Download BCBSTX Health Insurance Marketplace 3 Tier Drug List

June 2017
Health Insurance Marketplace 3 Tier Drug List
Please consider talking to your doctor about prescribing preferred medications, which may
help reduce your out-of-pocket costs. This list may help guide you and your doctor in
selecting an appropriate medication for you.
The drug list is regularly updated. Please visit bcbstx.com for the most up-to-date
information.
To find a contracting pharmacy, please access the link below:
https://www.myprime.com/en/find-medicine.html
Contents
Therapeutic Class Drug List
Introduction ...................................................................... I Anti-Infective Agents ....................................................... 1
How drugs are selected ................................................... I Biologicals ..................................................................... 13
How member payment is determined .............................. I Antineoplastic Agents ................................................... 16
How to use this list .......................................................... II Endocrine and Metabolic Drugs ................................... 22
Drugs used to treat multiple conditions .......................... II Cardiovascular Agents .................................................. 39
Generic drugs ................................................................. II Respiratory Agents ....................................................... 55
Consider talking to your doctor about generic
Gastrointestinal Agents ................................................. 60
drugs ........................................................................... II Genitourinary Agents .................................................... 66
Coverage considerations ............................................... III Central Nervous System Drugs .................................... 68
Specialty drugs ............................................................... V Analgesics and Anesthetics .......................................... 85
Prime Therapeutics Specialty Pharmacy
Neuromuscular Drugs ................................................... 96
Program ...................................................................... V Nutritional Products .................................................... 105
Abbreviation key ............................................................ VI Hematological Agents ................................................. 133
Topical Products ......................................................... 143
Miscellaneous Products .............................................. 155
Index ........................................................................... 160
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.
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
41722-Q TX HIM © Prime Therapeutics LLC 06/17
Introduction
Members are encouraged to show this list to their physicians and pharmacists. Physicians are
encouraged to prescribe drugs on this list, when right for the member. However decisions regarding
therapy and treatment are always between members and their physician.
Drug list updates – This list is regularly updated as generic drugs become available and changes take place in
the pharmaceuticals market. For the most up-to-date information, visit bcbstx.com and log in to
Blue Access for MembersSM or call the number on the back of your ID card. Physicians can access the list from
the provider portal at bcbstx.com.
How drugs are selected
Drugs on this list are selected based on the recommendations of a committee made up of physicians and
pharmacists from throughout the country. The committee, which includes at least one representative from
BCBSTX, reviews drugs regulated by the U.S. Food and Drug Administration (FDA).
Both drugs that are newly approved by the FDA as well as those that have been on the market for some time are
considered. Drugs are selected based on safety, efficacy, cost and how they compare to other drugs currently on
the list.
How member payment is determined
This list shows prescription drug products in tiers. Generally, each drug is placed into one of three member
payment tiers: Generic (Tier 1), Preferred Brand (Tier 2) or Non-preferred Brand (Tier 3). Please refer to the ACA
Preventive (ACA) section for drugs marked with an "A" in the drug tier column. To verify your payment amount for
a drug, visit bcbstx.com and log in to Blue Access for Members or call the number on the back of your ID card.
Your pharmacy benefit includes coverage for many prescription drugs, although some exclusions may apply.
Generally, if a drug is not listed on the drug list it is not covered. For example, drugs indicated for cosmetic
purposes, e.g., Propecia, for hair growth, may not be covered. Drugs that are not FDA-approved for selfadministration may be available through your medical benefit.
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
I
How to use this list
Generic drugs are shown in lower-case boldface type. Most generic drugs are followed by a reference brand
drug in (parentheses). Some generic products have no reference brand.
Example: atorvastatin (Lipitor – brand is NF)
Brand prescription drugs are shown in capital letters followed by the generic name.
Drugs used to treat multiple conditions
Some drugs in the same dosage form may be used to treat more than one medical condition. In these instances,
each medication is classified according to its first FDA-approved use. Please check the index if you do not find
your particular medication in the class/condition section that corresponds to your use.
Generic drugs
Using generic drugs, when right for you, can help you save on your out-of-pocket medication costs. Generic drugs
must be approved by the FDA just as brand drugs are, and must meet the same standards.
There are two types of generic drugs:

A generic equivalent is made with the same active ingredient(s) at the same dosage as the reference drug.

A generic alternative is a drug typically used to treat the same condition, but the active ingredient(s)
differs from the brand drug.
According to the FDA, compared to its brand counterpart, an FDA-approved generic drug:

Is chemically the same

Works just as well in the body

Is as safe and effective

Meets the same standards set by the FDA
The main difference between the reference brand drug and the generic equivalent is that the generic often costs
much less.
Preferred brand drugs typically move to a non-preferred brand tier after a generic equivalent becomes available.
You may be responsible for the brand member payment amount plus the difference in cost between the brand
and generic equivalent if you or your doctor requests the reference brand rather than the generic. Generic drugs
have the lowest member payment amount.
Consider talking to your doctor about generic drugs
If your doctor writes a prescription for a brand drug that does not have a generic equivalent, consider asking if an
appropriate generic alternative is available.
You can also let your pharmacist know that you would like a generic equivalent for a brand drug, whenever one is
available. Your pharmacist can usually substitute a generic equivalent for its brand counterpart without a new
prescription from your doctor.
Only your doctor can determine whether a generic alternative is right for you and must prescribe the medication.
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
II
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.
Over-the-counter exclusions: Your benefit plan does not provide coverage for prescription medications that
have an over-the-counter version. You should refer to your benefit plan materials for details about your particular
benefits.
Compounded medications: Your benefit plan does not provide coverage for compounded medications. Please
see your plan materials or call the number on the back of your ID card to determine whether compounded
medications are covered and/or verify your payment amount.
Repackaged medications: Repackaged versions of medications already available on the market are not covered.
Prior Authorization (PA): Your benefit plan may require prior authorization for certain drugs. This means that
your doctor will need to submit a prior authorization request for coverage of these medications, and the request
will need to be approved, before the medication will be covered under your plan. For the preferred medications
listed in this document, if a prior authorization is commonly required, it will be noted next to the medication with a
dot under the prior authorization column. Some plans may have prior authorization on additional medications
beyond those noted in this document.
Step Therapy (ST): Your benefit plan may include a step therapy program. This means you may need to try
another proven, cost-effective medication before coverage may be available for the drug included in the program.
Many brand drugs have less-expensive generic or brand alternatives that might be an option for you. For the
preferred medications listed in this document, if a step therapy is commonly required it will generally be noted
next to the medication with a dot under the step therapy column. Some plans may have step therapy programs
on additional medications beyond those noted in this document.
Dispensing Limits (DL): Drug Dispensing limits are designed to help encourage medication use as intended by
the FDA. Coverage limits are placed on medications in certain drug categories. For the preferred medications
listed in this document, if a dispensing limit applies, it will generally be noted next to the medication with a dot
under the dispensing limits column. Limits may include: quantity of covered medication per prescription, quantity
of covered medication in a given time period, coverage only for members within a certain age range, and
coverage only for members of a specific gender. If your doctor prescribes a greater quantity of medication than
what the dispensing limit allows, you can still get the medication. However, you will be responsible for the full cost
of the prescription beyond what your coverage allows.* For a list of medications and their dispensing limits, visit
bcbstx.com.
*Please note: For certain controlled substance medications, some state laws may not allow coverage by a health
benefit plan of such medication if dispensed in a quantity beyond what the dispensing limit allows. You will be
responsible for the full cost of the prescription with no benefits applied if the dispensed quantity exceeds the
dispensing limit.
Limited Distribution (LD): Medicines marked as "Limited Distribution" have restrictions on where you may obtain
a medication. This may include requiring the use of a designated pharmacy to fill a prescription.
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
III
ACA Preventive (ACA): Medicines marked in the ACA column are under the Affordable Care Act coverage of
preventive services. These products have limited or $0 member cost-sharing (copay or co-insurance), when
meeting the conditions as outlined under the regulation. These are also indicated with an "A" in the drug tier
column. Examples of these drug categories include aspirin, breast cancer preventive, fluoride supplements, folic
acid supplements, gonorrhea prophylaxis (newborn), iron supplements, tobacco cessation, vaccines, vitamin D
supplements, and some FDA approved contraceptive methods. To see what contraceptive products may be
covered, visit www.bcbstx.com/pdf/rx/contraceptive-list-tx.pdf
Remember, medication decisions are between you and your doctor. Only you and your doctor can determine
which medication is right for you. Discuss any questions or concerns you have about medications you are taking
or are prescribed with your doctor. BCBSTX does not provide health care services and, therefore, cannot
guarantee any results or outcomes.
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
IV
Specialty drugs
Specialty drugs are used in the treatment of medical conditions such as hepatitis, hemophilia, multiple sclerosis
and rheumatoid arthritis. Specialty drugs may be oral, topical, or injectable medications that can either be selfadministered or administered by a health care professional. For a current list of specialty medications,
visit myprime.com or bcbstx.com and log in to Blue Access for Members.
Note that some drug classes may be excluded by some plans and therefore may not be covered under your
pharmacy benefit. Your plan may have a different coverage level for self-administered specialty drugs. If you
have questions about your coverage for specialty medications or your prescription drug benefit, call the
number on the back of your ID card.
Prime Therapeutics Specialty Pharmacy Program
Through Prime Therapeutics Specialty Pharmacy, members can have covered specialty medications delivered
directly to them or their doctor’s office. When you receive specialty medications through Prime, you also receive at
no additional charge the following services:

Coordination of coverage between you, your doctor and your health plan

Educational materials about your particular condition and information about managing potential
medication side effects

Syringes, sharps containers and other supplies with every shipment for self-injectables

24/7/365 phone access to a pharmacist for urgent medication issues
To order through Prime Therapeutics Specialty Pharmacy:

Have your doctor call or fax your prescription to Prime Therapeutics Specialty Pharmacy. Your doctor can
call 877-627-6337 or fax to 877-828-3939.

If you have an existing prescription for a covered specialty medication, you can call 877-627-6337 to
transfer your prescription.

A Prime Therapeutics coordinator will contact you to arrange delivery of your medication.

The prescription can be shipped directly to you or your prescribing doctor’s office. Each package is
individually marked for each member. Refrigerated drugs are shipped in temperature-controlled packaging.
If you have questions, please contact Prime Therapeutics Specialty Pharmacy at 877-627-6337,
visit www.PrimeTherapeutics.com/specialty, or call the number on the back of your ID card.
*
Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company (“HCSC”).
HCSC is an independent licensee of the Blue Cross Blue Shield Association. HCSC contracts with Prime Therapeutics to provide
pharmacy benefit management and mail order pharmacy services and to administer this specialty pharmacy program. HCSC, as
well as several other independent Blue Cross and Blue Shield licensees, has an ownership interest in Prime Therapeutics LLC.
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
V
Abbreviation key
cap ...................................................................... capsules
chew .................................................................. chewable
conc ............................................................. concentrate
cr .......................................................... controlled release
dr ............................................................. delayed release
ec ................................................................enteric coated
odt ............................................. orally disintegrating tabs
oint ..................................................................... ointment
ophth ................................................................. opthalmic
osm .......................................................... osmotic release
powd ..................................................................... powder
effe................................................................. effervescent
sa ............................................................ sustained action
sl ...................................................................... sublingual
equiv ................................................................ equivalent
er ...........................................................extended release
soln ....................................................................... solution
sr .......................................................... sustained release
inhal................................................................... inhalation
inj ......................................................................... injection
suppos ........................................................ suppositories
susp ................................................................ suspension
liq .............................................................................. liquid
lotn ........................................................................... lotion
tab ...........................................................................tablets
td ................................................................... transdermal
nebu ................................................................... nebulizer
You, or your prescribing health care provider, can ask for a Drug List exception if your drug is not on the Drug List
(also known as a formulary). To request this exception, you, or your prescriber, can call the number on the back of
your ID card to ask for a review. If you have a health condition that may jeopardize your life, health or keep you
from regaining function, or your current drug therapy uses a non-covered drug, you, or your prescriber, may be
able to ask for an expedited review process. BCBSTX will let you, and your prescriber, know the coverage decision
within 24 hours after they receive your request for an expedited review. If the coverage request is denied, BCBSTX
will let you and your prescriber know why it was denied and offer you a covered alternative drug (if applicable). Call
the number on the back of your ID card if you have any questions.
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
VI
bcbstx.com
Health care coverage is important for everyone.
We provide free communication aids and services for anyone with a disability or who needs language assistance.
We do not discriminate on the basis of race, color, national origin, sex, gender identity, age or disability.
To receive language or communication assistance free of charge, please call us at 855-710-6984.
If you believe we have failed to provide a service, or think we have discriminated in another way, contact us to file a grievance.
Office of Civil Rights Coordinator
Phone:
855-664-7270 (voicemail)
300 E. Randolph St.
TTY/TDD: 855-661-6965
35th Floor
Fax:
855-661-6960
Chicago, Illinois 60601
Email:
[email protected]
You may file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, at:
U.S. Dept. of Health & Human Services
Phone:
800-368-1019
200 Independence Avenue SW
TTY/TDD:
800-537-7697
Room 509F, HHH Building 1019
Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Washington, DC 20201
Complaint Forms: http://www.hhs.gov/ocr/office/file/index.html
bcbstx.com
3
1
AMOXICILLIN/CLAVULANATE
P - amoxicillin & k
clavulanate chew tab 400-57
mg
3
1
AMPICILLIN - ampicillin for
susp 125 mg/5ml
3
1
AMPICILLIN - ampicillin for
susp 250 mg/5ml
ampicillin cap 250 mg
1
1
1
1
ampicillin cap 500 mg
1
AUGMENTIN - amoxicillin
& k clavulanate for susp
125-31.25 mg/5ml
3
1
dicloxacillin sodium cap
250 mg
1
amoxicillin & k clavulanate
for susp 250-62.5 mg/5ml
(Augmentin)
1
dicloxacillin sodium cap
500 mg
amoxicillin & k clavulanate
for susp 400-57 mg/5ml
1
amoxicillin (trihydrate) tab
875 mg
amoxicillin & k clavulanate
for susp 200-28.5 mg/5ml
amoxicillin & k clavulanate
for susp 600-42.9 mg/5ml
(Augmentin es-600)
1
amoxicillin & k clavulanate
tab sr 12hr 1000-62.5 mg
(Augmentin xr)
1
amoxicillin & k clavulanate
tab 250-125 mg
1
3
penicillin v potassium for
soln 125 mg/5ml
1
penicillin v potassium tab
250 mg
penicillin v potassium tab
500 mg
Limited Distribution
ACA
Dispensing Limits
1
MOXATAG - amoxicillin
(trihydrate) tab sr 24hr 775
mg
penicillin v potassium for
soln 250 mg/5ml
Step Therapy
1
1
amoxicillin (trihydrate) tab
500 mg
Prior Authorization
Drug Tier
3
amoxicillin (trihydrate) cap
250 mg
amoxicillin (trihydrate) for
susp 400 mg/5ml
Limited Distribution
AMOXICILLIN/CLAVULANATE
P - amoxicillin & k
clavulanate chew tab
200-28.5 mg
3
amoxicillin (trihydrate) for
susp 250 mg/5ml
ACA
1
AMOXICILLIN - amoxicillin
(trihydrate) chew tab 250 mg
amoxicillin (trihydrate) for
susp 200 mg/5ml
Dispensing Limits
amoxicillin & k clavulanate
tab 875-125 mg
(Augmentin)
3
amoxicillin (trihydrate) for
susp 125 mg/5ml
Step Therapy
1
AMOXICILLIN - amoxicillin
(trihydrate) chew tab 125 mg
amoxicillin (trihydrate) cap
500 mg
Drug Name
amoxicillin & k clavulanate
tab 500-125 mg
(Augmentin)
ANTI-INFECTIVE AGENTS
PENICILLINS
Prior Authorization
Drug Name
Drug Tier
2017
1
1
1
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
1
CEPHALOSPORINS
CEDAX - ceftibuten cap 400
mg
3
cefpodoxime proxetil for
susp 100 mg/5ml
CEDAX - ceftibuten for susp
180 mg/5ml
3
cefpodoxime proxetil tab
100 mg
CEFACLOR - cefaclor for susp
125 mg/5ml
3
cefpodoxime proxetil tab
200 mg
CEFACLOR - cefaclor for susp
250 mg/5ml
3
cefprozil for susp
125 mg/5ml
CEFACLOR - cefaclor for susp
375 mg/5ml
3
cefprozil for susp
250 mg/5ml
cefaclor cap 250 mg
1
cefaclor cap 500 mg
1
cefdinir for susp 125 mg/5ml
cefdinir for susp 250 mg/5ml
3
1
CEFTIN - cefuroxime axetil for
susp 250 mg/5ml
1
1
cefuroxime axetil tab 250 mg
(Ceftin)
cefuroxime axetil tab 500 mg
(Ceftin)
1
CEPHALEXIN - cephalexin tab
250 mg
3
CEPHALEXIN - cephalexin tab
500 mg
3
cephalexin cap 250 mg
(Keflex)
1
cephalexin cap 500 mg
(Keflex)
1
cephalexin cap 750 mg
(Keflex)
1
cephalexin for susp
125 mg/5ml
1
1
1
CEFDITOREN PIVOXIL cefditoren pivoxil tab 400 mg
(base equivalent)
3
cefixime for susp
100 mg/5ml (Suprax)
1
1
1
Limited Distribution
ACA
Dispensing Limits
1
1
1
Step Therapy
1
2
3
cefpodoxime proxetil for
susp 50 mg/5ml
1
CEFTIN - cefuroxime axetil for
susp 125 mg/5ml
CEFDITOREN PIVOXIL cefditoren pivoxil tab 200 mg
(base equivalent)
cefixime for susp
200 mg/5ml (Suprax)
1
3
1
cefdinir cap 300 mg
1
CEFTIBUTEN - ceftibuten for
susp 180 mg/5ml
cefadroxil cap 500 mg
cefadroxil tab 1 gm
1
3
3
cefadroxil for susp
500 mg/5ml
cefprozil tab 500 mg
1
CEFTIBUTEN - ceftibuten cap
400 mg
CEFACLOR ER - cefaclor
monohydrate tab sr 12hr 500
mg
cefadroxil for susp
250 mg/5ml
cefprozil tab 250 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
2
1
clarithromycin tab 250 mg
(Biaxin)
1
SPECTRACEF - cefditoren
pivoxil tab 400 mg (base
equivalent)
3
clarithromycin tab 500 mg
(Biaxin)
1
DIFICID - fidaxomicin tab 200
mg
3
SUPRAX - cefixime cap 400
mg
3
3
E.E.S. GRANULES erythromycin ethylsuccinate
for susp 200 mg/5ml
3
SUPRAX - cefixime chew tab
100 mg
SUPRAX - cefixime chew tab
200 mg
3
E.E.S. 400 - erythromycin
ethylsuccinate tab 400 mg
3
SUPRAX - cefixime for susp
100 mg/5ml
3
ERY-TAB - erythromycin tab
delayed release 250 mg
3
SUPRAX - cefixime for susp
200 mg/5ml
3
ERY-TAB - erythromycin tab
delayed release 333 mg
3
SUPRAX - cefixime for susp
500 mg/5ml
3
ERY-TAB - erythromycin tab
delayed release 500 mg
3
3
cephalexin for susp
250 mg/5ml
MACROLIDES
AZITHROMYCIN azithromycin powd pack for
susp 1 gm
3
ERYPED 200 - erythromycin
ethylsuccinate for susp 200
mg/5ml
3
azithromycin for susp
100 mg/5ml (Zithromax)
1
ERYPED 400 - erythromycin
ethylsuccinate for susp 400
mg/5ml
ERYTHROCIN STEARATE erythromycin stearate tab
250 mg
3
ERYTHROMYCIN BASE erythromycin tab 250 mg
3
ERYTHROMYCIN BASE erythromycin tab 500 mg
3
ERYTHROMYCIN
ETHYLSUCCINA erythromycin ethylsuccinate
tab 400 mg
3
azithromycin for susp
200 mg/5ml (Zithromax)
1
azithromycin tab 250 mg
(Zithromax)
1
•
azithromycin tab 500 mg
(Zithromax)
1
•
azithromycin tab 600 mg
(Zithromax)
1
•
clarithromycin for susp
125 mg/5ml
1
clarithromycin for susp
250 mg/5ml (Biaxin)
clarithromycin tab sr 24hr
500 mg (Biaxin xl pac)
1
1
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
erythromycin ethylsuccinate 1
for susp 200 mg/5ml (E.e.s.
granules)
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
3
erythromycin w/ delayed
release particles cap
250 mg
1
doxycycline monohydrate
tab 75 mg (Adoxa)
doxycycline monohydrate
tab 100 mg (Adoxa pak
1/100)
1
1
PCE - erythromycin w/ enteric
coated particles tab 333 mg
PCE - erythromycin w/ enteric
coated particles tab 500 mg
3
ZITHROMAX - azithromycin
powd pack for susp 1 gm
3
doxycycline monohydrate
tab 150 mg (Adoxa pak
1/150)
1
ZMAX - azithromycin extended
release for oral susp 2 gm
3
minocycline hcl cap 50 mg
(Minocin)
minocycline hcl cap 75 mg
(Minocin)
1
1
minocycline hcl cap 100 mg
(Minocin)
1
1
minocycline hcl tab sr 24hr
45 mg
1
•
1
minocycline hcl tab sr 24hr
90 mg
1
•
1
minocycline hcl tab sr 24hr
135 mg
1
•
1
minocycline hcl tab 50 mg
demeclocycline hcl tab
150 mg
demeclocycline hcl tab
300 mg
doxycycline hyclate cap
50 mg
doxycycline hyclate cap
100 mg (Vibramycin)
doxycycline hyclate tab
20 mg
doxycycline hyclate tab
100 mg
doxycycline monohydrate
cap 50 mg
doxycycline monohydrate
cap 75 mg (Monodox)
doxycycline monohydrate
cap 100 mg (Monodox)
doxycycline monohydrate
cap 150 mg (Adoxa)
minocycline hcl tab 75 mg
1
minocycline hcl tab 100 mg
1
1
•
1
1
doxycycline monohydrate
for susp 25 mg/5ml
(Vibramycin)
1
doxycycline monohydrate
tab 50 mg (Adoxa)
1
•
Limited Distribution
1
TETRACYCLINE HCL tetracycline hcl cap 500 mg
3
tetracycline hcl cap 250 mg
(Tetracycline hcl)
1
tetracycline hcl cap 500 mg
(Tetracycline hcl)
1
ciprofloxacin for oral
susp 500 mg/5ml (10%)
(10 gm/100ml) (Cipro)
ACA
1
3
ciprofloxacin for oral
susp 250 mg/5ml (5%)
(5 gm/100ml) (Cipro)
•
1
TETRACYCLINE HCL tetracycline hcl cap 250 mg
FLUOROQUINOLONES
Dispensing Limits
1
3
TETRACYCLINES
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
4
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
CIPROFLOXACIN HCL ciprofloxacin hcl tab 100 mg
(base equiv)
3
TOBI PODHALER - tobramycin
inhal cap 28 mg
3
ciprofloxacin hcl tab 250 mg
(base equiv) (Cipro)
1
•
•
•
1
TOBRAMYCIN - tobramycin
nebu soln 300 mg/5ml
3
•
•
•
1
tobramycin nebu soln
300 mg/5ml (Tobi)
1
•
•
•
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)
paromomycin sulfate cap
250 mg
SULFONAMIDES
1
SULFADIAZINE - sulfadiazine
tab 500 mg
3
ANTIMYCOBACTERIAL AGENTS
3
CYCLOSERINE - cycloserine
cap 250 mg
1
ethambutol hcl tab 100 mg
(Myambutol)
1
ethambutol hcl tab 400 mg
(Myambutol)
ISONIAZID - isoniazid syrup 50 3
mg/5ml
1
isoniazid tab 100 mg
1
ciprofloxacin-ciprofloxacin
hcl tab sr 24hr
1000 mg(base eq) (Cipro xr)
3
FACTIVE - gemifloxacin
mesylate tab 320 mg (base
equiv)
LEVOFLOXACIN - levofloxacin 1
oral soln 25 mg/ml
1
levofloxacin tab 250 mg
(Levaquin)
1
levofloxacin tab 500 mg
(Levaquin)
1
levofloxacin tab 750 mg
(Levaquin)
1
moxifloxacin hcl tab 400 mg
(base equiv) (Avelox)
3
OFLOXACIN - ofloxacin tab
300 mg
1
ofloxacin tab 400 mg
AMINOGLYCOSIDES
1
isoniazid tab 300 mg
BETHKIS - tobramycin nebu
soln 300 mg/4ml
3
•
•
•
KITABIS PAK - tobramycin
nebu soln 300 mg/5ml
3
•
•
•
neomycin sulfate tab 500 mg
1
1
PASER - aminosalicylic acid cr
granules packet 4 gm
3
PRIFTIN - rifapentine tab 150
mg
2
pyrazinamide tab 500 mg
1
rifabutin cap 150 mg
(Mycobutin)
1
RIFAMATE - isoniazid &
rifampin cap 150-300 mg
3
rifampin cap 150 mg (Rifadin) 1
rifampin cap 300 mg (Rifadin) 1
RIFATER - isoniazid-rifampin
w/ pyrazinamide tab
50-120-300 mg
3
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
5
SIRTURO - bedaquiline
fumarate tab 100 mg (base
equiv)
3
TRECATOR - ethionamide tab
250 mg
3
ANTIFUNGALS
CRESEMBA isavuconazonium sulfate cap
186 mg
3
fluconazole for susp 10 mg/
ml (Diflucan)
1
fluconazole for susp 40 mg/
ml (Diflucan)
•
1
NOXAFIL - posaconazole tab
delayed release 100 mg
2
nystatin tab 500000 unit
1
terbinafine hcl tab 250 mg
(Lamisil)
1
voriconazole for susp
40 mg/ml (Vfend)
1
•
voriconazole tab 50 mg
(Vfend)
1
•
voriconazole tab 200 mg
(Vfend)
1
•
fluconazole tab 100 mg
(Diflucan)
1
abacavir sulfate tab 300 mg
(base equiv) (Ziagen)
fluconazole tab 150 mg
(Diflucan)
1
abacavir sulfate-lamivudine
tab 600-300 mg (Epzicom)
fluconazole tab 200 mg
(Diflucan)
1
flucytosine cap 250 mg
(Ancobon)
1
flucytosine cap 500 mg
(Ancobon)
1
griseofulvin microsize susp
125 mg/5ml
1
griseofulvin ultramicrosize
tab 125 mg (Gris-peg)
griseofulvin ultramicrosize
tab 250 mg (Gris-peg)
ANTIVIRALS
abacavir sulfatelamivudine-zidovudine tab
300-150-300 mg (Trizivir)
1
1
itraconazole cap 100 mg
(Sporanox)
1
NOXAFIL - posaconazole susp
40 mg/ml
2
•
•
•
3
1
1
Limited Distribution
ACA
Dispensing Limits
Step Therapy
•
SPORANOX - itraconazole oral
soln 10 mg/ml
fluconazole tab 50 mg
(Diflucan)
griseofulvin microsize tab
500 mg (Grifulvin v)
Prior Authorization
•
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
1
•
1
•
1
•
acyclovir cap 200 mg
(Zovirax)
1
acyclovir susp 200 mg/5ml
(Zovirax)
1
acyclovir tab 400 mg
(Zovirax)
1
acyclovir tab 800 mg
(Zovirax)
1
adefovir dipivoxil tab 10 mg
(Hepsera)
1
APTIVUS - tipranavir cap 250
mg
3
•
APTIVUS - tipranavir oral soln
100 mg/ml
3
•
ATRIPLA - efavirenzemtricitabine-tenofovir df tab
600-200-300 mg
2
•
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
6
BARACLUDE - entecavir oral
soln 0.05 mg/ml
2
COMPLERA - emtricitabinerilpivirine-tenofovir df tab
200-25-300 mg
3
CRIXIVAN - indinavir sulfate
cap 200 mg
3
CRIXIVAN - indinavir sulfate
cap 400 mg
3
DAKLINZA - daclatasvir
dihydrochloride tab 30 mg
(base equivalent)
2
•
DAKLINZA - daclatasvir
dihydrochloride tab 60 mg
(base equivalent)
2
•
DAKLINZA - daclatasvir
dihydrochloride tab 90 mg
(base equivalent)
2
DESCOVY - emtricitabinetenofovir alafenamide
fumarate tab 200-25 mg
2
didanosine delayed release
capsule 125 mg (Videx ec)
entecavir tab 1 mg
(Baraclude)
1
EPCLUSA - sofosbuvirvelpatasvir tab 400-100 mg
2
•
EPIVIR HBV - lamivudine oral
soln 5 mg/ml (hbv)
3
•
EPZICOM - abacavir sulfatelamivudine tab 600-300 mg
2
•
•
EVOTAZ - atazanavir sulfatecobicistat tab 300-150 mg
(base equiv)
3
•
•
famciclovir tab 125 mg
(Famvir)
1
famciclovir tab 250 mg
(Famvir)
1
famciclovir tab 500 mg
(Famvir)
1
•
FUZEON - enfuvirtide for inj 90
mg
3
•
2
•
1
•
GENVOYA - elvitegrav-cobicemtricitab-tenofov af tab
150-150-200-10 mg
1
•
HARVONI - ledipasvirsofosbuvir tab 90-400 mg
2
1
•
INTELENCE - etravirine tab 25
mg
2
•
1
•
INTELENCE - etravirine tab
100 mg
2
•
EDURANT - rilpivirine hcl tab
25 mg (base equivalent)
3
•
INTELENCE - etravirine tab
200 mg
2
•
EMTRIVA - emtricitabine caps
200 mg
3
•
INVIRASE - saquinavir
mesylate cap 200 mg
3
•
EMTRIVA - emtricitabine soln
10 mg/ml
3
•
INVIRASE - saquinavir
mesylate tab 500 mg
3
•
entecavir tab 0.5 mg
(Baraclude)
1
ISENTRESS - raltegravir
potassium chew tab 25 mg
(base equiv)
2
•
didanosine delayed release
capsule 200 mg (Videx ec)
didanosine delayed release
capsule 250 mg (Videx ec)
didanosine delayed release
capsule 400 mg (Videx ec)
•
•
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
7
2
•
KALETRA - lopinavir-ritonavir
soln 400-100 mg/5ml (80-20
mg/ml)
2
•
KALETRA - lopinavir-ritonavir
tab 100-25 mg
2
•
KALETRA - lopinavir-ritonavir
tab 200-50 mg
2
•
lamivudine oral soln 10 mg/
ml (Epivir)
1
•
MODERIBA - ribavirin tab 400
mg & ribavirin tab 600 mg
dose pack
3
•
MODERIBA 1200 DOSE
PACK - ribavirin tab 600 mg
3
•
MODERIBA 800 DOSE PACK - 3
ribavirin tab 400 mg
NEVIRAPINE - nevirapine susp 3
50 mg/5ml
1
nevirapine tab sr 24hr
100 mg
1
nevirapine tab sr 24hr
400 mg (Viramune xr)
1
nevirapine tab 200 mg
(Viramune)
NORVIR - ritonavir cap 100 mg 3
•
NORVIR - ritonavir oral soln 80
mg/ml
2
NORVIR - ritonavir tab 100 mg
2
ODEFSEY - emtricitabinerilpivirine-tenofovir af tab
200-25-25 mg
2
OLYSIO - simeprevir sodium
cap 150 mg (base
equivalent)
3
•
•
•
•
•
•
lamivudine tab 100 mg (hbv)
(Epivir hbv)
1
lamivudine tab 150 mg
(Epivir)
1
•
lamivudine tab 300 mg
(Epivir)
1
•
lamivudine-zidovudine tab
150-300 mg (Combivir)
1
•
LEXIVA - fosamprenavir
calcium susp 50 mg/ml
(base equiv)
3
•
oseltamivir phosphate
cap 30 mg (base equiv)
(Tamiflu)
1
•
LEXIVA - fosamprenavir
calcium tab 700 mg (base
equiv)
3
•
oseltamivir phosphate
cap 45 mg (base equiv)
(Tamiflu)
1
•
lopinavir-ritonavir soln
400-100 mg/5ml (80-20 mg/
ml) (Kaletra)
1
•
oseltamivir phosphate
cap 75 mg (base equiv)
(Tamiflu)
1
•
PEG-INTRON REDIPEN peginterferon alfa-2b for inj
kit 50 mcg/0.5ml
3
MODERIBA - ribavirin tab 200
mg & ribavirin tab 400 mg
dose pack
3
•
Limited Distribution
ISENTRESS - raltegravir
potassium tab 400 mg (base
equiv)
ACA
•
Dispensing Limits
2
Step Therapy
ISENTRESS - raltegravir
potassium packet for susp
100 mg (base equiv)
Prior Authorization
•
Drug Name
Drug Tier
2
Limited Distribution
ISENTRESS - raltegravir
potassium chew tab 100 mg
(base equiv)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
•
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
8
3
•
•
PEG-INTRON REDIPEN peginterferon alfa-2b for inj
kit 150 mcg/0.5ml
3
•
•
PEG-INTRON REDIPEN PAK
4 - peginterferon alfa-2b for
inj kit 120 mcg/0.5ml
3
•
•
PEGASYS - peginterferon
alfa-2a inj 180 mcg/ml
2
•
•
PEGASYS - peginterferon
alfa-2a inj 180 mcg/0.5ml
2
•
•
PEGASYS PROCLICK peginterferon alfa-2a inj 135
mcg/0.5ml
2
•
•
PEGASYS PROCLICK peginterferon alfa-2a inj 180
mcg/0.5ml
2
•
•
PEGINTRON - peginterferon
alfa-2b for inj kit 50
mcg/0.5ml
3
•
•
PEGINTRON - peginterferon
alfa-2b for inj kit 80
mcg/0.5ml
3
•
•
PEGINTRON - peginterferon
alfa-2b for inj kit 120
mcg/0.5ml
3
•
PEGINTRON - peginterferon
alfa-2b for inj kit 150
mcg/0.5ml
3
•
PREZCOBIX - darunavircobicistat tab 800-150 mg
3
•
PREZISTA - darunavir
ethanolate susp 100 mg/ml
(base equiv)
2
•
Limited Distribution
PEG-INTRON REDIPEN peginterferon alfa-2b for inj
kit 120 mcg/0.5ml
ACA
•
Dispensing Limits
•
Step Therapy
3
Prior Authorization
PEG-INTRON REDIPEN peginterferon alfa-2b for inj
kit 80 mcg/0.5ml
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
PREZISTA - darunavir
ethanolate tab 75 mg (base
equiv)
2
•
PREZISTA - darunavir
ethanolate tab 150 mg (base
equiv)
2
•
PREZISTA - darunavir
ethanolate tab 600 mg (base
equiv)
2
•
PREZISTA - darunavir
ethanolate tab 800 mg (base
equiv)
2
•
REBETOL - ribavirin soln 40
mg/ml
3
RELENZA DISKHALER zanamivir aero powder
breath activated 5 mg/blister
3
•
RESCRIPTOR - delavirdine
mesylate tab 100 mg
3
•
RESCRIPTOR - delavirdine
mesylate tab 200 mg
3
•
REYATAZ - atazanavir sulfate
cap 150 mg (base equiv)
2
•
REYATAZ - atazanavir sulfate
cap 200 mg (base equiv)
2
•
REYATAZ - atazanavir sulfate
cap 300 mg (base equiv)
2
•
•
REYATAZ - atazanavir sulfate
oral powder packet 50 mg
(base equiv)
3
•
•
RIBASPHERE - ribavirin tab
400 mg
3
•
RIBASPHERE - ribavirin tab
600 mg
3
•
RIBASPHERE RIBAPAK ribavirin tab 400 mg
3
•
RIBASPHERE RIBAPAK ribavirin tab 600 mg
3
•
•
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9
3
RIBASPHERE RIBAPAK ribavirin tab 400 mg &
ribavirin tab 600 mg dose
pack
3
•
ribavirin cap 200 mg
(Rebetol)
1
•
ribavirin for inhal soln 6 gm
(Virazole)
1
ribavirin tab 200 mg
(Copegus)
1
rimantadine hydrochloride
tab 100 mg (Flumadine)
1
•
SELZENTRY - maraviroc tab
25 mg
3
•
SELZENTRY - maraviroc tab
75 mg
3
•
SELZENTRY - maraviroc tab
150 mg
3
SELZENTRY - maraviroc tab
300 mg
3
SITAVIG - acyclovir buccal tab
50 mg
3
SOVALDI - sofosbuvir tab 400
mg
2
stavudine cap 15 mg (Zerit)
1
stavudine cap 20 mg (Zerit)
stavudine cap 30 mg (Zerit)
stavudine cap 40 mg (Zerit)
1
1
1
STRIBILD - elvitegrav-cobicemtricitab-tenofovdf tab
150-150-200-300 mg
2
SUSTIVA - efavirenz cap 50
mg
2
•
•
•
•
•
•
•
•
•
•
•
•
2
•
SUSTIVA - efavirenz tab 600
mg
2
•
TAMIFLU - oseltamivir
phosphate cap 30 mg (base
equiv)
3
•
TAMIFLU - oseltamivir
phosphate cap 45 mg (base
equiv)
3
•
TAMIFLU - oseltamivir
phosphate cap 75 mg (base
equiv)
3
•
TAMIFLU - oseltamivir
phosphate for susp 6 mg/ml
(base equiv)
3
•
TECHNIVIE - ombitasvirparitaprevir-ritonavir tab
12.5-75-50 mg
3
TIVICAY - dolutegravir sodium
tab 10 mg (base equiv)
2
•
TIVICAY - dolutegravir sodium
tab 25 mg (base equiv)
2
•
TIVICAY - dolutegravir sodium
tab 50 mg (base equiv)
2
•
TRIUMEQ - abacavirdolutegravir-lamivudine tab
600-50-300 mg
3
•
TRUVADA - emtricitabinetenofovir disoproxil fumarate
tab 100-150 mg
2
•
TRUVADA - emtricitabinetenofovir disoproxil fumarate
tab 133-200 mg
2
•
TRUVADA - emtricitabinetenofovir disoproxil fumarate
tab 167-250 mg
2
•
•
Limited Distribution
SUSTIVA - efavirenz cap 200
mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
•
RIBASPHERE RIBAPAK ribavirin tab 200 mg &
ribavirin tab 400 mg dose
pack
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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10
•
VIREAD - tenofovir disoproxil
fumarate tab 200 mg
2
•
VIREAD - tenofovir disoproxil
fumarate tab 250 mg
2
valacyclovir hcl tab 500 mg
(Valtrex)
1
•
1
VIREAD - tenofovir disoproxil
fumarate tab 300 mg
2
valacyclovir hcl tab 1 gm
(Valtrex)
•
ZEPATIER - elbasvirgrazoprevir tab 50-100 mg
3
VALCYTE - valganciclovir hcl
for soln 50 mg/ml (base
equiv)
2
3
•
valganciclovir hcl for soln
50 mg/ml (base equiv)
(Valcyte)
1
ZERIT - stavudine for oral soln
1 mg/ml
ZIAGEN - abacavir sulfate soln
20 mg/ml (base equiv)
2
•
valganciclovir hcl tab
450 mg (base equivalent)
(Valcyte)
1
zidovudine cap 100 mg
(Retrovir)
1
•
1
•
VIDEX - didanosine for soln 2
gm
2
•
zidovudine syrup 10 mg/ml
(Retrovir)
zidovudine tab 300 mg
1
•
VIDEX - didanosine for soln 4
gm
2
•
VIEKIRA PAK - ombitasparitapre-riton & dasab tab
pak 12.5-75-50 & 250 mg
3
VIEKIRA XR - dasab-ombitparitap-riton tab sr 24hr
200-8.33-50-33.33 mg
3
VIRACEPT - nelfinavir
mesylate tab 250 mg
3
•
VIRACEPT - nelfinavir
mesylate tab 625 mg
3
•
VIRAMUNE - nevirapine susp
50 mg/5ml
2
•
VIRAZOLE - ribavirin for inhal
soln 6 gm
3
VIREAD - tenofovir disoproxil
fumarate oral powder 40 mg/
gm
2
TYBOST - cobicistat tab 150
mg
3
•
ANTIMALARIALS
•
•
•
•
•
atovaquone-proguanil hcl
tab 62.5-25 mg (Malarone)
atovaquone-proguanil hcl
tab 250-100 mg (Malarone)
•
1
1
CHLOROQUINE
PHOSPHATE - chloroquine
phosphate tab 250 mg
1
chloroquine phosphate tab
500 mg (Aralen)
1
COARTEM - artemetherlumefantrine tab 20-120 mg
3
DARAPRIM - pyrimethamine
tab 25 mg
2
hydroxychloroquine sulfate
tab 200 mg (Plaquenil)
1
mefloquine hcl tab 250 mg
•
Limited Distribution
2
2
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
Drug Name
VIREAD - tenofovir disoproxil
fumarate tab 150 mg
TRUVADA - emtricitabinetenofovir disoproxil fumarate
tab 200-300 mg
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
•
•
1
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11
PRIMAQUINE PHOSPHATE primaquine phosphate tab
26.3 mg
2
quinine sulfate cap 324 mg
(Qualaquin)
1
ANTHELMINTICS
linezolid for susp
100 mg/5ml (Zyvox)
linezolid tab 600 mg (Zyvox)
1
metronidazole tab 250 mg
(Flagyl)
1
2
metronidazole tab 500 mg
(Flagyl)
1
BILTRICIDE - praziquantel tab
600 mg
NEBUPENT - pentamidine
isethionate for nebulization
soln 300 mg
3
EMVERM - mebendazole chew
tab 100 mg
3
ivermectin tab 3 mg
(Stromectol)
1
PRIMSOL - trimethoprim hcl
oral soln 50 mg/5ml (base
equiv)
3
•
SIVEXTRO - tedizolid
phosphate tab 200 mg
3
•
sulfamethoxazoletrimethoprim susp
200-40 mg/5ml
1
dapsone tab 100 mg
IMPAVIDO - miltefosine cap 50
mg
1
2
•
•
sulfamethoxazoletrimethoprim tab
800-160 mg (Bactrim ds)
Limited Distribution
•
ACA
1
2
•
Dispensing Limits
•
metronidazole cap 375 mg
(Flagyl)
sulfamethoxazoletrimethoprim tab
400-80 mg (Bactrim)
Step Therapy
1
ALBENZA - albendazole tab
200 mg
ANTI-INFECTIVE AGENTS - MISC.
ALINIA - nitazoxanide for susp 3
100 mg/5ml
3
ALINIA - nitazoxanide tab 500
mg
1
atovaquone susp
750 mg/5ml (Mepron)
3
CAYSTON - aztreonam lysine
for inhal soln 75 mg (base
equivalent)
1
clindamycin hcl cap 75 mg
(Cleocin)
1
clindamycin hcl cap 150 mg
(Cleocin)
1
clindamycin hcl cap 300 mg
(Cleocin)
1
clindamycin palmitate hcl
for soln 75 mg/5ml (base
equiv) (Cleocin pediatric gr)
1
dapsone tab 25 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
tinidazole tab 250 mg
(Tindamax)
1
tinidazole tab 500 mg
(Tindamax)
1
trimethoprim tab 100 mg
1
vancomycin hcl cap 125 mg
(Vancocin hcl)
1
vancomycin hcl cap 250 mg
(Vancocin hcl)
1
XIFAXAN - rifaximin tab 200
mg
3
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
12
XIFAXAN - rifaximin tab 550
mg
2
BIOLOGICALS
VACCINES
FLUARIX QUADRIVALENT
2014 - influenza virus vac
split quadrivalent susp pref
syr 0.5ml
A
•
FLUARIX QUADRIVALENT
2015 - influenza virus vac
split quadrivalent susp pref
syr 0.5ml
A
•
A
•
AFLURIA PF 2014-2015 influenza virus vaccine split
pf susp pref syringe 0.5 ml
A
•
AFLURIA PF 2015-2016 influenza virus vaccine split
pf susp pref syringe 0.5 ml
A
•
AFLURIA PF 2016-2017 influenza virus vaccine split
pf susp pref syringe 0.5 ml
A
•
FLUARIX QUADRIVALENT
2016 - influenza virus vac
split quadrivalent susp pref
syr 0.5ml
A
•
AFLURIA QUADRIVALENT
2016 - influenza virus vac
split quadrivalent susp pref
syr 0.5ml
A
•
FLUARIX 2014-2015 influenza virus vaccine split
pf susp pref syringe 0.5 ml
A
•
AFLURIA 2015-2016 influenza virus vaccine split
im susp
A
•
FLUBLOK 2014-2015 influenza virus vac
recombinant hemagglutinin
(ha) inj
A
•
AFLURIA 2016-2017 influenza virus vaccine split
im susp
A
FLUBLOK 2015-2016 influenza virus vac
recombinant hemagglutinin
(ha) inj
•
•
ENGERIX-B - hepatitis b
vaccine (recombinant) susp
20 mcg/ml
A
•
FLUBLOK 2016-2017 influenza virus vac
recombinant hemagglutinin
(ha) inj
A
ENGERIX-B - hepatitis b
vaccine (recombinant) susp
10 mcg/0.5ml
A
A
•
ENGERIX-B - hepatitis b
vaccine (recombinant) 10
mcg/0.5ml
A
•
FLUCELVAX QUADRIVALENT
20 - influenza vac tiss-cult
subunt quad susp pref syr
0.5 ml
A
•
ENGERIX-B - hepatitis b
vaccine (recombinant) 20
mcg/ml
A
FLUCELVAX 2014-2015 influenza virus vac tiss-cult
subunit susp pref syr 0.5 ml
A
•
FLUAD 2016-2017 - influenza
vac type a&b surface ant adj
susp pref syr 0.5 ml
A
FLUCELVAX 2015-2016 influenza virus vac tiss-cult
subunit susp pref syr 0.5 ml
•
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
13
FLUZONE HIGH-DOSE PF
2015 - influenza virus vac
split high-dose pf susp pref
syr 0.5ml
A
•
FLUZONE HIGH-DOSE PF
2016 - influenza virus vac
split high-dose pf susp pref
syr 0.5ml
A
•
FLULAVAL 2014-2015 influenza virus vaccine split
im susp
A
•
FLUZONE INTRADERMAL
QUADR - influenza virus vac
split quad intradermal pen 9
mcg/strain
A
•
FLUMIST QUADRIVALENT influenza virus vaccine live
quadrivalent intranasal susp
A
•
FLUZONE PF 2014-2015 influenza virus vaccine split
pf susp pref syringe 0.5 ml
A
•
FLUVIRIN PF 2014-2015 influenza virus vac types a &
b pf susp prefilled syr 0.5 ml
A
•
FLUZONE QUADRIVALENT
2014 - influenza virus vac
split quadrivalent susp pref
syr 0.25 ml
A
FLUVIRIN 2014-2015 influenza virus vaccine types
a & b surface antigen im
susp
A
•
•
FLUZONE QUADRIVALENT
2014 - influenza virus vac
split quadrivalent susp pref
syr 0.5ml
A
•
FLUVIRIN 2015-2016 influenza vac type a&b
surface antigen susp pref syr
0.5 ml
A
•
FLUZONE QUADRIVALENT
2014 - influenza virus
vaccine split quadrivalent im
inj
A
•
FLUVIRIN 2015-2016 influenza virus vaccine types
a & b surface antigen im
susp
A
•
FLUZONE QUADRIVALENT
2014 - influenza virus
vaccine split quadrivalent inj
0.5 ml
A
•
FLUVIRIN 2016-2017 influenza vac type a&b
surface antigen susp pref syr
0.5 ml
A
•
FLUZONE QUADRIVALENT
2015 - influenza virus vac
split quadrivalent susp pref
syr 0.25 ml
A
•
FLUVIRIN 2016-2017 influenza virus vaccine types
a & b surface antigen im
susp
A
•
FLUZONE QUADRIVALENT
2015 - influenza virus vac
split quadrivalent susp pref
syr 0.5ml
A
•
FLUZONE HIGH-DOSE PF
2014 - influenza virus vac
split high-dose pf susp pref
syr 0.5ml
A
•
Limited Distribution
•
ACA
A
Dispensing Limits
FLULAVAL QUADRIVALENT
201 - influenza virus vaccine
split quadrivalent im inj
Step Therapy
•
Prior Authorization
A
Drug Name
Drug Tier
FLULAVAL QUADRIVALENT
201 - influenza virus vac split
quadrivalent susp pref syr
0.5ml
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
14
MEDICAL PROVIDER
SINGLE U - influenza virus
vac types a & b pf pref
syringe kit 0.5 ml
A
•
MEDICAL PROVIDER
SINGLE U - influenza virus
vaccine split pf susp pref syr
kit 0.5 ml
A
•
FLUZONE QUADRIVALENT
2016 - influenza virus vac
split quadrivalent susp pref
syr 0.25 ml
A
•
PNEUMOVAX 23 pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml
A
•
FLUZONE QUADRIVALENT
2016 - influenza virus vac
split quadrivalent susp pref
syr 0.5ml
A
•
PNEUMOVAX 23/1 DOSE pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml
A
•
PNEUMOVAX 23/5 DOSE pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml
A
•
FLUZONE QUADRIVALENT
2016 - influenza virus
vaccine split quadrivalent im
inj
A
PREVNAR 13 - pneumococcal
13-valent conjugate vaccine
inj
A
•
FLUZONE QUADRIVALENT
2016 - influenza virus
vaccine split quadrivalent inj
0.5 ml
A
RABAVERT - rabies vaccine,
pcec for inj
A
•
A
•
•
RECOMBIVAX HB - hepatitis b
vaccine (recombinant) susp
5 mcg/0.5ml
FLUZONE SPLIT 2014-2015 influenza virus vaccine split
im susp
A
A
•
•
RECOMBIVAX HB - hepatitis b
vaccine (recombinant) susp
10 mcg/ml
FLUZONE SPLIT 2015-2016 influenza virus vaccine split
im susp
A
A
•
A
•
RECOMBIVAX HB - hepatitis b
vaccine (recombinant) susp
40 mcg/ml
IMOVAX RABIES (H.D.C.V.) rabies virus vaccine, hdc inj
MEDICAL PROVIDER EZ FLU
S - influenza virus vac types
a & b pf pref syringe kit 0.5
ml
A
•
VIVOTIF - typhoid vaccine cap
delayed release
3
3
MEDICAL PROVIDER
SINGLE U - influenza virus
vac split quad inj prefilled syr
kit 0.25 ml
A
ZOSTAVAX - zoster vaccine
live for subcutaneous susp
19400 unit/0.65ml
•
•
•
Limited Distribution
•
ACA
A
Dispensing Limits
FLUZONE QUADRIVALENT
2015 - influenza virus
vaccine split quadrivalent inj
0.5 ml
Step Therapy
•
Prior Authorization
A
Drug Name
Drug Tier
FLUZONE QUADRIVALENT
2015 - influenza virus
vaccine split quadrivalent im
inj
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
TOXOIDS
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
15
DAPTACEL - diph, acellular
pert & tet tox inj 15 lf-10
mcg-5 lf/0.5ml
Limited Distribution
•
ACA
A
Dispensing Limits
BOOSTRIX - tet tox-diph-acell
pertuss ad inj 5-2.5-18.5 lf-lfmcg/0.5ml
Step Therapy
•
Prior Authorization
A
Drug Name
Drug Tier
ADACEL - tet tox-diph-acell
pertuss ad inj 5-2-15.5 lf-lfmcg/0.5ml
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
HYQVIA - immun glob inj 5
gm/50ml-hyaluron inj 400
unt/2.5 ml kit
3
•
HYQVIA - immun glob inj 10
gm/100ml-hyaluron inj 800
unt/5 ml kit
3
•
•
3
HYQVIA - immun glob inj 20
gm/200ml-hyaluron inj 1600
unt/10 ml kit
3
•
•
DIPHTHERIA/TETANUS
TOXOID - diphtheria-tetanus
tox adsorbed (dt) im inj 25-5
unit/0.5ml
3
HYQVIA - immun glob inj 30
gm/300ml-hyaluron inj 2400
unt/15 ml kit
3
•
•
INFANRIX - diph, acellular pert
& tet tox inj 25 lf-58 mcg-10
lf/0.5ml
3
3
•
•
KINRIX - diph-tetanus tox adacell pert & polio virus, ipv
vac inj
3
GRASTEK - timothy grass
pollen allergen ext tab sl
2800 bau
3
•
•
•
PEDIARIX - diph-tetanus toxacell pert-hepatitis b-polio
ipv vac inj
3
ORALAIR - grass mixed pollen
ext tab sl 300 ir (index of
reactivity)
3
•
•
•
PENTACEL - diph-ac per-tet
tox ad-poliov-haemoph b
poly vac for im susp
3
ORALAIR ADULT SAMPLE
KIT - grass mixed pollen
ext tab sl 300 ir (index of
reactivity)
3
•
•
•
QUADRACEL - diph-tetanus
tox ad-acell pert & polio
virus, ipv vac inj
3
ORALAIR ADULT STARTER
PAC - grass mixed pollen
ext tab sl 300 ir (index of
reactivity)
3
•
•
•
TETANUS/DIPHTHERIA
TOXOID - tetanus-diphtheria
toxoids (td) inj 2-2 lf/0.5ml
3
ORALAIR CHILDREN/
ADOLESCE - grass mixed
pollen ext tab sl 100 ir (index
of reactivity)
3
TENIVAC - tetanus-diphtheria
toxoids (td) inj 5-2 lfu
ORALAIR CHILDREN/
ADOLESCE - grass mixed
pollen tab sl therpak 100 (3)
ir & 300 (6) ir
3
RAGWITEK - short ragweed
pollen allergen extract tab sl
12 amb a 1-u
3
PASSIVE IMMUNIZING AGENTS
3
HYQVIA - immun glob inj 2.5
gm/25ml-hyaluron inj 200
unt/1.25 ml kit
BIOLOGICALS MISC
•
•
•
•
•
•
ANTINEOPLASTIC AGENTS
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
16
ANTINEOPLASTICS
ACTIMMUNE - interferon
gamma-1b inj 100
mcg/0.5ml (2000000
unit/0.5ml)
2
AFINITOR - everolimus tab 2.5
mg
3
AFINITOR - everolimus tab 5
mg
•
•
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
CABOMETYX - cabozantinib
s-malate tab 20 mg (base
equivalent)
3
•
•
CABOMETYX - cabozantinib
s-malate tab 40 mg (base
equivalent)
3
•
•
•
3
•
•
•
•
•
•
3
•
•
•
CABOMETYX - cabozantinib
s-malate tab 60 mg (base
equivalent)
AFINITOR - everolimus tab 7.5
mg
3
•
•
•
capecitabine tab 150 mg
(Xeloda)
1
•
•
AFINITOR - everolimus tab 10
mg
3
•
•
•
capecitabine tab 500 mg
(Xeloda)
1
•
•
AFINITOR DISPERZ everolimus tab for oral susp
2 mg
3
•
•
•
CAPRELSA - vandetanib tab
100 mg
3
•
•
•
3
•
•
•
AFINITOR DISPERZ everolimus tab for oral susp
3 mg
3
CAPRELSA - vandetanib tab
300 mg
3
•
•
•
AFINITOR DISPERZ everolimus tab for oral susp
5 mg
3
COMETRIQ - cabozantinib smal cap 1 x 80 mg & 1 x 20
mg (100 dose) kit
3
•
•
•
ALECENSA - alectinib hcl cap
150 mg (base equivalent)
3
COMETRIQ - cabozantinib smal cap 1 x 80 mg & 3 x 20
mg (140 dose) kit
3
•
•
•
ALKERAN - melphalan tab 2
mg
2
COMETRIQ - cabozantinib smalate cap 3 x 20 mg (60
mg dose) kit
anastrozole tab 1 mg
(Arimidex)
1
3
•
•
•
bexarotene cap 75 mg
(Targretin)
1
COTELLIC - cobimetinib
fumarate tab 20 mg (base
equivalent)
3
bicalutamide tab 50 mg
(Casodex)
1
CYCLOPHOSPHAMIDE cyclophosphamide cap 25
mg
BOSULIF - bosutinib tab 100
mg
3
•
•
•
3
BOSULIF - bosutinib tab 500
mg
3
•
•
•
CYCLOPHOSPHAMIDE cyclophosphamide cap 50
mg
ELIGARD - leuprolide acetate
(3 month) for subcutaneous
inj kit 22.5mg
3
•
•
•
•
•
•
•
•
•
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
17
3
ERIVEDGE - vismodegib cap
150 mg
3
ETOPOSIDE - etoposide cap
50 mg
3
exemestane tab 25 mg
(Aromasin)
1
FARESTON - toremifene citrate 3
tab 60 mg (base equivalent)
3
FARYDAK - panobinostat
lactate cap 10 mg (base
equivalent)
3
FARYDAK - panobinostat
lactate cap 15 mg (base
equivalent)
3
FARYDAK - panobinostat
lactate cap 20 mg (base
equivalent)
1
flutamide cap 125 mg
•
•
•
•
•
•
•
•
•
•
•
•
•
GILOTRIF - afatinib dimaleate
tab 20 mg (base equivalent)
3
•
•
•
GILOTRIF - afatinib dimaleate
tab 30 mg (base equivalent)
3
•
•
•
GILOTRIF - afatinib dimaleate
tab 40 mg (base equivalent)
3
•
•
•
GLEEVEC - imatinib
mesylate tab 100 mg (base
equivalent)
3
•
•
•
Limited Distribution
EMCYT - estramustine
phosphate sodium cap 140
mg
•
•
ACA
3
Dispensing Limits
ELIGARD - leuprolide acetate
for subcutaneous inj kit 7.5
mg
•
•
Step Therapy
•
Prior Authorization
3
•
Drug Name
Drug Tier
ELIGARD - leuprolide acetate
(6 month) for subcutaneous
inj kit 45 mg
Limited Distribution
•
ACA
3
Dispensing Limits
ELIGARD - leuprolide acetate
(4 month) for subcutaneous
inj kit 30 mg
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
GLEEVEC - imatinib
mesylate tab 400 mg (base
equivalent)
3
GLEOSTINE - lomustine cap 5
mg
3
GLEOSTINE - lomustine cap
10 mg
3
GLEOSTINE - lomustine cap
40 mg
3
GLEOSTINE - lomustine cap
100 mg
3
HEXALEN - altretamine cap 50
mg
3
•
•
HYCAMTIN - topotecan hcl cap 3
0.25 mg (base equiv)
HYCAMTIN - topotecan hcl cap 3
1 mg (base equiv)
1
hydroxyurea cap 500 mg
(Hydrea)
3
IBRANCE - palbociclib cap 75
mg
IBRANCE - palbociclib cap 100 3
mg
IBRANCE - palbociclib cap 125 3
mg
ICLUSIG - ponatinib hcl tab 15 3
mg (base equiv)
ICLUSIG - ponatinib hcl tab 45 3
mg (base equiv)
1
imatinib mesylate tab
100 mg (base equivalent)
(Gleevec)
1
imatinib mesylate tab
400 mg (base equivalent)
(Gleevec)
IMBRUVICA - ibrutinib cap 140 3
mg
3
INLYTA - axitinib tab 1 mg
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
18
INTRON A - interferon alfa-2b
inj 10000000 unit/ml
3
•
•
INTRON A - interferon alfa-2b
for inj 10000000 unit
3
•
•
INTRON A - interferon alfa-2b
for inj 18000000 unit
3
•
•
INTRON A - interferon alfa-2b
for inj 50000000 unit
3
•
•
INTRON A W/DILUENT interferon alfa-2b for inj
10000000 unit
3
•
•
INTRON A W/DILUENT interferon alfa-2b for inj
18000000 unit
3
•
•
INTRON A W/DILUENT interferon alfa-2b for inj
50000000 unit
3
•
•
IRESSA - gefitinib tab 250 mg
3
JAKAFI - ruxolitinib phosphate
tab 5 mg (base equivalent)
3
•
•
•
•
•
•
JAKAFI - ruxolitinib phosphate
tab 10 mg (base equivalent)
3
•
•
JAKAFI - ruxolitinib phosphate
tab 15 mg (base equivalent)
3
•
JAKAFI - ruxolitinib phosphate
tab 20 mg (base equivalent)
3
JAKAFI - ruxolitinib phosphate
tab 25 mg (base equivalent)
3
LENVIMA 10 MG DAILY
DOSE - lenvatinib cap
therapy pack 10 mg (10 mg
daily dose)
3
Limited Distribution
3
LENVIMA 14 MG DAILY
DOSE - lenvatinib cap
therapy pack 10 & 4 mg (14
mg daily dose)
3
•
LENVIMA 18 MG DAILY
DOSE - lenvatinib cap
therapy pack 10 & 4 (2) mg
(18 mg daily dose)
3
•
•
•
LENVIMA 20 MG DAILY
DOSE - lenvatinib cap
therapy pack 10 (2) mg (20
mg daily dose)
3
•
•
•
LENVIMA 24 MG DAILY
DOSE - lenvatinib cap
therapy pack 10 (2) & 4 mg
(24 mg daily dose)
3
•
•
•
LENVIMA 8 MG DAILY DOSE - 3
lenvatinib cap therapy pack
4 (2) mg (8 mg daily dose)
letrozole tab 2.5 mg (Femara) 1
•
•
•
LEUCOVORIN CALCIUM leucovorin calcium tab 10
mg
2
•
LEUCOVORIN CALCIUM leucovorin calcium tab 15
mg
2
•
•
leucovorin calcium tab 5 mg
1
•
•
•
•
•
•
•
•
•
leucovorin calcium tab
25 mg
•
ACA
•
•
Dispensing Limits
INTRON A - interferon alfa-2b
inj 6000000 unit/ml
•
•
Step Therapy
3
Prior Authorization
INLYTA - axitinib tab 5 mg
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
1
LEUKERAN - chlorambucil tab
2 mg
2
LONSURF - trifluridine-tipiracil
tab 15-6.14 mg
3
•
•
•
LONSURF - trifluridine-tipiracil
tab 20-8.19 mg
3
•
•
•
LYNPARZA - olaparib cap 50
mg
3
•
•
•
LYSODREN - mitotane tab 500
mg
3
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
19
MATULANE - procarbazine hcl
cap 50 mg
3
megestrol acetate susp
40 mg/ml (Megace oral)
megestrol acetate tab 20 mg
megestrol acetate tab 40 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
•
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
NILANDRON - nilutamide tab
150 mg
3
1
nilutamide tab 150 mg
(Nilandron)
1
1
NINLARO - ixazomib
citrate cap 2.3 mg (base
equivalent)
3
•
•
•
NINLARO - ixazomib citrate
cap 3 mg (base equivalent)
3
•
•
•
NINLARO - ixazomib citrate
cap 4 mg (base equivalent)
3
•
•
•
ODOMZO - sonidegib
phosphate cap 200 mg
(base equivalent)
3
•
•
•
POMALYST - pomalidomide
cap 1 mg
3
•
•
•
POMALYST - pomalidomide
cap 2 mg
3
•
•
•
1
MEKINIST - trametinib dimethyl 2
sulfoxide tab 0.5 mg (base
equivalent)
MEKINIST - trametinib dimethyl 2
sulfoxide tab 2 mg (base
equivalent)
1
mercaptopurine tab 50 mg
(Purinethol)
3
MESNEX - mesna tab 400 mg
•
•
•
•
•
•
METHOTREXATE SODIUM methotrexate sodium inj 250
mg/10ml (25 mg/ml)
3
methotrexate sodium for inj
1 gm
1
POMALYST - pomalidomide
cap 3 mg
3
•
•
•
1
POMALYST - pomalidomide
cap 4 mg
3
•
•
•
1
PURIXAN - mercaptopurine
susp 2000 mg/100ml (20
mg/ml)
3
RUBRACA - rucaparib
camsylate tab 200 mg (base
equivalent)
3
•
•
•
RUBRACA - rucaparib
camsylate tab 300 mg (base
equivalent)
3
•
•
•
3
1
SOLTAMOX - tamoxifen citrate
oral soln 10 mg/5ml (base
equivalent)
2
3
MYLERAN - busulfan tab 2 mg
SPRYCEL - dasatinib tab 20
mg
•
•
•
NEXAVAR - sorafenib
tosylate tab 200 mg (base
equivalent)
2
SPRYCEL - dasatinib tab 50
mg
3
•
•
•
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)
methotrexate sodium inj pf
1000 mg/40ml (25 mg/ml)
methotrexate sodium inj
50 mg/2ml (25 mg/ml)
methotrexate sodium tab
2.5 mg (base equiv)
1
1
1
1
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
20
3
•
•
•
SPRYCEL - dasatinib tab 100
mg
3
•
•
•
SPRYCEL - dasatinib tab 140
mg
3
•
•
•
STIVARGA - regorafenib tab 40 3
mg
SUTENT - sunitinib malate cap 2
12.5 mg (base equivalent)
SUTENT - sunitinib malate cap 2
25 mg (base equivalent)
SUTENT - sunitinib malate cap 2
37.5 mg (base equivalent)
SUTENT - sunitinib malate cap 2
50 mg (base equivalent)
2
SYLATRON - peginterferon
alfa-2b for inj kit 296 mcg
2
SYLATRON - peginterferon
alfa-2b for inj kit 444 mcg
2
SYLATRON - peginterferon
alfa-2b for inj kit 888 mcg
3
TABLOID - thioguanine tab 40
mg
2
TAFINLAR - dabrafenib
mesylate cap 50 mg (base
equivalent)
2
TAFINLAR - dabrafenib
mesylate cap 75 mg (base
equivalent)
3
TAGRISSO - osimertinib
mesylate tab 40 mg (base
equivalent)
3
TAGRISSO - osimertinib
mesylate tab 80 mg (base
equivalent)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
TARCEVA - erlotinib hcl tab
100 mg (base equivalent)
2
•
•
•
TARCEVA - erlotinib hcl tab
150 mg (base equivalent)
2
•
•
•
•
•
•
•
•
•
•
TASIGNA - nilotinib hcl cap 150 2
mg (base equivalent)
TASIGNA - nilotinib hcl cap 200 2
mg (base equivalent)
1
temozolomide cap 5 mg
(Temodar)
1
temozolomide cap 20 mg
(Temodar)
1
temozolomide cap 100 mg
(Temodar)
1
temozolomide cap 140 mg
(Temodar)
1
temozolomide cap 180 mg
(Temodar)
1
temozolomide cap 250 mg
(Temodar)
1
tretinoin cap 10 mg
3
•
TREXALL - methotrexate
sodium tab 5 mg (base
equiv)
3
•
TREXALL - methotrexate
sodium tab 7.5 mg (base
equiv)
3
•
TREXALL - methotrexate
sodium tab 10 mg (base
equiv)
•
•
•
•
•
•
•
•
•
•
•
•
•
1
2
•
•
•
TARCEVA - erlotinib hcl tab 25
mg (base equivalent)
•
•
tamoxifen citrate tab 20 mg
(base equivalent)
1
Limited Distribution
SPRYCEL - dasatinib tab 80
mg
tamoxifen citrate tab 10 mg
(base equivalent)
ACA
•
Dispensing Limits
•
Step Therapy
3
Prior Authorization
SPRYCEL - dasatinib tab 70
mg
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
•
•
•
•
•
•
•
•
•
•
•
•
•
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21
TREXALL - methotrexate
sodium tab 15 mg (base
equiv)
3
TYKERB - lapatinib ditosylate
tab 250 mg (base equiv)
3
VOTRIENT - pazopanib hcl tab
200 mg (base equiv)
2
•
XALKORI - crizotinib cap 200
mg
2
DEXAMETHASONE dexamethasone tab 2 mg
3
•
dexamethasone elixir
0.5 mg/5ml
1
•
•
3
•
•
•
DEXAMETHASONE
INTENSOL - dexamethasone
conc 1 mg/ml
dexamethasone tab 0.5 mg
1
XALKORI - crizotinib cap 250
mg
2
•
•
•
XTANDI - enzalutamide cap 40
mg
3
•
•
•
dexamethasone tab 4 mg
ZELBORAF - vemurafenib tab
240 mg
2
•
•
•
fludrocortisone acetate tab
0.1 mg
ZOLINZA - vorinostat cap 100
mg
3
•
•
•
hydrocortisone tab 5 mg
(Cortef)
1
ZYDELIG - idelalisib tab 100
mg
3
•
•
•
hydrocortisone tab 10 mg
(Cortef)
1
ZYDELIG - idelalisib tab 150
mg
3
•
•
•
hydrocortisone tab 20 mg
(Cortef)
1
ZYKADIA - ceritinib cap 150
mg
3
•
•
•
3
ZYTIGA - abiraterone acetate
tab 250 mg
2
•
•
•
INTERARTICULAR JOINT
KIT - triamcinolone inj 40
mg/ml & lidocaine 1% &
ammonia inh kit
JTT PHYSICIANS KIT triamcinolone inj 40 mg/ml &
lidocaine 1% & ammonia inh
kit
3
MEDROL - methylprednisolone
tab 2 mg
3
methylprednisolone tab
therapy pack 4 mg (21)
(Medrol dosepak)
1
methylprednisolone tab
4 mg (Medrol)
1
•
ENDOCRINE AND METABOLIC DRUGS
CORTICOSTEROIDS
budesonide delayed
release particles cap 3 mg
(Entocort ec)
1
CORTISONE ACETATE cortisone acetate tab 25 mg
2
DEXAMETHASONE dexamethasone soln 0.5
mg/5ml
3
DEXAMETHASONE dexamethasone tab 1 mg
3
•
dexamethasone tab 0.75 mg
dexamethasone tab 1.5 mg
dexamethasone tab 6 mg
methylprednisolone tab
8 mg (Medrol)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
1
1
1
1
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22
methylprednisolone tab
16 mg (Medrol)
methylprednisolone tab
32 mg (Medrol)
1
1
PREDNISOLONE SODIUM
PHOSP - prednisolone
sodium phosphate oral soln
25 mg/5ml (base eq)
3
1
MILLIPRED - prednisolone
sod phosphate oral soln 10
mg/5ml (base equiv)
3
prednisolone syrup
15 mg/5ml (usp solution
equivalent) (Prelone)
MILLIPRED - prednisolone tab
5 mg
3
PREDNISONE - prednisone
oral soln 5 mg/5ml
3
MILLIPRED DP - prednisolone
tab therapy pack 5 mg (21)
3
PREDNISONE - prednisone
tab therapy pack 5 mg (21)
3
MILLIPRED DP - prednisolone
tab therapy pack 5 mg (48)
3
PREDNISONE - prednisone
tab therapy pack 5 mg (48)
3
PREDNISONE - prednisone
tab therapy pack 10 mg (21)
3
PREDNISONE - prednisone
tab therapy pack 10 mg (48)
3
PREDNISONE - prednisone
tab 50 mg
3
PREDNISONE INTENSOL prednisone conc 5 mg/ml
3
prednisone tab 1 mg
1
3
PHYSICIANS EZ USE JOINT
T - triamcinolone inj 40 mg/ml
& lidocaine 1% & ammonia
inh kit
1
prednisolone sod phos
orally disintegr tab 10 mg
(base eq) (Orapred odt)
1
prednisolone sod phos
orally disintegr tab 15 mg
(base eq) (Orapred odt)
1
prednisolone sod phos
orally disintegr tab 30 mg
(base eq) (Orapred odt)
1
prednisolone sod phosph
oral soln 6.7 mg/5ml
(5 mg/5ml base)
(Pediapred)
prednisolone sod phosphate 1
oral soln 15 mg/5ml (base
equiv)
prednisolone sod phosphate 1
oral soln 10 mg/5ml (base
equiv) (Millipred)
prednisolone sod phosphate 1
oral soln 20 mg/5ml (base
equiv) (Veripred 20)
prednisone tab 2.5 mg
prednisone tab 5 mg
prednisone tab 10 mg
prednisone tab 20 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1
1
1
1
UCERIS - budesonide tab sr
24hr 9 mg
3
VERIPRED 20 - prednisolone
sod phosphate oral soln 20
mg/5ml (base equiv)
3
ANDROGEN-ANABOLIC
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
ANADROL-50 - oxymetholone
tab 50 mg
3
•
ANDRODERM - testosterone
td patch 24hr 2 mg/24hr
3
•
•
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23
ANDROGEL - testosterone td
gel 40.5 mg/2.5gm (1.62%)
2
•
•
ANDROGEL PUMP testosterone td gel 20.25
mg/act (1.62%)
2
•
•
ANDROXY - fluoxymesterone
tab 10 mg
3
•
AXIRON - testosterone td soln
30 mg/act
2
•
danazol cap 50 mg
1
•
•
•
•
•
•
•
danazol cap 200 mg
1
1
•
testosterone td gel
25 mg/2.5gm (1%)
(Androgel)
1
•
•
testosterone td gel
50 mg/5gm (1%) (Androgel)
1
•
•
1
•
•
testosterone td gel 12.5 mg/
act (1%) (Androgel pump)
ESTROGENS
•
ALORA - estradiol td patch
biweekly 0.025 mg/24hr
3
•
ALORA - estradiol td patch
biweekly 0.05 mg/24hr
3
•
ALORA - estradiol td patch
biweekly 0.075 mg/24hr
3
•
ALORA - estradiol td patch
biweekly 0.1 mg/24hr
3
•
ANGELIQ - drospirenoneestradiol tab 0.25-0.5 mg
3
ANGELIQ - drospirenoneestradiol tab 0.5-1 mg
3
3
DEPO-TESTOSTERONE testosterone cypionate im inj
in oil 100 mg/ml
3
DEPO-TESTOSTERONE testosterone cypionate im inj
in oil 200 mg/ml
3
METHITEST methyltestosterone oral tab
10 mg
3
•
CLIMARA PRO - estradiollevonorgestrel td patch
weekly 0.045-0.015 mg/day
1
•
oxandrolone tab 2.5 mg
(Oxandrin)
1
•
COMBIPATCH - estradiolnorethindrone ace td pttw
0.05-0.14 mg/day
2
methyltestosterone cap
10 mg (Testred)
2
oxandrolone tab 10 mg
(Oxandrin)
1
•
COMBIPATCH - estradiolnorethindrone ace td pttw
0.05-0.25 mg/day
2
testosterone cypionate im
inj in oil 100 mg/ml (Depotestosterone)
1
DIVIGEL - estradiol td gel 0.25
mg/0.25gm (0.1%)
DIVIGEL - estradiol td gel 0.5
mg/0.5gm (0.1%)
2
testosterone cypionate im
inj in oil 200 mg/ml (Depotestosterone)
1
DIVIGEL - estradiol td gel 1
mg/gm (0.1%)
2
•
•
•
•
•
Limited Distribution
•
1
testosterone enanthate im
inj in oil 200 mg/ml
ACA
•
Dispensing Limits
2
Step Therapy
ANDROGEL - testosterone
td gel 20.25 mg/1.25gm
(1.62%)
danazol cap 100 mg
•
Prior Authorization
•
Drug Name
Drug Tier
3
Limited Distribution
ANDRODERM - testosterone
td patch 24hr 4 mg/24hr
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
24
DUAVEE - conjugated
estrogens-bazedoxifene tab
0.45-20 mg
3
ELESTRIN - estradiol gel
0.06% (0.52 mg/0.87 gm
metered-dose pump)
3
estradiol & norethindrone
acetate tab 0.5-0.1 mg
(Activella)
1
estradiol & norethindrone
acetate tab 1-0.5 mg
(Activella)
1
estradiol tab 2 mg (Estrace)
estradiol td patch weekly
0.1 mg/24hr (Climara)
estradiol valerate im in oil
20 mg/ml (Delestrogen)
estradiol valerate im in oil
40 mg/ml (Delestrogen)
•
1
•
1
1
ESTROGEL - estradiol gel
0.06% (0.75 mg/1.25 gm
metered-dose pump)
3
ESTROPIPATE - estropipate
tab 0.75 mg
3
ESTROPIPATE - estropipate
tab 1.5 mg
3
ESTROPIPATE - estropipate
tab 3 mg
3
estradiol td patch twice
weekly 0.025 mg/24hr
(Vivelle-dot)
1
•
1
•
EVAMIST - estradiol
transdermal spray 1.53 mg/
spray
3
estradiol td patch twice
weekly 0.0375 mg/24hr
(Vivelle-dot)
•
MENEST - esterified estrogens
tab 0.3 mg
3
estradiol td patch twice
weekly 0.05 mg/24hr
(Vivelle-dot)
1
3
estradiol td patch twice
weekly 0.075 mg/24hr
(Vivelle-dot)
1
•
MENEST - esterified estrogens
tab 0.625 mg
MENEST - esterified estrogens
tab 1.25 mg
3
estradiol td patch twice
weekly 0.1 mg/24hr
(Vivelle-dot)
1
•
MENOSTAR - estradiol td
patch weekly 14 mcg/24hr
3
•
3
•
estradiol td patch weekly
0.025 mg/24hr (Climara)
1
•
MINIVELLE - estradiol td patch
biweekly 0.0375 mg/24hr
3
•
1
•
MINIVELLE - estradiol td patch
biweekly 0.05 mg/24hr
MINIVELLE - estradiol td patch
biweekly 0.075 mg/24hr
3
•
1
•
MINIVELLE - estradiol td patch
biweekly 0.1 mg/24hr
3
•
1
•
MINIVELLE - estradiol td patch
twice weekly 0.025 mg/24hr
3
•
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)
Limited Distribution
1
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
Drug Name
estradiol td patch weekly
0.075 mg/24hr (Climara)
estradiol tab 0.5 mg (Estrace) 1
1
estradiol tab 1 mg (Estrace)
1
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
25
1
norethindrone acetateethinyl estradiol tab
0.5 mg-2.5 mcg (Femhrt low
dose)
1
norethindrone acetateethinyl estradiol tab
1 mg-5 mcg
3
PREFEST - estradiol tab 1
mg(15)/estrad-norgestimate
tab 1-0.09mg(15)
3
PREMARIN - estrogens,
conjugated tab 0.3 mg
3
PREMARIN - estrogens,
conjugated tab 0.45 mg
3
PREMARIN - estrogens,
conjugated tab 0.625 mg
3
PREMARIN - estrogens,
conjugated tab 0.9 mg
3
PREMARIN - estrogens,
conjugated tab 1.25 mg
3
PREMPHASE - conj est
0.625(14)/conj estmedroxypro ac tab
0.625-5mg(14)
3
PREMPRO - conjugated
estrogen-medroxyprogest
acetate tab 0.3-1.5 mg
3
PREMPRO - conjugated
estrogen-medroxyprogest
acetate tab 0.45-1.5 mg
3
PREMPRO - conjugated
estrogen-medroxyprogest
acetate tab 0.625-2.5 mg
3
PREMPRO - conjugated
estrogen-medroxyprogest
acetate tab 0.625-5 mg
CONTRACEPTIVES
BEYAZ - drospirenone-ethinyl
estrad-levomefolate tab
3-0.02-0.451 mg
3
DEPO-PROVERA
CONTRACEPTIV medroxyprogesterone
acetate im susp prefilled syr
150 mg/ml
A
•
DEPO-PROVERA
CONTRACEPTIV medroxyprogesterone
acetate im susp 150 mg/ml
A
•
DEPO-SUBQ PROVERA
104 - medroxyprogesterone
acetate susp pref syr 104
mg/0.65ml
A
•
desogest-eth estrad
& eth estrad tab
0.15-0.02/0.01 mg(21/5)
(Mircette)
A
•
1
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg (Cyclessa)
1
desogestrel & ethinyl
estradiol tab
0.15 mg-30 mcg (Desogen)
1
drospirenone-ethinyl
estrad-levomefolate tab
3-0.02-0.451 mg (Beyaz)
1
drospirenone-ethinyl
estradiol tab 3-0.02 mg
(Yaz)
1
drospirenone-ethinyl
estradiol tab 3-0.03 mg
(Yasmin 28)
ELLA - ulipristal acetate tab 30 A
mg
1
ethynodiol diacetate &
ethinyl estradiol tab
1 mg-35 mcg
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
• •
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26
•
levonor-eth est tab
0.15-0.02/0.025/0.03 mg
&eth est 0.01 mg
(Quartette)
1
levonorg-eth est tab
0.1-0.02mg(84) & eth
est tab 0.01mg(7)
(Loseasonique)
A
levonorg-eth est tab
0.15-0.03mg(84) & eth est
tab 0.01mg(7) (Seasonique)
1
levonorgestrel & ethinyl
estradiol (91-day) tab
0.15-0.03 mg
levonorgestrel &
ethinyl estradiol tab
0.1 mg-20 mcg
levonorgestrel &
ethinyl estradiol tab
0.15 mg-30 mcg
levonorgestrel tab 1.5 mg
(Plan b one-step)
•
•
•
A
1
1
1
1
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mgmcg
1
levonorgestrel-ethinyl
estradiol (continuous) tab
90-20 mcg
•
LO LOESTRIN FE - norethineth estradiol-fe tab 1 mg-10
mcg (24)/10 mcg (2)
3
medroxyprogesterone
acetate im susp prefilled
syr 150 mg/ml (Depoprovera contrac)
A
•
medroxyprogesterone
acetate im susp 150 mg/ml
(Depo-provera contrac)
A
•
MINASTRIN 24 FE norethindrone ace-eth
estradiol-fe chew tab 1
mg-20 mcg (24)
3
•
NATAZIA - estradiol valeratedienogest tab 3 mg /2-2
mg/2-3 mg/1 mg
3
•
NECON 1/50-28 norethindrone & mestranol
tab 1 mg-50 mcg
3
•
NECON 10/11-28 norethindrone-eth estradiol
tab 0.5-35/1-35 mg-mcg
(10/11)
3
•
norethindrone &
ethinyl estradiol tab
0.4 mg-35 mcg (Ovcon-35)
1
norethindrone &
ethinyl estradiol
tab 0.5 mg-35 mcg
(Brevicon-28)
1
norethindrone & ethinyl
estradiol tab 1 mg-35 mcg
(Norinyl 1+35)
1
norethindrone & ethinyl
estradiol-fe chew tab
0.4 mg-35 mcg (Femcon fe)
A
Limited Distribution
3
•
ACA
GENERESS FE norethindrone & ethinyl
estradiol-fe chew tab 0.8
mg-25 mcg
Dispensing Limits
•
Step Therapy
3
Prior Authorization
FALESSA - levonorgest-eth
estrad tab 0.1 mg-20 mcg &
fa tab 1 mg kit
Drug Name
Drug Tier
•
Limited Distribution
1
ethynodiol diacetate &
ethinyl estradiol tab
1 mg-50 mcg (Zovia 1/50e)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
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27
norethindrone & ethinyl
estradiol-fe chew tab
0.8 mg-25 mcg (Generess
fe)
1
norgestimate &
ethinyl estradiol tab
0.25 mg-35 mcg (Orthocyclen)
norethindrone acethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg
(Estrostep fe)
1
norethindrone ace & ethinyl
estradiol tab 1 mg-20 mcg
(Loestrin 1/20-21)
1
norethindrone ace &
ethinyl estradiol tab
1.5 mg-30 mcg (Loestrin
1.5/30-21)
1
norethindrone ace &
ethinyl estradiol-fe tab
1 mg-20 mcg (Loestrin fe
1/20)
A
norethindrone ace &
ethinyl estradiol-fe tab
1.5 mg-30 mcg (Loestrin fe
1.5/30)
1
1
norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mgmcg (Ortho tri-cyclen lo)
A
norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mgmcg (Ortho tri-cyclen)
1
norgestrel & ethinyl
estradiol tab
0.3 mg-30 mcg
A
NUVARING - etonogestrelethinyl estradiol va ring
0.120-0.015 mg/24hr
3
OGESTREL - norgestrel &
ethinyl estradiol tab 0.5
mg-50 mcg
3
ORTHO TRI-CYCLEN LO norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25
mg-mcg
A
PARAGARD INTRAUTERINE
COP - copper iud
QUARTETTE - levonor-eth est 3
tab 0.15-0.02/0.025/0.03 mg
&eth est 0.01 mg
3
SAFYRAL - drospirenoneethinyl estrad-levomefolate
tab 3-0.03-0.451 mg
A
XULANE - norelgestrominethinyl estradiol td ptwk
150-35 mcg/24hr
1
norethindrone ace-eth
estradiol-fe chew tab
1 mg-20 mcg (24) (Minastrin
24 fe)
1
norethindrone aceethinyl estradiol-fe tab
1 mg-20 mcg (24) (Lomedia
24 fe)
A
norethindrone tab 0.35 mg
(Nor-qd)
1
norethindrone-eth estradiol
tab 0.5-35/0.75-35/1-35 mgmcg (Ortho-novum 7/7/7)
1
norethindrone-eth estradiol
tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28)
•
•
•
PROGESTINS
medroxyprogesterone
acetate tab 2.5 mg
(Provera)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
•
• •
•
•
• •
•
•
• •
1
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28
medroxyprogesterone
acetate tab 5 mg (Provera)
1
1
medroxyprogesterone
acetate tab 10 mg (Provera)
1
megestrol acetate susp
625 mg/5ml (Megace es)
1
norethindrone acetate tab
5 mg (Aygestin)
1
progesterone im in oil
50 mg/ml
1
progesterone micronized
cap 100 mg (Prometrium)
1
progesterone micronized
cap 200 mg (Prometrium)
ANTIDIABETICS
3
•
ALOGLIPTIN/METFORMIN
HCL - alogliptin-metformin
hcl tab 12.5-1000 mg
3
•
ALOGLIPTIN/
PIOGLITAZONE - alogliptinpioglitazone tab 12.5-15 mg
3
•
ALOGLIPTIN/
PIOGLITAZONE - alogliptinpioglitazone tab 12.5-30 mg
3
•
ALOGLIPTIN/
PIOGLITAZONE - alogliptinpioglitazone tab 12.5-45 mg
3
•
ALOGLIPTIN/
PIOGLITAZONE - alogliptinpioglitazone tab 25-15 mg
3
•
ALOGLIPTIN/
PIOGLITAZONE - alogliptinpioglitazone tab 25-30 mg
3
•
3
•
acarbose tab 25 mg
(Precose)
1
acarbose tab 50 mg
(Precose)
1
acarbose tab 100 mg
(Precose)
1
ACTOPLUS MET XR pioglitazone hcl-metformin
hcl tab sr 24hr 15-1000 mg
3
ALOGLIPTIN/
PIOGLITAZONE - alogliptinpioglitazone tab 25-45 mg
3
ACTOPLUS MET XR pioglitazone hcl-metformin
hcl tab sr 24hr 30-1000 mg
3
AVANDIA - rosiglitazone
maleate tab 2 mg (base
equiv)
3
ALOGLIPTIN - alogliptin
benzoate tab 6.25 mg (base
equiv)
3
AVANDIA - rosiglitazone
maleate tab 4 mg (base
equiv)
3
• •
ALOGLIPTIN - alogliptin
benzoate tab 12.5 mg (base
equiv)
3
BYDUREON - exenatide for inj
extended release susp 2 mg
3
• •
ALOGLIPTIN - alogliptin
benzoate tab 25 mg (base
equiv)
3
BYDUREON PEN - exenatide
extended release for susp
pen-injector 2 mg
BYETTA - exenatide soln peninjector 5 mcg/0.02ml
3
• •
BYETTA - exenatide soln peninjector 10 mcg/0.04ml
3
• •
•
•
•
Limited Distribution
ALOGLIPTIN/METFORMIN
HCL - alogliptin-metformin
hcl tab 12.5-500 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
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CHLORPROPAMIDE chlorpropamide tab 100 mg
3
GLUCAGEN HYPOKIT glucagon hcl (rdna) for inj 1
mg (base equiv)
3
CHLORPROPAMIDE chlorpropamide tab 250 mg
3
GLUCAGON EMERGENCY
KIT - glucagon (rdna) for inj
kit 1 mg
2
CYCLOSET - bromocriptine
mesylate tab 0.8 mg (base
equivalent)
3
DEX4 QUICK DISSOLVE
GLUCO - glucose chew tab 4
gm
3
FARXIGA - dapagliflozin
propanediol tab 5 mg (base
equivalent)
3
•
FARXIGA - dapagliflozin
propanediol tab 10 mg (base
equivalent)
3
•
glimepiride tab 1 mg
(Amaryl)
1
glimepiride tab 2 mg
(Amaryl)
1
glimepiride tab 4 mg
(Amaryl)
1
glipizide tab sr 24hr 2.5 mg
(Glucotrol xl)
1
glyburide-metformin tab
1.25-250 mg (Glucovance)
glipizide tab sr 24hr 5 mg
(Glucotrol xl)
1
glyburide-metformin tab
2.5-500 mg (Glucovance)
glipizide tab sr 24hr 10 mg
(Glucotrol xl)
1
glyburide-metformin tab
5-500 mg (Glucovance)
glipizide tab 5 mg (Glucotrol)
1
GLUMETZA - metformin hcl tab 3
sr 24hr modified release 500
mg
3
GLUMETZA - metformin hcl
tab sr 24hr modified release
1000 mg
1
glyburide micronized tab
1.5 mg (Glynase)
1
glyburide micronized tab
3 mg (Glynase)
1
glyburide micronized tab
6 mg (Glynase)
1
glyburide tab 1.25 mg
glyburide tab 2.5 mg
glyburide tab 5 mg
•
•
•
•
1
1
1
1
GLYSET - miglitol tab 25 mg
3
GLYSET - miglitol tab 50 mg
3
GLYSET - miglitol tab 100 mg
3
1
glipizide-metformin hcl tab
2.5-250 mg
1
GLYXAMBI - empagliflozinlinagliptin tab 10-5 mg
3
•
1
GLYXAMBI - empagliflozinlinagliptin tab 25-5 mg
3
•
1
INVOKAMET - canagliflozinmetformin hcl tab 50-500 mg
2
•
glipizide-metformin hcl tab
5-500 mg
Limited Distribution
1
glipizide tab 10 mg
(Glucotrol)
glipizide-metformin hcl tab
2.5-500 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
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2
•
JANUVIA - sitagliptin
phosphate tab 50 mg (base
equiv)
2
•
INVOKAMET - canagliflozinmetformin hcl tab 150-1000
mg
2
•
JANUVIA - sitagliptin
phosphate tab 100 mg (base
equiv)
2
•
INVOKAMET XR canagliflozin-metformin hcl
tab sr 24hr 50-500 mg
2
•
JARDIANCE - empagliflozin
tab 10 mg
2
•
INVOKAMET XR canagliflozin-metformin hcl
tab sr 24hr 50-1000 mg
2
•
JARDIANCE - empagliflozin
tab 25 mg
2
•
3
•
•
JENTADUETO - linagliptinmetformin hcl tab 2.5-500
mg
INVOKAMET XR canagliflozin-metformin hcl
tab sr 24hr 150-500 mg
2
3
•
•
JENTADUETO - linagliptinmetformin hcl tab 2.5-850
mg
INVOKAMET XR canagliflozin-metformin hcl
tab sr 24hr 150-1000 mg
2
3
•
•
JENTADUETO - linagliptinmetformin hcl tab 2.5-1000
mg
INVOKANA - canagliflozin tab
100 mg
2
INVOKANA - canagliflozin tab
300 mg
2
JENTADUETO XR - linagliptinmetformin hcl tab sr 24hr
2.5-1000 mg
3
•
•
JANUMET - sitagliptinmetformin hcl tab 50-500 mg
2
•
JENTADUETO XR - linagliptinmetformin hcl tab sr 24hr
5-1000 mg
3
•
JANUMET - sitagliptinmetformin hcl tab 50-1000
mg
2
•
KAZANO - alogliptin-metformin
hcl tab 12.5-500 mg
3
•
•
JANUMET XR - sitagliptinmetformin hcl tab sr 24hr
50-500 mg
2
KAZANO - alogliptin-metformin
hcl tab 12.5-1000 mg
3
•
•
JANUMET XR - sitagliptinmetformin hcl tab sr 24hr
50-1000 mg
2
•
KOMBIGLYZE XR saxagliptin-metformin hcl tab
sr 24hr 2.5-1000 mg
2
•
JANUMET XR - sitagliptinmetformin hcl tab sr 24hr
100-1000 mg
2
•
KOMBIGLYZE XR saxagliptin-metformin hcl tab
sr 24hr 5-500 mg
2
•
•
Limited Distribution
JANUVIA - sitagliptin
phosphate tab 25 mg (base
equiv)
ACA
•
Dispensing Limits
2
Step Therapy
INVOKAMET - canagliflozinmetformin hcl tab 150-500
mg
Prior Authorization
•
Drug Name
Drug Tier
2
Limited Distribution
INVOKAMET - canagliflozinmetformin hcl tab 50-1000
mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
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KOMBIGLYZE XR saxagliptin-metformin hcl tab
sr 24hr 5-1000 mg
2
KORLYM - mifepristone tab
300 mg
3
metformin hcl tab sr 24hr
500 mg (Glucophage xr)
metformin hcl tab sr 24hr
750 mg (Glucophage xr)
3
ONGLYZA - saxagliptin hcl tab
2.5 mg (base equiv)
2
•
1
ONGLYZA - saxagliptin hcl tab
5 mg (base equiv)
2
•
1
OSENI - alogliptin-pioglitazone
tab 12.5-15 mg
3
•
•
•
•
•
1
•
OSENI - alogliptin-pioglitazone
tab 12.5-30 mg
3
•
•
•
OSENI - alogliptin-pioglitazone
tab 12.5-45 mg
3
metformin hcl tab sr
24hr osmotic 1000 mg
(Fortamet)
1
•
•
3
•
•
metformin hcl tab sr 24hr
modified release 500 mg
(Glumetza)
1
•
•
OSENI - alogliptin-pioglitazone
tab 25-15 mg
OSENI - alogliptin-pioglitazone
tab 25-30 mg
3
•
•
metformin hcl tab sr 24hr
modified release 1000 mg
(Glumetza)
1
•
•
OSENI - alogliptin-pioglitazone
tab 25-45 mg
3
•
•
1
metformin hcl tab 500 mg
(Glucophage)
1
pioglitazone hcl tab 15 mg
(base equiv) (Actos)
metformin hcl tab 850 mg
(Glucophage)
1
metformin hcl tab 1000 mg
(Glucophage)
1
miglitol tab 25 mg (Glyset)
1
metformin hcl tab sr 24hr
osmotic 500 mg (Fortamet)
miglitol tab 50 mg (Glyset)
miglitol tab 100 mg (Glyset)
pioglitazone hcl tab 30 mg
(base equiv) (Actos)
pioglitazone hcl tab 45 mg
(base equiv) (Actos)
1
1
nateglinide tab 60 mg
(Starlix)
1
nateglinide tab 120 mg
(Starlix)
1
NESINA - alogliptin benzoate
tab 6.25 mg (base equiv)
3
•
•
NESINA - alogliptin benzoate
tab 12.5 mg (base equiv)
3
•
•
Limited Distribution
•
NESINA - alogliptin benzoate
tab 25 mg (base equiv)
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
1
pioglitazone hcl-metformin
hcl tab 15-500 mg (Actoplus
met)
1
pioglitazone hcl-metformin
hcl tab 15-850 mg (Actoplus
met)
PROGLYCEM - diazoxide susp 3
50 mg/ml
1
repaglinide tab 0.5 mg
(Prandin)
1
repaglinide tab 1 mg
(Prandin)
1
repaglinide tab 2 mg
(Prandin)
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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3
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr
5-500 mg
3
•
REPAGLINIDE/METFORMIN
HYD - repaglinide-metformin
hcl tab 2-500 mg
3
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr
5-1000 mg
3
•
RIOMET - metformin hcl oral
soln 500 mg/5ml
3
3
•
SYNJARDY - empagliflozinmetformin hcl tab 5-500 mg
3
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr
10-500 mg
•
3
•
3
SYNJARDY - empagliflozinmetformin hcl tab 5-1000 mg
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr
10-1000 mg
SYNJARDY - empagliflozinmetformin hcl tab 12.5-500
mg
3
•
Rapid-Acting Insulins
SYNJARDY - empagliflozinmetformin hcl tab 12.5-1000
mg
3
•
TANZEUM - albiglutide for soln
pen-injector 30 mg
3
• •
TANZEUM - albiglutide for soln
pen-injector 50 mg
3
• •
TOLAZAMIDE - tolazamide tab
250 mg
3
TOLAZAMIDE - tolazamide tab
500 mg
3
TOLBUTAMIDE - tolbutamide
tab 500 mg
3
TRADJENTA - linagliptin tab 5
mg
3
•
TRULICITY - dulaglutide soln
pen-injector 0.75 mg/0.5ml
3
• •
TRULICITY - dulaglutide soln
pen-injector 1.5 mg/0.5ml
3
• •
VICTOZA - liraglutide soln peninjector 18 mg/3ml (6 mg/ml)
2
• •
WALGREENS GLUCOSE glucose chew tab 4 gm
3
•
APIDRA - insulin glulisine inj
100 unit/ml
3
•
•
APIDRA SOLOSTAR - insulin
glulisine soln pen-injector inj
100 unit/ml
3
•
•
HUMALOG - insulin lispro inj
100 unit/ml
3
•
•
HUMALOG - insulin lispro soln
cartridge 100 unit/ml
3
•
•
HUMALOG KWIKPEN - insulin
lispro soln pen-injector 100
unit/ml
3
•
•
HUMALOG KWIKPEN - insulin
lispro soln pen-injector 200
unit/ml
3
•
•
NOVOLOG - insulin aspart inj
100 unit/ml
1
•
NOVOLOG FLEXPEN - insulin
aspart soln pen-injector 100
unit/ml
1
•
NOVOLOG PENFILL - insulin
aspart soln cartridge 100
unit/ml
1
•
Limited Distribution
REPAGLINIDE/METFORMIN
HYD - repaglinide-metformin
hcl tab 1-500 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Short-Acting Insulins
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•
•
•
AFREZZA - insulin regular
(human) inhal powd 4 (30) &
8 (60) unit/cart
3
•
•
AFREZZA - insulin regular
(human) inhal powd 4 (60) &
8 (30) unit/cart
3
•
•
AFREZZA - insulin regular
(human) inhal powd 4 (90) &
8 (90) unit/cart
3
AFREZZA - insulin regular
(human) inhalation powder 4
unit/cartridge
3
HUMULIN R - insulin regular
(human) inj 100 unit/ml
3
HUMALOG MIX 75/25 - insulin
lispro prot & lispro inj 100
unit/ml (75-25)
3
•
•
HUMALOG MIX 75/25
KWIKPEN - insulin lispro prot
& lispro sus pen-inj 100 unit/
ml (75-25)
3
•
•
•
HUMULIN N - insulin nph
(human) (isophane) inj 100
unit/ml
3
•
•
•
•
HUMULIN N KWIKPEN insulin nph (human)
(isophane) susp pen-injector
100 unit/ml
3
•
•
•
•
HUMULIN 70/30 - insulin nph
isophane & regular human
inj 100 unit/ml (70-30)
3
•
•
HUMULIN 70/30 KWIKPEN insulin nph & regular susp
pen-inj 100 unit/ml (70-30)
3
•
•
NOVOLIN N - insulin nph
(human) (isophane) inj 100
unit/ml
1
•
NOVOLIN N RELION - insulin
nph (human) (isophane) inj
100 unit/ml
1
•
NOVOLIN 70/30 - insulin nph
isophane & regular human
inj 100 unit/ml (70-30)
1
•
NOVOLIN 70/30 RELION insulin nph isophane &
regular human inj 100 unit/
ml (70-30)
1
•
NOVOLOG MIX 70/30 - insulin
aspart prot & aspart (human)
inj 100 unit/ml (70-30)
1
•
•
3
HUMULIN R U-500
(CONCENTR - insulin regular
(human) inj 500 unit/ml
3
HUMULIN R U-500
KWIKPEN - insulin regular
(human) soln pen-injector
500 unit/ml
1
NOVOLIN R - insulin regular
(human) inj 100 unit/ml
1
NOVOLIN R RELION - insulin
regular (human) inj 100 unit/
ml
2
RELION R - insulin regular
(human) inj 100 unit/ml
Intermediate-Acting Insulins
HUMALOG MIX 50/50 - insulin
lispro protamine & lispro inj
100 unit/ml (50-50)
3
•
•
•
•
•
•
•
Limited Distribution
3
ACA
3
Dispensing Limits
AFREZZA - insulin regular
(human) inh powd 4 & 8 &
12 unit/cart (60)
Step Therapy
HUMALOG MIX 50/50
KWIKPEN - insulin lispro prot
& lispro sus pen-inj 100 unit/
ml (50-50)
•
•
Prior Authorization
•
Drug Name
Drug Tier
3
Limited Distribution
AFREZZA - insulin regular
(human) inh powd 8 (60) &
12 (30) unit/cart
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
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NOVOLOG MIX 70/30
PREFILL - insulin aspart prot
& aspart sus pen-inj 100
unit/ml (70-30)
Basal Insulins
1
levothyroxine sodium tab
50 mcg (Synthroid)
levothyroxine sodium tab
75 mcg (Synthroid)
LANTUS - insulin glargine inj
100 unit/ml
2
•
levothyroxine sodium tab
88 mcg (Synthroid)
LANTUS SOLOSTAR - insulin
glargine soln pen-injector
100 unit/ml
2
•
levothyroxine sodium tab
100 mcg (Synthroid)
LEVEMIR - insulin detemir inj
100 unit/ml
2
•
LEVEMIR FLEXTOUCH insulin detemir soln peninjector 100 unit/ml
2
•
TOUJEO SOLOSTAR - insulin
glargine soln pen-injector
300 unit/ml
2
•
TRESIBA FLEXTOUCH insulin degludec soln peninjector 100 unit/ml
2
•
TRESIBA FLEXTOUCH insulin degludec soln peninjector 200 unit/ml
2
•
THYROID AGENTS
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)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
1
1
1
1
1
1
1
1
1
1
1
ARMOUR THYROID - thyroid
tab 15 mg (1/4 grain)
3
liothyronine sodium tab
25 mcg (Cytomel)
ARMOUR THYROID - thyroid
tab 120 mg (2 grain)
3
liothyronine sodium tab
50 mcg (Cytomel)
ARMOUR THYROID - thyroid
tab 180 mg (3 grain)
3
methimazole tab 5 mg
(Tapazole)
1
ARMOUR THYROID - thyroid
tab 240 mg (4 grain)
3
methimazole tab 10 mg
(Tapazole)
1
ARMOUR THYROID - thyroid
tab 300 mg (5 grain)
3
NATURE-THROID - thyroid tab
16.25 mg
3
levothyroxine sodium tab
25 mcg (Synthroid)
1
NATURE-THROID - thyroid tab
32.5 mg
3
NATURE-THROID - thyroid tab
48.75 mg (3/4 grain)
3
1
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NATURE-THROID - thyroid tab
65 mg
3
SYNTHROID - levothyroxine
sodium tab 175 mcg
3
NATURE-THROID - thyroid tab
81.25 mg
3
SYNTHROID - levothyroxine
sodium tab 200 mcg
3
NATURE-THROID - thyroid tab
97.5 mg
3
SYNTHROID - levothyroxine
sodium tab 300 mcg
3
NATURE-THROID - thyroid tab
113.75 mg
3
thyroid tab 30 mg (1/2 grain)
(Armour thyroid)
1
NATURE-THROID - thyroid tab
130 mg
3
thyroid tab 60 mg (1 grain)
(Armour thyroid)
1
NATURE-THROID - thyroid tab
195 mg
3
1
NATURE-THROID - thyroid tab
260 mg
3
thyroid tab 90 mg (1
1/2 grain) (Armour thyroid)
NATURE-THROID - thyroid tab
325 mg (5 grain)
THYROLAR-1 - liotrix (t3-t4)
tab 60 mg (12.5-50 mcg)
3
3
THYROLAR-1/2 - liotrix (t3-t4)
tab 30 mg (6.25-25 mcg)
3
NATURE-THROID - thyroid tab
146.25 mg
3
THYROLAR-1/4 - liotrix (t3-t4)
tab 15 mg (3.1-12.5 mcg)
3
propylthiouracil tab 50 mg
1
3
SYNTHROID - levothyroxine
sodium tab 25 mcg
3
THYROLAR-2 - liotrix (t3-t4)
tab 120 mg (25-100 mcg)
3
SYNTHROID - levothyroxine
sodium tab 50 mcg
3
THYROLAR-3 - liotrix (t3-t4)
tab 180 mg (37.5-150 mcg)
3
SYNTHROID - levothyroxine
sodium tab 75 mcg
3
TIROSINT - levothyroxine
sodium cap 13 mcg
3
SYNTHROID - levothyroxine
sodium tab 88 mcg
3
TIROSINT - levothyroxine
sodium cap 25 mcg
3
SYNTHROID - levothyroxine
sodium tab 100 mcg
3
TIROSINT - levothyroxine
sodium cap 50 mcg
3
SYNTHROID - levothyroxine
sodium tab 112 mcg
3
TIROSINT - levothyroxine
sodium cap 75 mcg
3
SYNTHROID - levothyroxine
sodium tab 125 mcg
3
TIROSINT - levothyroxine
sodium cap 88 mcg
3
SYNTHROID - levothyroxine
sodium tab 137 mcg
3
TIROSINT - levothyroxine
sodium cap 100 mcg
3
SYNTHROID - levothyroxine
sodium tab 150 mcg
3
TIROSINT - levothyroxine
sodium cap 112 mcg
TIROSINT - levothyroxine
sodium cap 125 mcg
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
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TIROSINT - levothyroxine
sodium cap 137 mcg
3
PROSTIN E2 - dinoprostone
vaginal suppos 20 mg
TIROSINT - levothyroxine
sodium cap 150 mcg
3
WESTHROID - thyroid tab 32.5
mg
3
WESTHROID - thyroid tab 65
mg
3
WESTHROID - thyroid tab 97.5
mg
3
WESTHROID - thyroid tab 130
mg
3
WESTHROID - thyroid tab 195
mg
3
WP THYROID - thyroid tab
16.25 mg
3
WP THYROID - thyroid tab
32.5 mg
3
ENDOCRINE and METABOLIC AGENTS - MISC.
3
•
ALENDRONATE SODIUM alendronate sodium tab 40
mg
1
•
alendronate sodium tab
5 mg
1
•
alendronate sodium tab
10 mg
1
•
alendronate sodium tab
35 mg
1
•
alendronate sodium tab
70 mg (Fosamax)
3 •
BUPHENYL - sodium
phenylbutyrate tab 500 mg
1
cabergoline tab 0.5 mg
WP THYROID - thyroid tab
48.75 mg (3/4 grain)
3
WP THYROID - thyroid tab 65
mg
3
calcitonin (salmon)
nasal soln 200 unit/act
(Miacalcin)
1
3
calcitriol cap 0.25 mcg
(Rocaltrol)
1
WP THYROID - thyroid tab
81.25 mg
3
calcitriol cap 0.5 mcg
(Rocaltrol)
1
WP THYROID - thyroid tab
97.5 mg
3
calcitriol oral soln 1 mcg/ml
(Rocaltrol)
1
WP THYROID - thyroid tab
113.75 mg
3
CARBAGLU - carglumic acid
tab 200 mg
3
WP THYROID - thyroid tab 130
mg
3
desmopressin acetate inj
4 mcg/ml (Ddavp)
1
OXYTOCICS
CERVIDIL - dinoprostone
vaginal inserts 10 mg
3
desmopressin acetate nasal
soln 0.01% (refrigerated)
(Ddavp)
METHERGINE methylergonovine maleate
tab 0.2 mg
1
desmopressin acetate nasal
spray soln 0.01% (Ddavp)
PREPIDIL - dinoprostone
cervical gel 0.5 mg/3gm
3
desmopressin acetate
nasal spray soln 0.01%
(refrigerated)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
•
•
•
1
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Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
KUVAN - sapropterin
dihydrochloride powder
packet 500 mg
3
•
3
•
•
doxercalciferol cap 0.5 mcg
(Hectorol)
1
KUVAN - sapropterin
dihydrochloride soluble tab
100 mg
doxercalciferol cap 1 mcg
(Hectorol)
1
levocarnitine oral soln
1 gm/10ml (10%) (Carnitor)
1
doxercalciferol cap 2.5 mcg
(Hectorol)
1
levocarnitine tab 330 mg
(Carnitor)
1
EGRIFTA - tesamorelin acetate
for inj 1 mg (base equiv)
3
•
•
MYALEPT - metreleptin for
subcutaneous inj 11.3 mg
3
•
•
EGRIFTA - tesamorelin acetate
for inj 2 mg (base equiv)
3
•
•
1
•
•
ETIDRONATE DISODIUM etidronate disodium tab 200
mg
3
octreotide acetate inj
50 mcg/ml (0.05 mg/ml)
(Sandostatin)
1
•
•
FORTEO - teriparatide
(recombinant) inj 600
mcg/2.4ml
3
octreotide acetate inj
100 mcg/ml (0.1 mg/ml)
(Sandostatin)
1
•
•
FOSAMAX PLUS D alendronate sodiumcholecalciferol tab 70-2800
mg-unit
3
•
octreotide acetate inj
200 mcg/ml (0.2 mg/ml)
(Sandostatin)
octreotide acetate inj
500 mcg/ml (0.5 mg/ml)
(Sandostatin)
1
•
•
FOSAMAX PLUS D alendronate sodiumcholecalciferol tab 70-5600
mg-unit
3
•
octreotide acetate inj
1000 mcg/ml (1 mg/ml)
(Sandostatin)
1
•
•
2
•
•
H.P. ACTHAR - corticotropin inj
gel 80 unit/ml
3
OMNITROPE - somatropin for
inj 5.8 mg
•
•
ibandronate sodium tab
150 mg (base equivalent)
(Boniva)
1
OMNITROPE - somatropin inj 5 2
mg/1.5ml
2
OMNITROPE - somatropin inj
10 mg/1.5ml
ORFADIN - nitisinone cap 2 mg 2
•
•
•
•
•
•
•
•
desmopressin acetate tab
0.1 mg (Ddavp)
desmopressin acetate tab
0.2 mg (Ddavp)
1
1
INCRELEX - mecasermin inj 40 2
mg/4ml (10 mg/ml)
3
KUVAN - sapropterin
dihydrochloride powder
packet 100 mg
•
•
•
•
•
•
•
•
•
•
ORFADIN - nitisinone cap 5 mg 2
2
ORFADIN - nitisinone cap 10
mg
•
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•
paricalcitol cap 1 mcg
(Zemplar)
1
paricalcitol cap 2 mcg
(Zemplar)
1
paricalcitol cap 4 mcg
(Zemplar)
1
raloxifene hcl tab 60 mg
(Evista)
1
RAVICTI - glycerol
phenylbutyrate liquid 1.1 gm/
ml
3
risedronate sodium tab
delayed release 35 mg
(Atelvia)
1
risedronate sodium tab 5 mg
(Actonel)
1
risedronate sodium tab
30 mg (Actonel)
1
risedronate sodium tab
35 mg (Actonel)
risedronate sodium tab
150 mg (Actonel)
•
•
•
•
•
•
1
•
1
•
SAMSCA - tolvaptan tab 15 mg
3
SAMSCA - tolvaptan tab 30 mg
3
SENSIPAR - cinacalcet hcl tab
30 mg (base equiv)
2
SENSIPAR - cinacalcet hcl tab
60 mg (base equiv)
2
SENSIPAR - cinacalcet hcl tab
90 mg (base equiv)
2
SIGNIFOR - pasireotide
diaspartate inj 0.3 mg/ml
(base equiv)
3
•
•
•
•
•
•
•
•
Limited Distribution
2
ACA
ORFADIN - nitisinone susp 4
mg/ml
Dispensing Limits
•
Step Therapy
2
Prior Authorization
ORFADIN - nitisinone cap 20
mg
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
SIGNIFOR - pasireotide
diaspartate inj 0.6 mg/ml
(base equiv)
3
•
•
SIGNIFOR - pasireotide
diaspartate inj 0.9 mg/ml
(base equiv)
3
•
sodium phenylbutyrate oral
powder 3 gm/teaspoonful
(Buphenyl)
1
•
•
SOMAVERT - pegvisomant for
inj 10 mg (as protein)
3
•
•
SOMAVERT - pegvisomant for
inj 15 mg (as protein)
3
•
•
SOMAVERT - pegvisomant for
inj 20 mg (as protein)
3
•
•
SOMAVERT - pegvisomant for
inj 25 mg (as protein)
3
•
•
SOMAVERT - pegvisomant for
inj 30 mg (as protein)
3
•
•
STIMATE - desmopressin
acetate nasal soln 1.5 mg/ml
2
STRENSIQ - asfotase alfa
subcutaneous inj 18
mg/0.45ml
2
•
•
STRENSIQ - asfotase alfa
subcutaneous inj 28
mg/0.7ml
2
•
•
STRENSIQ - asfotase alfa
subcutaneous inj 40 mg/ml
2
•
•
STRENSIQ - asfotase alfa
subcutaneous inj 80
mg/0.8ml
2
•
•
SYNAREL - nafarelin acetate
nasal soln 2 mg/ml (200
mcg/act) (base eq)
3
•
CARDIOVASCULAR AGENTS
CARDIOTONICS
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DIGOXIN - digoxin oral soln
0.05 mg/ml
3
digoxin tab 125 mcg
(0.125 mg) (Lanoxin)
1
digoxin tab 250 mcg
(0.25 mg) (Lanoxin)
1
isosorbide mononitrate tab
10 mg
isosorbide mononitrate tab
20 mg
LANOXIN - digoxin tab 62.5
mcg (0.0625 mg)
3
NITRO-DUR - nitroglycerin td
patch 24hr 0.3 mg/hr
3
LANOXIN - digoxin tab 125
mcg (0.125 mg)
3
NITRO-DUR - nitroglycerin td
patch 24hr 0.8 mg/hr
3
LANOXIN - digoxin tab 187.5
mcg (0.1875 mg)
3
nitroglycerin cap cr 2.5 mg
1
LANOXIN - digoxin tab 250
mcg (0.25 mg)
3
3
3
3
nitroglycerin sl tab 0.3 mg
(Nitrostat)
1
ISORDIL TITRADOSE isosorbide dinitrate tab 40
mg
nitroglycerin sl tab 0.4 mg
(Nitrostat)
1
nitroglycerin sl tab 0.6 mg
(Nitrostat)
1
nitroglycerin td patch 24hr
0.1 mg/hr (Nitro-dur)
1
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)
Limited Distribution
1
DILATRATE SR - isosorbide
dinitrate cap cr 40 mg
ISOSORBIDE DINITRATE ER - 3
isosorbide dinitrate tab cr 40
mg
isosorbide dinitrate tab 5 mg 1
(Isordil titradose)
1
isosorbide dinitrate tab
10 mg
1
isosorbide dinitrate tab
20 mg
1
isosorbide dinitrate tab
30 mg
1
isosorbide mononitrate tab
sr 24hr 30 mg (Imdur)
1
isosorbide mononitrate tab
sr 24hr 60 mg (Imdur)
1
isosorbide mononitrate tab
sr 24hr 120 mg (Imdur)
ACA
1
NITROGLYCERIN LINGUAL nitroglycerin lingual aerosol
400 mcg/spray
ANTIANGINAL AGENTS
Dispensing Limits
1
3
nitroglycerin cap cr 9 mg
Step Therapy
1
NITRO-BID - nitroglycerin oint
2%
nitroglycerin cap cr 6.5 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
1
nitroglycerin tl soln 0.4 mg/
spray (400 mcg/spray)
(Nitrolingual pumpspr)
1
NITROMIST - nitroglycerin
lingual aerosol 400 mcg/
spray
3
NITROSTAT - nitroglycerin sl
tab 0.3 mg
2
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NITROSTAT - nitroglycerin sl
tab 0.4 mg
2
carvedilol tab 6.25 mg
(Coreg)
1
NITROSTAT - nitroglycerin sl
tab 0.6 mg
2
carvedilol tab 12.5 mg
(Coreg)
1
RANEXA - ranolazine tab sr
12hr 500 mg
3
carvedilol tab 25 mg (Coreg)
1
3
COREG CR - carvedilol
phosphate cap sr 24hr 10
mg
3
RANEXA - ranolazine tab sr
12hr 1000 mg
3
acebutolol hcl cap 200 mg
(Sectral)
1
COREG CR - carvedilol
phosphate cap sr 24hr 20
mg
acebutolol hcl cap 400 mg
(Sectral)
1
3
atenolol tab 25 mg
(Tenormin)
1
COREG CR - carvedilol
phosphate cap sr 24hr 40
mg
3
atenolol tab 50 mg
(Tenormin)
1
COREG CR - carvedilol
phosphate cap sr 24hr 80
mg
atenolol tab 100 mg
(Tenormin)
1
labetalol hcl tab 100 mg
(Trandate)
1
betaxolol hcl tab 10 mg
(Kerlone)
1
labetalol hcl tab 200 mg
(Trandate)
1
betaxolol hcl tab 20 mg
(Kerlone)
1
labetalol hcl tab 300 mg
(Trandate)
1
bisoprolol fumarate tab 5 mg
(Zebeta)
1
1
bisoprolol fumarate tab
10 mg (Zebeta)
1
metoprolol succinate tab sr
24hr 25 mg (tartrate equiv)
(Toprol xl)
metoprolol succinate tab sr
24hr 50 mg (tartrate equiv)
(Toprol xl)
1
metoprolol succinate tab
sr 24hr 100 mg (tartrate
equiv) (Toprol xl)
1
BETA BLOCKERS
BYSTOLIC - nebivolol hcl tab
2.5 mg (base equivalent)
3
BYSTOLIC - nebivolol hcl tab 5
mg (base equivalent)
3
BYSTOLIC - nebivolol hcl tab
10 mg (base equivalent)
3
BYSTOLIC - nebivolol hcl tab
20 mg (base equivalent)
3
metoprolol succinate tab
sr 24hr 200 mg (tartrate
equiv) (Toprol xl)
carvedilol tab 3.125 mg
(Coreg)
1
metoprolol tartrate tab
25 mg
metoprolol tartrate tab
50 mg (Lopressor)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
1
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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
propranolol hcl cap sr 24hr
60 mg (Inderal la)
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)
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)
TIMOLOL MALEATE - timolol
maleate tab 10 mg
3
1
TIMOLOL MALEATE - timolol
maleate tab 20 mg
3
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
sotalol hcl tab 120 mg
(Betapace)
1
sotalol hcl tab 160 mg
(Betapace)
1
sotalol hcl tab 240 mg
1
3
CALCIUM CHANNEL BLOCKERS
1
amlodipine besylate tab
2.5 mg (Norvasc)
1
amlodipine besylate tab
5 mg (Norvasc)
1
amlodipine besylate tab
10 mg (Norvasc)
3
CARDIZEM LA - diltiazem hcl
coated beads tab sr 24hr
120 mg
1
diltiazem hcl cap sr 12hr
60 mg
1
diltiazem hcl cap sr 12hr
90 mg
1
diltiazem hcl cap sr 12hr
120 mg
1
diltiazem hcl cap sr 24hr
120 mg
1
diltiazem hcl cap sr 24hr
180 mg
1
diltiazem hcl cap sr 24hr
240 mg
1
diltiazem hcl coated beads
cap sr 24hr 120 mg
(Cardizem cd)
1
diltiazem hcl coated beads
cap sr 24hr 180 mg
(Cardizem cd)
1
diltiazem hcl coated beads
cap sr 24hr 240 mg
(Cardizem cd)
1
diltiazem hcl coated beads
cap sr 24hr 300 mg
(Cardizem cd)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Drug Name
1
sotalol hcl tab 80 mg
(Betapace)
TIMOLOL MALEATE - timolol
maleate tab 5 mg
Prior Authorization
Drug Name
Drug Tier
2017
•
•
•
•
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diltiazem hcl coated beads
cap sr 24hr 360 mg
(Cardizem cd)
1
diltiazem hcl coated beads
tab sr 24hr 180 mg
(Cardizem la)
1
diltiazem hcl coated beads
tab sr 24hr 240 mg
(Cardizem la)
1
diltiazem hcl coated beads
tab sr 24hr 300 mg
(Cardizem la)
1
diltiazem hcl coated beads
tab sr 24hr 360 mg
(Cardizem la)
1
nicardipine hcl cap 20 mg
1
diltiazem hcl coated beads
tab sr 24hr 420 mg
(Cardizem la)
1
nifedipine cap 10 mg
(Procardia)
nifedipine cap 20 mg
1
diltiazem hcl extended
release beads cap sr 24hr
120 mg (Tiazac)
1
diltiazem hcl extended
release beads cap sr 24hr
180 mg (Tiazac)
diltiazem hcl extended
release beads cap sr 24hr
240 mg (Tiazac)
diltiazem hcl extended
release beads cap sr 24hr
300 mg (Tiazac)
diltiazem hcl extended
release beads cap sr 24hr
360 mg (Tiazac)
diltiazem hcl extended
release beads cap sr 24hr
420 mg (Tiazac)
diltiazem hcl tab 30 mg
(Cardizem)
diltiazem hcl tab 60 mg
(Cardizem)
1
diltiazem hcl tab 90 mg
1
diltiazem hcl tab 120 mg
(Cardizem)
1
felodipine tab sr 24hr 2.5 mg
1
felodipine tab sr 24hr 5 mg
felodipine tab sr 24hr 10 mg
isradipine cap 2.5 mg
isradipine cap 5 mg
nicardipine hcl cap 30 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1
1
1
1
1
1
nifedipine tab sr 24hr 30 mg
(Adalat cc)
1
nifedipine tab sr 24hr 60 mg
(Adalat cc)
1
nifedipine tab sr 24hr 90 mg
(Adalat cc)
1
1
nifedipine tab sr 24hr
osmotic release 30 mg
(Procardia xl)
1
1
nifedipine tab sr 24hr
osmotic release 60 mg
(Procardia xl)
1
1
nifedipine tab sr 24hr
osmotic release 90 mg
(Procardia xl)
1
1
nimodipine cap 30 mg
1
NISOLDIPINE ER - nisoldipine
tab sr 24hr 20 mg
3
1
NISOLDIPINE ER - nisoldipine
tab sr 24hr 25.5 mg
3
NISOLDIPINE ER - nisoldipine
tab sr 24hr 30 mg
3
1
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
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NISOLDIPINE ER - nisoldipine
tab sr 24hr 40 mg
3
amiodarone hcl tab 200 mg
(Cordarone)
1
nisoldipine tab sr 24hr
8.5 mg (Sular)
1
amiodarone hcl tab 400 mg
1
1
disopyramide phosphate
cap 100 mg (Norpace)
1
disopyramide phosphate
cap 150 mg (Norpace)
NYMALIZE - nimodipine oral
soln 60 mg/20ml
3
dofetilide cap 125 mcg
(0.125 mg) (Tikosyn)
verapamil hcl cap sr 24hr
100 mg (Verelan pm)
1
dofetilide cap 250 mcg
(0.25 mg) (Tikosyn)
1
dofetilide cap 500 mcg
(0.5 mg) (Tikosyn)
nisoldipine tab sr 24hr
17 mg (Sular)
nisoldipine tab sr 24hr
34 mg (Sular)
verapamil hcl cap sr 24hr
120 mg (Verelan)
verapamil hcl cap sr 24hr
180 mg (Verelan)
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)
1
1
1
1
flecainide acetate tab 50 mg
flecainide acetate tab
100 mg
flecainide acetate tab
150 mg
mexiletine hcl cap 150 mg
mexiletine hcl cap 200 mg
mexiletine hcl cap 250 mg
1
1
1
1
1
1
1
1
NORPACE - disopyramide
phosphate cap 100 mg
3
verapamil hcl tab cr 180 mg
(Calan sr)
1
NORPACE - disopyramide
phosphate cap 150 mg
3
verapamil hcl tab cr 240 mg
(Calan sr)
1
3
verapamil hcl tab 40 mg
1
NORPACE CR - disopyramide
phosphate cap sr 12hr 100
mg
NORPACE CR - disopyramide
phosphate cap sr 12hr 150
mg
3
propafenone hcl cap sr 12hr
225 mg (Rythmol sr)
1
1
ANTIARRHYTHMICS
amiodarone hcl tab 100 mg
1
propafenone hcl cap sr 12hr
325 mg (Rythmol sr)
Limited Distribution
1
verapamil hcl tab cr 120 mg
(Calan sr)
verapamil hcl tab 120 mg
(Calan)
ACA
1
3
1
Dispensing Limits
1
MULTAQ - dronedarone hcl tab
400 mg (base equivalent)
verapamil hcl tab 80 mg
(Calan)
Step Therapy
1
1
verapamil hcl cap sr 24hr
360 mg (Verelan)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
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propafenone hcl cap sr 12hr
425 mg (Rythmol sr)
1
propafenone hcl tab 150 mg
(Rythmol)
1
propafenone hcl tab 225 mg
(Rythmol)
1
propafenone hcl tab 300 mg
1
quinidine gluconate tab cr
324 mg
1
QUINIDINE SULFATE quinidine sulfate tab 200 mg
3
QUINIDINE SULFATE quinidine sulfate tab 300 mg
3
TIKOSYN - dofetilide cap 125
mcg (0.125 mg)
3
TIKOSYN - dofetilide cap 250
mcg (0.25 mg)
3
TIKOSYN - dofetilide cap 500
mcg (0.5 mg)
3
ANTIHYPERTENSIVES
amlodipine besylatebenazepril hcl cap
2.5-10 mg (Lotrel)
1
amlodipine besylatevalsartan tab 5-160 mg
(Exforge)
1
amlodipine besylatevalsartan tab 5-320 mg
(Exforge)
1
amlodipine besylatevalsartan tab 10-160 mg
(Exforge)
1
amlodipine besylatevalsartan tab 10-320 mg
(Exforge)
1
amlodipine-valsartanhydrochlorothiazide tab
5-160-12.5 mg (Exforge hct)
1
amlodipine-valsartanhydrochlorothiazide tab
5-160-25 mg (Exforge hct)
1
amlodipine-valsartanhydrochlorothiazide tab
10-160-25 mg (Exforge hct)
1
amlodipine besylatebenazepril hcl cap 5-10 mg
(Lotrel)
1
amlodipine besylatebenazepril hcl cap 5-20 mg
(Lotrel)
1
amlodipine besylatebenazepril hcl cap 5-40 mg
(Lotrel)
1
atenolol & chlorthalidone
tab 100-25 mg (Tenoretic
100)
1
amlodipine besylatebenazepril hcl cap
10-20 mg (Lotrel)
1
benazepril &
hydrochlorothiazide tab
5-6.25 mg
1
1
benazepril &
hydrochlorothiazide tab
10-12.5 mg (Lotensin hct)
amlodipine besylatebenazepril hcl cap
10-40 mg (Lotrel)
atenolol & chlorthalidone
tab 50-25 mg (Tenoretic 50)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1
amlodipine-valsartanhydrochlorothiazide tab
10-160-12.5 mg (Exforge
hct)
amlodipine-valsartanhydrochlorothiazide tab
10-320-25 mg (Exforge hct)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
1
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45
benazepril &
hydrochlorothiazide tab
20-12.5 mg (Lotensin hct)
benazepril &
hydrochlorothiazide tab
20-25 mg (Lotensin hct)
benazepril hcl tab 5 mg
1
1
1
candesartan cilexetilhydrochlorothiazide tab
16-12.5 mg (Atacand hct)
candesartan cilexetilhydrochlorothiazide tab
32-12.5 mg (Atacand hct)
benazepril hcl tab 10 mg
(Lotensin)
1
candesartan cilexetilhydrochlorothiazide tab
32-25 mg (Atacand hct)
benazepril hcl tab 20 mg
(Lotensin)
1
captopril tab 12.5 mg
benazepril hcl tab 40 mg
(Lotensin)
1
BENICAR - olmesartan
medoxomil tab 5 mg
3
BENICAR - olmesartan
medoxomil tab 20 mg
3
BENICAR - olmesartan
medoxomil tab 40 mg
3
bisoprolol &
hydrochlorothiazide tab
2.5-6.25 mg (Ziac)
1
bisoprolol &
hydrochlorothiazide tab
5-6.25 mg (Ziac)
bisoprolol &
hydrochlorothiazide tab
10-6.25 mg (Ziac)
candesartan cilexetil tab
4 mg (Atacand)
candesartan cilexetil tab
8 mg (Atacand)
candesartan cilexetil tab
16 mg (Atacand)
candesartan cilexetil tab
32 mg (Atacand)
1
1
1
1
1
1
captopril tab 25 mg
captopril tab 50 mg
captopril tab 100 mg
Limited Distribution
ACA
1
1
1
1
1
clonidine hcl tab 0.2 mg
(Catapres)
1
clonidine hcl tab 0.3 mg
(Catapres)
1
clonidine hcl td patch
weekly 0.1 mg/24hr
(Catapres-tts-1)
1
clonidine hcl td patch
weekly 0.2 mg/24hr
(Catapres-tts-2)
1
clonidine hcl td patch
weekly 0.3 mg/24hr
(Catapres-tts-3)
1
DEMSER - metyrosine cap 250
mg
3
doxazosin mesylate tab
1 mg (Cardura)
1
doxazosin mesylate tab
8 mg (Cardura)
Dispensing Limits
1
1
doxazosin mesylate tab
4 mg (Cardura)
Step Therapy
1
clonidine hcl tab 0.1 mg
(Catapres)
doxazosin mesylate tab
2 mg (Cardura)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
1
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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46
EDARBI - azilsartan medoxomil 3
tab 40 mg
EDARBI - azilsartan medoxomil 3
tab 80 mg
1
enalapril maleate &
hydrochlorothiazide tab
5-12.5 mg
1
enalapril maleate &
hydrochlorothiazide tab
10-25 mg (Vaseretic)
1
enalapril maleate tab 2.5 mg
(Vasotec)
1
enalapril maleate tab 5 mg
(Vasotec)
1
enalapril maleate tab 10 mg
(Vasotec)
1
enalapril maleate tab 20 mg
(Vasotec)
1
eplerenone tab 25 mg
(Inspra)
1
eplerenone tab 50 mg
(Inspra)
3
EPROSARTAN MESYLATE eprosartan mesylate tab 600
mg
1
fosinopril sodium &
hydrochlorothiazide tab
10-12.5 mg
1
fosinopril sodium &
hydrochlorothiazide tab
20-12.5 mg
1
fosinopril sodium tab 10 mg
hydralazine hcl tab 10 mg
fosinopril sodium tab 20 mg
losartan potassium &
hydrochlorothiazide tab
50-12.5 mg (Hyzaar)
fosinopril sodium tab 40 mg
1
1
guanfacine hcl tab 1 mg
(Tenex)
1
guanfacine hcl tab 2 mg
(Tenex)
1
hydralazine hcl tab 25 mg
hydralazine hcl tab 50 mg
hydralazine hcl tab 100 mg
irbesartan tab 300 mg
(Avapro)
1
irbesartanhydrochlorothiazide tab
150-12.5 mg (Avalide)
1
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
100-12.5 mg (Hyzaar)
Limited Distribution
1
1
lisinopril &
hydrochlorothiazide tab
20-25 mg (Zestoretic)
ACA
1
irbesartan tab 150 mg
(Avapro)
lisinopril &
hydrochlorothiazide tab
20-12.5 mg (Zestoretic)
Dispensing Limits
1
1
lisinopril &
hydrochlorothiazide tab
10-12.5 mg (Zestoretic)
Step Therapy
1
irbesartan tab 75 mg
(Avapro)
irbesartanhydrochlorothiazide tab
300-12.5 mg (Avalide)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
1
1
1
1
1
1
1
1
1
1
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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47
losartan potassium &
hydrochlorothiazide tab
100-25 mg (Hyzaar)
losartan potassium tab
25 mg (Cozaar)
losartan potassium tab
50 mg (Cozaar)
losartan potassium tab
100 mg (Cozaar)
methyldopa tab 250 mg
methyldopa tab 500 mg
metoprolol &
hydrochlorothiazide tab
50-25 mg (Lopressor hct)
metoprolol &
hydrochlorothiazide tab
100-25 mg (Lopressor hct)
metoprolol &
hydrochlorothiazide tab
100-50 mg
minoxidil tab 2.5 mg
minoxidil tab 10 mg
1
1
1
1
1
1
1
1
1
1
1
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)
perindopril erbumine tab
2 mg
perindopril erbumine tab
4 mg (Aceon)
perindopril erbumine tab
8 mg (Aceon)
phenoxybenzamine hcl cap
10 mg (Dibenzyline)
Limited Distribution
1
1
1
1
1
prazosin hcl cap 1 mg
(Minipress)
1
prazosin hcl cap 2 mg
(Minipress)
1
1
1
moexipril hcl tab 15 mg
(Univasc)
1
quinapril hcl tab 5 mg
(Accupril)
1
moexiprilhydrochlorothiazide tab
7.5-12.5 mg
1
quinapril hcl tab 10 mg
(Accupril)
quinapril hcl tab 20 mg
(Accupril)
1
quinapril hcl tab 40 mg
(Accupril)
1
1
quinaprilhydrochlorothiazide tab
10-12.5 mg (Accuretic)
1
1
quinaprilhydrochlorothiazide tab
20-12.5 mg (Accuretic)
nadolol &
bendroflumethiazide tab
40-5 mg (Corzide)
ACA
1
1
moexiprilhydrochlorothiazide tab
15-25 mg
Dispensing Limits
1
moexipril hcl tab 7.5 mg
(Univasc)
1
Step Therapy
1
prazosin hcl cap 5 mg
(Minipress)
moexiprilhydrochlorothiazide tab
15-12.5 mg (Uniretic)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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48
quinaprilhydrochlorothiazide 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)
1
1
1
1
1
telmisartanhydrochlorothiazide tab
40-12.5 mg (Micardis hct)
telmisartanhydrochlorothiazide tab
80-12.5 mg (Micardis hct)
telmisartanhydrochlorothiazide tab
80-25 mg (Micardis hct)
3
TEKTURNA HCT - aliskirenhydrochlorothiazide tab
150-12.5 mg
3
TEKTURNA HCT - aliskirenhydrochlorothiazide tab
150-25 mg
3
TEKTURNA HCT - aliskirenhydrochlorothiazide tab
300-12.5 mg
3
telmisartan tab 20 mg
(Micardis)
1
trandolapril-verapamil hcl
tab cr 2-240 mg (Tarka)
telmisartan tab 40 mg
(Micardis)
1
trandolapril-verapamil hcl
tab cr 4-240 mg (Tarka)
telmisartan tab 80 mg
(Micardis)
1
valsartan tab 160 mg
(Diovan)
1
telmisartan-amlodipine tab
40-5 mg (Twynsta)
1
1
valsartan tab 320 mg
(Diovan)
1
1
valsartanhydrochlorothiazide tab
80-12.5 mg (Diovan hct)
1
telmisartan-amlodipine tab
40-10 mg (Twynsta)
telmisartan-amlodipine tab
80-5 mg (Twynsta)
telmisartan-amlodipine tab
80-10 mg (Twynsta)
terazosin hcl cap 10 mg
trandolapril tab 1 mg (Mavik)
trandolapril tab 2 mg (Mavik)
1
trandolapril tab 4 mg (Mavik)
trandolapril-verapamil hcl
tab cr 1-240 mg (Tarka)
trandolapril-verapamil hcl
tab cr 2-180 mg (Tarka)
valsartan tab 40 mg (Diovan)
valsartan tab 80 mg (Diovan)
valsartanhydrochlorothiazide tab
160-12.5 mg (Diovan hct)
Limited Distribution
ACA
1
TEKTURNA - aliskiren
fumarate tab 300 mg (base
equivalent)
terazosin hcl cap 5 mg
Dispensing Limits
1
3
terazosin hcl cap 2 mg
Step Therapy
1
TEKTURNA - aliskiren
fumarate tab 150 mg (base
equivalent)
terazosin hcl cap 1 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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49
valsartanhydrochlorothiazide tab
160-25 mg (Diovan hct)
valsartanhydrochlorothiazide tab
320-12.5 mg (Diovan hct)
valsartanhydrochlorothiazide tab
320-25 mg (Diovan hct)
acetazolamide cap sr 12hr
500 mg (Diamox)
acetazolamide tab 125 mg
acetazolamide tab 250 mg
EDECRIN - ethacrynic acid tab
25 mg
3
ethacrynic acid tab 25 mg
1
furosemide tab 40 mg (Lasix)
furosemide tab 80 mg (Lasix)
1
1
hydrochlorothiazide tab
12.5 mg
1
1
1
1
1
hydrochlorothiazide tab
25 mg
hydrochlorothiazide tab
50 mg
indapamide tab 1.25 mg
indapamide tab 2.5 mg
1
1
1
1
1
1
methazolamide tab 25 mg
(Neptazane)
1
methazolamide tab 50 mg
(Neptazane)
1
METHYCLOTHIAZIDE methyclothiazide tab 5 mg
3
chlorothiazide tab 500 mg
1
metolazone tab 5 mg
(Zaroxolyn)
1
metolazone tab 10 mg
1
DIURIL - chlorothiazide susp
250 mg/5ml
3
DYRENIUM - triamterene cap
50 mg
3
spironolactone &
hydrochlorothiazide tab
25-25 mg (Aldactazide)
spironolactone tab 25 mg
(Aldactone)
Limited Distribution
1
1
1
ACA
1
metolazone tab 2.5 mg
(Zaroxolyn)
chlorthalidone tab 50 mg
Dispensing Limits
1
3
1
Step Therapy
1
CHLOROTHIAZIDE chlorothiazide tab 250 mg
chlorthalidone tab 25 mg
Prior Authorization
ACA
Limited Distribution
•
Drug Tier
3
hydrochlorothiazide cap
12.5 mg (Microzide)
1
bumetanide tab 2 mg
DYRENIUM - triamterene cap
100 mg
furosemide tab 20 mg (Lasix)
amiloride &
hydrochlorothiazide tab
5-50 mg
bumetanide tab 1 mg
Drug Name
furosemide oral soln 10 mg/
ml
1
3
bumetanide tab 0.5 mg
Dispensing Limits
1
ALDACTAZIDE spironolactone &
hydrochlorothiazide tab
50-50 mg
amiloride hcl tab 5 mg
Step Therapy
1
VECAMYL - mecamylamine hcl 3
tab 2.5 mg
DIURETICS
Prior Authorization
Drug Name
Drug Tier
2017
1
1
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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50
spironolactone tab 50 mg
(Aldactone)
1
spironolactone tab 100 mg
(Aldactone)
1
torsemide tab 5 mg
(Demadex)
1
torsemide tab 10 mg
(Demadex)
1
torsemide tab 20 mg
(Demadex)
1
torsemide tab 100 mg
(Demadex)
1
triamterene &
hydrochlorothiazide cap
37.5-25 mg (Dyazide)
1
triamterene &
hydrochlorothiazide tab
37.5-25 mg (Maxzide-25)
triamterene &
hydrochlorothiazide tab
75-50 mg (Maxzide)
TRIAMTERENE/
HYDROCHLOROTH triamterene &
hydrochlorothiazide cap
50-25 mg
VASOPRESSORS
1
1
EPINEPHRINE AUTHORIZED GENERIC
TO EPIPEN - epinephrine
solution auto-injector 0.15
mg/0.3ml (1:2000)
2
EPINEPHRINE AUTHORIZED GENERIC
TO EPIPEN - epinephrine
solution auto-injector 0.3
mg/0.3ml (1:1000)
2
EPIPEN 2-PAK - epinephrine
solution auto-injector 0.3
mg/0.3ml (1:1000)
2
EPIPEN-JR 2-PAK epinephrine solution autoinjector 0.15 mg/0.3ml
(1:2000)
2
midodrine hcl tab 2.5 mg
1
midodrine hcl tab 5 mg
midodrine hcl tab 10 mg
ANTIHYPERLIPIDEMICS
3
Limited Distribution
ACA
Dispensing Limits
1
1
atorvastatin calcium tab
20 mg (base equivalent)
(Lipitor)
1
ADRENACLICK - epinephrine
solution auto-injector 0.15
mg/0.15ml (1:1000)
3
atorvastatin calcium tab
40 mg (base equivalent)
(Lipitor)
1
ADRENACLICK - epinephrine
solution auto-injector 0.3
mg/0.3ml (1:1000)
3
atorvastatin calcium tab
80 mg (base equivalent)
(Lipitor)
1
EPINEPHRINE - epinephrine
solution auto-injector 0.15
mg/0.15ml (1:1000)
3
cholestyramine light powder
packets 4 gm
1
EPINEPHRINE - epinephrine
solution auto-injector 0.3
mg/0.3ml (1:1000)
3
cholestyramine powder
packets 4 gm (Questran)
Step Therapy
1
atorvastatin calcium tab
10 mg (base equivalent)
(Lipitor)
cholestyramine light powder
4 gm/dose (Questran light)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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51
cholestyramine powder
4 gm/dose (Questran)
choline fenofibrate cap dr
45 mg (fenofibric acid
equiv) (Trilipix)
choline fenofibrate cap dr
135 mg (fenofibric acid
equiv) (Trilipix)
1
•
1
•
1
1
colestipol hcl granules 5 gm
(Colestid flavored)
1
colestipol hcl tab 1 gm
(Colestid)
1
CRESTOR - rosuvastatin
calcium tab 5 mg
3
•
CRESTOR - rosuvastatin
calcium tab 10 mg
3
•
CRESTOR - rosuvastatin
calcium tab 20 mg
3
•
CRESTOR - rosuvastatin
calcium tab 40 mg
3
•
ezetimibe tab 10 mg (Zetia)
1
fenofibrate micronized cap
67 mg (Lofibra)
fenofibrate micronized cap
130 mg
fenofibrate micronized cap
134 mg (Lofibra)
fenofibrate tab 48 mg (Tricor)
1
•
•
1
•
1
•
1
•
1
•
•
fenofibrate tab 54 mg
(Lofibra)
1
fenofibrate tab 145 mg
(Tricor)
1
•
fenofibrate tab 160 mg
(Lofibra)
1
fluvastatin sodium cap
20 mg (Lescol)
1
fluvastatin sodium cap
40 mg (Lescol)
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
ACA
Drug Name
fluvastatin sodium tab sr 24
hr 80 mg (Lescol xl)
colestipol hcl granule
packets 5 gm (Colestid
flavored)
fenofibrate micronized cap
43 mg
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
•
gemfibrozil tab 600 mg
(Lopid)
1
JUXTAPID - lomitapide
mesylate cap 5 mg (base
equiv)
3
•
•
•
JUXTAPID - lomitapide
mesylate cap 10 mg (base
equiv)
3
•
•
•
JUXTAPID - lomitapide
mesylate cap 20 mg (base
equiv)
3
•
•
•
JUXTAPID - lomitapide
mesylate cap 30 mg (base
equiv)
3
•
•
•
JUXTAPID - lomitapide
mesylate cap 40 mg (base
equiv)
3
•
•
•
JUXTAPID - lomitapide
mesylate cap 60 mg (base
equiv)
3
•
•
•
KYNAMRO - mipomersen
sodium soln prefilled syringe
200 mg/ml
3
•
•
•
LIVALO - pitavastatin calcium
tab 1 mg (base equiv)
3
•
LIVALO - pitavastatin calcium
tab 2 mg (base equiv)
3
•
LIVALO - pitavastatin calcium
tab 4 mg (base equiv)
3
•
lovastatin tab 10 mg
1
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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52
lovastatin tab 20 mg
(Mevacor)
1
lovastatin tab 40 mg
(Mevacor)
1
niacin tab cr 500 mg
(antihyperlipidemic)
(Niaspan)
1
niacin tab cr 750 mg
(antihyperlipidemic)
(Niaspan)
1
niacin tab cr 1000 mg
(antihyperlipidemic)
(Niaspan)
1
PRALUENT - alirocumab
subcutaneous soln peninjector 75 mg/ml
2
•
•
•
PRALUENT - alirocumab
subcutaneous soln peninjector 150 mg/ml
2
•
•
•
pravastatin sodium tab
10 mg
1
pravastatin sodium tab
20 mg (Pravachol)
pravastatin sodium tab
40 mg (Pravachol)
pravastatin sodium tab
80 mg (Pravachol)
rosuvastatin calcium tab
10 mg (Crestor)
rosuvastatin calcium tab
20 mg (Crestor)
rosuvastatin calcium tab
40 mg (Crestor)
simvastatin tab 5 mg (Zocor)
1
1
1
REPATHA - evolocumab
subcutaneous soln prefilled
syringe 140 mg/ml
2
•
•
•
REPATHA PUSHTRONEX
SYSTEM - evolocumab
subcutaneous soln cartridge/
infusor 420 mg/3.5ml
2
•
•
•
REPATHA SURECLICK evolocumab subcutaneous
soln auto-injector 140 mg/ml
2
rosuvastatin calcium tab
5 mg (Crestor)
1
•
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
1
1
simvastatin tab 10 mg
(Zocor)
1
simvastatin tab 20 mg
(Zocor)
1
simvastatin tab 40 mg
(Zocor)
1
simvastatin tab 80 mg
(Zocor)
1
VASCEPA - icosapent ethyl cap 2
0.5 gm
VASCEPA - icosapent ethyl cap 2
1 gm
3
WELCHOL - colesevelam hcl
packet for susp 3.75 gm
3
WELCHOL - colesevelam hcl
tab 625 mg
3
ZETIA - ezetimibe tab 10 mg
•
CARDIOVASCULAR AGENTS - MISC.
ADCIRCA - tadalafil tab 20 mg 2 •
(pah)
3 •
ADEMPAS - riociguat tab 0.5
mg
ADEMPAS - riociguat tab 1 mg 3 •
•
•
•
•
•
•
•
•
ADEMPAS - riociguat tab 1.5
mg
3
•
•
•
ADEMPAS - riociguat tab 2 mg
3
ADEMPAS - riociguat tab 2.5
mg
3
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
53
BIDIL - isosorbide dinitratehydralazine hcl tab 20-37.5
mg
3
CIALIS - tadalafil tab 2.5 mg
2
CIALIS - tadalafil tab 5 mg
2
CORLANOR - ivabradine hcl
tab 5 mg (base equiv)
3
•
•
•
CORLANOR - ivabradine hcl
tab 7.5 mg (base equiv)
3
•
•
ENTRESTO - sacubitrilvalsartan tab 24-26 mg
3
•
•
ENTRESTO - sacubitrilvalsartan tab 49-51 mg
3
•
•
ENTRESTO - sacubitrilvalsartan tab 97-103 mg
3
•
•
LETAIRIS - ambrisentan tab 5
mg
3
•
•
•
LETAIRIS - ambrisentan tab 10
mg
3
•
•
•
OPSUMIT - macitentan tab 10
mg
2
•
•
•
ORENITRAM - treprostinil
diolamine tab cr 0.125 mg
(base equiv)
3
•
•
•
ORENITRAM - treprostinil
diolamine tab cr 0.25 mg
(base equiv)
3
•
•
•
ORENITRAM - treprostinil
diolamine tab cr 1 mg (base
equiv)
3
•
•
•
ORENITRAM - treprostinil
diolamine tab cr 2.5 mg
(base equiv)
3
•
•
•
REVATIO - sildenafil citrate for
suspension 10 mg/ml
3
•
•
•
sildenafil citrate tab 20 mg
(Revatio)
1
•
•
Limited Distribution
•
TRACLEER - bosentan tab 125 2
mg
3
TYVASO - treprostinil
inhalation solution 0.6 mg/ml
3
TYVASO REFILL - treprostinil
inhalation solution 0.6 mg/ml
3
TYVASO STARTER treprostinil inhalation
solution 0.6 mg/ml
2
UPTRAVI - selexipag tab
therapy pack 200 mcg (140)
& 800 mcg (60)
2
UPTRAVI - selexipag tab 200
mcg
2
UPTRAVI - selexipag tab 400
mcg
2
UPTRAVI - selexipag tab 600
mcg
2
UPTRAVI - selexipag tab 800
mcg
UPTRAVI - selexipag tab 1000 2
mcg
UPTRAVI - selexipag tab 1200 2
mcg
UPTRAVI - selexipag tab 1400 2
mcg
UPTRAVI - selexipag tab 1600 2
mcg
VENTAVIS - iloprost inhalation 3
solution 10 mcg/ml
VENTAVIS - iloprost inhalation 3
solution 20 mcg/ml
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
ERECTILE DYSFUNCTION
CIALIS - tadalafil tab 2.5 mg
2
CIALIS - tadalafil tab 5 mg
2
•
ACA
Dispensing Limits
Step Therapy
2
TRACLEER - bosentan tab
62.5 mg
•
•
•
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
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RESPIRATORY AGENTS
ANTIHISTAMINES
carbinoxamine maleate soln
4 mg/5ml
carbinoxamine maleate tab
4 mg
1
1
1
cyproheptadine hcl syrup
2 mg/5ml
1
1
DESLORATADINE ODT desloratadine tab orally
disintegrating 2.5 mg
3
DESLORATADINE ODT desloratadine tab orally
disintegrating 5 mg
3
desloratadine tab 5 mg
(Clarinex)
1
KARBINAL ER - carbinoxamine 3
maleate extended release
susp 4 mg/5ml
1
levocetirizine
dihydrochloride soln
2.5 mg/5ml (0.5 mg/ml)
(Xyzal)
1
levocetirizine
dihydrochloride tab 5 mg
(Xyzal)
1
promethazine hcl suppos
12.5 mg
1
promethazine hcl suppos
25 mg
1
promethazine hcl suppos
50 mg
1
promethazine hcl syrup
6.25 mg/5ml
promethazine hcl tab 25 mg
promethazine hcl tab 50 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Drug Name
promethazine hcl tab
12.5 mg
CLEMASTINE FUMARATE clemastine fumarate tab
2.68 mg
cyproheptadine hcl tab 4 mg
Prior Authorization
Drug Name
Drug Tier
2017
1
1
1
NASAL AGENTS - SYSTEMIC and TOPICAL
1
•
azelastine hcl nasal spray
137 mcg/spray (1 mg/ml)
1
•
azelastine hcl nasal spray
0.15% (205.5 mcg/spray)
(Astepro)
3
•
BACTROBAN NASAL mupirocin calcium nasal oint
2%
1
•
budesonide nasal susp
32 mcg/act (Rhinocort
aqua)
1
•
flunisolide nasal soln
25 mcg/act (0.025%)
(Flunisolide)
•
fluticasone propionate nasal 1
susp 50 mcg/act (Flonase)
1
•
ipratropium bromide nasal
soln 0.03% (21 mcg/spray)
(Atrovent)
1
•
ipratropium bromide nasal
soln 0.06% (42 mcg/spray)
(Atrovent)
1
•
mometasone furoate nasal
susp 50 mcg/act (Nasonex)
1
•
olopatadine hcl nasal soln
0.6% (Patanase)
3
•
OMNARIS - ciclesonide nasal
susp 50 mcg/act
1
•
triamcinolone acetonide
nasal aerosol suspension
55 mcg/act
COUGH/COLD/ALLERGY
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acetylcysteine inhal soln
10%
acetylcysteine inhal soln
20%
1
1
MAR-COF BP pseudoephedrinebromphen-codeine liqd
30-2-7.5 mg/5ml
3
BENZONATATE - benzonatate
cap 150 mg
1
NINJACOF-XG - guaifenesincodeine liquid 200-8 mg/5ml
1
benzonatate cap 100 mg
(Tessalon perles)
1
3
benzonatate cap 200 mg
1
PHENYLHISTINE DH pseudoephedrine-chlorphen
w/ codeine liq 30-2-10
mg/5ml
POLY-TUSSIN AC phenylephrine-bromphen
w/ codeine liquid 10-4-10
mg/5ml
3
PRO-CLEAR AC - codeinepyrilamine syrup 9-8.33
mg/5ml
3
3
1
CAPCOF - phenylephrinechlorphen w/ codeine syrup
5-2-10 mg/5ml
3
guaifenesin-codeine liquid
225-7.5 mg/5ml
1
guaifenesin-codeine soln
100-6.3 mg/5ml
1
1
HISTEX-AC - phenylephrinetriprolidine-codeine syrup
10-2.5-10 mg/5ml
3
PRO-RED AC - phenylephrinedexchlorphenir-codeine
syrup 5-1-9 mg/5ml
hydrocod polst-chlorphen
polst er susp 10-8 mg/5ml
(Tussionex pennkineti)
1
promethazine &
phenylephrine syrup
6.25-5 mg/5ml
hydrocodone w/
homatropine syrup
5-1.5 mg/5ml
1
guaifenesin-codeine soln
100-10 mg/5ml
hydrocodone w/
homatropine tab 5-1.5 mg
promethazine w/ codeine
syrup 6.25-10 mg/5ml
1
M-END MAX D pseudoephedrinedexbromphen-codeine liqd
20-0.667-6 mg/5ml
3
M-END PE - phenylephrinebromphen w/ codeine liqd
3.33-1.33-6.33 mg/5ml
3
promethazine-dm syrup
6.25-15 mg/5ml
promethazinephenylephrine-codeine
syrup 6.25-5-10 mg/5ml
pseudoeph-chlorphen
w/ hydrocodone soln
60-4-5 mg/5ml (Zutripro)
pseudoephed-bromphen-dm
syrup 30-2-10 mg/5ml
pseudoephedrine w/ cod-gg
soln 30-10-100 mg/5ml
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
1
1
1
1
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pseudoephedrinebromphen-codeine liq
10-1.33-6.33 mg/5ml
1
TUSNEL C - pseudoephedrine
w/ cod-gg syrup 30-10-100
mg/5ml
1
VITUZ - hydrocodonechlorpheniramine soln 5-4
mg/5ml
3
Z-TUSS AC - chlorpheniramine
w/ codeine liquid 2-9 mg/5ml
3
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
ANTIASTHMATIC and BRONCHODILATOR AGENTS
•
ADVAIR DISKUS - fluticasone- 2
salmeterol aer powder ba
100-50 mcg/dose
•
ADVAIR DISKUS - fluticasone- 2
salmeterol aer powder ba
250-50 mcg/dose
•
ADVAIR DISKUS - fluticasone- 2
salmeterol aer powder ba
500-50 mcg/dose
2
•
ADVAIR HFA - fluticasonesalmeterol inhal aerosol
45-21 mcg/act
2
•
ADVAIR HFA - fluticasonesalmeterol inhal aerosol
115-21 mcg/act
2
•
ADVAIR HFA - fluticasonesalmeterol inhal aerosol
230-21 mcg/act
1
•
albuterol sulfate soln nebu
0.083% (2.5 mg/3ml)
1
•
albuterol sulfate soln nebu
0.5% (5 mg/ml)
1
•
albuterol sulfate soln nebu
0.63 mg/3ml (base equiv)
1
•
albuterol sulfate soln nebu
1.25 mg/3ml (base equiv)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
1
1
1
ANORO ELLIPTA umeclidinium-vilanterol aero
powd ba 62.5-25 mcg/inh
2
•
ARCAPTA NEOHALER indacaterol maleate inhal
powder cap 75 mcg (base
equiv)
3
•
ARNUITY ELLIPTA fluticasone furoate aerosol
powder breath activ 100
mcg/act
2
•
ARNUITY ELLIPTA fluticasone furoate aerosol
powder breath activ 200
mcg/act
2
•
ASMANEX HFA - mometasone
furoate inhal aerosol
suspension 100 mcg/act
2
•
ASMANEX HFA - mometasone
furoate inhal aerosol
suspension 200 mcg/act
2
•
ASMANEX TWISTHALER 120
ME - mometasone furoate
inhal powd 220 mcg/inh
(breath activated)
2
•
ASMANEX TWISTHALER 30
MET - mometasone furoate
inhal powd 110 mcg/inh
(breath activated)
2
•
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2
ASMANEX TWISTHALER 60
MET - mometasone furoate
inhal powd 220 mcg/inh
(breath activated)
2
ATROVENT HFA - ipratropium
bromide hfa inhal aerosol 17
mcg/act
3
•
BREO ELLIPTA - fluticasone
furoate-vilanterol aero powd
ba 100-25 mcg/inh
2
•
BREO ELLIPTA - fluticasone
furoate-vilanterol aero powd
ba 200-25 mcg/inh
2
•
BROVANA - arformoterol
tartrate soln nebu 15
mcg/2ml (base equiv)
3
budesonide inhalation susp
0.25 mg/2ml (Pulmicort)
1
•
1
•
budesonide inhalation susp
0.5 mg/2ml (Pulmicort)
•
1
•
COMBIVENT RESPIMAT ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act
3
•
CROMOLYN SODIUM cromolyn sodium soln nebu
20 mg/2ml
3
budesonide inhalation susp
1 mg/2ml (Pulmicort)
DALIRESP - roflumilast tab 500 3
mcg
2
DULERA - mometasone
furoate-formoterol fumarate
aerosol 100-5 mcg/act
•
•
2
ELIXOPHYLLIN - theophylline
elixir 80 mg/15ml
3
FLOVENT DISKUS fluticasone propionate aer
pow ba 50 mcg/blister
2
•
FLOVENT DISKUS fluticasone propionate aer
pow ba 100 mcg/blister
2
•
FLOVENT DISKUS fluticasone propionate aer
pow ba 250 mcg/blister
2
•
FLOVENT HFA - fluticasone
propionate hfa inhal aero 44
mcg/act (50/valve)
2
•
FLOVENT HFA - fluticasone
propionate hfa inhal aer 110
mcg/act (125/valve)
2
•
FLOVENT HFA - fluticasone
propionate hfa inhal aer 220
mcg/act (250/valve)
2
•
INCRUSE ELLIPTA umeclidinium br aero powd
breath act 62.5 mcg/inh
(base eq)
2
•
ipratropium bromide inhal
soln 0.02%
1
•
1
•
1
•
1
•
ipratropium-albuterol nebu
soln 0.5-2.5(3) mg/3ml
levalbuterol hcl soln nebu
conc 1.25 mg/0.5ml (base
equiv)
levalbuterol hcl soln nebu
0.31 mg/3ml (base equiv)
(Xopenex)
Limited Distribution
•
DULERA - mometasone
furoate-formoterol fumarate
aerosol 200-5 mcg/act
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ASMANEX TWISTHALER 30
MET - mometasone furoate
inhal powd 220 mcg/inh
(breath activated)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
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58
2
•
SPIRIVA HANDIHALER tiotropium bromide
monohydrate inhal cap 18
mcg (base equiv)
2
•
3
SPIRIVA RESPIMAT tiotropium bromide
monohydrate inhal aerosol
1.25 mcg/act
2
•
METAPROTERENOL
SULFATE - metaproterenol
sulfate tab 20 mg
3
montelukast sodium chew
tab 4 mg (base equiv)
(Singulair)
1
SPIRIVA RESPIMAT tiotropium bromide
monohydrate inhal aerosol
2.5 mcg/act
2
•
montelukast sodium chew
tab 5 mg (base equiv)
(Singulair)
1
STIOLTO RESPIMAT tiotropium br-olodaterol inhal
aero soln 2.5-2.5 mcg/act
2
•
montelukast sodium tab
10 mg (base equiv)
(Singulair)
1
STRIVERDI RESPIMAT olodaterol hcl inhal aerosol
soln 2.5 mcg/act (base
equiv)
2
•
NUCALA - mepolizumab for inj
100 mg
3
PERFOROMIST - formoterol
fumarate soln nebu 20
mcg/2ml
3
SYMBICORT - budesonideformoterol fumarate dihyd
aerosol 80-4.5 mcg/act
2
•
•
SYMBICORT - budesonideformoterol fumarate dihyd
aerosol 160-4.5 mcg/act
2
•
•
terbutaline sulfate tab
2.5 mg
1
•
•
terbutaline sulfate tab 5 mg
•
•
Limited Distribution
METAPROTERENOL
SULFATE - metaproterenol
sulfate syrup 10 mg/5ml
PROAIR HFA - albuterol sulfate 2
inhal aero 108 mcg/act
(90mcg base equiv)
2
PROAIR RESPICLICK albuterol sulfate aer pow ba
108 mcg/act (90 mcg base
equiv)
2
QVAR - beclomethasone
diprop inhal aero soln 40
mcg/act (50/valve)
2
QVAR - beclomethasone
diprop inhal aero soln 80
mcg/act (100/valve)
SEREVENT DISKUS salmeterol xinafoate aer
pow ba 50 mcg/dose (base
equiv)
ACA
•
Dispensing Limits
1
Step Therapy
levalbuterol hcl soln nebu
1.25 mg/3ml (base equiv)
(Xopenex)
Prior Authorization
•
Drug Name
Drug Tier
1
Limited Distribution
levalbuterol hcl soln nebu
0.63 mg/3ml (base equiv)
(Xopenex)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
THEO-24 - theophylline cap sr
24hr 100 mg
3
THEO-24 - theophylline cap sr
24hr 200 mg
3
THEO-24 - theophylline cap sr
24hr 300 mg
3
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THEO-24 - theophylline cap sr
24hr 400 mg
3
theophylline soln
80 mg/15ml
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
3
1
INFASURF - calfactant in nacl
0.9% intratracheal susp 35
mg/ml
2
•
•
•
1
KALYDECO - ivacaftor packet
50 mg
2
•
•
•
1
KALYDECO - ivacaftor packet
75 mg
2
•
•
•
1
KALYDECO - ivacaftor tab 150
mg
3
•
•
•
1
OFEV - nintedanib esylate cap
100 mg (base equivalent)
3
•
•
•
1
OFEV - nintedanib esylate cap
150 mg (base equivalent)
3
•
•
•
1
ORKAMBI - lumacaftorivacaftor tab 100-125 mg
3
•
•
•
VENTOLIN HFA - albuterol
sulfate inhal aero 108 mcg/
act (90mcg base equiv)
2
ORKAMBI - lumacaftorivacaftor tab 200-125 mg
PULMOZYME - dornase alfa
inhal soln 1 mg/ml
2
•
zafirlukast tab 10 mg
(Accolate)
1
3
zafirlukast tab 20 mg
(Accolate)
1
SURVANTA
INTRATRACHEAL beractant in nacl 0.9%
intratracheal susp 25 mg/ml
zileuton tab sr 12hr 600 mg
(Zyflo cr)
1
ZYFLO - zileuton tab 600 mg
3
ZYFLO CR - zileuton tab sr
12hr 600 mg
3
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
RESPIRATORY AGENTS - MISC.
3
CUROSURF - poractant alfa
intratracheal susp 120
mg/1.5ml
3
CUROSURF - poractant alfa
intratracheal susp 240
mg/3ml
ESBRIET - pirfenidone cap 267 3
mg
•
•
•
•
•
•
•
•
•
•
GASTROINTESTINAL AGENTS
LAXATIVES
bisacodyl tab & peg 3350kcl-sod bicarb-nacl for
soln kit
•
1
GIALAX - polyethylene glycol
3350 - kit
3
GOLYTELY - peg 3350-kcl-na
bicarb-nacl-na sulfate packet
227.1 gm
3
KRISTALOSE - lactulose oral
crystal packet 10 gm
3
KRISTALOSE - lactulose oral
crystal packet 20 gm
3
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60
1
MYTESI - crofelemer tab
delayed release 125 mg
MOVIPREP - peg 3350-kclnacl-na sulfate-na acorbatec for soln 100 gm
3
ULCER DRUGS
OSMOPREP - sod phos
mono-sod phos di tabs
1.102-0.398 gm(1.5gm na
phos)
3
PCP 100 - mag citbisacodyl-petrolat-pegmetoclopramide-electrol kit
3
peg 3350-kcl-sod bicarb-nacl
for soln 420 gm (Nulytely/
flavor pack)
1
•
peg 3350-kcl-na bicarb-naclna sulfate for soln 236 gm
(Golytely)
1
•
peg 3350-kcl-na bicarb-naclna sulfate for soln 240 gm
(Colyte-flavor packs)
1
•
polyethylene glycol 3350
oral packet
1
lactulose solution
10 gm/15ml
polyethylene glycol 3350
oral powder
PREPOPIK - sod picosulfatemg oxide-citric acid pack 10
mg-3.5 gm-12 gm
3
SUPREP BOWEL PREP KIT sodium sulfate-potassium
sulfate-magnesium sulfate
oral soln
3
ANTIDIARRHEALS
diphenoxylate w/ atropine
tab 2.5-0.025 mg (Lomotil)
DIPHENOXYLATE/
ATROPINE - diphenoxylate
w/ atropine liq 2.5-0.025
mg/5ml
3
cimetidine hcl soln
300 mg/5ml
1
cimetidine tab 400 mg
cimetidine tab 800 mg
1
1
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
3
CARAFATE - sucralfate susp 1
gm/10ml
cimetidine tab 300 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
1
CUVPOSA - glycopyrrolate oral 3
soln 1 mg/5ml
3
DEXILANT - dexlansoprazole
cap delayed release 30 mg
3
DEXILANT - dexlansoprazole
cap delayed release 60 mg
1
dicyclomine hcl cap 10 mg
(Bentyl)
1
dicyclomine hcl oral soln
10 mg/5ml
1
dicyclomine hcl tab 20 mg
(Bentyl)
1
esomeprazole magnesium
cap delayed release 20 mg
(base eq) (Nexium)
1
esomeprazole magnesium
cap delayed release 40 mg
(base eq) (Nexium)
1
famotidine for susp
40 mg/5ml (Pepcid)
1
famotidine tab 40 mg
(Pepcid)
1
glycopyrrolate tab 1 mg
(Robinul)
1
glycopyrrolate tab 2 mg
(Robinul forte)
•
•
•
•
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lansoprazole cap delayed
release 15 mg (Prevacid)
lansoprazole cap delayed
release 30 mg (Prevacid)
methscopolamine bromide
tab 2.5 mg (Pamine)
methscopolamine bromide
tab 5 mg (Pamine forte)
1
1
1
•
pantoprazole sodium ec
tab 40 mg (base equiv)
(Protonix)
1
•
PROPANTHELINE BROMIDE - 3
propantheline bromide tab
15 mg
1
rabeprazole sodium ec tab
20 mg (Aciphex)
1
ranitidine hcl cap 150 mg
•
misoprostol tab 100 mcg
(Cytotec)
1
misoprostol tab 200 mcg
(Cytotec)
1
NEXIUM - esomeprazole
magnesium for delayed
release susp packet 5 mg
3
NEXIUM - esomeprazole
magnesium for delayed
release susp packet 10 mg
3
•
NEXIUM - esomeprazole
magnesium for delayed
release susp packet 20 mg
3
•
NEXIUM - esomeprazole
magnesium for delayed
release susp packet 40 mg
3
•
AKYNZEO - netupitantpalonosetron cap 300-0.5
mg
3
•
NEXIUM - esomeprazole
magnesium for delayed
release susp pack 2.5 mg
3
•
ANZEMET - dolasetron
mesylate tab 50 mg
3
•
3
•
NIZATIDINE - nizatidine oral
soln 15 mg/ml
3
ANZEMET - dolasetron
mesylate tab 100 mg
1
•
nizatidine cap 150 mg
1
aprepitant capsule therapy
pack 80 & 125 mg (Emend)
aprepitant capsule 80 mg
(Emend)
1
•
CESAMET - nabilone cap 1 mg
3
DICLEGIS - doxylaminepyridoxine tab delayed
release 10-10 mg
3
dronabinol cap 2.5 mg
(Marinol)
1
nizatidine cap 300 mg (Axid)
omeprazole cap delayed
release 10 mg (Prilosec)
omeprazole cap delayed
release 20 mg (Prilosec)
omeprazole cap delayed
release 40 mg (Prilosec)
•
ranitidine hcl cap 300 mg
ranitidine hcl syrup 15 mg/
ml (75 mg/5ml)
1
1
•
1
•
1
•
1
1
ranitidine hcl tab 300 mg
(Zantac)
1
sucralfate tab 1 gm
(Carafate)
1
ANTIEMETICS
Limited Distribution
pantoprazole sodium ec
tab 20 mg (base equiv)
(Protonix)
ACA
Dispensing Limits
Step Therapy
•
Prior Authorization
1
Drug Name
Drug Tier
•
Limited Distribution
1
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
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2
•
EMEND - aprepitant capsule
40 mg
2
•
EMEND - aprepitant capsule
80 mg
2
•
EMEND - aprepitant capsule
125 mg
2
•
EMEND - aprepitant for oral
susp 125 mg (125 mg/5ml)
2
•
granisetron hcl tab 1 mg
1
1
•
•
ondansetron hcl tab 4 mg
(Zofran)
1
•
ondansetron hcl tab 8 mg
(Zofran)
1
•
ondansetron hcl tab 24 mg
1
ondansetron hcl oral soln
4 mg/5ml (Zofran)
ondansetron orally
disintegrating tab 4 mg
(Zofran odt)
1
•
•
ondansetron orally
disintegrating tab 8 mg
(Zofran odt)
1
•
TRANSDERM-SCOP scopolamine td patch 72hr
1.5 mg
3
trimethobenzamide hcl cap
300 mg (Tigan)
1
VARUBI - rolapitant hcl tab 90
mg (base equiv)
DIGESTIVE AIDS
3
•
•
2
CREON - pancrelipase
(lip-prot-amyl) dr cap
12000-38000-60000 unit
2
CREON - pancrelipase
(lip-prot-amyl) dr cap
24000-76000-120000 unit
2
CREON - pancrelipase
(lip-prot-amyl) dr cap
36000-114000-180000 unit
2
PANCREAZE - pancrelipase
(lip-prot-amyl) dr cap
2600-6200-10850 unit
3
PANCREAZE - pancrelipase
(lip-prot-amyl) dr cap
4200-14200-24600 unit
3
PANCREAZE - pancrelipase
(lip-prot-amyl) dr cap
10500-35500-61500 unit
3
PANCREAZE - pancrelipase
(lip-prot-amyl) dr cap
16800-56800-98400 unit
3
PANCREAZE - pancrelipase
(lip-prot-amyl) dr cap
21000-54700-83900 unit
3
PERTZYE - pancrelipase
(lip-prot-amyl) dr cap
4000-14375-15125 unit
3
PERTZYE - pancrelipase
(lip-prot-amyl) dr cap
8000-28750-30250 unit
3
PERTZYE - pancrelipase
(lip-prot-amyl) dr cap
16000-57500-60500 unit
3
Limited Distribution
EMEND - aprepitant capsule
therapy pack 80 & 125 mg
CREON - pancrelipase
(lip-prot-amyl) dr cap
6000-19000-30000 unit
ACA
•
Dispensing Limits
1
2
Step Therapy
dronabinol cap 10 mg
(Marinol)
CREON - pancrelipase
(lip-prot-amyl) dr cap
3000-9500-15000 unit
Prior Authorization
•
Drug Name
Drug Tier
1
Limited Distribution
dronabinol cap 5 mg
(Marinol)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
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1
Limited Distribution
ACA
VIOKACE - pancrelipase
(lip-prot-amyl) tab
10440-39150-39150 unit
3
VIOKACE - pancrelipase
(lip-prot-amyl) tab
20880-78300-78300 unit
3
calcium acetate (phosphate
binder) cap 667 mg
(169 mg ca) (Phoslo)
2
calcium acetate (phosphate
binder) tab 667 mg
(Eliphos)
1
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
3000-10000-16000 unit
CANASA - mesalamine suppos
1000 mg
2
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
5000-17000-27000 unit
2
2
•
•
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
10000-34000-55000 unit
2
CHENODAL - chenodiol tab
250 mg
CHOLBAM - cholic acid cap 50
mg
3
•
•
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
15000-51000-82000 unit
2
CHOLBAM - cholic acid cap
250 mg
3
•
•
•
•
•
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
20000-68000-109000 unit
2
•
•
•
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
25000-85000-136000 unit
2
ZENPEP - pancrelipase
(lip-prot-amyl) dr cap
40000-136000-218000 unit
2
CIMZIA - certolizumab pegol inj 3
kit 2 x 200 mg/ml
3
CIMZIA STARTER KIT certolizumab pegol inj kit 6 x
200 mg/ml
1
cromolyn sodium oral conc
100 mg/5ml (Gastrocrom)
3
DELZICOL - mesalamine cap
dr 400 mg
3
DIPENTUM - olsalazine
sodium cap 250 mg
ENTEREG - alvimopan cap 12 3
mg
3
FOSRENOL - lanthanum
carbonate chew tab 500 mg
(elemental)
3
FOSRENOL - lanthanum
carbonate chew tab 750 mg
(elemental)
•
balsalazide disodium cap
750 mg (Colazal)
Dispensing Limits
3
•
3
Step Therapy
SUCRAID - sacrosidase soln
8500 unit/ml
GASTROINTESTINAL AGENTS- MISC.
1
alosetron hcl tab 0.5 mg
(base equiv) (Lotronex)
alosetron hcl tab 1 mg (base 1
equiv) (Lotronex)
3
APRISO - mesalamine cap sr
24hr 0.375 gm
ASACOL HD - mesalamine tab 3
delayed release 800 mg
AURYXIA - ferric citrate tab 1
gm (210 mg ferric iron)
Prior Authorization
•
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
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64
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
FOSRENOL - lanthanum
carbonate chew tab 1000
mg (elemental)
3
METOCLOPRAMIDE ODT metoclopramide hcl orally
disintegrating tab 10 mg
3
FOSRENOL - lanthanum
carbonate oral powder pack
750 mg (elemental)
3
MOVANTIK - naloxegol
oxalate tab 12.5 mg (base
equivalent)
2
•
FOSRENOL - lanthanum
carbonate oral powder pack
1000 mg (elemental)
3
MOVANTIK - naloxegol oxalate
tab 25 mg (base equivalent)
2
•
3
OCALIVA - obeticholic acid tab
5 mg
3
GATTEX - teduglutide (rdna)
for inj kit 5 mg
•
•
•
OCALIVA - obeticholic acid tab
10 mg
3
GIAZO - balsalazide disodium
tab 1.1 gm
3
•
•
•
PENTASA - mesalamine cap cr
250 mg
3
lactulose (encephalopathy)
solution 10 gm/15ml
1
PENTASA - mesalamine cap cr
500 mg
3
LIALDA - mesalamine tab
delayed release 1.2 gm
3
2
PHOSLYRA - calcium acetate
(phosphate binder) oral soln
667 mg/5ml
3
LINZESS - linaclotide cap 72
mcg
LINZESS - linaclotide cap 145
mcg
2
RENAGEL - sevelamer hcl tab
400 mg
3
LINZESS - linaclotide cap 290
mcg
2
RENAGEL - sevelamer hcl tab
800 mg
3
MESALAMINE DR mesalamine tab delayed
release 800 mg
3
RENVELA - sevelamer
carbonate packet 0.8 gm
2
1
RENVELA - sevelamer
carbonate packet 2.4 gm
2
mesalamine enema 4 gm
1
RENVELA - sevelamer
carbonate tab 800 mg
2
1
SFROWASA - mesalamine
sulfite-free (sf) enema 4
gm/60ml
3
sulfasalazine tab delayed
release 500 mg (Azulfidine
en-tabs)
1
sulfasalazine tab 500 mg
(Azulfidine)
1
metoclopramide hcl soln
5 mg/5ml (10 mg/10ml)
metoclopramide hcl tab
5 mg (Reglan)
metoclopramide hcl tab
10 mg (Reglan)
METOCLOPRAMIDE ODT metoclopramide hcl orally
disintegrating tab 5 mg
1
1
•
•
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65
ursodiol cap 300 mg
(Actigall)
1
ursodiol tab 250 mg (Urso
250)
1
ursodiol tab 500 mg (Urso
forte)
1
VELPHORO - sucroferric
oxyhydroxide chew tab 500
mg
2
VIBERZI - eluxadoline tab 75
mg
3
•
VIBERZI - eluxadoline tab 100
mg
3
•
GENITOURINARY AGENTS
URINARY ANTI-INFECTIVES
methenamine hippurate tab
1 gm (Hiprex)
1
MONUROL - fosfomycin
tromethamine powd pack 3
gm (base equivalent)
3
nitrofurantoin
macrocrystalline cap
25 mg (Macrodantin)
1
nitrofurantoin
macrocrystalline cap
50 mg (Macrodantin)
nitrofurantoin
macrocrystalline cap
100 mg (Macrodantin)
nitrofurantoin monohydrate
macrocrystalline cap
100 mg (Macrobid)
nitrofurantoin susp
25 mg/5ml (Furadantin)
URINARY ANTISPASMODICS
bethanechol chloride tab
5 mg (Urecholine)
1
1
1
1
1
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)
darifenacin hydrobromide
tab sr 24hr 15 mg (base
equiv) (Enablex)
1
flavoxate hcl tab 100 mg
1
MYRBETRIQ - mirabegron tab
sr 24 hr 25 mg
2
MYRBETRIQ - mirabegron tab
sr 24 hr 50 mg
2
oxybutynin chloride syrup
5 mg/5ml
1
tolterodine tartrate cap sr
24hr 2 mg (Detrol la)
tolterodine tartrate cap sr
24hr 4 mg (Detrol la)
Limited Distribution
1
3
oxybutynin chloride tab
5 mg
ACA
1
ENABLEX - darifenacin
hydrobromide tab sr 24hr 15
mg (base equiv)
oxybutynin chloride tab sr
24hr 15 mg (Ditropan xl)
Dispensing Limits
1
3
oxybutynin chloride tab sr
24hr 10 mg (Ditropan xl)
Step Therapy
1
ENABLEX - darifenacin
hydrobromide tab sr 24hr 7.5
mg (base equiv)
oxybutynin chloride tab sr
24hr 5 mg (Ditropan xl)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
1
1
1
1
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66
tolterodine tartrate tab 1 mg
(Detrol)
1
tolterodine tartrate tab 2 mg
(Detrol)
3
1
GYNAZOLE-1 - butoconazole
nitrate (one dose) vaginal
cream 2%
1
TOVIAZ - fesoterodine
fumarate tab sr 24hr 4 mg
3
metronidazole vaginal gel
0.75% (Metrogel-vaginal)
TOVIAZ - fesoterodine
fumarate tab sr 24hr 8 mg
trospium chloride cap sr
24hr 60 mg
trospium chloride tab 20 mg
3
3
MICONAZOLE 3 - miconazole
nitrate vaginal suppos 200
mg
1
NUVESSA - metronidazole
vaginal gel 1.3%
3
1
PREMARIN - estrogens,
conjugated vaginal cream
0.625 mg/gm
3
terconazole vaginal cream
0.4% (Terazol 7)
1
VESICARE - solifenacin
succinate tab 5 mg
2
VESICARE - solifenacin
succinate tab 10 mg
2
VAGINAL PRODUCTS
AVC - sulfanilamide vaginal
cream 15%
3
CLEOCIN - clindamycin
phosphate vaginal suppos
100 mg
3
clindamycin phosphate
vaginal cream 2% (Cleocin)
1
CLINDESSE - clindamycin
phosphate (one dose)
vaginal cream 2%
3
ESTRACE - estradiol vaginal
cream 0.1 mg/gm
2
estradiol vaginal tab 10 mcg
(Vagifem)
1
ESTRING - estradiol vaginal
ring 2 mg (7.5 mcg/24hrs)
3
FEMRING - estradiol acetate
vaginal ring 0.05 mg/24hr
3
FEMRING - estradiol acetate
vaginal ring 0.1 mg/24hr
3
terconazole vaginal cream
0.8% (Terazol 3)
terconazole vaginal suppos
80 mg
VAGIFEM - estradiol vaginal
tab 10 mcg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
2
GENITOURINARY AGENTS - MISC.
1
alfuzosin hcl tab sr 24hr
10 mg (Uroxatral)
2
CYSTAGON - cysteamine
bitartrate cap 50 mg
2
CYSTAGON - cysteamine
bitartrate cap 150 mg
1
dutasteride cap 0.5 mg
(Avodart)
1
dutasteride-tamsulosin hcl
cap 0.5-0.4 mg (Jalyn)
3
ELMIRON - pentosan
polysulfate sodium caps 100
mg
1
finasteride tab 5 mg
(Proscar)
•
•
•
•
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LITHOSTAT - acetohydroxamic
acid tab 250 mg
3
alprazolam tab sr 24hr 2 mg
(Xanax xr)
1
potassium citrate tab cr 5
meq (540 mg) (Urocit-k 5)
1
alprazolam tab sr 24hr 3 mg
(Xanax xr)
1
alprazolam tab 0.25 mg
(Xanax)
1
alprazolam tab 0.5 mg
(Xanax)
1
alprazolam tab 1 mg (Xanax)
1
1
potassium citrate tab cr 10
meq (1080 mg) (Urocit-k 10)
1
potassium citrate tab cr 15
meq (1620 mg) (Urocit-k 15)
3
PROCYSBI - cysteamine
bitartrate cap delayed
release 25 mg (base equiv)
3
PROCYSBI - cysteamine
bitartrate cap delayed
release 75 mg (base equiv)
RAPAFLO - silodosin cap 4 mg 3
RAPAFLO - silodosin cap 8 mg
3
tamsulosin hcl cap 0.4 mg
(Flomax)
1
THIOLA - tiopronin tab 100 mg
3
•
alprazolam tab 2 mg (Xanax)
•
CENTRAL NERVOUS SYSTEM DRUGS
ANTIANXIETY AGENTS
•
•
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
1
1
1
1
1
alprazolam orally
disintegrating tab 0.5 mg
1
clorazepate dipotassium tab
15 mg (Tranxene t)
1
DIAZEPAM - diazepam oral
soln 1 mg/ml
3
1
diazepam conc 5 mg/ml
1
alprazolam tab sr 24hr
0.5 mg (Xanax xr)
alprazolam tab sr 24hr 1 mg
(Xanax xr)
1
1
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
Limited Distribution
1
1
alprazolam orally
disintegrating tab 2 mg
ACA
1
alprazolam orally
disintegrating tab 0.25 mg
(Niravam)
alprazolam orally
disintegrating tab 1 mg
Dispensing Limits
1
3
clorazepate dipotassium tab
7.5 mg (Tranxene t)
Step Therapy
1
ALPRAZOLAM INTENSOL alprazolam conc 1 mg/ml
clorazepate dipotassium tab
3.75 mg (Tranxene t)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
1
1
1
1
1
1
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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68
hydroxyzine hcl tab 25 mg
hydroxyzine hcl tab 50 mg
1
bupropion hcl tab sr 12hr
100 mg (Wellbutrin sr)
1
bupropion hcl tab sr 12hr
150 mg (Wellbutrin sr)
hydroxyzine pamoate cap
25 mg (Vistaril)
1
bupropion hcl tab sr 12hr
200 mg (Wellbutrin sr)
1
bupropion hcl tab sr 24hr
150 mg (Wellbutrin xl)
lorazepam conc 2 mg/ml
(Lorazepam intensol)
1
bupropion hcl tab sr 24hr
300 mg (Wellbutrin xl)
1
lorazepam tab 0.5 mg
(Ativan)
1
bupropion hcl tab 75 mg
(Wellbutrin)
1
lorazepam tab 1 mg (Ativan)
1
bupropion hcl tab 100 mg
(Wellbutrin)
citalopram hydrobromide
oral soln 10 mg/5ml
1
lorazepam tab 2 mg (Ativan)
meprobamate tab 200 mg
meprobamate tab 400 mg
oxazepam cap 10 mg
oxazepam cap 15 mg
oxazepam cap 30 mg
ANTIDEPRESSANTS
amitriptyline hcl tab 10 mg
amitriptyline hcl tab 25 mg
amitriptyline hcl tab 50 mg
amitriptyline hcl tab 75 mg
amitriptyline hcl tab 100 mg
amitriptyline hcl tab 150 mg
1
1
1
1
1
1
1
1
1
1
1
1
•
•
Limited Distribution
ACA
Dispensing Limits
1
3
•
Step Therapy
1
HYDROXYZINE PAMOATE hydroxyzine pamoate cap
100 mg
hydroxyzine pamoate cap
50 mg (Vistaril)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
1
citalopram hydrobromide
tab 10 mg (base equiv)
(Celexa)
1
citalopram hydrobromide
tab 20 mg (base equiv)
(Celexa)
1
citalopram hydrobromide
tab 40 mg (base equiv)
(Celexa)
1
clomipramine hcl cap 25 mg
(Anafranil)
1
clomipramine hcl cap 50 mg
(Anafranil)
1
AMOXAPINE - amoxapine tab
25 mg
3
clomipramine hcl cap 75 mg
(Anafranil)
1
AMOXAPINE - amoxapine tab
50 mg
3
desipramine hcl tab 10 mg
(Norpramin)
1
AMOXAPINE - amoxapine tab
100 mg
3
desipramine hcl tab 25 mg
(Norpramin)
1
AMOXAPINE - amoxapine tab
150 mg
3
desipramine hcl tab 50 mg
(Norpramin)
1
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desipramine hcl tab 75 mg
(Norpramin)
1
EMSAM - selegiline td patch
24hr 9 mg/24hr
3
desipramine hcl tab 100 mg
(Norpramin)
1
EMSAM - selegiline td patch
24hr 12 mg/24hr
3
desipramine hcl tab 150 mg
(Norpramin)
1
1
desvenlafaxine succinate
tab sr 24hr 25 mg (base
equiv) (Pristiq)
1
escitalopram oxalate soln
5 mg/5ml (base equiv)
(Lexapro)
escitalopram oxalate
tab 5 mg (base equiv)
(Lexapro)
1
escitalopram oxalate
tab 10 mg (base equiv)
(Lexapro)
1
escitalopram oxalate
tab 20 mg (base equiv)
(Lexapro)
1
FLUOXETINE DR - fluoxetine
hcl cap delayed release 90
mg
1
fluoxetine hcl cap 10 mg
(Prozac)
1
fluoxetine hcl cap 20 mg
(Prozac)
1
• •
fluoxetine hcl cap 40 mg
(Prozac)
1
1
•
fluoxetine hcl solution
20 mg/5ml
fluoxetine hcl tab 10 mg
desvenlafaxine succinate
tab sr 24hr 50 mg (base
equiv) (Pristiq)
desvenlafaxine succinate
tab sr 24hr 100 mg (base
equiv) (Pristiq)
1
1
DOXEPIN HCL - doxepin hcl
cap 75 mg
3
doxepin hcl cap 10 mg
1
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
•
•
•
1
1
1
1
1
DULOXETINE HCL duloxetine hcl enteric coated
pellets cap 40 mg
3
duloxetine hcl enteric
coated pellets cap 20 mg
(Cymbalta)
1
duloxetine hcl enteric
coated pellets cap 30 mg
(Cymbalta)
1
duloxetine hcl enteric
coated pellets cap 60 mg
(Cymbalta)
1
EMSAM - selegiline td patch
24hr 6 mg/24hr
3
fluoxetine hcl tab 20 mg
•
•
fluvoxamine maleate tab
25 mg
fluvoxamine maleate tab
50 mg
fluvoxamine maleate tab
100 mg
imipramine hcl tab 10 mg
(Tofranil)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
• •
1
1
1
1
1
1
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
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imipramine hcl tab 25 mg
(Tofranil)
1
NEFAZODONE HCL nefazodone hcl tab 150 mg
3
imipramine hcl tab 50 mg
(Tofranil)
1
NEFAZODONE HCL nefazodone hcl tab 200 mg
3
imipramine pamoate cap
75 mg (Tofranil-pm)
1
nefazodone hcl tab 50 mg
1
imipramine pamoate cap
100 mg (Tofranil-pm)
nefazodone hcl tab 250 mg
1
3
1
1
nortriptyline hcl cap 10 mg
(Pamelor)
1
•
nortriptyline hcl cap 25 mg
(Pamelor)
1
MAPROTILINE HCL maprotiline hcl tab 25 mg
3
•
nortriptyline hcl cap 50 mg
(Pamelor)
1
MAPROTILINE HCL maprotiline hcl tab 50 mg
3
3
•
nortriptyline hcl cap 75 mg
(Pamelor)
1
MAPROTILINE HCL maprotiline hcl tab 75 mg
paroxetine hcl tab sr 24hr
25 mg (Paxil cr)
1
MARPLAN - isocarboxazid tab
10 mg
3
paroxetine hcl tab 10 mg
(Paxil)
1
mirtazapine orally
disintegrating tab 15 mg
(Remeron soltab)
1
1
mirtazapine orally
disintegrating tab 30 mg
(Remeron soltab)
1
paroxetine hcl tab 20 mg
(Paxil)
paroxetine hcl tab 30 mg
(Paxil)
1
mirtazapine orally
disintegrating tab 45 mg
(Remeron soltab)
1
paroxetine hcl tab 40 mg
(Paxil)
1
1
mirtazapine tab 7.5 mg
1
phenelzine sulfate tab 15 mg
(Nardil)
PRISTIQ - desvenlafaxine
succinate tab sr 24hr 25 mg
(base equiv)
3
• •
PRISTIQ - desvenlafaxine
succinate tab sr 24hr 50 mg
(base equiv)
3
• •
PRISTIQ - desvenlafaxine
succinate tab sr 24hr 100
mg (base equiv)
3
• •
imipramine pamoate cap
150 mg (Tofranil-pm)
mirtazapine tab 15 mg
(Remeron)
1
mirtazapine tab 30 mg
(Remeron)
1
mirtazapine tab 45 mg
(Remeron)
1
NEFAZODONE HCL nefazodone hcl tab 100 mg
3
Limited Distribution
1
NORTRIPTYLINE HCL nortriptyline hcl soln 10
mg/5ml
imipramine pamoate cap
125 mg (Tofranil-pm)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
71
protriptyline hcl tab 5 mg
(Vivactil)
1
protriptyline hcl tab 10 mg
(Vivactil)
1
sertraline hcl oral conc
20 mg/ml (Zoloft)
venlafaxine hcl tab sr 24hr
75 mg (base equivalent)
(Venlafaxine hcl er)
1
1
1
venlafaxine hcl tab sr 24hr
150 mg (base equivalent)
(Venlafaxine hcl er)
sertraline hcl tab 25 mg
(Zoloft)
1
venlafaxine hcl tab 25 mg
1
sertraline hcl tab 50 mg
(Zoloft)
1
sertraline hcl tab 100 mg
(Zoloft)
1
SURMONTIL - trimipramine
maleate cap 25 mg
3
VIIBRYD - vilazodone hcl tab
10 mg
3
•
SURMONTIL - trimipramine
maleate cap 50 mg
3
VIIBRYD - vilazodone hcl tab
20 mg
3
•
SURMONTIL - trimipramine
maleate cap 100 mg
3
VIIBRYD - vilazodone hcl tab
40 mg
3
•
tranylcypromine sulfate tab
10 mg (Parnate)
1
VIIBRYD STARTER PACK vilazodone hcl tab starter kit
10 (7) & 20 (23) mg
3
•
trazodone hcl tab 50 mg
trazodone hcl tab 100 mg
trazodone hcl tab 150 mg
trazodone hcl tab 300 mg
1
1
1
1
venlafaxine hcl cap sr 24hr
37.5 mg (base equivalent)
(Effexor xr)
1
venlafaxine hcl cap sr 24hr
75 mg (base equivalent)
(Effexor xr)
1
venlafaxine hcl cap sr 24hr
150 mg (base equivalent)
(Effexor xr)
1
venlafaxine hcl tab sr 24hr
37.5 mg (base equivalent)
(Venlafaxine hcl er)
1
venlafaxine hcl tab 37.5 mg
venlafaxine hcl tab 50 mg
venlafaxine hcl tab 75 mg
venlafaxine hcl tab 100 mg
ANTIPSYCHOTICS
1
1
1
3
aripiprazole oral solution
1 mg/ml
1
•
1
•
1
•
1
aripiprazole orally
disintegrating tab 15 mg
aripiprazole tab 10 mg
(Abilify)
1
•
•
•
aripiprazole tab 15 mg
(Abilify)
1
•
aripiprazole tab 2 mg (Abilify)
aripiprazole tab 5 mg (Abilify)
Limited Distribution
1
ADASUVE - loxapine aerosol
powder breath activated 10
mg
aripiprazole orally
disintegrating tab 10 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
72
3
FANAPT - iloperidone tab 4 mg
3
FANAPT - iloperidone tab 6 mg
3
FANAPT - iloperidone tab 8 mg
3
FANAPT - iloperidone tab 10
mg
3
•
•
•
•
•
•
• •
FANAPT - iloperidone tab 12
mg
3
• •
3
• •
• •
FANAPT TITRATION PACK iloperidone tab 1 mg & 2 mg
& 4 mg & 6 mg titration pak
FAZACLO - clozapine orally
disintegrating tab 12.5 mg
3
• •
FAZACLO - clozapine orally
disintegrating tab 150 mg
3
• •
FAZACLO - clozapine orally
disintegrating tab 200 mg
3
• •
•
FLUPHENAZINE HCL fluphenazine hcl elixir 2.5
mg/5ml
2
FLUPHENAZINE HCL fluphenazine hcl oral conc 5
mg/ml
2
fluphenazine hcl tab 1 mg
1
•
chlorpromazine hcl tab
10 mg
chlorpromazine hcl tab
100 mg
chlorpromazine hcl tab
200 mg
1
1
1
CLOZAPINE ODT - clozapine
orally disintegrating tab 12.5
mg
3
CLOZAPINE ODT - clozapine
orally disintegrating tab 150
mg
3
CLOZAPINE ODT - clozapine
orally disintegrating tab 200
mg
3
• •
clozapine orally
disintegrating tab 25 mg
(Fazaclo)
1
•
clozapine orally
disintegrating tab 100 mg
(Fazaclo)
1
clozapine tab 25 mg
(Clozaril)
1
•
clozapine tab 50 mg
1
•
•
clozapine tab 100 mg
(Clozaril)
1
clozapine tab 200 mg
1
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr
100 mg
3
•
fluphenazine hcl tab 2.5 mg
fluphenazine hcl tab 5 mg
fluphenazine hcl tab 10 mg
haloperidol lactate oral conc
2 mg/ml
haloperidol tab 0.5 mg
Limited Distribution
Dispensing Limits
FANAPT - iloperidone tab 2 mg
•
•
•
•
•
•
1
ACA
Step Therapy
3
aripiprazole tab 30 mg
(Abilify)
chlorpromazine hcl tab
50 mg
Prior Authorization
FANAPT - iloperidone tab 1 mg
•
Drug Name
Drug Tier
1
1
chlorpromazine hcl tab
25 mg
Limited Distribution
3
1
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr
300 mg
aripiprazole tab 20 mg
(Abilify)
ACA
Dispensing Limits
3
Step Therapy
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr
200 mg
Drug Tier
Drug Name
Prior Authorization
2017
1
1
1
1
1
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
73
haloperidol tab 1 mg
haloperidol tab 2 mg
haloperidol tab 5 mg
haloperidol tab 10 mg
haloperidol tab 20 mg
1
loxapine succinate cap
25 mg
1
1
1
1
loxapine succinate cap
50 mg
• •
MOLINDONE
HYDROCHLORIDE molindone hcl tab 5 mg
3
MOLINDONE
HYDROCHLORIDE molindone hcl tab 10 mg
3
MOLINDONE
HYDROCHLORIDE molindone hcl tab 25 mg
3
NUPLAZID - pimavanserin
tartrate tab 17 mg (base
equivalent)
3
olanzapine orally
disintegrating tab 5 mg
(Zyprexa zydis)
1
•
olanzapine orally
disintegrating tab 10 mg
(Zyprexa zydis)
1
•
olanzapine orally
disintegrating tab 15 mg
(Zyprexa zydis)
1
•
olanzapine orally
disintegrating tab 20 mg
(Zyprexa zydis)
1
•
olanzapine tab 2.5 mg
(Zyprexa)
1
•
olanzapine tab 5 mg
(Zyprexa)
1
•
olanzapine tab 7.5 mg
(Zyprexa)
1
•
olanzapine tab 10 mg
(Zyprexa)
1
•
• •
• •
Limited Distribution
1
• •
• •
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Tier
Limited Distribution
loxapine succinate cap
10 mg
1
LATUDA - lurasidone hcl tab 20 3
mg
LATUDA - lurasidone hcl tab 40 3
mg
LATUDA - lurasidone hcl tab 60 3
mg
LATUDA - lurasidone hcl tab 80 3
mg
3
LATUDA - lurasidone hcl tab
120 mg
LITHIUM - lithium oral solution 3
8 meq/5ml
3
LITHIUM CARBONATE lithium carbonate cap 150
mg
3
LITHIUM CARBONATE lithium carbonate cap 600
mg
1
lithium carbonate cap
150 mg (Lithium carbonate)
1
lithium carbonate cap
300 mg
1
lithium carbonate cap
600 mg (Lithium carbonate)
1
lithium carbonate tab cr
300 mg (Lithobid)
1
lithium carbonate tab cr
450 mg
1
lithium carbonate tab
300 mg
3
LITHOBID - lithium carbonate
tab cr 300 mg
Drug Name
loxapine succinate cap 5 mg
1
1
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
74
1
•
1
•
1
•
1
•
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 (Compazine)
prochlorperazine maleate
tab 10 mg (Compazine)
prochlorperazine suppos
25 mg
•
1
•
1
•
1
•
1
•
REXULTI - brexpiprazole tab
0.25 mg
3
• •
REXULTI - brexpiprazole tab
0.5 mg
3
• •
REXULTI - brexpiprazole tab 1
mg
3
• •
1
REXULTI - brexpiprazole tab 2
mg
3
• •
1
REXULTI - brexpiprazole tab 3
mg
3
• •
1
REXULTI - brexpiprazole tab 4
mg
3
• •
• •
risperidone orally
disintegrating tab 0.25 mg
1
•
1
•
• •
risperidone orally
disintegrating tab 0.5 mg
(Risperdal m-tab)
1
•
• •
risperidone orally
disintegrating tab 1 mg
(Risperdal m-tab)
1
•
• •
risperidone orally
disintegrating tab 2 mg
(Risperdal m-tab)
1
•
•
risperidone orally
disintegrating tab 3 mg
(Risperdal m-tab)
1
1
1
1
QUETIAPINE FUMARATE ER - 3
quetiapine fumarate tab sr
24hr 50 mg
QUETIAPINE FUMARATE ER - 3
quetiapine fumarate tab sr
24hr 150 mg
QUETIAPINE FUMARATE ER - 3
quetiapine fumarate tab sr
24hr 200 mg
QUETIAPINE FUMARATE ER - 3
quetiapine fumarate tab sr
24hr 300 mg
1
quetiapine fumarate tab sr
24hr 400 mg (Seroquel xr)
1
quetiapine fumarate tab
25 mg (Seroquel)
quetiapine fumarate tab
100 mg (Seroquel)
quetiapine fumarate tab
200 mg (Seroquel)
quetiapine fumarate tab
300 mg (Seroquel)
quetiapine fumarate tab
400 mg (Seroquel)
Limited Distribution
paliperidone tab sr 24hr
1.5 mg (Invega)
paliperidone tab sr 24hr
3 mg (Invega)
1
quetiapine fumarate tab
50 mg (Seroquel)
ACA
•
Dispensing Limits
1
Step Therapy
olanzapine tab 20 mg
(Zyprexa)
Prior Authorization
•
Drug Name
Drug Tier
1
Limited Distribution
olanzapine tab 15 mg
(Zyprexa)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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75
risperidone orally
disintegrating tab 4 mg
(Risperdal m-tab)
1
risperidone soln 1 mg/ml
(Risperdal)
1
•
thiothixene cap 5 mg
risperidone tab 0.25 mg
(Risperdal)
1
•
trifluoperazine hcl tab 1 mg
risperidone tab 0.5 mg
(Risperdal)
1
•
trifluoperazine hcl tab 5 mg
risperidone tab 1 mg
(Risperdal)
1
•
risperidone tab 2 mg
(Risperdal)
1
•
risperidone tab 3 mg
(Risperdal)
1
•
risperidone tab 4 mg
(Risperdal)
1
•
SAPHRIS - asenapine maleate
sl tab 2.5 mg (base equiv)
3
• •
SAPHRIS - asenapine maleate
sl tab 5 mg (base equiv)
3
• •
SAPHRIS - asenapine maleate
sl tab 10 mg (base equiv)
3
• •
DORAL - quazepam tab 15 mg
3
1
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 50 mg
2
• •
estazolam tab 1 mg
estazolam tab 2 mg
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 150 mg
2
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 200 mg
2
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 300 mg
2
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 400 mg
2
thioridazine hcl tab 10 mg
1
thioridazine hcl tab 25 mg
thioridazine hcl tab 50 mg
thioridazine hcl tab 100 mg
thiothixene cap 1 mg
thiothixene cap 2 mg
1
1
1
• •
• •
• •
• •
thiothixene cap 10 mg
trifluoperazine hcl tab 2 mg
trifluoperazine hcl tab 10 mg
Limited Distribution
1
1
1
1
1
1
1
1
VERSACLOZ - clozapine susp
50 mg/ml
3
• •
ziprasidone hcl cap 20 mg
(Geodon)
1
•
ziprasidone hcl cap 40 mg
(Geodon)
1
•
ziprasidone hcl cap 60 mg
(Geodon)
1
•
ziprasidone hcl cap 80 mg
(Geodon)
1
•
HYPNOTICS
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
eszopiclone tab 1 mg
(Lunesta)
1
•
eszopiclone tab 2 mg
(Lunesta)
1
•
eszopiclone tab 3 mg
(Lunesta)
1
•
FLURAZEPAM HCL flurazepam hcl cap 15 mg
3
FLURAZEPAM HCL flurazepam hcl cap 30 mg
3
HETLIOZ - tasimelteon capsule 3
20 mg
3
PHENOBARBITAL phenobarbital tab 15 mg
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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PHENOBARBITAL phenobarbital tab 30 mg
3
zolpidem tartrate tab 10 mg
(Ambien)
PHENOBARBITAL phenobarbital tab 60 mg
3
PHENOBARBITAL phenobarbital tab 100 mg
3
phenobarbital elixir
20 mg/5ml
1
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/
ANOREXIANTS
2
ADDERALL XR amphetaminedextroamphetamine cap sr
24hr 5 mg
2
ADDERALL XR amphetaminedextroamphetamine cap sr
24hr 10 mg
2
ADDERALL XR amphetaminedextroamphetamine cap sr
24hr 15 mg
2
ADDERALL XR amphetaminedextroamphetamine cap sr
24hr 20 mg
2
ADDERALL XR amphetaminedextroamphetamine cap sr
24hr 25 mg
2
ADDERALL XR amphetaminedextroamphetamine cap sr
24hr 30 mg
1
amphetaminedextroamphetamine cap sr
24hr 5 mg (Adderall xr)
1
amphetaminedextroamphetamine cap sr
24hr 10 mg (Adderall xr)
1
amphetaminedextroamphetamine cap sr
24hr 15 mg (Adderall xr)
1
amphetaminedextroamphetamine cap sr
24hr 20 mg (Adderall xr)
phenobarbital tab 16.2 mg
phenobarbital tab 32.4 mg
phenobarbital tab 64.8 mg
phenobarbital tab 97.2 mg
1
1
1
1
QUAZEPAM - quazepam tab
15 mg
3
ROZEREM - ramelteon tab 8
mg
3
temazepam cap 7.5 mg
(Restoril)
1
temazepam cap 15 mg
(Restoril)
1
temazepam cap 22.5 mg
(Restoril)
1
temazepam cap 30 mg
(Restoril)
1
zaleplon cap 5 mg (Sonata)
1
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)
•
1
•
•
•
1
•
1
•
1
•
1
•
1
1
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
•
•
•
•
•
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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77
amphetaminedextroamphetamine cap sr
24hr 25 mg (Adderall xr)
amphetaminedextroamphetamine cap sr
24hr 30 mg (Adderall xr)
amphetaminedextroamphetamine tab
5 mg (Adderall)
amphetaminedextroamphetamine tab
7.5 mg (Adderall)
amphetaminedextroamphetamine tab
10 mg (Adderall)
amphetaminedextroamphetamine tab
12.5 mg (Adderall)
amphetaminedextroamphetamine tab
15 mg (Adderall)
amphetaminedextroamphetamine tab
20 mg (Adderall)
•
1
•
•
APTENSIO XR methylphenidate hcl cap er
24hr 50 mg (xr)
3
•
APTENSIO XR methylphenidate hcl cap er
24hr 60 mg (xr)
3
•
armodafinil tab 50 mg
(Nuvigil)
1
•
•
armodafinil tab 150 mg
(Nuvigil)
1
•
•
armodafinil tab 200 mg
(Nuvigil)
1
•
•
armodafinil tab 250 mg
(Nuvigil)
1
•
•
1
1
•
1
•
caffeine citrate oral soln
60 mg/3ml (10 mg/ml base
equiv) (Cafcit)
1
•
clonidine hcl tab sr 12hr
0.1 mg (Kapvay)
1
•
APTENSIO XR methylphenidate hcl cap er
24hr 10 mg (xr)
3
•
APTENSIO XR methylphenidate hcl cap er
24hr 15 mg (xr)
3
APTENSIO XR methylphenidate hcl cap er
24hr 20 mg (xr)
3
APTENSIO XR methylphenidate hcl cap er
24hr 30 mg (xr)
3
amphetaminedextroamphetamine tab
30 mg (Adderall)
3
•
•
•
1
•
CONCERTA - methylphenidate
hcl tab sa osm 18 mg
2
•
CONCERTA - methylphenidate
hcl tab sa osm 27 mg
2
•
CONCERTA - methylphenidate
hcl tab sa osm 36 mg
2
•
CONCERTA - methylphenidate
hcl tab sa osm 54 mg
2
•
dexmethylphenidate hcl cap
sr 24 hr 5 mg (Focalin xr)
1
•
1
•
1
•
1
•
dexmethylphenidate hcl cap
sr 24 hr 10 mg (Focalin xr)
dexmethylphenidate hcl cap
sr 24 hr 15 mg (Focalin xr)
dexmethylphenidate hcl cap
sr 24 hr 20 mg (Focalin xr)
Limited Distribution
1
APTENSIO XR methylphenidate hcl cap er
24hr 40 mg (xr)
ACA
•
Dispensing Limits
1
Step Therapy
•
Prior Authorization
1
Drug Name
Drug Tier
•
Limited Distribution
1
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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78
•
1
•
1
•
1
•
dextroamphetamine
sulfate cap sr 24hr 5 mg
(Dexedrine)
1
•
dextroamphetamine
sulfate cap sr 24hr 10 mg
(Dexedrine)
1
•
dextroamphetamine
sulfate cap sr 24hr 15 mg
(Dexedrine)
1
•
dextroamphetamine sulfate
oral solution 5 mg/5ml
(Procentra)
1
•
dextroamphetamine sulfate
tab 5 mg
1
•
1
•
FOCALIN XR dexmethylphenidate hcl cap
sr 24 hr 25 mg
3
•
FOCALIN XR dexmethylphenidate hcl cap
sr 24 hr 35 mg
3
•
guanfacine hcl tab sr 24hr
1 mg (base equiv) (Intuniv)
1
•
dexmethylphenidate hcl tab
2.5 mg (Focalin)
dexmethylphenidate hcl tab
5 mg (Focalin)
dexmethylphenidate hcl tab
10 mg (Focalin)
dextroamphetamine sulfate
tab 10 mg
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
METHYLPHENIDATE HCL
ER - methylphenidate hcl tab
sr 24hr 18 mg
1
•
METHYLPHENIDATE HCL
ER - methylphenidate hcl tab
sr 24hr 27 mg
1
•
guanfacine hcl tab sr 24hr
3 mg (base equiv) (Intuniv)
guanfacine hcl tab sr 24hr
4 mg (base equiv) (Intuniv)
methamphetamine hcl tab
5 mg (Desoxyn)
methylphenidate hcl cap cr
10 mg (cd) (Metadate cd)
methylphenidate hcl cap cr
20 mg (cd) (Metadate cd)
methylphenidate hcl cap cr
30 mg (cd) (Metadate cd)
methylphenidate hcl cap cr
40 mg (cd) (Metadate cd)
methylphenidate hcl cap cr
50 mg (cd) (Metadate cd)
methylphenidate hcl cap cr
60 mg (cd) (Metadate cd)
methylphenidate hcl cap sr
24hr 20 mg (la) (Ritalin la)
methylphenidate hcl cap sr
24hr 30 mg (la) (Ritalin la)
methylphenidate hcl cap sr
24hr 40 mg (la) (Ritalin la)
methylphenidate hcl chew
tab 2.5 mg (Methylin)
methylphenidate hcl chew
tab 5 mg (Methylin)
methylphenidate hcl chew
tab 10 mg (Methylin)
Limited Distribution
1
dexmethylphenidate hcl cap
sr 24 hr 40 mg (Focalin xr)
1
guanfacine hcl tab sr 24hr
2 mg (base equiv) (Intuniv)
ACA
•
Dispensing Limits
1
dexmethylphenidate hcl cap
sr 24 hr 35 mg (Focalin xr)
Step Therapy
•
Prior Authorization
1
dexmethylphenidate hcl cap
sr 24 hr 30 mg (Focalin xr)
Drug Name
Drug Tier
•
Limited Distribution
1
dexmethylphenidate hcl cap
sr 24 hr 25 mg (Focalin xr)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
79
1
METHYLPHENIDATE HCL
ER - methylphenidate hcl tab
sr 24hr 54 mg
1
methylphenidate hcl soln
5 mg/5ml (Methylin)
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
1
•
methylphenidate hcl soln
10 mg/5ml (Methylin)
methylphenidate hcl tab cr
10 mg
methylphenidate hcl tab cr
20 mg (Ritalin sr)
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)
1
•
•
modafinil tab 200 mg
(Provigil)
1
•
•
NUVIGIL - armodafinil tab 50
mg
3
•
•
NUVIGIL - armodafinil tab 150
mg
3
•
•
NUVIGIL - armodafinil tab 200
mg
3
•
•
3
STRATTERA - atomoxetine hcl
cap 10 mg (base equiv)
3
•
STRATTERA - atomoxetine hcl
cap 18 mg (base equiv)
3
•
STRATTERA - atomoxetine hcl
cap 25 mg (base equiv)
3
•
STRATTERA - atomoxetine hcl
cap 40 mg (base equiv)
3
•
STRATTERA - atomoxetine hcl
cap 60 mg (base equiv)
3
•
STRATTERA - atomoxetine hcl
cap 80 mg (base equiv)
3
•
STRATTERA - atomoxetine hcl
cap 100 mg (base equiv)
3
•
VYVANSE - lisdexamfetamine
dimesylate cap 10 mg
2
•
VYVANSE - lisdexamfetamine
dimesylate cap 20 mg
2
•
VYVANSE - lisdexamfetamine
dimesylate cap 30 mg
2
•
VYVANSE - lisdexamfetamine
dimesylate cap 40 mg
2
•
VYVANSE - lisdexamfetamine
dimesylate cap 50 mg
2
•
VYVANSE - lisdexamfetamine
dimesylate cap 60 mg
2
•
VYVANSE - lisdexamfetamine
dimesylate cap 70 mg
2
•
VYVANSE - lisdexamfetamine
dimesylate chew tab 10 mg
2
•
VYVANSE - lisdexamfetamine
dimesylate chew tab 20 mg
2
•
VYVANSE - lisdexamfetamine
dimesylate chew tab 30 mg
2
•
VYVANSE - lisdexamfetamine
dimesylate chew tab 40 mg
2
•
Limited Distribution
•
NUVIGIL - armodafinil tab 250
mg
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
METHYLPHENIDATE HCL
ER - methylphenidate hcl tab
sr 24hr 36 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
80
PSYCHOTHERAPEUTIC and NEUROLOGICAL
AGENTS - MISC.
1
acamprosate calcium tab
delayed release 333 mg
(Campral)
•
AMPYRA - dalfampridine tab sr 3 •
12hr 10 mg
•
AUBAGIO - teriflunomide tab 7 2
mg
2
•
AUBAGIO - teriflunomide tab
14 mg
2
•
AVONEX - interferon beta-1a
for im inj kit 30mcg
(33mcg(6.6 mu)/vial)
2
•
AVONEX - interferon beta-1a
im prefilled syringe kit 30
mcg/0.5ml
2
•
AVONEX PEN - interferon
beta-1a im auto-injector kit
30 mcg/0.5ml
2
•
BETASERON - interferon
beta-1b for inj kit 0.3 mg
A
bupropion hcl (smoking
deterrent) tab sr 12hr
150 mg (Zyban)
CHANTIX - varenicline tartrate A
tab 0.5 mg (base equiv)
CHANTIX - varenicline tartrate A
tab 1 mg (base equiv)
A
CHANTIX CONTINUING
MONTH - varenicline tartrate
tab 1 mg (base equiv)
•
Limited Distribution
ACA
•
Dispensing Limits
2
Step Therapy
VYVANSE - lisdexamfetamine
dimesylate chew tab 60 mg
Prior Authorization
•
Drug Name
Drug Tier
2
Limited Distribution
VYVANSE - lisdexamfetamine
dimesylate chew tab 50 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
CHANTIX STARTING MONTH
PA - varenicline tartrate tab
0.5 mg x 11 & tab 1 mg x 42
pack
A
CHLORDIAZEPOXIDE/
AMITRIPT chlordiazepoxideamitriptyline tab 5-12.5 mg
3
CHLORDIAZEPOXIDE/
AMITRIPT chlordiazepoxideamitriptyline tab 10-25 mg
3
COMMIT - nicotine polacrilex
lozenge 2 mg
A
•
COMMIT - nicotine polacrilex
lozenge 4 mg
A
•
COPAXONE - glatiramer
acetate soln prefilled syringe
20 mg/ml
2
•
•
COPAXONE - glatiramer
acetate soln prefilled syringe
40 mg/ml
2
•
•
disulfiram tab 250 mg
(Antabuse)
1
disulfiram tab 500 mg
(Antabuse)
1
•
donepezil hydrochloride
orally disintegrating tab
5 mg
1
•
donepezil hydrochloride
orally disintegrating tab
10 mg (Aricept odt)
•
•
•
•
•
•
•
•
•
donepezil hydrochloride tab
5 mg (Aricept)
donepezil hydrochloride tab
10 mg (Aricept)
donepezil hydrochloride tab
23 mg (Aricept)
1
1
1
1
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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81
3
•
3
HORIZANT - gabapentin
enacarbil tab cr 300 mg
3
•
FLUOXETINE - fluoxetine hcl
(pmdd) cap 20 mg
3
HORIZANT - gabapentin
enacarbil tab cr 600 mg
3
•
GALANTAMINE
HYDROBROMIDE galantamine hydrobromide
oral soln 4 mg/ml
3
memantine hcl oral solution
2 mg/ml (Namenda)
1
galantamine hydrobromide
cap sr 24hr 8 mg
(Razadyne er)
1
3
EXTAVIA - interferon beta-1b
for inj kit 0.3 mg
3
FLUOXETINE - fluoxetine hcl
(pmdd) cap 10 mg
• •
•
memantine hcl tab 5 mg
(Namenda)
1
memantine hcl tab 10 mg
(Namenda)
1
memantine hcl tab 5 mg (28)
& 10 mg (21) titration pak
(Namenda titration pa)
1
galantamine hydrobromide
cap sr 24hr 16 mg
(Razadyne er)
1
1
NAMENDA XR - memantine
hcl cap sr 24hr 7 mg
3
galantamine hydrobromide
cap sr 24hr 24 mg
(Razadyne er)
3
galantamine hydrobromide
tab 4 mg (Razadyne)
1
NAMENDA XR - memantine
hcl cap sr 24hr 14 mg
NAMENDA XR - memantine
hcl cap sr 24hr 21 mg
3
NAMENDA XR - memantine
hcl cap sr 24hr 28 mg
3
galantamine hydrobromide
tab 8 mg (Razadyne)
galantamine hydrobromide
tab 12 mg (Razadyne)
1
1
GILENYA - fingolimod hcl cap
0.5 mg (base equiv)
2
•
•
glatiramer acetate soln
prefilled syringe 20 mg/ml
(Copaxone)
1
•
•
GRALISE - gabapentin (oncedaily) tab 300 mg
3
•
GRALISE - gabapentin (oncedaily) tab 600 mg
3
•
Limited Distribution
GRALISE STARTER gabapentin (once-daily) tab
pack 300 mg (9) & 600 mg
(69)
ERGOLOID MESYLATES ergoloid mesylates tab 1 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
3
NAMENDA XR TITRATION
PACK - memantine hcl cap sr
24hr 7 mg & 14 mg & 21 mg
& 28 mg pack
3
NAMZARIC - memantine hcldonepezil hcl cap sr 24hr
7-10 mg
3
NAMZARIC - memantine hcldonepezil hcl cap sr 24hr
14-10 mg
3
NAMZARIC - memantine hcldonepezil hcl cap sr 24hr
21-10 mg
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
82
NICOTINE TRANSDERMAL
SYST - nicotine td patch 24
hr kit 21-14-7 mg/24hr
A
•
NICOTROL INHALER nicotine inhaler system 10
mg (4 mg delivered)
A
•
NICOTROL NS - nicotine nasal
spray 10 mg/ml (0.5 mg/
spray)
A
•
NUEDEXTA dextromethorphan hbrquinidine sulfate cap 20-10
mg
2
olanzapine-fluoxetine hcl
cap 3-25 mg (Symbyax)
1
NAMZARIC - memantinedonepezil cap er 24hr 7 & 14
& 21 & 28-10 mg pack
NICODERM CQ - nicotine td
patch 24hr 7 mg/24hr
A
•
NICODERM CQ - nicotine td
patch 24hr 14 mg/24hr
A
•
NICODERM CQ - nicotine td
patch 24hr 21 mg/24hr
A
•
NICORETTE - nicotine
polacrilex gum 2 mg
A
•
NICORETTE - nicotine
polacrilex gum 4 mg
A
•
NICORETTE - nicotine
polacrilex lozenge 2 mg
A
•
NICORETTE - nicotine
polacrilex lozenge 4 mg
A
•
NICORETTE MINI - nicotine
polacrilex lozenge 2 mg
A
•
NICORETTE MINI - nicotine
polacrilex lozenge 4 mg
A
•
NICORETTE STARTER KIT nicotine polacrilex gum 2 mg
A
•
NICORETTE STARTER KIT nicotine polacrilex gum 4 mg
A
•
nicotine polacrilex gum
2 mg
A
•
nicotine polacrilex lozenge
4 mg
nicotine td patch 24hr
7 mg/24hr
A
•
A
•
A
•
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)
Limited Distribution
•
nicotine td patch 24hr
21 mg/24hr
nicotine polacrilex lozenge
2 mg
ACA
A
3
nicotine td patch 24hr
14 mg/24hr
•
Dispensing Limits
•
3
A
Step Therapy
A
NAMZARIC - memantine hcldonepezil hcl cap sr 24hr
28-10 mg
nicotine polacrilex gum
4 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
1
1
ORAP - pimozide tab 1 mg
3
ORAP - pimozide tab 2 mg
3
PERPHENAZINE/
AMITRIPTYLIN perphenazine-amitriptyline
tab 2-10 mg
3
PERPHENAZINE/
AMITRIPTYLIN perphenazine-amitriptyline
tab 2-25 mg
3
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
83
•
2
•
PERPHENAZINE/
AMITRIPTYLIN perphenazine-amitriptyline
tab 4-50 mg
3
REBIF TITRATION PACK interferon beta-1a pref syr
6x8.8 mcg/0.2ml & 6x22
mcg/0.5ml
rivastigmine tartrate cap
1.5 mg (Exelon)
1
pimozide tab 1 mg (Orap)
1
3
PERPHENAZINE/
AMITRIPTYLIN perphenazine-amitriptyline
tab 4-25 mg
pimozide tab 2 mg (Orap)
1
rivastigmine tartrate cap
3 mg (Exelon)
•
•
2
•
•
PLEGRIDY STARTER PACK peginterferon beta-1a soln
pen-inj 63 & 94 mcg/0.5ml
pack
2
•
•
PLEGRIDY STARTER PACK peginterferon beta-1a soln
pref syr 63 & 94 mcg/0.5ml
pack
2
REBIF - interferon beta-1a
soln pref syr 22 mcg/0.5ml
(12mu/ml)
2
REBIF - interferon beta-1a
soln pref syr 44 mcg/0.5ml
(24mu/ml)
2
REBIF REBIDOSE - interferon
beta-1a soln auto-inj 22
mcg/0.5ml (12mu/ml)
2
REBIF REBIDOSE - interferon
beta-1a soln auto-inj 44
mcg/0.5ml (24mu/ml)
2
PLEGRIDY - peginterferon
beta-1a soln pen-injector
125 mcg/0.5ml
2
PLEGRIDY - peginterferon
beta-1a soln prefilled syringe
125 mcg/0.5ml
rivastigmine tartrate cap
4.5 mg (Exelon)
rivastigmine tartrate cap
6 mg (Exelon)
rivastigmine td patch 24hr
4.6 mg/24hr (Exelon)
rivastigmine td patch 24hr
9.5 mg/24hr (Exelon)
rivastigmine td patch 24hr
13.3 mg/24hr (Exelon)
•
•
•
•
•
•
•
•
•
•
Limited Distribution
2
3
REBIF REBIDOSE
TITRATION - interferon
beta-1a auto-inj 6x8.8
mcg/0.2ml & 6x22
mcg/0.5ml
PERPHENAZINE/
AMITRIPTYLIN perphenazine-amitriptyline
tab 4-10 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
•
1
1
1
1
1
1
SAVELLA - milnacipran hcl tab
12.5 mg
3
•
SAVELLA - milnacipran hcl tab
25 mg
3
•
SAVELLA - milnacipran hcl tab
50 mg
3
•
SAVELLA - milnacipran hcl tab
100 mg
3
•
SAVELLA TITRATION PACK milnacipran hcl tab 12.5 mg
(5) & 25 mg (8) & 50 mg (42)
pak
3
•
TECFIDERA - dimethyl
fumarate capsule delayed
release 120 mg
2
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
84
ABSTRAL - fentanyl citrate sl
tab 300 mcg (base equiv)
3
•
•
•
ABSTRAL - fentanyl citrate sl
tab 400 mcg (base equiv)
3
•
•
•
•
ABSTRAL - fentanyl citrate sl
tab 600 mcg (base equiv)
3
•
•
•
•
ABSTRAL - fentanyl citrate sl
tab 800 mcg (base equiv)
3
•
•
acetaminophen w/ codeine
soln 120-12 mg/5ml
1
•
•
tetrabenazine tab 25 mg
(Xenazine)
1
•
XYREM - sodium oxybate oral
solution 500 mg/ml
3
•
ZYBAN - bupropion hcl
(smoking deterrent) tab sr
12hr 150 mg
A
•
•
ANALGESICS AND ANESTHETICS
•
•
acetaminophen w/ codeine
tab 300-15 mg (Tylenol/
codeine)
1
acetaminophen w/ codeine
tab 300-30 mg (Tylenol/
codeine #3)
1
acetaminophen w/ codeine
tab 300-60 mg (Tylenol/
codeine #4)
1
1
butalbital-acetaminophencaffeine cap 50-300-40 mg
(Fioricet)
1
acetaminophen-caffeinedihydrocodeine cap
320.5-30-16 mg (Trezix)
butalbital-acetaminophencaffeine cap 50-325-40 mg
1
BELBUCA - buprenorphine hcl
buccal film 75 mcg (base
equivalent)
3
•
BELBUCA - buprenorphine hcl
buccal film 150 mcg (base
equivalent)
3
•
BELBUCA - buprenorphine hcl
buccal film 300 mcg (base
equivalent)
3
•
BELBUCA - buprenorphine hcl
buccal film 450 mcg (base
equivalent)
3
•
butalbital-acetaminophencaffeine tab 50-325-40 mg
(Esgic)
1
butalbital-aspirin-caffeine
cap 50-325-40 mg (Fiorinal)
1
diflunisal tab 500 mg
TENCON - butalbitalacetaminophen tab 50-325
mg
ANALGESICS - NARCOTIC
1
1
Limited Distribution
•
•
•
ACA
•
1
1
Dispensing Limits
3
tetrabenazine tab 12.5 mg
(Xenazine)
butalbital-acetaminophen
tab 50-325 mg
Step Therapy
ABSTRAL - fentanyl citrate sl
tab 200 mcg (base equiv)
TECFIDERA STARTER
PACK - dimethyl fumarate
capsule dr starter pack 120
mg & 240 mg
A
Prior Authorization
•
2
aspirin tab delayed release
81 mg
Drug Tier
3
2
•
Drug Name
ABSTRAL - fentanyl citrate sl
tab 100 mcg (base equiv)
TECFIDERA - dimethyl
fumarate capsule delayed
release 240 mg
ANALGESICS - NON-NARCOTIC
A
aspirin chew tab 81 mg
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
85
BUTRANS - buprenorphine td
patch weekly 7.5 mcg/hr
3
•
BUTRANS - buprenorphine td
patch weekly 10 mcg/hr
3
•
BUTRANS - buprenorphine td
patch weekly 15 mcg/hr
3
•
BUTRANS - buprenorphine td
patch weekly 20 mcg/hr
3
•
codeine sulfate tab 15 mg
(Codeine sulfate)
1
•
codeine sulfate tab 30 mg
1
1
•
EMBEDA - morphinenaltrexone cap cr 20-0.8 mg
3
•
1
•
EMBEDA - morphinenaltrexone cap cr 30-1.2 mg
3
•
1
•
EMBEDA - morphinenaltrexone cap cr 50-2 mg
3
•
EMBEDA - morphinenaltrexone cap cr 60-2.4 mg
3
•
EMBEDA - morphinenaltrexone cap cr 80-3.2 mg
3
•
EMBEDA - morphinenaltrexone cap cr 100-4 mg
3
•
EXALGO - hydromorphone hcl
tab er 24hr deter 32 mg
3
•
FENTANYL - fentanyl td patch
72hr 37.5 mcg/hr
3
•
FENTANYL - fentanyl td patch
72hr 62.5 mcg/hr
3
•
FENTANYL - fentanyl td patch
72hr 87.5 mcg/hr
3
•
BELBUCA - buprenorphine hcl
buccal film 900 mcg (base
equivalent)
3
•
BUNAVAIL - buprenorphinenaloxone buccal film 2.1-0.3
mg (base equiv)
3
•
BUNAVAIL - buprenorphinenaloxone buccal film 4.2-0.7
mg (base equiv)
3
•
BUNAVAIL - buprenorphinenaloxone buccal film 6.3-1
mg (base equiv)
3
buprenorphine hcl sl tab
2 mg (base equiv)
1
butalbital-acetaminophencaff w/ cod cap
50-300-40-30 mg (Fioricet/
codeine)
1
butalbital-acetaminophencaff w/ cod cap
50-325-40-30 mg
1
1
•
•
codeine sulfate tab 60 mg
1
Limited Distribution
•
butorphanol tartrate nasal
soln 10 mg/ml
ACA
Dispensing Limits
Step Therapy
3
BELBUCA - buprenorphine hcl
buccal film 750 mcg (base
equivalent)
butalbital-aspirincaff w/ codeine cap
50-325-40-30 mg (Fiorinal/
codeine #3)
Prior Authorization
BUTRANS - buprenorphine td
patch weekly 5 mcg/hr
3
buprenorphine hcl-naloxone
hcl sl tab 8-2 mg (base
equiv)
Drug Tier
•
3
buprenorphine hcl-naloxone
hcl sl tab 2-0.5 mg (base
equiv)
Drug Name
1
BELBUCA - buprenorphine hcl
buccal film 600 mcg (base
equivalent)
buprenorphine hcl sl tab
8 mg (base equiv)
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
86
fentanyl citrate lollipop
200 mcg (Actiq)
fentanyl citrate lollipop
400 mcg (Actiq)
fentanyl citrate lollipop
600 mcg (Actiq)
fentanyl citrate lollipop
800 mcg (Actiq)
fentanyl citrate lollipop
1200 mcg (Actiq)
fentanyl citrate lollipop
1600 mcg (Actiq)
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)
•
•
1
•
•
1
•
•
1
•
•
1
•
1
•
1
•
1
•
1
•
•
•
•
•
3
•
•
FENTORA - fentanyl citrate
buccal tab 600 mcg (base
equiv)
3
•
•
FENTORA - fentanyl citrate
buccal tab 800 mcg (base
equiv)
3
FENTORA - fentanyl citrate
buccal tab 100 mcg (base
equiv)
3
FENTORA - fentanyl citrate
buccal tab 200 mcg (base
equiv)
3
FENTORA - fentanyl citrate
buccal tab 400 mcg (base
equiv)
•
•
hydrocodoneacetaminophen tab
2.5-325 mg
hydrocodoneacetaminophen tab
10-325 mg (Norco)
hydrocodoneacetaminophen tab
5-300 mg (Xodol)
hydrocodoneacetaminophen tab
7.5-300 mg (Xodol)
hydrocodoneacetaminophen tab
5-325 mg (Norco)
hydrocodoneacetaminophen tab
7.5-325 mg (Norco)
hydrocodoneacetaminophen tab
10-300 mg (Xodol)
hydrocodone-ibuprofen tab
5-200 mg (Reprexain)
hydrocodone-ibuprofen tab
7.5-200 mg (Vicoprofen)
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)
Limited Distribution
1
hydrocodoneacetaminophen soln
10-325 mg/15ml (Zamicet)
ACA
•
Dispensing Limits
•
Step Therapy
1
hydrocodoneacetaminophen soln
7.5-325 mg/15ml (Hycet)
Prior Authorization
•
Drug Name
Drug Tier
•
Limited Distribution
1
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
1
1
1
1
1
1
1
1
1
1
1
1
•
1
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
87
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)
3
•
1
LAZANDA - fentanyl citrate
nasal spray 400 mcg/act
(base equiv)
1
LEVORPHANOL TARTRATE levorphanol tartrate tab 2 mg
3
1
MEPERIDINE HCL meperidine hcl oral soln 50
mg/5ml
3
methadone hcl conc 10 mg/
ml (Methadose)
1
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter
20 mg
3
•
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter
30 mg
3
•
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter
40 mg
3
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter
60 mg
3
•
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter
80 mg
3
•
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter
100 mg
3
•
HYSINGLA ER - hydrocodone
bitartrate tab er 24hr deter
120 mg
3
•
IONSYS - fentanyl hcl
iontophoretic td system 40
mcg/act (base equiv)
3
LAZANDA - fentanyl citrate
nasal spray 100 mcg/act
(base equiv)
3
•
methadone hcl soln
5 mg/5ml (Methadone hcl)
methadone hcl soln
10 mg/5ml (Methadone hcl)
methadone hcl tab for oral
susp 40 mg
1
1
1
1
methadone hcl tab 10 mg
(Dolophine)
1
MORPHINE SULFATE morphine sulfate tab 15 mg
2
MORPHINE SULFATE morphine sulfate tab 30 mg
2
morphine sulfate cap sr 24hr
10 mg (Kadian)
1
•
1
•
1
•
1
•
1
•
morphine sulfate cap sr 24hr
30 mg (Kadian)
•
•
methadone hcl tab 5 mg
(Dolophine hcl)
morphine sulfate cap sr 24hr
20 mg (Kadian)
•
•
morphine sulfate cap sr 24hr
50 mg (Kadian)
morphine sulfate cap sr 24hr
60 mg (Kadian)
Limited Distribution
•
ACA
3
Dispensing Limits
LAZANDA - fentanyl citrate
nasal spray 300 mcg/act
(base equiv)
Step Therapy
•
Prior Authorization
1
Drug Name
Drug Tier
•
Limited Distribution
1
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
88
morphine sulfate cap sr 24hr
80 mg (Kadian)
morphine sulfate cap sr 24hr
100 mg (Kadian)
•
OPANA ER (CRUSH
RESISTANT - oxymorphone
hcl tab er 12hr deter 7.5 mg
3
•
•
OPANA ER (CRUSH
RESISTANT - oxymorphone
hcl tab er 12hr deter 10 mg
3
•
•
OPANA ER (CRUSH
RESISTANT - oxymorphone
hcl tab er 12hr deter 15 mg
3
•
•
OPANA ER (CRUSH
RESISTANT - oxymorphone
hcl tab er 12hr deter 20 mg
3
•
•
OPANA ER (CRUSH
RESISTANT - oxymorphone
hcl tab er 12hr deter 30 mg
3
•
•
OPANA ER (CRUSH
RESISTANT - oxymorphone
hcl tab er 12hr deter 40 mg
3
•
3
MORPHINE SULFATE ER morphine sulfate beads cap
sr 24hr 45 mg
3
MORPHINE SULFATE ER morphine sulfate beads cap
sr 24hr 60 mg
3
MORPHINE SULFATE ER morphine sulfate beads cap
sr 24hr 75 mg
3
MORPHINE SULFATE ER morphine sulfate beads cap
sr 24hr 90 mg
3
MORPHINE SULFATE ER morphine sulfate beads cap
sr 24hr 120 mg
3
morphine sulfate oral soln
10 mg/5ml
1
OXAYDO - oxycodone hcl tab
abuse deter 5 mg
3
1
OXAYDO - oxycodone hcl tab
abuse deter 7.5 mg
oxycodone hcl cap 5 mg
1
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)
1
1
•
1
•
1
•
1
•
1
•
oxycodone hcl conc
100 mg/5ml (20 mg/ml)
(Oxycodone hcl)
1
OXYCODONE HCL ER oxycodone hcl tab er 12hr
deter 10 mg
3
•
OXYCODONE HCL ER oxycodone hcl tab er 12hr
deter 15 mg
3
•
OXYCODONE HCL ER oxycodone hcl tab er 12hr
deter 20 mg
3
•
Limited Distribution
•
ACA
3
MORPHINE SULFATE ER morphine sulfate beads cap
sr 24hr 30 mg
morphine sulfate oral soln
100 mg/5ml (20 mg/ml)
Dispensing Limits
OPANA ER (CRUSH
RESISTANT - oxymorphone
hcl tab er 12hr deter 5 mg
3
morphine sulfate oral soln
20 mg/5ml
Step Therapy
•
Prior Authorization
1
Drug Name
Drug Tier
•
Limited Distribution
1
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
89
3
OXYCODONE HCL ER oxycodone hcl tab er 12hr
deter 80 mg
3
oxycodone hcl soln
5 mg/5ml (Oxycodone hcl)
1
OXYCODONE/IBUPROFEN oxycodone-ibuprofen tab
5-400 mg
3
OXYCONTIN - oxycodone hcl
tab er 12hr deter 10 mg
2
•
OXYCONTIN - oxycodone hcl
tab er 12hr deter 15 mg
2
•
1
OXYCONTIN - oxycodone hcl
tab er 12hr deter 20 mg
2
•
oxycodone hcl tab 5 mg
(Roxicodone)
1
OXYCONTIN - oxycodone hcl
tab er 12hr deter 30 mg
2
•
oxycodone hcl tab 10 mg
1
2
•
•
•
oxycodone hcl tab 15 mg
(Roxicodone)
1
OXYCONTIN - oxycodone hcl
tab er 12hr deter 40 mg
2
•
oxycodone hcl tab 20 mg
1
OXYCONTIN - oxycodone hcl
tab er 12hr deter 60 mg
•
oxycodone hcl tab 30 mg
(Roxicodone)
1
OXYCONTIN - oxycodone hcl
tab er 12hr deter 80 mg
2
oxycodone w/
acetaminophen tab
2.5-325 mg (Percocet)
1
oxymorphone hcl tab 5 mg
(Opana)
1
oxymorphone hcl tab 10 mg
(Opana)
1
OXYMORPHONE
HYDROCHLORIDE oxymorphone hcl tab sr 12hr
5 mg
1
•
OXYMORPHONE
HYDROCHLORIDE oxymorphone hcl tab sr 12hr
7.5 mg
1
•
OXYMORPHONE
HYDROCHLORIDE oxymorphone hcl tab sr 12hr
10 mg
1
•
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 (Percodan)
1
1
1
1
Limited Distribution
OXYCODONE HCL ER oxycodone hcl tab er 12hr
deter 60 mg
OXYCODONE/
ACETAMINOPHEN oxycodone w/
acetaminophen soln 5-325
mg/5ml
ACA
•
Dispensing Limits
3
Step Therapy
OXYCODONE HCL ER oxycodone hcl tab er 12hr
deter 40 mg
Prior Authorization
•
Drug Name
Drug Tier
3
Limited Distribution
OXYCODONE HCL ER oxycodone hcl tab er 12hr
deter 30 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
90
3
•
SUBSYS - fentanyl sublingual
spray 1600 mcg (800 mcg x
2)
3
•
tramadol hcl tab sr 24hr
100 mg (Ultram er)
1
•
1
•
1
•
1
•
1
•
1
•
tramadol hcl tab 50 mg
(Ultram)
1
•
•
tramadol-acetaminophen tab
37.5-325 mg (Ultracet)
1
•
XARTEMIS XR - oxycodone
w/ acetaminophen tab cr
7.5-325 mg
1
OXYMORPHONE
HYDROCHLORIDE oxymorphone hcl tab sr 12hr
20 mg
1
OXYMORPHONE
HYDROCHLORIDE oxymorphone hcl tab sr 12hr
30 mg
1
OXYMORPHONE
HYDROCHLORIDE oxymorphone hcl tab sr 12hr
40 mg
1
SUBOXONE - buprenorphine
hcl-naloxone hcl sl film 2-0.5
mg (base equiv)
3
SUBOXONE - buprenorphine
hcl-naloxone hcl sl film 4-1
mg (base equiv)
3
•
SUBOXONE - buprenorphine
hcl-naloxone hcl sl film 8-2
mg (base equiv)
3
SUBOXONE - buprenorphine
hcl-naloxone hcl sl film 12-3
mg (base equiv)
3
SUBSYS - fentanyl sublingual
spray 100 mcg
3
•
•
SUBSYS - fentanyl sublingual
spray 200 mcg
3
•
•
SUBSYS - fentanyl sublingual
spray 400 mcg
3
•
•
SUBSYS - fentanyl sublingual
spray 600 mcg
3
•
•
SUBSYS - fentanyl sublingual
spray 800 mcg
3
•
•
•
•
•
•
tramadol hcl tab sr 24hr
200 mg (Ultram er)
tramadol hcl tab sr 24hr
300 mg (Ultram er)
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
•
Limited Distribution
SUBSYS - fentanyl sublingual
spray 1200 mcg (600 mcg x
2)
OXYMORPHONE
HYDROCHLORIDE oxymorphone hcl tab sr 12hr
15 mg
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
3
•
XTAMPZA ER - oxycodone cap 3
er 12hr abuse-deterrent 9
mg
XTAMPZA ER - oxycodone cap 3
er 12hr abuse-deterrent 13.5
mg
XTAMPZA ER - oxycodone cap 3
er 12hr abuse-deterrent 18
mg
XTAMPZA ER - oxycodone cap 3
er 12hr abuse-deterrent 27
mg
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
91
XTAMPZA ER - oxycodone cap 3
er 12hr abuse-deterrent 36
mg
3
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr abusedeterrent 10 mg
3
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr abusedeterrent 15 mg
3
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr abusedeterrent 20 mg
3
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr abusedeterrent 30 mg
3
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr abusedeterrent 40 mg
3
ZOHYDRO ER - hydrocodone
bitartrate cap sr 12hr abusedeterrent 50 mg
ZUBSOLV - buprenorphine hcl- 3
naloxone hcl sl tab 0.7-0.18
mg (base eq)
ZUBSOLV - buprenorphine hcl- 3
naloxone hcl sl tab 1.4-0.36
mg (base eq)
ZUBSOLV - buprenorphine hcl- 3
naloxone hcl sl tab 2.9-0.71
mg (base eq)
ZUBSOLV - buprenorphine hcl- 3
naloxone hcl sl tab 5.7-1.4
mg (base eq)
ZUBSOLV - buprenorphine hcl- 3
naloxone hcl sl tab 8.6-2.1
mg (base eq)
ZUBSOLV - buprenorphine hcl- 3
naloxone hcl sl tab 11.4-2.9
mg (base eq)
•
•
•
•
•
•
•
•
•
•
•
•
ANALGESICS - ANTI-INFLAMMATORY
3 •
ACTEMRA - tocilizumab
subcutaneous soln prefilled
syringe 162 mg/0.9ml
3 •
ARCALYST - rilonacept for inj
220 mg
1
celecoxib cap 50 mg
(Celebrex)
1
celecoxib cap 100 mg
(Celebrex)
1
celecoxib cap 200 mg
(Celebrex)
1
celecoxib cap 400 mg
(Celebrex)
1
diclofenac potassium tab
50 mg (Cataflam)
1
diclofenac sodium tab
delayed release 25 mg
1
diclofenac sodium tab
delayed release 50 mg
1
diclofenac sodium tab
delayed release 75 mg
1
diclofenac sodium tab sr
24hr 100 mg (Voltaren-xr)
1
diclofenac w/ misoprostol
tab delayed release
50-0.2 mg (Arthrotec 50)
1
diclofenac w/ misoprostol
tab delayed release
75-0.2 mg (Arthrotec 75)
2 •
ENBREL - etanercept for
subcutaneous inj 25 mg
2 •
ENBREL - etanercept
subcutaneous soln prefilled
syringe 25 mg/0.5ml
2 •
ENBREL - etanercept
subcutaneous soln prefilled
syringe 50 mg/ml
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
92
ibuprofen tab 400 mg
1
1
ibuprofen tab 600 mg
1
ibuprofen tab 800 mg
1
indomethacin cap cr 75 mg
1
indomethacin cap 25 mg
FENOPROFEN CALCIUM fenoprofen calcium cap 200
mg
3
indomethacin cap 50 mg
FENOPROFEN CALCIUM fenoprofen calcium cap 400
mg
3
FENOPROFEN CALCIUM fenoprofen calcium tab 600
mg
3
flurbiprofen tab 50 mg
1
etodolac tab sr 24hr 400 mg
etodolac tab sr 24hr 500 mg
etodolac tab sr 24hr 600 mg
etodolac tab 400 mg
etodolac tab 500 mg
flurbiprofen tab 100 mg
ketoprofen cap 50 mg
1
HUMIRA - adalimumab
prefilled syringe kit 10
mg/0.2ml
2
HUMIRA - adalimumab
prefilled syringe kit 20
mg/0.4ml
2
HUMIRA - adalimumab
prefilled syringe kit 40
mg/0.8ml
2
HUMIRA PEDIATRIC
CROHNS D - adalimumab
prefilled syringe kit 40
mg/0.8ml
2
HUMIRA PEN - adalimumab
pen-injector kit 40 mg/0.8ml
2
ketoprofen cap 75 mg
ketorolac tromethamine tab
10 mg
•
•
•
•
•
•
•
•
•
•
•
1
1
1
1
1
1
•
1
3
leflunomide tab 10 mg
(Arava)
1
•
leflunomide tab 20 mg
(Arava)
1
3
•
MECLOFENAMATE SODIUM meclofenamate sodium cap
50 mg
3
•
MECLOFENAMATE SODIUM meclofenamate sodium cap
100 mg
mefenamic acid cap 250 mg
(Ponstel)
1
meloxicam tab 7.5 mg
(Mobic)
1
•
•
1
KINERET - anakinra
subcutaneous soln prefilled
syringe 100 mg/0.67ml
•
•
Limited Distribution
1
etodolac cap 300 mg
•
ACA
•
etodolac cap 200 mg
Dispensing Limits
2
1
HUMIRA PEN-PSORIASIS
STAR - adalimumab peninjector kit 40 mg/0.8ml
Step Therapy
Prior Authorization
•
1
•
Drug Tier
Limited Distribution
ACA
Dispensing Limits
2
2
•
Drug Name
HUMIRA PEN-CROHNS
DISEASE - adalimumab peninjector kit 40 mg/0.8ml
ENBREL SURECLICK etanercept subcutaneous
solution auto-injector 50 mg/
ml
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
•
•
meloxicam tab 15 mg (Mobic) 1
1
nabumetone tab 500 mg
nabumetone tab 750 mg
1
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
93
naproxen sodium tab sr
24hr 375 mg (base equiv)
(Naprelan)
1
OTREXUP - methotrexate
soln pf auto-injector 12.5
mg/0.4ml
3
naproxen sodium tab sr
24hr 500 mg (base equiv)
(Naprelan)
1
OTREXUP - methotrexate soln
pf auto-injector 15mg/0.4ml
3
1
3
naproxen sodium tab
275 mg (Anaprox)
OTREXUP - methotrexate
soln pf auto-injector 17.5
mg/0.4ml
1
OTREXUP - methotrexate soln
pf auto-injector 20mg/0.4ml
3
naproxen susp 125 mg/5ml
(Naprosyn)
1
3
naproxen tab ec 375 mg (Ecnaprosyn)
1
OTREXUP - methotrexate
soln pf auto-injector 22.5
mg/0.4ml
3
naproxen tab ec 500 mg (Ecnaprosyn)
1
OTREXUP - methotrexate soln
pf auto-injector 25mg/0.4ml
1
naproxen tab 250 mg
(Naprosyn)
1
oxaprozin tab 600 mg
(Daypro)
1
naproxen tab 375 mg
(Naprosyn)
1
piroxicam cap 10 mg
(Feldene)
1
naproxen tab 500 mg
(Naprosyn)
1
piroxicam cap 20 mg
(Feldene)
3
ORENCIA - abatacept
subcutaneous soln prefilled
syringe 125 mg/ml
3
RASUVO - methotrexate
soln pf auto-injector 7.5
mg/0.15ml
3
ORENCIA CLICKJECT abatacept subcutaneous
soln auto-injector 125 mg/ml
3
RASUVO - methotrexate soln
pf auto-injector 10 mg/0.2ml
3
OTEZLA - apremilast tab
starter therapy pack 10 mg &
20 mg & 30 mg
2
RASUVO - methotrexate
soln pf auto-injector 12.5
mg/0.25ml
RASUVO - methotrexate soln
pf auto-injector 15 mg/0.3ml
3
OTEZLA - apremilast tab 30
mg
2
3
OTREXUP - methotrexate soln
pf auto-injector 7.5 mg/0.4ml
3
RASUVO - methotrexate
soln pf auto-injector 17.5
mg/0.35ml
3
OTREXUP - methotrexate soln
pf auto-injector 10mg/0.4ml
3
RASUVO - methotrexate soln
pf auto-injector 20 mg/0.4ml
RASUVO - methotrexate
soln pf auto-injector 22.5
mg/0.45ml
3
naproxen sodium tab
550 mg (Anaprox ds)
•
•
•
•
•
•
•
•
•
•
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
94
RASUVO - methotrexate soln
pf auto-injector 25 mg/0.5ml
3
RASUVO - methotrexate
soln pf auto-injector 27.5
mg/0.55ml
3
RASUVO - methotrexate soln
pf auto-injector 30 mg/0.6ml
3
RIDAURA - auranofin cap 3 mg 3
2
SIMPONI - golimumab
subcutaneous soln autoinjector 50 mg/0.5ml
2
SIMPONI - golimumab
subcutaneous soln autoinjector 100 mg/ml
2
SIMPONI - golimumab
subcutaneous soln prefilled
syringe 50 mg/0.5ml
2
SIMPONI - golimumab
subcutaneous soln prefilled
syringe 100 mg/ml
1
sulindac tab 150 mg
sulindac tab 200 mg
ergotamine w/ caffeine tab
1-100 mg (Cafergot)
•
1
•
MIGRANAL dihydroergotamine mesylate
nasal spray 4 mg/ml
3
•
naratriptan hcl tab 1 mg
(base equiv) (Amerge)
1
•
1
•
RELPAX - eletriptan
hydrobromide tab 20 mg
(base equivalent)
3
•
RELPAX - eletriptan
hydrobromide tab 40 mg
(base equivalent)
3
•
rizatriptan benzoate oral
disintegrating tab 5 mg
(base eq) (Maxalt-mlt)
1
•
1
•
rizatriptan benzoate tab
5 mg (base equivalent)
(Maxalt)
1
•
1
•
•
rizatriptan benzoate tab
10 mg (base equivalent)
(Maxalt)
•
sumatriptan nasal spray
5 mg/act (Imitrex)
1
•
•
sumatriptan nasal spray
20 mg/act (Imitrex)
1
•
1
•
•
•
•
•
•
•
•
•
•
•
•
3
•
•
•
XELJANZ XR - tofacitinib
citrate tab sr 24hr 11 mg
(base equivalent)
3
•
•
•
almotriptan malate tab
12.5 mg (Axert)
dihydroergotamine mesylate
inj 1 mg/ml (D.h.e. 45)
ERGOMAR - ergotamine
tartrate sl tab 2 mg
1
3
naratriptan hcl tab 2.5 mg
(base equiv) (Amerge)
rizatriptan benzoate oral
disintegrating tab 10 mg
(base eq) (Maxalt-mlt)
sumatriptan succinate inj
6 mg/0.5ml (Imitrex)
Limited Distribution
ACA
Dispensing Limits
frovatriptan succinate tab
2.5 mg (base equivalent)
(Frova)
XELJANZ - tofacitinib citrate
tab 5 mg (base equivalent)
1
Step Therapy
•
1
1
Prior Authorization
3
1
almotriptan malate tab
6.25 mg (Axert)
1
FROVA - frovatriptan succinate
tab 2.5 mg (base equivalent)
TOLMETIN SODIUM - tolmetin
sodium cap 400 mg
MIGRAINE PRODUCTS
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
95
1
sumatriptan succinate
solution auto-injector
4 mg/0.5ml (Imitrex statdose
sys)
1
sumatriptan succinate
solution auto-injector
6 mg/0.5ml (Imitrex statdose
sys)
1
sumatriptan succinate
solution cartridge
4 mg/0.5ml (Imitrex statdose
ref)
1
sumatriptan succinate
solution cartridge
6 mg/0.5ml (Imitrex statdose
ref)
1
sumatriptan succinate tab
25 mg (Imitrex)
1
sumatriptan succinate tab
50 mg (Imitrex)
1
sumatriptan succinate tab
100 mg (Imitrex)
1
zolmitriptan orally
disintegrating tab 2.5 mg
(Zomig zmt)
1
zolmitriptan orally
disintegrating tab 5 mg
(Zomig zmt)
1
zolmitriptan tab 2.5 mg
(Zomig)
1
zolmitriptan tab 5 mg
(Zomig)
3
ZOMIG - zolmitriptan nasal
spray 2.5 mg/spray unit
GOUT AGENTS
allopurinol tab 100 mg
(Zyloprim)
1
allopurinol tab 300 mg
(Zyloprim)
1
•
•
•
•
COLCHICINE - colchicine cap
0.6 mg
3
COLCHICINE - colchicine tab
0.6 mg
3
colchicine w/ probenecid tab
0.5-500 mg
1
COLCRYS - colchicine tab 0.6
mg
3
MITIGARE - colchicine cap 0.6
mg
3
probenecid tab 500 mg
1
ANTICONVULSANTS
APTIOM - eslicarbazepine
acetate tab 400 mg
3
APTIOM - eslicarbazepine
acetate tab 600 mg
3
APTIOM - eslicarbazepine
acetate tab 800 mg
3
BANZEL - rufinamide susp 40
mg/ml
3
•
BANZEL - rufinamide tab 200
mg
3
•
BANZEL - rufinamide tab 400
mg
3
•
BRIVIACT - brivaracetam oral
soln 10 mg/ml
3
BRIVIACT - brivaracetam tab
10 mg
3
BRIVIACT - brivaracetam tab
25 mg
3
BRIVIACT - brivaracetam tab
50 mg
3
•
•
Limited Distribution
ACA
Dispensing Limits
NEUROMUSCULAR DRUGS
3
•
Step Therapy
ULORIC - febuxostat tab 40 mg 3
ULORIC - febuxostat tab 80 mg 3
APTIOM - eslicarbazepine
acetate tab 200 mg
•
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
96
BRIVIACT - brivaracetam tab
75 mg
3
BRIVIACT - brivaracetam tab
100 mg
3
carbamazepine cap sr 12hr
100 mg (Carbatrol)
1
carbamazepine cap sr 12hr
200 mg (Carbatrol)
carbamazepine cap sr 12hr
300 mg (Carbatrol)
carbamazepine chew tab
100 mg
carbamazepine susp
100 mg/5ml (Tegretol)
carbamazepine tab sr 12hr
100 mg (Tegretol-xr)
carbamazepine tab sr 12hr
200 mg (Tegretol-xr)
carbamazepine tab sr 12hr
400 mg (Tegretol-xr)
clonazepam orally
disintegrating tab 1 mg
clonazepam orally
disintegrating tab 2 mg
1
clonazepam tab 1 mg
(Klonopin)
1
1
clonazepam tab 2 mg
(Klonopin)
1
1
3
1
DEPAKENE - valproate sodium
oral soln 250 mg/5ml (base
equiv)
3
1
DEPAKENE - valproic acid cap
250 mg
carbamazepine tab 200 mg
(Tegretol)
1
CARBATROL - carbamazepine
cap sr 12hr 100 mg
3
CARBATROL - carbamazepine
cap sr 12hr 200 mg
3
CARBATROL - carbamazepine
cap sr 12hr 300 mg
3
CELONTIN - methsuximide cap 3
300 mg
1
clonazepam orally
disintegrating tab
0.125 mg
1
clonazepam orally
disintegrating tab 0.25 mg
1
clonazepam orally
disintegrating tab 0.5 mg
Limited Distribution
ACA
Dispensing Limits
1
1
1
Step Therapy
1
clonazepam tab 0.5 mg
(Klonopin)
1
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
DIASTAT ACUDIAL - diazepam 2
rectal gel delivery system 10
mg
DIASTAT ACUDIAL - diazepam 2
rectal gel delivery system 20
mg
2
DIASTAT PEDIATRIC diazepam rectal gel delivery
system 2.5 mg
3
DIAZEPAM - diazepam rectal
gel delivery system 2.5 mg
3
DIAZEPAM - diazepam rectal
gel delivery system 10 mg
3
DIAZEPAM - diazepam rectal
gel delivery system 20 mg
3
DILANTIN - phenytoin sodium
extended cap 30 mg
3
DILANTIN - phenytoin sodium
extended cap 100 mg
3
DILANTIN INFATABS phenytoin chew tab 50 mg
3
DILANTIN-125 - phenytoin
susp 125 mg/5ml
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
97
divalproex sodium cap
delayed release sprinkle
125 mg (Depakote
sprinkles)
1
divalproex sodium tab
delayed release 125 mg
(Depakote)
1
divalproex sodium tab
delayed release 250 mg
(Depakote)
1
divalproex sodium tab
delayed release 500 mg
(Depakote)
1
divalproex sodium tab sr 24
hr 250 mg (Depakote er)
1
gabapentin tab 600 mg
(Neurontin)
1
1
gabapentin tab 800 mg
(Neurontin)
1
ethosuximide cap 250 mg
(Zarontin)
1
GABITRIL - tiagabine hcl tab
12 mg
3
ethosuximide soln
250 mg/5ml (Zarontin)
1
GABITRIL - tiagabine hcl tab
16 mg
3
felbamate susp 600 mg/5ml
(Felbatol)
1
3
felbamate tab 400 mg
(Felbatol)
1
LAMICTAL STARTER/NOT
TAKI - lamotrigine tab 25 mg
(42) & 100 mg (7) starter kit
3
felbamate tab 600 mg
(Felbatol)
1
LAMICTAL STARTER/TAKING
C - lamotrigine tab 25 mg
(84) & 100 mg (14) starter kit
FYCOMPA - perampanel susp
0.5 mg/ml
3
3
FYCOMPA - perampanel tab 2
mg
3
LAMICTAL STARTER/TAKING
V - lamotrigine tab 25 mg
(35) starter kit
FYCOMPA - perampanel tab 4
mg
3
FYCOMPA - perampanel tab 6
mg
3
FYCOMPA - perampanel tab 8
mg
3
divalproex sodium tab sr 24
hr 500 mg (Depakote er)
FYCOMPA - perampanel tab
10 mg
3
FYCOMPA - perampanel tab
12 mg
3
gabapentin cap 100 mg
(Neurontin)
1
gabapentin cap 300 mg
(Neurontin)
1
gabapentin cap 400 mg
(Neurontin)
1
gabapentin oral soln
250 mg/5ml (Neurontin)
1
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
LAMICTAL XR - lamotrigine tab 3
sr 24hr 25 mg (21) & 50 mg
(7) titration kit
LAMICTAL XR - lamotrigine tab 3
sr 24hr 25 (14) & 50 mg (14)
& 100 mg(7) kit
3
LAMICTAL XR - lamotrigine
tab sr 24hr 50 (14) & 100
mg(14) & 200 mg(7) kit
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
98
lamotrigine orally
disintegrating tab 25 mg
(Lamictal odt)
1
lamotrigine orally
disintegrating tab 50 mg
(Lamictal odt)
1
lamotrigine orally
disintegrating tab 100 mg
(Lamictal odt)
1
lamotrigine orally
disintegrating tab 200 mg
(Lamictal odt)
1
lamotrigine tab chewable
dispersible 5 mg (Lamictal
chewable di)
1
1
lamotrigine tab chewable
dispersible 25 mg (Lamictal
chewable di)
1
lamotrigine tab disp 25 mg
(21) & 50 mg (7) titration
kit (LAMICTAL ODT)
1
lamotrigine tab disp 50 mg
(42) & 100 mg (14) titration
kit (LAMICTAL ODT)
1
lamotrigine tab disp 25 (14)
& 50 mg (14) & 100 mg (7)
kit (LAMICTAL ODT)
1
lamotrigine tab sr 24hr
25 mg (Lamictal xr)
1
lamotrigine tab sr 24hr
50 mg (Lamictal xr)
1
lamotrigine tab sr 24hr
100 mg (Lamictal xr)
1
lamotrigine tab sr 24hr
200 mg (Lamictal xr)
1
lamotrigine tab sr 24hr
250 mg (Lamictal xr)
1
lamotrigine tab sr 24hr
300 mg (Lamictal xr)
lamotrigine tab 25 mg
(Lamictal)
1
lamotrigine tab 100 mg
(Lamictal)
1
lamotrigine tab 150 mg
(Lamictal)
1
lamotrigine tab 200 mg
(Lamictal)
1
levetiracetam oral soln
100 mg/ml (Keppra)
1
levetiracetam tab sr 24hr
500 mg (Keppra xr)
levetiracetam tab sr 24hr
750 mg (Keppra xr)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
levetiracetam tab 250 mg
(Keppra)
1
levetiracetam tab 500 mg
(Keppra)
1
levetiracetam tab 750 mg
(Keppra)
1
levetiracetam tab 1000 mg
(Keppra)
1
LYRICA - pregabalin cap 25
mg
3
•
LYRICA - pregabalin cap 50
mg
3
•
LYRICA - pregabalin cap 75
mg
3
•
LYRICA - pregabalin cap 100
mg
3
•
LYRICA - pregabalin cap 150
mg
3
•
LYRICA - pregabalin cap 200
mg
3
•
LYRICA - pregabalin cap 225
mg
3
•
LYRICA - pregabalin cap 300
mg
3
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
99
LYRICA - pregabalin soln 20
mg/ml
3
ONFI - clobazam suspension
2.5 mg/ml
3
ONFI - clobazam tab 10 mg
3
ONFI - clobazam tab 20 mg
3
oxcarbazepine susp
300 mg/5ml (60 mg/ml)
(Trileptal)
1
oxcarbazepine tab 150 mg
(Trileptal)
1
oxcarbazepine tab 300 mg
(Trileptal)
1
oxcarbazepine tab 600 mg
(Trileptal)
1
OXTELLAR XR oxcarbazepine tab sr 24hr
150 mg
3
OXTELLAR XR oxcarbazepine tab sr 24hr
300 mg
3
OXTELLAR XR oxcarbazepine tab sr 24hr
600 mg
3
PEGANONE - ethotoin tab 250
mg
3
PHENYTEK - phenytoin
sodium extended cap 200
mg
3
PHENYTEK - phenytoin
sodium extended cap 300
mg
3
phenytoin chew tab 50 mg
(Dilantin infatabs)
1
phenytoin sodium extended
cap 100 mg (Dilantin)
1
phenytoin sodium extended
cap 200 mg (Phenytek)
1
phenytoin sodium extended
cap 300 mg (Phenytek)
phenytoin susp 125 mg/5ml
(Dilantin)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
•
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
POTIGA - ezogabine tab 50 mg 3
3
POTIGA - ezogabine tab 200
mg
3
POTIGA - ezogabine tab 300
mg
3
POTIGA - ezogabine tab 400
mg
1
primidone tab 50 mg
(Mysoline)
1
primidone tab 250 mg
(Mysoline)
3
QUDEXY XR - topiramate cap
er 24hr sprinkle 25 mg
3
QUDEXY XR - topiramate cap
er 24hr sprinkle 50 mg
3
QUDEXY XR - topiramate cap
er 24hr sprinkle 100 mg
3
QUDEXY XR - topiramate cap
er 24hr sprinkle 150 mg
3
QUDEXY XR - topiramate cap
er 24hr sprinkle 200 mg
SABRIL - vigabatrin powd pack 2
500 mg
2
SABRIL - vigabatrin tab 500
mg
3
TEGRETOL - carbamazepine
susp 100 mg/5ml
3
TEGRETOL - carbamazepine
tab 200 mg
3
TEGRETOL-XR carbamazepine tab sr 12hr
100 mg
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
100
TEGRETOL-XR carbamazepine tab sr 12hr
200 mg
3
TROKENDI XR - topiramate
cap sr 24hr 200 mg
3
valproate sodium oral soln
250 mg/5ml (base equiv)
(Depakene)
1
TEGRETOL-XR carbamazepine tab sr 12hr
400 mg
3
1
1
tiagabine hcl tab 2 mg
(Gabitril)
valproic acid cap 250 mg
(Depakene)
1
VIMPAT - lacosamide oral
solution 10 mg/ml
3
tiagabine hcl tab 4 mg
(Gabitril)
VIMPAT - lacosamide tab 50
mg
3
TOPIRAMATE ER - topiramate
cap er 24hr sprinkle 25 mg
3
VIMPAT - lacosamide tab 100
mg
3
TOPIRAMATE ER - topiramate
cap er 24hr sprinkle 50 mg
3
VIMPAT - lacosamide tab 150
mg
3
TOPIRAMATE ER - topiramate
cap er 24hr sprinkle 100 mg
3
3
VIMPAT - lacosamide tab 200
mg
3
TOPIRAMATE ER - topiramate
cap er 24hr sprinkle 150 mg
3
ZARONTIN - ethosuximide cap
250 mg
3
TOPIRAMATE ER - topiramate
cap er 24hr sprinkle 200 mg
topiramate sprinkle cap
15 mg (Topamax sprinkle)
1
topiramate sprinkle cap
25 mg (Topamax sprinkle)
1
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
ZARONTIN - ethosuximide soln 3
250 mg/5ml
1
zonisamide cap 25 mg
(Zonegran)
1
zonisamide cap 50 mg
topiramate tab 25 mg
(Topamax)
1
topiramate tab 50 mg
(Topamax)
1
topiramate tab 100 mg
(Topamax)
1
topiramate tab 200 mg
(Topamax)
1
TROKENDI XR - topiramate
cap sr 24hr 25 mg
3
APOKYN - apomorphine hcl
soln cartridge 30 mg/3ml
3
TROKENDI XR - topiramate
cap sr 24hr 50 mg
3
AZILECT - rasagiline mesylate
tab 0.5 mg (base equiv)
3
TROKENDI XR - topiramate
cap sr 24hr 100 mg
3
AZILECT - rasagiline mesylate
tab 1 mg (base equiv)
3
zonisamide cap 100 mg
(Zonegran)
ANTIPARKINSON AGENTS
amantadine hcl cap 100 mg
amantadine hcl syrup
50 mg/5ml
amantadine hcl tab 100 mg
1
1
1
1
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
101
benztropine mesylate tab
0.5 mg
benztropine mesylate tab
1 mg
benztropine mesylate tab
2 mg
1
1
1
bromocriptine mesylate cap
5 mg (base equivalent)
(Parlodel)
1
bromocriptine mesylate tab
2.5 mg (base equivalent)
(Parlodel)
1
carbidopa & levodopa
orally disintegrating tab
10-100 mg
1
carbidopa & levodopa
orally disintegrating tab
25-100 mg
carbidopa & levodopa
orally disintegrating tab
25-250 mg
carbidopa & levodopa tab cr
25-100 mg (Sinemet cr)
carbidopa & levodopa tab cr
50-200 mg (Sinemet cr)
carbidopa & levodopa tab
10-100 mg (Sinemet)
carbidopa & levodopa tab
25-100 mg (Sinemet)
carbidopa & levodopa tab
25-250 mg (Sinemet)
1
1
1
1
1
1
1
carbidopa tab 25 mg
(Lodosyn)
1
CARBIDOPA/LEVODOPA/
ENTACA - carbidopalevodopa-entacapone tabs
12.5-50-200 mg
3
CARBIDOPA/LEVODOPA/
ENTACA - carbidopalevodopa-entacapone tabs
18.75-75-200 mg
3
CARBIDOPA/LEVODOPA/
ENTACA - carbidopalevodopa-entacapone tabs
25-100-200 mg
3
CARBIDOPA/LEVODOPA/
ENTACA - carbidopalevodopa-entacapone tabs
31.25-125-200 mg
3
CARBIDOPA/LEVODOPA/
ENTACA - carbidopalevodopa-entacapone tabs
37.5-150-200 mg
3
CARBIDOPA/LEVODOPA/
ENTACA - carbidopalevodopa-entacapone tabs
50-200-200 mg
3
DUOPA - carbidopa-levodopa
enteral susp 4.63-20 mg/ml
3
entacapone tab 200 mg
(Comtan)
1
NEUPRO - rotigotine td patch
24hr 1 mg/24hr
3
NEUPRO - rotigotine td patch
24hr 2 mg/24hr
3
NEUPRO - rotigotine td patch
24hr 3 mg/24hr
3
NEUPRO - rotigotine td patch
24hr 4 mg/24hr
3
NEUPRO - rotigotine td patch
24hr 6 mg/24hr
3
NEUPRO - rotigotine td patch
24hr 8 mg/24hr
3
pramipexole dihydrochloride
tab sr 24hr 0.375 mg
(Mirapex er)
1
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
102
pramipexole dihydrochloride
tab sr 24hr 0.75 mg
(Mirapex er)
1
pramipexole dihydrochloride
tab sr 24hr 1.5 mg (Mirapex
er)
1
pramipexole dihydrochloride
tab sr 24hr 2.25 mg
(Mirapex er)
1
pramipexole dihydrochloride
tab sr 24hr 3 mg (Mirapex
er)
1
pramipexole dihydrochloride
tab sr 24hr 3.75 mg
(Mirapex er)
1
pramipexole dihydrochloride
tab sr 24hr 4.5 mg (Mirapex
er)
1
pramipexole dihydrochloride
tab 0.125 mg (Mirapex)
1
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)
1
1
1
1
ropinirole hydrochloride
tab sr 24hr 4 mg (base
equivalent) (Requip xl)
ropinirole hydrochloride
tab sr 24hr 6 mg (base
equivalent) (Requip xl)
ropinirole hydrochloride
tab sr 24hr 8 mg (base
equivalent) (Requip xl)
ropinirole hydrochloride
tab sr 24hr 12 mg (base
equivalent) (Requip xl)
ropinirole hydrochloride tab
0.25 mg (Requip)
ropinirole hydrochloride tab
0.5 mg (Requip)
ropinirole hydrochloride tab
1 mg (Requip)
ropinirole hydrochloride tab
2 mg (Requip)
ropinirole hydrochloride tab
3 mg (Requip)
ropinirole hydrochloride tab
4 mg (Requip)
ropinirole hydrochloride tab
5 mg (Requip)
Limited Distribution
1
1
1
1
1
1
1
1
3
rasagiline mesylate tab
0.5 mg (base equiv)
(Azilect)
RYTARY - carbidopa &
levodopa cap cr 36.25-145
mg
RYTARY - carbidopa &
levodopa cap cr 48.75-195
mg
3
rasagiline mesylate tab 1 mg
(base equiv) (Azilect)
1
RYTARY - carbidopa &
levodopa cap cr 61.25-245
mg
3
1
ACA
1
1
ropinirole hydrochloride
tab sr 24hr 2 mg (base
equivalent) (Requip xl)
Dispensing Limits
1
3
1
Step Therapy
1
RYTARY - carbidopa &
levodopa cap cr 23.75-95
mg
pramipexole dihydrochloride
tab 1.5 mg (Mirapex)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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103
selegiline hcl cap 5 mg
(Eldepryl)
1
carisoprodol tab 250 mg
(Soma)
1
selegiline hcl tab 5 mg
1
carisoprodol tab 350 mg
(Soma)
1
chlorzoxazone tab 500 mg
(Parafon forte dsc)
1
cyclobenzaprine hcl tab
5 mg
1
STALEVO 100 - carbidopalevodopa-entacapone tabs
25-100-200 mg
3
STALEVO 125 - carbidopalevodopa-entacapone tabs
31.25-125-200 mg
3
STALEVO 150 - carbidopalevodopa-entacapone tabs
37.5-150-200 mg
3
STALEVO 200 - carbidopalevodopa-entacapone tabs
50-200-200 mg
3
STALEVO 50 - carbidopalevodopa-entacapone tabs
12.5-50-200 mg
3
STALEVO 75 - carbidopalevodopa-entacapone tabs
18.75-75-200 mg
3
TASMAR - tolcapone tab 100
mg
cyclobenzaprine hcl tab
7.5 mg (Fexmid)
cyclobenzaprine hcl tab
10 mg
dantrolene sodium cap
25 mg (Dantrium)
dantrolene sodium cap
50 mg (Dantrium)
dantrolene sodium cap
100 mg
1
1
tolcapone tab 100 mg
(Tasmar)
1
methocarbamol tab 500 mg
(Robaxin)
1
trihexyphenidyl hcl elixir
0.4 mg/ml
1
methocarbamol tab 750 mg
(Robaxin-750)
1
1
orphenadrine citrate tab sr
12hr 100 mg
1
NEUROMUSCULAR AGENTS
riluzole tab 50 mg (Rilutek)
3
1
MUSCULOSKELETAL THERAPY AGENTS
1
baclofen tab 10 mg
baclofen tab 20 mg
1
Limited Distribution
1
metaxalone tab 800 mg
(Skelaxin)
ZELAPAR - selegiline hcl orally
disintegrating tab 1.25 mg
ACA
1
3
1
Dispensing Limits
1
3
trihexyphenidyl hcl tab 5 mg
Step Therapy
1
METAXALONE - metaxalone
tab 400 mg
trihexyphenidyl hcl tab 2 mg
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
tizanidine hcl cap 2 mg
(base equivalent)
(Zanaflex)
1
•
tizanidine hcl cap 4 mg
(base equivalent)
(Zanaflex)
1
•
tizanidine hcl cap 6 mg
(base equivalent)
(Zanaflex)
1
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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104
tizanidine hcl tab 2 mg (base
equivalent)
tizanidine hcl tab 4 mg (base
equivalent) (Zanaflex)
ANTIMYASTHENIC AGENTS
D-VI-SOL - cholecalciferol oral
liquid 400 unit/ml
A
•
DDROPS - cholecalciferol
drops 1000 unit/0.03ml (per
drop)
A
•
GUANIDINE HCL - guanidine
hcl tab 125 mg
3
ergocalciferol cap 50000 unit
(Drisdol)
1
MESTINON - pyridostigmine
bromide syrup 60 mg/5ml
3
MEPHYTON - phytonadione
tab 5 mg
2
pyridostigmine bromide
tab cr 180 mg (Mestinon
timespan)
1
phytonadione inj 1 mg/0.5ml
(2 mg/ml)
1
A
•
pyridostigmine bromide tab
60 mg (Mestinon)
1
SUPER DAILY D3 cholecalciferol drops 1000
unit/0.03ml (per drop)
VITAMELTS VITAMIN D cholecalciferol orally
disintegrating tab 1000 unit
A
•
VITAMIN D2 - ergocalciferol
tab 400 unit
A
•
VITAMIN D3 - cholecalciferol
oral liquid 1200 unit/15ml
A
•
1
VITAMIN D3 - cholecalciferol
spray 1000 unit/spray
A
•
A
•
A
•
A
•
WELLESSE VITAMIN D3 cholecalciferol oral liquid
1000 unit/10ml
MULTIVITAMINS
A
•
3
A
•
ACTIVE OB - prenatal w/o a w/
fe cbn-fa-dha cap 20-1-320
mg
3
A
•
ATABEX EC - prenatal vit w/
dss-iron carbonyl-fa tab dr
29-1 mg
BAL-CARE DHA - prenat w/fe
poly-na fered-fa tab 27-1 &
omega cap dr 430mg
3
NUTRITIONAL PRODUCTS
VITAMINS
BABY DDROPS cholecalciferol drops 400
unit/0.03ml (per drop)
A
•
cholecalciferol cap 400 unit
A
•
•
cholecalciferol cap 1000 unit
cholecalciferol cap 50000
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 oral liquid
400 unit/ml
cholecalciferol tab 400 unit
cholecalciferol tab 1000 unit
cholecalciferol tab 50000
unit
A
A
A
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
•
Prior Authorization
1
Drug Name
Drug Tier
•
Limited Distribution
1
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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105
BP FOLINATAL PLUS
B - prenatal w/ calcium
carbonate-b6-b12-fa tab 1
mg
3
COMPLETE NATAL DHA prenat-fe bis-fe prot succ-faca tab & omega 3 cap 250
pk
3
BP MULTINATAL PLUS prenatal w/o a vit w/ fe fumfa tab chew 40-1 mg
3
COMPLETENATE - prenatal vit
w/ fe fumarate-fa chew tab
29-1 mg
3
BP MULTINATAL PLUS prenatal w/o a vit w/ fe
fumarate-fa tab 30-1 mg
3
CONCEPT DHA - prenatal w/fe
fum-fe poly -fa-omega 3 cap
53.5-38-1 mg
3
C-BUFF - multiple vitamins w/
minerals powder
3
3
C-NATE DHA - prenatal vit
w/ fe fum-fa-omega 3 cap
28-1-200 mg
3
CONCEPT OB - prenatal w/
o a w/fe fum-fe poly-fa cap
130-92.4-1 mg
3
CALCIUM PNV - prenatal w/o
vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg
3
DOTHELLE DHA - prenatal w/
fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg
3
CITRANATAL ASSURE prenat w/o a w/fecbn-fegldss-fa tab & dha cap 300 mg
pack
3
DUET DHA BALANCED prenat w/fe poly-na fered-fa
tab 25-1 & omega cap 267
mg
3
CITRANATAL B-CALM - prenat
w/o a w/fecbn-feglu-fa tab
20-1 mg & vit b6 tab pak
3
DUET DHA 400 - prenat w/fe
poly-na fered-fa tab 25-1 &
omega cap 400 mg
ELITE-OB - prenatal vit w/ iron
carbonyl-fa tab 50-1.25 mg
3
CITRANATAL DHA - prenat w/
o a w/fecbn-fegl-dss-fa tab &
dha cap 250 mg pack
3
ENBRACE HR - prenatal vit w/
fe gly cys-fa-omega 3 fatty
acids cap
3
CITRANATAL HARMONY prenat w/o a w/fe fum-fe
cbn-dss-fa-dha cap 27-1-260
mg
3
END FATIGUE DAILY
ENERGY - multiple vitamins
w/ minerals powder
3
EXTRA-VIRT PLUS DHA prenatal w/o vit a w/ fe fumdoc-fa-dha cap 29-1.25-350
mg
3
CITRANATAL RX - prenatal w/
o a w/ fe carbonyl-fe glucdss-fa tab 27-1mg
3
CITRANATAL 90 DHA - prenat
w/o a w/fecbn-fegl-dss-fa tab
90 &dha cap 300mg pak
3
FOCALGIN CA - prenat w/o
a w/fecbn-fegl-dss-fa tab &
dha cap 300 mg pack
3
CO-NATAL FA - prenatal vit w/
fe fumarate-fa tab 29-1 mg
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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106
FOCALGIN 90 DHA - prenat w/
o a w/fecbn-fegl-dss-fa tab
90 &dha cap 300mg pak
3
FOLCAL DHA - prenatal w/o vit
a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
3
FOLCAPS OMEGA 3 - prenatal 3
vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg
3
FOLET DHA - prenat w/fecbnbisg-methylf-dss tab dr &
dha cap pak
3
FOLET ONE - prenat w/o a w/
fecbn-bisg-methylf-dss-dha
cap 38-1-225 mg
3
FOLIVANE-OB - prenatal w/
o a w/fe fum-fe poly-fa cap
130-92.4-1 mg
HEMENATAL OB - prenat vit-fe 3
poly cmplx-fe heme poly-fa
tab 28-6-1 mg
3
HEMENATAL OB + DHA prenat-fe poly cmplx-fe
heme poly-fa tab & omega 3
cap pck
3
INATAL ADVANCE - prenatal
vit w/ dss-iron carbonyl-fa
tab 90-1 mg
3
INATAL GT - prenatal vit w/
dss-iron carbonyl-fa tab 90-1
mg
INATAL ULTRA - prenatal vit w/ 3
dss-iron carbonyl-fa tab 90-1
mg
3
INFANATE BALANCE prenatal w/o a w/fe cbn-dssfa-dha cap 29-1-265 mg
3
M-VIT - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
MACNATAL CN DHA - prenatal 3
w/o a w/fe cbn-dss-fa-dha
cap 28-1-250 mg
MARNATAL-F - prenatal w/o vit 3
a w/ fe polysac cmplx-fa cap
60-1 mg
3
MEGA MULTIVITAMIN multiple vitamins w/ minerals
powder
3
MYNATAL - prenatal
multivitamins & minerals w/
iron & fa cap 1 mg
3
MYNATAL ADVANCE prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg
3
MYNATAL PLUS - prenatal vit
w/ fe fumarate-fa tab 65-1
mg
3
MYNATAL ULTRACAPLET prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg
MYNATAL-Z - prenatal vit w/ fe 3
fumarate-fa tab 65-1 mg
3
MYNATE 90 PLUS - prenatal
vit w/ dss-fe fumarate-fa tab
cr 90-1 mg
NATACHEW - prenatal vit w/ fe 3
fum-fe bisglycin-fa chew tab
28-1 mg
3
NATALVIT - prenatal vit w/ fe
fumarate-fa tab 75-1 mg
3
NATELLE ONE - prenatal w/o
vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg
NEEVO DHA - prenat w/o a w/ 3
fefum-methylfol-omegas cap
27-1.13 mg
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107
NESTABS - prenatal vit w/o vit
a w/ fe bisglycinate-fa tab
32-1 mg
3
OB COMPLETE/DHA - prenat
w/ iron cbn-fe asp glyc-faomega cap 30-10-1-200 mg
3
NESTABS ABC - prenatal w/o
vit a w/fe polysac-fa-ca tab &
omega 3 cap
3
OBSTETRIX DHA - prenat w/
fecbn-fa-dss tab 29-1 mg &
omega 3 cap 387 mg pak
3
NESTABS DHA - prenat w/o a
w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack
3
OBSTETRIX EC - prenatal vit
w/ dss-iron carbonyl-fa tab
29-1 mg
3
NEWGEN - prenatal vit w/o vit
a w/ fe bisglycinate-fa tab
32-1 mg
3
OBSTETRIX ONE - prenat w/o
a w/fecbn-bisg-methylf-dssdha cap 38-1-225 mg
3
NEXA PLUS - prenatal w/o vit
a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg
3
PHLEXY-VITS - multiple
vitamins w/ minerals powder
3
PNV FERROUS FUMARATE/
DOCU - prenatal vit w/ dss-fe
fumarate-fa tab 29-1 mg
3
NIVA-PLUS - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
3
O-CAL FA - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
3
3
O-CAL PRENATAL - prenatal
vit w/ fe fumarate-fa tab 15-1
mg
3
PNV OB+DHA - prenat w/o a
w/fecbn-fegl-dss-fa tab &
dha cap 250 mg pack
3
OB COMPLETE - prenatal
vit w/ iron carbonyl-fa tab
50-1.25 mg
3
PNV PRENATAL PLUS
MULTIVI - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
3
OB COMPLETE GOLD prenat w/o a w/fecbnmethfol-fa-dha cap
27.5-1-200 mg
3
PNV TABS 29-1 - prenatal vit
w/ iron carbonyl-fa tab 29-1
mg
PNV-DHA - prenat w/o a w/
fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
3
OB COMPLETE ONE prenatal w/o a w/fecbnfe asp glyc-fa-fish cap
50-1-476 mg
3
PNV-DHA+DOCUSATE prenatal w/o vit a w/ fe fumdss-fa-dha cap 27-1.25-300
mg
3
OB COMPLETE PETITE prenat w/o a w/fecbnfeaspglyc-fa-omega cap
35-5-1-200 mg
3
PNV-OMEGA - prenat w/o a w/
fe fumerate-methylfolate-faomega 3 cap
3
PNV-SELECT - prenatal vit w/
fe fum-methylfolate-fa tab
27-0.6-0.4 mg
3
OB COMPLETE PREMIER prenatal vit w/ fe cbn-fe asp
glyc-fa tab 30-20-1 mg
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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108
PNV-TOTAL - prenat w/ fe
cbn-fe bisglyc-fa-fish oil cap
35-5-1.2 mg
3
PRENAISSANCE NEXT-B prenatal w/ calcium-vit b6-faginger tab 1.22 mg
3
PNV-VP-U - prenatal w/o a
vit w/ fe fumarate-fa cap
106.5-1 mg
3
PRENAISSANCE PLUS prenatal w/o a w/fe cbn-dssfa-dha cap 28-1-250 mg
3
PR NATAL 400 - prenat-fe
bis-fe prot succ-fa-ca tab &
omega 3 cap 400 pk
3
PRENATABS FA - prenatal vit
w/ fe fumarate-fa tab 29-1
mg
3
PR NATAL 400 EC - prenat-fe
bis-fe prot succ-fa-ca tab &
omega cap dr 400 pk
3
PRENATABS RX - prenatal vit
w/ iron carbonyl-fa tab 29-1
mg
3
PR NATAL 430 - prenat-fe
bis-fe prot succ-fa-ca tab &
omega 3 cap 430 pk
3
PRENATAL - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
3
PRENATAL PLUS - prenatal vit
w/ fe fumarate-fa tab 27-1
mg
2
PR NATAL 430 EC - prenat-fe
bis-fe prot succ-fa-ca tab &
omega cap dr 430 pk
3
3
PRENATAL PLUS IRON prenatal vit w/ iron carbonylfa tab 29-1 mg
3
PREFERA OB - prenat vit-fe
poly cmplx-fe heme poly-fa
tab 34-1 mg
PRENATAL VITAMINS PLUS
LO - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
2
PREFERAOB +DHA - prenatfe poly cmplx 28mg-fe heme
poly-fa tab&dha cap pack
3
PRENATAL 19 - prenatal vit w/
dss-fe fumarate-fa tab 29-1
mg
3
PREFERAOB ONE - prenat-fe
poly cmplx-fe heme poly-fadha cap 22-6-1-200 mg
3
3
3
PRENAISSANCE - prenatal w/
o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg
PRENATAL 19 - prenatal vit w/
fe fumarate-fa chew tab 29-1
mg
3
PRENATAL-U - prenatal w/o
a vit w/ fe fumarate-fa cap
106.5-1 mg
3
PRENAISSANCE BALANCE prenatal w/o vit a w/ fe cbndss-fa-dha cap 30-1-260 mg
PRENATE - prenat mv & min
w/ l-methylfolate-fa chew tab
0.6-0.4 mg
3
PRENAISSANCE HARMONY
DHA - prenat w/fe poly-na
fered-fa tab 27-1 & omega
cap dr 380mg
3
3
PRENAISSANCE NEXT prenatal w/ calcium-vit b6-faginger tab 1.2 mg
3
PRENATE AM - prenatal w/
calcium-vit b6-vit b12-faginger tab 1 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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109
PRENATE DHA - prenat w/o a
w/feaspg-methfol-fa-dha cap
18-0.6-0.4-300 mg
3
PRENA1 CHEW - prenat w/
b2-b6-b12-d3-folic acid chew
tab 1.4 mg
3
PRENATE DHA - prenat w/o a
w/fefum-methfol-fa-dha cap
28-0.6-0.4-300 mg
3
PRENA1 PEARL - prenat w/oa
w/fefum-na fered-fa-dha cap
cr 30-1.4-200 mg
3
PRENATE ELITE - prenatal vit
w/ fe fum-methylfolate-fa tab
26-0.6-0.4 mg
3
PREPLUS - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
3
3
PRETAB - prenatal vit w/ fe
fumarate-fa tab 29-1 mg
3
PRENATE ELITE - prenatal w/
fe asp gly-l methylfol-fa tab
20-0.6-0.4 mg
3
PRENATE ENHANCE - prenat
w/o a w/fefum-methfol-fadha cap 28-0.6-0.4-400 mg
3
PROVIDA DHA - prenat w/o a
w/fe fum-fe poly-fa-dha cap
16-16-1.25-110 mg
3
PRENATE ESSENTIAL prenat w/o a w/feaspmethylf-fa-omeg cap
29-0.6-0.4-340 mg
3
PROVIDA OB - prenatal w/o
a w/fe fum-fe poly-fa cap
20-20-1.25 mg
3
PRENATE ESSENTIAL prenat w/o a w/feaspgmethfol-fa-dha cap
18-0.6-0.4-300 mg
3
PUREFE OB PLUS - prenatal
w/o a w/fe fum-fe poly-fa cap
162.115.2-1 mg
R-NATAL OB - prenatal w/
o a w/fe cbn-fa-dha cap
20-1-320 mg
3
PRENATE MINI - prenat w/o a
w/fecbn-methylf-fa-dha cap
29-0.6-0.4-350 mg
3
RELNATE DHA - prenatal vit
w/ fe fum-fa-omega 3 cap
28-1-200 mg
3
PRENATE MINI - prenat w/oa
w/fecb-feasp-meth-fa-dha
cap 18-0.6-0.4-350 mg
3
RULAVITE DHA - prenat w/o a
w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
3
PRENATE PIXIE - prenat w/o a
w/feaspg-methfol-fa-dha cap
10-0.6-0.4-200 mg
3
SE-NATAL 19 - prenatal vit w/
dss-fe fumarate-fa tab 29-1
mg
3
PRENATE RESTORE - prenat
w/o a w/fefum-methfol-fadha cap 27-0.6-0.4-400 mg
3
SE-NATAL 19 - prenatal vit w/
fe fumarate-fa chew tab 29-1
mg
3
PRENATE STAR - prenatal vit
w/ fe asparto glycinate-fa tab
20-1 mg
3
SELECT-OB - prenat w/
fepolycmplx-methylfol-fa
chew tab 29-0.6-0.4 mg
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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110
SELECT-OB - prenatal vit w/ fe
polysac cmplx-fa chew tab
29-1 mg
3
TRICARE PRENATAL - prenat
w/o a w/fepyro-mfol chw
4.5-1 mg & dha cap 150 thpk
3
SELECT-OB+DHA - prenatal
mv w/fe poly-fa chw 29-1 mg
& dha cap 250 mg pak
3
TRICARE PRENATAL - prenat
w/o vit a w/ fe pyrophosmethylf chew tab 4.5-1 mg
3
SUPER NU-THERA - multiple
vitamins w/ minerals powder
3
TRICARE PRENATAL
COMPLEAT - prenat w/o a
fefum-fa tab 27-1 mg & fish
oil chew cap pak
3
TRICARE PRENATAL
DHA ONE - prenatal w/fe
fumarate-fa-dss-fish oil cap
27-1-500 mg
3
TRINATAL GT - prenatal vit w/
dss-iron carbonyl-fa tab 90-1
mg
3
TRINATAL RX 1 - prenatal vit
w/ fe fumarate-fa tab 60-1
mg
3
TRINATE - prenatal vit w/ fe
fumarate-fa tab 28-1 mg
3
TRISTART DHA - prenat w/o a
w/fecbn-methylf-fa-dha cap
31-0.6-0.4-200 mg
3
TRIVEEN-DUO DHA - prenatfe bis-fe prot succ-fa-ca tab
& omega 3 cap 400 pk
3
TRIVEEN-PRX RNF - prenatal
w/o vit a w/ fe fum-dss-fadha cap 26-1.2-300 mg
3
ULTIMATECARE ONE prenatal vit w/ fe cbn-fe asp
glyc-fa-omega 3 cap 27-1mg
3
ULTIMATECARE ONE NF prenatal w/fe cbnyl-fe asp
glyc-fa-dss-omega cap
20-7-1 mg
3
TARON-BC - prenat w/o a w/ fe 3
cbnyl-fa tab 20-1 mg & vit b6
tab pak
TARON-C DHA - prenatal w/fe 3
fum-fe poly -fa-omega 3 cap
53.5-38-1 mg
3
TARON-PREX - prenatal w/o
vit a w/ fe fum-dss-fa-dha
cap 30-1.2-265 mg
3
THRIVITE RX - prenatal vit w/
iron carbonyl-fa tab 29-1 mg
3
THRIVITE 19 - prenatal vit w/
dss-fe fumarate-fa tab 29-1
mg
3
TL FOLATE - prenatal vit w/
fe fum-methylfolate-fa tab
27-0.5-0.5 mg
3
TL-CARE DHA - prenatal w/fe
fumarate-fa-dss-fish oil cap
27-1-500 mg
3
TL-SELECT - prenatal w/o vit
a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg
3
TRI-TABS DHA - prenat w/o a
w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack
TRIADVANCE - prenatal vit w/ 3
dss-iron carbonyl-fa tab 90-1
mg
3
TRICARE - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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VEMAVITE-PRX 2 - prenatal w/ 3
o vit a w/ fe fum-dss-fa-dha
cap 27-1.25-300 mg
3
VENA-BAL DHA - prenat w/fe
poly-na fered-fa tab 27-1 &
omega cap dr 430mg
3
VINATE DHA RF - prenat w/o
a w/fefum-methylfol-omegas
cap 27-1.13 mg
3
VINATE II - prenatal vit w/ fe
bisglycinate chelate-fa tab
29-1 mg
VINATE M - prenatal vit w/ sel- 3
fe fumarate-fa tab 27-1 mg
3
VINATE ONE - prenatal vit w/
fe fumarate-fa tab 60-1 mg
3
VIRT NATE - prenatal vit w/ fe
fumarate-fa tab 28-1 mg
3
VIRT-ADVANCE - prenatal vit
w/ dss-iron carbonyl-fa tab
90-1 mg
3
VIRT-C DHA - prenatal w/fe
fum-fe poly -fa-omega 3 cap
53.5-38-1 mg
3
VIRT-CARE ONE - prenatal
vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg
3
VIRT-NATE DHA - prenatal vit
w/ fe fum-fa-omega 3 cap
28-1-200 mg
3
VIRT-PN - prenatal vit w/ fe
fum-methylfolate-fa tab
27-0.6-0.4 mg
3
VIRT-PN DHA - prenat w/o a
w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
3
VIRT-PN PLUS - prenat w/o a
w/ fe fumerate-methylfolatefa-omega 3 cap
VIRT-SELECT - prenatal w/o
vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg
3
VIRT-VITE GT - prenatal vit w/
dss-iron carbonyl-fa tab 90-1
mg
3
VIRTPREX - prenatal w/o vit
a w/ fe fum-dss-fa-dha cap
26-1.2-300 mg
3
VITA-PREN - prenatal vit w/
docusate-iron-fa tab 65-1 mg
3
VITAFOL FE+ - prenat-fepolymethol-fa-dha cap 90-1-200
mg & dss 50mg cap
3
VITAFOL ULTRA - prenat w/
fe poly-methylfol-fa-dha cap
29-0.6-0.4-200 mg
3
VITAFOL-NANO - prenatal w/o
a w/ fefum-l methylfol-fa tab
18-0.6-0.4 mg
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
VITAFOL-OB - prenatal vit w/ fe 3
fumarate-fa tab 65-1 mg
3
VITAFOL-OB+DHA - prenatal
mv w/fe fum-fa tab 65-1 mg
& dha cap 250 mg pack
VITAFOL-ONE - prenatal mv w/ 3
fe polysac cmplx-fa-dha cap
29-1-200 mg
3
VITAMEDMD ONE RX/
QUATREFO - prenat w/o a
w/fefum-methfol-fa-dha cap
30-0.6-0.4-200 mg
VITAMEDMD REDICHEW RX - 3
prenat w/ b2-b6-b12-d3-folic
acid chew tab 1.4 mg
3
VITAPEARL - prenat w/oa w/
fefum-na fered-fa-dha cap cr
30-1.4-200 mg
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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VITATRUE - prenat w/o a w/fe
chel-fa tab 30-1.4 mg & dha
cap 300mg pk
3
ZATEAN-PN PLUS - prenat
w/o a w/ fe fumeratemethylfolate-fa-omega 3 cap
VIVA DHA - prenatal vit w/
fe fum-fa-omega 3 cap
28-1-200 mg
3
VOL-NATE - prenatal vit w/ fe
fumarate-fa tab 28-1 mg
3
VOL-PLUS - prenatal vit w/ fe
fumarate-fa tab 27-1 mg
3
VOL-TAB RX - prenatal vit w/
iron carbonyl-fa tab 29-1 mg
3
VP-CH PLUS - prenatal w/o
a w/fe cbn-dss-fa-dha cap
29-1-265 mg
3
VP-CH-PNV - prenatal w/o vit
a w/ fe cbn-dss-fa-dha cap
30-1-260 mg
3
VP-GGR-B6 PRENATAL prenatal w/ calcium-vit b6-faginger tab 1.2 mg
3
VP-HEME OB - prenat vit-fe
poly cmplx-fe heme poly-fa
tab 28-6-1 mg
3
VP-HEME OB + DHA - prenatfe poly cmplx-fe heme polyfa tab & omega 3 cap pck
3
MINERALS and ELECTROLYTES
FLORICAL - sodium fluoride w/ A
calcium carb cap 8.3-364 mg
FLORICAL - sodium fluoride w/ A
calcium carb tab 8.3-364 mg
3
FLORIVA - sodium fluoridevitamin d liqd drops 0.25 mg/
ml-400 unit/ml
3
FLUOR-A-DAY - sodium
fluoride-xylitol chew tab 0.55
(0.25 mg f)-236.79 mg
3
FLUOR-A-DAY - sodium
fluoride-xylitol chew tab 2.2
(1 mg f)-236.79 mg
FLUORABON - sodium fluoride 3
soln 0.25 mg/0.6ml (from
0.55 mg/0.6ml naf)
3
FLURA-DROPS - sodium
fluoride soln 0.25 mg/drop f
(from 0.55 mg/drop naf)
3
GALZIN - zinc acetate cap 25
mg (elemental zinc)
3
GALZIN - zinc acetate cap 50
mg (elemental zinc)
K-TAB - potassium chloride tab 3
cr 8 meq (600 mg)
K-TAB - potassium chloride tab 3
cr 20 meq (1500 mg)
3
KLOR-CON M15 - potassium
chloride microencapsulated
crys cr tab 15 meq
3
LOZI-FLUR - sodium fluoride
lozenge 1 mg f (from 2.2 mg
naf)
VP-HEME ONE - prenat-fe poly 3
cmplx-fe heme poly-fa-dha
cap 22-6-1-200 mg
3
VP-PNV-DHA - prenatal vit
w/ fe fum-fa-omega 3 cap
28-1-215.8 mg
3
ZATEAN-CH - prenatal w/o
a w/fe cbn-dss-fa-dha cap
27-1-250 mg
3
ZATEAN-PN DHA - prenat w/
o a w/fefum-methfol-fa-dha
cap 27-0.6-0.4-300 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
3
•
•
•
•
•
•
•
•
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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POTASSIUM CHLORIDE potassium chloride oral soln
20% (40 meq/15ml)
1
potassium chloride cap cr 8
meq (Micro-k)
1
potassium chloride cap cr
10 meq (Micro-k)
1
SODIUM FLUORIDE - sodium
fluoride tab 1 mg f (from 2.2
mg naf)
3
•
sodium fluoride chew tab
0.25 mg f (from 0.55 mg
naf) (Luride)
1
•
sodium fluoride chew tab
0.5 mg f (from 1.1 mg naf)
(Luride)
1
•
sodium fluoride chew tab
1 mg f (from 2.2 mg naf)
(Luride)
1
•
1
•
1
•
POTASSIUM CHLORIDE ER potassium chloride tab cr 8
meq (600 mg)
3
sodium fluoride soln
0.125 mg/drop f (0.275 mg/
drop naf)
POTASSIUM CHLORIDE ER potassium chloride tab cr 20
meq (1500 mg)
3
sodium fluoride soln 0.5 mg/
ml f (from 1.1 mg/ml naf)
(Luride)
potassium chloride
microencapsulated crys cr
tab 10 meq
1
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)
SODIUM FLUORIDE - sodium
fluoride tab 0.5 mg f (from
1.1 mg naf)
NUTRIENTS
ADD-INS COMPLETE - amino
acids pack
3
amino acids cap
1
1
1
amino acids tab
ARGIMENT - amino acids pack
3
3
1
ARGIMENT AT - amino acids
pack
3
1
COMPLETE AMINO ACID
MIX - amino acids oral
powder
1
COMPLEX ESSENTIAL MSD amino acids oral powder
3
1
COMPLEX JUNIOR MSD amino acids oral powder
3
COMPLEX MSUD - amino
acids oral powder
3
COMPLEX MSUD AMINO
ACID B - amino acids bar
3
DEQUASINE - amino acids tab
3
3
•
Limited Distribution
•
ACA
A
Dispensing Limits
MONOCAL - sodium
monofluorophosphatecalcium carb tab 22.75-625
mg
Step Therapy
•
Prior Authorization
3
Drug Name
Drug Tier
LURIDE - sodium fluoride soln
0.5 mg/ml f (from 1.1 mg/ml
naf)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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114
ESSENTIAL AMINO ACID
MIX - amino acids oral
powder
3
PHENYLADE PHEBLOC amino acids oral powder
3
PHENYLADE PHEBLOC amino acids tab
3
G-PREPROTEIN - amino acids
oral liquid
3
PHENYLADE40 DRINK MIX amino acids pack
3
GLUTARADE AMINO ACID
BLEN - amino acids oral
powder
3
PHLEXY-10 - amino acids cap
3
GLUTARADE ESSENTIAL
GA-1 - amino acids oral
powder
3
PREPROTEIN - amino acids
oral liquid
3
3
GLUTARADE JUNIOR GA-1 amino acids oral powder
3
PREPROTEIN 20 - amino
acids oral liquid
SOLVIL - amino acids pack
3
HEPAMENT - amino acids
pack
3
SUPER-AMINO 1600 - amino
acids tab
3
L-CARNITINE - amino acids
oral liquid
3
TRIAMINO - amino acids tab
3
3
LIQUACEL - amino acids oral
liquid
3
XPHE MAXAMUM - amino
acids oral powder
3
LIQUACEL PUMP + GO amino acids oral liquid
3
XPHE MAXAMUM - amino
acids pack
NUTRASENTIALS - amino
acids oral powder
3
NUTRESTORE - glutamine
powd pack 5 gm
3
PERIFLEX LQ PKU - amino
acids oral liquid
3
PHENYLADE - amino acids
oral powder
3
PHENYLADE AMINO ACID amino acids bar
3
PHENYLADE AMINO ACID
BLEN - amino acids pack
3
PHENYLADE MTE - amino
acids oral powder
3
PHENYLADE MTE AMINO
ACID - amino acids pack
3
DIETARY PRODUCTS
A-SOY - nutritional supplement
liquid
3
ACERFLEX - nutritional
supplement powder
3
ADVERA - nutritional
supplement liquid
3
ALITRAQ - nutritional
supplement pack
3
ARGINAID - nutritional
supplement pack
3
ARGINAID EXTRA - nutritional
supplement liquid
3
BALANCE TOTAL
NUTRITIONAL - nutritional
supplement liquid
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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115
3
BALANCED NUTRITIONAL
DRIN - nutritional supplement
liquid
3
BALANCED NUTRITIONAL
SHAK - nutritional
supplement liquid
3
BCAD 1 - nutritional
supplement powder
3
BCAD 2 - nutritional
supplement powder
3
BEEF/POTATOES/PEAS nutritional supplement liquid
3
BENECALORIE - nutritional
supplement liquid
3
BOOST - nutritional
supplement liquid
3
BOOST BREEZE - nutritional
supplement liquid
3
BOOST CALORIE SMART nutritional supplement liquid
BOOST COMPACT - nutritional 3
supplement liquid
3
BOOST GLUCOSE
CONTROL - nutritional
supplement liquid
3
BOOST HIGH PROTEIN nutritional supplement liquid
3
BOOST HIGH PROTEIN nutritional supplement
powder
3
BOOST KID ESSENTIALS
1.0 - nutritional supplement
liquid
3
BOOST KID ESSENTIALS
1.5 - nutritional supplement
liquid
3
BOOST KIDS ESSENTIALS nutritional supplement liquid
BOOST PLUS - nutritional
supplement liquid
3
BOOST PUDDING - nutritional
supplement pudding
3
BOOST SMOOTHIE nutritional supplement liquid
3
BOOST VHC - nutritional
supplement liquid
3
BOOST 100 CALORIE
SMART - nutritional
supplement liquid
3
BOOST/BENEFIBER nutritional supplement liquid
3
CALCILO XD - infant foods
powder
3
CAMINO PRO BETTERMILK/
GLY - nutritional supplement
pack
3
CAMINO PRO COMPLETE/
GLYTA - nutritional
supplement bar
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
CAMINO PRO PKU - nutritional 3
supplement liquid
3
CAMINO PRO RESTORE/
GLYTAC - nutritional
supplement liquid
3
CAMINO PRO SWIRL nutritional supplement pack
3
CAMINO PRO 15PE nutritional supplement liquid
3
CARNATION BREAKFAST
ESSEN - nutritional
supplement liquid
3
CARNATION BREAKFAST
ESSEN - nutritional
supplement pack
3
CARNATION INSTANT
BREAKFA - nutritional
supplement liquid
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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CHOICE DM - nutritional
supplement liquid
3
CYCLINEX-1 - nutritional
supplement powder
3
CHOICE DM TF - nutritional
supplement liquid
3
CYCLINEX-2 - nutritional
supplement powder
3
CHOLEXTRA - nutritional
supplement powder
3
DIABETIC TF - nutritional
supplement liquid
3
CLICK ESPRESSO PROTEIN
DR - nutritional supplement
powder
3
DIABETISHIELD - nutritional
supplement liquid
3
DIABETISOURCE - nutritional
supplement liquid
3
COMPLEAT - nutritional
supplement liquid
3
DIABETISOURCE AC nutritional supplement liquid
3
COMPLEAT CLOSED
SYSTEM - nutritional
supplement liquid
3
3
COMPLEAT PEDIATRIC nutritional supplement liquid
3
DUOCAL - nutritional
supplement powder
3
COMPLEAT PEDIATRIC
REDUCE - nutritional
supplement liquid
3
EAA SUPPLEMENT nutritional supplement pack
EGG/PRO - nutritional
supplement powder
3
COMPLETE NUTRITION nutritional supplement liquid
3
ELECARE - nutritional
supplement powder
3
COMPLETE NUTRITION
PLUS - nutritional
supplement liquid
3
ELECARE JR - nutritional
supplement powder
3
3
COMPLETE PROTEIN
& VITAMI - nutritional
supplement powder
3
ELECARE/DHA/ARA nutritional supplement
powder
3
CRITICARE HN - nutritional
supplement liquid
3
ENLIVE - nutritional
supplement liquid
3
CRUCIAL - nutritional
supplement liquid
3
ENSURE - nutritional
supplement bar
3
CVS NUTRITION LIQUID nutritional supplement liquid
3
ENSURE - nutritional
supplement liquid
3
CVS NUTRITION PLUS nutritional supplement liquid
3
ENSURE - nutritional
supplement powder
3
CVS NUTRITIONAL SHAKE nutritional supplement liquid
3
ENSURE ACTIVE - nutritional
supplement liquid
ENSURE ACTIVE HEART
HEALT - nutritional
supplement liquid
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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117
ENSURE ACTIVE HIGH
PROTEI - nutritional
supplement liquid
3
ENSURE NUTRA SHAKE HICAL - nutritional supplement
liquid
3
ENSURE ACTIVE LIGHT nutritional supplement liquid
3
3
ENSURE BONE HEALTH
REVIGO - nutritional
supplement liquid
3
ENSURE NUTRITION
SHAKE - nutritional
supplement liquid
ENSURE PLUS - nutritional
supplement liquid
3
ENSURE CLEAR - nutritional
supplement liquid
3
ENSURE CLINICAL
STRENGTH - nutritional
supplement liquid
3
ENSURE COMPACT nutritional supplement liquid
3
ENSURE COMPLETE nutritional supplement liquid
3
ENSURE COMPLETE
NUTRITION - nutritional
supplement liquid
3
ENSURE ENLIVE - nutritional
supplement liquid
3
ENSURE HEALTHY MOM nutritional supplement bar
3
ENSURE HEALTHY MOM nutritional supplement liquid
3
ENSURE HIGH CALCIUM nutritional supplement liquid
3
ENSURE HIGH PROTEIN nutritional supplement liquid
3
ENSURE HIGH PROTEIN nutritional supplement
powder
3
ENSURE IMMUNE HEALTH nutritional supplement liquid
3
ENSURE MUSCLE HEALTH
REVI - nutritional supplement
liquid
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
ENSURE PLUS HN - nutritional 3
supplement liquid
3
ENSURE PRE-SURGERY nutritional supplement liquid
3
ENSURE PUDDING nutritional supplement
pudding
3
ENSURE SURGERY
IMMUNONUTR - nutritional
supplement liquid
3
ENSURE/FIBER - nutritional
supplement liquid
3
ENU NUTRITIONAL SHAKE nutritional supplement liquid
3
EO28 SPLASH - nutritional
supplement liquid
3
EQ NUTRITIONAL SHAKE nutritional supplement liquid
3
EQ NUTRITIONAL SHAKE
PLUS - nutritional
supplement liquid
3
EQ WEIGHT LOSS
SHAKE ULTR - nutritional
supplement liquid
3
EQUATE - nutritional
supplement liquid
3
EQUATE PLUS - nutritional
supplement liquid
3
F.A.A. - nutritional supplement
liquid
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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FIBER FLOW - nutritional
supplement liquid
3
GLUCERNA CARBSTEADY nutritional supplement liquid
3
FIBER-STAT - nutritional
supplement liquid
3
3
FIBERSOURCE CLOSED
SYSTEM - nutritional
supplement liquid
3
GLUCERNA CEREAL
CRUNCHY F - nutritional
supplement misc
3
FIBERSOURCE HN nutritional supplement liquid
3
GLUCERNA CRISPY
DELIGHTS - nutritional
supplement bar
3
FIBERSOURCE HN CLOSED
SYS - nutritional supplement
liquid
3
GLUCERNA HUNGER
SMART SHA - nutritional
supplement liquid
GLUCERNA MEAL - nutritional
supplement bar
3
GLUCERNA MEAL
REPLACEMENT - nutritional
supplement bar
3
GLUCERNA MINI SNACK nutritional supplement bar
3
GLUCERNA MINI SNACKS nutritional supplement bar
3
GLUCERNA OS - nutritional
supplement liquid
3
GLUCERNA SELECT nutritional supplement liquid
3
GLUCERNA SHAKE nutritional supplement liquid
3
GLUCERNA SNACK nutritional supplement bar
3
GLUCERNA SNACK SHAKE nutritional supplement liquid
3
GLUCERNA WEIGHT
LOSS SHAK - nutritional
supplement liquid
3
GLUCERNA 1.0 CAL nutritional supplement liquid
3
GLUCERNA 1.0 CAL/FIBER nutritional supplement liquid
3
FLAVOR PACKETS - nutritional 3
supplement flavor pack
3
FLAVOUR PAC - nutritional
supplement flavor pack
3
FORTA DRINK - nutritional
supplement powder
3
FORTA SHAKE - nutritional
supplement powder
3
FRUITIVITS - nutritional
supplement pack
3
GA - nutritional supplement
powder
3
GA EXPRESS15 - nutritional
supplement pack
3
GA GEL - nutritional
supplement pack
3
GA-1 ANAMIX EARLY
YEARS - nutritional
supplement powder
3
GLUCERNA - nutritional
supplement bar
3
GLUCERNA - nutritional
supplement liquid
3
GLUCERNA ADVANCE
SHAKE - nutritional
supplement liquid
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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119
GLUCERNA 1.0 WITH
CARBSTE - nutritional
supplement liquid
3
GLYTACTIN RTD 15 nutritional supplement liquid
3
GLYTROL - nutritional
supplement liquid
3
GLUCERNA 1.2 CAL nutritional supplement liquid
3
GLYTROL PREBIO1 nutritional supplement liquid
3
GLUCERNA 1.5 CAL nutritional supplement liquid
3
3
GNP NUTRITIONAL DRINK nutritional supplement liquid
3
GLUCO BURST - nutritional
supplement liquid
GNP NUTRITIONAL DRINK
PLU - nutritional supplement
liquid
3
GLUTAREX-1 - nutritional
supplement powder
3
GLUTAREX-2 - nutritional
supplement powder
3
GOAT MILK - nutritional
supplement powder
3
GLYCOSADE - nutritional
supplement pack
3
3
GLYTACTIN BETTERMILK
DE-L - nutritional supplement
pack
3
HAELAN HTPI FERMENTED
ORG - nutritional supplement
liquid
HAELAN 951 FERMENTED
ORGA - nutritional
supplement liquid
3
GLYTACTIN BETTERMILK 15 - 3
nutritional supplement pack
3
GLYTACTIN BUILD 10PE nutritional supplement pack
3
GLYTACTIN COMPLETE
10PE - nutritional supplement
bar
3
GLYTACTIN RESTORE LITE
10 - nutritional supplement
liquid
3
GLYTACTIN RESTORE LITE
10 - nutritional supplement
pack
3
GLYTACTIN RESTORE 10 nutritional supplement liquid
3
GLYTACTIN RESTORE 5 nutritional supplement pack
3
GLYTACTIN RTD 10 nutritional supplement liquid
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
HCU ANAMIX EARLY YEARS - 3
nutritional supplement
powder
3
HCU ANAMIX NEXT nutritional supplement
powder
3
HCU COOLER - nutritional
supplement liquid
3
HCU EXPRESS - nutritional
supplement pack
HCU EXPRESS20 - nutritional 3
supplement pack
3
HCU GEL - nutritional
supplement pack
HCU LOPHLEX LQ - nutritional 3
supplement liquid
HCY 1 - nutritional supplement 3
powder
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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HCY 2 - nutritional supplement
powder
3
HEALTH SOURCE SOY
PROTEIN - nutritional
supplement powder
3
HEALTHY ACCENTS NUTRA
FIT - nutritional supplement
liquid
3
HEARTBAR - nutritional
supplement bar
3
HI-CAL - nutritional supplement 3
liquid
3
HIGH-PROTEIN
NUTRITIONAL - nutritional
supplement liquid
3
HM NUTRISURE - nutritional
supplement liquid
3
HM NUTRISURE PLUS nutritional supplement liquid
HOM 2 - nutritional supplement 3
powder
3
HOMACTIN AA PLUS nutritional supplement liquid
3
HOMINEX-1 - nutritional
supplement powder
3
HOMINEX-2 - nutritional
supplement powder
3
I-VALEX-1 - nutritional
supplement powder
3
I-VALEX-2 - nutritional
supplement powder
3
IMMULIFE - nutritional
supplement powder
3
IMMUNOPRO RX - nutritional
supplement powder
3
IMPACT - nutritional
supplement liquid
IMPACT ADVANCED
RECOVERY - nutritional
supplement liquid
3
IMPACT GLUTAMINE nutritional supplement liquid
3
IMPACT PEPTIDE 1.5 nutritional supplement liquid
3
IMPACT 1.5 - nutritional
supplement liquid
3
IMPACT/FIBER - nutritional
supplement liquid
3
IMUPLUS - nutritional
supplement pack
3
INNOVACIN - nutritional
supplement liquid
3
INTROLITE - nutritional
supplement liquid
3
ISOCAL - nutritional
supplement liquid
3
ISOCAL HN - nutritional
supplement liquid
3
ISOCAL HN PLUS - nutritional
supplement liquid
3
ISOSOURCE - nutritional
supplement liquid
3
ISOSOURCE CLOSED
SYSTEM - nutritional
supplement liquid
3
ISOSOURCE HN - nutritional
supplement liquid
3
ISOSOURCE VHN - nutritional
supplement liquid
3
ISOSOURCE 1.5 CAL nutritional supplement liquid
3
ISOVACTIN AA PLUS nutritional supplement liquid
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
121
IVA ANAMIX EARLY YEARS nutritional supplement
powder
3
KETOCAL 4:1 LQ MULTI
FIBE - nutritional supplement
liquid
3
IVA ANAMIX NEXT - nutritional
supplement powder
3
KETOGEN - nutritional
supplement powder
3
JEVITY 1 CAL - nutritional
supplement liquid
3
KETONEX-1 - nutritional
supplement powder
3
JEVITY 1 CAL/FIBER nutritional supplement liquid
3
KETONEX-2 - nutritional
supplement powder
3
JEVITY 1.2 CAL - nutritional
supplement liquid
3
KETOVIE - nutritional
supplement liquid
3
JEVITY 1.2 CAL/FIBER nutritional supplement liquid
3
KETOVIE PEPTIDE nutritional supplement liquid
3
JEVITY 1.5 CAL - nutritional
supplement liquid
3
KETOVOLVE 4:1 - nutritional
supplement powder
3
JEVITY 1.5 CAL/FIBER nutritional supplement liquid
3
KINRAY PREFERRED PLUS nutritional supplement liquid
3
JUICE PLUS FIBRE nutritional supplement liquid
3
LANAFLEX - nutritional
supplement pack
3
LEU-FREE COOLER nutritional supplement liquid
3
LIPISTART - nutritional
supplement powder
3
LIQUID HOPE - nutritional
supplement liquid
3
LMD - nutritional supplement
powder
3
LOPHLEX - nutritional
supplement pack
3
LOPHLEX LQ 20 - nutritional
supplement liquid
3
LPS CRITICAL CARE SUGAR
F - nutritional supplement
liquid
3
LPS SUGAR FREE - nutritional
supplement liquid
3
MCT PRO-CAL - nutritional
supplement pack
3
JUVEN - nutritional supplement 3
pack
JUVEN - nutritional supplement 3
powder
3
JUVEN NUTRIVIGOR nutritional supplement pack
3
JUVEN REVIGOR - nutritional
supplement pack
3
K-PAX IMMUNE BOOSTER
PROT - nutritional
supplement powder
3
KETOCAL 3:1 - nutritional
supplement powder
3
KETOCAL 4:1 - nutritional
supplement liquid
3
KETOCAL 4:1 - nutritional
supplement powder
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
122
MCT PROCAL - nutritional
supplement powder
3
MSUD LOPHLEX LQ nutritional supplement liquid
3
MERITENE - nutritional
supplement powder
3
MSUD MAXAMAID - nutritional
supplement powder
3
METAFORM - nutritional
supplement pack
3
MSUD MAXAMUM - nutritional
supplement powder
3
METHIONAID - nutritional
supplement powder
3
MSUD 2 - nutritional
supplement powder
3
MMA/PA ANAMIX EARLY
YEARS - nutritional
supplement powder
3
NEOCATE INFANT DHA/
ARA - nutritional supplement
powder
3
MMA/PA ANAMIX NEXT nutritional supplement
powder
3
MMA/PA COOLER - nutritional
supplement liquid
3
MMA/PA COOLER15 nutritional supplement liquid
3
MMA/PA GEL - nutritional
supplement pack
3
MODULEN IBD - nutritional
supplement powder
3
MONOGEN - nutritional
supplement powder
3
MSUD AID - nutritional
supplement powder
3
MSUD ANAMIX EARLY
YEARS - nutritional
supplement powder
3
MSUD COOLER - nutritional
supplement liquid
3
MSUD EXPRESS - nutritional
supplement pack
3
MSUD EXPRESS20 nutritional supplement pack
3
MSUD GEL - nutritional
supplement pack
3
NEOCATE JUNIOR - nutritional 3
supplement powder
3
NEOCATE JUNIOR/
PREBIOTICS - nutritional
supplement powder
NEOCATE NUTRA - nutritional 3
supplement powder
3
NEOCATE SPLASH nutritional supplement liquid
3
NEPRO - nutritional
supplement liquid
3
NEPRO WITH CARB
STEADY - nutritional
supplement liquid
3
NEPRO WITH
CARBSTEADY - nutritional
supplement liquid
3
NESTLE FLAVOR - nutritional
supplement flavor pack
3
NESTLE FLAVOR EXTRA
STREN - nutritional
supplement flavor pack
NESTLE FLAVOR FOR KIDS - 3
nutritional supplement flavor
pack
3
NOURISH - nutritional
supplement liquid
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
123
NOVASOURCE
PULMONARY - nutritional
supplement liquid
3
NUTRAMINE APPLE AMINO
BIT - nutritional supplement
pack
3
NOVASOURCE RENAL nutritional supplement liquid
3
3
NUTRA BALANCE DIABETIC
NU - nutritional supplement
bar
3
NUTRAMINE BANANA
AMINO B - nutritional
supplement pack
3
NUTRA BALANCE FIBER
COOKI - nutritional
supplement misc
3
NUTRAMINE CHOCOLATE
AMINO - nutritional
supplement pack
3
NUTRA BALANCE PROTEIN
FOR - nutritional supplement
misc
3
NUTRAMINE MANGO AMINO
BI - nutritional supplement
pack
3
NUTRA SHAKE - nutritional
supplement liquid (frozen)
3
NUTRAMINE MIXED
FLAVORS A - nutritional
supplement pack
3
NUTRA SHAKE/SUPREME nutritional supplement liquid
(frozen)
3
NUTRAMINE PEACHES
& CREAM - nutritional
supplement pack
3
NUTRA/BALANCE RE/GEN nutritional supplement liquid
(frozen)
3
NUTRAMINE PINEAPPLE
AMINO - nutritional
supplement pack
3
NUTRA/BALANCE RE/
GEN FREE - nutritional
supplement liquid (frozen)
3
NUTREN JR - nutritional
supplement liquid
NUTREN JR FIBER nutritional supplement liquid
3
NUTRA/SHAKE - nutritional
supplement liquid (frozen)
3
NUTREN JUNIOR - nutritional
supplement liquid
3
NUTRA/SHAKE FRUIT PLUS nutritional supplement liquid
(frozen)
3
NUTREN JUNIOR 1.0 nutritional supplement liquid
3
NUTREN JUNIOR/FIBER nutritional supplement liquid
3
NUTRA/SHAKE SUPREME nutritional supplement liquid
(frozen)
3
3
NUTRA/SHAKE SUPREME nutritional supplement liquid
3
NUTREN PULMONARY nutritional supplement liquid
3
NUTRAMENT - nutritional
supplement liquid
3
NUTREN RENAL - nutritional
supplement liquid
3
NUTRAMINE - nutritional
supplement pack
3
NUTREN 1.0 - nutritional
supplement liquid
NUTREN 1.0 CAL - nutritional
supplement liquid
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
124
NUTREN 1.0/FIBER nutritional supplement liquid
3
NUTREN 1.0/FIBER/
ULTRAPAK - nutritional
supplement liquid
3
NUTREN 1.5 - nutritional
supplement liquid
3
NUTREN 1.5 CAL - nutritional
supplement liquid
3
NUTREN 1.5 FIBER nutritional supplement liquid
NUTRITIONAL SHAKE
COMPLET - nutritional
supplement liquid
3
NUTRITIONAL SHAKE PLUS nutritional supplement liquid
3
NUTRITIONAL SHAKE PLUS
PR - nutritional supplement
liquid
3
3
3
NUTRITIONAL
SUPPLEMENT - nutritional
supplement liquid
NUTREN 2.0 - nutritional
supplement liquid
3
nutritional supplement liquid
1
3
NUTREN 2.0 CAL - nutritional
supplement liquid
3
NUTRITIONAL SUPPLEMENT
PL - nutritional supplement
liquid
NUTRICIA PREOP - nutritional
supplement pack
3
NUTRIVENT - nutritional
supplement liquid
3
NUTRIFOCUS - nutritional
supplement liquid
3
NUTRIVENT 1.5 - nutritional
supplement liquid
3
NUTRIHEAL - nutritional
supplement liquid
3
NUTRIVIR - nutritional
supplement powder
3
NUTRIHEP 1.5 CAL nutritional supplement liquid
3
NUTRIVIR NSA - nutritional
supplement powder
3
NUTRIRENAL - nutritional
supplement liquid
3
OA 1 - nutritional supplement
powder
3
NUTRITIONAL DRINK nutritional supplement liquid
3
OA 2 - nutritional supplement
powder
3
NUTRITIONAL DRINK MIX nutritional supplement
powder
3
OPTIMENTAL - nutritional
supplement liquid
3
3
NUTRITIONAL DRINK PLUS nutritional supplement liquid
3
OPTISOURCE VERY
HIGH PROT - nutritional
supplement liquid
NUTRITIONAL DRINK SHAKE
M - nutritional supplement
powder
3
ORANGE CHICKEN/
CARROTS/BR - nutritional
supplement liquid
3
NUTRITIONAL SHAKE nutritional supplement liquid
3
ORGANIC PEDIA SMART nutritional supplement
powder
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
125
OS 2 - nutritional supplement
powder
3
OSMOLITE - nutritional
supplement liquid
3
3
PEDIASURE SHAKE WITH
FIBE - nutritional supplement
liquid
3
OSMOLITE HN - nutritional
supplement liquid
3
PEDIASURE SIDEKICKS nutritional supplement liquid
3
OSMOLITE 1 CAL - nutritional
supplement liquid
3
PEDIASURE SIDEKICKS nutritional supplement
powder
OSMOLITE 1.2 CAL nutritional supplement liquid
3
3
OSMOLITE 1.5 CAL nutritional supplement liquid
3
PEDIASURE SIDEKICKS
CLEAR - nutritional
supplement liquid
3
OXEPA - nutritional
supplement liquid
3
PEDIASURE SIDEKICKS
SHAKE - nutritional
supplement liquid
OXEPA 1.5 - nutritional
supplement liquid
3
PEDIASURE WITH FIBER nutritional supplement liquid
3
PEDIASURE - nutritional
supplement liquid
3
PEDIASURE 1.0 CAL/FIBER nutritional supplement liquid
3
PEDIASURE ENTERAL
FORMULA - nutritional
supplement liquid
3
PEDIASURE 1.5 CAL nutritional supplement liquid
3
3
PEDIASURE GROW & GAIN nutritional supplement liquid
3
PEDIASURE 1.5 CAL WITH
FI - nutritional supplement
liquid
PEDIASURE NUTRIPALS nutritional supplement bar
3
PEDIASURE 1.5 CAL/FIBER nutritional supplement liquid
3
PEDIASURE NUTRIPALS nutritional supplement liquid
3
PEDIATRIC DRINK - nutritional
supplement liquid
3
PEDIASURE PEDIATRIC nutritional supplement liquid
3
PEDIATRIC PEPTINEX DT nutritional supplement liquid
3
PEDIASURE PEPTIDE 1.0
CAL - nutritional supplement
liquid
3
PEDIATRIC PEPTINEX DT/
FIB - nutritional supplement
liquid
3
PEDIASURE PEPTIDE 1.5
CAL - nutritional supplement
liquid
3
PEPDITE JUNIOR - nutritional
supplement pack
3
3
PEDIASURE SHAKE MIX nutritional supplement
powder
3
PEPTAMEN - nutritional
supplement liquid
PEPTAMEN AF - nutritional
supplement liquid
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
126
PEPTAMEN BARIATRIC nutritional supplement liquid
3
PEPTAMEN INTENSE VHP nutritional supplement liquid
3
3
PEPTAMEN 1.5 CAL/
PREBIO1 - nutritional
supplement liquid
3
PEPTAMEN JUNIOR nutritional supplement liquid
3
PEPTAMEN/PREBIO1 nutritional supplement liquid
3
PEPTAMEN JUNIOR nutritional supplement
powder
3
PEPTINEX DT - nutritional
supplement liquid
3
PEPTAMEN JUNIOR FIBER nutritional supplement liquid
3
PEPTINEX DT WITH
PREBIOTI - nutritional
supplement liquid
3
PEPTAMEN JUNIOR HP nutritional supplement liquid
3
PEPTINEX 1.0 - nutritional
supplement liquid
3
PEPTAMEN JUNIOR 1 CAL nutritional supplement liquid
3
PEPTINEX 1.5 - nutritional
supplement liquid
3
PEPTAMEN JUNIOR 1 CAL/
PRE - nutritional supplement
liquid
3
PERATIVE - nutritional
supplement liquid
PERIFLEX ADVANCE nutritional supplement
powder
3
PERIFLEX JUNIOR nutritional supplement
powder
3
PFD 1 - nutritional supplement
powder
3
PFD 2 - nutritional supplement
powder
3
PHENACTIN AA PLUS nutritional supplement liquid
3
PHENEX-1 - nutritional
supplement powder
3
PHENEX-2 - nutritional
supplement powder
3
PHENYL-FREE 2 - nutritional
supplement powder
3
PHENYL-FREE 2HP nutritional supplement
powder
3
PEPTAMEN JUNIOR 1.5 CAL - 3
nutritional supplement liquid
3
PEPTAMEN JUNIOR/
PREBIO1 - nutritional
supplement liquid
3
PEPTAMEN OS - nutritional
supplement liquid
PEPTAMEN OS 1.5 - nutritional 3
supplement liquid
3
PEPTAMEN VHP - nutritional
supplement liquid
PEPTAMEN 1 CAL - nutritional 3
supplement liquid
PEPTAMEN 1 CAL/PREBIO1 - 3
nutritional supplement liquid
3
PEPTAMEN 1.5 - nutritional
supplement liquid
3
PEPTAMEN 1.5 CAL nutritional supplement liquid
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
127
PHENYLADE DRINK MIX nutritional supplement
powder
3
PKU GEL - nutritional
supplement pack
3
PKU LOPHLEX LQ 20 nutritional supplement liquid
3
PHENYLADE ESSENTIAL
DRINK - nutritional
supplement pack
3
3
PHENYLADE ESSENTIAL
DRINK - nutritional
supplement powder
3
PKU PERIFLEX EARLY
YEARS - nutritional
supplement powder
3
PHENYLADE GMP - nutritional
supplement pack
3
PKU PERIFLEX JUNIOR
PLUS - nutritional
supplement powder
PKU SPHERE 20 - nutritional
supplement pack
3
PHENYLADE GMP - nutritional
supplement powder
3
PKU TRIO - nutritional
supplement powder
3
PHENYLADE GMP MIX-IN nutritional supplement pack
3
PKU 2 - nutritional supplement
powder
3
PHENYLADE RTD PKU 10 nutritional supplement liquid
3
3
PKU 3 - nutritional supplement
powder
3
PHENYLADE60 DRINK MIX nutritional supplement pack
POLYCAL - nutritional
supplement powder
3
PHENYLADE60 DRINK MIX nutritional supplement
powder
3
3
PHLEXY-10 - nutritional
supplement pack
3
PORTAGEN - nutritional
supplement powder
3
PHYTOFUSION - nutritional
supplement pack
3
PPA/MMA EXPRESS nutritional supplement pack
3
PIVOT 1.5 CAL - nutritional
supplement liquid
3
PRO-CAL - nutritional
supplement pack
3
PKU COOLER 10 - nutritional
supplement liquid
3
PRO-CAL - nutritional
supplement powder
3
PKU COOLER 15 - nutritional
supplement liquid
3
PRO-PHREE - nutritional
supplement powder
3
PKU COOLER 20 - nutritional
supplement liquid
3
PROBALANCE - nutritional
supplement liquid
3
PKU EXPRESS - nutritional
supplement pack
3
PROMACTIN AA PLUS nutritional supplement liquid
3
PKU EXPRESS20 - nutritional
supplement pack
3
PROMOD - nutritional
supplement liquid
PROMOD - nutritional
supplement powder
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
128
PROMOTE - nutritional
supplement liquid
3
PULMOCARE 1.5 - nutritional
supplement liquid
3
PROMOTE WITH FIBER nutritional supplement liquid
3
PX VANILLA PLUS - nutritional
supplement liquid
3
PROMOTE 1.0 - nutritional
supplement liquid
3
QUINOA KALE & HEMP nutritional supplement liquid
3
PROMOTE 1.0 WITH FIBER nutritional supplement liquid
3
3
PROMOTE/FIBER - nutritional
supplement liquid
3
RA BALANCED
NUTRITIONAL - nutritional
supplement liquid
3
PROPIMEX-1 - nutritional
supplement powder
3
RA BALANCED
NUTRITIONAL P - nutritional
supplement liquid
PROPIMEX-2 - nutritional
supplement powder
3
3
PROSOURCE - nutritional
supplement liquid
3
RA NUTRITIONAL
SUPPLEMENT - nutritional
supplement liquid
PROSOURCE - nutritional
supplement powder
3
PROSOURCE NO CARB nutritional supplement liquid
3
PROSOURCE PLUS nutritional supplement liquid
3
PROSOURCE TF - nutritional
supplement liquid
3
PROSOURCE ZAC - nutritional 3
supplement liquid
3
PROSURE - nutritional
supplement liquid
3
PROTAIN XL - nutritional
supplement liquid
3
PROTEIN FORTIFIED
COOKIE - nutritional
supplement misc
3
PROVIMIN - nutritional
supplement powder
3
PULMOCARE - nutritional
supplement liquid
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
RA NUTRITIONAL SUPPORT - 3
nutritional supplement
powder
3
RA PEDIATRIC
NUTRITIONAL - nutritional
supplement liquid
3
RE/GEN PROTEIN
FORTIFIED - nutritional
supplement misc
3
RE/NEPH - nutritional
supplement liquid
3
RE/NEPH HP/HC - nutritional
supplement liquid (frozen)
3
RE/NEPH LP/HC - nutritional
supplement liquid
3
RE/NEPH REDUCED
SUGAR - nutritional
supplement liquid
3
RENALCAL - nutritional
supplement liquid
3
RENASTART - nutritional
supplement powder
3
REPLETE - nutritional
supplement liquid
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
129
REPLETE FIBER - nutritional
supplement liquid
3
RESURGEX SELECT nutritional supplement pack
3
REPLETE FIBER 1 CAL nutritional supplement liquid
3
S.O.S. 15 - nutritional
supplement pack
3
REPLETE/FIBER/ULTRAPAK nutritional supplement liquid
3
S.O.S. 20 - nutritional
supplement pack
3
RESOURCE ARGINAID nutritional supplement pack
3
S.O.S. 25 - nutritional
supplement pack
3
RESOURCE DAIRY
THICK HONE - nutritional
supplement liquid
3
SALMON/OATS/SQUASH nutritional supplement liquid
3
SB COMPLETE NUTRITION nutritional supplement liquid
3
RESOURCE DIABETIC TF nutritional supplement liquid
3
SB COMPLETE NUTRITION
PLU - nutritional supplement
liquid
3
RESOURCE JUICE DRINK nutritional supplement liquid
(frozen)
3
3
SCANDICAL - nutritional
supplement powder
3
RESOURCE JUST FOR
KIDS - nutritional supplement
liquid
3
RESOURCE JUST FOR KIDS
WI - nutritional supplement
liquid
3
SCANDISHAKE - nutritional
supplement misc
SCANDISHAKE - nutritional
supplement pack
3
RESOURCE JUST FOR KIDS
1. - nutritional supplement
liquid
3
SCANDISHAKE - nutritional
supplement powder
3
3
RESOURCE SUPPORT nutritional supplement liquid
3
SM NUTRI-DRINK - nutritional
supplement liquid
3
RESOURCE THICKENUP
THICKE - nutritional
supplement liquid
3
SM NUTRI-DRINK + nutritional supplement liquid
SOL CARB - nutritional
supplement powder
3
RESOURCE 2.0 - nutritional
supplement liquid
3
SOURCE COOKIE BAR nutritional supplement bar
3
RESPALOR - nutritional
supplement liquid
3
3
RESURGEX - nutritional
supplement pack
3
SOY PROTEIN SHAKE nutritional supplement
powder
3
RESURGEX PLUS - nutritional
supplement pack
3
SUBDUE - nutritional
supplement liquid
SUBDUE PLUS - nutritional
supplement liquid
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
https://www.myprime.com/v/BCBSTX/COMMERCIAL/TXMKT3TRG/en/find-medicine.html
BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
130
SUPLENA - nutritional
supplement liquid
3
TYLACTIN RESTORE 10 nutritional supplement liquid
3
SUPLENA RTU - nutritional
supplement liquid
3
TYLACTIN RESTORE 5PE nutritional supplement pack
3
SUPLENA WITH CARB
STEADY - nutritional
supplement liquid
3
TYLACTIN RTD 15 - nutritional
supplement liquid
3
3
TYR ANAMIX EARLY YEARS nutritional supplement
powder
3
SUPLENA 1.8 WITH
CARBSTEA - nutritional
supplement liquid
TYR ANAMIX NEXT nutritional supplement
powder
3
THICK-IT BEEF LASAGNA
PUR - nutritional supplement
misc
3
TYR COOLER - nutritional
supplement liquid
3
TYR COOLER20 - nutritional
supplement liquid
3
TYR EXPRESS - nutritional
supplement pack
3
TYR EXPRESS20 - nutritional
supplement pack
3
TYR GEL - nutritional
supplement pack
3
TYR LOPHLEX LQ - nutritional
supplement liquid
3
TYREX-1 - nutritional
supplement powder
3
TYREX-2 - nutritional
supplement powder
3
TYROS 1 - nutritional
supplement powder
3
TYROS 2 - nutritional
supplement powder
3
UCD ANAMIX JUNIOR nutritional supplement
powder
3
UCD TRIO - nutritional
supplement powder
3
THICK-IT CHICKEN A LA KIN - 3
nutritional supplement misc
THICK-IT MAPLE CINNAMON 3
F - nutritional supplement
misc
THICK-IT MIXED FRUIT AND - 3
nutritional supplement misc
3
THICK-IT SEASONED
CHICKEN - nutritional
supplement misc
3
THICK-IT SWEET CORN
PUREE - nutritional
supplement misc
3
THICK-IT THICKENED
CRANBE - nutritional
supplement liquid
3
THRIVACIN DETOX nutritional supplement liquid
3
THRIVACIN 30 - nutritional
supplement liquid
3
TOLEREX - nutritional
supplement pack
3
TWOCAL HN - nutritional
supplement liquid
3
TWOCAL HN 2.0 - nutritional
supplement liquid
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
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UCD 2 - nutritional supplement
powder
3
VIVONEX PLUS - nutritional
supplement powder
3
ULTRACAL - nutritional
supplement liquid
3
VIVONEX RTF - nutritional
supplement liquid
3
ULTRACAL HN PLUS nutritional supplement liquid
3
VIVONEX T.E.N. - nutritional
supplement pack
3
ULTRAMINO SOY PROTEIN nutritional supplement
powder
3
WELLNESS ESSENTIALS nutritional supplement kit
3
WELLNESS ESSENTIALS AI nutritional supplement kit
3
UTYMAX - nutritional
supplement pack
3
WELLNESS ESSENTIALS
BLOOD - nutritional
supplement kit
3
VHC 2.25 - nutritional
supplement liquid
3
VILACTIN AA PLUS nutritional supplement liquid
3
3
VITAJOULE - nutritional
supplement powder
3
WELLNESS ESSENTIALS
FOR J - nutritional
supplement kit
3
VITAL AF 1.2 CAL - nutritional
supplement liquid
3
WELLNESS ESSENTIALS
FOR M - nutritional
supplement kit
VITAL HIGH PROTEIN nutritional supplement liquid
3
3
VITAL HN - nutritional
supplement pack
3
WELLNESS ESSENTIALS
FOR P - nutritional
supplement kit
3
VITAL JR - nutritional
supplement liquid
3
WELLNESS ESSENTIALS
FOR W - nutritional
supplement kit
VITAL PEPTIDE 1.5 CAL nutritional supplement liquid
3
WND 1 - nutritional supplement
powder
3
VITAL 1.0 CAL - nutritional
supplement liquid
3
WND 2 - nutritional supplement
powder
3
VITAL 1.5 CAL - nutritional
supplement liquid
3
XLEU MAXAMAID - nutritional
supplement powder
3
VITAPRO - nutritional
supplement powder
3
XLEU MAXAMUM - nutritional
supplement powder
3
VITAQUICK - nutritional
supplement powder
3
3
VIVONEX PEDIATRIC nutritional supplement pack
3
XLYS-XTRP MAXAMAID nutritional supplement
powder
XLYS-XTRP MAXAMUM nutritional supplement
powder
3
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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XMET MAXAMAID - nutritional
supplement powder
3
XMET MAXAMUM - nutritional
supplement powder
3
XMTVI MAXAMAID - nutritional
supplement powder
3
XMTVI MAXAMUM - nutritional
supplement powder
3
XPHE MAXAMAID - nutritional
supplement powder
3
XPHE-XTYR MAXAMAID nutritional supplement
powder
3
XTRACAL PLUS - nutritional
supplement liquid
3
HEMATOLOGICAL AGENTS
HEMATOPOIETIC AGENTS
•
•
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 25
mcg/ml
3
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 40
mcg/ml
3
•
•
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 60
mcg/ml
3
•
•
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 100
mcg/ml
3
•
•
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 200
mcg/ml
3
•
•
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 300
mcg/ml
3
•
•
ARANESP ALBUMIN
FREE - darbepoetin alfa
soln prefilled syringe 10
mcg/0.4ml
3
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
ARANESP ALBUMIN
FREE - darbepoetin alfa
soln prefilled syringe 25
mcg/0.42ml
3
•
ARANESP ALBUMIN
FREE - darbepoetin alfa
soln prefilled syringe 40
mcg/0.4ml
3
•
•
ARANESP ALBUMIN
FREE - darbepoetin alfa
soln prefilled syringe 60
mcg/0.3ml
3
•
•
ARANESP ALBUMIN FREE darbepoetin alfa soln
prefilled syringe 100
mcg/0.5ml
3
•
•
ARANESP ALBUMIN FREE darbepoetin alfa soln
prefilled syringe 150
mcg/0.3ml
3
•
•
ARANESP ALBUMIN FREE darbepoetin alfa soln
prefilled syringe 200
mcg/0.4ml
3
•
•
ARANESP ALBUMIN FREE darbepoetin alfa soln
prefilled syringe 300
mcg/0.6ml
3
•
•
ARANESP ALBUMIN FREE darbepoetin alfa soln
prefilled syringe 500 mcg/ml
3
•
•
carbonyl iron susp
15 mg/1.25ml (elemental
iron)
A
CERDELGA - eliglustat tartrate
cap 84 mg (base equivalent)
3
cyanocobalamin inj
1000 mcg/ml
1
DROXIA - hydroxyurea cap
200 mg
•
•
•
•
•
3
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DROXIA - hydroxyurea cap
300 mg
3
DROXIA - hydroxyurea cap
400 mg
3
EPOGEN - epoetin alfa inj
2000 unit/ml
3
•
•
EPOGEN - epoetin alfa inj
3000 unit/ml
3
•
•
EPOGEN - epoetin alfa inj
4000 unit/ml
3
•
•
EPOGEN - epoetin alfa inj
10000 unit/ml
3
•
•
EPOGEN - epoetin alfa inj
20000 unit/ml
3
•
•
FER-IN-SOL - ferrous sulfate
soln 75 mg/ml (15 mg/ml
elemental fe)
A
FERRETTS CHEWABLE
IRON - carbonyl iron chew
tab 18 mg (elemental iron)
Limited Distribution
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
GRANIX - tbo-filgrastim
soln prefilled syringe 480
mcg/0.8ml
3
ICAR PEDIATRIC - carbonyl
iron susp 15 mg/1.25ml
(elemental iron)
A
•
IRON CHEWS PEDIATRIC carbonyl iron chew tab 15
mg (elemental iron)
A
•
LEUKINE - sargramostim
lyophilized for inj 250 mcg
3
•
MIRCERA - methoxy pegepoetin beta soln prefilled
syr 30 mcg/0.3ml
3
•
•
MIRCERA - methoxy pegepoetin beta soln prefilled
syr 50 mcg/0.3ml
3
•
A
•
MIRCERA - methoxy pegepoetin beta soln prefilled
syr 75 mcg/0.3ml
3
•
FERROUS SULFATE - ferrous
sulfate liquid 220 mg/5ml (44
mg/5ml elemental fe)
A
•
MIRCERA - methoxy pegepoetin beta soln prefilled
syr 100 mcg/0.3ml
3
•
FERROUS SULFATE - ferrous
sulfate syrup 300 mg/5ml
(60 mg/5ml elemental fe)
A
•
MIRCERA - methoxy pegepoetin beta soln prefilled
syr 150 mcg/0.3ml
3
•
ferrous sulfate elixir
220 mg/5ml (44 mg/5ml
elemental fe)
A
•
MIRCERA - methoxy pegepoetin beta soln prefilled
syr 200 mcg/0.3ml
3
•
A
•
MYKIDZ IRON 10 - iron susp
15 mg/1.5ml
A
A
•
•
•
NASCOBAL - cyanocobalamin
nasal spray 500 mcg/0.1ml
3
NEULASTA - pegfilgrastim soln
prefilled syringe 6 mg/0.6ml
3
•
•
NEULASTA ONPRO KIT pegfilgrastim soln prefilled
syringe kit 6 mg/0.6ml
3
•
•
ferrous sulfate soln 75 mg/
ml (15 mg/ml elemental fe)
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
A
A
1
3
•
•
•
•
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2
•
•
NEUPOGEN - filgrastim
soln prefilled syringe 300
mcg/0.5ml
2
•
•
NEUPOGEN - filgrastim
soln prefilled syringe 480
mcg/0.8ml (600 mcg/ml)
2
•
•
PROCRIT - epoetin alfa inj
2000 unit/ml
2
•
•
PROCRIT - epoetin alfa inj
3000 unit/ml
2
•
•
PROCRIT - epoetin alfa inj
4000 unit/ml
2
•
•
PROCRIT - epoetin alfa inj
10000 unit/ml
2
•
•
PROCRIT - epoetin alfa inj
20000 unit/ml
2
•
•
PROCRIT - epoetin alfa inj
40000 unit/ml
2
•
•
PROMACTA - eltrombopag
olamine tab 12.5 mg (base
equiv)
3
•
•
•
PROMACTA - eltrombopag
olamine tab 25 mg (base
equiv)
3
•
•
•
PROMACTA - eltrombopag
olamine tab 50 mg (base
equiv)
3
PROMACTA - eltrombopag
olamine tab 75 mg (base
equiv)
3
ZARXIO - filgrastim-sndz
soln prefilled syringe 300
mcg/0.5ml
3
•
•
•
•
•
•
•
•
3
•
ZAVESCA - miglustat cap 100
mg
3
•
ANTICOAGULANTS
3
COUMADIN - warfarin sodium
tab 2 mg
3
COUMADIN - warfarin sodium
tab 2.5 mg
3
COUMADIN - warfarin sodium
tab 3 mg
3
COUMADIN - warfarin sodium
tab 4 mg
3
COUMADIN - warfarin sodium
tab 5 mg
3
COUMADIN - warfarin sodium
tab 6 mg
3
COUMADIN - warfarin sodium
tab 7.5 mg
3
COUMADIN - warfarin sodium
tab 10 mg
3
ELIQUIS - apixaban tab 2.5 mg
2
ELIQUIS - apixaban tab 5 mg
2
enoxaparin sodium inj
30 mg/0.3ml (Lovenox)
1
•
•
•
1
•
1
•
1
•
1
•
enoxaparin sodium inj
60 mg/0.6ml (Lovenox)
enoxaparin sodium inj
80 mg/0.8ml (Lovenox)
enoxaparin sodium inj
100 mg/ml (Lovenox)
•
•
COUMADIN - warfarin sodium
tab 1 mg
enoxaparin sodium inj
40 mg/0.4ml (Lovenox)
Limited Distribution
NEUPOGEN - filgrastim inj 480
mcg/1.6ml (300 mcg/ml)
ZARXIO - filgrastim-sndz
soln prefilled syringe 480
mcg/0.8ml
ACA
•
Dispensing Limits
•
Step Therapy
2
Prior Authorization
NEUPOGEN - filgrastim inj 300
mcg/ml
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
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135
•
1
•
1
•
1
•
FRAGMIN - dalteparin sodium
inj 10000 unit/ml
3
1
1
1
PRADAXA - dabigatran
etexilate mesylate cap 75
mg (etexilate base eq)
3
•
PRADAXA - dabigatran
etexilate mesylate cap 110
mg (etexilate base eq)
3
•
PRADAXA - dabigatran
etexilate mesylate cap 150
mg (etexilate base eq)
3
•
SAVAYSA - edoxaban tosylate
tab 15 mg (base equivalent)
3
•
•
SAVAYSA - edoxaban tosylate
tab 30 mg (base equivalent)
3
•
•
SAVAYSA - edoxaban tosylate
tab 60 mg (base equivalent)
3
FRAGMIN - dalteparin sodium
inj 2500 unit/0.2ml
3
•
•
warfarin sodium tab 1 mg
(Coumadin)
1
FRAGMIN - dalteparin sodium
inj 5000 unit/0.2ml
3
•
warfarin sodium tab 2 mg
(Coumadin)
1
FRAGMIN - dalteparin sodium
inj 7500 unit/0.3ml
3
3
•
warfarin sodium tab 2.5 mg
(Coumadin)
1
FRAGMIN - dalteparin sodium
inj 12500 unit/0.5ml
3
•
warfarin sodium tab 3 mg
(Coumadin)
1
FRAGMIN - dalteparin sodium
inj 15000 unit/0.6ml
•
warfarin sodium tab 4 mg
(Coumadin)
1
FRAGMIN - dalteparin sodium
inj 18000 unit/0.72ml
3
•
warfarin sodium tab 5 mg
(Coumadin)
1
FRAGMIN - dalteparin sodium
inj 95000 unit/3.8ml
3
warfarin sodium tab 6 mg
(Coumadin)
1
heparin sodium (porcine) inj
1000 unit/ml
1
1
warfarin sodium tab 7.5 mg
(Coumadin)
1
fondaparinux sodium
subcutaneous inj
2.5 mg/0.5ml (Arixtra)
fondaparinux sodium
subcutaneous inj
5 mg/0.4ml (Arixtra)
fondaparinux sodium
subcutaneous inj
7.5 mg/0.6ml (Arixtra)
fondaparinux sodium
subcutaneous inj
10 mg/0.8ml (Arixtra)
heparin sodium (porcine) inj
5000 unit/ml
Limited Distribution
1
heparin sodium (porcine) pf
inj 5000 unit/0.5ml
ACA
•
Dispensing Limits
1
enoxaparin sodium inj
300 mg/3ml (Lovenox)
heparin sodium (porcine) inj
20000 unit/ml
Step Therapy
•
heparin sodium (porcine) inj
10000 unit/ml
Prior Authorization
1
enoxaparin sodium inj
150 mg/ml (Lovenox)
Drug Name
Drug Tier
•
Limited Distribution
1
enoxaparin sodium inj
120 mg/0.8ml (Lovenox)
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
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136
warfarin sodium tab 10 mg
(Coumadin)
1
XARELTO - rivaroxaban tab 10
mg
2
XARELTO - rivaroxaban tab 15
mg
2
•
XARELTO - rivaroxaban tab 20
mg
2
•
XARELTO STARTER PACK rivaroxaban tab starter
therapy pack 15 mg & 20 mg
2
•
HEMOSTATICS
AMICAR - aminocaproic acid
oral soln 0.25 gm/ml
3
AMICAR - aminocaproic acid
tab 500 mg
3
AMICAR - aminocaproic acid
tab 1000 mg
3
tranexamic acid tab 650 mg
(Lysteda)
1
HEMATOLOGICAL AGENTS - MISC.
ADVATE - antihemophilic factor 2 •
rahf-pfm for inj 250 unit
ADVATE - antihemophilic factor 2 •
rahf-pfm for inj 500 unit
ADVATE - antihemophilic factor 2 •
rahf-pfm for inj 1000 unit
ADVATE - antihemophilic factor 2 •
rahf-pfm for inj 1500 unit
ADVATE - antihemophilic factor 2 •
rahf-pfm for inj 2000 unit
ADVATE - antihemophilic factor 2 •
rahf-pfm for inj 3000 unit
ADVATE - antihemophilic factor 2 •
rahf-pfm for inj 4000 unit
2 •
ADYNOVATE - antihemophilic
factor recomb pegylated for
inj 250 unit
•
•
•
•
•
•
•
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
ADYNOVATE - antihemophilic
factor recomb pegylated for
inj 500 unit
2
•
•
ADYNOVATE - antihemophilic
factor recomb pegylated for
inj 750 unit
2
•
•
ADYNOVATE - antihemophilic
factor recomb pegylated for
inj 1000 unit
2
•
•
ADYNOVATE - antihemophilic
factor recomb pegylated for
inj 1500 unit
2
•
•
ADYNOVATE - antihemophilic
factor recomb pegylated for
inj 2000 unit
2
•
•
AGGRENOX - aspirindipyridamole cap sr 12hr
25-200 mg
3
ALPHANATE/VON
WILLEBRAND antihemophilic factor/vwf
(human) for inj 250 unit
2
•
•
ALPHANATE/VON
WILLEBRAND antihemophilic factor/vwf
(human) for inj 500 unit
2
•
•
ALPHANATE/VON
WILLEBRAND antihemophilic factor/vwf
(human) for inj 1000 unit
2
•
•
ALPHANATE/VON
WILLEBRAND antihemophilic factor/vwf
(human) for inj 1500 unit
2
•
•
ALPHANATE/VON
WILLEBRAND antihemophilic factor/vwf
(human) for inj 2000 unit
2
•
•
ALPHANINE SD - coagulation
factor ix for inj 500 unit
2
•
•
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137
•
•
ALPROLIX - coagulation factor
ix (recomb) (rfixfc) for inj 250
unit
2
•
ALPROLIX - coagulation factor
ix (recomb) (rfixfc) for inj 500
unit
2
ALPROLIX - coagulation factor
ix (recomb) (rfixfc) for inj
1000 unit
2
ALPROLIX - coagulation factor
ix (recomb) (rfixfc) for inj
2000 unit
2
ALPROLIX - coagulation factor
ix (recomb) (rfixfc) for inj
3000 unit
2
ALPROLIX - coagulation factor
ix (recomb) (rfixfc) for inj
4000 unit
2
anagrelide hcl cap 0.5 mg
(Agrylin)
1
anagrelide hcl cap 1 mg
1
aspirin-dipyridamole cap sr
12hr 25-200 mg (Aggrenox)
BENEFIX - coagulation factor
ix (recombinant) for inj kit
2000 unit
2
•
•
BENEFIX - coagulation factor
ix (recombinant) for inj kit
3000 unit
2
•
•
•
BERINERT - c1 esterase
inhibitor (human) for iv inj kit
500 unit
3
•
•
2
•
•
BRILINTA - ticagrelor tab 60
mg
2
•
•
BRILINTA - ticagrelor tab 90
mg
cilostazol tab 50 mg (Pletal)
1
cilostazol tab 100 mg (Pletal)
•
•
•
1
1
•
clopidogrel bisulfate tab
75 mg (base equiv) (Plavix)
1
•
clopidogrel bisulfate tab
300 mg (base equiv)
(Plavix)
COAGADEX - coagulation
factor x (human) for inj 250
unit
2
•
•
COAGADEX - coagulation
factor x (human) for inj 500
unit
2
•
•
CORIFACT - factor xiii
concentrate (human) for inj
kit 1000-1600 unit
2
•
•
dipyridamole tab 25 mg
(Persantine)
1
dipyridamole tab 50 mg
(Persantine)
1
dipyridamole tab 75 mg
(Persantine)
1
EFFIENT - prasugrel hcl tab 5
mg (base equiv)
3
1
BEBULIN - factor ix complex
for inj 200-1200 unit
2
•
•
BENEFIX - coagulation factor
ix (recombinant) for inj kit
250 unit
2
•
•
BENEFIX - coagulation factor
ix (recombinant) for inj kit
500 unit
2
•
•
BENEFIX - coagulation factor
ix (recombinant) for inj kit
1000 unit
2
•
Limited Distribution
2
ACA
ALPHANINE SD - coagulation
factor ix for inj 1500 unit
•
•
Dispensing Limits
•
Step Therapy
2
Prior Authorization
ALPHANINE SD - coagulation
factor ix for inj 1000 unit
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
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138
EFFIENT - prasugrel hcl tab 10
mg (base equiv)
3
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
250 unit
2
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
500 unit
2
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
750 unit
2
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
1000 unit
2
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
1500 unit
2
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
2000 unit
2
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
3000 unit
2
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
4000 unit
2
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
5000 unit
2
ELOCTATE - antihemophilic
factor (recomb) rfviiifc for inj
6000 unit
2
FEIBA - antiinhibitor coagulant
complex for inj
2
FIRAZYR - icatibant acetate inj
30 mg/3ml (base equivalent)
2
•
HELIXATE FS - antihemophilic
factor (recombinant) for inj
kit 250 unit
2
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
HELIXATE FS - antihemophilic
factor (recombinant) for inj
kit 500 unit
2
•
•
HELIXATE FS - antihemophilic
factor (recombinant) for inj
kit 1000 unit
2
•
•
HELIXATE FS - antihemophilic
factor (recombinant) for inj
kit 2000 unit
2
•
•
HELIXATE FS - antihemophilic
factor (recombinant) for inj
kit 3000 unit
2
•
•
HEMOFIL M - antihemophilic
factor (human) for inj 250
unit
2
•
•
HEMOFIL M - antihemophilic
factor (human) for inj 500
unit
2
•
•
HEMOFIL M - antihemophilic
factor (human) for inj 1000
unit
2
•
•
HEMOFIL M - antihemophilic
factor (human) for inj 1700
unit
2
•
•
HUMATE-P - antihemophilic
factor/vwf (human) for inj
250-600 unit
2
•
•
HUMATE-P - antihemophilic
factor/vwf (human) for inj
500-1200 unit
2
•
•
HUMATE-P - antihemophilic
factor/vwf (human) for inj
1000-2400 unit
2
•
•
IDELVION - coagulation factor
ix (recomb) (rix-fp) for inj 250
unit
2
•
•
IDELVION - coagulation factor
ix (recomb) (rix-fp) for inj 500
unit
2
•
•
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139
•
•
IXINITY - coagulation factor ix
(recombinant) for inj 250 unit
2
•
•
IXINITY - coagulation factor ix
(recombinant) for inj 500 unit
2
•
•
IXINITY - coagulation factor ix
(recombinant) for inj 1000
unit
2
•
•
IXINITY - coagulation factor ix
(recombinant) for inj 1500
unit
2
•
•
IXINITY - coagulation factor ix
(recombinant) for inj 2000
unit
2
•
•
IXINITY - coagulation factor ix
(recombinant) for inj 3000
unit
2
KCENTRA - prothrombin
complex conc human for inj
kit 500 unit
3
KCENTRA - prothrombin
complex conc human for inj
kit 1000 unit
3
KOATE - antihemophilic factor
(human) for inj 250 unit
2
•
•
KOATE - antihemophilic factor
(human) for inj 500 unit
2
•
•
KOATE - antihemophilic factor
(human) for inj 1000 unit
2
•
•
KOATE-DVI - antihemophilic
factor (human) for inj 250
unit
2
•
•
•
Limited Distribution
2
ACA
IDELVION - coagulation factor
ix (recomb) (rix-fp) for inj
2000 unit
•
•
Dispensing Limits
•
Step Therapy
2
Prior Authorization
IDELVION - coagulation factor
ix (recomb) (rix-fp) for inj
1000 unit
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
KOATE-DVI - antihemophilic
factor (human) for inj 500
unit
2
•
•
KOATE-DVI - antihemophilic
factor (human) for inj 1000
unit
2
•
•
KOGENATE FS antihemophilic factor
(recombinant) for inj kit 250
unit
2
•
•
KOGENATE FS antihemophilic factor
(recombinant) for inj kit 500
unit
2
•
•
KOGENATE FS antihemophilic factor
(recombinant) for inj kit 1000
unit
2
•
•
KOGENATE FS antihemophilic factor
(recombinant) for inj kit 2000
unit
2
•
•
KOGENATE FS antihemophilic factor
(recombinant) for inj kit 3000
unit
2
•
•
KOGENATE FS BIO-SET antihemophilic factor
(recombinant) for inj kit 250
unit
2
•
•
KOGENATE FS BIO-SET antihemophilic factor
(recombinant) for inj kit 500
unit
2
•
•
KOGENATE FS BIO-SET antihemophilic factor
(recombinant) for inj kit 1000
unit
2
•
•
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2
KOGENATE FS BIO-SET antihemophilic factor
(recombinant) for inj kit 3000
unit
2
KOVALTRY - antihemophilic
factor (recombinant) for inj
250 unit
2
KOVALTRY - antihemophilic
factor (recombinant) for inj
500 unit
2
•
•
KOVALTRY - antihemophilic
factor (recombinant) for inj
1000 unit
2
•
•
KOVALTRY - antihemophilic
factor (recombinant) for inj
2000 unit
2
•
•
KOVALTRY - antihemophilic
factor (recombinant) for inj
3000 unit
2
•
•
MONOCLATE-P antihemophilic factor
(human) for inj kit 1000 unit
2
•
•
MONOCLATE-P antihemophilic factor
(human) for inj kit 1500 unit
2
•
•
MONONINE - coagulation
factor ix for inj 1000 unit
2
•
•
NOVOEIGHT - antihemophilic
factor (recombinant) for inj
250 unit
2
•
•
NOVOEIGHT - antihemophilic
factor (recombinant) for inj
500 unit
2
•
•
NOVOEIGHT - antihemophilic
factor (recombinant) for inj
1000 unit
2
•
•
•
•
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
•
KOGENATE FS BIO-SET antihemophilic factor
(recombinant) for inj kit 2000
unit
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
NOVOEIGHT - antihemophilic
factor (recombinant) for inj
1500 unit
2
•
•
NOVOEIGHT - antihemophilic
factor (recombinant) for inj
2000 unit
2
•
•
NOVOEIGHT - antihemophilic
factor (recombinant) for inj
3000 unit
2
•
•
NOVOSEVEN RT - coagulation 2
factor viia (recomb) for inj 1
mg (1000 mcg)
NOVOSEVEN RT - coagulation 2
factor viia (recomb) for inj 2
mg (2000 mcg)
NOVOSEVEN RT - coagulation 2
factor viia (recomb) for inj 5
mg (5000 mcg)
NOVOSEVEN RT - coagulation 2
factor viia (recomb) for inj 8
mg (8000 mcg)
NUWIQ - antihemophilic factor 2
(bdd-rfviii) for inj kit 250 unit
NUWIQ - antihemophilic factor 2
(bdd-rfviii) for inj kit 500 unit
NUWIQ - antihemophilic factor 2
(bdd-rfviii) for inj kit 1000 unit
NUWIQ - antihemophilic factor 2
(bdd-rfviii) for inj kit 2000 unit
NUWIQ - antihemophilic factor 2
(bdd-rfviii) for inj 250 unit
NUWIQ - antihemophilic factor 2
(bdd-rfviii) for inj 500 unit
NUWIQ - antihemophilic factor 2
(bdd-rfviii) for inj 1000 unit
NUWIQ - antihemophilic factor 2
(bdd-rfviii) for inj 2000 unit
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
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OBIZUR - antihemophilic factor
(recomb porc) rpfviii for inj
500 unit
2
pentoxifylline tab cr 400 mg
1
PROFILNINE - factor ix
complex for inj 500 unit
2
•
•
PROFILNINE - factor ix
complex for inj 1000 unit
2
•
•
PROFILNINE - factor ix
complex for inj 1500 unit
2
•
•
PROFILNINE SD - factor ix
complex for inj 500 unit
2
•
•
PROFILNINE SD - factor ix
complex for inj 1000 unit
2
•
•
PROFILNINE SD - factor ix
complex for inj 1500 unit
2
•
•
RECOMBINATE antihemophilic factor
(recombinant) for inj 220-400
unit
2
•
•
RECOMBINATE antihemophilic factor
(recombinant) for inj 401-800
unit
2
RECOMBINATE antihemophilic factor
(recombinant) for inj
801-1240 unit
2
•
•
RECOMBINATE antihemophilic factor
(recombinant) for inj
1241-1800 unit
2
•
•
RECOMBINATE antihemophilic factor
(recombinant) for inj
1801-2400 unit
2
RIASTAP - fibrinogen conc
(human) inj approximately 1
gm (900-1300 mg)
3
•
•
•
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
•
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
RIXUBIS - coagulation factor ix
(recombinant) for inj 250 unit
2
•
•
RIXUBIS - coagulation factor ix
(recombinant) for inj 500 unit
2
•
•
RIXUBIS - coagulation factor
ix (recombinant) for inj 1000
unit
2
•
•
RIXUBIS - coagulation factor
ix (recombinant) for inj 2000
unit
2
•
•
RIXUBIS - coagulation factor
ix (recombinant) for inj 3000
unit
2
•
•
RUCONEST - c1 esterase
inhibitor (recombinant) for iv
inj 2100 unit
3
TRETTEN - coagulation
factor xiii a-subunit for inj
2000-3125 unit
2
•
•
WILATE - antihemophilic factor/ 2
vwf (human) for inj 500-500
unit kit
2
WILATE - antihemophilic
factor/vwf (human) for inj
1000-1000 unit kit
2
XYNTHA - antihemophilic
factor recombinant paf for inj
kit 250 unit
2
XYNTHA - antihemophilic
factor recombinant paf for inj
kit 500 unit
2
XYNTHA - antihemophilic
factor recombinant paf for inj
kit 1000 unit
2
XYNTHA - antihemophilic
factor recombinant paf for inj
kit 2000 unit
•
•
•
•
•
•
•
•
•
•
•
•
•
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2
XYNTHA SOLOFUSE antihemophilic factor
recombinant paf for inj kit
500 unit
2
XYNTHA SOLOFUSE antihemophilic factor
recombinant paf for inj kit
1000 unit
2
XYNTHA SOLOFUSE antihemophilic factor
recombinant paf for inj kit
2000 unit
2
•
•
XYNTHA SOLOFUSE antihemophilic factor
recombinant paf for inj kit
3000 unit
2
•
•
ZONTIVITY - vorapaxar
sulfate tab 2.08 mg (base
equivalent)
3
TOPICAL PRODUCTS
OPHTHALMIC AGENTS
ACUVAIL - ketorolac
tromethamine ophth soln
0.45%
3
AKTEN - lidocaine hcl ophth
gel 3.5%
3
ALOCRIL - nedocromil sodium
ophth soln 2%
3
ALOMIDE - lodoxamide
tromethamine ophth soln
0.1%
3
ALPHAGAN P - brimonidine
tartrate ophth soln 0.1%
3
ALREX - loteprednol etabonate
ophth susp 0.2%
3
•
•
•
•
apraclonidine hcl ophth soln
0.5% (base equivalent)
(Iopidine)
1
ATROPINE SULFATE atropine sulfate ophth soln
1%
1
AZASITE - azithromycin ophth
soln 1%
3
azelastine hcl ophth soln
0.05% (Optivar)
1
AZOPT - brinzolamide ophth
susp 1%
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
•
XYNTHA SOLOFUSE antihemophilic factor
recombinant paf for inj kit
250 unit
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
•
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
3
BACITRACIN - bacitracin ophth 2
oint 500 unit/gm
1
bacitracin-polymyxin b
ophth oint
1
bacitracin-polymyxinneomycin-hc ophth oint
1%
3
BEPREVE - bepotastine
besilate ophth soln 1.5%
3
BESIVANCE - besifloxacin
hcl ophth susp 0.6% (base
equiv)
3
BETADINE OPHTHALMIC
PREP - povidone-iodine
ophth soln 5%
1
betaxolol hcl ophth soln
0.5%
3
BETIMOL - timolol ophth soln
0.25%
3
BETIMOL - timolol ophth soln
0.5%
3
BETOPTIC-S - betaxolol hcl
ophth susp 0.25%
3
BIMATOPROST - bimatoprost
ophth soln 0.03%
• •
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BLEPHAMIDE - sulfacetamide
sodium-prednisolone ophth
susp 10-0.2%
3
BLEPHAMIDE S.O.P. sulfacetamide sodiumprednisolone ophth oint
10-0.2%
3
brimonidine tartrate ophth
soln 0.15% (Alphagan p)
1
brimonidine tartrate ophth
soln 0.2%
1
cyclopentolate hcl ophth
soln 1% (Cyclogyl)
cyclopentolate hcl ophth
soln 2% (Cyclogyl)
DEXAMETHASONE SODIUM
PHOS - dexamethasone
sodium phosphate ophth
soln 0.1%
3
diclofenac sodium ophth
soln 0.1%
1
bromfenac sodium ophth
soln 0.09% (base equiv)
(once-daily)
1
dorzolamide hcl ophth soln
2% (Trusopt)
1
dorzolamide hcl-timolol
maleate ophth soln
22.3-6.8 mg/ml (Cosopt)
CILOXAN - ciprofloxacin hcl
ophth oint 0.3%
3
ciprofloxacin hcl ophth soln
0.3% (Ciloxan)
1
COMBIGAN - brimonidine
tartrate-timolol maleate
ophth soln 0.2-0.5%
3
COSOPT PF - dorzolamide hcl- 3
timolol maleate ophth sol
22.3-6.8 mg/ml pf
cromolyn sodium ophth soln 1
4%
3
CYCLOGYL - cyclopentolate
hcl ophth soln 0.5%
3
CYCLOMYDRIL cyclopentolate w/
phenylephrine ophth soln
0.2-1%
1
cyclopentolate hcl ophth
soln 0.5% (Cyclogyl)
ACA
Dispensing Limits
Limited Distribution
•
1
3
EMADINE - emedastine
difumarate ophth soln 0.05%
(base equiv)
3
epinastine hcl ophth soln
0.05% (Elestat)
1
1
FLAREX - fluorometholone
acetate ophth susp 0.1%
3
fluorometholone ophth susp
0.1% (Fml liquifilm)
1
flurbiprofen sodium ophth
soln 0.03% (Ocufen)
•
1
DUREZOL - difluprednate
ophth emulsion 0.05%
erythromycin ophth oint
5 mg/gm
Step Therapy
1
3
3
carteolol hcl ophth soln 1%
1
CYSTARAN - cysteamine hcl
ophth soln 0.44% (base
equivalent)
BROMFENAC - bromfenac
sodium ophth soln 0.09%
(base equivalent)
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
FML - fluorometholone ophth
oint 0.1%
3
FML FORTE - fluorometholone
ophth susp 0.25%
3
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144
gatifloxacin ophth soln 0.5%
(Zymaxid)
1
gentamicin sulfate ophth
oint 0.3%
gentamicin sulfate ophth
soln 0.3% (Garamycin)
3
1
METIPRANOLOL metipranolol ophth soln
0.3%
3
1
MITOSOL - mitomycin for
ophth soln kit 0.2 mg
3
ILEVRO - nepafenac ophth
susp 0.3%
3
MOXEZA - moxifloxacin hcl
ophth soln 0.5% (base eq) (2
times daily)
IOPIDINE - apraclonidine
hcl ophth soln 1% (base
equivalent)
3
NATACYN - natamycin ophth
susp 5%
2
1
ISTALOL - timolol maleate
ophth soln 0.5% (once-daily)
3
ketorolac tromethamine
ophth soln 0.4% (Acular ls)
1
neomycin-bacitrac
zn-polymyx
5(3.5)mg-400unt-10000unt
op oin
ketorolac tromethamine
ophth soln 0.5% (Acular)
1
LACRISERT - artificial tear
ophth insert
3
LASTACAFT - alcaftadine
ophth soln 0.25%
3
latanoprost ophth soln
0.005% (Xalatan)
1
levobunolol hcl ophth soln
0.5% (Betagan)
levofloxacin ophth soln 0.5%
neomycin-polymygramicid op sol
1.75-10000-0.025mg-untmg/ml (Neosporin)
neomycin-polymyxindexamethasone ophth oint
0.1% (Maxitrol)
•
1
1
neomycin-polymyxindexamethasone ophth
susp 0.1% (Maxitrol)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1
1
1
NEOMYCIN/POLYMYXIN/
HYDROC - neomycinpolymyxin-hc ophth susp
3
LOTEMAX - loteprednol
etabonate ophth gel 0.5%
3
NEVANAC - nepafenac ophth
susp 0.1%
3
LOTEMAX - loteprednol
etabonate ophth oint 0.5%
3
ofloxacin ophth soln 0.3%
(Ocuflox)
1
LOTEMAX - loteprednol
etabonate ophth susp 0.5%
3
1
LUMIGAN - bimatoprost ophth
soln 0.01%
3
olopatadine hcl ophth soln
0.1% (base equivalent)
(Patanol)
3
MAXIDEX - dexamethasone
ophth susp 0.1%
3
PATADAY - olopatadine hcl
ophth soln 0.2% (base
equivalent)
phenylephrine hcl ophth
soln 2.5%
1
• •
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
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2
3
1
SULFACETAMIDE SODIUM sulfacetamide sodium ophth
oint 10%
1
sulfacetamide sodium ophth
soln 10% (Bleph-10)
1
1
sulfacetamide sodiumprednisolone ophth soln
10-0.23(0.25)%
PRED MILD - prednisolone
acetate ophth susp 0.12%
3
tetracaine hcl ophth soln
0.5%
PRED-G - gentamicinprednisolone ace ophth susp
0.3-1%
3
timolol maleate ophth gel
forming soln 0.25%
(Timoptic-xe)
1
PRED-G S.O.P. - gentamicinprednisolone ace ophth oint
0.3-0.6%
3
timolol maleate ophth gel
forming soln 0.5%
(Timoptic-xe)
1
prednisolone acetate ophth
susp 1% (Pred forte)
1
timolol maleate ophth soln
0.25% (Timoptic)
1
PREDNISOLONE SODIUM
PHOSP - prednisolone
sodium phosphate ophth
soln 1%
3
timolol maleate ophth soln
0.5% (Timoptic)
PROLENSA - bromfenac
sodium ophth soln 0.07%
(base equivalent)
proparacaine hcl ophth soln
0.5% (Alcaine)
pilocarpine hcl ophth soln
1% (Isopto carpine)
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)
1
3
1
TIMOPTIC OCUDOSE - timolol
maleate preservative free
ophth soln 0.5%
TOBRADEX - tobramycindexamethasone ophth oint
0.3-0.1%
3
TOBRADEX ST - tobramycindexamethasone ophth susp
0.3-0.05%
3
tobramycin ophth soln 0.3%
(Tobrex)
1
RESTASIS - cyclosporine
(ophth) emulsion 0.05%
3
•
•
RESTASIS MULTIDOSE cyclosporine (ophth)
emulsion 0.05%
3
•
•
Limited Distribution
ACA
1
3
• •
Dispensing Limits
1
3
3
Step Therapy
1
TIMOPTIC OCUDOSE - timolol
maleate preservative free
ophth soln 0.25%
RESCULA - unoprostone
isopropyl ophth soln 0.15%
Prior Authorization
Drug Tier
Limited Distribution
Drug Name
SIMBRINZA - brinzolamidebrimonidine tartrate ophth
susp 1-0.2%
phenylephrine hcl ophth
soln 10%
1
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
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tobramycin-dexamethasone
ophth susp 0.3-0.1%
(Tobradex)
1
CIPROFLOXACIN ciprofloxacin hcl otic soln
0.2% (base equivalent)
3
TOBREX - tobramycin ophth
oint 0.3%
3
3
TRAVATAN Z - travoprost
ophth soln 0.004%
(benzalkonium free) (bak
free)
3
COLY-MYCIN S - neomycincolistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml
fluocinolone acetonide (otic)
oil 0.01% (Dermotic)
1
trifluridine ophth soln 1%
(Viroptic)
1
VIGAMOX - moxifloxacin hcl
ophth soln 0.5% (base
equiv)
3
XIIDRA - lifitegrast ophth soln
5%
3
ZIOPTAN - tafluprost ophth
soln 0.0015%
3
ZIRGAN - ganciclovir ophth gel
0.15%
3
• •
•
•
• •
hydrocortisone w/ acetic
acid otic soln 1-2% (Vosol
hc)
1
neomycin-polymyxin-hc otic
soln 1% (Cortisporin)
1
neomycin-polymyxin-hc otic
susp 3.5 mg/ml-10000 unit/
ml-1%
ofloxacin otic soln 0.3%
1
1
ACETIC ACID/ALUMINUM
ACET - acetic acid 2% in
aluminum acetate otic soln
3
MOUTH/THROAT/DENTAL AGENTS
A
ACT TOTAL CARE DRY
MOUTH - sodium fluoride
rinse 0.02%
1
cevimeline hcl cap 30 mg
(Evoxac)
1
chlorhexidine gluconate
soln 0.12% (Peridex)
1
clotrimazole troche 10 mg
A
•
CETRAXAL - ciprofloxacin
hcl otic soln 0.2% (base
equivalent)
3
COLGATE DRY MOUTH
RELIEF - sodium fluoride
mouthwash 2.1 mg/10ml
A
•
CIPRO HC - ciprofloxacinhydrocortisone otic susp
0.2-1%
3
CREST COMPLETE - sodium
fluoride paste 0.243%
3
CIPRODEX - ciprofloxacindexamethasone otic susp
0.3-0.1%
3
DEBACTEROL - sulfuric acidsulfonated phenolics soln
30-50%
EQL DENTAL TRAVEL PACK sodium fluoride paste
0.243% & mouthwash kit
3
ZYLET - loteprednol etabonate- 3
tobramycin ophth susp
0.5-0.3%
OTIC AGENTS
acetic acid otic soln 2%
1
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
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NAFRINSE DAILY/
ACIDULATED - sodium
fluoride-phosphoric acid for
soln 1 mg/5ml (f equiv)
3
•
NAFRINSE DAILY/NEUTRAL sodium fluoride for soln rinse
0.05%
3
•
GEL-KAM ORAL CARE
RINSE - stannous fluoride
conc 0.63%
3
•
NAFRINSE WEEKLY - sodium
fluoride for soln rinse 0.2%
3
•
LIDOCAINE HCL - lidocaine
hcl laryngotracheal soln 4%
3
nystatin susp 100000 unit/ml
1
1
OMNI GEL - stannous fluoride
gel 0.4%
A
lidocaine hcl viscous soln
2%
ORAVIG - miconazole buccal
tab 50 mg (mouth-throat)
3
LISTERINE ESSENTIAL
CARE - sod
monofluorophosph-eucalmen-methyl sal-thymol gel
0.76%
A
PARODONTAX - stannous
fluoride paste 0.454%
A
•
A
•
LISTERINE NATURALS WITH
F - sodium fluoride rinse
0.02%
3
•
PHOS FLUR - sodium fluoride
rinse 0.044%
A
•
LISTERINE RESTORING sodium fluoride rinse
0.0221% (0.01% f)
A
•
PHOS-FLUR ORTHO
DEFENSE - sodium fluoride
rinse 0.044%
pilocarpine hcl tab 5 mg
(Salagen)
1
LISTERINE SMART RINSE sodium fluoride rinse
0.0221% (0.01% f)
A
•
pilocarpine hcl tab 7.5 mg
(Salagen)
1
3
A
•
LISTERINE TOTAL CARE sodium fluoride rinse
0.0221% (0.01% f)
PREVIDENT FLUORIDE sodium fluoride gel 1.1%
(0.5% f)
A
•
•
LISTERINE TOTAL CARE
PLUS - sodium fluoride rinse
0.0221% (0.01% f)
LISTERINE TOTAL CARE
ZERO - sodium fluoride rinse
0.02%
A
•
LISTERINE WHITENING/
RESTO - sodium fluoride
rinse 0.0221% (0.01% f)
A
•
PREVIDENT 5000 BOOSTER - 3
sodium fluoride paste 1.1%
3
PREVIDENT 5000 BOOSTER
PL - sodium fluoride paste
1.1%
3
PREVIDENT 5000 DRY
MOUTH - sodium fluoride gel
1.1% (0.5% f)
•
•
Limited Distribution
•
ACA
A
Dispensing Limits
GEL-KAM - stannous fluoride
gel 0.4%
Step Therapy
•
Prior Authorization
A
Drug Name
Drug Tier
EQL TRAVEL TOOTHBRUSH/
TOO - sodium
monofluorophosphate paste
0.15%
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
•
•
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PREVIDENT 5000 ENAMEL
PRO - sodium fluoridepotassium nitrate paste
1.1-5%
3
PREVIDENT 5000 PLUS sodium fluoride cream 1.1%
3
•
PREVIDENT 5000
SENSITIVE - sodium
fluoride-potassium nitrate
paste 1.1-5%
3
•
REMBRANDT DEEPLY
WHITE+PE - sodium
monofluorophosphate paste
0.884%
A
•
SENSODYNE REPAIR &
PROTEC - stannous fluoride
paste 0.454%
A
•
sodium fluoride cream 1.1%
(Prevident 5000 plus)
1
•
hydrocortisone rectal cream
2.5% (Anusol-hc)
sodium fluoride gel 1.1%
(0.5% f) (Prevident fluoride)
1
•
3
sodium fluoride paste 1.1%
(Prevident 5000 boost)
1
•
PROCTOFOAM HC hydrocortisone acetate w/
pramoxine rectal foam 1-1%
3
sodium fluoride rinse
0.0221% (0.01% f)
A
•
RECTIV - nitroglycerin oint
0.4%
3
A
UCERIS - budesonide rectal
foam 2 mg/act
ANORECTAL AGENTS
sodium fluoride rinse 0.2%
(Prevident)
1
•
•
sodium fluoride-potassium
nitrate paste 1.1-5%
(Prevident 5000 sensi)
1
•
stannous fluoride conc
0.63% (Gel-kam oral care ri)
A
A
sodium fluoride rinse 0.05%
stannous fluoride gel 0.4%
triamcinolone acetonide
dental paste 0.1%
STANNOUS FLUORIDE
RINSE - stannous fluoride liq
0.1%
A
THERA-FLUR-N - sodium
fluoride gel 1.1% (0.5% f)
3
3
CORTIFOAM - hydrocortisone
acetate rectal foam 10% (90
mg/dose)
2
hydrocortisone acetate w/
pramoxine rectal cream
1-1% (Analpram-hc)
1
hydrocortisone rectal cream
1% (Proctocort)
DERMATOLOGICALS
Limited Distribution
ACA
1
1
1
acitretin cap 17.5 mg
(Soriatane)
1
•
acitretin cap 25 mg
(Soriatane)
1
•
•
acyclovir oint 5% (Zovirax)
1
adapalene cream 0.1%
(Differin)
1
adapalene gel 0.1% (Differin)
1
adapalene gel 0.3% (Differin)
Dispensing Limits
1
acitretin cap 10 mg
(Soriatane)
•
Step Therapy
1
ANALPRAM-HC hydrocortisone acetate w/
pramoxine rectal lotn 2.5-1%
hydrocortisone enema
100 mg/60ml (Cortenema)
Prior Authorization
Drug Name
Drug Tier
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
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alclometasone dipropionate
cream 0.05% (Aclovate)
alclometasone dipropionate
oint 0.05%
1
3
AMCINONIDE - amcinonide
cream 0.1%
betamethasone valerate oint
0.1%
3
calcipotriene oint 0.005%
1
AMCINONIDE - amcinonide
lotion 0.1%
3
calcipotriene soln 0.005%
(50 mcg/ml)
AMCINONIDE - amcinonide
oint 0.1%
3
ASTERO - lidocaine hcl gel 4%
3
benzoyl peroxideerythromycin gel 5-3%
(Benzamycin)
1
betamethasone dipropionate
augmented cream 0.05%
(Diprolene af)
1
betamethasone dipropionate
augmented gel 0.05%
1
betamethasone dipropionate
augmented lotion 0.05%
(Diprolene)
1
betamethasone dipropionate
augmented oint 0.05%
(Diprolene)
1
betamethasone dipropionate
cream 0.05%
1
betamethasone dipropionate
lotion 0.05%
betamethasone dipropionate
oint 0.05%
betamethasone valerate
aerosol foam 0.12% (Luxiq)
betamethasone valerate
cream 0.1%
CENTANY - mupirocin oint 2%
3
ciclopirox gel 0.77%
1
ciclopirox solution 8%
(Penlac Nail Lacquer)
1
clindamycin phosph-benzoyl
peroxide (refrig) gel 1.2
(1)-5% (Duac)
1
1
clindamycin phosphate gel
1% (Cleocin-t)
1
clindamycin phosphate
lotion 1% (Cleocin-t)
1
clindamycin phosphate soln
1% (Cleocin-t)
clindamycin phosphate
swab 1% (Cleocin-t)
•
•
•
1
1
clindamycin phosphate
foam 1% (Evoclin)
•
1
ciclopirox shampoo 1%
(Loprox shampoo)
1
Limited Distribution
1
3
ciclopirox olamine susp
0.77% (base equiv)
ACA
1
CARAC - fluorouracil cream
0.5%
ciclopirox olamine cream
0.77% (base equiv)
Dispensing Limits
1
1
•
Step Therapy
1
calcipotriene cream 0.005%
(Dovonex)
calcipotrienebetamethasone
dipropionate oint
0.005-0.064% (Taclonex)
Prior Authorization
Drug Tier
Limited Distribution
Drug Name
betamethasone valerate
lotion 0.1%
1
ALTABAX - retapamulin oint
1%
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
1
1
1
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Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
clindamycin phosphatebenzoyl peroxide gel 1-5%
(Benzaclin)
1
CORTISPORIN - bacitracinpolymyxin-neomycin hc oint
1%
3
clindamycin phosphatetretinoin gel 1.2-0.025%
(Ziana)
1
CORTISPORIN - neomycinpolymyxin-hc crm 3.5 mg/
gm-10000 unt/gm-0.5%
3
clobetasol propionate cream
0.05% (Temovate)
1
COSENTYX - secukinumab
subcutaneous soln prefilled
syringe 150 mg/ml
3
•
•
•
COSENTYX SENSOREADY
PEN - secukinumab
subcutaneous soln autoinjector 150 mg/ml
3
•
•
•
1
DENAVIR - penciclovir cream
1%
3
1
desonide cream 0.05%
(Desowen)
1
1
desonide lotion 0.05%
(Desowen)
1
1
desonide oint 0.05%
(Desowen)
1
CLOCORTOLONE PIVALATE clocortolone pivalate cream
0.1%
3
desoximetasone cream
0.25% (Topicort)
1
CLOCORTOLONE PIVALATE
PUM - clocortolone pivalate
cream 0.1%
3
clotrimazole w/
betamethasone cream
1-0.05% (Lotrisone)
•
•
clobetasol propionate
emollient base cream
0.05% (Temovate e)
clobetasol propionate gel
0.05% (Temovate)
clobetasol propionate lotion
0.05% (Clobex)
clobetasol propionate oint
0.05% (Temovate)
clobetasol propionate
shampoo 0.05% (Clobex)
clobetasol propionate soln
0.05% (Temovate)
1
1
desoximetasone gel 0.05%
(Topicort)
1
desoximetasone oint 0.25%
(Topicort)
1
1
diclofenac sodium (actinic
keratoses) gel 3%
(Solaraze)
1
1
diclofenac sodium gel 1%
(Voltaren)
1
•
diclofenac sodium soln 1.5%
(Pennsaid)
1
CONDYLOX - podofilox gel
0.5%
3
•
DIFLORASONE DIACETATE diflorasone diacetate oint
0.05%
3
CORDRAN - flurandrenolide
tape 4 mcg/sqcm
3
clotrimazole w/
betamethasone lotion
1-0.05%
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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DOXEPIN
HYDROCHLORIDE doxepin hcl cream 5%
3
econazole nitrate cream 1%
1
fluocinolone acetonide oint
0.025% (Synalar)
fluocinolone acetonide soln
0.01% (Synalar)
ELIDEL - pimecrolimus cream
1%
3
ENSTILAR - calcipotrienebetamethasone dipropionate
foam 0.005-0.064%
3
ERTACZO - sertaconazole
nitrate cream 2%
3
FLUOROPLEX - fluorouracil
cream 1%
3
erythromycin gel 2% (Erygel)
1
FLUOROURACIL - fluorouracil
cream 0.5%
3
fluorouracil cream 5%
(Efudex)
1
fluorouracil soln 2%
1
erythromycin pads 2%
erythromycin soln 2%
EURAX - crotamiton cream
10%
fluocinonide emulsified base
cream 0.05%
fluocinonide gel 0.05%
fluocinonide oint 0.05%
fluocinonide soln 0.05%
1
1
3
EURAX - crotamiton lotion 10% 3
3
EXELDERM - sulconazole
nitrate cream 1%
3
EXELDERM - sulconazole
nitrate solution 1%
2
FINACEA - azelaic acid foam
15%
2
FINACEA - azelaic acid gel
15%
1
fluocinolone acetonide
cream 0.01%
1
fluocinolone acetonide
cream 0.025% (Synalar)
1
fluocinolone acetonide oil
0.01% (body oil) (Dermasmoothe/fs bod)
1
fluocinolone acetonide oil
0.01% (scalp oil) (Dermasmoothe/fs sca)
fluorouracil soln 5%
flurandrenolide cream 0.05%
1
1
1
•
•
1
1
fluticasone propionate
cream 0.05% (Cutivate)
1
1
GENTAMICIN SULFATE gentamicin sulfate oint 0.1%
3
gentamicin sulfate cream
0.1%
1
halobetasol propionate oint
0.05% (Ultravate)
Limited Distribution
1
1
halobetasol propionate
cream 0.05% (Ultravate)
ACA
1
flurandrenolide lotion 0.05%
(Cordran)
fluticasone propionate oint
0.005% (Cutivate)
Dispensing Limits
1
3
•
Step Therapy
1
ECOZA - econazole nitrate
foam 1%
fluocinonide cream 0.05%
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
1
HALOG - halcinonide oint 0.1%
3
hydrocortisone butyrate
cream 0.1% (Locoid)
1
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hydrocortisone butyrate oint
0.1% (Locoid)
hydrocortisone butyrate
soln 0.1% (Locoid)
hydrocortisone cream 2.5%
hydrocortisone lotion 2.5%
hydrocortisone oint 2.5%
hydrocortisone valerate
cream 0.2%
hydrocortisone valerate oint
0.2% (Westcort)
1
lidocaine-prilocaine cream
2.5-2.5% (Emla)
1
1
1
LUZU - luliconazole cream 1%
3
1
malathion lotion 0.5%
(Ovide)
1
1
MENTAX - butenafine hcl
cream 1%
3
1
methoxsalen rapid cap
10 mg (Oxsoralen ultra)
1
imiquimod cream 5%
(Aldara)
1
•
metronidazole cream 0.75%
(Metrocream)
1
isotretinoin cap 10 mg
1
metronidazole gel 0.75%
1
JUBLIA - efinaconazole soln
10%
3
•
•
•
•
•
•
KERYDIN - tavaborole soln 5%
3
•
•
ketoconazole cream 2%
1
isotretinoin cap 20 mg
isotretinoin cap 30 mg
isotretinoin cap 40 mg
1
1
1
ketoconazole shampoo 2%
(Nizoral)
1
lactic acid (ammonium
lactate) lotion 12% (Lachydrin)
1
LEVULAN KERASTICK aminolevulinic acid hcl for
soln 20% (stick applicator)
3
lidocaine hcl gel 2%
1
lidocaine hcl soln 4%
(Xylocaine)
1
lidocaine patch 5%
(Lidoderm)
1
lidocaine-prilocaine cream
kit 2.5-2.5%
1
•
•
•
•
metronidazole gel 1%
(Metrogel)
1
metronidazole lotion 0.75%
(Metrolotion)
1
mometasone furoate cream
0.1% (Elocon)
1
mometasone furoate oint
0.1% (Elocon)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1
LINDANE - lindane shampoo
1%
1
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
mometasone furoate
solution 0.1% (lotion)
(Elocon)
1
mupirocin calcium cream
2% (Bactroban)
1
mupirocin oint 2%
(Bactroban)
1
naftifine hcl cream 1%
1
naftifine hcl cream 2%
(Naftin)
1
NAFTIN - naftifine hcl cream
2%
3
NAFTIN - naftifine hcl gel 1%
3
NAFTIN - naftifine hcl gel 2%
3
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NATROBA - spinosad susp
0.9%
3
PRUDOXIN - doxepin hcl
cream 5%
3
NEO-SYNALAR - neomycin
sulfate-fluocinolone
acetonide cream 0.5-0.025%
3
REGRANEX - becaplermin gel
0.01%
3
nystatin cream 100000 unit/
gm
1
nystatin oint 100000 unit/gm
nystatin topical powder
100000 unit/gm
nystatin-triamcinolone
cream 100000-0.1 unit/gm%
nystatin-triamcinolone oint
100000-0.1 unit/gm-%
oxiconazole nitrate cream
1% (Oxistat)
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
SANTYL - collagenase oint 250 3
unit/gm
1
selenium sulfide lotion 2.5%
1
1
silver sulfadiazine cream 1%
(Silvadene)
1
1
SKLICE - ivermectin lotion
0.5%
3
SOOLANTRA - ivermectin
cream 1%
2
SPINOSAD - spinosad susp
0.9%
3
STELARA - ustekinumab inj 45
mg/0.5ml
2
•
•
•
STELARA - ustekinumab soln
prefilled syringe 45 mg/0.5ml
2
•
•
•
STELARA - ustekinumab soln
prefilled syringe 90 mg/ml
2
•
•
•
sulfacetamide sodium lotion
10% (acne) (Klaron)
1
1
1
OXISTAT - oxiconazole nitrate
cream 1%
3
OXISTAT - oxiconazole nitrate
lotion 1%
3
PANRETIN - alitretinoin gel
0.1%
3
permethrin cream 5%
(Elimite)
1
PICATO - ingenol mebutate gel
0.015%
3
•
PICATO - ingenol mebutate gel
0.05%
3
•
PLIAGLIS - lidocaine-tetracaine 3
cream 7-7%
1
podofilox soln 0.5%
(Condylox)
1
prednicarbate cream 0.1%
(Dermatop)
1
prednicarbate oint 0.1%
(Dermatop)
SULFAMYLON - mafenide
acetate cream 85 mg/gm
3
SYNERA - lidocaine-tetracaine
topical patch 70-70 mg
3
TACLONEX - calcipotrienebetamethasone dipropionate
susp 0.005-0.064%
3
tacrolimus oint 0.03%
(Protopic)
1
•
tacrolimus oint 0.1%
(Protopic)
1
•
TARGRETIN - bexarotene gel
1%
3
tazarotene cream 0.1%
(Tazorac)
1
•
•
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TAZORAC - tazarotene cream
0.05%
2
TAZORAC - tazarotene cream
0.1%
2
TAZORAC - tazarotene gel
0.05%
2
TAZORAC - tazarotene gel
0.1%
2
TOLAK - fluorouracil cream 4%
3
tretinoin cream 0.025%
(Retin-a)
1
tretinoin cream 0.05% (Retina)
1
tretinoin cream 0.1% (Retina)
1
tretinoin gel 0.01% (Retin-a)
1
tretinoin gel 0.025% (Retin-a)
tretinoin gel 0.05% (Atralin)
tretinoin microsphere gel
0.04% (Retin-a micro)
tretinoin microsphere gel
0.1% (Retin-a micro)
1
1
1
1
triamcinolone acetonide
aerosol soln 0.147 mg/gm
(Kenalog)
1
triamcinolone acetonide
cream 0.025%
1
triamcinolone acetonide
cream 0.1%
triamcinolone acetonide
cream 0.5%
triamcinolone acetonide
lotion 0.025%
triamcinolone acetonide
lotion 0.1%
triamcinolone acetonide oint
0.025%
1
1
1
1
1
triamcinolone acetonide oint
0.1%
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
TRIDESILON - desonide cream 1
0.05%
3
ULESFIA - benzyl alcohol
lotion 5%
VALCHLOR - mechlorethamine 2
hcl gel 0.016% (base
equivalent)
VEREGEN - sinecatechins oint 3
15%
2
VOLTAREN - diclofenac
sodium gel 1%
3
VUSION - miconazole-zinc
oxide-white petrolatum oint
0.25-15-81.35%
3
XOLEGEL - ketoconazole gel
2%
ZONALON - doxepin hcl cream 3
5%
3
ZYCLARA - imiquimod cream
3.75%
3
ZYCLARA PUMP - imiquimod
cream 2.5%
3
ZYCLARA PUMP - imiquimod
cream 3.75%
•
•
• •
•
•
•
MISCELLANEOUS PRODUCTS
ANTIDOTES
CETYLEV - acetylcysteine
effervescent tab 500 mg
3
CETYLEV - acetylcysteine
effervescent tab 2.5 gm
3
CHEMET - succimer cap 100
mg
2
EVZIO - naloxone hcl solution
auto-injector 0.4 mg/0.4ml
3
•
•
EVZIO - naloxone hcl solution
auto-injector 2 mg/0.4ml
3
•
•
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3
•
•
EXJADE - deferasirox tab for
oral susp 500 mg
3
•
•
FERRIPROX - deferiprone oral
soln 100 mg/ml
3
•
•
FERRIPROX - deferiprone tab
500 mg
3
•
•
JADENU - deferasirox tab 90
mg
3
•
•
JADENU - deferasirox tab 180
mg
3
•
•
JADENU - deferasirox tab 360
mg
3
•
•
NALOXONE HCL - naloxone
hcl soln prefilled syringe 2
mg/2ml
3
naloxone hcl inj 0.4 mg/ml
1
2
BREATHERITE
COLLAPSIBLE - spacer/
aerosol-holding chambers device
2
BREATHERITE RIGID
SPACER - spacer/aerosolholding chambers - device
2
BREATHERITE W/LARGE
MASK - spacer/aerosolholding chambers - device
2
BREATHERITE W/MEDIUM
MASK - spacer/aerosolholding chambers - device
2
BREATHERITE W/SMALL
MASK - spacer/aerosolholding chambers - device
2
CAYA - diaphragm arc-spring
A
HURRISEAL - dental
desensitizing product solution
3
•
naltrexone hcl tab 50 mg
(Revia)
1
NARCAN - naloxone hcl nasal
spray 4 mg/0.1ml
2
INSULIN PEN NEEDLESVARIOUS
2
•
RADIOGARDASE - prussian
blue insoluble cap 0.5 gm
3
INSULIN SYRINGESVARIOUS
2
•
LANCETS-VARIOUS
2
LANCING DEVICE-VARIOUS
3
OMNIFLEX DIAPHRAGM diaphragms
A
SPACERS – VARIOUS
3
WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 60 mm
A
•
WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 65 mm
A
•
DIAGNOSTIC PRODUCTS
BAYER BREEZE 2 TEST
DISC - glucose blood test
disk
1
BAYER CONTOUR BLOOD
GLUCO - glucose blood test
strip
1
BAYER CONTOUR NEXT
BLOOD - glucose blood test
strip
1
MEDICAL DEVICES
•
•
•
Limited Distribution
EXJADE - deferasirox tab for
oral susp 250 mg
BREATHERITE - spacer/
aerosol-holding chambers device
ACA
•
Dispensing Limits
•
Step Therapy
3
Prior Authorization
EXJADE - deferasirox tab for
oral susp 125 mg
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
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A
WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 75 mm
A
WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 80 mm
A
WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 85 mm
A
WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 90 mm
A
•
WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 95 mm
A
•
ASSORTED CLASSES
cyclosporine cap 100 mg
(Sandimmune)
1
•
CYCLOSPORINE MODIFIED cyclosporine modified cap
50 mg
2
•
cyclosporine modified cap
25 mg (Neoral)
1
1
•
cyclosporine modified
cap 50 mg (Cyclosporine
modifie)
cyclosporine modified cap
100 mg (Neoral)
1
cyclosporine modified oral
soln 100 mg/ml (Neoral)
DEPEN TITRATABS penicillamine tab 250 mg
2
ENVARSUS XR - tacrolimus
tab sr 24hr 0.75 mg
3
3
•
ENVARSUS XR - tacrolimus
tab sr 24hr 1 mg
3
ASTAGRAF XL - tacrolimus
cap sr 24hr 1 mg
3
•
ENVARSUS XR - tacrolimus
tab sr 24hr 4 mg
3
ASTAGRAF XL - tacrolimus
cap sr 24hr 5 mg
3
•
mycophenolate mofetil cap
250 mg (Cellcept)
1
ATGAM - lymphocyte immune
globulin anti-thymocyte g inj
50 mg/ml(eq)
3
AZASAN - azathioprine tab 75
mg
3
mycophenolate mofetil
for oral susp 200 mg/ml
(Cellcept)
1
mycophenolate mofetil tab
500 mg (Cellcept)
1
mycophenolate sodium tab
dr 180 mg (mycophenolic
acid equiv) (Myfortic)
•
•
•
mycophenolate sodium tab
dr 360 mg (mycophenolic
acid equiv) (Myfortic)
NEORAL - cyclosporine
modified cap 25 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
1
ASTAGRAF XL - tacrolimus
cap sr 24hr 0.5 mg
AZASAN - azathioprine tab 100 3
mg
1
azathioprine tab 50 mg
(Imuran)
3
CUPRIMINE - penicillamine
cap 250 mg
1
cyclosporine cap 25 mg
(Sandimmune)
Prior Authorization
Drug Name
Drug Tier
•
WIDE-SEAL SILICONE
DIAPHR - diaphragm wide
seal 70 mm
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
•
•
1
1
3
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NEORAL - cyclosporine
modified cap 100 mg
3
NEORAL - cyclosporine
modified oral soln 100 mg/ml
3
PROGRAF - tacrolimus cap 0.5 3
mg
3
PROGRAF - tacrolimus cap 1
mg
3
PROGRAF - tacrolimus cap 5
mg
2
RAPAMUNE - sirolimus oral
soln 1 mg/ml
REVLIMID - lenalidomide caps 2
2.5 mg
REVLIMID - lenalidomide cap 5 2
mg
2
REVLIMID - lenalidomide cap
10 mg
2
REVLIMID - lenalidomide cap
15 mg
2
REVLIMID - lenalidomide cap
20 mg
2
REVLIMID - lenalidomide cap
25 mg
3
SANDIMMUNE - cyclosporine
cap 25 mg
3
SANDIMMUNE - cyclosporine
cap 100 mg
3
SANDIMMUNE - cyclosporine
oral soln 100 mg/ml
1
sirolimus tab 0.5 mg
(Rapamune)
1
sirolimus tab 1 mg
(Rapamune)
1
sirolimus tab 2 mg
(Rapamune)
sodium polystyrene
sulfonate oral susp
15 gm/60ml (Sps)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
1
sodium polystyrene
sulfonate powder
(Kayexalate)
1
sodium polystyrene
sulfonate rectal susp
30 gm/120ml
1
•
•
SYPRINE - trientine hcl cap
250 mg
3
tacrolimus cap 0.5 mg
(Prograf)
1
tacrolimus cap 1 mg
(Prograf)
1
tacrolimus cap 5 mg
(Prograf)
1
THALOMID - thalidomide cap
50 mg
2
•
•
•
THALOMID - thalidomide cap
100 mg
2
•
•
•
THALOMID - thalidomide cap
150 mg
2
•
•
•
THALOMID - thalidomide cap
200 mg
2
•
•
•
VELTASSA - patiromer sorbitex 3
calcium for susp packet 8.4
gm (base eq)
VELTASSA - patiromer sorbitex 3
calcium for susp packet 16.8
gm (base eq)
VELTASSA - patiromer sorbitex 3
calcium for susp packet 25.2
gm (base eq)
3
ZORTRESS - everolimus tab
0.25 mg
3
ZORTRESS - everolimus tab
0.5 mg
•
•
•
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ZORTRESS - everolimus tab
0.75 mg
Limited Distribution
ACA
Dispensing Limits
Step Therapy
Prior Authorization
Drug Name
Drug Tier
2017
3
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2017
INDEX
A
abacavir sulfate-lamivudine tab 600-300 mg
(Epzicom)......................................................................... 6
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg (Trizivir)................................................ 6
abacavir sulfate tab 300 mg (base equiv) (Ziagen)........ 6
ABSTRAL -fentanyl citrate sl tab 100 mcg (base
equiv)............................................................................... 85
ABSTRAL -fentanyl citrate sl tab 200 mcg (base
equiv)............................................................................... 85
ABSTRAL -fentanyl citrate sl tab 300 mcg (base
equiv)............................................................................... 85
ABSTRAL -fentanyl citrate sl tab 400 mcg (base
equiv)............................................................................... 85
ABSTRAL -fentanyl citrate sl tab 600 mcg (base
equiv)............................................................................... 85
ABSTRAL -fentanyl citrate sl tab 800 mcg (base
equiv)............................................................................... 85
acamprosate calcium tab delayed release 333 mg
(Campral)........................................................................ 81
acarbose tab 25 mg (Precose)....................................... 29
acarbose tab 50 mg (Precose)....................................... 29
acarbose tab 100 mg (Precose)..................................... 29
acebutolol hcl cap 200 mg (Sectral).............................. 41
acebutolol hcl cap 400 mg (Sectral).............................. 41
ACERFLEX -nutritional supplement powder................... 115
acetaminophen-caffeine-dihydrocodeine cap
320.5-30-16 mg (Trezix)................................................ 85
acetaminophen w/ codeine soln 120-12 mg/5ml.......... 85
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
codeine).......................................................................... 85
acetaminophen w/ codeine tab 300-30 mg (Tylenol/
codeine #3).................................................................... 85
acetaminophen w/ codeine tab 300-60 mg (Tylenol/
codeine #4).................................................................... 85
acetazolamide cap sr 12hr 500 mg (Diamox)............... 50
acetazolamide tab 125 mg.............................................. 50
acetazolamide tab 250 mg.............................................. 50
ACETIC ACID/ALUMINUM ACET -acetic acid 2% in
aluminum acetate otic soln...........................................147
acetic acid otic soln 2%................................................ 147
acetylcysteine inhal soln 10%........................................ 56
acetylcysteine inhal soln 20%........................................ 56
acitretin cap 10 mg (Soriatane).................................... 149
acitretin cap 17.5 mg (Soriatane)................................. 149
acitretin cap 25 mg (Soriatane).................................... 149
ACTEMRA -tocilizumab subcutaneous soln prefilled
syringe 162 mg/0.9ml..................................................... 92
ACTIMMUNE -interferon gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)....................................................... 17
ACTIVE OB -prenatal w/o a w/fe cbn-fa-dha cap 20-1-320
mg.................................................................................. 105
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab
sr 24hr 15-1000 mg........................................................ 29
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab
sr 24hr 30-1000 mg........................................................ 29
ACT TOTAL CARE DRY MOUTH -sodium fluoride rinse
0.02%.............................................................................147
ACUVAIL -ketorolac tromethamine ophth soln
0.45%.............................................................................143
acyclovir cap 200 mg (Zovirax)........................................ 6
acyclovir oint 5% (Zovirax)........................................... 149
acyclovir susp 200 mg/5ml (Zovirax).............................. 6
acyclovir tab 400 mg (Zovirax)........................................ 6
acyclovir tab 800 mg (Zovirax)........................................ 6
ADACEL -tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lfmcg/0.5ml........................................................................ 16
adapalene cream 0.1% (Differin).................................. 149
adapalene gel 0.1% (Differin)....................................... 149
adapalene gel 0.3% (Differin)....................................... 149
ADASUVE -loxapine aerosol powder breath activated 10
mg.................................................................................... 72
ADCIRCA -tadalafil tab 20 mg (pah)................................. 53
ADDERALL XR -amphetamine-dextroamphetamine cap
sr 24hr 5 mg................................................................... 77
ADDERALL XR -amphetamine-dextroamphetamine cap
sr 24hr 10 mg................................................................. 77
ADDERALL XR -amphetamine-dextroamphetamine cap
sr 24hr 15 mg................................................................. 77
ADDERALL XR -amphetamine-dextroamphetamine cap
sr 24hr 20 mg................................................................. 77
ADDERALL XR -amphetamine-dextroamphetamine cap
sr 24hr 25 mg................................................................. 77
ADDERALL XR -amphetamine-dextroamphetamine cap
sr 24hr 30 mg................................................................. 77
ADD-INS COMPLETE -amino acids pack...................... 114
adefovir dipivoxil tab 10 mg (Hepsera)........................... 6
ADEMPAS -riociguat tab 0.5 mg....................................... 53
ADEMPAS -riociguat tab 1 mg.......................................... 53
ADEMPAS -riociguat tab 1.5 mg....................................... 53
ADEMPAS -riociguat tab 2 mg.......................................... 53
ADEMPAS -riociguat tab 2.5 mg....................................... 53
ADRENACLICK -epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)......................................................... 51
ADRENACLICK -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)........................................................... 51
ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
100-50 mcg/dose............................................................ 57
ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
250-50 mcg/dose............................................................ 57
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ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
500-50 mcg/dose............................................................ 57
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 45-21
mcg/act............................................................................ 57
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 115-21
mcg/act............................................................................ 57
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 230-21
mcg/act............................................................................ 57
ADVATE -antihemophilic factor rahf-pfm for inj 250
unit................................................................................. 137
ADVATE -antihemophilic factor rahf-pfm for inj 500
unit................................................................................. 137
ADVATE -antihemophilic factor rahf-pfm for inj 1000
unit................................................................................. 137
ADVATE -antihemophilic factor rahf-pfm for inj 1500
unit................................................................................. 137
ADVATE -antihemophilic factor rahf-pfm for inj 2000
unit................................................................................. 137
ADVATE -antihemophilic factor rahf-pfm for inj 3000
unit................................................................................. 137
ADVATE -antihemophilic factor rahf-pfm for inj 4000
unit................................................................................. 137
ADVERA -nutritional supplement liquid...........................115
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 250 unit.................................................................... 137
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 500 unit.................................................................... 137
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 750 unit.................................................................... 137
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 1000 unit.................................................................. 137
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 1500 unit.................................................................. 137
ADYNOVATE -antihemophilic factor recomb pegylated for
inj 2000 unit.................................................................. 137
AFINITOR DISPERZ -everolimus tab for oral susp 2
mg.................................................................................... 17
AFINITOR DISPERZ -everolimus tab for oral susp 3
mg.................................................................................... 17
AFINITOR DISPERZ -everolimus tab for oral susp 5
mg.................................................................................... 17
AFINITOR -everolimus tab 2.5 mg.................................... 17
AFINITOR -everolimus tab 5 mg....................................... 17
AFINITOR -everolimus tab 7.5 mg.................................... 17
AFINITOR -everolimus tab 10 mg..................................... 17
AFLURIA 2015-2016 -influenza virus vaccine split im
susp................................................................................. 13
AFLURIA 2016-2017 -influenza virus vaccine split im
susp................................................................................. 13
AFLURIA PF 2014-2015 -influenza virus vaccine split pf
susp pref syringe 0.5 ml................................................. 13
AFLURIA PF 2015-2016 -influenza virus vaccine split pf
susp pref syringe 0.5 ml................................................. 13
AFLURIA PF 2016-2017 -influenza virus vaccine split pf
susp pref syringe 0.5 ml................................................. 13
AFLURIA QUADRIVALENT 2016 -influenza virus vac split
quadrivalent susp pref syr 0.5ml.................................... 13
AFREZZA -insulin regular (human) inhalation powder 4
unit/cartridge.................................................................... 34
AFREZZA -insulin regular (human) inhal powd 4 (30) & 8
(60) unit/cart.................................................................... 34
AFREZZA -insulin regular (human) inhal powd 4 (60) & 8
(30) unit/cart.................................................................... 34
AFREZZA -insulin regular (human) inhal powd 4 (90) & 8
(90) unit/cart.................................................................... 34
AFREZZA -insulin regular (human) inh powd 4 & 8 & 12
unit/cart (60).................................................................... 34
AFREZZA -insulin regular (human) inh powd 8 (60) & 12
(30) unit/cart.................................................................... 34
AGGRENOX -aspirin-dipyridamole cap sr 12hr 25-200
mg.................................................................................. 137
AKTEN -lidocaine hcl ophth gel 3.5%............................. 143
AKYNZEO -netupitant-palonosetron cap 300-0.5 mg....... 62
ALBENZA -albendazole tab 200 mg................................. 12
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)......... 57
albuterol sulfate soln nebu 0.5% (5 mg/ml).................. 57
albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv).............................................................................. 57
albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv).............................................................................. 57
albuterol sulfate syrup 2 mg/5ml................................... 57
albuterol sulfate tab 2 mg...............................................57
albuterol sulfate tab 4 mg...............................................57
albuterol sulfate tab sr 12hr 4 mg (Vospire er)............ 57
albuterol sulfate tab sr 12hr 8 mg (Vospire er)............ 57
alclometasone dipropionate cream 0.05%
(Aclovate)..................................................................... 150
alclometasone dipropionate oint 0.05%......................150
ALDACTAZIDE -spironolactone & hydrochlorothiazide tab
50-50 mg......................................................................... 50
ALECENSA -alectinib hcl cap 150 mg (base
equivalent)....................................................................... 17
ALENDRONATE SODIUM -alendronate sodium tab 40
mg.................................................................................... 37
alendronate sodium tab 5 mg........................................ 37
alendronate sodium tab 10 mg...................................... 37
alendronate sodium tab 35 mg...................................... 37
alendronate sodium tab 70 mg (Fosamax)................... 37
alfuzosin hcl tab sr 24hr 10 mg (Uroxatral).................. 67
ALINIA -nitazoxanide for susp 100 mg/5ml.......................12
ALINIA -nitazoxanide tab 500 mg..................................... 12
ALITRAQ -nutritional supplement pack........................... 115
ALKERAN -melphalan tab 2 mg....................................... 17
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2017
allopurinol tab 100 mg (Zyloprim)................................. 96
allopurinol tab 300 mg (Zyloprim)................................. 96
almotriptan malate tab 6.25 mg (Axert).........................95
almotriptan malate tab 12.5 mg (Axert).........................95
ALOCRIL -nedocromil sodium ophth soln 2%................ 143
ALOGLIPTIN/METFORMIN HCL -alogliptin-metformin hcl
tab 12.5-500 mg............................................................. 29
ALOGLIPTIN/METFORMIN HCL -alogliptin-metformin hcl
tab 12.5-1000 mg........................................................... 29
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab
12.5-15 mg...................................................................... 29
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab
12.5-30 mg...................................................................... 29
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab
12.5-45 mg...................................................................... 29
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab
25-15 mg......................................................................... 29
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab
25-30 mg......................................................................... 29
ALOGLIPTIN/PIOGLITAZONE -alogliptin-pioglitazone tab
25-45 mg......................................................................... 29
ALOGLIPTIN -alogliptin benzoate tab 6.25 mg (base
equiv)............................................................................... 29
ALOGLIPTIN -alogliptin benzoate tab 12.5 mg (base
equiv)............................................................................... 29
ALOGLIPTIN -alogliptin benzoate tab 25 mg (base
equiv)............................................................................... 29
ALOMIDE -lodoxamide tromethamine ophth soln
0.1%...............................................................................143
ALORA -estradiol td patch biweekly 0.025 mg/24hr......... 24
ALORA -estradiol td patch biweekly 0.05 mg/24hr........... 24
ALORA -estradiol td patch biweekly 0.075 mg/24hr......... 24
ALORA -estradiol td patch biweekly 0.1 mg/24hr............. 24
alosetron hcl tab 0.5 mg (base equiv) (Lotronex)........ 64
alosetron hcl tab 1 mg (base equiv) (Lotronex)........... 64
ALPHAGAN P -brimonidine tartrate ophth soln 0.1%..... 143
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 250 unit......................................... 137
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 500 unit......................................... 137
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 1000 unit....................................... 137
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 1500 unit....................................... 137
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 2000 unit....................................... 137
ALPHANINE SD -coagulation factor ix for inj 500
unit................................................................................. 137
ALPHANINE SD -coagulation factor ix for inj 1000
unit................................................................................. 138
ALPHANINE SD -coagulation factor ix for inj 1500
unit................................................................................. 138
ALPRAZOLAM INTENSOL -alprazolam conc 1 mg/
ml..................................................................................... 68
alprazolam orally disintegrating tab 0.5 mg................. 68
alprazolam orally disintegrating tab 1 mg.................... 68
alprazolam orally disintegrating tab 2 mg.................... 68
alprazolam orally disintegrating tab 0.25 mg
(Niravam)........................................................................ 68
alprazolam tab 0.25 mg (Xanax).................................... 68
alprazolam tab 0.5 mg (Xanax)...................................... 68
alprazolam tab 1 mg (Xanax)..........................................68
alprazolam tab 2 mg (Xanax)..........................................68
alprazolam tab sr 24hr 0.5 mg (Xanax xr)..................... 68
alprazolam tab sr 24hr 1 mg (Xanax xr)........................ 68
alprazolam tab sr 24hr 2 mg (Xanax xr)........................ 68
alprazolam tab sr 24hr 3 mg (Xanax xr)........................ 68
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
250 unit......................................................................... 138
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
500 unit......................................................................... 138
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
1000 unit....................................................................... 138
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
2000 unit....................................................................... 138
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
3000 unit....................................................................... 138
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
4000 unit....................................................................... 138
ALREX -loteprednol etabonate ophth susp 0.2%........... 143
ALTABAX -retapamulin oint 1%.......................................150
amantadine hcl cap 100 mg......................................... 101
amantadine hcl syrup 50 mg/5ml................................ 101
amantadine hcl tab 100 mg.......................................... 101
AMCINONIDE -amcinonide cream 0.1%........................ 150
AMCINONIDE -amcinonide lotion 0.1%.......................... 150
AMCINONIDE -amcinonide oint 0.1%.............................150
AMICAR -aminocaproic acid oral soln 0.25 gm/ml......... 137
AMICAR -aminocaproic acid tab 500 mg........................ 137
AMICAR -aminocaproic acid tab 1000 mg...................... 137
amiloride & hydrochlorothiazide tab 5-50 mg.............. 50
amiloride hcl tab 5 mg.................................................... 50
amino acids cap............................................................. 114
amino acids tab.............................................................. 114
amiodarone hcl tab 100 mg............................................ 44
amiodarone hcl tab 400 mg............................................ 44
amiodarone hcl tab 200 mg (Cordarone)...................... 44
amitriptyline hcl tab 10 mg............................................. 69
amitriptyline hcl tab 25 mg............................................. 69
amitriptyline hcl tab 50 mg............................................. 69
amitriptyline hcl tab 75 mg............................................. 69
amitriptyline hcl tab 100 mg........................................... 69
amitriptyline hcl tab 150 mg........................................... 69
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2017
amlodipine besylate-benazepril hcl cap 2.5-10 mg
(Lotrel)............................................................................ 45
amlodipine besylate-benazepril hcl cap 5-10 mg
(Lotrel)............................................................................ 45
amlodipine besylate-benazepril hcl cap 5-20 mg
(Lotrel)............................................................................ 45
amlodipine besylate-benazepril hcl cap 5-40 mg
(Lotrel)............................................................................ 45
amlodipine besylate-benazepril hcl cap 10-20 mg
(Lotrel)............................................................................ 45
amlodipine besylate-benazepril hcl cap 10-40 mg
(Lotrel)............................................................................ 45
amlodipine besylate tab 2.5 mg (Norvasc)................... 42
amlodipine besylate tab 5 mg (Norvasc)...................... 42
amlodipine besylate tab 10 mg (Norvasc).................... 42
amlodipine besylate-valsartan tab 5-160 mg
(Exforge)......................................................................... 45
amlodipine besylate-valsartan tab 5-320 mg
(Exforge)......................................................................... 45
amlodipine besylate-valsartan tab 10-160 mg
(Exforge)......................................................................... 45
amlodipine besylate-valsartan tab 10-320 mg
(Exforge)......................................................................... 45
amlodipine-valsartan-hydrochlorothiazide tab
5-160-12.5 mg (Exforge hct)........................................ 45
amlodipine-valsartan-hydrochlorothiazide tab
5-160-25 mg (Exforge hct)........................................... 45
amlodipine-valsartan-hydrochlorothiazide tab
10-160-12.5 mg (Exforge hct)...................................... 45
amlodipine-valsartan-hydrochlorothiazide tab
10-160-25 mg (Exforge hct)......................................... 45
amlodipine-valsartan-hydrochlorothiazide tab
10-320-25 mg (Exforge hct)......................................... 45
AMOXAPINE -amoxapine tab 25 mg................................ 69
AMOXAPINE -amoxapine tab 50 mg................................ 69
AMOXAPINE -amoxapine tab 100 mg.............................. 69
AMOXAPINE -amoxapine tab 150 mg.............................. 69
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 (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)................................................................... 77
amphetamine-dextroamphetamine cap sr 24hr 10 mg
(Adderall xr)................................................................... 77
amphetamine-dextroamphetamine cap sr 24hr 15 mg
(Adderall xr)................................................................... 77
amphetamine-dextroamphetamine cap sr 24hr 20 mg
(Adderall xr)................................................................... 77
amphetamine-dextroamphetamine cap sr 24hr 25 mg
(Adderall xr)................................................................... 78
amphetamine-dextroamphetamine cap sr 24hr 30 mg
(Adderall xr)................................................................... 78
amphetamine-dextroamphetamine tab 5 mg
(Adderall)........................................................................ 78
amphetamine-dextroamphetamine tab 7.5 mg
(Adderall)........................................................................ 78
amphetamine-dextroamphetamine tab 10 mg
(Adderall)........................................................................ 78
amphetamine-dextroamphetamine tab 12.5 mg
(Adderall)........................................................................ 78
amphetamine-dextroamphetamine tab 15 mg
(Adderall)........................................................................ 78
amphetamine-dextroamphetamine tab 20 mg
(Adderall)........................................................................ 78
amphetamine-dextroamphetamine tab 30 mg
(Adderall)........................................................................ 78
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...................... 81
ANADROL-50 -oxymetholone tab 50 mg.......................... 23
anagrelide hcl cap 1 mg............................................... 138
anagrelide hcl cap 0.5 mg (Agrylin)............................ 138
ANALPRAM-HC -hydrocortisone acetate w/ pramoxine
rectal lotn 2.5-1%..........................................................149
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2017
anastrozole tab 1 mg (Arimidex)................................... 17
ANDRODERM -testosterone td patch 24hr 2 mg/24hr..... 23
ANDRODERM -testosterone td patch 24hr 4 mg/24hr..... 24
ANDROGEL PUMP -testosterone td gel 20.25 mg/act
(1.62%)............................................................................ 24
ANDROGEL -testosterone td gel 20.25 mg/1.25gm
(1.62%)............................................................................ 24
ANDROGEL -testosterone td gel 40.5 mg/2.5gm
(1.62%)............................................................................ 24
ANDROXY -fluoxymesterone tab 10 mg........................... 24
ANGELIQ -drospirenone-estradiol tab 0.25-0.5 mg.......... 24
ANGELIQ -drospirenone-estradiol tab 0.5-1 mg............... 24
ANORO ELLIPTA -umeclidinium-vilanterol aero powd ba
62.5-25 mcg/inh.............................................................. 57
ANZEMET -dolasetron mesylate tab 50 mg..................... 62
ANZEMET -dolasetron mesylate tab 100 mg................... 62
APIDRA -insulin glulisine inj 100 unit/ml........................... 33
APIDRA SOLOSTAR -insulin glulisine soln pen-injector inj
100 unit/ml.......................................................................33
APOKYN -apomorphine hcl soln cartridge 30
mg/3ml........................................................................... 101
apraclonidine hcl ophth soln 0.5% (base equivalent)
(Iopidine)...................................................................... 143
aprepitant capsule 80 mg (Emend)............................... 62
aprepitant capsule therapy pack 80 & 125 mg
(Emend).......................................................................... 62
APRISO -mesalamine cap sr 24hr 0.375 gm.................... 64
APTENSIO XR -methylphenidate hcl cap er 24hr 10 mg
(xr)................................................................................... 78
APTENSIO XR -methylphenidate hcl cap er 24hr 15 mg
(xr)................................................................................... 78
APTENSIO XR -methylphenidate hcl cap er 24hr 20 mg
(xr)................................................................................... 78
APTENSIO XR -methylphenidate hcl cap er 24hr 30 mg
(xr)................................................................................... 78
APTENSIO XR -methylphenidate hcl cap er 24hr 40 mg
(xr)................................................................................... 78
APTENSIO XR -methylphenidate hcl cap er 24hr 50 mg
(xr)................................................................................... 78
APTENSIO XR -methylphenidate hcl cap er 24hr 60 mg
(xr)................................................................................... 78
APTIOM -eslicarbazepine acetate tab 200 mg................. 96
APTIOM -eslicarbazepine acetate tab 400 mg................. 96
APTIOM -eslicarbazepine acetate tab 600 mg................. 96
APTIOM -eslicarbazepine acetate tab 800 mg................. 96
APTIVUS -tipranavir cap 250 mg........................................ 6
APTIVUS -tipranavir oral soln 100 mg/ml........................... 6
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 25
mcg/ml........................................................................... 133
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 40
mcg/ml........................................................................... 133
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 60
mcg/ml........................................................................... 133
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 100
mcg/ml........................................................................... 133
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 200
mcg/ml........................................................................... 133
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 300
mcg/ml........................................................................... 133
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 10 mcg/0.4ml..................................... 133
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 25 mcg/0.42ml................................... 133
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 40 mcg/0.4ml..................................... 133
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 60 mcg/0.3ml..................................... 133
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 100 mcg/0.5ml................................... 133
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 150 mcg/0.3ml................................... 133
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 200 mcg/0.4ml................................... 133
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 300 mcg/0.6ml................................... 133
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 500 mcg/ml........................................ 133
ARCALYST -rilonacept for inj 220 mg...............................92
ARCAPTA NEOHALER -indacaterol maleate inhal powder
cap 75 mcg (base equiv)................................................57
ARGIMENT -amino acids pack....................................... 114
ARGIMENT AT -amino acids pack.................................. 114
ARGINAID EXTRA -nutritional supplement liquid........... 115
ARGINAID -nutritional supplement pack......................... 115
aripiprazole orally disintegrating tab 10 mg.................72
aripiprazole orally disintegrating tab 15 mg.................72
aripiprazole oral solution 1 mg/ml................................. 72
aripiprazole tab 2 mg (Abilify)........................................ 72
aripiprazole tab 5 mg (Abilify)........................................ 72
aripiprazole tab 10 mg (Abilify)...................................... 72
aripiprazole tab 15 mg (Abilify)...................................... 72
aripiprazole tab 20 mg (Abilify)...................................... 73
aripiprazole tab 30 mg (Abilify)...................................... 73
armodafinil tab 50 mg (Nuvigil)......................................78
armodafinil tab 150 mg (Nuvigil)................................... 78
armodafinil tab 200 mg (Nuvigil)................................... 78
armodafinil tab 250 mg (Nuvigil)................................... 78
ARMOUR THYROID -thyroid tab 15 mg (1/4 grain)......... 35
ARMOUR THYROID -thyroid tab 120 mg (2 grain).......... 35
ARMOUR THYROID -thyroid tab 180 mg (3 grain).......... 35
ARMOUR THYROID -thyroid tab 240 mg (4 grain).......... 35
ARMOUR THYROID -thyroid tab 300 mg (5 grain).......... 35
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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ARNUITY ELLIPTA -fluticasone furoate aerosol powder
breath activ 100 mcg/act................................................ 57
ARNUITY ELLIPTA -fluticasone furoate aerosol powder
breath activ 200 mcg/act................................................ 57
ASACOL HD -mesalamine tab delayed release 800
mg.................................................................................... 64
ASMANEX HFA -mometasone furoate inhal aerosol
suspension 100 mcg/act................................................. 57
ASMANEX HFA -mometasone furoate inhal aerosol
suspension 200 mcg/act................................................. 57
ASMANEX TWISTHALER 120 ME -mometasone furoate
inhal powd 220 mcg/inh (breath activated).................... 57
ASMANEX TWISTHALER 30 MET -mometasone furoate
inhal powd 110 mcg/inh (breath activated).................... 57
ASMANEX TWISTHALER 30 MET -mometasone furoate
inhal powd 220 mcg/inh (breath activated).................... 58
ASMANEX TWISTHALER 60 MET -mometasone furoate
inhal powd 220 mcg/inh (breath activated).................... 58
A-SOY -nutritional supplement liquid.............................. 115
aspirin chew tab 81 mg...................................................85
aspirin-dipyridamole cap sr 12hr 25-200 mg
(Aggrenox)................................................................... 138
aspirin tab delayed release 81 mg.................................85
ASTAGRAF XL -tacrolimus cap sr 24hr 0.5 mg.............. 157
ASTAGRAF XL -tacrolimus cap sr 24hr 1 mg................. 157
ASTAGRAF XL -tacrolimus cap sr 24hr 5 mg................. 157
ASTERO -lidocaine hcl gel 4%....................................... 150
ATABEX EC -prenatal vit w/ dss-iron carbonyl-fa tab dr
29-1 mg......................................................................... 105
atenolol & chlorthalidone tab 50-25 mg (Tenoretic
50).................................................................................... 45
atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100).................................................................................. 45
atenolol tab 25 mg (Tenormin)....................................... 41
atenolol tab 50 mg (Tenormin)....................................... 41
atenolol tab 100 mg (Tenormin)..................................... 41
ATGAM -lymphocyte immune globulin anti-thymocyte g inj
50 mg/ml(eq)................................................................. 157
atorvastatin calcium tab 10 mg (base equivalent)
(Lipitor)........................................................................... 51
atorvastatin calcium tab 20 mg (base equivalent)
(Lipitor)........................................................................... 51
atorvastatin calcium tab 40 mg (base equivalent)
(Lipitor)........................................................................... 51
atorvastatin calcium tab 80 mg (base equivalent)
(Lipitor)........................................................................... 51
atovaquone-proguanil hcl tab 62.5-25 mg
(Malarone)...................................................................... 11
atovaquone-proguanil hcl tab 250-100 mg
(Malarone)...................................................................... 11
atovaquone susp 750 mg/5ml (Mepron)....................... 12
ATRIPLA -efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg................................................................6
ATROPINE SULFATE -atropine sulfate ophth soln
1%.................................................................................. 143
ATROVENT HFA -ipratropium bromide hfa inhal aerosol
17 mcg/act.......................................................................58
AUBAGIO -teriflunomide tab 7 mg.................................... 81
AUBAGIO -teriflunomide tab 14 mg.................................. 81
AUGMENTIN -amoxicillin & k clavulanate for susp
125-31.25 mg/5ml............................................................. 1
AURYXIA -ferric citrate tab 1 gm (210 mg ferric iron)....... 64
AVANDIA -rosiglitazone maleate tab 2 mg (base
equiv)............................................................................... 29
AVANDIA -rosiglitazone maleate tab 4 mg (base
equiv)............................................................................... 29
AVC -sulfanilamide vaginal cream 15%............................ 67
AVONEX -interferon beta-1a for im inj kit 30mcg
(33mcg(6.6 mu)/vial)....................................................... 81
AVONEX -interferon beta-1a im prefilled syringe kit 30
mcg/0.5ml........................................................................ 81
AVONEX PEN -interferon beta-1a im auto-injector kit 30
mcg/0.5ml........................................................................ 81
AXIRON -testosterone td soln 30 mg/act.......................... 24
AZASAN -azathioprine tab 75 mg................................... 157
AZASAN -azathioprine tab 100 mg................................. 157
AZASITE -azithromycin ophth soln 1%........................... 143
azathioprine tab 50 mg (Imuran).................................. 157
azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
(Astepro).........................................................................55
azelastine hcl nasal spray 137 mcg/spray (1 mg/
ml)................................................................................... 55
azelastine hcl ophth soln 0.05% (Optivar).................. 143
AZILECT -rasagiline mesylate tab 0.5 mg (base
equiv)............................................................................. 101
AZILECT -rasagiline mesylate tab 1 mg (base
equiv)............................................................................. 101
AZITHROMYCIN -azithromycin powd pack for susp 1
gm...................................................................................... 3
azithromycin for susp 100 mg/5ml (Zithromax)............. 3
azithromycin for susp 200 mg/5ml (Zithromax)............. 3
azithromycin tab 250 mg (Zithromax)............................. 3
azithromycin tab 500 mg (Zithromax)............................. 3
azithromycin tab 600 mg (Zithromax)............................. 3
AZOPT -brinzolamide ophth susp 1%............................. 143
B
BABY DDROPS -cholecalciferol drops 400 unit/0.03ml
(per drop)...................................................................... 105
BACITRACIN -bacitracin ophth oint 500 unit/gm............ 143
bacitracin-polymyxin b ophth oint.............................. 143
bacitracin-polymyxin-neomycin-hc ophth oint
1%.................................................................................. 143
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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baclofen tab 10 mg........................................................ 104
baclofen tab 20 mg........................................................ 104
BACTROBAN NASAL -mupirocin calcium nasal oint
2%.................................................................................... 55
BALANCED NUTRITIONAL DRIN -nutritional supplement
liquid.............................................................................. 116
BALANCED NUTRITIONAL SHAK -nutritional
supplement liquid.......................................................... 116
BALANCE TOTAL NUTRITIONAL -nutritional supplement
liquid.............................................................................. 115
BAL-CARE DHA -prenat w/fe poly-na fered-fa tab 27-1 &
omega cap dr 430mg................................................... 105
balsalazide disodium cap 750 mg (Colazal)................. 64
BANZEL -rufinamide susp 40 mg/ml................................. 96
BANZEL -rufinamide tab 200 mg...................................... 96
BANZEL -rufinamide tab 400 mg...................................... 96
BARACLUDE -entecavir oral soln 0.05 mg/ml.................... 7
BAYER BREEZE 2 TEST DISC -glucose blood test
disk................................................................................ 156
BAYER CONTOUR BLOOD GLUCO -glucose blood test
strip................................................................................ 156
BAYER CONTOUR NEXT BLOOD -glucose blood test
strip................................................................................ 156
BCAD 1 -nutritional supplement powder......................... 116
BCAD 2 -nutritional supplement powder......................... 116
BEBULIN -factor ix complex for inj 200-1200 unit.......... 138
BEEF/POTATOES/PEAS -nutritional supplement
liquid.............................................................................. 116
BELBUCA -buprenorphine hcl buccal film 75 mcg (base
equivalent)....................................................................... 85
BELBUCA -buprenorphine hcl buccal film 150 mcg (base
equivalent)....................................................................... 85
BELBUCA -buprenorphine hcl buccal film 300 mcg (base
equivalent)....................................................................... 85
BELBUCA -buprenorphine hcl buccal film 450 mcg (base
equivalent)....................................................................... 85
BELBUCA -buprenorphine hcl buccal film 600 mcg (base
equivalent)....................................................................... 86
BELBUCA -buprenorphine hcl buccal film 750 mcg (base
equivalent)....................................................................... 86
BELBUCA -buprenorphine hcl buccal film 900 mcg (base
equivalent)....................................................................... 86
benazepril & hydrochlorothiazide tab 5-6.25 mg......... 45
benazepril & hydrochlorothiazide tab 10-12.5 mg
(Lotensin hct)................................................................ 45
benazepril & hydrochlorothiazide tab 20-12.5 mg
(Lotensin hct)................................................................ 46
benazepril & hydrochlorothiazide tab 20-25 mg
(Lotensin hct)................................................................ 46
benazepril hcl tab 5 mg.................................................. 46
benazepril hcl tab 10 mg (Lotensin).............................. 46
benazepril hcl tab 20 mg (Lotensin).............................. 46
benazepril hcl tab 40 mg (Lotensin).............................. 46
BENECALORIE -nutritional supplement liquid................ 116
BENEFIX -coagulation factor ix (recombinant) for inj kit
250 unit......................................................................... 138
BENEFIX -coagulation factor ix (recombinant) for inj kit
500 unit......................................................................... 138
BENEFIX -coagulation factor ix (recombinant) for inj kit
1000 unit....................................................................... 138
BENEFIX -coagulation factor ix (recombinant) for inj kit
2000 unit....................................................................... 138
BENEFIX -coagulation factor ix (recombinant) for inj kit
3000 unit....................................................................... 138
BENICAR -olmesartan medoxomil tab 5 mg.....................46
BENICAR -olmesartan medoxomil tab 20 mg...................46
BENICAR -olmesartan medoxomil tab 40 mg...................46
BENZONATATE -benzonatate cap 150 mg...................... 56
benzonatate cap 200 mg................................................. 56
benzonatate cap 100 mg (Tessalon perles).................. 56
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin)............................................................... 150
benztropine mesylate tab 0.5 mg................................ 102
benztropine mesylate tab 1 mg................................... 102
benztropine mesylate tab 2 mg................................... 102
BEPREVE -bepotastine besilate ophth soln 1.5%.......... 143
BERINERT -c1 esterase inhibitor (human) for iv inj kit 500
unit................................................................................. 138
BESIVANCE -besifloxacin hcl ophth susp 0.6% (base
equiv)............................................................................. 143
BETADINE OPHTHALMIC PREP -povidone-iodine ophth
soln 5%......................................................................... 143
betamethasone dipropionate augmented cream 0.05%
(Diprolene af)............................................................... 150
betamethasone dipropionate augmented gel
0.05%.............................................................................150
betamethasone dipropionate augmented lotion 0.05%
(Diprolene)................................................................... 150
betamethasone dipropionate augmented oint 0.05%
(Diprolene)................................................................... 150
betamethasone dipropionate cream 0.05%................ 150
betamethasone dipropionate lotion 0.05%................. 150
betamethasone dipropionate oint 0.05%.................... 150
betamethasone valerate aerosol foam 0.12%
(Luxiq)........................................................................... 150
betamethasone valerate cream 0.1%.......................... 150
betamethasone valerate lotion 0.1%........................... 150
betamethasone valerate oint 0.1%.............................. 150
BETASERON -interferon beta-1b for inj kit 0.3 mg........... 81
betaxolol hcl ophth soln 0.5%......................................143
betaxolol hcl tab 10 mg (Kerlone)................................. 41
betaxolol hcl tab 20 mg (Kerlone)................................. 41
bethanechol chloride tab 5 mg (Urecholine)................ 66
bethanechol chloride tab 10 mg (Urecholine).............. 66
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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bethanechol chloride tab 25 mg (Urecholine).............. 66
bethanechol chloride tab 50 mg (Urecholine).............. 66
BETHKIS -tobramycin nebu soln 300 mg/4ml.................... 5
BETIMOL -timolol ophth soln 0.25%............................... 143
BETIMOL -timolol ophth soln 0.5%................................. 143
BETOPTIC-S -betaxolol hcl ophth susp 0.25%.............. 143
bexarotene cap 75 mg (Targretin)..................................17
BEYAZ -drospirenone-ethinyl estrad-levomefolate tab
3-0.02-0.451 mg..............................................................26
bicalutamide tab 50 mg (Casodex)................................ 17
BIDIL -isosorbide dinitrate-hydralazine hcl tab 20-37.5
mg.................................................................................... 54
BILTRICIDE -praziquantel tab 600 mg.............................. 12
BIMATOPROST -bimatoprost ophth soln 0.03%............ 143
bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln
kit..................................................................................... 60
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
(Ziac)............................................................................... 46
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
(Ziac)............................................................................... 46
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
(Ziac)............................................................................... 46
bisoprolol fumarate tab 5 mg (Zebeta)..........................41
bisoprolol fumarate tab 10 mg (Zebeta)........................41
BLEPHAMIDE S.O.P. -sulfacetamide sodiumprednisolone ophth oint 10-0.2%................................. 144
BLEPHAMIDE -sulfacetamide sodium-prednisolone ophth
susp 10-0.2%................................................................ 144
BOOST/BENEFIBER -nutritional supplement liquid....... 116
BOOST BREEZE -nutritional supplement liquid............. 116
BOOST CALORIE SMART -nutritional supplement
liquid.............................................................................. 116
BOOST 100 CALORIE SMART -nutritional supplement
liquid.............................................................................. 116
BOOST COMPACT -nutritional supplement liquid.......... 116
BOOST GLUCOSE CONTROL -nutritional supplement
liquid.............................................................................. 116
BOOST HIGH PROTEIN -nutritional supplement
liquid.............................................................................. 116
BOOST HIGH PROTEIN -nutritional supplement
powder........................................................................... 116
BOOST KID ESSENTIALS 1.0 -nutritional supplement
liquid.............................................................................. 116
BOOST KID ESSENTIALS 1.5 -nutritional supplement
liquid.............................................................................. 116
BOOST KIDS ESSENTIALS -nutritional supplement
liquid.............................................................................. 116
BOOST -nutritional supplement liquid............................. 116
BOOST PLUS -nutritional supplement liquid.................. 116
BOOST PUDDING -nutritional supplement pudding.......116
BOOSTRIX -tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lflf-mcg/0.5ml..................................................................... 16
BOOST SMOOTHIE -nutritional supplement liquid........ 116
BOOST VHC -nutritional supplement liquid.................... 116
BOSULIF -bosutinib tab 100 mg....................................... 17
BOSULIF -bosutinib tab 500 mg....................................... 17
BP FOLINATAL PLUS B -prenatal w/ calcium carbonateb6-b12-fa tab 1 mg....................................................... 106
BP MULTINATAL PLUS -prenatal w/o a vit w/ fe fumaratefa tab 30-1 mg.............................................................. 106
BP MULTINATAL PLUS -prenatal w/o a vit w/ fe fum-fa
tab chew 40-1 mg......................................................... 106
BREATHERITE COLLAPSIBLE -spacer/aerosol-holding
chambers - device........................................................ 156
BREATHERITE RIGID SPACER -spacer/aerosol-holding
chambers - device........................................................ 156
BREATHERITE -spacer/aerosol-holding chambers device............................................................................ 156
BREATHERITE W/LARGE MASK -spacer/aerosol-holding
chambers - device........................................................ 156
BREATHERITE W/MEDIUM MASK -spacer/aerosolholding chambers - device........................................... 156
BREATHERITE W/SMALL MASK -spacer/aerosol-holding
chambers - device........................................................ 156
BREO ELLIPTA -fluticasone furoate-vilanterol aero powd
ba 100-25 mcg/inh.......................................................... 58
BREO ELLIPTA -fluticasone furoate-vilanterol aero powd
ba 200-25 mcg/inh.......................................................... 58
BRILINTA -ticagrelor tab 60 mg...................................... 138
BRILINTA -ticagrelor tab 90 mg...................................... 138
brimonidine tartrate ophth soln 0.2%......................... 144
brimonidine tartrate ophth soln 0.15% (Alphagan
p)................................................................................... 144
BRIVIACT -brivaracetam oral soln 10 mg/ml.................... 96
BRIVIACT -brivaracetam tab 10 mg................................. 96
BRIVIACT -brivaracetam tab 25 mg................................. 96
BRIVIACT -brivaracetam tab 50 mg................................. 96
BRIVIACT -brivaracetam tab 75 mg................................. 97
BRIVIACT -brivaracetam tab 100 mg............................... 97
BROMFENAC -bromfenac sodium ophth soln 0.09%
(base equivalent).......................................................... 144
bromfenac sodium ophth soln 0.09% (base equiv)
(once-daily).................................................................. 144
bromocriptine mesylate cap 5 mg (base equivalent)
(Parlodel)...................................................................... 102
bromocriptine mesylate tab 2.5 mg (base equivalent)
(Parlodel)...................................................................... 102
BROVANA -arformoterol tartrate soln nebu 15 mcg/2ml
(base equiv).................................................................... 58
budesonide delayed release particles cap 3 mg
(Entocort ec).................................................................. 22
budesonide inhalation susp 0.25 mg/2ml
(Pulmicort)......................................................................58
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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budesonide inhalation susp 0.5 mg/2ml
(Pulmicort)......................................................................58
budesonide inhalation susp 1 mg/2ml (Pulmicort)...... 58
budesonide nasal susp 32 mcg/act (Rhinocort
aqua)............................................................................... 55
bumetanide tab 0.5 mg................................................... 50
bumetanide tab 1 mg...................................................... 50
bumetanide tab 2 mg...................................................... 50
BUNAVAIL -buprenorphine-naloxone buccal film 2.1-0.3
mg (base equiv).............................................................. 86
BUNAVAIL -buprenorphine-naloxone buccal film 4.2-0.7
mg (base equiv).............................................................. 86
BUNAVAIL -buprenorphine-naloxone buccal film 6.3-1 mg
(base equiv).................................................................... 86
BUPHENYL -sodium phenylbutyrate tab 500 mg............. 37
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base
equiv).............................................................................. 86
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv).............................................................................. 86
buprenorphine hcl sl tab 2 mg (base equiv)................ 86
buprenorphine hcl sl tab 8 mg (base equiv)................ 86
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
(Zyban)............................................................................ 81
bupropion hcl tab 75 mg (Wellbutrin)........................... 69
bupropion hcl tab 100 mg (Wellbutrin)......................... 69
bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr)........ 69
bupropion hcl tab sr 12hr 150 mg (Wellbutrin sr)........ 69
bupropion hcl tab sr 12hr 200 mg (Wellbutrin sr)........ 69
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl)........ 69
bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl)........ 69
buspirone hcl tab 5 mg................................................... 68
buspirone hcl tab 7.5 mg................................................ 68
buspirone hcl tab 10 mg................................................. 68
buspirone hcl tab 15 mg................................................. 68
buspirone hcl tab 30 mg................................................. 68
butalbital-acetaminophen-caffeine cap 50-325-40
mg................................................................................... 85
butalbital-acetaminophen-caffeine cap 50-300-40 mg
(Fioricet)......................................................................... 85
butalbital-acetaminophen-caffeine tab 50-325-40 mg
(Esgic)............................................................................. 85
butalbital-acetaminophen-caff w/ cod cap
50-325-40-30 mg............................................................ 86
butalbital-acetaminophen-caff w/ cod cap
50-300-40-30 mg (Fioricet/codeine)............................ 86
butalbital-acetaminophen tab 50-325 mg......................85
butalbital-aspirin-caffeine cap 50-325-40 mg
(Fiorinal)......................................................................... 85
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
(Fiorinal/codeine #3)..................................................... 86
butorphanol tartrate nasal soln 10 mg/ml.................... 86
BUTRANS -buprenorphine td patch weekly 5 mcg/hr.......86
BUTRANS -buprenorphine td patch weekly 7.5 mcg/
hr...................................................................................... 86
BUTRANS -buprenorphine td patch weekly 10 mcg/
hr...................................................................................... 86
BUTRANS -buprenorphine td patch weekly 15 mcg/
hr...................................................................................... 86
BUTRANS -buprenorphine td patch weekly 20 mcg/
hr...................................................................................... 86
BYDUREON -exenatide for inj extended release susp 2
mg.................................................................................... 29
BYDUREON PEN -exenatide extended release for susp
pen-injector 2 mg............................................................ 29
BYETTA -exenatide soln pen-injector 5 mcg/0.02ml........ 29
BYETTA -exenatide soln pen-injector 10 mcg/0.04ml...... 29
BYSTOLIC -nebivolol hcl tab 2.5 mg (base
equivalent)....................................................................... 41
BYSTOLIC -nebivolol hcl tab 5 mg (base equivalent).......41
BYSTOLIC -nebivolol hcl tab 10 mg (base
equivalent)....................................................................... 41
BYSTOLIC -nebivolol hcl tab 20 mg (base
equivalent)....................................................................... 41
C
cabergoline tab 0.5 mg................................................... 37
CABOMETYX -cabozantinib s-malate tab 20 mg (base
equivalent)....................................................................... 17
CABOMETYX -cabozantinib s-malate tab 40 mg (base
equivalent)....................................................................... 17
CABOMETYX -cabozantinib s-malate tab 60 mg (base
equivalent)....................................................................... 17
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base
equiv) (Cafcit)................................................................ 78
CALCILO XD -infant foods powder................................. 116
calcipotriene-betamethasone dipropionate oint
0.005-0.064% (Taclonex)............................................ 150
calcipotriene cream 0.005% (Dovonex).......................150
calcipotriene oint 0.005%..............................................150
calcipotriene soln 0.005% (50 mcg/ml)....................... 150
calcitonin (salmon) nasal soln 200 unit/act
(Miacalcin)...................................................................... 37
calcitriol cap 0.25 mcg (Rocaltrol)................................. 37
calcitriol cap 0.5 mcg (Rocaltrol)................................... 37
calcitriol oral soln 1 mcg/ml (Rocaltrol)........................37
calcium acetate (phosphate binder) cap 667 mg (169
mg ca) (Phoslo)............................................................. 64
calcium acetate (phosphate binder) tab 667 mg
(Eliphos)......................................................................... 64
CALCIUM PNV -prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg.......................................................... 106
CAMINO PRO BETTERMILK/GLY -nutritional supplement
pack............................................................................... 116
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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CAMINO PRO COMPLETE/GLYTA -nutritional
supplement bar............................................................. 116
CAMINO PRO 15PE -nutritional supplement liquid........ 116
CAMINO PRO PKU -nutritional supplement liquid..........116
CAMINO PRO RESTORE/GLYTAC -nutritional
supplement liquid.......................................................... 116
CAMINO PRO SWIRL -nutritional supplement pack...... 116
CANASA -mesalamine suppos 1000 mg.......................... 64
candesartan cilexetil-hydrochlorothiazide tab 16-12.5
mg (Atacand hct).......................................................... 46
candesartan cilexetil-hydrochlorothiazide tab 32-12.5
mg (Atacand hct).......................................................... 46
candesartan cilexetil-hydrochlorothiazide tab 32-25
mg (Atacand hct).......................................................... 46
candesartan cilexetil tab 4 mg (Atacand)..................... 46
candesartan cilexetil tab 8 mg (Atacand)..................... 46
candesartan cilexetil tab 16 mg (Atacand)................... 46
candesartan cilexetil tab 32 mg (Atacand)................... 46
CAPCOF -phenylephrine-chlorphen w/ codeine syrup
5-2-10 mg/5ml................................................................. 56
capecitabine tab 150 mg (Xeloda)................................. 17
capecitabine tab 500 mg (Xeloda)................................. 17
CAPRELSA -vandetanib tab 100 mg................................ 17
CAPRELSA -vandetanib tab 300 mg................................ 17
captopril tab 12.5 mg...................................................... 46
captopril tab 25 mg......................................................... 46
captopril tab 50 mg......................................................... 46
captopril tab 100 mg....................................................... 46
CARAC -fluorouracil cream 0.5%.................................... 150
CARAFATE -sucralfate susp 1 gm/10ml........................... 61
CARBAGLU -carglumic acid tab 200 mg.......................... 37
carbamazepine cap sr 12hr 100 mg (Carbatrol)........... 97
carbamazepine cap sr 12hr 200 mg (Carbatrol)........... 97
carbamazepine cap sr 12hr 300 mg (Carbatrol)........... 97
carbamazepine chew tab 100 mg.................................. 97
carbamazepine susp 100 mg/5ml (Tegretol)................. 97
carbamazepine tab 200 mg (Tegretol)........................... 97
carbamazepine tab sr 12hr 100 mg (Tegretol-xr)......... 97
carbamazepine tab sr 12hr 200 mg (Tegretol-xr)......... 97
carbamazepine tab sr 12hr 400 mg (Tegretol-xr)......... 97
CARBATROL -carbamazepine cap sr 12hr 100 mg......... 97
CARBATROL -carbamazepine cap sr 12hr 200 mg......... 97
CARBATROL -carbamazepine cap sr 12hr 300 mg......... 97
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 12.5-50-200 mg................................ 102
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 18.75-75-200 mg.............................. 102
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 25-100-200 mg................................. 102
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 31.25-125-200 mg............................ 102
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 37.5-150-200 mg.............................. 102
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 50-200-200 mg................................. 102
carbidopa & levodopa orally disintegrating tab 10-100
mg................................................................................. 102
carbidopa & levodopa orally disintegrating tab 25-100
mg................................................................................. 102
carbidopa & levodopa orally disintegrating tab 25-250
mg................................................................................. 102
carbidopa & levodopa tab cr 25-100 mg (Sinemet
cr).................................................................................. 102
carbidopa & levodopa tab cr 50-200 mg (Sinemet
cr).................................................................................. 102
carbidopa & levodopa tab 10-100 mg (Sinemet)........ 102
carbidopa & levodopa tab 25-100 mg (Sinemet)........ 102
carbidopa & levodopa tab 25-250 mg (Sinemet)........ 102
carbidopa tab 25 mg (Lodosyn)................................... 102
carbinoxamine maleate soln 4 mg/5ml......................... 55
carbinoxamine maleate tab 4 mg.................................. 55
carbonyl iron susp 15 mg/1.25ml (elemental
iron)............................................................................... 133
CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr
120 mg............................................................................ 42
carisoprodol tab 250 mg (Soma)................................. 104
carisoprodol tab 350 mg (Soma)................................. 104
CARNATION BREAKFAST ESSEN -nutritional
supplement liquid.......................................................... 116
CARNATION BREAKFAST ESSEN -nutritional
supplement pack........................................................... 116
CARNATION INSTANT BREAKFA -nutritional supplement
liquid.............................................................................. 116
carteolol hcl ophth soln 1%......................................... 144
carvedilol tab 3.125 mg (Coreg)..................................... 41
carvedilol tab 6.25 mg (Coreg)....................................... 41
carvedilol tab 12.5 mg (Coreg)....................................... 41
carvedilol tab 25 mg (Coreg).......................................... 41
CAYA -diaphragm arc-spring........................................... 156
CAYSTON -aztreonam lysine for inhal soln 75 mg (base
equivalent)....................................................................... 12
C-BUFF -multiple vitamins w/ minerals powder.............. 106
CEDAX -ceftibuten cap 400 mg.......................................... 2
CEDAX -ceftibuten for susp 180 mg/5ml............................ 2
cefaclor cap 250 mg.......................................................... 2
cefaclor cap 500 mg.......................................................... 2
CEFACLOR -cefaclor for susp 125 mg/5ml........................ 2
CEFACLOR -cefaclor for susp 250 mg/5ml........................ 2
CEFACLOR -cefaclor for susp 375 mg/5ml........................ 2
CEFACLOR ER -cefaclor monohydrate tab sr 12hr 500
mg...................................................................................... 2
cefadroxil cap 500 mg....................................................... 2
cefadroxil for susp 250 mg/5ml....................................... 2
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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cefadroxil for susp 500 mg/5ml....................................... 2
cefadroxil tab 1 gm............................................................ 2
cefdinir cap 300 mg........................................................... 2
cefdinir for susp 125 mg/5ml........................................... 2
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 (Ceftin)............................. 2
cefuroxime axetil tab 500 mg (Ceftin)............................. 2
celecoxib cap 50 mg (Celebrex).................................... 92
celecoxib cap 100 mg (Celebrex).................................. 92
celecoxib cap 200 mg (Celebrex).................................. 92
celecoxib cap 400 mg (Celebrex).................................. 92
CELONTIN -methsuximide cap 300 mg............................ 97
CENTANY -mupirocin oint 2%.........................................150
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
cephalexin for susp 250 mg/5ml...................................... 3
CERDELGA -eliglustat tartrate cap 84 mg (base
equivalent)..................................................................... 133
CERVIDIL -dinoprostone vaginal inserts 10 mg............... 37
CESAMET -nabilone cap 1 mg......................................... 62
CETRAXAL -ciprofloxacin hcl otic soln 0.2% (base
equivalent)..................................................................... 147
CETYLEV -acetylcysteine effervescent tab 2.5 gm........ 155
CETYLEV -acetylcysteine effervescent tab 500 mg....... 155
cevimeline hcl cap 30 mg (Evoxac)............................. 147
CHANTIX CONTINUING MONTH -varenicline tartrate tab
1 mg (base equiv).......................................................... 81
CHANTIX STARTING MONTH PA -varenicline tartrate tab
0.5 mg x 11 & tab 1 mg x 42 pack.................................81
CHANTIX -varenicline tartrate tab 0.5 mg (base
equiv)............................................................................... 81
CHANTIX -varenicline tartrate tab 1 mg (base equiv).......81
CHEMET -succimer cap 100 mg.................................... 155
CHENODAL -chenodiol tab 250 mg................................. 64
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 5-12.5 mg............................................. 81
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 10-25 mg.............................................. 81
chlordiazepoxide hcl cap 5 mg...................................... 68
chlordiazepoxide hcl cap 10 mg.................................... 68
chlordiazepoxide hcl cap 25 mg.................................... 68
chlorhexidine gluconate soln 0.12% (Peridex)...........147
CHLOROQUINE PHOSPHATE -chloroquine phosphate
tab 250 mg...................................................................... 11
chloroquine phosphate tab 500 mg (Aralen)................ 11
CHLOROTHIAZIDE -chlorothiazide tab 250 mg............... 50
chlorothiazide tab 500 mg.............................................. 50
chlorpromazine hcl tab 10 mg....................................... 73
chlorpromazine hcl tab 25 mg....................................... 73
chlorpromazine hcl tab 50 mg....................................... 73
chlorpromazine hcl tab 100 mg..................................... 73
chlorpromazine hcl tab 200 mg..................................... 73
CHLORPROPAMIDE -chlorpropamide tab 100 mg.......... 30
CHLORPROPAMIDE -chlorpropamide tab 250 mg.......... 30
chlorthalidone tab 25 mg................................................ 50
chlorthalidone tab 50 mg................................................ 50
chlorzoxazone tab 500 mg (Parafon forte dsc).......... 104
CHOICE DM -nutritional supplement liquid.....................117
CHOICE DM TF -nutritional supplement liquid............... 117
CHOLBAM -cholic acid cap 50 mg................................... 64
CHOLBAM -cholic acid cap 250 mg................................. 64
cholecalciferol cap 400 unit......................................... 105
cholecalciferol cap 1000 unit....................................... 105
cholecalciferol cap 50000 unit..................................... 105
cholecalciferol chew tab 400 unit................................ 105
cholecalciferol chew tab 1000 unit.............................. 105
cholecalciferol drops 400 unit/0.03ml (per drop)....... 105
cholecalciferol drops 5000 unit/ml (1000
unit/0.2ml).....................................................................105
cholecalciferol oral liquid 400 unit/ml......................... 105
cholecalciferol tab 400 unit.......................................... 105
cholecalciferol tab 1000 unit........................................ 105
cholecalciferol tab 50000 unit...................................... 105
cholestyramine light powder 4 gm/dose (Questran
light)................................................................................ 51
cholestyramine light powder packets 4 gm................. 51
cholestyramine powder 4 gm/dose (Questran)............ 52
cholestyramine powder packets 4 gm (Questran)....... 51
CHOLEXTRA -nutritional supplement powder................ 117
choline fenofibrate cap dr 45 mg (fenofibric acid
equiv) (Trilipix).............................................................. 52
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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choline fenofibrate cap dr 135 mg (fenofibric acid
equiv) (Trilipix).............................................................. 52
CIALIS -tadalafil tab 2.5 mg......................................... 54,54
CIALIS -tadalafil tab 5 mg............................................ 54,54
ciclopirox gel 0.77%...................................................... 150
ciclopirox olamine cream 0.77% (base equiv)............150
ciclopirox olamine susp 0.77% (base equiv).............. 150
ciclopirox shampoo 1% (Loprox shampoo)............... 150
ciclopirox solution 8% (Penlac Nail Lacquer)............ 150
cilostazol tab 50 mg (Pletal)......................................... 138
cilostazol tab 100 mg (Pletal)....................................... 138
CILOXAN -ciprofloxacin hcl ophth oint 0.3%.................. 144
cimetidine hcl soln 300 mg/5ml..................................... 61
cimetidine tab 300 mg..................................................... 61
cimetidine tab 400 mg..................................................... 61
cimetidine tab 800 mg..................................................... 61
CIMZIA -certolizumab pegol inj kit 2 x 200 mg/ml............ 64
CIMZIA STARTER KIT -certolizumab pegol inj kit 6 x 200
mg/ml............................................................................... 64
CIPRODEX -ciprofloxacin-dexamethasone otic susp
0.3-0.1%........................................................................ 147
CIPROFLOXACIN -ciprofloxacin hcl otic soln 0.2% (base
equivalent)..................................................................... 147
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 1000
mg(base eq) (Cipro xr)................................................... 5
ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500 mg
(base eq) (Cipro xr)........................................................ 5
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)...................................................................... 5
ciprofloxacin hcl ophth soln 0.3% (Ciloxan).............. 144
ciprofloxacin hcl tab 750 mg (base equiv)..................... 5
ciprofloxacin hcl tab 250 mg (base equiv) (Cipro)......... 5
ciprofloxacin hcl tab 500 mg (base equiv) (Cipro)......... 5
CIPRO HC -ciprofloxacin-hydrocortisone otic susp
0.2-1%........................................................................... 147
citalopram hydrobromide oral soln 10 mg/5ml............ 69
citalopram hydrobromide tab 10 mg (base equiv)
(Celexa)........................................................................... 69
citalopram hydrobromide tab 20 mg (base equiv)
(Celexa)........................................................................... 69
citalopram hydrobromide tab 40 mg (base equiv)
(Celexa)........................................................................... 69
CITRANATAL ASSURE -prenat w/o a w/fecbn-fegl-dss-fa
tab & dha cap 300 mg pack......................................... 106
CITRANATAL B-CALM -prenat w/o a w/fecbn-feglu-fa tab
20-1 mg & vit b6 tab pak............................................. 106
CITRANATAL DHA -prenat w/o a w/fecbn-fegl-dss-fa tab
& dha cap 250 mg pack............................................... 106
CITRANATAL 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa
tab 90 &dha cap 300mg pak........................................ 106
CITRANATAL HARMONY -prenat w/o a w/fe fum-fe cbndss-fa-dha cap 27-1-260 mg........................................ 106
CITRANATAL RX -prenatal w/o a w/ fe carbonyl-fe glucdss-fa tab 27-1mg.........................................................106
clarithromycin for susp 125 mg/5ml............................... 3
clarithromycin for susp 250 mg/5ml (Biaxin)................. 3
clarithromycin tab 250 mg (Biaxin)................................. 3
clarithromycin tab 500 mg (Biaxin)................................. 3
clarithromycin tab sr 24hr 500 mg (Biaxin xl pac)......... 3
CLEMASTINE FUMARATE -clemastine fumarate tab 2.68
mg.................................................................................... 55
CLEOCIN -clindamycin phosphate vaginal suppos 100
mg.................................................................................... 67
CLICK ESPRESSO PROTEIN DR -nutritional supplement
powder........................................................................... 117
CLIMARA PRO -estradiol-levonorgestrel td patch weekly
0.045-0.015 mg/day........................................................ 24
clindamycin hcl cap 75 mg (Cleocin)............................ 12
clindamycin hcl cap 150 mg (Cleocin).......................... 12
clindamycin hcl cap 300 mg (Cleocin).......................... 12
clindamycin palmitate hcl for soln 75 mg/5ml (base
equiv) (Cleocin pediatric gr)........................................12
clindamycin phosphate-benzoyl peroxide gel 1-5%
(Benzaclin)................................................................... 151
clindamycin phosphate foam 1% (Evoclin)................ 150
clindamycin phosphate gel 1% (Cleocin-t)................. 150
clindamycin phosphate lotion 1% (Cleocin-t)............ 150
clindamycin phosphate soln 1% (Cleocin-t)............... 150
clindamycin phosphate swab 1% (Cleocin-t)............. 150
clindamycin phosphate-tretinoin gel 1.2-0.025%
(Ziana)........................................................................... 151
clindamycin phosphate vaginal cream 2%
(Cleocin)......................................................................... 67
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5% (Duac)............................................................... 150
CLINDESSE -clindamycin phosphate (one dose) vaginal
cream 2%........................................................................ 67
clobetasol propionate cream 0.05% (Temovate)........ 151
clobetasol propionate emollient base cream 0.05%
(Temovate e)................................................................ 151
clobetasol propionate gel 0.05% (Temovate)............. 151
clobetasol propionate lotion 0.05% (Clobex)............. 151
clobetasol propionate oint 0.05% (Temovate)............ 151
clobetasol propionate shampoo 0.05% (Clobex)....... 151
clobetasol propionate soln 0.05% (Temovate)........... 151
CLOCORTOLONE PIVALATE -clocortolone pivalate
cream 0.1%................................................................... 151
CLOCORTOLONE PIVALATE PUM -clocortolone pivalate
cream 0.1%................................................................... 151
clomipramine hcl cap 25 mg (Anafranil)....................... 69
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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clomipramine hcl cap 50 mg (Anafranil)....................... 69
clomipramine hcl cap 75 mg (Anafranil)....................... 69
clonazepam orally disintegrating tab 0.125 mg........... 97
clonazepam orally disintegrating tab 0.25 mg............. 97
clonazepam orally disintegrating tab 0.5 mg............... 97
clonazepam orally disintegrating tab 1 mg.................. 97
clonazepam orally disintegrating tab 2 mg.................. 97
clonazepam tab 0.5 mg (Klonopin)................................ 97
clonazepam tab 1 mg (Klonopin)................................... 97
clonazepam tab 2 mg (Klonopin)................................... 97
clonidine hcl tab 0.1 mg (Catapres).............................. 46
clonidine hcl tab 0.2 mg (Catapres).............................. 46
clonidine hcl tab 0.3 mg (Catapres).............................. 46
clonidine hcl tab sr 12hr 0.1 mg (Kapvay).................... 78
clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1)................................................................................ 46
clonidine hcl td patch weekly 0.2 mg/24hr (Cataprestts-2)................................................................................ 46
clonidine hcl td patch weekly 0.3 mg/24hr (Cataprestts-3)................................................................................ 46
clopidogrel bisulfate tab 75 mg (base equiv)
(Plavix).......................................................................... 138
clopidogrel bisulfate tab 300 mg (base equiv)
(Plavix).......................................................................... 138
clorazepate dipotassium tab 3.75 mg (Tranxene t)...... 68
clorazepate dipotassium tab 7.5 mg (Tranxene t)........ 68
clorazepate dipotassium tab 15 mg (Tranxene t)......... 68
clotrimazole troche 10 mg............................................ 147
clotrimazole w/ betamethasone cream 1-0.05%
(Lotrisone).................................................................... 151
clotrimazole w/ betamethasone lotion 1-0.05%..........151
CLOZAPINE ODT -clozapine orally disintegrating tab 12.5
mg.................................................................................... 73
CLOZAPINE ODT -clozapine orally disintegrating tab 150
mg.................................................................................... 73
CLOZAPINE ODT -clozapine orally disintegrating tab 200
mg.................................................................................... 73
clozapine orally disintegrating tab 25 mg
(Fazaclo)......................................................................... 73
clozapine orally disintegrating tab 100 mg
(Fazaclo)......................................................................... 73
clozapine tab 50 mg........................................................ 73
clozapine tab 200 mg...................................................... 73
clozapine tab 25 mg (Clozaril)........................................73
clozapine tab 100 mg (Clozaril)..................................... 73
C-NATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................. 106
COAGADEX -coagulation factor x (human) for inj 250
unit................................................................................. 138
COAGADEX -coagulation factor x (human) for inj 500
unit................................................................................. 138
COARTEM -artemether-lumefantrine tab 20-120 mg....... 11
codeine sulfate tab 30 mg.............................................. 86
codeine sulfate tab 60 mg.............................................. 86
codeine sulfate tab 15 mg (Codeine sulfate)................ 86
COLCHICINE -colchicine cap 0.6 mg............................... 96
COLCHICINE -colchicine tab 0.6 mg................................ 96
colchicine w/ probenecid tab 0.5-500 mg..................... 96
COLCRYS -colchicine tab 0.6 mg..................................... 96
colestipol hcl granule packets 5 gm (Colestid
flavored)......................................................................... 52
colestipol hcl granules 5 gm (Colestid flavored)......... 52
colestipol hcl tab 1 gm (Colestid)..................................52
COLGATE DRY MOUTH RELIEF -sodium fluoride
mouthwash 2.1 mg/10ml.............................................. 147
COLY-MYCIN S -neomycin-colistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml.............................................. 147
COMBIGAN -brimonidine tartrate-timolol maleate ophth
soln 0.2-0.5%................................................................ 144
COMBIPATCH -estradiol-norethindrone ace td pttw
0.05-0.14 mg/day............................................................ 24
COMBIPATCH -estradiol-norethindrone ace td pttw
0.05-0.25 mg/day............................................................ 24
COMBIVENT RESPIMAT -ipratropium-albuterol inhal
aerosol soln 20-100 mcg/act.......................................... 58
COMETRIQ -cabozantinib s-malate cap 3 x 20 mg (60 mg
dose) kit........................................................................... 17
COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 1 x 20
mg (100 dose) kit............................................................17
COMETRIQ -cabozantinib s-mal cap 1 x 80 mg & 3 x 20
mg (140 dose) kit............................................................17
COMMIT -nicotine polacrilex lozenge 2 mg...................... 81
COMMIT -nicotine polacrilex lozenge 4 mg...................... 81
COMPLEAT CLOSED SYSTEM -nutritional supplement
liquid.............................................................................. 117
COMPLEAT -nutritional supplement liquid...................... 117
COMPLEAT PEDIATRIC -nutritional supplement
liquid.............................................................................. 117
COMPLEAT PEDIATRIC REDUCE -nutritional
supplement liquid.......................................................... 117
COMPLERA -emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg.................................................................. 7
COMPLETE AMINO ACID MIX -amino acids oral
powder........................................................................... 114
COMPLETE NATAL DHA -prenat-fe bis-fe prot succ-fa-ca
tab & omega 3 cap 250 pk.......................................... 106
COMPLETENATE -prenatal vit w/ fe fumarate-fa chew tab
29-1 mg......................................................................... 106
COMPLETE NUTRITION -nutritional supplement
liquid.............................................................................. 117
COMPLETE NUTRITION PLUS -nutritional supplement
liquid.............................................................................. 117
COMPLETE PROTEIN & VITAMI -nutritional supplement
powder........................................................................... 117
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COMPLEX ESSENTIAL MSD -amino acids oral
powder........................................................................... 114
COMPLEX JUNIOR MSD -amino acids oral powder...... 114
COMPLEX MSUD AMINO ACID B -amino acids bar..... 114
COMPLEX MSUD -amino acids oral powder..................114
CO-NATAL FA -prenatal vit w/ fe fumarate-fa tab 29-1
mg.................................................................................. 106
CONCEPT DHA -prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg......................................................... 106
CONCEPT OB -prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg...............................................................106
CONCERTA -methylphenidate hcl tab sa osm 18 mg...... 78
CONCERTA -methylphenidate hcl tab sa osm 27 mg...... 78
CONCERTA -methylphenidate hcl tab sa osm 36 mg...... 78
CONCERTA -methylphenidate hcl tab sa osm 54 mg...... 78
CONDYLOX -podofilox gel 0.5%.................................... 151
COPAXONE -glatiramer acetate soln prefilled syringe 20
mg/ml............................................................................... 81
COPAXONE -glatiramer acetate soln prefilled syringe 40
mg/ml............................................................................... 81
CORDRAN -flurandrenolide tape 4 mcg/sqcm............... 151
COREG CR -carvedilol phosphate cap sr 24hr 10 mg..... 41
COREG CR -carvedilol phosphate cap sr 24hr 20 mg..... 41
COREG CR -carvedilol phosphate cap sr 24hr 40 mg..... 41
COREG CR -carvedilol phosphate cap sr 24hr 80 mg..... 41
CORIFACT -factor xiii concentrate (human) for inj kit
1000-1600 unit.............................................................. 138
CORLANOR -ivabradine hcl tab 5 mg (base equiv)......... 54
CORLANOR -ivabradine hcl tab 7.5 mg (base equiv)...... 54
CORTIFOAM -hydrocortisone acetate rectal foam 10%
(90 mg/dose)................................................................. 149
CORTISONE ACETATE -cortisone acetate tab 25 mg..... 22
CORTISPORIN -bacitracin-polymyxin-neomycin hc oint
1%.................................................................................. 151
CORTISPORIN -neomycin-polymyxin-hc crm 3.5 mg/
gm-10000 unt/gm-0.5%................................................ 151
COSENTYX -secukinumab subcutaneous soln prefilled
syringe 150 mg/ml........................................................ 151
COSENTYX SENSOREADY PEN -secukinumab
subcutaneous soln auto-injector 150 mg/ml................ 151
COSOPT PF -dorzolamide hcl-timolol maleate ophth sol
22.3-6.8 mg/ml pf..........................................................144
COTELLIC -cobimetinib fumarate tab 20 mg (base
equivalent)....................................................................... 17
COUMADIN -warfarin sodium tab 1 mg.......................... 135
COUMADIN -warfarin sodium tab 2 mg.......................... 135
COUMADIN -warfarin sodium tab 2.5 mg....................... 135
COUMADIN -warfarin sodium tab 3 mg.......................... 135
COUMADIN -warfarin sodium tab 4 mg.......................... 135
COUMADIN -warfarin sodium tab 5 mg.......................... 135
COUMADIN -warfarin sodium tab 6 mg.......................... 135
COUMADIN -warfarin sodium tab 7.5 mg....................... 135
COUMADIN -warfarin sodium tab 10 mg........................ 135
CREON -pancrelipase (lip-prot-amyl) dr cap
3000-9500-15000 unit.....................................................63
CREON -pancrelipase (lip-prot-amyl) dr cap
6000-19000-30000 unit...................................................63
CREON -pancrelipase (lip-prot-amyl) dr cap
12000-38000-60000 unit................................................ 63
CREON -pancrelipase (lip-prot-amyl) dr cap
24000-76000-120000 unit.............................................. 63
CREON -pancrelipase (lip-prot-amyl) dr cap
36000-114000-180000 unit............................................. 63
CRESEMBA -isavuconazonium sulfate cap 186 mg.......... 6
CREST COMPLETE -sodium fluoride paste 0.243%..... 147
CRESTOR -rosuvastatin calcium tab 5 mg.......................52
CRESTOR -rosuvastatin calcium tab 10 mg.....................52
CRESTOR -rosuvastatin calcium tab 20 mg.....................52
CRESTOR -rosuvastatin calcium tab 40 mg.....................52
CRITICARE HN -nutritional supplement liquid................117
CRIXIVAN -indinavir sulfate cap 200 mg............................ 7
CRIXIVAN -indinavir sulfate cap 400 mg............................ 7
CROMOLYN SODIUM -cromolyn sodium soln nebu 20
mg/2ml............................................................................. 58
cromolyn sodium ophth soln 4%................................ 144
cromolyn sodium oral conc 100 mg/5ml
(Gastrocrom).................................................................. 64
CRUCIAL -nutritional supplement liquid..........................117
CUPRIMINE -penicillamine cap 250 mg......................... 157
CUROSURF -poractant alfa intratracheal susp 120
mg/1.5ml.......................................................................... 60
CUROSURF -poractant alfa intratracheal susp 240
mg/3ml............................................................................. 60
CUVPOSA -glycopyrrolate oral soln 1 mg/5ml................. 61
CVS NUTRITIONAL SHAKE -nutritional supplement
liquid.............................................................................. 117
CVS NUTRITION LIQUID -nutritional supplement
liquid.............................................................................. 117
CVS NUTRITION PLUS -nutritional supplement
liquid.............................................................................. 117
cyanocobalamin inj 1000 mcg/ml................................ 133
CYCLINEX-1 -nutritional supplement powder................. 117
CYCLINEX-2 -nutritional supplement powder................. 117
cyclobenzaprine hcl tab 5 mg...................................... 104
cyclobenzaprine hcl tab 10 mg.................................... 104
cyclobenzaprine hcl tab 7.5 mg (Fexmid)................... 104
CYCLOGYL -cyclopentolate hcl ophth soln 0.5%........... 144
CYCLOMYDRIL -cyclopentolate w/ phenylephrine ophth
soln 0.2-1%................................................................... 144
cyclopentolate hcl ophth soln 0.5% (Cyclogyl)..........144
cyclopentolate hcl ophth soln 1% (Cyclogyl).............144
cyclopentolate hcl ophth soln 2% (Cyclogyl).............144
CYCLOPHOSPHAMIDE -cyclophosphamide cap 25
mg.................................................................................... 17
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CYCLOPHOSPHAMIDE -cyclophosphamide cap 50
mg.................................................................................... 17
CYCLOSERINE -cycloserine cap 250 mg.......................... 5
CYCLOSET -bromocriptine mesylate tab 0.8 mg (base
equivalent)....................................................................... 30
cyclosporine cap 25 mg (Sandimmune)..................... 157
cyclosporine cap 100 mg (Sandimmune)................... 157
cyclosporine modified cap 50 mg (Cyclosporine
modifie)......................................................................... 157
cyclosporine modified cap 25 mg (Neoral).................157
cyclosporine modified cap 100 mg (Neoral)...............157
CYCLOSPORINE MODIFIED -cyclosporine modified cap
50 mg............................................................................ 157
cyclosporine modified oral soln 100 mg/ml
(Neoral)......................................................................... 157
cyproheptadine hcl syrup 2 mg/5ml.............................. 55
cyproheptadine hcl tab 4 mg......................................... 55
CYSTAGON -cysteamine bitartrate cap 50 mg.................67
CYSTAGON -cysteamine bitartrate cap 150 mg...............67
CYSTARAN -cysteamine hcl ophth soln 0.44% (base
equivalent)..................................................................... 144
D
DAKLINZA -daclatasvir dihydrochloride tab 30 mg (base
equivalent)......................................................................... 7
DAKLINZA -daclatasvir dihydrochloride tab 60 mg (base
equivalent)......................................................................... 7
DAKLINZA -daclatasvir dihydrochloride tab 90 mg (base
equivalent)......................................................................... 7
DALIRESP -roflumilast tab 500 mcg................................. 58
danazol cap 50 mg.......................................................... 24
danazol cap 100 mg........................................................ 24
danazol cap 200 mg........................................................ 24
dantrolene sodium cap 100 mg................................... 104
dantrolene sodium cap 25 mg (Dantrium).................. 104
dantrolene sodium cap 50 mg (Dantrium).................. 104
dapsone tab 25 mg.......................................................... 12
dapsone tab 100 mg........................................................ 12
DAPTACEL -diph, acellular pert & tet tox inj 15 lf-10
mcg-5 lf/0.5ml................................................................. 16
DARAPRIM -pyrimethamine tab 25 mg............................ 11
darifenacin hydrobromide tab sr 24hr 7.5 mg (base
equiv) (Enablex)............................................................ 66
darifenacin hydrobromide tab sr 24hr 15 mg (base
equiv) (Enablex)............................................................ 66
DDROPS -cholecalciferol drops 1000 unit/0.03ml (per
drop).............................................................................. 105
DEBACTEROL -sulfuric acid-sulfonated phenolics soln
30-50%.......................................................................... 147
DELZICOL -mesalamine cap dr 400 mg........................... 64
demeclocycline hcl tab 150 mg....................................... 4
demeclocycline hcl tab 300 mg....................................... 4
DEMSER -metyrosine cap 250 mg................................... 46
DENAVIR -penciclovir cream 1%.................................... 151
DEPAKENE -valproate sodium oral soln 250 mg/5ml
(base equiv).................................................................... 97
DEPAKENE -valproic acid cap 250 mg.............................97
DEPEN TITRATABS -penicillamine tab 250 mg............. 157
DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp 150 mg/ml........ 26
DEPO-PROVERA CONTRACEPTIV medroxyprogesterone acetate im susp prefilled syr 150
mg/ml............................................................................... 26
DEPO-SUBQ PROVERA 104 -medroxyprogesterone
acetate susp pref syr 104 mg/0.65ml.............................26
DEPO-TESTOSTERONE -testosterone cypionate im inj in
oil 100 mg/ml.................................................................. 24
DEPO-TESTOSTERONE -testosterone cypionate im inj in
oil 200 mg/ml.................................................................. 24
DEQUASINE -amino acids tab........................................ 114
DESCOVY -emtricitabine-tenofovir alafenamide fumarate
tab 200-25 mg...................................................................7
desipramine hcl tab 10 mg (Norpramin)....................... 69
desipramine hcl tab 25 mg (Norpramin)....................... 69
desipramine hcl tab 50 mg (Norpramin)....................... 69
desipramine hcl tab 75 mg (Norpramin)....................... 70
desipramine hcl tab 100 mg (Norpramin)..................... 70
desipramine hcl tab 150 mg (Norpramin)..................... 70
DESLORATADINE ODT -desloratadine tab orally
disintegrating 2.5 mg...................................................... 55
DESLORATADINE ODT -desloratadine tab orally
disintegrating 5 mg......................................................... 55
desloratadine tab 5 mg (Clarinex)................................. 55
desmopressin acetate inj 4 mcg/ml (Ddavp)................ 37
desmopressin acetate nasal soln 0.01% (refrigerated)
(Ddavp)........................................................................... 37
desmopressin acetate nasal spray soln 0.01%
(Ddavp)........................................................................... 37
desmopressin acetate nasal spray soln 0.01%
(refrigerated).................................................................. 37
desmopressin acetate tab 0.1 mg (Ddavp)................... 38
desmopressin acetate tab 0.2 mg (Ddavp)................... 38
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01
mg(21/5) (Mircette)........................................................ 26
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg
(Cyclessa).......................................................................26
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
(Desogen)....................................................................... 26
desonide cream 0.05% (Desowen).............................. 151
desonide lotion 0.05% (Desowen)............................... 151
desonide oint 0.05% (Desowen).................................. 151
desoximetasone cream 0.25% (Topicort)....................151
desoximetasone gel 0.05% (Topicort)......................... 151
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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desoximetasone oint 0.25% (Topicort)........................ 151
desvenlafaxine succinate tab sr 24hr 25 mg (base
equiv) (Pristiq)............................................................... 70
desvenlafaxine succinate tab sr 24hr 50 mg (base
equiv) (Pristiq)............................................................... 70
desvenlafaxine succinate tab sr 24hr 100 mg (base
equiv) (Pristiq)............................................................... 70
DEXAMETHASONE -dexamethasone soln 0.5
mg/5ml............................................................................. 22
DEXAMETHASONE -dexamethasone tab 1 mg...............22
DEXAMETHASONE -dexamethasone tab 2 mg...............22
dexamethasone elixir 0.5 mg/5ml.................................. 22
DEXAMETHASONE INTENSOL -dexamethasone conc 1
mg/ml............................................................................... 22
DEXAMETHASONE SODIUM PHOS -dexamethasone
sodium phosphate ophth soln 0.1%............................. 144
dexamethasone tab 0.5 mg............................................ 22
dexamethasone tab 0.75 mg.......................................... 22
dexamethasone tab 1.5 mg............................................ 22
dexamethasone tab 4 mg............................................... 22
dexamethasone tab 6 mg............................................... 22
DEXILANT -dexlansoprazole cap delayed release 30
mg.................................................................................... 61
DEXILANT -dexlansoprazole cap delayed release 60
mg.................................................................................... 61
dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalin
xr).................................................................................... 78
dexmethylphenidate hcl cap sr 24 hr 10 mg (Focalin
xr).................................................................................... 78
dexmethylphenidate hcl cap sr 24 hr 15 mg (Focalin
xr).................................................................................... 78
dexmethylphenidate hcl cap sr 24 hr 20 mg (Focalin
xr).................................................................................... 78
dexmethylphenidate hcl cap sr 24 hr 25 mg (Focalin
xr).................................................................................... 79
dexmethylphenidate hcl cap sr 24 hr 30 mg (Focalin
xr).................................................................................... 79
dexmethylphenidate hcl cap sr 24 hr 35 mg (Focalin
xr).................................................................................... 79
dexmethylphenidate hcl cap sr 24 hr 40 mg (Focalin
xr).................................................................................... 79
dexmethylphenidate hcl tab 2.5 mg (Focalin).............. 79
dexmethylphenidate hcl tab 5 mg (Focalin)................. 79
dexmethylphenidate hcl tab 10 mg (Focalin)............... 79
DEX4 QUICK DISSOLVE GLUCO -glucose chew tab 4
gm.................................................................................... 30
dextroamphetamine sulfate cap sr 24hr 5 mg
(Dexedrine)..................................................................... 79
dextroamphetamine sulfate cap sr 24hr 10 mg
(Dexedrine)..................................................................... 79
dextroamphetamine sulfate cap sr 24hr 15 mg
(Dexedrine)..................................................................... 79
dextroamphetamine sulfate oral solution 5 mg/5ml
(Procentra)..................................................................... 79
dextroamphetamine sulfate tab 5 mg........................... 79
dextroamphetamine sulfate tab 10 mg......................... 79
DIABETIC TF -nutritional supplement liquid................... 117
DIABETISHIELD -nutritional supplement liquid.............. 117
DIABETISOURCE AC -nutritional supplement liquid...... 117
DIABETISOURCE -nutritional supplement liquid............ 117
DIASTAT ACUDIAL -diazepam rectal gel delivery system
10 mg.............................................................................. 97
DIASTAT ACUDIAL -diazepam rectal gel delivery system
20 mg.............................................................................. 97
DIASTAT PEDIATRIC -diazepam rectal gel delivery
system 2.5 mg................................................................ 97
diazepam conc 5 mg/ml.................................................. 68
DIAZEPAM -diazepam oral soln 1 mg/ml..........................68
DIAZEPAM -diazepam rectal gel delivery system 2.5
mg.................................................................................... 97
DIAZEPAM -diazepam rectal gel delivery system 10
mg.................................................................................... 97
DIAZEPAM -diazepam rectal gel delivery system 20
mg.................................................................................... 97
diazepam tab 2 mg (Valium)........................................... 68
diazepam tab 5 mg (Valium)........................................... 68
diazepam tab 10 mg (Valium)......................................... 68
DICLEGIS -doxylamine-pyridoxine tab delayed release
10-10 mg......................................................................... 62
diclofenac potassium tab 50 mg (Cataflam)................. 92
diclofenac sodium (actinic keratoses) gel 3%
(Solaraze)..................................................................... 151
diclofenac sodium gel 1% (Voltaren)...........................151
diclofenac sodium ophth soln 0.1%............................ 144
diclofenac sodium soln 1.5% (Pennsaid)................... 151
diclofenac sodium tab delayed release 25 mg............. 92
diclofenac sodium tab delayed release 50 mg............. 92
diclofenac sodium tab delayed release 75 mg............. 92
diclofenac sodium tab sr 24hr 100 mg (Voltarenxr).................................................................................... 92
diclofenac w/ misoprostol tab delayed release 50-0.2
mg (Arthrotec 50)..........................................................92
diclofenac w/ misoprostol tab delayed release 75-0.2
mg (Arthrotec 75)..........................................................92
dicloxacillin sodium cap 250 mg..................................... 1
dicloxacillin sodium cap 500 mg..................................... 1
dicyclomine hcl cap 10 mg (Bentyl).............................. 61
dicyclomine hcl oral soln 10 mg/5ml............................ 61
dicyclomine hcl tab 20 mg (Bentyl)............................... 61
didanosine delayed release capsule 125 mg (Videx
ec)...................................................................................... 7
didanosine delayed release capsule 200 mg (Videx
ec)...................................................................................... 7
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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didanosine delayed release capsule 250 mg (Videx
ec)...................................................................................... 7
didanosine delayed release capsule 400 mg (Videx
ec)...................................................................................... 7
DIFICID -fidaxomicin tab 200 mg........................................ 3
DIFLORASONE DIACETATE -diflorasone diacetate oint
0.05%.............................................................................151
diflunisal tab 500 mg....................................................... 85
DIGOXIN -digoxin oral soln 0.05 mg/ml............................ 40
digoxin tab 125 mcg (0.125 mg) (Lanoxin)................... 40
digoxin tab 250 mcg (0.25 mg) (Lanoxin)..................... 40
dihydroergotamine mesylate inj 1 mg/ml (D.h.e.
45).................................................................................... 95
DILANTIN INFATABS -phenytoin chew tab 50 mg........... 97
DILANTIN -phenytoin sodium extended cap 30 mg......... 97
DILANTIN -phenytoin sodium extended cap 100 mg........97
DILANTIN-125 -phenytoin susp 125 mg/5ml.................... 97
DILATRATE SR -isosorbide dinitrate cap cr 40 mg.......... 40
diltiazem hcl cap sr 12hr 60 mg.....................................42
diltiazem hcl cap sr 12hr 90 mg.....................................42
diltiazem hcl cap sr 12hr 120 mg...................................42
diltiazem hcl cap sr 24hr 120 mg...................................42
diltiazem hcl cap sr 24hr 180 mg...................................42
diltiazem hcl cap sr 24hr 240 mg...................................42
diltiazem hcl coated beads cap sr 24hr 120 mg
(Cardizem cd)................................................................ 42
diltiazem hcl coated beads cap sr 24hr 180 mg
(Cardizem cd)................................................................ 42
diltiazem hcl coated beads cap sr 24hr 240 mg
(Cardizem cd)................................................................ 42
diltiazem hcl coated beads cap sr 24hr 300 mg
(Cardizem cd)................................................................ 42
diltiazem hcl coated beads cap sr 24hr 360 mg
(Cardizem cd)................................................................ 43
diltiazem hcl coated beads tab sr 24hr 180 mg
(Cardizem la)................................................................. 43
diltiazem hcl coated beads tab sr 24hr 240 mg
(Cardizem la)................................................................. 43
diltiazem hcl coated beads tab sr 24hr 300 mg
(Cardizem la)................................................................. 43
diltiazem hcl coated beads tab sr 24hr 360 mg
(Cardizem la)................................................................. 43
diltiazem hcl coated beads tab sr 24hr 420 mg
(Cardizem la)................................................................. 43
diltiazem hcl extended release beads cap sr 24hr 120
mg (Tiazac).................................................................... 43
diltiazem hcl extended release beads cap sr 24hr 180
mg (Tiazac).................................................................... 43
diltiazem hcl extended release beads cap sr 24hr 240
mg (Tiazac).................................................................... 43
diltiazem hcl extended release beads cap sr 24hr 300
mg (Tiazac).................................................................... 43
diltiazem hcl extended release beads cap sr 24hr 360
mg (Tiazac).................................................................... 43
diltiazem hcl extended release beads cap sr 24hr 420
mg (Tiazac).................................................................... 43
diltiazem hcl tab 90 mg................................................... 43
diltiazem hcl tab 30 mg (Cardizem)............................... 43
diltiazem hcl tab 60 mg (Cardizem)............................... 43
diltiazem hcl tab 120 mg (Cardizem)............................. 43
DIPENTUM -olsalazine sodium cap 250 mg.....................64
DIPHENOXYLATE/ATROPINE -diphenoxylate w/ atropine
liq 2.5-0.025 mg/5ml....................................................... 61
diphenoxylate w/ atropine tab 2.5-0.025 mg
(Lomotil)......................................................................... 61
DIPHTHERIA/TETANUS TOXOID -diphtheria-tetanus tox
adsorbed (dt) im inj 25-5 unit/0.5ml............................... 16
dipyridamole tab 25 mg (Persantine).......................... 138
dipyridamole tab 50 mg (Persantine).......................... 138
dipyridamole tab 75 mg (Persantine).......................... 138
disopyramide phosphate cap 100 mg (Norpace)......... 44
disopyramide phosphate cap 150 mg (Norpace)......... 44
disulfiram tab 250 mg (Antabuse)................................. 81
disulfiram tab 500 mg (Antabuse)................................. 81
DIURIL -chlorothiazide susp 250 mg/5ml......................... 50
divalproex sodium cap delayed release sprinkle 125
mg (Depakote sprinkles).............................................. 98
divalproex sodium tab delayed release 125 mg
(Depakote)...................................................................... 98
divalproex sodium tab delayed release 250 mg
(Depakote)...................................................................... 98
divalproex sodium tab delayed release 500 mg
(Depakote)...................................................................... 98
divalproex sodium tab sr 24 hr 250 mg (Depakote
er).................................................................................... 98
divalproex sodium tab sr 24 hr 500 mg (Depakote
er).................................................................................... 98
DIVIGEL -estradiol td gel 0.25 mg/0.25gm (0.1%)........... 24
DIVIGEL -estradiol td gel 0.5 mg/0.5gm (0.1%)............... 24
DIVIGEL -estradiol td gel 1 mg/gm (0.1%)....................... 24
dofetilide cap 125 mcg (0.125 mg) (Tikosyn)................44
dofetilide cap 250 mcg (0.25 mg) (Tikosyn)..................44
dofetilide cap 500 mcg (0.5 mg) (Tikosyn)....................44
donepezil hydrochloride orally disintegrating tab 5
mg................................................................................... 81
donepezil hydrochloride orally disintegrating tab 10
mg (Aricept odt)............................................................ 81
donepezil hydrochloride tab 5 mg (Aricept)................. 81
donepezil hydrochloride tab 10 mg (Aricept)............... 81
donepezil hydrochloride tab 23 mg (Aricept)............... 81
DORAL -quazepam tab 15 mg.......................................... 76
dorzolamide hcl ophth soln 2% (Trusopt).................. 144
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml (Cosopt)............................................................144
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DOTHELLE DHA -prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg......................................................... 106
doxazosin mesylate tab 1 mg (Cardura)....................... 46
doxazosin mesylate tab 2 mg (Cardura)....................... 46
doxazosin mesylate tab 4 mg (Cardura)....................... 46
doxazosin mesylate tab 8 mg (Cardura)....................... 46
doxepin hcl cap 10 mg....................................................70
doxepin hcl cap 25 mg....................................................70
doxepin hcl cap 50 mg....................................................70
doxepin hcl cap 100 mg..................................................70
doxepin hcl cap 150 mg..................................................70
doxepin hcl conc 10 mg/ml............................................ 70
DOXEPIN HCL -doxepin hcl cap 75 mg........................... 70
DOXEPIN HYDROCHLORIDE -doxepin hcl cream
5%.................................................................................. 152
doxercalciferol cap 0.5 mcg (Hectorol)......................... 38
doxercalciferol cap 1 mcg (Hectorol)............................ 38
doxercalciferol cap 2.5 mcg (Hectorol)......................... 38
doxycycline hyclate cap 50 mg....................................... 4
doxycycline hyclate cap 100 mg (Vibramycin)...............4
doxycycline hyclate tab 20 mg........................................ 4
doxycycline hyclate tab 100 mg...................................... 4
doxycycline monohydrate cap 50 mg............................. 4
doxycycline monohydrate cap 150 mg (Adoxa).............4
doxycycline monohydrate cap 75 mg (Monodox)..........4
doxycycline monohydrate cap 100 mg (Monodox)........4
doxycycline monohydrate for susp 25 mg/5ml
(Vibramycin)..................................................................... 4
doxycycline monohydrate tab 50 mg (Adoxa)............... 4
doxycycline monohydrate tab 75 mg (Adoxa)............... 4
doxycycline monohydrate tab 100 mg (Adoxa pak
1/100)................................................................................. 4
doxycycline monohydrate tab 150 mg (Adoxa pak
1/150)................................................................................. 4
dronabinol cap 2.5 mg (Marinol).................................... 62
dronabinol cap 5 mg (Marinol)....................................... 63
dronabinol cap 10 mg (Marinol)..................................... 63
drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin
28).................................................................................... 26
drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)..... 26
drospirenone-ethinyl estrad-levomefolate tab
3-0.02-0.451 mg (Beyaz)............................................... 26
DROXIA -hydroxyurea cap 200 mg................................ 133
DROXIA -hydroxyurea cap 300 mg................................ 134
DROXIA -hydroxyurea cap 400 mg................................ 134
DUAVEE -conjugated estrogens-bazedoxifene tab
0.45-20 mg...................................................................... 25
DUET DHA BALANCED -prenat w/fe poly-na fered-fa tab
25-1 & omega cap 267 mg.......................................... 106
DUET DHA 400 -prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 400 mg...................................................... 106
DULERA -mometasone furoate-formoterol fumarate
aerosol 100-5 mcg/act.................................................... 58
DULERA -mometasone furoate-formoterol fumarate
aerosol 200-5 mcg/act.................................................... 58
DULOXETINE HCL -duloxetine hcl enteric coated pellets
cap 40 mg....................................................................... 70
duloxetine hcl enteric coated pellets cap 20 mg
(Cymbalta)...................................................................... 70
duloxetine hcl enteric coated pellets cap 30 mg
(Cymbalta)...................................................................... 70
duloxetine hcl enteric coated pellets cap 60 mg
(Cymbalta)...................................................................... 70
DUOCAL -nutritional supplement powder....................... 117
DUOPA -carbidopa-levodopa enteral susp 4.63-20 mg/
ml................................................................................... 102
DUREZOL -difluprednate ophth emulsion 0.05%........... 144
dutasteride cap 0.5 mg (Avodart).................................. 67
dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn)...... 67
D-VI-SOL -cholecalciferol oral liquid 400 unit/ml............ 105
DYRENIUM -triamterene cap 50 mg................................. 50
DYRENIUM -triamterene cap 100 mg............................... 50
E
EAA SUPPLEMENT -nutritional supplement pack......... 117
econazole nitrate cream 1%......................................... 152
ECOZA -econazole nitrate foam 1%............................... 152
EDARBI -azilsartan medoxomil tab 40 mg........................47
EDARBI -azilsartan medoxomil tab 80 mg........................47
EDECRIN -ethacrynic acid tab 25 mg.............................. 50
EDURANT -rilpivirine hcl tab 25 mg (base equivalent)....... 7
E.E.S. 400 -erythromycin ethylsuccinate tab 400 mg......... 3
E.E.S. GRANULES -erythromycin ethylsuccinate for susp
200 mg/5ml....................................................................... 3
EFFIENT -prasugrel hcl tab 5 mg (base equiv).............. 138
EFFIENT -prasugrel hcl tab 10 mg (base equiv)............ 139
EGG/PRO -nutritional supplement powder..................... 117
EGRIFTA -tesamorelin acetate for inj 1 mg (base
equiv)............................................................................... 38
EGRIFTA -tesamorelin acetate for inj 2 mg (base
equiv)............................................................................... 38
ELECARE/DHA/ARA -nutritional supplement
powder........................................................................... 117
ELECARE JR -nutritional supplement powder................117
ELECARE -nutritional supplement powder..................... 117
ELESTRIN -estradiol gel 0.06% (0.52 mg/0.87 gm
metered-dose pump)...................................................... 25
ELIDEL -pimecrolimus cream 1%................................... 152
ELIGARD -leuprolide acetate for subcutaneous inj kit 7.5
mg.................................................................................... 18
ELIGARD -leuprolide acetate (3 month) for subcutaneous
inj kit 22.5mg...................................................................17
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ELIGARD -leuprolide acetate (4 month) for subcutaneous
inj kit 30 mg.................................................................... 18
ELIGARD -leuprolide acetate (6 month) for subcutaneous
inj kit 45 mg.................................................................... 18
ELIQUIS -apixaban tab 2.5 mg....................................... 135
ELIQUIS -apixaban tab 5 mg.......................................... 135
ELITE-OB -prenatal vit w/ iron carbonyl-fa tab 50-1.25
mg.................................................................................. 106
ELIXOPHYLLIN -theophylline elixir 80 mg/15ml............... 58
ELLA -ulipristal acetate tab 30 mg.................................... 26
ELMIRON -pentosan polysulfate sodium caps 100
mg.................................................................................... 67
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
250 unit......................................................................... 139
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
500 unit......................................................................... 139
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
750 unit......................................................................... 139
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
1000 unit....................................................................... 139
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
1500 unit....................................................................... 139
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
2000 unit....................................................................... 139
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
3000 unit....................................................................... 139
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
4000 unit....................................................................... 139
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
5000 unit....................................................................... 139
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
6000 unit....................................................................... 139
EMADINE -emedastine difumarate ophth soln 0.05%
(base equiv).................................................................. 144
EMBEDA -morphine-naltrexone cap cr 20-0.8 mg............86
EMBEDA -morphine-naltrexone cap cr 30-1.2 mg............86
EMBEDA -morphine-naltrexone cap cr 50-2 mg...............86
EMBEDA -morphine-naltrexone cap cr 60-2.4 mg............86
EMBEDA -morphine-naltrexone cap cr 80-3.2 mg............86
EMBEDA -morphine-naltrexone cap cr 100-4 mg.............86
EMCYT -estramustine phosphate sodium cap 140
mg.................................................................................... 18
EMEND -aprepitant capsule 40 mg.................................. 63
EMEND -aprepitant capsule 80 mg.................................. 63
EMEND -aprepitant capsule 125 mg................................ 63
EMEND -aprepitant capsule therapy pack 80 & 125
mg.................................................................................... 63
EMEND -aprepitant for oral susp 125 mg (125
mg/5ml)............................................................................ 63
EMSAM -selegiline td patch 24hr 6 mg/24hr.................... 70
EMSAM -selegiline td patch 24hr 9 mg/24hr.................... 70
EMSAM -selegiline td patch 24hr 12 mg/24hr.................. 70
EMTRIVA -emtricitabine caps 200 mg................................ 7
EMTRIVA -emtricitabine soln 10 mg/ml.............................. 7
EMVERM -mebendazole chew tab 100 mg...................... 12
ENABLEX -darifenacin hydrobromide tab sr 24hr 7.5 mg
(base equiv).................................................................... 66
ENABLEX -darifenacin hydrobromide tab sr 24hr 15 mg
(base equiv).................................................................... 66
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg................................................................................... 47
enalapril maleate & hydrochlorothiazide tab 10-25 mg
(Vaseretic)...................................................................... 47
enalapril maleate tab 2.5 mg (Vasotec)......................... 47
enalapril maleate tab 5 mg (Vasotec)............................ 47
enalapril maleate tab 10 mg (Vasotec).......................... 47
enalapril maleate tab 20 mg (Vasotec).......................... 47
ENBRACE HR -prenatal vit w/ fe gly cys-fa-omega 3 fatty
acids cap....................................................................... 106
ENBREL -etanercept for subcutaneous inj 25 mg............ 92
ENBREL -etanercept subcutaneous soln prefilled syringe
25 mg/0.5ml.................................................................... 92
ENBREL -etanercept subcutaneous soln prefilled syringe
50 mg/ml......................................................................... 92
ENBREL SURECLICK -etanercept subcutaneous solution
auto-injector 50 mg/ml.................................................... 93
END FATIGUE DAILY ENERGY -multiple vitamins w/
minerals powder............................................................106
ENGERIX-B -hepatitis b vaccine (recombinant) 10
mcg/0.5ml........................................................................ 13
ENGERIX-B -hepatitis b vaccine (recombinant) 20 mcg/
ml..................................................................................... 13
ENGERIX-B -hepatitis b vaccine (recombinant) susp 10
mcg/0.5ml........................................................................ 13
ENGERIX-B -hepatitis b vaccine (recombinant) susp 20
mcg/ml............................................................................. 13
ENLIVE -nutritional supplement liquid.............................117
enoxaparin sodium inj 30 mg/0.3ml (Lovenox).......... 135
enoxaparin sodium inj 40 mg/0.4ml (Lovenox).......... 135
enoxaparin sodium inj 60 mg/0.6ml (Lovenox).......... 135
enoxaparin sodium inj 80 mg/0.8ml (Lovenox).......... 135
enoxaparin sodium inj 100 mg/ml (Lovenox)............. 135
enoxaparin sodium inj 120 mg/0.8ml (Lovenox)........ 136
enoxaparin sodium inj 150 mg/ml (Lovenox)............. 136
enoxaparin sodium inj 300 mg/3ml (Lovenox)........... 136
ENSTILAR -calcipotriene-betamethasone dipropionate
foam 0.005-0.064%...................................................... 152
ENSURE/FIBER -nutritional supplement liquid............... 118
ENSURE ACTIVE HEART HEALT -nutritional supplement
liquid.............................................................................. 117
ENSURE ACTIVE HIGH PROTEI -nutritional supplement
liquid.............................................................................. 118
ENSURE ACTIVE LIGHT -nutritional supplement
liquid.............................................................................. 118
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2017
ENSURE ACTIVE -nutritional supplement liquid............ 117
ENSURE BONE HEALTH REVIGO -nutritional
supplement liquid.......................................................... 118
ENSURE CLEAR -nutritional supplement liquid............. 118
ENSURE CLINICAL STRENGTH -nutritional supplement
liquid.............................................................................. 118
ENSURE COMPACT -nutritional supplement liquid....... 118
ENSURE COMPLETE -nutritional supplement liquid..... 118
ENSURE COMPLETE NUTRITION -nutritional
supplement liquid.......................................................... 118
ENSURE ENLIVE -nutritional supplement liquid............ 118
ENSURE HEALTHY MOM -nutritional supplement
bar.................................................................................. 118
ENSURE HEALTHY MOM -nutritional supplement
liquid.............................................................................. 118
ENSURE HIGH CALCIUM -nutritional supplement
liquid.............................................................................. 118
ENSURE HIGH PROTEIN -nutritional supplement
liquid.............................................................................. 118
ENSURE HIGH PROTEIN -nutritional supplement
powder........................................................................... 118
ENSURE IMMUNE HEALTH -nutritional supplement
liquid.............................................................................. 118
ENSURE MUSCLE HEALTH REVI -nutritional
supplement liquid.......................................................... 118
ENSURE NUTRA SHAKE HI-CAL -nutritional supplement
liquid.............................................................................. 118
ENSURE -nutritional supplement bar..............................117
ENSURE -nutritional supplement liquid.......................... 117
ENSURE -nutritional supplement powder....................... 117
ENSURE NUTRITION SHAKE -nutritional supplement
liquid.............................................................................. 118
ENSURE PLUS HN -nutritional supplement liquid..........118
ENSURE PLUS -nutritional supplement liquid................ 118
ENSURE PRE-SURGERY -nutritional supplement
liquid.............................................................................. 118
ENSURE PUDDING -nutritional supplement
pudding.......................................................................... 118
ENSURE SURGERY IMMUNONUTR -nutritional
supplement liquid.......................................................... 118
entacapone tab 200 mg (Comtan)............................... 102
entecavir tab 0.5 mg (Baraclude)..................................... 7
entecavir tab 1 mg (Baraclude)........................................ 7
ENTEREG -alvimopan cap 12 mg.................................... 64
ENTRESTO -sacubitril-valsartan tab 24-26 mg................ 54
ENTRESTO -sacubitril-valsartan tab 49-51 mg................ 54
ENTRESTO -sacubitril-valsartan tab 97-103 mg.............. 54
ENU NUTRITIONAL SHAKE -nutritional supplement
liquid.............................................................................. 118
ENVARSUS XR -tacrolimus tab sr 24hr 0.75 mg............157
ENVARSUS XR -tacrolimus tab sr 24hr 1 mg................ 157
ENVARSUS XR -tacrolimus tab sr 24hr 4 mg................ 157
EO28 SPLASH -nutritional supplement liquid................. 118
EPCLUSA -sofosbuvir-velpatasvir tab 400-100 mg............ 7
epinastine hcl ophth soln 0.05% (Elestat).................. 144
EPINEPHRINE - AUTHORIZED GENERIC TO EPIPEN
-epinephrine solution auto-injector 0.15 mg/0.3ml
(1:2000)........................................................................... 51
EPINEPHRINE - AUTHORIZED GENERIC TO EPIPEN
-epinephrine solution auto-injector 0.3 mg/0.3ml
(1:1000)........................................................................... 51
EPINEPHRINE -epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)......................................................... 51
EPINEPHRINE -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)........................................................... 51
EPIPEN-JR 2-PAK -epinephrine solution auto-injector
0.15 mg/0.3ml (1:2000).................................................. 51
EPIPEN 2-PAK -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)........................................................... 51
EPIVIR HBV -lamivudine oral soln 5 mg/ml (hbv)............... 7
eplerenone tab 25 mg (Inspra)....................................... 47
eplerenone tab 50 mg (Inspra)....................................... 47
EPOGEN -epoetin alfa inj 2000 unit/ml...........................134
EPOGEN -epoetin alfa inj 3000 unit/ml...........................134
EPOGEN -epoetin alfa inj 4000 unit/ml...........................134
EPOGEN -epoetin alfa inj 10000 unit/ml.........................134
EPOGEN -epoetin alfa inj 20000 unit/ml.........................134
EPROSARTAN MESYLATE -eprosartan mesylate tab 600
mg.................................................................................... 47
EPZICOM -abacavir sulfate-lamivudine tab 600-300
mg...................................................................................... 7
EQL DENTAL TRAVEL PACK -sodium fluoride paste
0.243% & mouthwash kit..............................................147
EQL TRAVEL TOOTHBRUSH/TOO -sodium
monofluorophosphate paste 0.15%............................. 148
EQ NUTRITIONAL SHAKE -nutritional supplement
liquid.............................................................................. 118
EQ NUTRITIONAL SHAKE PLUS -nutritional supplement
liquid.............................................................................. 118
EQUATE -nutritional supplement liquid........................... 118
EQUATE PLUS -nutritional supplement liquid................ 118
EQUETRO -carbamazepine (antipsychotic) cap sr 12hr
100 mg............................................................................ 73
EQUETRO -carbamazepine (antipsychotic) cap sr 12hr
200 mg............................................................................ 73
EQUETRO -carbamazepine (antipsychotic) cap sr 12hr
300 mg............................................................................ 73
EQ WEIGHT LOSS SHAKE ULTR -nutritional supplement
liquid.............................................................................. 118
ergocalciferol cap 50000 unit (Drisdol)....................... 105
ERGOLOID MESYLATES -ergoloid mesylates tab 1
mg.................................................................................... 82
ERGOMAR -ergotamine tartrate sl tab 2 mg.................... 95
ergotamine w/ caffeine tab 1-100 mg (Cafergot).......... 95
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
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2017
ERIVEDGE -vismodegib cap 150 mg............................... 18
ERTACZO -sertaconazole nitrate cream 2%.................. 152
ERYPED 200 -erythromycin ethylsuccinate for susp 200
mg/5ml............................................................................... 3
ERYPED 400 -erythromycin ethylsuccinate for susp 400
mg/5ml............................................................................... 3
ERY-TAB -erythromycin tab delayed release 250 mg........ 3
ERY-TAB -erythromycin tab delayed release 333 mg........ 3
ERY-TAB -erythromycin tab delayed release 500 mg........ 3
ERYTHROCIN STEARATE -erythromycin stearate tab
250 mg.............................................................................. 3
ERYTHROMYCIN BASE -erythromycin tab 250 mg.......... 3
ERYTHROMYCIN BASE -erythromycin tab 500 mg.......... 3
ERYTHROMYCIN ETHYLSUCCINA -erythromycin
ethylsuccinate tab 400 mg............................................... 3
erythromycin ethylsuccinate for susp 200 mg/5ml
(E.e.s. granules).............................................................. 3
erythromycin gel 2% (Erygel)....................................... 152
erythromycin ophth oint 5 mg/gm............................... 144
erythromycin pads 2%.................................................. 152
erythromycin soln 2%................................................... 152
erythromycin w/ delayed release particles cap 250
mg......................................................................................4
ESBRIET -pirfenidone cap 267 mg................................... 60
escitalopram oxalate soln 5 mg/5ml (base equiv)
(Lexapro)........................................................................ 70
escitalopram oxalate tab 5 mg (base equiv)
(Lexapro)........................................................................ 70
escitalopram oxalate tab 10 mg (base equiv)
(Lexapro)........................................................................ 70
escitalopram oxalate tab 20 mg (base equiv)
(Lexapro)........................................................................ 70
esomeprazole magnesium cap delayed release 20 mg
(base eq) (Nexium)....................................................... 61
esomeprazole magnesium cap delayed release 40 mg
(base eq) (Nexium)....................................................... 61
ESSENTIAL AMINO ACID MIX -amino acids oral
powder........................................................................... 115
estazolam tab 1 mg......................................................... 76
estazolam tab 2 mg......................................................... 76
ESTRACE -estradiol vaginal cream 0.1 mg/gm................ 67
estradiol & norethindrone acetate tab 0.5-0.1 mg
(Activella)....................................................................... 25
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella)....................................................................... 25
estradiol tab 0.5 mg (Estrace)........................................ 25
estradiol tab 1 mg (Estrace)........................................... 25
estradiol tab 2 mg (Estrace)........................................... 25
estradiol td patch twice weekly 0.025 mg/24hr (Vivelledot).................................................................................. 25
estradiol td patch twice weekly 0.0375 mg/24hr
(Vivelle-dot).................................................................... 25
estradiol td patch twice weekly 0.05 mg/24hr (Vivelledot).................................................................................. 25
estradiol td patch twice weekly 0.075 mg/24hr (Vivelledot).................................................................................. 25
estradiol td patch twice weekly 0.1 mg/24hr (Vivelledot).................................................................................. 25
estradiol td patch weekly 0.025 mg/24hr (Climara)......25
estradiol td patch weekly 0.05 mg/24hr (Climara)........25
estradiol td patch weekly 0.06 mg/24hr (Climara)........25
estradiol td patch weekly 0.075 mg/24hr (Climara)......25
estradiol td patch weekly 0.1 mg/24hr (Climara)..........25
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr) (Climara)...................................................... 25
estradiol vaginal tab 10 mcg (Vagifem).........................67
estradiol valerate im in oil 20 mg/ml (Delestrogen)..... 25
estradiol valerate im in oil 40 mg/ml (Delestrogen)..... 25
ESTRING -estradiol vaginal ring 2 mg (7.5
mcg/24hrs).......................................................................67
ESTROGEL -estradiol gel 0.06% (0.75 mg/1.25 gm
metered-dose pump)...................................................... 25
ESTROPIPATE -estropipate tab 0.75 mg......................... 25
ESTROPIPATE -estropipate tab 1.5 mg........................... 25
ESTROPIPATE -estropipate tab 3 mg.............................. 25
eszopiclone tab 1 mg (Lunesta).................................... 76
eszopiclone tab 2 mg (Lunesta).................................... 76
eszopiclone tab 3 mg (Lunesta).................................... 76
ethacrynic acid tab 25 mg.............................................. 50
ethambutol hcl tab 100 mg (Myambutol)........................ 5
ethambutol hcl tab 400 mg (Myambutol)........................ 5
ethosuximide cap 250 mg (Zarontin)............................ 98
ethosuximide soln 250 mg/5ml (Zarontin).................... 98
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35
mcg................................................................................. 26
ethynodiol diacetate & ethinyl estradiol tab 1 mg-50
mcg (Zovia 1/50e)......................................................... 27
ETIDRONATE DISODIUM -etidronate disodium tab 200
mg.................................................................................... 38
etodolac cap 200 mg....................................................... 93
etodolac cap 300 mg....................................................... 93
etodolac tab 400 mg........................................................ 93
etodolac tab 500 mg........................................................ 93
etodolac tab sr 24hr 400 mg.......................................... 93
etodolac tab sr 24hr 500 mg.......................................... 93
etodolac tab sr 24hr 600 mg.......................................... 93
ETOPOSIDE -etoposide cap 50 mg..................................18
EURAX -crotamiton cream 10%...................................... 152
EURAX -crotamiton lotion 10%....................................... 152
EVAMIST -estradiol transdermal spray 1.53 mg/spray..... 25
EVOTAZ -atazanavir sulfate-cobicistat tab 300-150 mg
(base equiv)...................................................................... 7
EVZIO -naloxone hcl solution auto-injector 0.4
mg/0.4ml........................................................................ 155
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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EVZIO -naloxone hcl solution auto-injector 2
mg/0.4ml........................................................................ 155
EXALGO -hydromorphone hcl tab er 24hr deter 32
mg.................................................................................... 86
EXELDERM -sulconazole nitrate cream 1%................... 152
EXELDERM -sulconazole nitrate solution 1%................ 152
exemestane tab 25 mg (Aromasin)................................ 18
EXJADE -deferasirox tab for oral susp 125 mg.............. 156
EXJADE -deferasirox tab for oral susp 250 mg.............. 156
EXJADE -deferasirox tab for oral susp 500 mg.............. 156
EXTAVIA -interferon beta-1b for inj kit 0.3 mg.................. 82
EXTRA-VIRT PLUS DHA -prenatal w/o vit a w/ fe fumdoc-fa-dha cap 29-1.25-350 mg................................... 106
ezetimibe tab 10 mg (Zetia)............................................ 52
F
F.A.A. -nutritional supplement liquid................................ 118
FACTIVE -gemifloxacin mesylate tab 320 mg (base
equiv)................................................................................. 5
FALESSA -levonorgest-eth estrad tab 0.1 mg-20 mcg & fa
tab 1 mg kit..................................................................... 27
famciclovir tab 125 mg (Famvir)...................................... 7
famciclovir tab 250 mg (Famvir)...................................... 7
famciclovir tab 500 mg (Famvir)...................................... 7
famotidine for susp 40 mg/5ml (Pepcid)....................... 61
famotidine tab 40 mg (Pepcid)....................................... 61
FANAPT -iloperidone tab 1 mg......................................... 73
FANAPT -iloperidone tab 2 mg......................................... 73
FANAPT -iloperidone tab 4 mg......................................... 73
FANAPT -iloperidone tab 6 mg......................................... 73
FANAPT -iloperidone tab 8 mg......................................... 73
FANAPT -iloperidone tab 10 mg....................................... 73
FANAPT -iloperidone tab 12 mg....................................... 73
FANAPT TITRATION PACK -iloperidone tab 1 mg & 2 mg
& 4 mg & 6 mg titration pak........................................... 73
FARESTON -toremifene citrate tab 60 mg (base
equivalent)....................................................................... 18
FARXIGA -dapagliflozin propanediol tab 5 mg (base
equivalent)....................................................................... 30
FARXIGA -dapagliflozin propanediol tab 10 mg (base
equivalent)....................................................................... 30
FARYDAK -panobinostat lactate cap 10 mg (base
equivalent)....................................................................... 18
FARYDAK -panobinostat lactate cap 15 mg (base
equivalent)....................................................................... 18
FARYDAK -panobinostat lactate cap 20 mg (base
equivalent)....................................................................... 18
FAZACLO -clozapine orally disintegrating tab 12.5
mg.................................................................................... 73
FAZACLO -clozapine orally disintegrating tab 150 mg..... 73
FAZACLO -clozapine orally disintegrating tab 200 mg..... 73
FEIBA -antiinhibitor coagulant complex for inj................ 139
felbamate susp 600 mg/5ml (Felbatol).......................... 98
felbamate tab 400 mg (Felbatol).................................... 98
felbamate tab 600 mg (Felbatol).................................... 98
felodipine tab sr 24hr 2.5 mg......................................... 43
felodipine tab sr 24hr 5 mg............................................ 43
felodipine tab sr 24hr 10 mg.......................................... 43
FEMRING -estradiol acetate vaginal ring 0.05
mg/24hr........................................................................... 67
FEMRING -estradiol acetate vaginal ring 0.1 mg/24hr..... 67
fenofibrate micronized cap 43 mg................................. 52
fenofibrate micronized cap 130 mg............................... 52
fenofibrate micronized cap 67 mg (Lofibra)................. 52
fenofibrate micronized cap 134 mg (Lofibra)............... 52
fenofibrate tab 54 mg (Lofibra)...................................... 52
fenofibrate tab 160 mg (Lofibra).................................... 52
fenofibrate tab 48 mg (Tricor)........................................ 52
fenofibrate tab 145 mg (Tricor)...................................... 52
FENOPROFEN CALCIUM -fenoprofen calcium cap 200
mg.................................................................................... 93
FENOPROFEN CALCIUM -fenoprofen calcium cap 400
mg.................................................................................... 93
FENOPROFEN CALCIUM -fenoprofen calcium tab 600
mg.................................................................................... 93
fentanyl citrate lollipop 200 mcg (Actiq)....................... 87
fentanyl citrate lollipop 400 mcg (Actiq)....................... 87
fentanyl citrate lollipop 600 mcg (Actiq)....................... 87
fentanyl citrate lollipop 800 mcg (Actiq)....................... 87
fentanyl citrate lollipop 1200 mcg (Actiq)..................... 87
fentanyl citrate lollipop 1600 mcg (Actiq)..................... 87
FENTANYL -fentanyl td patch 72hr 37.5 mcg/hr...............86
FENTANYL -fentanyl td patch 72hr 62.5 mcg/hr...............86
FENTANYL -fentanyl td patch 72hr 87.5 mcg/hr...............86
fentanyl td patch 72hr 12 mcg/hr (Duragesic).............. 87
fentanyl td patch 72hr 25 mcg/hr (Duragesic).............. 87
fentanyl td patch 72hr 50 mcg/hr (Duragesic).............. 87
fentanyl td patch 72hr 75 mcg/hr (Duragesic).............. 87
fentanyl td patch 72hr 100 mcg/hr (Duragesic)............ 87
FENTORA -fentanyl citrate buccal tab 100 mcg (base
equiv)............................................................................... 87
FENTORA -fentanyl citrate buccal tab 200 mcg (base
equiv)............................................................................... 87
FENTORA -fentanyl citrate buccal tab 400 mcg (base
equiv)............................................................................... 87
FENTORA -fentanyl citrate buccal tab 600 mcg (base
equiv)............................................................................... 87
FENTORA -fentanyl citrate buccal tab 800 mcg (base
equiv)............................................................................... 87
FER-IN-SOL -ferrous sulfate soln 75 mg/ml (15 mg/ml
elemental fe)................................................................. 134
FERRETTS CHEWABLE IRON -carbonyl iron chew tab
18 mg (elemental iron)................................................. 134
FERRIPROX -deferiprone oral soln 100 mg/ml.............. 156
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2017
FERRIPROX -deferiprone tab 500 mg............................ 156
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental
fe).................................................................................. 134
FERROUS SULFATE -ferrous sulfate liquid 220 mg/5ml
(44 mg/5ml elemental fe)............................................. 134
FERROUS SULFATE -ferrous sulfate syrup 300 mg/5ml
(60 mg/5ml elemental fe)............................................. 134
ferrous sulfate soln 75 mg/ml (15 mg/ml elemental
fe).................................................................................. 134
FIBER FLOW -nutritional supplement liquid................... 119
FIBERSOURCE CLOSED SYSTEM -nutritional
supplement liquid.......................................................... 119
FIBERSOURCE HN CLOSED SYS -nutritional
supplement liquid.......................................................... 119
FIBERSOURCE HN -nutritional supplement liquid......... 119
FIBER-STAT -nutritional supplement liquid..................... 119
FINACEA -azelaic acid foam 15%.................................. 152
FINACEA -azelaic acid gel 15%..................................... 152
finasteride tab 5 mg (Proscar)....................................... 67
FIRAZYR -icatibant acetate inj 30 mg/3ml (base
equivalent)..................................................................... 139
FLAREX -fluorometholone acetate ophth susp 0.1%..... 144
FLAVOR PACKETS -nutritional supplement flavor
pack............................................................................... 119
FLAVOUR PAC -nutritional supplement flavor pack....... 119
flavoxate hcl tab 100 mg.................................................66
flecainide acetate tab 50 mg.......................................... 44
flecainide acetate tab 100 mg........................................ 44
flecainide acetate tab 150 mg........................................ 44
FLORICAL -sodium fluoride w/ calcium carb cap 8.3-364
mg.................................................................................. 113
FLORICAL -sodium fluoride w/ calcium carb tab 8.3-364
mg.................................................................................. 113
FLORIVA -sodium fluoride-vitamin d liqd drops 0.25 mg/
ml-400 unit/ml............................................................... 113
FLOVENT DISKUS -fluticasone propionate aer pow ba 50
mcg/blister....................................................................... 58
FLOVENT DISKUS -fluticasone propionate aer pow ba
100 mcg/blister................................................................ 58
FLOVENT DISKUS -fluticasone propionate aer pow ba
250 mcg/blister................................................................ 58
FLOVENT HFA -fluticasone propionate hfa inhal aer 110
mcg/act (125/valve)........................................................ 58
FLOVENT HFA -fluticasone propionate hfa inhal aer 220
mcg/act (250/valve)........................................................ 58
FLOVENT HFA -fluticasone propionate hfa inhal aero 44
mcg/act (50/valve)...........................................................58
FLUAD 2016-2017 -influenza vac type a&b surface ant
adj susp pref syr 0.5 ml................................................. 13
FLUARIX 2014-2015 -influenza virus vaccine split pf susp
pref syringe 0.5 ml.......................................................... 13
FLUARIX QUADRIVALENT 2014 -influenza virus vac split
quadrivalent susp pref syr 0.5ml.................................... 13
FLUARIX QUADRIVALENT 2015 -influenza virus vac split
quadrivalent susp pref syr 0.5ml.................................... 13
FLUARIX QUADRIVALENT 2016 -influenza virus vac split
quadrivalent susp pref syr 0.5ml.................................... 13
FLUBLOK 2014-2015 -influenza virus vac recombinant
hemagglutinin (ha) inj..................................................... 13
FLUBLOK 2015-2016 -influenza virus vac recombinant
hemagglutinin (ha) inj..................................................... 13
FLUBLOK 2016-2017 -influenza virus vac recombinant
hemagglutinin (ha) inj..................................................... 13
FLUCELVAX 2014-2015 -influenza virus vac tiss-cult
subunit susp pref syr 0.5 ml........................................... 13
FLUCELVAX 2015-2016 -influenza virus vac tiss-cult
subunit susp pref syr 0.5 ml........................................... 13
FLUCELVAX QUADRIVALENT 20 -influenza vac tiss-cult
subunt quad susp pref syr 0.5 ml.................................. 13
fluconazole for susp 10 mg/ml (Diflucan)....................... 6
fluconazole for susp 40 mg/ml (Diflucan)....................... 6
fluconazole tab 50 mg (Diflucan)..................................... 6
fluconazole tab 100 mg (Diflucan)................................... 6
fluconazole tab 150 mg (Diflucan)................................... 6
fluconazole tab 200 mg (Diflucan)................................... 6
flucytosine cap 250 mg (Ancobon)................................. 6
flucytosine cap 500 mg (Ancobon)................................. 6
fludrocortisone acetate tab 0.1 mg............................... 22
FLULAVAL 2014-2015 -influenza virus vaccine split im
susp................................................................................. 14
FLULAVAL QUADRIVALENT 201 -influenza virus vaccine
split quadrivalent im inj................................................... 14
FLULAVAL QUADRIVALENT 201 -influenza virus vac split
quadrivalent susp pref syr 0.5ml.................................... 14
FLUMIST QUADRIVALENT -influenza virus vaccine live
quadrivalent intranasal susp...........................................14
flunisolide nasal soln 25 mcg/act (0.025%)
(Flunisolide)................................................................... 55
fluocinolone acetonide cream 0.01%.......................... 152
fluocinolone acetonide cream 0.025% (Synalar)........152
fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod).......................................................... 152
fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)...........................................................152
fluocinolone acetonide oint 0.025% (Synalar)............ 152
fluocinolone acetonide (otic) oil 0.01%
(Dermotic).................................................................... 147
fluocinolone acetonide soln 0.01% (Synalar)............. 152
fluocinonide cream 0.05%............................................ 152
fluocinonide emulsified base cream 0.05%................ 152
fluocinonide gel 0.05%.................................................. 152
fluocinonide oint 0.05%................................................ 152
fluocinonide soln 0.05%................................................ 152
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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FLUORABON -sodium fluoride soln 0.25 mg/0.6ml (from
0.55 mg/0.6ml naf)........................................................113
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 0.55
(0.25 mg f)-236.79 mg..................................................113
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 2.2 (1 mg
f)-236.79 mg.................................................................. 113
fluorometholone ophth susp 0.1% (Fml liquifilm)..... 144
FLUOROPLEX -fluorouracil cream 1%........................... 152
fluorouracil cream 5% (Efudex)................................... 152
FLUOROURACIL -fluorouracil cream 0.5%.................... 152
fluorouracil soln 2%...................................................... 152
fluorouracil soln 5%...................................................... 152
FLUOXETINE DR -fluoxetine hcl cap delayed release 90
mg.................................................................................... 70
FLUOXETINE -fluoxetine hcl (pmdd) cap 10 mg.............. 82
FLUOXETINE -fluoxetine hcl (pmdd) cap 20 mg.............. 82
fluoxetine hcl cap 10 mg (Prozac)................................. 70
fluoxetine hcl cap 20 mg (Prozac)................................. 70
fluoxetine hcl cap 40 mg (Prozac)................................. 70
fluoxetine hcl solution 20 mg/5ml................................. 70
fluoxetine hcl tab 10 mg................................................. 70
fluoxetine hcl tab 20 mg................................................. 70
FLUPHENAZINE HCL -fluphenazine hcl elixir 2.5
mg/5ml............................................................................. 73
FLUPHENAZINE HCL -fluphenazine hcl oral conc 5 mg/
ml..................................................................................... 73
fluphenazine hcl tab 1 mg.............................................. 73
fluphenazine hcl tab 2.5 mg........................................... 73
fluphenazine hcl tab 5 mg.............................................. 73
fluphenazine hcl tab 10 mg............................................ 73
FLURA-DROPS -sodium fluoride soln 0.25 mg/drop f
(from 0.55 mg/drop naf)............................................... 113
flurandrenolide cream 0.05%....................................... 152
flurandrenolide lotion 0.05% (Cordran).......................152
FLURAZEPAM HCL -flurazepam hcl cap 15 mg.............. 76
FLURAZEPAM HCL -flurazepam hcl cap 30 mg.............. 76
flurbiprofen sodium ophth soln 0.03% (Ocufen)........144
flurbiprofen tab 50 mg.................................................... 93
flurbiprofen tab 100 mg.................................................. 93
flutamide cap 125 mg...................................................... 18
fluticasone propionate cream 0.05% (Cutivate)......... 152
fluticasone propionate nasal susp 50 mcg/act
(Flonase)......................................................................... 55
fluticasone propionate oint 0.005% (Cutivate)........... 152
fluvastatin sodium cap 20 mg (Lescol)......................... 52
fluvastatin sodium cap 40 mg (Lescol)......................... 52
fluvastatin sodium tab sr 24 hr 80 mg (Lescol xl)........52
FLUVIRIN 2015-2016 -influenza vac type a&b surface
antigen susp pref syr 0.5 ml...........................................14
FLUVIRIN 2016-2017 -influenza vac type a&b surface
antigen susp pref syr 0.5 ml...........................................14
FLUVIRIN 2014-2015 -influenza virus vaccine types a & b
surface antigen im susp................................................. 14
FLUVIRIN 2015-2016 -influenza virus vaccine types a & b
surface antigen im susp................................................. 14
FLUVIRIN 2016-2017 -influenza virus vaccine types a & b
surface antigen im susp................................................. 14
FLUVIRIN PF 2014-2015 -influenza virus vac types a & b
pf susp prefilled syr 0.5 ml............................................. 14
fluvoxamine maleate tab 25 mg..................................... 70
fluvoxamine maleate tab 50 mg..................................... 70
fluvoxamine maleate tab 100 mg................................... 70
FLUZONE HIGH-DOSE PF 2014 -influenza virus vac split
high-dose pf susp pref syr 0.5ml....................................14
FLUZONE HIGH-DOSE PF 2015 -influenza virus vac split
high-dose pf susp pref syr 0.5ml....................................14
FLUZONE HIGH-DOSE PF 2016 -influenza virus vac split
high-dose pf susp pref syr 0.5ml....................................14
FLUZONE INTRADERMAL QUADR -influenza virus vac
split quad intradermal pen 9 mcg/strain......................... 14
FLUZONE PF 2014-2015 -influenza virus vaccine split pf
susp pref syringe 0.5 ml................................................. 14
FLUZONE QUADRIVALENT 2014 -influenza virus
vaccine split quadrivalent im inj..................................... 14
FLUZONE QUADRIVALENT 2015 -influenza virus
vaccine split quadrivalent im inj..................................... 15
FLUZONE QUADRIVALENT 2016 -influenza virus
vaccine split quadrivalent im inj..................................... 15
FLUZONE QUADRIVALENT 2014 -influenza virus
vaccine split quadrivalent inj 0.5 ml............................... 14
FLUZONE QUADRIVALENT 2015 -influenza virus
vaccine split quadrivalent inj 0.5 ml............................... 15
FLUZONE QUADRIVALENT 2016 -influenza virus
vaccine split quadrivalent inj 0.5 ml............................... 15
FLUZONE QUADRIVALENT 2014 -influenza virus vac
split quadrivalent susp pref syr 0.25 ml......................... 14
FLUZONE QUADRIVALENT 2014 -influenza virus vac
split quadrivalent susp pref syr 0.5ml............................ 14
FLUZONE QUADRIVALENT 2015 -influenza virus vac
split quadrivalent susp pref syr 0.25 ml......................... 14
FLUZONE QUADRIVALENT 2015 -influenza virus vac
split quadrivalent susp pref syr 0.5ml............................ 14
FLUZONE QUADRIVALENT 2016 -influenza virus vac
split quadrivalent susp pref syr 0.25 ml......................... 15
FLUZONE QUADRIVALENT 2016 -influenza virus vac
split quadrivalent susp pref syr 0.5ml............................ 15
FLUZONE SPLIT 2014-2015 -influenza virus vaccine split
im susp............................................................................ 15
FLUZONE SPLIT 2015-2016 -influenza virus vaccine split
im susp............................................................................ 15
FML -fluorometholone ophth oint 0.1%........................... 144
FML FORTE -fluorometholone ophth susp 0.25%.......... 144
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2017
FOCALGIN CA -prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 300 mg pack...................................................106
FOCALGIN 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa tab
90 &dha cap 300mg pak.............................................. 107
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 25
mg.................................................................................... 79
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 35
mg.................................................................................... 79
FOLCAL DHA -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 27-1.25-300 mg..................................................... 107
FOLCAPS OMEGA 3 -prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg............................................... 107
FOLET DHA -prenat w/fecbn-bisg-methylf-dss tab dr &
dha cap pak.................................................................. 107
FOLET ONE -prenat w/o a w/fecbn-bisg-methylf-dss-dha
cap 38-1-225 mg.......................................................... 107
folic acid cap 0.8 mg..................................................... 134
folic acid tab 400 mcg................................................... 134
folic acid tab 800 mcg................................................... 134
folic acid tab 1 mg......................................................... 134
FOLIVANE-OB -prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg...............................................................107
fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml
(Arixtra).........................................................................136
fondaparinux sodium subcutaneous inj 5 mg/0.4ml
(Arixtra).........................................................................136
fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml
(Arixtra).........................................................................136
fondaparinux sodium subcutaneous inj 10 mg/0.8ml
(Arixtra).........................................................................136
FORTA DRINK -nutritional supplement powder.............. 119
FORTA SHAKE -nutritional supplement powder............. 119
FORTEO -teriparatide (recombinant) inj 600
mcg/2.4ml........................................................................ 38
FOSAMAX PLUS D -alendronate sodium-cholecalciferol
tab 70-2800 mg-unit....................................................... 38
FOSAMAX PLUS D -alendronate sodium-cholecalciferol
tab 70-5600 mg-unit....................................................... 38
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg................................................................................... 47
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg................................................................................... 47
fosinopril sodium tab 10 mg.......................................... 47
fosinopril sodium tab 20 mg.......................................... 47
fosinopril sodium tab 40 mg.......................................... 47
FOSRENOL -lanthanum carbonate chew tab 500 mg
(elemental).......................................................................64
FOSRENOL -lanthanum carbonate chew tab 750 mg
(elemental).......................................................................64
FOSRENOL -lanthanum carbonate chew tab 1000 mg
(elemental).......................................................................65
FOSRENOL -lanthanum carbonate oral powder pack 750
mg (elemental)................................................................ 65
FOSRENOL -lanthanum carbonate oral powder pack
1000 mg (elemental).......................................................65
FRAGMIN -dalteparin sodium inj 10000 unit/ml..............136
FRAGMIN -dalteparin sodium inj 2500 unit/0.2ml...........136
FRAGMIN -dalteparin sodium inj 5000 unit/0.2ml...........136
FRAGMIN -dalteparin sodium inj 7500 unit/0.3ml...........136
FRAGMIN -dalteparin sodium inj 12500 unit/0.5ml.........136
FRAGMIN -dalteparin sodium inj 15000 unit/0.6ml.........136
FRAGMIN -dalteparin sodium inj 18000 unit/0.72ml.......136
FRAGMIN -dalteparin sodium inj 95000 unit/3.8ml.........136
FROVA -frovatriptan succinate tab 2.5 mg (base
equivalent)....................................................................... 95
frovatriptan succinate tab 2.5 mg (base equivalent)
(Frova).............................................................................95
FRUITIVITS -nutritional supplement pack.......................119
furosemide oral soln 10 mg/ml...................................... 50
furosemide tab 20 mg (Lasix)........................................ 50
furosemide tab 40 mg (Lasix)........................................ 50
furosemide tab 80 mg (Lasix)........................................ 50
FUZEON -enfuvirtide for inj 90 mg..................................... 7
FYCOMPA -perampanel susp 0.5 mg/ml.......................... 98
FYCOMPA -perampanel tab 2 mg.................................... 98
FYCOMPA -perampanel tab 4 mg.................................... 98
FYCOMPA -perampanel tab 6 mg.................................... 98
FYCOMPA -perampanel tab 8 mg.................................... 98
FYCOMPA -perampanel tab 10 mg.................................. 98
FYCOMPA -perampanel tab 12 mg.................................. 98
G
GA-1 ANAMIX EARLY YEARS -nutritional supplement
powder........................................................................... 119
gabapentin cap 100 mg (Neurontin).............................. 98
gabapentin cap 300 mg (Neurontin).............................. 98
gabapentin cap 400 mg (Neurontin).............................. 98
gabapentin oral soln 250 mg/5ml (Neurontin).............. 98
gabapentin tab 600 mg (Neurontin)............................... 98
gabapentin tab 800 mg (Neurontin)............................... 98
GABITRIL -tiagabine hcl tab 12 mg.................................. 98
GABITRIL -tiagabine hcl tab 16 mg.................................. 98
GA EXPRESS15 -nutritional supplement pack............... 119
GA GEL -nutritional supplement pack............................. 119
galantamine hydrobromide cap sr 24hr 8 mg
(Razadyne er)................................................................ 82
galantamine hydrobromide cap sr 24hr 16 mg
(Razadyne er)................................................................ 82
galantamine hydrobromide cap sr 24hr 24 mg
(Razadyne er)................................................................ 82
GALANTAMINE HYDROBROMIDE -galantamine
hydrobromide oral soln 4 mg/ml.................................... 82
galantamine hydrobromide tab 4 mg (Razadyne)........ 82
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2017
galantamine hydrobromide tab 8 mg (Razadyne)........ 82
galantamine hydrobromide tab 12 mg (Razadyne)...... 82
GALZIN -zinc acetate cap 25 mg (elemental zinc)......... 113
GALZIN -zinc acetate cap 50 mg (elemental zinc)......... 113
GA -nutritional supplement powder................................. 119
gatifloxacin ophth soln 0.5% (Zymaxid)..................... 145
GATTEX -teduglutide (rdna) for inj kit 5 mg...................... 65
GEL-KAM ORAL CARE RINSE -stannous fluoride conc
0.63%.............................................................................148
GEL-KAM -stannous fluoride gel 0.4%........................... 148
gemfibrozil tab 600 mg (Lopid)...................................... 52
GENERESS FE -norethindrone & ethinyl estradiol-fe
chew tab 0.8 mg-25 mcg................................................27
gentamicin sulfate cream 0.1%.................................... 152
GENTAMICIN SULFATE -gentamicin sulfate oint
0.1%...............................................................................152
gentamicin sulfate ophth oint 0.3%............................. 145
gentamicin sulfate ophth soln 0.3% (Garamycin)...... 145
GENVOYA -elvitegrav-cobic-emtricitab-tenofov af tab
150-150-200-10 mg.......................................................... 7
GIALAX -polyethylene glycol 3350 - kit............................ 60
GIAZO -balsalazide disodium tab 1.1 gm......................... 65
GILENYA -fingolimod hcl cap 0.5 mg (base equiv)........... 82
GILOTRIF -afatinib dimaleate tab 20 mg (base
equivalent)....................................................................... 18
GILOTRIF -afatinib dimaleate tab 30 mg (base
equivalent)....................................................................... 18
GILOTRIF -afatinib dimaleate tab 40 mg (base
equivalent)....................................................................... 18
glatiramer acetate soln prefilled syringe 20 mg/ml
(Copaxone)..................................................................... 82
GLEEVEC -imatinib mesylate tab 100 mg (base
equivalent)....................................................................... 18
GLEEVEC -imatinib mesylate tab 400 mg (base
equivalent)....................................................................... 18
GLEOSTINE -lomustine cap 5 mg.................................... 18
GLEOSTINE -lomustine cap 10 mg.................................. 18
GLEOSTINE -lomustine cap 40 mg.................................. 18
GLEOSTINE -lomustine cap 100 mg................................ 18
glimepiride tab 1 mg (Amaryl)........................................30
glimepiride tab 2 mg (Amaryl)........................................30
glimepiride tab 4 mg (Amaryl)........................................30
glipizide-metformin hcl tab 2.5-250 mg......................... 30
glipizide-metformin hcl tab 2.5-500 mg......................... 30
glipizide-metformin hcl tab 5-500 mg............................ 30
glipizide tab 5 mg (Glucotrol).........................................30
glipizide tab 10 mg (Glucotrol).......................................30
glipizide tab sr 24hr 2.5 mg (Glucotrol xl).................... 30
glipizide tab sr 24hr 5 mg (Glucotrol xl)....................... 30
glipizide tab sr 24hr 10 mg (Glucotrol xl)..................... 30
GLUCAGEN HYPOKIT -glucagon hcl (rdna) for inj 1 mg
(base equiv).................................................................... 30
GLUCAGON EMERGENCY KIT -glucagon (rdna) for inj
kit 1 mg........................................................................... 30
GLUCERNA ADVANCE SHAKE -nutritional supplement
liquid.............................................................................. 119
GLUCERNA 1.0 CAL/FIBER -nutritional supplement
liquid.............................................................................. 119
GLUCERNA 1.0 CAL -nutritional supplement liquid....... 119
GLUCERNA 1.2 CAL -nutritional supplement liquid....... 120
GLUCERNA 1.5 CAL -nutritional supplement liquid....... 120
GLUCERNA CARBSTEADY -nutritional supplement
liquid.............................................................................. 119
GLUCERNA CEREAL CRUNCHY F -nutritional
supplement misc........................................................... 119
GLUCERNA CRISPY DELIGHTS -nutritional supplement
bar.................................................................................. 119
GLUCERNA HUNGER SMART SHA -nutritional
supplement liquid.......................................................... 119
GLUCERNA MEAL -nutritional supplement bar..............119
GLUCERNA MEAL REPLACEMENT -nutritional
supplement bar............................................................. 119
GLUCERNA MINI SNACK -nutritional supplement
bar.................................................................................. 119
GLUCERNA MINI SNACKS -nutritional supplement
bar.................................................................................. 119
GLUCERNA -nutritional supplement bar.........................119
GLUCERNA -nutritional supplement liquid..................... 119
GLUCERNA OS -nutritional supplement liquid............... 119
GLUCERNA SELECT -nutritional supplement liquid...... 119
GLUCERNA SHAKE -nutritional supplement liquid........ 119
GLUCERNA SNACK -nutritional supplement bar........... 119
GLUCERNA SNACK SHAKE -nutritional supplement
liquid.............................................................................. 119
GLUCERNA WEIGHT LOSS SHAK -nutritional
supplement liquid.......................................................... 119
GLUCERNA 1.0 WITH CARBSTE -nutritional supplement
liquid.............................................................................. 120
GLUCO BURST -nutritional supplement liquid............... 120
GLUMETZA -metformin hcl tab sr 24hr modified release
500 mg............................................................................ 30
GLUMETZA -metformin hcl tab sr 24hr modified release
1000 mg.......................................................................... 30
GLUTARADE AMINO ACID BLEN -amino acids oral
powder........................................................................... 115
GLUTARADE ESSENTIAL GA-1 -amino acids oral
powder........................................................................... 115
GLUTARADE JUNIOR GA-1 -amino acids oral
powder........................................................................... 115
GLUTAREX-1 -nutritional supplement powder................120
GLUTAREX-2 -nutritional supplement powder................120
glyburide-metformin tab 1.25-250 mg
(Glucovance).................................................................. 30
glyburide-metformin tab 2.5-500 mg (Glucovance)..... 30
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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BCBSTX Health Insurance Marketplace 3 Tier Drug List June 2017
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2017
glyburide-metformin tab 5-500 mg (Glucovance)........ 30
glyburide micronized tab 1.5 mg (Glynase)..................30
glyburide micronized tab 3 mg (Glynase).....................30
glyburide micronized tab 6 mg (Glynase).....................30
glyburide tab 1.25 mg..................................................... 30
glyburide tab 2.5 mg....................................................... 30
glyburide tab 5 mg.......................................................... 30
glycopyrrolate tab 1 mg (Robinul)................................. 61
glycopyrrolate tab 2 mg (Robinul forte)........................61
GLYCOSADE -nutritional supplement pack.................... 120
GLYSET -miglitol tab 25 mg.............................................. 30
GLYSET -miglitol tab 50 mg.............................................. 30
GLYSET -miglitol tab 100 mg............................................ 30
GLYTACTIN BETTERMILK DE-L -nutritional supplement
pack............................................................................... 120
GLYTACTIN BETTERMILK 15 -nutritional supplement
pack............................................................................... 120
GLYTACTIN BUILD 10PE -nutritional supplement
pack............................................................................... 120
GLYTACTIN COMPLETE 10PE -nutritional supplement
bar.................................................................................. 120
GLYTACTIN RESTORE LITE 10 -nutritional supplement
liquid.............................................................................. 120
GLYTACTIN RESTORE LITE 10 -nutritional supplement
pack............................................................................... 120
GLYTACTIN RESTORE 10 -nutritional supplement
liquid.............................................................................. 120
GLYTACTIN RESTORE 5 -nutritional supplement
pack............................................................................... 120
GLYTACTIN RTD 10 -nutritional supplement liquid........ 120
GLYTACTIN RTD 15 -nutritional supplement liquid........ 120
GLYTROL -nutritional supplement liquid......................... 120
GLYTROL PREBIO1 -nutritional supplement liquid........ 120
GLYXAMBI -empagliflozin-linagliptin tab 10-5 mg............ 30
GLYXAMBI -empagliflozin-linagliptin tab 25-5 mg............ 30
GNP NUTRITIONAL DRINK -nutritional supplement
liquid.............................................................................. 120
GNP NUTRITIONAL DRINK PLU -nutritional supplement
liquid.............................................................................. 120
GOAT MILK -nutritional supplement powder.................. 120
GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate
packet 227.1 gm............................................................. 60
G-PREPROTEIN -amino acids oral liquid....................... 115
GRALISE -gabapentin (once-daily) tab 300 mg................82
GRALISE -gabapentin (once-daily) tab 600 mg................82
GRALISE STARTER -gabapentin (once-daily) tab pack
300 mg (9) & 600 mg (69)............................................. 82
granisetron hcl tab 1 mg................................................ 63
GRANIX -tbo-filgrastim soln prefilled syringe 300
mcg/0.5ml...................................................................... 134
GRANIX -tbo-filgrastim soln prefilled syringe 480
mcg/0.8ml...................................................................... 134
GRASTEK -timothy grass pollen allergen ext tab sl 2800
bau................................................................................... 16
griseofulvin microsize susp 125 mg/5ml........................ 6
griseofulvin microsize tab 500 mg (Grifulvin v)............. 6
griseofulvin ultramicrosize tab 125 mg (Gris-peg)........ 6
griseofulvin ultramicrosize tab 250 mg (Gris-peg)........ 6
guaifenesin-codeine liquid 225-7.5 mg/5ml.................. 56
guaifenesin-codeine soln 100-6.3 mg/5ml.................... 56
guaifenesin-codeine soln 100-10 mg/5ml..................... 56
guanfacine hcl tab 1 mg (Tenex)................................... 47
guanfacine hcl tab 2 mg (Tenex)................................... 47
guanfacine hcl tab sr 24hr 1 mg (base equiv)
(Intuniv).......................................................................... 79
guanfacine hcl tab sr 24hr 2 mg (base equiv)
(Intuniv).......................................................................... 79
guanfacine hcl tab sr 24hr 3 mg (base equiv)
(Intuniv).......................................................................... 79
guanfacine hcl tab sr 24hr 4 mg (base equiv)
(Intuniv).......................................................................... 79
GUANIDINE HCL -guanidine hcl tab 125 mg................. 105
GYNAZOLE-1 -butoconazole nitrate (one dose) vaginal
cream 2%........................................................................ 67
H
HAELAN 951 FERMENTED ORGA -nutritional
supplement liquid.......................................................... 120
HAELAN HTPI FERMENTED ORG -nutritional
supplement liquid.......................................................... 120
halobetasol propionate cream 0.05% (Ultravate)....... 152
halobetasol propionate oint 0.05% (Ultravate)........... 152
HALOG -halcinonide oint 0.1%....................................... 152
haloperidol lactate oral conc 2 mg/ml...........................73
haloperidol tab 0.5 mg.................................................... 73
haloperidol tab 1 mg....................................................... 74
haloperidol tab 2 mg....................................................... 74
haloperidol tab 5 mg....................................................... 74
haloperidol tab 10 mg..................................................... 74
haloperidol tab 20 mg..................................................... 74
HARVONI -ledipasvir-sofosbuvir tab 90-400 mg................ 7
HCU ANAMIX EARLY YEARS -nutritional supplement
powder........................................................................... 120
HCU ANAMIX NEXT -nutritional supplement
powder........................................................................... 120
HCU COOLER -nutritional supplement liquid................. 120
HCU EXPRESS -nutritional supplement pack................ 120
HCU EXPRESS20 -nutritional supplement pack............ 120
HCU GEL -nutritional supplement pack.......................... 120
HCU LOPHLEX LQ -nutritional supplement liquid.......... 120
HCY 1 -nutritional supplement powder........................... 120
HCY 2 -nutritional supplement powder........................... 121
HEALTH SOURCE SOY PROTEIN -nutritional
supplement powder...................................................... 121
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HEALTHY ACCENTS NUTRA FIT -nutritional supplement
liquid.............................................................................. 121
HEARTBAR -nutritional supplement bar......................... 121
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 250 unit.................................................................... 139
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 500 unit.................................................................... 139
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 1000 unit.................................................................. 139
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 2000 unit.................................................................. 139
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 3000 unit.................................................................. 139
HEMENATAL OB + DHA -prenat-fe poly cmplx-fe heme
poly-fa tab & omega 3 cap pck.................................... 107
HEMENATAL OB -prenat vit-fe poly cmplx-fe heme polyfa tab 28-6-1 mg........................................................... 107
HEMOFIL M -antihemophilic factor (human) for inj 250
unit................................................................................. 139
HEMOFIL M -antihemophilic factor (human) for inj 500
unit................................................................................. 139
HEMOFIL M -antihemophilic factor (human) for inj 1000
unit................................................................................. 139
HEMOFIL M -antihemophilic factor (human) for inj 1700
unit................................................................................. 139
HEPAMENT -amino acids pack.......................................115
heparin sodium (porcine) inj 1000 unit/ml.................. 136
heparin sodium (porcine) inj 5000 unit/ml.................. 136
heparin sodium (porcine) inj 10000 unit/ml................ 136
heparin sodium (porcine) inj 20000 unit/ml................ 136
heparin sodium (porcine) pf inj 5000 unit/0.5ml........ 136
HETLIOZ -tasimelteon capsule 20 mg.............................. 76
HEXALEN -altretamine cap 50 mg................................... 18
HI-CAL -nutritional supplement liquid..............................121
HIGH-PROTEIN NUTRITIONAL -nutritional supplement
liquid.............................................................................. 121
HISTEX-AC -phenylephrine-triprolidine-codeine syrup
10-2.5-10 mg/5ml............................................................ 56
HM NUTRISURE -nutritional supplement liquid..............121
HM NUTRISURE PLUS -nutritional supplement
liquid.............................................................................. 121
HOMACTIN AA PLUS -nutritional supplement liquid...... 121
HOMINEX-1 -nutritional supplement powder.................. 121
HOMINEX-2 -nutritional supplement powder.................. 121
HOM 2 -nutritional supplement powder.......................... 121
HORIZANT -gabapentin enacarbil tab cr 300 mg............. 82
HORIZANT -gabapentin enacarbil tab cr 600 mg............. 82
H.P. ACTHAR -corticotropin inj gel 80 unit/ml................... 38
HUMALOG -insulin lispro inj 100 unit/ml...........................33
HUMALOG -insulin lispro soln cartridge 100 unit/ml.........33
HUMALOG KWIKPEN -insulin lispro soln pen-injector 100
unit/ml.............................................................................. 33
HUMALOG KWIKPEN -insulin lispro soln pen-injector 200
unit/ml.............................................................................. 33
HUMALOG MIX 75/25 -insulin lispro prot & lispro inj 100
unit/ml (75-25)................................................................. 34
HUMALOG MIX 50/50 -insulin lispro protamine & lispro inj
100 unit/ml (50-50)......................................................... 34
HUMALOG MIX 50/50 KWIKPEN -insulin lispro prot &
lispro sus pen-inj 100 unit/ml (50-50).............................34
HUMALOG MIX 75/25 KWIKPEN -insulin lispro prot &
lispro sus pen-inj 100 unit/ml (75-25).............................34
HUMATE-P -antihemophilic factor/vwf (human) for inj
250-600 unit.................................................................. 139
HUMATE-P -antihemophilic factor/vwf (human) for inj
500-1200 unit................................................................ 139
HUMATE-P -antihemophilic factor/vwf (human) for inj
1000-2400 unit.............................................................. 139
HUMIRA -adalimumab prefilled syringe kit 10
mg/0.2ml.......................................................................... 93
HUMIRA -adalimumab prefilled syringe kit 20
mg/0.4ml.......................................................................... 93
HUMIRA -adalimumab prefilled syringe kit 40
mg/0.8ml.......................................................................... 93
HUMIRA PEDIATRIC CROHNS D -adalimumab prefilled
syringe kit 40 mg/0.8ml.................................................. 93
HUMIRA PEN -adalimumab pen-injector kit 40
mg/0.8ml.......................................................................... 93
HUMIRA PEN-CROHNS DISEASE -adalimumab peninjector kit 40 mg/0.8ml.................................................. 93
HUMIRA PEN-PSORIASIS STAR -adalimumab peninjector kit 40 mg/0.8ml.................................................. 93
HUMULIN 70/30 -insulin nph isophane & regular human
inj 100 unit/ml (70-30).................................................... 34
HUMULIN 70/30 KWIKPEN -insulin nph & regular susp
pen-inj 100 unit/ml (70-30)............................................. 34
HUMULIN N -insulin nph (human) (isophane) inj 100 unit/
ml..................................................................................... 34
HUMULIN N KWIKPEN -insulin nph (human) (isophane)
susp pen-injector 100 unit/ml......................................... 34
HUMULIN R -insulin regular (human) inj 100 unit/ml........ 34
HUMULIN R U-500 (CONCENTR -insulin regular (human)
inj 500 unit/ml..................................................................34
HUMULIN R U-500 KWIKPEN -insulin regular (human)
soln pen-injector 500 unit/ml.......................................... 34
HURRISEAL -dental desensitizing product - solution..... 156
HYCAMTIN -topotecan hcl cap 0.25 mg (base equiv)...... 18
HYCAMTIN -topotecan hcl cap 1 mg (base equiv)........... 18
hydralazine hcl tab 10 mg.............................................. 47
hydralazine hcl tab 25 mg.............................................. 47
hydralazine hcl tab 50 mg.............................................. 47
hydralazine hcl tab 100 mg............................................ 47
hydrochlorothiazide cap 12.5 mg (Microzide).............. 50
hydrochlorothiazide tab 12.5 mg................................... 50
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hydrochlorothiazide tab 25 mg...................................... 50
hydrochlorothiazide tab 50 mg...................................... 50
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
(Hycet).............................................................................87
hydrocodone-acetaminophen soln 10-325 mg/15ml
(Zamicet).........................................................................87
hydrocodone-acetaminophen tab 2.5-325 mg.............. 87
hydrocodone-acetaminophen tab 7.5-325 mg
(Norco)............................................................................ 87
hydrocodone-acetaminophen tab 5-325 mg
(Norco)............................................................................ 87
hydrocodone-acetaminophen tab 10-325 mg
(Norco)............................................................................ 87
hydrocodone-acetaminophen tab 7.5-300 mg
(Xodol)............................................................................ 87
hydrocodone-acetaminophen tab 5-300 mg
(Xodol)............................................................................ 87
hydrocodone-acetaminophen tab 10-300 mg
(Xodol)............................................................................ 87
hydrocodone-ibuprofen tab 10-200 mg (Ibudone)....... 87
hydrocodone-ibuprofen tab 5-200 mg (Reprexain)......87
hydrocodone-ibuprofen tab 7.5-200 mg
(Vicoprofen)................................................................... 87
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml...... 56
hydrocodone w/ homatropine tab 5-1.5 mg..................56
hydrocod polst-chlorphen polst er susp 10-8 mg/5ml
(Tussionex pennkineti)................................................. 56
hydrocortisone acetate w/ pramoxine rectal cream
1-1% (Analpram-hc).................................................... 149
hydrocortisone butyrate cream 0.1% (Locoid)...........152
hydrocortisone butyrate oint 0.1% (Locoid)............... 153
hydrocortisone butyrate soln 0.1% (Locoid).............. 153
hydrocortisone cream 2.5%..........................................153
hydrocortisone enema 100 mg/60ml
(Cortenema)................................................................. 149
hydrocortisone lotion 2.5%.......................................... 153
hydrocortisone oint 2.5%..............................................153
hydrocortisone rectal cream 2.5% (Anusol-hc)......... 149
hydrocortisone rectal cream 1% (Proctocort)............ 149
hydrocortisone tab 5 mg (Cortef).................................. 22
hydrocortisone tab 10 mg (Cortef)................................ 22
hydrocortisone tab 20 mg (Cortef)................................ 22
hydrocortisone valerate cream 0.2%...........................153
hydrocortisone valerate oint 0.2% (Westcort)............ 153
hydrocortisone w/ acetic acid otic soln 1-2% (Vosol
hc)................................................................................. 147
hydromorphone hcl liqd 1 mg/ml (Dilaudid).................87
hydromorphone hcl tab er 24hr deter 8 mg
(Exalgo).......................................................................... 87
hydromorphone hcl tab er 24hr deter 12 mg
(Exalgo).......................................................................... 87
hydromorphone hcl tab er 24hr deter 16 mg
(Exalgo).......................................................................... 88
hydromorphone hcl tab er 24hr deter 32 mg
(Exalgo).......................................................................... 88
hydromorphone hcl tab 2 mg (Dilaudid)....................... 88
hydromorphone hcl tab 4 mg (Dilaudid)....................... 88
hydromorphone hcl tab 8 mg (Dilaudid)....................... 88
hydroxychloroquine sulfate tab 200 mg
(Plaquenil)...................................................................... 11
hydroxyurea cap 500 mg (Hydrea)................................ 18
hydroxyzine hcl syrup 10 mg/5ml................................. 68
hydroxyzine hcl tab 10 mg............................................. 68
hydroxyzine hcl tab 25 mg............................................. 69
hydroxyzine hcl tab 50 mg............................................. 69
hydroxyzine pamoate cap 25 mg (Vistaril)................... 69
hydroxyzine pamoate cap 50 mg (Vistaril)................... 69
HYDROXYZINE PAMOATE -hydroxyzine pamoate cap
100 mg............................................................................ 69
HYQVIA -immun glob inj 2.5 gm/25ml-hyaluron inj 200
unt/1.25 ml kit................................................................. 16
HYQVIA -immun glob inj 5 gm/50ml-hyaluron inj 400
unt/2.5 ml kit................................................................... 16
HYQVIA -immun glob inj 10 gm/100ml-hyaluron inj 800
unt/5 ml kit...................................................................... 16
HYQVIA -immun glob inj 20 gm/200ml-hyaluron inj 1600
unt/10 ml kit.................................................................... 16
HYQVIA -immun glob inj 30 gm/300ml-hyaluron inj 2400
unt/15 ml kit.................................................................... 16
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
20 mg.............................................................................. 88
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
30 mg.............................................................................. 88
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
40 mg.............................................................................. 88
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
60 mg.............................................................................. 88
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
80 mg.............................................................................. 88
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
100 mg............................................................................ 88
HYSINGLA ER -hydrocodone bitartrate tab er 24hr deter
120 mg............................................................................ 88
I
ibandronate sodium tab 150 mg (base equivalent)
(Boniva).......................................................................... 38
IBRANCE -palbociclib cap 75 mg..................................... 18
IBRANCE -palbociclib cap 100 mg................................... 18
IBRANCE -palbociclib cap 125 mg................................... 18
ibuprofen tab 400 mg...................................................... 93
ibuprofen tab 600 mg...................................................... 93
ibuprofen tab 800 mg...................................................... 93
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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ICAR PEDIATRIC -carbonyl iron susp 15 mg/1.25ml
(elemental iron)............................................................. 134
ICLUSIG -ponatinib hcl tab 15 mg (base equiv)............... 18
ICLUSIG -ponatinib hcl tab 45 mg (base equiv)............... 18
IDELVION -coagulation factor ix (recomb) (rix-fp) for inj
250 unit......................................................................... 139
IDELVION -coagulation factor ix (recomb) (rix-fp) for inj
500 unit......................................................................... 139
IDELVION -coagulation factor ix (recomb) (rix-fp) for inj
1000 unit....................................................................... 140
IDELVION -coagulation factor ix (recomb) (rix-fp) for inj
2000 unit....................................................................... 140
ILEVRO -nepafenac ophth susp 0.3%............................ 145
imatinib mesylate tab 100 mg (base equivalent)
(Gleevec)........................................................................ 18
imatinib mesylate tab 400 mg (base equivalent)
(Gleevec)........................................................................ 18
IMBRUVICA -ibrutinib cap 140 mg................................... 18
imipramine hcl tab 10 mg (Tofranil).............................. 70
imipramine hcl tab 25 mg (Tofranil).............................. 71
imipramine hcl tab 50 mg (Tofranil).............................. 71
imipramine pamoate cap 75 mg (Tofranil-pm)............. 71
imipramine pamoate cap 100 mg (Tofranil-pm)........... 71
imipramine pamoate cap 125 mg (Tofranil-pm)........... 71
imipramine pamoate cap 150 mg (Tofranil-pm)........... 71
imiquimod cream 5% (Aldara)...................................... 153
IMMULIFE -nutritional supplement powder..................... 121
IMMUNOPRO RX -nutritional supplement powder......... 121
IMOVAX RABIES (H.D.C.V.) -rabies virus vaccine, hdc
inj..................................................................................... 15
IMPACT/FIBER -nutritional supplement liquid................ 121
IMPACT ADVANCED RECOVERY -nutritional
supplement liquid.......................................................... 121
IMPACT GLUTAMINE -nutritional supplement liquid...... 121
IMPACT -nutritional supplement liquid............................ 121
IMPACT 1.5 -nutritional supplement liquid...................... 121
IMPACT PEPTIDE 1.5 -nutritional supplement liquid..... 121
IMPAVIDO -miltefosine cap 50 mg.................................... 12
IMUPLUS -nutritional supplement pack.......................... 121
INATAL ADVANCE -prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg...................................................................107
INATAL GT -prenatal vit w/ dss-iron carbonyl-fa tab 90-1
mg.................................................................................. 107
INATAL ULTRA -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg......................................................................... 107
INCRELEX -mecasermin inj 40 mg/4ml (10 mg/ml)..........38
INCRUSE ELLIPTA -umeclidinium br aero powd breath
act 62.5 mcg/inh (base eq)............................................ 58
indapamide tab 1.25 mg..................................................50
indapamide tab 2.5 mg.................................................... 50
indomethacin cap cr 75 mg............................................ 93
indomethacin cap 25 mg................................................ 93
indomethacin cap 50 mg................................................ 93
INFANATE BALANCE -prenatal w/o a w/fe cbn-dss-fa-dha
cap 29-1-265 mg.......................................................... 107
INFANRIX -diph, acellular pert & tet tox inj 25 lf-58
mcg-10 lf/0.5ml............................................................... 16
INFASURF -calfactant in nacl 0.9% intratracheal susp 35
mg/ml............................................................................... 60
INLYTA -axitinib tab 1 mg.................................................. 18
INLYTA -axitinib tab 5 mg.................................................. 19
INNOVACIN -nutritional supplement liquid......................121
INSULIN PEN NEEDLES-VARIOUS............................... 156
INSULIN SYRINGES-VARIOUS...................................... 156
INTELENCE -etravirine tab 25 mg...................................... 7
INTELENCE -etravirine tab 100 mg.................................... 7
INTELENCE -etravirine tab 200 mg.................................... 7
INTERARTICULAR JOINT KIT -triamcinolone inj 40 mg/
ml & lidocaine 1% & ammonia inh kit............................ 22
INTROLITE -nutritional supplement liquid.......................121
INTRON A -interferon alfa-2b for inj 10000000 unit.......... 19
INTRON A -interferon alfa-2b for inj 18000000 unit.......... 19
INTRON A -interferon alfa-2b for inj 50000000 unit.......... 19
INTRON A -interferon alfa-2b inj 6000000 unit/ml............ 19
INTRON A -interferon alfa-2b inj 10000000 unit/ml.......... 19
INTRON A W/DILUENT -interferon alfa-2b for inj
10000000 unit................................................................. 19
INTRON A W/DILUENT -interferon alfa-2b for inj
18000000 unit................................................................. 19
INTRON A W/DILUENT -interferon alfa-2b for inj
50000000 unit................................................................. 19
INVIRASE -saquinavir mesylate cap 200 mg..................... 7
INVIRASE -saquinavir mesylate tab 500 mg...................... 7
INVOKAMET -canagliflozin-metformin hcl tab 50-500
mg.................................................................................... 30
INVOKAMET -canagliflozin-metformin hcl tab 150-500
mg.................................................................................... 31
INVOKAMET -canagliflozin-metformin hcl tab 50-1000
mg.................................................................................... 31
INVOKAMET -canagliflozin-metformin hcl tab 150-1000
mg.................................................................................... 31
INVOKAMET XR -canagliflozin-metformin hcl tab sr 24hr
50-500 mg....................................................................... 31
INVOKAMET XR -canagliflozin-metformin hcl tab sr 24hr
50-1000 mg..................................................................... 31
INVOKAMET XR -canagliflozin-metformin hcl tab sr 24hr
150-500 mg..................................................................... 31
INVOKAMET XR -canagliflozin-metformin hcl tab sr 24hr
150-1000 mg................................................................... 31
INVOKANA -canagliflozin tab 100 mg.............................. 31
INVOKANA -canagliflozin tab 300 mg.............................. 31
IONSYS -fentanyl hcl iontophoretic td system 40 mcg/act
(base equiv).................................................................... 88
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2017
IOPIDINE -apraclonidine hcl ophth soln 1% (base
equivalent)..................................................................... 145
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml..... 58
ipratropium bromide inhal soln 0.02%.......................... 58
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
(Atrovent)....................................................................... 55
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
(Atrovent)....................................................................... 55
irbesartan-hydrochlorothiazide tab 150-12.5 mg
(Avalide)..........................................................................47
irbesartan-hydrochlorothiazide tab 300-12.5 mg
(Avalide)..........................................................................47
irbesartan tab 75 mg (Avapro)....................................... 47
irbesartan tab 150 mg (Avapro)..................................... 47
irbesartan tab 300 mg (Avapro)..................................... 47
IRESSA -gefitinib tab 250 mg........................................... 19
IRON CHEWS PEDIATRIC -carbonyl iron chew tab 15 mg
(elemental iron)............................................................. 134
ISENTRESS -raltegravir potassium chew tab 25 mg (base
equiv)................................................................................. 7
ISENTRESS -raltegravir potassium chew tab 100 mg
(base equiv)...................................................................... 8
ISENTRESS -raltegravir potassium packet for susp 100
mg (base equiv)................................................................ 8
ISENTRESS -raltegravir potassium tab 400 mg (base
equiv)................................................................................. 8
ISOCAL HN -nutritional supplement liquid...................... 121
ISOCAL HN PLUS -nutritional supplement liquid........... 121
ISOCAL -nutritional supplement liquid............................ 121
ISONIAZID -isoniazid syrup 50 mg/5ml.............................. 5
isoniazid tab 100 mg......................................................... 5
isoniazid tab 300 mg......................................................... 5
ISORDIL TITRADOSE -isosorbide dinitrate tab 40
mg.................................................................................... 40
ISOSORBIDE DINITRATE ER -isosorbide dinitrate tab cr
40 mg.............................................................................. 40
isosorbide dinitrate tab 10 mg....................................... 40
isosorbide dinitrate tab 20 mg....................................... 40
isosorbide dinitrate tab 30 mg....................................... 40
isosorbide dinitrate tab 5 mg (Isordil titradose).......... 40
isosorbide mononitrate tab 10 mg................................ 40
isosorbide mononitrate tab 20 mg................................ 40
isosorbide mononitrate tab sr 24hr 30 mg (Imdur)...... 40
isosorbide mononitrate tab sr 24hr 60 mg (Imdur)...... 40
isosorbide mononitrate tab sr 24hr 120 mg
(Imdur)............................................................................ 40
ISOSOURCE 1.5 CAL -nutritional supplement liquid......121
ISOSOURCE CLOSED SYSTEM -nutritional supplement
liquid.............................................................................. 121
ISOSOURCE HN -nutritional supplement liquid............. 121
ISOSOURCE -nutritional supplement liquid.................... 121
ISOSOURCE VHN -nutritional supplement liquid........... 121
isotretinoin cap 10 mg.................................................. 153
isotretinoin cap 20 mg.................................................. 153
isotretinoin cap 30 mg.................................................. 153
isotretinoin cap 40 mg.................................................. 153
ISOVACTIN AA PLUS -nutritional supplement liquid...... 121
isradipine cap 2.5 mg...................................................... 43
isradipine cap 5 mg......................................................... 43
ISTALOL -timolol maleate ophth soln 0.5% (oncedaily).............................................................................. 145
itraconazole cap 100 mg (Sporanox).............................. 6
IVA ANAMIX EARLY YEARS -nutritional supplement
powder........................................................................... 122
IVA ANAMIX NEXT -nutritional supplement powder....... 122
I-VALEX-1 -nutritional supplement powder..................... 121
I-VALEX-2 -nutritional supplement powder..................... 121
ivermectin tab 3 mg (Stromectol).................................. 12
IXINITY -coagulation factor ix (recombinant) for inj 250
unit................................................................................. 140
IXINITY -coagulation factor ix (recombinant) for inj 500
unit................................................................................. 140
IXINITY -coagulation factor ix (recombinant) for inj 1000
unit................................................................................. 140
IXINITY -coagulation factor ix (recombinant) for inj 1500
unit................................................................................. 140
IXINITY -coagulation factor ix (recombinant) for inj 2000
unit................................................................................. 140
IXINITY -coagulation factor ix (recombinant) for inj 3000
unit................................................................................. 140
J
JADENU -deferasirox tab 90 mg..................................... 156
JADENU -deferasirox tab 180 mg................................... 156
JADENU -deferasirox tab 360 mg................................... 156
JAKAFI -ruxolitinib phosphate tab 5 mg (base
equivalent)....................................................................... 19
JAKAFI -ruxolitinib phosphate tab 10 mg (base
equivalent)....................................................................... 19
JAKAFI -ruxolitinib phosphate tab 15 mg (base
equivalent)....................................................................... 19
JAKAFI -ruxolitinib phosphate tab 20 mg (base
equivalent)....................................................................... 19
JAKAFI -ruxolitinib phosphate tab 25 mg (base
equivalent)....................................................................... 19
JANUMET -sitagliptin-metformin hcl tab 50-500 mg......... 31
JANUMET -sitagliptin-metformin hcl tab 50-1000 mg....... 31
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr
50-500 mg....................................................................... 31
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr
50-1000 mg..................................................................... 31
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr
100-1000 mg................................................................... 31
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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JANUVIA -sitagliptin phosphate tab 25 mg (base
equiv)............................................................................... 31
JANUVIA -sitagliptin phosphate tab 50 mg (base
equiv)............................................................................... 31
JANUVIA -sitagliptin phosphate tab 100 mg (base
equiv)............................................................................... 31
JARDIANCE -empagliflozin tab 10 mg............................. 31
JARDIANCE -empagliflozin tab 25 mg............................. 31
JENTADUETO -linagliptin-metformin hcl tab 2.5-1000
mg.................................................................................... 31
JENTADUETO -linagliptin-metformin hcl tab 2.5-500
mg.................................................................................... 31
JENTADUETO -linagliptin-metformin hcl tab 2.5-850
mg.................................................................................... 31
JENTADUETO XR -linagliptin-metformin hcl tab sr 24hr
2.5-1000 mg.................................................................... 31
JENTADUETO XR -linagliptin-metformin hcl tab sr 24hr
5-1000 mg....................................................................... 31
JEVITY 1 CAL/FIBER -nutritional supplement liquid...... 122
JEVITY 1.2 CAL/FIBER -nutritional supplement
liquid.............................................................................. 122
JEVITY 1.5 CAL/FIBER -nutritional supplement
liquid.............................................................................. 122
JEVITY 1 CAL -nutritional supplement liquid.................. 122
JEVITY 1.2 CAL -nutritional supplement liquid............... 122
JEVITY 1.5 CAL -nutritional supplement liquid............... 122
JTT PHYSICIANS KIT -triamcinolone inj 40 mg/ml &
lidocaine 1% & ammonia inh kit..................................... 22
JUBLIA -efinaconazole soln 10%.................................... 153
JUICE PLUS FIBRE -nutritional supplement liquid......... 122
JUVEN -nutritional supplement pack.............................. 122
JUVEN -nutritional supplement powder.......................... 122
JUVEN NUTRIVIGOR -nutritional supplement pack.......122
JUVEN REVIGOR -nutritional supplement pack.............122
JUXTAPID -lomitapide mesylate cap 5 mg (base
equiv)............................................................................... 52
JUXTAPID -lomitapide mesylate cap 10 mg (base
equiv)............................................................................... 52
JUXTAPID -lomitapide mesylate cap 20 mg (base
equiv)............................................................................... 52
JUXTAPID -lomitapide mesylate cap 30 mg (base
equiv)............................................................................... 52
JUXTAPID -lomitapide mesylate cap 40 mg (base
equiv)............................................................................... 52
JUXTAPID -lomitapide mesylate cap 60 mg (base
equiv)............................................................................... 52
K
KALETRA -lopinavir-ritonavir soln 400-100 mg/5ml (80-20
mg/ml)................................................................................ 8
KALETRA -lopinavir-ritonavir tab 100-25 mg...................... 8
KALETRA -lopinavir-ritonavir tab 200-50 mg...................... 8
KALYDECO -ivacaftor packet 50 mg................................ 60
KALYDECO -ivacaftor packet 75 mg................................ 60
KALYDECO -ivacaftor tab 150 mg.................................... 60
KARBINAL ER -carbinoxamine maleate extended release
susp 4 mg/5ml................................................................ 55
KAZANO -alogliptin-metformin hcl tab 12.5-1000 mg....... 31
KAZANO -alogliptin-metformin hcl tab 12.5-500 mg......... 31
KCENTRA -prothrombin complex conc human for inj kit
500 unit......................................................................... 140
KCENTRA -prothrombin complex conc human for inj kit
1000 unit....................................................................... 140
KERYDIN -tavaborole soln 5%........................................153
KETOCAL 4:1 LQ MULTI FIBE -nutritional supplement
liquid.............................................................................. 122
KETOCAL 4:1 -nutritional supplement liquid.................. 122
KETOCAL 3:1 -nutritional supplement powder............... 122
KETOCAL 4:1 -nutritional supplement powder............... 122
ketoconazole cream 2%................................................ 153
ketoconazole shampoo 2% (Nizoral)........................... 153
KETOGEN -nutritional supplement powder.................... 122
KETONEX-1 -nutritional supplement powder..................122
KETONEX-2 -nutritional supplement powder..................122
ketoprofen cap 50 mg..................................................... 93
ketoprofen cap 75 mg..................................................... 93
ketorolac tromethamine ophth soln 0.5%
(Acular)......................................................................... 145
ketorolac tromethamine ophth soln 0.4% (Acular
ls)................................................................................... 145
ketorolac tromethamine tab 10 mg............................... 93
KETOVIE -nutritional supplement liquid.......................... 122
KETOVIE PEPTIDE -nutritional supplement liquid......... 122
KETOVOLVE 4:1 -nutritional supplement powder.......... 122
KINERET -anakinra subcutaneous soln prefilled syringe
100 mg/0.67ml................................................................ 93
KINRAY PREFERRED PLUS -nutritional supplement
liquid.............................................................................. 122
KINRIX -diph-tetanus tox ad-acell pert & polio virus, ipv
vac inj.............................................................................. 16
KITABIS PAK -tobramycin nebu soln 300 mg/5ml.............. 5
KLOR-CON M15 -potassium chloride microencapsulated
crys cr tab 15 meq....................................................... 113
KOATE -antihemophilic factor (human) for inj 250
unit................................................................................. 140
KOATE -antihemophilic factor (human) for inj 500
unit................................................................................. 140
KOATE -antihemophilic factor (human) for inj 1000
unit................................................................................. 140
KOATE-DVI -antihemophilic factor (human) for inj 250
unit................................................................................. 140
KOATE-DVI -antihemophilic factor (human) for inj 500
unit................................................................................. 140
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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KOATE-DVI -antihemophilic factor (human) for inj 1000
unit................................................................................. 140
KOGENATE FS -antihemophilic factor (recombinant) for
inj kit 250 unit............................................................... 140
KOGENATE FS -antihemophilic factor (recombinant) for
inj kit 500 unit............................................................... 140
KOGENATE FS -antihemophilic factor (recombinant) for
inj kit 1000 unit............................................................. 140
KOGENATE FS -antihemophilic factor (recombinant) for
inj kit 2000 unit............................................................. 140
KOGENATE FS -antihemophilic factor (recombinant) for
inj kit 3000 unit............................................................. 140
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 250 unit.................................. 140
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 500 unit.................................. 140
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 1000 unit................................ 140
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 2000 unit................................ 141
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 3000 unit................................ 141
KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr
2.5-1000 mg.................................................................... 31
KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr
5-500 mg......................................................................... 31
KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr
5-1000 mg....................................................................... 32
KORLYM -mifepristone tab 300 mg.................................. 32
KOVALTRY -antihemophilic factor (recombinant) for inj
250 unit......................................................................... 141
KOVALTRY -antihemophilic factor (recombinant) for inj
500 unit......................................................................... 141
KOVALTRY -antihemophilic factor (recombinant) for inj
1000 unit....................................................................... 141
KOVALTRY -antihemophilic factor (recombinant) for inj
2000 unit....................................................................... 141
KOVALTRY -antihemophilic factor (recombinant) for inj
3000 unit....................................................................... 141
K-PAX IMMUNE BOOSTER PROT -nutritional
supplement powder...................................................... 122
KRISTALOSE -lactulose oral crystal packet 10 gm.......... 60
KRISTALOSE -lactulose oral crystal packet 20 gm.......... 60
K-TAB -potassium chloride tab cr 8 meq (600 mg)......... 113
K-TAB -potassium chloride tab cr 20 meq (1500 mg)..... 113
KUVAN -sapropterin dihydrochloride powder packet 100
mg.................................................................................... 38
KUVAN -sapropterin dihydrochloride powder packet 500
mg.................................................................................... 38
KUVAN -sapropterin dihydrochloride soluble tab 100
mg.................................................................................... 38
KYNAMRO -mipomersen sodium soln prefilled syringe
200 mg/ml....................................................................... 52
L
labetalol hcl tab 100 mg (Trandate)............................... 41
labetalol hcl tab 200 mg (Trandate)............................... 41
labetalol hcl tab 300 mg (Trandate)............................... 41
LACRISERT -artificial tear ophth insert...........................145
lactic acid (ammonium lactate) lotion 12% (Lachydrin).......................................................................... 153
lactulose (encephalopathy) solution 10 gm/15ml........ 65
lactulose solution 10 gm/15ml....................................... 61
LAMICTAL STARTER/NOT TAKI -lamotrigine tab 25 mg
(42) & 100 mg (7) starter kit...........................................98
LAMICTAL STARTER/TAKING C -lamotrigine tab 25 mg
(84) & 100 mg (14) starter kit.........................................98
LAMICTAL STARTER/TAKING V -lamotrigine tab 25 mg
(35) starter kit..................................................................98
LAMICTAL XR -lamotrigine tab sr 24hr 25 (14) & 50 mg
(14) & 100 mg(7) kit....................................................... 98
LAMICTAL XR -lamotrigine tab sr 24hr 50 (14) & 100
mg(14) & 200 mg(7) kit.................................................. 98
LAMICTAL XR -lamotrigine tab sr 24hr 25 mg (21) & 50
mg (7) titration kit............................................................98
lamivudine oral soln 10 mg/ml (Epivir)........................... 8
lamivudine tab 150 mg (Epivir)........................................ 8
lamivudine tab 300 mg (Epivir)........................................ 8
lamivudine tab 100 mg (hbv) (Epivir hbv)....................... 8
lamivudine-zidovudine tab 150-300 mg (Combivir)....... 8
lamotrigine orally disintegrating tab 25 mg (Lamictal
odt).................................................................................. 99
lamotrigine orally disintegrating tab 50 mg (Lamictal
odt).................................................................................. 99
lamotrigine orally disintegrating tab 100 mg (Lamictal
odt).................................................................................. 99
lamotrigine orally disintegrating tab 200 mg (Lamictal
odt).................................................................................. 99
lamotrigine tab chewable dispersible 5 mg (Lamictal
chewable di).................................................................. 99
lamotrigine tab chewable dispersible 25 mg (Lamictal
chewable di).................................................................. 99
lamotrigine tab disp 25 (14) & 50 mg (14) & 100 mg (7)
kit (LAMICTAL ODT)..................................................... 99
lamotrigine tab disp 25 mg (21) & 50 mg (7) titration
kit (LAMICTAL ODT)..................................................... 99
lamotrigine tab disp 50 mg (42) & 100 mg (14) titration
kit (LAMICTAL ODT)..................................................... 99
lamotrigine tab 25 mg (Lamictal)................................... 99
lamotrigine tab 100 mg (Lamictal)................................. 99
lamotrigine tab 150 mg (Lamictal)................................. 99
lamotrigine tab 200 mg (Lamictal)................................. 99
lamotrigine tab sr 24hr 25 mg (Lamictal xr)................. 99
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2017
lamotrigine tab sr 24hr 50 mg (Lamictal xr)................. 99
lamotrigine tab sr 24hr 100 mg (Lamictal xr)............... 99
lamotrigine tab sr 24hr 200 mg (Lamictal xr)............... 99
lamotrigine tab sr 24hr 250 mg (Lamictal xr)............... 99
lamotrigine tab sr 24hr 300 mg (Lamictal xr)............... 99
LANAFLEX -nutritional supplement pack........................ 122
LANCETS-VARIOUS........................................................156
LANCING DEVICE-VARIOUS......................................... 156
LANOXIN -digoxin tab 62.5 mcg (0.0625 mg).................. 40
LANOXIN -digoxin tab 125 mcg (0.125 mg)..................... 40
LANOXIN -digoxin tab 187.5 mcg (0.1875 mg)................ 40
LANOXIN -digoxin tab 250 mcg (0.25 mg)....................... 40
lansoprazole cap delayed release 15 mg
(Prevacid)....................................................................... 62
lansoprazole cap delayed release 30 mg
(Prevacid)....................................................................... 62
LANTUS -insulin glargine inj 100 unit/ml.......................... 35
LANTUS SOLOSTAR -insulin glargine soln pen-injector
100 unit/ml.......................................................................35
LASTACAFT -alcaftadine ophth soln 0.25%................... 145
latanoprost ophth soln 0.005% (Xalatan).................... 145
LATUDA -lurasidone hcl tab 20 mg...................................74
LATUDA -lurasidone hcl tab 40 mg...................................74
LATUDA -lurasidone hcl tab 60 mg...................................74
LATUDA -lurasidone hcl tab 80 mg...................................74
LATUDA -lurasidone hcl tab 120 mg.................................74
LAZANDA -fentanyl citrate nasal spray 100 mcg/act (base
equiv)............................................................................... 88
LAZANDA -fentanyl citrate nasal spray 300 mcg/act (base
equiv)............................................................................... 88
LAZANDA -fentanyl citrate nasal spray 400 mcg/act (base
equiv)............................................................................... 88
L-CARNITINE -amino acids oral liquid............................ 115
leflunomide tab 10 mg (Arava)....................................... 93
leflunomide tab 20 mg (Arava)....................................... 93
LENVIMA 14 MG DAILY DOSE -lenvatinib cap therapy
pack 10 & 4 mg (14 mg daily dose)............................... 19
LENVIMA 18 MG DAILY DOSE -lenvatinib cap therapy
pack 10 & 4 (2) mg (18 mg daily dose)......................... 19
LENVIMA 24 MG DAILY DOSE -lenvatinib cap therapy
pack 10 (2) & 4 mg (24 mg daily dose)......................... 19
LENVIMA 10 MG DAILY DOSE -lenvatinib cap therapy
pack 10 mg (10 mg daily dose)..................................... 19
LENVIMA 20 MG DAILY DOSE -lenvatinib cap therapy
pack 10 (2) mg (20 mg daily dose)................................ 19
LENVIMA 8 MG DAILY DOSE -lenvatinib cap therapy
pack 4 (2) mg (8 mg daily dose).................................... 19
LETAIRIS -ambrisentan tab 5 mg..................................... 54
LETAIRIS -ambrisentan tab 10 mg................................... 54
letrozole tab 2.5 mg (Femara)........................................ 19
LEUCOVORIN CALCIUM -leucovorin calcium tab 10
mg.................................................................................... 19
LEUCOVORIN CALCIUM -leucovorin calcium tab 15
mg.................................................................................... 19
leucovorin calcium tab 5 mg.......................................... 19
leucovorin calcium tab 25 mg........................................ 19
LEU-FREE COOLER -nutritional supplement liquid....... 122
LEUKERAN -chlorambucil tab 2 mg................................. 19
LEUKINE -sargramostim lyophilized for inj 250 mcg...... 134
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base
equiv).............................................................................. 58
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
(Xopenex)....................................................................... 58
levalbuterol hcl soln nebu 0.63 mg/3ml (base equiv)
(Xopenex)....................................................................... 59
levalbuterol hcl soln nebu 1.25 mg/3ml (base equiv)
(Xopenex)....................................................................... 59
LEVEMIR FLEXTOUCH -insulin detemir soln pen-injector
100 unit/ml.......................................................................35
LEVEMIR -insulin detemir inj 100 unit/ml..........................35
levetiracetam oral soln 100 mg/ml (Keppra).................99
levetiracetam tab 250 mg (Keppra)............................... 99
levetiracetam tab 500 mg (Keppra)............................... 99
levetiracetam tab 750 mg (Keppra)............................... 99
levetiracetam tab 1000 mg (Keppra)............................. 99
levetiracetam tab sr 24hr 500 mg (Keppra xr).............. 99
levetiracetam tab sr 24hr 750 mg (Keppra xr).............. 99
levobunolol hcl ophth soln 0.5% (Betagan)............... 145
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)..... 38
levocarnitine tab 330 mg (Carnitor)............................... 38
levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5
mg/ml) (Xyzal)................................................................ 55
levocetirizine dihydrochloride tab 5 mg (Xyzal)...........55
LEVOFLOXACIN -levofloxacin oral soln 25 mg/ml............. 5
levofloxacin ophth soln 0.5%....................................... 145
levofloxacin tab 250 mg (Levaquin)................................ 5
levofloxacin tab 500 mg (Levaquin)................................ 5
levofloxacin tab 750 mg (Levaquin)................................ 5
levonor-eth est tab 0.15-0.02/0.025/0.03 mg &eth est
0.01 mg (Quartette)....................................................... 27
levonorgestrel & ethinyl estradiol (91-day) tab
0.15-0.03 mg.................................................................. 27
levonorgestrel & ethinyl estradiol tab 0.1 mg-20
mcg................................................................................. 27
levonorgestrel & ethinyl estradiol tab 0.15 mg-30
mcg................................................................................. 27
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg............................... 27
levonorgestrel-ethinyl estradiol (continuous) tab
90-20 mcg.......................................................................27
levonorgestrel tab 1.5 mg (Plan b one-step)................ 27
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab
0.01mg(7) (Loseasonique)........................................... 27
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levonorg-eth est tab 0.15-0.03mg(84) & eth est tab
0.01mg(7) (Seasonique)............................................... 27
LEVORPHANOL TARTRATE -levorphanol tartrate tab 2
mg.................................................................................... 88
levothyroxine sodium tab 25 mcg (Synthroid)............. 35
levothyroxine sodium tab 50 mcg (Synthroid)............. 35
levothyroxine sodium tab 75 mcg (Synthroid)............. 35
levothyroxine sodium tab 88 mcg (Synthroid)............. 35
levothyroxine sodium tab 100 mcg (Synthroid)........... 35
levothyroxine sodium tab 112 mcg (Synthroid)........... 35
levothyroxine sodium tab 125 mcg (Synthroid)........... 35
levothyroxine sodium tab 137 mcg (Synthroid)........... 35
levothyroxine sodium tab 150 mcg (Synthroid)........... 35
levothyroxine sodium tab 175 mcg (Synthroid)........... 35
levothyroxine sodium tab 200 mcg (Synthroid)........... 35
levothyroxine sodium tab 300 mcg (Synthroid)........... 35
LEVULAN KERASTICK -aminolevulinic acid hcl for soln
20% (stick applicator)................................................... 153
LEXIVA -fosamprenavir calcium susp 50 mg/ml (base
equiv)................................................................................. 8
LEXIVA -fosamprenavir calcium tab 700 mg (base
equiv)................................................................................. 8
LIALDA -mesalamine tab delayed release 1.2 gm........... 65
lidocaine hcl gel 2%...................................................... 153
LIDOCAINE HCL -lidocaine hcl laryngotracheal soln
4%.................................................................................. 148
lidocaine hcl soln 4% (Xylocaine)............................... 153
lidocaine hcl viscous soln 2%..................................... 148
lidocaine patch 5% (Lidoderm).................................... 153
lidocaine-prilocaine cream 2.5-2.5% (Emla)............... 153
lidocaine-prilocaine cream kit 2.5-2.5%...................... 153
LINDANE -lindane shampoo 1%..................................... 153
linezolid for susp 100 mg/5ml (Zyvox).......................... 12
linezolid tab 600 mg (Zyvox).......................................... 12
LINZESS -linaclotide cap 72 mcg..................................... 65
LINZESS -linaclotide cap 145 mcg................................... 65
LINZESS -linaclotide cap 290 mcg................................... 65
liothyronine sodium tab 5 mcg (Cytomel).................... 35
liothyronine sodium tab 25 mcg (Cytomel).................. 35
liothyronine sodium tab 50 mcg (Cytomel).................. 35
LIPISTART -nutritional supplement powder.................... 122
LIQUACEL -amino acids oral liquid................................ 115
LIQUACEL PUMP + GO -amino acids oral liquid........... 115
LIQUID HOPE -nutritional supplement liquid.................. 122
lisinopril & hydrochlorothiazide tab 10-12.5 mg
(Zestoretic)..................................................................... 47
lisinopril & hydrochlorothiazide tab 20-12.5 mg
(Zestoretic)..................................................................... 47
lisinopril & hydrochlorothiazide tab 20-25 mg
(Zestoretic)..................................................................... 47
lisinopril tab 5 mg (Prinivil)............................................ 47
lisinopril tab 10 mg (Prinivil).......................................... 47
lisinopril tab 20 mg (Prinivil).......................................... 47
lisinopril tab 2.5 mg (Zestril).......................................... 47
lisinopril tab 30 mg (Zestril)........................................... 47
lisinopril tab 40 mg (Zestril)........................................... 47
LISTERINE ESSENTIAL CARE -sod monofluorophospheucal-men-methyl sal-thymol gel 0.76%...................... 148
LISTERINE NATURALS WITH F -sodium fluoride rinse
0.02%.............................................................................148
LISTERINE RESTORING -sodium fluoride rinse 0.0221%
(0.01% f)........................................................................148
LISTERINE SMART RINSE -sodium fluoride rinse
0.0221% (0.01% f)........................................................ 148
LISTERINE TOTAL CARE PLUS -sodium fluoride rinse
0.0221% (0.01% f)........................................................ 148
LISTERINE TOTAL CARE -sodium fluoride rinse 0.0221%
(0.01% f)........................................................................148
LISTERINE TOTAL CARE ZERO -sodium fluoride rinse
0.02%.............................................................................148
LISTERINE WHITENING/RESTO -sodium fluoride rinse
0.0221% (0.01% f)........................................................ 148
lithium carbonate cap 300 mg....................................... 74
lithium carbonate cap 150 mg (Lithium carbonate)..... 74
lithium carbonate cap 600 mg (Lithium carbonate)..... 74
LITHIUM CARBONATE -lithium carbonate cap 150
mg.................................................................................... 74
LITHIUM CARBONATE -lithium carbonate cap 600
mg.................................................................................... 74
lithium carbonate tab cr 450 mg.................................... 74
lithium carbonate tab cr 300 mg (Lithobid).................. 74
lithium carbonate tab 300 mg........................................ 74
LITHIUM -lithium oral solution 8 meq/5ml......................... 74
LITHOBID -lithium carbonate tab cr 300 mg..................... 74
LITHOSTAT -acetohydroxamic acid tab 250 mg............... 68
LIVALO -pitavastatin calcium tab 1 mg (base equiv)........ 52
LIVALO -pitavastatin calcium tab 2 mg (base equiv)........ 52
LIVALO -pitavastatin calcium tab 4 mg (base equiv)........ 52
LMD -nutritional supplement powder.............................. 122
LO LOESTRIN FE -norethin-eth estradiol-fe tab 1 mg-10
mcg (24)/10 mcg (2)....................................................... 27
LONSURF -trifluridine-tipiracil tab 15-6.14 mg................. 19
LONSURF -trifluridine-tipiracil tab 20-8.19 mg................. 19
LOPHLEX LQ 20 -nutritional supplement liquid.............. 122
LOPHLEX -nutritional supplement pack..........................122
lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)
(Kaletra)............................................................................ 8
lorazepam conc 2 mg/ml (Lorazepam intensol)........... 69
lorazepam tab 0.5 mg (Ativan)....................................... 69
lorazepam tab 1 mg (Ativan).......................................... 69
lorazepam tab 2 mg (Ativan).......................................... 69
losartan potassium & hydrochlorothiazide tab 50-12.5
mg (Hyzaar)....................................................................47
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losartan potassium & hydrochlorothiazide tab
100-12.5 mg (Hyzaar).................................................... 47
losartan potassium & hydrochlorothiazide tab 100-25
mg (Hyzaar)....................................................................48
losartan potassium tab 25 mg (Cozaar)........................ 48
losartan potassium tab 50 mg (Cozaar)........................ 48
losartan potassium tab 100 mg (Cozaar)...................... 48
LOTEMAX -loteprednol etabonate ophth gel 0.5%......... 145
LOTEMAX -loteprednol etabonate ophth oint 0.5%........ 145
LOTEMAX -loteprednol etabonate ophth susp 0.5%...... 145
lovastatin tab 10 mg........................................................ 52
lovastatin tab 20 mg (Mevacor)..................................... 53
lovastatin tab 40 mg (Mevacor)..................................... 53
loxapine succinate cap 5 mg......................................... 74
loxapine succinate cap 10 mg....................................... 74
loxapine succinate cap 25 mg....................................... 74
loxapine succinate cap 50 mg....................................... 74
LOZI-FLUR -sodium fluoride lozenge 1 mg f (from 2.2 mg
naf)................................................................................. 113
LPS CRITICAL CARE SUGAR F -nutritional supplement
liquid.............................................................................. 122
LPS SUGAR FREE -nutritional supplement liquid.......... 122
LUMIGAN -bimatoprost ophth soln 0.01%...................... 145
LURIDE -sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml
naf)................................................................................. 114
LUZU -luliconazole cream 1%......................................... 153
LYNPARZA -olaparib cap 50 mg....................................... 19
LYRICA -pregabalin cap 25 mg.........................................99
LYRICA -pregabalin cap 50 mg.........................................99
LYRICA -pregabalin cap 75 mg.........................................99
LYRICA -pregabalin cap 100 mg.......................................99
LYRICA -pregabalin cap 150 mg.......................................99
LYRICA -pregabalin cap 200 mg.......................................99
LYRICA -pregabalin cap 225 mg.......................................99
LYRICA -pregabalin cap 300 mg.......................................99
LYRICA -pregabalin soln 20 mg/ml................................. 100
LYSODREN -mitotane tab 500 mg....................................19
M
MACNATAL CN DHA -prenatal w/o a w/fe cbn-dss-fa-dha
cap 28-1-250 mg.......................................................... 107
malathion lotion 0.5% (Ovide)...................................... 153
MAPROTILINE HCL -maprotiline hcl tab 25 mg............... 71
MAPROTILINE HCL -maprotiline hcl tab 50 mg............... 71
MAPROTILINE HCL -maprotiline hcl tab 75 mg............... 71
MAR-COF BP -pseudoephedrine-bromphen-codeine liqd
30-2-7.5 mg/5ml.............................................................. 56
MARNATAL-F -prenatal w/o vit a w/ fe polysac cmplx-fa
cap 60-1 mg.................................................................. 107
MARPLAN -isocarboxazid tab 10 mg............................... 71
MATULANE -procarbazine hcl cap 50 mg........................ 20
MAXIDEX -dexamethasone ophth susp 0.1%................ 145
MCT PRO-CAL -nutritional supplement pack................. 122
MCT PROCAL -nutritional supplement powder.............. 123
MECLOFENAMATE SODIUM -meclofenamate sodium
cap 50 mg....................................................................... 93
MECLOFENAMATE SODIUM -meclofenamate sodium
cap 100 mg..................................................................... 93
MEDICAL PROVIDER EZ FLU S -influenza virus vac
types a & b pf pref syringe kit 0.5 ml............................. 15
MEDICAL PROVIDER SINGLE U -influenza virus vaccine
split pf susp pref syr kit 0.5 ml....................................... 15
MEDICAL PROVIDER SINGLE U -influenza virus vac
split quad inj prefilled syr kit 0.25 ml.............................. 15
MEDICAL PROVIDER SINGLE U -influenza virus vac
types a & b pf pref syringe kit 0.5 ml............................. 15
MEDROL -methylprednisolone tab 2 mg.......................... 22
medroxyprogesterone acetate im susp 150 mg/ml
(Depo-provera contrac)................................................ 27
medroxyprogesterone acetate im susp prefilled syr
150 mg/ml (Depo-provera contrac)............................. 27
medroxyprogesterone acetate tab 2.5 mg
(Provera)......................................................................... 28
medroxyprogesterone acetate tab 5 mg (Provera)...... 29
medroxyprogesterone acetate tab 10 mg
(Provera)......................................................................... 29
mefenamic acid cap 250 mg (Ponstel).......................... 93
mefloquine hcl tab 250 mg............................................. 11
MEGA MULTIVITAMIN -multiple vitamins w/ minerals
powder........................................................................... 107
megestrol acetate susp 625 mg/5ml (Megace es)........ 29
megestrol acetate susp 40 mg/ml (Megace oral)......... 20
megestrol acetate tab 20 mg.......................................... 20
megestrol acetate tab 40 mg.......................................... 20
MEKINIST -trametinib dimethyl sulfoxide tab 0.5 mg
(base equivalent)............................................................ 20
MEKINIST -trametinib dimethyl sulfoxide tab 2 mg (base
equivalent)....................................................................... 20
meloxicam tab 7.5 mg (Mobic)....................................... 93
meloxicam tab 15 mg (Mobic)........................................ 93
memantine hcl oral solution 2 mg/ml (Namenda)........ 82
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
(Namenda titration pa)................................................. 82
memantine hcl tab 5 mg (Namenda)............................. 82
memantine hcl tab 10 mg (Namenda)........................... 82
M-END MAX D -pseudoephedrine-dexbromphen-codeine
liqd 20-0.667-6 mg/5ml................................................... 56
M-END PE -phenylephrine-bromphen w/ codeine liqd
3.33-1.33-6.33 mg/5ml....................................................56
MENEST -esterified estrogens tab 0.3 mg....................... 25
MENEST -esterified estrogens tab 0.625 mg................... 25
MENEST -esterified estrogens tab 1.25 mg..................... 25
MENOSTAR -estradiol td patch weekly 14 mcg/24hr....... 25
MENTAX -butenafine hcl cream 1%................................153
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2017
MEPERIDINE HCL -meperidine hcl oral soln 50
mg/5ml............................................................................. 88
MEPHYTON -phytonadione tab 5 mg............................. 105
meprobamate tab 200 mg............................................... 69
meprobamate tab 400 mg............................................... 69
mercaptopurine tab 50 mg (Purinethol)........................ 20
MERITENE -nutritional supplement powder................... 123
MESALAMINE DR -mesalamine tab delayed release 800
mg.................................................................................... 65
mesalamine enema 4 gm................................................ 65
MESNEX -mesna tab 400 mg........................................... 20
MESTINON -pyridostigmine bromide syrup 60
mg/5ml........................................................................... 105
METAFORM -nutritional supplement pack...................... 123
METAPROTERENOL SULFATE -metaproterenol sulfate
syrup 10 mg/5ml............................................................. 59
METAPROTERENOL SULFATE -metaproterenol sulfate
tab 20 mg........................................................................ 59
METAXALONE -metaxalone tab 400 mg........................ 104
metaxalone tab 800 mg (Skelaxin).............................. 104
metformin hcl tab 500 mg (Glucophage)...................... 32
metformin hcl tab 850 mg (Glucophage)...................... 32
metformin hcl tab 1000 mg (Glucophage).................... 32
metformin hcl tab sr 24hr 500 mg (Glucophage xr)..... 32
metformin hcl tab sr 24hr 750 mg (Glucophage xr)..... 32
metformin hcl tab sr 24hr modified release 500 mg
(Glumetza)...................................................................... 32
metformin hcl tab sr 24hr modified release 1000 mg
(Glumetza)...................................................................... 32
metformin hcl tab sr 24hr osmotic 500 mg
(Fortamet)....................................................................... 32
metformin hcl tab sr 24hr osmotic 1000 mg
(Fortamet)....................................................................... 32
methadone hcl conc 10 mg/ml (Methadose)................ 88
methadone hcl soln 5 mg/5ml (Methadone hcl)........... 88
methadone hcl soln 10 mg/5ml (Methadone hcl)......... 88
methadone hcl tab for oral susp 40 mg........................ 88
methadone hcl tab 10 mg (Dolophine).......................... 88
methadone hcl tab 5 mg (Dolophine hcl)..................... 88
methamphetamine hcl tab 5 mg (Desoxyn).................. 79
methazolamide tab 25 mg (Neptazane)......................... 50
methazolamide tab 50 mg (Neptazane)......................... 50
methenamine hippurate tab 1 gm (Hiprex)................... 66
METHERGINE -methylergonovine maleate tab 0.2
mg.................................................................................... 37
methimazole tab 5 mg (Tapazole).................................. 35
methimazole tab 10 mg (Tapazole)................................ 35
METHIONAID -nutritional supplement powder............... 123
METHITEST -methyltestosterone oral tab 10 mg............. 24
methocarbamol tab 750 mg (Robaxin-750).................104
methocarbamol tab 500 mg (Robaxin)........................ 104
methotrexate sodium for inj 1 gm................................. 20
methotrexate sodium inj 50 mg/2ml (25 mg/ml)........... 20
methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)...... 20
methotrexate sodium inj pf 100 mg/4ml (25 mg/
ml)................................................................................... 20
methotrexate sodium inj pf 200 mg/8ml (25 mg/
ml)................................................................................... 20
methotrexate sodium inj pf 250 mg/10ml (25 mg/
ml)................................................................................... 20
methotrexate sodium inj pf 1000 mg/40ml (25 mg/
ml)................................................................................... 20
METHOTREXATE SODIUM -methotrexate sodium inj 250
mg/10ml (25 mg/ml)........................................................20
methotrexate sodium tab 2.5 mg (base equiv)............. 20
methoxsalen rapid cap 10 mg (Oxsoralen ultra)........ 153
methscopolamine bromide tab 2.5 mg (Pamine)......... 62
methscopolamine bromide tab 5 mg (Pamine
forte)................................................................................62
METHYCLOTHIAZIDE -methyclothiazide tab 5 mg..........50
methyldopa tab 250 mg.................................................. 48
methyldopa tab 500 mg.................................................. 48
methylphenidate hcl cap cr 10 mg (cd) (Metadate
cd)................................................................................... 79
methylphenidate hcl cap cr 20 mg (cd) (Metadate
cd)................................................................................... 79
methylphenidate hcl cap cr 30 mg (cd) (Metadate
cd)................................................................................... 79
methylphenidate hcl cap cr 40 mg (cd) (Metadate
cd)................................................................................... 79
methylphenidate hcl cap cr 50 mg (cd) (Metadate
cd)................................................................................... 79
methylphenidate hcl cap cr 60 mg (cd) (Metadate
cd)................................................................................... 79
methylphenidate hcl cap sr 24hr 20 mg (la) (Ritalin
la)..................................................................................... 79
methylphenidate hcl cap sr 24hr 30 mg (la) (Ritalin
la)..................................................................................... 79
methylphenidate hcl cap sr 24hr 40 mg (la) (Ritalin
la)..................................................................................... 79
methylphenidate hcl chew tab 2.5 mg (Methylin)........ 79
methylphenidate hcl chew tab 5 mg (Methylin)........... 79
methylphenidate hcl chew tab 10 mg (Methylin)......... 79
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sr 24hr 18 mg................................................................. 79
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sr 24hr 27 mg................................................................. 79
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sr 24hr 36 mg................................................................. 80
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sr 24hr 54 mg................................................................. 80
methylphenidate hcl soln 5 mg/5ml (Methylin)............ 80
methylphenidate hcl soln 10 mg/5ml (Methylin).......... 80
methylphenidate hcl tab cr 10 mg................................. 80
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2017
methylphenidate hcl tab cr 20 mg (Ritalin sr).............. 80
methylphenidate hcl tab 5 mg (Ritalin)......................... 80
methylphenidate hcl tab 10 mg (Ritalin)....................... 80
methylphenidate hcl tab 20 mg (Ritalin)....................... 80
methylphenidate hcl tab sa osm 18 mg (Concerta)..... 80
methylphenidate hcl tab sa osm 27 mg (Concerta)..... 80
methylphenidate hcl tab sa osm 36 mg (Concerta)..... 80
methylphenidate hcl tab sa osm 54 mg (Concerta)..... 80
methylprednisolone tab 4 mg (Medrol)......................... 22
methylprednisolone tab 8 mg (Medrol)......................... 22
methylprednisolone tab 16 mg (Medrol)....................... 23
methylprednisolone tab 32 mg (Medrol)....................... 23
methylprednisolone tab therapy pack 4 mg (21)
(Medrol dosepak).......................................................... 22
methyltestosterone cap 10 mg (Testred)...................... 24
METIPRANOLOL -metipranolol ophth soln 0.3%........... 145
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)........ 65
metoclopramide hcl tab 5 mg (Reglan)......................... 65
metoclopramide hcl tab 10 mg (Reglan)....................... 65
METOCLOPRAMIDE ODT -metoclopramide hcl orally
disintegrating tab 5 mg................................................... 65
METOCLOPRAMIDE ODT -metoclopramide hcl orally
disintegrating tab 10 mg................................................. 65
metolazone tab 10 mg..................................................... 50
metolazone tab 2.5 mg (Zaroxolyn)............................... 50
metolazone tab 5 mg (Zaroxolyn).................................. 50
metoprolol & hydrochlorothiazide tab 100-50 mg....... 48
metoprolol & hydrochlorothiazide tab 50-25 mg
(Lopressor hct)..............................................................48
metoprolol & hydrochlorothiazide tab 100-25 mg
(Lopressor hct)..............................................................48
metoprolol succinate tab sr 24hr 25 mg (tartrate
equiv) (Toprol xl)........................................................... 41
metoprolol succinate tab sr 24hr 50 mg (tartrate
equiv) (Toprol xl)........................................................... 41
metoprolol succinate tab sr 24hr 100 mg (tartrate
equiv) (Toprol xl)........................................................... 41
metoprolol succinate tab sr 24hr 200 mg (tartrate
equiv) (Toprol xl)........................................................... 41
metoprolol tartrate tab 25 mg........................................ 41
metoprolol tartrate tab 50 mg (Lopressor)................... 41
metoprolol tartrate tab 100 mg (Lopressor)................. 42
metronidazole cap 375 mg (Flagyl)............................... 12
metronidazole cream 0.75% (Metrocream)................. 153
metronidazole gel 0.75%............................................... 153
metronidazole gel 1% (Metrogel)................................. 153
metronidazole lotion 0.75% (Metrolotion)................... 153
metronidazole tab 250 mg (Flagyl)................................ 12
metronidazole tab 500 mg (Flagyl)................................ 12
metronidazole vaginal gel 0.75% (Metrogelvaginal)........................................................................... 67
mexiletine hcl cap 150 mg.............................................. 44
mexiletine hcl cap 200 mg.............................................. 44
mexiletine hcl cap 250 mg.............................................. 44
MICONAZOLE 3 -miconazole nitrate vaginal suppos 200
mg.................................................................................... 67
midodrine hcl tab 2.5 mg................................................ 51
midodrine hcl tab 5 mg................................................... 51
midodrine hcl tab 10 mg................................................. 51
miglitol tab 25 mg (Glyset)............................................. 32
miglitol tab 50 mg (Glyset)............................................. 32
miglitol tab 100 mg (Glyset)........................................... 32
MIGRANAL -dihydroergotamine mesylate nasal spray 4
mg/ml............................................................................... 95
MILLIPRED DP -prednisolone tab therapy pack 5 mg
(21).................................................................................. 23
MILLIPRED DP -prednisolone tab therapy pack 5 mg
(48).................................................................................. 23
MILLIPRED -prednisolone sod phosphate oral soln 10
mg/5ml (base equiv)....................................................... 23
MILLIPRED -prednisolone tab 5 mg................................. 23
MINASTRIN 24 FE -norethindrone ace-eth estradiol-fe
chew tab 1 mg-20 mcg (24)........................................... 27
MINIVELLE -estradiol td patch biweekly 0.0375
mg/24hr........................................................................... 25
MINIVELLE -estradiol td patch biweekly 0.05
mg/24hr........................................................................... 25
MINIVELLE -estradiol td patch biweekly 0.075
mg/24hr........................................................................... 25
MINIVELLE -estradiol td patch biweekly 0.1 mg/24hr.......25
MINIVELLE -estradiol td patch twice weekly 0.025
mg/24hr........................................................................... 25
minocycline hcl cap 50 mg (Minocin)............................. 4
minocycline hcl cap 75 mg (Minocin)............................. 4
minocycline hcl cap 100 mg (Minocin)........................... 4
minocycline hcl tab 50 mg............................................... 4
minocycline hcl tab 75 mg............................................... 4
minocycline hcl tab 100 mg............................................. 4
minocycline hcl tab sr 24hr 45 mg.................................. 4
minocycline hcl tab sr 24hr 90 mg.................................. 4
minocycline hcl tab sr 24hr 135 mg................................ 4
minoxidil tab 2.5 mg........................................................ 48
minoxidil tab 10 mg......................................................... 48
MIRCERA -methoxy peg-epoetin beta soln prefilled syr 30
mcg/0.3ml...................................................................... 134
MIRCERA -methoxy peg-epoetin beta soln prefilled syr 50
mcg/0.3ml...................................................................... 134
MIRCERA -methoxy peg-epoetin beta soln prefilled syr 75
mcg/0.3ml...................................................................... 134
MIRCERA -methoxy peg-epoetin beta soln prefilled syr
100 mcg/0.3ml.............................................................. 134
MIRCERA -methoxy peg-epoetin beta soln prefilled syr
150 mcg/0.3ml.............................................................. 134
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2017
MIRCERA -methoxy peg-epoetin beta soln prefilled syr
200 mcg/0.3ml.............................................................. 134
mirtazapine orally disintegrating tab 15 mg (Remeron
soltab)............................................................................. 71
mirtazapine orally disintegrating tab 30 mg (Remeron
soltab)............................................................................. 71
mirtazapine orally disintegrating tab 45 mg (Remeron
soltab)............................................................................. 71
mirtazapine tab 7.5 mg....................................................71
mirtazapine tab 15 mg (Remeron)................................. 71
mirtazapine tab 30 mg (Remeron)................................. 71
mirtazapine tab 45 mg (Remeron)................................. 71
misoprostol tab 100 mcg (Cytotec)............................... 62
misoprostol tab 200 mcg (Cytotec)............................... 62
MITIGARE -colchicine cap 0.6 mg.................................... 96
MITOSOL -mitomycin for ophth soln kit 0.2 mg.............. 145
MMA/PA ANAMIX EARLY YEARS -nutritional supplement
powder........................................................................... 123
MMA/PA ANAMIX NEXT -nutritional supplement
powder........................................................................... 123
MMA/PA COOLER -nutritional supplement liquid........... 123
MMA/PA COOLER15 -nutritional supplement liquid....... 123
MMA/PA GEL -nutritional supplement pack.................... 123
modafinil tab 100 mg (Provigil)...................................... 80
modafinil tab 200 mg (Provigil)...................................... 80
MODERIBA 1200 DOSE PACK -ribavirin tab 600 mg........ 8
MODERIBA 800 DOSE PACK -ribavirin tab 400 mg.......... 8
MODERIBA -ribavirin tab 200 mg & ribavirin tab 400 mg
dose pack.......................................................................... 8
MODERIBA -ribavirin tab 400 mg & ribavirin tab 600 mg
dose pack.......................................................................... 8
MODULEN IBD -nutritional supplement powder............. 123
moexipril hcl tab 7.5 mg (Univasc)................................ 48
moexipril hcl tab 15 mg (Univasc)................................. 48
moexipril-hydrochlorothiazide tab 7.5-12.5 mg........... 48
moexipril-hydrochlorothiazide tab 15-25 mg............... 48
moexipril-hydrochlorothiazide tab 15-12.5 mg
(Uniretic)......................................................................... 48
MOLINDONE HYDROCHLORIDE -molindone hcl tab 5
mg.................................................................................... 74
MOLINDONE HYDROCHLORIDE -molindone hcl tab 10
mg.................................................................................... 74
MOLINDONE HYDROCHLORIDE -molindone hcl tab 25
mg.................................................................................... 74
mometasone furoate cream 0.1% (Elocon)................ 153
mometasone furoate nasal susp 50 mcg/act
(Nasonex)....................................................................... 55
mometasone furoate oint 0.1% (Elocon).................... 153
mometasone furoate solution 0.1% (lotion)
(Elocon)........................................................................ 153
MONOCAL -sodium monofluorophosphate-calcium carb
tab 22.75-625 mg......................................................... 114
MONOCLATE-P -antihemophilic factor (human) for inj kit
1000 unit....................................................................... 141
MONOCLATE-P -antihemophilic factor (human) for inj kit
1500 unit....................................................................... 141
MONOGEN -nutritional supplement powder................... 123
MONONINE -coagulation factor ix for inj 1000 unit........ 141
montelukast sodium chew tab 4 mg (base equiv)
(Singulair)....................................................................... 59
montelukast sodium chew tab 5 mg (base equiv)
(Singulair)....................................................................... 59
montelukast sodium tab 10 mg (base equiv)
(Singulair)....................................................................... 59
MONUROL -fosfomycin tromethamine powd pack 3 gm
(base equivalent)............................................................ 66
morphine sulfate cap sr 24hr 10 mg (Kadian).............. 88
morphine sulfate cap sr 24hr 20 mg (Kadian).............. 88
morphine sulfate cap sr 24hr 30 mg (Kadian).............. 88
morphine sulfate cap sr 24hr 50 mg (Kadian).............. 88
morphine sulfate cap sr 24hr 60 mg (Kadian).............. 88
morphine sulfate cap sr 24hr 80 mg (Kadian).............. 89
morphine sulfate cap sr 24hr 100 mg (Kadian)............ 89
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 30 mg......................................................................89
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 45 mg......................................................................89
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 60 mg......................................................................89
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 75 mg......................................................................89
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 90 mg......................................................................89
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 120 mg....................................................................89
MORPHINE SULFATE -morphine sulfate tab 15 mg........ 88
MORPHINE SULFATE -morphine sulfate tab 30 mg........ 88
morphine sulfate oral soln 10 mg/5ml.......................... 89
morphine sulfate oral soln 20 mg/5ml.......................... 89
morphine sulfate oral soln 100 mg/5ml (20 mg/ml)..... 89
morphine sulfate tab cr 15 mg (Ms contin).................. 89
morphine sulfate tab cr 30 mg (Ms contin).................. 89
morphine sulfate tab cr 60 mg (Ms contin).................. 89
morphine sulfate tab cr 100 mg (Ms contin)................ 89
morphine sulfate tab cr 200 mg (Ms contin)................ 89
MOVANTIK -naloxegol oxalate tab 12.5 mg (base
equivalent)....................................................................... 65
MOVANTIK -naloxegol oxalate tab 25 mg (base
equivalent)....................................................................... 65
MOVIPREP -peg 3350-kcl-nacl-na sulfate-na acorbate-c
for soln 100 gm...............................................................61
MOXATAG -amoxicillin (trihydrate) tab sr 24hr 775 mg...... 1
MOXEZA -moxifloxacin hcl ophth soln 0.5% (base eq) (2
times daily).................................................................... 145
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2017
moxifloxacin hcl tab 400 mg (base equiv) (Avelox)....... 5
MSUD AID -nutritional supplement powder.................... 123
MSUD ANAMIX EARLY YEARS -nutritional supplement
powder........................................................................... 123
MSUD COOLER -nutritional supplement liquid.............. 123
MSUD EXPRESS -nutritional supplement pack............. 123
MSUD EXPRESS20 -nutritional supplement pack......... 123
MSUD GEL -nutritional supplement pack....................... 123
MSUD LOPHLEX LQ -nutritional supplement liquid....... 123
MSUD MAXAMAID -nutritional supplement powder....... 123
MSUD MAXAMUM -nutritional supplement powder....... 123
MSUD 2 -nutritional supplement powder........................ 123
MULTAQ -dronedarone hcl tab 400 mg (base
equivalent)....................................................................... 44
mupirocin calcium cream 2% (Bactroban)................. 153
mupirocin oint 2% (Bactroban).................................... 153
M-VIT -prenatal vit w/ fe fumarate-fa tab 27-1 mg.......... 107
MYALEPT -metreleptin for subcutaneous inj 11.3 mg...... 38
mycophenolate mofetil cap 250 mg (Cellcept)........... 157
mycophenolate mofetil for oral susp 200 mg/ml
(Cellcept)...................................................................... 157
mycophenolate mofetil tab 500 mg (Cellcept)............157
mycophenolate sodium tab dr 180 mg (mycophenolic
acid equiv) (Myfortic)................................................. 157
mycophenolate sodium tab dr 360 mg (mycophenolic
acid equiv) (Myfortic)................................................. 157
MYKIDZ IRON 10 -iron susp 15 mg/1.5ml...................... 134
MYLERAN -busulfan tab 2 mg.......................................... 20
MYNATAL ADVANCE -prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg...................................................................107
MYNATAL PLUS -prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................. 107
MYNATAL -prenatal multivitamins & minerals w/ iron & fa
cap 1 mg....................................................................... 107
MYNATAL ULTRACAPLET -prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg............................................... 107
MYNATAL-Z -prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................. 107
MYNATE 90 PLUS -prenatal vit w/ dss-fe fumarate-fa tab
cr 90-1 mg.....................................................................107
MYRBETRIQ -mirabegron tab sr 24 hr 25 mg.................. 66
MYRBETRIQ -mirabegron tab sr 24 hr 50 mg.................. 66
MYTESI -crofelemer tab delayed release 125 mg............ 61
N
nabumetone tab 500 mg................................................. 93
nabumetone tab 750 mg................................................. 93
nadolol & bendroflumethiazide tab 40-5 mg
(Corzide)......................................................................... 48
nadolol & bendroflumethiazide tab 80-5 mg
(Corzide)......................................................................... 48
nadolol tab 20 mg (Corgard).......................................... 42
nadolol tab 40 mg (Corgard).......................................... 42
nadolol tab 80 mg (Corgard).......................................... 42
NAFRINSE DAILY/ACIDULATED -sodium fluoridephosphoric acid for soln 1 mg/5ml (f equiv)................. 148
NAFRINSE DAILY/NEUTRAL -sodium fluoride for soln
rinse 0.05%................................................................... 148
NAFRINSE WEEKLY -sodium fluoride for soln rinse
0.2%...............................................................................148
naftifine hcl cream 1%.................................................. 153
naftifine hcl cream 2% (Naftin).................................... 153
NAFTIN -naftifine hcl cream 2%..................................... 153
NAFTIN -naftifine hcl gel 1%........................................... 153
NAFTIN -naftifine hcl gel 2%........................................... 153
naloxone hcl inj 0.4 mg/ml........................................... 156
NALOXONE HCL -naloxone hcl soln prefilled syringe 2
mg/2ml........................................................................... 156
naltrexone hcl tab 50 mg (Revia)................................. 156
NAMENDA XR -memantine hcl cap sr 24hr 7 mg............ 82
NAMENDA XR -memantine hcl cap sr 24hr 14 mg.......... 82
NAMENDA XR -memantine hcl cap sr 24hr 21 mg.......... 82
NAMENDA XR -memantine hcl cap sr 24hr 28 mg.......... 82
NAMENDA XR TITRATION PACK -memantine hcl cap sr
24hr 7 mg & 14 mg & 21 mg & 28 mg pack.................. 82
NAMZARIC -memantine-donepezil cap er 24hr 7 & 14 &
21 & 28-10 mg pack....................................................... 83
NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr
7-10 mg........................................................................... 82
NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr
14-10 mg......................................................................... 82
NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr
21-10 mg......................................................................... 82
NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr
28-10 mg......................................................................... 83
naproxen sodium tab 275 mg (Anaprox)...................... 94
naproxen sodium tab 550 mg (Anaprox ds)................. 94
naproxen sodium tab sr 24hr 375 mg (base equiv)
(Naprelan)....................................................................... 94
naproxen sodium tab sr 24hr 500 mg (base equiv)
(Naprelan)....................................................................... 94
naproxen susp 125 mg/5ml (Naprosyn)........................ 94
naproxen tab ec 375 mg (Ec-naprosyn)........................ 94
naproxen tab ec 500 mg (Ec-naprosyn)........................ 94
naproxen tab 250 mg (Naprosyn).................................. 94
naproxen tab 375 mg (Naprosyn).................................. 94
naproxen tab 500 mg (Naprosyn).................................. 94
naratriptan hcl tab 1 mg (base equiv) (Amerge).......... 95
naratriptan hcl tab 2.5 mg (base equiv) (Amerge)....... 95
NARCAN -naloxone hcl nasal spray 4 mg/0.1ml............ 156
NASCOBAL -cyanocobalamin nasal spray 500
mcg/0.1ml...................................................................... 134
NATACHEW -prenatal vit w/ fe fum-fe bisglycin-fa chew
tab 28-1 mg...................................................................107
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NATACYN -natamycin ophth susp 5%............................ 145
NATALVIT -prenatal vit w/ fe fumarate-fa tab 75-1
mg.................................................................................. 107
NATAZIA -estradiol valerate-dienogest tab 3 mg /2-2
mg/2-3 mg/1 mg............................................................. 27
nateglinide tab 60 mg (Starlix)....................................... 32
nateglinide tab 120 mg (Starlix)..................................... 32
NATELLE ONE -prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg.......................................................... 107
NATROBA -spinosad susp 0.9%..................................... 154
NATURE-THROID -thyroid tab 16.25 mg..........................35
NATURE-THROID -thyroid tab 32.5 mg............................35
NATURE-THROID -thyroid tab 65 mg...............................36
NATURE-THROID -thyroid tab 81.25 mg..........................36
NATURE-THROID -thyroid tab 97.5 mg............................36
NATURE-THROID -thyroid tab 113.75 mg........................ 36
NATURE-THROID -thyroid tab 130 mg.............................36
NATURE-THROID -thyroid tab 146.25 mg....................... 36
NATURE-THROID -thyroid tab 195 mg.............................36
NATURE-THROID -thyroid tab 260 mg.............................36
NATURE-THROID -thyroid tab 48.75 mg (3/4 grain)........ 35
NATURE-THROID -thyroid tab 325 mg (5 grain).............. 36
NEBUPENT -pentamidine isethionate for nebulization
soln 300 mg.................................................................... 12
NECON 1/50-28 -norethindrone & mestranol tab 1 mg-50
mcg.................................................................................. 27
NECON 10/11-28 -norethindrone-eth estradiol tab
0.5-35/1-35 mg-mcg (10/11)........................................... 27
NEEVO DHA -prenat w/o a w/fefum-methylfol-omegas
cap 27-1.13 mg............................................................. 107
NEFAZODONE HCL -nefazodone hcl tab 100 mg........... 71
NEFAZODONE HCL -nefazodone hcl tab 150 mg........... 71
NEFAZODONE HCL -nefazodone hcl tab 200 mg........... 71
nefazodone hcl tab 50 mg.............................................. 71
nefazodone hcl tab 250 mg............................................ 71
NEOCATE INFANT DHA/ARA -nutritional supplement
powder........................................................................... 123
NEOCATE JUNIOR/PREBIOTICS -nutritional supplement
powder........................................................................... 123
NEOCATE JUNIOR -nutritional supplement powder...... 123
NEOCATE NUTRA -nutritional supplement powder....... 123
NEOCATE SPLASH -nutritional supplement liquid......... 123
NEOMYCIN/POLYMYXIN/HYDROC -neomycinpolymyxin-hc ophth susp.............................................. 145
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin............................. 145
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml (Neosporin)........... 145
neomycin-polymyxin-dexamethasone ophth oint 0.1%
(Maxitrol)...................................................................... 145
neomycin-polymyxin-dexamethasone ophth susp
0.1% (Maxitrol).............................................................145
neomycin-polymyxin-hc otic soln 1%
(Cortisporin).................................................................147
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000
unit/ml-1%.................................................................... 147
neomycin sulfate tab 500 mg........................................... 5
NEORAL -cyclosporine modified cap 25 mg...................157
NEORAL -cyclosporine modified cap 100 mg.................158
NEORAL -cyclosporine modified oral soln 100 mg/
ml................................................................................... 158
NEO-SYNALAR -neomycin sulfate-fluocinolone acetonide
cream 0.5-0.025%........................................................ 154
NEPRO -nutritional supplement liquid.............................123
NEPRO WITH CARBSTEADY -nutritional supplement
liquid.............................................................................. 123
NEPRO WITH CARB STEADY -nutritional supplement
liquid.............................................................................. 123
NESINA -alogliptin benzoate tab 6.25 mg (base
equiv)............................................................................... 32
NESINA -alogliptin benzoate tab 12.5 mg (base
equiv)............................................................................... 32
NESINA -alogliptin benzoate tab 25 mg (base equiv).......32
NESTABS ABC -prenatal w/o vit a w/fe polysac-fa-ca tab
& omega 3 cap............................................................. 108
NESTABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack....................................................... 108
NESTABS -prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg......................................................................... 108
NESTLE FLAVOR EXTRA STREN -nutritional
supplement flavor pack................................................ 123
NESTLE FLAVOR FOR KIDS -nutritional supplement
flavor pack..................................................................... 123
NESTLE FLAVOR -nutritional supplement flavor
pack............................................................................... 123
NEULASTA ONPRO KIT -pegfilgrastim soln prefilled
syringe kit 6 mg/0.6ml.................................................. 134
NEULASTA -pegfilgrastim soln prefilled syringe 6
mg/0.6ml........................................................................ 134
NEUPOGEN -filgrastim inj 300 mcg/ml........................... 135
NEUPOGEN -filgrastim inj 480 mcg/1.6ml (300 mcg/
ml).................................................................................. 135
NEUPOGEN -filgrastim soln prefilled syringe 300
mcg/0.5ml...................................................................... 135
NEUPOGEN -filgrastim soln prefilled syringe 480
mcg/0.8ml (600 mcg/ml)............................................... 135
NEUPRO -rotigotine td patch 24hr 1 mg/24hr................ 102
NEUPRO -rotigotine td patch 24hr 2 mg/24hr................ 102
NEUPRO -rotigotine td patch 24hr 3 mg/24hr................ 102
NEUPRO -rotigotine td patch 24hr 4 mg/24hr................ 102
NEUPRO -rotigotine td patch 24hr 6 mg/24hr................ 102
NEUPRO -rotigotine td patch 24hr 8 mg/24hr................ 102
NEVANAC -nepafenac ophth susp 0.1%........................ 145
NEVIRAPINE -nevirapine susp 50 mg/5ml......................... 8
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nevirapine tab 200 mg (Viramune)...................................8
nevirapine tab sr 24hr 100 mg......................................... 8
nevirapine tab sr 24hr 400 mg (Viramune xr)................. 8
NEWGEN -prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg......................................................................... 108
NEXA PLUS -prenatal w/o vit a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg.............................................................108
NEXAVAR -sorafenib tosylate tab 200 mg (base
equivalent)....................................................................... 20
NEXIUM -esomeprazole magnesium for delayed release
susp packet 5 mg........................................................... 62
NEXIUM -esomeprazole magnesium for delayed release
susp packet 10 mg......................................................... 62
NEXIUM -esomeprazole magnesium for delayed release
susp packet 20 mg......................................................... 62
NEXIUM -esomeprazole magnesium for delayed release
susp packet 40 mg......................................................... 62
NEXIUM -esomeprazole magnesium for delayed release
susp pack 2.5 mg........................................................... 62
niacin tab cr 500 mg (antihyperlipidemic)
(Niaspan)........................................................................ 53
niacin tab cr 750 mg (antihyperlipidemic)
(Niaspan)........................................................................ 53
niacin tab cr 1000 mg (antihyperlipidemic)
(Niaspan)........................................................................ 53
nicardipine hcl cap 20 mg.............................................. 43
nicardipine hcl cap 30 mg.............................................. 43
NICODERM CQ -nicotine td patch 24hr 7 mg/24hr.......... 83
NICODERM CQ -nicotine td patch 24hr 14 mg/24hr........ 83
NICODERM CQ -nicotine td patch 24hr 21 mg/24hr........ 83
NICORETTE MINI -nicotine polacrilex lozenge 2 mg....... 83
NICORETTE MINI -nicotine polacrilex lozenge 4 mg....... 83
NICORETTE -nicotine polacrilex gum 2 mg..................... 83
NICORETTE -nicotine polacrilex gum 4 mg..................... 83
NICORETTE -nicotine polacrilex lozenge 2 mg................ 83
NICORETTE -nicotine polacrilex lozenge 4 mg................ 83
NICORETTE STARTER KIT -nicotine polacrilex gum 2
mg.................................................................................... 83
NICORETTE STARTER KIT -nicotine polacrilex gum 4
mg.................................................................................... 83
nicotine polacrilex gum 2 mg.........................................83
nicotine polacrilex gum 4 mg.........................................83
nicotine polacrilex lozenge 2 mg................................... 83
nicotine polacrilex lozenge 4 mg................................... 83
nicotine td patch 24hr 7 mg/24hr...................................83
nicotine td patch 24hr 14 mg/24hr.................................83
nicotine td patch 24hr 21 mg/24hr.................................83
NICOTINE TRANSDERMAL SYST -nicotine td patch 24
hr kit 21-14-7 mg/24hr.................................................... 83
NICOTROL INHALER -nicotine inhaler system 10 mg (4
mg delivered).................................................................. 83
NICOTROL NS -nicotine nasal spray 10 mg/ml (0.5 mg/
spray)............................................................................... 83
nifedipine cap 20 mg....................................................... 43
nifedipine cap 10 mg (Procardia).................................. 43
nifedipine tab sr 24hr 30 mg (Adalat cc).......................43
nifedipine tab sr 24hr 60 mg (Adalat cc).......................43
nifedipine tab sr 24hr 90 mg (Adalat cc).......................43
nifedipine tab sr 24hr osmotic release 30 mg
(Procardia xl)................................................................. 43
nifedipine tab sr 24hr osmotic release 60 mg
(Procardia xl)................................................................. 43
nifedipine tab sr 24hr osmotic release 90 mg
(Procardia xl)................................................................. 43
NILANDRON -nilutamide tab 150 mg............................... 20
nilutamide tab 150 mg (Nilandron)................................ 20
nimodipine cap 30 mg..................................................... 43
NINJACOF-XG -guaifenesin-codeine liquid 200-8
mg/5ml............................................................................. 56
NINLARO -ixazomib citrate cap 2.3 mg (base
equivalent)....................................................................... 20
NINLARO -ixazomib citrate cap 3 mg (base
equivalent)....................................................................... 20
NINLARO -ixazomib citrate cap 4 mg (base
equivalent)....................................................................... 20
NISOLDIPINE ER -nisoldipine tab sr 24hr 20 mg............. 43
NISOLDIPINE ER -nisoldipine tab sr 24hr 25.5 mg.......... 43
NISOLDIPINE ER -nisoldipine tab sr 24hr 30 mg............. 43
NISOLDIPINE ER -nisoldipine tab sr 24hr 40 mg............. 44
nisoldipine tab sr 24hr 8.5 mg (Sular)........................... 44
nisoldipine tab sr 24hr 17 mg (Sular)............................44
nisoldipine tab sr 24hr 34 mg (Sular)............................44
NITRO-BID -nitroglycerin oint 2%..................................... 40
NITRO-DUR -nitroglycerin td patch 24hr 0.3 mg/hr.......... 40
NITRO-DUR -nitroglycerin td patch 24hr 0.8 mg/hr.......... 40
nitrofurantoin macrocrystalline cap 25 mg
(Macrodantin).................................................................66
nitrofurantoin macrocrystalline cap 50 mg
(Macrodantin).................................................................66
nitrofurantoin macrocrystalline cap 100 mg
(Macrodantin).................................................................66
nitrofurantoin monohydrate macrocrystalline cap 100
mg (Macrobid)............................................................... 66
nitrofurantoin susp 25 mg/5ml (Furadantin)................ 66
nitroglycerin cap cr 2.5 mg............................................ 40
nitroglycerin cap cr 6.5 mg............................................ 40
nitroglycerin cap cr 9 mg............................................... 40
NITROGLYCERIN LINGUAL -nitroglycerin lingual aerosol
400 mcg/spray................................................................ 40
nitroglycerin sl tab 0.3 mg (Nitrostat)........................... 40
nitroglycerin sl tab 0.4 mg (Nitrostat)........................... 40
nitroglycerin sl tab 0.6 mg (Nitrostat)........................... 40
nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)......... 40
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nitroglycerin td patch 24hr 0.2 mg/hr (Nitro-dur)......... 40
nitroglycerin td patch 24hr 0.4 mg/hr (Nitro-dur)......... 40
nitroglycerin td patch 24hr 0.6 mg/hr (Nitro-dur)......... 40
nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)
(Nitrolingual pumpspr)................................................. 40
NITROMIST -nitroglycerin lingual aerosol 400 mcg/
spray................................................................................ 40
NITROSTAT -nitroglycerin sl tab 0.3 mg........................... 40
NITROSTAT -nitroglycerin sl tab 0.4 mg........................... 41
NITROSTAT -nitroglycerin sl tab 0.6 mg........................... 41
NIVA-PLUS -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 108
nizatidine cap 150 mg..................................................... 62
nizatidine cap 300 mg (Axid).......................................... 62
NIZATIDINE -nizatidine oral soln 15 mg/ml...................... 62
norethindrone & ethinyl estradiol-fe chew tab 0.4
mg-35 mcg (Femcon fe)............................................... 27
norethindrone & ethinyl estradiol-fe chew tab 0.8
mg-25 mcg (Generess fe)............................................ 28
norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg
(Brevicon-28)................................................................. 27
norethindrone & ethinyl estradiol tab 1 mg-35 mcg
(Norinyl 1+35)................................................................ 27
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg
(Ovcon-35)...................................................................... 27
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20
mcg (Loestrin fe 1/20).................................................. 28
norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30
mcg (Loestrin fe 1.5/30)............................................... 28
norethindrone ace & ethinyl estradiol tab 1 mg-20
mcg (Loestrin 1/20-21)................................................. 28
norethindrone ace & ethinyl estradiol tab 1.5 mg-30
mcg (Loestrin 1.5/30-21).............................................. 28
norethindrone ace-eth estradiol-fe chew tab 1 mg-20
mcg (24) (Minastrin 24 fe)............................................28
norethindrone ace-ethinyl estradiol-fe tab 1 mg-20
mcg (24) (Lomedia 24 fe)............................................. 28
norethindrone acetate-ethinyl estradiol tab 1 mg-5
mcg................................................................................. 26
norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5
mcg (Femhrt low dose)................................................ 26
norethindrone acetate tab 5 mg (Aygestin).................. 29
norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35
mg-mcg (Estrostep fe)................................................. 28
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35
mg-mcg (Ortho-novum 7/7/7)...................................... 28
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28)...................................................... 28
norethindrone tab 0.35 mg (Nor-qd).............................. 28
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg
(Ortho-cyclen)................................................................ 28
norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35
mg-mcg (Ortho tri-cyclen)........................................... 28
norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25
mg-mcg (Ortho tri-cyclen lo)....................................... 28
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg........ 28
NORPACE CR -disopyramide phosphate cap sr 12hr 100
mg.................................................................................... 44
NORPACE CR -disopyramide phosphate cap sr 12hr 150
mg.................................................................................... 44
NORPACE -disopyramide phosphate cap 100 mg........... 44
NORPACE -disopyramide phosphate cap 150 mg........... 44
nortriptyline hcl cap 10 mg (Pamelor)...........................71
nortriptyline hcl cap 25 mg (Pamelor)...........................71
nortriptyline hcl cap 50 mg (Pamelor)...........................71
nortriptyline hcl cap 75 mg (Pamelor)...........................71
NORTRIPTYLINE HCL -nortriptyline hcl soln 10
mg/5ml............................................................................. 71
NORVIR -ritonavir cap 100 mg........................................... 8
NORVIR -ritonavir oral soln 80 mg/ml.................................8
NORVIR -ritonavir tab 100 mg............................................ 8
NOURISH -nutritional supplement liquid......................... 123
NOVASOURCE PULMONARY -nutritional supplement
liquid.............................................................................. 124
NOVASOURCE RENAL -nutritional supplement
liquid.............................................................................. 124
NOVOEIGHT -antihemophilic factor (recombinant) for inj
250 unit......................................................................... 141
NOVOEIGHT -antihemophilic factor (recombinant) for inj
500 unit......................................................................... 141
NOVOEIGHT -antihemophilic factor (recombinant) for inj
1000 unit....................................................................... 141
NOVOEIGHT -antihemophilic factor (recombinant) for inj
1500 unit....................................................................... 141
NOVOEIGHT -antihemophilic factor (recombinant) for inj
2000 unit....................................................................... 141
NOVOEIGHT -antihemophilic factor (recombinant) for inj
3000 unit....................................................................... 141
NOVOLIN 70/30 -insulin nph isophane & regular human
inj 100 unit/ml (70-30).................................................... 34
NOVOLIN 70/30 RELION -insulin nph isophane & regular
human inj 100 unit/ml (70-30)........................................ 34
NOVOLIN N -insulin nph (human) (isophane) inj 100 unit/
ml..................................................................................... 34
NOVOLIN N RELION -insulin nph (human) (isophane) inj
100 unit/ml.......................................................................34
NOVOLIN R -insulin regular (human) inj 100 unit/ml........ 34
NOVOLIN R RELION -insulin regular (human) inj 100
unit/ml.............................................................................. 34
NOVOLOG FLEXPEN -insulin aspart soln pen-injector
100 unit/ml.......................................................................33
NOVOLOG -insulin aspart inj 100 unit/ml......................... 33
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NOVOLOG MIX 70/30 -insulin aspart prot & aspart
(human) inj 100 unit/ml (70-30)...................................... 34
NOVOLOG MIX 70/30 PREFILL -insulin aspart prot &
aspart sus pen-inj 100 unit/ml (70-30)........................... 35
NOVOLOG PENFILL -insulin aspart soln cartridge 100
unit/ml.............................................................................. 33
NOVOSEVEN RT -coagulation factor viia (recomb) for inj
1 mg (1000 mcg).......................................................... 141
NOVOSEVEN RT -coagulation factor viia (recomb) for inj
2 mg (2000 mcg).......................................................... 141
NOVOSEVEN RT -coagulation factor viia (recomb) for inj
5 mg (5000 mcg).......................................................... 141
NOVOSEVEN RT -coagulation factor viia (recomb) for inj
8 mg (8000 mcg).......................................................... 141
NOXAFIL -posaconazole susp 40 mg/ml............................ 6
NOXAFIL -posaconazole tab delayed release 100 mg....... 6
NUCALA -mepolizumab for inj 100 mg............................. 59
NUEDEXTA -dextromethorphan hbr-quinidine sulfate cap
20-10 mg......................................................................... 83
NUPLAZID -pimavanserin tartrate tab 17 mg (base
equivalent)....................................................................... 74
NUTRA/BALANCE RE/GEN FREE -nutritional
supplement liquid (frozen)............................................ 124
NUTRA/BALANCE RE/GEN -nutritional supplement liquid
(frozen).......................................................................... 124
NUTRA/SHAKE FRUIT PLUS -nutritional supplement
liquid (frozen)................................................................ 124
NUTRA/SHAKE -nutritional supplement liquid
(frozen).......................................................................... 124
NUTRA/SHAKE SUPREME -nutritional supplement
liquid.............................................................................. 124
NUTRA/SHAKE SUPREME -nutritional supplement liquid
(frozen).......................................................................... 124
NUTRA BALANCE DIABETIC NU -nutritional supplement
bar.................................................................................. 124
NUTRA BALANCE FIBER COOKI -nutritional supplement
misc............................................................................... 124
NUTRA BALANCE PROTEIN FOR -nutritional
supplement misc........................................................... 124
NUTRAMENT -nutritional supplement liquid................... 124
NUTRAMINE APPLE AMINO BIT -nutritional supplement
pack............................................................................... 124
NUTRAMINE BANANA AMINO B -nutritional supplement
pack............................................................................... 124
NUTRAMINE CHOCOLATE AMINO -nutritional
supplement pack........................................................... 124
NUTRAMINE MANGO AMINO BI -nutritional supplement
pack............................................................................... 124
NUTRAMINE MIXED FLAVORS A -nutritional supplement
pack............................................................................... 124
NUTRAMINE -nutritional supplement pack..................... 124
NUTRAMINE PEACHES & CREAM -nutritional
supplement pack........................................................... 124
NUTRAMINE PINEAPPLE AMINO -nutritional
supplement pack........................................................... 124
NUTRASENTIALS -amino acids oral powder................. 115
NUTRA SHAKE/SUPREME -nutritional supplement liquid
(frozen).......................................................................... 124
NUTRA SHAKE -nutritional supplement liquid
(frozen).......................................................................... 124
NUTREN 1.0/FIBER/ULTRAPAK -nutritional supplement
liquid.............................................................................. 125
NUTREN 1.0/FIBER -nutritional supplement liquid.........125
NUTREN 1.0 CAL -nutritional supplement liquid............ 124
NUTREN 1.5 CAL -nutritional supplement liquid............ 125
NUTREN 2.0 CAL -nutritional supplement liquid............ 125
NUTREN 1.5 FIBER -nutritional supplement liquid.........125
NUTREN JR FIBER -nutritional supplement liquid......... 124
NUTREN JR -nutritional supplement liquid..................... 124
NUTREN JUNIOR/FIBER -nutritional supplement
liquid.............................................................................. 124
NUTREN JUNIOR -nutritional supplement liquid............ 124
NUTREN JUNIOR 1.0 -nutritional supplement liquid...... 124
NUTREN 1.0 -nutritional supplement liquid.................... 124
NUTREN 1.5 -nutritional supplement liquid.................... 125
NUTREN 2.0 -nutritional supplement liquid.................... 125
NUTREN PULMONARY -nutritional supplement
liquid.............................................................................. 124
NUTREN RENAL -nutritional supplement liquid............. 124
NUTRESTORE -glutamine powd pack 5 gm.................. 115
NUTRICIA PREOP -nutritional supplement pack........... 125
NUTRIFOCUS -nutritional supplement liquid.................. 125
NUTRIHEAL -nutritional supplement liquid..................... 125
NUTRIHEP 1.5 CAL -nutritional supplement liquid......... 125
NUTRIRENAL -nutritional supplement liquid.................. 125
NUTRITIONAL DRINK MIX -nutritional supplement
powder........................................................................... 125
NUTRITIONAL DRINK -nutritional supplement liquid..... 125
NUTRITIONAL DRINK PLUS -nutritional supplement
liquid.............................................................................. 125
NUTRITIONAL DRINK SHAKE M -nutritional supplement
powder........................................................................... 125
NUTRITIONAL SHAKE COMPLET -nutritional
supplement liquid.......................................................... 125
NUTRITIONAL SHAKE -nutritional supplement
liquid.............................................................................. 125
NUTRITIONAL SHAKE PLUS -nutritional supplement
liquid.............................................................................. 125
NUTRITIONAL SHAKE PLUS PR -nutritional supplement
liquid.............................................................................. 125
nutritional supplement liquid....................................... 125
NUTRITIONAL SUPPLEMENT -nutritional supplement
liquid.............................................................................. 125
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NUTRITIONAL SUPPLEMENT PL -nutritional supplement
liquid.............................................................................. 125
NUTRIVENT -nutritional supplement liquid..................... 125
NUTRIVENT 1.5 -nutritional supplement liquid...............125
NUTRIVIR NSA -nutritional supplement powder............ 125
NUTRIVIR -nutritional supplement powder..................... 125
NUVARING -etonogestrel-ethinyl estradiol va ring
0.120-0.015 mg/24hr...................................................... 28
NUVESSA -metronidazole vaginal gel 1.3%.....................67
NUVIGIL -armodafinil tab 50 mg....................................... 80
NUVIGIL -armodafinil tab 150 mg..................................... 80
NUVIGIL -armodafinil tab 200 mg..................................... 80
NUVIGIL -armodafinil tab 250 mg..................................... 80
NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 250
unit................................................................................. 141
NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 500
unit................................................................................. 141
NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 1000
unit................................................................................. 141
NUWIQ -antihemophilic factor (bdd-rfviii) for inj kit 2000
unit................................................................................. 141
NUWIQ -antihemophilic factor (bdd-rfviii) for inj 250
unit................................................................................. 141
NUWIQ -antihemophilic factor (bdd-rfviii) for inj 500
unit................................................................................. 141
NUWIQ -antihemophilic factor (bdd-rfviii) for inj 1000
unit................................................................................. 141
NUWIQ -antihemophilic factor (bdd-rfviii) for inj 2000
unit................................................................................. 141
NYMALIZE -nimodipine oral soln 60 mg/20ml.................. 44
nystatin cream 100000 unit/gm.................................... 154
nystatin oint 100000 unit/gm........................................ 154
nystatin susp 100000 unit/ml....................................... 148
nystatin tab 500000 unit....................................................6
nystatin topical powder 100000 unit/gm..................... 154
nystatin-triamcinolone cream 100000-0.1 unit/gm%.................................................................................... 154
nystatin-triamcinolone oint 100000-0.1 unit/gm%.................................................................................... 154
O
OA 1 -nutritional supplement powder.............................. 125
OA 2 -nutritional supplement powder.............................. 125
OB COMPLETE/DHA -prenat w/ iron cbn-fe asp glyc-faomega cap 30-10-1-200 mg......................................... 108
OB COMPLETE GOLD -prenat w/o a w/fecbn-methfol-fadha cap 27.5-1-200 mg................................................ 108
OB COMPLETE ONE -prenatal w/o a w/fecbn-fe asp
glyc-fa-fish cap 50-1-476 mg........................................108
OB COMPLETE PETITE -prenat w/o a w/fecbnfeaspglyc-fa-omega cap 35-5-1-200 mg...................... 108
OB COMPLETE PREMIER -prenatal vit w/ fe cbn-fe asp
glyc-fa tab 30-20-1 mg................................................. 108
OB COMPLETE -prenatal vit w/ iron carbonyl-fa tab
50-1.25 mg.................................................................... 108
OBIZUR -antihemophilic factor (recomb porc) rpfviii for inj
500 unit......................................................................... 142
OBSTETRIX DHA -prenat w/fecbn-fa-dss tab 29-1 mg &
omega 3 cap 387 mg pak............................................ 108
OBSTETRIX EC -prenatal vit w/ dss-iron carbonyl-fa tab
29-1 mg......................................................................... 108
OBSTETRIX ONE -prenat w/o a w/fecbn-bisg-methylfdss-dha cap 38-1-225 mg............................................ 108
O-CAL FA -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 108
OCALIVA -obeticholic acid tab 5 mg................................. 65
OCALIVA -obeticholic acid tab 10 mg............................... 65
O-CAL PRENATAL -prenatal vit w/ fe fumarate-fa tab 15-1
mg.................................................................................. 108
octreotide acetate inj 50 mcg/ml (0.05 mg/ml)
(Sandostatin)................................................................. 38
octreotide acetate inj 100 mcg/ml (0.1 mg/ml)
(Sandostatin)................................................................. 38
octreotide acetate inj 200 mcg/ml (0.2 mg/ml)
(Sandostatin)................................................................. 38
octreotide acetate inj 500 mcg/ml (0.5 mg/ml)
(Sandostatin)................................................................. 38
octreotide acetate inj 1000 mcg/ml (1 mg/ml)
(Sandostatin)................................................................. 38
ODEFSEY -emtricitabine-rilpivirine-tenofovir af tab
200-25-25 mg.................................................................... 8
ODOMZO -sonidegib phosphate cap 200 mg (base
equivalent)....................................................................... 20
OFEV -nintedanib esylate cap 100 mg (base
equivalent)....................................................................... 60
OFEV -nintedanib esylate cap 150 mg (base
equivalent)....................................................................... 60
OFLOXACIN -ofloxacin tab 300 mg.................................... 5
ofloxacin ophth soln 0.3% (Ocuflox)........................... 145
ofloxacin otic soln 0.3%................................................147
ofloxacin tab 400 mg......................................................... 5
OGESTREL -norgestrel & ethinyl estradiol tab 0.5 mg-50
mcg.................................................................................. 28
olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax)...... 83
olanzapine-fluoxetine hcl cap 6-25 mg (Symbyax)...... 83
olanzapine-fluoxetine hcl cap 6-50 mg (Symbyax)...... 83
olanzapine-fluoxetine hcl cap 12-25 mg
(Symbyax)...................................................................... 83
olanzapine-fluoxetine hcl cap 12-50 mg
(Symbyax)...................................................................... 83
olanzapine orally disintegrating tab 5 mg (Zyprexa
zydis)...............................................................................74
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2017
olanzapine orally disintegrating tab 10 mg (Zyprexa
zydis)...............................................................................74
olanzapine orally disintegrating tab 15 mg (Zyprexa
zydis)...............................................................................74
olanzapine orally disintegrating tab 20 mg (Zyprexa
zydis)...............................................................................74
olanzapine tab 2.5 mg (Zyprexa)................................... 74
olanzapine tab 5 mg (Zyprexa)...................................... 74
olanzapine tab 7.5 mg (Zyprexa)................................... 74
olanzapine tab 10 mg (Zyprexa).................................... 74
olanzapine tab 15 mg (Zyprexa).................................... 75
olanzapine tab 20 mg (Zyprexa).................................... 75
olmesartan medoxomil tab 5 mg (Benicar).................. 48
olmesartan medoxomil tab 20 mg (Benicar)................ 48
olmesartan medoxomil tab 40 mg (Benicar)................ 48
olopatadine hcl nasal soln 0.6% (Patanase).................55
olopatadine hcl ophth soln 0.1% (base equivalent)
(Patanol)....................................................................... 145
OLYSIO -simeprevir sodium cap 150 mg (base
equivalent)......................................................................... 8
omeprazole cap delayed release 10 mg (Prilosec)...... 62
omeprazole cap delayed release 20 mg (Prilosec)...... 62
omeprazole cap delayed release 40 mg (Prilosec)...... 62
OMNARIS -ciclesonide nasal susp 50 mcg/act................ 55
OMNIFLEX DIAPHRAGM -diaphragms.......................... 156
OMNI GEL -stannous fluoride gel 0.4%.......................... 148
OMNITROPE -somatropin for inj 5.8 mg.......................... 38
OMNITROPE -somatropin inj 5 mg/1.5ml......................... 38
OMNITROPE -somatropin inj 10 mg/1.5ml....................... 38
ondansetron hcl oral soln 4 mg/5ml (Zofran)............... 63
ondansetron hcl tab 24 mg............................................ 63
ondansetron hcl tab 4 mg (Zofran)................................63
ondansetron hcl tab 8 mg (Zofran)................................63
ondansetron orally disintegrating tab 4 mg (Zofran
odt).................................................................................. 63
ondansetron orally disintegrating tab 8 mg (Zofran
odt).................................................................................. 63
ONFI -clobazam suspension 2.5 mg/ml.......................... 100
ONFI -clobazam tab 10 mg............................................. 100
ONFI -clobazam tab 20 mg............................................. 100
ONGLYZA -saxagliptin hcl tab 2.5 mg (base equiv)......... 32
ONGLYZA -saxagliptin hcl tab 5 mg (base equiv)............ 32
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 5 mg......................................................... 89
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 7.5 mg...................................................... 89
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 10 mg....................................................... 89
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 15 mg....................................................... 89
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 20 mg....................................................... 89
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 30 mg....................................................... 89
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 40 mg....................................................... 89
OPSUMIT -macitentan tab 10 mg..................................... 54
OPTIMENTAL -nutritional supplement liquid...................125
OPTISOURCE VERY HIGH PROT -nutritional
supplement liquid.......................................................... 125
ORALAIR ADULT SAMPLE KIT -grass mixed pollen ext
tab sl 300 ir (index of reactivity)..................................... 16
ORALAIR ADULT STARTER PAC -grass mixed pollen ext
tab sl 300 ir (index of reactivity)..................................... 16
ORALAIR CHILDREN/ADOLESCE -grass mixed pollen
ext tab sl 100 ir (index of reactivity)............................... 16
ORALAIR CHILDREN/ADOLESCE -grass mixed pollen
tab sl therpak 100 (3) ir & 300 (6) ir.............................. 16
ORALAIR -grass mixed pollen ext tab sl 300 ir (index of
reactivity)......................................................................... 16
ORANGE CHICKEN/CARROTS/BR -nutritional
supplement liquid.......................................................... 125
ORAP -pimozide tab 1 mg................................................ 83
ORAP -pimozide tab 2 mg................................................ 83
ORAVIG -miconazole buccal tab 50 mg (mouththroat)............................................................................ 148
ORENCIA -abatacept subcutaneous soln prefilled syringe
125 mg/ml....................................................................... 94
ORENCIA CLICKJECT -abatacept subcutaneous soln
auto-injector 125 mg/ml.................................................. 94
ORENITRAM -treprostinil diolamine tab cr 0.125 mg
(base equiv).................................................................... 54
ORENITRAM -treprostinil diolamine tab cr 0.25 mg (base
equiv)............................................................................... 54
ORENITRAM -treprostinil diolamine tab cr 1 mg (base
equiv)............................................................................... 54
ORENITRAM -treprostinil diolamine tab cr 2.5 mg (base
equiv)............................................................................... 54
ORFADIN -nitisinone cap 2 mg......................................... 38
ORFADIN -nitisinone cap 5 mg......................................... 38
ORFADIN -nitisinone cap 10 mg....................................... 38
ORFADIN -nitisinone cap 20 mg....................................... 39
ORFADIN -nitisinone susp 4 mg/ml.................................. 39
ORGANIC PEDIA SMART -nutritional supplement
powder........................................................................... 125
ORKAMBI -lumacaftor-ivacaftor tab 100-125 mg............. 60
ORKAMBI -lumacaftor-ivacaftor tab 200-125 mg............. 60
orphenadrine citrate tab sr 12hr 100 mg.................... 104
ORTHO TRI-CYCLEN LO -norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg................................. 28
oseltamivir phosphate cap 30 mg (base equiv)
(Tamiflu)............................................................................ 8
oseltamivir phosphate cap 45 mg (base equiv)
(Tamiflu)............................................................................ 8
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oseltamivir phosphate cap 75 mg (base equiv)
(Tamiflu)............................................................................ 8
OSENI -alogliptin-pioglitazone tab 12.5-15 mg................. 32
OSENI -alogliptin-pioglitazone tab 12.5-30 mg................. 32
OSENI -alogliptin-pioglitazone tab 12.5-45 mg................. 32
OSENI -alogliptin-pioglitazone tab 25-15 mg.................... 32
OSENI -alogliptin-pioglitazone tab 25-30 mg.................... 32
OSENI -alogliptin-pioglitazone tab 25-45 mg.................... 32
OSMOLITE 1 CAL -nutritional supplement liquid............126
OSMOLITE 1.2 CAL -nutritional supplement liquid.........126
OSMOLITE 1.5 CAL -nutritional supplement liquid.........126
OSMOLITE HN -nutritional supplement liquid................ 126
OSMOLITE -nutritional supplement liquid....................... 126
OSMOPREP -sod phos mono-sod phos di tabs
1.102-0.398 gm(1.5gm na phos).................................... 61
OS 2 -nutritional supplement powder.............................. 126
OTEZLA -apremilast tab 30 mg........................................ 94
OTEZLA -apremilast tab starter therapy pack 10 mg & 20
mg & 30 mg.................................................................... 94
OTREXUP -methotrexate soln pf auto-injector 7.5
mg/0.4ml.......................................................................... 94
OTREXUP -methotrexate soln pf auto-injector
10mg/0.4ml...................................................................... 94
OTREXUP -methotrexate soln pf auto-injector 12.5
mg/0.4ml.......................................................................... 94
OTREXUP -methotrexate soln pf auto-injector
15mg/0.4ml...................................................................... 94
OTREXUP -methotrexate soln pf auto-injector 17.5
mg/0.4ml.......................................................................... 94
OTREXUP -methotrexate soln pf auto-injector
20mg/0.4ml...................................................................... 94
OTREXUP -methotrexate soln pf auto-injector 22.5
mg/0.4ml.......................................................................... 94
OTREXUP -methotrexate soln pf auto-injector
25mg/0.4ml...................................................................... 94
oxandrolone tab 2.5 mg (Oxandrin).............................. 24
oxandrolone tab 10 mg (Oxandrin)............................... 24
oxaprozin tab 600 mg (Daypro)..................................... 94
OXAYDO -oxycodone hcl tab abuse deter 5 mg.............. 89
OXAYDO -oxycodone hcl tab abuse deter 7.5 mg............89
oxazepam cap 10 mg...................................................... 69
oxazepam cap 15 mg...................................................... 69
oxazepam cap 30 mg...................................................... 69
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
(Trileptal)...................................................................... 100
oxcarbazepine tab 150 mg (Trileptal).......................... 100
oxcarbazepine tab 300 mg (Trileptal).......................... 100
oxcarbazepine tab 600 mg (Trileptal).......................... 100
OXEPA -nutritional supplement liquid............................. 126
OXEPA 1.5 -nutritional supplement liquid....................... 126
oxiconazole nitrate cream 1% (Oxistat)...................... 154
OXISTAT -oxiconazole nitrate cream 1%........................ 154
OXISTAT -oxiconazole nitrate lotion 1%......................... 154
OXTELLAR XR -oxcarbazepine tab sr 24hr 150 mg...... 100
OXTELLAR XR -oxcarbazepine tab sr 24hr 300 mg...... 100
OXTELLAR XR -oxcarbazepine tab sr 24hr 600 mg...... 100
oxybutynin chloride syrup 5 mg/5ml............................ 66
oxybutynin chloride tab 5 mg........................................ 66
oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)..... 66
oxybutynin chloride tab sr 24hr 10 mg (Ditropan
xl)..................................................................................... 66
oxybutynin chloride tab sr 24hr 15 mg (Ditropan
xl)..................................................................................... 66
OXYCODONE/ACETAMINOPHEN -oxycodone w/
acetaminophen soln 5-325 mg/5ml................................ 90
OXYCODONE/IBUPROFEN -oxycodone-ibuprofen tab
5-400 mg......................................................................... 90
oxycodone-aspirin tab 4.8355-325 mg (Percodan)...... 90
oxycodone hcl cap 5 mg................................................ 89
oxycodone hcl conc 100 mg/5ml (20 mg/ml)
(Oxycodone hcl)............................................................ 89
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
10 mg.............................................................................. 89
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
15 mg.............................................................................. 89
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
20 mg.............................................................................. 89
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
30 mg.............................................................................. 90
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
40 mg.............................................................................. 90
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
60 mg.............................................................................. 90
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
80 mg.............................................................................. 90
oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)...........90
oxycodone hcl tab 10 mg............................................... 90
oxycodone hcl tab 20 mg............................................... 90
oxycodone hcl tab 5 mg (Roxicodone)......................... 90
oxycodone hcl tab 15 mg (Roxicodone)....................... 90
oxycodone hcl tab 30 mg (Roxicodone)....................... 90
oxycodone w/ acetaminophen tab 2.5-325 mg
(Percocet)....................................................................... 90
oxycodone w/ acetaminophen tab 5-325 mg
(Percocet)....................................................................... 90
oxycodone w/ acetaminophen tab 7.5-325 mg
(Percocet)....................................................................... 90
oxycodone w/ acetaminophen tab 10-325 mg
(Percocet)....................................................................... 90
OXYCONTIN -oxycodone hcl tab er 12hr deter 10 mg..... 90
OXYCONTIN -oxycodone hcl tab er 12hr deter 15 mg..... 90
OXYCONTIN -oxycodone hcl tab er 12hr deter 20 mg..... 90
OXYCONTIN -oxycodone hcl tab er 12hr deter 30 mg..... 90
OXYCONTIN -oxycodone hcl tab er 12hr deter 40 mg..... 90
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OXYCONTIN -oxycodone hcl tab er 12hr deter 60 mg..... 90
OXYCONTIN -oxycodone hcl tab er 12hr deter 80 mg..... 90
oxymorphone hcl tab 5 mg (Opana)..............................90
oxymorphone hcl tab 10 mg (Opana)............................90
OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
tab sr 12hr 5 mg............................................................. 90
OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
tab sr 12hr 7.5 mg.......................................................... 90
OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
tab sr 12hr 10 mg........................................................... 90
OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
tab sr 12hr 15 mg........................................................... 91
OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
tab sr 12hr 20 mg........................................................... 91
OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
tab sr 12hr 30 mg........................................................... 91
OXYMORPHONE HYDROCHLORIDE -oxymorphone hcl
tab sr 12hr 40 mg........................................................... 91
P
paliperidone tab sr 24hr 1.5 mg (Invega)...................... 75
paliperidone tab sr 24hr 3 mg (Invega)......................... 75
paliperidone tab sr 24hr 6 mg (Invega)......................... 75
paliperidone tab sr 24hr 9 mg (Invega)......................... 75
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
2600-6200-10850 unit.....................................................63
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
4200-14200-24600 unit...................................................63
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
10500-35500-61500 unit................................................ 63
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
16800-56800-98400 unit................................................ 63
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
21000-54700-83900 unit................................................ 63
PANRETIN -alitretinoin gel 0.1%..................................... 154
pantoprazole sodium ec tab 20 mg (base equiv)
(Protonix)........................................................................62
pantoprazole sodium ec tab 40 mg (base equiv)
(Protonix)........................................................................62
PARAGARD INTRAUTERINE COP -copper iud............... 28
paricalcitol cap 1 mcg (Zemplar)................................... 39
paricalcitol cap 2 mcg (Zemplar)................................... 39
paricalcitol cap 4 mcg (Zemplar)................................... 39
PARODONTAX -stannous fluoride paste 0.454%........... 148
paromomycin sulfate cap 250 mg................................... 5
paroxetine hcl tab 10 mg (Paxil).................................... 71
paroxetine hcl tab 20 mg (Paxil).................................... 71
paroxetine hcl tab 30 mg (Paxil).................................... 71
paroxetine hcl tab 40 mg (Paxil).................................... 71
paroxetine hcl tab sr 24hr 25 mg (Paxil cr).................. 71
PASER -aminosalicylic acid cr granules packet 4 gm.........5
PATADAY -olopatadine hcl ophth soln 0.2% (base
equivalent)..................................................................... 145
PCE -erythromycin w/ enteric coated particles tab 333
mg...................................................................................... 4
PCE -erythromycin w/ enteric coated particles tab 500
mg...................................................................................... 4
PCP 100 -mag cit-bisacodyl-petrolat-pegmetoclopramide-electrol kit............................................. 61
PEDIARIX -diph-tetanus tox-acell pert-hepatitis b-polio ipv
vac inj.............................................................................. 16
PEDIASURE 1.0 CAL/FIBER -nutritional supplement
liquid.............................................................................. 126
PEDIASURE 1.5 CAL/FIBER -nutritional supplement
liquid.............................................................................. 126
PEDIASURE 1.5 CAL -nutritional supplement liquid...... 126
PEDIASURE 1.5 CAL WITH FI -nutritional supplement
liquid.............................................................................. 126
PEDIASURE ENTERAL FORMULA -nutritional
supplement liquid.......................................................... 126
PEDIASURE GROW & GAIN -nutritional supplement
liquid.............................................................................. 126
PEDIASURE NUTRIPALS -nutritional supplement
bar.................................................................................. 126
PEDIASURE NUTRIPALS -nutritional supplement
liquid.............................................................................. 126
PEDIASURE -nutritional supplement liquid.................... 126
PEDIASURE PEDIATRIC -nutritional supplement
liquid.............................................................................. 126
PEDIASURE PEPTIDE 1.0 CAL -nutritional supplement
liquid.............................................................................. 126
PEDIASURE PEPTIDE 1.5 CAL -nutritional supplement
liquid.............................................................................. 126
PEDIASURE SHAKE MIX -nutritional supplement
powder........................................................................... 126
PEDIASURE SHAKE WITH FIBE -nutritional supplement
liquid.............................................................................. 126
PEDIASURE SIDEKICKS CLEAR -nutritional supplement
liquid.............................................................................. 126
PEDIASURE SIDEKICKS -nutritional supplement
liquid.............................................................................. 126
PEDIASURE SIDEKICKS -nutritional supplement
powder........................................................................... 126
PEDIASURE SIDEKICKS SHAKE -nutritional supplement
liquid.............................................................................. 126
PEDIASURE WITH FIBER -nutritional supplement
liquid.............................................................................. 126
PEDIATRIC DRINK -nutritional supplement liquid.......... 126
PEDIATRIC PEPTINEX DT/FIB -nutritional supplement
liquid.............................................................................. 126
PEDIATRIC PEPTINEX DT -nutritional supplement
liquid.............................................................................. 126
PEGANONE -ethotoin tab 250 mg.................................. 100
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2017
PEGASYS -peginterferon alfa-2a inj 180 mcg/ml............... 9
PEGASYS -peginterferon alfa-2a inj 180 mcg/0.5ml.......... 9
PEGASYS PROCLICK -peginterferon alfa-2a inj 135
mcg/0.5ml.......................................................................... 9
PEGASYS PROCLICK -peginterferon alfa-2a inj 180
mcg/0.5ml.......................................................................... 9
PEGINTRON -peginterferon alfa-2b for inj kit 50
mcg/0.5ml.......................................................................... 9
PEGINTRON -peginterferon alfa-2b for inj kit 80
mcg/0.5ml.......................................................................... 9
PEGINTRON -peginterferon alfa-2b for inj kit 120
mcg/0.5ml.......................................................................... 9
PEGINTRON -peginterferon alfa-2b for inj kit 150
mcg/0.5ml.......................................................................... 9
PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for
inj kit 120 mcg/0.5ml........................................................ 9
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
50 mcg/0.5ml.....................................................................8
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
80 mcg/0.5ml.....................................................................9
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
120 mcg/0.5ml.................................................................. 9
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
150 mcg/0.5ml.................................................................. 9
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240
gm (Colyte-flavor packs)............................................. 61
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236
gm (Golytely)................................................................. 61
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
(Nulytely/flavor pack)................................................... 61
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
PENTACEL -diph-ac per-tet tox ad-poliov-haemoph b poly
vac for im susp............................................................... 16
PENTASA -mesalamine cap cr 250 mg............................ 65
PENTASA -mesalamine cap cr 500 mg............................ 65
pentoxifylline tab cr 400 mg......................................... 142
PEPDITE JUNIOR -nutritional supplement pack............ 126
PEPTAMEN/PREBIO1 -nutritional supplement liquid..... 127
PEPTAMEN AF -nutritional supplement liquid................ 126
PEPTAMEN BARIATRIC -nutritional supplement
liquid.............................................................................. 127
PEPTAMEN 1 CAL/PREBIO1 -nutritional supplement
liquid.............................................................................. 127
PEPTAMEN 1.5 CAL/PREBIO1 -nutritional supplement
liquid.............................................................................. 127
PEPTAMEN 1 CAL -nutritional supplement liquid...........127
PEPTAMEN 1.5 CAL -nutritional supplement liquid........127
PEPTAMEN INTENSE VHP -nutritional supplement
liquid.............................................................................. 127
PEPTAMEN JUNIOR/PREBIO1 -nutritional supplement
liquid.............................................................................. 127
PEPTAMEN JUNIOR 1 CAL/PRE -nutritional supplement
liquid.............................................................................. 127
PEPTAMEN JUNIOR 1 CAL -nutritional supplement
liquid.............................................................................. 127
PEPTAMEN JUNIOR 1.5 CAL -nutritional supplement
liquid.............................................................................. 127
PEPTAMEN JUNIOR FIBER -nutritional supplement
liquid.............................................................................. 127
PEPTAMEN JUNIOR HP -nutritional supplement
liquid.............................................................................. 127
PEPTAMEN JUNIOR -nutritional supplement liquid....... 127
PEPTAMEN JUNIOR -nutritional supplement
powder........................................................................... 127
PEPTAMEN -nutritional supplement liquid...................... 126
PEPTAMEN 1.5 -nutritional supplement liquid................ 127
PEPTAMEN OS -nutritional supplement liquid............... 127
PEPTAMEN OS 1.5 -nutritional supplement liquid......... 127
PEPTAMEN VHP -nutritional supplement liquid............. 127
PEPTINEX DT -nutritional supplement liquid..................127
PEPTINEX DT WITH PREBIOTI -nutritional supplement
liquid.............................................................................. 127
PEPTINEX 1.0 -nutritional supplement liquid................. 127
PEPTINEX 1.5 -nutritional supplement liquid................. 127
PERATIVE -nutritional supplement liquid........................ 127
PERFOROMIST -formoterol fumarate soln nebu 20
mcg/2ml........................................................................... 59
PERIFLEX ADVANCE -nutritional supplement
powder........................................................................... 127
PERIFLEX JUNIOR -nutritional supplement powder...... 127
PERIFLEX LQ PKU -amino acids oral liquid.................. 115
perindopril erbumine tab 2 mg...................................... 48
perindopril erbumine tab 4 mg (Aceon)........................ 48
perindopril erbumine tab 8 mg (Aceon)........................ 48
permethrin cream 5% (Elimite).................................... 154
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-10 mg................................................ 83
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-25 mg................................................ 83
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-10 mg................................................ 84
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-25 mg................................................ 84
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 4-50 mg................................................ 84
perphenazine tab 2 mg................................................... 75
perphenazine tab 4 mg................................................... 75
perphenazine tab 8 mg................................................... 75
perphenazine tab 16 mg................................................. 75
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
4000-14375-15125 unit...................................................63
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2017
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
8000-28750-30250 unit...................................................63
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
16000-57500-60500 unit................................................ 63
PFD 1 -nutritional supplement powder............................ 127
PFD 2 -nutritional supplement powder............................ 127
PHENACTIN AA PLUS -nutritional supplement
liquid.............................................................................. 127
phenelzine sulfate tab 15 mg (Nardil)........................... 71
PHENEX-1 -nutritional supplement powder.................... 127
PHENEX-2 -nutritional supplement powder.................... 127
phenobarbital elixir 20 mg/5ml...................................... 77
PHENOBARBITAL -phenobarbital tab 15 mg................... 76
PHENOBARBITAL -phenobarbital tab 30 mg................... 77
PHENOBARBITAL -phenobarbital tab 60 mg................... 77
PHENOBARBITAL -phenobarbital tab 100 mg................. 77
phenobarbital tab 16.2 mg.............................................. 77
phenobarbital tab 32.4 mg.............................................. 77
phenobarbital tab 64.8 mg.............................................. 77
phenobarbital tab 97.2 mg.............................................. 77
phenoxybenzamine hcl cap 10 mg (Dibenzyline)........ 48
PHENYLADE AMINO ACID -amino acids bar................ 115
PHENYLADE AMINO ACID BLEN -amino acids
pack............................................................................... 115
PHENYLADE -amino acids oral powder......................... 115
PHENYLADE40 DRINK MIX -amino acids pack.............115
PHENYLADE60 DRINK MIX -nutritional supplement
pack............................................................................... 128
PHENYLADE DRINK MIX -nutritional supplement
powder........................................................................... 128
PHENYLADE60 DRINK MIX -nutritional supplement
powder........................................................................... 128
PHENYLADE ESSENTIAL DRINK -nutritional supplement
pack............................................................................... 128
PHENYLADE ESSENTIAL DRINK -nutritional supplement
powder........................................................................... 128
PHENYLADE GMP MIX-IN -nutritional supplement
pack............................................................................... 128
PHENYLADE GMP -nutritional supplement pack........... 128
PHENYLADE GMP -nutritional supplement powder....... 128
PHENYLADE MTE AMINO ACID -amino acids pack..... 115
PHENYLADE MTE -amino acids oral powder................ 115
PHENYLADE PHEBLOC -amino acids oral powder....... 115
PHENYLADE PHEBLOC -amino acids tab..................... 115
PHENYLADE RTD PKU 10 -nutritional supplement
liquid.............................................................................. 128
phenylephrine hcl ophth soln 2.5%............................. 145
phenylephrine hcl ophth soln 10%.............................. 146
PHENYL-FREE 2HP -nutritional supplement
powder........................................................................... 127
PHENYL-FREE 2 -nutritional supplement powder..........127
PHENYLHISTINE DH -pseudoephedrine-chlorphen w/
codeine liq 30-2-10 mg/5ml............................................ 56
PHENYTEK -phenytoin sodium extended cap 200
mg.................................................................................. 100
PHENYTEK -phenytoin sodium extended cap 300
mg.................................................................................. 100
phenytoin chew tab 50 mg (Dilantin infatabs)............100
phenytoin sodium extended cap 100 mg
(Dilantin)....................................................................... 100
phenytoin sodium extended cap 200 mg
(Phenytek).................................................................... 100
phenytoin sodium extended cap 300 mg
(Phenytek).................................................................... 100
phenytoin susp 125 mg/5ml (Dilantin)........................ 100
PHLEXY-10 -amino acids cap......................................... 115
PHLEXY-10 -nutritional supplement pack....................... 128
PHLEXY-VITS -multiple vitamins w/ minerals
powder........................................................................... 108
PHOS-FLUR ORTHO DEFENSE -sodium fluoride rinse
0.044%.......................................................................... 148
PHOS FLUR -sodium fluoride rinse 0.044%................... 148
PHOSLYRA -calcium acetate (phosphate binder) oral soln
667 mg/5ml..................................................................... 65
PHYSICIANS EZ USE JOINT T -triamcinolone inj 40 mg/
ml & lidocaine 1% & ammonia inh kit............................ 23
PHYTOFUSION -nutritional supplement pack................ 128
phytonadione inj 1 mg/0.5ml (2 mg/ml).......................105
PICATO -ingenol mebutate gel 0.015%.......................... 154
PICATO -ingenol mebutate gel 0.05%............................ 154
pilocarpine hcl ophth soln 1% (Isopto carpine)......... 146
pilocarpine hcl ophth soln 2% (Isopto carpine)......... 146
pilocarpine hcl ophth soln 4% (Isopto carpine)......... 146
pilocarpine hcl tab 5 mg (Salagen)..............................148
pilocarpine hcl tab 7.5 mg (Salagen)...........................148
pimozide tab 1 mg (Orap)............................................... 84
pimozide tab 2 mg (Orap)............................................... 84
pindolol tab 5 mg............................................................. 42
pindolol tab 10 mg........................................................... 42
pioglitazone hcl-metformin hcl tab 15-500 mg
(Actoplus met)............................................................... 32
pioglitazone hcl-metformin hcl tab 15-850 mg
(Actoplus met)............................................................... 32
pioglitazone hcl tab 15 mg (base equiv) (Actos)..........32
pioglitazone hcl tab 30 mg (base equiv) (Actos)..........32
pioglitazone hcl tab 45 mg (base equiv) (Actos)..........32
piroxicam cap 10 mg (Feldene)..................................... 94
piroxicam cap 20 mg (Feldene)..................................... 94
PIVOT 1.5 CAL -nutritional supplement liquid................ 128
PKU COOLER 10 -nutritional supplement liquid.............128
PKU COOLER 15 -nutritional supplement liquid.............128
PKU COOLER 20 -nutritional supplement liquid.............128
PKU EXPRESS -nutritional supplement pack.................128
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PKU EXPRESS20 -nutritional supplement pack.............128
PKU GEL -nutritional supplement pack.......................... 128
PKU LOPHLEX LQ 20 -nutritional supplement liquid..... 128
PKU 2 -nutritional supplement powder........................... 128
PKU 3 -nutritional supplement powder........................... 128
PKU PERIFLEX EARLY YEARS -nutritional supplement
powder........................................................................... 128
PKU PERIFLEX JUNIOR PLUS -nutritional supplement
powder........................................................................... 128
PKU SPHERE 20 -nutritional supplement pack.............. 128
PKU TRIO -nutritional supplement powder..................... 128
PLEGRIDY -peginterferon beta-1a soln pen-injector 125
mcg/0.5ml........................................................................ 84
PLEGRIDY -peginterferon beta-1a soln prefilled syringe
125 mcg/0.5ml................................................................ 84
PLEGRIDY STARTER PACK -peginterferon beta-1a soln
pen-inj 63 & 94 mcg/0.5ml pack.................................... 84
PLEGRIDY STARTER PACK -peginterferon beta-1a soln
pref syr 63 & 94 mcg/0.5ml pack................................... 84
PLIAGLIS -lidocaine-tetracaine cream 7-7%.................. 154
PNEUMOVAX 23/1 DOSE -pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml............................................ 15
PNEUMOVAX 23/5 DOSE -pneumococcal vaccine
polyvalent inj 25 mcg/0.5ml............................................ 15
PNEUMOVAX 23 -pneumococcal vaccine polyvalent inj
25 mcg/0.5ml.................................................................. 15
PNV-DHA+DOCUSATE -prenatal w/o vit a w/ fe fum-dssfa-dha cap 27-1.25-300 mg.......................................... 108
PNV-DHA -prenat w/o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg........................................................ 108
PNV FERROUS FUMARATE/DOCU -prenatal vit w/ dssfe fumarate-fa tab 29-1 mg.......................................... 108
PNV OB+DHA -prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 250 mg pack...................................................108
PNV-OMEGA -prenat w/o a w/ fe fumerate-methylfolatefa-omega 3 cap............................................................. 108
PNV PRENATAL PLUS MULTIVI -prenatal vit w/ fe
fumarate-fa tab 27-1 mg...............................................108
PNV-SELECT -prenatal vit w/ fe fum-methylfolate-fa tab
27-0.6-0.4 mg................................................................ 108
PNV TABS 29-1 -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................. 108
PNV-TOTAL -prenat w/ fe cbn-fe bisglyc-fa-fish oil cap
35-5-1.2 mg................................................................... 109
PNV-VP-U -prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg.................................................................... 109
podofilox soln 0.5% (Condylox)................................... 154
POLYCAL -nutritional supplement powder......................128
polyethylene glycol 3350 oral packet............................ 61
polyethylene glycol 3350 oral powder.......................... 61
polymyxin b-trimethoprim ophth soln 10000 unit/
ml-0.1% (Polytrim)...................................................... 146
POLY-TUSSIN AC -phenylephrine-bromphen w/ codeine
liquid 10-4-10 mg/5ml..................................................... 56
POMALYST -pomalidomide cap 1 mg.............................. 20
POMALYST -pomalidomide cap 2 mg.............................. 20
POMALYST -pomalidomide cap 3 mg.............................. 20
POMALYST -pomalidomide cap 4 mg.............................. 20
PORTAGEN -nutritional supplement powder.................. 128
potassium chloride cap cr 8 meq (Micro-k)................ 114
potassium chloride cap cr 10 meq (Micro-k).............. 114
POTASSIUM CHLORIDE ER -potassium chloride tab cr 8
meq (600 mg)............................................................... 114
POTASSIUM CHLORIDE ER -potassium chloride tab cr
20 meq (1500 mg)........................................................ 114
potassium chloride microencapsulated crys cr tab 10
meq............................................................................... 114
potassium chloride microencapsulated crys cr tab 20
meq............................................................................... 114
potassium chloride oral soln 10% (20 meq/15ml)...... 114
POTASSIUM CHLORIDE -potassium chloride oral soln
20% (40 meq/15ml)...................................................... 114
potassium chloride powder packet 20 meq............... 114
potassium chloride tab cr 10 meq (K-tab).................. 114
potassium chloride tab cr 8 meq (600 mg)................. 114
potassium citrate tab cr 5 meq (540 mg) (Urocit-k
5)...................................................................................... 68
potassium citrate tab cr 10 meq (1080 mg) (Urocit-k
10).................................................................................... 68
potassium citrate tab cr 15 meq (1620 mg) (Urocit-k
15).................................................................................... 68
POTIGA -ezogabine tab 50 mg....................................... 100
POTIGA -ezogabine tab 200 mg..................................... 100
POTIGA -ezogabine tab 300 mg..................................... 100
POTIGA -ezogabine tab 400 mg..................................... 100
PPA/MMA EXPRESS -nutritional supplement pack........ 128
PRADAXA -dabigatran etexilate mesylate cap 75 mg
(etexilate base eq)........................................................ 136
PRADAXA -dabigatran etexilate mesylate cap 110 mg
(etexilate base eq)........................................................ 136
PRADAXA -dabigatran etexilate mesylate cap 150 mg
(etexilate base eq)........................................................ 136
PRALUENT -alirocumab subcutaneous soln pen-injector
75 mg/ml......................................................................... 53
PRALUENT -alirocumab subcutaneous soln pen-injector
150 mg/ml....................................................................... 53
pramipexole dihydrochloride tab 0.125 mg
(Mirapex).......................................................................103
pramipexole dihydrochloride tab 0.25 mg
(Mirapex).......................................................................103
pramipexole dihydrochloride tab 0.5 mg
(Mirapex).......................................................................103
pramipexole dihydrochloride tab 0.75 mg
(Mirapex).......................................................................103
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pramipexole dihydrochloride tab 1 mg (Mirapex)...... 103
pramipexole dihydrochloride tab 1.5 mg
(Mirapex).......................................................................103
pramipexole dihydrochloride tab sr 24hr 0.375 mg
(Mirapex er).................................................................. 102
pramipexole dihydrochloride tab sr 24hr 0.75 mg
(Mirapex er).................................................................. 103
pramipexole dihydrochloride tab sr 24hr 1.5 mg
(Mirapex er).................................................................. 103
pramipexole dihydrochloride tab sr 24hr 2.25 mg
(Mirapex er).................................................................. 103
pramipexole dihydrochloride tab sr 24hr 3 mg
(Mirapex er).................................................................. 103
pramipexole dihydrochloride tab sr 24hr 3.75 mg
(Mirapex er).................................................................. 103
pramipexole dihydrochloride tab sr 24hr 4.5 mg
(Mirapex er).................................................................. 103
pravastatin sodium tab 10 mg....................................... 53
pravastatin sodium tab 20 mg (Pravachol)...................53
pravastatin sodium tab 40 mg (Pravachol)...................53
pravastatin sodium tab 80 mg (Pravachol)...................53
prazosin hcl cap 1 mg (Minipress)................................ 48
prazosin hcl cap 2 mg (Minipress)................................ 48
prazosin hcl cap 5 mg (Minipress)................................ 48
PRED-G -gentamicin-prednisolone ace ophth susp
0.3-1%........................................................................... 146
PRED-G S.O.P. -gentamicin-prednisolone ace ophth oint
0.3-0.6%........................................................................ 146
PRED MILD -prednisolone acetate ophth susp
0.12%.............................................................................146
prednicarbate cream 0.1% (Dermatop)....................... 154
prednicarbate oint 0.1% (Dermatop)........................... 154
prednisolone acetate ophth susp 1% (Pred forte)..... 146
PREDNISOLONE SODIUM PHOSP -prednisolone
sodium phosphate ophth soln 1%................................ 146
PREDNISOLONE SODIUM PHOSP -prednisolone
sodium phosphate oral soln 25 mg/5ml (base eq)......... 23
prednisolone sod phos orally disintegr tab 10 mg
(base eq) (Orapred odt)............................................... 23
prednisolone sod phos orally disintegr tab 15 mg
(base eq) (Orapred odt)............................................... 23
prednisolone sod phos orally disintegr tab 30 mg
(base eq) (Orapred odt)............................................... 23
prednisolone sod phosphate oral soln 15 mg/5ml
(base equiv)................................................................... 23
prednisolone sod phosphate oral soln 10 mg/5ml
(base equiv) (Millipred)................................................ 23
prednisolone sod phosphate oral soln 20 mg/5ml
(base equiv) (Veripred 20)........................................... 23
prednisolone sod phosph oral soln 6.7 mg/5ml (5
mg/5ml base) (Pediapred)............................................23
prednisolone syrup 15 mg/5ml (usp solution
equivalent) (Prelone).................................................... 23
PREDNISONE INTENSOL -prednisone conc 5 mg/ml..... 23
PREDNISONE -prednisone oral soln 5 mg/5ml................ 23
PREDNISONE -prednisone tab 50 mg............................. 23
PREDNISONE -prednisone tab therapy pack 5 mg
(21).................................................................................. 23
PREDNISONE -prednisone tab therapy pack 5 mg
(48).................................................................................. 23
PREDNISONE -prednisone tab therapy pack 10 mg
(21).................................................................................. 23
PREDNISONE -prednisone tab therapy pack 10 mg
(48).................................................................................. 23
prednisone tab 1 mg....................................................... 23
prednisone tab 2.5 mg.................................................... 23
prednisone tab 5 mg....................................................... 23
prednisone tab 10 mg..................................................... 23
prednisone tab 20 mg..................................................... 23
PREFERAOB +DHA -prenat-fe poly cmplx 28mg-fe heme
poly-fa tab&dha cap pack.............................................109
PREFERAOB ONE -prenat-fe poly cmplx-fe heme polyfa-dha cap 22-6-1-200 mg............................................109
PREFERA OB -prenat vit-fe poly cmplx-fe heme poly-fa
tab 34-1 mg...................................................................109
PREFEST -estradiol tab 1 mg(15)/estrad-norgestimate
tab 1-0.09mg(15)............................................................ 26
PREMARIN -estrogens, conjugated tab 0.3 mg............... 26
PREMARIN -estrogens, conjugated tab 0.45 mg............. 26
PREMARIN -estrogens, conjugated tab 0.625 mg........... 26
PREMARIN -estrogens, conjugated tab 0.9 mg............... 26
PREMARIN -estrogens, conjugated tab 1.25 mg............. 26
PREMARIN -estrogens, conjugated vaginal cream 0.625
mg/gm.............................................................................. 67
PREMPHASE -conj est 0.625(14)/conj est-medroxypro ac
tab 0.625-5mg(14).......................................................... 26
PREMPRO -conjugated estrogen-medroxyprogest
acetate tab 0.3-1.5 mg................................................... 26
PREMPRO -conjugated estrogen-medroxyprogest
acetate tab 0.45-1.5 mg................................................. 26
PREMPRO -conjugated estrogen-medroxyprogest
acetate tab 0.625-2.5 mg............................................... 26
PREMPRO -conjugated estrogen-medroxyprogest
acetate tab 0.625-5 mg.................................................. 26
PRENA1 CHEW -prenat w/ b2-b6-b12-d3-folic acid chew
tab 1.4 mg..................................................................... 110
PRENAISSANCE BALANCE -prenatal w/o vit a w/ fe cbndss-fa-dha cap 30-1-260 mg........................................ 109
PRENAISSANCE HARMONY DHA -prenat w/fe poly-na
fered-fa tab 27-1 & omega cap dr 380mg....................109
PRENAISSANCE NEXT-B -prenatal w/ calcium-vit b6-faginger tab 1.22 mg....................................................... 109
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PRENAISSANCE NEXT -prenatal w/ calcium-vit b6-faginger tab 1.2 mg......................................................... 109
PRENAISSANCE PLUS -prenatal w/o a w/fe cbn-dss-fadha cap 28-1-250 mg................................................... 109
PRENAISSANCE -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg..................................................... 109
PRENA1 PEARL -prenat w/oa w/fefum-na fered-fa-dha
cap cr 30-1.4-200 mg................................................... 110
PRENATABS FA -prenatal vit w/ fe fumarate-fa tab 29-1
mg.................................................................................. 109
PRENATABS RX -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................. 109
PRENATAL PLUS IRON -prenatal vit w/ iron carbonyl-fa
tab 29-1 mg...................................................................109
PRENATAL PLUS -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 109
PRENATAL 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg.................................................................................. 109
PRENATAL 19 -prenatal vit w/ fe fumarate-fa chew tab
29-1 mg......................................................................... 109
PRENATAL -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 109
PRENATAL-U -prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg.................................................................... 109
PRENATAL VITAMINS PLUS LO -prenatal vit w/ fe
fumarate-fa tab 27-1 mg...............................................109
PRENATE AM -prenatal w/ calcium-vit b6-vit b12-faginger tab 1 mg............................................................ 109
PRENATE DHA -prenat w/o a w/feaspg-methfol-fa-dha
cap 18-0.6-0.4-300 mg................................................. 110
PRENATE DHA -prenat w/o a w/fefum-methfol-fa-dha cap
28-0.6-0.4-300 mg........................................................ 110
PRENATE ELITE -prenatal vit w/ fe fum-methylfolate-fa
tab 26-0.6-0.4 mg......................................................... 110
PRENATE ELITE -prenatal w/ fe asp gly-l methylfol-fa tab
20-0.6-0.4 mg................................................................ 110
PRENATE ENHANCE -prenat w/o a w/fefum-methfol-fadha cap 28-0.6-0.4-400 mg.......................................... 110
PRENATE ESSENTIAL -prenat w/o a w/feaspg-methfolfa-dha cap 18-0.6-0.4-300 mg..................................... 110
PRENATE ESSENTIAL -prenat w/o a w/feasp-methylf-faomeg cap 29-0.6-0.4-340 mg....................................... 110
PRENATE MINI -prenat w/oa w/fecb-feasp-meth-fa-dha
cap 18-0.6-0.4-350 mg................................................. 110
PRENATE MINI -prenat w/o a w/fecbn-methylf-fa-dha cap
29-0.6-0.4-350 mg........................................................ 110
PRENATE PIXIE -prenat w/o a w/feaspg-methfol-fa-dha
cap 10-0.6-0.4-200 mg................................................. 110
PRENATE -prenat mv & min w/ l-methylfolate-fa chew tab
0.6-0.4 mg..................................................................... 109
PRENATE RESTORE -prenat w/o a w/fefum-methfol-fadha cap 27-0.6-0.4-400 mg.......................................... 110
PRENATE STAR -prenatal vit w/ fe asparto glycinate-fa
tab 20-1 mg...................................................................110
PREPIDIL -dinoprostone cervical gel 0.5 mg/3gm............37
PREPLUS -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 110
PREPOPIK -sod picosulfate-mg oxide-citric acid pack 10
mg-3.5 gm-12 gm........................................................... 61
PREPROTEIN -amino acids oral liquid........................... 115
PREPROTEIN 20 -amino acids oral liquid...................... 115
PRETAB -prenatal vit w/ fe fumarate-fa tab 29-1 mg...... 110
PREVIDENT 5000 BOOSTER PL -sodium fluoride paste
1.1%...............................................................................148
PREVIDENT 5000 BOOSTER -sodium fluoride paste
1.1%...............................................................................148
PREVIDENT 5000 DRY MOUTH -sodium fluoride gel
1.1% (0.5% f)................................................................ 148
PREVIDENT 5000 ENAMEL PRO -sodium fluoridepotassium nitrate paste 1.1-5%................................... 149
PREVIDENT FLUORIDE -sodium fluoride gel 1.1% (0.5%
f)..................................................................................... 148
PREVIDENT 5000 PLUS -sodium fluoride cream
1.1%...............................................................................149
PREVIDENT 5000 SENSITIVE -sodium fluoridepotassium nitrate paste 1.1-5%................................... 149
PREVNAR 13 -pneumococcal 13-valent conjugate
vaccine inj....................................................................... 15
PREZCOBIX -darunavir-cobicistat tab 800-150 mg............9
PREZISTA -darunavir ethanolate susp 100 mg/ml (base
equiv)................................................................................. 9
PREZISTA -darunavir ethanolate tab 75 mg (base
equiv)................................................................................. 9
PREZISTA -darunavir ethanolate tab 150 mg (base
equiv)................................................................................. 9
PREZISTA -darunavir ethanolate tab 600 mg (base
equiv)................................................................................. 9
PREZISTA -darunavir ethanolate tab 800 mg (base
equiv)................................................................................. 9
PRIFTIN -rifapentine tab 150 mg........................................ 5
PRIMAQUINE PHOSPHATE -primaquine phosphate tab
26.3 mg........................................................................... 12
primidone tab 50 mg (Mysoline).................................. 100
primidone tab 250 mg (Mysoline)................................ 100
PRIMSOL -trimethoprim hcl oral soln 50 mg/5ml (base
equiv)............................................................................... 12
PRISTIQ -desvenlafaxine succinate tab sr 24hr 25 mg
(base equiv).................................................................... 71
PRISTIQ -desvenlafaxine succinate tab sr 24hr 50 mg
(base equiv).................................................................... 71
PRISTIQ -desvenlafaxine succinate tab sr 24hr 100 mg
(base equiv).................................................................... 71
PR NATAL 400 EC -prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 400 pk................................................... 109
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PR NATAL 430 EC -prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 430 pk................................................... 109
PR NATAL 400 -prenat-fe bis-fe prot succ-fa-ca tab &
omega 3 cap 400 pk.................................................... 109
PR NATAL 430 -prenat-fe bis-fe prot succ-fa-ca tab &
omega 3 cap 430 pk.................................................... 109
PROAIR HFA -albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv)........................................................ 59
PROAIR RESPICLICK -albuterol sulfate aer pow ba 108
mcg/act (90 mcg base equiv)......................................... 59
PROBALANCE -nutritional supplement liquid................. 128
probenecid tab 500 mg................................................... 96
PRO-CAL -nutritional supplement pack.......................... 128
PRO-CAL -nutritional supplement powder...................... 128
prochlorperazine maleate tab 5 mg (Compazine)........ 75
prochlorperazine maleate tab 10 mg (Compazine)...... 75
prochlorperazine suppos 25 mg.................................... 75
PRO-CLEAR AC -codeine-pyrilamine syrup 9-8.33
mg/5ml............................................................................. 56
PROCRIT -epoetin alfa inj 2000 unit/ml.......................... 135
PROCRIT -epoetin alfa inj 3000 unit/ml.......................... 135
PROCRIT -epoetin alfa inj 4000 unit/ml.......................... 135
PROCRIT -epoetin alfa inj 10000 unit/ml........................ 135
PROCRIT -epoetin alfa inj 20000 unit/ml........................ 135
PROCRIT -epoetin alfa inj 40000 unit/ml........................ 135
PROCTOFOAM HC -hydrocortisone acetate w/
pramoxine rectal foam 1-1%........................................ 149
PROCYSBI -cysteamine bitartrate cap delayed release 25
mg (base equiv).............................................................. 68
PROCYSBI -cysteamine bitartrate cap delayed release 75
mg (base equiv).............................................................. 68
PROFILNINE -factor ix complex for inj 500 unit............. 142
PROFILNINE -factor ix complex for inj 1000 unit........... 142
PROFILNINE -factor ix complex for inj 1500 unit........... 142
PROFILNINE SD -factor ix complex for inj 500 unit........142
PROFILNINE SD -factor ix complex for inj 1000 unit......142
PROFILNINE SD -factor ix complex for inj 1500 unit......142
progesterone im in oil 50 mg/ml.................................... 29
progesterone micronized cap 100 mg
(Prometrium).................................................................. 29
progesterone micronized cap 200 mg
(Prometrium).................................................................. 29
PROGLYCEM -diazoxide susp 50 mg/ml......................... 32
PROGRAF -tacrolimus cap 0.5 mg................................. 158
PROGRAF -tacrolimus cap 1 mg.................................... 158
PROGRAF -tacrolimus cap 5 mg.................................... 158
PROLENSA -bromfenac sodium ophth soln 0.07% (base
equivalent)..................................................................... 146
PROMACTA -eltrombopag olamine tab 12.5 mg (base
equiv)............................................................................. 135
PROMACTA -eltrombopag olamine tab 25 mg (base
equiv)............................................................................. 135
PROMACTA -eltrombopag olamine tab 50 mg (base
equiv)............................................................................. 135
PROMACTA -eltrombopag olamine tab 75 mg (base
equiv)............................................................................. 135
PROMACTIN AA PLUS -nutritional supplement
liquid.............................................................................. 128
promethazine & phenylephrine syrup 6.25-5
mg/5ml............................................................................ 56
promethazine-dm syrup 6.25-15 mg/5ml.......................56
promethazine hcl suppos 12.5 mg................................ 55
promethazine hcl suppos 25 mg................................... 55
promethazine hcl suppos 50 mg................................... 55
promethazine hcl syrup 6.25 mg/5ml............................ 55
promethazine hcl tab 12.5 mg........................................ 55
promethazine hcl tab 25 mg........................................... 55
promethazine hcl tab 50 mg........................................... 55
promethazine-phenylephrine-codeine syrup 6.25-5-10
mg/5ml............................................................................ 56
promethazine w/ codeine syrup 6.25-10 mg/5ml..........56
PROMOD -nutritional supplement liquid......................... 128
PROMOD -nutritional supplement powder...................... 128
PROMOTE/FIBER -nutritional supplement liquid........... 129
PROMOTE -nutritional supplement liquid....................... 129
PROMOTE 1.0 -nutritional supplement liquid................. 129
PROMOTE WITH FIBER -nutritional supplement
liquid.............................................................................. 129
PROMOTE 1.0 WITH FIBER -nutritional supplement
liquid.............................................................................. 129
propafenone hcl cap sr 12hr 225 mg (Rythmol sr)...... 44
propafenone hcl cap sr 12hr 325 mg (Rythmol sr)...... 44
propafenone hcl cap sr 12hr 425 mg (Rythmol sr)...... 45
propafenone hcl tab 300 mg.......................................... 45
propafenone hcl tab 150 mg (Rythmol)........................ 45
propafenone hcl tab 225 mg (Rythmol)........................ 45
PROPANTHELINE BROMIDE -propantheline bromide tab
15 mg.............................................................................. 62
proparacaine hcl ophth soln 0.5% (Alcaine).............. 146
PRO-PHREE -nutritional supplement powder................ 128
PROPIMEX-1 -nutritional supplement powder................ 129
PROPIMEX-2 -nutritional supplement powder................ 129
propranolol hcl cap sr 24hr 60 mg (Inderal la)............. 42
propranolol hcl cap sr 24hr 80 mg (Inderal la)............. 42
propranolol hcl cap sr 24hr 120 mg (Inderal la)........... 42
propranolol hcl cap sr 24hr 160 mg (Inderal la)........... 42
propranolol hcl tab 10 mg.............................................. 42
propranolol hcl tab 20 mg.............................................. 42
propranolol hcl tab 40 mg.............................................. 42
propranolol hcl tab 60 mg.............................................. 42
propranolol hcl tab 80 mg.............................................. 42
propylthiouracil tab 50 mg............................................. 36
PRO-RED AC -phenylephrine-dexchlorphenir-codeine
syrup 5-1-9 mg/5ml.........................................................56
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PROSOURCE NO CARB -nutritional supplement
liquid.............................................................................. 129
PROSOURCE -nutritional supplement liquid.................. 129
PROSOURCE -nutritional supplement powder............... 129
PROSOURCE PLUS -nutritional supplement liquid........129
PROSOURCE TF -nutritional supplement liquid.............129
PROSOURCE ZAC -nutritional supplement liquid.......... 129
PROSTIN E2 -dinoprostone vaginal suppos 20 mg......... 37
PROSURE -nutritional supplement liquid........................129
PROTAIN XL -nutritional supplement liquid.................... 129
PROTEIN FORTIFIED COOKIE -nutritional supplement
misc............................................................................... 129
protriptyline hcl tab 5 mg (Vivactil)............................... 72
protriptyline hcl tab 10 mg (Vivactil)............................. 72
PROVIDA DHA -prenat w/o a w/fe fum-fe poly-fa-dha cap
16-16-1.25-110 mg........................................................110
PROVIDA OB -prenatal w/o a w/fe fum-fe poly-fa cap
20-20-1.25 mg...............................................................110
PROVIMIN -nutritional supplement powder.................... 129
PRUDOXIN -doxepin hcl cream 5%............................... 154
pseudoeph-chlorphen w/ hydrocodone soln 60-4-5
mg/5ml (Zutripro).......................................................... 56
pseudoephed-bromphen-dm syrup 30-2-10
mg/5ml............................................................................ 56
pseudoephedrine-bromphen-codeine liq 10-1.33-6.33
mg/5ml............................................................................ 57
pseudoephedrine w/ cod-gg soln 30-10-100
mg/5ml............................................................................ 56
PULMOCARE -nutritional supplement liquid.................. 129
PULMOCARE 1.5 -nutritional supplement liquid............ 129
PULMOZYME -dornase alfa inhal soln 1 mg/ml............... 60
PUREFE OB PLUS -prenatal w/o a w/fe fum-fe poly-fa
cap 162.115.2-1 mg...................................................... 110
PURIXAN -mercaptopurine susp 2000 mg/100ml (20 mg/
ml).................................................................................... 20
PX VANILLA PLUS -nutritional supplement liquid.......... 129
pyrazinamide tab 500 mg..................................................5
pyridostigmine bromide tab cr 180 mg (Mestinon
timespan)......................................................................105
pyridostigmine bromide tab 60 mg (Mestinon).......... 105
Q
QUADRACEL -diph-tetanus tox ad-acell pert & polio
virus, ipv vac inj.............................................................. 16
QUARTETTE -levonor-eth est tab 0.15-0.02/0.025/0.03
mg &eth est 0.01 mg...................................................... 28
QUAZEPAM -quazepam tab 15 mg.................................. 77
QUDEXY XR -topiramate cap er 24hr sprinkle 25
mg.................................................................................. 100
QUDEXY XR -topiramate cap er 24hr sprinkle 50
mg.................................................................................. 100
QUDEXY XR -topiramate cap er 24hr sprinkle 100
mg.................................................................................. 100
QUDEXY XR -topiramate cap er 24hr sprinkle 150
mg.................................................................................. 100
QUDEXY XR -topiramate cap er 24hr sprinkle 200
mg.................................................................................. 100
QUETIAPINE FUMARATE ER -quetiapine fumarate tab sr
24hr 50 mg......................................................................75
QUETIAPINE FUMARATE ER -quetiapine fumarate tab sr
24hr 150 mg....................................................................75
QUETIAPINE FUMARATE ER -quetiapine fumarate tab sr
24hr 200 mg....................................................................75
QUETIAPINE FUMARATE ER -quetiapine fumarate tab sr
24hr 300 mg....................................................................75
quetiapine fumarate tab 25 mg (Seroquel)................... 75
quetiapine fumarate tab 50 mg (Seroquel)................... 75
quetiapine fumarate tab 100 mg (Seroquel)................. 75
quetiapine fumarate tab 200 mg (Seroquel)................. 75
quetiapine fumarate tab 300 mg (Seroquel)................. 75
quetiapine fumarate tab 400 mg (Seroquel)................. 75
quetiapine fumarate tab sr 24hr 400 mg (Seroquel
xr).................................................................................... 75
quinapril hcl tab 5 mg (Accupril)................................... 48
quinapril hcl tab 10 mg (Accupril)................................. 48
quinapril hcl tab 20 mg (Accupril)................................. 48
quinapril hcl tab 40 mg (Accupril)................................. 48
quinapril-hydrochlorothiazide tab 10-12.5 mg
(Accuretic)...................................................................... 48
quinapril-hydrochlorothiazide tab 20-12.5 mg
(Accuretic)...................................................................... 48
quinapril-hydrochlorothiazide tab 20-25 mg
(Accuretic)...................................................................... 49
quinidine gluconate tab cr 324 mg................................ 45
QUINIDINE SULFATE -quinidine sulfate tab 200 mg....... 45
QUINIDINE SULFATE -quinidine sulfate tab 300 mg....... 45
quinine sulfate cap 324 mg (Qualaquin)....................... 12
QUINOA KALE & HEMP -nutritional supplement
liquid.............................................................................. 129
QVAR -beclomethasone diprop inhal aero soln 40 mcg/act
(50/valve)......................................................................... 59
QVAR -beclomethasone diprop inhal aero soln 80 mcg/act
(100/valve)....................................................................... 59
R
RA BALANCED NUTRITIONAL -nutritional supplement
liquid.............................................................................. 129
RA BALANCED NUTRITIONAL P -nutritional supplement
liquid.............................................................................. 129
RABAVERT -rabies vaccine, pcec for inj.......................... 15
rabeprazole sodium ec tab 20 mg (Aciphex)................ 62
RADIOGARDASE -prussian blue insoluble cap 0.5
gm.................................................................................. 156
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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RAGWITEK -short ragweed pollen allergen extract tab sl
12 amb a 1-u.................................................................. 16
raloxifene hcl tab 60 mg (Evista)................................... 39
ramipril cap 1.25 mg (Altace)......................................... 49
ramipril cap 2.5 mg (Altace)........................................... 49
ramipril cap 5 mg (Altace).............................................. 49
ramipril cap 10 mg (Altace)............................................ 49
RANEXA -ranolazine tab sr 12hr 500 mg......................... 41
RANEXA -ranolazine tab sr 12hr 1000 mg....................... 41
ranitidine hcl cap 150 mg............................................... 62
ranitidine hcl cap 300 mg............................................... 62
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)................... 62
ranitidine hcl tab 300 mg (Zantac)................................. 62
RA NUTRITIONAL SUPPLEMENT -nutritional
supplement liquid.......................................................... 129
RA NUTRITIONAL SUPPORT -nutritional supplement
powder........................................................................... 129
RAPAFLO -silodosin cap 4 mg..........................................68
RAPAFLO -silodosin cap 8 mg..........................................68
RAPAMUNE -sirolimus oral soln 1 mg/ml....................... 158
RA PEDIATRIC NUTRITIONAL -nutritional supplement
liquid.............................................................................. 129
rasagiline mesylate tab 0.5 mg (base equiv)
(Azilect).........................................................................103
rasagiline mesylate tab 1 mg (base equiv)
(Azilect).........................................................................103
RASUVO -methotrexate soln pf auto-injector 7.5
mg/0.15ml........................................................................ 94
RASUVO -methotrexate soln pf auto-injector 10
mg/0.2ml.......................................................................... 94
RASUVO -methotrexate soln pf auto-injector 12.5
mg/0.25ml........................................................................ 94
RASUVO -methotrexate soln pf auto-injector 15
mg/0.3ml.......................................................................... 94
RASUVO -methotrexate soln pf auto-injector 17.5
mg/0.35ml........................................................................ 94
RASUVO -methotrexate soln pf auto-injector 20
mg/0.4ml.......................................................................... 94
RASUVO -methotrexate soln pf auto-injector 22.5
mg/0.45ml........................................................................ 94
RASUVO -methotrexate soln pf auto-injector 25
mg/0.5ml.......................................................................... 95
RASUVO -methotrexate soln pf auto-injector 27.5
mg/0.55ml........................................................................ 95
RASUVO -methotrexate soln pf auto-injector 30
mg/0.6ml.......................................................................... 95
RAVICTI -glycerol phenylbutyrate liquid 1.1 gm/ml...........39
RE/GEN PROTEIN FORTIFIED -nutritional supplement
misc............................................................................... 129
RE/NEPH HP/HC -nutritional supplement liquid
(frozen).......................................................................... 129
RE/NEPH LP/HC -nutritional supplement liquid..............129
RE/NEPH -nutritional supplement liquid......................... 129
RE/NEPH REDUCED SUGAR -nutritional supplement
liquid.............................................................................. 129
REBETOL -ribavirin soln 40 mg/ml..................................... 9
REBIF -interferon beta-1a soln pref syr 22 mcg/0.5ml
(12mu/ml)........................................................................ 84
REBIF -interferon beta-1a soln pref syr 44 mcg/0.5ml
(24mu/ml)........................................................................ 84
REBIF REBIDOSE -interferon beta-1a soln auto-inj 22
mcg/0.5ml (12mu/ml)...................................................... 84
REBIF REBIDOSE -interferon beta-1a soln auto-inj 44
mcg/0.5ml (24mu/ml)...................................................... 84
REBIF REBIDOSE TITRATION -interferon beta-1a autoinj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml.......................... 84
REBIF TITRATION PACK -interferon beta-1a pref syr
6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml............................... 84
RECOMBINATE -antihemophilic factor (recombinant) for
inj 220-400 unit............................................................. 142
RECOMBINATE -antihemophilic factor (recombinant) for
inj 401-800 unit............................................................. 142
RECOMBINATE -antihemophilic factor (recombinant) for
inj 801-1240 unit........................................................... 142
RECOMBINATE -antihemophilic factor (recombinant) for
inj 1241-1800 unit......................................................... 142
RECOMBINATE -antihemophilic factor (recombinant) for
inj 1801-2400 unit......................................................... 142
RECOMBIVAX HB -hepatitis b vaccine (recombinant)
susp 5 mcg/0.5ml........................................................... 15
RECOMBIVAX HB -hepatitis b vaccine (recombinant)
susp 10 mcg/ml.............................................................. 15
RECOMBIVAX HB -hepatitis b vaccine (recombinant)
susp 40 mcg/ml.............................................................. 15
RECTIV -nitroglycerin oint 0.4%..................................... 149
REGRANEX -becaplermin gel 0.01%............................. 154
RELENZA DISKHALER -zanamivir aero powder breath
activated 5 mg/blister........................................................9
RELION R -insulin regular (human) inj 100 unit/ml........... 34
RELNATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................. 110
RELPAX -eletriptan hydrobromide tab 20 mg (base
equivalent)....................................................................... 95
RELPAX -eletriptan hydrobromide tab 40 mg (base
equivalent)....................................................................... 95
REMBRANDT DEEPLY WHITE+PE -sodium
monofluorophosphate paste 0.884%........................... 149
RENAGEL -sevelamer hcl tab 400 mg............................. 65
RENAGEL -sevelamer hcl tab 800 mg............................. 65
RENALCAL -nutritional supplement liquid...................... 129
RENASTART -nutritional supplement powder................ 129
RENVELA -sevelamer carbonate packet 0.8 gm.............. 65
RENVELA -sevelamer carbonate packet 2.4 gm.............. 65
RENVELA -sevelamer carbonate tab 800 mg.................. 65
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2017
REPAGLINIDE/METFORMIN HYD -repaglinide-metformin
hcl tab 1-500 mg.............................................................33
REPAGLINIDE/METFORMIN HYD -repaglinide-metformin
hcl tab 2-500 mg.............................................................33
repaglinide tab 0.5 mg (Prandin)................................... 32
repaglinide tab 1 mg (Prandin)...................................... 32
repaglinide tab 2 mg (Prandin)...................................... 32
REPATHA -evolocumab subcutaneous soln prefilled
syringe 140 mg/ml.......................................................... 53
REPATHA PUSHTRONEX SYSTEM -evolocumab
subcutaneous soln cartridge/infusor 420 mg/3.5ml....... 53
REPATHA SURECLICK -evolocumab subcutaneous soln
auto-injector 140 mg/ml.................................................. 53
REPLETE/FIBER/ULTRAPAK -nutritional supplement
liquid.............................................................................. 130
REPLETE FIBER 1 CAL -nutritional supplement
liquid.............................................................................. 130
REPLETE FIBER -nutritional supplement liquid............. 130
REPLETE -nutritional supplement liquid......................... 129
RESCRIPTOR -delavirdine mesylate tab 100 mg.............. 9
RESCRIPTOR -delavirdine mesylate tab 200 mg.............. 9
RESCULA -unoprostone isopropyl ophth soln
0.15%.............................................................................146
RESOURCE ARGINAID -nutritional supplement
pack............................................................................... 130
RESOURCE DAIRY THICK HONE -nutritional
supplement liquid.......................................................... 130
RESOURCE DIABETIC TF -nutritional supplement
liquid.............................................................................. 130
RESOURCE JUICE DRINK -nutritional supplement liquid
(frozen).......................................................................... 130
RESOURCE JUST FOR KIDS -nutritional supplement
liquid.............................................................................. 130
RESOURCE JUST FOR KIDS 1. -nutritional supplement
liquid.............................................................................. 130
RESOURCE JUST FOR KIDS WI -nutritional supplement
liquid.............................................................................. 130
RESOURCE 2.0 -nutritional supplement liquid............... 130
RESOURCE SUPPORT -nutritional supplement
liquid.............................................................................. 130
RESOURCE THICKENUP THICKE -nutritional
supplement liquid.......................................................... 130
RESPALOR -nutritional supplement liquid...................... 130
RESTASIS -cyclosporine (ophth) emulsion 0.05%......... 146
RESTASIS MULTIDOSE -cyclosporine (ophth) emulsion
0.05%.............................................................................146
RESURGEX -nutritional supplement pack...................... 130
RESURGEX PLUS -nutritional supplement pack........... 130
RESURGEX SELECT -nutritional supplement pack....... 130
REVATIO -sildenafil citrate for suspension 10 mg/ml....... 54
REVLIMID -lenalidomide cap 5 mg................................. 158
REVLIMID -lenalidomide cap 10 mg............................... 158
REVLIMID -lenalidomide cap 15 mg............................... 158
REVLIMID -lenalidomide cap 20 mg............................... 158
REVLIMID -lenalidomide cap 25 mg............................... 158
REVLIMID -lenalidomide caps 2.5 mg............................ 158
REXULTI -brexpiprazole tab 0.25 mg............................... 75
REXULTI -brexpiprazole tab 0.5 mg................................. 75
REXULTI -brexpiprazole tab 1 mg.................................... 75
REXULTI -brexpiprazole tab 2 mg.................................... 75
REXULTI -brexpiprazole tab 3 mg.................................... 75
REXULTI -brexpiprazole tab 4 mg.................................... 75
REYATAZ -atazanavir sulfate cap 150 mg (base equiv)..... 9
REYATAZ -atazanavir sulfate cap 200 mg (base equiv)..... 9
REYATAZ -atazanavir sulfate cap 300 mg (base equiv)..... 9
REYATAZ -atazanavir sulfate oral powder packet 50 mg
(base equiv)...................................................................... 9
RIASTAP -fibrinogen conc (human) inj approximately 1
gm (900-1300 mg)........................................................ 142
RIBASPHERE RIBAPAK -ribavirin tab 400 mg................... 9
RIBASPHERE RIBAPAK -ribavirin tab 600 mg................... 9
RIBASPHERE RIBAPAK -ribavirin tab 200 mg & ribavirin
tab 400 mg dose pack....................................................10
RIBASPHERE RIBAPAK -ribavirin tab 400 mg & ribavirin
tab 600 mg dose pack....................................................10
RIBASPHERE -ribavirin tab 400 mg................................... 9
RIBASPHERE -ribavirin tab 600 mg................................... 9
ribavirin cap 200 mg (Rebetol)....................................... 10
ribavirin for inhal soln 6 gm (Virazole)......................... 10
ribavirin tab 200 mg (Copegus)..................................... 10
RIDAURA -auranofin cap 3 mg......................................... 95
rifabutin cap 150 mg (Mycobutin).................................... 5
RIFAMATE -isoniazid & rifampin cap 150-300 mg.............. 5
rifampin cap 150 mg (Rifadin).......................................... 5
rifampin cap 300 mg (Rifadin).......................................... 5
RIFATER -isoniazid-rifampin w/ pyrazinamide tab
50-120-300 mg.................................................................. 5
riluzole tab 50 mg (Rilutek).......................................... 104
rimantadine hydrochloride tab 100 mg
(Flumadine).................................................................... 10
RIOMET -metformin hcl oral soln 500 mg/5ml.................. 33
risedronate sodium tab delayed release 35 mg
(Atelvia).......................................................................... 39
risedronate sodium tab 5 mg (Actonel)........................ 39
risedronate sodium tab 30 mg (Actonel)...................... 39
risedronate sodium tab 35 mg (Actonel)...................... 39
risedronate sodium tab 150 mg (Actonel).................... 39
risperidone orally disintegrating tab 0.25 mg.............. 75
risperidone orally disintegrating tab 0.5 mg (Risperdal
m-tab).............................................................................. 75
risperidone orally disintegrating tab 1 mg (Risperdal
m-tab).............................................................................. 75
risperidone orally disintegrating tab 2 mg (Risperdal
m-tab).............................................................................. 75
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2017
risperidone orally disintegrating tab 3 mg (Risperdal
m-tab).............................................................................. 75
risperidone orally disintegrating tab 4 mg (Risperdal
m-tab).............................................................................. 76
risperidone soln 1 mg/ml (Risperdal)............................ 76
risperidone tab 0.25 mg (Risperdal).............................. 76
risperidone tab 0.5 mg (Risperdal)................................ 76
risperidone tab 1 mg (Risperdal)................................... 76
risperidone tab 2 mg (Risperdal)................................... 76
risperidone tab 3 mg (Risperdal)................................... 76
risperidone tab 4 mg (Risperdal)................................... 76
rivastigmine tartrate cap 1.5 mg (Exelon).....................84
rivastigmine tartrate cap 3 mg (Exelon)........................84
rivastigmine tartrate cap 4.5 mg (Exelon).....................84
rivastigmine tartrate cap 6 mg (Exelon)........................84
rivastigmine td patch 24hr 4.6 mg/24hr (Exelon)......... 84
rivastigmine td patch 24hr 9.5 mg/24hr (Exelon)......... 84
rivastigmine td patch 24hr 13.3 mg/24hr (Exelon)....... 84
RIXUBIS -coagulation factor ix (recombinant) for inj 250
unit................................................................................. 142
RIXUBIS -coagulation factor ix (recombinant) for inj 500
unit................................................................................. 142
RIXUBIS -coagulation factor ix (recombinant) for inj 1000
unit................................................................................. 142
RIXUBIS -coagulation factor ix (recombinant) for inj 2000
unit................................................................................. 142
RIXUBIS -coagulation factor ix (recombinant) for inj 3000
unit................................................................................. 142
rizatriptan benzoate oral disintegrating tab 5 mg (base
eq) (Maxalt-mlt)............................................................. 95
rizatriptan benzoate oral disintegrating tab 10 mg
(base eq) (Maxalt-mlt).................................................. 95
rizatriptan benzoate tab 5 mg (base equivalent)
(Maxalt)........................................................................... 95
rizatriptan benzoate tab 10 mg (base equivalent)
(Maxalt)........................................................................... 95
R-NATAL OB -prenatal w/o a w/fe cbn-fa-dha cap
20-1-320 mg.................................................................. 110
ropinirole hydrochloride tab 0.25 mg (Requip).......... 103
ropinirole hydrochloride tab 0.5 mg (Requip)............ 103
ropinirole hydrochloride tab 1 mg (Requip)............... 103
ropinirole hydrochloride tab 2 mg (Requip)............... 103
ropinirole hydrochloride tab 3 mg (Requip)............... 103
ropinirole hydrochloride tab 4 mg (Requip)............... 103
ropinirole hydrochloride tab 5 mg (Requip)............... 103
ropinirole hydrochloride tab sr 24hr 2 mg (base
equivalent) (Requip xl)............................................... 103
ropinirole hydrochloride tab sr 24hr 4 mg (base
equivalent) (Requip xl)............................................... 103
ropinirole hydrochloride tab sr 24hr 6 mg (base
equivalent) (Requip xl)............................................... 103
ropinirole hydrochloride tab sr 24hr 8 mg (base
equivalent) (Requip xl)............................................... 103
ropinirole hydrochloride tab sr 24hr 12 mg (base
equivalent) (Requip xl)............................................... 103
rosuvastatin calcium tab 5 mg (Crestor)...................... 53
rosuvastatin calcium tab 10 mg (Crestor).................... 53
rosuvastatin calcium tab 20 mg (Crestor).................... 53
rosuvastatin calcium tab 40 mg (Crestor).................... 53
ROZEREM -ramelteon tab 8 mg....................................... 77
RUBRACA -rucaparib camsylate tab 200 mg (base
equivalent)....................................................................... 20
RUBRACA -rucaparib camsylate tab 300 mg (base
equivalent)....................................................................... 20
RUCONEST -c1 esterase inhibitor (recombinant) for iv inj
2100 unit....................................................................... 142
RULAVITE DHA -prenat w/o a w/fefum-methfol-fa-dha
cap 27-0.6-0.4-300 mg................................................. 110
RYTARY -carbidopa & levodopa cap cr 23.75-95 mg..... 103
RYTARY -carbidopa & levodopa cap cr 36.25-145
mg.................................................................................. 103
RYTARY -carbidopa & levodopa cap cr 48.75-195
mg.................................................................................. 103
RYTARY -carbidopa & levodopa cap cr 61.25-245
mg.................................................................................. 103
S
SABRIL -vigabatrin powd pack 500 mg.......................... 100
SABRIL -vigabatrin tab 500 mg...................................... 100
SAFYRAL -drospirenone-ethinyl estrad-levomefolate tab
3-0.03-0.451 mg..............................................................28
SALMON/OATS/SQUASH -nutritional supplement
liquid.............................................................................. 130
SAMSCA -tolvaptan tab 15 mg......................................... 39
SAMSCA -tolvaptan tab 30 mg......................................... 39
SANDIMMUNE -cyclosporine cap 25 mg....................... 158
SANDIMMUNE -cyclosporine cap 100 mg..................... 158
SANDIMMUNE -cyclosporine oral soln 100 mg/ml......... 158
SANTYL -collagenase oint 250 unit/gm.......................... 154
SAPHRIS -asenapine maleate sl tab 2.5 mg (base
equiv)............................................................................... 76
SAPHRIS -asenapine maleate sl tab 5 mg (base
equiv)............................................................................... 76
SAPHRIS -asenapine maleate sl tab 10 mg (base
equiv)............................................................................... 76
SAVAYSA -edoxaban tosylate tab 15 mg (base
equivalent)..................................................................... 136
SAVAYSA -edoxaban tosylate tab 30 mg (base
equivalent)..................................................................... 136
SAVAYSA -edoxaban tosylate tab 60 mg (base
equivalent)..................................................................... 136
SAVELLA -milnacipran hcl tab 12.5 mg............................ 84
SAVELLA -milnacipran hcl tab 25 mg............................... 84
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2017
SAVELLA -milnacipran hcl tab 50 mg............................... 84
SAVELLA -milnacipran hcl tab 100 mg............................. 84
SAVELLA TITRATION PACK -milnacipran hcl tab 12.5 mg
(5) & 25 mg (8) & 50 mg (42) pak................................. 84
SB COMPLETE NUTRITION -nutritional supplement
liquid.............................................................................. 130
SB COMPLETE NUTRITION PLU -nutritional supplement
liquid.............................................................................. 130
SCANDICAL -nutritional supplement powder................. 130
SCANDISHAKE -nutritional supplement misc................ 130
SCANDISHAKE -nutritional supplement pack................ 130
SCANDISHAKE -nutritional supplement powder............ 130
SELECT-OB+DHA -prenatal mv w/fe poly-fa chw 29-1 mg
& dha cap 250 mg pak................................................. 111
SELECT-OB -prenatal vit w/ fe polysac cmplx-fa chew tab
29-1 mg......................................................................... 111
SELECT-OB -prenat w/ fepolycmplx-methylfol-fa chew
tab 29-0.6-0.4 mg......................................................... 110
selegiline hcl cap 5 mg (Eldepryl)............................... 104
selegiline hcl tab 5 mg.................................................. 104
selenium sulfide lotion 2.5%........................................ 154
SELZENTRY -maraviroc tab 25 mg.................................. 10
SELZENTRY -maraviroc tab 75 mg.................................. 10
SELZENTRY -maraviroc tab 150 mg................................ 10
SELZENTRY -maraviroc tab 300 mg................................ 10
SE-NATAL 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg.................................................................................. 110
SE-NATAL 19 -prenatal vit w/ fe fumarate-fa chew tab
29-1 mg......................................................................... 110
SENSIPAR -cinacalcet hcl tab 30 mg (base equiv).......... 39
SENSIPAR -cinacalcet hcl tab 60 mg (base equiv).......... 39
SENSIPAR -cinacalcet hcl tab 90 mg (base equiv).......... 39
SENSODYNE REPAIR & PROTEC -stannous fluoride
paste 0.454%................................................................ 149
SEREVENT DISKUS -salmeterol xinafoate aer pow ba 50
mcg/dose (base equiv)................................................... 59
SEROQUEL XR -quetiapine fumarate tab sr 24hr 50
mg.................................................................................... 76
SEROQUEL XR -quetiapine fumarate tab sr 24hr 150
mg.................................................................................... 76
SEROQUEL XR -quetiapine fumarate tab sr 24hr 200
mg.................................................................................... 76
SEROQUEL XR -quetiapine fumarate tab sr 24hr 300
mg.................................................................................... 76
SEROQUEL XR -quetiapine fumarate tab sr 24hr 400
mg.................................................................................... 76
sertraline hcl oral conc 20 mg/ml (Zoloft).................... 72
sertraline hcl tab 25 mg (Zoloft).................................... 72
sertraline hcl tab 50 mg (Zoloft).................................... 72
sertraline hcl tab 100 mg (Zoloft).................................. 72
SFROWASA -mesalamine sulfite-free (sf) enema 4
gm/60ml........................................................................... 65
SIGNIFOR -pasireotide diaspartate inj 0.3 mg/ml (base
equiv)............................................................................... 39
SIGNIFOR -pasireotide diaspartate inj 0.6 mg/ml (base
equiv)............................................................................... 39
SIGNIFOR -pasireotide diaspartate inj 0.9 mg/ml (base
equiv)............................................................................... 39
sildenafil citrate tab 20 mg (Revatio)............................ 54
silver sulfadiazine cream 1% (Silvadene)................... 154
SIMBRINZA -brinzolamide-brimonidine tartrate ophth
susp 1-0.2%.................................................................. 146
SIMPONI -golimumab subcutaneous soln auto-injector 50
mg/0.5ml.......................................................................... 95
SIMPONI -golimumab subcutaneous soln auto-injector
100 mg/ml....................................................................... 95
SIMPONI -golimumab subcutaneous soln prefilled syringe
50 mg/0.5ml.................................................................... 95
SIMPONI -golimumab subcutaneous soln prefilled syringe
100 mg/ml....................................................................... 95
simvastatin tab 5 mg (Zocor)......................................... 53
simvastatin tab 10 mg (Zocor)....................................... 53
simvastatin tab 20 mg (Zocor)....................................... 53
simvastatin tab 40 mg (Zocor)....................................... 53
simvastatin tab 80 mg (Zocor)....................................... 53
sirolimus tab 0.5 mg (Rapamune)............................... 158
sirolimus tab 1 mg (Rapamune).................................. 158
sirolimus tab 2 mg (Rapamune).................................. 158
SIRTURO -bedaquiline fumarate tab 100 mg (base
equiv)................................................................................. 6
SITAVIG -acyclovir buccal tab 50 mg................................ 10
SIVEXTRO -tedizolid phosphate tab 200 mg....................12
SKLICE -ivermectin lotion 0.5%...................................... 154
SM NUTRI-DRINK + -nutritional supplement liquid........ 130
SM NUTRI-DRINK -nutritional supplement liquid........... 130
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)
(Luride)......................................................................... 114
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)
(Luride)......................................................................... 114
sodium fluoride chew tab 1 mg f (from 2.2 mg naf)
(Luride)......................................................................... 114
sodium fluoride cream 1.1% (Prevident 5000
plus).............................................................................. 149
sodium fluoride gel 1.1% (0.5% f) (Prevident
fluoride)........................................................................ 149
sodium fluoride paste 1.1% (Prevident 5000
boost)............................................................................ 149
sodium fluoride-potassium nitrate paste 1.1-5%
(Prevident 5000 sensi)............................................... 149
sodium fluoride rinse 0.05%.........................................149
sodium fluoride rinse 0.0221% (0.01% f).................... 149
sodium fluoride rinse 0.2% (Prevident)...................... 149
SODIUM FLUORIDE -sodium fluoride tab 0.5 mg f (from
1.1 mg naf)....................................................................114
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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SODIUM FLUORIDE -sodium fluoride tab 1 mg f (from
2.2 mg naf)....................................................................114
sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop
naf)................................................................................ 114
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)
(Luride)......................................................................... 114
sodium phenylbutyrate oral powder 3 gm/teaspoonful
(Buphenyl)...................................................................... 39
sodium polystyrene sulfonate oral susp 15 gm/60ml
(Sps).............................................................................. 158
sodium polystyrene sulfonate powder
(Kayexalate)................................................................. 158
sodium polystyrene sulfonate rectal susp 30
gm/120ml...................................................................... 158
SOL CARB -nutritional supplement powder....................130
SOLTAMOX -tamoxifen citrate oral soln 10 mg/5ml (base
equivalent)....................................................................... 20
SOLVIL -amino acids pack.............................................. 115
SOMAVERT -pegvisomant for inj 10 mg (as protein)....... 39
SOMAVERT -pegvisomant for inj 15 mg (as protein)....... 39
SOMAVERT -pegvisomant for inj 20 mg (as protein)....... 39
SOMAVERT -pegvisomant for inj 25 mg (as protein)....... 39
SOMAVERT -pegvisomant for inj 30 mg (as protein)....... 39
SOOLANTRA -ivermectin cream 1%.............................. 154
S.O.S. 15 -nutritional supplement pack.......................... 130
S.O.S. 20 -nutritional supplement pack.......................... 130
S.O.S. 25 -nutritional supplement pack.......................... 130
sotalol hcl (afib/afl) tab 80 mg (Betapace af)................ 42
sotalol hcl (afib/afl) tab 120 mg (Betapace af).............. 42
sotalol hcl (afib/afl) tab 160 mg (Betapace af).............. 42
sotalol hcl tab 240 mg.....................................................42
sotalol hcl tab 80 mg (Betapace)................................... 42
sotalol hcl tab 120 mg (Betapace)................................. 42
sotalol hcl tab 160 mg (Betapace)................................. 42
SOURCE COOKIE BAR -nutritional supplement bar......130
SOVALDI -sofosbuvir tab 400 mg..................................... 10
SOY PROTEIN SHAKE -nutritional supplement
powder........................................................................... 130
SPACERS – VARIOUS.................................................... 156
SPECTRACEF -cefditoren pivoxil tab 400 mg (base
equivalent)......................................................................... 3
SPINOSAD -spinosad susp 0.9%................................... 154
SPIRIVA HANDIHALER -tiotropium bromide monohydrate
inhal cap 18 mcg (base equiv)....................................... 59
SPIRIVA RESPIMAT -tiotropium bromide monohydrate
inhal aerosol 1.25 mcg/act............................................. 59
SPIRIVA RESPIMAT -tiotropium bromide monohydrate
inhal aerosol 2.5 mcg/act............................................... 59
spironolactone & hydrochlorothiazide tab 25-25 mg
(Aldactazide).................................................................. 50
spironolactone tab 25 mg (Aldactone).......................... 50
spironolactone tab 50 mg (Aldactone).......................... 51
spironolactone tab 100 mg (Aldactone)........................ 51
SPORANOX -itraconazole oral soln 10 mg/ml....................6
SPRYCEL -dasatinib tab 20 mg........................................ 20
SPRYCEL -dasatinib tab 50 mg........................................ 20
SPRYCEL -dasatinib tab 70 mg........................................ 21
SPRYCEL -dasatinib tab 80 mg........................................ 21
SPRYCEL -dasatinib tab 100 mg...................................... 21
SPRYCEL -dasatinib tab 140 mg...................................... 21
STALEVO 100 -carbidopa-levodopa-entacapone tabs
25-100-200 mg..............................................................104
STALEVO 125 -carbidopa-levodopa-entacapone tabs
31.25-125-200 mg........................................................ 104
STALEVO 150 -carbidopa-levodopa-entacapone tabs
37.5-150-200 mg.......................................................... 104
STALEVO 200 -carbidopa-levodopa-entacapone tabs
50-200-200 mg..............................................................104
STALEVO 50 -carbidopa-levodopa-entacapone tabs
12.5-50-200 mg.............................................................104
STALEVO 75 -carbidopa-levodopa-entacapone tabs
18.75-75-200 mg.......................................................... 104
stannous fluoride conc 0.63% (Gel-kam oral care
ri)................................................................................... 149
stannous fluoride gel 0.4%........................................... 149
STANNOUS FLUORIDE RINSE -stannous fluoride liq
0.1%...............................................................................149
stavudine cap 15 mg (Zerit)............................................10
stavudine cap 20 mg (Zerit)............................................10
stavudine cap 30 mg (Zerit)............................................10
stavudine cap 40 mg (Zerit)............................................10
STELARA -ustekinumab inj 45 mg/0.5ml........................ 154
STELARA -ustekinumab soln prefilled syringe 45
mg/0.5ml........................................................................ 154
STELARA -ustekinumab soln prefilled syringe 90 mg/
ml................................................................................... 154
STIMATE -desmopressin acetate nasal soln 1.5 mg/
ml..................................................................................... 39
STIOLTO RESPIMAT -tiotropium br-olodaterol inhal aero
soln 2.5-2.5 mcg/act....................................................... 59
STIVARGA -regorafenib tab 40 mg................................... 21
STRATTERA -atomoxetine hcl cap 10 mg (base
equiv)............................................................................... 80
STRATTERA -atomoxetine hcl cap 18 mg (base
equiv)............................................................................... 80
STRATTERA -atomoxetine hcl cap 25 mg (base
equiv)............................................................................... 80
STRATTERA -atomoxetine hcl cap 40 mg (base
equiv)............................................................................... 80
STRATTERA -atomoxetine hcl cap 60 mg (base
equiv)............................................................................... 80
STRATTERA -atomoxetine hcl cap 80 mg (base
equiv)............................................................................... 80
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STRATTERA -atomoxetine hcl cap 100 mg (base
equiv)............................................................................... 80
STRENSIQ -asfotase alfa subcutaneous inj 18
mg/0.45ml........................................................................ 39
STRENSIQ -asfotase alfa subcutaneous inj 28
mg/0.7ml.......................................................................... 39
STRENSIQ -asfotase alfa subcutaneous inj 40 mg/ml..... 39
STRENSIQ -asfotase alfa subcutaneous inj 80
mg/0.8ml.......................................................................... 39
STRIBILD -elvitegrav-cobic-emtricitab-tenofovdf tab
150-150-200-300 mg...................................................... 10
STRIVERDI RESPIMAT -olodaterol hcl inhal aerosol soln
2.5 mcg/act (base equiv)................................................ 59
SUBDUE -nutritional supplement liquid.......................... 130
SUBDUE PLUS -nutritional supplement liquid................ 130
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 2-0.5
mg (base equiv).............................................................. 91
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 4-1
mg (base equiv).............................................................. 91
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 8-2
mg (base equiv).............................................................. 91
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 12-3
mg (base equiv).............................................................. 91
SUBSYS -fentanyl sublingual spray 100 mcg................... 91
SUBSYS -fentanyl sublingual spray 200 mcg................... 91
SUBSYS -fentanyl sublingual spray 400 mcg................... 91
SUBSYS -fentanyl sublingual spray 600 mcg................... 91
SUBSYS -fentanyl sublingual spray 800 mcg................... 91
SUBSYS -fentanyl sublingual spray 1200 mcg (600 mcg x
2)...................................................................................... 91
SUBSYS -fentanyl sublingual spray 1600 mcg (800 mcg x
2)...................................................................................... 91
SUCRAID -sacrosidase soln 8500 unit/ml........................ 64
sucralfate tab 1 gm (Carafate)....................................... 62
sulfacetamide sodium lotion 10% (acne) (Klaron)..... 154
sulfacetamide sodium ophth soln 10%
(Bleph-10)..................................................................... 146
sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%............................................................. 146
SULFACETAMIDE SODIUM -sulfacetamide sodium ophth
oint 10%........................................................................ 146
SULFADIAZINE -sulfadiazine tab 500 mg.......................... 5
sulfamethoxazole-trimethoprim susp 200-40
mg/5ml............................................................................ 12
sulfamethoxazole-trimethoprim tab 400-80 mg
(Bactrim)......................................................................... 12
sulfamethoxazole-trimethoprim tab 800-160 mg
(Bactrim ds)................................................................... 12
SULFAMYLON -mafenide acetate cream 85 mg/gm...... 154
sulfasalazine tab delayed release 500 mg (Azulfidine
en-tabs)........................................................................... 65
sulfasalazine tab 500 mg (Azulfidine)........................... 65
sulindac tab 150 mg........................................................ 95
sulindac tab 200 mg........................................................ 95
sumatriptan nasal spray 5 mg/act (Imitrex).................. 95
sumatriptan nasal spray 20 mg/act (Imitrex)................ 95
sumatriptan succinate inj 6 mg/0.5ml (Imitrex)............ 95
sumatriptan succinate solution auto-injector 4
mg/0.5ml (Imitrex statdose sys)................................. 96
sumatriptan succinate solution auto-injector 6
mg/0.5ml (Imitrex statdose sys)................................. 96
sumatriptan succinate solution cartridge 4 mg/0.5ml
(Imitrex statdose ref).................................................... 96
sumatriptan succinate solution cartridge 6 mg/0.5ml
(Imitrex statdose ref).................................................... 96
sumatriptan succinate tab 25 mg (Imitrex)................... 96
sumatriptan succinate tab 50 mg (Imitrex)................... 96
sumatriptan succinate tab 100 mg (Imitrex)................. 96
SUPER-AMINO 1600 -amino acids tab.......................... 115
SUPER DAILY D3 -cholecalciferol drops 1000 unit/0.03ml
(per drop)...................................................................... 105
SUPER NU-THERA -multiple vitamins w/ minerals
powder........................................................................... 111
SUPLENA -nutritional supplement liquid.........................131
SUPLENA RTU -nutritional supplement liquid................ 131
SUPLENA WITH CARB STEADY -nutritional supplement
liquid.............................................................................. 131
SUPLENA 1.8 WITH CARBSTEA -nutritional supplement
liquid.............................................................................. 131
SUPRAX -cefixime cap 400 mg.......................................... 3
SUPRAX -cefixime chew tab 100 mg................................. 3
SUPRAX -cefixime chew tab 200 mg................................. 3
SUPRAX -cefixime for susp 100 mg/5ml............................ 3
SUPRAX -cefixime for susp 200 mg/5ml............................ 3
SUPRAX -cefixime for susp 500 mg/5ml............................ 3
SUPREP BOWEL PREP KIT -sodium sulfate-potassium
sulfate-magnesium sulfate oral soln.............................. 61
SURMONTIL -trimipramine maleate cap 25 mg............... 72
SURMONTIL -trimipramine maleate cap 50 mg............... 72
SURMONTIL -trimipramine maleate cap 100 mg............. 72
SURVANTA INTRATRACHEAL -beractant in nacl 0.9%
intratracheal susp 25 mg/ml........................................... 60
SUSTIVA -efavirenz cap 50 mg........................................ 10
SUSTIVA -efavirenz cap 200 mg...................................... 10
SUSTIVA -efavirenz tab 600 mg....................................... 10
SUTENT -sunitinib malate cap 12.5 mg (base
equivalent)....................................................................... 21
SUTENT -sunitinib malate cap 25 mg (base
equivalent)....................................................................... 21
SUTENT -sunitinib malate cap 37.5 mg (base
equivalent)....................................................................... 21
SUTENT -sunitinib malate cap 50 mg (base
equivalent)....................................................................... 21
SYLATRON -peginterferon alfa-2b for inj kit 296 mcg...... 21
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SYLATRON -peginterferon alfa-2b for inj kit 444 mcg...... 21
SYLATRON -peginterferon alfa-2b for inj kit 888 mcg...... 21
SYMBICORT -budesonide-formoterol fumarate dihyd
aerosol 80-4.5 mcg/act................................................... 59
SYMBICORT -budesonide-formoterol fumarate dihyd
aerosol 160-4.5 mcg/act................................................. 59
SYNAREL -nafarelin acetate nasal soln 2 mg/ml (200
mcg/act) (base eq)..........................................................39
SYNERA -lidocaine-tetracaine topical patch 70-70
mg.................................................................................. 154
SYNJARDY -empagliflozin-metformin hcl tab 12.5-1000
mg.................................................................................... 33
SYNJARDY -empagliflozin-metformin hcl tab 12.5-500
mg.................................................................................... 33
SYNJARDY -empagliflozin-metformin hcl tab 5-500
mg.................................................................................... 33
SYNJARDY -empagliflozin-metformin hcl tab 5-1000
mg.................................................................................... 33
SYNTHROID -levothyroxine sodium tab 25 mcg.............. 36
SYNTHROID -levothyroxine sodium tab 50 mcg.............. 36
SYNTHROID -levothyroxine sodium tab 75 mcg.............. 36
SYNTHROID -levothyroxine sodium tab 88 mcg.............. 36
SYNTHROID -levothyroxine sodium tab 100 mcg............ 36
SYNTHROID -levothyroxine sodium tab 112 mcg............ 36
SYNTHROID -levothyroxine sodium tab 125 mcg............ 36
SYNTHROID -levothyroxine sodium tab 137 mcg............ 36
SYNTHROID -levothyroxine sodium tab 150 mcg............ 36
SYNTHROID -levothyroxine sodium tab 175 mcg............ 36
SYNTHROID -levothyroxine sodium tab 200 mcg............ 36
SYNTHROID -levothyroxine sodium tab 300 mcg............ 36
SYPRINE -trientine hcl cap 250 mg................................ 158
T
TABLOID -thioguanine tab 40 mg..................................... 21
TACLONEX -calcipotriene-betamethasone dipropionate
susp 0.005-0.064%....................................................... 154
tacrolimus cap 0.5 mg (Prograf).................................. 158
tacrolimus cap 1 mg (Prograf)..................................... 158
tacrolimus cap 5 mg (Prograf)..................................... 158
tacrolimus oint 0.03% (Protopic)................................. 154
tacrolimus oint 0.1% (Protopic)................................... 154
TAFINLAR -dabrafenib mesylate cap 50 mg (base
equivalent)....................................................................... 21
TAFINLAR -dabrafenib mesylate cap 75 mg (base
equivalent)....................................................................... 21
TAGRISSO -osimertinib mesylate tab 40 mg (base
equivalent)....................................................................... 21
TAGRISSO -osimertinib mesylate tab 80 mg (base
equivalent)....................................................................... 21
TAMIFLU -oseltamivir phosphate cap 30 mg (base
equiv)............................................................................... 10
TAMIFLU -oseltamivir phosphate cap 45 mg (base
equiv)............................................................................... 10
TAMIFLU -oseltamivir phosphate cap 75 mg (base
equiv)............................................................................... 10
TAMIFLU -oseltamivir phosphate for susp 6 mg/ml (base
equiv)............................................................................... 10
tamoxifen citrate tab 10 mg (base equivalent)............. 21
tamoxifen citrate tab 20 mg (base equivalent)............. 21
tamsulosin hcl cap 0.4 mg (Flomax)............................. 68
TANZEUM -albiglutide for soln pen-injector 30 mg........... 33
TANZEUM -albiglutide for soln pen-injector 50 mg........... 33
TARCEVA -erlotinib hcl tab 25 mg (base equivalent)....... 21
TARCEVA -erlotinib hcl tab 100 mg (base equivalent)..... 21
TARCEVA -erlotinib hcl tab 150 mg (base equivalent)..... 21
TARGRETIN -bexarotene gel 1%....................................154
TARON-BC -prenat w/o a w/ fe cbnyl-fa tab 20-1 mg & vit
b6 tab pak..................................................................... 111
TARON-C DHA -prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg......................................................... 111
TARON-PREX -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 30-1.2-265 mg....................................................... 111
TASIGNA -nilotinib hcl cap 150 mg (base equivalent)...... 21
TASIGNA -nilotinib hcl cap 200 mg (base equivalent)...... 21
TASMAR -tolcapone tab 100 mg.....................................104
tazarotene cream 0.1% (Tazorac)................................. 154
TAZORAC -tazarotene cream 0.05%.............................. 155
TAZORAC -tazarotene cream 0.1%................................ 155
TAZORAC -tazarotene gel 0.05%................................... 155
TAZORAC -tazarotene gel 0.1%..................................... 155
TECFIDERA -dimethyl fumarate capsule delayed release
120 mg............................................................................ 84
TECFIDERA -dimethyl fumarate capsule delayed release
240 mg............................................................................ 85
TECFIDERA STARTER PACK -dimethyl fumarate
capsule dr starter pack 120 mg & 240 mg..................... 85
TECHNIVIE -ombitasvir-paritaprevir-ritonavir tab
12.5-75-50 mg................................................................. 10
TEGRETOL -carbamazepine susp 100 mg/5ml............. 100
TEGRETOL -carbamazepine tab 200 mg....................... 100
TEGRETOL-XR -carbamazepine tab sr 12hr 100
mg.................................................................................. 100
TEGRETOL-XR -carbamazepine tab sr 12hr 200
mg.................................................................................. 101
TEGRETOL-XR -carbamazepine tab sr 12hr 400
mg.................................................................................. 101
TEKTURNA -aliskiren fumarate tab 150 mg (base
equivalent)....................................................................... 49
TEKTURNA -aliskiren fumarate tab 300 mg (base
equivalent)....................................................................... 49
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
150-12.5 mg.................................................................... 49
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TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
150-25 mg....................................................................... 49
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
300-12.5 mg.................................................................... 49
telmisartan-amlodipine tab 40-5 mg (Twynsta)............ 49
telmisartan-amlodipine tab 80-5 mg (Twynsta)............ 49
telmisartan-amlodipine tab 40-10 mg (Twynsta).......... 49
telmisartan-amlodipine tab 80-10 mg (Twynsta).......... 49
telmisartan-hydrochlorothiazide tab 40-12.5 mg
(Micardis hct)................................................................. 49
telmisartan-hydrochlorothiazide tab 80-12.5 mg
(Micardis hct)................................................................. 49
telmisartan-hydrochlorothiazide tab 80-25 mg
(Micardis hct)................................................................. 49
telmisartan tab 20 mg (Micardis)................................... 49
telmisartan tab 40 mg (Micardis)................................... 49
telmisartan tab 80 mg (Micardis)................................... 49
temazepam cap 7.5 mg (Restoril).................................. 77
temazepam cap 15 mg (Restoril)................................... 77
temazepam cap 22.5 mg (Restoril)................................ 77
temazepam cap 30 mg (Restoril)................................... 77
temozolomide cap 5 mg (Temodar)............................... 21
temozolomide cap 20 mg (Temodar)............................. 21
temozolomide cap 100 mg (Temodar)........................... 21
temozolomide cap 140 mg (Temodar)........................... 21
temozolomide cap 180 mg (Temodar)........................... 21
temozolomide cap 250 mg (Temodar)........................... 21
TENCON -butalbital-acetaminophen tab 50-325 mg........ 85
TENIVAC -tetanus-diphtheria toxoids (td) inj 5-2 lfu......... 16
terazosin hcl cap 1 mg....................................................49
terazosin hcl cap 2 mg....................................................49
terazosin hcl cap 5 mg....................................................49
terazosin hcl cap 10 mg..................................................49
terbinafine hcl tab 250 mg (Lamisil)................................ 6
terbutaline sulfate tab 2.5 mg........................................ 59
terbutaline sulfate tab 5 mg........................................... 59
terconazole vaginal cream 0.4% (Terazol 7)................. 67
terconazole vaginal cream 0.8% (Terazol 3)................. 67
terconazole vaginal suppos 80 mg............................... 67
testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone).................................................................. 24
testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone).................................................................. 24
testosterone enanthate im inj in oil 200 mg/ml............ 24
testosterone td gel 12.5 mg/act (1%) (Androgel
pump).............................................................................. 24
testosterone td gel 25 mg/2.5gm (1%) (Androgel)....... 24
testosterone td gel 50 mg/5gm (1%) (Androgel).......... 24
TETANUS/DIPHTHERIA TOXOID -tetanus-diphtheria
toxoids (td) inj 2-2 lf/0.5ml.............................................. 16
tetrabenazine tab 12.5 mg (Xenazine)........................... 85
tetrabenazine tab 25 mg (Xenazine).............................. 85
tetracaine hcl ophth soln 0.5%.................................... 146
tetracycline hcl cap 250 mg (Tetracycline hcl)............... 4
tetracycline hcl cap 500 mg (Tetracycline hcl)............... 4
TETRACYCLINE HCL -tetracycline hcl cap 250 mg...........4
TETRACYCLINE HCL -tetracycline hcl cap 500 mg...........4
THALOMID -thalidomide cap 50 mg............................... 158
THALOMID -thalidomide cap 100 mg............................. 158
THALOMID -thalidomide cap 150 mg............................. 158
THALOMID -thalidomide cap 200 mg............................. 158
theophylline soln 80 mg/15ml........................................ 60
theophylline tab sr 12hr 100 mg.................................... 60
theophylline tab sr 12hr 200 mg.................................... 60
theophylline tab sr 12hr 300 mg.................................... 60
theophylline tab sr 12hr 450 mg.................................... 60
theophylline tab sr 24hr 400 mg.................................... 60
theophylline tab sr 24hr 600 mg.................................... 60
THEO-24 -theophylline cap sr 24hr 100 mg..................... 59
THEO-24 -theophylline cap sr 24hr 200 mg..................... 59
THEO-24 -theophylline cap sr 24hr 300 mg..................... 59
THEO-24 -theophylline cap sr 24hr 400 mg..................... 60
THERA-FLUR-N -sodium fluoride gel 1.1% (0.5% f)...... 149
THICK-IT BEEF LASAGNA PUR -nutritional supplement
misc............................................................................... 131
THICK-IT CHICKEN A LA KIN -nutritional supplement
misc............................................................................... 131
THICK-IT MAPLE CINNAMON F -nutritional supplement
misc............................................................................... 131
THICK-IT MIXED FRUIT AND -nutritional supplement
misc............................................................................... 131
THICK-IT SEASONED CHICKEN -nutritional supplement
misc............................................................................... 131
THICK-IT SWEET CORN PUREE -nutritional supplement
misc............................................................................... 131
THICK-IT THICKENED CRANBE -nutritional supplement
liquid.............................................................................. 131
THIOLA -tiopronin tab 100 mg.......................................... 68
thioridazine hcl tab 10 mg.............................................. 76
thioridazine hcl tab 25 mg.............................................. 76
thioridazine hcl tab 50 mg.............................................. 76
thioridazine hcl tab 100 mg............................................ 76
thiothixene cap 1 mg....................................................... 76
thiothixene cap 2 mg....................................................... 76
thiothixene cap 5 mg....................................................... 76
thiothixene cap 10 mg..................................................... 76
THRIVACIN DETOX -nutritional supplement liquid......... 131
THRIVACIN 30 -nutritional supplement liquid................. 131
THRIVITE 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg.................................................................................. 111
THRIVITE RX -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................. 111
thyroid tab 30 mg (1/2 grain) (Armour thyroid)............ 36
thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)......... 36
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thyroid tab 60 mg (1 grain) (Armour thyroid)............... 36
THYROLAR-1/2 -liotrix (t3-t4) tab 30 mg (6.25-25
mcg)................................................................................. 36
THYROLAR-1/4 -liotrix (t3-t4) tab 15 mg (3.1-12.5
mcg)................................................................................. 36
THYROLAR-1 -liotrix (t3-t4) tab 60 mg (12.5-50 mcg)......36
THYROLAR-2 -liotrix (t3-t4) tab 120 mg (25-100
mcg)................................................................................. 36
THYROLAR-3 -liotrix (t3-t4) tab 180 mg (37.5-150
mcg)................................................................................. 36
tiagabine hcl tab 2 mg (Gabitril).................................. 101
tiagabine hcl tab 4 mg (Gabitril).................................. 101
TIKOSYN -dofetilide cap 125 mcg (0.125 mg)................. 45
TIKOSYN -dofetilide cap 250 mcg (0.25 mg)................... 45
TIKOSYN -dofetilide cap 500 mcg (0.5 mg)..................... 45
timolol maleate ophth gel forming soln 0.25%
(Timoptic-xe)................................................................ 146
timolol maleate ophth gel forming soln 0.5%
(Timoptic-xe)................................................................ 146
timolol maleate ophth soln 0.25% (Timoptic)............. 146
timolol maleate ophth soln 0.5% (Timoptic)............... 146
TIMOLOL MALEATE -timolol maleate tab 5 mg............... 42
TIMOLOL MALEATE -timolol maleate tab 10 mg............. 42
TIMOLOL MALEATE -timolol maleate tab 20 mg............. 42
TIMOPTIC OCUDOSE -timolol maleate preservative free
ophth soln 0.25%.......................................................... 146
TIMOPTIC OCUDOSE -timolol maleate preservative free
ophth soln 0.5%............................................................ 146
tinidazole tab 250 mg (Tindamax)..................................12
tinidazole tab 500 mg (Tindamax)..................................12
TIROSINT -levothyroxine sodium cap 13 mcg..................36
TIROSINT -levothyroxine sodium cap 25 mcg..................36
TIROSINT -levothyroxine sodium cap 50 mcg..................36
TIROSINT -levothyroxine sodium cap 75 mcg..................36
TIROSINT -levothyroxine sodium cap 88 mcg..................36
TIROSINT -levothyroxine sodium cap 100 mcg................36
TIROSINT -levothyroxine sodium cap 112 mcg................ 36
TIROSINT -levothyroxine sodium cap 125 mcg................36
TIROSINT -levothyroxine sodium cap 137 mcg................37
TIROSINT -levothyroxine sodium cap 150 mcg................37
TIVICAY -dolutegravir sodium tab 10 mg (base equiv)..... 10
TIVICAY -dolutegravir sodium tab 25 mg (base equiv)..... 10
TIVICAY -dolutegravir sodium tab 50 mg (base equiv)..... 10
tizanidine hcl cap 2 mg (base equivalent)
(Zanaflex)......................................................................104
tizanidine hcl cap 4 mg (base equivalent)
(Zanaflex)......................................................................104
tizanidine hcl cap 6 mg (base equivalent)
(Zanaflex)......................................................................104
tizanidine hcl tab 2 mg (base equivalent)................... 105
tizanidine hcl tab 4 mg (base equivalent)
(Zanaflex)......................................................................105
TL-CARE DHA -prenatal w/fe fumarate-fa-dss-fish oil cap
27-1-500 mg.................................................................. 111
TL FOLATE -prenatal vit w/ fe fum-methylfolate-fa tab
27-0.5-0.5 mg................................................................ 111
TL-SELECT -prenatal w/o vit a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg.............................................................111
TOBI PODHALER -tobramycin inhal cap 28 mg.................5
TOBRADEX ST -tobramycin-dexamethasone ophth susp
0.3-0.05%...................................................................... 146
TOBRADEX -tobramycin-dexamethasone ophth oint
0.3-0.1%........................................................................ 146
tobramycin-dexamethasone ophth susp 0.3-0.1%
(Tobradex).................................................................... 147
tobramycin nebu soln 300 mg/5ml (Tobi)....................... 5
tobramycin ophth soln 0.3% (Tobrex)......................... 146
TOBRAMYCIN -tobramycin nebu soln 300 mg/5ml............ 5
TOBREX -tobramycin ophth oint 0.3%........................... 147
TOLAK -fluorouracil cream 4%........................................155
TOLAZAMIDE -tolazamide tab 250 mg.............................33
TOLAZAMIDE -tolazamide tab 500 mg.............................33
TOLBUTAMIDE -tolbutamide tab 500 mg......................... 33
tolcapone tab 100 mg (Tasmar)................................... 104
TOLEREX -nutritional supplement pack......................... 131
TOLMETIN SODIUM -tolmetin sodium cap 400 mg......... 95
tolterodine tartrate cap sr 24hr 2 mg (Detrol la).......... 66
tolterodine tartrate cap sr 24hr 4 mg (Detrol la).......... 66
tolterodine tartrate tab 1 mg (Detrol)............................ 67
tolterodine tartrate tab 2 mg (Detrol)............................ 67
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 25
mg.................................................................................. 101
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 50
mg.................................................................................. 101
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 100
mg.................................................................................. 101
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 150
mg.................................................................................. 101
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 200
mg.................................................................................. 101
topiramate sprinkle cap 15 mg (Topamax
sprinkle)........................................................................101
topiramate sprinkle cap 25 mg (Topamax
sprinkle)........................................................................101
topiramate tab 25 mg (Topamax)................................. 101
topiramate tab 50 mg (Topamax)................................. 101
topiramate tab 100 mg (Topamax)............................... 101
topiramate tab 200 mg (Topamax)............................... 101
torsemide tab 5 mg (Demadex)...................................... 51
torsemide tab 10 mg (Demadex).................................... 51
torsemide tab 20 mg (Demadex).................................... 51
torsemide tab 100 mg (Demadex).................................. 51
TOUJEO SOLOSTAR -insulin glargine soln pen-injector
300 unit/ml.......................................................................35
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TOVIAZ -fesoterodine fumarate tab sr 24hr 4 mg.............67
TOVIAZ -fesoterodine fumarate tab sr 24hr 8 mg.............67
TRACLEER -bosentan tab 62.5 mg.................................. 54
TRACLEER -bosentan tab 125 mg................................... 54
TRADJENTA -linagliptin tab 5 mg..................................... 33
tramadol-acetaminophen tab 37.5-325 mg
(Ultracet)......................................................................... 91
tramadol hcl tab 50 mg (Ultram).................................... 91
tramadol hcl tab sr 24hr biphasic release 100 mg....... 91
tramadol hcl tab sr 24hr biphasic release 200 mg....... 91
tramadol hcl tab sr 24hr biphasic release 300 mg....... 91
tramadol hcl tab sr 24hr 100 mg (Ultram er)................ 91
tramadol hcl tab sr 24hr 200 mg (Ultram er)................ 91
tramadol hcl tab sr 24hr 300 mg (Ultram er)................ 91
trandolapril tab 1 mg (Mavik)......................................... 49
trandolapril tab 2 mg (Mavik)......................................... 49
trandolapril tab 4 mg (Mavik)......................................... 49
trandolapril-verapamil hcl tab cr 1-240 mg (Tarka)...... 49
trandolapril-verapamil hcl tab cr 2-180 mg (Tarka)...... 49
trandolapril-verapamil hcl tab cr 2-240 mg (Tarka)...... 49
trandolapril-verapamil hcl tab cr 4-240 mg (Tarka)...... 49
tranexamic acid tab 650 mg (Lysteda)........................ 137
TRANSDERM-SCOP -scopolamine td patch 72hr 1.5
mg.................................................................................... 63
tranylcypromine sulfate tab 10 mg (Parnate)............... 72
TRAVATAN Z -travoprost ophth soln 0.004%
(benzalkonium free) (bak free)..................................... 147
trazodone hcl tab 50 mg................................................. 72
trazodone hcl tab 100 mg............................................... 72
trazodone hcl tab 150 mg............................................... 72
trazodone hcl tab 300 mg............................................... 72
TRECATOR -ethionamide tab 250 mg................................ 6
TRESIBA FLEXTOUCH -insulin degludec soln peninjector 100 unit/ml......................................................... 35
TRESIBA FLEXTOUCH -insulin degludec soln peninjector 200 unit/ml......................................................... 35
tretinoin cap 10 mg......................................................... 21
tretinoin cream 0.025% (Retin-a)................................. 155
tretinoin cream 0.05% (Retin-a)................................... 155
tretinoin cream 0.1% (Retin-a)..................................... 155
tretinoin gel 0.05% (Atralin).......................................... 155
tretinoin gel 0.01% (Retin-a)......................................... 155
tretinoin gel 0.025% (Retin-a)....................................... 155
tretinoin microsphere gel 0.04% (Retin-a micro)....... 155
tretinoin microsphere gel 0.1% (Retin-a micro)......... 155
TRETTEN -coagulation factor xiii a-subunit for inj
2000-3125 unit.............................................................. 142
TREXALL -methotrexate sodium tab 5 mg (base
equiv)............................................................................... 21
TREXALL -methotrexate sodium tab 7.5 mg (base
equiv)............................................................................... 21
TREXALL -methotrexate sodium tab 10 mg (base
equiv)............................................................................... 21
TREXALL -methotrexate sodium tab 15 mg (base
equiv)............................................................................... 22
TRIADVANCE -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg......................................................................... 111
triamcinolone acetonide aerosol soln 0.147 mg/gm
(Kenalog)...................................................................... 155
triamcinolone acetonide cream 0.025%...................... 155
triamcinolone acetonide cream 0.1%.......................... 155
triamcinolone acetonide cream 0.5%.......................... 155
triamcinolone acetonide dental paste 0.1%............... 149
triamcinolone acetonide lotion 0.025%....................... 155
triamcinolone acetonide lotion 0.1%........................... 155
triamcinolone acetonide nasal aerosol suspension 55
mcg/act........................................................................... 55
triamcinolone acetonide oint 0.025%.......................... 155
triamcinolone acetonide oint 0.1%.............................. 155
TRIAMINO -amino acids tab........................................... 115
TRIAMTERENE/HYDROCHLOROTH -triamterene &
hydrochlorothiazide cap 50-25 mg................................. 51
triamterene & hydrochlorothiazide cap 37.5-25 mg
(Dyazide).........................................................................51
triamterene & hydrochlorothiazide tab 37.5-25 mg
(Maxzide-25)................................................................... 51
triamterene & hydrochlorothiazide tab 75-50 mg
(Maxzide)........................................................................ 51
TRICARE PRENATAL COMPLEAT -prenat w/o a fefum-fa
tab 27-1 mg & fish oil chew cap pak............................111
TRICARE PRENATAL DHA ONE -prenatal w/fe fumaratefa-dss-fish oil cap 27-1-500 mg................................... 111
TRICARE PRENATAL -prenat w/o a w/fepyro-mfol chw
4.5-1 mg & dha cap 150 thpk...................................... 111
TRICARE PRENATAL -prenat w/o vit a w/ fe pyrophosmethylf chew tab 4.5-1 mg........................................... 111
TRICARE -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 111
TRIDESILON -desonide cream 0.05%............................155
trifluoperazine hcl tab 1 mg........................................... 76
trifluoperazine hcl tab 2 mg........................................... 76
trifluoperazine hcl tab 5 mg........................................... 76
trifluoperazine hcl tab 10 mg......................................... 76
trifluridine ophth soln 1% (Viroptic)............................ 147
trihexyphenidyl hcl elixir 0.4 mg/ml............................ 104
trihexyphenidyl hcl tab 2 mg........................................104
trihexyphenidyl hcl tab 5 mg........................................104
trimethobenzamide hcl cap 300 mg (Tigan)................. 63
trimethoprim tab 100 mg................................................ 12
TRINATAL GT -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg......................................................................... 111
TRINATAL RX 1 -prenatal vit w/ fe fumarate-fa tab 60-1
mg.................................................................................. 111
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TRINATE -prenatal vit w/ fe fumarate-fa tab 28-1 mg..... 111
TRISTART DHA -prenat w/o a w/fecbn-methylf-fa-dha cap
31-0.6-0.4-200 mg........................................................ 111
TRI-TABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack....................................................... 111
TRIUMEQ -abacavir-dolutegravir-lamivudine tab
600-50-300 mg................................................................10
TRIVEEN-DUO DHA -prenat-fe bis-fe prot succ-fa-ca tab
& omega 3 cap 400 pk................................................. 111
TRIVEEN-PRX RNF -prenatal w/o vit a w/ fe fum-dss-fadha cap 26-1.2-300 mg................................................ 111
TROKENDI XR -topiramate cap sr 24hr 25 mg.............. 101
TROKENDI XR -topiramate cap sr 24hr 50 mg.............. 101
TROKENDI XR -topiramate cap sr 24hr 100 mg............ 101
TROKENDI XR -topiramate cap sr 24hr 200 mg............ 101
trospium chloride cap sr 24hr 60 mg............................ 67
trospium chloride tab 20 mg.......................................... 67
TRULICITY -dulaglutide soln pen-injector 0.75
mg/0.5ml.......................................................................... 33
TRULICITY -dulaglutide soln pen-injector 1.5
mg/0.5ml.......................................................................... 33
TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab
100-150 mg..................................................................... 10
TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab
133-200 mg..................................................................... 10
TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab
167-250 mg..................................................................... 10
TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab
200-300 mg..................................................................... 11
TUSNEL C -pseudoephedrine w/ cod-gg syrup 30-10-100
mg/5ml............................................................................. 57
TWOCAL HN -nutritional supplement liquid....................131
TWOCAL HN 2.0 -nutritional supplement liquid..............131
TYBOST -cobicistat tab 150 mg....................................... 11
TYKERB -lapatinib ditosylate tab 250 mg (base
equiv)............................................................................... 22
TYLACTIN RESTORE 10 -nutritional supplement
liquid.............................................................................. 131
TYLACTIN RESTORE 5PE -nutritional supplement
pack............................................................................... 131
TYLACTIN RTD 15 -nutritional supplement liquid.......... 131
TYR ANAMIX EARLY YEARS -nutritional supplement
powder........................................................................... 131
TYR ANAMIX NEXT -nutritional supplement powder..... 131
TYR COOLER -nutritional supplement liquid.................. 131
TYR COOLER20 -nutritional supplement liquid.............. 131
TYREX-1 -nutritional supplement powder....................... 131
TYREX-2 -nutritional supplement powder....................... 131
TYR EXPRESS -nutritional supplement pack................. 131
TYR EXPRESS20 -nutritional supplement pack............. 131
TYR GEL -nutritional supplement pack........................... 131
TYR LOPHLEX LQ -nutritional supplement liquid...........131
TYROS 1 -nutritional supplement powder...................... 131
TYROS 2 -nutritional supplement powder...................... 131
TYVASO REFILL -treprostinil inhalation solution 0.6 mg/
ml..................................................................................... 54
TYVASO STARTER -treprostinil inhalation solution 0.6
mg/ml............................................................................... 54
TYVASO -treprostinil inhalation solution 0.6 mg/ml.......... 54
U
UCD ANAMIX JUNIOR -nutritional supplement
powder........................................................................... 131
UCD 2 -nutritional supplement powder........................... 132
UCD TRIO -nutritional supplement powder.................... 131
UCERIS -budesonide rectal foam 2 mg/act.................... 149
UCERIS -budesonide tab sr 24hr 9 mg............................ 23
ULESFIA -benzyl alcohol lotion 5%................................ 155
ULORIC -febuxostat tab 40 mg......................................... 96
ULORIC -febuxostat tab 80 mg......................................... 96
ULTIMATECARE ONE NF -prenatal w/fe cbnyl-fe asp
glyc-fa-dss-omega cap 20-7-1 mg............................... 111
ULTIMATECARE ONE -prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg............................................... 111
ULTRACAL HN PLUS -nutritional supplement liquid...... 132
ULTRACAL -nutritional supplement liquid....................... 132
ULTRAMINO SOY PROTEIN -nutritional supplement
powder........................................................................... 132
UPTRAVI -selexipag tab 200 mcg.....................................54
UPTRAVI -selexipag tab 400 mcg.....................................54
UPTRAVI -selexipag tab 600 mcg.....................................54
UPTRAVI -selexipag tab 800 mcg.....................................54
UPTRAVI -selexipag tab 1000 mcg...................................54
UPTRAVI -selexipag tab 1200 mcg...................................54
UPTRAVI -selexipag tab 1400 mcg...................................54
UPTRAVI -selexipag tab 1600 mcg...................................54
UPTRAVI -selexipag tab therapy pack 200 mcg (140) &
800 mcg (60)...................................................................54
ursodiol cap 300 mg (Actigall)....................................... 66
ursodiol tab 250 mg (Urso 250)..................................... 66
ursodiol tab 500 mg (Urso forte)................................... 66
UTYMAX -nutritional supplement pack........................... 132
V
VAGIFEM -estradiol vaginal tab 10 mcg........................... 67
valacyclovir hcl tab 1 gm (Valtrex)................................ 11
valacyclovir hcl tab 500 mg (Valtrex)............................ 11
VALCHLOR -mechlorethamine hcl gel 0.016% (base
equivalent)..................................................................... 155
VALCYTE -valganciclovir hcl for soln 50 mg/ml (base
equiv)............................................................................... 11
valganciclovir hcl for soln 50 mg/ml (base equiv)
(Valcyte).......................................................................... 11
valganciclovir hcl tab 450 mg (base equivalent)
(Valcyte).......................................................................... 11
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valproate sodium oral soln 250 mg/5ml (base equiv)
(Depakene)................................................................... 101
valproic acid cap 250 mg (Depakene)......................... 101
valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan
hct).................................................................................. 49
valsartan-hydrochlorothiazide tab 160-12.5 mg
(Diovan hct)................................................................... 49
valsartan-hydrochlorothiazide tab 160-25 mg (Diovan
hct).................................................................................. 50
valsartan-hydrochlorothiazide tab 320-12.5 mg
(Diovan hct)................................................................... 50
valsartan-hydrochlorothiazide tab 320-25 mg (Diovan
hct).................................................................................. 50
valsartan tab 40 mg (Diovan)......................................... 49
valsartan tab 80 mg (Diovan)......................................... 49
valsartan tab 160 mg (Diovan)....................................... 49
valsartan tab 320 mg (Diovan)....................................... 49
vancomycin hcl cap 125 mg (Vancocin hcl)................. 12
vancomycin hcl cap 250 mg (Vancocin hcl)................. 12
VARUBI -rolapitant hcl tab 90 mg (base equiv)................ 63
VASCEPA -icosapent ethyl cap 0.5 gm............................ 53
VASCEPA -icosapent ethyl cap 1 gm............................... 53
VECAMYL -mecamylamine hcl tab 2.5 mg....................... 50
VELPHORO -sucroferric oxyhydroxide chew tab 500
mg.................................................................................... 66
VELTASSA -patiromer sorbitex calcium for susp packet
8.4 gm (base eq).......................................................... 158
VELTASSA -patiromer sorbitex calcium for susp packet
16.8 gm (base eq)........................................................ 158
VELTASSA -patiromer sorbitex calcium for susp packet
25.2 gm (base eq)........................................................ 158
VEMAVITE-PRX 2 -prenatal w/o vit a w/ fe fum-dss-fadha cap 27-1.25-300 mg.............................................. 112
VENA-BAL DHA -prenat w/fe poly-na fered-fa tab 27-1 &
omega cap dr 430mg................................................... 112
venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent)
(Effexor xr)..................................................................... 72
venlafaxine hcl cap sr 24hr 75 mg (base equivalent)
(Effexor xr)..................................................................... 72
venlafaxine hcl cap sr 24hr 150 mg (base equivalent)
(Effexor xr)..................................................................... 72
venlafaxine hcl tab 25 mg...............................................72
venlafaxine hcl tab 37.5 mg............................................72
venlafaxine hcl tab 50 mg...............................................72
venlafaxine hcl tab 75 mg...............................................72
venlafaxine hcl tab 100 mg.............................................72
venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent)
(Venlafaxine hcl er)....................................................... 72
venlafaxine hcl tab sr 24hr 75 mg (base equivalent)
(Venlafaxine hcl er)....................................................... 72
venlafaxine hcl tab sr 24hr 150 mg (base equivalent)
(Venlafaxine hcl er)....................................................... 72
VENTAVIS -iloprost inhalation solution 10 mcg/ml........... 54
VENTAVIS -iloprost inhalation solution 20 mcg/ml........... 54
VENTOLIN HFA -albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv)........................................................ 60
verapamil hcl cap sr 24hr 120 mg (Verelan)................. 44
verapamil hcl cap sr 24hr 180 mg (Verelan)................. 44
verapamil hcl cap sr 24hr 240 mg (Verelan)................. 44
verapamil hcl cap sr 24hr 360 mg (Verelan)................. 44
verapamil hcl cap sr 24hr 100 mg (Verelan pm)........... 44
verapamil hcl cap sr 24hr 200 mg (Verelan pm)........... 44
verapamil hcl cap sr 24hr 300 mg (Verelan pm)........... 44
verapamil hcl tab cr 120 mg (Calan sr)......................... 44
verapamil hcl tab cr 180 mg (Calan sr)......................... 44
verapamil hcl tab cr 240 mg (Calan sr)......................... 44
verapamil hcl tab 40 mg................................................. 44
verapamil hcl tab 80 mg (Calan).................................... 44
verapamil hcl tab 120 mg (Calan).................................. 44
VEREGEN -sinecatechins oint 15%................................155
VERIPRED 20 -prednisolone sod phosphate oral soln 20
mg/5ml (base equiv)....................................................... 23
VERSACLOZ -clozapine susp 50 mg/ml.......................... 76
VESICARE -solifenacin succinate tab 5 mg..................... 67
VESICARE -solifenacin succinate tab 10 mg................... 67
VHC 2.25 -nutritional supplement liquid.......................... 132
VIBERZI -eluxadoline tab 75 mg....................................... 66
VIBERZI -eluxadoline tab 100 mg..................................... 66
VICTOZA -liraglutide soln pen-injector 18 mg/3ml (6 mg/
ml).................................................................................... 33
VIDEX -didanosine for soln 2 gm...................................... 11
VIDEX -didanosine for soln 4 gm...................................... 11
VIEKIRA PAK -ombitas-paritapre-riton & dasab tab pak
12.5-75-50 & 250 mg..................................................... 11
VIEKIRA XR -dasab-ombit-paritap-riton tab sr 24hr
200-8.33-50-33.33 mg.................................................... 11
VIGAMOX -moxifloxacin hcl ophth soln 0.5% (base
equiv)............................................................................. 147
VIIBRYD STARTER PACK -vilazodone hcl tab starter kit
10 (7) & 20 (23) mg....................................................... 72
VIIBRYD -vilazodone hcl tab 10 mg..................................72
VIIBRYD -vilazodone hcl tab 20 mg..................................72
VIIBRYD -vilazodone hcl tab 40 mg..................................72
VILACTIN AA PLUS -nutritional supplement liquid......... 132
VIMPAT -lacosamide oral solution 10 mg/ml.................. 101
VIMPAT -lacosamide tab 50 mg...................................... 101
VIMPAT -lacosamide tab 100 mg.................................... 101
VIMPAT -lacosamide tab 150 mg.................................... 101
VIMPAT -lacosamide tab 200 mg.................................... 101
VINATE DHA RF -prenat w/o a w/fefum-methylfol-omegas
cap 27-1.13 mg............................................................. 112
VINATE II -prenatal vit w/ fe bisglycinate chelate-fa tab
29-1 mg......................................................................... 112
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VINATE M -prenatal vit w/ sel-fe fumarate-fa tab 27-1
mg.................................................................................. 112
VINATE ONE -prenatal vit w/ fe fumarate-fa tab 60-1
mg.................................................................................. 112
VIOKACE -pancrelipase (lip-prot-amyl) tab
10440-39150-39150 unit................................................ 64
VIOKACE -pancrelipase (lip-prot-amyl) tab
20880-78300-78300 unit................................................ 64
VIRACEPT -nelfinavir mesylate tab 250 mg..................... 11
VIRACEPT -nelfinavir mesylate tab 625 mg..................... 11
VIRAMUNE -nevirapine susp 50 mg/5ml.......................... 11
VIRAZOLE -ribavirin for inhal soln 6 gm........................... 11
VIREAD -tenofovir disoproxil fumarate oral powder 40
mg/gm.............................................................................. 11
VIREAD -tenofovir disoproxil fumarate tab 150 mg.......... 11
VIREAD -tenofovir disoproxil fumarate tab 200 mg.......... 11
VIREAD -tenofovir disoproxil fumarate tab 250 mg.......... 11
VIREAD -tenofovir disoproxil fumarate tab 300 mg.......... 11
VIRT-ADVANCE -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg......................................................................... 112
VIRT-CARE ONE -prenatal vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg................................................... 112
VIRT-C DHA -prenatal w/fe fum-fe poly -fa-omega 3 cap
53.5-38-1 mg................................................................. 112
VIRT-NATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................. 112
VIRT NATE -prenatal vit w/ fe fumarate-fa tab 28-1
mg.................................................................................. 112
VIRT-PN DHA -prenat w/o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg........................................................ 112
VIRT-PN PLUS -prenat w/o a w/ fe fumerate-methylfolatefa-omega 3 cap............................................................. 112
VIRT-PN -prenatal vit w/ fe fum-methylfolate-fa tab
27-0.6-0.4 mg................................................................ 112
VIRTPREX -prenatal w/o vit a w/ fe fum-dss-fa-dha cap
26-1.2-300 mg...............................................................112
VIRT-SELECT -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg..................................................... 112
VIRT-VITE GT -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg......................................................................... 112
VITAFOL FE+ -prenat-fepoly-methol-fa-dha cap 90-1-200
mg & dss 50mg cap..................................................... 112
VITAFOL-NANO -prenatal w/o a w/ fefum-l methylfol-fa
tab 18-0.6-0.4 mg......................................................... 112
VITAFOL-OB+DHA -prenatal mv w/fe fum-fa tab 65-1 mg
& dha cap 250 mg pack............................................... 112
VITAFOL-OB -prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................. 112
VITAFOL-ONE -prenatal mv w/ fe polysac cmplx-fa-dha
cap 29-1-200 mg.......................................................... 112
VITAFOL ULTRA -prenat w/fe poly-methylfol-fa-dha cap
29-0.6-0.4-200 mg........................................................ 112
VITAJOULE -nutritional supplement powder...................132
VITAL AF 1.2 CAL -nutritional supplement liquid............ 132
VITAL 1.0 CAL -nutritional supplement liquid................. 132
VITAL 1.5 CAL -nutritional supplement liquid................. 132
VITAL HIGH PROTEIN -nutritional supplement
liquid.............................................................................. 132
VITAL HN -nutritional supplement pack.......................... 132
VITAL JR -nutritional supplement liquid.......................... 132
VITAL PEPTIDE 1.5 CAL -nutritional supplement
liquid.............................................................................. 132
VITAMEDMD ONE RX/QUATREFO -prenat w/o a w/
fefum-methfol-fa-dha cap 30-0.6-0.4-200 mg.............. 112
VITAMEDMD REDICHEW RX -prenat w/ b2-b6-b12-d3folic acid chew tab 1.4 mg........................................... 112
VITAMELTS VITAMIN D -cholecalciferol orally
disintegrating tab 1000 unit.......................................... 105
VITAMIN D3 -cholecalciferol oral liquid 1200
unit/15ml........................................................................ 105
VITAMIN D3 -cholecalciferol spray 1000 unit/spray........105
VITAMIN D2 -ergocalciferol tab 400 unit.........................105
VITAPEARL -prenat w/oa w/fefum-na fered-fa-dha cap cr
30-1.4-200 mg...............................................................112
VITA-PREN -prenatal vit w/ docusate-iron-fa tab 65-1
mg.................................................................................. 112
VITAPRO -nutritional supplement powder...................... 132
VITAQUICK -nutritional supplement powder................... 132
VITATRUE -prenat w/o a w/fe chel-fa tab 30-1.4 mg & dha
cap 300mg pk............................................................... 113
VITUZ -hydrocodone-chlorpheniramine soln 5-4
mg/5ml............................................................................. 57
VIVA DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................. 113
VIVONEX PEDIATRIC -nutritional supplement pack...... 132
VIVONEX PLUS -nutritional supplement powder........... 132
VIVONEX RTF -nutritional supplement liquid................. 132
VIVONEX T.E.N. -nutritional supplement pack............... 132
VIVOTIF -typhoid vaccine cap delayed release................ 15
VOL-NATE -prenatal vit w/ fe fumarate-fa tab 28-1
mg.................................................................................. 113
VOL-PLUS -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 113
VOL-TAB RX -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................. 113
VOLTAREN -diclofenac sodium gel 1%.......................... 155
voriconazole for susp 40 mg/ml (Vfend)......................... 6
voriconazole tab 50 mg (Vfend)....................................... 6
voriconazole tab 200 mg (Vfend)..................................... 6
VOTRIENT -pazopanib hcl tab 200 mg (base equiv)....... 22
VP-CH PLUS -prenatal w/o a w/fe cbn-dss-fa-dha cap
29-1-265 mg.................................................................. 113
VP-CH-PNV -prenatal w/o vit a w/ fe cbn-dss-fa-dha cap
30-1-260 mg.................................................................. 113
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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2017
VP-GGR-B6 PRENATAL -prenatal w/ calcium-vit b6-faginger tab 1.2 mg......................................................... 113
VP-HEME OB + DHA -prenat-fe poly cmplx-fe heme polyfa tab & omega 3 cap pck............................................ 113
VP-HEME OB -prenat vit-fe poly cmplx-fe heme poly-fa
tab 28-6-1 mg............................................................... 113
VP-HEME ONE -prenat-fe poly cmplx-fe heme poly-fadha cap 22-6-1-200 mg................................................ 113
VP-PNV-DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-215.8 mg...............................................................113
VUSION -miconazole-zinc oxide-white petrolatum oint
0.25-15-81.35%............................................................. 155
VYVANSE -lisdexamfetamine dimesylate cap 10 mg....... 80
VYVANSE -lisdexamfetamine dimesylate cap 20 mg....... 80
VYVANSE -lisdexamfetamine dimesylate cap 30 mg....... 80
VYVANSE -lisdexamfetamine dimesylate cap 40 mg....... 80
VYVANSE -lisdexamfetamine dimesylate cap 50 mg....... 80
VYVANSE -lisdexamfetamine dimesylate cap 60 mg....... 80
VYVANSE -lisdexamfetamine dimesylate cap 70 mg....... 80
VYVANSE -lisdexamfetamine dimesylate chew tab 10
mg.................................................................................... 80
VYVANSE -lisdexamfetamine dimesylate chew tab 20
mg.................................................................................... 80
VYVANSE -lisdexamfetamine dimesylate chew tab 30
mg.................................................................................... 80
VYVANSE -lisdexamfetamine dimesylate chew tab 40
mg.................................................................................... 80
VYVANSE -lisdexamfetamine dimesylate chew tab 50
mg.................................................................................... 81
VYVANSE -lisdexamfetamine dimesylate chew tab 60
mg.................................................................................... 81
W
WALGREENS GLUCOSE -glucose chew tab 4 gm......... 33
warfarin sodium tab 1 mg (Coumadin)....................... 136
warfarin sodium tab 2 mg (Coumadin)....................... 136
warfarin sodium tab 2.5 mg (Coumadin).................... 136
warfarin sodium tab 3 mg (Coumadin)....................... 136
warfarin sodium tab 4 mg (Coumadin)....................... 136
warfarin sodium tab 5 mg (Coumadin)....................... 136
warfarin sodium tab 6 mg (Coumadin)....................... 136
warfarin sodium tab 7.5 mg (Coumadin).................... 136
warfarin sodium tab 10 mg (Coumadin)..................... 137
WELCHOL -colesevelam hcl packet for susp 3.75 gm..... 53
WELCHOL -colesevelam hcl tab 625 mg......................... 53
WELLESSE VITAMIN D3 -cholecalciferol oral liquid 1000
unit/10ml........................................................................ 105
WELLNESS ESSENTIALS AI -nutritional supplement
kit................................................................................... 132
WELLNESS ESSENTIALS BLOOD -nutritional
supplement kit............................................................... 132
WELLNESS ESSENTIALS FOR J -nutritional supplement
kit................................................................................... 132
WELLNESS ESSENTIALS FOR M -nutritional
supplement kit............................................................... 132
WELLNESS ESSENTIALS FOR P -nutritional supplement
kit................................................................................... 132
WELLNESS ESSENTIALS FOR W -nutritional
supplement kit............................................................... 132
WELLNESS ESSENTIALS -nutritional supplement
kit................................................................................... 132
WESTHROID -thyroid tab 32.5 mg................................... 37
WESTHROID -thyroid tab 65 mg...................................... 37
WESTHROID -thyroid tab 97.5 mg................................... 37
WESTHROID -thyroid tab 130 mg.................................... 37
WESTHROID -thyroid tab 195 mg.................................... 37
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 60
mm................................................................................. 156
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 65
mm................................................................................. 156
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 70
mm................................................................................. 157
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 75
mm................................................................................. 157
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 80
mm................................................................................. 157
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 85
mm................................................................................. 157
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 90
mm................................................................................. 157
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 95
mm................................................................................. 157
WILATE -antihemophilic factor/vwf (human) for inj
500-500 unit kit............................................................. 142
WILATE -antihemophilic factor/vwf (human) for inj
1000-1000 unit kit......................................................... 142
WND 1 -nutritional supplement powder.......................... 132
WND 2 -nutritional supplement powder.......................... 132
WP THYROID -thyroid tab 16.25 mg................................ 37
WP THYROID -thyroid tab 32.5 mg.................................. 37
WP THYROID -thyroid tab 65 mg..................................... 37
WP THYROID -thyroid tab 81.25 mg................................ 37
WP THYROID -thyroid tab 97.5 mg.................................. 37
WP THYROID -thyroid tab 113.75 mg.............................. 37
WP THYROID -thyroid tab 130 mg................................... 37
WP THYROID -thyroid tab 48.75 mg (3/4 grain).............. 37
X
XALKORI -crizotinib cap 200 mg...................................... 22
XALKORI -crizotinib cap 250 mg...................................... 22
XARELTO -rivaroxaban tab 10 mg..................................137
XARELTO -rivaroxaban tab 15 mg..................................137
XARELTO -rivaroxaban tab 20 mg..................................137
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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XARELTO STARTER PACK -rivaroxaban tab starter
therapy pack 15 mg & 20 mg.......................................137
XARTEMIS XR -oxycodone w/ acetaminophen tab cr
7.5-325 mg...................................................................... 91
XELJANZ -tofacitinib citrate tab 5 mg (base
equivalent)....................................................................... 95
XELJANZ XR -tofacitinib citrate tab sr 24hr 11 mg (base
equivalent)....................................................................... 95
XIFAXAN -rifaximin tab 200 mg........................................ 12
XIFAXAN -rifaximin tab 550 mg........................................ 13
XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr
5-500 mg......................................................................... 33
XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr
5-1000 mg....................................................................... 33
XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr
10-500 mg....................................................................... 33
XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr
10-1000 mg..................................................................... 33
XIIDRA -lifitegrast ophth soln 5%.................................... 147
XLEU MAXAMAID -nutritional supplement powder........ 132
XLEU MAXAMUM -nutritional supplement powder.........132
XLYS-XTRP MAXAMAID -nutritional supplement
powder........................................................................... 132
XLYS-XTRP MAXAMUM -nutritional supplement
powder........................................................................... 132
XMET MAXAMAID -nutritional supplement powder........133
XMET MAXAMUM -nutritional supplement powder........ 133
XMTVI MAXAMAID -nutritional supplement powder.......133
XMTVI MAXAMUM -nutritional supplement powder....... 133
XOLEGEL -ketoconazole gel 2%.................................... 155
XPHE MAXAMAID -nutritional supplement powder........ 133
XPHE MAXAMUM -amino acids oral powder................. 115
XPHE MAXAMUM -amino acids pack............................ 115
XPHE-XTYR MAXAMAID -nutritional supplement
powder........................................................................... 133
XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent 9
mg.................................................................................... 91
XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent
13.5 mg........................................................................... 91
XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent
18 mg.............................................................................. 91
XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent
27 mg.............................................................................. 91
XTAMPZA ER -oxycodone cap er 12hr abuse-deterrent
36 mg.............................................................................. 92
XTANDI -enzalutamide cap 40 mg.................................... 22
XTRACAL PLUS -nutritional supplement liquid.............. 133
XULANE -norelgestromin-ethinyl estradiol td ptwk 150-35
mcg/24hr.......................................................................... 28
XYNTHA -antihemophilic factor recombinant paf for inj kit
250 unit......................................................................... 142
XYNTHA -antihemophilic factor recombinant paf for inj kit
500 unit......................................................................... 142
XYNTHA -antihemophilic factor recombinant paf for inj kit
1000 unit....................................................................... 142
XYNTHA -antihemophilic factor recombinant paf for inj kit
2000 unit....................................................................... 142
XYNTHA SOLOFUSE -antihemophilic factor recombinant
paf for inj kit 250 unit................................................... 143
XYNTHA SOLOFUSE -antihemophilic factor recombinant
paf for inj kit 500 unit................................................... 143
XYNTHA SOLOFUSE -antihemophilic factor recombinant
paf for inj kit 1000 unit................................................. 143
XYNTHA SOLOFUSE -antihemophilic factor recombinant
paf for inj kit 2000 unit................................................. 143
XYNTHA SOLOFUSE -antihemophilic factor recombinant
paf for inj kit 3000 unit................................................. 143
XYREM -sodium oxybate oral solution 500 mg/ml........... 85
Y
Z
zafirlukast tab 10 mg (Accolate).................................... 60
zafirlukast tab 20 mg (Accolate).................................... 60
zaleplon cap 5 mg (Sonata)............................................ 77
zaleplon cap 10 mg (Sonata).......................................... 77
ZARONTIN -ethosuximide cap 250 mg.......................... 101
ZARONTIN -ethosuximide soln 250 mg/5ml................... 101
ZARXIO -filgrastim-sndz soln prefilled syringe 300
mcg/0.5ml...................................................................... 135
ZARXIO -filgrastim-sndz soln prefilled syringe 480
mcg/0.8ml...................................................................... 135
ZATEAN-CH -prenatal w/o a w/fe cbn-dss-fa-dha cap
27-1-250 mg.................................................................. 113
ZATEAN-PN DHA -prenat w/o a w/fefum-methfol-fa-dha
cap 27-0.6-0.4-300 mg................................................. 113
ZATEAN-PN PLUS -prenat w/o a w/ fe fumeratemethylfolate-fa-omega 3 cap........................................ 113
ZAVESCA -miglustat cap 100 mg................................... 135
ZELAPAR -selegiline hcl orally disintegrating tab 1.25
mg.................................................................................. 104
ZELBORAF -vemurafenib tab 240 mg.............................. 22
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
3000-10000-16000 unit...................................................64
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
5000-17000-27000 unit...................................................64
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
10000-34000-55000 unit................................................ 64
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
15000-51000-82000 unit................................................ 64
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
20000-68000-109000 unit.............................................. 64
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
25000-85000-136000 unit.............................................. 64
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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ZENPEP -pancrelipase (lip-prot-amyl) dr cap
40000-136000-218000 unit............................................ 64
ZEPATIER -elbasvir-grazoprevir tab 50-100 mg............... 11
ZERIT -stavudine for oral soln 1 mg/ml............................ 11
ZETIA -ezetimibe tab 10 mg............................................. 53
ZIAGEN -abacavir sulfate soln 20 mg/ml (base equiv)..... 11
zidovudine cap 100 mg (Retrovir)................................. 11
zidovudine syrup 10 mg/ml (Retrovir)........................... 11
zidovudine tab 300 mg.................................................... 11
zileuton tab sr 12hr 600 mg (Zyflo cr)........................... 60
ZIOPTAN -tafluprost ophth soln 0.0015%....................... 147
ziprasidone hcl cap 20 mg (Geodon)............................ 76
ziprasidone hcl cap 40 mg (Geodon)............................ 76
ziprasidone hcl cap 60 mg (Geodon)............................ 76
ziprasidone hcl cap 80 mg (Geodon)............................ 76
ZIRGAN -ganciclovir ophth gel 0.15%............................ 147
ZITHROMAX -azithromycin powd pack for susp 1 gm....... 4
ZMAX -azithromycin extended release for oral susp 2
gm...................................................................................... 4
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 10 mg................................................... 92
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 15 mg................................................... 92
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 20 mg................................................... 92
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 30 mg................................................... 92
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 40 mg................................................... 92
ZOHYDRO ER -hydrocodone bitartrate cap sr 12hr
abuse-deterrent 50 mg................................................... 92
ZOLINZA -vorinostat cap 100 mg..................................... 22
zolmitriptan orally disintegrating tab 2.5 mg (Zomig
zmt)................................................................................. 96
zolmitriptan orally disintegrating tab 5 mg (Zomig
zmt)................................................................................. 96
zolmitriptan tab 2.5 mg (Zomig)..................................... 96
zolmitriptan tab 5 mg (Zomig)........................................ 96
zolpidem tartrate sl tab 1.75 mg (Intermezzo).............. 77
zolpidem tartrate sl tab 3.5 mg (Intermezzo)................ 77
zolpidem tartrate tab cr 6.25 mg (Ambien cr)............... 77
zolpidem tartrate tab cr 12.5 mg (Ambien cr)............... 77
zolpidem tartrate tab 5 mg (Ambien).............................77
zolpidem tartrate tab 10 mg (Ambien)...........................77
ZOMIG -zolmitriptan nasal spray 2.5 mg/spray unit..........96
ZONALON -doxepin hcl cream 5%................................. 155
zonisamide cap 50 mg.................................................. 101
zonisamide cap 25 mg (Zonegran).............................. 101
zonisamide cap 100 mg (Zonegran)............................ 101
ZONTIVITY -vorapaxar sulfate tab 2.08 mg (base
equivalent)..................................................................... 143
ZORTRESS -everolimus tab 0.25 mg............................. 158
ZORTRESS -everolimus tab 0.5 mg............................... 158
ZORTRESS -everolimus tab 0.75 mg............................. 159
ZOSTAVAX -zoster vaccine live for subcutaneous susp
19400 unit/0.65ml........................................................... 15
Z-TUSS AC -chlorpheniramine w/ codeine liquid 2-9
mg/5ml............................................................................. 57
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab
0.7-0.18 mg (base eq).................................................... 92
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab
1.4-0.36 mg (base eq).................................................... 92
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab
2.9-0.71 mg (base eq).................................................... 92
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 5.7-1.4
mg (base eq)...................................................................92
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 8.6-2.1
mg (base eq)...................................................................92
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 11.4-2.9
mg (base eq)...................................................................92
ZYBAN -bupropion hcl (smoking deterrent) tab sr 12hr
150 mg............................................................................ 85
ZYCLARA -imiquimod cream 3.75%............................... 155
ZYCLARA PUMP -imiquimod cream 2.5%..................... 155
ZYCLARA PUMP -imiquimod cream 3.75%................... 155
ZYDELIG -idelalisib tab 100 mg........................................ 22
ZYDELIG -idelalisib tab 150 mg........................................ 22
ZYFLO CR -zileuton tab sr 12hr 600 mg.......................... 60
ZYFLO -zileuton tab 600 mg............................................. 60
ZYKADIA -ceritinib cap 150 mg........................................ 22
ZYLET -loteprednol etabonate-tobramycin ophth susp
0.5-0.3%........................................................................ 147
ZYTIGA -abiraterone acetate tab 250 mg......................... 22
Texas Residents -- Find and estimate prices for medicines on this formulary at:
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