Care Choices Med Guide

January 2016
Care Choices Medication Guide
Contents
Introduction .................................................................... I
Endocrine and Metabolic Drugs ................................. 20
Introduction .................................................................... I
Cardiovascular Agents ............................................... 37
Medication List .............................................................. II
Respiratory Agents ..................................................... 58
Exception Process ....................................................... III
Gastrointestinal Agents .............................................. 63
Your Share of Expenses .............................................. III
Genitourinary Agents ................................................. 69
Pharmacy Benefits ..................................................... IV
Central Nervous System Drugs .................................. 72
Utilization Management Programs ............................. VI
Analgesics and Anesthetics ....................................... 89
Notice ........................................................................ VIII
Neuromuscular Drugs .............................................. 101
Using the Medication Guide ..................................... VIII
Nutritional Products .................................................. 110
Abbreviation/acronym key .......................................... IX

Medication List .............................................................. 1
Hematological Agents .............................................. 119
Anti-Infective Drugs ...................................................... 1
Miscellaneous Products ........................................... 143

Index ........................................................................... 206
Biologicals................................................................... 12
Topical Products....................................................... 126
Antineoplastic Agents ................................................. 16
Please consider talking to your doctor about prescribing formulary 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 formulary is regularly updated. Please visit www.floridablue.com for the most up-to-date information.
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.
3022-O FL HIM Prime Therapeutics LLC 01/16
Introduction
Florida Blue is pleased to present the Care Choices Medication Guide. This is a general guide that includes a
comprehensive listing of medications that may be covered under your plan. Since coverage for medication varies by the
plan purchased by you or your employer, its important that you refer to your plan documents for complete coverage
details. When we refer to plan documents we are referring to one or more of the following: Benefit Booklet, Certificate of
Coverage, Contract, Member Handbook or prescription drug endorsement.
If you are a current member, we encourage you to log on to your member account for plan specific details about your
medication coverage. Go to www.floridablue.com, click on the Members tab. Once registered, you can look up a
medication by name and compare your cost at different pharmacies. Youll see notes that indicate if a medication requires
a prior authorization or is not covered by your plan.
Si desea hablar sobre esta gua en espaol con uno de nuestros representantes, por favor llame al nmero de
atencin al cliente indicado en su tarjeta de asegurado y pida ser transferido a un representante bilinge.
NOTE: The decision concerning whether a prescription medication should be prescribed must be made by you and your
physician. Any and all decisions that require or pertain to independent professional medical judgment or training, or the
need for, and dosage of, a prescription medication, must be made solely by you and your treating physician in accordance
with the patient/physician relationship.
Key Tips and Coverage Guidelines
By following these simple guidelines, you will be assured that you are getting the maximum benefit from your plan.
When you have your prescriptions filled, ask your pharmacist if a generic equivalent is available. Generic
medications are usually less expensive and most generics are covered unless specifically excluded under your
plan documents.
Consider asking your physician to prescribe generic medications, or if necessary, one of the preferred brand name
medications whenever appropriate. Your cost for generic and preferred brand name medications is lower than nonpreferred brand name medications
If you are currently taking a medication, take a moment to review the medication list to determine if it is covered. If
not, check with your doctor to understand available options and review the EXCEPTION PROCESS section of
this Guide for exception procedures.
If you or your provider request a covered brand name medication when there is a generic available; you will be
responsible for: (1) the difference in cost between the generic medication and the brand name medication you
received; and (2) the cost share applicable to the brand name medication you received, as indicated on your
Schedule of Benefits
Florida Blue is a trade name of Blue Cross and Blue Shield of Florida, Inc. Florida Blue HMO is a trade name of
Health Options, Inc., an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies are Independent Licensees of the
Blue Cross and Blue Shield Association.
I
Florida Blue January 2016 Care Choices Medication Guide
Medication List
What you need to know about generic medications
Florida Blue encourages the use of generic medications as a way to provide high-quality medications at reduced costs.
Generic medications are as safe and effective as their brand name counterparts, and are usually considerably less
expensive.
A Food and Drug Administration (FDA) approved generic medication may be substituted for its brand name counterpart
because it:
Contains the same active ingredient(s) as the Brand medication
Is identical in strength, dosage form, and route of administration
Is therapeutically equivalent and can be expected to have the same clinical effect and safety profile
Changes to the formulary

This guide includes the medication list which reflects the current recommendations of Florida Blue and is developed in
conjunction with Prime Therapeutics National Pharmacy & Therapeutics Committee. Florida Blue reserves the right to
add or remove or change the tier of any medication in this Medication Guide at any time.
The medication list is reviewed quarterly to examine new medications and new information about medications that are
already on the market concerning safety, effectiveness and current use in therapy. The most up-to-date information about
modifications to the medications listed in this medication guide can be found by:
Navigate to www.floridablue.com.
Click on the Member Login button.
Login or Register.
Click on Pharmacy.
Under Medication Guide and Specialty Pharmacy click on the Medication Guide link or the Medication Guide
Updates link.
Updated medication guides are posted periodically throughout the year.

There are varying reasons changes are made to the medications listed in the Care Choices Medication Guide:
The tier level of a brand name medication included on the medication list may increase (change to a higher tier)
when an FDA-approved bioequivalent generic medication becomes available.
Newly marketed prescription medications may not be covered until the Pharmacy & Therapeutics Committee has
had an opportunity to review the medication to determine whether the medication will be covered and if so, which
tier will apply based on safety, efficacy and the availability of other products within that class of medications.
Formulary addition request

Physicians may request the addition of a medication to the formulary list by submitting a written request to Florida Blue.
Please mail to:
Florida Blue
Attn: Pharmacy Programs
P.O. Box 1798
Jacksonville, FL 32231-0014
II
Exception Process
Pursuant to 45 C.F.R. 156.122, if a medication is not covered on our formulary, you may request an exception. We have
established processes for both standard exception requests and expedited exception requests, as described below.
Standard Exception Requests
To request a standard exception, you, your designee or the prescribing physician (or other prescriber), as appropriate
may submit an exception request by completing and submitting the Coverage Exception Request Form at the link below.
We will notify you or your designee and the prescribing physician (or other prescriber, as appropriate) of our decision
within 72 hours of our receipt of the request. If we approve the exception, we will provide coverage of the excepted
medication for the duration of the prescription, including refills.
Expedited Exception Requests
You may request an expedited exception based on exigent circumstances. Exigent circumstances exist when:
1. you are suffering from a medical condition that may seriously jeopardize your life, health or ability to regain
maximum function; or
2. you are undergoing a current course of treatment using a medication that is not covered on our formulary.
To request an expedited exception, you, your designee or the prescribing physician (or other prescriber) may submit an
exception request by completing and submitting the Coverage Exception Request Form at the link below.
We will notify you or your designee and the prescribing physician (or other prescriber, as appropriate) of our decision
within 24 hours of our receipt of the request. If we approve the exception, we will provide coverage of the excepted
medication for the duration of the exigency.
Coverage Exception Request Form
What if my exception request is denied?
If we deny your standard or expedited request for exception, you, your designee, or the prescribing physician (or other
prescriber) may request a review of the original request and our denial by an external independent review organization.
1. If the original exception request was a standard request, we will notify you or your designee and the prescribing
physician (or other prescriber, as appropriate) of our decision within 72 hours of our receipt of the request. If we
approve the exception, we will provide coverage of the excepted medication for the duration of the prescription.
2. If the original exception request was an expedited request, we will notify you or your designee and the prescribing
physician (or other prescriber, as appropriate) of our decision within 24 hours of our receipt of the request. If we
approve the exception, we will provide coverage of the excepted medication for the duration of the exigency.
Your Share of Expenses

Your cost share will depend on which cost share tier the medication is assigned to:
Tier 1: Preferred generic medications and supplies
Tier 2: Preferred brand name medications and supplies
Tier 3: Non-preferred medications and supplies
Tier 4: Specialty medications
III
Pharmacy Benefits
Condition Care Rx Program
The Condition Care Rx Program is designed to help manage the cost of medications used to treat certain chronic
conditions and encourage medication adherence. If you have the Condition Care Rx Program as part of your benefits, you
can purchase medications from the Condition Care Rx Program Value List/Health Savings Account Preventive List at a
reduced cost.
A list of medications that are part of the Condition Care Rx Value Program may be found at: Condition Care Rx Program
Value List
A list of medications that are part of the Condition Care Rx Program for Health Savings Account (HSA) compatible plans
may be found at: Condition Care Rx Program HSA Preventive List
NOTE: Check your Schedule of Benefits to determine if the Condition Care Rx Program applies to your plan and the
applicable cost share. Coverage details may also be available to you by logging into the member section of
www.floridablue.com.
Immunizations
Certain vaccines which are covered under your preventive benefits can be administered by pharmacists that are certified.
Not all pharmacies provide services for vaccine administration. It is important to contact the pharmacy prior to your visit to
ensure availability and administration of the vaccine.
A list of vaccines that are covered under your pharmacy benefits may be found at: Pharmacy Benefit Vaccines List
Mail Order Pharmacy
Obtaining prescription medications through the mail order pharmacy may reduce the cost you pay for your prescription
medications.
Check your plan documents to determine if your plan provides a mail order pharmacy benefit.
Members who have pharmacy benefits through Florida Blue can access and print out the Mail Order Pharmacy Form on
our website at www.floridablue.com.
NOTE: If the original prescription was filled at a pharmacy other than the mail order pharmacy, you must submit a new,
original three-month supply prescription with a quantity of up to a three-month supply and not less than a two-month
supply along with the Registration and Prescription Order Form. Prescriptions may not be transferred from a retail
pharmacy to the mail order pharmacy.
Medications that are not covered
Your pharmacy benefit may not cover select medications. Some of the reasons a medication may not be covered are:
The medication has been shown to have excessive adverse effects and/or safer alternatives
The medication has a preferred formulary alternative or over-the-counter (OTC) alternative
The medication is no longer marketed
The medication has a widely available/distributed AB rated generic equivalent formulation
The medication has been repackaged a pharmaceutical product that is removed from the original manufacturer
container (Brand Originator) and repackaged by another manufacturer with a different NDC
In addition to any drug not listed in the medication guide, a list of certain medications that are not covered may be found at
Medications Not Covered List
IV
NOTE: To determine the medication exclusions that apply to your plan, check your plan documents. Coverage details are
also available to you by logging into the member section of www.floridablue.com
Oral Chemotherapy Drugs
Oral chemotherapy drugs are drugs prescribed by a physician to kill or slow the growth of cancerous cells in a manner
consistent with the national accepted standards of practice. A list of these drugs can be found at: Oral Chemotherapy
Drug List
Over-the-counter (OTC) medications
An over-the-counter medication can be an appropriate treatment for some conditions and may offer a lower cost
alternative to some commonly prescribed medications. Your pharmacy benefit may provide coverage for select OTC
medications. Some groups may customize their pharmacy plan to exclude coverage for OTC medications, so it is
important to check your plan documents to determine if OTC medications are covered under your plan. Only those OTC
medications prescribed by your physician and designated on the formulary with OTC in parenthesis following the
medication name are eligible for coverage.
NOTE: Check your plan documents to determine if this benefit applies to your plan. Coverage details are also available to
you logging into the member section of www.floridablue.com.
Patient Protection and Affordable Care Act (ACA) Preventive Services
Preventive Medications Certain preventive care services, medications, and immunizations are covered at no
cost share when purchased at a participating pharmacy. A list of medications covered under this benefit may be
found at: Preventive Medications List
Womens Preventive Services Certain contraceptive medications or devices (e.g., oral contraceptives,
emergency contraceptive, and diaphragms) are covered at no cost share when purchased at a participating
pharmacy. A list of medications and devices covered under this benefit may be found at: Womens Preventive
Services List
Specialty Pharmacy medications

Specialty Pharmacy medications are high-cost injectable, infused, oral or inhaled medications that generally require close
supervision and monitoring of the patients therapy.
NOTE: Check your plan documents for information on how Specialty Pharmacy medications are covered on your plan.
Specialty Medications are divided into two categories:
Self-Administered Specialty Medications Patients administer these Specialty Pharmacy medications themselves.
Because these medications are intended to be self-administered, these medications may not be covered if
administered in a physicians office. If these medications are not obtained from a participating specialty pharmacy,
out-of-network coverage is not available. A current listing of Self-Administered Specialty Medications can be
found here
Provider-Administered Specialty Medications These medications require the administration to be performed by

a physician. The Specialty Pharmacy medications are ordered by a provider and administered in an office or
outpatient setting. Provider-administered Specialty Pharmacy medications are covered under your medical benefit.
These medications can be obtained from any in-network health care provider. A current listing of ProviderAdministered Specialty Medications can be found here
NOTE: We have noted medications that may be covered as either Self-Administered and/or Provider-Administered. These
Specialty Pharmacy products can be obtained in either setting.
V
Participating Specialty Pharmacy Providers

Your network for Specialty Pharmacies is limited to the following participating Specialty Pharmacy providers. Unless
indicated below, any other pharmacy is considered a non-participating Specialty Pharmacy even if it participates in
Florida Blues networks for non-Specialty Pharmacy medications.
Caremark Specialty Pharmacy Services
All Products
Phone: 866-278-5108
Fax: 800-323-2445
Caremark Specialty Pharmacy
Caremark Hemophilia Services
Hemophilia Products
Telephone: 866-792-2731
(Mon-Fri., 9:00 a.m. to 7:30 p.m. EST)
Fax: 866-811-7450
Prime Therapeutics Specialty Pharmacy

(Prime Specialty Pharmacy)
Telephone: 877-627-MEDS (6337)
Fax: 877-828-3939
TTY 711
Prime Specialty Pharmacy
TLCRx Specialty Pharmacy
Phone: 855.274.1694
Fax: 855.819.6922
TLC Specialty Pharmacy
Caremark Hemophilia
NOTE: Specialty Pharmacy medications are not covered when purchased through the mail order pharmacy.
If you receive a written prescription directly from your provider for a provider-administered specialty medication you should
contact customer service for further assistance.
Three-month supply
In addition to being able to obtain up to a three-month supply of medication through our mail order pharmacy, you may be
able to receive up to a three-month supply of your medication through a participating retail pharmacy. Please refer to your
plan documents to determine if your plan includes this benefit.
Utilization Management Programs

Prior Authorization Program
The Prior Authorization Program encourages the appropriate, safe and cost-effective use of medications. If you are
currently taking or are prescribed a medication that is included in the Prior Authorization Program, your physician will need
to submit a request form in order for your prescription to be considered for coverage. If you do not request and/or receive
prior approval, the medication will not be covered. Medications that require prior authorization for coverage are indicated
in the prior authorization column following the product name in the medication list.
NOTE: Some groups may customize their pharmacy plan to exclude prior authorization requirements, so it is important to
check your plan documents to determine if prior authorization requirements apply to your plan. Coverage details are also
available to you by logging into the member section of www.floridablue.com.
Obtaining Prior Authorization
Information about prior authorization and forms for how to obtain a prior authorization approval can be found here: Prior
Authorization Program Information and Forms
NOTE: Your provider is required to complete and submit the Prior Authorization form in order for a coverage
determination to be made.
VI
Once a decision is made, you and/or your doctor will be informed of the decision.
1. If the decision is made to authorize coverage, the medication(s) and/or supplies may be obtained from a
participating pharmacy or at the appropriate location if the medication(s) will be administered by a health
professional. Prior authorization approval does not waive your cost share.
2. If a decision is made to deny authorization, you are free to purchase the prescription medication, supplies or
Over-the-Counter (OTC) medication, but you will have to pay the full cost of the medication and will not be entitled
to reimbursement under your plan.
NOTE: You have the right to request an appeal if prior authorization is denied. Please refer to the How to Appeal an
Adverse Benefit Determination subsection of the Complaint and Grievance Process section in your current Benefit
Booklet or Contract for information on how to file an appeal.
Responsible Quantity Program
The Responsible Quantity Program encourages the appropriate, safe and cost-effective use of medication by setting a
maximum quantity per month for a medication or supply. The quantity limitations are based on the Food and Drug
Administration guidelines and the manufacturers dosing recommendations. Medications that are subject to this program
are indicated in the quantity limits column following the product name in the medication list.
Information about the Responsible Quantity Program and steps for how to obtain an exception can be found here:
Responsible Quantity Program Information
Responsible Steps Program
The Responsible Steps Program promotes the appropriate, safe, and effective use of medications and helps you save on
prescriptions. Responsible Steps is based on nationally recognized therapeutic guidelines, clinical evidence, and research.
Prescription medications included in the Responsible Steps Program are not covered unless you have tried one or more
covered alternative medications first.
Responsible Steps Program (Medical Pharmacy)
Physician-administered Prescription Drugs which are rendered in a physicians office may be included in the Responsible
Steps for Medical Pharmacy Program. If you are taking a medication in the Responsible Steps Program, please contact
your physician/provider to discuss what medication options are best for you.
Information about the Responsible Steps Program and the Responsible Steps for Medical Pharmacy Program and steps
for how to obtain an exception can be found at: Responsible Steps Program Information or Responsible Steps for Medical
Pharmacy Program Information.
NOTE: Check your plan documents to determine if Responsible Steps requirements apply to your plan. Coverage details are
also available to you by logging into the member section of www.FloridaBlue.com or by calling the customer service number
listed on your ID card.
U/M Exception requests
If, for medical reasons, you require a quantity of medication outside the Responsible Quantity Program limits or you
cannot use one of the alternative medications and require the medication listed in the Responsible Steps or Responsible
Steps for Medical Pharmacy Programs, require a tier exception for a contraceptive, your physician may submit an
exception request by completing one of the forms below
Prior Authorization Forms
Responsible Quantity Authorization Form
Contraceptives Tier Exception Request Form
VII
Notice
This Medication Guide shall not extend, vary, alter, replace, or waive any of the provisions, benefits, exclusions,
limitations, or conditions contained in the Benefit Booklet, Contract, or prescription drug endorsement. In the event of any
inconsistencies between the Medication Guide and the provisions contained in the Benefit Booklet, Contract or
prescription drug endorsement, the provisions contained in the Benefit Booklet, Contract or prescription drug endorsement
shall control to the extent necessary to effectuate the intent of Florida Blue and Florida Blue HMO.
Using the Medication Guide

The medication list is organized into broad categories (e.g., Antibacterials). Below are descriptions of the columns
included the medication list.
Column 1.
Drug Name: lists the medication name. Generic medications are listed in lowercase boldface (e.g.,
demeclocycline) Brand name medications are capitalized (e.g., ZITHROMAX packets)
Separate medication entries are shown for each dosage form and strength.
Note: Self-administered injectable medications are designated in the medication list with inj following the
medication name (e.g., enoxaparin inj).
Column 2.
Drug Tier: indicates the tier level and whether the medication is on the preventive list or Condition Care Rx
List:
P: Preventive medications
Tier 1: Preferred generic medications and supplies
Tier 2: Preferred brand name medications and supplies
Tier 3: Non-preferred medications
Tier 4: Specialty medications
Column 3.
Specialty: indicates if the medication is a Self-Administered Specialty medication.
Column 4.
Prior Authorization: indicates if the prior authorization requirement applies to the medication. If an indicator
is present in the column, then the prior authorization requirement applies.
Column 5.
Responsible Quantity: indicates if quantity limits apply to the medication. If an indicator is present in the
column, then quantity limits apply.
Column 6.
Responsible Steps: indicates if step therapy applies to the medication. If an indicator is present in the
column, then step therapy applies.
Column 7.
Limited Distribution: indicates if the medication has limited distribution. If an indicator is present in the
column, the medication may be available only at certain pharmacies. For more information, consult your
pharmacy directory.
VIII
Abbreviation/acronym key
caps ....................................................................capsules
chew tabs .............................................. chewable tablets
OTC ........................................................ over-the-counter

PA ......................................... Prior Authorization required
conc ............................................................... concentrate

crm .......................................................................... cream
QL ............................... Responsible Quantity Program
ext-release............................................ extended-release
inhal .................................................................. inhalation
quantity limit applies

SI ......................................... Self-Administered Injectable
SL...................................................................... sublingual
inj .........................................................................injection
lotn ........................................................................... lotion
SP ..................................................... Specialty Pharmacy

soln ....................................................................... solution
NP ............................................................... non-preferred
ODT ........................................ orally disintegrating tablets
supp ............................................................ suppositories

susp ................................................................ suspension
oint ...................................................................... ointment

OSM ........................................................ osmotic-release
tabs .........................................................................tablets
IX
ANTI-INFECTIVE AGENTS
PENICILLINS
amoxicillin & k clavulanate tab

875-125 mg (Augmentin)
AMOXICILLIN ER - amoxicillin
(trihydrate) tab sr 24hr 775 mg
AMOXICILLIN - amoxicillin
(trihydrate) chew tab 250 mg
amoxicillin (trihydrate) cap

250 mg
AMPICILLIN - ampicillin for susp 125 2

mg/5ml
AMPICILLIN - ampicillin for susp 250 2
mg/5ml
1
ampicillin cap 250 mg
amoxicillin (trihydrate) for susp

125 mg/5ml
200 mg/5ml
250 mg/5ml
400 mg/5ml
amoxicillin (trihydrate) tab 500 mg
amoxicillin (trihydrate) tab 875 mg
amoxicillin & k clavulanate chew
tab 200-28.5 mg
amoxicillin & k clavulanate chew
tab 400-57 mg
amoxicillin & k clavulanate for
susp 200-28.5 mg/5ml
AUGMENTIN - amoxicillin & k

clavulanate for susp 250-62.5
mg/5ml

clavulanate tab 500-125 mg

clavulanate tab 875-125 mg
AUGMENTIN ES-600 - amoxicillin

& k clavulanate for susp 600-42.9
mg/5ml
AUGMENTIN XR - amoxicillin & k

clavulanate tab sr 12hr 1000-62.5
mg
dicloxacillin sodium cap 250 mg
1
1
1
1
1
amoxicillin & k clavulanate for

susp 400-57 mg/5ml
amoxicillin & k clavulanate

for susp 600-42.9 mg/5ml
(Augmentin es-600)
amoxicillin & k clavulanate tab sr

12hr 1000-62.5 mg (Augmentin
xr)

250-125 mg
dicloxacillin sodium cap 500 mg
penicillin v potassium for soln

125 mg/5ml
penicillin v potassium tab 250 mg

penicillin v potassium tab 500 mg
CEPHALOSPORINS
1
1
1
CEDAX - ceftibuten cap 400 mg
CEDAX - ceftibuten for susp 90

mg/5ml
Florida Blue January 2016 Care Choices Rx Medication Drug Guide
Limited Distribution
MOXATAG - amoxicillin (trihydrate)

tab sr 24hr 775 mg
penicillin v potassium for soln

250 mg/5ml
Responsible Steps

clavulanate for susp 125-31.25
mg/5ml
amoxicillin & k clavulanate

for susp 250-62.5 mg/5ml
(Augmentin)

500-125 mg (Augmentin)
ampicillin cap 500 mg
Quantity Limits
Prior Authorization
AMOXICILLIN - amoxicillin
(trihydrate) chew tab 125 mg
amoxicillin (trihydrate) cap

500 mg
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
CEDAX - ceftibuten for susp 180

mg/5ml
CEFTIBUTEN - ceftibuten cap 400

mg
CEFACLOR - cefaclor for susp 125

mg/5ml
CEFTIBUTEN - ceftibuten for susp

180 mg/5ml

mg/5ml
CEFTIN - cefuroxime axetil for susp

125 mg/5ml

mg/5ml
CEFTIN - cefuroxime axetil for susp

250 mg/5ml
cefaclor cap 250 mg
CEFTIN - cefuroxime axetil tab 250

mg
cefaclor cap 500 mg
CEFACLOR ER - cefaclor
monohydrate tab sr 12hr 500 mg
CEFTIN - cefuroxime axetil tab 500

mg
cefadroxil cap 500 mg
cefuroxime axetil tab 250 mg

(Ceftin)
cefuroxime axetil tab 500 mg

(Ceftin)
CEPHALEXIN - cephalexin tab 250

mg
3
3
CEPHALEXIN - cephalexin tab 500

mg
CEFDITOREN PIVOXIL - cefditoren

pivoxil tab 200 mg (base
equivalent)
cephalexin cap 250 mg (Keflex)
CEFDITOREN PIVOXIL - cefditoren

pivoxil tab 400 mg (base
equivalent)
cefixime for susp 100 mg/5ml

(Suprax)
cefixime for susp 200 mg/5ml

(Suprax)
cefpodoxime proxetil for susp
50 mg/5ml
cefadroxil for susp 250 mg/5ml

cefadroxil for susp 500 mg/5ml
cefadroxil tab 1 gm
cefdinir cap 300 mg
cefdinir for susp 125 mg/5ml
cefdinir for susp 250 mg/5ml
cefpodoxime proxetil for susp

100 mg/5ml
cefpodoxime proxetil tab 100 mg
cefpodoxime proxetil tab 200 mg
cefprozil for susp 125 mg/5ml
cefprozil for susp 250 mg/5ml
cefprozil tab 250 mg
cefprozil tab 500 mg
2
1
1
1
1
1

cephalexin for susp 125 mg/5ml
cephalexin for susp 250 mg/5ml
KEFLEX - cephalexin cap 750 mg
SPECTRACEF - cefditoren pivoxil

tab 200 mg (base equivalent)
SPECTRACEF - cefditoren pivoxil

SUPRAX - cefixime cap 400 mg
SUPRAX - cefixime chew tab 100

mg
SUPRAX - cefixime chew tab 200

mg
SUPRAX - cefixime for susp 100

mg/5ml
1
1
1
3
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016

mg/5ml

mg/5ml
MACROLIDES
AZITHROMYCIN - azithromycin
powd pack for susp 1 gm
azithromycin for susp 100 mg/5ml

(Zithromax)
azithromycin for susp 200 mg/5ml

(Zithromax)
azithromycin tab 250 mg

(Zithromax)

(Zithromax)

(Zithromax)
BIAXIN - clarithromycin for susp 250

mg/5ml
BIAXIN - clarithromycin tab 250 mg
BIAXIN - clarithromycin tab 500 mg
BIAXIN XL - clarithromycin tab sr

24hr 500 mg
BIAXIN XL PAC - clarithromycin tab

sr 24hr 500 mg
clarithromycin for susp

125 mg/5ml
clarithromycin for susp

250 mg/5ml (Biaxin)
clarithromycin tab sr 24hr 500 mg
DIFICID - fidaxomicin tab 200 mg
E.E.S. GRANULES - erythromycin

ethylsuccinate for susp 200
mg/5ml
E.E.S. 400 - erythromycin

ethylsuccinate tab 400 mg
clarithromycin tab 250 mg (Biaxin) 1

clarithromycin tab 500 mg (Biaxin) 1
ERY-TAB - erythromycin tab delayed 2

release 250 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016

release 333 mg
release 500 mg
3
ERYPED 200 - erythromycin
mg/5ml
3
ERYPED 400 - erythromycin
mg/5ml
3
ERYTHROCIN STEARATE erythromycin stearate tab 250 mg
3
ERYTHROMYCIN BASE erythromycin tab 250 mg
3
ERYTHROMYCIN BASE erythromycin tab 500 mg
2
ERYTHROMYCIN
ETHYLSUCCINA - erythromycin
ethylsuccinate tab 400 mg
1
erythromycin w/ delayed release
particles cap 250 mg
3
PCE - erythromycin w/ enteric
coated particles tab 333 mg
3
PCE - erythromycin w/ enteric
coated particles tab 500 mg
ZITHROMAX - azithromycin for susp 3
100 mg/5ml
ZITHROMAX - azithromycin for susp 3
200 mg/5ml
2
ZITHROMAX - azithromycin powd
pack for susp 1 gm
ZITHROMAX - azithromycin tab 250 3
mg
mg
mg
3
ZITHROMAX TRI-PAK azithromycin tab 500 mg
3
ZITHROMAX Z-PAK - azithromycin
tab 250 mg
ZMAX - azithromycin extended

release for oral susp 2 gm
TETRACYCLINES
demeclocycline hcl tab 150 mg
demeclocycline hcl tab 300 mg
doxycycline hyclate cap 50 mg
minocycline hcl tab sr 24hr 45 mg

minocycline hcl tab sr 24hr 90 mg
1
1
1
minocycline hcl tab sr 24hr

135 mg
minocycline hcl tab 50 mg
1
2
doxycycline hyclate tab delayed

release 75 mg
TETRACYCLINE HCL - tetracycline

hcl cap 500 mg
VIBRAMYCIN - doxycycline calcium

syrup 50 mg/5ml
doxycycline hyclate tab 100 mg

doxycycline monohydrate cap
50 mg
75 mg (Monodox)
100 mg (Monodox)
150 mg (Adoxa)
doxycycline monohydrate for
susp 25 mg/5ml (Vibramycin)
doxycycline monohydrate tab
50 mg (Adoxa)
75 mg (Adoxa)
100 mg (Adoxa pak 1/100)
150 mg (Adoxa pak 1/150)
AVELOX - moxifloxacin hcl tab 400

mg (base equiv)
AVELOX ABC PACK - moxifloxacin

hcl tab 400 mg (base equiv)
CIPRO - ciprofloxacin for oral susp

250 mg/5ml (5%) (5 gm/100ml)
CIPRO - ciprofloxacin for oral susp

500 mg/5ml (10%) (10 gm/100ml)
CIPRO - ciprofloxacin hcl tab 250 mg 3

(base equiv)
CIPRO - ciprofloxacin hcl tab 500 mg 3
(base equiv)
3
CIPRO XR - ciprofloxacinciprofloxacin hcl tab sr 24hr 500
mg (base eq)
3
CIPRO XR - ciprofloxacinciprofloxacin hcl tab sr 24hr 1000
mg(base eq)
1
ciprofloxacin for oral susp
250 mg/5ml (5%) (5 gm/100ml)
(Cipro)
1
ciprofloxacin for oral susp
500 mg/5ml (10%) (10 gm/100ml)
(Cipro)
3
CIPROFLOXACIN HCL ciprofloxacin hcl tab 100 mg (base
equiv)
1
1
1
1
1
minocycline hcl cap 50 mg

(Minocin)

(Minocin)

(Minocin)
FLUOROQUINOLONES
TETRACYCLINE HCL - tetracycline

hcl cap 250 mg
doxycycline hyclate tab 20 mg
Responsible Steps

release 150 mg
Quantity Limits

release 100 mg
Prior Authorization
doxycycline hyclate cap 100 mg

(Vibramycin)
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
ciprofloxacin hcl tab 250 mg

(base equiv) (Cipro)
(base equiv) (Cipro)
(base equiv)
tobramycin nebu soln 300 mg/5ml

(Tobi)
SULFONAMIDES
SULFADIAZINE - sulfadiazine tab

500 mg
ciprofloxacin-ciprofloxacin hcl
tab sr 24hr 500 mg (base eq)
(Cipro xr)
ciprofloxacin-ciprofloxacin hcl
tab sr 24hr 1000 mg(base eq)
(Cipro xr)
FACTIVE - gemifloxacin mesylate

tab 320 mg (base equiv)
ANTIMYCOBACTERIAL AGENTS
LEVAQUIN - levofloxacin tab 250 mg 3

KITABIS PAK - tobramycin nebu soln 4

300 mg/5ml
1
neomycin sulfate tab 500 mg
paromomycin sulfate cap 250 mg
ethambutol hcl tab 100 mg

(Myambutol)
ethambutol hcl tab 400 mg

(Myambutol)
ISONIAZID - isoniazid syrup 50

mg/5ml
isoniazid tab 100 mg
TOBI PODHALER - tobramycin inhal

cap 28 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
MYAMBUTOL - ethambutol hcl tab

100 mg
MYAMBUTOL - ethambutol hcl tab

400 mg
MYCOBUTIN - rifabutin cap 150 mg
PASER - aminosalicylic acid cr

granules packet 4 gm
PRIFTIN - rifapentine tab 150 mg
pyrazinamide tab 500 mg
1
1
RIFADIN - rifampin cap 150 mg
RIFADIN - rifampin cap 300 mg
RIFAMATE - isoniazid & rifampin cap 2

150-300 mg
1
rifampin cap 150 mg (Rifadin)
rifampin cap 300 mg (Rifadin)
TOBI - tobramycin nebu soln 300

mg/5ml
rifabutin cap 150 mg (Mycobutin)
BETHKIS - tobramycin nebu soln

300 mg/4ml
CYCLOSERINE - cycloserine cap

250 mg
isoniazid tab 300 mg

1
levofloxacin oral soln 25 mg/ml
(Levaquin)
1
levofloxacin tab 250 mg
(Levaquin)
1
(Levaquin)
1
(Levaquin)
moxifloxacin hcl tab 400 mg (base 1
equiv) (Avelox)
OFLOXACIN - ofloxacin tab 400 mg 3
AMINOGLYCOSIDES
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
RIFATER - isoniazid-rifampin w/
pyrazinamide tab 50-120-300 mg
1
3
SIRTURO - bedaquiline fumarate tab 3

100 mg (base equiv)
3
TRECATOR - ethionamide tab 250
mg
ANTIFUNGALS
ANCOBON - flucytosine cap 250 mg
ANCOBON - flucytosine cap 500 mg
BIO-STATIN - nystatin cap 500000

unit
itraconazole cap 100 mg

(Sporanox)
BIO-STATIN - nystatin cap 1000000

unit
ketoconazole tab 200 mg
1
2
CRESEMBA - isavuconazonium
sulfate cap 186 mg
LAMISIL - terbinafine hcl oral

granules packet 125 mg
DIFLUCAN - fluconazole for susp 10

mg/ml
LAMISIL - terbinafine hcl oral

granules packet 187.5 mg
LAMISIL - terbinafine hcl tab 250 mg
DIFLUCAN - fluconazole for susp 40

mg/ml
NOXAFIL - posaconazole susp 40

mg/ml
DIFLUCAN - fluconazole tab 50 mg
NOXAFIL - posaconazole tab

delayed release 100 mg
nystatin tab 500000 unit
fluconazole for susp 10 mg/ml

(Diflucan)
SPORANOX - itraconazole cap 100

mg
fluconazole for susp 40 mg/ml

(Diflucan)
SPORANOX - itraconazole oral soln

10 mg/ml
fluconazole tab 50 mg (Diflucan)
SPORANOX PULSEPAK itraconazole cap 100 mg

terbinafine hcl tab 250 mg
(Lamisil)
VFEND - voriconazole for susp 40

mg/ml
VFEND - voriconazole tab 50 mg
VFEND - voriconazole tab 200 mg
GRIFULVIN V - griseofulvin
microsize tab 500 mg
voriconazole for susp 40 mg/ml

(Vfend)
GRIS-PEG - griseofulvin
ultramicrosize tab 125 mg
voriconazole tab 50 mg (Vfend)
GRIS-PEG - griseofulvin
ultramicrosize tab 250 mg
griseofulvin microsize susp

125 mg/5ml

flucytosine cap 250 mg (Ancobon)
flucytosine cap 500 mg (Ancobon)
1
1
griseofulvin microsize tab 500 mg

(Grifulvin v)
griseofulvin ultramicrosize tab

125 mg (Gris-peg)
griseofulvin ultramicrosize tab

250 mg (Gris-peg)
voriconazole tab 200 mg (Vfend)

ANTIVIRALS
abacavir sulfate-lamivudinezidovudine tab 300-150-300 mg

(Trizivir)
acyclovir cap 200 mg (Zovirax)
acyclovir susp 200 mg/5ml

(Zovirax)
abacavir sulfate tab 300 mg (base

equiv) (Ziagen)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
acyclovir tab 400 mg (Zovirax)

acyclovir tab 800 mg (Zovirax)
EMTRIVA - emtricitabine soln 10 mg/ 2

ml
1
entecavir tab 0.5 mg (Baraclude)
adefovir dipivoxil tab 10 mg

(Hepsera)
APTIVUS - tipranavir cap 250 mg
APTIVUS - tipranavir oral soln 100

mg/ml
ATRIPLA - efavirenz-emtricitabinetenofovir df tab 600-200-300 mg
entecavir tab 1 mg (Baraclude)
EPIVIR - lamivudine oral soln 10 mg/ 3

ml
3
EPIVIR - lamivudine tab 150 mg
EPIVIR - lamivudine tab 300 mg
EPIVIR HBV - lamivudine oral soln 5

mg/ml (hbv)
BARACLUDE - entecavir oral soln

0.05 mg/ml
EPIVIR HBV - lamivudine tab 100

mg (hbv)
BARACLUDE - entecavir tab 0.5 mg
BARACLUDE - entecavir tab 1 mg
COMBIVIR - lamivudine-zidovudine
tab 150-300 mg
EPZICOM - abacavir sulfatelamivudine tab 600-300 mg
COMPLERA - emtricitabinerilpivirine-tenofovir df tab

200-25-300 mg
EVOTAZ - atazanavir sulfatecobicistat tab 300-150 mg (base

equiv)
COPEGUS - ribavirin tab 200 mg
famciclovir tab 125 mg (Famvir)
CRIXIVAN - indinavir sulfate cap 200 2

mg
CRIXIVAN - indinavir sulfate cap 400 2
mg
4
DAKLINZA - daclatasvir
dihydrochloride tab 30 mg (base
equivalent)
4
DAKLINZA - daclatasvir
dihydrochloride tab 60 mg (base
equivalent)
1
didanosine delayed release
capsule 125 mg (Videx ec)
1
1
1
EDURANT - rilpivirine hcl tab 25 mg 2
(base equivalent)
2
EMTRIVA - emtricitabine caps 200
mg

1
1
FAMVIR - famciclovir tab 125 mg
FLUMADINE - rimantadine
hydrochloride tab 100 mg
FUZEON - enfuvirtide for inj 90 mg
HARVONI - ledipasvir-sofosbuvir tab

90-400 mg
HEPSERA - adefovir dipivoxil tab 10

mg
INTELENCE - etravirine tab 25 mg
INVIRASE - saquinavir mesylate cap 2

200 mg
INVIRASE - saquinavir mesylate tab 2
500 mg
ISENTRESS - raltegravir potassium 2
chew tab 25 mg (base equiv)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
KALETRA - lopinavir-ritonavir soln

400-100 mg/5ml (80-20 mg/ml)
KALETRA - lopinavir-ritonavir tab

100-25 mg
KALETRA - lopinavir-ritonavir tab

200-50 mg
lamivudine oral soln 10 mg/ml

(Epivir)
lamivudine tab 100 mg (hbv)

(Epivir hbv)
lamivudine tab 150 mg (Epivir)
1
1
LEXIVA - fosamprenavir calcium

susp 50 mg/ml (base equiv)
LEXIVA - fosamprenavir calcium tab

700 mg (base equiv)
MODERIBA - ribavirin tab 200 mg &

ribavirin tab 400 mg dose pack
MODERIBA - ribavirin tab 400 mg &

MODERIBA 1200 DOSE PACK ribavirin tab 600 mg
MODERIBA 800 DOSE PACK ribavirin tab 400 mg
NEVIRAPINE - nevirapine susp 50

mg/5ml
nevirapine tab sr 24hr 400 mg

(Viramune xr)
nevirapine tab 200 mg (Viramune)
lamivudine tab 300 mg (Epivir)

lamivudine-zidovudine tab
150-300 mg (Combivir)
NORVIR - ritonavir cap 100 mg
NORVIR - ritonavir oral soln 80 mg/

ml
Responsible Steps
ISENTRESS - raltegravir potassium

OLYSIO - simeprevir sodium cap 150 4

mg (base equivalent)
PEG-INTRON - peginterferon alfa-2b 4
for inj kit 50 mcg/0.5ml
4
PEG-INTRON REDIPEN peginterferon alfa-2b for inj kit 50
mcg/0.5ml
4
mcg/0.5ml
4
mcg/0.5ml
4
mcg/0.5ml
4
PEG-INTRON REDIPEN PAK 4 peginterferon alfa-2b for inj kit 50
mcg/0.5ml
4
mcg/0.5ml
4
mcg/0.5ml
4
mcg/0.5ml
PEGASYS - peginterferon alfa-2a inj 4
180 mcg/ml
PEGASYS - peginterferon alfa-2a inj 4
180 mcg/0.5ml
4
PEGASYS PROCLICK peginterferon alfa-2a inj 135
mcg/0.5ml
Quantity Limits
Prior Authorization

packet for susp 100 mg (base
equiv)
NORVIR - ritonavir tab 100 mg
Specialty
Drug Name
Drug Tier

chew tab 100 mg (base equiv)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
PEGINTRON - peginterferon alfa-2b



RIBASPHERE - ribavirin tab 400 mg
RIBASPHERE - ribavirin tab 600 mg
RIBASPHERE RIBAPAK - ribavirin

tab 400 mg

tab 600 mg

PREZCOBIX - darunavir-cobicistat
tab 800-150 mg

tab 200 mg & ribavirin tab 400 mg
dose pack
PREZISTA - darunavir ethanolate


tab 400 mg & ribavirin tab 600 mg
dose pack
RIBATAB - ribavirin tab 400 mg
RIBATAB - ribavirin tab 600 mg
RIBATAB - ribavirin tab 400 mg &

ribavirin cap 200 mg (Rebetol)
rimantadine hydrochloride tab

100 mg (Flumadine)
SOVALDI - sofosbuvir tab 400 mg
stavudine cap 15 mg (Zerit)
ribavirin tab 200 mg (Copegus)
stavudine for oral soln 1 mg/ml

(Zerit)
STRIBILD - elvitegrav-cobicisemtricitab-tenofov tab

150-150-200-300 mg
SUSTIVA - efavirenz cap 50 mg
SUSTIVA - efavirenz cap 200 mg
SUSTIVA - efavirenz tab 600 mg
TAMIFLU - oseltamivir phosphate

cap 30 mg (base equiv)
SELZENTRY - maraviroc tab 150 mg 2

SELZENTRY - maraviroc tab 300 mg 2
REBETOL - ribavirin soln 40 mg/ml
RELENZA DISKHALER - zanamivir

aero powder breath activated 5
mg/blister
RESCRIPTOR - delavirdine
mesylate tab 100 mg
RESCRIPTOR - delavirdine
mesylate tab 200 mg
RETROVIR - zidovudine cap 100 mg 3

3
RETROVIR - zidovudine syrup 10
mg/ml
2
REYATAZ - atazanavir sulfate cap
150 mg (base equiv)
2
200 mg (base equiv)
2
300 mg (base equiv)

1
1
1
Responsible Steps
REYATAZ - atazanavir sulfate oral

powder packet 50 mg (base equiv)
PREZISTA - darunavir ethanolate tab 2

75 mg (base equiv)
150 mg (base equiv)
600 mg (base equiv)
800 mg (base equiv)
4
REBETOL - ribavirin cap 200 mg
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
PEGASYS PROCLICK peginterferon alfa-2a inj 180

mcg/0.5ml
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
TECHNIVIE - ombitasvir-paritaprevir- 4
ritonavir tab 12.5-75-50 mg
TIVICAY - dolutegravir sodium tab 50 2
mg (base equiv)
2
TRIUMEQ - abacavir-dolutegravirlamivudine tab 600-50-300 mg
3
TRIZIVIR - abacavir sulfatelamivudine-zidovudine tab
300-150-300 mg
2
TRUVADA - emtricitabine-tenofovir
disoproxil fumarate tab 200-300
mg
2
TYBOST - cobicistat tab 150 mg
VIDEX EC - didanosine delayed

release capsule 400 mg
VIEKIRA PAK - ombitas-paritapreriton & dasab tab pak 12.5-75-50

& 250 mg
VIRACEPT - nelfinavir mesylate tab

250 mg
VIRACEPT - nelfinavir mesylate tab

625 mg
VIRAMUNE - nevirapine susp 50

mg/5ml
VIRAMUNE - nevirapine tab 200 mg
VIRAMUNE XR - nevirapine tab sr

24hr 100 mg
VIRAMUNE XR - nevirapine tab sr

24hr 400 mg
VIRAZOLE - ribavirin for inhal soln 6

gm
TYZEKA - telbivudine tab 600 mg
valacyclovir hcl tab 500 mg

(Valtrex)
VIREAD - tenofovir disoproxil

fumarate oral powder 40 mg/gm
valacyclovir hcl tab 1 gm (Valtrex)

fumarate tab 150 mg

fumarate tab 200 mg

fumarate tab 250 mg

fumarate tab 300 mg
VITEKTA - elvitegravir tab 85 mg
VITEKTA - elvitegravir tab 150 mg
ZERIT - stavudine cap 15 mg
VALCYTE - valganciclovir hcl for soln 2

50 mg/ml (base equiv)
3
VALCYTE - valganciclovir hcl tab
450 mg (base equivalent)
1
valganciclovir hcl tab 450 mg
(base equivalent) (Valcyte)
3
VALTREX - valacyclovir hcl tab 500
mg
VALTREX - valacyclovir hcl tab 1 gm 3
VICTRELIS - boceprevir cap 200 mg
VIDEX - didanosine for soln 2 gm
VIDEX - didanosine for soln 4 gm


10
ZERIT - stavudine for oral soln 1 mg/ 3

ml
2
ZIAGEN - abacavir sulfate soln 20
mg/ml (base equiv)
TAMIFLU - oseltamivir phosphate for


Responsible Steps
Quantity Limits
Prior Authorization

Specialty
Drug Name
Drug Tier

Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
zidovudine syrup 10 mg/ml

(Retrovir)
zidovudine tab 300 mg
ZOVIRAX - acyclovir cap 200 mg
ZOVIRAX - acyclovir susp 200

mg/5ml
ZOVIRAX - acyclovir tab 400 mg
ZOVIRAX - acyclovir tab 800 mg
ANTIMALARIALS
AMEBICIDES
YODOXIN - iodoquinol tab 210 mg
YODOXIN - iodoquinol tab 650 mg
ANTHELMINTICS
ALBENZA - albendazole tab 200 mg
BILTRICIDE - praziquantel tab 600

mg
ivermectin tab 3 mg (Stromectol)
STROMECTOL - ivermectin tab 3

mg
ANTI-INFECTIVE AGENTS - MISC.
ALINIA - nitazoxanide for susp 100

mg/5ml
atovaquone-proguanil hcl tab

62.5-25 mg (Malarone)
ALINIA - nitazoxanide tab 500 mg
atovaquone susp 750 mg/5ml

(Mepron)
BACTRIM - sulfamethoxazoletrimethoprim tab 400-80 mg
BACTRIM DS - sulfamethoxazoletrimethoprim tab 800-160 mg
CAYSTON - aztreonam lysine for

inhal soln 75 mg (base equivalent)
CLEOCIN - clindamycin hcl cap 75

mg

mg

mg
CLEOCIN PEDIATRIC GRANULE clindamycin palmitate hcl for soln

75 mg/5ml (base equiv)
chloroquine phosphate tab

250 mg
chloroquine phosphate tab
500 mg (Aralen)
1
1
1
COARTEM - artemetherlumefantrine tab 20-120 mg
DARAPRIM - pyrimethamine tab 25

mg
hydroxychloroquine sulfate tab

200 mg (Plaquenil)
MALARONE - atovaquone-proguanil
hcl tab 62.5-25 mg
MALARONE - atovaquone-proguanil
hcl tab 250-100 mg
mefloquine hcl tab 250 mg
PLAQUENIL - hydroxychloroquine
sulfate tab 200 mg
clindamycin hcl cap 75 mg

(Cleocin)
PRIMAQUINE PHOSPHATE primaquine phosphate tab 26.3

mg (15 mg base)

(Cleocin)

(Cleocin)
QUALAQUIN - quinine sulfate cap

324 mg
ARALEN - chloroquine phosphate

tab 500 mg
atovaquone-proguanil hcl tab

250-100 mg (Malarone)
Responsible Steps
Quantity Limits
Prior Authorization
zidovudine cap 100 mg (Retrovir)
quinine sulfate cap 324 mg

(Qualaquin)
Specialty
Drug Name
Drug Tier
ZIAGEN - abacavir sulfate tab 300

mg (base equiv)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
11
clindamycin palmitate hcl for soln

75 mg/5ml (base equiv) (Cleocin
pediatric gr)
DAPSONE - dapsone tab 25 mg
DAPSONE - dapsone tab 100 mg
FLAGYL - metronidazole cap 375

mg
FLAGYL - metronidazole tab 250 mg 3

FLAGYL - metronidazole tab 500 mg 3
FLAGYL ER - metronidazole tab sr
24hr 750 mg
KETEK - telithromycin tab 300 mg
KETEK - telithromycin tab 400 mg
linezolid tab 600 mg (Zyvox)
MEPRON - atovaquone susp 750

mg/5ml
metronidazole cap 375 mg (Flagyl) 1

metronidazole tab 250 mg (Flagyl) 1
vancomycin hcl cap 125 mg

(Vancocin hcl)
vancomycin hcl cap 250 mg

(Vancocin hcl)
XIFAXAN - rifaximin tab 200 mg
XIFAXAN - rifaximin tab 550 mg
ZYVOX - linezolid for susp 100

mg/5ml
ZYVOX - linezolid tab 600 mg
ACTHIB - haemophilus b
polysaccharide conjugate vaccine
for inj
AFLURIA PF 2012-2013 - influenza

virus vaccine split pf susp pref
syringe 0.5 ml
NEBUPENT - pentamidine
isethionate for nebulization soln
300 mg

syringe 0.5 ml
PRIMSOL - trimethoprim hcl oral

soln 50 mg/5ml (base equiv)

syringe 0.5 ml
SIVEXTRO - tedizolid phosphate tab

200 mg

syringe 0.5 ml
sulfamethoxazole-trimethoprim
susp 200-40 mg/5ml
AFLURIA 2012-2013 - influenza

virus vaccine split im susp


TINDAMAX - tinidazole tab 250 mg
TINDAMAX - tinidazole tab 500 mg

tinidazole tab 250 mg (Tindamax)
BEXSERO - meningococcal vac b

(recomb adsorbed) inj prefilled
syringe
CERVARIX - human papillomavirus

(hpv) bival (type 16, 18) recmb
vac inj
metronidazole tab 500 mg (Flagyl)
tab 400-80 mg (Bactrim)
tab 800-160 mg (Bactrim ds)
tinidazole tab 500 mg (Tindamax)

trimethoprim tab 100 mg
VANCOCIN HCL - vancomycin hcl
cap 125 mg
12
1
1
3
Responsible Steps
Quantity Limits
Prior Authorization
VANCOCIN HCL - vancomycin hcl

cap 250 mg
BIOLOGICALS
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
FLUCELVAX 2015-2016 - influenza

virus vac tiss-cult subunit susp
pref syr 0.5 ml
ENGERIX-B - hepatitis b vaccine

(recombinant) susp 10 mcg/0.5ml

(recombinant) susp 20 mcg/ml
FLULAVAL QUADRIVALENT
201 - influenza virus vac split
quadrivalent susp pref syr 0.5ml

(recombinant) 10 mcg/0.5ml
FLULAVAL QUADRIVALENT 201 influenza virus vaccine split

quadrivalent im inj

(recombinant) 20 mcg/ml
FLULAVAL 2013-2014 - influenza

FLUARIX QUADRIVALENT
FLULAVAL 2014-2015 - influenza

FLUMIST QUADRIVALENT influenza virus vaccine live

quadrivalent intranasal susp
FLUVIRIN PF 2013-2014 - influenza

virus vac types a & b pf susp
prefilled syr 0.5 ml
FLUARIX 2013-2014 - influenza

syringe 0.5 ml
FLUVIRIN PF 2014-2015 - influenza

virus vac types a & b pf susp
prefilled syr 0.5 ml
FLUARIX 2014-2015 - influenza

syringe 0.5 ml
FLUVIRIN 2013-2014 - influenza

virus vaccine types a & b surface
antigen im susp
FLUBLOK 2013-2014 - influenza

virus vac recombinant
hemagglutinin (ha) inj

antigen im susp



pref syr 0.5 ml

pref syr 0.5 ml
FLUVIRIN 2015-2016 - influenza vac P

type a&b surface antigen susp
pref syr 0.5 ml
P
antigen im susp
P
FLUZONE HIGH-DOSE PF 2013 influenza virus vac split high-dose
pf susp pref syr 0.5ml
P
P
COMVAX - haemophilus b polysac

conj-hepatitis b (recomb) vac im
susp
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
13
FLUZONE QUADRIVALENT
quadrivalent susp pref syr 0.25 ml
FLUZONE QUADRIVALENT 2013 influenza virus vaccine split

quadrivalent inj 0.5 ml

quadrivalent im inj


quadrivalent im inj

14
FLUZONE SPLIT 2014-2015 influenza virus vaccine split im

susp

susp
GARDASIL - human papillomavirus

(hpv) quadrivalent recombinant
vac inj
GARDASIL 9 - human
papillomavirus (hpv) 9-valent
recomb vac im susp
GARDASIL 9 - human
papillomavirus (hpv) 9-valent
recomb vac susp pref syr
HAVRIX - hepatitis a vaccine inj susp P

720 el unit/0.5ml
HAVRIX - hepatitis a vaccine inj susp P
1440 el unit/ml
P
HIBERIX - haemophilus b
polysaccharide conjugate vac for
inj 10 mcg
P
M-M-R II - measles, mumps &
rubella virus vaccines for inj
P
MEDICAL PROVIDER EZ FLU
S - influenza virus vac tiss-cult
subunit pref syr kit 0.5 ml
P
MEDICAL PROVIDER EZ FLU S influenza virus vac types a & b pf
pref syringe kit 0.5 ml
P
MENACTRA - meningococcal (a, c,
y, and w-135) conjugate vaccine
inj
P
MENHIBRIX - meningococcal (c &
y)-haemophilus b tet tox conj vac
for inj
P
MENOMUNE-A/C/Y/W-135 meningococcal vaccine a, c, y,
and w-135 inj
FLUZONE PF 2014-2015 - influenza

syringe 0.5 ml

susp
Responsible Steps
Quantity Limits
Prior Authorization
FLUZONE PF 2013-2014 - influenza

syringe 0.5 ml
Specialty
Drug Name
Drug Tier
FLUZONE INTRADERMAL
QUADR - influenza virus vac split
quad intradermal pen 9 mcg/strain
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
MENVEO - meningococcal (a, c, y,

and w-135) oligo conj vac for inj
ADACEL - tet tox-diph-acell pertuss

ad inj 5-2-15.5 lf-lf-mcg/0.5ml
PEDVAX HIB - haemophilus b

polysaccharide conj vac im susp
7.5 mcg/0.5 ml
BOOSTRIX - tet tox-diph-acell

pertuss ad inj 5-2.5-18.5 lf-lfmcg/0.5ml
PNEUMOVAX 23 - pneumococcal
vaccine polyvalent inj 25
mcg/0.5ml
DAPTACEL - diph, acellular pert &

tet tox inj 15 lf-10 mcg-5 lf/0.5ml
DIPHTHERIA/TETANUS TOXOID diphtheria-tetanus tox adsorbed

(dt) im inj 25-5 unit/0.5ml
PNEUMOVAX 23/1 DOSE pneumococcal vaccine polyvalent

inj 25 mcg/0.5ml
INFANRIX - diph, acellular pert & tet

tox inj 25 lf-58 mcg-10 lf/0.5ml
PNEUMOVAX 23/5 DOSE pneumococcal vaccine polyvalent

inj 25 mcg/0.5ml
PREVNAR 13 - pneumococcal 13valent conjugate vaccine inj
KINRIX - diph-tetanus tox ad-acell

pert & polio virus, ipv vac inj
PROQUAD - measles-mumpsrubella-varicella virus vaccines for

inj
PEDIARIX - diph-tetanus tox-acell

pert-hepatitis b-polio ipv vac inj
RECOMBIVAX HB - hepatitis b
vaccine (recombinant) susp 5
mcg/0.5ml
PENTACEL - diph-ac per-tet tox adpoliov-haemoph b poly vac for im

susp
QUADRACEL - diph-tetanus tox adacell pert & polio virus, ipv vac inj
mcg/ml
TENIVAC - tetanus-diphtheria
toxoids (td) inj 5-2 lfu
P
P
mcg/ml
TETANUS/DIPHTHERIA TOXOID tetanus-diphtheria toxoids (td) inj

2-2 lf/0.5ml
TRUMENBA - meningococcal group

b vaccine im susp prefilled syringe
GAMMAGARD LIQUID immune globulin (human) iv or

subcutaneous soln 1 gm/10ml
TWINRIX - hepatitis a (inact)-hep b

(recomb) vac inj 720-20 elu-mcg/
ml

subcutaneous soln 2.5 gm/25ml
VAQTA - hepatitis a vaccine inj susp

25 unit/0.5ml
VAQTA - hepatitis a vaccine inj susp

50 unit/ml

VARIVAX - varicella virus vac live for

subcutaneous inj 1350 pfu/0.5ml


ZOSTAVAX - zoster vaccine live for

inj 19400 unit/0.65ml
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
15
GAMMAKED - immune globulin

(human) iv or subcutaneous soln 5
gm/50ml

(human) iv or subcutaneous soln
10 gm/100ml

20 gm/200ml
GAMUNEX-C - immune globulin

gm/10ml

2.5 gm/25ml

gm/50ml

10 gm/100ml

20 gm/200ml

40 gm/400ml
HIZENTRA - immune globulin

(human) subcutaneous inj 1
gm/5ml

gm/10ml
16

gm/50ml
HYQVIA - immun glob inj 2.5

gm/25ml-hyaluron inj 200 unt/1.25
ml kit
HYQVIA - immun glob inj 5 gm/50ml- 4

hyaluron inj 400 unt/2.5 ml kit
4
HYQVIA - immun glob inj 10
gm/100ml-hyaluron inj 800 unt/5
ml kit
4
gm/200ml-hyaluron inj 1600
unt/10 ml kit
4
gm/300ml-hyaluron inj 2400
unt/15 ml kit
ANTINEOPLASTICS

gm/20ml
ANTINEOPLASTIC AGENTS
Responsible Steps

2.5 gm/25ml
Quantity Limits
Prior Authorization
Specialty

gm/10ml
Drug Name
Drug Tier
Responsible Steps

Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
ACTIMMUNE - interferon gamma-1b

inj 100 mcg/0.5ml (2000000
unit/0.5ml)
AFINITOR - everolimus tab 2.5 mg
AFINITOR - everolimus tab 5 mg
AFINITOR - everolimus tab 7.5 mg
AFINITOR - everolimus tab 10 mg
AFINITOR DISPERZ - everolimus

tab for oral susp 2 mg


ALKERAN - melphalan tab 2 mg
anastrozole tab 1 mg (Arimidex)
ARIMIDEX - anastrozole tab 1 mg
AROMASIN - exemestane tab 25 mg 3

4
bexarotene cap 75 mg (Targretin)
bicalutamide tab 50 mg (Casodex)
BOSULIF - bosutinib tab 100 mg
BOSULIF - bosutinib tab 500 mg
capecitabine tab 150 mg (Xeloda)
capecitabine tab 500 mg (Xeloda)
CAPRELSA - vandetanib tab 100 mg 4

CAPRELSA - vandetanib tab 300 mg 4
CASODEX - bicalutamide tab 50 mg
COMETRIQ - cabozantinib s-mal

cap 1 x 80 mg & 1 x 20 mg (100
dose) kit
COMETRIQ - cabozantinib s-mal

cap 1 x 80 mg & 3 x 20 mg (140
dose) kit
COMETRIQ - cabozantinib s-malate

cap 3 x 20 mg (60 mg dose) kit
CYCLOPHOSPHAMIDE cyclophosphamide cap 25 mg
CYCLOPHOSPHAMIDE cyclophosphamide cap 50 mg
EMCYT - estramustine phosphate

sodium cap 140 mg
ERIVEDGE - vismodegib cap 150

mg
ETOPOSIDE - etoposide cap 50 mg
exemestane tab 25 mg (Aromasin)
FARESTON - toremifene citrate tab

FARYDAK - panobinostat lactate cap 4

3
FEMARA - letrozole tab 2.5 mg
flutamide cap 125 mg
GILOTRIF - afatinib dimaleate tab 20 4


4
GLEEVEC - imatinib mesylate tab
4
GLEEVEC - imatinib mesylate tab
GLEOSTINE - lomustine cap 10 mg 4
GLEOSTINE - lomustine cap 40 mg
GLEOSTINE - lomustine cap 100 mg 4

4
HEXALEN - altretamine cap 50 mg
HYCAMTIN - topotecan hcl cap 0.25
mg (base equiv)
HYCAMTIN - topotecan hcl cap 1 mg 4

(base equiv)
HYDREA - hydroxyurea cap 500 mg 3
hydroxyurea cap 500 mg (Hydrea)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
ICLUSIG - ponatinib hcl tab 45 mg

(base equiv)
IMBRUVICA - ibrutinib cap 140 mg
INLYTA - axitinib tab 1 mg
INLYTA - axitinib tab 5 mg
INTRON A - interferon alfa-2b inj

6000000 unit/ml
INTRON A - interferon alfa-2b inj

10000000 unit/ml
INTRON A - interferon alfa-2b for inj

10000000 unit

18000000 unit

50000000 unit
INTRON A W/DILUENT - interferon

alfa-2b for inj 10000000 unit
IBRANCE - palbociclib cap 75 mg
ICLUSIG - ponatinib hcl tab 15 mg

(base equiv)
17
IRESSA - gefitinib tab 250 mg
JAKAFI - ruxolitinib phosphate tab 5

JAKAFI - ruxolitinib phosphate tab




LENVIMA 10MG DAILY DOSE lenvatinib cap therapy pack 10 mg

(10 mg daily dose)
MEKINIST - trametinib dimethyl

sulfoxide tab 0.5 mg (base
equivalent)
LENVIMA 14MG DAILY DOSE lenvatinib cap therapy pack 10 & 4

mg (14 mg daily dose)
LENVIMA 20MG DAILY DOSE lenvatinib cap therapy pack 10 (2)

mg (20 mg daily dose)
LENVIMA 24MG DAILY DOSE lenvatinib cap therapy pack 10 (2)

& 4 mg (24 mg daily dose)
letrozole tab 2.5 mg (Femara)
LEUCOVORIN CALCIUM leucovorin calcium tab 10 mg
LEUCOVORIN CALCIUM leucovorin calcium tab 15 mg
leucovorin calcium tab 5 mg
leucovorin calcium tab 25 mg
leuprolide acetate inj kit 5 mg/ml
LOMUSTINE - lomustine cap 10 mg
LOMUSTINE - lomustine cap 40 mg
LOMUSTINE - lomustine cap 100

mg
18
LONSURF - trifluridine-tipiracil tab

15-6.14 mg
LONSURF - trifluridine-tipiracil tab

20-8.19 mg
LYNPARZA - olaparib cap 50 mg
LYSODREN - mitotane tab 500 mg
MATULANE - procarbazine hcl cap

50 mg
MEGACE ORAL - megestrol acetate

susp 40 mg/ml
megestrol acetate susp 40 mg/ml

(Megace oral)
megestrol acetate tab 20 mg
MEKINIST - trametinib dimethyl

sulfoxide tab 2 mg (base
equivalent)
mercaptopurine tab 50 mg
megestrol acetate tab 40 mg
methotrexate sodium for inj 1 gm
methotrexate sodium inj pf 25 mg/

ml
methotrexate sodium tab 2.5 mg
(base equiv)
MESNEX - mesna tab 400 mg
methotrexate sodium inj 25 mg/ml
LEUKERAN - chlorambucil tab 2 mg
Responsible Steps

Quantity Limits
Prior Authorization
Specialty

Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
MYLERAN - busulfan tab 2 mg
NEXAVAR - sorafenib tosylate tab

NILANDRON - nilutamide tab 150

mg
ODOMZO - sonidegib phosphate

cap 200 mg (base equivalent)
POMALYST - pomalidomide cap 1

mg

mg
PURIXAN - mercaptopurine susp

2000 mg/100ml (20 mg/ml)
SOLTAMOX - tamoxifen citrate oral

soln 10 mg/5ml (base equivalent)
SPRYCEL - dasatinib tab 20 mg
STIVARGA - regorafenib tab 40 mg
SUTENT - sunitinib malate cap 12.5

SUTENT - sunitinib malate cap 25

SUTENT - sunitinib malate cap 37.5

SUTENT - sunitinib malate cap 50

SYLATRON - peginterferon alfa-2b

for inj kit 200 mcg

for inj kit 300 mcg

for inj kit 600 mcg
TABLOID - thioguanine tab 40 mg
TAFINLAR - dabrafenib mesylate

TAFINLAR - dabrafenib mesylate

tamoxifen citrate tab 10 mg (base

equivalent)
tamoxifen citrate tab 20 mg (base

equivalent)
TARCEVA - erlotinib hcl tab 25 mg
(base equivalent)
P
4
Responsible Steps

mg
Quantity Limits
Prior Authorization
Specialty

mg
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016

(base equivalent)

(base equivalent)
TARGRETIN - bexarotene cap 75

mg
TASIGNA - nilotinib hcl cap 150 mg

(base equivalent)
TASIGNA - nilotinib hcl cap 200 mg

(base equivalent)
TEMODAR - temozolomide cap 5

mg

mg

mg

mg

mg

mg
temozolomide cap 5 mg (Temodar) 4

4
temozolomide cap 20 mg
(Temodar)
4
(Temodar)
4
(Temodar)
4
(Temodar)
4
(Temodar)
4
tretinoin cap 10 mg
TREXALL - methotrexate sodium tab 3

5 mg (base equiv)
7.5 mg (base equiv)
10 mg (base equiv)
19

15 mg (base equiv)
4
TYKERB - lapatinib ditosylate tab
250 mg (base equiv)
4
VOTRIENT - pazopanib hcl tab 200
mg (base equiv)
4
XALKORI - crizotinib cap 200 mg
XALKORI - crizotinib cap 250 mg
XELODA - capecitabine tab 150 mg
XELODA - capecitabine tab 500 mg
XTANDI - enzalutamide cap 40 mg
ZELBORAF - vemurafenib tab 240

mg
ZOLINZA - vorinostat cap 100 mg
ZYDELIG - idelalisib tab 100 mg
ZYDELIG - idelalisib tab 150 mg
ZYKADIA - ceritinib cap 150 mg
ZYTIGA - abiraterone acetate tab

250 mg
ENDOCRINE AND METABOLIC DRUGS

CORTICOSTEROIDS
budesonide cap sr 24hr 3 mg
(Entocort ec)
CORTEF - hydrocortisone tab 5 mg
CORTISONE ACETATE - cortisone

acetate tab 25 mg
DEXAMETHASONE dexamethasone soln 0.5 mg/5ml
DEXAMETHASONE dexamethasone tab 1 mg
DEXAMETHASONE dexamethasone tab 2 mg
dexamethasone elixir 0.5 mg/5ml
DEXAMETHASONE INTENSOL dexamethasone conc 1 mg/ml
dexamethasone tab 0.5 mg

20

dexamethasone tab 4 mg
DEXPAK 10 DAY - dexamethasone

tab 1.5 mg taper pack


Responsible Steps
Quantity Limits
Prior Authorization
dexamethasone tab 6 mg
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
ENTOCORT EC - budesonide cap sr 3

24hr 3 mg
3
FLO-PRED - prednisolone acetate
oral susp 16.7 mg/5ml (15 mg/5ml
base)
1
fludrocortisone acetate tab
0.1 mg
1
hydrocortisone tab 5 mg (Cortef)
1
1
MEDROL - methylprednisolone tab 2 3

mg
mg
mg
3
MEDROL - methylprednisolone tab
16 mg
3
MEDROL - methylprednisolone tab
32 mg
3
MEDROL DOSEPAK methylprednisolone tab 4 mg dose
pack
1
methylprednisolone tab 4 mg
dose pack (Medrol dosepak)
1
(Medrol)
1
(Medrol)
1
(Medrol)
(Medrol)
PREDNISONE - prednisone tab 50

mg
MILLIPRED - prednisolone sod

phosphate oral soln 10 mg/5ml
(base equiv)

mg dose pack

mg dose pack
MILLIPRED - prednisolone tab 5 mg
MILLIPRED DP - prednisolone tab 5

mg dose pack
PREDNISONE INTENSOL prednisone conc 5 mg/ml
ORAPRED ODT - prednisolone sod

phos orally disintegr tab 10 mg
(base eq)
prednisone tab 1 mg

(base eq)

(base eq)
PEDIAPRED - prednisolone sod

phosph oral soln 6.7 mg/5ml (5
mg/5ml base)
prednisolone sod phos orally

disintegr tab 10 mg (base eq)
(Orapred odt)

(Orapred odt)

(Orapred odt)
prednisolone sod phosph oral

soln 6.7 mg/5ml (5 mg/5ml base)
(Pediapred)
prednisolone sod phosphate oral

prednisone tab 2.5 mg
PREDNISOLONE SODIUM
PHOSP - prednisolone sodium
(base eq)
prednisolone syrup 15 mg/5ml

(usp solution equivalent)
PREDNISONE - prednisone oral

soln 5 mg/5ml
prednisone tab 5 mg
prednisone tab 10 mg
prednisone tab 20 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
1
RAYOS - prednisone tab delayed

release 1 mg

release 2 mg

release 5 mg
UCERIS - budesonide tab sr 24hr 9

mg
VERIPRED 20 - prednisolone sod

(base equiv)
ANDROGEN-ANABOLIC
ANADROL-50 - oxymetholone tab 50 3

mg
2
ANDRODERM - testosterone td
patch 24hr 2 mg/24hr
2
ANDRODERM - testosterone td
patch 24hr 4 mg/24hr
ANDROGEL - testosterone td gel 25 2
mg/2.5gm (1%)
ANDROGEL - testosterone td gel 50 3
mg/5gm (1%)
2
ANDROGEL - testosterone td gel
20.25 mg/1.25gm (1.62%)
2
ANDROGEL - testosterone td gel
40.5 mg/2.5gm (1.62%)
21
ANDROGEL PUMP - testosterone td 2

gel 12.5 mg/act (1%)
ANDROGEL PUMP - testosterone td 2
gel 20.25 mg/act (1.62%)
ANDROID - methyltestosterone cap 3
10 mg
ANDROXY - fluoxymesterone tab 10 3
mg
1
danazol cap 50 mg
danazol cap 100 mg
danazol cap 200 mg
ALORA - estradiol td patch twice

weekly 0.025 mg/24hr

weekly 0.05 mg/24hr


weekly 0.1 mg/24hr
ANGELIQ - drospirenone-estradiol
tab 0.25-0.5 mg
ANGELIQ - drospirenone-estradiol
tab 0.5-1 mg
FORTESTA - testosterone td gel

10mg/act (2%)
METHITEST - methyltestosterone
oral tab 10 mg
methyltestosterone cap 10 mg
(Testred)
OXANDRIN - oxandrolone tab 2.5

mg
OXANDRIN - oxandrolone tab 10 mg 3

oxandrolone tab 2.5 mg (Oxandrin) 1
testosterone cypionate im
inj in oil 100 mg/ml (Depotestosterone)
testosterone cypionate im
inj in oil 200 mg/ml (Depotestosterone)
testosterone enanthate im inj in

oil 200 mg/ml
CLIMARA - estradiol td patch weekly 3

0.025 mg/24hr
0.0375 mg/24hr (37.5 mcg/24hr)
0.05 mg/24hr
0.06 mg/24hr
0.075 mg/24hr
0.1 mg/24hr
2
CLIMARA PRO - estradiollevonorgestrel td patch weekly
0.045-0.015 mg/day
3
COMBIPATCH - estradiolnorethindrone ace td pttw
0.05-0.14 mg/day
3
COMBIPATCH - estradiolnorethindrone ace td pttw
0.05-0.25 mg/day
2
DIVIGEL - estradiol td gel 0.25
mg/0.25gm (0.1%)
Responsible Steps
Quantity Limits
DEPO-TESTOSTERONE testosterone cypionate im inj in oil

200 mg/ml
TESTRED - methyltestosterone cap

10 mg
Prior Authorization
testosterone td gel 50 mg/5gm

(1%) (Androgel)
Specialty
ACTIVELLA - estradiol &

norethindrone acetate tab 1-0.5
mg
Drug Tier
3
DEPO-TESTOSTERONE testosterone cypionate im inj in oil

100 mg/ml
oxandrolone tab 10 mg (Oxandrin)
Drug Name
ACTIVELLA - estradiol &
norethindrone acetate tab 0.5-0.1
mg
1
1
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
ESTROGENS
22
ELESTRIN - estradiol gel 0.06%

(0.52 mg/0.87 gm metered-dose
pump)
ENJUVIA - estrogens, conjugated

synthetic b tab 0.3 mg




esterified estrogens &

methyltestosterone tab
0.625-1.25 mg
esterified estrogens &

methyltestosterone tab
1.25-2.5 mg
estradiol td patch weekly

0.05 mg/24hr (Climara)
ESTROGEL - estradiol gel 0.06%

(0.75 mg/1.25 gm metered-dose
pump)
ESTROPIPATE - estropipate tab 3

mg
estropipate tab 0.75 mg

MENEST - esterified estrogens tab

0.3 mg

0.625 mg
1.25 mg
estradiol & norethindrone acetate

tab 0.5-0.1 mg (Activella)
estradiol td patch twice weekly

0.05 mg/24hr (Vivelle-dot)


0.0375 mg/24hr (37.5 mcg/24hr)
(Climara)
FEMHRT LOW DOSE norethindrone acetate-ethinyl

estradiol tab 0.5 mg-2.5 mcg
ESTRACE - estradiol tab 2 mg

estradiol tab 2 mg (Estrace)

EVAMIST - estradiol transdermal

spray 1.53 mg/spray
ESTRACE - estradiol tab 1 mg
estradiol tab 1 mg (Estrace)
estropipate tab 1.5 mg

3
estradiol tab 0.5 mg (Estrace)


ESTRACE - estradiol tab 0.5 mg
estradiol & norethindrone acetate

tab 1-0.5 mg (Activella)
1
1

2.5 mg
MENOSTAR - estradiol td patch

weekly 14 mcg/24hr
MINIVELLE - estradiol td patch twice 3

DUAVEE - conjugated estrogensbazedoxifene tab 0.45-20 mg

Responsible Steps
Quantity Limits
Prior Authorization
DIVIGEL - estradiol td gel 1 mg/gm

(0.1%)
Specialty
Drug Name
Drug Tier
DIVIGEL - estradiol td gel 0.5

mg/0.5gm (0.1%)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
23

weekly 0.05 mg/24hr
weekly 0.1 mg/24hr
1
norethindrone acetate-ethinyl
estradiol tab 0.5 mg-2.5 mcg
(Femhrt low dose)
1
norethindrone acetate-ethinyl
estradiol tab 1 mg-5 mcg
3
PREFEST - estradiol tab 1
mg(15)/estrad-norgestimate tab
1-0.09mg(15)
PREMARIN - estrogens, conjugated 2
tab 0.3 mg
tab 0.45 mg
tab 0.625 mg
tab 0.9 mg
tab 1.25 mg
2
PREMPHASE - conj est 0.625(14)/
conj est-medroxypro ac tab
0.625-5mg(14)
2
PREMPRO - conjugated estrogenmedroxyprogest acetate tab
0.3-1.5 mg
2
0.45-1.5 mg
2
0.625-2.5 mg
2
0.625-5 mg
24
VIVELLE-DOT - estradiol td patch

twice weekly 0.0375 mg/24hr



CONTRACEPTIVES
BEYAZ - drospirenone-ethinyl
estrad-levomefolate tab
3-0.02-0.451 mg
BREVICON-28 - norethindrone &

ethinyl estradiol tab 0.5 mg-35
mcg

Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
CYCLESSA - desogest-ethin est tab 3

0.1-0.025/0.125-0.025/0.15-0.025mgmg
3
DESOGEN - desogestrel & ethinyl
estradiol tab 0.15 mg-30 mcg
P
desogest-eth estrad & eth estrad
tab 0.15-0.02/0.01 mg(21/5)
(Mircette)
P
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mgmg (Cyclessa)
P
desogestrel & ethinyl estradiol
tab 0.15 mg-30 mcg (Desogen)
drospirenone-ethinyl estradiol tab P
3-0.02 mg (Yaz)
drospirenone-ethinyl estradiol tab P
3-0.03 mg (Yasmin 28)
P
ELLA - ulipristal acetate tab 30 mg
ESTROSTEP FE - norethindrone
ac-ethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg
ethynodiol diacetate & ethinyl

FEMCON FE - norethindrone &

ethinyl estradiol-fe chew tab 0.4
mg-35 mcg
NATAZIA - estradiol valeratedienogest tab 3 mg /2-2 mg/2-3

mg/1 mg
GENERESS FE - norethindrone &

ethinyl estradiol-fe chew tab 0.8
mg-25 mcg
NECON 1/50-28 - norethindrone &

mestranol tab 1 mg-50 mcg
levonorg-eth est tab

0.1-0.02mg(84) & eth est tab
0.01mg(7) (Loseasonique)
NECON 10/11-28 - norethindroneeth estradiol tab 0.5-35/1-35 mgmcg (10/11)
NOR-QD - norethindrone tab 0.35

mg
norethindrone & ethinyl estradiol

tab 0.4 mg-35 mcg (Ovcon-35)
levonorg-eth est tab

0.15-0.03mg(84) & eth est tab
0.01mg(7) (Seasonique)
levonorgestrel & ethinyl estradiol
(91-day) tab 0.15-0.03 mg
tab 0.1 mg-20 mcg
tab 0.15 mg-30 mcg
levonorgestrel tab 1.5 mg
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mgmcg
levonorgestrel-ethinyl estradiol
(continuous) tab 90-20 mcg
P
P
P

tab 0.5 mg-35 mcg (Brevicon-28)
tab 1 mg-35 mcg (Norinyl 1+35)
norethindrone & ethinyl estradiolfe chew tab 0.8 mg-25 mcg

(Generess fe)
LO LOESTRIN FE - norethin-eth
estradiol-fe tab 1 mg-10 mcg
(24)/10 mcg (2)
norethindrone ac-ethinyl estradfe tab 1-20/1-30/1-35 mg-mcg

(Estrostep fe)
LOESTRIN FE 1.5/30 norethindrone ace & ethinyl

estradiol-fe tab 1.5 mg-30 mcg
norethindrone ace & ethinyl

(Loestrin 1/20-21)
LOESTRIN FE 1/20 - norethindrone

ace & ethinyl estradiol-fe tab 1
mg-20 mcg

(Loestrin 1.5/30-21)
LOSEASONIQUE - levonorg-eth est

tab 0.1-0.02mg(84) & eth est tab
0.01mg(7)

(Loestrin fe 1/20)
MINASTRIN 24 FE - norethindrone
ace-eth estradiol-fe chew tab 1
mg-20 mcg (24)

estradiol-fe tab 1.5 mg-30 mcg
(Loestrin fe 1.5/30)
MODICON - norethindrone & ethinyl

norethindrone ace-ethinyl
(24)
Responsible Steps
Quantity Limits
P
P
norethindrone tab 0.35 mg (Norqd)
Prior Authorization
norethindrone & ethinyl estradiolfe chew tab 0.4 mg-35 mcg

(Femcon fe)
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
25
norethindrone-eth estradiol tab

0.5-35/0.75-35/1-35 mg-mcg
(Ortho-novum 7/7/7)
ORTHO-NOVUM 7/7/7 norethindrone-eth estradiol tab

0.5-35/0.75-35/1-35 mg-mcg
norethindrone-eth estradiol tab

0.5-35/1-35/0.5-35 mg-mcg (Trinorinyl 28)
PLAN B ONE-STEP - levonorgestrel

tab 1.5 mg
norgestimate & ethinyl estradiol

tab 0.25 mg-35 mcg (Orthocyclen)
QUARTETTE - levonor-eth est tab

0.15-0.02/0.025/0.03 mg &eth est
0.01 mg
SAFYRAL - drospirenoneethinyl estrad-levomefolate tab

3-0.03-0.451 mg
norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mgmcg (Ortho tri-cyclen)
SEASONIQUE - levonorg-eth est

tab 0.15-0.03mg(84) & eth est tab
0.01mg(7)
norgestrel & ethinyl estradiol tab

0.3 mg-30 mcg
NORINYL 1+35 - norethindrone &
ethinyl estradiol tab 1 mg-35 mcg
NORINYL 1+50 - norethindrone &

mestranol tab 1 mg-50 mcg
TRI-NORINYL 28 norethindrone-eth estradiol tab

0.5-35/1-35/0.5-35 mg-mcg
NUVARING - etonogestrel-ethinyl
estradiol va ring 0.120-0.015
mg/24hr
XULANE - norelgestromin-ethinyl
estradiol td ptwk 150-35 mcg/24hr
YASMIN 28 - drospirenone-ethinyl
estradiol tab 3-0.03 mg
OGESTREL - norgestrel & ethinyl

YAZ - drospirenone-ethinyl estradiol

tab 3-0.02 mg
ORTHO EVRA - norelgestrominethinyl estradiol td ptwk 150-35

mcg/24hr
ZOVIA 1/50E - ethynodiol diacetate

& ethinyl estradiol tab 1 mg-50
mcg
ORTHO MICRONOR - norethindrone 3

tab 0.35 mg
3
ORTHO TRI-CYCLEN norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg
3
ORTHO TRI-CYCLEN LO norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg
3
ORTHO-CEPT - desogestrel &
mcg
3
ORTHO-CYCLEN - norgestimate &
mcg
3
ORTHO-NOVUM 1/35 norethindrone & ethinyl estradiol
tab 1 mg-35 mcg
26
PROGESTINS
AYGESTIN - norethindrone acetate
tab 5 mg
medroxyprogesterone acetate tab

2.5 mg (Provera)

5 mg (Provera)
10 mg (Provera)
Responsible Steps
Quantity Limits
Prior Authorization
1
1
MEGACE ES - megestrol acetate

susp 625 mg/5ml
megestrol acetate susp

625 mg/5ml (Megace es)
norethindrone acetate tab 5 mg

(Aygestin)
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
AVANDAMET - rosiglitazone
maleate-metformin hcl tab 2-1000
mg
PROMETRIUM - progesterone
micronized cap 100 mg
AVANDIA - rosiglitazone maleate tab

2 mg (base equiv)
PROMETRIUM - progesterone
micronized cap 200 mg

4 mg (base equiv)
PROVERA - medroxyprogesterone
acetate tab 2.5 mg

8 mg (base equiv)
acetate tab 5 mg
BYDUREON - exenatide extended

release for inj susp 2 mg
acetate tab 10 mg
BYDUREON - exenatide extended

release for susp pen-injector 2 mg
BYETTA - exenatide soln peninjector 5 mcg/0.02ml
BYETTA - exenatide soln peninjector 10 mcg/0.04ml
CHLORPROPAMIDE chlorpropamide tab 100 mg
CHLORPROPAMIDE chlorpropamide tab 250 mg
CYCLOSET - bromocriptine
mesylate tab 0.8 mg (base
equivalent)
DIABETA - glyburide tab 1.25 mg
DIABETA - glyburide tab 2.5 mg
progesterone micronized cap

100 mg (Prometrium)
progesterone micronized cap
200 mg (Prometrium)
ANTIDIABETICS
Antidiabetics
acarbose tab 25 mg (Precose)
1
1
1
ACTOPLUS MET - pioglitazone hclmetformin hcl tab 15-500 mg
ACTOPLUS MET - pioglitazone hclmetformin hcl tab 15-850 mg
ACTOPLUS MET XR - pioglitazone

hcl-metformin hcl tab sr 24hr
15-1000 mg
ACTOPLUS MET XR - pioglitazone

hcl-metformin hcl tab sr 24hr
30-1000 mg
DIABETA - glyburide tab 5 mg
DUETACT - pioglitazone hclglimepiride tab 30-2 mg
ACTOS - pioglitazone hcl tab 15 mg

(base equiv)
DUETACT - pioglitazone hclglimepiride tab 30-4 mg

(base equiv)

(base equiv)
AMARYL - glimepiride tab 1 mg
FARXIGA - dapagliflozin propanediol 3

FARXIGA - dapagliflozin propanediol 3
1
glimepiride tab 1 mg (Amaryl)

glipizide tab sr 24hr 2.5 mg
(Glucotrol xl)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
27
glipizide tab sr 24hr 5 mg

(Glucotrol xl)
glipizide tab sr 24hr 10 mg

(Glucotrol xl)
glipizide tab 5 mg (Glucotrol)
glipizide tab 10 mg (Glucotrol)

glipizide-metformin hcl tab
2.5-250 mg
2.5-500 mg
5-500 mg
GLYBURIDE - glyburide tab 1.25 mg
GLYBURIDE - glyburide tab 2.5 mg
GLYBURIDE - glyburide tab 5 mg
glyburide micronized tab 1.5 mg

(Glynase)
glyburide micronized tab 3 mg

(Glynase)
glyburide micronized tab 6 mg

(Glynase)
glyburide tab 1.25 mg
glyburide tab 2.5 mg

glyburide tab 5 mg
1
1
GLUCAGEN HYPOKIT - glucagon

hcl (rdna) for inj 1 mg (base equiv)
GLUCAGON EMERGENCY KIT glucagon (rdna) for inj kit 1 mg
GLUCOPHAGE - metformin hcl tab

500 mg

850 mg

1000 mg
GLUCOPHAGE XR - metformin hcl

tab sr 24hr 500 mg
GLUCOPHAGE XR - metformin hcl

tab sr 24hr 750 mg
GLUCOTROL - glipizide tab 5 mg
GLYSET - miglitol tab 50 mg
GLUCOTROL - glipizide tab 10 mg
GLUCOTROL XL - glipizide tab sr

24hr 2.5 mg
GLYXAMBI - empagliflozin-linagliptin
tab 10-5 mg

24hr 5 mg
GLYXAMBI - empagliflozin-linagliptin
tab 25-5 mg

24hr 10 mg
INVOKAMET - canagliflozinmetformin hcl tab 50-500 mg
GLUCOVANCE - glyburidemetformin tab 1.25-250 mg
GLUCOVANCE - glyburidemetformin tab 2.5-500 mg
GLUCOVANCE - glyburidemetformin tab 5-500 mg
28
glyburide-metformin tab
1.25-250 mg (Glucovance)
glyburide-metformin tab
2.5-500 mg (Glucovance)
glyburide-metformin tab 5-500 mg
(Glucovance)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
GLYNASE - glyburide micronized tab 3

1.5 mg
3 mg
6 mg
2
JANUMET - sitagliptin-metformin hcl

tab 50-500 mg
JANUMET - sitagliptin-metformin hcl

tab 50-1000 mg
JANUMET XR - sitagliptin-metformin
hcl tab sr 24hr 50-500 mg
JANUVIA - sitagliptin phosphate tab

25 mg (base equiv)

50 mg (base equiv)

100 mg (base equiv)
JARDIANCE - empagliflozin tab 10

mg
JARDIANCE - empagliflozin tab 25

mg
JENTADUETO - linagliptin-metformin 3
hcl tab 2.5-500 mg
hcl tab 2.5-850 mg
hcl tab 2.5-1000 mg
3
KAZANO - alogliptin-metformin hcl
tab 12.5-500 mg
3
KAZANO - alogliptin-metformin hcl
tab 12.5-1000 mg
2
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 2.5-1000
mg
2
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 5-500
mg
KORLYM - mifepristone tab 300 mg
metformin hcl tab sr 24hr 500 mg

(Glucophage xr)
metformin hcl tab sr 24hr 750 mg

(Glucophage xr)
metformin hcl tab 500 mg

(Glucophage)

(Glucophage)

(Glucophage)
nateglinide tab 60 mg (Starlix)
nateglinide tab 120 mg (Starlix)
NESINA - alogliptin benzoate tab

6.25 mg (base equiv)
NESINA - alogliptin benzoate tab

12.5 mg (base equiv)
NESINA - alogliptin benzoate tab 25

mg (base equiv)
ONGLYZA - saxagliptin hcl tab 2.5

mg (base equiv)
ONGLYZA - saxagliptin hcl tab 5 mg

(base equiv)
OSENI - alogliptin-pioglitazone tab

12.5-15 mg

12.5-30 mg

12.5-45 mg

25-15 mg

25-30 mg

25-45 mg
pioglitazone hcl tab 15 mg (base

equiv) (Actos)
Responsible Steps
Quantity Limits
INVOKANA - canagliflozin tab 300

mg
KOMBIGLYZE XR - saxagliptinmetformin hcl tab sr 24hr 5-1000

mg
Prior Authorization
Specialty
Drug Name
Drug Tier
INVOKANA - canagliflozin tab 100

mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
29

equiv) (Actos)
equiv) (Actos)
pioglitazone hcl-glimepiride tab
30-2 mg (Duetact)
pioglitazone hcl-glimepiride tab
30-4 mg (Duetact)
pioglitazone hcl-metformin hcl
tab 15-500 mg (Actoplus met)
pioglitazone hcl-metformin hcl
tab 15-850 mg (Actoplus met)
PRANDIMET - repaglinide-metformin 3
hcl tab 1-500 mg
PRANDIMET - repaglinide-metformin 3
hcl tab 2-500 mg
3
PRANDIN - repaglinide tab 0.5 mg
PRANDIN - repaglinide tab 1 mg
PRANDIN - repaglinide tab 2 mg
PRECOSE - acarbose tab 25 mg
PROGLYCEM - diazoxide susp 50

mg/ml
repaglinide tab 0.5 mg (Prandin)
repaglinide tab 1 mg (Prandin)

repaglinide tab 2 mg (Prandin)
1
1
RIOMET - metformin hcl oral soln

500 mg/5ml
STARLIX - nateglinide tab 60 mg
STARLIX - nateglinide tab 120 mg
SYMLINPEN 120 - pramlintide

acetate pen-inj 2700 mcg/2.7ml
(1000 mcg/ml)
SYMLINPEN 60 - pramlintide
acetate pen-inj 1500 mcg/1.5ml
(1000 mcg/ml)
SYNJARDY - empagliflozinmetformin hcl tab 5-500 mg
30
SYNJARDY - empagliflozinmetformin hcl tab 5-1000 mg
SYNJARDY - empagliflozinmetformin hcl tab 12.5-500 mg
SYNJARDY - empagliflozinmetformin hcl tab 12.5-1000 mg
TANZEUM - albiglutide for soln peninjector 30 mg
TANZEUM - albiglutide for soln peninjector 50 mg
TOLAZAMIDE - tolazamide tab 500

mg
tolazamide tab 250 mg
TOLBUTAMIDE - tolbutamide tab

500 mg
TRADJENTA - linagliptin tab 5 mg
TRULICITY - dulaglutide soln peninjector 0.75 mg/0.5ml
TRULICITY - dulaglutide soln peninjector 1.5 mg/0.5ml
VICTOZA - liraglutide soln peninjector 18 mg/3ml (6 mg/ml)
XIGDUO XR - dapagliflozinmetformin hcl tab sr 24hr 5-500

mg

mg

mg

mg
Rapid-Acting Insulins
APIDRA - insulin glulisine inj 100

unit/ml
APIDRA SOLOSTAR - insulin

glulisine soln pen-injector inj 100
unit/ml
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
NOVOLOG - insulin aspart inj 100

unit/ml
NOVOLOG FLEXPEN - insulin

aspart soln pen-injector 100 unit/
ml
LANTUS - insulin glargine inj 100

unit/ml
NOVOLOG PENFILL - insulin aspart

inj 100 unit/ml
2
2
LANTUS SOLOSTAR - insulin

glargine soln pen-injector 100 unit/
ml
NOVOLOG PENFILL - insulin aspart

soln cartridge 100 unit/ml
LEVEMIR - insulin detemir inj 100

unit/ml
LEVEMIR FLEXPEN - insulin

detemir soln pen-injector 100 unit/
ml
LEVEMIR FLEXTOUCH - insulin

detemir soln pen-injector 100 unit/
ml
TOUJEO SOLOSTAR - insulin

glargine soln pen-injector 300 unit/
ml
Short-Acting Insulins
NOVOLOG MIX 70/30 PREFILL insulin aspart prot & aspart sus
pen-inj 100 unit/ml (70-30)
Basal Insulins
AFREZZA - insulin regular (human)

inhal powd 4 (30) & 8 (60) unit/cart

inhal powd 4 (60) & 8 (30) unit/cart

inhalation powder 4 unit/cartridge
HUMULIN R U-500 (CONCENTR insulin regular (human) inj 500

unit/ml
NOVOLIN R - insulin regular

(human) inj 100 unit/ml
ARMOUR THYROID - thyroid tab 15

mg (1/4 grain)
NOVOLIN R RELION - insulin

regular (human) inj 100 unit/ml

mg (1/2 grain)
RELION R - insulin regular (human)

inj 100 unit/ml

mg (1 grain)

mg (1 1/2 grain)
ARMOUR THYROID - thyroid tab

120 mg (2 grain)

180 mg (3 grain)

240 mg (4 grain)

300 mg (5 grain)
CYTOMEL - liothyronine sodium tab

5 mcg

25 mcg
Intermediate-Acting Insulins
NOVOLIN N - insulin nph (human)
(isophane) inj 100 unit/ml
NOVOLIN N RELION - insulin nph

(human) (isophane) inj 100 unit/ml
NOVOLIN 70/30 - insulin nph

isophane & regular human inj 100
unit/ml (70-30)
NOVOLIN 70/30 RELION - insulin

nph isophane & regular human inj
100 unit/ml (70-30)
NOVOLOG MIX 70/30 - insulin

aspart prot & aspart (human) inj
100 unit/ml (70-30)
Responsible Steps
Quantity Limits
Prior Authorization

inh powd 8 (60) & 12 (30) unit/cart
THYROID AGENTS
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
31

50 mcg
NATURE-THROID - thyroid tab 65

mg
levothyroxine sodium tab 25 mcg

(Synthroid)
NATURE-THROID - thyroid tab

81.25 mg

(Synthroid)
NATURE-THROID - thyroid tab 97.5

mg

(Synthroid)

113.75 mg

(Synthroid)

mg
levothyroxine sodium tab

100 mcg (Synthroid)

mg

mg

mg (5 grain)

146.25 mg
NATURE-THROID NT-2.5 - thyroid

tab 162.5 mg (2 1/2 grain)
propylthiouracil tab 50 mg
SYNTHROID - levothyroxine sodium

tab 25 mcg

tab 50 mcg

tab 75 mcg
liothyronine sodium tab 5 mcg

(Cytomel)

tab 88 mcg

(Cytomel)

tab 100 mcg

(Cytomel)

tab 112 mcg
methimazole tab 5 mg (Tapazole)

112 mcg (Synthroid)
125 mcg (Synthroid)
137 mcg (Synthroid)
150 mcg (Synthroid)
175 mcg (Synthroid)
200 mcg (Synthroid)
300 mcg (Synthroid)
methimazole tab 10 mg (Tapazole)

16.25 mg

tab 125 mcg
NATURE-THROID - thyroid tab 32.5

mg

tab 137 mcg

48.75 mg (3/4 grain)

tab 150 mcg
tab 175 mcg
32
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016

tab 200 mcg
TIROSINT - levothyroxine sodium

cap 150 mcg

tab 300 mcg
WESTHROID - thyroid tab 16.25 mg
TAPAZOLE - methimazole tab 5 mg

(3/4 grain)
WESTHROID - thyroid tab 65 mg
WESTHROID - thyroid tab 113.75

mg

(2 1/2 grain)
TAPAZOLE - methimazole tab 10 mg 3

1
thyroid tab 30 mg (1/2 grain)
(Armour thyroid)
1
thyroid tab 60 mg (1 grain)
(Armour thyroid)
1
thyroid tab 90 mg (1 1/2 grain)
(Armour thyroid)
2
THYROLAR-1 - liotrix (t3-t4) tab 60
mg (12.5-50 mcg)
THYROLAR-1/2 - liotrix (t3-t4) tab 30 2
mg (6.25-25 mcg)
THYROLAR-1/4 - liotrix (t3-t4) tab 15 2
mg (3.1-12.5 mcg)
THYROLAR-2 - liotrix (t3-t4) tab 120 2
mg (25-100 mcg)
THYROLAR-3 - liotrix (t3-t4) tab 180 2
mg (37.5-150 mcg)
3
cap 13 mcg
3
cap 25 mcg
3
cap 50 mcg
3
cap 75 mcg
3
cap 88 mcg
3
cap 100 mcg
3
cap 112 mcg
3
cap 125 mcg
3
cap 137 mcg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
WESTHROID - thyroid tab 325 mg (5 3

grain)
3
WESTHROID - thyroid tab 146.25
mg
WP THYROID - thyroid tab 16.25 mg 3
WP THYROID - thyroid tab 32.5 mg

(3/4 grain)
3
WP THYROID - thyroid tab 65 mg
WP THYROID - thyroid tab 113.75
mg
WP THYROID - thyroid tab 130 mg
OXYTOCICS
methylergonovine maleate tab
0.2 mg
ENDOCRINE and METABOLIC AGENTS - MISC.

3
ACTONEL - risedronate sodium tab

5 mg
3

30 mg
33
ALENDRONATE SODIUM alendronate sodium oral soln 70

mg/75ml
ALENDRONATE SODIUM alendronate sodium tab 40 mg
alendronate sodium tab 5 mg
DDAVP - desmopressin acetate inj 4

mcg/ml
DDAVP - desmopressin acetate

nasal soln 0.01% (refrigerated)
DDAVP - desmopressin acetate

nasal spray soln 0.01%
DDAVP - desmopressin acetate tab

0.1 mg
DDAVP - desmopressin acetate tab

0.2 mg
desmopressin acetate inj 4 mcg/

ml (Ddavp)

(Fosamax)
ATELVIA - risedronate sodium tab

desmopressin acetate nasal soln

0.01% (refrigerated) (Ddavp)
BINOSTO - alendronate sodium

effervescent tab 70 mg
desmopressin acetate nasal

spray soln 0.01% (Ddavp)
BONIVA - ibandronate sodium tab

desmopressin acetate nasal

spray soln 0.01% (refrigerated)

1
1
BUPHENYL - sodium phenylbutyrate 4

oral powder 3 gm/teaspoonful
BUPHENYL - sodium phenylbutyrate 4
tab 500 mg
1
cabergoline tab 0.5 mg
calcitonin (salmon) nasal soln 200
unit/act (Miacalcin)
calcitriol cap 0.25 mcg (Rocaltrol)
calcitriol cap 0.5 mcg (Rocaltrol)
calcitriol oral soln 1 mcg/ml
(Rocaltrol)
34
1
1
1
desmopressin acetate tab 0.1 mg

(Ddavp)
desmopressin acetate tab 0.2 mg

(Ddavp)
doxercalciferol cap 0.5 mcg

(Hectorol)
doxercalciferol cap 1 mcg

(Hectorol)
doxercalciferol cap 2.5 mcg

(Hectorol)
EGRIFTA - tesamorelin acetate for

inj 1 mg (base equiv)
EGRIFTA - tesamorelin acetate for

ETIDRONATE DISODIUM etidronate disodium tab 200 mg
ETIDRONATE DISODIUM etidronate disodium tab 400 mg
EVISTA - raloxifene hcl tab 60 mg
1
1
1
1
CARBAGLU - carglumic acid tab 200 4

mg
3
CARNITOR - levocarnitine oral soln
1 gm/10ml (10%)
3
CARNITOR - levocarnitine tab 330
mg
3
CARNITOR SF - levocarnitine oral
soln 1 gm/10ml (10%)
Responsible Steps
Quantity Limits

150 mg
CYSTADANE - betaine powder for

oral solution
Prior Authorization
Specialty
Drug Name
Drug Tier

35 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
FORTEO - teriparatide (recombinant) 4

inj 600 mcg/2.4ml
FORTICAL - calcitonin (salmon)

nasal soln 200 unit/act
FOSAMAX - alendronate sodium tab

70 mg
FOSAMAX PLUS D - alendronate

sodium-cholecalciferol tab
70-2800 mg-unit
FOSAMAX PLUS D - alendronate

sodium-cholecalciferol tab
70-5600 mg-unit
GENOTROPIN - somatropin for inj

12 mg (13.8 mg overfill)
GENOTROPIN - somatropin for

subcutaneous inj 5 mg
GENOTROPIN MINIQUICK somatropin for inj 0.2 mg
GENOTROPIN MINIQUICK somatropin for inj 1 mg
HECTOROL - doxercalciferol cap 2.5 3

mcg
4
HUMATROPE - somatropin for inj 5
mg
4
HUMATROPE - somatropin for inj 6
mg (18 unit)
HUMATROPE - somatropin for inj 12 4
mg (36 unit)
HUMATROPE - somatropin for inj 24 4
mg
4
HUMATROPE COMBO PACK somatropin for inj 5 mg
1
ibandronate sodium tab 150 mg
(base equivalent) (Boniva)
4
INCRELEX - mecasermin inj 40
mg/4ml (10 mg/ml)
KUVAN - sapropterin dihydrochloride 4
powder packet 100 mg
powder packet 500 mg
soluble tab 100 mg
levocarnitine oral soln 1 gm/10ml 1
(10%) (Carnitor)
levocarnitine tab 330 mg (Carnitor) 1
MIACALCIN - calcitonin (salmon) inj

200 unit/ml
MIACALCIN - calcitonin (salmon)

nasal soln 200 unit/act
MYALEPT - metreleptin for

subcutaneous inj 11.3 mg
GENOTROPIN MINIQUICK somatropin for inj 2 mg
H.P. ACTHAR - corticotropin inj gel

80 unit/ml
HECTOROL - doxercalciferol cap 0.5 3

mcg
3
HECTOROL - doxercalciferol cap 1
mcg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
NATPARA - parathyroid hormone

(recombinant) for inj cartridge 25
mcg

mcg

mcg
35
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
OMNITROPE - somatropin inj 10

mg/1.5ml
ORFADIN - nitisinone cap 2 mg
OSPHENA - ospemifene tab 60 mg
paricalcitol cap 1 mcg (Zemplar)
paricalcitol cap 4 mcg
NORDITROPIN FLEXPRO somatropin inj 30 mg/3ml
NORDITROPIN NORDIFLEX PEN somatropin inj 30 mg/3ml
NUTROPIN - somatropin for inj 10

mg
NUTROPIN AQ NUSPIN 10 somatropin inj 10 mg/2ml
NUTROPIN AQ PEN - somatropin inj 4

10 mg/2ml
NUTROPIN AQ PEN - somatropin inj 4
20 mg/2ml
4
octreotide acetate inj 50 mcg/ml
(0.05 mg/ml) (Sandostatin)
4
4
4
4
octreotide acetate inj 1000 mcg/
ml (1 mg/ml) (Sandostatin)
OMNITROPE - somatropin for inj 5.8 4
mg
4
OMNITROPE - somatropin inj 5
mg/1.5ml

mcg
NORDITROPIN CARTRIDGE somatropin inj 5 mg/1.5ml
NORDITROPIN FLEXPRO somatropin inj 5 mg/1.5ml
36
paricalcitol cap 2 mcg (Zemplar)

raloxifene hcl tab 60 mg (Evista)
1
1
P
RAVICTI - glycerol phenylbutyrate

liquid 1.1 gm/ml
risedronate sodium tab delayed

release 35 mg (Atelvia)
risedronate sodium tab 5 mg

(Actonel)

(Actonel)

(Actonel)

(Actonel)
ROCALTROL - calcitriol cap 0.25

mcg
ROCALTROL - calcitriol cap 0.5 mcg
ROCALTROL - calcitriol oral soln 1

mcg/ml
SAIZEN - somatropin (nonrefrigerated) for inj 5 mg
SAIZEN - somatropin (nonrefrigerated) for inj 8.8 mg
SAIZEN CLICK.EASY - somatropin

(non-refrigerated) for inj 8.8 mg
SAMSCA - tolvaptan tab 15 mg
SAMSCA - tolvaptan tab 30 mg
SANDOSTATIN - octreotide acetate

inj 50 mcg/ml (0.05 mg/ml)


inj 1000 mcg/ml (1 mg/ml)
SENSIPAR - cinacalcet hcl tab 30

mg (base equiv)

mg (base equiv)

mg (base equiv)
SEROSTIM - somatropin (nonrefrigerated) for subcutaneous inj

4 mg

5 mg

6 mg
SIGNIFOR - pasireotide diaspartate

inj 0.3 mg/ml (base equiv)


sodium phenylbutyrate oral

powder 3 gm/teaspoonful
(Buphenyl)
SOMAVERT - pegvisomant for inj 10

mg (as protein)

mg (as protein)

mg (as protein)

mg (as protein)

mg (as protein)
STIMATE - desmopressin acetate

nasal soln 1.5 mg/ml
Responsible Steps

Quantity Limits
Prior Authorization
Specialty

Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
SYNAREL - nafarelin acetate nasal

soln 2 mg/ml
TEV-TROPIN - somatropin for

ZEMPLAR - paricalcitol cap 1 mcg
ZEMPLAR - paricalcitol cap 2 mcg
ZOMACTON - somatropin for inj 10

mg
ZOMACTON - somatropin for

ZORBTIVE - somatropin (nonrefrigerated) for subcutaneous inj

8.8 mg
CARDIOVASCULAR AGENTS
CARDIOTONICS
DIGOXIN - digoxin oral soln 0.05 mg/ 2

ml
1
digoxin tab 125 mcg (0.125 mg)
(Lanoxin)
1
digoxin tab 250 mcg (0.25 mg)
(Lanoxin)
3
LANOXIN - digoxin tab 62.5 mcg
(0.0625 mg)
3
LANOXIN - digoxin tab 125 mcg
(0.125 mg)
3
LANOXIN - digoxin tab 187.5 mcg
(0.1875 mg)
3
LANOXIN - digoxin tab 250 mcg
(0.25 mg)
ANTIANGINAL AGENTS
DILATRATE SR - isosorbide dinitrate 3

cap cr 40 mg
3
ISORDIL TITRADOSE - isosorbide
dinitrate tab 5 mg
3
ISORDIL TITRADOSE - isosorbide
dinitrate tab 40 mg
2
ISOSORBIDE DINITRATE isosorbide dinitrate tab 30 mg
3
ISOSORBIDE DINITRATE ER isosorbide dinitrate tab cr 40 mg
37
isosorbide dinitrate tab 5 mg

(Isordil titradose)

isosorbide mononitrate tab sr
24hr 30 mg
24hr 60 mg
24hr 120 mg
isosorbide mononitrate tab 10 mg
isosorbide mononitrate tab 20 mg
nitroglycerin tl soln 0.4 mg/spray

(400 mcg/spray) (Nitrolingual
pumpspr)
NITROLINGUAL PUMPSPRAY nitroglycerin tl soln 0.4 mg/spray

(400 mcg/spray)
NITROMIST - nitroglycerin lingual

aerosol 400 mcg/spray
NITROSTAT - nitroglycerin sl tab 0.3

mg

mg

mg
1
1
NITRO-BID - nitroglycerin oint 2%
NITRO-DUR - nitroglycerin td patch

24hr 0.1 mg/hr
RANEXA - ranolazine tab sr 12hr

500 mg

24hr 0.2 mg/hr
RANEXA - ranolazine tab sr 12hr

1000 mg

24hr 0.3 mg/hr
BETA BLOCKERS
acebutolol hcl cap 200 mg
(Sectral)

24hr 0.4 mg/hr
acebutolol hcl cap 400 mg

(Sectral)

24hr 0.6 mg/hr
3
2

24hr 0.8 mg/hr
atenolol tab 25 mg (Tenormin)
nitroglycerin cap cr 2.5 mg
nitroglycerin cap cr 6.5 mg

nitroglycerin cap cr 9 mg
1
1

BETAPACE - sotalol hcl tab 80 mg
BETAPACE AF - sotalol hcl (afib/afl)

tab 80 mg
nitroglycerin td patch 24hr

0.1 mg/hr (Nitro-dur)

tab 120 mg

tab 160 mg
betaxolol hcl tab 10 mg (Kerlone)

38
betaxolol hcl tab 20 mg (Kerlone)

bisoprolol fumarate tab 5 mg
(Zebeta)
Responsible Steps
Quantity Limits

Prior Authorization
NITROGLYCERIN LINGUAL nitroglycerin lingual aerosol 400

mcg/spray

Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
bisoprolol fumarate tab 10 mg

(Zebeta)
BYSTOLIC - nebivolol hcl tab 2.5 mg 3

(base equivalent)
3
BYSTOLIC - nebivolol hcl tab 5 mg
(base equivalent)
BYSTOLIC - nebivolol hcl tab 10 mg 3
(base equivalent)
BYSTOLIC - nebivolol hcl tab 20 mg 3
(base equivalent)
1
carvedilol tab 3.125 mg (Coreg)
carvedilol tab 25 mg (Coreg)
1
1
1
COREG - carvedilol tab 3.125 mg
COREG - carvedilol tab 25 mg
COREG CR - carvedilol phosphate

cap sr 24hr 10 mg

cap sr 24hr 20 mg

cap sr 24hr 40 mg

cap sr 24hr 80 mg
CORGARD - nadolol tab 20 mg
HEMANGEOL - propranolol hcl oral

soln 4.28 mg/ml
INDERAL LA - propranolol hcl cap sr 3

24hr 60 mg
24hr 80 mg
24hr 120 mg
24hr 160 mg
INDERAL XL - propranolol hcl

sustained-release beads cap sr
24hr 80 mg
INDERAL XL - propranolol hcl

24hr 120 mg
INNOPRAN XL - propranolol hcl

24hr 80 mg
INNOPRAN XL - propranolol hcl

24hr 120 mg
KERLONE - betaxolol hcl tab 10 mg
KERLONE - betaxolol hcl tab 20 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
labetalol hcl tab 100 mg (Trandate) 1


LEVATOL - penbutolol sulfate tab 20 3
mg
3
LOPRESSOR - metoprolol tartrate
tab 50 mg
3
LOPRESSOR - metoprolol tartrate
tab 100 mg
1
metoprolol succinate tab sr 24hr
25 mg (Toprol xl)
1
50 mg (Toprol xl)
1
100 mg (Toprol xl)
1
200 mg (Toprol xl)
1
metoprolol tartrate tab 25 mg
(Lopressor)

(Lopressor)
nadolol tab 20 mg (Corgard)

pindolol tab 5 mg
1
1
1
39
pindolol tab 10 mg
PROPRANOLOL HCL - propranolol

hcl oral soln 20 mg/5ml
TIMOLOL MALEATE - timolol

maleate tab 10 mg
PROPRANOLOL HCL - propranolol

hcl oral soln 40 mg/5ml

maleate tab 20 mg
propranolol hcl cap sr 24hr 60 mg

(Inderal la)
TOPROL XL - metoprolol succinate

tab sr 24hr 25 mg
propranolol hcl cap sr 24hr 80 mg

(Inderal la)

tab sr 24hr 50 mg
propranolol hcl cap sr 24hr

120 mg (Inderal la)

tab sr 24hr 100 mg

tab sr 24hr 200 mg
TRANDATE - labetalol hcl tab 100

mg
mg

mg
ZEBETA - bisoprolol fumarate tab 5

mg
SECTRAL - acebutolol hcl cap 200

mg
ZEBETA - bisoprolol fumarate tab 10

mg
SECTRAL - acebutolol hcl cap 400

mg
sotalol hcl (afib/afl) tab 80 mg

(Betapace af)

(Betapace af)

(Betapace af)
sotalol hcl tab 80 mg (Betapace)
propranolol hcl cap sr 24hr

160 mg (Inderal la)
propranolol hcl tab 10 mg

sotalol hcl tab 240 mg
1
1
1
1
1
1
1
CALCIUM CHANNEL BLOCKERS

ADALAT CC - nifedipine tab sr 24hr
30 mg

60 mg

90 mg
amlodipine besylate tab 2.5 mg

(Norvasc)
amlodipine besylate tab 5 mg

(Norvasc)
SOTYLIZE - sotalol hcl oral solution

5 mg/ml
amlodipine besylate tab 10 mg

(Norvasc)
TENORMIN - atenolol tab 25 mg
CALAN - verapamil hcl tab 80 mg
CALAN - verapamil hcl tab 120 mg

maleate tab 5 mg
CALAN SR - verapamil hcl tab cr

120 mg
180 mg
40
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016

240 mg
CARDIZEM - diltiazem hcl tab 30 mg 3

CARDIZEM - diltiazem hcl tab 60 mg 3
diltiazem hcl coated beads cap sr

24hr 300 mg (Cardizem cd)
CARDIZEM CD - diltiazem hcl

coated beads cap sr 24hr 120 mg
diltiazem hcl coated beads tab sr

24hr 240 mg (Cardizem la)







diltiazem hcl extended release

beads cap sr 24hr 120 mg
(Tiazac)

(Tiazac)

(Tiazac)

(Tiazac)

(Tiazac)

(Tiazac)
diltiazem hcl cap sr 12hr 120 mg

1
1
1
1
1
1
1
Responsible Steps

Quantity Limits
Prior Authorization
CARDIZEM - diltiazem hcl tab 120

mg
CARDIZEM LA - diltiazem hcl coated 3

beads tab sr 24hr 120 mg
1
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
1
diltiazem hcl tab 30 mg (Cardizem) 1

diltiazem hcl tab 60 mg (Cardizem) 1
diltiazem hcl tab 90 mg
diltiazem hcl tab 120 mg

(Cardizem)
felodipine tab sr 24hr 2.5 mg
felodipine tab sr 24hr 5 mg

felodipine tab sr 24hr 10 mg
1
1
41
ISOPTIN SR - verapamil hcl tab cr

120 mg
NORVASC - amlodipine besylate tab

2.5 mg

180 mg

5 mg

240 mg

10 mg
isradipine cap 2.5 mg
NYMALIZE - nimodipine oral soln 60

mg/20ml
PROCARDIA - nifedipine cap 10 mg
PROCARDIA XL - nifedipine tab sr

24hr osmotic release 30 mg


SULAR - nisoldipine tab sr 24hr 8.5

mg
SULAR - nisoldipine tab sr 24hr 17

mg
SULAR - nisoldipine tab sr 24hr 34

mg
TIAZAC - diltiazem hcl extended

release beads cap sr 24hr 120 mg

isradipine cap 5 mg
nicardipine hcl cap 20 mg
nicardipine hcl cap 30 mg
nifedipine cap 10 mg (Procardia)
nifedipine cap 20 mg
1
1
nifedipine tab sr 24hr 30 mg

(Adalat cc)

(Adalat cc)

(Adalat cc)
nifedipine tab sr 24hr osmotic

release 30 mg (Procardia xl)

nimodipine cap 30 mg
1
1
1
2

NISOLDIPINE - nisoldipine tab sr

24hr 20 mg


24hr 30 mg


24hr 40 mg

NISOLDIPINE ER - nisoldipine tab sr 2

24hr 25.5 mg
1
nisoldipine tab sr 24hr 8.5 mg
(Sular)
1
nisoldipine tab sr 24hr 17 mg
(Sular)
1
nisoldipine tab sr 24hr 34 mg
(Sular)
42
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
VERAPAMIL HCL - verapamil hcl tab 2

40 mg
1
verapamil hcl cap sr 24hr 100 mg
(Verelan pm)
1
(Verelan)
1
(Verelan)

(Verelan pm)

(Verelan)

(Verelan pm)

(Verelan)
mexiletine hcl cap 150 mg
verapamil hcl tab cr 120 mg

(Calan sr)

(Calan sr)
MULTAQ - dronedarone hcl tab 400


(Calan sr)
NORPACE - disopyramide
phosphate cap 100 mg
verapamil hcl tab 80 mg (Calan)
NORPACE - disopyramide
phosphate cap 150 mg
NORPACE CR - disopyramide
phosphate cap sr 12hr 100 mg
NORPACE CR - disopyramide
phosphate cap sr 12hr 150 mg
propafenone hcl cap sr 12hr

225 mg (Rythmol sr)
verapamil hcl tab 120 mg (Calan)
VERELAN - verapamil hcl cap sr

24hr 120 mg

24hr 180 mg

24hr 240 mg

24hr 360 mg
VERELAN PM - verapamil hcl cap sr

24hr 100 mg

24hr 200 mg

24hr 300 mg
ANTIARRHYTHMICS
amiodarone hcl tab 100 mg
disopyramide phosphate cap

150 mg (Norpace)
flecainide acetate tab 50 mg

325 mg (Rythmol sr)
425 mg (Rythmol sr)

(Cordarone)
CORDARONE - amiodarone hcl tab

200 mg
disopyramide phosphate cap

100 mg (Norpace)
Responsible Steps
Quantity Limits
1
1
1
1
1
1
1
1
1
propafenone hcl tab 225 mg

(Rythmol)
QUINIDINE SULFATE - quinidine

sulfate tab 200 mg
Prior Authorization

(Rythmol)
quinidine gluconate tab cr 324 mg
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
2
QUINIDINE SULFATE ER - quinidine 2

sulfate tab cr 300 mg
1
quinidine sulfate tab 300 mg
RYTHMOL - propafenone hcl tab
150 mg
RYTHMOL - propafenone hcl tab

225 mg
43
RYTHMOL SR - propafenone hcl cap 3

sr 12hr 225 mg
sr 12hr 325 mg
sr 12hr 425 mg
3
TIKOSYN - dofetilide cap 125 mcg
(0.125 mg)
3
(0.25 mg)
3
(0.5 mg)
amlodipine besylate-benazepril
hcl cap 5-40 mg (Lotrel)
ANTIHYPERTENSIVES
amlodipine besylate-valsartan tab

10-320 mg (Exforge)
5-160 mg (Exforge)
5-320 mg (Exforge)
10-160 mg (Exforge)
1
1
1
1
ACCUPRIL - quinapril hcl tab 5 mg
ACCURETIC - quinaprilhydrochlorothiazide tab 10-12.5

mg
amlodipine-valsartanhydrochlorothiazide tab
5-160-25 mg (Exforge hct)
ACCURETIC - quinaprilhydrochlorothiazide tab 20-12.5

mg
10-160-12.5 mg (Exforge hct)
ACCURETIC - quinaprilhydrochlorothiazide tab 20-25 mg
ACEON - perindopril erbumine tab 4

mg
ACEON - perindopril erbumine tab 8

mg
ALTACE - ramipril cap 1.25 mg
ATACAND - candesartan cilexetil tab

4 mg
ALTACE - ramipril cap 2.5 mg
ALTACE - ramipril cap 5 mg

8 mg
ALTACE - ramipril cap 10 mg
hcl cap 2.5-10 mg (Lotrel)

16 mg
32 mg
ATACAND HCT - candesartan

cilexetil-hydrochlorothiazide tab
16-12.5 mg
44
1
1
5-160-12.5 mg (Exforge hct)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016

32-12.5 mg

32-25 mg
atenolol & chlorthalidone tab

50-25 mg (Tenoretic 50)
atenolol & chlorthalidone tab

100-25 mg (Tenoretic 100)
AVALIDE - irbesartanhydrochlorothiazide tab 150-12.5

mg
AVALIDE - irbesartanhydrochlorothiazide tab 300-12.5

mg
AVAPRO - irbesartan tab 75 mg
AZOR - amlodipine besylateolmesartan medoxomil tab 5-20

mg

mg

mg

mg
benazepril & hydrochlorothiazide

tab 5-6.25 mg

tab 10-12.5 mg (Lotensin hct)
tab 20-12.5 mg (Lotensin hct)
tab 20-25 mg (Lotensin hct)
benazepril hcl tab 5 mg
(Lotensin)
1
1
1
1
1

(Lotensin)

(Lotensin)
BENICAR - olmesartan medoxomil

tab 5 mg

tab 20 mg

tab 40 mg
BENICAR HCT - olmesartan

medoxomil-hydrochlorothiazide
tab 20-12.5 mg

tab 40-12.5 mg

tab 40-25 mg
bisoprolol & hydrochlorothiazide

tab 2.5-6.25 mg (Ziac)

tab 5-6.25 mg (Ziac)
tab 10-6.25 mg (Ziac)
1
1
candesartan cilexetil tab 4 mg

(Atacand)

(Atacand)

(Atacand)

(Atacand)
candesartan cilexetilhydrochlorothiazide tab

16-12.5 mg (Atacand hct)

32-12.5 mg (Atacand hct)
32-25 mg (Atacand hct)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
45
captopril tab 12.5 mg

captopril tab 25 mg
captopril tab 50 mg
captopril tab 100 mg
1
1
1
1
CAPTOPRIL/
HYDROCHLOROTHIA - captopril
& hydrochlorothiazide tab 25-15
mg
CAPTOPRIL/
mg
CAPTOPRIL/
mg
CAPTOPRIL/
mg
clonidine hcl tab 0.2 mg

(Catapres)

(Catapres)
clonidine hcl td patch weekly

0.1 mg/24hr (Catapres-tts-1)

Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name

CARDURA - doxazosin mesylate tab 3

1 mg
2 mg
4 mg
8 mg
3
CATAPRES - clonidine hcl tab 0.1
mg
3
mg
3
mg
CATAPRES-TTS-1 - clonidine hcl td 3
patch weekly 0.1 mg/24hr
1
(Catapres)
46
Specialty
Drug Name
Drug Tier
2016
1
1
CLORPRES - clonidine &

chlorthalidone tab 0.1-15 mg


CORZIDE - nadolol &

bendroflumethiazide tab 40-5 mg
CORZIDE - nadolol &

bendroflumethiazide tab 80-5 mg
COZAAR - losartan potassium tab

25 mg

50 mg

100 mg
DEMSER - metyrosine cap 250 mg
DIBENZYLINE - phenoxybenzamine
hcl cap 10 mg
DIOVAN - valsartan tab 40 mg
DIOVAN HCT - valsartanhydrochlorothiazide tab 80-12.5

mg

mg
enalapril maleate tab 10 mg

(Vasotec)

(Vasotec)
EPANED - enalapril maleate for oral

soln 1 mg/ml
eplerenone tab 25 mg (Inspra)
DIOVAN HCT - valsartanhydrochlorothiazide tab 320-25

mg
doxazosin mesylate tab 1 mg

(Cardura)

(Cardura)

(Cardura)
EPROSARTAN MESYLATE eprosartan mesylate tab 600 mg

(Cardura)
EXFORGE - amlodipine besylatevalsartan tab 5-160 mg
DUTOPROL - metoprolol &

hydrochlorothiazide tab sr 24hr
25-12.5 mg

50-12.5 mg

100-12.5 mg
EDARBI - azilsartan medoxomil tab

40 mg
EXFORGE HCT - amlodipinevalsartan-hydrochlorothiazide tab

5-160-12.5 mg
EDARBI - azilsartan medoxomil tab

80 mg

5-160-25 mg
EDARBYCLOR - azilsartan
medoxomil-chlorthalidone tab
40-12.5 mg

10-160-12.5 mg
EDARBYCLOR - azilsartan
medoxomil-chlorthalidone tab
40-25 mg

10-160-25 mg
enalapril maleate &

hydrochlorothiazide tab
5-12.5 mg

10-320-25 mg
fosinopril sodium &

10-12.5 mg
eplerenone tab 50 mg (Inspra)
Responsible Steps

mg
enalapril maleate &

10-25 mg (Vaseretic)

(Vasotec)
Quantity Limits
Prior Authorization
DIOVAN HCT - valsartanhydrochlorothiazide tab 160-25

mg
enalapril maleate tab 2.5 mg

(Vasotec)
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
47
fosinopril sodium &

20-12.5 mg
fosinopril sodium tab 10 mg
guanfacine hcl tab 1 mg (Tenex)
guanfacine hcl tab 2 mg (Tenex)
hydralazine hcl tab 10 mg
losartan potassium tab 25 mg

(Cozaar)

(Cozaar)

(Cozaar)
LOTENSIN - benazepril hcl tab 10

mg

mg

mg
LOTENSIN HCT - benazepril &

hydrochlorothiazide tab 10-12.5
mg

mg

hydrochlorothiazide tab 20-25 mg
LOTREL - amlodipine besylatebenazepril hcl cap 2.5-10 mg
LOTREL - amlodipine besylatebenazepril hcl cap 5-10 mg
1
1
1
1
1
1
1
losartan potassium &

100-12.5 mg (Hyzaar)
100-25 mg (Hyzaar)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Tier
irbesartan tab 75 mg (Avapro)
48
lisinopril tab 10 mg (Prinivil)
Responsible Steps

50-12.5 mg (Hyzaar)
INSPRA - eplerenone tab 50 mg
Quantity Limits
INSPRA - eplerenone tab 25 mg
lisinopril tab 2.5 mg (Zestril)
LOPRESSOR HCT - metoprolol &

hydrochlorothiazide tab 100-25
mg
lisinopril & hydrochlorothiazide

tab 20-25 mg (Zestoretic)
1
3

tab 20-12.5 mg (Zestoretic)
LOPRESSOR HCT - metoprolol &

HYZAAR - losartan potassium &

hydrochlorothiazide tab 100-25
mg

tab 10-12.5 mg (Zestoretic)
lisinopril tab 40 mg (Zestril)
irbesartan-hydrochlorothiazide
tab 300-12.5 mg (Avalide)

mg
irbesartan-hydrochlorothiazide
tab 150-12.5 mg (Avalide)
Drug Name
lisinopril tab 30 mg (Zestril)
Prior Authorization

mg
Specialty
Drug Name
Drug Tier
2016
moexipril-hydrochlorothiazide tab
7.5-12.5 mg
MAVIK - trandolapril tab 1 mg
15-12.5 mg
methyldopa tab 250 mg
methyldopa tab 500 mg
minoxidil tab 10 mg
moexipril hcl tab 7.5 mg
moexipril hcl tab 15 mg
15-25 mg
nadolol & bendroflumethiazide
tab 40-5 mg (Corzide)
3
METHYLDOPA/
HYDROCHLOROTHI - methyldopa
mg
3
METHYLDOPA/
HYDROCHLOROTHI - methyldopa
mg
metoprolol & hydrochlorothiazide 1
tab 50-25 mg (Lopressor hct)
tab 100-25 mg (Lopressor hct)
tab 100-50 mg
3
MICARDIS - telmisartan tab 20 mg
nadolol & bendroflumethiazide

tab 80-5 mg (Corzide)
perindopril erbumine tab 2 mg
MICARDIS HCT - telmisartanhydrochlorothiazide tab 40-12.5

mg
MICARDIS HCT - telmisartanhydrochlorothiazide tab 80-12.5

mg
MICARDIS HCT - telmisartanhydrochlorothiazide tab 80-25 mg
MINIPRESS - prazosin hcl cap 1 mg
minoxidil tab 2.5 mg
Responsible Steps
Quantity Limits
1
1
1
1
1
1
1

(Aceon)
phenoxybenzamine hcl cap 10 mg

(Dibenzyline)
prazosin hcl cap 1 mg (Minipress)
1
1
1
PRESTALIA - perindopril arginineamlodipine besylate tab 3.5-2.5

mg
PRESTALIA - perindopril arginineamlodipine besylate tab 7-5 mg
PRESTALIA - perindopril arginineamlodipine besylate tab 14-10 mg
PRINIVIL - lisinopril tab 5 mg
PROPRANOLOL/
HYDROCHLOROTH - propranolol
mg
PROPRANOLOL/
HYDROCHLOROTH - propranolol
Prior Authorization

(Aceon)
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
49
quinapril hcl tab 5 mg (Accupril)

quinapril-hydrochlorothiazide tab
10-12.5 mg (Accuretic)
20-12.5 mg (Accuretic)
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)
RESERPINE - reserpine tab 0.1 mg
1
1
telmisartan tab 20 mg (Micardis)
telmisartan-amlodipine tab
40-5 mg (Twynsta)
40-10 mg (Twynsta)
80-5 mg (Twynsta)
80-10 mg (Twynsta)
telmisartan-hydrochlorothiazide
tab 40-12.5 mg (Micardis hct)
1
1
tab 80-12.5 mg (Micardis hct)
tab 80-25 mg (Micardis hct)
1
1
TENEX - guanfacine hcl tab 1 mg
TENEX - guanfacine hcl tab 2 mg
TENORETIC 100 - atenolol &

chlorthalidone tab 100-25 mg
TENORETIC 50 - atenolol &

chlorthalidone tab 50-25 mg
terazosin hcl cap 1 mg

1
1
3
trandolapril tab 1 mg (Mavik)
TEVETEN - eprosartan mesylate tab

600 mg
trandolapril-verapamil hcl tab cr
1-240 mg (Tarka)
2-180 mg (Tarka)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
TEKTURNA HCT - aliskirenhydrochlorothiazide tab 300-25
mg
RESERPINE - reserpine tab 0.25 mg 2

3
TARKA - trandolapril-verapamil hcl
tab cr 1-240 mg
3
tab cr 2-180 mg
3
tab cr 2-240 mg
3
tab cr 4-240 mg
TEKTURNA - aliskiren fumarate tab 3
TEKTURNA - aliskiren fumarate tab 3
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
50
Specialty
Drug Name
mg
Drug Tier
2016
1
1
1
1

2-240 mg (Tarka)
4-240 mg (Tarka)
VASERETIC - enalapril maleate &

VASOTEC - enalapril maleate tab

2.5 mg
VASOTEC - enalapril maleate tab 5

mg

mg

mg
VECAMYL - mecamylamine hcl tab

2.5 mg
TRIBENZOR - olmesartanamlodipine-hydrochlorothiazide
tab 20-5-12.5 mg
tab 40-5-12.5 mg
tab 40-5-25 mg
tab 40-10-12.5 mg
ZESTORETIC - lisinopril &

mg
tab 40-10-25 mg

mg
TWYNSTA - telmisartan-amlodipine
tab 40-5 mg

tab 40-10 mg
ZESTRIL - lisinopril tab 2.5 mg
ZESTRIL - lisinopril tab 5 mg
tab 80-5 mg
tab 80-10 mg


ZIAC - bisoprolol &
hydrochlorothiazide tab 2.5-6.25
mg
ZIAC - bisoprolol &

hydrochlorothiazide tab 5-6.25 mg
valsartan tab 40 mg (Diovan)
ZIAC - bisoprolol &

mg

valsartan-hydrochlorothiazide tab
80-12.5 mg (Diovan hct)
160-25 mg (Diovan hct)
320-25 mg (Diovan hct)
1
1
1
DIURETICS
ACETAZOLAMIDE - acetazolamide
tab 125 mg
acetazolamide cap sr 12hr 500 mg

(Diamox)
acetazolamide tab 250 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
51
ALDACTAZIDE - spironolactone &

FUROSEMIDE - furosemide oral

soln 8 mg/ml
ALDACTAZIDE - spironolactone &

furosemide oral soln 10 mg/ml
ALDACTONE - spironolactone tab

25 mg

50 mg

100 mg
amiloride & hydrochlorothiazide

tab 5-50 mg
amiloride hcl tab 5 mg

bumetanide tab 0.5 mg
1
1
1
furosemide tab 20 mg (Lasix)

indapamide tab 2.5 mg
1
1
1
3
CHLOROTHIAZIDE - chlorothiazide
tab 250 mg
LASIX - furosemide tab 20 mg
3
3
chlorothiazide tab 500 mg

MAXZIDE - triamterene &

MAXZIDE-25 - triamterene &

hydrochlorothiazide tab 37.5-25
mg
methazolamide tab 25 mg
(Neptazane)
methazolamide tab 50 mg
(Neptazane)
METHYCLOTHIAZIDE methyclothiazide tab 5 mg
3
1
bumetanide tab 2 mg
CHLORTHALIDONE - chlorthalidone 2
tab 25 mg
tab 50 mg
tab 100 mg
3
DEMADEX - torsemide tab 5 mg
DIAMOX - acetazolamide cap sr

12hr 500 mg
DIURIL - chlorothiazide susp 250

mg/5ml
metolazone tab 2.5 mg
DYAZIDE - triamterene &

hydrochlorothiazide cap 37.5-25
mg
metolazone tab 10 mg
DYRENIUM - triamterene cap 50 mg
DYRENIUM - triamterene cap 100

mg
EDECRIN - ethacrynic acid tab 25
mg
52
metolazone tab 5 mg
KEVEYIS - dichlorphenamide tab 50

mg
bumetanide tab 1 mg
Responsible Steps
hydrochlorothiazide tab 12.5 mg
indapamide tab 1.25 mg
Quantity Limits
1
1
hydrochlorothiazide tab 50 mg
Prior Authorization
hydrochlorothiazide cap 12.5 mg

(Microzide)
hydrochlorothiazide tab 25 mg
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
MICROZIDE - hydrochlorothiazide
cap 12.5 mg
3
3
NEPTAZANE - methazolamide tab

25 mg
NEPTAZANE - methazolamide tab

50 mg
EPINEPHRINE - epinephrine
solution auto-injector 0.3 mg/0.3ml
(1:1000)
spironolactone tab 25 mg
(Aldactone)
(Aldactone)
EPIPEN 2-PAK - epinephrine

(1:1000)

(Aldactone)
EPIPEN-JR 2-PAK - epinephrine

solution auto-injector 0.15
mg/0.3ml (1:2000)
torsemide tab 5 mg (Demadex)
midodrine hcl tab 2.5 mg
midodrine hcl tab 5 mg
midodrine hcl tab 10 mg
ANTIHYPERLIPIDEMICS
ADVICOR - niacin-lovastatin tab sr

24hr 500-20 mg

24hr 750-20 mg

24hr 1000-20 mg

24hr 1000-40 mg
ALTOPREV - lovastatin tab sr 24hr

20 mg

40 mg

60 mg
ANTARA - fenofibrate micronized

cap 30 mg
ANTARA - fenofibrate micronized

cap 90 mg
atorvastatin calcium tab 10 mg

(base equivalent) (Lipitor)
spironolactone &
25-25 mg (Aldactazide)

triamterene &
hydrochlorothiazide cap
37.5-25 mg (Dyazide)
triamterene &
37.5-25 mg (Maxzide-25)
triamterene &
75-50 mg (Maxzide)
TRIAMTERENE/
HYDROCHLOROTH - triamterene
& hydrochlorothiazide cap 50-25
mg
VASOPRESSORS
ADRENACLICK - epinephrine
mg/0.15ml (1:1000)
ADRENACLICK - epinephrine
(1:1000)
AUVI-Q - epinephrine solution autoinjector 0.15 mg/0.15ml (1:1000)
AUVI-Q - epinephrine solution autoinjector 0.3 mg/0.3ml (1:1000)
EPINEPHRINE - epinephrine
mg/0.15ml (1:1000)

cholestyramine light powder
packets 4 gm
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
53
cholestyramine light powder

4 gm/dose (Questran light)
cholestyramine powder packets
4 gm (Questran)
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)
FENOFIBRATE - fenofibrate tab 40

mg
FENOFIBRATE - fenofibrate tab 120

mg
fenofibrate micronized cap 43 mg
fenofibrate micronized cap 67 mg

(Lofibra)
fenofibrate micronized cap

130 mg
COLESTID - colestipol hcl granule

packets 5 gm

134 mg (Lofibra)
COLESTID - colestipol hcl granules

5 gm

200 mg (Lofibra)
COLESTID - colestipol hcl tab 1 gm
COLESTID FLAVORED - colestipol

hcl granule packets 5 gm
COLESTID FLAVORED - colestipol

hcl granules 5 gm
colestipol hcl granule packets

5 gm (Colestid flavored)
colestipol hcl granules 5 gm

(Colestid flavored)
colestipol hcl tab 1 gm (Colestid)
CRESTOR - rosuvastatin calcium tab 2

5 mg
10 mg
20 mg
40 mg
3
EQUAPAX/ATORVASTATIN
CALC - atorvastatin tab 20 mg &
coenzyme q10 cap 100 mg ther
pack
FENOFIBRATE - fenofibrate cap 50 3
mg
FENOFIBRATE - fenofibrate cap 150 3
mg
FENOFIBRIC ACID - fenofibric acid

tab 35 mg
FENOFIBRIC ACID - fenofibric acid

tab 105 mg
FENOGLIDE - fenofibrate tab 40 mg
FENOGLIDE - fenofibrate tab 120

mg
FIBRICOR - fenofibric acid tab 35

mg
FIBRICOR - fenofibric acid tab 105

mg
fluvastatin sodium cap 20 mg

(Lescol)
fluvastatin sodium cap 40 mg

(Lescol)
fluvastatin sodium tab sr 24 hr

80 mg (Lescol xl)
fenofibrate tab 48 mg (Tricor)

fenofibrate tab 54 mg (Lofibra)
fenofibrate tab 145 mg (Tricor)
fenofibrate tab 160 mg (Lofibra)
Responsible Steps
Quantity Limits
Prior Authorization
54
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
gemfibrozil tab 600 mg (Lopid)
1
1
1
JUXTAPID - lomitapide mesylate cap 4

5 mg (base equiv)
10 mg (base equiv)

20 mg (base equiv)
30 mg (base equiv)
40 mg (base equiv)
60 mg (base equiv)
4
KYNAMRO - mipomersen sodium
soln prefilled syringe 200 mg/ml
LESCOL - fluvastatin sodium cap 20 3
mg
LESCOL XL - fluvastatin sodium tab 3
sr 24 hr 80 mg
3
LIPOFEN - fenofibrate cap 50 mg
LIPOFEN - fenofibrate cap 150 mg
LIVALO - pitavastatin calcium tab 1

mg (base equiv)

mg (base equiv)

mg (base equiv)
LOFIBRA - fenofibrate micronized

cap 67 mg

cap 134 mg

cap 200 mg
LOFIBRA - fenofibrate tab 54 mg
LOFIBRA - fenofibrate tab 160 mg
LOPID - gemfibrozil tab 600 mg
lovastatin tab 10 mg
lovastatin tab 40 mg (Mevacor)
1
1
LOVAZA - omega-3-acid ethyl esters

cap 1 gm
MEVACOR - lovastatin tab 40 mg
niacin tab cr 500 mg

(antihyperlipidemic) (Niaspan)

1
1
NIACOR - niacin (antihyperlipidemic) 3

tab 500 mg
3
NIASPAN - niacin tab cr 500 mg
(antihyperlipidemic)
3
3
1
omega-3-acid ethyl esters cap
1 gm (Lovaza)
3
OMEGA-3/D-3 WELLNESS PACK omega-3-acid ethyl esters cap
1gm & vit d3 cap 1000 unit kit
4
PRALUENT - alirocumab
subcutaneous soln pen-injector 75
mg/ml
4
subcutaneous soln pen-injector
150 mg/ml
4
subcutaneous soln prefilled
syringe 75 mg/ml
4
syringe 150 mg/ml
3
PRAVACHOL - pravastatin sodium
tab 20 mg
3
tab 40 mg
3
tab 80 mg
1
pravastatin sodium tab 10 mg

(Pravachol)

(Pravachol)

(Pravachol)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
lovastatin tab 20 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
55
QUESTRAN - cholestyramine
powder packets 4 gm
VYTORIN - ezetimibe-simvastatin
tab 10-40 mg
QUESTRAN - cholestyramine
powder 4 gm/dose
tab 10-80 mg
WELCHOL - colesevelam hcl packet

for susp 3.75 gm
WELCHOL - colesevelam hcl tab

625 mg
ZETIA - ezetimibe tab 10 mg
ZOCOR - simvastatin tab 5 mg
QUESTRAN LIGHT - cholestyramine 3

light powder 4 gm/dose
4
REPATHA - evolocumab
syringe 140 mg/ml
4
REPATHA SURECLICK evolocumab subcutaneous soln
auto-injector 140 mg/ml
3
SIMCOR - niacin-simvastatin tab sr
24hr 500-20 mg
3
24hr 500-40 mg
3
24hr 750-20 mg
3
24hr 1000-20 mg
3
24hr 1000-40 mg
1
simvastatin tab 5 mg (Zocor)
CARDIOVASCULAR AGENTS - MISC.

ADCIRCA - tadalafil tab 20 mg (pah) 4
ADEMPAS - riociguat tab 0.5 mg
ADEMPAS - riociguat tab 1 mg
ADEMPAS - riociguat tab 2 mg
amlodipine besylate-atorvastatin
calcium tab 2.5-10 mg (Caduet)
TRICOR - fenofibrate tab 48 mg
TRICOR - fenofibrate tab 145 mg
TRIGLIDE - fenofibrate tab 160 mg
TRILIPIX - choline fenofibrate cap dr

45 mg (fenofibric acid equiv)
TRILIPIX - choline fenofibrate cap dr

135 mg (fenofibric acid equiv)
VASCEPA - icosapent ethyl cap 1

gm
tab 10-10 mg
tab 10-20 mg

56
1
1
1
1
calcium tab 5-10 mg (Caduet)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
1
1
1
1
1
BIDIL - isosorbide dinitratehydralazine hcl tab 20-37.5 mg
ORENITRAM - treprostinil diolamine

tab cr 0.125 mg (base equiv)
CADUET - amlodipine besylateatorvastatin calcium tab 2.5-10 mg


tab cr 1 mg (base equiv)

CADUET - amlodipine besylateatorvastatin calcium tab 5-10 mg
REMODULIN - treprostinil sodium inj 4

2.5 mg/ml (base equiv)
4
REVATIO - sildenafil citrate for
suspension 10 mg/ml
4
REVATIO - sildenafil citrate tab 20
mg
4
sildenafil citrate tab 20 mg
(Revatio)
TRACLEER - bosentan tab 62.5 mg 4
CORLANOR - ivabradine hcl tab 5

mg (base equiv)
CORLANOR - ivabradine hcl tab 7.5
mg (base equiv)
1
1
LETAIRIS - ambrisentan tab 5 mg
LETAIRIS - ambrisentan tab 10 mg
OPSUMIT - macitentan tab 10 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
TRACLEER - bosentan tab 125 mg
TYVASO - treprostinil inhalation

solution 0.6 mg/ml
TYVASO REFILL - treprostinil

inhalation solution 0.6 mg/ml
TYVASO STARTER - treprostinil

inhalation solution 0.6 mg/ml
VENTAVIS - iloprost inhalation

solution 10 mcg/ml
VENTAVIS - iloprost inhalation

solution 20 mcg/ml
CIALIS - tadalafil tab 2.5 mg
CIALIS - tadalafil tab 5 mg
ENTRESTO - sacubitril-valsartan tab 3

24-26 mg
49-51 mg
97-103 mg
3
ISOXSUPRINE HCL - isoxsuprine
hcl tab 20 mg
1
isoxsuprine hcl tab 10 mg
ERECTLIE DYSFUNCTION
57
carbinoxamine maleate soln

4 mg/5ml
carbinoxamine maleate tab 4 mg
cetirizine hcl oral soln 1 mg/ml
(5 mg/5ml)
clemastine fumarate tab 2.68 mg
cyproheptadine hcl syrup
2 mg/5ml
cyproheptadine hcl tab 4 mg
ASTEPRO - azelastine hcl nasal

spray 0.15% (205.5 mcg/spray)
ATROVENT - ipratropium bromide

nasal soln 0.03% (21 mcg/spray)
ATROVENT - ipratropium bromide

nasal soln 0.06% (42 mcg/spray)
azelastine hcl nasal spray 0.1%

(137 mcg/spray)
azelastine hcl nasal spray 0.15%

(205.5 mcg/spray) (Astepro)
1
1
desloratadine tab orally

disintegrating 5 mg (Clarinex
reditabs)
desloratadine tab 5 mg (Clarinex)
1
1
1
BACTROBAN NASAL - mupirocin

calcium nasal oint 2%
flunisolide nasal soln 25 mcg/act

(0.025%) (Flunisolide)
olopatadine hcl nasal soln 0.6%

(Patanase)
fluticasone propionate nasal susp

50 mcg/act
ipratropium bromide nasal soln
0.03% (21 mcg/spray) (Atrovent)
ipratropium bromide nasal soln
0.06% (42 mcg/spray) (Atrovent)
levocetirizine dihydrochloride
soln 2.5 mg/5ml (0.5 mg/ml)
(Xyzal)
levocetirizine dihydrochloride tab

5 mg (Xyzal)
PATANASE - olopatadine hcl nasal

soln 0.6%
triamcinolone acetonide nasal

aerosol suspension 55 mcg/act
TYZINE - tetrahydrozoline hcl nasal

soln 0.1%
3
3
TYZINE PEDIATRIC NASAL DR tetrahydrozoline hcl nasal soln

0.05%
COUGH/COLD/ALLERGY
acetylcysteine inhal soln 10%
loratadine rapidly-disintegrating
tab 10 mg (Claritin)
loratadine syrup 5 mg/5ml
loratadine tab 10 mg
promethazine hcl suppos 12.5 mg
promethazine hcl suppos 25 mg
promethazine hcl suppos 50 mg
promethazine hcl syrup
6.25 mg/5ml
promethazine hcl tab 12.5 mg
promethazine hcl tab 25 mg
promethazine hcl tab 50 mg
1
1
acetylcysteine inhal soln 20%

1
1
1
NASAL AGENTS - SYSTEMIC and TOPICAL

58
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Tier
diphenhydramine hcl elixir

12.5 mg/5ml
Responsible Steps
desloratadine tab orally

disintegrating 2.5 mg (Clarinex
reditabs)
diphenhydramine hcl cap 50 mg
Drug Name
ADRENALIN - epinephrine hcl nasal
soln 0.1%
RESPIRATORY AGENTS
ANTIHISTAMINES
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
benzonatate cap 100 mg (Tessalon 1

perles)
1
benzonatate cap 150 mg
(Zonatuss)
1
benzonatate cap 200 mg
CODAR AR - chlorpheniramine w/
codeine liquid 2-8 mg/5ml
sodium chloride soln nebu 3%

(Hyper-sal)
GILTUSS PED-C - phenylephrine w/

codeine-gg liquid 2.5-3-50 mg/ml
hydrocod polst-chlorphen polst

cr susp 10-8 mg/5ml (Tussionex
pennkineti)
hydrocodone w/ homatropine
syrup 5-1.5 mg/5ml
SUTTAR-2 - pseudoephedrine w/
cod-gg syrup 30-10-100 mg/5ml
TESSALON PERLES - benzonatate

cap 100 mg
TUSSICAPS - hydrocod polstchlorphen polst cap sr 12hr 5-4

mg
TUSSICAPS - hydrocod polstchlorphen polst cap sr 12hr 10-8

mg
TUSSIONEX PENNKINETIC EXT hydrocod polst-chlorphen polst cr

susp 10-8 mg/5ml
TUZISTRA XR - codeine polistchlorphen polist er susp 14.7-2.8

mg/5ml
NEBUSAL - sodium chloride soln

nebu 6%
VITUZ - hydrocodonechlorpheniramine soln 5-4 mg/5ml
phenylephrine-promethazine w/
codeine syrup 5-6.25-10 mg/5ml
ZONATUSS - benzonatate cap 150

mg
ZUTRIPRO - pseudoeph-chlorphen
w/ hydrocodone soln 60-4-5
mg/5ml
HYPER-SAL - sodium chloride soln

nebu 7%
HYPERSAL - sodium chloride soln

nebu 3.5%
HYPERSAL - sodium chloride soln

nebu 7%
LEXUSS 210 - chlorpheniramine w/

codeine liquid 2-10 mg/5ml
loratadine & pseudoephedrine tab

sr 12hr 5-120 mg
loratadine & pseudoephedrine tab

sr 24hr 10-240 mg
promethazine & phenylephrine

syrup 6.25-5 mg/5ml
promethazine w/ codeine syrup
6.25-10 mg/5ml
promethazine-dm syrup
6.25-15 mg/5ml
pseudoeph-chlorphen
w/ hydrocodone soln
60-4-5 mg/5ml (Zutripro)
pseudoephed-bromphen-dm
syrup 30-2-10 mg/5ml
1
1
ANTIASTHMATIC and BRONCHODILATOR AGENTS

3
ACCOLATE - zafirlukast tab 10 mg
ACCOLATE - zafirlukast tab 20 mg
ADVAIR DISKUS - fluticasonesalmeterol aer powder ba 100-50

mcg/dose

mcg/dose

mcg/dose
REZIRA - pseudoephedrine w/
hydrocodone soln 60-5 mg/5ml
sodium chloride soln nebu 0.9%
Responsible Steps
Quantity Limits
Prior Authorization
SUTTAR-SF - pseudoephedrine w/
cod-gg syrup 30-10-100 mg/5ml
hydrocodone w/ homatropine tab

5-1.5 mg
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
59
ADVAIR HFA - fluticasone-salmeterol 2

inhal aerosol 45-21 mcg/act
3
AEROSPAN - flunisolide hfa inhal
aerosol 80 mcg/act
1
albuterol sulfate soln nebu
0.083% (2.5 mg/3ml)
1
albuterol sulfate soln nebu 0.5%
(5 mg/ml)
1
0.63 mg/3ml (base equiv)
1
1
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
ALVESCO - ciclesonide inhal aerosol 3

80 mcg/act
ALVESCO - ciclesonide inhal aerosol 3
160 mcg/act
2
ANORO ELLIPTA - umeclidiniumvilanterol aero powd ba 62.5-25
mcg/inh
ARCAPTA NEOHALER - indacaterol 3
maleate inhal powder cap 75 mcg
(base equiv)
2
ARNUITY ELLIPTA - fluticasone
furoate aerosol powder breath
activ 100 mcg/act
2
ARNUITY ELLIPTA - fluticasone
furoate aerosol powder breath
activ 200 mcg/act
60
ASMANEX HFA - mometasone

furoate inhal aerosol suspension
200 mcg/act
ASMANEX TWISTHALER 120 ME mometasone furoate inhal powd

220 mcg/inh (breath activated)
ASMANEX TWISTHALER 14 MET mometasone furoate inhal powd




ASMANEX TWISTHALER 7 METE mometasone furoate inhal powd

ATROVENT HFA - ipratropium

bromide hfa inhal aerosol 17 mcg/
act
BREO ELLIPTA - fluticasone furoate- 2

vilanterol aero powd ba 100-25
mcg/inh
BREO ELLIPTA - fluticasone furoate- 2
vilanterol aero powd ba 200-25
mcg/inh
3
BROVANA - arformoterol tartrate
soln nebu 15 mcg/2ml (base
equiv)
1
budesonide inhalation susp
0.25 mg/2ml (Pulmicort)
1
0.5 mg/2ml (Pulmicort)
1
1 mg/2ml (Pulmicort)
ASMANEX HFA - mometasone

furoate inhal aerosol suspension
100 mcg/act
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
COMBIVENT RESPIMAT ipratropium-albuterol inhal aerosol

soln 20-100 mcg/act
CROMOLYN SODIUM - cromolyn

sodium soln nebu 20 mg/2ml
ipratropium-albuterol nebu soln

0.5-2.5(3) mg/3ml
DULERA - mometasone furoateformoterol fumarate aerosol 100-5

mcg/act
levalbuterol hcl soln nebu conc

1.25 mg/0.5ml (base equiv)
(Xopenex concentrate)
DALIRESP - roflumilast tab 500 mcg
DULERA - mometasone furoateformoterol fumarate aerosol 200-5

mcg/act
levalbuterol hcl soln nebu

(Xopenex)
dyphylline-guaifenesin liqd
100-100 mg/5ml

(Xopenex)
ipratropium bromide inhal soln

0.02%
ELIXOPHYLLIN - theophylline elixir

80 mg/15ml
epinephrine hcl inj 1 mg/ml
LUFYLLIN - dyphylline tab 400 mg
METAPROTERENOL SULFATE metaproterenol sulfate syrup 10

mg/5ml
METAPROTERENOL SULFATE metaproterenol sulfate tab 10 mg
METAPROTERENOL SULFATE metaproterenol sulfate tab 20 mg
montelukast sodium chew tab

4 mg (base equiv) (Singulair)
FLOVENT DISKUS - fluticasone

propionate aer pow ba 50 mcg/
blister

blister

blister
FLOVENT HFA - fluticasone

propionate hfa inhal aero 44 mcg/
act (50/valve)

propionate hfa inhal aer 110 mcg/
act (125/valve)

propionate hfa inhal aer 220 mcg/
act (250/valve)
FORADIL AEROLIZER - formoterol

fumarate inhal cap 12 mcg
INCRUSE ELLIPTA - umeclidinium

br aero powd breath act 62.5 mcg/
inh (base eq)
montelukast sodium chew tab

5 mg (base equiv) (Singulair)
montelukast sodium
oral granules packet 4 mg (base
equiv) (Singulair)
montelukast sodium tab 10 mg
(base equiv) (Singulair)
PERFOROMIST - formoterol
fumarate soln nebu 20 mcg/2ml
PROAIR HFA - albuterol sulfate inhal 2

aero 108 mcg/act (90mcg base
equiv)
2
PROAIR RESPICLICK - albuterol
sulfate aer pow ba 108 mcg/act
(90 mcg base equiv)

(Xopenex)
epinephrine hcl soln prefilled

syringe 0.1 mg/ml
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
61
PROVENTIL HFA - albuterol sulfate

inhal aero 108 mcg/act (90mcg
base equiv)
PULMICORT - budesonide inhalation 3

susp 0.25 mg/2ml
susp 0.5 mg/2ml
susp 1 mg/2ml
3
PULMICORT FLEXHALER budesonide inhal aero powd 90
mcg/act (breath activated)
3
PULMICORT FLEXHALER budesonide inhal aero powd 180
mcg/act (breath activated)
QVAR - beclomethasone diprop inhal 2
aero soln 40 mcg/act (50/valve)
QVAR - beclomethasone diprop inhal 2
aero soln 80 mcg/act (100/valve)
3
SEREVENT DISKUS - salmeterol
xinafoate aer pow ba 50 mcg/dose
(base equiv)
3
SINGULAIR - montelukast sodium
oral granules packet 4 mg (base
equiv)
SPIRIVA HANDIHALER - tiotropium 2
bromide monohydrate inhal cap
18 mcg (base equiv)
2
SPIRIVA RESPIMAT - tiotropium
bromide monohydrate inhal
aerosol 1.25 mcg/act
2
SPIRIVA RESPIMAT - tiotropium
bromide monohydrate inhal
aerosol 2.5 mcg/act
STIOLTO RESPIMAT - tiotropium br- 3
olodaterol inhal aero soln 2.5-2.5
mcg/act
STRIVERDI RESPIMAT - olodaterol 3
hcl inhal aerosol soln 2.5 mcg/act
(base equiv)
2
SYMBICORT - budesonideformoterol fumarate dihyd aerosol
80-4.5 mcg/act
62
SYMBICORT - budesonideformoterol fumarate dihyd aerosol

160-4.5 mcg/act
terbutaline sulfate tab 2.5 mg
terbutaline sulfate tab 5 mg
THEO-24 - theophylline cap sr 24hr

200 mg

300 mg

400 mg
theophylline soln 80 mg/15ml
theophylline tab sr 12hr 100 mg

1
1
1
1
1
3
VENTOLIN HFA - albuterol sulfate

inhal aero 108 mcg/act (90mcg
base equiv)
VOSPIRE ER - albuterol sulfate tab

sr 12hr 4 mg
VOSPIRE ER - albuterol sulfate tab

sr 12hr 8 mg
XOPENEX - levalbuterol hcl soln

nebu 0.31 mg/3ml (base equiv)


3
3
XOPENEX CONCENTRATE levalbuterol hcl soln nebu conc

1.25 mg/0.5ml (base equiv)
TUDORZA PRESSAIR - aclidinium

bromide aerosol powd breath
activated 400 mcg/act
Responsible Steps
Quantity Limits
Prior Authorization

100 mg
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
XOPENEX HFA - levalbuterol tartrate 3

inhal aerosol 45 mcg/act (base
equiv)
1
zafirlukast tab 10 mg (Accolate)
zafirlukast tab 20 mg (Accolate)
ZYFLO - zileuton tab 600 mg
1
3
KALYDECO - ivacaftor tab 150 mg
OFEV - nintedanib esylate cap 100

OFEV - nintedanib esylate cap 150

ORKAMBI - lumacaftor-ivacaftor tab

200-125 mg
PULMOZYME - dornase alfa inhal

soln 1 mg/ml
ESBRIET - pirfenidone cap 267 mg
KALYDECO - ivacaftor packet 50 mg 4

KALYDECO - ivacaftor packet 75 mg 4
GASTROINTESTINAL AGENTS
LAXATIVES
MOVIPREP - peg 3350-kcl-nacl-na

sulfate-na ascorbate-c for soln
100 gm
NULYTELY/FLAVOR PACKS - peg

3350-kcl-sod bicarb-nacl for soln
420 gm
OSMOPREP - sod phos monosod phos di tabs 1.102-0.398

gm(1.5gm na phos)
peg 3350-kcl-sod bicarb-nacl

for soln 420 gm (Nulytely/flavor
pack)
peg 3350-kcl-na bicarb-naclna sulfate for soln 236 gm

(Golytely)
peg 3350-kcl-na bicarb-nacl-na

sulfate for soln 240 gm (Colyteflavor packs)
PREPOPIK - sod picosulfate-mg

oxide-citric acid pack 10 mg-3.5
gm-12 gm
SUPREP BOWEL PREP - sodium

sulfate-potassium sulfatemagnesium sulfate oral soln
ANTIDIARRHEALS
diphenoxylate w/ atropine tab
2.5-0.025 mg (Lomotil)
COLYTE-FLAVOR PACKS - peg

3350-kcl-na bicarb-nacl-na sulfate
for soln 240 gm
DIPHENOXYLATE/ATROPINE diphenoxylate w/ atropine liq

2.5-0.025 mg/5ml
GOLYTELY - peg 3350-kcl-na

bicarb-nacl-na sulfate packet
227.1 gm
FULYZAQ - crofelemer tab delayed

release 125 mg
3
3
GOLYTELY - peg 3350-kcl-na

bicarb-nacl-na sulfate for soln 236
gm
LOMOTIL - diphenoxylate w/
atropine tab 2.5-0.025 mg
loperamide hcl cap 2 mg
KRISTALOSE - lactulose oral crystal

packet 10 gm
MOTOFEN - difenoxin w/ atropine

tab 1-0.025 mg
OPIUM TINCTURE (PAREGORIC paregoric 2 mg/5ml
KRISTALOSE - lactulose oral crystal

packet 20 gm
opium tincture 1% (10 mg/ml)

(morphine equiv)
lactulose solution 10 gm/15ml
Responsible Steps
Quantity Limits
Prior Authorization
bisacodyl tab & peg 3350-kcl-sod

bicarb-nacl for soln kit
Specialty
Drug Name
Drug Tier
Responsible Steps
ZYFLO CR - zileuton tab sr 12hr 600 3

mg
RESPIRATORY AGENTS - MISC.
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
63
RESTORA RX - lactobacillus caseifolic acid cap 60-1.25 mg

ULCER DRUGS
amoxicillin cap-clarithro tablansopraz cap dr therapy pack

(Prevpac)
ANASPAZ - hyoscyamine sulfate tab

disp 0.125 mg
AXID - nizatidine cap 300 mg
BELLADONNA & OPIUM belladonna alkaloids & opium

suppos 16.2-30 mg
BELLADONNA ALKALOIDS & OP belladonna alkaloids & opium

suppos 16.2-60 mg
BENTYL - dicyclomine hcl cap 10

mg
cimetidine hcl soln 300 mg/5ml

cimetidine tab 200 mg
1
1
1
1
1
1
CUVPOSA - glycopyrrolate oral soln

1 mg/5ml
CYTOTEC - misoprostol tab 100

mcg
CYTOTEC - misoprostol tab 200

mcg
dicyclomine hcl cap 10 mg

(Bentyl)
dicyclomine hcl oral soln

10 mg/5ml
64
dicyclomine hcl tab 20 mg (Bentyl) 1

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 20 mg (Pepcid)
3
glycopyrrolate tab 1 mg (Robinul)
glycopyrrolate tab 2 mg (Robinul

forte)
hyoscyamine sulfate elixir

0.125 mg/5ml
hyoscyamine sulfate tab disp

0.125 mg (Anaspaz)
hyoscyamine sulfate tab sl
0.125 mg (Levsin/sl)
hyoscyamine sulfate tab sr 12hr
0.375 mg (Levbid)
Responsible Steps
Prior Authorization
Quantity Limits
1
1
1
1
hyoscyamine sulfate tab 0.125 mg

(Levsin)
lansoprazole cap delayed release

15 mg (Prevacid)
lansoprazole cap delayed release

30 mg (Prevacid)
GASTRINEX NF - hyoscyaminephenyltoloxamine cap 0.0625-15

mg
hyoscyamine sulfate soln

0.125 mg/ml
Specialty
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
famotidine tab 40 mg (Pepcid)
BENTYL - dicyclomine hcl tab 20 mg 3

3
CANTIL - mepenzolate bromide tab
25 mg
2
CARAFATE - sucralfate susp 1
gm/10ml
3
CARAFATE - sucralfate tab 1 gm
chlordiazepoxide hcl-clidinium
bromide cap 5-2.5 mg (Librax)
Specialty
Drug Name
Drug Tier
2016
LEVBID - hyoscyamine sulfate tab sr 3

12hr 0.375 mg
3
LEVSIN - hyoscyamine sulfate tab
0.125 mg
3
LEVSIN/SL - hyoscyamine sulfate
tab sl 0.125 mg
3
LIBRAX - chlordiazepoxide hclclidinium bromide cap 5-2.5 mg
methscopolamine bromide tab

2.5 mg (Pamine)
omeprazole-sodium bicarbonate
cap 40-1100 mg (Zegerid)
ranitidine hcl cap 300 mg
methscopolamine bromide tab

5 mg (Pamine forte)
NEXIUM - esomeprazole
magnesium cap delayed release
20 mg (base eq)
magnesium cap delayed release
40 mg (base eq)
magnesium for delayed release
susp packet 5 mg
susp packet 10 mg
susp packet 20 mg
susp packet 40 mg
susp pack 2.5 mg
nizatidine cap 150 mg
ranitidine hcl tab 150 mg (Zantac)
ranitidine hcl tab 300 mg (Zantac)
ROBINUL - glycopyrrolate tab 1 mg
ROBINUL FORTE - glycopyrrolate

tab 2 mg
sucralfate tab 1 gm (Carafate)
misoprostol tab 100 mcg (Cytotec) 1

misoprostol tab 200 mcg (Cytotec) 1
nizatidine cap 300 mg (Axid)

nizatidine oral soln 15 mg/ml
OMECLAMOX-PAK - amoxicillin cap- 3

clarithro tab w/ omepraz cap dr
therapy pack
1
omeprazole cap delayed release
10 mg (Prilosec)
1
20 mg (Prilosec)
1
40 mg (Prilosec)
1
omeprazole-sodium bicarbonate
cap 20-1100 mg (Zegerid)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
PAMINE - methscopolamine bromide 3

tab 2.5 mg
PAMINE FORTE - methscopolamine 3
bromide tab 5 mg
1
pantoprazole sodium ec tab
20 mg (base equiv) (Protonix)
1
pantoprazole sodium ec tab
40 mg (base equiv) (Protonix)
PREVPAC - amoxicillin cap-clarithro 3
tab-lansopraz cap dr therapy pack
1
PRILOSEC OTC - omeprazole
magnesium delayed release tab
20 mg (base equiv)
2
PROPANTHELINE BROMIDE propantheline bromide tab 15 mg
3
PYLERA - bismuth subcitmetronidazole-tetracycline cap
140-125-125 mg
rabeprazole sodium ec tab 20 mg 1
(Aciphex)
1
ranitidine hcl cap 150 mg
ranitidine hcl syrup 15 mg/ml
(75 mg/5ml)
SYMAX DUOTAB - hyoscyamine

sulfate tab cr 0.375 mg (0.125 mg
ir/0.25 mg cr)
ANTIEMETICS
1
1
1
ANZEMET - dolasetron mesylate tab 3

50 mg
AKYNZEO - netupitant-palonosetron
cap 300-0.5 mg
65
ANZEMET - dolasetron mesylate tab 3

100 mg
3
CESAMET - nabilone cap 1 mg
DICLEGIS - doxylamine-pyridoxine
tab delayed release 10-10 mg
dronabinol cap 2.5 mg (Marinol)
dronabinol cap 5 mg (Marinol)

dronabinol cap 10 mg (Marinol)
EMEND - aprepitant capsule 125 mg 2

1
granisetron hcl tab 1 mg
MARINOL - dronabinol cap 2.5 mg
MARINOL - dronabinol cap 5 mg
MARINOL - dronabinol cap 10 mg
meclizine hcl tab 12.5 mg
meclizine hcl tab 25 mg

ondansetron hcl oral soln
4 mg/5ml (Zofran)
SANCUSO - granisetron td patch 3.1 3

mg/24hr (contains 34.3 mg)
TIGAN - trimethobenzamide hcl cap 3
300 mg
TRANSDERM-SCOP - scopolamine 3
td patch 72hr 1 mg/3days
1
trimethobenzamide hcl cap
300 mg (Tigan)
ZOFRAN - ondansetron hcl oral soln 3
4 mg/5ml
ZOFRAN - ondansetron hcl tab 4 mg 3
ondansetron hcl tab 24 mg

ondansetron orally disintegrating
tab 4 mg (Zofran odt)
ondansetron orally disintegrating
tab 8 mg (Zofran odt)
66
ZOFRAN - ondansetron hcl tab 8 mg 3

3
ZOFRAN ODT - ondansetron orally
disintegrating tab 4 mg
3
ZOFRAN ODT - ondansetron orally
CREON - pancrelipase (lip-protamyl) dr cap 3000-9500-15000
unit

unit

unit

unit
CREON - pancrelipase
(lip-prot-amyl) dr cap
36000-114000-180000 unit
PANCREAZE - pancrelipase
4200-10000-17500 unit
10500-25000-43750 unit
16800-40000-70000 unit
21000-37000-61000 unit
PANCRELIPASE - pancrelipase
5000-17000-27000 unit
PERTZYE - pancrelipase (lip-protamyl) dr cap 8000-28750-30250

unit
PERTZYE - pancrelipase (lip-protamyl) dr cap 16000-57500-60500

unit
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Tier
Drug Name
DIGESTIVE AIDS
ondansetron hcl tab 4 mg (Zofran) 1

ondansetron hcl tab 8 mg (Zofran) 1
Responsible Steps
Quantity Limits
Prior Authorization
EMEND - aprepitant capsule therapy 2

pack 80 & 125 mg
2
EMEND - aprepitant capsule 40 mg
EMEND - aprepitant capsule 80 mg
Specialty
Drug Name
Drug Tier
2016
SUCRAID - sacrosidase soln 8500

unit/ml
ULTRESA - pancrelipase (lip-protamyl) dr cap 13800-27600-27600

unit

unit

unit
VIOKACE - pancrelipase (lip-protamyl) tab 10440-39150-39150 unit
VIOKACE - pancrelipase (lip-protamyl) tab 20880-78300-78300 unit
ZENPEP - pancrelipase (lip-protamyl) dr cap 3000-10000-16000

unit

unit

unit

unit

unit
AMITIZA - lubiprostone cap 8 mcg
AMITIZA - lubiprostone cap 24 mcg
APRISO - mesalamine cap sr 24hr

0.375 gm
ASACOL HD - mesalamine tab

AZULFIDINE - sulfasalazine tab 500

mg
AZULFIDINE EN-TABS sulfasalazine tab delayed release

500 mg
balsalazide disodium cap 750 mg

(Colazal)
calcium acetate (phosphate

binder) cap 667 mg (169 mg ca)
(Phoslo)
calcium acetate (phosphate

binder) tab 667 mg (Eliphos)
CANASA - mesalamine suppos 1000 2

mg
CHENODAL - chenodiol tab 250 mg 2
CHOLBAM - cholic acid cap 50 mg
CHOLBAM - cholic acid cap 250 mg
CIMZIA - certolizumab pegol for inj

kit 2 x 200 mg
CIMZIA - certolizumab pegol inj kit 2

x 200 mg/ml

unit
CIMZIA STARTER KIT certolizumab pegol inj kit 6 x 200

mg/ml
ZENPEP - pancrelipase
40000-136000-218000 unit
COLAZAL - balsalazide disodium

cap 750 mg
cromolyn sodium oral conc
100 mg/5ml (Gastrocrom)
DELZICOL - mesalamine cap dr 400

mg
DIPENTUM - olsalazine sodium cap

250 mg
ELIPHOS - calcium acetate

(phosphate binder) tab 667 mg
ENTEREG - alvimopan cap 12 mg
GASTROINTESTINAL AGENTS- MISC.

3
ACTIGALL - ursodiol cap 300 mg
alosetron hcl tab 0.5 mg (base
equiv) (Lotronex)
alosetron hcl tab 1 mg (base
equiv) (Lotronex)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
67
FOSRENOL - lanthanum carbonate

chew tab 500 mg (elemental)
PENTASA - mesalamine cap cr 500

mg


PHOSLO - calcium acetate

(phosphate binder) cap 667 mg
(169 mg ca)

oral powder pack 750 mg
(elemental)
PHOSLYRA - calcium acetate

(phosphate binder) oral soln 667
mg/5ml

oral powder pack 1000 mg
(elemental)
REGLAN - metoclopramide hcl tab 5

mg
REGLAN - metoclopramide hcl tab
10 mg
GASTROCROM - cromolyn sodium

oral conc 100 mg/5ml
RELISTOR - methylnaltrexone
bromide inj 8 mg/0.4ml (20 mg/ml)
GATTEX - teduglutide (rdna) for inj

kit 5 mg
GIAZO - balsalazide disodium tab

1.1 gm
RELISTOR - methylnaltrexone
bromide inj 12 mg/0.6ml (20 mg/
ml)
lactulose (encephalopathy)
solution 10 gm/15ml
RENAGEL - sevelamer hcl tab 400

mg
LIALDA - mesalamine tab delayed

release 1.2 gm
RENAGEL - sevelamer hcl tab 800

mg
LINZESS - linaclotide cap 145 mcg
RENVELA - sevelamer carbonate

packet 0.8 gm
LINZESS - linaclotide cap 290 mcg
LOTRONEX - alosetron hcl tab 0.5

mg (base equiv)

packet 2.4 gm
LOTRONEX - alosetron hcl tab 1 mg

(base equiv)

tab 800 mg
mesalamine enema 4 gm
SEVELAMER CARBONATE sevelamer carbonate tab 800 mg
SFROWASA - mesalamine sulfitefree (sf) enema 4 gm/60ml
metoclopramide hcl tab 5 mg

(Reglan)
sulfasalazine tab delayed release

500 mg (Azulfidine en-tabs)
metoclopramide hcl tab 10 mg

(Reglan)
sulfasalazine tab 500 mg

(Azulfidine)
MOVANTIK - naloxegol oxalate tab

12.5 mg (base equivalent)
URSO FORTE - ursodiol tab 500 mg
URSO 250 - ursodiol tab 250 mg
MOVANTIK - naloxegol oxalate tab

ursodiol cap 300 mg (Actigall)
PENTASA - mesalamine cap cr 250

mg
metoclopramide hcl soln

5 mg/5ml (10 mg/10ml)
68
ursodiol tab 250 mg (Urso 250)

ursodiol tab 500 mg (Urso forte)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
VELPHORO - sucroferric
oxyhydroxide chew tab 500 mg
GENITOURINARY AGENTS
URINARY ANTI-INFECTIVES
bethanechol chloride tab 25 mg

(Urecholine)

(Urecholine)
FURADANTIN - nitrofurantoin susp

25 mg/5ml
DETROL - tolterodine tartrate tab 1

mg
HIPREX - methenamine hippurate

tab 1 gm
DETROL - tolterodine tartrate tab 2

mg
MACROBID - nitrofurantoin
monohydrate macrocrystalline cap
100 mg
MACRODANTIN - nitrofurantoin
macrocrystalline cap 25 mg
methenamine hippurate tab 1 gm

(Hiprex)
MONUROL - fosfomycin
tromethamine powd pack 3 gm
(base equivalent)
nitrofurantoin macrocrystalline
cap 25 mg (Macrodantin)
1
1
DETROL LA - tolterodine tartrate cap 3

sr 24hr 2 mg
DETROL LA - tolterodine tartrate cap 3
sr 24hr 4 mg
DITROPAN XL - oxybutynin chloride 3
tab sr 24hr 5 mg
tab sr 24hr 10 mg
tab sr 24hr 15 mg
3
ENABLEX - darifenacin
hydrobromide tab sr 24hr 7.5 mg
(base equiv)
3
ENABLEX - darifenacin
hydrobromide tab sr 24hr 15 mg
(base equiv)
1
flavoxate hcl tab 100 mg
3
GELNIQUE - oxybutynin chloride td

gel 10%
nitrofurantoin monohydrate
(Macrobid)
GELNIQUE - oxybutynin td gel 3%

(28 mg/act metered-dose pump)
MYRBETRIQ - mirabegron tab sr 24
hr 25 mg
nitrofurantoin susp 25 mg/5ml

(Furadantin)
MYRBETRIQ - mirabegron tab sr 24

hr 50 mg
UROGESIC-BLUE - methenaminehyoscamine-meth blue-sod phos

tab 81.6 mg
oxybutynin chloride syrup

5 mg/5ml
URINARY ANTISPASMODICS
(Urecholine)

(Urecholine)
oxybutynin chloride tab sr 24hr

5 mg (Ditropan xl)
10 mg (Ditropan xl)
15 mg (Ditropan xl)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
69
tolterodine tartrate tab 1 mg

(Detrol)
tolterodine tartrate tab 2 mg

(Detrol)
TOVIAZ - fesoterodine fumarate tab

sr 24hr 4 mg
TOVIAZ - fesoterodine fumarate tab

sr 24hr 8 mg
trospium chloride cap sr 24hr

60 mg
trospium chloride tab 20 mg

URECHOLINE - bethanechol
chloride tab 5 mg
chloride tab 10 mg
chloride tab 25 mg
chloride tab 50 mg
VESICARE - solifenacin succinate

tab 5 mg
VESICARE - solifenacin succinate

tab 10 mg
VAGINAL PRODUCTS
CRINONE - progesterone vaginal gel 3

4%
P
ENCARE - nonoxynol-9 vaginal
suppos 100 mg
ESTRACE - estradiol vaginal cream 3
0.1 mg/gm
3
ESTRING - estradiol vaginal ring 2
mg (7.5 mcg/24hrs)
3
FEM PH - acetic acid-oxyquinoline
vaginal gel 0.9-0.025%
FEMRING - estradiol acetate vaginal 3
ring 0.05 mg/24hr
FEMRING - estradiol acetate vaginal 3
ring 0.1 mg/24hr
GYNAZOLE-1 - butoconazole nitrate 3
(one dose) vaginal cream 2%
3
METROGEL-VAGINAL metronidazole vaginal gel 0.75%
1
metronidazole vaginal gel 0.75%
(Metrogel-vaginal)
MICONAZOLE 3 - miconazole nitrate 3
vaginal suppos 200 mg
OPTIONS CONCEPTROL VAGINA - P
nonoxynol-9 gel 4%
P
OPTIONS GYNOL II VAGINAL nonoxynol-9 gel 3%
vaginal cream 0.625 mg/gm
3
RELAGARD - acetic acidoxyquinoline vaginal gel
0.9-0.025%
P
SHUR-SEAL - nonoxynol-9 gel 2%
AVC - sulfanilamide vaginal cream

15%
CLEOCIN - clindamycin phosphate

vaginal cream 2%
CLEOCIN - clindamycin phosphate

vaginal suppos 100 mg
TERAZOL 3 - terconazole vaginal

cream 0.8%
clindamycin phosphate vaginal

cream 2% (Cleocin)
TERAZOL 7 - terconazole vaginal

cream 0.4%
terconazole vaginal cream 0.4%

(Terazol 7)
70
Responsible Steps
tolterodine tartrate cap sr 24hr

4 mg (Detrol la)
Quantity Limits
Prior Authorization
CLINDESSE - clindamycin
phosphate (one dose) vaginal
cream 2%
Specialty
tolterodine tartrate cap sr 24hr

2 mg (Detrol la)
Drug Name
Drug Tier
OXYTROL - oxybutynin td patch

oxybutynin chloride tab 5 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
terconazole vaginal cream 0.8%

(Terazol 3)
phenazopyridine hcl tab 100 mg

(Pyridium)
terconazole vaginal suppos

80 mg
phenazopyridine hcl tab 200 mg

(Pyridium)
TODAY SPONGE - nonoxynol-9

vaginal sponge 1000 mg
VAGIFEM - estradiol vaginal tab 10

mcg
pot & sod citrates w/ cit ac soln

550-500-334 mg/5ml
VCF VAGINAL CONTRACEPTIVE nonoxynol-9 film 28%
VCF VAGINAL CONTRACEPTIVE nonoxynol-9 foam 12.5%
GENITOURINARY AGENTS - MISC.

acetic acid irrigation soln 0.25%
potassium citrate & citric acid

powder pack 3300-1002 mg
potassium citrate & citric acid
soln 1100-334 mg/5ml
potassium citrate tab cr 5 meq
(540 mg) (Urocit-k 5)
(1080 mg) (Urocit-k 10)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
1
1
alfuzosin hcl tab sr 24hr 10 mg

(Uroxatral)

(1620 mg) (Urocit-k 15)
AVODART - dutasteride cap 0.5 mg
CARDURA XL - doxazosin mesylate

tab sr 24 hr 4 mg (base equiv)
PROCYSBI - cysteamine bitartrate

cap delayed release 25 mg (base
equiv)
CARDURA XL - doxazosin mesylate

tab sr 24 hr 8 mg (base equiv)
CYSTAGON - cysteamine bitartrate

cap 50 mg
PROCYSBI - cysteamine bitartrate

cap delayed release 75 mg (base
equiv)
PROSCAR - finasteride tab 5 mg
CYSTAGON - cysteamine bitartrate

cap 150 mg
CYTRA-3 - pot & sod citrates w/ cit

ac syrup 550-500-334 mg/5ml
ELMIRON - pentosan polysulfate

sodium caps 100 mg
finasteride tab 5 mg (Proscar)
FLOMAX - tamsulosin hcl cap 0.4

mg
JALYN - dutasteride-tamsulosin hcl

cap 0.5-0.4 mg
K-PHOS NO 2 - potassium & sodium 2

acid phosphates tab 305-700 mg
LITHOSTAT - acetohydroxamic acid 3
tab 250 mg
ORACIT - sodium citrate & citric acid 3
soln 490-640 mg/5ml
PYRIDIUM - phenazopyridine hcl tab 3

100 mg
PYRIDIUM - phenazopyridine hcl tab 3
200 mg
3
RAPAFLO - silodosin cap 4 mg
RAPAFLO - silodosin cap 8 mg
SHOHLS SOLUTION MODIFIED sodium citrate & citric acid soln

500-334 mg/5ml
sodium chloride irrigation soln

0.9%
sodium citrate & citric acid soln

500-334 mg/5ml (Shohls solution
modi)
tamsulosin hcl cap 0.4 mg

(Flomax)
THIOLA - tiopronin tab 100 mg
71
UROCIT-K 10 - potassium citrate tab 3

cr 10 meq (1080 mg)
cr 15 meq (1620 mg)
cr 5 meq (540 mg)
3
UROXATRAL - alfuzosin hcl tab sr
24hr 10 mg
chlordiazepoxide hcl cap 25 mg
DIAZEPAM - diazepam soln 1 mg/ml
CENTRAL NERVOUS SYSTEM DRUGS
diazepam conc 5 mg/ml
ANTIANXIETY AGENTS
clorazepate dipotassium tab

3.75 mg (Tranxene t)
7.5 mg (Tranxene t)
15 mg (Tranxene t)
diazepam tab 2 mg (Valium)
ALPRAZOLAM INTENSOL alprazolam conc 1 mg/ml
alprazolam orally disintegrating

tab 0.25 mg (Niravam)
hydroxyzine hcl tab 10 mg

tab 0.5 mg
tab 1 mg

hydroxyzine hcl syrup 10 mg/5ml
1
1
1
1
1
1
1
alprazolam tab sr 24hr 0.5 mg

(Xanax xr)
hydroxyzine pamoate cap 25 mg

(Vistaril)
hydroxyzine pamoate cap 50 mg
(Vistaril)
alprazolam tab sr 24hr 1 mg

(Xanax xr)
1
1
lorazepam conc 2 mg/ml

(Lorazepam intensol)

(Xanax xr)
lorazepam tab 0.5 mg (Ativan)

(Xanax xr)
alprazolam tab 0.25 mg (Xanax)
alprazolam tab 1 mg (Xanax)

alprazolam tab 2 mg (Xanax)
buspirone hcl tab 5 mg
buspirone hcl tab 7.5 mg
72
1
1
1
1
1
1
1
1
1
1
meprobamate tab 200 mg

meprobamate tab 400 mg
oxazepam cap 10 mg
oxazepam cap 15 mg
oxazepam cap 30 mg
1
1
1
1
1
1
1
VISTARIL - hydroxyzine pamoate

cap 25 mg
VISTARIL - hydroxyzine pamoate

cap 50 mg
ANTIDEPRESSANTS
amitriptyline hcl tab 10 mg
alprazolam tab 0.5 mg (Xanax)
Responsible Steps
lorazepam tab 2 mg (Ativan)
Quantity Limits
HYDROXYZINE PAMOATE hydroxyzine pamoate cap 100 mg
lorazepam tab 1 mg (Ativan)
Prior Authorization

tab 2 mg
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016

1
1
1
1
1
AMOXAPINE - amoxapine tab 25 mg 2

AMOXAPINE - amoxapine tab 50 mg 2
bupropion hcl tab 75 mg

(Wellbutrin)
bupropion hcl tab 100 mg

(Wellbutrin)
CELEXA - citalopram hydrobromide


AMOXAPINE - amoxapine tab 100

mg

AMOXAPINE - amoxapine tab 150

mg
citalopram hydrobromide oral

soln 10 mg/5ml
ANAFRANIL - clomipramine hcl cap

25 mg
citalopram hydrobromide tab

10 mg (base equiv) (Celexa)

50 mg


75 mg
APLENZIN - bupropion hbr tab sr

24hr 174 mg


24hr 348 mg

24hr 522 mg
BRINTELLIX - vortioxetine hbr tab 5

mg (base equiv)
BRINTELLIX - vortioxetine hbr tab 10 3

mg (base equiv)
BRINTELLIX - vortioxetine hbr tab 20 3
mg (base equiv)
bupropion hcl tab sr 12hr 100 mg 1
(Wellbutrin sr)
(Wellbutrin sr)
(Wellbutrin sr)
(Wellbutrin xl)
(Wellbutrin xl)
clomipramine hcl cap 25 mg

(Anafranil)

(Anafranil)

(Anafranil)
CYMBALTA - duloxetine hcl enteric

coated pellets cap 20 mg


desipramine hcl tab 10 mg

(Norpramin)

(Norpramin)

(Norpramin)

(Norpramin)

(Norpramin)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
73

(Norpramin)
DESVENLAFAXINE ER desvenlafaxine fumarate tab sr

24hr 50 mg (base equiv)
DESVENLAFAXINE ER desvenlafaxine fumarate tab sr

24hr 100 mg (base equiv)
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 50 mg
DESVENLAFAXINE ER desvenlafaxine tab sr 24hr 100 mg
DOXEPIN HCL - doxepin hcl cap 75

mg
doxepin hcl cap 10 mg

doxepin hcl conc 10 mg/ml
duloxetine hcl enteric coated
pellets cap 20 mg (Cymbalta)
1
1
1
1
1
FETZIMA - levomilnacipran hcl cap

sr 24hr 20 mg (base equivalent)



FETZIMA TITRATION PACK levomilnacipran hcl cap sr 24hr 20

& 40 mg therapy pack
FLUOXETINE HCL - fluoxetine hcl

tab 60 mg
fluoxetine hcl cap delayed release

90 mg (Prozac weekly)
escitalopram oxalate tab 10 mg

(base equiv) (Lexapro)
fluoxetine hcl cap 20 mg (Prozac)
fluoxetine hcl solution 20 mg/5ml

fluoxetine hcl tab 20 mg

fluoxetine hcl tab 10 mg
EFFEXOR XR - venlafaxine hcl cap

fluvoxamine maleate cap sr 24hr

100 mg

fluvoxamine maleate cap sr 24hr

150 mg
EMSAM - selegiline td patch 24hr 6

mg/24hr

mg/24hr

mg/24hr
escitalopram oxalate soln

5 mg/5ml (base equiv) (Lexapro)
fluvoxamine maleate tab 25 mg

FORFIVO XL - bupropion hcl tab sr
24hr 450 mg
1
1
1
1
1
1
1
3
Responsible Steps
Quantity Limits

sr 24hr 37.5 mg (base equivalent)
74
Prior Authorization

Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
imipramine hcl tab 10 mg (Tofranil) 1

imipramine pamoate cap 75 mg

(Tofranil-pm)
NEFAZODONE HCL - nefazodone

hcl tab 100 mg

(Tofranil-pm)

hcl tab 150 mg

(Tofranil-pm)

hcl tab 200 mg

(Tofranil-pm)
nefazodone hcl tab 50 mg
KHEDEZLA - desvenlafaxine tab sr

24hr 50 mg
KHEDEZLA - desvenlafaxine tab sr

24hr 100 mg
LEXAPRO - escitalopram oxalate

LEXAPRO - escitalopram oxalate tab 3

5 mg (base equiv)
10 mg (base equiv)
20 mg (base equiv)
MAPROTILINE HCL - maprotiline hcl 3
tab 25 mg
tab 50 mg
tab 75 mg
3
MARPLAN - isocarboxazid tab 10
mg
1
mirtazapine orally disintegrating
tab 15 mg (Remeron soltab)
1
1
1
mirtazapine tab 7.5 mg
mirtazapine tab 15 mg (Remeron)

NARDIL - phenelzine sulfate tab 15
mg
1
1
1
3
nefazodone hcl tab 250 mg
Responsible Steps
Quantity Limits
Prior Authorization
NORPRAMIN - desipramine hcl tab

10 mg

25 mg

50 mg

75 mg

100 mg

150 mg
NORTRIPTYLINE HCL - nortriptyline 3

hcl soln 10 mg/5ml
1
nortriptyline hcl cap 10 mg
(Pamelor)
1
(Pamelor)
1
(Pamelor)
1
(Pamelor)
3
OLEPTRO - trazodone hcl tab sr
24hr 150 mg
3
OLEPTRO - trazodone hcl tab sr
24hr 300 mg
3
PAMELOR - nortriptyline hcl cap 10
mg
3
mg
3
mg
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
75
Responsible Steps
REMERON SOLTAB - mirtazapine

orally disintegrating tab 30 mg

sertraline hcl oral conc 20 mg/ml

(Zoloft)
sertraline hcl tab 25 mg (Zoloft)
PRISTIQ - desvenlafaxine succinate

tab sr 24hr 100 mg (base equiv)
PARNATE - tranylcypromine sulfate

tab 10 mg
protriptyline hcl tab 5 mg
paroxetine hcl tab sr 24hr 12.5 mg

(Paxil cr)
paroxetine hcl tab sr 24hr 25 mg

(Paxil cr)
paroxetine hcl tab sr 24hr 37.5 mg

(Paxil cr)
paroxetine hcl tab 10 mg (Paxil)
protriptyline hcl tab 10 mg
PROZAC - fluoxetine hcl cap 10 mg
PROZAC WEEKLY - fluoxetine hcl

cap delayed release 90 mg
REMERON - mirtazapine tab 15 mg

1
1
1
PAXIL - paroxetine hcl oral susp 10

mg/5ml (base equiv)
PAXIL - paroxetine hcl tab 10 mg
PAXIL CR - paroxetine hcl tab sr

24hr 12.5 mg

24hr 25 mg

24hr 37.5 mg
SURMONTIL - trimipramine maleate

cap 25 mg
PEXEVA - paroxetine mesylate tab

10 mg (base equiv)

cap 50 mg

20 mg (base equiv)

cap 100 mg

30 mg (base equiv)
TOFRANIL - imipramine hcl tab 10

mg

40 mg (base equiv)

mg
phenelzine sulfate tab 15 mg

(Nardil)

mg

TOFRANIL-PM - imipramine
pamoate cap 75 mg

pamoate cap 100 mg
76

1
1
Quantity Limits
Prior Authorization

mg
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
pamoate cap 150 mg
tranylcypromine sulfate tab 10 mg

(Parnate)
trazodone hcl tab 50 mg

trimipramine maleate cap 25 mg
venlafaxine hcl tab 50 mg

1
1
1
1
venlafaxine hcl cap sr 24hr

(Effexor xr)
venlafaxine hcl cap sr 24hr 75 mg

(base equivalent) (Effexor xr)
venlafaxine hcl cap sr 24hr

(Effexor xr)
VENLAFAXINE HCL ER venlafaxine hcl tab sr 24hr 37.5

VENLAFAXINE HCL ER venlafaxine hcl tab sr 24hr 75 mg

(base equivalent)

(base equivalent)

(base equivalent)
venlafaxine hcl tab sr 24hr

(Venlafaxine hcl er)
venlafaxine hcl tab sr 24hr 75 mg

(base equivalent) (Venlafaxine
hcl er)
1
1
VIIBRYD - vilazodone hcl tab 10 mg
VIIBRYD STARTER PACK vilazodone hcl tab starter kit 10 (7)

& 20 (23) mg
WELLBUTRIN - bupropion hcl tab 75 3

mg
3
WELLBUTRIN - bupropion hcl tab
100 mg
3
WELLBUTRIN SR - bupropion hcl
tab sr 12hr 100 mg
3
tab sr 12hr 150 mg
3
tab sr 12hr 200 mg
3
WELLBUTRIN XL - bupropion hcl
tab sr 24hr 150 mg
3
WELLBUTRIN XL - bupropion hcl
tab sr 24hr 300 mg
ZOLOFT - sertraline hcl oral conc 20 3
mg/ml
3
ZOLOFT - sertraline hcl tab 25 mg
ANTIPSYCHOTICS
ABILIFY - aripiprazole tab 2 mg
Prior Authorization
Specialty
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
venlafaxine hcl tab 37.5 mg
venlafaxine hcl tab sr 24hr

(Venlafaxine hcl er)
Responsible Steps
Quantity Limits
pamoate cap 125 mg
Specialty
Drug Name
Drug Tier
2016
77
ABILIFY DISCMELT - aripiprazole

ABILIFY DISCMELT - aripiprazole

ARIPIPRAZOLE ODT - aripiprazole

ARIPIPRAZOLE ODT - aripiprazole

aripiprazole oral solution 1 mg/ml
aripiprazole tab 2 mg (Abilify)
chlorpromazine hcl tab 10 mg
EQUETRO - carbamazepine
(antipsychotic) cap sr 12hr 100 mg
3
3
FANAPT - iloperidone tab 1 mg

FANAPT TITRATION PACK iloperidone tab 1 mg & 2 mg & 4

mg & 6 mg titration pak
FAZACLO - clozapine orally

disintegrating tab 12.5 mg


1
1
1
1
1
1
1
1
1
1
1
CLOZAPINE ODT - clozapine orally







FLUPHENAZINE HCL - fluphenazine 2

hcl elixir 2.5 mg/5ml
FLUPHENAZINE HCL - fluphenazine 2
hcl oral conc 5 mg/ml
1
fluphenazine hcl tab 1 mg
clozapine tab 25 mg (Clozaril)
clozapine tab 50 mg
clozapine tab 100 mg (Clozaril)
clozapine tab 200 mg
1
1
1
CLOZARIL - clozapine tab 25 mg
CLOZARIL - clozapine tab 100 mg
78
fluphenazine hcl tab 2.5 mg

Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
GEODON - ziprasidone hcl cap 20

mg

mg

mg

mg
haloperidol lactate oral conc

2 mg/ml
haloperidol tab 0.5 mg

haloperidol tab 1 mg
LITHOBID - lithium carbonate tab cr

300 mg
loxapine succinate cap 5 mg
olanzapine orally disintegrating

tab 5 mg (Zyprexa zydis)
1
1

INVEGA - paliperidone tab sr 24hr

1.5 mg

INVEGA - paliperidone tab sr 24hr 3

mg


mg
olanzapine tab 2.5 mg (Zyprexa)

mg
olanzapine tab 7.5 mg (Zyprexa)
LATUDA - lurasidone hcl tab 20 mg
LITHIUM - lithium oral solution 8

meq/5ml
1
1
1
paliperidone tab sr 24hr 1.5 mg

(Invega)
1
1
paliperidone tab sr 24hr 3 mg

(Invega)
LITHIUM CARBONATE - lithium

carbonate cap 150 mg

(Invega)
LITHIUM CARBONATE - lithium

carbonate cap 600 mg

(Invega)
lithium carbonate cap 150 mg

(Lithium carbonate)
perphenazine tab 2 mg

(Lithium carbonate)
lithium carbonate tab cr 300 mg

(Lithobid)
lithium carbonate tab cr 450 mg
lithium carbonate tab 300 mg
olanzapine tab 10 mg (Zyprexa)

1
1
1
1
1
1
1
1
prochlorperazine maleate
(Compazine)
prochlorperazine maleate tab

(Compazine)
prochlorperazine suppos 25 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Tier
Drug Name
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
79
quetiapine fumarate tab 200 mg

(Seroquel)

(Seroquel)

(Seroquel)
REXULTI - brexpiprazole tab 0.25

mg
REXULTI - brexpiprazole tab 0.5 mg
REXULTI - brexpiprazole tab 1 mg
RISPERDAL - risperidone soln 1 mg/ 3

ml
3
RISPERDAL - risperidone tab 0.25
mg
3
RISPERDAL - risperidone tab 0.5
mg
3
RISPERDAL - risperidone tab 1 mg
RISPERDAL M-TAB - risperidone

orally disintegrating tab 0.5 mg




80
risperidone soln 1 mg/ml

(Risperdal)
risperidone tab 0.25 mg

(Risperdal)
risperidone tab 0.5 mg (Risperdal)
risperidone orally disintegrating

tab 0.5 mg (Risperdal m-tab)
tab 1 mg (Risperdal m-tab)
risperidone tab 1 mg (Risperdal)

1
1
1
1
SAPHRIS - asenapine maleate sl tab 3

2.5 mg (base equiv)
5 mg (base equiv)
10 mg (base equiv)
3
SEROQUEL - quetiapine fumarate
tab 25 mg
3
tab 50 mg
3
tab 100 mg
3
tab 200 mg
3
tab 300 mg
3
tab 400 mg

(Seroquel)

tab 0.25 mg
Responsible Steps
Quantity Limits
Prior Authorization

(Seroquel)
Specialty
Drug Name
Drug Tier

(Seroquel)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
SEROQUEL XR - quetiapine
fumarate tab sr 24hr 300 mg
thioridazine hcl tab 10 mg

thiothixene cap 1 mg
trifluoperazine hcl tab 1 mg
HYPNOTICS
BUTISOL SODIUM - butabarbital
sodium tab 30 mg
3
3
BUTISOL SODIUM - butabarbital

sodium tab 50 mg
estazolam tab 1 mg
estazolam tab 2 mg
eszopiclone tab 1 mg (Lunesta)
HETLIOZ - tasimelteon capsule 20

mg
LUNESTA - eszopiclone tab 1 mg
1
1
1
1
1
1
1
FLURAZEPAM HCL - flurazepam hcl 3

cap 15 mg
FLURAZEPAM HCL - flurazepam hcl 3
cap 30 mg
3
HALCION - triazolam tab 0.25 mg
VERSACLOZ - clozapine susp 50

mg/ml
ziprasidone hcl cap 20 mg

(Geodon)

(Geodon)

(Geodon)
PHENOBARBITAL - phenobarbital
tab 15 mg

(Geodon)
tab 30 mg
ZYPREXA - olanzapine tab 2.5 mg
3
3
tab 60 mg
ZYPREXA - olanzapine tab 5 mg

ZYPREXA - olanzapine tab 7.5 mg
3
3
tab 100 mg
phenobarbital elixir 20 mg/5ml
phenobarbital tab 16.2 mg

Responsible Steps
Quantity Limits
Prior Authorization
ZYPREXA ZYDIS - olanzapine orally 3

Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
81

ROZEREM - ramelteon tab 8 mg
1
3
SONATA - zaleplon cap 10 mg
temazepam cap 7.5 mg (Restoril)
temazepam cap 22.5 mg (Restoril)

temazepam cap 30 mg (Restoril)
triazolam tab 0.125 mg
triazolam tab 0.25 mg (Halcion)
1
1
1
1
1
zolpidem tartrate tab cr 6.25 mg

(Ambien cr)
zolpidem tartrate tab cr 12.5 mg

(Ambien cr)
zolpidem tartrate tab 5 mg

(Ambien)
zolpidem tartrate tab 10 mg

(Ambien)
zaleplon cap 5 mg (Sonata)

zaleplon cap 10 mg (Sonata)
1
1
ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/
ANOREXIANTS
3
ADDERALL - amphetaminedextroamphetamine tab 5 mg
3
ADDERALL - amphetaminedextroamphetamine tab 7.5 mg
3
3
ADDERALL - amphetaminedextroamphetamine tab 12.5 mg
3
82
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr 5

mg
ADDERALL XR - amphetaminedextroamphetamine cap sr 24hr

10 mg

15 mg

20 mg

25 mg

30 mg
amphetaminedextroamphetamine cap sr 24hr

5 mg (Adderall xr)

10 mg (Adderall xr)
15 mg (Adderall xr)
20 mg (Adderall xr)
25 mg (Adderall xr)
30 mg (Adderall xr)
amphetaminedextroamphetamine tab 5 mg
(Adderall)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
SECONAL - secobarbital sodium cap 3

100 mg
SILENOR - doxepin hcl (sleep) tab 3 3
mg (base equiv)
SILENOR - doxepin hcl (sleep) tab 6 3
mg (base equiv)
3
SONATA - zaleplon cap 5 mg
temazepam cap 15 mg (Restoril)
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
(Adderall)
amphetaminedextroamphetamine tab 12.5 mg

(Adderall)
(Adderall)
(Adderall)
(Adderall)
APTENSIO XR - methylphenidate hcl 3

cap er 24hr 10 mg (xr)
1
caffeine citrate oral soln
60 mg/3ml (10 mg/ml base
equiv)
1
clonidine hcl tab sr 12hr 0.1 mg
(Kapvay)
3
CONCERTA - methylphenidate hcl
tab sa osm 18 mg
3
tab sa osm 27 mg

tab sa osm 54 mg
DAYTRANA - methylphenidate td
patch 10 mg/9hr
patch 15 mg/9hr
patch 20 mg/9hr
patch 30 mg/9hr
DESOXYN - methamphetamine hcl

tab 5 mg
DEXEDRINE - dextroamphetamine
sulfate cap sr 24hr 5 mg
dexmethylphenidate hcl cap sr 24

hr 5 mg (Focalin xr)
dexmethylphenidate hcl tab 5 mg

(Focalin)
dexmethylphenidate hcl tab

10 mg (Focalin)

dexmethylphenidate hcl tab
2.5 mg (Focalin)
dextroamphetamine sulfate cap sr

24hr 5 mg (Dexedrine)

tab sa osm 36 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
amphetaminedextroamphetamine tab 7.5 mg

(Adderall)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
83
EVEKEO - amphetamine sulfate tab

5 mg
EVEKEO - amphetamine sulfate tab

10 mg
FOCALIN - dexmethylphenidate hcl

tab 2.5 mg

tab 5 mg

tab 10 mg
FOCALIN XR - dexmethylphenidate
hcl cap sr 24 hr 5 mg
guanfacine hcl tab sr 24hr 1 mg

(base equiv) (Intuniv)
dextroamphetamine sulfate tab

10 mg

84
INTUNIV - guanfacine hcl tab sr 24hr 3

1 mg (base equiv)
2 mg (base equiv)
3 mg (base equiv)
4 mg (base equiv)
3
KAPVAY - clonidine hcl tab sr 12hr
0.1 mg
3
METADATE CD - methylphenidate
hcl cap cr 10 mg
3
hcl cap cr 20 mg
3
hcl cap cr 30 mg
3
hcl cap cr 40 mg
3
hcl cap cr 50 mg
3
hcl cap cr 60 mg
1
methamphetamine hcl tab 5 mg
(Desoxyn)
3
METHYLIN - methylphenidate hcl
chew tab 2.5 mg
3
chew tab 5 mg
3
chew tab 10 mg
3
soln 5 mg/5ml
3
soln 10 mg/5ml
methylphenidate hcl cap cr 10 mg 1
(Metadate cd)

dextroamphetamine sulfate tab

5 mg

Responsible Steps
Quantity Limits
dextroamphetamine sulfate oral

solution 5 mg/5ml (Procentra)
Prior Authorization
Specialty

Drug Name
Drug Tier

Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
METHYLPHENIDATE HCL ER methylphenidate hcl tab sr 24hr 54

mg
methylphenidate hcl cap cr 40 mg

(Metadate cd)

(Metadate cd)
methylphenidate hcl soln

5 mg/5ml (Methylin)

(Metadate cd)
methylphenidate hcl soln

10 mg/5ml (Methylin)
methylphenidate hcl cap sr 24hr

20 mg (la) (Ritalin la)
methylphenidate hcl tab cr 10 mg
METHYLPHENIDATE HCL ER methylphenidate hcl tab sa osm

18 mg

27 mg

36 mg

54 mg

mg

mg

methylphenidate hcl chew tab
2.5 mg (Methylin)
5 mg (Methylin)
10 mg (Methylin)
methylphenidate hcl tab 5 mg

(Ritalin)

(Ritalin)

(Ritalin)
modafinil tab 100 mg (Provigil)
methylphenidate hcl tab cr 20 mg
modafinil tab 200 mg (Provigil)
NUVIGIL - armodafinil tab 50 mg
PROCENTRA - dextroamphetamine
sulfate oral solution 5 mg/5ml
PROVIGIL - modafinil tab 100 mg
PROVIGIL - modafinil tab 200 mg
QUILLIVANT XR - methylphenidate
hcl for er susp 25 mg/5ml (5 mg/
ml)
RITALIN - methylphenidate hcl tab 5

mg
RITALIN - methylphenidate hcl tab

10 mg
RITALIN - methylphenidate hcl tab

20 mg
RITALIN LA - methylphenidate hcl

cap sr 24hr 10 mg (la)

mg
Responsible Steps
Quantity Limits
Prior Authorization

(Metadate cd)
Specialty
Drug Name
Drug Tier

(Metadate cd)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
85

STRATTERA - atomoxetine hcl cap

10 mg (base equiv)

18 mg (base equiv)

25 mg (base equiv)

40 mg (base equiv)

60 mg (base equiv)

80 mg (base equiv)

100 mg (base equiv)
VYVANSE - lisdexamfetamine
dimesylate cap 10 mg
ZENZEDI - dextroamphetamine
sulfate tab 2.5 mg
sulfate tab 7.5 mg
86
sulfate tab 20 mg
sulfate tab 30 mg

sulfate tab 15 mg
Responsible Steps
Quantity Limits
Prior Authorization

Specialty
Drug Name
Drug Tier

Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
PSYCHOTHERAPEUTIC and NEUROLOGICAL AGENTS

- MISC.
acamprosate calcium tab delayed 1
release 333 mg
AMPYRA - dalfampridine tab sr 12hr 4

10 mg
3
ANTABUSE - disulfiram tab 250 mg
ANTABUSE - disulfiram tab 500 mg
ARICEPT - donepezil hydrochloride

tab 5 mg

tab 10 mg

tab 23 mg
AUBAGIO - teriflunomide tab 7 mg
AUBAGIO - teriflunomide tab 14 mg
AVONEX - interferon beta-1a for im

inj kit 30mcg (33mcg(6.6 mu)/vial)
AVONEX - interferon beta-1a im

prefilled syringe kit 30 mcg/0.5ml
AVONEX PEN - interferon beta-1a

im auto-injector kit 30 mcg/0.5ml
BETASERON - interferon beta-1b for 4

inj kit 0.3 mg
3
BRISDELLE - paroxetine mesylate
cap 7.5 mg (base equiv)
P
bupropion hcl (smoking
deterrent) tab sr 12hr 150 mg
(Zyban)
P
CHANTIX - varenicline tartrate tab
0.5 mg (base equiv)
CHANTIX - varenicline tartrate tab 1 P
mg (base equiv)
CHANTIX CONTINUING MONTH varenicline tartrate tab 1 mg (base

equiv)
CHANTIX STARTING MONTH PA varenicline tartrate tab 0.5 mg x 11

& tab 1 mg x 42 pack
CHLORDIAZEPOXIDE/AMITRIPT chlordiazepoxide-amitriptyline tab

5-12.5 mg
CHLORDIAZEPOXIDE/AMITRIPT chlordiazepoxide-amitriptyline tab

10-25 mg
COPAXONE - glatiramer acetate

COPAXONE - glatiramer acetate

disulfiram tab 250 mg (Antabuse)
disulfiram tab 500 mg (Antabuse)
EXELON - rivastigmine td patch 24hr 2

9.5 mg/24hr
13.3 mg/24hr
4
EXTAVIA - interferon beta-1b for inj
kit 0.3 mg
1
fluoxetine hcl (pmdd) cap 10 mg
fluoxetine hcl (pmdd) cap 20 mg
galantamine hydrobromide cap sr

24hr 8 mg (Razadyne er)

galantamine hydrobromide tab

4 mg (Razadyne)

8 mg (Razadyne)
donepezil hydrochloride tab 5 mg

(Aricept)

12 mg (Razadyne)
donepezil hydrochloride tab

10 mg (Aricept)
donepezil hydrochloride orally

donepezil hydrochloride orally
donepezil hydrochloride tab

23 mg (Aricept)
ERGOLOID MESYLATES - ergoloid

mesylates tab 1 mg
EXELON - rivastigmine tartrate cap

1.5 mg
EXELON - rivastigmine tartrate cap 3 3

mg
3
EXELON - rivastigmine tartrate cap
4.5 mg
EXELON - rivastigmine tartrate cap 6 3
mg
4.6 mg/24hr
Responsible Steps
Quantity Limits
Prior Authorization
1
1
1
1
1
GILENYA - fingolimod hcl cap 0.5 mg 4

(base equiv)
4
glatiramer acetate soln prefilled
syringe 20 mg/ml (Copaxone)
3
GRALISE - gabapentin (once-daily)
tab 300 mg
3
GRALISE - gabapentin (once-daily)
tab 600 mg
3
GRALISE STARTER - gabapentin
(once-daily) tab pack 300 mg (9) &
600 mg (69)
3
HORIZANT - gabapentin enacarbil
tab cr 300 mg
3
HORIZANT - gabapentin enacarbil
tab cr 600 mg
1
memantine hcl tab 5 mg
(Namenda)
GALANTAMINE HYDROBROMIDE galantamine hydrobromide oral

soln 4 mg/ml

Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
87
memantine hcl tab 10 mg

(Namenda)
memantine hcl tab 5 mg (28)

& 10 mg (21) titration pak
(Namenda titration pa)
NAMENDA - memantine hcl oral

solution 2 mg/ml
olanzapine-fluoxetine hcl cap

12-25 mg (Symbyax)
NAMENDA - memantine hcl tab 5

mg

12-50 mg (Symbyax)
NAMENDA - memantine hcl tab 10

mg
NAMENDA TITRATION PAK memantine hcl tab 5 mg (28) & 10

mg (21) titration pak
NAMENDA XR - memantine hcl cap

sr 24hr 7 mg

sr 24hr 14 mg

sr 24hr 21 mg

sr 24hr 28 mg
NAMENDA XR TITRATION PACK memantine hcl cap sr 24hr 7 mg &

14 mg & 21 mg & 28 mg pack

6-25 mg (Symbyax)
6-50 mg (Symbyax)
PERPHENAZINE/AMITRIPTYLIN perphenazine-amitriptyline tab

2-10 mg

2-25 mg

4-10 mg

4-25 mg

4-50 mg
NAMZARIC - memantine hcldonepezil hcl cap sr 24hr 14-10

mg
pimozide tab 1 mg (Orap)
NAMZARIC - memantine hcldonepezil hcl cap sr 24hr 28-10

mg
nicotine polacrilex gum 2 mg
nicotine td patch 24hr 7 mg/24hr

P
P
P
NUEDEXTA - dextromethorphan hbr- 3

quinidine sulfate cap 20-10 mg
1
3-25 mg (Symbyax)
88
Responsible Steps
ORAP - pimozide tab 2 mg
Quantity Limits
nicotine polacrilex gum 4 mg
Prior Authorization
ORAP - pimozide tab 1 mg
pimozide tab 2 mg (Orap)
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
PLEGRIDY - peginterferon beta-1a

soln pen-injector 125 mcg/0.5ml
PLEGRIDY - peginterferon beta-1a

soln prefilled syringe 125
mcg/0.5ml
PLEGRIDY STARTER PACK peginterferon beta-1a soln pen-inj

63 & 94 mcg/0.5ml pack
PLEGRIDY STARTER PACK peginterferon beta-1a soln pref syr

63 & 94 mcg/0.5ml pack
RAZADYNE - galantamine
hydrobromide oral soln 4 mg/ml
hydrobromide tab 4 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
SARAFEM - fluoxetine hcl (pmdd)

tab 20 mg
SAVELLA - milnacipran hcl tab 12.5

mg
RAZADYNE ER - galantamine
hydrobromide cap sr 24hr 8 mg
SAVELLA - milnacipran hcl tab 25

mg

mg
REBIF - interferon beta-1a soln pref

syr 22 mcg/0.5ml (12mu/ml)

mg
REBIF - interferon beta-1a soln pref

syr 44 mcg/0.5ml (24mu/ml)
SAVELLA TITRATION PACK milnacipran hcl tab 12.5 mg (5) &

25 mg (8) & 50 mg (42) pak
REBIF REBIDOSE - interferon

beta-1a soln auto-inj 22 mcg/0.5ml
(12mu/ml)
SYMBYAX - olanzapine-fluoxetine
hcl cap 3-25 mg
REBIF REBIDOSE - interferon

beta-1a soln auto-inj 44 mcg/0.5ml
(24mu/ml)
hcl cap 6-25 mg
hcl cap 6-50 mg
hcl cap 12-25 mg
REBIF REBIDOSE TITRATION interferon beta-1a auto-inj 6x8.8

mcg/0.2ml & 6x22 mcg/0.5ml
hcl cap 12-50 mg
TECFIDERA - dimethyl fumarate

capsule delayed release 120 mg
TECFIDERA - dimethyl fumarate

capsule delayed release 240 mg
TECFIDERA STARTER PACK dimethyl fumarate capsule dr

starter pack 120 mg & 240 mg
tetrabenazine tab 12.5 mg

(Xenazine)
tetrabenazine tab 25 mg
(Xenazine)
XENAZINE - tetrabenazine tab 12.5

mg
XENAZINE - tetrabenazine tab 25

mg
XYREM - sodium oxybate oral

solution 500 mg/ml
REBIF TITRATION PACK - interferon 4

beta-1a pref syr 6x8.8 mcg/0.2ml
& 6x22 mcg/0.5ml
1
rivastigmine tartrate cap 1.5 mg
(Exelon)
1
rivastigmine tartrate cap 3 mg
(Exelon)
1
rivastigmine tartrate cap 4.5 mg
(Exelon)
1
rivastigmine tartrate cap 6 mg
(Exelon)
1
rivastigmine td patch 24hr
4.6 mg/24hr (Exelon)
1
1
3
SARAFEM - fluoxetine hcl (pmdd)
tab 10 mg
ANALGESICS AND ANESTHETICS
89
ANALGESICS - NON-NARCOTIC
aspirin chew tab 81 mg
aspirin tab delayed release 81 mg
butalbital-acetaminophen tab
50-325 mg
butalbital-acetaminophen-caffeine
cap 50-300-40 mg (Fioricet)
cap 50-325-40 mg
tab 50-325-40 mg (Esgic)
butalbital-aspirin-caffeine cap
50-325-40 mg (Fiorinal)
diflunisal tab 500 mg
DISALCID - salsalate tab 500 mg
DISALCID - salsalate tab 750 mg
EQUAGESIC - meprobamate-aspirin 3
tab 200-325 mg
1
salsalate tab 500 mg (Disalcid)
salsalate tab 750 mg (Disalcid)
ANALGESICS - NARCOTIC
ABSTRAL - fentanyl citrate sl tab

100 mcg (base equiv)





acetaminophen w/ codeine soln

120-12 mg/5ml
acetaminophen w/ codeine tab

300-15 mg (Tylenol/codeine)
300-30 mg (Tylenol/codeine #3)
90
ACTIQ - fentanyl citrate lozenge on a 3

handle 200 mcg
handle 400 mcg
handle 600 mcg
handle 800 mcg
handle 1200 mcg
handle 1600 mcg
3
ASPIRIN-CAFFEINE-DIHYDROC aspirin-caffeine-dihydrocodeine
cap 356.4-30-16 mg
3
AVINZA - morphine sulfate beads
cap sr 24hr 30 mg
3
cap sr 24hr 45 mg
3
cap sr 24hr 60 mg
3
cap sr 24hr 75 mg
3
cap sr 24hr 90 mg
3
cap sr 24hr 120 mg
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)
acetaminophen-caffeinedihydrocodeine cap
320.5-30-16 mg (Trezix)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Tier
Drug Name
300-60 mg (Tylenol/codeine #4)
P
P
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
butalbital-aspirin-caff w/ codeine
cap 50-325-40-30 mg (Fiorinal/
codeine #3)
butorphanol tartrate nasal soln

10 mg/ml
butalbital-acetaminophen-caff w/
cod cap 50-325-40-30 mg
BUTRANS - buprenorphine td patch

weekly 5 mcg/hr

weekly 7.5 mcg/hr

weekly 10 mcg/hr

weekly 15 mcg/hr

weekly 20 mcg/hr
CAPITAL/CODEINE acetaminophen w/ codeine susp

120-12 mg/5ml
CODEINE SULFATE - codeine

sulfate tab 15 mg

sulfate tab 30 mg

sulfate tab 60 mg
codeine sulfate tab 15 mg

(Codeine sulfate)

(Codeine sulfate)

(Codeine sulfate)
DEMEROL - meperidine hcl tab 100

mg
DILAUDID - hydromorphone hcl liqd

1 mg/ml
DILAUDID - hydromorphone hcl tab

2 mg

4 mg

8 mg
DOLOPHINE - methadone hcl tab 5

mg
DOLOPHINE - methadone hcl tab 10 3

mg
DURAGESIC - fentanyl td patch 72hr 3
12 mcg/hr
25 mcg/hr
50 mcg/hr
75 mcg/hr
100 mcg/hr
EMBEDA - morphine-naltrexone cap 3
cr 20-0.8 mg
cr 30-1.2 mg
cr 50-2 mg
cr 60-2.4 mg
cr 80-3.2 mg
cr 100-4 mg
EXALGO - hydromorphone hcl tab er 3
24hr deter 8 mg
buprenorphine hcl-naloxone hcl

sl tab 8-2 mg (base equiv)
DEMEROL - meperidine hcl tab 50

mg
Responsible Steps
Quantity Limits
buprenorphine hcl-naloxone hcl

sl tab 2-0.5 mg (base equiv)
Prior Authorization
Specialty
buprenorphine hcl sl tab 8 mg

(base equiv)
Drug Name
Drug Tier
buprenorphine hcl sl tab 2 mg

(base equiv)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
91

24hr deter 12 mg
24hr deter 16 mg
24hr deter 32 mg
3
FENTANYL - fentanyl td patch 72hr
37.5 mcg/hr
3
62.5 mcg/hr
3
87.5 mcg/hr
1
fentanyl citrate lozenge on a
handle 200 mcg (Actiq)
1
1
1
1
1
1
fentanyl td patch 72hr 12 mcg/hr
(Duragesic)
1
(Duragesic)
1
(Duragesic)
1
(Duragesic)
fentanyl td patch 72hr 100 mcg/hr 1
(Duragesic)
3
FENTORA - fentanyl citrate buccal
tab 100 mcg (base equiv)
3
3
92

FIORINAL/CODEINE #3 - butalbitalaspirin-caff w/ codeine cap

50-325-40-30 mg
hydrocodone-acetaminophen
soln 7.5-325 mg/15ml (Hycet)
HYDROCODONE/
ACETAMINOPHEN hydrocodone-acetaminophen soln
10-325 mg/15ml
HYDROMORPHONE HCL hydromorphone hcl suppos 3 mg
HYDROMORPHONE HCL ER hydromorphone hcl tab er 24hr

deter 32 mg
hydromorphone hcl liqd 1 mg/ml

(Dilaudid)
hydrocodone-acetaminophen tab
2.5-325 mg
10-325 mg (Norco)
5-300 mg (Xodol)
7.5-300 mg (Xodol)
5-325 mg (Norco)
7.5-325 mg (Norco)
10-300 mg (Xodol)
hydrocodone-ibuprofen tab
2.5-200 mg (Reprexain)
5-200 mg (Reprexain)
7.5-200 mg (Vicoprofen)
10-200 mg (Ibudone)

Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
hydromorphone hcl tab er 24hr

deter 8 mg (Exalgo)
deter 12 mg (Exalgo)
deter 16 mg (Exalgo)
hydromorphone hcl tab 2 mg
(Dilaudid)

(Dilaudid)

(Dilaudid)
KADIAN - morphine sulfate cap sr

24hr 10 mg

24hr 20 mg

24hr 30 mg

24hr 40 mg

24hr 50 mg

24hr 60 mg

24hr 80 mg

24hr 100 mg

24hr 200 mg
LAZANDA - fentanyl citrate nasal

spray 100 mcg/act (base equiv)
LAZANDA - fentanyl citrate nasal

spray 400 mcg/act (base equiv)
LEVORPHANOL TARTRATE levorphanol tartrate tab 2 mg
MEPERIDINE HCL - meperidine hcl

oral soln 50 mg/5ml
meperidine hcl tab 50 mg

(Demerol)
MEPERIDINE HCL/PROMETHAZI meperidine w/ promethazine cap

50-25 mg
METHADONE HCL - methadone hcl

soln 5 mg/5ml
METHADONE HCL - methadone hcl

soln 10 mg/5ml
methadone hcl conc 10 mg/ml

(Methadose)
methadone hcl soln 5 mg/5ml

(Methadone hcl)
methadone hcl soln 10 mg/5ml

(Methadone hcl)
methadone hcl tab for oral susp

40 mg
methadone hcl tab 5 mg

(Dolophine hcl)
methadone hcl tab 10 mg

(Dolophine)
METHADOSE - methadone hcl conc

10 mg/ml
METHADOSE SUGAR-FREE methadone hcl conc 10 mg/ml
MORPHINE SULFATE - morphine

sulfate suppos 5 mg

sulfate suppos 10 mg



sulfate tab 15 mg

sulfate tab 30 mg
morphine sulfate cap sr 24hr

10 mg (Kadian)

20 mg (Kadian)
meperidine hcl tab 100 mg

(Demerol)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
93
MORPHINE SULFATE ER morphine sulfate beads cap sr

24hr 30 mg

24hr 45 mg

24hr 60 mg

24hr 75 mg

24hr 90 mg

24hr 120 mg
morphine sulfate oral soln

10 mg/5ml
morphine sulfate tab cr 15 mg (Ms 1

contin)
contin)
contin)
1
morphine sulfate tab cr 100 mg
(Ms contin)

100 mg (Kadian)

20 mg/5ml
100 mg/5ml (20 mg/ml)
94
MS CONTIN - morphine sulfate tab

cr 15 mg

cr 30 mg

cr 60 mg

cr 100 mg

cr 200 mg
NUCYNTA - tapentadol hcl tab 50

mg

mg

mg
NUCYNTA ER - tapentadol hcl tab sr 2

12hr 50 mg
12hr 100 mg
12hr 150 mg
12hr 200 mg
12hr 250 mg
OPANA - oxymorphone hcl tab 5 mg 3

80 mg (Kadian)
morphine sulfate tab cr 200 mg

(Ms contin)
Responsible Steps
Quantity Limits

60 mg (Kadian)
Prior Authorization
Specialty

50 mg (Kadian)
Drug Name
Drug Tier

30 mg (Kadian)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
OPANA - oxymorphone hcl tab 10

mg
OPANA ER (CRUSH RESISTANT oxymorphone hcl tab er 12hr deter

5 mg

7.5 mg

10 mg
oxycodone hcl tab 20 mg

20 mg

30 mg

40 mg
OXAYDO - oxycodone hcl tab abuse

deter 5 mg
oxycodone w/ acetaminophen tab

10-325 mg (Percocet)
OXAYDO - oxycodone hcl tab abuse

deter 7.5 mg
oxycodone-aspirin tab
4.8355-325 mg (Percodan)
OXECTA - oxycodone hcl tab abuse

deter 5 mg
oxycodone-ibuprofen tab
5-400 mg
OXECTA - oxycodone hcl tab abuse

deter 7.5 mg
OXYCODONE HCL - oxycodone hcl

conc 100 mg/5ml (20 mg/ml)
OXYCODONE HCL - oxycodone hcl

soln 5 mg/5ml
oxycodone hcl cap 5 mg

(Roxicodone)

2.5-325 mg (Percocet)
OXYCONTIN - oxycodone hcl tab er

12hr deter 10 mg

12hr deter 15 mg

12hr deter 20 mg

12hr deter 30 mg
OXYCODONE HCL ER - oxycodone

hcl tab er 12hr deter 10 mg

12hr deter 40 mg


12hr deter 60 mg


12hr deter 80 mg

oxymorphone hcl tab sr 12hr

5 mg
oxycodone hcl soln 5 mg/5ml

(Oxycodone hcl)

(Roxicodone)
oxycodone hcl conc 100 mg/5ml

(20 mg/ml) (Oxycodone hcl)

5-325 mg (Percocet)
7.5-325 mg (Percocet)

7.5 mg
10 mg
15 mg
20 mg

(Roxicodone)

15 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
95
SUBSYS - fentanyl sublingual spray

400 mcg

600 mcg
oxymorphone hcl tab 10 mg

(Opana)

800 mcg
pentazocine w/ naloxone tab

50-0.5 mg

1200 mcg (600 mcg x 2)

1600 mcg (800 mcg x 2)
SYNALGOS-DC - aspirin-caffeinedihydrocodeine cap 356.4-30-16

mg
tramadol hcl tab sr 24hr 100 mg

(Ultram er)

(Ultram er)

(Ultram er)
tramadol hcl tab sr 24hr biphasic

release 100 mg
1
1
TREZIX - acetaminophen-caffeinedihydrocodeine cap 320.5-30-16

mg
TYLENOL/CODEINE acetaminophen w/ codeine tab

300-15 mg
TYLENOL/CODEINE #3 acetaminophen w/ codeine tab

300-30 mg
TYLENOL/CODEINE #4 acetaminophen w/ codeine tab

300-60 mg
PERCOCET - oxycodone w/
acetaminophen tab 2.5-325 mg
acetaminophen tab 5-325 mg
acetaminophen tab 7.5-325 mg
acetaminophen tab 10-325 mg
PERCODAN - oxycodone-aspirin tab 3

4.8355-325 mg
2
ROXICET - oxycodone w/
acetaminophen soln 5-325 mg/5ml
ROXICODONE - oxycodone hcl tab 3
5 mg
15 mg
30 mg
2
SUBOXONE - buprenorphine hclnaloxone hcl sl film 2-0.5 mg
(base equiv)
2
SUBOXONE - buprenorphine hclnaloxone hcl sl film 4-1 mg (base
equiv)
2
equiv)
2
equiv)
SUBSYS - fentanyl sublingual spray 3
100 mcg
96

release 200 mg
release 300 mg
tramadol hcl tab 50 mg (Ultram)
tramadol-acetaminophen tab
37.5-325 mg (Ultracet)

200 mcg
Responsible Steps
Quantity Limits
oxymorphone hcl tab 5 mg

(Opana)
Prior Authorization
Specialty

40 mg
Drug Name
Drug Tier

30 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
ZUBSOLV - buprenorphine hclnaloxone hcl sl tab 1.4-0.36 mg

(base eq)

(base eq)

(base eq)

(base eq)

(base eq)
celecoxib cap 100 mg (Celebrex)

ANALGESICS - ANTI-INFLAMMATORY
4
ACTEMRA - tocilizumab
syringe 162 mg/0.9ml
3
ANAPROX - naproxen sodium tab
275 mg
3
ANAPROX DS - naproxen sodium
tab 550 mg
3
ARAVA - leflunomide tab 10 mg
ARAVA - leflunomide tab 20 mg
ARCALYST - rilonacept for inj 220

mg
ARTHROTEC 50 - diclofenac w/
misoprostol tab delayed release
50-0.2 mg
ARTHROTEC 75 - diclofenac w/
misoprostol tab delayed release
75-0.2 mg
CELEBREX - celecoxib cap 50 mg
diclofenac sodium tab sr 24hr

100 mg (Voltaren-xr)
1
1
1
1
diclofenac w/ misoprostol tab

delayed release 75-0.2 mg
(Arthrotec 75)
EC-NAPROSYN - naproxen tab ec

375 mg
EC-NAPROSYN - naproxen tab ec

500 mg
ENBREL - etanercept for

subcutaneous inj kit 25 mg
ENBREL - etanercept subcutaneous

soln prefilled syringe 25 mg/0.5ml
ENBREL - etanercept subcutaneous

ENBREL SURECLICK - etanercept

subcutaneous solution autoinjector 50 mg/ml
EQUAPAX/IBUPROFEN/MINREX ibuprofen tab 800 mg & multiple

minerals cap therapy pack
etodolac cap 200 mg
etodolac tab sr 24hr 400 mg

diclofenac w/ misoprostol tab

delayed release 50-0.2 mg
(Arthrotec 50)
etodolac cap 300 mg
Responsible Steps
Quantity Limits
Prior Authorization
diclofenac potassium tab 50 mg
diclofenac sodium tab delayed

release 75 mg
1
3

release 50 mg
DAYPRO - oxaprozin tab 600 mg

release 25 mg
Specialty
Drug Name
Drug Tier
ZAMICET - hydrocodoneacetaminophen soln 10-325

mg/15ml
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
1
97
etodolac tab 400 mg

etodolac tab 500 mg
ketoprofen cap 75 mg
1
3
FELDENE - piroxicam cap 20 mg
FENOPROFEN CALCIUM fenoprofen calcium cap 400 mg
FENOPROFEN CALCIUM fenoprofen calcium tab 600 mg
flurbiprofen tab 50 mg
1
1
ketorolac tromethamine tab

10 mg
KINERET - anakinra subcutaneous

soln prefilled syringe 100
mg/0.67ml
leflunomide tab 10 mg (Arava)
MECLOFENAMATE SODIUM meclofenamate sodium cap 50 mg
HUMIRA - adalimumab prefilled

syringe kit 20 mg/0.4ml

MECLOFENAMATE SODIUM meclofenamate sodium cap 100

mg
HUMIRA PEDIATRIC CROHNS D adalimumab prefilled syringe kit

40 mg/0.8ml
mefenamic acid cap 250 mg

(Ponstel)
meloxicam tab 7.5 mg (Mobic)
HUMIRA PEN - adalimumab peninjector kit 40 mg/0.8ml
HUMIRA PEN-CROHNS DISEASE adalimumab pen-injector kit 40

mg/0.8ml
HUMIRA PEN-PSORIASIS STAR adalimumab pen-injector kit 40

mg/0.8ml
ibuprofen susp 100 mg/5ml
meloxicam tab 15 mg (Mobic)

nabumetone tab 500 mg
nabumetone tab 750 mg
NAPROSYN - naproxen susp 125

mg/5ml
NAPROSYN - naproxen tab 250 mg
NAPROXEN - naproxen susp 125

mg/5ml
naproxen sodium tab 275 mg

(Anaprox)
INDOCIN - indomethacin suppos 50

mg
3
3
naproxen sodium tab 550 mg

(Anaprox ds)
INDOCIN - indomethacin susp 25

mg/5ml
naproxen tab ec 375 mg (Ecnaprosyn)
indomethacin cap cr 75 mg
naproxen tab ec 500 mg (Ecnaprosyn)
naproxen tab 250 mg (Naprosyn)
ibuprofen tab 800 mg
indomethacin cap 25 mg
indomethacin cap 50 mg
ketoprofen cap 50 mg
98
1
1
1
3
Responsible Steps
NALFON - fenoprofen calcium cap

400 mg
Quantity Limits

Prior Authorization
KETOPROFEN ER - ketoprofen cap

sr 24hr 200 mg
leflunomide tab 20 mg (Arava)
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
FELDENE - piroxicam cap 10 mg
flurbiprofen tab 100 mg
Specialty
Drug Name
Drug Tier
2016
ORENCIA - abatacept subcutaneous 4

4
OTEZLA - apremilast tab starter
therapy pack 10 mg & 20 mg & 30
mg
4
OTEZLA - apremilast tab 30 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
RIDAURA - auranofin cap 3 mg
SIMPONI - golimumab
subcutaneous soln auto-injector
50 mg/0.5ml
SIMPONI - golimumab
subcutaneous soln auto-injector
100 mg/ml
SIMPONI - golimumab
syringe 50 mg/0.5ml
SIMPONI - golimumab
syringe 100 mg/ml
SPRIX - ketorolac tromethamine

nasal spray 15.75 mg/spray
sulindac tab 150 mg
OTREXUP - methotrexate soln pf

auto-injector 10 mg/0.4ml



oxaprozin tab 600 mg (Daypro)
1
1
1
PONSTEL - mefenamic acid cap 250 3

mg
3
RASUVO - methotrexate soln pf
auto-injector 7.5 mg/0.15ml
3
3
3
3
3
3
3
3
piroxicam cap 20 mg (Feldene)

RHEUMATREX - methotrexate
sodium tab 2.5 mg (antirheumatic)

piroxicam cap 10 mg (Feldene)
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
sulindac tab 200 mg
TOLMETIN SODIUM - tolmetin

sodium tab 200 mg
TOLMETIN SODIUM - tolmetin

sodium tab 600 mg
tolmetin sodium cap 400 mg
XELJANZ - tofacitinib citrate tab 5

MIGRAINE PRODUCTS
acetaminophen-isometheptenedichloral cap 325-65-100 mg
almotriptan malate tab 6.25 mg

(Axert)
almotriptan malate tab 12.5 mg

(Axert)
ALSUMA - sumatriptan succinate

solution auto-injector 6 mg/0.5ml
AMERGE - naratriptan hcl tab 1 mg

(base equiv)
AMERGE - naratriptan hcl tab 2.5

mg (base equiv)
99
AXERT - almotriptan malate tab 6.25 3

mg
AXERT - almotriptan malate tab 12.5 3
mg
CAFERGOT - ergotamine w/ caffeine 3
tab 1-100 mg
3
DIHYDROERGOTAMINE
MESYLAT - dihydroergotamine
mesylate nasal spray 4 mg/ml
2
ERGOMAR - ergotamine tartrate sl
tab 2 mg
3
FROVA - frovatriptan succinate tab
IMITREX - sumatriptan nasal spray 5 2
mg/act
2
IMITREX - sumatriptan nasal spray
20 mg/act
IMITREX - sumatriptan succinate inj 3
6 mg/0.5ml
IMITREX - sumatriptan succinate tab 3
25 mg
50 mg
100 mg
3
IMITREX STATDOSE REFILL sumatriptan succinate solution
cartridge 4 mg/0.5ml
3
IMITREX STATDOSE REFILL sumatriptan succinate solution
cartridge 6 mg/0.5ml
3
IMITREX STATDOSE SYSTEM sumatriptan succinate solution
3
IMITREX STATDOSE SYSTEM sumatriptan succinate solution
1
isometheptene-caffeineacetaminophen tab
65-20-325 mg (Prodrin)
MAXALT - rizatriptan benzoate tab 5 3
mg
100
MAXALT-MLT - rizatriptan benzoate

MAXALT-MLT - rizatriptan benzoate

MIGERGOT - ergotamine w/ caffeine 3

suppos 2-100 mg
2
MIGRANAL - dihydroergotamine
mesylate nasal spray 4 mg/ml
1
naratriptan hcl tab 1 mg (base
equiv) (Amerge)
1
naratriptan hcl tab 2.5 mg (base
equiv) (Amerge)
PRODRIN - isometheptene-caffeine- 3
acetaminophen tab 65-20-325 mg
3
RELPAX - eletriptan hydrobromide
3
RELPAX - eletriptan hydrobromide
1
rizatriptan benzoate orally
disintegrating tab 5 mg (Maxaltmlt)
1
rizatriptan benzoate orally
(Maxalt-mlt)
1
rizatriptan benzoate tab 5 mg
(Maxalt)
1
rizatriptan benzoate tab 10 mg
(Maxalt)
SUMATRIPTAN - sumatriptan nasal 3
spray 5 mg/act
SUMATRIPTAN - sumatriptan nasal 3
spray 20 mg/act
2
SUMATRIPTAN SUCCINATE sumatriptan succinate inj 4
mg/0.5ml
3
SUMATRIPTAN SUCCINATE sumatriptan succinate solution
prefilled syringe 6 mg/0.5ml
1
sumatriptan succinate inj
6 mg/0.5ml (Imitrex)
MAXALT - rizatriptan benzoate tab

10 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
sumatriptan succinate solution

auto-injector 4 mg/0.5ml (Imitrex
statdose sys)

auto-injector 6 mg/0.5ml (Imitrex
statdose sys)

cartridge 4 mg/0.5ml (Imitrex
statdose ref)
allopurinol tab 100 mg (Zyloprim)

allopurinol tab 300 mg (Zyloprim)

cartridge 6 mg/0.5ml (Imitrex
statdose ref)
sumatriptan succinate tab 25 mg

(Imitrex)
ULORIC - febuxostat tab 40 mg
ULORIC - febuxostat tab 80 mg

(Imitrex)
ZYLOPRIM - allopurinol tab 100 mg

(Imitrex)
ZYLOPRIM - allopurinol tab 300 mg

NEUROMUSCULAR DRUGS
SUMAVEL DOSEPRO - sumatriptan

succinate solution jet-injector 4
mg/0.5ml
SUMAVEL DOSEPRO - sumatriptan

succinate solution jet-injector 6
mg/0.5ml
zolmitriptan orally disintegrating

tab 2.5 mg (Zomig zmt)
zolmitriptan tab 5 mg (Zomig)
ZOMIG - zolmitriptan nasal spray 2.5 3

mg/spray unit
3
ZOMIG - zolmitriptan tab 2.5 mg
ZOMIG - zolmitriptan tab 5 mg
ZOMIG NASAL SPRAY - zolmitriptan 3

nasal spray 5 mg/spray unit
3
ZOMIG ZMT - zolmitriptan orally
3
ZOMIG ZMT - zolmitriptan orally
GOUT AGENTS
MITIGARE - colchicine cap 0.6 mg
probenecid tab 500 mg
APTIOM - eslicarbazepine acetate

tab 200 mg

tab 400 mg

tab 600 mg

tab 800 mg
BANZEL - rufinamide susp 40 mg/ml
BANZEL - rufinamide tab 200 mg
BANZEL - rufinamide tab 400 mg
carbamazepine cap sr 12hr

100 mg (Carbatrol)

200 mg (Carbatrol)
300 mg (Carbatrol)
carbamazepine chew tab 100 mg
1
1
1
carbamazepine susp 100 mg/5ml

(Tegretol)
carbamazepine tab sr 12hr

200 mg (Tegretol-xr)
Responsible Steps
COLCHICINE - colchicine tab 0.6 mg 3

1
colchicine w/ probenecid tab
0.5-500 mg
2
COLCRYS - colchicine tab 0.6 mg
zolmitriptan tab 2.5 mg (Zomig)
Quantity Limits
COLCHICINE - colchicine cap 0.6

mg
zolmitriptan orally disintegrating

tab 5 mg (Zomig zmt)
Prior Authorization
ANTICONVULSANTS
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
101
carbamazepine tab sr 12hr

400 mg (Tegretol-xr)
carbamazepine tab 200 mg

(Tegretol)
DEPAKOTE SPRINKLES divalproex sodium cap sprinkle

125 mg
CARBATROL - carbamazepine cap

sr 12hr 100 mg
DIASTAT ACUDIAL - diazepam

rectal gel delivery system 10 mg

sr 12hr 200 mg
DIASTAT ACUDIAL - diazepam

rectal gel delivery system 20 mg

sr 12hr 300 mg
DIASTAT PEDIATRIC - diazepam

rectal gel delivery system 2.5 mg
CELONTIN - methsuximide cap 300

mg
DIAZEPAM - diazepam rectal gel

delivery system 2.5 mg
clonazepam orally disintegrating

tab 0.125 mg

delivery system 10 mg

delivery system 20 mg
DILANTIN - phenytoin sodium

extended cap 30 mg
DILANTIN - phenytoin sodium

extended cap 100 mg
DILANTIN INFATABS - phenytoin

chew tab 50 mg
DILANTIN-125 - phenytoin susp 125

mg/5ml
divalproex sodium cap sprinkle
125 mg (Depakote sprinkles)

tab 0.25 mg
tab 0.5 mg
tab 1 mg
tab 2 mg
clonazepam tab 0.5 mg (Klonopin)
clonazepam tab 1 mg (Klonopin)
clonazepam tab 2 mg (Klonopin)
1
1
Responsible Steps
Quantity Limits
Prior Authorization
DEPAKENE - valproate sodium

syrup 250 mg/5ml (base equiv)
divalproex sodium tab delayed

release 125 mg (Depakote)
DEPAKENE - valproic acid cap 250

mg

DEPAKOTE - divalproex sodium tab



divalproex sodium tab sr 24 hr

250 mg (Depakote er)

divalproex sodium tab sr 24 hr

500 mg (Depakote er)
DEPAKOTE ER - divalproex sodium

tab sr 24 hr 250 mg
ethosuximide cap 250 mg

(Zarontin)
DEPAKOTE ER - divalproex sodium

tab sr 24 hr 500 mg
ethosuximide soln 250 mg/5ml

(Zarontin)
felbamate susp 600 mg/5ml

(Felbatol)
102
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
1
LAMICTAL - lamotrigine tab 100 mg
FELBATOL - felbamate susp 600

mg/5ml
FELBATOL - felbamate tab 600 mg
LAMICTAL CHEWABLE DISPERS lamotrigine tab chewable

dispersible 5 mg
FELBATOL - felbamate tab 400 mg
FYCOMPA - perampanel tab 2 mg
LAMICTAL CHEWABLE DISPERS lamotrigine tab chewable

dispersible 25 mg
LAMICTAL ODT - lamotrigine orally

gabapentin cap 100 mg

(Neurontin)


(Neurontin)


(Neurontin)
gabapentin oral soln 250 mg/5ml

(Neurontin)
LAMICTAL ODT - lamotrigine tab

disp 25 mg (21) & 50 mg (7)
titration kit
disp 50 mg (42) & 100 mg (14)
titration kit

disp 25 (14) & 50 mg (14) & 100
mg (7) kit
LAMICTAL STARTER/NOT TAKI lamotrigine tab 25 mg (42) & 100

mg (7) starter kit
LAMICTAL STARTER/TAKING C lamotrigine tab 25 mg (84) & 100

mg (14) starter kit
LAMICTAL STARTER/TAKING V lamotrigine tab 25 mg (35) starter

kit
LAMICTAL XR - lamotrigine tab

sr 24hr 25 mg (21) & 50 mg (7)
titration kit
LAMICTAL XR - lamotrigine tab sr

24hr 25 (14) & 50 mg (14) & 100
mg(7) kit
felbamate tab 400 mg (Felbatol)

felbamate tab 600 mg (Felbatol)
gabapentin tab 600 mg (Neurontin) 1

gabapentin tab 800 mg (Neurontin) 1
GABITRIL - tiagabine hcl tab 2 mg
KEPPRA - levetiracetam oral soln

100 mg/ml
KEPPRA - levetiracetam tab 250 mg
KEPPRA - levetiracetam tab 1000

mg
KEPPRA XR - levetiracetam tab sr

24hr 500 mg
KEPPRA XR - levetiracetam tab sr

24hr 750 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
103

24hr 25 mg

24hr 50 mg
levetiracetam oral soln 100 mg/ml

(Keppra)

24hr 100 mg
levetiracetam tab sr 24hr 500 mg

(Keppra xr)

24hr 200 mg
levetiracetam tab sr 24hr 750 mg

(Keppra xr)

24hr 250 mg

24hr 300 mg
levetiracetam tab 250 mg (Keppra) 1

lamotrigine orally disintegrating

tab 25 mg (Lamictal odt)

lamotrigine tab 100 mg (Lamictal)


1
levetiracetam tab 1000 mg
(Keppra)
3
LYRICA - pregabalin cap 25 mg
3
LYRICA - pregabalin soln 20 mg/ml
MYSOLINE - primidone tab 50 mg
MYSOLINE - primidone tab 250 mg
NEURONTIN - gabapentin cap 100

mg

mg

mg
NEURONTIN - gabapentin oral soln

250 mg/5ml
NEURONTIN - gabapentin tab 600

mg
NEURONTIN - gabapentin tab 800

mg
lamotrigine tab sr 24hr 25 mg

(Lamictal xr)

(Lamictal xr)

(Lamictal xr)

(Lamictal xr)

(Lamictal xr)

(Lamictal xr)
Prior Authorization
lamotrigine tab chewable

dispersible 25 mg (Lamictal
chewable di)
lamotrigine tab chewable

dispersible 5 mg (Lamictal
chewable di)
104
Responsible Steps
Quantity Limits

24hr 50 (14) & 100 mg(14) & 200
mg(7) kit
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
ONFI - clobazam suspension 2.5

mg/ml
QUDEXY XR - topiramate cap er

24hr sprinkle 100 mg
ONFI - clobazam tab 10 mg
ONFI - clobazam tab 20 mg

oxcarbazepine susp 300 mg/5ml

(60 mg/ml) (Trileptal)

oxcarbazepine tab 150 mg

(Trileptal)
SABRIL - vigabatrin powd pack 500

mg

(Trileptal)
SABRIL - vigabatrin tab 500 mg

(Trileptal)
STAVZOR - valproic acid cap

OXTELLAR XR - oxcarbazepine tab

sr 24hr 150 mg


sr 24hr 300 mg


sr 24hr 600 mg
TEGRETOL - carbamazepine susp

100 mg/5ml
PEGANONE - ethotoin tab 250 mg
TEGRETOL - carbamazepine tab

200 mg
PHENYTEK - phenytoin sodium

extended cap 200 mg
PHENYTEK - phenytoin sodium

extended cap 300 mg
phenytoin chew tab 50 mg

(Dilantin infatabs)
phenytoin sodium extended cap

100 mg (Dilantin)
phenytoin susp 125 mg/5ml

(Dilantin-125)
POTIGA - ezogabine tab 50 mg
primidone tab 50 mg (Mysoline)
primidone tab 250 mg (Mysoline)
TEGRETOL-XR - carbamazepine tab 2

sr 12hr 100 mg
sr 12hr 200 mg
sr 12hr 400 mg
1
tiagabine hcl tab 2 mg (Gabitril)
tiagabine hcl tab 4 mg (Gabitril)
TOPAMAX - topiramate tab 25 mg
TOPAMAX SPRINKLE - topiramate

sprinkle cap 15 mg
TOPAMAX SPRINKLE - topiramate

sprinkle cap 25 mg

24hr sprinkle 25 mg
TOPIRAMATE ER - topiramate cap

er 24hr sprinkle 25 mg

24hr sprinkle 50 mg

105

VIMPAT - lacosamide tab 200 mg
ZARONTIN - ethosuximide cap 250

mg

ZARONTIN - ethosuximide soln 250

mg/5ml

3
1
ZONEGRAN - zonisamide cap 25

mg
topiramate sprinkle cap 15 mg

(Topamax sprinkle)
ZONEGRAN - zonisamide cap 100

mg
topiramate sprinkle cap 25 mg

(Topamax sprinkle)
zonisamide cap 25 mg (Zonegran)
topiramate tab 25 mg (Topamax)

zonisamide cap 50 mg
zonisamide cap 100 mg

(Zonegran)
ANTIPARKINSON AGENTS
Responsible Steps
Quantity Limits
Prior Authorization
1
1
TRILEPTAL - oxcarbazepine susp

300 mg/5ml (60 mg/ml)
TRILEPTAL - oxcarbazepine tab 150

mg

mg

mg
TROKENDI XR - topiramate cap sr

24hr 25 mg

24hr 50 mg

24hr 100 mg

24hr 200 mg
bromocriptine mesylate cap 5 mg

(Parlodel)
valproate sodium syrup

250 mg/5ml (base equiv)
(Depakene)
bromocriptine mesylate tab

2.5 mg
valproic acid cap 250 mg

(Depakene)
carbidopa & levodopa orally

disintegrating tab 10-100 mg
VIMPAT - lacosamide oral solution

10 mg/ml


106
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
AMANTADINE HCL - amantadine hcl 2

tab 100 mg
1
amantadine hcl cap 100 mg
amantadine hcl syrup 50 mg/5ml
APOKYN - apomorphine
hydrochloride inj 10 mg/ml
AZILECT - rasagiline mesylate tab

0.5 mg (base equiv)
AZILECT - rasagiline mesylate tab 1

mg (base equiv)
benztropine mesylate tab 0.5 mg
benztropine mesylate tab 1 mg

benztropine mesylate tab 2 mg
carbidopa & levodopa tab cr

25-100 mg (Sinemet cr)
1
1
1
1
1
1
carbidopa & levodopa tab cr

50-200 mg (Sinemet cr)
carbidopa & levodopa tab
10-100 mg (Sinemet)
25-100 mg (Sinemet)
25-250 mg (Sinemet)
carbidopa tab 25 mg (Lodosyn)
MIRAPEX - pramipexole
dihydrochloride tab 1.5 mg
MIRAPEX ER - pramipexole
dihydrochloride tab sr 24hr 0.375
mg
mg
dihydrochloride tab sr 24hr 1.5 mg
mg
dihydrochloride tab sr 24hr 3 mg
mg
dihydrochloride tab sr 24hr 4.5 mg
NEUPRO - rotigotine td patch 24hr 1

mg/24hr

mg/24hr

mg/24hr

mg/24hr

mg/24hr

mg/24hr
CARBIDOPA/LEVODOPA/ENTACA - 3
carbidopa-levodopa-entacapone
tabs 12.5-50-200 mg
tabs 18.75-75-200 mg
tabs 25-100-200 mg
tabs 31.25-125-200 mg
tabs 37.5-150-200 mg
tabs 50-200-200 mg
3
COMTAN - entacapone tab 200 mg
ELDEPRYL - selegiline hcl cap 5 mg
entacapone tab 200 mg (Comtan)
LODOSYN - carbidopa tab 25 mg
dihydrochloride tab 1 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
PARLODEL - bromocriptine mesylate 3

cap 5 mg
1
pramipexole dihydrochloride tab
sr 24hr 0.375 mg (Mirapex er)
1
1
1
sr 24hr 3 mg (Mirapex er)
107

0.125 mg (Mirapex)
0.25 mg (Mirapex)
0.5 mg (Mirapex)
0.75 mg (Mirapex)
1 mg (Mirapex)
1.5 mg (Mirapex)
1
1
1
1
1
1
1
REQUIP XL - ropinirole
hydrochloride tab sr 24hr 12 mg
(base equivalent)
ropinirole hydrochloride tab sr

24hr 2 mg (base equivalent)
(Requip xl)

(Requip xl)

(Requip xl)

(Requip xl)
REQUIP - ropinirole hydrochloride

tab 0.25 mg

tab 0.5 mg

(Requip xl)

tab 1 mg
ropinirole hydrochloride tab

0.25 mg (Requip)

tab 2 mg
ropinirole hydrochloride tab

0.5 mg (Requip)
ropinirole hydrochloride tab 1 mg
(Requip)

tab 3 mg
3
3

tab 4 mg

(Requip)

(Requip)

tab 5 mg

(Requip)
(base equivalent)
(base equivalent)

(Requip)
selegiline hcl cap 5 mg (Eldepryl)
(base equivalent)
(base equivalent)
108
selegiline hcl tab 5 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
SINEMET - carbidopa & levodopa

tab 10-100 mg

tab 25-100 mg

tab 25-250 mg
SINEMET CR - carbidopa &

levodopa tab cr 25-100 mg
SINEMET CR - carbidopa &

levodopa tab cr 50-200 mg
trihexyphenidyl hcl elixir 0.4 mg/

ml
trihexyphenidyl hcl tab 2 mg
trihexyphenidyl hcl tab 5 mg
ZELAPAR - selegiline hcl orally
NEUROMUSCULAR AGENTS
methocarbamol tab 500 mg

(Robaxin)
methocarbamol tab 750 mg

(Robaxin-750)
orphenadrine citrate tab sr 12hr

100 mg
1
3
ROBAXIN - methocarbamol tab 500

mg
ROBAXIN-750 - methocarbamol tab

750 mg
SKELAXIN - metaxalone tab 800 mg
tizanidine hcl cap 2 mg (base

equivalent) (Zanaflex)

chlorzoxazone tab 500 mg

(Parafon forte dsc)

cyclobenzaprine hcl tab 5 mg
tizanidine hcl tab 2 mg (base

equivalent)
riluzole tab 50 mg (Rilutek)
MUSCULOSKELETAL THERAPY AGENTS

1
baclofen tab 10 mg
baclofen tab 20 mg
carisoprodol tab 350 mg (Soma)
carisoprodol w/ aspirin & codeine
tab 200-325-16 mg
carisoprodol w/ aspirin tab
200-325 mg
cyclobenzaprine hcl tab 7.5 mg

(Fexmid)
Responsible Steps
Quantity Limits
PARAFON FORTE DSC chlorzoxazone tab 500 mg
Prior Authorization
DANTRIUM - dantrolene sodium cap 3

25 mg
50 mg
100 mg
2
DANTROLENE SODIUM dantrolene sodium cap 100 mg
1
dantrolene sodium cap 25 mg
(Dantrium)
1
dantrolene sodium cap 50 mg
(Dantrium)
METAXALONE - metaxalone tab 400 3
mg
metaxalone tab 800 mg (Skelaxin) 1
orphenadrine w/ aspirin &

caffeine tab 25-385-30 mg
RILUTEK - riluzole tab 50 mg
Specialty
Drug Tier
Responsible Steps
Quantity Limits
Drug Name
cyclobenzaprine hcl tab 10 mg
STALEVO 100 - carbidopa-levodopa- 3

entacapone tabs 25-100-200 mg
entacapone tabs 31.25-125-200
mg
entacapone tabs 37.5-150-200 mg
entacapone tabs 50-200-200 mg
3
TASMAR - tolcapone tab 100 mg
tolcapone tab 100 mg (Tasmar)
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
tizanidine hcl tab 4 mg (base

1
1
1
1
109
ZANAFLEX - tizanidine hcl cap 2 mg

(base equivalent)
ergocalciferol cap 50000 unit

(Drisdol)

(base equivalent)
MEPHYTON - phytonadione tab 5

mg

(base equivalent)
POTABA - potassium
aminobenzoate cap 500 mg
ZANAFLEX - tizanidine hcl tab 4 mg

(base equivalent)
POTABA - potassium
aminobenzoate tab 500 mg
ANTIMYASTHENIC AGENTS
GUANIDINE HCL - guanidine hcl tab 3

125 mg
2
MESTINON - pyridostigmine
bromide syrup 60 mg/5ml
3
MESTINON - pyridostigmine
bromide tab 60 mg
3
MESTINON TIMESPAN pyridostigmine bromide tab cr 180
mg
1
pyridostigmine bromide tab cr
180 mg (Mestinon timespan)
1
pyridostigmine bromide tab
60 mg (Mestinon)
NUTRITIONAL PRODUCTS
VITAMINS
AMINOBENZOATE POTASSIUM potassium aminobenzoate packet
2 gm
cholecalciferol cap 1000 unit
cholecalciferol chew tab 400 unit

cholecalciferol chew tab 1000 unit
cholecalciferol drops 5000 unit/ml
(1000 unit/0.2ml)
cholecalciferol drops 400
unit/0.03ml (per drop)
cholecalciferol oral liquid 400
unit/ml
cholecalciferol tab 400 unit
cholecalciferol tab 1000 unit
DRISDOL - ergocalciferol cap 50000
unit
110
P
P
P
P
P
P
P
3
MULTIVITAMINS
ACTIVE OB - prenatal w/o a w/fe
cbn-fa-dha cap 20-1-320 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
ATABEX EC - prenatal vit w/ dss-iron 3

carbonyl-fa tab dr 29-1 mg
3
BAL-CARE DHA - prenat w/fe polyna fered-fa tab 27-1 & omega cap
dr 430mg
3
BP FOLINATAL PLUS B - prenatal
w/ calcium carbonate-b6-b12-fa
tab 1 mg
BP MULTINATAL PLUS - prenatal w/ 3
o a vit w/ fe fum-fa tab chew 40-1
mg
BP MULTINATAL PLUS - prenatal w/ 3
o a vit w/ fe fumarate-fa tab 30-1
mg
C-NATE DHA - prenatal vit w/ fe fum- 3
fa-omega 3 cap 28-1-200 mg
3
CALCIUM PNV - prenatal w/o vit
a w/ fe fum-fa-omega 3 cap
28-1-250 mg
3
CHOICE-OB+DHA - prenatal mv w/
fe poly-fa chw 29-1 mg & dha cap
250 mg pak
3
CITRANATAL ASSURE - prenat w/
o a w/fecbn-fegl-dss-fa tab & dha
cap 300 mg pack
3
CITRANATAL B-CALM - prenat w/o
a w/fecbn-feglu-fa tab 20-1 mg &
vit b6 tab pak
CITRANATAL DHA - prenat w/o a w/ 3
fecbn-fegl-dss-fa tab & dha cap
250 mg pack
CITRANATAL HARMONY - prenat

w/o a w/fe fum-fe cbn-dss-fa-dha
cap 27-1-260 mg
FOCALGIN 90 DHA - prenat w/o a

w/fecbn-fegl-dss-fa tab 90 &dha
cap 300mg pak
CITRANATAL HARMONY - prenatal

w/o a w/fe cbn-dss-fa-dha cap
29-1-265 mg
FOCALGIN-B - prenatal w/ calciumvit b6-fa-ginger tab 1.22 mg
CITRANATAL RX - prenatal w/o a

w/ fe carbonyl-fe gluc-dss-fa tab
27-1mg
FOLBECAL - prenatal w/ calcium

carbonate-b6-b12-fa tab 1 mg
CITRANATAL 90 DHA - prenat w/o

a w/fecbn-fegl-dss-fa tab 90 &dha
cap 300mg pak
FOLCAL DHA - prenatal w/o vit

a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
CO-NATAL FA - prenatal vit w/ fe

fumarate-fa tab 29-1 mg
FOLCAPS OMEGA 3 - prenatal vit

w/ fe cbn-fe asp glyc-fa-omega 3
cap 27-1mg
FOLET DHA - prenat w/fecbn-bisgmethylf-dss tab dr & dha cap pak
COMPLETE NATAL DHA - prenat-fe

bis-fe prot succ-fa-ca tab & omega
3 cap 250 pk
COMPLETENATE - prenatal vit w/ fe

fumarate-fa chew tab 29-1 mg
FOLET ONE - prenat w/o a w/

fecbn-bisg-methylf-dss-dha cap
38-1-225 mg
FOLIVANE-OB - prenatal w/o a w/fe

fum-fe poly-fa cap 130-92.4-1 mg
CONCEPT DHA - prenatal w/fe fumfe poly -fa-omega 3 cap 53.5-38-1

mg
CONCEPT OB - prenatal w/o a w/fe

fum-fe poly-fa cap 130-92.4-1 mg
HEMENATAL OB - prenat vit-fe poly

cmplx-fe heme poly-fa tab 28-6-1
mg
HEMENATAL OB + DHA - prenat-fe
poly cmplx-fe heme poly-fa tab &
omega 3 cap pck
DOTHELLE DHA - prenatal w/fe

fum-fe poly -fa-omega 3 cap
53.5-38-1 mg
INATAL ADVANCE - prenatal vit w/

dss-iron carbonyl-fa tab 90-1 mg
DUET DHA BALANCED - prenat

w/fe poly-na fered-fa tab 25-1 &
omega cap 267 mg
DUET DHA 400 - prenat w/fe polyna fered-fa tab 25-1 & omega cap
400 mg
INATAL GT - prenatal vit w/ dss-iron

carbonyl-fa tab 90-1 mg
INATAL ULTRA - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
ELITE-OB - prenatal vit w/ iron

carbonyl-fa tab 50-1.25 mg
INFANATE BALANCE - prenatal

29-1-265 mg
INFANATE PLUS - prenat w/o a

w/fe fum-fe cbn-dss-fa-dha cap
27-1-260 mg
LEVOMEFOLATE DHA - prenat w/

fe fum-l methylfolate-fa-dha cap
27-1.13-0.4 mg
ENBRACE HR - prenatal vit w/ fe gly 3

cys-fa-omega 3 fatty acids cap
3
EXTRA-VIRT PLUS DHA - prenatal
w/o vit a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg
3
FOCALGIN CA - prenat w/o a w/
300 mg pack
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
111
M-VIT - prenatal vit w/ fe fumarate-fa 3

tab 27-1 mg
3
MACNATAL CN DHA - prenatal
28-1-250 mg
MARNATAL-F - prenatal w/o vit a w/ 3
fe polysac cmplx-fa cap 60-1 mg
MYNATAL - prenatal multivitamins & 3
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
MYNATAL ULTRACAPLET - prenatal 3
vit w/ dss-iron carbonyl-fa tab 90-1
mg
3
MYNATAL-Z - prenatal vit w/ fe
3
MYNATE 90 PLUS - prenatal vit w/
dss-fe fumarate-fa tab cr 90-1 mg
NATACHEW - prenatal vit w/ fe fum- 3
fe bisglycin-fa chew tab 28-1 mg
3
NATAL-V RX - prenatal vit w/ iron
3
NATALVIRT CA - prenat w/o a w/
300 mg pack
3
NATALVIRT 90 DHA - prenat w/o a
w/fecbn-fegl-dss-fa tab 90 &dha
cap 300mg pak
3
NATALVIT - prenatal vit w/ fe
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/fefum- 3
methylfol-omegas cap 27-1.13 mg
3
NEPHROCAPS QT - b-complex w/
c-biotin-d & folic acid tab disp 1
mg
112
NESTABS - prenatal vit w/o vit a w/

fe bisglycinate-fa tab 32-1 mg
NESTABS ABC - prenatal w/o vit a

w/fe polysac-fa-ca tab & omega 3
cap
NESTABS DHA - prenat w/o a w/ fe

bisglyc-fa tab 32-1 mg & omega
cap pack
NEWGEN - prenatal vit w/o vit a w/

fe bisglycinate-fa tab 32-1 mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
NEXA PLUS - prenatal w/o vit a w/ fe 3

fum-doc-fa-dha cap 29-1.25-350
mg
3
NIVA-PLUS - prenatal vit w/ fe
3
O-CAL FA - prenatal vit w/ fe
3
O-CAL PRENATAL - prenatal vit w/
fe fumarate-fa tab 15-1 mg
OB COMPLETE - prenatal vit w/ iron 3
carbonyl-fa tab 50-1.25 mg
OB COMPLETE ONE - prenatal w/o 3
a w/fecbn-fe asp glyc-fa-fish cap
50-1-476 mg
OB COMPLETE PETITE - prenat w/ 3
o a w/fecbn-feaspglyc-fa-omega
cap 35-5-1-200 mg
3
OB COMPLETE PREMIER prenatal vit w/ fe cbn-fe asp glycfa tab 30-20-1 mg
3
OB COMPLETE/DHA - prenat w/
iron cbn-fe asp glyc-fa-omega cap
30-10-1-200 mg
3
OB-NATAL ONE - prenatal vit w/ fe
cbn-fe asp glyc-fa-omega 3 cap
27-1mg
OBSTETRIX DHA - prenat w/fecbn- 3
fa-dss tab 29-1 mg & omega 3 cap
387 mg pak
3
OBSTETRIX EC - prenatal vit w/
PAIRE OB - prenat w/ fe poly cmplxfe asp-fe gly-fa tab & dha cap pak
PNV FERROUS FUMARATE/

DOCU - prenatal vit w/ dss-fe
PNV FOLIC ACID + IRON MUL prenatal vit w/ fe fumarate-fa tab

27-1 mg
PNV OB+DHA - prenat w/o a w/

250 mg pack
PNV PRENATAL PLUS MULTIVI prenatal vit w/ fe fumarate-fa tab

27-1 mg
PNV TABS 29-1 - prenatal vit w/ iron

PNV-DHA - prenat w/o a w/fefummethfol-fa-dha cap 27-0.6-0.4-300

mg
PNV-DHA+DOCUSATE - prenatal w/ 3
o vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
3
PNV-FIRST - prenatal mv w/
fe polysac cmplx-fa-dha cap
29-1-200 mg
3
PNV-OB/DHA - prenatal mv w/fe
fum-fa tab 65-1 mg & dha cap 250
mg pack
3
PNV-OMEGA - prenat w/o a w/ fe
fumerate-methylfolate-fa-omega 3
cap
3
PNV-SELECT - prenatal vit w/ fe
fum-methylfolate-fa tab 27-0.6-0.4
mg
3
PNV-TOTAL - prenat w/ fe cbn-fe
bisglyc-fa-fish oil cap 35-5-1.2 mg
3
PNV-VP-U - prenatal w/o a vit w/ fe
fumarate-fa cap 106.5-1 mg
PR NATAL 400 - prenat-fe bis-fe prot 3
succ-fa-ca tab & omega 3 cap 400
pk
PR NATAL 400 EC - prenat-fe bis-fe

prot succ-fa-ca tab & omega cap
dr 400 pk
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
PR NATAL 430 - prenat-fe bis-fe prot 3

pk
PR NATAL 430 EC - prenat-fe bis-fe 3
prot succ-fa-ca tab & omega cap
dr 430 pk
3
PREFERA OB - prenat vit-fe poly
mg
3
PREFERA OB + DHA - prenat-fe
omega 3 cap pck
3
PREFERAOB +DHA - prenat-fe
poly cmplx 28mg-fe heme poly-fa
tab&dha cap pack
3
PREFERAOB ONE - prenat-fe poly
cmplx-fe heme poly-fa-dha cap
22-6-1-200 mg
PREFOL-DHA - prenatal w/o vit a w/ 3
fe fum-dss-fa-dha cap 26-1.2-300
mg
3
PRENAISSANCE - prenatal w/o
vit a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg
3
PRENAISSANCE BALANCE prenatal w/o vit a w/ fe cbn-dss-fadha cap 30-1-260 mg
3
PRENAISSANCE DHA - prenat w/
o a w/fecbn-fegl-dss-fa tab & dha
cap 250 mg pack
PRENAISSANCE HARMONY DHA - 3
prenat w/fe poly-na fered-fa tab
27-1 & omega cap dr 380mg
3
PRENAISSANCE NEXT - prenatal
w/ calcium-vit b6-fa-ginger tab 1.2
mg
PRENAISSANCE NEXT-B - prenatal 3
w/ calcium-vit b6-fa-ginger tab
1.22 mg
113
PRENAISSANCE PLUS - prenatal

28-1-250 mg
PRENAISSANCE PROMISE - prenat 3

w/o a w/fecbn-fegl-dss-fa tab &
dha cap 300 mg pack
3
PRENAISSANCE 90 DHA - prenat
w/o a w/fecbn-fegl-dss-fa tab 90
&dha cap 300mg pak
3
PRENAPLUS - prenatal vit w/ fe
3
PRENATA - prenatal w/o a vit w/ fe
fum-fa tab chew 29-1 mg
3
PRENATABS FA - prenatal vit w/ fe
3
PRENATABS RX - prenatal vit w/
iron carbonyl-fa tab 29-1 mg
3
PRENATAL - prenatal vit w/ fe
PRENATAL AD - prenatal vit w/ dss- 3
PRENATAL LOW IRON - prenatal vit 3
w/ fe fumarate-fa tab 27-1 mg
PRENATAL PLUS - prenatal vit w/ fe 3
3
PRENATAL PLUS IRON - prenatal
vit w/ iron carbonyl-fa tab 29-1 mg
3
PRENATAL 19 - prenatal vit w/ dssfe fumarate-fa tab 29-1 mg
3
PRENATAL 19 - prenatal vit w/ fe
PRENATAL-U - prenatal w/o a vit w/ 3
fe fumarate-fa cap 106.5-1 mg
3
PRENATE - prenat mv & min w/ lmethylfolate-fa chew tab 0.6-0.4
mg
PRENATE AM - prenatal w/ calcium- 3
vit b6-vit b12-fa-ginger tab 1 mg
3
PRENATE DHA - prenat w/o a
w/feaspg-methfol-fa-dha cap
18-0.6-0.4-300 mg
114
PRENATE DHA - prenat w/o a

w/fefum-methfol-fa-dha cap
28-0.6-0.4-300 mg
PRENATE ELITE - prenatal vit w/ fe

fum-methylfolate-fa tab 26-0.6-0.4
mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
PRENATE ELITE - prenatal w/ fe asp 3

gly-l methylfol-fa tab 20-0.6-0.4
mg
3
PRENATE ENHANCE - prenat w/
o a w/fefum-methfol-fa-dha cap
28-0.6-0.4-400 mg
3
PRENATE ESSENTIAL - prenat w/
o a w/feasp-methylf-fa-omeg cap
29-0.6-0.4-340 mg
3
PRENATE ESSENTIAL - prenat w/
o a w/feaspg-methfol-fa-dha cap
18-0.6-0.4-300 mg
3
PRENATE MINI - prenat w/o a
w/fecbn-methylf-fa-dha cap
29-0.6-0.4-350 mg
3
PRENATE MINI - prenat w/oa w/
fecb-feasp-meth-fa-dha cap
18-0.6-0.4-350 mg
3
PRENATE PIXIE - prenat w/o a
w/feaspg-methfol-fa-dha cap
10-0.6-0.4-200 mg
3
PRENATE RESTORE - prenat w/
o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-400 mg
3
PRENATE STAR - prenatal vit w/ fe
asparto glycinate-fa tab 20-1 mg
3
PRENA1 CHEW - prenat w/ b2-b6b12-d3-folic acid chew tab 1.4 mg
3
PRENA1 PEARL - prenat w/oa w/
fefum-na fered-fa-dha cap cr
30-1.4-200 mg
3
PRENA1 PLUS/QUATREFOLIC prenat w/o a w/ fe chelate-l
methylfol-fa tab & dha cap pk
3
PRENA1/QUATREFOLIC - prenat
w/o a w/fefum-methfol-fa-dha cap
30-0.6-0.4-200 mg
PREPLUS - prenatal vit w/ fe

PREQUE 10 - prenatal mv w/
fe carbonyl-dss-fa-dha tab
15-25-0.5-50 mg
SETONET - prenat-fe bis-fe prot

pk
PRETAB - prenatal vit w/ fe

TARON-BC - prenat w/o a w/ fe

cbnyl-fa tab 20-1 mg & vit b6 tab
pak
PROVIDA DHA - prenat w/o a

w/fe fum-fe poly-fa-dha cap
16-16-1.25-110 mg
TARON-C DHA - prenatal w/fe fumfe poly -fa-omega 3 cap 53.5-38-1

mg
PROVIDA OB - prenatal w/o a w/fe

fum-fe poly-fa cap 20-20-1.25 mg
TARON-PREX - prenatal w/o vit a w/

fe fum-dss-fa-dha cap 30-1.2-265
mg
PUREFE OB PLUS - prenatal

w/o a w/fe fum-fe poly-fa cap
162.115.2-1 mg
THRIVITE RX - prenatal vit w/ iron

3
3
R-NATAL OB - prenatal w/o a w/fe

cbn-fa-dha cap 20-1-320 mg
THRIVITE 19 - prenatal vit w/ dss-fe

RELNATE DHA - prenatal vit w/ fe

fum-fa-omega 3 cap 28-1-200 mg
TL FOLATE - prenatal vit w/ fe fummethylfolate-fa tab 27-0.5-0.5 mg
RULAVITE DHA - prenat w/o a

27-0.6-0.4-300 mg
TL-CARE DHA - prenatal w/fe

fumarate-fa-dss-fish oil cap
27-1-500 mg
SE-NATAL 19 - prenatal vit w/ dss-fe

TL-SELECT - prenatal w/o vit a w/ fe

fum-dss-fa-dha cap 29-1.25-325
mg
SE-NATAL 19 - prenatal vit w/ fe

SE-TAN DHA - prenatal w/fe fum-fe

poly -fa-omega 3 cap 15-15-1 mg
TL-SELECT DHA - prenatal w/o

vit a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg
SELECT-OB - prenat w/
fepolycmplx-methylfol-fa chew tab
29-0.6-0.4 mg
TRI-TABS DHA - prenat w/o a w/ fe

bisglyc-fa tab 32-1 mg & omega
cap pack
SELECT-OB - prenatal vit w/ fe

polysac cmplx-fa chew tab 29-1
mg
TRIADVANCE - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg

TRICARE - prenatal vit w/ fe
SELECT-OB+DHA - prenatal mv w/
fe poly-fa chw 29-1 mg & dha cap
250 mg pak
TRICARE PRENATAL COMPLEAT prenat w/o a fefum-fa tab 27-1 mg

& fish oil chew cap pak
TRICARE PRENATAL DHA ONE prenatal w/fe fumarate-fa-dss-fish

oil cap 27-1-500 mg
TRINATAL GT - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
SETON ET-EC - prenat-fe bis-fe prot 3

succ-fa-ca tab & omega cap dr
430 pk
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
115
TRINATAL RX 1 - prenatal vit w/ fe

TRINATAL ULTRA - prenatal vit w/

TRINATE - prenatal vit w/ fe

TRISTART DHA - prenat w/o a

w/fecbn-methylf-fa-dha cap
31-0.6-0.4-200 mg
TRIVEEN-DUO DHA - prenat-fe bisfe prot succ-fa-ca tab & omega 3

cap 400 pk
TRIVEEN-PRX RNF - prenatal w/

o vit a w/ fe fum-dss-fa-dha cap
26-1.2-300 mg
ULTIMATE OB DHA - prenat w/ fe

poly cmplx-fe asp-fe gly-fa tab &
dha cap pak
ULTIMATECARE ONE - prenatal vit

w/ fe cbn-fe asp glyc-fa-omega 3
cap 27-1mg
ULTIMATECARE ONE NF - prenatal

w/fe cbnyl-fe asp glyc-fa-dssomega cap 20-7-1 mg
ULTRA TABS - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
VEMAVITE-PRX 2 - prenatal w/o

vit a w/ fe fum-dss-fa-dha cap
27-1.25-300 mg
VENA-BAL DHA - prenat w/fe polyna fered-fa tab 27-1 & omega cap
dr 430mg
VENATAL-FA - prenatal vit w/ fe

VINACAL B - prenat w/o a w/fecbnfeglu-fa tab 20-1 mg & vit b6 tab

pak
VINATE AZ EXTRA - prenatal vit w/

fe bisglycinate chelate-fa tab 29-1
mg
VINATE C - prenatal w/o a vit w/ fe

116
VINATE CALCIUM - prenatal vit w/

iron carbonyl-fe gluc-fa tab 27-1
mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
VINATE CARE - prenatal w/o a vit w/ 3

fe fum-fa tab chew 40-1 mg
3
VINATE DHA RF - prenat w/o a
w/fefum-methylfol-omegas cap
27-1.13 mg
VINATE GT - prenatal vit w/ dss-iron 3
VINATE IC - prenatal w/o a w/fe fum- 3
fe poly-fa cap 162.115.2-1 mg
3
VINATE II - prenatal vit w/ fe
bisglycinate chelate-fa tab 29-1
mg
3
VINATE M - prenatal vit w/ sel-fe
3
VINATE ONE - prenatal vit w/ fe
VINATE ULTRA - prenatal vit w/ dss- 3
3
VIRT NATE - prenatal vit w/ fe
3
VIRT-ADVANCE - prenatal vit w/
3
VIRT-C DHA - prenatal w/fe fum-fe
poly -fa-omega 3 cap 53.5-38-1
mg
VIRT-CARE ONE - prenatal vit w/ fe 3
cbn-fe asp glyc-fa-omega 3 cap
27-1mg
3
VIRT-PN - prenatal vit w/ fe fummethylfolate-fa tab 27-0.6-0.4 mg
3
VIRT-PN DHA - prenat w/o a
27-0.6-0.4-300 mg
3
VIRT-PN PLUS - prenat w/o a w/ fe
fumerate-methylfolate-fa-omega 3
cap
3
VIRT-SELECT - prenatal w/o vit
a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg
VIRT-VITE GT - prenatal vit w/ dssiron carbonyl-fa tab 90-1 mg
VOL-PLUS - prenatal vit w/ fe

VIRTPREX - prenatal w/o vit a w/ fe

fum-dss-fa-dha cap 26-1.2-300
mg
VOL-TAB RX - prenatal vit w/ iron

VP CH ULTRA - prenat w/o a w/

fe fum-fe cbn-dss-fa-dha cap
27-1-260 mg
VITA-PREN - prenatal vit w/

docusate-iron-fa tab 65-1 mg
VITAFOL FE+ - prenat-fepolymethol-fa-dha cap 90-1-200 mg &

dss 50mg cap
VP-CH PLUS - prenatal w/o a w/fe

cbn-dss-fa-dha cap 29-1-265 mg
VITAFOL ULTRA - prenat w/

fe poly-methylfol-fa-dha cap
29-0.6-0.4-200 mg
VITAFOL-NANO - prenatal w/o a w/

fefum-l methylfol-fa tab 18-0.6-0.4
mg
VITAFOL-OB - prenatal vit w/ fe

VITAFOL-OB+DHA - prenatal mv w/
fe fum-fa tab 65-1 mg & dha cap
250 mg pack
VITAFOL-ONE - prenatal mv w/
fe polysac cmplx-fa-dha cap
29-1-200 mg
VITAFOL-PN - prenatal vit w/ fe

VITAMEDMD ONE RX/QUATREFO - 3

prenat w/o a w/fefum-methfol-fadha cap 30-0.6-0.4-200 mg
3
VITAMEDMD PLUS RX/QUATRE prenat w/o a w/ fe chelate-l
methylfol-fa tab & dha cap pk
3
VITAMEDMD REDICHEW RX prenat w/ b2-b6-b12-d3-folic acid
chew tab 1.4 mg
3
VITAPEARL - prenat w/oa w/fefumna fered-fa-dha cap cr 30-1.4-200
mg
VIVA DHA - prenatal vit w/ fe fum-fa- 3
omega 3 cap 28-1-200 mg
3
VOL-NATE - prenatal vit w/ fe
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
VP-CH-PNV - prenatal w/o vit a w/ fe 3

3
VP-GGR-B6 PRENATAL - prenatal
w/ calcium-vit b6-fa-ginger tab 1.2
mg
3
VP-HEME OB - prenat vit-fe poly
mg
3
VP-HEME OB + DHA - prenat-fe
omega 3 cap pck
3
VP-HEME ONE - prenat-fe poly
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
ZATEAN-PN - prenatal vit w/ fe fum- 3
methylfolate-fa tab 27-0.6-0.4 mg
3
ZATEAN-PN DHA - prenat w/o
a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
ZATEAN-PN PLUS - prenat w/o a w/ 3
fe fumerate-methylfolate-fa-omega
3 cap
3
ZINGIBER - prenatal w/ calcium-vit
b6-fa-ginger tab 1.2 mg
MINERALS and ELECTROLYTES
EFFER-K - potassium bicarbonatecitric acid effer tab 10 meq
117
EFFER-K - potassium bicarbonatecitric acid effer tab 20 meq
LOZI-FLUR - sodium fluoride

lozenge 1 mg f (from 2.2 mg naf)
FLORIVA - sodium fluoride-vitamin d

liqd drops 0.25 mg/ml-400 unit/ml
LURIDE - sodium fluoride chew tab

0.25 mg f (from 0.55 mg naf)
FLUOR-A-DAY - sodium fluoridexylitol chew tab 0.55 (0.25 mg

f)-236.79 mg
LURIDE - sodium fluoride chew tab

0.5 mg f (from 1.1 mg naf)
FLUOR-A-DAY - sodium fluoridexylitol chew tab 1.1 (0.5 mg

f)-236.79 mg
FLUOR-A-DAY - sodium fluoridexylitol chew tab 2.2 (1 mg

f)-236.79 mg
FLUORABON - sodium fluoride

soln 0.25 mg/0.6ml (from 0.55
mg/0.6ml naf)
FLURA-DROPS - sodium fluoride

soln 0.25 mg/drop f (from 0.55 mg/
drop naf)
GALZIN - zinc acetate cap 25 mg

(elemental zinc)
GALZIN - zinc acetate cap 50 mg

(elemental zinc)
K-PHOS - potassium phosphate

monobasic tab 500 mg
K-PHOS NEUTRAL - pot phos

monobasic w/sod phos di &
monobas tab 155-852-130mg
K-TAB - potassium chloride tab cr 8

meq (600 mg)

meq

meq (1500 mg)
KLOR-CON M15 - potassium

chloride microencapsulated crys
cr tab 15 meq
KLOR-CON 25 - potassium chloride

powder packet 25 meq
KLOR-CON/25 - potassium chloride

powder packet 25 meq
118
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
LURIDE - sodium fluoride chew tab 1 3

mg f (from 2.2 mg naf)
3
LURIDE - sodium fluoride soln 0.5
mg/ml f (from 1.1 mg/ml naf)
3
MICRO-K - potassium chloride cap
cr 8 meq
3
MICRO-K - potassium chloride cap
cr 10 meq
1
pot bicarbonate & chloride effer
tab 25 meq
1
pot phos monobasic w/sod
phos di & monobas tab
155-852-130mg (K-phos neutral)
1
potassium bicarbonate effer tab
25 meq
1
potassium chloride cap cr 8 meq
(Micro-k)
potassium chloride cap cr 10 meq 1
(Micro-k)
3
POTASSIUM CHLORIDE ER potassium chloride tab cr 8 meq
(600 mg)
3
POTASSIUM CHLORIDE ER potassium chloride tab cr 20 meq
(1500 mg)
1
potassium chloride
microencapsulated crys cr tab
10 meq
1
potassium chloride
microencapsulated crys cr tab
20 meq
potassium chloride oral soln 10% 1
(20 meq/15ml)
potassium chloride oral soln 20% 1
(40 meq/15ml)
potassium chloride powder

packet 20 meq
potassium chloride tab cr 8 meq
(600 mg) (K-tab)
1
1
ARANESP ALBUMIN FREE darbepoetin alfa soln inj 200 mcg/

ml
potassium chloride tab cr 10 meq

(K-tab)
SODIUM FLUORIDE - sodium

fluoride tab 0.5 mg f (from 1.1 mg
naf)

ml
SODIUM FLUORIDE - sodium

fluoride tab 1 mg f (from 2.2 mg
naf)
ARANESP ALBUMIN FREE darbepoetin alfa soln prefilled

syringe 10 mcg/0.4ml
sodium fluoride chew tab 0.25 mg

f (from 0.55 mg naf) (Luride)







syringe 500 mcg/ml
carbonyl iron susp 15 mg/1.25ml

(elemental iron)
sodium fluoride chew tab 0.5 mg f

(from 1.1 mg naf) (Luride)
sodium fluoride chew tab 1 mg f
(from 2.2 mg naf) (Luride)
sodium fluoride soln 0.125 mg/
drop f (0.275 mg/drop naf)
sodium fluoride soln 0.5 mg/ml f
(from 1.1 mg/ml naf) (Luride)
SSKI - potassium iodide soln 1 gm/
ml
NUTRIENTS
acetylcysteine cap 600 mg
P
P
P
P
LECITHIN - lecithin granules
NUTRESTORE - glutamine powd

pack 5 gm
HEMATOLOGICAL AGENTS
HEMATOPOIETIC AGENTS
ml

ml

ml
CERDELGA - eliglustat tartrate cap

CIFEREX - folic acid-cholecalciferol

cap 1 mg-3775 unit
cyanocobalamin inj 1000 mcg/ml
Responsible Steps

ml
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
119
DROXIA - hydroxyurea cap 200 mg
DURACHOL - folic acidcholecalciferol cap 1 mg-3775 unit
EPOGEN - epoetin alfa inj 2000 unit/ 4

ml
ml
ml
4
EPOGEN - epoetin alfa inj 10000
unit/ml
4
EPOGEN - epoetin alfa inj 20000
unit/ml
3
FERROUS SULFATE - ferrous
sulfate liquid 220 mg/5ml (44
mg/5ml elemental fe)
P
ferrous sulfate elixir 220 mg/5ml
(44 mg/5ml elemental fe)
P
ferrous sulfate soln 75 mg/ml
(15 mg/ml elemental fe)
P
folic acid tab 400 mcg
folic acid tab 800 mcg
folic acid tab 1 mg
FOLIVANE-F - fe fum-fe poly-fa-c-b3
cap 62.5-62.5-1-40-3mg(125 mg
fe)
MIRCERA - methoxy peg-epoetin

beta soln prefilled syr 100
mcg/0.3ml

mcg/0.3ml
NASCOBAL - cyanocobalamin nasal

spray 500 mcg/0.1ml
NEULASTA - pegfilgrastim soln

NEULASTA DELIVERY KIT pegfilgrastim soln prefilled syringe

kit 6 mg/0.6ml
1
3
NEUPOGEN - filgrastim inj 300 mcg/ 4

ml
4
NEUPOGEN - filgrastim inj 480
mcg/1.6ml (300 mcg/ml)
NEUPOGEN - filgrastim soln prefilled 4
NEUPOGEN - filgrastim soln prefilled 4
syringe 480 mcg/0.8ml (600 mcg/
ml)
ORTHO D - folic acid-cholecalciferol 3
cap 1 mg-3775 unit
PROCRIT - epoetin alfa inj 2000 unit/ 4
ml
ml
ml
4
PROCRIT - epoetin alfa inj 10000
unit/ml
4
unit/ml
4
unit/ml
PROMACTA - eltrombopag olamine 4
tab 12.5 mg (base equiv)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Drug Name
mcg/0.3ml
GRANIX - tbo-filgrastim soln prefilled 4

GRANIX - tbo-filgrastim soln prefilled 4
3
INTEGRA F - fe fum-fe poly-fa-c-b3
cap 62.5-62.5-1-40-3mg(125 mg
fe)
LEUKINE - sargramostim lyophilized 4
for inj 250 mcg
4
mcg/0.3ml
120
Specialty
Drug Name
Drug Tier
2016
PROMACTA - eltrombopag olamine


REVESTA - folic acid-cholecalciferol

cap 1 mg-5750 unit
enoxaparin sodium inj 100 mg/ml

(Lovenox)
ZAVESCA - miglustat cap 100 mg
enoxaparin sodium inj

120 mg/0.8ml (Lovenox)
ARIXTRA - fondaparinux sodium

subcutaneous inj 2.5 mg/0.5ml
enoxaparin sodium inj 150 mg/ml

(Lovenox)

subcutaneous inj 5 mg/0.4ml

300 mg/3ml (Lovenox)


fondaparinux sodium
(Arixtra)
COUMADIN - warfarin sodium tab 1

mg
fondaparinux sodium
(Arixtra)

mg
COUMADIN - warfarin sodium tab

2.5 mg
fondaparinux sodium
(Arixtra)

mg
fondaparinux sodium
(Arixtra)
FRAGMIN - dalteparin sodium inj

10000 unit/ml

mg

2500 unit/0.2ml

mg

5000 unit/0.2ml

mg

7500 unit/0.3ml
COUMADIN - warfarin sodium tab

7.5 mg

12500 unit/0.5ml

15000 unit/0.6ml

18000 unit/0.72ml

95000 unit/3.8ml
COUMADIN - warfarin sodium tab 10 3

mg
2
ELIQUIS - apixaban tab 2.5 mg
ELIQUIS - apixaban tab 5 mg



Responsible Steps
ANTICOAGULANTS
Quantity Limits
Prior Authorization
Specialty

Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
121
heparin sodium (porcine) inj 5000

unit/ml
warfarin sodium tab 5 mg

(Coumadin)

(Coumadin)
warfarin sodium tab 7.5 mg

(Coumadin)

(Coumadin)
XARELTO - rivaroxaban tab 10 mg
XARELTO STARTER PACK rivaroxaban tab starter therapy

pack 15 mg & 20 mg
LOVENOX - enoxaparin sodium inj

30 mg/0.3ml

40 mg/0.4ml

60 mg/0.6ml

80 mg/0.8ml

100 mg/ml

120 mg/0.8ml

150 mg/ml

300 mg/3ml
AMICAR - aminocaproic acid oral

soln 0.25 gm/ml
PRADAXA - dabigatran etexilate

mesylate cap 75 mg (etexilate
base eq)
AMICAR - aminocaproic acid syrup

25%
PRADAXA - dabigatran etexilate

mesylate cap 150 mg (etexilate
base eq)
SAVAYSA - edoxaban tosylate tab




(Coumadin)
HEMATOLOGICAL AGENTS - MISC.

(Coumadin)
ADVATE - antihemophilic factor rahfpfm for inj 250 unit
warfarin sodium tab 2.5 mg

(Coumadin)

(Coumadin)

(Coumadin)

122
HEMOSTATICS
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
AMICAR - aminocaproic acid tab 500 3

mg
3
AMICAR - aminocaproic acid tab
1000 mg
3
AMINOCAPROIC ACID aminocaproic acid tab 1000 mg
LYSTEDA - tranexamic acid tab 650 3
mg
1
tranexamic acid tab 650 mg
(Lysteda)
BEBULIN VH - factor ix complex for

inj 200-1200 unit
AGGRENOX - aspirin-dipyridamole
cap sr 12hr 25-200 mg
BENEFIX - coagulation factor ix

(recombinant) for inj 250 unit
AGRYLIN - anagrelide hcl cap 0.5

mg
ALPHANATE/VON WILLEBRAND antihemophilic factor/vwf (human)

for inj 250 unit



for inj 500 unit

for inj 1000 unit

BERINERT - c1 esterase inhibitor
(human) for iv inj kit 500 unit

for inj 1500 unit
BRILINTA - ticagrelor tab 60 mg
BRILINTA - ticagrelor tab 90 mg
3
1

for inj 2000 unit
cilostazol tab 50 mg (Pletal)
ALPHANINE SD - coagulation factor

ix for inj 500 unit

ix for inj 1000 unit

ix for inj 1500 unit
ALPROLIX - coagulation factor ix

(recomb) (rfixfc) for inj 500 unit



anagrelide hcl cap 0.5 mg (Agrylin) 1

1
anagrelide hcl cap 1 mg
ASPIRIN/DIPYRIDAMOLE - aspirindipyridamole cap sr 12hr 25-200
mg
cilostazol tab 100 mg (Pletal)
CINRYZE - c1 esterase inhibitor

(human) for iv inj 500 unit
clopidogrel bisulfate tab 75 mg

(base equiv) (Plavix)
clopidogrel bisulfate tab 300 mg

(base equiv) (Plavix)
CORIFACT - factor xiii concentrate

(human) for inj kit 1000-1600 unit
dipyridamole tab 25 mg
(Persantine)
(Persantine)
(Persantine)
DURLAZA - aspirin capsule sr 24hr

162.5 mg
EFFIENT - prasugrel hcl tab 5 mg

(base equiv)
EFFIENT - prasugrel hcl tab 10 mg

(base equiv)
Responsible Steps
BEBULIN - factor ix complex for inj

200-1200 unit
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
123
ELOCTATE - antihemophilic factor

(recomb) rfviiifc for inj 750 unit




FEIBA - antiinhibitor coagulant

complex for inj
FEIBA NF - antiinhibitor coagulant

complex for inj
FIRAZYR - icatibant acetate inj 30

mg/3ml (base equivalent)
HELIXATE FS - antihemophilic factor 4

(recombinant) for inj kit 250 unit
4
HEMOFIL M - antihemophilic factor
(human) for inj 220-400 unit
4
(human) for inj 250 unit
4
4
4
124
Responsible Steps

Quantity Limits
Prior Authorization
Specialty

Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016



HUMATE-P - antihemophilic factor/

vwf (human) for inj 250-600 unit


IXINITY - coagulation factor ix



KOATE-DVI - antihemophilic factor



KOGENATE FS - antihemophilic
factor (recombinant) for inj kit 250
unit
factor (recombinant) for inj kit 500
unit
factor (recombinant) for inj kit
1000 unit
2000 unit
3000 unit
KOGENATE FS BIO-SET antihemophilic factor



MONOCLATE-P - antihemophilic
factor (human) for inj kit 250 unit
MONONINE - coagulation factor ix

for inj 250 unit

for inj 500 unit

for inj 1000 unit
NOVOEIGHT - antihemophilic factor






NOVOSEVEN - coagulation factor

viia (recomb) for inj 2.4 mg (2400
mcg)
Responsible Steps

Quantity Limits
Prior Authorization
Specialty

Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
NOVOSEVEN RT - coagulation
factor viia (recomb) for inj 1 mg
(1000 mcg)
(2000 mcg)
(5000 mcg)
(8000 mcg)
OBIZUR - antihemophilic factor

(recomb porc) rpfviii for inj 500
unit
pentoxifylline tab cr 400 mg
PERSANTINE - dipyridamole tab 25

mg

mg

mg
PLAVIX - clopidogrel bisulfate tab 75

mg (base equiv)
PLAVIX - clopidogrel bisulfate tab

300 mg (base equiv)
PLETAL - cilostazol tab 50 mg
PLETAL - cilostazol tab 100 mg
PROFILNINE - factor ix complex for

inj 500 unit

inj 1000 unit

inj 1500 unit
PROFILNINE SD - factor ix complex

for inj 500 unit

for inj 1000 unit

for inj 1500 unit
125
RECOMBINATE - antihemophilic
factor (recombinant) for inj
801-1240 unit
1241-1800 unit
1801-2400 unit
RIXUBIS - coagulation factor ix





XYNTHA SOLOFUSE antihemophilic factor recombinant

paf for inj kit 250 unit




ZONTIVITY - vorapaxar sulfate tab

TOPICAL PRODUCTS
OPHTHALMIC AGENTS
ACULAR - ketorolac tromethamine

ophth soln 0.5%
ACULAR LS - ketorolac
tromethamine ophth soln 0.4%
RUCONEST - c1 esterase inhibitor

(recombinant) for iv inj 2100 unit
4
4
ACUVAIL - ketorolac tromethamine

ophth soln 0.45%
TRETTEN - coagulation factor xiii asubunit for inj 2000-3125 unit
AKTEN - lidocaine hcl ophth gel

3.5%
WILATE - antihemophilic factor/vwf

ALCAINE - proparacaine hcl ophth

soln 0.5%
WILATE - antihemophilic factor/vwf

XYNTHA - antihemophilic factor

recombinant paf for inj kit 250 unit

recombinant paf for inj kit 500 unit

recombinant paf for inj kit 1000
unit
126
Responsible Steps
401-800 unit

recombinant paf for inj kit 2000
unit
Quantity Limits
Prior Authorization
Specialty
220-400 unit
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
ALOCRIL - nedocromil sodium ophth 3

soln 2%
3
ALOMIDE - lodoxamide
tromethamine ophth soln 0.1%
ALPHAGAN P - brimonidine tartrate 2
ophth soln 0.1%
ALPHAGAN P - brimonidine tartrate 3
ophth soln 0.15%
3
ALREX - loteprednol etabonate
ophth susp 0.2%
apraclonidine hcl ophth soln 0.5%

(base equivalent) (Iopidine)
ATROPINE SULFATE - atropine

sulfate ophth oint 1%
atropine sulfate ophth soln 1%

(Isopto atropine)
AZASITE - azithromycin ophth soln

1%
azelastine hcl ophth soln 0.05%
brimonidine tartrate ophth soln

0.2%
bromfenac sodium ophth soln
0.09% (base equivalent)
bromfenac sodium ophth soln
0.09% (base equiv) (once-daily)
carteolol hcl ophth soln 1%
CILOXAN - ciprofloxacin hcl ophth
oint 0.3%
BACITRACIN - bacitracin ophth oint

500 unit/gm
ciprofloxacin hcl ophth soln 0.3%

(Ciloxan)
bacitracin-polymyxin b ophth oint
COMBIGAN - brimonidine tartratetimolol maleate ophth soln

0.2-0.5%
COSOPT - dorzolamide hcl-timolol

maleate ophth soln 22.3-6.8 mg/
ml
COSOPT PF - dorzolamide hcltimolol maleate ophth sol 22.3-6.8

mg/ml pf
cromolyn sodium ophth soln 4%
BESIVANCE - besifloxacin hcl ophth

susp 0.6% (base equiv)
BETADINE OPHTHALMIC PREP povidone-iodine ophth soln 5%
BETAGAN - levobunolol hcl ophth

soln 0.5%
betaxolol hcl ophth soln 0.5%
CYCLOGYL - cyclopentolate hcl

ophth soln 0.5%

ophth soln 1%
BETIMOL - timolol ophth soln 0.25%
BETIMOL - timolol ophth soln 0.5%

ophth soln 2%
BETOPTIC-S - betaxolol hcl ophth

susp 0.25%
CYCLOMYDRIL - cyclopentolate w/
phenylephrine ophth soln 0.2-1%
BIMATOPROST - bimatoprost ophth

soln 0.03%
cyclopentolate hcl ophth soln 1%

(Cyclogyl)
BLEPH-10 - sulfacetamide sodium

ophth soln 10%
3
2
BLEPHAMIDE - sulfacetamide
sodium-prednisolone ophth susp
10-0.2%
cyclopentolate hcl ophth soln 2%

(Cyclogyl)
BLEPHAMIDE S.O.P. sulfacetamide sodiumprednisolone ophth oint 10-0.2%
CYSTARAN - cysteamine hcl ophth

soln 0.44% (base equivalent)
dexamethasone sodium
phosphate ophth soln 0.1%
brimonidine tartrate ophth soln

0.15% (Alphagan p)
diclofenac sodium ophth soln

0.1%
Responsible Steps
CILOXAN - ciprofloxacin hcl ophth

soln 0.3%
BEPREVE - bepotastine besilate

ophth soln 1.5%
Quantity Limits
Prior Authorization
AZOPT - brinzolamide ophth susp

1%
bacitracin-polymyxin-neomycinhc ophth oint 1%
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
127
dorzolamide hcl ophth soln 2%

(Trusopt)
IOPIDINE - apraclonidine hcl ophth

soln 1% (base equivalent)
dorzolamide hcl-timolol maleate

ophth soln 22.3-6.8 mg/ml
(Cosopt)
ISOPTO CARBACHOL - carbachol

ophth soln 1.5%
ISOPTO CARBACHOL - carbachol

ophth soln 3%
DUREZOL - difluprednate ophth

emulsion 0.05%
3
3
ISOPTO CARPINE - pilocarpine hcl

ophth soln 1%
ELESTAT - epinastine hcl ophth soln

0.05%

ophth soln 2%
EMADINE - emedastine difumarate

ophth soln 0.05% (base equiv)

ophth soln 4%
epinastine hcl ophth soln 0.05%

(Elestat)
ISOPTO HOMATROPINE homatropine hbr ophth soln 2%
erythromycin ophth oint 5 mg/gm
FLAREX - fluorometholone acetate

ophth susp 0.1%
ISOPTO HOMATROPINE homatropine hbr ophth soln 5%
fluorometholone ophth susp 0.1%

(Fml liquifilm)
ISOPTO HYOSCINE - scopolamine

hbr ophth soln 0.25%
flurbiprofen sodium ophth soln

0.03% (Ocufen)
ISTALOL - timolol maleate ophth

soln 0.5% (once-daily)
ketorolac tromethamine ophth

soln 0.4% (Acular ls)
FML - fluorometholone ophth oint

0.1%
FML FORTE - fluorometholone ophth 3

susp 0.25%
3
FML LIQUIFILM - fluorometholone
ophth susp 0.1%
3
GARAMYCIN - gentamicin sulfate
ophth soln 0.3%
1
gatifloxacin ophth soln 0.5%
(Zymaxid)
1
gentamicin sulfate ophth oint
0.3%
1
gentamicin sulfate ophth soln
0.3% (Garamycin)
1
homatropine hbr ophth soln 5%
(Isopto homatropine)
3
ILEVRO - nepafenac ophth susp
0.3%
3
IOPIDINE - apraclonidine hcl ophth
128
ketorolac tromethamine ophth

soln 0.5% (Acular)
LACRISERT - artificial tear ophth
insert
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
3
LASTACAFT - alcaftadine ophth soln 3

0.25%
1
latanoprost ophth soln 0.005%
(Xalatan)
3
LEVOBUNOLOL HCL - levobunolol
hcl ophth soln 0.25%
1
levobunolol hcl ophth soln 0.5%
(Betagan)
1
levofloxacin ophth soln 0.5%
LOTEMAX - loteprednol etabonate
ophth gel 0.5%

ophth oint 0.5%

ophth susp 0.5%
LUMIGAN - bimatoprost ophth soln

0.01%
MAXIDEX - dexamethasone ophth

susp 0.1%
MAXITROL - neomycin-polymyxindexamethasone ophth oint 0.1%
MAXITROL - neomycin-polymyxindexamethasone ophth susp 0.1%
METIPRANOLOL - metipranolol
ophth soln 0.3%
MITOSOL - mitomycin for ophth soln

kit 0.2 mg
MOXEZA - moxifloxacin hcl ophth

soln 0.5% (base eq) (2 times
daily)
MYDRIACYL - tropicamide ophth

soln 1%
NAPHAZOLINE HCL - naphazoline

hcl ophth soln 0.1%
NATACYN - natamycin ophth susp

5%
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op
oin
2
1
pilocarpine hcl ophth soln 1%

(Isopto carpine)

(Isopto carpine)

(Isopto carpine)
polymyxin b-trimethoprim
ophth soln 10000 unit/ml-0.1%
(Polytrim)
POLYTRIM - polymyxin btrimethoprim ophth soln 10000

unit/ml-0.1%
PRED FORTE - prednisolone

acetate ophth susp 1%
PRED MILD - prednisolone acetate

ophth susp 0.12%
PRED-G - gentamicin-prednisolone
ace ophth susp 0.3-1%
PRED-G S.O.P. - gentamicinprednisolone ace ophth oint

0.3-0.6%
neomycin-polymyxindexamethasone ophth oint 0.1%

(Maxitrol)
neomycin-polymyxindexamethasone ophth susp

0.1% (Maxitrol)
NEOMYCIN/POLYMYXIN/
HYDROC - neomycin-polymyxinhc ophth susp
NEOSPORIN - neomycinpolymy-gramicid op sol

1.75-10000-0.025mg-unt-mg/ml
NEVANAC - nepafenac ophth susp

0.1%
Responsible Steps
Quantity Limits
Prior Authorization
OCUFEN - flurbiprofen sodium ophth 3

soln 0.03%
3
OCUFLOX - ofloxacin ophth soln
0.3%
1
ofloxacin ophth soln 0.3%
(Ocuflox)
3
OMNIPRED - prednisolone acetate
ophth susp 1%
2
PATADAY - olopatadine hcl ophth
3
PATANOL - olopatadine hcl ophth
PAZEO - olopatadine hcl ophth soln 2
0.7% (base equivalent)
1
phenylephrine hcl ophth soln
2.5%
phenylephrine hcl ophth soln 10% 1
PHOSPHOLINE IODIDE echothiophate iodide ophth for
soln 0.125%
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml
(Neosporin)
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
129
prednisolone acetate ophth susp

1% (Pred forte)
PREDNISOLONE SODIUM
PHOSP - prednisolone sodium
phosphate ophth soln 1%
PROLENSA - bromfenac sodium

ophth soln 0.07% (base
equivalent)
proparacaine hcl ophth soln 0.5%

(Alcaine)
RESCULA - unoprostone isopropyl

ophth soln 0.15%
RESTASIS - cyclosporine (ophth)

emulsion 0.05%
SIMBRINZA - brinzolamidebrimonidine tartrate ophth susp

1-0.2%
SULFACETAMIDE SODIUM sulfacetamide sodium ophth oint

10%
sulfacetamide sodium ophth soln

10% (Bleph-10)
TIMOPTIC OCUDOSE - timolol

maleate preservative free ophth
soln 0.5%
TIMOPTIC-XE - timolol maleate

ophth gel forming soln 0.25%
TIMOPTIC-XE - timolol maleate

ophth gel forming soln 0.5%
TOBRADEX - tobramycindexamethasone ophth oint

0.3-0.1%
TOBRADEX - tobramycindexamethasone ophth susp

0.3-0.1%
TOBRADEX ST - tobramycindexamethasone ophth susp

0.3-0.05%
tobramycin ophth soln 0.3%

(Tobrex)
tobramycin-dexamethasone
ophth susp 0.3-0.1% (Tobradex)
TOBREX - tobramycin ophth oint

0.3%
TOBREX - tobramycin ophth soln

0.3%
3
2
TRAVATAN Z - travoprost ophth soln

0.004% (benzalkonium free) (bak
free)
TRAVOPROST - travoprost ophth

soln 0.004%
timolol maleate ophth soln 0.25%

(Timoptic)
trifluridine ophth soln 1%

(Viroptic)
timolol maleate ophth soln 0.5%

(Timoptic)
tropicamide ophth soln 0.5%
TIMOPTIC - timolol maleate ophth

soln 0.25%
sulfacetamide sodiumprednisolone ophth soln

10-0.23(0.25)%
tetracaine hcl ophth soln 0.5%
timolol maleate ophth gel forming
soln 0.25% (Timoptic-xe)
timolol maleate ophth gel forming
soln 0.5% (Timoptic-xe)
tropicamide ophth soln 1%

(Mydriacyl)
TRUSOPT - dorzolamide hcl ophth

soln 2%
TIMOPTIC - timolol maleate ophth

soln 0.5%
VEXOL - rimexolone ophth susp 1%
VIGAMOX - moxifloxacin hcl ophth

soln 0.5% (base equiv)
TIMOPTIC OCUDOSE - timolol

maleate preservative free ophth
soln 0.25%
VIROPTIC - trifluridine ophth soln

1%
130
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
ZYLET - loteprednol etabonatetobramycin ophth susp 0.5-0.3%
ZYMAXID - gatifloxacin ophth soln

0.5%
OTIC AGENTS
acetic acid otic soln 2%
ACETIC ACID/ALUMINUM ACET acetic acid 2% in aluminum

acetate otic soln
antipyrine-benzocaine otic soln

54-14 mg/ml (5.4-1.4%)
neomycin-polymyxin-hc otic susp

3.5 mg/ml-10000 unit/ml-1%
ofloxacin otic soln 0.3%
TREAGAN OTIC - antipyrinebenzocaine-polycosanol otic sol
5.4-1.4-0.0097%
MOUTH/THROAT/DENTAL AGENTS
benzocaine dental soln 20%
1
1
1
1
3
cevimeline hcl cap 30 mg (Evoxac) 1

1
chlorhexidine gluconate soln
0.12% (Peridex)
1
clotrimazole troche 10 mg
CETRAXAL - ciprofloxacin hcl otic

CIPRO HC - ciprofloxacinhydrocortisone otic susp 0.2-1%
EVOXAC - cevimeline hcl cap 30 mg 3

3
GELX - oral wound care products gel
lidocaine hcl laryngotracheal soln 1
4% (Lta 360 kit)
1
lidocaine hcl viscous soln 2%
3
CIPRODEX - ciprofloxacindexamethasone otic susp

0.3-0.1%
LTA 360 KIT - lidocaine hcl

laryngotracheal soln 4%
nystatin susp 100000 unit/ml
ORAVIG - miconazole buccal tab 50

mg (mouth-throat)
CIPROFLOXACIN - ciprofloxacin hcl

otic soln 0.2% (base equivalent)
PERIDEX - chlorhexidine gluconate

soln 0.12%
COLY-MYCIN S - neomycincolistin-hc-thonzonium otic susp

3.3-3-10-0.5 mg/ml
CORTISPORIN - neomycinpolymyxin-hc otic soln 1%
CORTISPORIN-TC - neomycincolistin-hc-thonzonium otic susp

3.3-3-10-0.5 mg/ml
pilocarpine hcl tab 5 mg (Salagen) 1

1
pilocarpine hcl tab 7.5 mg
(Salagen)
SALAGEN - pilocarpine hcl tab 5 mg 3
DERMOTIC - fluocinolone acetonide

(otic) oil 0.01%
fluocinolone acetonide (otic) oil
0.01% (Dermotic)
antipyrine-benzocainepolycosanol otic sol

5.4-1.4-0.0097% (Treagan otic)
ZIRGAN - ganciclovir ophth gel

0.15%
neomycin-polymyxin-hc otic soln

1% (Cortisporin)
Responsible Steps
Quantity Limits
Prior Authorization
ZIOPTAN - tafluprost ophth soln

0.0015%
hydrocortisone w/ acetic acid otic

soln 1-2%
Specialty
Drug Name
Drug Tier
XALATAN - latanoprost ophth soln

0.005%
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
SALAGEN - pilocarpine hcl tab 7.5

mg
triamcinolone acetonide dental

paste 0.1%
ANORECTAL AGENTS
131
ANALPRAM HC - hydrocortisone
acetate w/ pramoxine rectal cream
2.5-1%
hydrocortisone rectal cream 1%

(Proctocort)
hydrocortisone rectal cream 2.5%

(Anusol-hc)
ANALPRAM HC SINGLES hydrocortisone acetate w/

pramoxine rectal cream 2.5-1%
ANALPRAM-HC - hydrocortisone
1-1%
LIDOCAINE HCL-HYDROCORTIS lidocaine-hydrocortisone acetate

rectal gel 2.8-0.55%
2.5-1%
lidocaine-hydrocortisone acetate
rectal cream kit 3-0.5%
acetate w/ pramoxine rectal lotn
2.5-1%
ANALPRAM-HC SINGLES hydrocortisone acetate w/

pramoxine rectal cream 1-1%
ANALPRAM-HC SINGLES hydrocortisone acetate w/

ANUSOL-HC - hydrocortisone
acetate suppos 25 mg
ANUSOL-HC - hydrocortisone rectal

cream 2.5%
UCERIS - budesonide rectal foam 2

mg/act
CORTENEMA - hydrocortisone
enema 100 mg/60ml
DERMATOLOGICALS
CORTIFOAM - hydrocortisone
acetate rectal foam 10% (90 mg/
dose)
ACANYA - clindamycin phosphatebenzoyl peroxide gel 1.2-2.5%

acitretin cap 10 mg (Soriatane)
hydrocortisone acetate suppos

25 mg (Anusol-hc)
lidocaine-hydrocortisone acetate
rectal cream 3-0.5%
PROCORT - hydrocortisone acetate
w/ pramoxine rectal cream
1.85-1.15%
PROCTOCORT - hydrocortisone
acetate suppos 30 mg
PROCTOCORT - hydrocortisone
rectal cream 1%
Responsible Steps
Quantity Limits
PROCTOFOAM HC - hydrocortisone 2
acetate w/ pramoxine rectal foam
1-1%
3
RECTIV - nitroglycerin oint 0.4%
acitretin cap 17.5 mg (Soriatane)

acitretin cap 25 mg (Soriatane)
1
1
ACLOVATE - alclometasone
dipropionate cream 0.05%
hydrocortisone acetate w/
pramoxine rectal cream 1-1%
(Analpram-hc)
ACUICYN DAILY EYELID & EY eyelid cleansers - liquid
acyclovir oint 5% (Zovirax)
hydrocortisone acetate w/
(Analpram-hc)
hydrocortisone enema
100 mg/60ml (Cortenema)
132
Prior Authorization
hydrocortisone acetate suppos

30 mg (Proctocort)
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
ACZONE - dapsone gel 5%
ADAPALENE - adapalene lotion

0.1%
adapalene cream 0.1% (Differin)
adapalene gel 0.1% (Differin)
adapalene gel 0.3% (Differin)
ALA SCALP - hydrocortisone lotion

2%
BENSAL HP - salicylic acid &

benzoic acid oint 3-6%
ALA-QUIN - clioquinol-hc cream

3-0.5%
BENZAC AC WASH - benzoyl

peroxide liq 5%
alclometasone dipropionate
cream 0.05% (Aclovate)
BENZAC W WASH - benzoyl

peroxide liq 5%
BENZACLIN - clindamycin
phosphate-benzoyl peroxide gel
1-5%
BENZACLIN WITH PUMP clindamycin phosphate-benzoyl

peroxide gel 1-5%
BENZAMYCIN - benzoyl peroxideerythromycin gel 5-3%
3
3
alclometasone dipropionate oint

0.05%
ALDARA - imiquimod cream 5%
ALOQUIN - iodoquinol-aloe
polysaccharides gel 1.25-1%
ALTABAX - retapamulin oint 1%
AMCINONIDE - amcinonide cream

0.1%
AMCINONIDE - amcinonide lotion

0.1%
BENZAMYCINPAK - benzoyl
peroxide-erythromycin gel pack
5-3%
BENZIQ - benzoyl peroxide gel 5.25

%
AMCINONIDE - amcinonide oint

0.1%
BENZIQ LS - benzoyl peroxide gel

2.75%
ANACAINE - benzocaine oint 10%
APEXICON E - diflorasone diacetate

emollient base cream 0.05%
benzoyl peroxide cloth 6%
ARZOL SILVER NITRATE APP silver nitrate-potassium nitrate

applicator 75-25%
ATRALIN - tretinoin gel 0.05%
benzoyl peroxide liq 10%
AVAR - sulfacetamide sodium w/

sulfur foam 9.5-5%
benzoyl peroxide liq 5.25%
AVAR LS - sulfacetamide sodium w/

sulfur foam 10-2%
AVAR LS CLEANSER sulfacetamide sodium w/ sulfur

cleanser 10-2%
benzoyl peroxide gel 10%

benzoyl peroxide liq 2.5%
benzoyl peroxide liq 7%
benzoyl peroxide lotion 6%
Responsible Steps
Quantity Limits
1
1
1
1
1
1
AVAR-E LS - sulfacetamide sodium

w/ sulfur cream 10-2%
betamethasone dipropionate
augmented cream 0.05%
(Diprolene af)
AZELEX - azelaic acid cream 20%
augmented gel 0.05%
BACTROBAN - mupirocin calcium

cream 2%
BACTROBAN - mupirocin oint 2%
Prior Authorization
benzoyl peroxideerythromycin gel 5-3%

(Benzamycin)
augmented lotion 0.05%
(Diprolene)
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
133
augmented oint 0.05%
(Diprolene)
cream 0.05%
lotion 0.05%
betamethasone dipropionate oint
0.05%
betamethasone valerate aerosol
foam 0.12% (Luxiq)
betamethasone valerate cream
0.1%
betamethasone valerate lotion
0.1%
betamethasone valerate oint 0.1%
ciclopirox olamine susp 0.77%

(base equiv)
1
1
1
1
1
3
BPO - benzoyl peroxide gel 4%
BPO - benzoyl peroxide gel 8%
calcipotriene cream 0.005%

(Dovonex)
calcipotriene oint 0.005%
1
1
calcipotriene-betamethasone
dipropionate oint 0.005-0.064%
(Taclonex)
CALCITRIOL - calcitriol oint 3 mcg/

gm
CENTANY - mupirocin oint 2%
CENTANY AT - mupirocin oint kit 2% 3

CETACAINE - butamben-tetracaine- 3
benzocaine aerosol spray
2-2-14%
134
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Tier
ciclopirox olamine cream 0.77%

(base equiv)
CAMPHOMEX - camphor-histamine- 3
menthol liqd spray 4-0.025-10%
2
CAPEX - fluocinolone acetonide
shampoo 0.01%
2
CARAC - fluorouracil cream 0.5%
Drug Name
ciclopirox gel 0.77%
BP CLEANSING WASH sulfacetamide sodium-sulfur in

urea emulsion 10-4%
calcipotriene soln 0.005%

(50 mcg/ml)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
ciclopirox shampoo 1% (Loprox

shampoo)
ciclopirox solution 8% (Penlac

Nail Lacquer)
CLARAVIS - isotretinoin cap 30 mg
CLARIFOAM EF - sulfacetamide
sodium w/ sulfur foam 10-5%
CLEOCIN-T - clindamycin phosphate 3

gel 1%
lotion 1%
soln 1%
swab 1%
3
CLINDAGEL - clindamycin
phosphate gel 1%
1
clindamycin phosph-benzoyl
peroxide (refrig) gel 1.2 (1)-5%
(Duac)
1
clindamycin phosphate foam 1%
(Evoclin)
1
clindamycin phosphate gel 1%
(Cleocin-t)
clindamycin phosphate lotion 1% 1
(Cleocin-t)
1
clindamycin phosphate soln 1%
(Cleocin-t)
1
clindamycin phosphate swab 1%
(Cleocin-t)
1
clindamycin phosphate-benzoyl
peroxide gel 1-5% (Benzaclin)
1
clobetasol propionate cream
0.05% (Temovate)
1
clobetasol propionate emollient
base cream 0.05% (Temovate e)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
CORDRAN - flurandrenolide cream

0.05%
clobetasol propionate foam 0.05%

(Olux)
CORDRAN - flurandrenolide lotion

0.05%
clobetasol propionate gel 0.05%

(Temovate)
CORDRAN - flurandrenolide oint

0.05%
clobetasol propionate lotion

0.05% (Clobex)
CORDRAN TAPE - flurandrenolide

tape 4 mcg/sqcm
clobetasol propionate oint 0.05%

(Temovate)
clobetasol propionate shampoo

0.05% (Clobex)
CORTANE-B - hydrocortisonepramoxine-chloroxylenol lot

10-10-1mg/ml
clobetasol propionate soln 0.05%

(Temovate)
CORTISPORIN - bacitracinpolymyxin-neomycin hc oint 1%
clobetasol propionate spray

0.05% (Clobex)
CORTISPORIN - neomycinpolymyxin-hc cream 0.5%

COSENTYX - secukinumab
syringe 150 mg/ml
COSENTYX SENSOREADY PEN secukinumab subcutaneous soln

auto-injector 150 mg/ml
CUTIVATE - fluticasone propionate

cream 0.05%
CUTIVATE - fluticasone propionate

lotion 0.05%
DENAVIR - penciclovir cream 1%
DERMA-SMOOTHE/FS BODY fluocinolone acetonide oil 0.01%

(body oil)
DERMA-SMOOTHE/FS SCALP fluocinolone acetonide oil 0.01%

(scalp oil)
DERMAPAK PLUS - tretinoin cr

0.025% & men-zinc ox oint &
silicone tape pak
DERMATOP - prednicarbate cream

0.1%
COLLIGINIX - dimethicone-allantoin
bandage 5-2%
DERMATOP - prednicarbate oint

0.1%
CONDYLOX - podofilox gel 0.5%
DESONATE - desonide gel 0.05%
CONDYLOX - podofilox soln 0.5%
desonide cream 0.05% (Desowen)
clobetasol propionate emulsion

foam 0.05% (Olux-e)
CLOBEX - clobetasol propionate

lotion 0.05%

shampoo 0.05%

spray 0.05%
CLOCORTOLONE PIVALATE clocortolone pivalate cream 0.1%
CLOCORTOLONE PIVALATE PUM - 3

clocortolone pivalate cream 0.1%
3
CLODERM - clocortolone pivalate
cream 0.1%
3
CLODERM PUMP - clocortolone
pivalate cream 0.1%
1
clotrimazole cream 1%
clotrimazole soln 1%
clotrimazole w/ betamethasone
cream 1-0.05% (Lotrisone)
clotrimazole w/ betamethasone
lotion 1-0.05%
1
1
135
desonide lotion 0.05% (Desowen)

desonide oint 0.05% (Desowen)
econazole nitrate cream 1%
DESOWEN - desonide cream 0.05% 3

DESOWEN - desonide lotion 0.05% 3
EFUDEX - fluorouracil cream 5%
ELIDEL - pimecrolimus cream 1%
ELIMITE - permethrin cream 5%
3
3
DESOXIMETASONE desoximetasone cream 0.05%
ELOCON - mometasone furoate

cream 0.1%
DESOXIMETASONE desoximetasone oint 0.05%
ELOCON - mometasone furoate oint

0.1%
desoximetasone cream 0.25%

(Topicort)
ELOCON - mometasone furoate

solution 0.1% (lotion)
desoximetasone gel 0.05%

(Topicort)
EMLA - lidocaine-prilocaine cream

2.5-2.5%
desoximetasone oint 0.25%

(Topicort)
EPIDUO - adapalene-benzoyl
peroxide gel 0.1-2.5%
diclofenac sodium (actinic

keratoses) gel 3% (Solaraze)
EPIDUO FORTE - adapalenebenzoyl peroxide gel 0.3-2.5%

EPIFOAM - pramoxine-hc aerosol
foam 1-1%
ERTACZO - sertaconazole nitrate

cream 2%
ERYGEL - erythromycin gel 2%
erythromycin gel 2% (Erygel)
diclofenac sodium soln 1.5%
DIFFERIN - adapalene cream 0.1%
DIFFERIN - adapalene gel 0.1%
DIFFERIN - adapalene gel 0.3%
DIFFERIN - adapalene lotion 0.1%
DIFLORASONE DIACETATE diflorasone diacetate cream

0.05%
DIFLORASONE DIACETATE diflorasone diacetate oint 0.05%
DIPROLENE - betamethasone
dipropionate augmented lotion
0.05%
DIPROLENE - betamethasone
dipropionate augmented oint
0.05%
DIPROLENE AF - betamethasone
dipropionate augmented cream
0.05%
DOVONEX - calcipotriene cream

0.005%
DUAC - clindamycin phosph-benzoyl 3

peroxide (refrig) gel 1.2 (1)-5%
136
erythromycin pads 2%
erythromycin soln 2%
Responsible Steps
Quantity Limits
Prior Authorization
DESOWEN - desonide oint 0.05%
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
ESSENTRA WIPES 9X9" CLEAN isopropyl alcohol wipes 70%
EURAX - crotamiton cream 10%
EURAX - crotamiton lotion 10%
EVOCLIN - clindamycin phosphate

foam 1%
EXELDERM - sulconazole nitrate

cream 1%
EXELDERM - sulconazole nitrate

solution 1%
EXTINA - ketoconazole foam 2%
FINACEA - azelaic acid foam 15%
FINACEA - azelaic acid gel 15%
FLECTOR - diclofenac epolamine

patch 1.3%
GENTAMICIN SULFATE gentamicin sulfate cream 0.1%
GENTAMICIN SULFATE gentamicin sulfate oint 0.1%
fluocinolone acetonide oil 0.01%

(body oil) (Derma-smoothe/fs
bod)
fluocinolone acetonide oil 0.01%

(scalp oil) (Derma-smoothe/fs
sca)
fluocinolone acetonide oint

0.025% (Synalar)
GORDOFILM - salicylic & lactic acids 3

soln 16.7-16.7%
GRANULEX - trypsin w/ castor oil & 3
peruvian balsam spray
1
halobetasol propionate cream
0.05% (Ultravate)
halobetasol propionate oint 0.05% 1
(Ultravate)
3
HALOG - halcinonide cream 0.1%
fluocinolone acetonide cream

0.01%
fluocinolone acetonide cream
0.025% (Synalar)
fluocinolone acetonide soln

0.01% (Synalar)
fluocinonide cream 0.05%
fluocinonide cream 0.1% (Vanos)
fluocinonide emulsified base
cream 0.05%
fluocinonide gel 0.05%
fluocinonide oint 0.05%
HALOG - halcinonide oint 0.1%
HALOTIN - haloprogin cream 1%
HYDRO 35 - urea in lactic acid

vehicle foam 35%
hydrocortisone butyrate cream

0.1% (Locoid)
1
1
FLUOROPLEX - fluorouracil cream

1%
FLUOROURACIL - fluorouracil
cream 0.5%
hydrocortisone butyrate oint 0.1%

(Locoid)
fluorouracil cream 5% (Efudex)
hydrocortisone butyrate soln

0.1% (Locoid)
hydrocortisone cream 1%
hydrocortisone cream 2.5%
hydrocortisone lotion 2% (Ala

scalp)
hydrocortisone lotion 2.5%
fluocinonide soln 0.05%
fluorouracil soln 2%
fluorouracil soln 5%
fluticasone propionate cream
0.05% (Cutivate)
fluticasone propionate lotion
0.05% (Cutivate)
fluticasone propionate oint
0.005%
GEBAUERS PAIN EASE pentafluoropropanetetrafluoroethane aero spray
GEBAUERS SPRAY AND

STRETC - pentafluoropropanetetrafluoroethane aero spray
hydrocortisone oint 1%
hydrocortisone oint 2.5%
hydrocortisone valerate cream
0.2%
Responsible Steps
1
1
1
1
imiquimod cream 5% (Aldara)
Quantity Limits
hydrocortisone valerate oint 0.2%

(Westcort)
iodoquinol-hc cream 1%
Prior Authorization
hydrocortisone butyrate
hydrophilic lipo base cream
0.1% (Locoid lipocream)
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
137
iodoquinol-hydrocortisone in aloe
vehicle cream 1-1.9% (Vytone)
isotretinoin cap 10 mg
ketoconazole foam 2% (Extina)
LIDOZOL - lidocaine hcl cream

3.75%
lindane lotion 1%
lindane shampoo 1%
1
1
1
1
LOCOID - hydrocortisone butyrate

lotion 0.1%

oint 0.1%

soln 0.1%
KLARON - sulfacetamide sodium

lotion 10% (acne)
3
3
LOPROX SHAMPOO - ciclopirox

shampoo 1%
LAC-HYDRIN - lactic acid

(ammonium lactate) cream 12%
LOTRISONE - clotrimazole w/
betamethasone cream 1-0.05%
LAC-HYDRIN - lactic acid

(ammonium lactate) lotion 12%
LUXIQ - betamethasone valerate

aerosol foam 0.12%
lactic acid (ammonium lactate)

cream 12% (Lac-hydrin)
malathion lotion 0.5% (Ovide)
MEDI-DERM-RX - capsaicinmenthol-methyl salicylate cream

0.035-5-20%
MEDI-DERM/L-RX - lidocainecapsaicin-menthol-methyl sal

cream 2-0.035-5-20%
MEDROX-RX - capsaicin-mentholmethyl salicylate oint 0.05-7-20%
LAMISIL SPRAY - terbinafine hcl

soln 1%
LDO PLUS - lidocaine hcl gel 4%
LEVULAN KERASTICK aminolevulinic acid hcl for soln

20% (stick applicator)
lidocaine hcl gel 2%
MENTAX - butenafine hcl cream 1%
MENTHOLIX - lidocaine-menthol
liquid spray 4-1%
methoxsalen rapid cap 10 mg

(Oxsoralen ultra)
METROCREAM - metronidazole
cream 0.75%
METROGEL - metronidazole gel 1%
METROLOTION - metronidazole
lotion 0.75%
lidocaine oint 5%
lidocaine patch 5% (Lidoderm)
lidocaine-prilocaine cream
2.5-2.5% (Emla)
lidocaine-prilocaine kit 2.5-2.5%
1
1
1
1
LIDODERM - lidocaine patch 5%
LIDOVIN - lidocaine hcl cream

3.95%
138
Responsible Steps
LOCOID LIPOCREAM hydrocortisone butyrate

hydrophilic lipo base cream 0.1%
lidocaine hcl soln 4% (Xylocaine)
Quantity Limits
lactic acid (ammonium lactate)

lotion 12% (Lac-hydrin)
Prior Authorization

cream 0.1%
ketoconazole shampoo 2%
(Nizoral)
Specialty
Drug Tier
Drug Name
KENALOG - triamcinolone acetonide 3

aerosol soln 0.147 mg/gm
3
KERALYT - salicylic acid gel 6%
ketoconazole cream 2%
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
metronidazole cream 0.75%

(Metrocream)
OLUX - clobetasol propionate foam

0.05%
metronidazole gel 0.75%
OLUX-E - clobetasol propionate

emulsion foam 0.05%
metronidazole gel 1% (Metrogel)
metronidazole lotion 0.75%

(Metrolotion)
OPTASE - trypsin w/ castor oil &

peruvian balsam gel
METVIXIA - methyl aminolevulinate

hcl cream 16.8% (base equiv)
OVACE PLUS - sulfacetamide

sodium cream 10%
mometasone furoate cream 0.1%

(Elocon)
OVACE PLUS - sulfacetamide

sodium shampoo 10%
mometasone furoate oint 0.1%

(Elocon)
OVIDE - malathion lotion 0.5%
mometasone furoate solution

0.1% (lotion) (Elocon)
mupirocin calcium cream 2%

(Bactroban)
mupirocin oint 2% (Bactroban)
naftifine hcl cream 1% (Naftin)
NAFTIN - naftifine hcl cream 1%
NAFTIN - naftifine hcl cream 2%
NAFTIN - naftifine hcl gel 1%
NAFTIN - naftifine hcl gel 2%
NATROBA - spinosad susp 0.9%
NIZORAL - ketoconazole shampoo

2%
OXISTAT - oxiconazole nitrate cream 3

1%
OXISTAT - oxiconazole nitrate lotion 3
1%
3
OXSORALEN - methoxsalen lotion
1%
OXSORALEN ULTRA - methoxsalen 3
rapid cap 10 mg
PANDEL - hydrocortisone probutate 3
cream 0.1%
3
PANRETIN - alitretinoin gel 0.1%
PENLAC NAIL LACQUER ciclopirox solution 8%
PENNSAID - diclofenac sodium soln

2%
NOVACORT - hydrocortisone acepramoxine-aloe polysacch gel

2-1-1%
permethrin cream 5% (Elimite)
NUCORT - hydrocortisone acetate

lotion 2%
NUOX - benzoyl peroxide-sulfur gel

6-3%
nystatin cream 100000 unit/gm
nystatin oint 100000 unit/gm

nystatin topical powder
nystatin-triamcinolone cream
100000-0.1 unit/gm-%
nystatin-triamcinolone oint
100000-0.1 unit/gm-%
PICATO - ingenol mebutate gel

0.015%
PICATO - ingenol mebutate gel

0.05%
PLEXION - sulfacetamide sodium w/

sulfur cream 9.8-4.8%
PLEXION - sulfacetamide sodium w/

sulfur lotion 9.8-4.8%
3
3
PLEXION CLEANSER sulfacetamide sodium w/ sulfur

cleanser 9.8-4.8%
podofilox soln 0.5% (Condylox)
1
1
PRAMOSONE - pramoxine-hc
cream 1-1%
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
139
PRAMOSONE - pramoxine-hc
cream 1-2.5%
RETIN-A MICRO PUMP - tretinoin

microsphere gel 0.04%
PRAMOSONE - pramoxine-hc lotion

1-1%

PRAMOSONE - pramoxine-hc lotion

1-2.5%

PRAMOSONE - pramoxine-hc oint

1-1%
ROSULA - sulfacetamide sodium w/

sulfur wash 10-4.5%
PRAMOSONE - pramoxine-hc oint

1-2.5%
SALEX - salicylic acid shampoo 6%
PRAMOSONE E - pramoxine-hc
emollient base cream 1-2.5%
pramoxine hcl gel 1%
SALICYLIC ACID - salicylic acid soln 3

26%
1
salicylic acid cream 6%
pramoxine-hc cream 1-2.5%

(Pramosone)
prednicarbate cream 0.1%

(Dermatop)
prednicarbate oint 0.1%

(Dermatop)
PROTOPIC - tacrolimus oint 0.03%
PROTOPIC - tacrolimus oint 0.1%
PROZENA - lidocaine patch 4%
PRUDOXIN - doxepin hcl cream 5%
PSORCON - diflorasone diacetate

cream 0.05%
PYROGALLIC ACID - pyrogallolchlorobutanol oint 25-2%
salicylic acid film forming liquid

27.5% (Virasal)
salicylic acid foam 6% (Salvax)
salicylic acid gel 6% (Keralyt)
Responsible Steps
Quantity Limits
1
1
3
salicylic acid lotion 6%
SANTYL - collagenase oint 250 unit/

gm
REGENECARE - lidocaine hclcollagen-aloe vera gel 2%
selenium sulfide lotion 2.5%
REGRANEX - becaplermin gel

0.01%
selenium sulfide-pyrithione zinc

in urea shampoo 2.25%
SILVADENE - silver sulfadiazine
cream 1%
RETIN-A - tretinoin cream 0.025%
SILVER NITRATE - silver nitrate oint

10%
RETIN-A - tretinoin gel 0.01%
RETIN-A - tretinoin gel 0.025%
RETIN-A MICRO - tretinoin

RETIN-A MICRO - tretinoin

140
Prior Authorization
SALICYLIC ACID IN AMMONIU salicylic acid in ammonium lactate

vehicle foam 6%
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
salicylic acid shampoo 6% (Salex) 1

3
SALKERA - salicylic acid in
ammonium lactate vehicle foam
6%
3
SALVAX - salicylic acid foam 6%
SILVER NITRATE - silver nitrate soln 3

0.5%
10%
25%

50%
1
silver nitrate-potassium nitrate
applicator 75-25% (Arzol silver
nitrate)
1
silver sulfadiazine cream 1%
(Silvadene)
3
SKLICE - ivermectin lotion 0.5%
SODIUM SULFACETAMIDE WASH - 3
sulfacetamide sodium in bakuchiol
vehicle wash 10%
SODIUM SULFACETAMIDE/SULF - 3
sulfacetamide sodium-sulfur in
urea emulsion 10-5%
SODIUM SULFACETAMIDE/SULF - 3
sulfacetamide sodium-sulfur in
urea gel 10-5%
3
SOLARAZE - diclofenac sodium
(actinic keratoses) gel 3%
SOOLANTRA - ivermectin cream 1% 3
SORIATANE - acitretin cap 17.5 mg
SORIATANE - acitretin cap 25 mg
SORILUX - calcipotriene foam

0.005%
SPINOSAD - spinosad susp 0.9%
STELARA - ustekinumab soln

STELARA - ustekinumab soln

prefilled syringe 90 mg/ml
sulfacetamide sodium
cleansing gel 10% (Ovace plus
wash)
sulfacetamide sodium liquid 10%

(Ovace wash)
sulfacetamide sodium lotion 10%
(acne) (Klaron)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Tier
Drug Name
sulfacetamide sodium w/ sulfur
cleanser 9.8-4.8% (Plexion
cleanser)
SORIATANE - acitretin cap 10 mg
sulfacetamide sodium shampoo

10% (Ovace plus)
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
cleanser 10-2% (Avar ls cleanser)
1
cream 9.8-4.8% (Plexion)
1
cream 10-2% (Avar-e ls)
1
cream 10-5%
1
emulsion 10-1%
1
emulsion 10-5%
1
foam 10-5% (Clarifoam ef)
1
lotion 9.8-4.8% (Plexion)
1
lotion 10-5%
1
susp 8-4% (Sumaxin ts)
1
wash 9-4% (Sumaxin wash)
1
wash 9-4.5% (Sumadan wash)
3
SULFAMYLON - mafenide acetate
cream 85 mg/gm
3
SULFAMYLON - mafenide acetate
packet for topical soln 5% (50 gm)
3
SULFOAM - sulfur shampoo 2%
3
SUMADAN WASH - sulfacetamide

sodium w/ sulfur wash 9-4.5%
SUMAXIN WASH - sulfacetamide

sodium w/ sulfur wash 9-4%
SYNALAR - fluocinolone acetonide

cream 0.025%
oint 0.025%
141

soln 0.01%
TOPICORT - desoximetasone gel

0.05%
SYNERA - lidocaine-tetracaine
topical patch 70-70 mg
TACLONEX - calcipotrienebetamethasone dipropionate oint

0.005-0.064%
TOPICORT - desoximetasone oint

0.05%
TOPICORT - desoximetasone oint
0.25%
TOPICORT - desoximetasone spray

0.25%
TACLONEX - calcipotrienebetamethasone dipropionate susp

0.005-0.064%
tretinoin cream 0.025% (Retin-a)
tacrolimus oint 0.03% (Protopic)
tacrolimus oint 0.1% (Protopic)

TARGRETIN - bexarotene gel 1%

1
3
TAZORAC - tazarotene cream 0.05% 2

TAZORAC - tazarotene cream 0.1% 2
tretinoin gel 0.01% (Retin-a)
tretinoin gel 0.025% (Retin-a)

tretinoin gel 0.05% (Atralin)
TEMOVATE - clobetasol propionate

cream 0.05%
TRIAMCINOLONE ACETONIDE triamcinolone acetonide oint 0.5%

gel 0.05%
triamcinolone acetonide aerosol

soln 0.147 mg/gm (Kenalog)

oint 0.05%

soln 0.05%
triamcinolone acetonide cream

0.025%
TEMOVATE E - clobetasol
propionate emollient base cream
0.05%

0.1%
TERSI FOAM - selenium sulfide

foam 2.25%
TETRAMEX - tetracaine-mentholcamphor liqd spray 2-1-3%
TEXACORT - hydrocortisone soln

2.5%
TOLAK - fluorouracil cream 4%
TOPICORT - desoximetasone cream 3

0.05%
TOPICORT - desoximetasone cream 3
0.25%
142
triamcinolone acetonide lotion

0.025%
triamcinolone acetonide lotion
0.1%
triamcinolone acetonide oint
0.025%
triamcinolone acetonide oint 0.1%
TRIAMSIL COMBIPAK triamcinolone acet cr 0.1% &
silicone gel 5% therapy pack

0.5%
Responsible Steps
tretinoin microsphere gel 0.1%

(Retin-a micro pump)
Quantity Limits
TAZORAC - tazarotene gel 0.1%
Prior Authorization
tretinoin microsphere gel 0.04%

(Retin-a micro)
TAZORAC - tazarotene gel 0.05%
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
1
1
1
1
1
3
TRIAMSIL MULTIPAK triamcinolone cr 0.1% & silicon gel

5% & silicon tape pack
WHYTEDERM TDPAK triamcinolone acet cr 0.1% &

dimeth cr 2% & silicone tape
TRIANEX - triamcinolone acetonide

oint 0.05%
XENADERM - trypsin w/ castor oil &

peruvian balsam oint
trypsin w/ castor oil & peruvian

balsam spray (Granulex)
XERESE - acyclovir-hydrocortisone
cream 5-1%
ULESFIA - benzyl alcohol lotion 5%
XOLEGEL - ketoconazole gel 2%
ULTRAVATE - halobetasol
propionate cream 0.05%
XYLOCAINE - lidocaine hcl soln 4%
ZACLIR CLEANSING - benzoyl

peroxide lotion 8%
ULTRAVATE - halobetasol
propionate oint 0.05%
ZENATANE - isotretinoin cap 30 mg
UMECTA PD - urea-hyaluronate
sodium emulsion 40-0.3%
ZONALON - doxepin hcl cream 5%
UMECTA PD - urea-hyaluronate
sodium susp 40-0.3%
ZOVIRAX - acyclovir cream 5%
ZOVIRAX - acyclovir oint 5%
URAMAXIN - urea in ammonium

lactate vehicle foam 20%
ZYCLARA - imiquimod cream 3.75%
urea in lactic acid vehicle foam

35% (Hydro 35)
VALCHLOR - mechlorethamine hcl

gel 0.016% (base equivalent)
VANOS - fluocinonide cream 0.1%
VANOXIDE-HC - benzoyl peroxidehc lotion 5-0.5%
VECTICAL - calcitriol oint 3 mcg/gm
VERDESO - desonide foam 0.05%
VEREGEN - sinecatechins oint 15%
VIRASAL - salicylic acid film forming

liquid 27.5%
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
ZYCLARA PUMP - imiquimod cream 3

2.5%
ZYCLARA PUMP - imiquimod cream 3
3.75%
2
8-MOP - methoxsalen cap 10 mg
MISCELLANEOUS PRODUCTS
ANTIDOTES
CHEMET - succimer cap 100 mg
EVZIO - naloxone hcl solution autoinjector 0.4 mg/0.4ml
3
4
EXJADE - deferasirox tab for oral

susp 125 mg
VOLTAREN - diclofenac sodium gel

1%

susp 250 mg
VUSION - miconazole-zinc
oxide-white petrolatum oint
0.25-15-81.35%

susp 500 mg
FERRIPROX - deferiprone tab 500
mg
JADENU - deferasirox tab 90 mg
VYTONE - iodoquinol-hydrocortisone 3
in aloe vehicle cream 1-1.9%
3
WESTCORT - hydrocortisone
valerate oint 0.2%
NALOXONE HCL - naloxone hcl inj 1 3

mg/ml
143
naloxone hcl inj 0.4 mg/ml

naltrexone hcl tab 50 mg (Revia)
1
1
RADIOGARDASE - prussian blue

insoluble cap 0.5 gm
AGAMATRIX KEYNOTE TEST ST glucose blood test strip
REVIA - naltrexone hcl tab 50 mg
AGAMATRIX PRESTO TEST STR glucose blood test strip
DIAGNOSTIC PRODUCTS
ACCU-CHEK ACTIVE STRIPS glucose blood test strip
ASCENSIA AUTODISC TEST ST glucose blood test disk
ACCU-CHEK AVIVA - glucose blood

test strip
ASSURE II - glucose blood test strip
ACCU-CHEK AVIVA PLUS - glucose

blood test strip
ACCU-CHEK COMFORT CURVE

T - glucose blood test strip
ACCU-CHEK COMPACT PLUS glucose blood test strip
ACCU-CHEK COMPACT STRIPS glucose blood test strip
ACCU-CHEK COMPACT TEST DR - 3

glucose blood test strip
ACCU-CHEK SMARTVIEW STRIP - 3
ACCUTREND GLUCOSE - glucose 3
blood test strip
ACETEST - acetone (urine) test tab 2
ACURA BLOOD GLUCOSE TEST glucose blood test strip
ADVANCE INTUITION TEST ST glucose blood test strip
ADVANCE MICRO-DRAW TEST S glucose blood test strip
ADVOCATE REDI-CODE - glucose

blood test strip
ADVOCATE REDI-CODE+ TEST glucose blood test strip
ADVOCATE TEST STRIPS - glucose 3

blood test strip
AGAMATRIX AMP NO CODE TES - 3
144
ASSURE II CHECK STRIP - glucose 3

blood test strip
ASSURE II TEST STRIPS - glucose 3
blood test strip
3
ASSURE PLATINUM TEST STRI glucose blood test strip
3
ASSURE PRISM MULTI TEST S glucose blood test strip
3
ASSURE PRO TEST STRIPS glucose blood test strip
ASSURE 3 TEST STRIPS - glucose 3
blood test strip
ASSURE 4 TEST STRIPS - glucose 3
blood test strip
3
AT LAST TEST STRIPS - glucose
blood test strip
2
BAYER BREEZE 2 TEST DISC glucose blood test disk
2
BAYER CONTOUR BLOOD
GLUCO - glucose blood test strip
BAYER CONTOUR NEXT BLOOD - 2
BG STAR BLOOD GLUCOSE TES - 3
BIOSCANNER GLUCOSE TEST S - 3
BLOOD GLUCOSE TEST STRIPS - 3
3
CAREONE BLOOD GLUCOSE
TES - glucose blood test strip
CARESENS N BLOOD GLUCOSE - 3
AGAMATRIX JAZZ TEST STRIP glucose blood test strip
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
EASY TRAK BLOOD GLUCOSE T glucose blood test strip
CHEK-STIX CONTROL - acetone

(urine) test strip
EASYGLUCO - glucose blood test

strip
EASYGLUCO PLUS - glucose blood

test strip
EASYMAX TEST STRIPS - glucose

blood test strip
EASYMAX 15 TEST STRIPS glucose blood test strip
EASYPLUS BLOOD GLUCOSE TE - 3

3
EASYPRO BLOOD GLUCOSE
3
EASYPRO PLUS - glucose blood
test strip
3
ECLIPSE TEST STRIPS - glucose
blood test strip
ELEMENT COMPACT TEST STRI - 3
3
ELEMENT PLUS TEST STRIPS glucose blood test strip
ELEMENT TEST STRIPS - glucose 3
blood test strip
3
EMBRACE BLOOD GLUCOSE
3
EMBRACE EVO BLOOD
GLUCOSE - glucose blood test
strip
3
EMBRACE PRO BLOOD
strip
3
ENVISION AUTOCODE TEST ST glucose blood test strip
EQ BLOOD GLUCOSE TEST STR - 3
EQL TRUETEST BLOOD GLUCOS - 3
3
EQL TRUETRACK TEST - glucose
blood test strip
CHEMSTRIP-K - acetone (urine) test 2

strip
3
CHOICE DM FORA G20 TEST S glucose blood test strip
CLEVER CHEK AUTO-CODE TES - 3
CLEVER CHEK AUTO-CODE VOI - 3
3
CLEVER CHEK TEST STRIPS glucose blood test strip
CLEVER CHOICE AUTO-CODE P - 3
3
CLEVER CHOICE MICRO TEST glucose blood test strip
CONTROL AST - glucose blood test 3
strip
CONTROL TEST STRIPS - glucose 3
blood test strip
3
CVS ADVANCED GLUCOSE
METE - glucose blood test strip
DIATRUE PLUS BLOOD GLUCOS - 3
DUO-CARE TEST STRIPS - glucose 3
blood test strip
EASY PLUS BLOOD GLUCOSE T - 3
3
EASY PLUS II BLOOD GLUCOS glucose blood test strip
3
EASY STEP TEST STRIPS glucose blood test strip
EASY TALK BLOOD GLUCOSE T - 3
EASY TOUCH GLUCOSE TEST S - 3
EASY TOUCH HEALTHPRO GLUC - 3
CHEK-STIX COMBO PAK URINA acetone (urine) test strip
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
145
EVENCARE G3 TEST STRIPS glucose blood test strip
EVENCARE MINI BLOOD GLUCO glucose blood test strip
EVOLUTION AUTOCODE - glucose

blood test strip
EXACTECH R-S-G TEST STRIP glucose blood test strip
EXACTECH TEST STRIPS - glucose 3

blood test strip
EZ SMART BLOOD GLUCOSE TE - 3
EZ SMART PLUS BLOOD GLUCO - 3
FASTTAKE TEST STRIPS - glucose 3
blood test strip
3
FIFTY50 GLUCOSE TEST STRI glucose blood test strip
FORA D10 BLOOD GLUCOSE TE - 3
FORA D15C BLOOD GLUCOSE T - 3
FORA D15G BLOOD GLUCOSE T - 3
FORA D15Z BLOOD GLUCOSE T - 3
FORA D20 BLOOD GLUCOSE TE - 3
3
FORA GD20 TEST STRIPS glucose blood test strip
FORA GD50 BLOOD GLUCOSE T - 3
FORA G20 BLOOD GLUCOSE TE - 3
146
FORA G71A BLOOD GLUCOSE T glucose blood test strip
FORA G90 BLOOD GLUCOSE TE glucose blood test strip
FORA TEST N' GO BLOOD GLU glucose blood test strip
FORA V10 BLOOD GLUCOSE TE glucose blood test strip
FORA V30A BLOOD GLUCOSE T glucose blood test strip
FORACARE GD40 - glucose blood

test strip
FORACARE PREMIUM V10 TEST glucose blood test strip
FORACARE TEST N GO TEST S glucose blood test strip
FREESTYLE INSULINX BLOOD glucose blood test strip
FREESTYLE LITE TEST STRIP glucose blood test strip
FREESTYLE TEST STRIPS glucose blood test strip
GE100 BLOOD GLUCOSE TEST glucose blood test strip
GHT TEST STRIPS - glucose blood

test strip
GLUCAGEN DIAGNOSTIC glucagon hcl (rdna) diagnostic for

GLUCO PERFECT 3 TEST STRI glucose blood test strip
GLUCOCARD EXPRESSION
BLOO - glucose blood test strip
EVENCARE G2 TEST STRIPS glucose blood test strip
FORA G30A BLOOD GLUCOSE T glucose blood test strip
Responsible Steps
Quantity Limits
Prior Authorization
EVENCARE BLOOD GLUCOSE

TE - glucose blood test strip
Specialty
Drug Name
Drug Tier
EVENCARE + BLOOD GLUCOSE glucose blood test strip
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
GLUCOCARD 01 SENSOR PLUS glucose blood test strip
GLUCOCOM TEST STRIPS glucose blood test strip
GLUCOLAB TEST STRIPS - glucose 3

blood test strip
3
GLUCONAVII BLOOD GLUCOSE glucose blood test strip
GMATE BLOOD GLUCOSE TEST - 3
IN TOUCH BLOOD GLUCOSE TE - 3
3
INFINITY BLOOD GLUCOSE TE glucose blood test strip
2
KETOCARE - acetone (urine) test
strip
2
KETONE TEST STRIPS - acetone
(urine) test strip
2
KETOSTIX - acetone (urine) test
strip
3
KROGER BLOOD GLUCOSE
TEST - glucose blood test strip
3
KROGER PREMIUM BLOOD
GLUC - glucose blood test strip
3
KROGER TEST STRIPS - glucose
blood test strip
3
LIBERTY NEXT GENERATION B glucose blood test strip
3
LIBERTY TEST STRIPS - glucose
blood test strip
MAXIMA BLOOD GLUCOSE TEST - 3
MEIJER BLOOD GLUCOSE TEST - 3
MEIJER PREMIUM BLOOD GLUC glucose blood test strip
MEIJER TRUETEST BLOOD GLU glucose blood test strip
MEIJER TRUETRACK BLOOD GL glucose blood test strip
MICRODOT TEST STRIPS - glucose 3

blood test strip
3
MYGLUCOHEALTH BLOOD
3
NEUTEK 2TEK TEST STRIPS glucose blood test strip
3
NEXGEN TEST STRIPS - glucose
blood test strip
NOVA MAX GLUCOSE TEST STR - 3
ON CALL EXPRESS BLOOD GLU - 3
ON CALL PLUS BLOOD GLUCOS - 3
3
ON CALL VIVID BLOOD GLUCO glucose blood test strip
3
ONETOUCH BASIC/PROFILE TE glucose blood test strip
ONETOUCH ULTRA BLUE - glucose 3
blood test strip
ONETOUCH ULTRA TEST STRIP - 3
3
ONETOUCH VERIO TEST STRIP glucose blood test strip
3
OPTIUM TEST STRIPS - glucose
blood test strip
OPTIUMEZ TEST STRIPS - glucose 3
blood test strip
3
OPTUMRX BLOOD GLUCOSE
3
PHARMACIST CHOICE
AUTOCOD - glucose blood test
strip
GLUCOCARD X-SENSOR - glucose

blood test strip
MEIJER ESSENTIAL BLOOD GL glucose blood test strip
Responsible Steps
Quantity Limits
Prior Authorization
GLUCOCARD VITAL TEST STRI glucose blood test strip
Specialty
Drug Name
Drug Tier
GLUCOCARD SHINE TEST STRI glucose blood test strip
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
147
PRECISION POINT OF CARE T glucose blood test strip
PRECISION QID TEST STRIPS glucose blood test strip
PRECISION SOF-TACT TEST S glucose blood test strip
PRECISION XTRA BLOOD GLUC glucose blood test strip
PRESTIGE TEST STRIPS - glucose

blood test strip
PRODIGY NO CODING BLOOD G glucose blood test strip
PTS PANELS GLUCOSE TEST glucose blood test strip
QUICKTEK TEST STRIPS - glucose

blood test strip
QUINTET AC BLOOD GLUCOSE glucose blood test strip
QUINTET BLOOD GLUCOSE TES glucose blood test strip
RA TRUETEST STRIPS - glucose

blood test strip
REFUAH PLUS BLOOD

strip
RELION BLOOD GLUCOSE TEST glucose blood test strip
RELION CONFIRM/MICRO TEST glucose blood test strip
RELION KETONE - acetone (urine)

test strip
RELION KETONE TEST STRIPS acetone (urine) test strip
RELION PRIME BLOOD GLUCOS glucose blood test strip
148
RELION ULTIMA TEST STRIPS glucose blood test strip
REVEAL BLOOD GLUCOSE TEST - 3

REXALL BLOOD GLUCOSE TEST - 3
RIGHTEST GS100 BLOOD GLUC - 3
SMART DIABETES XPRES BLOO - 3
3
SMART SENSE PREMIUM
BLOOD - glucose blood test strip
SMART SENSE VALUE BLOOD G - 3
3
SMARTEST BLOOD GLUCOSE
3
SOLUS V2 AUDIBLE TEST glucose blood test strip
SUPREME TEST STRIPS - glucose 3
blood test strip
SURE EDGE BLOOD GLUCOSE T - 3
3
SURE-TEST EASYPLUS MINI B glucose blood test strip
3
SURECHEK BLOOD GLUCOSE
3
SURESTEP PRO TEST STRIPS glucose blood test strip
SURESTEP TEST STRIPS - glucose 3
blood test strip
TELCARE BLOOD GLUCOSE TES - 3
TGT BLOOD GLUCOSE TEST ST - 3
PRECISION PCX PLUS TEST S glucose blood test strip
RELION ULTIMA BLOOD GLUCO glucose blood test strip
Responsible Steps
Quantity Limits
Prior Authorization
PRECISION PCX - glucose blood

test strip
Specialty
Drug Name
Drug Tier
POCKETCHEM EZ BLOOD
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
TRUE METRIX BLOOD GLUCOSE - 3

3
TRUE METRIX SELF MONITORI glucose blood test strip
3
TRUETEST BLOOD GLUCOSE T glucose blood test strip
TRUETEST STRIPS - glucose blood 3
test strip
3
TRUETRACK BLOOD GLUCOSE
T - glucose blood test strip
TRUETRACK TEST - glucose blood 3
test strip
3
ULTIMA TEST STRIPS - glucose
blood test strip
3
ULTRATRAK PRO TEST STRIPS glucose blood test strip
3
ULTRATRAK ULTIMATE TEST S glucose blood test strip
3
UNISTRIP1 GENERIC - glucose
blood test strip
3
VICTORY AGM-4000 TEST STR glucose blood test strip
VOCAL POINT BLOOD GLUCOSE - 3
WAVESENSE PRESTO TEST STR - 3
3
CO-VERATROL - ubiquinol-vit b12resveratrol-fa cap 200-5-400-0.8
mg
MEDICAL DEVICES
ACCU-CHEK FASTCLIX LANCET lancets
ACCU-CHEK MULTICLIX LANC lancets kit
ACCU-CHEK MULTICLIX LANCE lancets
ACCU-CHEK NANO SMARTVIEW blood glucose monitoring kit w/

device
ACCU-CHEK SAFE-T-PRO LANC lancets
ACCU-CHEK SAFE-T-PRO PLUS lancets
ACCU-CHEK SOFT TOUCH LANC lancets
ACCU-CHEK SOFTCLIX LANCET lancet devices
ACCU-CHEK SOFTCLIX LANCET lancets kit
ACCU-CHEK SOFTCLIX LANCET lancets
ACCU-CHEK VOICEMATE - blood

glucose monitoring kit w/ device
ACTI-LANCE LANCETS 28G lancets
ACTI-LANCE LITE SAFETY LA lancets
ACTI-LANCE SPECIAL SAFETY lancets
ACTI-LANCE UNIVERSAL SAFE lancets
2
3
ACCU-CHEK AVIVA - blood glucose

monitoring devices
ACCU-CHEK AVIVA CONNECT blood glucose monitoring kit w/

device
ACURA BLOOD GLUCOSE

MONIT - blood glucose monitoring
kit w/ device
ACCU-CHEK AVIVA PLUS - blood

ACURA PLUS BLOOD GLUCOSE blood glucose monitoring kit w/

device
ADJUSTABLE LANCING DEVICE lancet devices
ADVANCE INTUITION BLOOD G blood glucose monitoring devices
ACCU-CHEK COMPACT PLUS CA - 3

blood glucose monitoring kit
ACCU-CHEK FASTCLIX LANCET - 2
lancets kit
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
149
ADVANCE INTUITION BLOOD G blood glucose monitoring kit w/

device
ADVOCATE INSULIN SYRINGE/ insulin syringe/needle u-100 0.3

ml 31 x 5/16"
ADVANCE MICRO-DRAW METER blood glucose monitoring devices
ADVOCATE LANCETS - lancets
ADVOCATE LANCETS 30G lancets
ADVOCATE BLOOD GLUCOSE

MO - blood glucose monitoring
devices
ADVOCATE BLOOD GLUCOSE

MO - blood glucose monitoring kit
w/ device
ADVOCATE LANCING DEVICE lancet devices

ADVOCATE RAPID-SAFE LANCI lancet devices
ADVOCATE INSULIN PEN NEED insulin pen needle 29 g x 12.7 mm
ADVOCATE REDI-CODE - blood

glucose monitoring devices
ADVOCATE INSULIN PEN NEED insulin pen needle 31 g x 5 mm

(3/16")
ADVOCATE INSULIN PEN NEED insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

ml 29 x 1/2"

ml 30 x 5/16"
ADVOCATE INSULIN SYRINGE/ insulin syringe/needle u-100 1/2

ml 31 x 5/16"

ml 29 x 1/2"

ml 30 x 5/16"
ADVOCATE INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml

29 x 1/2"

30 x 5/16"

31 x 5/16"
150
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
ADVOCATE REDI-CODE+ BLOOD - 3

blood glucose monitoring devices
3
ADVOCATE REDI-CODE+/ TALK blood glucose monitoring kit w/
device
3
ADVOCATE REDI-CODE/TALKIN blood glucose monitoring devices
3
ADVOCATE REDI-CODE/TALKIN blood glucose monitoring kit w/
device
2
ADVOCATE SAFETY LANCETS lancets
ADVOCATE SAFETY LANCETS 2 - 2
lancets
2
AF LANCETS SUPER THIN lancets
AGAMATRIX AMP NO CODE ADV - 3
3
AGAMATRIX JAZZ - blood glucose
monitoring kit w/ device
3
AGAMATRIX PRESTO - blood
AGAMATRIX PRESTO PRO METE - 3
2
AGAMATRIX ULTRA-THIN LANC lancets
2
ALTERNATE SITE LANCING DE lancet devices
ANTI-STICK INSULIN SYRING insulin syringe/needle u-100 1/2

ml 28 x 1/2"
ANTI-STICK INSULIN SYRING insulin syringe/needle u-100 1/2

ml 29 x 1/2"
ANTI-STICK INSULIN SYRING insulin syringe/needle u-100 1 ml

29 x 1/2"
ANTI-STICK TUBERCULIN SYR tuberculin/allergy syringe/needle

(disp) 1 ml 25 x 5/8"
ANTI-STICK TUBERCULIN SYR tuberculin/allergy syringe/needle

(disp) 1 ml 27 x 1/2"
AQUA LANCE ADJUSTABLE LAN lancet devices
ASSURE COMFORT LANCETS UL - 2

lancets
ASSURE HAEMOLANCE PLUS HI - 2
lancets
ASSURE HAEMOLANCE PLUS LO - 2
lancets
ASSURE HAEMOLANCE PLUS MI - 2
lancets
2
ASSURE HAEMOLANCE PLUS
NO - lancets
ASSURE HAEMOLANCE PLUS PE - 2
lancets
2
ASSURE ID INSULIN SAFETY insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
ASSURE ID INSULIN SAFETY insulin syringe/needle u-100 1 ml
29 x 1/2"
2
ASSURE LANCE LANCETS lancets
2
ASSURE LANCE LANCETS 21G lancets
2
ASSURE LANCE PLUS SAFETY lancets
2
ASSURE LANCETS - lancets
ASSURE PLATINUM BLOOD GLU blood glucose monitoring devices
ASSURE PRISM MULTI BLOOD blood glucose monitoring devices
ASSURE PRO BLOOD GLUCOSE blood glucose monitoring devices
ASSURE 3 METER - blood glucose

monitoring kit
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
ASSURE 4 BLOOD GLUCOSE ME - 3

AT LAST BLOOD GLUCOSE SYS - 3
blood glucose monitoring kit
2
AT LAST LANCETS - lancets
AURORA LANCET SUPER THIN lancets
AURORA LANCET THIN 23G lancets
AURORA PEN NEEDLES 29GX12 insulin pen needle 29 g x 12 mm

(1/2")
AURORA PEN NEEDLES 31G X insulin pen needle 31 g x 6 mm

(1/4")
AURORA PEN NEEDLES 31G X insulin pen needle 31 g x 8 mm

(1/3" or 5/16")
AURORA UNIFINE PENTIPS/MI insulin pen needle 31 g x 5 mm

(3/16")
AURORA UNIFINE PENTIPS/32 insulin pen needle 32 g x 4 mm

(5/32")
AUTO-LANCET - lancet devices
AUTO-LANCET MINI - lancet

devices
AUTOLET IMPRESSION - lancet

devices
AUTOLET IMPRESSION LANCIN lancet devices
AUTOLET MINI - lancet devices
151
AUTOPEN - injection device for

insulin
AXILLARY BLOCK NEEDLE BLO needle (disp) 22 x 1"
AXILLARY BLOCK NEEDLE BLO needle (disp) 25 x 1"
BAYER CONTOUR NEXT USB BL blood glucose monitoring kit w/

device
BAYER CONTOUR USB BLOOD

G - blood glucose monitoring kit w/
device
B-D INSULIN SYRINGE MICRO insulin syringe/needle u-100 1 ml

28 x 1/2"
BAYER MICROLET LANCETS lancets
2
2
B-D INSULIN SYRINGE ULTRA insulin syringe/needle u-100 0.3

ml 30 x 1/2"
BAYER MICROLET 2 LANCING lancet devices
B-D INSULIN SYRINGE ULTRA insulin syringe/needle u-100 1 ml

31 x 5/16"
BD LO-DOSE INSULIN SYRIN insulin syringe/needle u-100 1/2

ml 28 x 1/2"
B-D INSULIN SYRINGE ULTRA insulin syringe/needle u-100 0.3

ml 31 x 5/16"
BD ALLERGY/SYRINGE NEEDLE tuberculin/allergy syringe/needle

(disp) 1 ml 28 x 1/2"
BAYER BREEZE 2 BLOOD GLUC blood glucose monitoring kit w/

device
BD ALLERGY/SYRINGE/NEEDLE tuberculin/allergy syringe/needle

(disp) 1 ml 28 x 1/2"
BD AUTOSHIELD DUO 30G X 3 insulin pen needle 30 g x 5 mm
(3/16")
BD AUTOSHIELD 29G X 3/16" insulin pen needle 29 g x 5 mm

(3/16")
BD AUTOSHIELD 29G X 5/16" insulin pen needle 29 g x 8 mm

(5/16")
BD BLUNT FILL NEEDLE - needle

(disp) 18 x 1-1/2"
BD DISPOSABLE NEEDLE REGU needle (disp) 24 x 1"
BD DISPOSABLE NEEDLE REGU needle (disp) 22 x 3/4"
BD DISPOSABLE NEEDLE 23GX needle (disp) 23 x 1"
BD DISPOSABLE NEEDLE 23GX needle (disp) 23 x 1-1/4"
2
BAYER CONTOUR BLOOD
GLUCO - blood glucose monitoring
devices
2
BAYER CONTOUR BLOOD
kit w/ device
2
BAYER CONTOUR LINK BLOOD blood glucose monitoring kit w/
device
BAYER CONTOUR NEXT BLOOD - 2
blood glucose monitoring kit w/
device
BAYER CONTOUR NEXT EZ BLO - 2
device
2
BAYER CONTOUR NEXT LINK B blood glucose monitoring kit w/
device
BAYER CONTOUR NEXT LINK W - 2
device
152
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
BD DISPOSABLE NEEDLE 27GX needle (disp) 27 x 1-1/4"
BD DISPOSABLE NEEDLE/30GX needle (disp) 30 x 1"
BD ECLIPSE NEEDLE 21G X 1 needle (disp) 21 x 1"
BD ECLIPSE NEEDLE 21G X 1 needle (disp) 21 x 1-1/2"
BD ECLIPSE NEEDLE 25G X 1 needle (disp) 25 x 1-1/2"
BD ECLIPSE NEEDLE 25GX1" needle (disp) 25 x 1"
BD ECLIPSE NEEDLE 30G X needle (disp) 30 x 1/2"
BD ECLIPSE NEEDLE/22G X 1 needle (disp) 22 x 1-1/2"
BD ECLIPSE NEEDLE/25G X needle (disp) 25 x 5/8"
BD ECLIPSE 18G X 1-1/2" - needle

(disp) 18 x 1-1/2"
BD ECLIPSE 22G X 1" - needle

(disp) 22 x 1"
BD ECLIPSE 23G X 1" NEEDL needle (disp) 23 x 1"
BD HYPODERMIC NEEDLE REGU - 2

needle (disp) 18 x 1-1/2"
needle (disp) 21 x 1"
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016

needle (disp) 25 x 5/8"
BD HYPODERMIC NEEDLE SHOR - 3
2
BD INSULIN SYRINGE LUER-L insulin syringe (disp) u-100 1 ml
2
BD INSULIN SYRINGE MICROF insulin syringe/needle u-100 0.3
ml 28 x 1/2"
2
BD INSULIN SYRINGE MICROF insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
BD INSULIN SYRINGE MICROF insulin syringe/needle u-100 1 ml
27 x 5/8"
2
BD INSULIN SYRINGE MICROF insulin syringe/needle u-100 1 ml
28 x 1/2"
2
BD INSULIN SYRINGE SAFETY insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
BD INSULIN SYRINGE SAFETY insulin syringe/needle u-100 1 ml
29 x 1/2"
153
BD INSULIN SYRINGE SAFETY insulin syringe/needle u-100 0.3

ml 31 x 5/16"
BD INSULIN SYRINGE ULTRAF insulin syringe/needle u-100 1 ml

31 x 15/64"
BD INSULIN SYRINGE SLIP T insulin syringe (disp) u-100 1 ml
BD INSULIN SYRINGE U-40/1 insulin syringe/needle u-40 1 ml

25 x 5/8"
BD INSULIN SYRINGE/DETACH insulin syringe/needle u-100 1 ml

25 x 5/8"
BD INSULIN SYRINGE ULTRAF insulin syringe/needle u-100 0.3

ml 29 x 1/2"

25 x 1"

ml 30 x 1/2"

26 x 1/2"
BD INSULIN SYRINGE ULTRAF insulin syringe/needle u-100 1/2

ml 31 x 5/16"
BD INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2

ml 30 x 1/2"

ml 29 x 1/2"
BD INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml

27 x 1/2"

ml 30 x 1/2"

28 x 1/2"

ml 31 x 15/64"

27.5 x 5/8"

29 x 1/2"

29 x 1/2"

30 x 1/2"
BD INTEGRA INSULIN SYRING insulin syringe/needle u-100 1 ml

29 x 1/2"
BD INTEGRA RETRACTABLE NE needle (disp) 23 x 1"

31 x 5/16"
BD INTEGRA SYRINGE/RETRAC insulin syringe/needle u-100 1 ml

25 x 1"

ml 31 x 5/16"
BD KLATSKIN BIOPSY - needle

(disp) 16 x 4"
BD LANCET DEVICE - lancet

devices

ml 31 x 15/64"
BD LANCET ULTRAFINE 30G lancets
BD LANCET ULTRAFINE 33G lancets
154
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
BD LATITUDE DIABETES MANA blood glucose monitoring kit w/

device
BD PEN NEEDLE/NANO/ULTRA insulin pen needle 32 g x 4 mm

(5/32")
BD LOGIC BLOOD GLUCOSE MO blood glucose monitoring kit w/

device
BD PEN NEEDLE/SHORT/ULTRA insulin pen needle 31 g x 8 mm

(1/3" or 5/16")
BD MAGNI-GUIDE MAGNIFIER blood glucose monitoring supplies
BD PEN NEEDLE/ULTRAFINE/2 insulin pen needle 29 g x 12.7 mm
BD MICROTAINER LANCETS lancets
BD NEEDLE/16G X 1-1/2" - needle

(disp) 16 x 1-1/2"
BD PEN NEEDLES SHORT/ULTR insulin pen needle 31 g x 8 mm

(1/3" or 5/16")
BD NEEDLE/18G 1-1/2" - needle

(disp) 18 x 1-1/2"
BD PLASTIPAK SYRINGES ALL tuberculin/allergy syringe/needle

(disp) 1 ml 28 x 1/2"
BD NEEDLE/19G X 1" - needle

(disp) 19 x 1"
BD PRECISIONGLIDE NEEDLE needle (disp) 27 x 1-1/2"

(disp) 20 x 1-1/2"
BD ROSENTHAL BIOPSY - needle

(disp) 16 x 1-5/16"
BD NEEDLE/20G X 1" - needle

(disp) 20 x 1"
BD NEEDLE/21G 1-1/2" - needle

(disp) 21 x 1-1/2"
BD SAFETY-GLIDE INSULIN S insulin syringe/needle u-100 1/2

ml 29 x 1/2"

(disp) 22 x 1-1/2"
BD SAFETY-LOK INSULIN SYR insulin syringe/needle u-100 1 ml

29 x 1/2"
BD NEEDLE/25G X 5/8" - needle

(disp) 25 x 5/8"

(disp) 25 x 7/8"
BD SAFETYGLIDE ALLERGY S tuberculin/allergy syringe/needle

(disp) 1 ml 26 x 3/8"

(disp) 27 x 1/2"
BD SAFETYGLIDE ALLERGY SY tuberculin/allergy syringe/needle

(disp) 1 ml 27 x 1/2"
BD SAFETYGLIDE HYPODERMIC needle (disp) 18 x 1-1/2"

(disp) 30 x 1/2"
BD SAFETYGLIDE HYPODERMIC needle (disp) 25 x 5/8"
BD OSGOOD BIOPSY - needle

(disp) 16 x 1-5/16"
3
3
BD PEN - injection device for insulin
BD SAFETYGLIDE INJECTION needle (disp) 22 x 1-1/2"
BD PEN MINI - injection device for

insulin
BD SAFETYGLIDE INJECTION needle (disp) 25 x 1"
BD PEN NEEDLE/MINI/ULTRAF insulin pen needle 31 g x 5 mm

(3/16")
BD SAFETYGLIDE INSULIN SY insulin syringe/needle u-100 1/2

ml 30 x 5/16"
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
155
BD SAFETYGLIDE SHIELDED N needle (disp) 23 x 1"
BD SAFETYGLIDE 21G X 1-1/ needle (disp) 21 x 1-1/2"
BD SAFETYGLIDE 21G X 1" needle (disp) 21 x 1"
CAREFINE PEN NEEDLES 32GX insulin pen needle 32 g x 5 mm

(1/5" or 3/16")
CAREFINE PEN NEEDLES 32GX insulin pen needle 32 g x 6 mm

(1/4")
BD 1ML TUBERCULIN SYRINGE tuberculin/allergy syringe/needle

(disp) 1 ml 26 x 3/8"
CAREONE ADVANCED LANCING lancet devices
BD 1ML TUBERCULIN SYRINGE tuberculin/allergy syringe/needle

(disp) 1 ml 27 x 1/2"
BLOOD GLUCOSE MONITORING blood glucose monitoring kit w/

device
BLOOD GLUCOSE SYSTEM PAK blood glucose monitoring kit w/

device
BREEZE 2 BLOOD GLUCOSE MO - 2

2
BULLSEYE MINI SAFETY LANC lancets
2
BULLSEYE SAFETY LANCETS lancets
2
CARDIOCOM LANCING DEVICE lancet devices
2
CAREFINE PEN NEEDLE 32GX4 insulin pen needle 32 g x 4 mm
(5/32")
CAREFINE PEN NEEDLES 29GX - 2
insulin pen needle 29 g x 12 mm
(1/2")
(1/3" or 5/16")
(1/4")
(1/3" or 5/16")
156
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
3
CAREONE BLOOD GLUCOSE
MON - blood glucose monitoring kit
w/ device
2
CAREONE INSULIN SYRINGES/ insulin syringe/needle u-100 0.3
ml 30 x 1/2"
2
CAREONE INSULIN SYRINGES/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
CAREONE INSULIN SYRINGES/ insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
CAREONE INSULIN SYRINGES/ insulin syringe/needle u-100 1 ml
30 x 1/2"
2
CAREONE INSULIN SYRINGES/ insulin syringe/needle u-100 1 ml
31 x 5/16"
2
CAREONE INSULIN SYRINGES/ insulin syringe/needle u-100 0.3
ml 31 x 5/16"
CAREONE LANCET THIN - lancets 2
CAREONE LANCET ULTRA THIN lancets
CAREONE UNIFINE PENTIPS P insulin pen needle 29 g x 12 mm

(1/2")

(3/16")

(1/4")

(1/3" or 5/16")
CLEVER CHEK LANCETS ULTRA lancets
CLEVER CHOICE AUTO-CODE P blood glucose monitoring devices

(5/32")
CAREONE UNIFINE PENTIPS 2 insulin pen needle 29 g x 12 mm

(1/2")
CLEVER CHOICE COMFORT EZ insulin pen needle 29 g x 12 mm

(1/2")

(3/16")

(3/16")

(1/4")

(1/4")

(1/3" or 5/16")

(1/3" or 5/16")
CARESENS N BLOOD GLUCOSE blood glucose monitoring devices

(5/32")
(1/5" or 3/16")
CARESENS N GLUCOSE
MONITO - blood glucose
monitoring devices

(1/4")
CARESENS N VOICE BLOOD GL blood glucose monitoring devices
CAYA - diaphragm arc-spring

(5/32")

(1/5" or 3/16")

(1/4")

(1/3" or 5/16")
CLEVER CHOICE COMFORT EZ insulin syringe/needle u-100 0.3

ml 29 x 1/2"
CHEMSTRIP BG LOG BOOK - blood 3

glucose monitoring misc.
3
CHOICE DM DIABETES RISK I blood glucose monitoring kit
3
CHOICE DM FORA G20 BLOOD blood glucose monitoring devices
CLEANLET LANCETS 28G - lancets 2
CLEVER CHEK AUTO CODE VOI blood glucose monitoring devices
CLEVER CHEK AUTO-CODE BLO blood glucose monitoring devices
CLEVER CHEK AUTO-CODE VOI blood glucose monitoring devices
CLEVER CHEK BLOOD

GLUCOSE - blood glucose
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
157

ml 30 x 5/16"
CLEVER CHOICE MINI BLOOD blood glucose monitoring devices
CLICKFINE PEN NEEDLE UNIV insulin pen needle 31 g x 6 mm

(1/4")

ml 30 x 1/2"
CLEVER CHOICE COMFORT EZ insulin syringe/needle u-100 1/2

ml 31 x 5/16"
CLICKFINE PEN NEEDLE UNIV insulin pen needle 31 g x 8 mm

(1/3" or 5/16")
CLICKFINE PEN NEEDLE 32GX insulin pen needle 32 g x 4 mm

(5/32")

ml 28 x 1/2"
CLICKFINE PEN NEEDLES/31G insulin pen needle 31 g x 6 mm

(1/4")

ml 29 x 1/2"
CLICKFINE PEN NEEDLES/31G insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

ml 30 x 5/16"
CLICKFINE UNIVERSAL PEN N insulin pen needle 31 g x 6 mm

(1/4")

ml 30 x 1/2"
CLICKFINE UNIVERSAL PEN N insulin pen needle 31 g x 8 mm

(1/3" or 5/16")
CLEVER CHOICE COMFORT EZ insulin syringe/needle u-100 1 ml

28 x 1/2"
CLOSERCARE - lancet devices

29 x 1/2"
COAGUCHEK LANCETS - lancets
2
2

30 x 5/16"
COMFORT ASSIST INSULIN SY insulin syringe/needle u-100 0.3

ml 29 x 1/2"

30 x 1/2"

ml 30 x 5/16"

31 x 5/16"
COMFORT ASSIST INSULIN SY insulin syringe/needle u-100 1/2

ml 31 x 5/16"

ml 31 x 5/16"

ml 29 x 1/2"
CLEVER CHOICE MICRO BLOOD blood glucose monitoring kit w/

device

ml 30 x 5/16"
COMFORT ASSIST INSULIN SY insulin syringe/needle u-100 1 ml
29 x 1/2"
158
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016

30 x 5/16"

31 x 5/16"

ml 31 x 5/16"
COMFORT ASSURED LANCETS

M - lancets
CVS LANCING DEVICE - lancet

devices
CVS ULTRA THIN LANCETS lancets
DIASTAR EASY TEST II LANC lancets
DIASTAR EASY TEST LANCETS lancets
DIATRUE PLUS BLOOD GLUCOS blood glucose monitoring devices
COMFORT ASSURED LANCETS

S - lancets
DIDGET - blood glucose monitoring

kit w/ device
COMFORT LANCETS - lancets
DROPLET LANCETS ULTRA THI lancets
DROPLET LANCING DEVICE lancet devices
DRUG MART ADJUSTABLE LANC lancet devices
DRUG MART LANCETS THIN lancets
DRUG MART LANCETS ULTRA T lancets
DRUG MART ON-THE-GO LANCE lancets
DRUG MART ULTRA COMFORT I insulin syringe/needle u-100 0.3

ml 29 x 1/2"

ml 30 x 5/16"
DRUG MART ULTRA COMFORT I insulin syringe/needle u-100 1/2

ml 31 x 5/16"
DRUG MART ULTRA COMFORT I insulin syringe/needle u-100 1/2

ml 30 x 5/16"
DRUG MART ULTRA COMFORT I insulin syringe/needle u-100 1 ml

29 x 1/2"
DRUG MART ULTRA COMFORT I insulin syringe/needle u-100 1 ml

30 x 5/16"
3
CONTROL BLOOD GLUCOSE
w/ device
3
CVS ADVANCED GLUCOSE
METE - blood glucose monitoring
kit w/ device
2
CVS INSULIN SYRINGE/0.3ML insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
CVS INSULIN SYRINGE/0.3ML insulin syringe/needle u-100 0.3
ml 30 x 1/2"
2
CVS INSULIN SYRINGE/0.5ML insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
CVS INSULIN SYRINGE/0.5ML insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
CVS INSULIN SYRINGE/1ML/2 insulin syringe/needle u-100 1 ml
29 x 1/2"
2
CVS LANCETS MICRO THIN 33 lancets
CVS LANCETS ORIGINAL - lancets 2
CVS LANCETS THIN 26G - lancets
CVS LANCETS ULTRA THIN 30 lancets
CVS LANCETS 21G - lancets
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
159

ml 31 x 5/16"
DRUG MART UNIFINE PENTIPS insulin pen needle 29 g x 12 mm

(1/2")

(3/16")

(1/4")

(1/3" or 5/16")

(5/32")
DRUG MART UNILET LANCETS lancets
DUANE READE LANCET ALTERN lancets
DUANE READE LANCET SUPER lancets
DUANE READE LANCET ULTRA lancets
DUANE READE UNIFINE PENTI insulin pen needle 29 g x 12 mm

(1/2")
E-Z JECT LANCETS 21G - lancets
E-ZJECT LANCETS MICRO-THI lancets
EASY COMFORT INSULIN SYRI insulin syringe/needle u-100 0.3

ml 30 x 5/16"
EASY COMFORT INSULIN SYRI insulin syringe/needle u-100 1/2

ml 30 x 5/16"
EASY COMFORT INSULIN SYRI insulin syringe/needle u-100 1/2

ml 30 x 1/2"
EASY COMFORT INSULIN SYRI insulin syringe/needle u-100 1 ml

30 x 5/16"
EASY COMFORT INSULIN SYRI insulin syringe/needle u-100 1 ml

30 x 1/2"
EASY COMFORT LANCETS lancets
EASY COMFORT LANCETS 30G/ lancets
EASY COMFORT PEN NEEDLES insulin pen needle 31 g x 5 mm

(3/16")

(1/4")

(1/3" or 5/16")

(1/4")

(5/32")

(1/3" or 5/16")
EASY MINI LANCING DEVICE lancet devices
E-Z JECT LANCETS - lancets
E-Z JECT LANCETS COLOR lancets
EASY PLUS BLOOD GLUCOSE M blood glucose monitoring devices
E-Z JECT LANCETS SUPER TH lancets
E-Z JECT LANCETS THIN 26G lancets
EASY PLUS BLOOD GLUCOSE M blood glucose monitoring kit w/

device
160
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
EASY PLUS II BLOOD GLUCOS blood glucose monitoring devices
EASY STEP BLOOD GLUCOSE M blood glucose monitoring devices
EASY STEP BLOOD GLUCOSE M blood glucose monitoring kit w/

device
EASY TOUCH INSULIN SYRING insulin syringe/needle u-100 1/2

ml 30 x 5/16"

ml 30 x 1/2"
EASY TALK BLOOD GLUCOSE M blood glucose monitoring devices
EASY TOUCH INSULIN SYRING insulin syringe/needle u-100 1 ml

27 x 1/2"
EASY TALK BLOOD GLUCOSE M blood glucose monitoring kit w/

device

28 x 1/2"
EASY TOUCH ALLERGY TRAY S tuberculin/allergy syringe/needle

(disp) 1 ml 26 x 3/8"

29 x 1/2"
EASY TOUCH ALLERGY TRAY S tuberculin/allergy syringe/needle

(disp) 1 ml 27 x 1/2"

30 x 5/16"
EASY TOUCH GLUCOSE

MONITO - blood glucose

30 x 1/2"
EASY TOUCH HEALTHPRO GLUC - 3

device
2
EASY TOUCH INSULIN SYRING insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
ml 30 x 1/2"
2
ml 27 x 1/2"
2
ml 31 x 5/16"
2
ml 28 x 1/2"
2
ml 29 x 1/2"

31 x 5/16"

ml 31 x 5/16"
EASY TOUCH LANCETS 21G/PR lancets
EASY TOUCH LANCETS 26G/PU lancets
EASY TOUCH LANCETS 26G/TW lancets
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
161
EASY TOUCH SAFETY LANCETS lancets
EASY TOUCH LANCETS 30G/BU lancets
EASY TOUCH 32GX5MM - insulin

pen needle 32 g x 5 mm (1/5" or
3/16")
EASY TOUCH 32GX6MM - insulin

pen needle 32 g x 6 mm (1/4")
EASY TOUCH LANCING DEVICE lancet devices
EASY TOUCH PEN NEEDLES 29 insulin pen needle 29 g x 12 mm

(1/2")

(1/4")

(1/3" or 5/16")

(5/32")

(1/5" or 3/16")

(1/4")
EASY TOUCH PEN NEEDLES/31 insulin pen needle 31 g x 5 mm

(3/16")
162
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
EASY TRAK BLOOD GLUCOSE M - 3

EASY TRAK BLOOD GLUCOSE M - 3
device
2
EASY TWIST & CAP LANCETS lancets
3
EASYGLUCO - blood glucose
monitoring kit
EASYGLUCO VALUE PACK - blood 3
glucose monitoring kit
EASYMAX L BLOOD GLUCOSE S - 3
3
EASYMAX L BLOOD GLUCOSE
S - blood glucose monitoring kit w/
device
EASYMAX N BLOOD GLUCOSE S - 3
3
EASYMAX N BLOOD GLUCOSE
device
EASYMAX NG SELF-MONITORIN - 3
EASYMAX NG SELF-MONITORIN - 3
device
EASYMAX V BLOOD GLUCOSE S - 3
3
EASYMAX V BLOOD GLUCOSE
device
3
EASYMAX V2 SELF-MONITORIN blood glucose monitoring devices
EASYMAX V2 SELF-MONITORIN blood glucose monitoring kit w/

device
ELITE-THIN INSULIN SYRING insulin syringe/needle u-100 1/2

ml 29 x 1/2"
EASYPLUS R13N SELF-MONITO blood glucose monitoring kit w/

device

ml 30 x 5/16"
EASYPLUS V SELF-MONITORIN blood glucose monitoring kit w/

device
ELITE-THIN INSULIN SYRING insulin syringe/needle u-100 1 ml

28 x 5/16"
3
EASYPRO BLOOD GLUCOSE
w/ device
3
EASYPRO PLUS - blood glucose
2
EASYTEST II LANCETS - lancets

28 x 1/2"

29 x 1/2"

29 x 5/16"

30 x 5/16"

31 x 5/16"
ELITE-THIN INSULIN SYRING insulin syringe/needle u-100 0.3

ml 31 x 5/16"
EMBRACE BLOOD GLUCOSE

MON - blood glucose monitoring
devices
EMBRACE EVO BLOOD

EMBRACE LANCETS ULTRA THI lancets
EMBRACE PRO BLOOD

monitoring devices
ENVISION AUTOCODE - blood

EQL COLOR LANCETS MICRO T lancets
EASYTEST LANCETS - lancets
ECLIPSE BLOOD GLUCOSE MON - 3

device
3
ELEMENT AUTOCODE SYSTEM blood glucose monitoring kit w/
device
3
ELEMENT COMPACT BLOOD
GLU - blood glucose monitoring
devices
3
ELEMENT COMPACT V BLOOD blood glucose monitoring devices
ELEMENT PLUS BLOOD GLUCOS - 3
2
ml 31 x 5/16"
2
ml 28 x 5/16"
2
ml 28 x 1/2"
2
ml 29 x 5/16"
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
163
EQL COLOR LANCETS 21G lancets
EQL THIN LANCETS 26G - lancets
EQL TRUE2GO BLOOD

EQL INSULIN SYRINGE/U-100 insulin syringe/needle u-100 0.3

ml 29 x 1/2"
EQL ULTRA COMFORT INSULIN insulin syringe/needle u-100 1 ml

30 x 5/16"
EQL INSULIN SYRINGE/U-100 insulin syringe/needle u-100 1/2

ml 29 x 1/2"
EQL ULTRA COMFORT INSULIN insulin syringe/needle u-100 0.3

ml 31 x 5/16"
EQL INSULIN SYRINGE/U-100 insulin syringe/needle u-100 1 ml

29 x 1/2"
EQL ULTRA SHORT PEN NEEDL insulin pen needle 31 g x 6 mm

(1/4")
EQL INSULIN SYRINGE/0.3ML insulin syringe/needle u-100 0.3

ml 29 x 1/2"
EVENCARE BLOOD GLUCOSE


ml 30 x 5/16"

ml 31 x 5/16"
EVENCARE G2 BLOOD
monitoring devices
EQL INSULIN SYRINGE/0.5ML insulin syringe/needle u-100 1/2

ml 31 x 5/16"
EVENCARE G3 BLOOD
monitoring devices

ml 29 x 1/2"
EVENCARE MINI BLOOD GLUCO blood glucose monitoring devices

EVOLUTION AUTOCODE - blood

ml 30 x 5/16"
EXCEL COMFORT POINT INSUL insulin pen needle 31 g x 4 mm

(1/6")
EQL INSULIN SYRINGE/1ML/2 insulin syringe/needle u-100 1 ml

29 x 1/2"
EXEL COMFORT POINT INSULI insulin pen needle 29 g x 12 mm

(1/2")

30 x 5/16"

(1/4")

31 x 5/16"

(1/3" or 5/16")
EQL SHORT PEN NEEDLES 31G insulin pen needle 31 g x 8 mm

(1/3" or 5/16")
EXEL COMFORT POINT INSULI insulin syringe/needle u-100 0.3

ml 29 x 1/2"
EQL SUPER THIN LANCETS 30 lancets
EXEL COMFORT POINT INSULI insulin syringe/needle u-100 0.3

ml 30 x 5/16"
164
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
EXEL COMFORT POINT INSULI insulin syringe/needle u-100 1/2

ml 28 x 1/2"
FIFTY50 GLUCOSE METER 2.0 blood glucose monitoring kit w/

device

ml 29 x 1/2"
FIFTY50 LANCING DEVICE - lancet

devices

ml 30 x 5/16"
FIFTY50 PEN NEEDLES 31G X insulin pen needle 31 g x 5 mm

(3/16")
FIFTY50 PEN NEEDLES 31G X insulin pen needle 31 g x 8 mm

(1/3" or 5/16")
EXEL COMFORT POINT INSULI insulin syringe/needle u-100 1 ml

28 x 1/2"
FIFTY50 SAFETY SEAL LANCE lancets

29 x 1/2"

30 x 5/16"
FIFTY50 SUPERIOR COMFORT insulin syringe/needle u-100 1/2

ml 31 x 5/16"
EZ SMART BLOOD GLUCOSE LA lancets
FIFTY50 SUPERIOR COMFORT insulin syringe/needle u-100 1 ml

31 x 5/16"
FIFTY50 SUPERIOR COMFORT insulin syringe/needle u-100 0.3
ml 31 x 5/16"
EZ SMART DIABETES MONITOR blood glucose monitoring devices
EZ SMART PLUS DIABETES MO blood glucose monitoring devices
FINE 30 - lancets
FINGERSTIX LANCETS - lancets
EZ-LETS LANCETS 21G - lancets
FLOW-EZE VENTED NEEDLE hypodermic needles (disposable)
EZ-LETS LANCETS 26G SUPER lancets
EZ-LETS LANCETS 28G ULTRA lancets
FASTTAKE COMPACT MONITORI blood glucose monitoring kit w/

device
FC FEMALE CONDOM - condoms female
FC2 FEMALE CONDOM - condoms

- female
FEMCAP - cervical cap 22 mm
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
FORA GD20 BLOOD GLUCOSE M - 3

FORA GD50 BLOOD GLUCOSE M - 3
FORA G20 BLOOD GLUCOSE MO - 3
device
FORA G30A BLOOD GLUCOSE M - 3
3
FORA G71A BLOOD GLUCOSE
M - blood glucose monitoring kit w/
device
FORA G90 BLOOD GLUCOSE MO - 3
2
FORA LANCETS - lancets
165
FORA LANCING DEVICE - lancet

devices
FREDS PHARMACY UNILET LAN lancets
FORA TEST N' GO VOICE BLO blood glucose monitoring devices
FREESTYLE FLASH SYSTEM blood glucose monitoring kit
FREESTYLE FREEDOM - blood

FREESTYLE FREEDOM LITE blood glucose monitoring kit w/

device
FREESTYLE INSULINX BLOOD blood glucose monitoring kit w/

device
FREESTYLE LANCETS - lancets
FREESTYLE LITE BLOOD GLUC blood glucose monitoring devices
FREESTYLE PRECISION INSUL insulin syringe/needle u-100 1/2

ml 31 x 5/16"
FREESTYLE PRECISION INSUL insulin syringe/needle u-100 1/2

ml 30 x 5/16"
FREESTYLE PRECISION INSUL insulin syringe/needle u-100 1 ml

30 x 5/16"
FREESTYLE PRECISION INSUL insulin syringe/needle u-100 1 ml

31 x 5/16"
FREESTYLE SIDEKICK II VAL blood glucose monitoring kit w/

device
FREESTYLE SYSTEM KIT - blood

FREESTYLE UNISTICK II LAN lancets
GENTLE-LET GP LANCETS lancets
GENTLE-LET LANCETS GENERA lancets
GENTLE-LET LANCETS SAFETY lancets
FORA V10 BLOOD GLUCOSE MO - 3

3
FORA V10/V12/D10/D20 BLOO blood glucose monitoring kit
device
FORA V30A BLOOD GLUCOSE M - 3
FORA V30A BLOOD GLUCOSE M - 3
device
3
FORACARE GD40 BLOOD
devices
FORACARE PREMIUM V10 BLOO - 3
3
FORACARE TEST N GO BLOOD blood glucose monitoring devices
FORTISCARE SELF-MONITORIN - 3
device
FREDS PHARMACY AUTOLET LA - 2
lancet devices
FREDS PHARMACY UNIFINE PE - 2
(3/16")
(1/3" or 5/16")
(5/32")
166
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
GE100 BLOOD GLUCOSE MONIT blood glucose monitoring kit w/

device
GLOBAL INJECT EASE INSULI insulin syringe/needle u-100 1 ml

28 x 1/2"
GHT BLOOD GLUCOSE MONITO blood glucose monitoring kit w/

device

29 x 1/2"
GLOBAL EASE INJECT PEN NE insulin pen needle 29 g x 12 mm

(1/2")

30 x 5/16"

(3/16")

30 x 1/2"

(1/3" or 5/16")

31 x 5/16"

(5/32")
GLOBAL INJECT EASE INSULI insulin syringe/needle u-100 0.3

ml 31 x 5/16"

ml 29 x 1/2"
GLOBAL INJECT EASE LANCET lancets

ml 30 x 5/16"

ml 30 x 1/2"
GLOBAL INJECT EASE INSULI insulin syringe/needle u-100 1/2

ml 31 x 5/16"

ml 28 x 1/2"

ml 29 x 1/2"

ml 30 x 5/16"

ml 30 x 1/2"
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
GLOBAL LANCING DEVICE - lancet 2

devices
GLUCO PERFECT 3 BLOOD GLU - 3
GLUCOCARD EXPRESSION AUDI - 3
device
3
GLUCOCARD SHINE - blood
3
GLUCOCARD SHINE - blood
GLUCOCARD VITAL BLOOD GLU - 3
device
3
GLUCOCARD X-METER - blood
3
GLUCOCARD 01 BLOOD
GLUCOS - blood glucose
monitoring devices
3
GLUCOCARD 01 BLOOD
GLUCOS - blood glucose
167
GLUCOCARD 01-MINI BLOOD G blood glucose monitoring kit w/

device
GLUCOPRO INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml

30 x 1/2"
GLUCOCOM AUTOLINK
TELEMON - blood glucose
monitoring misc.

31 x 5/16"
GLUCOCOM BLOOD GLUCOSE

devices
GLUCOPRO INSULIN SYRINGE/ insulin syringe/needle u-100 0.3

ml 31 x 5/16"
GLUCOCOM BLOOD GLUCOSE

w/ device
GLUCOSOURCE LANCET
DEVICE - lancet devices
GLUCOSOURCE LANCETS lancets
GLUCOCOM LANCETS 28G lancets
GMATE LANCETS 30G - lancets
GMATE LANCING DEVICE - lancet

devices
GLUCOLAB BLOOD GLUCOSE

GMATE ORIGIN BLOOD GLUCOS blood glucose monitoring devices
GLUCOLET 2 AUTOMATIC LANC lancet devices
GMATE SMART METER KIT - blood

GLUCONAVII BLOOD GLUCOSE blood glucose monitoring kit w/

device
GMATE SMART STARTER KIT blood glucose monitoring kit w/

device

ml 30 x 5/16"

ml 30 x 1/2"
GLUCOPRO INSULIN SYRINGE/ insulin syringe/needle u-100 1/2

ml 31 x 5/16"

ml 30 x 5/16"

ml 30 x 1/2"

30 x 5/16"
168
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
GMATE VOICE BLOOD GLUCOSE - 3

2
GNP CLICKFINE PEN NEEDLE insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
GNP CLICKFINE UNIVERSAL P insulin pen needle 31 g x 6 mm
(1/4")
2
GNP CLICKFINE UNIVERSAL P insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
2
GNP INSULIN SYRINGE/0.3ML insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ml 30 x 5/16"

ml 31 x 5/16"
GNP ULTRA COMFORT INSULIN insulin syringe/needle u-100 0.3

ml 30 x 5/16"
GNP INSULIN SYRINGE/0.5ML insulin syringe/needle u-100 1/2

ml 31 x 5/16"
GNP ULTRA COMFORT INSULIN insulin syringe/needle u-100 1/2

ml 31 x 5/16"

ml 28 x 1/2"

ml 28 x 1/2"

ml 29 x 1/2"

ml 29 x 1/2"

ml 30 x 5/16"

ml 30 x 5/16"
GNP INSULIN SYRINGE/1ML/2 insulin syringe/needle u-100 1 ml

28 x 1/2"
GNP ULTRA COMFORT INSULIN insulin syringe/needle u-100 1 ml

28 x 1/2"

29 x 1/2"

29 x 1/2"

30 x 5/16"

30 x 5/16"

31 x 5/16"

31 x 5/16"
GNP LANCETS - lancets
GNP LANCETS MICRO THIN 33 lancets

ml 31 x 5/16"
GNP LANCETS SUPER THIN 30 lancets
H&H THINLET LANCETS 26G lancets
GNP LANCETS THIN - lancets
GNP LANCETS THIN 26G - lancets
H&H THINLET SUPER THIN LA lancets
GNP LANCETS 21G - lancets
GNP MICRO THIN LANCETS 33 lancets
H-E-B IN CONTROL PEN NEED insulin pen needle 31 g x 5 mm

(3/16")

(1/4")
GNP SUPER THIN LANCETS/30 lancets

ml 29 x 1/2"

(1/3" or 5/16")
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
169

(5/32")
H-E-B INCONTROL ADVANCED lancet devices
H-E-B INCONTROL LANCETS S lancets
H-E-B INCONTROL LANCETS U lancets
H-E-B INCONTROL PEN NEEDL insulin pen needle 29 g x 12 mm

(1/2")
HEALTHY ACCENTS AUTOLET I lancet devices
HEALTHY ACCENTS UNIFINE P insulin pen needle 29 g x 12 mm

(1/2")

(3/16")

(1/4")
HAEMOLANCE - lancets
HAEMOLANCE LOW FLOW

LANCE - lancets

(1/3" or 5/16")
HAEMOLANCE PLUS - lancets

(5/32")
HEALTHY ACCENTS UNILET LA lancets
HM LANCETS MICRO THIN 33G lancets
HM LANCETS ULTRA THIN 30G lancets
HUBER NEEDLE 20GX3/4"/R needle (disp) 20 x 3/4"
HUBER NEEDLE/RIGHT ANGLE needle (disp) 19 x 1"
HUBER NEEDLE/RIGHT ANGLE needle (disp) 20 x 1-1/2"
HUBER NEEDLE/RIGHT ANGLE needle (disp) 22 x 3/4"
HUBER NEEDLE/RIGHT ANGLE needle (disp) 22 x 1-1/2"
HUBER NEEDLE/STRAIGHT 19G needle (disp) 19 x 1-1/4"
HUBER NEEDLE/STRAIGHT 20G needle (disp) 20 x 1"
HAEMOLANCE PLUS HIGH FLOW - 2

lancets
HAEMOLANCE PLUS LOW FLOW - 2
lancets
HAEMOLANCE PLUS MAX FLOW - 2
lancets
HAEMOLANCE PLUS PEDIATRIC - 2
lancets
2
HEALTH CARE LANCING DEVIC lancet devices
2
HEALTHWISE LANCETS 30G lancets
2
HEALTHWISE LANCING PEN lancet devices
2
HEALTHWISE MINI PEN NEEDL insulin pen needle 31 g x 6 mm
(1/4")
2
HEALTHWISE PEN NEEDLES 29 insulin pen needle 29 g x 12 mm
(1/2")
HEALTHWISE SHORT PEN NEED - 2
(1/3" or 5/16")
2
HEALTHWISE UNIFINE PENTIP insulin pen needle 32 g x 4 mm
(5/32")
170
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
HYPODERMIC NEEDLE 22GX1-1 needle (disp) 22 x 1-1/2"
HUBER NEEDLE/STRAIGHT 22G needle (disp) 22 x 1"
HYPODERMIC NEEDLE 22GX1" needle (disp) 22 x 1"
HYPODERMIC NEEDLE 22GX3/4 needle (disp) 22 x 3/4"
HUBER NEEDLE/19GX3/4"/RIG needle (disp) 19 x 3/4"
HUBER NEEDLE/20G X 1-1/4" needle (disp) 20 x 1-1/4"
HUBER NEEDLE/22GX1-1/4"/4 needle (disp) 22 x 1-1/4"
HY-VEE LANCETS - lancets
HY-VEE THIN LANCETS - lancets
HYPODERMIC NEEDLE 16G X 1 needle (disp) 16 x 1"
HYPODERMIC NEEDLE 16G X 1 needle (disp) 16 x 1-1/2"
IBG STAR BLOOD GLUCOSE MO blood glucose monitoring kit w/

device
IN TOUCH - blood glucose

monitoring devices
IN TOUCH DIABETES MANAGEM blood glucose monitoring misc.

IN TOUCH LANCING DEVICE lancet devices
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
171
IN TOUCH STERILE LANCETS lancets
INFINITY BLOOD GLUCOSE MO blood glucose monitoring kit w/

device
INSULIN SYRINGE/0.5ML/27G insulin syringe/needle u-100 1/2

ml 27 x 1/2"
INSUL-TOTE - blood glucose

monitoring supplies

ml 28 x 1/2"
INSUL-TOTE JR - blood glucose

monitoring supplies

ml 29 x 1/2"
INSULIN SYRINGE/U-100/0.3 insulin syringe/needle u-100 0.3

ml 29 x 1/2"

ml 30 x 5/16"
INSULIN SYRINGE/U-100/0.5 insulin syringe/needle u-100 1/2

ml 28 x 1/2"

ml 30 x 1/2"
INSULIN SYRINGE/U-100/0.5 insulin syringe/needle u-100 1/2

ml 29 x 1/2"

ml 31 x 5/16"
INSULIN SYRINGE/U-100/1ML insulin syringe/needle u-100 1 ml

28 x 1/2"
INSULIN SYRINGE/1ML/28G X insulin syringe/needle u-100 1 ml

28 x 1/2"

29 x 1/2"

29 x 1/2"

30 x 5/16"

30 x 5/16"

31 x 5/16"

31 x 5/16"
INSULIN SYRINGE/0.3ML/29G insulin syringe/needle u-100 0.3

ml 29 x 1/2"
INSUPEN PEN NEEDLES 32G X insulin pen needle 32 g x 4 mm

(5/32")

ml 29 x 1"
INSUPEN SENSITIVE 32GX6MM insulin pen needle 32 g x 6 mm

(1/4")

ml 30 x 5/16"
INSUPEN SENSITIVE 32GX8MM insulin pen needle 32 g x 8 mm
2
2

ml 31 x 5/16"
INSUPEN ULTRAFIN 29GX12MM insulin pen needle 29 g x 12 mm

(1/2")
172
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016

(1/3" or 5/16")
KROGER INSULIN SYRINGE/0. insulin syringe/needle u-100 0.3

ml 30 x 5/16"

(1/4")
KROGER INSULIN SYRINGE/0. insulin syringe/needle u-100 1/2

ml 31 x 5/16"

(1/3" or 5/16")

ml 29 x 1/2"
INSUPEN 33GX4MM - insulin pen

needle 33 g x 4 mm (5/32")
KINNEY LANCETS - lancets

ml 30 x 5/16"
KINNEY THIN LANCETS - lancets
KINRAY INSULIN SYRINGE PR insulin syringe/needle u-100 1/2

ml 31 x 5/16"

ml 31 x 5/16"
KINRAY INSULIN SYRINGE PR insulin syringe/needle u-100 1 ml

31 x 5/16"
KROGER INSULIN SYRINGE/1M insulin syringe/needle u-100 1 ml

29 x 1/2"
KINRAY INSULIN SYRINGE PR insulin syringe/needle u-100 0.3

ml 31 x 5/16"

30 x 5/16"
KINRAY INSULIN SYRINGE/0. insulin syringe/needle u-100 1/2

ml 29 x 1/2"

31 x 5/16"
KROGER LANCETS - lancets
KMART VALU PLUS INSULIN S insulin syringe (disp) u-100 0.3 ml
KROGER LANCETS MICRO THIN lancets
KMART VALU PLUS INSULIN S insulin syringe (disp) u-100 1/2 ml
KROGER LANCETS SUPER THIN lancets
KMART VALU PLUS INSULIN S insulin syringe (disp) u-100 1 ml
KROGER LANCETS THIN - lancets
2
2
KROGER BLOOD GLUCOSE

MONI - blood glucose monitoring
kit w/ device
KROGER LANCETS THIN 26G lancets

KROGER LANCETS ULTRATHIN lancets
KROGER INSULIN SYRINGE/U- insulin syringe/needle u-100 0.3

ml 30 x 1/2"
KROGER LANCETS 21G - lancets
2
2

ml 29 x 1/2"
KROGER LANCING DEVICE lancet devices

KROGER PEN NEEDLES 29G X insulin pen needle 29 g x 12 mm
(1/2")
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
173
KROGER PEN NEEDLES 31G X insulin pen needle 31 g x 8 mm

(1/3" or 5/16")
KROGER PEN NEEDLES 31GX1/ insulin pen needle 31 g x 6 mm

(1/4")
KROGER PREMIUM BLOOD

GLUC - blood glucose monitoring
kit w/ device
LANCET DEVICE ADJUSTABLE lancet devices
LANCET DEVICE WITH EJECTO lancet devices
LANCETS - lancets
LANCETS MICRO THIN 33G lancets
LANCETS SAFETY SEAL 21G lancets
LANCETS SUPER THIN 28G lancets
LANCETS THIN - lancets
LANCETS TWIST TOP - lancets
LANCETS ULTRA FINE - lancets
LANCETS ULTRA THIN - lancets
LANCETS ULTRA THIN 30G lancets
LANCETS 26G TWIST TOP lancets
LANCETS 28G - lancets
LANCETS 30G - lancets
LANCETS 30G/TWIST TOP lancets
174
LANCETS 33G UNIVERSAL DES lancets
LANCING DEVICE - lancet devices
LANCING DEVICE ADJUSTABLE lancet devices
LANZO - lancet devices
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
LDR BLOOD GLUCOSE TRUETES - 3

device
LEADER ADVANCED LANCING D - 2
lancet devices
2
LEADER INSULIN SYRINGE/0. insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ml 30 x 5/16"
2
LEADER INSULIN SYRINGE/0. insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ml 28 x 1/2"
2
ml 29 x 1/2"
2
ml 30 x 5/16"
2
ml 31 x 5/16"
2
LEADER INSULIN SYRINGE/1M insulin syringe/needle u-100 1 ml
28 x 1/2"
2
29 x 1/2"

30 x 5/16"
LITE TOUCH LANCING DEVICE lancet devices
LITE TOUCH LANCING PEN lancet devices

31 x 5/16"
LEADER LANCETS COLORED lancets
LITE TOUCH PEN NEEDLES/31 insulin pen needle 31 g x 5 mm

(3/16")
LITETOUCH INSULIN SYRINGE insulin syringe/needle u-100 0.3

ml 29 x 1/2"
LEADER SUPER THIN LANCET lancets

LEADER THIN LANCETS - lancets
LEADER UNIFINE PENTIPS PL insulin pen needle 31 g x 5 mm

(3/16")

ml 30 x 5/16"
LEADER UNIFINE PENTIPS PL insulin pen needle 31 g x 8 mm

(1/3" or 5/16")
LITETOUCH INSULIN SYRINGE insulin syringe/needle u-100 1/2

ml 31 x 5/16"
LEADER UNIFINE PENTIPS/MI insulin pen needle 31 g x 5 mm

(3/16")

ml 28 x 1/2"
LEADER UNIFINE PENTIPS/NA insulin pen needle 32 g x 4 mm

(5/32")

ml 29 x 1/2"
LEADER UNIFINE PENTIPS/PL insulin pen needle 32 g x 4 mm

(5/32")

ml 30 x 5/16"
LIBERTY BLOOD GLUCOSE MET blood glucose monitoring devices
LITETOUCH INSULIN SYRINGE insulin syringe/needle u-100 1 ml

28 x 1/2"
29 x 1/2"

30 x 5/16"

31 x 5/16"

ml 31 x 5/16"
LITETOUCH LANCETS MICRO T lancets
LIBERTY BLOOD GLUCOSE MON - 3

2
LIBERTY MEDICAL LANCETS 3 lancets
2
LIBERTY MINI LANCING DEVI lancet devices
3
LIBERTY NEXT GENERATION B blood glucose monitoring devices
2
LIFESCAN UNISTIK II LANCE lancets
2
LIFESCAN UNISTIK 2 DEEP P lancets
2
LITE TOUCH LANCETS - lancets
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
175
LITETOUCH PEN NEEDLES 29G insulin pen needle 29 g x 12.7 mm
LITETOUCH PEN NEEDLES 31G insulin pen needle 31 g x 6 mm

(1/4")
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 0.3

ml 30 x 5/16"
LITETOUCH PEN NEEDLES 31G insulin pen needle 31 g x 8 mm

(1/3" or 5/16")
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 1/2

ml 29 x 1/2"
LIVE BETTER ADVANCED LANC lancet devices
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 1/2

ml 30 x 5/16"
LIVE BETTER LANCET SUPER lancets
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 1 ml

29 x 1/2"
LIVE BETTER LANCET ULTRA lancets
LIVE BETTER PEN NEEDLES 2 insulin pen needle 29 g x 12 mm

(1/2")
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 1 ml

30 x 5/16"

(1/4")
MAGELLAN TUBERCULIN SAFET tuberculin/allergy syringe/needle

(disp) 1 ml 27 x 1/2"

(1/3" or 5/16")
MAGELLAN TUBERCULIN SAFET tuberculin/allergy syringe/needle

(disp) 1 ml 28 x 1/2"
LOCAL ANESTHESIA SECURITY needle (disp) 20 x 4"
MAXI-COMFORT INSULIN SYRI insulin syringe/needle u-100 1/2

ml 28 x 1/2"
MAXI-COMFORT INSULIN SYRI insulin syringe/needle u-100 1 ml

28 x 1/2"
LONGS INSULIN SYRINGE/0.5 insulin syringe/needle u-100 1/2

ml 31 x 5/16"
LONGS LANCETS STANDARD lancets
LONGS LANCETS THIN - lancets
LONGS LANCETS ULTRA THIN lancets
MAGELLAN INSULIN SAFETY S insulin syringe/needle u-100 0.3

ml 29 x 1/2"
176
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
MAXIMA BLOOD GLUCOSE MONI - 3

device
3
MAXIMA METER KIT - blood
3
MAXIMA STARTER KIT - blood
2
MD SAFETYGLIDE 27G X 5/8" needle (disp) 27 x 5/8"
2
MEDIC INSULIN SYRINGE/0.3 insulin syringe/needle u-100 0.3
ml 30 x 5/16"
2
MEDIC INSULIN SYRINGE/0.5 insulin syringe/needle u-100 1/2
ml 30 x 5/16"
MEDICHOICE PRE-SET SAFETY lancets
MEIJER COLOR LANCETS UNIV lancets
MEDICHOICE SAFETY LANCET lancets
MEDICINE SHOPPE LANCETS lancets
MEIJER ESSENTIAL BLOOD GL blood glucose monitoring kit w/

device
MEIJER LANCETS - lancets
MEDICINE SHOPPE LANCETS T lancets
MEIJER LANCETS THIN - lancets
MEIJER LANCETS UNIVERSAL lancets
MEDICINE SHOPPE PEN NEEDL insulin pen needle 29 g x 12 mm

(1/2")

(1/4")
MEIJER PEN NEEDLES 29G X insulin pen needle 29 g x 12 mm

(1/2")

(1/3" or 5/16")

(1/4")
MEDISENSE THIN LANCETS lancets

(1/3" or 5/16")
MEIJER PREMIUM BLOOD GLUC blood glucose monitoring kit w/
device
MEIJER SUPER THIN LANCETS lancets
MEIJER TRUERESULT BLOOD G blood glucose monitoring kit w/

device
MEIJER TRUETRACK BLOOD GL blood glucose monitoring kit w/

device
MEIJER TRUE2GO BLOOD GLUC blood glucose monitoring kit w/

device
MICRODOT BLOOD GLUCOSE

w/ device
MICROLET LANCETS - lancets
MICROTAINER SAFETY FLOW L lancets
MINI LANCING DEVICE - lancet

devices
MONOJECT BLUNT CANNULA/15 needle (disp) 15 x 1-1/2"
MEDLANCE PLUS EXTRA LANCE - 2

lancets
2
MEDLANCE PLUS LANCETS lancets
2
MEDLANCE PLUS LANCETS LIT lancets
2
MEDLANCE PLUS LITE LANCET lancets
MEDLANCE PLUS SPECIAL LAN - 2
lancets
2
MEDLANCE PLUS SUPERLITE 3 lancets
MEDLANCE PLUS UNIVERSAL L - 2
lancets
2
MEDLANCE PLUS/LITE 25G lancets
2
MEDLANCE/EXTRA - lancets
MEDLANCE/LITE - lancets
MEDLANCE/UNIVERSAL - lancets
MEIJER BLOOD GLUCOSE MONI blood glucose monitoring kit w/

device
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
177
MONOJECT BLUNT CANNULA/18 needle (disp) 18 x 1"
MONOJECT HYPO/ALUM HUB/LU - 3

178
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016

MONOJECT HYPO/ALUM HUB/16 - 3
MONOJECT HYPO/ALUM HUB/18 - 2
3
MONOJECT HYPO/
POLYPROPYLE - needle (disp) 18
x 1"
3
MONOJECT HYPO/
x 1-1/2"
3
MONOJECT HYPO/
x 1"
3
MONOJECT HYPO/
x 1-1/2"
3
MONOJECT HYPO/
x 1"
3
MONOJECT HYPO/
x 1-1/2"
MONOJECT HYPO/
x 1"
MONOJECT INSULIN SYRINGE insulin syringe (disp) u-100 1 ml
MONOJECT INSULIN SYRINGE/ insulin syringe (disp) u-100 1 ml
MONOJECT HYPO/
x 1-1/2"
MONOJECT HYPO/
x 1"
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 0.3

ml 29 x 1/2"
MONOJECT HYPO/
x 1-1/2"
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 0.3

ml 30 x 5/16"
MONOJECT HYPO/
x 3/4"
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 1/2

ml 28 x 1/2"
MONOJECT HYPO/
x 1"

ml 29 x 1/2"
MONOJECT HYPO/
x 5/8"

ml 30 x 5/16"
MONOJECT HYPO/
x 1"
MONOJECT INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml

25 x 5/8"
MONOJECT HYPO/
x 1-1/2"

27 x 1/2"
MONOJECT HYPO/
x 1/2"

28 x 1/2"
MONOJECT HYPO/
x 1/2"

29 x 1/2"
MONOJECT HYPO/
x 3/4"

30 x 5/16"
MONOJECT HYPODERMIC
NEEDL - needle (disp) 18 x 1"

31 x 5/16"
MONOJECT MAGELLAN SAFETY needle (disp) 18 x 1"
MONOJECT HYPODERMIC
NEEDL - needle (disp) 27 x 1-1/2"
MONOJECT MAGELLAN SAFETY needle (disp) 18 x 1-1/2"
MONOJECT HYPODERMIC
NEEDL - needle (disp) 30 x 3/4"
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
179
MONOJECT STANDARD
HYPODER - needle (disp) 20 x
1-1/2"
MONOJECT STANDARD
HYPODER - needle (disp) 21 x 1"
MONOJECT MAGELLAN SAFETY needle (disp) 21 x 5/8"
MONOJECT STANDARD
1-1/2"
MONOJECT STANDARD
MONOJECT STANDARD
MONOJECT STANDARD
1-1/2"
MONOJECT STANDARD
1/2"
MONOJECT STANDARD
MONOJECT STANDARD
5/8"
MONOJECT STANDARD
MONOJECT STANDARD
1-1/2"
MONOJECT STANDARD
1-1/2"
MONOJECT STANDARD
1/2"
MONOJECT TB SYRINGE-NDL 1 tuberculin/allergy syringe/needle

(disp) 1 ml 26 x 3/8"
MONOJECT TB SYRINGE-NDL 1 tuberculin/allergy syringe/needle

(disp) 1 ml 27 x 1/2"
MONOJECT MEDICATION TRANS - 3

hypodermic needles (disposable)
3
MONOJECT STANDARD
1-1/2"
3
MONOJECT STANDARD
3
MONOJECT STANDARD
1-1/2"
3
MONOJECT STANDARD
3
MONOJECT STANDARD
1-1/2"
3
MONOJECT STANDARD
180
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
MONOJECT TUBERCULIN SAFET - 2

tuberculin/allergy syringe/needle
(disp) 1 ml 25 x 5/8"
MONOJECT TUBERCULIN SAFET - 3

(disp) 1 ml 28 x 1/2"
MONOJECT TUBERCULIN SYRIN - 2
(disp) 1 ml 25 x 5/8"
(disp) 1 ml 26 x 3/8"
(disp) 1 ml 27 x 1/2"
(disp) 1 ml 28 x 1/2"
MONOJECT ULTRA COMFORT IN - 2
insulin syringe/needle u-100 0.3
ml 29 x 1/2"
ml 30 x 5/16"
insulin syringe/needle u-100 1/2
ml 31 x 5/16"
ml 28 x 1/2"
ml 29 x 1/2"
ml 30 x 5/16"
insulin syringe/needle u-100 1 ml
28 x 1/2"
29 x 1/2"
30 x 5/16"
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016

ml 31 x 5/16"
2
MONOLET LANCETS - lancets
MONOLET OPD LANCETS - lancets 2
2
MONOLETTOR SAFETY
LANCETS - lancets
MOORE MED MONOJECT INSULI - 2
ml 28 x 1/2"
ml 29 x 1/2"
28 x 1/2"
29 x 1/2"
2
MS INSULIN SYRINGE/0.3ML/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
ml 30 x 5/16"
2
ml 31 x 5/16"
2
MS INSULIN SYRINGE/0.5ML/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
ml 29 x 1/2"
2
ml 30 x 5/16"
2
MS INSULIN SYRINGE/1ML/29 insulin syringe/needle u-100 1 ml
29 x 1/2"
2
30 x 5/16"
181

31 x 5/16"
MULTI-DRAW NEEDLE 20GX1- needle (disp) 20 x 1-1/2"
MULTI-DRAW NEEDLE 21GX1-1 needle (disp) 21 x 1-1/2"
MULTI-DRAW NEEDLE 22GX1-1 needle (disp) 22 x 1-1/2"

MULTI-LANCET DEVICE - lancet
devices
NOVA SUREFLEX LANCING DEV lancet devices
NOVOFINE AUTOCOVER
30GX8M - insulin pen needle 30 g
x 8 mm (1/3" or 5/16")
NOVOFINE PLUS 32GX4MM insulin pen needle 32 g x 4 mm

(5/32")
NOVOFINE 30GX8MM - insulin pen

needle 30 g x 8 mm (1/3" or 5/16")
NOVOFINE 32GX6MM - insulin pen
needle 32 g x 6 mm (1/4")
NOVOPEN ECHO - injection device

for insulin
NOVOPEN JR (GREEN) - injection

device for insulin
3
3
3
MYGLUCOHEALTH BLOOD
kit w/ device
2
MYGLUCOHEALTH MGH
SOFTLAN - lancets
2
NETGROUP LANCETS - lancets
NEXGEN METER KIT - blood
NOVOPEN JR (YELLOW) - injection

device for insulin
NOKOR ADMIX NEEDLE THIN W needle (disp) 16 x 1"
NOVOPEN 3 INSULIN DELIVER injection device for insulin
NOKOR ADMIX NEEDLE THIN W needle (disp) 18 x 1-1/2"
NOVOPEN 3 PENMATE - injection

device for insulin
NOKOR VENTED NEEDLE THIN needle (disp) 16 x 1"
NOVOTWIST 30GX8MM - insulin

5/16")
NOKOR VENTED NEEDLE THIN needle (disp) 18 x 1"
NOKOR VENTED NEEDLE THIN needle (disp) 18 x 1-1/2"
NOVOTWIST 32GX5MM - insulin

3/16")
NOVA MAX BLOOD GLUCOSE

devices
OMNIFLEX DIAPHRAGM diaphragms

OMNIPOD STARTER KIT - insulin
infusion disposable pump kit
NOVA MAX BLOOD GLUCOSE

w/ device
ON CALL EXPRESS BLOOD GLU blood glucose monitoring devices
3
3
NOVA SAFETY LANCETS 23G lancets
ON CALL EXPRESS BLOOD GLU blood glucose monitoring kit w/

device
NOVA SAFETY LANCETS 28G lancets
ON CALL LANCETS - lancets
2
2
NOVA SUREFLEX LANCETS lancets
ON CALL LANCING DEVICE lancet devices

ON CALL PLUS BLOOD GLUCOS blood glucose monitoring devices
182
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
ON CALL PLUS BLOOD GLUCOS blood glucose monitoring kit w/

device
ONETOUCH ULTRA SYSTEM KIT blood glucose monitoring kit w/

device
ON CALL PLUS LANCETS - lancets
ON CALL PLUS LANCING DEVI lancet devices
ONETOUCH ULTRA 2 - blood

ON CALL VIVID BLOOD GLUCO blood glucose monitoring devices
ON CALL VIVID BLOOD GLUCO blood glucose monitoring kit w/

device
ON CALL VIVID PAL BLOOD G blood glucose monitoring devices
ON CALL VIVID PAL BLOOD G blood glucose monitoring kit w/

device
ONETOUCH BASIC SYSTEM blood glucose monitoring kit w/

device
ONETOUCH CLUB LANCETS FIN lancets
ONETOUCH COMBO PACK lancets
ONETOUCH DELICA LANCETS E lancets
ONETOUCH DELICA LANCETS F lancets
ONETOUCH DELICA LANCING D lancet devices
ONETOUCH FINEPOINT LANCET lancets
ONETOUCH LANCETS - lancets
3
ONETOUCH PING METER
REMOT - blood glucose monitoring
supplies
3
ONETOUCH PROFILE SYSTEM blood glucose monitoring kit w/
device
2
ONETOUCH SURESOFT
LANCING - lancets misc.
3
ONETOUCH ULTRA MINI - blood
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
ONETOUCH ULTRALINK SYSTEM - 3

device
ONETOUCH ULTRASMART - blood 3
2
ONETOUCH ULTRASOFT
LANCET - lancets
ONETOUCH VERIO - blood glucose 3
ONETOUCH VERIO IQ BLOOD G - 3
device
3
ONETOUCH VERIO SYNC
BLOOD - blood glucose monitoring
kit w/ device
OPTIUM BLOOD GLUCOSE MONI - 3
OPTIUM BLOOD GLUCOSE MONI - 3
device
3
MET - blood glucose monitoring kit
w/ device
3
w/ device
ORTHO DIAPHRAGM COIL SPRI - P
diaphragm coil spring kit 50 mm
ORTHO DIAPHRAGM FLAT SPRI - P
diaphragm flat spring kit 55 mm
ORTHO DIAPHRAGM FLAT SPRI - P
diaphragm flat spring kit 60 mm
183
ORTHO DIAPHRAGM FLAT SPRI diaphragm flat spring kit 65 mm
PARADIGM LINK BLOOD GLUCO blood glucose monitoring kit w/

device
PC LANCETS SUPER THIN 30G lancets
PEN NEEDLES 31G X 3/16" - insulin 2

PEN NEEDLES 31G X 6MM - insulin 2
PEN NEEDLES 31GX5/16" - insulin 2
5/16")
3
PEN-TOTE - blood glucose
monitoring supplies
2
PENLET II REPLACEMENT CAP lancets misc.
2
PENTIPS 31GX5MM - insulin pen
needle 31 g x 5 mm (3/16")
2
needle 31 g x 8 mm (1/3" or 5/16")
2
needle 32 g x 4 mm (5/32")
PERFECT LANCETS 30G - lancets 2
PERFECT PRESSURE ACTIVATE lancets
PC UNIFINE PENTIPS 29G X insulin pen needle 29 g x 12 mm

(1/2")

(3/16")
PHARMACIST CHOICE
AUTOCOD - blood glucose

(1/4")
PHARMACIST CHOICE ULTRA T lancets

(1/3" or 5/16")
PEN NEEDLES 29G X 12MM insulin pen needle 29 g x 12 mm

(1/2")
PEN NEEDLES 29GX1/2" - insulin

PEN NEEDLES 30GX5/16" - insulin

5/16")
PEN NEEDLES 31G X 1/4" SH insulin pen needle 31 g x 6 mm

(1/4")
184
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
PHARMACY COUNTER LANCETS - 2

lancets
3
POCKETCHEM EZ BLOOD
kit w/ device
3
POLY HUB NEEDLE/18G X 1-1 needle (disp) 18 x 1-1/2"
3
POLY HUB NEEDLE/18G X 1" needle (disp) 18 x 1"
3
3
3
PRECISION SURE-DOSE PLUS insulin syringe/needle u-100 1 ml

29 x 1/2"
PRECISION THIN LANCETS lancets
PRECISION THINS GP LANCET lancets
PRECISION ULTRA LANCET lancets
POLY HUB NEEDLE/25G X 5/8 needle (disp) 25 x 5/8"
PRECISION XTRA - blood glucose

monitoring devices
PRECISION XTRA - blood glucose

monitoring kit
PRECISION XTRA MONITOR blood glucose monitoring devices
PREFERRED PLUS INSULIN SY insulin syringe/needle u-100 0.3

ml 29 x 1/2"
PRECISION LINK - blood glucose

PRECISION QID MONITOR - blood

PREFERRED PLUS INSULIN SY insulin syringe/needle u-100 0.3

ml 30 x 5/16"
PRECISION SOF-TACT MONITO blood glucose monitoring devices
PREFERRED PLUS INSULIN SY insulin syringe/needle u-100 1/2

ml 28 x 1/2"
PRECISION SURE-DOSE INSUL insulin syringe/needle u-100 0.3

ml 30 x 5/16"

ml 29 x 1/2"
PRECISION SURE-DOSE INSUL insulin syringe/needle u-100 1/2

ml 30 x 3/8"

ml 30 x 5/16"

ml 28 x 1/2"
PREFERRED PLUS INSULIN SY insulin syringe/needle u-100 1 ml

28 x 1/2"

ml 29 x 1/2"

29 x 1/2"
PRECISION SURE-DOSE INSUL insulin syringe/needle u-100 1 ml

28 x 1/2"

30 x 5/16"
PRECISION SURE-DOSE PLUS insulin syringe/needle u-100 0.3

ml 29 x 1/2"
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
PREFERRED PLUS LANCETS CO - 2

lancets
185
PREFERRED PLUS LANCETS SU lancets
PREFERRED PLUS LANCETS TH lancets
PREFERRED PLUS UNIFINE PE insulin pen needle 29 g x 12 mm

(1/2")
PRODIGY INSULIN SYRING/U- insulin syringe/needle u-100 0.3

ml 31 x 5/16"
PRODIGY INSULIN SYRINGE/1 insulin syringe/needle u-100 1/2

ml 31 x 5/16"

(3/16")
PRODIGY INSULIN SYRINGE/1 insulin syringe/needle u-100 1 ml

28 x 1/2"

(1/4")
PRODIGY LANCING DEVICE lancet devices

(1/3" or 5/16")

(5/32")
PRENTIF CAVITY-RIM CERVIC cervical cap 22 mm
PRENTIF FITTING SET - cervical

caps
PRODIGY AUTOCODE BLOOD

GL - blood glucose monitoring
devices
PRODIGY AUTOCODE BLOOD

GL - blood glucose monitoring kit
w/ device
PRODIGY INSULIN MINI PEN insulin pen needle 31 g x 5 mm

(3/16")
PRODIGY INSULIN SHORT PEN insulin pen needle 31 g x 8 mm

(1/3" or 5/16")
186
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
PRODIGY POCKET BLOOD GLUC - 3

device
PRODIGY PRESSURE ACTIVATE - 2
lancets
PRODIGY TWIST TOP LANCETS - 2
lancets
PRODIGY VOICE BLOOD GLUCO - 3
device
2
PSS SELECT GP LANCETS lancets
PSS SELECT SAFETY LANCETS - 2
lancets
2
PX ADVANCED LANCING DEVIC lancet devices
PX EXTRA SHORT PEN NEEDLE - 2
(1/4")
2
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 0.3
ml 30 x 1/2"
2
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2
ml 30 x 1/2"
2
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml
30 x 1/2"
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml

31 x 5/16"
QC INSULIN SYRINGE/1ML/29 insulin syringe/needle u-100 1 ml

29 x 1/2"
PX INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 0.3

ml 31 x 5/16"

30 g
PX LANCET AUTO INJECTOR lancet devices
PX LANCETS - lancets

31 x 5/16"
QC LANCETS SUPER THIN lancets
QC LANCETS ULTRA THIN lancets
QC PEN NEEDLES 29G X 12MM insulin pen needle 29 g x 12 mm

(1/2")

(1/4")

(1/3" or 5/16")
QC UNIFINE PENTIPS 32GX4M insulin pen needle 32 g x 4 mm

(5/32")
QUICKTEK - blood glucose

QUICKTEK - blood glucose

monitoring kit
QUINTET AC BLOOD GLUCOSE blood glucose monitoring devices
QUINTET BLOOD GLUCOSE

devices
RA BLOOD GLUCOSE MONITOR blood glucose monitoring devices
RA E-ZJECT COLOR LANCETS lancets
RA E-ZJECT LANCETS THIN 2 lancets
RA E-ZJECT LANCETS ULTRA lancets
PX LANCETS ULTRA THIN - lancets 2

2
PX MINI PEN NEEDLES 31GX5 insulin pen needle 31 g x 5 mm
(3/16")
2
PX PEN NEEDLE 29GX12MM insulin pen needle 29 g x 12 mm
(1/2")
2
PX PEN NEEDLE 31GX8MM insulin pen needle 31 g x 8 mm
(1/3" or 5/16")
PX SHORTLENGTH PEN NEEDLE - 2
(1/3" or 5/16")
QC ADVANCED LANCING DEVIC - 2
lancet devices
2
QC INSULIN SYRINGE 0.5ML/ insulin syringe/needle u-100 1/2
ml 29 g
2
QC INSULIN SYRINGE 0.5ML/ insulin syringe/needle u-100 1/2
ml 30 g
2
QC INSULIN SYRINGE/0.3ML/ insulin syringe/needle u-100 0.3
ml 29 g
2
QC INSULIN SYRINGE/0.3ML/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
QC INSULIN SYRINGE/0.5ML/ insulin syringe/needle u-100 1/2
ml 31 x 5/16"
2
QC INSULIN SYRINGE/0.5ML/ insulin syringe/needle u-100 1/2
ml 29 x 1/2"
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
187
RA E-ZJECT LANCETS 28G lancets
RA INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2

ml 30 x 5/16"
RA INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml

30 x 5/16"
REFUAH PLUS BLOOD

REGIONAL BLOCK NEEDLE SAF needle (disp) 22 x 1-1/2"
RELION CONFIRM BLOOD GLUC blood glucose monitoring kit w/

device
RA INSULIN SYRINGE/0.5ML/ insulin syringe/needle u-100 1/2

ml 29 x 1/2"
RELION INSULIN SYRINGE/U insulin syringe/needle u-100 1/2

ml 29 g
RA INSULIN SYRINGE/1ML/29 insulin syringe/needle u-100 1 ml

29 x 1/2"
RELION INSULIN SYRINGE/U- insulin syringe/needle u-100 0.3

ml 29 g
RA LANCING DEVICE - lancet

devices
RA PEN NEEDLES 31G X 5MM insulin pen needle 31 g x 5 mm

(3/16")

ml 30 g
RA PEN NEEDLES 31G X 8MM insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

ml 29 x 1/2"
ml 30 x 5/16"
RELION INSULIN SYRINGE/U- insulin syringe/needle u-100 1/2

ml 30 g

ml 31 x 5/16"

ml 29 x 1/2"

ml 30 x 5/16"
RELION INSULIN SYRINGE/U- insulin syringe/needle u-100 1 ml

29 x 1/2"

30 g
RA TRUERESULT BLOOD GLUCO - 3

device
RA TRUE2GO BLOOD GLUCOSE - 3
device
2
REALITY INSULIN SYRINGE/U insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
REALITY INSULIN SYRINGE/U insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
REALITY INSULIN SYRINGE/U insulin syringe/needle u-100 1 ml
28 x 1/2"
2
REALITY INSULIN SYRINGE/U insulin syringe/needle u-100 1 ml
29 x 1/2"
2
REALITY LANCETS - lancets
REALITY TRIGGER LANCETS lancets
188
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016

30 x 5/16"
RELION ULTIMA BLOOD GLUCO blood glucose monitoring kit w/

device

31 x 5/16"
RELION ULTRA THIN LANCETS lancets

ml 31 x 5/16"
RELION ULTRA THIN PLUS LA lancets
RELION LANCETS - lancets
RELION LANCETS MICRO-THIN lancets
RELION LANCETS STANDARD 2 lancets
RELION LANCETS THIN 26G lancets
RELION LANCETS ULTRA-THIN lancets
RELION LANCING DEVICE - lancet

devices
RELION MICRO BLOOD GLUCOS blood glucose monitoring kit w/

device
RELION MINI PEN NEEDLES 3 insulin pen needle 31 g x 6 mm

(1/4")
RELION PEN NEEDLES 29GX12 insulin pen needle 29 g x 12 mm

(1/2")
RELION PEN NEEDLES 31GX8M insulin pen needle 31 g x 8 mm

(1/3" or 5/16")
RELION PEN NEEDLES 32GX4M insulin pen needle 32 g x 4 mm

(5/32")
RELION PRIME BLOOD GLUCOS blood glucose monitoring devices
RELION SHORT PEN NEEDLES insulin pen needle 31 g x 8 mm

(1/3" or 5/16")
RELION THIN LANCETS - lancets
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
RENEW ADVANCED LANCING CA - 2

lancets
RENEW ADVANCED LANCING DE - 2
lancet devices
RETROBULBAR NEEDLE 25G TW - 3
REVEAL BLOOD GLUCOSE MONI - 3
device
REXALL BLOOD GLUCOSE MONI - 3
device
2
REXALL LANCETS ULTRA THIN lancets
2
RIGHTEST GD500 LANCING DE lancet devices
2
RIGHTEST GL300 LANCETS lancets
RIGHTEST GM100 BLOOD GLUC - 3
device
device
device
3
RIGHTSOURCE BLOOD
monitoring devices
2
SAFE-T-LANCE LOW FLOW 25G lancets
2
SAFE-T-LANCE NORMAL FLOW lancets
189
SAFE-T-LANCE PLUS SAFETY lancets
SAFESNAP ALLERGY SYRINGE/ tuberculin/allergy syringe/needle

(disp) 1 ml 27 x 1/2"
SAFETY-GLIDE INSULIN SYRI insulin syringe/needle u-100 0.3

ml 29 x 1/2"
SAFESNAP INSULIN SYRINGE/ insulin syringe/needle u-100 0.3

ml 30 x 5/16"
SAFETY-LOK SAFETY SYRINGE tuberculin/allergy syringe/needle

(disp) 1 ml 25 x 5/8"
SAFESNAP INSULIN SYRINGE/ insulin syringe/needle u-100 1/2

ml 29 x 1/2"
SAFETY-LOK TB SYRINGE PER tuberculin/allergy syringe/needle

(disp) 1 ml 27 x 1/2"
SAPSCARE TWIST TOP LANCET lancets
SAFESNAP INSULIN SYRINGE/ insulin syringe/needle u-100 1/2

ml 30 x 5/16"
SB INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2

ml 29 x 1/2"
SAFESNAP INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml

28 x 1/2"
SB INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2

ml 30 x 5/16"
SAFESNAP INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml

29 x 1/2"
SB INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml

29 x 1/2"
SAFESNAP TUBERCULIN SYRIN tuberculin/allergy syringe/needle

(disp) 1 ml 25 x 5/8"

30 x 5/16"
SAFESNAP TUBERCULIN SYRIN tuberculin/allergy syringe/needle

(disp) 1 ml 27 x 1/2"

31 x 5/16"
SAFETY LANCET 2MM - lancets
SB LANCETS THIN - lancets
SAFETY LANCET 21G/PRESSUR lancets
SAFETY LANCET 28G/PRESSUR lancets
SAFETY LANCETS - lancets
SAFETY LANCETS 21G - lancets
SAFETY LANCETS 28G - lancets
SAFETY LET LANCETS - lancets
SAFETY SEAL LANCETS 28G lancets
SAFETY SEAL LANCETS 30G lancets
SAFETY-GARD SHIELDED NEED hypodermic needles (disposable)
SB LANCETS ULTRA THIN - lancets 2

2
SCHNUCKS INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
SCHNUCKS INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 30 x 5/16"
2
SELECT-LITE LANCING DEVIC lancet devices
SHOPKO AUTOLET LANCING DE - 2
lancet devices
SHOPKO ON-THE-GO COMFORT - 2
lancets
190
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
SHOPKO UNIFINE PENTIPS PE insulin pen needle 29 g x 12 mm

(1/2")
SM INSULIN SYRINGE/0.3ML/ insulin syringe/needle u-100 0.3

ml 31 x 5/16"

(3/16")
SM INSULIN SYRINGE/0.5ML/ insulin syringe/needle u-100 1/2

ml 31 x 5/16"

(1/3" or 5/16")
SM INSULIN SYRINGE/1ML/31 insulin syringe/needle u-100 1 ml

31 x 5/16"

(5/32")
SM LANCETS 21G - lancets
2
2
SHOPKO UNILET LANCETS SUP lancets
SM MICRO THIN LANCETS 33G lancets
SHOPKO UNILET LANCETS ULT lancets
SM SUPER THIN LANCETS 30G lancets

SM THIN LANCETS 26G - lancets
SIMPLE DIAGNOSTICS LANCIN lancet devices
SINGLE-LET - lancets
SM ULTRA COMFORT INSULIN insulin syringe/needle u-100 1 ml

30 x 5/16"
SMART DIABETES VANTAGE LA lancet devices
SM INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 0.3

ml 29 x 1/2"
SM INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 0.3

ml 30 x 5/16"
SMART DIABETES VANTAGE UN lancets
SM INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1/2

ml 28 x 1/2"
SMART DIABETES XPRES BLOO blood glucose monitoring kit w/

device

ml 29 x 1/2"

ml 30 x 5/16"
SM INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 1 ml

28 x 1/2"

29 x 1/2"

30 x 5/16"
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
SMART SENSE COLOR LANCETS - 2

lancets
3
SMART SENSE PREMIUM
BLOOD - blood glucose monitoring
kit w/ device
SMART SENSE STANDARD LANC - 2
lancets
2
SMART SENSE SUPER THIN LA lancets
2
SMART SENSE THIN LANCETS lancets
3
SMART SENSE VALUE BLOOD blood glucose monitoring kit w/
device
SMARTEST EJECT BLOOD GLUC - 3
191
SMARTEST EJECT STARTER KI blood glucose monitoring kit w/

device
SURE COMFORT INSULIN SYRI insulin syringe/needle u-100 0.3

ml 30 x 5/16"
SMARTEST LANCETS 28G lancets
SMARTEST PERSONA STARTER blood glucose monitoring kit w/

device

ml 30 x 1/2"
SMARTEST PRONTO STARTER blood glucose monitoring kit w/

device
SURE COMFORT INSULIN SYRI insulin syringe/needle u-100 1/2

ml 31 x 5/16"
SMARTEST PROTEGE BLOOD

GL - blood glucose monitoring
devices

ml 28 x 1/2"
SMARTEST PROTEGE STARTER blood glucose monitoring kit w/

device

ml 29 x 1/2"
SOLUS V2 AUDIBLE BLOOD GL blood glucose monitoring devices

ml 30 x 5/16"
SOLUS V2 AUDIBLE BLOOD GL blood glucose monitoring kit w/

device

ml 30 x 1/2"
SOLUS V2 LANCING DEVICE lancet devices
SURE COMFORT INSULIN SYRI insulin syringe/needle u-100 1 ml

28 x 1/2"
SOLUS V2 PRESSURE ACTIVAT lancets
SOLUS V2 TWIST LANCETS 30 lancets

29 x 1/2"
STERILANCE TL - lancets
STIMEX INSULATED NEEDLE T needle (disp) 22 x 1-1/2"

30 x 5/16"

30 x 1/2"
31 x 5/16"
SUPER THIN LANCETS - lancets
SUPREME II CONFIDENCE PAD blood glucose monitoring misc.

ml 31 x 5/16"

ml 29 x 1/2"
SURE COMFORT LANCETS 28G lancets
SURE COMFORT LANCETS 30G lancets
192
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
SURE COMFORT LANCING PEN lancet devices
SURE COMFORT PEN NEEDLES insulin pen needle 29 g x 12.7 mm
SURE COMFORT PEN NEEDLES insulin pen needle 30 g x 8 mm

(1/3" or 5/16")
SURE-JECT INSULIN SYRINGE insulin syringe/needle u-100 1/2

ml 29 x 1/2"

ml 30 x 5/16"

(3/16")
SURE-JECT INSULIN SYRINGE insulin syringe/needle u-100 1 ml

28 x 1/2"

(1/3" or 5/16")

29 x 1/2"

(5/32")

30 x 5/16"

(1/4")

31 x 5/16"
SURE EDGE BLOOD GLUCOSE

M - blood glucose monitoring
devices
SURE-JECT INSULIN SYRINGE insulin syringe/needle u-100 0.3

ml 31 x 5/16"
SURE-FINE PEN NEEDLES 29G insulin pen needle 29 g x 12.7 mm
SURE-LANCE FLAT LANCETS lancets
SURE-FINE PEN NEEDLES 31G insulin pen needle 31 g x 5 mm

(3/16")
SURE-LANCE LANCETS 26G lancets

SURE-LANCE THIN LANCETS 2 lancets
SURE-FINE PEN NEEDLES 31G insulin pen needle 31 g x 8 mm

(1/3" or 5/16")
SURE-LANCE ULTRA THIN LAN lancets
SURE-PEN - lancet devices

ml 29 x 1/2"
SURE-TEST EASYPLUS MINI S blood glucose monitoring devices

ml 30 x 5/16"
SURE-TOUCH LANCETS UNIVER lancets
2
3

ml 31 x 5/16"

devices

ml 28 x 1/2"

w/ device
SURELITE LANCETS - lancets
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
193
SURESTEP PRO LINEARITY KI blood glucose monitoring misc.
SYMPATHETIC NERVE NEEDLE needle (disp) 18 x 6"
TECHLITE AST LANCETS - lancets
TECHLITE LANCETS - lancets
TECHLITE LANCETS 30G - lancets
3
TELCARE BLOOD GLUCOSE
w/ device
TERUMO ALLERGY SYRINGE 1M - 2
(disp) 1 ml 27 x 1/2"
2
TERUMO INSULIN SYRINGE/U- insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
TERUMO INSULIN SYRINGE/U- insulin syringe/needle u-100 1/2
ml 27 x 1/2"
2
TERUMO INSULIN SYRINGE/U- insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
TERUMO INSULIN SYRINGE/U- insulin syringe/needle u-100 1 ml
28 x 1/2"
2
TERUMO INSULIN SYRINGE/0. insulin syringe/needle u-100 1/2
ml 30 x 3/8"
2
TERUMO INSULIN SYRINGE/0. insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
TERUMO INSULIN SYRINGE/1M insulin syringe/needle u-100 1 ml
27 x 1/2"
2
TERUMO INSULIN SYRINGE/1M insulin syringe/needle u-100 1 ml
29 x 1/2"
194
TERUMO SURGUARD INSULIN S insulin syringe/needle u-100 0.3

ml 29 x 1/2"
TERUMO SURGUARD INSULIN S insulin syringe/needle u-100 1/2

ml 28 x 1/2"
TERUMO SURGUARD INSULIN S insulin syringe/needle u-100 1/2

ml 29 x 1/2"
TERUMO SURGUARD INSULIN S insulin syringe/needle u-100 1 ml

28 x 1/2"
TERUMO SURGUARD INSULIN S insulin syringe/needle u-100 1 ml

29 x 1/2"
TERUMO SURGUARD2
NEEDLE/2 - needle (disp) 25 x 1"
TERUMO SURGUARD2 SAFETY

N - needle (disp) 18 x 1"

N - needle (disp) 18 x 1-1/2"










Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016

N - needle (disp) 25 x 5/8"





TGT ADVANCED LANCING DEVI lancet devices
TGT BLOOD GLUCOSE

MONITOR - blood glucose
TGT LANCET ALTERNATE SITE lancets
TGT LANCET MICRO THIN 33G lancets
TGT LANCET SUPER THIN 30G lancets
THINPRO INSULIN SYRINGE/0 insulin syringe/needle u-100 1/2

ml 28 x 1/2"

ml 29 x 1/2"
THINPRO INSULIN SYRINGE/1 insulin syringe/needle u-100 1 ml

28 x 1/2"
THINPRO INSULIN SYRINGE/1 insulin syringe/needle u-100 1 ml

29 x 1/2"
TODAYS HEALTH ADVANCED LA lancet devices
TODAYS HEALTH MINI PEN NE insulin pen needle 31 g x 6 mm

(1/4")
TODAYS HEALTH ORIGINAL PE insulin pen needle 29 g x 12 mm

(1/2")
TODAYS HEALTH SHORT PEN N insulin pen needle 31 g x 8 mm

(1/3" or 5/16")
TODAYS HEALTH SUPER THIN lancets
TGT LANCET THIN 23G - lancets
TGT LANCET THIN 26G - lancets
TGT LANCET ULTRA THIN 28G lancets
TODAYS HEALTH ULTRA THIN lancets
TGT LANCET ULTRA THIN 30G lancets
TOPCARE CLICKFINE UNIVERS insulin pen needle 31 g x 6 mm

(1/4")
TGT LANCING DEVICE - lancet

devices
THINLETS GP LANCETS - lancets
TOPCARE CLICKFINE UNIVERS insulin pen needle 31 g x 8 mm

(1/3" or 5/16")
THINLETS LANCET - lancets
THINPRO INSULIN SYRINGE/0 insulin syringe/needle u-100 0.3

ml 29 x 1/2"
TOPCARE ULTRA COMFORT INS insulin syringe/needle u-100 0.3

ml 29 x 1/2"

ml 30 x 3/8"

ml 30 x 5/16"
TOPCARE ULTRA COMFORT INS insulin syringe/needle u-100 1/2
ml 31 x 5/16"
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
195

ml 29 x 1/2"
TRUEDRAW LANCING DEVICE lancet devices
TRUEPLUS INSULIN SYRINGE/ insulin syringe/needle u-100 0.3

ml 29 x 1/2"

ml 30 x 5/16"
TOPCARE ULTRA COMFORT INS insulin syringe/needle u-100 1 ml

29 x 1/2"

ml 30 x 5/16"
TRUEPLUS INSULIN SYRINGE/ insulin syringe/needle u-100 1/2

ml 31 x 5/16"

30 x 5/16"

ml 28 x 1/2"

31 x 5/16"

ml 29 x 1/2"

ml 31 x 5/16"

ml 30 x 5/16"
TOPCO INSULIN SYRINGE/U-1 insulin syringe/needle u-100 0.3

ml 29 x 1/2"
TRUEPLUS INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml

28 x 1/2"
TOPCO INSULIN SYRINGE/U-1 insulin syringe/needle u-100 1/2

ml 28 x 1/2"

29 x 1/2"
TOPCO INSULIN SYRINGE/U-1 insulin syringe/needle u-100 1/2

ml 29 x 1/2"
TOPCO INSULIN SYRINGE/U-1 insulin syringe/needle u-100 1 ml

28 x 1/2"

30 x 5/16"

31 x 5/16"
TOPCO INSULIN SYRINGE/U-1 insulin syringe/needle u-100 1 ml

29 x 1/2"

ml 31 x 5/16"
TRACER II 3 VOLT BATTERY blood glucose monitoring misc.
TRAVEL LANCETS 30G - lancets
TRUE METRIX AIR BLOOD GLU blood glucose monitoring kit w/

device
TRUE METRIX BLOOD GLUCOSE - 3

device
196
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
TRUEPLUS LANCETS 26G - lancets 2

TRUEPLUS LANCETS 28G SUPE lancets

TRUEPLUS LANCETS 30G ULTR - 2
lancets

TRUEPLUS LANCETS 33G MICR - 2
lancets
TRUEPLUS SAFETY LANCETS 2 - 2
lancets
TRUERESULT BLOOD GLUCOSE - 3
device
3
M - blood glucose monitoring
devices
3
M - blood glucose monitoring kit w/
device
3
TRUETRACK SMART SYSTEM blood glucose monitoring kit w/
device
3
TRUE2GO BLOOD GLUCOSE
w/ device
TWO-FER VENTED NEEDLE/NON - 3
2
ULTI-LANCE AUTO-ADJUST DE lancet devices
2
ULTI-LANCE AUTOMATIC/ CLE lancet devices
2
ULTI-LANCE MINI ADJUSTABL lancet devices
2
ULTICARE INSULIN SAFETY S insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
ULTICARE INSULIN SAFETY S insulin syringe/needle u-100 1 ml
29 x 1/2"
2
ULTICARE INSULIN SYRINGE insulin syringe/needle u-100 1/2
ml 31 x 5/16"
ULTICARE INSULIN SYRINGE insulin syringe/needle u-100 1 ml

31 x 5/16"
ULTICARE INSULIN SYRINGE insulin syringe/needle u-100 0.3

ml 31 x 5/16"
ULTICARE INSULIN SYRINGE/ insulin syringe/needle u-100 0.3

ml 29 x 1/2"

ml 30 x 5/16"

ml 30 x 1/2"
ULTICARE INSULIN SYRINGE/ insulin syringe/needle u-100 1/2

ml 31 x 5/16"

ml 28 x 1/2"

ml 29 x 1/2"

ml 30 x 5/16"

ml 30 x 1/2"
ULTICARE INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml

28 x 1/2"

29 x 1/2"

30 x 5/16"

30 x 1/2"
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
197

31 x 5/16"
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 1 ml

30 x 5/16"

ml 31 x 5/16"
ULTILET BASIC LANCETS 30G lancets
ULTICARE MICRO PEN NEEDLE insulin pen needle 32 g x 4 mm

(5/32")
ULTILET CLASSIC LANCETS lancets
ULTICARE MINI PEN NEEDLES insulin pen needle 31 g x 6 mm

(1/4")
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 0.3

ml 30 x 5/16"
ULTICARE ORIGINAL PEN NEE insulin pen needle 29 g x 12 mm

(1/2")
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 1/2

ml 31 x 5/16"
ULTICARE PEN NEEDLES/29G insulin pen needle 29 g x 12.7 mm
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 1/2

ml 30 x 5/16"
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 1 ml

30 x 5/16"
ULTICARE SHORT PEN NEEDLE insulin pen needle 31 g x 8 mm

(1/3" or 5/16")
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 1 ml

31 x 5/16"
ULTICARE THIN LANCETS 30G lancets
ULTICARE TUBERCULIN SAFET tuberculin/allergy syringe/needle

(disp) 1 ml 25 x 5/8"
ULTILET INSULIN SYRINGE/S insulin syringe/needle u-100 0.3

ml 31 x 5/16"
ULTICARE TUBERCULIN SAFET tuberculin/allergy syringe/needle

(disp) 1 ml 25 x 1"
ULTILET LANCETS - lancets
ULTILET LANCETS 33G - lancets
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 0.3

ml 29 x 1/2"
ULTILET OPERATING DEVICE lancet devices
2
2
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 0.3

ml 30 x 5/16"
ULTILET PEN NEEDLE 32GX4M insulin pen needle 32 g x 4 mm

(5/32")
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 1/2

ml 29 x 1/2"
ULTILET SAFETY LANCETS 23 lancets
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 1/2

ml 30 x 5/16"
ULTILET SHORT PEN NEEDLES insulin pen needle 31 g x 5 mm

(3/16")
ULTIGUARD INSULIN SYRINGE insulin syringe/needle u-100 1 ml

29 x 1/2"
ULTILET SHORT PEN NEEDLES insulin pen needle 31 g x 8 mm

(1/3" or 5/16")
ULTILET ULTI-LANCE ADJ DE lancet devices
198
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
ULTIMA - blood glucose monitoring

kit
ULTRA COMFORT INSULIN SYR insulin syringe/needle u-100 0.3

ml 30 x 5/16"
ULTRA-COMFORT INSULIN SYR insulin syringe/needle u-100 1 ml

30 x 5/16"
ULTRA COMFORT INSULIN SYR insulin syringe/needle u-100 1/2

ml 28 x 1/2"

31 x 5/16"
ULTRA INSULIN SYRINGE/U-1 insulin syringe/needle u-100 1/2

ml 29 x 1/2"
ULTRA-COMFORT INSULIN SYR insulin syringe/needle u-100 0.3

ml 31 x 5/16"
ULTRA-THIN II AUTO LANCET lancets
ULTRA THIN LANCETS 28G lancets
ULTRA THIN LANCETS 30G lancets
ULTRA-THIN II INSULIN SYR insulin syringe/needle u-100 0.3

ml 29 x 1/2"
ULTRA TRAK PRO BLOOD GLUC blood glucose monitoring kit w/

device

ml 30 x 5/16"

ml 29 x 1/2"
ULTRA-THIN II INSULIN SYR insulin syringe/needle u-100 1/2

ml 31 x 5/16"

ml 30 x 5/16"

ml 29 x 1/2"
ULTRA-COMFORT INSULIN SYR insulin syringe/needle u-100 1/2

ml 31 x 5/16"

ml 30 x 5/16"

ml 28 x 1/2"
ULTRA-THIN II INSULIN SYR insulin syringe/needle u-100 1 ml

29 x 1/2"

ml 29 x 1/2"

30 x 5/16"

ml 30 x 5/16"

31 x 5/16"

28 x 1/2"

ml 31 x 5/16"

29 x 1/2"
ULTRA-THIN II LANCETS 28G lancets

ULTRA-THIN II LANCETS 30G lancets
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
199
ULTRA-THIN II MINI PEN NE insulin pen needle 31 g x 5 mm

(3/16")
UNIFINE PENTIPS 31GX5MM insulin pen needle 31 g x 5 mm

(3/16")
ULTRA-THIN II PEN NEEDLES insulin pen needle 29 g x 12.7 mm
ULTRA-THIN II PEN NEEDLES insulin pen needle 31 g x 8 mm

(1/3" or 5/16")

(1/4")
ULTRA-THIN II SAFETY AUTO lancets

(1/3" or 5/16")
ULTRATRAK ACTIVE - blood


(5/32")
ULTRATRAK PRO - blood glucose

monitoring devices
UNILET COMFORTOUCH
LANCET - lancets
ULTRATRAK ULTIMATE MONITO blood glucose monitoring devices
UNILET EXCELITE - lancets
UNILET EXCELITE II - lancets
UNIFINE PENTIPS PLUS 29GX insulin pen needle 29 g x 12 mm

(1/2")
UNILET G.P. LANCET - lancets
2
2

(3/16")
UNILET G.P. SUPERLITE LAN lancets

UNILET GP 28 ULTRA THIN lancets

(1/4")
UNILET LANCET - lancets
UNILET LANCETS MICRO-THIN lancets

(1/3" or 5/16")
UNILET LANCETS SUPER-THIN lancets
2
2

(5/32")
UNILET LANCETS ULTRA-THIN lancets

(1/2")
UNILET SUPERLITE LANCET lancets

UNISTIK SAFETY LANCETS 28 lancets
UNISTIK SAFETY LANCETS 30 lancets
UNIFINE PENTIPS 31G X 3/1 insulin pen needle 31 g x 5 mm

(3/16")
UNISTIK 3 GENTLE - lancets
UNIFINE PENTIPS 31G X 6MM insulin pen needle 31 g x 6 mm

(1/4")
UNIVERSAL 1 LANCETS THIN lancets
2
2
UNIFINE PENTIPS 31G X 8MM insulin pen needle 31 g x 8 mm

(1/3" or 5/16")
UNIVERSAL 1 LANCETS ULTRA lancets
200
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
V-GO 20 - insulin infusion disposable 3

pump kit

pump kit
pump kit
2
V-R MONOJECT INSULIN SYRI insulin syringe/needle u-100 0.3
ml 29 x 1/2"
2
V-R MONOJECT INSULIN SYRI insulin syringe/needle u-100 1/2
ml 28 x 1/2"
2
V-R MONOJECT INSULIN SYRI insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
V-R MONOJECT INSULIN SYRI insulin syringe/needle u-100 1 ml
28 x 1/2"
2
V-R MONOJECT INSULIN SYRI insulin syringe/needle u-100 1 ml
29 x 1/2"
2
VALUE HEALTH INSULIN SYRI insulin syringe/needle u-100 1/2
ml 29 x 1/2"
2
VALUE HEALTH INSULIN SYRI insulin syringe/needle u-100 1 ml
29 x 1/2"
VALUE PLUS LANCETS STANDA - 2
lancets
2
VALUE PLUS LANCETS SUPER lancets
2
VALUE PLUS LANCETS THIN 2 lancets
2
VALUE PLUS LANCING DEVICE lancet devices
VALUMARK LANCET SUPER THI - 2
lancets
2
VALUMARK LANCET ULTRA THI lancets
VALUMARK PEN NEEDLES 29GX - 2
(1/2")
VALUMARK PEN NEEDLES 31G insulin pen needle 31 g x 6 mm

(1/4")
VALUMARK PEN NEEDLES 31G insulin pen needle 31 g x 8 mm

(1/3" or 5/16")
VANISHPOINT INSULIN SYRIN insulin syringe/needle u-100 1/2

ml 30 x 1/2"
VANISHPOINT INSULIN SYRIN insulin syringe/needle u-100 1 ml

29 x 1/2"
VICTORY BLOOD GLUCOSE

devices
VIDA MIA AUTOLET LANCING lancet devices
VIDA MIA UNIFINE PENTIPS insulin pen needle 29 g x 12 mm

(1/2")

(1/4")

(5/32")
VIDA MIA UNILET LANCETS S lancets
VIDA MIA UNILET LANCETS U lancets
VIDA MIA UNIPFINE PENTIPS insulin pen needle 31 g x 8 mm

(1/3" or 5/16")
VITALET PRO LANCETS - lancets
VITALET PRO PLUS LANCETS lancets
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
VOCAL POINT BLOOD GLUCOSE - 3

2
VP INSULIN SYRINGE/U-100/ insulin syringe/needle u-100 0.3
ml 29 x 1/2"
201
W&F LANCETS COLORED 21G lancets
W&F LANCETS 26G - lancets
WALGREENS ADVANCED
TRAVEL - lancets
WALGREENS COMFORT
ASSURED - lancets
WALGREENS LANCETS - lancets
WALGREENS THIN LANCETS lancets
WALGREENS ULTRA THIN LANC lancets
WAVESENSE AMP - blood glucose

WAVESENSE KEYNOTE - blood

WAVESENSE KEYNOTE PRO

MET - blood glucose monitoring
devices
WD MEDIC INSULIN SYRINGE/ insulin syringe/needle u-100 0.3

ml 29 x 1/2"
WD MEDIC INSULIN SYRINGE/ insulin syringe/needle u-100 0.3

ml 30 x 5/16"
WD MEDIC INSULIN SYRINGE/ insulin syringe/needle u-100 1/2

ml 29 x 1/2"
WD MEDIC INSULIN SYRINGE/ insulin syringe/needle u-100 1/2

ml 30 x 5/16"
WD MEDIC INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml

29 x 1/2"
WD MEDIC INSULIN SYRINGE/ insulin syringe/needle u-100 1 ml

30 x 5/16"
WEGMANS UNIFINE PENTIPS P insulin pen needle 31 g x 5 mm

(3/16")
202

(1/4")

(1/3" or 5/16")

(5/32")
WHITE PEDIATRIC ARTERIAL needle (disp) 19 x 1-1/2"
WHITE PEDIATRIC ARTERIAL needle (disp) 20 x 1-1/2"
WIDE-SEAL SILICONE DIAPHR diaphragm wide seal 60 mm
YALE NEEDLES - needle (disp) 18 x

1"

2"

1"

3/4"
YALE NEEDLES SHORT BEVEL needle (disp) 23 x 1"
YALE NEEDLES 16G X 1" - needle

(disp) 16 x 1"
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
YALE NEEDLES 18G X 1-1/2" needle (disp) 18 x 1-1/2"

(disp) 21 x 1"

(disp) 21 x 1"

(disp) 22 x 1"
YALE NEEDLES 26G X 1/2" - needle 2

(disp) 26 x 1/2"
YALE NEEDLES 26G X 3/8" - needle 2
(disp) 26 x 3/8"
YALE NEEDLES/REGULAR BEVE - 3
3
YALE NEEDLES/SHORT BEVEL/ needle (disp) 19 x 1"
3
YALE NEEDLES/SHORT BEVEL/ needle (disp) 19 x 1-1/2"
2
1ML ALLERGIST SYRINGE DET tuberculin/allergy syringe/needle
(disp) 1 ml 27 x 1/2"
2
1ML ALLERGY SYRINGE tuberculin/allergy syringe/needle
(disp) 1 ml 27 x 1/2"
3
1ML ALLERGY SYRINGE 28G X tuberculin/allergy syringe/needle
(disp) 1 ml 28 x 1/2"
2
1ML TB SYRINGE/25G X 5/8" tuberculin/allergy syringe/needle
(disp) 1 ml 25 x 5/8"

(disp) 1 ml 26 x 3/8"

(disp) 1 ml 27 x 1/2"
1ML TUBERCULIN SYRINGE DE tuberculin/allergy syringe/needle

(disp) 1 ml 25 x 5/8"
1ML TUBERCULIN SYRINGE DE tuberculin/allergy syringe/needle

(disp) 1 ml 26 x 3/8"
1ML VANISHPOINT TUBERCULI tuberculin/allergy syringe/needle

(disp) 1 ml 25 x 5/8"

(disp) 1 ml 25 x 1"

(disp) 1 ml 27 x 1/2"
1ST CHOICE LANCETS SUPER lancets
1ST CHOICE LANCETS THIN lancets
1ST CHOICE LANCETS ULTRA lancets
1ST TIER UNIFINE PENTIPS insulin pen needle 29 g x 12 mm

(1/2")

(3/16")

(1/4")

(1/3" or 5/16")

(5/32")
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
203
1ST TIER UNILET COMFORTOU lancets

ASSORTED CLASSES
ASTAGRAF XL - tacrolimus cap sr
24hr 0.5 mg
24hr 1 mg

24hr 5 mg
AZASAN - azathioprine tab 75 mg
AZASAN - azathioprine tab 100 mg
azathioprine tab 50 mg (Imuran)
CELLCEPT - mycophenolate mofetil

cap 250 mg

for oral susp 200 mg/ml

tab 500 mg
CUPRIMINE - penicillamine cap 250

mg
cyclosporine cap 25 mg
(Sandimmune)
cyclosporine cap 100 mg

(Sandimmune)
CYCLOSPORINE MODIFIED cyclosporine modified cap 50 mg
cyclosporine modified cap 25 mg

(Neoral)
cyclosporine modified cap

100 mg (Neoral)
IMURAN - azathioprine tab 50 mg
irrigation solution, physiological
KAYEXALATE - sodium polystyrene

sulfonate powder
lactated ringer's for irrigation
mycophenolate mofetil cap

250 mg (Cellcept)
mycophenolate mofetil for oral
susp 200 mg/ml (Cellcept)
mycophenolate mofetil tab
500 mg (Cellcept)
mycophenolate sodium tab dr
180 mg (mycophenolic acid
equiv) (Myfortic)
Responsible Steps
Quantity Limits
Prior Authorization
1
1
1
1
mycophenolate sodium tab dr

360 mg (mycophenolic acid
equiv) (Myfortic)
PROGRAF - tacrolimus cap 1 mg
PROGRAF - tacrolimus cap 5 mg
MYFORTIC - mycophenolate sodium 3

tab dr 180 mg (mycophenolic acid
equiv)
MYFORTIC - mycophenolate sodium 3
tab dr 360 mg (mycophenolic acid
equiv)
3
NEORAL - cyclosporine modified
cap 25 mg
3
cap 100 mg
3
oral soln 100 mg/ml
3
PHYSIOSOL IRRIGATION PH 7 irrigation solution, physiological
3
PROGRAF - tacrolimus cap 0.5 mg
DEPEN TITRATABS - penicillamine

tab 250 mg
ENVARSUS XR - tacrolimus tab sr

24hr 0.75 mg
RAPAMUNE - sirolimus oral soln 1

mg/ml

24hr 1 mg
RAPAMUNE - sirolimus tab 0.5 mg
RAPAMUNE - sirolimus tab 1 mg

24hr 4 mg
RAPAMUNE - sirolimus tab 2 mg
204
Specialty
Drug Name
Drug Tier
Responsible Steps
Quantity Limits
Prior Authorization
cyclosporine modified oral soln

100 mg/ml (Neoral)
Specialty
Drug Name
Drug Tier
2016
REVLIMID - lenalidomide cap 15 mg
ringer's solution for irrigation
SANDIMMUNE - cyclosporine cap

25 mg
SANDIMMUNE - cyclosporine cap

100 mg
SANDIMMUNE - cyclosporine oral

soln 100 mg/ml
sirolimus tab 0.5 mg (Rapamune)
sirolimus tab 1 mg (Rapamune)

sirolimus tab 2 mg (Rapamune)
sodium polystyrene sulfonate
oral susp 15 gm/60ml (Sps)
powder (Kayexalate)
rectal susp 30 gm/120ml
1
1
1
1
4
tacrolimus cap 0.5 mg (Prograf)
tacrolimus cap 5 mg (Prograf)
SYPRINE - trientine hcl cap 250 mg

tacrolimus cap 1 mg (Prograf)
Responsible Steps
Quantity Limits
ZORTRESS - everolimus tab 0.75

mg
Prior Authorization
Specialty
Drug Name
Drug Tier
REVLIMID - lenalidomide caps 2.5

mg
Responsible Steps
Quantity Limits
Prior Authorization
Specialty
Drug Name
Drug Tier
2016
1
1
THALOMID - thalidomide cap 50 mg
THALOMID - thalidomide cap 100

mg

mg

mg
water for irrigation, sterile

irrigation soln
ZORTRESS - everolimus tab 0.25

mg
ZORTRESS - everolimus tab 0.5 mg
205
2016
INDEX
A
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg (Trizivir)................................................ 6
abacavir sulfate tab 300 mg (base equiv) (Ziagen)........ 6
ABILIFY -aripiprazole tab 2 mg......................................... 77
ABILIFY -aripiprazole tab 5 mg......................................... 77
ABILIFY -aripiprazole tab 10 mg....................................... 77
ABILIFY DISCMELT -aripiprazole orally disintegrating tab
10 mg.............................................................................. 78
ABILIFY DISCMELT -aripiprazole orally disintegrating tab
15 mg.............................................................................. 78
ABSTRAL -fentanyl citrate sl tab 100 mcg (base
equiv)............................................................................... 90
equiv)............................................................................... 90
equiv)............................................................................... 90
equiv)............................................................................... 90
equiv)............................................................................... 90
equiv)............................................................................... 90
acamprosate calcium tab delayed release 333 mg...... 86
ACANYA -clindamycin phosphate-benzoyl peroxide gel
1.2-2.5%........................................................................ 132
acarbose tab 25 mg (Precose)....................................... 27
acarbose tab 50 mg (Precose)....................................... 27
acarbose tab 100 mg (Precose)..................................... 27
ACCOLATE -zafirlukast tab 10 mg....................................59
ACCOLATE -zafirlukast tab 20 mg....................................59
ACCU-CHEK ACTIVE STRIPS -glucose blood test
strip................................................................................ 144
ACCU-CHEK AVIVA -blood glucose monitoring
devices.......................................................................... 149
ACCU-CHEK AVIVA CONNECT -blood glucose
monitoring kit w/ device................................................ 149
ACCU-CHEK AVIVA -glucose blood test strip................ 144
ACCU-CHEK AVIVA PLUS -blood glucose monitoring kit
w/ device....................................................................... 149
ACCU-CHEK AVIVA PLUS -glucose blood test strip...... 144
ACCU-CHEK COMFORT CURVE T -glucose blood test
strip................................................................................ 144
ACCU-CHEK COMPACT PLUS CA -blood glucose
monitoring kit................................................................. 149
ACCU-CHEK COMPACT PLUS -glucose blood test
strip................................................................................ 144
ACCU-CHEK COMPACT STRIPS -glucose blood test
strip................................................................................ 144
206
ACCU-CHEK COMPACT TEST DR -glucose blood test

strip................................................................................ 144
ACCU-CHEK FASTCLIX LANCET -lancets.................... 149
ACCU-CHEK FASTCLIX LANCET -lancets kit............... 149
ACCU-CHEK MULTICLIX LANCE -lancets.....................149
ACCU-CHEK MULTICLIX LANC -lancets kit.................. 149
ACCU-CHEK NANO SMARTVIEW -blood glucose
ACCU-CHEK SAFE-T-PRO LANC -lancets.................... 149
ACCU-CHEK SAFE-T-PRO PLUS -lancets.................... 149
ACCU-CHEK SMARTVIEW STRIP -glucose blood test
strip................................................................................ 144
ACCU-CHEK SOFTCLIX LANCET -lancet devices........ 149
ACCU-CHEK SOFTCLIX LANCET -lancets................... 149
ACCU-CHEK SOFTCLIX LANCET -lancets kit............... 149
ACCU-CHEK SOFT TOUCH LANC -lancets.................. 149
ACCU-CHEK VOICEMATE -blood glucose monitoring kit
w/ device....................................................................... 149
ACCUPRIL -quinapril hcl tab 5 mg................................... 44
ACCUPRIL -quinapril hcl tab 10 mg................................. 44
ACCURETIC -quinapril-hydrochlorothiazide tab 10-12.5
mg.................................................................................... 44
ACCURETIC -quinapril-hydrochlorothiazide tab 20-12.5
mg.................................................................................... 44
ACCURETIC -quinapril-hydrochlorothiazide tab 20-25
mg.................................................................................... 44
ACCUTREND GLUCOSE -glucose blood test strip........ 144
acebutolol hcl cap 200 mg (Sectral).............................. 38
acebutolol hcl cap 400 mg (Sectral).............................. 38
ACEON -perindopril erbumine tab 4 mg........................... 44
ACEON -perindopril erbumine tab 8 mg........................... 44
acetaminophen-caffeine-dihydrocodeine cap
320.5-30-16 mg (Trezix)................................................ 90
acetaminophen-isometheptene-dichloral cap
325-65-100 mg............................................................... 99
acetaminophen w/ codeine soln 120-12 mg/5ml.......... 90
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
codeine).......................................................................... 90
codeine #3).................................................................... 90
codeine #4).................................................................... 90
ACETAZOLAMIDE -acetazolamide tab 125 mg............... 51
acetazolamide cap sr 12hr 500 mg (Diamox)............... 51
acetazolamide tab 250 mg.............................................. 51
ACETEST -acetone (urine) test tab................................ 144
ACETIC ACID/ALUMINUM ACET -acetic acid 2% in
aluminum acetate otic soln...........................................131
acetic acid irrigation soln 0.25%................................... 71
acetic acid otic soln 2%................................................ 131
acetylcysteine cap 600 mg........................................... 119
acetylcysteine inhal soln 10%........................................ 58
acetylcysteine inhal soln 20%........................................ 58
acitretin cap 10 mg (Soriatane).................................... 132
acitretin cap 17.5 mg (Soriatane)................................. 132
2016
acitretin cap 25 mg (Soriatane).................................... 132
ACLOVATE -alclometasone dipropionate cream
0.05%.............................................................................132
ACTEMRA -tocilizumab subcutaneous soln prefilled
syringe 162 mg/0.9ml..................................................... 97
ACTHIB -haemophilus b polysaccharide conjugate
vaccine for inj.................................................................. 12
ACTIGALL -ursodiol cap 300 mg...................................... 67
ACTI-LANCE LANCETS 28G -lancets............................ 149
ACTI-LANCE LITE SAFETY LA -lancets........................ 149
ACTI-LANCE SPECIAL SAFETY -lancets...................... 149
ACTI-LANCE UNIVERSAL SAFE -lancets..................... 149
ACTIMMUNE -interferon gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)....................................................... 16
ACTIQ -fentanyl citrate lozenge on a handle 200 mcg..... 90
ACTIQ -fentanyl citrate lozenge on a handle 1200
mcg.................................................................................. 90
ACTIQ -fentanyl citrate lozenge on a handle 1600
mcg.................................................................................. 90
ACTIVELLA -estradiol & norethindrone acetate tab
0.5-0.1 mg....................................................................... 22
ACTIVELLA -estradiol & norethindrone acetate tab 1-0.5
mg.................................................................................... 22
ACTIVE OB -prenatal w/o a w/fe cbn-fa-dha cap 20-1-320
mg.................................................................................. 110
ACTONEL -risedronate sodium tab 5 mg......................... 33
ACTONEL -risedronate sodium tab 30 mg....................... 33
ACTONEL -risedronate sodium tab 35 mg....................... 34
ACTONEL -risedronate sodium tab 150 mg..................... 34
ACTOPLUS MET -pioglitazone hcl-metformin hcl tab
15-500 mg....................................................................... 27
ACTOPLUS MET -pioglitazone hcl-metformin hcl tab
15-850 mg....................................................................... 27
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab
sr 24hr 15-1000 mg........................................................ 27
ACTOPLUS MET XR -pioglitazone hcl-metformin hcl tab
sr 24hr 30-1000 mg........................................................ 27
ACTOS -pioglitazone hcl tab 15 mg (base equiv)............. 27
ACUICYN DAILY EYELID & EY -eyelid cleansers liquid.............................................................................. 132
ACULAR -ketorolac tromethamine ophth soln 0.5%....... 126
ACULAR LS -ketorolac tromethamine ophth soln
0.4%...............................................................................126
ACURA BLOOD GLUCOSE MONIT -blood glucose
ACURA BLOOD GLUCOSE TEST -glucose blood test
strip................................................................................ 144
ACURA PLUS BLOOD GLUCOSE -blood glucose
ACUVAIL -ketorolac tromethamine ophth soln
0.45%.............................................................................126
acyclovir cap 200 mg (Zovirax)........................................ 6
acyclovir oint 5% (Zovirax)........................................... 132

acyclovir susp 200 mg/5ml (Zovirax).............................. 6
acyclovir tab 400 mg (Zovirax)........................................ 7
acyclovir tab 800 mg (Zovirax)........................................ 7
ACZONE -dapsone gel 5%............................................. 132
ADACEL -tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lfmcg/0.5ml........................................................................ 15
ADALAT CC -nifedipine tab sr 24hr 30 mg....................... 40
ADAPALENE -adapalene lotion 0.1%............................. 132
adapalene cream 0.1% (Differin).................................. 132
adapalene gel 0.1% (Differin)....................................... 132
adapalene gel 0.3% (Differin)....................................... 133
ADCIRCA -tadalafil tab 20 mg (pah)................................. 56
ADDERALL -amphetamine-dextroamphetamine tab 5
mg.................................................................................... 82
ADDERALL -amphetamine-dextroamphetamine tab 7.5
mg.................................................................................... 82
mg.................................................................................... 82
ADDERALL -amphetamine-dextroamphetamine tab 12.5
mg.................................................................................... 82
mg.................................................................................... 82
mg.................................................................................... 82
mg.................................................................................... 82
ADDERALL XR -amphetamine-dextroamphetamine cap
sr 24hr 5 mg................................................................... 82
sr 24hr 10 mg................................................................. 82
sr 24hr 15 mg................................................................. 82
sr 24hr 20 mg................................................................. 82
sr 24hr 25 mg................................................................. 82
sr 24hr 30 mg................................................................. 82
adefovir dipivoxil tab 10 mg (Hepsera)........................... 7
ADEMPAS -riociguat tab 0.5 mg....................................... 56
ADEMPAS -riociguat tab 1 mg.......................................... 56
ADEMPAS -riociguat tab 2 mg.......................................... 56
ADJUSTABLE LANCING DEVICE -lancet devices......... 149
ADRENACLICK -epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)......................................................... 53
ADRENACLICK -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)........................................................... 53
ADRENALIN -epinephrine hcl nasal soln 0.1%................ 58
ADVAIR DISKUS -fluticasone-salmeterol aer powder ba
100-50 mcg/dose............................................................ 59
250-50 mcg/dose............................................................ 59
207
2016
500-50 mcg/dose............................................................ 59
ADVAIR HFA -fluticasone-salmeterol inhal aerosol 45-21
mcg/act............................................................................ 60
mcg/act............................................................................ 60
mcg/act............................................................................ 60
ADVANCE INTUITION BLOOD G -blood glucose
monitoring devices........................................................ 149
ADVANCE INTUITION BLOOD G -blood glucose
ADVANCE INTUITION TEST ST -glucose blood test
strip................................................................................ 144
ADVANCE MICRO-DRAW METER -blood glucose
ADVANCE MICRO-DRAW TEST S -glucose blood test
strip................................................................................ 144
ADVATE -antihemophilic factor rahf-pfm for inj 250
unit................................................................................. 122
unit................................................................................. 122
unit................................................................................. 122
unit................................................................................. 122
unit................................................................................. 122
unit................................................................................. 123
unit................................................................................. 123
ADVICOR -niacin-lovastatin tab sr 24hr 500-20 mg......... 53
ADVICOR -niacin-lovastatin tab sr 24hr 750-20 mg......... 53
ADVICOR -niacin-lovastatin tab sr 24hr 1000-20 mg....... 53
ADVICOR -niacin-lovastatin tab sr 24hr 1000-40 mg....... 53
ADVOCATE BLOOD GLUCOSE MO -blood glucose
ADVOCATE BLOOD GLUCOSE MO -blood glucose
ADVOCATE INSULIN PEN NEED -insulin pen needle 29
g x 12.7 mm..................................................................150
g x 5 mm (3/16")...........................................................150
g x 8 mm (1/3" or 5/16")...............................................150
ADVOCATE INSULIN SYRINGE/ -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 150
u-100 1/2 ml 29 x 1/2".................................................. 150
u-100 1/2 ml 30 x 5/16"................................................ 150
u-100 0.3 ml 29 x 1/2".................................................. 150
u-100 0.3 ml 30 x 5/16"................................................ 150
208

u-100 1 ml 29 x 1/2".....................................................150
u-100 1 ml 30 x 5/16"...................................................150
u-100 1 ml 31 x 5/16"...................................................150
u-100 0.3 ml 31 x 5/16"................................................ 150
ADVOCATE LANCETS 30G -lancets.............................. 150
ADVOCATE LANCETS -lancets...................................... 150
ADVOCATE LANCING DEVICE -lancet devices............ 150
ADVOCATE RAPID-SAFE LANCI -lancet devices......... 150
ADVOCATE REDI-CODE/TALKIN -blood glucose
ADVOCATE REDI-CODE/TALKIN -blood glucose
ADVOCATE REDI-CODE+/ TALK -blood glucose
ADVOCATE REDI-CODE+ BLOOD -blood glucose
ADVOCATE REDI-CODE+ TEST -glucose blood test
strip................................................................................ 144
ADVOCATE REDI-CODE -blood glucose monitoring
devices.......................................................................... 150
ADVOCATE REDI-CODE -glucose blood test strip........ 144
ADVOCATE SAFETY LANCETS -lancets...................... 150
ADVOCATE SAFETY LANCETS 2 -lancets................... 150
ADVOCATE TEST STRIPS -glucose blood test strip..... 144
AEROSPAN -flunisolide hfa inhal aerosol 80 mcg/act...... 60
AFINITOR DISPERZ -everolimus tab for oral susp 2
mg.................................................................................... 16
mg.................................................................................... 16
mg.................................................................................... 16
AFINITOR -everolimus tab 2.5 mg.................................... 16
AFINITOR -everolimus tab 5 mg....................................... 16
AFINITOR -everolimus tab 7.5 mg.................................... 16
AFINITOR -everolimus tab 10 mg..................................... 16
AF LANCETS SUPER THIN -lancets............................. 150
AFLURIA 2012-2013 -influenza virus vaccine split im
susp................................................................................. 12
susp................................................................................. 12
susp................................................................................. 12
susp................................................................................. 12
AFLURIA PF 2012-2013 -influenza virus vaccine split pf
susp pref syringe 0.5 ml................................................. 12
2016
AFREZZA -insulin regular (human) inhalation powder 4
unit/cartridge.................................................................... 31
AFREZZA -insulin regular (human) inhal powd 4 (30) & 8
(60) unit/cart.................................................................... 31
AFREZZA -insulin regular (human) inhal powd 4 (60) & 8
(30) unit/cart.................................................................... 31
AFREZZA -insulin regular (human) inh powd 8 (60) & 12
(30) unit/cart.................................................................... 31
AGAMATRIX AMP NO CODE ADV -blood glucose
AGAMATRIX AMP NO CODE TES -glucose blood test
strip................................................................................ 144
AGAMATRIX JAZZ -blood glucose monitoring kit w/
device............................................................................ 150
AGAMATRIX JAZZ TEST STRIP -glucose blood test
strip................................................................................ 144
AGAMATRIX KEYNOTE TEST ST -glucose blood test
strip................................................................................ 144
AGAMATRIX PRESTO -blood glucose monitoring kit w/
device............................................................................ 150
AGAMATRIX PRESTO PRO METE -blood glucose
AGAMATRIX PRESTO TEST STR -glucose blood test
strip................................................................................ 144
AGAMATRIX ULTRA-THIN LANC -lancets..................... 150
AGGRENOX -aspirin-dipyridamole cap sr 12hr 25-200
mg.................................................................................. 123
AGRYLIN -anagrelide hcl cap 0.5 mg............................. 123
AKTEN -lidocaine hcl ophth gel 3.5%............................. 126
AKYNZEO -netupitant-palonosetron cap 300-0.5 mg....... 65
ALA-QUIN -clioquinol-hc cream 3-0.5%..........................133
ALA SCALP -hydrocortisone lotion 2%........................... 133
ALBENZA -albendazole tab 200 mg................................. 11
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml)......... 60
albuterol sulfate soln nebu 0.5% (5 mg/ml).................. 60
albuterol sulfate soln nebu 0.63 mg/3ml (base
equiv).............................................................................. 60
albuterol sulfate soln nebu 1.25 mg/3ml (base
equiv).............................................................................. 60
albuterol sulfate syrup 2 mg/5ml................................... 60
albuterol sulfate tab 2 mg...............................................60
albuterol sulfate tab 4 mg...............................................60
albuterol sulfate tab sr 12hr 4 mg (Vospire er)............ 60
albuterol sulfate tab sr 12hr 8 mg (Vospire er)............ 60
ALCAINE -proparacaine hcl ophth soln 0.5%................. 126
alclometasone dipropionate cream 0.05%
(Aclovate)..................................................................... 133
alclometasone dipropionate oint 0.05%......................133
ALDACTAZIDE -spironolactone & hydrochlorothiazide tab
25-25 mg......................................................................... 52
ALDACTAZIDE -spironolactone & hydrochlorothiazide tab
50-50 mg......................................................................... 52
ALDACTONE -spironolactone tab 25 mg......................... 52
ALDACTONE -spironolactone tab 50 mg......................... 52
ALDACTONE -spironolactone tab 100 mg....................... 52
ALDARA -imiquimod cream 5%...................................... 133
ALENDRONATE SODIUM -alendronate sodium oral soln

70 mg/75ml..................................................................... 34
ALENDRONATE SODIUM -alendronate sodium tab 40
mg.................................................................................... 34
alendronate sodium tab 5 mg........................................ 34
alendronate sodium tab 10 mg...................................... 34
alendronate sodium tab 35 mg...................................... 34
alendronate sodium tab 70 mg (Fosamax)................... 34
alfuzosin hcl tab sr 24hr 10 mg (Uroxatral).................. 71
ALINIA -nitazoxanide for susp 100 mg/5ml.......................11
ALINIA -nitazoxanide tab 500 mg..................................... 11
ALKERAN -melphalan tab 2 mg....................................... 16
allopurinol tab 100 mg (Zyloprim)............................... 101
allopurinol tab 300 mg (Zyloprim)............................... 101
almotriptan malate tab 6.25 mg (Axert).........................99
almotriptan malate tab 12.5 mg (Axert).........................99
ALOCRIL -nedocromil sodium ophth soln 2%................ 126
ALOMIDE -lodoxamide tromethamine ophth soln
0.1%...............................................................................126
ALOQUIN -iodoquinol-aloe polysaccharides gel
1.25-1%......................................................................... 133
ALORA -estradiol td patch twice weekly 0.025
mg/24hr........................................................................... 22
ALORA -estradiol td patch twice weekly 0.05 mg/24hr..... 22
ALORA -estradiol td patch twice weekly 0.075
mg/24hr........................................................................... 22
ALORA -estradiol td patch twice weekly 0.1 mg/24hr....... 22
alosetron hcl tab 0.5 mg (base equiv) (Lotronex)........ 67
alosetron hcl tab 1 mg (base equiv) (Lotronex)........... 67
ALPHAGAN P -brimonidine tartrate ophth soln 0.1%..... 126
ALPHAGAN P -brimonidine tartrate ophth soln
0.15%.............................................................................126
ALPHANATE/VON WILLEBRAND -antihemophilic factor/
vwf (human) for inj 250 unit......................................... 123
vwf (human) for inj 500 unit......................................... 123
vwf (human) for inj 1000 unit....................................... 123
ALPHANINE SD -coagulation factor ix for inj 500
unit................................................................................. 123
unit................................................................................. 123
unit................................................................................. 123
ALPRAZOLAM INTENSOL -alprazolam conc 1 mg/
ml..................................................................................... 72
alprazolam orally disintegrating tab 0.5 mg................. 72
alprazolam orally disintegrating tab 1 mg.................... 72
alprazolam orally disintegrating tab 2 mg.................... 72
alprazolam orally disintegrating tab 0.25 mg
(Niravam)........................................................................ 72
alprazolam tab 0.25 mg (Xanax).................................... 72
alprazolam tab 0.5 mg (Xanax)...................................... 72
209
2016
alprazolam tab 1 mg (Xanax)..........................................72
alprazolam tab 2 mg (Xanax)..........................................72
alprazolam tab sr 24hr 0.5 mg (Xanax xr)..................... 72
alprazolam tab sr 24hr 1 mg (Xanax xr)........................ 72
ALPROLIX -coagulation factor ix (recomb) (rfixfc) for inj
500 unit......................................................................... 123
1000 unit....................................................................... 123
2000 unit....................................................................... 123
3000 unit....................................................................... 123
ALREX -loteprednol etabonate ophth susp 0.2%........... 126
ALSUMA -sumatriptan succinate solution auto-injector 6
mg/0.5ml.......................................................................... 99
ALTABAX -retapamulin oint 1%.......................................133
ALTACE -ramipril cap 1.25 mg.......................................... 44
ALTACE -ramipril cap 2.5 mg............................................ 44
ALTACE -ramipril cap 5 mg............................................... 44
ALTACE -ramipril cap 10 mg............................................. 44
ALTERNATE SITE LANCING DE -lancet devices.......... 150
ALTOPREV -lovastatin tab sr 24hr 20 mg........................ 53
ALVESCO -ciclesonide inhal aerosol 80 mcg/act............. 60
ALVESCO -ciclesonide inhal aerosol 160 mcg/act........... 60
AMANTADINE HCL -amantadine hcl tab 100 mg........... 106
amantadine hcl cap 100 mg......................................... 106
amantadine hcl syrup 50 mg/5ml................................ 106
AMARYL -glimepiride tab 1 mg......................................... 27
AMCINONIDE -amcinonide cream 0.1%........................ 133
AMCINONIDE -amcinonide lotion 0.1%.......................... 133
AMCINONIDE -amcinonide oint 0.1%.............................133
AMERGE -naratriptan hcl tab 1 mg (base equiv)............. 99
AMERGE -naratriptan hcl tab 2.5 mg (base equiv).......... 99
AMICAR -aminocaproic acid oral soln 0.25 gm/ml......... 122
AMICAR -aminocaproic acid syrup 25%......................... 122
AMICAR -aminocaproic acid tab 500 mg........................ 122
AMICAR -aminocaproic acid tab 1000 mg...................... 122
amiloride & hydrochlorothiazide tab 5-50 mg.............. 52
amiloride hcl tab 5 mg.................................................... 52
AMINOBENZOATE POTASSIUM -potassium
aminobenzoate packet 2 gm........................................ 110
AMINOCAPROIC ACID -aminocaproic acid tab 1000
mg.................................................................................. 122
amiodarone hcl tab 100 mg............................................ 43
amiodarone hcl tab 400 mg............................................ 43
amiodarone hcl tab 200 mg (Cordarone)...................... 43
AMITIZA -lubiprostone cap 8 mcg.................................... 67
AMITIZA -lubiprostone cap 24 mcg.................................. 67
amitriptyline hcl tab 10 mg............................................. 72
210

amitriptyline hcl tab 100 mg........................................... 73
amitriptyline hcl tab 150 mg........................................... 73
amlodipine besylate-atorvastatin calcium tab 2.5-10
mg (Caduet)................................................................... 56
mg (Caduet)................................................................... 56
mg (Caduet)................................................................... 56
amlodipine besylate-atorvastatin calcium tab 5-10 mg
(Caduet).......................................................................... 56
(Caduet).......................................................................... 56
(Caduet).......................................................................... 56
(Caduet).......................................................................... 56
amlodipine besylate-atorvastatin calcium tab 10-10
mg (Caduet)................................................................... 56
mg (Caduet)................................................................... 56
mg (Caduet)................................................................... 57
mg (Caduet)................................................................... 57
amlodipine besylate-benazepril hcl cap 2.5-10 mg
(Lotrel)............................................................................ 44
amlodipine besylate-benazepril hcl cap 5-10 mg
(Lotrel)............................................................................ 44
(Lotrel)............................................................................ 44
(Lotrel)............................................................................ 44
(Lotrel)............................................................................ 44
(Lotrel)............................................................................ 44
amlodipine besylate tab 2.5 mg (Norvasc)................... 40
amlodipine besylate tab 5 mg (Norvasc)...................... 40
amlodipine besylate tab 10 mg (Norvasc).................... 40
amlodipine besylate-valsartan tab 5-160 mg
(Exforge)......................................................................... 44
(Exforge)......................................................................... 44
(Exforge)......................................................................... 44
(Exforge)......................................................................... 44
amlodipine-valsartan-hydrochlorothiazide tab
5-160-12.5 mg (Exforge hct)........................................ 44
5-160-25 mg (Exforge hct)........................................... 44
10-160-12.5 mg (Exforge hct)...................................... 44
10-160-25 mg (Exforge hct)......................................... 44
2016
10-320-25 mg (Exforge hct)......................................... 44
AMOXAPINE -amoxapine tab 25 mg................................ 73
AMOXAPINE -amoxapine tab 50 mg................................ 73
AMOXAPINE -amoxapine tab 100 mg.............................. 73
AMOXAPINE -amoxapine tab 150 mg.............................. 73
amoxicillin & k clavulanate chew tab 200-28.5 mg........ 1
amoxicillin & k clavulanate chew tab 400-57 mg........... 1
amoxicillin & k clavulanate for susp 200-28.5
mg/5ml.............................................................................. 1
amoxicillin & k clavulanate for susp 400-57 mg/5ml..... 1
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
(Augmentin)..................................................................... 1
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
(Augmentin es-600)........................................................ 1
amoxicillin & k clavulanate tab 250-125 mg................... 1
amoxicillin & k clavulanate tab 500-125 mg
(Augmentin)..................................................................... 1
amoxicillin & k clavulanate tab 875-125 mg
(Augmentin)..................................................................... 1
amoxicillin & k clavulanate tab sr 12hr 1000-62.5 mg
(Augmentin xr)................................................................ 1
AMOXICILLIN -amoxicillin (trihydrate) chew tab 125
mg...................................................................................... 1
AMOXICILLIN -amoxicillin (trihydrate) chew tab 250
mg...................................................................................... 1
amoxicillin cap-clarithro tab-lansopraz cap dr therapy
pack (Prevpac).............................................................. 64
AMOXICILLIN ER -amoxicillin (trihydrate) tab sr 24hr 775
mg...................................................................................... 1
amoxicillin (trihydrate) cap 250 mg................................. 1
amoxicillin (trihydrate) cap 500 mg................................. 1
amoxicillin (trihydrate) for susp 125 mg/5ml..................1
amoxicillin (trihydrate) tab 500 mg.................................. 1
amoxicillin (trihydrate) tab 875 mg.................................. 1
amphetamine-dextroamphetamine cap sr 24hr 5 mg
(Adderall xr)................................................................... 82
(Adderall xr)................................................................... 82
(Adderall xr)................................................................... 82
(Adderall xr)................................................................... 82
(Adderall xr)................................................................... 82
(Adderall xr)................................................................... 82
amphetamine-dextroamphetamine tab 5 mg
(Adderall)........................................................................ 82
amphetamine-dextroamphetamine tab 7.5 mg
(Adderall)........................................................................ 83
(Adderall)........................................................................ 83
amphetamine-dextroamphetamine tab 12.5 mg

(Adderall)........................................................................ 83
(Adderall)........................................................................ 83
(Adderall)........................................................................ 83
(Adderall)........................................................................ 83
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...................... 86
ANACAINE -benzocaine oint 10%.................................. 133
ANADROL-50 -oxymetholone tab 50 mg.......................... 21
ANAFRANIL -clomipramine hcl cap 25 mg....................... 73
anagrelide hcl cap 1 mg............................................... 123
anagrelide hcl cap 0.5 mg (Agrylin)............................ 123
ANALPRAM-HC -hydrocortisone acetate w/ pramoxine
rectal cream 1-1%........................................................ 132
rectal cream 2.5-1%..................................................... 132
ANALPRAM HC -hydrocortisone acetate w/ pramoxine
rectal cream 2.5-1%..................................................... 132
rectal lotn 2.5-1%..........................................................132
ANALPRAM-HC SINGLES -hydrocortisone acetate w/
pramoxine rectal cream 1-1%...................................... 132
ANALPRAM-HC SINGLES -hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%................................... 132
ANALPRAM HC SINGLES -hydrocortisone acetate w/
pramoxine rectal cream 2.5-1%................................... 132
ANAPROX DS -naproxen sodium tab 550 mg................. 97
ANAPROX -naproxen sodium tab 275 mg........................97
ANASPAZ -hyoscyamine sulfate tab disp 0.125 mg......... 64
anastrozole tab 1 mg (Arimidex)................................... 16
ANCOBON -flucytosine cap 250 mg................................... 6
ANCOBON -flucytosine cap 500 mg................................... 6
ANDRODERM -testosterone td patch 24hr 2 mg/24hr..... 21
ANDRODERM -testosterone td patch 24hr 4 mg/24hr..... 21
ANDROGEL PUMP -testosterone td gel 12.5 mg/act
(1%)................................................................................. 22
ANDROGEL PUMP -testosterone td gel 20.25 mg/act
(1.62%)............................................................................ 22
ANDROGEL -testosterone td gel 25 mg/2.5gm (1%)....... 21
ANDROGEL -testosterone td gel 50 mg/5gm (1%).......... 21
ANDROGEL -testosterone td gel 20.25 mg/1.25gm
(1.62%)............................................................................ 21
ANDROGEL -testosterone td gel 40.5 mg/2.5gm
(1.62%)............................................................................ 21
ANDROID -methyltestosterone cap 10 mg....................... 22
ANDROXY -fluoxymesterone tab 10 mg........................... 22
ANGELIQ -drospirenone-estradiol tab 0.25-0.5 mg.......... 22
ANGELIQ -drospirenone-estradiol tab 0.5-1 mg............... 22
211
2016
ANORO ELLIPTA -umeclidinium-vilanterol aero powd ba
62.5-25 mcg/inh.............................................................. 60
ANTABUSE -disulfiram tab 250 mg.................................. 86
ANTABUSE -disulfiram tab 500 mg.................................. 86
ANTARA -fenofibrate micronized cap 30 mg.................... 53
ANTARA -fenofibrate micronized cap 90 mg.................... 53
antipyrine-benzocaine otic soln 54-14 mg/ml
(5.4-1.4%)...................................................................... 131
antipyrine-benzocaine-polycosanol otic sol
5.4-1.4-0.0097% (Treagan otic).................................. 131
ANTI-STICK INSULIN SYRING -insulin syringe/needle
u-100 1/2 ml 28 x 1/2".................................................. 151
u-100 1/2 ml 29 x 1/2".................................................. 151
u-100 1 ml 29 x 1/2".....................................................151
ANTI-STICK TUBERCULIN SYR -tuberculin/allergy
syringe/needle (disp) 1 ml 25 x 5/8"............................ 151
ANTI-STICK TUBERCULIN SYR -tuberculin/allergy
ANUSOL-HC -hydrocortisone acetate suppos 25
mg.................................................................................. 132
ANUSOL-HC -hydrocortisone rectal cream 2.5%........... 132
ANZEMET -dolasetron mesylate tab 50 mg..................... 65
ANZEMET -dolasetron mesylate tab 100 mg................... 66
APEXICON E -diflorasone diacetate emollient base
cream 0.05%................................................................. 133
APIDRA -insulin glulisine inj 100 unit/ml........................... 30
APIDRA SOLOSTAR -insulin glulisine soln pen-injector inj
100 unit/ml.......................................................................30
APLENZIN -bupropion hbr tab sr 24hr 174 mg.................73
APOKYN -apomorphine hydrochloride inj 10 mg/ml....... 106
apraclonidine hcl ophth soln 0.5% (base equivalent)
(Iopidine)...................................................................... 127
APRISO -mesalamine cap sr 24hr 0.375 gm.................... 67
APTENSIO XR -methylphenidate hcl cap er 24hr 10 mg
(xr)................................................................................... 83
(xr)................................................................................... 83
(xr)................................................................................... 83
(xr)................................................................................... 83
(xr)................................................................................... 83
(xr)................................................................................... 83
(xr)................................................................................... 83
APTIOM -eslicarbazepine acetate tab 200 mg............... 101
APTIVUS -tipranavir cap 250 mg........................................ 7
APTIVUS -tipranavir oral soln 100 mg/ml........................... 7
212
AQUA LANCE ADJUSTABLE LAN -lancet devices........ 151

ARALEN -chloroquine phosphate tab 500 mg.................. 11
ARANESP ALBUMIN FREE -darbepoetin alfa soln inj 25
mcg/ml........................................................................... 119
mcg/ml........................................................................... 119
mcg/ml........................................................................... 119
mcg/ml........................................................................... 119
mcg/ml........................................................................... 119
mcg/ml........................................................................... 119
ARANESP ALBUMIN FREE -darbepoetin alfa soln
prefilled syringe 10 mcg/0.4ml..................................... 119
prefilled syringe 25 mcg/0.42ml................................... 119
prefilled syringe 500 mcg/ml........................................ 119
ARAVA -leflunomide tab 10 mg......................................... 97
ARAVA -leflunomide tab 20 mg......................................... 97
ARCALYST -rilonacept for inj 220 mg...............................97
ARCAPTA NEOHALER -indacaterol maleate inhal powder
cap 75 mcg (base equiv)................................................60
ARICEPT -donepezil hydrochloride tab 5 mg................... 86
ARICEPT -donepezil hydrochloride tab 10 mg................. 86
ARICEPT -donepezil hydrochloride tab 23 mg................. 86
ARIMIDEX -anastrozole tab 1 mg..................................... 16
ARIPIPRAZOLE ODT -aripiprazole orally disintegrating
tab 10 mg........................................................................ 78
ARIPIPRAZOLE ODT -aripiprazole orally disintegrating
tab 15 mg........................................................................ 78
aripiprazole oral solution 1 mg/ml................................. 78
aripiprazole tab 2 mg (Abilify)........................................ 78
aripiprazole tab 5 mg (Abilify)........................................ 78
aripiprazole tab 10 mg (Abilify)...................................... 78
ARIXTRA -fondaparinux sodium subcutaneous inj 2.5
mg/0.5ml........................................................................ 121
ARIXTRA -fondaparinux sodium subcutaneous inj 5
mg/0.4ml........................................................................ 121
2016
ARIXTRA -fondaparinux sodium subcutaneous inj 7.5
mg/0.6ml........................................................................ 121
ARIXTRA -fondaparinux sodium subcutaneous inj 10
mg/0.8ml........................................................................ 121
ARMOUR THYROID -thyroid tab 15 mg (1/4 grain)......... 31
ARMOUR THYROID -thyroid tab 30 mg (1/2 grain)......... 31
ARMOUR THYROID -thyroid tab 90 mg (1 1/2 grain)...... 31
ARMOUR THYROID -thyroid tab 60 mg (1 grain)............ 31
ARMOUR THYROID -thyroid tab 120 mg (2 grain).......... 31
ARNUITY ELLIPTA -fluticasone furoate aerosol powder
breath activ 100 mcg/act................................................ 60
ARNUITY ELLIPTA -fluticasone furoate aerosol powder
breath activ 200 mcg/act................................................ 60
AROMASIN -exemestane tab 25 mg................................ 16
ARTHROTEC 50 -diclofenac w/ misoprostol tab delayed
release 50-0.2 mg...........................................................97
ARTHROTEC 75 -diclofenac w/ misoprostol tab delayed
release 75-0.2 mg...........................................................97
ARZOL SILVER NITRATE APP -silver nitrate-potassium
nitrate applicator 75-25%............................................. 133
ASACOL HD -mesalamine tab delayed release 800
mg.................................................................................... 67
ASCENSIA AUTODISC TEST ST -glucose blood test
disk................................................................................ 144
ASMANEX HFA -mometasone furoate inhal aerosol
suspension 100 mcg/act................................................. 60
ASMANEX HFA -mometasone furoate inhal aerosol
suspension 200 mcg/act................................................. 60
ASMANEX TWISTHALER 120 ME -mometasone furoate
inhal powd 220 mcg/inh (breath activated).................... 60
ASMANEX TWISTHALER 7 METE -mometasone furoate
ASMANEX TWISTHALER 14 MET -mometasone furoate
ASPIRIN/DIPYRIDAMOLE -aspirin-dipyridamole cap sr
12hr 25-200 mg............................................................ 123
ASPIRIN-CAFFEINE-DIHYDROC -aspirin-caffeinedihydrocodeine cap 356.4-30-16 mg............................. 90
aspirin chew tab 81 mg...................................................90
aspirin tab delayed release 81 mg.................................90
ASSURE 4 BLOOD GLUCOSE ME -blood glucose
ASSURE COMFORT LANCETS UL -lancets................. 151
ASSURE HAEMOLANCE PLUS HI -lancets.................. 151
ASSURE HAEMOLANCE PLUS LO -lancets................. 151
ASSURE HAEMOLANCE PLUS MI -lancets.................. 151
ASSURE HAEMOLANCE PLUS NO -lancets................. 151
ASSURE HAEMOLANCE PLUS PE -lancets................. 151
ASSURE ID INSULIN SAFETY -insulin syringe/needle

u-100 1/2 ml 29 x 1/2".................................................. 151
ASSURE ID INSULIN SAFETY -insulin syringe/needle
u-100 1 ml 29 x 1/2".....................................................151
ASSURE II CHECK STRIP -glucose blood test strip...... 144
ASSURE II -glucose blood test strip............................... 144
ASSURE II TEST STRIPS -glucose blood test strip....... 144
ASSURE LANCE LANCETS 21G -lancets..................... 151
ASSURE LANCE LANCETS -lancets............................. 151
ASSURE LANCE PLUS SAFETY -lancets..................... 151
ASSURE LANCETS -lancets...........................................151
ASSURE 3 METER -blood glucose monitoring kit.......... 151
ASSURE PLATINUM BLOOD GLU -blood glucose
ASSURE PLATINUM TEST STRI -glucose blood test
strip................................................................................ 144
ASSURE PRISM MULTI BLOOD -blood glucose
ASSURE PRISM MULTI TEST S -glucose blood test
strip................................................................................ 144
ASSURE PRO BLOOD GLUCOSE -blood glucose
ASSURE PRO TEST STRIPS -glucose blood test
strip................................................................................ 144
ASSURE 3 TEST STRIPS -glucose blood test strip....... 144
ASSURE 4 TEST STRIPS -glucose blood test strip....... 144
ASTAGRAF XL -tacrolimus cap sr 24hr 0.5 mg.............. 204
ASTAGRAF XL -tacrolimus cap sr 24hr 1 mg................. 204
ASTAGRAF XL -tacrolimus cap sr 24hr 5 mg................. 204
ASTEPRO -azelastine hcl nasal spray 0.15% (205.5 mcg/
spray)............................................................................... 58
ATABEX EC -prenatal vit w/ dss-iron carbonyl-fa tab dr
29-1 mg......................................................................... 110
ATACAND -candesartan cilexetil tab 4 mg....................... 44
ATACAND -candesartan cilexetil tab 8 mg....................... 44
ATACAND -candesartan cilexetil tab 16 mg..................... 44
ATACAND -candesartan cilexetil tab 32 mg..................... 44
ATACAND HCT -candesartan cilexetil-hydrochlorothiazide
tab 16-12.5 mg............................................................... 44
tab 32-12.5 mg............................................................... 45
tab 32-25 mg...................................................................45
ATELVIA -risedronate sodium tab delayed release 35
mg.................................................................................... 34
atenolol & chlorthalidone tab 50-25 mg (Tenoretic
50).................................................................................... 45
atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100).................................................................................. 45
atenolol tab 25 mg (Tenormin)....................................... 38
atenolol tab 50 mg (Tenormin)....................................... 38
atenolol tab 100 mg (Tenormin)..................................... 38
AT LAST BLOOD GLUCOSE SYS -blood glucose
monitoring kit................................................................. 151
AT LAST LANCETS -lancets........................................... 151
AT LAST TEST STRIPS -glucose blood test strip.......... 144
213
2016
atorvastatin calcium tab 10 mg (base equivalent)
(Lipitor)........................................................................... 53
(Lipitor)........................................................................... 53
(Lipitor)........................................................................... 53
(Lipitor)........................................................................... 53
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)....................... 11
ATRALIN -tretinoin gel 0.05%......................................... 133
ATRIPLA -efavirenz-emtricitabine-tenofovir df tab
600-200-300 mg................................................................7
ATROPINE SULFATE -atropine sulfate ophth oint
1%.................................................................................. 127
atropine sulfate ophth soln 1% (Isopto atropine)...... 127
ATROVENT HFA -ipratropium bromide hfa inhal aerosol
17 mcg/act.......................................................................60
ATROVENT -ipratropium bromide nasal soln 0.03% (21
mcg/spray)....................................................................... 58
ATROVENT -ipratropium bromide nasal soln 0.06% (42
mcg/spray)....................................................................... 58
AUBAGIO -teriflunomide tab 7 mg.................................... 86
AUBAGIO -teriflunomide tab 14 mg.................................. 86
AUGMENTIN -amoxicillin & k clavulanate for susp
125-31.25 mg/5ml............................................................. 1
AUGMENTIN -amoxicillin & k clavulanate for susp
250-62.5 mg/5ml............................................................... 1
AUGMENTIN -amoxicillin & k clavulanate tab 500-125
mg...................................................................................... 1
AUGMENTIN -amoxicillin & k clavulanate tab 875-125
mg...................................................................................... 1
AUGMENTIN ES-600 -amoxicillin & k clavulanate for
susp 600-42.9 mg/5ml...................................................... 1
AUGMENTIN XR -amoxicillin & k clavulanate tab sr 12hr
1000-62.5 mg.................................................................... 1
AURORA LANCET SUPER THIN -lancets..................... 151
AURORA LANCET THIN 23G -lancets........................... 151
AURORA PEN NEEDLES 29GX12 -insulin pen needle 29
g x 12 mm (1/2")...........................................................151
AURORA PEN NEEDLES 31G X -insulin pen needle 31 g
x 6 mm (1/4")................................................................ 151
AURORA PEN NEEDLES 31G X -insulin pen needle 31 g
x 8 mm (1/3" or 5/16").................................................. 151
AURORA UNIFINE PENTIPS/32 -insulin pen needle 32 g
x 4 mm (5/32").............................................................. 151
AURORA UNIFINE PENTIPS/MI -insulin pen needle 31 g
x 5 mm (3/16").............................................................. 151
AUTO-LANCET -lancet devices...................................... 151
AUTO-LANCET MINI -lancet devices............................. 151
AUTOLET IMPRESSION -lancet devices....................... 151
AUTOLET IMPRESSION LANCIN -lancet devices......... 151
AUTOLET MINI -lancet devices...................................... 151
AUTOPEN -injection device for insulin............................152
214
AUVI-Q -epinephrine solution auto-injector 0.15

mg/0.15ml (1:1000)......................................................... 53
AUVI-Q -epinephrine solution auto-injector 0.3 mg/0.3ml
(1:1000)........................................................................... 53
AVALIDE -irbesartan-hydrochlorothiazide tab 150-12.5
mg.................................................................................... 45
AVALIDE -irbesartan-hydrochlorothiazide tab 300-12.5
mg.................................................................................... 45
AVANDAMET -rosiglitazone maleate-metformin hcl tab
2-1000 mg....................................................................... 27
AVANDIA -rosiglitazone maleate tab 2 mg (base
equiv)............................................................................... 27
equiv)............................................................................... 27
equiv)............................................................................... 27
AVAPRO -irbesartan tab 75 mg........................................ 45
AVAPRO -irbesartan tab 150 mg...................................... 45
AVAPRO -irbesartan tab 300 mg...................................... 45
AVAR-E LS -sulfacetamide sodium w/ sulfur cream
10-2%............................................................................ 133
AVAR LS CLEANSER -sulfacetamide sodium w/ sulfur
cleanser 10-2%............................................................. 133
AVAR LS -sulfacetamide sodium w/ sulfur foam
10-2%............................................................................ 133
AVAR -sulfacetamide sodium w/ sulfur foam 9.5-5%...... 133
AVC -sulfanilamide vaginal cream 15%............................ 70
AVELOX ABC PACK -moxifloxacin hcl tab 400 mg (base
equiv)................................................................................. 4
AVELOX -moxifloxacin hcl tab 400 mg (base equiv).......... 4
AVINZA -morphine sulfate beads cap sr 24hr 30 mg........90
AVINZA -morphine sulfate beads cap sr 24hr 120 mg......90
AVODART -dutasteride cap 0.5 mg.................................. 71
AVONEX -interferon beta-1a for im inj kit 30mcg
(33mcg(6.6 mu)/vial)....................................................... 86
AVONEX -interferon beta-1a im prefilled syringe kit 30
mcg/0.5ml........................................................................ 86
AVONEX PEN -interferon beta-1a im auto-injector kit 30
mcg/0.5ml........................................................................ 86
AXERT -almotriptan malate tab 6.25 mg........................ 100
AXERT -almotriptan malate tab 12.5 mg........................ 100
AXID -nizatidine cap 300 mg............................................ 64
AXILLARY BLOCK NEEDLE BLO -needle (disp) 22 x
1".................................................................................... 152
AXILLARY BLOCK NEEDLE BLO -needle (disp) 25 x
1".................................................................................... 152
AYGESTIN -norethindrone acetate tab 5 mg.................... 26
AZASAN -azathioprine tab 75 mg................................... 204
AZASAN -azathioprine tab 100 mg................................. 204
AZASITE -azithromycin ophth soln 1%........................... 127
azathioprine tab 50 mg (Imuran).................................. 204
azelastine hcl nasal spray 0.1% (137 mcg/spray)........ 58
2016
azelastine hcl nasal spray 0.15% (205.5 mcg/spray)
(Astepro).........................................................................58
azelastine hcl ophth soln 0.05%.................................. 127
AZELEX -azelaic acid cream 20%.................................. 133
AZILECT -rasagiline mesylate tab 0.5 mg (base
equiv)............................................................................. 106
AZILECT -rasagiline mesylate tab 1 mg (base
equiv)............................................................................. 106
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
AZOPT -brinzolamide ophth susp 1%............................. 127
AZOR -amlodipine besylate-olmesartan medoxomil tab
5-20 mg........................................................................... 45
5-40 mg........................................................................... 45
10-20 mg......................................................................... 45
10-40 mg......................................................................... 45
AZULFIDINE EN-TABS -sulfasalazine tab delayed
release 500 mg............................................................... 67
AZULFIDINE -sulfasalazine tab 500 mg........................... 67
B
BACITRACIN -bacitracin ophth oint 500 unit/gm............ 127
bacitracin-polymyxin b ophth oint.............................. 127
bacitracin-polymyxin-neomycin-hc ophth oint
1%.................................................................................. 127
baclofen tab 10 mg........................................................ 109
baclofen tab 20 mg........................................................ 109
BACTRIM DS -sulfamethoxazole-trimethoprim tab
800-160 mg..................................................................... 11
BACTRIM -sulfamethoxazole-trimethoprim tab 400-80
mg.................................................................................... 11
BACTROBAN -mupirocin calcium cream 2%................. 133
BACTROBAN -mupirocin oint 2%................................... 133
BACTROBAN NASAL -mupirocin calcium nasal oint
2%.................................................................................... 58
BAL-CARE DHA -prenat w/fe poly-na fered-fa tab 27-1 &
omega cap dr 430mg................................................... 110
balsalazide disodium cap 750 mg (Colazal)................. 67
BANZEL -rufinamide susp 40 mg/ml............................... 101
BANZEL -rufinamide tab 200 mg.................................... 101
BANZEL -rufinamide tab 400 mg.................................... 101
BARACLUDE -entecavir oral soln 0.05 mg/ml.................... 7
BARACLUDE -entecavir tab 0.5 mg................................... 7
BARACLUDE -entecavir tab 1 mg...................................... 7
BAYER BREEZE 2 BLOOD GLUC -blood glucose
BAYER BREEZE 2 TEST DISC -glucose blood test
disk................................................................................ 144
BAYER CONTOUR BLOOD GLUCO -blood glucose

BAYER CONTOUR BLOOD GLUCO -blood glucose
BAYER CONTOUR BLOOD GLUCO -glucose blood test
strip................................................................................ 144
BAYER CONTOUR LINK BLOOD -blood glucose
BAYER CONTOUR NEXT BLOOD -blood glucose
BAYER CONTOUR NEXT BLOOD -glucose blood test
strip................................................................................ 144
BAYER CONTOUR NEXT EZ BLO -blood glucose
BAYER CONTOUR NEXT LINK B -blood glucose
BAYER CONTOUR NEXT LINK W -blood glucose
BAYER CONTOUR NEXT USB BL -blood glucose
BAYER CONTOUR USB BLOOD G -blood glucose
BAYER MICROLET LANCETS -lancets......................... 152
BAYER MICROLET 2 LANCING -lancet devices........... 152
BD ALLERGY/SYRINGE/NEEDLE -tuberculin/allergy
BD ALLERGY/SYRINGE NEEDLE -tuberculin/allergy
BD AUTOSHIELD DUO 30G X 3 -insulin pen needle 30 g
x 5 mm (3/16").............................................................. 152
BD AUTOSHIELD 29G X 3/16" -insulin pen needle 29 g x
5 mm (3/16")................................................................. 152
BD AUTOSHIELD 29G X 5/16" -insulin pen needle 29 g x
8 mm (5/16")................................................................. 152
BD BLUNT FILL NEEDLE -needle (disp) 18 x 1-1/2"..... 152
BD DISPOSABLE NEEDLE/30GX -needle (disp) 30 x
1".................................................................................... 153
BD DISPOSABLE NEEDLE 23GX -needle (disp) 23 x
1-1/4"............................................................................. 152
1-1/4"............................................................................. 153
1".................................................................................... 152
BD DISPOSABLE NEEDLE REGU -needle (disp) 22 x
3/4".................................................................................152
1".................................................................................... 152
1".................................................................................... 152
1".................................................................................... 152
BD ECLIPSE 18G X 1-1/2" -needle (disp) 18 x
1-1/2"............................................................................. 153
BD ECLIPSE 22G X 1" -needle (disp) 22 x 1"................ 153
BD ECLIPSE 23G X 1" NEEDL -needle (disp) 23 x
1".................................................................................... 153
215
2016
BD ECLIPSE NEEDLE/22G X 1 -needle (disp) 22 x
1-1/2"............................................................................. 153
BD ECLIPSE NEEDLE/25G X -needle (disp) 25 x
5/8".................................................................................153
BD ECLIPSE NEEDLE 25GX1" -needle (disp) 25 x
1".................................................................................... 153
BD ECLIPSE NEEDLE 21G X 1 -needle (disp) 21 x
1-1/2"............................................................................. 153
1-1/2"............................................................................. 153
BD ECLIPSE NEEDLE 30G X -needle (disp) 30 x
1/2".................................................................................153
1".................................................................................... 153
BD HYPODERMIC NEEDLE REGU -needle (disp) 18 x
1-1/2"............................................................................. 153
1-1/2"............................................................................. 153
1-1/2"............................................................................. 153
1-1/2"............................................................................. 153
1-1/2"............................................................................. 153
1-1/2"............................................................................. 153
5/8".................................................................................153
5/8".................................................................................153
1".................................................................................... 153
1".................................................................................... 153
1".................................................................................... 153
1".................................................................................... 153
BD HYPODERMIC NEEDLE SHOR -needle (disp) 18 x
1-1/2"............................................................................. 153
1-1/2"............................................................................. 153
1-1/2"............................................................................. 153
BD INSULIN SYRINGE/DETACH -insulin syringe/needle
u-100 1 ml 25 x 5/8".....................................................154
u-100 1 ml 26 x 1/2".....................................................154
u-100 1 ml 25 x 1"........................................................154
BD INSULIN SYRINGE/U-100/ -insulin syringe/needle
u-100 1/2 ml 30 x 1/2".................................................. 154
u-100 1 ml 27 x 1/2".....................................................154
u-100 1 ml 28 x 1/2".....................................................154
216

u-100 2 ml 27.5 x 5/8".................................................. 154
u-100 2 ml 29 x 1/2".....................................................154
BD INSULIN SYRINGE LUER-L -insulin syringe (disp)
u-100 1 ml..................................................................... 153
BD INSULIN SYRINGE MICROF -insulin syringe/needle
u-100 1/2 ml 28 x 1/2".................................................. 153
u-100 0.3 ml 28 x 1/2".................................................. 153
u-100 1 ml 27 x 5/8".....................................................153
u-100 1 ml 28 x 1/2".....................................................153
B-D INSULIN SYRINGE MICRO -insulin syringe/needle
u-100 1 ml 28 x 1/2".....................................................152
BD INSULIN SYRINGE SAFETY -insulin syringe/needle
u-100 1/2 ml 29 x 1/2".................................................. 153
u-100 1 ml 29 x 1/2".....................................................153
u-100 0.3 ml 31 x 5/16"................................................ 154
BD INSULIN SYRINGE SLIP T -insulin syringe (disp)
u-100 1 ml..................................................................... 154
BD INSULIN SYRINGE U-40/1 -insulin syringe/needle
u-40 1 ml 25 x 5/8".......................................................154
BD INSULIN SYRINGE ULTRAF -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 154
u-100 1/2 ml 29 x 1/2".................................................. 154
u-100 1/2 ml 30 x 1/2".................................................. 154
u-100 1/2 ml 31 x 15/64".............................................. 154
u-100 0.3 ml 29 x 1/2".................................................. 154
u-100 0.3 ml 30 x 1/2".................................................. 154
u-100 0.3 ml 31 x 15/64".............................................. 154
u-100 1 ml 29 x 1/2".....................................................154
u-100 1 ml 30 x 1/2".....................................................154
u-100 1 ml 31 x 5/16"...................................................154
u-100 0.3 ml 31 x 5/16"................................................ 154
u-100 1 ml 31 x 15/64"................................................. 154
B-D INSULIN SYRINGE ULTRA -insulin syringe/needle
u-100 0.3 ml 30 x 1/2".................................................. 152
u-100 1 ml 31 x 5/16"...................................................152
u-100 0.3 ml 31 x 5/16"................................................ 152
2016
BD INTEGRA INSULIN SYRING -insulin syringe/needle
u-100 1 ml 29 x 1/2".....................................................154
BD INTEGRA RETRACTABLE NE -needle (disp) 23 x
1".................................................................................... 154
BD INTEGRA SYRINGE/RETRAC -insulin syringe/needle
u-100 1 ml 25 x 1"........................................................154
BD KLATSKIN BIOPSY -needle (disp) 16 x 4"............... 154
BD LANCET DEVICE -lancet devices............................ 154
BD LANCET ULTRAFINE 30G -lancets.......................... 154
BD LANCET ULTRAFINE 33G -lancets.......................... 154
BD LATITUDE DIABETES MANA -blood glucose
BD LO-DOSE INSULIN SYRIN -insulin syringe/needle
u-100 1/2 ml 28 x 1/2".................................................. 152
BD LOGIC BLOOD GLUCOSE MO -blood glucose
BD MAGNI-GUIDE MAGNIFIER -blood glucose
monitoring supplies....................................................... 155
BD MICROTAINER LANCETS -lancets.......................... 155
BD 1ML TUBERCULIN SYRINGE -tuberculin/allergy
BD 1ML TUBERCULIN SYRINGE -tuberculin/allergy
BD NEEDLE/18G 1-1/2" -needle (disp) 18 x 1-1/2"........ 155
BD NEEDLE/21G 1-1/2" -needle (disp) 21 x 1-1/2"........ 155
BD NEEDLE/16G X 1-1/2" -needle (disp) 16 x
1-1/2"............................................................................. 155
1-1/2"............................................................................. 155
1-1/2"............................................................................. 155
BD NEEDLE/25G X 5/8" -needle (disp) 25 x 5/8"........... 155
BD NEEDLE/19G X 1" -needle (disp) 19 x 1"................. 155
BD NEEDLE/20G X 1" -needle (disp) 20 x 1"................. 155
BD OSGOOD BIOPSY -needle (disp) 16 x 1-5/16"........ 155
BD PEN -injection device for insulin............................... 155
BD PEN MINI -injection device for insulin....................... 155
BD PEN NEEDLE/MINI/ULTRAF -insulin pen needle 31 g
x 5 mm (3/16").............................................................. 155
BD PEN NEEDLE/NANO/ULTRA -insulin pen needle 32 g
x 4 mm (5/32").............................................................. 155
BD PEN NEEDLE/SHORT/ULTRA -insulin pen needle 31
g x 8 mm (1/3" or 5/16")...............................................155
BD PEN NEEDLE/ULTRAFINE/2 -insulin pen needle 29 g
x 12.7 mm..................................................................... 155
BD PEN NEEDLES SHORT/ULTR -insulin pen needle 31
g x 8 mm (1/3" or 5/16")...............................................155
BD PLASTIPAK SYRINGES ALL -tuberculin/allergy
BD PRECISIONGLIDE NEEDLE -needle (disp) 27 x
1-1/2"............................................................................. 155
BD ROSENTHAL BIOPSY -needle (disp) 16 x
1-5/16"........................................................................... 155
BD SAFETYGLIDE ALLERGY S -tuberculin/allergy

BD SAFETYGLIDE ALLERGY SY -tuberculin/allergy
BD SAFETYGLIDE 21G X 1-1/ -needle (disp) 21 x
1-1/2"............................................................................. 156
BD SAFETYGLIDE 21G X 1" -needle (disp) 21 x 1".......156
BD SAFETYGLIDE HYPODERMIC -needle (disp) 18 x
1-1/2"............................................................................. 155
BD SAFETYGLIDE HYPODERMIC -needle (disp) 25 x
5/8".................................................................................155
BD SAFETYGLIDE INJECTION -needle (disp) 22 x
1-1/2"............................................................................. 155
BD SAFETYGLIDE INJECTION -needle (disp) 25 x
1".................................................................................... 155
BD SAFETY-GLIDE INSULIN S -insulin syringe/needle
u-100 1/2 ml 29 x 1/2".................................................. 155
BD SAFETYGLIDE INSULIN SY -insulin syringe/needle
u-100 1/2 ml 30 x 5/16"................................................ 155
BD SAFETYGLIDE SHIELDED N -needle (disp) 23 x
1".................................................................................... 156
BD SAFETY-LOK INSULIN SYR -insulin syringe/needle
u-100 1 ml 29 x 1/2".....................................................155
BEBULIN -factor ix complex for inj 200-1200 unit.......... 123
BEBULIN VH -factor ix complex for inj 200-1200
unit................................................................................. 123
BELLADONNA & OPIUM -belladonna alkaloids & opium
suppos 16.2-30 mg......................................................... 64
BELLADONNA ALKALOIDS & OP -belladonna alkaloids
& opium suppos 16.2-60 mg.......................................... 64
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)................................................................ 45
benazepril & hydrochlorothiazide tab 20-25 mg
(Lotensin hct)................................................................ 45
benazepril hcl tab 5 mg.................................................. 45
benazepril hcl tab 10 mg (Lotensin).............................. 45
BENEFIX -coagulation factor ix (recombinant) for inj 250
unit................................................................................. 123
unit................................................................................. 123
unit................................................................................. 123
unit................................................................................. 123
unit................................................................................. 123
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 20-12.5 mg...............................45
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-12.5 mg...............................45
BENICAR HCT -olmesartan medoxomilhydrochlorothiazide tab 40-25 mg.................................. 45
217
2016
BENICAR -olmesartan medoxomil tab 5 mg.....................45
BENICAR -olmesartan medoxomil tab 20 mg...................45
BENICAR -olmesartan medoxomil tab 40 mg...................45
BENSAL HP -salicylic acid & benzoic acid oint 3-6%..... 133
BENTYL -dicyclomine hcl cap 10 mg............................... 64
BENTYL -dicyclomine hcl tab 20 mg................................ 64
BENZAC AC WASH -benzoyl peroxide liq 5%............... 133
BENZACLIN -clindamycin phosphate-benzoyl peroxide
gel 1-5%........................................................................ 133
BENZACLIN WITH PUMP -clindamycin phosphatebenzoyl peroxide gel 1-5%........................................... 133
BENZAC W WASH -benzoyl peroxide liq 5%................. 133
BENZAMYCIN -benzoyl peroxide-erythromycin gel
5-3%.............................................................................. 133
BENZAMYCINPAK -benzoyl peroxide-erythromycin gel
pack 5-3%..................................................................... 133
BENZIQ -benzoyl peroxide gel 5.25 %........................... 133
BENZIQ LS -benzoyl peroxide gel 2.75%....................... 133
benzocaine dental soln 20%.........................................131
benzonatate cap 200 mg................................................. 58
benzonatate cap 100 mg (Tessalon perles).................. 58
benzonatate cap 150 mg (Zonatuss)............................. 58
benzoyl peroxide cloth 6%........................................... 133
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin)............................................................... 133
benzoyl peroxide gel 10%.............................................133
benzoyl peroxide liq 2.5%.............................................133
benzoyl peroxide liq 5.25%...........................................133
benzoyl peroxide liq 7%................................................133
benzoyl peroxide liq 10%..............................................133
benzoyl peroxide lotion 6%.......................................... 133
benztropine mesylate tab 0.5 mg................................ 106
benztropine mesylate tab 1 mg................................... 106
benztropine mesylate tab 2 mg................................... 106
BEPREVE -bepotastine besilate ophth soln 1.5%.......... 127
BERINERT -c1 esterase inhibitor (human) for iv inj kit 500
unit................................................................................. 123
BESIVANCE -besifloxacin hcl ophth susp 0.6% (base
equiv)............................................................................. 127
BETADINE OPHTHALMIC PREP -povidone-iodine ophth
soln 5%......................................................................... 127
BETAGAN -levobunolol hcl ophth soln 0.5%.................. 127
betamethasone dipropionate augmented cream 0.05%
(Diprolene af)............................................................... 133
betamethasone dipropionate augmented gel
0.05%.............................................................................133
betamethasone dipropionate augmented lotion 0.05%
(Diprolene)................................................................... 133
betamethasone dipropionate augmented oint 0.05%
(Diprolene)................................................................... 134
betamethasone dipropionate cream 0.05%................ 134
betamethasone dipropionate lotion 0.05%................. 134
betamethasone dipropionate oint 0.05%.................... 134
betamethasone valerate aerosol foam 0.12%
(Luxiq)........................................................................... 134
betamethasone valerate cream 0.1%.......................... 134
betamethasone valerate lotion 0.1%........................... 134
218
betamethasone valerate oint 0.1%.............................. 134

BETAPACE AF -sotalol hcl (afib/afl) tab 80 mg................ 38
BETAPACE AF -sotalol hcl (afib/afl) tab 120 mg.............. 38
BETAPACE AF -sotalol hcl (afib/afl) tab 160 mg.............. 38
BETAPACE -sotalol hcl tab 80 mg.................................... 38
BETAPACE -sotalol hcl tab 120 mg.................................. 38
BETAPACE -sotalol hcl tab 160 mg.................................. 38
BETASERON -interferon beta-1b for inj kit 0.3 mg........... 86
betaxolol hcl ophth soln 0.5%......................................127
betaxolol hcl tab 10 mg (Kerlone)................................. 38
betaxolol hcl tab 20 mg (Kerlone)................................. 38
bethanechol chloride tab 5 mg (Urecholine)................ 69
bethanechol chloride tab 10 mg (Urecholine).............. 69
BETHKIS -tobramycin nebu soln 300 mg/4ml.................... 5
BETIMOL -timolol ophth soln 0.25%............................... 127
BETIMOL -timolol ophth soln 0.5%................................. 127
BETOPTIC-S -betaxolol hcl ophth susp 0.25%.............. 127
bexarotene cap 75 mg (Targretin)..................................16
BEXSERO -meningococcal vac b (recomb adsorbed) inj
prefilled syringe............................................................... 12
BEYAZ -drospirenone-ethinyl estrad-levomefolate tab
3-0.02-0.451 mg..............................................................24
BG STAR BLOOD GLUCOSE TES -glucose blood test
strip................................................................................ 144
BIAXIN -clarithromycin for susp 250 mg/5ml...................... 3
BIAXIN -clarithromycin tab 250 mg..................................... 3
BIAXIN -clarithromycin tab 500 mg..................................... 3
BIAXIN XL -clarithromycin tab sr 24hr 500 mg................... 3
BIAXIN XL PAC -clarithromycin tab sr 24hr 500 mg........... 3
bicalutamide tab 50 mg (Casodex)................................ 17
BIDIL -isosorbide dinitrate-hydralazine hcl tab 20-37.5
mg.................................................................................... 57
BILTRICIDE -praziquantel tab 600 mg.............................. 11
BIMATOPROST -bimatoprost ophth soln 0.03%............ 127
BINOSTO -alendronate sodium effervescent tab 70
mg.................................................................................... 34
BIOSCANNER GLUCOSE TEST S -glucose blood test
strip................................................................................ 144
BIO-STATIN -nystatin cap 500000 unit............................... 6
BIO-STATIN -nystatin cap 1000000 unit............................. 6
bisacodyl tab & peg 3350-kcl-sod bicarb-nacl for soln
kit..................................................................................... 63
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg
(Ziac)............................................................................... 45
bisoprolol & hydrochlorothiazide tab 5-6.25 mg
(Ziac)............................................................................... 45
bisoprolol & hydrochlorothiazide tab 10-6.25 mg
(Ziac)............................................................................... 45
bisoprolol fumarate tab 5 mg (Zebeta)..........................38
bisoprolol fumarate tab 10 mg (Zebeta)........................39
BLEPHAMIDE S.O.P. -sulfacetamide sodiumprednisolone ophth oint 10-0.2%................................. 127
BLEPHAMIDE -sulfacetamide sodium-prednisolone ophth
susp 10-0.2%................................................................ 127
BLEPH-10 -sulfacetamide sodium ophth soln 10%........ 127
2016
BLOOD GLUCOSE MONITORING -blood glucose
BLOOD GLUCOSE SYSTEM PAK -blood glucose
BLOOD GLUCOSE TEST STRIPS -glucose blood test
strip................................................................................ 144
BONIVA -ibandronate sodium tab 150 mg (base
equivalent)....................................................................... 34
BOOSTRIX -tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lflf-mcg/0.5ml..................................................................... 15
BOSULIF -bosutinib tab 100 mg....................................... 17
BOSULIF -bosutinib tab 500 mg....................................... 17
BP CLEANSING WASH -sulfacetamide sodium-sulfur in
urea emulsion 10-4%................................................... 134
BP FOLINATAL PLUS B -prenatal w/ calcium carbonateb6-b12-fa tab 1 mg....................................................... 110
BP MULTINATAL PLUS -prenatal w/o a vit w/ fe fumaratefa tab 30-1 mg.............................................................. 110
BP MULTINATAL PLUS -prenatal w/o a vit w/ fe fum-fa
tab chew 40-1 mg......................................................... 110
BPO -benzoyl peroxide gel 4%....................................... 134
BPO -benzoyl peroxide gel 8%....................................... 134
BREEZE 2 BLOOD GLUCOSE MO -blood glucose
BREO ELLIPTA -fluticasone furoate-vilanterol aero powd
ba 100-25 mcg/inh.......................................................... 60
BREO ELLIPTA -fluticasone furoate-vilanterol aero powd
ba 200-25 mcg/inh.......................................................... 60
BREVICON-28 -norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg...................................................................... 24
BRILINTA -ticagrelor tab 60 mg...................................... 123
BRILINTA -ticagrelor tab 90 mg...................................... 123
brimonidine tartrate ophth soln 0.2%......................... 127
brimonidine tartrate ophth soln 0.15% (Alphagan
p)................................................................................... 127
BRINTELLIX -vortioxetine hbr tab 5 mg (base equiv)....... 73
BRINTELLIX -vortioxetine hbr tab 10 mg (base equiv)..... 73
BRINTELLIX -vortioxetine hbr tab 20 mg (base equiv)..... 73
BRISDELLE -paroxetine mesylate cap 7.5 mg (base
equiv)............................................................................... 86
bromfenac sodium ophth soln 0.09% (base
equivalent)................................................................... 127
bromfenac sodium ophth soln 0.09% (base equiv)
(once-daily).................................................................. 127
bromocriptine mesylate cap 5 mg (Parlodel)............. 106
bromocriptine mesylate tab 2.5 mg............................. 106
BROVANA -arformoterol tartrate soln nebu 15 mcg/2ml
(base equiv).................................................................... 60
budesonide cap sr 24hr 3 mg (Entocort ec)................. 20
budesonide inhalation susp 0.25 mg/2ml
(Pulmicort)......................................................................60
budesonide inhalation susp 0.5 mg/2ml
(Pulmicort)......................................................................60
budesonide inhalation susp 1 mg/2ml (Pulmicort)...... 60
BULLSEYE MINI SAFETY LANC -lancets...................... 156
BULLSEYE SAFETY LANCETS -lancets....................... 156
bumetanide tab 0.5 mg................................................... 52
bumetanide tab 1 mg...................................................... 52

bumetanide tab 2 mg...................................................... 52
BUNAVAIL -buprenorphine-naloxone buccal film 2.1-0.3
mg (base equiv).............................................................. 90
BUNAVAIL -buprenorphine-naloxone buccal film 4.2-0.7
mg (base equiv).............................................................. 90
BUNAVAIL -buprenorphine-naloxone buccal film 6.3-1 mg
(base equiv).................................................................... 90
BUPHENYL -sodium phenylbutyrate oral powder 3 gm/
teaspoonful...................................................................... 34
BUPHENYL -sodium phenylbutyrate tab 500 mg............. 34
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base
equiv).............................................................................. 91
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv).............................................................................. 91
buprenorphine hcl sl tab 2 mg (base equiv)................ 91
buprenorphine hcl sl tab 8 mg (base equiv)................ 91
bupropion hcl (smoking deterrent) tab sr 12hr 150 mg
(Zyban)............................................................................ 86
bupropion hcl tab 75 mg (Wellbutrin)........................... 73
bupropion hcl tab 100 mg (Wellbutrin)......................... 73
bupropion hcl tab sr 12hr 100 mg (Wellbutrin sr)........ 73
bupropion hcl tab sr 24hr 150 mg (Wellbutrin xl)........ 73
bupropion hcl tab sr 24hr 300 mg (Wellbutrin xl)........ 73
buspirone hcl tab 5 mg................................................... 72
buspirone hcl tab 7.5 mg................................................ 72
buspirone hcl tab 10 mg................................................. 72
butalbital-acetaminophen-caffeine cap 50-325-40
mg................................................................................... 90
butalbital-acetaminophen-caffeine cap 50-300-40 mg
(Fioricet)......................................................................... 90
butalbital-acetaminophen-caffeine tab 50-325-40 mg
(Esgic)............................................................................. 90
butalbital-acetaminophen-caff w/ cod cap
50-325-40-30 mg............................................................ 91
butalbital-acetaminophen tab 50-325 mg......................90
butalbital-aspirin-caffeine cap 50-325-40 mg
(Fiorinal)......................................................................... 90
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
(Fiorinal/codeine #3)..................................................... 91
BUTISOL SODIUM -butabarbital sodium tab 30 mg.........81
BUTISOL SODIUM -butabarbital sodium tab 50 mg.........81
butorphanol tartrate nasal soln 10 mg/ml.................... 91
BUTRANS -buprenorphine td patch weekly 5 mcg/hr.......91
BUTRANS -buprenorphine td patch weekly 7.5 mcg/
hr...................................................................................... 91
BUTRANS -buprenorphine td patch weekly 10 mcg/
hr...................................................................................... 91
hr...................................................................................... 91
hr...................................................................................... 91
219
2016
BYDUREON -exenatide extended release for inj susp 2
mg.................................................................................... 27
BYDUREON -exenatide extended release for susp peninjector 2 mg................................................................... 27
BYETTA -exenatide soln pen-injector 5 mcg/0.02ml........ 27
BYETTA -exenatide soln pen-injector 10 mcg/0.04ml...... 27
BYSTOLIC -nebivolol hcl tab 2.5 mg (base
equivalent)....................................................................... 39
BYSTOLIC -nebivolol hcl tab 5 mg (base equivalent).......39
BYSTOLIC -nebivolol hcl tab 10 mg (base
equivalent)....................................................................... 39
BYSTOLIC -nebivolol hcl tab 20 mg (base
equivalent)....................................................................... 39
C
cabergoline tab 0.5 mg................................................... 34
CADUET -amlodipine besylate-atorvastatin calcium tab
2.5-10 mg........................................................................ 57
2.5-20 mg........................................................................ 57
2.5-40 mg........................................................................ 57
5-10 mg........................................................................... 57
5-20 mg........................................................................... 57
5-40 mg........................................................................... 57
5-80 mg........................................................................... 57
10-10 mg......................................................................... 57
10-20 mg......................................................................... 57
10-40 mg......................................................................... 57
10-80 mg......................................................................... 57
CAFERGOT -ergotamine w/ caffeine tab 1-100 mg....... 100
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base
equiv).............................................................................. 83
CALAN SR -verapamil hcl tab cr 120 mg......................... 40
CALAN -verapamil hcl tab 80 mg..................................... 40
CALAN -verapamil hcl tab 120 mg................................... 40
calcipotriene-betamethasone dipropionate oint
0.005-0.064% (Taclonex)............................................ 134
calcipotriene cream 0.005% (Dovonex).......................134
calcipotriene oint 0.005%..............................................134
calcipotriene soln 0.005% (50 mcg/ml)....................... 134
calcitonin (salmon) nasal soln 200 unit/act
(Miacalcin)...................................................................... 34
CALCITRIOL -calcitriol oint 3 mcg/gm............................ 134
calcitriol cap 0.25 mcg (Rocaltrol)................................. 34
calcitriol cap 0.5 mcg (Rocaltrol)................................... 34
calcitriol oral soln 1 mcg/ml (Rocaltrol)........................34
220
calcium acetate (phosphate binder) cap 667 mg (169

mg ca) (Phoslo)............................................................. 67
calcium acetate (phosphate binder) tab 667 mg
(Eliphos)......................................................................... 67
CALCIUM PNV -prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg.......................................................... 110
CAMPHOMEX -camphor-histamine-menthol liqd spray
4-0.025-10%.................................................................. 134
CANASA -mesalamine suppos 1000 mg.......................... 67
candesartan cilexetil-hydrochlorothiazide tab 16-12.5
mg (Atacand hct).......................................................... 45
candesartan cilexetil-hydrochlorothiazide tab 32-12.5
mg (Atacand hct).......................................................... 45
candesartan cilexetil-hydrochlorothiazide tab 32-25
mg (Atacand hct).......................................................... 45
candesartan cilexetil tab 4 mg (Atacand)..................... 45
candesartan cilexetil tab 8 mg (Atacand)..................... 45
candesartan cilexetil tab 16 mg (Atacand)................... 45
candesartan cilexetil tab 32 mg (Atacand)................... 45
CANTIL -mepenzolate bromide tab 25 mg....................... 64
capecitabine tab 150 mg (Xeloda)................................. 17
capecitabine tab 500 mg (Xeloda)................................. 17
CAPEX -fluocinolone acetonide shampoo 0.01%........... 134
CAPITAL/CODEINE -acetaminophen w/ codeine susp
120-12 mg/5ml................................................................ 91
CAPRELSA -vandetanib tab 100 mg................................ 17
CAPRELSA -vandetanib tab 300 mg................................ 17
CAPTOPRIL/HYDROCHLOROTHIA -captopril &
hydrochlorothiazide tab 25-15 mg.................................. 46
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%.................................... 134
CARAFATE -sucralfate susp 1 gm/10ml........................... 64
CARAFATE -sucralfate tab 1 gm.......................................64
CARBAGLU -carglumic acid tab 200 mg.......................... 34
carbamazepine cap sr 12hr 100 mg (Carbatrol)......... 101
carbamazepine chew tab 100 mg................................ 101
carbamazepine susp 100 mg/5ml (Tegretol)............... 101
carbamazepine tab 200 mg (Tegretol)......................... 102
carbamazepine tab sr 12hr 200 mg (Tegretol-xr)....... 101
carbamazepine tab sr 12hr 400 mg (Tegretol-xr)....... 102
CARBATROL -carbamazepine cap sr 12hr 100 mg....... 102
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 12.5-50-200 mg................................ 107
2016
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 18.75-75-200 mg.............................. 107
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 25-100-200 mg................................. 107
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 31.25-125-200 mg............................ 107
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 37.5-150-200 mg.............................. 107
CARBIDOPA/LEVODOPA/ENTACA -carbidopa-levodopaentacapone tabs 50-200-200 mg................................. 107
carbidopa & levodopa orally disintegrating tab 10-100
mg................................................................................. 106
mg................................................................................. 106
mg................................................................................. 106
carbidopa & levodopa tab cr 25-100 mg (Sinemet
cr).................................................................................. 106
carbidopa & levodopa tab cr 50-200 mg (Sinemet
cr).................................................................................. 107
carbidopa & levodopa tab 10-100 mg (Sinemet)........ 107
carbidopa tab 25 mg (Lodosyn)................................... 107
carbinoxamine maleate soln 4 mg/5ml......................... 58
carbinoxamine maleate tab 4 mg.................................. 58
carbonyl iron susp 15 mg/1.25ml (elemental
iron)............................................................................... 119
CARDIOCOM LANCING DEVICE -lancet devices......... 156
CARDIZEM CD -diltiazem hcl coated beads cap sr 24hr
120 mg............................................................................ 41
180 mg............................................................................ 41
240 mg............................................................................ 41
300 mg............................................................................ 41
360 mg............................................................................ 41
CARDIZEM -diltiazem hcl tab 30 mg................................ 41
CARDIZEM -diltiazem hcl tab 60 mg................................ 41
CARDIZEM -diltiazem hcl tab 120 mg.............................. 41
CARDIZEM LA -diltiazem hcl coated beads tab sr 24hr
120 mg............................................................................ 41
180 mg............................................................................ 41
240 mg............................................................................ 41
300 mg............................................................................ 41
360 mg............................................................................ 41
420 mg............................................................................ 41
CARDURA -doxazosin mesylate tab 1 mg....................... 46

CARDURA XL -doxazosin mesylate tab sr 24 hr 4 mg
(base equiv).................................................................... 71
CARDURA XL -doxazosin mesylate tab sr 24 hr 8 mg
(base equiv).................................................................... 71
CAREFINE PEN NEEDLE 32GX4 -insulin pen needle 32
g x 4 mm (5/32")...........................................................156
CAREFINE PEN NEEDLES 29GX -insulin pen needle 29
g x 12 mm (1/2")...........................................................156
g x 6 mm (1/4").............................................................156
g x 6 mm (1/4").............................................................156
g x 8 mm (1/3" or 5/16")...............................................156
g x 8 mm (1/3" or 5/16")...............................................156
g x 5 mm (1/5" or 3/16")...............................................156
CAREONE ADVANCED LANCING -lancet devices....... 156
CAREONE BLOOD GLUCOSE MON -blood glucose
CAREONE BLOOD GLUCOSE TES -glucose blood test
strip................................................................................ 144
CAREONE INSULIN SYRINGES/ -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 156
u-100 1/2 ml 30 x 1/2".................................................. 156
u-100 0.3 ml 30 x 1/2".................................................. 156
u-100 1 ml 30 x 1/2".....................................................156
u-100 1 ml 31 x 5/16"...................................................156
u-100 0.3 ml 31 x 5/16"................................................ 156
CAREONE LANCET THIN -lancets................................ 156
CAREONE LANCET ULTRA THIN -lancets................... 156
CAREONE UNIFINE PENTIPS 2 -insulin pen needle 29 g
x 12 mm (1/2").............................................................. 157
x 5 mm (3/16").............................................................. 157
x 6 mm (1/4")................................................................ 157
x 8 mm (1/3" or 5/16").................................................. 157
CAREONE UNIFINE PENTIPS P -insulin pen needle 29 g
x 12 mm (1/2").............................................................. 156
x 5 mm (3/16").............................................................. 156
x 6 mm (1/4")................................................................ 156
x 4 mm (5/32").............................................................. 157
x 8 mm (1/3" or 5/16").................................................. 157
221
2016
CARESENS N BLOOD GLUCOSE -blood glucose
CARESENS N BLOOD GLUCOSE -glucose blood test
strip................................................................................ 144
CARESENS N GLUCOSE MONITO -blood glucose
CARESENS N VOICE BLOOD GL -blood glucose
carisoprodol tab 350 mg (Soma)................................. 109
carisoprodol w/ aspirin & codeine tab 200-325-16
mg................................................................................. 109
carisoprodol w/ aspirin tab 200-325 mg......................109
CARNITOR -levocarnitine oral soln 1 gm/10ml (10%)...... 34
CARNITOR -levocarnitine tab 330 mg.............................. 34
CARNITOR SF -levocarnitine oral soln 1 gm/10ml
(10%)............................................................................... 34
carteolol hcl ophth soln 1%......................................... 127
carvedilol tab 3.125 mg (Coreg)..................................... 39
carvedilol tab 6.25 mg (Coreg)....................................... 39
carvedilol tab 12.5 mg (Coreg)....................................... 39
carvedilol tab 25 mg (Coreg).......................................... 39
CASODEX -bicalutamide tab 50 mg................................. 17
CATAPRES -clonidine hcl tab 0.1 mg............................... 46
CATAPRES-TTS-1 -clonidine hcl td patch weekly 0.1
mg/24hr........................................................................... 46
mg/24hr........................................................................... 46
mg/24hr........................................................................... 46
CAYA -diaphragm arc-spring........................................... 157
CAYSTON -aztreonam lysine for inhal soln 75 mg (base
equivalent)....................................................................... 11
CEDAX -ceftibuten cap 400 mg.......................................... 1
CEDAX -ceftibuten for susp 90 mg/5ml.............................. 1
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 ER -cefaclor monohydrate tab sr 12hr 500
mg...................................................................................... 2
cefadroxil cap 500 mg....................................................... 2
cefadroxil for susp 250 mg/5ml....................................... 2
cefadroxil for susp 500 mg/5ml....................................... 2
cefadroxil tab 1 gm............................................................ 2
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
222
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
CEFTIN -cefuroxime axetil tab 250 mg............................... 2
CEFTIN -cefuroxime axetil tab 500 mg............................... 2
cefuroxime axetil tab 250 mg (Ceftin)............................. 2
cefuroxime axetil tab 500 mg (Ceftin)............................. 2
CELEBREX -celecoxib cap 50 mg.................................... 97
CELEBREX -celecoxib cap 100 mg.................................. 97
celecoxib cap 50 mg (Celebrex).................................... 97
celecoxib cap 100 mg (Celebrex).................................. 97
CELEXA -citalopram hydrobromide tab 10 mg (base
equiv)............................................................................... 73
equiv)............................................................................... 73
equiv)............................................................................... 73
CELLCEPT -mycophenolate mofetil cap 250 mg........... 204
CELLCEPT -mycophenolate mofetil for oral susp 200 mg/
ml................................................................................... 204
CELLCEPT -mycophenolate mofetil tab 500 mg............ 204
CELONTIN -methsuximide cap 300 mg.......................... 102
CENTANY AT -mupirocin oint kit 2%.............................. 134
CENTANY -mupirocin oint 2%.........................................134
cephalexin cap 250 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...................................... 2
CERDELGA -eliglustat tartrate cap 84 mg (base
equivalent)..................................................................... 119
CERVARIX -human papillomavirus (hpv) bival (type 16,
18) recmb vac inj............................................................ 12
CESAMET -nabilone cap 1 mg......................................... 66
CETACAINE -butamben-tetracaine-benzocaine aerosol
spray 2-2-14%...............................................................134
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml).................. 58
CETRAXAL -ciprofloxacin hcl otic soln 0.2% (base
equivalent)..................................................................... 131
cevimeline hcl cap 30 mg (Evoxac)............................. 131
CHANTIX CONTINUING MONTH -varenicline tartrate tab
1 mg (base equiv).......................................................... 87
2016
CHANTIX STARTING MONTH PA -varenicline tartrate tab
0.5 mg x 11 & tab 1 mg x 42 pack.................................87
CHANTIX -varenicline tartrate tab 0.5 mg (base
equiv)............................................................................... 86
CHANTIX -varenicline tartrate tab 1 mg (base equiv).......86
CHEK-STIX COMBO PAK URINA -acetone (urine) test
strip................................................................................ 145
CHEK-STIX CONTROL -acetone (urine) test strip......... 145
CHEMET -succimer cap 100 mg.................................... 143
CHEMSTRIP BG LOG BOOK -blood glucose monitoring
misc............................................................................... 157
CHEMSTRIP-K -acetone (urine) test strip...................... 145
CHENODAL -chenodiol tab 250 mg................................. 67
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 5-12.5 mg............................................. 87
CHLORDIAZEPOXIDE/AMITRIPT -chlordiazepoxideamitriptyline tab 10-25 mg.............................................. 87
chlordiazepoxide hcl cap 5 mg...................................... 72
chlordiazepoxide hcl cap 10 mg.................................... 72
chlordiazepoxide hcl cap 25 mg.................................... 72
chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg
(Librax)........................................................................... 64
chlorhexidine gluconate soln 0.12% (Peridex)...........131
chloroquine phosphate tab 250 mg.............................. 11
chloroquine phosphate tab 500 mg (Aralen)................ 11
CHLOROTHIAZIDE -chlorothiazide tab 250 mg............... 52
chlorothiazide tab 500 mg.............................................. 52
chlorpromazine hcl tab 10 mg....................................... 78
chlorpromazine hcl tab 100 mg..................................... 78
chlorpromazine hcl tab 200 mg..................................... 78
CHLORPROPAMIDE -chlorpropamide tab 100 mg.......... 27
CHLORPROPAMIDE -chlorpropamide tab 250 mg.......... 27
CHLORTHALIDONE -chlorthalidone tab 25 mg............... 52
CHLORTHALIDONE -chlorthalidone tab 50 mg............... 52
CHLORTHALIDONE -chlorthalidone tab 100 mg............. 52
chlorzoxazone tab 500 mg (Parafon forte dsc).......... 109
CHOICE DM DIABETES RISK I -blood glucose
monitoring kit................................................................. 157
CHOICE DM FORA G20 BLOOD -blood glucose
CHOICE DM FORA G20 TEST S -glucose blood test
strip................................................................................ 145
CHOICE-OB+DHA -prenatal mv w/fe poly-fa chw 29-1 mg
& dha cap 250 mg pak................................................. 110
CHOLBAM -cholic acid cap 50 mg................................... 67
CHOLBAM -cholic acid cap 250 mg................................. 67
cholecalciferol cap 1000 unit....................................... 110
cholecalciferol chew tab 400 unit................................ 110
cholecalciferol chew tab 1000 unit.............................. 110
cholecalciferol drops 400 unit/0.03ml (per drop)....... 110
cholecalciferol drops 5000 unit/ml (1000
unit/0.2ml).....................................................................110
cholecalciferol oral liquid 400 unit/ml......................... 110
cholecalciferol tab 400 unit.......................................... 110
cholecalciferol tab 1000 unit........................................ 110
cholestyramine light powder 4 gm/dose (Questran

light)................................................................................ 54
cholestyramine light powder packets 4 gm................. 53
cholestyramine powder 4 gm/dose (Questran)............ 54
cholestyramine powder packets 4 gm (Questran)....... 54
choline fenofibrate cap dr 45 mg (fenofibric acid
equiv) (Trilipix).............................................................. 54
choline fenofibrate cap dr 135 mg (fenofibric acid
equiv) (Trilipix).............................................................. 54
CIALIS -tadalafil tab 2.5 mg.............................................. 57
CIALIS -tadalafil tab 5 mg................................................. 57
ciclopirox gel 0.77%...................................................... 134
ciclopirox olamine cream 0.77% (base equiv)............134
ciclopirox olamine susp 0.77% (base equiv).............. 134
ciclopirox shampoo 1% (Loprox shampoo)............... 134
ciclopirox solution 8% (Penlac Nail Lacquer)............ 134
CIFEREX -folic acid-cholecalciferol cap 1 mg-3775
unit................................................................................. 119
cilostazol tab 50 mg (Pletal)......................................... 123
cilostazol tab 100 mg (Pletal)....................................... 123
CILOXAN -ciprofloxacin hcl ophth oint 0.3%.................. 127
CILOXAN -ciprofloxacin hcl ophth soln 0.3%..................127
cimetidine hcl soln 300 mg/5ml..................................... 64
cimetidine tab 200 mg..................................................... 64
CIMZIA -certolizumab pegol for inj kit 2 x 200 mg............ 67
CIMZIA -certolizumab pegol inj kit 2 x 200 mg/ml............ 67
CIMZIA STARTER KIT -certolizumab pegol inj kit 6 x 200
mg/ml............................................................................... 67
CINRYZE -c1 esterase inhibitor (human) for iv inj 500
unit................................................................................. 123
CIPRO -ciprofloxacin for oral susp 250 mg/5ml (5%) (5
gm/100ml).......................................................................... 4
CIPRO -ciprofloxacin for oral susp 500 mg/5ml (10%) (10
gm/100ml).......................................................................... 4
CIPRO -ciprofloxacin hcl tab 250 mg (base equiv)............. 4
CIPRO -ciprofloxacin hcl tab 500 mg (base equiv)............. 4
CIPRODEX -ciprofloxacin-dexamethasone otic susp
0.3-0.1%........................................................................ 131
CIPROFLOXACIN -ciprofloxacin hcl otic soln 0.2% (base
equivalent)..................................................................... 131
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)...................................................................... 4
ciprofloxacin hcl ophth soln 0.3% (Ciloxan).............. 127
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
223
2016
CIPRO HC -ciprofloxacin-hydrocortisone otic susp
0.2-1%........................................................................... 131
CIPRO XR -ciprofloxacin-ciprofloxacin hcl tab sr 24hr
1000 mg(base eq)............................................................ 4
CIPRO XR -ciprofloxacin-ciprofloxacin hcl tab sr 24hr 500
mg (base eq).....................................................................4
citalopram hydrobromide oral soln 10 mg/5ml............ 73
citalopram hydrobromide tab 10 mg (base equiv)
(Celexa)........................................................................... 73
(Celexa)........................................................................... 73
(Celexa)........................................................................... 73
CITRANATAL ASSURE -prenat w/o a w/fecbn-fegl-dss-fa
tab & dha cap 300 mg pack......................................... 110
CITRANATAL B-CALM -prenat w/o a w/fecbn-feglu-fa tab
20-1 mg & vit b6 tab pak............................................. 110
CITRANATAL DHA -prenat w/o a w/fecbn-fegl-dss-fa tab
& dha cap 250 mg pack............................................... 110
CITRANATAL 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa
tab 90 &dha cap 300mg pak........................................ 111
CITRANATAL HARMONY -prenatal w/o a w/fe cbn-dssfa-dha cap 29-1-265 mg............................................... 111
CITRANATAL HARMONY -prenat w/o a w/fe fum-fe cbndss-fa-dha cap 27-1-260 mg........................................ 111
CITRANATAL RX -prenatal w/o a w/ fe carbonyl-fe glucdss-fa tab 27-1mg.........................................................111
CLARAVIS -isotretinoin cap 30 mg................................. 134
CLARIFOAM EF -sulfacetamide sodium w/ sulfur foam
10-5%............................................................................ 134
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.................................. 3
CLEANLET LANCETS 28G -lancets...............................157
clemastine fumarate tab 2.68 mg.................................. 58
CLEOCIN -clindamycin hcl cap 75 mg............................. 11
CLEOCIN -clindamycin hcl cap 150 mg........................... 11
CLEOCIN -clindamycin hcl cap 300 mg........................... 11
CLEOCIN -clindamycin phosphate vaginal cream 2%......70
CLEOCIN -clindamycin phosphate vaginal suppos 100
mg.................................................................................... 70
CLEOCIN PEDIATRIC GRANULE -clindamycin palmitate
hcl for soln 75 mg/5ml (base equiv)...............................11
CLEOCIN-T -clindamycin phosphate gel 1%.................. 134
CLEOCIN-T -clindamycin phosphate lotion 1%.............. 134
CLEOCIN-T -clindamycin phosphate soln 1%................ 134
CLEOCIN-T -clindamycin phosphate swab 1%.............. 134
CLEVER CHEK AUTO-CODE BLO -blood glucose
CLEVER CHEK AUTO-CODE TES -glucose blood test
strip................................................................................ 145
CLEVER CHEK AUTO-CODE VOI -blood glucose
CLEVER CHEK AUTO CODE VOI -blood glucose
224
CLEVER CHEK AUTO-CODE VOI -glucose blood test

strip................................................................................ 145
CLEVER CHEK BLOOD GLUCOSE -blood glucose
CLEVER CHEK LANCETS ULTRA -lancets................... 157
CLEVER CHEK TEST STRIPS -glucose blood test
strip................................................................................ 145
CLEVER CHOICE AUTO-CODE P -blood glucose
CLEVER CHOICE AUTO-CODE P -glucose blood test
strip................................................................................ 145
CLEVER CHOICE COMFORT EZ -insulin pen needle 32
g x 8 mm....................................................................... 157
g x 12 mm (1/2")...........................................................157
g x 5 mm (3/16")...........................................................157
g x 6 mm (1/4").............................................................157
g x 4 mm (5/32")...........................................................157
g x 6 mm (1/4").............................................................157
g x 4 mm (5/32")...........................................................157
g x 6 mm (1/4").............................................................157
g x 8 mm (1/3" or 5/16")...............................................157
g x 5 mm (1/5" or 3/16")...............................................157
g x 5 mm (1/5" or 3/16")...............................................157
g x 8 mm (1/3" or 5/16")...............................................157
CLEVER CHOICE COMFORT EZ -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 158
u-100 1/2 ml 28 x 1/2".................................................. 158
u-100 1/2 ml 29 x 1/2".................................................. 158
u-100 1/2 ml 30 x 5/16"................................................ 158
u-100 1/2 ml 30 x 1/2".................................................. 158
u-100 0.3 ml 29 x 1/2".................................................. 157
u-100 0.3 ml 30 x 5/16"................................................ 158
u-100 0.3 ml 30 x 1/2".................................................. 158
u-100 1 ml 28 x 1/2".....................................................158
u-100 1 ml 29 x 1/2".....................................................158
u-100 1 ml 30 x 5/16"...................................................158
2016
u-100 1 ml 30 x 1/2".....................................................158
u-100 1 ml 31 x 5/16"...................................................158
u-100 0.3 ml 31 x 5/16"................................................ 158
CLEVER CHOICE MICRO BLOOD -blood glucose
CLEVER CHOICE MICRO TEST -glucose blood test
strip................................................................................ 145
CLEVER CHOICE MINI BLOOD -blood glucose
CLICKFINE PEN NEEDLE 32GX -insulin pen needle 32 g
x 4 mm (5/32").............................................................. 158
CLICKFINE PEN NEEDLES/31G -insulin pen needle 31 g
x 6 mm (1/4")................................................................ 158
CLICKFINE PEN NEEDLES/31G -insulin pen needle 31 g
x 8 mm (1/3" or 5/16").................................................. 158
CLICKFINE PEN NEEDLE UNIV -insulin pen needle 31 g
x 6 mm (1/4")................................................................ 158
CLICKFINE PEN NEEDLE UNIV -insulin pen needle 31 g
x 8 mm (1/3" or 5/16").................................................. 158
CLICKFINE UNIVERSAL PEN N -insulin pen needle 31 g
x 6 mm (1/4")................................................................ 158
CLICKFINE UNIVERSAL PEN N -insulin pen needle 31 g
x 8 mm (1/3" or 5/16").................................................. 158
CLIMARA -estradiol td patch weekly 0.025 mg/24hr........ 22
CLIMARA -estradiol td patch weekly 0.05 mg/24hr.......... 22
CLIMARA -estradiol td patch weekly 0.06 mg/24hr.......... 22
CLIMARA -estradiol td patch weekly 0.075 mg/24hr........ 22
CLIMARA -estradiol td patch weekly 0.1 mg/24hr............ 22
CLIMARA -estradiol td patch weekly 0.0375 mg/24hr
(37.5 mcg/24hr)...............................................................22
CLIMARA PRO -estradiol-levonorgestrel td patch weekly
0.045-0.015 mg/day........................................................ 22
CLINDAGEL -clindamycin phosphate gel 1%................. 134
clindamycin hcl cap 75 mg (Cleocin)............................ 11
clindamycin hcl cap 150 mg (Cleocin).......................... 11
clindamycin hcl cap 300 mg (Cleocin).......................... 11
clindamycin palmitate hcl for soln 75 mg/5ml (base
equiv) (Cleocin pediatric gr)........................................12
clindamycin phosphate-benzoyl peroxide gel 1-5%
(Benzaclin)................................................................... 134
clindamycin phosphate foam 1% (Evoclin)................ 134
clindamycin phosphate gel 1% (Cleocin-t)................. 134
clindamycin phosphate lotion 1% (Cleocin-t)............ 134
clindamycin phosphate soln 1% (Cleocin-t)............... 134
clindamycin phosphate swab 1% (Cleocin-t)............. 134
clindamycin phosphate vaginal cream 2%
(Cleocin)......................................................................... 70
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5% (Duac)............................................................... 134
CLINDESSE -clindamycin phosphate (one dose) vaginal
cream 2%........................................................................ 70
clobetasol propionate cream 0.05% (Temovate)........ 134
clobetasol propionate emollient base cream 0.05%
(Temovate e)................................................................ 134
clobetasol propionate emulsion foam 0.05% (Oluxe).................................................................................... 135

clobetasol propionate foam 0.05% (Olux).................. 135
clobetasol propionate gel 0.05% (Temovate)............. 135
clobetasol propionate lotion 0.05% (Clobex)............. 135
clobetasol propionate oint 0.05% (Temovate)............ 135
clobetasol propionate shampoo 0.05% (Clobex)....... 135
clobetasol propionate soln 0.05% (Temovate)........... 135
clobetasol propionate spray 0.05% (Clobex)............. 135
CLOBEX -clobetasol propionate lotion 0.05%................ 135
CLOBEX -clobetasol propionate shampoo 0.05%.......... 135
CLOBEX -clobetasol propionate spray 0.05%................ 135
CLOCORTOLONE PIVALATE -clocortolone pivalate
cream 0.1%................................................................... 135
CLOCORTOLONE PIVALATE PUM -clocortolone pivalate
cream 0.1%................................................................... 135
CLODERM -clocortolone pivalate cream 0.1%............... 135
CLODERM PUMP -clocortolone pivalate cream
0.1%...............................................................................135
clomipramine hcl cap 25 mg (Anafranil)....................... 73
clonazepam orally disintegrating tab 0.125 mg......... 102
clonazepam orally disintegrating tab 0.25 mg........... 102
clonazepam orally disintegrating tab 0.5 mg............. 102
clonazepam orally disintegrating tab 1 mg................ 102
clonazepam orally disintegrating tab 2 mg................ 102
clonazepam tab 0.5 mg (Klonopin).............................. 102
clonazepam tab 1 mg (Klonopin)................................. 102
clonazepam tab 2 mg (Klonopin)................................. 102
clonidine hcl tab 0.1 mg (Catapres).............................. 46
clonidine hcl tab sr 12hr 0.1 mg (Kapvay).................... 83
clonidine hcl td patch weekly 0.1 mg/24hr (Cataprestts-1)................................................................................ 46
clopidogrel bisulfate tab 75 mg (base equiv)
(Plavix).......................................................................... 123
clopidogrel bisulfate tab 300 mg (base equiv)
(Plavix).......................................................................... 123
clorazepate dipotassium tab 3.75 mg (Tranxene t)...... 72
clorazepate dipotassium tab 7.5 mg (Tranxene t)........ 72
clorazepate dipotassium tab 15 mg (Tranxene t)......... 72
CLORPRES -clonidine & chlorthalidone tab 0.1-15
mg.................................................................................... 46
mg.................................................................................... 46
mg.................................................................................... 46
CLOSERCARE -lancet devices....................................... 158
clotrimazole cream 1%.................................................. 135
clotrimazole soln 1%..................................................... 135
clotrimazole troche 10 mg............................................ 131
225
2016
clotrimazole w/ betamethasone cream 1-0.05%
(Lotrisone).................................................................... 135
clotrimazole w/ betamethasone lotion 1-0.05%..........135
CLOZAPINE ODT -clozapine orally disintegrating tab 12.5
mg.................................................................................... 78
CLOZAPINE ODT -clozapine orally disintegrating tab 25
mg.................................................................................... 78
mg.................................................................................... 78
mg.................................................................................... 78
mg.................................................................................... 78
clozapine tab 50 mg........................................................ 78
clozapine tab 200 mg...................................................... 78
clozapine tab 25 mg (Clozaril)........................................78
clozapine tab 100 mg (Clozaril)..................................... 78
CLOZARIL -clozapine tab 25 mg...................................... 78
CLOZARIL -clozapine tab 100 mg.................................... 78
C-NATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................. 110
COAGUCHEK LANCETS -lancets.................................. 158
COARTEM -artemether-lumefantrine tab 20-120 mg....... 11
CODAR AR -chlorpheniramine w/ codeine liquid 2-8
mg/5ml............................................................................. 59
CODEINE SULFATE -codeine sulfate tab 15 mg............. 91
codeine sulfate tab 15 mg (Codeine sulfate)................ 91
COLAZAL -balsalazide disodium cap 750 mg.................. 67
COLCHICINE -colchicine cap 0.6 mg............................. 101
COLCHICINE -colchicine tab 0.6 mg.............................. 101
colchicine w/ probenecid tab 0.5-500 mg................... 101
COLCRYS -colchicine tab 0.6 mg................................... 101
COLESTID -colestipol hcl granule packets 5 gm.............. 54
COLESTID -colestipol hcl granules 5 gm......................... 54
COLESTID -colestipol hcl tab 1 gm.................................. 54
COLESTID FLAVORED -colestipol hcl granule packets 5
gm.................................................................................... 54
COLESTID FLAVORED -colestipol hcl granules 5 gm..... 54
colestipol hcl granule packets 5 gm (Colestid
flavored)......................................................................... 54
colestipol hcl granules 5 gm (Colestid flavored)......... 54
colestipol hcl tab 1 gm (Colestid)..................................54
COLLIGINIX -dimethicone-allantoin bandage 5-2%....... 135
COLY-MYCIN S -neomycin-colistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml.............................................. 131
COLYTE-FLAVOR PACKS -peg 3350-kcl-na bicarb-naclna sulfate for soln 240 gm............................................. 63
COMBIGAN -brimonidine tartrate-timolol maleate ophth
soln 0.2-0.5%................................................................ 127
COMBIPATCH -estradiol-norethindrone ace td pttw
0.05-0.14 mg/day............................................................ 22
COMBIPATCH -estradiol-norethindrone ace td pttw
0.05-0.25 mg/day............................................................ 22
226
COMBIVENT RESPIMAT -ipratropium-albuterol inhal

aerosol soln 20-100 mcg/act.......................................... 61
COMBIVIR -lamivudine-zidovudine tab 150-300 mg.......... 7
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
COMFORT ASSIST INSULIN SY -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 158
u-100 1/2 ml 29 x 1/2".................................................. 158
u-100 1/2 ml 30 x 5/16"................................................ 158
u-100 0.3 ml 29 x 1/2".................................................. 158
u-100 0.3 ml 30 x 5/16"................................................ 158
u-100 1 ml 29 x 1/2".....................................................158
u-100 1 ml 30 x 5/16"...................................................159
u-100 1 ml 31 x 5/16"...................................................159
u-100 0.3 ml 31 x 5/16"................................................ 159
COMFORT ASSURED LANCETS M -lancets................ 159
COMFORT ASSURED LANCETS S -lancets................. 159
COMFORT LANCETS -lancets....................................... 159
COMPLERA -emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg.................................................................. 7
COMPLETE NATAL DHA -prenat-fe bis-fe prot succ-fa-ca
tab & omega 3 cap 250 pk.......................................... 111
COMPLETENATE -prenatal vit w/ fe fumarate-fa chew tab
29-1 mg......................................................................... 111
COMTAN -entacapone tab 200 mg................................. 107
COMVAX -haemophilus b polysac conj-hepatitis b
(recomb) vac im susp..................................................... 13
CO-NATAL FA -prenatal vit w/ fe fumarate-fa tab 29-1
mg.................................................................................. 111
CONCEPT DHA -prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg......................................................... 111
CONCEPT OB -prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg...............................................................111
CONCERTA -methylphenidate hcl tab sa osm 18 mg...... 83
CONDYLOX -podofilox gel 0.5%.................................... 135
CONDYLOX -podofilox soln 0.5%................................... 135
CONTROL AST -glucose blood test strip....................... 145
CONTROL BLOOD GLUCOSE MON -blood glucose
CONTROL TEST STRIPS -glucose blood test strip....... 145
COPAXONE -glatiramer acetate soln prefilled syringe 20
mg/ml............................................................................... 87
2016
COPAXONE -glatiramer acetate soln prefilled syringe 40
mg/ml............................................................................... 87
COPEGUS -ribavirin tab 200 mg........................................ 7
CORDARONE -amiodarone hcl tab 200 mg..................... 43
CORDRAN -flurandrenolide cream 0.05%...................... 135
CORDRAN -flurandrenolide lotion 0.05%....................... 135
CORDRAN -flurandrenolide oint 0.05%.......................... 135
CORDRAN TAPE -flurandrenolide tape 4 mcg/sqcm..... 135
COREG -carvedilol tab 3.125 mg..................................... 39
COREG -carvedilol tab 6.25 mg....................................... 39
COREG -carvedilol tab 12.5 mg....................................... 39
COREG -carvedilol tab 25 mg.......................................... 39
COREG CR -carvedilol phosphate cap sr 24hr 10 mg..... 39
CORGARD -nadolol tab 20 mg......................................... 39
CORIFACT -factor xiii concentrate (human) for inj kit
1000-1600 unit.............................................................. 123
CORLANOR -ivabradine hcl tab 5 mg (base equiv)......... 57
CORLANOR -ivabradine hcl tab 7.5 mg (base equiv)...... 57
CORTANE-B -hydrocortisone-pramoxine-chloroxylenol lot
10-10-1mg/ml................................................................ 135
CORTEF -hydrocortisone tab 5 mg...................................20
CORTEF -hydrocortisone tab 10 mg.................................20
CORTEF -hydrocortisone tab 20 mg.................................20
CORTENEMA -hydrocortisone enema 100 mg/60ml..... 132
CORTIFOAM -hydrocortisone acetate rectal foam 10%
(90 mg/dose)................................................................. 132
CORTISONE ACETATE -cortisone acetate tab 25 mg..... 20
CORTISPORIN -bacitracin-polymyxin-neomycin hc oint
1%.................................................................................. 135
CORTISPORIN -neomycin-polymyxin-hc cream
0.5%...............................................................................135
CORTISPORIN -neomycin-polymyxin-hc otic soln
1%.................................................................................. 131
CORTISPORIN-TC -neomycin-colistin-hc-thonzonium otic
susp 3.3-3-10-0.5 mg/ml.............................................. 131
CORZIDE -nadolol & bendroflumethiazide tab 40-5
mg.................................................................................... 46
CORZIDE -nadolol & bendroflumethiazide tab 80-5
mg.................................................................................... 46
COSENTYX -secukinumab subcutaneous soln prefilled
syringe 150 mg/ml........................................................ 135
COSENTYX SENSOREADY PEN -secukinumab
subcutaneous soln auto-injector 150 mg/ml................ 135
COSOPT -dorzolamide hcl-timolol maleate ophth soln
22.3-6.8 mg/ml.............................................................. 127
COSOPT PF -dorzolamide hcl-timolol maleate ophth sol
22.3-6.8 mg/ml pf..........................................................127
COUMADIN -warfarin sodium tab 1 mg.......................... 121
COUMADIN -warfarin sodium tab 2.5 mg....................... 121

COUMADIN -warfarin sodium tab 7.5 mg....................... 121
COUMADIN -warfarin sodium tab 10 mg........................ 121
CO-VERATROL -ubiquinol-vit b12-resveratrol-fa cap
200-5-400-0.8 mg......................................................... 149
COZAAR -losartan potassium tab 25 mg..........................46
COZAAR -losartan potassium tab 50 mg..........................46
COZAAR -losartan potassium tab 100 mg........................46
CREON -pancrelipase (lip-prot-amyl) dr cap
3000-9500-15000 unit.....................................................66
6000-19000-30000 unit...................................................66
12000-38000-60000 unit................................................ 66
24000-76000-120000 unit.............................................. 66
36000-114000-180000 unit............................................. 66
CRESEMBA -isavuconazonium sulfate cap 186 mg.......... 6
CRESTOR -rosuvastatin calcium tab 5 mg.......................54
CRESTOR -rosuvastatin calcium tab 10 mg.....................54
CRINONE -progesterone vaginal gel 4%.......................... 70
CRIXIVAN -indinavir sulfate cap 200 mg............................ 7
CRIXIVAN -indinavir sulfate cap 400 mg............................ 7
CROMOLYN SODIUM -cromolyn sodium soln nebu 20
mg/2ml............................................................................. 61
cromolyn sodium ophth soln 4%................................ 127
cromolyn sodium oral conc 100 mg/5ml
(Gastrocrom).................................................................. 67
CUPRIMINE -penicillamine cap 250 mg......................... 204
CUTIVATE -fluticasone propionate cream 0.05%........... 135
CUTIVATE -fluticasone propionate lotion 0.05%.............135
CUVPOSA -glycopyrrolate oral soln 1 mg/5ml................. 64
CVS ADVANCED GLUCOSE METE -blood glucose
CVS ADVANCED GLUCOSE METE -glucose blood test
strip................................................................................ 145
CVS INSULIN SYRINGE/1ML/2 -insulin syringe/needle
u-100 1 ml 29 x 1/2".....................................................159
CVS INSULIN SYRINGE/0.5ML -insulin syringe/needle
u-100 1/2 ml 29 x 1/2".................................................. 159
u-100 1/2 ml 30 x 1/2".................................................. 159
u-100 0.3 ml 29 x 1/2".................................................. 159
u-100 0.3 ml 30 x 1/2".................................................. 159
CVS LANCETS 21G -lancets.......................................... 159
CVS LANCETS MICRO THIN 33 -lancets...................... 159
CVS LANCETS ORIGINAL -lancets............................... 159
CVS LANCETS THIN 26G -lancets................................ 159
CVS LANCETS ULTRA THIN 30 -lancets...................... 159
CVS LANCING DEVICE -lancet devices........................ 159
CVS ULTRA THIN LANCETS -lancets............................159
227
2016
cyanocobalamin inj 1000 mcg/ml................................ 119
CYCLESSA -desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg...................... 24
cyclobenzaprine hcl tab 5 mg...................................... 109
cyclobenzaprine hcl tab 10 mg.................................... 109
cyclobenzaprine hcl tab 7.5 mg (Fexmid)................... 109
CYCLOGYL -cyclopentolate hcl ophth soln 0.5%........... 127
CYCLOGYL -cyclopentolate hcl ophth soln 1%.............. 127
CYCLOGYL -cyclopentolate hcl ophth soln 2%.............. 127
CYCLOMYDRIL -cyclopentolate w/ phenylephrine ophth
soln 0.2-1%................................................................... 127
cyclopentolate hcl ophth soln 1% (Cyclogyl).............127
cyclopentolate hcl ophth soln 2% (Cyclogyl).............127
CYCLOPHOSPHAMIDE -cyclophosphamide cap 25
mg.................................................................................... 17
CYCLOPHOSPHAMIDE -cyclophosphamide cap 50
mg.................................................................................... 17
CYCLOSERINE -cycloserine cap 250 mg.......................... 5
CYCLOSET -bromocriptine mesylate tab 0.8 mg (base
equivalent)....................................................................... 27
cyclosporine cap 25 mg (Sandimmune)..................... 204
cyclosporine cap 100 mg (Sandimmune)................... 204
cyclosporine modified cap 25 mg (Neoral).................204
cyclosporine modified cap 100 mg (Neoral)...............204
CYCLOSPORINE MODIFIED -cyclosporine modified cap
50 mg............................................................................ 204
cyclosporine modified oral soln 100 mg/ml
(Neoral)......................................................................... 204
CYMBALTA -duloxetine hcl enteric coated pellets cap 20
mg.................................................................................... 73
mg.................................................................................... 73
mg.................................................................................... 73
cyproheptadine hcl syrup 2 mg/5ml.............................. 58
cyproheptadine hcl tab 4 mg......................................... 58
CYSTADANE -betaine powder for oral solution................ 34
CYSTAGON -cysteamine bitartrate cap 50 mg.................71
CYSTAGON -cysteamine bitartrate cap 150 mg...............71
CYSTARAN -cysteamine hcl ophth soln 0.44% (base
equivalent)..................................................................... 127
CYTOMEL -liothyronine sodium tab 5 mcg.......................31
CYTOMEL -liothyronine sodium tab 25 mcg.....................31
CYTOMEL -liothyronine sodium tab 50 mcg.....................32
CYTOTEC -misoprostol tab 100 mcg................................64
CYTOTEC -misoprostol tab 200 mcg................................64
CYTRA-3 -pot & sod citrates w/ cit ac syrup 550-500-334
mg/5ml............................................................................. 71
D
DAKLINZA -daclatasvir dihydrochloride tab 30 mg (base
equivalent)......................................................................... 7
DAKLINZA -daclatasvir dihydrochloride tab 60 mg (base
equivalent)......................................................................... 7
DALIRESP -roflumilast tab 500 mcg................................. 61
danazol cap 50 mg.......................................................... 22
danazol cap 100 mg........................................................ 22
228
danazol cap 200 mg........................................................ 22

DANTRIUM -dantrolene sodium cap 25 mg................... 109
DANTRIUM -dantrolene sodium cap 50 mg................... 109
DANTRIUM -dantrolene sodium cap 100 mg................. 109
dantrolene sodium cap 25 mg (Dantrium).................. 109
dantrolene sodium cap 50 mg (Dantrium).................. 109
DANTROLENE SODIUM -dantrolene sodium cap 100
mg.................................................................................. 109
DAPSONE -dapsone tab 25 mg....................................... 12
DAPSONE -dapsone tab 100 mg..................................... 12
DAPTACEL -diph, acellular pert & tet tox inj 15 lf-10
mcg-5 lf/0.5ml................................................................. 15
DARAPRIM -pyrimethamine tab 25 mg............................ 11
DAYPRO -oxaprozin tab 600 mg...................................... 97
DAYTRANA -methylphenidate td patch 10 mg/9hr........... 83
DDAVP -desmopressin acetate inj 4 mcg/ml.................... 34
DDAVP -desmopressin acetate nasal soln 0.01%
(refrigerated).................................................................... 34
DDAVP -desmopressin acetate nasal spray soln
0.01%...............................................................................34
DDAVP -desmopressin acetate tab 0.1 mg...................... 34
DDAVP -desmopressin acetate tab 0.2 mg...................... 34
DELZICOL -mesalamine cap dr 400 mg........................... 67
DEMADEX -torsemide tab 5 mg....................................... 52
DEMADEX -torsemide tab 10 mg..................................... 52
DEMADEX -torsemide tab 20 mg..................................... 52
demeclocycline hcl tab 150 mg....................................... 4
demeclocycline hcl tab 300 mg....................................... 4
DEMEROL -meperidine hcl tab 50 mg............................. 91
DEMEROL -meperidine hcl tab 100 mg........................... 91
DEMSER -metyrosine cap 250 mg................................... 46
DENAVIR -penciclovir cream 1%.................................... 135
DEPAKENE -valproate sodium syrup 250 mg/5ml (base
equiv)............................................................................. 102
DEPAKENE -valproic acid cap 250 mg...........................102
DEPAKOTE -divalproex sodium tab delayed release 125
mg.................................................................................. 102
mg.................................................................................. 102
mg.................................................................................. 102
DEPAKOTE ER -divalproex sodium tab sr 24 hr 250
mg.................................................................................. 102
DEPAKOTE ER -divalproex sodium tab sr 24 hr 500
mg.................................................................................. 102
DEPAKOTE SPRINKLES -divalproex sodium cap sprinkle
125 mg.......................................................................... 102
DEPEN TITRATABS -penicillamine tab 250 mg............. 204
DEPO-TESTOSTERONE -testosterone cypionate im inj in
oil 100 mg/ml.................................................................. 22
DEPO-TESTOSTERONE -testosterone cypionate im inj in
oil 200 mg/ml.................................................................. 22
DERMAPAK PLUS -tretinoin cr 0.025% & men-zinc ox
oint & silicone tape pak................................................ 135
2016
DERMA-SMOOTHE/FS BODY -fluocinolone acetonide oil
0.01% (body oil)............................................................ 135
DERMA-SMOOTHE/FS SCALP -fluocinolone acetonide
oil 0.01% (scalp oil)...................................................... 135
DERMATOP -prednicarbate cream 0.1%........................ 135
DERMATOP -prednicarbate oint 0.1%............................ 135
DERMOTIC -fluocinolone acetonide (otic) oil 0.01%...... 131
desipramine hcl tab 10 mg (Norpramin)....................... 73
desipramine hcl tab 100 mg (Norpramin)..................... 73
desipramine hcl tab 150 mg (Norpramin)..................... 74
desloratadine tab 5 mg (Clarinex)................................. 58
desloratadine tab orally disintegrating 2.5 mg
(Clarinex reditabs)........................................................ 58
desloratadine tab orally disintegrating 5 mg (Clarinex
reditabs)......................................................................... 58
desmopressin acetate inj 4 mcg/ml (Ddavp)................ 34
desmopressin acetate nasal soln 0.01% (refrigerated)
(Ddavp)........................................................................... 34
desmopressin acetate nasal spray soln 0.01%
(Ddavp)........................................................................... 34
desmopressin acetate nasal spray soln 0.01%
(refrigerated).................................................................. 34
desmopressin acetate tab 0.1 mg (Ddavp)................... 34
desmopressin acetate tab 0.2 mg (Ddavp)................... 34
DESOGEN -desogestrel & ethinyl estradiol tab 0.15
mg-30 mcg...................................................................... 24
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01
mg(21/5) (Mircette)........................................................ 24
desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg
(Cyclessa).......................................................................24
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
(Desogen)....................................................................... 24
DESONATE -desonide gel 0.05%................................... 135
desonide cream 0.05% (Desowen).............................. 135
desonide lotion 0.05% (Desowen)............................... 136
desonide oint 0.05% (Desowen).................................. 136
DESOWEN -desonide cream 0.05%...............................136
DESOWEN -desonide lotion 0.05%................................ 136
DESOWEN -desonide oint 0.05%................................... 136
desoximetasone cream 0.25% (Topicort)....................136
DESOXIMETASONE -desoximetasone cream
0.05%.............................................................................136
DESOXIMETASONE -desoximetasone oint 0.05%........ 136
desoximetasone gel 0.05% (Topicort)......................... 136
desoximetasone oint 0.25% (Topicort)........................ 136
DESOXYN -methamphetamine hcl tab 5 mg.................... 83
DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr
24hr 50 mg (base equiv)................................................ 74
DESVENLAFAXINE ER -desvenlafaxine fumarate tab sr
24hr 100 mg (base equiv).............................................. 74
DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 50
mg.................................................................................... 74
DESVENLAFAXINE ER -desvenlafaxine tab sr 24hr 100

mg.................................................................................... 74
DETROL LA -tolterodine tartrate cap sr 24hr 2 mg.......... 69
DETROL LA -tolterodine tartrate cap sr 24hr 4 mg.......... 69
DETROL -tolterodine tartrate tab 1 mg............................. 69
DETROL -tolterodine tartrate tab 2 mg............................. 69
DEXAMETHASONE -dexamethasone soln 0.5
mg/5ml............................................................................. 20
DEXAMETHASONE -dexamethasone tab 1 mg...............20
DEXAMETHASONE -dexamethasone tab 2 mg...............20
dexamethasone elixir 0.5 mg/5ml.................................. 20
DEXAMETHASONE INTENSOL -dexamethasone conc 1
mg/ml............................................................................... 20
dexamethasone sodium phosphate ophth soln
0.1%...............................................................................127
dexamethasone tab 0.5 mg............................................ 20
dexamethasone tab 0.75 mg.......................................... 20
dexamethasone tab 1.5 mg............................................ 20
dexamethasone tab 4 mg............................................... 20
dexamethasone tab 6 mg............................................... 20
DEXEDRINE -dextroamphetamine sulfate cap sr 24hr 5
mg.................................................................................... 83
mg.................................................................................... 83
mg.................................................................................... 83
dexmethylphenidate hcl cap sr 24 hr 5 mg (Focalin
xr).................................................................................... 83
xr).................................................................................... 83
xr).................................................................................... 83
xr).................................................................................... 83
xr).................................................................................... 83
xr).................................................................................... 83
dexmethylphenidate hcl tab 2.5 mg (Focalin).............. 83
dexmethylphenidate hcl tab 5 mg (Focalin)................. 83
dexmethylphenidate hcl tab 10 mg (Focalin)............... 83
DEXPAK 10 DAY -dexamethasone tab 1.5 mg taper
pack................................................................................. 20
pack................................................................................. 20
pack................................................................................. 20
dextroamphetamine sulfate cap sr 24hr 5 mg
(Dexedrine)..................................................................... 83
(Dexedrine)..................................................................... 84
(Dexedrine)..................................................................... 84
dextroamphetamine sulfate oral solution 5 mg/5ml
(Procentra)..................................................................... 84
dextroamphetamine sulfate tab 5 mg........................... 84
dextroamphetamine sulfate tab 10 mg......................... 84
229
2016
DIABETA -glyburide tab 1.25 mg...................................... 27
DIABETA -glyburide tab 2.5 mg........................................ 27
DIABETA -glyburide tab 5 mg........................................... 27
DIAMOX -acetazolamide cap sr 12hr 500 mg.................. 52
DIASTAR EASY TEST II LANC -lancets......................... 159
DIASTAR EASY TEST LANCETS -lancets..................... 159
DIASTAT ACUDIAL -diazepam rectal gel delivery system
10 mg............................................................................ 102
DIASTAT ACUDIAL -diazepam rectal gel delivery system
20 mg............................................................................ 102
DIASTAT PEDIATRIC -diazepam rectal gel delivery
system 2.5 mg.............................................................. 102
DIATRUE PLUS BLOOD GLUCOS -blood glucose
DIATRUE PLUS BLOOD GLUCOS -glucose blood test
strip................................................................................ 145
diazepam conc 5 mg/ml.................................................. 72
DIAZEPAM -diazepam rectal gel delivery system 2.5
mg.................................................................................. 102
DIAZEPAM -diazepam rectal gel delivery system 10
mg.................................................................................. 102
DIAZEPAM -diazepam rectal gel delivery system 20
mg.................................................................................. 102
DIAZEPAM -diazepam soln 1 mg/ml................................. 72
diazepam tab 2 mg (Valium)........................................... 72
diazepam tab 5 mg (Valium)........................................... 72
diazepam tab 10 mg (Valium)......................................... 72
DIBENZYLINE -phenoxybenzamine hcl cap 10 mg..........46
DICLEGIS -doxylamine-pyridoxine tab delayed release
10-10 mg......................................................................... 66
diclofenac potassium tab 50 mg................................... 97
diclofenac sodium (actinic keratoses) gel 3%
(Solaraze)..................................................................... 136
diclofenac sodium ophth soln 0.1%............................ 127
diclofenac sodium soln 1.5%....................................... 136
diclofenac sodium tab delayed release 25 mg............. 97
diclofenac sodium tab sr 24hr 100 mg (Voltarenxr).................................................................................... 97
diclofenac w/ misoprostol tab delayed release 50-0.2
mg (Arthrotec 50)..........................................................97
diclofenac w/ misoprostol tab delayed release 75-0.2
mg (Arthrotec 75)..........................................................97
dicloxacillin sodium cap 250 mg..................................... 1
dicloxacillin sodium cap 500 mg..................................... 1
dicyclomine hcl cap 10 mg (Bentyl).............................. 64
dicyclomine hcl oral soln 10 mg/5ml............................ 64
dicyclomine hcl tab 20 mg (Bentyl)............................... 64
didanosine delayed release capsule 125 mg (Videx
ec)...................................................................................... 7
ec)...................................................................................... 7
ec)...................................................................................... 7
ec)...................................................................................... 7
230
DIDGET -blood glucose monitoring kit w/ device........... 159

DIFFERIN -adapalene cream 0.1%................................ 136
DIFFERIN -adapalene gel 0.1%...................................... 136
DIFFERIN -adapalene gel 0.3%...................................... 136
DIFFERIN -adapalene lotion 0.1%.................................. 136
DIFICID -fidaxomicin tab 200 mg........................................ 3
DIFLORASONE DIACETATE -diflorasone diacetate
cream 0.05%................................................................. 136
DIFLORASONE DIACETATE -diflorasone diacetate oint
0.05%.............................................................................136
DIFLUCAN -fluconazole for susp 10 mg/ml........................ 6
DIFLUCAN -fluconazole for susp 40 mg/ml........................ 6
DIFLUCAN -fluconazole tab 50 mg..................................... 6
DIFLUCAN -fluconazole tab 100 mg................................... 6
diflunisal tab 500 mg....................................................... 90
DIGOXIN -digoxin oral soln 0.05 mg/ml............................ 37
digoxin tab 125 mcg (0.125 mg) (Lanoxin)................... 37
digoxin tab 250 mcg (0.25 mg) (Lanoxin)..................... 37
DIHYDROERGOTAMINE MESYLAT -dihydroergotamine
mesylate nasal spray 4 mg/ml..................................... 100
DILANTIN INFATABS -phenytoin chew tab 50 mg......... 102
DILANTIN -phenytoin sodium extended cap 30 mg........102
DILANTIN -phenytoin sodium extended cap 100 mg......102
DILANTIN-125 -phenytoin susp 125 mg/5ml.................. 102
DILATRATE SR -isosorbide dinitrate cap cr 40 mg.......... 37
DILAUDID -hydromorphone hcl liqd 1 mg/ml.................... 91
DILAUDID -hydromorphone hcl tab 2 mg......................... 91
diltiazem hcl cap sr 12hr 60 mg.....................................41
diltiazem hcl cap sr 12hr 90 mg.....................................41
diltiazem hcl cap sr 12hr 120 mg...................................41
diltiazem hcl coated beads cap sr 24hr 120 mg
(Cardizem cd)................................................................ 41
(Cardizem cd)................................................................ 41
(Cardizem cd)................................................................ 41
(Cardizem cd)................................................................ 41
(Cardizem cd)................................................................ 41
diltiazem hcl coated beads tab sr 24hr 180 mg
(Cardizem la)................................................................. 41
(Cardizem la)................................................................. 41
(Cardizem la)................................................................. 41
(Cardizem la)................................................................. 41
(Cardizem la)................................................................. 41
2016
diltiazem hcl extended release beads cap sr 24hr 120
mg (Tiazac).................................................................... 41
mg (Tiazac).................................................................... 41
mg (Tiazac).................................................................... 41
mg (Tiazac).................................................................... 41
mg (Tiazac).................................................................... 41
mg (Tiazac).................................................................... 41
diltiazem hcl tab 90 mg................................................... 41
diltiazem hcl tab 30 mg (Cardizem)............................... 41
diltiazem hcl tab 60 mg (Cardizem)............................... 41
diltiazem hcl tab 120 mg (Cardizem)............................. 41
DIOVAN HCT -valsartan-hydrochlorothiazide tab 80-12.5
mg.................................................................................... 46
mg.................................................................................... 46
DIOVAN HCT -valsartan-hydrochlorothiazide tab 160-25
mg.................................................................................... 47
mg.................................................................................... 47
DIOVAN HCT -valsartan-hydrochlorothiazide tab 320-25
mg.................................................................................... 47
DIOVAN -valsartan tab 40 mg........................................... 46
DIOVAN -valsartan tab 80 mg........................................... 46
DIOVAN -valsartan tab 160 mg......................................... 46
DIOVAN -valsartan tab 320 mg......................................... 46
DIPENTUM -olsalazine sodium cap 250 mg.....................67
diphenhydramine hcl cap 50 mg................................... 58
diphenhydramine hcl elixir 12.5 mg/5ml....................... 58
DIPHENOXYLATE/ATROPINE -diphenoxylate w/ atropine
liq 2.5-0.025 mg/5ml....................................................... 63
diphenoxylate w/ atropine tab 2.5-0.025 mg
(Lomotil)......................................................................... 63
DIPHTHERIA/TETANUS TOXOID -diphtheria-tetanus tox
adsorbed (dt) im inj 25-5 unit/0.5ml............................... 15
DIPROLENE AF -betamethasone dipropionate
augmented cream 0.05%............................................. 136
DIPROLENE -betamethasone dipropionate augmented
lotion 0.05%.................................................................. 136
DIPROLENE -betamethasone dipropionate augmented
oint 0.05%..................................................................... 136
dipyridamole tab 25 mg (Persantine).......................... 123
DISALCID -salsalate tab 500 mg...................................... 90
DISALCID -salsalate tab 750 mg...................................... 90
disopyramide phosphate cap 100 mg (Norpace)......... 43
disopyramide phosphate cap 150 mg (Norpace)......... 43
disulfiram tab 250 mg (Antabuse)................................. 87
disulfiram tab 500 mg (Antabuse)................................. 87
DITROPAN XL -oxybutynin chloride tab sr 24hr 5 mg...... 69
DITROPAN XL -oxybutynin chloride tab sr 24hr 10
mg.................................................................................... 69
DITROPAN XL -oxybutynin chloride tab sr 24hr 15

mg.................................................................................... 69
DIURIL -chlorothiazide susp 250 mg/5ml......................... 52
divalproex sodium cap sprinkle 125 mg (Depakote
sprinkles)......................................................................102
divalproex sodium tab delayed release 125 mg
(Depakote).................................................................... 102
(Depakote).................................................................... 102
(Depakote).................................................................... 102
divalproex sodium tab sr 24 hr 250 mg (Depakote
er).................................................................................. 102
divalproex sodium tab sr 24 hr 500 mg (Depakote
er).................................................................................. 102
DIVIGEL -estradiol td gel 0.25 mg/0.25gm (0.1%)........... 22
DIVIGEL -estradiol td gel 0.5 mg/0.5gm (0.1%)............... 23
DIVIGEL -estradiol td gel 1 mg/gm (0.1%)....................... 23
DOLOPHINE -methadone hcl tab 5 mg............................ 91
DOLOPHINE -methadone hcl tab 10 mg.......................... 91
donepezil hydrochloride orally disintegrating tab 5
mg................................................................................... 87
donepezil hydrochloride orally disintegrating tab 10
mg................................................................................... 87
donepezil hydrochloride tab 5 mg (Aricept)................. 87
donepezil hydrochloride tab 10 mg (Aricept)............... 87
donepezil hydrochloride tab 23 mg (Aricept)............... 87
dorzolamide hcl ophth soln 2% (Trusopt).................. 128
dorzolamide hcl-timolol maleate ophth soln 22.3-6.8
mg/ml (Cosopt)............................................................128
DOTHELLE DHA -prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg......................................................... 111
DOVONEX -calcipotriene cream 0.005%........................136
doxazosin mesylate tab 1 mg (Cardura)....................... 47
doxepin hcl cap 10 mg....................................................74
doxepin hcl cap 100 mg..................................................74
doxepin hcl cap 150 mg..................................................74
doxepin hcl conc 10 mg/ml............................................ 74
DOXEPIN HCL -doxepin hcl cap 75 mg........................... 74
doxercalciferol cap 0.5 mcg (Hectorol)......................... 34
doxercalciferol cap 1 mcg (Hectorol)............................ 34
doxercalciferol cap 2.5 mcg (Hectorol)......................... 34
doxycycline hyclate cap 50 mg....................................... 4
doxycycline hyclate cap 100 mg (Vibramycin)...............4
doxycycline hyclate tab delayed release 75 mg............ 4
doxycycline hyclate tab delayed release 100 mg.......... 4
doxycycline hyclate tab delayed release 150 mg.......... 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
231
2016
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
DRISDOL -ergocalciferol cap 50000 unit........................ 110
dronabinol cap 2.5 mg (Marinol).................................... 66
dronabinol cap 5 mg (Marinol)....................................... 66
dronabinol cap 10 mg (Marinol)..................................... 66
DROPLET LANCETS ULTRA THI -lancets.................... 159
DROPLET LANCING DEVICE -lancet devices...............159
drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin
28).................................................................................... 24
drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)..... 24
DROXIA -hydroxyurea cap 200 mg................................ 120
DRUG MART ADJUSTABLE LANC -lancet devices....... 159
DRUG MART LANCETS THIN -lancets.......................... 159
DRUG MART LANCETS ULTRA T -lancets................... 159
DRUG MART ON-THE-GO LANCE -lancets.................. 159
DRUG MART ULTRA COMFORT I -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 159
u-100 1/2 ml 30 x 5/16"................................................ 159
u-100 0.3 ml 29 x 1/2".................................................. 159
u-100 0.3 ml 30 x 5/16"................................................ 159
u-100 1 ml 29 x 1/2".....................................................159
u-100 1 ml 30 x 5/16"...................................................159
u-100 0.3 ml 31 x 5/16"................................................ 160
DRUG MART UNIFINE PENTIPS -insulin pen needle 29
g x 12 mm (1/2")...........................................................160
g x 5 mm (3/16")...........................................................160
g x 6 mm (1/4").............................................................160
g x 4 mm (5/32")...........................................................160
g x 8 mm (1/3" or 5/16")...............................................160
DRUG MART UNILET LANCETS -lancets..................... 160
DUAC -clindamycin phosph-benzoyl peroxide (refrig) gel
1.2 (1)-5%..................................................................... 136
DUANE READE LANCET ALTERN -lancets.................. 160
DUANE READE LANCET SUPER -lancets.................... 160
DUANE READE LANCET ULTRA -lancets..................... 160
DUANE READE UNIFINE PENTI -insulin pen needle 29 g
x 12 mm (1/2").............................................................. 160
232

x 6 mm (1/4")................................................................ 160
x 8 mm (1/3" or 5/16").................................................. 160
DUAVEE -conjugated estrogens-bazedoxifene tab
0.45-20 mg...................................................................... 23
DUETACT -pioglitazone hcl-glimepiride tab 30-2 mg....... 27
DUETACT -pioglitazone hcl-glimepiride tab 30-4 mg....... 27
DUET DHA BALANCED -prenat w/fe poly-na fered-fa tab
25-1 & omega cap 267 mg.......................................... 111
DUET DHA 400 -prenat w/fe poly-na fered-fa tab 25-1 &
omega cap 400 mg...................................................... 111
DULERA -mometasone furoate-formoterol fumarate
aerosol 100-5 mcg/act.................................................... 61
DULERA -mometasone furoate-formoterol fumarate
aerosol 200-5 mcg/act.................................................... 61
duloxetine hcl enteric coated pellets cap 20 mg
(Cymbalta)...................................................................... 74
(Cymbalta)...................................................................... 74
(Cymbalta)...................................................................... 74
DUO-CARE TEST STRIPS -glucose blood test strip......145
DURACHOL -folic acid-cholecalciferol cap 1 mg-3775
unit................................................................................. 120
DURAGESIC -fentanyl td patch 72hr 12 mcg/hr............... 91
DURAGESIC -fentanyl td patch 72hr 100 mcg/hr............. 91
DUREZOL -difluprednate ophth emulsion 0.05%........... 128
DURLAZA -aspirin capsule sr 24hr 162.5 mg................. 123
DUTOPROL -metoprolol & hydrochlorothiazide tab sr
24hr 25-12.5 mg............................................................. 47
24hr 50-12.5 mg............................................................. 47
24hr 100-12.5 mg........................................................... 47
DYAZIDE -triamterene & hydrochlorothiazide cap 37.5-25
mg.................................................................................... 52
dyphylline-guaifenesin liqd 100-100 mg/5ml................ 61
DYRENIUM -triamterene cap 50 mg................................. 52
DYRENIUM -triamterene cap 100 mg............................... 52
E
EASY COMFORT INSULIN SYRI -insulin syringe/needle
u-100 1/2 ml 30 x 5/16"................................................ 160
u-100 1/2 ml 30 x 1/2".................................................. 160
u-100 0.3 ml 30 x 5/16"................................................ 160
u-100 1 ml 30 x 5/16"...................................................160
u-100 1 ml 30 x 1/2".....................................................160
EASY COMFORT LANCETS 30G/ -lancets................... 160
EASY COMFORT LANCETS -lancets............................ 160
2016
EASY COMFORT PEN NEEDLES -insulin pen needle 31
g x 5 mm (3/16")...........................................................160
g x 6 mm (1/4").............................................................160
g x 4 mm (5/32")...........................................................160
g x 8 mm (1/3" or 5/16")...............................................160
EASYGLUCO -blood glucose monitoring kit................... 162
EASYGLUCO -glucose blood test strip........................... 145
EASYGLUCO PLUS -glucose blood test strip................ 145
EASYGLUCO VALUE PACK -blood glucose monitoring
kit................................................................................... 162
EASYMAX L BLOOD GLUCOSE S -blood glucose
EASYMAX L BLOOD GLUCOSE S -blood glucose
EASYMAX N BLOOD GLUCOSE S -blood glucose
EASYMAX N BLOOD GLUCOSE S -blood glucose
EASYMAX NG SELF-MONITORIN -blood glucose
EASYMAX NG SELF-MONITORIN -blood glucose
EASYMAX TEST STRIPS -glucose blood test strip....... 145
EASYMAX 15 TEST STRIPS -glucose blood test
strip................................................................................ 145
EASYMAX V BLOOD GLUCOSE S -blood glucose
EASYMAX V BLOOD GLUCOSE S -blood glucose
EASYMAX V2 SELF-MONITORIN -blood glucose
EASYMAX V2 SELF-MONITORIN -blood glucose
EASY MINI LANCING DEVICE -lancet devices............. 160
EASY PLUS BLOOD GLUCOSE M -blood glucose
EASY PLUS BLOOD GLUCOSE M -blood glucose
EASYPLUS BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 145
EASY PLUS BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 145
EASY PLUS II BLOOD GLUCOS -blood glucose
EASY PLUS II BLOOD GLUCOS -glucose blood test
strip................................................................................ 145
EASYPLUS R13N SELF-MONITO -blood glucose
EASYPLUS V SELF-MONITORIN -blood glucose
EASYPRO BLOOD GLUCOSE MON -blood glucose
EASYPRO BLOOD GLUCOSE TES -glucose blood test
strip................................................................................ 145
EASYPRO PLUS -blood glucose monitoring kit w/

device............................................................................ 163
EASYPRO PLUS -glucose blood test strip..................... 145
EASY STEP BLOOD GLUCOSE M -blood glucose
EASY STEP BLOOD GLUCOSE M -blood glucose
EASY STEP TEST STRIPS -glucose blood test strip..... 145
EASY TALK BLOOD GLUCOSE M -blood glucose
EASY TALK BLOOD GLUCOSE M -blood glucose
EASY TALK BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 145
EASYTEST II LANCETS -lancets................................... 163
EASYTEST LANCETS -lancets...................................... 163
EASY TOUCH ALLERGY TRAY S -tuberculin/allergy
EASY TOUCH ALLERGY TRAY S -tuberculin/allergy
EASY TOUCH GLUCOSE MONITO -blood glucose
EASY TOUCH GLUCOSE TEST S -glucose blood test
strip................................................................................ 145
EASY TOUCH 32GX6MM -insulin pen needle 32 g x 6
mm (1/4")...................................................................... 162
EASY TOUCH 32GX5MM -insulin pen needle 32 g x 5
mm (1/5" or 3/16")........................................................ 162
EASY TOUCH HEALTHPRO GLUC -blood glucose
EASY TOUCH HEALTHPRO GLUC -glucose blood test
strip................................................................................ 145
EASY TOUCH INSULIN SYRING -insulin syringe/needle
u-100 1/2 ml 27 x 1/2".................................................. 161
u-100 1/2 ml 31 x 5/16"................................................ 161
u-100 1/2 ml 28 x 1/2".................................................. 161
u-100 1/2 ml 29 x 1/2".................................................. 161
u-100 1/2 ml 30 x 5/16"................................................ 161
u-100 1/2 ml 30 x 1/2".................................................. 161
u-100 0.3 ml 30 x 5/16"................................................ 161
u-100 0.3 ml 30 x 1/2".................................................. 161
u-100 1 ml 27 x 1/2".....................................................161
u-100 1 ml 28 x 1/2".....................................................161
u-100 1 ml 29 x 1/2".....................................................161
u-100 1 ml 30 x 5/16"...................................................161
233
2016
u-100 1 ml 30 x 1/2".....................................................161
u-100 1 ml 31 x 5/16"...................................................161
u-100 0.3 ml 31 x 5/16"................................................ 161
EASY TOUCH LANCETS 30G/BU -lancets.................... 162
EASY TOUCH LANCETS 21G/PR -lancets.................... 161
EASY TOUCH LANCETS 26G/PU -lancets.................... 161
EASY TOUCH LANCETS 26G/TW -lancets................... 161
EASY TOUCH LANCING DEVICE -lancet devices........ 162
EASY TOUCH PEN NEEDLES/31 -insulin pen needle 31
g x 5 mm (3/16")...........................................................162
EASY TOUCH PEN NEEDLES 29 -insulin pen needle 29
g x 12 mm (1/2")...........................................................162
g x 6 mm (1/4").............................................................162
g x 4 mm (5/32")...........................................................162
g x 6 mm (1/4").............................................................162
g x 8 mm (1/3" or 5/16")...............................................162
g x 5 mm (1/5" or 3/16")...............................................162
EASY TOUCH SAFETY LANCETS -lancets...................162
EASY TRAK BLOOD GLUCOSE M -blood glucose
EASY TRAK BLOOD GLUCOSE M -blood glucose
EASY TRAK BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 145
EASY TWIST & CAP LANCETS -lancets....................... 162
ECLIPSE BLOOD GLUCOSE MON -blood glucose
ECLIPSE TEST STRIPS -glucose blood test strip..........145
EC-NAPROSYN -naproxen tab ec 375 mg.......................97
EC-NAPROSYN -naproxen tab ec 500 mg.......................97
econazole nitrate cream 1%......................................... 136
EDARBI -azilsartan medoxomil tab 40 mg........................47
EDARBI -azilsartan medoxomil tab 80 mg........................47
EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab
40-12.5 mg...................................................................... 47
EDARBYCLOR -azilsartan medoxomil-chlorthalidone tab
40-25 mg......................................................................... 47
234
EDECRIN -ethacrynic acid tab 25 mg.............................. 52

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
EFFER-K -potassium bicarbonate-citric acid effer tab 10
meq................................................................................ 117
EFFER-K -potassium bicarbonate-citric acid effer tab 20
meq................................................................................ 118
EFFEXOR XR -venlafaxine hcl cap sr 24hr 37.5 mg (base
equivalent)....................................................................... 74
EFFEXOR XR -venlafaxine hcl cap sr 24hr 75 mg (base
equivalent)....................................................................... 74
EFFEXOR XR -venlafaxine hcl cap sr 24hr 150 mg (base
equivalent)....................................................................... 74
EFFIENT -prasugrel hcl tab 5 mg (base equiv).............. 123
EFFIENT -prasugrel hcl tab 10 mg (base equiv)............ 123
EFUDEX -fluorouracil cream 5%..................................... 136
EGRIFTA -tesamorelin acetate for inj 1 mg (base
equiv)............................................................................... 34
EGRIFTA -tesamorelin acetate for inj 2 mg (base
equiv)............................................................................... 34
ELDEPRYL -selegiline hcl cap 5 mg...............................107
ELEMENT AUTOCODE SYSTEM -blood glucose
ELEMENT COMPACT BLOOD GLU -blood glucose
ELEMENT COMPACT TEST STRI -glucose blood test
strip................................................................................ 145
ELEMENT COMPACT V BLOOD -blood glucose
ELEMENT PLUS BLOOD GLUCOS -blood glucose
ELEMENT PLUS TEST STRIPS -glucose blood test
strip................................................................................ 145
ELEMENT TEST STRIPS -glucose blood test strip........ 145
ELESTAT -epinastine hcl ophth soln 0.05%................... 128
ELESTRIN -estradiol gel 0.06% (0.52 mg/0.87 gm
metered-dose pump)...................................................... 23
ELIDEL -pimecrolimus cream 1%................................... 136
ELIMITE -permethrin cream 5%...................................... 136
ELIPHOS -calcium acetate (phosphate binder) tab 667
mg.................................................................................... 67
ELIQUIS -apixaban tab 2.5 mg....................................... 121
ELIQUIS -apixaban tab 5 mg.......................................... 121
ELITE-OB -prenatal vit w/ iron carbonyl-fa tab 50-1.25
mg.................................................................................. 111
ELITE-THIN INSULIN SYRING -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 163
u-100 1/2 ml 28 x 5/16"................................................ 163
u-100 1/2 ml 28 x 1/2".................................................. 163
u-100 1/2 ml 29 x 5/16"................................................ 163
u-100 1/2 ml 29 x 1/2".................................................. 163
2016
u-100 1/2 ml 30 x 5/16"................................................ 163
u-100 1 ml 28 x 5/16"...................................................163
u-100 1 ml 28 x 1/2".....................................................163
u-100 1 ml 29 x 1/2".....................................................163
u-100 1 ml 29 x 5/16"...................................................163
u-100 1 ml 30 x 5/16"...................................................163
u-100 1 ml 31 x 5/16"...................................................163
u-100 0.3 ml 31 x 5/16"................................................ 163
ELIXOPHYLLIN -theophylline elixir 80 mg/15ml............... 61
ELLA -ulipristal acetate tab 30 mg.................................... 24
ELMIRON -pentosan polysulfate sodium caps 100
mg.................................................................................... 71
ELOCON -mometasone furoate cream 0.1%................. 136
ELOCON -mometasone furoate oint 0.1%......................136
ELOCON -mometasone furoate solution 0.1%
(lotion)............................................................................ 136
ELOCTATE -antihemophilic factor (recomb) rfviiifc for inj
250 unit......................................................................... 124
500 unit......................................................................... 124
750 unit......................................................................... 124
1000 unit....................................................................... 124
1500 unit....................................................................... 124
2000 unit....................................................................... 124
3000 unit....................................................................... 124
EMADINE -emedastine difumarate ophth soln 0.05%
(base equiv).................................................................. 128
EMBEDA -morphine-naltrexone cap cr 20-0.8 mg............91
EMBEDA -morphine-naltrexone cap cr 50-2 mg...............91
EMBEDA -morphine-naltrexone cap cr 100-4 mg.............91
EMBRACE BLOOD GLUCOSE MON -blood glucose
EMBRACE BLOOD GLUCOSE TES -glucose blood test
strip................................................................................ 145
EMBRACE EVO BLOOD GLUCOSE -blood glucose
EMBRACE EVO BLOOD GLUCOSE -glucose blood test
strip................................................................................ 145
EMBRACE LANCETS ULTRA THI -lancets.................... 163
EMBRACE PRO BLOOD GLUCOSE -blood glucose
EMBRACE PRO BLOOD GLUCOSE -glucose blood test

strip................................................................................ 145
EMCYT -estramustine phosphate sodium cap 140
mg.................................................................................... 17
EMEND -aprepitant capsule 40 mg.................................. 66
EMEND -aprepitant capsule 80 mg.................................. 66
EMEND -aprepitant capsule 125 mg................................ 66
EMEND -aprepitant capsule therapy pack 80 & 125
mg.................................................................................... 66
EMLA -lidocaine-prilocaine cream 2.5-2.5%................... 136
EMSAM -selegiline td patch 24hr 6 mg/24hr.................... 74
EMSAM -selegiline td patch 24hr 9 mg/24hr.................... 74
EMSAM -selegiline td patch 24hr 12 mg/24hr.................. 74
EMTRIVA -emtricitabine caps 200 mg................................ 7
EMTRIVA -emtricitabine soln 10 mg/ml.............................. 7
ENABLEX -darifenacin hydrobromide tab sr 24hr 7.5 mg
(base equiv).................................................................... 69
ENABLEX -darifenacin hydrobromide tab sr 24hr 15 mg
(base equiv).................................................................... 69
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....................................................................... 111
ENBREL -etanercept for subcutaneous inj kit 25 mg....... 97
ENBREL -etanercept subcutaneous soln prefilled syringe
25 mg/0.5ml.................................................................... 97
ENBREL -etanercept subcutaneous soln prefilled syringe
50 mg/ml......................................................................... 97
ENBREL SURECLICK -etanercept subcutaneous solution
auto-injector 50 mg/ml.................................................... 97
ENCARE -nonoxynol-9 vaginal suppos 100 mg............... 70
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
ENJUVIA -estrogens, conjugated synthetic b tab 0.3
mg.................................................................................... 23
mg.................................................................................... 23
mg.................................................................................... 23
mg.................................................................................... 23
mg.................................................................................... 23
enoxaparin sodium inj 30 mg/0.3ml (Lovenox).......... 121
235
2016
enoxaparin sodium inj 100 mg/ml (Lovenox)............. 121
enoxaparin sodium inj 120 mg/0.8ml (Lovenox)........ 121
enoxaparin sodium inj 150 mg/ml (Lovenox)............. 121
enoxaparin sodium inj 300 mg/3ml (Lovenox)........... 121
entacapone tab 200 mg (Comtan)............................... 107
entecavir tab 0.5 mg (Baraclude)..................................... 7
entecavir tab 1 mg (Baraclude)........................................ 7
ENTEREG -alvimopan cap 12 mg.................................... 67
ENTOCORT EC -budesonide cap sr 24hr 3 mg............... 20
ENTRESTO -sacubitril-valsartan tab 24-26 mg................ 57
ENTRESTO -sacubitril-valsartan tab 49-51 mg................ 57
ENTRESTO -sacubitril-valsartan tab 97-103 mg.............. 57
ENVARSUS XR -tacrolimus tab sr 24hr 0.75 mg............204
ENVARSUS XR -tacrolimus tab sr 24hr 1 mg................ 204
ENVARSUS XR -tacrolimus tab sr 24hr 4 mg................ 204
ENVISION AUTOCODE -blood glucose monitoring kit w/
device............................................................................ 163
ENVISION AUTOCODE TEST ST -glucose blood test
strip................................................................................ 145
EPANED -enalapril maleate for oral soln 1 mg/ml............ 47
EPIDUO -adapalene-benzoyl peroxide gel 0.1-2.5%......136
EPIDUO FORTE -adapalene-benzoyl peroxide gel
0.3-2.5%........................................................................ 136
EPIFOAM -pramoxine-hc aerosol foam 1-1%.................136
epinastine hcl ophth soln 0.05% (Elestat).................. 128
EPINEPHRINE -epinephrine solution auto-injector 0.15
mg/0.15ml (1:1000)......................................................... 53
EPINEPHRINE -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)........................................................... 53
epinephrine hcl inj 1 mg/ml............................................ 61
epinephrine hcl soln prefilled syringe 0.1 mg/ml.........61
EPIPEN-JR 2-PAK -epinephrine solution auto-injector
0.15 mg/0.3ml (1:2000).................................................. 53
EPIPEN 2-PAK -epinephrine solution auto-injector 0.3
mg/0.3ml (1:1000)........................................................... 53
EPIVIR HBV -lamivudine oral soln 5 mg/ml (hbv)............... 7
EPIVIR HBV -lamivudine tab 100 mg (hbv)........................ 7
EPIVIR -lamivudine oral soln 10 mg/ml.............................. 7
EPIVIR -lamivudine tab 150 mg.......................................... 7
EPIVIR -lamivudine tab 300 mg.......................................... 7
eplerenone tab 25 mg (Inspra)....................................... 47
eplerenone tab 50 mg (Inspra)....................................... 47
EPOGEN -epoetin alfa inj 2000 unit/ml...........................120
EPOGEN -epoetin alfa inj 10000 unit/ml.........................120
EPOGEN -epoetin alfa inj 20000 unit/ml.........................120
EPROSARTAN MESYLATE -eprosartan mesylate tab 600
mg.................................................................................... 47
EPZICOM -abacavir sulfate-lamivudine tab 600-300
mg...................................................................................... 7
EQ BLOOD GLUCOSE TEST STR -glucose blood test
strip................................................................................ 145
EQL COLOR LANCETS 21G -lancets............................ 164
EQL COLOR LANCETS MICRO T -lancets....................163
236
EQL INSULIN SYRINGE/1ML/2 -insulin syringe/needle

u-100 1 ml 29 x 1/2".....................................................164
u-100 1 ml 30 x 5/16"...................................................164
u-100 1 ml 31 x 5/16"...................................................164
EQL INSULIN SYRINGE/0.5ML -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 164
u-100 1/2 ml 29 x 1/2".................................................. 164
u-100 1/2 ml 30 x 5/16"................................................ 164
u-100 0.3 ml 29 x 1/2".................................................. 164
u-100 0.3 ml 30 x 5/16"................................................ 164
u-100 0.3 ml 31 x 5/16"................................................ 164
EQL INSULIN SYRINGE/U-100 -insulin syringe/needle
u-100 1/2 ml 29 x 1/2".................................................. 164
u-100 0.3 ml 29 x 1/2".................................................. 164
u-100 1 ml 29 x 1/2".....................................................164
EQL SHORT PEN NEEDLES 31G -insulin pen needle 31
g x 8 mm (1/3" or 5/16")...............................................164
EQL SUPER THIN LANCETS 30 -lancets...................... 164
EQL THIN LANCETS 26G -lancets................................ 164
EQL TRUE2GO BLOOD GLUCOSE -blood glucose
EQL TRUETEST BLOOD GLUCOS -glucose blood test
strip................................................................................ 145
EQL TRUETRACK TEST -glucose blood test strip.........145
EQL ULTRA COMFORT INSULIN -insulin syringe/needle
u-100 1 ml 30 x 5/16"...................................................164
EQL ULTRA COMFORT INSULIN -insulin syringe/needle
u-100 0.3 ml 31 x 5/16"................................................ 164
EQL ULTRA SHORT PEN NEEDL -insulin pen needle 31
g x 6 mm (1/4").............................................................164
EQUAGESIC -meprobamate-aspirin tab 200-325 mg...... 90
EQUAPAX/ATORVASTATIN CALC -atorvastatin tab 20
mg & coenzyme q10 cap 100 mg ther pack.................. 54
EQUAPAX/IBUPROFEN/MINREX -ibuprofen tab 800 mg
& multiple minerals cap therapy pack............................ 97
EQUETRO -carbamazepine (antipsychotic) cap sr 12hr
100 mg............................................................................ 78
200 mg............................................................................ 78
300 mg............................................................................ 78
ergocalciferol cap 50000 unit (Drisdol)....................... 110
ERGOLOID MESYLATES -ergoloid mesylates tab 1
mg.................................................................................... 87
ERGOMAR -ergotamine tartrate sl tab 2 mg.................. 100
ERIVEDGE -vismodegib cap 150 mg............................... 17
ERTACZO -sertaconazole nitrate cream 2%.................. 136
ERYGEL -erythromycin gel 2%....................................... 136
2016
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
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 gel 2% (Erygel)....................................... 136
erythromycin ophth oint 5 mg/gm............................... 128
erythromycin pads 2%.................................................. 136
erythromycin soln 2%................................................... 136
erythromycin w/ delayed release particles cap 250
mg......................................................................................3
ESBRIET -pirfenidone cap 267 mg................................... 63
escitalopram oxalate soln 5 mg/5ml (base equiv)
(Lexapro)........................................................................ 74
escitalopram oxalate tab 5 mg (base equiv)
(Lexapro)........................................................................ 74
(Lexapro)........................................................................ 74
(Lexapro)........................................................................ 74
esomeprazole magnesium cap delayed release 20 mg
(base eq) (Nexium)....................................................... 64
esomeprazole magnesium cap delayed release 40 mg
(base eq) (Nexium)....................................................... 64
ESSENTRA WIPES 9X9" CLEAN -isopropyl alcohol
wipes 70%..................................................................... 136
estazolam tab 1 mg......................................................... 81
estazolam tab 2 mg......................................................... 81
esterified estrogens & methyltestosterone tab
0.625-1.25 mg................................................................ 23
esterified estrogens & methyltestosterone tab
1.25-2.5 mg.....................................................................23
ESTRACE -estradiol tab 0.5 mg....................................... 23
ESTRACE -estradiol tab 1 mg.......................................... 23
ESTRACE -estradiol tab 2 mg.......................................... 23
ESTRACE -estradiol vaginal cream 0.1 mg/gm................ 70
estradiol & norethindrone acetate tab 0.5-0.1 mg
(Activella)....................................................................... 23
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella)....................................................................... 23
estradiol tab 0.5 mg (Estrace)........................................ 23
estradiol tab 1 mg (Estrace)........................................... 23
estradiol tab 2 mg (Estrace)........................................... 23
estradiol td patch twice weekly 0.025 mg/24hr (Vivelledot).................................................................................. 23
estradiol td patch twice weekly 0.0375 mg/24hr
(Vivelle-dot).................................................................... 23

estradiol td patch weekly 0.025 mg/24hr (Climara)......23
estradiol td patch weekly 0.05 mg/24hr (Climara)........23
estradiol td patch weekly 0.06 mg/24hr (Climara)........23
estradiol td patch weekly 0.075 mg/24hr (Climara)......23
estradiol td patch weekly 0.1 mg/24hr (Climara)..........23
estradiol td patch weekly 0.0375 mg/24hr (37.5
mcg/24hr) (Climara)...................................................... 23
ESTRING -estradiol vaginal ring 2 mg (7.5
mcg/24hrs).......................................................................70
ESTROGEL -estradiol gel 0.06% (0.75 mg/1.25 gm
metered-dose pump)...................................................... 23
ESTROPIPATE -estropipate tab 3 mg.............................. 23
estropipate tab 0.75 mg.................................................. 23
estropipate tab 1.5 mg.................................................... 23
ESTROSTEP FE -norethindrone ac-ethinyl estrad-fe tab
1-20/1-30/1-35 mg-mcg.................................................. 24
eszopiclone tab 1 mg (Lunesta).................................... 81
ethambutol hcl tab 100 mg (Myambutol)........................ 5
ethambutol hcl tab 400 mg (Myambutol)........................ 5
ethosuximide cap 250 mg (Zarontin).......................... 102
ethosuximide soln 250 mg/5ml (Zarontin).................. 102
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35
mcg................................................................................. 24
ETIDRONATE DISODIUM -etidronate disodium tab 200
mg.................................................................................... 34
ETIDRONATE DISODIUM -etidronate disodium tab 400
mg.................................................................................... 34
etodolac cap 200 mg....................................................... 97
etodolac cap 300 mg....................................................... 97
etodolac tab 400 mg........................................................ 98
etodolac tab 500 mg........................................................ 98
etodolac tab sr 24hr 400 mg.......................................... 97
ETOPOSIDE -etoposide cap 50 mg..................................17
EURAX -crotamiton cream 10%...................................... 136
EURAX -crotamiton lotion 10%....................................... 136
EVAMIST -estradiol transdermal spray 1.53 mg/spray..... 23
EVEKEO -amphetamine sulfate tab 5 mg.........................84
EVEKEO -amphetamine sulfate tab 10 mg.......................84
EVENCARE + BLOOD GLUCOSE -glucose blood test
strip................................................................................ 146
EVENCARE BLOOD GLUCOSE MO -blood glucose
monitoring kit................................................................. 164
EVENCARE BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 146
EVENCARE G2 BLOOD GLUCOSE -blood glucose
EVENCARE G3 BLOOD GLUCOSE -blood glucose
237
2016
EVENCARE G2 TEST STRIPS -glucose blood test
strip................................................................................ 146
EVENCARE G3 TEST STRIPS -glucose blood test
strip................................................................................ 146
EVENCARE MINI BLOOD GLUCO -blood glucose
EVENCARE MINI BLOOD GLUCO -glucose blood test
strip................................................................................ 146
EVISTA -raloxifene hcl tab 60 mg..................................... 34
EVOCLIN -clindamycin phosphate foam 1%.................. 136
EVOLUTION AUTOCODE -blood glucose monitoring
devices.......................................................................... 164
EVOLUTION AUTOCODE -glucose blood test strip....... 146
EVOTAZ -atazanavir sulfate-cobicistat tab 300-150 mg
(base equiv)...................................................................... 7
EVOXAC -cevimeline hcl cap 30 mg.............................. 131
EVZIO -naloxone hcl solution auto-injector 0.4
mg/0.4ml........................................................................ 143
EXACTECH R-S-G TEST STRIP -glucose blood test
strip................................................................................ 146
EXACTECH TEST STRIPS -glucose blood test strip..... 146
EXALGO -hydromorphone hcl tab er 24hr deter 8 mg......91
EXALGO -hydromorphone hcl tab er 24hr deter 12
mg.................................................................................... 92
mg.................................................................................... 92
mg.................................................................................... 92
EXCEL COMFORT POINT INSUL -insulin pen needle 31
g x 4 mm (1/6").............................................................164
EXEL COMFORT POINT INSULI -insulin pen needle 29 g
x 12 mm (1/2").............................................................. 164
x 6 mm (1/4")................................................................ 164
x 8 mm (1/3" or 5/16").................................................. 164
EXEL COMFORT POINT INSULI -insulin syringe/needle
u-100 1/2 ml 28 x 1/2".................................................. 165
u-100 1/2 ml 29 x 1/2".................................................. 165
u-100 1/2 ml 30 x 5/16"................................................ 165
u-100 0.3 ml 29 x 1/2".................................................. 164
u-100 0.3 ml 30 x 5/16"................................................ 164
u-100 1 ml 28 x 1/2".....................................................165
u-100 1 ml 29 x 1/2".....................................................165
u-100 1 ml 30 x 5/16"...................................................165
EXELDERM -sulconazole nitrate cream 1%................... 136
EXELDERM -sulconazole nitrate solution 1%................ 136
EXELON -rivastigmine tartrate cap 1.5 mg....................... 87
EXELON -rivastigmine tartrate cap 3 mg.......................... 87
EXELON -rivastigmine tartrate cap 4.5 mg....................... 87
238
EXELON -rivastigmine tartrate cap 6 mg.......................... 87

EXELON -rivastigmine td patch 24hr 4.6 mg/24hr............ 87
EXELON -rivastigmine td patch 24hr 9.5 mg/24hr............ 87
EXELON -rivastigmine td patch 24hr 13.3 mg/24hr.......... 87
exemestane tab 25 mg (Aromasin)................................ 17
EXFORGE -amlodipine besylate-valsartan tab 5-160
mg.................................................................................... 47
mg.................................................................................... 47
mg.................................................................................... 47
mg.................................................................................... 47
EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 5-160-12.5 mg......................... 47
EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 5-160-25 mg............................ 47
EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 10-160-12.5 mg....................... 47
EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 10-160-25 mg.......................... 47
EXFORGE HCT -amlodipine-valsartanhydrochlorothiazide tab 10-320-25 mg.......................... 47
EXJADE -deferasirox tab for oral susp 125 mg.............. 143
EXTAVIA -interferon beta-1b for inj kit 0.3 mg.................. 87
EXTINA -ketoconazole foam 2%..................................... 136
EXTRA-VIRT PLUS DHA -prenatal w/o vit a w/ fe fumdoc-fa-dha cap 29-1.25-350 mg................................... 111
E-Z JECT LANCETS COLOR -lancets........................... 160
E-Z JECT LANCETS 21G -lancets................................. 160
E-Z JECT LANCETS -lancets......................................... 160
E-ZJECT LANCETS MICRO-THI -lancets...................... 160
E-Z JECT LANCETS SUPER TH -lancets...................... 160
E-Z JECT LANCETS THIN 26G -lancets........................ 160
EZ-LETS LANCETS 21G -lancets.................................. 165
EZ-LETS LANCETS 26G SUPER -lancets..................... 165
EZ-LETS LANCETS 28G ULTRA -lancets...................... 165
EZ SMART BLOOD GLUCOSE LA -lancets...................165
EZ SMART BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 146
EZ SMART DIABETES MONITOR -blood glucose
EZ SMART PLUS BLOOD GLUCO -glucose blood test
strip................................................................................ 146
EZ SMART PLUS DIABETES MO -blood glucose
F
FACTIVE -gemifloxacin mesylate tab 320 mg (base
equiv)................................................................................. 5
famciclovir tab 125 mg (Famvir)...................................... 7
2016
famotidine for susp 40 mg/5ml (Pepcid)....................... 64
famotidine tab 20 mg (Pepcid)....................................... 64
famotidine tab 40 mg (Pepcid)....................................... 64
FAMVIR -famciclovir tab 125 mg........................................ 7
FANAPT -iloperidone tab 1 mg......................................... 78
FANAPT -iloperidone tab 10 mg....................................... 78
FANAPT -iloperidone tab 12 mg....................................... 78
FANAPT TITRATION PACK -iloperidone tab 1 mg & 2 mg
& 4 mg & 6 mg titration pak........................................... 78
FARESTON -toremifene citrate tab 60 mg (base
equivalent)....................................................................... 17
FARXIGA -dapagliflozin propanediol tab 5 mg (base
equivalent)....................................................................... 27
FARXIGA -dapagliflozin propanediol tab 10 mg (base
equivalent)....................................................................... 27
FARYDAK -panobinostat lactate cap 10 mg (base
equivalent)....................................................................... 17
equivalent)....................................................................... 17
equivalent)....................................................................... 17
FASTTAKE COMPACT MONITORI -blood glucose
FASTTAKE TEST STRIPS -glucose blood test strip....... 146
FAZACLO -clozapine orally disintegrating tab 12.5
mg.................................................................................... 78
FAZACLO -clozapine orally disintegrating tab 25 mg....... 78
FAZACLO -clozapine orally disintegrating tab 100 mg..... 78
FC FEMALE CONDOM -condoms - female....................165
FC2 FEMALE CONDOM -condoms - female..................165
FEIBA -antiinhibitor coagulant complex for inj................ 124
FEIBA NF -antiinhibitor coagulant complex for inj.......... 124
felbamate susp 600 mg/5ml (Felbatol)........................ 102
felbamate tab 400 mg (Felbatol).................................. 103
felbamate tab 600 mg (Felbatol).................................. 103
FELBATOL -felbamate susp 600 mg/5ml........................103
FELBATOL -felbamate tab 400 mg................................. 103
FELBATOL -felbamate tab 600 mg................................. 103
FELDENE -piroxicam cap 10 mg...................................... 98
FELDENE -piroxicam cap 20 mg...................................... 98
felodipine tab sr 24hr 2.5 mg......................................... 41
felodipine tab sr 24hr 5 mg............................................ 41
felodipine tab sr 24hr 10 mg.......................................... 41
FEMARA -letrozole tab 2.5 mg......................................... 17
FEMCAP -cervical cap 22 mm........................................ 165
FEMCON FE -norethindrone & ethinyl estradiol-fe chew
tab 0.4 mg-35 mcg......................................................... 25
FEMHRT LOW DOSE -norethindrone acetate-ethinyl

estradiol tab 0.5 mg-2.5 mcg......................................... 23
FEM PH -acetic acid-oxyquinoline vaginal gel
0.9-0.025%...................................................................... 70
FEMRING -estradiol acetate vaginal ring 0.05
mg/24hr........................................................................... 70
FEMRING -estradiol acetate vaginal ring 0.1 mg/24hr..... 70
FENOFIBRATE -fenofibrate cap 50 mg............................ 54
FENOFIBRATE -fenofibrate cap 150 mg.......................... 54
FENOFIBRATE -fenofibrate tab 40 mg............................. 54
FENOFIBRATE -fenofibrate tab 120 mg........................... 54
fenofibrate micronized cap 43 mg................................. 54
fenofibrate micronized cap 130 mg............................... 54
fenofibrate micronized cap 67 mg (Lofibra)................. 54
fenofibrate micronized cap 134 mg (Lofibra)............... 54
fenofibrate micronized cap 200 mg (Lofibra)............... 54
fenofibrate tab 54 mg (Lofibra)...................................... 54
fenofibrate tab 160 mg (Lofibra).................................... 54
fenofibrate tab 48 mg (Tricor)........................................ 54
fenofibrate tab 145 mg (Tricor)...................................... 54
FENOFIBRIC ACID -fenofibric acid tab 35 mg................. 54
FENOFIBRIC ACID -fenofibric acid tab 105 mg............... 54
FENOGLIDE -fenofibrate tab 40 mg................................. 54
FENOGLIDE -fenofibrate tab 120 mg............................... 54
FENOPROFEN CALCIUM -fenoprofen calcium cap 400
mg.................................................................................... 98
FENOPROFEN CALCIUM -fenoprofen calcium tab 600
mg.................................................................................... 98
fentanyl citrate lozenge on a handle 200 mcg
(Actiq)............................................................................. 92
(Actiq)............................................................................. 92
(Actiq)............................................................................. 92
(Actiq)............................................................................. 92
(Actiq)............................................................................. 92
(Actiq)............................................................................. 92
FENTANYL -fentanyl td patch 72hr 37.5 mcg/hr...............92
fentanyl td patch 72hr 12 mcg/hr (Duragesic).............. 92
fentanyl td patch 72hr 100 mcg/hr (Duragesic)............ 92
FENTORA -fentanyl citrate buccal tab 100 mcg (base
equiv)............................................................................... 92
equiv)............................................................................... 92
equiv)............................................................................... 92
equiv)............................................................................... 92
239
2016
equiv)............................................................................... 92
FERRIPROX -deferiprone tab 500 mg............................ 143
ferrous sulfate elixir 220 mg/5ml (44 mg/5ml elemental
fe).................................................................................. 120
FERROUS SULFATE -ferrous sulfate liquid 220 mg/5ml
(44 mg/5ml elemental fe)............................................. 120
ferrous sulfate soln 75 mg/ml (15 mg/ml elemental
fe).................................................................................. 120
FETZIMA -levomilnacipran hcl cap sr 24hr 20 mg (base
equivalent)....................................................................... 74
equivalent)....................................................................... 74
equivalent)....................................................................... 74
equivalent)....................................................................... 74
FETZIMA TITRATION PACK -levomilnacipran hcl cap sr
24hr 20 & 40 mg therapy pack...................................... 74
FIBRICOR -fenofibric acid tab 35 mg............................... 54
FIBRICOR -fenofibric acid tab 105 mg............................. 54
FIFTY50 GLUCOSE METER 2.0 -blood glucose
FIFTY50 GLUCOSE TEST STRI -glucose blood test
strip................................................................................ 146
FIFTY50 LANCING DEVICE -lancet devices.................. 165
FIFTY50 PEN NEEDLES 31G X -insulin pen needle 31 g
x 5 mm (3/16").............................................................. 165
FIFTY50 PEN NEEDLES 31G X -insulin pen needle 31 g
x 8 mm (1/3" or 5/16").................................................. 165
FIFTY50 SAFETY SEAL LANCE -lancets...................... 165
FIFTY50 SUPERIOR COMFORT -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 165
u-100 1 ml 31 x 5/16"...................................................165
u-100 0.3 ml 31 x 5/16"................................................ 165
FINACEA -azelaic acid foam 15%.................................. 136
FINACEA -azelaic acid gel 15%..................................... 136
finasteride tab 5 mg (Proscar)....................................... 71
FINE 30 -lancets.............................................................. 165
FINGERSTIX LANCETS -lancets.................................... 165
FIORINAL/CODEINE #3 -butalbital-aspirin-caff w/ codeine
cap 50-325-40-30 mg..................................................... 92
FIRAZYR -icatibant acetate inj 30 mg/3ml (base
equivalent)..................................................................... 124
FLAGYL ER -metronidazole tab sr 24hr 750 mg.............. 12
FLAGYL -metronidazole cap 375 mg................................ 12
FLAGYL -metronidazole tab 250 mg................................ 12
FLAGYL -metronidazole tab 500 mg................................ 12
FLAREX -fluorometholone acetate ophth susp 0.1%..... 128
flavoxate hcl tab 100 mg.................................................69
flecainide acetate tab 50 mg.......................................... 43
flecainide acetate tab 100 mg........................................ 43
flecainide acetate tab 150 mg........................................ 43
FLECTOR -diclofenac epolamine patch 1.3%................ 136
FLOMAX -tamsulosin hcl cap 0.4 mg............................... 71
240
FLO-PRED -prednisolone acetate oral susp 16.7 mg/5ml

(15 mg/5ml base)............................................................ 20
FLORIVA -sodium fluoride-vitamin d liqd drops 0.25 mg/
ml-400 unit/ml............................................................... 118
FLOVENT DISKUS -fluticasone propionate aer pow ba 50
mcg/blister....................................................................... 61
FLOVENT DISKUS -fluticasone propionate aer pow ba
100 mcg/blister................................................................ 61
FLOVENT DISKUS -fluticasone propionate aer pow ba
250 mcg/blister................................................................ 61
FLOVENT HFA -fluticasone propionate hfa inhal aer 110
mcg/act (125/valve)........................................................ 61
FLOVENT HFA -fluticasone propionate hfa inhal aer 220
mcg/act (250/valve)........................................................ 61
FLOVENT HFA -fluticasone propionate hfa inhal aero 44
mcg/act (50/valve)...........................................................61
FLOW-EZE VENTED NEEDLE -hypodermic needles
(disposable)................................................................... 165
FLUARIX 2013-2014 -influenza virus vaccine split pf susp
pref syringe 0.5 ml.......................................................... 13
FLUARIX 2014-2015 -influenza virus vaccine split pf susp
pref syringe 0.5 ml.......................................................... 13
FLUARIX QUADRIVALENT 2013 -influenza virus vac split
quadrivalent susp pref syr 0.5ml.................................... 13
FLUBLOK 2013-2014 -influenza virus vac recombinant
hemagglutinin (ha) inj..................................................... 13
FLUCELVAX 2013-2014 -influenza virus vac tiss-cult
subunit 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
flucytosine cap 250 mg (Ancobon)................................. 6
flucytosine cap 500 mg (Ancobon)................................. 6
fludrocortisone acetate tab 0.1 mg............................... 20
FLULAVAL 2013-2014 -influenza virus vaccine split im
susp................................................................................. 13
FLULAVAL 2014-2015 -influenza virus vaccine split im
susp................................................................................. 13
FLULAVAL QUADRIVALENT 201 -influenza virus vaccine
split quadrivalent im inj................................................... 13
FLULAVAL QUADRIVALENT 201 -influenza virus vac split
2016
FLUMADINE -rimantadine hydrochloride tab 100 mg.........7
FLUMIST QUADRIVALENT -influenza virus vaccine live
quadrivalent intranasal susp...........................................13
flunisolide nasal soln 25 mcg/act (0.025%)
(Flunisolide)................................................................... 58
fluocinolone acetonide cream 0.01%.......................... 137
fluocinolone acetonide cream 0.025% (Synalar)........137
fluocinolone acetonide oil 0.01% (body oil) (Dermasmoothe/fs bod).......................................................... 137
fluocinolone acetonide oil 0.01% (scalp oil) (Dermasmoothe/fs sca)...........................................................137
fluocinolone acetonide oint 0.025% (Synalar)............ 137
fluocinolone acetonide (otic) oil 0.01%
(Dermotic).................................................................... 131
fluocinolone acetonide soln 0.01% (Synalar)............. 137
fluocinonide cream 0.05%............................................ 137
fluocinonide cream 0.1% (Vanos)................................ 137
fluocinonide emulsified base cream 0.05%................ 137
fluocinonide gel 0.05%.................................................. 137
fluocinonide oint 0.05%................................................ 137
fluocinonide soln 0.05%................................................ 137
FLUORABON -sodium fluoride soln 0.25 mg/0.6ml (from
0.55 mg/0.6ml naf)........................................................118
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 0.55
(0.25 mg f)-236.79 mg..................................................118
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 1.1 (0.5
mg f)-236.79 mg........................................................... 118
FLUOR-A-DAY -sodium fluoride-xylitol chew tab 2.2 (1 mg
f)-236.79 mg.................................................................. 118
fluorometholone ophth susp 0.1% (Fml liquifilm)..... 128
FLUOROPLEX -fluorouracil cream 1%........................... 137
fluorouracil cream 5% (Efudex)................................... 137
FLUOROURACIL -fluorouracil cream 0.5%.................... 137
fluorouracil soln 2%...................................................... 137
fluorouracil soln 5%...................................................... 137
fluoxetine hcl cap delayed release 90 mg (Prozac
weekly)............................................................................ 74
fluoxetine hcl cap 10 mg (Prozac)................................. 74
FLUOXETINE HCL -fluoxetine hcl tab 60 mg................... 74
fluoxetine hcl (pmdd) cap 10 mg................................... 87
fluoxetine hcl (pmdd) cap 20 mg................................... 87
fluoxetine hcl solution 20 mg/5ml................................. 74
fluoxetine hcl tab 10 mg................................................. 74
fluoxetine hcl tab 20 mg................................................. 74
FLUPHENAZINE HCL -fluphenazine hcl elixir 2.5
mg/5ml............................................................................. 78
FLUPHENAZINE HCL -fluphenazine hcl oral conc 5 mg/
ml..................................................................................... 78
fluphenazine hcl tab 1 mg.............................................. 78
fluphenazine hcl tab 2.5 mg........................................... 78
fluphenazine hcl tab 5 mg.............................................. 78
fluphenazine hcl tab 10 mg............................................ 78
FLURA-DROPS -sodium fluoride soln 0.25 mg/drop f
(from 0.55 mg/drop naf)............................................... 118
FLURAZEPAM HCL -flurazepam hcl cap 15 mg.............. 81
FLURAZEPAM HCL -flurazepam hcl cap 30 mg.............. 81

flurbiprofen sodium ophth soln 0.03% (Ocufen)........128
flurbiprofen tab 50 mg.................................................... 98
flurbiprofen tab 100 mg.................................................. 98
flutamide cap 125 mg...................................................... 17
fluticasone propionate cream 0.05% (Cutivate)......... 137
fluticasone propionate lotion 0.05% (Cutivate).......... 137
fluticasone propionate nasal susp 50 mcg/act............ 58
fluticasone propionate oint 0.005%............................. 137
fluvastatin sodium cap 20 mg (Lescol)......................... 54
fluvastatin sodium cap 40 mg (Lescol)......................... 54
fluvastatin sodium tab sr 24 hr 80 mg (Lescol xl)........54
FLUVIRIN 2015-2016 -influenza vac type a&b surface
antigen susp pref syr 0.5 ml...........................................13
FLUVIRIN 2013-2014 -influenza virus vaccine types a & b
surface antigen im susp................................................. 13
FLUVIRIN PF 2013-2014 -influenza virus vac types a & b
pf susp prefilled syr 0.5 ml............................................. 13
FLUVIRIN PF 2014-2015 -influenza virus vac types a & b
pf susp prefilled syr 0.5 ml............................................. 13
fluvoxamine maleate cap sr 24hr 100 mg..................... 74
fluvoxamine maleate cap sr 24hr 150 mg..................... 74
fluvoxamine maleate tab 25 mg..................................... 74
fluvoxamine maleate tab 50 mg..................................... 74
fluvoxamine maleate tab 100 mg................................... 74
FLUZONE HIGH-DOSE PF 2013 -influenza virus vac split
high-dose pf susp pref syr 0.5ml....................................13
FLUZONE INTRADERMAL QUADR -influenza virus vac
split quad intradermal pen 9 mcg/strain......................... 14
FLUZONE PF 2013-2014 -influenza virus vaccine split pf
FLUZONE PF 2014-2015 -influenza virus vaccine split pf
FLUZONE QUADRIVALENT 2014 -influenza virus
vaccine split quadrivalent im inj..................................... 14
vaccine split quadrivalent im inj..................................... 14
vaccine split quadrivalent inj 0.5 ml............................... 14
FLUZONE QUADRIVALENT 2013 -influenza virus vac
split quadrivalent susp pref syr 0.25 ml......................... 14
split quadrivalent susp pref syr 0.5ml............................ 14
241
2016
FLUZONE SPLIT 2013-2014 -influenza virus vaccine split
im susp............................................................................ 14
im susp............................................................................ 14
im susp............................................................................ 14
FML -fluorometholone ophth oint 0.1%........................... 128
FML FORTE -fluorometholone ophth susp 0.25%.......... 128
FML LIQUIFILM -fluorometholone ophth susp 0.1%...... 128
FOCALGIN-B -prenatal w/ calcium-vit b6-fa-ginger tab
1.22 mg......................................................................... 111
FOCALGIN CA -prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 300 mg pack...................................................111
FOCALGIN 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa tab
90 &dha cap 300mg pak.............................................. 111
FOCALIN -dexmethylphenidate hcl tab 2.5 mg................ 84
FOCALIN -dexmethylphenidate hcl tab 5 mg................... 84
FOCALIN -dexmethylphenidate hcl tab 10 mg................. 84
FOCALIN XR -dexmethylphenidate hcl cap sr 24 hr 5
mg.................................................................................... 84
mg.................................................................................... 84
mg.................................................................................... 84
mg.................................................................................... 84
mg.................................................................................... 84
mg.................................................................................... 84
mg.................................................................................... 84
mg.................................................................................... 84
FOLBECAL -prenatal w/ calcium carbonate-b6-b12-fa tab
1 mg.............................................................................. 111
FOLCAL DHA -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 27-1.25-300 mg..................................................... 111
FOLCAPS OMEGA 3 -prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg............................................... 111
FOLET DHA -prenat w/fecbn-bisg-methylf-dss tab dr &
dha cap pak.................................................................. 111
FOLET ONE -prenat w/o a w/fecbn-bisg-methylf-dss-dha
cap 38-1-225 mg.......................................................... 111
folic acid tab 400 mcg................................................... 120
folic acid tab 800 mcg................................................... 120
folic acid tab 1 mg......................................................... 120
FOLIVANE-F -fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe)................................... 120
FOLIVANE-OB -prenatal w/o a w/fe fum-fe poly-fa cap
130-92.4-1 mg...............................................................111
242
fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml

(Arixtra).........................................................................121
fondaparinux sodium subcutaneous inj 5 mg/0.4ml
(Arixtra).........................................................................121
fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml
(Arixtra).........................................................................121
fondaparinux sodium subcutaneous inj 10 mg/0.8ml
(Arixtra).........................................................................121
FORACARE GD40 BLOOD GLUCO -blood glucose
FORACARE GD40 -glucose blood test strip...................146
FORACARE PREMIUM V10 BLOO -blood glucose
FORACARE PREMIUM V10 TEST -glucose blood test
strip................................................................................ 146
FORACARE TEST N GO BLOOD -blood glucose
FORACARE TEST N GO TEST S -glucose blood test
strip................................................................................ 146
FORA D10 BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 146
FORA D20 BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 146
FORA D15C BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 146
FORA D15G BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 146
FORADIL AEROLIZER -formoterol fumarate inhal cap 12
mcg.................................................................................. 61
FORA D15Z BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 146
FORA G30A BLOOD GLUCOSE M -blood glucose
FORA G71A BLOOD GLUCOSE M -blood glucose
FORA G30A BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 146
FORA G71A BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 146
FORA G90 BLOOD GLUCOSE MO -blood glucose
FORA G20 BLOOD GLUCOSE MO -blood glucose
FORA G20 BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 146
FORA G90 BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 146
FORA GD20 BLOOD GLUCOSE M -blood glucose
FORA GD50 BLOOD GLUCOSE M -blood glucose
FORA GD50 BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 146
FORA GD20 TEST STRIPS -glucose blood test
strip................................................................................ 146
FORA LANCETS -lancets............................................... 165
FORA LANCING DEVICE -lancet devices...................... 166
2016
FORA TEST N' GO BLOOD GLU -glucose blood test
strip................................................................................ 146
FORA TEST N' GO VOICE BLO -blood glucose
FORA V10/V12/D10/D20 BLOO -blood glucose
monitoring kit................................................................. 166
FORA V30A BLOOD GLUCOSE M -blood glucose
FORA V30A BLOOD GLUCOSE M -blood glucose
FORA V30A BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 146
FORA V10 BLOOD GLUCOSE MO -blood glucose
FORA V10 BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 146
strip................................................................................ 146
strip................................................................................ 146
strip................................................................................ 146
FORFIVO XL -bupropion hcl tab sr 24hr 450 mg............. 74
FORTEO -teriparatide (recombinant) inj 600
mcg/2.4ml........................................................................ 34
FORTESTA -testosterone td gel 10mg/act (2%)............... 22
FORTICAL -calcitonin (salmon) nasal soln 200 unit/
act.................................................................................... 35
FORTISCARE SELF-MONITORIN -blood glucose
FOSAMAX -alendronate sodium tab 70 mg......................35
FOSAMAX PLUS D -alendronate sodium-cholecalciferol
tab 70-2800 mg-unit....................................................... 35
FOSAMAX PLUS D -alendronate sodium-cholecalciferol
tab 70-5600 mg-unit....................................................... 35
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg................................................................................... 47
fosinopril sodium & hydrochlorothiazide tab 20-12.5
mg................................................................................... 48
fosinopril sodium tab 10 mg.......................................... 48
FOSRENOL -lanthanum carbonate chew tab 500 mg
(elemental).......................................................................68
(elemental).......................................................................68
(elemental).......................................................................68
FOSRENOL -lanthanum carbonate oral powder pack 750
mg (elemental)................................................................ 68
FOSRENOL -lanthanum carbonate oral powder pack

1000 mg (elemental).......................................................68
FRAGMIN -dalteparin sodium inj 10000 unit/ml..............121
FRAGMIN -dalteparin sodium inj 2500 unit/0.2ml...........121
FRAGMIN -dalteparin sodium inj 12500 unit/0.5ml.........121
FRAGMIN -dalteparin sodium inj 18000 unit/0.72ml.......121
FREDS PHARMACY AUTOLET LA -lancet devices...... 166
FREDS PHARMACY UNIFINE PE -insulin pen needle 31
g x 5 mm (3/16")...........................................................166
g x 4 mm (5/32")...........................................................166
g x 8 mm (1/3" or 5/16")...............................................166
FREDS PHARMACY UNILET LAN -lancets................... 166
FREESTYLE FLASH SYSTEM -blood glucose monitoring
kit................................................................................... 166
FREESTYLE FREEDOM -blood glucose monitoring kit w/
device............................................................................ 166
FREESTYLE FREEDOM LITE -blood glucose monitoring
kit w/ device.................................................................. 166
FREESTYLE INSULINX BLOOD -blood glucose
FREESTYLE INSULINX BLOOD -glucose blood test
strip................................................................................ 146
FREESTYLE LANCETS -lancets.................................... 166
FREESTYLE LITE BLOOD GLUC -blood glucose
FREESTYLE LITE TEST STRIP -glucose blood test
strip................................................................................ 146
FREESTYLE PRECISION INSUL -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 166
u-100 1/2 ml 30 x 5/16"................................................ 166
u-100 1 ml 30 x 5/16"...................................................166
u-100 1 ml 31 x 5/16"...................................................166
FREESTYLE SIDEKICK II VAL -blood glucose monitoring
kit w/ device.................................................................. 166
FREESTYLE SYSTEM KIT -blood glucose monitoring
kit................................................................................... 166
FREESTYLE TEST STRIPS -glucose blood test
strip................................................................................ 146
FREESTYLE UNISTICK II LAN -lancets......................... 166
FROVA -frovatriptan succinate tab 2.5 mg (base
equivalent)..................................................................... 100
FULYZAQ -crofelemer tab delayed release 125 mg......... 63
FURADANTIN -nitrofurantoin susp 25 mg/5ml................. 69
FUROSEMIDE -furosemide oral soln 8 mg/ml..................52
furosemide oral soln 10 mg/ml...................................... 52
furosemide tab 20 mg (Lasix)........................................ 52
243
2016
FUZEON -enfuvirtide for inj 90 mg..................................... 7
FYCOMPA -perampanel tab 2 mg.................................. 103
FYCOMPA -perampanel tab 10 mg................................ 103
FYCOMPA -perampanel tab 12 mg................................ 103
G
gabapentin cap 100 mg (Neurontin)............................ 103
gabapentin oral soln 250 mg/5ml (Neurontin)............ 103
gabapentin tab 600 mg (Neurontin)............................. 103
gabapentin tab 800 mg (Neurontin)............................. 103
GABITRIL -tiagabine hcl tab 2 mg.................................. 103
GABITRIL -tiagabine hcl tab 4 mg.................................. 103
GABITRIL -tiagabine hcl tab 12 mg................................ 103
GABITRIL -tiagabine hcl tab 16 mg................................ 103
galantamine hydrobromide cap sr 24hr 8 mg
(Razadyne er)................................................................ 87
(Razadyne er)................................................................ 87
(Razadyne er)................................................................ 87
GALANTAMINE HYDROBROMIDE -galantamine
hydrobromide oral soln 4 mg/ml.................................... 87
galantamine hydrobromide tab 4 mg (Razadyne)........ 87
galantamine hydrobromide tab 8 mg (Razadyne)........ 87
galantamine hydrobromide tab 12 mg (Razadyne)...... 87
GALZIN -zinc acetate cap 25 mg (elemental zinc)......... 118
GALZIN -zinc acetate cap 50 mg (elemental zinc)......... 118
GAMMAGARD LIQUID -immune globulin (human) iv or
subcutaneous soln 1 gm/10ml....................................... 15
subcutaneous soln 2.5 gm/25ml.................................... 15
subcutaneous soln 10 gm/100ml................................... 15
GAMMAKED -immune globulin (human) iv or
GAMUNEX-C -immune globulin (human) iv or
244

GARAMYCIN -gentamicin sulfate ophth soln 0.3%........ 128
GARDASIL -human papillomavirus (hpv) quadrivalent
recombinant vac inj.........................................................14
GARDASIL 9 -human papillomavirus (hpv) 9-valent
recomb vac im susp....................................................... 14
GARDASIL 9 -human papillomavirus (hpv) 9-valent
recomb vac susp pref syr............................................... 14
GASTRINEX NF -hyoscyamine-phenyltoloxamine cap
0.0625-15 mg.................................................................. 64
GASTROCROM -cromolyn sodium oral conc 100
mg/5ml............................................................................. 68
gatifloxacin ophth soln 0.5% (Zymaxid)..................... 128
GATTEX -teduglutide (rdna) for inj kit 5 mg...................... 68
GEBAUERS PAIN EASE -pentafluoropropanetetrafluoroethane aero spray........................................ 137
GEBAUERS SPRAY AND STRETC -pentafluoropropanetetrafluoroethane aero spray........................................ 137
GE100 BLOOD GLUCOSE MONIT -blood glucose
GE100 BLOOD GLUCOSE TEST -glucose blood test
strip................................................................................ 146
GELNIQUE -oxybutynin chloride td gel 10%.................... 69
GELNIQUE -oxybutynin td gel 3% (28 mg/act metereddose pump)..................................................................... 69
GELX -oral wound care products - gel............................131
gemfibrozil tab 600 mg (Lopid)...................................... 54
GENERESS FE -norethindrone & ethinyl estradiol-fe
chew tab 0.8 mg-25 mcg................................................25
GENOTROPIN MINIQUICK -somatropin for inj 0.2
mg.................................................................................... 35
mg.................................................................................... 35
mg.................................................................................... 35
mg.................................................................................... 35
GENOTROPIN MINIQUICK -somatropin for inj 1 mg....... 35
mg.................................................................................... 35
mg.................................................................................... 35
mg.................................................................................... 35
mg.................................................................................... 35
GENOTROPIN MINIQUICK -somatropin for inj 2 mg....... 35
2016
GENOTROPIN -somatropin for inj 12 mg (13.8 mg
overfill)............................................................................. 35
GENOTROPIN -somatropin for subcutaneous inj 5
mg.................................................................................... 35
GENTAMICIN SULFATE -gentamicin sulfate cream
0.1%...............................................................................137
GENTAMICIN SULFATE -gentamicin sulfate oint
0.1%...............................................................................137
gentamicin sulfate ophth oint 0.3%............................. 128
gentamicin sulfate ophth soln 0.3% (Garamycin)...... 128
GENTLE-LET GP LANCETS -lancets.............................166
GENTLE-LET LANCETS GENERA -lancets...................166
GENTLE-LET LANCETS SAFETY -lancets.................... 166
GEODON -ziprasidone hcl cap 20 mg.............................. 78
GHT BLOOD GLUCOSE MONITO -blood glucose
GHT TEST STRIPS -glucose blood test strip................. 146
GIAZO -balsalazide disodium tab 1.1 gm......................... 68
GILENYA -fingolimod hcl cap 0.5 mg (base equiv)........... 87
GILOTRIF -afatinib dimaleate tab 20 mg (base
equivalent)....................................................................... 17
equivalent)....................................................................... 17
equivalent)....................................................................... 17
GILTUSS PED-C -phenylephrine w/ codeine-gg liquid
2.5-3-50 mg/ml................................................................ 59
glatiramer acetate soln prefilled syringe 20 mg/ml
(Copaxone)..................................................................... 87
GLEEVEC -imatinib mesylate tab 100 mg (base
equivalent)....................................................................... 17
GLEEVEC -imatinib mesylate tab 400 mg (base
equivalent)....................................................................... 17
GLEOSTINE -lomustine cap 10 mg.................................. 17
GLEOSTINE -lomustine cap 40 mg.................................. 17
GLEOSTINE -lomustine cap 100 mg................................ 17
glimepiride tab 1 mg (Amaryl)........................................27
glipizide-metformin hcl tab 2.5-250 mg......................... 28
glipizide-metformin hcl tab 2.5-500 mg......................... 28
glipizide-metformin hcl tab 5-500 mg............................ 28
glipizide tab 5 mg (Glucotrol).........................................28
glipizide tab 10 mg (Glucotrol).......................................28
glipizide tab sr 24hr 2.5 mg (Glucotrol xl).................... 27
glipizide tab sr 24hr 5 mg (Glucotrol xl)....................... 28
glipizide tab sr 24hr 10 mg (Glucotrol xl)..................... 28
GLOBAL EASE INJECT PEN NE -insulin pen needle 29 g
x 12 mm (1/2").............................................................. 167
x 5 mm (3/16").............................................................. 167
x 4 mm (5/32").............................................................. 167

x 8 mm (1/3" or 5/16").................................................. 167
GLOBAL INJECT EASE INSULI -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 167
u-100 1/2 ml 28 x 1/2".................................................. 167
u-100 1/2 ml 29 x 1/2".................................................. 167
u-100 1/2 ml 30 x 5/16"................................................ 167
u-100 1/2 ml 30 x 1/2".................................................. 167
u-100 0.3 ml 29 x 1/2".................................................. 167
u-100 0.3 ml 30 x 5/16"................................................ 167
u-100 0.3 ml 30 x 1/2".................................................. 167
u-100 1 ml 28 x 1/2".....................................................167
u-100 1 ml 29 x 1/2".....................................................167
u-100 1 ml 30 x 5/16"...................................................167
u-100 1 ml 30 x 1/2".....................................................167
u-100 1 ml 31 x 5/16"...................................................167
u-100 0.3 ml 31 x 5/16"................................................ 167
GLOBAL INJECT EASE LANCET -lancets..................... 167
GLOBAL LANCING DEVICE -lancet devices................. 167
GLUCAGEN DIAGNOSTIC -glucagon hcl (rdna)
diagnostic for inj 1 mg (base equiv)............................. 146
GLUCAGEN HYPOKIT -glucagon hcl (rdna) for inj 1 mg
(base equiv).................................................................... 28
GLUCAGON EMERGENCY KIT -glucagon (rdna) for inj
kit 1 mg........................................................................... 28
GLUCOCARD 01 BLOOD GLUCOS -blood glucose
GLUCOCARD 01 BLOOD GLUCOS -blood glucose
GLUCOCARD EXPRESSION AUDI -blood glucose
GLUCOCARD EXPRESSION BLOO -glucose blood test
strip................................................................................ 146
GLUCOCARD 01-MINI BLOOD G -blood glucose
GLUCOCARD 01 SENSOR PLUS -glucose blood test
strip................................................................................ 147
GLUCOCARD SHINE -blood glucose monitoring
devices.......................................................................... 167
GLUCOCARD SHINE -blood glucose monitoring kit w/
device............................................................................ 167
GLUCOCARD SHINE TEST STRI -glucose blood test
strip................................................................................ 147
245
2016
GLUCOCARD VITAL BLOOD GLU -blood glucose
GLUCOCARD VITAL TEST STRI -glucose blood test
strip................................................................................ 147
GLUCOCARD X-METER -blood glucose monitoring kit w/
device............................................................................ 167
GLUCOCARD X-SENSOR -glucose blood test strip...... 147
GLUCOCOM AUTOLINK TELEMON -blood glucose
monitoring misc............................................................. 168
GLUCOCOM BLOOD GLUCOSE MO -blood glucose
GLUCOCOM BLOOD GLUCOSE MO -blood glucose
GLUCOCOM LANCETS 28G -lancets............................ 168
GLUCOCOM TEST STRIPS -glucose blood test
strip................................................................................ 147
GLUCOLAB BLOOD GLUCOSE MO -blood glucose
monitoring kit................................................................. 168
GLUCOLAB TEST STRIPS -glucose blood test strip..... 147
GLUCOLET 2 AUTOMATIC LANC -lancet devices........ 168
GLUCONAVII BLOOD GLUCOSE -blood glucose
GLUCONAVII BLOOD GLUCOSE -glucose blood test
strip................................................................................ 147
GLUCO PERFECT 3 BLOOD GLU -blood glucose
GLUCO PERFECT 3 TEST STRI -glucose blood test
strip................................................................................ 146
GLUCOPHAGE -metformin hcl tab 500 mg...................... 28
GLUCOPHAGE -metformin hcl tab 850 mg...................... 28
GLUCOPHAGE -metformin hcl tab 1000 mg.................... 28
GLUCOPHAGE XR -metformin hcl tab sr 24hr 500
mg.................................................................................... 28
GLUCOPHAGE XR -metformin hcl tab sr 24hr 750
mg.................................................................................... 28
GLUCOPRO INSULIN SYRINGE/ -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 168
u-100 1/2 ml 30 x 5/16"................................................ 168
u-100 1/2 ml 30 x 1/2".................................................. 168
u-100 0.3 ml 30 x 5/16"................................................ 168
u-100 0.3 ml 30 x 1/2".................................................. 168
u-100 1 ml 30 x 5/16"...................................................168
u-100 1 ml 30 x 1/2".....................................................168
u-100 1 ml 31 x 5/16"...................................................168
u-100 0.3 ml 31 x 5/16"................................................ 168
GLUCOSOURCE LANCET DEVICE -lancet devices..... 168
GLUCOSOURCE LANCETS -lancets............................. 168
246
GLUCOTROL -glipizide tab 5 mg..................................... 28

GLUCOTROL -glipizide tab 10 mg................................... 28
GLUCOTROL XL -glipizide tab sr 24hr 2.5 mg.................28
GLUCOTROL XL -glipizide tab sr 24hr 5 mg....................28
GLUCOTROL XL -glipizide tab sr 24hr 10 mg..................28
GLUCOVANCE -glyburide-metformin tab 1.25-250
mg.................................................................................... 28
GLUCOVANCE -glyburide-metformin tab 2.5-500 mg...... 28
GLUCOVANCE -glyburide-metformin tab 5-500 mg......... 28
GLYBURIDE -glyburide tab 1.25 mg................................. 28
GLYBURIDE -glyburide tab 2.5 mg................................... 28
GLYBURIDE -glyburide tab 5 mg...................................... 28
glyburide-metformin tab 1.25-250 mg
(Glucovance).................................................................. 28
glyburide-metformin tab 2.5-500 mg (Glucovance)..... 28
glyburide-metformin tab 5-500 mg (Glucovance)........ 28
glyburide micronized tab 1.5 mg (Glynase)..................28
glyburide micronized tab 3 mg (Glynase).....................28
glyburide micronized tab 6 mg (Glynase).....................28
glyburide tab 1.25 mg..................................................... 28
glyburide tab 2.5 mg....................................................... 28
glyburide tab 5 mg.......................................................... 28
glycopyrrolate tab 1 mg (Robinul)................................. 64
glycopyrrolate tab 2 mg (Robinul forte)........................64
GLYNASE -glyburide micronized tab 1.5 mg.................... 28
GLYNASE -glyburide micronized tab 3 mg....................... 28
GLYNASE -glyburide micronized tab 6 mg....................... 28
GLYSET -miglitol tab 25 mg.............................................. 28
GLYSET -miglitol tab 50 mg.............................................. 28
GLYSET -miglitol tab 100 mg............................................ 28
GLYXAMBI -empagliflozin-linagliptin tab 10-5 mg............ 28
GLYXAMBI -empagliflozin-linagliptin tab 25-5 mg............ 28
GMATE BLOOD GLUCOSE TEST -glucose blood test
strip................................................................................ 147
GMATE LANCETS 30G -lancets..................................... 168
GMATE LANCING DEVICE -lancet devices................... 168
GMATE ORIGIN BLOOD GLUCOS -blood glucose
GMATE SMART METER KIT -blood glucose monitoring
devices.......................................................................... 168
GMATE SMART STARTER KIT -blood glucose monitoring
kit w/ device.................................................................. 168
GMATE VOICE BLOOD GLUCOSE -blood glucose
GNP CLICKFINE PEN NEEDLE -insulin pen needle 31 g
x 8 mm (1/3" or 5/16").................................................. 168
GNP CLICKFINE UNIVERSAL P -insulin pen needle 31 g
x 6 mm (1/4")................................................................ 168
GNP CLICKFINE UNIVERSAL P -insulin pen needle 31 g
x 8 mm (1/3" or 5/16").................................................. 168
GNP INSULIN SYRINGE/1ML/2 -insulin syringe/needle
u-100 1 ml 28 x 1/2".....................................................169
u-100 1 ml 29 x 1/2".....................................................169
u-100 1 ml 30 x 5/16"...................................................169
2016
u-100 1 ml 31 x 5/16"...................................................169
GNP INSULIN SYRINGE/0.5ML -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 169
u-100 1/2 ml 28 x 1/2".................................................. 169
u-100 1/2 ml 29 x 1/2".................................................. 169
u-100 1/2 ml 30 x 5/16"................................................ 169
u-100 0.3 ml 29 x 1/2".................................................. 168
u-100 0.3 ml 30 x 5/16"................................................ 168
u-100 0.3 ml 31 x 5/16"................................................ 169
GNP LANCETS 21G -lancets..........................................169
GNP LANCETS -lancets.................................................. 169
GNP LANCETS MICRO THIN 33 -lancets......................169
GNP LANCETS SUPER THIN 30 -lancets..................... 169
GNP LANCETS THIN 26G -lancets................................ 169
GNP LANCETS THIN -lancets........................................ 169
GNP MICRO THIN LANCETS 33 -lancets......................169
GNP SUPER THIN LANCETS/30 -lancets..................... 169
GNP ULTRA COMFORT INSULIN -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 169
u-100 1/2 ml 28 x 1/2".................................................. 169
u-100 1/2 ml 29 x 1/2".................................................. 169
u-100 1/2 ml 30 x 5/16"................................................ 169
u-100 0.3 ml 29 x 1/2".................................................. 169
u-100 0.3 ml 30 x 5/16"................................................ 169
u-100 1 ml 28 x 1/2".....................................................169
u-100 1 ml 29 x 1/2".....................................................169
u-100 1 ml 30 x 5/16"...................................................169
u-100 1 ml 31 x 5/16"...................................................169
u-100 0.3 ml 31 x 5/16"................................................ 169
GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate for
soln 236 gm.................................................................... 63
GOLYTELY -peg 3350-kcl-na bicarb-nacl-na sulfate
packet 227.1 gm............................................................. 63
GORDOFILM -salicylic & lactic acids soln
16.7-16.7%.................................................................... 137
GRALISE -gabapentin (once-daily) tab 300 mg................87
GRALISE -gabapentin (once-daily) tab 600 mg................87
GRALISE STARTER -gabapentin (once-daily) tab pack
300 mg (9) & 600 mg (69)............................................. 87
granisetron hcl tab 1 mg................................................ 66
GRANIX -tbo-filgrastim soln prefilled syringe 300

mcg/0.5ml...................................................................... 120
GRANIX -tbo-filgrastim soln prefilled syringe 480
mcg/0.8ml...................................................................... 120
GRANULEX -trypsin w/ castor oil & peruvian balsam
spray.............................................................................. 137
GRIFULVIN V -griseofulvin microsize tab 500 mg.............. 6
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
GRIS-PEG -griseofulvin ultramicrosize tab 125 mg............ 6
GRIS-PEG -griseofulvin ultramicrosize tab 250 mg............ 6
guanfacine hcl tab 1 mg (Tenex)................................... 48
guanfacine hcl tab 2 mg (Tenex)................................... 48
guanfacine hcl tab sr 24hr 1 mg (base equiv)
(Intuniv).......................................................................... 84
(Intuniv).......................................................................... 84
(Intuniv).......................................................................... 84
(Intuniv).......................................................................... 84
GUANIDINE HCL -guanidine hcl tab 125 mg................. 110
GYNAZOLE-1 -butoconazole nitrate (one dose) vaginal
cream 2%........................................................................ 70
H
H&H THINLET LANCETS 26G -lancets......................... 169
H&H THINLET SUPER THIN LA -lancets.......................169
HAEMOLANCE -lancets.................................................. 170
HAEMOLANCE LOW FLOW LANCE -lancets................ 170
HAEMOLANCE PLUS HIGH FLOW -lancets................. 170
HAEMOLANCE PLUS -lancets....................................... 170
HAEMOLANCE PLUS LOW FLOW -lancets.................. 170
HAEMOLANCE PLUS MAX FLOW -lancets................... 170
HAEMOLANCE PLUS PEDIATRIC -lancets................... 170
HALCION -triazolam tab 0.25 mg..................................... 81
halobetasol propionate cream 0.05% (Ultravate)....... 137
halobetasol propionate oint 0.05% (Ultravate)........... 137
HALOG -halcinonide cream 0.1%................................... 137
HALOG -halcinonide oint 0.1%....................................... 137
haloperidol lactate oral conc 2 mg/ml...........................79
haloperidol tab 0.5 mg.................................................... 79
haloperidol tab 1 mg....................................................... 79
haloperidol tab 10 mg..................................................... 79
haloperidol tab 20 mg..................................................... 79
HALOTIN -haloprogin cream 1%.................................... 137
HARVONI -ledipasvir-sofosbuvir tab 90-400 mg................ 7
HAVRIX -hepatitis a vaccine inj susp 720 el
unit/0.5ml......................................................................... 14
HAVRIX -hepatitis a vaccine inj susp 1440 el unit/ml....... 14
HEALTH CARE LANCING DEVIC -lancet devices......... 170
HEALTHWISE LANCETS 30G -lancets.......................... 170
HEALTHWISE LANCING PEN -lancet devices.............. 170
247
2016
HEALTHWISE MINI PEN NEEDL -insulin pen needle 31 g
x 6 mm (1/4")................................................................ 170
HEALTHWISE PEN NEEDLES 29 -insulin pen needle 29
g x 12 mm (1/2")...........................................................170
HEALTHWISE SHORT PEN NEED -insulin pen needle 31
g x 8 mm (1/3" or 5/16")...............................................170
HEALTHWISE UNIFINE PENTIP -insulin pen needle 32 g
x 4 mm (5/32").............................................................. 170
HEALTHY ACCENTS AUTOLET I -lancet devices......... 170
HEALTHY ACCENTS UNIFINE P -insulin pen needle 29 g
x 12 mm (1/2").............................................................. 170
x 5 mm (3/16").............................................................. 170
x 6 mm (1/4")................................................................ 170
x 4 mm (5/32").............................................................. 170
x 8 mm (1/3" or 5/16").................................................. 170
HEALTHY ACCENTS UNILET LA -lancets..................... 170
H-E-B INCONTROL ADVANCED -lancet devices.......... 170
H-E-B INCONTROL LANCETS S -lancets..................... 170
H-E-B INCONTROL LANCETS U -lancets..................... 170
H-E-B IN CONTROL PEN NEED -insulin pen needle 31 g
x 5 mm (3/16").............................................................. 169
x 6 mm (1/4")................................................................ 169
x 4 mm (5/32").............................................................. 170
x 8 mm (1/3" or 5/16").................................................. 169
H-E-B INCONTROL PEN NEEDL -insulin pen needle 29
g x 12 mm (1/2")...........................................................170
HECTOROL -doxercalciferol cap 0.5 mcg........................ 35
HECTOROL -doxercalciferol cap 1 mcg........................... 35
HECTOROL -doxercalciferol cap 2.5 mcg........................ 35
HELIXATE FS -antihemophilic factor (recombinant) for inj
kit 250 unit.................................................................... 124
kit 500 unit.................................................................... 124
kit 1000 unit.................................................................. 124
kit 2000 unit.................................................................. 124
kit 3000 unit.................................................................. 124
HEMANGEOL -propranolol hcl oral soln 4.28 mg/ml........ 39
HEMENATAL OB + DHA -prenat-fe poly cmplx-fe heme
poly-fa tab & omega 3 cap pck.................................... 111
HEMENATAL OB -prenat vit-fe poly cmplx-fe heme polyfa tab 28-6-1 mg........................................................... 111
HEMOFIL M -antihemophilic factor (human) for inj 250
unit................................................................................. 124
unit................................................................................. 124
unit................................................................................. 124
248

unit................................................................................. 124
HEMOFIL M -antihemophilic factor (human) for inj
220-400 unit.................................................................. 124
401-800 unit.................................................................. 124
801-1500 unit................................................................ 124
1501-2000 unit.............................................................. 124
heparin sodium (porcine) inj 5000 unit/ml.................. 122
HEPSERA -adefovir dipivoxil tab 10 mg............................. 7
HETLIOZ -tasimelteon capsule 20 mg.............................. 81
HEXALEN -altretamine cap 50 mg................................... 17
HIBERIX -haemophilus b polysaccharide conjugate vac
for inj 10 mcg.................................................................. 14
HIPREX -methenamine hippurate tab 1 gm......................69
HIZENTRA -immune globulin (human) subcutaneous inj 1
gm/5ml............................................................................. 16
gm/10ml........................................................................... 16
gm/20ml........................................................................... 16
HIZENTRA -immune globulin (human) subcutaneous inj
10 gm/50ml..................................................................... 16
HM LANCETS MICRO THIN 33G -lancets..................... 170
HM LANCETS ULTRA THIN 30G -lancets..................... 170
homatropine hbr ophth soln 5% (Isopto
homatropine)............................................................... 128
HORIZANT -gabapentin enacarbil tab cr 300 mg............. 87
HORIZANT -gabapentin enacarbil tab cr 600 mg............. 87
H.P. ACTHAR -corticotropin inj gel 80 unit/ml................... 35
HUBER NEEDLE/22GX1-1/4"/4 -needle (disp) 22 x
1-1/4"............................................................................. 171
HUBER NEEDLE/19GX3/4"/RIG -needle (disp) 19 x
3/4".................................................................................171
HUBER NEEDLE/20G X 1-1/4" -needle (disp) 20 x
1-1/4"............................................................................. 171
HUBER NEEDLE/RIGHT ANGLE -needle (disp) 20 x
1-1/2"............................................................................. 170
3/4".................................................................................170
1-1/2"............................................................................. 170
1".................................................................................... 170
1".................................................................................... 170
1".................................................................................... 170
HUBER NEEDLE/STRAIGHT 19G -needle (disp) 19 x
1-1/4"............................................................................. 170
1-1/2"............................................................................. 171
1-1/2"............................................................................. 171
2016
1".................................................................................... 170
1".................................................................................... 171
HUBER NEEDLE 20GX3/4"/R -needle (disp) 20 x
3/4".................................................................................170
HUMATE-P -antihemophilic factor/vwf (human) for inj
250-600 unit.................................................................. 124
500-1200 unit................................................................ 124
1000-2400 unit.............................................................. 124
HUMATROPE COMBO PACK -somatropin for inj 5
mg.................................................................................... 35
HUMATROPE -somatropin for inj 5 mg............................ 35
HUMATROPE -somatropin for inj 24 mg.......................... 35
HUMATROPE -somatropin for inj 6 mg (18 unit).............. 35
HUMATROPE -somatropin for inj 12 mg (36 unit)............ 35
HUMIRA -adalimumab prefilled syringe kit 10
mg/0.2ml.......................................................................... 98
mg/0.4ml.......................................................................... 98
mg/0.8ml.......................................................................... 98
HUMIRA PEDIATRIC CROHNS D -adalimumab prefilled
syringe kit 40 mg/0.8ml.................................................. 98
HUMIRA PEN -adalimumab pen-injector kit 40
mg/0.8ml.......................................................................... 98
HUMIRA PEN-CROHNS DISEASE -adalimumab peninjector kit 40 mg/0.8ml.................................................. 98
HUMIRA PEN-PSORIASIS STAR -adalimumab peninjector kit 40 mg/0.8ml.................................................. 98
HUMULIN R U-500 (CONCENTR -insulin regular (human)
inj 500 unit/ml..................................................................31
HYCAMTIN -topotecan hcl cap 0.25 mg (base equiv)...... 17
HYCAMTIN -topotecan hcl cap 1 mg (base equiv)........... 17
hydralazine hcl tab 10 mg.............................................. 48
hydralazine hcl tab 100 mg............................................ 48
HYDREA -hydroxyurea cap 500 mg................................. 17
hydrochlorothiazide cap 12.5 mg (Microzide).............. 52
hydrochlorothiazide tab 12.5 mg................................... 52
hydrochlorothiazide tab 25 mg...................................... 52
hydrochlorothiazide tab 50 mg...................................... 52
HYDROCODONE/ACETAMINOPHEN -hydrocodoneacetaminophen soln 10-325 mg/15ml............................ 92
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
(Hycet).............................................................................92
hydrocodone-acetaminophen tab 2.5-325 mg.............. 92
hydrocodone-acetaminophen tab 7.5-325 mg
(Norco)............................................................................ 92
hydrocodone-acetaminophen tab 5-325 mg
(Norco)............................................................................ 92
(Norco)............................................................................ 92
hydrocodone-acetaminophen tab 7.5-300 mg

(Xodol)............................................................................ 92
(Xodol)............................................................................ 92
(Xodol)............................................................................ 92
hydrocodone-ibuprofen tab 10-200 mg (Ibudone)....... 92
hydrocodone-ibuprofen tab 2.5-200 mg
(Reprexain)..................................................................... 92
hydrocodone-ibuprofen tab 5-200 mg (Reprexain)......92
hydrocodone-ibuprofen tab 7.5-200 mg
(Vicoprofen)................................................................... 92
hydrocodone w/ homatropine syrup 5-1.5 mg/5ml...... 59
hydrocodone w/ homatropine tab 5-1.5 mg..................59
hydrocod polst-chlorphen polst cr susp 10-8 mg/5ml
(Tussionex pennkineti)................................................. 59
hydrocortisone acetate suppos 25 mg (Anusolhc)................................................................................. 132
hydrocortisone acetate suppos 30 mg
(Proctocort).................................................................. 132
hydrocortisone acetate w/ pramoxine rectal cream
1-1% (Analpram-hc).................................................... 132
hydrocortisone acetate w/ pramoxine rectal cream
2.5-1% (Analpram-hc)................................................. 132
hydrocortisone butyrate cream 0.1% (Locoid)...........137
hydrocortisone butyrate hydrophilic lipo base cream
0.1% (Locoid lipocream)............................................ 137
hydrocortisone butyrate oint 0.1% (Locoid)............... 137
hydrocortisone butyrate soln 0.1% (Locoid).............. 137
hydrocortisone cream 1%.............................................137
hydrocortisone cream 2.5%..........................................137
hydrocortisone enema 100 mg/60ml
(Cortenema)................................................................. 132
hydrocortisone lotion 2.5%.......................................... 137
hydrocortisone lotion 2% (Ala scalp).......................... 137
hydrocortisone oint 1%................................................. 137
hydrocortisone oint 2.5%..............................................137
hydrocortisone rectal cream 2.5% (Anusol-hc)......... 132
hydrocortisone rectal cream 1% (Proctocort)............ 132
hydrocortisone tab 5 mg (Cortef).................................. 20
hydrocortisone tab 10 mg (Cortef)................................ 20
hydrocortisone tab 20 mg (Cortef)................................ 20
hydrocortisone valerate cream 0.2%...........................137
hydrocortisone valerate oint 0.2% (Westcort)............ 137
hydrocortisone w/ acetic acid otic soln 1-2%............ 131
HYDROMORPHONE HCL ER -hydromorphone hcl tab er
24hr deter 32 mg............................................................ 92
HYDROMORPHONE HCL -hydromorphone hcl suppos 3
mg.................................................................................... 92
hydromorphone hcl liqd 1 mg/ml (Dilaudid).................92
hydromorphone hcl tab er 24hr deter 8 mg
(Exalgo).......................................................................... 93
(Exalgo).......................................................................... 93
(Exalgo).......................................................................... 93
hydromorphone hcl tab 2 mg (Dilaudid)....................... 93
249
2016
HYDRO 35 -urea in lactic acid vehicle foam 35%.......... 137
hydroxychloroquine sulfate tab 200 mg
(Plaquenil)...................................................................... 11
hydroxyurea cap 500 mg (Hydrea)................................ 17
hydroxyzine hcl syrup 10 mg/5ml................................. 72
hydroxyzine hcl tab 10 mg............................................. 72
hydroxyzine pamoate cap 25 mg (Vistaril)................... 72
hydroxyzine pamoate cap 50 mg (Vistaril)................... 72
HYDROXYZINE PAMOATE -hydroxyzine pamoate cap
100 mg............................................................................ 72
hyoscyamine sulfate elixir 0.125 mg/5ml...................... 64
hyoscyamine sulfate soln 0.125 mg/ml......................... 64
hyoscyamine sulfate tab disp 0.125 mg (Anaspaz)..... 64
hyoscyamine sulfate tab 0.125 mg (Levsin)................. 64
hyoscyamine sulfate tab sl 0.125 mg (Levsin/sl)......... 64
hyoscyamine sulfate tab sr 12hr 0.375 mg
(Levbid)........................................................................... 64
HYPERSAL -sodium chloride soln nebu 3.5%..................59
HYPER-SAL -sodium chloride soln nebu 7%................... 59
HYPERSAL -sodium chloride soln nebu 7%.....................59
HYPODERMIC NEEDLE 20GX3/4 -needle (disp) 20 x
3/4".................................................................................171
3/4".................................................................................171
3/4".................................................................................171
3/4".................................................................................171
5/8".................................................................................171
1/2".................................................................................171
3/8".................................................................................171
5/8".................................................................................171
1/2".................................................................................171
1/2".................................................................................171
HYPODERMIC NEEDLE 21GX1" -needle (disp) 21 x
1".................................................................................... 171
1".................................................................................... 171
1".................................................................................... 171
1".................................................................................... 171
HYPODERMIC NEEDLE 21GX1-1 -needle (disp) 21 x
1-1/4"............................................................................. 171
1-1/2"............................................................................. 171
250

1-1/4"............................................................................. 171
1-1/2"............................................................................. 171
1-1/2"............................................................................. 171
1-1/4"............................................................................. 171
1-1/2"............................................................................. 171
HYPODERMIC NEEDLE 16G X 1 -needle (disp) 16 x
1-1/2"............................................................................. 171
1-1/2"............................................................................. 171
1-1/2"............................................................................. 171
1-1/2"............................................................................. 171
1".................................................................................... 171
1".................................................................................... 171
1".................................................................................... 171
1".................................................................................... 171
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
unt/5 ml kit...................................................................... 16
unt/10 ml kit.................................................................... 16
unt/15 ml kit.................................................................... 16
HY-VEE LANCETS -lancets............................................ 171
HY-VEE THIN LANCETS -lancets.................................. 171
HYZAAR -losartan potassium & hydrochlorothiazide tab
50-12.5 mg...................................................................... 48
100-12.5 mg.................................................................... 48
100-25 mg....................................................................... 48
I
ibandronate sodium tab 150 mg (base equivalent)
(Boniva).......................................................................... 35
IBG STAR BLOOD GLUCOSE MO -blood glucose
IBRANCE -palbociclib cap 75 mg..................................... 17
IBRANCE -palbociclib cap 100 mg................................... 17
IBRANCE -palbociclib cap 125 mg................................... 17
ibuprofen susp 100 mg/5ml............................................ 98
ibuprofen tab 400 mg...................................................... 98
ibuprofen tab 600 mg...................................................... 98
ibuprofen tab 800 mg...................................................... 98
2016
ICLUSIG -ponatinib hcl tab 15 mg (base equiv)............... 17
ICLUSIG -ponatinib hcl tab 45 mg (base equiv)............... 17
ILEVRO -nepafenac ophth susp 0.3%............................ 128
IMBRUVICA -ibrutinib cap 140 mg................................... 17
imipramine hcl tab 10 mg (Tofranil).............................. 74
imipramine pamoate cap 75 mg (Tofranil-pm)............. 75
imipramine pamoate cap 100 mg (Tofranil-pm)........... 75
imiquimod cream 5% (Aldara)...................................... 137
IMITREX STATDOSE REFILL -sumatriptan succinate
solution cartridge 4 mg/0.5ml....................................... 100
IMITREX STATDOSE REFILL -sumatriptan succinate
solution cartridge 6 mg/0.5ml....................................... 100
IMITREX STATDOSE SYSTEM -sumatriptan succinate
solution auto-injector 4 mg/0.5ml................................. 100
IMITREX STATDOSE SYSTEM -sumatriptan succinate
solution auto-injector 6 mg/0.5ml................................. 100
IMITREX -sumatriptan nasal spray 5 mg/act.................. 100
IMITREX -sumatriptan nasal spray 20 mg/act................ 100
IMITREX -sumatriptan succinate inj 6 mg/0.5ml............. 100
IMITREX -sumatriptan succinate tab 25 mg................... 100
IMITREX -sumatriptan succinate tab 50 mg................... 100
IMITREX -sumatriptan succinate tab 100 mg................. 100
IMURAN -azathioprine tab 50 mg................................... 204
INATAL ADVANCE -prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg...................................................................111
INATAL GT -prenatal vit w/ dss-iron carbonyl-fa tab 90-1
mg.................................................................................. 111
INATAL ULTRA -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg......................................................................... 111
INCRELEX -mecasermin inj 40 mg/4ml (10 mg/ml)..........35
INCRUSE ELLIPTA -umeclidinium br aero powd breath
act 62.5 mcg/inh (base eq)............................................ 61
indapamide tab 1.25 mg..................................................52
indapamide tab 2.5 mg.................................................... 52
INDERAL LA -propranolol hcl cap sr 24hr 60 mg............. 39
INDERAL LA -propranolol hcl cap sr 24hr 80 mg............. 39
INDERAL LA -propranolol hcl cap sr 24hr 120 mg........... 39
INDERAL LA -propranolol hcl cap sr 24hr 160 mg........... 39
INDERAL XL -propranolol hcl sustained-release beads
cap sr 24hr 80 mg.......................................................... 39
INDERAL XL -propranolol hcl sustained-release beads
cap sr 24hr 120 mg........................................................ 39
INDOCIN -indomethacin suppos 50 mg............................ 98
INDOCIN -indomethacin susp 25 mg/5ml......................... 98
indomethacin cap cr 75 mg............................................ 98
indomethacin cap 25 mg................................................ 98
indomethacin cap 50 mg................................................ 98
INFANATE BALANCE -prenatal w/o a w/fe cbn-dss-fa-dha
cap 29-1-265 mg.......................................................... 111
INFANATE PLUS -prenat w/o a w/fe fum-fe cbn-dss-fadha cap 27-1-260 mg................................................... 111
INFANRIX -diph, acellular pert & tet tox inj 25 lf-58
mcg-10 lf/0.5ml............................................................... 15
INFINITY BLOOD GLUCOSE MO -blood glucose

INFINITY BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 147
INLYTA -axitinib tab 1 mg.................................................. 17
INLYTA -axitinib tab 5 mg.................................................. 17
INNOPRAN XL -propranolol hcl sustained-release beads
cap sr 24hr 80 mg.......................................................... 39
INNOPRAN XL -propranolol hcl sustained-release beads
cap sr 24hr 120 mg........................................................ 39
INSPRA -eplerenone tab 25 mg....................................... 48
INSPRA -eplerenone tab 50 mg....................................... 48
INSULIN SYRINGE/0.5ML/27G -insulin syringe/needle
u-100 1/2 ml 27 x 1/2".................................................. 172
u-100 1/2 ml 28 x 1/2".................................................. 172
u-100 1/2 ml 29 x 1/2".................................................. 172
u-100 1/2 ml 30 x 5/16"................................................ 172
u-100 1/2 ml 30 x 1/2".................................................. 172
u-100 1/2 ml 31 x 5/16"................................................ 172
u-100 0.3 ml 29 x 1/2".................................................. 172
u-100 0.3 ml 30 x 5/16"................................................ 172
u-100 0.3 ml 31 x 5/16"................................................ 172
u-100 0.3 ml 29 x 1".....................................................172
INSULIN SYRINGE/1ML/28G X -insulin syringe/needle
u-100 1 ml 28 x 1/2".....................................................172
u-100 1 ml 29 x 1/2".....................................................172
u-100 1 ml 30 x 5/16"...................................................172
u-100 1 ml 31 x 5/16"...................................................172
INSULIN SYRINGE/U-100/0.5 -insulin syringe/needle
u-100 1/2 ml 28 x 1/2".................................................. 172
u-100 1/2 ml 29 x 1/2".................................................. 172
u-100 0.3 ml 29 x 1/2".................................................. 172
INSULIN SYRINGE/U-100/1ML -insulin syringe/needle
u-100 1 ml 28 x 1/2".....................................................172
u-100 1 ml 29 x 1/2".....................................................172
u-100 1 ml 30 x 5/16"...................................................172
u-100 1 ml 31 x 5/16"...................................................172
INSUL-TOTE -blood glucose monitoring supplies.......... 172
INSUL-TOTE JR -blood glucose monitoring supplies..... 172
251
2016
INSUPEN 33GX4MM -insulin pen needle 33 g x 4 mm
(5/32")............................................................................ 173
INSUPEN PEN NEEDLES 32G X -insulin pen needle 32
g x 4 mm (5/32")...........................................................172
INSUPEN SENSITIVE 32GX8MM -insulin pen needle 32
g x 8 mm....................................................................... 172
INSUPEN SENSITIVE 32GX6MM -insulin pen needle 32
g x 6 mm (1/4").............................................................172
INSUPEN ULTRAFIN 29GX12MM -insulin pen needle 29
g x 12 mm (1/2")...........................................................172
INSUPEN ULTRAFIN 31GX6MM -insulin pen needle 31 g
x 6 mm (1/4")................................................................ 173
x 8 mm (1/3" or 5/16").................................................. 173
x 8 mm (1/3" or 5/16").................................................. 173
INTEGRA F -fe fum-fe poly-fa-c-b3 cap
62.5-62.5-1-40-3mg(125 mg fe)................................... 120
INTELENCE -etravirine tab 25 mg...................................... 7
INTELENCE -etravirine tab 100 mg.................................... 7
INTELENCE -etravirine tab 200 mg.................................... 7
IN TOUCH -blood glucose monitoring devices............... 171
IN TOUCH BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 147
IN TOUCH DIABETES MANAGEM -blood glucose
monitoring misc............................................................. 171
IN TOUCH LANCING DEVICE -lancet devices.............. 171
IN TOUCH STERILE LANCETS -lancets........................172
INTRON A -interferon alfa-2b for inj 10000000 unit.......... 17
INTRON A -interferon alfa-2b inj 6000000 unit/ml............ 17
INTRON A -interferon alfa-2b inj 10000000 unit/ml.......... 17
INTRON A W/DILUENT -interferon alfa-2b for inj
10000000 unit................................................................. 17
18000000 unit................................................................. 18
50000000 unit................................................................. 18
INTUNIV -guanfacine hcl tab sr 24hr 1 mg (base
equiv)............................................................................... 84
equiv)............................................................................... 84
equiv)............................................................................... 84
equiv)............................................................................... 84
INVEGA -paliperidone tab sr 24hr 1.5 mg........................ 79
INVEGA -paliperidone tab sr 24hr 3 mg........................... 79
INVIRASE -saquinavir mesylate cap 200 mg..................... 7
INVIRASE -saquinavir mesylate tab 500 mg...................... 7
INVOKAMET -canagliflozin-metformin hcl tab 50-500
mg.................................................................................... 28
mg.................................................................................... 28
252

mg.................................................................................... 28
mg.................................................................................... 28
INVOKANA -canagliflozin tab 100 mg.............................. 29
INVOKANA -canagliflozin tab 300 mg.............................. 29
iodoquinol-hc cream 1%............................................... 137
iodoquinol-hydrocortisone in aloe vehicle cream
1-1.9% (Vytone)........................................................... 138
IOPIDINE -apraclonidine hcl ophth soln 0.5% (base
equivalent)..................................................................... 128
IOPIDINE -apraclonidine hcl ophth soln 1% (base
equivalent)..................................................................... 128
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml..... 61
ipratropium bromide inhal soln 0.02%.......................... 61
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
(Atrovent)....................................................................... 58
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
(Atrovent)....................................................................... 58
irbesartan-hydrochlorothiazide tab 150-12.5 mg
(Avalide)..........................................................................48
irbesartan-hydrochlorothiazide tab 300-12.5 mg
(Avalide)..........................................................................48
irbesartan tab 75 mg (Avapro)....................................... 48
irbesartan tab 150 mg (Avapro)..................................... 48
irbesartan tab 300 mg (Avapro)..................................... 48
IRESSA -gefitinib tab 250 mg........................................... 18
irrigation solution, physiological................................. 204
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
isometheptene-caffeine-acetaminophen tab 65-20-325
mg (Prodrin)................................................................ 100
ISONIAZID -isoniazid syrup 50 mg/5ml.............................. 5
isoniazid tab 100 mg......................................................... 5
isoniazid tab 300 mg......................................................... 5
ISOPTIN SR -verapamil hcl tab cr 120 mg....................... 42
ISOPTO CARBACHOL -carbachol ophth soln 1.5%...... 128
ISOPTO CARBACHOL -carbachol ophth soln 3%......... 128
ISOPTO CARPINE -pilocarpine hcl ophth soln 1%........ 128
ISOPTO HOMATROPINE -homatropine hbr ophth soln
2%.................................................................................. 128
ISOPTO HOMATROPINE -homatropine hbr ophth soln
5%.................................................................................. 128
ISOPTO HYOSCINE -scopolamine hbr ophth soln
0.25%.............................................................................128
ISORDIL TITRADOSE -isosorbide dinitrate tab 5 mg.......37
2016
ISORDIL TITRADOSE -isosorbide dinitrate tab 40
mg.................................................................................... 37
ISOSORBIDE DINITRATE ER -isosorbide dinitrate tab cr
40 mg.............................................................................. 37
ISOSORBIDE DINITRATE -isosorbide dinitrate tab 30
mg.................................................................................... 37
isosorbide dinitrate tab 10 mg....................................... 38
isosorbide dinitrate tab 20 mg....................................... 38
isosorbide dinitrate tab 5 mg (Isordil titradose).......... 38
isosorbide mononitrate tab 10 mg................................ 38
isosorbide mononitrate tab 20 mg................................ 38
isosorbide mononitrate tab sr 24hr 30 mg................... 38
isosorbide mononitrate tab sr 24hr 60 mg................... 38
isosorbide mononitrate tab sr 24hr 120 mg................. 38
isotretinoin cap 10 mg.................................................. 138
ISOXSUPRINE HCL -isoxsuprine hcl tab 20 mg.............. 57
isoxsuprine hcl tab 10 mg.............................................. 57
isradipine cap 2.5 mg...................................................... 42
isradipine cap 5 mg......................................................... 42
ISTALOL -timolol maleate ophth soln 0.5% (oncedaily).............................................................................. 128
itraconazole cap 100 mg (Sporanox).............................. 6
ivermectin tab 3 mg (Stromectol).................................. 11
IXINITY -coagulation factor ix (recombinant) for inj 500
unit................................................................................. 124
unit................................................................................. 124
unit................................................................................. 124
J
JADENU -deferasirox tab 90 mg..................................... 143
JADENU -deferasirox tab 180 mg................................... 143
JADENU -deferasirox tab 360 mg................................... 143
JAKAFI -ruxolitinib phosphate tab 5 mg (base
equivalent)....................................................................... 18
equivalent)....................................................................... 18
equivalent)....................................................................... 18
equivalent)....................................................................... 18
equivalent)....................................................................... 18
JALYN -dutasteride-tamsulosin hcl cap 0.5-0.4 mg.......... 71
JANUMET -sitagliptin-metformin hcl tab 50-500 mg......... 29
JANUMET -sitagliptin-metformin hcl tab 50-1000 mg....... 29
JANUMET XR -sitagliptin-metformin hcl tab sr 24hr
50-500 mg....................................................................... 29
50-1000 mg..................................................................... 29
100-1000 mg................................................................... 29
JANUVIA -sitagliptin phosphate tab 25 mg (base

equiv)............................................................................... 29
equiv)............................................................................... 29
equiv)............................................................................... 29
JARDIANCE -empagliflozin tab 10 mg............................. 29
JARDIANCE -empagliflozin tab 25 mg............................. 29
JENTADUETO -linagliptin-metformin hcl tab 2.5-1000
mg.................................................................................... 29
mg.................................................................................... 29
mg.................................................................................... 29
JUXTAPID -lomitapide mesylate cap 5 mg (base
equiv)............................................................................... 54
equiv)............................................................................... 54
equiv)............................................................................... 55
equiv)............................................................................... 55
equiv)............................................................................... 55
equiv)............................................................................... 55
K
KADIAN -morphine sulfate cap sr 24hr 10 mg..................93
KADIAN -morphine sulfate cap sr 24hr 100 mg................93
KADIAN -morphine sulfate cap sr 24hr 200 mg................93
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................................ 63
KALYDECO -ivacaftor packet 75 mg................................ 63
KALYDECO -ivacaftor tab 150 mg.................................... 63
KAPVAY -clonidine hcl tab sr 12hr 0.1 mg........................ 84
KAYEXALATE -sodium polystyrene sulfonate
powder........................................................................... 204
KAZANO -alogliptin-metformin hcl tab 12.5-1000 mg....... 29
KAZANO -alogliptin-metformin hcl tab 12.5-500 mg......... 29
KEFLEX -cephalexin cap 250 mg....................................... 2
KENALOG -triamcinolone acetonide aerosol soln 0.147
mg/gm............................................................................ 138
KEPPRA -levetiracetam oral soln 100 mg/ml................. 103
KEPPRA -levetiracetam tab 250 mg............................... 103
253
2016
KEPPRA -levetiracetam tab 1000 mg............................. 103
KEPPRA XR -levetiracetam tab sr 24hr 500 mg............ 103
KEPPRA XR -levetiracetam tab sr 24hr 750 mg............ 103
KERALYT -salicylic acid gel 6%...................................... 138
KERLONE -betaxolol hcl tab 10 mg................................. 39
KERLONE -betaxolol hcl tab 20 mg................................. 39
KETEK -telithromycin tab 300 mg..................................... 12
KETEK -telithromycin tab 400 mg..................................... 12
KETOCARE -acetone (urine) test strip........................... 147
ketoconazole cream 2%................................................ 138
ketoconazole foam 2% (Extina)................................... 138
ketoconazole shampoo 2% (Nizoral)........................... 138
ketoconazole tab 200 mg.................................................. 6
KETONE TEST STRIPS -acetone (urine) test strip........ 147
ketoprofen cap 50 mg..................................................... 98
ketoprofen cap 75 mg..................................................... 98
KETOPROFEN ER -ketoprofen cap sr 24hr 200 mg........ 98
ketorolac tromethamine ophth soln 0.5%
(Acular)......................................................................... 128
ketorolac tromethamine ophth soln 0.4% (Acular
ls)................................................................................... 128
ketorolac tromethamine tab 10 mg............................... 98
KETOSTIX -acetone (urine) test strip............................. 147
KEVEYIS -dichlorphenamide tab 50 mg........................... 52
KHEDEZLA -desvenlafaxine tab sr 24hr 50 mg............... 75
KHEDEZLA -desvenlafaxine tab sr 24hr 100 mg............. 75
KINERET -anakinra subcutaneous soln prefilled syringe
100 mg/0.67ml................................................................ 98
KINNEY LANCETS -lancets............................................ 173
KINNEY THIN LANCETS -lancets.................................. 173
KINRAY INSULIN SYRINGE/0. -insulin syringe/needle
u-100 1/2 ml 29 x 1/2".................................................. 173
KINRAY INSULIN SYRINGE PR -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 173
u-100 1 ml 31 x 5/16"...................................................173
u-100 0.3 ml 31 x 5/16"................................................ 173
KINRIX -diph-tetanus tox ad-acell pert & polio virus, ipv
vac inj.............................................................................. 15
KITABIS PAK -tobramycin nebu soln 300 mg/5ml.............. 5
KLARON -sulfacetamide sodium lotion 10% (acne)....... 138
KLOR-CON/25 -potassium chloride powder packet 25
meq................................................................................ 118
KLOR-CON M15 -potassium chloride microencapsulated
crys cr tab 15 meq....................................................... 118
KLOR-CON 25 -potassium chloride powder packet 25
meq................................................................................ 118
KMART VALU PLUS INSULIN S -insulin syringe (disp)
u-100 1/2 ml.................................................................. 173
u-100 0.3 ml.................................................................. 173
u-100 1 ml..................................................................... 173
KOATE-DVI -antihemophilic factor (human) for inj 250
unit................................................................................. 124
254

unit................................................................................. 124
unit................................................................................. 124
KOGENATE FS -antihemophilic factor (recombinant) for
inj kit 250 unit............................................................... 124
inj kit 500 unit............................................................... 124
inj kit 1000 unit............................................................. 124
inj kit 2000 unit............................................................. 124
inj kit 3000 unit............................................................. 124
KOGENATE FS BIO-SET -antihemophilic factor
(recombinant) for inj kit 250 unit.................................. 124
(recombinant) for inj kit 500 unit.................................. 125
(recombinant) for inj kit 1000 unit................................ 125
KOMBIGLYZE XR -saxagliptin-metformin hcl tab sr 24hr
2.5-1000 mg.................................................................... 29
5-500 mg......................................................................... 29
5-1000 mg....................................................................... 29
KORLYM -mifepristone tab 300 mg.................................. 29
K-PHOS NEUTRAL -pot phos monobasic w/sod phos di &
monobas tab 155-852-130mg...................................... 118
K-PHOS NO 2 -potassium & sodium acid phosphates tab
305-700 mg..................................................................... 71
K-PHOS -potassium phosphate monobasic tab 500
mg.................................................................................. 118
KRISTALOSE -lactulose oral crystal packet 10 gm.......... 63
KRISTALOSE -lactulose oral crystal packet 20 gm.......... 63
KROGER BLOOD GLUCOSE MONI -blood glucose
KROGER BLOOD GLUCOSE TEST -glucose blood test
strip................................................................................ 147
KROGER INSULIN SYRINGE/0. -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 173
u-100 1/2 ml 29 x 1/2".................................................. 173
u-100 1/2 ml 30 x 5/16"................................................ 173
u-100 0.3 ml 29 x 1/2".................................................. 173
u-100 0.3 ml 30 x 5/16"................................................ 173
u-100 0.3 ml 31 x 5/16"................................................ 173
KROGER INSULIN SYRINGE/1M -insulin syringe/needle
u-100 1 ml 29 x 1/2".....................................................173
2016
u-100 1 ml 30 x 5/16"...................................................173
u-100 1 ml 31 x 5/16"...................................................173
KROGER INSULIN SYRINGE/U- -insulin syringe/needle
u-100 0.3 ml 30 x 1/2".................................................. 173
KROGER LANCETS 21G -lancets.................................. 173
KROGER LANCETS -lancets.......................................... 173
KROGER LANCETS MICRO THIN -lancets................... 173
KROGER LANCETS SUPER THIN -lancets.................. 173
KROGER LANCETS THIN 26G -lancets........................ 173
KROGER LANCETS THIN -lancets................................ 173
KROGER LANCETS ULTRATHIN -lancets..................... 173
KROGER LANCING DEVICE -lancet devices................ 173
KROGER PEN NEEDLES 31GX1/ -insulin pen needle 31
g x 6 mm (1/4").............................................................174
KROGER PEN NEEDLES 29G X -insulin pen needle 29 g
x 12 mm (1/2").............................................................. 173
KROGER PEN NEEDLES 31G X -insulin pen needle 31 g
x 8 mm (1/3" or 5/16").................................................. 174
KROGER PREMIUM BLOOD GLUC -blood glucose
KROGER PREMIUM BLOOD GLUC -glucose blood test
strip................................................................................ 147
KROGER TEST STRIPS -glucose blood test strip......... 147
K-TAB -potassium chloride tab cr 10 meq...................... 118
K-TAB -potassium chloride tab cr 8 meq (600 mg)......... 118
K-TAB -potassium chloride tab cr 20 meq (1500 mg)..... 118
KUVAN -sapropterin dihydrochloride powder packet 100
mg.................................................................................... 35
KUVAN -sapropterin dihydrochloride powder packet 500
mg.................................................................................... 35
KUVAN -sapropterin dihydrochloride soluble tab 100
mg.................................................................................... 35
KYNAMRO -mipomersen sodium soln prefilled syringe
200 mg/ml....................................................................... 55
L
labetalol hcl tab 100 mg (Trandate)............................... 39
LAC-HYDRIN -lactic acid (ammonium lactate) cream
12%................................................................................138
LAC-HYDRIN -lactic acid (ammonium lactate) lotion
12%................................................................................138
LACRISERT -artificial tear ophth insert...........................128
lactated ringer's for irrigation...................................... 204
lactic acid (ammonium lactate) cream 12% (Lachydrin).......................................................................... 138
lactic acid (ammonium lactate) lotion 12% (Lachydrin).......................................................................... 138
lactulose (encephalopathy) solution 10 gm/15ml........ 68
lactulose solution 10 gm/15ml....................................... 63
LAMICTAL CHEWABLE DISPERS -lamotrigine tab
chewable dispersible 5 mg........................................... 103
LAMICTAL CHEWABLE DISPERS -lamotrigine tab
chewable dispersible 25 mg......................................... 103
LAMICTAL -lamotrigine tab 25 mg.................................. 103

LAMICTAL -lamotrigine tab 100 mg................................ 103
LAMICTAL ODT -lamotrigine orally disintegrating tab 25
mg.................................................................................. 103
mg.................................................................................. 103
mg.................................................................................. 103
mg.................................................................................. 103
LAMICTAL ODT -lamotrigine tab disp 25 (14) & 50 mg
(14) & 100 mg (7) kit.................................................... 103
LAMICTAL ODT -lamotrigine tab disp 25 mg (21) & 50 mg
(7) titration kit................................................................ 103
LAMICTAL ODT -lamotrigine tab disp 50 mg (42) & 100
mg (14) titration kit....................................................... 103
LAMICTAL STARTER/NOT TAKI -lamotrigine tab 25 mg
(42) & 100 mg (7) starter kit.........................................103
LAMICTAL STARTER/TAKING C -lamotrigine tab 25 mg
(84) & 100 mg (14) starter kit.......................................103
LAMICTAL STARTER/TAKING V -lamotrigine tab 25 mg
(35) starter kit............................................................... 103
LAMICTAL XR -lamotrigine tab sr 24hr 25 (14) & 50 mg
(14) & 100 mg(7) kit..................................................... 103
LAMICTAL XR -lamotrigine tab sr 24hr 50 (14) & 100
mg(14) & 200 mg(7) kit................................................ 104
LAMICTAL XR -lamotrigine tab sr 24hr 25 mg............... 104
LAMICTAL XR -lamotrigine tab sr 24hr 50 mg............... 104
LAMICTAL XR -lamotrigine tab sr 24hr 100 mg............. 104
LAMICTAL XR -lamotrigine tab sr 24hr 25 mg (21) & 50
mg (7) titration kit......................................................... 103
LAMISIL SPRAY -terbinafine hcl soln 1%....................... 138
LAMISIL -terbinafine hcl oral granules packet 125 mg....... 6
LAMISIL -terbinafine hcl oral granules packet 187.5
mg...................................................................................... 6
LAMISIL -terbinafine hcl tab 250 mg.................................. 6
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)................................................................................ 104
odt)................................................................................ 104
odt)................................................................................ 104
odt)................................................................................ 104
lamotrigine tab chewable dispersible 5 mg (Lamictal
chewable di)................................................................ 104
255
2016
lamotrigine tab chewable dispersible 25 mg (Lamictal
chewable di)................................................................ 104
lamotrigine tab 25 mg (Lamictal)................................. 104
lamotrigine tab 100 mg (Lamictal)............................... 104
lamotrigine tab sr 24hr 25 mg (Lamictal xr)............... 104
lamotrigine tab sr 24hr 50 mg (Lamictal xr)............... 104
lamotrigine tab sr 24hr 100 mg (Lamictal xr)............. 104
LANCET DEVICE ADJUSTABLE -lancet devices.......... 174
LANCET DEVICE WITH EJECTO -lancet devices......... 174
LANCETS 30G/TWIST TOP -lancets.............................. 174
LANCETS 28G -lancets................................................... 174
LANCETS 30G -lancets................................................... 174
LANCETS 26G TWIST TOP -lancets..............................174
LANCETS 33G UNIVERSAL DES -lancets.................... 174
LANCETS -lancets........................................................... 174
LANCETS MICRO THIN 33G -lancets............................ 174
LANCETS SAFETY SEAL 21G -lancets......................... 174
LANCETS SUPER THIN 28G -lancets........................... 174
LANCETS THIN -lancets................................................. 174
LANCETS TWIST TOP -lancets......................................174
LANCETS ULTRA FINE -lancets.................................... 174
LANCETS ULTRA THIN 30G -lancets............................ 174
LANCETS ULTRA THIN -lancets.................................... 174
LANCING DEVICE ADJUSTABLE -lancet devices......... 174
LANCING DEVICE -lancet devices................................. 174
LANOXIN -digoxin tab 62.5 mcg (0.0625 mg).................. 37
LANOXIN -digoxin tab 125 mcg (0.125 mg)..................... 37
LANOXIN -digoxin tab 187.5 mcg (0.1875 mg)................ 37
LANOXIN -digoxin tab 250 mcg (0.25 mg)....................... 37
lansoprazole cap delayed release 15 mg
(Prevacid)....................................................................... 64
lansoprazole cap delayed release 30 mg
(Prevacid)....................................................................... 64
LANTUS -insulin glargine inj 100 unit/ml.......................... 31
LANTUS SOLOSTAR -insulin glargine soln pen-injector
100 unit/ml.......................................................................31
LANZO -lancet devices.................................................... 174
LASIX -furosemide tab 20 mg........................................... 52
LASTACAFT -alcaftadine ophth soln 0.25%................... 128
latanoprost ophth soln 0.005% (Xalatan).................... 128
LATUDA -lurasidone hcl tab 20 mg...................................79
LATUDA -lurasidone hcl tab 120 mg.................................79
256
LAZANDA -fentanyl citrate nasal spray 100 mcg/act (base

equiv)............................................................................... 93
LAZANDA -fentanyl citrate nasal spray 400 mcg/act (base
equiv)............................................................................... 93
LDO PLUS -lidocaine hcl gel 4%.................................... 138
LDR BLOOD GLUCOSE TRUETES -blood glucose
LEADER ADVANCED LANCING D -lancet devices....... 174
LEADER INSULIN SYRINGE/0. -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 174
u-100 1/2 ml 28 x 1/2".................................................. 174
u-100 1/2 ml 29 x 1/2".................................................. 174
u-100 1/2 ml 30 x 5/16"................................................ 174
u-100 0.3 ml 29 x 1/2".................................................. 174
u-100 0.3 ml 30 x 5/16"................................................ 174
u-100 0.3 ml 31 x 5/16"................................................ 174
LEADER INSULIN SYRINGE/1M -insulin syringe/needle
u-100 1 ml 28 x 1/2".....................................................174
u-100 1 ml 29 x 1/2".....................................................174
u-100 1 ml 30 x 5/16"...................................................175
u-100 1 ml 31 x 5/16"...................................................175
LEADER LANCETS COLORED -lancets........................ 175
LEADER SUPER THIN LANCET -lancets...................... 175
LEADER THIN LANCETS -lancets................................. 175
LEADER UNIFINE PENTIPS/MI -insulin pen needle 31 g
x 5 mm (3/16").............................................................. 175
LEADER UNIFINE PENTIPS/NA -insulin pen needle 32 g
x 4 mm (5/32").............................................................. 175
LEADER UNIFINE PENTIPS/PL -insulin pen needle 32 g
x 4 mm (5/32").............................................................. 175
LEADER UNIFINE PENTIPS PL -insulin pen needle 31 g
x 5 mm (3/16").............................................................. 175
LEADER UNIFINE PENTIPS PL -insulin pen needle 31 g
x 8 mm (1/3" or 5/16").................................................. 175
LECITHIN -lecithin granules............................................ 119
leflunomide tab 10 mg (Arava)....................................... 98
leflunomide tab 20 mg (Arava)....................................... 98
LENVIMA 14MG DAILY DOSE -lenvatinib cap therapy
pack 10 & 4 mg (14 mg daily dose)............................... 18
pack 10 (2) & 4 mg (24 mg daily dose)......................... 18
pack 10 mg (10 mg daily dose)..................................... 18
pack 10 (2) mg (20 mg daily dose)................................ 18
LESCOL -fluvastatin sodium cap 20 mg........................... 55
LESCOL XL -fluvastatin sodium tab sr 24 hr 80 mg......... 55
LETAIRIS -ambrisentan tab 5 mg..................................... 57
2016
LETAIRIS -ambrisentan tab 10 mg................................... 57
letrozole tab 2.5 mg (Femara)........................................ 18
LEUCOVORIN CALCIUM -leucovorin calcium tab 10
mg.................................................................................... 18
LEUCOVORIN CALCIUM -leucovorin calcium tab 15
mg.................................................................................... 18
leucovorin calcium tab 5 mg.......................................... 18
leucovorin calcium tab 25 mg........................................ 18
LEUKERAN -chlorambucil tab 2 mg................................. 18
LEUKINE -sargramostim lyophilized for inj 250 mcg...... 120
leuprolide acetate inj kit 5 mg/ml.................................. 18
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base
equiv) (Xopenex concentrate)..................................... 61
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv)
(Xopenex)....................................................................... 61
(Xopenex)....................................................................... 61
(Xopenex)....................................................................... 61
LEVAQUIN -levofloxacin tab 250 mg.................................. 5
LEVATOL -penbutolol sulfate tab 20 mg........................... 39
LEVBID -hyoscyamine sulfate tab sr 12hr 0.375 mg........ 64
LEVEMIR FLEXPEN -insulin detemir soln pen-injector
100 unit/ml.......................................................................31
LEVEMIR FLEXTOUCH -insulin detemir soln pen-injector
100 unit/ml.......................................................................31
LEVEMIR -insulin detemir inj 100 unit/ml..........................31
levetiracetam oral soln 100 mg/ml (Keppra)...............104
levetiracetam tab 250 mg (Keppra)............................. 104
levetiracetam tab 1000 mg (Keppra)........................... 104
levetiracetam tab sr 24hr 500 mg (Keppra xr)............ 104
levetiracetam tab sr 24hr 750 mg (Keppra xr)............ 104
LEVOBUNOLOL HCL -levobunolol hcl ophth soln
0.25%.............................................................................128
levobunolol hcl ophth soln 0.5% (Betagan)............... 128
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)..... 35
levocarnitine tab 330 mg (Carnitor)............................... 35
levocetirizine dihydrochloride soln 2.5 mg/5ml (0.5
mg/ml) (Xyzal)................................................................ 58
levocetirizine dihydrochloride tab 5 mg (Xyzal)...........58
levofloxacin ophth soln 0.5%....................................... 128
levofloxacin oral soln 25 mg/ml (Levaquin)................... 5
levofloxacin tab 250 mg (Levaquin)................................ 5
LEVOMEFOLATE DHA -prenat w/fe fum-l methylfolate-fadha cap 27-1.13-0.4 mg............................................... 111
levonorgestrel & ethinyl estradiol (91-day) tab
0.15-0.03 mg.................................................................. 25
levonorgestrel & ethinyl estradiol tab 0.1 mg-20
mcg................................................................................. 25
levonorgestrel & ethinyl estradiol tab 0.15 mg-30
mcg................................................................................. 25
levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg............................... 25
levonorgestrel-ethinyl estradiol (continuous) tab
90-20 mcg.......................................................................25
levonorgestrel tab 1.5 mg............................................... 25
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab
0.01mg(7) (Loseasonique)........................................... 25
levonorg-eth est tab 0.15-0.03mg(84) & eth est tab
0.01mg(7) (Seasonique)............................................... 25
LEVORPHANOL TARTRATE -levorphanol tartrate tab 2
mg.................................................................................... 93
levothyroxine sodium tab 25 mcg (Synthroid)............. 32
levothyroxine sodium tab 100 mcg (Synthroid)........... 32
LEVSIN/SL -hyoscyamine sulfate tab sl 0.125 mg........... 64
LEVSIN -hyoscyamine sulfate tab 0.125 mg.................... 64
LEVULAN KERASTICK -aminolevulinic acid hcl for soln
20% (stick applicator)................................................... 138
LEXAPRO -escitalopram oxalate soln 5 mg/5ml (base
equiv)............................................................................... 75
LEXAPRO -escitalopram oxalate tab 5 mg (base
equiv)............................................................................... 75
equiv)............................................................................... 75
equiv)............................................................................... 75
LEXIVA -fosamprenavir calcium susp 50 mg/ml (base
equiv)................................................................................. 8
LEXIVA -fosamprenavir calcium tab 700 mg (base
equiv)................................................................................. 8
LEXUSS 210 -chlorpheniramine w/ codeine liquid 2-10
mg/5ml............................................................................. 59
LIALDA -mesalamine tab delayed release 1.2 gm........... 68
LIBERTY BLOOD GLUCOSE MET -blood glucose
LIBERTY BLOOD GLUCOSE MON -blood glucose
LIBERTY MEDICAL LANCETS 3 -lancets...................... 175
LIBERTY MINI LANCING DEVI -lancet devices............. 175
LIBERTY NEXT GENERATION B -blood glucose
LIBERTY NEXT GENERATION B -glucose blood test
strip................................................................................ 147
LIBERTY TEST STRIPS -glucose blood test strip.......... 147
LIBRAX -chlordiazepoxide hcl-clidinium bromide cap
5-2.5 mg.......................................................................... 64
lidocaine hcl gel 2%...................................................... 138
257
2016
LIDOCAINE HCL-HYDROCORTIS -lidocainehydrocortisone acetate rectal gel 2.8-0.55%............... 132
lidocaine hcl laryngotracheal soln 4% (Lta 360
kit)................................................................................. 131
lidocaine hcl soln 4% (Xylocaine)............................... 138
lidocaine hcl viscous soln 2%..................................... 131
lidocaine-hydrocortisone acetate rectal cream
3-0.5%........................................................................... 132
lidocaine-hydrocortisone acetate rectal cream kit
3-0.5%........................................................................... 132
lidocaine oint 5%........................................................... 138
lidocaine patch 5% (Lidoderm).................................... 138
lidocaine-prilocaine cream 2.5-2.5% (Emla)............... 138
lidocaine-prilocaine kit 2.5-2.5%.................................. 138
LIDODERM -lidocaine patch 5%..................................... 138
LIDOVIN -lidocaine hcl cream 3.95%............................. 138
LIDOZOL -lidocaine hcl cream 3.75%............................ 138
LIFESCAN UNISTIK 2 DEEP P -lancets........................ 175
LIFESCAN UNISTIK II LANCE -lancets.......................... 175
lindane lotion 1%........................................................... 138
lindane shampoo 1%..................................................... 138
linezolid tab 600 mg (Zyvox).......................................... 12
LINZESS -linaclotide cap 145 mcg................................... 68
LINZESS -linaclotide cap 290 mcg................................... 68
liothyronine sodium tab 5 mcg (Cytomel).................... 32
liothyronine sodium tab 25 mcg (Cytomel).................. 32
liothyronine sodium tab 50 mcg (Cytomel).................. 32
LIPOFEN -fenofibrate cap 50 mg...................................... 55
LIPOFEN -fenofibrate cap 150 mg.................................... 55
lisinopril & hydrochlorothiazide tab 10-12.5 mg
(Zestoretic)..................................................................... 48
lisinopril & hydrochlorothiazide tab 20-12.5 mg
(Zestoretic)..................................................................... 48
lisinopril & hydrochlorothiazide tab 20-25 mg
(Zestoretic)..................................................................... 48
lisinopril tab 5 mg (Prinivil)............................................ 48
lisinopril tab 10 mg (Prinivil).......................................... 48
lisinopril tab 20 mg (Prinivil).......................................... 48
lisinopril tab 2.5 mg (Zestril).......................................... 48
lisinopril tab 30 mg (Zestril)........................................... 48
lisinopril tab 40 mg (Zestril)........................................... 48
LITETOUCH INSULIN SYRINGE -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 175
u-100 1/2 ml 28 x 1/2".................................................. 175
u-100 1/2 ml 29 x 1/2".................................................. 175
u-100 1/2 ml 30 x 5/16"................................................ 175
u-100 0.3 ml 29 x 1/2".................................................. 175
u-100 0.3 ml 30 x 5/16"................................................ 175
u-100 1 ml 28 x 1/2".....................................................175
u-100 1 ml 29 x 1/2".....................................................175
258

u-100 1 ml 30 x 5/16"...................................................175
u-100 1 ml 31 x 5/16"...................................................175
u-100 0.3 ml 31 x 5/16"................................................ 175
LITE TOUCH LANCETS -lancets.................................... 175
LITETOUCH LANCETS MICRO T -lancets.................... 175
LITE TOUCH LANCING DEVICE -lancet devices.......... 175
LITE TOUCH LANCING PEN -lancet devices................ 175
LITE TOUCH PEN NEEDLES/31 -insulin pen needle 31 g
x 5 mm (3/16").............................................................. 175
LITETOUCH PEN NEEDLES 29G -insulin pen needle 29
g x 12.7 mm..................................................................176
g x 6 mm (1/4").............................................................176
g x 8 mm (1/3" or 5/16")...............................................176
lithium carbonate cap 300 mg....................................... 79
lithium carbonate cap 150 mg (Lithium carbonate)..... 79
lithium carbonate cap 600 mg (Lithium carbonate)..... 79
LITHIUM CARBONATE -lithium carbonate cap 150
mg.................................................................................... 79
LITHIUM CARBONATE -lithium carbonate cap 600
mg.................................................................................... 79
lithium carbonate tab cr 450 mg.................................... 79
lithium carbonate tab cr 300 mg (Lithobid).................. 79
lithium carbonate tab 300 mg........................................ 79
LITHIUM -lithium oral solution 8 meq/5ml......................... 79
LITHOBID -lithium carbonate tab cr 300 mg..................... 79
LITHOSTAT -acetohydroxamic acid tab 250 mg............... 71
LIVALO -pitavastatin calcium tab 1 mg (base equiv)........ 55
LIVE BETTER ADVANCED LANC -lancet devices......... 176
LIVE BETTER LANCET SUPER -lancets....................... 176
LIVE BETTER LANCET ULTRA -lancets........................ 176
LIVE BETTER PEN NEEDLES 2 -insulin pen needle 29 g
x 12 mm (1/2").............................................................. 176
x 6 mm (1/4")................................................................ 176
x 8 mm (1/3" or 5/16").................................................. 176
LOCAL ANESTHESIA SECURITY -needle (disp) 20 x
4".................................................................................... 176
2".................................................................................... 176
3".................................................................................... 176
4".................................................................................... 176
LOCOID -hydrocortisone butyrate cream 0.1%.............. 138
LOCOID -hydrocortisone butyrate lotion 0.1%................138
LOCOID -hydrocortisone butyrate oint 0.1%.................. 138
LOCOID -hydrocortisone butyrate soln 0.1%..................138
LOCOID LIPOCREAM -hydrocortisone butyrate
hydrophilic lipo base cream 0.1%................................ 138
2016
LODOSYN -carbidopa tab 25 mg................................... 107
LOESTRIN FE 1.5/30 -norethindrone ace & ethinyl
estradiol-fe tab 1.5 mg-30 mcg...................................... 25
LOESTRIN FE 1/20 -norethindrone ace & ethinyl
estradiol-fe tab 1 mg-20 mcg......................................... 25
LOFIBRA -fenofibrate micronized cap 67 mg................... 55
LOFIBRA -fenofibrate micronized cap 134 mg................. 55
LOFIBRA -fenofibrate micronized cap 200 mg................. 55
LOFIBRA -fenofibrate tab 54 mg...................................... 55
LOFIBRA -fenofibrate tab 160 mg.................................... 55
LO LOESTRIN FE -norethin-eth estradiol-fe tab 1 mg-10
mcg (24)/10 mcg (2)....................................................... 25
LOMOTIL -diphenoxylate w/ atropine tab 2.5-0.025
mg.................................................................................... 63
LOMUSTINE -lomustine cap 10 mg.................................. 18
LOMUSTINE -lomustine cap 40 mg.................................. 18
LOMUSTINE -lomustine cap 100 mg................................ 18
LONGS INSULIN SYRINGE/0.5 -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 176
LONGS LANCETS STANDARD -lancets........................ 176
LONGS LANCETS THIN -lancets................................... 176
LONGS LANCETS ULTRA THIN -lancets...................... 176
LONSURF -trifluridine-tipiracil tab 15-6.14 mg................. 18
LONSURF -trifluridine-tipiracil tab 20-8.19 mg................. 18
loperamide hcl cap 2 mg................................................ 63
LOPID -gemfibrozil tab 600 mg......................................... 55
LOPRESSOR HCT -metoprolol & hydrochlorothiazide tab
50-25 mg......................................................................... 48
LOPRESSOR HCT -metoprolol & hydrochlorothiazide tab
100-25 mg....................................................................... 48
LOPRESSOR -metoprolol tartrate tab 50 mg................... 39
LOPRESSOR -metoprolol tartrate tab 100 mg................. 39
LOPROX SHAMPOO -ciclopirox shampoo 1%.............. 138
loratadine & pseudoephedrine tab sr 12hr 5-120
mg................................................................................... 59
loratadine & pseudoephedrine tab sr 24hr 10-240
mg................................................................................... 59
loratadine rapidly-disintegrating tab 10 mg
(Claritin).......................................................................... 58
loratadine syrup 5 mg/5ml.............................................. 58
loratadine tab 10 mg....................................................... 58
lorazepam conc 2 mg/ml (Lorazepam intensol)........... 72
lorazepam tab 0.5 mg (Ativan)....................................... 72
lorazepam tab 1 mg (Ativan).......................................... 72
lorazepam tab 2 mg (Ativan).......................................... 72
losartan potassium & hydrochlorothiazide tab 50-12.5
mg (Hyzaar)....................................................................48
losartan potassium & hydrochlorothiazide tab
100-12.5 mg (Hyzaar).................................................... 48
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
LOSEASONIQUE -levonorg-eth est tab 0.1-0.02mg(84) &
eth est tab 0.01mg(7)..................................................... 25
LOTEMAX -loteprednol etabonate ophth gel 0.5%......... 128
LOTEMAX -loteprednol etabonate ophth oint 0.5%........ 128

LOTEMAX -loteprednol etabonate ophth susp 0.5%...... 128
LOTENSIN -benazepril hcl tab 10 mg.............................. 48
LOTENSIN HCT -benazepril & hydrochlorothiazide tab
10-12.5 mg...................................................................... 48
20-12.5 mg...................................................................... 48
20-25 mg......................................................................... 48
LOTREL -amlodipine besylate-benazepril hcl cap 2.5-10
mg.................................................................................... 48
LOTREL -amlodipine besylate-benazepril hcl cap 5-10
mg.................................................................................... 48
mg.................................................................................... 49
mg.................................................................................... 49
mg.................................................................................... 49
LOTRISONE -clotrimazole w/ betamethasone cream
1-0.05%......................................................................... 138
LOTRONEX -alosetron hcl tab 0.5 mg (base equiv)......... 68
LOTRONEX -alosetron hcl tab 1 mg (base equiv)............ 68
lovastatin tab 10 mg........................................................ 55
lovastatin tab 20 mg........................................................ 55
lovastatin tab 40 mg (Mevacor)..................................... 55
LOVAZA -omega-3-acid ethyl esters cap 1 gm.................55
LOVENOX -enoxaparin sodium inj 30 mg/0.3ml.............122
LOVENOX -enoxaparin sodium inj 100 mg/ml................122
LOVENOX -enoxaparin sodium inj 120 mg/0.8ml...........122
LOVENOX -enoxaparin sodium inj 150 mg/ml................122
LOVENOX -enoxaparin sodium inj 300 mg/3ml..............122
loxapine succinate cap 5 mg......................................... 79
loxapine succinate cap 10 mg....................................... 79
LOZI-FLUR -sodium fluoride lozenge 1 mg f (from 2.2 mg
naf)................................................................................. 118
LTA 360 KIT -lidocaine hcl laryngotracheal soln 4%....... 131
LUFYLLIN -dyphylline tab 400 mg.................................... 61
LUMIGAN -bimatoprost ophth soln 0.01%...................... 129
LUNESTA -eszopiclone tab 1 mg......................................81
LURIDE -sodium fluoride chew tab 0.25 mg f (from 0.55
mg naf).......................................................................... 118
LURIDE -sodium fluoride chew tab 0.5 mg f (from 1.1 mg
naf)................................................................................. 118
LURIDE -sodium fluoride chew tab 1 mg f (from 2.2 mg
naf)................................................................................. 118
LURIDE -sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml
naf)................................................................................. 118
259
2016
LUXIQ -betamethasone valerate aerosol foam
0.12%.............................................................................138
LYNPARZA -olaparib cap 50 mg....................................... 18
LYRICA -pregabalin cap 25 mg.......................................104
LYRICA -pregabalin cap 100 mg.....................................104
LYRICA -pregabalin soln 20 mg/ml................................. 104
LYSODREN -mitotane tab 500 mg....................................18
LYSTEDA -tranexamic acid tab 650 mg......................... 122
M
MACNATAL CN DHA -prenatal w/o a w/fe cbn-dss-fa-dha
cap 28-1-250 mg.......................................................... 112
MACROBID -nitrofurantoin monohydrate macrocrystalline
cap 100 mg..................................................................... 69
MACRODANTIN -nitrofurantoin macrocrystalline cap 25
mg.................................................................................... 69
mg.................................................................................... 69
mg.................................................................................... 69
MAGELLAN INSULIN SAFETY S -insulin syringe/needle
u-100 1/2 ml 29 x 1/2".................................................. 176
u-100 1/2 ml 30 x 5/16"................................................ 176
u-100 0.3 ml 29 x 1/2".................................................. 176
u-100 0.3 ml 30 x 5/16"................................................ 176
u-100 1 ml 29 x 1/2".....................................................176
u-100 1 ml 30 x 5/16"...................................................176
MAGELLAN TUBERCULIN SAFET -tuberculin/allergy
MAGELLAN TUBERCULIN SAFET -tuberculin/allergy
MALARONE -atovaquone-proguanil hcl tab 62.5-25
mg.................................................................................... 11
MALARONE -atovaquone-proguanil hcl tab 250-100
mg.................................................................................... 11
malathion lotion 0.5% (Ovide)...................................... 138
MAPROTILINE HCL -maprotiline hcl tab 25 mg............... 75
MARINOL -dronabinol cap 2.5 mg.................................... 66
MARINOL -dronabinol cap 5 mg....................................... 66
MARINOL -dronabinol cap 10 mg..................................... 66
MARNATAL-F -prenatal w/o vit a w/ fe polysac cmplx-fa
cap 60-1 mg.................................................................. 112
MARPLAN -isocarboxazid tab 10 mg............................... 75
MATULANE -procarbazine hcl cap 50 mg........................ 18
260
MAVIK -trandolapril tab 1 mg............................................ 49

MAXALT-MLT -rizatriptan benzoate orally disintegrating
tab 5 mg........................................................................ 100
MAXALT-MLT -rizatriptan benzoate orally disintegrating
tab 10 mg...................................................................... 100
MAXALT -rizatriptan benzoate tab 5 mg......................... 100
MAXALT -rizatriptan benzoate tab 10 mg....................... 100
MAXI-COMFORT INSULIN SYRI -insulin syringe/needle
u-100 1/2 ml 28 x 1/2".................................................. 176
MAXI-COMFORT INSULIN SYRI -insulin syringe/needle
u-100 1 ml 28 x 1/2".....................................................176
MAXIDEX -dexamethasone ophth susp 0.1%................ 129
MAXIMA BLOOD GLUCOSE MONI -blood glucose
MAXIMA BLOOD GLUCOSE TEST -glucose blood test
strip................................................................................ 147
MAXIMA METER KIT -blood glucose monitoring kit w/
device............................................................................ 176
MAXIMA STARTER KIT -blood glucose monitoring kit w/
device............................................................................ 176
MAXITROL -neomycin-polymyxin-dexamethasone ophth
oint 0.1%....................................................................... 129
MAXITROL -neomycin-polymyxin-dexamethasone ophth
susp 0.1%..................................................................... 129
MAXZIDE -triamterene & hydrochlorothiazide tab 75-50
mg.................................................................................... 52
MAXZIDE-25 -triamterene & hydrochlorothiazide tab
37.5-25 mg...................................................................... 52
MD SAFETYGLIDE 27G X 5/8" -needle (disp) 27 x
5/8".................................................................................176
meclizine hcl tab 12.5 mg............................................... 66
meclizine hcl tab 25 mg.................................................. 66
MECLOFENAMATE SODIUM -meclofenamate sodium
cap 50 mg....................................................................... 98
MECLOFENAMATE SODIUM -meclofenamate sodium
cap 100 mg..................................................................... 98
MEDICAL PROVIDER EZ FLU S -influenza virus vac tisscult subunit pref syr kit 0.5 ml........................................ 14
MEDICAL PROVIDER EZ FLU S -influenza virus vac
types a & b pf pref syringe kit 0.5 ml............................. 14
MEDICHOICE PRE-SET SAFETY -lancets.................... 177
MEDICHOICE SAFETY LANCET -lancets..................... 177
MEDICINE SHOPPE LANCETS -lancets....................... 177
MEDICINE SHOPPE LANCETS T -lancets.................... 177
MEDICINE SHOPPE PEN NEEDL -insulin pen needle 29
g x 12 mm (1/2")...........................................................177
g x 6 mm (1/4").............................................................177
g x 8 mm (1/3" or 5/16")...............................................177
MEDIC INSULIN SYRINGE/0.5 -insulin syringe/needle
u-100 1/2 ml 30 x 5/16"................................................ 176
MEDIC INSULIN SYRINGE/0.3 -insulin syringe/needle
u-100 0.3 ml 30 x 5/16"................................................ 176
2016
MEDI-DERM/L-RX -lidocaine-capsaicin-menthol-methyl
sal cream 2-0.035-5-20%............................................. 138
MEDI-DERM-RX -capsaicin-menthol-methyl salicylate
cream 0.035-5-20%...................................................... 138
MEDISENSE THIN LANCETS -lancets.......................... 177
MEDLANCE/EXTRA -lancets.......................................... 177
MEDLANCE/LITE -lancets............................................... 177
MEDLANCE/UNIVERSAL -lancets..................................177
MEDLANCE PLUS/LITE 25G -lancets............................ 177
MEDLANCE PLUS EXTRA LANCE -lancets.................. 177
MEDLANCE PLUS LANCETS -lancets...........................177
MEDLANCE PLUS LANCETS LIT -lancets.................... 177
MEDLANCE PLUS LITE LANCET -lancets.................... 177
MEDLANCE PLUS SPECIAL LAN -lancets.................... 177
MEDLANCE PLUS SUPERLITE 3 -lancets.................... 177
MEDLANCE PLUS UNIVERSAL L -lancets.................... 177
MEDROL DOSEPAK -methylprednisolone tab 4 mg dose
pack................................................................................. 20
MEDROL -methylprednisolone tab 2 mg.......................... 20
MEDROL -methylprednisolone tab 16 mg........................ 20
MEDROL -methylprednisolone tab 32 mg........................ 20
MEDROX-RX -capsaicin-menthol-methyl salicylate oint
0.05-7-20%.................................................................... 138
medroxyprogesterone acetate tab 2.5 mg
(Provera)......................................................................... 26
medroxyprogesterone acetate tab 5 mg (Provera)...... 26
medroxyprogesterone acetate tab 10 mg
(Provera)......................................................................... 26
mefenamic acid cap 250 mg (Ponstel).......................... 98
mefloquine hcl tab 250 mg............................................. 11
MEGACE ES -megestrol acetate susp 625 mg/5ml......... 26
MEGACE ORAL -megestrol acetate susp 40 mg/ml........ 18
megestrol acetate susp 625 mg/5ml (Megace es)........ 26
megestrol acetate susp 40 mg/ml (Megace oral)......... 18
megestrol acetate tab 20 mg.......................................... 18
megestrol acetate tab 40 mg.......................................... 18
MEIJER BLOOD GLUCOSE MONI -blood glucose
MEIJER BLOOD GLUCOSE TEST -glucose blood test
strip................................................................................ 147
MEIJER COLOR LANCETS UNIV -lancets.................... 177
MEIJER ESSENTIAL BLOOD GL -blood glucose
MEIJER ESSENTIAL BLOOD GL -glucose blood test
strip................................................................................ 147
MEIJER LANCETS -lancets............................................ 177
MEIJER LANCETS THIN -lancets.................................. 177
MEIJER LANCETS UNIVERSAL -lancets...................... 177
MEIJER PEN NEEDLES 29G X -insulin pen needle 29 g
x 12 mm (1/2").............................................................. 177
x 6 mm (1/4")................................................................ 177
x 8 mm (1/3" or 5/16").................................................. 177
MEIJER PREMIUM BLOOD GLUC -blood glucose

MEIJER PREMIUM BLOOD GLUC -glucose blood test
strip................................................................................ 147
MEIJER SUPER THIN LANCETS -lancets..................... 177
MEIJER TRUE2GO BLOOD GLUC -blood glucose
MEIJER TRUERESULT BLOOD G -blood glucose
MEIJER TRUETEST BLOOD GLU -glucose blood test
strip................................................................................ 147
MEIJER TRUETRACK BLOOD GL -blood glucose
MEIJER TRUETRACK BLOOD GL -glucose blood test
strip................................................................................ 147
MEKINIST -trametinib dimethyl sulfoxide tab 0.5 mg
(base equivalent)............................................................ 18
MEKINIST -trametinib dimethyl sulfoxide tab 2 mg (base
equivalent)....................................................................... 18
meloxicam tab 7.5 mg (Mobic)....................................... 98
meloxicam tab 15 mg (Mobic)........................................ 98
memantine hcl tab 5 mg (28) & 10 mg (21) titration pak
(Namenda titration pa)................................................. 88
memantine hcl tab 5 mg (Namenda)............................. 87
memantine hcl tab 10 mg (Namenda)........................... 88
MENACTRA -meningococcal (a, c, y, and w-135)
conjugate vaccine inj...................................................... 14
MENEST -esterified estrogens tab 0.3 mg....................... 23
MENEST -esterified estrogens tab 0.625 mg................... 23
MENEST -esterified estrogens tab 1.25 mg..................... 23
MENEST -esterified estrogens tab 2.5 mg....................... 23
MENHIBRIX -meningococcal (c & y)-haemophilus b tet
tox conj vac for inj.......................................................... 14
MENOMUNE-A/C/Y/W-135 -meningococcal vaccine a, c,
y, and w-135 inj.............................................................. 14
MENOSTAR -estradiol td patch weekly 14 mcg/24hr....... 23
MENTAX -butenafine hcl cream 1%................................138
MENTHOLIX -lidocaine-menthol liquid spray 4-1%........ 138
MENVEO -meningococcal (a, c, y, and w-135) oligo conj
vac for inj........................................................................ 15
MEPERIDINE HCL/PROMETHAZI -meperidine w/
promethazine cap 50-25 mg.......................................... 93
MEPERIDINE HCL -meperidine hcl oral soln 50
mg/5ml............................................................................. 93
meperidine hcl tab 50 mg (Demerol)............................. 93
meperidine hcl tab 100 mg (Demerol)........................... 93
MEPHYTON -phytonadione tab 5 mg............................. 110
meprobamate tab 200 mg............................................... 72
meprobamate tab 400 mg............................................... 72
MEPRON -atovaquone susp 750 mg/5ml......................... 12
mercaptopurine tab 50 mg............................................. 18
mesalamine enema 4 gm................................................ 68
MESNEX -mesna tab 400 mg........................................... 18
MESTINON -pyridostigmine bromide syrup 60
mg/5ml........................................................................... 110
MESTINON -pyridostigmine bromide tab 60 mg.............110
261
2016
MESTINON TIMESPAN -pyridostigmine bromide tab cr
180 mg.......................................................................... 110
METADATE CD -methylphenidate hcl cap cr 10 mg......... 84
METAPROTERENOL SULFATE -metaproterenol sulfate
syrup 10 mg/5ml............................................................. 61
tab 10 mg........................................................................ 61
tab 20 mg........................................................................ 61
METAXALONE -metaxalone tab 400 mg........................ 109
metaxalone tab 800 mg (Skelaxin).............................. 109
metformin hcl tab 500 mg (Glucophage)...................... 29
metformin hcl tab 850 mg (Glucophage)...................... 29
metformin hcl tab 1000 mg (Glucophage).................... 29
metformin hcl tab sr 24hr 500 mg (Glucophage xr)..... 29
metformin hcl tab sr 24hr 750 mg (Glucophage xr)..... 29
methadone hcl conc 10 mg/ml (Methadose)................ 93
METHADONE HCL -methadone hcl soln 5 mg/5ml..........93
METHADONE HCL -methadone hcl soln 10 mg/5ml........93
methadone hcl soln 5 mg/5ml (Methadone hcl)........... 93
methadone hcl soln 10 mg/5ml (Methadone hcl)......... 93
methadone hcl tab for oral susp 40 mg........................ 93
methadone hcl tab 10 mg (Dolophine).......................... 93
methadone hcl tab 5 mg (Dolophine hcl)..................... 93
METHADOSE -methadone hcl conc 10 mg/ml................. 93
METHADOSE SUGAR-FREE -methadone hcl conc 10
mg/ml............................................................................... 93
methamphetamine hcl tab 5 mg (Desoxyn).................. 84
methazolamide tab 25 mg (Neptazane)......................... 52
methazolamide tab 50 mg (Neptazane)......................... 52
methenamine hippurate tab 1 gm (Hiprex)................... 69
methimazole tab 5 mg (Tapazole).................................. 32
methimazole tab 10 mg (Tapazole)................................ 32
METHITEST -methyltestosterone oral tab 10 mg............. 22
methocarbamol tab 750 mg (Robaxin-750).................109
methocarbamol tab 500 mg (Robaxin)........................ 109
methotrexate sodium for inj 1 gm................................. 18
methotrexate sodium inj 25 mg/ml................................ 18
methotrexate sodium inj pf 25 mg/ml........................... 18
methotrexate sodium tab 2.5 mg (base equiv)............. 18
methoxsalen rapid cap 10 mg (Oxsoralen ultra)........ 138
methscopolamine bromide tab 2.5 mg (Pamine)......... 65
methscopolamine bromide tab 5 mg (Pamine
forte)................................................................................65
METHYCLOTHIAZIDE -methyclothiazide tab 5 mg..........52
METHYLDOPA/HYDROCHLOROTHI -methyldopa &
hydrochlorothiazide tab 250-15 mg................................ 49
METHYLDOPA/HYDROCHLOROTHI -methyldopa &
hydrochlorothiazide tab 250-25 mg................................ 49
methyldopa tab 250 mg.................................................. 49
methyldopa tab 500 mg.................................................. 49
methylergonovine maleate tab 0.2 mg.......................... 33
262
METHYLIN -methylphenidate hcl chew tab 2.5 mg.......... 84

METHYLIN -methylphenidate hcl chew tab 5 mg............. 84
METHYLIN -methylphenidate hcl chew tab 10 mg........... 84
METHYLIN -methylphenidate hcl soln 5 mg/5ml.............. 84
METHYLIN -methylphenidate hcl soln 10 mg/5ml............ 84
methylphenidate hcl cap cr 10 mg (Metadate cd)........ 84
methylphenidate hcl cap sr 24hr 20 mg (la) (Ritalin
la)..................................................................................... 85
la)..................................................................................... 85
la)..................................................................................... 85
methylphenidate hcl chew tab 2.5 mg (Methylin)........ 85
methylphenidate hcl chew tab 5 mg (Methylin)........... 85
methylphenidate hcl chew tab 10 mg (Methylin)......... 85
METHYLPHENIDATE HCL ER -methylphenidate hcl tab
sa osm 18 mg................................................................. 85
sa osm 27 mg................................................................. 85
sa osm 36 mg................................................................. 85
sa osm 54 mg................................................................. 85
sr 24hr 18 mg................................................................. 85
sr 24hr 27 mg................................................................. 85
sr 24hr 36 mg................................................................. 85
sr 24hr 54 mg................................................................. 85
methylphenidate hcl soln 5 mg/5ml (Methylin)............ 85
methylphenidate hcl soln 10 mg/5ml (Methylin).......... 85
methylphenidate hcl tab cr 10 mg................................. 85
methylphenidate hcl tab cr 20 mg................................. 85
methylphenidate hcl tab 5 mg (Ritalin)......................... 85
methylphenidate hcl tab 10 mg (Ritalin)....................... 85
methylphenidate hcl tab 20 mg (Ritalin)....................... 85
methylprednisolone tab 4 mg dose pack (Medrol
dosepak)......................................................................... 20
methylprednisolone tab 4 mg (Medrol)......................... 20
methylprednisolone tab 8 mg (Medrol)......................... 20
methylprednisolone tab 16 mg (Medrol)....................... 20
methylprednisolone tab 32 mg (Medrol)....................... 21
methyltestosterone cap 10 mg (Testred)...................... 22
METIPRANOLOL -metipranolol ophth soln 0.3%........... 129
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)........ 68
metoclopramide hcl tab 5 mg (Reglan)......................... 68
metoclopramide hcl tab 10 mg (Reglan)....................... 68
metolazone tab 2.5 mg.................................................... 52
metolazone tab 5 mg....................................................... 52
metolazone tab 10 mg..................................................... 52
2016
metoprolol & hydrochlorothiazide tab 100-50 mg....... 49
metoprolol & hydrochlorothiazide tab 50-25 mg
(Lopressor hct)..............................................................49
metoprolol & hydrochlorothiazide tab 100-25 mg
(Lopressor hct)..............................................................49
metoprolol succinate tab sr 24hr 25 mg (Toprol xl)..... 39
metoprolol succinate tab sr 24hr 50 mg (Toprol xl)..... 39
metoprolol succinate tab sr 24hr 100 mg (Toprol
xl)..................................................................................... 39
metoprolol succinate tab sr 24hr 200 mg (Toprol
xl)..................................................................................... 39
metoprolol tartrate tab 25 mg........................................ 39
metoprolol tartrate tab 50 mg (Lopressor)................... 39
metoprolol tartrate tab 100 mg (Lopressor)................. 39
METROCREAM -metronidazole cream 0.75%............... 138
METROGEL -metronidazole gel 1%............................... 138
METROGEL-VAGINAL -metronidazole vaginal gel
0.75%...............................................................................70
METROLOTION -metronidazole lotion 0.75%................ 138
metronidazole cap 375 mg (Flagyl)............................... 12
metronidazole cream 0.75% (Metrocream)................. 139
metronidazole gel 0.75%............................................... 139
metronidazole gel 1% (Metrogel)................................. 139
metronidazole lotion 0.75% (Metrolotion)................... 139
metronidazole tab 250 mg (Flagyl)................................ 12
metronidazole tab 500 mg (Flagyl)................................ 12
metronidazole vaginal gel 0.75% (Metrogelvaginal)........................................................................... 70
METVIXIA -methyl aminolevulinate hcl cream 16.8%
(base equiv).................................................................. 139
MEVACOR -lovastatin tab 40 mg...................................... 55
mexiletine hcl cap 150 mg.............................................. 43
MIACALCIN -calcitonin (salmon) inj 200 unit/ml............... 35
MIACALCIN -calcitonin (salmon) nasal soln 200 unit/
act.................................................................................... 35
MICARDIS HCT -telmisartan-hydrochlorothiazide tab
40-12.5 mg...................................................................... 49
80-12.5 mg...................................................................... 49
80-25 mg......................................................................... 49
MICARDIS -telmisartan tab 20 mg.................................... 49
MICONAZOLE 3 -miconazole nitrate vaginal suppos 200
mg.................................................................................... 70
MICRODOT BLOOD GLUCOSE MO -blood glucose
MICRODOT TEST STRIPS -glucose blood test strip..... 147
MICRO-K -potassium chloride cap cr 8 meq.................. 118
MICRO-K -potassium chloride cap cr 10 meq................ 118
MICROLET LANCETS -lancets....................................... 177
MICROTAINER SAFETY FLOW L -lancets.................... 177
MICROZIDE -hydrochlorothiazide cap 12.5 mg................52
midodrine hcl tab 2.5 mg................................................ 53
midodrine hcl tab 5 mg................................................... 53

midodrine hcl tab 10 mg................................................. 53
MIGERGOT -ergotamine w/ caffeine suppos 2-100
mg.................................................................................. 100
MIGRANAL -dihydroergotamine mesylate nasal spray 4
mg/ml............................................................................. 100
MILLIPRED DP -prednisolone tab 5 mg dose pack.......... 21
MILLIPRED -prednisolone sod phosphate oral soln 10
mg/5ml (base equiv)....................................................... 21
MILLIPRED -prednisolone tab 5 mg................................. 21
MINASTRIN 24 FE -norethindrone ace-eth estradiol-fe
chew tab 1 mg-20 mcg (24)........................................... 25
MINI LANCING DEVICE -lancet devices........................ 177
MINIPRESS -prazosin hcl cap 1 mg................................. 49
MINIVELLE -estradiol td patch twice weekly 0.025
mg/24hr........................................................................... 23
mg/24hr........................................................................... 24
mg/24hr........................................................................... 24
mg/24hr........................................................................... 24
mg/24hr........................................................................... 24
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........................................................ 49
minoxidil tab 10 mg......................................................... 49
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr
0.375 mg....................................................................... 107
0.75 mg......................................................................... 107
1.5 mg........................................................................... 107
2.25 mg......................................................................... 107
MIRAPEX ER -pramipexole dihydrochloride tab sr 24hr 3
mg.................................................................................. 107
3.75 mg......................................................................... 107
4.5 mg........................................................................... 107
MIRAPEX -pramipexole dihydrochloride tab 0.125
mg.................................................................................. 107
mg.................................................................................. 107
MIRAPEX -pramipexole dihydrochloride tab 0.5 mg.......107
263
2016
mg.................................................................................. 107
MIRAPEX -pramipexole dihydrochloride tab 1 mg..........107
MIRAPEX -pramipexole dihydrochloride tab 1.5 mg.......107
MIRCERA -methoxy peg-epoetin beta soln prefilled syr 50
mcg/0.3ml...................................................................... 120
MIRCERA -methoxy peg-epoetin beta soln prefilled syr 75
mcg/0.3ml...................................................................... 120
MIRCERA -methoxy peg-epoetin beta soln prefilled syr
100 mcg/0.3ml.............................................................. 120
MIRCERA -methoxy peg-epoetin beta soln prefilled syr
200 mcg/0.3ml.............................................................. 120
mirtazapine orally disintegrating tab 15 mg (Remeron
soltab)............................................................................. 75
soltab)............................................................................. 75
soltab)............................................................................. 75
mirtazapine tab 7.5 mg....................................................75
mirtazapine tab 15 mg (Remeron)................................. 75
misoprostol tab 100 mcg (Cytotec)............................... 65
misoprostol tab 200 mcg (Cytotec)............................... 65
MITIGARE -colchicine cap 0.6 mg.................................. 101
MITOSOL -mitomycin for ophth soln kit 0.2 mg.............. 129
1ML ALLERGIST SYRINGE DET -tuberculin/allergy
1ML ALLERGY SYRINGE 28G X -tuberculin/allergy
1ML ALLERGY SYRINGE -tuberculin/allergy syringe/
needle (disp) 1 ml 27 x 1/2"......................................... 203
1ML TB SYRINGE/25G X 5/8" -tuberculin/allergy syringe/
needle (disp) 1 ml 25 x 5/8"......................................... 203
needle (disp) 1 ml 26 x 3/8"......................................... 203
needle (disp) 1 ml 27 x 1/2"......................................... 203
1ML TUBERCULIN SYRINGE DE -tuberculin/allergy
1ML TUBERCULIN SYRINGE DE -tuberculin/allergy
1ML VANISHPOINT TUBERCULI -tuberculin/allergy
syringe/needle (disp) 1 ml 25 x 1"............................... 203
M-M-R II -measles, mumps & rubella virus vaccines for
inj..................................................................................... 14
modafinil tab 100 mg (Provigil)...................................... 85
modafinil tab 200 mg (Provigil)...................................... 85
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
264
MODERIBA -ribavirin tab 400 mg & ribavirin tab 600 mg

dose pack.......................................................................... 8
MODICON -norethindrone & ethinyl estradiol tab 0.5
mg-35 mcg...................................................................... 25
moexipril hcl tab 7.5 mg................................................. 49
moexipril hcl tab 15 mg.................................................. 49
moexipril-hydrochlorothiazide tab 7.5-12.5 mg........... 49
moexipril-hydrochlorothiazide tab 15-12.5 mg............ 49
moexipril-hydrochlorothiazide tab 15-25 mg............... 49
mometasone furoate cream 0.1% (Elocon)................ 139
mometasone furoate oint 0.1% (Elocon).................... 139
mometasone furoate solution 0.1% (lotion)
(Elocon)........................................................................ 139
MONOCLATE-P -antihemophilic factor (human) for inj kit
250 unit......................................................................... 125
500 unit......................................................................... 125
1000 unit....................................................................... 125
1500 unit....................................................................... 125
MONOJECT BLUNT CANNULA/15 -needle (disp) 15 x
1-1/2"............................................................................. 177
1-1/2"............................................................................. 178
1-1/2"............................................................................. 178
1-1/2"............................................................................. 178
1-1/2"............................................................................. 178
1-1/2"............................................................................. 178
1".................................................................................... 178
1".................................................................................... 178
1".................................................................................... 178
MONOJECT HYPO/ALUM HUB/LU -needle (disp) 15 x
1-1/2"............................................................................. 178
5/8".................................................................................178
3/4".................................................................................178
1-1/2"............................................................................. 178
1-1/2"............................................................................. 178
1-1/4"............................................................................. 178
1-1/2"............................................................................. 178
1-1/2"............................................................................. 178
1-1/2"............................................................................. 178
2016
5/8".................................................................................178
1-1/4"............................................................................. 178
1/2".................................................................................178
1-1/4"............................................................................. 178
1".................................................................................... 178
2".................................................................................... 178
1".................................................................................... 178
1".................................................................................... 178
1".................................................................................... 178
1".................................................................................... 178
1".................................................................................... 178
2".................................................................................... 178
MONOJECT HYPO/ALUM HUB/18 -needle (disp) 18 x
1-1/2"............................................................................. 178
MONOJECT HYPO/ALUM HUB/16 -needle (disp) 16 x
1".................................................................................... 178
MONOJECT HYPO/POLYPROPYLE -needle (disp) 18 x
1-1/2"............................................................................. 178
1-1/2"............................................................................. 178
1-1/2"............................................................................. 178
1-1/2"............................................................................. 179
1-1/2"............................................................................. 179
3/4".................................................................................179
5/8".................................................................................179
1-1/2"............................................................................. 179
1/2".................................................................................179
1/2".................................................................................179
3/4".................................................................................179
1".................................................................................... 178
1".................................................................................... 178
1".................................................................................... 178

1".................................................................................... 179
1".................................................................................... 179
1".................................................................................... 179
1".................................................................................... 179
MONOJECT HYPODERMIC NEEDL -needle (disp) 27 x
1-1/2"............................................................................. 179
3/4".................................................................................179
1".................................................................................... 179
MONOJECT INSULIN SYRINGE/ -insulin syringe/needle
u-100 1/2 ml 28 x 1/2".................................................. 179
u-100 1/2 ml 29 x 1/2".................................................. 179
u-100 1/2 ml 30 x 5/16"................................................ 179
u-100 0.3 ml 29 x 1/2".................................................. 179
u-100 0.3 ml 30 x 5/16"................................................ 179
u-100 1 ml 25 x 5/8".....................................................179
u-100 1 ml 27 x 1/2".....................................................179
u-100 1 ml 28 x 1/2".....................................................179
u-100 1 ml 29 x 1/2".....................................................179
u-100 1 ml 30 x 5/16"...................................................179
u-100 1 ml 31 x 5/16"...................................................179
MONOJECT INSULIN SYRINGE/ -insulin syringe (disp)
u-100 1 ml..................................................................... 179
MONOJECT INSULIN SYRINGE -insulin syringe (disp)
u-100 1 ml..................................................................... 179
MONOJECT MAGELLAN SAFETY -needle (disp) 18 x
1-1/2"............................................................................. 179
1-1/2"............................................................................. 180
1-1/2"............................................................................. 180
5/8".................................................................................180
1-1/2"............................................................................. 180
1-1/2"............................................................................. 180
5/8".................................................................................180
5/8".................................................................................180
265
2016
1".................................................................................... 179
1".................................................................................... 179
1".................................................................................... 180
1".................................................................................... 180
1".................................................................................... 180
1".................................................................................... 180
1".................................................................................... 180
MONOJECT MEDICATION TRANS -hypodermic needles
(disposable)................................................................... 180
MONOJECT STANDARD HYPODER -needle (disp) 14 x
1-1/2"............................................................................. 180
1-1/2"............................................................................. 180
1-1/2"............................................................................. 180
1-1/2"............................................................................. 180
1-1/2"............................................................................. 180
1-1/2"............................................................................. 180
1/2".................................................................................180
5/8".................................................................................180
1-1/2"............................................................................. 180
1-1/2"............................................................................. 180
1/2".................................................................................180
1".................................................................................... 180
1".................................................................................... 180
1".................................................................................... 180
1".................................................................................... 180
2".................................................................................... 180
1".................................................................................... 180
1".................................................................................... 180
1".................................................................................... 180
MONOJECT TB SYRINGE-NDL 1 -tuberculin/allergy
266
MONOJECT TB SYRINGE-NDL 1 -tuberculin/allergy

MONOJECT TUBERCULIN SAFET -tuberculin/allergy
MONOJECT TUBERCULIN SAFET -tuberculin/allergy
MONOJECT TUBERCULIN SYRIN -tuberculin/allergy
MONOJECT ULTRA COMFORT IN -insulin syringe/
needle u-100 1/2 ml 31 x 5/16".................................... 181
needle u-100 1/2 ml 28 x 1/2"...................................... 181
needle u-100 1/2 ml 29 x 1/2"...................................... 181
needle u-100 1/2 ml 30 x 5/16".................................... 181
needle u-100 0.3 ml 29 x 1/2"...................................... 181
needle u-100 0.3 ml 30 x 5/16".................................... 181
needle u-100 1 ml 28 x 1/2"......................................... 181
needle u-100 1 ml 29 x 1/2"......................................... 181
needle u-100 1 ml 30 x 5/16"....................................... 181
needle u-100 0.3 ml 31 x 5/16".................................... 181
MONOLET LANCETS -lancets....................................... 181
MONOLET OPD LANCETS -lancets.............................. 181
MONOLETTOR SAFETY LANCETS -lancets.................181
MONONINE -coagulation factor ix for inj 250 unit.......... 125
MONONINE -coagulation factor ix for inj 500 unit.......... 125
MONONINE -coagulation factor ix for inj 1000 unit........ 125
montelukast sodium chew tab 4 mg (base equiv)
(Singulair)....................................................................... 61
montelukast sodium chew tab 5 mg (base equiv)
(Singulair)....................................................................... 61
montelukast sodium oral granules packet 4 mg (base
equiv) (Singulair)...........................................................61
montelukast sodium tab 10 mg (base equiv)
(Singulair)....................................................................... 61
MONUROL -fosfomycin tromethamine powd pack 3 gm
(base equivalent)............................................................ 69
MOORE MED MONOJECT INSULI -insulin syringe/
needle u-100 1/2 ml 28 x 1/2"...................................... 181
needle u-100 1/2 ml 29 x 1/2"...................................... 181
needle u-100 1 ml 28 x 1/2"......................................... 181
2016
needle u-100 1 ml 29 x 1/2"......................................... 181
8-MOP -methoxsalen cap 10 mg.................................... 143
morphine sulfate cap sr 24hr 10 mg (Kadian).............. 93
morphine sulfate cap sr 24hr 100 mg (Kadian)............ 94
MORPHINE SULFATE ER -morphine sulfate beads cap sr
24hr 30 mg......................................................................94
24hr 45 mg......................................................................94
24hr 60 mg......................................................................94
24hr 75 mg......................................................................94
24hr 90 mg......................................................................94
24hr 120 mg....................................................................94
MORPHINE SULFATE -morphine sulfate suppos 5
mg.................................................................................... 93
mg.................................................................................... 93
mg.................................................................................... 93
mg.................................................................................... 93
MORPHINE SULFATE -morphine sulfate tab 15 mg........ 93
MORPHINE SULFATE -morphine sulfate tab 30 mg........ 93
morphine sulfate oral soln 10 mg/5ml.......................... 94
morphine sulfate oral soln 20 mg/5ml.......................... 94
morphine sulfate oral soln 100 mg/5ml (20 mg/ml)..... 94
morphine sulfate tab cr 15 mg (Ms contin).................. 94
morphine sulfate tab cr 100 mg (Ms contin)................ 94
morphine sulfate tab cr 200 mg (Ms contin)................ 94
MOTOFEN -difenoxin w/ atropine tab 1-0.025 mg............63
MOVANTIK -naloxegol oxalate tab 12.5 mg (base
equivalent)....................................................................... 68
MOVANTIK -naloxegol oxalate tab 25 mg (base
equivalent)....................................................................... 68
MOVIPREP -peg 3350-kcl-nacl-na sulfate-na ascorbate-c
for soln 100 gm...............................................................63
MOXATAG -amoxicillin (trihydrate) tab sr 24hr 775 mg...... 1
MOXEZA -moxifloxacin hcl ophth soln 0.5% (base eq) (2
times daily).................................................................... 129
moxifloxacin hcl tab 400 mg (base equiv) (Avelox)....... 5
MS CONTIN -morphine sulfate tab cr 15 mg.................... 94
MS CONTIN -morphine sulfate tab cr 100 mg.................. 94
MS CONTIN -morphine sulfate tab cr 200 mg.................. 94
MS INSULIN SYRINGE/0.5ML/ -insulin syringe/needle

u-100 1/2 ml 31 x 5/16"................................................ 181
u-100 1/2 ml 29 x 1/2".................................................. 181
u-100 1/2 ml 30 x 5/16"................................................ 181
u-100 0.3 ml 29 x 1/2".................................................. 181
u-100 0.3 ml 30 x 5/16"................................................ 181
u-100 0.3 ml 31 x 5/16"................................................ 181
MS INSULIN SYRINGE/1ML/29 -insulin syringe/needle
u-100 1 ml 29 x 1/2".....................................................181
u-100 1 ml 30 x 5/16"...................................................181
u-100 1 ml 31 x 5/16"...................................................182
MULTAQ -dronedarone hcl tab 400 mg (base
equivalent)....................................................................... 43
MULTI-DRAW NEEDLE 20GX1- -needle (disp) 20 x
1-1/2"............................................................................. 182
MULTI-DRAW NEEDLE 21GX1-1 -needle (disp) 21 x
1-1/2"............................................................................. 182
MULTI-DRAW NEEDLE 22GX1-1 -needle (disp) 22 x
1-1/2"............................................................................. 182
MULTI-LANCET DEVICE -lancet devices....................... 182
mupirocin calcium cream 2% (Bactroban)................. 139
mupirocin oint 2% (Bactroban).................................... 139
M-VIT -prenatal vit w/ fe fumarate-fa tab 27-1 mg.......... 112
MYALEPT -metreleptin for subcutaneous inj 11.3 mg...... 35
MYAMBUTOL -ethambutol hcl tab 100 mg......................... 5
MYAMBUTOL -ethambutol hcl tab 400 mg......................... 5
MYCOBUTIN -rifabutin cap 150 mg.................................... 5
mycophenolate mofetil cap 250 mg (Cellcept)........... 204
mycophenolate mofetil for oral susp 200 mg/ml
(Cellcept)...................................................................... 204
mycophenolate mofetil tab 500 mg (Cellcept)............204
mycophenolate sodium tab dr 180 mg (mycophenolic
acid equiv) (Myfortic)................................................. 204
mycophenolate sodium tab dr 360 mg (mycophenolic
acid equiv) (Myfortic)................................................. 204
MYDRIACYL -tropicamide ophth soln 1%...................... 129
MYFORTIC -mycophenolate sodium tab dr 180 mg
(mycophenolic acid equiv)............................................ 204
MYFORTIC -mycophenolate sodium tab dr 360 mg
(mycophenolic acid equiv)............................................ 204
MYGLUCOHEALTH BLOOD GLUCO -blood glucose
MYGLUCOHEALTH BLOOD GLUCO -glucose blood test
strip................................................................................ 147
MYGLUCOHEALTH MGH SOFTLAN -lancets............... 182
MYLERAN -busulfan tab 2 mg.......................................... 18
MYNATAL ADVANCE -prenatal vit w/ dss-iron carbonyl-fa
tab 90-1 mg...................................................................112
MYNATAL PLUS -prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................. 112
267
2016
MYNATAL -prenatal multivitamins & minerals w/ iron & fa
cap 1 mg....................................................................... 112
MYNATAL ULTRACAPLET -prenatal vit w/ dss-iron
carbonyl-fa tab 90-1 mg............................................... 112
MYNATAL-Z -prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................. 112
MYNATE 90 PLUS -prenatal vit w/ dss-fe fumarate-fa tab
cr 90-1 mg.....................................................................112
MYRBETRIQ -mirabegron tab sr 24 hr 25 mg.................. 69
MYRBETRIQ -mirabegron tab sr 24 hr 50 mg.................. 69
MYSOLINE -primidone tab 50 mg.................................. 104
MYSOLINE -primidone tab 250 mg................................ 104
N
nabumetone tab 500 mg................................................. 98
nabumetone tab 750 mg................................................. 98
nadolol & bendroflumethiazide tab 40-5 mg
(Corzide)......................................................................... 49
nadolol & bendroflumethiazide tab 80-5 mg
(Corzide)......................................................................... 49
nadolol tab 20 mg (Corgard).......................................... 39
naftifine hcl cream 1% (Naftin).................................... 139
NAFTIN -naftifine hcl cream 1%..................................... 139
NAFTIN -naftifine hcl cream 2%..................................... 139
NAFTIN -naftifine hcl gel 1%........................................... 139
NAFTIN -naftifine hcl gel 2%........................................... 139
NALFON -fenoprofen calcium cap 400 mg....................... 98
naloxone hcl inj 0.4 mg/ml........................................... 144
NALOXONE HCL -naloxone hcl inj 1 mg/ml................... 143
naltrexone hcl tab 50 mg (Revia)................................. 144
NAMENDA -memantine hcl oral solution 2 mg/ml............ 88
NAMENDA -memantine hcl tab 5 mg............................... 88
NAMENDA -memantine hcl tab 10 mg............................. 88
NAMENDA TITRATION PAK -memantine hcl tab 5 mg
(28) & 10 mg (21) titration pak....................................... 88
NAMENDA XR -memantine hcl cap sr 24hr 7 mg............ 88
NAMENDA XR -memantine hcl cap sr 24hr 14 mg.......... 88
NAMENDA XR TITRATION PACK -memantine hcl cap sr
24hr 7 mg & 14 mg & 21 mg & 28 mg pack.................. 88
NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr
14-10 mg......................................................................... 88
NAMZARIC -memantine hcl-donepezil hcl cap sr 24hr
28-10 mg......................................................................... 88
NAPHAZOLINE HCL -naphazoline hcl ophth soln
0.1%...............................................................................129
NAPROSYN -naproxen susp 125 mg/5ml........................ 98
NAPROSYN -naproxen tab 250 mg.................................. 98
NAPROXEN -naproxen susp 125 mg/5ml........................ 98
naproxen sodium tab 275 mg (Anaprox)...................... 98
naproxen sodium tab 550 mg (Anaprox ds)................. 98
naproxen tab ec 375 mg (Ec-naprosyn)........................ 98
268
naproxen tab ec 500 mg (Ec-naprosyn)........................ 98

naproxen tab 250 mg (Naprosyn).................................. 98
naratriptan hcl tab 1 mg (base equiv) (Amerge)........ 100
naratriptan hcl tab 2.5 mg (base equiv) (Amerge)..... 100
NARDIL -phenelzine sulfate tab 15 mg............................ 75
NASCOBAL -cyanocobalamin nasal spray 500
mcg/0.1ml...................................................................... 120
NATACHEW -prenatal vit w/ fe fum-fe bisglycin-fa chew
tab 28-1 mg...................................................................112
NATACYN -natamycin ophth susp 5%............................ 129
NATALVIRT CA -prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 300 mg pack...................................................112
NATALVIRT 90 DHA -prenat w/o a w/fecbn-fegl-dss-fa tab
90 &dha cap 300mg pak.............................................. 112
NATALVIT -prenatal vit w/ fe fumarate-fa tab 75-1
mg.................................................................................. 112
NATAL-V RX -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................. 112
NATAZIA -estradiol valerate-dienogest tab 3 mg /2-2
mg/2-3 mg/1 mg............................................................. 25
nateglinide tab 60 mg (Starlix)....................................... 29
nateglinide tab 120 mg (Starlix)..................................... 29
NATELLE ONE -prenatal w/o vit a w/ fe fum-fa-omega 3
cap 28-1-250 mg.......................................................... 112
NATPARA -parathyroid hormone (recombinant) for inj
cartridge 25 mcg............................................................. 35
cartridge 50 mcg............................................................. 35
cartridge 75 mcg............................................................. 35
cartridge 100 mcg........................................................... 36
NATROBA -spinosad susp 0.9%..................................... 139
NATURE-THROID NT-2.5 -thyroid tab 162.5 mg (2 1/2
grain)................................................................................32
NATURE-THROID -thyroid tab 16.25 mg..........................32
NATURE-THROID -thyroid tab 32.5 mg............................32
NATURE-THROID -thyroid tab 65 mg...............................32
NATURE-THROID -thyroid tab 81.25 mg..........................32
NATURE-THROID -thyroid tab 97.5 mg............................32
NATURE-THROID -thyroid tab 113.75 mg........................ 32
NATURE-THROID -thyroid tab 130 mg.............................32
NATURE-THROID -thyroid tab 146.25 mg....................... 32
NATURE-THROID -thyroid tab 48.75 mg (3/4 grain)........ 32
NATURE-THROID -thyroid tab 325 mg (5 grain).............. 32
NEBUPENT -pentamidine isethionate for nebulization
soln 300 mg.................................................................... 12
NEBUSAL -sodium chloride soln nebu 6%....................... 59
NECON 1/50-28 -norethindrone & mestranol tab 1 mg-50
mcg.................................................................................. 25
NECON 10/11-28 -norethindrone-eth estradiol tab
0.5-35/1-35 mg-mcg (10/11)........................................... 25
2016
NEEVO DHA -prenat w/o a w/fefum-methylfol-omegas
cap 27-1.13 mg............................................................. 112
NEFAZODONE HCL -nefazodone hcl tab 100 mg........... 75
nefazodone hcl tab 50 mg.............................................. 75
nefazodone hcl tab 250 mg............................................ 75
NEOMYCIN/POLYMYXIN/HYDROC -neomycinpolymyxin-hc ophth susp.............................................. 129
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin............................. 129
neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml (Neosporin)........... 129
neomycin-polymyxin-dexamethasone ophth oint 0.1%
(Maxitrol)...................................................................... 129
neomycin-polymyxin-dexamethasone ophth susp
0.1% (Maxitrol).............................................................129
neomycin-polymyxin-hc otic soln 1%
(Cortisporin).................................................................131
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000
unit/ml-1%.................................................................... 131
neomycin sulfate tab 500 mg........................................... 5
NEORAL -cyclosporine modified cap 25 mg...................204
NEORAL -cyclosporine modified cap 100 mg.................204
NEORAL -cyclosporine modified oral soln 100 mg/
ml................................................................................... 204
NEOSPORIN -neomycin-polymy-gramicid op sol
1.75-10000-0.025mg-unt-mg/ml................................... 129
NEPHROCAPS QT -b-complex w/ c-biotin-d & folic acid
tab disp 1 mg................................................................ 112
NEPTAZANE -methazolamide tab 25 mg......................... 52
NEPTAZANE -methazolamide tab 50 mg......................... 52
NESINA -alogliptin benzoate tab 6.25 mg (base
equiv)............................................................................... 29
NESINA -alogliptin benzoate tab 12.5 mg (base
equiv)............................................................................... 29
NESINA -alogliptin benzoate tab 25 mg (base equiv).......29
NESTABS ABC -prenatal w/o vit a w/fe polysac-fa-ca tab
& omega 3 cap............................................................. 112
NESTABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack....................................................... 112
NESTABS -prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg......................................................................... 112
NETGROUP LANCETS -lancets..................................... 182
NEULASTA DELIVERY KIT -pegfilgrastim soln prefilled
syringe kit 6 mg/0.6ml.................................................. 120
NEULASTA -pegfilgrastim soln prefilled syringe 6
mg/0.6ml........................................................................ 120
NEUPOGEN -filgrastim inj 300 mcg/ml........................... 120
NEUPOGEN -filgrastim inj 480 mcg/1.6ml (300 mcg/
ml).................................................................................. 120
NEUPOGEN -filgrastim soln prefilled syringe 300
mcg/0.5ml...................................................................... 120
NEUPOGEN -filgrastim soln prefilled syringe 480
mcg/0.8ml (600 mcg/ml)............................................... 120
NEUPRO -rotigotine td patch 24hr 1 mg/24hr................ 107

NEURONTIN -gabapentin cap 100 mg........................... 104
NEURONTIN -gabapentin oral soln 250 mg/5ml............ 104
NEURONTIN -gabapentin tab 600 mg............................ 104
NEURONTIN -gabapentin tab 800 mg............................ 104
NEUTEK 2TEK TEST STRIPS -glucose blood test
strip................................................................................ 147
NEVANAC -nepafenac ophth susp 0.1%........................ 129
NEVIRAPINE -nevirapine susp 50 mg/5ml......................... 8
nevirapine tab 200 mg (Viramune)...................................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......................................................................... 112
NEXA PLUS -prenatal w/o vit a w/ fe fum-doc-fa-dha cap
29-1.25-350 mg.............................................................112
NEXAVAR -sorafenib tosylate tab 200 mg (base
equivalent)....................................................................... 18
NEXGEN METER KIT -blood glucose monitoring kit...... 182
NEXGEN TEST STRIPS -glucose blood test strip..........147
NEXIUM -esomeprazole magnesium cap delayed release
20 mg (base eq)............................................................. 65
NEXIUM -esomeprazole magnesium cap delayed release
40 mg (base eq)............................................................. 65
NEXIUM -esomeprazole magnesium for delayed release
susp packet 5 mg........................................................... 65
susp packet 10 mg......................................................... 65
susp packet 20 mg......................................................... 65
susp packet 40 mg......................................................... 65
susp pack 2.5 mg........................................................... 65
niacin tab cr 500 mg (antihyperlipidemic)
(Niaspan)........................................................................ 55
(Niaspan)........................................................................ 55
(Niaspan)........................................................................ 55
NIACOR -niacin (antihyperlipidemic) tab 500 mg............. 55
NIASPAN -niacin tab cr 500 mg (antihyperlipidemic)........55
NIASPAN -niacin tab cr 750 mg (antihyperlipidemic)........55
NIASPAN -niacin tab cr 1000 mg (antihyperlipidemic)......55
nicardipine hcl cap 20 mg.............................................. 42
nicardipine hcl cap 30 mg.............................................. 42
nicotine polacrilex gum 2 mg.........................................88
nicotine polacrilex gum 4 mg.........................................88
nicotine td patch 24hr 7 mg/24hr...................................88
nicotine td patch 24hr 14 mg/24hr.................................88
nicotine td patch 24hr 21 mg/24hr.................................88
nifedipine cap 20 mg....................................................... 42
nifedipine cap 10 mg (Procardia).................................. 42
269
2016
nifedipine tab sr 24hr 30 mg (Adalat cc).......................42
nifedipine tab sr 24hr osmotic release 30 mg
(Procardia xl)................................................................. 42
(Procardia xl)................................................................. 42
(Procardia xl)................................................................. 42
NILANDRON -nilutamide tab 150 mg............................... 18
nimodipine cap 30 mg..................................................... 42
NISOLDIPINE ER -nisoldipine tab sr 24hr 25.5 mg.......... 42
NISOLDIPINE -nisoldipine tab sr 24hr 20 mg................... 42
nisoldipine tab sr 24hr 8.5 mg (Sular)........................... 42
nisoldipine tab sr 24hr 17 mg (Sular)............................42
nisoldipine tab sr 24hr 34 mg (Sular)............................42
NITRO-BID -nitroglycerin oint 2%..................................... 38
NITRO-DUR -nitroglycerin td patch 24hr 0.1 mg/hr.......... 38
nitrofurantoin macrocrystalline cap 25 mg
(Macrodantin).................................................................69
(Macrodantin).................................................................69
(Macrodantin).................................................................69
nitrofurantoin monohydrate macrocrystalline cap 100
mg (Macrobid)............................................................... 69
nitrofurantoin susp 25 mg/5ml (Furadantin)................ 69
nitroglycerin cap cr 2.5 mg............................................ 38
nitroglycerin cap cr 6.5 mg............................................ 38
nitroglycerin cap cr 9 mg............................................... 38
NITROGLYCERIN LINGUAL -nitroglycerin lingual aerosol
400 mcg/spray................................................................ 38
nitroglycerin td patch 24hr 0.1 mg/hr (Nitro-dur)......... 38
nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)
(Nitrolingual pumpspr)................................................. 38
NITROLINGUAL PUMPSPRAY -nitroglycerin tl soln 0.4
mg/spray (400 mcg/spray)..............................................38
NITROMIST -nitroglycerin lingual aerosol 400 mcg/
spray................................................................................ 38
NITROSTAT -nitroglycerin sl tab 0.3 mg........................... 38
NIVA-PLUS -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 112
nizatidine cap 150 mg..................................................... 65
nizatidine cap 300 mg (Axid).......................................... 65
nizatidine oral soln 15 mg/ml......................................... 65
270
NIZORAL -ketoconazole shampoo 2%........................... 139

NOKOR ADMIX NEEDLE THIN W -needle (disp) 18 x
1-1/2"............................................................................. 182
NOKOR ADMIX NEEDLE THIN W -needle (disp) 16 x
1".................................................................................... 182
NOKOR VENTED NEEDLE THIN -needle (disp) 18 x
1-1/2"............................................................................. 182
1".................................................................................... 182
1".................................................................................... 182
NORDITROPIN CARTRIDGE -somatropin inj 5
mg/1.5ml.......................................................................... 36
NORDITROPIN FLEXPRO -somatropin inj 5
mg/1.5ml.......................................................................... 36
mg/1.5ml.......................................................................... 36
mg/1.5ml.......................................................................... 36
mg/3ml............................................................................. 36
NORDITROPIN NORDIFLEX PEN -somatropin inj 30
mg/3ml............................................................................. 36
norethindrone & ethinyl estradiol-fe chew tab 0.4
mg-35 mcg (Femcon fe)............................................... 25
norethindrone & ethinyl estradiol-fe chew tab 0.8
mg-25 mcg (Generess fe)............................................ 25
norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg
(Brevicon-28)................................................................. 25
norethindrone & ethinyl estradiol tab 1 mg-35 mcg
(Norinyl 1+35)................................................................ 25
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg
(Ovcon-35)...................................................................... 25
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20
mcg (Loestrin fe 1/20).................................................. 25
norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30
mcg (Loestrin fe 1.5/30)............................................... 25
norethindrone ace & ethinyl estradiol tab 1 mg-20
mcg (Loestrin 1/20-21)................................................. 25
norethindrone ace & ethinyl estradiol tab 1.5 mg-30
mcg (Loestrin 1.5/30-21).............................................. 25
norethindrone ace-ethinyl estradiol-fe tab 1 mg-20
mcg (24)......................................................................... 25
norethindrone acetate-ethinyl estradiol tab 1 mg-5
mcg................................................................................. 24
norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5
mcg (Femhrt low dose)................................................ 24
norethindrone acetate tab 5 mg (Aygestin).................. 26
norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35
mg-mcg (Estrostep fe)................................................. 25
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35
mg-mcg (Ortho-novum 7/7/7)...................................... 26
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mgmcg (Tri-norinyl 28)...................................................... 26
norethindrone tab 0.35 mg (Nor-qd).............................. 25
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg
(Ortho-cyclen)................................................................ 26
2016
norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35
mg-mcg (Ortho tri-cyclen)........................................... 26
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg........ 26
NORINYL 1+35 -norethindrone & ethinyl estradiol tab 1
mg-35 mcg...................................................................... 26
NORINYL 1+50 -norethindrone & mestranol tab 1 mg-50
mcg.................................................................................. 26
NORPACE CR -disopyramide phosphate cap sr 12hr 100
mg.................................................................................... 43
NORPACE CR -disopyramide phosphate cap sr 12hr 150
mg.................................................................................... 43
NORPACE -disopyramide phosphate cap 100 mg........... 43
NORPACE -disopyramide phosphate cap 150 mg........... 43
NORPRAMIN -desipramine hcl tab 10 mg........................75
NORPRAMIN -desipramine hcl tab 100 mg......................75
NORPRAMIN -desipramine hcl tab 150 mg......................75
NOR-QD -norethindrone tab 0.35 mg............................... 25
nortriptyline hcl cap 10 mg (Pamelor)...........................75
NORTRIPTYLINE HCL -nortriptyline hcl soln 10
mg/5ml............................................................................. 75
NORVASC -amlodipine besylate tab 2.5 mg.................... 42
NORVASC -amlodipine besylate tab 5 mg....................... 42
NORVASC -amlodipine besylate tab 10 mg..................... 42
NORVIR -ritonavir cap 100 mg........................................... 8
NORVIR -ritonavir oral soln 80 mg/ml.................................8
NORVIR -ritonavir tab 100 mg............................................ 8
NOVACORT -hydrocortisone ace-pramoxine-aloe
polysacch gel 2-1-1%................................................... 139
NOVA MAX BLOOD GLUCOSE MO -blood glucose
NOVA MAX BLOOD GLUCOSE MO -blood glucose
NOVA MAX GLUCOSE TEST STR -glucose blood test
strip................................................................................ 147
NOVA SAFETY LANCETS 23G -lancets........................ 182
NOVA SAFETY LANCETS 28G -lancets........................ 182
NOVA SUREFLEX LANCETS -lancets........................... 182
NOVA SUREFLEX LANCING DEV -lancet devices........ 182
NOVOEIGHT -antihemophilic factor (recombinant) for inj
250 unit......................................................................... 125
500 unit......................................................................... 125
1000 unit....................................................................... 125
1500 unit....................................................................... 125
2000 unit....................................................................... 125
3000 unit....................................................................... 125
NOVOFINE AUTOCOVER 30GX8M -insulin pen needle

30 g x 8 mm (1/3" or 5/16")......................................... 182
NOVOFINE 32GX6MM -insulin pen needle 32 g x 6 mm
(1/4").............................................................................. 182
NOVOFINE 30GX8MM -insulin pen needle 30 g x 8 mm
(1/3" or 5/16")................................................................182
NOVOFINE PLUS 32GX4MM -insulin pen needle 32 g x 4
mm (5/32").................................................................... 182
NOVOLIN 70/30 -insulin nph isophane & regular human
inj 100 unit/ml (70-30).................................................... 31
NOVOLIN 70/30 RELION -insulin nph isophane & regular
human inj 100 unit/ml (70-30)........................................ 31
NOVOLIN N -insulin nph (human) (isophane) inj 100 unit/
ml..................................................................................... 31
NOVOLIN N RELION -insulin nph (human) (isophane) inj
100 unit/ml.......................................................................31
NOVOLIN R -insulin regular (human) inj 100 unit/ml........ 31
NOVOLIN R RELION -insulin regular (human) inj 100
unit/ml.............................................................................. 31
NOVOLOG FLEXPEN -insulin aspart soln pen-injector
100 unit/ml.......................................................................31
NOVOLOG -insulin aspart inj 100 unit/ml......................... 31
NOVOLOG MIX 70/30 -insulin aspart prot & aspart
(human) inj 100 unit/ml (70-30)...................................... 31
NOVOLOG MIX 70/30 PREFILL -insulin aspart prot &
aspart sus pen-inj 100 unit/ml (70-30)........................... 31
NOVOLOG PENFILL -insulin aspart inj 100 unit/ml..........31
NOVOLOG PENFILL -insulin aspart soln cartridge 100
unit/ml.............................................................................. 31
NOVOPEN ECHO -injection device for insulin............... 182
NOVOPEN 3 INSULIN DELIVER -injection device for
insulin.............................................................................182
NOVOPEN JR (GREEN) -injection device for insulin..... 182
NOVOPEN JR (YELLOW) -injection device for
insulin.............................................................................182
NOVOPEN 3 PENMATE -injection device for insulin...... 182
NOVOSEVEN -coagulation factor viia (recomb) for inj 2.4
mg (2400 mcg)............................................................. 125
NOVOSEVEN RT -coagulation factor viia (recomb) for inj
1 mg (1000 mcg).......................................................... 125
2 mg (2000 mcg).......................................................... 125
5 mg (5000 mcg).......................................................... 125
8 mg (8000 mcg).......................................................... 125
NOVOTWIST 30GX8MM -insulin pen needle 30 g x 8 mm
(1/3" or 5/16")................................................................182
NOVOTWIST 32GX5MM -insulin pen needle 32 g x 5 mm
(1/5" or 3/16")................................................................182
NOXAFIL -posaconazole susp 40 mg/ml............................ 6
NOXAFIL -posaconazole tab delayed release 100 mg....... 6
NUCORT -hydrocortisone acetate lotion 2%.................. 139
NUCYNTA ER -tapentadol hcl tab sr 12hr 50 mg............. 94
NUCYNTA ER -tapentadol hcl tab sr 12hr 100 mg........... 94
271
2016
NUCYNTA -tapentadol hcl tab 50 mg............................... 94
NUCYNTA -tapentadol hcl tab 75 mg............................... 94
NUCYNTA -tapentadol hcl tab 100 mg............................. 94
NUEDEXTA -dextromethorphan hbr-quinidine sulfate cap
20-10 mg......................................................................... 88
NULYTELY/FLAVOR PACKS -peg 3350-kcl-sod bicarbnacl for soln 420 gm.......................................................63
NUOX -benzoyl peroxide-sulfur gel 6-3%....................... 139
NUTRESTORE -glutamine powd pack 5 gm.................. 119
NUTROPIN AQ NUSPIN 10 -somatropin inj 10
mg/2ml............................................................................. 36
NUTROPIN AQ NUSPIN 20 -somatropin inj 20
mg/2ml............................................................................. 36
NUTROPIN AQ NUSPIN 5 -somatropin inj 5 mg/2ml....... 36
NUTROPIN AQ PEN -somatropin inj 10 mg/2ml.............. 36
NUTROPIN AQ PEN -somatropin inj 20 mg/2ml.............. 36
NUTROPIN -somatropin for inj 10 mg.............................. 36
NUVARING -etonogestrel-ethinyl estradiol va ring
0.120-0.015 mg/24hr...................................................... 26
NUVIGIL -armodafinil tab 50 mg....................................... 85
NUVIGIL -armodafinil tab 150 mg..................................... 85
NYMALIZE -nimodipine oral soln 60 mg/20ml.................. 42
nystatin cream 100000 unit/gm.................................... 139
nystatin oint 100000 unit/gm........................................ 139
nystatin susp 100000 unit/ml....................................... 131
nystatin tab 500000 unit....................................................6
nystatin topical powder................................................ 139
nystatin-triamcinolone cream 100000-0.1 unit/gm%.................................................................................... 139
nystatin-triamcinolone oint 100000-0.1 unit/gm%.................................................................................... 139
O
OB COMPLETE/DHA -prenat w/ iron cbn-fe asp glyc-faomega cap 30-10-1-200 mg......................................... 112
OB COMPLETE ONE -prenatal w/o a w/fecbn-fe asp
glyc-fa-fish cap 50-1-476 mg........................................112
OB COMPLETE PETITE -prenat w/o a w/fecbnfeaspglyc-fa-omega cap 35-5-1-200 mg...................... 112
OB COMPLETE PREMIER -prenatal vit w/ fe cbn-fe asp
glyc-fa tab 30-20-1 mg................................................. 112
OB COMPLETE -prenatal vit w/ iron carbonyl-fa tab
50-1.25 mg.................................................................... 112
OBIZUR -antihemophilic factor (recomb porc) rpfviii for inj
500 unit......................................................................... 125
OB-NATAL ONE -prenatal vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg................................................... 112
OBSTETRIX DHA -prenat w/fecbn-fa-dss tab 29-1 mg &
omega 3 cap 387 mg pak............................................ 112
OBSTETRIX EC -prenatal vit w/ dss-iron carbonyl-fa tab
29-1 mg......................................................................... 112
O-CAL FA -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 112
272
O-CAL PRENATAL -prenatal vit w/ fe fumarate-fa tab 15-1

mg.................................................................................. 112
octreotide acetate inj 50 mcg/ml (0.05 mg/ml)
(Sandostatin)................................................................. 36
(Sandostatin)................................................................. 36
(Sandostatin)................................................................. 36
(Sandostatin)................................................................. 36
octreotide acetate inj 1000 mcg/ml (1 mg/ml)
(Sandostatin)................................................................. 36
OCUFEN -flurbiprofen sodium ophth soln 0.03%........... 129
OCUFLOX -ofloxacin ophth soln 0.3%........................... 129
ODOMZO -sonidegib phosphate cap 200 mg (base
equivalent)....................................................................... 18
OFEV -nintedanib esylate cap 100 mg (base
equivalent)....................................................................... 63
OFEV -nintedanib esylate cap 150 mg (base
equivalent)....................................................................... 63
OFLOXACIN -ofloxacin tab 400 mg.................................... 5
ofloxacin ophth soln 0.3% (Ocuflox)........................... 129
ofloxacin otic soln 0.3%................................................131
OGESTREL -norgestrel & ethinyl estradiol tab 0.5 mg-50
mcg.................................................................................. 26
olanzapine-fluoxetine hcl cap 3-25 mg (Symbyax)...... 88
olanzapine-fluoxetine hcl cap 12-25 mg
(Symbyax)...................................................................... 88
olanzapine-fluoxetine hcl cap 12-50 mg
(Symbyax)...................................................................... 88
olanzapine orally disintegrating tab 5 mg (Zyprexa
zydis)...............................................................................79
zydis)...............................................................................79
zydis)...............................................................................79
zydis)...............................................................................79
olanzapine tab 2.5 mg (Zyprexa)................................... 79
olanzapine tab 5 mg (Zyprexa)...................................... 79
olanzapine tab 7.5 mg (Zyprexa)................................... 79
olanzapine tab 10 mg (Zyprexa).................................... 79
OLEPTRO -trazodone hcl tab sr 24hr 150 mg..................75
OLEPTRO -trazodone hcl tab sr 24hr 300 mg..................75
olopatadine hcl nasal soln 0.6% (Patanase).................58
OLUX -clobetasol propionate foam 0.05%......................139
OLUX-E -clobetasol propionate emulsion foam
0.05%.............................................................................139
OLYSIO -simeprevir sodium cap 150 mg (base
equivalent)......................................................................... 8
OMECLAMOX-PAK -amoxicillin cap-clarithro tab w/
omepraz cap dr therapy pack........................................ 65
2016
OMEGA-3/D-3 WELLNESS PACK -omega-3-acid ethyl
esters cap 1gm & vit d3 cap 1000 unit kit......................55
omega-3-acid ethyl esters cap 1 gm (Lovaza)............. 55
omeprazole cap delayed release 10 mg (Prilosec)...... 65
omeprazole-sodium bicarbonate cap 20-1100 mg
(Zegerid)......................................................................... 65
omeprazole-sodium bicarbonate cap 40-1100 mg
(Zegerid)......................................................................... 65
OMNIFLEX DIAPHRAGM -diaphragms.......................... 182
OMNIPOD STARTER KIT -insulin infusion disposable
pump kit.........................................................................182
OMNIPRED -prednisolone acetate ophth susp 1%........ 129
OMNITROPE -somatropin for inj 5.8 mg.......................... 36
OMNITROPE -somatropin inj 5 mg/1.5ml......................... 36
OMNITROPE -somatropin inj 10 mg/1.5ml....................... 36
ON CALL EXPRESS BLOOD GLU -blood glucose
ON CALL EXPRESS BLOOD GLU -blood glucose
ON CALL EXPRESS BLOOD GLU -glucose blood test
strip................................................................................ 147
ON CALL LANCETS -lancets.......................................... 182
ON CALL LANCING DEVICE -lancet devices................ 182
ON CALL PLUS BLOOD GLUCOS -blood glucose
ON CALL PLUS BLOOD GLUCOS -blood glucose
ON CALL PLUS BLOOD GLUCOS -glucose blood test
strip................................................................................ 147
ON CALL PLUS LANCETS -lancets............................... 183
ON CALL PLUS LANCING DEVI -lancet devices........... 183
ON CALL VIVID BLOOD GLUCO -blood glucose
ON CALL VIVID BLOOD GLUCO -blood glucose
ON CALL VIVID BLOOD GLUCO -glucose blood test
strip................................................................................ 147
ON CALL VIVID PAL BLOOD G -blood glucose
ON CALL VIVID PAL BLOOD G -blood glucose
ondansetron hcl oral soln 4 mg/5ml (Zofran)............... 66
ondansetron hcl tab 24 mg............................................ 66
ondansetron hcl tab 4 mg (Zofran)................................66
ondansetron hcl tab 8 mg (Zofran)................................66
ondansetron orally disintegrating tab 4 mg (Zofran
odt).................................................................................. 66
ondansetron orally disintegrating tab 8 mg (Zofran
odt).................................................................................. 66
ONETOUCH BASIC/PROFILE TE -glucose blood test
strip................................................................................ 147
ONETOUCH BASIC SYSTEM -blood glucose monitoring
kit w/ device.................................................................. 183
ONETOUCH CLUB LANCETS FIN -lancets................... 183
ONETOUCH COMBO PACK -lancets............................. 183
ONETOUCH DELICA LANCETS E -lancets................... 183

ONETOUCH DELICA LANCETS F -lancets................... 183
ONETOUCH DELICA LANCING D -lancet devices........ 183
ONETOUCH FINEPOINT LANCET -lancets...................183
ONETOUCH LANCETS -lancets..................................... 183
ONETOUCH PING METER REMOT -blood glucose
monitoring supplies....................................................... 183
ONETOUCH PROFILE SYSTEM -blood glucose
ONETOUCH SURESOFT LANCING -lancets misc........ 183
ONETOUCH ULTRA 2 -blood glucose monitoring kit w/
device............................................................................ 183
ONETOUCH ULTRA BLUE -glucose blood test strip..... 147
ONETOUCH ULTRALINK SYSTEM -blood glucose
ONETOUCH ULTRA MINI -blood glucose monitoring kit
w/ device....................................................................... 183
ONETOUCH ULTRASMART -blood glucose monitoring kit
w/ device....................................................................... 183
ONETOUCH ULTRASOFT LANCET -lancets................. 183
ONETOUCH ULTRA SYSTEM KIT -blood glucose
ONETOUCH ULTRA TEST STRIP -glucose blood test
strip................................................................................ 147
ONETOUCH VERIO -blood glucose monitoring kit w/
device............................................................................ 183
ONETOUCH VERIO IQ BLOOD G -blood glucose
ONETOUCH VERIO SYNC BLOOD -blood glucose
ONETOUCH VERIO TEST STRIP -glucose blood test
strip................................................................................ 147
ONFI -clobazam suspension 2.5 mg/ml.......................... 105
ONFI -clobazam tab 10 mg............................................. 105
ONFI -clobazam tab 20 mg............................................. 105
ONGLYZA -saxagliptin hcl tab 2.5 mg (base equiv)......... 29
ONGLYZA -saxagliptin hcl tab 5 mg (base equiv)............ 29
OPANA ER (CRUSH RESISTANT -oxymorphone hcl tab
er 12hr deter 5 mg......................................................... 94
er 12hr deter 7.5 mg...................................................... 94
er 12hr deter 10 mg....................................................... 94
er 12hr deter 15 mg....................................................... 95
er 12hr deter 20 mg....................................................... 95
er 12hr deter 30 mg....................................................... 95
er 12hr deter 40 mg....................................................... 95
OPANA -oxymorphone hcl tab 5 mg................................. 94
OPANA -oxymorphone hcl tab 10 mg............................... 94
opium tincture 1% (10 mg/ml) (morphine equiv)..........63
OPIUM TINCTURE (PAREGORIC -paregoric 2
mg/5ml............................................................................. 63
OPSUMIT -macitentan tab 10 mg..................................... 57
273
2016
OPTASE -trypsin w/ castor oil & peruvian balsam
gel.................................................................................. 139
OPTIONS CONCEPTROL VAGINA -nonoxynol-9 gel
4%.................................................................................... 70
OPTIONS GYNOL II VAGINAL -nonoxynol-9 gel 3%....... 70
OPTIUM BLOOD GLUCOSE MONI -blood glucose
OPTIUM BLOOD GLUCOSE MONI -blood glucose
OPTIUMEZ TEST STRIPS -glucose blood test strip...... 147
OPTIUM TEST STRIPS -glucose blood test strip........... 147
OPTUMRX BLOOD GLUCOSE MET -blood glucose
OPTUMRX BLOOD GLUCOSE MON -blood glucose
OPTUMRX BLOOD GLUCOSE TES -glucose blood test
strip................................................................................ 147
ORACIT -sodium citrate & citric acid soln 490-640
mg/5ml............................................................................. 71
ORAP -pimozide tab 1 mg................................................ 88
ORAP -pimozide tab 2 mg................................................ 88
ORAPRED ODT -prednisolone sod phos orally disintegr
tab 10 mg (base eq)....................................................... 21
tab 15 mg (base eq)....................................................... 21
tab 30 mg (base eq)....................................................... 21
ORAVIG -miconazole buccal tab 50 mg (mouththroat)............................................................................ 131
ORENCIA -abatacept subcutaneous soln prefilled syringe
125 mg/ml....................................................................... 99
ORENITRAM -treprostinil diolamine tab cr 0.125 mg
(base equiv).................................................................... 57
ORENITRAM -treprostinil diolamine tab cr 0.25 mg (base
equiv)............................................................................... 57
ORENITRAM -treprostinil diolamine tab cr 1 mg (base
equiv)............................................................................... 57
ORENITRAM -treprostinil diolamine tab cr 2.5 mg (base
equiv)............................................................................... 57
ORFADIN -nitisinone cap 2 mg......................................... 36
ORFADIN -nitisinone cap 5 mg......................................... 36
ORFADIN -nitisinone cap 10 mg....................................... 36
ORKAMBI -lumacaftor-ivacaftor tab 200-125 mg............. 63
orphenadrine citrate tab sr 12hr 100 mg.................... 109
orphenadrine w/ aspirin & caffeine tab 25-385-30
mg................................................................................. 109
ORTHO-CEPT -desogestrel & ethinyl estradiol tab 0.15
mg-30 mcg...................................................................... 26
ORTHO-CYCLEN -norgestimate & ethinyl estradiol tab
0.25 mg-35 mcg.............................................................. 26
ORTHO D -folic acid-cholecalciferol cap 1 mg-3775
unit................................................................................. 120
ORTHO DIAPHRAGM COIL SPRI -diaphragm coil spring
kit 50 mm...................................................................... 183
kit 100 mm.................................................................... 183
274

kit 105 mm.................................................................... 183
ORTHO DIAPHRAGM FLAT SPRI -diaphragm flat spring
kit 55 mm...................................................................... 183
kit 60 mm...................................................................... 183
kit 65 mm...................................................................... 184
kit 70 mm...................................................................... 184
kit 75 mm...................................................................... 184
kit 80 mm...................................................................... 184
kit 85 mm...................................................................... 184
kit 90 mm...................................................................... 184
kit 95 mm...................................................................... 184
ORTHO EVRA -norelgestromin-ethinyl estradiol td ptwk
150-35 mcg/24hr............................................................. 26
ORTHO MICRONOR -norethindrone tab 0.35 mg............26
ORTHO-NOVUM 7/7/7 -norethindrone-eth estradiol tab
0.5-35/0.75-35/1-35 mg-mcg.......................................... 26
ORTHO-NOVUM 1/35 -norethindrone & ethinyl estradiol
tab 1 mg-35 mcg............................................................ 26
ORTHO TRI-CYCLEN LO -norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg................................. 26
ORTHO TRI-CYCLEN -norgestimate-eth estrad tab
0.18-35/0.215-35/0.25-35 mg-mcg................................. 26
OSENI -alogliptin-pioglitazone tab 12.5-15 mg................. 29
OSENI -alogliptin-pioglitazone tab 25-15 mg.................... 29
OSMOPREP -sod phos mono-sod phos di tabs
1.102-0.398 gm(1.5gm na phos).................................... 63
OSPHENA -ospemifene tab 60 mg................................... 36
OTEZLA -apremilast tab 30 mg........................................ 99
OTEZLA -apremilast tab starter therapy pack 10 mg & 20
mg & 30 mg.................................................................... 99
OTREXUP -methotrexate soln pf auto-injector 7.5
mg/0.4ml.......................................................................... 99
OTREXUP -methotrexate soln pf auto-injector 10
mg/0.4ml.......................................................................... 99
mg/0.4ml.......................................................................... 99
mg/0.4ml.......................................................................... 99
mg/0.4ml.......................................................................... 99
OVACE PLUS -sulfacetamide sodium cream 10%......... 139
OVACE PLUS -sulfacetamide sodium shampoo
10%................................................................................139
OVIDE -malathion lotion 0.5%........................................ 139
2016
OXANDRIN -oxandrolone tab 2.5 mg............................... 22
OXANDRIN -oxandrolone tab 10 mg................................ 22
oxandrolone tab 2.5 mg (Oxandrin).............................. 22
oxandrolone tab 10 mg (Oxandrin)............................... 22
oxaprozin tab 600 mg (Daypro)..................................... 99
OXAYDO -oxycodone hcl tab abuse deter 5 mg.............. 95
OXAYDO -oxycodone hcl tab abuse deter 7.5 mg............95
oxazepam cap 10 mg...................................................... 72
oxazepam cap 15 mg...................................................... 72
oxazepam cap 30 mg...................................................... 72
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
(Trileptal)...................................................................... 105
oxcarbazepine tab 150 mg (Trileptal).......................... 105
OXECTA -oxycodone hcl tab abuse deter 5 mg............... 95
OXECTA -oxycodone hcl tab abuse deter 7.5 mg............ 95
OXISTAT -oxiconazole nitrate cream 1%........................ 139
OXISTAT -oxiconazole nitrate lotion 1%......................... 139
OXSORALEN -methoxsalen lotion 1%........................... 139
OXSORALEN ULTRA -methoxsalen rapid cap 10
mg.................................................................................. 139
OXTELLAR XR -oxcarbazepine tab sr 24hr 150 mg...... 105
oxybutynin chloride syrup 5 mg/5ml............................ 69
oxybutynin chloride tab 5 mg........................................ 70
oxybutynin chloride tab sr 24hr 5 mg (Ditropan xl)..... 69
oxybutynin chloride tab sr 24hr 10 mg (Ditropan
xl)..................................................................................... 69
oxybutynin chloride tab sr 24hr 15 mg (Ditropan
xl)..................................................................................... 69
oxycodone-aspirin tab 4.8355-325 mg (Percodan)...... 95
oxycodone hcl cap 5 mg................................................ 95
oxycodone hcl conc 100 mg/5ml (20 mg/ml)
(Oxycodone hcl)............................................................ 95
OXYCODONE HCL ER -oxycodone hcl tab er 12hr deter
10 mg.............................................................................. 95
20 mg.............................................................................. 95
40 mg.............................................................................. 95
80 mg.............................................................................. 95
OXYCODONE HCL -oxycodone hcl conc 100 mg/5ml (20
mg/ml).............................................................................. 95
OXYCODONE HCL -oxycodone hcl soln 5 mg/5ml.......... 95
oxycodone hcl soln 5 mg/5ml (Oxycodone hcl)...........95
oxycodone hcl tab 10 mg............................................... 95
oxycodone hcl tab 20 mg............................................... 95
oxycodone hcl tab 5 mg (Roxicodone)......................... 95
oxycodone hcl tab 15 mg (Roxicodone)....................... 95
oxycodone hcl tab 30 mg (Roxicodone)....................... 95
oxycodone-ibuprofen tab 5-400 mg.............................. 95
oxycodone w/ acetaminophen tab 2.5-325 mg
(Percocet)....................................................................... 95
oxycodone w/ acetaminophen tab 5-325 mg

(Percocet)....................................................................... 95
oxycodone w/ acetaminophen tab 7.5-325 mg
(Percocet)....................................................................... 95
oxycodone w/ acetaminophen tab 10-325 mg
(Percocet)....................................................................... 95
OXYCONTIN -oxycodone hcl tab er 12hr deter 10 mg..... 95
oxymorphone hcl tab 5 mg (Opana)..............................96
oxymorphone hcl tab 10 mg (Opana)............................96
oxymorphone hcl tab sr 12hr 5 mg............................... 95
oxymorphone hcl tab sr 12hr 7.5 mg............................ 95
oxymorphone hcl tab sr 12hr 10 mg............................. 95
OXYTROL -oxybutynin td patch twice weekly 3.9
mg/24hr........................................................................... 70
P
PAIRE OB -prenat w/ fe poly cmplx-fe asp-fe gly-fa tab &
dha cap pak.................................................................. 113
paliperidone tab sr 24hr 1.5 mg (Invega)...................... 79
paliperidone tab sr 24hr 3 mg (Invega)......................... 79
PAMELOR -nortriptyline hcl cap 10 mg............................ 75
PAMINE FORTE -methscopolamine bromide tab 5
mg.................................................................................... 65
PAMINE -methscopolamine bromide tab 2.5 mg.............. 65
PANCREAZE -pancrelipase (lip-prot-amyl) dr cap
4200-10000-17500 unit...................................................66
10500-25000-43750 unit................................................ 66
16800-40000-70000 unit................................................ 66
21000-37000-61000 unit................................................ 66
PANCRELIPASE -pancrelipase (lip-prot-amyl) dr cap
5000-17000-27000 unit...................................................66
PANDEL -hydrocortisone probutate cream 0.1%............ 139
PANRETIN -alitretinoin gel 0.1%..................................... 139
pantoprazole sodium ec tab 20 mg (base equiv)
(Protonix)........................................................................65
pantoprazole sodium ec tab 40 mg (base equiv)
(Protonix)........................................................................65
PARADIGM LINK BLOOD GLUCO -blood glucose
275
2016
PARAFON FORTE DSC -chlorzoxazone tab 500 mg..... 109
paricalcitol cap 4 mcg..................................................... 36
paricalcitol cap 1 mcg (Zemplar)................................... 36
paricalcitol cap 2 mcg (Zemplar)................................... 36
PARLODEL -bromocriptine mesylate cap 5 mg.............. 107
PARNATE -tranylcypromine sulfate tab 10 mg................. 76
paromomycin sulfate cap 250 mg................................... 5
paroxetine hcl tab 10 mg (Paxil).................................... 76
paroxetine hcl tab sr 24hr 12.5 mg (Paxil cr)............... 76
paroxetine hcl tab sr 24hr 25 mg (Paxil cr).................. 76
paroxetine hcl tab sr 24hr 37.5 mg (Paxil cr)............... 76
PASER -aminosalicylic acid cr granules packet 4 gm.........5
PATADAY -olopatadine hcl ophth soln 0.2% (base
equivalent)..................................................................... 129
PATANASE -olopatadine hcl nasal soln 0.6%................... 58
PATANOL -olopatadine hcl ophth soln 0.1% (base
equivalent)..................................................................... 129
PAXIL CR -paroxetine hcl tab sr 24hr 12.5 mg................. 76
PAXIL CR -paroxetine hcl tab sr 24hr 25 mg.................... 76
PAXIL CR -paroxetine hcl tab sr 24hr 37.5 mg................. 76
PAXIL -paroxetine hcl oral susp 10 mg/5ml (base
equiv)............................................................................... 76
PAXIL -paroxetine hcl tab 10 mg...................................... 76
PAZEO -olopatadine hcl ophth soln 0.7% (base
equivalent)..................................................................... 129
PCE -erythromycin w/ enteric coated particles tab 333
mg...................................................................................... 3
PCE -erythromycin w/ enteric coated particles tab 500
mg...................................................................................... 3
PC LANCETS SUPER THIN 30G -lancets..................... 184
PC UNIFINE PENTIPS 29G X -insulin pen needle 29 g x
12 mm (1/2")................................................................. 184
5 mm (3/16")................................................................. 184
6 mm (1/4")................................................................... 184
8 mm (1/3" or 5/16")..................................................... 184
PEDIAPRED -prednisolone sod phosph oral soln 6.7
mg/5ml (5 mg/5ml base)................................................ 21
PEDIARIX -diph-tetanus tox-acell pert-hepatitis b-polio ipv
vac inj.............................................................................. 15
PEDVAX HIB -haemophilus b polysaccharide conj vac im
susp 7.5 mcg/0.5 ml....................................................... 15
PEGANONE -ethotoin tab 250 mg.................................. 105
PEGASYS -peginterferon alfa-2a inj 180 mcg/ml............... 8
PEGASYS -peginterferon alfa-2a inj 180 mcg/0.5ml.......... 8
PEGASYS PROCLICK -peginterferon alfa-2a inj 135
mcg/0.5ml.......................................................................... 8
PEGASYS PROCLICK -peginterferon alfa-2a inj 180
mcg/0.5ml.......................................................................... 9
276
PEG-INTRON -peginterferon alfa-2b for inj kit 50

mcg/0.5ml.......................................................................... 8
mcg/0.5ml.......................................................................... 8
mcg/0.5ml.......................................................................... 8
mcg/0.5ml.......................................................................... 8
PEGINTRON -peginterferon alfa-2b for inj kit 50
mcg/0.5ml.......................................................................... 9
mcg/0.5ml.......................................................................... 9
mcg/0.5ml.......................................................................... 9
mcg/0.5ml.......................................................................... 9
PEG-INTRON REDIPEN PAK 4 -peginterferon alfa-2b for
inj kit 50 mcg/0.5ml...........................................................8
inj kit 80 mcg/0.5ml...........................................................8
inj kit 120 mcg/0.5ml........................................................ 8
inj kit 150 mcg/0.5ml........................................................ 8
PEG-INTRON REDIPEN -peginterferon alfa-2b for inj kit
50 mcg/0.5ml.....................................................................8
80 mcg/0.5ml.....................................................................8
120 mcg/0.5ml.................................................................. 8
150 mcg/0.5ml.................................................................. 8
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240
gm (Colyte-flavor packs)............................................. 63
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236
gm (Golytely)................................................................. 63
peg 3350-kcl-sod bicarb-nacl for soln 420 gm
(Nulytely/flavor pack)................................................... 63
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
PENLAC NAIL LACQUER -ciclopirox solution 8%......... 139
PENLET II REPLACEMENT CAP -lancets misc.............184
PEN NEEDLES 29GX1/2" -insulin pen needle 29 g x 12
mm (1/2")...................................................................... 184
PEN NEEDLES 31G X 3/16" -insulin pen needle 31 g x 5
mm (3/16").................................................................... 184
mm (1/3" or 5/16")........................................................ 184
mm (1/3" or 5/16")........................................................ 184
PEN NEEDLES 31G X 1/4" SH -insulin pen needle 31 g x
6 mm (1/4")................................................................... 184
PEN NEEDLES 29G X 12MM -insulin pen needle 29 g x
12 mm (1/2")................................................................. 184
2016
PEN NEEDLES 31G X 6MM -insulin pen needle 31 g x 6
mm (1/4")...................................................................... 184
PENNSAID -diclofenac sodium soln 2%......................... 139
PENTACEL -diph-ac per-tet tox ad-poliov-haemoph b poly
vac for im susp............................................................... 15
PENTASA -mesalamine cap cr 250 mg............................ 68
PENTASA -mesalamine cap cr 500 mg............................ 68
pentazocine w/ naloxone tab 50-0.5 mg........................96
PENTIPS 31GX5MM -insulin pen needle 31 g x 5 mm
(3/16")............................................................................ 184
(5/32")............................................................................ 184
(1/3" or 5/16")................................................................184
PEN-TOTE -blood glucose monitoring supplies............. 184
pentoxifylline tab cr 400 mg......................................... 125
PERCOCET -oxycodone w/ acetaminophen tab 2.5-325
mg.................................................................................... 96
PERCOCET -oxycodone w/ acetaminophen tab 5-325
mg.................................................................................... 96
PERCOCET -oxycodone w/ acetaminophen tab 7.5-325
mg.................................................................................... 96
PERCOCET -oxycodone w/ acetaminophen tab 10-325
mg.................................................................................... 96
PERCODAN -oxycodone-aspirin tab 4.8355-325 mg....... 96
PERFECT LANCETS 30G -lancets................................ 184
PERFECT PRESSURE ACTIVATE -lancets................... 184
PERFOROMIST -formoterol fumarate soln nebu 20
mcg/2ml........................................................................... 61
PERIDEX -chlorhexidine gluconate soln 0.12%............. 131
perindopril erbumine tab 2 mg...................................... 49
perindopril erbumine tab 4 mg (Aceon)........................ 49
perindopril erbumine tab 8 mg (Aceon)........................ 49
permethrin cream 5% (Elimite).................................... 139
PERPHENAZINE/AMITRIPTYLIN -perphenazineamitriptyline tab 2-10 mg................................................ 88
perphenazine tab 2 mg................................................... 79
perphenazine tab 16 mg................................................. 79
PERSANTINE -dipyridamole tab 25 mg......................... 125
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
8000-28750-30250 unit...................................................66
PERTZYE -pancrelipase (lip-prot-amyl) dr cap
16000-57500-60500 unit................................................ 66
PEXEVA -paroxetine mesylate tab 10 mg (base
equiv)............................................................................... 76

equiv)............................................................................... 76
equiv)............................................................................... 76
equiv)............................................................................... 76
PHARMACIST CHOICE AUTOCOD -blood glucose
PHARMACIST CHOICE AUTOCOD -glucose blood test
strip................................................................................ 147
PHARMACIST CHOICE ULTRA T -lancets.................... 184
PHARMACY COUNTER LANCETS -lancets.................. 184
phenazopyridine hcl tab 100 mg (Pyridium).................71
phenazopyridine hcl tab 200 mg (Pyridium).................71
phenelzine sulfate tab 15 mg (Nardil)........................... 76
phenobarbital elixir 20 mg/5ml...................................... 81
PHENOBARBITAL -phenobarbital tab 15 mg................... 81
PHENOBARBITAL -phenobarbital tab 100 mg................. 81
phenobarbital tab 16.2 mg.............................................. 81
phenoxybenzamine hcl cap 10 mg (Dibenzyline)........ 49
phenylephrine hcl ophth soln 2.5%............................. 129
phenylephrine hcl ophth soln 10%.............................. 129
phenylephrine-promethazine w/ codeine syrup
5-6.25-10 mg/5ml........................................................... 59
PHENYTEK -phenytoin sodium extended cap 200
mg.................................................................................. 105
PHENYTEK -phenytoin sodium extended cap 300
mg.................................................................................. 105
phenytoin chew tab 50 mg (Dilantin infatabs)............105
phenytoin sodium extended cap 100 mg
(Dilantin)....................................................................... 105
phenytoin susp 125 mg/5ml (Dilantin-125)................. 105
PHOSLO -calcium acetate (phosphate binder) cap 667
mg (169 mg ca).............................................................. 68
PHOSLYRA -calcium acetate (phosphate binder) oral soln
667 mg/5ml..................................................................... 68
PHOSPHOLINE IODIDE -echothiophate iodide ophth for
soln 0.125%.................................................................. 129
PHYSIOSOL IRRIGATION PH 7 -irrigation solution,
physiological.................................................................. 204
PICATO -ingenol mebutate gel 0.015%.......................... 139
PICATO -ingenol mebutate gel 0.05%............................ 139
pilocarpine hcl ophth soln 1% (Isopto carpine)......... 129
pilocarpine hcl tab 5 mg (Salagen)..............................131
pilocarpine hcl tab 7.5 mg (Salagen)...........................131
pimozide tab 1 mg (Orap)............................................... 88
pimozide tab 2 mg (Orap)............................................... 88
pindolol tab 5 mg............................................................. 39
pindolol tab 10 mg........................................................... 40
pioglitazone hcl-glimepiride tab 30-2 mg (Duetact)..... 30
277
2016
pioglitazone hcl-glimepiride tab 30-4 mg (Duetact)..... 30
pioglitazone hcl-metformin hcl tab 15-500 mg
(Actoplus met)............................................................... 30
pioglitazone hcl-metformin hcl tab 15-850 mg
(Actoplus met)............................................................... 30
pioglitazone hcl tab 15 mg (base equiv) (Actos)..........29
piroxicam cap 10 mg (Feldene)..................................... 99
piroxicam cap 20 mg (Feldene)..................................... 99
PLAN B ONE-STEP -levonorgestrel tab 1.5 mg............... 26
PLAQUENIL -hydroxychloroquine sulfate tab 200 mg...... 11
PLAVIX -clopidogrel bisulfate tab 75 mg (base
equiv)............................................................................. 125
PLAVIX -clopidogrel bisulfate tab 300 mg (base
equiv)............................................................................. 125
PLEGRIDY -peginterferon beta-1a soln pen-injector 125
mcg/0.5ml........................................................................ 88
PLEGRIDY -peginterferon beta-1a soln prefilled syringe
125 mcg/0.5ml................................................................ 88
PLEGRIDY STARTER PACK -peginterferon beta-1a soln
pen-inj 63 & 94 mcg/0.5ml pack.................................... 88
PLEGRIDY STARTER PACK -peginterferon beta-1a soln
pref syr 63 & 94 mcg/0.5ml pack................................... 88
PLETAL -cilostazol tab 50 mg......................................... 125
PLETAL -cilostazol tab 100 mg....................................... 125
PLEXION CLEANSER -sulfacetamide sodium w/ sulfur
cleanser 9.8-4.8%......................................................... 139
PLEXION -sulfacetamide sodium w/ sulfur cream
9.8-4.8%........................................................................ 139
PLEXION -sulfacetamide sodium w/ sulfur lotion
9.8-4.8%........................................................................ 139
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.......................................... 113
PNV-DHA -prenat w/o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg........................................................ 113
PNV FERROUS FUMARATE/DOCU -prenatal vit w/ dssfe fumarate-fa tab 29-1 mg.......................................... 113
PNV-FIRST -prenatal mv w/ fe polysac cmplx-fa-dha cap
29-1-200 mg.................................................................. 113
PNV FOLIC ACID + IRON MUL -prenatal vit w/ fe
fumarate-fa tab 27-1 mg...............................................113
PNV-OB/DHA -prenatal mv w/fe fum-fa tab 65-1 mg &
dha cap 250 mg pack...................................................113
PNV OB+DHA -prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 250 mg pack...................................................113
PNV-OMEGA -prenat w/o a w/ fe fumerate-methylfolatefa-omega 3 cap............................................................. 113
PNV PRENATAL PLUS MULTIVI -prenatal vit w/ fe
fumarate-fa tab 27-1 mg...............................................113
278
PNV-SELECT -prenatal vit w/ fe fum-methylfolate-fa tab

27-0.6-0.4 mg................................................................ 113
PNV TABS 29-1 -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................. 113
PNV-TOTAL -prenat w/ fe cbn-fe bisglyc-fa-fish oil cap
35-5-1.2 mg................................................................... 113
PNV-VP-U -prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg.................................................................... 113
POCKETCHEM EZ BLOOD GLUCO -blood glucose
POCKETCHEM EZ BLOOD GLUCO -glucose blood test
strip................................................................................ 148
podofilox soln 0.5% (Condylox)................................... 139
POLY HUB NEEDLE/25G X 5/8 -needle (disp) 25 x
5/8".................................................................................185
1/2".................................................................................185
1/2".................................................................................185
POLY HUB NEEDLE/18G X 1" -needle (disp) 18 x
1".................................................................................... 184
1".................................................................................... 184
1".................................................................................... 185
1".................................................................................... 185
1".................................................................................... 185
POLY HUB NEEDLE/18G X 1-1 -needle (disp) 18 x
1-1/2"............................................................................. 184
1-1/2"............................................................................. 184
1-1/2"............................................................................. 184
1-1/2"............................................................................. 185
1-1/2"............................................................................. 185
1-1/4"............................................................................. 185
polymyxin b-trimethoprim ophth soln 10000 unit/
ml-0.1% (Polytrim)...................................................... 129
POLYTRIM -polymyxin b-trimethoprim ophth soln 10000
unit/ml-0.1%.................................................................. 129
POMALYST -pomalidomide cap 1 mg.............................. 18
PONSTEL -mefenamic acid cap 250 mg.......................... 99
pot & sod citrates w/ cit ac soln 550-500-334
mg/5ml............................................................................ 71
POTABA -potassium aminobenzoate cap 500 mg..........110
POTABA -potassium aminobenzoate tab 500 mg.......... 110
potassium bicarbonate effer tab 25 meq.................... 118
potassium chloride cap cr 8 meq (Micro-k)................ 118
potassium chloride cap cr 10 meq (Micro-k).............. 118
2016
POTASSIUM CHLORIDE ER -potassium chloride tab cr 8
meq (600 mg)............................................................... 118
POTASSIUM CHLORIDE ER -potassium chloride tab cr
20 meq (1500 mg)........................................................ 118
potassium chloride microencapsulated crys cr tab 10
meq............................................................................... 118
potassium chloride microencapsulated crys cr tab 20
meq............................................................................... 118
potassium chloride oral soln 10% (20 meq/15ml)...... 118
potassium chloride oral soln 20% (40 meq/15ml)...... 118
potassium chloride powder packet 20 meq............... 119
potassium chloride tab cr 10 meq (K-tab).................. 119
potassium chloride tab cr 8 meq (600 mg) (Ktab)................................................................................ 119
potassium citrate & citric acid powder pack 3300-1002
mg................................................................................... 71
potassium citrate & citric acid soln 1100-334
mg/5ml............................................................................ 71
potassium citrate tab cr 5 meq (540 mg) (Urocit-k
5)...................................................................................... 71
10).................................................................................... 71
15).................................................................................... 71
pot bicarbonate & chloride effer tab 25 meq.............. 118
POTIGA -ezogabine tab 50 mg....................................... 105
POTIGA -ezogabine tab 200 mg..................................... 105
pot phos monobasic w/sod phos di & monobas tab
155-852-130mg (K-phos neutral)...............................118
PRADAXA -dabigatran etexilate mesylate cap 75 mg
(etexilate base eq)........................................................ 122
PRADAXA -dabigatran etexilate mesylate cap 150 mg
(etexilate base eq)........................................................ 122
PRALUENT -alirocumab subcutaneous soln pen-injector
75 mg/ml......................................................................... 55
PRALUENT -alirocumab subcutaneous soln pen-injector
150 mg/ml....................................................................... 55
PRALUENT -alirocumab subcutaneous soln prefilled
syringe 75 mg/ml............................................................ 55
PRALUENT -alirocumab subcutaneous soln prefilled
syringe 150 mg/ml.......................................................... 55
pramipexole dihydrochloride tab 0.125 mg
(Mirapex).......................................................................108
(Mirapex).......................................................................108
(Mirapex).......................................................................108
(Mirapex).......................................................................108
pramipexole dihydrochloride tab 1 mg (Mirapex)...... 108
(Mirapex).......................................................................108
pramipexole dihydrochloride tab sr 24hr 0.375 mg
(Mirapex er).................................................................. 107

(Mirapex er).................................................................. 107
(Mirapex er).................................................................. 107
pramipexole dihydrochloride tab sr 24hr 3 mg
(Mirapex er).................................................................. 107
(Mirapex er).................................................................. 108
PRAMOSONE E -pramoxine-hc emollient base cream
1-2.5%........................................................................... 140
PRAMOSONE -pramoxine-hc cream 1-1%.................... 139
PRAMOSONE -pramoxine-hc cream 1-2.5%................. 140
PRAMOSONE -pramoxine-hc lotion 1-1%...................... 140
PRAMOSONE -pramoxine-hc lotion 1-2.5%................... 140
PRAMOSONE -pramoxine-hc oint 1-1%.........................140
PRAMOSONE -pramoxine-hc oint 1-2.5%......................140
pramoxine-hc cream 1-2.5% (Pramosone)................. 140
pramoxine hcl gel 1%....................................................140
PRANDIMET -repaglinide-metformin hcl tab 1-500
mg.................................................................................... 30
PRANDIMET -repaglinide-metformin hcl tab 2-500
mg.................................................................................... 30
PRANDIN -repaglinide tab 0.5 mg.................................... 30
PRANDIN -repaglinide tab 1 mg....................................... 30
PRANDIN -repaglinide tab 2 mg....................................... 30
PRAVACHOL -pravastatin sodium tab 20 mg................... 55
pravastatin sodium tab 10 mg....................................... 55
pravastatin sodium tab 20 mg (Pravachol)...................55
prazosin hcl cap 1 mg (Minipress)................................ 49
PRECISION LINK -blood glucose monitoring kit w/
device............................................................................ 185
PRECISION PCX -glucose blood test strip..................... 148
PRECISION PCX PLUS TEST S -glucose blood test
strip................................................................................ 148
PRECISION POINT OF CARE T -glucose blood test
strip................................................................................ 148
PRECISION QID MONITOR -blood glucose monitoring
devices.......................................................................... 185
PRECISION QID TEST STRIPS -glucose blood test
strip................................................................................ 148
PRECISION SOF-TACT MONITO -blood glucose
PRECISION SOF-TACT TEST S -glucose blood test
strip................................................................................ 148
PRECISION SURE-DOSE INSUL -insulin syringe/needle
u-100 1/2 ml 30 x 3/8".................................................. 185
u-100 1/2 ml 28 x 1/2".................................................. 185
u-100 1/2 ml 29 x 1/2".................................................. 185
279
2016
u-100 0.3 ml 30 x 5/16"................................................ 185
u-100 1 ml 28 x 1/2".....................................................185
PRECISION SURE-DOSE PLUS -insulin syringe/needle
u-100 0.3 ml 29 x 1/2".................................................. 185
PRECISION SURE-DOSE PLUS -insulin syringe/needle
u-100 1 ml 29 x 1/2".....................................................185
PRECISION THIN LANCETS -lancets............................ 185
PRECISION THINS GP LANCET -lancets..................... 185
PRECISION ULTRA LANCET -lancets........................... 185
PRECISION XTRA BLOOD GLUC -glucose blood test
strip................................................................................ 148
PRECISION XTRA -blood glucose monitoring
devices.......................................................................... 185
PRECISION XTRA -blood glucose monitoring kit........... 185
PRECISION XTRA MONITOR -blood glucose monitoring
devices.......................................................................... 185
PRECOSE -acarbose tab 25 mg...................................... 30
PRECOSE -acarbose tab 50 mg...................................... 30
PRECOSE -acarbose tab 100 mg.................................... 30
PRED FORTE -prednisolone acetate ophth susp
1%.................................................................................. 129
PRED-G -gentamicin-prednisolone ace ophth susp
0.3-1%........................................................................... 129
PRED-G S.O.P. -gentamicin-prednisolone ace ophth oint
0.3-0.6%........................................................................ 129
PRED MILD -prednisolone acetate ophth susp
0.12%.............................................................................129
prednicarbate cream 0.1% (Dermatop)....................... 140
prednicarbate oint 0.1% (Dermatop)........................... 140
prednisolone acetate ophth susp 1% (Pred forte)..... 130
PREDNISOLONE SODIUM PHOSP -prednisolone
sodium phosphate ophth soln 1%................................ 130
PREDNISOLONE SODIUM PHOSP -prednisolone
sodium phosphate oral soln 25 mg/5ml (base eq)......... 21
prednisolone sod phos orally disintegr tab 10 mg
(base eq) (Orapred odt)............................................... 21
prednisolone sod phosphate oral soln 15 mg/5ml
(base equiv)................................................................... 21
prednisolone sod phosph oral soln 6.7 mg/5ml (5
mg/5ml base) (Pediapred)............................................21
prednisolone syrup 15 mg/5ml (usp solution
equivalent)......................................................................21
PREDNISONE INTENSOL -prednisone conc 5 mg/ml..... 21
PREDNISONE -prednisone oral soln 5 mg/5ml................ 21
PREDNISONE -prednisone tab 50 mg............................. 21
PREDNISONE -prednisone tab 5 mg dose pack.............. 21
PREDNISONE -prednisone tab 10 mg dose pack............ 21
prednisone tab 1 mg....................................................... 21
prednisone tab 2.5 mg.................................................... 21
prednisone tab 5 mg....................................................... 21
prednisone tab 10 mg..................................................... 21
280
prednisone tab 20 mg..................................................... 21

PREFERA OB + DHA -prenat-fe poly cmplx-fe heme polyfa tab & omega 3 cap pck............................................ 113
PREFERAOB +DHA -prenat-fe poly cmplx 28mg-fe heme
poly-fa tab&dha cap pack.............................................113
PREFERAOB ONE -prenat-fe poly cmplx-fe heme polyfa-dha cap 22-6-1-200 mg............................................113
PREFERA OB -prenat vit-fe poly cmplx-fe heme poly-fa
tab 28-6-1 mg............................................................... 113
PREFERRED PLUS INSULIN SY -insulin syringe/needle
u-100 1/2 ml 28 x 1/2".................................................. 185
u-100 1/2 ml 29 x 1/2".................................................. 185
u-100 1/2 ml 30 x 5/16"................................................ 185
u-100 0.3 ml 29 x 1/2".................................................. 185
u-100 0.3 ml 30 x 5/16"................................................ 185
u-100 1 ml 28 x 1/2".....................................................185
u-100 1 ml 29 x 1/2".....................................................185
u-100 1 ml 30 x 5/16"...................................................185
PREFERRED PLUS LANCETS CO -lancets.................. 185
PREFERRED PLUS LANCETS SU -lancets.................. 186
PREFERRED PLUS LANCETS TH -lancets.................. 186
PREFERRED PLUS UNIFINE PE -insulin pen needle 29
g x 12 mm (1/2")...........................................................186
g x 5 mm (3/16")...........................................................186
g x 6 mm (1/4").............................................................186
g x 4 mm (5/32")...........................................................186
g x 8 mm (1/3" or 5/16")...............................................186
PREFEST -estradiol tab 1 mg(15)/estrad-norgestimate
tab 1-0.09mg(15)............................................................ 24
PREFOL-DHA -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 26-1.2-300 mg....................................................... 113
PREMARIN -estrogens, conjugated tab 0.3 mg............... 24
PREMARIN -estrogens, conjugated tab 0.45 mg............. 24
PREMARIN -estrogens, conjugated tab 0.625 mg........... 24
PREMARIN -estrogens, conjugated tab 0.9 mg............... 24
PREMARIN -estrogens, conjugated tab 1.25 mg............. 24
PREMARIN -estrogens, conjugated vaginal cream 0.625
mg/gm.............................................................................. 70
PREMPHASE -conj est 0.625(14)/conj est-medroxypro ac
tab 0.625-5mg(14).......................................................... 24
PREMPRO -conjugated estrogen-medroxyprogest
acetate tab 0.3-1.5 mg................................................... 24
acetate tab 0.45-1.5 mg................................................. 24
acetate tab 0.625-2.5 mg............................................... 24
2016
acetate tab 0.625-5 mg.................................................. 24
PRENA1/QUATREFOLIC -prenat w/o a w/fefum-methfolfa-dha cap 30-0.6-0.4-200 mg..................................... 114
PRENA1 CHEW -prenat w/ b2-b6-b12-d3-folic acid chew
tab 1.4 mg..................................................................... 114
PRENAISSANCE BALANCE -prenatal w/o vit a w/ fe cbndss-fa-dha cap 30-1-260 mg........................................ 113
PRENAISSANCE DHA -prenat w/o a w/fecbn-fegl-dss-fa
tab & dha cap 250 mg pack......................................... 113
PRENAISSANCE 90 DHA -prenat w/o a w/fecbn-fegl-dssfa tab 90 &dha cap 300mg pak....................................114
PRENAISSANCE HARMONY DHA -prenat w/fe poly-na
fered-fa tab 27-1 & omega cap dr 380mg....................113
PRENAISSANCE NEXT-B -prenatal w/ calcium-vit b6-faginger tab 1.22 mg....................................................... 113
PRENAISSANCE NEXT -prenatal w/ calcium-vit b6-faginger tab 1.2 mg......................................................... 113
PRENAISSANCE PLUS -prenatal w/o a w/fe cbn-dss-fadha cap 28-1-250 mg................................................... 114
PRENAISSANCE -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg..................................................... 113
PRENAISSANCE PROMISE -prenat w/o a w/fecbn-fegldss-fa tab & dha cap 300 mg pack.............................. 114
PRENA1 PEARL -prenat w/oa w/fefum-na fered-fa-dha
cap cr 30-1.4-200 mg................................................... 114
PRENA1 PLUS/QUATREFOLIC -prenat w/o a w/ fe
chelate-l methylfol-fa tab & dha cap pk....................... 114
PRENAPLUS -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 114
PRENATABS FA -prenatal vit w/ fe fumarate-fa tab 29-1
mg.................................................................................. 114
PRENATABS RX -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................. 114
PRENATAL AD -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg......................................................................... 114
PRENATAL LOW IRON -prenatal vit w/ fe fumarate-fa tab
27-1 mg......................................................................... 114
PRENATAL PLUS IRON -prenatal vit w/ iron carbonyl-fa
tab 29-1 mg...................................................................114
PRENATAL PLUS -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 114
PRENATAL 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg.................................................................................. 114
PRENATAL 19 -prenatal vit w/ fe fumarate-fa chew tab
29-1 mg......................................................................... 114
PRENATAL -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 114
PRENATAL-U -prenatal w/o a vit w/ fe fumarate-fa cap
106.5-1 mg.................................................................... 114
PRENATA -prenatal w/o a vit w/ fe fum-fa tab chew 29-1
mg.................................................................................. 114
PRENATE AM -prenatal w/ calcium-vit b6-vit b12-faginger tab 1 mg............................................................ 114
PRENATE DHA -prenat w/o a w/feaspg-methfol-fa-dha
cap 18-0.6-0.4-300 mg................................................. 114
PRENATE DHA -prenat w/o a w/fefum-methfol-fa-dha cap

28-0.6-0.4-300 mg........................................................ 114
PRENATE ELITE -prenatal vit w/ fe fum-methylfolate-fa
tab 26-0.6-0.4 mg......................................................... 114
PRENATE ELITE -prenatal w/ fe asp gly-l methylfol-fa tab
20-0.6-0.4 mg................................................................ 114
PRENATE ENHANCE -prenat w/o a w/fefum-methfol-fadha cap 28-0.6-0.4-400 mg.......................................... 114
PRENATE ESSENTIAL -prenat w/o a w/feaspg-methfolfa-dha cap 18-0.6-0.4-300 mg..................................... 114
PRENATE ESSENTIAL -prenat w/o a w/feasp-methylf-faomeg cap 29-0.6-0.4-340 mg....................................... 114
PRENATE MINI -prenat w/oa w/fecb-feasp-meth-fa-dha
cap 18-0.6-0.4-350 mg................................................. 114
PRENATE MINI -prenat w/o a w/fecbn-methylf-fa-dha cap
29-0.6-0.4-350 mg........................................................ 114
PRENATE PIXIE -prenat w/o a w/feaspg-methfol-fa-dha
cap 10-0.6-0.4-200 mg................................................. 114
PRENATE -prenat mv & min w/ l-methylfolate-fa chew tab
0.6-0.4 mg..................................................................... 114
PRENATE RESTORE -prenat w/o a w/fefum-methfol-fadha cap 27-0.6-0.4-400 mg.......................................... 114
PRENATE STAR -prenatal vit w/ fe asparto glycinate-fa
tab 20-1 mg...................................................................114
PRENTIF CAVITY-RIM CERVIC -cervical cap 22
mm................................................................................. 186
mm................................................................................. 186
mm................................................................................. 186
mm................................................................................. 186
PRENTIF FITTING SET -cervical caps........................... 186
PREPLUS -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 115
PREPOPIK -sod picosulfate-mg oxide-citric acid pack 10
mg-3.5 gm-12 gm........................................................... 63
PREQUE 10 -prenatal mv w/fe carbonyl-dss-fa-dha tab
15-25-0.5-50 mg........................................................... 115
PRESTALIA -perindopril arginine-amlodipine besylate tab
3.5-2.5 mg....................................................................... 49
7-5 mg............................................................................. 49
14-10 mg......................................................................... 49
PRESTIGE TEST STRIPS -glucose blood test strip.......148
PRETAB -prenatal vit w/ fe fumarate-fa tab 29-1 mg...... 115
PREVNAR 13 -pneumococcal 13-valent conjugate
vaccine inj....................................................................... 15
PREVPAC -amoxicillin cap-clarithro tab-lansopraz cap dr
therapy pack................................................................... 65
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
281
2016
equiv)................................................................................. 9
equiv)................................................................................. 9
equiv)................................................................................. 9
PRIFTIN -rifapentine tab 150 mg........................................ 5
PRILOSEC OTC -omeprazole magnesium delayed
release tab 20 mg (base equiv)..................................... 65
PRIMAQUINE PHOSPHATE -primaquine phosphate tab
26.3 mg (15 mg base).................................................... 11
primidone tab 50 mg (Mysoline).................................. 105
primidone tab 250 mg (Mysoline)................................ 105
PRIMSOL -trimethoprim hcl oral soln 50 mg/5ml (base
equiv)............................................................................... 12
PRINIVIL -lisinopril tab 5 mg............................................. 49
PRINIVIL -lisinopril tab 10 mg........................................... 49
PRINIVIL -lisinopril tab 20 mg........................................... 49
PRISTIQ -desvenlafaxine succinate tab sr 24hr 25 mg
(base equiv).................................................................... 76
(base equiv).................................................................... 76
(base equiv).................................................................... 76
PR NATAL 400 EC -prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 400 pk................................................... 113
PR NATAL 430 EC -prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 430 pk................................................... 113
PR NATAL 400 -prenat-fe bis-fe prot succ-fa-ca tab &
omega 3 cap 400 pk.................................................... 113
PR NATAL 430 -prenat-fe bis-fe prot succ-fa-ca tab &
omega 3 cap 430 pk.................................................... 113
PROAIR HFA -albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv)........................................................ 61
PROAIR RESPICLICK -albuterol sulfate aer pow ba 108
mcg/act (90 mcg base equiv)......................................... 61
probenecid tab 500 mg................................................. 101
PROCARDIA -nifedipine cap 10 mg................................. 42
PROCARDIA XL -nifedipine tab sr 24hr osmotic release
30 mg.............................................................................. 42
60 mg.............................................................................. 42
90 mg.............................................................................. 42
PROCENTRA -dextroamphetamine sulfate oral solution 5
mg/5ml............................................................................. 85
prochlorperazine maleate tab 5 mg (base equivalent)
(Compazine)................................................................... 79
prochlorperazine maleate tab 10 mg (base equivalent)
(Compazine)................................................................... 79
prochlorperazine suppos 25 mg.................................... 79
PROCORT -hydrocortisone acetate w/ pramoxine rectal
cream 1.85-1.15%........................................................ 132
PROCRIT -epoetin alfa inj 2000 unit/ml.......................... 120
PROCRIT -epoetin alfa inj 10000 unit/ml........................ 120
282

PROCTOCORT -hydrocortisone acetate suppos 30
mg.................................................................................. 132
PROCTOCORT -hydrocortisone rectal cream 1%.......... 132
PROCTOFOAM HC -hydrocortisone acetate w/
pramoxine rectal foam 1-1%........................................ 132
PROCYSBI -cysteamine bitartrate cap delayed release 25
mg (base equiv).............................................................. 71
PROCYSBI -cysteamine bitartrate cap delayed release 75
mg (base equiv).............................................................. 71
PRODIGY AUTOCODE BLOOD GL -blood glucose
PRODIGY AUTOCODE BLOOD GL -blood glucose
PRODIGY INSULIN MINI PEN -insulin pen needle 31 g x
5 mm (3/16")................................................................. 186
PRODIGY INSULIN SHORT PEN -insulin pen needle 31
g x 8 mm (1/3" or 5/16")...............................................186
PRODIGY INSULIN SYRING/U- -insulin syringe/needle
u-100 0.3 ml 31 x 5/16"................................................ 186
PRODIGY INSULIN SYRINGE/1 -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 186
PRODIGY INSULIN SYRINGE/1 -insulin syringe/needle
u-100 1 ml 28 x 1/2".....................................................186
PRODIGY LANCING DEVICE -lancet devices............... 186
PRODIGY NO CODING BLOOD G -glucose blood test
strip................................................................................ 148
PRODIGY POCKET BLOOD GLUC -blood glucose
PRODIGY PRESSURE ACTIVATE -lancets................... 186
PRODIGY TWIST TOP LANCETS -lancets.................... 186
PRODIGY VOICE BLOOD GLUCO -blood glucose
PRODRIN -isometheptene-caffeine-acetaminophen tab
65-20-325 mg................................................................100
PROFILNINE -factor ix complex for inj 500 unit............. 125
PROFILNINE -factor ix complex for inj 1000 unit........... 125
PROFILNINE -factor ix complex for inj 1500 unit........... 125
PROFILNINE SD -factor ix complex for inj 500 unit........125
PROFILNINE SD -factor ix complex for inj 1000 unit......125
PROFILNINE SD -factor ix complex for inj 1500 unit......125
progesterone micronized cap 100 mg
(Prometrium).................................................................. 27
progesterone micronized cap 200 mg
(Prometrium).................................................................. 27
PROGLYCEM -diazoxide susp 50 mg/ml......................... 30
PROGRAF -tacrolimus cap 0.5 mg................................. 204
PROGRAF -tacrolimus cap 1 mg.................................... 204
PROGRAF -tacrolimus cap 5 mg.................................... 204
PROLENSA -bromfenac sodium ophth soln 0.07% (base
equivalent)..................................................................... 130
PROMACTA -eltrombopag olamine tab 12.5 mg (base
equiv)............................................................................. 120
PROMACTA -eltrombopag olamine tab 25 mg (base
equiv)............................................................................. 121
2016
equiv)............................................................................. 121
equiv)............................................................................. 121
promethazine & phenylephrine syrup 6.25-5
mg/5ml............................................................................ 59
promethazine-dm syrup 6.25-15 mg/5ml.......................59
promethazine hcl suppos 12.5 mg................................ 58
promethazine hcl suppos 25 mg................................... 58
promethazine hcl suppos 50 mg................................... 58
promethazine hcl syrup 6.25 mg/5ml............................ 58
promethazine hcl tab 12.5 mg........................................ 58
promethazine hcl tab 25 mg........................................... 58
promethazine hcl tab 50 mg........................................... 58
promethazine w/ codeine syrup 6.25-10 mg/5ml..........59
PROMETRIUM -progesterone micronized cap 100
mg.................................................................................... 27
PROMETRIUM -progesterone micronized cap 200
mg.................................................................................... 27
propafenone hcl cap sr 12hr 225 mg (Rythmol sr)...... 43
propafenone hcl tab 300 mg.......................................... 43
propafenone hcl tab 150 mg (Rythmol)........................ 43
propafenone hcl tab 225 mg (Rythmol)........................ 43
PROPANTHELINE BROMIDE -propantheline bromide tab
15 mg.............................................................................. 65
proparacaine hcl ophth soln 0.5% (Alcaine).............. 130
PROPRANOLOL/HYDROCHLOROTH -propranolol &
PROPRANOLOL/HYDROCHLOROTH -propranolol &
propranolol hcl cap sr 24hr 60 mg (Inderal la)............. 40
propranolol hcl cap sr 24hr 80 mg (Inderal la)............. 40
propranolol hcl cap sr 24hr 120 mg (Inderal la)........... 40
propranolol hcl cap sr 24hr 160 mg (Inderal la)........... 40
PROPRANOLOL HCL -propranolol hcl oral soln 20
mg/5ml............................................................................. 40
PROPRANOLOL HCL -propranolol hcl oral soln 40
mg/5ml............................................................................. 40
propranolol hcl tab 10 mg.............................................. 40
propylthiouracil tab 50 mg............................................. 32
PROQUAD -measles-mumps-rubella-varicella virus
vaccines for inj................................................................ 15
PROSCAR -finasteride tab 5 mg...................................... 71
PROTOPIC -tacrolimus oint 0.03%................................. 140
PROTOPIC -tacrolimus oint 0.1%................................... 140
protriptyline hcl tab 5 mg............................................... 76
protriptyline hcl tab 10 mg............................................. 76
PROVENTIL HFA -albuterol sulfate inhal aero 108 mcg/
act (90mcg base equiv).................................................. 62
PROVERA -medroxyprogesterone acetate tab 2.5
mg.................................................................................... 27
PROVERA -medroxyprogesterone acetate tab 5 mg....... 27

PROVERA -medroxyprogesterone acetate tab 10 mg..... 27
PROVIDA DHA -prenat w/o a w/fe fum-fe poly-fa-dha cap
16-16-1.25-110 mg........................................................115
PROVIDA OB -prenatal w/o a w/fe fum-fe poly-fa cap
20-20-1.25 mg...............................................................115
PROVIGIL -modafinil tab 100 mg..................................... 85
PROVIGIL -modafinil tab 200 mg..................................... 85
PROZAC -fluoxetine hcl cap 10 mg.................................. 76
PROZAC WEEKLY -fluoxetine hcl cap delayed release 90
mg.................................................................................... 76
PROZENA -lidocaine patch 4%...................................... 140
PRUDOXIN -doxepin hcl cream 5%............................... 140
pseudoeph-chlorphen w/ hydrocodone soln 60-4-5
mg/5ml (Zutripro).......................................................... 59
pseudoephed-bromphen-dm syrup 30-2-10
mg/5ml............................................................................ 59
PSORCON -diflorasone diacetate cream 0.05%............ 140
PSS SELECT GP LANCETS -lancets............................ 186
PSS SELECT SAFETY LANCETS -lancets.................... 186
PTS PANELS GLUCOSE TEST -glucose blood test
strip................................................................................ 148
PULMICORT -budesonide inhalation susp 0.25
mg/2ml............................................................................. 62
PULMICORT -budesonide inhalation susp 0.5
mg/2ml............................................................................. 62
PULMICORT -budesonide inhalation susp 1 mg/2ml....... 62
PULMICORT FLEXHALER -budesonide inhal aero powd
90 mcg/act (breath activated).........................................62
PULMICORT FLEXHALER -budesonide inhal aero powd
180 mcg/act (breath activated)...................................... 62
PULMOZYME -dornase alfa inhal soln 1 mg/ml............... 63
PUREFE OB PLUS -prenatal w/o a w/fe fum-fe poly-fa
cap 162.115.2-1 mg...................................................... 115
PURIXAN -mercaptopurine susp 2000 mg/100ml (20 mg/
ml).................................................................................... 19
PX ADVANCED LANCING DEVIC -lancet devices........ 186
PX EXTRA SHORT PEN NEEDLE -insulin pen needle 31
g x 6 mm (1/4").............................................................186
PX INSULIN SYRINGE/U-100/ -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 186
u-100 1/2 ml 30 x 1/2".................................................. 186
u-100 0.3 ml 30 x 1/2".................................................. 186
u-100 1 ml 30 x 1/2".....................................................186
u-100 1 ml 31 x 5/16"...................................................187
u-100 0.3 ml 31 x 5/16"................................................ 187
PX LANCET AUTO INJECTOR -lancet devices............. 187
PX LANCETS -lancets..................................................... 187
PX LANCETS ULTRA THIN -lancets.............................. 187
283
2016
PX MINI PEN NEEDLES 31GX5 -insulin pen needle 31 g
x 5 mm (3/16").............................................................. 187
PX PEN NEEDLE 29GX12MM -insulin pen needle 29 g x
12 mm (1/2")................................................................. 187
PX PEN NEEDLE 31GX8MM -insulin pen needle 31 g x 8
mm (1/3" or 5/16")........................................................ 187
PX SHORTLENGTH PEN NEEDLE -insulin pen needle
31 g x 8 mm (1/3" or 5/16")......................................... 187
PYLERA -bismuth subcit-metronidazole-tetracycline cap
140-125-125 mg..............................................................65
pyrazinamide tab 500 mg..................................................5
PYRIDIUM -phenazopyridine hcl tab 100 mg................... 71
PYRIDIUM -phenazopyridine hcl tab 200 mg................... 71
pyridostigmine bromide tab cr 180 mg (Mestinon
timespan)......................................................................110
pyridostigmine bromide tab 60 mg (Mestinon).......... 110
PYROGALLIC ACID -pyrogallol-chlorobutanol oint
25-2%............................................................................ 140
Q
QC ADVANCED LANCING DEVIC -lancet devices........ 187
QC INSULIN SYRINGE/0.5ML/ -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 187
u-100 1/2 ml 29 x 1/2".................................................. 187
u-100 0.3 ml 29 g......................................................... 187
QC INSULIN SYRINGE/1ML/30 -insulin syringe/needle
u-100 1 ml 30 g............................................................ 187
u-100 0.3 ml 29 x 1/2".................................................. 187
u-100 1 ml 29 x 1/2".....................................................187
u-100 1 ml 31 x 5/16"...................................................187
QC INSULIN SYRINGE 0.5ML/ -insulin syringe/needle
u-100 1/2 ml 29 g......................................................... 187
QC INSULIN SYRINGE 0.5ML/ -insulin syringe/needle
u-100 1/2 ml 30 g......................................................... 187
QC LANCETS SUPER THIN -lancets............................. 187
QC LANCETS ULTRA THIN -lancets..............................187
QC PEN NEEDLES 29G X 12MM -insulin pen needle 29
g x 12 mm (1/2")...........................................................187
QC PEN NEEDLES 31G X 6MM -insulin pen needle 31 g
x 6 mm (1/4")................................................................ 187
QC PEN NEEDLES 31G X 8MM -insulin pen needle 31 g
x 8 mm (1/3" or 5/16").................................................. 187
QC UNIFINE PENTIPS 32GX4M -insulin pen needle 32 g
x 4 mm (5/32").............................................................. 187
QUADRACEL -diph-tetanus tox ad-acell pert & polio
virus, ipv vac inj.............................................................. 15
QUALAQUIN -quinine sulfate cap 324 mg........................11
QUARTETTE -levonor-eth est tab 0.15-0.02/0.025/0.03
mg &eth est 0.01 mg...................................................... 26
QUDEXY XR -topiramate cap er 24hr sprinkle 25
mg.................................................................................. 105
284

mg.................................................................................. 105
mg.................................................................................. 105
mg.................................................................................. 105
mg.................................................................................. 105
QUESTRAN -cholestyramine powder 4 gm/dose............. 56
QUESTRAN -cholestyramine powder packets 4 gm........ 56
QUESTRAN LIGHT -cholestyramine light powder 4 gm/
dose................................................................................. 56
quetiapine fumarate tab 25 mg (Seroquel)................... 80
quetiapine fumarate tab 50 mg (Seroquel)................... 80
quetiapine fumarate tab 100 mg (Seroquel)................. 80
QUICKTEK -blood glucose monitoring kit....................... 187
QUICKTEK -blood glucose monitoring kit w/ device....... 187
QUICKTEK TEST STRIPS -glucose blood test strip...... 148
QUILLIVANT XR -methylphenidate hcl for er susp 25
mg/5ml (5 mg/ml)............................................................ 85
quinapril hcl tab 5 mg (Accupril)................................... 50
quinapril hcl tab 10 mg (Accupril)................................. 50
quinapril-hydrochlorothiazide tab 10-12.5 mg
(Accuretic)...................................................................... 50
quinapril-hydrochlorothiazide tab 20-12.5 mg
(Accuretic)...................................................................... 50
quinapril-hydrochlorothiazide tab 20-25 mg
(Accuretic)...................................................................... 50
quinidine gluconate tab cr 324 mg................................ 43
QUINIDINE SULFATE ER -quinidine sulfate tab cr 300
mg.................................................................................... 43
QUINIDINE SULFATE -quinidine sulfate tab 200 mg....... 43
quinidine sulfate tab 300 mg.......................................... 43
quinine sulfate cap 324 mg (Qualaquin)....................... 11
QUINTET AC BLOOD GLUCOSE -blood glucose
QUINTET AC BLOOD GLUCOSE -glucose blood test
strip................................................................................ 148
QUINTET BLOOD GLUCOSE MON -blood glucose
QUINTET BLOOD GLUCOSE TES -glucose blood test
strip................................................................................ 148
QVAR -beclomethasone diprop inhal aero soln 40 mcg/act
(50/valve)......................................................................... 62
QVAR -beclomethasone diprop inhal aero soln 80 mcg/act
(100/valve)....................................................................... 62
R
rabeprazole sodium ec tab 20 mg (Aciphex)................ 65
RA BLOOD GLUCOSE MONITOR -blood glucose
2016
RADIOGARDASE -prussian blue insoluble cap 0.5
gm.................................................................................. 144
RA E-ZJECT COLOR LANCETS -lancets...................... 187
RA E-ZJECT LANCETS 28G -lancets............................ 188
RA E-ZJECT LANCETS THIN 2 -lancets........................187
RA E-ZJECT LANCETS ULTRA -lancets........................187
RA INSULIN SYRINGE/0.5ML/ -insulin syringe/needle
u-100 1/2 ml 29 x 1/2".................................................. 188
RA INSULIN SYRINGE/1ML/29 -insulin syringe/needle
u-100 1 ml 29 x 1/2".....................................................188
RA INSULIN SYRINGE/U-100/ -insulin syringe/needle
u-100 1/2 ml 30 x 5/16"................................................ 188
RA INSULIN SYRINGE/U-100/ -insulin syringe/needle
u-100 1 ml 30 x 5/16"...................................................188
RA LANCING DEVICE -lancet devices........................... 188
raloxifene hcl tab 60 mg (Evista)................................... 36
ramipril cap 1.25 mg (Altace)......................................... 50
ramipril cap 2.5 mg (Altace)........................................... 50
ramipril cap 5 mg (Altace).............................................. 50
ramipril cap 10 mg (Altace)............................................ 50
RANEXA -ranolazine tab sr 12hr 500 mg......................... 38
RANEXA -ranolazine tab sr 12hr 1000 mg....................... 38
ranitidine hcl cap 150 mg............................................... 65
ranitidine hcl cap 300 mg............................................... 65
ranitidine hcl syrup 15 mg/ml (75 mg/5ml)................... 65
ranitidine hcl tab 150 mg (Zantac)................................. 65
ranitidine hcl tab 300 mg (Zantac)................................. 65
RAPAFLO -silodosin cap 4 mg..........................................71
RAPAFLO -silodosin cap 8 mg..........................................71
RAPAMUNE -sirolimus oral soln 1 mg/ml....................... 204
RAPAMUNE -sirolimus tab 0.5 mg..................................204
RAPAMUNE -sirolimus tab 1 mg.....................................204
RAPAMUNE -sirolimus tab 2 mg.....................................204
RA PEN NEEDLES 31G X 5MM -insulin pen needle 31 g
x 5 mm (3/16").............................................................. 188
RA PEN NEEDLES 31G X 8MM -insulin pen needle 31 g
x 8 mm (1/3" or 5/16").................................................. 188
RASUVO -methotrexate soln pf auto-injector 7.5
mg/0.15ml........................................................................ 99
RASUVO -methotrexate soln pf auto-injector 10
mg/0.2ml.......................................................................... 99
mg/0.25ml........................................................................ 99
mg/0.3ml.......................................................................... 99
mg/0.35ml........................................................................ 99
mg/0.4ml.......................................................................... 99
mg/0.45ml........................................................................ 99
mg/0.5ml.......................................................................... 99
mg/0.55ml........................................................................ 99
mg/0.6ml.......................................................................... 99
RA TRUE2GO BLOOD GLUCOSE -blood glucose

RA TRUERESULT BLOOD GLUCO -blood glucose
RA TRUETEST STRIPS -glucose blood test strip.......... 148
RAVICTI -glycerol phenylbutyrate liquid 1.1 gm/ml...........36
RAYOS -prednisone tab delayed release 1 mg................ 21
RAZADYNE ER -galantamine hydrobromide cap sr 24hr 8
mg.................................................................................... 89
RAZADYNE ER -galantamine hydrobromide cap sr 24hr
16 mg.............................................................................. 89
RAZADYNE ER -galantamine hydrobromide cap sr 24hr
24 mg.............................................................................. 89
RAZADYNE -galantamine hydrobromide oral soln 4 mg/
ml..................................................................................... 88
RAZADYNE -galantamine hydrobromide tab 4 mg...........88
RAZADYNE -galantamine hydrobromide tab 8 mg...........89
RAZADYNE -galantamine hydrobromide tab 12 mg.........89
REALITY INSULIN SYRINGE/U -insulin syringe/needle
u-100 1/2 ml 28 x 1/2".................................................. 188
u-100 1/2 ml 29 x 1/2".................................................. 188
u-100 1 ml 28 x 1/2".....................................................188
u-100 1 ml 29 x 1/2".....................................................188
REALITY LANCETS -lancets.......................................... 188
REALITY TRIGGER LANCETS -lancets.........................188
REBETOL -ribavirin cap 200 mg......................................... 9
REBETOL -ribavirin soln 40 mg/ml..................................... 9
REBIF -interferon beta-1a soln pref syr 22 mcg/0.5ml
(12mu/ml)........................................................................ 89
REBIF -interferon beta-1a soln pref syr 44 mcg/0.5ml
(24mu/ml)........................................................................ 89
REBIF REBIDOSE -interferon beta-1a soln auto-inj 22
mcg/0.5ml (12mu/ml)...................................................... 89
REBIF REBIDOSE -interferon beta-1a soln auto-inj 44
mcg/0.5ml (24mu/ml)...................................................... 89
REBIF REBIDOSE TITRATION -interferon beta-1a autoinj 6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml.......................... 89
REBIF TITRATION PACK -interferon beta-1a pref syr
6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml............................... 89
RECOMBINATE -antihemophilic factor (recombinant) for
inj 220-400 unit............................................................. 126
inj 401-800 unit............................................................. 126
inj 801-1240 unit........................................................... 126
inj 1241-1800 unit......................................................... 126
inj 1801-2400 unit......................................................... 126
RECOMBIVAX HB -hepatitis b vaccine (recombinant)
susp 5 mcg/0.5ml........................................................... 15
285
2016
susp 10 mcg/ml.............................................................. 15
susp 40 mcg/ml.............................................................. 15
RECTIV -nitroglycerin oint 0.4%..................................... 132
REFUAH PLUS BLOOD GLUCOSE -blood glucose
REFUAH PLUS BLOOD GLUCOSE -glucose blood test
strip................................................................................ 148
REGENECARE -lidocaine hcl-collagen-aloe vera gel
2%.................................................................................. 140
REGIONAL BLOCK NEEDLE SAF -needle (disp) 22 x
1-1/2"............................................................................. 188
REGLAN -metoclopramide hcl tab 5 mg........................... 68
REGLAN -metoclopramide hcl tab 10 mg......................... 68
REGRANEX -becaplermin gel 0.01%............................. 140
RELAGARD -acetic acid-oxyquinoline vaginal gel
0.9-0.025%...................................................................... 70
RELENZA DISKHALER -zanamivir aero powder breath
activated 5 mg/blister........................................................9
RELION BLOOD GLUCOSE TEST -glucose blood test
strip................................................................................ 148
RELION CONFIRM/MICRO TEST -glucose blood test
strip................................................................................ 148
RELION CONFIRM BLOOD GLUC -blood glucose
RELION INSULIN SYRINGE/U -insulin syringe/needle
u-100 1/2 ml 29 g......................................................... 188
RELION INSULIN SYRINGE/U- -insulin syringe/needle
u-100 1/2 ml 30 g......................................................... 188
u-100 1/2 ml 31 x 5/16"................................................ 188
u-100 1/2 ml 29 x 1/2".................................................. 188
u-100 1/2 ml 30 x 5/16"................................................ 188
u-100 0.3 ml 29 g......................................................... 188
u-100 0.3 ml 30 g......................................................... 188
u-100 1 ml 30 g............................................................ 188
u-100 0.3 ml 29 x 1/2".................................................. 188
u-100 0.3 ml 30 x 5/16"................................................ 188
u-100 1 ml 29 x 1/2".....................................................188
u-100 1 ml 30 x 5/16"...................................................189
u-100 1 ml 31 x 5/16"...................................................189
u-100 0.3 ml 31 x 5/16"................................................ 189
RELION KETONE -acetone (urine) test strip.................. 148
RELION KETONE TEST STRIPS -acetone (urine) test
strip................................................................................ 148
286
RELION LANCETS -lancets............................................ 189

RELION LANCETS MICRO-THIN -lancets..................... 189
RELION LANCETS STANDARD 2 -lancets.................... 189
RELION LANCETS THIN 26G -lancets.......................... 189
RELION LANCETS ULTRA-THIN -lancets..................... 189
RELION LANCING DEVICE -lancet devices.................. 189
RELION MICRO BLOOD GLUCOS -blood glucose
RELION MINI PEN NEEDLES 3 -insulin pen needle 31 g
x 6 mm (1/4")................................................................ 189
RELION PEN NEEDLES 29GX12 -insulin pen needle 29
g x 12 mm (1/2")...........................................................189
RELION PEN NEEDLES 32GX4M -insulin pen needle 32
g x 4 mm (5/32")...........................................................189
RELION PEN NEEDLES 31GX8M -insulin pen needle 31
g x 8 mm (1/3" or 5/16")...............................................189
RELION PRIME BLOOD GLUCOS -blood glucose
RELION PRIME BLOOD GLUCOS -glucose blood test
strip................................................................................ 148
RELION R -insulin regular (human) inj 100 unit/ml........... 31
RELION SHORT PEN NEEDLES -insulin pen needle 31 g
x 8 mm (1/3" or 5/16").................................................. 189
RELION THIN LANCETS -lancets.................................. 189
RELION ULTIMA BLOOD GLUCO -blood glucose
RELION ULTIMA BLOOD GLUCO -glucose blood test
strip................................................................................ 148
RELION ULTIMA TEST STRIPS -glucose blood test
strip................................................................................ 148
RELION ULTRA THIN LANCETS -lancets......................189
RELION ULTRA THIN PLUS LA -lancets....................... 189
RELISTOR -methylnaltrexone bromide inj 8 mg/0.4ml (20
mg/ml).............................................................................. 68
RELISTOR -methylnaltrexone bromide inj 12 mg/0.6ml
(20 mg/ml)....................................................................... 68
RELNATE DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................. 115
RELPAX -eletriptan hydrobromide tab 20 mg (base
equivalent)..................................................................... 100
RELPAX -eletriptan hydrobromide tab 40 mg (base
equivalent)..................................................................... 100
REMERON -mirtazapine tab 15 mg.................................. 76
REMERON SOLTAB -mirtazapine orally disintegrating tab
15 mg.............................................................................. 76
30 mg.............................................................................. 76
45 mg.............................................................................. 76
REMODULIN -treprostinil sodium inj 1 mg/ml (base
equiv)............................................................................... 57
REMODULIN -treprostinil sodium inj 2.5 mg/ml (base
equiv)............................................................................... 57
equiv)............................................................................... 57
2016
equiv)............................................................................... 57
RENAGEL -sevelamer hcl tab 400 mg............................. 68
RENAGEL -sevelamer hcl tab 800 mg............................. 68
RENEW ADVANCED LANCING CA -lancets................. 189
RENEW ADVANCED LANCING DE -lancet devices...... 189
RENVELA -sevelamer carbonate packet 0.8 gm.............. 68
RENVELA -sevelamer carbonate packet 2.4 gm.............. 68
RENVELA -sevelamer carbonate tab 800 mg.................. 68
repaglinide tab 0.5 mg (Prandin)................................... 30
repaglinide tab 1 mg (Prandin)...................................... 30
repaglinide tab 2 mg (Prandin)...................................... 30
REPATHA -evolocumab subcutaneous soln prefilled
syringe 140 mg/ml.......................................................... 56
REPATHA SURECLICK -evolocumab subcutaneous soln
auto-injector 140 mg/ml.................................................. 56
REQUIP -ropinirole hydrochloride tab 0.25 mg...............108
REQUIP -ropinirole hydrochloride tab 0.5 mg.................108
REQUIP -ropinirole hydrochloride tab 1 mg....................108
REQUIP XL -ropinirole hydrochloride tab sr 24hr 2 mg
(base equivalent).......................................................... 108
(base equivalent).......................................................... 108
(base equivalent).......................................................... 108
(base equivalent).......................................................... 108
(base equivalent).......................................................... 108
RESCRIPTOR -delavirdine mesylate tab 100 mg.............. 9
RESCRIPTOR -delavirdine mesylate tab 200 mg.............. 9
RESCULA -unoprostone isopropyl ophth soln
0.15%.............................................................................130
RESERPINE -reserpine tab 0.1 mg.................................. 50
RESERPINE -reserpine tab 0.25 mg................................ 50
RESTASIS -cyclosporine (ophth) emulsion 0.05%......... 130
RESTORA RX -lactobacillus casei-folic acid cap 60-1.25
mg.................................................................................... 64
RETIN-A MICRO PUMP -tretinoin microsphere gel
0.04%.............................................................................140
0.08%.............................................................................140
0.1%...............................................................................140
RETIN-A MICRO -tretinoin microsphere gel 0.04%........ 140
RETIN-A MICRO -tretinoin microsphere gel 0.1%.......... 140
RETIN-A -tretinoin cream 0.025%................................... 140
RETIN-A -tretinoin cream 0.05%..................................... 140
RETIN-A -tretinoin cream 0.1%....................................... 140
RETIN-A -tretinoin gel 0.01%.......................................... 140
RETIN-A -tretinoin gel 0.025%........................................ 140
RETROBULBAR NEEDLE 25G TW -needle (disp) 25 x
1-1/2"............................................................................. 189
RETROVIR -zidovudine cap 100 mg.................................. 9

RETROVIR -zidovudine syrup 10 mg/ml............................ 9
REVATIO -sildenafil citrate for suspension 10 mg/ml....... 57
REVATIO -sildenafil citrate tab 20 mg............................... 57
REVEAL BLOOD GLUCOSE MONI -blood glucose
REVEAL BLOOD GLUCOSE TEST -glucose blood test
strip................................................................................ 148
REVESTA -folic acid-cholecalciferol cap 1 mg-5750
unit................................................................................. 121
REVIA -naltrexone hcl tab 50 mg................................... 144
REVLIMID -lenalidomide cap 5 mg................................. 205
REVLIMID -lenalidomide cap 10 mg............................... 205
REVLIMID -lenalidomide caps 2.5 mg............................ 205
REXALL BLOOD GLUCOSE MONI -blood glucose
REXALL BLOOD GLUCOSE TEST -glucose blood test
strip................................................................................ 148
REXALL LANCETS ULTRA THIN -lancets..................... 189
REXULTI -brexpiprazole tab 0.25 mg............................... 80
REXULTI -brexpiprazole tab 0.5 mg................................. 80
REXULTI -brexpiprazole tab 1 mg.................................... 80
REYATAZ -atazanavir sulfate cap 150 mg (base equiv)..... 9
REYATAZ -atazanavir sulfate oral powder packet 50 mg
(base equiv)...................................................................... 9
REZIRA -pseudoephedrine w/ hydrocodone soln 60-5
mg/5ml............................................................................. 59
RHEUMATREX -methotrexate sodium tab 2.5 mg
(antirheumatic)................................................................ 99
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......................................................9
RIBASPHERE RIBAPAK -ribavirin tab 400 mg & ribavirin
tab 600 mg dose pack......................................................9
RIBASPHERE -ribavirin tab 400 mg................................... 9
RIBASPHERE -ribavirin tab 600 mg................................... 9
RIBATAB -ribavirin tab 400 mg........................................... 9
RIBATAB -ribavirin tab 600 mg........................................... 9
RIBATAB -ribavirin tab 400 mg & ribavirin tab 600 mg
dose pack.......................................................................... 9
ribavirin cap 200 mg (Rebetol)......................................... 9
ribavirin tab 200 mg (Copegus)....................................... 9
RIDAURA -auranofin cap 3 mg......................................... 99
rifabutin cap 150 mg (Mycobutin).................................... 5
RIFADIN -rifampin cap 150 mg........................................... 5
RIFADIN -rifampin cap 300 mg........................................... 5
RIFAMATE -isoniazid & rifampin cap 150-300 mg.............. 5
rifampin cap 150 mg (Rifadin).......................................... 5
287
2016
rifampin cap 300 mg (Rifadin).......................................... 5
RIFATER -isoniazid-rifampin w/ pyrazinamide tab
50-120-300 mg.................................................................. 5
RIGHTEST GD500 LANCING DE -lancet devices......... 189
RIGHTEST GL300 LANCETS -lancets........................... 189
RIGHTEST GM100 BLOOD GLUC -blood glucose
RIGHTEST GS100 BLOOD GLUC -glucose blood test
strip................................................................................ 148
strip................................................................................ 148
strip................................................................................ 148
RIGHTSOURCE BLOOD GLUCOSE -blood glucose
RILUTEK -riluzole tab 50 mg.......................................... 109
riluzole tab 50 mg (Rilutek).......................................... 109
rimantadine hydrochloride tab 100 mg (Flumadine)..... 9
ringer's solution for irrigation...................................... 205
RIOMET -metformin hcl oral soln 500 mg/5ml.................. 30
risedronate sodium tab delayed release 35 mg
(Atelvia).......................................................................... 36
risedronate sodium tab 5 mg (Actonel)........................ 36
risedronate sodium tab 30 mg (Actonel)...................... 36
risedronate sodium tab 35 mg (Actonel)...................... 36
risedronate sodium tab 150 mg (Actonel).................... 36
RISPERDAL M-TAB -risperidone orally disintegrating tab
0.5 mg............................................................................. 80
1 mg................................................................................ 80
2 mg................................................................................ 80
3 mg................................................................................ 80
4 mg................................................................................ 80
RISPERDAL -risperidone soln 1 mg/ml............................ 80
RISPERDAL -risperidone tab 0.25 mg.............................. 80
RISPERDAL -risperidone tab 0.5 mg................................ 80
RISPERDAL -risperidone tab 1 mg................................... 80
risperidone orally disintegrating tab 0.25 mg.............. 80
risperidone orally disintegrating tab 0.5 mg (Risperdal
m-tab).............................................................................. 80
risperidone orally disintegrating tab 1 mg (Risperdal
m-tab).............................................................................. 80
m-tab).............................................................................. 80
m-tab).............................................................................. 80
288

m-tab).............................................................................. 80
risperidone soln 1 mg/ml (Risperdal)............................ 80
risperidone tab 0.25 mg (Risperdal).............................. 80
risperidone tab 0.5 mg (Risperdal)................................ 80
risperidone tab 1 mg (Risperdal)................................... 80
RITALIN LA -methylphenidate hcl cap sr 24hr 10 mg
(la).................................................................................... 85
(la).................................................................................... 86
(la).................................................................................... 86
(la).................................................................................... 86
(la).................................................................................... 86
RITALIN -methylphenidate hcl tab 5 mg........................... 85
RITALIN -methylphenidate hcl tab 10 mg......................... 85
RITALIN -methylphenidate hcl tab 20 mg......................... 85
rivastigmine tartrate cap 1.5 mg (Exelon).....................89
rivastigmine tartrate cap 3 mg (Exelon)........................89
rivastigmine tartrate cap 4.5 mg (Exelon).....................89
rivastigmine tartrate cap 6 mg (Exelon)........................89
rivastigmine td patch 24hr 4.6 mg/24hr (Exelon)......... 89
rivastigmine td patch 24hr 9.5 mg/24hr (Exelon)......... 89
rivastigmine td patch 24hr 13.3 mg/24hr (Exelon)....... 89
RIXUBIS -coagulation factor ix (recombinant) for inj 250
unit................................................................................. 126
unit................................................................................. 126
unit................................................................................. 126
unit................................................................................. 126
unit................................................................................. 126
rizatriptan benzoate orally disintegrating tab 5 mg
(Maxalt-mlt).................................................................. 100
rizatriptan benzoate orally disintegrating tab 10 mg
(Maxalt-mlt).................................................................. 100
rizatriptan benzoate tab 5 mg (Maxalt)........................100
rizatriptan benzoate tab 10 mg (Maxalt)......................100
R-NATAL OB -prenatal w/o a w/fe cbn-fa-dha cap
20-1-320 mg.................................................................. 115
ROBAXIN-750 -methocarbamol tab 750 mg...................109
ROBAXIN -methocarbamol tab 500 mg.......................... 109
ROBINUL FORTE -glycopyrrolate tab 2 mg..................... 65
ROBINUL -glycopyrrolate tab 1 mg.................................. 65
ROCALTROL -calcitriol cap 0.25 mcg...............................36
ROCALTROL -calcitriol cap 0.5 mcg.................................36
ROCALTROL -calcitriol oral soln 1 mcg/ml....................... 36
ropinirole hydrochloride tab 0.25 mg (Requip).......... 108
ropinirole hydrochloride tab 0.5 mg (Requip)............ 108
ropinirole hydrochloride tab 1 mg (Requip)............... 108
2016
ropinirole hydrochloride tab sr 24hr 2 mg (base
equivalent) (Requip xl)............................................... 108
ROSULA -sulfacetamide sodium w/ sulfur wash
10-4.5%......................................................................... 140
ROXICET -oxycodone w/ acetaminophen soln 5-325
mg/5ml............................................................................. 96
ROXICODONE -oxycodone hcl tab 5 mg......................... 96
ROXICODONE -oxycodone hcl tab 15 mg....................... 96
ROXICODONE -oxycodone hcl tab 30 mg....................... 96
ROZEREM -ramelteon tab 8 mg....................................... 82
RUCONEST -c1 esterase inhibitor (recombinant) for iv inj
2100 unit....................................................................... 126
RULAVITE DHA -prenat w/o a w/fefum-methfol-fa-dha
cap 27-0.6-0.4-300 mg................................................. 115
RYTHMOL -propafenone hcl tab 150 mg......................... 43
RYTHMOL -propafenone hcl tab 225 mg......................... 43
RYTHMOL SR -propafenone hcl cap sr 12hr 225 mg...... 44
S
SABRIL -vigabatrin powd pack 500 mg.......................... 105
SABRIL -vigabatrin tab 500 mg...................................... 105
SAFESNAP ALLERGY SYRINGE/ -tuberculin/allergy
SAFESNAP INSULIN SYRINGE/ -insulin syringe/needle
u-100 1/2 ml 29 x 1/2".................................................. 190
u-100 1/2 ml 30 x 5/16"................................................ 190
u-100 0.3 ml 30 x 5/16"................................................ 190
u-100 1 ml 28 x 1/2".....................................................190
u-100 1 ml 29 x 1/2".....................................................190
SAFESNAP TUBERCULIN SYRIN -tuberculin/allergy
SAFESNAP TUBERCULIN SYRIN -tuberculin/allergy
SAFE-T-LANCE LOW FLOW 25G -lancets.................... 189
SAFE-T-LANCE NORMAL FLOW -lancets..................... 189
SAFE-T-LANCE PLUS SAFETY -lancets....................... 190
SAFETY-GARD SHIELDED NEED -hypodermic needles
(disposable)................................................................... 190
SAFETY-GLIDE INSULIN SYRI -insulin syringe/needle

u-100 0.3 ml 29 x 1/2".................................................. 190
SAFETY LANCET 21G/PRESSUR -lancets................... 190
SAFETY LANCET 28G/PRESSUR -lancets................... 190
SAFETY LANCET 2MM -lancets.................................... 190
SAFETY LANCETS 21G -lancets................................... 190
SAFETY LANCETS 28G -lancets................................... 190
SAFETY LANCETS -lancets........................................... 190
SAFETY LET LANCETS -lancets................................... 190
SAFETY-LOK SAFETY SYRINGE -tuberculin/allergy
SAFETY-LOK TB SYRINGE PER -tuberculin/allergy
SAFETY SEAL LANCETS 28G -lancets......................... 190
SAFETY SEAL LANCETS 30G -lancets......................... 190
SAFYRAL -drospirenone-ethinyl estrad-levomefolate tab
3-0.03-0.451 mg..............................................................26
SAIZEN CLICK.EASY -somatropin (non-refrigerated) for
inj 8.8 mg........................................................................ 36
SAIZEN -somatropin (non-refrigerated) for inj 5 mg......... 36
SAIZEN -somatropin (non-refrigerated) for inj 8.8 mg...... 36
SALAGEN -pilocarpine hcl tab 5 mg............................... 131
SALAGEN -pilocarpine hcl tab 7.5 mg............................ 131
SALEX -salicylic acid shampoo 6%................................ 140
salicylic acid cream 6%................................................ 140
salicylic acid film forming liquid 27.5% (Virasal)....... 140
salicylic acid foam 6% (Salvax)................................... 140
salicylic acid gel 6% (Keralyt)...................................... 140
SALICYLIC ACID IN AMMONIU -salicylic acid in
ammonium lactate vehicle foam 6%............................ 140
salicylic acid lotion 6%................................................. 140
SALICYLIC ACID -salicylic acid soln 26%...................... 140
salicylic acid shampoo 6% (Salex).............................. 140
SALKERA -salicylic acid in ammonium lactate vehicle
foam 6%........................................................................ 140
salsalate tab 500 mg (Disalcid)...................................... 90
salsalate tab 750 mg (Disalcid)...................................... 90
SALVAX -salicylic acid foam 6%..................................... 140
SAMSCA -tolvaptan tab 15 mg......................................... 36
SAMSCA -tolvaptan tab 30 mg......................................... 36
SANCUSO -granisetron td patch 3.1 mg/24hr (contains
34.3 mg).......................................................................... 66
SANDIMMUNE -cyclosporine cap 25 mg....................... 205
SANDIMMUNE -cyclosporine cap 100 mg..................... 205
SANDIMMUNE -cyclosporine oral soln 100 mg/ml......... 205
SANDOSTATIN -octreotide acetate inj 50 mcg/ml (0.05
mg/ml).............................................................................. 36
mg/ml).............................................................................. 36
mg/ml).............................................................................. 37
mg/ml).............................................................................. 37
SANDOSTATIN -octreotide acetate inj 1000 mcg/ml (1
mg/ml).............................................................................. 37
SANTYL -collagenase oint 250 unit/gm.......................... 140
289
2016
SAPHRIS -asenapine maleate sl tab 2.5 mg (base
equiv)............................................................................... 80
SAPHRIS -asenapine maleate sl tab 5 mg (base
equiv)............................................................................... 80
SAPHRIS -asenapine maleate sl tab 10 mg (base
equiv)............................................................................... 80
SAPSCARE TWIST TOP LANCET -lancets................... 190
SARAFEM -fluoxetine hcl (pmdd) tab 10 mg.................... 89
SARAFEM -fluoxetine hcl (pmdd) tab 20 mg.................... 89
SAVAYSA -edoxaban tosylate tab 15 mg (base
equivalent)..................................................................... 122
equivalent)..................................................................... 122
equivalent)..................................................................... 122
SAVELLA -milnacipran hcl tab 12.5 mg............................ 89
SAVELLA -milnacipran hcl tab 25 mg............................... 89
SAVELLA -milnacipran hcl tab 50 mg............................... 89
SAVELLA -milnacipran hcl tab 100 mg............................. 89
SAVELLA TITRATION PACK -milnacipran hcl tab 12.5 mg
(5) & 25 mg (8) & 50 mg (42) pak................................. 89
SB INSULIN SYRINGE/U-100/ -insulin syringe/needle
u-100 1/2 ml 29 x 1/2".................................................. 190
u-100 1/2 ml 30 x 5/16"................................................ 190
u-100 1 ml 29 x 1/2".....................................................190
u-100 1 ml 30 x 5/16"...................................................190
u-100 1 ml 31 x 5/16"...................................................190
SB LANCETS THIN -lancets........................................... 190
SB LANCETS ULTRA THIN -lancets.............................. 190
SCHNUCKS INSULIN SYRINGE -insulin syringe/needle
u-100 1/2 ml 29 x 1/2".................................................. 190
SCHNUCKS INSULIN SYRINGE -insulin syringe/needle
u-100 1/2 ml 30 x 5/16"................................................ 190
SEASONIQUE -levonorg-eth est tab 0.15-0.03mg(84) &
eth est tab 0.01mg(7)..................................................... 26
SECONAL -secobarbital sodium cap 100 mg................... 82
SECTRAL -acebutolol hcl cap 200 mg............................. 40
SECTRAL -acebutolol hcl cap 400 mg............................. 40
SELECT-LITE LANCING DEVIC -lancet devices........... 190
SELECT-OB+DHA -prenatal mv w/fe poly-fa chw 29-1 mg
& dha cap 250 mg pak................................................. 115
SELECT-OB -prenatal vit w/ fe polysac cmplx-fa chew tab
29-1 mg......................................................................... 115
SELECT-OB -prenat w/ fepolycmplx-methylfol-fa chew
tab 29-0.6-0.4 mg......................................................... 115
selegiline hcl cap 5 mg (Eldepryl)............................... 108
selegiline hcl tab 5 mg.................................................. 108
selenium sulfide lotion 2.5%........................................ 140
selenium sulfide-pyrithione zinc in urea shampoo
2.25%.............................................................................140
SELZENTRY -maraviroc tab 150 mg.................................. 9
SELZENTRY -maraviroc tab 300 mg.................................. 9
290
SE-NATAL 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1

mg.................................................................................. 115
SE-NATAL 19 -prenatal vit w/ fe fumarate-fa chew tab
29-1 mg......................................................................... 115
SENSIPAR -cinacalcet hcl tab 30 mg (base equiv).......... 37
SEREVENT DISKUS -salmeterol xinafoate aer pow ba 50
mcg/dose (base equiv)................................................... 62
SEROQUEL -quetiapine fumarate tab 25 mg................... 80
SEROQUEL -quetiapine fumarate tab 50 mg................... 80
SEROQUEL -quetiapine fumarate tab 100 mg................. 80
SEROQUEL XR -quetiapine fumarate tab sr 24hr 50
mg.................................................................................... 81
mg.................................................................................... 81
mg.................................................................................... 81
mg.................................................................................... 81
mg.................................................................................... 81
SEROSTIM -somatropin (non-refrigerated) for
subcutaneous inj 4 mg................................................... 37
sertraline hcl oral conc 20 mg/ml (Zoloft).................... 76
sertraline hcl tab 25 mg (Zoloft).................................... 76
sertraline hcl tab 50 mg (Zoloft).................................... 76
sertraline hcl tab 100 mg (Zoloft).................................. 76
SE-TAN DHA -prenatal w/fe fum-fe poly -fa-omega 3 cap
15-15-1 mg.................................................................... 115
SETON ET-EC -prenat-fe bis-fe prot succ-fa-ca tab &
omega cap dr 430 pk................................................... 115
SETONET -prenat-fe bis-fe prot succ-fa-ca tab & omega 3
cap 430 pk.................................................................... 115
SEVELAMER CARBONATE -sevelamer carbonate tab
800 mg............................................................................ 68
SFROWASA -mesalamine sulfite-free (sf) enema 4
gm/60ml........................................................................... 68
SHOHLS SOLUTION MODIFIED -sodium citrate & citric
acid soln 500-334 mg/5ml.............................................. 71
SHOPKO AUTOLET LANCING DE -lancet devices....... 190
SHOPKO ON-THE-GO COMFORT -lancets.................. 190
SHOPKO UNIFINE PENTIPS PE -insulin pen needle 29 g
x 12 mm (1/2").............................................................. 191
x 5 mm (3/16").............................................................. 191
x 4 mm (5/32").............................................................. 191
x 8 mm (1/3" or 5/16").................................................. 191
2016
SHOPKO UNILET LANCETS SUP -lancets................... 191
SHOPKO UNILET LANCETS ULT -lancets.................... 191
SHUR-SEAL -nonoxynol-9 gel 2%.................................... 70
SIGNIFOR -pasireotide diaspartate inj 0.3 mg/ml (base
equiv)............................................................................... 37
equiv)............................................................................... 37
equiv)............................................................................... 37
sildenafil citrate tab 20 mg (Revatio)............................ 57
SILENOR -doxepin hcl (sleep) tab 3 mg (base equiv)...... 82
SILENOR -doxepin hcl (sleep) tab 6 mg (base equiv)...... 82
SILVADENE -silver sulfadiazine cream 1%.....................140
silver nitrate-potassium nitrate applicator 75-25%
(Arzol silver nitrate).................................................... 141
SILVER NITRATE -silver nitrate oint 10%....................... 140
SILVER NITRATE -silver nitrate soln 0.5%..................... 140
SILVER NITRATE -silver nitrate soln 10%...................... 140
silver sulfadiazine cream 1% (Silvadene)................... 141
SIMBRINZA -brinzolamide-brimonidine tartrate ophth
susp 1-0.2%.................................................................. 130
SIMCOR -niacin-simvastatin tab sr 24hr 500-20 mg........ 56
SIMCOR -niacin-simvastatin tab sr 24hr 1000-20 mg...... 56
SIMCOR -niacin-simvastatin tab sr 24hr 1000-40 mg...... 56
SIMPLE DIAGNOSTICS LANCIN -lancet devices.......... 191
SIMPONI -golimumab subcutaneous soln auto-injector 50
mg/0.5ml.......................................................................... 99
SIMPONI -golimumab subcutaneous soln auto-injector
100 mg/ml....................................................................... 99
SIMPONI -golimumab subcutaneous soln prefilled syringe
50 mg/0.5ml.................................................................... 99
SIMPONI -golimumab subcutaneous soln prefilled syringe
100 mg/ml....................................................................... 99
simvastatin tab 5 mg (Zocor)......................................... 56
simvastatin tab 10 mg (Zocor)....................................... 56
SINEMET -carbidopa & levodopa tab 10-100 mg........... 108
SINEMET CR -carbidopa & levodopa tab cr 25-100
mg.................................................................................. 108
SINEMET CR -carbidopa & levodopa tab cr 50-200
mg.................................................................................. 109
SINGLE-LET -lancets...................................................... 191
SINGULAIR -montelukast sodium oral granules packet 4
mg (base equiv).............................................................. 62
sirolimus tab 0.5 mg (Rapamune)............................... 205
sirolimus tab 1 mg (Rapamune).................................. 205
sirolimus tab 2 mg (Rapamune).................................. 205
SIRTURO -bedaquiline fumarate tab 100 mg (base
equiv)................................................................................. 5
SIVEXTRO -tedizolid phosphate tab 200 mg....................12

SKELAXIN -metaxalone tab 800 mg............................... 109
SKLICE -ivermectin lotion 0.5%...................................... 141
SMART DIABETES VANTAGE LA -lancet devices.........191
SMART DIABETES VANTAGE UN -lancets................... 191
SMART DIABETES XPRES BLOO -blood glucose
SMART DIABETES XPRES BLOO -glucose blood test
strip................................................................................ 148
SMARTEST BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 148
SMARTEST EJECT BLOOD GLUC -blood glucose
SMARTEST EJECT STARTER KI -blood glucose
SMARTEST LANCETS 28G -lancets.............................. 192
SMARTEST PERSONA STARTER -blood glucose
SMARTEST PRONTO STARTER -blood glucose
SMARTEST PROTEGE BLOOD GL -blood glucose
SMARTEST PROTEGE STARTER -blood glucose
SMART SENSE COLOR LANCETS -lancets................. 191
SMART SENSE PREMIUM BLOOD -blood glucose
SMART SENSE PREMIUM BLOOD -glucose blood test
strip................................................................................ 148
SMART SENSE STANDARD LANC -lancets..................191
SMART SENSE SUPER THIN LA -lancets.................... 191
SMART SENSE THIN LANCETS -lancets...................... 191
SMART SENSE VALUE BLOOD -blood glucose
SMART SENSE VALUE BLOOD G -glucose blood test
strip................................................................................ 148
SM INSULIN SYRINGE/0.5ML/ -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 191
SM INSULIN SYRINGE/0.3ML/ -insulin syringe/needle
u-100 0.3 ml 31 x 5/16"................................................ 191
SM INSULIN SYRINGE/1ML/31 -insulin syringe/needle
u-100 1 ml 31 x 5/16"...................................................191
SM INSULIN SYRINGE/U-100/ -insulin syringe/needle
u-100 1/2 ml 28 x 1/2".................................................. 191
u-100 1/2 ml 29 x 1/2".................................................. 191
u-100 1/2 ml 30 x 5/16"................................................ 191
u-100 0.3 ml 29 x 1/2".................................................. 191
u-100 0.3 ml 30 x 5/16"................................................ 191
u-100 1 ml 28 x 1/2".....................................................191
u-100 1 ml 29 x 1/2".....................................................191
291
2016
u-100 1 ml 30 x 5/16"...................................................191
SM LANCETS 21G -lancets............................................ 191
SM MICRO THIN LANCETS 33G -lancets..................... 191
SM SUPER THIN LANCETS 30G -lancets..................... 191
SM THIN LANCETS 26G -lancets.................................. 191
SM ULTRA COMFORT INSULIN -insulin syringe/needle
u-100 1 ml 30 x 5/16"...................................................191
sodium chloride irrigation soln 0.9%............................ 71
sodium chloride soln nebu 0.9%................................... 59
sodium chloride soln nebu 3%...................................... 59
sodium chloride soln nebu 10%.................................... 59
sodium chloride soln nebu 7% (Hyper-sal).................. 59
sodium citrate & citric acid soln 500-334 mg/5ml
(Shohls solution modi)................................................ 71
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf)
(Luride)......................................................................... 119
sodium fluoride chew tab 0.5 mg f (from 1.1 mg naf)
(Luride)......................................................................... 119
sodium fluoride chew tab 1 mg f (from 2.2 mg naf)
(Luride)......................................................................... 119
SODIUM FLUORIDE -sodium fluoride tab 0.5 mg f (from
1.1 mg naf)....................................................................119
SODIUM FLUORIDE -sodium fluoride tab 1 mg f (from
2.2 mg naf)....................................................................119
sodium fluoride soln 0.125 mg/drop f (0.275 mg/drop
naf)................................................................................ 119
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)
(Luride)......................................................................... 119
sodium phenylbutyrate oral powder 3 gm/teaspoonful
(Buphenyl)...................................................................... 37
sodium polystyrene sulfonate oral susp 15 gm/60ml
(Sps).............................................................................. 205
sodium polystyrene sulfonate powder
(Kayexalate)................................................................. 205
sodium polystyrene sulfonate rectal susp 30
gm/120ml...................................................................... 205
SODIUM SULFACETAMIDE/SULF -sulfacetamide
sodium-sulfur in urea emulsion 10-5%........................ 141
SODIUM SULFACETAMIDE/SULF -sulfacetamide
sodium-sulfur in urea gel 10-5%.................................. 141
SODIUM SULFACETAMIDE WASH -sulfacetamide
sodium in bakuchiol vehicle wash 10%....................... 141
SOLARAZE -diclofenac sodium (actinic keratoses) gel
3%.................................................................................. 141
SOLTAMOX -tamoxifen citrate oral soln 10 mg/5ml (base
equivalent)....................................................................... 19
SOLUS V2 AUDIBLE BLOOD GL -blood glucose
SOLUS V2 AUDIBLE BLOOD GL -blood glucose
SOLUS V2 AUDIBLE TEST -glucose blood test strip..... 148
SOLUS V2 LANCING DEVICE -lancet devices.............. 192
SOLUS V2 PRESSURE ACTIVAT -lancets.................... 192
SOLUS V2 TWIST LANCETS 30 -lancets...................... 192
SOMAVERT -pegvisomant for inj 10 mg (as protein)....... 37
292

SONATA -zaleplon cap 5 mg............................................ 82
SONATA -zaleplon cap 10 mg.......................................... 82
SOOLANTRA -ivermectin cream 1%.............................. 141
SORIATANE -acitretin cap 10 mg................................... 141
SORIATANE -acitretin cap 17.5 mg................................ 141
SORIATANE -acitretin cap 25 mg................................... 141
SORILUX -calcipotriene foam 0.005%............................ 141
sotalol hcl (afib/afl) tab 80 mg (Betapace af)................ 40
sotalol hcl (afib/afl) tab 120 mg (Betapace af).............. 40
sotalol hcl (afib/afl) tab 160 mg (Betapace af).............. 40
sotalol hcl tab 240 mg.....................................................40
sotalol hcl tab 80 mg (Betapace)................................... 40
sotalol hcl tab 120 mg (Betapace)................................. 40
sotalol hcl tab 160 mg (Betapace)................................. 40
SOTYLIZE -sotalol hcl oral solution 5 mg/ml.................... 40
SOVALDI -sofosbuvir tab 400 mg....................................... 9
SPECTRACEF -cefditoren pivoxil tab 200 mg (base
equivalent)......................................................................... 2
SPECTRACEF -cefditoren pivoxil tab 400 mg (base
equivalent)......................................................................... 2
SPINOSAD -spinosad susp 0.9%................................... 141
SPIRIVA HANDIHALER -tiotropium bromide monohydrate
inhal cap 18 mcg (base equiv)....................................... 62
SPIRIVA RESPIMAT -tiotropium bromide monohydrate
inhal aerosol 1.25 mcg/act............................................. 62
SPIRIVA RESPIMAT -tiotropium bromide monohydrate
inhal aerosol 2.5 mcg/act............................................... 62
spironolactone & hydrochlorothiazide tab 25-25 mg
(Aldactazide).................................................................. 53
spironolactone tab 25 mg (Aldactone).......................... 53
spironolactone tab 50 mg (Aldactone).......................... 53
spironolactone tab 100 mg (Aldactone)........................ 53
SPORANOX -itraconazole cap 100 mg.............................. 6
SPORANOX -itraconazole oral soln 10 mg/ml....................6
SPORANOX PULSEPAK -itraconazole cap 100 mg.......... 6
SPRIX -ketorolac tromethamine nasal spray 15.75 mg/
spray................................................................................ 99
SPRYCEL -dasatinib tab 20 mg........................................ 19
SPRYCEL -dasatinib tab 100 mg...................................... 19
SPRYCEL -dasatinib tab 140 mg...................................... 19
SSKI -potassium iodide soln 1 gm/ml............................. 119
STALEVO 100 -carbidopa-levodopa-entacapone tabs
25-100-200 mg..............................................................109
31.25-125-200 mg........................................................ 109
37.5-150-200 mg.......................................................... 109
50-200-200 mg..............................................................109
12.5-50-200 mg.............................................................109
2016
18.75-75-200 mg.......................................................... 109
STARLIX -nateglinide tab 60 mg....................................... 30
STARLIX -nateglinide tab 120 mg..................................... 30
stavudine cap 15 mg (Zerit)..............................................9
stavudine for oral soln 1 mg/ml (Zerit)........................... 9
STAVZOR -valproic acid cap delayed release 125
mg.................................................................................. 105
mg.................................................................................. 105
mg.................................................................................. 105
1ST CHOICE LANCETS SUPER -lancets...................... 203
1ST CHOICE LANCETS THIN -lancets.......................... 203
1ST CHOICE LANCETS ULTRA -lancets....................... 203
STELARA -ustekinumab soln prefilled syringe 45
mg/0.5ml........................................................................ 141
STELARA -ustekinumab soln prefilled syringe 90 mg/
ml................................................................................... 141
STERILANCE TL -lancets............................................... 192
STIMATE -desmopressin acetate nasal soln 1.5 mg/
ml..................................................................................... 37
STIMEX INSULATED NEEDLE T -needle (disp) 22 x
1-1/2"............................................................................. 192
2-1/8"............................................................................. 192
4-1/4"............................................................................. 192
STIOLTO RESPIMAT -tiotropium br-olodaterol inhal aero
soln 2.5-2.5 mcg/act....................................................... 62
STIVARGA -regorafenib tab 40 mg................................... 19
STRATTERA -atomoxetine hcl cap 10 mg (base
equiv)............................................................................... 86
equiv)............................................................................... 86
equiv)............................................................................... 86
equiv)............................................................................... 86
equiv)............................................................................... 86
equiv)............................................................................... 86
equiv)............................................................................... 86
STRIBILD -elvitegrav-cobicis-emtricitab-tenofov tab
150-150-200-300 mg........................................................ 9
STRIVERDI RESPIMAT -olodaterol hcl inhal aerosol soln
2.5 mcg/act (base equiv)................................................ 62
STROMECTOL -ivermectin tab 3 mg................................11
1ST TIER UNIFINE PENTIPS -insulin pen needle 29 g x
12 mm (1/2")................................................................. 203
5 mm (3/16")................................................................. 203

6 mm (1/4")................................................................... 203
4 mm (5/32")................................................................. 203
8 mm (1/3" or 5/16")..................................................... 203
1ST TIER UNILET COMFORTOU -lancets.................... 204
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 2-0.5
mg (base equiv).............................................................. 96
SUBOXONE -buprenorphine hcl-naloxone hcl sl film 4-1
mg (base equiv).............................................................. 96
mg (base equiv).............................................................. 96
mg (base equiv).............................................................. 96
SUBSYS -fentanyl sublingual spray 100 mcg................... 96
SUBSYS -fentanyl sublingual spray 1200 mcg (600 mcg x
2)...................................................................................... 96
SUBSYS -fentanyl sublingual spray 1600 mcg (800 mcg x
2)...................................................................................... 96
SUCRAID -sacrosidase soln 8500 unit/ml........................ 67
sucralfate tab 1 gm (Carafate)....................................... 65
SULAR -nisoldipine tab sr 24hr 8.5 mg............................ 42
SULAR -nisoldipine tab sr 24hr 17 mg............................. 42
SULAR -nisoldipine tab sr 24hr 34 mg............................. 42
sulfacetamide sodium cleansing gel 10% (Ovace plus
wash).............................................................................141
sulfacetamide sodium liquid 10% (Ovace wash)....... 141
sulfacetamide sodium lotion 10% (acne) (Klaron)..... 141
sulfacetamide sodium ophth soln 10%
(Bleph-10)..................................................................... 130
sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%............................................................. 130
sulfacetamide sodium shampoo 10% (Ovace
plus).............................................................................. 141
SULFACETAMIDE SODIUM -sulfacetamide sodium ophth
oint 10%........................................................................ 130
sulfacetamide sodium w/ sulfur cleanser 10-2% (Avar
ls cleanser).................................................................. 141
sulfacetamide sodium w/ sulfur cleanser 9.8-4.8%
(Plexion cleanser)....................................................... 141
sulfacetamide sodium w/ sulfur cream 10-5%........... 141
sulfacetamide sodium w/ sulfur cream 10-2% (Avar-e
ls)................................................................................... 141
sulfacetamide sodium w/ sulfur cream 9.8-4.8%
(Plexion)....................................................................... 141
sulfacetamide sodium w/ sulfur emulsion 10-1%...... 141
sulfacetamide sodium w/ sulfur emulsion 10-5%...... 141
sulfacetamide sodium w/ sulfur foam 10-5%
(Clarifoam ef)............................................................... 141
sulfacetamide sodium w/ sulfur lotion 10-5%............ 141
sulfacetamide sodium w/ sulfur lotion 9.8-4.8%
(Plexion)....................................................................... 141
293
2016
sulfacetamide sodium w/ sulfur susp 8-4% (Sumaxin
ts).................................................................................. 141
sulfacetamide sodium w/ sulfur wash 9-4.5%
(Sumadan wash)......................................................... 141
sulfacetamide sodium w/ sulfur wash 9-4% (Sumaxin
wash).............................................................................141
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...... 141
SULFAMYLON -mafenide acetate packet for topical soln
5% (50 gm)................................................................... 141
sulfasalazine tab delayed release 500 mg (Azulfidine
en-tabs)........................................................................... 68
sulfasalazine tab 500 mg (Azulfidine)........................... 68
SULFOAM -sulfur shampoo 2%...................................... 141
sulindac tab 150 mg........................................................ 99
sulindac tab 200 mg........................................................ 99
SUMADAN WASH -sulfacetamide sodium w/ sulfur wash
9-4.5%........................................................................... 141
sumatriptan succinate inj 6 mg/0.5ml (Imitrex).......... 100
sumatriptan succinate solution auto-injector 4
mg/0.5ml (Imitrex statdose sys)............................... 101
sumatriptan succinate solution auto-injector 6
mg/0.5ml (Imitrex statdose sys)............................... 101
sumatriptan succinate solution cartridge 4 mg/0.5ml
(Imitrex statdose ref).................................................. 101
sumatriptan succinate solution cartridge 6 mg/0.5ml
(Imitrex statdose ref).................................................. 101
SUMATRIPTAN SUCCINATE -sumatriptan succinate inj 4
mg/0.5ml........................................................................ 100
SUMATRIPTAN SUCCINATE -sumatriptan succinate
solution prefilled syringe 6 mg/0.5ml........................... 100
sumatriptan succinate tab 25 mg (Imitrex)................. 101
sumatriptan succinate tab 50 mg (Imitrex)................. 101
sumatriptan succinate tab 100 mg (Imitrex)............... 101
SUMATRIPTAN -sumatriptan nasal spray 5 mg/act....... 100
SUMATRIPTAN -sumatriptan nasal spray 20 mg/act..... 100
SUMAVEL DOSEPRO -sumatriptan succinate solution jetinjector 4 mg/0.5ml....................................................... 101
SUMAVEL DOSEPRO -sumatriptan succinate solution jetinjector 6 mg/0.5ml....................................................... 101
SUMAXIN WASH -sulfacetamide sodium w/ sulfur wash
9-4%.............................................................................. 141
SUPER THIN LANCETS -lancets................................... 192
SUPRAX -cefixime cap 400 mg.......................................... 2
SUPRAX -cefixime chew tab 100 mg................................. 2
SUPRAX -cefixime chew tab 200 mg................................. 2
SUPRAX -cefixime for susp 100 mg/5ml............................ 2
SUPREME II CONFIDENCE PAD -blood glucose
monitoring misc............................................................. 192
294
SUPREME TEST STRIPS -glucose blood test strip....... 148

SUPREP BOWEL PREP -sodium sulfate-potassium
sulfate-magnesium sulfate oral soln.............................. 63
SURECHEK BLOOD GLUCOSE MO -blood glucose
SURECHEK BLOOD GLUCOSE MO -blood glucose
SURECHEK BLOOD GLUCOSE TE -glucose blood test
strip................................................................................ 148
SURE COMFORT INSULIN SYRI -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 192
u-100 1/2 ml 28 x 1/2".................................................. 192
u-100 1/2 ml 29 x 1/2".................................................. 192
u-100 1/2 ml 30 x 5/16"................................................ 192
u-100 1/2 ml 30 x 1/2".................................................. 192
u-100 0.3 ml 29 x 1/2".................................................. 192
u-100 0.3 ml 30 x 5/16"................................................ 192
u-100 0.3 ml 30 x 1/2".................................................. 192
u-100 1 ml 28 x 1/2".....................................................192
u-100 1 ml 29 x 1/2".....................................................192
u-100 1 ml 30 x 5/16"...................................................192
u-100 1 ml 30 x 1/2".....................................................192
u-100 1 ml 31 x 5/16"...................................................192
u-100 0.3 ml 31 x 5/16"................................................ 192
SURE COMFORT LANCETS 28G -lancets.................... 192
SURE COMFORT LANCETS 30G -lancets.................... 192
SURE COMFORT LANCING PEN -lancet devices........ 193
SURE COMFORT PEN NEEDLES -insulin pen needle 29
g x 12.7 mm..................................................................193
g x 5 mm (3/16")...........................................................193
g x 4 mm (5/32")...........................................................193
g x 6 mm (1/4").............................................................193
g x 8 mm (1/3" or 5/16")...............................................193
g x 8 mm (1/3" or 5/16")...............................................193
SURE EDGE BLOOD GLUCOSE M -blood glucose
SURE EDGE BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 148
2016
SURE-FINE PEN NEEDLES 29G -insulin pen needle 29
g x 12.7 mm..................................................................193
g x 5 mm (3/16")...........................................................193
g x 8 mm (1/3" or 5/16")...............................................193
SURE-JECT INSULIN SYRINGE -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 193
u-100 1/2 ml 28 x 1/2".................................................. 193
u-100 1/2 ml 29 x 1/2".................................................. 193
u-100 1/2 ml 30 x 5/16"................................................ 193
u-100 0.3 ml 29 x 1/2".................................................. 193
u-100 0.3 ml 30 x 5/16"................................................ 193
u-100 1 ml 28 x 1/2".....................................................193
u-100 1 ml 29 x 1/2".....................................................193
u-100 1 ml 30 x 5/16"...................................................193
u-100 1 ml 31 x 5/16"...................................................193
u-100 0.3 ml 31 x 5/16"................................................ 193
SURE-LANCE FLAT LANCETS -lancets........................ 193
SURE-LANCE LANCETS 26G -lancets.......................... 193
SURE-LANCE THIN LANCETS 2 -lancets..................... 193
SURE-LANCE ULTRA THIN LAN -lancets..................... 193
SURELITE LANCETS -lancets........................................ 193
SURE-PEN -lancet devices............................................. 193
SURESTEP PRO LINEARITY KI -blood glucose
monitoring misc............................................................. 194
SURESTEP PRO TEST STRIPS -glucose blood test
strip................................................................................ 148
SURESTEP TEST STRIPS -glucose blood test strip..... 148
SURE-TEST EASYPLUS MINI B -glucose blood test
strip................................................................................ 148
SURE-TEST EASYPLUS MINI S -blood glucose
SURE-TOUCH LANCETS UNIVER -lancets.................. 193
SURMONTIL -trimipramine maleate cap 25 mg............... 76
SURMONTIL -trimipramine maleate cap 50 mg............... 76
SURMONTIL -trimipramine maleate cap 100 mg............. 76
SUSTIVA -efavirenz cap 50 mg.......................................... 9
SUSTIVA -efavirenz cap 200 mg........................................ 9
SUSTIVA -efavirenz tab 600 mg......................................... 9
SUTENT -sunitinib malate cap 12.5 mg (base
equivalent)....................................................................... 19
SUTENT -sunitinib malate cap 25 mg (base
equivalent)....................................................................... 19
SUTENT -sunitinib malate cap 37.5 mg (base
equivalent)....................................................................... 19
SUTENT -sunitinib malate cap 50 mg (base

equivalent)....................................................................... 19
SUTTAR-2 -pseudoephedrine w/ cod-gg syrup 30-10-100
mg/5ml............................................................................. 59
SUTTAR-SF -pseudoephedrine w/ cod-gg syrup
30-10-100 mg/5ml........................................................... 59
SYLATRON -peginterferon alfa-2b for inj kit 200 mcg...... 19
SYMAX DUOTAB -hyoscyamine sulfate tab cr 0.375 mg
(0.125 mg ir/0.25 mg cr).................................................65
SYMBICORT -budesonide-formoterol fumarate dihyd
aerosol 80-4.5 mcg/act................................................... 62
SYMBICORT -budesonide-formoterol fumarate dihyd
aerosol 160-4.5 mcg/act................................................. 62
SYMBYAX -olanzapine-fluoxetine hcl cap 3-25 mg.......... 89
SYMBYAX -olanzapine-fluoxetine hcl cap 12-25 mg........ 89
SYMBYAX -olanzapine-fluoxetine hcl cap 12-50 mg........ 89
SYMLINPEN 120 -pramlintide acetate pen-inj 2700
mcg/2.7ml (1000 mcg/ml)............................................... 30
SYMLINPEN 60 -pramlintide acetate pen-inj 1500
mcg/1.5ml (1000 mcg/ml)............................................... 30
SYMPATHETIC NERVE NEEDLE -needle (disp) 18 x
6".................................................................................... 194
5".................................................................................... 194
5".................................................................................... 194
SYNALAR -fluocinolone acetonide cream 0.025%......... 141
SYNALAR -fluocinolone acetonide oint 0.025%............. 141
SYNALAR -fluocinolone acetonide soln 0.01%.............. 142
SYNALGOS-DC -aspirin-caffeine-dihydrocodeine cap
356.4-30-16 mg...............................................................96
SYNAREL -nafarelin acetate nasal soln 2 mg/ml............. 37
SYNERA -lidocaine-tetracaine topical patch 70-70
mg.................................................................................. 142
SYNJARDY -empagliflozin-metformin hcl tab 12.5-1000
mg.................................................................................... 30
SYNJARDY -empagliflozin-metformin hcl tab 12.5-500
mg.................................................................................... 30
SYNJARDY -empagliflozin-metformin hcl tab 5-500
mg.................................................................................... 30
SYNJARDY -empagliflozin-metformin hcl tab 5-1000
mg.................................................................................... 30
SYNTHROID -levothyroxine sodium tab 25 mcg.............. 32
SYNTHROID -levothyroxine sodium tab 100 mcg............ 32
295
2016
SYPRINE -trientine hcl cap 250 mg................................ 205
T
TABLOID -thioguanine tab 40 mg..................................... 19
TACLONEX -calcipotriene-betamethasone dipropionate
oint 0.005-0.064%......................................................... 142
TACLONEX -calcipotriene-betamethasone dipropionate
susp 0.005-0.064%....................................................... 142
tacrolimus cap 0.5 mg (Prograf).................................. 205
tacrolimus cap 1 mg (Prograf)..................................... 205
tacrolimus cap 5 mg (Prograf)..................................... 205
tacrolimus oint 0.03% (Protopic)................................. 142
tacrolimus oint 0.1% (Protopic)................................... 142
TAFINLAR -dabrafenib mesylate cap 50 mg (base
equivalent)....................................................................... 19
TAFINLAR -dabrafenib mesylate cap 75 mg (base
equivalent)....................................................................... 19
TAMIFLU -oseltamivir phosphate cap 30 mg (base
equiv)................................................................................. 9
equiv)............................................................................... 10
equiv)............................................................................... 10
TAMIFLU -oseltamivir phosphate for susp 6 mg/ml (base
equiv)............................................................................... 10
tamoxifen citrate tab 10 mg (base equivalent)............. 19
tamoxifen citrate tab 20 mg (base equivalent)............. 19
tamsulosin hcl cap 0.4 mg (Flomax)............................. 71
TANZEUM -albiglutide for soln pen-injector 30 mg........... 30
TANZEUM -albiglutide for soln pen-injector 50 mg........... 30
TAPAZOLE -methimazole tab 5 mg.................................. 33
TAPAZOLE -methimazole tab 10 mg................................ 33
TARCEVA -erlotinib hcl tab 25 mg (base equivalent)....... 19
TARCEVA -erlotinib hcl tab 100 mg (base equivalent)..... 19
TARCEVA -erlotinib hcl tab 150 mg (base equivalent)..... 19
TARGRETIN -bexarotene cap 75 mg................................19
TARGRETIN -bexarotene gel 1%....................................142
TARKA -trandolapril-verapamil hcl tab cr 1-240 mg..........50
TARON-BC -prenat w/o a w/ fe cbnyl-fa tab 20-1 mg & vit
b6 tab pak..................................................................... 115
TARON-C DHA -prenatal w/fe fum-fe poly -fa-omega 3
cap 53.5-38-1 mg......................................................... 115
TARON-PREX -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 30-1.2-265 mg....................................................... 115
TASIGNA -nilotinib hcl cap 150 mg (base equivalent)...... 19
TASIGNA -nilotinib hcl cap 200 mg (base equivalent)...... 19
TASMAR -tolcapone tab 100 mg.....................................109
TAZORAC -tazarotene cream 0.05%.............................. 142
TAZORAC -tazarotene cream 0.1%................................ 142
TAZORAC -tazarotene gel 0.05%................................... 142
TAZORAC -tazarotene gel 0.1%..................................... 142
TECFIDERA -dimethyl fumarate capsule delayed release
120 mg............................................................................ 89
296
TECFIDERA -dimethyl fumarate capsule delayed release

240 mg............................................................................ 89
TECFIDERA STARTER PACK -dimethyl fumarate
capsule dr starter pack 120 mg & 240 mg..................... 89
TECHLITE AST LANCETS -lancets................................ 194
TECHLITE LANCETS 30G -lancets................................ 194
TECHLITE LANCETS -lancets........................................ 194
TECHNIVIE -ombitasvir-paritaprevir-ritonavir tab
12.5-75-50 mg................................................................. 10
TEGRETOL -carbamazepine susp 100 mg/5ml............. 105
TEGRETOL -carbamazepine tab 200 mg....................... 105
TEGRETOL-XR -carbamazepine tab sr 12hr 100
mg.................................................................................. 105
mg.................................................................................. 105
mg.................................................................................. 105
TEKTURNA -aliskiren fumarate tab 150 mg (base
equivalent)....................................................................... 50
TEKTURNA -aliskiren fumarate tab 300 mg (base
equivalent)....................................................................... 50
TEKTURNA HCT -aliskiren-hydrochlorothiazide tab
150-12.5 mg.................................................................... 50
150-25 mg....................................................................... 50
300-12.5 mg.................................................................... 50
300-25 mg....................................................................... 50
TELCARE BLOOD GLUCOSE MON -blood glucose
TELCARE BLOOD GLUCOSE TES -glucose blood test
strip................................................................................ 148
telmisartan-amlodipine tab 40-5 mg (Twynsta)............ 50
telmisartan-amlodipine tab 80-5 mg (Twynsta)............ 50
telmisartan-amlodipine tab 40-10 mg (Twynsta).......... 50
telmisartan-amlodipine tab 80-10 mg (Twynsta).......... 50
telmisartan-hydrochlorothiazide tab 40-12.5 mg
(Micardis hct)................................................................. 50
telmisartan-hydrochlorothiazide tab 80-12.5 mg
(Micardis hct)................................................................. 50
telmisartan-hydrochlorothiazide tab 80-25 mg
(Micardis hct)................................................................. 50
telmisartan tab 20 mg (Micardis)................................... 50
temazepam cap 7.5 mg (Restoril).................................. 82
temazepam cap 15 mg (Restoril)................................... 82
temazepam cap 22.5 mg (Restoril)................................ 82
temazepam cap 30 mg (Restoril)................................... 82
TEMODAR -temozolomide cap 5 mg................................ 19
TEMODAR -temozolomide cap 20 mg.............................. 19
TEMODAR -temozolomide cap 100 mg............................ 19
TEMOVATE -clobetasol propionate cream 0.05%.......... 142
2016
TEMOVATE -clobetasol propionate gel 0.05%............... 142
TEMOVATE -clobetasol propionate oint 0.05%.............. 142
TEMOVATE -clobetasol propionate soln 0.05%..............142
TEMOVATE E -clobetasol propionate emollient base
cream 0.05%................................................................. 142
temozolomide cap 5 mg (Temodar)............................... 19
temozolomide cap 20 mg (Temodar)............................. 19
temozolomide cap 100 mg (Temodar)........................... 19
TENEX -guanfacine hcl tab 1 mg..................................... 50
TENEX -guanfacine hcl tab 2 mg..................................... 50
TENIVAC -tetanus-diphtheria toxoids (td) inj 5-2 lfu......... 15
TENORETIC 100 -atenolol & chlorthalidone tab 100-25
mg.................................................................................... 50
TENORETIC 50 -atenolol & chlorthalidone tab 50-25
mg.................................................................................... 50
TENORMIN -atenolol tab 25 mg....................................... 40
TENORMIN -atenolol tab 50 mg....................................... 40
TENORMIN -atenolol tab 100 mg..................................... 40
TERAZOL 3 -terconazole vaginal cream 0.8%................. 70
TERAZOL 7 -terconazole vaginal cream 0.4%................. 70
terazosin hcl cap 1 mg....................................................50
terazosin hcl cap 10 mg..................................................50
terbinafine hcl tab 250 mg (Lamisil)................................ 6
terbutaline sulfate tab 2.5 mg........................................ 62
terbutaline sulfate tab 5 mg........................................... 62
terconazole vaginal cream 0.4% (Terazol 7)................. 70
terconazole vaginal cream 0.8% (Terazol 3)................. 71
terconazole vaginal suppos 80 mg............................... 71
TERSI FOAM -selenium sulfide foam 2.25%.................. 142
TERUMO ALLERGY SYRINGE 1M -tuberculin/allergy
TERUMO INSULIN SYRINGE/0. -insulin syringe/needle
u-100 1/2 ml 30 x 3/8".................................................. 194
TERUMO INSULIN SYRINGE/0. -insulin syringe/needle
u-100 1/2 ml 29 x 1/2".................................................. 194
TERUMO INSULIN SYRINGE/1M -insulin syringe/needle
u-100 1 ml 27 x 1/2".....................................................194
TERUMO INSULIN SYRINGE/1M -insulin syringe/needle
u-100 1 ml 29 x 1/2".....................................................194
TERUMO INSULIN SYRINGE/U- -insulin syringe/needle
u-100 1/2 ml 27 x 1/2".................................................. 194
u-100 1/2 ml 28 x 1/2".................................................. 194
u-100 0.3 ml 29 x 1/2".................................................. 194
u-100 1 ml 28 x 1/2".....................................................194
TERUMO SURGUARD INSULIN S -insulin syringe/
needle u-100 1/2 ml 28 x 1/2"...................................... 194
needle u-100 1/2 ml 29 x 1/2"...................................... 194

needle u-100 0.3 ml 29 x 1/2"...................................... 194
needle u-100 1 ml 28 x 1/2"......................................... 194
needle u-100 1 ml 29 x 1/2"......................................... 194
TERUMO SURGUARD2 NEEDLE/2 -needle (disp) 25 x
1".................................................................................... 194
TERUMO SURGUARD2 SAFETY N -needle (disp) 18 x
1-1/2"............................................................................. 194
1-1/2"............................................................................. 194
1-1/2"............................................................................. 194
1-1/2"............................................................................. 194
1-1/2"............................................................................. 194
1-1/2"............................................................................. 194
5/8".................................................................................195
1-1/2"............................................................................. 195
1/2".................................................................................195
1/2".................................................................................195
1/2".................................................................................195
1".................................................................................... 194
1".................................................................................... 194
1".................................................................................... 194
1".................................................................................... 194
1".................................................................................... 194
1".................................................................................... 194
1".................................................................................... 195
TESSALON PERLES -benzonatate cap 100 mg.............. 59
testosterone cypionate im inj in oil 100 mg/ml (Depotestosterone).................................................................. 22
testosterone cypionate im inj in oil 200 mg/ml (Depotestosterone).................................................................. 22
testosterone enanthate im inj in oil 200 mg/ml............ 22
testosterone td gel 50 mg/5gm (1%) (Androgel).......... 22
TESTRED -methyltestosterone cap 10 mg....................... 22
TETANUS/DIPHTHERIA TOXOID -tetanus-diphtheria
toxoids (td) inj 2-2 lf/0.5ml.............................................. 15
tetrabenazine tab 12.5 mg (Xenazine)........................... 89
tetrabenazine tab 25 mg (Xenazine).............................. 89
tetracaine hcl ophth soln 0.5%.................................... 130
297
2016
TETRACYCLINE HCL -tetracycline hcl cap 250 mg...........4
TETRACYCLINE HCL -tetracycline hcl cap 500 mg...........4
TETRAMEX -tetracaine-menthol-camphor liqd spray
2-1-3%........................................................................... 142
TEVETEN -eprosartan mesylate tab 600 mg....................50
TEV-TROPIN -somatropin for subcutaneous inj 5 mg...... 37
TEXACORT -hydrocortisone soln 2.5%.......................... 142
TGT ADVANCED LANCING DEVI -lancet devices......... 195
TGT BLOOD GLUCOSE MONITOR -blood glucose
TGT BLOOD GLUCOSE TEST ST -glucose blood test
strip................................................................................ 148
TGT LANCET ALTERNATE SITE -lancets..................... 195
TGT LANCET MICRO THIN 33G -lancets...................... 195
TGT LANCET SUPER THIN 30G -lancets..................... 195
TGT LANCET THIN 23G -lancets................................... 195
TGT LANCET THIN 26G -lancets................................... 195
TGT LANCET ULTRA THIN 28G -lancets...................... 195
TGT LANCET ULTRA THIN 30G -lancets...................... 195
TGT LANCING DEVICE -lancet devices........................ 195
THALOMID -thalidomide cap 50 mg............................... 205
THALOMID -thalidomide cap 100 mg............................. 205
theophylline soln 80 mg/15ml........................................ 62
theophylline tab sr 12hr 100 mg.................................... 62
THEO-24 -theophylline cap sr 24hr 100 mg..................... 62
THINLETS GP LANCETS -lancets................................. 195
THINLETS LANCET -lancets.......................................... 195
THINPRO INSULIN SYRINGE/0 -insulin syringe/needle
u-100 1/2 ml 30 x 3/8".................................................. 195
u-100 1/2 ml 28 x 1/2".................................................. 195
u-100 1/2 ml 29 x 1/2".................................................. 195
u-100 0.3 ml 29 x 1/2".................................................. 195
u-100 1 ml 28 x 1/2".....................................................195
u-100 1 ml 29 x 1/2".....................................................195
THIOLA -tiopronin tab 100 mg.......................................... 71
thioridazine hcl tab 10 mg.............................................. 81
thioridazine hcl tab 100 mg............................................ 81
thiothixene cap 1 mg....................................................... 81
298
thiothixene cap 10 mg..................................................... 81

THRIVITE 19 -prenatal vit w/ dss-fe fumarate-fa tab 29-1
mg.................................................................................. 115
THRIVITE RX -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................. 115
thyroid tab 30 mg (1/2 grain) (Armour thyroid)............ 33
thyroid tab 90 mg (1 1/2 grain) (Armour thyroid)......... 33
thyroid tab 60 mg (1 grain) (Armour thyroid)............... 33
THYROLAR-1/2 -liotrix (t3-t4) tab 30 mg (6.25-25
mcg)................................................................................. 33
THYROLAR-1/4 -liotrix (t3-t4) tab 15 mg (3.1-12.5
mcg)................................................................................. 33
THYROLAR-1 -liotrix (t3-t4) tab 60 mg (12.5-50 mcg)......33
THYROLAR-2 -liotrix (t3-t4) tab 120 mg (25-100
mcg)................................................................................. 33
THYROLAR-3 -liotrix (t3-t4) tab 180 mg (37.5-150
mcg)................................................................................. 33
tiagabine hcl tab 2 mg (Gabitril).................................. 105
tiagabine hcl tab 4 mg (Gabitril).................................. 105
TIAZAC -diltiazem hcl extended release beads cap sr
24hr 120 mg....................................................................42
24hr 180 mg....................................................................42
24hr 240 mg....................................................................42
24hr 300 mg....................................................................42
24hr 360 mg....................................................................42
24hr 420 mg....................................................................42
TIGAN -trimethobenzamide hcl cap 300 mg..................... 66
TIKOSYN -dofetilide cap 125 mcg (0.125 mg)................. 44
TIKOSYN -dofetilide cap 250 mcg (0.25 mg)................... 44
TIKOSYN -dofetilide cap 500 mcg (0.5 mg)..................... 44
timolol maleate ophth gel forming soln 0.25%
(Timoptic-xe)................................................................ 130
timolol maleate ophth gel forming soln 0.5%
(Timoptic-xe)................................................................ 130
timolol maleate ophth soln 0.25% (Timoptic)............. 130
timolol maleate ophth soln 0.5% (Timoptic)............... 130
TIMOLOL MALEATE -timolol maleate tab 5 mg............... 40
TIMOLOL MALEATE -timolol maleate tab 10 mg............. 40
TIMOLOL MALEATE -timolol maleate tab 20 mg............. 40
TIMOPTIC OCUDOSE -timolol maleate preservative free
ophth soln 0.25%.......................................................... 130
TIMOPTIC OCUDOSE -timolol maleate preservative free
ophth soln 0.5%............................................................ 130
TIMOPTIC -timolol maleate ophth soln 0.25%................130
TIMOPTIC -timolol maleate ophth soln 0.5%..................130
TIMOPTIC-XE -timolol maleate ophth gel forming soln
0.25%.............................................................................130
TIMOPTIC-XE -timolol maleate ophth gel forming soln
0.5%...............................................................................130
TINDAMAX -tinidazole tab 250 mg................................... 12
TINDAMAX -tinidazole tab 500 mg................................... 12
tinidazole tab 250 mg (Tindamax)..................................12
2016
tinidazole tab 500 mg (Tindamax)..................................12
TIROSINT -levothyroxine sodium cap 13 mcg..................33
TIROSINT -levothyroxine sodium cap 100 mcg................33
TIROSINT -levothyroxine sodium cap 112 mcg................ 33
TIVICAY -dolutegravir sodium tab 50 mg (base equiv)..... 10
tizanidine hcl cap 2 mg (base equivalent)
(Zanaflex)......................................................................109
(Zanaflex)......................................................................109
(Zanaflex)......................................................................109
tizanidine hcl tab 2 mg (base equivalent)................... 109
tizanidine hcl tab 4 mg (base equivalent)
(Zanaflex)......................................................................109
TL-CARE DHA -prenatal w/fe fumarate-fa-dss-fish oil cap
27-1-500 mg.................................................................. 115
TL FOLATE -prenatal vit w/ fe fum-methylfolate-fa tab
27-0.5-0.5 mg................................................................ 115
TL-SELECT DHA -prenatal w/o vit a w/ fe fum-doc-fa-dha
cap 29-1.25-350 mg..................................................... 115
TL-SELECT -prenatal w/o vit a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg.............................................................115
TOBI PODHALER -tobramycin inhal cap 28 mg.................5
TOBI -tobramycin nebu soln 300 mg/5ml........................... 5
TOBRADEX ST -tobramycin-dexamethasone ophth susp
0.3-0.05%...................................................................... 130
TOBRADEX -tobramycin-dexamethasone ophth oint
0.3-0.1%........................................................................ 130
TOBRADEX -tobramycin-dexamethasone ophth susp
0.3-0.1%........................................................................ 130
tobramycin-dexamethasone ophth susp 0.3-0.1%
(Tobradex).................................................................... 130
tobramycin nebu soln 300 mg/5ml (Tobi)....................... 5
tobramycin ophth soln 0.3% (Tobrex)......................... 130
TOBREX -tobramycin ophth oint 0.3%........................... 130
TOBREX -tobramycin ophth soln 0.3%........................... 130
TODAYS HEALTH ADVANCED LA -lancet devices....... 195
TODAYS HEALTH MINI PEN NE -insulin pen needle 31 g
x 6 mm (1/4")................................................................ 195
TODAYS HEALTH ORIGINAL PE -insulin pen needle 29
g x 12 mm (1/2")...........................................................195
TODAYS HEALTH SHORT PEN N -insulin pen needle 31
g x 8 mm (1/3" or 5/16")...............................................195
TODAYS HEALTH SUPER THIN -lancets...................... 195
TODAYS HEALTH ULTRA THIN -lancets....................... 195
TODAY SPONGE -nonoxynol-9 vaginal sponge 1000
mg.................................................................................... 71
TOFRANIL -imipramine hcl tab 10 mg.............................. 76
TOFRANIL-PM -imipramine pamoate cap 75 mg............. 76

TOFRANIL-PM -imipramine pamoate cap 100 mg........... 76
TOLAK -fluorouracil cream 4%........................................142
tolazamide tab 250 mg.................................................... 30
TOLAZAMIDE -tolazamide tab 500 mg.............................30
TOLBUTAMIDE -tolbutamide tab 500 mg......................... 30
tolcapone tab 100 mg (Tasmar)................................... 109
tolmetin sodium cap 400 mg.......................................... 99
TOLMETIN SODIUM -tolmetin sodium tab 200 mg.......... 99
TOLMETIN SODIUM -tolmetin sodium tab 600 mg.......... 99
tolterodine tartrate cap sr 24hr 2 mg (Detrol la).......... 70
tolterodine tartrate cap sr 24hr 4 mg (Detrol la).......... 70
tolterodine tartrate tab 1 mg (Detrol)............................ 70
tolterodine tartrate tab 2 mg (Detrol)............................ 70
TOPAMAX SPRINKLE -topiramate sprinkle cap 15
mg.................................................................................. 105
TOPAMAX SPRINKLE -topiramate sprinkle cap 25
mg.................................................................................. 105
TOPAMAX -topiramate tab 25 mg...................................105
TOPAMAX -topiramate tab 50 mg...................................105
TOPAMAX -topiramate tab 100 mg.................................105
TOPAMAX -topiramate tab 200 mg.................................105
TOPCARE CLICKFINE UNIVERS -insulin pen needle 31
g x 6 mm (1/4").............................................................195
TOPCARE CLICKFINE UNIVERS -insulin pen needle 31
g x 8 mm (1/3" or 5/16")...............................................195
TOPCARE ULTRA COMFORT INS -insulin syringe/
needle u-100 1/2 ml 31 x 5/16".................................... 195
needle u-100 1/2 ml 29 x 1/2"...................................... 196
needle u-100 1/2 ml 30 x 5/16".................................... 196
needle u-100 0.3 ml 29 x 1/2"...................................... 195
needle u-100 0.3 ml 30 x 5/16".................................... 195
needle u-100 1 ml 29 x 1/2"......................................... 196
needle u-100 1 ml 30 x 5/16"....................................... 196
needle u-100 1 ml 31 x 5/16"....................................... 196
needle u-100 0.3 ml 31 x 5/16".................................... 196
TOPCO INSULIN SYRINGE/U-1 -insulin syringe/needle
u-100 1/2 ml 28 x 1/2".................................................. 196
u-100 1/2 ml 29 x 1/2".................................................. 196
u-100 0.3 ml 29 x 1/2".................................................. 196
u-100 1 ml 28 x 1/2".....................................................196
u-100 1 ml 29 x 1/2".....................................................196
TOPICORT -desoximetasone cream 0.05%................... 142
299
2016
TOPICORT -desoximetasone cream 0.25%................... 142
TOPICORT -desoximetasone gel 0.05%........................ 142
TOPICORT -desoximetasone oint 0.05%....................... 142
TOPICORT -desoximetasone oint 0.25%....................... 142
TOPICORT -desoximetasone spray 0.25%.................... 142
TOPIRAMATE ER -topiramate cap er 24hr sprinkle 25
mg.................................................................................. 105
mg.................................................................................. 105
mg.................................................................................. 106
mg.................................................................................. 106
mg.................................................................................. 106
topiramate sprinkle cap 15 mg (Topamax
sprinkle)........................................................................106
topiramate sprinkle cap 25 mg (Topamax
sprinkle)........................................................................106
topiramate tab 25 mg (Topamax)................................. 106
topiramate tab 50 mg (Topamax)................................. 106
topiramate tab 100 mg (Topamax)............................... 106
topiramate tab 200 mg (Topamax)............................... 106
TOPROL XL -metoprolol succinate tab sr 24hr 25 mg..... 40
TOPROL XL -metoprolol succinate tab sr 24hr 50 mg..... 40
TOPROL XL -metoprolol succinate tab sr 24hr 100
mg.................................................................................... 40
TOPROL XL -metoprolol succinate tab sr 24hr 200
mg.................................................................................... 40
torsemide tab 5 mg (Demadex)...................................... 53
torsemide tab 10 mg (Demadex).................................... 53
torsemide tab 20 mg (Demadex).................................... 53
torsemide tab 100 mg (Demadex).................................. 53
TOUJEO SOLOSTAR -insulin glargine soln pen-injector
300 unit/ml.......................................................................31
TOVIAZ -fesoterodine fumarate tab sr 24hr 4 mg.............70
TOVIAZ -fesoterodine fumarate tab sr 24hr 8 mg.............70
TRACER II 3 VOLT BATTERY -blood glucose monitoring
misc............................................................................... 196
TRACLEER -bosentan tab 62.5 mg.................................. 57
TRACLEER -bosentan tab 125 mg................................... 57
TRADJENTA -linagliptin tab 5 mg..................................... 30
tramadol-acetaminophen tab 37.5-325 mg
(Ultracet)......................................................................... 96
tramadol hcl tab 50 mg (Ultram).................................... 96
tramadol hcl tab sr 24hr biphasic release 100 mg....... 96
tramadol hcl tab sr 24hr 100 mg (Ultram er)................ 96
TRANDATE -labetalol hcl tab 100 mg...............................40
trandolapril tab 1 mg (Mavik)......................................... 50
300
trandolapril-verapamil hcl tab cr 1-240 mg (Tarka)...... 50

tranexamic acid tab 650 mg (Lysteda)........................ 122
TRANSDERM-SCOP -scopolamine td patch 72hr 1
mg/3days......................................................................... 66
tranylcypromine sulfate tab 10 mg (Parnate)............... 77
TRAVATAN Z -travoprost ophth soln 0.004%
(benzalkonium free) (bak free)..................................... 130
TRAVEL LANCETS 30G -lancets....................................196
TRAVOPROST -travoprost ophth soln 0.004%.............. 130
trazodone hcl tab 50 mg................................................. 77
trazodone hcl tab 100 mg............................................... 77
TREAGAN OTIC -antipyrine-benzocaine-polycosanol otic
sol 5.4-1.4-0.0097%......................................................131
TRECATOR -ethionamide tab 250 mg................................ 5
tretinoin cap 10 mg......................................................... 19
tretinoin cream 0.025% (Retin-a)................................. 142
tretinoin cream 0.05% (Retin-a)................................... 142
tretinoin cream 0.1% (Retin-a)..................................... 142
tretinoin gel 0.05% (Atralin).......................................... 142
tretinoin gel 0.01% (Retin-a)......................................... 142
tretinoin gel 0.025% (Retin-a)....................................... 142
tretinoin microsphere gel 0.04% (Retin-a micro)....... 142
tretinoin microsphere gel 0.1% (Retin-a micro
pump)............................................................................ 142
TRETTEN -coagulation factor xiii a-subunit for inj
2000-3125 unit.............................................................. 126
TREXALL -methotrexate sodium tab 5 mg (base
equiv)............................................................................... 19
TREXALL -methotrexate sodium tab 7.5 mg (base
equiv)............................................................................... 19
equiv)............................................................................... 19
equiv)............................................................................... 20
TREZIX -acetaminophen-caffeine-dihydrocodeine cap
320.5-30-16 mg...............................................................96
TRIADVANCE -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg......................................................................... 115
triamcinolone acetonide aerosol soln 0.147 mg/gm
(Kenalog)...................................................................... 142
triamcinolone acetonide cream 0.025%...................... 142
triamcinolone acetonide cream 0.1%.......................... 142
triamcinolone acetonide cream 0.5%.......................... 142
triamcinolone acetonide dental paste 0.1%............... 131
triamcinolone acetonide lotion 0.025%....................... 142
triamcinolone acetonide lotion 0.1%........................... 142
triamcinolone acetonide nasal aerosol suspension 55
mcg/act........................................................................... 58
triamcinolone acetonide oint 0.025%.......................... 142
triamcinolone acetonide oint 0.1%.............................. 142
TRIAMCINOLONE ACETONIDE -triamcinolone acetonide
oint 0.5%....................................................................... 142
2016
TRIAMSIL COMBIPAK -triamcinolone acet cr 0.1% &
silicone gel 5% therapy pack....................................... 142
TRIAMSIL MULTIPAK -triamcinolone cr 0.1% & silicon gel
5% & silicon tape pack................................................. 143
TRIAMTERENE/HYDROCHLOROTH -triamterene &
hydrochlorothiazide cap 50-25 mg................................. 53
triamterene & hydrochlorothiazide cap 37.5-25 mg
(Dyazide).........................................................................53
triamterene & hydrochlorothiazide tab 37.5-25 mg
(Maxzide-25)................................................................... 53
triamterene & hydrochlorothiazide tab 75-50 mg
(Maxzide)........................................................................ 53
TRIANEX -triamcinolone acetonide oint 0.05%.............. 143
triazolam tab 0.125 mg.................................................... 82
triazolam tab 0.25 mg (Halcion)..................................... 82
TRIBENZOR -olmesartan-amlodipine-hydrochlorothiazide
tab 20-5-12.5 mg............................................................ 51
tab 40-5-12.5 mg............................................................ 51
tab 40-5-25 mg............................................................... 51
tab 40-10-12.5 mg.......................................................... 51
tab 40-10-25 mg............................................................. 51
TRICARE PRENATAL COMPLEAT -prenat w/o a fefum-fa
tab 27-1 mg & fish oil chew cap pak............................115
TRICARE PRENATAL DHA ONE -prenatal w/fe fumaratefa-dss-fish oil cap 27-1-500 mg................................... 115
TRICARE -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 115
TRICOR -fenofibrate tab 48 mg........................................ 56
TRICOR -fenofibrate tab 145 mg...................................... 56
trifluoperazine hcl tab 1 mg........................................... 81
trifluoperazine hcl tab 10 mg......................................... 81
trifluridine ophth soln 1% (Viroptic)............................ 130
TRIGLIDE -fenofibrate tab 160 mg................................... 56
trihexyphenidyl hcl elixir 0.4 mg/ml............................ 109
trihexyphenidyl hcl tab 2 mg........................................109
trihexyphenidyl hcl tab 5 mg........................................109
TRILEPTAL -oxcarbazepine susp 300 mg/5ml (60 mg/
ml).................................................................................. 106
TRILEPTAL -oxcarbazepine tab 150 mg........................ 106
TRILIPIX -choline fenofibrate cap dr 45 mg (fenofibric
acid equiv)....................................................................... 56
TRILIPIX -choline fenofibrate cap dr 135 mg (fenofibric
acid equiv)....................................................................... 56
trimethobenzamide hcl cap 300 mg (Tigan)................. 66
trimethoprim tab 100 mg................................................ 12
trimipramine maleate cap 25 mg................................... 77
trimipramine maleate cap 50 mg................................... 77
trimipramine maleate cap 100 mg................................. 77
TRINATAL GT -prenatal vit w/ dss-iron carbonyl-fa tab

90-1 mg......................................................................... 115
TRINATAL RX 1 -prenatal vit w/ fe fumarate-fa tab 60-1
mg.................................................................................. 116
TRINATAL ULTRA -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg......................................................................... 116
TRINATE -prenatal vit w/ fe fumarate-fa tab 28-1 mg..... 116
TRI-NORINYL 28 -norethindrone-eth estradiol tab
0.5-35/1-35/0.5-35 mg-mcg............................................ 26
TRISTART DHA -prenat w/o a w/fecbn-methylf-fa-dha cap
31-0.6-0.4-200 mg........................................................ 116
TRI-TABS DHA -prenat w/o a w/ fe bisglyc-fa tab 32-1 mg
& omega cap pack....................................................... 115
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................................................. 116
TRIVEEN-PRX RNF -prenatal w/o vit a w/ fe fum-dss-fadha cap 26-1.2-300 mg................................................ 116
TRIZIVIR -abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg..............................................................10
TROKENDI XR -topiramate cap sr 24hr 25 mg.............. 106
TROKENDI XR -topiramate cap sr 24hr 50 mg.............. 106
TROKENDI XR -topiramate cap sr 24hr 100 mg............ 106
TROKENDI XR -topiramate cap sr 24hr 200 mg............ 106
tropicamide ophth soln 0.5%....................................... 130
tropicamide ophth soln 1% (Mydriacyl)...................... 130
trospium chloride cap sr 24hr 60 mg............................ 70
trospium chloride tab 20 mg.......................................... 70
TRUEDRAW LANCING DEVICE -lancet devices........... 196
TRUE2GO BLOOD GLUCOSE MON -blood glucose
TRUE METRIX AIR BLOOD GLU -blood glucose
TRUE METRIX BLOOD GLUCOSE -blood glucose
TRUE METRIX BLOOD GLUCOSE -glucose blood test
strip................................................................................ 149
TRUE METRIX SELF MONITORI -glucose blood test
strip................................................................................ 149
TRUEPLUS INSULIN SYRINGE/ -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 196
u-100 1/2 ml 28 x 1/2".................................................. 196
u-100 1/2 ml 29 x 1/2".................................................. 196
u-100 1/2 ml 30 x 5/16"................................................ 196
u-100 0.3 ml 29 x 1/2".................................................. 196
u-100 0.3 ml 30 x 5/16"................................................ 196
u-100 1 ml 28 x 1/2".....................................................196
u-100 1 ml 29 x 1/2".....................................................196
301
2016
u-100 1 ml 30 x 5/16"...................................................196
u-100 1 ml 31 x 5/16"...................................................196
u-100 0.3 ml 31 x 5/16"................................................ 196
TRUEPLUS LANCETS 26G -lancets.............................. 196
TRUEPLUS LANCETS 33G MICR -lancets.................... 197
TRUEPLUS LANCETS 28G SUPE -lancets................... 196
TRUEPLUS LANCETS 30G ULTR -lancets.................... 196
TRUEPLUS SAFETY LANCETS 2 -lancets.................... 197
TRUERESULT BLOOD GLUCOSE -blood glucose
TRUETEST BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 149
TRUETEST STRIPS -glucose blood test strip................ 149
TRUETRACK BLOOD GLUCOSE M -blood glucose
TRUETRACK BLOOD GLUCOSE M -blood glucose
TRUETRACK BLOOD GLUCOSE T -glucose blood test
strip................................................................................ 149
TRUETRACK SMART SYSTEM -blood glucose
TRUETRACK TEST -glucose blood test strip................. 149
TRULICITY -dulaglutide soln pen-injector 0.75
mg/0.5ml.......................................................................... 30
TRULICITY -dulaglutide soln pen-injector 1.5
mg/0.5ml.......................................................................... 30
TRUMENBA -meningococcal group b vaccine im susp
prefilled syringe............................................................... 15
TRUSOPT -dorzolamide hcl ophth soln 2%....................130
TRUVADA -emtricitabine-tenofovir disoproxil fumarate tab
200-300 mg..................................................................... 10
trypsin w/ castor oil & peruvian balsam spray
(Granulex).................................................................... 143
TUDORZA PRESSAIR -aclidinium bromide aerosol powd
breath activated 400 mcg/act......................................... 62
TUSSICAPS -hydrocod polst-chlorphen polst cap sr 12hr
5-4 mg............................................................................. 59
TUSSICAPS -hydrocod polst-chlorphen polst cap sr 12hr
10-8 mg........................................................................... 59
TUSSIONEX PENNKINETIC EXT -hydrocod polstchlorphen polst cr susp 10-8 mg/5ml............................. 59
TUZISTRA XR -codeine polist-chlorphen polist er susp
14.7-2.8 mg/5ml.............................................................. 59
TWINRIX -hepatitis a (inact)-hep b (recomb) vac inj
720-20 elu-mcg/ml.......................................................... 15
TWO-FER VENTED NEEDLE/NON -needle (disp) 16 x
1-1/2"............................................................................. 197
1-1/2"............................................................................. 197
1".................................................................................... 197
302
TWYNSTA -telmisartan-amlodipine tab 40-5 mg.............. 51

TWYNSTA -telmisartan-amlodipine tab 80-5 mg.............. 51
TWYNSTA -telmisartan-amlodipine tab 40-10 mg............ 51
TWYNSTA -telmisartan-amlodipine tab 80-10 mg............ 51
TYBOST -cobicistat tab 150 mg....................................... 10
TYKERB -lapatinib ditosylate tab 250 mg (base
equiv)............................................................................... 20
TYLENOL/CODEINE #3 -acetaminophen w/ codeine tab
300-30 mg....................................................................... 96
TYLENOL/CODEINE #4 -acetaminophen w/ codeine tab
300-60 mg....................................................................... 96
TYLENOL/CODEINE -acetaminophen w/ codeine tab
300-15 mg....................................................................... 96
TYVASO REFILL -treprostinil inhalation solution 0.6 mg/
ml..................................................................................... 57
TYVASO STARTER -treprostinil inhalation solution 0.6
mg/ml............................................................................... 57
TYVASO -treprostinil inhalation solution 0.6 mg/ml.......... 57
TYZEKA -telbivudine tab 600 mg...................................... 10
TYZINE PEDIATRIC NASAL DR -tetrahydrozoline hcl
nasal soln 0.05%............................................................ 58
TYZINE -tetrahydrozoline hcl nasal soln 0.1%................. 58
U
UCERIS -budesonide rectal foam 2 mg/act.................... 132
UCERIS -budesonide tab sr 24hr 9 mg............................ 21
ULESFIA -benzyl alcohol lotion 5%................................ 143
ULORIC -febuxostat tab 40 mg....................................... 101
ULORIC -febuxostat tab 80 mg....................................... 101
ULTICARE INSULIN SAFETY S -insulin syringe/needle
u-100 1/2 ml 29 x 1/2".................................................. 197
ULTICARE INSULIN SAFETY S -insulin syringe/needle
u-100 1 ml 29 x 1/2".....................................................197
ULTICARE INSULIN SYRINGE/ -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 197
u-100 1/2 ml 28 x 1/2".................................................. 197
u-100 1/2 ml 29 x 1/2".................................................. 197
u-100 1/2 ml 30 x 5/16"................................................ 197
u-100 1/2 ml 30 x 1/2".................................................. 197
u-100 0.3 ml 29 x 1/2".................................................. 197
u-100 0.3 ml 30 x 5/16"................................................ 197
u-100 0.3 ml 30 x 1/2".................................................. 197
u-100 1 ml 28 x 1/2".....................................................197
u-100 1 ml 29 x 1/2".....................................................197
u-100 1 ml 30 x 5/16"...................................................197
u-100 1 ml 30 x 1/2".....................................................197
2016
u-100 1 ml 31 x 5/16"...................................................198
u-100 0.3 ml 31 x 5/16"................................................ 198
ULTICARE INSULIN SYRINGE -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 197
u-100 1 ml 31 x 5/16"...................................................197
u-100 0.3 ml 31 x 5/16"................................................ 197
ULTICARE MICRO PEN NEEDLE -insulin pen needle 32
g x 4 mm (5/32")...........................................................198
ULTICARE MINI PEN NEEDLES -insulin pen needle 31 g
x 6 mm (1/4")................................................................ 198
ULTICARE ORIGINAL PEN NEE -insulin pen needle 29 g
x 12 mm (1/2").............................................................. 198
ULTICARE PEN NEEDLES/29G -insulin pen needle 29 g
x 12.7 mm..................................................................... 198
ULTICARE SHORT PEN NEEDLE -insulin pen needle 31
g x 8 mm (1/3" or 5/16")...............................................198
ULTICARE THIN LANCETS 30G -lancets...................... 198
ULTICARE TUBERCULIN SAFET -tuberculin/allergy
ULTICARE TUBERCULIN SAFET -tuberculin/allergy
syringe/needle (disp) 1 ml 25 x 1"............................... 198
ULTIGUARD INSULIN SYRINGE -insulin syringe/needle
u-100 1/2 ml 29 x 1/2".................................................. 198
u-100 1/2 ml 30 x 5/16"................................................ 198
u-100 0.3 ml 29 x 1/2".................................................. 198
u-100 0.3 ml 30 x 5/16"................................................ 198
u-100 1 ml 29 x 1/2".....................................................198
u-100 1 ml 30 x 5/16"...................................................198
ULTI-LANCE AUTO-ADJUST DE -lancet devices.......... 197
ULTI-LANCE AUTOMATIC/ CLE -lancet devices........... 197
ULTI-LANCE MINI ADJUSTABL -lancet devices............ 197
ULTILET BASIC LANCETS 30G -lancets....................... 198
ULTILET CLASSIC LANCETS -lancets.......................... 198
ULTILET INSULIN SYRINGE/S -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 198
u-100 1/2 ml 30 x 5/16"................................................ 198
u-100 0.3 ml 30 x 5/16"................................................ 198
u-100 1 ml 30 x 5/16"...................................................198
u-100 1 ml 31 x 5/16"...................................................198
u-100 0.3 ml 31 x 5/16"................................................ 198
ULTILET LANCETS 33G -lancets................................... 198
ULTILET LANCETS -lancets........................................... 198
ULTILET OPERATING DEVICE -lancet devices.............198
ULTILET PEN NEEDLE 32GX4M -insulin pen needle 32 g

x 4 mm (5/32").............................................................. 198
ULTILET SAFETY LANCETS 23 -lancets....................... 198
ULTILET SHORT PEN NEEDLES -insulin pen needle 31
g x 5 mm (3/16")...........................................................198
ULTILET SHORT PEN NEEDLES -insulin pen needle 31
g x 8 mm (1/3" or 5/16")...............................................198
ULTILET ULTI-LANCE ADJ DE -lancet devices............. 198
ULTIMA -blood glucose monitoring kit............................ 199
ULTIMATECARE ONE NF -prenatal w/fe cbnyl-fe asp
glyc-fa-dss-omega cap 20-7-1 mg............................... 116
ULTIMATECARE ONE -prenatal vit w/ fe cbn-fe asp glycfa-omega 3 cap 27-1mg............................................... 116
ULTIMATE OB DHA -prenat w/ fe poly cmplx-fe asp-fe
gly-fa tab & dha cap pak.............................................. 116
ULTIMA TEST STRIPS -glucose blood test strip............ 149
ULTRA-COMFORT INSULIN SYR -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 199
u-100 1/2 ml 28 x 1/2".................................................. 199
u-100 1/2 ml 29 x 1/2".................................................. 199
u-100 1/2 ml 30 x 5/16"................................................ 199
ULTRA COMFORT INSULIN SYR -insulin syringe/needle
u-100 1/2 ml 28 x 1/2".................................................. 199
u-100 0.3 ml 29 x 1/2".................................................. 199
u-100 0.3 ml 30 x 5/16"................................................ 199
u-100 1 ml 28 x 1/2".....................................................199
u-100 1 ml 29 x 1/2".....................................................199
u-100 1 ml 30 x 5/16"...................................................199
u-100 1 ml 31 x 5/16"...................................................199
u-100 0.3 ml 31 x 5/16"................................................ 199
ULTRA COMFORT INSULIN SYR -insulin syringe/needle
u-100 0.3 ml 30 x 5/16"................................................ 199
ULTRA INSULIN SYRINGE/U-1 -insulin syringe/needle
u-100 1/2 ml 29 x 1/2".................................................. 199
ULTRA TABS -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg......................................................................... 116
ULTRA-THIN II AUTO LANCET -lancets........................ 199
ULTRA-THIN II INSULIN SYR -insulin syringe/needle
u-100 1/2 ml 31 x 5/16"................................................ 199
u-100 1/2 ml 29 x 1/2".................................................. 199
u-100 1/2 ml 30 x 5/16"................................................ 199
u-100 0.3 ml 29 x 1/2".................................................. 199
u-100 0.3 ml 30 x 5/16"................................................ 199
303
2016
u-100 1 ml 29 x 1/2".....................................................199
u-100 1 ml 30 x 5/16"...................................................199
u-100 1 ml 31 x 5/16"...................................................199
u-100 0.3 ml 31 x 5/16"................................................ 199
ULTRA-THIN II LANCETS 28G -lancets......................... 199
ULTRA-THIN II LANCETS 30G -lancets......................... 199
ULTRA-THIN II MINI PEN NE -insulin pen needle 31 g x 5
mm (3/16").................................................................... 200
ULTRA-THIN II PEN NEEDLES -insulin pen needle 29 g x
12.7 mm........................................................................ 200
ULTRA-THIN II PEN NEEDLES -insulin pen needle 31 g x
8 mm (1/3" or 5/16")..................................................... 200
ULTRA-THIN II SAFETY AUTO -lancets........................ 200
ULTRA THIN LANCETS 28G -lancets............................ 199
ULTRA THIN LANCETS 30G -lancets............................ 199
ULTRATRAK ACTIVE -blood glucose monitoring
devices.......................................................................... 200
ULTRA TRAK PRO BLOOD GLUC -blood glucose
ULTRATRAK PRO -blood glucose monitoring
devices.......................................................................... 200
ULTRATRAK PRO TEST STRIPS -glucose blood test
strip................................................................................ 149
ULTRATRAK ULTIMATE MONITO -blood glucose
ULTRATRAK ULTIMATE TEST S -glucose blood test
strip................................................................................ 149
ULTRAVATE -halobetasol propionate cream 0.05%....... 143
ULTRAVATE -halobetasol propionate oint 0.05%........... 143
ULTRESA -pancrelipase (lip-prot-amyl) dr cap
13800-27600-27600 unit................................................ 67
20700-41400-41400 unit................................................ 67
23000-46000-46000 unit................................................ 67
UMECTA PD -urea-hyaluronate sodium emulsion
40-0.3%......................................................................... 143
UMECTA PD -urea-hyaluronate sodium susp
40-0.3%......................................................................... 143
UNIFINE PENTIPS 31G X 3/1 -insulin pen needle 31 g x
5 mm (3/16")................................................................. 200
UNIFINE PENTIPS 29GX12MM -insulin pen needle 29 g
x 12 mm (1/2").............................................................. 200
UNIFINE PENTIPS 31GX5MM -insulin pen needle 31 g x
5 mm (3/16")................................................................. 200
6 mm (1/4")................................................................... 200
4 mm (5/32")................................................................. 200
UNIFINE PENTIPS 31G X 6MM -insulin pen needle 31 g
x 6 mm (1/4")................................................................ 200
8 mm (1/3" or 5/16")..................................................... 200
304
UNIFINE PENTIPS 31G X 8MM -insulin pen needle 31 g

x 8 mm (1/3" or 5/16").................................................. 200
UNIFINE PENTIPS PLUS 29GX -insulin pen needle 29 g
x 12 mm (1/2").............................................................. 200
x 5 mm (3/16").............................................................. 200
x 6 mm (1/4")................................................................ 200
x 4 mm (5/32").............................................................. 200
x 8 mm (1/3" or 5/16").................................................. 200
UNILET COMFORTOUCH LANCET -lancets................. 200
UNILET EXCELITE II -lancets.........................................200
UNILET EXCELITE -lancets............................................ 200
UNILET G.P. LANCET -lancets....................................... 200
UNILET G.P. SUPERLITE LAN -lancets......................... 200
UNILET GP 28 ULTRA THIN -lancets............................ 200
UNILET LANCET -lancets............................................... 200
UNILET LANCETS MICRO-THIN -lancets......................200
UNILET LANCETS SUPER-THIN -lancets..................... 200
UNILET LANCETS ULTRA-THIN -lancets...................... 200
UNILET SUPERLITE LANCET -lancets..........................200
UNISTIK 3 GENTLE -lancets.......................................... 200
UNISTIK SAFETY LANCETS 28 -lancets....................... 200
UNISTIK SAFETY LANCETS 30 -lancets....................... 200
UNISTRIP1 GENERIC -glucose blood test strip............. 149
UNIVERSAL 1 LANCETS THIN -lancets........................ 200
UNIVERSAL 1 LANCETS ULTRA -lancets..................... 200
URAMAXIN -urea in ammonium lactate vehicle foam
20%................................................................................143
urea in lactic acid vehicle foam 35% (Hydro 35)........ 143
URECHOLINE -bethanechol chloride tab 5 mg................ 70
URECHOLINE -bethanechol chloride tab 10 mg.............. 70
UROCIT-K 10 -potassium citrate tab cr 10 meq (1080
mg)................................................................................... 72
mg)................................................................................... 72
mg)................................................................................... 72
UROGESIC-BLUE -methenamine-hyoscamine-meth bluesod phos tab 81.6 mg.................................................... 69
UROXATRAL -alfuzosin hcl tab sr 24hr 10 mg................. 72
ursodiol cap 300 mg (Actigall)....................................... 68
ursodiol tab 250 mg (Urso 250)..................................... 68
ursodiol tab 500 mg (Urso forte)................................... 68
URSO FORTE -ursodiol tab 500 mg.................................68
URSO 250 -ursodiol tab 250 mg....................................... 68
V
VAGIFEM -estradiol vaginal tab 10 mcg........................... 71
valacyclovir hcl tab 1 gm (Valtrex)................................ 10
valacyclovir hcl tab 500 mg (Valtrex)............................ 10
VALCHLOR -mechlorethamine hcl gel 0.016% (base
equivalent)..................................................................... 143
2016
VALCYTE -valganciclovir hcl for soln 50 mg/ml (base
equiv)............................................................................... 10
VALCYTE -valganciclovir hcl tab 450 mg (base
equivalent)....................................................................... 10
valganciclovir hcl tab 450 mg (base equivalent)
(Valcyte).......................................................................... 10
valproate sodium syrup 250 mg/5ml (base equiv)
(Depakene)................................................................... 106
valproic acid cap 250 mg (Depakene)......................... 106
valsartan-hydrochlorothiazide tab 80-12.5 mg (Diovan
hct).................................................................................. 51
valsartan-hydrochlorothiazide tab 160-12.5 mg
(Diovan hct)................................................................... 51
valsartan-hydrochlorothiazide tab 160-25 mg (Diovan
hct).................................................................................. 51
valsartan-hydrochlorothiazide tab 320-12.5 mg
(Diovan hct)................................................................... 51
valsartan-hydrochlorothiazide tab 320-25 mg (Diovan
hct).................................................................................. 51
valsartan tab 40 mg (Diovan)......................................... 51
valsartan tab 80 mg (Diovan)......................................... 51
valsartan tab 160 mg (Diovan)....................................... 51
valsartan tab 320 mg (Diovan)....................................... 51
VALTREX -valacyclovir hcl tab 1 gm................................. 10
VALTREX -valacyclovir hcl tab 500 mg............................. 10
VALUE HEALTH INSULIN SYRI -insulin syringe/needle
u-100 1/2 ml 29 x 1/2".................................................. 201
VALUE HEALTH INSULIN SYRI -insulin syringe/needle
u-100 1 ml 29 x 1/2".....................................................201
VALUE PLUS LANCETS STANDA -lancets....................201
VALUE PLUS LANCETS SUPER -lancets..................... 201
VALUE PLUS LANCETS THIN 2 -lancets...................... 201
VALUE PLUS LANCING DEVICE -lancet devices.......... 201
VALUMARK LANCET SUPER THI -lancets................... 201
VALUMARK LANCET ULTRA THI -lancets.................... 201
VALUMARK PEN NEEDLES 31G -insulin pen needle 31
g x 6 mm (1/4").............................................................201
VALUMARK PEN NEEDLES 31G -insulin pen needle 31
g x 8 mm (1/3" or 5/16")...............................................201
VALUMARK PEN NEEDLES 29GX -insulin pen needle 29
g x 12 mm (1/2")...........................................................201
VANCOCIN HCL -vancomycin hcl cap 125 mg................ 12
VANCOCIN HCL -vancomycin hcl cap 250 mg................ 12
vancomycin hcl cap 125 mg (Vancocin hcl)................. 12
vancomycin hcl cap 250 mg (Vancocin hcl)................. 12
VANISHPOINT INSULIN SYRIN -insulin syringe/needle
u-100 1/2 ml 30 x 1/2".................................................. 201
VANISHPOINT INSULIN SYRIN -insulin syringe/needle
u-100 1 ml 29 x 1/2".....................................................201
VANOS -fluocinonide cream 0.1%.................................. 143
VANOXIDE-HC -benzoyl peroxide-hc lotion 5-0.5%....... 143
VAQTA -hepatitis a vaccine inj susp 25 unit/0.5ml............15
VAQTA -hepatitis a vaccine inj susp 50 unit/ml.................15
VARIVAX -varicella virus vac live for subcutaneous inj
1350 pfu/0.5ml................................................................ 15
VASCEPA -icosapent ethyl cap 1 gm............................... 56
VASERETIC -enalapril maleate & hydrochlorothiazide tab

10-25 mg......................................................................... 51
VASOTEC -enalapril maleate tab 2.5 mg......................... 51
VASOTEC -enalapril maleate tab 5 mg............................ 51
VASOTEC -enalapril maleate tab 10 mg.......................... 51
VASOTEC -enalapril maleate tab 20 mg.......................... 51
VCF VAGINAL CONTRACEPTIVE -nonoxynol-9 film
28%.................................................................................. 71
VCF VAGINAL CONTRACEPTIVE -nonoxynol-9 foam
12.5%...............................................................................71
VECAMYL -mecamylamine hcl tab 2.5 mg....................... 51
VECTICAL -calcitriol oint 3 mcg/gm................................ 143
VELPHORO -sucroferric oxyhydroxide chew tab 500
mg.................................................................................... 69
VEMAVITE-PRX 2 -prenatal w/o vit a w/ fe fum-dss-fadha cap 27-1.25-300 mg.............................................. 116
VENA-BAL DHA -prenat w/fe poly-na fered-fa tab 27-1 &
omega cap dr 430mg................................................... 116
VENATAL-FA -prenatal vit w/ fe fumarate-fa tab 29-1
mg.................................................................................. 116
venlafaxine hcl cap sr 24hr 37.5 mg (base equivalent)
(Effexor xr)..................................................................... 77
venlafaxine hcl cap sr 24hr 75 mg (base equivalent)
(Effexor xr)..................................................................... 77
venlafaxine hcl cap sr 24hr 150 mg (base equivalent)
(Effexor xr)..................................................................... 77
VENLAFAXINE HCL ER -venlafaxine hcl tab sr 24hr 37.5
mg (base equivalent)...................................................... 77
VENLAFAXINE HCL ER -venlafaxine hcl tab sr 24hr 75
venlafaxine hcl tab 25 mg...............................................77
venlafaxine hcl tab 37.5 mg............................................77
venlafaxine hcl tab 100 mg.............................................77
venlafaxine hcl tab sr 24hr 37.5 mg (base equivalent)
(Venlafaxine hcl er)....................................................... 77
venlafaxine hcl tab sr 24hr 75 mg (base equivalent)
venlafaxine hcl tab sr 24hr 150 mg (base equivalent)
VENTAVIS -iloprost inhalation solution 10 mcg/ml........... 57
VENTAVIS -iloprost inhalation solution 20 mcg/ml........... 57
VENTOLIN HFA -albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv)........................................................ 62
verapamil hcl cap sr 24hr 120 mg (Verelan)................. 42
verapamil hcl cap sr 24hr 100 mg (Verelan pm)........... 42
verapamil hcl tab cr 120 mg (Calan sr)......................... 43
305
2016
verapamil hcl tab 80 mg (Calan).................................... 43
verapamil hcl tab 120 mg (Calan).................................. 43
VERAPAMIL HCL -verapamil hcl tab 40 mg..................... 42
VERDESO -desonide foam 0.05%.................................. 143
VEREGEN -sinecatechins oint 15%................................143
VERELAN PM -verapamil hcl cap sr 24hr 100 mg........... 43
VERELAN -verapamil hcl cap sr 24hr 120 mg..................43
VERIPRED 20 -prednisolone sod phosphate oral soln 20
mg/5ml (base equiv)....................................................... 21
VERSACLOZ -clozapine susp 50 mg/ml.......................... 81
VESICARE -solifenacin succinate tab 5 mg..................... 70
VESICARE -solifenacin succinate tab 10 mg................... 70
VEXOL -rimexolone ophth susp 1%............................... 130
VFEND -voriconazole for susp 40 mg/ml............................ 6
VFEND -voriconazole tab 50 mg........................................ 6
VFEND -voriconazole tab 200 mg...................................... 6
V-GO 20 -insulin infusion disposable pump kit............... 200
VIBRAMYCIN -doxycycline calcium syrup 50 mg/5ml........ 4
VICTORY AGM-4000 TEST STR -glucose blood test
strip................................................................................ 149
VICTORY BLOOD GLUCOSE MON -blood glucose
VICTOZA -liraglutide soln pen-injector 18 mg/3ml (6 mg/
ml).................................................................................... 30
VICTRELIS -boceprevir cap 200 mg................................. 10
VIDA MIA AUTOLET LANCING -lancet devices............. 201
VIDA MIA UNIFINE PENTIPS -insulin pen needle 29 g x
12 mm (1/2")................................................................. 201
6 mm (1/4")................................................................... 201
4 mm (5/32")................................................................. 201
VIDA MIA UNILET LANCETS S -lancets........................ 201
VIDA MIA UNILET LANCETS U -lancets........................201
VIDA MIA UNIPFINE PENTIPS -insulin pen needle 31 g x
8 mm (1/3" or 5/16")..................................................... 201
VIDEX -didanosine for soln 2 gm...................................... 10
VIDEX -didanosine for soln 4 gm...................................... 10
VIDEX EC -didanosine delayed release capsule 125
mg.................................................................................... 10
mg.................................................................................... 10
mg.................................................................................... 10
mg.................................................................................... 10
VIEKIRA PAK -ombitas-paritapre-riton & dasab tab pak
12.5-75-50 & 250 mg..................................................... 10
306
VIGAMOX -moxifloxacin hcl ophth soln 0.5% (base

equiv)............................................................................. 130
VIIBRYD STARTER PACK -vilazodone hcl tab starter kit
10 (7) & 20 (23) mg....................................................... 77
VIIBRYD -vilazodone hcl tab 10 mg..................................77
VIMPAT -lacosamide oral solution 10 mg/ml.................. 106
VIMPAT -lacosamide tab 50 mg...................................... 106
VIMPAT -lacosamide tab 100 mg.................................... 106
VINACAL B -prenat w/o a w/fecbn-feglu-fa tab 20-1 mg &
vit b6 tab pak................................................................ 116
VINATE AZ EXTRA -prenatal vit w/ fe bisglycinate
chelate-fa tab 29-1 mg................................................. 116
VINATE CALCIUM -prenatal vit w/ iron carbonyl-fe gluc-fa
tab 27-1 mg...................................................................116
VINATE CARE -prenatal w/o a vit w/ fe fum-fa tab chew
40-1 mg......................................................................... 116
VINATE C -prenatal w/o a vit w/ fe fumarate-fa tab 30-1
mg.................................................................................. 116
VINATE DHA RF -prenat w/o a w/fefum-methylfol-omegas
cap 27-1.13 mg............................................................. 116
VINATE GT -prenatal vit w/ dss-iron carbonyl-fa tab 90-1
mg.................................................................................. 116
VINATE IC -prenatal w/o a w/fe fum-fe poly-fa cap
162.115.2-1 mg............................................................. 116
VINATE II -prenatal vit w/ fe bisglycinate chelate-fa tab
29-1 mg......................................................................... 116
VINATE M -prenatal vit w/ sel-fe fumarate-fa tab 27-1
mg.................................................................................. 116
VINATE ONE -prenatal vit w/ fe fumarate-fa tab 60-1
mg.................................................................................. 116
VINATE ULTRA -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg......................................................................... 116
VIOKACE -pancrelipase (lip-prot-amyl) tab
10440-39150-39150 unit................................................ 67
VIOKACE -pancrelipase (lip-prot-amyl) tab
20880-78300-78300 unit................................................ 67
VIRACEPT -nelfinavir mesylate tab 250 mg..................... 10
VIRACEPT -nelfinavir mesylate tab 625 mg..................... 10
VIRAMUNE -nevirapine susp 50 mg/5ml.......................... 10
VIRAMUNE -nevirapine tab 200 mg................................. 10
VIRAMUNE XR -nevirapine tab sr 24hr 100 mg............... 10
VIRAMUNE XR -nevirapine tab sr 24hr 400 mg............... 10
VIRASAL -salicylic acid film forming liquid 27.5%.......... 143
VIRAZOLE -ribavirin for inhal soln 6 gm........................... 10
VIREAD -tenofovir disoproxil fumarate oral powder 40
mg/gm.............................................................................. 10
VIREAD -tenofovir disoproxil fumarate tab 150 mg.......... 10
VIROPTIC -trifluridine ophth soln 1%............................. 130
VIRT-ADVANCE -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg......................................................................... 116
2016
VIRT-CARE ONE -prenatal vit w/ fe cbn-fe asp glyc-faomega 3 cap 27-1mg................................................... 116
VIRT-C DHA -prenatal w/fe fum-fe poly -fa-omega 3 cap
53.5-38-1 mg................................................................. 116
VIRT NATE -prenatal vit w/ fe fumarate-fa tab 28-1
mg.................................................................................. 116
VIRT-PN DHA -prenat w/o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg........................................................ 116
VIRT-PN PLUS -prenat w/o a w/ fe fumerate-methylfolatefa-omega 3 cap............................................................. 116
VIRT-PN -prenatal vit w/ fe fum-methylfolate-fa tab
27-0.6-0.4 mg................................................................ 116
VIRTPREX -prenatal w/o vit a w/ fe fum-dss-fa-dha cap
26-1.2-300 mg...............................................................117
VIRT-SELECT -prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 29-1.25-325 mg..................................................... 116
VIRT-VITE GT -prenatal vit w/ dss-iron carbonyl-fa tab
90-1 mg......................................................................... 117
VISTARIL -hydroxyzine pamoate cap 25 mg.................... 72
VISTARIL -hydroxyzine pamoate cap 50 mg.................... 72
VITAFOL FE+ -prenat-fepoly-methol-fa-dha cap 90-1-200
mg & dss 50mg cap..................................................... 117
VITAFOL-NANO -prenatal w/o a w/ fefum-l methylfol-fa
tab 18-0.6-0.4 mg......................................................... 117
VITAFOL-OB+DHA -prenatal mv w/fe fum-fa tab 65-1 mg
& dha cap 250 mg pack............................................... 117
VITAFOL-OB -prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................. 117
VITAFOL-ONE -prenatal mv w/ fe polysac cmplx-fa-dha
cap 29-1-200 mg.......................................................... 117
VITAFOL-PN -prenatal vit w/ fe fumarate-fa tab 65-1
mg.................................................................................. 117
VITAFOL ULTRA -prenat w/fe poly-methylfol-fa-dha cap
29-0.6-0.4-200 mg........................................................ 117
VITALET PRO LANCETS -lancets.................................. 201
VITALET PRO PLUS LANCETS -lancets....................... 201
VITAMEDMD ONE RX/QUATREFO -prenat w/o a w/
fefum-methfol-fa-dha cap 30-0.6-0.4-200 mg.............. 117
VITAMEDMD PLUS RX/QUATRE -prenat w/o a w/ fe
chelate-l methylfol-fa tab & dha cap pk....................... 117
VITAMEDMD REDICHEW RX -prenat w/ b2-b6-b12-d3folic acid chew tab 1.4 mg........................................... 117
VITAPEARL -prenat w/oa w/fefum-na fered-fa-dha cap cr
30-1.4-200 mg...............................................................117
VITA-PREN -prenatal vit w/ docusate-iron-fa tab 65-1
mg.................................................................................. 117
VITEKTA -elvitegravir tab 85 mg....................................... 10
VITEKTA -elvitegravir tab 150 mg..................................... 10
VITUZ -hydrocodone-chlorpheniramine soln 5-4
mg/5ml............................................................................. 59
VIVA DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg.................................................................. 117
VIVELLE-DOT -estradiol td patch twice weekly 0.025
mg/24hr........................................................................... 24
mg/24hr........................................................................... 24

mg/24hr........................................................................... 24
mg/24hr........................................................................... 24
mg/24hr........................................................................... 24
VOCAL POINT BLOOD GLUCOSE -blood glucose
VOCAL POINT BLOOD GLUCOSE -glucose blood test
strip................................................................................ 149
VOL-NATE -prenatal vit w/ fe fumarate-fa tab 28-1
mg.................................................................................. 117
VOL-PLUS -prenatal vit w/ fe fumarate-fa tab 27-1
mg.................................................................................. 117
VOL-TAB RX -prenatal vit w/ iron carbonyl-fa tab 29-1
mg.................................................................................. 117
VOLTAREN -diclofenac sodium gel 1%.......................... 143
voriconazole for susp 40 mg/ml (Vfend)......................... 6
voriconazole tab 50 mg (Vfend)....................................... 6
voriconazole tab 200 mg (Vfend)..................................... 6
VOSPIRE ER -albuterol sulfate tab sr 12hr 4 mg............. 62
VOSPIRE ER -albuterol sulfate tab sr 12hr 8 mg............. 62
VOTRIENT -pazopanib hcl tab 200 mg (base equiv)....... 20
VP-CH PLUS -prenatal w/o a w/fe cbn-dss-fa-dha cap
29-1-265 mg.................................................................. 117
VP-CH-PNV -prenatal w/o vit a w/ fe cbn-dss-fa-dha cap
30-1-260 mg.................................................................. 117
VP CH ULTRA -prenat w/o a w/fe fum-fe cbn-dss-fa-dha
cap 27-1-260 mg.......................................................... 117
VP-GGR-B6 PRENATAL -prenatal w/ calcium-vit b6-faginger tab 1.2 mg......................................................... 117
VP-HEME OB + DHA -prenat-fe poly cmplx-fe heme polyfa tab & omega 3 cap pck............................................ 117
VP-HEME OB -prenat vit-fe poly cmplx-fe heme poly-fa
tab 28-6-1 mg............................................................... 117
VP-HEME ONE -prenat-fe poly cmplx-fe heme poly-fadha cap 22-6-1-200 mg................................................ 117
VP INSULIN SYRINGE/U-100/ -insulin syringe/needle
u-100 0.3 ml 29 x 1/2".................................................. 201
VP-PNV-DHA -prenatal vit w/ fe fum-fa-omega 3 cap
28-1-215.8 mg...............................................................117
V-R MONOJECT INSULIN SYRI -insulin syringe/needle
u-100 1/2 ml 28 x 1/2".................................................. 201
u-100 1/2 ml 29 x 1/2".................................................. 201
u-100 0.3 ml 29 x 1/2".................................................. 201
u-100 1 ml 28 x 1/2".....................................................201
u-100 1 ml 29 x 1/2".....................................................201
VUSION -miconazole-zinc oxide-white petrolatum oint
0.25-15-81.35%............................................................. 143
VYTONE -iodoquinol-hydrocortisone in aloe vehicle
cream 1-1.9%................................................................ 143
VYTORIN -ezetimibe-simvastatin tab 10-10 mg............... 56
307
2016
VYVANSE -lisdexamfetamine dimesylate cap 10 mg....... 86
W
W&F LANCETS COLORED 21G -lancets...................... 202
W&F LANCETS 26G -lancets......................................... 202
WALGREENS ADVANCED TRAVEL -lancets................ 202
WALGREENS COMFORT ASSURED -lancets.............. 202
WALGREENS LANCETS -lancets.................................. 202
WALGREENS THIN LANCETS -lancets......................... 202
WALGREENS ULTRA THIN LANC -lancets................... 202
warfarin sodium tab 1 mg (Coumadin)....................... 122
warfarin sodium tab 2.5 mg (Coumadin).................... 122
warfarin sodium tab 7.5 mg (Coumadin).................... 122
warfarin sodium tab 10 mg (Coumadin)..................... 122
water for irrigation, sterile irrigation soln...................205
WAVESENSE AMP -blood glucose monitoring kit w/
device............................................................................ 202
WAVESENSE KEYNOTE -blood glucose monitoring kit w/
device............................................................................ 202
WAVESENSE KEYNOTE PRO MET -blood glucose
WAVESENSE PRESTO TEST STR -glucose blood test
strip................................................................................ 149
WD MEDIC INSULIN SYRINGE/ -insulin syringe/needle
u-100 1/2 ml 29 x 1/2".................................................. 202
u-100 1/2 ml 30 x 5/16"................................................ 202
u-100 0.3 ml 29 x 1/2".................................................. 202
u-100 0.3 ml 30 x 5/16"................................................ 202
u-100 1 ml 29 x 1/2".....................................................202
u-100 1 ml 30 x 5/16"...................................................202
WEGMANS UNIFINE PENTIPS P -insulin pen needle 31
g x 5 mm (3/16")...........................................................202
g x 6 mm (1/4").............................................................202
g x 4 mm (5/32")...........................................................202
g x 8 mm (1/3" or 5/16")...............................................202
WELCHOL -colesevelam hcl packet for susp 3.75 gm..... 56
308
WELCHOL -colesevelam hcl tab 625 mg......................... 56

WELLBUTRIN -bupropion hcl tab 75 mg.......................... 77
WELLBUTRIN -bupropion hcl tab 100 mg........................ 77
WELLBUTRIN SR -bupropion hcl tab sr 12hr 100 mg...... 77
WELLBUTRIN XL -bupropion hcl tab sr 24hr 150 mg...... 77
WELLBUTRIN XL -bupropion hcl tab sr 24hr 300 mg...... 77
WESTCORT -hydrocortisone valerate oint 0.2%............ 143
WESTHROID -thyroid tab 16.25 mg................................. 33
WESTHROID -thyroid tab 32.5 mg................................... 33
WESTHROID -thyroid tab 65 mg...................................... 33
WESTHROID -thyroid tab 81.25 mg................................. 33
WESTHROID -thyroid tab 97.5 mg................................... 33
WESTHROID -thyroid tab 113.75 mg............................... 33
WESTHROID -thyroid tab 130 mg.................................... 33
WESTHROID -thyroid tab 146.25 mg............................... 33
WESTHROID -thyroid tab 48.75 mg (3/4 grain)............... 33
WESTHROID -thyroid tab 162.5 mg (2 1/2 grain)............ 33
WESTHROID -thyroid tab 325 mg (5 grain)..................... 33
WHITE PEDIATRIC ARTERIAL -needle (disp) 19 x
1-1/2"............................................................................. 202
WHITE PEDIATRIC ARTERIAL -needle (disp) 20 x
1-1/2"............................................................................. 202
WHYTEDERM TDPAK -triamcinolone acet cr 0.1% &
dimeth cr 2% & silicone tape....................................... 143
WIDE-SEAL SILICONE DIAPHR -diaphragm wide seal 60
mm................................................................................. 202
mm................................................................................. 202
mm................................................................................. 202
mm................................................................................. 202
mm................................................................................. 202
mm................................................................................. 202
mm................................................................................. 202
mm................................................................................. 202
WILATE -antihemophilic factor/vwf (human) for inj
500-500 unit.................................................................. 126
WILATE -antihemophilic factor/vwf (human) for inj
1000-1000 unit.............................................................. 126
WP THYROID -thyroid tab 16.25 mg................................ 33
WP THYROID -thyroid tab 32.5 mg.................................. 33
WP THYROID -thyroid tab 65 mg..................................... 33
WP THYROID -thyroid tab 81.25 mg................................ 33
WP THYROID -thyroid tab 97.5 mg.................................. 33
WP THYROID -thyroid tab 113.75 mg.............................. 33
WP THYROID -thyroid tab 130 mg................................... 33
WP THYROID -thyroid tab 48.75 mg (3/4 grain).............. 33
2016
X
XALATAN -latanoprost ophth soln 0.005%..................... 131
XALKORI -crizotinib cap 200 mg...................................... 20
XALKORI -crizotinib cap 250 mg...................................... 20
XARELTO -rivaroxaban tab 10 mg..................................122
XARELTO STARTER PACK -rivaroxaban tab starter
therapy pack 15 mg & 20 mg.......................................122
XELJANZ -tofacitinib citrate tab 5 mg (base
equivalent)....................................................................... 99
XELODA -capecitabine tab 150 mg.................................. 20
XELODA -capecitabine tab 500 mg.................................. 20
XENADERM -trypsin w/ castor oil & peruvian balsam
oint................................................................................. 143
XENAZINE -tetrabenazine tab 12.5 mg............................ 89
XENAZINE -tetrabenazine tab 25 mg............................... 89
XERESE -acyclovir-hydrocortisone cream 5-1%............ 143
XIFAXAN -rifaximin tab 200 mg........................................ 12
XIFAXAN -rifaximin tab 550 mg........................................ 12
XIGDUO XR -dapagliflozin-metformin hcl tab sr 24hr
5-500 mg......................................................................... 30
5-1000 mg....................................................................... 30
10-500 mg....................................................................... 30
10-1000 mg..................................................................... 30
XOLEGEL -ketoconazole gel 2%.................................... 143
XOPENEX CONCENTRATE -levalbuterol hcl soln nebu
conc 1.25 mg/0.5ml (base equiv)................................... 62
XOPENEX HFA -levalbuterol tartrate inhal aerosol 45
mcg/act (base equiv)...................................................... 63
XOPENEX -levalbuterol hcl soln nebu 0.31 mg/3ml (base
equiv)............................................................................... 62
equiv)............................................................................... 62
equiv)............................................................................... 62
XTANDI -enzalutamide cap 40 mg.................................... 20
XULANE -norelgestromin-ethinyl estradiol td ptwk 150-35
mcg/24hr.......................................................................... 26
XYLOCAINE -lidocaine hcl soln 4%................................ 143
XYNTHA -antihemophilic factor recombinant paf for inj kit
250 unit......................................................................... 126
500 unit......................................................................... 126
1000 unit....................................................................... 126
2000 unit....................................................................... 126
XYNTHA SOLOFUSE -antihemophilic factor recombinant
paf for inj kit 250 unit................................................... 126
paf for inj kit 500 unit................................................... 126

paf for inj kit 1000 unit................................................. 126
XYREM -sodium oxybate oral solution 500 mg/ml........... 89
Y
YALE NEEDLES/REGULAR BEVE -needle (disp) 19 x
1-1/2"............................................................................. 203
YALE NEEDLES/SHORT BEVEL/ -needle (disp) 19 x
1-1/2"............................................................................. 203
YALE NEEDLES/SHORT BEVEL/ -needle (disp) 19 x
1".................................................................................... 203
YALE NEEDLES 18G X 1-1/2" -needle (disp) 18 x
1-1/2"............................................................................. 203
1-1/2"............................................................................. 203
1-1/4"............................................................................. 203
1-1/2"............................................................................. 203
1-1/4"............................................................................. 203
1-1/2"............................................................................. 203
YALE NEEDLES 26G X 1/2" -needle (disp) 26 x 1/2"..... 203
YALE NEEDLES 26G X 3/8" -needle (disp) 26 x 3/8"..... 203
YALE NEEDLES 16G X 1" -needle (disp) 16 x 1"...........202
YALE NEEDLES -needle (disp) 23 x 3/4"....................... 202
YALE NEEDLES -needle (disp) 18 x 1".......................... 202
YALE NEEDLES SHORT BEVEL -needle (disp) 23 x
1".................................................................................... 202
YASMIN 28 -drospirenone-ethinyl estradiol tab 3-0.03
mg.................................................................................... 26
YAZ -drospirenone-ethinyl estradiol tab 3-0.02 mg...........26
YODOXIN -iodoquinol tab 210 mg.................................... 11
YODOXIN -iodoquinol tab 650 mg.................................... 11
Z
ZACLIR CLEANSING -benzoyl peroxide lotion 8%........ 143
zafirlukast tab 10 mg (Accolate).................................... 63
zafirlukast tab 20 mg (Accolate).................................... 63
zaleplon cap 5 mg (Sonata)............................................ 82
zaleplon cap 10 mg (Sonata).......................................... 82
ZAMICET -hydrocodone-acetaminophen soln 10-325
mg/15ml........................................................................... 97
ZANAFLEX -tizanidine hcl cap 2 mg (base
equivalent)..................................................................... 110
equivalent)..................................................................... 110
309
2016
equivalent)..................................................................... 110
ZANAFLEX -tizanidine hcl tab 4 mg (base
equivalent)..................................................................... 110
ZARONTIN -ethosuximide cap 250 mg.......................... 106
ZARONTIN -ethosuximide soln 250 mg/5ml................... 106
ZATEAN-CH -prenatal w/o a w/fe cbn-dss-fa-dha cap
27-1-250 mg.................................................................. 117
ZATEAN-PN DHA -prenat w/o a w/fefum-methfol-fa-dha
cap 27-0.6-0.4-300 mg................................................. 117
ZATEAN-PN PLUS -prenat w/o a w/ fe fumeratemethylfolate-fa-omega 3 cap........................................ 117
ZATEAN-PN -prenatal vit w/ fe fum-methylfolate-fa tab
27-0.6-0.4 mg................................................................ 117
ZAVESCA -miglustat cap 100 mg................................... 121
ZEBETA -bisoprolol fumarate tab 5 mg............................ 40
ZEBETA -bisoprolol fumarate tab 10 mg.......................... 40
ZELAPAR -selegiline hcl orally disintegrating tab 1.25
mg.................................................................................. 109
ZELBORAF -vemurafenib tab 240 mg.............................. 20
ZEMPLAR -paricalcitol cap 1 mcg.................................... 37
ZEMPLAR -paricalcitol cap 2 mcg.................................... 37
ZENATANE -isotretinoin cap 30 mg................................ 143
ZENPEP -pancrelipase (lip-prot-amyl) dr cap
3000-10000-16000 unit...................................................67
5000-17000-27000 unit...................................................67
10000-34000-55000 unit................................................ 67
15000-51000-82000 unit................................................ 67
20000-68000-109000 unit.............................................. 67
25000-85000-136000 unit.............................................. 67
40000-136000-218000 unit............................................ 67
ZENZEDI -dextroamphetamine sulfate tab 2.5 mg........... 86
ZENZEDI -dextroamphetamine sulfate tab 7.5 mg........... 86
ZENZEDI -dextroamphetamine sulfate tab 15 mg............ 86
ZERIT -stavudine cap 15 mg............................................ 10
ZERIT -stavudine for oral soln 1 mg/ml............................ 10
ZESTORETIC -lisinopril & hydrochlorothiazide tab
10-12.5 mg...................................................................... 51
ZESTORETIC -lisinopril & hydrochlorothiazide tab
20-12.5 mg...................................................................... 51
ZESTORETIC -lisinopril & hydrochlorothiazide tab 20-25
mg.................................................................................... 51
ZESTRIL -lisinopril tab 2.5 mg.......................................... 51
ZESTRIL -lisinopril tab 5 mg............................................. 51
ZESTRIL -lisinopril tab 10 mg........................................... 51
310

ZETIA -ezetimibe tab 10 mg............................................. 56
ZIAC -bisoprolol & hydrochlorothiazide tab 2.5-6.25
mg.................................................................................... 51
ZIAC -bisoprolol & hydrochlorothiazide tab 5-6.25 mg..... 51
ZIAC -bisoprolol & hydrochlorothiazide tab 10-6.25
mg.................................................................................... 51
ZIAGEN -abacavir sulfate soln 20 mg/ml (base equiv)..... 10
ZIAGEN -abacavir sulfate tab 300 mg (base equiv)......... 11
zidovudine cap 100 mg (Retrovir)................................. 11
zidovudine syrup 10 mg/ml (Retrovir)........................... 11
zidovudine tab 300 mg.................................................... 11
ZINGIBER -prenatal w/ calcium-vit b6-fa-ginger tab 1.2
mg.................................................................................. 117
ZIOPTAN -tafluprost ophth soln 0.0015%....................... 131
ziprasidone hcl cap 20 mg (Geodon)............................ 81
ZIRGAN -ganciclovir ophth gel 0.15%............................ 131
ZITHROMAX -azithromycin for susp 100 mg/5ml............... 3
ZITHROMAX -azithromycin for susp 200 mg/5ml............... 3
ZITHROMAX -azithromycin powd pack for susp 1 gm....... 3
ZITHROMAX -azithromycin tab 250 mg............................. 3
ZITHROMAX TRI-PAK -azithromycin tab 500 mg.............. 3
ZITHROMAX Z-PAK -azithromycin tab 250 mg.................. 3
ZMAX -azithromycin extended release for oral susp 2
gm...................................................................................... 4
ZOCOR -simvastatin tab 5 mg.......................................... 56
ZOCOR -simvastatin tab 10 mg........................................ 56
ZOFRAN ODT -ondansetron orally disintegrating tab 4
mg.................................................................................... 66
ZOFRAN ODT -ondansetron orally disintegrating tab 8
mg.................................................................................... 66
ZOFRAN -ondansetron hcl oral soln 4 mg/5ml................. 66
ZOFRAN -ondansetron hcl tab 4 mg................................ 66
ZOFRAN -ondansetron hcl tab 8 mg................................ 66
ZOLINZA -vorinostat cap 100 mg..................................... 20
zolmitriptan orally disintegrating tab 2.5 mg (Zomig
zmt)............................................................................... 101
zolmitriptan orally disintegrating tab 5 mg (Zomig
zmt)............................................................................... 101
zolmitriptan tab 2.5 mg (Zomig)................................... 101
zolmitriptan tab 5 mg (Zomig)...................................... 101
ZOLOFT -sertraline hcl oral conc 20 mg/ml...................... 77
ZOLOFT -sertraline hcl tab 25 mg.................................... 77
ZOLOFT -sertraline hcl tab 50 mg.................................... 77
ZOLOFT -sertraline hcl tab 100 mg.................................. 77
zolpidem tartrate tab cr 6.25 mg (Ambien cr)............... 82
zolpidem tartrate tab cr 12.5 mg (Ambien cr)............... 82
zolpidem tartrate tab 5 mg (Ambien).............................82
2016
zolpidem tartrate tab 10 mg (Ambien)...........................82
ZOMACTON -somatropin for inj 10 mg.............................37
ZOMACTON -somatropin for subcutaneous inj 5 mg....... 37
ZOMIG NASAL SPRAY -zolmitriptan nasal spray 5 mg/
spray unit.......................................................................101
ZOMIG ZMT -zolmitriptan orally disintegrating tab 2.5
mg.................................................................................. 101
ZOMIG ZMT -zolmitriptan orally disintegrating tab 5
mg.................................................................................. 101
ZOMIG -zolmitriptan nasal spray 2.5 mg/spray unit........101
ZOMIG -zolmitriptan tab 2.5 mg...................................... 101
ZOMIG -zolmitriptan tab 5 mg......................................... 101
ZONALON -doxepin hcl cream 5%................................. 143
ZONATUSS -benzonatate cap 150 mg............................. 59
ZONEGRAN -zonisamide cap 25 mg............................. 106
ZONEGRAN -zonisamide cap 100 mg........................... 106
zonisamide cap 50 mg.................................................. 106
zonisamide cap 25 mg (Zonegran).............................. 106
zonisamide cap 100 mg (Zonegran)............................ 106
ZONTIVITY -vorapaxar sulfate tab 2.08 mg (base
equivalent)..................................................................... 126
ZORBTIVE -somatropin (non-refrigerated) for
subcutaneous inj 8.8 mg................................................ 37
ZORTRESS -everolimus tab 0.25 mg............................. 205
ZORTRESS -everolimus tab 0.5 mg............................... 205
ZORTRESS -everolimus tab 0.75 mg............................. 205
ZOSTAVAX -zoster vaccine live for inj 19400
unit/0.65ml....................................................................... 15
ZOVIA 1/50E -ethynodiol diacetate & ethinyl estradiol tab
1 mg-50 mcg................................................................... 26
ZOVIRAX -acyclovir cap 200 mg...................................... 11
ZOVIRAX -acyclovir cream 5%....................................... 143
ZOVIRAX -acyclovir oint 5%........................................... 143
ZOVIRAX -acyclovir susp 200 mg/5ml.............................. 11
ZOVIRAX -acyclovir tab 400 mg....................................... 11
ZOVIRAX -acyclovir tab 800 mg....................................... 11
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab
1.4-0.36 mg (base eq).................................................... 97
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab
2.9-0.71 mg (base eq).................................................... 97
ZUBSOLV -buprenorphine hcl-naloxone hcl sl tab 5.7-1.4
mg (base eq)...................................................................97
mg (base eq)...................................................................97
mg (base eq)...................................................................97
ZUTRIPRO -pseudoeph-chlorphen w/ hydrocodone soln
60-4-5 mg/5ml................................................................. 59
ZYCLARA -imiquimod cream 3.75%............................... 143
ZYCLARA PUMP -imiquimod cream 2.5%..................... 143
ZYCLARA PUMP -imiquimod cream 3.75%................... 143
ZYDELIG -idelalisib tab 100 mg........................................ 20
ZYDELIG -idelalisib tab 150 mg........................................ 20
ZYFLO CR -zileuton tab sr 12hr 600 mg.......................... 63
ZYFLO -zileuton tab 600 mg............................................. 63
ZYKADIA -ceritinib cap 150 mg........................................ 20
ZYLET -loteprednol etabonate-tobramycin ophth susp

0.5-0.3%........................................................................ 131
ZYLOPRIM -allopurinol tab 100 mg................................ 101
ZYLOPRIM -allopurinol tab 300 mg................................ 101
ZYMAXID -gatifloxacin ophth soln 0.5%......................... 131
ZYPREXA -olanzapine tab 2.5 mg.................................... 81
ZYPREXA -olanzapine tab 5 mg....................................... 81
ZYPREXA -olanzapine tab 7.5 mg.................................... 81
ZYPREXA -olanzapine tab 10 mg..................................... 81
ZYPREXA ZYDIS -olanzapine orally disintegrating tab 5
mg.................................................................................... 81
mg.................................................................................... 81
mg.................................................................................... 81
mg.................................................................................... 81
ZYTIGA -abiraterone acetate tab 250 mg......................... 20
ZYVOX -linezolid for susp 100 mg/5ml............................. 12
ZYVOX -linezolid tab 600 mg............................................ 12
311

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January 2016

Care Choices Medication Guide

Endocrine and Metabolic Drugs ................................. 20

Cardiovascular Agents ............................................... 37

Medication List .............................................................. II

Respiratory Agents ..................................................... 58

Exception Process ....................................................... III

Gastrointestinal Agents .............................................. 63

Your Share of Expenses .............................................. III

Genitourinary Agents ................................................. 69

Pharmacy Benefits ..................................................... IV

Central Nervous System Drugs .................................. 72

Utilization Management Programs ............................. VI

Analgesics and Anesthetics ....................................... 89

Notice ........................................................................ VIII

Neuromuscular Drugs .............................................. 101

Using the Medication Guide ..................................... VIII

Nutritional Products .................................................. 110

Abbreviation/acronym key .......................................... IX

Hematological Agents .............................................. 119

Anti-Infective Drugs ...................................................... 1

Miscellaneous Products ........................................... 143

Topical Products....................................................... 126

Antineoplastic Agents ................................................. 16

3022-O FL HIM Prime Therapeutics LLC 01/16

Florida Blue January 2016 Care Choices Medication Guide

Contains the same active ingredient(s) as the Brand medication

Is identical in strength, dosage form, and route of administration

Changes to the formulary

Click on the Member Login button.

Updated medication guides are posted periodically throughout the year.

Formulary addition request

Your Share of Expenses

Florida Blue January 2016 Care Choices Medication Guide

The medication has a preferred formulary alternative or over-the-counter (OTC) alternative

The medication is no longer marketed

The medication has a widely available/distributed AB rated generic equivalent formulation

Specialty Pharmacy medications

Provider-Administered Specialty Medications These medications require the administration to be performed by

Florida Blue January 2016 Care Choices Medication Guide

Participating Specialty Pharmacy Providers

Prime Therapeutics Specialty Pharmacy

Utilization Management Programs

Florida Blue January 2016 Care Choices Medication Guide

Using the Medication Guide

Specialty: indicates if the medication is a Self-Administered Specialty medication.

OTC ........................................................ over-the-counter

conc ............................................................... concentrate

QL ............................... Responsible Quantity Program

quantity limit applies

SP ..................................................... Specialty Pharmacy

supp ............................................................ suppositories

oint ...................................................................... ointment

Florida Blue January 2016 Care Choices Medication Guide

amoxicillin & k clavulanate tab

amoxicillin (trihydrate) cap

AMPICILLIN - ampicillin for susp 125 2

amoxicillin (trihydrate) for susp

AUGMENTIN - amoxicillin & k

AUGMENTIN - amoxicillin & k

AUGMENTIN - amoxicillin & k

AUGMENTIN ES-600 - amoxicillin

AUGMENTIN XR - amoxicillin & k

dicloxacillin sodium cap 250 mg