazodone hcl tab 50 mg
trazodone hcl tab 100 mg
trazodone hcl tab 150 mg
trazodone hcl tab 300 mg
trimipramine maleate cap 25 mg
(Surmontil)
trimipramine maleate cap 50 mg
(Surmontil)
trimipramine maleate cap 100 mg
(Surmontil)
p
p
p
p
np
np
np
TRINTELLIX- vortioxetine hbr tab
20 mg (base equiv)
NP
venlafaxine hcl tab sr 24hr 37.5 mg
(base equivalent) (Venlafaxine hcl
er)
venlafaxine hcl tab 37.5 mg
venlafaxine hcl tab 50 mg
venlafaxine hcl tab 75 mg
NP
ADASUVE- loxapine aerosol powder
breath activated 10 mg
NP
aripiprazole oral solution 1 mg/ml
np
• •
aripiprazole tab 2 mg (Abilify)
aripiprazole tab 5 mg (Abilify)
p
•
aripiprazole tab 20 mg (Abilify)
•
chlorpromazine hcl tab 10 mg
•
•
aripiprazole tab 15 mg (Abilify)
aripiprazole tab 30 mg (Abilify)
chlorpromazine hcl tab 25 mg
chlorpromazine hcl tab 50 mg
chlorpromazine hcl tab 100 mg
chlorpromazine hcl tab 200 mg
Prior Authorization
Specialty
Tier Designation
VIIBRYD STARTER PACKvilazodone hcl tab starter kit 10 (7)
& 20 (23) mg
aripiprazole tab 10 mg (Abilify)
np
venlafaxine hcl tab sr 24hr 75 mg
(base equivalent) (Venlafaxine hcl
er)
np
venlafaxine hcl tab sr 24hr 150 mg
(base equivalent) (Venlafaxine hcl
er)
np
NP
aripiprazole orally disintegrating
tab 15 mg
•
p
VIIBRYD- vilazodone hcl tab 40 mg
•
np
p
NP
p
p
p
VIIBRYD- vilazodone hcl tab 20 mg
aripiprazole orally disintegrating
tab 10 mg
• •
p
NP
• •
•
•
•
•
•
•
•
•
•
•
•
•
•
NC
VIIBRYD- vilazodone hcl tab 10 mg
ANTIPSYCHOTICS
np
TRINTELLIX- vortioxetine hbr tab
10 mg (base equiv)
venlafaxine hcl cap sr 24hr 150 mg
(base equivalent) (Effexor xr)
Dispensing Limits
p
NP
venlafaxine hcl tab 25 mg
venlafaxine hcl tab 100 mg
p
TRINTELLIX- vortioxetine hbr tab
5 mg (base equiv)
venlafaxine hcl cap sr 24hr 75 mg
(base equivalent) (Effexor xr)
•
•
•
np
NP
venlafaxine hcl cap sr 24hr 37.5 mg
(base equivalent) (Effexor xr)
•
venlafaxine hcl tab sr 24hr 225 mg
(base equivalent)
Dispensing Limits
sertraline hcl tab 25 mg (Zoloft)
np
Drug Name
Step Therapy
sertraline hcl oral conc 20 mg/ml
(Zoloft)
Step Therapy
np
Prior Authorization
protriptyline hcl tab 10 mg
Specialty
Drug Name
Tier Designation
2017
np
•
•
np
•
np
•
•
•
•
•
•
np
np
np
np
np
np
np
np
np
np
CLOZAPINE ODT- clozapine orally
disintegrating tab 12.5 mg
NP
• •
CLOZAPINE ODT- clozapine orally
disintegrating tab 150 mg
NP
• •
CLOZAPINE ODT- clozapine orally
disintegrating tab 200 mg
NP
• •
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
61
clozapine tab 25 mg (Clozaril)
clozapine tab 50 mg
clozapine tab 100 mg (Clozaril)
clozapine tab 200 mg
•
•
•
•
np
np
np
np
EQUETRO- carbamazepine
(antipsychotic) cap sr 12hr 200 mg
NP
EQUETRO- carbamazepine
(antipsychotic) cap sr 12hr 300 mg
NP
FANAPT- iloperidone tab 1 mg
NP
FANAPT- iloperidone tab 2 mg
NP
FANAPT- iloperidone tab 4 mg
NP
FANAPT- iloperidone tab 6 mg
NP
FANAPT- iloperidone tab 8 mg
NP
FANAPT- iloperidone tab 10 mg
NP
FANAPT- iloperidone tab 12 mg
NP
NP
FANAPT TITRATION PACKiloperidone tab 1 mg & 2 mg & 4 mg
& 6 mg titration pak
NP
FAZACLO- clozapine orally
disintegrating tab 12.5 mg
NP
FAZACLO- clozapine orally
disintegrating tab 150 mg
NP
FAZACLO- clozapine orally
disintegrating tab 200 mg
NP
FLUPHENAZINE HCL- fluphenazine
hcl elixir 2.5 mg/5ml
NP
FLUPHENAZINE HCL- fluphenazine
hcl oral conc 5 mg/ml
p
fluphenazine hcl tab 1 mg
fluphenazine hcl tab 10 mg
p
p
p
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
• •
• •
• •
haloperidol lactate oral conc 2 mg/
ml
haloperidol tab 0.5 mg
haloperidol tab 1 mg
haloperidol tab 2 mg
haloperidol tab 5 mg
haloperidol tab 10 mg
haloperidol tab 20 mg
np
np
np
np
NP
LATUDA- lurasidone hcl tab 60 mg
NP
LATUDA- lurasidone hcl tab 80 mg
NP
LATUDA- lurasidone hcl tab 120 mg
NP
LITHIUM- lithium oral solution 8
meq/5ml
P
LITHIUM CARBONATE- lithium
carbonate cap 150 mg
NP
LITHIUM CARBONATE- lithium
carbonate cap 600 mg
NP
lithium carbonate cap 150 mg
(Lithium carbonate)
p
lithium carbonate tab cr 450 mg
lithium carbonate tab 300 mg
p
p
p
p
p
LITHOBID- lithium carbonate tab cr
300 mg
NP
loxapine succinate cap 5 mg
np
loxapine succinate cap 10 mg
loxapine succinate cap 25 mg
loxapine succinate cap 50 mg
np
np
np
NUPLAZID- pimavanserin tartrate tab
17 mg (base equivalent)
NC
olanzapine orally disintegrating tab
5 mg (Zyprexa zydis)
np
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Prior Authorization
p
LATUDA- lurasidone hcl tab 40 mg
lithium carbonate tab cr 300 mg
(Lithobid)
•
•
•
•
•
p
NP
lithium carbonate cap 600 mg
(Lithium carbonate)
•
•
•
•
•
p
LATUDA- lurasidone hcl tab 20 mg
lithium carbonate cap 300 mg
Specialty
Tier Designation
Dispensing Limits
•
EQUETRO- carbamazepine
(antipsychotic) cap sr 12hr 100 mg
fluphenazine hcl tab 5 mg
Step Therapy
np
NP
fluphenazine hcl tab 2.5 mg
Prior Authorization
•
Dispensing Limits
clozapine orally disintegrating tab
100 mg (Fazaclo)
np
Drug Name
Step Therapy
clozapine orally disintegrating tab
25 mg (Fazaclo)
Specialty
Drug Name
Tier Designation
2017
•
62
olanzapine orally disintegrating tab
10 mg (Zyprexa zydis)
olanzapine orally disintegrating tab
15 mg (Zyprexa zydis)
olanzapine orally disintegrating tab
20 mg (Zyprexa zydis)
olanzapine tab 2.5 mg (Zyprexa)
olanzapine tab 5 mg (Zyprexa)
olanzapine tab 7.5 mg (Zyprexa)
olanzapine tab 10 mg (Zyprexa)
olanzapine tab 15 mg (Zyprexa)
olanzapine tab 20 mg (Zyprexa)
paliperidone tab sr 24hr 1.5 mg
(Invega)
paliperidone tab sr 24hr 3 mg
(Invega)
paliperidone tab sr 24hr 6 mg
(Invega)
paliperidone tab sr 24hr 9 mg
(Invega)
perphenazine tab 2 mg
perphenazine tab 4 mg
perphenazine tab 8 mg
perphenazine tab 16 mg
prochlorperazine maleate tab 5 mg
(base equivalent)
prochlorperazine maleate tab 10 mg
(base equivalent)
prochlorperazine suppos 25 mg
quetiapine fumarate tab sr 24hr
50 mg (Seroquel xr)
quetiapine fumarate tab sr 24hr
150 mg (Seroquel xr)
quetiapine fumarate tab sr 24hr
200 mg (Seroquel xr)
quetiapine fumarate tab sr 24hr
300 mg (Seroquel xr)
quetiapine fumarate tab sr 24hr
400 mg (Seroquel xr)
np
•
p
np
•
•
•
•
•
•
•
np
np
p
p
p
p
p
np
quetiapine fumarate tab 100 mg
(Seroquel)
quetiapine fumarate tab 200 mg
(Seroquel)
quetiapine fumarate tab 300 mg
(Seroquel)
quetiapine fumarate tab 400 mg
(Seroquel)
•
p
•
p
•
p
•
p
•
p
•
NP
REXULTI- brexpiprazole tab 0.5 mg
NP
•
REXULTI- brexpiprazole tab 1 mg
NP
REXULTI- brexpiprazole tab 2 mg
NP
•
REXULTI- brexpiprazole tab 3 mg
NP
•
REXULTI- brexpiprazole tab 4 mg
NP
risperidone orally disintegrating tab np
0.25 mg
risperidone orally disintegrating tab np
0.5 mg (Risperdal m-tab)
risperidone orally disintegrating tab np
1 mg (Risperdal m-tab)
risperidone orally disintegrating tab np
2 mg (Risperdal m-tab)
risperidone orally disintegrating tab np
3 mg (Risperdal m-tab)
risperidone orally disintegrating tab np
4 mg (Risperdal m-tab)
np
risperidone soln 1 mg/ml
(Risperdal)
risperidone tab 0.25 mg (Risperdal) p
np
np
np
p
p
np
•
np
•
np
•
risperidone tab 0.5 mg (Risperdal)
np
•
risperidone tab 2 mg (Risperdal)
•
risperidone tab 4 mg (Risperdal)
np
p
REXULTI- brexpiprazole tab 0.25 mg
np
np
quetiapine fumarate tab 50 mg
(Seroquel)
risperidone tab 1 mg (Risperdal)
risperidone tab 3 mg (Risperdal)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
•
Step Therapy
np
quetiapine fumarate tab 25 mg
(Seroquel)
Prior Authorization
•
Specialty
np
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
p
p
p
p
p
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
63
NP
• •
SAPHRIS- asenapine maleate sl tab
10 mg (base equiv)
NP
• •
SEROQUEL XR- quetiapine fumarate
tab sr 24hr 50 mg
P
• •
SEROQUEL XR- quetiapine fumarate
tab sr 24hr 150 mg
P
• •
SEROQUEL XR- quetiapine fumarate
tab sr 24hr 200 mg
P
• •
SEROQUEL XR- quetiapine fumarate
tab sr 24hr 300 mg
P
• •
thioridazine hcl tab 10 mg
thioridazine hcl tab 25 mg
thioridazine hcl tab 50 mg
thioridazine hcl tab 100 mg
thiothixene cap 1 mg
thiothixene cap 2 mg
thiothixene cap 5 mg
thiothixene cap 10 mg
trifluoperazine hcl tab 1 mg
trifluoperazine hcl tab 2 mg
trifluoperazine hcl tab 5 mg
trifluoperazine hcl tab 10 mg
ziprasidone hcl cap 40 mg
(Geodon)
ziprasidone hcl cap 60 mg
(Geodon)
ziprasidone hcl cap 80 mg
(Geodon)
HYPNOTICS
np
•
np
•
np
•
np
•
BELSOMRA- suvorexant tab 5 mg
NC
BELSOMRA- suvorexant tab 10 mg
NC
BELSOMRA- suvorexant tab 15 mg
NC
BELSOMRA- suvorexant tab 20 mg
NC
BUTISOL SODIUM- butabarbital
sodium tab 30 mg
NC
DORAL- quazepam tab 15 mg
NP
EDLUAR- zolpidem tartrate sl tab
5 mg
NC
np
EDLUAR- zolpidem tartrate sl tab
10 mg
NC
np
estazolam tab 1 mg
np
NC
NC
NC
NC
np
np
estazolam tab 2 mg
np
eszopiclone tab 1 mg (Lunesta)
np
eszopiclone tab 2 mg (Lunesta)
np
np
VERSACLOZ- clozapine susp 50 mg/
ml
NP
VRAYLAR- cariprazine hcl cap
therapy pack 1.5 mg (1) & 3 mg (6)
NP
VRAYLAR- cariprazine hcl cap 1.5 mg NP
(base equivalent)
NP
VRAYLAR- cariprazine hcl cap 3 mg
(base equivalent)
VRAYLAR- cariprazine hcl cap 4.5 mg NP
(base equivalent)
NP
VRAYLAR- cariprazine hcl cap 6 mg
(base equivalent)
eszopiclone tab 3 mg (Lunesta)
np
p
p
NP
• •
FLURAZEPAM HCL- flurazepam hcl
cap 30 mg
NP
• •
HALCION- triazolam tab 0.25 mg
NC
HETLIOZ- tasimelteon capsule 20 mg
NP
• •
PHENOBARBITAL- phenobarbital tab
15 mg
P
• •
PHENOBARBITAL- phenobarbital tab
30 mg
P
• •
PHENOBARBITAL- phenobarbital tab
60 mg
P
PHENOBARBITAL- phenobarbital tab
100 mg
P
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
•
•
•
np
FLURAZEPAM HCL- flurazepam hcl
cap 15 mg
• •
Dispensing Limits
SAPHRIS- asenapine maleate sl tab
5 mg (base equiv)
ziprasidone hcl cap 20 mg
(Geodon)
Step Therapy
• •
Prior Authorization
NP
Specialty
SAPHRIS- asenapine maleate sl tab
2.5 mg (base equiv)
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
•
•
64
phenobarbital tab 16.2 mg
phenobarbital tab 32.4 mg
phenobarbital tab 64.8 mg
phenobarbital tab 97.2 mg
np
np
np
NP
ROZEREM- ramelteon tab 8 mg
NP
SECONAL SODIUM- secobarbital
sodium cap 100 mg
NC
SILENOR- doxepin hcl (sleep) tab
3 mg (base equiv)
NC
SILENOR- doxepin hcl (sleep) tab
6 mg (base equiv)
NC
temazepam cap 7.5 mg (Restoril)
np
temazepam cap 22.5 mg (Restoril)
temazepam cap 30 mg (Restoril)
np
p
NC
triazolam tab 0.25 mg (Halcion)
NC
zaleplon cap 10 mg (Sonata)
zolpidem tartrate sl tab 1.75 mg
(Intermezzo)
zolpidem tartrate sl tab 3.5 mg
(Intermezzo)
zolpidem tartrate tab cr 6.25 mg
(Ambien cr)
zolpidem tartrate tab cr 12.5 mg
(Ambien cr)
zolpidem tartrate tab 5 mg (Ambien)
zolpidem tartrate tab 10 mg
(Ambien)
ZOLPIMIST- zolpidem tartrate oral
spray 5 mg/act
• •
p
TRIAZOLAM- triazolam tab 0.125 mg
zaleplon cap 5 mg (Sonata)
np
•
•
•
np
•
np
•
np
•
p
•
•
p
p
p
Dispensing Limits
Step Therapy
Prior Authorization
np
•
ADDERALL XR- amphetaminedextroamphetamine cap sr 24hr
15 mg
np
•
ADDERALL XR- amphetaminedextroamphetamine cap sr 24hr
20 mg
np
•
ADDERALL XR- amphetaminedextroamphetamine cap sr 24hr
25 mg
np
•
ADDERALL XR- amphetaminedextroamphetamine cap sr 24hr
30 mg
np
•
ADZENYS XR-ODT- amphetamine
tab extended release dispersible
3.1 mg
NC
ADZENYS XR-ODT- amphetamine
tab extended release dispersible
6.3 mg
NC
ADZENYS XR-ODT- amphetamine
tab extended release dispersible
9.4 mg
NC
ADZENYS XR-ODT- amphetamine
tab extended release dispersible
12.5 mg
NC
ADZENYS XR-ODT- amphetamine
tab extended release dispersible
15.7 mg
NC
ADZENYS XR-ODT- amphetamine
tab extended release dispersible
18.8 mg
NC
amphetamine-dextroamphetamine
cap sr 24hr 5 mg (Adderall xr)
NC
amphetamine-dextroamphetamine
cap sr 24hr 15 mg (Adderall xr)
•
Specialty
ADDERALL XR- amphetaminedextroamphetamine cap sr 24hr
10 mg
amphetamine-dextroamphetamine
cap sr 24hr 10 mg (Adderall xr)
NC
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/
ANOREXIANTS
np
ADDERALL XR- amphetaminedextroamphetamine cap sr 24hr
5 mg
Drug Name
Tier Designation
Dispensing Limits
np
QUAZEPAM- quazepam tab 15 mg
temazepam cap 15 mg (Restoril)
Step Therapy
np
Prior Authorization
phenobarbital elixir 20 mg/5ml
Specialty
Drug Name
Tier Designation
2017
amphetamine-dextroamphetamine
cap sr 24hr 20 mg (Adderall xr)
amphetamine-dextroamphetamine
cap sr 24hr 25 mg (Adderall xr)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
NC
NC
NC
NC
65
amphetamine-dextroamphetamine
cap sr 24hr 30 mg (Adderall xr)
amphetamine-dextroamphetamine
tab 5 mg (Adderall)
amphetamine-dextroamphetamine
tab 7.5 mg (Adderall)
amphetamine-dextroamphetamine
tab 10 mg (Adderall)
amphetamine-dextroamphetamine
tab 12.5 mg (Adderall)
amphetamine-dextroamphetamine
tab 15 mg (Adderall)
amphetamine-dextroamphetamine
tab 20 mg (Adderall)
amphetamine-dextroamphetamine
tab 30 mg (Adderall)
np
•
np
•
np
•
np
•
np
•
np
•
NC
APTENSIO XR- methylphenidate hcl
cap er 24hr 20 mg (xr)
NC
APTENSIO XR- methylphenidate hcl
cap er 24hr 30 mg (xr)
NC
APTENSIO XR- methylphenidate hcl
cap er 24hr 40 mg (xr)
NC
APTENSIO XR- methylphenidate hcl
cap er 24hr 50 mg (xr)
NC
APTENSIO XR- methylphenidate hcl
cap er 24hr 60 mg (xr)
NC
armodafinil tab 50 mg (Nuvigil)
np
BELVIQ- lorcaserin hcl tab 10 mg
np
np
np
NP
BELVIQ XR- lorcaserin hcl tab sr 24hr NP
20 mg
NC
benzphetamine hcl tab 25 mg
(Regimex)
NC
benzphetamine hcl tab 50 mg
•
•
•
•
•
•
•
•
caffeine citrate oral soln 60 mg/3ml
(10 mg/ml base equiv)
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
•
APTENSIO XR- methylphenidate hcl
cap er 24hr 15 mg (xr)
armodafinil tab 250 mg (Nuvigil)
Step Therapy
np
NC
armodafinil tab 200 mg (Nuvigil)
Prior Authorization
NC
APTENSIO XR- methylphenidate hcl
cap er 24hr 10 mg (xr)
armodafinil tab 150 mg (Nuvigil)
Specialty
Drug Name
Tier Designation
2017
np
np
•
CONCERTA- methylphenidate hcl tab
sa osm 18 mg
np
•
CONCERTA- methylphenidate hcl tab
sa osm 27 mg
np
•
CONCERTA- methylphenidate hcl tab
sa osm 36 mg
np
•
CONCERTA- methylphenidate hcl tab
sa osm 54 mg
np
•
clonidine hcl tab sr 12hr 0.1 mg
(Kapvay)
CONTRAVE- naltrexone hcl-bupropion NP
hcl tab sr 12hr 8-90 mg
NC
DAYTRANA- methylphenidate td
patch 10 mg/9hr
NC
DAYTRANA- methylphenidate td
patch 15 mg/9hr
NC
DAYTRANA- methylphenidate td
patch 20 mg/9hr
NC
DAYTRANA- methylphenidate td
patch 30 mg/9hr
np
dexmethylphenidate hcl cap sr 24
hr 5 mg (Focalin xr)
np
dexmethylphenidate hcl cap sr 24
hr 10 mg (Focalin xr)
np
dexmethylphenidate hcl cap sr 24
hr 15 mg (Focalin xr)
np
dexmethylphenidate hcl cap sr 24
hr 20 mg (Focalin xr)
np
dexmethylphenidate hcl cap sr 24
hr 25 mg (Focalin xr)
np
dexmethylphenidate hcl cap sr 24
hr 30 mg (Focalin xr)
np
dexmethylphenidate hcl cap sr 24
hr 35 mg (Focalin xr)
np
dexmethylphenidate hcl cap sr 24
hr 40 mg (Focalin xr)
dexmethylphenidate hcl tab 2.5 mg np
(Focalin)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
•
•
•
•
•
•
•
•
•
66
dexmethylphenidate hcl tab 5 mg
(Focalin)
dexmethylphenidate hcl tab 10 mg
(Focalin)
dextroamphetamine sulfate cap sr
24hr 5 mg (Dexedrine)
dextroamphetamine sulfate cap sr
24hr 10 mg (Dexedrine)
dextroamphetamine sulfate cap sr
24hr 15 mg (Dexedrine)
dextroamphetamine sulfate oral
solution 5 mg/5ml (Procentra)
dextroamphetamine sulfate tab
5 mg
dextroamphetamine sulfate tab
10 mg
np
•
METHYLPHENIDATE HCLmethylphenidate hcl chew tab
2.5 mg
np
•
METHYLPHENIDATE HCLmethylphenidate hcl chew tab 5 mg
np
•
np
•
np
•
np
•
np
•
np
•
np
•
np
•
np
•
np
•
np
•
np
•
METHYLPHENIDATE HCLmethylphenidate hcl chew tab
10 mg
np
•
methylphenidate hcl cap cr 10 mg
(cd) (Metadate cd)
np
•
methylphenidate hcl cap cr 20 mg
(cd) (Metadate cd)
np
•
methylphenidate hcl cap cr 30 mg
(cd) (Metadate cd)
np
•
methylphenidate hcl cap cr 40 mg
(cd) (Metadate cd)
DIETHYLPROPION HCLdiethylpropion hcl tab 25 mg
NC
methylphenidate hcl cap cr 50 mg
(cd) (Metadate cd)
diethylpropion hcl tab sr 24hr
75 mg
NC
methylphenidate hcl cap cr 60 mg
(cd) (Metadate cd)
NC
methylphenidate hcl cap sr 24hr
20 mg (la) (Ritalin la)
DYANAVEL XR- amphetamine
extended release susp 2.5 mg/ml
NC
methylphenidate hcl cap sr 24hr
30 mg (la) (Ritalin la)
EVEKEO- amphetamine sulfate tab
5 mg
NC
methylphenidate hcl cap sr 24hr
40 mg (la) (Ritalin la)
EVEKEO- amphetamine sulfate tab
10 mg
NC
NC
guanfacine hcl tab sr 24hr 1 mg
(base equiv) (Intuniv)
np
•
METHYLPHENIDATE HCL ERmethylphenidate hcl tab sr 24hr
18 mg
NC
np
•
METHYLPHENIDATE HCL ERmethylphenidate hcl tab sr 24hr
27 mg
np
•
NC
np
•
METHYLPHENIDATE HCL ERmethylphenidate hcl tab sr 24hr
36 mg
METHYLPHENIDATE HCL ERmethylphenidate hcl tab sr 24hr
54 mg
NC
METHYLPHENIDATE HCL ER (Lmethylphenidate hcl cap sr 24hr
60 mg (la)
NC
diethylpropion hcl tab 25 mg
(Diethylpropion hcl)
guanfacine hcl tab sr 24hr 2 mg
(base equiv) (Intuniv)
guanfacine hcl tab sr 24hr 3 mg
(base equiv) (Intuniv)
guanfacine hcl tab sr 24hr 4 mg
(base equiv) (Intuniv)
LOMAIRA- phentermine hcl tab 8 mg
NP
methamphetamine hcl tab 5 mg
(Desoxyn)
np
•
Dispensing Limits
•
Step Therapy
np
Prior Authorization
•
Specialty
np
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
67
methylphenidate hcl soln 5 mg/5ml
(Methylin)
methylphenidate hcl soln
10 mg/5ml (Methylin)
methylphenidate hcl tab cr 10 mg
methylphenidate hcl tab cr 20 mg
methylphenidate hcl tab sa osm
18 mg (Concerta)
methylphenidate hcl tab sa osm
27 mg (Concerta)
methylphenidate hcl tab sa osm
36 mg (Concerta)
methylphenidate hcl tab sa osm
54 mg (Concerta)
methylphenidate hcl tab 5 mg
(Ritalin)
methylphenidate hcl tab 10 mg
(Ritalin)
methylphenidate hcl tab 20 mg
(Ritalin)
modafinil tab 100 mg (Provigil)
modafinil tab 200 mg (Provigil)
phentermine hcl cap 30 mg
phentermine hcl cap 37.5 mg
(Adipex-p)
phentermine hcl tab 37.5 mg
(Adipex-p)
•
•
np
np
NC
NC
NC
NC
np
•
np
•
np
•
np
np
p
p
p
p
QSYMIA- phentermine hcl-topiramate
cap sr 24hr 3.75-23 mg
NP
QSYMIA- phentermine hcl-topiramate
cap sr 24hr 7.5-46 mg
NP
QSYMIA- phentermine hcl-topiramate
cap sr 24hr 11.25-69 mg
NP
QSYMIA- phentermine hcl-topiramate
cap sr 24hr 15-92 mg
NP
•
•
•
•
QUILLICHEW ER- methylphenidate
hcl chew tab extended release
30 mg
NC
QUILLICHEW ER- methylphenidate
hcl chew tab extended release
40 mg
NC
QUILLIVANT XR- methylphenidate hcl NC
for er susp 25 mg/5ml (5 mg/ml)
NC
REGIMEX- benzphetamine hcl tab
25 mg
RITALIN LA- methylphenidate hcl cap NC
sr 24hr 10 mg (la)
NP
SAXENDA- liraglutide (weight
management) soln pen-injector
18 mg/3ml
NP
STRATTERA- atomoxetine hcl cap
10 mg (base equiv)
NP
STRATTERA- atomoxetine hcl cap
18 mg (base equiv)
NP
STRATTERA- atomoxetine hcl cap
25 mg (base equiv)
NP
STRATTERA- atomoxetine hcl cap
40 mg (base equiv)
NP
STRATTERA- atomoxetine hcl cap
60 mg (base equiv)
NP
STRATTERA- atomoxetine hcl cap
80 mg (base equiv)
NP
STRATTERA- atomoxetine hcl cap
100 mg (base equiv)
P
VYVANSE- lisdexamfetamine
dimesylate cap 10 mg
P
VYVANSE- lisdexamfetamine
dimesylate cap 20 mg
P
VYVANSE- lisdexamfetamine
dimesylate cap 30 mg
P
VYVANSE- lisdexamfetamine
dimesylate cap 40 mg
P
VYVANSE- lisdexamfetamine
dimesylate cap 50 mg
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
Step Therapy
•
NC
Prior Authorization
np
QUILLICHEW ER- methylphenidate
hcl chew tab extended release
20 mg
Specialty
•
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
np
NC
PHENDIMETRAZINE TARTRATEphendimetrazine tartrate cap sr 24hr
105 mg
phendimetrazine tartrate tab 35 mg NC
phentermine hcl cap 15 mg
Specialty
Drug Name
Tier Designation
2017
•
•
•
•
•
•
•
•
•
•
•
•
68
P
•
VYVANSE- lisdexamfetamine
dimesylate chew tab 10 mg
P
•
VYVANSE- lisdexamfetamine
dimesylate chew tab 20 mg
P
•
VYVANSE- lisdexamfetamine
dimesylate chew tab 30 mg
P
•
VYVANSE- lisdexamfetamine
dimesylate chew tab 40 mg
P
•
VYVANSE- lisdexamfetamine
dimesylate chew tab 50 mg
P
•
VYVANSE- lisdexamfetamine
dimesylate chew tab 60 mg
P
•
XENICAL- orlistat cap 120 mg
NP
ZENZEDI- dextroamphetamine sulfate NC
tab 2.5 mg
ZENZEDI- dextroamphetamine sulfate NC
tab 7.5 mg
ZENZEDI- dextroamphetamine sulfate NC
tab 15 mg
ZENZEDI- dextroamphetamine sulfate NC
tab 20 mg
ZENZEDI- dextroamphetamine sulfate NC
tab 30 mg
PSYCHOTHERAPEUTIC and NEUROLOGICAL
AGENTS - MISC.
np
acamprosate calcium tab delayed
release 333 mg
NP
•
ADDYI- flibanserin tab 100 mg
• •
•
•
AUBAGIO- teriflunomide tab 7 mg
P
AUBAGIO- teriflunomide tab 14 mg
P
AVONEX- interferon beta-1a im
prefilled syringe kit 30 mcg/0.5ml
P
• •
• •
• •
•
•
•
AVONEX- interferon beta-1a for im inj
kit 30mcg (33mcg(6.6 mu)/vial)
P
• •
•
AMPYRA- dalfampridine tab sr 12hr
10 mg
AVONEX PEN- interferon beta-1a im
auto-injector kit 30 mcg/0.5ml
P
• •
BETASERON- interferon beta-1b for
inj kit 0.3 mg
P
• •
•
• •
•
• •
•
BRISDELLE- paroxetine mesylate cap NC
7.5 mg (base equiv)
np
bupropion hcl (smoking deterrent)
tab sr 12hr 150 mg (Zyban)
P
CHANTIX- varenicline tartrate tab
0.5 mg (base equiv)
P
CHANTIX- varenicline tartrate tab
1 mg (base equiv)
P
CHANTIX CONTINUING MONTHvarenicline tartrate tab 1 mg (base
equiv)
P
CHANTIX STARTING MONTH PAvarenicline tartrate tab 0.5 mg x 11
& tab 1 mg x 42 pack
NP
CHLORDIAZEPOXIDE/AMITRIPTchlordiazepoxide-amitriptyline tab
5-12.5 mg
NP
CHLORDIAZEPOXIDE/AMITRIPTchlordiazepoxide-amitriptyline tab
10-25 mg
P
COPAXONE- glatiramer acetate soln
prefilled syringe 20 mg/ml
P
COPAXONE- glatiramer acetate soln
prefilled syringe 40 mg/ml
np
disulfiram tab 250 mg (Antabuse)
disulfiram tab 500 mg (Antabuse)
NP
Dispensing Limits
VYVANSE- lisdexamfetamine
dimesylate cap 70 mg
Step Therapy
•
Prior Authorization
P
Specialty
VYVANSE- lisdexamfetamine
dimesylate cap 60 mg
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
donepezil hydrochloride orally
disintegrating tab 5 mg
donepezil hydrochloride orally
disintegrating tab 10 mg
donepezil hydrochloride tab 5 mg
(Aricept)
donepezil hydrochloride tab 10 mg
(Aricept)
donepezil hydrochloride tab 23 mg
(Aricept)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
•
np
p
p
p
p
np
69
ERGOLOID MESYLATES- ergoloid
mesylates tab 1 mg
NC
HORIZANT- gabapentin enacarbil tab
cr 600 mg
NC
EXTAVIA- interferon beta-1b for inj kit
0.3 mg
NC
np
FLUOXETINE- fluoxetine hcl (pmdd)
cap 10 mg
NP
memantine hcl oral solution 2 mg/
ml (Namenda)
FLUOXETINE- fluoxetine hcl (pmdd)
cap 20 mg
NP
fluoxetine hcl (pmdd) tab 10 mg
(Sarafem)
NC
fluoxetine hcl (pmdd) tab 20 mg
(Sarafem)
NC
GALANTAMINE
HYDROBROMIDE- galantamine
hydrobromide oral soln 4 mg/ml
NP
galantamine hydrobromide cap sr
24hr 8 mg (Razadyne er)
np
galantamine hydrobromide cap sr
24hr 16 mg (Razadyne er)
galantamine hydrobromide cap sr
24hr 24 mg (Razadyne er)
galantamine hydrobromide tab
4 mg (Razadyne)
galantamine hydrobromide tab
8 mg (Razadyne)
galantamine hydrobromide tab
12 mg (Razadyne)
memantine hcl tab 5 mg (Namenda)
np
np
np
np
np
GILENYA- fingolimod hcl cap 0.5 mg
(base equiv)
P
• •
•
glatiramer acetate soln prefilled
syringe 20 mg/ml (Copaxone)
np
• •
•
GRALISE- gabapentin (once-daily) tab NC
300 mg
GRALISE- gabapentin (once-daily) tab NC
600 mg
NC
GRALISE STARTER- gabapentin
(once-daily) tab pack 300 mg (9) &
600 mg (69)
HORIZANT- gabapentin enacarbil tab NC
cr 300 mg
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
p
memantine hcl tab 10 mg
(Namenda)
p
nicotine polacrilex gum 4 mg
np
np
memantine hcl tab 5 mg (28) &
10 mg (21) titration pak (Namenda
titration pa)
NAMENDA XR- memantine hcl cap sr NC
24hr 7 mg
NAMENDA XR- memantine hcl cap sr NC
24hr 14 mg
NAMENDA XR- memantine hcl cap sr NC
24hr 21 mg
NAMENDA XR- memantine hcl cap sr NC
24hr 28 mg
NC
NAMENDA XR TITRATION PACKmemantine hcl cap sr 24hr 7 mg &
14 mg & 21 mg & 28 mg pack
NC
NAMZARIC- memantine-donepezil
cap er 24hr 7 & 14 & 21 & 28-10 mg
pack
NAMZARIC- memantine hcl-donepezil NC
hcl cap sr 24hr 7-10 mg
NAMZARIC- memantine hcl-donepezil NC
hcl cap sr 24hr 14-10 mg
NAMZARIC- memantine hcl-donepezil NC
hcl cap sr 24hr 21-10 mg
NAMZARIC- memantine hcl-donepezil NC
hcl cap sr 24hr 28-10 mg
np
nicotine polacrilex gum 2 mg
nicotine polacrilex lozenge 2 mg
nicotine polacrilex lozenge 4 mg
nicotine td patch 24hr 7 mg/24hr
nicotine td patch 24hr 14 mg/24hr
nicotine td patch 24hr 21 mg/24hr
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
np
np
np
np
np
70
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
NICOTINE TRANSDERMAL
SYST- nicotine td patch 24 hr kit
21-14-7 mg/24hr
P
PLEGRIDY STARTER PACKpeginterferon beta-1a soln pen-inj
63 & 94 mcg/0.5ml pack
P
• •
NICOTROL INHALER- nicotine
inhaler system 10 mg (4 mg
delivered)
P
PLEGRIDY STARTER PACKpeginterferon beta-1a soln pref syr
63 & 94 mcg/0.5ml pack
P
• •
•
NICOTROL NS- nicotine nasal spray
10 mg/ml (0.5 mg/spray)
P
REBIF- interferon beta-1a soln pref
syr 22 mcg/0.5ml (12mu/ml)
P
• •
•
NUEDEXTA- dextromethorphan hbrquinidine sulfate cap 20-10 mg
P
REBIF- interferon beta-1a soln pref
syr 44 mcg/0.5ml (24mu/ml)
P
• •
•
REBIF REBIDOSE- interferon beta-1a
soln auto-inj 22 mcg/0.5ml (12mu/
ml)
P
• •
•
REBIF REBIDOSE- interferon beta-1a
soln auto-inj 44 mcg/0.5ml (24mu/
ml)
P
• •
•
REBIF REBIDOSE TITRATIONinterferon beta-1a auto-inj
6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml
P
• •
•
REBIF TITRATION PACK- interferon
beta-1a pref syr 6x8.8 mcg/0.2ml &
6x22 mcg/0.5ml
P
• •
•
rivastigmine tartrate cap 1.5 mg
np
olanzapine-fluoxetine hcl cap
3-25 mg (Symbyax)
olanzapine-fluoxetine hcl cap
6-25 mg (Symbyax)
olanzapine-fluoxetine hcl cap
6-50 mg (Symbyax)
olanzapine-fluoxetine hcl cap
12-25 mg (Symbyax)
olanzapine-fluoxetine hcl cap
12-50 mg (Symbyax)
NC
NC
NC
NC
NC
•
PERPHENAZINE/AMITRIPTYLINperphenazine-amitriptyline tab
2-10 mg
NP
PERPHENAZINE/AMITRIPTYLINperphenazine-amitriptyline tab
2-25 mg
NP
PERPHENAZINE/AMITRIPTYLINperphenazine-amitriptyline tab
4-10 mg
NP
PERPHENAZINE/AMITRIPTYLINperphenazine-amitriptyline tab
4-25 mg
NP
PERPHENAZINE/AMITRIPTYLINperphenazine-amitriptyline tab
4-50 mg
NP
rivastigmine td patch 24hr
13.3 mg/24hr (Exelon)
SAVELLA- milnacipran hcl tab
12.5 mg
NP
•
pimozide tab 1 mg (Orap)
np
SAVELLA- milnacipran hcl tab 25 mg
NP
np
SAVELLA- milnacipran hcl tab 50 mg
NP
•
•
•
•
pimozide tab 2 mg (Orap)
rivastigmine tartrate cap 3 mg
rivastigmine tartrate cap 4.5 mg
rivastigmine tartrate cap 6 mg
rivastigmine td patch 24hr
4.6 mg/24hr (Exelon)
rivastigmine td patch 24hr
9.5 mg/24hr (Exelon)
PLEGRIDY- peginterferon beta-1a
soln pen-injector 125 mcg/0.5ml
P
• •
•
PLEGRIDY- peginterferon beta-1a
soln prefilled syringe 125 mcg/0.5ml
P
• •
•
np
np
np
np
np
np
SAVELLA- milnacipran hcl tab 100 mg NP
NP
SAVELLA TITRATION PACKmilnacipran hcl tab 12.5 mg (5) &
25 mg (8) & 50 mg (42) pak
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
71
P
• •
•
TECFIDERA STARTER PACKdimethyl fumarate capsule dr starter
pack 120 mg & 240 mg
P
• •
•
tetrabenazine tab 12.5 mg
(Xenazine)
np
• •
•
np
• •
• •
•
•
XYREM- sodium oxybate oral solution NP
500 mg/ml
ZINBRYTA- daclizumab soln prefilled NC
syringe 150 mg/ml
ALLZITAL- butalbital-acetaminophen
tab 25-325 mg
aspirin chew tab 81 mg
aspirin tab delayed release 81 mg
butalbital-acetaminophen tab
50-300 mg
butalbital-acetaminophen tab
50-325 mg
butalbital-acetaminophen-caffeine
cap 50-300-40 mg (Fioricet)
butalbital-acetaminophen-caffeine
cap 50-325-40 mg
butalbital-acetaminophen-caffeine
tab 50-325-40 mg (Esgic)
butalbital-aspirin-caffeine cap
50-325-40 mg (Fiorinal)
diflunisal tab 500 mg
ABSTRAL- fentanyl citrate sl tab
200 mcg (base equiv)
NC
ABSTRAL- fentanyl citrate sl tab
300 mcg (base equiv)
NC
ABSTRAL- fentanyl citrate sl tab
400 mcg (base equiv)
NC
ABSTRAL- fentanyl citrate sl tab
600 mcg (base equiv)
NC
ABSTRAL- fentanyl citrate sl tab
800 mcg (base equiv)
NC
acetaminophen w/ codeine tab
300-15 mg (Tylenol/codeine)
NC
acetaminophen w/ codeine tab
300-30 mg (Tylenol/codeine #3)
p
acetaminophen w/ codeine tab
300-60 mg (Tylenol/codeine #4)
p
NC
np
•
np
•
np
•
np
•
np
•
np
TENCON- butalbital-acetaminophen
tab 50-325 mg
NP
VANATOL LQ- butalbitalacetaminophen-caffeine soln
50-325-40 mg/15ml
NC
ANALGESICS - NARCOTIC
NC
acetaminophen w/ codeine soln
120-12 mg/5ml
ANALGESICS AND ANESTHETICS
ANALGESICS - NON-NARCOTIC
ABSTRAL- fentanyl citrate sl tab
100 mcg (base equiv)
•
acetaminophen-caffeinedihydrocodeine cap
320.5-30-16 mg (Trezix)
p
•
p
•
p
•
np
•
np
•
ACETAMINOPHEN/CAFFEINE/
DI- acetaminophen-caffeinedihydrocodeine tab 325-30-16 mg
NC
ASPIRIN-CAFFEINE-DIHYDROCaspirin-caffeine-dihydrocodeine cap
356.4-30-16 mg
NC
BELBUCA- buprenorphine hcl buccal
film 75 mcg (base equivalent)
NC
BELBUCA- buprenorphine hcl buccal
film 150 mcg (base equivalent)
NC
BELBUCA- buprenorphine hcl buccal
film 300 mcg (base equivalent)
NC
BELBUCA- buprenorphine hcl buccal
film 450 mcg (base equivalent)
NC
BELBUCA- buprenorphine hcl buccal
film 600 mcg (base equivalent)
NC
BELBUCA- buprenorphine hcl buccal
film 750 mcg (base equivalent)
NC
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
TECFIDERA- dimethyl fumarate
capsule delayed release 240 mg
tetrabenazine tab 25 mg (Xenazine)
•
Step Therapy
• •
Prior Authorization
P
Specialty
TECFIDERA- dimethyl fumarate
capsule delayed release 120 mg
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
72
BELBUCA- buprenorphine hcl buccal
film 900 mcg (base equivalent)
NC
BUNAVAIL- buprenorphine-naloxone
buccal film 2.1-0.3 mg (base equiv)
NC
BUNAVAIL- buprenorphine-naloxone
buccal film 4.2-0.7 mg (base equiv)
codeine sulfate tab 60 mg (Codeine
sulfate)
NC
NC
CONZIP- tramadol hcl cap sr 24hr
biphasic release 200 mg
NC
BUNAVAIL- buprenorphine-naloxone
buccal film 6.3-1 mg (base equiv)
NC
NC
buprenorphine hcl sl tab 2 mg
(base equiv)
np
•
•
CONZIP- tramadol hcl cap sr 24hr
biphasic release 300 mg
NC
np
•
•
DEMEROL- meperidine hcl tab
100 mg
np
•
•
np
•
•
buprenorphine hcl-naloxone hcl sl
tab 2-0.5 mg (base equiv)
buprenorphine hcl-naloxone hcl sl
tab 8-2 mg (base equiv)
butalbital-acetaminophen-caff
w/ cod cap 50-300-40-30 mg
(Fioricet/codeine)
butalbital-acetaminophen-caff w/
cod cap 50-325-40-30 mg
butalbital-aspirin-caff w/ codeine
cap 50-325-40-30 mg (Fiorinal/
codeine #3)
butorphanol tartrate nasal soln
10 mg/ml
NC
np
•
np
•
np
•
BUTRANS- buprenorphine td patch
weekly 5 mcg/hr
NC
BUTRANS- buprenorphine td patch
weekly 7.5 mcg/hr
NC
BUTRANS- buprenorphine td patch
weekly 10 mcg/hr
NC
BUTRANS- buprenorphine td patch
weekly 15 mcg/hr
NC
BUTRANS- buprenorphine td patch
weekly 20 mcg/hr
NC
codeine sulfate tab 15 mg (Codeine
sulfate)
np
•
np
•
codeine sulfate tab 30 mg (Codeine
sulfate)
EMBEDA- morphine-naltrexone cap cr NC
20-0.8 mg
EMBEDA- morphine-naltrexone cap cr NC
30-1.2 mg
EMBEDA- morphine-naltrexone cap cr NC
50-2 mg
EMBEDA- morphine-naltrexone cap cr NC
60-2.4 mg
EMBEDA- morphine-naltrexone cap cr NC
80-3.2 mg
EMBEDA- morphine-naltrexone cap cr NC
100-4 mg
NC
FENTANYL- fentanyl td patch 72hr
37.5 mcg/hr
NC
FENTANYL- fentanyl td patch 72hr
62.5 mcg/hr
NC
FENTANYL- fentanyl td patch 72hr
87.5 mcg/hr
fentanyl citrate lozenge on a handle np
200 mcg (Actiq)
fentanyl citrate lozenge on a handle np
400 mcg (Actiq)
fentanyl citrate lozenge on a handle np
600 mcg (Actiq)
fentanyl citrate lozenge on a handle np
800 mcg (Actiq)
fentanyl citrate lozenge on a handle np
1200 mcg (Actiq)
fentanyl citrate lozenge on a handle np
1600 mcg (Actiq)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
Step Therapy
Prior Authorization
np
CONZIP- tramadol hcl cap sr 24hr
biphasic release 100 mg
buprenorphine hcl sl tab 8 mg
(base equiv)
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
•
•
•
•
•
•
•
•
•
•
•
•
•
73
fentanyl td patch 72hr 12 mcg/hr
(Duragesic)
fentanyl td patch 72hr 25 mcg/hr
(Duragesic)
fentanyl td patch 72hr 50 mcg/hr
(Duragesic)
fentanyl td patch 72hr 75 mcg/hr
(Duragesic)
fentanyl td patch 72hr 100 mcg/hr
(Duragesic)
np
•
np
•
np
•
FENTORA- fentanyl citrate buccal tab NC
100 mcg (base equiv)
FENTORA- fentanyl citrate buccal tab NC
200 mcg (base equiv)
FENTORA- fentanyl citrate buccal tab NC
400 mcg (base equiv)
FENTORA- fentanyl citrate buccal tab NC
600 mcg (base equiv)
FENTORA- fentanyl citrate buccal tab NC
800 mcg (base equiv)
np
hydrocodone-acetaminophen soln
7.5-325 mg/15ml (Hycet)
np
hydrocodone-acetaminophen soln
10-325 mg/15ml (Zamicet)
np
hydrocodone-acetaminophen tab
2.5-325 mg
np
hydrocodone-acetaminophen tab
10-325 mg (Norco)
np
hydrocodone-acetaminophen tab
5-300 mg (Xodol)
np
hydrocodone-acetaminophen tab
7.5-300 mg (Xodol)
p
hydrocodone-acetaminophen tab
5-325 mg (Norco)
p
hydrocodone-acetaminophen tab
7.5-325 mg (Norco)
np
hydrocodone-acetaminophen tab
10-300 mg (Xodol)
np
hydrocodone-ibuprofen tab
5-200 mg (Reprexain)
hydrocodone-ibuprofen tab
10-200 mg (Ibudone)
hydromorphone hcl liqd 1 mg/ml
(Dilaudid)
hydromorphone hcl tab er 24hr
deter 8 mg (Exalgo)
hydromorphone hcl tab er 24hr
deter 12 mg (Exalgo)
hydromorphone hcl tab er 24hr
deter 16 mg (Exalgo)
hydromorphone hcl tab er 24hr
deter 32 mg (Exalgo)
hydromorphone hcl tab 2 mg
(Dilaudid)
hydromorphone hcl tab 4 mg
(Dilaudid)
•
•
•
•
•
•
•
•
•
•
hydromorphone hcl tab 8 mg
(Dilaudid)
Dispensing Limits
•
Step Therapy
np
hydrocodone-ibuprofen tab
7.5-200 mg
Prior Authorization
•
Specialty
np
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
np
•
np
•
np
•
NC
NC
NC
NC
p
•
p
•
np
•
HYSINGLA ER- hydrocodone
bitartrate tab er 24hr deter 20 mg
NC
HYSINGLA ER- hydrocodone
bitartrate tab er 24hr deter 30 mg
NC
HYSINGLA ER- hydrocodone
bitartrate tab er 24hr deter 40 mg
NC
HYSINGLA ER- hydrocodone
bitartrate tab er 24hr deter 60 mg
NC
HYSINGLA ER- hydrocodone
bitartrate tab er 24hr deter 80 mg
NC
HYSINGLA ER- hydrocodone
bitartrate tab er 24hr deter 100 mg
NC
HYSINGLA ER- hydrocodone
bitartrate tab er 24hr deter 120 mg
NC
KADIAN- morphine sulfate cap sr 24hr NC
40 mg
KADIAN- morphine sulfate cap sr 24hr NC
200 mg
NC
LAZANDA- fentanyl citrate nasal
spray 100 mcg/act (base equiv)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
74
LAZANDA- fentanyl citrate nasal
spray 300 mcg/act (base equiv)
NC
LAZANDA- fentanyl citrate nasal
spray 400 mcg/act (base equiv)
NC
LEVORPHANOL TARTRATElevorphanol tartrate tab 2 mg
NC
LORTAB- hydrocodoneacetaminophen soln
10-300 mg/15ml
NC
morphine sulfate cap sr 24hr 80 mg
(Kadian)
morphine sulfate cap sr 24hr
100 mg (Kadian)
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
np
•
np
•
MORPHINE SULFATE ER- morphine
sulfate beads cap sr 24hr 30 mg
NC
MORPHINE SULFATE ER- morphine
sulfate beads cap sr 24hr 45 mg
NC
MORPHINE SULFATE ER- morphine
sulfate beads cap sr 24hr 60 mg
NC
MEPERIDINE HCL- meperidine hcl
oral soln 50 mg/5ml
NC
MORPHINE SULFATE ER- morphine
sulfate beads cap sr 24hr 75 mg
NC
meperidine hcl tab 50 mg
NC
MORPHINE SULFATE ER- morphine
sulfate beads cap sr 24hr 90 mg
NC
MORPHINE SULFATE ER- morphine
sulfate beads cap sr 24hr 120 mg
NC
morphine sulfate oral soln
10 mg/5ml
np
•
np
•
np
•
np
•
np
•
np
•
np
•
np
•
meperidine hcl tab 100 mg
(Demerol)
NC
np
•
np
•
np
•
np
•
p
•
np
•
MORPHINE SULFATE- morphine
sulfate tab 15 mg
P
•
MORPHINE SULFATE- morphine
sulfate tab 30 mg
P
•
morphine sulfate cap sr 24hr 10 mg
(Kadian)
np
•
np
•
np
•
np
•
np
•
methadone hcl conc 10 mg/ml
(Methadose)
methadone hcl soln 5 mg/5ml
(Methadone hcl)
methadone hcl soln 10 mg/5ml
(Methadone hcl)
methadone hcl tab for oral susp
40 mg
methadone hcl tab 5 mg
(Dolophine)
methadone hcl tab 10 mg
(Dolophine)
morphine sulfate cap sr 24hr 20 mg
(Kadian)
morphine sulfate cap sr 24hr 30 mg
(Kadian)
morphine sulfate cap sr 24hr 50 mg
(Kadian)
morphine sulfate cap sr 24hr 60 mg
(Kadian)
morphine sulfate oral soln
20 mg/5ml
morphine sulfate oral soln
100 mg/5ml (20 mg/ml)
morphine sulfate tab cr 15 mg (Ms
contin)
morphine sulfate tab cr 30 mg (Ms
contin)
morphine sulfate tab cr 60 mg (Ms
contin)
morphine sulfate tab cr 100 mg (Ms
contin)
morphine sulfate tab cr 200 mg (Ms
contin)
NUCYNTA- tapentadol hcl tab 50 mg
NC
NUCYNTA- tapentadol hcl tab 75 mg
NC
NUCYNTA- tapentadol hcl tab 100 mg NC
NC
NUCYNTA ER- tapentadol hcl tab sr
12hr 50 mg
NC
NUCYNTA ER- tapentadol hcl tab sr
12hr 100 mg
NC
NUCYNTA ER- tapentadol hcl tab sr
12hr 150 mg
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
75
NUCYNTA ER- tapentadol hcl tab sr
12hr 200 mg
NC
OXYCODONE HCL ER- oxycodone
hcl tab er 12hr deter 60 mg
NC
NUCYNTA ER- tapentadol hcl tab sr
12hr 250 mg
NC
OXYCODONE HCL ER- oxycodone
hcl tab er 12hr deter 80 mg
NC
OPANA ER (CRUSH RESISTANToxymorphone hcl tab er 12hr deter
5 mg
NC
oxycodone hcl soln 5 mg/5ml
np
OPANA ER (CRUSH RESISTANToxymorphone hcl tab er 12hr deter
7.5 mg
NC
OPANA ER (CRUSH RESISTANToxymorphone hcl tab er 12hr deter
10 mg
NC
oxycodone hcl tab 15 mg
(Roxicodone)
OPANA ER (CRUSH RESISTANToxymorphone hcl tab er 12hr deter
15 mg
NC
oxycodone hcl tab 30 mg
(Roxicodone)
OPANA ER (CRUSH RESISTANToxymorphone hcl tab er 12hr deter
20 mg
NC
OPANA ER (CRUSH RESISTANToxymorphone hcl tab er 12hr deter
30 mg
NC
OPANA ER (CRUSH RESISTANToxymorphone hcl tab er 12hr deter
40 mg
NC
OXAYDO- oxycodone hcl tab abuse
deter 5 mg
NC
OXAYDO- oxycodone hcl tab abuse
deter 7.5 mg
NC
oxycodone hcl cap 5 mg
np
oxycodone hcl tab 5 mg
(Roxicodone)
oxycodone hcl tab 10 mg
p
np
np
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
•
•
•
•
np
•
•
np
•
p
•
np
•
np
•
np
•
OXYCODONE/ACETAMINOPHENoxycodone w/ acetaminophen soln
5-325 mg/5ml
NP
•
OXYCODONE/IBUPROFENoxycodone-ibuprofen tab 5-400 mg
NP
•
OXYCONTIN- oxycodone hcl tab er
12hr deter 10 mg
P
•
OXYCONTIN- oxycodone hcl tab er
12hr deter 15 mg
P
OXYCODONE HCL ER- oxycodone
hcl tab er 12hr deter 10 mg
NC
•
OXYCONTIN- oxycodone hcl tab er
12hr deter 20 mg
P
OXYCODONE HCL ER- oxycodone
hcl tab er 12hr deter 15 mg
NC
•
NC
OXYCONTIN- oxycodone hcl tab er
12hr deter 30 mg
P
OXYCODONE HCL ER- oxycodone
hcl tab er 12hr deter 20 mg
•
NC
OXYCONTIN- oxycodone hcl tab er
12hr deter 40 mg
P
OXYCODONE HCL ER- oxycodone
hcl tab er 12hr deter 30 mg
•
OXYCONTIN- oxycodone hcl tab er
12hr deter 60 mg
P
OXYCODONE HCL ER- oxycodone
hcl tab er 12hr deter 40 mg
NC
•
oxycodone hcl conc 100 mg/5ml
(20 mg/ml)
np
oxycodone hcl tab 20 mg
oxycodone w/ acetaminophen tab
2.5-325 mg (Percocet)
oxycodone w/ acetaminophen tab
5-325 mg (Percocet)
oxycodone w/ acetaminophen tab
7.5-325 mg (Percocet)
oxycodone w/ acetaminophen tab
10-325 mg (Percocet)
oxycodone-aspirin tab
4.8355-325 mg
•
•
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
np
76
np
np
•
•
OXYMORPHONE
HYDROCHLORIDE- oxymorphone
hcl tab sr 12hr 5 mg
NP
•
OXYMORPHONE
HYDROCHLORIDE- oxymorphone
hcl tab sr 12hr 7.5 mg
NP
•
OXYMORPHONE
HYDROCHLORIDE- oxymorphone
hcl tab sr 12hr 10 mg
NP
OXYMORPHONE
HYDROCHLORIDE- oxymorphone
hcl tab sr 12hr 15 mg
NP
•
OXYMORPHONE
HYDROCHLORIDE- oxymorphone
hcl tab sr 12hr 20 mg
NP
•
OXYMORPHONE
HYDROCHLORIDE- oxymorphone
hcl tab sr 12hr 30 mg
NP
•
OXYMORPHONE
HYDROCHLORIDE- oxymorphone
hcl tab sr 12hr 40 mg
NP
•
pentazocine w/ naloxone tab
50-0.5 mg
NC
oxymorphone hcl tab 10 mg
(Opana)
PRIMLEV- oxycodone w/
acetaminophen tab 5-300 mg
NC
PRIMLEV- oxycodone w/
acetaminophen tab 7.5-300 mg
NC
PRIMLEV- oxycodone w/
acetaminophen tab 10-300 mg
NC
•
P
•
SUBOXONE- buprenorphine hclnaloxone hcl sl film 12-3 mg (base
equiv)
P
•
SUBSYS- fentanyl sublingual spray
100 mcg
NC
SUBSYS- fentanyl sublingual spray
200 mcg
NC
SUBSYS- fentanyl sublingual spray
400 mcg
NC
SUBSYS- fentanyl sublingual spray
600 mcg
NC
SUBSYS- fentanyl sublingual spray
800 mcg
NC
SUBSYS- fentanyl sublingual spray
1200 mcg (600 mcg x 2)
NC
SUBSYS- fentanyl sublingual spray
1600 mcg (800 mcg x 2)
NC
NC
SYNALGOS-DC- aspirin-caffeinedihydrocodeine cap 356.4-30-16 mg
NC
TRAMADOL HCL ER- tramadol hcl
cap sr 24hr biphasic release 100 mg
NC
TRAMADOL HCL ER- tramadol hcl
cap sr 24hr biphasic release 150 mg
NC
TRAMADOL HCL ER- tramadol hcl
cap sr 24hr biphasic release 200 mg
NC
TRAMADOL HCL ER- tramadol hcl
cap sr 24hr biphasic release 300 mg
np
tramadol hcl tab sr 24hr 100 mg
tramadol hcl tab sr 24hr 200 mg
SUBOXONE- buprenorphine hclnaloxone hcl sl film 2-0.5 mg (base
equiv)
P
•
•
SUBOXONE- buprenorphine hclnaloxone hcl sl film 4-1 mg (base
equiv)
P
•
•
tramadol hcl tab sr 24hr 300 mg
tramadol hcl tab sr 24hr biphasic
release 100 mg
tramadol hcl tab sr 24hr biphasic
release 200 mg
tramadol hcl tab sr 24hr biphasic
release 300 mg
tramadol hcl tab 50 mg (Ultram)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
oxymorphone hcl tab 5 mg (Opana)
SUBOXONE- buprenorphine hclnaloxone hcl sl film 8-2 mg (base
equiv)
Step Therapy
•
Prior Authorization
P
Specialty
OXYCONTIN- oxycodone hcl tab er
12hr deter 80 mg
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
•
•
np
•
•
•
•
np
•
np
•
p
•
np
np
77
tramadol-acetaminophen tab
37.5-325 mg (Ultracet)
p
XTAMPZA ER- oxycodone cap er 12hr NP
abuse-deterrent 9 mg
XTAMPZA ER- oxycodone cap er 12hr NP
abuse-deterrent 13.5 mg
XTAMPZA ER- oxycodone cap er 12hr NP
abuse-deterrent 18 mg
XTAMPZA ER- oxycodone cap er 12hr NP
abuse-deterrent 27 mg
XTAMPZA ER- oxycodone cap er 12hr NP
abuse-deterrent 36 mg
NC
ZOHYDRO ER- hydrocodone
bitartrate cap sr 12hr abusedeterrent 10 mg
NC
ZOHYDRO ER- hydrocodone
bitartrate cap sr 12hr abusedeterrent 15 mg
NC
ZOHYDRO ER- hydrocodone
bitartrate cap sr 12hr abusedeterrent 20 mg
NC
ZOHYDRO ER- hydrocodone
bitartrate cap sr 12hr abusedeterrent 30 mg
NC
ZOHYDRO ER- hydrocodone
bitartrate cap sr 12hr abusedeterrent 40 mg
NC
ZOHYDRO ER- hydrocodone
bitartrate cap sr 12hr abusedeterrent 50 mg
NC
ZUBSOLV- buprenorphine hclnaloxone hcl sl tab 0.7-0.18 mg
(base eq)
NC
ZUBSOLV- buprenorphine hclnaloxone hcl sl tab 1.4-0.36 mg
(base eq)
NC
ZUBSOLV- buprenorphine hclnaloxone hcl sl tab 2.9-0.71 mg
(base eq)
NC
ZUBSOLV- buprenorphine hclnaloxone hcl sl tab 5.7-1.4 mg (base
eq)
•
•
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
•
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
NC
ZUBSOLV- buprenorphine hclnaloxone hcl sl tab 8.6-2.1 mg (base
eq)
NC
ZUBSOLV- buprenorphine hclnaloxone hcl sl tab 11.4-2.9 mg
(base eq)
ANALGESICS - ANTI-INFLAMMATORY
ACTEMRA- tocilizumab subcutaneous NP
soln prefilled syringe 162 mg/0.9ml
ARCALYST- rilonacept for inj 220 mg NP
celecoxib cap 50 mg (Celebrex)
celecoxib cap 100 mg (Celebrex)
celecoxib cap 200 mg (Celebrex)
celecoxib cap 400 mg (Celebrex)
diclofenac potassium tab 50 mg
diclofenac sodium tab delayed
release 25 mg
diclofenac sodium tab delayed
release 50 mg
diclofenac sodium tab delayed
release 75 mg
diclofenac sodium tab sr 24hr
100 mg
diclofenac w/ misoprostol tab
delayed release 50-0.2 mg
(Arthrotec 50)
diclofenac w/ misoprostol tab
delayed release 75-0.2 mg
(Arthrotec 75)
DUEXIS- ibuprofen-famotidine tab
800-26.6 mg
• •
•
• •
•
np
np
np
np
np
np
p
p
p
np
np
NC
ENBREL- etanercept for
subcutaneous inj 25 mg
P
• •
•
ENBREL- etanercept subcutaneous
soln prefilled syringe 25 mg/0.5ml
P
• •
•
ENBREL- etanercept subcutaneous
soln prefilled syringe 50 mg/ml
P
• •
•
ENBREL SURECLICK- etanercept
subcutaneous solution auto-injector
50 mg/ml
P
• •
•
etodolac cap 200 mg
np
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
78
etodolac tab sr 24hr 400 mg
etodolac tab sr 24hr 500 mg
etodolac tab sr 24hr 600 mg
etodolac tab 400 mg (Lodine)
etodolac tab 500 mg
np
np
np
FENOPROFEN CALCIUMfenoprofen calcium cap 200 mg
NC
FENOPROFEN CALCIUMfenoprofen calcium cap 400 mg
NC
FENORTHO- fenoprofen calcium cap
200 mg
NC
FENORTHO- fenoprofen calcium cap
400 mg
NC
NC
INDOCIN- indomethacin suppos
50 mg
NC
indomethacin cap cr 75 mg
np
ketoprofen cap 50 mg
KINERET- anakinra subcutaneous
soln prefilled syringe 100 mg/0.67ml
NC
leflunomide tab 10 mg (Arava)
np
NC
P
• •
•
HUMIRA- adalimumab prefilled
syringe kit 20 mg/0.4ml
P
• •
•
HUMIRA- adalimumab prefilled
syringe kit 40 mg/0.8ml
P
• •
•
HUMIRA PEDIATRIC CROHNS Dadalimumab prefilled syringe kit
40 mg/0.8ml
P
• •
•
HUMIRA PEN- adalimumab peninjector kit 40 mg/0.8ml
P
• •
•
NALFON- fenoprofen calcium cap
400 mg
NC
HUMIRA PEN-CROHNS DISEASEadalimumab pen-injector kit
40 mg/0.8ml
P
• •
•
NAPRELAN- naproxen sodium tab sr
24hr 750 mg (base equiv)
NC
np
HUMIRA PEN-PSORIASIS STARadalimumab pen-injector kit
40 mg/0.8ml
P
naproxen sodium tab sr 24hr
375 mg (base equiv) (Naprelan)
ibuprofen susp 100 mg/5ml
ibuprofen tab 400 mg
ibuprofen tab 600 mg
ibuprofen tab 800 mg
NC
MECLOFENAMATE SODIUMmeclofenamate sodium cap 100 mg
np
mefenamic acid cap 250 mg
(Ponstel)
p
meloxicam tab 7.5 mg (Mobic)
meloxicam tab 15 mg (Mobic)
nabumetone tab 500 mg
nabumetone tab 750 mg
NC
p
p
p
•
np
HUMIRA- adalimumab prefilled
syringe kit 10 mg/0.2ml
•
Dispensing Limits
np
KETOPROFEN ER- ketoprofen cap sr NC
24hr 200 mg
p
ketorolac tromethamine tab 10 mg
• •
Step Therapy
p
np
MECLOFENAMATE SODIUMmeclofenamate sodium cap 50 mg
Prior Authorization
p
ketoprofen cap 75 mg
leflunomide tab 20 mg (Arava)
Specialty
Tier Designation
INDOCIN- indomethacin susp
25 mg/5ml
indomethacin cap 50 mg
p
np
Drug Name
indomethacin cap 25 mg
np
NC
flurbiprofen tab 100 mg
Dispensing Limits
np
FENOPROFEN CALCIUMfenoprofen calcium tab 600 mg
flurbiprofen tab 50 mg
Step Therapy
np
Prior Authorization
etodolac cap 300 mg
Specialty
Drug Name
Tier Designation
2017
naproxen sodium tab sr 24hr
500 mg (base equiv) (Naprelan)
naproxen sodium tab 275 mg
naproxen sodium tab 550 mg
(Anaprox ds)
naproxen susp 125 mg/5ml
(Naprosyn)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
p
p
p
np
np
np
np
79
naproxen tab ec 375 mg (Ecnaprosyn)
naproxen tab ec 500 mg (Ecnaprosyn)
naproxen tab 250 mg
naproxen tab 375 mg
naproxen tab 500 mg (Naprosyn)
NP
•
p
RASUVO- methotrexate soln pf autoinjector 15 mg/0.3ml
NP
•
p
RASUVO- methotrexate soln pf autoinjector 17.5 mg/0.35ml
NP
•
RASUVO- methotrexate soln pf autoinjector 20 mg/0.4ml
NP
•
RASUVO- methotrexate soln pf autoinjector 22.5 mg/0.45ml
NP
•
RASUVO- methotrexate soln pf autoinjector 25 mg/0.5ml
NP
•
RASUVO- methotrexate soln pf autoinjector 27.5 mg/0.55ml
NP
•
RASUVO- methotrexate soln pf autoinjector 30 mg/0.6ml
NP
•
RIDAURA- auranofin cap 3 mg
NP
p
p
• •
•
ORENCIA CLICKJECT- abatacept
subcutaneous soln auto-injector
125 mg/ml
NP
• •
•
OTEZLA- apremilast tab starter
therapy pack 10 mg & 20 mg &
30 mg
P
• •
•
OTEZLA- apremilast tab 30 mg
P
OTREXUP- methotrexate soln pf auto- NP
injector 7.5 mg/0.4ml
OTREXUP- methotrexate soln pf auto- NP
injector 10 mg/0.4ml
OTREXUP- methotrexate soln pf auto- NP
injector 12.5 mg/0.4ml
OTREXUP- methotrexate soln pf auto- NP
injector 15 mg/0.4ml
OTREXUP- methotrexate soln pf auto- NP
injector 17.5 mg/0.4ml
OTREXUP- methotrexate soln pf auto- NP
injector 20 mg/0.4ml
OTREXUP- methotrexate soln pf auto- NP
injector 22.5 mg/0.4ml
OTREXUP- methotrexate soln pf auto- NP
injector 25 mg/0.4ml
np
oxaprozin tab 600 mg (Daypro)
• •
•
•
•
•
•
•
•
•
np
np
RASUVO- methotrexate soln pf autoinjector 7.5 mg/0.15ml
NP
•
RASUVO- methotrexate soln pf autoinjector 10 mg/0.2ml
NP
•
•
Dispensing Limits
Step Therapy
Prior Authorization
RASUVO- methotrexate soln pf autoinjector 12.5 mg/0.25ml
NP
piroxicam cap 20 mg (Feldene)
Specialty
p
ORENCIA- abatacept subcutaneous
soln prefilled syringe 125 mg/ml
piroxicam cap 10 mg (Feldene)
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
SIMPONI- golimumab subcutaneous
soln auto-injector 50 mg/0.5ml
P
• •
•
SIMPONI- golimumab subcutaneous
soln auto-injector 100 mg/ml
P
• •
•
SIMPONI- golimumab subcutaneous
soln prefilled syringe 50 mg/0.5ml
P
• •
•
SIMPONI- golimumab subcutaneous
soln prefilled syringe 100 mg/ml
P
• •
•
SPRIX- ketorolac tromethamine nasal NC
spray 15.75 mg/spray
p
sulindac tab 150 mg
sulindac tab 200 mg
p
TIVORBEX- indomethacin cap 20 mg
NC
TIVORBEX- indomethacin cap 40 mg
NC
TOLMETIN SODIUM- tolmetin sodium NP
cap 400 mg
TOLMETIN SODIUM- tolmetin sodium NC
tab 200 mg
TOLMETIN SODIUM- tolmetin sodium NC
tab 600 mg
NC
VIMOVO- naproxen-esomeprazole
magnesium tab dr 375-20 mg
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
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Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
VIMOVO- naproxen-esomeprazole
magnesium tab dr 500-20 mg
NC
RELPAX- eletriptan hydrobromide tab
20 mg (base equivalent)
P
•
VIVLODEX- meloxicam cap 5 mg
NC
P
•
VIVLODEX- meloxicam cap 10 mg
NC
RELPAX- eletriptan hydrobromide tab
40 mg (base equivalent)
XELJANZ- tofacitinib citrate tab 5 mg
(base equivalent)
NP
• •
•
p
•
XELJANZ XR- tofacitinib citrate tab sr
24hr 11 mg (base equivalent)
NP
• •
•
rizatriptan benzoate oral
disintegrating tab 5 mg (base eq)
(Maxalt-mlt)
•
ZIPSOR- diclofenac potassium cap
25 mg
NC
ZORVOLEX- diclofenac cap 18 mg
NC
ZORVOLEX- diclofenac cap 35 mg
NC
np
rizatriptan benzoate oral
disintegrating tab 10 mg (base eq)
(Maxalt-mlt)
rizatriptan benzoate tab 5 mg (base p
equivalent) (Maxalt)
p
rizatriptan benzoate tab 10 mg
(base equivalent) (Maxalt)
np
sumatriptan nasal spray 5 mg/act
(Imitrex)
sumatriptan nasal spray 20 mg/act np
(Imitrex)
P
SUMATRIPTAN SUCCINATEsumatriptan succinate solution
prefilled syringe 6 mg/0.5ml
np
sumatriptan succinate inj
6 mg/0.5ml (Imitrex)
np
sumatriptan succinate solution
auto-injector 4 mg/0.5ml (Imitrex
statdose sys)
np
sumatriptan succinate solution
auto-injector 6 mg/0.5ml (Imitrex
statdose sys)
np
sumatriptan succinate solution
cartridge 4 mg/0.5ml (Imitrex
statdose ref)
np
sumatriptan succinate solution
cartridge 6 mg/0.5ml (Imitrex
statdose ref)
p
sumatriptan succinate tab 25 mg
(Imitrex)
p
sumatriptan succinate tab 50 mg
(Imitrex)
p
sumatriptan succinate tab 100 mg
(Imitrex)
MIGRAINE PRODUCTS
almotriptan malate tab 6.25 mg
(Axert)
almotriptan malate tab 12.5 mg
(Axert)
np
•
np
•
CAMBIA- diclofenac potassium packet NC
50 mg
DIHYDROERGOTAMINE MESYLAT- NP
dihydroergotamine mesylate nasal
spray 4 mg/ml
NC
dihydroergotamine mesylate inj
1 mg/ml (D.h.e. 45)
ERGOMAR- ergotamine tartrate sl tab NP
2 mg
np
ergotamine w/ caffeine tab
1-100 mg (Cafergot)
np
frovatriptan succinate tab 2.5 mg
(base equivalent) (Frova)
NP
MIGERGOT- ergotamine w/ caffeine
suppos 2-100 mg
NP
MIGRANAL- dihydroergotamine
mesylate nasal spray 4 mg/ml
np
naratriptan hcl tab 1 mg (base
equiv) (Amerge)
np
naratriptan hcl tab 2.5 mg (base
equiv) (Amerge)
NC
ONZETRA XSAIL- sumatriptan
succinate exhaler powder 11 mg/
nosepiece
•
•
•
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
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•
•
•
•
•
•
•
•
•
•
•
•
81
SUMAVEL DOSEPRO- sumatriptan
succinate solution jet-injector
4 mg/0.5ml
NC
SUMAVEL DOSEPRO- sumatriptan
succinate solution jet-injector
6 mg/0.5ml
NC
TREXIMET- sumatriptan-naproxen
sodium tab 10-60 mg
NC
TREXIMET- sumatriptan-naproxen
sodium tab 85-500 mg
NC
NC
ZEMBRACE SYMTOUCHsumatriptan succinate solution autoinjector 3 mg/0.5ml
np
zolmitriptan orally disintegrating
tab 2.5 mg (Zomig zmt)
np
zolmitriptan orally disintegrating
tab 5 mg (Zomig zmt)
np
zolmitriptan tab 2.5 mg (Zomig)
zolmitriptan tab 5 mg (Zomig)
np
ZOMIG- zolmitriptan nasal spray
2.5 mg/spray unit
NC
ZOMIG- zolmitriptan nasal spray
5 mg/spray unit
NC
GOUT AGENTS
allopurinol tab 100 mg (Zyloprim)
allopurinol tab 300 mg (Zyloprim)
p
p
APTIOM- eslicarbazepine acetate tab
200 mg
NP
APTIOM- eslicarbazepine acetate tab
400 mg
NP
APTIOM- eslicarbazepine acetate tab
600 mg
NP
APTIOM- eslicarbazepine acetate tab
800 mg
NP
BANZEL- rufinamide susp 40 mg/ml
NP
BANZEL- rufinamide tab 200 mg
NP
BANZEL- rufinamide tab 400 mg
NP
•
BRIVIACT- brivaracetam oral soln
10 mg/ml
NC
•
BRIVIACT- brivaracetam tab 10 mg
NC
BRIVIACT- brivaracetam tab 25 mg
NC
BRIVIACT- brivaracetam tab 50 mg
NC
BRIVIACT- brivaracetam tab 75 mg
NC
BRIVIACT- brivaracetam tab 100 mg
NC
carbamazepine cap sr 12hr 100 mg
(Carbatrol)
np
•
•
carbamazepine cap sr 12hr 200 mg
(Carbatrol)
carbamazepine cap sr 12hr 300 mg
(Carbatrol)
carbamazepine chew tab 100 mg
COLCHICINE- colchicine cap 0.6 mg
NC
COLCHICINE- colchicine tab 0.6 mg
NC
colchicine w/ probenecid tab
0.5-500 mg
np
carbamazepine tab sr 12hr 100 mg
(Tegretol-xr)
COLCRYS- colchicine tab 0.6 mg
P
MITIGARE- colchicine cap 0.6 mg
NC
carbamazepine tab sr 12hr 200 mg
(Tegretol-xr)
probenecid tab 500 mg
np
ULORIC- febuxostat tab 40 mg
NP
ULORIC- febuxostat tab 80 mg
NP
ZURAMPIC- lesinurad tab 200 mg
NC
NEUROMUSCULAR DRUGS
ANTICONVULSANTS
carbamazepine susp 100 mg/5ml
(Tegretol)
carbamazepine tab sr 12hr 400 mg
(Tegretol-xr)
carbamazepine tab 200 mg
(Tegretol)
Dispensing Limits
Step Therapy
Prior Authorization
np
np
np
np
np
np
np
np
CARBATROL- carbamazepine cap sr
12hr 100 mg
NP
CARBATROL- carbamazepine cap sr
12hr 200 mg
NP
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
82
CARBATROL- carbamazepine cap sr
12hr 300 mg
NP
CELONTIN- methsuximide cap
300 mg
NP
divalproex sodium cap delayed
release sprinkle 125 mg
(Depakote sprinkles)
clonazepam orally disintegrating
tab 0.125 mg
np
divalproex sodium tab delayed
release 125 mg (Depakote)
np
divalproex sodium tab delayed
release 250 mg (Depakote)
np
divalproex sodium tab delayed
release 500 mg (Depakote)
np
divalproex sodium tab sr 24 hr
250 mg (Depakote er)
np
divalproex sodium tab sr 24 hr
500 mg (Depakote er)
p
ethosuximide cap 250 mg
(Zarontin)
clonazepam orally disintegrating
tab 0.25 mg
clonazepam orally disintegrating
tab 0.5 mg
clonazepam orally disintegrating
tab 1 mg
clonazepam orally disintegrating
tab 2 mg
clonazepam tab 0.5 mg (Klonopin)
clonazepam tab 1 mg (Klonopin)
clonazepam tab 2 mg (Klonopin)
DEPAKENE- valproate sodium oral
soln 250 mg/5ml (base equiv)
p
p
NP
DEPAKENE- valproic acid cap 250 mg NP
P
DIASTAT ACUDIAL- diazepam
rectal gel delivery system 10 mg
P
DIASTAT ACUDIAL- diazepam
rectal gel delivery system 20 mg
P
DIASTAT PEDIATRIC- diazepam
rectal gel delivery system 2.5 mg
NP
DIAZEPAM- diazepam rectal gel
delivery system 2.5 mg
NP
DIAZEPAM- diazepam rectal gel
delivery system 10 mg
NP
DIAZEPAM- diazepam rectal gel
delivery system 20 mg
P
DILANTIN- phenytoin sodium
extended cap 30 mg
NP
DILANTIN- phenytoin sodium
extended cap 100 mg
DILANTIN INFATABS- phenytoin chew NP
tab 50 mg
NP
DILANTIN-125- phenytoin susp
125 mg/5ml
ethosuximide soln 250 mg/5ml
(Zarontin)
felbamate susp 600 mg/5ml
(Felbatol)
felbamate tab 400 mg (Felbatol)
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
np
p
p
p
np
np
np
np
np
np
felbamate tab 600 mg (Felbatol)
np
FYCOMPA- perampanel tab 4 mg
NP
FYCOMPA- perampanel tab 6 mg
NP
FYCOMPA- perampanel tab 8 mg
NP
FYCOMPA- perampanel tab 10 mg
NP
FYCOMPA- perampanel tab 12 mg
NP
FYCOMPA- perampanel susp 0.5 mg/ NP
ml
NP
FYCOMPA- perampanel tab 2 mg
gabapentin cap 100 mg (Neurontin)
gabapentin cap 300 mg (Neurontin)
gabapentin cap 400 mg (Neurontin)
gabapentin oral soln 250 mg/5ml
(Neurontin)
gabapentin tab 600 mg (Neurontin)
gabapentin tab 800 mg (Neurontin)
p
p
p
np
p
np
GABITRIL- tiagabine hcl tab 12 mg
NP
GABITRIL- tiagabine hcl tab 16 mg
NP
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
83
LAMICTAL STARTER/NOT TAKIlamotrigine tab 25 mg (42) &
100 mg (7) starter kit
NP
LAMICTAL STARTER/TAKING
C- lamotrigine tab 25 mg (84) &
100 mg (14) starter kit
NP
NP
LAMICTAL STARTER/TAKING Vlamotrigine tab 25 mg (35) starter kit
LAMICTAL XR- lamotrigine tab sr 24hr NP
25 mg (21) & 50 mg (7) titration kit
LAMICTAL XR- lamotrigine tab sr 24hr NP
25 (14) & 50 mg (14) & 100 mg(7)
kit
LAMICTAL XR- lamotrigine tab sr 24hr NP
50 (14) & 100 mg(14) & 200 mg(7)
kit
lamotrigine orally disintegrating tab np
25 mg (Lamictal odt)
lamotrigine orally disintegrating tab np
50 mg (Lamictal odt)
lamotrigine orally disintegrating tab np
100 mg (Lamictal odt)
lamotrigine orally disintegrating tab np
200 mg (Lamictal odt)
np
lamotrigine tab chewable
dispersible 5 mg (Lamictal
chewable di)
np
lamotrigine tab chewable
dispersible 25 mg (Lamictal
chewable di)
np
lamotrigine tab disp 25 mg (21) &
50 mg (7) titration kit (Lamictal
odt)
np
lamotrigine tab disp 50 mg (42) &
100 mg (14) titration kit (Lamictal
odt)
np
lamotrigine tab disp 25 (14) &
50 mg (14) & 100 mg (7) kit
(Lamictal odt)
np
lamotrigine tab sr 24hr 25 mg
(Lamictal xr)
lamotrigine tab sr 24hr 50 mg
(Lamictal xr)
lamotrigine tab sr 24hr 100 mg
(Lamictal xr)
lamotrigine tab sr 24hr 200 mg
(Lamictal xr)
lamotrigine tab sr 24hr 250 mg
(Lamictal xr)
lamotrigine tab sr 24hr 300 mg
(Lamictal xr)
lamotrigine tab 25 mg (Lamictal)
lamotrigine tab 100 mg (Lamictal)
lamotrigine tab 150 mg (Lamictal)
lamotrigine tab 200 mg (Lamictal)
levetiracetam oral soln 100 mg/ml
(Keppra)
levetiracetam tab sr 24hr 500 mg
(Keppra xr)
levetiracetam tab sr 24hr 750 mg
(Keppra xr)
levetiracetam tab 250 mg (Keppra)
levetiracetam tab 500 mg (Keppra)
levetiracetam tab 750 mg (Keppra)
levetiracetam tab 1000 mg (Keppra)
Dispensing Limits
Step Therapy
Prior Authorization
np
np
np
np
np
p
p
p
p
np
np
np
p
p
np
np
LYRICA- pregabalin soln 20 mg/ml
P
LYRICA- pregabalin cap 25 mg
P
LYRICA- pregabalin cap 50 mg
P
LYRICA- pregabalin cap 75 mg
P
LYRICA- pregabalin cap 100 mg
P
LYRICA- pregabalin cap 150 mg
P
LYRICA- pregabalin cap 200 mg
P
LYRICA- pregabalin cap 225 mg
P
LYRICA- pregabalin cap 300 mg
P
MYSOLINE- primidone tab 50 mg
NP
MYSOLINE- primidone tab 250 mg
NP
ONFI- clobazam suspension 2.5 mg/
ml
NP
ONFI- clobazam tab 10 mg
NP
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
•
•
•
•
•
•
•
•
•
84
oxcarbazepine tab 150 mg
(Trileptal)
oxcarbazepine tab 300 mg
(Trileptal)
oxcarbazepine tab 600 mg
(Trileptal)
NP
np
QUDEXY XR- topiramate cap er 24hr
sprinkle 100 mg
NP
p
QUDEXY XR- topiramate cap er 24hr
sprinkle 150 mg
NP
np
QUDEXY XR- topiramate cap er 24hr
sprinkle 200 mg
SABRIL- vigabatrin tab 500 mg
NP
SABRIL- vigabatrin powd pack
500 mg
NP
SPRITAM- levetiracetam tab
disintegrating soluble 250 mg
NP
SPRITAM- levetiracetam tab
disintegrating soluble 500 mg
NP
SPRITAM- levetiracetam tab
disintegrating soluble 750 mg
NP
NP
np
OXTELLAR XR- oxcarbazepine tab sr NC
24hr 150 mg
OXTELLAR XR- oxcarbazepine tab sr NC
24hr 300 mg
OXTELLAR XR- oxcarbazepine tab sr NC
24hr 600 mg
NP
PEGANONE- ethotoin tab 250 mg
PHENYTEK- phenytoin sodium
extended cap 200 mg
NP
SPRITAM- levetiracetam tab
disintegrating soluble 1000 mg
NP
PHENYTEK- phenytoin sodium
extended cap 300 mg
NP
TEGRETOL- carbamazepine tab
200 mg
NP
phenytoin chew tab 50 mg (Dilantin
infatabs)
np
TEGRETOL- carbamazepine susp
100 mg/5ml
NP
np
TEGRETOL-XR- carbamazepine tab
sr 12hr 100 mg
NP
np
TEGRETOL-XR- carbamazepine tab
sr 12hr 200 mg
NP
np
TEGRETOL-XR- carbamazepine tab
sr 12hr 400 mg
tiagabine hcl tab 2 mg (Gabitril)
np
phenytoin sodium extended cap
100 mg (Dilantin)
phenytoin sodium extended cap
200 mg (Phenytek)
phenytoin sodium extended cap
300 mg (Phenytek)
phenytoin susp 125 mg/5ml
(Dilantin-125)
np
POTIGA- ezogabine tab 50 mg
NP
POTIGA- ezogabine tab 200 mg
NP
POTIGA- ezogabine tab 300 mg
NP
POTIGA- ezogabine tab 400 mg
NP
primidone tab 50 mg (Mysoline)
primidone tab 250 mg (Mysoline)
p
p
QUDEXY XR- topiramate cap er 24hr
sprinkle 25 mg
NP
QUDEXY XR- topiramate cap er 24hr
sprinkle 50 mg
NP
tiagabine hcl tab 4 mg (Gabitril)
Dispensing Limits
Step Therapy
Prior Authorization
np
TOPIRAMATE ER- topiramate cap er
24hr sprinkle 25 mg
NP
TOPIRAMATE ER- topiramate cap er
24hr sprinkle 50 mg
NP
TOPIRAMATE ER- topiramate cap er
24hr sprinkle 100 mg
NP
TOPIRAMATE ER- topiramate cap er
24hr sprinkle 150 mg
NP
TOPIRAMATE ER- topiramate cap er
24hr sprinkle 200 mg
NP
topiramate sprinkle cap 15 mg
(Topamax sprinkle)
np
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Specialty
Drug Name
Tier Designation
Dispensing Limits
oxcarbazepine susp 300 mg/5ml
(60 mg/ml) (Trileptal)
Step Therapy
NP
Prior Authorization
ONFI- clobazam tab 20 mg
Specialty
Drug Name
Tier Designation
2017
85
topiramate sprinkle cap 25 mg
(Topamax sprinkle)
topiramate tab 25 mg (Topamax)
topiramate tab 50 mg (Topamax)
topiramate tab 100 mg (Topamax)
topiramate tab 200 mg (Topamax)
np
benztropine mesylate tab 1 mg
benztropine mesylate tab 2 mg
p
bromocriptine mesylate cap 5 mg
(base equivalent) (Parlodel)
p
p
bromocriptine mesylate tab 2.5 mg
(base equivalent) (Parlodel)
p
TROKENDI XR- topiramate cap sr
24hr 25 mg
NP
carbidopa & levodopa orally
disintegrating tab 10-100 mg
TROKENDI XR- topiramate cap sr
24hr 50 mg
NP
carbidopa & levodopa orally
disintegrating tab 25-100 mg
TROKENDI XR- topiramate cap sr
24hr 100 mg
NP
carbidopa & levodopa orally
disintegrating tab 25-250 mg
TROKENDI XR- topiramate cap sr
24hr 200 mg
NP
carbidopa & levodopa tab cr
25-100 mg (Sinemet cr)
valproate sodium oral soln
250 mg/5ml (base equiv)
(Depakene)
np
carbidopa & levodopa tab cr
50-200 mg (Sinemet cr)
np
np
np
np
np
np
p
VIMPAT- lacosamide oral solution
10 mg/ml
NP
VIMPAT- lacosamide tab 50 mg
NP
carbidopa & levodopa tab
25-250 mg (Sinemet)
VIMPAT- lacosamide tab 100 mg
NP
carbidopa tab 25 mg (Lodosyn)
VIMPAT- lacosamide tab 150 mg
NP
NP
VIMPAT- lacosamide tab 200 mg
NP
ZARONTIN- ethosuximide cap
250 mg
NP
CARBIDOPA/LEVODOPA/ENTACAcarbidopa-levodopa-entacapone
tabs 12.5-50-200 mg
NP
ZARONTIN- ethosuximide soln
250 mg/5ml
NP
CARBIDOPA/LEVODOPA/ENTACAcarbidopa-levodopa-entacapone
tabs 18.75-75-200 mg
CARBIDOPA/LEVODOPA/ENTACAcarbidopa-levodopa-entacapone
tabs 25-100-200 mg
NP
CARBIDOPA/LEVODOPA/ENTACAcarbidopa-levodopa-entacapone
tabs 31.25-125-200 mg
NP
CARBIDOPA/LEVODOPA/ENTACAcarbidopa-levodopa-entacapone
tabs 37.5-150-200 mg
NP
CARBIDOPA/LEVODOPA/ENTACAcarbidopa-levodopa-entacapone
tabs 50-200-200 mg
NP
zonisamide cap 50 mg
zonisamide cap 100 mg (Zonegran)
ANTIPARKINSON AGENTS
amantadine hcl cap 100 mg
amantadine hcl syrup 50 mg/5ml
amantadine hcl tab 100 mg
APOKYN- apomorphine hcl soln
cartridge 30 mg/3ml
benztropine mesylate tab 0.5 mg
p
p
np
p
np
NP
p
•
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
np
carbidopa & levodopa tab
25-100 mg (Sinemet)
zonisamide cap 25 mg (Zonegran)
Step Therapy
p
np
p
Prior Authorization
p
carbidopa & levodopa tab
10-100 mg (Sinemet)
valproic acid cap 250 mg
(Depakene)
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
p
np
np
86
DUOPA- carbidopa-levodopa enteral
susp 4.63-20 mg/ml
NP
entacapone tab 200 mg (Comtan)
np
NEUPRO- rotigotine td patch 24hr
1 mg/24hr
NP
NEUPRO- rotigotine td patch 24hr
2 mg/24hr
NP
NEUPRO- rotigotine td patch 24hr
3 mg/24hr
NP
NEUPRO- rotigotine td patch 24hr
4 mg/24hr
NP
NEUPRO- rotigotine td patch 24hr
6 mg/24hr
NP
NEUPRO- rotigotine td patch 24hr
8 mg/24hr
NP
pramipexole dihydrochloride tab sr
24hr 0.375 mg (Mirapex er)
np
pramipexole dihydrochloride tab sr
24hr 0.75 mg (Mirapex er)
pramipexole dihydrochloride tab sr
24hr 1.5 mg (Mirapex er)
pramipexole dihydrochloride tab sr
24hr 2.25 mg (Mirapex er)
pramipexole dihydrochloride tab sr
24hr 3 mg (Mirapex er)
pramipexole dihydrochloride tab sr
24hr 3.75 mg (Mirapex er)
pramipexole dihydrochloride tab sr
24hr 4.5 mg (Mirapex er)
pramipexole dihydrochloride tab
0.125 mg (Mirapex)
pramipexole dihydrochloride tab
0.25 mg (Mirapex)
pramipexole dihydrochloride tab
0.5 mg (Mirapex)
pramipexole dihydrochloride tab
0.75 mg (Mirapex)
pramipexole dihydrochloride tab
1 mg (Mirapex)
pramipexole dihydrochloride tab
1.5 mg (Mirapex)
np
np
np
np
np
np
p
p
p
p
p
p
rasagiline mesylate tab 0.5 mg
(base equiv) (Azilect)
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
np
rasagiline mesylate tab 1 mg (base
equiv) (Azilect)
np
selegiline hcl tab 5 mg
np
ropinirole hydrochloride tab sr 24hr np
2 mg (base equivalent) (Requip xl)
ropinirole hydrochloride tab sr 24hr np
4 mg (base equivalent) (Requip xl)
ropinirole hydrochloride tab sr 24hr np
6 mg (base equivalent) (Requip xl)
ropinirole hydrochloride tab sr 24hr np
8 mg (base equivalent) (Requip xl)
ropinirole hydrochloride tab sr 24hr np
12 mg (base equivalent) (Requip
xl)
p
ropinirole hydrochloride tab
0.25 mg (Requip)
ropinirole hydrochloride tab 0.5 mg p
(Requip)
p
ropinirole hydrochloride tab 1 mg
(Requip)
p
ropinirole hydrochloride tab 2 mg
(Requip)
p
ropinirole hydrochloride tab 3 mg
(Requip)
p
ropinirole hydrochloride tab 4 mg
(Requip)
p
ropinirole hydrochloride tab 5 mg
(Requip)
NP
RYTARY- carbidopa & levodopa cap
cr 23.75-95 mg
NP
RYTARY- carbidopa & levodopa cap
cr 36.25-145 mg
NP
RYTARY- carbidopa & levodopa cap
cr 48.75-195 mg
NP
RYTARY- carbidopa & levodopa cap
cr 61.25-245 mg
np
selegiline hcl cap 5 mg (Eldepryl)
STALEVO 100- carbidopa-levodopaentacapone tabs 25-100-200 mg
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
NP
87
STALEVO 125- carbidopa-levodopaentacapone tabs 31.25-125-200 mg
NP
STALEVO 150- carbidopa-levodopaentacapone tabs 37.5-150-200 mg
NP
STALEVO 200- carbidopa-levodopaentacapone tabs 50-200-200 mg
NP
dantrolene sodium cap 25 mg
(Dantrium)
STALEVO 50- carbidopa-levodopaentacapone tabs 12.5-50-200 mg
NP
dantrolene sodium cap 50 mg
(Dantrium)
STALEVO 75- carbidopa-levodopaentacapone tabs 18.75-75-200 mg
NP
tolcapone tab 100 mg (Tasmar)
np
trihexyphenidyl hcl elixir 0.4 mg/ml
trihexyphenidyl hcl tab 2 mg
trihexyphenidyl hcl tab 5 mg
ZELAPAR- selegiline hcl orally
disintegrating tab 1.25 mg
NEUROMUSCULAR AGENTS
np
p
p
NP
cyclobenzaprine hcl tab 7.5 mg
(Fexmid)
cyclobenzaprine hcl tab 10 mg
dantrolene sodium cap 100 mg
np
np
LORZONE- chlorzoxazone tab
750 mg
NC
METAXALONE- metaxalone tab
400 mg
NP
metaxalone tab 800 mg (Skelaxin)
np
p
p
NC
methocarbamol tab 750 mg
(Robaxin-750)
EXONDYS 51- eteplirsen iv soln
500 mg/10ml (50 mg/ml)
NC
orphenadrine citrate tab sr 12hr
100 mg
riluzole tab 50 mg (Rilutek)
np
SOMA- carisoprodol tab 250 mg
NC
SOMA- carisoprodol tab 350 mg
NC
tizanidine hcl cap 2 mg (base
equivalent) (Zanaflex)
np
baclofen tab 20 mg
carisoprodol tab 250 mg (Soma)
carisoprodol tab 350 mg (Soma)
carisoprodol w/ aspirin & codeine
tab 200-325-16 mg
carisoprodol w/ aspirin tab
200-325 mg
chlorzoxazone tab 500 mg (Parafon
forte dsc)
cyclobenzaprine hcl tab 5 mg
np
NC
NC
NC
NC
p
p
tizanidine hcl cap 6 mg (base
equivalent) (Zanaflex)
tizanidine hcl tab 2 mg (base
equivalent)
tizanidine hcl tab 4 mg (base
equivalent) (Zanaflex)
ANTIMYASTHENIC AGENTS
p
np
np
p
p
GUANIDINE HCL- guanidine hcl tab
125 mg
NP
MESTINON- pyridostigmine bromide
syrup 60 mg/5ml
NP
pyridostigmine bromide tab cr
180 mg (Mestinon timespan)
np
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
np
NC
tizanidine hcl cap 4 mg (base
equivalent) (Zanaflex)
Step Therapy
p
EXONDYS 51- eteplirsen iv soln
100 mg/2ml (50 mg/ml)
MUSCULOSKELETAL THERAPY AGENTS
NC
AMRIX- cyclobenzaprine hcl cap sr
24hr 15 mg
NC
AMRIX- cyclobenzaprine hcl cap sr
24hr 30 mg
p
baclofen tab 10 mg
Prior Authorization
np
LORZONE- chlorzoxazone tab
375 mg
methocarbamol tab 500 mg
(Robaxin)
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
88
pyridostigmine bromide tab 60 mg
(Mestinon)
np
NUTRITIONAL PRODUCTS
VITAMINS
cholecalciferol cap 400 unit
cholecalciferol cap 1000 unit
cholecalciferol chew tab 400 unit
cholecalciferol chew tab 1000 unit
cholecalciferol drops 5000 unit/ml
(1000 unit/0.2ml)
cholecalciferol drops 400
unit/0.03ml (per drop)
cholecalciferol drops 2000
unit/0.03ml (per drop)
cholecalciferol oral liquid 400 unit/
ml
cholecalciferol tab 400 unit
cholecalciferol tab 1000 unit
ergocalciferol cap 50000 unit
MEPHYTON- phytonadione tab 5 mg
MULTIVITAMINS
p
p
p
p
p
np
np
np
p
p
p
P
ACTIVE OB- prenatal w/o a w/fe cbnfa-dha cap 20-1-320 mg
NC
BAL-CARE DHA- prenat w/fe poly-na
fered-fa tab 27-1 & omega cap dr
430mg
NC
BP FOLINATAL PLUS B- prenatal w/
calcium carbonate-b6-b12-fa tab
1 mg
NC
BP MULTINATAL PLUS- prenatal w/o
a vit w/ fe fumarate-fa tab 30-1 mg
NC
BP MULTINATAL PLUS- prenatal w/o
a vit w/ fe fum-fa tab chew 40-1 mg
NC
C-NATE DHA- prenatal vit w/ fe fumfa-omega 3 cap 28-1-200 mg
NC
CALCIUM PNV- prenatal w/o vit a w/ NC
fe fum-fa-omega 3 cap 28-1-250 mg
CITRANATAL ASSURE- prenat w/o a NC
w/fecbn-fegl-dss-fa tab & dha cap
300 mg pack
CITRANATAL B-CALM- prenat w/o a
w/fecbn-feglu-fa tab 20-1 mg & vit
b6 tab pak
NC
CITRANATAL DHA- prenat w/o a w/
fecbn-fegl-dss-fa tab & dha cap
250 mg pack
NC
CITRANATAL HARMONY- prenat w/
o a w/fe fum-fe cbn-dss-fa-dha cap
27-1-260 mg
NC
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
CITRANATAL RX- prenatal w/o a w/ fe NC
carbonyl-fe gluc-dss-fa tab 27-1mg
NC
CITRANATAL 90 DHA- prenat w/o a
w/fecbn-fegl-dss-fa tab 90 &dha cap
300mg pak
NC
CO-NATAL FA- prenatal vit w/ fe
fumarate-fa tab 29-1 mg
NC
COMPLETE NATAL DHA- prenat-fe
bis-fe prot succ-fa-ca tab & omega 3
cap 250 pk
NC
COMPLETENATE- prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
CONCEPT DHA- prenatal w/fe fum-fe NC
poly -fa-omega 3 cap 53.5-38-1 mg
NC
CONCEPT OB- prenatal w/o a w/fe
fum-fe poly-fa cap 130-92.4-1 mg
NC
DOTHELLE DHA- prenatal w/fe
fum-fe poly -fa-omega 3 cap
53.5-38-1 mg
DUET DHA BALANCED- prenat w/fe NC
poly-na fered-fa tab 25-1 & omega
cap 267 mg
NC
DUET DHA 400- prenat w/fe polyna fered-fa tab 25-1 & omega cap
400 mg
NC
ELITE-OB- prenatal vit w/ iron
carbonyl-fa tab 50-1.25 mg
NC
ENBRACE HR- prenatal vit w/ fe gly
cys-fa-omega 3 fatty acids cap
NC
EXTRA-VIRT PLUS DHA- prenatal
w/o vit a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
89
FOCALGIN CA- prenat w/o a w/fecbn- NC
fegl-dss-fa tab & dha cap 300 mg
pack
FOCALGIN 90 DHA- prenat w/o a w/ NC
fecbn-fegl-dss-fa tab 90 &dha cap
300mg pak
FOLCAL DHA- prenatal w/o vit a w/ fe NC
fum-dss-fa-dha cap 27-1.25-300 mg
FOLCAPS OMEGA 3- prenatal vit w/ NC
fe cbn-fe asp glyc-fa-omega 3 cap
27-1mg
NC
FOLET DHA- prenat w/fecbn-bisgmethylf-dss tab dr & dha cap pak
NC
FOLET ONE- prenat w/o a w/
fecbn-bisg-methylf-dss-dha cap
38-1-225 mg
NC
FOLIVANE-OB- prenatal w/o a w/fe
fum-fe poly-fa cap 130-92.4-1 mg
NC
HEMENATAL OB- prenat vit-fe
poly cmplx-fe heme poly-fa tab
28-6-1 mg
NC
HEMENATAL OB + DHA- prenat-fe
poly cmplx-fe heme poly-fa tab &
omega 3 cap pck
NC
INATAL ADVANCE- prenatal vit w/
dss-iron carbonyl-fa tab 90-1 mg
NC
INATAL GT- prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg
NC
INATAL ULTRA- prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
NC
INFANATE BALANCE- prenatal
w/o a w/fe cbn-dss-fa-dha cap
29-1-265 mg
NC
KOSHER PRENATAL PLUS IRONprenatal vit w/ iron carbonyl-fa tab
30-1 mg
NC
LEVOMEFOLATE DHA- prenat w/
fe fum-l methylfolate-fa-dha cap
27-1.13-0.4 mg
NC
M-VIT- prenatal vit w/ fe fumarate-fa
tab 27-1 mg
MACNATAL CN DHA- prenatal
w/o a w/fe cbn-dss-fa-dha cap
28-1-250 mg
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
NC
MARNATAL-F- prenatal w/o vit a w/ fe NC
polysac cmplx-fa cap 60-1 mg
NC
MYNATAL- prenatal multivitamins &
minerals w/ iron & fa cap 1 mg
P
MYNATAL ADVANCE- prenatal vit w/
dss-iron carbonyl-fa tab 90-1 mg
P
MYNATAL PLUS- prenatal vit w/ fe
fumarate-fa tab 65-1 mg
P
MYNATAL ULTRACAPLET- prenatal
vit w/ dss-iron carbonyl-fa tab
90-1 mg
P
MYNATAL-Z- prenatal vit w/ fe
fumarate-fa tab 65-1 mg
NC
MYNATE 90 PLUS- prenatal vit w/
dss-fe fumarate-fa tab cr 90-1 mg
NATACHEW- prenatal vit w/ fe fum-fe NC
bisglycin-fa chew tab 28-1 mg
NATALVIT- prenatal vit w/ fe fumarate- NC
fa tab 75-1 mg
NATELLE ONE- prenatal w/o vit a w/ NC
fe fum-fa-omega 3 cap 28-1-250 mg
NC
NEEVO DHA- prenat w/o a w/fefummethylfol-omegas cap 27-1.13 mg
NESTABS- prenatal vit w/o vit a w/ fe NC
bisglycinate-fa tab 32-1 mg
NESTABS ABC- prenatal w/o vit a w/ NC
fe polysac-fa-ca tab & omega 3 cap
NC
NESTABS DHA- prenat w/o a w/ fe
bisglyc-fa tab 32-1 mg & omega cap
pack
NEWGEN- prenatal vit w/o vit a w/ fe NC
bisglycinate-fa tab 32-1 mg
NC
NEXA PLUS- prenatal w/o vit a w/ fe
fum-doc-fa-dha cap 29-1.25-350 mg
NC
NIVA-PLUS- prenatal vit w/ fe
fumarate-fa tab 27-1 mg
O-CAL FA- prenatal vit w/ fe fumarate- NC
fa tab 27-1 mg
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
90
O-CAL PRENATAL- prenatal vit w/ fe
fumarate-fa tab 15-1 mg
NC
PNV TABS 29-1- prenatal vit w/ iron
carbonyl-fa tab 29-1 mg
NC
OB COMPLETE- prenatal vit w/ iron
carbonyl-fa tab 50-1.25 mg
NC
NC
OB COMPLETE GOLD- prenat w/
o a w/fecbn-methfol-fa-dha cap
27.5-1-200 mg
NC
PNV-DHA- prenat w/o a w/
fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
NC
OB COMPLETE ONE- prenatal w/o
a w/fecbn-fe asp glyc-fa-fish cap
50-1-476 mg
NC
PNV-DHA+DOCUSATE- prenatal w/
o vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
NC
OB COMPLETE PETITE- prenat w/o
a w/fecbn-feaspglyc-fa-omega cap
35-5-1-200 mg
NC
PNV-OMEGA- prenat w/o a w/ fe
fumerate-methylfolate-fa-omega 3
cap
PNV-SELECT- prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg
NC
OB COMPLETE PREMIER- prenatal
vit w/ fe cbn-fe asp glyc-fa tab
30-20-1 mg
NC
PNV-TOTAL- prenat w/ fe cbn-fe
bisglyc-fa-fish oil cap 35-5-1.2 mg
NC
NC
NC
OB COMPLETE/DHA- prenat w/
iron cbn-fe asp glyc-fa-omega cap
30-10-1-200 mg
PNV-VP-U- prenatal w/o a vit w/ fe
fumarate-fa cap 106.5-1 mg
NC
OBSTETRIX DHA- prenat w/fecbnfa-dss tab 29-1 mg & omega 3 cap
387 mg pak
NC
PR NATAL 400- prenat-fe bis-fe prot
succ-fa-ca tab & omega 3 cap 400
pk
NC
OBSTETRIX EC- prenatal vit w/ dssiron carbonyl-fa tab 29-1 mg
NC
PR NATAL 400 EC- prenat-fe bis-fe
prot succ-fa-ca tab & omega cap dr
400 pk
PR NATAL 430- prenat-fe bis-fe prot
succ-fa-ca tab & omega 3 cap 430
pk
NC
OBSTETRIX ONE- prenat w/o a w/
fecbn-bisg-methylf-dss-dha cap
38-1-225 mg
NC
PR NATAL 430 EC- prenat-fe bis-fe
prot succ-fa-ca tab & omega cap dr
430 pk
NC
PREFERA OB- prenat vit-fe poly
cmplx-fe heme poly-fa tab 34-1 mg
NC
PREFERAOB +DHA- prenat-fe
poly cmplx 28mg-fe heme poly-fa
tab&dha cap pack
NC
PREFERAOB ONE- prenat-fe poly
cmplx-fe heme poly-fa-dha cap
22-6-1-200 mg
NC
PRENA 1 TRUE- prenat w/o a w/fe
chel-fa tab 30-1.4 mg & dha cap
300mg pk
NC
PRENAISSANCE- prenatal w/o
vit a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg
NC
PNV FERROUS FUMARATE/DOCU- NC
prenatal vit w/ dss-fe fumarate-fa tab
29-1 mg
NC
PNV FOLIC ACID + IRON MULprenatal vit w/ fe fumarate-fa tab
27-1 mg
PNV OB+DHA- prenat w/o a w/fecbn- NC
fegl-dss-fa tab & dha cap 250 mg
pack
NC
PNV PRENATAL PLUS MULTIVIprenat w/ fe fum-fa tab 27-1 mg &
omega 3 cap 312 mg pak
NC
PNV PRENATAL PLUS MULTIVIprenatal vit w/ fe fumarate-fa tab
27-1 mg
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
91
PRENAISSANCE BALANCE- prenatal NC
w/o vit a w/ fe cbn-dss-fa-dha cap
30-1-260 mg
NC
PRENAISSANCE HARMONY DHAprenat w/fe poly-na fered-fa tab 27-1
& omega cap dr 380mg
PRENAISSANCE NEXT- prenatal w/ NC
calcium-vit b6-fa-ginger tab 1.2 mg
NC
PRENAISSANCE NEXT-B- prenatal
w/ calcium-vit b6-fa-ginger tab
1.22 mg
NC
PRENAISSANCE PLUS- prenatal
w/o a w/fe cbn-dss-fa-dha cap
28-1-250 mg
NC
PRENATA- prenatal w/o a vit w/ fe
fum-fa tab chew 29-1 mg
P
PRENATABS RX- prenatal vit w/ iron
carbonyl-fa tab 29-1 mg
NC
PRENATAL- prenatal vit w/ fe
fumarate-fa tab 27-1 mg
NC
PRENATAL PLUS- prenatal vit w/ fe
fumarate-fa tab 27-1 mg
P
PRENATAL PLUS- prenatal vit w/ fe
fumarate-fa tab 27-1 mg
P
PRENATAL PLUS IRON- prenatal vit
w/ iron carbonyl-fa tab 29-1 mg
P
PRENATAL VITAMINS PLUS LOprenatal vit w/ fe fumarate-fa tab
27-1 mg
P
PRENATAL 19- prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
P
PRENATAL 19- prenatal vit w/ dss-fe
fumarate-fa tab 29-1 mg
PRENATAL-U- prenatal w/o a vit w/ fe P
fumarate-fa cap 106.5-1 mg
NC
PRENATE- prenat mv & min w/ lmethylfolate-fa chew tab 0.6-0.4 mg
PRENATE AM- prenatal w/ calcium-vit NC
b6-vit b12-fa-ginger tab 1 mg
NC
PRENATE DHA- prenat w/o a
w/fefum-methfol-fa-dha cap
28-0.6-0.4-300 mg
PRENATE DHA- prenat w/o a
w/feaspg-methfol-fa-dha cap
18-0.6-0.4-300 mg
NC
PRENATE ELITE- prenatal w/
fe asp gly-l methylfol-fa tab
20-0.6-0.4 mg
NC
PRENATE ELITE- prenatal vit
w/ fe fum-methylfolate-fa tab
26-0.6-0.4 mg
NC
PRENATE ENHANCE- prenat w/
o a w/fefum-methfol-fa-dha cap
28-0.6-0.4-400 mg
NC
PRENATE ESSENTIAL- prenat w/
o a w/feasp-methylf-fa-omeg cap
29-0.6-0.4-340 mg
NC
PRENATE ESSENTIAL- prenat w/
o a w/feaspg-methfol-fa-dha cap
18-0.6-0.4-300 mg
NC
PRENATE MINI- prenat w/oa w/
fecb-feasp-meth-fa-dha cap
18-0.6-0.4-350 mg
NC
PRENATE MINI- prenat w/o a
w/fecbn-methylf-fa-dha cap
29-0.6-0.4-350 mg
NC
PRENATE PIXIE- prenat w/o a
w/feaspg-methfol-fa-dha cap
10-0.6-0.4-200 mg
NC
PRENATE RESTORE- prenat w/
o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-400 mg
NC
PRENATE STAR- prenatal vit w/ fe
asparto glycinate-fa tab 20-1 mg
NC
PRENA1 CHEW- prenat w/ b2-b6b12-d3-folic acid chew tab 1.4 mg
NC
PRENA1 PEARL- prenat w/oa w/
fefum-na fered-fa-dha cap cr
30-1.4-200 mg
NC
PREPLUS- prenatal vit w/ fe
fumarate-fa tab 27-1 mg
NC
PRETAB- prenatal vit w/ fe fumaratefa tab 29-1 mg
NC
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
92
PRIMACARE- prenat w/o a w/
feasp-methlf-fa-omeg cap
30-0.75-0.25-470mg
NC
TL-CARE DHA- prenatal w/fe
fumarate-fa-dss-fish oil cap
27-1-500 mg
PROVIDA DHA- prenat w/o a
w/fe fum-fe poly-fa-dha cap
16-16-1.25-110 mg
NC
PROVIDA OB- prenatal w/o a w/fe
fum-fe poly-fa cap 20-20-1.25 mg
NC
PUREFE OB PLUS- prenatal
w/o a w/fe fum-fe poly-fa cap
162.115.2-1 mg
NC
NC
TL-SELECT- prenatal w/o vit a w/ fe
fum-dss-fa-dha cap 29-1.25-325 mg
NC
TRI-TABS DHA- prenat w/o a w/ fe
bisglyc-fa tab 32-1 mg & omega cap
pack
TRIADVANCE- prenatal vit w/ dss-iron NC
carbonyl-fa tab 90-1 mg
TRICARE- prenatal vit w/ fe fumarate- NC
fa tab 27-1 mg
NC
TRICARE PRENATAL- prenat w/o a
w/fepyro-mfol chw 4.5-1 mg & dha
cap 150 thpk
TRICARE PRENATAL- prenat w/o vit NC
a w/ fe pyrophos-methylf chew tab
4.5-1 mg
NC
TRICARE PRENATAL COMPLEATprenat w/o a fefum-fa tab 27-1 mg &
fish oil chew cap pak
NC
TRICARE PRENATAL DHA ONEprenatal w/fe fumarate-fa-dss-fish oil
cap 27-1-500 mg
TRINATAL GT- prenatal vit w/ dss-iron NC
carbonyl-fa tab 90-1 mg
NC
TRINATAL RX 1- prenatal vit w/ fe
fumarate-fa tab 60-1 mg
TRINATE- prenatal vit w/ fe fumarate- P
fa tab 28-1 mg
NC
TRISTART DHA- prenat w/o a
w/fecbn-methylf-fa-dha cap
31-0.6-0.4-200 mg
TRIVEEN-DUO DHA- prenat-fe bis-fe NC
prot succ-fa-ca tab & omega 3 cap
400 pk
NC
TRIVEEN-PRX RNF- prenatal w/
o vit a w/ fe fum-dss-fa-dha cap
26-1.2-300 mg
ULTIMATECARE ONE- prenatal vit w/ NC
fe cbn-fe asp glyc-fa-omega 3 cap
27-1mg
R-NATAL OB- prenatal w/o a w/fe cbn- NC
fa-dha cap 20-1-320 mg
RELNATE DHA- prenatal vit w/ fe fum- NC
fa-omega 3 cap 28-1-200 mg
NC
RULAVITE DHA- prenat w/o a
w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
P
SE-NATAL 19- prenatal vit w/ fe
fumarate-fa chew tab 29-1 mg
P
SE-NATAL 19- prenatal vit w/ dss-fe
fumarate-fa tab 29-1 mg
NC
SELECT-OB- prenatal vit w/ fe
polysac cmplx-fa chew tab 29-1 mg
SELECT-OB- prenat w/ fepolycmplx- NC
methylfol-fa chew tab 29-0.6-0.4 mg
NC
SELECT-OB+DHA- prenatal mv w/
fe poly-fa chw 29-1 mg & dha cap
250 mg pak
TARON-BC- prenat w/o a w/ fe cbnyl- NC
fa tab 20-1 mg & vit b6 tab pak
TARON-C DHA- prenatal w/fe fum-fe NC
poly -fa-omega 3 cap 53.5-38-1 mg
TARON-PREX- prenatal w/o vit a w/ fe NC
fum-dss-fa-dha cap 30-1.2-265 mg
NC
THRIVITE RX- prenatal vit w/ iron
carbonyl-fa tab 29-1 mg
NC
THRIVITE 19- prenatal vit w/ dss-fe
fumarate-fa tab 29-1 mg
NC
TL FOLATE- prenatal vit w/ fe fummethylfolate-fa tab 27-0.5-0.5 mg
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
NC
93
NC
ULTIMATECARE ONE NF- prenatal
w/fe cbnyl-fe asp glyc-fa-dss-omega
cap 20-7-1 mg
NC
VEMAVITE-PRX 2- prenatal w/o
vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
VENA-BAL DHA- prenat w/fe poly-na NC
fered-fa tab 27-1 & omega cap dr
430mg
NC
VINATE DHA RF- prenat w/o a
w/fefum-methylfol-omegas cap
27-1.13 mg
P
VINATE II- prenatal vit w/ fe
bisglycinate chelate-fa tab 29-1 mg
P
VINATE M- prenatal vit w/ sel-fe
fumarate-fa tab 27-1 mg
P
VINATE ONE- prenatal vit w/ fe
fumarate-fa tab 60-1 mg
NC
VIRT NATE- prenatal vit w/ fe
fumarate-fa tab 28-1 mg
VIRT-ADVANCE- prenatal vit w/ dss- NC
iron carbonyl-fa tab 90-1 mg
NC
VIRT-C DHA- prenatal w/fe fum-fe
poly -fa-omega 3 cap 53.5-38-1 mg
NC
VIRT-CARE ONE- prenatal vit w/ fe
cbn-fe asp glyc-fa-omega 3 cap
27-1mg
NC
VIRT-NATE DHA- prenatal vit w/ fe
fum-fa-omega 3 cap 28-1-200 mg
NC
VIRT-PN- prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg
NC
VIRT-PN DHA- prenat w/o a
w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
NC
VIRT-PN PLUS- prenat w/o a w/ fe
fumerate-methylfolate-fa-omega 3
cap
VIRT-SELECT- prenatal w/o vit a w/ fe NC
fum-dss-fa-dha cap 29-1.25-325 mg
VIRT-VITE GT- prenatal vit w/ dss-iron NC
carbonyl-fa tab 90-1 mg
VIRTPREX- prenatal w/o vit a w/ fe
fum-dss-fa-dha cap 26-1.2-300 mg
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
NC
VITA-PREN- prenatal vit w/ docusate- NC
iron-fa tab 65-1 mg
VITAFOL FE+- prenat-fepoly-methol- NC
fa-dha cap 90-1-200 mg & dss
50mg cap
NC
VITAFOL GUMMIES- prenat vit
w/ fe phos-fa-omega chew tab
3.33-0.333-34.8 mg
NC
VITAFOL ULTRA- prenat w/
fe poly-methylfol-fa-dha cap
29-0.6-0.4-200 mg
NC
VITAFOL-NANO- prenatal w/o
a w/ fefum-l methylfol-fa tab
18-0.6-0.4 mg
NC
VITAFOL-OB- prenatal vit w/ fe
fumarate-fa tab 65-1 mg
NC
VITAFOL-OB+DHA- prenatal mv w/
fe fum-fa tab 65-1 mg & dha cap
250 mg pack
NC
VITAFOL-ONE- prenatal mv w/
fe polysac cmplx-fa-dha cap
29-1-200 mg
NC
VITAMEDMD ONE RX/QUATREFOprenat w/o a w/fefum-methfol-fa-dha
cap 30-0.6-0.4-200 mg
VITAMEDMD REDICHEW RX- prenat NC
w/ b2-b6-b12-d3-folic acid chew tab
1.4 mg
VITAPEARL- prenat w/oa w/fefum-na NC
fered-fa-dha cap cr 30-1.4-200 mg
VITATRUE- prenat w/o a w/fe chel-fa NC
tab 30-1.4 mg & dha cap 300mg pk
NC
VIVA DHA- prenatal vit w/ fe fum-faomega 3 cap 28-1-200 mg
NC
VOL-NATE- prenatal vit w/ fe
fumarate-fa tab 28-1 mg
NC
VOL-PLUS- prenatal vit w/ fe
fumarate-fa tab 27-1 mg
NC
VOL-TAB RX- prenatal vit w/ iron
carbonyl-fa tab 29-1 mg
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
94
VP-CH PLUS- prenatal w/o a w/fe
cbn-dss-fa-dha cap 29-1-265 mg
NC
GALZIN- zinc acetate cap 50 mg
(elemental zinc)
NP
VP-CH-PNV- prenatal w/o vit a w/ fe
cbn-dss-fa-dha cap 30-1-260 mg
NC
K-TAB- potassium chloride tab cr 8
meq (600 mg)
NP
VP-GGR-B6 PRENATAL- prenatal w/
calcium-vit b6-fa-ginger tab 1.2 mg
NC
K-TAB- potassium chloride tab cr 20
meq (1500 mg)
NP
VP-HEME OB- prenat vit-fe poly
cmplx-fe heme poly-fa tab
28-6-1 mg
NC
KLOR-CON M15- potassium chloride
microencapsulated crys cr tab 15
meq
NP
VP-HEME OB + DHA- prenat-fe poly
cmplx-fe heme poly-fa tab & omega
3 cap pck
NC
LOZI-FLUR- sodium fluoride lozenge
1 mg f (from 2.2 mg naf)
NP
POTASSIUM CHLORIDE- potassium
chloride oral soln 20% (40
meq/15ml)
np
VP-HEME ONE- prenat-fe poly
cmplx-fe heme poly-fa-dha cap
22-6-1-200 mg
NC
potassium chloride cap cr 8 meq
(Micro-k)
np
VP-PNV-DHA- prenatal vit w/ fe fumfa-omega 3 cap 28-1-215.8 mg
NC
ZATEAN-CH- prenatal w/o a w/fe cbn- NC
dss-fa-dha cap 27-1-250 mg
NC
ZATEAN-PN DHA- prenat w/o
a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
ZATEAN-PN PLUS- prenat w/o a w/ fe NC
fumerate-methylfolate-fa-omega 3
cap
MINERALS and ELECTROLYTES
FLORIVA- sodium fluoride-vitamin d
liqd drops 0.25 mg/ml-400 unit/ml
NP
FLUOR-A-DAY- sodium fluoridexylitol chew tab 0.55 (0.25 mg
f)-236.79 mg
NP
FLUOR-A-DAY- sodium fluoride-xylitol NP
chew tab 2.2 (1 mg f)-236.79 mg
NP
FLUORABON- sodium fluoride soln
0.25 mg/0.6ml (from 0.55 mg/0.6ml
naf)
FLURA-DROPS- sodium fluoride soln NP
0.25 mg/drop f (from 0.55 mg/drop
naf)
NP
GALZIN- zinc acetate cap 25 mg
(elemental zinc)
potassium chloride cap cr 10 meq
(Micro-k)
NP
POTASSIUM CHLORIDE ERpotassium chloride tab cr 20 meq
(1500 mg)
NP
potassium chloride
microencapsulated crys cr tab 20
meq
potassium chloride oral soln 10%
(20 meq/15ml)
potassium chloride powder packet
20 meq
potassium chloride tab cr 8 meq
(600 mg)
potassium chloride tab cr 10 meq
(K-tab)
Dispensing Limits
Step Therapy
p
p
np
np
p
p
SODIUM FLUORIDE- sodium fluoride
tab 0.5 mg f (from 1.1 mg naf)
NP
SODIUM FLUORIDE- sodium fluoride
tab 1 mg f (from 2.2 mg naf)
NP
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Prior Authorization
np
POTASSIUM CHLORIDE ERpotassium chloride tab cr 8 meq
(600 mg)
potassium chloride
microencapsulated crys cr tab 10
meq
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
95
sodium fluoride chew tab 0.25 mg f
(from 0.55 mg naf)
sodium fluoride chew tab 0.5 mg f
(from 1.1 mg naf)
sodium fluoride chew tab 1 mg f
(from 2.2 mg naf)
amino acids cap
NC
p
PHENACTIN AA PLUS- nutritional
supplement liquid
NC
p
PROMACTIN AA PLUS- nutritional
supplement liquid
NC
TYLACTIN RESTORE 10- nutritional
supplement liquid
NC
NC
HEMATOLOGICAL AGENTS
NC
HEMATOPOIETIC AGENTS
P
• •
folic acid-pyridoxinecyanocobalamin tab 2.5-25-2 mg
np
ARANESP ALBUMIN FREEdarbepoetin alfa soln prefilled
syringe 10 mcg/0.4ml
ARANESP ALBUMIN FREEdarbepoetin alfa soln prefilled
syringe 25 mcg/0.42ml
P
• •
ARANESP ALBUMIN FREEdarbepoetin alfa soln prefilled
syringe 40 mcg/0.4ml
P
• •
ARANESP ALBUMIN FREEdarbepoetin alfa soln prefilled
syringe 60 mcg/0.3ml
P
• •
ARANESP ALBUMIN FREEdarbepoetin alfa soln prefilled
syringe 100 mcg/0.5ml
P
• •
ARANESP ALBUMIN FREEdarbepoetin alfa soln prefilled
syringe 150 mcg/0.3ml
P
• •
ARANESP ALBUMIN FREEdarbepoetin alfa soln prefilled
syringe 200 mcg/0.4ml
P
• •
ARANESP ALBUMIN FREEdarbepoetin alfa soln prefilled
syringe 300 mcg/0.6ml
P
• •
NC
GLYTACTIN BETTERMILK 15nutritional supplement pack
NC
GLYTACTIN BUILD 10PE- nutritional
supplement pack
NC
GLYTACTIN COMPLETE 10PEnutritional supplement bar
NC
GLYTACTIN RESTORE LITE 10nutritional supplement pack
NC
GLYTACTIN RESTORE 5- nutritional
supplement pack
NC
GLYTACTIN RTD 10- nutritional
supplement liquid
NC
GLYTACTIN RTD 15- nutritional
supplement liquid
NC
HOMACTIN AA PLUS- nutritional
supplement liquid
NC
ISOVACTIN AA PLUS- nutritional
supplement liquid
NC
KETOVIE- nutritional supplement
liquid
NC
Dispensing Limits
TYLACTIN RESTORE 5PE- nutritional NC
supplement pack
NC
TYLACTIN RTD 15- nutritional
supplement liquid
NC
VILACTIN AA PLUS- nutritional
supplement liquid
CAMINO PRO 15PE- nutritional
supplement liquid
GLYTACTIN BETTERMILK DE-Lnutritional supplement pack
Step Therapy
Prior Authorization
Specialty
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
KETOVIE PEPTIDE- nutritional
supplement liquid
NUTRESTORE- glutamine powd pack NP
5 gm
DIETARY PRODUCTS
Drug Name
p
sodium fluoride soln 0.125 mg/drop np
f (0.275 mg/drop naf)
p
sodium fluoride soln 0.5 mg/ml f
(from 1.1 mg/ml naf)
NUTRIENTS
Specialty
Drug Name
Tier Designation
2017
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
96
ARANESP ALBUMIN FREEdarbepoetin alfa soln prefilled
syringe 500 mcg/ml
P
ARANESP ALBUMIN FREEdarbepoetin alfa soln inj 25 mcg/ml
P
GRANIX- tbo-filgrastim soln prefilled
syringe 480 mcg/0.8ml
P
• •
HYDROXOCOBALAMINhydroxocobalamin inj 1000 mcg/ml
NP
• •
LEUKINE- sargramostim lyophilized
for inj 250 mcg
NP
ARANESP ALBUMIN FREEdarbepoetin alfa soln inj 40 mcg/ml
P
ARANESP ALBUMIN FREEdarbepoetin alfa soln inj 60 mcg/ml
P
• •
ARANESP ALBUMIN FREEdarbepoetin alfa soln inj 100 mcg/ml
P
• •
ARANESP ALBUMIN FREEdarbepoetin alfa soln inj 200 mcg/ml
P
• •
ARANESP ALBUMIN FREEdarbepoetin alfa soln inj 300 mcg/ml
P
• •
carbonyl iron susp 15 mg/1.25ml
(elemental iron)
p
CERDELGA- eliglustat tartrate cap
84 mg (base equivalent)
NP
cyanocobalamin inj 1000 mcg/ml
p
DROXIA- hydroxyurea cap 200 mg
NP
DROXIA- hydroxyurea cap 300 mg
NP
DROXIA- hydroxyurea cap 400 mg
NP
EPOGEN- epoetin alfa inj 2000 unit/ml NP
EPOGEN- epoetin alfa inj 3000 unit/ml NP
EPOGEN- epoetin alfa inj 4000 unit/ml NP
EPOGEN- epoetin alfa inj 10000 unit/ NP
ml
EPOGEN- epoetin alfa inj 20000 unit/ NP
ml
p
ferrous sulfate elixir 220 mg/5ml
(44 mg/5ml elemental fe)
p
ferrous sulfate soln 75 mg/ml
(15 mg/ml elemental fe)
np
folic acid cap 0.8 mg
folic acid tab 400 mcg
folic acid tab 800 mcg
folic acid tab 1 mg
GRANIX- tbo-filgrastim soln prefilled
syringe 300 mcg/0.5ml
• •
•
•
•
•
• •
p
p
p
P
•
•
•
•
•
•
MIRCERA- methoxy peg-epoetin beta NP
soln prefilled syr 30 mcg/0.3ml
MIRCERA- methoxy peg-epoetin beta NP
soln prefilled syr 50 mcg/0.3ml
MIRCERA- methoxy peg-epoetin beta NP
soln prefilled syr 75 mcg/0.3ml
MIRCERA- methoxy peg-epoetin beta NP
soln prefilled syr 100 mcg/0.3ml
MIRCERA- methoxy peg-epoetin beta NP
soln prefilled syr 150 mcg/0.3ml
MIRCERA- methoxy peg-epoetin beta NP
soln prefilled syr 200 mcg/0.3ml
NP
NASCOBAL- cyanocobalamin nasal
spray 500 mcg/0.1ml
P
NEULASTA- pegfilgrastim soln
prefilled syringe 6 mg/0.6ml
NP
NEUPOGEN- filgrastim soln prefilled
syringe 300 mcg/0.5ml
NP
NEUPOGEN- filgrastim soln prefilled
syringe 480 mcg/0.8ml (600 mcg/ml)
NEUPOGEN- filgrastim inj 300 mcg/ml NP
NEUPOGEN- filgrastim inj
480 mcg/1.6ml (300 mcg/ml)
NP
Dispensing Limits
•
•
•
•
•
•
•
•
•
•
•
•
PROCRIT- epoetin alfa inj 2000 unit/
ml
P
• •
PROCRIT- epoetin alfa inj 3000 unit/
ml
P
• •
PROCRIT- epoetin alfa inj 4000 unit/
ml
P
• •
PROCRIT- epoetin alfa inj 10000 unit/
ml
P
• •
PROCRIT- epoetin alfa inj 20000 unit/
ml
P
• •
PROCRIT- epoetin alfa inj 40000 unit/
ml
P
• •
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Step Therapy
•
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
• •
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
97
NP
• •
•
PROMACTA- eltrombopag olamine
tab 50 mg (base equiv)
NP
• •
•
PROMACTA- eltrombopag olamine
tab 75 mg (base equiv)
NP
• •
•
P
•
ZARXIO- filgrastim-sndz soln prefilled
syringe 480 mcg/0.8ml
P
•
ZAVESCA- miglustat cap 100 mg
ANTICOAGULANTS
NP
• •
np
•
np
•
np
•
np
•
np
•
np
•
np
•
np
•
np
•
NP
•
FRAGMIN- dalteparin sodium inj 2500 NP
unit/0.2ml
FRAGMIN- dalteparin sodium inj 5000 NP
unit/0.2ml
FRAGMIN- dalteparin sodium inj 7500 NP
unit/0.3ml
NP
FRAGMIN- dalteparin sodium inj
12500 unit/0.5ml
NP
FRAGMIN- dalteparin sodium inj
15000 unit/0.6ml
NP
FRAGMIN- dalteparin sodium inj
18000 unit/0.72ml
NP
FRAGMIN- dalteparin sodium inj
95000 unit/3.8ml
np
heparin sodium (porcine) inj 1000
unit/ml
np
heparin sodium (porcine) inj 5000
unit/ml
•
enoxaparin sodium inj 80 mg/0.8ml
(Lovenox)
enoxaparin sodium inj 100 mg/ml
(Lovenox)
enoxaparin sodium inj
120 mg/0.8ml (Lovenox)
enoxaparin sodium inj 150 mg/ml
(Lovenox)
enoxaparin sodium inj 300 mg/3ml
(Lovenox)
•
fondaparinux sodium
subcutaneous inj 2.5 mg/0.5ml
(Arixtra)
fondaparinux sodium
subcutaneous inj 5 mg/0.4ml
(Arixtra)
COUMADIN- warfarin sodium tab
1 mg
NP
COUMADIN- warfarin sodium tab
2 mg
NP
COUMADIN- warfarin sodium tab
2.5 mg
NP
COUMADIN- warfarin sodium tab
3 mg
NP
fondaparinux sodium
subcutaneous inj 10 mg/0.8ml
(Arixtra)
COUMADIN- warfarin sodium tab
4 mg
NP
FRAGMIN- dalteparin sodium inj
10000 unit/ml
COUMADIN- warfarin sodium tab
5 mg
NP
COUMADIN- warfarin sodium tab
6 mg
NP
COUMADIN- warfarin sodium tab
7.5 mg
NP
COUMADIN- warfarin sodium tab
10 mg
NP
fondaparinux sodium
subcutaneous inj 7.5 mg/0.6ml
(Arixtra)
ELIQUIS- apixaban tab 2.5 mg
P
ELIQUIS- apixaban tab 5 mg
P
enoxaparin sodium inj 30 mg/0.3ml
(Lovenox)
np
•
•
•
np
•
np
•
enoxaparin sodium inj 40 mg/0.4ml
(Lovenox)
enoxaparin sodium inj 60 mg/0.6ml
(Lovenox)
Dispensing Limits
PROMACTA- eltrombopag olamine
tab 25 mg (base equiv)
ZARXIO- filgrastim-sndz soln prefilled
syringe 300 mcg/0.5ml
•
Step Therapy
• •
Prior Authorization
NP
Specialty
PROMACTA- eltrombopag olamine
tab 12.5 mg (base equiv)
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
•
•
•
•
•
•
98
heparin sodium (porcine) inj 10000
unit/ml
heparin sodium (porcine) inj 20000
unit/ml
heparin sodium (porcine) pf inj
5000 unit/0.5ml
PRADAXA- dabigatran etexilate
mesylate cap 75 mg (etexilate base
eq)
XARELTO- rivaroxaban tab 20 mg
P
np
XARELTO STARTER PACKrivaroxaban tab starter therapy pack
15 mg & 20 mg
P
np
HEMOSTATICS
NP
P
•
•
•
•
•
•
•
•
AMICAR- aminocaproic acid oral soln
0.25 gm/ml
NP
AMICAR- aminocaproic acid tab
500 mg
NP
AMICAR- aminocaproic acid tab
1000 mg
NP
ARTISS- fibrin sealant component
solution
NP
EVICEL- fibrin sealant component kit
2 ml
NP
EVICEL- fibrin sealant component kit
5 ml
NP
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
np
NP
PRADAXA- dabigatran etexilate
mesylate cap 110 mg (etexilate base
eq)
NP
PRADAXA- dabigatran etexilate
mesylate cap 150 mg (etexilate
base eq)
NP
SAVAYSA- edoxaban tosylate tab
15 mg (base equivalent)
NP
SAVAYSA- edoxaban tosylate tab
30 mg (base equivalent)
NP
SAVAYSA- edoxaban tosylate tab
60 mg (base equivalent)
p
warfarin sodium tab 1 mg
(Coumadin)
p
warfarin sodium tab 2 mg
(Coumadin)
p
warfarin sodium tab 2.5 mg
(Coumadin)
p
warfarin sodium tab 3 mg
(Coumadin)
p
warfarin sodium tab 4 mg
(Coumadin)
p
warfarin sodium tab 5 mg
(Coumadin)
p
warfarin sodium tab 6 mg
(Coumadin)
p
warfarin sodium tab 7.5 mg
(Coumadin)
p
warfarin sodium tab 10 mg
(Coumadin)
P
XARELTO- rivaroxaban tab 10 mg
XARELTO- rivaroxaban tab 15 mg
Specialty
Drug Name
Tier Designation
2017
•
•
EVITHROM- thrombin (human) topical NP
soln 800-1200 unit/ml
RAPLIXA- fibrinogen-thrombin powder NC
79-699 mg-unit/gm
NP
RECOTHROM- thrombin
(recombinant) for soln 5000 unit
NP
RECOTHROM- thrombin
(recombinant) for soln 20000 unit
RECOTHROM SPRAY KIT- thrombin NP
(recombinant) for soln 20000 unit
THROMBIN-JMI DILUENT- thrombin NP
for soln 5000 unit
THROMBIN-JMI DILUENT- thrombin NP
for soln 20000 unit
NP
THROMBIN-JMI EPISTAXISthrombin for soln kit 5000 unit
NP
THROMBIN-JMI SYRINGE SPRAthrombin for soln kit 5000 unit
NP
THROMBIN-JMI SYRINGE SPRAthrombin for soln kit 20000 unit
NP
THROMBIN-JMI W/DIL SPRAYthrombin for soln kit 20000 unit
NP
TISSEEL- fibrin sealant component
solution
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
99
AFSTYLA- antihemophilic fact rcmb
single chain for inj kit 2000 unit
P
•
TISSEEL VH- fibrin sealant
component kit 4 ml
NP
AFSTYLA- antihemophilic fact rcmb
single chain for inj kit 3000 unit
P
•
TISSEEL VH- fibrin sealant
component kit 10 ml
NP
P
•
tranexamic acid tab 650 mg
(Lysteda)
np
ALPHANATE/VON WILLEBRANDantihemophilic factor/vwf (human)
for inj 250 unit
ALPHANATE/VON WILLEBRANDantihemophilic factor/vwf (human)
for inj 500 unit
P
•
ALPHANATE/VON WILLEBRANDantihemophilic factor/vwf (human)
for inj 1000 unit
P
•
ALPHANATE/VON WILLEBRANDantihemophilic factor/vwf (human)
for inj 1500 unit
P
•
P
•
HEMATOLOGICAL AGENTS - MISC.
ADVATE- antihemophilic factor rahfpfm for inj 250 unit
P
•
ADVATE- antihemophilic factor rahfpfm for inj 500 unit
P
•
ADVATE- antihemophilic factor rahfpfm for inj 1000 unit
P
•
ADVATE- antihemophilic factor rahfpfm for inj 1500 unit
P
•
ADVATE- antihemophilic factor rahfpfm for inj 2000 unit
P
•
ALPHANATE/VON WILLEBRANDantihemophilic factor/vwf (human)
for inj 2000 unit
•
ALPHANINE SD- coagulation factor ix
for inj 500 unit
P
ADVATE- antihemophilic factor rahfpfm for inj 3000 unit
P
•
•
ALPHANINE SD- coagulation factor ix
for inj 1000 unit
P
ADVATE- antihemophilic factor rahfpfm for inj 4000 unit
P
•
•
ALPHANINE SD- coagulation factor ix
for inj 1500 unit
P
ADYNOVATE- antihemophilic factor
recomb pegylated for inj 250 unit
P
•
P
•
P
ADYNOVATE- antihemophilic factor
recomb pegylated for inj 500 unit
ALPROLIX- coagulation factor ix
(recomb) (rfixfc) for inj 250 unit
•
P
•
ALPROLIX- coagulation factor ix
(recomb) (rfixfc) for inj 500 unit
P
ADYNOVATE- antihemophilic factor
recomb pegylated for inj 750 unit
•
•
ALPROLIX- coagulation factor ix
(recomb) (rfixfc) for inj 1000 unit
P
ADYNOVATE- antihemophilic factor
recomb pegylated for inj 1000 unit
P
•
•
ALPROLIX- coagulation factor ix
(recomb) (rfixfc) for inj 2000 unit
P
ADYNOVATE- antihemophilic factor
recomb pegylated for inj 1500 unit
P
•
P
•
P
ADYNOVATE- antihemophilic factor
recomb pegylated for inj 2000 unit
ALPROLIX- coagulation factor ix
(recomb) (rfixfc) for inj 3000 unit
•
P
•
ALPROLIX- coagulation factor ix
(recomb) (rfixfc) for inj 4000 unit
P
AFSTYLA- antihemophilic fact rcmb
single chain for inj kit 250 unit
•
•
anagrelide hcl cap 0.5 mg (Agrylin)
np
AFSTYLA- antihemophilic fact rcmb
single chain for inj kit 500 unit
P
AFSTYLA- antihemophilic fact rcmb
single chain for inj kit 1000 unit
P
•
anagrelide hcl cap 1 mg
aspirin-dipyridamole cap sr 12hr
25-200 mg (Aggrenox)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
NP
Step Therapy
TISSEEL VH- fibrin sealant
component kit 2 ml
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
np
np
100
P
•
ELOCTATE- antihemophilic factor
(recomb) rfviiifc for inj 750 unit
P
•
P
•
ELOCTATE- antihemophilic factor
(recomb) rfviiifc for inj 1000 unit
P
•
BENEFIX- coagulation factor ix
(recombinant) for inj kit 1000 unit
P
•
ELOCTATE- antihemophilic factor
(recomb) rfviiifc for inj 1500 unit
P
•
BENEFIX- coagulation factor ix
(recombinant) for inj kit 2000 unit
P
•
ELOCTATE- antihemophilic factor
(recomb) rfviiifc for inj 2000 unit
P
•
BENEFIX- coagulation factor ix
(recombinant) for inj kit 3000 unit
P
•
ELOCTATE- antihemophilic factor
(recomb) rfviiifc for inj 3000 unit
P
•
ELOCTATE- antihemophilic factor
(recomb) rfviiifc for inj 4000 unit
P
•
ELOCTATE- antihemophilic factor
(recomb) rfviiifc for inj 5000 unit
P
•
ELOCTATE- antihemophilic factor
(recomb) rfviiifc for inj 6000 unit
P
•
p
FEIBA- antiinhibitor coagulant
complex for inj
P
•
np
FIRAZYR- icatibant acetate inj
30 mg/3ml (base equivalent)
P
• •
NP
BRILINTA- ticagrelor tab 60 mg
P
BRILINTA- ticagrelor tab 90 mg
P
cilostazol tab 50 mg
p
cilostazol tab 100 mg
clopidogrel bisulfate tab 75 mg
(base equiv) (Plavix)
clopidogrel bisulfate tab 300 mg
(base equiv) (Plavix)
• •
p
•
COAGADEX- coagulation factor x
(human) for inj 250 unit
P
•
HELIXATE FS- antihemophilic factor
(recombinant) for inj kit 250 unit
P
•
COAGADEX- coagulation factor x
(human) for inj 500 unit
P
•
HELIXATE FS- antihemophilic factor
(recombinant) for inj kit 500 unit
P
•
CORIFACT- factor xiii concentrate
(human) for inj kit 1000-1600 unit
P
•
HELIXATE FS- antihemophilic factor
(recombinant) for inj kit 1000 unit
P
•
dipyridamole tab 25 mg
p
HELIXATE FS- antihemophilic factor
(recombinant) for inj kit 2000 unit
P
•
HELIXATE FS- antihemophilic factor
(recombinant) for inj kit 3000 unit
P
•
NC
HEMOFIL M- antihemophilic factor
(human) for inj 250 unit
P
•
EFFIENT- prasugrel hcl tab 5 mg
(base equiv)
P
HEMOFIL M- antihemophilic factor
(human) for inj 500 unit
P
•
EFFIENT- prasugrel hcl tab 10 mg
(base equiv)
P
HEMOFIL M- antihemophilic factor
(human) for inj 1000 unit
P
•
ELOCTATE- antihemophilic factor
(recomb) rfviiifc for inj 250 unit
P
HEMOFIL M- antihemophilic factor
(human) for inj 1700 unit
P
•
dipyridamole tab 50 mg
dipyridamole tab 75 mg
DURLAZA- aspirin capsule sr 24hr
162.5 mg
np
p
•
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
BENEFIX- coagulation factor ix
(recombinant) for inj kit 500 unit
BERINERT- c1 esterase inhibitor
(human) for iv inj kit 500 unit
ELOCTATE- antihemophilic factor
(recomb) rfviiifc for inj 500 unit
Step Therapy
•
Prior Authorization
P
Specialty
BENEFIX- coagulation factor ix
(recombinant) for inj kit 250 unit
Drug Name
Tier Designation
•
Dispensing Limits
P
Step Therapy
BEBULIN- factor ix complex for inj
200-1200 unit
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
•
101
•
•
KOGENATE FS BIO-SETantihemophilic factor (recombinant)
for inj kit 1000 unit
P
HUMATE-P- antihemophilic factor/vwf
(human) for inj 1000-2400 unit
P
•
•
IDELVION- coagulation factor ix
(recomb) (rix-fp) for inj 250 unit
P
•
KOGENATE FS BIO-SETantihemophilic factor (recombinant)
for inj kit 2000 unit
P
•
IDELVION- coagulation factor ix
(recomb) (rix-fp) for inj 500 unit
P
•
P
•
•
KOGENATE FS BIO-SETantihemophilic factor (recombinant)
for inj kit 3000 unit
IDELVION- coagulation factor ix
(recomb) (rix-fp) for inj 1000 unit
P
IDELVION- coagulation factor ix
(recomb) (rix-fp) for inj 2000 unit
P
•
KOVALTRY- antihemophilic factor
(recombinant) for inj 250 unit
P
•
KOATE- antihemophilic factor (human) P
for inj 250 unit
KOATE- antihemophilic factor (human) P
for inj 500 unit
KOATE- antihemophilic factor (human) P
for inj 1000 unit
P
KOATE-DVI- antihemophilic factor
(human) for inj 250 unit
P
KOATE-DVI- antihemophilic factor
(human) for inj 500 unit
P
KOATE-DVI- antihemophilic factor
(human) for inj 1000 unit
KOGENATE FS- antihemophilic factor P
(recombinant) for inj kit 250 unit
KOGENATE FS- antihemophilic factor P
(recombinant) for inj kit 500 unit
KOGENATE FS- antihemophilic factor P
(recombinant) for inj kit 1000 unit
KOGENATE FS- antihemophilic factor P
(recombinant) for inj kit 2000 unit
KOGENATE FS- antihemophilic factor P
(recombinant) for inj kit 3000 unit
P
KOGENATE FS BIO-SETantihemophilic factor (recombinant)
for inj kit 250 unit
•
KOVALTRY- antihemophilic factor
(recombinant) for inj 500 unit
P
•
•
KOVALTRY- antihemophilic factor
(recombinant) for inj 1000 unit
P
•
•
KOVALTRY- antihemophilic factor
(recombinant) for inj 2000 unit
P
•
•
KOVALTRY- antihemophilic factor
(recombinant) for inj 3000 unit
P
•
•
MONOCLATE-P- antihemophilic factor
(human) for inj kit 1000 unit
P
•
•
MONOCLATE-P- antihemophilic factor
(human) for inj kit 1500 unit
P
•
•
MONONINE- coagulation factor ix for
inj 1000 unit
P
•
•
NOVOEIGHT- antihemophilic factor
(recombinant) for inj 250 unit
P
•
•
NOVOEIGHT- antihemophilic factor
(recombinant) for inj 500 unit
P
•
•
NOVOEIGHT- antihemophilic factor
(recombinant) for inj 1000 unit
P
•
•
NOVOEIGHT- antihemophilic factor
(recombinant) for inj 1500 unit
P
•
•
NOVOEIGHT- antihemophilic factor
(recombinant) for inj 2000 unit
P
•
NOVOEIGHT- antihemophilic factor
(recombinant) for inj 3000 unit
P
•
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
P
Step Therapy
KOGENATE FS BIO-SETantihemophilic factor (recombinant)
for inj kit 500 unit
Prior Authorization
P
Specialty
HUMATE-P- antihemophilic factor/vwf
(human) for inj 500-1200 unit
Drug Name
Tier Designation
•
Dispensing Limits
P
Step Therapy
HUMATE-P- antihemophilic factor/vwf
(human) for inj 250-600 unit
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
102
P
NOVOSEVEN RT- coagulation
factor viia (recomb) for inj 2 mg
(2000 mcg)
P
NOVOSEVEN RT- coagulation
factor viia (recomb) for inj 5 mg
(5000 mcg)
P
•
NOVOSEVEN RT- coagulation
factor viia (recomb) for inj 8 mg
(8000 mcg)
P
•
NUWIQ- antihemophilic factor (bddrfviii) for inj 250 unit
P
•
NUWIQ- antihemophilic factor (bddrfviii) for inj 500 unit
P
•
NUWIQ- antihemophilic factor (bddrfviii) for inj 1000 unit
P
•
NUWIQ- antihemophilic factor (bddrfviii) for inj 2000 unit
P
•
NUWIQ- antihemophilic factor (bddrfviii) for inj kit 250 unit
P
•
NUWIQ- antihemophilic factor (bddrfviii) for inj kit 500 unit
P
•
NUWIQ- antihemophilic factor (bddrfviii) for inj kit 1000 unit
P
•
NUWIQ- antihemophilic factor (bddrfviii) for inj kit 2000 unit
P
•
OBIZUR- antihemophilic factor
(recomb porc) rpfviii for inj 500 unit
P
•
pentoxifylline tab cr 400 mg
p
•
•
RECOMBINATE- antihemophilic factor
(recombinant) for inj 220-400 unit
P
•
RECOMBINATE- antihemophilic factor
(recombinant) for inj 401-800 unit
P
•
RECOMBINATE- antihemophilic factor
(recombinant) for inj 801-1240 unit
P
•
RECOMBINATE- antihemophilic factor
(recombinant) for inj 1241-1800 unit
P
•
RECOMBINATE- antihemophilic factor
(recombinant) for inj 1801-2400 unit
P
•
RIASTAP- fibrinogen conc (human) inj
approximately 1 gm (900-1300 mg)
P
RIXUBIS- coagulation factor ix
(recombinant) for inj 250 unit
P
•
RIXUBIS- coagulation factor ix
(recombinant) for inj 500 unit
P
•
RIXUBIS- coagulation factor ix
(recombinant) for inj 1000 unit
P
•
RIXUBIS- coagulation factor ix
(recombinant) for inj 2000 unit
P
•
RIXUBIS- coagulation factor ix
(recombinant) for inj 3000 unit
P
•
• •
RUCONEST- c1 esterase inhibitor
(recombinant) for iv inj 2100 unit
NP
TRETTEN- coagulation factor xiii asubunit for inj 2000-3125 unit
P
•
VONVENDI- von willebrand factor
(recombinant) for inj 650 unit
P
•
PROFILNINE- factor ix complex for inj
500 unit
P
•
VONVENDI- von willebrand factor
(recombinant) for inj 1300 unit
P
•
PROFILNINE- factor ix complex for inj
1000 unit
P
•
WILATE- antihemophilic factor/vwf
(human) for inj 500-500 unit kit
P
•
PROFILNINE- factor ix complex for inj
1500 unit
P
•
WILATE- antihemophilic factor/vwf
(human) for inj 1000-1000 unit kit
P
•
PROFILNINE SD- factor ix complex
for inj 500 unit
P
•
XYNTHA- antihemophilic factor
recombinant paf for inj kit 250 unit
P
•
PROFILNINE SD- factor ix complex
for inj 1000 unit
P
•
XYNTHA- antihemophilic factor
recombinant paf for inj kit 500 unit
P
•
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
P
Step Therapy
PROFILNINE SD- factor ix complex
for inj 1500 unit
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
•
NOVOSEVEN RT- coagulation
factor viia (recomb) for inj 1 mg
(1000 mcg)
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
•
103
P
•
XYNTHA SOLOFUSE- antihemophilic
factor recombinant paf for inj kit 500
unit
P
XYNTHA SOLOFUSE- antihemophilic
factor recombinant paf for inj kit
1000 unit
P
•
XYNTHA SOLOFUSE- antihemophilic
factor recombinant paf for inj kit
2000 unit
P
•
XYNTHA SOLOFUSE- antihemophilic
factor recombinant paf for inj kit
3000 unit
P
•
•
NP
AZASITE- azithromycin ophth soln 1% NC
np
azelastine hcl ophth soln 0.05%
AZOPT- brinzolamide ophth susp 1%
NC
BACITRACIN- bacitracin ophth oint
500 unit/gm
P
bacitracin-polymyxin b ophth oint
p
bacitracin-polymyxin-neomycin-hc
ophth oint 1%
np
BEPREVE- bepotastine besilate ophth NC
soln 1.5%
NC
BESIVANCE- besifloxacin hcl ophth
susp 0.6% (base equiv)
NC
BETADINE OPHTHALMIC PREPpovidone-iodine ophth soln 5%
np
betaxolol hcl ophth soln 0.5%
YOSPRALA- aspirin-omeprazole tab
delayed release 81-40 mg
NC
BETIMOL- timolol ophth soln 0.25%
NC
BETIMOL- timolol ophth soln 0.5%
NC
YOSPRALA- aspirin-omeprazole tab
delayed release 325-40 mg
NC
BETOPTIC-S- betaxolol hcl ophth
susp 0.25%
NC
ZONTIVITY- vorapaxar sulfate tab
2.08 mg (base equivalent)
NP
BIMATOPROST- bimatoprost ophth
soln 0.03%
NC
TOPICAL PRODUCTS
OPHTHALMIC AGENTS
ACUVAIL- ketorolac tromethamine
ophth soln 0.45%
NC
AKTEN- lidocaine hcl ophth gel 3.5%
NP
ALOCRIL- nedocromil sodium ophth
soln 2%
NC
ALOMIDE- lodoxamide tromethamine
ophth soln 0.1%
NC
ALPHAGAN P- brimonidine tartrate
ophth soln 0.1%
NC
ALREX- loteprednol etabonate ophth
susp 0.2%
P
apraclonidine hcl ophth soln 0.5%
(base equivalent) (Iopidine)
np
Dispensing Limits
XYNTHA SOLOFUSE- antihemophilic
factor recombinant paf for inj kit 250
unit
Step Therapy
•
Prior Authorization
P
ATROPINE SULFATE- atropine
sulfate ophth soln 1%
Specialty
XYNTHA- antihemophilic factor
recombinant paf for inj kit 2000 unit
Drug Name
Tier Designation
•
Dispensing Limits
P
Step Therapy
XYNTHA- antihemophilic factor
recombinant paf for inj kit 1000 unit
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
BLEPHAMIDE- sulfacetamide sodium- NC
prednisolone ophth susp 10-0.2%
BLEPHAMIDE S.O.P.- sulfacetamide NC
sodium-prednisolone ophth oint
10-0.2%
np
brimonidine tartrate ophth soln
0.15% (Alphagan p)
p
brimonidine tartrate ophth soln
0.2%
NP
BROMFENAC- bromfenac sodium
ophth soln 0.09% (base equivalent)
np
bromfenac sodium ophth soln
0.09% (base equiv) (once-daily)
BROMSITE- bromfenac sodium ophth NC
soln 0.075% (base equivalent)
p
carteolol hcl ophth soln 1%
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
104
CILOXAN- ciprofloxacin hcl ophth oint NC
0.3%
p
ciprofloxacin hcl ophth soln 0.3%
(Ciloxan)
NC
COMBIGAN- brimonidine tartratetimolol maleate ophth soln 0.2-0.5%
COSOPT PF- dorzolamide hcl-timolol NC
maleate ophth sol 22.3-6.8 mg/ml pf
p
cromolyn sodium ophth soln 4%
gentamicin sulfate ophth soln 0.3%
ILEVRO- nepafenac ophth susp 0.3%
NC
IOPIDINE- apraclonidine hcl ophth
soln 1% (base equivalent)
NC
cyclopentolate hcl ophth soln 0.5%
(Cyclogyl)
np
ISTALOL- timolol maleate ophth soln
0.5% (once-daily)
NC
p
ketorolac tromethamine ophth soln
0.4% (Acular ls)
np
np
ketorolac tromethamine ophth soln
0.5% (Acular)
CYSTARAN- cysteamine hcl ophth
soln 0.44% (base equivalent)
NP
DEXAMETHASONE SODIUM PHOSdexamethasone sodium phosphate
ophth soln 0.1%
P
diclofenac sodium ophth soln 0.1%
p
dorzolamide hcl ophth soln 2%
(Trusopt)
dorzolamide hcl-timolol maleate
ophth soln 22.3-6.8 mg/ml
(Cosopt)
p
p
•
LACRISERT- artificial tear ophth insert NP
NC
LASTACAFT- alcaftadine ophth soln
0.25%
p
latanoprost ophth soln 0.005%
(Xalatan)
p
levobunolol hcl ophth soln 0.5%
(Betagan)
np
levofloxacin ophth soln 0.5%
LOTEMAX- loteprednol etabonate
ophth gel 0.5%
P
P
DUREZOL- difluprednate ophth
emulsion 0.05%
NC
P
EMADINE- emedastine difumarate
ophth soln 0.05% (base equiv)
NC
LOTEMAX- loteprednol etabonate
ophth susp 0.5%
NC
epinastine hcl ophth soln 0.05%
(Elestat)
NC
LUMIGAN- bimatoprost ophth soln
0.01%
NP
p
MAXIDEX- dexamethasone ophth
susp 0.1%
FLAREX- fluorometholone acetate
ophth susp 0.1%
NP
METIPRANOLOL- metipranolol ophth
soln 0.3%
NP
fluorometholone ophth susp 0.1%
(Fml liquifilm)
np
MITOSOL- mitomycin for ophth soln
kit 0.2 mg
NC
p
MOXEZA- moxifloxacin hcl ophth soln NC
0.5% (base eq) (2 times daily)
flurbiprofen sodium ophth soln
0.03% (Ocufen)
Dispensing Limits
p
LOTEMAX- loteprednol etabonate
ophth oint 0.5%
erythromycin ophth oint 5 mg/gm
Step Therapy
p
NP
cyclopentolate hcl ophth soln 2%
(Cyclogyl)
Prior Authorization
FML- fluorometholone ophth oint 0.1% NC
FML FORTE- fluorometholone ophth NC
susp 0.25%
np
gatifloxacin ophth soln 0.5%
(Zymaxid)
p
gentamicin sulfate ophth oint 0.3%
CYCLOMYDRIL- cyclopentolate w/
phenylephrine ophth soln 0.2-1%
cyclopentolate hcl ophth soln 1%
(Cyclogyl)
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
•
105
NATACYN- natamycin ophth susp 5%
P
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml
(Neosporin)
neomycin-polymyxindexamethasone ophth oint 0.1%
(Maxitrol)
neomycin-polymyxindexamethasone ophth susp 0.1%
(Maxitrol)
NP
np
PRED-G S.O.P.- gentamicinprednisolone ace ophth oint
0.3-0.6%
np
prednisolone acetate ophth susp
1% (Pred forte)
np
p
PREDNISOLONE SODIUM PHOSPprednisolone sodium phosphate
ophth soln 1%
p
PROLENSA- bromfenac sodium ophth NC
soln 0.07% (base equivalent)
np
proparacaine hcl ophth soln 0.5%
NC
NEOMYCIN/POLYMYXIN/HYDROCneomycin-polymyxin-hc ophth susp
RESCULA- unoprostone isopropyl
ophth soln 0.15%
RESTASIS- cyclosporine (ophth)
emulsion 0.05%
NC
NEVANAC- nepafenac ophth susp
0.1%
NC
olopatadine hcl ophth soln 0.1%
(base equivalent) (Patanol)
p
NC
PATADAY- olopatadine hcl ophth soln
0.2% (base equivalent)
NC
PAZEO- olopatadine hcl ophth soln
0.7% (base equivalent)
NC
phenylephrine hcl ophth soln 2.5%
np
phenylephrine hcl ophth soln 10%
np
PHOSPHOLINE IODIDEechothiophate iodide ophth for soln
0.125%
NC
pilocarpine hcl ophth soln 1%
(Isopto carpine)
np
pilocarpine hcl ophth soln 2%
(Isopto carpine)
pilocarpine hcl ophth soln 4%
(Isopto carpine)
polymyxin b-trimethoprim ophth
soln 10000 unit/ml-0.1% (Polytrim)
np
np
p
PRED MILD- prednisolone acetate
ophth susp 0.12%
NC
PRED-G- gentamicin-prednisolone
ace ophth susp 0.3-1%
NP
Dispensing Limits
Step Therapy
Prior Authorization
NP
NC
ofloxacin ophth soln 0.3% (Ocuflox)
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
RESTASIS MULTIDOSE- cyclosporine NC
(ophth) emulsion 0.05%
P
SIMBRINZA- brinzolamidebrimonidine tartrate ophth susp
1-0.2%
NP
SULFACETAMIDE SODIUMsulfacetamide sodium ophth oint
10%
np
sulfacetamide sodium ophth soln
10% (Bleph-10)
p
sulfacetamide sodiumprednisolone ophth soln
10-0.23(0.25)%
p
tetracaine hcl ophth soln 0.5%
timolol maleate ophth gel forming
soln 0.25% (Timoptic-xe)
timolol maleate ophth gel forming
soln 0.5% (Timoptic-xe)
timolol maleate ophth soln 0.25%
(Timoptic)
timolol maleate ophth soln 0.5%
(Timoptic)
np
np
p
p
NC
TIMOPTIC OCUDOSE- timolol
maleate preservative free ophth soln
0.25%
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
106
NC
TIMOPTIC OCUDOSE- timolol
maleate preservative free ophth soln
0.5%
NP
TOBRADEX- tobramycindexamethasone ophth oint 0.3-0.1%
NC
TOBRADEX ST- tobramycindexamethasone ophth susp
0.3-0.05%
p
tobramycin ophth soln 0.3%
(Tobrex)
np
tobramycin-dexamethasone ophth
susp 0.3-0.1% (Tobradex)
TOBREX- tobramycin ophth oint 0.3% NP
TRAVATAN Z- travoprost ophth soln
0.004% (benzalkonium free) (bak
free)
NC
trifluridine ophth soln 1% (Viroptic)
np
VIGAMOX- moxifloxacin hcl ophth
soln 0.5% (base equiv)
NC
XIIDRA- lifitegrast ophth soln 5%
NC
ZIOPTAN- tafluprost ophth soln
0.0015%
NC
ZIRGAN- ganciclovir ophth gel 0.15%
NC
ZYLET- loteprednol etabonatetobramycin ophth susp 0.5-0.3%
NC
OTIC AGENTS
acetic acid otic soln 2%
ACETIC ACID/ALUMINUM ACETacetic acid 2% in aluminum acetate
otic soln
np
NP
CETRAXAL- ciprofloxacin hcl otic soln NP
0.2% (base equivalent)
NP
CIPRO HC- ciprofloxacinhydrocortisone otic susp 0.2-1%
NP
CIPRODEX- ciprofloxacindexamethasone otic susp 0.3-0.1%
NP
CIPROFLOXACIN- ciprofloxacin hcl
otic soln 0.2% (base equivalent)
NP
COLY-MYCIN S- neomycincolistin-hc-thonzonium otic susp
3.3-3-10-0.5 mg/ml
fluocinolone acetonide (otic) oil
0.01% (Dermotic)
hydrocortisone w/ acetic acid otic
soln 1-2%
neomycin-polymyxin-hc otic soln
1%
neomycin-polymyxin-hc otic susp
3.5 mg/ml-10000 unit/ml-1%
ofloxacin otic soln 0.3% (Floxin
otic)
OTOVEL- ciprofloxacin-fluocinolone
aceton (pf) otic soln 0.3-0.025%
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
np
np
np
np
np
NC
MOUTH/THROAT/DENTAL AGENTS
ARESTIN- minocycline hcl subgingival NC
powder cartridge 1 mg
cevimeline hcl cap 30 mg (Evoxac) np
chlorhexidine gluconate soln 0.12%
(Peridex)
clotrimazole troche 10 mg
p
np
LIDOCAINE HCL- lidocaine hcl
laryngotracheal soln 4%
NP
lidocaine hcl viscous soln 2%
p
NAFRINSE DAILY/ACIDULATEDsodium fluoride-phosphoric acid for
soln 1 mg/5ml (f equiv)
NP
NAFRINSE DAILY/NEUTRAL- sodium NP
fluoride for soln rinse 0.05%
NAFRINSE WEEKLY- sodium fluoride NP
for soln rinse 0.2%
np
nystatin susp 100000 unit/ml
ORAVIG- miconazole buccal tab
50 mg (mouth-throat)
NP
pilocarpine hcl tab 5 mg (Salagen)
np
pilocarpine hcl tab 7.5 mg (Salagen) np
p
sodium fluoride cream 1.1%
(Prevident 5000 plus)
p
sodium fluoride gel 1.1% (0.5% f)
(Prevident fluoride)
p
sodium fluoride paste 1.1%
(Prevident 5000 boost)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
107
sodium fluoride-potassium nitrate
paste 1.1-5% (Prevident 5000
sensi)
stannous fluoride conc 0.63% (Gelkam oral care ri)
stannous fluoride gel 0.4%
triamcinolone acetonide dental
paste 0.1%
ANORECTAL AGENTS
ANALPRAM-HC- hydrocortisone
acetate w/ pramoxine rectal lotn
2.5-1%
p
p
acitretin cap 25 mg (Soriatane)
NC
np
ADAPALENE- adapalene lotion 0.1%
NC
np
adapalene cream 0.1% (Differin)
np
NP
hydrocortisone acetate w/
pramoxine rectal cream 1-1%
(Analpram-hc)
np
hydrocortisone enema 100 mg/60ml np
(Cortenema)
np
hydrocortisone rectal cream 1%
(Proctocort)
np
hydrocortisone rectal cream 2.5%
(Anusol-hc)
NP
PROCTOFOAM HC- hydrocortisone
acetate w/ pramoxine rectal foam
1-1%
NP
RECTIV- nitroglycerin oint 0.4%
NP
ABSORICA- isotretinoin cap 10 mg
NC
ABSORICA- isotretinoin cap 20 mg
NC
ABSORICA- isotretinoin cap 25 mg
NC
ABSORICA- isotretinoin cap 30 mg
NC
ABSORICA- isotretinoin cap 35 mg
NC
ABSORICA- isotretinoin cap 40 mg
NC
ACANYA- clindamycin phosphatebenzoyl peroxide gel 1.2-2.5%
NC
acitretin cap 10 mg (Soriatane)
np
alclometasone dipropionate cream
0.05%
alclometasone dipropionate oint
0.05%
np
np
AMCINONIDE- amcinonide cream
0.1%
NC
AMCINONIDE- amcinonide lotion
0.1%
NC
AMCINONIDE- amcinonide oint 0.1%
NC
AMELUZ- aminolevulinic acid hcl gel
10%
NC
APEXICON E- diflorasone diacetate
emollient base cream 0.05%
NC
AZELEX- azelaic acid cream 20%
NC
benzoyl peroxide-erythromycin gel
5-3% (Benzamycin)
NC
betamethasone dipropionate
augmented lotion 0.05%
(Diprolene)
Dispensing Limits
np
NC
betamethasone dipropionate
augmented gel 0.05%
•
•
•
np
ALTABAX- retapamulin oint 1%
betamethasone dipropionate
augmented cream 0.05%
(Diprolene af)
Step Therapy
NC
ACZONE- dapsone gel 7.5%
adapalene gel 0.3% (Differin)
Prior Authorization
np
NC
adapalene gel 0.1% (Differin)
Specialty
Dispensing Limits
Step Therapy
Prior Authorization
np
ACZONE- dapsone gel 5%
p
CORTIFOAM- hydrocortisone acetate
rectal foam 10% (90 mg/dose)
DERMATOLOGICALS
acitretin cap 17.5 mg (Soriatane)
acyclovir oint 5% (Zovirax)
P
UCERIS- budesonide rectal foam
2 mg/act
Drug Name
Tier Designation
sodium fluoride rinse 0.2%
Specialty
Drug Name
Tier Designation
2017
np
np
np
np
betamethasone dipropionate
augmented oint 0.05% (Diprolene)
betamethasone dipropionate cream np
0.05%
betamethasone dipropionate lotion np
0.05%
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
108
betamethasone dipropionate oint
0.05%
betamethasone valerate aerosol
foam 0.12% (Luxiq)
betamethasone valerate cream
0.1%
np
clindamycin phosphate lotion 1%
(Cleocin-t)
np
clindamycin phosphate soln 1%
(Cleocin-t)
np
clindamycin phosphate swab 1%
(Cleocin-t)
betamethasone valerate lotion 0.1% np
np
betamethasone valerate oint 0.1%
calcipotriene cream 0.005%
(Dovonex)
calcipotriene oint 0.005%
calcipotriene soln 0.005% (50 mcg/
ml)
calcipotriene-betamethasone
dipropionate oint 0.005-0.064%
(Taclonex)
clindamycin phosphatetretinoin gel 1.2-0.025% (Ziana)
np
clobetasol propionate cream 0.05%
(Temovate)
np
CAPEX- fluocinolone acetonide
shampoo 0.01%
NC
CARAC- fluorouracil cream 0.5%
NC
CENTANY- mupirocin oint 2%
NC
ciclopirox gel 0.77%
np
ciclopirox shampoo 1% (Loprox
shampoo)
ciclopirox solution 8% (Penlac Nail
Lacquer)
clobetasol propionate foam 0.05%
(Olux)
clobetasol propionate gel 0.05%
(Temovate)
clobetasol propionate lotion 0.05%
(Clobex)
clobetasol propionate oint 0.05%
(Temovate)
np
clobetasol propionate shampoo
0.05% (Clobex)
np
clobetasol propionate soln 0.05%
(Temovate)
np
CLINDAGEL- clindamycin
phosphate gel 1%
clindamycin phosph-benzoyl
peroxide (refrig) gel 1.2 (1)-5%
(Duac)
np
clindamycin phosphate gel 1%
(Cleocin-t)
clobetasol propionate emulsion
foam 0.05% (Olux-e)
p
NP
clindamycin phosphate foam 1%
(Evoclin)
clobetasol propionate emollient
base cream 0.05%
NC
NC
ciclopirox olamine susp 0.77%
(base equiv) (Loprox)
clindamycin phosphate-benzoyl
peroxide gel 1-5% (Benzaclin)
np
CALCITRIOL- calcitriol oint 3 mcg/gm
ciclopirox olamine cream 0.77%
(base equiv) (Loprox)
NC
np
•
•
•
clobetasol propionate spray 0.05%
(Clobex)
Dispensing Limits
Step Therapy
np
np
np
NC
np
np
NC
NC
np
np
np
np
np
NC
NC
CLOCORTOLONE PIVALATE PUMclocortolone pivalate cream 0.1%
NC
CLODERM- clocortolone pivalate
cream 0.1%
NC
CLODERM PUMP- clocortolone
pivalate cream 0.1%
NC
clotrimazole cream 1%
NC
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Prior Authorization
np
CLOCORTOLONE PIVALATEclocortolone pivalate cream 0.1%
clotrimazole soln 1%
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
NC
109
np
DIFLORASONE DIACETATEdiflorasone diacetate cream 0.05%
NC
np
DOXEPIN HYDROCHLORIDEdoxepin hcl cream 5%
NP
CONDYLOX- podofilox gel 0.5%
NP
NC
CORDRAN- flurandrenolide tape
4 mcg/sqcm
NC
DOXYCYCLINE- doxycycline
(rosacea) cap delayed release
40 mg
econazole nitrate cream 1%
np
clotrimazole w/ betamethasone
cream 1-0.05% (Lotrisone)
clotrimazole w/ betamethasone
lotion 1-0.05%
CORTISPORIN- neomycin-polymyxin- NC
hc crm 3.5 mg/gm-10000 unt/
gm-0.5%
CORTISPORIN- bacitracin-polymyxin- NC
neomycin hc oint 1%
NP
COSENTYX- secukinumab
subcutaneous soln prefilled syringe
150 mg/ml
NP
COSENTYX SENSOREADY PENsecukinumab subcutaneous soln
auto-injector 150 mg/ml
NC
DENAVIR- penciclovir cream 1%
• •
• •
•
•
ECOZA- econazole nitrate foam 1%
NC
ELIDEL- pimecrolimus cream 1%
NC
ENSTILAR- calcipotrienebetamethasone dipropionate foam
0.005-0.064%
EPIDUO- adapalene-benzoyl
peroxide gel 0.1-2.5%
NC
EPIDUO FORTE- adapalene-benzoyl
peroxide gel 0.3-2.5%
NC
EPIFOAM- pramoxine-hc aerosol
foam 1-1%
NC
NC
ERTACZO- sertaconazole nitrate
cream 2%
NC
desonide cream 0.05% (Desowen)
np
np
erythromycin gel 2% (Erygel)
np
desonide oint 0.05%
np
DESOXIMETASONEdesoximetasone cream 0.05%
NC
desoximetasone cream 0.25%
(Topicort)
np
desoximetasone gel 0.05%
(Topicort)
desoximetasone oint 0.05%
(Topicort)
desoximetasone oint 0.25%
(Topicort)
diclofenac sodium (actinic
keratoses) gel 3% (Solaraze)
erythromycin pads 2%
erythromycin soln 2%
np
NC
np
np
diclofenac sodium gel 1% (Voltaren) np
np
diclofenac sodium soln 1.5%
DIFFERIN- adapalene lotion 0.1%
NC
DIFLORASONE DIACETATEdiflorasone diacetate oint 0.05%
NC
•
• •
• •
Dispensing Limits
Step Therapy
np
np
EUCRISA- crisaborole oint 2%
NC
EURAX- crotamiton cream 10%
NP
EURAX- crotamiton lotion 10%
NP
EXELDERM- sulconazole nitrate
solution 1%
NC
EXELDERM- sulconazole nitrate
cream 1%
NC
FABIOR- tazarotene (acne) foam
0.1%
NC
FINACEA- azelaic acid foam 15%
P
FINACEA- azelaic acid gel 15%
P
FLECTOR- diclofenac epolamine
patch 1.3%
NC
fluocinolone acetonide cream
0.01%
np
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Prior Authorization
P
DESONATE- desonide gel 0.05%
desonide lotion 0.05% (Desowen)
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
110
fluocinolone acetonide cream
0.025% (Synalar)
fluocinolone acetonide oil 0.01%
(body oil) (Derma-smoothe/fs
bod)
fluocinolone acetonide oil 0.01%
(scalp oil) (Derma-smoothe/fs
sca)
fluocinolone acetonide oint 0.025%
(Synalar)
fluocinolone acetonide soln 0.01%
(Synalar)
fluocinonide cream 0.05%
fluocinonide cream 0.1% (Vanos)
np
halobetasol propionate cream
0.05% (Ultravate)
np
halobetasol propionate oint 0.05%
(Ultravate)
np
np
np
NC
fluocinonide soln 0.05%
fluorouracil soln 2%
fluorouracil soln 5%
flurandrenolide cream 0.05%
(Cordran)
flurandrenolide lotion 0.05%
(Cordran)
flurandrenolide oint 0.05%
(Cordran)
np
np
NC
NC
NC
fluticasone propionate cream 0.05% np
(Cutivate)
fluticasone propionate lotion 0.05% NC
(Cutivate)
fluticasone propionate oint 0.005% np
NC
hydrocortisone butyrate cream
0.1% (Locoid)
np
hydrocortisone cream 1%
hydrocortisone cream 2.5%
hydrocortisone lotion 2.5%
np
FLUOROPLEX- fluorouracil cream 1% NC
FLUOROURACIL- fluorouracil cream NC
0.5%
np
fluorouracil cream 5% (Efudex)
HALOG- halcinonide oint 0.1%
hydrocortisone butyrate soln 0.1%
(Locoid)
np
hydrocortisone oint 1%
hydrocortisone oint 2.5%
•
hydrocortisone valerate cream
0.2%
hydrocortisone valerate oint 0.2%
(Westcort)
imiquimod cream 5% (Aldara)
isotretinoin cap 10 mg
isotretinoin cap 20 mg
isotretinoin cap 30 mg
isotretinoin cap 40 mg
NC
p
p
NC
p
np
np
np
np
np
np
ketoconazole cream 2%
np
GENTAMICIN SULFATE- gentamicin
sulfate oint 0.1%
gentamicin sulfate cream 0.1%
np
lactic acid (ammonium lactate)
lotion 12% (Lac-hydrin)
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
•
np
NC
lactic acid (ammonium lactate)
cream 12% (Lac-hydrin)
Dispensing Limits
np
KERYDIN- tavaborole soln 5%
NC
Step Therapy
np
NC
ketoconazole shampoo 2% (Nizoral)
Prior Authorization
NC
JUBLIA- efinaconazole soln 10%
ketoconazole foam 2% (Extina)
Specialty
np
NC
hydrocortisone butyrate oint 0.1%
(Locoid)
np
np
HALOG- halcinonide cream 0.1%
hydrocortisone butyrate
hydrophilic lipo base cream 0.1%
(Locoid lipocream)
fluocinonide emulsified base cream np
0.05%
np
fluocinonide gel 0.05%
fluocinonide oint 0.05%
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
NC
p
NC
NC
111
LEVULAN KERASTICKaminolevulinic acid hcl for soln 20%
(stick applicator)
NC
NATROBA- spinosad susp 0.9%
NP
NC
lidocaine hcl gel 2%
NC
NEO-SYNALAR- neomycin sulfatefluocinolone acetonide cream
0.5-0.025%
NORITATE- metronidazole cream 1%
NC
lidocaine hcl soln 4% (Xylocaine)
lidocaine oint 5%
lidocaine patch 5% (Lidoderm)
p
NC
np
lidocaine-prilocaine cream 2.5-2.5% np
NP
LINDANE- lindane shampoo 1%
•
•
nystatin cream 100000 unit/gm
nystatin oint 100000 unit/gm
nystatin topical powder 100000
unit/gm
LOCOID- hydrocortisone butyrate
lotion 0.1%
NC
nystatin-triamcinolone cream
100000-0.1 unit/gm-%
LUZU- luliconazole cream 1%
NC
malathion lotion 0.5% (Ovide)
np
nystatin-triamcinolone oint
100000-0.1 unit/gm-%
MENTAX- butenafine hcl cream 1%
NC
methoxsalen rapid cap 10 mg
(Oxsoralen ultra)
np
metronidazole cream 0.75%
(Metrocream)
metronidazole gel 0.75%
np
np
NC
NC
ONEXTON- clindamycin phosphatebenzoyl peroxide gel 1.2-3.75%
NC
ORACEA- doxycycline (rosacea) cap
delayed release 40 mg
NC
oxiconazole nitrate cream 1%
(Oxistat)
np
PANDEL- hydrocortisone probutate
cream 0.1%
NC
MICORT-HC- hydrocortisone acetate
cream 2.5%
NC
PANRETIN- alitretinoin gel 0.1%
NC
NP
PENNSAID- diclofenac sodium soln
2%
NC
MIRVASO- brimonidine tartrate gel
0.33% (base equivalent)
permethrin cream 5% (Elimite)
np
mometasone furoate cream 0.1%
(Elocon)
p
mometasone furoate oint 0.1%
(Elocon)
mometasone furoate solution 0.1%
(lotion) (Elocon)
mupirocin calcium cream 2%
(Bactroban)
mupirocin oint 2%
naftifine hcl cream 1%
naftifine hcl cream 2% (Naftin)
p
p
np
p
NC
NC
NAFTIN- naftifine hcl gel 1%
NC
NAFTIN- naftifine hcl gel 2%
NC
Dispensing Limits
np
np
metronidazole lotion 0.75%
(Metrolotion)
Step Therapy
np
NC
metronidazole gel 1% (Metrogel)
Prior Authorization
p
OXISTAT- oxiconazole nitrate lotion
1%
np
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
PICATO- ingenol mebutate gel
0.015%
NC
PICATO- ingenol mebutate gel 0.05%
NC
PLIAGLIS- lidocaine-tetracaine cream NC
7-7%
np
podofilox soln 0.5% (Condylox)
PRAMOSONE- pramoxine-hc cream
1-1%
NC
PRAMOSONE- pramoxine-hc lotion
1-1%
NC
PRAMOSONE- pramoxine-hc lotion
1-2.5%
NC
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
112
prednicarbate cream 0.1%
(Dermatop)
np
prednicarbate oint 0.1% (Dermatop) np
NP
PRUDOXIN- doxepin hcl cream 5%
PSORCON- diflorasone diacetate
cream 0.05%
NC
REGRANEX- becaplermin gel 0.01%
NP
RETIN-A MICRO PUMP- tretinoin
microsphere gel 0.08%
NC
SANTYL- collagenase oint 250 unit/
gm
NP
selenium sulfide lotion 2.5%
SERNIVO- betamethasone
dipropionate spray emulsion 0.05%
(base equiv)
silver sulfadiazine cream 1%
(Silvadene)
SKLICE- ivermectin lotion 0.5%
SOOLANTRA- ivermectin cream 1%
p
NC
p
NP
P
SORILUX- calcipotriene foam 0.005% NC
NP
SPINOSAD- spinosad susp 0.9%
TALTZ- ixekizumab subcutaneous
soln prefilled syringe 80 mg/ml
NC
TARGRETIN- bexarotene gel 1%
NC
tazarotene cream 0.1% (Tazorac)
np
TAZORAC- tazarotene cream 0.05%
P
TAZORAC- tazarotene cream 0.1%
P
TAZORAC- tazarotene gel 0.05%
P
TAZORAC- tazarotene gel 0.1%
P
TEXACORT- hydrocortisone soln
2.5%
NC
TOLAK- fluorouracil cream 4%
NC
TOPICORT- desoximetasone spray
0.25%
NC
TOPICORT- desoximetasone oint
0.05%
NC
TOPICORT- desoximetasone cream
0.05%
NC
TRETIN-X- tretinoin cream 0.075%
NC
tretinoin cream 0.025% (Retin-a)
np
tretinoin cream 0.05% (Retin-a)
STELARA- ustekinumab inj
45 mg/0.5ml
P
• •
•
tretinoin cream 0.1% (Retin-a)
STELARA- ustekinumab soln prefilled
syringe 45 mg/0.5ml
P
• •
•
tretinoin gel 0.025% (Retin-a)
STELARA- ustekinumab soln prefilled
syringe 90 mg/ml
P
• •
•
sulfacetamide sodium lotion 10%
(acne) (Klaron)
np
SULFAMYLON- mafenide acetate
cream 85 mg/gm
NP
SYNERA- lidocaine-tetracaine topical
patch 70-70 mg
NC
TACLONEX- calcipotrienebetamethasone dipropionate susp
0.005-0.064%
NC
tacrolimus oint 0.03% (Protopic)
np
tacrolimus oint 0.1% (Protopic)
TALTZ- ixekizumab subcutaneous
soln auto-injector 80 mg/ml
np
NC
tretinoin gel 0.01% (Retin-a)
tretinoin gel 0.05% (Atralin)
tretinoin microsphere gel 0.04%
(Retin-a micro)
tretinoin microsphere gel 0.1%
(Retin-a micro)
triamcinolone acetonide aerosol
soln 0.147 mg/gm (Kenalog)
triamcinolone acetonide cream
0.025%
triamcinolone acetonide cream
0.1%
•
•
triamcinolone acetonide cream
0.5%
triamcinolone acetonide lotion
0.025%
np
np
np
np
np
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
•
•
•
•
•
•
NC
NC
np
p
p
p
np
triamcinolone acetonide lotion 0.1% np
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
113
triamcinolone acetonide oint
0.025%
triamcinolone acetonide oint 0.1%
triamcinolone acetonide oint 0.5%
p
p
NC
ULESFIA- benzyl alcohol lotion 5%
NP
ULTRAVATE- halobetasol propionate
lotion 0.05%
NC
VALCHLOR- mechlorethamine hcl gel
0.016% (base equivalent)
P
•
FERRIPROX- deferiprone oral soln
100 mg/ml
NP
JADENU- deferasirox tab 90 mg
NP
JADENU- deferasirox tab 180 mg
NP
VECTICAL- calcitriol oint 3 mcg/gm
NC
JADENU- deferasirox tab 360 mg
NP
VELTIN- clindamycin phosphatetretinoin gel 1.2-0.025%
NC
NALOXONE HCL- naloxone hcl soln
cartridge 0.4 mg/ml
NP
VERDESO- desonide foam 0.05%
NC
NP
VEREGEN- sinecatechins oint 15%
NP
NALOXONE HCL- naloxone hcl soln
prefilled syringe 2 mg/2ml
naloxone hcl inj 0.4 mg/ml
np
VUSION- miconazole-zinc oxide-white NC
petrolatum oint 0.25-15-81.35%
NC
XERESE- acyclovir-hydrocortisone
cream 5-1%
NC
XOLEGEL- ketoconazole gel 2%
ZONALON- doxepin hcl cream 5%
NP
ZOVIRAX- acyclovir cream 5%
NC
ZYCLARA- imiquimod cream 3.75%
NC
ZYCLARA PUMP- imiquimod cream
2.5%
NC
ZYCLARA PUMP- imiquimod cream
3.75%
NC
MISCELLANEOUS PRODUCTS
ANTIDOTES
naloxone hcl inj 4 mg/10ml
naltrexone hcl tab 50 mg
NARCAN- naloxone hcl nasal spray
4 mg/0.1ml
NP
VISTOGARD- uridine triacetate
oral granules packet 10 gm
NC
ACCU-CHEK AVIVA PLUS- glucose
blood test strip
NC
ACCU-CHEK COMPACT
PLUS- glucose blood test strip
NC
ACCU-CHEK COMPACT
STRIPS- glucose blood test strip
NC
CETYLEV- acetylcysteine
effervescent tab 2.5 gm
NP
ACCU-CHEK COMPACT TEST
DR- glucose blood test strip
NC
ACCU-CHEK GUIDE- glucose blood
test strip
NC
ACCU-CHEK SMARTVIEW
STRIP- glucose blood test strip
NC
ACCUTREND GLUCOSE- glucose
blood test strip
NC
EVZIO- naloxone hcl solution autoinjector 0.4 mg/0.4ml
NC
EVZIO- naloxone hcl solution autoinjector 2 mg/0.4ml
NC
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
Step Therapy
Prior Authorization
•
•
•
•
•
•
P
NP
P
•
np
CETYLEV- acetylcysteine
effervescent tab 500 mg
CHEMET- succimer cap 100 mg
•
np
RADIOGARDASE- prussian blue
insoluble cap 0.5 gm
DIAGNOSTIC PRODUCTS
Specialty
Tier Designation
Dispensing Limits
Step Therapy
Drug Name
EXJADE- deferasirox tab for oral susp NP
125 mg
EXJADE- deferasirox tab for oral susp NP
250 mg
EXJADE- deferasirox tab for oral susp NP
500 mg
FERRIPROX- deferiprone tab 500 mg NP
p
TRIANEX- triamcinolone acetonide
oint 0.05%
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
114
ADVANCE INTUITION TEST
ST- glucose blood test strip
NC
BIOSCANNER GLUCOSE TEST
S- glucose blood test strip
NC
ADVANCE MICRO-DRAW TEST
S- glucose blood test strip
NC
BLOOD GLUCOSE TEST
STRIPS- glucose blood test strip
NC
ADVOCATE REDI-CODE- glucose
blood test strip
NC
CAREONE BLOOD GLUCOSE
TES- glucose blood test strip
NC
ADVOCATE REDI-CODE+
TEST- glucose blood test strip
NC
CARESENS N BLOOD
GLUCOSE- glucose blood test strip
NC
ADVOCATE TEST STRIPS- glucose
blood test strip
NC
CLEVER CHEK AUTO-CODE
TES- glucose blood test strip
NC
AGAMATRIX AMP NO CODE
TES- glucose blood test strip
NC
CLEVER CHEK AUTO-CODE
VOI- glucose blood test strip
NC
AGAMATRIX JAZZ TEST
STRIP- glucose blood test strip
NC
CLEVER CHEK TEST
STRIPS- glucose blood test strip
NC
AGAMATRIX KEYNOTE TEST
ST- glucose blood test strip
NC
CLEVER CHOICE AUTO-CODE
P- glucose blood test strip
NC
AGAMATRIX PRESTO TEST
STR- glucose blood test strip
NC
CLEVER CHOICE MICRO
TEST- glucose blood test strip
NC
ASSURE II- glucose blood test strip
NC
NC
ASSURE II CHECK STRIP- glucose
blood test strip
NC
COOL BLOOD GLUCOSE TEST
S- glucose blood test strip
NC
ASSURE II TEST STRIPS- glucose
blood test strip
NC
CVS ADVANCED GLUCOSE
METE- glucose blood test strip
NC
ASSURE PLATINUM TEST
STRI- glucose blood test strip
NC
DIATRUE PLUS BLOOD
GLUCOS- glucose blood test strip
NC
ASSURE PRISM MULTI TEST
S- glucose blood test strip
NC
DUO-CARE TEST STRIPS- glucose
blood test strip
NC
ASSURE PRO TEST
STRIPS- glucose blood test strip
NC
EASY PLUS BLOOD GLUCOSE
T- glucose blood test strip
NC
ASSURE 3 TEST STRIPS- glucose
blood test strip
NC
EASY PLUS II BLOOD
GLUCOS- glucose blood test strip
NC
ASSURE 4 TEST STRIPS- glucose
blood test strip
NC
EASY STEP TEST STRIPS- glucose
blood test strip
NC
AT LAST TEST STRIPS- glucose
blood test strip
NC
EASY TALK BLOOD GLUCOSE
T- glucose blood test strip
NC
BAYER BREEZE 2 TEST
DISC- glucose blood test disk
P
EASY TOUCH GLUCOSE TEST
S- glucose blood test strip
NC
BAYER CONTOUR BLOOD
GLUCO- glucose blood test strip
P
EASY TOUCH HEALTHPRO
GLUC- glucose blood test strip
NC
BAYER CONTOUR NEXT
BLOOD- glucose blood test strip
P
EASY TRAK BLOOD GLUCOSE
T- glucose blood test strip
•
•
•
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
EASYGLUCO- glucose blood test strip NC
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
115
EASYGLUCO PLUS- glucose blood
test strip
NC
EZ SMART BLOOD GLUCOSE
TE- glucose blood test strip
NC
EASYMAX TEST STRIPS- glucose
blood test strip
NC
EZ SMART PLUS BLOOD
GLUCO- glucose blood test strip
NC
FIFTY50 GLUCOSE TEST
STRI- glucose blood test strip
NC
FORA BLOOD GLUCOSE TEST
S- glucose blood test strip
NC
FORA D15G BLOOD GLUCOSE
T- glucose blood test strip
NC
FORA D20 BLOOD GLUCOSE
TE- glucose blood test strip
NC
FORA D40/G31 BLOOD
GLUCOS- glucose blood test strip
NC
FORA GD20 TEST STRIPS- glucose
blood test strip
NC
FORA GD50 BLOOD GLUCOSE
T- glucose blood test strip
NC
FORA G20 BLOOD GLUCOSE
TE- glucose blood test strip
NC
FORA G30A BLOOD GLUCOSE
T- glucose blood test strip
NC
FORA TN'G/TN'G VOICE
BLOO- glucose blood test strip
NC
FORA V10 BLOOD GLUCOSE
TE- glucose blood test strip
NC
FORA V12 BLOOD GLUCOSE
TE- glucose blood test strip
NC
FORA V20 BLOOD GLUCOSE
TE- glucose blood test strip
NC
FORA V30A BLOOD GLUCOSE
T- glucose blood test strip
NC
FORACARE GD40- glucose blood
test strip
NC
FORACARE PREMIUM V10
TEST- glucose blood test strip
NC
FORACARE TEST N GO TEST
S- glucose blood test strip
NC
FORTISCARE BLOOD
GLUCOSE- glucose blood test strip
NC
EASYMAX 15 TEST STRIPS- glucose NC
blood test strip
NC
EASYPLUS BLOOD GLUCOSE
TE- glucose blood test strip
NC
EASYPRO BLOOD GLUCOSE
TES- glucose blood test strip
EASYPRO PLUS- glucose blood test NC
strip
NC
ELEMENT COMPACT TEST
STRI- glucose blood test strip
NC
ELEMENT TEST STRIPS- glucose
blood test strip
NC
EMBRACE BLOOD GLUCOSE
TES- glucose blood test strip
NC
EMBRACE EVO BLOOD
GLUCOSE- glucose blood test strip
NC
EMBRACE PRO BLOOD
GLUCOSE- glucose blood test strip
NC
EQ BLOOD GLUCOSE TEST
STR- glucose blood test strip
NC
EVENCARE + BLOOD
GLUCOSE- glucose blood test strip
NC
EVENCARE BLOOD GLUCOSE
TE- glucose blood test strip
NC
EVENCARE G2 TEST
STRIPS- glucose blood test strip
NC
EVENCARE G3 TEST
STRIPS- glucose blood test strip
NC
EVENCARE MINI BLOOD
GLUCO- glucose blood test strip
NC
EVOLUTION AUTOCODE- glucose
blood test strip
NC
EXACTECH R-S-G TEST
STRIP- glucose blood test strip
EXACTECH TEST STRIPS- glucose NC
blood test strip
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
116
FREESTYLE INSULINX
BLOOD- glucose blood test strip
NC
INFINITY BLOOD GLUCOSE
TE- glucose blood test strip
NC
FREESTYLE LITE TEST
STRIP- glucose blood test strip
NC
KROGER BLOOD GLUCOSE
TEST- glucose blood test strip
NC
FREESTYLE PRECISION NEO
B- glucose blood test strip
NC
KROGER PREMIUM BLOOD
GLUC- glucose blood test strip
NC
FREESTYLE TEST STRIPS- glucose
blood test strip
NC
KROGER TEST STRIPS- glucose
blood test strip
NC
GENSTRIP 50- glucose blood test
strip
NC
LIBERTY NEXT GENERATION
B- glucose blood test strip
NC
GENULTIMATE TEST
STRIPS- glucose blood test strip
NC
LIBERTY TEST STRIPS- glucose
blood test strip
NC
GE100 BLOOD GLUCOSE
TEST- glucose blood test strip
NC
MEIJER BLOOD GLUCOSE
TEST- glucose blood test strip
NC
GHT TEST STRIPS- glucose blood
test strip
NC
MEIJER ESSENTIAL BLOOD
GL- glucose blood test strip
NC
GLUCO PERFECT 3 TEST
STRI- glucose blood test strip
NC
MEIJER PREMIUM BLOOD
GLUC- glucose blood test strip
NC
GLUCOCARD EXPRESSION
BLOO- glucose blood test strip
NC
MEIJER TRUETEST BLOOD
GLU- glucose blood test strip
NC
GLUCOCARD SHINE TEST
STRI- glucose blood test strip
NC
MEIJER TRUETRACK BLOOD
GL- glucose blood test strip
NC
GLUCOCARD VITAL TEST
STRI- glucose blood test strip
NC
MICRODOT TEST STRIPS- glucose
blood test strip
NC
GLUCOCARD X-SENSOR- glucose
blood test strip
NC
MYGLUCOHEALTH BLOOD
GLUCO- glucose blood test strip
NC
GLUCOCARD 01 SENSOR
PLUS- glucose blood test strip
NC
NEUTEK 2TEK TEST
STRIPS- glucose blood test strip
NC
GLUCOCOM TEST STRIPS- glucose
blood test strip
NC
NEXGEN TEST STRIPS- glucose
blood test strip
NC
GLUCONAVII BLOOD
GLUCOSE- glucose blood test strip
NC
NOVA MAX GLUCOSE TEST
STR- glucose blood test strip
NC
GLUCOSE METER TEST
STRIPS- glucose blood test strip
NC
ON CALL EXPRESS BLOOD
GLU- glucose blood test strip
NC
GMATE BLOOD GLUCOSE
TEST- glucose blood test strip
NC
ON CALL PLUS BLOOD
GLUCOS- glucose blood test strip
NC
GNP EASY TOUCH GLUCOSE
TE- glucose blood test strip
NC
ON CALL VIVID BLOOD
GLUCO- glucose blood test strip
NC
IN TOUCH BLOOD GLUCOSE
TE- glucose blood test strip
NC
ONETOUCH ULTRA BLUE- glucose
blood test strip
NC
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
117
ONETOUCH ULTRA TEST
STRIP- glucose blood test strip
NC
QUINTET BLOOD GLUCOSE
TES- glucose blood test strip
NC
ONETOUCH VERIO TEST
STRIP- glucose blood test strip
NC
RA TRUETEST STRIPS- glucose
blood test strip
NC
OPTIUM TEST STRIPS- glucose
blood test strip
NC
REFUAH PLUS BLOOD
GLUCOSE- glucose blood test strip
NC
OPTIUMEZ TEST STRIPS- glucose
blood test strip
NC
RELION BLOOD GLUCOSE
TEST- glucose blood test strip
NC
OPTUMRX BLOOD GLUCOSE
TES- glucose blood test strip
NC
RELION CONFIRM/MICRO
TEST- glucose blood test strip
NC
PHARMACIST CHOICE
AUTOCOD- glucose blood test strip
NC
RELION PRIME BLOOD
GLUCOS- glucose blood test strip
NC
PHARMACIST CHOICE NO
CODI- glucose blood test strip
NC
RELION ULTIMA BLOOD
GLUCO- glucose blood test strip
NC
POCKETCHEM EZ BLOOD
GLUCO- glucose blood test strip
NC
RELION ULTIMA TEST
STRIPS- glucose blood test strip
NC
PRECISION PCX- glucose blood test
strip
NC
REVEAL BLOOD GLUCOSE
TEST- glucose blood test strip
NC
PRECISION PCX PLUS TEST
S- glucose blood test strip
NC
REXALL BLOOD GLUCOSE
TEST- glucose blood test strip
NC
PRECISION POINT OF CARE
T- glucose blood test strip
NC
RIGHTEST GS100 BLOOD
GLUC- glucose blood test strip
NC
PRECISION QID TEST
STRIPS- glucose blood test strip
NC
RIGHTEST GS300 BLOOD
GLUC- glucose blood test strip
NC
PRECISION SOF-TACT TEST
S- glucose blood test strip
NC
RIGHTEST GS550 BLOOD
GLUC- glucose blood test strip
NC
PRECISION XTRA BLOOD
GLUC- glucose blood test strip
NC
SMART SENSE PREMIUM
BLOOD- glucose blood test strip
NC
PREMIUM BLOOD GLUCOSE
TES- glucose blood test strip
NC
SMART SENSE VALUE BLOOD
G- glucose blood test strip
NC
PRESTIGE TEST STRIPS- glucose
blood test strip
NC
SMARTEST BLOOD GLUCOSE
TE- glucose blood test strip
NC
PRODIGY NO CODING BLOOD
G- glucose blood test strip
NC
SOLUS V2 AUDIBLE TEST- glucose
blood test strip
NC
PTS PANELS GLUCOSE
TEST- glucose blood test strip
NC
SUPREME TEST STRIPS- glucose
blood test strip
NC
QUICKTEK TEST STRIPS- glucose
blood test strip
NC
SURE EDGE BLOOD GLUCOSE
T- glucose blood test strip
NC
QUINTET AC BLOOD
GLUCOSE- glucose blood test strip
NC
SURE-TEST EASYPLUS MINI
B- glucose blood test strip
NC
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
118
SURECHEK BLOOD GLUCOSE
TE- glucose blood test strip
NC
AEROCHAMBER MV- spacer/
aerosol-holding chambers - device
P
TELCARE BLOOD GLUCOSE
TES- glucose blood test strip
NC
P
TGT BLOOD GLUCOSE TEST
ST- glucose blood test strip
NC
AEROCHAMBER PLUS FLOW-VUspacer/aerosol-holding chambers device
P
TRUE METRIX BLOOD
GLUCOSE- glucose blood test strip
NC
AEROCHAMBER PLUS FLOW-VU/spacer/aerosol-holding chambers device
TRUE METRIX SELF
MONITORI- glucose blood test strip
NC
P
TRUETEST BLOOD GLUCOSE
T- glucose blood test strip
NC
AEROCHAMBER Z-STAT PLUS Vspacer/aerosol-holding chambers device
P
TRUETEST STRIPS- glucose blood
test strip
NC
AEROCHAMBER Z-STAT PLUS/Fspacer/aerosol-holding chambers device
TRUETRACK BLOOD GLUCOSE
T- glucose blood test strip
NC
P
TRUETRACK TEST- glucose blood
test strip
NC
AEROCHAMBER Z-STAT PLUS/Lspacer/aerosol-holding chambers device
AEROCHAMBER Z-STAT PLUS/Mspacer/aerosol-holding chambers device
P
AEROCHAMBER Z-STAT PLUS/Sspacer/aerosol-holding chambers device
P
AEROVENT PLUS HOLDING CHAspacer/aerosol-holding chambers device
P
ALL FLOW 1000 PFT FILTERrespiratory therapy supplies devices
P
ALL FLOW 2000 PFT FILTERrespiratory therapy supplies devices
P
ALL FLOW 3000 PFT FILTERrespiratory therapy supplies devices
P
ALL FLOW 4000 PFT FILTERrespiratory therapy supplies devices
P
ALL FLOW 5000 PFT FILTERrespiratory therapy supplies devices
P
ULTIMA TEST STRIPS- glucose blood NC
test strip
NC
ULTRATRAK PRO TEST
STRIPS- glucose blood test strip
NC
ULTRATRAK ULTIMATE TEST
S- glucose blood test strip
UNISTRIP1 GENERIC- glucose blood NC
test strip
NC
VICTORY AGM-4000 TEST
STR- glucose blood test strip
NC
VOCAL POINT BLOOD
GLUCOSE- glucose blood test strip
NC
WAVESENSE PRESTO TEST
STR- glucose blood test strip
MEDICAL DEVICES
ADULT MASK- respiratory therapy
supplies - devices
P
AEROBIKA- respiratory therapy
supplies - devices
P
AEROCHAMBER MINI AEROSOLspacer/aerosol-holding chambers device
P
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
119
ALL FLOW 6000 PFT FILTERrespiratory therapy supplies devices
P
BREATHERITE W/LARGE MASKspacer/aerosol-holding chambers device
P
ALL FLOW 7000 PFT FILTERrespiratory therapy supplies devices
P
BREATHERITE W/MEDIUM MASKspacer/aerosol-holding chambers device
P
ARIAL CHAMBER- spacer/aerosolholding chambers - device
P
P
BAYER BREEZE 2 HIGH CONTRblood glucose calibration - liquid high
P
BREATHERITE W/SMALL MASKspacer/aerosol-holding chambers device
CAYA- diaphragm arc-spring
P
CLEVER CHOICE ANTI-STATICspacer/aerosol-holding chambers device
P
BAYER BREEZE 2 LOW CONTROblood glucose calibration - liquid low
P
CO MONITOR- respiratory therapy
supplies - devices
P
BAYER BREEZE 2 NORMAL CONblood glucose calibration - liquid normal
P
P
BAYER CONTOUR HIGH CONTROblood glucose calibration - liquid high
P
COMPACT SPACE CHAMBER/ANTspacer/aerosol-holding chambers device
P
BAYER CONTOUR LOW CONTROLblood glucose calibration - liquid low
P
DEVILBISS COMRESSORrespiratory therapy supplies devices
P
BAYER CONTOUR NEXT CONTROblood glucose calibration - liquid normal
P
E-Z SPACER- spacer/aerosol-holding
chambers - device
P
BAYER CONTOUR NEXT CONTROblood glucose calibration - liquid low
P
E-Z SPACER THE BODY GUARDspacer/aerosol-holding chambers device
EASIVENT- spacer/aerosol-holding
chambers - device
P
BAYER CONTOUR NORMAL CONTblood glucose calibration - liquid normal
P
EASIVENT/MASK-LARGE- spacer/
aerosol-holding chambers - device
P
P
BREATHERITE- spacer/aerosolholding chambers - device
P
EASIVENT/MASK-MEDIUM- spacer/
aerosol-holding chambers - device
P
BREATHERITE COLLAPSIBLEspacer/aerosol-holding chambers device
P
EASIVENT/MASK-SMALL- spacer/
aerosol-holding chambers - device
FC FEMALE CONDOM- condoms female
P
BREATHERITE RIGID SPACERspacer/aerosol-holding chambers device
P
FC2 FEMALE CONDOM- condoms female
P
P
BREATHERITE VALVED MDI CHrespiratory therapy supplies devices
P
FEMCAP- cervical cap 22 mm
FEMCAP- cervical cap 26 mm
P
FEMCAP- cervical cap 30 mm
P
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
120
FLEXICHAMBER- spacer/aerosolholding chambers - device
P
LITEAIRE- spacer/aerosol-holding
chambers - device
P
FLEXICHAMBER ADULT MASK/Sspacer/aerosol-holding chamber
supplies - masks
P
MASK VORTEX/BABY WHIRL DUspacer/aerosol-holding chamber
supplies - masks
P
FLEXICHAMBER CHILD MASK/Lspacer/aerosol-holding chamber
supplies - masks
P
MASK VORTEX/CHILD/FROGspacer/aerosol-holding chamber
supplies - masks
P
FLEXICHAMBER CHILD MASK/Sspacer/aerosol-holding chamber
supplies - masks
P
MASK VORTEX/SPINNER THE Dspacer/aerosol-holding chamber
supplies - masks
P
FLUTTER- respiratory therapy
supplies - devices
P
P
IN-CHECK DIAL INSPIRATORYrespiratory therapy supplies devices
P
MASK VORTEX/TODDLER/LADYspacer/aerosol-holding chamber
supplies - masks
MICROCHAMBER- spacer/aerosolholding chambers - device
P
IN-CHECK INSPIRATORY FLOWrespiratory therapy supplies devices
P
MICROSPACER- spacer/aerosolholding chambers - device
P
P
MISC NEEDLES & SYRINGES –
VARIOUS
P
INSPIRACHAMBER/ANTI-STATIspacer/aerosol-holding chambers device
P
INSPIRACHAMBER/LARGE- spacer/
aerosol-holding chambers - device
P
MISTASSIST- respiratory therapy
supplies - devices
P
INSPIRACHAMBER/SOOTHERMASspacer/aerosol-holding chambers device
P
NEBULIZER CUP/TUBINGrespiratory therapy supplies devices
P
INSPIREASE BAGS- spacer/aerosolholding chamber supplies - bags
P
OMNIFLEX DIAPHRAGMdiaphragms
P
INSPIREASE DRUG DELIVERYspacer/aerosol-holding chambers device
P
ONE FLOW FVC MONITORING
S- respiratory therapy supplies devices
P
INSPIREASE MOUTHPIECE- spacer/
aerosol-holding chamber supplies mouthpieces
P
OPTICHAMBER- spacer/aerosolholding chambers - device
P
INSPIREASE RESERVOIR BAGSspacer/aerosol-holding chamber
supplies - bags
P
OPTICHAMBER ADVANTAGEspacer/aerosol-holding chambers device
P
INSULIN PEN NEEDLES – VARIOUS
P
OPTICHAMBER ADVANTAGE/LARspacer/aerosol-holding chambers device
P
LANCETS – VARIOUS
P
OPTICHAMBER ADVANTAGE/MEDspacer/aerosol-holding chambers device
P
INSULIN SYRINGES – VARIOUS
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
121
OPTICHAMBER ADVANTAGE/SMAspacer/aerosol-holding chambers device
P
PEDIATRIC PANDA MASK- spacer/
aerosol-holding chamber supplies masks
P
OPTICHAMBER DIAMOND- spacer/
aerosol-holding chambers - device
P
POCKET CHAMBER- spacer/aerosolholding chambers - device
P
OPTICHAMBER DIAMOND/LARGEspacer/aerosol-holding chambers device
P
POCKET SPACER- spacer/aerosolholding chambers - device
P
P
PRENTIF CAVITY-RIM CERVICcervical cap 22 mm
P
OPTICHAMBER DIAMOND/MEDIUspacer/aerosol-holding chambers device
P
OPTICHAMBER DIAMOND/SMALLspacer/aerosol-holding chambers device
P
PRENTIF CAVITY-RIM CERVICcervical cap 25 mm
PRENTIF CAVITY-RIM CERVICcervical cap 28 mm
P
OPTICHAMBER FACE MASK/LARspacer/aerosol-holding chambers device
P
PRENTIF CAVITY-RIM CERVICcervical cap 31 mm
P
PRENTIF FITTING SET- cervical caps
P
OPTICHAMBER FACE MASK/MEDspacer/aerosol-holding chambers device
P
PRIMEAIRE DUAL-VALVED HOLrespiratory therapy supplies devices
P
OPTICHAMBER FACE MASK/SMAspacer/aerosol-holding chambers device
P
PULMO-AIDE COMPRESSOR/
PUL- respiratory therapy supplies devices
P
OPTIHALER- spacer/aerosol-holding
chambers - device
P
P
OPTIHALER MDI DRUG DELIVEspacer/aerosol-holding chambers device
P
PULMO-AIDE LT COMPRESSOR/respiratory therapy supplies devices
P
PANDA MASK LARGE- spacer/
aerosol-holding chamber supplies masks
P
PULMO-AIDE TRAVELER COMPRrespiratory therapy supplies devices
P
PANDA MASK MEDIUM- spacer/
aerosol-holding chamber supplies masks
P
PULMONEB LT COMPRESSOR/
NE- respiratory therapy supplies devices
QUAKE- respiratory therapy supplies devices
P
PANDA MASK SMALL- spacer/
aerosol-holding chamber supplies masks
P
RITEFLO- spacer/aerosol-holding
chambers - device
P
P
PARI MANUAL INTERRUPTERrespiratory therapy supplies devices
P
SPIRO PD- respiratory therapy
supplies - devices
P
PARI TREK S COMBO PACKrespiratory therapy supplies devices
P
THRESHOLD PEP- respiratory
therapy supplies - devices
VALVED HOLDING CHAMBERspacer/aerosol-holding chambers device
P
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
122
VORTEX HOLDING CHAMBER/
MA- respiratory therapy supplies devices
P
VORTEX VALVED HOLDING CHAspacer/aerosol-holding chambers device
P
WATCHHALER- spacer/aerosolholding chambers - device
P
WIDE-SEAL SILICONE DIAPHRdiaphragm wide seal 60 mm
P
WIDE-SEAL SILICONE DIAPHRdiaphragm wide seal 65 mm
P
WIDE-SEAL SILICONE DIAPHRdiaphragm wide seal 70 mm
P
WIDE-SEAL SILICONE DIAPHRdiaphragm wide seal 75 mm
P
WIDE-SEAL SILICONE DIAPHRdiaphragm wide seal 80 mm
P
WIDE-SEAL SILICONE DIAPHRdiaphragm wide seal 85 mm
P
WIDE-SEAL SILICONE DIAPHRdiaphragm wide seal 90 mm
P
WIDE-SEAL SILICONE DIAPHRdiaphragm wide seal 95 mm
P
ASSORTED CLASSES
ASTAGRAF XL- tacrolimus cap sr
24hr 0.5 mg
NP
ASTAGRAF XL- tacrolimus cap sr
24hr 1 mg
NP
ASTAGRAF XL- tacrolimus cap sr
24hr 5 mg
NP
AZASAN- azathioprine tab 75 mg
NP
AZASAN- azathioprine tab 100 mg
NP
azathioprine tab 50 mg (Imuran)
np
CELLCEPT- mycophenolate mofetil
cap 250 mg
NP
CELLCEPT- mycophenolate mofetil
tab 500 mg
NP
CUPRIMINE- penicillamine cap
250 mg
NC
cyclosporine cap 25 mg
(Sandimmune)
cyclosporine cap 100 mg
(Sandimmune)
cyclosporine modified cap 25 mg
(Neoral)
np
cyclosporine modified oral soln
100 mg/ml (Neoral)
np
np
P
ENVARSUS XR- tacrolimus tab sr
24hr 0.75 mg
NP
ENVARSUS XR- tacrolimus tab sr
24hr 1 mg
NP
ENVARSUS XR- tacrolimus tab sr
24hr 4 mg
NP
IMURAN- azathioprine tab 50 mg
NP
mycophenolate mofetil cap 250 mg
(Cellcept)
np
mycophenolate mofetil tab 500 mg
(Cellcept)
mycophenolate sodium tab dr
180 mg (mycophenolic acid
equiv) (Myfortic)
mycophenolate sodium tab dr
360 mg (mycophenolic acid
equiv) (Myfortic)
•
np
np
np
np
MYFORTIC- mycophenolate sodium
tab dr 180 mg (mycophenolic acid
equiv)
NP
MYFORTIC- mycophenolate sodium
tab dr 360 mg (mycophenolic acid
equiv)
NP
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
Dispensing Limits
np
DEPEN TITRATABS- penicillamine
tab 250 mg
mycophenolate mofetil for oral
susp 200 mg/ml (Cellcept)
Step Therapy
np
P
cyclosporine modified cap 100 mg
(Neoral)
Prior Authorization
np
CYCLOSPORINE MODIFIEDcyclosporine modified cap 50 mg
cyclosporine modified cap 50 mg
(Cyclosporine modifie)
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
123
NEORAL- cyclosporine modified oral
soln 100 mg/ml
NP
NEORAL- cyclosporine modified cap
25 mg
NP
NEORAL- cyclosporine modified cap
100 mg
NP
PROGRAF- tacrolimus cap 0.5 mg
NP
PROGRAF- tacrolimus cap 1 mg
NP
PROGRAF- tacrolimus cap 5 mg
NP
RAPAMUNE- sirolimus oral soln 1 mg/ NP
ml
REVLIMID- lenalidomide caps 2.5 mg P
REVLIMID- lenalidomide cap 5 mg
P
REVLIMID- lenalidomide cap 10 mg
P
REVLIMID- lenalidomide cap 15 mg
P
REVLIMID- lenalidomide cap 20 mg
P
REVLIMID- lenalidomide cap 25 mg
P
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
• •
• •
•
•
THALOMID- thalidomide cap 150 mg
P
THALOMID- thalidomide cap 200 mg
P
VELTASSA- patiromer sorbitex
calcium for susp packet 8.4 gm
(base eq)
NP
VELTASSA- patiromer sorbitex
calcium for susp packet 16.8 gm
(base eq)
NP
VELTASSA- patiromer sorbitex
calcium for susp packet 25.2 gm
(base eq)
NP
ZORTRESS- everolimus tab 0.25 mg
NP
ZORTRESS- everolimus tab 0.5 mg
NP
ZORTRESS- everolimus tab 0.75 mg
NP
Dispensing Limits
• •
• •
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
Dispensing Limits
Step Therapy
Prior Authorization
Specialty
Drug Name
Tier Designation
2017
•
•
SANDIMMUNE- cyclosporine oral soln NP
100 mg/ml
NP
SANDIMMUNE- cyclosporine cap
25 mg
NP
SANDIMMUNE- cyclosporine cap
100 mg
np
sirolimus tab 0.5 mg (Rapamune)
sirolimus tab 1 mg (Rapamune)
sirolimus tab 2 mg (Rapamune)
sodium polystyrene sulfonate oral
susp 15 gm/60ml
sodium polystyrene sulfonate
powder (Kayexalate)
sodium polystyrene sulfonate
rectal susp 30 gm/120ml
np
np
np
np
np
SYPRINE- trientine hcl cap 250 mg
NP
tacrolimus cap 0.5 mg (Prograf)
np
tacrolimus cap 1 mg (Prograf)
tacrolimus cap 5 mg (Prograf)
•
np
np
THALOMID- thalidomide cap 50 mg
P
THALOMID- thalidomide cap 100 mg
P
Prime Therapeutics NetResults F-Series July 2017 Prescription Drug Guide
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INDEX
A
abacavir sulfate-lamivudine tab 600-300 mg
(Epzicom)......................................................................... 5
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg (Trizivir)................................................ 5
abacavir sulfate tab 300 mg (base equiv) (Ziagen)........ 5
ABSORICA -isotretinoin cap 10 mg................................ 108
ABSORICA -isotretinoin cap 20 mg................................ 108
ABSORICA -isotretinoin cap 25 mg................................ 108
ABSORICA -isotretinoin cap 30 mg................................ 108
ABSORICA -isotretinoin cap 35 mg................................ 108
ABSORICA -isotretinoin cap 40 mg................................ 108
ABSTRAL -fentanyl citrate sl tab 100 mcg (base
equiv)............................................................................... 72
ABSTRAL -fentanyl citrate sl tab 200 mcg (base
equiv)............................................................................... 72
ABSTRAL -fentanyl citrate sl tab 300 mcg (base
equiv)............................................................................... 72
ABSTRAL -fentanyl citrate sl tab 400 mcg (base
equiv)............................................................................... 72
ABSTRAL -fentanyl citrate sl tab 600 mcg (base
equiv)............................................................................... 72
ABSTRAL -fentanyl citrate sl tab 800 mcg (base
equiv)............................................................................... 72
acamprosate calcium tab delayed release 333 mg...... 69
ACANYA -clindamycin phosphate-benzoyl peroxide gel
1.2-2.5%........................................................................ 108
acarbose tab 25 mg (Precose)....................................... 21
acarbose tab 50 mg (Precose)....................................... 21
acarbose tab 100 mg (Precose)..................................... 21
ACCU-CHEK AVIVA PLUS -glucose blood test strip...... 114
ACCU-CHEK COMPACT PLUS -glucose blood test
strip................................................................................ 114
ACCU-CHEK COMPACT STRIPS -glucose blood test
strip................................................................................ 114
ACCU-CHEK COMPACT TEST DR -glucose blood test
strip................................................................................ 114
ACCU-CHEK GUIDE -glucose blood test strip............... 114
ACCU-CHEK SMARTVIEW STRIP -glucose blood test
strip................................................................................ 114
ACCUTREND GLUCOSE -glucose blood test strip........ 114
acebutolol hcl cap 200 mg............................................. 32
acebutolol hcl cap 400 mg............................................. 32
ACETAMINOPHEN/CAFFEINE/DI -acetaminophencaffeine-dihydrocodeine tab 325-30-16 mg................... 72
acetaminophen-caffeine-dihydrocodeine cap
320.5-30-16 mg (Trezix)................................................ 72
acetaminophen w/ codeine soln 120-12 mg/5ml.......... 72
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
codeine).......................................................................... 72
acetaminophen w/ codeine tab 300-30 mg (Tylenol/
codeine #3).................................................................... 72
acetaminophen w/ codeine tab 300-60 mg (Tylenol/
codeine #4).................................................................... 72
acetazolamide cap sr 12hr 500 mg (Diamox)............... 41
acetazolamide tab 125 mg.............................................. 41
acetazolamide tab 250 mg.............................................. 41
ACETIC ACID/ALUMINUM ACET -acetic acid 2% in
aluminum acetate otic soln...........................................107
acetic acid otic soln 2%................................................ 107
acetylcysteine inhal soln 10%........................................ 46
acetylcysteine inhal soln 20%........................................ 46
ACIPHEX SPRINKLE -rabeprazole sodium capsule
sprinkle dr 5 mg.............................................................. 51
ACIPHEX SPRINKLE -rabeprazole sodium capsule
sprinkle dr 10 mg............................................................ 51
acitretin cap 10 mg (Soriatane).................................... 108
acitretin cap 17.5 mg (Soriatane)................................. 108
acitretin cap 25 mg (Soriatane).................................... 108
ACTEMRA -tocilizumab subcutaneous soln prefilled
syringe 162 mg/0.9ml..................................................... 78
ACTHIB -haemophilus b polysaccharide conjugate
vaccine for inj.................................................................. 10
ACTICLATE -doxycycline hyclate tab 75 mg...................... 3
ACTICLATE -doxycycline hyclate tab 150 mg.................... 3
ACTIMMUNE -interferon gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)....................................................... 12
ACTIVE OB -prenatal w/o a w/fe cbn-fa-dha cap 20-1-320
mg.................................................................................... 89
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab
sr 24hr 15-1000 mg........................................................ 21
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab
sr 24hr 30-1000 mg........................................................ 22
ACUVAIL -ketorolac tromethamine ophth soln
0.45%.............................................................................104
acyclovir cap 200 mg (Zovirax)........................................ 5
acyclovir oint 5% (Zovirax)........................................... 108
acyclovir susp 200 mg/5ml (Zovirax).............................. 5
acyclovir tab 400 mg (Zovirax)........................................ 5
acyclovir tab 800 mg (Zovirax)........................................ 5
ACZONE -dapsone gel 5%............................................. 108
ACZONE -dapsone gel 7.5%.......................................... 108
ADACEL -tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lfmcg/0.5ml........................................................................ 11
ADAPALENE -adapalene lotion 0.1%............................. 108
adapalene cream 0.1% (Differin).................................. 108
adapalene gel 0.1% (Differin)....................................... 108
adapalene gel 0.3% (Differin)....................................... 108
ADASUVE -loxapine aerosol powder breath activated 10
mg.................................................................................... 61
ADCIRCA -tadalafil tab 20 mg (pah)................................. 44
ADDERALL XR -amphetamine-dextroamphetamine cap
sr 24hr 5 mg................................................................... 65
ADDERALL XR -amphetamine-dextroamphetamine cap
sr 24hr 10 mg................................................................. 65
ADDERALL XR -amphetamine-dextroamphetamine cap
sr 24hr 15 mg................................................................. 65
ADDERALL XR -amphetamine-dextroamphetamine cap
sr 24hr 20 mg................................................................. 65
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ADDERALL XR -amphetamine-dextroamphetamine cap
sr 24hr 25 mg................................................................. 65
ADDERALL XR -amphetamine-dextroamphetamine cap
sr 24hr 30 mg................................................................. 65
ADDYI -flibanserin tab 100 mg......................................... 69
adefovir dipivoxil tab 10 mg (Hepsera)........................... 5
ADEMPAS -riociguat tab 0.5 mg....................................... 44
ADEMPAS -riociguat tab 1 mg.......................................... 44
ADEMPAS -riociguat tab 1.5 mg....................................... 44
ADEMPAS -riociguat tab 2 mg.......................................... 44
ADEMPAS -riociguat tab 2.5 mg....................................... 44
ADLYXIN -lixisenatide soln pen-injector 20 mcg/0.2ml
(100 mcg/ml)................................................................... 22
ADLYXIN STARTER PACK -lixisenatide pen-inj starter kit
10 mcg/0.2ml & 20 mcg/0.2ml....................................... 22
ADULT MASK -respiratory therapy supplies devices.......................................................................... 119
ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
100-50 mcg/dose............................................................ 47
ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
250-50 mcg/dose............................................................ 47
ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
500-50 mcg/dose............................................................ 47
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 45-21
mcg/act............................................................................ 47
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 115-21
mcg/act............................................................................ 47
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 230-21
mcg/act............................................................................ 48
ADVANCE INTUITION TEST ST -glucose blood test
strip................................................................................ 115
ADVANCE MICRO-DRAW TEST S -glucose blood test
strip................................................................................ 115
ADVATE -antihemophilic factor rahf-pfm for inj 250
unit................................................................................. 100
ADVATE -antihemophilic factor rahf-pfm for inj 500
unit................................................................................. 100
ADVATE -antihemophilic factor rahf-pfm for inj 1000
unit................................................................................. 100
ADVATE -antihemophilic factor rahf-pfm for inj 1500
unit................................................................................. 100
ADVATE -antihemophilic factor rahf-pfm for inj 2000
unit................................................................................. 100
ADVATE -antihemophilic factor rahf-pfm for inj 3000
unit................................................................................. 100
ADVATE -antihemophilic factor rahf-pfm for inj 4000
unit................................................................................. 100
ADVOCATE REDI-CODE+ TEST -glucose blood test
strip................................................................................ 115
ADVOCATE REDI-CODE -glucose blood test strip........ 115
ADVOCATE TEST STRIPS -glucose blood test strip..... 115
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 250 unit.................................................................... 100
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 500 unit.................................................................... 100
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 750 unit.................................................................... 100
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 1000 unit.................................................................. 100
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 1500 unit.................................................................. 100
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 2000 unit.................................................................. 100
ADZENYS XR-ODT -amphetamine tab extended release
dispersible 3.1 mg.......................................................... 65
ADZENYS XR-ODT -amphetamine tab extended release
dispersible 6.3 mg.......................................................... 65
ADZENYS XR-ODT -amphetamine tab extended release
dispersible 9.4 mg.......................................................... 65
ADZENYS XR-ODT -amphetamine tab extended release
dispersible 12.5 mg........................................................ 65
ADZENYS XR-ODT -amphetamine tab extended release
dispersible 15.7 mg........................................................ 65
ADZENYS XR-ODT -amphetamine tab extended release
dispersible 18.8 mg........................................................ 65
AEROBIKA -respiratory therapy supplies - devices........ 119
AEROCHAMBER MINI AEROSOL -spacer/aerosolholding chambers - device........................................... 119
AEROCHAMBER MV -spacer/aerosol-holding chambers device............................................................................ 119
AEROCHAMBER PLUS FLOW-VU/ -spacer/aerosolholding chambers - device........................................... 119
AEROCHAMBER PLUS FLOW-VU -spacer/aerosolholding chambers - device........................................... 119
AEROCHAMBER Z-STAT PLUS/F -spacer/aerosolholding chambers - device........................................... 119
AEROCHAMBER Z-STAT PLUS/L -spacer/aerosolholding chambers - device........................................... 119
AEROCHAMBER Z-STAT PLUS/M -spacer/aerosolholding chambers - device........................................... 119
AEROCHAMBER Z-STAT PLUS/S -spacer/aerosolholding chambers - device........................................... 119
AEROCHAMBER Z-STAT PLUS V -spacer/aerosolholding chambers - device........................................... 119
AEROSPAN -flunisolide hfa inhal aerosol 80 mcg/act...... 48
AEROVENT PLUS HOLDING CHA -spacer/aerosolholding chambers - device........................................... 119
AFINITOR DISPERZ -everolimus tab for oral susp 2
mg.................................................................................... 12
AFINITOR DISPERZ -everolimus tab for oral susp 3
mg.................................................................................... 12
AFINITOR DISPERZ -everolimus tab for oral susp 5
mg.................................................................................... 12
AFINITOR -everolimus tab 2.5 mg.................................... 12
AFINITOR -everolimus tab 5 mg....................................... 12
AFINITOR -everolimus tab 7.5 mg.................................... 12
AFINITOR -everolimus tab 10 mg..................................... 12
AFLURIA 2015-2016 -influenza virus vaccine split im
susp................................................................................. 10
AFLURIA 2016-2017 -influenza virus vaccine split im
susp................................................................................. 10
AFLURIA PF 2015-2016 -influenza virus vaccine split pf
susp pref syringe 0.5 ml................................................. 10
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AFLURIA PF 2016-2017 -influenza virus vaccine split pf
susp pref syringe 0.5 ml................................................. 10
AFLURIA QUADRIVALENT 2016 -influenza virus vac split
quadrivalent susp pref syr 0.5ml.................................... 10
AFREZZA -insulin regular (human) inhalation powder 4
unit/cartridge.................................................................... 25
AFREZZA -insulin regular (human) inhal powd 4 (30) & 8
(60) unit/cart.................................................................... 25
AFREZZA -insulin regular (human) inhal powd 4 (60) & 8
(30) unit/cart.................................................................... 25
AFREZZA -insulin regular (human) inhal powd 4 (90) & 8
(90) unit/cart.................................................................... 25
AFREZZA -insulin regular (human) inh powd 4 & 8 & 12
unit/cart (60).................................................................... 25
AFREZZA -insulin regular (human) inh powd 8 (60) & 12
(30) unit/cart.................................................................... 25
AFSTYLA -antihemophilic fact rcmb single chain for inj kit
250 unit......................................................................... 100
AFSTYLA -antihemophilic fact rcmb single chain for inj kit
500 unit......................................................................... 100
AFSTYLA -antihemophilic fact rcmb single chain for inj kit
1000 unit....................................................................... 100
AFSTYLA -antihemophilic fact rcmb single chain for inj kit
2000 unit....................................................................... 100
AFSTYLA -antihemophilic fact rcmb single chain for inj kit
3000 unit....................................................................... 100
AGAMATRIX AMP NO CODE TES -glucose blood test
strip................................................................................ 115
AGAMATRIX JAZZ TEST STRIP -glucose blood test
strip................................................................................ 115
AGAMATRIX KEYNOTE TEST ST -glucose blood test
strip................................................................................ 115
AGAMATRIX PRESTO TEST STR -glucose blood test
strip................................................................................ 115
AKTEN -lidocaine hcl ophth gel 3.5%............................. 104
AKYNZEO -netupitant-palonosetron cap 300-0.5 mg....... 53
ALBENZA -albendazole tab 200 mg................................... 9
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)......... 48
albuterol sulfate soln nebu 0.5% (5 mg/ml).................. 48
albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv).............................................................................. 48
albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv).............................................................................. 48
albuterol sulfate syrup 2 mg/5ml................................... 48
albuterol sulfate tab 2 mg...............................................48
albuterol sulfate tab 4 mg...............................................48
albuterol sulfate tab sr 12hr 4 mg (Vospire er)............ 48
albuterol sulfate tab sr 12hr 8 mg (Vospire er)............ 48
alclometasone dipropionate cream 0.05%................. 108
alclometasone dipropionate oint 0.05%......................108
ALDACTAZIDE -spironolactone & hydrochlorothiazide tab
50-50 mg......................................................................... 41
ALECENSA -alectinib hcl cap 150 mg (base
equivalent)....................................................................... 12
ALENDRONATE SODIUM -alendronate sodium oral soln
70 mg/75ml..................................................................... 28
ALENDRONATE SODIUM -alendronate sodium tab 40
mg.................................................................................... 28
alendronate sodium tab 5 mg........................................ 28
alendronate sodium tab 10 mg...................................... 28
alendronate sodium tab 35 mg...................................... 28
alendronate sodium tab 70 mg (Fosamax)................... 28
alfuzosin hcl tab sr 24hr 10 mg (Uroxatral).................. 57
ALINIA -nitazoxanide for susp 100 mg/5ml.........................9
ALINIA -nitazoxanide tab 500 mg....................................... 9
ALKERAN -melphalan tab 2 mg....................................... 12
ALL FLOW 1000 PFT FILTER -respiratory therapy
supplies - devices......................................................... 119
ALL FLOW 2000 PFT FILTER -respiratory therapy
supplies - devices......................................................... 119
ALL FLOW 3000 PFT FILTER -respiratory therapy
supplies - devices......................................................... 119
ALL FLOW 4000 PFT FILTER -respiratory therapy
supplies - devices......................................................... 119
ALL FLOW 5000 PFT FILTER -respiratory therapy
supplies - devices......................................................... 119
ALL FLOW 6000 PFT FILTER -respiratory therapy
supplies - devices......................................................... 120
ALL FLOW 7000 PFT FILTER -respiratory therapy
supplies - devices......................................................... 120
allopurinol tab 100 mg (Zyloprim)................................. 82
allopurinol tab 300 mg (Zyloprim)................................. 82
ALLZITAL -butalbital-acetaminophen tab 25-325 mg....... 72
almotriptan malate tab 6.25 mg (Axert).........................81
almotriptan malate tab 12.5 mg (Axert).........................81
ALOCRIL -nedocromil sodium ophth soln 2%................ 104
ALOGLIPTIN/METFORMIN HCL -alogliptin-metformin hcl
tab 12.5-500 mg............................................................. 22
ALOGLIPTIN/METFORMIN HCL -alogliptin-metformin hcl
tab 12.5-1000 mg........................................................... 22
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab
12.5-15 mg...................................................................... 22
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab
12.5-30 mg...................................................................... 22
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab
12.5-45 mg...................................................................... 22
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab
25-15 mg......................................................................... 22
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab
25-30 mg......................................................................... 22
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab
25-45 mg......................................................................... 22
ALOGLIPTIN -alogliptin benzoate tab 6.25 mg (base
equiv)............................................................................... 22
ALOGLIPTIN -alogliptin benzoate tab 12.5 mg (base
equiv)............................................................................... 22
ALOGLIPTIN -alogliptin benzoate tab 25 mg (base
equiv)............................................................................... 22
ALOMIDE -lodoxamide tromethamine ophth soln
0.1%...............................................................................104
ALORA -estradiol td patch twice weekly 0.025
mg/24hr........................................................................... 18
ALORA -estradiol td patch twice weekly 0.05 mg/24hr..... 18
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ALORA -estradiol td patch twice weekly 0.075
mg/24hr........................................................................... 18
ALORA -estradiol td patch twice weekly 0.1 mg/24hr....... 18
alosetron hcl tab 0.5 mg (base equiv) (Lotronex)........ 54
alosetron hcl tab 1 mg (base equiv) (Lotronex)........... 54
ALPHAGAN P -brimonidine tartrate ophth soln 0.1%..... 104
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 250 unit......................................... 100
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 500 unit......................................... 100
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 1000 unit....................................... 100
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 1500 unit....................................... 100
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 2000 unit....................................... 100
ALPHANINE SD -coagulation factor ix for inj 500
unit................................................................................. 100
ALPHANINE SD -coagulation factor ix for inj 1000
unit................................................................................. 100
ALPHANINE SD -coagulation factor ix for inj 1500
unit................................................................................. 100
ALPRAZOLAM INTENSOL -alprazolam conc 1 mg/
ml..................................................................................... 57
alprazolam orally disintegrating tab 0.25 mg............... 57
alprazolam orally disintegrating tab 0.5 mg................. 57
alprazolam orally disintegrating tab 1 mg.................... 57
alprazolam orally disintegrating tab 2 mg.................... 57
alprazolam tab 0.25 mg (Xanax).................................... 57
alprazolam tab 0.5 mg (Xanax)...................................... 57
alprazolam tab 1 mg (Xanax)..........................................57
alprazolam tab 2 mg (Xanax)..........................................58
alprazolam tab sr 24hr 0.5 mg (Xanax xr)..................... 57
alprazolam tab sr 24hr 1 mg (Xanax xr)........................ 57
alprazolam tab sr 24hr 2 mg (Xanax xr)........................ 57
alprazolam tab sr 24hr 3 mg (Xanax xr)........................ 57
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
250 unit......................................................................... 100
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
500 unit......................................................................... 100
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
1000 unit....................................................................... 100
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
2000 unit....................................................................... 100
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
3000 unit....................................................................... 100
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
4000 unit....................................................................... 100
ALREX -loteprednol etabonate ophth susp 0.2%........... 104
ALTABAX -retapamulin oint 1%.......................................108
ALTOPREV -lovastatin tab sr 24hr 20 mg........................ 42
ALTOPREV -lovastatin tab sr 24hr 40 mg........................ 42
ALTOPREV -lovastatin tab sr 24hr 60 mg........................ 42
ALVESCO -ciclesonide inhal aerosol 80 mcg/act............. 48
ALVESCO -ciclesonide inhal aerosol 160 mcg/act........... 48
amantadine hcl cap 100 mg........................................... 86
amantadine hcl syrup 50 mg/5ml.................................. 86
amantadine hcl tab 100 mg............................................ 86
AMCINONIDE -amcinonide cream 0.1%........................ 108
AMCINONIDE -amcinonide lotion 0.1%.......................... 108
AMCINONIDE -amcinonide oint 0.1%.............................108
AMELUZ -aminolevulinic acid hcl gel 10%..................... 108
AMICAR -aminocaproic acid oral soln 0.25 gm/ml........... 99
AMICAR -aminocaproic acid tab 500 mg.......................... 99
AMICAR -aminocaproic acid tab 1000 mg........................ 99
amiloride & hydrochlorothiazide tab 5-50 mg.............. 41
amiloride hcl tab 5 mg.................................................... 41
amino acids cap............................................................... 96
amiodarone hcl tab 100 mg............................................ 35
amiodarone hcl tab 200 mg............................................ 35
amiodarone hcl tab 400 mg............................................ 35
AMITIZA -lubiprostone cap 8 mcg.................................... 54
AMITIZA -lubiprostone cap 24 mcg.................................. 54
amitriptyline hcl tab 10 mg............................................. 58
amitriptyline hcl tab 50 mg............................................. 58
amitriptyline hcl tab 75 mg............................................. 58
amitriptyline hcl tab 100 mg........................................... 58
amitriptyline hcl tab 150 mg........................................... 58
amitriptyline hcl tab 25 mg (Elavil)................................ 58
amlodipine besylate-atorvastatin calcium tab 2.5-10
mg................................................................................... 44
amlodipine besylate-atorvastatin calcium tab 2.5-20
mg................................................................................... 44
amlodipine besylate-atorvastatin calcium tab 2.5-40
mg................................................................................... 44
amlodipine besylate-atorvastatin calcium tab 5-10 mg
(Caduet).......................................................................... 44
amlodipine besylate-atorvastatin calcium tab 5-20 mg
(Caduet).......................................................................... 44
amlodipine besylate-atorvastatin calcium tab 5-40 mg
(Caduet).......................................................................... 44
amlodipine besylate-atorvastatin calcium tab 5-80 mg
(Caduet).......................................................................... 44
amlodipine besylate-atorvastatin calcium tab 10-10
mg (Caduet)................................................................... 44
amlodipine besylate-atorvastatin calcium tab 10-20
mg (Caduet)................................................................... 44
amlodipine besylate-atorvastatin calcium tab 10-40
mg (Caduet)................................................................... 44
amlodipine besylate-atorvastatin calcium tab 10-80
mg (Caduet)................................................................... 44
amlodipine besylate-benazepril hcl cap 2.5-10 mg......36
amlodipine besylate-benazepril hcl cap 5-40 mg.........36
amlodipine besylate-benazepril hcl cap 5-10 mg
(Lotrel)............................................................................ 36
amlodipine besylate-benazepril hcl cap 5-20 mg
(Lotrel)............................................................................ 36
amlodipine besylate-benazepril hcl cap 10-20 mg
(Lotrel)............................................................................ 36
amlodipine besylate-benazepril hcl cap 10-40 mg
(Lotrel)............................................................................ 36
amlodipine besylate-olmesartan medoxomil tab 5-20
mg (Azor)....................................................................... 36
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amlodipine besylate-olmesartan medoxomil tab 5-40
mg (Azor)....................................................................... 36
amlodipine besylate-olmesartan medoxomil tab 10-20
mg (Azor)....................................................................... 36
amlodipine besylate-olmesartan medoxomil tab 10-40
mg (Azor)....................................................................... 36
amlodipine besylate tab 2.5 mg (Norvasc)................... 34
amlodipine besylate tab 5 mg (Norvasc)...................... 34
amlodipine besylate tab 10 mg (Norvasc).................... 34
amlodipine besylate-valsartan tab 5-160 mg
(Exforge)......................................................................... 36
amlodipine besylate-valsartan tab 5-320 mg
(Exforge)......................................................................... 36
amlodipine besylate-valsartan tab 10-160 mg
(Exforge)......................................................................... 36
amlodipine besylate-valsartan tab 10-320 mg
(Exforge)......................................................................... 36
amlodipine-valsartan-hydrochlorothiazide tab
5-160-12.5 mg (Exforge hct)........................................ 36
amlodipine-valsartan-hydrochlorothiazide tab
5-160-25 mg (Exforge hct)........................................... 36
amlodipine-valsartan-hydrochlorothiazide tab
10-160-12.5 mg (Exforge hct)...................................... 36
amlodipine-valsartan-hydrochlorothiazide tab
10-160-25 mg (Exforge hct)......................................... 36
amlodipine-valsartan-hydrochlorothiazide tab
10-320-25 mg (Exforge hct)......................................... 36
AMOXAPINE -amoxapine tab 25 mg................................ 58
AMOXAPINE -amoxapine tab 50 mg................................ 58
AMOXAPINE -amoxapine tab 100 mg.............................. 58
AMOXAPINE -amoxapine tab 150 mg.............................. 58
AMOXICILLIN/CLAVULANATE P -amoxicillin & k
clavulanate chew tab 200-28.5 mg.................................. 1
AMOXICILLIN/CLAVULANATE P -amoxicillin & k
clavulanate chew tab 400-57 mg..................................... 1
amoxicillin & k clavulanate for susp 200-28.5
mg/5ml.............................................................................. 1
amoxicillin & k clavulanate for susp 400-57 mg/5ml..... 1
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
(Augmentin)..................................................................... 1
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
(Augmentin es-600)........................................................ 1
amoxicillin & k clavulanate tab 250-125 mg................... 1
amoxicillin & k clavulanate tab 500-125 mg
(Augmentin)..................................................................... 1
amoxicillin & k clavulanate tab 875-125 mg
(Augmentin)..................................................................... 1
amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg
(Augmentin xr)................................................................ 1
AMOXICILLIN -amoxicillin (trihydrate) chew tab 125
mg...................................................................................... 1
AMOXICILLIN -amoxicillin (trihydrate) chew tab 250
mg...................................................................................... 1
amoxicillin cap-clarithro tab-lansopraz cap dr therapy
pack (Prevpac).............................................................. 51
amoxicillin (trihydrate) cap 250 mg................................. 1
amoxicillin (trihydrate) cap 500 mg................................. 1
amoxicillin (trihydrate) for susp 125 mg/5ml..................1
amoxicillin (trihydrate) for susp 200 mg/5ml..................1
amoxicillin (trihydrate) for susp 250 mg/5ml..................1
amoxicillin (trihydrate) for susp 400 mg/5ml..................1
amoxicillin (trihydrate) tab 500 mg.................................. 1
amoxicillin (trihydrate) tab 875 mg.................................. 1
amphetamine-dextroamphetamine cap sr 24hr 5 mg
(Adderall xr)................................................................... 65
amphetamine-dextroamphetamine cap sr 24hr 10 mg
(Adderall xr)................................................................... 65
amphetamine-dextroamphetamine cap sr 24hr 15 mg
(Adderall xr)................................................................... 65
amphetamine-dextroamphetamine cap sr 24hr 20 mg
(Adderall xr)................................................................... 65
amphetamine-dextroamphetamine cap sr 24hr 25 mg
(Adderall xr)................................................................... 65
amphetamine-dextroamphetamine cap sr 24hr 30 mg
(Adderall xr)................................................................... 66
amphetamine-dextroamphetamine tab 5 mg
(Adderall)........................................................................ 66
amphetamine-dextroamphetamine tab 7.5 mg
(Adderall)........................................................................ 66
amphetamine-dextroamphetamine tab 10 mg
(Adderall)........................................................................ 66
amphetamine-dextroamphetamine tab 12.5 mg
(Adderall)........................................................................ 66
amphetamine-dextroamphetamine tab 15 mg
(Adderall)........................................................................ 66
amphetamine-dextroamphetamine tab 20 mg
(Adderall)........................................................................ 66
amphetamine-dextroamphetamine tab 30 mg
(Adderall)........................................................................ 66
AMPICILLIN -ampicillin for susp 125 mg/5ml..................... 1
AMPICILLIN -ampicillin for susp 250 mg/5ml..................... 1
ampicillin cap 250 mg....................................................... 1
ampicillin cap 500 mg....................................................... 1
AMPYRA -dalfampridine tab sr 12hr 10 mg...................... 69
AMRIX -cyclobenzaprine hcl cap sr 24hr 15 mg...............88
AMRIX -cyclobenzaprine hcl cap sr 24hr 30 mg...............88
ANADROL-50 -oxymetholone tab 50 mg.......................... 17
anagrelide hcl cap 1 mg............................................... 100
anagrelide hcl cap 0.5 mg (Agrylin)............................ 100
ANALPRAM-HC -hydrocortisone acetate w/ pramoxine
rectal lotn 2.5-1%..........................................................108
anastrozole tab 1 mg (Arimidex)................................... 12
ANDRODERM -testosterone td patch 24hr 2 mg/24hr..... 17
ANDRODERM -testosterone td patch 24hr 4 mg/24hr..... 17
ANDROGEL PUMP -testosterone td gel 20.25 mg/act
(1.62%)............................................................................ 17
ANDROGEL -testosterone td gel 20.25 mg/1.25gm
(1.62%)............................................................................ 17
ANDROGEL -testosterone td gel 40.5 mg/2.5gm
(1.62%)............................................................................ 17
ANDROXY -fluoxymesterone tab 10 mg........................... 17
ANGELIQ -drospirenone-estradiol tab 0.25-0.5 mg.......... 18
ANGELIQ -drospirenone-estradiol tab 0.5-1 mg............... 18
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ANORO ELLIPTA -umeclidinium-vilanterol aero powd ba
62.5-25 mcg/inh.............................................................. 48
ANTARA -fenofibrate micronized cap 30 mg.................... 42
ANTARA -fenofibrate micronized cap 90 mg.................... 42
ANZEMET -dolasetron mesylate tab 50 mg..................... 53
ANZEMET -dolasetron mesylate tab 100 mg................... 53
APEXICON E -diflorasone diacetate emollient base
cream 0.05%................................................................. 108
APIDRA -insulin glulisine inj 100 unit/ml........................... 25
APIDRA SOLOSTAR -insulin glulisine soln pen-injector inj
100 unit/ml.......................................................................25
APLENZIN -bupropion hbr tab sr 24hr 174 mg.................58
APLENZIN -bupropion hbr tab sr 24hr 348 mg.................58
APLENZIN -bupropion hbr tab sr 24hr 522 mg.................58
APOKYN -apomorphine hcl soln cartridge 30 mg/3ml...... 86
apraclonidine hcl ophth soln 0.5% (base equivalent)
(Iopidine)...................................................................... 104
aprepitant capsule 80 mg (Emend)............................... 53
aprepitant capsule therapy pack 80 & 125 mg
(Emend).......................................................................... 53
APRISO -mesalamine cap sr 24hr 0.375 gm.................... 54
APTENSIO XR -methylphenidate hcl cap er 24hr 10 mg
(xr)................................................................................... 66
APTENSIO XR -methylphenidate hcl cap er 24hr 15 mg
(xr)................................................................................... 66
APTENSIO XR -methylphenidate hcl cap er 24hr 20 mg
(xr)................................................................................... 66
APTENSIO XR -methylphenidate hcl cap er 24hr 30 mg
(xr)................................................................................... 66
APTENSIO XR -methylphenidate hcl cap er 24hr 40 mg
(xr)................................................................................... 66
APTENSIO XR -methylphenidate hcl cap er 24hr 50 mg
(xr)................................................................................... 66
APTENSIO XR -methylphenidate hcl cap er 24hr 60 mg
(xr)................................................................................... 66
APTIOM -eslicarbazepine acetate tab 200 mg................. 82
APTIOM -eslicarbazepine acetate tab 400 mg................. 82
APTIOM -eslicarbazepine acetate tab 600 mg................. 82
APTIOM -eslicarbazepine acetate tab 800 mg................. 82
APTIVUS -tipranavir cap 250 mg........................................ 5
APTIVUS -tipranavir oral soln 100 mg/ml........................... 5
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 25
mcg/ml............................................................................. 97
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 40
mcg/ml............................................................................. 97
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 60
mcg/ml............................................................................. 97
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 100
mcg/ml............................................................................. 97
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 200
mcg/ml............................................................................. 97
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 300
mcg/ml............................................................................. 97
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 10 mcg/0.4ml....................................... 96
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 25 mcg/0.42ml..................................... 96
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 40 mcg/0.4ml....................................... 96
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 60 mcg/0.3ml....................................... 96
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 100 mcg/0.5ml..................................... 96
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 150 mcg/0.3ml..................................... 96
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 200 mcg/0.4ml..................................... 96
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 300 mcg/0.6ml..................................... 96
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 500 mcg/ml.......................................... 97
ARCALYST -rilonacept for inj 220 mg...............................78
ARCAPTA NEOHALER -indacaterol maleate inhal powder
cap 75 mcg (base equiv)................................................48
ARESTIN -minocycline hcl subgingival powder cartridge 1
mg.................................................................................. 107
ARIAL CHAMBER -spacer/aerosol-holding chambers device............................................................................ 120
aripiprazole orally disintegrating tab 10 mg.................61
aripiprazole orally disintegrating tab 15 mg.................61
aripiprazole oral solution 1 mg/ml................................. 61
aripiprazole tab 2 mg (Abilify)........................................ 61
aripiprazole tab 5 mg (Abilify)........................................ 61
aripiprazole tab 10 mg (Abilify)...................................... 61
aripiprazole tab 15 mg (Abilify)...................................... 61
aripiprazole tab 20 mg (Abilify)...................................... 61
aripiprazole tab 30 mg (Abilify)...................................... 61
armodafinil tab 50 mg (Nuvigil)......................................66
armodafinil tab 150 mg (Nuvigil)................................... 66
armodafinil tab 200 mg (Nuvigil)................................... 66
armodafinil tab 250 mg (Nuvigil)................................... 66
ARMOUR THYROID -thyroid tab 15 mg (1/4 grain)......... 26
ARMOUR THYROID -thyroid tab 30 mg (1/2 grain)......... 26
ARMOUR THYROID -thyroid tab 90 mg (1 1/2 grain)...... 26
ARMOUR THYROID -thyroid tab 60 mg (1 grain)............ 26
ARMOUR THYROID -thyroid tab 120 mg (2 grain).......... 26
ARMOUR THYROID -thyroid tab 180 mg (3 grain).......... 26
ARMOUR THYROID -thyroid tab 240 mg (4 grain).......... 26
ARMOUR THYROID -thyroid tab 300 mg (5 grain).......... 26
ARNUITY ELLIPTA -fluticasone furoate aerosol powder
breath activ 100 mcg/act................................................ 48
ARNUITY ELLIPTA -fluticasone furoate aerosol powder
breath activ 200 mcg/act................................................ 48
ARTISS -fibrin sealant component solution...................... 99
ASACOL HD -mesalamine tab delayed release 800
mg.................................................................................... 54
ASMANEX HFA -mometasone furoate inhal aerosol
suspension 100 mcg/act................................................. 48
ASMANEX HFA -mometasone furoate inhal aerosol
suspension 200 mcg/act................................................. 48
ASMANEX TWISTHALER 120 ME -mometasone furoate
inhal powd 220 mcg/inh (breath activated).................... 48
ASMANEX TWISTHALER 30 MET -mometasone furoate
inhal powd 110 mcg/inh (breath activated).................... 48
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ASMANEX TWISTHALER 30 MET -mometasone furoate
inhal powd 220 mcg/inh (breath activated).................... 48
ASMANEX TWISTHALER 60 MET -mometasone furoate
inhal powd 220 mcg/inh (breath activated).................... 48
ASPIRIN-CAFFEINE-DIHYDROC -aspirin-caffeinedihydrocodeine cap 356.4-30-16 mg............................. 72
aspirin chew tab 81 mg...................................................72
aspirin-dipyridamole cap sr 12hr 25-200 mg
(Aggrenox)................................................................... 100
aspirin tab delayed release 81 mg.................................72
ASSURE II CHECK STRIP -glucose blood test strip...... 115
ASSURE II -glucose blood test strip............................... 115
ASSURE II TEST STRIPS -glucose blood test strip....... 115
ASSURE PLATINUM TEST STRI -glucose blood test
strip................................................................................ 115
ASSURE PRISM MULTI TEST S -glucose blood test
strip................................................................................ 115
ASSURE PRO TEST STRIPS -glucose blood test
strip................................................................................ 115
ASSURE 3 TEST STRIPS -glucose blood test strip....... 115
ASSURE 4 TEST STRIPS -glucose blood test strip....... 115
ASTAGRAF XL -tacrolimus cap sr 24hr 0.5 mg.............. 123
ASTAGRAF XL -tacrolimus cap sr 24hr 1 mg................. 123
ASTAGRAF XL -tacrolimus cap sr 24hr 5 mg................. 123
atenolol & chlorthalidone tab 50-25 mg (Tenoretic
50).................................................................................... 36
atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100).................................................................................. 36
atenolol tab 25 mg (Tenormin)....................................... 32
atenolol tab 50 mg (Tenormin)....................................... 33
atenolol tab 100 mg (Tenormin)..................................... 33
AT LAST TEST STRIPS -glucose blood test strip.......... 115
atorvastatin calcium tab 10 mg (base equivalent)
(Lipitor)........................................................................... 42
atorvastatin calcium tab 20 mg (base equivalent)
(Lipitor)........................................................................... 42
atorvastatin calcium tab 40 mg (base equivalent)
(Lipitor)........................................................................... 42
atorvastatin calcium tab 80 mg (base equivalent)
(Lipitor)........................................................................... 42
atovaquone-proguanil hcl tab 62.5-25 mg
(Malarone)........................................................................ 9
atovaquone-proguanil hcl tab 250-100 mg
(Malarone)........................................................................ 9
atovaquone susp 750 mg/5ml (Mepron)......................... 9
ATRIPLA -efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg................................................................5
ATROPINE SULFATE -atropine sulfate ophth soln
1%.................................................................................. 104
ATROVENT HFA -ipratropium bromide hfa inhal aerosol
17 mcg/act.......................................................................48
AUBAGIO -teriflunomide tab 7 mg.................................... 69
AUBAGIO -teriflunomide tab 14 mg.................................. 69
AUGMENTIN -amoxicillin & k clavulanate for susp
125-31.25 mg/5ml............................................................. 1
AURYXIA -ferric citrate tab 1 gm (210 mg ferric iron)....... 54
AUVI-Q -epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)......................................................... 41
AUVI-Q -epinephrine solution auto-injector 0.3 mg/0.3ml
(1:1000)........................................................................... 41
AVANDIA -rosiglitazone maleate tab 2 mg (base
equiv)............................................................................... 22
AVANDIA -rosiglitazone maleate tab 4 mg (base
equiv)............................................................................... 22
AVC -sulfanilamide vaginal cream 15%............................ 56
AVEED -testosterone undecanoate im inj in oil 750
mg/3ml (250mg/ml)......................................................... 17
AVONEX -interferon beta-1a for im inj kit 30mcg
(33mcg(6.6 mu)/vial)....................................................... 69
AVONEX -interferon beta-1a im prefilled syringe kit 30
mcg/0.5ml........................................................................ 69
AVONEX PEN -interferon beta-1a im auto-injector kit 30
mcg/0.5ml........................................................................ 69
AXIRON -testosterone td soln 30 mg/act.......................... 17
AZASAN -azathioprine tab 75 mg................................... 123
AZASAN -azathioprine tab 100 mg................................. 123
AZASITE -azithromycin ophth soln 1%........................... 104
azathioprine tab 50 mg (Imuran).................................. 123
azelastine hcl nasal spray 0.1% (137 mcg/spray)........ 46
azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
(Astepro).........................................................................46
azelastine hcl ophth soln 0.05%.................................. 104
AZELEX -azelaic acid cream 20%.................................. 108
AZITHROMYCIN -azithromycin powd pack for susp 1
gm...................................................................................... 2
azithromycin for susp 100 mg/5ml (Zithromax)............. 2
azithromycin for susp 200 mg/5ml (Zithromax)............. 2
azithromycin tab 250 mg (Zithromax)............................. 2
azithromycin tab 500 mg (Zithromax)............................. 2
azithromycin tab 600 mg (Zithromax)............................. 2
AZOPT -brinzolamide ophth susp 1%............................. 104
B
BACITRACIN -bacitracin ophth oint 500 unit/gm............ 104
bacitracin-polymyxin b ophth oint.............................. 104
bacitracin-polymyxin-neomycin-hc ophth oint
1%.................................................................................. 104
baclofen tab 10 mg.......................................................... 88
baclofen tab 20 mg.......................................................... 88
BACTROBAN NASAL -mupirocin calcium nasal oint
2%.................................................................................... 46
BAL-CARE DHA -prenat w/fe poly-na fered-fa tab 27-1 &
omega cap dr 430mg..................................................... 89
balsalazide disodium cap 750 mg (Colazal)................. 54
BANZEL -rufinamide susp 40 mg/ml................................. 82
BANZEL -rufinamide tab 200 mg...................................... 82
BANZEL -rufinamide tab 400 mg...................................... 82
BARACLUDE -entecavir oral soln 0.05 mg/ml.................... 5
BASAGLAR KWIKPEN -insulin glargine soln pen-injector
100 unit/ml.......................................................................26
BAYER BREEZE 2 HIGH CONTR -blood glucose
calibration - liquid - high............................................... 120
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BAYER BREEZE 2 LOW CONTRO -blood glucose
calibration - liquid - low................................................ 120
BAYER BREEZE 2 NORMAL CON -blood glucose
calibration - liquid - normal........................................... 120
BAYER BREEZE 2 TEST DISC -glucose blood test
disk................................................................................ 115
BAYER CONTOUR BLOOD GLUCO -glucose blood test
strip................................................................................ 115
BAYER CONTOUR HIGH CONTRO -blood glucose
calibration - liquid - high............................................... 120
BAYER CONTOUR LOW CONTROL -blood glucose
calibration - liquid - low................................................ 120
BAYER CONTOUR NEXT BLOOD -glucose blood test
strip................................................................................ 115
BAYER CONTOUR NEXT CONTRO -blood glucose
calibration - liquid - low................................................ 120
BAYER CONTOUR NEXT CONTRO -blood glucose
calibration - liquid - normal........................................... 120
BAYER CONTOUR NORMAL CONT -blood glucose
calibration - liquid - normal........................................... 120
BEBULIN -factor ix complex for inj 200-1200 unit.......... 101
BECONASE AQ -beclomethasone dipropionate monohyd
nasal susp 42 mcg/spray............................................... 46
BELBUCA -buprenorphine hcl buccal film 75 mcg (base
equivalent)....................................................................... 72
BELBUCA -buprenorphine hcl buccal film 150 mcg (base
equivalent)....................................................................... 72
BELBUCA -buprenorphine hcl buccal film 300 mcg (base
equivalent)....................................................................... 72
BELBUCA -buprenorphine hcl buccal film 450 mcg (base
equivalent)....................................................................... 72
BELBUCA -buprenorphine hcl buccal film 600 mcg (base
equivalent)....................................................................... 72
BELBUCA -buprenorphine hcl buccal film 750 mcg (base
equivalent)....................................................................... 72
BELBUCA -buprenorphine hcl buccal film 900 mcg (base
equivalent)....................................................................... 73
BELSOMRA -suvorexant tab 5 mg................................... 64
BELSOMRA -suvorexant tab 10 mg................................. 64
BELSOMRA -suvorexant tab 15 mg................................. 64
BELSOMRA -suvorexant tab 20 mg................................. 64
BELVIQ -lorcaserin hcl tab 10 mg..................................... 66
BELVIQ XR -lorcaserin hcl tab sr 24hr 20 mg.................. 66
benazepril & hydrochlorothiazide tab 5-6.25 mg......... 36
benazepril & hydrochlorothiazide tab 10-12.5 mg
(Lotensin hct)................................................................ 36
benazepril & hydrochlorothiazide tab 20-12.5 mg
(Lotensin hct)................................................................ 36
benazepril & hydrochlorothiazide tab 20-25 mg
(Lotensin hct)................................................................ 36
benazepril hcl tab 5 mg.................................................. 36
benazepril hcl tab 10 mg................................................ 36
benazepril hcl tab 20 mg (Lotensin).............................. 37
benazepril hcl tab 40 mg (Lotensin).............................. 37
BENEFIX -coagulation factor ix (recombinant) for inj kit
250 unit......................................................................... 101
BENEFIX -coagulation factor ix (recombinant) for inj kit
500 unit......................................................................... 101
BENEFIX -coagulation factor ix (recombinant) for inj kit
1000 unit....................................................................... 101
BENEFIX -coagulation factor ix (recombinant) for inj kit
2000 unit....................................................................... 101
BENEFIX -coagulation factor ix (recombinant) for inj kit
3000 unit....................................................................... 101
BENZONATATE -benzonatate cap 150 mg...................... 46
benzonatate cap 200 mg................................................. 46
benzonatate cap 100 mg (Tessalon perles).................. 46
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin)............................................................... 108
benzphetamine hcl tab 50 mg........................................ 66
benzphetamine hcl tab 25 mg (Regimex)..................... 66
benztropine mesylate tab 0.5 mg.................................. 86
benztropine mesylate tab 1 mg..................................... 86
benztropine mesylate tab 2 mg..................................... 86
BEPREVE -bepotastine besilate ophth soln 1.5%.......... 104
BERINERT -c1 esterase inhibitor (human) for iv inj kit 500
unit................................................................................. 101
BESIVANCE -besifloxacin hcl ophth susp 0.6% (base
equiv)............................................................................. 104
BETADINE OPHTHALMIC PREP -povidone-iodine ophth
soln 5%......................................................................... 104
betamethasone dipropionate augmented cream 0.05%
(Diprolene af)............................................................... 108
betamethasone dipropionate augmented gel
0.05%.............................................................................108
betamethasone dipropionate augmented lotion 0.05%
(Diprolene)................................................................... 108
betamethasone dipropionate augmented oint 0.05%
(Diprolene)................................................................... 108
betamethasone dipropionate cream 0.05%................ 108
betamethasone dipropionate lotion 0.05%................. 108
betamethasone dipropionate oint 0.05%.................... 109
betamethasone valerate aerosol foam 0.12%
(Luxiq)........................................................................... 109
betamethasone valerate cream 0.1%.......................... 109
betamethasone valerate lotion 0.1%........................... 109
betamethasone valerate oint 0.1%.............................. 109
BETASERON -interferon beta-1b for inj kit 0.3 mg........... 69
betaxolol hcl ophth soln 0.5%......................................104
betaxolol hcl tab 10 mg.................................................. 33
betaxolol hcl tab 20 mg.................................................. 33
bethanechol chloride tab 5 mg (Urecholine)................ 56
bethanechol chloride tab 10 mg (Urecholine).............. 56
bethanechol chloride tab 25 mg (Urecholine).............. 56
bethanechol chloride tab 50 mg (Urecholine).............. 56
BETHKIS -tobramycin nebu soln 300 mg/4ml.................... 4
BETIMOL -timolol ophth soln 0.25%............................... 104
BETIMOL -timolol ophth soln 0.5%................................. 104
BETOPTIC-S -betaxolol hcl ophth susp 0.25%.............. 104
BEVESPI AEROSPHERE -glycopyrrolate-formoterol
fumarate aerosol 9-4.8 mcg/act..................................... 48
bexarotene cap 75 mg (Targretin)..................................12
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BEXSERO -meningococcal vac b (recomb omv adjuv) inj
prefilled syringe............................................................... 10
bicalutamide tab 50 mg (Casodex)................................ 12
BIDIL -isosorbide dinitrate-hydralazine hcl tab 20-37.5
mg.................................................................................... 44
BILTRICIDE -praziquantel tab 600 mg................................ 9
BIMATOPROST -bimatoprost ophth soln 0.03%............ 104
BINOSTO -alendronate sodium effervescent tab 70
mg.................................................................................... 28
BIOSCANNER GLUCOSE TEST S -glucose blood test
strip................................................................................ 115
bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln
kit..................................................................................... 51
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
(Ziac)............................................................................... 37
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
(Ziac)............................................................................... 37
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
(Ziac)............................................................................... 37
bisoprolol fumarate tab 5 mg......................................... 33
bisoprolol fumarate tab 10 mg....................................... 33
BLEPHAMIDE S.O.P. -sulfacetamide sodiumprednisolone ophth oint 10-0.2%................................. 104
BLEPHAMIDE -sulfacetamide sodium-prednisolone ophth
susp 10-0.2%................................................................ 104
BLOOD GLUCOSE TEST STRIPS -glucose blood test
strip................................................................................ 115
BOOSTRIX -tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lflf-mcg/0.5ml..................................................................... 11
BOSULIF -bosutinib tab 100 mg....................................... 12
BOSULIF -bosutinib tab 500 mg....................................... 12
BP FOLINATAL PLUS B -prenatal w/ calcium carbonateb6-b12-fa tab 1 mg......................................................... 89
BP MULTINATAL PLUS -prenatal w/o a vit w/ fe fumaratefa tab 30-1 mg................................................................ 89
BP MULTINATAL PLUS -prenatal w/o a vit w/ fe fum-fa
tab chew 40-1 mg........................................................... 89
BRAVELLE -urofollitropin purified for inj 75 unit............... 28
BREATHERITE COLLAPSIBLE -spacer/aerosol-holding
chambers - device........................................................ 120
BREATHERITE RIGID SPACER -spacer/aerosol-holding
chambers - device........................................................ 120
BREATHERITE -spacer/aerosol-holding chambers device............................................................................ 120
BREATHERITE VALVED MDI CH -respiratory therapy
supplies - devices......................................................... 120
BREATHERITE W/LARGE MASK -spacer/aerosol-holding
chambers - device........................................................ 120
BREATHERITE W/MEDIUM MASK -spacer/aerosolholding chambers - device........................................... 120
BREATHERITE W/SMALL MASK -spacer/aerosol-holding
chambers - device........................................................ 120
BREO ELLIPTA -fluticasone furoate-vilanterol aero powd
ba 100-25 mcg/inh.......................................................... 48
BREO ELLIPTA -fluticasone furoate-vilanterol aero powd
ba 200-25 mcg/inh.......................................................... 48
BRILINTA -ticagrelor tab 60 mg...................................... 101
BRILINTA -ticagrelor tab 90 mg...................................... 101
brimonidine tartrate ophth soln 0.2%......................... 104
brimonidine tartrate ophth soln 0.15% (Alphagan
p)................................................................................... 104
BRISDELLE -paroxetine mesylate cap 7.5 mg (base
equiv)............................................................................... 69
BRIVIACT -brivaracetam oral soln 10 mg/ml.................... 82
BRIVIACT -brivaracetam tab 10 mg................................. 82
BRIVIACT -brivaracetam tab 25 mg................................. 82
BRIVIACT -brivaracetam tab 50 mg................................. 82
BRIVIACT -brivaracetam tab 75 mg................................. 82
BRIVIACT -brivaracetam tab 100 mg............................... 82
BROMFENAC -bromfenac sodium ophth soln 0.09%
(base equivalent).......................................................... 104
bromfenac sodium ophth soln 0.09% (base equiv)
(once-daily).................................................................. 104
bromocriptine mesylate cap 5 mg (base equivalent)
(Parlodel)........................................................................ 86
bromocriptine mesylate tab 2.5 mg (base equivalent)
(Parlodel)........................................................................ 86
BROMSITE -bromfenac sodium ophth soln 0.075% (base
equivalent)..................................................................... 104
BROVANA -arformoterol tartrate soln nebu 15 mcg/2ml
(base equiv).................................................................... 48
budesonide delayed release particles cap 3 mg
(Entocort ec).................................................................. 16
budesonide inhalation susp 0.25 mg/2ml
(Pulmicort)......................................................................48
budesonide inhalation susp 0.5 mg/2ml
(Pulmicort)......................................................................48
budesonide inhalation susp 1 mg/2ml (Pulmicort)...... 48
budesonide nasal susp 32 mcg/act (Rhinocort
aqua)............................................................................... 46
bumetanide tab 0.5 mg (Bumex).................................... 41
bumetanide tab 1 mg (Bumex)....................................... 41
bumetanide tab 2 mg (Bumex)....................................... 41
BUNAVAIL -buprenorphine-naloxone buccal film 2.1-0.3
mg (base equiv).............................................................. 73
BUNAVAIL -buprenorphine-naloxone buccal film 4.2-0.7
mg (base equiv).............................................................. 73
BUNAVAIL -buprenorphine-naloxone buccal film 6.3-1 mg
(base equiv).................................................................... 73
BUPHENYL -sodium phenylbutyrate tab 500 mg............. 28
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base
equiv).............................................................................. 73
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv).............................................................................. 73
buprenorphine hcl sl tab 2 mg (base equiv)................ 73
buprenorphine hcl sl tab 8 mg (base equiv)................ 73
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
(Zyban)............................................................................ 69
bupropion hcl tab 75 mg................................................ 58
bupropion hcl tab 100 mg.............................................. 58
bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr)........ 58
bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr)........ 58
bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr)........ 58
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl)........ 58
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bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl)........ 58
buspirone hcl tab 5 mg................................................... 58
buspirone hcl tab 7.5 mg................................................ 58
buspirone hcl tab 10 mg................................................. 58
buspirone hcl tab 15 mg................................................. 58
buspirone hcl tab 30 mg................................................. 58
butalbital-acetaminophen-caffeine cap 50-325-40
mg................................................................................... 72
butalbital-acetaminophen-caffeine cap 50-300-40 mg
(Fioricet)......................................................................... 72
butalbital-acetaminophen-caffeine tab 50-325-40 mg
(Esgic)............................................................................. 72
butalbital-acetaminophen-caff w/ cod cap
50-325-40-30 mg............................................................ 73
butalbital-acetaminophen-caff w/ cod cap
50-300-40-30 mg (Fioricet/codeine)............................ 73
butalbital-acetaminophen tab 50-300 mg......................72
butalbital-acetaminophen tab 50-325 mg......................72
butalbital-aspirin-caffeine cap 50-325-40 mg
(Fiorinal)......................................................................... 72
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
(Fiorinal/codeine #3)..................................................... 73
BUTISOL SODIUM -butabarbital sodium tab 30 mg.........64
butorphanol tartrate nasal soln 10 mg/ml.................... 73
BUTRANS -buprenorphine td patch weekly 5 mcg/hr.......73
BUTRANS -buprenorphine td patch weekly 7.5 mcg/
hr...................................................................................... 73
BUTRANS -buprenorphine td patch weekly 10 mcg/
hr...................................................................................... 73
BUTRANS -buprenorphine td patch weekly 15 mcg/
hr...................................................................................... 73
BUTRANS -buprenorphine td patch weekly 20 mcg/
hr...................................................................................... 73
BYDUREON -exenatide for inj extended release susp 2
mg.................................................................................... 22
BYDUREON PEN -exenatide extended release for susp
pen-injector 2 mg............................................................ 22
BYETTA -exenatide soln pen-injector 5 mcg/0.02ml........ 22
BYETTA -exenatide soln pen-injector 10 mcg/0.04ml...... 22
BYSTOLIC -nebivolol hcl tab 2.5 mg (base
equivalent)....................................................................... 33
BYSTOLIC -nebivolol hcl tab 5 mg (base equivalent).......33
BYSTOLIC -nebivolol hcl tab 10 mg (base
equivalent)....................................................................... 33
BYSTOLIC -nebivolol hcl tab 20 mg (base
equivalent)....................................................................... 33
BYVALSON -nebivolol-valsartan tab 5-80 mg.................. 37
C
cabergoline tab 0.5 mg................................................... 28
CABOMETYX -cabozantinib s-malate tab 20 mg (base
equivalent)....................................................................... 12
CABOMETYX -cabozantinib s-malate tab 40 mg (base
equivalent)....................................................................... 12
CABOMETYX -cabozantinib s-malate tab 60 mg (base
equivalent)....................................................................... 12
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base
equiv).............................................................................. 66
calcipotriene-betamethasone dipropionate oint
0.005-0.064% (Taclonex)............................................ 109
calcipotriene cream 0.005% (Dovonex).......................109
calcipotriene oint 0.005%..............................................109
calcipotriene soln 0.005% (50 mcg/ml)....................... 109
calcitonin (salmon) nasal soln 200 unit/act.................. 28
CALCITRIOL -calcitriol oint 3 mcg/gm............................ 109
calcitriol cap 0.25 mcg (Rocaltrol)................................. 28
calcitriol cap 0.5 mcg (Rocaltrol)................................... 28
calcitriol oral soln 1 mcg/ml (Rocaltrol)........................28
calcium acetate (phosphate binder) cap 667 mg (169
mg ca)............................................................................. 54
calcium acetate (phosphate binder) tab 667 mg
(Eliphos)......................................................................... 54
CALCIUM PNV -prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg............................................................ 89
CAMBIA -diclofenac potassium packet 50 mg.................. 81
CAMINO PRO 15PE -nutritional supplement liquid.......... 96
CANASA -mesalamine suppos 1000 mg.......................... 54
candesartan cilexetil-hydrochlorothiazide tab 16-12.5
mg (Atacand hct).......................................................... 37
candesartan cilexetil-hydrochlorothiazide tab 32-12.5
mg (Atacand hct).......................................................... 37
candesartan cilexetil-hydrochlorothiazide tab 32-25
mg (Atacand hct).......................................................... 37
candesartan cilexetil tab 4 mg (Atacand)..................... 37
candesartan cilexetil tab 8 mg (Atacand)..................... 37
candesartan cilexetil tab 16 mg (Atacand)................... 37
candesartan cilexetil tab 32 mg (Atacand)................... 37
CAPCOF -phenylephrine-chlorphen w/ codeine syrup
5-2-10 mg/5ml................................................................. 46
capecitabine tab 150 mg (Xeloda)................................. 12
capecitabine tab 500 mg (Xeloda)................................. 12
CAPEX -fluocinolone acetonide shampoo 0.01%........... 109
CAPRELSA -vandetanib tab 100 mg................................ 12
CAPRELSA -vandetanib tab 300 mg................................ 12
CAPTOPRIL/HYDROCHLOROTHIA -captopril &
hydrochlorothiazide tab 25-15 mg.................................. 37
CAPTOPRIL/HYDROCHLOROTHIA -captopril &
hydrochlorothiazide tab 25-25 mg.................................. 37
CAPTOPRIL/HYDROCHLOROTHIA -captopril &
hydrochlorothiazide tab 50-15 mg.................................. 37
CAPTOPRIL/HYDROCHLOROTHIA -captopril &
hydrochlorothiazide tab 50-25 mg.................................. 37
captopril tab 12.5 mg...................................................... 37
captopril tab 25 mg......................................................... 37
captopril tab 50 mg......................................................... 37
captopril tab 100 mg....................................................... 37
CARAC -fluorouracil cream 0.5%.................................... 109
CARAFATE -sucralfate susp 1 gm/10ml........................... 51
CARBAGLU -carglumic acid tab 200 mg.......................... 28
carbamazepine cap sr 12hr 100 mg (Carbatrol)........... 82
carbamazepine cap sr 12hr 200 mg (Carbatrol)........... 82
carbamazepine cap sr 12hr 300 mg (Carbatrol)........... 82
carbamazepine chew tab 100 mg.................................. 82
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carbamazepine susp 100 mg/5ml (Tegretol)................. 82
carbamazepine tab 200 mg (Tegretol)........................... 82
carbamazepine tab sr 12hr 100 mg (Tegretol-xr)......... 82
carbamazepine tab sr 12hr 200 mg (Tegretol-xr)......... 82
carbamazepine tab sr 12hr 400 mg (Tegretol-xr)......... 82
CARBATROL -carbamazepine cap sr 12hr 100 mg......... 82
CARBATROL -carbamazepine cap sr 12hr 200 mg......... 82
CARBATROL -carbamazepine cap sr 12hr 300 mg......... 83
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 12.5-50-200 mg.................................. 86
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 18.75-75-200 mg................................ 86
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 25-100-200 mg................................... 86
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 31.25-125-200 mg.............................. 86
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 37.5-150-200 mg................................ 86
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 50-200-200 mg................................... 86
carbidopa & levodopa orally disintegrating tab 10-100
mg................................................................................... 86
carbidopa & levodopa orally disintegrating tab 25-100
mg................................................................................... 86
carbidopa & levodopa orally disintegrating tab 25-250
mg................................................................................... 86
carbidopa & levodopa tab cr 25-100 mg (Sinemet
cr).................................................................................... 86
carbidopa & levodopa tab cr 50-200 mg (Sinemet
cr).................................................................................... 86
carbidopa & levodopa tab 10-100 mg (Sinemet).......... 86
carbidopa & levodopa tab 25-100 mg (Sinemet).......... 86
carbidopa & levodopa tab 25-250 mg (Sinemet).......... 86
carbidopa tab 25 mg (Lodosyn)..................................... 86
carbinoxamine maleate soln 4 mg/5ml......................... 45
carbinoxamine maleate tab 4 mg.................................. 45
carbonyl iron susp 15 mg/1.25ml (elemental iron)...... 97
CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr
120 mg............................................................................ 34
CARDURA XL -doxazosin mesylate tab sr 24 hr 4 mg
(base equiv).................................................................... 57
CARDURA XL -doxazosin mesylate tab sr 24 hr 8 mg
(base equiv).................................................................... 57
CAREONE BLOOD GLUCOSE TES -glucose blood test
strip................................................................................ 115
CARESENS N BLOOD GLUCOSE -glucose blood test
strip................................................................................ 115
carisoprodol tab 250 mg (Soma)................................... 88
carisoprodol tab 350 mg (Soma)................................... 88
carisoprodol w/ aspirin & codeine tab 200-325-16
mg................................................................................... 88
carisoprodol w/ aspirin tab 200-325 mg........................88
carteolol hcl ophth soln 1%......................................... 104
carvedilol tab 3.125 mg (Coreg)..................................... 33
carvedilol tab 6.25 mg (Coreg)....................................... 33
carvedilol tab 12.5 mg (Coreg)....................................... 33
carvedilol tab 25 mg (Coreg).......................................... 33
CAVERJECT -alprostadil for inj 20 mcg............................45
CAVERJECT -alprostadil for inj 40 mcg............................45
CAVERJECT IMPULSE -alprostadil for inj kit 10 mcg...... 45
CAVERJECT IMPULSE -alprostadil for inj kit 20 mcg...... 45
CAYA -diaphragm arc-spring........................................... 120
CAYSTON -aztreonam lysine for inhal soln 75 mg (base
equivalent)......................................................................... 9
CEDAX -ceftibuten cap 400 mg.......................................... 1
CEDAX -ceftibuten for susp 180 mg/5ml............................ 1
cefaclor cap 250 mg.......................................................... 1
cefaclor cap 500 mg.......................................................... 1
CEFACLOR -cefaclor for susp 125 mg/5ml........................ 1
CEFACLOR -cefaclor for susp 250 mg/5ml........................ 1
CEFACLOR -cefaclor for susp 375 mg/5ml........................ 1
CEFACLOR ER -cefaclor monohydrate tab sr 12hr 500
mg...................................................................................... 1
cefadroxil cap 500 mg....................................................... 1
cefadroxil for susp 250 mg/5ml....................................... 1
cefadroxil for susp 500 mg/5ml....................................... 1
cefadroxil tab 1 gm............................................................ 1
cefdinir cap 300 mg........................................................... 1
cefdinir for susp 125 mg/5ml........................................... 1
cefdinir for susp 250 mg/5ml........................................... 2
CEFDITOREN PIVOXIL -cefditoren pivoxil tab 200 mg
(base equivalent).............................................................. 2
CEFDITOREN PIVOXIL -cefditoren pivoxil tab 400 mg
(base equivalent).............................................................. 2
cefixime for susp 100 mg/5ml (Suprax).......................... 2
cefixime for susp 200 mg/5ml (Suprax).......................... 2
cefpodoxime proxetil for susp 50 mg/5ml...................... 2
cefpodoxime proxetil for susp 100 mg/5ml.................... 2
cefpodoxime proxetil tab 100 mg.................................... 2
cefpodoxime proxetil tab 200 mg.................................... 2
cefprozil for susp 125 mg/5ml..........................................2
cefprozil for susp 250 mg/5ml..........................................2
cefprozil tab 250 mg.......................................................... 2
cefprozil tab 500 mg.......................................................... 2
CEFTIBUTEN -ceftibuten cap 400 mg................................ 2
CEFTIBUTEN -ceftibuten for susp 180 mg/5ml.................. 2
CEFTIN -cefuroxime axetil for susp 125 mg/5ml................ 2
CEFTIN -cefuroxime axetil for susp 250 mg/5ml................ 2
cefuroxime axetil tab 250 mg........................................... 2
cefuroxime axetil tab 500 mg........................................... 2
celecoxib cap 50 mg (Celebrex).................................... 78
celecoxib cap 100 mg (Celebrex).................................. 78
celecoxib cap 200 mg (Celebrex).................................. 78
celecoxib cap 400 mg (Celebrex).................................. 78
CELLCEPT -mycophenolate mofetil cap 250 mg........... 123
CELLCEPT -mycophenolate mofetil tab 500 mg............ 123
CELONTIN -methsuximide cap 300 mg............................ 83
CENTANY -mupirocin oint 2%.........................................109
cephalexin cap 250 mg (Keflex)....................................... 2
cephalexin cap 500 mg (Keflex)....................................... 2
cephalexin cap 750 mg (Keflex)....................................... 2
CEPHALEXIN -cephalexin tab 250 mg............................... 2
CEPHALEXIN -cephalexin tab 500 mg............................... 2
cephalexin for susp 125 mg/5ml...................................... 2
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cephalexin for susp 250 mg/5ml...................................... 2
CERDELGA -eliglustat tartrate cap 84 mg (base
equivalent)....................................................................... 97
CERVIDIL -dinoprostone vaginal inserts 10 mg............... 28
CESAMET -nabilone cap 1 mg......................................... 53
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml).................. 45
CETRAXAL -ciprofloxacin hcl otic soln 0.2% (base
equivalent)..................................................................... 107
CETROTIDE -cetrorelix acetate for inj kit 0.25 mg........... 28
CETYLEV -acetylcysteine effervescent tab 2.5 gm........ 114
CETYLEV -acetylcysteine effervescent tab 500 mg....... 114
cevimeline hcl cap 30 mg (Evoxac)............................. 107
CHANTIX CONTINUING MONTH -varenicline tartrate tab
1 mg (base equiv).......................................................... 69
CHANTIX STARTING MONTH PA -varenicline tartrate tab
0.5 mg x 11 & tab 1 mg x 42 pack.................................69
CHANTIX -varenicline tartrate tab 0.5 mg (base
equiv)............................................................................... 69
CHANTIX -varenicline tartrate tab 1 mg (base equiv).......69
CHEMET -succimer cap 100 mg.................................... 114
CHENODAL -chenodiol tab 250 mg................................. 54
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 5-12.5 mg............................................. 69
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 10-25 mg.............................................. 69
chlordiazepoxide hcl cap 5 mg...................................... 58
chlordiazepoxide hcl cap 10 mg.................................... 58
chlordiazepoxide hcl cap 25 mg.................................... 58
chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg
(Librax)........................................................................... 51
chlorhexidine gluconate soln 0.12% (Peridex)...........107
CHLOROQUINE PHOSPHATE -chloroquine phosphate
tab 250 mg........................................................................ 9
chloroquine phosphate tab 500 mg................................ 9
CHLOROTHIAZIDE -chlorothiazide tab 250 mg............... 41
chlorothiazide tab 500 mg.............................................. 41
chlorpromazine hcl tab 10 mg....................................... 61
chlorpromazine hcl tab 25 mg....................................... 61
chlorpromazine hcl tab 50 mg....................................... 61
chlorpromazine hcl tab 100 mg..................................... 61
chlorpromazine hcl tab 200 mg..................................... 61
CHLORPROPAMIDE -chlorpropamide tab 100 mg.......... 22
CHLORPROPAMIDE -chlorpropamide tab 250 mg.......... 22
chlorthalidone tab 25 mg................................................ 41
chlorthalidone tab 50 mg................................................ 41
chlorzoxazone tab 500 mg (Parafon forte dsc)............ 88
CHOLBAM -cholic acid cap 50 mg................................... 54
CHOLBAM -cholic acid cap 250 mg................................. 54
cholecalciferol cap 400 unit........................................... 89
cholecalciferol cap 1000 unit......................................... 89
cholecalciferol chew tab 400 unit.................................. 89
cholecalciferol chew tab 1000 unit................................ 89
cholecalciferol drops 400 unit/0.03ml (per drop)......... 89
cholecalciferol drops 2000 unit/0.03ml (per drop)....... 89
cholecalciferol drops 5000 unit/ml (1000
unit/0.2ml).......................................................................89
cholecalciferol oral liquid 400 unit/ml........................... 89
cholecalciferol tab 400 unit............................................ 89
cholecalciferol tab 1000 unit.......................................... 89
cholestyramine light powder 4 gm/dose (Questran
light)................................................................................ 42
cholestyramine light powder packets 4 gm................. 42
cholestyramine powder 4 gm/dose (Questran)............ 42
cholestyramine powder packets 4 gm (Questran)....... 42
choline fenofibrate cap dr 45 mg (fenofibric acid
equiv) (Trilipix).............................................................. 42
choline fenofibrate cap dr 135 mg (fenofibric acid
equiv) (Trilipix).............................................................. 42
chorionic gonadotropin for inj 10000 unit.................... 28
CIALIS -tadalafil tab 2.5 mg.............................................. 45
CIALIS -tadalafil tab 5 mg................................................. 45
CIALIS -tadalafil tab 10 mg............................................... 45
CIALIS -tadalafil tab 20 mg............................................... 45
ciclopirox gel 0.77%...................................................... 109
ciclopirox olamine cream 0.77% (base equiv)
(Loprox)........................................................................ 109
ciclopirox olamine susp 0.77% (base equiv)
(Loprox)........................................................................ 109
ciclopirox shampoo 1% (Loprox shampoo)............... 109
ciclopirox solution 8% (Penlac Nail Lacquer)............ 109
cilostazol tab 50 mg...................................................... 101
cilostazol tab 100 mg.................................................... 101
CILOXAN -ciprofloxacin hcl ophth oint 0.3%.................. 105
cimetidine hcl soln 300 mg/5ml..................................... 51
cimetidine tab 200 mg..................................................... 51
cimetidine tab 300 mg..................................................... 51
cimetidine tab 400 mg..................................................... 51
cimetidine tab 800 mg..................................................... 51
CIMZIA -certolizumab pegol for inj kit 2 x 200 mg............ 54
CIMZIA -certolizumab pegol inj kit 2 x 200 mg/ml............ 54
CIMZIA STARTER KIT -certolizumab pegol inj kit 6 x 200
mg/ml............................................................................... 54
CIPRODEX -ciprofloxacin-dexamethasone otic susp
0.3-0.1%........................................................................ 107
CIPROFLOXACIN -ciprofloxacin hcl otic soln 0.2% (base
equivalent)..................................................................... 107
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000
mg(base eq) (Cipro xr)................................................... 4
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg
(base eq) (Cipro xr)........................................................ 4
ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml) (Cipro)........................................................... 4
ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml) (Cipro)........................................................... 4
CIPROFLOXACIN HCL -ciprofloxacin hcl tab 100 mg
(base equiv)...................................................................... 4
ciprofloxacin hcl ophth soln 0.3% (Ciloxan).............. 105
ciprofloxacin hcl tab 750 mg (base equiv)..................... 4
ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)......... 4
ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)......... 4
CIPRO HC -ciprofloxacin-hydrocortisone otic susp
0.2-1%........................................................................... 107
citalopram hydrobromide oral soln 10 mg/5ml............ 58
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citalopram hydrobromide tab 10 mg (base equiv)
(Celexa)........................................................................... 58
citalopram hydrobromide tab 20 mg (base equiv)
(Celexa)........................................................................... 58
citalopram hydrobromide tab 40 mg (base equiv)
(Celexa)........................................................................... 58
CITRANATAL ASSURE -prenat w/o a w/fecbn-fegl-dss-fa
tab & dha cap 300 mg pack........................................... 89
CITRANATAL B-CALM -prenat w/o a w/fecbn-feglu-fa tab
20-1 mg & vit b6 tab pak............................................... 89
CITRANATAL DHA -prenat w/o a w/fecbn-fegl-dss-fa tab
& dha cap 250 mg pack................................................. 89
CITRANATAL 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa
tab 90 &dha cap 300mg pak.......................................... 89
CITRANATAL HARMONY -prenat w/o a w/fe fum-fe cbndss-fa-dha cap 27-1-260 mg.......................................... 89
CITRANATAL RX -prenatal w/o a w/ fe carbonyl-fe glucdss-fa tab 27-1mg...........................................................89
CLARINEX -desloratadine syrup 0.5 mg/ml......................45
CLARINEX-D 12 HOUR -desloratadine &
pseudoephedrine tab sr 12hr 2.5-120 mg......................46
clarithromycin for susp 125 mg/5ml............................... 2
clarithromycin for susp 250 mg/5ml............................... 2
clarithromycin tab 250 mg................................................ 2
clarithromycin tab 500 mg (Biaxin)................................. 2
clarithromycin tab sr 24hr 500 mg.................................. 2
CLEMASTINE FUMARATE -clemastine fumarate tab 2.68
mg.................................................................................... 45
CLEOCIN -clindamycin phosphate vaginal suppos 100
mg.................................................................................... 56
CLEVER CHEK AUTO-CODE TES -glucose blood test
strip................................................................................ 115
CLEVER CHEK AUTO-CODE VOI -glucose blood test
strip................................................................................ 115
CLEVER CHEK TEST STRIPS -glucose blood test
strip................................................................................ 115
CLEVER CHOICE ANTI-STATIC -spacer/aerosol-holding
chambers - device........................................................ 120
CLEVER CHOICE AUTO-CODE P -glucose blood test
strip................................................................................ 115
CLEVER CHOICE MICRO TEST -glucose blood test
strip................................................................................ 115
CLIMARA PRO -estradiol-levonorgestrel td patch weekly
0.045-0.015 mg/day........................................................ 18
CLINDAGEL -clindamycin phosphate gel 1%................. 109
clindamycin hcl cap 75 mg (Cleocin).............................. 9
clindamycin hcl cap 150 mg (Cleocin)............................ 9
clindamycin hcl cap 300 mg (Cleocin)............................ 9
clindamycin palmitate hcl for soln 75 mg/5ml (base
equiv) (Cleocin pediatric gr)..........................................9
clindamycin phosphate-benzoyl peroxide gel 1-5%
(Benzaclin)................................................................... 109
clindamycin phosphate foam 1% (Evoclin)................ 109
clindamycin phosphate gel 1% (Cleocin-t)................. 109
clindamycin phosphate lotion 1% (Cleocin-t)............ 109
clindamycin phosphate soln 1% (Cleocin-t)............... 109
clindamycin phosphate swab 1% (Cleocin-t)............. 109
clindamycin phosphate-tretinoin gel 1.2-0.025%
(Ziana)........................................................................... 109
clindamycin phosphate vaginal cream 2%
(Cleocin)......................................................................... 56
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5% (Duac)............................................................... 109
CLINDESSE -clindamycin phosphate (one dose) vaginal
cream 2%........................................................................ 56
clobetasol propionate cream 0.05% (Temovate)........ 109
clobetasol propionate emollient base cream
0.05%.............................................................................109
clobetasol propionate emulsion foam 0.05% (Oluxe).................................................................................... 109
clobetasol propionate foam 0.05% (Olux).................. 109
clobetasol propionate gel 0.05% (Temovate)............. 109
clobetasol propionate lotion 0.05% (Clobex)............. 109
clobetasol propionate oint 0.05% (Temovate)............ 109
clobetasol propionate shampoo 0.05% (Clobex)....... 109
clobetasol propionate soln 0.05% (Temovate)........... 109
clobetasol propionate spray 0.05% (Clobex)............. 109
CLOCORTOLONE PIVALATE -clocortolone pivalate
cream 0.1%................................................................... 109
CLOCORTOLONE PIVALATE PUM -clocortolone pivalate
cream 0.1%................................................................... 109
CLODERM -clocortolone pivalate cream 0.1%............... 109
CLODERM PUMP -clocortolone pivalate cream
0.1%...............................................................................109
CLOMIPHENE CITRATE -clomiphene citrate tab 50
mg.................................................................................... 29
clomipramine hcl cap 25 mg (Anafranil)....................... 59
clomipramine hcl cap 50 mg (Anafranil)....................... 59
clomipramine hcl cap 75 mg (Anafranil)....................... 59
clonazepam orally disintegrating tab 0.125 mg........... 83
clonazepam orally disintegrating tab 0.25 mg............. 83
clonazepam orally disintegrating tab 0.5 mg............... 83
clonazepam orally disintegrating tab 1 mg.................. 83
clonazepam orally disintegrating tab 2 mg.................. 83
clonazepam tab 0.5 mg (Klonopin)................................ 83
clonazepam tab 1 mg (Klonopin)................................... 83
clonazepam tab 2 mg (Klonopin)................................... 83
clonidine hcl tab 0.1 mg (Catapres).............................. 37
clonidine hcl tab 0.2 mg (Catapres).............................. 37
clonidine hcl tab 0.3 mg (Catapres).............................. 37
clonidine hcl tab sr 12hr 0.1 mg (Kapvay).................... 66
clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1)................................................................................ 37
clonidine hcl td patch weekly 0.2 mg/24hr (Cataprestts-2)................................................................................ 37
clonidine hcl td patch weekly 0.3 mg/24hr (Cataprestts-3)................................................................................ 37
clopidogrel bisulfate tab 75 mg (base equiv)
(Plavix).......................................................................... 101
clopidogrel bisulfate tab 300 mg (base equiv)
(Plavix).......................................................................... 101
clorazepate dipotassium tab 3.75 mg........................... 58
clorazepate dipotassium tab 15 mg.............................. 58
clorazepate dipotassium tab 7.5 mg (Tranxene t)........ 58
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CLORPRES -clonidine & chlorthalidone tab 0.1-15
mg.................................................................................... 37
CLORPRES -clonidine & chlorthalidone tab 0.2-15
mg.................................................................................... 37
CLORPRES -clonidine & chlorthalidone tab 0.3-15
mg.................................................................................... 37
clotrimazole cream 1%.................................................. 109
clotrimazole soln 1%..................................................... 109
clotrimazole troche 10 mg............................................ 107
clotrimazole w/ betamethasone cream 1-0.05%
(Lotrisone).................................................................... 110
clotrimazole w/ betamethasone lotion 1-0.05%..........110
CLOZAPINE ODT -clozapine orally disintegrating tab 12.5
mg.................................................................................... 61
CLOZAPINE ODT -clozapine orally disintegrating tab 150
mg.................................................................................... 61
CLOZAPINE ODT -clozapine orally disintegrating tab 200
mg.................................................................................... 61
clozapine orally disintegrating tab 25 mg
(Fazaclo)......................................................................... 62
clozapine orally disintegrating tab 100 mg
(Fazaclo)......................................................................... 62
clozapine tab 50 mg........................................................ 62
clozapine tab 200 mg...................................................... 62
clozapine tab 25 mg (Clozaril)........................................62
clozapine tab 100 mg (Clozaril)..................................... 62
C-NATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................... 89
COAGADEX -coagulation factor x (human) for inj 250
unit................................................................................. 101
COAGADEX -coagulation factor x (human) for inj 500
unit................................................................................. 101
COARTEM -artemether-lumefantrine tab 20-120 mg......... 9
codeine sulfate tab 15 mg (Codeine sulfate)................ 73
codeine sulfate tab 30 mg (Codeine sulfate)................ 73
codeine sulfate tab 60 mg (Codeine sulfate)................ 73
CODITUSSIN AC -guaifenesin-codeine liquid 200-10
mg/5ml............................................................................. 46
CODITUSSIN DAC -pseudoephedrine w/ cod-gg liquid
30-10-200 mg/5ml........................................................... 46
COLCHICINE -colchicine cap 0.6 mg............................... 82
COLCHICINE -colchicine tab 0.6 mg................................ 82
colchicine w/ probenecid tab 0.5-500 mg..................... 82
COLCRYS -colchicine tab 0.6 mg..................................... 82
colestipol hcl granule packets 5 gm (Colestid
flavored)......................................................................... 42
colestipol hcl granules 5 gm (Colestid)........................ 42
colestipol hcl tab 1 gm (Colestid)..................................42
COLY-MYCIN S -neomycin-colistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml.............................................. 107
COMBIGAN -brimonidine tartrate-timolol maleate ophth
soln 0.2-0.5%................................................................ 105
COMBIPATCH -estradiol-norethindrone ace td pttw
0.05-0.14 mg/day............................................................ 18
COMBIPATCH -estradiol-norethindrone ace td pttw
0.05-0.25 mg/day............................................................ 18
COMBIVENT RESPIMAT -ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act.......................................... 48
COMETRIQ -cabozantinib s-malate cap 3 x 20 mg (60 mg
dose) kit........................................................................... 12
COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 1 x 20
mg (100 dose) kit............................................................12
COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 3 x 20
mg (140 dose) kit............................................................12
CO MONITOR -respiratory therapy supplies devices.......................................................................... 120
COMPACT SPACE CHAMBER/ANT -spacer/aerosolholding chambers - device........................................... 120
COMPLERA -emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg.................................................................. 5
COMPLETE NATAL DHA -prenat-fe bis-fe prot succ-fa-ca
tab & omega 3 cap 250 pk............................................ 89
COMPLETENATE -prenatal vit w/ fe fumarate-fa chew tab
29-1 mg........................................................................... 89
CO-NATAL FA -prenatal vit w/ fe fumarate-fa tab 29-1
mg.................................................................................... 89
CONCEPT DHA -prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg........................................................... 89
CONCEPT OB -prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg................................................................. 89
CONCERTA -methylphenidate hcl tab sa osm 18 mg...... 66
CONCERTA -methylphenidate hcl tab sa osm 27 mg...... 66
CONCERTA -methylphenidate hcl tab sa osm 36 mg...... 66
CONCERTA -methylphenidate hcl tab sa osm 54 mg...... 66
CONDYLOX -podofilox gel 0.5%.................................... 110
CONTRAVE -naltrexone hcl-bupropion hcl tab sr 12hr
8-90 mg........................................................................... 66
CONZIP -tramadol hcl cap sr 24hr biphasic release 100
mg.................................................................................... 73
CONZIP -tramadol hcl cap sr 24hr biphasic release 200
mg.................................................................................... 73
CONZIP -tramadol hcl cap sr 24hr biphasic release 300
mg.................................................................................... 73
COOL BLOOD GLUCOSE TEST S -glucose blood test
strip................................................................................ 115
COPAXONE -glatiramer acetate soln prefilled syringe 20
mg/ml............................................................................... 69
COPAXONE -glatiramer acetate soln prefilled syringe 40
mg/ml............................................................................... 69
CORDRAN -flurandrenolide tape 4 mcg/sqcm............... 110
COREG CR -carvedilol phosphate cap sr 24hr 10 mg..... 33
COREG CR -carvedilol phosphate cap sr 24hr 20 mg..... 33
COREG CR -carvedilol phosphate cap sr 24hr 40 mg..... 33
COREG CR -carvedilol phosphate cap sr 24hr 80 mg..... 33
CORIFACT -factor xiii concentrate (human) for inj kit
1000-1600 unit.............................................................. 101
CORLANOR -ivabradine hcl tab 5 mg (base equiv)......... 44
CORLANOR -ivabradine hcl tab 7.5 mg (base equiv)...... 44
CORTIFOAM -hydrocortisone acetate rectal foam 10%
(90 mg/dose)................................................................. 108
CORTISONE ACETATE -cortisone acetate tab 25 mg..... 16
CORTISPORIN -bacitracin-polymyxin-neomycin hc oint
1%.................................................................................. 110
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CORTISPORIN -neomycin-polymyxin-hc crm 3.5 mg/
gm-10000 unt/gm-0.5%................................................ 110
COSENTYX -secukinumab subcutaneous soln prefilled
syringe 150 mg/ml........................................................ 110
COSENTYX SENSOREADY PEN -secukinumab
subcutaneous soln auto-injector 150 mg/ml................ 110
COSOPT PF -dorzolamide hcl-timolol maleate ophth sol
22.3-6.8 mg/ml pf..........................................................105
COTELLIC -cobimetinib fumarate tab 20 mg (base
equivalent)....................................................................... 12
COUMADIN -warfarin sodium tab 1 mg............................ 98
COUMADIN -warfarin sodium tab 2 mg............................ 98
COUMADIN -warfarin sodium tab 2.5 mg......................... 98
COUMADIN -warfarin sodium tab 3 mg............................ 98
COUMADIN -warfarin sodium tab 4 mg............................ 98
COUMADIN -warfarin sodium tab 5 mg............................ 98
COUMADIN -warfarin sodium tab 6 mg............................ 98
COUMADIN -warfarin sodium tab 7.5 mg......................... 98
COUMADIN -warfarin sodium tab 10 mg.......................... 98
CREON -pancrelipase (lip-prot-amyl) dr cap
3000-9500-15000 unit.....................................................53
CREON -pancrelipase (lip-prot-amyl) dr cap
6000-19000-30000 unit...................................................53
CREON -pancrelipase (lip-prot-amyl) dr cap
12000-38000-60000 unit................................................ 53
CREON -pancrelipase (lip-prot-amyl) dr cap
24000-76000-120000 unit.............................................. 53
CREON -pancrelipase (lip-prot-amyl) dr cap
36000-114000-180000 unit............................................. 53
CRESEMBA -isavuconazonium sulfate cap 186 mg.......... 5
CRINONE -progesterone vaginal gel 4%.......................... 56
CRINONE -progesterone vaginal gel 8%.......................... 56
CRIXIVAN -indinavir sulfate cap 200 mg............................ 5
CRIXIVAN -indinavir sulfate cap 400 mg............................ 5
CROMOLYN SODIUM -cromolyn sodium soln nebu 20
mg/2ml............................................................................. 48
cromolyn sodium ophth soln 4%................................ 105
cromolyn sodium oral conc 100 mg/5ml
(Gastrocrom).................................................................. 54
CUPRIMINE -penicillamine cap 250 mg......................... 123
CUVPOSA -glycopyrrolate oral soln 1 mg/5ml................. 51
CVS ADVANCED GLUCOSE METE -glucose blood test
strip................................................................................ 115
cyanocobalamin inj 1000 mcg/ml.................................. 97
cyclobenzaprine hcl tab 5 mg........................................ 88
cyclobenzaprine hcl tab 10 mg...................................... 88
cyclobenzaprine hcl tab 7.5 mg (Fexmid)..................... 88
CYCLOMYDRIL -cyclopentolate w/ phenylephrine ophth
soln 0.2-1%................................................................... 105
cyclopentolate hcl ophth soln 0.5% (Cyclogyl)..........105
cyclopentolate hcl ophth soln 1% (Cyclogyl).............105
cyclopentolate hcl ophth soln 2% (Cyclogyl).............105
CYCLOPHOSPHAMIDE -cyclophosphamide cap 25
mg.................................................................................... 12
CYCLOPHOSPHAMIDE -cyclophosphamide cap 50
mg.................................................................................... 12
CYCLOSERINE -cycloserine cap 250 mg.......................... 4
CYCLOSET -bromocriptine mesylate tab 0.8 mg (base
equivalent)....................................................................... 22
cyclosporine cap 25 mg (Sandimmune)..................... 123
cyclosporine cap 100 mg (Sandimmune)................... 123
cyclosporine modified cap 50 mg (Cyclosporine
modifie)......................................................................... 123
cyclosporine modified cap 25 mg (Neoral).................123
cyclosporine modified cap 100 mg (Neoral)...............123
CYCLOSPORINE MODIFIED -cyclosporine modified cap
50 mg............................................................................ 123
cyclosporine modified oral soln 100 mg/ml
(Neoral)......................................................................... 123
cyproheptadine hcl syrup 2 mg/5ml.............................. 45
cyproheptadine hcl tab 4 mg......................................... 45
CYSTADANE -betaine powder for oral solution................ 29
CYSTAGON -cysteamine bitartrate cap 50 mg.................57
CYSTAGON -cysteamine bitartrate cap 150 mg...............57
CYSTARAN -cysteamine hcl ophth soln 0.44% (base
equivalent)..................................................................... 105
D
DAKLINZA -daclatasvir dihydrochloride tab 30 mg (base
equivalent)......................................................................... 5
DAKLINZA -daclatasvir dihydrochloride tab 60 mg (base
equivalent)......................................................................... 5
DAKLINZA -daclatasvir dihydrochloride tab 90 mg (base
equivalent)......................................................................... 5
DALIRESP -roflumilast tab 500 mcg................................. 48
danazol cap 50 mg.......................................................... 17
danazol cap 100 mg........................................................ 17
danazol cap 200 mg........................................................ 17
dantrolene sodium cap 100 mg..................................... 88
dantrolene sodium cap 25 mg (Dantrium).................... 88
dantrolene sodium cap 50 mg (Dantrium).................... 88
dapsone tab 25 mg............................................................ 9
dapsone tab 100 mg.......................................................... 9
DAPTACEL -diph, acellular pert & tet tox inj 15 lf-10
mcg-5 lf/0.5ml................................................................. 11
DARAPRIM -pyrimethamine tab 25 mg.............................. 9
darifenacin hydrobromide tab sr 24hr 7.5 mg (base
equiv) (Enablex)............................................................ 56
darifenacin hydrobromide tab sr 24hr 15 mg (base
equiv) (Enablex)............................................................ 56
DAXBIA -cephalexin cap 333 mg........................................ 2
DAYTRANA -methylphenidate td patch 10 mg/9hr........... 66
DAYTRANA -methylphenidate td patch 15 mg/9hr........... 66
DAYTRANA -methylphenidate td patch 20 mg/9hr........... 66
DAYTRANA -methylphenidate td patch 30 mg/9hr........... 66
DELESTROGEN -estradiol valerate im in oil 10 mg/
ml..................................................................................... 18
DELZICOL -mesalamine cap dr 400 mg........................... 54
demeclocycline hcl tab 150 mg....................................... 3
demeclocycline hcl tab 300 mg....................................... 3
DEMEROL -meperidine hcl tab 100 mg........................... 73
DEMSER -metyrosine cap 250 mg................................... 37
DENAVIR -penciclovir cream 1%.................................... 110
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DEPAKENE -valproate sodium oral soln 250 mg/5ml
(base equiv).................................................................... 83
DEPAKENE -valproic acid cap 250 mg.............................83
DEPEN TITRATABS -penicillamine tab 250 mg............. 123
DEPO-ESTRADIOL -estradiol cypionate im in oil 5 mg/
ml..................................................................................... 18
DEPO-SUBQ PROVERA 104 -medroxyprogesterone
acetate susp pref syr 104 mg/0.65ml.............................20
DESCOVY -emtricitabine-tenofovir alafenamide fumarate
tab 200-25 mg...................................................................5
desipramine hcl tab 50 mg............................................. 59
desipramine hcl tab 75 mg............................................. 59
desipramine hcl tab 100 mg........................................... 59
desipramine hcl tab 150 mg........................................... 59
desipramine hcl tab 10 mg (Norpramin)....................... 59
desipramine hcl tab 25 mg (Norpramin)....................... 59
DESLORATADINE ODT -desloratadine tab orally
disintegrating 2.5 mg...................................................... 45
DESLORATADINE ODT -desloratadine tab orally
disintegrating 5 mg......................................................... 45
desloratadine tab 5 mg (Clarinex)................................. 45
desmopressin acetate inj 4 mcg/ml (Ddavp)................ 29
desmopressin acetate nasal soln 0.01% (refrigerated)
(Ddavp)........................................................................... 29
desmopressin acetate nasal spray soln 0.01%
(Ddavp)........................................................................... 29
desmopressin acetate nasal spray soln 0.01%
(refrigerated).................................................................. 29
desmopressin acetate tab 0.1 mg (Ddavp)................... 29
desmopressin acetate tab 0.2 mg (Ddavp)................... 29
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01
mg(21/5) (Mircette)........................................................ 20
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg
(Cyclessa).......................................................................20
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
(Desogen)....................................................................... 20
DESONATE -desonide gel 0.05%................................... 110
desonide cream 0.05% (Desowen).............................. 110
desonide lotion 0.05% (Desowen)............................... 110
desonide oint 0.05%...................................................... 110
desoximetasone cream 0.25% (Topicort)....................110
DESOXIMETASONE -desoximetasone cream
0.05%.............................................................................110
desoximetasone gel 0.05% (Topicort)......................... 110
desoximetasone oint 0.05% (Topicort)........................ 110
desoximetasone oint 0.25% (Topicort)........................ 110
DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 50
mg.................................................................................... 59
DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 100
mg.................................................................................... 59
desvenlafaxine succinate tab sr 24hr 25 mg (base
equiv) (Pristiq)............................................................... 59
desvenlafaxine succinate tab sr 24hr 50 mg (base
equiv) (Pristiq)............................................................... 59
desvenlafaxine succinate tab sr 24hr 100 mg (base
equiv) (Pristiq)............................................................... 59
DEVILBISS COMRESSOR -respiratory therapy supplies devices.......................................................................... 120
DEXAMETHASONE -dexamethasone soln 0.5
mg/5ml............................................................................. 16
DEXAMETHASONE -dexamethasone tab 1 mg...............16
DEXAMETHASONE -dexamethasone tab 2 mg...............16
dexamethasone elixir 0.5 mg/5ml.................................. 16
DEXAMETHASONE INTENSOL -dexamethasone conc 1
mg/ml............................................................................... 16
DEXAMETHASONE SODIUM PHOS -dexamethasone
sodium phosphate ophth soln 0.1%............................. 105
dexamethasone tab 0.5 mg............................................ 16
dexamethasone tab 0.75 mg.......................................... 16
dexamethasone tab 1.5 mg............................................ 16
dexamethasone tab 4 mg............................................... 16
dexamethasone tab 6 mg............................................... 16
DEXILANT -dexlansoprazole cap delayed release 30
mg.................................................................................... 51
DEXILANT -dexlansoprazole cap delayed release 60
mg.................................................................................... 51
dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalin
xr).................................................................................... 66
dexmethylphenidate hcl cap sr 24 hr 10 mg (Focalin
xr).................................................................................... 66
dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin
xr).................................................................................... 66
dexmethylphenidate hcl cap sr 24 hr 20 mg (Focalin
xr).................................................................................... 66
dexmethylphenidate hcl cap sr 24 hr 25 mg (Focalin
xr).................................................................................... 66
dexmethylphenidate hcl cap sr 24 hr 30 mg (Focalin
xr).................................................................................... 66
dexmethylphenidate hcl cap sr 24 hr 35 mg (Focalin
xr).................................................................................... 66
dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin
xr).................................................................................... 66
dexmethylphenidate hcl tab 2.5 mg (Focalin).............. 66
dexmethylphenidate hcl tab 5 mg (Focalin)................. 67
dexmethylphenidate hcl tab 10 mg (Focalin)............... 67
DEXPAK 10 DAY -dexamethasone tab therapy pack 1.5
mg (35)............................................................................ 16
DEXPAK 13 DAY -dexamethasone tab therapy pack 1.5
mg (51)............................................................................ 16
DEXPAK 6 DAY -dexamethasone tab therapy pack 1.5
mg (21)............................................................................ 16
dextroamphetamine sulfate cap sr 24hr 5 mg
(Dexedrine)..................................................................... 67
dextroamphetamine sulfate cap sr 24hr 10 mg
(Dexedrine)..................................................................... 67
dextroamphetamine sulfate cap sr 24hr 15 mg
(Dexedrine)..................................................................... 67
dextroamphetamine sulfate oral solution 5 mg/5ml
(Procentra)..................................................................... 67
dextroamphetamine sulfate tab 5 mg........................... 67
dextroamphetamine sulfate tab 10 mg......................... 67
DIASTAT ACUDIAL -diazepam rectal gel delivery system
10 mg.............................................................................. 83
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DIASTAT ACUDIAL -diazepam rectal gel delivery system
20 mg.............................................................................. 83
DIASTAT PEDIATRIC -diazepam rectal gel delivery
system 2.5 mg................................................................ 83
DIATRUE PLUS BLOOD GLUCOS -glucose blood test
strip................................................................................ 115
diazepam conc 5 mg/ml.................................................. 58
DIAZEPAM -diazepam oral soln 1 mg/ml..........................58
DIAZEPAM -diazepam rectal gel delivery system 2.5
mg.................................................................................... 83
DIAZEPAM -diazepam rectal gel delivery system 10
mg.................................................................................... 83
DIAZEPAM -diazepam rectal gel delivery system 20
mg.................................................................................... 83
diazepam tab 2 mg (Valium)........................................... 58
diazepam tab 5 mg (Valium)........................................... 58
diazepam tab 10 mg (Valium)......................................... 58
DICLEGIS -doxylamine-pyridoxine tab delayed release
10-10 mg......................................................................... 53
diclofenac potassium tab 50 mg................................... 78
diclofenac sodium (actinic keratoses) gel 3%
(Solaraze)..................................................................... 110
diclofenac sodium gel 1% (Voltaren)...........................110
diclofenac sodium ophth soln 0.1%............................ 105
diclofenac sodium soln 1.5%....................................... 110
diclofenac sodium tab delayed release 25 mg............. 78
diclofenac sodium tab delayed release 50 mg............. 78
diclofenac sodium tab delayed release 75 mg............. 78
diclofenac sodium tab sr 24hr 100 mg......................... 78
diclofenac w/ misoprostol tab delayed release 50-0.2
mg (Arthrotec 50)..........................................................78
diclofenac w/ misoprostol tab delayed release 75-0.2
mg (Arthrotec 75)..........................................................78
dicloxacillin sodium cap 250 mg..................................... 1
dicloxacillin sodium cap 500 mg..................................... 1
dicyclomine hcl cap 10 mg (Bentyl).............................. 51
dicyclomine hcl oral soln 10 mg/5ml............................ 51
dicyclomine hcl tab 20 mg............................................. 51
didanosine delayed release capsule 125 mg (Videx
ec)...................................................................................... 6
didanosine delayed release capsule 200 mg (Videx
ec)...................................................................................... 6
didanosine delayed release capsule 250 mg (Videx
ec)...................................................................................... 6
didanosine delayed release capsule 400 mg (Videx
ec)...................................................................................... 6
DIETHYLPROPION HCL -diethylpropion hcl tab 25
mg.................................................................................... 67
diethylpropion hcl tab 25 mg (Diethylpropion hcl)...... 67
diethylpropion hcl tab sr 24hr 75 mg............................ 67
DIFFERIN -adapalene lotion 0.1%.................................. 110
DIFICID -fidaxomicin tab 200 mg........................................ 2
DIFLORASONE DIACETATE -diflorasone diacetate
cream 0.05%................................................................. 110
DIFLORASONE DIACETATE -diflorasone diacetate oint
0.05%.............................................................................110
diflunisal tab 500 mg....................................................... 72
DIGOXIN -digoxin oral soln 0.05 mg/ml............................ 32
digoxin tab 125 mcg (0.125 mg) (Lanoxin)................... 32
digoxin tab 250 mcg (0.25 mg) (Lanoxin)..................... 32
DIHYDROERGOTAMINE MESYLAT -dihydroergotamine
mesylate nasal spray 4 mg/ml....................................... 81
dihydroergotamine mesylate inj 1 mg/ml (D.h.e.
45).................................................................................... 81
DILANTIN INFATABS -phenytoin chew tab 50 mg........... 83
DILANTIN -phenytoin sodium extended cap 30 mg......... 83
DILANTIN -phenytoin sodium extended cap 100 mg........83
DILANTIN-125 -phenytoin susp 125 mg/5ml.................... 83
DILATRATE SR -isosorbide dinitrate cap cr 40 mg.......... 32
diltiazem hcl cap sr 12hr 60 mg.....................................34
diltiazem hcl cap sr 12hr 90 mg.....................................34
diltiazem hcl cap sr 12hr 120 mg...................................34
diltiazem hcl cap sr 24hr 120 mg...................................34
diltiazem hcl cap sr 24hr 180 mg...................................34
diltiazem hcl cap sr 24hr 240 mg...................................34
diltiazem hcl coated beads cap sr 24hr 300 mg........... 34
diltiazem hcl coated beads cap sr 24hr 120 mg
(Cardizem cd)................................................................ 34
diltiazem hcl coated beads cap sr 24hr 180 mg
(Cardizem cd)................................................................ 34
diltiazem hcl coated beads cap sr 24hr 240 mg
(Cardizem cd)................................................................ 34
diltiazem hcl coated beads cap sr 24hr 360 mg
(Cardizem cd)................................................................ 34
diltiazem hcl coated beads tab sr 24hr 180 mg
(Cardizem la)................................................................. 34
diltiazem hcl coated beads tab sr 24hr 240 mg
(Cardizem la)................................................................. 34
diltiazem hcl coated beads tab sr 24hr 300 mg
(Cardizem la)................................................................. 34
diltiazem hcl coated beads tab sr 24hr 360 mg
(Cardizem la)................................................................. 34
diltiazem hcl coated beads tab sr 24hr 420 mg
(Cardizem la)................................................................. 34
diltiazem hcl extended release beads cap sr 24hr 120
mg (Tiazac).................................................................... 34
diltiazem hcl extended release beads cap sr 24hr 180
mg (Tiazac).................................................................... 34
diltiazem hcl extended release beads cap sr 24hr 240
mg (Tiazac).................................................................... 34
diltiazem hcl extended release beads cap sr 24hr 300
mg (Tiazac).................................................................... 34
diltiazem hcl extended release beads cap sr 24hr 360
mg (Tiazac).................................................................... 34
diltiazem hcl extended release beads cap sr 24hr 420
mg (Tiazac).................................................................... 34
diltiazem hcl tab 90 mg................................................... 34
diltiazem hcl tab 30 mg (Cardizem)............................... 34
diltiazem hcl tab 60 mg (Cardizem)............................... 34
diltiazem hcl tab 120 mg (Cardizem)............................. 34
DIPENTUM -olsalazine sodium cap 250 mg.....................54
diphenhydramine hcl elixir 12.5 mg/5ml....................... 46
DIPHENOXYLATE/ATROPINE -diphenoxylate w/ atropine
liq 2.5-0.025 mg/5ml....................................................... 51
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diphenoxylate w/ atropine tab 2.5-0.025 mg
(Lomotil)......................................................................... 51
DIPHTHERIA/TETANUS TOXOID -diphtheria-tetanus tox
adsorbed (dt) im inj 25-5 unit/0.5ml............................... 11
dipyridamole tab 25 mg................................................ 101
dipyridamole tab 50 mg................................................ 101
dipyridamole tab 75 mg................................................ 101
disopyramide phosphate cap 100 mg (Norpace)......... 35
disopyramide phosphate cap 150 mg (Norpace)......... 35
disulfiram tab 250 mg (Antabuse)................................. 69
disulfiram tab 500 mg (Antabuse)................................. 69
DIURIL -chlorothiazide susp 250 mg/5ml......................... 41
divalproex sodium cap delayed release sprinkle 125
mg (Depakote sprinkles).............................................. 83
divalproex sodium tab delayed release 125 mg
(Depakote)...................................................................... 83
divalproex sodium tab delayed release 250 mg
(Depakote)...................................................................... 83
divalproex sodium tab delayed release 500 mg
(Depakote)...................................................................... 83
divalproex sodium tab sr 24 hr 250 mg (Depakote
er).................................................................................... 83
divalproex sodium tab sr 24 hr 500 mg (Depakote
er).................................................................................... 83
DIVIGEL -estradiol td gel 0.25 mg/0.25gm (0.1%)........... 18
DIVIGEL -estradiol td gel 0.5 mg/0.5gm (0.1%)............... 18
DIVIGEL -estradiol td gel 1 mg/gm (0.1%)....................... 18
dofetilide cap 125 mcg (0.125 mg) (Tikosyn)................35
dofetilide cap 250 mcg (0.25 mg) (Tikosyn)..................35
dofetilide cap 500 mcg (0.5 mg) (Tikosyn)....................35
donepezil hydrochloride orally disintegrating tab 5
mg................................................................................... 69
donepezil hydrochloride orally disintegrating tab 10
mg................................................................................... 69
donepezil hydrochloride tab 5 mg (Aricept)................. 69
donepezil hydrochloride tab 10 mg (Aricept)............... 69
donepezil hydrochloride tab 23 mg (Aricept)............... 69
DONNATAL -pb-hyoscy-atrop-scopol elix
16.2-0.1037-0.0194-0.0065 mg/5ml............................... 51
DONNATAL -pb-hyoscy-atrop-scopol tab
16.2-0.1037-0.0194-0.0065 mg...................................... 51
DORAL -quazepam tab 15 mg.......................................... 64
DORYX MPC -doxycycline hyclate tab delayed release
120 mg.............................................................................. 3
dorzolamide hcl ophth soln 2% (Trusopt).................. 105
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml (Cosopt)............................................................105
DOTHELLE DHA -prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg........................................................... 89
doxazosin mesylate tab 1 mg (Cardura)....................... 37
doxazosin mesylate tab 2 mg (Cardura)....................... 37
doxazosin mesylate tab 4 mg (Cardura)....................... 37
doxazosin mesylate tab 8 mg (Cardura)....................... 37
doxepin hcl cap 10 mg....................................................59
doxepin hcl cap 25 mg....................................................59
doxepin hcl cap 50 mg....................................................59
doxepin hcl cap 100 mg..................................................59
doxepin hcl cap 150 mg..................................................59
doxepin hcl conc 10 mg/ml............................................ 59
DOXEPIN HCL -doxepin hcl cap 75 mg........................... 59
DOXEPIN HYDROCHLORIDE -doxepin hcl cream
5%.................................................................................. 110
doxercalciferol cap 0.5 mcg (Hectorol)......................... 29
doxercalciferol cap 1 mcg (Hectorol)............................ 29
doxercalciferol cap 2.5 mcg (Hectorol)......................... 29
DOXYCYCLINE -doxycycline (rosacea) cap delayed
release 40 mg............................................................... 110
doxycycline hyclate cap 50 mg....................................... 3
doxycycline hyclate cap 100 mg (Vibramycin)...............3
doxycycline hyclate tab delayed release 75 mg............ 3
doxycycline hyclate tab delayed release 100 mg.......... 3
doxycycline hyclate tab delayed release 150 mg.......... 3
doxycycline hyclate tab delayed release 50 mg
(Doryx).............................................................................. 3
doxycycline hyclate tab delayed release 200 mg
(Doryx).............................................................................. 3
doxycycline hyclate tab 20 mg........................................ 3
doxycycline hyclate tab 100 mg...................................... 3
doxycycline monohydrate cap 50 mg............................. 3
doxycycline monohydrate cap 150 mg (Adoxa).............3
doxycycline monohydrate cap 75 mg (Monodox)..........3
doxycycline monohydrate cap 100 mg (Monodox)........3
doxycycline monohydrate for susp 25 mg/5ml
(Vibramycin)..................................................................... 3
doxycycline monohydrate tab 50 mg.............................. 3
doxycycline monohydrate tab 75 mg.............................. 3
doxycycline monohydrate tab 100 mg............................ 3
doxycycline monohydrate tab 150 mg............................ 3
dronabinol cap 2.5 mg (Marinol).................................... 53
dronabinol cap 5 mg (Marinol)....................................... 53
dronabinol cap 10 mg (Marinol)..................................... 53
drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin
28).................................................................................... 20
drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)..... 20
drospirenone-ethinyl estrad-levomefolate tab
3-0.02-0.451 mg (Beyaz)............................................... 20
DROXIA -hydroxyurea cap 200 mg.................................. 97
DROXIA -hydroxyurea cap 300 mg.................................. 97
DROXIA -hydroxyurea cap 400 mg.................................. 97
DUAVEE -conjugated estrogens-bazedoxifene tab
0.45-20 mg...................................................................... 18
DUET DHA BALANCED -prenat w/fe poly-na fered-fa tab
25-1 & omega cap 267 mg............................................ 89
DUET DHA 400 -prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 400 mg........................................................ 89
DUEXIS -ibuprofen-famotidine tab 800-26.6 mg.............. 78
DULERA -mometasone furoate-formoterol fumarate
aerosol 100-5 mcg/act.................................................... 48
DULERA -mometasone furoate-formoterol fumarate
aerosol 200-5 mcg/act.................................................... 49
DULOXETINE HCL -duloxetine hcl enteric coated pellets
cap 40 mg....................................................................... 59
duloxetine hcl enteric coated pellets cap 20 mg
(Cymbalta)...................................................................... 59
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duloxetine hcl enteric coated pellets cap 30 mg
(Cymbalta)...................................................................... 59
duloxetine hcl enteric coated pellets cap 60 mg
(Cymbalta)...................................................................... 59
DUO-CARE TEST STRIPS -glucose blood test strip......115
DUOPA -carbidopa-levodopa enteral susp 4.63-20 mg/
ml..................................................................................... 87
DUREZOL -difluprednate ophth emulsion 0.05%........... 105
DURLAZA -aspirin capsule sr 24hr 162.5 mg................. 101
dutasteride cap 0.5 mg (Avodart).................................. 57
dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn)...... 57
DUTOPROL -metoprolol & hydrochlorothiazide tab sr
24hr 25-12.5 mg............................................................. 37
DUTOPROL -metoprolol & hydrochlorothiazide tab sr
24hr 50-12.5 mg............................................................. 37
DUTOPROL -metoprolol & hydrochlorothiazide tab sr
24hr 100-12.5 mg........................................................... 37
DYANAVEL XR -amphetamine extended release susp 2.5
mg/ml............................................................................... 67
DYMISTA -azelastine hcl-fluticasone prop nasal spray
137-50 mcg/act............................................................... 46
DYRENIUM -triamterene cap 50 mg................................. 41
DYRENIUM -triamterene cap 100 mg............................... 41
E
EASIVENT/MASK-LARGE -spacer/aerosol-holding
chambers - device........................................................ 120
EASIVENT/MASK-MEDIUM -spacer/aerosol-holding
chambers - device........................................................ 120
EASIVENT/MASK-SMALL -spacer/aerosol-holding
chambers - device........................................................ 120
EASIVENT -spacer/aerosol-holding chambers device............................................................................ 120
EASYGLUCO -glucose blood test strip........................... 115
EASYGLUCO PLUS -glucose blood test strip................ 116
EASYMAX TEST STRIPS -glucose blood test strip....... 116
EASYMAX 15 TEST STRIPS -glucose blood test
strip................................................................................ 116
EASYPLUS BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 116
EASY PLUS BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 115
EASY PLUS II BLOOD GLUCOS -glucose blood test
strip................................................................................ 115
EASYPRO BLOOD GLUCOSE TES -glucose blood test
strip................................................................................ 116
EASYPRO PLUS -glucose blood test strip..................... 116
EASY STEP TEST STRIPS -glucose blood test strip..... 115
EASY TALK BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 115
EASY TOUCH GLUCOSE TEST S -glucose blood test
strip................................................................................ 115
EASY TOUCH HEALTHPRO GLUC -glucose blood test
strip................................................................................ 115
EASY TRAK BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 115
econazole nitrate cream 1%......................................... 110
ECOZA -econazole nitrate foam 1%............................... 110
EDARBI -azilsartan medoxomil tab 40 mg........................37
EDARBI -azilsartan medoxomil tab 80 mg........................37
EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab
40-12.5 mg...................................................................... 38
EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab
40-25 mg......................................................................... 38
EDEX -alprostadil for inj kit 10 mcg.................................. 45
EDEX -alprostadil for inj kit 20 mcg.................................. 45
EDEX -alprostadil for inj kit 40 mcg.................................. 45
EDLUAR -zolpidem tartrate sl tab 5 mg............................64
EDLUAR -zolpidem tartrate sl tab 10 mg..........................64
EDURANT -rilpivirine hcl tab 25 mg (base equivalent)....... 6
E.E.S. 400 -erythromycin ethylsuccinate tab 400 mg......... 2
EFFIENT -prasugrel hcl tab 5 mg (base equiv).............. 101
EFFIENT -prasugrel hcl tab 10 mg (base equiv)............ 101
EGRIFTA -tesamorelin acetate for inj 1 mg (base
equiv)............................................................................... 29
EGRIFTA -tesamorelin acetate for inj 2 mg (base
equiv)............................................................................... 29
ELEMENT COMPACT TEST STRI -glucose blood test
strip................................................................................ 116
ELEMENT TEST STRIPS -glucose blood test strip........ 116
ELESTRIN -estradiol gel 0.06% (0.52 mg/0.87 gm
metered-dose pump)...................................................... 18
ELIDEL -pimecrolimus cream 1%................................... 110
ELIGARD -leuprolide acetate for subcutaneous inj kit 7.5
mg.................................................................................... 13
ELIGARD -leuprolide acetate (3 month) for subcutaneous
inj kit 22.5mg...................................................................13
ELIGARD -leuprolide acetate (4 month) for subcutaneous
inj kit 30 mg.................................................................... 13
ELIGARD -leuprolide acetate (6 month) for subcutaneous
inj kit 45 mg.................................................................... 13
ELIQUIS -apixaban tab 2.5 mg......................................... 98
ELIQUIS -apixaban tab 5 mg............................................ 98
ELITE-OB -prenatal vit w/ iron carbonyl-fa tab 50-1.25
mg.................................................................................... 89
ELIXOPHYLLIN -theophylline elixir 80 mg/15ml............... 49
ELLA -ulipristal acetate tab 30 mg.................................... 20
ELMIRON -pentosan polysulfate sodium caps 100
mg.................................................................................... 57
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
250 unit......................................................................... 101
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
500 unit......................................................................... 101
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
750 unit......................................................................... 101
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
1000 unit....................................................................... 101
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
1500 unit....................................................................... 101
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
2000 unit....................................................................... 101
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
3000 unit....................................................................... 101
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ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
4000 unit....................................................................... 101
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
5000 unit....................................................................... 101
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
6000 unit....................................................................... 101
EMADINE -emedastine difumarate ophth soln 0.05%
(base equiv).................................................................. 105
EMBEDA -morphine-naltrexone cap cr 20-0.8 mg............73
EMBEDA -morphine-naltrexone cap cr 30-1.2 mg............73
EMBEDA -morphine-naltrexone cap cr 50-2 mg...............73
EMBEDA -morphine-naltrexone cap cr 60-2.4 mg............73
EMBEDA -morphine-naltrexone cap cr 80-3.2 mg............73
EMBEDA -morphine-naltrexone cap cr 100-4 mg.............73
EMBRACE BLOOD GLUCOSE TES -glucose blood test
strip................................................................................ 116
EMBRACE EVO BLOOD GLUCOSE -glucose blood test
strip................................................................................ 116
EMBRACE PRO BLOOD GLUCOSE -glucose blood test
strip................................................................................ 116
EMCYT -estramustine phosphate sodium cap 140
mg.................................................................................... 13
EMEND -aprepitant for oral susp 125 mg (125
mg/5ml)............................................................................ 53
EMFLAZA -deflazacort susp 22.75 mg/ml........................ 16
EMFLAZA -deflazacort tab 6 mg....................................... 16
EMFLAZA -deflazacort tab 18 mg..................................... 16
EMFLAZA -deflazacort tab 30 mg..................................... 16
EMFLAZA -deflazacort tab 36 mg..................................... 16
EMSAM -selegiline td patch 24hr 6 mg/24hr.................... 59
EMSAM -selegiline td patch 24hr 9 mg/24hr.................... 59
EMSAM -selegiline td patch 24hr 12 mg/24hr.................. 59
EMTRIVA -emtricitabine caps 200 mg................................ 6
EMTRIVA -emtricitabine soln 10 mg/ml.............................. 6
EMVERM -mebendazole chew tab 100 mg........................ 9
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg................................................................................... 38
enalapril maleate & hydrochlorothiazide tab 10-25 mg
(Vaseretic)...................................................................... 38
enalapril maleate tab 2.5 mg (Vasotec)......................... 38
enalapril maleate tab 5 mg (Vasotec)............................ 38
enalapril maleate tab 10 mg (Vasotec).......................... 38
enalapril maleate tab 20 mg (Vasotec).......................... 38
ENBRACE HR -prenatal vit w/ fe gly cys-fa-omega 3 fatty
acids cap......................................................................... 89
ENBREL -etanercept for subcutaneous inj 25 mg............ 78
ENBREL -etanercept subcutaneous soln prefilled syringe
25 mg/0.5ml.................................................................... 78
ENBREL -etanercept subcutaneous soln prefilled syringe
50 mg/ml......................................................................... 78
ENBREL SURECLICK -etanercept subcutaneous solution
auto-injector 50 mg/ml.................................................... 78
ENCARE -nonoxynol-9 vaginal suppos 100 mg............... 56
ENDOMETRIN -progesterone vaginal insert 100 mg....... 56
ENGERIX-B -hepatitis b vaccine (recombinant) 10
mcg/0.5ml........................................................................ 10
ENGERIX-B -hepatitis b vaccine (recombinant) 20 mcg/
ml..................................................................................... 10
ENGERIX-B -hepatitis b vaccine (recombinant) susp 10
mcg/0.5ml........................................................................ 10
ENGERIX-B -hepatitis b vaccine (recombinant) susp 20
mcg/ml............................................................................. 10
enoxaparin sodium inj 30 mg/0.3ml (Lovenox)............ 98
enoxaparin sodium inj 40 mg/0.4ml (Lovenox)............ 98
enoxaparin sodium inj 60 mg/0.6ml (Lovenox)............ 98
enoxaparin sodium inj 80 mg/0.8ml (Lovenox)............ 98
enoxaparin sodium inj 100 mg/ml (Lovenox)............... 98
enoxaparin sodium inj 120 mg/0.8ml (Lovenox).......... 98
enoxaparin sodium inj 150 mg/ml (Lovenox)............... 98
enoxaparin sodium inj 300 mg/3ml (Lovenox)............. 98
ENSTILAR -calcipotriene-betamethasone dipropionate
foam 0.005-0.064%...................................................... 110
entacapone tab 200 mg (Comtan)................................. 87
entecavir tab 0.5 mg (Baraclude)..................................... 6
entecavir tab 1 mg (Baraclude)........................................ 6
ENTRESTO -sacubitril-valsartan tab 24-26 mg................ 44
ENTRESTO -sacubitril-valsartan tab 49-51 mg................ 44
ENTRESTO -sacubitril-valsartan tab 97-103 mg.............. 44
ENVARSUS XR -tacrolimus tab sr 24hr 0.75 mg............123
ENVARSUS XR -tacrolimus tab sr 24hr 1 mg................ 123
ENVARSUS XR -tacrolimus tab sr 24hr 4 mg................ 123
EPANED -enalapril maleate oral soln 1 mg/ml................. 38
EPCLUSA -sofosbuvir-velpatasvir tab 400-100 mg............ 6
EPIDUO -adapalene-benzoyl peroxide gel 0.1-2.5%......110
EPIDUO FORTE -adapalene-benzoyl peroxide gel
0.3-2.5%........................................................................ 110
EPIFOAM -pramoxine-hc aerosol foam 1-1%.................110
epinastine hcl ophth soln 0.05% (Elestat).................. 105
EPINEPHRINE -epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)......................................................... 42
EPINEPHRINE -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)........................................................... 42
EPINEPHRINE(Mylan Products) -epinephrine solution
auto-injector 0.15 mg/0.3ml (1:2000)............................. 42
EPINEPHRINE(Mylan Products) -epinephrine solution
auto-injector 0.3 mg/0.3ml (1:1000)............................... 42
EPIPEN-JR 2-PAK -epinephrine solution auto-injector
0.15 mg/0.3ml (1:2000).................................................. 42
EPIPEN 2-PAK -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)........................................................... 42
EPIVIR HBV -lamivudine oral soln 5 mg/ml (hbv)............... 6
eplerenone tab 25 mg (Inspra)....................................... 38
eplerenone tab 50 mg (Inspra)....................................... 38
EPOGEN -epoetin alfa inj 2000 unit/ml.............................97
EPOGEN -epoetin alfa inj 3000 unit/ml.............................97
EPOGEN -epoetin alfa inj 4000 unit/ml.............................97
EPOGEN -epoetin alfa inj 10000 unit/ml...........................97
EPOGEN -epoetin alfa inj 20000 unit/ml...........................97
EPROSARTAN MESYLATE -eprosartan mesylate tab 600
mg.................................................................................... 38
EQ BLOOD GLUCOSE TEST STR -glucose blood test
strip................................................................................ 116
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EQUETRO -carbamazepine (antipsychotic) cap sr 12hr
100 mg............................................................................ 62
EQUETRO -carbamazepine (antipsychotic) cap sr 12hr
200 mg............................................................................ 62
EQUETRO -carbamazepine (antipsychotic) cap sr 12hr
300 mg............................................................................ 62
ergocalciferol cap 50000 unit......................................... 89
ERGOLOID MESYLATES -ergoloid mesylates tab 1
mg.................................................................................... 70
ERGOMAR -ergotamine tartrate sl tab 2 mg.................... 81
ergotamine w/ caffeine tab 1-100 mg (Cafergot).......... 81
ERIVEDGE -vismodegib cap 150 mg............................... 13
ERTACZO -sertaconazole nitrate cream 2%.................. 110
ERYPED 400 -erythromycin ethylsuccinate for susp 400
mg/5ml............................................................................... 2
ERY-TAB -erythromycin tab delayed release 250 mg........ 2
ERY-TAB -erythromycin tab delayed release 333 mg........ 2
ERY-TAB -erythromycin tab delayed release 500 mg........ 2
ERYTHROCIN STEARATE -erythromycin stearate tab
250 mg.............................................................................. 2
ERYTHROMYCIN BASE -erythromycin tab 250 mg.......... 2
ERYTHROMYCIN BASE -erythromycin tab 500 mg.......... 2
ERYTHROMYCIN ETHYLSUCCINA -erythromycin
ethylsuccinate tab 400 mg............................................... 3
erythromycin ethylsuccinate for susp 200 mg/5ml
(E.e.s. granules).............................................................. 3
erythromycin gel 2% (Erygel)....................................... 110
erythromycin ophth oint 5 mg/gm............................... 105
erythromycin pads 2%.................................................. 110
erythromycin soln 2%................................................... 110
erythromycin w/ delayed release particles cap 250
mg......................................................................................3
ESBRIET -pirfenidone cap 267 mg................................... 50
ESBRIET -pirfenidone tab 267 mg.................................... 50
ESBRIET -pirfenidone tab 801 mg.................................... 50
escitalopram oxalate soln 5 mg/5ml (base equiv)....... 59
escitalopram oxalate tab 5 mg (base equiv)
(Lexapro)........................................................................ 59
escitalopram oxalate tab 10 mg (base equiv)
(Lexapro)........................................................................ 59
escitalopram oxalate tab 20 mg (base equiv)
(Lexapro)........................................................................ 59
esomeprazole magnesium cap delayed release 20 mg
(base eq) (Nexium)....................................................... 51
esomeprazole magnesium cap delayed release 40 mg
(base eq) (Nexium)....................................................... 52
ESOMEPRAZOLE STRONTIUM -esomeprazole
strontium cap delayed release 24.65 mg....................... 52
ESOMEPRAZOLE STRONTIUM -esomeprazole
strontium cap delayed release 49.3 mg......................... 52
estazolam tab 1 mg......................................................... 64
estazolam tab 2 mg......................................................... 64
ESTRACE -estradiol vaginal cream 0.1 mg/gm................ 56
estradiol & norethindrone acetate tab 0.5-0.1 mg
(Activella)....................................................................... 18
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella)....................................................................... 18
estradiol tab 0.5 mg (Estrace)........................................ 18
estradiol tab 1 mg (Estrace)........................................... 18
estradiol tab 2 mg (Estrace)........................................... 18
estradiol td patch twice weekly 0.025 mg/24hr (Vivelledot).................................................................................. 19
estradiol td patch twice weekly 0.0375 mg/24hr
(Vivelle-dot).................................................................... 19
estradiol td patch twice weekly 0.05 mg/24hr (Vivelledot).................................................................................. 19
estradiol td patch twice weekly 0.075 mg/24hr (Vivelledot).................................................................................. 19
estradiol td patch twice weekly 0.1 mg/24hr (Vivelledot).................................................................................. 19
estradiol td patch weekly 0.025 mg/24hr (Climara)......19
estradiol td patch weekly 0.05 mg/24hr (Climara)........19
estradiol td patch weekly 0.06 mg/24hr (Climara)........19
estradiol td patch weekly 0.075 mg/24hr (Climara)......19
estradiol td patch weekly 0.1 mg/24hr (Climara)..........19
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr) (Climara)...................................................... 19
estradiol vaginal tab 10 mcg (Vagifem).........................56
estradiol valerate im in oil 20 mg/ml (Delestrogen)..... 19
estradiol valerate im in oil 40 mg/ml (Delestrogen)..... 19
ESTRING -estradiol vaginal ring 2 mg (7.5
mcg/24hrs).......................................................................56
ESTROGEL -estradiol gel 0.06% (0.75 mg/1.25 gm
metered-dose pump)...................................................... 19
ESTROPIPATE -estropipate tab 0.75 mg......................... 19
ESTROPIPATE -estropipate tab 1.5 mg........................... 19
ESTROPIPATE -estropipate tab 3 mg.............................. 19
eszopiclone tab 1 mg (Lunesta).................................... 64
eszopiclone tab 2 mg (Lunesta).................................... 64
eszopiclone tab 3 mg (Lunesta).................................... 64
ethacrynic acid tab 25 mg (Edecrin)............................. 41
ethambutol hcl tab 100 mg (Myambutol)........................ 4
ethambutol hcl tab 400 mg (Myambutol)........................ 4
ethosuximide cap 250 mg (Zarontin)............................ 83
ethosuximide soln 250 mg/5ml (Zarontin).................... 83
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35
mcg................................................................................. 20
ethynodiol diacetate & ethinyl estradiol tab 1 mg-50
mcg................................................................................. 20
ETIDRONATE DISODIUM -etidronate disodium tab 200
mg.................................................................................... 29
ETIDRONATE DISODIUM -etidronate disodium tab 400
mg.................................................................................... 29
etodolac cap 200 mg....................................................... 78
etodolac cap 300 mg....................................................... 79
etodolac tab 500 mg........................................................ 79
etodolac tab 400 mg (Lodine)........................................ 79
etodolac tab sr 24hr 400 mg.......................................... 79
etodolac tab sr 24hr 500 mg.......................................... 79
etodolac tab sr 24hr 600 mg.......................................... 79
ETOPOSIDE -etoposide cap 50 mg..................................13
EUCRISA -crisaborole oint 2%....................................... 110
EURAX -crotamiton cream 10%...................................... 110
EURAX -crotamiton lotion 10%....................................... 110
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EVAMIST -estradiol transdermal spray 1.53 mg/spray..... 19
EVEKEO -amphetamine sulfate tab 5 mg.........................67
EVEKEO -amphetamine sulfate tab 10 mg.......................67
EVENCARE + BLOOD GLUCOSE -glucose blood test
strip................................................................................ 116
EVENCARE BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 116
EVENCARE G2 TEST STRIPS -glucose blood test
strip................................................................................ 116
EVENCARE G3 TEST STRIPS -glucose blood test
strip................................................................................ 116
EVENCARE MINI BLOOD GLUCO -glucose blood test
strip................................................................................ 116
EVICEL -fibrin sealant component kit 2 ml....................... 99
EVICEL -fibrin sealant component kit 5 ml....................... 99
EVITHROM -thrombin (human) topical soln 800-1200
unit/ml.............................................................................. 99
EVOLUTION AUTOCODE -glucose blood test strip....... 116
EVOTAZ -atazanavir sulfate-cobicistat tab 300-150 mg
(base equiv)...................................................................... 6
EVZIO -naloxone hcl solution auto-injector 0.4
mg/0.4ml........................................................................ 114
EVZIO -naloxone hcl solution auto-injector 2
mg/0.4ml........................................................................ 114
EXACTECH R-S-G TEST STRIP -glucose blood test
strip................................................................................ 116
EXACTECH TEST STRIPS -glucose blood test strip..... 116
EXELDERM -sulconazole nitrate cream 1%................... 110
EXELDERM -sulconazole nitrate solution 1%................ 110
exemestane tab 25 mg (Aromasin)................................ 13
EXJADE -deferasirox tab for oral susp 125 mg.............. 114
EXJADE -deferasirox tab for oral susp 250 mg.............. 114
EXJADE -deferasirox tab for oral susp 500 mg.............. 114
EXONDYS 51 -eteplirsen iv soln 100 mg/2ml (50 mg/
ml).................................................................................... 88
EXONDYS 51 -eteplirsen iv soln 500 mg/10ml (50 mg/
ml).................................................................................... 88
EXTAVIA -interferon beta-1b for inj kit 0.3 mg.................. 70
EXTRA-VIRT PLUS DHA -prenatal w/o vit a w/ fe fumdoc-fa-dha cap 29-1.25-350 mg..................................... 89
ezetimibe-simvastatin tab 10-10 mg (Vytorin).............. 42
ezetimibe-simvastatin tab 10-20 mg (Vytorin).............. 42
ezetimibe-simvastatin tab 10-40 mg (Vytorin).............. 42
ezetimibe-simvastatin tab 10-80 mg (Vytorin).............. 42
ezetimibe tab 10 mg (Zetia)............................................ 42
EZ SMART BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 116
EZ SMART PLUS BLOOD GLUCO -glucose blood test
strip................................................................................ 116
E-Z SPACER -spacer/aerosol-holding chambers device............................................................................ 120
E-Z SPACER THE BODY GUARD -spacer/aerosolholding chambers - device........................................... 120
F
FABIOR -tazarotene (acne) foam 0.1%.......................... 110
FACTIVE -gemifloxacin mesylate tab 320 mg (base
equiv)................................................................................. 4
FALESSA -levonorgest-eth estrad tab 0.1 mg-20 mcg & fa
tab 1 mg kit..................................................................... 20
famciclovir tab 125 mg...................................................... 6
famciclovir tab 250 mg...................................................... 6
famciclovir tab 500 mg...................................................... 6
famotidine for susp 40 mg/5ml (Pepcid)....................... 52
famotidine tab 20 mg (Pepcid)....................................... 52
famotidine tab 40 mg (Pepcid)....................................... 52
FANAPT -iloperidone tab 1 mg......................................... 62
FANAPT -iloperidone tab 2 mg......................................... 62
FANAPT -iloperidone tab 4 mg......................................... 62
FANAPT -iloperidone tab 6 mg......................................... 62
FANAPT -iloperidone tab 8 mg......................................... 62
FANAPT -iloperidone tab 10 mg....................................... 62
FANAPT -iloperidone tab 12 mg....................................... 62
FANAPT TITRATION PACK -iloperidone tab 1 mg & 2 mg
& 4 mg & 6 mg titration pak........................................... 62
FARESTON -toremifene citrate tab 60 mg (base
equivalent)....................................................................... 13
FARXIGA -dapagliflozin propanediol tab 5 mg (base
equivalent)....................................................................... 22
FARXIGA -dapagliflozin propanediol tab 10 mg (base
equivalent)....................................................................... 22
FARYDAK -panobinostat lactate cap 10 mg (base
equivalent)....................................................................... 13
FARYDAK -panobinostat lactate cap 15 mg (base
equivalent)....................................................................... 13
FARYDAK -panobinostat lactate cap 20 mg (base
equivalent)....................................................................... 13
FAZACLO -clozapine orally disintegrating tab 12.5
mg.................................................................................... 62
FAZACLO -clozapine orally disintegrating tab 150 mg..... 62
FAZACLO -clozapine orally disintegrating tab 200 mg..... 62
FC FEMALE CONDOM -condoms - female....................120
FC2 FEMALE CONDOM -condoms - female..................120
FEIBA -antiinhibitor coagulant complex for inj................ 101
felbamate susp 600 mg/5ml (Felbatol).......................... 83
felbamate tab 400 mg (Felbatol).................................... 83
felbamate tab 600 mg (Felbatol).................................... 83
felodipine tab sr 24hr 2.5 mg......................................... 34
felodipine tab sr 24hr 5 mg............................................ 34
felodipine tab sr 24hr 10 mg.......................................... 34
FEMCAP -cervical cap 22 mm........................................ 120
FEMCAP -cervical cap 26 mm........................................ 120
FEMCAP -cervical cap 30 mm........................................ 120
FEMRING -estradiol acetate vaginal ring 0.05
mg/24hr........................................................................... 56
FEMRING -estradiol acetate vaginal ring 0.1 mg/24hr..... 56
FENOFIBRATE -fenofibrate cap 50 mg............................ 42
FENOFIBRATE -fenofibrate cap 150 mg.......................... 42
fenofibrate micronized cap 43 mg................................. 42
fenofibrate micronized cap 130 mg............................... 42
fenofibrate micronized cap 67 mg (Lofibra)................. 42
fenofibrate micronized cap 134 mg (Lofibra)............... 42
fenofibrate micronized cap 200 mg (Lofibra)............... 42
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fenofibrate tab 40 mg (Fenoglide)................................. 42
fenofibrate tab 120 mg (Fenoglide)............................... 43
fenofibrate tab 54 mg (Lofibra)...................................... 43
fenofibrate tab 160 mg (Lofibra).................................... 43
fenofibrate tab 48 mg (Tricor)........................................ 42
fenofibrate tab 145 mg (Tricor)...................................... 43
FENOFIBRIC ACID -fenofibric acid tab 35 mg................. 43
FENOFIBRIC ACID -fenofibric acid tab 105 mg............... 43
FENOPROFEN CALCIUM -fenoprofen calcium cap 200
mg.................................................................................... 79
FENOPROFEN CALCIUM -fenoprofen calcium cap 400
mg.................................................................................... 79
FENOPROFEN CALCIUM -fenoprofen calcium tab 600
mg.................................................................................... 79
FENORTHO -fenoprofen calcium cap 200 mg................. 79
FENORTHO -fenoprofen calcium cap 400 mg................. 79
fentanyl citrate lozenge on a handle 200 mcg
(Actiq)............................................................................. 73
fentanyl citrate lozenge on a handle 400 mcg
(Actiq)............................................................................. 73
fentanyl citrate lozenge on a handle 600 mcg
(Actiq)............................................................................. 73
fentanyl citrate lozenge on a handle 800 mcg
(Actiq)............................................................................. 73
fentanyl citrate lozenge on a handle 1200 mcg
(Actiq)............................................................................. 73
fentanyl citrate lozenge on a handle 1600 mcg
(Actiq)............................................................................. 73
FENTANYL -fentanyl td patch 72hr 37.5 mcg/hr...............73
FENTANYL -fentanyl td patch 72hr 62.5 mcg/hr...............73
FENTANYL -fentanyl td patch 72hr 87.5 mcg/hr...............73
fentanyl td patch 72hr 12 mcg/hr (Duragesic).............. 74
fentanyl td patch 72hr 25 mcg/hr (Duragesic).............. 74
fentanyl td patch 72hr 50 mcg/hr (Duragesic).............. 74
fentanyl td patch 72hr 75 mcg/hr (Duragesic).............. 74
fentanyl td patch 72hr 100 mcg/hr (Duragesic)............ 74
FENTORA -fentanyl citrate buccal tab 100 mcg (base
equiv)............................................................................... 74
FENTORA -fentanyl citrate buccal tab 200 mcg (base
equiv)............................................................................... 74
FENTORA -fentanyl citrate buccal tab 400 mcg (base
equiv)............................................................................... 74
FENTORA -fentanyl citrate buccal tab 600 mcg (base
equiv)............................................................................... 74
FENTORA -fentanyl citrate buccal tab 800 mcg (base
equiv)............................................................................... 74
FERRIPROX -deferiprone oral soln 100 mg/ml.............. 114
FERRIPROX -deferiprone tab 500 mg............................ 114
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental
fe).....................................................................................97
ferrous sulfate soln 75 mg/ml (15 mg/ml elemental
fe).....................................................................................97
FETZIMA -levomilnacipran hcl cap sr 24hr 20 mg (base
equivalent)....................................................................... 59
FETZIMA -levomilnacipran hcl cap sr 24hr 40 mg (base
equivalent)....................................................................... 59
FETZIMA -levomilnacipran hcl cap sr 24hr 80 mg (base
equivalent)....................................................................... 59
FETZIMA -levomilnacipran hcl cap sr 24hr 120 mg (base
equivalent)....................................................................... 59
FETZIMA TITRATION PACK -levomilnacipran hcl cap sr
24hr 20 & 40 mg therapy pack...................................... 59
FIBRICOR -fenofibric acid tab 35 mg............................... 43
FIBRICOR -fenofibric acid tab 105 mg............................. 43
FIFTY50 GLUCOSE TEST STRI -glucose blood test
strip................................................................................ 116
FINACEA -azelaic acid foam 15%.................................. 110
FINACEA -azelaic acid gel 15%..................................... 110
finasteride tab 5 mg (Proscar)....................................... 57
FIRAZYR -icatibant acetate inj 30 mg/3ml (base
equivalent)..................................................................... 101
FLAREX -fluorometholone acetate ophth susp 0.1%..... 105
flavoxate hcl tab 100 mg.................................................56
flecainide acetate tab 50 mg.......................................... 35
flecainide acetate tab 100 mg........................................ 35
flecainide acetate tab 150 mg........................................ 35
FLECTOR -diclofenac epolamine patch 1.3%................ 110
FLEXICHAMBER ADULT MASK/S -spacer/aerosolholding chamber supplies - masks.............................. 121
FLEXICHAMBER CHILD MASK/L -spacer/aerosolholding chamber supplies - masks.............................. 121
FLEXICHAMBER CHILD MASK/S -spacer/aerosolholding chamber supplies - masks.............................. 121
FLEXICHAMBER -spacer/aerosol-holding chambers device............................................................................ 121
FLORIVA -sodium fluoride-vitamin d liqd drops 0.25 mg/
ml-400 unit/ml................................................................. 95
FLOVENT DISKUS -fluticasone propionate aer pow ba 50
mcg/blister....................................................................... 49
FLOVENT DISKUS -fluticasone propionate aer pow ba
100 mcg/blister................................................................ 49
FLOVENT DISKUS -fluticasone propionate aer pow ba
250 mcg/blister................................................................ 49
FLOVENT HFA -fluticasone propionate hfa inhal aer 110
mcg/act (125/valve)........................................................ 49
FLOVENT HFA -fluticasone propionate hfa inhal aer 220
mcg/act (250/valve)........................................................ 49
FLOVENT HFA -fluticasone propionate hfa inhal aero 44
mcg/act (50/valve)...........................................................49
FLOWTUSS -hydrocodone-guaifenesin soln 2.5-200
mg/5ml............................................................................. 46
FLUAD 2016-2017 -influenza vac type a&b surface ant
adj susp pref syr 0.5 ml................................................. 10
FLUARIX QUADRIVALENT 2016 -influenza virus vac split
quadrivalent susp pref syr 0.5ml.................................... 10
FLUBLOK 2015-2016 -influenza virus vac recombinant
hemagglutinin (ha) inj..................................................... 10
FLUBLOK 2016-2017 -influenza virus vac recombinant
hemagglutinin (ha) inj..................................................... 10
FLUCELVAX QUADRIVALENT 20 -influenza vac tiss-cult
subunt quad susp pref syr 0.5 ml.................................. 10
fluconazole for susp 10 mg/ml (Diflucan)....................... 5
fluconazole for susp 40 mg/ml (Diflucan)....................... 5
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fluconazole tab 50 mg (Diflucan)..................................... 5
fluconazole tab 100 mg (Diflucan)................................... 5
fluconazole tab 150 mg (Diflucan)................................... 5
fluconazole tab 200 mg (Diflucan)................................... 5
flucytosine cap 250 mg (Ancobon)................................. 5
flucytosine cap 500 mg (Ancobon)................................. 5
fludrocortisone acetate tab 0.1 mg............................... 16
FLULAVAL QUADRIVALENT 201 -influenza virus vaccine
split quadrivalent im inj................................................... 10
FLULAVAL QUADRIVALENT 201 -influenza virus vac split
quadrivalent susp pref syr 0.5ml.................................... 10
FLUMIST QUADRIVALENT -influenza virus vaccine live
quadrivalent intranasal susp...........................................10
flunisolide nasal soln 25 mcg/act (0.025%).................. 46
fluocinolone acetonide cream 0.01%.......................... 110
fluocinolone acetonide cream 0.025% (Synalar)........111
fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod).......................................................... 111
fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)...........................................................111
fluocinolone acetonide oint 0.025% (Synalar)............ 111
fluocinolone acetonide (otic) oil 0.01%
(Dermotic).................................................................... 107
fluocinolone acetonide soln 0.01% (Synalar)............. 111
fluocinonide cream 0.05%............................................ 111
fluocinonide cream 0.1% (Vanos)................................ 111
fluocinonide emulsified base cream 0.05%................ 111
fluocinonide gel 0.05%.................................................. 111
fluocinonide oint 0.05%................................................ 111
fluocinonide soln 0.05%................................................ 111
FLUORABON -sodium fluoride soln 0.25 mg/0.6ml (from
0.55 mg/0.6ml naf)..........................................................95
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 0.55
(0.25 mg f)-236.79 mg.................................................... 95
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 2.2 (1 mg
f)-236.79 mg.................................................................... 95
fluorometholone ophth susp 0.1% (Fml liquifilm)..... 105
FLUOROPLEX -fluorouracil cream 1%........................... 111
fluorouracil cream 5% (Efudex)................................... 111
FLUOROURACIL -fluorouracil cream 0.5%.................... 111
fluorouracil soln 2%...................................................... 111
fluorouracil soln 5%...................................................... 111
FLUOXETINE DR -fluoxetine hcl cap delayed release 90
mg.................................................................................... 59
FLUOXETINE -fluoxetine hcl (pmdd) cap 10 mg.............. 70
FLUOXETINE -fluoxetine hcl (pmdd) cap 20 mg.............. 70
fluoxetine hcl cap 10 mg (Prozac)................................. 59
fluoxetine hcl cap 20 mg (Prozac)................................. 59
fluoxetine hcl cap 40 mg (Prozac)................................. 59
FLUOXETINE HCL -fluoxetine hcl tab 60 mg................... 59
fluoxetine hcl (pmdd) tab 10 mg (Sarafem).................. 70
fluoxetine hcl (pmdd) tab 20 mg (Sarafem).................. 70
fluoxetine hcl solution 20 mg/5ml................................. 59
fluoxetine hcl tab 10 mg................................................. 59
fluoxetine hcl tab 20 mg................................................. 59
FLUPHENAZINE HCL -fluphenazine hcl elixir 2.5
mg/5ml............................................................................. 62
FLUPHENAZINE HCL -fluphenazine hcl oral conc 5 mg/
ml..................................................................................... 62
fluphenazine hcl tab 1 mg.............................................. 62
fluphenazine hcl tab 2.5 mg........................................... 62
fluphenazine hcl tab 5 mg.............................................. 62
fluphenazine hcl tab 10 mg............................................ 62
FLURA-DROPS -sodium fluoride soln 0.25 mg/drop f
(from 0.55 mg/drop naf)................................................. 95
flurandrenolide cream 0.05% (Cordran)...................... 111
flurandrenolide lotion 0.05% (Cordran).......................111
flurandrenolide oint 0.05% (Cordran).......................... 111
FLURAZEPAM HCL -flurazepam hcl cap 15 mg.............. 64
FLURAZEPAM HCL -flurazepam hcl cap 30 mg.............. 64
flurbiprofen sodium ophth soln 0.03% (Ocufen)........105
flurbiprofen tab 50 mg.................................................... 79
flurbiprofen tab 100 mg.................................................. 79
flutamide cap 125 mg...................................................... 13
fluticasone propionate cream 0.05% (Cutivate)......... 111
fluticasone propionate lotion 0.05% (Cutivate).......... 111
fluticasone propionate nasal susp 50 mcg/act............ 46
fluticasone propionate oint 0.005%............................. 111
FLUTTER -respiratory therapy supplies - devices.......... 121
fluvastatin sodium cap 20 mg........................................ 43
fluvastatin sodium cap 40 mg........................................ 43
fluvastatin sodium tab sr 24 hr 80 mg (Lescol xl)........43
FLUVIRIN 2015-2016 -influenza vac type a&b surface
antigen susp pref syr 0.5 ml...........................................10
FLUVIRIN 2016-2017 -influenza vac type a&b surface
antigen susp pref syr 0.5 ml...........................................10
FLUVIRIN 2015-2016 -influenza virus vaccine types a & b
surface antigen im susp................................................. 10
FLUVIRIN 2016-2017 -influenza virus vaccine types a & b
surface antigen im susp................................................. 10
fluvoxamine maleate cap sr 24hr 100 mg..................... 59
fluvoxamine maleate cap sr 24hr 150 mg..................... 59
fluvoxamine maleate tab 25 mg..................................... 59
fluvoxamine maleate tab 50 mg..................................... 60
fluvoxamine maleate tab 100 mg................................... 60
FLUZONE HIGH-DOSE PF 2016 -influenza virus vac split
high-dose pf susp pref syr 0.5ml....................................10
FLUZONE INTRADERMAL QUADR -influenza virus vac
split quad intradermal pen 9 mcg/strain......................... 10
FLUZONE QUADRIVALENT 2016 -influenza virus
vaccine split quadrivalent im inj..................................... 10
FLUZONE QUADRIVALENT 2016 -influenza virus
vaccine split quadrivalent inj 0.5 ml............................... 11
FLUZONE QUADRIVALENT 2016 -influenza virus vac
split quadrivalent susp pref syr 0.25 ml......................... 10
FLUZONE QUADRIVALENT 2016 -influenza virus vac
split quadrivalent susp pref syr 0.5ml............................ 10
FML -fluorometholone ophth oint 0.1%........................... 105
FML FORTE -fluorometholone ophth susp 0.25%.......... 105
FOCALGIN CA -prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 300 mg pack.....................................................90
FOCALGIN 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa tab
90 &dha cap 300mg pak................................................ 90
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FOLCAL DHA -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 27-1.25-300 mg....................................................... 90
FOLCAPS OMEGA 3 -prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg................................................. 90
FOLET DHA -prenat w/fecbn-bisg-methylf-dss tab dr &
dha cap pak.................................................................... 90
FOLET ONE -prenat w/o a w/fecbn-bisg-methylf-dss-dha
cap 38-1-225 mg............................................................ 90
folic acid cap 0.8 mg....................................................... 97
folic acid-pyridoxine-cyanocobalamin tab 2.5-25-2
mg................................................................................... 96
folic acid tab 400 mcg..................................................... 97
folic acid tab 800 mcg..................................................... 97
folic acid tab 1 mg........................................................... 97
FOLIVANE-OB -prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg................................................................. 90
FOLLISTIM AQ -follitropin beta inj 75 unit/0.5ml.............. 29
FOLLISTIM AQ -follitropin beta inj 300 unit/0.36ml.......... 29
FOLLISTIM AQ -follitropin beta inj 600 unit/0.72ml.......... 29
FOLLISTIM AQ -follitropin beta inj 900 unit/1.08ml.......... 29
fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml
(Arixtra)........................................................................... 98
fondaparinux sodium subcutaneous inj 5 mg/0.4ml
(Arixtra)........................................................................... 98
fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml
(Arixtra)........................................................................... 98
fondaparinux sodium subcutaneous inj 10 mg/0.8ml
(Arixtra)........................................................................... 98
FORA BLOOD GLUCOSE TEST S -glucose blood test
strip................................................................................ 116
FORACARE GD40 -glucose blood test strip...................116
FORACARE PREMIUM V10 TEST -glucose blood test
strip................................................................................ 116
FORACARE TEST N GO TEST S -glucose blood test
strip................................................................................ 116
FORA D40/G31 BLOOD GLUCOS -glucose blood test
strip................................................................................ 116
FORA D20 BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 116
FORA D15G BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 116
FORA G30A BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 116
FORA G20 BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 116
FORA GD50 BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 116
FORA GD20 TEST STRIPS -glucose blood test
strip................................................................................ 116
FORA TN'G/TN'G VOICE BLOO -glucose blood test
strip................................................................................ 116
FORA V30A BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 116
FORA V10 BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 116
FORA V12 BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 116
FORA V20 BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 116
FORFIVO XL -bupropion hcl tab sr 24hr 450 mg............. 60
FORTEO -teriparatide (recombinant) inj 600
mcg/2.4ml........................................................................ 29
FORTESTA -testosterone td gel 10mg/act (2%)............... 18
FORTISCARE BLOOD GLUCOSE -glucose blood test
strip................................................................................ 116
FOSAMAX PLUS D -alendronate sodium-cholecalciferol
tab 70-2800 mg-unit....................................................... 29
FOSAMAX PLUS D -alendronate sodium-cholecalciferol
tab 70-5600 mg-unit....................................................... 29
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg................................................................................... 38
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg................................................................................... 38
fosinopril sodium tab 10 mg.......................................... 38
fosinopril sodium tab 20 mg.......................................... 38
fosinopril sodium tab 40 mg.......................................... 38
FOSRENOL -lanthanum carbonate chew tab 500 mg
(elemental).......................................................................54
FOSRENOL -lanthanum carbonate chew tab 750 mg
(elemental).......................................................................54
FOSRENOL -lanthanum carbonate chew tab 1000 mg
(elemental).......................................................................54
FOSRENOL -lanthanum carbonate oral powder pack 750
mg (elemental)................................................................ 54
FOSRENOL -lanthanum carbonate oral powder pack
1000 mg (elemental).......................................................54
FRAGMIN -dalteparin sodium inj 10000 unit/ml................98
FRAGMIN -dalteparin sodium inj 2500 unit/0.2ml.............98
FRAGMIN -dalteparin sodium inj 5000 unit/0.2ml.............98
FRAGMIN -dalteparin sodium inj 7500 unit/0.3ml.............98
FRAGMIN -dalteparin sodium inj 12500 unit/0.5ml...........98
FRAGMIN -dalteparin sodium inj 15000 unit/0.6ml...........98
FRAGMIN -dalteparin sodium inj 18000 unit/0.72ml.........98
FRAGMIN -dalteparin sodium inj 95000 unit/3.8ml...........98
FREESTYLE INSULINX BLOOD -glucose blood test
strip................................................................................ 117
FREESTYLE LITE TEST STRIP -glucose blood test
strip................................................................................ 117
FREESTYLE PRECISION NEO B -glucose blood test
strip................................................................................ 117
FREESTYLE TEST STRIPS -glucose blood test
strip................................................................................ 117
frovatriptan succinate tab 2.5 mg (base equivalent)
(Frova).............................................................................81
FUROSEMIDE -furosemide oral soln 8 mg/ml..................41
furosemide oral soln 10 mg/ml...................................... 41
furosemide tab 20 mg (Lasix)........................................ 41
furosemide tab 40 mg (Lasix)........................................ 41
furosemide tab 80 mg (Lasix)........................................ 41
FUZEON -enfuvirtide for inj 90 mg..................................... 6
FYCOMPA -perampanel susp 0.5 mg/ml.......................... 83
FYCOMPA -perampanel tab 2 mg.................................... 83
FYCOMPA -perampanel tab 4 mg.................................... 83
FYCOMPA -perampanel tab 6 mg.................................... 83
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FYCOMPA -perampanel tab 8 mg.................................... 83
FYCOMPA -perampanel tab 10 mg.................................. 83
FYCOMPA -perampanel tab 12 mg.................................. 83
G
gabapentin cap 100 mg (Neurontin).............................. 83
gabapentin cap 300 mg (Neurontin).............................. 83
gabapentin cap 400 mg (Neurontin).............................. 83
gabapentin oral soln 250 mg/5ml (Neurontin).............. 83
gabapentin tab 600 mg (Neurontin)............................... 83
gabapentin tab 800 mg (Neurontin)............................... 83
GABITRIL -tiagabine hcl tab 12 mg.................................. 83
GABITRIL -tiagabine hcl tab 16 mg.................................. 83
galantamine hydrobromide cap sr 24hr 8 mg
(Razadyne er)................................................................ 70
galantamine hydrobromide cap sr 24hr 16 mg
(Razadyne er)................................................................ 70
galantamine hydrobromide cap sr 24hr 24 mg
(Razadyne er)................................................................ 70
GALANTAMINE HYDROBROMIDE -galantamine
hydrobromide oral soln 4 mg/ml.................................... 70
galantamine hydrobromide tab 4 mg (Razadyne)........ 70
galantamine hydrobromide tab 8 mg (Razadyne)........ 70
galantamine hydrobromide tab 12 mg (Razadyne)...... 70
GALZIN -zinc acetate cap 25 mg (elemental zinc)........... 95
GALZIN -zinc acetate cap 50 mg (elemental zinc)........... 95
GANIRELIX ACETATE -ganirelix acetate inj 250
mcg/0.5ml........................................................................ 29
GARDASIL -human papillomavirus (hpv) quadrivalent
recombinant vac inj.........................................................11
GARDASIL 9 -human papillomavirus (hpv) 9-valent
recomb vac im susp....................................................... 11
GARDASIL 9 -human papillomavirus (hpv) 9-valent
recomb vac susp pref syr............................................... 11
gatifloxacin ophth soln 0.5% (Zymaxid)..................... 105
GATTEX -teduglutide (rdna) for inj kit 5 mg...................... 54
GE100 BLOOD GLUCOSE TEST -glucose blood test
strip................................................................................ 117
GELNIQUE -oxybutynin chloride td gel 10%.................... 56
GELNIQUE PUMP -oxybutynin chloride td gel 10%......... 56
gemfibrozil tab 600 mg (Lopid)...................................... 43
GENOTROPIN MINIQUICK -somatropin for inj 0.2
mg.................................................................................... 29
GENOTROPIN MINIQUICK -somatropin for inj 0.4
mg.................................................................................... 29
GENOTROPIN MINIQUICK -somatropin for inj 0.6
mg.................................................................................... 29
GENOTROPIN MINIQUICK -somatropin for inj 0.8
mg.................................................................................... 29
GENOTROPIN MINIQUICK -somatropin for inj 1 mg....... 29
GENOTROPIN MINIQUICK -somatropin for inj 1.2
mg.................................................................................... 29
GENOTROPIN MINIQUICK -somatropin for inj 1.4
mg.................................................................................... 29
GENOTROPIN MINIQUICK -somatropin for inj 1.6
mg.................................................................................... 29
GENOTROPIN MINIQUICK -somatropin for inj 1.8
mg.................................................................................... 29
GENOTROPIN MINIQUICK -somatropin for inj 2 mg....... 29
GENOTROPIN -somatropin for inj 12 mg (13.8 mg
overfill)............................................................................. 29
GENOTROPIN -somatropin for subcutaneous inj 5
mg.................................................................................... 29
GENSTRIP 50 -glucose blood test strip..........................117
gentamicin sulfate cream 0.1%.................................... 111
GENTAMICIN SULFATE -gentamicin sulfate oint
0.1%...............................................................................111
gentamicin sulfate ophth oint 0.3%............................. 105
gentamicin sulfate ophth soln 0.3%............................ 105
GENULTIMATE TEST STRIPS -glucose blood test
strip................................................................................ 117
GENVOYA -elvitegrav-cobic-emtricitab-tenofov af tab
150-150-200-10 mg.......................................................... 6
GHT TEST STRIPS -glucose blood test strip................. 117
GIALAX -polyethylene glycol 3350 - kit............................ 51
GIAZO -balsalazide disodium tab 1.1 gm......................... 54
GILENYA -fingolimod hcl cap 0.5 mg (base equiv)........... 70
GILOTRIF -afatinib dimaleate tab 20 mg (base
equivalent)....................................................................... 13
GILOTRIF -afatinib dimaleate tab 30 mg (base
equivalent)....................................................................... 13
GILOTRIF -afatinib dimaleate tab 40 mg (base
equivalent)....................................................................... 13
GLASSIA -alpha1-proteinase inhibitor (human) inj 1000
mg/50ml........................................................................... 50
glatiramer acetate soln prefilled syringe 20 mg/ml
(Copaxone)..................................................................... 70
GLEOSTINE -lomustine cap 5 mg.................................... 13
GLEOSTINE -lomustine cap 10 mg.................................. 13
GLEOSTINE -lomustine cap 40 mg.................................. 13
GLEOSTINE -lomustine cap 100 mg................................ 13
glimepiride tab 1 mg (Amaryl)........................................22
glimepiride tab 2 mg (Amaryl)........................................22
glimepiride tab 4 mg (Amaryl)........................................22
glipizide-metformin hcl tab 2.5-250 mg......................... 22
glipizide-metformin hcl tab 2.5-500 mg......................... 22
glipizide-metformin hcl tab 5-500 mg............................ 22
glipizide tab 5 mg (Glucotrol).........................................22
glipizide tab 10 mg (Glucotrol).......................................22
glipizide tab sr 24hr 2.5 mg (Glucotrol xl).................... 22
glipizide tab sr 24hr 5 mg (Glucotrol xl)....................... 22
glipizide tab sr 24hr 10 mg (Glucotrol xl)..................... 22
GLUCAGEN HYPOKIT -glucagon hcl (rdna) for inj 1 mg
(base equiv).................................................................... 22
GLUCAGON EMERGENCY KIT -glucagon (rdna) for inj
kit 1 mg........................................................................... 22
GLUCOCARD EXPRESSION BLOO -glucose blood test
strip................................................................................ 117
GLUCOCARD 01 SENSOR PLUS -glucose blood test
strip................................................................................ 117
GLUCOCARD SHINE TEST STRI -glucose blood test
strip................................................................................ 117
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GLUCOCARD VITAL TEST STRI -glucose blood test
strip................................................................................ 117
GLUCOCARD X-SENSOR -glucose blood test strip...... 117
GLUCOCOM TEST STRIPS -glucose blood test
strip................................................................................ 117
GLUCONAVII BLOOD GLUCOSE -glucose blood test
strip................................................................................ 117
GLUCO PERFECT 3 TEST STRI -glucose blood test
strip................................................................................ 117
GLUCOSE METER TEST STRIPS -glucose blood test
strip................................................................................ 117
glyburide-metformin tab 1.25-250 mg........................... 23
glyburide-metformin tab 2.5-500 mg (Glucovance)..... 23
glyburide-metformin tab 5-500 mg (Glucovance)........ 23
glyburide micronized tab 1.5 mg (Glynase)..................22
glyburide micronized tab 3 mg (Glynase).....................23
glyburide micronized tab 6 mg (Glynase).....................23
glyburide tab 1.25 mg..................................................... 23
glyburide tab 2.5 mg....................................................... 23
glyburide tab 5 mg.......................................................... 23
glycopyrrolate tab 1 mg (Robinul)................................. 52
glycopyrrolate tab 2 mg (Robinul forte)........................52
GLYTACTIN BETTERMILK DE-L -nutritional supplement
pack................................................................................. 96
GLYTACTIN BETTERMILK 15 -nutritional supplement
pack................................................................................. 96
GLYTACTIN BUILD 10PE -nutritional supplement
pack................................................................................. 96
GLYTACTIN COMPLETE 10PE -nutritional supplement
bar.................................................................................... 96
GLYTACTIN RESTORE LITE 10 -nutritional supplement
pack................................................................................. 96
GLYTACTIN RESTORE 5 -nutritional supplement
pack................................................................................. 96
GLYTACTIN RTD 10 -nutritional supplement liquid.......... 96
GLYTACTIN RTD 15 -nutritional supplement liquid.......... 96
GLYXAMBI -empagliflozin-linagliptin tab 10-5 mg............ 23
GLYXAMBI -empagliflozin-linagliptin tab 25-5 mg............ 23
GMATE BLOOD GLUCOSE TEST -glucose blood test
strip................................................................................ 117
GNP EASY TOUCH GLUCOSE TE -glucose blood test
strip................................................................................ 117
GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate
packet 227.1 gm............................................................. 51
GONAL-F -follitropin alfa for inj 450 unit........................... 29
GONAL-F -follitropin alfa for inj 1050 unit......................... 29
GONAL-F RFF -follitropin alfa for inj 75 unit..................... 29
GONAL-F RFF REDIJECT -follitropin alfa inj 300
unit/0.5ml......................................................................... 29
GONAL-F RFF REDIJECT -follitropin alfa inj 450
unit/0.75ml....................................................................... 30
GONAL-F RFF REDIJECT -follitropin alfa inj 900
unit/1.5ml......................................................................... 30
GONITRO -nitroglycerin sublingual powder packet 400
mcg.................................................................................. 32
GRALISE -gabapentin (once-daily) tab 300 mg................70
GRALISE -gabapentin (once-daily) tab 600 mg................70
GRALISE STARTER -gabapentin (once-daily) tab pack
300 mg (9) & 600 mg (69)............................................. 70
granisetron hcl tab 1 mg................................................ 53
GRANIX -tbo-filgrastim soln prefilled syringe 300
mcg/0.5ml........................................................................ 97
GRANIX -tbo-filgrastim soln prefilled syringe 480
mcg/0.8ml........................................................................ 97
GRASTEK -timothy grass pollen allergen ext tab sl 2800
bau................................................................................... 12
griseofulvin microsize susp 125 mg/5ml........................ 5
griseofulvin microsize tab 500 mg.................................. 5
griseofulvin ultramicrosize tab 125 mg (Gris-peg)........ 5
griseofulvin ultramicrosize tab 250 mg (Gris-peg)........ 5
guaifenesin-codeine liquid 225-7.5 mg/5ml.................. 46
guaifenesin-codeine soln 100-6.3 mg/5ml.................... 46
guaifenesin-codeine soln 100-10 mg/5ml..................... 47
guanfacine hcl tab 1 mg................................................. 38
guanfacine hcl tab 2 mg................................................. 38
guanfacine hcl tab sr 24hr 1 mg (base equiv)
(Intuniv).......................................................................... 67
guanfacine hcl tab sr 24hr 2 mg (base equiv)
(Intuniv).......................................................................... 67
guanfacine hcl tab sr 24hr 3 mg (base equiv)
(Intuniv).......................................................................... 67
guanfacine hcl tab sr 24hr 4 mg (base equiv)
(Intuniv).......................................................................... 67
GUANIDINE HCL -guanidine hcl tab 125 mg................... 88
GYNAZOLE-1 -butoconazole nitrate (one dose) vaginal
cream 2%........................................................................ 56
H
HALCION -triazolam tab 0.25 mg..................................... 64
halobetasol propionate cream 0.05% (Ultravate)....... 111
halobetasol propionate oint 0.05% (Ultravate)........... 111
HALOG -halcinonide cream 0.1%................................... 111
HALOG -halcinonide oint 0.1%....................................... 111
haloperidol lactate oral conc 2 mg/ml...........................62
haloperidol tab 0.5 mg.................................................... 62
haloperidol tab 1 mg....................................................... 62
haloperidol tab 2 mg....................................................... 62
haloperidol tab 5 mg....................................................... 62
haloperidol tab 10 mg..................................................... 62
haloperidol tab 20 mg..................................................... 62
HARVONI -ledipasvir-sofosbuvir tab 90-400 mg................ 6
HAVRIX -hepatitis a vaccine inj susp 720 el
unit/0.5ml......................................................................... 11
HAVRIX -hepatitis a vaccine inj susp 1440 el unit/ml....... 11
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 250 unit.................................................................... 101
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 500 unit.................................................................... 101
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 1000 unit.................................................................. 101
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 2000 unit.................................................................. 101
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 3000 unit.................................................................. 101
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HEMANGEOL -propranolol hcl oral soln 4.28 mg/ml (3.75
mg/ml base equiv).......................................................... 33
HEMENATAL OB + DHA -prenat-fe poly cmplx-fe heme
poly-fa tab & omega 3 cap pck...................................... 90
HEMENATAL OB -prenat vit-fe poly cmplx-fe heme polyfa tab 28-6-1 mg............................................................. 90
HEMOFIL M -antihemophilic factor (human) for inj 250
unit................................................................................. 101
HEMOFIL M -antihemophilic factor (human) for inj 500
unit................................................................................. 101
HEMOFIL M -antihemophilic factor (human) for inj 1000
unit................................................................................. 101
HEMOFIL M -antihemophilic factor (human) for inj 1700
unit................................................................................. 101
heparin sodium (porcine) inj 1000 unit/ml.................... 98
heparin sodium (porcine) inj 5000 unit/ml.................... 98
heparin sodium (porcine) inj 10000 unit/ml.................. 99
heparin sodium (porcine) inj 20000 unit/ml.................. 99
heparin sodium (porcine) pf inj 5000 unit/0.5ml.......... 99
HETLIOZ -tasimelteon capsule 20 mg.............................. 64
HEXALEN -altretamine cap 50 mg................................... 13
HIBERIX -haemophilus b polysaccharide conjugate vac
for inj 10 mcg.................................................................. 11
HISTEX-AC -phenylephrine-triprolidine-codeine syrup
10-2.5-10 mg/5ml............................................................ 47
HOMACTIN AA PLUS -nutritional supplement liquid........ 96
HORIZANT -gabapentin enacarbil tab cr 300 mg............. 70
HORIZANT -gabapentin enacarbil tab cr 600 mg............. 70
H.P. ACTHAR -corticotropin inj gel 80 unit/ml................... 30
HUMALOG -insulin lispro inj 100 unit/ml...........................25
HUMALOG -insulin lispro soln cartridge 100 unit/ml.........25
HUMALOG KWIKPEN -insulin lispro soln pen-injector 100
unit/ml.............................................................................. 25
HUMALOG KWIKPEN -insulin lispro soln pen-injector 200
unit/ml.............................................................................. 25
HUMALOG MIX 75/25 -insulin lispro prot & lispro inj 100
unit/ml (75-25)................................................................. 26
HUMALOG MIX 50/50 -insulin lispro protamine & lispro inj
100 unit/ml (50-50)......................................................... 25
HUMALOG MIX 50/50 KWIKPEN -insulin lispro prot &
lispro sus pen-inj 100 unit/ml (50-50).............................26
HUMALOG MIX 75/25 KWIKPEN -insulin lispro prot &
lispro sus pen-inj 100 unit/ml (75-25).............................26
HUMATE-P -antihemophilic factor/vwf (human) for inj
250-600 unit.................................................................. 102
HUMATE-P -antihemophilic factor/vwf (human) for inj
500-1200 unit................................................................ 102
HUMATE-P -antihemophilic factor/vwf (human) for inj
1000-2400 unit.............................................................. 102
HUMATROPE COMBO PACK -somatropin for inj 5
mg.................................................................................... 30
HUMATROPE -somatropin for inj 5 mg............................ 30
HUMATROPE -somatropin for inj 24 mg.......................... 30
HUMATROPE -somatropin for inj 6 mg (18 unit).............. 30
HUMATROPE -somatropin for inj 12 mg (36 unit)............ 30
HUMIRA -adalimumab prefilled syringe kit 10
mg/0.2ml.......................................................................... 79
HUMIRA -adalimumab prefilled syringe kit 20
mg/0.4ml.......................................................................... 79
HUMIRA -adalimumab prefilled syringe kit 40
mg/0.8ml.......................................................................... 79
HUMIRA PEDIATRIC CROHNS D -adalimumab prefilled
syringe kit 40 mg/0.8ml.................................................. 79
HUMIRA PEN -adalimumab pen-injector kit 40
mg/0.8ml.......................................................................... 79
HUMIRA PEN-CROHNS DISEASE -adalimumab peninjector kit 40 mg/0.8ml.................................................. 79
HUMIRA PEN-PSORIASIS STAR -adalimumab peninjector kit 40 mg/0.8ml.................................................. 79
HUMULIN 70/30 -insulin nph isophane & regular human
inj 100 unit/ml (70-30).................................................... 26
HUMULIN 70/30 KWIKPEN -insulin nph & regular susp
pen-inj 100 unit/ml (70-30)............................................. 26
HUMULIN N -insulin nph (human) (isophane) inj 100 unit/
ml..................................................................................... 26
HUMULIN N KWIKPEN -insulin nph (human) (isophane)
susp pen-injector 100 unit/ml......................................... 26
HUMULIN R -insulin regular (human) inj 100 unit/ml........ 25
HUMULIN R U-500 (CONCENTR -insulin regular (human)
inj 500 unit/ml..................................................................25
HUMULIN R U-500 KWIKPEN -insulin regular (human)
soln pen-injector 500 unit/ml.......................................... 25
HYCAMTIN -topotecan hcl cap 0.25 mg (base equiv)...... 13
HYCAMTIN -topotecan hcl cap 1 mg (base equiv)........... 13
HYCOFENIX -pseudoephedrine w/ hydrocodone-gg soln
30-2.5-200 mg/5ml.......................................................... 47
hydralazine hcl tab 10 mg.............................................. 38
hydralazine hcl tab 25 mg.............................................. 38
hydralazine hcl tab 50 mg.............................................. 38
hydralazine hcl tab 100 mg............................................ 38
hydrochlorothiazide cap 12.5 mg (Microzide).............. 41
hydrochlorothiazide tab 12.5 mg................................... 41
hydrochlorothiazide tab 25 mg...................................... 41
hydrochlorothiazide tab 50 mg...................................... 41
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
(Hycet).............................................................................74
hydrocodone-acetaminophen soln 10-325 mg/15ml
(Zamicet).........................................................................74
hydrocodone-acetaminophen tab 2.5-325 mg.............. 74
hydrocodone-acetaminophen tab 7.5-325 mg
(Norco)............................................................................ 74
hydrocodone-acetaminophen tab 5-325 mg
(Norco)............................................................................ 74
hydrocodone-acetaminophen tab 10-325 mg
(Norco)............................................................................ 74
hydrocodone-acetaminophen tab 7.5-300 mg
(Xodol)............................................................................ 74
hydrocodone-acetaminophen tab 5-300 mg
(Xodol)............................................................................ 74
hydrocodone-acetaminophen tab 10-300 mg
(Xodol)............................................................................ 74
hydrocodone-ibuprofen tab 7.5-200 mg........................74
hydrocodone-ibuprofen tab 10-200 mg (Ibudone)....... 74
hydrocodone-ibuprofen tab 5-200 mg (Reprexain)......74
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hydrocodone w/ homatropine syrup 5-1.5 mg/5ml...... 47
hydrocodone w/ homatropine tab 5-1.5 mg..................47
hydrocod polst-chlorphen polst er susp 10-8 mg/5ml
(Tussionex pennkineti)................................................. 47
hydrocortisone acetate w/ pramoxine rectal cream
1-1% (Analpram-hc).................................................... 108
hydrocortisone butyrate cream 0.1% (Locoid)...........111
hydrocortisone butyrate hydrophilic lipo base cream
0.1% (Locoid lipocream)............................................ 111
hydrocortisone butyrate oint 0.1% (Locoid)............... 111
hydrocortisone butyrate soln 0.1% (Locoid).............. 111
hydrocortisone cream 1%.............................................111
hydrocortisone cream 2.5%..........................................111
hydrocortisone enema 100 mg/60ml
(Cortenema)................................................................. 108
hydrocortisone lotion 2.5%.......................................... 111
hydrocortisone oint 1%................................................. 111
hydrocortisone oint 2.5%..............................................111
hydrocortisone rectal cream 2.5% (Anusol-hc)......... 108
hydrocortisone rectal cream 1% (Proctocort)............ 108
hydrocortisone tab 5 mg (Cortef).................................. 16
hydrocortisone tab 10 mg (Cortef)................................ 16
hydrocortisone tab 20 mg (Cortef)................................ 16
hydrocortisone valerate cream 0.2%...........................111
hydrocortisone valerate oint 0.2% (Westcort)............ 111
hydrocortisone w/ acetic acid otic soln 1-2%............ 107
hydromorphone hcl liqd 1 mg/ml (Dilaudid).................74
hydromorphone hcl tab er 24hr deter 8 mg
(Exalgo).......................................................................... 74
hydromorphone hcl tab er 24hr deter 12 mg
(Exalgo).......................................................................... 74
hydromorphone hcl tab er 24hr deter 16 mg
(Exalgo).......................................................................... 74
hydromorphone hcl tab er 24hr deter 32 mg
(Exalgo).......................................................................... 74
hydromorphone hcl tab 2 mg (Dilaudid)....................... 74
hydromorphone hcl tab 4 mg (Dilaudid)....................... 74
hydromorphone hcl tab 8 mg (Dilaudid)....................... 74
HYDROXOCOBALAMIN -hydroxocobalamin inj 1000
mcg/ml............................................................................. 97
hydroxychloroquine sulfate tab 200 mg (Plaquenil)......9
hydroxyurea cap 500 mg (Hydrea)................................ 13
hydroxyzine hcl syrup 10 mg/5ml................................. 58
hydroxyzine hcl tab 10 mg............................................. 58
hydroxyzine hcl tab 25 mg............................................. 58
hydroxyzine hcl tab 50 mg............................................. 58
hydroxyzine pamoate cap 25 mg (Vistaril)................... 58
hydroxyzine pamoate cap 50 mg (Vistaril)................... 58
HYDROXYZINE PAMOATE -hydroxyzine pamoate cap
100 mg............................................................................ 58
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
20 mg.............................................................................. 74
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
30 mg.............................................................................. 74
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
40 mg.............................................................................. 74
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
60 mg.............................................................................. 74
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
80 mg.............................................................................. 74
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
100 mg............................................................................ 74
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
120 mg............................................................................ 74
I
ibandronate sodium tab 150 mg (base equivalent)
(Boniva).......................................................................... 30
IBRANCE -palbociclib cap 75 mg..................................... 13
IBRANCE -palbociclib cap 100 mg................................... 13
IBRANCE -palbociclib cap 125 mg................................... 13
ibuprofen susp 100 mg/5ml............................................ 79
ibuprofen tab 400 mg...................................................... 79
ibuprofen tab 600 mg...................................................... 79
ibuprofen tab 800 mg...................................................... 79
ICLUSIG -ponatinib hcl tab 15 mg (base equiv)............... 13
ICLUSIG -ponatinib hcl tab 45 mg (base equiv)............... 13
IDELVION -coagulation factor ix (recomb) (rix-fp) for inj
250 unit......................................................................... 102
IDELVION -coagulation factor ix (recomb) (rix-fp) for inj
500 unit......................................................................... 102
IDELVION -coagulation factor ix (recomb) (rix-fp) for inj
1000 unit....................................................................... 102
IDELVION -coagulation factor ix (recomb) (rix-fp) for inj
2000 unit....................................................................... 102
ILEVRO -nepafenac ophth susp 0.3%............................ 105
imatinib mesylate tab 100 mg (base equivalent)
(Gleevec)........................................................................ 13
imatinib mesylate tab 400 mg (base equivalent)
(Gleevec)........................................................................ 13
IMBRUVICA -ibrutinib cap 140 mg................................... 13
imipramine hcl tab 10 mg (Tofranil).............................. 60
imipramine hcl tab 25 mg (Tofranil).............................. 60
imipramine hcl tab 50 mg (Tofranil).............................. 60
imipramine pamoate cap 75 mg.................................... 60
imipramine pamoate cap 100 mg.................................. 60
imipramine pamoate cap 125 mg.................................. 60
imipramine pamoate cap 150 mg.................................. 60
imiquimod cream 5% (Aldara)...................................... 111
IMOVAX RABIES (H.D.C.V.) -rabies virus vaccine, hdc
inj..................................................................................... 11
IMPAVIDO -miltefosine cap 50 mg...................................... 9
IMURAN -azathioprine tab 50 mg................................... 123
INATAL ADVANCE -prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg.....................................................................90
INATAL GT -prenatal vit w/ dss-iron carbonyl-fa tab 90-1
mg.................................................................................... 90
INATAL ULTRA -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg........................................................................... 90
IN-CHECK DIAL INSPIRATORY -respiratory therapy
supplies - devices......................................................... 121
IN-CHECK INSPIRATORY FLOW -respiratory therapy
supplies - devices......................................................... 121
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INCRELEX -mecasermin inj 40 mg/4ml (10 mg/ml)..........30
INCRUSE ELLIPTA -umeclidinium br aero powd breath
act 62.5 mcg/inh (base eq)............................................ 49
indapamide tab 1.25 mg..................................................41
indapamide tab 2.5 mg.................................................... 41
INDERAL XL -propranolol hcl sustained-release beads
cap sr 24hr 80 mg.......................................................... 33
INDERAL XL -propranolol hcl sustained-release beads
cap sr 24hr 120 mg........................................................ 33
INDOCIN -indomethacin suppos 50 mg............................ 79
INDOCIN -indomethacin susp 25 mg/5ml......................... 79
indomethacin cap cr 75 mg............................................ 79
indomethacin cap 25 mg................................................ 79
indomethacin cap 50 mg................................................ 79
INFANATE BALANCE -prenatal w/o a w/fe cbn-dss-fa-dha
cap 29-1-265 mg............................................................ 90
INFANRIX -diph, acellular pert & tet tox inj 25 lf-58
mcg-10 lf/0.5ml............................................................... 12
INFINITY BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 117
INLYTA -axitinib tab 1 mg.................................................. 13
INLYTA -axitinib tab 5 mg.................................................. 13
INNOPRAN XL -propranolol hcl sustained-release beads
cap sr 24hr 80 mg.......................................................... 33
INNOPRAN XL -propranolol hcl sustained-release beads
cap sr 24hr 120 mg........................................................ 33
INSPIRACHAMBER/ANTI-STATI -spacer/aerosol-holding
chambers - device........................................................ 121
INSPIRACHAMBER/LARGE -spacer/aerosol-holding
chambers - device........................................................ 121
INSPIRACHAMBER/SOOTHERMAS -spacer/aerosolholding chambers - device........................................... 121
INSPIREASE BAGS -spacer/aerosol-holding chamber
supplies - bags............................................................. 121
INSPIREASE DRUG DELIVERY -spacer/aerosol-holding
chambers - device........................................................ 121
INSPIREASE MOUTHPIECE -spacer/aerosol-holding
chamber supplies - mouthpieces................................. 121
INSPIREASE RESERVOIR BAGS -spacer/aerosolholding chamber supplies - bags................................. 121
INSULIN PEN NEEDLES – VARIOUS............................ 121
INSULIN SYRINGES – VARIOUS...................................121
INTELENCE -etravirine tab 25 mg...................................... 6
INTELENCE -etravirine tab 100 mg.................................... 6
INTELENCE -etravirine tab 200 mg.................................... 6
IN TOUCH BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 117
INTRON A -interferon alfa-2b for inj 10000000 unit.......... 13
INTRON A -interferon alfa-2b for inj 18000000 unit.......... 13
INTRON A -interferon alfa-2b for inj 50000000 unit.......... 13
INTRON A -interferon alfa-2b inj 6000000 unit/ml............ 13
INTRON A -interferon alfa-2b inj 10000000 unit/ml.......... 13
INTRON A W/DILUENT -interferon alfa-2b for inj
10000000 unit................................................................. 13
INTRON A W/DILUENT -interferon alfa-2b for inj
18000000 unit................................................................. 13
INTRON A W/DILUENT -interferon alfa-2b for inj
50000000 unit................................................................. 13
INVIRASE -saquinavir mesylate cap 200 mg..................... 6
INVIRASE -saquinavir mesylate tab 500 mg...................... 6
INVOKAMET -canagliflozin-metformin hcl tab 50-500
mg.................................................................................... 23
INVOKAMET -canagliflozin-metformin hcl tab 150-500
mg.................................................................................... 23
INVOKAMET -canagliflozin-metformin hcl tab 50-1000
mg.................................................................................... 23
INVOKAMET -canagliflozin-metformin hcl tab 150-1000
mg.................................................................................... 23
INVOKAMET XR -canagliflozin-metformin hcl tab sr 24hr
50-500 mg....................................................................... 23
INVOKAMET XR -canagliflozin-metformin hcl tab sr 24hr
50-1000 mg..................................................................... 23
INVOKAMET XR -canagliflozin-metformin hcl tab sr 24hr
150-500 mg..................................................................... 23
INVOKAMET XR -canagliflozin-metformin hcl tab sr 24hr
150-1000 mg................................................................... 23
INVOKANA -canagliflozin tab 100 mg.............................. 23
INVOKANA -canagliflozin tab 300 mg.............................. 23
IOPIDINE -apraclonidine hcl ophth soln 1% (base
equivalent)..................................................................... 105
IPOL INACTIVATED IPV -poliovirus vaccine, ipv
injection........................................................................... 11
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml..... 49
ipratropium bromide inhal soln 0.02%.......................... 49
ipratropium bromide nasal soln 0.03% (21 mcg/
spray).............................................................................. 46
ipratropium bromide nasal soln 0.06% (42 mcg/
spray).............................................................................. 46
irbesartan-hydrochlorothiazide tab 150-12.5 mg
(Avalide)..........................................................................38
irbesartan-hydrochlorothiazide tab 300-12.5 mg
(Avalide)..........................................................................38
irbesartan tab 75 mg (Avapro)....................................... 38
irbesartan tab 150 mg (Avapro)..................................... 38
irbesartan tab 300 mg (Avapro)..................................... 38
IRESSA -gefitinib tab 250 mg........................................... 13
ISENTRESS -raltegravir potassium chew tab 25 mg (base
equiv)................................................................................. 6
ISENTRESS -raltegravir potassium chew tab 100 mg
(base equiv)...................................................................... 6
ISENTRESS -raltegravir potassium packet for susp 100
mg (base equiv)................................................................ 6
ISENTRESS -raltegravir potassium tab 400 mg (base
equiv)................................................................................. 6
ISONIAZID -isoniazid syrup 50 mg/5ml.............................. 4
isoniazid tab 100 mg......................................................... 4
isoniazid tab 300 mg......................................................... 4
ISORDIL TITRADOSE -isosorbide dinitrate tab 40
mg.................................................................................... 32
ISOSORBIDE DINITRATE ER -isosorbide dinitrate tab cr
40 mg.............................................................................. 32
isosorbide dinitrate tab 10 mg....................................... 32
isosorbide dinitrate tab 20 mg....................................... 32
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isosorbide dinitrate tab 30 mg....................................... 32
isosorbide dinitrate tab 5 mg (Isordil titradose).......... 32
isosorbide mononitrate tab 10 mg................................ 32
isosorbide mononitrate tab 20 mg................................ 32
isosorbide mononitrate tab sr 24hr 30 mg................... 32
isosorbide mononitrate tab sr 24hr 60 mg................... 32
isosorbide mononitrate tab sr 24hr 120 mg................. 32
isotretinoin cap 10 mg.................................................. 111
isotretinoin cap 20 mg.................................................. 111
isotretinoin cap 30 mg.................................................. 111
isotretinoin cap 40 mg.................................................. 111
ISOVACTIN AA PLUS -nutritional supplement liquid........ 96
isradipine cap 2.5 mg...................................................... 34
isradipine cap 5 mg......................................................... 35
ISTALOL -timolol maleate ophth soln 0.5% (oncedaily).............................................................................. 105
itraconazole cap 100 mg (Sporanox).............................. 5
ivermectin tab 3 mg (Stromectol).................................... 9
J
JADENU -deferasirox tab 90 mg..................................... 114
JADENU -deferasirox tab 180 mg................................... 114
JADENU -deferasirox tab 360 mg................................... 114
JAKAFI -ruxolitinib phosphate tab 5 mg (base
equivalent)....................................................................... 13
JAKAFI -ruxolitinib phosphate tab 10 mg (base
equivalent)....................................................................... 13
JAKAFI -ruxolitinib phosphate tab 15 mg (base
equivalent)....................................................................... 13
JAKAFI -ruxolitinib phosphate tab 20 mg (base
equivalent)....................................................................... 13
JAKAFI -ruxolitinib phosphate tab 25 mg (base
equivalent)....................................................................... 14
JANUMET -sitagliptin-metformin hcl tab 50-500 mg......... 23
JANUMET -sitagliptin-metformin hcl tab 50-1000 mg....... 23
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr
50-500 mg....................................................................... 23
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr
50-1000 mg..................................................................... 23
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr
100-1000 mg................................................................... 23
JANUVIA -sitagliptin phosphate tab 25 mg (base
equiv)............................................................................... 23
JANUVIA -sitagliptin phosphate tab 50 mg (base
equiv)............................................................................... 23
JANUVIA -sitagliptin phosphate tab 100 mg (base
equiv)............................................................................... 23
JARDIANCE -empagliflozin tab 10 mg............................. 23
JARDIANCE -empagliflozin tab 25 mg............................. 23
JENTADUETO -linagliptin-metformin hcl tab 2.5-1000
mg.................................................................................... 23
JENTADUETO -linagliptin-metformin hcl tab 2.5-500
mg.................................................................................... 23
JENTADUETO -linagliptin-metformin hcl tab 2.5-850
mg.................................................................................... 23
JENTADUETO XR -linagliptin-metformin hcl tab sr 24hr
2.5-1000 mg.................................................................... 23
JENTADUETO XR -linagliptin-metformin hcl tab sr 24hr
5-1000 mg....................................................................... 23
JUBLIA -efinaconazole soln 10%.................................... 111
JUXTAPID -lomitapide mesylate cap 5 mg (base
equiv)............................................................................... 43
JUXTAPID -lomitapide mesylate cap 10 mg (base
equiv)............................................................................... 43
JUXTAPID -lomitapide mesylate cap 20 mg (base
equiv)............................................................................... 43
JUXTAPID -lomitapide mesylate cap 30 mg (base
equiv)............................................................................... 43
JUXTAPID -lomitapide mesylate cap 40 mg (base
equiv)............................................................................... 43
JUXTAPID -lomitapide mesylate cap 60 mg (base
equiv)............................................................................... 43
K
KADIAN -morphine sulfate cap sr 24hr 40 mg..................74
KADIAN -morphine sulfate cap sr 24hr 200 mg................74
KALETRA -lopinavir-ritonavir tab 100-25 mg...................... 6
KALETRA -lopinavir-ritonavir tab 200-50 mg...................... 6
KALYDECO -ivacaftor packet 50 mg................................ 50
KALYDECO -ivacaftor packet 75 mg................................ 50
KALYDECO -ivacaftor tab 150 mg.................................... 50
KARBINAL ER -carbinoxamine maleate extended release
susp 4 mg/5ml................................................................ 46
KAZANO -alogliptin-metformin hcl tab 12.5-1000 mg....... 23
KAZANO -alogliptin-metformin hcl tab 12.5-500 mg......... 23
KERYDIN -tavaborole soln 5%........................................111
ketoconazole cream 2%................................................ 111
ketoconazole foam 2% (Extina)................................... 111
ketoconazole shampoo 2% (Nizoral)........................... 111
ketoconazole tab 200 mg.................................................. 5
ketoprofen cap 50 mg..................................................... 79
ketoprofen cap 75 mg..................................................... 79
KETOPROFEN ER -ketoprofen cap sr 24hr 200 mg........ 79
ketorolac tromethamine ophth soln 0.5%
(Acular)......................................................................... 105
ketorolac tromethamine ophth soln 0.4% (Acular
ls)................................................................................... 105
ketorolac tromethamine tab 10 mg............................... 79
KETOVIE -nutritional supplement liquid............................ 96
KETOVIE PEPTIDE -nutritional supplement liquid........... 96
KEVEYIS -dichlorphenamide tab 50 mg........................... 41
KHEDEZLA -desvenlafaxine tab sr 24hr 50 mg............... 60
KHEDEZLA -desvenlafaxine tab sr 24hr 100 mg............. 60
KINERET -anakinra subcutaneous soln prefilled syringe
100 mg/0.67ml................................................................ 79
KINRIX -diph-tetanus tox ad-acell pert & polio virus, ipv
vac inj.............................................................................. 12
KISQALI -ribociclib succinate tab 200 mg (base
equiv)............................................................................... 14
KITABIS PAK -tobramycin nebu soln 300 mg/5ml.............. 4
KLOR-CON M15 -potassium chloride microencapsulated
crys cr tab 15 meq......................................................... 95
KOATE -antihemophilic factor (human) for inj 250
unit................................................................................. 102
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KOATE -antihemophilic factor (human) for inj 500
unit................................................................................. 102
KOATE -antihemophilic factor (human) for inj 1000
unit................................................................................. 102
KOATE-DVI -antihemophilic factor (human) for inj 250
unit................................................................................. 102
KOATE-DVI -antihemophilic factor (human) for inj 500
unit................................................................................. 102
KOATE-DVI -antihemophilic factor (human) for inj 1000
unit................................................................................. 102
KOGENATE FS -antihemophilic factor (recombinant) for
inj kit 250 unit............................................................... 102
KOGENATE FS -antihemophilic factor (recombinant) for
inj kit 500 unit............................................................... 102
KOGENATE FS -antihemophilic factor (recombinant) for
inj kit 1000 unit............................................................. 102
KOGENATE FS -antihemophilic factor (recombinant) for
inj kit 2000 unit............................................................. 102
KOGENATE FS -antihemophilic factor (recombinant) for
inj kit 3000 unit............................................................. 102
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 250 unit.................................. 102
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 500 unit.................................. 102
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 1000 unit................................ 102
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 2000 unit................................ 102
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 3000 unit................................ 102
KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr
2.5-1000 mg.................................................................... 23
KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr
5-500 mg......................................................................... 23
KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr
5-1000 mg....................................................................... 23
KORLYM -mifepristone tab 300 mg.................................. 23
KOSHER PRENATAL PLUS IRON -prenatal vit w/ iron
carbonyl-fa tab 30-1 mg................................................. 90
KOVALTRY -antihemophilic factor (recombinant) for inj
250 unit......................................................................... 102
KOVALTRY -antihemophilic factor (recombinant) for inj
500 unit......................................................................... 102
KOVALTRY -antihemophilic factor (recombinant) for inj
1000 unit....................................................................... 102
KOVALTRY -antihemophilic factor (recombinant) for inj
2000 unit....................................................................... 102
KOVALTRY -antihemophilic factor (recombinant) for inj
3000 unit....................................................................... 102
KRISTALOSE -lactulose oral crystal packet 10 gm.......... 51
KRISTALOSE -lactulose oral crystal packet 20 gm.......... 51
KROGER BLOOD GLUCOSE TEST -glucose blood test
strip................................................................................ 117
KROGER PREMIUM BLOOD GLUC -glucose blood test
strip................................................................................ 117
KROGER TEST STRIPS -glucose blood test strip......... 117
K-TAB -potassium chloride tab cr 8 meq (600 mg)........... 95
K-TAB -potassium chloride tab cr 20 meq (1500 mg)....... 95
KUVAN -sapropterin dihydrochloride powder packet 100
mg.................................................................................... 30
KUVAN -sapropterin dihydrochloride powder packet 500
mg.................................................................................... 30
KUVAN -sapropterin dihydrochloride soluble tab 100
mg.................................................................................... 30
KYNAMRO -mipomersen sodium soln prefilled syringe
200 mg/ml....................................................................... 43
L
labetalol hcl tab 100 mg..................................................33
labetalol hcl tab 200 mg..................................................33
labetalol hcl tab 300 mg..................................................33
LACRISERT -artificial tear ophth insert...........................105
lactic acid (ammonium lactate) cream 12% (Lachydrin).......................................................................... 111
lactic acid (ammonium lactate) lotion 12% (Lachydrin).......................................................................... 111
lactulose (encephalopathy) solution 10 gm/15ml........ 55
lactulose solution 10 gm/15ml....................................... 51
LAMICTAL STARTER/NOT TAKI -lamotrigine tab 25 mg
(42) & 100 mg (7) starter kit...........................................84
LAMICTAL STARTER/TAKING C -lamotrigine tab 25 mg
(84) & 100 mg (14) starter kit.........................................84
LAMICTAL STARTER/TAKING V -lamotrigine tab 25 mg
(35) starter kit..................................................................84
LAMICTAL XR -lamotrigine tab sr 24hr 25 (14) & 50 mg
(14) & 100 mg(7) kit....................................................... 84
LAMICTAL XR -lamotrigine tab sr 24hr 50 (14) & 100
mg(14) & 200 mg(7) kit.................................................. 84
LAMICTAL XR -lamotrigine tab sr 24hr 25 mg (21) & 50
mg (7) titration kit............................................................84
lamivudine oral soln 10 mg/ml (Epivir)........................... 6
lamivudine tab 150 mg (Epivir)........................................ 6
lamivudine tab 300 mg (Epivir)........................................ 6
lamivudine tab 100 mg (hbv) (Epivir hbv)....................... 6
lamivudine-zidovudine tab 150-300 mg (Combivir)....... 6
lamotrigine orally disintegrating tab 25 mg (Lamictal
odt).................................................................................. 84
lamotrigine orally disintegrating tab 50 mg (Lamictal
odt).................................................................................. 84
lamotrigine orally disintegrating tab 100 mg (Lamictal
odt).................................................................................. 84
lamotrigine orally disintegrating tab 200 mg (Lamictal
odt).................................................................................. 84
lamotrigine tab chewable dispersible 5 mg (Lamictal
chewable di).................................................................. 84
lamotrigine tab chewable dispersible 25 mg (Lamictal
chewable di).................................................................. 84
lamotrigine tab disp 25 (14) & 50 mg (14) & 100 mg (7)
kit (Lamictal odt)........................................................... 84
lamotrigine tab disp 25 mg (21) & 50 mg (7) titration
kit (Lamictal odt)........................................................... 84
lamotrigine tab disp 50 mg (42) & 100 mg (14) titration
kit (Lamictal odt)........................................................... 84
lamotrigine tab 25 mg (Lamictal)................................... 84
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lamotrigine tab 100 mg (Lamictal)................................. 84
lamotrigine tab 150 mg (Lamictal)................................. 84
lamotrigine tab 200 mg (Lamictal)................................. 84
lamotrigine tab sr 24hr 25 mg (Lamictal xr)................. 84
lamotrigine tab sr 24hr 50 mg (Lamictal xr)................. 84
lamotrigine tab sr 24hr 100 mg (Lamictal xr)............... 84
lamotrigine tab sr 24hr 200 mg (Lamictal xr)............... 84
lamotrigine tab sr 24hr 250 mg (Lamictal xr)............... 84
lamotrigine tab sr 24hr 300 mg (Lamictal xr)............... 84
LANCETS – VARIOUS.................................................... 121
LANOXIN -digoxin tab 62.5 mcg (0.0625 mg).................. 32
LANOXIN -digoxin tab 125 mcg (0.125 mg)..................... 32
LANOXIN -digoxin tab 187.5 mcg (0.1875 mg)................ 32
LANOXIN -digoxin tab 250 mcg (0.25 mg)....................... 32
lansoprazole cap delayed release 15 mg
(Prevacid)....................................................................... 52
lansoprazole cap delayed release 30 mg
(Prevacid)....................................................................... 52
LANTUS -insulin glargine inj 100 unit/ml.......................... 26
LANTUS SOLOSTAR -insulin glargine soln pen-injector
100 unit/ml.......................................................................26
LASTACAFT -alcaftadine ophth soln 0.25%................... 105
latanoprost ophth soln 0.005% (Xalatan).................... 105
LATUDA -lurasidone hcl tab 20 mg...................................62
LATUDA -lurasidone hcl tab 40 mg...................................62
LATUDA -lurasidone hcl tab 60 mg...................................62
LATUDA -lurasidone hcl tab 80 mg...................................62
LATUDA -lurasidone hcl tab 120 mg.................................62
LAZANDA -fentanyl citrate nasal spray 100 mcg/act (base
equiv)............................................................................... 74
LAZANDA -fentanyl citrate nasal spray 300 mcg/act (base
equiv)............................................................................... 75
LAZANDA -fentanyl citrate nasal spray 400 mcg/act (base
equiv)............................................................................... 75
leflunomide tab 10 mg (Arava)....................................... 79
leflunomide tab 20 mg (Arava)....................................... 79
LENVIMA 14 MG DAILY DOSE -lenvatinib cap therapy
pack 10 & 4 mg (14 mg daily dose)............................... 14
LENVIMA 18 MG DAILY DOSE -lenvatinib cap therapy
pack 10 & 4 (2) mg (18 mg daily dose)......................... 14
LENVIMA 24 MG DAILY DOSE -lenvatinib cap therapy
pack 10 (2) & 4 mg (24 mg daily dose)......................... 14
LENVIMA 10 MG DAILY DOSE -lenvatinib cap therapy
pack 10 mg (10 mg daily dose)..................................... 14
LENVIMA 20 MG DAILY DOSE -lenvatinib cap therapy
pack 10 (2) mg (20 mg daily dose)................................ 14
LENVIMA 8 MG DAILY DOSE -lenvatinib cap therapy
pack 4 (2) mg (8 mg daily dose).................................... 14
LETAIRIS -ambrisentan tab 5 mg..................................... 44
LETAIRIS -ambrisentan tab 10 mg................................... 44
letrozole tab 2.5 mg (Femara)........................................ 14
LEUCOVORIN CALCIUM -leucovorin calcium tab 10
mg.................................................................................... 14
LEUCOVORIN CALCIUM -leucovorin calcium tab 15
mg.................................................................................... 14
leucovorin calcium tab 5 mg.......................................... 14
leucovorin calcium tab 25 mg........................................ 14
LEUKERAN -chlorambucil tab 2 mg................................. 14
LEUKINE -sargramostim lyophilized for inj 250 mcg........ 97
leuprolide acetate inj kit 5 mg/ml.................................. 14
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base
equiv) (Xopenex concentrate)..................................... 49
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
(Xopenex)....................................................................... 49
levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv)
(Xopenex)....................................................................... 49
levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv)
(Xopenex)....................................................................... 49
LEVALBUTEROL TARTRATE HFA -levalbuterol tartrate
inhal aerosol 45 mcg/act (base equiv)........................... 49
LEVEMIR FLEXTOUCH -insulin detemir soln pen-injector
100 unit/ml.......................................................................26
LEVEMIR -insulin detemir inj 100 unit/ml..........................26
levetiracetam oral soln 100 mg/ml (Keppra).................84
levetiracetam tab 250 mg (Keppra)............................... 84
levetiracetam tab 500 mg (Keppra)............................... 84
levetiracetam tab 750 mg (Keppra)............................... 84
levetiracetam tab 1000 mg (Keppra)............................. 84
levetiracetam tab sr 24hr 500 mg (Keppra xr).............. 84
levetiracetam tab sr 24hr 750 mg (Keppra xr).............. 84
LEVITRA -vardenafil hcl tab 2.5 mg................................. 45
LEVITRA -vardenafil hcl tab 5 mg.................................... 45
LEVITRA -vardenafil hcl tab 10 mg.................................. 45
LEVITRA -vardenafil hcl tab 20 mg.................................. 45
levobunolol hcl ophth soln 0.5% (Betagan)............... 105
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)..... 30
levocarnitine tab 330 mg (Carnitor)............................... 30
levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5
mg/ml) (Xyzal)................................................................ 46
levocetirizine dihydrochloride tab 5 mg (Xyzal)...........46
LEVOFLOXACIN -levofloxacin oral soln 25 mg/ml............. 4
levofloxacin ophth soln 0.5%....................................... 105
levofloxacin tab 250 mg (Levaquin)................................ 4
levofloxacin tab 500 mg (Levaquin)................................ 4
levofloxacin tab 750 mg (Levaquin)................................ 4
LEVOMEFOLATE DHA -prenat w/fe fum-l methylfolate-fadha cap 27-1.13-0.4 mg................................................. 90
levonor-eth est tab 0.15-0.02/0.025/0.03 mg &eth est
0.01 mg (Quartette)....................................................... 20
levonorgestrel & ethinyl estradiol (91-day) tab
0.15-0.03 mg.................................................................. 20
levonorgestrel & ethinyl estradiol tab 0.1 mg-20
mcg................................................................................. 20
levonorgestrel & ethinyl estradiol tab 0.15 mg-30
mcg................................................................................. 20
LEVONORGESTREL AND ETHINY -levonorgestrelethinyl estradiol (continuous) tab 90-20 mcg................. 20
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg............................... 20
levonorgestrel tab 1.5 mg............................................... 20
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab
0.01mg(7) (Loseasonique)........................................... 20
levonorg-eth est tab 0.15-0.03mg(84) & eth est tab
0.01mg(7) (Seasonique)............................................... 20
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LEVORPHANOL TARTRATE -levorphanol tartrate tab 2
mg.................................................................................... 75
levothyroxine sodium tab 25 mcg (Synthroid)............. 26
levothyroxine sodium tab 50 mcg (Synthroid)............. 26
levothyroxine sodium tab 75 mcg (Synthroid)............. 26
levothyroxine sodium tab 88 mcg (Synthroid)............. 26
levothyroxine sodium tab 100 mcg (Synthroid)........... 26
levothyroxine sodium tab 112 mcg (Synthroid)........... 27
levothyroxine sodium tab 125 mcg (Synthroid)........... 27
levothyroxine sodium tab 137 mcg (Synthroid)........... 27
levothyroxine sodium tab 150 mcg (Synthroid)........... 27
levothyroxine sodium tab 175 mcg (Synthroid)........... 27
levothyroxine sodium tab 200 mcg (Synthroid)........... 27
levothyroxine sodium tab 300 mcg (Synthroid)........... 27
LEVULAN KERASTICK -aminolevulinic acid hcl for soln
20% (stick applicator)................................................... 112
LEXIVA -fosamprenavir calcium susp 50 mg/ml (base
equiv)................................................................................. 6
LEXIVA -fosamprenavir calcium tab 700 mg (base
equiv)................................................................................. 6
LIALDA -mesalamine tab delayed release 1.2 gm........... 55
LIBERTY NEXT GENERATION B -glucose blood test
strip................................................................................ 117
LIBERTY TEST STRIPS -glucose blood test strip.......... 117
LIBRAX -chlordiazepoxide hcl-clidinium bromide cap
5-2.5 mg.......................................................................... 52
lidocaine hcl gel 2%...................................................... 112
LIDOCAINE HCL -lidocaine hcl laryngotracheal soln
4%.................................................................................. 107
lidocaine hcl soln 4% (Xylocaine)............................... 112
lidocaine hcl viscous soln 2%..................................... 107
lidocaine oint 5%........................................................... 112
lidocaine patch 5% (Lidoderm).................................... 112
lidocaine-prilocaine cream 2.5-2.5%............................112
LINDANE -lindane shampoo 1%..................................... 112
linezolid for susp 100 mg/5ml (Zyvox)............................ 9
linezolid tab 600 mg (Zyvox)............................................ 9
LINZESS -linaclotide cap 72 mcg..................................... 55
LINZESS -linaclotide cap 145 mcg................................... 55
LINZESS -linaclotide cap 290 mcg................................... 55
liothyronine sodium tab 5 mcg (Cytomel).................... 27
liothyronine sodium tab 25 mcg (Cytomel).................. 27
liothyronine sodium tab 50 mcg (Cytomel).................. 27
LIPOFEN -fenofibrate cap 50 mg...................................... 43
LIPOFEN -fenofibrate cap 150 mg.................................... 43
lisinopril & hydrochlorothiazide tab 10-12.5 mg
(Zestoretic)..................................................................... 38
lisinopril & hydrochlorothiazide tab 20-12.5 mg
(Zestoretic)..................................................................... 38
lisinopril & hydrochlorothiazide tab 20-25 mg
(Zestoretic)..................................................................... 38
lisinopril tab 5 mg (Prinivil)............................................ 38
lisinopril tab 10 mg (Prinivil).......................................... 38
lisinopril tab 20 mg (Prinivil).......................................... 38
lisinopril tab 2.5 mg (Zestril).......................................... 38
lisinopril tab 30 mg (Zestril)........................................... 38
lisinopril tab 40 mg (Zestril)........................................... 38
LITEAIRE -spacer/aerosol-holding chambers device............................................................................ 121
lithium carbonate cap 300 mg....................................... 62
lithium carbonate cap 150 mg (Lithium carbonate)..... 62
lithium carbonate cap 600 mg (Lithium carbonate)..... 62
LITHIUM CARBONATE -lithium carbonate cap 150
mg.................................................................................... 62
LITHIUM CARBONATE -lithium carbonate cap 600
mg.................................................................................... 62
lithium carbonate tab cr 450 mg.................................... 62
lithium carbonate tab cr 300 mg (Lithobid).................. 62
lithium carbonate tab 300 mg........................................ 62
LITHIUM -lithium oral solution 8 meq/5ml......................... 62
LITHOBID -lithium carbonate tab cr 300 mg..................... 62
LITHOSTAT -acetohydroxamic acid tab 250 mg............... 57
LIVALO -pitavastatin calcium tab 1 mg (base equiv)........ 43
LIVALO -pitavastatin calcium tab 2 mg (base equiv)........ 43
LIVALO -pitavastatin calcium tab 4 mg (base equiv)........ 43
LOCOID -hydrocortisone butyrate lotion 0.1%................112
LOCORT 11-DAY -dexamethasone tab therapy pack 1.5
mg (41)............................................................................ 16
LOCORT 7-DAY -dexamethasone tab therapy pack 1.5
mg (27)............................................................................ 16
LO LOESTRIN FE -norethin-eth estradiol-fe tab 1 mg-10
mcg (24)/10 mcg (2)....................................................... 20
LOMAIRA -phentermine hcl tab 8 mg............................... 67
LONSURF -trifluridine-tipiracil tab 15-6.14 mg................. 14
LONSURF -trifluridine-tipiracil tab 20-8.19 mg................. 14
loperamide hcl cap 2 mg................................................ 51
lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)
(Kaletra)............................................................................ 6
lorazepam conc 2 mg/ml.................................................58
lorazepam tab 0.5 mg (Ativan)....................................... 58
lorazepam tab 1 mg (Ativan).......................................... 58
lorazepam tab 2 mg (Ativan).......................................... 58
LORTAB -hydrocodone-acetaminophen soln 10-300
mg/15ml........................................................................... 75
LORTUSS EX -pseudoephedrine w/ cod-gg liquid
30-10-100 mg/5ml........................................................... 47
LORZONE -chlorzoxazone tab 375 mg............................ 88
LORZONE -chlorzoxazone tab 750 mg............................ 88
losartan potassium & hydrochlorothiazide tab 50-12.5
mg (Hyzaar)....................................................................38
losartan potassium & hydrochlorothiazide tab
100-12.5 mg (Hyzaar).................................................... 38
losartan potassium & hydrochlorothiazide tab 100-25
mg (Hyzaar)....................................................................38
losartan potassium tab 25 mg (Cozaar)........................ 38
losartan potassium tab 50 mg (Cozaar)........................ 38
losartan potassium tab 100 mg (Cozaar)...................... 38
LOTEMAX -loteprednol etabonate ophth gel 0.5%......... 105
LOTEMAX -loteprednol etabonate ophth oint 0.5%........ 105
LOTEMAX -loteprednol etabonate ophth susp 0.5%...... 105
lovastatin tab 10 mg........................................................ 43
lovastatin tab 20 mg........................................................ 43
lovastatin tab 40 mg........................................................ 43
loxapine succinate cap 5 mg......................................... 62
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loxapine succinate cap 10 mg....................................... 62
loxapine succinate cap 25 mg....................................... 62
loxapine succinate cap 50 mg....................................... 62
LOZI-FLUR -sodium fluoride lozenge 1 mg f (from 2.2 mg
naf)................................................................................... 95
LUMIGAN -bimatoprost ophth soln 0.01%...................... 105
LUZU -luliconazole cream 1%......................................... 112
LYNPARZA -olaparib cap 50 mg....................................... 14
LYRICA -pregabalin cap 25 mg.........................................84
LYRICA -pregabalin cap 50 mg.........................................84
LYRICA -pregabalin cap 75 mg.........................................84
LYRICA -pregabalin cap 100 mg.......................................84
LYRICA -pregabalin cap 150 mg.......................................84
LYRICA -pregabalin cap 200 mg.......................................84
LYRICA -pregabalin cap 225 mg.......................................84
LYRICA -pregabalin cap 300 mg.......................................84
LYRICA -pregabalin soln 20 mg/ml................................... 84
LYSODREN -mitotane tab 500 mg....................................14
M
MACNATAL CN DHA -prenatal w/o a w/fe cbn-dss-fa-dha
cap 28-1-250 mg............................................................ 90
malathion lotion 0.5% (Ovide)...................................... 112
MAPROTILINE HCL -maprotiline hcl tab 25 mg............... 60
MAPROTILINE HCL -maprotiline hcl tab 50 mg............... 60
MAPROTILINE HCL -maprotiline hcl tab 75 mg............... 60
MAR-COF BP -pseudoephedrine-bromphen-codeine liqd
30-2-7.5 mg/5ml.............................................................. 47
MARNATAL-F -prenatal w/o vit a w/ fe polysac cmplx-fa
cap 60-1 mg.................................................................... 90
MARPLAN -isocarboxazid tab 10 mg............................... 60
MASK VORTEX/BABY WHIRL DU -spacer/aerosolholding chamber supplies - masks.............................. 121
MASK VORTEX/CHILD/FROG -spacer/aerosol-holding
chamber supplies - masks........................................... 121
MASK VORTEX/SPINNER THE D -spacer/aerosolholding chamber supplies - masks.............................. 121
MASK VORTEX/TODDLER/LADY -spacer/aerosolholding chamber supplies - masks.............................. 121
MATULANE -procarbazine hcl cap 50 mg........................ 14
MAXIDEX -dexamethasone ophth susp 0.1%................ 105
meclizine hcl tab 12.5 mg............................................... 53
meclizine hcl tab 25 mg.................................................. 53
MECLOFENAMATE SODIUM -meclofenamate sodium
cap 50 mg....................................................................... 79
MECLOFENAMATE SODIUM -meclofenamate sodium
cap 100 mg..................................................................... 79
MEDROL -methylprednisolone tab 2 mg.......................... 16
medroxyprogesterone acetate im susp 150 mg/ml
(Depo-provera contrac)................................................ 20
medroxyprogesterone acetate im susp prefilled syr
150 mg/ml (Depo-provera contrac)............................. 20
medroxyprogesterone acetate tab 2.5 mg
(Provera)......................................................................... 21
medroxyprogesterone acetate tab 5 mg (Provera)...... 21
medroxyprogesterone acetate tab 10 mg
(Provera)......................................................................... 21
mefenamic acid cap 250 mg (Ponstel).......................... 79
mefloquine hcl tab 250 mg............................................... 9
megestrol acetate susp 625 mg/5ml (Megace es)........ 21
megestrol acetate susp 40 mg/ml (Megace oral)......... 14
megestrol acetate tab 20 mg.......................................... 14
megestrol acetate tab 40 mg.......................................... 14
MEIJER BLOOD GLUCOSE TEST -glucose blood test
strip................................................................................ 117
MEIJER ESSENTIAL BLOOD GL -glucose blood test
strip................................................................................ 117
MEIJER PREMIUM BLOOD GLUC -glucose blood test
strip................................................................................ 117
MEIJER TRUETEST BLOOD GLU -glucose blood test
strip................................................................................ 117
MEIJER TRUETRACK BLOOD GL -glucose blood test
strip................................................................................ 117
MEKINIST -trametinib dimethyl sulfoxide tab 0.5 mg
(base equivalent)............................................................ 14
MEKINIST -trametinib dimethyl sulfoxide tab 2 mg (base
equivalent)....................................................................... 14
meloxicam tab 7.5 mg (Mobic)....................................... 79
meloxicam tab 15 mg (Mobic)........................................ 79
memantine hcl oral solution 2 mg/ml (Namenda)........ 70
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
(Namenda titration pa)................................................. 70
memantine hcl tab 5 mg (Namenda)............................. 70
memantine hcl tab 10 mg (Namenda)........................... 70
MENACTRA -meningococcal (a, c, y, and w-135)
conjugate vaccine inj...................................................... 11
M-END PE -phenylephrine-bromphen w/ codeine liqd
3.33-1.33-6.33 mg/5ml....................................................47
MENEST -esterified estrogens tab 0.3 mg....................... 19
MENEST -esterified estrogens tab 0.625 mg................... 19
MENEST -esterified estrogens tab 1.25 mg..................... 19
MENHIBRIX -meningococcal (c & y)-haemophilus b tet
tox conj vac for inj.......................................................... 11
MENOPUR -menotropins for subcutaneous inj 75
unit................................................................................... 30
MENOSTAR -estradiol td patch weekly 14 mcg/24hr....... 19
MENTAX -butenafine hcl cream 1%................................112
MENVEO -meningococcal (a, c, y, and w-135) oligo conj
vac for inj........................................................................ 11
MEPERIDINE HCL -meperidine hcl oral soln 50
mg/5ml............................................................................. 75
meperidine hcl tab 50 mg............................................... 75
meperidine hcl tab 100 mg (Demerol)........................... 75
MEPHYTON -phytonadione tab 5 mg............................... 89
meprobamate tab 200 mg............................................... 58
meprobamate tab 400 mg............................................... 58
mercaptopurine tab 50 mg............................................. 14
MESALAMINE DR -mesalamine tab delayed release 800
mg.................................................................................... 55
mesalamine enema 4 gm................................................ 55
MESNEX -mesna tab 400 mg........................................... 14
MESTINON -pyridostigmine bromide syrup 60
mg/5ml............................................................................. 88
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METAPROTERENOL SULFATE -metaproterenol sulfate
syrup 10 mg/5ml............................................................. 49
METAPROTERENOL SULFATE -metaproterenol sulfate
tab 10 mg........................................................................ 49
METAPROTERENOL SULFATE -metaproterenol sulfate
tab 20 mg........................................................................ 49
METAXALONE -metaxalone tab 400 mg.......................... 88
metaxalone tab 800 mg (Skelaxin)................................ 88
metformin hcl tab 500 mg (Glucophage)...................... 24
metformin hcl tab 850 mg (Glucophage)...................... 24
metformin hcl tab 1000 mg (Glucophage).................... 24
metformin hcl tab sr 24hr 500 mg (Glucophage xr)..... 23
metformin hcl tab sr 24hr 750 mg (Glucophage xr)..... 24
metformin hcl tab sr 24hr modified release 500 mg
(Glumetza)...................................................................... 24
metformin hcl tab sr 24hr modified release 1000 mg
(Glumetza)...................................................................... 24
metformin hcl tab sr 24hr osmotic 500 mg
(Fortamet)....................................................................... 24
metformin hcl tab sr 24hr osmotic 1000 mg
(Fortamet)....................................................................... 24
methadone hcl conc 10 mg/ml (Methadose)................ 75
methadone hcl soln 5 mg/5ml (Methadone hcl)........... 75
methadone hcl soln 10 mg/5ml (Methadone hcl)......... 75
methadone hcl tab for oral susp 40 mg........................ 75
methadone hcl tab 5 mg (Dolophine)............................ 75
methadone hcl tab 10 mg (Dolophine).......................... 75
methamphetamine hcl tab 5 mg (Desoxyn).................. 67
methazolamide tab 25 mg (Neptazane)......................... 41
methazolamide tab 50 mg (Neptazane)......................... 41
methenamine hippurate tab 1 gm (Hiprex)................... 55
METHERGINE -methylergonovine maleate tab 0.2
mg.................................................................................... 28
methimazole tab 5 mg (Tapazole).................................. 27
methimazole tab 10 mg (Tapazole)................................ 27
METHITEST -methyltestosterone oral tab 10 mg............. 18
methocarbamol tab 750 mg (Robaxin-750)................... 88
methocarbamol tab 500 mg (Robaxin).......................... 88
methotrexate sodium for inj 1 gm................................. 14
methotrexate sodium inj 50 mg/2ml (25 mg/ml)........... 14
methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)...... 14
methotrexate sodium inj pf 100 mg/4ml (25 mg/
ml)................................................................................... 14
methotrexate sodium inj pf 200 mg/8ml (25 mg/
ml)................................................................................... 14
methotrexate sodium inj pf 250 mg/10ml (25 mg/
ml)................................................................................... 14
methotrexate sodium inj pf 1000 mg/40ml (25 mg/
ml)................................................................................... 14
METHOTREXATE SODIUM -methotrexate sodium inj 250
mg/10ml (25 mg/ml)........................................................14
methotrexate sodium tab 2.5 mg (base equiv)............. 14
methoxsalen rapid cap 10 mg (Oxsoralen ultra)........ 112
methscopolamine bromide tab 2.5 mg (Pamine)......... 52
methscopolamine bromide tab 5 mg (Pamine
forte)................................................................................52
METHYCLOTHIAZIDE -methyclothiazide tab 5 mg..........41
METHYLDOPA/HYDROCHLOROTHI -methyldopa &
hydrochlorothiazide tab 250-15 mg................................ 38
METHYLDOPA/HYDROCHLOROTHI -methyldopa &
hydrochlorothiazide tab 250-25 mg................................ 39
methyldopa tab 250 mg.................................................. 38
methyldopa tab 500 mg.................................................. 38
methylphenidate hcl cap cr 10 mg (cd) (Metadate
cd)................................................................................... 67
methylphenidate hcl cap cr 20 mg (cd) (Metadate
cd)................................................................................... 67
methylphenidate hcl cap cr 30 mg (cd) (Metadate
cd)................................................................................... 67
methylphenidate hcl cap cr 40 mg (cd) (Metadate
cd)................................................................................... 67
methylphenidate hcl cap cr 50 mg (cd) (Metadate
cd)................................................................................... 67
methylphenidate hcl cap cr 60 mg (cd) (Metadate
cd)................................................................................... 67
methylphenidate hcl cap sr 24hr 20 mg (la) (Ritalin
la)..................................................................................... 67
methylphenidate hcl cap sr 24hr 30 mg (la) (Ritalin
la)..................................................................................... 67
methylphenidate hcl cap sr 24hr 40 mg (la) (Ritalin
la)..................................................................................... 67
METHYLPHENIDATE HCL ER (L -methylphenidate hcl
cap sr 24hr 60 mg (la)................................................... 67
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sr 24hr 18 mg................................................................. 67
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sr 24hr 27 mg................................................................. 67
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sr 24hr 36 mg................................................................. 67
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sr 24hr 54 mg................................................................. 67
METHYLPHENIDATE HCL -methylphenidate hcl chew
tab 2.5 mg....................................................................... 67
METHYLPHENIDATE HCL -methylphenidate hcl chew
tab 5 mg.......................................................................... 67
METHYLPHENIDATE HCL -methylphenidate hcl chew
tab 10 mg........................................................................ 67
methylphenidate hcl soln 5 mg/5ml (Methylin)............ 68
methylphenidate hcl soln 10 mg/5ml (Methylin).......... 68
methylphenidate hcl tab cr 10 mg................................. 68
methylphenidate hcl tab cr 20 mg................................. 68
methylphenidate hcl tab 5 mg (Ritalin)......................... 68
methylphenidate hcl tab 10 mg (Ritalin)....................... 68
methylphenidate hcl tab 20 mg (Ritalin)....................... 68
methylphenidate hcl tab sa osm 18 mg (Concerta)..... 68
methylphenidate hcl tab sa osm 27 mg (Concerta)..... 68
methylphenidate hcl tab sa osm 36 mg (Concerta)..... 68
methylphenidate hcl tab sa osm 54 mg (Concerta)..... 68
methylprednisolone tab 4 mg (Medrol)......................... 16
methylprednisolone tab 8 mg (Medrol)......................... 16
methylprednisolone tab 16 mg (Medrol)....................... 16
methylprednisolone tab 32 mg (Medrol)....................... 16
methylprednisolone tab therapy pack 4 mg (21)
(Medrol dosepak).......................................................... 16
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methyltestosterone cap 10 mg (Testred)...................... 18
METIPRANOLOL -metipranolol ophth soln 0.3%........... 105
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)........ 55
metoclopramide hcl tab 5 mg (Reglan)......................... 55
metoclopramide hcl tab 10 mg (Reglan)....................... 55
METOCLOPRAMIDE ODT -metoclopramide hcl orally
disintegrating tab 5 mg................................................... 55
METOCLOPRAMIDE ODT -metoclopramide hcl orally
disintegrating tab 10 mg................................................. 55
metolazone tab 2.5 mg.................................................... 41
metolazone tab 5 mg....................................................... 41
metolazone tab 10 mg..................................................... 41
metoprolol & hydrochlorothiazide tab 100-25 mg....... 39
metoprolol & hydrochlorothiazide tab 100-50 mg....... 39
metoprolol & hydrochlorothiazide tab 50-25 mg
(Lopressor hct)..............................................................39
METOPROLOL SUCCINATE ER/H -metoprolol &
hydrochlorothiazide tab sr 24hr 25-12.5 mg.................. 39
METOPROLOL SUCCINATE ER/H -metoprolol &
hydrochlorothiazide tab sr 24hr 50-12.5 mg.................. 39
METOPROLOL SUCCINATE ER/H -metoprolol &
hydrochlorothiazide tab sr 24hr 100-12.5 mg................ 39
metoprolol succinate tab sr 24hr 25 mg (tartrate
equiv) (Toprol xl)........................................................... 33
metoprolol succinate tab sr 24hr 50 mg (tartrate
equiv) (Toprol xl)........................................................... 33
metoprolol succinate tab sr 24hr 100 mg (tartrate
equiv) (Toprol xl)........................................................... 33
metoprolol succinate tab sr 24hr 200 mg (tartrate
equiv) (Toprol xl)........................................................... 33
METOPROLOL TARTRATE -metoprolol tartrate tab 37.5
mg.................................................................................... 33
METOPROLOL TARTRATE -metoprolol tartrate tab 75
mg.................................................................................... 33
metoprolol tartrate tab 25 mg........................................ 33
metoprolol tartrate tab 50 mg (Lopressor)................... 33
metoprolol tartrate tab 100 mg (Lopressor)................. 33
metronidazole cap 375 mg (Flagyl)................................. 9
metronidazole cream 0.75% (Metrocream)................. 112
metronidazole gel 0.75%............................................... 112
metronidazole gel 1% (Metrogel)................................. 112
metronidazole lotion 0.75% (Metrolotion)................... 112
metronidazole tab 250 mg (Flagyl).................................. 9
metronidazole tab 500 mg (Flagyl).................................. 9
metronidazole vaginal gel 0.75% (Metrogelvaginal)........................................................................... 57
mexiletine hcl cap 150 mg.............................................. 35
mexiletine hcl cap 200 mg.............................................. 35
mexiletine hcl cap 250 mg.............................................. 35
MIACALCIN -calcitonin (salmon) inj 200 unit/ml............... 30
MICONAZOLE 3 -miconazole nitrate vaginal suppos 200
mg.................................................................................... 57
MICORT-HC -hydrocortisone acetate cream 2.5%......... 112
MICROCHAMBER -spacer/aerosol-holding chambers device............................................................................ 121
MICRODOT TEST STRIPS -glucose blood test strip..... 117
MICROSPACER -spacer/aerosol-holding chambers device............................................................................ 121
midodrine hcl tab 2.5 mg................................................ 42
midodrine hcl tab 5 mg................................................... 42
midodrine hcl tab 10 mg................................................. 42
MIGERGOT -ergotamine w/ caffeine suppos 2-100
mg.................................................................................... 81
miglitol tab 25 mg (Glyset)............................................. 24
miglitol tab 50 mg (Glyset)............................................. 24
miglitol tab 100 mg (Glyset)........................................... 24
MIGRANAL -dihydroergotamine mesylate nasal spray 4
mg/ml............................................................................... 81
MILLIPRED DP -prednisolone tab therapy pack 5 mg
(21).................................................................................. 16
MILLIPRED DP -prednisolone tab therapy pack 5 mg
(48).................................................................................. 16
MILLIPRED -prednisolone sod phosphate oral soln 10
mg/5ml (base equiv)....................................................... 16
MILLIPRED -prednisolone tab 5 mg................................. 16
MINASTRIN 24 FE -norethindrone ace-eth estradiol-fe
chew tab 1 mg-20 mcg (24)........................................... 20
MINIVELLE -estradiol td patch twice weekly 0.025
mg/24hr........................................................................... 19
MINIVELLE -estradiol td patch twice weekly 0.0375
mg/24hr........................................................................... 19
MINIVELLE -estradiol td patch twice weekly 0.05
mg/24hr........................................................................... 19
MINIVELLE -estradiol td patch twice weekly 0.075
mg/24hr........................................................................... 19
MINIVELLE -estradiol td patch twice weekly 0.1
mg/24hr........................................................................... 19
minocycline hcl cap 50 mg (Minocin)............................. 3
minocycline hcl cap 75 mg (Minocin)............................. 3
minocycline hcl cap 100 mg (Minocin)........................... 3
MINOCYCLINE HCL ER -minocycline hcl tab sr 24hr 45
mg...................................................................................... 3
minocycline hcl tab 50 mg............................................... 3
minocycline hcl tab 75 mg............................................... 3
minocycline hcl tab 100 mg............................................. 3
minocycline hcl tab sr 24hr 90 mg.................................. 3
minocycline hcl tab sr 24hr 135 mg................................ 3
minoxidil tab 2.5 mg........................................................ 39
minoxidil tab 10 mg......................................................... 39
MIRCERA -methoxy peg-epoetin beta soln prefilled syr 30
mcg/0.3ml........................................................................ 97
MIRCERA -methoxy peg-epoetin beta soln prefilled syr 50
mcg/0.3ml........................................................................ 97
MIRCERA -methoxy peg-epoetin beta soln prefilled syr 75
mcg/0.3ml........................................................................ 97
MIRCERA -methoxy peg-epoetin beta soln prefilled syr
100 mcg/0.3ml................................................................ 97
MIRCERA -methoxy peg-epoetin beta soln prefilled syr
150 mcg/0.3ml................................................................ 97
MIRCERA -methoxy peg-epoetin beta soln prefilled syr
200 mcg/0.3ml................................................................ 97
mirtazapine orally disintegrating tab 15 mg (Remeron
soltab)............................................................................. 60
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mirtazapine orally disintegrating tab 30 mg (Remeron
soltab)............................................................................. 60
mirtazapine orally disintegrating tab 45 mg (Remeron
soltab)............................................................................. 60
mirtazapine tab 7.5 mg....................................................60
mirtazapine tab 15 mg (Remeron)................................. 60
mirtazapine tab 30 mg (Remeron)................................. 60
mirtazapine tab 45 mg (Remeron)................................. 60
MIRVASO -brimonidine tartrate gel 0.33% (base
equivalent)..................................................................... 112
MISC NEEDLES & SYRINGES – VARIOUS.................. 121
misoprostol tab 100 mcg (Cytotec)............................... 52
misoprostol tab 200 mcg (Cytotec)............................... 52
MISTASSIST -respiratory therapy supplies - devices..... 121
MITIGARE -colchicine cap 0.6 mg.................................... 82
MITOSOL -mitomycin for ophth soln kit 0.2 mg.............. 105
M-M-R II -measles, mumps & rubella virus vaccines for
inj..................................................................................... 11
modafinil tab 100 mg (Provigil)...................................... 68
modafinil tab 200 mg (Provigil)...................................... 68
MODERIBA 1200 DOSE PACK -ribavirin tab 600 mg........ 6
MODERIBA 800 DOSE PACK -ribavirin tab 400 mg.......... 6
MODERIBA -ribavirin tab 200 mg & ribavirin tab 400 mg
dose pack.......................................................................... 6
MODERIBA -ribavirin tab 400 mg & ribavirin tab 600 mg
dose pack.......................................................................... 6
moexipril hcl tab 7.5 mg................................................. 39
moexipril hcl tab 15 mg.................................................. 39
moexipril-hydrochlorothiazide tab 7.5-12.5 mg........... 39
moexipril-hydrochlorothiazide tab 15-12.5 mg............ 39
moexipril-hydrochlorothiazide tab 15-25 mg............... 39
mometasone furoate cream 0.1% (Elocon)................ 112
mometasone furoate nasal susp 50 mcg/act
(Nasonex)....................................................................... 46
mometasone furoate oint 0.1% (Elocon).................... 112
mometasone furoate solution 0.1% (lotion)
(Elocon)........................................................................ 112
MONOCLATE-P -antihemophilic factor (human) for inj kit
1000 unit....................................................................... 102
MONOCLATE-P -antihemophilic factor (human) for inj kit
1500 unit....................................................................... 102
MONONINE -coagulation factor ix for inj 1000 unit........ 102
montelukast sodium chew tab 4 mg (base equiv)
(Singulair)....................................................................... 49
montelukast sodium chew tab 5 mg (base equiv)
(Singulair)....................................................................... 49
montelukast sodium oral granules packet 4 mg (base
equiv) (Singulair)...........................................................49
montelukast sodium tab 10 mg (base equiv)
(Singulair)....................................................................... 49
MONUROL -fosfomycin tromethamine powd pack 3 gm
(base equivalent)............................................................ 55
morphine sulfate cap sr 24hr 10 mg (Kadian).............. 75
morphine sulfate cap sr 24hr 20 mg (Kadian).............. 75
morphine sulfate cap sr 24hr 30 mg (Kadian).............. 75
morphine sulfate cap sr 24hr 50 mg (Kadian).............. 75
morphine sulfate cap sr 24hr 60 mg (Kadian).............. 75
morphine sulfate cap sr 24hr 80 mg (Kadian).............. 75
morphine sulfate cap sr 24hr 100 mg (Kadian)............ 75
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 30 mg......................................................................75
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 45 mg......................................................................75
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 60 mg......................................................................75
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 75 mg......................................................................75
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 90 mg......................................................................75
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 120 mg....................................................................75
MORPHINE SULFATE -morphine sulfate tab 15 mg........ 75
MORPHINE SULFATE -morphine sulfate tab 30 mg........ 75
morphine sulfate oral soln 10 mg/5ml.......................... 75
morphine sulfate oral soln 20 mg/5ml.......................... 75
morphine sulfate oral soln 100 mg/5ml (20 mg/ml)..... 75
morphine sulfate tab cr 15 mg (Ms contin).................. 75
morphine sulfate tab cr 30 mg (Ms contin).................. 75
morphine sulfate tab cr 60 mg (Ms contin).................. 75
morphine sulfate tab cr 100 mg (Ms contin)................ 75
morphine sulfate tab cr 200 mg (Ms contin)................ 75
MOTOFEN -difenoxin w/ atropine tab 1-0.025 mg............51
MOVANTIK -naloxegol oxalate tab 12.5 mg (base
equivalent)....................................................................... 55
MOVANTIK -naloxegol oxalate tab 25 mg (base
equivalent)....................................................................... 55
MOVIPREP -peg 3350-kcl-nacl-na sulfate-na ascorbate-c
for soln 100 gm...............................................................51
MOXATAG -amoxicillin (trihydrate) tab sr 24hr 775 mg...... 1
MOXEZA -moxifloxacin hcl ophth soln 0.5% (base eq) (2
times daily).................................................................... 105
moxifloxacin hcl tab 400 mg (base equiv) (Avelox)....... 4
MULTAQ -dronedarone hcl tab 400 mg (base
equivalent)....................................................................... 35
mupirocin calcium cream 2% (Bactroban)................. 112
mupirocin oint 2%..........................................................112
MUSE -alprostadil urethral pellet 125 mcg....................... 45
MUSE -alprostadil urethral pellet 250 mcg....................... 45
MUSE -alprostadil urethral pellet 500 mcg....................... 45
MUSE -alprostadil urethral pellet 1000 mcg..................... 45
M-VIT -prenatal vit w/ fe fumarate-fa tab 27-1 mg............ 90
MYALEPT -metreleptin for subcutaneous inj 11.3 mg...... 30
mycophenolate mofetil cap 250 mg (Cellcept)........... 123
mycophenolate mofetil for oral susp 200 mg/ml
(Cellcept)...................................................................... 123
mycophenolate mofetil tab 500 mg (Cellcept)............123
mycophenolate sodium tab dr 180 mg (mycophenolic
acid equiv) (Myfortic)................................................. 123
mycophenolate sodium tab dr 360 mg (mycophenolic
acid equiv) (Myfortic)................................................. 123
MYFORTIC -mycophenolate sodium tab dr 180 mg
(mycophenolic acid equiv)............................................ 123
MYFORTIC -mycophenolate sodium tab dr 360 mg
(mycophenolic acid equiv)............................................ 123
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MYGLUCOHEALTH BLOOD GLUCO -glucose blood test
strip................................................................................ 117
MYLERAN -busulfan tab 2 mg.......................................... 14
MYNATAL ADVANCE -prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg.....................................................................90
MYNATAL PLUS -prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................... 90
MYNATAL -prenatal multivitamins & minerals w/ iron & fa
cap 1 mg......................................................................... 90
MYNATAL ULTRACAPLET -prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg................................................. 90
MYNATAL-Z -prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................... 90
MYNATE 90 PLUS -prenatal vit w/ dss-fe fumarate-fa tab
cr 90-1 mg.......................................................................90
MYRBETRIQ -mirabegron tab sr 24 hr 25 mg.................. 56
MYRBETRIQ -mirabegron tab sr 24 hr 50 mg.................. 56
MYSOLINE -primidone tab 50 mg.................................... 84
MYSOLINE -primidone tab 250 mg.................................. 84
MYTESI -crofelemer tab delayed release 125 mg............ 51
N
nabumetone tab 500 mg................................................. 79
nabumetone tab 750 mg................................................. 79
nadolol & bendroflumethiazide tab 40-5 mg
(Corzide)......................................................................... 39
nadolol & bendroflumethiazide tab 80-5 mg
(Corzide)......................................................................... 39
nadolol tab 20 mg (Corgard).......................................... 33
nadolol tab 40 mg (Corgard).......................................... 33
nadolol tab 80 mg (Corgard).......................................... 33
NAFRINSE DAILY/ACIDULATED -sodium fluoridephosphoric acid for soln 1 mg/5ml (f equiv)................. 107
NAFRINSE DAILY/NEUTRAL -sodium fluoride for soln
rinse 0.05%................................................................... 107
NAFRINSE WEEKLY -sodium fluoride for soln rinse
0.2%...............................................................................107
naftifine hcl cream 1%.................................................. 112
naftifine hcl cream 2% (Naftin).................................... 112
NAFTIN -naftifine hcl gel 1%........................................... 112
NAFTIN -naftifine hcl gel 2%........................................... 112
NALFON -fenoprofen calcium cap 400 mg....................... 79
naloxone hcl inj 0.4 mg/ml........................................... 114
naloxone hcl inj 4 mg/10ml.......................................... 114
NALOXONE HCL -naloxone hcl soln cartridge 0.4 mg/
ml................................................................................... 114
NALOXONE HCL -naloxone hcl soln prefilled syringe 2
mg/2ml........................................................................... 114
naltrexone hcl tab 50 mg.............................................. 114
NAMENDA XR -memantine hcl cap sr 24hr 7 mg............ 70
NAMENDA XR -memantine hcl cap sr 24hr 14 mg.......... 70
NAMENDA XR -memantine hcl cap sr 24hr 21 mg.......... 70
NAMENDA XR -memantine hcl cap sr 24hr 28 mg.......... 70
NAMENDA XR TITRATION PACK -memantine hcl cap sr
24hr 7 mg & 14 mg & 21 mg & 28 mg pack.................. 70
NAMZARIC -memantine-donepezil cap er 24hr 7 & 14 &
21 & 28-10 mg pack....................................................... 70
NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr
7-10 mg........................................................................... 70
NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr
14-10 mg......................................................................... 70
NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr
21-10 mg......................................................................... 70
NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr
28-10 mg......................................................................... 70
NAPRELAN -naproxen sodium tab sr 24hr 750 mg (base
equiv)............................................................................... 79
naproxen sodium tab 275 mg........................................ 79
naproxen sodium tab 550 mg (Anaprox ds)................. 79
naproxen sodium tab sr 24hr 375 mg (base equiv)
(Naprelan)....................................................................... 79
naproxen sodium tab sr 24hr 500 mg (base equiv)
(Naprelan)....................................................................... 79
naproxen susp 125 mg/5ml (Naprosyn)........................ 79
naproxen tab ec 375 mg (Ec-naprosyn)........................ 80
naproxen tab ec 500 mg (Ec-naprosyn)........................ 80
naproxen tab 250 mg...................................................... 80
naproxen tab 375 mg...................................................... 80
naproxen tab 500 mg (Naprosyn).................................. 80
naratriptan hcl tab 1 mg (base equiv) (Amerge).......... 81
naratriptan hcl tab 2.5 mg (base equiv) (Amerge)....... 81
NARCAN -naloxone hcl nasal spray 4 mg/0.1ml............ 114
NASCOBAL -cyanocobalamin nasal spray 500
mcg/0.1ml........................................................................ 97
NATACHEW -prenatal vit w/ fe fum-fe bisglycin-fa chew
tab 28-1 mg.....................................................................90
NATACYN -natamycin ophth susp 5%............................ 106
NATALVIT -prenatal vit w/ fe fumarate-fa tab 75-1 mg......90
NATAZIA -estradiol valerate-dienogest tab 3 mg /2-2
mg/2-3 mg/1 mg............................................................. 20
nateglinide tab 60 mg (Starlix)....................................... 24
nateglinide tab 120 mg (Starlix)..................................... 24
NATELLE ONE -prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg............................................................ 90
NATESTO -testosterone nasal gel 5.5 mg/act.................. 18
NATPARA -parathyroid hormone (recombinant) for inj
cartridge 25 mcg............................................................. 30
NATPARA -parathyroid hormone (recombinant) for inj
cartridge 50 mcg............................................................. 30
NATPARA -parathyroid hormone (recombinant) for inj
cartridge 75 mcg............................................................. 30
NATPARA -parathyroid hormone (recombinant) for inj
cartridge 100 mcg........................................................... 30
NATROBA -spinosad susp 0.9%..................................... 112
NATURE-THROID NT-2.5 -thyroid tab 162.5 mg (2 1/2
grain)................................................................................27
NATURE-THROID -thyroid tab 16.25 mg..........................27
NATURE-THROID -thyroid tab 32.5 mg............................27
NATURE-THROID -thyroid tab 65 mg...............................27
NATURE-THROID -thyroid tab 81.25 mg..........................27
NATURE-THROID -thyroid tab 97.5 mg............................27
NATURE-THROID -thyroid tab 113.75 mg........................ 27
NATURE-THROID -thyroid tab 130 mg.............................27
NATURE-THROID -thyroid tab 146.25 mg....................... 27
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NATURE-THROID -thyroid tab 195 mg.............................27
NATURE-THROID -thyroid tab 260 mg.............................27
NATURE-THROID -thyroid tab 48.75 mg (3/4 grain)........ 27
NATURE-THROID -thyroid tab 325 mg (5 grain).............. 27
NEBULIZER CUP/TUBING -respiratory therapy supplies devices.......................................................................... 121
NEBUPENT -pentamidine isethionate for nebulization
soln 300 mg...................................................................... 9
NECON 1/50-28 -norethindrone & mestranol tab 1 mg-50
mcg.................................................................................. 20
NECON 10/11-28 -norethindrone-eth estradiol tab
0.5-35/1-35 mg-mcg (10/11)........................................... 20
NEEVO DHA -prenat w/o a w/fefum-methylfol-omegas
cap 27-1.13 mg............................................................... 90
NEFAZODONE HCL -nefazodone hcl tab 100 mg........... 60
NEFAZODONE HCL -nefazodone hcl tab 150 mg........... 60
NEFAZODONE HCL -nefazodone hcl tab 200 mg........... 60
nefazodone hcl tab 50 mg.............................................. 60
nefazodone hcl tab 250 mg............................................ 60
NEOMYCIN/POLYMYXIN/HYDROC -neomycinpolymyxin-hc ophth susp.............................................. 106
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin............................. 106
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml (Neosporin)........... 106
neomycin-polymyxin-dexamethasone ophth oint 0.1%
(Maxitrol)...................................................................... 106
neomycin-polymyxin-dexamethasone ophth susp
0.1% (Maxitrol).............................................................106
neomycin-polymyxin-hc otic soln 1%......................... 107
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000
unit/ml-1%.................................................................... 107
neomycin sulfate tab 500 mg........................................... 4
NEORAL -cyclosporine modified cap 25 mg...................124
NEORAL -cyclosporine modified cap 100 mg.................124
NEORAL -cyclosporine modified oral soln 100 mg/
ml................................................................................... 124
NEO-SYNALAR -neomycin sulfate-fluocinolone acetonide
cream 0.5-0.025%........................................................ 112
NESINA -alogliptin benzoate tab 6.25 mg (base
equiv)............................................................................... 24
NESINA -alogliptin benzoate tab 12.5 mg (base
equiv)............................................................................... 24
NESINA -alogliptin benzoate tab 25 mg (base equiv).......24
NESTABS ABC -prenatal w/o vit a w/fe polysac-fa-ca tab
& omega 3 cap............................................................... 90
NESTABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack......................................................... 90
NESTABS -prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg........................................................................... 90
NEULASTA -pegfilgrastim soln prefilled syringe 6
mg/0.6ml.......................................................................... 97
NEUPOGEN -filgrastim inj 300 mcg/ml............................. 97
NEUPOGEN -filgrastim inj 480 mcg/1.6ml (300 mcg/
ml).................................................................................... 97
NEUPOGEN -filgrastim soln prefilled syringe 300
mcg/0.5ml........................................................................ 97
NEUPOGEN -filgrastim soln prefilled syringe 480
mcg/0.8ml (600 mcg/ml)................................................. 97
NEUPRO -rotigotine td patch 24hr 1 mg/24hr.................. 87
NEUPRO -rotigotine td patch 24hr 2 mg/24hr.................. 87
NEUPRO -rotigotine td patch 24hr 3 mg/24hr.................. 87
NEUPRO -rotigotine td patch 24hr 4 mg/24hr.................. 87
NEUPRO -rotigotine td patch 24hr 6 mg/24hr.................. 87
NEUPRO -rotigotine td patch 24hr 8 mg/24hr.................. 87
NEUTEK 2TEK TEST STRIPS -glucose blood test
strip................................................................................ 117
NEVANAC -nepafenac ophth susp 0.1%........................ 106
NEVIRAPINE -nevirapine susp 50 mg/5ml......................... 6
nevirapine tab 200 mg (Viramune)...................................6
nevirapine tab sr 24hr 100 mg (Viramune xr)................. 6
nevirapine tab sr 24hr 400 mg (Viramune xr)................. 6
NEWGEN -prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg........................................................................... 90
NEXA PLUS -prenatal w/o vit a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg...............................................................90
NEXAVAR -sorafenib tosylate tab 200 mg (base
equivalent)....................................................................... 14
NEXGEN TEST STRIPS -glucose blood test strip..........117
NEXIUM -esomeprazole magnesium for delayed release
susp packet 5 mg........................................................... 52
NEXIUM -esomeprazole magnesium for delayed release
susp packet 10 mg......................................................... 52
NEXIUM -esomeprazole magnesium for delayed release
susp packet 20 mg......................................................... 52
NEXIUM -esomeprazole magnesium for delayed release
susp packet 40 mg......................................................... 52
NEXIUM -esomeprazole magnesium for delayed release
susp pack 2.5 mg........................................................... 52
niacin tab cr 500 mg (antihyperlipidemic)
(Niaspan)........................................................................ 43
niacin tab cr 750 mg (antihyperlipidemic)
(Niaspan)........................................................................ 43
niacin tab cr 1000 mg (antihyperlipidemic)
(Niaspan)........................................................................ 43
NIACOR -niacin (antihyperlipidemic) tab 500 mg............. 43
nicardipine hcl cap 20 mg.............................................. 35
nicardipine hcl cap 30 mg.............................................. 35
nicotine polacrilex gum 2 mg.........................................70
nicotine polacrilex gum 4 mg.........................................70
nicotine polacrilex lozenge 2 mg................................... 70
nicotine polacrilex lozenge 4 mg................................... 70
nicotine td patch 24hr 7 mg/24hr...................................70
nicotine td patch 24hr 14 mg/24hr.................................70
nicotine td patch 24hr 21 mg/24hr.................................70
NICOTINE TRANSDERMAL SYST -nicotine td patch 24
hr kit 21-14-7 mg/24hr.................................................... 71
NICOTROL INHALER -nicotine inhaler system 10 mg (4
mg delivered).................................................................. 71
NICOTROL NS -nicotine nasal spray 10 mg/ml (0.5 mg/
spray)............................................................................... 71
nifedipine cap 20 mg....................................................... 35
nifedipine cap 10 mg (Procardia).................................. 35
nifedipine tab sr 24hr 30 mg (Adalat cc).......................35
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nifedipine tab sr 24hr 60 mg (Adalat cc).......................35
nifedipine tab sr 24hr 90 mg (Adalat cc).......................35
nifedipine tab sr 24hr osmotic release 30 mg
(Procardia xl)................................................................. 35
nifedipine tab sr 24hr osmotic release 60 mg
(Procardia xl)................................................................. 35
nifedipine tab sr 24hr osmotic release 90 mg
(Procardia xl)................................................................. 35
nilutamide tab 150 mg (Nilandron)................................ 14
nimodipine cap 30 mg..................................................... 35
NINJACOF-XG -guaifenesin-codeine liquid 200-8
mg/5ml............................................................................. 47
NINLARO -ixazomib citrate cap 2.3 mg (base
equivalent)....................................................................... 14
NINLARO -ixazomib citrate cap 3 mg (base
equivalent)....................................................................... 14
NINLARO -ixazomib citrate cap 4 mg (base
equivalent)....................................................................... 14
NISOLDIPINE ER -nisoldipine tab sr 24hr 20 mg............. 35
NISOLDIPINE ER -nisoldipine tab sr 24hr 25.5 mg.......... 35
NISOLDIPINE ER -nisoldipine tab sr 24hr 30 mg............. 35
NISOLDIPINE ER -nisoldipine tab sr 24hr 40 mg............. 35
nisoldipine tab sr 24hr 8.5 mg (Sular)........................... 35
nisoldipine tab sr 24hr 17 mg (Sular)............................35
nisoldipine tab sr 24hr 34 mg (Sular)............................35
NITRO-BID -nitroglycerin oint 2%..................................... 32
NITRO-DUR -nitroglycerin td patch 24hr 0.3 mg/hr.......... 32
NITRO-DUR -nitroglycerin td patch 24hr 0.8 mg/hr.......... 32
nitrofurantoin macrocrystalline cap 25 mg
(Macrodantin).................................................................55
nitrofurantoin macrocrystalline cap 50 mg
(Macrodantin).................................................................55
nitrofurantoin macrocrystalline cap 100 mg
(Macrodantin).................................................................55
nitrofurantoin monohydrate macrocrystalline cap 100
mg (Macrobid)............................................................... 55
nitrofurantoin susp 25 mg/5ml (Furadantin)................ 55
nitroglycerin cap cr 2.5 mg............................................ 32
nitroglycerin cap cr 6.5 mg............................................ 32
nitroglycerin cap cr 9 mg............................................... 32
NITROGLYCERIN LINGUAL -nitroglycerin lingual aerosol
400 mcg/spray................................................................ 32
nitroglycerin sl tab 0.3 mg (Nitrostat)........................... 32
nitroglycerin sl tab 0.4 mg (Nitrostat)........................... 32
nitroglycerin sl tab 0.6 mg (Nitrostat)........................... 32
nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)......... 32
nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)......... 32
nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)......... 32
nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)......... 32
nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)
(Nitrolingual pumpspr)................................................. 32
NITROMIST -nitroglycerin lingual aerosol 400 mcg/
spray................................................................................ 32
NIVA-PLUS -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................... 90
nizatidine cap 150 mg..................................................... 52
nizatidine cap 300 mg..................................................... 52
NIZATIDINE -nizatidine oral soln 15 mg/ml...................... 52
nonoxynol-9 gel 4%......................................................... 57
NORDITROPIN FLEXPRO -somatropin inj 5
mg/1.5ml.......................................................................... 30
NORDITROPIN FLEXPRO -somatropin inj 10
mg/1.5ml.......................................................................... 30
NORDITROPIN FLEXPRO -somatropin inj 15
mg/1.5ml.......................................................................... 30
NORDITROPIN FLEXPRO -somatropin inj 30
mg/3ml............................................................................. 30
norethindrone & ethinyl estradiol-fe chew tab 0.4
mg-35 mcg (Femcon fe)............................................... 20
norethindrone & ethinyl estradiol-fe chew tab 0.8
mg-25 mcg (Generess fe)............................................ 21
norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg
(Brevicon-28)................................................................. 20
norethindrone & ethinyl estradiol tab 1 mg-35 mcg
(Norinyl 1+35)................................................................ 20
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg
(Ovcon-35)...................................................................... 20
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20
mcg (Loestrin fe 1/20).................................................. 21
norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30
mcg (Loestrin fe 1.5/30)............................................... 21
norethindrone ace & ethinyl estradiol tab 1 mg-20
mcg (Loestrin 1/20-21)................................................. 21
norethindrone ace & ethinyl estradiol tab 1.5 mg-30
mcg (Loestrin 1.5/30-21).............................................. 21
norethindrone ace-eth estradiol-fe chew tab 1 mg-20
mcg (24) (Minastrin 24 fe)............................................21
norethindrone ace-ethinyl estradiol-fe tab 1 mg-20
mcg (24)......................................................................... 21
norethindrone acetate-ethinyl estradiol tab 1 mg-5
mcg................................................................................. 19
norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5
mcg (Femhrt low dose)................................................ 19
norethindrone acetate tab 5 mg (Aygestin).................. 21
norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35
mg-mcg (Estrostep fe)................................................. 21
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35
mg-mcg (Ortho-novum 7/7/7)...................................... 21
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28)...................................................... 21
norethindrone tab 0.35 mg (Ortho micronor)............... 21
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg
(Ortho-cyclen)................................................................ 21
norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35
mg-mcg (Ortho tri-cyclen)........................................... 21
norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25
mg-mcg (Ortho tri-cyclen lo)....................................... 21
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg........ 21
NORITATE -metronidazole cream 1%.............................112
NORPACE CR -disopyramide phosphate cap sr 12hr 100
mg.................................................................................... 36
NORPACE CR -disopyramide phosphate cap sr 12hr 150
mg.................................................................................... 36
NORPACE -disopyramide phosphate cap 100 mg........... 36
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NORPACE -disopyramide phosphate cap 150 mg........... 36
NORTHERA -droxidopa cap 100 mg................................ 42
NORTHERA -droxidopa cap 200 mg................................ 42
NORTHERA -droxidopa cap 300 mg................................ 42
nortriptyline hcl cap 10 mg (Pamelor)...........................60
nortriptyline hcl cap 25 mg (Pamelor)...........................60
nortriptyline hcl cap 50 mg (Pamelor)...........................60
nortriptyline hcl cap 75 mg (Pamelor)...........................60
NORTRIPTYLINE HCL -nortriptyline hcl soln 10
mg/5ml............................................................................. 60
NORVIR -ritonavir cap 100 mg........................................... 6
NORVIR -ritonavir oral soln 80 mg/ml.................................7
NORVIR -ritonavir tab 100 mg............................................ 7
NOVA MAX GLUCOSE TEST STR -glucose blood test
strip................................................................................ 117
NOVOEIGHT -antihemophilic factor (recombinant) for inj
250 unit......................................................................... 102
NOVOEIGHT -antihemophilic factor (recombinant) for inj
500 unit......................................................................... 102
NOVOEIGHT -antihemophilic factor (recombinant) for inj
1000 unit....................................................................... 102
NOVOEIGHT -antihemophilic factor (recombinant) for inj
1500 unit....................................................................... 102
NOVOEIGHT -antihemophilic factor (recombinant) for inj
2000 unit....................................................................... 102
NOVOEIGHT -antihemophilic factor (recombinant) for inj
3000 unit....................................................................... 102
NOVOLIN 70/30 -insulin nph isophane & regular human
inj 100 unit/ml (70-30).................................................... 26
NOVOLIN 70/30 RELION -insulin nph isophane & regular
human inj 100 unit/ml (70-30)........................................ 26
NOVOLIN N -insulin nph (human) (isophane) inj 100 unit/
ml..................................................................................... 26
NOVOLIN N RELION -insulin nph (human) (isophane) inj
100 unit/ml.......................................................................26
NOVOLIN R -insulin regular (human) inj 100 unit/ml........ 25
NOVOLIN R RELION -insulin regular (human) inj 100
unit/ml.............................................................................. 25
NOVOLOG FLEXPEN -insulin aspart soln pen-injector
100 unit/ml.......................................................................25
NOVOLOG -insulin aspart inj 100 unit/ml......................... 25
NOVOLOG MIX 70/30 -insulin aspart prot & aspart
(human) inj 100 unit/ml (70-30)...................................... 26
NOVOLOG MIX 70/30 PREFILL -insulin aspart prot &
aspart sus pen-inj 100 unit/ml (70-30)........................... 26
NOVOLOG PENFILL -insulin aspart soln cartridge 100
unit/ml.............................................................................. 25
NOVOSEVEN RT -coagulation factor viia (recomb) for inj
1 mg (1000 mcg).......................................................... 103
NOVOSEVEN RT -coagulation factor viia (recomb) for inj
2 mg (2000 mcg).......................................................... 103
NOVOSEVEN RT -coagulation factor viia (recomb) for inj
5 mg (5000 mcg).......................................................... 103
NOVOSEVEN RT -coagulation factor viia (recomb) for inj
8 mg (8000 mcg).......................................................... 103
NOXAFIL -posaconazole susp 40 mg/ml............................ 5
NOXAFIL -posaconazole tab delayed release 100 mg....... 5
NUCYNTA ER -tapentadol hcl tab sr 12hr 50 mg............. 75
NUCYNTA ER -tapentadol hcl tab sr 12hr 100 mg........... 75
NUCYNTA ER -tapentadol hcl tab sr 12hr 150 mg........... 75
NUCYNTA ER -tapentadol hcl tab sr 12hr 200 mg........... 76
NUCYNTA ER -tapentadol hcl tab sr 12hr 250 mg........... 76
NUCYNTA -tapentadol hcl tab 50 mg............................... 75
NUCYNTA -tapentadol hcl tab 75 mg............................... 75
NUCYNTA -tapentadol hcl tab 100 mg............................. 75
NUEDEXTA -dextromethorphan hbr-quinidine sulfate cap
20-10 mg......................................................................... 71
NUPLAZID -pimavanserin tartrate tab 17 mg (base
equivalent)....................................................................... 62
NUTRESTORE -glutamine powd pack 5 gm.................... 96
NUTROPIN AQ NUSPIN 10 -somatropin inj 10
mg/2ml............................................................................. 30
NUTROPIN AQ NUSPIN 20 -somatropin inj 20
mg/2ml............................................................................. 30
NUTROPIN AQ NUSPIN 5 -somatropin inj 5 mg/2ml....... 30
NUVARING -etonogestrel-ethinyl estradiol va ring
0.120-0.015 mg/24hr...................................................... 21
NUVESSA -metronidazole vaginal gel 1.3%.....................57
NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 250
unit................................................................................. 103
NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 500
unit................................................................................. 103
NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 1000
unit................................................................................. 103
NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 2000
unit................................................................................. 103
NUWIQ -antihemophilic factor (bdd-rfviii) for inj 250
unit................................................................................. 103
NUWIQ -antihemophilic factor (bdd-rfviii) for inj 500
unit................................................................................. 103
NUWIQ -antihemophilic factor (bdd-rfviii) for inj 1000
unit................................................................................. 103
NUWIQ -antihemophilic factor (bdd-rfviii) for inj 2000
unit................................................................................. 103
NYMALIZE -nimodipine oral soln 60 mg/20ml.................. 35
nystatin cream 100000 unit/gm.................................... 112
nystatin oint 100000 unit/gm........................................ 112
nystatin susp 100000 unit/ml....................................... 107
nystatin tab 500000 unit....................................................5
nystatin topical powder 100000 unit/gm..................... 112
nystatin-triamcinolone cream 100000-0.1 unit/gm%.................................................................................... 112
nystatin-triamcinolone oint 100000-0.1 unit/gm%.................................................................................... 112
O
OB COMPLETE/DHA -prenat w/ iron cbn-fe asp glyc-faomega cap 30-10-1-200 mg........................................... 91
OB COMPLETE GOLD -prenat w/o a w/fecbn-methfol-fadha cap 27.5-1-200 mg.................................................. 91
OB COMPLETE ONE -prenatal w/o a w/fecbn-fe asp
glyc-fa-fish cap 50-1-476 mg..........................................91
OB COMPLETE PETITE -prenat w/o a w/fecbnfeaspglyc-fa-omega cap 35-5-1-200 mg........................ 91
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OB COMPLETE PREMIER -prenatal vit w/ fe cbn-fe asp
glyc-fa tab 30-20-1 mg................................................... 91
OB COMPLETE -prenatal vit w/ iron carbonyl-fa tab
50-1.25 mg...................................................................... 91
OBIZUR -antihemophilic factor (recomb porc) rpfviii for inj
500 unit......................................................................... 103
OBREDON -hydrocodone-guaifenesin soln 2.5-200
mg/5ml............................................................................. 47
OBSTETRIX DHA -prenat w/fecbn-fa-dss tab 29-1 mg &
omega 3 cap 387 mg pak.............................................. 91
OBSTETRIX EC -prenatal vit w/ dss-iron carbonyl-fa tab
29-1 mg........................................................................... 91
OBSTETRIX ONE -prenat w/o a w/fecbn-bisg-methylfdss-dha cap 38-1-225 mg.............................................. 91
O-CAL FA -prenatal vit w/ fe fumarate-fa tab 27-1 mg......90
OCALIVA -obeticholic acid tab 5 mg................................. 55
OCALIVA -obeticholic acid tab 10 mg............................... 55
O-CAL PRENATAL -prenatal vit w/ fe fumarate-fa tab 15-1
mg.................................................................................... 91
octreotide acetate inj 50 mcg/ml (0.05 mg/ml)
(Sandostatin)................................................................. 30
octreotide acetate inj 100 mcg/ml (0.1 mg/ml)
(Sandostatin)................................................................. 30
octreotide acetate inj 200 mcg/ml (0.2 mg/ml)
(Sandostatin)................................................................. 30
octreotide acetate inj 500 mcg/ml (0.5 mg/ml)
(Sandostatin)................................................................. 30
octreotide acetate inj 1000 mcg/ml (1 mg/ml)
(Sandostatin)................................................................. 30
ODEFSEY -emtricitabine-rilpivirine-tenofovir af tab
200-25-25 mg.................................................................... 7
ODOMZO -sonidegib phosphate cap 200 mg (base
equivalent)....................................................................... 14
OFEV -nintedanib esylate cap 100 mg (base
equivalent)....................................................................... 50
OFEV -nintedanib esylate cap 150 mg (base
equivalent)....................................................................... 50
OFLOXACIN -ofloxacin tab 300 mg.................................... 4
ofloxacin ophth soln 0.3% (Ocuflox)........................... 106
ofloxacin otic soln 0.3% (Floxin otic).......................... 107
ofloxacin tab 400 mg......................................................... 4
OGESTREL -norgestrel & ethinyl estradiol tab 0.5 mg-50
mcg.................................................................................. 21
olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax)...... 71
olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax)...... 71
olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax)...... 71
olanzapine-fluoxetine hcl cap 12-25 mg
(Symbyax)...................................................................... 71
olanzapine-fluoxetine hcl cap 12-50 mg
(Symbyax)...................................................................... 71
olanzapine orally disintegrating tab 5 mg (Zyprexa
zydis)...............................................................................62
olanzapine orally disintegrating tab 10 mg (Zyprexa
zydis)...............................................................................63
olanzapine orally disintegrating tab 15 mg (Zyprexa
zydis)...............................................................................63
olanzapine orally disintegrating tab 20 mg (Zyprexa
zydis)...............................................................................63
olanzapine tab 2.5 mg (Zyprexa)................................... 63
olanzapine tab 5 mg (Zyprexa)...................................... 63
olanzapine tab 7.5 mg (Zyprexa)................................... 63
olanzapine tab 10 mg (Zyprexa).................................... 63
olanzapine tab 15 mg (Zyprexa).................................... 63
olanzapine tab 20 mg (Zyprexa).................................... 63
olmesartan-amlodipine-hydrochlorothiazide tab
20-5-12.5 mg (Tribenzor).............................................. 39
olmesartan-amlodipine-hydrochlorothiazide tab
40-5-12.5 mg (Tribenzor).............................................. 39
olmesartan-amlodipine-hydrochlorothiazide tab
40-5-25 mg (Tribenzor)................................................. 39
olmesartan-amlodipine-hydrochlorothiazide tab
40-10-12.5 mg (Tribenzor)............................................ 39
olmesartan-amlodipine-hydrochlorothiazide tab
40-10-25 mg (Tribenzor)............................................... 39
olmesartan medoxomil-hydrochlorothiazide tab
20-12.5 mg (Benicar hct)..............................................39
olmesartan medoxomil-hydrochlorothiazide tab
40-12.5 mg (Benicar hct)..............................................39
olmesartan medoxomil-hydrochlorothiazide tab 40-25
mg (Benicar hct)........................................................... 39
olmesartan medoxomil tab 5 mg (Benicar).................. 39
olmesartan medoxomil tab 20 mg (Benicar)................ 39
olmesartan medoxomil tab 40 mg (Benicar)................ 39
olopatadine hcl nasal soln 0.6% (Patanase).................46
olopatadine hcl ophth soln 0.1% (base equivalent)
(Patanol)....................................................................... 106
OLYSIO -simeprevir sodium cap 150 mg (base
equivalent)......................................................................... 7
OMECLAMOX-PAK -amoxicillin cap-clarithro tab w/
omepraz cap dr therapy pack........................................ 52
omega-3-acid ethyl esters cap 1 gm (Lovaza)............. 43
omeprazole cap delayed release 10 mg........................52
omeprazole cap delayed release 20 mg........................52
omeprazole cap delayed release 40 mg........................52
omeprazole-sodium bicarbonate cap 20-1100 mg
(Zegerid)......................................................................... 52
omeprazole-sodium bicarbonate cap 40-1100 mg
(Zegerid)......................................................................... 52
omeprazole-sodium bicarbonate powd pack for susp
20-1680 mg (Zegerid)....................................................52
omeprazole-sodium bicarbonate powd pack for susp
40-1680 mg (Zegerid)....................................................52
OMNARIS -ciclesonide nasal susp 50 mcg/act................ 46
OMNIFLEX DIAPHRAGM -diaphragms.......................... 121
OMNITROPE -somatropin for inj 5.8 mg.......................... 30
OMNITROPE -somatropin inj 5 mg/1.5ml......................... 30
OMNITROPE -somatropin inj 10 mg/1.5ml....................... 30
ON CALL EXPRESS BLOOD GLU -glucose blood test
strip................................................................................ 117
ON CALL PLUS BLOOD GLUCOS -glucose blood test
strip................................................................................ 117
ON CALL VIVID BLOOD GLUCO -glucose blood test
strip................................................................................ 117
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ondansetron hcl oral soln 4 mg/5ml (Zofran)............... 53
ondansetron hcl tab 24 mg............................................ 53
ondansetron hcl tab 4 mg (Zofran)................................53
ondansetron hcl tab 8 mg (Zofran)................................53
ondansetron orally disintegrating tab 4 mg (Zofran
odt).................................................................................. 53
ondansetron orally disintegrating tab 8 mg (Zofran
odt).................................................................................. 53
ONE FLOW FVC MONITORING S -respiratory therapy
supplies - devices......................................................... 121
ONETOUCH ULTRA BLUE -glucose blood test strip..... 117
ONETOUCH ULTRA TEST STRIP -glucose blood test
strip................................................................................ 118
ONETOUCH VERIO TEST STRIP -glucose blood test
strip................................................................................ 118
ONEXTON -clindamycin phosphate-benzoyl peroxide gel
1.2-3.75%...................................................................... 112
ONFI -clobazam suspension 2.5 mg/ml............................ 84
ONFI -clobazam tab 10 mg............................................... 84
ONFI -clobazam tab 20 mg............................................... 85
ONGLYZA -saxagliptin hcl tab 2.5 mg (base equiv)......... 24
ONGLYZA -saxagliptin hcl tab 5 mg (base equiv)............ 24
ONMEL -itraconazole tab 200 mg....................................... 5
ONZETRA XSAIL -sumatriptan succinate exhaler powder
11 mg/nosepiece............................................................. 81
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 5 mg......................................................... 76
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 7.5 mg...................................................... 76
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 10 mg....................................................... 76
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 15 mg....................................................... 76
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 20 mg....................................................... 76
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 30 mg....................................................... 76
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 40 mg....................................................... 76
OPSUMIT -macitentan tab 10 mg..................................... 44
OPTICHAMBER ADVANTAGE/LAR -spacer/aerosolholding chambers - device........................................... 121
OPTICHAMBER ADVANTAGE/MED -spacer/aerosolholding chambers - device........................................... 121
OPTICHAMBER ADVANTAGE/SMA -spacer/aerosolholding chambers - device........................................... 122
OPTICHAMBER ADVANTAGE -spacer/aerosol-holding
chambers - device........................................................ 121
OPTICHAMBER DIAMOND/LARGE -spacer/aerosolholding chambers - device........................................... 122
OPTICHAMBER DIAMOND/MEDIU -spacer/aerosolholding chambers - device........................................... 122
OPTICHAMBER DIAMOND/SMALL -spacer/aerosolholding chambers - device........................................... 122
OPTICHAMBER DIAMOND -spacer/aerosol-holding
chambers - device........................................................ 122
OPTICHAMBER FACE MASK/LAR -spacer/aerosolholding chambers - device........................................... 122
OPTICHAMBER FACE MASK/MED -spacer/aerosolholding chambers - device........................................... 122
OPTICHAMBER FACE MASK/SMA -spacer/aerosolholding chambers - device........................................... 122
OPTICHAMBER -spacer/aerosol-holding chambers device............................................................................ 121
OPTIHALER MDI DRUG DELIVE -spacer/aerosol-holding
chambers - device........................................................ 122
OPTIHALER -spacer/aerosol-holding chambers device............................................................................ 122
OPTIONS GYNOL II VAGINAL -nonoxynol-9 gel 3%....... 57
OPTIUMEZ TEST STRIPS -glucose blood test strip...... 118
OPTIUM TEST STRIPS -glucose blood test strip........... 118
OPTUMRX BLOOD GLUCOSE TES -glucose blood test
strip................................................................................ 118
ORACEA -doxycycline (rosacea) cap delayed release 40
mg.................................................................................. 112
ORALAIR ADULT SAMPLE KIT -grass mixed pollen ext
tab sl 300 ir (index of reactivity)..................................... 12
ORALAIR ADULT STARTER PAC -grass mixed pollen ext
tab sl 300 ir (index of reactivity)..................................... 12
ORALAIR CHILDREN/ADOLESCE -grass mixed pollen
ext tab sl 100 ir (index of reactivity)............................... 12
ORALAIR CHILDREN/ADOLESCE -grass mixed pollen
tab sl therpak 100 (3) ir & 300 (6) ir.............................. 12
ORALAIR -grass mixed pollen ext tab sl 300 ir (index of
reactivity)......................................................................... 12
ORAVIG -miconazole buccal tab 50 mg (mouththroat)............................................................................ 107
ORENCIA -abatacept subcutaneous soln prefilled syringe
125 mg/ml....................................................................... 80
ORENCIA CLICKJECT -abatacept subcutaneous soln
auto-injector 125 mg/ml.................................................. 80
ORENITRAM -treprostinil diolamine tab cr 0.125 mg
(base equiv).................................................................... 44
ORENITRAM -treprostinil diolamine tab cr 0.25 mg (base
equiv)............................................................................... 44
ORENITRAM -treprostinil diolamine tab cr 1 mg (base
equiv)............................................................................... 44
ORENITRAM -treprostinil diolamine tab cr 2.5 mg (base
equiv)............................................................................... 44
ORFADIN -nitisinone cap 2 mg......................................... 30
ORFADIN -nitisinone cap 5 mg......................................... 30
ORFADIN -nitisinone cap 10 mg....................................... 30
ORFADIN -nitisinone cap 20 mg....................................... 30
ORFADIN -nitisinone susp 4 mg/ml.................................. 30
ORKAMBI -lumacaftor-ivacaftor tab 100-125 mg............. 50
ORKAMBI -lumacaftor-ivacaftor tab 200-125 mg............. 50
orphenadrine citrate tab sr 12hr 100 mg...................... 88
oseltamivir phosphate cap 30 mg (base equiv)
(Tamiflu)............................................................................ 7
oseltamivir phosphate cap 45 mg (base equiv)
(Tamiflu)............................................................................ 7
oseltamivir phosphate cap 75 mg (base equiv)
(Tamiflu)............................................................................ 7
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OSENI -alogliptin-pioglitazone tab 12.5-15 mg................. 24
OSENI -alogliptin-pioglitazone tab 12.5-30 mg................. 24
OSENI -alogliptin-pioglitazone tab 12.5-45 mg................. 24
OSENI -alogliptin-pioglitazone tab 25-15 mg.................... 24
OSENI -alogliptin-pioglitazone tab 25-30 mg.................... 24
OSENI -alogliptin-pioglitazone tab 25-45 mg.................... 24
OSMOPREP -sod phos mono-sod phos di tabs
1.102-0.398 gm(1.5gm na phos).................................... 51
OSPHENA -ospemifene tab 60 mg................................... 31
OTEZLA -apremilast tab 30 mg........................................ 80
OTEZLA -apremilast tab starter therapy pack 10 mg & 20
mg & 30 mg.................................................................... 80
OTOVEL -ciprofloxacin-fluocinolone aceton (pf) otic soln
0.3-0.025%.................................................................... 107
OTREXUP -methotrexate soln pf auto-injector 7.5
mg/0.4ml.......................................................................... 80
OTREXUP -methotrexate soln pf auto-injector 10
mg/0.4ml.......................................................................... 80
OTREXUP -methotrexate soln pf auto-injector 12.5
mg/0.4ml.......................................................................... 80
OTREXUP -methotrexate soln pf auto-injector 15
mg/0.4ml.......................................................................... 80
OTREXUP -methotrexate soln pf auto-injector 17.5
mg/0.4ml.......................................................................... 80
OTREXUP -methotrexate soln pf auto-injector 20
mg/0.4ml.......................................................................... 80
OTREXUP -methotrexate soln pf auto-injector 22.5
mg/0.4ml.......................................................................... 80
OTREXUP -methotrexate soln pf auto-injector 25
mg/0.4ml.......................................................................... 80
OVIDREL -choriogonadotropin alfa inj 250 mcg/0.5ml..... 31
oxandrolone tab 2.5 mg (Oxandrin).............................. 18
oxandrolone tab 10 mg (Oxandrin)............................... 18
oxaprozin tab 600 mg (Daypro)..................................... 80
OXAYDO -oxycodone hcl tab abuse deter 5 mg.............. 76
OXAYDO -oxycodone hcl tab abuse deter 7.5 mg............76
oxazepam cap 10 mg...................................................... 58
oxazepam cap 15 mg...................................................... 58
oxazepam cap 30 mg...................................................... 58
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
(Trileptal)........................................................................ 85
oxcarbazepine tab 150 mg (Trileptal)............................ 85
oxcarbazepine tab 300 mg (Trileptal)............................ 85
oxcarbazepine tab 600 mg (Trileptal)............................ 85
oxiconazole nitrate cream 1% (Oxistat)...................... 112
OXISTAT -oxiconazole nitrate lotion 1%......................... 112
OXTELLAR XR -oxcarbazepine tab sr 24hr 150 mg........ 85
OXTELLAR XR -oxcarbazepine tab sr 24hr 300 mg........ 85
OXTELLAR XR -oxcarbazepine tab sr 24hr 600 mg........ 85
oxybutynin chloride syrup 5 mg/5ml............................ 56
oxybutynin chloride tab 5 mg........................................ 56
oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)..... 56
oxybutynin chloride tab sr 24hr 10 mg (Ditropan
xl)..................................................................................... 56
oxybutynin chloride tab sr 24hr 15 mg (Ditropan
xl)..................................................................................... 56
OXYCODONE/ACETAMINOPHEN -oxycodone w/
acetaminophen soln 5-325 mg/5ml................................ 76
OXYCODONE/IBUPROFEN -oxycodone-ibuprofen tab
5-400 mg......................................................................... 76
oxycodone-aspirin tab 4.8355-325 mg.......................... 76
oxycodone hcl cap 5 mg................................................ 76
oxycodone hcl conc 100 mg/5ml (20 mg/ml)................ 76
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
10 mg.............................................................................. 76
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
15 mg.............................................................................. 76
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
20 mg.............................................................................. 76
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
30 mg.............................................................................. 76
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
40 mg.............................................................................. 76
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
60 mg.............................................................................. 76
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
80 mg.............................................................................. 76
oxycodone hcl soln 5 mg/5ml........................................ 76
oxycodone hcl tab 10 mg............................................... 76
oxycodone hcl tab 20 mg............................................... 76
oxycodone hcl tab 5 mg (Roxicodone)......................... 76
oxycodone hcl tab 15 mg (Roxicodone)....................... 76
oxycodone hcl tab 30 mg (Roxicodone)....................... 76
oxycodone w/ acetaminophen tab 2.5-325 mg
(Percocet)....................................................................... 76
oxycodone w/ acetaminophen tab 5-325 mg
(Percocet)....................................................................... 76
oxycodone w/ acetaminophen tab 7.5-325 mg
(Percocet)....................................................................... 76
oxycodone w/ acetaminophen tab 10-325 mg
(Percocet)....................................................................... 76
OXYCONTIN -oxycodone hcl tab er 12hr deter 10 mg..... 76
OXYCONTIN -oxycodone hcl tab er 12hr deter 15 mg..... 76
OXYCONTIN -oxycodone hcl tab er 12hr deter 20 mg..... 76
OXYCONTIN -oxycodone hcl tab er 12hr deter 30 mg..... 76
OXYCONTIN -oxycodone hcl tab er 12hr deter 40 mg..... 76
OXYCONTIN -oxycodone hcl tab er 12hr deter 60 mg..... 76
OXYCONTIN -oxycodone hcl tab er 12hr deter 80 mg..... 77
oxymorphone hcl tab 5 mg (Opana)..............................77
oxymorphone hcl tab 10 mg (Opana)............................77
OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
tab sr 12hr 5 mg............................................................. 77
OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
tab sr 12hr 7.5 mg.......................................................... 77
OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
tab sr 12hr 10 mg........................................................... 77
OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
tab sr 12hr 15 mg........................................................... 77
OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
tab sr 12hr 20 mg........................................................... 77
OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
tab sr 12hr 30 mg........................................................... 77
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OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
tab sr 12hr 40 mg........................................................... 77
OXYTROL -oxybutynin td patch twice weekly 3.9
mg/24hr........................................................................... 56
P
paliperidone tab sr 24hr 1.5 mg (Invega)...................... 63
paliperidone tab sr 24hr 3 mg (Invega)......................... 63
paliperidone tab sr 24hr 6 mg (Invega)......................... 63
paliperidone tab sr 24hr 9 mg (Invega)......................... 63
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
2600-6200-10850 unit.....................................................53
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
4200-14200-24600 unit...................................................53
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
10500-35500-61500 unit................................................ 53
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
16800-56800-98400 unit................................................ 53
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
21000-54700-83900 unit................................................ 54
PANDA MASK LARGE -spacer/aerosol-holding chamber
supplies - masks........................................................... 122
PANDA MASK MEDIUM -spacer/aerosol-holding chamber
supplies - masks........................................................... 122
PANDA MASK SMALL -spacer/aerosol-holding chamber
supplies - masks........................................................... 122
PANDEL -hydrocortisone probutate cream 0.1%............ 112
PANRETIN -alitretinoin gel 0.1%..................................... 112
pantoprazole sodium ec tab 20 mg (base equiv)
(Protonix)........................................................................52
pantoprazole sodium ec tab 40 mg (base equiv)
(Protonix)........................................................................52
paricalcitol cap 4 mcg..................................................... 31
paricalcitol cap 1 mcg (Zemplar)................................... 31
paricalcitol cap 2 mcg (Zemplar)................................... 31
PARI MANUAL INTERRUPTER -respiratory therapy
supplies - devices......................................................... 122
PARI TREK S COMBO PACK -respiratory therapy
supplies - devices......................................................... 122
paromomycin sulfate cap 250 mg................................... 4
paroxetine hcl tab 10 mg (Paxil).................................... 60
paroxetine hcl tab 20 mg (Paxil).................................... 60
paroxetine hcl tab 30 mg (Paxil).................................... 60
paroxetine hcl tab 40 mg (Paxil).................................... 60
paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)............... 60
paroxetine hcl tab sr 24hr 25 mg (Paxil cr).................. 60
paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)............... 60
PASER -aminosalicylic acid cr granules packet 4 gm.........4
PATADAY -olopatadine hcl ophth soln 0.2% (base
equivalent)..................................................................... 106
PAXIL -paroxetine hcl oral susp 10 mg/5ml (base
equiv)............................................................................... 60
PAZEO -olopatadine hcl ophth soln 0.7% (base
equivalent)..................................................................... 106
PCE -erythromycin w/ enteric coated particles tab 333
mg...................................................................................... 3
PCE -erythromycin w/ enteric coated particles tab 500
mg...................................................................................... 3
PCP 100 -mag cit-bisacodyl-petrolat-pegmetoclopramide-electrol kit............................................. 51
PEDIARIX -diph-tetanus tox-acell pert-hepatitis b-polio ipv
vac inj.............................................................................. 12
PEDIATRIC PANDA MASK -spacer/aerosol-holding
chamber supplies - masks........................................... 122
PEDVAX HIB -haemophilus b polysaccharide conj vac im
susp 7.5 mcg/0.5 ml....................................................... 11
PEGANONE -ethotoin tab 250 mg.................................... 85
PEGASYS -peginterferon alfa-2a inj 180 mcg/ml............... 7
PEGASYS -peginterferon alfa-2a inj 180 mcg/0.5ml.......... 7
PEGASYS PROCLICK -peginterferon alfa-2a inj 135
mcg/0.5ml.......................................................................... 7
PEGASYS PROCLICK -peginterferon alfa-2a inj 180
mcg/0.5ml.......................................................................... 7
PEGINTRON -peginterferon alfa-2b for inj kit 50
mcg/0.5ml.......................................................................... 7
PEGINTRON -peginterferon alfa-2b for inj kit 80
mcg/0.5ml.......................................................................... 7
PEGINTRON -peginterferon alfa-2b for inj kit 120
mcg/0.5ml.......................................................................... 7
PEGINTRON -peginterferon alfa-2b for inj kit 150
mcg/0.5ml.......................................................................... 7
PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for
inj kit 120 mcg/0.5ml........................................................ 7
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
50 mcg/0.5ml.....................................................................7
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
80 mcg/0.5ml.....................................................................7
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
120 mcg/0.5ml.................................................................. 7
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
150 mcg/0.5ml.................................................................. 7
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240
gm (Colyte-flavor packs)............................................. 51
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236
gm (Golytely)................................................................. 51
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
(Nulytely/flavor pack)................................................... 51
penicillin v potassium for soln 125 mg/5ml................... 1
penicillin v potassium for soln 250 mg/5ml................... 1
penicillin v potassium tab 250 mg...................................1
penicillin v potassium tab 500 mg...................................1
PENNSAID -diclofenac sodium soln 2%......................... 112
PENTACEL -diph-ac per-tet tox ad-poliov-haemoph b poly
vac for im susp............................................................... 12
PENTASA -mesalamine cap cr 250 mg............................ 55
PENTASA -mesalamine cap cr 500 mg............................ 55
pentazocine w/ naloxone tab 50-0.5 mg........................77
pentoxifylline tab cr 400 mg......................................... 103
PERFOROMIST -formoterol fumarate soln nebu 20
mcg/2ml........................................................................... 49
perindopril erbumine tab 2 mg...................................... 39
perindopril erbumine tab 4 mg (Aceon)........................ 39
perindopril erbumine tab 8 mg (Aceon)........................ 39
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permethrin cream 5% (Elimite).................................... 112
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-10 mg................................................ 71
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-25 mg................................................ 71
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-10 mg................................................ 71
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-25 mg................................................ 71
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-50 mg................................................ 71
perphenazine tab 2 mg................................................... 63
perphenazine tab 4 mg................................................... 63
perphenazine tab 8 mg................................................... 63
perphenazine tab 16 mg................................................. 63
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
4000-14375-15125 unit...................................................54
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
8000-28750-30250 unit...................................................54
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
16000-57500-60500 unit................................................ 54
PEXEVA -paroxetine mesylate tab 10 mg (base
equiv)............................................................................... 60
PEXEVA -paroxetine mesylate tab 20 mg (base
equiv)............................................................................... 60
PEXEVA -paroxetine mesylate tab 30 mg (base
equiv)............................................................................... 60
PEXEVA -paroxetine mesylate tab 40 mg (base
equiv)............................................................................... 60
PHARMACIST CHOICE AUTOCOD -glucose blood test
strip................................................................................ 118
PHARMACIST CHOICE NO CODI -glucose blood test
strip................................................................................ 118
PHENACTIN AA PLUS -nutritional supplement liquid...... 96
PHENDIMETRAZINE TARTRATE -phendimetrazine
tartrate cap sr 24hr 105 mg........................................... 68
phendimetrazine tartrate tab 35 mg.............................. 68
phenelzine sulfate tab 15 mg (Nardil)........................... 60
phenobarbital elixir 20 mg/5ml...................................... 65
PHENOBARBITAL -phenobarbital tab 15 mg................... 64
PHENOBARBITAL -phenobarbital tab 30 mg................... 64
PHENOBARBITAL -phenobarbital tab 60 mg................... 64
PHENOBARBITAL -phenobarbital tab 100 mg................. 64
phenobarbital tab 16.2 mg.............................................. 65
phenobarbital tab 32.4 mg.............................................. 65
phenobarbital tab 64.8 mg.............................................. 65
phenobarbital tab 97.2 mg.............................................. 65
phenoxybenzamine hcl cap 10 mg (Dibenzyline)........ 39
phentermine hcl cap 15 mg............................................ 68
phentermine hcl cap 30 mg............................................ 68
phentermine hcl cap 37.5 mg (Adipex-p)...................... 68
phentermine hcl tab 37.5 mg (Adipex-p).......................68
phenylephrine hcl ophth soln 2.5%............................. 106
phenylephrine hcl ophth soln 10%.............................. 106
PHENYLHISTINE DH -pseudoephedrine-chlorphen w/
codeine liq 30-2-10 mg/5ml............................................ 47
PHENYTEK -phenytoin sodium extended cap 200
mg.................................................................................... 85
PHENYTEK -phenytoin sodium extended cap 300
mg.................................................................................... 85
phenytoin chew tab 50 mg (Dilantin infatabs)..............85
phenytoin sodium extended cap 100 mg (Dilantin)..... 85
phenytoin sodium extended cap 200 mg
(Phenytek)...................................................................... 85
phenytoin sodium extended cap 300 mg
(Phenytek)...................................................................... 85
phenytoin susp 125 mg/5ml (Dilantin-125)................... 85
PHOSLYRA -calcium acetate (phosphate binder) oral soln
667 mg/5ml..................................................................... 55
PHOSPHOLINE IODIDE -echothiophate iodide ophth for
soln 0.125%.................................................................. 106
PICATO -ingenol mebutate gel 0.015%.......................... 112
PICATO -ingenol mebutate gel 0.05%............................ 112
pilocarpine hcl ophth soln 1% (Isopto carpine)......... 106
pilocarpine hcl ophth soln 2% (Isopto carpine)......... 106
pilocarpine hcl ophth soln 4% (Isopto carpine)......... 106
pilocarpine hcl tab 5 mg (Salagen)..............................107
pilocarpine hcl tab 7.5 mg (Salagen)...........................107
pimozide tab 1 mg (Orap)............................................... 71
pimozide tab 2 mg (Orap)............................................... 71
pindolol tab 5 mg............................................................. 33
pindolol tab 10 mg........................................................... 33
pioglitazone hcl-glimepiride tab 30-2 mg (Duetact)..... 24
pioglitazone hcl-glimepiride tab 30-4 mg (Duetact)..... 24
pioglitazone hcl-metformin hcl tab 15-500 mg
(Actoplus met)............................................................... 24
pioglitazone hcl-metformin hcl tab 15-850 mg
(Actoplus met)............................................................... 24
pioglitazone hcl tab 15 mg (base equiv) (Actos)..........24
pioglitazone hcl tab 30 mg (base equiv) (Actos)..........24
pioglitazone hcl tab 45 mg (base equiv) (Actos)..........24
piroxicam cap 10 mg (Feldene)..................................... 80
piroxicam cap 20 mg (Feldene)..................................... 80
PLEGRIDY -peginterferon beta-1a soln pen-injector 125
mcg/0.5ml........................................................................ 71
PLEGRIDY -peginterferon beta-1a soln prefilled syringe
125 mcg/0.5ml................................................................ 71
PLEGRIDY STARTER PACK -peginterferon beta-1a soln
pen-inj 63 & 94 mcg/0.5ml pack.................................... 71
PLEGRIDY STARTER PACK -peginterferon beta-1a soln
pref syr 63 & 94 mcg/0.5ml pack................................... 71
PLIAGLIS -lidocaine-tetracaine cream 7-7%.................. 112
PNEUMOVAX 23/1 DOSE -pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml............................................ 11
PNEUMOVAX 23/5 DOSE -pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml............................................ 11
PNEUMOVAX 23 -pneumococcal vaccine polyvalent inj
25 mcg/0.5ml.................................................................. 11
PNV-DHA+DOCUSATE -prenatal w/o vit a w/ fe fum-dssfa-dha cap 27-1.25-300 mg............................................ 91
PNV-DHA -prenat w/o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg.......................................................... 91
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PNV FERROUS FUMARATE/DOCU -prenatal vit w/ dssfe fumarate-fa tab 29-1 mg............................................ 91
PNV FOLIC ACID + IRON MUL -prenatal vit w/ fe
fumarate-fa tab 27-1 mg.................................................91
PNV OB+DHA -prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 250 mg pack.....................................................91
PNV-OMEGA -prenat w/o a w/ fe fumerate-methylfolatefa-omega 3 cap............................................................... 91
PNV PRENATAL PLUS MULTIVI -prenatal vit w/ fe
fumarate-fa tab 27-1 mg.................................................91
PNV PRENATAL PLUS MULTIVI -prenat w/ fe fum-fa tab
27-1 mg & omega 3 cap 312 mg pak............................ 91
PNV-SELECT -prenatal vit w/ fe fum-methylfolate-fa tab
27-0.6-0.4 mg.................................................................. 91
PNV TABS 29-1 -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................... 91
PNV-TOTAL -prenat w/ fe cbn-fe bisglyc-fa-fish oil cap
35-5-1.2 mg..................................................................... 91
PNV-VP-U -prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg...................................................................... 91
POCKET CHAMBER -spacer/aerosol-holding chambers device............................................................................ 122
POCKETCHEM EZ BLOOD GLUCO -glucose blood test
strip................................................................................ 118
POCKET SPACER -spacer/aerosol-holding chambers device............................................................................ 122
podofilox soln 0.5% (Condylox)................................... 112
polyethylene glycol 3350 oral packet............................ 51
polyethylene glycol 3350 oral powder.......................... 51
polymyxin b-trimethoprim ophth soln 10000 unit/
ml-0.1% (Polytrim)...................................................... 106
POLY-TUSSIN AC -phenylephrine-bromphen w/ codeine
liquid 10-4-10 mg/5ml..................................................... 47
POMALYST -pomalidomide cap 1 mg.............................. 14
POMALYST -pomalidomide cap 2 mg.............................. 15
POMALYST -pomalidomide cap 3 mg.............................. 15
POMALYST -pomalidomide cap 4 mg.............................. 15
potassium chloride cap cr 8 meq (Micro-k).................. 95
potassium chloride cap cr 10 meq (Micro-k)................ 95
POTASSIUM CHLORIDE ER -potassium chloride tab cr 8
meq (600 mg)................................................................. 95
POTASSIUM CHLORIDE ER -potassium chloride tab cr
20 meq (1500 mg).......................................................... 95
potassium chloride microencapsulated crys cr tab 10
meq................................................................................. 95
potassium chloride microencapsulated crys cr tab 20
meq................................................................................. 95
potassium chloride oral soln 10% (20 meq/15ml)........ 95
POTASSIUM CHLORIDE -potassium chloride oral soln
20% (40 meq/15ml)........................................................ 95
potassium chloride powder packet 20 meq................. 95
potassium chloride tab cr 10 meq (K-tab).................... 95
potassium chloride tab cr 8 meq (600 mg)................... 95
potassium citrate tab cr 5 meq (540 mg) (Urocit-k
5)...................................................................................... 57
potassium citrate tab cr 10 meq (1080 mg) (Urocit-k
10).................................................................................... 57
potassium citrate tab cr 15 meq (1620 mg) (Urocit-k
15).................................................................................... 57
POTIGA -ezogabine tab 50 mg......................................... 85
POTIGA -ezogabine tab 200 mg....................................... 85
POTIGA -ezogabine tab 300 mg....................................... 85
POTIGA -ezogabine tab 400 mg....................................... 85
PRADAXA -dabigatran etexilate mesylate cap 75 mg
(etexilate base eq).......................................................... 99
PRADAXA -dabigatran etexilate mesylate cap 110 mg
(etexilate base eq).......................................................... 99
PRADAXA -dabigatran etexilate mesylate cap 150 mg
(etexilate base eq).......................................................... 99
PRALUENT -alirocumab subcutaneous soln pen-injector
75 mg/ml......................................................................... 43
PRALUENT -alirocumab subcutaneous soln pen-injector
150 mg/ml....................................................................... 43
pramipexole dihydrochloride tab 0.125 mg
(Mirapex).........................................................................87
pramipexole dihydrochloride tab 0.25 mg
(Mirapex).........................................................................87
pramipexole dihydrochloride tab 0.5 mg (Mirapex)..... 87
pramipexole dihydrochloride tab 0.75 mg
(Mirapex).........................................................................87
pramipexole dihydrochloride tab 1 mg (Mirapex)........ 87
pramipexole dihydrochloride tab 1.5 mg (Mirapex)..... 87
pramipexole dihydrochloride tab sr 24hr 0.375 mg
(Mirapex er).................................................................... 87
pramipexole dihydrochloride tab sr 24hr 0.75 mg
(Mirapex er).................................................................... 87
pramipexole dihydrochloride tab sr 24hr 1.5 mg
(Mirapex er).................................................................... 87
pramipexole dihydrochloride tab sr 24hr 2.25 mg
(Mirapex er).................................................................... 87
pramipexole dihydrochloride tab sr 24hr 3 mg
(Mirapex er).................................................................... 87
pramipexole dihydrochloride tab sr 24hr 3.75 mg
(Mirapex er).................................................................... 87
pramipexole dihydrochloride tab sr 24hr 4.5 mg
(Mirapex er).................................................................... 87
PRAMOSONE -pramoxine-hc cream 1-1%.................... 112
PRAMOSONE -pramoxine-hc lotion 1-1%...................... 112
PRAMOSONE -pramoxine-hc lotion 1-2.5%................... 112
pravastatin sodium tab 10 mg....................................... 43
pravastatin sodium tab 20 mg (Pravachol)...................43
pravastatin sodium tab 40 mg (Pravachol)...................43
pravastatin sodium tab 80 mg (Pravachol)...................43
prazosin hcl cap 1 mg (Minipress)................................ 39
prazosin hcl cap 2 mg (Minipress)................................ 39
prazosin hcl cap 5 mg (Minipress)................................ 39
PRECISION PCX -glucose blood test strip..................... 118
PRECISION PCX PLUS TEST S -glucose blood test
strip................................................................................ 118
PRECISION POINT OF CARE T -glucose blood test
strip................................................................................ 118
PRECISION QID TEST STRIPS -glucose blood test
strip................................................................................ 118
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PRECISION SOF-TACT TEST S -glucose blood test
strip................................................................................ 118
PRECISION XTRA BLOOD GLUC -glucose blood test
strip................................................................................ 118
PRED-G -gentamicin-prednisolone ace ophth susp
0.3-1%........................................................................... 106
PRED-G S.O.P. -gentamicin-prednisolone ace ophth oint
0.3-0.6%........................................................................ 106
PRED MILD -prednisolone acetate ophth susp
0.12%.............................................................................106
prednicarbate cream 0.1% (Dermatop)....................... 113
prednicarbate oint 0.1% (Dermatop)........................... 113
prednisolone acetate ophth susp 1% (Pred forte)..... 106
PREDNISOLONE SODIUM PHOSP -prednisolone
sodium phosphate ophth soln 1%................................ 106
PREDNISOLONE SODIUM PHOSP -prednisolone
sodium phosphate oral soln 25 mg/5ml (base eq)......... 17
prednisolone sod phos orally disintegr tab 10 mg
(base eq) (Orapred odt)............................................... 17
prednisolone sod phos orally disintegr tab 15 mg
(base eq) (Orapred odt)............................................... 17
prednisolone sod phos orally disintegr tab 30 mg
(base eq) (Orapred odt)............................................... 17
prednisolone sod phosphate oral soln 15 mg/5ml
(base equiv)................................................................... 17
prednisolone sod phosphate oral soln 10 mg/5ml
(base equiv) (Millipred)................................................ 17
prednisolone sod phosphate oral soln 20 mg/5ml
(base equiv) (Veripred 20)........................................... 17
prednisolone sod phosph oral soln 6.7 mg/5ml (5
mg/5ml base) (Pediapred)............................................17
prednisolone syrup 15 mg/5ml (usp solution
equivalent)......................................................................17
PREDNISONE INTENSOL -prednisone conc 5 mg/ml..... 17
PREDNISONE -prednisone oral soln 5 mg/5ml................ 17
PREDNISONE -prednisone tab 50 mg............................. 17
PREDNISONE -prednisone tab therapy pack 5 mg
(21).................................................................................. 17
PREDNISONE -prednisone tab therapy pack 5 mg
(48).................................................................................. 17
PREDNISONE -prednisone tab therapy pack 10 mg
(21).................................................................................. 17
PREDNISONE -prednisone tab therapy pack 10 mg
(48).................................................................................. 17
prednisone tab 1 mg....................................................... 17
prednisone tab 2.5 mg.................................................... 17
prednisone tab 5 mg....................................................... 17
prednisone tab 10 mg..................................................... 17
prednisone tab 20 mg..................................................... 17
PREFERAOB +DHA -prenat-fe poly cmplx 28mg-fe heme
poly-fa tab&dha cap pack...............................................91
PREFERAOB ONE -prenat-fe poly cmplx-fe heme polyfa-dha cap 22-6-1-200 mg..............................................91
PREFERA OB -prenat vit-fe poly cmplx-fe heme poly-fa
tab 34-1 mg.....................................................................91
PREFEST -estradiol tab 1 mg(15)/estrad-norgestimate
tab 1-0.09mg(15)............................................................ 19
PREMARIN -estrogens, conjugated tab 0.3 mg............... 19
PREMARIN -estrogens, conjugated tab 0.45 mg............. 19
PREMARIN -estrogens, conjugated tab 0.625 mg........... 19
PREMARIN -estrogens, conjugated tab 0.9 mg............... 19
PREMARIN -estrogens, conjugated tab 1.25 mg............. 19
PREMARIN -estrogens, conjugated vaginal cream 0.625
mg/gm.............................................................................. 57
PREMIUM BLOOD GLUCOSE TES -glucose blood test
strip................................................................................ 118
PREMPHASE -conj est 0.625(14)/conj est-medroxypro ac
tab 0.625-5mg(14).......................................................... 19
PREMPRO -conjugated estrogen-medroxyprogest
acetate tab 0.3-1.5 mg................................................... 19
PREMPRO -conjugated estrogen-medroxyprogest
acetate tab 0.45-1.5 mg................................................. 19
PREMPRO -conjugated estrogen-medroxyprogest
acetate tab 0.625-2.5 mg............................................... 20
PREMPRO -conjugated estrogen-medroxyprogest
acetate tab 0.625-5 mg.................................................. 20
PRENA1 CHEW -prenat w/ b2-b6-b12-d3-folic acid chew
tab 1.4 mg....................................................................... 92
PRENAISSANCE BALANCE -prenatal w/o vit a w/ fe cbndss-fa-dha cap 30-1-260 mg.......................................... 92
PRENAISSANCE HARMONY DHA -prenat w/fe poly-na
fered-fa tab 27-1 & omega cap dr 380mg......................92
PRENAISSANCE NEXT-B -prenatal w/ calcium-vit b6-faginger tab 1.22 mg......................................................... 92
PRENAISSANCE NEXT -prenatal w/ calcium-vit b6-faginger tab 1.2 mg........................................................... 92
PRENAISSANCE PLUS -prenatal w/o a w/fe cbn-dss-fadha cap 28-1-250 mg..................................................... 92
PRENAISSANCE -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg....................................................... 91
PRENA1 PEARL -prenat w/oa w/fefum-na fered-fa-dha
cap cr 30-1.4-200 mg..................................................... 92
PRENATABS RX -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................... 92
PRENATAL PLUS IRON -prenatal vit w/ iron carbonyl-fa
tab 29-1 mg.....................................................................92
PRENATAL PLUS -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................... 92
PRENATAL 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg.................................................................................... 92
PRENATAL 19 -prenatal vit w/ fe fumarate-fa chew tab
29-1 mg........................................................................... 92
PRENATAL -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................... 92
PRENATAL-U -prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg...................................................................... 92
PRENATAL VITAMINS PLUS LO -prenatal vit w/ fe
fumarate-fa tab 27-1 mg.................................................92
PRENATA -prenatal w/o a vit w/ fe fum-fa tab chew 29-1
mg.................................................................................... 92
PRENATE AM -prenatal w/ calcium-vit b6-vit b12-faginger tab 1 mg.............................................................. 92
PRENATE DHA -prenat w/o a w/feaspg-methfol-fa-dha
cap 18-0.6-0.4-300 mg................................................... 92
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PRENATE DHA -prenat w/o a w/fefum-methfol-fa-dha cap
28-0.6-0.4-300 mg.......................................................... 92
PRENATE ELITE -prenatal vit w/ fe fum-methylfolate-fa
tab 26-0.6-0.4 mg........................................................... 92
PRENATE ELITE -prenatal w/ fe asp gly-l methylfol-fa tab
20-0.6-0.4 mg.................................................................. 92
PRENATE ENHANCE -prenat w/o a w/fefum-methfol-fadha cap 28-0.6-0.4-400 mg............................................ 92
PRENATE ESSENTIAL -prenat w/o a w/feaspg-methfolfa-dha cap 18-0.6-0.4-300 mg....................................... 92
PRENATE ESSENTIAL -prenat w/o a w/feasp-methylf-faomeg cap 29-0.6-0.4-340 mg......................................... 92
PRENATE MINI -prenat w/oa w/fecb-feasp-meth-fa-dha
cap 18-0.6-0.4-350 mg................................................... 92
PRENATE MINI -prenat w/o a w/fecbn-methylf-fa-dha cap
29-0.6-0.4-350 mg.......................................................... 92
PRENATE PIXIE -prenat w/o a w/feaspg-methfol-fa-dha
cap 10-0.6-0.4-200 mg................................................... 92
PRENATE -prenat mv & min w/ l-methylfolate-fa chew tab
0.6-0.4 mg....................................................................... 92
PRENATE RESTORE -prenat w/o a w/fefum-methfol-fadha cap 27-0.6-0.4-400 mg............................................ 92
PRENATE STAR -prenatal vit w/ fe asparto glycinate-fa
tab 20-1 mg.....................................................................92
PRENA 1 TRUE -prenat w/o a w/fe chel-fa tab 30-1.4 mg
& dha cap 300mg pk...................................................... 91
PRENTIF CAVITY-RIM CERVIC -cervical cap 22
mm................................................................................. 122
PRENTIF CAVITY-RIM CERVIC -cervical cap 25
mm................................................................................. 122
PRENTIF CAVITY-RIM CERVIC -cervical cap 28
mm................................................................................. 122
PRENTIF CAVITY-RIM CERVIC -cervical cap 31
mm................................................................................. 122
PRENTIF FITTING SET -cervical caps........................... 122
PREPIDIL -dinoprostone cervical gel 0.5 mg/3gm............28
PREPLUS -prenatal vit w/ fe fumarate-fa tab 27-1 mg..... 92
PREPOPIK -sod picosulfate-mg oxide-citric acid pack 10
mg-3.5 gm-12 gm........................................................... 51
PRESTALIA -perindopril arginine-amlodipine besylate tab
3.5-2.5 mg....................................................................... 39
PRESTALIA -perindopril arginine-amlodipine besylate tab
7-5 mg............................................................................. 39
PRESTALIA -perindopril arginine-amlodipine besylate tab
14-10 mg......................................................................... 39
PRESTIGE TEST STRIPS -glucose blood test strip.......118
PRETAB -prenatal vit w/ fe fumarate-fa tab 29-1 mg........ 92
PREVACID SOLUTAB -lansoprazole tab delayed release
orally disintegrating 15 mg............................................. 52
PREVACID SOLUTAB -lansoprazole tab delayed release
orally disintegrating 30 mg............................................. 52
PREVNAR 13 -pneumococcal 13-valent conjugate
vaccine inj....................................................................... 11
PREZCOBIX -darunavir-cobicistat tab 800-150 mg............7
PREZISTA -darunavir ethanolate susp 100 mg/ml (base
equiv)................................................................................. 7
PREZISTA -darunavir ethanolate tab 75 mg (base
equiv)................................................................................. 7
PREZISTA -darunavir ethanolate tab 150 mg (base
equiv)................................................................................. 7
PREZISTA -darunavir ethanolate tab 600 mg (base
equiv)................................................................................. 7
PREZISTA -darunavir ethanolate tab 800 mg (base
equiv)................................................................................. 7
PRIFTIN -rifapentine tab 150 mg........................................ 4
PRILOSEC -omeprazole magnesium for delayed release
susp packet 2.5 mg........................................................ 52
PRILOSEC -omeprazole magnesium for delayed release
susp packet 10 mg......................................................... 52
PRIMACARE -prenat w/o a w/feasp-methlf-fa-omeg cap
30-0.75-0.25-470mg........................................................93
PRIMAQUINE PHOSPHATE -primaquine phosphate tab
26.3 mg (15 mg base)...................................................... 9
PRIMEAIRE DUAL-VALVED HOL -respiratory therapy
supplies - devices......................................................... 122
primidone tab 50 mg (Mysoline).................................... 85
primidone tab 250 mg (Mysoline).................................. 85
PRIMLEV -oxycodone w/ acetaminophen tab 5-300
mg.................................................................................... 77
PRIMLEV -oxycodone w/ acetaminophen tab 7.5-300
mg.................................................................................... 77
PRIMLEV -oxycodone w/ acetaminophen tab 10-300
mg.................................................................................... 77
PRIMSOL -trimethoprim hcl oral soln 50 mg/5ml (base
equiv)................................................................................. 9
PRISTIQ -desvenlafaxine succinate tab sr 24hr 25 mg
(base equiv).................................................................... 60
PRISTIQ -desvenlafaxine succinate tab sr 24hr 50 mg
(base equiv).................................................................... 60
PRISTIQ -desvenlafaxine succinate tab sr 24hr 100 mg
(base equiv).................................................................... 60
PR NATAL 400 EC -prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 400 pk..................................................... 91
PR NATAL 430 EC -prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 430 pk..................................................... 91
PR NATAL 400 -prenat-fe bis-fe prot succ-fa-ca tab &
omega 3 cap 400 pk...................................................... 91
PR NATAL 430 -prenat-fe bis-fe prot succ-fa-ca tab &
omega 3 cap 430 pk...................................................... 91
PROAIR HFA -albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv)........................................................ 49
PROAIR RESPICLICK -albuterol sulfate aer pow ba 108
mcg/act (90 mcg base equiv)......................................... 49
probenecid tab 500 mg................................................... 82
prochlorperazine maleate tab 5 mg (base
equivalent)......................................................................63
prochlorperazine maleate tab 10 mg (base
equivalent)......................................................................63
prochlorperazine suppos 25 mg.................................... 63
PRO-CLEAR AC -codeine-pyrilamine syrup 9-8.33
mg/5ml............................................................................. 47
PROCRIT -epoetin alfa inj 2000 unit/ml............................ 97
PROCRIT -epoetin alfa inj 3000 unit/ml............................ 97
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PROCRIT -epoetin alfa inj 4000 unit/ml............................ 97
PROCRIT -epoetin alfa inj 10000 unit/ml.......................... 97
PROCRIT -epoetin alfa inj 20000 unit/ml.......................... 97
PROCRIT -epoetin alfa inj 40000 unit/ml.......................... 97
PROCTOFOAM HC -hydrocortisone acetate w/
pramoxine rectal foam 1-1%........................................ 108
PROCYSBI -cysteamine bitartrate cap delayed release 25
mg (base equiv).............................................................. 57
PROCYSBI -cysteamine bitartrate cap delayed release 75
mg (base equiv).............................................................. 57
PRODIGY NO CODING BLOOD G -glucose blood test
strip................................................................................ 118
PROFILNINE -factor ix complex for inj 500 unit............. 103
PROFILNINE -factor ix complex for inj 1000 unit........... 103
PROFILNINE -factor ix complex for inj 1500 unit........... 103
PROFILNINE SD -factor ix complex for inj 500 unit........103
PROFILNINE SD -factor ix complex for inj 1000 unit......103
PROFILNINE SD -factor ix complex for inj 1500 unit......103
progesterone im in oil 50 mg/ml.................................... 21
progesterone micronized cap 100 mg
(Prometrium).................................................................. 21
progesterone micronized cap 200 mg
(Prometrium).................................................................. 21
PROGLYCEM -diazoxide susp 50 mg/ml......................... 24
PROGRAF -tacrolimus cap 0.5 mg................................. 124
PROGRAF -tacrolimus cap 1 mg.................................... 124
PROGRAF -tacrolimus cap 5 mg.................................... 124
PROLENSA -bromfenac sodium ophth soln 0.07% (base
equivalent)..................................................................... 106
PROMACTA -eltrombopag olamine tab 12.5 mg (base
equiv)............................................................................... 98
PROMACTA -eltrombopag olamine tab 25 mg (base
equiv)............................................................................... 98
PROMACTA -eltrombopag olamine tab 50 mg (base
equiv)............................................................................... 98
PROMACTA -eltrombopag olamine tab 75 mg (base
equiv)............................................................................... 98
PROMACTIN AA PLUS -nutritional supplement liquid..... 96
promethazine & phenylephrine syrup 6.25-5
mg/5ml............................................................................ 47
promethazine-dm syrup 6.25-15 mg/5ml.......................47
promethazine hcl suppos 12.5 mg................................ 46
promethazine hcl suppos 25 mg................................... 46
promethazine hcl suppos 50 mg................................... 46
promethazine hcl syrup 6.25 mg/5ml............................ 46
promethazine hcl tab 12.5 mg........................................ 46
promethazine hcl tab 25 mg........................................... 46
promethazine hcl tab 50 mg........................................... 46
promethazine-phenylephrine-codeine syrup 6.25-5-10
mg/5ml............................................................................ 47
promethazine w/ codeine syrup 6.25-10 mg/5ml..........47
propafenone hcl cap sr 12hr 225 mg (Rythmol sr)...... 36
propafenone hcl cap sr 12hr 325 mg (Rythmol sr)...... 36
propafenone hcl cap sr 12hr 425 mg (Rythmol sr)...... 36
propafenone hcl tab 150 mg.......................................... 36
propafenone hcl tab 225 mg.......................................... 36
propafenone hcl tab 300 mg.......................................... 36
PROPANTHELINE BROMIDE -propantheline bromide tab
15 mg.............................................................................. 53
proparacaine hcl ophth soln 0.5%............................... 106
PROPRANOLOL/HYDROCHLOROTH -propranolol &
hydrochlorothiazide tab 40-25 mg.................................. 39
PROPRANOLOL/HYDROCHLOROTH -propranolol &
hydrochlorothiazide tab 80-25 mg.................................. 40
propranolol hcl cap sr 24hr 60 mg (Inderal la)............. 33
propranolol hcl cap sr 24hr 80 mg (Inderal la)............. 33
propranolol hcl cap sr 24hr 120 mg (Inderal la)........... 33
propranolol hcl cap sr 24hr 160 mg (Inderal la)........... 33
PROPRANOLOL HCL -propranolol hcl oral soln 20
mg/5ml............................................................................. 33
PROPRANOLOL HCL -propranolol hcl oral soln 40
mg/5ml............................................................................. 33
propranolol hcl tab 10 mg.............................................. 34
propranolol hcl tab 20 mg.............................................. 34
propranolol hcl tab 40 mg.............................................. 34
propranolol hcl tab 60 mg.............................................. 34
propranolol hcl tab 80 mg.............................................. 34
propylthiouracil tab 50 mg............................................. 27
PROQUAD -measles-mumps-rubella-varicella virus
vaccines for inj................................................................ 11
PRO-RED AC -phenylephrine-dexchlorphenir-codeine
syrup 5-1-9 mg/5ml.........................................................47
PROSTIN E2 -dinoprostone vaginal suppos 20 mg......... 28
PROTONIX -pantoprazole sodium for delayed release
susp packet 40 mg......................................................... 53
protriptyline hcl tab 5 mg............................................... 60
protriptyline hcl tab 10 mg............................................. 61
PROVENTIL HFA -albuterol sulfate inhal aero 108 mcg/
act (90mcg base equiv).................................................. 49
PROVIDA DHA -prenat w/o a w/fe fum-fe poly-fa-dha cap
16-16-1.25-110 mg..........................................................93
PROVIDA OB -prenatal w/o a w/fe fum-fe poly-fa cap
20-20-1.25 mg................................................................. 93
PRUDOXIN -doxepin hcl cream 5%............................... 113
pseudoeph-chlorphen w/ hydrocodone soln 60-4-5
mg/5ml (Zutripro).......................................................... 47
pseudoephed-bromphen-dm syrup 30-2-10
mg/5ml............................................................................ 47
pseudoephedrine w/ cod-gg soln 30-10-100
mg/5ml............................................................................ 47
PSORCON -diflorasone diacetate cream 0.05%............ 113
PTS PANELS GLUCOSE TEST -glucose blood test
strip................................................................................ 118
PULMICORT FLEXHALER -budesonide inhal aero powd
90 mcg/act (breath activated).........................................49
PULMICORT FLEXHALER -budesonide inhal aero powd
180 mcg/act (breath activated)...................................... 49
PULMO-AIDE COMPRESSOR/PUL -respiratory therapy
supplies - devices......................................................... 122
PULMO-AIDE LT COMPRESSOR/ -respiratory therapy
supplies - devices......................................................... 122
PULMO-AIDE TRAVELER COMPR -respiratory therapy
supplies - devices......................................................... 122
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PULMONEB LT COMPRESSOR/NE -respiratory therapy
supplies - devices......................................................... 122
PULMOZYME -dornase alfa inhal soln 1 mg/ml............... 50
PUREFE OB PLUS -prenatal w/o a w/fe fum-fe poly-fa
cap 162.115.2-1 mg........................................................ 93
PURIXAN -mercaptopurine susp 2000 mg/100ml (20 mg/
ml).................................................................................... 15
PYLERA -bismuth subcit-metronidazole-tetracycline cap
140-125-125 mg..............................................................53
pyrazinamide tab 500 mg..................................................4
pyridostigmine bromide tab cr 180 mg (Mestinon
timespan)........................................................................88
pyridostigmine bromide tab 60 mg (Mestinon)............ 89
Q
QBRELIS -lisinopril oral soln 1 mg/ml............................... 40
QNASL -beclomethasone dipropionate nasal aerosol 80
mcg/act............................................................................ 46
QNASL CHILDRENS -beclomethasone dipropionate
nasal aerosol 40 mcg/act............................................... 46
QSYMIA -phentermine hcl-topiramate cap sr 24hr 3.75-23
mg.................................................................................... 68
QSYMIA -phentermine hcl-topiramate cap sr 24hr 7.5-46
mg.................................................................................... 68
QSYMIA -phentermine hcl-topiramate cap sr 24hr
11.25-69 mg.................................................................... 68
QSYMIA -phentermine hcl-topiramate cap sr 24hr 15-92
mg.................................................................................... 68
QUADRACEL -diph-tetanus tox ad-acell pert & polio
virus, ipv vac inj.............................................................. 12
QUAKE -respiratory therapy supplies - devices..............122
QUARTETTE -levonor-eth est tab 0.15-0.02/0.025/0.03
mg &eth est 0.01 mg...................................................... 21
QUAZEPAM -quazepam tab 15 mg.................................. 65
QUDEXY XR -topiramate cap er 24hr sprinkle 25 mg...... 85
QUDEXY XR -topiramate cap er 24hr sprinkle 50 mg...... 85
QUDEXY XR -topiramate cap er 24hr sprinkle 100
mg.................................................................................... 85
QUDEXY XR -topiramate cap er 24hr sprinkle 150
mg.................................................................................... 85
QUDEXY XR -topiramate cap er 24hr sprinkle 200
mg.................................................................................... 85
quetiapine fumarate tab 25 mg (Seroquel)................... 63
quetiapine fumarate tab 50 mg (Seroquel)................... 63
quetiapine fumarate tab 100 mg (Seroquel)................. 63
quetiapine fumarate tab 200 mg (Seroquel)................. 63
quetiapine fumarate tab 300 mg (Seroquel)................. 63
quetiapine fumarate tab 400 mg (Seroquel)................. 63
quetiapine fumarate tab sr 24hr 50 mg (Seroquel
xr).................................................................................... 63
quetiapine fumarate tab sr 24hr 150 mg (Seroquel
xr).................................................................................... 63
quetiapine fumarate tab sr 24hr 200 mg (Seroquel
xr).................................................................................... 63
quetiapine fumarate tab sr 24hr 300 mg (Seroquel
xr).................................................................................... 63
quetiapine fumarate tab sr 24hr 400 mg (Seroquel
xr).................................................................................... 63
QUICKTEK TEST STRIPS -glucose blood test strip...... 118
QUILLICHEW ER -methylphenidate hcl chew tab
extended release 20 mg.................................................68
QUILLICHEW ER -methylphenidate hcl chew tab
extended release 30 mg.................................................68
QUILLICHEW ER -methylphenidate hcl chew tab
extended release 40 mg.................................................68
QUILLIVANT XR -methylphenidate hcl for er susp 25
mg/5ml (5 mg/ml)............................................................ 68
quinapril hcl tab 5 mg (Accupril)................................... 40
quinapril hcl tab 10 mg (Accupril)................................. 40
quinapril hcl tab 20 mg (Accupril)................................. 40
quinapril hcl tab 40 mg (Accupril)................................. 40
quinapril-hydrochlorothiazide tab 10-12.5 mg
(Accuretic)...................................................................... 40
quinapril-hydrochlorothiazide tab 20-12.5 mg
(Accuretic)...................................................................... 40
quinapril-hydrochlorothiazide tab 20-25 mg
(Accuretic)...................................................................... 40
quinidine gluconate tab cr 324 mg................................ 36
QUINIDINE SULFATE -quinidine sulfate tab 200 mg....... 36
QUINIDINE SULFATE -quinidine sulfate tab 300 mg....... 36
quinine sulfate cap 324 mg (Qualaquin)......................... 9
QUINTET AC BLOOD GLUCOSE -glucose blood test
strip................................................................................ 118
QUINTET BLOOD GLUCOSE TES -glucose blood test
strip................................................................................ 118
QVAR -beclomethasone diprop inhal aero soln 40 mcg/act
(50/valve)......................................................................... 49
QVAR -beclomethasone diprop inhal aero soln 80 mcg/act
(100/valve)....................................................................... 49
R
RABAVERT -rabies vaccine, pcec for inj.......................... 11
rabeprazole sodium ec tab 20 mg (Aciphex)................ 53
RADIOGARDASE -prussian blue insoluble cap 0.5
gm.................................................................................. 114
RAGWITEK -short ragweed pollen allergen extract tab sl
12 amb a 1-u.................................................................. 12
raloxifene hcl tab 60 mg (Evista)................................... 31
ramipril cap 1.25 mg (Altace)......................................... 40
ramipril cap 2.5 mg (Altace)........................................... 40
ramipril cap 5 mg (Altace).............................................. 40
ramipril cap 10 mg (Altace)............................................ 40
RANEXA -ranolazine tab sr 12hr 500 mg......................... 32
RANEXA -ranolazine tab sr 12hr 1000 mg....................... 32
ranitidine hcl cap 150 mg............................................... 53
ranitidine hcl cap 300 mg............................................... 53
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)................... 53
ranitidine hcl tab 150 mg (Zantac)................................. 53
ranitidine hcl tab 300 mg (Zantac)................................. 53
RAPAFLO -silodosin cap 4 mg..........................................57
RAPAFLO -silodosin cap 8 mg..........................................57
RAPAMUNE -sirolimus oral soln 1 mg/ml....................... 124
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RAPLIXA -fibrinogen-thrombin powder 79-699 mg-unit/
gm.................................................................................... 99
rasagiline mesylate tab 0.5 mg (base equiv)
(Azilect)........................................................................... 87
rasagiline mesylate tab 1 mg (base equiv)
(Azilect)........................................................................... 87
RASUVO -methotrexate soln pf auto-injector 7.5
mg/0.15ml........................................................................ 80
RASUVO -methotrexate soln pf auto-injector 10
mg/0.2ml.......................................................................... 80
RASUVO -methotrexate soln pf auto-injector 12.5
mg/0.25ml........................................................................ 80
RASUVO -methotrexate soln pf auto-injector 15
mg/0.3ml.......................................................................... 80
RASUVO -methotrexate soln pf auto-injector 17.5
mg/0.35ml........................................................................ 80
RASUVO -methotrexate soln pf auto-injector 20
mg/0.4ml.......................................................................... 80
RASUVO -methotrexate soln pf auto-injector 22.5
mg/0.45ml........................................................................ 80
RASUVO -methotrexate soln pf auto-injector 25
mg/0.5ml.......................................................................... 80
RASUVO -methotrexate soln pf auto-injector 27.5
mg/0.55ml........................................................................ 80
RASUVO -methotrexate soln pf auto-injector 30
mg/0.6ml.......................................................................... 80
RA TRUETEST STRIPS -glucose blood test strip.......... 118
RAVICTI -glycerol phenylbutyrate liquid 1.1 gm/ml...........31
RAYALDEE -calcifediol cap cr 30 mcg.............................. 31
RAYOS -prednisone tab delayed release 1 mg................ 17
RAYOS -prednisone tab delayed release 2 mg................ 17
RAYOS -prednisone tab delayed release 5 mg................ 17
REBETOL -ribavirin soln 40 mg/ml..................................... 7
REBIF -interferon beta-1a soln pref syr 22 mcg/0.5ml
(12mu/ml)........................................................................ 71
REBIF -interferon beta-1a soln pref syr 44 mcg/0.5ml
(24mu/ml)........................................................................ 71
REBIF REBIDOSE -interferon beta-1a soln auto-inj 22
mcg/0.5ml (12mu/ml)...................................................... 71
REBIF REBIDOSE -interferon beta-1a soln auto-inj 44
mcg/0.5ml (24mu/ml)...................................................... 71
REBIF REBIDOSE TITRATION -interferon beta-1a autoinj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml.......................... 71
REBIF TITRATION PACK -interferon beta-1a pref syr
6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml............................... 71
RECOMBINATE -antihemophilic factor (recombinant) for
inj 220-400 unit............................................................. 103
RECOMBINATE -antihemophilic factor (recombinant) for
inj 401-800 unit............................................................. 103
RECOMBINATE -antihemophilic factor (recombinant) for
inj 801-1240 unit........................................................... 103
RECOMBINATE -antihemophilic factor (recombinant) for
inj 1241-1800 unit......................................................... 103
RECOMBINATE -antihemophilic factor (recombinant) for
inj 1801-2400 unit......................................................... 103
RECOMBIVAX HB -hepatitis b vaccine (recombinant)
susp 5 mcg/0.5ml........................................................... 11
RECOMBIVAX HB -hepatitis b vaccine (recombinant)
susp 10 mcg/ml.............................................................. 11
RECOMBIVAX HB -hepatitis b vaccine (recombinant)
susp 40 mcg/ml.............................................................. 11
RECOTHROM SPRAY KIT -thrombin (recombinant) for
soln 20000 unit............................................................... 99
RECOTHROM -thrombin (recombinant) for soln 5000
unit................................................................................... 99
RECOTHROM -thrombin (recombinant) for soln 20000
unit................................................................................... 99
RECTIV -nitroglycerin oint 0.4%..................................... 108
REFUAH PLUS BLOOD GLUCOSE -glucose blood test
strip................................................................................ 118
REGIMEX -benzphetamine hcl tab 25 mg........................ 68
REGRANEX -becaplermin gel 0.01%............................. 113
RELENZA DISKHALER -zanamivir aero powder breath
activated 5 mg/blister........................................................7
RELION BLOOD GLUCOSE TEST -glucose blood test
strip................................................................................ 118
RELION CONFIRM/MICRO TEST -glucose blood test
strip................................................................................ 118
RELION PRIME BLOOD GLUCOS -glucose blood test
strip................................................................................ 118
RELION ULTIMA BLOOD GLUCO -glucose blood test
strip................................................................................ 118
RELION ULTIMA TEST STRIPS -glucose blood test
strip................................................................................ 118
RELISTOR -methylnaltrexone bromide inj 8 mg/0.4ml (20
mg/ml).............................................................................. 55
RELISTOR -methylnaltrexone bromide inj 12 mg/0.6ml
(20 mg/ml)....................................................................... 55
RELISTOR -methylnaltrexone bromide tab 150 mg......... 55
RELNATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................... 93
RELPAX -eletriptan hydrobromide tab 20 mg (base
equivalent)....................................................................... 81
RELPAX -eletriptan hydrobromide tab 40 mg (base
equivalent)....................................................................... 81
RENAGEL -sevelamer hcl tab 400 mg............................. 55
RENAGEL -sevelamer hcl tab 800 mg............................. 55
RENVELA -sevelamer carbonate packet 0.8 gm.............. 55
RENVELA -sevelamer carbonate packet 2.4 gm.............. 55
RENVELA -sevelamer carbonate tab 800 mg.................. 55
REPAGLINIDE/METFORMIN HYD -repaglinide-metformin
hcl tab 1-500 mg.............................................................24
REPAGLINIDE/METFORMIN HYD -repaglinide-metformin
hcl tab 2-500 mg.............................................................24
repaglinide tab 0.5 mg.................................................... 24
repaglinide tab 1 mg (Prandin)...................................... 24
repaglinide tab 2 mg (Prandin)...................................... 24
REPATHA -evolocumab subcutaneous soln prefilled
syringe 140 mg/ml.......................................................... 43
REPATHA PUSHTRONEX SYSTEM -evolocumab
subcutaneous soln cartridge/infusor 420 mg/3.5ml....... 43
REPATHA SURECLICK -evolocumab subcutaneous soln
auto-injector 140 mg/ml.................................................. 43
RESCRIPTOR -delavirdine mesylate tab 100 mg.............. 7
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RESCRIPTOR -delavirdine mesylate tab 200 mg.............. 7
RESCULA -unoprostone isopropyl ophth soln
0.15%.............................................................................106
RESTASIS -cyclosporine (ophth) emulsion 0.05%......... 106
RESTASIS MULTIDOSE -cyclosporine (ophth) emulsion
0.05%.............................................................................106
RETIN-A MICRO PUMP -tretinoin microsphere gel
0.08%.............................................................................113
REVATIO -sildenafil citrate for suspension 10 mg/ml....... 44
REVEAL BLOOD GLUCOSE TEST -glucose blood test
strip................................................................................ 118
REVLIMID -lenalidomide cap 5 mg................................. 124
REVLIMID -lenalidomide cap 10 mg............................... 124
REVLIMID -lenalidomide cap 15 mg............................... 124
REVLIMID -lenalidomide cap 20 mg............................... 124
REVLIMID -lenalidomide cap 25 mg............................... 124
REVLIMID -lenalidomide caps 2.5 mg............................ 124
REXALL BLOOD GLUCOSE TEST -glucose blood test
strip................................................................................ 118
REXULTI -brexpiprazole tab 0.25 mg............................... 63
REXULTI -brexpiprazole tab 0.5 mg................................. 63
REXULTI -brexpiprazole tab 1 mg.................................... 63
REXULTI -brexpiprazole tab 2 mg.................................... 63
REXULTI -brexpiprazole tab 3 mg.................................... 63
REXULTI -brexpiprazole tab 4 mg.................................... 63
REYATAZ -atazanavir sulfate cap 150 mg (base equiv)..... 7
REYATAZ -atazanavir sulfate cap 200 mg (base equiv)..... 7
REYATAZ -atazanavir sulfate cap 300 mg (base equiv)..... 7
REYATAZ -atazanavir sulfate oral powder packet 50 mg
(base equiv)...................................................................... 7
REZIRA -pseudoephedrine w/ hydrocodone soln 60-5
mg/5ml............................................................................. 47
RIASTAP -fibrinogen conc (human) inj approximately 1
gm (900-1300 mg)........................................................ 103
RIBASPHERE RIBAPAK -ribavirin tab 400 mg................... 7
RIBASPHERE RIBAPAK -ribavirin tab 600 mg................... 7
RIBASPHERE RIBAPAK -ribavirin tab 200 mg & ribavirin
tab 400 mg dose pack......................................................7
RIBASPHERE RIBAPAK -ribavirin tab 400 mg & ribavirin
tab 600 mg dose pack......................................................8
RIBASPHERE -ribavirin tab 400 mg................................... 7
RIBASPHERE -ribavirin tab 600 mg................................... 7
ribavirin cap 200 mg (Rebetol)......................................... 8
ribavirin for inhal soln 6 gm (Virazole)........................... 8
ribavirin tab 200 mg (Copegus)....................................... 8
RIDAURA -auranofin cap 3 mg......................................... 80
rifabutin cap 150 mg (Mycobutin).................................... 4
RIFAMATE -isoniazid & rifampin cap 150-300 mg.............. 4
rifampin cap 300 mg.......................................................... 4
rifampin cap 150 mg (Rifadin).......................................... 4
RIFATER -isoniazid-rifampin w/ pyrazinamide tab
50-120-300 mg.................................................................. 4
RIGHTEST GS100 BLOOD GLUC -glucose blood test
strip................................................................................ 118
RIGHTEST GS300 BLOOD GLUC -glucose blood test
strip................................................................................ 118
RIGHTEST GS550 BLOOD GLUC -glucose blood test
strip................................................................................ 118
riluzole tab 50 mg (Rilutek)............................................ 88
rimantadine hydrochloride tab 100 mg (Flumadine)..... 8
RIOMET -metformin hcl oral soln 500 mg/5ml.................. 24
risedronate sodium tab delayed release 35 mg
(Atelvia).......................................................................... 31
risedronate sodium tab 5 mg (Actonel)........................ 31
risedronate sodium tab 30 mg (Actonel)...................... 31
risedronate sodium tab 35 mg (Actonel)...................... 31
risedronate sodium tab 150 mg (Actonel).................... 31
risperidone orally disintegrating tab 0.25 mg.............. 63
risperidone orally disintegrating tab 0.5 mg (Risperdal
m-tab).............................................................................. 63
risperidone orally disintegrating tab 1 mg (Risperdal
m-tab).............................................................................. 63
risperidone orally disintegrating tab 2 mg (Risperdal
m-tab).............................................................................. 63
risperidone orally disintegrating tab 3 mg (Risperdal
m-tab).............................................................................. 63
risperidone orally disintegrating tab 4 mg (Risperdal
m-tab).............................................................................. 63
risperidone soln 1 mg/ml (Risperdal)............................ 63
risperidone tab 0.25 mg (Risperdal).............................. 63
risperidone tab 0.5 mg (Risperdal)................................ 63
risperidone tab 1 mg (Risperdal)................................... 63
risperidone tab 2 mg (Risperdal)................................... 63
risperidone tab 3 mg (Risperdal)................................... 63
risperidone tab 4 mg (Risperdal)................................... 63
RITALIN LA -methylphenidate hcl cap sr 24hr 10 mg
(la).................................................................................... 68
RITEFLO -spacer/aerosol-holding chambers device............................................................................ 122
rivastigmine tartrate cap 1.5 mg.................................... 71
rivastigmine tartrate cap 3 mg....................................... 71
rivastigmine tartrate cap 4.5 mg.................................... 71
rivastigmine tartrate cap 6 mg....................................... 71
rivastigmine td patch 24hr 4.6 mg/24hr (Exelon)......... 71
rivastigmine td patch 24hr 9.5 mg/24hr (Exelon)......... 71
rivastigmine td patch 24hr 13.3 mg/24hr (Exelon)....... 71
RIXUBIS -coagulation factor ix (recombinant) for inj 250
unit................................................................................. 103
RIXUBIS -coagulation factor ix (recombinant) for inj 500
unit................................................................................. 103
RIXUBIS -coagulation factor ix (recombinant) for inj 1000
unit................................................................................. 103
RIXUBIS -coagulation factor ix (recombinant) for inj 2000
unit................................................................................. 103
RIXUBIS -coagulation factor ix (recombinant) for inj 3000
unit................................................................................. 103
rizatriptan benzoate oral disintegrating tab 5 mg (base
eq) (Maxalt-mlt)............................................................. 81
rizatriptan benzoate oral disintegrating tab 10 mg
(base eq) (Maxalt-mlt).................................................. 81
rizatriptan benzoate tab 5 mg (base equivalent)
(Maxalt)........................................................................... 81
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rizatriptan benzoate tab 10 mg (base equivalent)
(Maxalt)........................................................................... 81
R-NATAL OB -prenatal w/o a w/fe cbn-fa-dha cap
20-1-320 mg.................................................................... 93
ropinirole hydrochloride tab 0.25 mg (Requip)............ 87
ropinirole hydrochloride tab 0.5 mg (Requip).............. 87
ropinirole hydrochloride tab 1 mg (Requip)................. 87
ropinirole hydrochloride tab 2 mg (Requip)................. 87
ropinirole hydrochloride tab 3 mg (Requip)................. 87
ropinirole hydrochloride tab 4 mg (Requip)................. 87
ropinirole hydrochloride tab 5 mg (Requip)................. 87
ropinirole hydrochloride tab sr 24hr 2 mg (base
equivalent) (Requip xl)................................................. 87
ropinirole hydrochloride tab sr 24hr 4 mg (base
equivalent) (Requip xl)................................................. 87
ropinirole hydrochloride tab sr 24hr 6 mg (base
equivalent) (Requip xl)................................................. 87
ropinirole hydrochloride tab sr 24hr 8 mg (base
equivalent) (Requip xl)................................................. 87
ropinirole hydrochloride tab sr 24hr 12 mg (base
equivalent) (Requip xl)................................................. 87
rosuvastatin calcium tab 5 mg (Crestor)...................... 43
rosuvastatin calcium tab 10 mg (Crestor).................... 43
rosuvastatin calcium tab 20 mg (Crestor).................... 43
rosuvastatin calcium tab 40 mg (Crestor).................... 43
ROTARIX -rotavirus vaccine, live for oral susp................. 11
ROTATEQ -rotavirus vaccine, live oral pentavalent
soln.................................................................................. 11
ROZEREM -ramelteon tab 8 mg....................................... 65
RUBRACA -rucaparib camsylate tab 200 mg (base
equivalent)....................................................................... 15
RUBRACA -rucaparib camsylate tab 300 mg (base
equivalent)....................................................................... 15
RUCONEST -c1 esterase inhibitor (recombinant) for iv inj
2100 unit....................................................................... 103
RULAVITE DHA -prenat w/o a w/fefum-methfol-fa-dha
cap 27-0.6-0.4-300 mg................................................... 93
RYTARY -carbidopa & levodopa cap cr 23.75-95 mg....... 87
RYTARY -carbidopa & levodopa cap cr 36.25-145 mg..... 87
RYTARY -carbidopa & levodopa cap cr 48.75-195 mg..... 87
RYTARY -carbidopa & levodopa cap cr 61.25-245 mg..... 87
RYVENT -carbinoxamine maleate tab 6 mg..................... 46
S
SABRIL -vigabatrin powd pack 500 mg............................ 85
SABRIL -vigabatrin tab 500 mg........................................ 85
SAFYRAL -drospirenone-ethinyl estrad-levomefolate tab
3-0.03-0.451 mg..............................................................21
SAIZEN CLICK.EASY -somatropin (non-refrigerated) for
inj 8.8 mg........................................................................ 31
SAIZENPREP RECONSTITUTION -somatropin (nonrefrigerated) for inj 8.8 mg..............................................31
SAIZEN -somatropin (non-refrigerated) for inj 5 mg......... 31
SAIZEN -somatropin (non-refrigerated) for inj 8.8 mg...... 31
SAMSCA -tolvaptan tab 15 mg......................................... 31
SAMSCA -tolvaptan tab 30 mg......................................... 31
SANCUSO -granisetron td patch 3.1 mg/24hr (contains
34.3 mg).......................................................................... 53
SANDIMMUNE -cyclosporine cap 25 mg....................... 124
SANDIMMUNE -cyclosporine cap 100 mg..................... 124
SANDIMMUNE -cyclosporine oral soln 100 mg/ml......... 124
SANTYL -collagenase oint 250 unit/gm.......................... 113
SAPHRIS -asenapine maleate sl tab 2.5 mg (base
equiv)............................................................................... 64
SAPHRIS -asenapine maleate sl tab 5 mg (base
equiv)............................................................................... 64
SAPHRIS -asenapine maleate sl tab 10 mg (base
equiv)............................................................................... 64
SAVAYSA -edoxaban tosylate tab 15 mg (base
equivalent)....................................................................... 99
SAVAYSA -edoxaban tosylate tab 30 mg (base
equivalent)....................................................................... 99
SAVAYSA -edoxaban tosylate tab 60 mg (base
equivalent)....................................................................... 99
SAVELLA -milnacipran hcl tab 12.5 mg............................ 71
SAVELLA -milnacipran hcl tab 25 mg............................... 71
SAVELLA -milnacipran hcl tab 50 mg............................... 71
SAVELLA -milnacipran hcl tab 100 mg............................. 71
SAVELLA TITRATION PACK -milnacipran hcl tab 12.5 mg
(5) & 25 mg (8) & 50 mg (42) pak................................. 71
SAXENDA -liraglutide (weight management) soln peninjector 18 mg/3ml.......................................................... 68
SECONAL SODIUM -secobarbital sodium cap 100
mg.................................................................................... 65
SELECT-OB+DHA -prenatal mv w/fe poly-fa chw 29-1 mg
& dha cap 250 mg pak................................................... 93
SELECT-OB -prenatal vit w/ fe polysac cmplx-fa chew tab
29-1 mg........................................................................... 93
SELECT-OB -prenat w/ fepolycmplx-methylfol-fa chew
tab 29-0.6-0.4 mg........................................................... 93
selegiline hcl cap 5 mg (Eldepryl)................................. 87
selegiline hcl tab 5 mg.................................................... 87
selenium sulfide lotion 2.5%........................................ 113
SELZENTRY -maraviroc tab 25 mg.................................... 8
SELZENTRY -maraviroc tab 75 mg.................................... 8
SELZENTRY -maraviroc tab 150 mg.................................. 8
SELZENTRY -maraviroc tab 300 mg.................................. 8
SEMPREX-D -acrivastine & pseudoephedrine cap 8-60
mg.................................................................................... 47
SE-NATAL 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg.................................................................................... 93
SE-NATAL 19 -prenatal vit w/ fe fumarate-fa chew tab
29-1 mg........................................................................... 93
SENSIPAR -cinacalcet hcl tab 30 mg (base equiv).......... 31
SENSIPAR -cinacalcet hcl tab 60 mg (base equiv).......... 31
SENSIPAR -cinacalcet hcl tab 90 mg (base equiv).......... 31
SEREVENT DISKUS -salmeterol xinafoate aer pow ba 50
mcg/dose (base equiv)................................................... 50
SERNIVO -betamethasone dipropionate spray emulsion
0.05% (base equiv).......................................................113
SEROQUEL XR -quetiapine fumarate tab sr 24hr 50
mg.................................................................................... 64
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SEROQUEL XR -quetiapine fumarate tab sr 24hr 150
mg.................................................................................... 64
SEROQUEL XR -quetiapine fumarate tab sr 24hr 200
mg.................................................................................... 64
SEROQUEL XR -quetiapine fumarate tab sr 24hr 300
mg.................................................................................... 64
SEROSTIM -somatropin (non-refrigerated) for
subcutaneous inj 4 mg................................................... 31
SEROSTIM -somatropin (non-refrigerated) for
subcutaneous inj 5 mg................................................... 31
SEROSTIM -somatropin (non-refrigerated) for
subcutaneous inj 6 mg................................................... 31
sertraline hcl oral conc 20 mg/ml (Zoloft).................... 61
sertraline hcl tab 25 mg (Zoloft).................................... 61
sertraline hcl tab 50 mg (Zoloft).................................... 61
sertraline hcl tab 100 mg (Zoloft).................................. 61
SFROWASA -mesalamine sulfite-free (sf) enema 4
gm/60ml........................................................................... 55
SHUR-SEAL -nonoxynol-9 gel 2%.................................... 57
SIGNIFOR -pasireotide diaspartate inj 0.3 mg/ml (base
equiv)............................................................................... 31
SIGNIFOR -pasireotide diaspartate inj 0.6 mg/ml (base
equiv)............................................................................... 31
SIGNIFOR -pasireotide diaspartate inj 0.9 mg/ml (base
equiv)............................................................................... 31
sildenafil citrate tab 20 mg (Revatio)............................ 44
SILENOR -doxepin hcl (sleep) tab 3 mg (base equiv)...... 65
SILENOR -doxepin hcl (sleep) tab 6 mg (base equiv)...... 65
silver sulfadiazine cream 1% (Silvadene)................... 113
SIMBRINZA -brinzolamide-brimonidine tartrate ophth
susp 1-0.2%.................................................................. 106
SIMPONI -golimumab subcutaneous soln auto-injector 50
mg/0.5ml.......................................................................... 80
SIMPONI -golimumab subcutaneous soln auto-injector
100 mg/ml....................................................................... 80
SIMPONI -golimumab subcutaneous soln prefilled syringe
50 mg/0.5ml.................................................................... 80
SIMPONI -golimumab subcutaneous soln prefilled syringe
100 mg/ml....................................................................... 80
simvastatin tab 5 mg (Zocor)......................................... 43
simvastatin tab 10 mg (Zocor)....................................... 44
simvastatin tab 20 mg (Zocor)....................................... 44
simvastatin tab 40 mg (Zocor)....................................... 44
simvastatin tab 80 mg (Zocor)....................................... 44
sirolimus tab 0.5 mg (Rapamune)............................... 124
sirolimus tab 1 mg (Rapamune).................................. 124
sirolimus tab 2 mg (Rapamune).................................. 124
SIRTURO -bedaquiline fumarate tab 100 mg (base
equiv)................................................................................. 5
SITAVIG -acyclovir buccal tab 50 mg.................................. 8
SIVEXTRO -tedizolid phosphate tab 200 mg......................9
SKLICE -ivermectin lotion 0.5%...................................... 113
SMARTEST BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 118
SMART SENSE PREMIUM BLOOD -glucose blood test
strip................................................................................ 118
SMART SENSE VALUE BLOOD G -glucose blood test
strip................................................................................ 118
sodium fluoride chew tab 0.25 mg f (from 0.55 mg
naf).................................................................................. 96
sodium fluoride chew tab 0.5 mg f (from 1.1 mg
naf).................................................................................. 96
sodium fluoride chew tab 1 mg f (from 2.2 mg naf)..... 96
sodium fluoride cream 1.1% (Prevident 5000
plus).............................................................................. 107
sodium fluoride gel 1.1% (0.5% f) (Prevident
fluoride)........................................................................ 107
sodium fluoride paste 1.1% (Prevident 5000
boost)............................................................................ 107
sodium fluoride-potassium nitrate paste 1.1-5%
(Prevident 5000 sensi)............................................... 108
sodium fluoride rinse 0.2%...........................................108
SODIUM FLUORIDE -sodium fluoride tab 0.5 mg f (from
1.1 mg naf)......................................................................95
SODIUM FLUORIDE -sodium fluoride tab 1 mg f (from
2.2 mg naf)......................................................................95
sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop
naf).................................................................................. 96
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml
naf).................................................................................. 96
sodium phenylbutyrate oral powder 3 gm/teaspoonful
(Buphenyl)...................................................................... 31
sodium polystyrene sulfonate oral susp 15
gm/60ml........................................................................ 124
sodium polystyrene sulfonate powder
(Kayexalate)................................................................. 124
sodium polystyrene sulfonate rectal susp 30
gm/120ml...................................................................... 124
SOLIQUA 100/33 -insulin glargine-lixisenatide sol pen-inj
100-33 unit-mcg/ml......................................................... 24
SOLODYN -minocycline hcl tab sr 24hr 55 mg.................. 3
SOLODYN -minocycline hcl tab sr 24hr 65 mg.................. 3
SOLODYN -minocycline hcl tab sr 24hr 80 mg.................. 3
SOLODYN -minocycline hcl tab sr 24hr 105 mg................ 3
SOLODYN -minocycline hcl tab sr 24hr 115 mg................. 4
SOLTAMOX -tamoxifen citrate oral soln 10 mg/5ml (base
equivalent)....................................................................... 15
SOLUS V2 AUDIBLE TEST -glucose blood test strip..... 118
SOMA -carisoprodol tab 250 mg....................................... 88
SOMA -carisoprodol tab 350 mg....................................... 88
SOMAVERT -pegvisomant for inj 10 mg (as protein)....... 31
SOMAVERT -pegvisomant for inj 15 mg (as protein)....... 31
SOMAVERT -pegvisomant for inj 20 mg (as protein)....... 31
SOMAVERT -pegvisomant for inj 25 mg (as protein)....... 31
SOMAVERT -pegvisomant for inj 30 mg (as protein)....... 31
SOOLANTRA -ivermectin cream 1%.............................. 113
SORILUX -calcipotriene foam 0.005%............................ 113
sotalol hcl (afib/afl) tab 80 mg (Betapace af)................ 34
sotalol hcl (afib/afl) tab 120 mg (Betapace af).............. 34
sotalol hcl (afib/afl) tab 160 mg (Betapace af).............. 34
sotalol hcl tab 240 mg.....................................................34
sotalol hcl tab 80 mg (Betapace)................................... 34
sotalol hcl tab 120 mg (Betapace)................................. 34
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sotalol hcl tab 160 mg (Betapace)................................. 34
SOTYLIZE -sotalol hcl oral solution 5 mg/ml.................... 34
SOVALDI -sofosbuvir tab 400 mg....................................... 8
SPECTRACEF -cefditoren pivoxil tab 400 mg (base
equivalent)......................................................................... 2
SPINOSAD -spinosad susp 0.9%................................... 113
SPIRIVA HANDIHALER -tiotropium bromide monohydrate
inhal cap 18 mcg (base equiv)....................................... 50
SPIRIVA RESPIMAT -tiotropium bromide monohydrate
inhal aerosol 1.25 mcg/act............................................. 50
SPIRIVA RESPIMAT -tiotropium bromide monohydrate
inhal aerosol 2.5 mcg/act............................................... 50
spironolactone & hydrochlorothiazide tab 25-25 mg
(Aldactazide).................................................................. 41
spironolactone tab 25 mg (Aldactone).......................... 41
spironolactone tab 50 mg (Aldactone).......................... 41
spironolactone tab 100 mg (Aldactone)........................ 41
SPIRO PD -respiratory therapy supplies - devices......... 122
SPORANOX -itraconazole oral soln 10 mg/ml....................5
SPRITAM -levetiracetam tab disintegrating soluble 250
mg.................................................................................... 85
SPRITAM -levetiracetam tab disintegrating soluble 500
mg.................................................................................... 85
SPRITAM -levetiracetam tab disintegrating soluble 750
mg.................................................................................... 85
SPRITAM -levetiracetam tab disintegrating soluble 1000
mg.................................................................................... 85
SPRIX -ketorolac tromethamine nasal spray 15.75 mg/
spray................................................................................ 80
SPRYCEL -dasatinib tab 20 mg........................................ 15
SPRYCEL -dasatinib tab 50 mg........................................ 15
SPRYCEL -dasatinib tab 70 mg........................................ 15
SPRYCEL -dasatinib tab 80 mg........................................ 15
SPRYCEL -dasatinib tab 100 mg...................................... 15
SPRYCEL -dasatinib tab 140 mg...................................... 15
STALEVO 100 -carbidopa-levodopa-entacapone tabs
25-100-200 mg................................................................87
STALEVO 125 -carbidopa-levodopa-entacapone tabs
31.25-125-200 mg.......................................................... 88
STALEVO 150 -carbidopa-levodopa-entacapone tabs
37.5-150-200 mg.............................................................88
STALEVO 200 -carbidopa-levodopa-entacapone tabs
50-200-200 mg................................................................88
STALEVO 50 -carbidopa-levodopa-entacapone tabs
12.5-50-200 mg...............................................................88
STALEVO 75 -carbidopa-levodopa-entacapone tabs
18.75-75-200 mg.............................................................88
stannous fluoride conc 0.63% (Gel-kam oral care
ri)................................................................................... 108
stannous fluoride gel 0.4%........................................... 108
stavudine cap 15 mg (Zerit)..............................................8
stavudine cap 20 mg (Zerit)..............................................8
stavudine cap 30 mg (Zerit)..............................................8
stavudine cap 40 mg (Zerit)..............................................8
STAXYN -vardenafil hcl orally disintegrating tab 10
mg.................................................................................... 45
STELARA -ustekinumab inj 45 mg/0.5ml........................ 113
STELARA -ustekinumab soln prefilled syringe 45
mg/0.5ml........................................................................ 113
STELARA -ustekinumab soln prefilled syringe 90 mg/
ml................................................................................... 113
STENDRA -avanafil tab 50 mg......................................... 45
STENDRA -avanafil tab 100 mg....................................... 45
STENDRA -avanafil tab 200 mg....................................... 45
STIMATE -desmopressin acetate nasal soln 1.5 mg/
ml..................................................................................... 31
STIOLTO RESPIMAT -tiotropium br-olodaterol inhal aero
soln 2.5-2.5 mcg/act....................................................... 50
STIVARGA -regorafenib tab 40 mg................................... 15
STRATTERA -atomoxetine hcl cap 10 mg (base
equiv)............................................................................... 68
STRATTERA -atomoxetine hcl cap 18 mg (base
equiv)............................................................................... 68
STRATTERA -atomoxetine hcl cap 25 mg (base
equiv)............................................................................... 68
STRATTERA -atomoxetine hcl cap 40 mg (base
equiv)............................................................................... 68
STRATTERA -atomoxetine hcl cap 60 mg (base
equiv)............................................................................... 68
STRATTERA -atomoxetine hcl cap 80 mg (base
equiv)............................................................................... 68
STRATTERA -atomoxetine hcl cap 100 mg (base
equiv)............................................................................... 68
STRENSIQ -asfotase alfa subcutaneous inj 18
mg/0.45ml........................................................................ 31
STRENSIQ -asfotase alfa subcutaneous inj 28
mg/0.7ml.......................................................................... 31
STRENSIQ -asfotase alfa subcutaneous inj 40 mg/ml..... 31
STRENSIQ -asfotase alfa subcutaneous inj 80
mg/0.8ml.......................................................................... 31
STRIANT -testosterone buccal mucoadhesive system 30
mg.................................................................................... 18
STRIBILD -elvitegrav-cobic-emtricitab-tenofovdf tab
150-150-200-300 mg........................................................ 8
STRIVERDI RESPIMAT -olodaterol hcl inhal aerosol soln
2.5 mcg/act (base equiv)................................................ 50
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 2-0.5
mg (base equiv).............................................................. 77
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 4-1
mg (base equiv).............................................................. 77
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 8-2
mg (base equiv).............................................................. 77
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 12-3
mg (base equiv).............................................................. 77
SUBSYS -fentanyl sublingual spray 100 mcg................... 77
SUBSYS -fentanyl sublingual spray 200 mcg................... 77
SUBSYS -fentanyl sublingual spray 400 mcg................... 77
SUBSYS -fentanyl sublingual spray 600 mcg................... 77
SUBSYS -fentanyl sublingual spray 800 mcg................... 77
SUBSYS -fentanyl sublingual spray 1200 mcg (600 mcg x
2)...................................................................................... 77
SUBSYS -fentanyl sublingual spray 1600 mcg (800 mcg x
2)...................................................................................... 77
SUCRAID -sacrosidase soln 8500 unit/ml........................ 54
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sucralfate tab 1 gm (Carafate)....................................... 53
sulfacetamide sodium lotion 10% (acne) (Klaron)..... 113
sulfacetamide sodium ophth soln 10%
(Bleph-10)..................................................................... 106
sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%............................................................. 106
SULFACETAMIDE SODIUM -sulfacetamide sodium ophth
oint 10%........................................................................ 106
SULFADIAZINE -sulfadiazine tab 500 mg.......................... 4
sulfamethoxazole-trimethoprim susp 200-40
mg/5ml.............................................................................. 9
sulfamethoxazole-trimethoprim tab 400-80 mg
(Bactrim)........................................................................... 9
sulfamethoxazole-trimethoprim tab 800-160 mg
(Bactrim ds)..................................................................... 9
SULFAMYLON -mafenide acetate cream 85 mg/gm...... 113
sulfasalazine tab delayed release 500 mg (Azulfidine
en-tabs)........................................................................... 55
sulfasalazine tab 500 mg (Azulfidine)........................... 55
sulindac tab 150 mg........................................................ 80
sulindac tab 200 mg........................................................ 80
sumatriptan nasal spray 5 mg/act (Imitrex).................. 81
sumatriptan nasal spray 20 mg/act (Imitrex)................ 81
sumatriptan succinate inj 6 mg/0.5ml (Imitrex)............ 81
sumatriptan succinate solution auto-injector 4
mg/0.5ml (Imitrex statdose sys)................................. 81
sumatriptan succinate solution auto-injector 6
mg/0.5ml (Imitrex statdose sys)................................. 81
sumatriptan succinate solution cartridge 4 mg/0.5ml
(Imitrex statdose ref).................................................... 81
sumatriptan succinate solution cartridge 6 mg/0.5ml
(Imitrex statdose ref).................................................... 81
SUMATRIPTAN SUCCINATE -sumatriptan succinate
solution prefilled syringe 6 mg/0.5ml............................. 81
sumatriptan succinate tab 25 mg (Imitrex)................... 81
sumatriptan succinate tab 50 mg (Imitrex)................... 81
sumatriptan succinate tab 100 mg (Imitrex)................. 81
SUMAVEL DOSEPRO -sumatriptan succinate solution jetinjector 4 mg/0.5ml......................................................... 82
SUMAVEL DOSEPRO -sumatriptan succinate solution jetinjector 6 mg/0.5ml......................................................... 82
SUPRAX -cefixime cap 400 mg.......................................... 2
SUPRAX -cefixime chew tab 100 mg................................. 2
SUPRAX -cefixime chew tab 200 mg................................. 2
SUPRAX -cefixime for susp 500 mg/5ml............................ 2
SUPREME TEST STRIPS -glucose blood test strip....... 118
SUPREP BOWEL PREP KIT -sodium sulfate-potassium
sulfate-magnesium sulfate oral soln.............................. 51
SURECHEK BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 119
SURE EDGE BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 118
SURE-TEST EASYPLUS MINI B -glucose blood test
strip................................................................................ 118
SUSTIVA -efavirenz cap 50 mg.......................................... 8
SUSTIVA -efavirenz cap 200 mg........................................ 8
SUSTIVA -efavirenz tab 600 mg......................................... 8
SUTENT -sunitinib malate cap 12.5 mg (base
equivalent)....................................................................... 15
SUTENT -sunitinib malate cap 25 mg (base
equivalent)....................................................................... 15
SUTENT -sunitinib malate cap 37.5 mg (base
equivalent)....................................................................... 15
SUTENT -sunitinib malate cap 50 mg (base
equivalent)....................................................................... 15
SYLATRON -peginterferon alfa-2b for inj kit 200 mcg...... 15
SYLATRON -peginterferon alfa-2b for inj kit 300 mcg...... 15
SYLATRON -peginterferon alfa-2b for inj kit 600 mcg...... 15
SYMBICORT -budesonide-formoterol fumarate dihyd
aerosol 80-4.5 mcg/act................................................... 50
SYMBICORT -budesonide-formoterol fumarate dihyd
aerosol 160-4.5 mcg/act................................................. 50
SYMLINPEN 120 -pramlintide acetate pen-inj 2700
mcg/2.7ml (1000 mcg/ml)............................................... 24
SYMLINPEN 60 -pramlintide acetate pen-inj 1500
mcg/1.5ml (1000 mcg/ml)............................................... 24
SYNALGOS-DC -aspirin-caffeine-dihydrocodeine cap
356.4-30-16 mg...............................................................77
SYNAREL -nafarelin acetate nasal soln 2 mg/ml (200
mcg/act) (base eq)..........................................................31
SYNERA -lidocaine-tetracaine topical patch 70-70
mg.................................................................................. 113
SYNJARDY -empagliflozin-metformin hcl tab 12.5-1000
mg.................................................................................... 25
SYNJARDY -empagliflozin-metformin hcl tab 12.5-500
mg.................................................................................... 25
SYNJARDY -empagliflozin-metformin hcl tab 5-500
mg.................................................................................... 25
SYNJARDY -empagliflozin-metformin hcl tab 5-1000
mg.................................................................................... 25
SYNRIBO -omacetaxine mepesuccinate for inj 3.5
mg.................................................................................... 15
SYNTHROID -levothyroxine sodium tab 25 mcg.............. 27
SYNTHROID -levothyroxine sodium tab 50 mcg.............. 27
SYNTHROID -levothyroxine sodium tab 75 mcg.............. 27
SYNTHROID -levothyroxine sodium tab 88 mcg.............. 27
SYNTHROID -levothyroxine sodium tab 100 mcg............ 27
SYNTHROID -levothyroxine sodium tab 112 mcg............ 27
SYNTHROID -levothyroxine sodium tab 125 mcg............ 27
SYNTHROID -levothyroxine sodium tab 137 mcg............ 27
SYNTHROID -levothyroxine sodium tab 150 mcg............ 27
SYNTHROID -levothyroxine sodium tab 175 mcg............ 27
SYNTHROID -levothyroxine sodium tab 200 mcg............ 27
SYNTHROID -levothyroxine sodium tab 300 mcg............ 27
SYPRINE -trientine hcl cap 250 mg................................ 124
T
TABLOID -thioguanine tab 40 mg..................................... 15
TACLONEX -calcipotriene-betamethasone dipropionate
susp 0.005-0.064%....................................................... 113
tacrolimus cap 0.5 mg (Prograf).................................. 124
tacrolimus cap 1 mg (Prograf)..................................... 124
tacrolimus cap 5 mg (Prograf)..................................... 124
tacrolimus oint 0.03% (Protopic)................................. 113
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tacrolimus oint 0.1% (Protopic)................................... 113
TAFINLAR -dabrafenib mesylate cap 50 mg (base
equivalent)....................................................................... 15
TAFINLAR -dabrafenib mesylate cap 75 mg (base
equivalent)....................................................................... 15
TAGRISSO -osimertinib mesylate tab 40 mg (base
equivalent)....................................................................... 15
TAGRISSO -osimertinib mesylate tab 80 mg (base
equivalent)....................................................................... 15
TALTZ -ixekizumab subcutaneous soln auto-injector 80
mg/ml............................................................................. 113
TALTZ -ixekizumab subcutaneous soln prefilled syringe
80 mg/ml....................................................................... 113
TAMIFLU -oseltamivir phosphate for susp 6 mg/ml (base
equiv)................................................................................. 8
tamoxifen citrate tab 10 mg (base equivalent)............. 15
tamoxifen citrate tab 20 mg (base equivalent)............. 15
tamsulosin hcl cap 0.4 mg (Flomax)............................. 57
TANZEUM -albiglutide for soln pen-injector 30 mg........... 25
TANZEUM -albiglutide for soln pen-injector 50 mg........... 25
TARCEVA -erlotinib hcl tab 25 mg (base equivalent)....... 15
TARCEVA -erlotinib hcl tab 100 mg (base equivalent)..... 15
TARCEVA -erlotinib hcl tab 150 mg (base equivalent)..... 15
TARGADOX -doxycycline hyclate tab 50 mg...................... 4
TARGRETIN -bexarotene gel 1%....................................113
TARON-BC -prenat w/o a w/ fe cbnyl-fa tab 20-1 mg & vit
b6 tab pak....................................................................... 93
TARON-C DHA -prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg........................................................... 93
TARON-PREX -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 30-1.2-265 mg......................................................... 93
TASIGNA -nilotinib hcl cap 150 mg (base equivalent)...... 15
TASIGNA -nilotinib hcl cap 200 mg (base equivalent)...... 15
TAYTULLA -norethindrone ace-ethinyl estradiol-fe cap 1
mg-20 mcg (24).............................................................. 21
tazarotene cream 0.1% (Tazorac)................................. 113
TAZORAC -tazarotene cream 0.05%.............................. 113
TAZORAC -tazarotene cream 0.1%................................ 113
TAZORAC -tazarotene gel 0.05%................................... 113
TAZORAC -tazarotene gel 0.1%..................................... 113
TECFIDERA -dimethyl fumarate capsule delayed release
120 mg............................................................................ 72
TECFIDERA -dimethyl fumarate capsule delayed release
240 mg............................................................................ 72
TECFIDERA STARTER PACK -dimethyl fumarate
capsule dr starter pack 120 mg & 240 mg..................... 72
TECHNIVIE -ombitasvir-paritaprevir-ritonavir tab
12.5-75-50 mg................................................................... 8
TEGRETOL -carbamazepine susp 100 mg/5ml............... 85
TEGRETOL -carbamazepine tab 200 mg......................... 85
TEGRETOL-XR -carbamazepine tab sr 12hr 100 mg...... 85
TEGRETOL-XR -carbamazepine tab sr 12hr 200 mg...... 85
TEGRETOL-XR -carbamazepine tab sr 12hr 400 mg...... 85
TEKTURNA -aliskiren fumarate tab 150 mg (base
equivalent)....................................................................... 40
TEKTURNA -aliskiren fumarate tab 300 mg (base
equivalent)....................................................................... 40
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
150-12.5 mg.................................................................... 40
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
150-25 mg....................................................................... 40
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
300-12.5 mg.................................................................... 40
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
300-25 mg....................................................................... 40
TELCARE BLOOD GLUCOSE TES -glucose blood test
strip................................................................................ 119
telmisartan-amlodipine tab 40-5 mg (Twynsta)............ 40
telmisartan-amlodipine tab 80-5 mg (Twynsta)............ 40
telmisartan-amlodipine tab 40-10 mg (Twynsta).......... 40
telmisartan-amlodipine tab 80-10 mg (Twynsta).......... 40
telmisartan-hydrochlorothiazide tab 40-12.5 mg
(Micardis hct)................................................................. 40
telmisartan-hydrochlorothiazide tab 80-12.5 mg
(Micardis hct)................................................................. 40
telmisartan-hydrochlorothiazide tab 80-25 mg
(Micardis hct)................................................................. 40
telmisartan tab 20 mg (Micardis)................................... 40
telmisartan tab 40 mg (Micardis)................................... 40
telmisartan tab 80 mg (Micardis)................................... 40
temazepam cap 7.5 mg (Restoril).................................. 65
temazepam cap 15 mg (Restoril)................................... 65
temazepam cap 22.5 mg (Restoril)................................ 65
temazepam cap 30 mg (Restoril)................................... 65
temozolomide cap 5 mg (Temodar)............................... 15
temozolomide cap 20 mg (Temodar)............................. 15
temozolomide cap 100 mg (Temodar)........................... 15
temozolomide cap 140 mg (Temodar)........................... 15
temozolomide cap 180 mg (Temodar)........................... 15
temozolomide cap 250 mg (Temodar)........................... 15
TENCON -butalbital-acetaminophen tab 50-325 mg........ 72
TENIVAC -tetanus-diphtheria toxoids (td) inj 5-2 lfu......... 12
terazosin hcl cap 1 mg....................................................40
terazosin hcl cap 2 mg....................................................40
terazosin hcl cap 5 mg....................................................40
terazosin hcl cap 10 mg..................................................40
terbinafine hcl tab 250 mg (Lamisil)................................ 5
terbutaline sulfate tab 2.5 mg........................................ 50
terbutaline sulfate tab 5 mg........................................... 50
terconazole vaginal cream 0.8%.................................... 57
terconazole vaginal cream 0.4% (Terazol 7)................. 57
terconazole vaginal suppos 80 mg............................... 57
TESTIM -testosterone td gel 50 mg/5gm (1%)................. 18
testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone).................................................................. 18
testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone).................................................................. 18
testosterone enanthate im inj in oil 200 mg/ml............ 18
TESTOSTERONE PUMP -testosterone td gel 12.5 mg/act
(1%)................................................................................. 18
testosterone td gel 12.5 mg/act (1%).............................18
testosterone td gel 25 mg/2.5gm (1%) (Androgel)....... 18
testosterone td gel 50 mg/5gm (1%) (Androgel).......... 18
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TESTOSTERONE -testosterone td gel 10mg/act
(2%)................................................................................. 18
TESTOSTERONE -testosterone td gel 25 mg/2.5gm
(1%)................................................................................. 18
TESTOSTERONE -testosterone td gel 50 mg/5gm
(1%)................................................................................. 18
TETANUS/DIPHTHERIA TOXOID -tetanus-diphtheria
toxoids (td) inj 2-2 lf/0.5ml.............................................. 12
tetrabenazine tab 12.5 mg (Xenazine)........................... 72
tetrabenazine tab 25 mg (Xenazine).............................. 72
tetracaine hcl ophth soln 0.5%.................................... 106
tetracycline hcl cap 250 mg (Tetracycline hcl)............... 4
tetracycline hcl cap 500 mg (Tetracycline hcl)............... 4
TEXACORT -hydrocortisone soln 2.5%.......................... 113
TGT BLOOD GLUCOSE TEST ST -glucose blood test
strip................................................................................ 119
THALOMID -thalidomide cap 50 mg............................... 124
THALOMID -thalidomide cap 100 mg............................. 124
THALOMID -thalidomide cap 150 mg............................. 124
THALOMID -thalidomide cap 200 mg............................. 124
theophylline soln 80 mg/15ml........................................ 50
theophylline tab sr 12hr 100 mg.................................... 50
theophylline tab sr 12hr 200 mg.................................... 50
theophylline tab sr 12hr 300 mg.................................... 50
theophylline tab sr 12hr 450 mg.................................... 50
theophylline tab sr 24hr 400 mg.................................... 50
theophylline tab sr 24hr 600 mg.................................... 50
THEO-24 -theophylline cap sr 24hr 100 mg..................... 50
THEO-24 -theophylline cap sr 24hr 200 mg..................... 50
THEO-24 -theophylline cap sr 24hr 300 mg..................... 50
THEO-24 -theophylline cap sr 24hr 400 mg..................... 50
THIOLA -tiopronin tab 100 mg.......................................... 57
thioridazine hcl tab 10 mg.............................................. 64
thioridazine hcl tab 25 mg.............................................. 64
thioridazine hcl tab 50 mg.............................................. 64
thioridazine hcl tab 100 mg............................................ 64
thiothixene cap 1 mg....................................................... 64
thiothixene cap 2 mg....................................................... 64
thiothixene cap 5 mg....................................................... 64
thiothixene cap 10 mg..................................................... 64
THRESHOLD PEP -respiratory therapy supplies devices.......................................................................... 122
THRIVITE 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg.................................................................................... 93
THRIVITE RX -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................... 93
THROMBIN-JMI DILUENT -thrombin for soln 5000
unit................................................................................... 99
THROMBIN-JMI DILUENT -thrombin for soln 20000
unit................................................................................... 99
THROMBIN-JMI EPISTAXIS -thrombin for soln kit 5000
unit................................................................................... 99
THROMBIN-JMI SYRINGE SPRA -thrombin for soln kit
5000 unit......................................................................... 99
THROMBIN-JMI SYRINGE SPRA -thrombin for soln kit
20000 unit....................................................................... 99
THROMBIN-JMI W/DIL SPRAY -thrombin for soln kit
20000 unit....................................................................... 99
thyroid tab 15 mg (1/4 grain) (Armour thyroid)............ 27
thyroid tab 30 mg (1/2 grain) (Armour thyroid)............ 27
thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)......... 27
thyroid tab 60 mg (1 grain) (Armour thyroid)............... 27
THYROLAR-1/2 -liotrix (t3-t4) tab 30 mg (6.25-25
mcg)................................................................................. 27
THYROLAR-1/4 -liotrix (t3-t4) tab 15 mg (3.1-12.5
mcg)................................................................................. 28
THYROLAR-1 -liotrix (t3-t4) tab 60 mg (12.5-50 mcg)......27
THYROLAR-2 -liotrix (t3-t4) tab 120 mg (25-100
mcg)................................................................................. 28
THYROLAR-3 -liotrix (t3-t4) tab 180 mg (37.5-150
mcg)................................................................................. 28
tiagabine hcl tab 2 mg (Gabitril).................................... 85
tiagabine hcl tab 4 mg (Gabitril).................................... 85
timolol maleate ophth gel forming soln 0.25%
(Timoptic-xe)................................................................ 106
timolol maleate ophth gel forming soln 0.5%
(Timoptic-xe)................................................................ 106
timolol maleate ophth soln 0.25% (Timoptic)............. 106
timolol maleate ophth soln 0.5% (Timoptic)............... 106
TIMOLOL MALEATE -timolol maleate tab 5 mg............... 34
TIMOLOL MALEATE -timolol maleate tab 10 mg............. 34
TIMOLOL MALEATE -timolol maleate tab 20 mg............. 34
TIMOPTIC OCUDOSE -timolol maleate preservative free
ophth soln 0.25%.......................................................... 106
TIMOPTIC OCUDOSE -timolol maleate preservative free
ophth soln 0.5%............................................................ 107
tinidazole tab 250 mg........................................................ 9
tinidazole tab 500 mg (Tindamax)....................................9
TIROSINT -levothyroxine sodium cap 13 mcg..................28
TIROSINT -levothyroxine sodium cap 25 mcg..................28
TIROSINT -levothyroxine sodium cap 50 mcg..................28
TIROSINT -levothyroxine sodium cap 75 mcg..................28
TIROSINT -levothyroxine sodium cap 88 mcg..................28
TIROSINT -levothyroxine sodium cap 100 mcg................28
TIROSINT -levothyroxine sodium cap 112 mcg................ 28
TIROSINT -levothyroxine sodium cap 125 mcg................28
TIROSINT -levothyroxine sodium cap 137 mcg................28
TIROSINT -levothyroxine sodium cap 150 mcg................28
TISSEEL -fibrin sealant component solution.................... 99
TISSEEL VH -fibrin sealant component kit 2 ml............. 100
TISSEEL VH -fibrin sealant component kit 4 ml............. 100
TISSEEL VH -fibrin sealant component kit 10 ml........... 100
TIVICAY -dolutegravir sodium tab 10 mg (base equiv)....... 8
TIVICAY -dolutegravir sodium tab 25 mg (base equiv)....... 8
TIVICAY -dolutegravir sodium tab 50 mg (base equiv)....... 8
TIVORBEX -indomethacin cap 20 mg.............................. 80
TIVORBEX -indomethacin cap 40 mg.............................. 80
tizanidine hcl cap 2 mg (base equivalent)
(Zanaflex)........................................................................88
tizanidine hcl cap 4 mg (base equivalent)
(Zanaflex)........................................................................88
tizanidine hcl cap 6 mg (base equivalent)
(Zanaflex)........................................................................88
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tizanidine hcl tab 2 mg (base equivalent)..................... 88
tizanidine hcl tab 4 mg (base equivalent)
(Zanaflex)........................................................................88
TL-CARE DHA -prenatal w/fe fumarate-fa-dss-fish oil cap
27-1-500 mg.................................................................... 93
TL FOLATE -prenatal vit w/ fe fum-methylfolate-fa tab
27-0.5-0.5 mg.................................................................. 93
TL-SELECT -prenatal w/o vit a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg...............................................................93
TOBI PODHALER -tobramycin inhal cap 28 mg.................4
TOBRADEX ST -tobramycin-dexamethasone ophth susp
0.3-0.05%...................................................................... 107
TOBRADEX -tobramycin-dexamethasone ophth oint
0.3-0.1%........................................................................ 107
tobramycin-dexamethasone ophth susp 0.3-0.1%
(Tobradex).................................................................... 107
tobramycin nebu soln 300 mg/5ml (Tobi)....................... 4
tobramycin ophth soln 0.3% (Tobrex)......................... 107
TOBRAMYCIN -tobramycin nebu soln 300 mg/5ml............ 4
TOBREX -tobramycin ophth oint 0.3%........................... 107
TODAY SPONGE -nonoxynol-9 vaginal sponge 1000
mg.................................................................................... 57
TOLAK -fluorouracil cream 4%........................................113
TOLAZAMIDE -tolazamide tab 250 mg.............................25
TOLAZAMIDE -tolazamide tab 500 mg.............................25
TOLBUTAMIDE -tolbutamide tab 500 mg......................... 25
tolcapone tab 100 mg (Tasmar)..................................... 88
TOLMETIN SODIUM -tolmetin sodium cap 400 mg......... 80
TOLMETIN SODIUM -tolmetin sodium tab 200 mg.......... 80
TOLMETIN SODIUM -tolmetin sodium tab 600 mg.......... 80
tolterodine tartrate cap sr 24hr 2 mg (Detrol la).......... 56
tolterodine tartrate cap sr 24hr 4 mg (Detrol la).......... 56
tolterodine tartrate tab 1 mg (Detrol)............................ 56
tolterodine tartrate tab 2 mg (Detrol)............................ 56
TOPICORT -desoximetasone cream 0.05%................... 113
TOPICORT -desoximetasone oint 0.05%....................... 113
TOPICORT -desoximetasone spray 0.25%.................... 113
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 25
mg.................................................................................... 85
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 50
mg.................................................................................... 85
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 100
mg.................................................................................... 85
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 150
mg.................................................................................... 85
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 200
mg.................................................................................... 85
topiramate sprinkle cap 15 mg (Topamax
sprinkle).......................................................................... 85
topiramate sprinkle cap 25 mg (Topamax
sprinkle).......................................................................... 86
topiramate tab 25 mg (Topamax)................................... 86
topiramate tab 50 mg (Topamax)................................... 86
topiramate tab 100 mg (Topamax)................................. 86
topiramate tab 200 mg (Topamax)................................. 86
torsemide tab 5 mg......................................................... 41
torsemide tab 100 mg..................................................... 41
torsemide tab 10 mg (Demadex).................................... 41
torsemide tab 20 mg (Demadex).................................... 41
TOUJEO SOLOSTAR -insulin glargine soln pen-injector
300 unit/ml.......................................................................26
TOVIAZ -fesoterodine fumarate tab sr 24hr 4 mg.............56
TOVIAZ -fesoterodine fumarate tab sr 24hr 8 mg.............56
TRACLEER -bosentan tab 62.5 mg.................................. 44
TRACLEER -bosentan tab 125 mg................................... 44
TRADJENTA -linagliptin tab 5 mg..................................... 25
tramadol-acetaminophen tab 37.5-325 mg
(Ultracet)......................................................................... 78
TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic
release 100 mg............................................................... 77
TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic
release 150 mg............................................................... 77
TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic
release 200 mg............................................................... 77
TRAMADOL HCL ER -tramadol hcl cap sr 24hr biphasic
release 300 mg............................................................... 77
tramadol hcl tab 50 mg (Ultram).................................... 77
tramadol hcl tab sr 24hr biphasic release 100 mg....... 77
tramadol hcl tab sr 24hr biphasic release 200 mg....... 77
tramadol hcl tab sr 24hr biphasic release 300 mg....... 77
tramadol hcl tab sr 24hr 100 mg....................................77
tramadol hcl tab sr 24hr 200 mg....................................77
tramadol hcl tab sr 24hr 300 mg....................................77
trandolapril tab 4 mg....................................................... 40
trandolapril tab 1 mg (Mavik)......................................... 40
trandolapril tab 2 mg (Mavik)......................................... 40
trandolapril-verapamil hcl tab cr 1-240 mg (Tarka)...... 40
trandolapril-verapamil hcl tab cr 2-180 mg (Tarka)...... 40
trandolapril-verapamil hcl tab cr 2-240 mg (Tarka)...... 40
trandolapril-verapamil hcl tab cr 4-240 mg (Tarka)...... 40
tranexamic acid tab 650 mg (Lysteda)........................ 100
TRANSDERM-SCOP -scopolamine td patch 72hr 1
mg/3days......................................................................... 53
tranylcypromine sulfate tab 10 mg (Parnate)............... 61
TRAVATAN Z -travoprost ophth soln 0.004%
(benzalkonium free) (bak free)..................................... 107
trazodone hcl tab 50 mg................................................. 61
trazodone hcl tab 100 mg............................................... 61
trazodone hcl tab 150 mg............................................... 61
trazodone hcl tab 300 mg............................................... 61
TRECATOR -ethionamide tab 250 mg................................ 5
TRESIBA FLEXTOUCH -insulin degludec soln peninjector 100 unit/ml......................................................... 26
TRESIBA FLEXTOUCH -insulin degludec soln peninjector 200 unit/ml......................................................... 26
tretinoin cap 10 mg......................................................... 15
tretinoin cream 0.025% (Retin-a)................................. 113
tretinoin cream 0.05% (Retin-a)................................... 113
tretinoin cream 0.1% (Retin-a)..................................... 113
tretinoin gel 0.05% (Atralin).......................................... 113
tretinoin gel 0.01% (Retin-a)......................................... 113
tretinoin gel 0.025% (Retin-a)....................................... 113
tretinoin microsphere gel 0.04% (Retin-a micro)....... 113
tretinoin microsphere gel 0.1% (Retin-a micro)......... 113
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TRETIN-X -tretinoin cream 0.075%................................ 113
TRETTEN -coagulation factor xiii a-subunit for inj
2000-3125 unit.............................................................. 103
TREXALL -methotrexate sodium tab 5 mg (base
equiv)............................................................................... 15
TREXALL -methotrexate sodium tab 7.5 mg (base
equiv)............................................................................... 15
TREXALL -methotrexate sodium tab 10 mg (base
equiv)............................................................................... 15
TREXALL -methotrexate sodium tab 15 mg (base
equiv)............................................................................... 15
TREXIMET -sumatriptan-naproxen sodium tab 10-60
mg.................................................................................... 82
TREXIMET -sumatriptan-naproxen sodium tab 85-500
mg.................................................................................... 82
TRIADVANCE -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg........................................................................... 93
triamcinolone acetonide aerosol soln 0.147 mg/gm
(Kenalog)...................................................................... 113
triamcinolone acetonide cream 0.025%...................... 113
triamcinolone acetonide cream 0.1%.......................... 113
triamcinolone acetonide cream 0.5%.......................... 113
triamcinolone acetonide dental paste 0.1%............... 108
triamcinolone acetonide lotion 0.025%....................... 113
triamcinolone acetonide lotion 0.1%........................... 113
triamcinolone acetonide nasal aerosol suspension 55
mcg/act........................................................................... 46
triamcinolone acetonide oint 0.025%.......................... 114
triamcinolone acetonide oint 0.1%.............................. 114
triamcinolone acetonide oint 0.5%.............................. 114
TRIAMTERENE/HYDROCHLOROTH -triamterene &
hydrochlorothiazide cap 50-25 mg................................. 41
triamterene & hydrochlorothiazide cap 37.5-25 mg
(Dyazide).........................................................................41
triamterene & hydrochlorothiazide tab 37.5-25 mg
(Maxzide-25)................................................................... 41
triamterene & hydrochlorothiazide tab 75-50 mg
(Maxzide)........................................................................ 41
TRIANEX -triamcinolone acetonide oint 0.05%.............. 114
triazolam tab 0.25 mg (Halcion)..................................... 65
TRIAZOLAM -triazolam tab 0.125 mg............................... 65
TRICARE PRENATAL COMPLEAT -prenat w/o a fefum-fa
tab 27-1 mg & fish oil chew cap pak..............................93
TRICARE PRENATAL DHA ONE -prenatal w/fe fumaratefa-dss-fish oil cap 27-1-500 mg..................................... 93
TRICARE PRENATAL -prenat w/o a w/fepyro-mfol chw
4.5-1 mg & dha cap 150 thpk........................................ 93
TRICARE PRENATAL -prenat w/o vit a w/ fe pyrophosmethylf chew tab 4.5-1 mg............................................. 93
TRICARE -prenatal vit w/ fe fumarate-fa tab 27-1 mg...... 93
trifluoperazine hcl tab 1 mg........................................... 64
trifluoperazine hcl tab 2 mg........................................... 64
trifluoperazine hcl tab 5 mg........................................... 64
trifluoperazine hcl tab 10 mg......................................... 64
trifluridine ophth soln 1% (Viroptic)............................ 107
TRIGLIDE -fenofibrate tab 160 mg................................... 44
trihexyphenidyl hcl elixir 0.4 mg/ml.............................. 88
trihexyphenidyl hcl tab 2 mg..........................................88
trihexyphenidyl hcl tab 5 mg..........................................88
trimethobenzamide hcl cap 300 mg (Tigan)................. 53
trimethoprim tab 100 mg.................................................. 9
trimipramine maleate cap 25 mg (Surmontil)............... 61
trimipramine maleate cap 50 mg (Surmontil)............... 61
trimipramine maleate cap 100 mg (Surmontil)............. 61
TRINATAL GT -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg........................................................................... 93
TRINATAL RX 1 -prenatal vit w/ fe fumarate-fa tab 60-1
mg.................................................................................... 93
TRINATE -prenatal vit w/ fe fumarate-fa tab 28-1 mg....... 93
TRINTELLIX -vortioxetine hbr tab 5 mg (base equiv)....... 61
TRINTELLIX -vortioxetine hbr tab 10 mg (base equiv)..... 61
TRINTELLIX -vortioxetine hbr tab 20 mg (base equiv)..... 61
TRISTART DHA -prenat w/o a w/fecbn-methylf-fa-dha cap
31-0.6-0.4-200 mg.......................................................... 93
TRI-TABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack......................................................... 93
TRIUMEQ -abacavir-dolutegravir-lamivudine tab
600-50-300 mg.................................................................. 8
TRIVEEN-DUO DHA -prenat-fe bis-fe prot succ-fa-ca tab
& omega 3 cap 400 pk................................................... 93
TRIVEEN-PRX RNF -prenatal w/o vit a w/ fe fum-dss-fadha cap 26-1.2-300 mg.................................................. 93
TROKENDI XR -topiramate cap sr 24hr 25 mg................ 86
TROKENDI XR -topiramate cap sr 24hr 50 mg................ 86
TROKENDI XR -topiramate cap sr 24hr 100 mg.............. 86
TROKENDI XR -topiramate cap sr 24hr 200 mg.............. 86
trospium chloride cap sr 24hr 60 mg............................ 56
trospium chloride tab 20 mg.......................................... 56
TRUE METRIX BLOOD GLUCOSE -glucose blood test
strip................................................................................ 119
TRUE METRIX SELF MONITORI -glucose blood test
strip................................................................................ 119
TRUETEST BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 119
TRUETEST STRIPS -glucose blood test strip................ 119
TRUETRACK BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 119
TRUETRACK TEST -glucose blood test strip................. 119
TRULANCE -plecanatide tab 3 mg................................... 55
TRULICITY -dulaglutide soln pen-injector 0.75
mg/0.5ml.......................................................................... 25
TRULICITY -dulaglutide soln pen-injector 1.5
mg/0.5ml.......................................................................... 25
TRUMENBA -meningococcal group b vac (recomb) im
susp prefilled syr............................................................. 11
TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab
100-150 mg....................................................................... 8
TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab
133-200 mg....................................................................... 8
TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab
167-250 mg....................................................................... 8
TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab
200-300 mg....................................................................... 8
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TUDORZA PRESSAIR -aclidinium bromide aerosol powd
breath activated 400 mcg/act......................................... 50
TUSNEL C -pseudoephedrine w/ cod-gg syrup 30-10-100
mg/5ml............................................................................. 47
TUSSICAPS -hydrocod polst-chlorphen polst cap sr 12hr
5-4 mg............................................................................. 47
TUSSICAPS -hydrocod polst-chlorphen polst cap sr 12hr
10-8 mg........................................................................... 47
TUZISTRA XR -codeine polist-chlorphen polist er susp
14.7-2.8 mg/5ml.............................................................. 47
TWINRIX -hepatitis a (inact)-hep b (recomb) vac inj
720-20 elu-mcg/ml.......................................................... 11
TYBOST -cobicistat tab 150 mg..........................................8
TYKERB -lapatinib ditosylate tab 250 mg (base
equiv)............................................................................... 15
TYLACTIN RESTORE 10 -nutritional supplement
liquid................................................................................ 96
TYLACTIN RESTORE 5PE -nutritional supplement
pack................................................................................. 96
TYLACTIN RTD 15 -nutritional supplement liquid............ 96
TYVASO REFILL -treprostinil inhalation solution 0.6 mg/
ml..................................................................................... 45
TYVASO STARTER -treprostinil inhalation solution 0.6
mg/ml............................................................................... 45
TYVASO -treprostinil inhalation solution 0.6 mg/ml.......... 45
U
UCERIS -budesonide rectal foam 2 mg/act.................... 108
UCERIS -budesonide tab sr 24hr 9 mg............................ 17
ULESFIA -benzyl alcohol lotion 5%................................ 114
ULORIC -febuxostat tab 40 mg......................................... 82
ULORIC -febuxostat tab 80 mg......................................... 82
ULTIMATECARE ONE NF -prenatal w/fe cbnyl-fe asp
glyc-fa-dss-omega cap 20-7-1 mg................................. 94
ULTIMATECARE ONE -prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg................................................. 93
ULTIMA TEST STRIPS -glucose blood test strip............ 119
ULTRATRAK PRO TEST STRIPS -glucose blood test
strip................................................................................ 119
ULTRATRAK ULTIMATE TEST S -glucose blood test
strip................................................................................ 119
ULTRAVATE -halobetasol propionate lotion 0.05%........ 114
UNISTRIP1 GENERIC -glucose blood test strip............. 119
UPTRAVI -selexipag tab 200 mcg.....................................45
UPTRAVI -selexipag tab 400 mcg.....................................45
UPTRAVI -selexipag tab 600 mcg.....................................45
UPTRAVI -selexipag tab 800 mcg.....................................45
UPTRAVI -selexipag tab 1000 mcg...................................45
UPTRAVI -selexipag tab 1200 mcg...................................45
UPTRAVI -selexipag tab 1400 mcg...................................45
UPTRAVI -selexipag tab 1600 mcg...................................45
UPTRAVI -selexipag tab therapy pack 200 mcg (140) &
800 mcg (60)...................................................................45
ursodiol cap 300 mg (Actigall)....................................... 55
ursodiol tab 250 mg (Urso 250)..................................... 55
ursodiol tab 500 mg (Urso forte)................................... 55
UTIBRON NEOHALER -indacaterol-glycopyrrolate inhal
cap 27.5-15.6 mcg.......................................................... 50
V
VAGIFEM -estradiol vaginal tab 10 mcg........................... 57
valacyclovir hcl tab 1 gm (Valtrex).................................. 8
valacyclovir hcl tab 500 mg (Valtrex).............................. 8
VALCHLOR -mechlorethamine hcl gel 0.016% (base
equivalent)..................................................................... 114
valganciclovir hcl for soln 50 mg/ml (base equiv)
(Valcyte)............................................................................ 8
valganciclovir hcl tab 450 mg (base equivalent)
(Valcyte)............................................................................ 8
valproate sodium oral soln 250 mg/5ml (base equiv)
(Depakene)..................................................................... 86
valproic acid cap 250 mg (Depakene)........................... 86
valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan
hct).................................................................................. 40
valsartan-hydrochlorothiazide tab 160-12.5 mg
(Diovan hct)................................................................... 40
valsartan-hydrochlorothiazide tab 160-25 mg (Diovan
hct).................................................................................. 40
valsartan-hydrochlorothiazide tab 320-12.5 mg
(Diovan hct)................................................................... 40
valsartan-hydrochlorothiazide tab 320-25 mg (Diovan
hct).................................................................................. 40
valsartan tab 40 mg (Diovan)......................................... 40
valsartan tab 80 mg (Diovan)......................................... 40
valsartan tab 160 mg (Diovan)....................................... 40
valsartan tab 320 mg (Diovan)....................................... 40
VALVED HOLDING CHAMBER -spacer/aerosol-holding
chambers - device........................................................ 122
VANATOL LQ -butalbital-acetaminophen-caffeine soln
50-325-40 mg/15ml......................................................... 72
vancomycin hcl cap 125 mg (Vancocin hcl)................... 9
vancomycin hcl cap 250 mg (Vancocin hcl)................. 10
VAQTA -hepatitis a vaccine inj susp 25 unit/0.5ml............11
VAQTA -hepatitis a vaccine inj susp 50 unit/ml.................11
VARIVAX -varicella virus vac live for subcutaneous inj
1350 pfu/0.5ml................................................................ 11
VARUBI -rolapitant hcl tab 90 mg (base equiv)................ 53
VASCEPA -icosapent ethyl cap 0.5 gm............................ 44
VASCEPA -icosapent ethyl cap 1 gm............................... 44
VCF VAGINAL CONTRACEPTIVE -nonoxynol-9 film
28%.................................................................................. 57
VCF VAGINAL CONTRACEPTIVE -nonoxynol-9 foam
12.5%...............................................................................57
VECAMYL -mecamylamine hcl tab 2.5 mg....................... 41
VECTICAL -calcitriol oint 3 mcg/gm................................ 114
VELPHORO -sucroferric oxyhydroxide chew tab 500
mg.................................................................................... 55
VELTASSA -patiromer sorbitex calcium for susp packet
8.4 gm (base eq).......................................................... 124
VELTASSA -patiromer sorbitex calcium for susp packet
16.8 gm (base eq)........................................................ 124
VELTASSA -patiromer sorbitex calcium for susp packet
25.2 gm (base eq)........................................................ 124
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VELTIN -clindamycin phosphate-tretinoin gel
1.2-0.025%.................................................................... 114
VEMAVITE-PRX 2 -prenatal w/o vit a w/ fe fum-dss-fadha cap 27-1.25-300 mg................................................ 94
VEMLIDY -tenofovir alafenamide fumarate tab 25 mg....... 8
VENA-BAL DHA -prenat w/fe poly-na fered-fa tab 27-1 &
omega cap dr 430mg..................................................... 94
VENCLEXTA STARTING PACK -venetoclax tab therapy
starter pack 10 & 50 & 100 mg...................................... 16
VENCLEXTA -venetoclax tab 10 mg.................................15
VENCLEXTA -venetoclax tab 50 mg.................................16
VENCLEXTA -venetoclax tab 100 mg...............................16
venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent)
(Effexor xr)..................................................................... 61
venlafaxine hcl cap sr 24hr 75 mg (base equivalent)
(Effexor xr)..................................................................... 61
venlafaxine hcl cap sr 24hr 150 mg (base equivalent)
(Effexor xr)..................................................................... 61
venlafaxine hcl tab 25 mg...............................................61
venlafaxine hcl tab 37.5 mg............................................61
venlafaxine hcl tab 50 mg...............................................61
venlafaxine hcl tab 75 mg...............................................61
venlafaxine hcl tab 100 mg.............................................61
venlafaxine hcl tab sr 24hr 225 mg (base
equivalent)......................................................................61
venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent)
(Venlafaxine hcl er)....................................................... 61
venlafaxine hcl tab sr 24hr 75 mg (base equivalent)
(Venlafaxine hcl er)....................................................... 61
venlafaxine hcl tab sr 24hr 150 mg (base equivalent)
(Venlafaxine hcl er)....................................................... 61
VENTAVIS -iloprost inhalation solution 10 mcg/ml........... 45
VENTAVIS -iloprost inhalation solution 20 mcg/ml........... 45
VENTOLIN HFA -albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv)........................................................ 50
verapamil hcl cap sr 24hr 120 mg (Verelan)................. 35
verapamil hcl cap sr 24hr 180 mg (Verelan)................. 35
verapamil hcl cap sr 24hr 240 mg (Verelan)................. 35
verapamil hcl cap sr 24hr 360 mg (Verelan)................. 35
verapamil hcl cap sr 24hr 100 mg (Verelan pm)........... 35
verapamil hcl cap sr 24hr 200 mg (Verelan pm)........... 35
verapamil hcl cap sr 24hr 300 mg (Verelan pm)........... 35
verapamil hcl tab cr 120 mg (Calan sr)......................... 35
verapamil hcl tab cr 180 mg (Calan sr)......................... 35
verapamil hcl tab cr 240 mg (Calan sr)......................... 35
verapamil hcl tab 40 mg................................................. 35
verapamil hcl tab 80 mg (Calan).................................... 35
verapamil hcl tab 120 mg (Calan).................................. 35
VERDESO -desonide foam 0.05%.................................. 114
VEREGEN -sinecatechins oint 15%................................114
VERIPRED 20 -prednisolone sod phosphate oral soln 20
mg/5ml (base equiv)....................................................... 17
VERSACLOZ -clozapine susp 50 mg/ml.......................... 64
VESICARE -solifenacin succinate tab 5 mg..................... 56
VESICARE -solifenacin succinate tab 10 mg................... 56
VIAGRA -sildenafil citrate tab 25 mg................................ 45
VIAGRA -sildenafil citrate tab 50 mg................................ 45
VIAGRA -sildenafil citrate tab 100 mg.............................. 45
VIBERZI -eluxadoline tab 75 mg....................................... 55
VIBERZI -eluxadoline tab 100 mg..................................... 55
VIBRAMYCIN -doxycycline calcium syrup 50 mg/5ml........ 4
VICTORY AGM-4000 TEST STR -glucose blood test
strip................................................................................ 119
VICTOZA -liraglutide soln pen-injector 18 mg/3ml (6 mg/
ml).................................................................................... 25
VIDEX -didanosine for soln 2 gm........................................ 8
VIDEX -didanosine for soln 4 gm........................................ 8
VIEKIRA PAK -ombitas-paritapre-riton & dasab tab pak
12.5-75-50 & 250 mg....................................................... 8
VIEKIRA XR -dasab-ombit-paritap-riton tab sr 24hr
200-8.33-50-33.33 mg...................................................... 8
VIGAMOX -moxifloxacin hcl ophth soln 0.5% (base
equiv)............................................................................. 107
VIIBRYD STARTER PACK -vilazodone hcl tab starter kit
10 (7) & 20 (23) mg....................................................... 61
VIIBRYD -vilazodone hcl tab 10 mg..................................61
VIIBRYD -vilazodone hcl tab 20 mg..................................61
VIIBRYD -vilazodone hcl tab 40 mg..................................61
VILACTIN AA PLUS -nutritional supplement liquid........... 96
VIMOVO -naproxen-esomeprazole magnesium tab dr
375-20 mg....................................................................... 80
VIMOVO -naproxen-esomeprazole magnesium tab dr
500-20 mg....................................................................... 81
VIMPAT -lacosamide oral solution 10 mg/ml.................... 86
VIMPAT -lacosamide tab 50 mg........................................ 86
VIMPAT -lacosamide tab 100 mg...................................... 86
VIMPAT -lacosamide tab 150 mg...................................... 86
VIMPAT -lacosamide tab 200 mg...................................... 86
VINATE DHA RF -prenat w/o a w/fefum-methylfol-omegas
cap 27-1.13 mg............................................................... 94
VINATE II -prenatal vit w/ fe bisglycinate chelate-fa tab
29-1 mg........................................................................... 94
VINATE M -prenatal vit w/ sel-fe fumarate-fa tab 27-1
mg.................................................................................... 94
VINATE ONE -prenatal vit w/ fe fumarate-fa tab 60-1
mg.................................................................................... 94
VIOKACE -pancrelipase (lip-prot-amyl) tab
10440-39150-39150 unit................................................ 54
VIOKACE -pancrelipase (lip-prot-amyl) tab
20880-78300-78300 unit................................................ 54
VIRACEPT -nelfinavir mesylate tab 250 mg....................... 8
VIRACEPT -nelfinavir mesylate tab 625 mg....................... 8
VIRAMUNE -nevirapine susp 50 mg/5ml............................ 8
VIREAD -tenofovir disoproxil fumarate oral powder 40
mg/gm................................................................................ 8
VIREAD -tenofovir disoproxil fumarate tab 150 mg............ 8
VIREAD -tenofovir disoproxil fumarate tab 200 mg............ 8
VIREAD -tenofovir disoproxil fumarate tab 250 mg............ 8
VIREAD -tenofovir disoproxil fumarate tab 300 mg............ 8
VIRT-ADVANCE -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg........................................................................... 94
VIRT-CARE ONE -prenatal vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg..................................................... 94
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VIRT-C DHA -prenatal w/fe fum-fe poly -fa-omega 3 cap
53.5-38-1 mg................................................................... 94
VIRT-NATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................... 94
VIRT NATE -prenatal vit w/ fe fumarate-fa tab 28-1
mg.................................................................................... 94
VIRT-PN DHA -prenat w/o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg.......................................................... 94
VIRT-PN PLUS -prenat w/o a w/ fe fumerate-methylfolatefa-omega 3 cap............................................................... 94
VIRT-PN -prenatal vit w/ fe fum-methylfolate-fa tab
27-0.6-0.4 mg.................................................................. 94
VIRTPREX -prenatal w/o vit a w/ fe fum-dss-fa-dha cap
26-1.2-300 mg................................................................. 94
VIRT-SELECT -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg....................................................... 94
VIRT-VITE GT -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg........................................................................... 94
VISTOGARD -uridine triacetate oral granules packet 10
gm.................................................................................. 114
VITAFOL FE+ -prenat-fepoly-methol-fa-dha cap 90-1-200
mg & dss 50mg cap....................................................... 94
VITAFOL GUMMIES -prenat vit w/ fe phos-fa-omega
chew tab 3.33-0.333-34.8 mg........................................ 94
VITAFOL-NANO -prenatal w/o a w/ fefum-l methylfol-fa
tab 18-0.6-0.4 mg........................................................... 94
VITAFOL-OB+DHA -prenatal mv w/fe fum-fa tab 65-1 mg
& dha cap 250 mg pack................................................. 94
VITAFOL-OB -prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................... 94
VITAFOL-ONE -prenatal mv w/ fe polysac cmplx-fa-dha
cap 29-1-200 mg............................................................ 94
VITAFOL ULTRA -prenat w/fe poly-methylfol-fa-dha cap
29-0.6-0.4-200 mg.......................................................... 94
VITAMEDMD ONE RX/QUATREFO -prenat w/o a w/
fefum-methfol-fa-dha cap 30-0.6-0.4-200 mg................ 94
VITAMEDMD REDICHEW RX -prenat w/ b2-b6-b12-d3folic acid chew tab 1.4 mg............................................. 94
VITAPEARL -prenat w/oa w/fefum-na fered-fa-dha cap cr
30-1.4-200 mg................................................................. 94
VITA-PREN -prenatal vit w/ docusate-iron-fa tab 65-1
mg.................................................................................... 94
VITATRUE -prenat w/o a w/fe chel-fa tab 30-1.4 mg & dha
cap 300mg pk................................................................. 94
VITUZ -hydrocodone-chlorpheniramine soln 5-4
mg/5ml............................................................................. 47
VIVA DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................... 94
VIVLODEX -meloxicam cap 5 mg..................................... 81
VIVLODEX -meloxicam cap 10 mg................................... 81
VIVOTIF -typhoid vaccine cap delayed release................ 11
VOCAL POINT BLOOD GLUCOSE -glucose blood test
strip................................................................................ 119
VOGELXO PUMP -testosterone td gel 12.5 mg/act
(1%)................................................................................. 18
VOGELXO -testosterone td gel 50 mg/5gm (1%)............. 18
VOL-NATE -prenatal vit w/ fe fumarate-fa tab 28-1
mg.................................................................................... 94
VOL-PLUS -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................... 94
VOL-TAB RX -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................... 94
VONVENDI -von willebrand factor (recombinant) for inj
650 unit......................................................................... 103
VONVENDI -von willebrand factor (recombinant) for inj
1300 unit....................................................................... 103
voriconazole for susp 40 mg/ml (Vfend)......................... 5
voriconazole tab 50 mg (Vfend)....................................... 5
voriconazole tab 200 mg (Vfend)..................................... 5
VORTEX HOLDING CHAMBER/MA -respiratory therapy
supplies - devices......................................................... 123
VORTEX VALVED HOLDING CHA -spacer/aerosolholding chambers - device........................................... 123
VOTRIENT -pazopanib hcl tab 200 mg (base equiv)....... 16
VP-CH PLUS -prenatal w/o a w/fe cbn-dss-fa-dha cap
29-1-265 mg.................................................................... 95
VP-CH-PNV -prenatal w/o vit a w/ fe cbn-dss-fa-dha cap
30-1-260 mg.................................................................... 95
VP-GGR-B6 PRENATAL -prenatal w/ calcium-vit b6-faginger tab 1.2 mg........................................................... 95
VP-HEME OB + DHA -prenat-fe poly cmplx-fe heme polyfa tab & omega 3 cap pck.............................................. 95
VP-HEME OB -prenat vit-fe poly cmplx-fe heme poly-fa
tab 28-6-1 mg................................................................. 95
VP-HEME ONE -prenat-fe poly cmplx-fe heme poly-fadha cap 22-6-1-200 mg.................................................. 95
VP-PNV-DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-215.8 mg................................................................. 95
VRAYLAR -cariprazine hcl cap 1.5 mg (base
equivalent)....................................................................... 64
VRAYLAR -cariprazine hcl cap 3 mg (base
equivalent)....................................................................... 64
VRAYLAR -cariprazine hcl cap 4.5 mg (base
equivalent)....................................................................... 64
VRAYLAR -cariprazine hcl cap 6 mg (base
equivalent)....................................................................... 64
VRAYLAR -cariprazine hcl cap therapy pack 1.5 mg (1) &
3 mg (6).......................................................................... 64
VUSION -miconazole-zinc oxide-white petrolatum oint
0.25-15-81.35%............................................................. 114
VYTORIN -ezetimibe-simvastatin tab 10-10 mg............... 44
VYTORIN -ezetimibe-simvastatin tab 10-20 mg............... 44
VYTORIN -ezetimibe-simvastatin tab 10-40 mg............... 44
VYTORIN -ezetimibe-simvastatin tab 10-80 mg............... 44
VYVANSE -lisdexamfetamine dimesylate cap 10 mg....... 68
VYVANSE -lisdexamfetamine dimesylate cap 20 mg....... 68
VYVANSE -lisdexamfetamine dimesylate cap 30 mg....... 68
VYVANSE -lisdexamfetamine dimesylate cap 40 mg....... 68
VYVANSE -lisdexamfetamine dimesylate cap 50 mg....... 68
VYVANSE -lisdexamfetamine dimesylate cap 60 mg....... 69
VYVANSE -lisdexamfetamine dimesylate cap 70 mg....... 69
VYVANSE -lisdexamfetamine dimesylate chew tab 10
mg.................................................................................... 69
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VYVANSE -lisdexamfetamine dimesylate chew tab 20
mg.................................................................................... 69
VYVANSE -lisdexamfetamine dimesylate chew tab 30
mg.................................................................................... 69
VYVANSE -lisdexamfetamine dimesylate chew tab 40
mg.................................................................................... 69
VYVANSE -lisdexamfetamine dimesylate chew tab 50
mg.................................................................................... 69
VYVANSE -lisdexamfetamine dimesylate chew tab 60
mg.................................................................................... 69
W
warfarin sodium tab 1 mg (Coumadin)......................... 99
warfarin sodium tab 2 mg (Coumadin)......................... 99
warfarin sodium tab 2.5 mg (Coumadin)...................... 99
warfarin sodium tab 3 mg (Coumadin)......................... 99
warfarin sodium tab 4 mg (Coumadin)......................... 99
warfarin sodium tab 5 mg (Coumadin)......................... 99
warfarin sodium tab 6 mg (Coumadin)......................... 99
warfarin sodium tab 7.5 mg (Coumadin)...................... 99
warfarin sodium tab 10 mg (Coumadin)....................... 99
WATCHHALER -spacer/aerosol-holding chambers device............................................................................ 123
WAVESENSE PRESTO TEST STR -glucose blood test
strip................................................................................ 119
WELCHOL -colesevelam hcl packet for susp 3.75 gm..... 44
WELCHOL -colesevelam hcl tab 625 mg......................... 44
WESTHROID -thyroid tab 32.5 mg................................... 28
WESTHROID -thyroid tab 65 mg...................................... 28
WESTHROID -thyroid tab 97.5 mg................................... 28
WESTHROID -thyroid tab 130 mg.................................... 28
WESTHROID -thyroid tab 195 mg.................................... 28
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 60
mm................................................................................. 123
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 65
mm................................................................................. 123
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 70
mm................................................................................. 123
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 75
mm................................................................................. 123
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 80
mm................................................................................. 123
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 85
mm................................................................................. 123
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 90
mm................................................................................. 123
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 95
mm................................................................................. 123
WILATE -antihemophilic factor/vwf (human) for inj
500-500 unit kit............................................................. 103
WILATE -antihemophilic factor/vwf (human) for inj
1000-1000 unit kit......................................................... 103
WP THYROID -thyroid tab 16.25 mg................................ 28
WP THYROID -thyroid tab 32.5 mg.................................. 28
WP THYROID -thyroid tab 65 mg..................................... 28
WP THYROID -thyroid tab 81.25 mg................................ 28
WP THYROID -thyroid tab 97.5 mg.................................. 28
WP THYROID -thyroid tab 113.75 mg.............................. 28
WP THYROID -thyroid tab 130 mg................................... 28
WP THYROID -thyroid tab 48.75 mg (3/4 grain).............. 28
X
XALKORI -crizotinib cap 200 mg...................................... 16
XALKORI -crizotinib cap 250 mg...................................... 16
XARELTO -rivaroxaban tab 10 mg....................................99
XARELTO -rivaroxaban tab 15 mg....................................99
XARELTO -rivaroxaban tab 20 mg....................................99
XARELTO STARTER PACK -rivaroxaban tab starter
therapy pack 15 mg & 20 mg........................................ 99
XELJANZ -tofacitinib citrate tab 5 mg (base
equivalent)....................................................................... 81
XELJANZ XR -tofacitinib citrate tab sr 24hr 11 mg (base
equivalent)....................................................................... 81
XENICAL -orlistat cap 120 mg.......................................... 69
XERESE -acyclovir-hydrocortisone cream 5-1%............ 114
XIFAXAN -rifaximin tab 200 mg........................................ 10
XIFAXAN -rifaximin tab 550 mg........................................ 10
XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr
5-500 mg......................................................................... 25
XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr
5-1000 mg....................................................................... 25
XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr
10-500 mg....................................................................... 25
XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr
10-1000 mg..................................................................... 25
XIIDRA -lifitegrast ophth soln 5%.................................... 107
XOLEGEL -ketoconazole gel 2%.................................... 114
XOPENEX HFA -levalbuterol tartrate inhal aerosol 45
mcg/act (base equiv)...................................................... 50
XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent 9
mg.................................................................................... 78
XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent
13.5 mg........................................................................... 78
XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent
18 mg.............................................................................. 78
XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent
27 mg.............................................................................. 78
XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent
36 mg.............................................................................. 78
XTANDI -enzalutamide cap 40 mg.................................... 16
XULANE -norelgestromin-ethinyl estradiol td ptwk 150-35
mcg/24hr.......................................................................... 21
XULTOPHY 100/3.6 -insulin degludec-liraglutide sol peninj 100-3.6 unit-mg/ml..................................................... 25
XURIDEN -uridine triacetate oral granules packet 2
gm.................................................................................... 31
XYNTHA -antihemophilic factor recombinant paf for inj kit
250 unit......................................................................... 103
XYNTHA -antihemophilic factor recombinant paf for inj kit
500 unit......................................................................... 103
XYNTHA -antihemophilic factor recombinant paf for inj kit
1000 unit....................................................................... 104
XYNTHA -antihemophilic factor recombinant paf for inj kit
2000 unit....................................................................... 104
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XYNTHA SOLOFUSE -antihemophilic factor recombinant
paf for inj kit 250 unit................................................... 104
XYNTHA SOLOFUSE -antihemophilic factor recombinant
paf for inj kit 500 unit................................................... 104
XYNTHA SOLOFUSE -antihemophilic factor recombinant
paf for inj kit 1000 unit................................................. 104
XYNTHA SOLOFUSE -antihemophilic factor recombinant
paf for inj kit 2000 unit................................................. 104
XYNTHA SOLOFUSE -antihemophilic factor recombinant
paf for inj kit 3000 unit................................................. 104
XYREM -sodium oxybate oral solution 500 mg/ml........... 72
Y
YOSPRALA -aspirin-omeprazole tab delayed release
81-40 mg....................................................................... 104
YOSPRALA -aspirin-omeprazole tab delayed release
325-40 mg..................................................................... 104
Z
zafirlukast tab 10 mg (Accolate).................................... 50
zafirlukast tab 20 mg (Accolate).................................... 50
zaleplon cap 5 mg (Sonata)............................................ 65
zaleplon cap 10 mg (Sonata).......................................... 65
ZARONTIN -ethosuximide cap 250 mg............................ 86
ZARONTIN -ethosuximide soln 250 mg/5ml..................... 86
ZARXIO -filgrastim-sndz soln prefilled syringe 300
mcg/0.5ml........................................................................ 98
ZARXIO -filgrastim-sndz soln prefilled syringe 480
mcg/0.8ml........................................................................ 98
ZATEAN-CH -prenatal w/o a w/fe cbn-dss-fa-dha cap
27-1-250 mg.................................................................... 95
ZATEAN-PN DHA -prenat w/o a w/fefum-methfol-fa-dha
cap 27-0.6-0.4-300 mg................................................... 95
ZATEAN-PN PLUS -prenat w/o a w/ fe fumeratemethylfolate-fa-omega 3 cap.......................................... 95
ZAVESCA -miglustat cap 100 mg..................................... 98
ZELAPAR -selegiline hcl orally disintegrating tab 1.25
mg.................................................................................... 88
ZELBORAF -vemurafenib tab 240 mg.............................. 16
ZEMBRACE SYMTOUCH -sumatriptan succinate solution
auto-injector 3 mg/0.5ml................................................. 82
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
3000-10000-16000 unit...................................................54
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
5000-17000-27000 unit...................................................54
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
10000-34000-55000 unit................................................ 54
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
15000-51000-82000 unit................................................ 54
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
20000-68000-109000 unit.............................................. 54
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
25000-85000-136000 unit.............................................. 54
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
40000-136000-218000 unit............................................ 54
ZENZEDI -dextroamphetamine sulfate tab 2.5 mg........... 69
ZENZEDI -dextroamphetamine sulfate tab 7.5 mg........... 69
ZENZEDI -dextroamphetamine sulfate tab 15 mg............ 69
ZENZEDI -dextroamphetamine sulfate tab 20 mg............ 69
ZENZEDI -dextroamphetamine sulfate tab 30 mg............ 69
ZEPATIER -elbasvir-grazoprevir tab 50-100 mg................. 9
ZERIT -stavudine for oral soln 1 mg/ml.............................. 9
ZETIA -ezetimibe tab 10 mg............................................. 44
ZETONNA -ciclesonide nasal aerosol soln 37 mcg/act (50
mcg/valve)....................................................................... 46
ZIAGEN -abacavir sulfate soln 20 mg/ml (base equiv)....... 9
zidovudine cap 100 mg (Retrovir)................................... 9
zidovudine syrup 10 mg/ml (Retrovir)............................. 9
zidovudine tab 300 mg...................................................... 9
zileuton tab sr 12hr 600 mg (Zyflo cr)........................... 50
ZINBRYTA -daclizumab soln prefilled syringe 150 mg/
ml..................................................................................... 72
ZIOPTAN -tafluprost ophth soln 0.0015%....................... 107
ziprasidone hcl cap 20 mg (Geodon)............................ 64
ziprasidone hcl cap 40 mg (Geodon)............................ 64
ziprasidone hcl cap 60 mg (Geodon)............................ 64
ziprasidone hcl cap 80 mg (Geodon)............................ 64
ZIPSOR -diclofenac potassium cap 25 mg....................... 81
ZIRGAN -ganciclovir ophth gel 0.15%............................ 107
ZITHROMAX -azithromycin powd pack for susp 1 gm....... 3
ZMAX -azithromycin extended release for oral susp 2
gm...................................................................................... 3
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 10 mg................................................... 78
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 15 mg................................................... 78
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 20 mg................................................... 78
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 30 mg................................................... 78
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 40 mg................................................... 78
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 50 mg................................................... 78
ZOLINZA -vorinostat cap 100 mg..................................... 16
zolmitriptan orally disintegrating tab 2.5 mg (Zomig
zmt)................................................................................. 82
zolmitriptan orally disintegrating tab 5 mg (Zomig
zmt)................................................................................. 82
zolmitriptan tab 2.5 mg (Zomig)..................................... 82
zolmitriptan tab 5 mg (Zomig)........................................ 82
zolpidem tartrate sl tab 1.75 mg (Intermezzo).............. 65
zolpidem tartrate sl tab 3.5 mg (Intermezzo)................ 65
zolpidem tartrate tab cr 6.25 mg (Ambien cr)............... 65
zolpidem tartrate tab cr 12.5 mg (Ambien cr)............... 65
zolpidem tartrate tab 5 mg (Ambien).............................65
zolpidem tartrate tab 10 mg (Ambien)...........................65
ZOLPIMIST -zolpidem tartrate oral spray 5 mg/act.......... 65
ZOMACTON -somatropin for inj 10 mg.............................32
ZOMACTON -somatropin for subcutaneous inj 5 mg....... 31
ZOMIG -zolmitriptan nasal spray 2.5 mg/spray unit..........82
ZOMIG -zolmitriptan nasal spray 5 mg/spray unit............ 82
ZONACORT 11 DAY -dexamethasone tab therapy pack
1.5 mg (41)..................................................................... 17
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ZONACORT 7 DAY -dexamethasone tab therapy pack
1.5 mg (27)..................................................................... 17
ZONALON -doxepin hcl cream 5%................................. 114
zonisamide cap 50 mg.................................................... 86
zonisamide cap 25 mg (Zonegran)................................ 86
zonisamide cap 100 mg (Zonegran).............................. 86
ZONTIVITY -vorapaxar sulfate tab 2.08 mg (base
equivalent)..................................................................... 104
ZORBTIVE -somatropin (non-refrigerated) for
subcutaneous inj 8.8 mg................................................ 32
ZORTRESS -everolimus tab 0.25 mg............................. 124
ZORTRESS -everolimus tab 0.5 mg............................... 124
ZORTRESS -everolimus tab 0.75 mg............................. 124
ZORVOLEX -diclofenac cap 18 mg.................................. 81
ZORVOLEX -diclofenac cap 35 mg.................................. 81
ZOSTAVAX -zoster vaccine live for subcutaneous susp
19400 unit/0.65ml........................................................... 11
ZOVIRAX -acyclovir cream 5%....................................... 114
Z-TUSS AC -chlorpheniramine w/ codeine liquid 2-9
mg/5ml............................................................................. 47
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab
0.7-0.18 mg (base eq).................................................... 78
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab
1.4-0.36 mg (base eq).................................................... 78
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab
2.9-0.71 mg (base eq).................................................... 78
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 5.7-1.4
mg (base eq)...................................................................78
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 8.6-2.1
mg (base eq)...................................................................78
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 11.4-2.9
mg (base eq)...................................................................78
ZUPLENZ -ondansetron oral soluble film 4 mg................ 53
ZUPLENZ -ondansetron oral soluble film 8 mg................ 53
ZURAMPIC -lesinurad tab 200 mg................................... 82
ZYCLARA -imiquimod cream 3.75%............................... 114
ZYCLARA PUMP -imiquimod cream 2.5%..................... 114
ZYCLARA PUMP -imiquimod cream 3.75%................... 114
ZYDELIG -idelalisib tab 100 mg........................................ 16
ZYDELIG -idelalisib tab 150 mg........................................ 16
ZYFLO CR -zileuton tab sr 12hr 600 mg.......................... 50
ZYFLO -zileuton tab 600 mg............................................. 50
ZYKADIA -ceritinib cap 150 mg........................................ 16
ZYLET -loteprednol etabonate-tobramycin ophth susp
0.5-0.3%........................................................................ 107
ZYTIGA -abiraterone acetate tab 250 mg......................... 16
ZYTIGA -abiraterone acetate tab 500 mg......................... 16
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