Danh Sách Thuốc Được Chi Trả - mss.anthem.com · Danh Sách Thuốc Được Chi Trả...

Santa Clara County, CA

Anthem Blue Cross Cal MediConnect Plan(Medicare-Medicaid Plan)

Danh Sách Thuốc Được Chi Trả(Danh Mục Thuốc) năm 2020

VUI LÒNG ĐỌC: TÀI LIỆU NÀY CHỨA THÔNG TIN VỀ NHỮNG LOẠI THUỐC ĐƯỢC CHÚNG TÔI CHI TRẢ TRONG CHƯƠNG TRÌNH NÀY.

Danh mục thuốc này được cập nhật vào ngày 10/9/2019.Để biết thêm thông tin gần đây hoặc các câu hỏi khác, hãy liên hệ với chúng

tôi theo số

1-833-370-7466 (TTY: 711)24 giờ một ngày, 7 ngày một tuần

hoặc truy cập vào duals.anthem.com.

H6229_20_107805_T_VN_0001 CMS Approved 09/11/2019 ID danh mục thuốc: CA_MMP_20210_v8_2001_1 Phiên bản: v8

Đã phát hành 10/15/2019

Anthem Blue Cross Cal MediConnect Plan (Medicare-Medicaid Plan)

Danh Sách Thuốc Được Chi Trả năm 2020Giơi Thiêu

Tài liệu này là Danh Sách Thuốc Được Chi Trả (hay còn gọi là Danh Sách Thuốc). Danh sách này cho quý vị biết những loại thuốc theo toa, thuốc mua tự do và các mục nào được Anthem Blue Cross Cal MediConnect Plan chi trả. Qua đây, quý vị cũng biết được các quy định hoặc hạn chế đặc biệt đối với bất kỳ loại thuốc nào được Anthem Blue Cross Cal MediConnect Plan chi trả. Quý vị có thể xem những thuật ngữ chính và định nghĩa ở chương cuối của Sổ Tay Thành Viên.

Mục Lục

A. Tuyên bố miễn trừ trách nhiệm ................................................................................................3

B. Câu Hỏi Thường Gặp (FAQ) ....................................................................................................4

B1. Những loại thuốc theo toa nào có trong Danh Sách Thuốc Được Chi Trả? (Chúng tôi gọi tắt Danh Sách Thuốc Được Chi Trả là “Danh Sách Thuốc”.) .......................................... 4

B2. Danh Sách Thuốc có bao giờ thay đổi không? ................................................................ 4

B3. Điều gì sẽ xảy ra nếu Danh Sách Thuốc có sự thay đổi? ............................................... 5

B4. Có giới hạn hoặc hạn chế nào về việc chi trả thuốc không? Hoặc có hành động nào bắt buộc phải thực hiện để nhận được một số loại thuốc nhất định không? ......................... 6

B5. Làm thế nào quý vị biết liệu loại thuốc mà mình cần có các giới hạn hoặc có hành động nào bắt buộc phải thực hiện để nhận được thuốc hay không? ........................................ 7

B6. Điều gì sẽ xảy ra nếu chúng tôi thay đổi quy định về một số loại thuốc (ví dụ: nếu chúng tôi yêu cầu phải có thêm sự phê duyệt (chấp thuận) trước, giới hạn số lượng và/hoặc hạn chế về trị liệu từng bước)? ...............................................................................................7

B7. Quý vị có thể tìm một loại thuốc trong Danh Sách Thuốc bằng cách nào? ..................... 7

B8. Nêu thuốc quý vị cần không có trong Danh Sách Thuốc thì sao? ................................... 8

B9. Nếu quý vị là thành viên mới của Anthem Blue Cross Cal MediConnect Plan và không thể tìm thấy loại thuốc của mình trong Danh Sách Thuốc hoặc gặp khó khăn trong việc nhận thuốc thì sao? ..................................................................................................................8

B10.Quý vị có thể yêu cầu trường hợp ngoại lệ để chi trả cho loại thuốc của mình hay không? .............................................................................................................................9

B11. Làm thế nào để có thể yêu cầu trường hợp ngoại lệ? ..................................................... 9

B12.Mất bao lâu để được cấp trường hợp ngoại lệ? ............................................................... 9

B13. Thuốc gốc là gì? ............................................................................................................10

H6229_20_107805_T_VN_0001 CMS Approved 09/11/2019

? Nếu quý vị có thắc mắc, vui lòng gọi Anthem Blue Cross Cal MediConnect Plan theo số1-833-370-7466 (TTY: 711), 24 giờ một ngày, 7 ngày một tuần. Cuộc gọi này miễn phí. Để biết thêm thông tin, hãy truy cập vào duals.anthem.com.

1

B14. Thuốc mua tự do (OTC) là gì? .......................................................................................10

B15.Anthem Blue Cross Cal MediConnect Plan có chi trả cho sản phẩm mua tự do không phải là thuốc không? .............................................................................................................10

B16.Khoảng đồng thanh toán của quý vị là gì? ....................................................................10

C. Danh Sách Thuốc Được Chi Trả ...........................................................................................11

D. Danh Sách Thuốc theo Tình Trạng Bệnh Lý .........................................................................12

E. Danh Mục Thuốc Được Chi Trả ...........................................................................................196


2

A. Tuyên bố miễn trừ trách nhiệm

Đây là danh sách các loại thuốc mà thành viên có thể được Anthem Blue Cross Cal MediConnect Plan chi trả.

Anthem Blue Cross Cal MediConnect Plan là một chương trình bảo hiểm sức khỏe có hợp đồng với cả Medicare và Medi-Cal để cung cấp phúc lợi của cả hai chương trình cho các thành viên.

Quý vị lúc nào cũng có thể kiểm tra Danh Sách Thuốc Được Chi Trả mới nhất của Anthem Blue Cross Cal MediConnect Plan trên mạng tại địa chỉ duals.anthem.com hoặc bằng cách gọi đến 1-833-370-7466 (TTY 711), 24 giờ một ngày, 7 ngày một tuần

Giới hạn, khoản đồng chi trả và hạn chế có thể được áp dụng. Để biết thêm thông tin, hãy gọi Dịch Vụ Thành Viên Nhà Thuốc của Anthem Blue Cross Cal MediConnect Plan hoặc đọc Sổ Tay Thành Viên của Anthem Blue Cross Cal MediConnect Plan.

注意：如果您使用中文，您可以免費獲得語言援助服務。請致電 1-833-370-7466(TTY:711), 一週7 天，全天24 小時。通話免費。 ChineseATENCIÓN: Si usted habla español, tiene a su disposición servicios gratuitos de asistencia de idiomas. Llame al 1-833-370-7466 (TTY: 711), las 24 horas del día, los 7 días de la semana. La llamada es gratuita. SpanishPAALALA: Kung nagsasalita ka ng Tagalog, magagamit mo nang walang bayad ang mga serbisyo ng tulong sa wika. Tumawag sa 1-833-370-7466(TTY: 711), 24 na oras sa isang araw, 7 araw sa isang linggo. Libre ang tawag. TagalogCHU Ý: Nếu quý vị nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ, miễn phí, cho quý vị. Xin gọi số 1-833-370-7466 (TTY: 711), 24 giờ mỗi ngày, 7 ngày mỗi tuần. Cuộc gọi được miễn tính cước phí. Vietnamese

Quý vị có thể nhận tài liệu này miễn phí ở các ngôn ngữ và định dạng khác, chẳng hạn như chữ in lớn, chữ nổi braille hoặc âm thanh. Hãy gọi 1-833-370-7466 (TTY 711), 24 giờ một ngày, 7 ngày một tuần Cuộc gọi này miễn phí.

Khi quý vị gọi, hãy cho chúng tôi biết nếu quý vị muốn đây là một yêu cầu định kỳ. Điều này có nghĩa là hàng năm chúng tôi sẽ gửi cùng một tài liệu theo ngôn ngữ và định dạng quý vị yêu cầu.

Quý vị cũng có thể gọi cho chúng tôi để thay đổi hoặc hủy một yêu cầu định kỳ. Quý vị cũng có thể tìm tài liệu trực tuyến tại địa chỉ duals.anthem.com.


3

B. Câu Hỏi Thường Gặp (FAQ)

Hãy tìm câu trả lời tại đây cho các câu hỏi của quý vị về Danh Sách Thuốc Được Chi Trả này. Quý vị có thể đọc tất cả các câu hỏi thường gặp để tìm hiểu thêm hoặc để tìm kiếm câu hỏi và câu trả lời.

B1. Những loại thuốc theo toa nào có trong Danh Sách Thuốc Được Chi Trả? (Chúng tôi gọi tắt Danh Sách Thuốc Được Chi Trả là “Danh Sách Thuốc”.)

Các thuốc trong Danh Sách Thuốc là những loại thuốc được Anthem Blue Cross Cal MediConnect Plan chi trả. Những thuốc này có bán tại các nhà thuốc trong mạng lưới của chúng tôi. Một nhà thuốc được xem là nằm trong mạng lưới của chúng tôi nếu chúng tôi có thỏa thuận làm việc với họ và họ cung cấp dịch vụ cho quý vị. Chúng tôi gọi những nhà thuốc này là “nhà thuốc trong mạng lưới”.

Anthem Blue Cross Cal MediConnect Plan sẽ chi trả cho tất cả các loại thuốc cần thiết về mặt y tế có trong Danh Sách Thuốc nếu:

bác sĩ hoặc người kê toa khác cho rằng quý vị cần những loại thuốc này để cải thiện hoặc giữ gìn sức khỏe, và

quý vị mua thuốc theo toa tại một nhà thuốc trong mạng lưới của Anthem Blue Cross Cal MediConnect Plan.

Trong một số trường hợp, quý vị phải thực hiện một số thao tác trước khi có thể nhận thuốc (xem câu hỏi B4 bên dưới).

Nếu chúng tôi chỉ chi trả một loại thuốc cho một số tình trạng bệnh lý, chúng tôi sẽ chỉ rõ thuốc đó trong Danh Sách Thuốc cùng với các tình trạng bệnh lý cụ thể được chi trả.

Quý vị cũng có thể xem danh sách thuốc được chúng tôi chi trả đã cập nhật trên trang web của chúng tôi tại duals.anthem.com hoặc gọi Dịch Vụ Thành Viên Nhà Thuốc theo số 1-833-370-7466 (TTY: 711), 24 giờ một ngày, 7 ngày một tuần.

B2. Danh Sách Thuốc có bao giờ thay đổi không?Có, và Anthem Blue Cross Cal MediConnect Plan phải tuân theo các quy định của Medicare và Medicaid khi thực hiện thay đổi. Chúng tôi có thể thêm vào hoặc loại bỏ thuốc ra khỏi Danh Sách Thuốc trong cả năm.

Chúng tôi cũng có thể thay đổi các quy định về thuốc. Ví dụ, chúng tôi có thể:

Quyết định yêu cầu hoặc không yêu cầu sự chấp thuận trước cho một loại thuốc. (Chấp thuận trước là sự cho phép của Anthem Blue Cross Cal MediConnect Plan trước khi quý vị có thể nhận thuốc.)

Bổ sung hoặc thay đổi lượng thuốc mà quý vị được cấp (gọi là giới hạn số lượng).


4

Bổ sung hoặc thay đổi các hạn chế về trị liệu từng bước đối với một loại thuốc. (Trị liệu từng bước nghĩa là quý vị phải dùng thử một loại thuốc trước khi chúng tôi chi trả cho một loại thuốc khác.)

Hãy xem câu hỏi B4 để biết thêm thông tin về các quy định về thuốc.

Nếu quý vị đang dùng một loại thuốc đã được chi trả vào đầu năm, thì chúng tôi thường không loại bỏ hoặc thay đổi việc chi trả cho loại thuốc đó cho đến hết năm trừ khi:

xuất hiện một loại thuốc mới rẻ hơn có tác dụng giống như thuốc có trong Danh Sách Thuốc hiện tại, hoặc

chúng tôi phát hiện ra một loại thuốc không an toàn, hoặc

một loại thuốc bị ngừng lưu hành trên thị trường.

Các câu hỏi B3 và B6 bên dưới có thêm thông tin về điều sẽ xảy ra khi Danh Sách Thuốc thay đổi.

Quý vị lúc nào cũng có thể kiểm tra Danh Sách Thuốc mới nhất của Anthem Blue Cross Cal MediConnect Plan trên mạng tại duals.anthem.com.

Quý vị cũng có thể gọi Dịch Vụ Thành Viên Nhà Thuốc để kiểm tra Danh Sách Thuốc hiện tại theo số 1-833-370-7466 (TTY: 711), 24 giờ một ngày, 7 ngày một tuần.

B3. Điều gì sẽ xảy ra nếu Danh Sách Thuốc có sự thay đổi?Một số thay đổi về Danh Sách Thuốc sẽ có hiệu lực ngay lập tức. Ví dụ:

Xuất hiện một loại thuốc gốc mới. Đôi khi sẽ xuất hiện một loại thuốc gốc mới rẻ hơn có tác dụng giống như thuốc chính hiệu có trong Danh Sách Thuốc hiện tại. Khi điều này xảy ra, chúng tôi có thể sẽ loại bỏ thuốc chính hiệu và thêm thuốc gốc mới, nhưng giá tiền phải trả cho thuốc mới vẫn không thay đổi. Khi thêm một loại thuốc gốc mới, chúng tôi cũng có thể quyết định vẫn giữ thuốc chính hiệu trong danh sách nhưng sẽ thay đổi quy định hoặc giới hạn chi trả cho loại thuốc đó.

Chúng tôi có thể không báo trước cho quý vị về sự thay đổi này, nhưng chúng tôi sẽ gửi cho quý vị thông tin khi những thay đổi cụ thể có hiệu lực.

Quý vị hoặc nhà cung cấp của quý vị có thể yêu cầu trường hợp ngoại lệ với các thay đổi này. Chúng tôi sẽ gửi cho quý vị một thông báo có các bước cần thực hiện để yêu cầu trường hợp ngoại lệ. Vui lòng xem câu hỏi B10 để biết thêm thông tin về các trường hợp ngoại lệ.

Một loại thuốc bị ngừng lưu hành trên thị trường. Nếu Cơ Quan Quản Lý Thực Phẩm và Dược Phẩm (FDA) cho rằng loại thuốc quý vị đang dùng không an toàn hoặc bị nhà sản xuất ngừng lưu hành trên thị trường, thì chúng tôi sẽ loại bỏ thuốc đó ra khỏi Danh Sách Thuốc. Chúng tôi sẽ thông báo cho quý vị biết nếu quý vị đang dùng loại thuốc này. Vui lòng liên hệ với bác sĩ kê toa của quý vị ngay khi nhận được thư.


5

Chúng tôi có thể thực hiện những thay đổi khác gây ảnh hưởng đến loại thuốc quý vị dùng. Chúng tôi sẽ báo trước cho quý vị những thay đổi khác về Danh Sách Thuốc. Những thay đổi này có thể được áp dụng nếu:

FDA cung cấp hướng dẫn mới hoặc có các hướng dẫn điều trị mới cho một loại thuốc.

Chúng tôi bổ sung một loại thuốc gốc đã có trên thị trường và

Thay thế một loại thuốc chính hiệu hiện có trong Danh Sách Thuốc hoặc

Thay đổi quy định hoặc giới hạn chi trả cho loại thuốc chính hiệu này.

Khi những thay đổi này diễn ra, chúng tôi sẽ:

Cho quý vị biết ít nhất 30 ngày trước khi chúng tôi thay đổi Danh Sách Thuốc hoặc

Cho quý vị biết và cấp lượng thuốc dùng trong 31 ngày sau khi quý vị yêu cầu thêm thuốc.

Như vậy, quý vị sẽ có thời gian để trao đổi với bác sĩ hoặc người kê toa khác của mình. Họ có thể giúp quý vị quyết định:

Liệu có thuốc thay thế tương tự trong Danh Sách Thuốc quý vị có thể dùng hay không hoặc

Yêu cầu trường hợp ngoại lệ cho những thay đổi này hay không. Để tìm hiểu thêm về trường hợp ngoại lệ, hãy xem câu hỏi B10.

B4. Có giới hạn hoặc hạn chế nào về việc chi trả thuốc không? Hay có hành động nào bắt buộc phải thực hiện để nhận được một số loại thuốc nhất định không?

Có, một số loại thuốc có các quy định về việc chi trả hoặc giới hạn về số lượng thuốc quý vị có thể nhận được. Trong một số trường hợp, quý vị hoặc bác sĩ hay người kê toa khác của quý vị phải thực hiện việc gì đó trước khi quý vị có thể nhận thuốc. Ví dụ:

Chấp thuận trước (hoặc phê duyệt trước): Đối với một số loại thuốc, quý vị hoặc bác sĩ hay người kê toa khác của quý vị phải nhận được sự chấp thuận từ Anthem Blue Cross Cal MediConnect Plan trước khi quý vị có thể mua thuốc. Anthem Blue Cross Cal MediConnect Plan có thể không chi trả cho loại thuốc này nếu quý vị không được chấp thuận.

Giới hạn số lượng: Đôi khi Anthem Blue Cross Cal MediConnect Plan sẽ giới hạn số lượng thuốc mà quý vị được cấp.

Trị liệu từng bước: Đôi khi Anthem Blue Cross Cal MediConnect Plan sẽ yêu cầu quý vị tiến hành trị liệu từng bước. Điều này có nghĩa là quý vị sẽ phải dùng thử các loại thuốc theo một thứ tự nhất định cho tình trạng bệnh lý của mình. Quý vị có thể phải dùng thử một loại thuốc trước khi chúng tôi chi trả cho một loại thuốc khác. Nếu bác sĩ cho rằng loại thuốc đầu tiên không có tác dụng đối với quý vị thì chúng tôi sẽ chi trả cho loại thuốc thứ hai.


6

Chi trả theo chỉ định: Nếu Anthem Blue Cross Cal MediConnect Plan chỉ chi trả một loại thuốc cho một số tình trạng bệnh lý. Chúng tôi sẽ chỉ rõ thuốc đó trong Danh Sách Thuốc cùng với các tình trạng bệnh lý cụ thể được chi trả.

Quý vị có thể tìm hiểu xem thuốc của mình có yêu cầu hay giới hạn bổ sung nào không bằng cách xem các bảng ở trang 12 - 195. Quý vị cũng có thể truy cập vào trang web của chúng tôi tạiduals.anthem.com để biết thêm thông tin. Chúng tôi đã đăng tải trên mạng những tài liệu giải thích các hạn chế về sự phê duyệt trước và trị liệu từng bước. Quý vị cũng có thể yêu cầu chúng tôi gửi cho quý vị một bản sao.

Quý vị cũng có thể yêu cầu một trường hợp ngoại lệ với những giới hạn này. Như vậy, quý vị sẽ có thời gian để trao đổi với bác sĩ hoặc người kê toa khác của mình. Họ có thể giúp quý vị quyết định liệu có thể dùng một loại thuốc tương tự trong Danh Sách Thuốc để thay thế hoặc liệu có cần yêu cầu trường hợp ngoại lệ hay không. Vui lòng xem các câu hỏi B10- B12 để biết thêm thông tin về các trường hợp ngoại lệ.

B5. Làm thế nào quý vị biết liệu loại thuốc mà mình cần có các giới hạn hoặc có hành động nào bắt buộc phải thực hiện để nhận được thuốc hay không?

Danh Sách Thuốc Được Chi Trả ở trang 12 có một cột tên là “Hành Động Cần Thiết, Quy Định Hạn Chế hoặc Giới Hạn Sử Dụng”.

B6. Điều gì sẽ xảy ra nếu chúng tôi thay đổi quy định về một số loại thuốc (ví dụ: nếu chúng tôi yêu cầu phải có thêm sự phê duyệt (chấp thuận) trước, giới hạn số lượng và/hoặc hạn chế về trị liệu từng bước).

Trong một số trường hợp, chúng tôi sẽ thông báo trước cho quý vị nếu chúng tôi bổ sung hoặc thay đổi yêu cầu có thêm sự chấp thuận trước, giới hạn số lượng và/hoặc hạn chế về trị liệu từng bước đối với một loại thuốc. Hãy xem câu hỏi B3 để biết thêm thông tin về thông báo trước này và những tình huống mà chúng tôi không thể báo trước cho quý vị khi quy định về thuốc trong Danh Sách Thuốc có thay đổi.

B7. Quý vị có thể tìm một loại thuốc trong Danh Sách Thuốc bằng cách nào?

Có hai cách để tìm kiếm một loại thuốc:

Quý vị có thể tìm theo thứ tự bảng chữ cái (nếu quý vị biết cách đánh vần tên thuốc), hoặc

Quý vị có thể tìm theo tình trạng bệnh lý.

Để tìm kiếm theo thứ tự bảng chữ cái, hãy xem phần Danh Mục Thuốc Được Chi Trả. Quý vị có thể tìm thấy thuốc bằng cách chuyển đến danh sách bắt đầu ở trang 196, sau đó tìm tên thuốc trong danh sách.


7

Để tìm kiếm theo tình trạng bệnh lý, hãy tìm phần có tên “Danh Sách Thuốc Theo Tình Trạng Bệnh Lý” ở trang 12. Thuốc trong phần này được nhóm thành các mục theo tình trạng bệnh lý mà chúng được dùng để điều trị. Ví dụ: nếu bị bệnh về tim thì quý vị cần tìm mục Thuốc Tim Mạch. Đó là nơi quý vị sẽ tìm thấy thuốc điều trị bệnh về tim.

B8. Nêu thuốc quý vị cần không có trong Danh Sách Thuốc thì sao?Nếu quý vị không tìm thấy thuốc của mình trong Danh Sách Thuốc, hãy gọi cho Dịch Vụ Thành Viên Nhà Thuốc theo số 1-833-370-7466 (TTY: 711), 24 giờ một ngày, 7 ngày một tuần và hỏi về thuốc đó. Nếu biết rằng Anthem Blue Cross Cal MediConnect Plan sẽ không chi trả cho loại thuốc đó, quý vị có thể thực hiện một trong những điều sau đây:

Yêu cầu Dịch Vụ Thành Viên Nhà Thuốc cung cấp một danh sách các loại thuốc giống loại quý vị muốn dùng. Sau đó, cho bác sĩ hoặc người kê toa khác của quý vị xem danh sách đó. Họ có thể kê một loại thuốc có trong Danh Sách Thuốc giống loại thuốc quý vị muốn dùng.Hoặc

Quý vị có thể yêu cầu chương trình bảo hiểm sức khỏe đưa ra ngoại lệ để chi trả cho loại thuốc của quý vị. Vui lòng xem các câu hỏi B10- B12 để biết thêm thông tin về các trường hợp ngoại lệ.

B9. Nếu quý vị là thành viên mới củaAnthem Blue Cross Cal MediConnect Plan và không thể tìm thấy loại thuốc của mình trong Danh Sách Thuốc hoặc gặp khó khăn trong việc nhận thuốc thì sao?

Chúng tôi có thể trợ giúp. Chúng tôi có thể chi trả lượng thuốc tạm thời đủ dùng trong 31 ngày cho quý vị trong suốt 90 ngày đầu tiên quý vị là thành viên của Anthem Blue Cross Cal MediConnect Plan. Như vậy, quý vị sẽ có thời gian để trao đổi với bác sĩ hoặc người kê toa khác của mình. Họ có thể giúp quý vị quyết định liệu có thể dùng một loại thuốc tương tự trong Danh Sách Thuốc để thay thế hoặc liệu có cần yêu cầu trường hợp ngoại lệ hay không.

Nếu thuốc theo toa của quý vị được kê với số ngày ít hơn, thì chúng tôi sẽ cho phép mua thuốc nhiều lần để cung cấp tối đa 31 ngày dùng thuốc.

Chúng tôi sẽ chi trả cho lượng thuốc dùng trong 31 ngày của quý vị nếu:

quý vị đang dùng một loại thuốc không có trong Danh Sách Thuốc của chúng tôi, hoặc

các quy định của chương trình bảo hiểm sức khỏe không cho phép quý vị nhận được số lượng thuốc do người kê toa chỉ định, hoặc

loại thuốc này phải có sự chấp thuận trước của Anthem Blue Cross Cal MediConnect Plan,hoặc

quý vị đang dùng một loại thuốc phải chịu hạn chế về trị liệu từng bước.

Nếu quý vị sống trong viện dưỡng lão hoặc cơ sở chăm sóc lâu dài khác và cần một loại thuốc không có trong Danh Sách Thuốc hoặc nếu quý vị không thể dễ dàng nhận được loại thuốc mình


8

cần, chúng tôi có thể trợ giúp. Nếu quý vị đã tham gia chương trình này trên 90 ngày, sống trong cơ sở chăm sóc lâu dài và cần cấp thuốc ngay:

Chúng tôi sẽ chi trả cho lượng thuốc dùng trong 34 ngày (trừ khi thuốc theo toa của quý vị được kê với số ngày ít hơn), dù quý vị có phải là thành viên mới của Anthem Blue Cross Cal MediConnect Plan hay không.

Đây là phần bổ sung thêm cho lượng thuốc được cấp tạm thời trong 90 ngày đầu tiên quý vị là thành viên của Anthem Blue Cross Cal MediConnect Plan.

Nếu việc thay đổi về mức độ chăm sóc của quý vị yêu cầu quý vị phải chuyển từ một cơ sở hoặc trung tâm điều trị này sang một cơ sở hoặc trung tâm điều trị khác, thì quý vị có thể đủ điều kiện mua thuốc tạm thời một lần theo toa thuốc hiện tại. Ví dụ: nếu quý vị xuất viện và được cung cấp một danh sách thuốc khi xuất viện dựa trên danh mục thuốc của bệnh viện, thì quý vị có thể mua thuốc đó một lần. Quý vị có thể xin ngoại lệ để mua thuốc một lần tạm thời bất kể quý vị có đang trong giai đoạn 90 ngày đầu tiên kể từ khi tham gia chương trình hay không. Hãy yêu cầu người kê toa của quý vị gọi cho chúng tôi để biết thông tin chi tiết.

B10. Quý vị có thể yêu cầu trường hợp ngoại lệ để chi trả cho loại thuốc của mình hay không?

Có. Quý vị có thể yêu cầu Anthem Blue Cross Cal MediConnect Plan đưa ra trường hợp ngoại lệ để chi trả cho một loại thuốc không có trong Danh Sách Thuốc.

Quý vị cũng có thể yêu cầu chúng tôi thay đổi quy định về loại thuốc của quý vị.

Ví dụ: Anthem Blue Cross Cal MediConnect Plan có thể giới hạn số lượng của một loại thuốc chúng tôi sẽ chi trả. Nếu loại thuốc của quý vị có giới hạn thì quý vị có thể yêu cầu chúng tôi thay đổi giới hạn đó và chi trả cho số lượng lớn hơn.

Các ví dụ khác: Quý vị có thể yêu cầu chúng tôi hủy bỏ quy định hạn chế về trị liệu từng bước hoặc yêu cầu về sự chấp thuận trước.

B11. Làm thế nào để có thể yêu cầu trường hợp ngoại lệ?Để yêu cầu trường hợp ngoại lệ, vui lòng gọi Dịch Vụ Thành Viên Nhà Thuốc. Đại diện của Dịch Vụ Thành Viên Nhà Thuốc sẽ làm việc với quý vị và nhà cung cấp của quý vị để giúp quý vị yêu cầu trường hợp ngoại lệ.

Quý vị cũng có thể đọc Chương 9 trong Sổ Tay Thành Viên để tìm hiểu thêm về các trường hợp ngoại lệ.

B12. Mất bao lâu để được cấp trường hợp ngoại lệ?Đầu tiên, chúng tôi phải nhận được tờ khai từ người kê toa của quý vị với nội dung ủng hộ việc quý vị yêu cầu trường hợp ngoại lệ. Sau khi nhận được tờ khai, chúng tôi sẽ đưa ra quyết định cho yêu cầu trường hợp ngoại lệ của quý vị trong vòng 72 giờ.


9

Khi quý vị hoặc người kê toa của quý vị cho rằng nếu phải chờ đợi quyết định trong 72 giờ sẽ gây tổn hại đến sức khỏe của quý vị, thì quý vị có thể yêu cầu trường hợp ngoại lệ khẩn cấp. Quyết định này được đưa ra nhanh hơn. Nếu người kê toa của quý vị ủng hộ yêu cầu này, thì chúng tôi sẽ đưa ra quyết định trong vòng 24 giờ kể từ khi nhận được tờ khai ủng hộ của người kê toa.

B13. Thuốc gốc là gì?Thuốc gốc được sản xuất từ những thành phần tương tự như thuốc chính hiệu. Thuốc này thường rẻ hơn thuốc chính hiệu và thường ít được biết đến hơn. Thuôc gốc đươc Cơ Quan Quan Ly Thưc Phâm va Dươc Phâm (FDA) phê duyệt.

Anthem Blue Cross Cal MediConnect Plan chi trả cho cả thuốc chính hiệu và thuốc gốc.

B14. Thuốc mua tự do (OTC) là gì?OTC là viết tắt của từ “over-the-counter” (mua tự do). Anthem Blue Cross Cal MediConnect Plan chi trả cho một số loại thuốc OTC khi các thuốc này được nhà cung cấp của quý vị kê theo toa.

Quý vị có thể đọc Danh Sách Thuốc của Anthem Blue Cross Cal MediConnect Plan để xem những loại thuốc OTC nào được chi trả.

B15. Anthem Blue Cross Cal MediConnect Plan có chi trả cho các sản phẩm OTC không phải thuốc hay không?

Anthem Blue Cross Cal MediConnect Plan chi trả cho một số sản phẩm OTC không phải là thuốc khi các sản phẩm này được nhà cung cấp của quý vị kê theo toa.

Ví dụ về sản phẩm OTC không phải thuốc bao gồm mặt nạ, bao cao su và máy đo lưu lượng khí tối đa.

Quý vị có thể đọc Danh Sách Thuốc của Anthem Blue Cross Cal MediConnect Plan để xem những sản phẩm OTC không phải thuốc nào được chi trả.

B16. Khoản đồng chi trả là gì?Quý vị có thể đọc Danh Sách Thuốc của Anthem Blue Cross Cal MediConnect Plan để tìm hiểu thêm về khoản đồng chi trả đối với từng loại thuốc. Thành viên của Anthem Blue Cross Cal MediConnect Plan sống trong các viện dưỡng lão hoặc các cơ sở chăm sóc lâu dài sẽ không phải chịu các khoản đồng chi trả. Một số thành viên được chăm sóc lâu dài tại cộng đồng cũng sẽ không phải chịu các khoản đồng chi trả.

Các khoản đồng chi trả được liệt kê theo bậc. Bậc là các nhóm thuốc có cùng khoản đồng chi trả.

Bậc 1 – Các loại thuốc gốc và thuốc chính hiệu ưu tiên của Medicare Phần D Khoản đồng chi trả là $0. (Cấp tối đa 93 ngày thuốc tại nhà thuốc bán lẻ hoặc nhà thuốc nhận đặt hàng qua bưu điện trong mạng lưới)


10

Bậc 2 – Các loại thuốc gốc và thuốc chính hiệu ưu tiên hoặc không ưu tiên của Medicare Phần D Khoản đồng chi trả là từ $0 đến $8,95. (Cấp tối đa 93 ngày thuốc tại nhà thuốc bán lẻ hoặc nhà thuốc nhận đặt hàng qua bưu điện trong mạng lưới)

Bậc 3 – Các loại thuốc gốc và thuốc chính hiệu theo toa không phải của Medicare được Medi-Cal (tiểu bang) phê duyệt Khoản đồng chi trả là $0. (Cấp tối đa 31 ngày thuốc tại nhà thuốc bán lẻ trong mạng lưới)

Bậc 4 – Các loại thuốc gốc mua tự do (OTC) theo toa của nhà cung cấp, không phải của Medicare được Medi-Cal (tiểu bang) phê duyệt Khoản đồng chi trả là $0. (Cấp tối đa 31 ngày thuốc tại nhà thuốc bán lẻ trong mạng lưới)

C. Danh Sách Thuốc Được Chi Trả

Danh sách thuốc được chi trả sau đây cung cấp cho quý vị thông tin về các loại thuốc được Anthem Blue Cross Cal MediConnect Plan chi trả. Nếu quý vị gặp khó khăn khi tìm loại thuốc của mình trong danh sách, hãy chuyển đến phần Chỉ Mục bắt đầu ở trang 196. Phần Chỉ Mục liệt kê tất cả các loại thuốc được Anthem Blue Cross Cal MediConnect Plan chi trả theo thứ tự bảng chữ cái.

Cột đầu tiên của bảng liệt kê tên thuốc. Thuốc chính hiệu được viết hoa (ví dụ: SPIRIVA) còn thuốc gốc được viết bằng chữ thường, in nghiêng (ví dụ: atenolol).

Thông tin trong cột “Hành Động Cần Thiết, Quy Định Hạn Chế hoặc Giới Hạn Sử Dụng” cho quý vị biết liệu Anthem Blue Cross Cal MediConnect Plan có quy định nào về việc chi trả cho loại thuốc của quý vị hay không.

Lưu ý: Dấu sao (*) cạnh một loại thuốc có nghĩa là thuốc này không phải “thuốc Phần D.” Quý vị sẽ không phải chịu khoản đồng chi trả nào cho những loại thuốc này. Những loại thuốc này cũng có các quy định khác nhau về thủ tục kháng nghị.

Kháng nghị là cách chính thức để yêu cầu chúng tôi xem xét lại một quyết định chi trả cho quý vị và thay đổi quyết định đó nếu quý vị cho rằng chúng tôi đã có nhầm lẫn. Ví dụ: chúng tôi có thể đã quyết định rằng loại thuốc mà quý vị cần không được hoặc không còn được Medicare hay Medi-Cal chi trả nữa.

Nếu quý vị hoặc bác sĩ của quý vị không đồng tình với quyết định của chúng tôi thì quý vị có thể kháng nghị. Nếu quý vị có thắc mắc, hãy gọi cho Dịch Vụ Thành Viên Nhà Thuốc theo số 1-833-370-7466 (TTY: 711), 24 giờ một ngày, 7 ngày một tuần Quý vị cũng có thể đọc Chương 9 của Sổ Tay Thành Viên để tìm hiểu cách kháng nghị quyết định.


11

D. Danh Sách Thuốc theo Tình Trạng Bệnh Lý

Thuốc trong phần này được nhóm thành các mục theo tình trạng bệnh lý mà chúng được dùng để điều trị. Ví dụ: nếu bị bệnh về tim thì quý vị cần tìm mục Thuốc Tim Mạch. Đó là nơi quý vị sẽ tìm thấy thuốc điều trị bệnh về tim.

Dưới đây là ý nghĩa của các chữ viết tắt trong cột “Hành Động Cần Thiết, Quy Định Hạn Chế hoặc Giới Hạn Sử Dụng”:

GIẢI THÍCHMÔ TẢCHỮ VIẾT TẮT

Loại thuốc theo toa này được chi trả theo Medicare Phần B hay Phần D tùy từng trường hợp. Cần cung cấp thông tin mô tả cách dùng và liều lượng của thuốc để xác định.

Xác định Phần B hay Phần D

B/D PAR

Toa thuốc này có thể chỉ được bán tại một số nhà thuốc nhất định. Để biết thêm thông tin, vui lòng gọi Dịch Vụ

Giới Hạn Về Tính Sẵn Có

LA

Thành Viên Nhà Thuốc theo số 1-833-370-7466 (TTY:711), 24 giờ một ngày, 7 ngày một tuần.

Loại thuốc theo toa này được bán thông qua dịch vụ đặt hàng qua bưu điện, cũng như thông qua các nhà thuốc

Thuôc Đăt Qua Đường Bưu Điện

MO

bán lẻ trong mạng lưới của chúng tôi. Hãy cân nhắc sử dụng dịch vụ đặt hàng qua bưu điện cho các thuốc dùng lâu dài (duy trì) (chẳng hạn như thuốc điều trị cao huyết áp). Các nhà thuốc bán lẻ trong mạng lưới có thể phù hợp để mua các toa thuốc ngắn hạn (chẳng hạn như kháng sinh).

Những loại thuốc không gia hạn số ngày cấp bao gồm các thuốc biệt dược. Thuốc biệt dược được cấp trong 31

Không gia hạn NE

ngày thuốc. Quý vị có thể tìm hiểu xem việc cấp thuốc biệt dược hoặc thuốc không gia hạn số ngày cấp có bị giới hạn trong 31 ngày thuốc hay không bằng cách kiểm tra bảng phúc lợi ở mặt trước của Sổ Tay Thành Viên.

Anthem Blue Cross Cal MediConnect Plan yêu cầu quý vị hoặc bác sĩ của quý vị phải nhận được sự phê duyệt trước

Cần Phê Duyệt Trước

PAR

đối với một số loại thuốc nhất định. Điều này có nghĩa là quý vị phải nhận được sự chấp thuận trước khi mua thuốc theo toa. Nếu quý vị không nhận được sự chấp thuận thì chúng tôi có thể sẽ không chi trả cho loại thuốc đó.

Đối với những loại thuốc nhất định, Anthem Blue Cross Cal MediConnect Plan giới hạn số lượng thuốc mà chúng tôi sẽ chi trả.

Giới Hạn Số Lượng

QLL

Trong một số trường hợp, Anthem Blue Cross Cal MediConnect Plan yêu cầu quý vị

Trị liệu từng bước. ST

phải dùng thử những loại thuốc nhất định để điều trị trình trạng bệnh lý của mình, sau đó chúng tôi mới chi trả cho loại thuốc khác để điều trị bệnh đó. Ví dụ: nếu Thuốc A và Thuốc B đều chữa trị trình trạng bệnh lý của quý vị, thì chúng tôi sẽ không chi trả cho Thuốc B trừ khi quý vị dùng thử Thuốc A trước. Nếu Thuốc A không có tác dụng đối với quý vị thì chúng tôi sẽ chi trả cho Thuốc B.

B/D PAR: Cần Phê Duyệt Trước, Chỉ Để Xác Định Phần D hay Phần B LA: Giới Hạn Về Tính Sẵn Có MO: Đặt Qua Đường Bưu Điện NE: Không gia hạn số ngày cấp PAR: Cần Phê Duyệt TrướcQLL: Giới Hạn Mức Số Lượng ST: Trị Liệu Từng Bước 12

Hành Động Cần Thiết, Quy Định Hạn Chế hoặc Giới Hạn Sử Dụng

Giá Thuốc

(Theo Bậc)

Tên Thuốc

ANALGESICS

MO; NE; QLL (180 per 30 days)$0.00-$8.95 (Tier 2)

acetaminophen-codeine #3


acetaminophen-codeine #4


acetaminophen-codeine oral solution


acetaminophen-codeine oral tablet 300-15 mg, 300-60 mg

[*]$0 (Tier 4)all day relief tablet 220 mg oral[*]$0 (Tier 4)aspir-low tablet delayed release 81 mg oral[*]$0 (Tier 4)aspirin 81 tablet delayed release 81 mg oral[*]$0 (Tier 4)aspirin adult low strength tablet chewable 81

mg oral[*]$0 (Tier 4)aspirin ec tablet delayed release 325 mg oral[*]$0 (Tier 4)aspirin ec tablet delayed release 81 mg oral[*]$0 (Tier 4)aspirin low dose tablet chewable 81 mg oral[*]$0 (Tier 4)aspirin low dose tablet delayed release 81 mg

oral[*]$0 (Tier 4)aspirin low strength tablet chewable 81 mg oral[*]$0 (Tier 4)aspirin tablet 325 mg oral[*]$0 (Tier 4)aspirin tablet chewable 81 mg oral[*]$0 (Tier 4)aspirin tablet delayed release 81 mg oralMO; NE; QLL (90 per 30 days)$0.00-$8.95 (Tier

2)buprenorphine hcl injection

MO; QLL (240 per 30 days)$0.00-$8.95 (Tier 2)

buprenorphine hcl sublingual tablet sublingual 2 mg




butorphanol tartrate injection solution 1 mg/ml


butorphanol tartrate injection solution 2 mg/ml



Giá Thuốc

(Theo Bậc)

Tên Thuốc


butorphanol tartrate nasal

PAR; MO$0.00-$8.95 (Tier 2)

celecoxib oral

[*]$0 (Tier 4)childrens aspirin low strength tablet chewable 81 mg oral

MO$0.00-$8.95 (Tier 2)

diclofenac potassium

MO$0.00-$8.95 (Tier 2)

diclofenac sodium er

MO$0.00-$8.95 (Tier 2)

diclofenac sodium oral

MO$0.00-$8.95 (Tier 2)

diflunisal oral


duramorph

[*]$0 (Tier 4)ecpirin tablet delayed release 325 mg oralPAR; NE; QLL (8 per 28 days)$0.00-$8.95 (Tier

2)ENBREL MINI


endocet oral tablet 10-325 mg, 5-325 mg, 7.5- 325 mg


endocet oral tablet 2.5-325 mg

MO$0.00-$8.95 (Tier 2)

etodolac oral

MO$0.00-$8.95 (Tier 2)

fenoprofen calcium oral tablet

PAR; MO; NE; QLL (120 per 30 days)$0.00-$8.95 (Tier 2)

fentanyl citrate buccal lozenge on a handle


fentanyl citrate buccal lozenge on a handle


fentanyl transdermal patch 72 hour 100 mcg/ hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/ hr



Giá Thuốc

(Theo Bậc)

Tên Thuốc


fentanyl transdermal patch 72 hour 100 mcg/ hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/ hr

MO$0.00-$8.95 (Tier 2)

flurbiprofen oral

[*]$0 (Tier 4)gnp adult aspirin low strength tablet chewable 81 mg oral

[*]$0 (Tier 4)gnp aspirin low dose tablet delayed release 81 mg oral

[*]$0 (Tier 4)gnp aspirin tablet 325 mg oral[*]$0 (Tier 4)gnp aspirin tablet delayed release 325 mg oral[*]$0 (Tier 4)goodsense aspirin tablet 325 mg oral[*]$0 (Tier 4)goodsense aspirin tablet chewable 81 mg oral[*]$0 (Tier 4)hm aspirin ec low dose tablet delayed release

81 mg oral[*]$0 (Tier 4)hm aspirin ec tablet delayed release 325 mg

oral[*]$0 (Tier 4)hm aspirin tablet 325 mg oral[*]$0 (Tier 4)hm aspirin tablet chewable 81 mg oral[*]$0 (Tier 3)hydrocod polst-cpm polst er suspension

extended release 10-8 mg/5ml oralMO; NE; QLL (2700 per 30 days)$0.00-$8.95 (Tier

2)hydrocodone-acetaminophen oral solution 7.5- 325 mg/15ml


hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg

[*]$0 (Tier 3)hydrocodone-homatropine syrup 5-1.5 mg/5ml oral

[*]$0 (Tier 3)HYDROCODONE-HOMATROPINE SYRUP 5-1.5 MG/5ML ORAL

[*]$0 (Tier 3)hydrocodone-homatropine tablet 5-1.5 mg oralMO; NE; QLL (50 per 10 days)$0.00-$8.95 (Tier

2)hydrocodone-ibuprofen oral tablet 5-200 mg, 7.5-200 mg

[*]$0 (Tier 3)hydromet syrup 5-1.5 mg/5ml oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc


hydromorphone hcl oral tablet

MO$0.00-$8.95 (Tier 2)

ibu oral tablet 600 mg, 800 mg

MO$0.00-$8.95 (Tier 2)

ibuprofen oral suspension

MO$0.00-$8.95 (Tier 2)

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

PAR; LA; NE$0.00-$8.95 (Tier 2)

ILARIS SUBCUTANEOUS SOLUTION

PAR; MO$0.00-$8.95 (Tier 2)

indomethacin er

PAR; MO$0.00-$8.95 (Tier 2)

indomethacin oral


levorphanol tartrate oral tablet 2 mg


lorcet


lorcet hd


lorcet plus oral tablet 7.5-325 mg

MO$0.00-$8.95 (Tier 2)

meclofenamate sodium oral

MO$0.00-$8.95 (Tier 2)

meloxicam oral tablet


METHADONE HCL INJECTION


methadone hcl intensol


methadone hcl oral concentrate


methadone hcl oral solution



Giá Thuốc

(Theo Bậc)

Tên Thuốc


methadone hcl oral tablet


morphine sulfate (concentrate) oral solution 100 mg/5ml


morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml


morphine sulfate (pf) injection solution 0.5 mg/ ml, 1 mg/ml


MORPHINE SULFATE (PF) INJECTION SOLUTION 10 MG/ML, 4 MG/ML, 8 MG/ML


MORPHINE SULFATE (PF) INTRAVENOUS SOLUTION 10 MG/ML, 2 MG/ML, 4 MG/ML, 8 MG/ML


morphine sulfate er oral tablet extended release 100 mg, 200 mg


morphine sulfate er oral tablet extended release 15 mg, 30 mg, 60 mg


morphine sulfate injection solution 10 mg/ml, 8 mg/ml


morphine sulfate intravenous solution 1 mg/ml


MORPHINE SULFATE INTRAVENOUS SOLUTION 150 MG/30ML


morphine sulfate intravenous solution 25 mg/ ml


morphine sulfate intravenous solution 50 mg/ ml


morphine sulfate oral solution 20 mg/5ml


morphine sulfate oral solution 20 mg/5ml


morphine sulfate oral tablet


morphine sulfate oral tablet



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

nabumetone oral


nalbuphine hcl injection solution 10 mg/ml


nalbuphine hcl injection solution 20 mg/ml

MO$0.00-$8.95 (Tier 2)

naproxen dr

MO$0.00-$8.95 (Tier 2)

naproxen oral tablet

MO$0.00-$8.95 (Tier 2)

naproxen sodium oral tablet 275 mg, 550 mg

MO$0.00-$8.95 (Tier 2)

oxaprozin


oxycodone hcl oral capsule


oxycodone hcl oral concentrate 10 mg/0.5ml


oxycodone hcl oral concentrate 100 mg/5ml


oxycodone hcl oral tablet


oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg


oxycodone-aspirin oral tablet 4.8355-325 mg

MO$0.00-$8.95 (Tier 2)

piroxicam oral

[*]$0 (Tier 4)qc aspirin low dose tablet chewable 81 mg oral[*]$0 (Tier 4)qc aspirin tablet 325 mg oral[*]$0 (Tier 4)qc enteric aspirin tablet delayed release 325

mg oral[*]$0 (Tier 4)qc naproxen sodium tablet 220 mg oral[*]$0 (Tier 4)sb aspirin tablet 325 mg oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)sb ibuprofen tablet 200 mg oral[*]$0 (Tier 4)sm aspirin adult low strength tablet chewable

81 mg oral[*]$0 (Tier 4)sm aspirin adult low strength tablet delayed

release 81 mg oral[*]$0 (Tier 4)sm aspirin ec low strength tablet delayed

release 81 mg oral[*]$0 (Tier 4)sm aspirin ec tablet delayed release 325 mg

oral[*]$0 (Tier 4)sm aspirin low dose tablet chewable 81 mg oral[*]$0 (Tier 4)sm aspirin tablet 325 mg oral[*]$0 (Tier 4)sm childrens aspirin tablet chewable 81 mg

oral[*]$0 (Tier 4)sm urinary pain relief tablet 95 mg oralMO$0.00-$8.95 (Tier

2)sulindac oral


tramadol hcl oral


tramadol-acetaminophen

ANESTHETICS

MO$0.00-$8.95 (Tier 2)

glydo

PAR; MO; QLL (150 per 30 days)$0.00-$8.95 (Tier 2)

lidocaine external ointment


lidocaine external patch 5 %

MO$0.00-$8.95 (Tier 2)

lidocaine hcl (pf) injection solution 2 %


lidocaine hcl external solution


lidocaine hcl mouth/throat



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

lidocaine hcl urethral/mucosal


lidocaine pak

MO$0.00-$8.95 (Tier 2)

lidocaine viscous hcl


lidocaine-prilocaine external cream

ANTI-ADDICTION/ SUBSTANCE ABUSE TREATMENT AGENTS

MO$0.00-$8.95 (Tier 2)

acamprosate calcium





MO; QLL (360 per 30 days)$0 (Tier 1)buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg

MO; QLL (90 per 30 days)$0 (Tier 1)buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg


bupropion hcl er (smoking det)


CHANTIX CONTINUING MONTH PAK


CHANTIX ORAL TABLET 0.5 MG


CHANTIX ORAL TABLET 1 MG

PAR; MO; NE; QLL (106 per 365 days)

$0.00-$8.95 (Tier 2)

CHANTIX STARTING MONTH PAK

MO$0.00-$8.95 (Tier 2)

disulfiram oral

[*]; QLL (20 per 1 day)$0 (Tier 4)gnp nicotine mini lozenge 2 mg mouth/throat[*]$0 (Tier 4)gnp nicotine polacrilex gum 2 mg mouth/throat[*]$0 (Tier 4)gnp nicotine polacrilex gum 4 mg mouth/throat



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]; QLL (20 per 1 day)$0 (Tier 4)gnp nicotine polacrilex lozenge 2 mg mouth/ throat

[*]; QLL (20 per 1 day)$0 (Tier 4)gnp nicotine polacrilex lozenge 4 mg mouth/ throat

[*]$0 (Tier 4)goodsense nicotine gum 4 mg mouth/throat[*]; QLL (20 per 1 day)$0 (Tier 4)goodsense nicotine lozenge 4 mg mouth/throat[*]; QLL (30 per 30 days)$0 (Tier 4)hm nicotine patch 24 hour 14 mg/24hr

transdermal[*]; QLL (30 per 30 days)$0 (Tier 4)hm nicotine patch 24 hour 21 mg/24hr

transdermal[*]; QLL (30 per 30 days)$0 (Tier 4)hm nicotine patch 24 hour 7 mg/24hr

transdermal[*]$0 (Tier 4)hm nicotine polacrilex gum 2 mg mouth/throat[*]$0 (Tier 4)hm nicotine polacrilex gum 4 mg mouth/throat[*]; QLL (20 per 1 day)$0 (Tier 4)hm nicotine polacrilex lozenge 2 mg mouth/

throat[*]; QLL (20 per 1 day)$0 (Tier 4)hm nicotine polacrilex lozenge 4 mg mouth/

throatMO$0 (Tier 1)naloxone hcl injection solution 0.4 mg/ml, 4 mg/

10mlMO$0 (Tier 1)naloxone hcl injection solution cartridgeMO$0 (Tier 1)naloxone hcl injection solution prefilled syringeMO$0.00-$8.95 (Tier

2)naltrexone hcl oral

MO$0.00-$8.95 (Tier 2)

naltrexone hcl oral

MO$0.00-$8.95 (Tier 2)

NARCAN

[*]$0 (Tier 4)nicorelief gum 2 mg mouth/throat[*]; QLL (20 per 1 day)$0 (Tier 4)NICORETTE LOZENGE 2 MG MOUTH/

THROAT[*]; QLL (20 per 1 day)$0 (Tier 4)NICORETTE LOZENGE 4 MG MOUTH/

THROAT



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]; QLL (20 per 1 day)$0 (Tier 4)NICORETTE MINI LOZENGE 2 MG MOUTH/ THROAT

[*]; QLL (20 per 1 day)$0 (Tier 4)NICORETTE MINI LOZENGE 4 MG MOUTH/ THROAT

[*]; QLL (30 per 30 days)$0 (Tier 4)nicotine kit 21-14-7 mg/24hr transdermal[*]; QLL (30 per 30 days)$0 (Tier 4)nicotine patch 24 hour 14 mg/24hr transdermal

(otc)[*]; QLL (30 per 30 days)$0 (Tier 4)nicotine patch 24 hour 21 mg/24hr transdermal

(otc)[*]; QLL (30 per 30 days)$0 (Tier 4)nicotine patch 24 hour 7 mg/24hr transdermal

(otc)[*]$0 (Tier 4)nicotine polacrilex gum 2 mg mouth/throat[*]$0 (Tier 4)nicotine polacrilex gum 4 mg mouth/throat[*]; QLL (20 per 1 day)$0 (Tier 4)nicotine polacrilex lozenge 2 mg mouth/throat[*]; QLL (20 per 1 day)$0 (Tier 4)nicotine polacrilex lozenge 4 mg mouth/throatMO; QLL (120 per 30 days)$0.00-$8.95 (Tier

2)NICOTROL NS

[*]$0 (Tier 4)sm nicotine gum 4 mg mouth/throat[*]; QLL (20 per 1 day)$0 (Tier 4)sm nicotine lozenge 2 mg mouth/throat[*]; QLL (30 per 30 days)$0 (Tier 4)sm nicotine patch 24 hour 14 mg/24hr

transdermal[*]; QLL (30 per 30 days)$0 (Tier 4)sm nicotine patch 24 hour 21 mg/24hr

transdermal[*]; QLL (30 per 30 days)$0 (Tier 4)sm nicotine patch 24 hour 7 mg/24hr

transdermal[*]$0 (Tier 4)sm nicotine polacrilex gum 2 mg mouth/throat[*]$0 (Tier 4)sm nicotine polacrilex gum 4 mg mouth/throat[*]; QLL (20 per 1 day)$0 (Tier 4)sm nicotine polacrilex lozenge 4 mg mouth/

throat

ANTI-INFLAMMATORY AGENTS

[*]$0 (Tier 4)all day pain relief tablet 220 mg oralMO$0.00-$8.95 (Tier

2)betamethasone dipropionate aug external cream



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

betamethasone dipropionate aug external lotion

MO$0.00-$8.95 (Tier 2)

betamethasone dipropionate aug external ointment

MO$0.00-$8.95 (Tier 2)

betamethasone dipropionate external

MO$0.00-$8.95 (Tier 2)

betamethasone valerate external cream

MO$0.00-$8.95 (Tier 2)

betamethasone valerate external lotion

MO$0.00-$8.95 (Tier 2)

betamethasone valerate external ointment

MO$0.00-$8.95 (Tier 2)

BLEPHAMIDE S.O.P.

PAR; MO$0.00-$8.95 (Tier 2)

celecoxib oral

MO$0.00-$8.95 (Tier 2)

cortisone acetate oral

MO$0.00-$8.95 (Tier 2)

decadron

MO$0.00-$8.95 (Tier 2)

dexamethasone oral elixir

MO$0.00-$8.95 (Tier 2)

dexamethasone oral solution

MO$0.00-$8.95 (Tier 2)

dexamethasone oral tablet

MO$0.00-$8.95 (Tier 2)

DEXAMETHASONE SOD PHOSPHATE PF

MO$0.00-$8.95 (Tier 2)

dexamethasone sodium phosphate injection

MO$0.00-$8.95 (Tier 2)

diclofenac potassium

MO$0.00-$8.95 (Tier 2)

diclofenac sodium er



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

diclofenac sodium oral

MO$0.00-$8.95 (Tier 2)

diflunisal oral

MO$0.00-$8.95 (Tier 2)

etodolac oral capsule 200 mg

MO$0.00-$8.95 (Tier 2)

etodolac oral tablet

MO$0.00-$8.95 (Tier 2)

fenoprofen calcium oral tablet

MO$0.00-$8.95 (Tier 2)

flurbiprofen oral

[*]$0 (Tier 4)gnp all day pain relief tablet 220 mg oral[*]$0 (Tier 4)gnp ibuprofen capsule 200 mg oral[*]$0 (Tier 4)gnp ibuprofen tablet 200 mg oral[*]$0 (Tier 4)gnp naproxen sodium capsule 220 mg oral[*]$0 (Tier 4)goodsense ibuprofen tablet 200 mg oral[*]$0 (Tier 4)hm ibuprofen capsule 200 mg oral[*]$0 (Tier 4)hm ibuprofen ib tablet 200 mg oral[*]$0 (Tier 4)hm ibuprofen tablet 200 mg oral[*]$0 (Tier 4)hm naproxen sodium capsule 220 mg oral[*]$0 (Tier 4)hm naproxen sodium tablet 220 mg oralMO$0.00-$8.95 (Tier

2)hydrocortisone oral tablet 20 mg, 5 mg

MO$0.00-$8.95 (Tier 2)

ibu

[*]$0 (Tier 4)ibu-200 tablet 200 mg oralMO$0.00-$8.95 (Tier

2)ibuprofen oral suspension

MO$0.00-$8.95 (Tier 2)

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

[*]$0 (Tier 4)ibuprofen tablet 200 mg oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; MO$0.00-$8.95 (Tier 2)

indomethacin er

PAR; MO$0.00-$8.95 (Tier 2)

indomethacin oral

MO$0.00-$8.95 (Tier 2)

meclofenamate sodium oral

MO$0.00-$8.95 (Tier 2)

meloxicam oral tablet

MO$0.00-$8.95 (Tier 2)

methylprednisolone acetate injection suspension 40 mg/ml

MO$0.00-$8.95 (Tier 2)

METHYLPREDNISOLONE ACETATE INJECTION SUSPENSION 80 MG/ML

MO$0.00-$8.95 (Tier 2)

methylprednisolone oral tablet

MO$0.00-$8.95 (Tier 2)

methylprednisolone sodium succ injection solution reconstituted 1000 mg, 125 mg, 40 mg

MO$0.00-$8.95 (Tier 2)

nabumetone oral

MO$0.00-$8.95 (Tier 2)

naproxen dr

MO$0.00-$8.95 (Tier 2)

naproxen oral tablet

[*]$0 (Tier 4)naproxen sodium capsule 220 mg oralMO$0.00-$8.95 (Tier

2)naproxen sodium oral tablet 275 mg, 550 mg

[*]$0 (Tier 4)naproxen sodium tablet 220 mg oralMO$0.00-$8.95 (Tier

2)oxaprozin

MO$0.00-$8.95 (Tier 2)

piroxicam oral

MO$0.00-$8.95 (Tier 2)

prednisolone acetate ophthalmic

MO$0.00-$8.95 (Tier 2)

prednisolone oral solution



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

PREDNISOLONE SODIUM PHOSPHATE OPHTHALMIC

MO$0.00-$8.95 (Tier 2)

prednisolone sodium phosphate oral solution 15 mg/5ml, 6.7 (5 base) mg/5ml

MO$0.00-$8.95 (Tier 2)

PREDNISONE INTENSOL

MO$0.00-$8.95 (Tier 2)

prednisone oral

[*]$0 (Tier 4)provil tablet 200 mg oral[*]$0 (Tier 4)qc ibuprofen ib tablet 200 mg oral[*]$0 (Tier 4)qc ibuprofen tablet 200 mg oral[*]$0 (Tier 4)sb naproxen sodium tablet 220 mg oral[*]$0 (Tier 4)sm ibuprofen ib tablet 200 mg oral[*]$0 (Tier 4)sm ibuprofen tablet 200 mg oral[*]$0 (Tier 4)sm naproxen sodium tablet 220 mg oralMO$0.00-$8.95 (Tier

2)sulfacetamide-prednisolone ophthalmic solution

MO$0.00-$8.95 (Tier 2)

sulfazine

MO$0.00-$8.95 (Tier 2)

sulindac oral

MO$0.00-$8.95 (Tier 2)

triamcinolone acetonide injection suspension 40 mg/ml

ANTIBACTERIALS

MO$0.00-$8.95 (Tier 2)

acetic acid otic

MO$0.00-$8.95 (Tier 2)

amikacin sulfate injection solution 1 gm/4ml, 500 mg/2ml

MO$0.00-$8.95 (Tier 2)

amoxicillin oral capsule

MO$0.00-$8.95 (Tier 2)

amoxicillin oral suspension reconstituted

MO$0.00-$8.95 (Tier 2)

amoxicillin oral tablet



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

amoxicillin oral tablet chewable 125 mg, 250 mg

MO$0.00-$8.95 (Tier 2)

amoxicillin-pot clavulanate er

MO$0.00-$8.95 (Tier 2)

amoxicillin-pot clavulanate oral

MO$0.00-$8.95 (Tier 2)

ampicillin oral capsule 500 mg

MO$0.00-$8.95 (Tier 2)

ampicillin sodium injection solution reconstituted 1 gm, 125 mg, 2 gm, 250 mg, 500 mg

MO$0.00-$8.95 (Tier 2)

ampicillin sodium intravenous

MO$0.00-$8.95 (Tier 2)

ampicillin-sulbactam sodium

MO$0.00-$8.95 (Tier 2)

azithromycin intravenous

MO$0.00-$8.95 (Tier 2)

azithromycin oral suspension reconstituted

$0.00-$8.95 (Tier 2)

azithromycin oral tablet 250 mg (6 pack)

MO$0.00-$8.95 (Tier 2)

azithromycin oral tablet 250 mg, 500 mg, 600 mg

MO$0.00-$8.95 (Tier 2)

aztreonam injection solution reconstituted 1 gm

MO$0.00-$8.95 (Tier 2)

aztreonam injection solution reconstituted 2 gm

[*]$0 (Tier 4)bacitracin ointment 500 unit/gm externalMO$0.00-$8.95 (Tier

2)bacitracin ophthalmic

[*]$0 (Tier 4)bacitracin zinc ointment 500 unit/gm externalMO$0.00-$8.95 (Tier

2)BICILLIN C-R

PAR; LA; NE$0.00-$8.95 (Tier 2)

CAYSTON



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

cefaclor

MO$0.00-$8.95 (Tier 2)

CEFACLOR ER

MO$0.00-$8.95 (Tier 2)

cefadroxil

MO$0.00-$8.95 (Tier 2)

cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 500 mg

MO$0.00-$8.95 (Tier 2)

CEFAZOLIN SODIUM INJECTION SOLUTION RECONSTITUTED 100 GM, 300 GM

MO$0.00-$8.95 (Tier 2)

cefazolin sodium intravenous solution reconstituted

MO$0.00-$8.95 (Tier 2)

CEFAZOLIN SODIUM-DEXTROSE INTRAVENOUS SOLUTION 1-4 GM/50ML-%

MO$0.00-$8.95 (Tier 2)

CEFAZOLIN SODIUM-DEXTROSE INTRAVENOUS SOLUTION RECONSTITUTED 1-4 GM-%(50ML)

MO$0.00-$8.95 (Tier 2)

cefdinir

MO$0.00-$8.95 (Tier 2)

cefepime hcl injection

MO$0.00-$8.95 (Tier 2)

cefoxitin sodium

MO$0.00-$8.95 (Tier 2)

CEFOXITIN SODIUM-DEXTROSE INTRAVENOUS SOLUTION RECONSTITUTED 1-4 GM-%(50ML), 2-2.2 GM-%(50ML)

MO$0.00-$8.95 (Tier 2)

cefpodoxime proxetil

MO$0.00-$8.95 (Tier 2)

cefprozil

MO$0.00-$8.95 (Tier 2)

ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm

MO$0.00-$8.95 (Tier 2)

ceftriaxone sodium in dextrose



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg

MO$0.00-$8.95 (Tier 2)

CEFTRIAXONE SODIUM INJECTION SOLUTION RECONSTITUTED 100 GM

MO$0.00-$8.95 (Tier 2)

ceftriaxone sodium intravenous

MO$0.00-$8.95 (Tier 2)

CEFTRIAXONE SODIUM-DEXTROSE INTRAVENOUS SOLUTION RECONSTITUTED 1-3.74 GM-%(50ML), 2- 2.22 GM-%(50ML)

MO$0.00-$8.95 (Tier 2)

cefuroxime axetil oral tablet

MO$0.00-$8.95 (Tier 2)

cefuroxime sodium injection solution reconstituted 7.5 gm, 750 mg

MO$0.00-$8.95 (Tier 2)

cefuroxime sodium intravenous solution reconstituted 1.5 gm

MO$0.00-$8.95 (Tier 2)

cephalexin oral capsule 250 mg, 500 mg

MO$0.00-$8.95 (Tier 2)

cephalexin oral suspension reconstituted

MO$0.00-$8.95 (Tier 2)

chloramphenicol sod succinate

MO$0.00-$8.95 (Tier 2)

ciprofloxacin hcl ophthalmic

MO$0.00-$8.95 (Tier 2)

ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg

MO$0.00-$8.95 (Tier 2)

ciprofloxacin in d5w intravenous solution 200 mg/100ml

MO$0.00-$8.95 (Tier 2)

clarithromycin er

MO$0.00-$8.95 (Tier 2)

clarithromycin oral

MO$0.00-$8.95 (Tier 2)

clindacin-p

MO$0.00-$8.95 (Tier 2)

clindamycin hcl oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

clindamycin phosphate external

MO$0.00-$8.95 (Tier 2)

clindamycin phosphate injection solution 300 mg/2ml, 600 mg/4ml, 9 gm/60ml, 9000 mg/60ml

MO$0.00-$8.95 (Tier 2)

clindamycin phosphate intravenous solution 300 mg/2ml, 600 mg/4ml, 900 mg/6ml

MO$0.00-$8.95 (Tier 2)

clindamycin phosphate vaginal

MO$0.00-$8.95 (Tier 2)

colistimethate sodium (cba)

MO$0.00-$8.95 (Tier 2)

colistimethate sodium (cba)

MO; NE$0.00-$8.95 (Tier 2)

DAPTOMYCIN INTRAVENOUS SOLUTION RECONSTITUTED 350 MG

MO; NE$0.00-$8.95 (Tier 2)

daptomycin intravenous solution reconstituted 500 mg

MO$0.00-$8.95 (Tier 2)

demeclocycline hcl oral

MO$0.00-$8.95 (Tier 2)

dicloxacillin sodium

MO$0.00-$8.95 (Tier 2)

doxy 100

$0.00-$8.95 (Tier 2)

doxycycline hyclate intravenous

MO$0.00-$8.95 (Tier 2)

doxycycline hyclate oral capsule

MO$0.00-$8.95 (Tier 2)

doxycycline hyclate oral tablet 100 mg, 20 mg

MO$0.00-$8.95 (Tier 2)

doxycycline monohydrate oral capsule 100 mg, 50 mg, 75 mg

MO$0.00-$8.95 (Tier 2)

doxycycline monohydrate oral tablet 100 mg, 50 mg

MO$0.00-$8.95 (Tier 2)

e.e.s. 400 oral tablet



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

ertapenem sodium

MO$0.00-$8.95 (Tier 2)

ery

MO$0.00-$8.95 (Tier 2)

ery-tab

MO$0.00-$8.95 (Tier 2)

ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG

MO$0.00-$8.95 (Tier 2)

erythrocin stearate oral tablet 250 mg

MO$0.00-$8.95 (Tier 2)

erythromycin base oral tablet delayed release

MO$0.00-$8.95 (Tier 2)

erythromycin ethylsuccinate oral tablet

MO$0.00-$8.95 (Tier 2)

erythromycin external

MO$0.00-$8.95 (Tier 2)

erythromycin ophthalmic

MO$0.00-$8.95 (Tier 2)

erythromycin stearate oral tablet 250 mg

MO$0.00-$8.95 (Tier 2)

gentak ophthalmic ointment

MO$0.00-$8.95 (Tier 2)

gentamicin sulfate external

MO$0.00-$8.95 (Tier 2)

gentamicin sulfate injection

MO$0.00-$8.95 (Tier 2)

gentamicin sulfate ophthalmic solution

MO$0 (Tier 1)GLOBAL ALCOHOL PREP EASE[*]$0 (Tier 4)hm triple antibiotic ointment 3.5-400-5000

externalMO$0.00-$8.95 (Tier

2)imipenem-cilastatin



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

levofloxacin in d5w

MO$0.00-$8.95 (Tier 2)

levofloxacin intravenous

MO$0.00-$8.95 (Tier 2)

levofloxacin oral tablet

MO$0.00-$8.95 (Tier 2)

linezolid in sodium chloride

MO$0.00-$8.95 (Tier 2)

linezolid intravenous solution 600 mg/300ml


$0.00-$8.95 (Tier 2)

linezolid oral suspension reconstituted


linezolid oral tablet

MO$0.00-$8.95 (Tier 2)

meropenem

MO$0.00-$8.95 (Tier 2)

methenamine hippurate

MO$0.00-$8.95 (Tier 2)

metronidazole external cream

MO$0.00-$8.95 (Tier 2)

metronidazole external gel 0.75 %

MO$0.00-$8.95 (Tier 2)

metronidazole external lotion

MO$0.00-$8.95 (Tier 2)

metronidazole in nacl intravenous solution 5- 0.79 mg/ml-%, 500-0.79 mg/100ml-%

MO$0.00-$8.95 (Tier 2)

METRONIDAZOLE IN NACL INTRAVENOUS SOLUTION 500-0.74 MG/100ML-%

MO$0.00-$8.95 (Tier 2)

METRONIDAZOLE INTRAVENOUS

MO$0.00-$8.95 (Tier 2)

metronidazole oral

MO$0.00-$8.95 (Tier 2)

metronidazole vaginal



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

minocycline hcl oral

MO$0.00-$8.95 (Tier 2)

mondoxyne nl oral capsule 100 mg, 75 mg

MO$0.00-$8.95 (Tier 2)

MONUROL

MO$0.00-$8.95 (Tier 2)

morgidox oral

MO$0.00-$8.95 (Tier 2)

moxifloxacin hcl ophthalmic

MO$0.00-$8.95 (Tier 2)

moxifloxacin hcl oral

MO$0.00-$8.95 (Tier 2)

mupirocin calcium

MO$0.00-$8.95 (Tier 2)

mupirocin external

MO$0.00-$8.95 (Tier 2)

nafcillin sodium injection solution reconstituted 1 gm, 2 gm

MO; NE$0.00-$8.95 (Tier 2)

NAFCILLIN SODIUM INJECTION SOLUTION RECONSTITUTED 10 GM

MO; NE$0.00-$8.95 (Tier 2)

nafcillin sodium intravenous solution reconstituted 10 gm

MO$0.00-$8.95 (Tier 2)

nafcillin sodium intravenous solution reconstituted 2 gm

MO$0.00-$8.95 (Tier 2)

neomycin sulfate oral

MO$0.00-$8.95 (Tier 2)

nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg

MO$0.00-$8.95 (Tier 2)

nitrofurantoin monohyd macro

MO$0.00-$8.95 (Tier 2)

ofloxacin ophthalmic

MO$0.00-$8.95 (Tier 2)

ofloxacin oral tablet 400 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

ofloxacin otic

MO$0.00-$8.95 (Tier 2)

okebo oral capsule 75 mg

MO$0.00-$8.95 (Tier 2)

oxacillin sodium

MO$0.00-$8.95 (Tier 2)

paromomycin sulfate oral

MO$0.00-$8.95 (Tier 2)

PENICILLIN G POT IN DEXTROSE

MO$0.00-$8.95 (Tier 2)

penicillin g potassium

MO$0.00-$8.95 (Tier 2)

PENICILLIN G PROCAINE

MO$0.00-$8.95 (Tier 2)

penicillin g sodium

MO$0.00-$8.95 (Tier 2)

penicillin v potassium

MO$0.00-$8.95 (Tier 2)

pfizerpen

MO$0.00-$8.95 (Tier 2)

piperacillin sod-tazobactam so intravenous solution reconstituted 2.25 (2-0.25) gm, 3.375 (3-0.375) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm

MO$0.00-$8.95 (Tier 2)

silver sulfadiazine external

[*]$0 (Tier 4)sm double antibiotic ointment 500-10000 unit/ gm external

[*]$0 (Tier 4)sm triple antibiotic ointment 3.5-400-5000 external

MO$0.00-$8.95 (Tier 2)

ssd

MO; NE$0.00-$8.95 (Tier 2)

streptomycin sulfate intramuscular

MO$0.00-$8.95 (Tier 2)

sulfacetamide sodium (acne)



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

sulfacetamide sodium ophthalmic solution

MO$0.00-$8.95 (Tier 2)

SULFADIAZINE ORAL

MO$0.00-$8.95 (Tier 2)

sulfamethoxazole-trimethoprim intravenous

MO$0.00-$8.95 (Tier 2)

sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml

MO$0.00-$8.95 (Tier 2)

sulfamethoxazole-trimethoprim oral tablet

MO$0.00-$8.95 (Tier 2)

SULFAMYLON EXTERNAL CREAM

MO; NE$0.00-$8.95 (Tier 2)

SYNERCID

MO$0.00-$8.95 (Tier 2)

tazicef injection

MO; NE$0.00-$8.95 (Tier 2)

TEFLARO

MO$0.00-$8.95 (Tier 2)

tetracycline hcl oral

MO; NE$0.00-$8.95 (Tier 2)

tigecycline

B/D PAR; NE; QLL (280 per 28 days)$0.00-$8.95 (Tier 2)

tobramycin inhalation

MO$0.00-$8.95 (Tier 2)

tobramycin ophthalmic

MO$0.00-$8.95 (Tier 2)

tobramycin sulfate injection solution

MO; NE$0.00-$8.95 (Tier 2)

tobramycin sulfate injection solution reconstituted

MO$0.00-$8.95 (Tier 2)

trimethoprim oral

[*]$0 (Tier 4)triple antibiotic ointment 3.5-400-5000 external[*]$0 (Tier 4)triple antibiotic ointment 5-400-5000 external



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

VANCOMYCIN HCL IN DEXTROSE INTRAVENOUS SOLUTION 1-5 GM/200ML- %, 500-5 MG/100ML-%, 750-5 MG/150ML-%

MO$0.00-$8.95 (Tier 2)

VANCOMYCIN HCL IN NACL INTRAVENOUS SOLUTION 1-0.9 GM/200ML-%, 500-0.9 MG/ 100ML-%, 750-0.9 MG/150ML-%

MO$0.00-$8.95 (Tier 2)

vancomycin hcl intravenous solution reconstituted 1 gm, 10 gm, 5 gm, 500 mg

MO$0.00-$8.95 (Tier 2)

VANCOMYCIN HCL INTRAVENOUS SOLUTION RECONSTITUTED 1.25 GM, 1.5 GM, 250 MG

B/D PAR; MO$0.00-$8.95 (Tier 2)

vancomycin hcl intravenous solution reconstituted 750 mg


vancomycin hcl oral capsule 125 mg


vancomycin hcl oral capsule 250 mg

MO$0.00-$8.95 (Tier 2)

vandazole

ANTICONVULSANTS

ST; MO; NE$0.00-$8.95 (Tier 2)

APTIOM


$0.00-$8.95 (Tier 2)

BANZEL ORAL SUSPENSION


BANZEL ORAL TABLET 200 MG


BANZEL ORAL TABLET 400 MG

PAR; MO$0.00-$8.95 (Tier 2)

BRIVIACT INTRAVENOUS


BRIVIACT ORAL SOLUTION


BRIVIACT ORAL TABLET 10 MG


BRIVIACT ORAL TABLET 100 MG, 75 MG



Giá Thuốc

(Theo Bậc)

Tên Thuốc





MO$0.00-$8.95 (Tier 2)

carbamazepine er oral tablet extended release 12 hour

MO$0.00-$8.95 (Tier 2)

carbamazepine oral

MO$0.00-$8.95 (Tier 2)

CELONTIN


clobazam oral suspension


clobazam oral tablet 10 mg


clobazam oral tablet 20 mg


clonazepam oral tablet 0.5 mg


clonazepam oral tablet 1 mg




clonazepam oral tablet dispersible 0.125 mg






clonazepam oral tablet dispersible 1 mg



MO$0.00-$8.95 (Tier 2)

clorazepate dipotassium



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

DIASTAT ACUDIAL RECTAL GEL 10 MG

MO$0.00-$8.95 (Tier 2)


MO; NE$0.00-$8.95 (Tier 2)


MO; NE$0.00-$8.95 (Tier 2)


MO$0.00-$8.95 (Tier 2)

DIASTAT PEDIATRIC

MO$0.00-$8.95 (Tier 2)

DIASTAT PEDIATRIC


diazepam oral concentrate




diazepam oral solution 5 mg/5ml




diazepam oral tablet 10 mg











MO$0.00-$8.95 (Tier 2)

diazepam rectal



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

DILANTIN INFATABS

MO$0.00-$8.95 (Tier 2)

DILANTIN ORAL CAPSULE

MO$0.00-$8.95 (Tier 2)

divalproex sodium er oral tablet extended release 24 hour

MO$0.00-$8.95 (Tier 2)

divalproex sodium oral capsule delayed release sprinkle

MO$0.00-$8.95 (Tier 2)

divalproex sodium oral tablet delayed release

PAR; LA; NE$0.00-$8.95 (Tier 2)

EPIDIOLEX

MO$0.00-$8.95 (Tier 2)

epitol

MO$0.00-$8.95 (Tier 2)

ethosuximide oral

MO$0.00-$8.95 (Tier 2)

felbamate

MO$0.00-$8.95 (Tier 2)

fosphenytoin sodium


FYCOMPA ORAL SUSPENSION


FYCOMPA ORAL TABLET 10 MG, 12 MG


FYCOMPA ORAL TABLET 2 MG







MO; QLL (1080 per 30 days)$0 (Tier 1)gabapentin oral capsule 100 mgMO; QLL (360 per 30 days)$0 (Tier 1)gabapentin oral capsule 300 mgMO; QLL (270 per 30 days)$0 (Tier 1)gabapentin oral capsule 400 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc


gabapentin oral solution

MO; QLL (180 per 30 days)$0 (Tier 1)gabapentin oral tablet 600 mgMO; QLL (120 per 30 days)$0 (Tier 1)gabapentin oral tablet 800 mgMO$0.00-$8.95 (Tier

2)lamotrigine oral tablet

MO$0.00-$8.95 (Tier 2)

lamotrigine oral tablet chewable


levetiracetam er oral tablet extended release 24 hour 500 mg


levetiracetam er oral tablet extended release 24 hour 750 mg

MO$0.00-$8.95 (Tier 2)

LEVETIRACETAM IN NACL INTRAVENOUS SOLUTION 1000 MG/100ML, 1500 MG/100ML

MO; NE$0.00-$8.95 (Tier 2)

LEVETIRACETAM IN NACL INTRAVENOUS SOLUTION 500 MG/100ML

MO$0.00-$8.95 (Tier 2)

levetiracetam intravenous

MO$0.00-$8.95 (Tier 2)

levetiracetam oral


lorazepam oral concentrate


lorazepam oral tablet 0.5 mg, 1 mg


lorazepam oral tablet 2 mg

MO$0.00-$8.95 (Tier 2)

oxcarbazepine

MO$0.00-$8.95 (Tier 2)

PEGANONE


phenobarbital oral elixir


phenobarbital oral tablet 100 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc




phenobarbital oral tablet 16.2 mg











MO$0.00-$8.95 (Tier 2)

PHENYTEK

MO$0.00-$8.95 (Tier 2)

phenytoin oral suspension 125 mg/5ml

MO$0.00-$8.95 (Tier 2)

phenytoin oral tablet chewable

MO$0.00-$8.95 (Tier 2)

phenytoin sodium extended

MO$0.00-$8.95 (Tier 2)

phenytoin sodium injection


pregabalin oral capsule 100 mg






pregabalin oral capsule 225 mg, 300 mg





Giá Thuốc

(Theo Bậc)

Tên Thuốc






pregabalin oral solution

MO$0.00-$8.95 (Tier 2)

primidone oral

MO$0.00-$8.95 (Tier 2)

roweepra


roweepra xr oral tablet extended release 24 hour 500 mg


roweepra xr oral tablet extended release 24 hour 750 mg

PAR; LA; QLL (180 per 30 days)$0.00-$8.95 (Tier 2)

SABRIL ORAL PACKET


SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG, 250 MG, 500 MG


SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 750 MG

MO$0.00-$8.95 (Tier 2)

subvenite


SYMPAZAN ORAL FILM 10 MG, 20 MG


SYMPAZAN ORAL FILM 5 MG

MO$0.00-$8.95 (Tier 2)

tiagabine hcl

MO$0.00-$8.95 (Tier 2)

topiramate oral capsule sprinkle


topiramate oral tablet 100 mg





Giá Thuốc

(Theo Bậc)

Tên Thuốc





MO$0.00-$8.95 (Tier 2)

valproate sodium intravenous

MO$0.00-$8.95 (Tier 2)

valproic acid oral capsule

MO$0.00-$8.95 (Tier 2)

valproic acid oral solution

PAR; LA; NE; QLL (180 per 30 days)$0.00-$8.95 (Tier 2)

vigabatrin


vigadrone


VIMPAT INTRAVENOUS


VIMPAT ORAL SOLUTION


VIMPAT ORAL TABLET 100 MG


VIMPAT ORAL TABLET 150 MG, 200 MG


VIMPAT ORAL TABLET 50 MG

MO$0.00-$8.95 (Tier 2)

zonisamide oral

ANTIDEMENTIA AGENTS


donepezil hcl oral tablet 10 mg, 5 mg


donepezil hcl oral tablet dispersible

PAR; MO$0.00-$8.95 (Tier 2)

ergoloid mesylates oral


memantine hcl er



Giá Thuốc

(Theo Bậc)

Tên Thuốc


memantine hcl oral solution 2 mg/ml


memantine hcl oral tablet 10 mg


memantine hcl oral tablet 5 mg

PAR; MO$0.00-$8.95 (Tier 2)

NAMZARIC


rivastigmine


rivastigmine tartrate

ANTIDEPRESSANTS


ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE


ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER

PAR; MO$0.00-$8.95 (Tier 2)

amitriptyline hcl oral

PAR; MO$0.00-$8.95 (Tier 2)

amoxapine

MO; QLL (900 per 30 days)$0 (Tier 1)aripiprazole oral solutionMO; QLL (90 per 30 days)$0 (Tier 1)aripiprazole oral tablet 10 mgMO; QLL (60 per 30 days)$0 (Tier 1)aripiprazole oral tablet 15 mgMO; QLL (450 per 30 days)$0 (Tier 1)aripiprazole oral tablet 2 mgMO; NE; QLL (30 per 30 days)$0 (Tier 1)aripiprazole oral tablet 20 mg, 30 mgMO; QLL (180 per 30 days)$0 (Tier 1)aripiprazole oral tablet 5 mgMO; NE; QLL (90 per 30 days)$0 (Tier 1)aripiprazole oral tablet dispersible 10 mgMO; NE; QLL (60 per 30 days)$0 (Tier 1)aripiprazole oral tablet dispersible 15 mgMO; QLL (120 per 30 days)$0.00-$8.95 (Tier

2)bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg


bupropion hcl er (sr) oral tablet extended release 12 hour 150 mg, 200 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc


bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg


bupropion hcl er (xl) oral tablet extended release 24 hour 300 mg


bupropion hcl oral tablet 100 mg


bupropion hcl oral tablet 75 mg


citalopram hydrobromide oral solution


citalopram hydrobromide oral tablet 10 mg





PAR; MO$0.00-$8.95 (Tier 2)

clomipramine hcl oral

PAR; MO$0.00-$8.95 (Tier 2)

desipramine hcl oral


DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG


DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 50 MG


desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg





PAR; MO$0.00-$8.95 (Tier 2)

doxepin hcl oral


duloxetine hcl oral capsule delayed release particles 20 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc








EMSAM


escitalopram oxalate oral solution


escitalopram oxalate oral tablet 10 mg






FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG


FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG


FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 40 MG


FETZIMA TITRATION


fluoxetine hcl oral capsule 10 mg






fluoxetine hcl oral solution


fluvoxamine maleate oral tablet 100 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc





PAR; NE; QLL (30 per 30 days)$0.00-$8.95 (Tier 2)

GILENYA ORAL CAPSULE 0.25 MG

PAR; MO$0.00-$8.95 (Tier 2)

imipramine hcl oral

ST; MO; QLL (120 per 30 days)$0.00-$8.95 (Tier 2)

KHEDEZLA ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG


KHEDEZLA ORAL TABLET EXTENDED RELEASE 24 HOUR 50 MG


maprotiline hcl oral tablet 25 mg



MO$0.00-$8.95 (Tier 2)


MO$0.00-$8.95 (Tier 2)

MARPLAN


mirtazapine oral tablet 15 mg






mirtazapine oral tablet 7.5 mg


mirtazapine oral tablet dispersible 15 mg







Giá Thuốc

(Theo Bậc)

Tên Thuốc


nefazodone hcl oral tablet 100 mg









PAR; MO$0.00-$8.95 (Tier 2)

nortriptyline hcl oral


paroxetine hcl oral tablet 10 mg








PAXIL ORAL SUSPENSION

MO$0.00-$8.95 (Tier 2)

phenelzine sulfate oral

PAR; MO$0.00-$8.95 (Tier 2)

protriptyline hcl


quetiapine fumarate er oral tablet extended release 24 hour 150 mg









Giá Thuốc

(Theo Bậc)

Tên Thuốc



PAR; MO; QLL (240 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 100 mgPAR; MO; QLL (120 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 200 mgPAR; MO; QLL (960 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 25 mgPAR; MO; QLL (80 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 300 mgPAR; MO; QLL (60 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 400 mgPAR; MO; QLL (480 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 50 mgMO; QLL (300 per 30 days)$0.00-$8.95 (Tier

2)sertraline hcl oral concentrate


sertraline hcl oral tablet 100 mg






SPRAVATO (56 MG DOSE)


SPRAVATO (84 MG DOSE)

MO$0.00-$8.95 (Tier 2)

tranylcypromine sulfate

MO$0.00-$8.95 (Tier 2)

trazodone hcl oral

MO$0.00-$8.95 (Tier 2)

trimipramine maleate oral


TRINTELLIX ORAL TABLET 10 MG






venlafaxine hcl er oral capsule extended release 24 hour 150 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc


venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg




venlafaxine hcl er oral tablet extended release 24 hour 150 mg


venlafaxine hcl er oral tablet extended release 24 hour 37.5 mg




venlafaxine hcl oral tablet 100 mg




venlafaxine hcl oral tablet 37.5 mg






VIIBRYD ORAL TABLET 10 MG





ANTIEMETICS

B/D PAR; MO; QLL (5 per 30 days)$0.00-$8.95 (Tier 2)

aprepitant oral capsule 125 mg





MO$0.00-$8.95 (Tier 2)

chlorpromazine hcl oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

compro

B/D PAR; MO; NE; QLL (120 per 30 days)

$0.00-$8.95 (Tier 2)

dronabinol oral capsule 10 mg


dronabinol oral capsule 2.5 mg, 5 mg

[*]$0 (Tier 4)gnp motion sickness relief tablet 25 mg oral[*]$0 (Tier 4)hm motion relief tablet 25 mg oralPAR; MO$0.00-$8.95 (Tier

2)hydroxyzine hcl oral tablet

PAR; MO$0.00-$8.95 (Tier 2)

hydroxyzine pamoate oral capsule 25 mg, 50 mg

MO$0.00-$8.95 (Tier 2)

meclizine hcl oral tablet

[*]$0 (Tier 4)meclizine hcl tablet chewable 25 mg oral (otc)MO$0.00-$8.95 (Tier

2)metoclopramide hcl oral solution 5 mg/5ml

MO$0.00-$8.95 (Tier 2)

metoclopramide hcl oral tablet

[*]$0 (Tier 4)motion-time tablet chewable 25 mg oralB/D PAR; MO; QLL (90 per 30 days)$0.00-$8.95 (Tier

2)ondansetron

MO$0.00-$8.95 (Tier 2)

ondansetron hcl injection


ondansetron hcl oral tablet 24 mg


ondansetron hcl oral tablet 4 mg, 8 mg

MO$0 (Tier 1)perphenazine oralMO$0.00-$8.95 (Tier

2)prochlorperazine

MO$0.00-$8.95 (Tier 2)

prochlorperazine maleate oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; MO$0.00-$8.95 (Tier 2)

promethazine hcl oral tablet


scopolamine

[*]$0 (Tier 4)sm motion sickness tablet 25 mg oralMO; QLL (10 per 28 days)$0.00-$8.95 (Tier

2)TRANSDERM SCOP (1.5 MG)

[*]$0 (Tier 4)travel sickness tablet chewable 25 mg oral

ANTIFUNGALS

B/D PAR; MO; NE$0.00-$8.95 (Tier 2)

ABELCET

B/D PAR; MO$0.00-$8.95 (Tier 2)

AMBISOME

B/D PAR; MO$0.00-$8.95 (Tier 2)

amphotericin b intravenous

[*]$0 (Tier 4)antifungal cream 1 % external[*]$0 (Tier 4)athletes foot af cream 1 % external[*]$0 (Tier 4)athletes foot spray aerosol 1 % external[*]$0 (Tier 4)carrington antifungal cream 2 % externalMO$0.00-$8.95 (Tier

2)ciclopirox

MO$0.00-$8.95 (Tier 2)

ciclopirox olamine external

[*]$0 (Tier 4)clotrimazole anti-fungal cream 1 % external (otc)

[*]$0 (Tier 4)clotrimazole cream 1 % external (otc)[*]$0 (Tier 4)clotrimazole cream 1 % vaginalMO$0.00-$8.95 (Tier

2)clotrimazole external cream

MO$0.00-$8.95 (Tier 2)

clotrimazole external solution

MO$0.00-$8.95 (Tier 2)

clotrimazole mouth/throat lozenge



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)clotrimazole solution 1 % external (otc)PAR; MO; NE$0.00-$8.95 (Tier

2)ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG

MO$0.00-$8.95 (Tier 2)

fluconazole in sodium chloride intravenous solution 200-0.9 mg/100ml-%, 400-0.9 mg/ 200ml-%

MO$0.00-$8.95 (Tier 2)

fluconazole oral

MO$0.00-$8.95 (Tier 2)

flucytosine oral capsule 250 mg

MO; NE$0.00-$8.95 (Tier 2)

flucytosine oral capsule 500 mg

[*]$0 (Tier 4)fungoid-d cream 1 % external[*]$0 (Tier 4)gnp athletes foot cream 1 % external[*]$0 (Tier 4)gnp terbinafine hydrochloride cream 1 %

external[*]$0 (Tier 4)gnp tolnaftate cream 1 % externalMO$0.00-$8.95 (Tier

2)griseofulvin microsize oral suspension

MO$0.00-$8.95 (Tier 2)

griseofulvin ultramicrosize

PAR; MO$0.00-$8.95 (Tier 2)

itraconazole oral capsule

[*]$0 (Tier 4)jock itch spray aerosol powder 1 % externalMO$0.00-$8.95 (Tier

2)ketoconazole external cream

MO$0.00-$8.95 (Tier 2)

ketoconazole external shampoo 2 %

MO$0.00-$8.95 (Tier 2)

ketoconazole oral

[*]$0 (Tier 4)lamisil at cream 1 % external[*]$0 (Tier 4)LOTRIMIN AF CREAM 1 % EXTERNALMO$0.00-$8.95 (Tier

2)miconazole 3 vaginal suppository



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

NATACYN

PAR; MO; NE$0.00-$8.95 (Tier 2)

NOXAFIL ORAL SUSPENSION

MO$0.00-$8.95 (Tier 2)

nyamyc

MO$0.00-$8.95 (Tier 2)

nystatin external

MO$0.00-$8.95 (Tier 2)

nystatin mouth/throat

MO$0.00-$8.95 (Tier 2)

nystatin oral tablet

MO$0.00-$8.95 (Tier 2)

nystop

[*]$0 (Tier 4)qc tolnaftate cream 1 % external[*]$0 (Tier 4)sm antifungal clotrimazole cream 1 % external[*]$0 (Tier 4)sm antifungal miconazole cream 2 % external[*]$0 (Tier 4)sm antifungal tolnaftate cream 1 % external[*]$0 (Tier 4)sm athletes foot cream 1 % external[*]$0 (Tier 4)sm miconazole 3 kit 200 & 2 mg-% (9gm)

vaginal[*]$0 (Tier 4)sm miconazole 7 suppository 100 mg vaginal[*]$0 (Tier 4)soothe & cool inzo antifungal cream 2 %

external[*]$0 (Tier 4)terbinafine hcl cream 1 % externalMO$0.00-$8.95 (Tier

2)terbinafine hcl oral

MO$0.00-$8.95 (Tier 2)

terconazole

[*]$0 (Tier 4)tolnaftate cream 1 % externalMO; NE$0.00-$8.95 (Tier

2)voriconazole intravenous

PAR; MO; NE$0.00-$8.95 (Tier 2)

voriconazole oral suspension reconstituted



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; MO; NE$0.00-$8.95 (Tier 2)

voriconazole oral tablet 200 mg

PAR; MO$0.00-$8.95 (Tier 2)

voriconazole oral tablet 50 mg


ZOLINZA

ANTIGOUT AGENTS

MO$0.00-$8.95 (Tier 2)

allopurinol oral

MO$0 (Tier 1)colchicine oralMO$0.00-$8.95 (Tier

2)colchicine-probenecid

MO$0.00-$8.95 (Tier 2)

COLCRYS

MO$0.00-$8.95 (Tier 2)

febuxostat

MO$0.00-$8.95 (Tier 2)

probenecid oral

ST; MO$0.00-$8.95 (Tier 2)

ULORIC

ANTIMIGRAINE AGENTS


dihydroergotamine mesylate nasal

MO$0.00-$8.95 (Tier 2)


MO$0.00-$8.95 (Tier 2)


MO$0.00-$8.95 (Tier 2)


MO$0.00-$8.95 (Tier 2)

ERGOMAR

MO$0.00-$8.95 (Tier 2)

ergotamine-caffeine



Giá Thuốc

(Theo Bậc)

Tên Thuốc


rizatriptan benzoate

MO$0.00-$8.95 (Tier 2)

sumatriptan nasal


sumatriptan succinate oral

MO$0.00-$8.95 (Tier 2)

sumatriptan succinate subcutaneous solution auto-injector

MO$0 (Tier 1)timolol maleate oralMO$0.00-$8.95 (Tier

2)topiramate oral capsule sprinkle









MO$0.00-$8.95 (Tier 2)


MO$0.00-$8.95 (Tier 2)



zolmitriptan oral

ANTIMYASTHENIC AGENTS

MO$0.00-$8.95 (Tier 2)

GUANIDINE HCL ORAL

MO; NE$0.00-$8.95 (Tier 2)

MESTINON ORAL SYRUP

MO; NE$0.00-$8.95 (Tier 2)

pyridostigmine bromide oral solution

MO$0.00-$8.95 (Tier 2)

pyridostigmine bromide oral tablet 60 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

ANTIMYCOBACTERIALS

MO$0.00-$8.95 (Tier 2)

CAPASTAT SULFATE

MO$0.00-$8.95 (Tier 2)

dapsone oral

MO$0.00-$8.95 (Tier 2)

ethambutol hcl oral

MO$0.00-$8.95 (Tier 2)

isoniazid oral

MO$0.00-$8.95 (Tier 2)

PASER

MO$0.00-$8.95 (Tier 2)

PRIFTIN

MO$0.00-$8.95 (Tier 2)

pyrazinamide oral

MO$0.00-$8.95 (Tier 2)

rifabutin

MO$0.00-$8.95 (Tier 2)

rifampin intravenous

MO$0.00-$8.95 (Tier 2)

rifampin oral

MO$0.00-$8.95 (Tier 2)

RIFATER

PAR; MO; LA; NE$0.00-$8.95 (Tier 2)

SIRTURO

MO$0.00-$8.95 (Tier 2)

TRECATOR

ANTINEOPLASTICS


abiraterone acetate

PAR; NE$0.00-$8.95 (Tier 2)

ABRAXANE

B/D PAR$0.00-$8.95 (Tier 2)

adriamycin intravenous solution



Giá Thuốc

(Theo Bậc)

Tên Thuốc

B/D PAR$0.00-$8.95 (Tier 2)

adriamycin intravenous solution reconstituted 10 mg, 50 mg

B/D PAR$0.00-$8.95 (Tier 2)

adrucil

PAR; NE$0.00-$8.95 (Tier 2)

AFINITOR


ALECENSA

PAR; LA; NE$0.00-$8.95 (Tier 2)

ALIQOPA


ALUNBRIG ORAL TABLET 180 MG






ALUNBRIG ORAL TABLET THERAPY PACK


anastrozole oral

B/D PAR$0.00-$8.95 (Tier 2)

ARRANON

B/D PAR; NE$0.00-$8.95 (Tier 2)

arsenic trioxide intravenous

PAR; NE$0.00-$8.95 (Tier 2)

ARZERRA

PAR; LA; NE$0.00-$8.95 (Tier 2)

AVASTIN


avita

PAR; NE$0.00-$8.95 (Tier 2)

azacitidine


BALVERSA ORAL TABLET 3 MG



Giá Thuốc

(Theo Bậc)

Tên Thuốc





PAR; LA; NE$0.00-$8.95 (Tier 2)

BAVENCIO

PAR; NE$0.00-$8.95 (Tier 2)

BELEODAQ

B/D PAR; NE$0.00-$8.95 (Tier 2)

BENDEKA

B/D PAR; LA; NE$0.00-$8.95 (Tier 2)

BESPONSA


bexarotene


bicalutamide

B/D PAR$0.00-$8.95 (Tier 2)

bleomycin sulfate

PAR; NE$0.00-$8.95 (Tier 2)

BLINCYTO

PAR; NE$0.00-$8.95 (Tier 2)

BORTEZOMIB


BOSULIF ORAL TABLET 100 MG


BOSULIF ORAL TABLET 400 MG, 500 MG


BRAFTOVI ORAL CAPSULE 75 MG

B/D PAR$0.00-$8.95 (Tier 2)

busulfan

B/D PAR$0.00-$8.95 (Tier 2)

BUSULFEX


CABOMETYX



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; LA; NE$0.00-$8.95 (Tier 2)

CALQUENCE


CAPRELSA ORAL TABLET 100 MG


CAPRELSA ORAL TABLET 300 MG

B/D PAR$0.00-$8.95 (Tier 2)

carboplatin intravenous solution

B/D PAR; NE$0.00-$8.95 (Tier 2)

carmustine

B/D PAR$0.00-$8.95 (Tier 2)

cisplatin intravenous solution 100 mg/100ml, 200 mg/200ml, 50 mg/50ml

B/D PAR; NE$0.00-$8.95 (Tier 2)

cladribine intravenous solution 10 mg/10ml

B/D PAR; NE$0.00-$8.95 (Tier 2)

clofarabine

B/D PAR; NE$0.00-$8.95 (Tier 2)

CLOLAR


COMETRIQ (100 MG DAILY DOSE)






COPIKTRA


COTELLIC

B/D PAR$0.00-$8.95 (Tier 2)

cyclophosphamide oral capsule

PAR; LA; NE$0.00-$8.95 (Tier 2)

CYRAMZA

B/D PAR$0.00-$8.95 (Tier 2)

cytarabine (pf)



Giá Thuốc

(Theo Bậc)

Tên Thuốc

B/D PAR$0.00-$8.95 (Tier 2)

cytarabine injection solution

B/D PAR$0.00-$8.95 (Tier 2)

dacarbazine intravenous

B/D PAR; NE$0.00-$8.95 (Tier 2)

dactinomycin

PAR; LA; NE$0.00-$8.95 (Tier 2)

DARZALEX

B/D PAR$0.00-$8.95 (Tier 2)

daunorubicin hcl intravenous solution 20 mg/ 4ml

B/D PAR$0.00-$8.95 (Tier 2)

DAUNORUBICIN HCL INTRAVENOUS SOLUTION 50 MG/10ML


DAURISMO ORAL TABLET 100 MG


DAURISMO ORAL TABLET 25 MG

B/D PAR; NE$0.00-$8.95 (Tier 2)

decitabine

B/D PAR; NE$0.00-$8.95 (Tier 2)

dexrazoxane hcl

B/D PAR; NE$0.00-$8.95 (Tier 2)

DOCETAXEL INTRAVENOUS CONCENTRATE 160 MG/8ML, 20 MG/ML, 200 MG/10ML, 80 MG/4ML

B/D PAR; NE$0.00-$8.95 (Tier 2)

DOCETAXEL INTRAVENOUS SOLUTION 160 MG/16ML, 20 MG/2ML, 80 MG/8ML

B/D PAR; NE$0.00-$8.95 (Tier 2)

doxorubicin hcl intravenous solution

PAR; NE$0.00-$8.95 (Tier 2)

doxorubicin hcl liposomal

MO$0.00-$8.95 (Tier 2)

DROXIA

PAR; NE$0.00-$8.95 (Tier 2)

ELITEK

$0.00-$8.95 (Tier 2)

EMCYT



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; LA; NE$0.00-$8.95 (Tier 2)

EMPLICITI

B/D PAR$0.00-$8.95 (Tier 2)

epirubicin hcl intravenous solution 200 mg/ 100ml, 50 mg/25ml

PAR; NE$0.00-$8.95 (Tier 2)

ERBITUX


ERIVEDGE

PAR; LA; NE$0.00-$8.95 (Tier 2)

ERLEADA


erlotinib hcl oral tablet 100 mg, 150 mg


erlotinib hcl oral tablet 25 mg

PAR; LA; NE$0.00-$8.95 (Tier 2)

ERWINAZE INJECTION

B/D PAR; NE$0.00-$8.95 (Tier 2)

ETOPOPHOS

B/D PAR$0.00-$8.95 (Tier 2)

etoposide intravenous solution 1 gm/50ml, 100 mg/5ml, 500 mg/25ml

B/D PAR; NE$0.00-$8.95 (Tier 2)

EVOMELA


exemestane


FARYDAK ORAL CAPSULE 10 MG


FARYDAK ORAL CAPSULE 15 MG, 20 MG

PAR; NE$0.00-$8.95 (Tier 2)

FASLODEX INTRAMUSCULAR SOLUTION 250 MG/5ML

B/D PAR; NE$0.00-$8.95 (Tier 2)

fludarabine phosphate intravenous solution

B/D PAR$0.00-$8.95 (Tier 2)

fludarabine phosphate intravenous solution reconstituted



Giá Thuốc

(Theo Bậc)

Tên Thuốc

B/D PAR$0.00-$8.95 (Tier 2)

fluorouracil intravenous

MO$0.00-$8.95 (Tier 2)

flutamide

B/D PAR; NE$0.00-$8.95 (Tier 2)

FOLOTYN

PAR; NE$0.00-$8.95 (Tier 2)

fulvestrant

PAR; LA; NE$0.00-$8.95 (Tier 2)

GAZYVA

B/D PAR; NE$0.00-$8.95 (Tier 2)

GEMCITABINE HCL INTRAVENOUS SOLUTION 1 GM/10ML, 2 GM/20ML

B/D PAR; NE$0.00-$8.95 (Tier 2)

gemcitabine hcl intravenous solution 1 gm/ 26.3ml, 2 gm/52.6ml, 200 mg/2ml, 200 mg/ 5.26ml

B/D PAR$0.00-$8.95 (Tier 2)

gemcitabine hcl intravenous solution reconstituted 1 gm, 200 mg

B/D PAR; NE$0.00-$8.95 (Tier 2)

gemcitabine hcl intravenous solution reconstituted 2 gm


GILOTRIF

PAR; MO$0.00-$8.95 (Tier 2)

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG

PAR; NE$0.00-$8.95 (Tier 2)

HALAVEN

B/D PAR; NE$0.00-$8.95 (Tier 2)

HERCEPTIN HYLECTA

B/D PAR; NE$0.00-$8.95 (Tier 2)

HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 150 MG


hydroxyprogesterone caproate intramuscular solution

MO$0.00-$8.95 (Tier 2)

hydroxyurea oral


IBRANCE



Giá Thuốc

(Theo Bậc)

Tên Thuốc


ICLUSIG ORAL TABLET 15 MG


ICLUSIG ORAL TABLET 45 MG

B/D PAR; NE$0.00-$8.95 (Tier 2)

idarubicin hcl


IDHIFA ORAL TABLET 100 MG


IDHIFA ORAL TABLET 50 MG

B/D PAR$0.00-$8.95 (Tier 2)

IFEX INTRAVENOUS SOLUTION RECONSTITUTED 3 GM

B/D PAR$0.00-$8.95 (Tier 2)

ifosfamide intravenous solution

B/D PAR$0.00-$8.95 (Tier 2)

ifosfamide intravenous solution reconstituted 1 gm

B/D PAR$0.00-$8.95 (Tier 2)

IFOSFAMIDE INTRAVENOUS SOLUTION RECONSTITUTED 3 GM


imatinib mesylate oral tablet 100 mg


imatinib mesylate oral tablet 400 mg


IMBRUVICA ORAL CAPSULE 140 MG


IMBRUVICA ORAL CAPSULE 70 MG


IMBRUVICA ORAL TABLET 140 MG


IMBRUVICA ORAL TABLET 280 MG, 420 MG, 560 MG

PAR; LA; NE$0.00-$8.95 (Tier 2)

IMFINZI


INLYTA ORAL TABLET 1 MG



Giá Thuốc

(Theo Bậc)

Tên Thuốc


INLYTA ORAL TABLET 5 MG


INREBIC

LA; NE$0.00-$8.95 (Tier 2)

IRESSA

B/D PAR$0.00-$8.95 (Tier 2)

irinotecan hcl intravenous solution 100 mg/5ml, 500 mg/25ml

B/D PAR; NE$0.00-$8.95 (Tier 2)

irinotecan hcl intravenous solution 40 mg/2ml

PAR; NE$0.00-$8.95 (Tier 2)

ISTODAX (OVERFILL)

PAR; NE$0.00-$8.95 (Tier 2)

IXEMPRA KIT


JAKAFI ORAL TABLET 10 MG









PAR; NE$0.00-$8.95 (Tier 2)

JEVTANA

PAR; NE$0.00-$8.95 (Tier 2)

KADCYLA

MO$0.00-$8.95 (Tier 2)

KEPIVANCE

PAR; NE$0.00-$8.95 (Tier 2)

KHAPZORY


KISQALI (200 MG DOSE)



Giá Thuốc

(Theo Bậc)

Tên Thuốc






KISQALI FEMARA (400 MG DOSE)


KISQALI FEMARA (600 MG DOSE)


KISQALI FEMARA(200 MG DOSE)

PAR; LA; NE$0.00-$8.95 (Tier 2)

KYPROLIS

PAR; LA; NE$0.00-$8.95 (Tier 2)

LARTRUVO


LENVIMA (10 MG DAILY DOSE)
















letrozole oral

MO$0.00-$8.95 (Tier 2)

leucovorin calcium injection solution 100 mg/ 10ml



Giá Thuốc

(Theo Bậc)

Tên Thuốc

B/D PAR; MO$0.00-$8.95 (Tier 2)

leucovorin calcium injection solution reconstituted

MO$0.00-$8.95 (Tier 2)

leucovorin calcium oral

MO$0.00-$8.95 (Tier 2)

leucovorin calcium oral

MO$0.00-$8.95 (Tier 2)

LEUKERAN

PAR; NE$0.00-$8.95 (Tier 2)

levoleucovorin calcium intravenous solution reconstituted 50 mg

PAR; LA; NE$0.00-$8.95 (Tier 2)

LIBTAYO

PAR; NE$0.00-$8.95 (Tier 2)

LONSURF


LORBRENA ORAL TABLET 100 MG


LORBRENA ORAL TABLET 25 MG

PAR; LA; NE$0.00-$8.95 (Tier 2)

LUMOXITI


LYNPARZA ORAL TABLET

NE$0.00-$8.95 (Tier 2)

MARQIBO

LA; NE$0.00-$8.95 (Tier 2)

MATULANE


MEKINIST ORAL TABLET 0.5 MG


MEKINIST ORAL TABLET 2 MG


MEKTOVI

B/D PAR$0.00-$8.95 (Tier 2)

melphalan hcl



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

mesna

MO; NE$0.00-$8.95 (Tier 2)

MESNEX ORAL

MO$0.00-$8.95 (Tier 2)

methotrexate sodium (pf) injection solution 1 gm/40ml, 250 mg/10ml

MO$0.00-$8.95 (Tier 2)

methotrexate sodium injection solution 250 mg/ 10ml

MO$0.00-$8.95 (Tier 2)

methotrexate sodium injection solution reconstituted

B/D PAR$0.00-$8.95 (Tier 2)

mitomycin intravenous solution reconstituted 20 mg, 5 mg

B/D PAR; NE$0.00-$8.95 (Tier 2)

mitomycin intravenous solution reconstituted 40 mg

B/D PAR$0.00-$8.95 (Tier 2)

mitoxantrone hcl

B/D PAR$0.00-$8.95 (Tier 2)

mutamycin intravenous solution reconstituted 20 mg, 5 mg

B/D PAR; NE$0.00-$8.95 (Tier 2)

mutamycin intravenous solution reconstituted 40 mg

PAR; LA; NE$0.00-$8.95 (Tier 2)

MYLOTARG INTRAVENOUS SOLUTION RECONSTITUTED 4.5 MG


NERLYNX


NEXAVAR


nilutamide


NINLARO

B/D PAR; NE$0.00-$8.95 (Tier 2)

NIPENT


NUBEQA



Giá Thuốc

(Theo Bậc)

Tên Thuốc


ODOMZO


OFEV

PAR; LA; NE$0.00-$8.95 (Tier 2)

OPDIVO

B/D PAR$0.00-$8.95 (Tier 2)

oxaliplatin intravenous solution

B/D PAR; NE$0.00-$8.95 (Tier 2)

oxaliplatin intravenous solution reconstituted

B/D PAR$0.00-$8.95 (Tier 2)

paclitaxel intravenous concentrate 100 mg/ 16.7ml, 150 mg/25ml, 30 mg/5ml

NE$0.00-$8.95 (Tier 2)

PANRETIN

PAR; NE$0.00-$8.95 (Tier 2)

PERJETA


PIQRAY (200 MG DAILY DOSE)





B/D PAR; NE$0.00-$8.95 (Tier 2)

POLIVY


POMALYST ORAL CAPSULE 1 MG


POMALYST ORAL CAPSULE 2 MG


POMALYST ORAL CAPSULE 3 MG, 4 MG

LA; NE$0.00-$8.95 (Tier 2)

PORTRAZZA

B/D PAR; LA; NE$0.00-$8.95 (Tier 2)

POTELIGEO



Giá Thuốc

(Theo Bậc)

Tên Thuốc

B/D PAR; NE$0.00-$8.95 (Tier 2)

PROLEUKIN

PAR; NE$0.00-$8.95 (Tier 2)

PURIXAN


REVLIMID ORAL CAPSULE 10 MG


REVLIMID ORAL CAPSULE 15 MG, 25 MG


REVLIMID ORAL CAPSULE 2.5 MG, 20 MG


REVLIMID ORAL CAPSULE 5 MG

B/D PAR; MO; LA; NE$0.00-$8.95 (Tier 2)

RITUXAN HYCELA

B/D PAR; LA; NE$0.00-$8.95 (Tier 2)

RITUXAN INTRAVENOUS SOLUTION

PAR; NE$0.00-$8.95 (Tier 2)

romidepsin


RUBRACA ORAL TABLET 200 MG


RUBRACA ORAL TABLET 250 MG, 300 MG


RYDAPT

MO; NE$0.00-$8.95 (Tier 2)

SOLTAMOX


SPRYCEL


STIVARGA


SUTENT ORAL CAPSULE 12.5 MG


SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50 MG



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; NE$0.00-$8.95 (Tier 2)

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG

PAR; NE$0.00-$8.95 (Tier 2)

SYNRIBO

MO$0.00-$8.95 (Tier 2)

TABLOID


TAFINLAR


TAGRISSO ORAL TABLET 40 MG


TAGRISSO ORAL TABLET 80 MG


TALZENNA ORAL CAPSULE 0.25 MG


TALZENNA ORAL CAPSULE 1 MG

MO$0.00-$8.95 (Tier 2)

tamoxifen citrate oral


TARGRETIN EXTERNAL


TASIGNA

B/D PAR; NE$0.00-$8.95 (Tier 2)

TAXOTERE INTRAVENOUS CONCENTRATE 20 MG/ML, 80 MG/4ML


TECENTRIQ INTRAVENOUS SOLUTION 1200 MG/20ML


TECENTRIQ INTRAVENOUS SOLUTION 840 MG/14ML

PAR; NE$0.00-$8.95 (Tier 2)

temsirolimus


THALOMID ORAL CAPSULE 100 MG, 50 MG


THALOMID ORAL CAPSULE 150 MG, 200 MG



Giá Thuốc

(Theo Bậc)

Tên Thuốc

B/D PAR$0.00-$8.95 (Tier 2)

thiotepa injection


TIBSOVO

B/D PAR$0.00-$8.95 (Tier 2)

TICE BCG

B/D PAR$0.00-$8.95 (Tier 2)

toposar intravenous solution 1 gm/50ml, 100 mg/5ml

B/D PAR; NE$0.00-$8.95 (Tier 2)

TOPOTECAN HCL INTRAVENOUS SOLUTION

B/D PAR; NE$0.00-$8.95 (Tier 2)

topotecan hcl intravenous solution reconstituted

NE; QLL (30 per 30 days)$0.00-$8.95 (Tier 2)

toremifene citrate

B/D PAR; NE$0.00-$8.95 (Tier 2)

TREANDA INTRAVENOUS SOLUTION RECONSTITUTED


tretinoin external cream


tretinoin external gel 0.01 %, 0.025 %

MO; NE$0.00-$8.95 (Tier 2)

tretinoin oral

B/D PAR; NE$0.00-$8.95 (Tier 2)

TRISENOX INTRAVENOUS SOLUTION 12 MG/6ML


TURALIO


TYKERB

PAR; LA; NE$0.00-$8.95 (Tier 2)

VALCHLOR

PAR; NE$0.00-$8.95 (Tier 2)

VECTIBIX INTRAVENOUS SOLUTION 100 MG/5ML, 400 MG/20ML

PAR; NE$0.00-$8.95 (Tier 2)

VELCADE INJECTION



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; LA; QLL (60 per 30 days)$0.00-$8.95 (Tier 2)

VENCLEXTA ORAL TABLET 10 MG






VENCLEXTA STARTING PACK


VERZENIO

B/D PAR$0.00-$8.95 (Tier 2)

vinblastine sulfate intravenous solution

B/D PAR$0.00-$8.95 (Tier 2)

vincristine sulfate intravenous

B/D PAR$0.00-$8.95 (Tier 2)

vinorelbine tartrate


VITRAKVI ORAL CAPSULE 100 MG


VITRAKVI ORAL CAPSULE 25 MG


VITRAKVI ORAL SOLUTION


VIZIMPRO ORAL TABLET 15 MG


VIZIMPRO ORAL TABLET 30 MG, 45 MG


VOTRIENT

B/D PAR; NE$0.00-$8.95 (Tier 2)

VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED 44-100 MG


XALKORI


XOSPATA



Giá Thuốc

(Theo Bậc)

Tên Thuốc


XPOVIO (100 MG ONCE WEEKLY)






XPOVIO (80 MG TWICE WEEKLY)


XTANDI

PAR; NE$0.00-$8.95 (Tier 2)

YERVOY

B/D PAR; NE$0.00-$8.95 (Tier 2)

YONDELIS


YONSA

PAR; LA; NE$0.00-$8.95 (Tier 2)

ZALTRAP

B/D PAR; NE$0.00-$8.95 (Tier 2)

ZANOSAR


ZEJULA


ZELBORAF


ZOLINZA


ZYDELIG


ZYKADIA ORAL CAPSULE


ZYKADIA ORAL TABLET


ZYTIGA ORAL TABLET 500 MG



Giá Thuốc

(Theo Bậc)

Tên Thuốc

ANTIPARASITICS

MO$0.00-$8.95 (Tier 2)

albendazole oral


ALINIA ORAL SUSPENSION RECONSTITUTED


ALINIA ORAL TABLET

PAR; MO; NE$0.00-$8.95 (Tier 2)

atovaquone oral

MO$0.00-$8.95 (Tier 2)

atovaquone-proguanil hcl oral tablet 250-100 mg

MO$0.00-$8.95 (Tier 2)

chloroquine phosphate oral

MO; NE$0.00-$8.95 (Tier 2)

DARAPRIM

MO$0.00-$8.95 (Tier 2)

hydroxychloroquine sulfate oral

MO$0.00-$8.95 (Tier 2)

ivermectin oral

MO$0.00-$8.95 (Tier 2)

lindane external shampoo

MO$0.00-$8.95 (Tier 2)

mefloquine hcl

B/D PAR; MO$0.00-$8.95 (Tier 2)

NEBUPENT

MO$0.00-$8.95 (Tier 2)

PENTAM

MO$0.00-$8.95 (Tier 2)

pentamidine isethionate

MO$0.00-$8.95 (Tier 2)

permethrin external cream

MO$0.00-$8.95 (Tier 2)

praziquantel oral

MO$0.00-$8.95 (Tier 2)

primaquine phosphate oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

ANTIPARKINSON AGENTS

MO$0.00-$8.95 (Tier 2)

amantadine hcl oral

PAR; LA; NE$0.00-$8.95 (Tier 2)

APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE

PAR; MO$0.00-$8.95 (Tier 2)

benztropine mesylate oral

MO$0.00-$8.95 (Tier 2)

bromocriptine mesylate oral

MO$0.00-$8.95 (Tier 2)

carbidopa oral

MO$0.00-$8.95 (Tier 2)

carbidopa oral

MO$0.00-$8.95 (Tier 2)

carbidopa-levodopa

MO$0.00-$8.95 (Tier 2)

carbidopa-levodopa er oral tablet extended release 25-100 mg, 50-200 mg

MO$0.00-$8.95 (Tier 2)

carbidopa-levodopa-entacapone

MO$0.00-$8.95 (Tier 2)

carbidopa-levodopa-entacapone

MO$0.00-$8.95 (Tier 2)

entacapone


NEUPRO

MO$0.00-$8.95 (Tier 2)

pramipexole dihydrochloride

MO$0.00-$8.95 (Tier 2)

rasagiline mesylate oral

MO$0.00-$8.95 (Tier 2)

ropinirole hcl

MO$0.00-$8.95 (Tier 2)

selegiline hcl oral


tolcapone



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; MO$0.00-$8.95 (Tier 2)

trihexyphenidyl hcl

ANTIPSYCHOTICS


ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE


ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER

MO; QLL (900 per 30 days)$0 (Tier 1)aripiprazole oral solutionMO; QLL (90 per 30 days)$0 (Tier 1)aripiprazole oral tablet 10 mgMO; QLL (60 per 30 days)$0 (Tier 1)aripiprazole oral tablet 15 mgMO; QLL (450 per 30 days)$0 (Tier 1)aripiprazole oral tablet 2 mgMO; NE; QLL (30 per 30 days)$0 (Tier 1)aripiprazole oral tablet 20 mg, 30 mgMO; QLL (180 per 30 days)$0 (Tier 1)aripiprazole oral tablet 5 mgMO; NE; QLL (90 per 30 days)$0 (Tier 1)aripiprazole oral tablet dispersible 10 mgMO; NE; QLL (60 per 30 days)$0 (Tier 1)aripiprazole oral tablet dispersible 15 mgMO$0.00-$8.95 (Tier

2)CHLORPROMAZINE HCL INJECTION

MO$0.00-$8.95 (Tier 2)

chlorpromazine hcl oral

MO; QLL (270 per 30 days)$0 (Tier 1)clozapine oral tablet 100 mgMO; QLL (120 per 30 days)$0 (Tier 1)clozapine oral tablet 200 mgMO; QLL (1080 per 30 days)$0 (Tier 1)clozapine oral tablet 25 mgMO; QLL (540 per 30 days)$0 (Tier 1)clozapine oral tablet 50 mgMO; QLL (270 per 30 days)$0 (Tier 1)clozapine oral tablet dispersible 100 mgMO; QLL (2160 per 30 days)$0 (Tier 1)clozapine oral tablet dispersible 12.5 mgMO; NE; QLL (180 per 30 days)$0 (Tier 1)clozapine oral tablet dispersible 150 mgMO; NE; QLL (120 per 30 days)$0 (Tier 1)clozapine oral tablet dispersible 200 mgMO; QLL (1080 per 30 days)$0 (Tier 1)clozapine oral tablet dispersible 25 mgST; MO; QLL (720 per 30 days)$0.00-$8.95 (Tier

2)FANAPT ORAL TABLET 1 MG

ST; MO; NE; QLL (60 per 30 days)$0.00-$8.95 (Tier 2)

FANAPT ORAL TABLET 10 MG, 12 MG



Giá Thuốc

(Theo Bậc)

Tên Thuốc


FANAPT ORAL TABLET 2 MG








FANAPT TITRATION PACK

MO$0 (Tier 1)fluphenazine decanoate injectionMO$0 (Tier 1)fluphenazine hcl injectionMO$0 (Tier 1)fluphenazine hcl oralMO; QLL (6 per 28 days)$0.00-$8.95 (Tier

2)GEODON INTRAMUSCULAR

$0 (Tier 1)haloperidol decanoate intramuscular solution 100 mg/ml 1 ml

MO$0 (Tier 1)haloperidol decanoate intramuscular solution 100 mg/ml, 50 mg/ml

MO$0 (Tier 1)haloperidol lactateMO$0 (Tier 1)haloperidol oralMO; NE; QLL (0.75 per 28 days)$0.00-$8.95 (Tier

2)INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 117 MG/0.75ML


INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 156 MG/ML

MO; NE; QLL (1.5 per 28 days)$0.00-$8.95 (Tier 2)

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 234 MG/1.5ML

MO; QLL (0.25 per 28 days)$0.00-$8.95 (Tier 2)

INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 39 MG/ 0.25ML



Giá Thuốc

(Theo Bậc)

Tên Thuốc


INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 78 MG/ 0.5ML


INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 273 MG/0.875ML








LATUDA ORAL TABLET 120 MG, 60 MG


LATUDA ORAL TABLET 20 MG





MO$0.00-$8.95 (Tier 2)

loxapine succinate oral

MO$0.00-$8.95 (Tier 2)

molindone hcl


NUPLAZID ORAL CAPSULE


NUPLAZID ORAL TABLET 10 MG

MO; QLL (60 per 30 days)$0 (Tier 1)olanzapine intramuscularMO; QLL (60 per 30 days)$0 (Tier 1)olanzapine oral tablet 10 mgMO; QLL (40 per 30 days)$0 (Tier 1)olanzapine oral tablet 15 mgMO; QLL (240 per 30 days)$0 (Tier 1)olanzapine oral tablet 2.5 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO; QLL (30 per 30 days)$0 (Tier 1)olanzapine oral tablet 20 mgMO; QLL (120 per 30 days)$0 (Tier 1)olanzapine oral tablet 5 mgMO; QLL (80 per 30 days)$0 (Tier 1)olanzapine oral tablet 7.5 mgMO; QLL (60 per 30 days)$0 (Tier 1)olanzapine oral tablet dispersible 10 mgMO; QLL (40 per 30 days)$0 (Tier 1)olanzapine oral tablet dispersible 15 mgMO; QLL (30 per 30 days)$0 (Tier 1)olanzapine oral tablet dispersible 20 mgMO; QLL (120 per 30 days)$0 (Tier 1)olanzapine oral tablet dispersible 5 mgMO; QLL (240 per 30 days)$0 (Tier 1)paliperidone er oral tablet extended release 24

hour 1.5 mgMO; QLL (120 per 30 days)$0 (Tier 1)paliperidone er oral tablet extended release 24

hour 3 mgMO; NE; QLL (60 per 30 days)$0 (Tier 1)paliperidone er oral tablet extended release 24

hour 6 mgMO; NE; QLL (30 per 30 days)$0 (Tier 1)paliperidone er oral tablet extended release 24

hour 9 mgMO$0 (Tier 1)perphenazine oralMO$0.00-$8.95 (Tier

2)pimozide

MO$0.00-$8.95 (Tier 2)

prochlorperazine edisylate injection solution 10 mg/2ml, 50 mg/10ml

MO$0.00-$8.95 (Tier 2)

prochlorperazine maleate oral











PAR; MO; QLL (240 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 100 mgPAR; MO; QLL (120 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 200 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; MO; QLL (960 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 25 mgPAR; MO; QLL (80 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 300 mgPAR; MO; QLL (60 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 400 mgPAR; MO; QLL (480 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 50 mgPAR; MO; NE; QLL (60 per 30 days)$0.00-$8.95 (Tier

2)REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG


REXULTI ORAL TABLET 3 MG, 4 MG


RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG



MO; QLL (480 per 30 days)$0 (Tier 1)risperidone oral solutionMO; QLL (1920 per 30 days)$0 (Tier 1)risperidone oral tablet 0.25 mgMO; QLL (960 per 30 days)$0 (Tier 1)risperidone oral tablet 0.5 mgMO; QLL (480 per 30 days)$0 (Tier 1)risperidone oral tablet 1 mgMO; QLL (240 per 30 days)$0 (Tier 1)risperidone oral tablet 2 mgMO; QLL (150 per 30 days)$0 (Tier 1)risperidone oral tablet 3 mgMO; QLL (120 per 30 days)$0 (Tier 1)risperidone oral tablet 4 mgMO; QLL (1920 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 0.25 mgMO; QLL (960 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 0.5 mgMO; QLL (480 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 1 mgMO; QLL (240 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 2 mgMO; QLL (150 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 3 mgMO; QLL (120 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 4 mgMO; NE; QLL (60 per 30 days)$0.00-$8.95 (Tier

2)SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG


SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 2.5 MG


SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 5 MG



Giá Thuốc

(Theo Bậc)

Tên Thuốc

ST; MO$0 (Tier 1)thioridazine hcl oralMO$0 (Tier 1)thiothixene oralMO$0 (Tier 1)trifluoperazine hcl oralMO; QLL (600 per 30 days)$0.00-$8.95 (Tier

2)VERSACLOZ


VRAYLAR ORAL CAPSULE


VRAYLAR ORAL CAPSULE THERAPY PACK

MO; QLL (240 per 30 days)$0 (Tier 1)ziprasidone hcl oral capsule 20 mgMO; QLL (120 per 30 days)$0 (Tier 1)ziprasidone hcl oral capsule 40 mgMO; QLL (60 per 30 days)$0 (Tier 1)ziprasidone hcl oral capsule 60 mg, 80 mgMO; QLL (2 per 28 days)$0.00-$8.95 (Tier

2)ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG


ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 300 MG, 405 MG

ANTISPASTICITY AGENTS

MO$0.00-$8.95 (Tier 2)

baclofen oral

MO$0.00-$8.95 (Tier 2)

dantrolene sodium oral

MO$0.00-$8.95 (Tier 2)

tizanidine hcl oral tablet

ANTIVIRALS

QLL (960 per 30 days)$0.00-$8.95 (Tier 2)

abacavir sulfate oral solution

QLL (60 per 30 days)$0.00-$8.95 (Tier 2)

abacavir sulfate oral tablet


abacavir sulfate-lamivudine


abacavir-lamivudine-zidovudine



Giá Thuốc

(Theo Bậc)

Tên Thuốc


acyclovir external ointment

MO$0.00-$8.95 (Tier 2)

acyclovir oral

B/D PAR; MO$0.00-$8.95 (Tier 2)

acyclovir sodium intravenous solution

PAR$0.00-$8.95 (Tier 2)

adefovir dipivoxil

MO$0.00-$8.95 (Tier 2)

amantadine hcl oral


APTIVUS ORAL CAPSULE


APTIVUS ORAL SOLUTION


atazanavir sulfate oral capsule 150 mg, 200 mg


atazanavir sulfate oral capsule 300 mg


ATRIPLA

PAR; NE$0.00-$8.95 (Tier 2)

BARACLUDE ORAL SOLUTION


BIKTARVY


CIMDUO


COMPLERA

QLL (360 per 30 days)$0.00-$8.95 (Tier 2)

CRIXIVAN ORAL CAPSULE 200 MG

QLL (180 per 30 days)$0.00-$8.95 (Tier 2)

CRIXIVAN ORAL CAPSULE 400 MG


DELSTRIGO



Giá Thuốc

(Theo Bậc)

Tên Thuốc


DENAVIR


DESCOVY

QLL (60 per 30 days)$0.00-$8.95 (Tier 2)

didanosine oral capsule delayed release 200 mg

QLL (30 per 30 days)$0.00-$8.95 (Tier 2)

didanosine oral capsule delayed release 250 mg, 400 mg


DOVATO


EDURANT

QLL (120 per 30 days)$0.00-$8.95 (Tier 2)

efavirenz oral capsule 200 mg

QLL (360 per 30 days)$0.00-$8.95 (Tier 2)

efavirenz oral capsule 50 mg


efavirenz oral tablet

QLL (30 per 30 days)$0.00-$8.95 (Tier 2)

EMTRIVA ORAL CAPSULE

QLL (850 per 30 days)$0.00-$8.95 (Tier 2)

EMTRIVA ORAL SOLUTION

PAR; NE$0.00-$8.95 (Tier 2)

entecavir


EPCLUSA


EPCLUSA

$0.00-$8.95 (Tier 2)

EPIVIR HBV ORAL SOLUTION


EVOTAZ


famciclovir oral tablet 125 mg, 250 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc


famciclovir oral tablet 500 mg


fosamprenavir calcium


FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED

B/D PAR$0.00-$8.95 (Tier 2)

ganciclovir sodium intravenous solution reconstituted


GENVOYA


HARVONI


HARVONI


INTELENCE ORAL TABLET 100 MG



QLL (480 per 30 days)$0.00-$8.95 (Tier 2)


B/D PAR; NE$0.00-$8.95 (Tier 2)

INTRON A INJECTION SOLUTION

B/D PAR; NE$0.00-$8.95 (Tier 2)

INTRON A INJECTION SOLUTION 6000000 UNIT/ML

B/D PAR$0.00-$8.95 (Tier 2)

INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT

B/D PAR$0.00-$8.95 (Tier 2)

INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT

B/D PAR; NE$0.00-$8.95 (Tier 2)

INTRON A INJECTION SOLUTION RECONSTITUTED 50000000 UNIT


INVIRASE ORAL TABLET


ISENTRESS HD



Giá Thuốc

(Theo Bậc)

Tên Thuốc


ISENTRESS ORAL PACKET


ISENTRESS ORAL TABLET


ISENTRESS ORAL TABLET CHEWABLE 100 MG

QLL (720 per 30 days)$0.00-$8.95 (Tier 2)

ISENTRESS ORAL TABLET CHEWABLE 25 MG


JULUCA

QLL (300 per 30 days)$0.00-$8.95 (Tier 2)

KALETRA ORAL TABLET 100-25 MG


KALETRA ORAL TABLET 200-50 MG

QLL (960 per 30 days)$0.00-$8.95 (Tier 2)

lamivudine oral solution

QLL (960 per 30 days)$0.00-$8.95 (Tier 2)

lamivudine oral solution

$0.00-$8.95 (Tier 2)

lamivudine oral tablet 100 mg

$0.00-$8.95 (Tier 2)


QLL (60 per 30 days)$0.00-$8.95 (Tier 2)


QLL (60 per 30 days)$0.00-$8.95 (Tier 2)


QLL (30 per 30 days)$0.00-$8.95 (Tier 2)


QLL (30 per 30 days)$0.00-$8.95 (Tier 2)


QLL (60 per 30 days)$0.00-$8.95 (Tier 2)

lamivudine-zidovudine


LEDIPASVIR-SOFOSBUVIR



Giá Thuốc

(Theo Bậc)

Tên Thuốc

QLL (1800 per 30 days)$0.00-$8.95 (Tier 2)

LEXIVA ORAL SUSPENSION

QLL (480 per 30 days)$0.00-$8.95 (Tier 2)

lopinavir-ritonavir

QLL (90 per 30 days)$0.00-$8.95 (Tier 2)

nevirapine er oral tablet extended release 24 hour 100 mg

QLL (30 per 30 days)$0.00-$8.95 (Tier 2)

nevirapine er oral tablet extended release 24 hour 400 mg

QLL (1200 per 30 days)$0.00-$8.95 (Tier 2)

nevirapine oral suspension

QLL (60 per 30 days)$0.00-$8.95 (Tier 2)

nevirapine oral tablet

QLL (360 per 30 days)$0.00-$8.95 (Tier 2)

NORVIR ORAL PACKET

QLL (480 per 30 days)$0.00-$8.95 (Tier 2)

NORVIR ORAL SOLUTION


ODEFSEY

MO$0.00-$8.95 (Tier 2)

oseltamivir phosphate oral

NE$0.00-$8.95 (Tier 2)

PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 180 MCG/0.5ML

NE$0.00-$8.95 (Tier 2)

PEGASYS SUBCUTANEOUS SOLUTION

NE$0.00-$8.95 (Tier 2)

PEGINTRON SUBCUTANEOUS KIT 50 MCG/ 0.5ML


PIFELTRO


PREZCOBIX


PREZISTA ORAL SUSPENSION

QLL (180 per 30 days)$0.00-$8.95 (Tier 2)

PREZISTA ORAL TABLET 150 MG



Giá Thuốc

(Theo Bậc)

Tên Thuốc


PREZISTA ORAL TABLET 600 MG, 800 MG

QLL (300 per 30 days)$0.00-$8.95 (Tier 2)

PREZISTA ORAL TABLET 75 MG


RELENZA DISKHALER

QLL (180 per 30 days)$0.00-$8.95 (Tier 2)

RESCRIPTOR ORAL TABLET 200 MG

$0.00-$8.95 (Tier 2)

RETROVIR INTRAVENOUS

QLL (240 per 30 days)$0.00-$8.95 (Tier 2)

REYATAZ ORAL PACKET

$0.00-$8.95 (Tier 2)

ribasphere oral capsule

$0.00-$8.95 (Tier 2)

ribasphere oral capsule

$0.00-$8.95 (Tier 2)

ribasphere oral tablet 200 mg

$0.00-$8.95 (Tier 2)

ribavirin oral capsule

$0.00-$8.95 (Tier 2)

ribavirin oral capsule

NE$0.00-$8.95 (Tier 2)

ribavirin oral tablet 200 mg

NE$0.00-$8.95 (Tier 2)

ribavirin oral tablet 200 mg

MO$0.00-$8.95 (Tier 2)

rimantadine hcl

QLL (360 per 30 days)$0.00-$8.95 (Tier 2)

ritonavir


SELZENTRY ORAL SOLUTION


SELZENTRY ORAL TABLET 150 MG, 300 MG



Giá Thuốc

(Theo Bậc)

Tên Thuốc

QLL (120 per 30 days)$0.00-$8.95 (Tier 2)

SELZENTRY ORAL TABLET 25 MG

QLL (60 per 30 days)$0.00-$8.95 (Tier 2)

SELZENTRY ORAL TABLET 75 MG


SOFOSBUVIR-VELPATASVIR

QLL (120 per 30 days)$0.00-$8.95 (Tier 2)

stavudine oral capsule 15 mg, 20 mg

QLL (60 per 30 days)$0.00-$8.95 (Tier 2)

stavudine oral capsule 30 mg, 40 mg


STRIBILD

PAR; NE$0.00-$8.95 (Tier 2)

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG


SYMFI


SYMFI LO


SYMTUZA


tenofovir disoproxil fumarate


tenofovir disoproxil fumarate

QLL (60 per 30 days)$0.00-$8.95 (Tier 2)

TIVICAY ORAL TABLET 10 MG


TIVICAY ORAL TABLET 25 MG, 50 MG

MO$0.00-$8.95 (Tier 2)

trifluridine ophthalmic


TRIUMEQ

PAR; LA; NE; QLL (10.64 per 28 days)

$0.00-$8.95 (Tier 2)

TROGARZO



Giá Thuốc

(Theo Bậc)

Tên Thuốc


TRUVADA

QLL (30 per 30 days)$0.00-$8.95 (Tier 2)

TYBOST


valacyclovir hcl oral tablet 1 gm


valacyclovir hcl oral tablet 500 mg

NE$0.00-$8.95 (Tier 2)

valganciclovir hcl oral tablet


VEMLIDY

QLL (90 per 30 days)$0.00-$8.95 (Tier 2)

VIDEX EC ORAL CAPSULE DELAYED RELEASE 125 MG

QLL (1200 per 30 days)$0.00-$8.95 (Tier 2)

VIDEX ORAL SOLUTION RECONSTITUTED 2 GM


VIRACEPT ORAL TABLET 250 MG


VIRACEPT ORAL TABLET 625 MG

PAR; MO; NE$0.00-$8.95 (Tier 2)

VIRAZOLE


VIREAD ORAL POWDER


VIREAD ORAL POWDER


VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG


VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG


VOSEVI

MO$0.00-$8.95 (Tier 2)

XOFLUZA



Giá Thuốc

(Theo Bậc)

Tên Thuốc

QLL (180 per 30 days)$0.00-$8.95 (Tier 2)

zidovudine oral capsule

QLL (1920 per 30 days)$0.00-$8.95 (Tier 2)

zidovudine oral syrup

QLL (60 per 30 days)$0.00-$8.95 (Tier 2)

zidovudine oral tablet

MO$0.00-$8.95 (Tier 2)

ZIRGAN

ANXIOLYTICS


alprazolam oral tablet

MO$0.00-$8.95 (Tier 2)

buspirone hcl oral


clonazepam oral tablet 0.5 mg















MO$0.00-$8.95 (Tier 2)

clorazepate dipotassium

MO$0.00-$8.95 (Tier 2)


MO; NE$0.00-$8.95 (Tier 2)




Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

DIASTAT PEDIATRIC











PAR; MO$0.00-$8.95 (Tier 2)

doxepin hcl oral










escitalopram oxalate oral solution







PAR; MO$0.00-$8.95 (Tier 2)

hydroxyzine hcl oral tablet

PAR; MO$0.00-$8.95 (Tier 2)




Giá Thuốc

(Theo Bậc)

Tên Thuốc


lorazepam oral concentrate


lorazepam oral tablet 0.5 mg, 1 mg


lorazepam oral tablet 2 mg










PAXIL ORAL SUSPENSION


sertraline hcl oral concentrate










venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg






venlafaxine hcl er oral tablet extended release 24 hour 37.5 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc








venlafaxine hcl oral tablet 37.5 mg





BIPOLAR AGENTS

MO$0.00-$8.95 (Tier 2)

carbamazepine er oral capsule extended release 12 hour

MO$0.00-$8.95 (Tier 2)

carbamazepine er oral tablet extended release 12 hour 100 mg

MO$0.00-$8.95 (Tier 2)

carbamazepine oral

MO$0.00-$8.95 (Tier 2)


MO$0.00-$8.95 (Tier 2)


MO$0.00-$8.95 (Tier 2)


MO$0.00-$8.95 (Tier 2)

epitol


GEODON INTRAMUSCULAR

MO$0.00-$8.95 (Tier 2)

lamotrigine oral tablet

MO$0.00-$8.95 (Tier 2)

lamotrigine oral tablet chewable

MO$0.00-$8.95 (Tier 2)

LITHIUM



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 1)lithium carbonate erMO$0 (Tier 1)lithium carbonate oralMO; QLL (60 per 30 days)$0 (Tier 1)olanzapine intramuscularMO; QLL (60 per 30 days)$0 (Tier 1)olanzapine oral tablet 10 mgMO; QLL (40 per 30 days)$0 (Tier 1)olanzapine oral tablet 15 mgMO; QLL (240 per 30 days)$0 (Tier 1)olanzapine oral tablet 2.5 mgMO; QLL (30 per 30 days)$0 (Tier 1)olanzapine oral tablet 20 mgMO; QLL (120 per 30 days)$0 (Tier 1)olanzapine oral tablet 5 mgMO; QLL (80 per 30 days)$0 (Tier 1)olanzapine oral tablet 7.5 mgMO; QLL (60 per 30 days)$0 (Tier 1)olanzapine oral tablet dispersible 10 mgMO; QLL (40 per 30 days)$0 (Tier 1)olanzapine oral tablet dispersible 15 mgMO; QLL (30 per 30 days)$0 (Tier 1)olanzapine oral tablet dispersible 20 mgMO; QLL (120 per 30 days)$0 (Tier 1)olanzapine oral tablet dispersible 5 mgPAR; MO; QLL (150 per 30 days)$0.00-$8.95 (Tier

2)quetiapine fumarate er oral tablet extended release 24 hour 150 mg









PAR; MO; QLL (240 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 100 mgPAR; MO; QLL (120 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 200 mgPAR; MO; QLL (960 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 25 mgPAR; MO; QLL (80 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 300 mgPAR; MO; QLL (60 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 400 mgPAR; MO; QLL (480 per 30 days)$0 (Tier 1)quetiapine fumarate oral tablet 50 mgMO; QLL (2 per 28 days)$0.00-$8.95 (Tier

2)RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG



Giá Thuốc

(Theo Bậc)

Tên Thuốc



MO; QLL (480 per 30 days)$0 (Tier 1)risperidone oral solutionMO; QLL (1920 per 30 days)$0 (Tier 1)risperidone oral tablet 0.25 mgMO; QLL (960 per 30 days)$0 (Tier 1)risperidone oral tablet 0.5 mgMO; QLL (480 per 30 days)$0 (Tier 1)risperidone oral tablet 1 mgMO; QLL (240 per 30 days)$0 (Tier 1)risperidone oral tablet 2 mgMO; QLL (150 per 30 days)$0 (Tier 1)risperidone oral tablet 3 mgMO; QLL (120 per 30 days)$0 (Tier 1)risperidone oral tablet 4 mgMO; QLL (1920 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 0.25 mgMO; QLL (960 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 0.5 mgMO; QLL (480 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 1 mgMO; QLL (240 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 2 mgMO; QLL (150 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 3 mgMO; QLL (120 per 30 days)$0 (Tier 1)risperidone oral tablet dispersible 4 mgMO; NE; QLL (60 per 30 days)$0.00-$8.95 (Tier

2)SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG


SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 2.5 MG


SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 5 MG

MO$0.00-$8.95 (Tier 2)


MO$0.00-$8.95 (Tier 2)



VRAYLAR ORAL CAPSULE


VRAYLAR ORAL CAPSULE THERAPY PACK

MO; QLL (240 per 30 days)$0 (Tier 1)ziprasidone hcl oral capsule 20 mgMO; QLL (120 per 30 days)$0 (Tier 1)ziprasidone hcl oral capsule 40 mgMO; QLL (60 per 30 days)$0 (Tier 1)ziprasidone hcl oral capsule 60 mg, 80 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc


ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG

BLOOD GLUCOSE REGULATORS

MO$0 (Tier 1)1ST TIER UNIFINE PENTIPS 29G X 12MMMO; QLL (90 per 30 days)$0 (Tier 1)acarbose oral tablet 100 mgMO; QLL (360 per 30 days)$0 (Tier 1)acarbose oral tablet 25 mgMO; QLL (180 per 30 days)$0 (Tier 1)acarbose oral tablet 50 mg[*]$0 (Tier 4)ACCU-CHEK AVIVA PLUS STRIP IN VITRO[*]$0 (Tier 4)ACCU-CHEK COMPACT PLUS STRIP IN

VITRO[*]$0 (Tier 4)ACCU-CHEK FASTCLIX LANCETS[*]$0 (Tier 4)ACCU-CHEK MULTICLIX LANCETS[*]$0 (Tier 4)ACCU-CHEK SMARTVIEW STRIP IN VITRO[*]$0 (Tier 4)ACCU-CHEK SOFT TOUCH LANCETS[*]$0 (Tier 4)ACCU-CHEK SOFTCLIX LANCETS[*]$0 (Tier 4)AGAMATRIX ULTRA-THIN LANCETSMO; QLL (200 per 30 days)$0 (Tier 1)ASSURE ID INSULIN SAFETY SYR 29G X 1/

2" 1 MLMO; QLL (4 per 28 days)$0.00-$8.95 (Tier

2)BYDUREON BCISE


BYDUREON SUBCUTANEOUS PEN- INJECTOR


BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR


BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION PEN-INJECTOR

MO$0 (Tier 1)CAREONE UNIFINE PENTIPS PLUS 29G X 12MM

MO$0 (Tier 1)CLEVER CHOICE COMFORT EZ 29G X 12MMMO; QLL (200 per 30 days)$0 (Tier 1)COMFORT ASSIST INSULIN SYRINGE 29G

X 1/2" 1 MLMO; QLL (200 per 30 days)$0 (Tier 1)CVS GAUZE STERILE PAD 2"X2"



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)cvs glucose gel 40 % oral[*]$0 (Tier 4)cvs glucose tablet chewable 4 gm oral[*]$0 (Tier 4)cvs glucose tablet chewable 4-6 gm-mg oral[*]$0 (Tier 4)CVS LANCETS MICRO THIN 33G[*]$0 (Tier 4)CVS LANCETS THIN 26G[*]$0 (Tier 4)CVS LANCETS ULTRA THIN 30GST; MO; QLL (180 per 30 days)$0.00-$8.95 (Tier

2)CYCLOSET

[*]$0 (Tier 4)dex4 glucose tablet chewable 4-6 gm-mg oral[*]$0 (Tier 4)dex4 naturals tablet chewable 4-6 gm-mg oral[*]$0 (Tier 4)dex4 pouch pack tablet chewable 4-6 gm-mg

oral[*]$0 (Tier 4)dex4 quick dissolve glucose tablet chewable 4

gm oral[*]$0 (Tier 4)dex4 tablet chewable 4-6 gm-mg oralMO$0 (Tier 1)EASY TOUCH PEN NEEDLES 29G X 12MMMO; QLL (200 per 30 days)$0 (Tier 1)EXEL COMFORT POINT PEN NEEDLE 29G

X 12MMMO; QLL (240 per 30 days)$0 (Tier 1)glimepiride oral tablet 1 mgMO; QLL (120 per 30 days)$0 (Tier 1)glimepiride oral tablet 2 mgMO; QLL (60 per 30 days)$0 (Tier 1)glimepiride oral tablet 4 mgMO; QLL (60 per 30 days)$0 (Tier 1)glipizide er oral tablet extended release 24 hour

10 mgMO; QLL (240 per 30 days)$0 (Tier 1)glipizide er oral tablet extended release 24 hour

2.5 mgMO; QLL (120 per 30 days)$0 (Tier 1)glipizide er oral tablet extended release 24 hour

5 mgMO; QLL (120 per 30 days)$0 (Tier 1)glipizide oral tablet 10 mgMO; QLL (240 per 30 days)$0 (Tier 1)glipizide oral tablet 5 mgMO; QLL (60 per 30 days)$0 (Tier 1)glipizide xl oral tablet extended release 24 hour

10 mgMO; QLL (240 per 30 days)$0 (Tier 1)glipizide xl oral tablet extended release 24 hour

2.5 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO; QLL (120 per 30 days)$0 (Tier 1)glipizide xl oral tablet extended release 24 hour 5 mg

MO; QLL (240 per 30 days)$0 (Tier 1)glipizide-metformin hcl oral tablet 2.5-250 mgMO; QLL (120 per 30 days)$0 (Tier 1)glipizide-metformin hcl oral tablet 2.5-500 mg,

5-500 mgMO$0 (Tier 1)GLUCAGEN HYPOKITMO$0 (Tier 1)GLUCAGON EMERGENCY[*]$0 (Tier 4)gluco burst gel 40 % oral[*]$0 (Tier 4)glucose tablet chewable 4 gm oral[*]$0 (Tier 4)glucose tablet chewable 4-6 gm-mg oralPAR; MO; QLL (480 per 30 days)$0.00-$8.95 (Tier

2)glyburide oral tablet 1.25 mg


glyburide oral tablet 2.5 mg


glyburide oral tablet 5 mg

[*]$0 (Tier 4)gnp glucose tablet chewable 4 gm oral[*]$0 (Tier 4)gnp glucose tablet chewable 4-6 gm-mg oral[*]$0 (Tier 4)gnp quick dissolve glucose tablet chewable 4

gm oral[*]$0 (Tier 4)goodsense glucose tablet chewable 4-6 gm-

mg oralMO$0 (Tier 1)H-E-B INCONTROL PEN NEEDLES 29G X

12MM[*]$0 (Tier 4)hm glucose tablet chewable 4-6 gm-mg oralMO$0 (Tier 1)HUMALOG JUNIOR KWIKPENMO$0 (Tier 1)HUMALOG KWIKPEN SUBCUTANEOUS

SOLUTION PEN-INJECTOR 200 UNIT/MLMO$0 (Tier 1)HUMALOG MIX 50/50MO$0 (Tier 1)HUMALOG MIX 50/50 KWIKPEN

SUBCUTANEOUS SUSPENSION PEN- INJECTOR

MO$0 (Tier 1)HUMALOG MIX 75/25



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 1)HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR

MO$0 (Tier 1)HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE

MO$0 (Tier 1)HUMULIN 70/30MO$0 (Tier 1)HUMULIN 70/30 KWIKPEN SUBCUTANEOUS

SUSPENSION PEN-INJECTORMO$0 (Tier 1)HUMULIN NMO$0 (Tier 1)HUMULIN N KWIKPEN SUBCUTANEOUS

SUSPENSION PEN-INJECTORMO$0 (Tier 1)HUMULIN RPAR; MO; NE$0 (Tier 1)HUMULIN R U-500 (CONCENTRATED)PAR; MO; NE$0 (Tier 1)HUMULIN R U-500 KWIKPEN

SUBCUTANEOUS SOLUTION PEN- INJECTOR

MO$0 (Tier 1)INSULIN LISPROMO$0 (Tier 1)INSUPEN PEN NEEDLES 29G X 12MMMO$0 (Tier 1)INSUPEN ULTRAFIN 29G X 12MMMO; QLL (60 per 30 days)$0.00-$8.95 (Tier

2)JANUMET


JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MG


JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 50-1000 MG, 50-500 MG


JANUVIA ORAL TABLET 100 MG






JARDIANCE



Giá Thuốc

(Theo Bậc)

Tên Thuốc


JENTADUETO


JENTADUETO


JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG


JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000 MG


JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG


JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG

PAR; LA; NE$0.00-$8.95 (Tier 2)

KORLYM

[*]$0 (Tier 4)kroger glucose tablet chewable 4-6 gm-mg oral[*]$0 (Tier 4)LANCETS ULTRA THINMO$0 (Tier 1)LANTUSMO$0 (Tier 1)LANTUS SOLOSTAR SUBCUTANEOUS

SOLUTION PEN-INJECTOR[*]$0 (Tier 4)leader glucose tablet chewable 4-6 gm-mg oral[*]$0 (Tier 4)leader quick dissolve glucose tablet chewable

4 gm oralMO$0 (Tier 1)LEVEMIRMO$0 (Tier 1)LEVEMIR FLEXTOUCH[*]$0 (Tier 4)longs glucose tablet chewable 4-6 gm-mg oralMO$0 (Tier 1)MARATHON MEDICAL PENTIPS 29G X 12MM[*]$0 (Tier 4)meijer glucose tablet chewable 4-6 gm-mg oralMO; QLL (120 per 30 days)$0 (Tier 1)metformin hcl er oral tablet extended release

24 hour 500 mgMO; QLL (60 per 30 days)$0 (Tier 1)metformin hcl er oral tablet extended release

24 hour 750 mgMO; QLL (60 per 30 days)$0 (Tier 1)metformin hcl oral tablet 1000 mgMO; QLL (150 per 30 days)$0 (Tier 1)metformin hcl oral tablet 500 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO; QLL (90 per 30 days)$0 (Tier 1)metformin hcl oral tablet 850 mgMO; QLL (90 per 30 days)$0 (Tier 1)nateglinide oral tablet 120 mgMO; QLL (180 per 30 days)$0 (Tier 1)nateglinide oral tablet 60 mg[*]$0 (Tier 4)ONETOUCH DELICA LANCETS 33G[*]$0 (Tier 4)ONETOUCH DELICA LANCETS FINE[*]$0 (Tier 4)ONETOUCH ULTRA BLUE STRIP IN VITRO[*]$0 (Tier 4)ONETOUCH VERIO STRIP IN VITROMO$0.00-$8.95 (Tier

2)OZEMPIC (0.25 OR 0.5 MG/DOSE)

MO$0.00-$8.95 (Tier 2)

OZEMPIC (1 MG/DOSE)

MO$0 (Tier 1)PC UNIFINE PENTIPS 29G X 12MMMO; QLL (90 per 30 days)$0 (Tier 1)pioglitazone hcl oral tablet 15 mgMO; QLL (45 per 30 days)$0 (Tier 1)pioglitazone hcl oral tablet 30 mgMO; QLL (30 per 30 days)$0 (Tier 1)pioglitazone hcl oral tablet 45 mg[*]$0 (Tier 4)preferred plus glucose tablet chewable 4-6 gm-

mg oralMO; QLL (200 per 30 days)$0 (Tier 1)PREFERRED PLUS INSULIN SYRINGE 28G

X 1/2" 0.5 ML[*]$0 (Tier 4)PRODIGY TWIST TOP LANCETS 28GMO; NE$0.00-$8.95 (Tier

2)PROGLYCEM

[*]$0 (Tier 4)px glucose tablet chewable 4-6 gm-mg oral[*]$0 (Tier 4)ra glucose tablet chewable 6-4 mg-gm oralMO; QLL (200 per 30 days)$0 (Tier 1)RELI-ON INSULIN SYRINGE 29G 0.3 ML[*]$0 (Tier 4)relion glucose gel 15 gm/38gm oral[*]$0 (Tier 4)relion glucose tablet chewable 4-6 gm-mg oralMO$0 (Tier 1)RELION PEN NEEDLES 29G X 12MMMO; QLL (960 per 30 days)$0 (Tier 1)repaglinide oral tablet 0.5 mgMO; QLL (480 per 30 days)$0 (Tier 1)repaglinide oral tablet 1 mgMO; QLL (240 per 30 days)$0 (Tier 1)repaglinide oral tablet 2 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)sm glucose tablet chewable 4 gm oral[*]$0 (Tier 4)sm glucose tablet chewable 4-6 gm-mg oral[*]$0 (Tier 4)SMART SENSE COLOR LANCETS 33G[*]$0 (Tier 4)smart sense glucose tablet chewable 4-6 gm-

mg oral[*]$0 (Tier 4)SMART SENSE SUPER THIN LANCETS[*]$0 (Tier 4)SMART SENSE THIN LANCETS 26GPAR; MO; NE; QLL (11 per 30 days)$0.00-$8.95 (Tier

2)SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR


SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR


SYNJARDY


SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000 MG, 12.5-1000 MG, 5-1000 MG


SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 25-1000 MG

MO$0 (Tier 1)TECHLITE PEN NEEDLES 29G X 12MM[*]$0 (Tier 4)tgt glucose tablet chewable 4-6 gm-mg oral[*]$0 (Tier 4)TGT LANCET MICRO THIN 33G[*]$0 (Tier 4)TGT LANCET THIN 26G[*]$0 (Tier 4)TGT LANCET ULTRA THIN 30GMO$0.00-$8.95 (Tier

2)TOUJEO MAX SOLOSTAR

MO$0.00-$8.95 (Tier 2)

TOUJEO SOLOSTAR


TRADJENTA


TRULICITY

[*]$0 (Tier 4)UNILET COMFORTOUCH LANCET[*]$0 (Tier 4)UNILET GP 28 ULTRA THIN



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)UNILET MICRO-THIN 33G[*]$0 (Tier 4)UNILET SUPER-THIN 30G[*]$0 (Tier 4)UNILET ULTRA-THIN 28G[*]$0 (Tier 4)UNIVERSAL 1 LANCETS ULTRA THIN[*]$0 (Tier 4)up & up glucose tablet chewable 4-6 gm-mg

oralMO; QLL (9 per 30 days)$0.00-$8.95 (Tier

2)VICTOZA SUBCUTANEOUS SOLUTION PEN- INJECTOR

[*]$0 (Tier 4)walgreens glucose tablet chewable 4 gm oral[*]$0 (Tier 4)walgreens glucose tablet chewable 4-6 gm-mg

oral

BLOOD PRODUCTS/ MODIFIERS/ VOLUME EXPANDERS

MO$0.00-$8.95 (Tier 2)

anagrelide hcl


aspirin-dipyridamole er


BRILINTA

MO$0.00-$8.95 (Tier 2)

cilostazol

MO; QLL (1 per 30 days)$0 (Tier 1)clopidogrel bisulfate oral tablet 300 mgMO; QLL (30 per 30 days)$0 (Tier 1)clopidogrel bisulfate oral tablet 75 mgMO$0.00-$8.95 (Tier

2)COUMADIN ORAL


ELIQUIS


ELIQUIS STARTER PACK


enoxaparin sodium injection


enoxaparin sodium subcutaneous solution 100 mg/ml, 150 mg/ml


enoxaparin sodium subcutaneous solution 120 mg/0.8ml, 80 mg/0.8ml



Giá Thuốc

(Theo Bậc)

Tên Thuốc


enoxaparin sodium subcutaneous solution 30 mg/0.3ml






fondaparinux sodium subcutaneous solution 10 mg/0.8ml


fondaparinux sodium subcutaneous solution 2.5 mg/0.5ml


fondaparinux sodium subcutaneous solution 5 mg/0.4ml


fondaparinux sodium subcutaneous solution 7.5 mg/0.6ml

PAR; NE; QLL (1.2 per 28 days)$0.00-$8.95 (Tier 2)

FULPHILA

MO$0.00-$8.95 (Tier 2)

HEPARIN (PORCINE) IN NACL INJECTION SOLUTION 100-0.45 UNIT/ML-%

B/D PAR; MO$0.00-$8.95 (Tier 2)

HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 12500-0.45 UT/ 250ML-%, 25000-0.45 UT/500ML-%

MO$0.00-$8.95 (Tier 2)

HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 25000-0.45 UT/ 250ML-%

MO$0.00-$8.95 (Tier 2)

HEPARIN SOD (PORCINE) IN D5W INTRAVENOUS SOLUTION 100 UNIT/ML, 25000-5 UT/500ML-%

MO$0.00-$8.95 (Tier 2)

heparin sod (porcine) in d5w intravenous solution 40-5 unit/ml-%

B/D PAR; MO$0.00-$8.95 (Tier 2)

heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml

MO$0 (Tier 1)jantovenPAR; NE; QLL (1.2 per 28 days)$0.00-$8.95 (Tier

2)NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE



Giá Thuốc

(Theo Bậc)

Tên Thuốc


PRADAXA


prasugrel hcl

PAR$0.00-$8.95 (Tier 2)

PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ML

PAR; NE$0.00-$8.95 (Tier 2)

PROCRIT INJECTION SOLUTION 20000 UNIT/ML, 40000 UNIT/ML


PROMACTA ORAL PACKET


PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG


PROMACTA ORAL TABLET 50 MG

$0.00-$8.95 (Tier 2)

tranexamic acid intravenous solution 1000 mg/ 10ml

MO$0.00-$8.95 (Tier 2)

tranexamic acid oral

MO$0 (Tier 1)warfarin sodium oralMO; QLL (30 per 30 days)$0.00-$8.95 (Tier

2)XARELTO ORAL TABLET 10 MG, 20 MG


XARELTO ORAL TABLET 15 MG


XARELTO ORAL TABLET 2.5 MG


XARELTO STARTER PACK

PAR; NE$0.00-$8.95 (Tier 2)

ZARXIO

CARDIOVASCULAR AGENTS

MO$0 (Tier 1)acebutolol hcl oralMO$0.00-$8.95 (Tier

2)acetazolamide er



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

acetazolamide oral

MO$0.00-$8.95 (Tier 2)

acetazolamide sodium

MO$0 (Tier 1)afeditab cr oral tablet extended release 24 hour 30 mg

$0 (Tier 1)afeditab cr oral tablet extended release 24 hour 60 mg

MO$0.00-$8.95 (Tier 2)

aliskiren fumarate

MO$0.00-$8.95 (Tier 2)

aliskiren fumarate

MO$0.00-$8.95 (Tier 2)

amiloride hcl oral

MO$0.00-$8.95 (Tier 2)

amiloride-hydrochlorothiazide

B/D PAR; MO$0.00-$8.95 (Tier 2)

amiodarone hcl intravenous

MO$0.00-$8.95 (Tier 2)

amiodarone hcl oral

MO$0 (Tier 1)amlodipine besy-benazepril hclMO$0 (Tier 1)amlodipine besylate oralMO$0.00-$8.95 (Tier

2)amlodipine besylate-valsartan

MO$0.00-$8.95 (Tier 2)

amlodipine-olmesartan

MO$0.00-$8.95 (Tier 2)

amlodipine-valsartan-hctz

MO$0 (Tier 1)atenolol oralMO$0 (Tier 1)atenolol-chlorthalidoneMO$0 (Tier 1)atorvastatin calcium oralMO$0 (Tier 1)benazepril hcl oralMO$0 (Tier 1)benazepril-hydrochlorothiazideMO$0 (Tier 1)betaxolol hcl oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 1)bisoprolol fumarateMO$0 (Tier 1)bisoprolol-hydrochlorothiazideMO$0.00-$8.95 (Tier

2)bumetanide injection

MO$0.00-$8.95 (Tier 2)

bumetanide oral

MO$0 (Tier 1)candesartan cilexetilMO$0 (Tier 1)candesartan cilexetil-hctzMO$0 (Tier 1)cartia xtMO$0 (Tier 1)carvedilolMO$0.00-$8.95 (Tier

2)chlorothiazide oral

MO$0.00-$8.95 (Tier 2)

chlorthalidone oral tablet 25 mg, 50 mg

MO$0.00-$8.95 (Tier 2)

cholestyramine light

MO$0.00-$8.95 (Tier 2)

cholestyramine oral


clonidine

MO$0.00-$8.95 (Tier 2)

clonidine hcl oral

MO$0.00-$8.95 (Tier 2)

colestipol hcl


CORLANOR ORAL TABLET

MO; NE$0.00-$8.95 (Tier 2)

DEMSER

MO$0.00-$8.95 (Tier 2)

digitek oral tablet 125 mcg

PAR; MO$0.00-$8.95 (Tier 2)

digitek oral tablet 250 mcg

MO$0.00-$8.95 (Tier 2)

digox oral tablet 125 mcg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; MO$0.00-$8.95 (Tier 2)

digox oral tablet 250 mcg

MO$0.00-$8.95 (Tier 2)

digoxin oral solution

MO$0.00-$8.95 (Tier 2)

digoxin oral tablet 125 mcg

PAR; MO$0.00-$8.95 (Tier 2)

digoxin oral tablet 250 mcg

MO$0 (Tier 1)dilt-xr$0 (Tier 1)diltiazem hcl er beads oral capsule extended

release 24 hour 120 mg, 180 mg, 240 mg, 300 mg

MO$0 (Tier 1)diltiazem hcl er beads oral capsule extended release 24 hour 360 mg

MO$0 (Tier 1)diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg

MO$0.00-$8.95 (Tier 2)

diltiazem hcl er coated beads oral capsule extended release 24 hour 360 mg

MO$0 (Tier 1)diltiazem hcl er oral capsule extended release 12 hour

MO$0 (Tier 1)diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg

MO$0 (Tier 1)diltiazem hcl oral$0.00-$8.95 (Tier

2)dofetilide

MO$0 (Tier 1)doxazosin mesylate oralMO$0 (Tier 1)enalapril maleate oralMO$0 (Tier 1)enalapril-hydrochlorothiazidePAR; MO$0.00-$8.95 (Tier

2)ENTRESTO

MO$0.00-$8.95 (Tier 2)

eplerenone

MO$0 (Tier 1)eprosartan mesylate



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

ezetimibe

MO$0 (Tier 1)felodipine erMO$0.00-$8.95 (Tier

2)fenofibrate micronized

MO$0.00-$8.95 (Tier 2)

fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg

MO$0.00-$8.95 (Tier 2)

fenofibric acid oral capsule delayed release

MO$0.00-$8.95 (Tier 2)

flecainide acetate

MO$0 (Tier 1)fosinopril sodiumMO$0 (Tier 1)fosinopril sodium-hctzMO$0.00-$8.95 (Tier

2)furosemide injection solution 10 mg/ml

$0.00-$8.95 (Tier 2)

furosemide injection solution 10 mg/ml (4ml syringe)

MO$0.00-$8.95 (Tier 2)

furosemide oral solution 10 mg/ml, 8 mg/ml

MO$0 (Tier 1)furosemide oral tabletMO$0.00-$8.95 (Tier

2)gemfibrozil oral

MO$0.00-$8.95 (Tier 2)

hydralazine hcl injection

MO$0.00-$8.95 (Tier 2)

hydralazine hcl oral

MO$0 (Tier 1)hydrochlorothiazide oralMO$0.00-$8.95 (Tier

2)indapamide oral

MO$0 (Tier 1)irbesartanMO$0 (Tier 1)irbesartan-hydrochlorothiazideMO$0 (Tier 1)irbesartan-hydrochlorothiazideMO$0.00-$8.95 (Tier

2)isosorbide dinitrate er



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

isosorbide dinitrate oral

MO$0.00-$8.95 (Tier 2)

isosorbide mononitrate

MO$0.00-$8.95 (Tier 2)

isosorbide mononitrate er

PAR; LA; NE$0.00-$8.95 (Tier 2)

JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5 MG


JUXTAPID ORAL CAPSULE 30 MG, 40 MG, 60 MG

MO$0 (Tier 1)labetalol hcl intravenous solutionMO$0 (Tier 1)labetalol hcl oralPAR; MO$0.00-$8.95 (Tier

2)LANOXIN ORAL TABLET 250 MCG

MO$0.00-$8.95 (Tier 2)

LANOXIN ORAL TABLET 62.5 MCG

MO$0.00-$8.95 (Tier 2)

lidocaine hcl (cardiac) pf intravenous solution prefilled syringe 100 mg/5ml

MO$0 (Tier 1)lisinopril oralMO$0 (Tier 1)lisinopril-hydrochlorothiazideMO$0 (Tier 1)losartan potassiumMO$0 (Tier 1)losartan potassium-hctzMO$0 (Tier 1)lovastatinMO$0.00-$8.95 (Tier

2)methazolamide oral

MO$0.00-$8.95 (Tier 2)

methyclothiazide oral

MO$0.00-$8.95 (Tier 2)

metolazone

MO$0 (Tier 1)metoprolol succinate erMO$0 (Tier 1)metoprolol tartrate intravenous solution 5 mg/

5mlMO$0.00-$8.95 (Tier

2)metoprolol tartrate intravenous solution cartridge



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 1)metoprolol tartrate oralMO$0 (Tier 1)metoprolol-hydrochlorothiazideMO$0.00-$8.95 (Tier

2)mexiletine hcl oral

MO$0.00-$8.95 (Tier 2)

midodrine hcl

MO$0.00-$8.95 (Tier 2)

minitran

MO$0.00-$8.95 (Tier 2)

minoxidil oral


MULTAQ

MO$0 (Tier 1)nadolol oral tablet 20 mg, 40 mg, 80 mgMO$0 (Tier 1)nadolol-bendroflumethiazide oral tablet 40-5

mgMO$0.00-$8.95 (Tier

2)niacin (antihyperlipidemic)

MO$0.00-$8.95 (Tier 2)

niacin er (antihyperlipidemic)

MO$0.00-$8.95 (Tier 2)

niacor

MO$0 (Tier 1)nicardipine hcl oralMO$0 (Tier 1)nifedical xl oral tablet extended release 24 hour

60 mgMO$0 (Tier 1)nifedipine erMO$0 (Tier 1)nifedipine er osmotic releaseMO$0 (Tier 1)nimodipine oralMO$0.00-$8.95 (Tier

2)NITRO-BID

B/D PAR; MO$0.00-$8.95 (Tier 2)

NITROGLYCERIN INTRAVENOUS

MO$0.00-$8.95 (Tier 2)

nitroglycerin sublingual



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

nitroglycerin transdermal patch 24 hour


NORTHERA ORAL CAPSULE 100 MG





MO$0.00-$8.95 (Tier 2)

olmesartan-amlodipine-hctz

MO$0.00-$8.95 (Tier 2)

omega-3-acid ethyl esters

MO$0.00-$8.95 (Tier 2)

pacerone oral tablet 100 mg, 200 mg, 400 mg

MO$0.00-$8.95 (Tier 2)

pentoxifylline er

MO$0 (Tier 1)pindololPAR; NE; QLL (2 per 28 days)$0.00-$8.95 (Tier

2)PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR

MO$0 (Tier 1)pravastatin sodiumMO$0 (Tier 1)prazosin hcl oralMO$0.00-$8.95 (Tier

2)prevalite

MO$0.00-$8.95 (Tier 2)

procainamide hcl injection

MO$0.00-$8.95 (Tier 2)

propafenone hcl

MO$0 (Tier 1)propranolol hcl erMO$0 (Tier 1)propranolol hcl intravenousMO$0 (Tier 1)propranolol hcl oralMO$0 (Tier 1)quinapril hclMO$0 (Tier 1)quinapril-hydrochlorothiazideMO$0.00-$8.95 (Tier

2)quinidine sulfate oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 1)ramiprilST; MO$0.00-$8.95 (Tier

2)RANEXA

ST; MO$0.00-$8.95 (Tier 2)

ranolazine er


RECTIV


REPATHA


REPATHA PUSHTRONEX SYSTEM


REPATHA SURECLICK

MO$0.00-$8.95 (Tier 2)

rosuvastatin calcium

MO$0 (Tier 1)simvastatin oralMO$0 (Tier 1)sorineMO$0 (Tier 1)sotalol hcl (af) oral tablet 120 mgMO$0.00-$8.95 (Tier

2)sotalol hcl (af) oral tablet 160 mg, 80 mg

MO$0 (Tier 1)sotalol hcl oralMO$0.00-$8.95 (Tier

2)spironolactone oral

MO$0.00-$8.95 (Tier 2)

spironolactone-hctz

MO$0 (Tier 1)taztia xtMO$0.00-$8.95 (Tier

2)TEKTURNA

MO$0.00-$8.95 (Tier 2)

telmisartan

MO$0.00-$8.95 (Tier 2)

telmisartan-amlodipine oral tablet 80-5 mg

MO$0.00-$8.95 (Tier 2)

telmisartan-hctz



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 1)terazosin hcl oralMO$0 (Tier 1)timolol maleate oralMO$0.00-$8.95 (Tier

2)torsemide oral

MO$0 (Tier 1)trandolaprilMO$0.00-$8.95 (Tier

2)triamterene-hctz oral capsule 37.5-25 mg

MO$0.00-$8.95 (Tier 2)

triamterene-hctz oral tablet


UPTRAVI ORAL TABLET

PAR; LA; NE; QLL (400 per 365 days)

$0.00-$8.95 (Tier 2)

UPTRAVI ORAL TABLET THERAPY PACK

MO$0.00-$8.95 (Tier 2)

valsartan

MO$0 (Tier 1)valsartan-hydrochlorothiazideMO$0.00-$8.95 (Tier

2)VASCEPA

MO$0 (Tier 1)verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg

MO$0.00-$8.95 (Tier 2)

verapamil hcl er oral capsule extended release 24 hour 360 mg

MO$0 (Tier 1)verapamil hcl er oral tablet extended releaseMO$0 (Tier 1)verapamil hcl intravenousMO$0 (Tier 1)verapamil hcl oral

CENTRAL NERVOUS SYSTEM AGENTS

$0.00-$8.95 (Tier 2)

acetylcysteine intravenous


amphetamine-dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg


amphetamine-dextroamphetamine oral tablet 30 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc


atomoxetine hcl oral capsule 10 mg, 18 mg, 25 mg, 40 mg


atomoxetine hcl oral capsule 100 mg, 60 mg, 80 mg


AUBAGIO


AVONEX PEN INTRAMUSCULAR AUTO- INJECTOR KIT


AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT

PAR; [*]$0 (Tier 3)benzphetamine hcl tablet 50 mg oralPAR; NE; QLL (15 per 30 days)$0.00-$8.95 (Tier

2)BETASERON SUBCUTANEOUS KIT


dalfampridine er


dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 5 mg


dextroamphetamine sulfate er oral capsule extended release 24 hour 15 mg


dextroamphetamine sulfate oral tablet 10 mg


dextroamphetamine sulfate oral tablet 5 mg

MO$0.00-$8.95 (Tier 2)

diazepam injection


diazepam intensol











Giá Thuốc

(Theo Bậc)

Tên Thuốc


EXTAVIA SUBCUTANEOUS KIT


GILENYA ORAL CAPSULE 0.5 MG


glatiramer acetate subcutaneous solution prefilled syringe 20 mg/ml


glatiramer acetate subcutaneous solution prefilled syringe 40 mg/ml


glatopa subcutaneous solution prefilled syringe 20 mg/ml


glatopa subcutaneous solution prefilled syringe 40 mg/ml


guanfacine hcl er


lorazepam intensol


methylphenidate hcl oral tablet


NUEDEXTA

PAR; [*]$0 (Tier 3)phentermine hcl capsule 15 mg oralPAR; [*]$0 (Tier 3)phentermine hcl capsule 30 mg oralPAR; [*]$0 (Tier 3)phentermine hcl capsule 37.5 mg oralPAR; [*]$0 (Tier 3)phentermine hcl tablet 37.5 mg oral

$0.00-$8.95 (Tier 2)

riluzole


SAVELLA ORAL TABLET 100 MG


SAVELLA ORAL TABLET 12.5 MG







Giá Thuốc

(Theo Bậc)

Tên Thuốc


SAVELLA TITRATION PACK

PAR; LA; NE$0.00-$8.95 (Tier 2)

TECFIDERA


tetrabenazine oral tablet 12.5 mg


tetrabenazine oral tablet 25 mg

PAR; LA; NE$0.00-$8.95 (Tier 2)

TYSABRI

MO$0.00-$8.95 (Tier 2)

VECAMYL


zenzedi oral tablet 10 mg


zenzedi oral tablet 5 mg

PAR; MO; NE$0.00-$8.95 (Tier 2)

ZULRESSO

DENTAL AND ORAL AGENTS

MO$0.00-$8.95 (Tier 2)

chlorhexidine gluconate mouth/throat

MO$0.00-$8.95 (Tier 2)

clotrimazole mouth/throat troche

MO$0.00-$8.95 (Tier 2)

doxycycline hyclate oral capsule

MO$0.00-$8.95 (Tier 2)

doxycycline hyclate oral tablet 100 mg, 20 mg

MO$0.00-$8.95 (Tier 2)

doxycycline monohydrate oral tablet 50 mg

MO$0.00-$8.95 (Tier 2)

minocycline hcl oral

MO$0.00-$8.95 (Tier 2)

mondoxyne nl oral capsule 100 mg, 75 mg

MO$0.00-$8.95 (Tier 2)

oralone



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

paroex

MO$0.00-$8.95 (Tier 2)

periogard

MO$0.00-$8.95 (Tier 2)

pilocarpine hcl oral

MO$0.00-$8.95 (Tier 2)

triamcinolone acetonide mouth/throat

DERMATOLOGICAL AGENTS

[*]$0 (Tier 4)3 day vaginal cream 2 % vaginal[*]$0 (Tier 4)ABREVA CREAM 10 % EXTERNALMO$0.00-$8.95 (Tier

2)acitretin oral capsule 10 mg

MO; NE$0.00-$8.95 (Tier 2)

acitretin oral capsule 17.5 mg, 25 mg

[*]$0 (Tier 4)ACNE MEDICATION 10 GEL 10 % EXTERNALMO$0.00-$8.95 (Tier

2)adapalene external gel 0.3 %

MO$0.00-$8.95 (Tier 2)

ammonium lactate external

MO$0.00-$8.95 (Tier 2)

amnesteem

[*]$0 (Tier 4)anti-dandruff shampoo 1 % external[*]$0 (Tier 4)anti-itch maximum strength cream 1 % external[*]$0 (Tier 4)antifungal cream 2 % externalPAR; MO; QLL (45 per 30 days)$0.00-$8.95 (Tier

2)avita

[*]$0 (Tier 4)benzoyl peroxide gel 10 % external (otc)[*]$0 (Tier 4)benzoyl peroxide gel 5 % external (otc)MO$0.00-$8.95 (Tier

2)benzoyl peroxide-erythromycin

MO$0.00-$8.95 (Tier 2)

beser external lotion



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

betamethasone dipropionate external lotion

[*]$0 (Tier 4)calamine lotion 8-8 % externalMO; QLL (120 per 30 days)$0.00-$8.95 (Tier

2)calcipotriene external cream


calcipotriene external ointment


calcipotriene external solution


calcitrene

MO$0.00-$8.95 (Tier 2)

ciclodan external solution

MO$0.00-$8.95 (Tier 2)

claravis

MO$0.00-$8.95 (Tier 2)

clindacin etz external swab

MO$0.00-$8.95 (Tier 2)

clotrimazole-betamethasone external cream

[*]$0 (Tier 4)cvs lice killing shampoo 0.33-4 % external[*]$0 (Tier 4)cvs lice solution kit combination[*]$0 (Tier 4)desenex powder 2 % externalMO; QLL (1000 per 30 days)$0.00-$8.95 (Tier

2)diclofenac sodium transdermal gel 1 %

MO$0.00-$8.95 (Tier 2)

doxycycline hyclate oral capsule 50 mg

MO$0.00-$8.95 (Tier 2)

doxycycline monohydrate oral capsule 100 mg, 50 mg

MO$0.00-$8.95 (Tier 2)

doxycycline monohydrate oral tablet 100 mg, 50 mg

[*]$0 (Tier 4)eq lice killing max st shampoo 0.33-4 % external

[*]$0 (Tier 4)eql lice killing max st shampoo 0.33-4 % external



Giá Thuốc

(Theo Bậc)

Tên Thuốc


fluocinolone acetonide body


fluocinonide external cream 0.05 %

MO$0.00-$8.95 (Tier 2)

fluorouracil external cream 5 %

MO$0.00-$8.95 (Tier 2)

fluorouracil external solution

MO$0.00-$8.95 (Tier 2)

fluticasone propionate external

[*]$0 (Tier 4)gnp calamine lotion 8-8 % external[*]$0 (Tier 4)gnp clotrimazole 3 cream 2 % vaginal[*]$0 (Tier 4)gnp hydrocortisone cream 0.5 % external[*]$0 (Tier 4)gnp hydrocortisone max st ointment 1 %

external[*]$0 (Tier 4)gnp hydrocortisone plus cream 1 % external[*]$0 (Tier 4)gnp hydrocortisone/aloe cream 1 % external[*]$0 (Tier 4)gnp lice treatment liquid 1 % external[*]$0 (Tier 4)gnp lice treatment shampoo 0.33-4 % external[*]$0 (Tier 4)gnp miconazole 3 kit 200 & 2 mg-% (9gm)

vaginal[*]$0 (Tier 4)gnp miconazole 7 cream 2 % vaginal[*]$0 (Tier 4)gnp miconazorb af powder 2 % external[*]$0 (Tier 4)hm calamine lotion 8-8 % external[*]$0 (Tier 4)hm hydrocortisone plus cream 1 % external[*]$0 (Tier 4)hm hydrocortisone-aloe max st cream 1 %

external[*]$0 (Tier 4)hm lice killing max st shampoo 0.33-4 %

external[*]$0 (Tier 4)hm lice treatment liquid 1 % external[*]$0 (Tier 4)hydrocortisone cream 0.5 % external[*]$0 (Tier 4)hydrocortisone cream 1 % external (otc)[*]$0 (Tier 4)hydrocortisone max st cream 1 % external



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)hydrocortisone max st/12 moist cream 1 % external

[*]$0 (Tier 4)hydrocortisone ointment 0.5 % external[*]$0 (Tier 4)hydrocortisone ointment 1 % external (otc)[*]$0 (Tier 4)hydrocortisone-aloe cream 0.5 % externalMO$0.00-$8.95 (Tier

2)imiquimod external

MO$0.00-$8.95 (Tier 2)

isotretinoin oral capsule 10 mg, 20 mg, 30 mg

MO; NE$0.00-$8.95 (Tier 2)

isotretinoin oral capsule 40 mg

[*]$0 (Tier 4)lice killing maximum strength shampoo 0.33-4 % external

MO$0.00-$8.95 (Tier 2)

mafenide acetate external

NE$0.00-$8.95 (Tier 2)

methoxsalen rapid

[*]$0 (Tier 4)miconazole 3 combo pack kit 200 & 2 mg-% (9gm) vaginal

[*]$0 (Tier 4)miconazole 7 cream 2 % vaginal[*]$0 (Tier 4)miconazole 7 suppository 100 mg vaginal[*]$0 (Tier 4)miconazole nitrate cream 2 % external[*]$0 (Tier 4)miconazole nitrate cream 2 % vaginalMO$0.00-$8.95 (Tier

2)mondoxyne nl oral capsule 100 mg, 75 mg

MO$0.00-$8.95 (Tier 2)

myorisan

MO$0.00-$8.95 (Tier 2)

nystatin-triamcinolone external cream

MO; NE$0.00-$8.95 (Tier 2)

PICATO


pimecrolimus



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

podofilox external

[*]$0 (Tier 4)qc 3 day cream 4 % vaginal[*]$0 (Tier 4)qc calamine lotion external[*]$0 (Tier 4)qc miconazole 7 cream 2 % vaginal[*]$0 (Tier 4)ra lice maximum strength shampoo 0.33-4 %

external[*]$0 (Tier 4)REESES PINWORM MEDICINE

SUSPENSION 144 (50 BASE) MG/ML ORAL[*]$0 (Tier 4)remedy phytoplex antifungal powder 2 %

external[*]$0 (Tier 4)rid complete lice elimination kit combinationMO$0.00-$8.95 (Tier

2)rosadan external cream

MO$0.00-$8.95 (Tier 2)

rosadan external gel


SANTYL

[*]$0 (Tier 4)sb lice killing max st shampoo 0.33-4 % external

[*]$0 (Tier 4)scalpicin maximum strength solution 1 % external

MO$0.00-$8.95 (Tier 2)

selenium sulfide external lotion

[*]$0 (Tier 4)sm 3-day vaginal cream 2 % vaginal[*]$0 (Tier 4)sm clotrimazole vaginal cream 1 % vaginal[*]$0 (Tier 4)sm hydrocortisone max st ointment 1 %

external[*]$0 (Tier 4)sm lice killing max strength shampoo 0.33-4 %

external[*]$0 (Tier 4)sm lice killing shampoo 0.33-4 % external[*]$0 (Tier 4)sm lice treatment lotion 1 % external[*]$0 (Tier 4)sm miconazole 7 cream 2 % vaginal



Giá Thuốc

(Theo Bậc)

Tên Thuốc


STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 45 MG/0.5ML

[*]$0 (Tier 4)stop lice maximum strength shampoo 0.33-4 % external


tacrolimus external

PAR; MO$0.00-$8.95 (Tier 2)

tazarotene external

PAR; MO$0.00-$8.95 (Tier 2)

TAZORAC EXTERNAL CREAM 0.05 %

PAR; MO$0.00-$8.95 (Tier 2)

TAZORAC EXTERNAL GEL


tretinoin external cream


tretinoin external gel 0.01 %, 0.025 %

MO$0.00-$8.95 (Tier 2)

triderm external cream 0.5 %

PAR; LA; NE$0.00-$8.95 (Tier 2)

VALCHLOR

[*]$0 (Tier 4)zeasorb-af powder 2 % externalMO$0.00-$8.95 (Tier

2)zenatane

ELECTROLYTES/MINERALS/METALS/VITAMINS

B/D PAR; MO$0.00-$8.95 (Tier 2)

AMINOSYN II INTRAVENOUS SOLUTION 10 %, 15 %

B/D PAR; MO$0.00-$8.95 (Tier 2)

AMINOSYN-PF

[*]$0 (Tier 4)antacid calcium extra strength tablet chewable 750 mg oral

[*]$0 (Tier 4)antacid calcium tablet chewable 500 mg oral[*]$0 (Tier 4)aqueous vitamin d liquid 400 unit/ml oral[*]$0 (Tier 4)ascorbic acid tablet 500 mg oral[*]$0 (Tier 4)b-1 tablet 100 mg oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)b-1 tablet 250 mg oral[*]$0 (Tier 4)b-12 dots tablet dispersible 500 mcg oral[*]$0 (Tier 4)b-12 tablet 100 mcg oral[*]$0 (Tier 4)b-12 tablet 500 mcg oral[*]$0 (Tier 4)b-2 tablet 100 mg oral[*]$0 (Tier 4)b-2 tablet 50 mg oral[*]$0 (Tier 4)b-6 tablet 100 mg oral[*]$0 (Tier 4)b-6 tablet 50 mg oral[*]$0 (Tier 4)c 1000 tablet 1000 mg oral[*]$0 (Tier 4)c 250 tablet 250 mg oral[*]$0 (Tier 4)c 500 tablet 500 mg oral[*]$0 (Tier 4)c-1000 tablet 1000 mg oral[*]$0 (Tier 4)c-1000/rose hips tablet 1000 mg oral[*]$0 (Tier 4)c-250 tablet 250 mg oral[*]$0 (Tier 4)c-500 tablet 500 mg oral[*]$0 (Tier 4)c-500/rose hips tablet 500 mg oral[*]$0 (Tier 4)cal-gest antacid tablet chewable 500 mg oral[*]$0 (Tier 4)calci-chew tablet chewable 1250 (500 ca) mg

oral[*]$0 (Tier 4)calcitrate tablet 950 mg oralMO$0.00-$8.95 (Tier

2)calcitriol intravenous solution 1 mcg/ml

[*]$0 (Tier 4)calcium + d3 tablet 600-200 mg-unit oral[*]$0 (Tier 4)calcium 500 + d tablet 500-125 mg-unit oral[*]$0 (Tier 4)calcium 500+d tablet 500-200 mg-unit oral[*]$0 (Tier 4)calcium 500+d tablet 500-400 mg-unit oral[*]$0 (Tier 4)calcium 500/d tablet 500-200 mg-unit oral[*]$0 (Tier 4)calcium 500/d tablet chewable 500-400 mg-unit

oral[*]$0 (Tier 4)calcium 600 high potency tablet 600 mg oral[*]$0 (Tier 4)calcium 600 tablet 1500 (600 ca) mg oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)calcium 600 tablet 600 mg oral[*]$0 (Tier 4)calcium 600+d tablet 600-200 mg-unit oral[*]$0 (Tier 4)calcium 600+d tablet 600-400 mg-unit oral[*]$0 (Tier 4)CALCIUM 600+D TABLET 600-800 MG-UNIT

ORAL[*]$0 (Tier 4)calcium 600+d3 tablet 600-400 mg-unit oral[*]$0 (Tier 4)CALCIUM 600+D3 TABLET 600-800 MG-UNIT

ORAL[*]$0 (Tier 4)calcium 600/vitamin d tablet 600-400 mg-unit

oral[*]$0 (Tier 4)calcium 600/vitamin d3 tablet 600-800 mg-unit

oral[*]$0 (Tier 4)CALCIUM 600/VITAMIN D3 TABLET 600-800

MG-UNIT ORAL[*]$0 (Tier 4)calcium antacid extra strength tablet chewable

750 mg oral[*]$0 (Tier 4)calcium antacid tablet chewable 500 mg oral[*]$0 (Tier 4)calcium ascorbate tablet 500 mg oral[*]$0 (Tier 4)calcium carbonate antacid suspension 1250

mg/5ml oral[*]$0 (Tier 4)calcium carbonate tablet 1250 (500 ca) mg oral[*]$0 (Tier 4)calcium carbonate tablet 1500 (600 ca) mg oral[*]$0 (Tier 4)calcium carbonate tablet 600 mg oral[*]$0 (Tier 4)calcium carbonate-vitamin d tablet 500-400

mg-unit oral[*]$0 (Tier 4)calcium carbonate-vitamin d tablet 600-400

mg-unit oral[*]$0 (Tier 4)calcium citrate + d tablet 250-200 mg-unit oral[*]$0 (Tier 4)calcium citrate + d tablet 315-200 mg-unit oral[*]$0 (Tier 4)CALCIUM CITRATE + D TABLET 315-200 MG-

UNIT ORAL[*]$0 (Tier 4)CALCIUM CITRATE + D3 MAXIMUM TABLET

315-250 MG-UNIT ORAL



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)calcium citrate tablet 200 mg oral[*]$0 (Tier 4)calcium citrate tablet 250 mg oral[*]$0 (Tier 4)CALCIUM CITRATE+D3 PETITES TABLET

200-250 MG-UNIT ORAL[*]$0 (Tier 4)CALCIUM CITRATE+D3 TABLET 315-250 MG-

UNIT ORAL[*]$0 (Tier 4)calcium citrate-vitamin d tablet 315-200 mg-unit

oral[*]$0 (Tier 4)CALCIUM CITRATE-VITAMIN D TABLET 315-

250 MG-UNIT ORAL[*]$0 (Tier 4)CALCIUM CITRATE-VITAMIN D3 TABLET

315-250 MG-UNIT ORAL[*]$0 (Tier 4)calcium high potency tablet 600 mg oral[*]$0 (Tier 4)CALCIUM HIGH POTENCY/VITAMIN D

TABLET 600-200 MG-UNIT ORAL[*]$0 (Tier 4)calcium plus vitamin d3 tablet 600-800 mg-unit

oral[*]$0 (Tier 4)CALCIUM TABLET CHEWABLE 500-100 MG-

UNIT ORAL[*]$0 (Tier 4)CALCIUM+D3 TABLET 600-800 MG-UNIT

ORAL[*]$0 (Tier 4)calcium-vitamin d tablet 500-200 mg-unit oral[*]$0 (Tier 4)CALCIUM-VITAMIN D TABLET 600-200 MG-

UNIT ORAL[*]$0 (Tier 4)calcium-vitamin d tablet 600-400 mg-unit oral[*]$0 (Tier 4)calcium-vitamin d3 tablet 250-125 mg-unit oral[*]$0 (Tier 4)calcium-vitamin d3 tablet 500-400 mg-unit oral[*]$0 (Tier 4)calcium-vitamin d3 tablet 600-400 mg-unit oral[*]$0 (Tier 4)calcium/c/d tablet chewable 500-10-250 mg-

mg-unit oral[*]$0 (Tier 4)CALTRATE 600+D3 TABLET 600-800 MG-

UNIT ORALPAR; LA; NE$0.00-$8.95 (Tier

2)CARBAGLU



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; LA; NE$0.00-$8.95 (Tier 2)

CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT

[*]$0 (Tier 4)classic prenatal tablet 28-0.8 mg oralB/D PAR; MO$0.00-$8.95 (Tier

2)CLINIMIX E/DEXTROSE (2.75/5)

B/D PAR; MO$0.00-$8.95 (Tier 2)

CLINIMIX E/DEXTROSE (4.25/10)

B/D PAR; MO$0.00-$8.95 (Tier 2)

CLINIMIX E/DEXTROSE (4.25/5)

B/D PAR; MO$0.00-$8.95 (Tier 2)

CLINIMIX E/DEXTROSE (5/15)

B/D PAR; MO$0.00-$8.95 (Tier 2)

CLINIMIX E/DEXTROSE (5/20)

B/D PAR; MO$0.00-$8.95 (Tier 2)

CLINIMIX N14G30E

B/D PAR; MO$0.00-$8.95 (Tier 2)

CLINIMIX N9G15E

B/D PAR; MO$0.00-$8.95 (Tier 2)

CLINIMIX N9G20E

B/D PAR; MO$0.00-$8.95 (Tier 2)

CLINIMIX/DEXTROSE (4.25/10)

B/D PAR; MO$0.00-$8.95 (Tier 2)


B/D PAR; MO$0.00-$8.95 (Tier 2)


B/D PAR; MO$0.00-$8.95 (Tier 2)

CLINIMIX/DEXTROSE (5/15)

B/D PAR; MO$0.00-$8.95 (Tier 2)


B/D PAR; MO$0.00-$8.95 (Tier 2)


[*]$0 (Tier 4)cvs b-1 tablet 100 mg oral[*]$0 (Tier 4)cvs b-12 tablet 500 mcg oral[*]$0 (Tier 4)CVS CALCIUM 600 & VITAMIN D3 TABLET

600-800 MG-UNIT ORAL



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)CVS CALCIUM 600+D TABLET 600-800 MG- UNIT ORAL

[*]$0 (Tier 4)CVS CALCIUM CITRATE +D TABLET 315-250 MG-UNIT ORAL

[*]$0 (Tier 4)CVS CALCIUM CITRATE +D3 MINI TABLET 200-250 MG-UNIT ORAL

[*]$0 (Tier 4)cvs d3 capsule 1000 unit oral[*]$0 (Tier 4)cvs d3 capsule 2000 unit oral[*]$0 (Tier 4)cvs d3 capsule 400 unit oral[*]$0 (Tier 4)cvs d3 capsule 5000 unit oral[*]$0 (Tier 4)cvs iron tablet 325 (65 fe) mg oral[*]$0 (Tier 4)cvs oyster shell calcium+vit d tablet 500-125

mg-unit oral[*]$0 (Tier 3)cyanocobalamin solution 1000 mcg/ml injection[*]$0 (Tier 4)d 1000 capsule 1000 unit oral[*]$0 (Tier 4)d 400 tablet 400 unit oral[*]$0 (Tier 4)d 5000 capsule 5000 unit oral[*]$0 (Tier 4)d 5000 tablet 5000 unit oral[*]$0 (Tier 4)d-3-5 capsule 5000 unit oral[*]$0 (Tier 4)d-vi-sol liquid 400 unit/ml oral[*]$0 (Tier 4)d2000 ultra strength capsule 2000 unit oral[*]$0 (Tier 4)D3 DOTS TABLET DISPERSIBLE 2000 UNIT

ORAL[*]$0 (Tier 4)d3 high potency capsule 1000 unit oral[*]$0 (Tier 4)d3 super strength capsule 2000 unit oral[*]$0 (Tier 4)d3-1000 capsule 1000 unit oral[*]$0 (Tier 4)d3-1000 tablet 1000 unit oralPAR; NE$0.00-$8.95 (Tier

2)deferasirox

[*]$0 (Tier 4)delta d3 tablet 400 unit oralMO; NE$0.00-$8.95 (Tier

2)DEPEN TITRATABS



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

dextrose in lactated ringers

MO$0.00-$8.95 (Tier 2)

dextrose intravenous solution 10 %, 5 %

MO$0.00-$8.95 (Tier 2)

DEXTROSE INTRAVENOUS SOLUTION 20 %, 40 %

MO$0.00-$8.95 (Tier 2)

dextrose intravenous solution 250 mg/ml, 30 %, 70 %

$0.00-$8.95 (Tier 2)

dextrose intravenous solution 50 %

MO$0.00-$8.95 (Tier 2)

DEXTROSE-NACL INTRAVENOUS SOLUTION 10-0.2 %

MO$0.00-$8.95 (Tier 2)

dextrose-nacl intravenous solution 10-0.45 %, 2.5-0.45 %, 5-0.2 %, 5-0.225 %, 5-0.33 %, 5- 0.45 %, 5-0.9 %

[*]$0 (Tier 4)dialyvite vitamin d 5000 capsule 5000 unit oralB/D PAR; MO$0.00-$8.95 (Tier

2)doxercalciferol oral capsule 0.5 mcg

MO$0.00-$8.95 (Tier 2)

elite-ob

[*]$0 (Tier 4)eq calcium 600+d tablet 600-800 mg-unit oral[*]$0 (Tier 4)EQ CALCIUM CITRATE+D TABLET 315-250

MG-UNIT ORAL[*]$0 (Tier 4)eql b-6 tablet 100 mg oral[*]$0 (Tier 4)eql vitamin b-12 tablet 500 mcg oral[*]$0 (Tier 4)eql vitamin c tablet 1000 mg oral[*]$0 (Tier 4)eql vitamin c tablet 500 mg oral[*]$0 (Tier 4)eql vitamin c/rose hips tablet 1000 mg oral[*]$0 (Tier 4)eql vitamin c/rose hips tablet 500 mg oralPAR; LA; NE$0.00-$8.95 (Tier

2)EXJADE

[*]$0 (Tier 4)ferate tablet 240 (27 fe) mg oral[*]$0 (Tier 4)ferosul tablet 325 (65 fe) mg oral[*]$0 (Tier 4)ferretts tablet 325 (106 fe) mg oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)ferrex 150 capsule 150 mg oral[*]$0 (Tier 4)ferric x-150 capsule 150 mg oral[*]$0 (Tier 4)ferrous gluconate tablet 240 (27 fe) mg oral[*]$0 (Tier 4)ferrous gluconate tablet 324 (37.5 fe) mg oral[*]$0 (Tier 4)ferrous gluconate tablet 324 (38 fe) mg oral[*]$0 (Tier 4)ferrous sulfate tablet 325 (65 fe) mg oral[*]$0 (Tier 4)ferrous sulfate tablet delayed release 324 (65

fe) mg oral[*]$0 (Tier 4)ferrous sulfate tablet delayed release 325 (65

fe) mg oral[*]$0 (Tier 4)ferrousul tablet 325 (65 fe) mg oral

$0.00-$8.95 (Tier 2)

fluoritab oral tablet chewable 2.2 (1 f) mg

[*]$0 (Tier 4)folic acid tablet 1 mg oral (otc)[*]$0 (Tier 3)folic acid tablet 1 mg oral (rx)[*]$0 (Tier 4)folic acid tablet 400 mcg oral[*]$0 (Tier 4)folic acid tablet 800 mcg oralB/D PAR; MO$0.00-$8.95 (Tier

2)FREAMINE III INTRAVENOUS SOLUTION 10 %

MO$0.00-$8.95 (Tier 2)

glucose intravenous

[*]$0 (Tier 4)gnp antacid anti-gas suspension 200-200-20 mg/5ml oral

[*]$0 (Tier 4)gnp calcium 500 +d3 tablet 500-600 mg-unit oral

[*]$0 (Tier 4)GNP CALCIUM 600 +D3 TABLET 600-800 MG-UNIT ORAL

[*]$0 (Tier 4)GNP CALCIUM CITRATE +D3 TABLET 315- 250 MG-UNIT ORAL

[*]$0 (Tier 4)gnp calcium tablet 600 mg oral[*]$0 (Tier 4)gnp folic acid tablet 400 mcg oral[*]$0 (Tier 4)gnp iron tablet 200 (65 fe) mg oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)gnp milk of magnesia suspension 1200 mg/ 15ml oral

[*]$0 (Tier 4)gnp niacin tablet 250 mg oral[*]$0 (Tier 4)gnp prenatal tablet 28-0.8 mg oral[*]$0 (Tier 4)gnp vitamin c tablet 1000 mg oral[*]$0 (Tier 4)gnp vitamin c tablet 250 mg oral[*]$0 (Tier 4)gnp vitamin c tablet 500 mg oral[*]$0 (Tier 4)gnp vitamin c w/rose hips tablet 500-37 mg oral[*]$0 (Tier 4)gnp vitamin c/rose hips tablet 1000 mg oral[*]$0 (Tier 4)gnp vitamin d-400 tablet 400 unit oralB/D PAR; MO$0.00-$8.95 (Tier

2)hepatamine

[*]$0 (Tier 4)HM CALCIUM CITRATE+D3 PETITE TABLET 200-250 MG-UNIT ORAL

[*]$0 (Tier 4)HM CALCIUM CITRATE+VITAMIN D TABLET 315-250 MG-UNIT ORAL

[*]$0 (Tier 4)hm calcium-vitamin d tablet 500-200 mg-unit oral



[*]$0 (Tier 4)hm folic acid tablet 400 mcg oral[*]$0 (Tier 4)hm iron tablet 200 (65 fe) mg oral[*]$0 (Tier 4)hm niacin tablet extended release 250 mg oral[*]$0 (Tier 4)hm vitamin b1 tablet 100 mg oral[*]$0 (Tier 4)hm vitamin b12 tablet 500 mcg oral[*]$0 (Tier 4)hm vitamin b6 tablet 100 mg oral[*]$0 (Tier 4)hm vitamin c tablet 1000 mg oral[*]$0 (Tier 4)hm vitamin c tablet 500 mg oral[*]$0 (Tier 4)hm vitamin c/rose hips tablet 500 mg oral[*]$0 (Tier 4)hm vitamin d3 capsule 2000 unit oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

B/D PAR; MO$0.00-$8.95 (Tier 2)

intralipid intravenous emulsion 20 %

B/D PAR; MO$0.00-$8.95 (Tier 2)

INTRALIPID INTRAVENOUS EMULSION 30 %

[*]$0 (Tier 4)iron (ferrous gluconate) tablet 256 (28 fe) mg oral

[*]$0 (Tier 4)iron tablet 325 (65 fe) mg oralMO$0.00-$8.95 (Tier

2)KCL IN D5W LACTATED RINGERS

MO$0.00-$8.95 (Tier 2)

kcl in dextrose-nacl intravenous solution 10-5- 0.45 meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5- 0.33 meq/l-%-%, 20-5-0.45 meq/l-%-%, 20-5- 0.9 meq/l-%-%, 30-5-0.45 meq/l-%-%, 40-5- 0.45 meq/l-%-%

MO$0.00-$8.95 (Tier 2)

KCL IN DEXTROSE-NACL INTRAVENOUS SOLUTION 20-5-0.225 MEQ/L-%-%

MO$0.00-$8.95 (Tier 2)

KCL IN DEXTROSE-NACL INTRAVENOUS SOLUTION 40-5-0.9 MEQ/L-%-%

MO$0.00-$8.95 (Tier 2)

KCL-LACTATED RINGERS-D5W

MO$0.00-$8.95 (Tier 2)

kionex oral suspension

MO$0.00-$8.95 (Tier 2)

klor-con 10

MO$0.00-$8.95 (Tier 2)

klor-con 10

MO$0 (Tier 1)klor-con m10MO$0 (Tier 1)klor-con m10MO$0.00-$8.95 (Tier

2)klor-con m15

MO$0.00-$8.95 (Tier 2)

klor-con m15

MO$0 (Tier 1)klor-con m20MO$0 (Tier 1)klor-con m20MO$0 (Tier 1)klor-con oral tablet extended release



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 1)klor-con oral tablet extended releaseMO$0 (Tier 1)klor-con sprinkleMO$0 (Tier 1)klor-con sprinkle oral capsule extended release

8 meq[*]$0 (Tier 4)KPN PRENATAL TABLET 0.1 MG ORALMO$0.00-$8.95 (Tier

2)lactated ringers intravenous

MO$0.00-$8.95 (Tier 2)

lactated ringers irrigation

B/D PAR; MO$0.00-$8.95 (Tier 2)

LEVOCARNITINE ORAL SOLUTION

B/D PAR; MO$0.00-$8.95 (Tier 2)

LEVOCARNITINE ORAL TABLET

MO$0.00-$8.95 (Tier 2)

ludent oral tablet chewable 2.2 (1 f) mg

[*]$0 (Tier 4)magnesium oxide (antacid) capsule 500 mg oral

MO$0.00-$8.95 (Tier 2)

magnesium sulfate injection solution 50 %

$0.00-$8.95 (Tier 2)

magnesium sulfate injection solution 50 % (10ml syringe)

MO$0.00-$8.95 (Tier 2)

MAGNESIUM SULFATE INTRAVENOUS SOLUTION 2 GM/50ML, 20 GM/500ML, 4 GM/ 100ML, 4 GM/50ML, 40 GM/1000ML

[*]$0 (Tier 4)meijer c tablet 500 mg oral[*]$0 (Tier 3)MEPHYTON TABLET 5 MG ORAL[*]$0 (Tier 4)mi-acid maximum strength suspension 400-

400-40 mg/5ml oral[*]$0 (Tier 4)mi-acid suspension 200-200-20 mg/5ml oral[*]$0 (Tier 4)milk of magnesia concentrate suspension 2400

mg/10ml oral[*]$0 (Tier 4)milk of magnesia suspension 400 mg/5ml oral[*]$0 (Tier 4)milk of magnesia suspension 7.75 % oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)mintox maximum strength suspension 400-400- 40 mg/5ml oral

PAR; NE$0.00-$8.95 (Tier 2)

MOZOBIL

[*]$0 (Tier 4)myferon 150 capsule 150 mg oral[*]$0 (Tier 4)natural c/rose hips tablet 1000 mg oral[*]$0 (Tier 4)natural vitamin d-3 tablet 5000 unit oralPAR; NE; QLL (1.2 per 28 days)$0.00-$8.95 (Tier

2)NEULASTA ONPRO

[*]$0 (Tier 4)niacin er capsule extended release 250 mg oral[*]$0 (Tier 4)niacin er capsule extended release 500 mg oral[*]$0 (Tier 4)niacin er tablet extended release 250 mg oral[*]$0 (Tier 4)niacin er tablet extended release 750 mg oral[*]$0 (Tier 4)niacin tablet 100 mg oral[*]$0 (Tier 4)niacin tablet 250 mg oral[*]$0 (Tier 4)niacin tablet 50 mg oral[*]$0 (Tier 4)niacin tablet 500 mg oralMO$0.00-$8.95 (Tier

2)NORMOSOL-M IN D5W

MO$0.00-$8.95 (Tier 2)

NORMOSOL-R

MO$0.00-$8.95 (Tier 2)

NORMOSOL-R PH 7.4

B/D PAR; MO$0.00-$8.95 (Tier 2)

nutrilipid

[*]$0 (Tier 4)omega-3 capsule 1000 mg oral[*]$0 (Tier 4)oysco 500 tablet 500 mg oral[*]$0 (Tier 4)oysco 500+d tablet 500-200 mg-unit oral[*]$0 (Tier 4)oyster shell calcium + d tablet 500-200 mg-unit

oral[*]$0 (Tier 4)oyster shell calcium + d3 tablet 500-400 mg-

unit oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)oyster shell calcium 250+d tablet 250-125 mg- unit oral

[*]$0 (Tier 4)oyster shell calcium 500 + d tablet 500-125 mg- unit oral

[*]$0 (Tier 4)oyster shell calcium 500+d tablet chewable 500-400 mg-unit oral

[*]$0 (Tier 4)oyster shell calcium plus d tablet 500-200 mg- unit oral

[*]$0 (Tier 4)oyster shell calcium tablet 500 mg oral[*]$0 (Tier 4)oyster shell calcium/d tablet 250-125 mg-unit

oral[*]$0 (Tier 4)oyster shell calcium/d tablet 500-200 mg-unit

oral[*]$0 (Tier 4)oyster shell calcium/d3 tablet 500-400 mg-unit

oral[*]$0 (Tier 4)oyster shell calcium/vitamin d tablet 250-125

mg-unit oral[*]$0 (Tier 4)oyster shell calcium/vitamin d tablet 500-200

mg-unit oral[*]$0 (Tier 4)oystercal-d tablet 500-400 mg-unit oralMO$0.00-$8.95 (Tier

2)PLASMA-LYTE 148

MO$0.00-$8.95 (Tier 2)

pnv-dha

[*]$0 (Tier 4)poly-iron 150 capsule 150 mg oralMO$0 (Tier 1)potassium chloride crys erMO$0 (Tier 1)potassium chloride erMO$0.00-$8.95 (Tier

2)potassium chloride in dextrose intravenous solution 20-5 meq/l-%, 40-5 meq/l-%

MO$0.00-$8.95 (Tier 2)

potassium chloride in nacl intravenous solution 20-0.45 meq/l-%, 20-0.9 meq/l-%

MO$0.00-$8.95 (Tier 2)

potassium chloride intravenous solution 10 meq/100ml, 2 meq/ml, 20 meq/100ml, 40 meq/ 100ml



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

potassium chloride intravenous solution 10 meq/50ml, 20 meq/50ml

MO$0 (Tier 1)potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%)

B/D PAR; MO$0.00-$8.95 (Tier 2)

PREMASOL INTRAVENOUS SOLUTION 10 %

[*]$0 (Tier 4)prenatal low iron tablet 27-0.8 mg oral[*]$0 (Tier 4)prenatal one daily tablet 27-0.8 mg oral[*]$0 (Tier 4)prenatal tablet 27-0.8 mg oral (otc)[*]$0 (Tier 4)prenatal tablet 28-0.8 mg oral[*]$0 (Tier 4)prenatal vitamin and mineral tablet 28-0.8 mg

oral[*]$0 (Tier 4)prenatal vitamins tablet 28-0.8 mg oral[*]$0 (Tier 4)pureway-c tablet 500 mg oral[*]$0 (Tier 4)ra calcium 600 tablet 600 mg oral[*]$0 (Tier 4)RA CALCIUM CIT-VIT D-3 PETITES TABLET

200-250 MG-UNIT ORAL[*]$0 (Tier 4)ra folic acid tablet 400 mcg oral[*]$0 (Tier 4)ra folic acid tablet 800 mcg oral[*]$0 (Tier 4)ra hi cal tablet 500-200 mg-unit oral[*]$0 (Tier 4)ra high potency iron tablet 27 mg oral[*]$0 (Tier 4)ra iron tablet 325 (65 fe) mg oral[*]$0 (Tier 4)ra magnesium capsule 500 mg oral[*]$0 (Tier 4)ra niacin tablet 100 mg oral[*]$0 (Tier 4)ra niacin tablet 500 mg oral[*]$0 (Tier 4)ra oyster shell calcium/d tablet 500-200 mg-unit

oral[*]$0 (Tier 4)ra vitamin c tablet 500 mg oral[*]$0 (Tier 4)ra vitamin c/rose hips tablet 1000 mg oral[*]$0 (Tier 4)ra vitamin c/rose hips tablet 500 mg oral[*]$0 (Tier 4)ra vitamin d-3 capsule 2000 unit oral[*]$0 (Tier 4)ra vitamin d-3 capsule 5000 unit oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

ringers

MO$0.00-$8.95 (Tier 2)

ringers irrigation

[*]$0 (Tier 4)risacal-d tablet 105-81-120 mg-mg-unit oral[*]$0 (Tier 4)sb vitamin c tablet 500 mg oral[*]$0 (Tier 4)slow iron tablet extended release 160 (50 fe)

mg oral[*]$0 (Tier 4)slow release iron tablet extended release 160

(50 fe) mg oral[*]$0 (Tier 4)sm antacid/antigas suspension 200-200-20 mg/

5ml oral[*]$0 (Tier 4)sm calcium 600/vitamin d tablet 600-400 mg-

unit oral[*]$0 (Tier 4)SM CALCIUM CITRATE W/VIT D3 TABLET

315-250 MG-UNIT ORAL[*]$0 (Tier 4)SM CALCIUM CITRATE+/VIT D3 TABLET 315-

250 MG-UNIT ORAL[*]$0 (Tier 4)sm calcium-vitamin d tablet 500-200 mg-unit

oral[*]$0 (Tier 4)sm chewable c tablet chewable 500 mg oral[*]$0 (Tier 4)sm folic acid tablet 400 mcg oral[*]$0 (Tier 4)sm iron slow release tablet extended release

160 (50 fe) mg oral[*]$0 (Tier 4)sm iron tablet 325 (65 fe) mg oral[*]$0 (Tier 4)sm niacin cr tablet extended release 250 mg

oral[*]$0 (Tier 4)sm oyster shell calcium/vit d3 tablet 500-400

mg-unit oral[*]$0 (Tier 4)sm prenatal vitamins tablet 28-0.8 mg oral[*]$0 (Tier 4)sm vit c/rose hips tablet 1000 mg oral[*]$0 (Tier 4)sm vitamin b-12 tablet 100 mcg oral[*]$0 (Tier 4)sm vitamin b-12 tablet 500 mcg oral[*]$0 (Tier 4)sm vitamin b-6 tablet 100 mg oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)sm vitamin b1 tablet 100 mg oral[*]$0 (Tier 4)sm vitamin c tablet 1000 mg oral[*]$0 (Tier 4)sm vitamin c tablet 250 mg oral[*]$0 (Tier 4)sm vitamin c tablet 500 mg oral[*]$0 (Tier 4)sm vitamin c/rose hips tablet 500 mg oral[*]$0 (Tier 4)sm vitamin d3 capsule 2000 unit oral[*]$0 (Tier 4)sm vitamin d3 tablet 1000 unit oral[*]$0 (Tier 4)sm vitamin e capsule 1000 unit oral[*]$0 (Tier 4)sm vitamin e capsule 200 unit oral[*]$0 (Tier 4)sm vitamin e capsule 400 unit oralMO$0.00-$8.95 (Tier

2)sodium chloride injection solution 2.5 meq/ml

MO$0.00-$8.95 (Tier 2)

sodium chloride intravenous solution 0.45 %, 0.9 %, 3 %, 5 %

MO$0.00-$8.95 (Tier 2)

sodium chloride intravenous solution 4 meq/ml

MO$0.00-$8.95 (Tier 2)

sodium chloride irrigation solution 0.9 %

MO$0.00-$8.95 (Tier 2)

sodium fluoride oral tablet 2.2 (1 f) mg

$0.00-$8.95 (Tier 2)

sodium fluoride oral tablet chewable 2.2 (1 f) mg

MO$0.00-$8.95 (Tier 2)

sodium polystyrene sulfonate oral suspension

MO$0.00-$8.95 (Tier 2)

sodium polystyrene sulfonate rectal

MO$0.00-$8.95 (Tier 2)

sps

MO$0.00-$8.95 (Tier 2)

sterile water for irrigation

[*]$0 (Tier 4)super calcium 600 + d 400 tablet 600-400 mg- unit oral

[*]$0 (Tier 4)super calcium 600 + d3 tablet 600-400 mg-unit oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)super calcium tablet 600 mg oralB/D PAR; MO$0.00-$8.95 (Tier

2)SYNTHAMIN 17

[*]$0 (Tier 4)TGT CALCIUM + VITAMIN D3 TABLET 600- 800 MG-UNIT ORAL

[*]$0 (Tier 4)thera-d rapid repletion tablet 2000 unit oral[*]$0 (Tier 4)thiamine hcl tablet 100 mg oralMO$0.00-$8.95 (Tier

2)tis-u-sol

B/D PAR; MO$0.00-$8.95 (Tier 2)

TRAVASOL

NE$0.00-$8.95 (Tier 2)

trientine hcl

B/D PAR; MO$0.00-$8.95 (Tier 2)

TROPHAMINE


VELPHORO

[*]$0 (Tier 4)VITAMIN A PALMITATE TABLET 10000 UNIT ORAL

[*]$0 (Tier 4)VITAMIN A PALMITATE TABLET 15000 UNIT ORAL

[*]$0 (Tier 4)vitamin b-1 tablet 100 mg oral[*]$0 (Tier 4)vitamin b-1 tablet 250 mg oral[*]$0 (Tier 4)vitamin b-1 tablet 50 mg oral[*]$0 (Tier 4)vitamin b-12 er tablet extended release 1000

mcg oral[*]$0 (Tier 4)vitamin b-12 tablet 100 mcg oral[*]$0 (Tier 4)vitamin b-12 tablet 1000 mcg oral[*]$0 (Tier 4)vitamin b-12 tablet 250 mcg oral[*]$0 (Tier 4)vitamin b-12 tablet 500 mcg oral[*]$0 (Tier 4)vitamin b-2 tablet 100 mg oral[*]$0 (Tier 4)vitamin b-2 tablet 25 mg oral[*]$0 (Tier 4)vitamin b-2 tablet 50 mg oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)vitamin b-6 tablet 100 mg oral[*]$0 (Tier 4)vitamin b-6 tablet 50 mg oral[*]$0 (Tier 4)vitamin b12 tablet 100 mcg oral[*]$0 (Tier 4)vitamin c tablet 1000 mg oral[*]$0 (Tier 4)vitamin c tablet 250 mg oral[*]$0 (Tier 4)vitamin c tablet 500 mg oral[*]$0 (Tier 4)vitamin c-rose hips tablet 1000 mg oral[*]$0 (Tier 4)vitamin c-rose hips tablet 500 mg oral[*]$0 (Tier 4)vitamin c/rose hips tablet 500 mg oral[*]$0 (Tier 4)vitamin d (cholecalciferol) capsule 1000 unit

oral[*]$0 (Tier 4)vitamin d (cholecalciferol) capsule 400 unit oral[*]$0 (Tier 4)vitamin d (cholecalciferol) tablet 1000 unit oral[*]$0 (Tier 4)vitamin d (cholecalciferol) tablet 400 unit oral[*]$0 (Tier 3)vitamin d (ergocalciferol) capsule 50000 unit

oral[*]$0 (Tier 4)vitamin d capsule 2000 unit oral[*]$0 (Tier 4)vitamin d high potency capsule 1000 unit oral[*]$0 (Tier 4)vitamin d liquid 400 unit/ml oral[*]$0 (Tier 4)vitamin d tablet 1000 unit oral[*]$0 (Tier 4)vitamin d tablet 2000 unit oral[*]$0 (Tier 4)vitamin d-3 capsule 1000 unit oral[*]$0 (Tier 4)vitamin d2 tablet 400 unit oral[*]$0 (Tier 4)vitamin d3 capsule 1000 unit oral[*]$0 (Tier 4)vitamin d3 capsule 2000 unit oral[*]$0 (Tier 4)vitamin d3 capsule 400 unit oral[*]$0 (Tier 4)vitamin d3 capsule 5000 unit oral[*]$0 (Tier 4)vitamin d3 maximum strength capsule 5000

unit oral[*]$0 (Tier 4)vitamin d3 tablet 1000 unit oral[*]$0 (Tier 4)vitamin d3 tablet 2000 unit oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)vitamin d3 tablet 400 unit oral[*]$0 (Tier 4)vitamin d3 tablet 5000 unit oral[*]$0 (Tier 4)vitamin e capsule 100 unit oral[*]$0 (Tier 4)vitamin e capsule 1000 unit oral[*]$0 (Tier 4)vitamin e capsule 200 unit oral[*]$0 (Tier 4)vitamin e capsule 400 unit oral[*]$0 (Tier 4)vitamin e water soluble capsule 1000 unit oralPAR; NE$0.00-$8.95 (Tier

2)VPRIV

GASTROINTESTINAL AGENTS

[*]$0 (Tier 4)acid gone suspension 95-358 mg/15ml oral[*]$0 (Tier 4)acid gone tablet chewable 160-105 mg oral[*]$0 (Tier 4)acid reducer maximum strength tablet 20 mg

oral[*]$0 (Tier 4)acid reducer tablet 10 mg oral[*]$0 (Tier 4)acid reducer tablet 75 mg oral[*]$0 (Tier 4)almacone double strength suspension 400-400-

40 mg/5ml oral[*]$0 (Tier 4)almacone suspension 200-200-20 mg/5ml oralPAR; MO; NE; QLL (60 per 30 days)$0.00-$8.95 (Tier

2)alosetron hcl

[*]$0 (Tier 4)aluminum hydroxide gel suspension 320 mg/ 5ml oral


AMITIZA

[*]$0 (Tier 4)antacid anti-gas max strength suspension 400- 400-40 mg/5ml oral

[*]$0 (Tier 4)antacid extra strength tablet chewable 750 mg oral

[*]$0 (Tier 4)antacid fast acting suspension 200-200-20 mg/ 5ml oral

[*]$0 (Tier 4)antacid fast relief suspension 200-200-20 mg/ 5ml oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)antacid maximum strength suspension 400- 400-40 mg/5ml oral

[*]$0 (Tier 4)antacid maximum tablet chewable 1000 mg oral

[*]$0 (Tier 4)antacid plus anti-gas fast act suspension 200- 200-20 mg/5ml oral

[*]$0 (Tier 4)antacid plus anti-gas relief suspension 200- 200-20 mg/5ml oral

[*]$0 (Tier 4)antacid plus anti-gas relief suspension 400- 400-40 mg/5ml oral

[*]$0 (Tier 4)antacid suspension 200-200-20 mg/5ml oral[*]$0 (Tier 4)antacid tablet chewable 500 mg oralMO$0.00-$8.95 (Tier

2)atropine sulfate injection solution prefilled syringe 0.25 mg/5ml, 1 mg/10ml

$0.00-$8.95 (Tier 2)

atropine sulfate injection solution prefilled syringe 0.5 mg/5ml

[*]$0 (Tier 4)bisacodyl ec tablet delayed release 5 mg oral[*]$0 (Tier 4)bisacodyl suppository 10 mg rectal[*]$0 (Tier 4)bismatrol maximum strength suspension 525

mg/15ml oral[*]$0 (Tier 4)bismatrol suspension 262 mg/15ml oral[*]$0 (Tier 4)bismatrol tablet chewable 262 mg oral[*]$0 (Tier 4)bismuth subsalicylate tablet chewable 262 mg

oralMO; NE$0.00-$8.95 (Tier

2)budesonide oral

[*]$0 (Tier 4)calcium antacid ultra max st tablet chewable 1000 mg oral

[*]$0 (Tier 4)calcium antacid ultra strength tablet chewable 1000 mg oral

[*]$0 (Tier 4)calcium carbonate antacid tablet chewable 750 mg oral

[*]$0 (Tier 4)clearlax powder oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

constulose

[*]$0 (Tier 4)cvs antacid kids tablet chewable 750 mg oral[*]$0 (Tier 4)cvs anti-diarrheal suspension 262 mg/15ml oral[*]$0 (Tier 4)cvs bismuth tablet 262 mg oral[*]$0 (Tier 4)cvs bismuth tablet chewable 262 mg oral[*]$0 (Tier 4)cvs chewy not chalky flavor tablet chewable

750 mg oral[*]$0 (Tier 4)cvs gas relief capsule 125 mg oral[*]$0 (Tier 4)cvs gas relief extra strength tablet chewable

125 mg oral[*]$0 (Tier 4)cvs gas relief ultra strength capsule 180 mg

oral[*]$0 (Tier 4)cvs glycerin adult suppository 2 gm rectal[*]$0 (Tier 4)cvs glycerin adult suppository 2.1 gm rectal[*]$0 (Tier 4)cvs heartburn relief tablet chewable 160-105

mg oral[*]$0 (Tier 4)cvs magnesium citrate solution 1.745 gm/30ml

oral[*]$0 (Tier 4)cvs mineral oil enema enema rectal[*]$0 (Tier 4)cvs mineral oil oil oral[*]$0 (Tier 4)cvs stomach relief suspension 525 mg/15ml

oral[*]$0 (Tier 4)cvs stomach relief tablet chewable 262 mg oral[*]$0 (Tier 4)diarrhea suspension 262 mg/15ml oralMO$0.00-$8.95 (Tier

2)dicyclomine hcl oral

MO$0.00-$8.95 (Tier 2)

diphenoxylate-atropine

[*]$0 (Tier 4)docu liquid 50 mg/5ml oral[*]$0 (Tier 4)docusate sodium capsule 100 mg oral[*]$0 (Tier 4)docusate sodium liquid 50 mg/5ml oral[*]$0 (Tier 4)docusate sodium tablet 100 mg oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)docusil capsule 100 mg oral[*]$0 (Tier 4)dok capsule 100 mg oral[*]$0 (Tier 4)dok capsule 250 mg oral[*]$0 (Tier 4)ducodyl tablet delayed release 5 mg oral[*]$0 (Tier 4)enema enema 7-19 gm/118ml rectal[*]$0 (Tier 4)enema mineral oil enema rectalMO$0.00-$8.95 (Tier

2)enulose

[*]$0 (Tier 4)eq antacid extra strength tablet chewable 750 mg oral

[*]$0 (Tier 4)eq antacid ultra strength tablet chewable 1000 mg oral

[*]$0 (Tier 4)eq gas relief capsule 125 mg oral[*]$0 (Tier 4)eq magnesium citrate solution 1.745 gm/30ml

oral[*]$0 (Tier 4)eq mineral oil oil oral[*]$0 (Tier 4)eq pink-bismuth tablet chewable 262 mg oral[*]$0 (Tier 4)eq stomach relief suspension 262 mg/15ml oral[*]$0 (Tier 4)eql stomach relief suspension 262 mg/15ml

oralMO$0.00-$8.95 (Tier

2)famotidine intravenous solution 20 mg/2ml, 200 mg/20ml, 40 mg/4ml

MO$0.00-$8.95 (Tier 2)

famotidine oral tablet 20 mg, 40 mg

MO$0.00-$8.95 (Tier 2)

famotidine premixed

[*]$0 (Tier 4)famotidine tablet 10 mg oral[*]$0 (Tier 4)gas relief capsule 180 mg oral[*]$0 (Tier 4)gas relief extra strength capsule 125 mg oral[*]$0 (Tier 4)gas relief extra strength tablet chewable 125

mg oral[*]$0 (Tier 4)gas relief tablet chewable 80 mg oral[*]$0 (Tier 4)gas relief ultra strength capsule 180 mg oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)GAS-X ULTRA STRENGTH CAPSULE 180 MG ORAL

PAR; LA; NE$0.00-$8.95 (Tier 2)

GATTEX

[*]$0 (Tier 4)gavilax powder oralMO$0.00-$8.95 (Tier

2)gavilyte-c

MO$0.00-$8.95 (Tier 2)

gavilyte-g

MO$0.00-$8.95 (Tier 2)

gavilyte-n with flavor pack

MO$0.00-$8.95 (Tier 2)

generlac

[*]$0 (Tier 4)geri-pectate suspension 262 mg/15ml oral[*]$0 (Tier 4)glycerin (adult) suppository 2 gm rectal[*]$0 (Tier 4)glycerin (adult) suppository 2.1 gm rectal[*]$0 (Tier 4)glycolax powder oralMO$0.00-$8.95 (Tier

2)glycopyrrolate injection solution 0.2 mg/ml

MO$0.00-$8.95 (Tier 2)

glycopyrrolate oral tablet 1 mg, 2 mg

[*]$0 (Tier 4)gnp acid control 150 max st tablet 150 mg oral[*]$0 (Tier 4)gnp acid reducer max st tablet 20 mg oral[*]$0 (Tier 4)gnp acid reducer tablet 75 mg oral[*]$0 (Tier 4)gnp antacid extra strength tablet chewable 160-

105 mg oral[*]$0 (Tier 4)gnp antacid extra strength tablet chewable 750

mg oral[*]$0 (Tier 4)gnp antacid tablet chewable 500 mg oral[*]$0 (Tier 4)gnp antacid ultra strength tablet chewable 1000

mg oral[*]$0 (Tier 4)gnp anti-gas capsule 180 mg oral[*]$0 (Tier 4)gnp bisa-lax tablet delayed release 5 mg oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)gnp clearlax powder oral[*]$0 (Tier 4)gnp gas relief extra strength capsule 125 mg

oral[*]$0 (Tier 4)gnp gas relief extra strength tablet chewable

125 mg oral[*]$0 (Tier 4)gnp gas relief tablet chewable 80 mg oral[*]$0 (Tier 4)gnp lansoprazole capsule delayed release 15

mg oral[*]$0 (Tier 4)gnp laxative tablet delayed release 5 mg oral[*]$0 (Tier 4)gnp magnesium citrate solution 1.745 gm/30ml

oral[*]$0 (Tier 4)gnp omeprazole tablet delayed release 20 mg

oral[*]$0 (Tier 4)gnp pink bismuth tablet 262 mg oral[*]$0 (Tier 4)gnp pink bismuth tablet chewable 262 mg oral[*]$0 (Tier 4)gnp stomach relief suspension 262 mg/15ml

oral[*]$0 (Tier 4)gnp stool softener capsule 100 mg oral[*]$0 (Tier 4)gnp stool softener capsule 250 mg oral[*]$0 (Tier 4)goodsense gas relief tablet chewable 125 mg

oral[*]$0 (Tier 4)healthylax packet oral[*]$0 (Tier 4)heartburn antacid ex st tablet chewable 160-

105 mg oral[*]$0 (Tier 4)heartburn relief max st tablet 150 mg oral[*]$0 (Tier 4)heartburn relief max st tablet 20 mg oral[*]$0 (Tier 4)heartburn relief tablet 10 mg oral[*]$0 (Tier 4)hm acid reducer tablet 75 mg oral[*]$0 (Tier 4)hm advanced antacid max st suspension 400-

400-40 mg/5ml oral[*]$0 (Tier 4)hm antacid anti-gas ex st suspension 400-400-

40 mg/5ml oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)hm antacid/antigas suspension 200-200-20 mg/5ml oral

[*]$0 (Tier 4)hm calcium antacid ex st tablet chewable 750 mg oral

[*]$0 (Tier 4)hm clearlax powder oral[*]$0 (Tier 4)hm enema mineral oil enema rectal[*]$0 (Tier 4)hm famotidine tablet 10 mg oral[*]$0 (Tier 4)hm famotidine tablet 20 mg oral[*]$0 (Tier 4)hm magnesium citrate solution 1.745 gm/30ml

oral[*]$0 (Tier 4)hm milk of magnesia suspension 1200 mg/15ml

oral[*]$0 (Tier 4)hm mineral oil oil oral[*]$0 (Tier 4)hm omeprazole tablet delayed release 20 mg

oral[*]$0 (Tier 4)hm stomach relief suspension 262 mg/15ml

oral[*]$0 (Tier 4)hm stomach relief tablet chewable 262 mg oral[*]$0 (Tier 4)hm stool softener capsule 100 mg oral[*]$0 (Tier 4)hm stool softener capsule 250 mg oral[*]$0 (Tier 4)kao-tin capsule 240 mg oral[*]$0 (Tier 4)kaopectate extra strength suspension 525 mg/

15ml oral[*]$0 (Tier 4)kaopectate suspension 262 mg/15ml oralMO$0.00-$8.95 (Tier

2)lactulose encephalopathy

MO$0.00-$8.95 (Tier 2)

lactulose oral solution

[*]$0 (Tier 4)lansoprazole capsule delayed release 15 mg oral (otc)

MO$0.00-$8.95 (Tier 2)

lansoprazole oral capsule delayed release 15 mg


lansoprazole oral capsule delayed release 30 mg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)laxative suppository 10 mg rectalMO; QLL (30 per 30 days)$0.00-$8.95 (Tier

2)LINZESS

MO$0.00-$8.95 (Tier 2)

loperamide hcl oral capsule

[*]$0 (Tier 4)mag-al plus liquid 200-200-20 mg/5ml oral[*]$0 (Tier 4)mag-al plus xs liquid 400-400-40 mg/5ml oral[*]$0 (Tier 4)magnesium citrate solution 1.745 gm/30ml oralMO$0.00-$8.95 (Tier

2)mesalamine-cleanser

MO$0.00-$8.95 (Tier 2)

metoclopramide hcl injection

MO$0.00-$8.95 (Tier 2)

metoclopramide hcl oral solution 10 mg/10ml, 5 mg/5ml

MO$0.00-$8.95 (Tier 2)

metoclopramide hcl oral tablet

[*]$0 (Tier 4)mi-acid gas relief tablet chewable 80 mg oral[*]$0 (Tier 4)milk of magnesia suspension 1200 mg/15ml

oral[*]$0 (Tier 4)mineral oil enema rectal[*]$0 (Tier 4)mineral oil oil oral[*]$0 (Tier 4)mintox suspension 200-200-20 mg/5ml oralMO$0.00-$8.95 (Tier

2)misoprostol oral


MOVANTIK

MO$0.00-$8.95 (Tier 2)

MOVIPREP

MO; QLL (30 per 30 days)$0 (Tier 1)omeprazole oral capsule delayed release[*]$0 (Tier 4)omeprazole tablet delayed release 20 mg oralMO$0.00-$8.95 (Tier

2)pantoprazole sodium intravenous

MO; QLL (30 per 30 days)$0 (Tier 1)pantoprazole sodium oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)peg 3350 packet oral[*]$0 (Tier 4)peg 3350 powder oralMO$0.00-$8.95 (Tier

2)peg 3350-kcl-na bicarb-nacl

MO$0.00-$8.95 (Tier 2)

peg 3350/electrolytes

MO$0.00-$8.95 (Tier 2)

peg-3350/electrolytes

[*]$0 (Tier 4)peptic relief tablet chewable 262 mg oral[*]$0 (Tier 4)pepto-bismol tablet chewable 262 mg oral[*]$0 (Tier 4)pepto-bismol to-go tablet chewable 262 mg

oral[*]$0 (Tier 4)PHAZYME ULTRA STRENGTH CAPSULE

180 MG ORAL$0.00-$8.95 (Tier

2)polyethylene glycol 3350 oral packet

MO$0.00-$8.95 (Tier 2)

polyethylene glycol 3350 oral powder

[*]$0 (Tier 4)polyethylene glycol 3350 packet oral (otc)[*]$0 (Tier 4)polyethylene glycol 3350 powder oral (otc)MO$0.00-$8.95 (Tier

2)proctozone-hc rectal

[*]$0 (Tier 4)px gas relief extra strength capsule 125 mg oral

[*]$0 (Tier 4)px gas relief ultra strength capsule 180 mg oral[*]$0 (Tier 4)px stomach relief max st suspension 525 mg/

15ml oral[*]$0 (Tier 4)px stomach relief suspension 262 mg/15ml oral[*]$0 (Tier 4)px stomach relief tablet chewable 262 mg oral[*]$0 (Tier 4)qc acid controller max st tablet 20 mg oral[*]$0 (Tier 4)qc acid controller tablet 10 mg oral[*]$0 (Tier 4)qc antacid suspension 200-200-20 mg/5ml oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)qc antacid/anti-gas suspension 200-200-20 mg/5ml oral

[*]$0 (Tier 4)qc gentle laxative suppository 10 mg rectal[*]$0 (Tier 4)qc heartburn antacid tablet chewable 160-105

mg oral[*]$0 (Tier 4)qc magnesium citrate solution 1.745 gm/30ml

oral[*]$0 (Tier 4)qc milk of magnesia suspension 400 mg/5ml

oral[*]$0 (Tier 4)qc mineral oil heavy oil oral[*]$0 (Tier 4)ra gas relief capsule 125 mg oral[*]$0 (Tier 4)ra gas relief extra strength tablet chewable 125

mg oral[*]$0 (Tier 4)ra glycerin adult suppository 80.7 % rectal[*]$0 (Tier 4)ra mineral oil oil oral[*]$0 (Tier 4)ra pink bismuth tablet 262 mg oral[*]$0 (Tier 4)ra pink bismuth tablet chewable 262 mg oral[*]$0 (Tier 4)ra stomach relief max st suspension 525 mg/

15ml oral[*]$0 (Tier 4)ra stomach relief suspension 262 mg/15ml oralMO$0.00-$8.95 (Tier

2)ranitidine hcl injection

MO$0.00-$8.95 (Tier 2)

ranitidine hcl oral syrup

MO$0.00-$8.95 (Tier 2)

ranitidine hcl oral tablet 150 mg, 300 mg

[*]$0 (Tier 4)ranitidine hcl tablet 150 mg oral (otc)PAR; MO; NE; QLL (18 per 30 days)$0.00-$8.95 (Tier

2)RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML


RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML (0.6ML SYRINGE)


RELISTOR SUBCUTANEOUS SOLUTION 8 MG/0.4ML



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; NE$0.00-$8.95 (Tier 2)

REMICADE

[*]$0 (Tier 4)sb antacid anti-gas suspension 200-200-20 mg/5ml oral

[*]$0 (Tier 4)sb omeprazole tablet delayed release 20 mg oral


scopolamine

[*]$0 (Tier 4)silace liquid 150 mg/15ml oral[*]$0 (Tier 4)silace syrup 60 mg/15ml oral[*]$0 (Tier 4)simethicone capsule 125 mg oral[*]$0 (Tier 4)simethicone capsule 180 mg oral[*]$0 (Tier 4)simethicone tablet chewable 125 mg oral[*]$0 (Tier 4)simethicone tablet chewable 80 mg oral[*]$0 (Tier 4)sm acid reducer max st tablet 20 mg oral[*]$0 (Tier 4)sm acid reducer tablet 10 mg oral[*]$0 (Tier 4)sm acid reducer tablet 75 mg oral[*]$0 (Tier 4)sm antacid advanced max st suspension 400-

400-40 mg/5ml oral[*]$0 (Tier 4)sm antacid anti-gas suspension 200-200-20

mg/5ml oral[*]$0 (Tier 4)sm calcium antacid ex st tablet chewable 750

mg oral[*]$0 (Tier 4)sm clearlax powder oral[*]$0 (Tier 4)sm foaming antacid tablet chewable 80-20 mg

oral[*]$0 (Tier 4)sm gas relief antiflatuent capsule 180 mg oral[*]$0 (Tier 4)sm magnesium citrate solution 1.745 gm/30ml

oral[*]$0 (Tier 4)sm milk of magnesia suspension 1200 mg/15ml

oral[*]$0 (Tier 4)sm mineral oil enema rectal



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)sm omeprazole tablet delayed release 20 mg oral

[*]$0 (Tier 4)sm stomach relief tablet 262 mg oral[*]$0 (Tier 4)sm stomach relief tablet chewable 262 mg oral[*]$0 (Tier 4)sm stool softener capsule 100 mg oral[*]$0 (Tier 4)sm stool softener capsule 240 mg oral[*]$0 (Tier 4)soothe suspension 262 mg/15ml oral[*]$0 (Tier 4)soothe tablet 262 mg oral[*]$0 (Tier 4)soothe tablet chewable 262 mg oral[*]$0 (Tier 4)stimulant laxative tablet delayed release 5 mg

oral[*]$0 (Tier 4)stomach relief max st suspension 525 mg/15ml

oral[*]$0 (Tier 4)stomach relief suspension 262 mg/15ml oral[*]$0 (Tier 4)stomach relief tablet chewable 262 mg oral[*]$0 (Tier 4)stool softener capsule 100 mg oral[*]$0 (Tier 4)stool softener capsule 240 mg oral[*]$0 (Tier 4)stool softener capsule 250 mg oralMO$0.00-$8.95 (Tier

2)sucralfate oral tablet

MO$0.00-$8.95 (Tier 2)

trilyte

[*]$0 (Tier 4)tums ultra 1000 tablet chewable 1000 mg oralMO$0.00-$8.95 (Tier

2)ursodiol oral

GENETIC OR ENZYME DISORDER: REPLACEMENT, MODIFIERS, TREATMENT

PAR; LA; NE$0.00-$8.95 (Tier 2)

ALDURAZYME

PAR; NE$0.00-$8.95 (Tier 2)

CERDELGA

MO$0.00-$8.95 (Tier 2)

CREON



Giá Thuốc

(Theo Bậc)

Tên Thuốc

LA; NE$0.00-$8.95 (Tier 2)

CYSTADANE

LA$0.00-$8.95 (Tier 2)

CYSTAGON

PAR; LA; NE$0.00-$8.95 (Tier 2)

ELAPRASE

PAR; LA; NE$0.00-$8.95 (Tier 2)

FABRAZYME

PAR; LA; NE$0.00-$8.95 (Tier 2)

KUVAN ORAL TABLET SOLUBLE

PAR; LA; NE$0.00-$8.95 (Tier 2)

LUMIZYME

PAR; LA; NE$0.00-$8.95 (Tier 2)

miglustat

PAR; LA; NE$0.00-$8.95 (Tier 2)

NAGLAZYME

PAR; LA; NE$0.00-$8.95 (Tier 2)

ORFADIN


RAVICTI

PAR; NE$0.00-$8.95 (Tier 2)

sodium phenylbutyrate oral tablet

ST; MO$0.00-$8.95 (Tier 2)

ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 25000-79000 UNIT, 3000-14000 UNIT, 40000- 126000 UNIT, 5000-24000 UNIT

GENITOURINARY AGENTS

MO$0.00-$8.95 (Tier 2)

alfuzosin hcl er

MO$0.00-$8.95 (Tier 2)

bethanechol chloride oral

MO$0.00-$8.95 (Tier 2)

calcium acetate (phos binder) oral capsule

MO; NE$0.00-$8.95 (Tier 2)

DEPEN TITRATABS



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0 (Tier 1)doxazosin mesylate oralMO; QLL (30 per 30 days)$0.00-$8.95 (Tier

2)dutasteride oral


dutasteride-tamsulosin hcl

MO$0.00-$8.95 (Tier 2)

finasteride oral tablet 5 mg


MYRBETRIQ

MO$0.00-$8.95 (Tier 2)

neomycin-polymyxin b gu


oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg


oxybutynin chloride er oral tablet extended release 24 hour 5 mg


oxybutynin chloride oral syrup


oxybutynin chloride oral tablet

MO$0.00-$8.95 (Tier 2)

PHOSLYRA

MO$0.00-$8.95 (Tier 2)

potassium citrate er

MO$0 (Tier 1)prazosin hcl oralMO; NE; QLL (540 per 30 days)$0.00-$8.95 (Tier

2)sevelamer carbonate oral packet 0.8 gm


sevelamer carbonate oral packet 2.4 gm


sevelamer carbonate oral tablet


solifenacin succinate

MO$0.00-$8.95 (Tier 2)

tamsulosin hcl

MO$0 (Tier 1)terazosin hcl oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc


tolterodine tartrate


tolterodine tartrate er


TOVIAZ


VELPHORO


VESICARE

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (ADRENAL)

PAR; LA; NE; This medication is covered for the following indication(s): Spasms, Infantile

$0.00-$8.95 (Tier 2)

ACTHAR

MO$0.00-$8.95 (Tier 2)

ala-cort external cream

MO$0.00-$8.95 (Tier 2)

alclometasone dipropionate

MO$0.00-$8.95 (Tier 2)

amcinonide external cream

MO$0.00-$8.95 (Tier 2)

amcinonide external lotion

MO$0.00-$8.95 (Tier 2)

AMCINONIDE EXTERNAL OINTMENT

MO$0.00-$8.95 (Tier 2)

betamethasone dipropionate aug external cream

MO$0.00-$8.95 (Tier 2)

betamethasone dipropionate aug external lotion

MO$0.00-$8.95 (Tier 2)

betamethasone dipropionate aug external ointment

MO$0.00-$8.95 (Tier 2)

betamethasone dipropionate external cream

MO$0.00-$8.95 (Tier 2)

betamethasone dipropionate external ointment



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

betamethasone valerate external cream

MO$0.00-$8.95 (Tier 2)

betamethasone valerate external lotion

MO$0.00-$8.95 (Tier 2)

betamethasone valerate external ointment

MO$0.00-$8.95 (Tier 2)

CAPEX


clobetasol prop emollient base


clobetasol propionate e


clobetasol propionate external cream

MO$0.00-$8.95 (Tier 2)

clobetasol propionate external solution

MO$0.00-$8.95 (Tier 2)


MO$0.00-$8.95 (Tier 2)

desoximetasone external cream

MO$0.00-$8.95 (Tier 2)

desoximetasone external gel

MO$0.00-$8.95 (Tier 2)

desoximetasone external ointment

MO$0.00-$8.95 (Tier 2)


MO$0.00-$8.95 (Tier 2)


MO$0.00-$8.95 (Tier 2)

fludrocortisone acetate oral


fluocinolone acetonide external

MO$0.00-$8.95 (Tier 2)

fluocinolone acetonide otic



Giá Thuốc

(Theo Bậc)

Tên Thuốc


fluocinolone acetonide scalp


fluocinonide emulsified base


fluocinonide external gel


fluocinonide external ointment


fluocinonide external solution

MO$0.00-$8.95 (Tier 2)

fluticasone propionate external

MO$0.00-$8.95 (Tier 2)

halobetasol propionate external cream

MO$0.00-$8.95 (Tier 2)

halobetasol propionate external ointment

MO$0.00-$8.95 (Tier 2)

hydrocortisone external cream 1 %, 2.5 %

MO$0.00-$8.95 (Tier 2)

hydrocortisone external lotion 2.5 %

MO$0.00-$8.95 (Tier 2)

hydrocortisone external ointment 1 %, 2.5 %

MO$0.00-$8.95 (Tier 2)

hydrocortisone oral

MO$0.00-$8.95 (Tier 2)

hydrocortisone valerate

MO$0.00-$8.95 (Tier 2)

methylprednisolone oral

MO$0.00-$8.95 (Tier 2)

mometasone furoate external

MO$0.00-$8.95 (Tier 2)


MO$0.00-$8.95 (Tier 2)

prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

PREDNISONE INTENSOL

MO$0.00-$8.95 (Tier 2)

prednisone oral

MO$0.00-$8.95 (Tier 2)

procto-pak

MO$0.00-$8.95 (Tier 2)

proctozone-hc rectal

MO$0.00-$8.95 (Tier 2)

triamcinolone acetonide external cream

MO$0.00-$8.95 (Tier 2)

triamcinolone acetonide external lotion

MO$0.00-$8.95 (Tier 2)

triamcinolone acetonide external ointment

MO$0.00-$8.95 (Tier 2)

triderm external cream 0.1 %

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PITUITARY)

MO$0.00-$8.95 (Tier 2)

desmopressin ace spray refrig

MO$0.00-$8.95 (Tier 2)

desmopressin acetate injection

MO$0.00-$8.95 (Tier 2)

desmopressin acetate oral

MO$0.00-$8.95 (Tier 2)

desmopressin acetate spray

PAR; LA; NE$0.00-$8.95 (Tier 2)

INCRELEX

PAR; NE$0.00-$8.95 (Tier 2)

NORDITROPIN FLEXPRO

PAR; LA; NE$0.00-$8.95 (Tier 2)

OMNITROPE

NE$0.00-$8.95 (Tier 2)

STIMATE



Giá Thuốc

(Theo Bậc)

Tên Thuốc

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (PROSTAGLANDINS)

MO$0.00-$8.95 (Tier 2)

misoprostol oral tablet 200 mcg

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (SEX HORMONES/ MODIFIERS)

MO$0.00-$8.95 (Tier 2)

afirmelle

[*]$0 (Tier 4)AFTERA TABLET 1.5 MG ORALMO$0.00-$8.95 (Tier

2)altavera

MO$0.00-$8.95 (Tier 2)

alyacen 1/35

MO$0.00-$8.95 (Tier 2)

alyacen 7/7/7

PAR; MO; NE$0.00-$8.95 (Tier 2)

ANADROL-50

MO$0.00-$8.95 (Tier 2)

apri

MO$0.00-$8.95 (Tier 2)

aranelle

MO$0.00-$8.95 (Tier 2)

aubra

MO$0.00-$8.95 (Tier 2)

aubra eq

MO$0.00-$8.95 (Tier 2)

aurovela 1.5/30

MO$0.00-$8.95 (Tier 2)

aurovela 1/20

MO$0.00-$8.95 (Tier 2)

aurovela fe 1.5/30

MO$0.00-$8.95 (Tier 2)

aurovela fe 1/20



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

aviane

MO$0.00-$8.95 (Tier 2)

ayuna

MO$0.00-$8.95 (Tier 2)

azurette

MO$0.00-$8.95 (Tier 2)

balziva

MO$0.00-$8.95 (Tier 2)

bekyree

MO$0.00-$8.95 (Tier 2)

blisovi fe 1.5/30

MO$0.00-$8.95 (Tier 2)

blisovi fe 1/20

MO$0.00-$8.95 (Tier 2)

briellyn

MO; NE$0.00-$8.95 (Tier 2)

budesonide oral

MO$0.00-$8.95 (Tier 2)

camila

MO$0.00-$8.95 (Tier 2)

caziant

MO$0.00-$8.95 (Tier 2)

chateal

MO$0.00-$8.95 (Tier 2)

chateal eq

MO$0.00-$8.95 (Tier 2)

cryselle-28

MO$0.00-$8.95 (Tier 2)

cyclafem 1/35

MO$0.00-$8.95 (Tier 2)

cyclafem 7/7/7

MO$0.00-$8.95 (Tier 2)

cyred



Giá Thuốc

(Theo Bậc)

Tên Thuốc

$0.00-$8.95 (Tier 2)

cyred eq

MO$0.00-$8.95 (Tier 2)

danazol oral

MO$0.00-$8.95 (Tier 2)

dasetta 1/35

MO$0.00-$8.95 (Tier 2)

dasetta 7/7/7

MO$0.00-$8.95 (Tier 2)

deblitane

MO$0.00-$8.95 (Tier 2)

delyla

MO$0.00-$8.95 (Tier 2)

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML

MO$0.00-$8.95 (Tier 2)

desogestrel-ethinyl estradiol

MO$0.00-$8.95 (Tier 2)

drospirenone-ethinyl estradiol oral tablet 3-0.03 mg

[*]$0 (Tier 4)econtra ez tablet 1.5 mg oralMO$0.00-$8.95 (Tier

2)elinest

$0.00-$8.95 (Tier 2)

ELLA

MO$0.00-$8.95 (Tier 2)

emoquette

MO$0.00-$8.95 (Tier 2)

enpresse-28

MO$0.00-$8.95 (Tier 2)

enskyce oral tablet 0.15-30 mg-mcg

MO$0.00-$8.95 (Tier 2)

errin

MO$0.00-$8.95 (Tier 2)

estarylla

PAR; MO$0.00-$8.95 (Tier 2)

estradiol oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc


estradiol transdermal patch weekly

MO$0.00-$8.95 (Tier 2)

estradiol vaginal cream


ESTRING

MO$0.00-$8.95 (Tier 2)

ethynodiol diac-eth estradiol

MO$0.00-$8.95 (Tier 2)

falmina

MO$0.00-$8.95 (Tier 2)

femynor

$0.00-$8.95 (Tier 2)

hailey 1.5/30

MO$0.00-$8.95 (Tier 2)

heather

MO$0.00-$8.95 (Tier 2)

incassia

MO$0.00-$8.95 (Tier 2)

introvale

MO$0.00-$8.95 (Tier 2)

isibloom

MO$0.00-$8.95 (Tier 2)

jencycla

MO$0.00-$8.95 (Tier 2)

jolessa

MO$0.00-$8.95 (Tier 2)

juleber

MO$0.00-$8.95 (Tier 2)

junel 1.5/30

MO$0.00-$8.95 (Tier 2)

junel 1/20

MO$0.00-$8.95 (Tier 2)

junel fe 1.5/30



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

junel fe 1/20

MO$0.00-$8.95 (Tier 2)

kalliga

MO$0.00-$8.95 (Tier 2)

kariva

MO$0.00-$8.95 (Tier 2)

kelnor 1/35

MO$0.00-$8.95 (Tier 2)

kelnor 1/50

MO$0.00-$8.95 (Tier 2)

kurvelo

MO$0.00-$8.95 (Tier 2)

larin 1.5/30

MO$0.00-$8.95 (Tier 2)

larin 1/20

MO$0.00-$8.95 (Tier 2)

larin fe 1.5/30

MO$0.00-$8.95 (Tier 2)

larin fe 1/20

MO$0.00-$8.95 (Tier 2)

larissia

MO$0.00-$8.95 (Tier 2)

leena

MO$0.00-$8.95 (Tier 2)

lessina

MO$0.00-$8.95 (Tier 2)

levonest

MO$0.00-$8.95 (Tier 2)

levonorg-eth estrad triphasic

MO$0.00-$8.95 (Tier 2)

levonorgest-eth estrad 91-day oral tablet 0.15- 0.03 mg

MO$0.00-$8.95 (Tier 2)

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

levora 0.15/30 (28)

MO$0.00-$8.95 (Tier 2)

lillow

MO$0.00-$8.95 (Tier 2)

low-ogestrel

MO$0.00-$8.95 (Tier 2)

lutera

MO$0.00-$8.95 (Tier 2)

lyza

MO$0.00-$8.95 (Tier 2)

marlissa

MO$0.00-$8.95 (Tier 2)

marlissa

MO$0.00-$8.95 (Tier 2)

marlissa

MO$0.00-$8.95 (Tier 2)

medroxyprogesterone acetate intramuscular

MO$0.00-$8.95 (Tier 2)

medroxyprogesterone acetate oral

PAR; MO$0.00-$8.95 (Tier 2)

megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml

PAR; MO$0.00-$8.95 (Tier 2)

megestrol acetate oral tablet

PAR; MO$0.00-$8.95 (Tier 2)

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG

MO$0.00-$8.95 (Tier 2)

microgestin 1.5/30

MO$0.00-$8.95 (Tier 2)

microgestin 1/20

MO$0.00-$8.95 (Tier 2)

microgestin fe 1.5/30

MO$0.00-$8.95 (Tier 2)

microgestin fe 1/20



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

mili

MO$0.00-$8.95 (Tier 2)

mono-linyah

MO$0.00-$8.95 (Tier 2)

mononessa

MO$0.00-$8.95 (Tier 2)

necon 0.5/35 (28)

MO$0.00-$8.95 (Tier 2)

nora-be

MO$0.00-$8.95 (Tier 2)

norethin ace-eth estrad-fe oral tablet 1-20 mg- mcg

MO$0.00-$8.95 (Tier 2)

norethindrone acet-ethinyl est oral tablet

MO$0.00-$8.95 (Tier 2)

norethindrone acetate oral

MO$0.00-$8.95 (Tier 2)

norethindrone oral

MO$0.00-$8.95 (Tier 2)

norgestim-eth estrad triphasic oral tablet 0.18/ 0.215/0.25 mg-35 mcg

MO$0.00-$8.95 (Tier 2)

norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg

MO$0.00-$8.95 (Tier 2)

norlyda

MO$0.00-$8.95 (Tier 2)

norlyroc

MO$0.00-$8.95 (Tier 2)

nortrel 0.5/35 (28)

MO$0.00-$8.95 (Tier 2)

nortrel 1/35 (21)

MO$0.00-$8.95 (Tier 2)

nortrel 1/35 (28)

MO$0.00-$8.95 (Tier 2)

nortrel 7/7/7



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

NUVARING

MO$0.00-$8.95 (Tier 2)

ocella

MO$0.00-$8.95 (Tier 2)

ogestrel

[*]$0 (Tier 4)opcicon one-step tablet 1.5 mg oralMO$0.00-$8.95 (Tier

2)orsythia


oxandrolone oral tablet 10 mg


oxandrolone oral tablet 2.5 mg

MO$0.00-$8.95 (Tier 2)

philith

MO$0.00-$8.95 (Tier 2)

pimtrea

MO$0.00-$8.95 (Tier 2)

pirmella 1/35

MO$0.00-$8.95 (Tier 2)

pirmella 7/7/7

[*]$0 (Tier 4)PLAN B ONE-STEP TABLET 1.5 MG ORAL (OTC)

MO$0.00-$8.95 (Tier 2)

portia-28

PAR; MO$0.00-$8.95 (Tier 2)

PREMARIN ORAL

MO$0.00-$8.95 (Tier 2)

PREMARIN VAGINAL

PAR; MO$0.00-$8.95 (Tier 2)

PREMPRO

MO$0.00-$8.95 (Tier 2)

previfem

MO$0.00-$8.95 (Tier 2)

progesterone micronized oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc


raloxifene hcl

MO$0.00-$8.95 (Tier 2)

reclipsen

MO$0.00-$8.95 (Tier 2)

setlakin

MO$0.00-$8.95 (Tier 2)

sharobel

MO$0.00-$8.95 (Tier 2)

sprintec 28

MO$0.00-$8.95 (Tier 2)

sronyx

MO$0.00-$8.95 (Tier 2)

syeda

[*]$0 (Tier 4)TAKE ACTION TABLET 1.5 MG ORALMO$0.00-$8.95 (Tier

2)tarina fe 1/20

MO$0.00-$8.95 (Tier 2)

tarina fe 1/20 eq

PAR; MO$0.00-$8.95 (Tier 2)

testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml

PAR; MO$0.00-$8.95 (Tier 2)

testosterone enanthate intramuscular solution

PAR; MO; QLL (112.5 per 30 days)$0.00-$8.95 (Tier 2)

testosterone transdermal gel 20.25 mg/1.25gm (1.62%)


testosterone transdermal gel 20.25 mg/act (1.62%), 40.5 mg/2.5gm (1.62%)


testosterone transdermal gel 25 mg/2.5gm (1%), 50 mg/5gm (1%)

MO$0.00-$8.95 (Tier 2)

tri femynor

MO$0.00-$8.95 (Tier 2)

tri-estarylla

MO$0.00-$8.95 (Tier 2)

tri-linyah



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

tri-mili

MO$0.00-$8.95 (Tier 2)

tri-previfem

MO$0.00-$8.95 (Tier 2)

tri-sprintec

MO$0.00-$8.95 (Tier 2)

tri-vylibra

MO$0.00-$8.95 (Tier 2)

trinessa (28)

MO$0.00-$8.95 (Tier 2)

trivora (28)

MO$0.00-$8.95 (Tier 2)

tulana

[*]$0 (Tier 4)vcf vaginal contraceptive foam 12.5 % vaginalMO$0.00-$8.95 (Tier

2)velivet

MO$0.00-$8.95 (Tier 2)

vienva

MO$0.00-$8.95 (Tier 2)

viorele

MO$0.00-$8.95 (Tier 2)

vyfemla

MO$0.00-$8.95 (Tier 2)

vylibra

MO$0.00-$8.95 (Tier 2)

wera

MO$0.00-$8.95 (Tier 2)

zarah

MO$0.00-$8.95 (Tier 2)

zovia 1/35e (28)

MO$0.00-$8.95 (Tier 2)

zumandimine



Giá Thuốc

(Theo Bậc)

Tên Thuốc

HORMONAL AGENTS, STIMULANT/ REPLACEMENT/ MODIFYING (THYROID)

MO$0 (Tier 1)levo-t oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

MO$0.00-$8.95 (Tier 2)

levo-t oral tablet 25 mcg

MO$0 (Tier 1)levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

MO$0.00-$8.95 (Tier 2)

levothyroxine sodium oral tablet 25 mcg

MO$0 (Tier 1)levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 50 mcg, 75 mcg, 88 mcg

MO$0.00-$8.95 (Tier 2)

levoxyl oral tablet 25 mcg

MO$0.00-$8.95 (Tier 2)

liothyronine sodium oral

MO$0.00-$8.95 (Tier 2)

SYNTHROID

MO$0 (Tier 1)unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

MO$0.00-$8.95 (Tier 2)

unithroid oral tablet 25 mcg

HORMONAL AGENTS, SUPPRESSANT (ADRENAL)

MO$0.00-$8.95 (Tier 2)

LYSODREN

HORMONAL AGENTS, SUPPRESSANT (PITUITARY)

MO$0.00-$8.95 (Tier 2)

bromocriptine mesylate oral

MO$0.00-$8.95 (Tier 2)

cabergoline


FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; QLL (1 per 28 days)$0.00-$8.95 (Tier 2)

FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG

PAR$0.00-$8.95 (Tier 2)

leuprolide acetate injection


LUPRON DEPOT (1-MONTH)


LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR KIT 7.5 MG

PAR$0.00-$8.95 (Tier 2)

octreotide acetate injection solution 100 mcg/ ml, 1000 mcg/ml, 200 mcg/ml, 50 mcg/ml

PAR; NE$0.00-$8.95 (Tier 2)

octreotide acetate injection solution 500 mcg/ ml

PAR; LA; NE$0.00-$8.95 (Tier 2)

SIGNIFOR

PAR; NE$0.00-$8.95 (Tier 2)

SOMATULINE DEPOT

PAR; LA; NE$0.00-$8.95 (Tier 2)

SOMAVERT

PAR; NE$0.00-$8.95 (Tier 2)

SYNAREL


TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.25 MG





HORMONAL AGENTS, SUPPRESSANT (THYROID)

MO$0.00-$8.95 (Tier 2)

methimazole oral

MO$0.00-$8.95 (Tier 2)

propylthiouracil oral

IMMUNOLOGICAL AGENTS

MO$0 (Tier 1)ACTHIB



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; LA; NE$0.00-$8.95 (Tier 2)

ACTIMMUNE

$0 (Tier 1)ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 (PREFILLED SYRINGE)

MO$0 (Tier 1)ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 LF-MCG/0.5

PAR; NE$0.00-$8.95 (Tier 2)

AFINITOR DISPERZ

PAR; NE$0.00-$8.95 (Tier 2)

AFINITOR ORAL TABLET 2.5 MG

PAR; NE$0.00-$8.95 (Tier 2)

ALIMTA

PAR; NE$0.00-$8.95 (Tier 2)

ARCALYST

B/D PAR$0.00-$8.95 (Tier 2)

ATGAM

B/D PAR; MO$0.00-$8.95 (Tier 2)

azathioprine oral

B/D PAR; MO$0.00-$8.95 (Tier 2)

AZATHIOPRINE SODIUM

MO$0.00-$8.95 (Tier 2)

BCG VACCINE

PAR; NE$0.00-$8.95 (Tier 2)

BENLYSTA

MO$0.00-$8.95 (Tier 2)

BEXSERO

$0 (Tier 1)BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 (0.5ML SYRINGE)

MO$0 (Tier 1)BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 , 5-2.5-18.5 LF-MCG/0.5

PAR; LA; NE$0.00-$8.95 (Tier 2)

CINRYZE

B/D PAR$0.00-$8.95 (Tier 2)

cyclosporine intravenous



Giá Thuốc

(Theo Bậc)

Tên Thuốc

B/D PAR$0.00-$8.95 (Tier 2)

cyclosporine modified

B/D PAR$0.00-$8.95 (Tier 2)

cyclosporine oral capsule

MO$0 (Tier 1)DAPTACEL INTRAMUSCULAR SUSPENSION 23-15-5

MO; NE$0.00-$8.95 (Tier 2)

DEPEN TITRATABS

MO$0.00-$8.95 (Tier 2)

DIPHTHERIA-TETANUS TOXOIDS DT


ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/0.5ML


ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML


ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED


ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO-INJECTOR

B/D PAR; MO$0 (Tier 1)ENGERIX-B INJECTIONPAR; NE$0.00-$8.95 (Tier

2)FIRAZYR

PAR; NE$0.00-$8.95 (Tier 2)

GAMUNEX-C

MO$0.00-$8.95 (Tier 2)

GARDASIL 9

B/D PAR$0.00-$8.95 (Tier 2)

gengraf oral capsule 100 mg, 25 mg

B/D PAR$0.00-$8.95 (Tier 2)

gengraf oral solution

$0 (Tier 1)HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML 1 ML, 720 EL U/0.5ML 0.5 ML

MO$0 (Tier 1)HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ML, 720 EL U/0.5ML

MO$0 (Tier 1)HIBERIX INJECTION



Giá Thuốc

(Theo Bậc)

Tên Thuốc


HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 40 MG/0.8ML (6 PACK), 80 MG/ 0.8ML


HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML & 40MG/0.4ML


HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT


HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML


HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML


HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML


HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML & 40MG/0.4ML


HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/0.2ML, 20 MG/0.2ML, 20 MG/0.4ML


HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.4ML, 40 MG/0.8ML

NE$0.00-$8.95 (Tier 2)

HYPERRAB

$0.00-$8.95 (Tier 2)

HYPERRAB S/D INJECTION SOLUTION 300 UNIT/2ML

PAR; NE$0.00-$8.95 (Tier 2)

icatibant acetate

$0.00-$8.95 (Tier 2)

IMOGAM RABIES-HT INJECTION SOLUTION 300 UNIT/2ML

MO$0.00-$8.95 (Tier 2)

IMOVAX RABIES



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

INFANRIX

MO$0 (Tier 1)IPOLMO$0.00-$8.95 (Tier

2)IXIARO

$0.00-$8.95 (Tier 2)

KEDRAB INJECTION SOLUTION 300 UNIT/ 2ML

PAR; NE$0.00-$8.95 (Tier 2)

KEYTRUDA INTRAVENOUS SOLUTION

MO$0.00-$8.95 (Tier 2)

KINRIX INTRAMUSCULAR SUSPENSION

$0.00-$8.95 (Tier 2)

KINRIX INTRAMUSCULAR SUSPENSION INJECTION 0.5 ML

MO$0.00-$8.95 (Tier 2)

leflunomide oral

MO$0.00-$8.95 (Tier 2)

leflunomide oral

MO$0 (Tier 1)M-M-R IIMO$0.00-$8.95 (Tier

2)MENACTRA

MO$0.00-$8.95 (Tier 2)

MENVEO

MO$0.00-$8.95 (Tier 2)

mercaptopurine oral

MO$0.00-$8.95 (Tier 2)

methotrexate oral

MO$0.00-$8.95 (Tier 2)

methotrexate sodium (pf) injection solution 50 mg/2ml

MO$0.00-$8.95 (Tier 2)

methotrexate sodium injection solution 50 mg/ 2ml

B/D PAR$0.00-$8.95 (Tier 2)

mycophenolate mofetil hcl

B/D PAR$0.00-$8.95 (Tier 2)

mycophenolate mofetil oral capsule



Giá Thuốc

(Theo Bậc)

Tên Thuốc

B/D PAR; NE$0.00-$8.95 (Tier 2)

mycophenolate mofetil oral suspension reconstituted

B/D PAR$0.00-$8.95 (Tier 2)

mycophenolate mofetil oral tablet

B/D PAR$0.00-$8.95 (Tier 2)

mycophenolate sodium

PAR; NE$0.00-$8.95 (Tier 2)

NULOJIX

PAR; NE$0.00-$8.95 (Tier 2)

OCTAGAM INTRAVENOUS SOLUTION 1 GM/ 20ML, 2 GM/20ML, 2.5 GM/50ML, 25 GM/ 500ML, 5 GM/100ML

MO$0.00-$8.95 (Tier 2)

PEDIARIX

MO$0 (Tier 1)PEDVAX HIB INTRAMUSCULAR SUSPENSION

MO$0.00-$8.95 (Tier 2)

PENTACEL


pimecrolimus

B/D PAR; NE$0.00-$8.95 (Tier 2)

PROGRAF INTRAVENOUS

B/D PAR$0.00-$8.95 (Tier 2)

PROGRAF ORAL PACKET

MO$0.00-$8.95 (Tier 2)

PROQUAD SUBCUTANEOUS SUSPENSION RECONSTITUTED

MO$0.00-$8.95 (Tier 2)

QUADRACEL

MO$0.00-$8.95 (Tier 2)

RABAVERT

B/D PAR$0 (Tier 1)RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML (1ML SYRINGE)

B/D PAR; MO$0 (Tier 1)RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML

MO; NE$0.00-$8.95 (Tier 2)

RIDAURA



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

ROTARIX

MO$0 (Tier 1)ROTATEQ ORAL SOLUTIONMO$0.00-$8.95 (Tier

2)SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG/0.5ML

B/D PAR; NE$0.00-$8.95 (Tier 2)

SIMULECT

B/D PAR; NE$0.00-$8.95 (Tier 2)

sirolimus oral solution

B/D PAR$0.00-$8.95 (Tier 2)

sirolimus oral tablet

MO$0.00-$8.95 (Tier 2)

STAMARIL

PAR; NE$0.00-$8.95 (Tier 2)

SYNAGIS

B/D PAR$0.00-$8.95 (Tier 2)

tacrolimus oral capsule 0.5 mg, 1 mg

B/D PAR; NE$0.00-$8.95 (Tier 2)

tacrolimus oral capsule 5 mg

MO$0 (Tier 1)TDVAXMO$0.00-$8.95 (Tier

2)TENIVAC

B/D PAR; NE$0.00-$8.95 (Tier 2)

THYMOGLOBULIN

MO$0.00-$8.95 (Tier 2)

TREXALL

MO$0.00-$8.95 (Tier 2)

TRUMENBA

MO$0 (Tier 1)TWINRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE

MO$0.00-$8.95 (Tier 2)

TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5ML

$0.00-$8.95 (Tier 2)

TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5ML (0.5ML SYRINGE)



Giá Thuốc

(Theo Bậc)

Tên Thuốc

$0.00-$8.95 (Tier 2)

VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML 0.5 ML, 50 UNIT/ML 1 ML

MO$0.00-$8.95 (Tier 2)

VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/0.5ML, 50 UNIT/ML

MO$0.00-$8.95 (Tier 2)

VARIVAX

$0.00-$8.95 (Tier 2)

VARIZIG INTRAMUSCULAR SOLUTION

$0.00-$8.95 (Tier 2)

XATMEP


XELJANZ

MO$0.00-$8.95 (Tier 2)

YF-VAX

B/D PAR; NE$0.00-$8.95 (Tier 2)

ZORTRESS

MO$0.00-$8.95 (Tier 2)

ZOSTAVAX SUBCUTANEOUS SUSPENSION RECONSTITUTED

INFLAMMATORY BOWEL DISEASE AGENTS

MO$0.00-$8.95 (Tier 2)

APRISO

MO$0.00-$8.95 (Tier 2)

balsalazide disodium

MO; NE$0.00-$8.95 (Tier 2)

budesonide oral

MO$0.00-$8.95 (Tier 2)

colocort

MO$0.00-$8.95 (Tier 2)


MO$0.00-$8.95 (Tier 2)


MO$0.00-$8.95 (Tier 2)


MO; NE$0.00-$8.95 (Tier 2)

DIPENTUM



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

hydrocortisone oral

MO$0.00-$8.95 (Tier 2)

hydrocortisone rectal

MO$0.00-$8.95 (Tier 2)

mesalamine oral tablet delayed release 1.2 gm

MO$0.00-$8.95 (Tier 2)

mesalamine rectal enema

MO; NE$0.00-$8.95 (Tier 2)

mesalamine rectal suppository

MO$0.00-$8.95 (Tier 2)

methylprednisolone oral

MO$0.00-$8.95 (Tier 2)

PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG

MO; NE$0.00-$8.95 (Tier 2)

PENTASA ORAL CAPSULE EXTENDED RELEASE 500 MG

MO$0.00-$8.95 (Tier 2)


MO$0.00-$8.95 (Tier 2)


MO$0.00-$8.95 (Tier 2)

prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml

MO$0.00-$8.95 (Tier 2)

PREDNISONE INTENSOL

MO$0.00-$8.95 (Tier 2)

prednisone oral solution

MO$0.00-$8.95 (Tier 2)

prednisone oral tablet

MO$0.00-$8.95 (Tier 2)

procto-med hc

MO$0.00-$8.95 (Tier 2)

proctosol hc

MO$0.00-$8.95 (Tier 2)

sulfasalazine oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

METABOLIC BONE DISEASE AGENTS


alendronate sodium oral solution


alendronate sodium oral tablet 10 mg, 40 mg, 5 mg


alendronate sodium oral tablet 35 mg, 70 mg


calcitonin (salmon)

B/D PAR; MO$0.00-$8.95 (Tier 2)

calcitriol oral capsule


cinacalcet hcl oral tablet 30 mg, 60 mg


cinacalcet hcl oral tablet 90 mg

B/D PAR; MO$0.00-$8.95 (Tier 2)

doxercalciferol oral capsule 0.5 mcg


FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4ML


ibandronate sodium oral

B/D PAR; MO; NE$0.00-$8.95 (Tier 2)

MIACALCIN INJECTION


NATPARA

$0.00-$8.95 (Tier 2)

pamidronate disodium intravenous solution 30 mg/10ml, 90 mg/10ml

B/D PAR$0.00-$8.95 (Tier 2)

PAMIDRONATE DISODIUM INTRAVENOUS SOLUTION 6 MG/ML

$0.00-$8.95 (Tier 2)

pamidronate disodium intravenous solution reconstituted

B/D PAR; MO$0.00-$8.95 (Tier 2)

paricalcitol oral capsule 1 mcg, 2 mcg

B/D PAR; MO; NE$0.00-$8.95 (Tier 2)

paricalcitol oral capsule 4 mcg



Giá Thuốc

(Theo Bậc)

Tên Thuốc


PROLIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE


XGEVA

PAR$0.00-$8.95 (Tier 2)

zoledronic acid intravenous concentrate

PAR; NE$0.00-$8.95 (Tier 2)

zoledronic acid intravenous solution 4 mg/ 100ml

OPHTHALMIC AGENTS

MO$0.00-$8.95 (Tier 2)

acetazolamide oral

MO$0.00-$8.95 (Tier 2)

ak-poly-bac

[*]$0 (Tier 4)alaway childrens allergy solution 0.025 % ophthalmic

[*]$0 (Tier 4)alaway solution 0.025 % ophthalmicMO$0.00-$8.95 (Tier

2)ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %

MO$0.00-$8.95 (Tier 2)

apraclonidine hcl

[*]$0 (Tier 4)artificial tears solution 1.4 % ophthalmicMO$0.00-$8.95 (Tier

2)atropine sulfate ophthalmic solution

MO$0.00-$8.95 (Tier 2)

azelastine hcl ophthalmic

MO$0.00-$8.95 (Tier 2)

AZOPT

MO$0.00-$8.95 (Tier 2)

bacitra-neomycin-polymyxin-hc

MO$0.00-$8.95 (Tier 2)

bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm

MO$0.00-$8.95 (Tier 2)

betaxolol hcl ophthalmic

MO$0.00-$8.95 (Tier 2)

BETIMOL



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

bimatoprost ophthalmic

MO$0.00-$8.95 (Tier 2)

bimatoprost ophthalmic

MO$0.00-$8.95 (Tier 2)

BLEPHAMIDE S.O.P.

MO$0.00-$8.95 (Tier 2)

brimonidine tartrate ophthalmic

MO$0.00-$8.95 (Tier 2)

carteolol hcl

MO$0.00-$8.95 (Tier 2)

COMBIGAN

MO$0.00-$8.95 (Tier 2)

cromolyn sodium ophthalmic

[*]$0 (Tier 4)cvs eye wash solution 99.05 % ophthalmicLA; NE$0.00-$8.95 (Tier

2)CYSTARAN

MO$0.00-$8.95 (Tier 2)

dexamethasone sodium phosphate ophthalmic

MO$0.00-$8.95 (Tier 2)

diclofenac sodium ophthalmic

MO$0.00-$8.95 (Tier 2)

dorzolamide hcl ophthalmic

MO$0.00-$8.95 (Tier 2)

dorzolamide hcl-timolol mal

[*]$0 (Tier 4)EYE STREAM SOLUTION OPHTHALMICMO$0.00-$8.95 (Tier

2)fluorometholone ophthalmic

MO$0.00-$8.95 (Tier 2)

flurbiprofen sodium

[*]$0 (Tier 4)gnp artificial tears solution 5-6 mg/ml ophthalmic

[*]$0 (Tier 4)gnp lubricating plus eye drops solution 0.5 % ophthalmic



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)goodsense artificial tears solution 0.5-0.6 % ophthalmic

[*]$0 (Tier 4)goodsense lubricating eye drop solution 0.5 % ophthalmic

[*]$0 (Tier 4)hm eye itch relief solution 0.025 % ophthalmic[*]$0 (Tier 4)hm lubricating plus solution 0.5 % ophthalmicMO$0.00-$8.95 (Tier

2)ILEVRO

MO$0.00-$8.95 (Tier 2)

isopto atropine

MO$0.00-$8.95 (Tier 2)

ketorolac tromethamine ophthalmic

[*]$0 (Tier 4)ketotifen fumarate solution 0.025 % ophthalmic (otc)

MO$0.00-$8.95 (Tier 2)

latanoprost ophthalmic

MO$0.00-$8.95 (Tier 2)

levobunolol hcl ophthalmic solution 0.5 %

[*]$0 (Tier 4)liquitears solution 1.4 % ophthalmic[*]$0 (Tier 4)lubricant eye drops pf solution 0.5 %

ophthalmic[*]$0 (Tier 4)LUBRICANT EYE DROPS SOLUTION 0.4-0.3

% OPHTHALMIC[*]$0 (Tier 4)lubricant eye drops solution 0.5 % ophthalmic[*]$0 (Tier 4)lubricating plus eye drops solution 0.5 %

ophthalmicMO$0.00-$8.95 (Tier

2)LUMIGAN OPHTHALMIC SOLUTION 0.01 %

MO$0.00-$8.95 (Tier 2)

methazolamide oral

MO$0.00-$8.95 (Tier 2)

neo-polycin

MO$0.00-$8.95 (Tier 2)

neo-polycin hc



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

neomycin-bacitracin zn-polymyx ophthalmic ointment 5-400-10000

MO$0.00-$8.95 (Tier 2)

neomycin-polymyxin-dexameth ophthalmic ointment

MO$0.00-$8.95 (Tier 2)

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1

MO$0.00-$8.95 (Tier 2)

neomycin-polymyxin-gramicidin ophthalmic solution 1.75-10000-.025

MO$0.00-$8.95 (Tier 2)

neomycin-polymyxin-hc ophthalmic suspension 3.5-10000-1

MO$0.00-$8.95 (Tier 2)

olopatadine hcl ophthalmic

MO$0.00-$8.95 (Tier 2)

PAZEO

MO$0.00-$8.95 (Tier 2)

PHOSPHOLINE IODIDE

MO$0.00-$8.95 (Tier 2)

pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 %

MO$0.00-$8.95 (Tier 2)

polycin

MO$0.00-$8.95 (Tier 2)

polymyxin b-trimethoprim

MO$0.00-$8.95 (Tier 2)


MO$0.00-$8.95 (Tier 2)

PREDNISOLONE SODIUM PHOSPHATE OPHTHALMIC

MO$0.00-$8.95 (Tier 2)

SIMBRINZA

[*]$0 (Tier 4)sm eye itch relief solution 0.025 % ophthalmic[*]$0 (Tier 4)sm eye wash solution 0.002 % ophthalmic[*]$0 (Tier 4)SM LUBRICANT EYE DROPS SOLUTION 0.4-

0.3 % OPHTHALMIC[*]$0 (Tier 4)SM LUBRICATING TEARS SOLUTION 0.4-0.3

% OPHTHALMIC



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)sodium chloride (hypertonic) ointment 5 % ophthalmic

[*]$0 (Tier 4)SODIUM CHLORIDE (HYPERTONIC) OINTMENT 5 % OPHTHALMIC

[*]$0 (Tier 4)sodium chloride (hypertonic) solution 5 % ophthalmic

MO$0.00-$8.95 (Tier 2)

sulfacetamide-prednisolone ophthalmic solution

MO$0.00-$8.95 (Tier 2)

timolol maleate ophthalmic

MO$0.00-$8.95 (Tier 2)

tobramycin-dexamethasone

MO$0.00-$8.95 (Tier 2)

TRAVATAN Z


XIIDRA

OTC-PRODUCT

[*]$0 (Tier 4)ALLI CAPSULE 60 MG ORAL[*]$0 (Tier 4)cvs nasal mist aerosol solution 0.9 % nasal[*]$0 (Tier 4)FANTASY LUBRICATED[*]$0 (Tier 4)FANTASY LUBRICATED/SPERMICIDE[*]$0 (Tier 4)KIMONO MICRO THIN PLUS[*]$0 (Tier 4)KIMONO SENSATION[*]$0 (Tier 4)KIMONO SENSATION PLUS[*]$0 (Tier 4)nasal mist aerosol solution 0.9 % inhalation[*]$0 (Tier 4)PREMIUM CONDOMS LUBRICATED[*]$0 (Tier 4)TRUSTEX LUB/RIBBED/STUDDED[*]$0 (Tier 4)TRUSTEX LUB/SPERMICIDE EX ST[*]$0 (Tier 4)TRUSTEX LUB/SPERMICIDE XL[*]$0 (Tier 4)TRUSTEX LUBRICATED[*]$0 (Tier 4)TRUSTEX LUBRICATED EX LARGE[*]$0 (Tier 4)TRUSTEX LUBRICATED EXTRA ST



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)TRUSTEX LUBRICATED/SPERMICIDE[*]$0 (Tier 4)TRUSTEX RIA LUB/SPERMICIDE[*]$0 (Tier 4)TRUSTEX RIA LUBRICATED[*]$0 (Tier 4)TRUSTEX-NONOXYNOL-9/RIB/STUD

OTIC AGENTS

MO$0.00-$8.95 (Tier 2)

CIPRODEX

MO$0.00-$8.95 (Tier 2)

COLY-MYCIN S

MO$0.00-$8.95 (Tier 2)

CORTISPORIN-TC

MO$0.00-$8.95 (Tier 2)

flac

MO$0.00-$8.95 (Tier 2)

hydrocortisone-acetic acid

MO$0.00-$8.95 (Tier 2)

neomycin-polymyxin-hc otic solution 1 %

MO$0.00-$8.95 (Tier 2)

neomycin-polymyxin-hc otic suspension

MO$0.00-$8.95 (Tier 2)

ofloxacin oral tablet 300 mg

RESPIRATORY TRACT/ PULMONARY AGENTS

B/D PAR; MO$0 (Tier 1)acetylcysteine inhalationPAR; LA; NE$0.00-$8.95 (Tier

2)ADEMPAS


ADVAIR DISKUS


ADVAIR DISKUS


ADVAIR DISKUS


ADVAIR HFA



Giá Thuốc

(Theo Bậc)

Tên Thuốc


ADVAIR HFA


ADVAIR HFA

MO$0 (Tier 1)albuterol sulfate erMO$0.00-$8.95 (Tier

2)ALBUTEROL SULFATE HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ ACT

B/D PAR; MO; QLL (360 per 30 days)$0 (Tier 1)albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/3ml, 1.25 mg/ 3ml

B/D PAR; MO; QLL (60 per 30 days)$0 (Tier 1)albuterol sulfate inhalation nebulization solution (5 mg/ml) 0.5%

MO$0 (Tier 1)albuterol sulfate oral[*]$0 (Tier 4)all day allergy tablet 10 mg oral[*]$0 (Tier 4)allergy relief capsule 25 mg oral[*]$0 (Tier 4)allergy relief childrens liquid 12.5 mg/5ml oral[*]$0 (Tier 4)allergy relief tablet 10 mg oral[*]$0 (Tier 4)allergy relief tablet 25 mg oral[*]$0 (Tier 4)allergy relief tablet dispersible 10 mg oral[*]$0 (Tier 4)allergy tablet 10 mg oralPAR; LA; NE; QLL (30 per 30 days)$0.00-$8.95 (Tier

2)AMBRISENTAN


ANORO ELLIPTA

[*]$0 (Tier 4)aprodine tablet 2.5-60 mg oralPAR; LA; NE$0.00-$8.95 (Tier

2)ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG, 500 MG


ARNUITY ELLIPTA


ATROVENT HFA


azelastine hcl nasal solution 0.1 %, 0.15 %



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)banophen capsule 25 mg oral[*]$0 (Tier 4)banophen capsule 50 mg oral[*]$0 (Tier 4)banophen liquid 12.5 mg/5ml oral[*]$0 (Tier 4)banophen tablet 25 mg oral[*]$0 (Tier 3)benzonatate capsule 100 mg oral[*]$0 (Tier 3)benzonatate capsule 200 mg oralPAR; LA; NE; QLL (60 per 30 days)$0.00-$8.95 (Tier

2)bosentan


BREO ELLIPTA


budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml


budesonide inhalation suspension 1 mg/2ml

PAR; MO$0.00-$8.95 (Tier 2)

carbinoxamine maleate oral solution

PAR; LA; NE$0.00-$8.95 (Tier 2)

CAYSTON

[*]$0 (Tier 4)cetirizine hcl tablet 10 mg oral[*]$0 (Tier 4)CETIRIZINE HCL TABLET 5 MG ORAL[*]$0 (Tier 4)cheratussin ac syrup 100-10 mg/5ml oral[*]$0 (Tier 4)childrens allergy liquid 12.5 mg/5ml oralPAR; MO$0.00-$8.95 (Tier

2)clemastine fumarate oral tablet 2.68 mg


COMBIVENT RESPIMAT

[*]$0 (Tier 4)complete allergy medicine capsule 25 mg oral[*]$0 (Tier 4)cromolyn sodium aerosol solution 5.2 mg/act

nasalB/D PAR; MO; QLL (240 per 30 days)$0 (Tier 1)cromolyn sodium inhalationMO$0.00-$8.95 (Tier

2)cromolyn sodium oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; MO$0.00-$8.95 (Tier 2)

cyproheptadine hcl oral tablet


DALIRESP

[*]$0 (Tier 4)diphenhist capsule 25 mg oral[*]$0 (Tier 4)diphenhydramine hcl capsule 25 mg oral (otc)[*]$0 (Tier 4)diphenhydramine hcl capsule 50 mg oral (otc)MO$0.00-$8.95 (Tier

2)diphenhydramine hcl injection

[*]$0 (Tier 4)diphenhydramine hcl tablet 25 mg oralMO; QLL (13 per 30 days)$0.00-$8.95 (Tier

2)DULERA

[*]$0 (Tier 4)ed a-hist tablet 4-10 mg oralMO$0.00-$8.95 (Tier

2)epinephrine injection solution 30 mg/30ml

MO; QLL (2 per 28 days)$0 (Tier 1)epinephrine injection solution auto-injector 0.15 mg/0.3ml, 0.3 mg/0.3ml

MO$0.00-$8.95 (Tier 2)

EPINEPHRINE PF INJECTION SOLUTION

$0.00-$8.95 (Tier 2)

epinephrine pf injection solution prefilled syringe


ESBRIET ORAL CAPSULE


ESBRIET ORAL CAPSULE


ESBRIET ORAL TABLET 267 MG









Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)FLONASE ALLERGY RELIEF SUSPENSION 50 MCG/ACT NASAL


FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ BLIST, 50 MCG/BLIST


FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250 MCG/ BLIST


FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT






flunisolide nasal solution 25 mcg/act (0.025%)

MO$0.00-$8.95 (Tier 2)

fluticasone propionate external lotion


fluticasone propionate nasal

[*]$0 (Tier 4)fluticasone propionate suspension 50 mcg/act nasal (otc)


fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose





[*]$0 (Tier 4)gnp all day allergy tablet 10 mg oral[*]$0 (Tier 4)gnp allergy capsule 25 mg oral[*]$0 (Tier 4)gnp allergy relief tablet dispersible 10 mg oral[*]$0 (Tier 4)gnp allergy tablet 25 mg oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)gnp childrens allergy liquid 12.5 mg/5ml oral[*]$0 (Tier 4)gnp cold & allergy tablet 4-10 mg oral[*]$0 (Tier 4)gnp dayhist allergy tablet 1.34 mg oral[*]$0 (Tier 4)gnp loratadine tablet 10 mg oral[*]$0 (Tier 4)gnp nasal decongestant tablet 30 mg oral[*]$0 (Tier 4)goodsense all day allergy tablet 10 mg oral[*]$0 (Tier 4)guaiatussin ac syrup 100-10 mg/5ml oral[*]$0 (Tier 4)guaifenesin ac syrup 100-10 mg/5ml oral[*]$0 (Tier 4)guaifenesin-codeine solution 100-10 mg/5ml

oral (otc)[*]$0 (Tier 4)hm all day allergy tablet 10 mg oral[*]$0 (Tier 4)hm allergy tablet 25 mg oralPAR; MO$0.00-$8.95 (Tier

2)hydroxyzine hcl oral tablet

PAR; MO$0.00-$8.95 (Tier 2)


B/D PAR; MO$0 (Tier 1)ipratropium bromide inhalationMO; QLL (30 per 30 days)$0.00-$8.95 (Tier

2)ipratropium bromide nasal


ipratropium-albuterol


KALYDECO ORAL TABLET


LETAIRIS

B/D PAR; MO; QLL (270 per 30 days)$0 (Tier 1)levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml

B/D PAR; MO; QLL (540 per 30 days)$0 (Tier 1)levalbuterol hcl inhalation nebulization solution 0.63 mg/3ml


levalbuterol tartrate

MO$0.00-$8.95 (Tier 2)

levocetirizine dihydrochloride oral tablet



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)loratadine tablet 10 mg oral[*]$0 (Tier 4)m-clear wc solution 100-6.3 mg/5ml oralMO$0 (Tier 1)metaproterenol sulfate oral syrupMO$0 (Tier 1)montelukast sodium oral[*]$0 (Tier 4)nasal decongestant tablet 30 mg oralPAR; NE; QLL (60 per 30 days)$0.00-$8.95 (Tier

2)OFEV


OFEV


ORKAMBI ORAL TABLET

[*]$0 (Tier 4)PEAK AIR PEAK FLOW METER DEVICE[*]$0 (Tier 4)pharbedryl capsule 25 mg oral[*]$0 (Tier 4)pharbedryl capsule 50 mg oralMO; QLL (18 per 30 days)$0.00-$8.95 (Tier

2)PROAIR HFA


PROAIR RESPICLICK

PAR; LA; NE$0.00-$8.95 (Tier 2)

PROLASTIN-C INTRAVENOUS SOLUTION

PAR; MO$0.00-$8.95 (Tier 2)

promethazine hcl oral tablet

[*]$0 (Tier 3)promethazine-codeine solution 6.25-10 mg/5ml oral

[*]$0 (Tier 3)promethazine-codeine syrup 6.25-10 mg/5ml oral

[*]$0 (Tier 3)promethazine-dm syrup 6.25-15 mg/5ml oral[*]$0 (Tier 3)promethazine-phenyleph-codeine syrup 6.25-

5-10 mg/5ml oral[*]$0 (Tier 4)pseudoephedrine hcl tablet 30 mg oral (otc)B/D PAR; NE$0.00-$8.95 (Tier

2)PULMOZYME

B/D PAR; NE$0.00-$8.95 (Tier 2)

PULMOZYME



Giá Thuốc

(Theo Bậc)

Tên Thuốc

[*]$0 (Tier 4)qc all day allergy tablet 10 mg oral[*]$0 (Tier 4)qc loratadine allergy relief tablet 10 mg oralMO; QLL (11 per 30 days)$0.00-$8.95 (Tier

2)QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT


QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 80 MCG/ACT

[*]$0 (Tier 4)rydex liquid 10-1.33-6.33 mg/5ml oralMO; QLL (60 per 30 days)$0.00-$8.95 (Tier

2)SEREVENT DISKUS

[*]$0 (Tier 4)siladryl allergy liquid 12.5 mg/5ml oralPAR; NE; QLL (90 per 30 days)$0.00-$8.95 (Tier

2)sildenafil citrate oral tablet 20 mg

[*]$0 (Tier 4)sm all day allergy tablet 10 mg oral[*]$0 (Tier 4)sm allergy relief capsule 25 mg oral[*]$0 (Tier 4)sm allergy relief liquid 12.5 mg/5ml oral[*]$0 (Tier 4)sm cold & allergy pe tablet 4-10 mg oral[*]$0 (Tier 4)sm loratadine tablet 10 mg oral[*]$0 (Tier 4)sm nasal decongestant max st tablet 30 mg

oralMO; QLL (30 per 30 days)$0.00-$8.95 (Tier

2)SPIRIVA HANDIHALER


SPIRIVA RESPIMAT


STIOLTO RESPIMAT

[*]$0 (Tier 4)sudogest sinus/allergy tablet 4-60 mg oral[*]$0 (Tier 4)sudogest tablet 30 mg oral[*]$0 (Tier 4)sudogest tablet 60 mg oralMO; QLL (2 per 28 days)$0.00-$8.95 (Tier

2)SYMJEPI

MO$0 (Tier 1)terbutaline sulfate injectionMO$0 (Tier 1)terbutaline sulfate oral



Giá Thuốc

(Theo Bậc)

Tên Thuốc

MO$0.00-$8.95 (Tier 2)

theophylline er oral tablet extended release 12 hour 300 mg, 450 mg

MO$0.00-$8.95 (Tier 2)

theophylline er oral tablet extended release 24 hour


TRACLEER ORAL TABLET SOLUBLE


VENTAVIS


VENTOLIN HFA

[*]$0 (Tier 4)virtussin a/c solution 100-10 mg/5ml oralMO; QLL (60 per 30 days)$0.00-$8.95 (Tier

2)wixela inhub


wixela inhub


XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED

MO$0 (Tier 1)zafirlukast

SKELETAL MUSCLE RELAXANTS

PAR; MO$0.00-$8.95 (Tier 2)

carisoprodol oral tablet 350 mg

PAR; MO$0.00-$8.95 (Tier 2)

cyclobenzaprine hcl oral

PAR; MO$0.00-$8.95 (Tier 2)

methocarbamol oral

MO$0.00-$8.95 (Tier 2)

tizanidine hcl oral tablet

SLEEP DISORDER AGENTS

PAR; MO$0.00-$8.95 (Tier 2)

doxepin hcl oral capsule 10 mg, 100 mg, 25 mg, 50 mg, 75 mg

PAR; MO$0.00-$8.95 (Tier 2)

doxepin hcl oral concentrate


HETLIOZ



Giá Thuốc

(Theo Bậc)

Tên Thuốc

PAR; MO$0.00-$8.95 (Tier 2)

modafinil oral tablet 100 mg


modafinil oral tablet 200 mg


ramelteon


ROZEREM


temazepam oral capsule 15 mg, 30 mg


XYREM


zaleplon oral capsule 10 mg


zaleplon oral capsule 5 mg


zolpidem tartrate oral


Danh Mục Thuốc

11ST TIER UNIFINE PENTIPS 29G X 12MM ............................ 9733 day vaginal cream 2 % vaginal ........................ 119Aabacavir sulfate oral solution ......................... 82abacavir sulfate oral tablet ............................. 82abacavir sulfate- lamivudine .................... 82abacavir-lamivudine- zidovudine .................... 82ABELCET ..................... 52ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE ..................... 44ABILIFY MAINTENA INTRAMUSCULAR PREFILLED SYRINGE ..................... 77ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER ................................. 44ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION RECONSTITUTED ER ................................. 77abiraterone acetate ...... 57ABRAXANE .................. 57ABREVA CREAM 10 % EXTERNAL ................. 119acamprosate calcium .... 20acarbose oral tablet 100 mg ................................. 97acarbose oral tablet 25 mg ................................. 97

acarbose oral tablet 50 mg ................................. 97ACCU-CHEK AVIVA PLUS STRIP IN VITRO .......... 97ACCU-CHEK COMPACT PLUS STRIP IN VITRO ........................... 97ACCU-CHEK FASTCLIX LANCETS ..................... 97ACCU-CHEK MULTICLIX LANCETS ..................... 97ACCU-CHEK SMARTVIEW STRIP IN VITRO .......... 97ACCU-CHEK SOFT TOUCH LANCETS ....... 97ACCU-CHEK SOFTCLIX LANCETS ..................... 97acebutolol hcl oral ...... 106acetaminophen-codeine #3 .................................. 13acetaminophen-codeine #4 .................................. 13acetaminophen-codeine oral solution ......................... 13acetaminophen-codeine oral tablet 300-15 mg, 300-60 mg ................................. 13acetazolamide er ........ 106acetazolamide oral ..... 107acetazolamide oral ..... 181acetazolamide sodium ........................ 107acetic acid otic .............. 26acetylcysteine inhalation .................... 186acetylcysteine intravenous ................. 115acid gone suspension 95- 358 mg/15ml oral ........ 142acid gone tablet chewable 160-105 mg oral ......... 142acid reducer maximum strength tablet 20 mg oral .............................. 142

acid reducer tablet 10 mg oral .............................. 142acid reducer tablet 75 mg oral .............................. 142acitretin oral capsule 10 mg ............................... 119acitretin oral capsule 17.5 mg, 25 mg ................... 119ACNE MEDICATION 10 GEL 10 % EXTERNAL ................. 119ACTHAR ..................... 156ACTHIB ...................... 171ACTIMMUNE .............. 172acyclovir external ointment ........................ 83acyclovir oral ................. 83acyclovir sodium intravenous solution ..... 83ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 (PREFILLED SYRINGE) .................. 172ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5 LF- MCG/0.5 ..................... 172adapalene external gel 0.3 % ................................ 119adefovir dipivoxil ........... 83ADEMPAS .................. 186adriamycin intravenous solution ......................... 57adriamycin intravenous solution reconstituted 10 mg, 50 mg ..................... 58adrucil ........................... 58ADVAIR DISKUS ........ 186ADVAIR DISKUS ........ 186ADVAIR DISKUS ........ 186ADVAIR HFA .............. 186ADVAIR HFA .............. 187ADVAIR HFA .............. 187

? Nếu quý vị có thắc mắc, vui lòng gọi Anthem Blue Cross Cal MediConnect Plan theo số1-833-370-7466 (TTY: 711), 24 giờ một ngày, 7 ngày một tuần. Cuộc gọi này miễn phí. Để biết thêm thông tin, hãy truy cập vào duals.anthem.com. 196

afeditab cr oral tablet extended release 24 hour 30 mg .......................... 107afeditab cr oral tablet extended release 24 hour 60 mg .......................... 107AFINITOR ..................... 58AFINITOR DISPERZ ... 172AFINITOR ORAL TABLET 2.5 MG ........................ 172afirmelle ...................... 160AFTERA TABLET 1.5 MG ORAL .......................... 160AGAMATRIX ULTRA-THIN LANCETS ..................... 97ak-poly-bac ................. 181ala-cort external cream .......................... 156alaway childrens allergy solution 0.025 % ophthalmic .................. 181alaway solution 0.025 % ophthalmic .................. 181albendazole oral ........... 75albuterol sulfate er ...... 187ALBUTEROL SULFATE HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ ACT ............................ 187albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%, 0.63 mg/ 3ml, 1.25 mg/3ml ........ 187albuterol sulfate inhalation nebulization solution (5 mg/ ml) 0.5% ..................... 187albuterol sulfate oral .... 187alclometasone dipropionate ................ 156ALDURAZYME ........... 153ALECENSA .................. 58alendronate sodium oral solution ....................... 180alendronate sodium oral tablet 10 mg, 40 mg, 5 mg ............................... 180

alendronate sodium oral tablet 35 mg, 70 mg .... 180alfuzosin hcl er ............ 154ALIMTA ....................... 172ALINIA ORAL SUSPENSION RECONSTITUTED ....... 75ALINIA ORAL TABLET ........................ 75ALIQOPA ...................... 58aliskiren fumarate ....... 107aliskiren fumarate ....... 107all day allergy tablet 10 mg oral .............................. 187all day pain relief tablet 220 mg oral .......................... 22all day relief tablet 220 mg oral ................................ 13allergy relief capsule 25 mg oral .............................. 187allergy relief childrens liquid 12.5 mg/5ml oral ......... 187allergy relief tablet 10 mg oral .............................. 187allergy relief tablet 25 mg oral .............................. 187allergy relief tablet dispersible 10 mg oral .............................. 187allergy tablet 10 mg oral .............................. 187ALLI CAPSULE 60 MG ORAL .......................... 185allopurinol oral .............. 55almacone double strength suspension 400-400-40 mg/ 5ml oral ....................... 142almacone suspension 200- 200-20 mg/5ml oral .... 142alosetron hcl ............... 142ALPHAGAN P OPHTHALMIC SOLUTION 0.1 % .......................... 181alprazolam oral tablet .... 91altavera ....................... 160aluminum hydroxide gel suspension 320 mg/5ml oral .............................. 142

ALUNBRIG ORAL TABLET 180 MG ......................... 58ALUNBRIG ORAL TABLET 30 MG ........................... 58ALUNBRIG ORAL TABLET 90 MG ........................... 58ALUNBRIG ORAL TABLET THERAPY PACK .......... 58alyacen 1/35 ............... 160alyacen 7/7/7 .............. 160amantadine hcl oral ...... 76amantadine hcl oral ...... 83AMBISOME .................. 52AMBRISENTAN .......... 187amcinonide external cream .......................... 156amcinonide external lotion ........................... 156AMCINONIDE EXTERNAL OINTMENT ................. 156amikacin sulfate injection solution 1 gm/4ml, 500 mg/ 2ml ................................ 26amiloride hcl oral ........ 107amiloride- hydrochlorothiazide .... 107AMINOSYN II INTRAVENOUS SOLUTION 10 %, 15 % ................. 124AMINOSYN-PF ........... 124amiodarone hcl intravenous ................. 107amiodarone hcl oral .... 107AMITIZA ..................... 142amitriptyline hcl oral ...... 44amlodipine besy-benazepril hcl ............................... 107amlodipine besylate oral .............................. 107amlodipine besylate- valsartan ..................... 107amlodipine- olmesartan .................. 107amlodipine-valsartan- hctz ............................. 107ammonium lactate external ....................... 119amnesteem ................. 119


amoxapine .................... 44amoxicillin oral capsule ......................... 26amoxicillin oral suspension reconstituted ................. 26amoxicillin oral tablet .... 26amoxicillin oral tablet chewable 125 mg, 250 mg ................................. 27amoxicillin-pot clavulanate er .................................. 27amoxicillin-pot clavulanate oral ................................ 27amphetamine- dextroamphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg ............................... 115amphetamine- dextroamphetamine oral tablet 30 mg ................ 115amphotericin b intravenous ................... 52ampicillin oral capsule 500 mg ................................. 27ampicillin sodium injection solution reconstituted 1 gm, 125 mg, 2 gm, 250 mg, 500 mg ................................. 27ampicillin sodium intravenous ................... 27ampicillin-sulbactam sodium .......................... 27ANADROL-50 ............. 160anagrelide hcl ............. 104anastrozole oral ............ 58ANORO ELLIPTA ....... 187antacid anti-gas max strength suspension 400- 400-40 mg/5ml oral .... 142antacid calcium extra strength tablet chewable 750 mg oral ................. 124antacid calcium tablet chewable 500 mg oral .............................. 124

antacid extra strength tablet chewable 750 mg oral .............................. 142antacid fast acting suspension 200-200-20 mg/ 5ml oral ....................... 142antacid fast relief suspension 200-200-20 mg/ 5ml oral ....................... 142antacid maximum strength suspension 400-400-40 mg/ 5ml oral ....................... 143antacid maximum tablet chewable 1000 mg oral .............................. 143antacid plus anti-gas fast act suspension 200-200-20 mg/5ml oral ................. 143antacid plus anti-gas relief suspension 200-200-20 mg/ 5ml oral ....................... 143antacid plus anti-gas relief suspension 400-400-40 mg/ 5ml oral ....................... 143antacid suspension 200- 200-20 mg/5ml oral .... 143antacid tablet chewable 500 mg oral ........................ 143anti-dandruff shampoo 1 % external ....................... 119anti-itch maximum strength cream 1 % external .... 119antifungal cream 1 % external ......................... 52antifungal cream 2 % external ....................... 119APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE ................ 76apraclonidine hcl ........ 181aprepitant oral capsule 125 mg ................................. 50aprepitant oral capsule 40 mg ................................. 50aprepitant oral capsule 80 mg ................................. 50apri .............................. 160

APRISO ...................... 178aprodine tablet 2.5-60 mg oral .............................. 187APTIOM ........................ 36APTIVUS ORAL CAPSULE ..................... 83APTIVUS ORAL SOLUTION ................... 83aqueous vitamin d liquid 400 unit/ml oral ........... 124ARALAST NP INTRAVENOUS SOLUTION RECONSTITUTED 1000 MG, 500 MG ............... 187aranelle ....................... 160ARCALYST ................. 172aripiprazole oral solution ......................... 44aripiprazole oral solution ......................... 77aripiprazole oral tablet 10 mg ................................. 44aripiprazole oral tablet 10 mg ................................. 77aripiprazole oral tablet 15 mg ................................. 44aripiprazole oral tablet 15 mg ................................. 77aripiprazole oral tablet 2 mg ................................. 44aripiprazole oral tablet 2 mg ................................. 77aripiprazole oral tablet 20 mg, 30 mg ..................... 44aripiprazole oral tablet 20 mg, 30 mg ..................... 77aripiprazole oral tablet 5 mg ................................. 44aripiprazole oral tablet 5 mg ................................. 77aripiprazole oral tablet dispersible 10 mg ......... 44aripiprazole oral tablet dispersible 10 mg ......... 77aripiprazole oral tablet dispersible 15 mg ......... 44aripiprazole oral tablet dispersible 15 mg ......... 77


ARNUITY ELLIPTA .... 187ARRANON .................... 58arsenic trioxide intravenous ................... 58artificial tears solution 1.4 % ophthalmic .................. 181ARZERRA .................... 58ascorbic acid tablet 500 mg oral .............................. 124aspir-low tablet delayed release 81 mg oral ........ 13aspirin 81 tablet delayed release 81 mg oral ........ 13aspirin adult low strength tablet chewable 81 mg oral ................................ 13aspirin ec tablet delayed release 325 mg oral ...... 13aspirin ec tablet delayed release 81 mg oral ........ 13aspirin low dose tablet chewable 81 mg oral .... 13aspirin low dose tablet delayed release 81 mg oral ................................ 13aspirin low strength tablet chewable 81 mg oral .... 13aspirin tablet 325 mg oral ................................ 13aspirin tablet chewable 81 mg oral .......................... 13aspirin tablet delayed release 81 mg oral ........ 13aspirin-dipyridamole er ................................ 104ASSURE ID INSULIN SAFETY SYR 29G X 1/2" 1 ML ................................. 97atazanavir sulfate oral capsule 150 mg, 200 mg ................................. 83atazanavir sulfate oral capsule 300 mg ............ 83atenolol oral ................ 107atenolol- chlorthalidone ............. 107ATGAM ....................... 172

athletes foot af cream 1 % external ......................... 52athletes foot spray aerosol 1 % external .................. 52atomoxetine hcl oral capsule 10 mg, 18 mg, 25 mg, 40 mg ................... 116atomoxetine hcl oral capsule 100 mg, 60 mg, 80 mg ............................... 116atorvastatin calcium oral .............................. 107atovaquone oral ............ 75atovaquone-proguanil hcl oral tablet 250-100 mg .. 75ATRIPLA ....................... 83atropine sulfate injection solution prefilled syringe 0.25 mg/5ml, 1 mg/ 10ml ............................ 143atropine sulfate injection solution prefilled syringe 0.5 mg/5ml ........................ 143atropine sulfate ophthalmic solution ....................... 181ATROVENT HFA ........ 187AUBAGIO ................... 116aubra .......................... 160aubra eq ..................... 160aurovela 1.5/30 ........... 160aurovela 1/20 .............. 160aurovela fe 1.5/30 ....... 160aurovela fe 1/20 .......... 160AVASTIN ...................... 58aviane ......................... 161avita .............................. 58avita ............................ 119AVONEX PEN INTRAMUSCULAR AUTO- INJECTOR KIT ........... 116AVONEX PREFILLED INTRAMUSCULAR PREFILLED SYRINGE KIT .............................. 116ayuna .......................... 161azacitidine ..................... 58azathioprine oral ......... 172

AZATHIOPRINE SODIUM ..................... 172azelastine hcl nasal solution 0.1 %, 0.15 % ............. 187azelastine hcl ophthalmic .................. 181azithromycin intravenous ................... 27azithromycin oral suspension reconstituted ................. 27azithromycin oral tablet 250 mg (6 pack) ................... 27azithromycin oral tablet 250 mg, 500 mg, 600 mg .... 27AZOPT ........................ 181aztreonam injection solution reconstituted 1 gm ........ 27aztreonam injection solution reconstituted 2 gm ........ 27azurette ....................... 161Bb-1 tablet 100 mg oral .............................. 124b-1 tablet 250 mg oral .............................. 125b-12 dots tablet dispersible 500 mcg oral ............... 125b-12 tablet 100 mcg oral .............................. 125b-12 tablet 500 mcg oral .............................. 125b-2 tablet 100 mg oral .............................. 125b-2 tablet 50 mg oral ... 125b-6 tablet 100 mg oral .............................. 125b-6 tablet 50 mg oral ... 125bacitra-neomycin- polymyxin-hc ............... 181bacitracin ointment 500 unit/ gm external ................... 27bacitracin ophthalmic .... 27bacitracin zinc ointment 500 unit/gm external ............ 27bacitracin-polymyxin b ophthalmic ointment 500- 10000 unit/gm ............. 181


baclofen oral ................. 82balsalazide disodium ... 178BALVERSA ORAL TABLET 3 MG ............................. 58BALVERSA ORAL TABLET 4 MG ............................. 59BALVERSA ORAL TABLET 5 MG ............................. 59balziva ........................ 161banophen capsule 25 mg oral .............................. 188banophen capsule 50 mg oral .............................. 188banophen liquid 12.5 mg/ 5ml oral ....................... 188banophen tablet 25 mg oral .............................. 188BANZEL ORAL SUSPENSION .............. 36BANZEL ORAL TABLET 200 MG ......................... 36BANZEL ORAL TABLET 400 MG ......................... 36BARACLUDE ORAL SOLUTION ................... 83BAVENCIO ................... 59BCG VACCINE ........... 172bekyree ....................... 161BELEODAQ .................. 59benazepril hcl oral ...... 107benazepril- hydrochlorothiazide .... 107BENDEKA .................... 59BENLYSTA ................. 172benzonatate capsule 100 mg oral ........................ 188benzonatate capsule 200 mg oral ........................ 188benzoyl peroxide gel 10 % external (otc) ............... 119benzoyl peroxide gel 5 % external (otc) ............... 119benzoyl peroxide- erythromycin ............... 119benzphetamine hcl tablet 50 mg oral ........................ 116benztropine mesylate oral ................................ 76

beser external lotion .... 119BESPONSA .................. 59betamethasone dipropionate aug external cream ............................ 22betamethasone dipropionate aug external cream .......................... 156betamethasone dipropionate aug external lotion ............................. 23betamethasone dipropionate aug external lotion ........................... 156betamethasone dipropionate aug external ointment ........................ 23betamethasone dipropionate aug external ointment ...................... 156betamethasone dipropionate external .... 23betamethasone dipropionate external cream .......................... 156betamethasone dipropionate external lotion ........................... 120betamethasone dipropionate external ointment ...................... 156betamethasone valerate external cream .............. 23betamethasone valerate external cream ............ 157betamethasone valerate external lotion ............... 23betamethasone valerate external lotion ............. 157betamethasone valerate external ointment .......... 23betamethasone valerate external ointment ........ 157BETASERON SUBCUTANEOUS KIT .............................. 116betaxolol hcl ophthalmic .................. 181

betaxolol hcl oral ........ 107bethanechol chloride oral .............................. 154BETIMOL .................... 181bexarotene .................... 59BEXSERO .................. 172bicalutamide ................. 59BICILLIN C-R ................ 27BIKTARVY .................... 83bimatoprost ophthalmic .................. 182bimatoprost ophthalmic .................. 182bisacodyl ec tablet delayed release 5 mg oral ........ 143bisacodyl suppository 10 mg rectal ........................... 143bismatrol maximum strength suspension 525 mg/15ml oral .............................. 143bismatrol suspension 262 mg/15ml oral ............... 143bismatrol tablet chewable 262 mg oral ................. 143bismuth subsalicylate tablet chewable 262 mg oral .............................. 143bisoprolol fumarate ..... 108bisoprolol- hydrochlorothiazide .... 108bleomycin sulfate .......... 59BLEPHAMIDE S.O.P. .... 23BLEPHAMIDE S.O.P. ......................... 182BLINCYTO .................... 59blisovi fe 1.5/30 ........... 161blisovi fe 1/20 .............. 161BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 (0.5ML SYRINGE) ...... 172BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-18.5 , 5-2.5-18.5 LF-MCG/ 0.5 ............................... 172BORTEZOMIB .............. 59bosentan ..................... 188


BOSULIF ORAL TABLET 100 MG ......................... 59BOSULIF ORAL TABLET 400 MG, 500 MG .......... 59BRAFTOVI ORAL CAPSULE 75 MG ......... 59BREO ELLIPTA .......... 188briellyn ........................ 161BRILINTA ................... 104brimonidine tartrate ophthalmic .................. 182BRIVIACT INTRAVENOUS ............ 36BRIVIACT ORAL SOLUTION ................... 36BRIVIACT ORAL TABLET 10 MG ........................... 36BRIVIACT ORAL TABLET 100 MG, 75 MG ............ 36BRIVIACT ORAL TABLET 25 MG ........................... 37BRIVIACT ORAL TABLET 50 MG ........................... 37bromocriptine mesylate oral ................................ 76bromocriptine mesylate oral .............................. 170budesonide inhalation suspension 0.25 mg/2ml, 0.5 mg/2ml .................. 188budesonide inhalation suspension 1 mg/2ml .. 188budesonide oral .......... 143budesonide oral .......... 161budesonide oral .......... 178bumetanide injection ... 108bumetanide oral .......... 108buprenorphine hcl injection ........................ 13buprenorphine hcl sublingual tablet sublingual 2 mg .............................. 13buprenorphine hcl sublingual tablet sublingual 2 mg .............................. 20buprenorphine hcl sublingual tablet sublingual 8 mg .............................. 13

buprenorphine hcl sublingual tablet sublingual 8 mg .............................. 20buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-0.5 mg ...... 20buprenorphine hcl-naloxone hcl sublingual tablet sublingual 8-2 mg ......... 20bupropion hcl er (smoking det) ............................... 20bupropion hcl er (sr) oral tablet extended release 12 hour 100 mg ................. 44bupropion hcl er (sr) oral tablet extended release 12 hour 150 mg, 200 mg .... 44bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg ................. 45bupropion hcl er (xl) oral tablet extended release 24 hour 300 mg ................. 45bupropion hcl oral tablet 100 mg ................................. 45bupropion hcl oral tablet 75 mg ................................. 45buspirone hcl oral ......... 91busulfan ........................ 59BUSULFEX ................... 59butorphanol tartrate injection solution 1 mg/ ml .................................. 13butorphanol tartrate injection solution 2 mg/ ml .................................. 13butorphanol tartrate nasal ............................. 14BYDUREON BCISE ..... 97BYDUREON SUBCUTANEOUS PEN- INJECTOR .................... 97BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION PEN- INJECTOR .................... 97BYETTA 5 MCG PEN SUBCUTANEOUS

SOLUTION PEN- INJECTOR .................... 97Cc 1000 tablet 1000 mg oral .............................. 125c 250 tablet 250 mg oral .............................. 125c 500 tablet 500 mg oral .............................. 125c-1000 tablet 1000 mg oral .............................. 125c-1000/rose hips tablet 1000 mg oral ........................ 125c-250 tablet 250 mg oral .............................. 125c-500 tablet 500 mg oral .............................. 125c-500/rose hips tablet 500 mg oral ........................ 125cabergoline ................. 170CABOMETYX ............... 59cal-gest antacid tablet chewable 500 mg oral .............................. 125calamine lotion 8-8 % external ....................... 120calci-chew tablet chewable 1250 (500 ca) mg oral .............................. 125calcipotriene external cream .......................... 120calcipotriene external ointment ...................... 120calcipotriene external solution ....................... 120calcitonin (salmon) ..... 180calcitrate tablet 950 mg oral .............................. 125calcitrene .................... 120calcitriol intravenous solution 1 mcg/ml ....... 125calcitriol oral capsule ... 180calcium + d3 tablet 600-200 mg-unit oral ................. 125calcium 500 + d tablet 500- 125 mg-unit oral ......... 125calcium 500+d tablet 500- 200 mg-unit oral ......... 125


calcium 500+d tablet 500- 400 mg-unit oral ......... 125calcium 500/d tablet 500- 200 mg-unit oral ......... 125calcium 500/d tablet chewable 500-400 mg-unit oral .............................. 125calcium 600 high potency tablet 600 mg oral ....... 125calcium 600 tablet 1500 (600 ca) mg oral ......... 125calcium 600 tablet 600 mg oral .............................. 126calcium 600+d tablet 600- 200 mg-unit oral ......... 126calcium 600+d tablet 600- 400 mg-unit oral ......... 126CALCIUM 600+D TABLET 600-800 MG-UNIT ORAL .......................... 126calcium 600+d3 tablet 600- 400 mg-unit oral ......... 126CALCIUM 600+D3 TABLET 600-800 MG-UNIT ORAL .......................... 126calcium 600/vitamin d tablet 600-400 mg-unit oral ... 126calcium 600/vitamin d3 tablet 600-800 mg-unit oral .............................. 126CALCIUM 600/VITAMIN D3 TABLET 600-800 MG-UNIT ORAL .......................... 126calcium acetate (phos binder) oral capsule .... 154calcium antacid extra strength tablet chewable 750 mg oral ................. 126calcium antacid tablet chewable 500 mg oral .............................. 126calcium antacid ultra max st tablet chewable 1000 mg oral .............................. 143calcium antacid ultra strength tablet chewable 1000 mg oral ............... 143

calcium ascorbate tablet 500 mg oral ................. 126calcium carbonate antacid suspension 1250 mg/5ml oral .............................. 126calcium carbonate antacid tablet chewable 750 mg oral .............................. 143calcium carbonate tablet 1250 (500 ca) mg oral .............................. 126calcium carbonate tablet 1500 (600 ca) mg oral .............................. 126calcium carbonate tablet 600 mg oral ................. 126calcium carbonate-vitamin d tablet 500-400 mg-unit oral .............................. 126calcium carbonate-vitamin d tablet 600-400 mg-unit oral .............................. 126calcium citrate + d tablet 250-200 mg-unit oral ... 126calcium citrate + d tablet 315-200 mg-unit oral ... 126CALCIUM CITRATE + D TABLET 315-200 MG-UNIT ORAL .......................... 126CALCIUM CITRATE + D3 MAXIMUM TABLET 315- 250 MG-UNIT ORAL ... 126calcium citrate tablet 200 mg oral ........................ 127calcium citrate tablet 250 mg oral ........................ 127CALCIUM CITRATE+D3 PETITES TABLET 200-250 MG-UNIT ORAL ......... 127CALCIUM CITRATE+D3 TABLET 315-250 MG-UNIT ORAL .......................... 127calcium citrate-vitamin d tablet 315-200 mg-unit oral .............................. 127CALCIUM CITRATE- VITAMIN D TABLET 315- 250 MG-UNIT ORAL ... 127

CALCIUM CITRATE- VITAMIN D3 TABLET 315- 250 MG-UNIT ORAL ... 127calcium high potency tablet 600 mg oral ................. 127CALCIUM HIGH POTENCY/VITAMIN D TABLET 600-200 MG-UNIT ORAL .......................... 127calcium plus vitamin d3 tablet 600-800 mg-unit oral .............................. 127CALCIUM TABLET CHEWABLE 500-100 MG- UNIT ORAL ................ 127CALCIUM+D3 TABLET 600-800 MG-UNIT ORAL .......................... 127calcium-vitamin d tablet 500-200 mg-unit oral ... 127CALCIUM-VITAMIN D TABLET 600-200 MG-UNIT ORAL .......................... 127calcium-vitamin d tablet 600-400 mg-unit oral ... 127calcium-vitamin d3 tablet 250-125 mg-unit oral ... 127calcium-vitamin d3 tablet 500-400 mg-unit oral ... 127calcium-vitamin d3 tablet 600-400 mg-unit oral ... 127calcium/c/d tablet chewable 500-10-250 mg-mg-unit oral .............................. 127CALQUENCE ............... 60CALTRATE 600+D3 TABLET 600-800 MG-UNIT ORAL .......................... 127camila ......................... 161candesartan cilexetil .... 108candesartan cilexetil- hctz ............................. 108CAPASTAT SULFATE ..................... 57CAPEX ....................... 157CAPRELSA ORAL TABLET 100 MG ......................... 60


CAPRELSA ORAL TABLET 300 MG ......................... 60CARBAGLU ................ 127carbamazepine er oral capsule extended release 12 hour ......................... 94carbamazepine er oral tablet extended release 12 hour .............................. 37carbamazepine er oral tablet extended release 12 hour 100 mg ................. 94carbamazepine oral ...... 37carbamazepine oral ...... 94carbidopa oral ............... 76carbidopa oral ............... 76carbidopa-levodopa ...... 76carbidopa-levodopa er oral tablet extended release 25- 100 mg, 50-200 mg ...... 76carbidopa-levodopa- entacapone ................... 76carbidopa-levodopa- entacapone ................... 76carbinoxamine maleate oral solution ....................... 188carboplatin intravenous solution ......................... 60CAREONE UNIFINE PENTIPS PLUS 29G X 12MM ............................ 97carisoprodol oral tablet 350 mg ............................... 194carmustine .................... 60carrington antifungal cream 2 % external .................. 52carteolol hcl ................ 182cartia xt ....................... 108carvedilol .................... 108CAYSTON .................... 27CAYSTON .................. 188caziant ........................ 161cefaclor ......................... 28CEFACLOR ER ............ 28cefadroxil ...................... 28cefazolin sodium injection solution reconstituted 1 gm, 10 gm, 500 mg .............. 28

CEFAZOLIN SODIUM INJECTION SOLUTION RECONSTITUTED 100 GM, 300 GM ......................... 28cefazolin sodium intravenous solution reconstituted ................. 28CEFAZOLIN SODIUM- DEXTROSE INTRAVENOUS SOLUTION 1-4 GM/50ML-% ........... 28CEFAZOLIN SODIUM- DEXTROSE INTRAVENOUS SOLUTION RECONSTITUTED 1-4 GM- %(50ML) ....................... 28cefdinir .......................... 28cefepime hcl injection .... 28cefoxitin sodium ............ 28CEFOXITIN SODIUM- DEXTROSE INTRAVENOUS SOLUTION RECONSTITUTED 1-4 GM- %(50ML), 2-2.2 GM- %(50ML) ....................... 28cefpodoxime proxetil .... 28cefprozil ........................ 28ceftazidime injection solution reconstituted 1 gm, 2 gm, 6 gm .................... 28ceftriaxone sodium in dextrose ........................ 28ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg .. 29CEFTRIAXONE SODIUM INJECTION SOLUTION RECONSTITUTED 100 GM ................................ 29ceftriaxone sodium intravenous ................... 29CEFTRIAXONE SODIUM- DEXTROSE INTRAVENOUS SOLUTION RECONSTITUTED 1-3.74 GM-%(50ML), 2-2.22 GM- %(50ML) ....................... 29

cefuroxime axetil oral tablet ............................. 29cefuroxime sodium injection solution reconstituted 7.5 gm, 750 mg ................... 29cefuroxime sodium intravenous solution reconstituted 1.5 gm ..... 29celecoxib oral ................ 14celecoxib oral ................ 23CELONTIN ................... 37cephalexin oral capsule 250 mg, 500 mg ................... 29cephalexin oral suspension reconstituted ................. 29CERDELGA ................ 153CEREZYME INTRAVENOUS SOLUTION RECONSTITUTED 400 UNIT ........................... 128cetirizine hcl tablet 10 mg oral .............................. 188CETIRIZINE HCL TABLET 5 MG ORAL ................ 188CHANTIX CONTINUING MONTH PAK ................ 20CHANTIX ORAL TABLET 0.5 MG .......................... 20CHANTIX ORAL TABLET 1 MG ................................ 20CHANTIX STARTING MONTH PAK ................ 20chateal ........................ 161chateal eq ................... 161cheratussin ac syrup 100-10 mg/5ml oral ................. 188childrens allergy liquid 12.5 mg/5ml oral ................. 188childrens aspirin low strength tablet chewable 81 mg oral .......................... 14chloramphenicol sod succinate ...................... 29chlorhexidine gluconate mouth/throat ............... 118chloroquine phosphate oral ................................ 75chlorothiazide oral ...... 108


CHLORPROMAZINE HCL INJECTION ................... 77chlorpromazine hcl oral ................................ 50chlorpromazine hcl oral ................................ 77chlorthalidone oral tablet 25 mg, 50 mg ................... 108cholestyramine light .... 108cholestyramine oral .... 108ciclodan external solution ....................... 120ciclopirox ....................... 52ciclopirox olamine external ......................... 52cilostazol ..................... 104CIMDUO ....................... 83cinacalcet hcl oral tablet 30 mg, 60 mg ................... 180cinacalcet hcl oral tablet 90 mg ............................... 180CINRYZE .................... 172CIPRODEX ................. 186ciprofloxacin hcl ophthalmic .................... 29ciprofloxacin hcl oral tablet 250 mg, 500 mg, 750 mg ................................. 29ciprofloxacin in d5w intravenous solution 200 mg/100ml ...................... 29cisplatin intravenous solution 100 mg/100ml, 200 mg/200ml, 50 mg/ 50ml .............................. 60citalopram hydrobromide oral solution .................. 45citalopram hydrobromide oral tablet 10 mg ........... 45citalopram hydrobromide oral tablet 20 mg ........... 45citalopram hydrobromide oral tablet 40 mg ........... 45cladribine intravenous solution 10 mg/10ml ..... 60claravis ....................... 120clarithromycin er ........... 29clarithromycin oral ........ 29

classic prenatal tablet 28- 0.8 mg oral .................. 128clearlax powder oral .... 143clemastine fumarate oral tablet 2.68 mg ............. 188CLEVER CHOICE COMFORT EZ 29G X 12MM ............................ 97clindacin etz external swab ........................... 120clindacin-p .................... 29clindamycin hcl oral ...... 29clindamycin phosphate external ......................... 30clindamycin phosphate injection solution 300 mg/ 2ml, 600 mg/4ml, 9 gm/ 60ml, 9000 mg/60ml ..... 30clindamycin phosphate intravenous solution 300 mg/2ml, 600 mg/4ml, 900 mg/6ml .......................... 30clindamycin phosphate vaginal .......................... 30CLINIMIX E/DEXTROSE (2.75/5) ....................... 128CLINIMIX E/DEXTROSE (4.25/10) ..................... 128CLINIMIX E/DEXTROSE (4.25/5) ....................... 128CLINIMIX E/DEXTROSE (5/ 15) .............................. 128CLINIMIX E/DEXTROSE (5/ 20) .............................. 128CLINIMIX N14G30E .... 128CLINIMIX N9G15E ..... 128CLINIMIX N9G20E ..... 128CLINIMIX/DEXTROSE (4.25/10) ..................... 128CLINIMIX/DEXTROSE (4.25/25) ..................... 128CLINIMIX/DEXTROSE (4.25/5) ....................... 128CLINIMIX/DEXTROSE (5/ 15) .............................. 128CLINIMIX/DEXTROSE (5/ 20) .............................. 128

CLINIMIX/DEXTROSE (5/ 25) .............................. 128clobazam oral suspension ................... 37clobazam oral tablet 10 mg ................................. 37clobazam oral tablet 20 mg ................................. 37clobetasol prop emollient base ............................ 157clobetasol propionate e .................................. 157clobetasol propionate external cream ............ 157clobetasol propionate external solution ......... 157clofarabine .................... 60CLOLAR ....................... 60clomipramine hcl oral .... 45clonazepam oral tablet 0.5 mg ................................. 37clonazepam oral tablet 0.5 mg ................................. 91clonazepam oral tablet 1 mg ................................. 37clonazepam oral tablet 1 mg ................................. 91clonazepam oral tablet 2 mg ................................. 37clonazepam oral tablet 2 mg ................................. 91clonazepam oral tablet dispersible 0.125 mg .... 37clonazepam oral tablet dispersible 0.125 mg .... 91clonazepam oral tablet dispersible 0.25 mg ...... 37clonazepam oral tablet dispersible 0.25 mg ...... 91clonazepam oral tablet dispersible 0.5 mg ........ 37clonazepam oral tablet dispersible 0.5 mg ........ 91clonazepam oral tablet dispersible 1 mg ........... 37clonazepam oral tablet dispersible 1 mg ........... 91


clonazepam oral tablet dispersible 2 mg ........... 37clonazepam oral tablet dispersible 2 mg ........... 91clonidine ..................... 108clonidine hcl oral ......... 108clopidogrel bisulfate oral tablet 300 mg .............. 104clopidogrel bisulfate oral tablet 75 mg ................ 104clorazepate dipotassium .................. 37clorazepate dipotassium .................. 91clotrimazole anti-fungal cream 1 % external (otc) .............................. 52clotrimazole cream 1 % external (otc) ................. 52clotrimazole cream 1 % vaginal .......................... 52clotrimazole external cream ............................ 52clotrimazole external solution ......................... 52clotrimazole mouth/throat lozenge ......................... 52clotrimazole mouth/throat troche .......................... 118clotrimazole solution 1 % external (otc) ................. 53clotrimazole-betamethasone external cream ............ 120clozapine oral tablet 100 mg ................................. 77clozapine oral tablet 200 mg ................................. 77clozapine oral tablet 25 mg ................................. 77clozapine oral tablet 50 mg ................................. 77clozapine oral tablet dispersible 100 mg ....... 77clozapine oral tablet dispersible 12.5 mg ...... 77clozapine oral tablet dispersible 150 mg ....... 77

clozapine oral tablet dispersible 200 mg ....... 77clozapine oral tablet dispersible 25 mg ......... 77colchicine oral ............... 55colchicine-probenecid .... 55COLCRYS .................... 55colestipol hcl ............... 108colistimethate sodium (cba) ............................. 30colistimethate sodium (cba) ............................. 30colocort ....................... 178COLY-MYCIN S .......... 186COMBIGAN ................ 182COMBIVENT RESPIMAT ................. 188COMETRIQ (100 MG DAILY DOSE) ............... 60COMETRIQ (140 MG DAILY DOSE) ............... 60COMETRIQ (60 MG DAILY DOSE) .......................... 60COMFORT ASSIST INSULIN SYRINGE 29G X 1/2" 1 ML ...................... 97COMPLERA ................. 83complete allergy medicine capsule 25 mg oral ..... 188compro .......................... 51constulose .................. 144COPIKTRA ................... 60CORLANOR ORAL TABLET ...................... 108cortisone acetate oral .... 23cortisone acetate oral .............................. 157cortisone acetate oral .............................. 178CORTISPORIN-TC ..... 186COTELLIC .................... 60COUMADIN ORAL ..... 104CREON ....................... 153CRIXIVAN ORAL CAPSULE 200 MG ....... 83CRIXIVAN ORAL CAPSULE 400 MG ....... 83

cromolyn sodium aerosol solution 5.2 mg/act nasal ........................... 188cromolyn sodium inhalation .................... 188cromolyn sodium ophthalmic .................. 182cromolyn sodium oral .............................. 188cryselle-28 .................. 161cvs antacid kids tablet chewable 750 mg oral .............................. 144cvs anti-diarrheal suspension 262 mg/15ml oral .............................. 144cvs b-1 tablet 100 mg oral .............................. 128cvs b-12 tablet 500 mcg oral .............................. 128cvs bismuth tablet 262 mg oral .............................. 144cvs bismuth tablet chewable 262 mg oral ................. 144CVS CALCIUM 600 & VITAMIN D3 TABLET 600- 800 MG-UNIT ORAL ... 128CVS CALCIUM 600+D TABLET 600-800 MG-UNIT ORAL .......................... 129CVS CALCIUM CITRATE +D TABLET 315-250 MG- UNIT ORAL ................ 129CVS CALCIUM CITRATE +D3 MINI TABLET 200-250 MG-UNIT ORAL ......... 129cvs chewy not chalky flavor tablet chewable 750 mg oral .............................. 144cvs d3 capsule 1000 unit oral .............................. 129cvs d3 capsule 2000 unit oral .............................. 129cvs d3 capsule 400 unit oral .............................. 129cvs d3 capsule 5000 unit oral .............................. 129


cvs eye wash solution 99.05 % ophthalmic .............. 182cvs gas relief capsule 125 mg oral ........................ 144cvs gas relief extra strength tablet chewable 125 mg oral .............................. 144cvs gas relief ultra strength capsule 180 mg oral .... 144CVS GAUZE STERILE PAD 2"X2" ............................. 97cvs glucose gel 40 % oral ................................ 98cvs glucose tablet chewable 4 gm oral ....................... 98cvs glucose tablet chewable 4-6 gm-mg oral ............. 98cvs glycerin adult suppository 2 gm rectal ........................... 144cvs glycerin adult suppository 2.1 gm rectal ........................... 144cvs heartburn relief tablet chewable 160-105 mg oral .............................. 144cvs iron tablet 325 (65 fe) mg oral ........................ 129CVS LANCETS MICRO THIN 33G ..................... 98CVS LANCETS THIN 26G ............................... 98CVS LANCETS ULTRA THIN 30G ..................... 98cvs lice killing shampoo 0.33-4 % external ....... 120cvs lice solution kit combination ................ 120cvs magnesium citrate solution 1.745 gm/30ml oral .............................. 144cvs mineral oil enema enema rectal ............... 144cvs mineral oil oil oral .............................. 144cvs nasal mist aerosol solution 0.9 % nasal .... 185

cvs oyster shell calcium+vit d tablet 500-125 mg-unit oral .............................. 129cvs stomach relief suspension 525 mg/15ml oral .............................. 144cvs stomach relief tablet chewable 262 mg oral .............................. 144cyanocobalamin solution 1000 mcg/ml injection ...................... 129cyclafem 1/35 ............. 161cyclafem 7/7/7 ............ 161cyclobenzaprine hcl oral .............................. 194cyclophosphamide oral capsule ......................... 60CYCLOSET .................. 98cyclosporine intravenous ................. 172cyclosporine modified ...................... 173cyclosporine oral capsule ....................... 173cyproheptadine hcl oral tablet ........................... 189CYRAMZA .................... 60cyred ........................... 161cyred eq ...................... 162CYSTADANE .............. 154CYSTAGON ............... 154CYSTARAN ................ 182cytarabine (pf) ............... 60cytarabine injection solution ......................... 61Dd 1000 capsule 1000 unit oral .............................. 129d 400 tablet 400 unit oral .............................. 129d 5000 capsule 5000 unit oral .............................. 129d 5000 tablet 5000 unit oral .............................. 129d-3-5 capsule 5000 unit oral .............................. 129

d-vi-sol liquid 400 unit/ml oral .............................. 129d2000 ultra strength capsule 2000 unit oral .............. 129D3 DOTS TABLET DISPERSIBLE 2000 UNIT ORAL .......................... 129d3 high potency capsule 1000 unit oral .............. 129d3 super strength capsule 2000 unit oral .............. 129d3-1000 capsule 1000 unit oral .............................. 129d3-1000 tablet 1000 unit oral .............................. 129dacarbazine intravenous ................... 61dactinomycin ................. 61dalfampridine er .......... 116DALIRESP .................. 189danazol oral ................ 162dantrolene sodium oral ................................ 82dapsone oral ................. 57DAPTACEL INTRAMUSCULAR SUSPENSION 23-15- 5 .................................. 173DAPTOMYCIN INTRAVENOUS SOLUTION RECONSTITUTED 350 MG ................................ 30daptomycin intravenous solution reconstituted 500 mg ................................. 30DARAPRIM ................... 75DARZALEX ................... 61dasetta 1/35 ................ 162dasetta 7/7/7 ............... 162daunorubicin hcl intravenous solution 20 mg/ 4ml ................................ 61DAUNORUBICIN HCL INTRAVENOUS SOLUTION 50 MG/10ML ................. 61DAURISMO ORAL TABLET 100 MG ......................... 61


DAURISMO ORAL TABLET 25 MG ........................... 61deblitane ..................... 162decadron ....................... 23decitabine ..................... 61deferasirox .................. 129DELSTRIGO ................. 83delta d3 tablet 400 unit oral .............................. 129delyla .......................... 162demeclocycline hcl oral ................................ 30DEMSER .................... 108DENAVIR ...................... 84DEPEN TITRATABS ... 129DEPEN TITRATABS ... 154DEPEN TITRATABS ... 173DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ ML ............................... 162DESCOVY .................... 84desenex powder 2 % external ....................... 120desipramine hcl oral ..... 45desmopressin ace spray refrig ........................... 159desmopressin acetate injection ...................... 159desmopressin acetate oral .............................. 159desmopressin acetate spray ........................... 159desogestrel-ethinyl estradiol ...................... 162desoximetasone external cream .......................... 157desoximetasone external gel ............................... 157desoximetasone external ointment ...................... 157DESVENLAFAXINE ER ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG ................................ 45DESVENLAFAXINE ER ORAL TABLET EXTENDED

RELEASE 24 HOUR 50 MG ................................ 45desvenlafaxine succinate er oral tablet extended release 24 hour 100 mg ............ 45desvenlafaxine succinate er oral tablet extended release 24 hour 25 mg .............. 45desvenlafaxine succinate er oral tablet extended release 24 hour 50 mg .............. 45dex4 glucose tablet chewable 4-6 gm-mg oral ................................ 98dex4 naturals tablet chewable 4-6 gm-mg oral ................................ 98dex4 pouch pack tablet chewable 4-6 gm-mg oral ................................ 98dex4 quick dissolve glucose tablet chewable 4 gm oral ................................ 98dex4 tablet chewable 4-6 gm-mg oral ................... 98dexamethasone oral elixir .............................. 23dexamethasone oral elixir ............................ 157dexamethasone oral elixir ............................ 178dexamethasone oral solution ......................... 23dexamethasone oral tablet ............................. 23dexamethasone oral tablet ........................... 157dexamethasone oral tablet ........................... 178DEXAMETHASONE SOD PHOSPHATE PF .......... 23dexamethasone sodium phosphate injection ...... 23dexamethasone sodium phosphate ophthalmic .................. 182dexrazoxane hcl ........... 61

dextroamphetamine sulfate er oral capsule extended release 24 hour 10 mg, 5 mg ............................... 116dextroamphetamine sulfate er oral capsule extended release 24 hour 15 mg ............................... 116dextroamphetamine sulfate oral tablet 10 mg ......... 116dextroamphetamine sulfate oral tablet 5 mg ........... 116dextrose in lactated ringers ......................... 130dextrose intravenous solution 10 %, 5 % ...... 130DEXTROSE INTRAVENOUS SOLUTION 20 %, 40 % ................. 130dextrose intravenous solution 250 mg/ml, 30 %, 70 % ........................... 130dextrose intravenous solution 50 % .............. 130DEXTROSE-NACL INTRAVENOUS SOLUTION 10-0.2 % ..................... 130dextrose-nacl intravenous solution 10-0.45 %, 2.5-0.45 %, 5-0.2 %, 5-0.225 %, 5- 0.33 %, 5-0.45 %, 5-0.9 % ................................ 130dialyvite vitamin d 5000 capsule 5000 unit oral .............................. 130diarrhea suspension 262 mg/15ml oral ............... 144DIASTAT ACUDIAL RECTAL GEL 10 MG .... 38DIASTAT ACUDIAL RECTAL GEL 10 MG .... 38DIASTAT ACUDIAL RECTAL GEL 10 MG .... 91DIASTAT ACUDIAL RECTAL GEL 20 MG .... 38DIASTAT ACUDIAL RECTAL GEL 20 MG .... 38


DIASTAT ACUDIAL RECTAL GEL 20 MG .... 91DIASTAT PEDIATRIC ... 38DIASTAT PEDIATRIC ... 38DIASTAT PEDIATRIC ... 92diazepam injection ...... 116diazepam intensol ...... 116diazepam oral concentrate ................... 38diazepam oral concentrate ................... 38diazepam oral concentrate ................... 92diazepam oral solution 5 mg/5ml .......................... 38diazepam oral solution 5 mg/5ml .......................... 38diazepam oral solution 5 mg/5ml .......................... 92diazepam oral tablet 10 mg ................................. 38diazepam oral tablet 10 mg ................................. 38diazepam oral tablet 10 mg ................................. 92diazepam oral tablet 2 mg ................................. 38diazepam oral tablet 2 mg ................................. 38diazepam oral tablet 2 mg ................................. 92diazepam oral tablet 5 mg ................................. 38diazepam oral tablet 5 mg ................................. 38diazepam oral tablet 5 mg ................................. 92diazepam rectal ............ 38diclofenac potassium .... 14diclofenac potassium .... 23diclofenac sodium er .... 14diclofenac sodium er .... 23diclofenac sodium ophthalmic .................. 182diclofenac sodium oral ... 14diclofenac sodium oral ... 24diclofenac sodium transdermal gel 1 % .... 120

dicloxacillin sodium ....... 30dicyclomine hcl oral .... 144didanosine oral capsule delayed release 200 mg ................................. 84didanosine oral capsule delayed release 250 mg, 400 mg .......................... 84diflunisal oral ................. 14diflunisal oral ................. 24digitek oral tablet 125 mcg ............................. 108digitek oral tablet 250 mcg ............................. 108digox oral tablet 125 mcg ............................. 108digox oral tablet 250 mcg ............................. 109digoxin oral solution .... 109digoxin oral tablet 125 mcg ............................. 109digoxin oral tablet 250 mcg ............................. 109dihydroergotamine mesylate nasal ............................. 55DILANTIN INFATABS .... 39DILANTIN ORAL CAPSULE ..................... 39dilt-xr ........................... 109diltiazem hcl er beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg ......... 109diltiazem hcl er beads oral capsule extended release 24 hour 360 mg .......... 109diltiazem hcl er coated beads oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 300 mg ........................ 109diltiazem hcl er coated beads oral capsule extended release 24 hour 360 mg ........................ 109diltiazem hcl er oral capsule extended release 12 hour ............................ 109

diltiazem hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg ............................... 109diltiazem hcl oral ......... 109DIPENTUM ................. 178diphenhist capsule 25 mg oral .............................. 189diphenhydramine hcl capsule 25 mg oral (otc) ............................ 189diphenhydramine hcl capsule 50 mg oral (otc) ............................ 189diphenhydramine hcl injection ...................... 189diphenhydramine hcl tablet 25 mg oral ................... 189diphenoxylate- atropine ....................... 144DIPHTHERIA-TETANUS TOXOIDS DT .............. 173disulfiram oral ............... 20divalproex sodium er oral tablet extended release 24 hour .............................. 39divalproex sodium er oral tablet extended release 24 hour .............................. 55divalproex sodium er oral tablet extended release 24 hour .............................. 94divalproex sodium oral capsule delayed release sprinkle ......................... 39divalproex sodium oral capsule delayed release sprinkle ......................... 55divalproex sodium oral capsule delayed release sprinkle ......................... 94divalproex sodium oral tablet delayed release ... 39divalproex sodium oral tablet delayed release ... 55divalproex sodium oral tablet delayed release ... 94


DOCETAXEL INTRAVENOUS CONCENTRATE 160 MG/ 8ML, 20 MG/ML, 200 MG/ 10ML, 80 MG/4ML ........ 61DOCETAXEL INTRAVENOUS SOLUTION 160 MG/16ML, 20 MG/2ML, 80 MG/8ML ................... 61docu liquid 50 mg/5ml oral .............................. 144docusate sodium capsule 100 mg oral ................. 144docusate sodium liquid 50 mg/5ml oral ................. 144docusate sodium tablet 100 mg oral ........................ 144docusil capsule 100 mg oral .............................. 145dofetilide ..................... 109dok capsule 100 mg oral .............................. 145dok capsule 250 mg oral .............................. 145donepezil hcl oral tablet 10 mg, 5 mg ....................... 43donepezil hcl oral tablet dispersible .................... 43dorzolamide hcl ophthalmic .................. 182dorzolamide hcl-timolol mal .............................. 182DOVATO ...................... 84doxazosin mesylate oral .............................. 109doxazosin mesylate oral .............................. 155doxepin hcl oral ............ 45doxepin hcl oral ............ 92doxepin hcl oral capsule 10 mg, 100 mg, 25 mg, 50 mg, 75 mg .......................... 194doxepin hcl oral concentrate ................. 194doxercalciferol oral capsule 0.5 mcg ....................... 130doxercalciferol oral capsule 0.5 mcg ....................... 180

doxorubicin hcl intravenous solution ......................... 61doxorubicin hcl liposomal ...................... 61doxy 100 ....................... 30doxycycline hyclate intravenous ................... 30doxycycline hyclate oral capsule ......................... 30doxycycline hyclate oral capsule ....................... 118doxycycline hyclate oral capsule 50 mg ............ 120doxycycline hyclate oral tablet 100 mg, 20 mg .... 30doxycycline hyclate oral tablet 100 mg, 20 mg ... 118doxycycline monohydrate oral capsule 100 mg, 50 mg ............................... 120doxycycline monohydrate oral capsule 100 mg, 50 mg, 75 mg ............................ 30doxycycline monohydrate oral tablet 100 mg, 50 mg ................................. 30doxycycline monohydrate oral tablet 100 mg, 50 mg ............................... 120doxycycline monohydrate oral tablet 50 mg ......... 118dronabinol oral capsule 10 mg ................................. 51dronabinol oral capsule 2.5 mg, 5 mg ....................... 51drospirenone-ethinyl estradiol oral tablet 3-0.03 mg ............................... 162DROXIA ........................ 61ducodyl tablet delayed release 5 mg oral ........ 145DULERA ..................... 189duloxetine hcl oral capsule delayed release particles 20 mg ................................. 45duloxetine hcl oral capsule delayed release particles 20 mg ................................. 92

duloxetine hcl oral capsule delayed release particles 20 mg ............................... 116duloxetine hcl oral capsule delayed release particles 30 mg ................................. 46duloxetine hcl oral capsule delayed release particles 30 mg ................................. 92duloxetine hcl oral capsule delayed release particles 30 mg ............................... 116duloxetine hcl oral capsule delayed release particles 40 mg ................................. 46duloxetine hcl oral capsule delayed release particles 40 mg ................................. 92duloxetine hcl oral capsule delayed release particles 40 mg ............................... 116duloxetine hcl oral capsule delayed release particles 60 mg ................................. 46duloxetine hcl oral capsule delayed release particles 60 mg ................................. 92duloxetine hcl oral capsule delayed release particles 60 mg ............................... 116duramorph .................... 14dutasteride oral ........... 155dutasteride-tamsulosin hcl ............................... 155Ee.e.s. 400 oral tablet ..... 30EASY TOUCH PEN NEEDLES 29G X 12MM ............................ 98econtra ez tablet 1.5 mg oral .............................. 162ecpirin tablet delayed release 325 mg oral ...... 14ed a-hist tablet 4-10 mg oral .............................. 189EDURANT .................... 84efavirenz oral capsule 200 mg ................................. 84


efavirenz oral capsule 50 mg ................................. 84efavirenz oral tablet ...... 84ELAPRASE ................. 154elinest ......................... 162ELIQUIS ..................... 104ELIQUIS STARTER PACK .......................... 104elite-ob ........................ 130ELITEK ......................... 61ELLA ........................... 162EMCYT ......................... 61emoquette ................... 162EMPLICITI .................... 62EMSAM ........................ 46EMTRIVA ORAL CAPSULE ..................... 84EMTRIVA ORAL SOLUTION ................... 84enalapril maleate oral .............................. 109enalapril- hydrochlorothiazide .... 109ENBREL MINI ............... 14ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 25 MG/ 0.5ML .......................... 173ENBREL SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 50 MG/ML .. 173ENBREL SUBCUTANEOUS SOLUTION RECONSTITUTED ..... 173ENBREL SURECLICK SUBCUTANEOUS SOLUTION AUTO- INJECTOR .................. 173endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg ................................. 14endocet oral tablet 2.5-325 mg ................................. 14enema enema 7-19 gm/ 118ml rectal ................ 145enema mineral oil enema rectal ........................... 145

ENGERIX-B INJECTION ................. 173enoxaparin sodium injection ...................... 104enoxaparin sodium subcutaneous solution 100 mg/ml, 150 mg/ml ....... 104enoxaparin sodium subcutaneous solution 120 mg/0.8ml, 80 mg/ 0.8ml ........................... 104enoxaparin sodium subcutaneous solution 30 mg/0.3ml ..................... 105enoxaparin sodium subcutaneous solution 40 mg/0.4ml ..................... 105enoxaparin sodium subcutaneous solution 60 mg/0.6ml ..................... 105enpresse-28 ................ 162enskyce oral tablet 0.15-30 mg-mcg ....................... 162entacapone ................... 76entecavir ....................... 84ENTRESTO ................ 109enulose ....................... 145EPCLUSA ..................... 84EPCLUSA ..................... 84EPIDIOLEX ................... 39epinephrine injection solution 30 mg/30ml .... 189epinephrine injection solution auto-injector 0.15 mg/0.3ml, 0.3 mg/ 0.3ml ........................... 189EPINEPHRINE PF INJECTION SOLUTION ................. 189epinephrine pf injection solution prefilled syringe ........................ 189epirubicin hcl intravenous solution 200 mg/100ml, 50 mg/25ml ........................ 62epitol ............................. 39epitol ............................. 94

EPIVIR HBV ORAL SOLUTION ................... 84eplerenone .................. 109eprosartan mesylate .... 109eq antacid extra strength tablet chewable 750 mg oral .............................. 145eq antacid ultra strength tablet chewable 1000 mg oral .............................. 145eq calcium 600+d tablet 600-800 mg-unit oral ... 130EQ CALCIUM CITRATE+D TABLET 315-250 MG-UNIT ORAL .......................... 130eq gas relief capsule 125 mg oral ........................ 145eq lice killing max st shampoo 0.33-4 % external ....................... 120eq magnesium citrate solution 1.745 gm/30ml oral .............................. 145eq mineral oil oil oral ... 145eq pink-bismuth tablet chewable 262 mg oral .............................. 145eq stomach relief suspension 262 mg/15ml oral .............................. 145eql b-6 tablet 100 mg oral .............................. 130eql lice killing max st shampoo 0.33-4 % external ....................... 120eql stomach relief suspension 262 mg/15ml oral .............................. 145eql vitamin b-12 tablet 500 mcg oral ...................... 130eql vitamin c tablet 1000 mg oral .............................. 130eql vitamin c tablet 500 mg oral .............................. 130eql vitamin c/rose hips tablet 1000 mg oral ............... 130eql vitamin c/rose hips tablet 500 mg oral ................. 130


ERAXIS INTRAVENOUS SOLUTION RECONSTITUTED 100 MG ................................ 53ERBITUX ...................... 62ergoloid mesylates oral ................................ 43ERGOMAR ................... 55ergotamine-caffeine ...... 55ERIVEDGE ................... 62ERLEADA ..................... 62erlotinib hcl oral tablet 100 mg, 150 mg ................... 62erlotinib hcl oral tablet 25 mg ................................. 62errin ............................ 162ertapenem sodium ........ 31ERWINAZE INJECTION ................... 62ery ................................. 31ery-tab .......................... 31ERYTHROCIN LACTOBIONATE INTRAVENOUS SOLUTION RECONSTITUTED 500 MG ................................ 31erythrocin stearate oral tablet 250 mg ................ 31erythromycin base oral tablet delayed release ... 31erythromycin ethylsuccinate oral tablet ...................... 31erythromycin external .... 31erythromycin ophthalmic .................... 31erythromycin stearate oral tablet 250 mg ................ 31ESBRIET ORAL CAPSULE ................... 189ESBRIET ORAL CAPSULE ................... 189ESBRIET ORAL TABLET 267 MG ....................... 189ESBRIET ORAL TABLET 267 MG ....................... 189ESBRIET ORAL TABLET 801 MG ....................... 189

ESBRIET ORAL TABLET 801 MG ....................... 189escitalopram oxalate oral solution ......................... 46escitalopram oxalate oral solution ......................... 92escitalopram oxalate oral tablet 10 mg .................. 46escitalopram oxalate oral tablet 10 mg .................. 92escitalopram oxalate oral tablet 20 mg .................. 46escitalopram oxalate oral tablet 20 mg .................. 92escitalopram oxalate oral tablet 5 mg .................... 46escitalopram oxalate oral tablet 5 mg .................... 92estarylla ...................... 162estradiol oral ............... 162estradiol transdermal patch weekly ......................... 163estradiol vaginal cream .......................... 163ESTRING .................... 163ethambutol hcl oral ....... 57ethosuximide oral ......... 39ethynodiol diac-eth estradiol ...................... 163etodolac oral ................. 14etodolac oral capsule 200 mg ................................. 24etodolac oral tablet ....... 24ETOPOPHOS ............... 62etoposide intravenous solution 1 gm/50ml, 100 mg/ 5ml, 500 mg/25ml ......... 62EVOMELA .................... 62EVOTAZ ....................... 84EXEL COMFORT POINT PEN NEEDLE 29G X 12MM ............................ 98exemestane .................. 62EXJADE ...................... 130EXTAVIA SUBCUTANEOUS KIT .............................. 117

EYE STREAM SOLUTION OPHTHALMIC ............ 182ezetimibe .................... 110FFABRAZYME .............. 154falmina ........................ 163famciclovir oral tablet 125 mg, 250 mg ................... 84famciclovir oral tablet 500 mg ................................. 85famotidine intravenous solution 20 mg/2ml, 200 mg/ 20ml, 40 mg/4ml ......... 145famotidine oral tablet 20 mg, 40 mg .......................... 145famotidine premixed .... 145famotidine tablet 10 mg oral .............................. 145FANAPT ORAL TABLET 1 MG ................................ 77FANAPT ORAL TABLET 10 MG, 12 MG ................... 77FANAPT ORAL TABLET 2 MG ................................ 78FANAPT ORAL TABLET 4 MG ................................ 78FANAPT ORAL TABLET 6 MG ................................ 78FANAPT ORAL TABLET 8 MG ................................ 78FANAPT TITRATION PACK ............................ 78FANTASY LUBRICATED ............. 185FANTASY LUBRICATED/ SPERMICIDE ............. 185FARYDAK ORAL CAPSULE 10 MG ......... 62FARYDAK ORAL CAPSULE 15 MG, 20 MG ................................ 62FASLODEX INTRAMUSCULAR SOLUTION 250 MG/ 5ML ............................... 62febuxostat ..................... 55felbamate ...................... 39felodipine er ................ 110


femynor ....................... 163fenofibrate micronized .................. 110fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg ............................... 110fenofibric acid oral capsule delayed release .......... 110fenoprofen calcium oral tablet ............................. 14fenoprofen calcium oral tablet ............................. 24fentanyl citrate buccal lozenge on a handle ..... 14fentanyl citrate buccal lozenge on a handle ..... 14fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/ hr, 75 mcg/hr ................ 14fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/ hr, 75 mcg/hr ................ 15ferate tablet 240 (27 fe) mg oral .............................. 130ferosul tablet 325 (65 fe) mg oral .............................. 130ferretts tablet 325 (106 fe) mg oral ........................ 130ferrex 150 capsule 150 mg oral .............................. 131ferric x-150 capsule 150 mg oral .............................. 131ferrous gluconate tablet 240 (27 fe) mg oral ............ 131ferrous gluconate tablet 324 (37.5 fe) mg oral ......... 131ferrous gluconate tablet 324 (38 fe) mg oral ............ 131ferrous sulfate tablet 325 (65 fe) mg oral ............ 131ferrous sulfate tablet delayed release 324 (65 fe) mg oral ........................ 131ferrous sulfate tablet delayed release 325 (65 fe) mg oral ........................ 131

ferrousul tablet 325 (65 fe) mg oral ........................ 131FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 80 MG ................................ 46FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 20 MG ............... 46FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 40 MG ............... 46FETZIMA TITRATION ... 46finasteride oral tablet 5 mg ............................... 155FIRAZYR .................... 173FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 120 MG .............................. 170FIRMAGON SUBCUTANEOUS SOLUTION RECONSTITUTED 80 MG .............................. 171flac .............................. 186flecainide acetate ....... 110FLONASE ALLERGY RELIEF SUSPENSION 50 MCG/ACT NASAL ...... 190FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 100 MCG/ BLIST, 50 MCG/ BLIST .......................... 190FLOVENT DISKUS INHALATION AEROSOL POWDER BREATH ACTIVATED 250 MCG/ BLIST .......................... 190FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT ............ 190FLOVENT HFA INHALATION AEROSOL 220 MCG/ACT ............ 190

FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT ................... 190fluconazole in sodium chloride intravenous solution 200-0.9 mg/100ml- %, 400-0.9 mg/200ml- % .................................. 53 fluconazole oral ............ 53flucytosine oral capsule 250 mg ................................. 53flucytosine oral capsule 500 mg ................................. 53fludarabine phosphate intravenous solution ..... 62fludarabine phosphate intravenous solution reconstituted ................. 62fludrocortisone acetate oral .............................. 157flunisolide nasal solution 25 mcg/act (0.025%) ....... 190fluocinolone acetonide body ............................ 121fluocinolone acetonide external ....................... 157fluocinolone acetonide otic .............................. 157fluocinolone acetonide scalp ........................... 158fluocinonide emulsified base ............................ 158fluocinonide external cream 0.05 % ........................ 121fluocinonide external gel ............................... 158fluocinonide external ointment ...................... 158fluocinonide external solution ....................... 158fluoritab oral tablet chewable 2.2 (1 f) mg ............................... 131fluorometholone ophthalmic .................. 182fluorouracil external cream 5 % ............................. 121


fluorouracil external solution ....................... 121fluorouracil intravenous ................... 63fluoxetine hcl oral capsule 10 mg ............................ 46fluoxetine hcl oral capsule 20 mg ............................ 46fluoxetine hcl oral capsule 40 mg ............................ 46fluoxetine hcl oral solution ......................... 46fluphenazine decanoate injection ........................ 78fluphenazine hcl injection ........................ 78fluphenazine hcl oral .... 78flurbiprofen oral ............. 15flurbiprofen oral ............. 24flurbiprofen sodium ..... 182flutamide ....................... 63fluticasone propionate external ....................... 121fluticasone propionate external ....................... 158fluticasone propionate external lotion ............. 190fluticasone propionate nasal ........................... 190fluticasone propionate suspension 50 mcg/act nasal (otc) ................... 190fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/ dose, 500-50 mcg/ dose ............................ 190fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/ dose, 500-50 mcg/ dose ............................ 190fluticasone-salmeterol inhalation aerosol powder breath activated 100-50

mcg/dose, 250-50 mcg/ dose, 500-50 mcg/ dose ............................ 190fluvoxamine maleate oral tablet 100 mg ................ 46fluvoxamine maleate oral tablet 25 mg .................. 47fluvoxamine maleate oral tablet 50 mg .................. 47folic acid tablet 1 mg oral (otc) ............................ 131folic acid tablet 1 mg oral (rx) .............................. 131folic acid tablet 400 mcg oral .............................. 131folic acid tablet 800 mcg oral .............................. 131FOLOTYN ..................... 63fondaparinux sodium subcutaneous solution 10 mg/0.8ml ..................... 105fondaparinux sodium subcutaneous solution 2.5 mg/0.5ml ..................... 105fondaparinux sodium subcutaneous solution 5 mg/0.4ml ..................... 105fondaparinux sodium subcutaneous solution 7.5 mg/0.6ml ..................... 105FORTEO SUBCUTANEOUS SOLUTION 600 MCG/ 2.4ML .......................... 180fosamprenavir calcium .. 85fosinopril sodium ........ 110fosinopril sodium- hctz ............................. 110fosphenytoin sodium .... 39FREAMINE III INTRAVENOUS SOLUTION 10 % ........................... 131FULPHILA .................. 105fulvestrant ..................... 63fungoid-d cream 1 % external ......................... 53furosemide injection solution 10 mg/ml ..................... 110

furosemide injection solution 10 mg/ml (4ml syringe) ....................... 110furosemide oral solution 10 mg/ml, 8 mg/ml ........... 110furosemide oral tablet ........................... 110FUZEON SUBCUTANEOUS SOLUTION RECONSTITUTED ....... 85FYCOMPA ORAL SUSPENSION .............. 39FYCOMPA ORAL TABLET 10 MG, 12 MG .............. 39FYCOMPA ORAL TABLET 2 MG ............................. 39FYCOMPA ORAL TABLET 4 MG ............................. 39FYCOMPA ORAL TABLET 6 MG ............................. 39FYCOMPA ORAL TABLET 8 MG ............................. 39Ggabapentin oral capsule 100 mg ................................. 39gabapentin oral capsule 300 mg ................................. 39gabapentin oral capsule 400 mg ................................. 39gabapentin oral solution ......................... 40gabapentin oral tablet 600 mg ................................. 40gabapentin oral tablet 800 mg ................................. 40GAMUNEX-C .............. 173ganciclovir sodium intravenous solution reconstituted ................. 85GARDASIL 9 .............. 173gas relief capsule 180 mg oral .............................. 145gas relief extra strength capsule 125 mg oral .... 145gas relief extra strength tablet chewable 125 mg oral .............................. 145


gas relief tablet chewable 80 mg oral ................... 145gas relief ultra strength capsule 180 mg oral .... 145GAS-X ULTRA STRENGTH CAPSULE 180 MG ORAL .......................... 146GATTEX ..................... 146gavilax powder oral .... 146gavilyte-c .................... 146gavilyte-g .................... 146gavilyte-n with flavor pack ............................ 146GAZYVA ....................... 63GEMCITABINE HCL INTRAVENOUS SOLUTION 1 GM/10ML, 2 GM/ 20ML ............................. 63gemcitabine hcl intravenous solution 1 gm/26.3ml, 2 gm/ 52.6ml, 200 mg/2ml, 200 mg/5.26ml ..................... 63gemcitabine hcl intravenous solution reconstituted 1 gm, 200 mg .......................... 63gemcitabine hcl intravenous solution reconstituted 2 gm ................................. 63gemfibrozil oral ........... 110generlac ...................... 146gengraf oral capsule 100 mg, 25 mg ................... 173gengraf oral solution .... 173gentak ophthalmic ointment ........................ 31gentamicin sulfate external ......................... 31gentamicin sulfate injection ........................ 31gentamicin sulfate ophthalmic solution ....... 31GENVOYA .................... 85GEODON INTRAMUSCULAR ....... 78GEODON INTRAMUSCULAR ....... 94geri-pectate suspension 262 mg/15ml oral ............... 146

GILENYA ORAL CAPSULE 0.25 MG ........................ 47GILENYA ORAL CAPSULE 0.5 MG ........................ 117GILOTRIF ..................... 63glatiramer acetate subcutaneous solution prefilled syringe 20 mg/ ml ................................ 117glatiramer acetate subcutaneous solution prefilled syringe 40 mg/ ml ................................ 117glatopa subcutaneous solution prefilled syringe 20 mg/ml .......................... 117glatopa subcutaneous solution prefilled syringe 40 mg/ml .......................... 117GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG ........................... 63glimepiride oral tablet 1 mg ................................. 98glimepiride oral tablet 2 mg ................................. 98glimepiride oral tablet 4 mg ................................. 98glipizide er oral tablet extended release 24 hour 10 mg ............................ 98glipizide er oral tablet extended release 24 hour 2.5 mg ........................... 98glipizide er oral tablet extended release 24 hour 5 mg ................................. 98glipizide oral tablet 10 mg ................................. 98glipizide oral tablet 5 mg ................................. 98glipizide xl oral tablet extended release 24 hour 10 mg ............................ 98glipizide xl oral tablet extended release 24 hour 2.5 mg ........................... 98

glipizide xl oral tablet extended release 24 hour 5 mg ................................. 99glipizide-metformin hcl oral tablet 2.5-250 mg ......... 99glipizide-metformin hcl oral tablet 2.5-500 mg, 5-500 mg ................................. 99GLOBAL ALCOHOL PREP EASE ............................ 31GLUCAGEN HYPOKIT ...................... 99GLUCAGON EMERGENCY .............. 99gluco burst gel 40 % oral ................................ 99glucose intravenous .... 131glucose tablet chewable 4 gm oral .......................... 99glucose tablet chewable 4- 6 gm-mg oral ................ 99glyburide oral tablet 1.25 mg ................................. 99glyburide oral tablet 2.5 mg ................................. 99glyburide oral tablet 5 mg ................................. 99glycerin (adult) suppository 2 gm rectal .................. 146glycerin (adult) suppository 2.1 gm rectal ............... 146glycolax powder oral .... 146glycopyrrolate injection solution 0.2 mg/ml ...... 146glycopyrrolate oral tablet 1 mg, 2 mg ..................... 146glydo ............................. 19gnp acid control 150 max st tablet 150 mg oral ....... 146gnp acid reducer max st tablet 20 mg oral ......... 146gnp acid reducer tablet 75 mg oral ........................ 146gnp adult aspirin low strength tablet chewable 81 mg oral .......................... 15gnp all day allergy tablet 10 mg oral ........................ 190


gnp all day pain relief tablet 220 mg oral ................... 24gnp allergy capsule 25 mg oral .............................. 190gnp allergy relief tablet dispersible 10 mg oral .............................. 190gnp allergy tablet 25 mg oral .............................. 190gnp antacid anti-gas suspension 200-200-20 mg/ 5ml oral ....................... 131gnp antacid extra strength tablet chewable 160-105 mg oral .............................. 146gnp antacid extra strength tablet chewable 750 mg oral .............................. 146gnp antacid tablet chewable 500 mg oral ................. 146gnp antacid ultra strength tablet chewable 1000 mg oral .............................. 146gnp anti-gas capsule 180 mg oral ........................ 146gnp artificial tears solution 5-6 mg/ml ophthalmic .................. 182gnp aspirin low dose tablet delayed release 81 mg oral ................................ 15gnp aspirin tablet 325 mg oral ................................ 15gnp aspirin tablet delayed release 325 mg oral ...... 15gnp athletes foot cream 1 % external ......................... 53gnp bisa-lax tablet delayed release 5 mg oral ........ 146gnp calamine lotion 8-8 % external ....................... 121gnp calcium 500 +d3 tablet 500-600 mg-unit oral ... 131GNP CALCIUM 600 +D3 TABLET 600-800 MG-UNIT ORAL .......................... 131

GNP CALCIUM CITRATE +D3 TABLET 315-250 MG- UNIT ORAL ................ 131gnp calcium tablet 600 mg oral .............................. 131gnp childrens allergy liquid 12.5 mg/5ml oral ......... 191gnp clearlax powder oral .............................. 147gnp clotrimazole 3 cream 2 % vaginal .................... 121gnp cold & allergy tablet 4- 10 mg oral ................... 191gnp dayhist allergy tablet 1.34 mg oral ................ 191gnp folic acid tablet 400 mcg oral ...................... 131gnp gas relief extra strength capsule 125 mg oral .... 147gnp gas relief extra strength tablet chewable 125 mg oral .............................. 147gnp gas relief tablet chewable 80 mg oral ... 147gnp glucose tablet chewable 4 gm oral ....................... 99gnp glucose tablet chewable 4-6 gm-mg oral ............. 99gnp hydrocortisone cream 0.5 % external ............. 121gnp hydrocortisone max st ointment 1 % external ....................... 121gnp hydrocortisone plus cream 1 % external .... 121gnp hydrocortisone/aloe cream 1 % external .... 121gnp ibuprofen capsule 200 mg oral .......................... 24gnp ibuprofen tablet 200 mg oral ................................ 24gnp iron tablet 200 (65 fe) mg oral ........................ 131gnp lansoprazole capsule delayed release 15 mg oral .............................. 147gnp laxative tablet delayed release 5 mg oral ........ 147

gnp lice treatment liquid 1 % external ................... 121gnp lice treatment shampoo 0.33-4 % external ....... 121gnp loratadine tablet 10 mg oral .............................. 191gnp lubricating plus eye drops solution 0.5 % ophthalmic .................. 182gnp magnesium citrate solution 1.745 gm/30ml oral .............................. 147gnp miconazole 3 kit 200 & 2 mg-% (9gm) vaginal ........................ 121gnp miconazole 7 cream 2 % vaginal .................... 121gnp miconazorb af powder 2 % external ................ 121gnp milk of magnesia suspension 1200 mg/15ml oral .............................. 132gnp motion sickness relief tablet 25 mg oral ........... 51gnp naproxen sodium capsule 220 mg oral ..... 24gnp nasal decongestant tablet 30 mg oral ......... 191gnp niacin tablet 250 mg oral .............................. 132gnp nicotine mini lozenge 2 mg mouth/throat ........... 20gnp nicotine polacrilex gum 2 mg mouth/throat ........ 20gnp nicotine polacrilex gum 4 mg mouth/throat ........ 20gnp nicotine polacrilex lozenge 2 mg mouth/ throat ............................ 21gnp nicotine polacrilex lozenge 4 mg mouth/ throat ............................ 21gnp omeprazole tablet delayed release 20 mg oral .............................. 147gnp pink bismuth tablet 262 mg oral ........................ 147


gnp pink bismuth tablet chewable 262 mg oral .............................. 147gnp prenatal tablet 28-0.8 mg oral ........................ 132gnp quick dissolve glucose tablet chewable 4 gm oral ................................ 99gnp stomach relief suspension 262 mg/15ml oral .............................. 147gnp stool softener capsule 100 mg oral ................. 147gnp stool softener capsule 250 mg oral ................. 147gnp terbinafine hydrochloride cream 1 % external ......................... 53gnp tolnaftate cream 1 % external ......................... 53gnp vitamin c tablet 1000 mg oral ........................ 132gnp vitamin c tablet 250 mg oral .............................. 132gnp vitamin c tablet 500 mg oral .............................. 132gnp vitamin c w/rose hips tablet 500-37 mg oral .. 132gnp vitamin c/rose hips tablet 1000 mg oral ..... 132gnp vitamin d-400 tablet 400 unit oral ....................... 132goodsense all day allergy tablet 10 mg oral ......... 191goodsense artificial tears solution 0.5-0.6 % ophthalmic .................. 183goodsense aspirin tablet 325 mg oral ................... 15goodsense aspirin tablet chewable 81 mg oral .... 15goodsense gas relief tablet chewable 125 mg oral .............................. 147goodsense glucose tablet chewable 4-6 gm-mg oral ................................ 99

goodsense ibuprofen tablet 200 mg oral ................... 24goodsense lubricating eye drop solution 0.5 % ophthalmic .................. 183goodsense nicotine gum 4 mg mouth/throat ........... 21goodsense nicotine lozenge 4 mg mouth/throat ........ 21griseofulvin microsize oral suspension ................... 53griseofulvin ultramicrosize ............... 53guaiatussin ac syrup 100-10 mg/5ml oral ................. 191guaifenesin ac syrup 100-10 mg/5ml oral ................. 191guaifenesin-codeine solution 100-10 mg/5ml oral (otc) ............................ 191guanfacine hcl er ........ 117GUANIDINE HCL ORAL ............................ 56HH-E-B INCONTROL PEN NEEDLES 29G X 12MM ............................ 99hailey 1.5/30 ............... 163HALAVEN ..................... 63halobetasol propionate external cream ............ 158halobetasol propionate external ointment ........ 158haloperidol decanoate intramuscular solution 100 mg/ml 1 ml .................... 78haloperidol decanoate intramuscular solution 100 mg/ml, 50 mg/ml ........... 78haloperidol lactate ........ 78haloperidol oral ............. 78HARVONI ..................... 85HARVONI ..................... 85HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ ML 1 ML, 720 EL U/0.5ML 0.5 ML ......................... 173

HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL U/ ML, 720 EL U/0.5ML ... 173healthylax packet oral .............................. 147heartburn antacid ex st tablet chewable 160-105 mg oral .............................. 147heartburn relief max st tablet 150 mg oral ....... 147heartburn relief max st tablet 20 mg oral ......... 147heartburn relief tablet 10 mg oral .............................. 147heather ....................... 163HEPARIN (PORCINE) IN NACL INJECTION SOLUTION 100-0.45 UNIT/ ML-% .......................... 105HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 12500-0.45 UT/ 250ML-%, 25000-0.45 UT/ 500ML-% .................... 105HEPARIN (PORCINE) IN NACL INTRAVENOUS SOLUTION 25000-0.45 UT/ 250ML-% .................... 105HEPARIN SOD (PORCINE) IN D5W INTRAVENOUS SOLUTION 100 UNIT/ML, 25000-5 UT/500ML- % ................................ 105heparin sod (porcine) in d5w intravenous solution 40-5 unit/ml-% ..................... 105heparin sodium (porcine) injection solution 1000 unit/ ml, 10000 unit/ml, 20000 unit/ml, 5000 unit/ml .... 105hepatamine ................. 132HERCEPTIN HYLECTA ..................... 63HERCEPTIN INTRAVENOUS SOLUTION RECONSTITUTED 150 MG ................................ 63HETLIOZ .................... 194


HIBERIX INJECTION ................. 173hm acid reducer tablet 75 mg oral ........................ 147hm advanced antacid max st suspension 400-400-40 mg/5ml oral ................. 147hm all day allergy tablet 10 mg oral ........................ 191hm allergy tablet 25 mg oral .............................. 191hm antacid anti-gas ex st suspension 400-400-40 mg/ 5ml oral ....................... 147hm antacid/antigas suspension 200-200-20 mg/ 5ml oral ....................... 148hm aspirin ec low dose tablet delayed release 81 mg oral .......................... 15hm aspirin ec tablet delayed release 325 mg oral ...... 15hm aspirin tablet 325 mg oral ................................ 15hm aspirin tablet chewable 81 mg oral ..................... 15hm calamine lotion 8-8 % external ....................... 121hm calcium antacid ex st tablet chewable 750 mg oral .............................. 148HM CALCIUM CITRATE+D3 PETITE TABLET 200-250 MG-UNIT ORAL .......................... 132HM CALCIUM CITRATE+VITAMIN D TABLET 315-250 MG-UNIT ORAL .......................... 132hm calcium-vitamin d tablet 500-200 mg-unit oral ... 132hm calcium-vitamin d tablet 600-400 mg-unit oral ... 132hm calcium-vitamin d tablet 600-800 mg-unit oral ... 132hm clearlax powder oral .............................. 148

hm enema mineral oil enema rectal ............... 148hm eye itch relief solution 0.025 % ophthalmic .... 183hm famotidine tablet 10 mg oral .............................. 148hm famotidine tablet 20 mg oral .............................. 148hm folic acid tablet 400 mcg oral .............................. 132hm glucose tablet chewable 4-6 gm-mg oral ............. 99hm hydrocortisone plus cream 1 % external .... 121hm hydrocortisone-aloe max st cream 1 % external ....................... 121hm ibuprofen capsule 200 mg oral .......................... 24hm ibuprofen ib tablet 200 mg oral .......................... 24hm ibuprofen tablet 200 mg oral ................................ 24hm iron tablet 200 (65 fe) mg oral ........................ 132hm lice killing max st shampoo 0.33-4 % external ....................... 121hm lice treatment liquid 1 % external ....................... 121hm lubricating plus solution 0.5 % ophthalmic ........ 183hm magnesium citrate solution 1.745 gm/30ml oral .............................. 148hm milk of magnesia suspension 1200 mg/15ml oral .............................. 148hm mineral oil oil oral .. 148hm motion relief tablet 25 mg oral .......................... 51hm naproxen sodium capsule 220 mg oral ..... 24hm naproxen sodium tablet 220 mg oral ................... 24hm niacin tablet extended release 250 mg oral .... 132

hm nicotine patch 24 hour 14 mg/24hr transdermal ................... 21hm nicotine patch 24 hour 21 mg/24hr transdermal ................... 21hm nicotine patch 24 hour 7 mg/24hr transdermal ................... 21hm nicotine polacrilex gum 2 mg mouth/throat ........ 21hm nicotine polacrilex gum 4 mg mouth/throat ........ 21hm nicotine polacrilex lozenge 2 mg mouth/ throat ............................ 21hm nicotine polacrilex lozenge 4 mg mouth/ throat ............................ 21hm omeprazole tablet delayed release 20 mg oral .............................. 148hm stomach relief suspension 262 mg/15ml oral .............................. 148hm stomach relief tablet chewable 262 mg oral .............................. 148hm stool softener capsule 100 mg oral ................. 148hm stool softener capsule 250 mg oral ................. 148hm triple antibiotic ointment 3.5-400-5000 external ... 31hm vitamin b1 tablet 100 mg oral .............................. 132hm vitamin b12 tablet 500 mcg oral ...................... 132hm vitamin b6 tablet 100 mg oral .............................. 132hm vitamin c tablet 1000 mg oral .............................. 132hm vitamin c tablet 500 mg oral .............................. 132hm vitamin c/rose hips tablet 500 mg oral ....... 132hm vitamin d3 capsule 2000 unit oral ....................... 132


HUMALOG JUNIOR KWIKPEN ..................... 99HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR 200 UNIT/ ML ................................. 99HUMALOG MIX 50/50 ... 99HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR .................... 99HUMALOG MIX 75/25 ... 99HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR .................. 100HUMALOG SUBCUTANEOUS SOLUTION CARTRIDGE .............. 100HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.8ML, 40 MG/ 0.8ML (6 PACK), 80 MG/ 0.8ML .......................... 174HUMIRA PEDIATRIC CROHNS START SUBCUTANEOUS PREFILLED SYRINGE KIT 80 MG/0.8ML & 40MG/ 0.4ML .......................... 174HUMIRA PEN SUBCUTANEOUS PEN- INJECTOR KIT ........... 174HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/ 0.8ML .......................... 174HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS PEN-

INJECTOR KIT 80 MG/ 0.8ML .......................... 174HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN- INJECTOR KIT 40 MG/ 0.8ML .......................... 174HUMIRA PEN-PS/UV/ADOL HS START SUBCUTANEOUS PEN- INJECTOR KIT 80 MG/ 0.8ML & 40MG/ 0.4ML .......................... 174HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 10 MG/0.1ML, 10 MG/ 0.2ML, 20 MG/0.2ML, 20 MG/0.4ML ................... 174HUMIRA SUBCUTANEOUS PREFILLED SYRINGE KIT 40 MG/0.4ML, 40 MG/ 0.8ML .......................... 174HUMULIN 70/30 ......... 100HUMULIN 70/30 KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR .................. 100HUMULIN N ................ 100HUMULIN N KWIKPEN SUBCUTANEOUS SUSPENSION PEN- INJECTOR .................. 100HUMULIN R ................ 100HUMULIN R U-500 (CONCENTRATED) .... 100HUMULIN R U-500 KWIKPEN SUBCUTANEOUS SOLUTION PEN- INJECTOR .................. 100hydralazine hcl injection ...................... 110hydralazine hcl oral .... 110hydrochlorothiazide oral .............................. 110

hydrocod polst-cpm polst er suspension extended release 10-8 mg/5ml oral ................................ 15hydrocodone- acetaminophen oral solution 7.5-325 mg/15ml .......... 15hydrocodone- acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5- 325 mg .......................... 15hydrocodone-homatropine syrup 5-1.5 mg/5ml oral ................................ 15HYDROCODONE- HOMATROPINE SYRUP 5- 1.5 MG/5ML ORAL ....... 15hydrocodone-homatropine tablet 5-1.5 mg oral ...... 15hydrocodone-ibuprofen oral tablet 5-200 mg, 7.5-200 mg ................................. 15hydrocortisone cream 0.5 % external ....................... 121hydrocortisone cream 1 % external (otc) ............... 121hydrocortisone external cream 1 %, 2.5 % ....... 158hydrocortisone external lotion 2.5 % ................. 158hydrocortisone external ointment 1 %, 2.5 % .... 158hydrocortisone max st cream 1 % external .... 121hydrocortisone max st/12 moist cream 1 % external ....................... 122hydrocortisone ointment 0.5 % external ................... 122hydrocortisone ointment 1 % external (otc) .......... 122hydrocortisone oral ..... 158hydrocortisone oral ..... 179hydrocortisone oral tablet 20 mg, 5 mg .................. 24hydrocortisone rectal ... 179hydrocortisone valerate ....................... 158


hydrocortisone-acetic acid ............................. 186hydrocortisone-aloe cream 0.5 % external ............. 122hydromet syrup 5-1.5 mg/ 5ml oral ......................... 15hydromorphone hcl oral tablet ............................. 16hydroxychloroquine sulfate oral ................................ 75hydroxyprogesterone caproate intramuscular solution ......................... 63hydroxyurea oral ........... 63hydroxyzine hcl oral tablet ............................. 51hydroxyzine hcl oral tablet ............................. 92hydroxyzine hcl oral tablet ........................... 191hydroxyzine pamoate oral capsule 25 mg, 50 mg ... 51hydroxyzine pamoate oral capsule 25 mg, 50 mg ... 92hydroxyzine pamoate oral capsule 25 mg, 50 mg ............................... 191HYPERRAB ................ 174HYPERRAB S/D INJECTION SOLUTION 300 UNIT/2ML ................... 174Iibandronate sodium oral .............................. 180IBRANCE ...................... 63ibu ................................. 24ibu oral tablet 600 mg, 800 mg ................................. 16ibu-200 tablet 200 mg oral ................................ 24ibuprofen oral suspension ................... 16ibuprofen oral suspension ................... 24ibuprofen oral tablet 400 mg, 600 mg, 800 mg .... 16ibuprofen oral tablet 400 mg, 600 mg, 800 mg .... 24

ibuprofen tablet 200 mg oral ................................ 24icatibant acetate ......... 174ICLUSIG ORAL TABLET 15 MG ................................ 64ICLUSIG ORAL TABLET 45 MG ................................ 64idarubicin hcl ................. 64IDHIFA ORAL TABLET 100 MG ................................ 64IDHIFA ORAL TABLET 50 MG ................................ 64IFEX INTRAVENOUS SOLUTION RECONSTITUTED 3 GM ................................ 64ifosfamide intravenous solution ......................... 64ifosfamide intravenous solution reconstituted 1 gm ................................. 64IFOSFAMIDE INTRAVENOUS SOLUTION RECONSTITUTED 3 GM ................................ 64ILARIS SUBCUTANEOUS SOLUTION ................... 16ILEVRO ...................... 183imatinib mesylate oral tablet 100 mg .......................... 64imatinib mesylate oral tablet 400 mg .......................... 64IMBRUVICA ORAL CAPSULE 140 MG ....... 64IMBRUVICA ORAL CAPSULE 70 MG ......... 64IMBRUVICA ORAL TABLET 140 MG ......................... 64IMBRUVICA ORAL TABLET 280 MG, 420 MG, 560 MG ................................ 64IMFINZI ......................... 64imipenem-cilastatin ....... 31imipramine hcl oral ....... 47imiquimod external ..... 122IMOGAM RABIES-HT INJECTION SOLUTION 300 UNIT/2ML ................... 174

IMOVAX RABIES ....... 174incassia ....................... 163INCRELEX .................. 159indapamide oral .......... 110indomethacin er ............ 16indomethacin er ............ 25indomethacin oral ......... 16indomethacin oral ......... 25INFANRIX ................... 175INLYTA ORAL TABLET 1 MG ................................ 64INLYTA ORAL TABLET 5 MG ................................ 65INREBIC ....................... 65INSULIN LISPRO ....... 100INSUPEN PEN NEEDLES 29G X 12MM .............. 100INSUPEN ULTRAFIN 29G X 12MM ...................... 100INTELENCE ORAL TABLET 100 MG .......... 85INTELENCE ORAL TABLET 200 MG .......... 85INTELENCE ORAL TABLET 25 MG ............ 85intralipid intravenous emulsion 20 % ............ 133INTRALIPID INTRAVENOUS EMULSION 30 % ....... 133INTRON A INJECTION SOLUTION ................... 85INTRON A INJECTION SOLUTION 6000000 UNIT/ ML ................................. 85INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT ............ 85INTRON A INJECTION SOLUTION RECONSTITUTED 10000000 UNIT, 18000000 UNIT ............................. 85INTRON A INJECTION SOLUTION RECONSTITUTED 50000000 UNIT ............ 85


introvale ...................... 163INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 117 MG/ 0.75ML .......................... 78INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 156 MG/ML .. 78INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 234 MG/ 1.5ML ............................ 78INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 39 MG/ 0.25ML .......................... 78INVEGA SUSTENNA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 78 MG/ 0.5ML ............................ 79INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 273 MG/ 0.875ML ........................ 79INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 410 MG/ 1.315ML ........................ 79INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 546 MG/ 1.75ML .......................... 79INVEGA TRINZA INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE 819 MG/ 2.625ML ........................ 79INVIRASE ORAL TABLET ........................ 85IPOL ........................... 175

ipratropium bromide inhalation .................... 191ipratropium bromide nasal ........................... 191ipratropium-albuterol ... 191irbesartan .................... 110irbesartan- hydrochlorothiazide .... 110irbesartan- hydrochlorothiazide .... 110IRESSA ........................ 65irinotecan hcl intravenous solution 100 mg/5ml, 500 mg/25ml ........................ 65irinotecan hcl intravenous solution 40 mg/2ml ....... 65iron (ferrous gluconate) tablet 256 (28 fe) mg oral .............................. 133iron tablet 325 (65 fe) mg oral .............................. 133ISENTRESS HD ........... 85ISENTRESS ORAL PACKET ....................... 86ISENTRESS ORAL TABLET ........................ 86ISENTRESS ORAL TABLET CHEWABLE 100 MG ................................ 86ISENTRESS ORAL TABLET CHEWABLE 25 MG ................................ 86isibloom ...................... 163isoniazid oral ................. 57isopto atropine ............ 183isosorbide dinitrate er ................................ 110isosorbide dinitrate oral .............................. 111isosorbide mononitrate ................. 111isosorbide mononitrate er ................................ 111isotretinoin oral capsule 10 mg, 20 mg, 30 mg ...... 122isotretinoin oral capsule 40 mg ............................... 122

ISTODAX (OVERFILL) .................. 65itraconazole oral capsule ......................... 53ivermectin oral .............. 75IXEMPRA KIT ............... 65IXIARO ....................... 175JJAKAFI ORAL TABLET 10 MG ................................ 65JAKAFI ORAL TABLET 15 MG ................................ 65JAKAFI ORAL TABLET 20 MG ................................ 65JAKAFI ORAL TABLET 25 MG ................................ 65JAKAFI ORAL TABLET 5 MG ................................ 65jantoven ...................... 105JANUMET ................... 100JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100- 1000 MG ..................... 100JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 50- 1000 MG, 50-500 MG .............................. 100JANUVIA ORAL TABLET 100 MG ....................... 100JANUVIA ORAL TABLET 25 MG ......................... 100JANUVIA ORAL TABLET 50 MG ......................... 100JARDIANCE ............... 100jencycla ....................... 163JENTADUETO ............ 101JENTADUETO ............ 101JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5- 1000 MG ..................... 101JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5- 1000 MG ..................... 101


JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG .............................. 101JENTADUETO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000 MG .............................. 101JEVTANA ..................... 65jock itch spray aerosol powder 1 % external ..... 53jolessa ........................ 163juleber ......................... 163JULUCA ........................ 86junel 1.5/30 ................. 163junel 1/20 .................... 163junel fe 1.5/30 ............. 163junel fe 1/20 ................ 164JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 5 MG ........................... 111JUXTAPID ORAL CAPSULE 30 MG, 40 MG, 60 MG ......................... 111KKADCYLA ..................... 65KALETRA ORAL TABLET 100-25 MG .................... 86KALETRA ORAL TABLET 200-50 MG .................... 86kalliga ......................... 164KALYDECO ORAL TABLET ...................... 191kao-tin capsule 240 mg oral .............................. 148kaopectate extra strength suspension 525 mg/15ml oral .............................. 148kaopectate suspension 262 mg/15ml oral ............... 148kariva .......................... 164KCL IN D5W LACTATED RINGERS ................... 133kcl in dextrose-nacl intravenous solution 10-5- 0.45 meq/l-%-%, 20-5-0.2 meq/l-%-%, 20-5-0.33 meq/ l-%-%, 20-5-0.45 meq/l-%-

%, 20-5-0.9 meq/l-%-%, 30- 5-0.45 meq/l-%-%, 40-5- 0.45 meq/l-%-% .......... 133KCL IN DEXTROSE-NACL INTRAVENOUS SOLUTION 20-5-0.225 MEQ/L-%- % ................................ 133KCL IN DEXTROSE-NACL INTRAVENOUS SOLUTION 40-5-0.9 MEQ/L-%- % ................................ 133KCL-LACTATED RINGERS-D5W .......... 133KEDRAB INJECTION SOLUTION 300 UNIT/ 2ML ............................. 175kelnor 1/35 .................. 164kelnor 1/50 .................. 164KEPIVANCE ................. 65ketoconazole external cream ............................ 53ketoconazole external shampoo 2 % ................ 53ketoconazole oral ......... 53ketorolac tromethamine ophthalmic .................. 183ketotifen fumarate solution 0.025 % ophthalmic (otc) ............................ 183KEYTRUDA INTRAVENOUS SOLUTION ................. 175KHAPZORY .................. 65KHEDEZLA ORAL TABLET EXTENDED RELEASE 24 HOUR 100 MG ............. 47KHEDEZLA ORAL TABLET EXTENDED RELEASE 24 HOUR 50 MG ............... 47KIMONO MICRO THIN PLUS .......................... 185KIMONO SENSATION ............... 185KIMONO SENSATION PLUS .......................... 185KINRIX INTRAMUSCULAR SUSPENSION ............ 175

KINRIX INTRAMUSCULAR SUSPENSION INJECTION 0.5 ML ......................... 175kionex oral suspension ................. 133KISQALI (200 MG DOSE) .......................... 65KISQALI (400 MG DOSE) .......................... 66KISQALI (600 MG DOSE) .......................... 66KISQALI FEMARA (400 MG DOSE) .......................... 66KISQALI FEMARA (600 MG DOSE) .......................... 66KISQALI FEMARA(200 MG DOSE) .......................... 66klor-con 10 .................. 133klor-con 10 .................. 133klor-con m10 ............... 133klor-con m10 ............... 133klor-con m15 ............... 133klor-con m15 ............... 133klor-con m20 ............... 133klor-con m20 ............... 133klor-con oral tablet extended release ........................ 133klor-con oral tablet extended release ........................ 134klor-con sprinkle ......... 134klor-con sprinkle oral capsule extended release 8 meq ............................. 134KORLYM .................... 101KPN PRENATAL TABLET 0.1 MG ORAL ............. 134kroger glucose tablet chewable 4-6 gm-mg oral .............................. 101kurvelo ........................ 164KUVAN ORAL TABLET SOLUBLE ................... 154KYPROLIS .................... 66Llabetalol hcl intravenous solution ....................... 111labetalol hcl oral ......... 111


lactated ringers intravenous ................. 134lactated ringers irrigation ...................... 134lactulose encephalopathy .......... 148lactulose oral solution ....................... 148lamisil at cream 1 % external ......................... 53lamivudine oral solution ......................... 86lamivudine oral solution ......................... 86lamivudine oral tablet 100 mg ................................. 86lamivudine oral tablet 100 mg ................................. 86lamivudine oral tablet 150 mg ................................. 86lamivudine oral tablet 150 mg ................................. 86lamivudine oral tablet 300 mg ................................. 86lamivudine oral tablet 300 mg ................................. 86lamivudine-zidovudine ... 86lamotrigine oral tablet .... 40lamotrigine oral tablet .... 94lamotrigine oral tablet chewable ...................... 40lamotrigine oral tablet chewable ...................... 94LANCETS ULTRA THIN ........................... 101LANOXIN ORAL TABLET 250 MCG .................... 111LANOXIN ORAL TABLET 62.5 MCG ................... 111lansoprazole capsule delayed release 15 mg oral (otc) ............................ 148lansoprazole oral capsule delayed release 15 mg ............................... 148lansoprazole oral capsule delayed release 30 mg ............................... 148

LANTUS ..................... 101LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION PEN- INJECTOR .................. 101larin 1.5/30 .................. 164larin 1/20 ..................... 164larin fe 1.5/30 .............. 164larin fe 1/20 ................. 164larissia ........................ 164LARTRUVO .................. 66latanoprost ophthalmic .................. 183LATUDA ORAL TABLET 120 MG, 60 MG ............ 79LATUDA ORAL TABLET 20 MG ................................ 79LATUDA ORAL TABLET 40 MG ................................ 79LATUDA ORAL TABLET 80 MG ................................ 79laxative suppository 10 mg rectal ........................... 149leader glucose tablet chewable 4-6 gm-mg oral .............................. 101leader quick dissolve glucose tablet chewable 4 gm oral ........................ 101LEDIPASVIR- SOFOSBUVIR .............. 86leena ........................... 164leflunomide oral .......... 175leflunomide oral .......... 175LENVIMA (10 MG DAILY DOSE) .......................... 66LENVIMA (12 MG DAILY DOSE) .......................... 66LENVIMA (14 MG DAILY DOSE) .......................... 66LENVIMA (18 MG DAILY DOSE) .......................... 66LENVIMA (20 MG DAILY DOSE) .......................... 66LENVIMA (24 MG DAILY DOSE) .......................... 66LENVIMA (4 MG DAILY DOSE) .......................... 66

LENVIMA (8 MG DAILY DOSE) .......................... 66lessina ........................ 164LETAIRIS .................... 191letrozole oral ................. 66leucovorin calcium injection solution 100 mg/10ml .... 66leucovorin calcium injection solution reconstituted .... 67leucovorin calcium oral ................................ 67leucovorin calcium oral ................................ 67LEUKERAN .................. 67leuprolide acetate injection ...................... 171levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml, 1.25 mg/0.5ml, 1.25 mg/3ml ................ 191levalbuterol hcl inhalation nebulization solution 0.63 mg/3ml ........................ 191levalbuterol tartrate ..... 191LEVEMIR .................... 101LEVEMIR FLEXTOUCH .............. 101levetiracetam er oral tablet extended release 24 hour 500 mg .......................... 40levetiracetam er oral tablet extended release 24 hour 750 mg .......................... 40LEVETIRACETAM IN NACL INTRAVENOUS SOLUTION 1000 MG/100ML, 1500 MG/ 100ML ........................... 40LEVETIRACETAM IN NACL INTRAVENOUS SOLUTION 500 MG/100ML ............. 40levetiracetam intravenous ................... 40levetiracetam oral ......... 40levo-t oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg .......... 170


levo-t oral tablet 25 mcg ............................. 170levobunolol hcl ophthalmic solution 0.5 % ............. 183LEVOCARNITINE ORAL SOLUTION ................. 134LEVOCARNITINE ORAL TABLET ...................... 134levocetirizine dihydrochloride oral tablet ........................... 191levofloxacin in d5w ....... 32levofloxacin intravenous ................... 32levofloxacin oral tablet ... 32levoleucovorin calcium intravenous solution reconstituted 50 mg ...... 67levonest ...................... 164levonorg-eth estrad triphasic ...................... 164levonorgest-eth estrad 91- day oral tablet 0.15-0.03 mg ............................... 164levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30 mg-mcg ......... 164levora 0.15/30 (28) ..... 165levorphanol tartrate oral tablet 2 mg .................... 16levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg ........................ 170levothyroxine sodium oral tablet 25 mcg .............. 170levoxyl oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 50 mcg, 75 mcg, 88 mcg ........................ 170levoxyl oral tablet 25 mcg ............................. 170LEXIVA ORAL SUSPENSION .............. 87LIBTAYO ...................... 67

lice killing maximum strength shampoo 0.33-4 % external ....................... 122lidocaine external ointment ........................ 19lidocaine external patch 5 % .................................. 19 lidocaine hcl (cardiac) pf intravenous solution prefilled syringe 100 mg/ 5ml .............................. 111lidocaine hcl (pf) injection solution 2 % .................. 19lidocaine hcl external solution ......................... 19lidocaine hcl mouth/ throat ............................ 19lidocaine hcl urethral/ mucosal ........................ 20lidocaine pak ................. 20lidocaine viscous hcl ..... 20lidocaine-prilocaine external cream ............................ 20lillow ............................ 165lindane external shampoo ....................... 75linezolid in sodium chloride ......................... 32linezolid intravenous solution 600 mg/ 300ml ............................ 32linezolid oral suspension reconstituted ................. 32linezolid oral tablet ........ 32LINZESS ..................... 149liothyronine sodium oral .............................. 170liquitears solution 1.4 % ophthalmic .................. 183lisinopril oral ................ 111lisinopril- hydrochlorothiazide .... 111LITHIUM ....................... 94lithium carbonate er ...... 95lithium carbonate oral .... 95longs glucose tablet chewable 4-6 gm-mg oral .............................. 101

LONSURF .................... 67loperamide hcl oral capsule ....................... 149lopinavir-ritonavir .......... 87loratadine tablet 10 mg oral .............................. 192lorazepam intensol ..... 117lorazepam oral concentrate ................... 40lorazepam oral concentrate ................... 93lorazepam oral tablet 0.5 mg, 1 mg ....................... 40lorazepam oral tablet 0.5 mg, 1 mg ....................... 93lorazepam oral tablet 2 mg ................................. 40lorazepam oral tablet 2 mg ................................. 93LORBRENA ORAL TABLET 100 MG ......................... 67LORBRENA ORAL TABLET 25 MG ........................... 67lorcet ............................. 16lorcet hd ........................ 16lorcet plus oral tablet 7.5- 325 mg .......................... 16losartan potassium ..... 111losartan potassium- hctz ............................. 111LOTRIMIN AF CREAM 1 % EXTERNAL ................... 53lovastatin .................... 111low-ogestrel ................ 165loxapine succinate oral ................................ 79lubricant eye drops pf solution 0.5 % ophthalmic .................. 183LUBRICANT EYE DROPS SOLUTION 0.4-0.3 % OPHTHALMIC ............ 183lubricant eye drops solution 0.5 % ophthalmic ........ 183lubricating plus eye drops solution 0.5 % ophthalmic .................. 183


ludent oral tablet chewable 2.2 (1 f) mg ................. 134LUMIGAN OPHTHALMIC SOLUTION 0.01 % ..... 183LUMIZYME ................. 154LUMOXITI ..................... 67LUPRON DEPOT (1- MONTH) ..................... 171LUPRON DEPOT-PED (1- MONTH) INTRAMUSCULAR KIT 7.5 MG .............................. 171lutera ........................... 165LYNPARZA ORAL TABLET ........................ 67LYSODREN ................ 170lyza ............................. 165Mm-clear wc solution 100-6.3 mg/5ml oral ................. 192M-M-R II ...................... 175mafenide acetate external ....................... 122mag-al plus liquid 200-200- 20 mg/5ml oral ............ 149mag-al plus xs liquid 400- 400-40 mg/5ml oral .... 149magnesium citrate solution 1.745 gm/30ml oral ..... 149magnesium oxide (antacid) capsule 500 mg oral .... 134magnesium sulfate injection solution 50 % .............. 134magnesium sulfate injection solution 50 % (10ml syringe) ....................... 134MAGNESIUM SULFATE INTRAVENOUS SOLUTION 2 GM/50ML, 20 GM/500ML, 4 GM/100ML, 4 GM/50ML, 40 GM/1000ML ........... 134maprotiline hcl oral tablet 25 mg ................................. 47maprotiline hcl oral tablet 50 mg ................................. 47maprotiline hcl oral tablet 75 mg ................................. 47

MARATHON MEDICAL PENTIPS 29G X 12MM .......................... 101marlissa ...................... 165marlissa ...................... 165marlissa ...................... 165MARPLAN .................... 47MARQIBO ..................... 67MATULANE .................. 67meclizine hcl oral tablet ............................. 51meclizine hcl tablet chewable 25 mg oral (otc) .............................. 51meclofenamate sodium oral ................................ 16meclofenamate sodium oral ................................ 25medroxyprogesterone acetate intramuscular .............. 165medroxyprogesterone acetate oral ................. 165mefloquine hcl .............. 75megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml ...................... 165megestrol acetate oral tablet ........................... 165meijer c tablet 500 mg oral .............................. 134meijer glucose tablet chewable 4-6 gm-mg oral .............................. 101MEKINIST ORAL TABLET 0.5 MG .......................... 67MEKINIST ORAL TABLET 2 MG ............................. 67MEKTOVI ..................... 67meloxicam oral tablet .... 16meloxicam oral tablet .... 25melphalan hcl ............... 67memantine hcl er .......... 43memantine hcl oral solution 2 mg/ml ......................... 44memantine hcl oral tablet 10 mg ................................. 44

memantine hcl oral tablet 5 mg ................................. 44MENACTRA ............... 175MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG .............................. 165MENVEO .................... 175MEPHYTON TABLET 5 MG ORAL .......................... 134mercaptopurine oral .... 175meropenem .................. 32mesalamine oral tablet delayed release 1.2 gm ............................... 179mesalamine rectal enema ......................... 179mesalamine rectal suppository ................. 179mesalamine- cleanser ...................... 149mesna ........................... 68MESNEX ORAL ............ 68MESTINON ORAL SYRUP ......................... 56metaproterenol sulfate oral syrup ........................... 192metformin hcl er oral tablet extended release 24 hour 500 mg ........................ 101metformin hcl er oral tablet extended release 24 hour 750 mg ........................ 101metformin hcl oral tablet 1000 mg ...................... 101metformin hcl oral tablet 500 mg ............................... 101metformin hcl oral tablet 850 mg ............................... 102METHADONE HCL INJECTION ................... 16methadone hcl intensol ......................... 16methadone hcl oral concentrate ................... 16methadone hcl oral solution ......................... 16methadone hcl oral tablet ............................. 17


methazolamide oral .... 111methazolamide oral .... 183methenamine hippurate ....................... 32methimazole oral ........ 171methocarbamol oral .... 194methotrexate oral ....... 175methotrexate sodium (pf) injection solution 1 gm/40ml, 250 mg/10ml ................. 68methotrexate sodium (pf) injection solution 50 mg/ 2ml .............................. 175methotrexate sodium injection solution 250 mg/ 10ml .............................. 68methotrexate sodium injection solution 50 mg/ 2ml .............................. 175methotrexate sodium injection solution reconstituted ................. 68methoxsalen rapid ...... 122methyclothiazide oral ... 111methylphenidate hcl oral tablet ........................... 117methylprednisolone acetate injection suspension 40 mg/ ml .................................. 25METHYLPREDNISOLONE ACETATE INJECTION SUSPENSION 80 MG/ ML ................................. 25methylprednisolone oral .............................. 158methylprednisolone oral .............................. 179methylprednisolone oral tablet ............................. 25methylprednisolone sodium succ injection solution reconstituted 1000 mg, 125 mg, 40 mg ..................... 25metoclopramide hcl injection ...................... 149metoclopramide hcl oral solution 10 mg/10ml, 5 mg/ 5ml .............................. 149

metoclopramide hcl oral solution 5 mg/5ml ......... 51metoclopramide hcl oral tablet ............................. 51metoclopramide hcl oral tablet ........................... 149metolazone ................. 111metoprolol succinate er ................................ 111metoprolol tartrate intravenous solution 5 mg/ 5ml .............................. 111metoprolol tartrate intravenous solution cartridge ...................... 111metoprolol tartrate oral .............................. 112metoprolol- hydrochlorothiazide .... 112metronidazole external cream ............................ 32metronidazole external gel 0.75 % .......................... 32metronidazole external lotion ............................. 32metronidazole in nacl intravenous solution 5-0.79 mg/ml-%, 500-0.79 mg/ 100ml-% ....................... 32METRONIDAZOLE IN NACL INTRAVENOUS SOLUTION 500-0.74 MG/ 100ML-% ...................... 32METRONIDAZOLE INTRAVENOUS ............ 32metronidazole oral ........ 32metronidazole vaginal ... 32mexiletine hcl oral ....... 112mi-acid gas relief tablet chewable 80 mg oral ... 149mi-acid maximum strength suspension 400-400-40 mg/ 5ml oral ....................... 134mi-acid suspension 200- 200-20 mg/5ml oral .... 134MIACALCIN INJECTION ................. 180

miconazole 3 combo pack kit 200 & 2 mg-% (9gm) vaginal ........................ 122miconazole 3 vaginal suppository ................... 53miconazole 7 cream 2 % vaginal ........................ 122miconazole 7 suppository 100 mg vaginal ........... 122miconazole nitrate cream 2 % external ................... 122miconazole nitrate cream 2 % vaginal .................... 122microgestin 1.5/30 ...... 165microgestin 1/20 ......... 165microgestin fe 1.5/30 ... 165microgestin fe 1/20 ..... 165midodrine hcl .............. 112miglustat ..................... 154mili .............................. 166milk of magnesia concentrate suspension 2400 mg/10ml oral ...... 134milk of magnesia suspension 1200 mg/15ml oral .............................. 149milk of magnesia suspension 400 mg/5ml oral .............................. 134milk of magnesia suspension 7.75 % oral .............................. 134mineral oil enema rectal ........................... 149mineral oil oil oral ....... 149minitran ....................... 112minocycline hcl oral ...... 33minocycline hcl oral .... 118minoxidil oral ............... 112mintox maximum strength suspension 400-400-40 mg/ 5ml oral ....................... 135mintox suspension 200-200- 20 mg/5ml oral ............ 149mirtazapine oral tablet 15 mg ................................. 47mirtazapine oral tablet 30 mg ................................. 47


mirtazapine oral tablet 45 mg ................................. 47mirtazapine oral tablet 7.5 mg ................................. 47mirtazapine oral tablet dispersible 15 mg ......... 47mirtazapine oral tablet dispersible 30 mg ......... 47mirtazapine oral tablet dispersible 45 mg ......... 47misoprostol oral .......... 149misoprostol oral tablet 200 mcg ............................. 160mitomycin intravenous solution reconstituted 20 mg, 5 mg ....................... 68mitomycin intravenous solution reconstituted 40 mg ................................. 68mitoxantrone hcl ........... 68modafinil oral tablet 100 mg ............................... 195modafinil oral tablet 200 mg ............................... 195molindone hcl ............... 79mometasone furoate external ....................... 158mondoxyne nl oral capsule 100 mg, 75 mg .............. 33mondoxyne nl oral capsule 100 mg, 75 mg ............ 118mondoxyne nl oral capsule 100 mg, 75 mg ............ 122mono-linyah ................ 166mononessa ................. 166montelukast sodium oral .............................. 192MONUROL ................... 33morgidox oral ................ 33morphine sulfate (concentrate) oral solution 100 mg/5ml ................... 17morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml ... 17morphine sulfate (pf) injection solution 0.5 mg/ml, 1 mg/ml ......................... 17

MORPHINE SULFATE (PF) INJECTION SOLUTION 10 MG/ML, 4 MG/ML, 8 MG/ ML ................................. 17MORPHINE SULFATE (PF) INTRAVENOUS SOLUTION 10 MG/ML, 2 MG/ML, 4 MG/ ML, 8 MG/ML ................ 17morphine sulfate er oral tablet extended release 100 mg, 200 mg ................... 17morphine sulfate er oral tablet extended release 15 mg, 30 mg, 60 mg ......... 17morphine sulfate injection solution 10 mg/ml, 8 mg/ ml .................................. 17morphine sulfate intravenous solution 1 mg/ ml .................................. 17MORPHINE SULFATE INTRAVENOUS SOLUTION 150 MG/30ML ............... 17morphine sulfate intravenous solution 25 mg/ ml .................................. 17morphine sulfate intravenous solution 50 mg/ ml .................................. 17morphine sulfate oral solution 20 mg/5ml ....... 17morphine sulfate oral solution 20 mg/5ml ....... 17morphine sulfate oral tablet ............................. 17morphine sulfate oral tablet ............................. 17motion-time tablet chewable 25 mg oral ..................... 51MOVANTIK ................. 149MOVIPREP ................. 149moxifloxacin hcl ophthalmic .................... 33moxifloxacin hcl oral ..... 33MOZOBIL ................... 135MULTAQ ..................... 112mupirocin calcium ......... 33mupirocin external ........ 33

mutamycin intravenous solution reconstituted 20 mg, 5 mg ....................... 68mutamycin intravenous solution reconstituted 40 mg ................................. 68mycophenolate mofetil hcl ............................... 175mycophenolate mofetil oral capsule ....................... 175mycophenolate mofetil oral suspension reconstituted ............... 176mycophenolate mofetil oral tablet ........................... 176mycophenolate sodium ........................ 176myferon 150 capsule 150 mg oral ........................ 135MYLOTARG INTRAVENOUS SOLUTION RECONSTITUTED 4.5 MG ................................ 68myorisan ..................... 122MYRBETRIQ .............. 155Nnabumetone oral .......... 18nabumetone oral .......... 25nadolol oral tablet 20 mg, 40 mg, 80 mg .............. 112nadolol-bendroflumethiazide oral tablet 40-5 mg ..... 112nafcillin sodium injection solution reconstituted 1 gm, 2 gm .............................. 33NAFCILLIN SODIUM INJECTION SOLUTION RECONSTITUTED 10 GM ................................ 33nafcillin sodium intravenous solution reconstituted 10 gm ................................. 33nafcillin sodium intravenous solution reconstituted 2 gm ................................. 33NAGLAZYME ............. 154nalbuphine hcl injection solution 10 mg/ml ......... 18


nalbuphine hcl injection solution 20 mg/ml ......... 18naloxone hcl injection solution 0.4 mg/ml, 4 mg/ 10ml .............................. 21naloxone hcl injection solution cartridge .......... 21naloxone hcl injection solution prefilled syringe .......................... 21naltrexone hcl oral ........ 21naltrexone hcl oral ........ 21NAMZARIC ................... 44naproxen dr .................. 18naproxen dr .................. 25naproxen oral tablet ...... 18naproxen oral tablet ...... 25naproxen sodium capsule 220 mg oral ................... 25naproxen sodium oral tablet 275 mg, 550 mg ............ 18naproxen sodium oral tablet 275 mg, 550 mg ............ 25naproxen sodium tablet 220 mg oral .......................... 25NARCAN ...................... 21nasal decongestant tablet 30 mg oral ................... 192nasal mist aerosol solution 0.9 % inhalation .......... 185NATACYN .................... 54nateglinide oral tablet 120 mg ............................... 102nateglinide oral tablet 60 mg ............................... 102NATPARA ................... 180natural c/rose hips tablet 1000 mg oral ............... 135natural vitamin d-3 tablet 5000 unit oral .............. 135NEBUPENT .................. 75necon 0.5/35 (28) ....... 166nefazodone hcl oral tablet 100 mg .......................... 48nefazodone hcl oral tablet 150 mg .......................... 48nefazodone hcl oral tablet 200 mg .......................... 48

nefazodone hcl oral tablet 250 mg .......................... 48nefazodone hcl oral tablet 50 mg ............................ 48neo-polycin ................. 183neo-polycin hc ............ 183neomycin sulfate oral .... 33neomycin-bacitracin zn- polymyx ophthalmic ointment 5-400- 10000 .......................... 184neomycin-polymyxin b gu ................................ 155neomycin-polymyxin- dexameth ophthalmic ointment ...................... 184neomycin-polymyxin- dexameth ophthalmic suspension 3.5-10000- 0.1 ............................... 184neomycin-polymyxin- gramicidin ophthalmic solution 1.75-10000- .025 ............................. 184neomycin-polymyxin-hc ophthalmic suspension 3.5- 10000-1 ...................... 184neomycin-polymyxin-hc otic solution 1 % ................ 186neomycin-polymyxin-hc otic suspension ................. 186NERLYNX ..................... 68NEULASTA ONPRO ... 135NEULASTA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE ................... 105NEUPRO ...................... 76nevirapine er oral tablet extended release 24 hour 100 mg .......................... 87nevirapine er oral tablet extended release 24 hour 400 mg .......................... 87nevirapine oral suspension ................... 87nevirapine oral tablet .... 87NEXAVAR .................... 68

niacin (antihyperlipidemic) .... 112niacin er (antihyperlipidemic) .... 112niacin er capsule extended release 250 mg oral .... 135niacin er capsule extended release 500 mg oral .... 135niacin er tablet extended release 250 mg oral .... 135niacin er tablet extended release 750 mg oral .... 135niacin tablet 100 mg oral .............................. 135niacin tablet 250 mg oral .............................. 135niacin tablet 50 mg oral .............................. 135niacin tablet 500 mg oral .............................. 135niacor .......................... 112nicardipine hcl oral ..... 112nicorelief gum 2 mg mouth/ throat ............................ 21NICORETTE LOZENGE 2 MG MOUTH/THROAT ... 21NICORETTE LOZENGE 4 MG MOUTH/THROAT ... 21NICORETTE MINI LOZENGE 2 MG MOUTH/ THROAT ....................... 22NICORETTE MINI LOZENGE 4 MG MOUTH/ THROAT ....................... 22nicotine kit 21-14-7 mg/24hr transdermal ................... 22nicotine patch 24 hour 14 mg/24hr transdermal (otc) .............................. 22nicotine patch 24 hour 21 mg/24hr transdermal (otc) .............................. 22nicotine patch 24 hour 7 mg/ 24hr transdermal (otc) ... 22nicotine polacrilex gum 2 mg mouth/throat ........... 22nicotine polacrilex gum 4 mg mouth/throat ........... 22


nicotine polacrilex lozenge 2 mg mouth/throat ........ 22nicotine polacrilex lozenge 4 mg mouth/throat ........ 22NICOTROL NS ............. 22nifedical xl oral tablet extended release 24 hour 60 mg .......................... 112nifedipine er ................ 112nifedipine er osmotic release ........................ 112nilutamide ..................... 68nimodipine oral ........... 112NINLARO ...................... 68NIPENT ........................ 68NITRO-BID ................. 112nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg ................................. 33nitrofurantoin monohyd macro ............................ 33NITROGLYCERIN INTRAVENOUS .......... 112nitroglycerin sublingual ................... 112nitroglycerin transdermal patch 24 hour .............. 113nora-be ....................... 166NORDITROPIN FLEXPRO ................... 159norethin ace-eth estrad-fe oral tablet 1-20 mg- mcg ............................. 166norethindrone acet-ethinyl est oral tablet .............. 166norethindrone acetate oral .............................. 166norethindrone oral ...... 166norgestim-eth estrad triphasic oral tablet 0.18/ 0.215/0.25 mg-35 mcg ............................. 166norgestimate-eth estradiol oral tablet 0.25-35 mg- mcg ............................. 166norlyda ........................ 166norlyroc ....................... 166

NORMOSOL-M IN D5W ............................ 135NORMOSOL-R ........... 135NORMOSOL-R PH 7.4 ............................... 135NORTHERA ORAL CAPSULE 100 MG ..... 113NORTHERA ORAL CAPSULE 200 MG ..... 113NORTHERA ORAL CAPSULE 300 MG ..... 113nortrel 0.5/35 (28) ....... 166nortrel 1/35 (21) .......... 166nortrel 1/35 (28) .......... 166nortrel 7/7/7 ................ 166nortriptyline hcl oral ...... 48NORVIR ORAL PACKET ....................... 87NORVIR ORAL SOLUTION ................... 87NOXAFIL ORAL SUSPENSION .............. 54NUBEQA ...................... 68NUEDEXTA ................ 117NULOJIX .................... 176NUPLAZID ORAL CAPSULE ..................... 79NUPLAZID ORAL TABLET 10 MG ........................... 79nutrilipid ...................... 135NUVARING ................. 167nyamyc ......................... 54nystatin external ........... 54nystatin mouth/throat .... 54nystatin oral tablet ........ 54nystatin-triamcinolone external cream ............ 122nystop ........................... 54Oocella .......................... 167OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 2 GM/20ML, 2.5 GM/50ML, 25 GM/500ML, 5 GM/ 100ML ......................... 176octreotide acetate injection solution 100 mcg/ml, 1000

mcg/ml, 200 mcg/ml, 50 mcg/ml ........................ 171octreotide acetate injection solution 500 mcg/ml .... 171ODEFSEY .................... 87ODOMZO ..................... 69OFEV ............................ 69OFEV .......................... 192OFEV .......................... 192ofloxacin ophthalmic ..... 33ofloxacin oral tablet 300 mg ............................... 186ofloxacin oral tablet 400 mg ................................. 33ofloxacin otic ................. 34ogestrel ....................... 167okebo oral capsule 75 mg ................................. 34olanzapine intramuscular ................ 79olanzapine intramuscular ................ 95olanzapine oral tablet 10 mg ................................. 79olanzapine oral tablet 10 mg ................................. 95olanzapine oral tablet 15 mg ................................. 79olanzapine oral tablet 15 mg ................................. 95olanzapine oral tablet 2.5 mg ................................. 79olanzapine oral tablet 2.5 mg ................................. 95olanzapine oral tablet 20 mg ................................. 80olanzapine oral tablet 20 mg ................................. 95olanzapine oral tablet 5 mg ................................. 80olanzapine oral tablet 5 mg ................................. 95olanzapine oral tablet 7.5 mg ................................. 80olanzapine oral tablet 7.5 mg ................................. 95olanzapine oral tablet dispersible 10 mg ......... 80


olanzapine oral tablet dispersible 10 mg ......... 95olanzapine oral tablet dispersible 15 mg ......... 80olanzapine oral tablet dispersible 15 mg ......... 95olanzapine oral tablet dispersible 20 mg ......... 80olanzapine oral tablet dispersible 20 mg ......... 95olanzapine oral tablet dispersible 5 mg ........... 80olanzapine oral tablet dispersible 5 mg ........... 95olmesartan-amlodipine- hctz ............................. 113olopatadine hcl ophthalmic .................. 184omega-3 capsule 1000 mg oral .............................. 135omega-3-acid ethyl esters .......................... 113omeprazole oral capsule delayed release .......... 149omeprazole tablet delayed release 20 mg oral ...... 149OMNITROPE .............. 159ondansetron .................. 51ondansetron hcl injection ........................ 51ondansetron hcl oral tablet 24 mg ............................ 51ondansetron hcl oral tablet 4 mg, 8 mg .................... 51ONETOUCH DELICA LANCETS 33G ........... 102ONETOUCH DELICA LANCETS FINE .......... 102ONETOUCH ULTRA BLUE STRIP IN VITRO ........ 102ONETOUCH VERIO STRIP IN VITRO .................... 102opcicon one-step tablet 1.5 mg oral ........................ 167OPDIVO ........................ 69oralone ........................ 118ORFADIN ................... 154

ORKAMBI ORAL TABLET ...................... 192orsythia ....................... 167oseltamivir phosphate oral ................................ 87oxacillin sodium ............ 34oxaliplatin intravenous solution ......................... 69oxaliplatin intravenous solution reconstituted .... 69oxandrolone oral tablet 10 mg ............................... 167oxandrolone oral tablet 2.5 mg ............................... 167oxaprozin ...................... 18oxaprozin ...................... 25oxcarbazepine .............. 40oxybutynin chloride er oral tablet extended release 24 hour 10 mg, 15 mg ..... 155oxybutynin chloride er oral tablet extended release 24 hour 5 mg ................... 155oxybutynin chloride oral syrup ........................... 155oxybutynin chloride oral tablet ........................... 155oxycodone hcl oral capsule ......................... 18oxycodone hcl oral concentrate 10 mg/ 0.5ml ............................. 18oxycodone hcl oral concentrate 100 mg/ 5ml ................................ 18oxycodone hcl oral tablet ............................. 18oxycodone-acetaminophen oral tablet 10-325 mg, 2.5- 325 mg, 5-325 mg, 7.5-325 mg ................................. 18oxycodone-aspirin oral tablet 4.8355-325 mg .... 18oysco 500 tablet 500 mg oral .............................. 135oysco 500+d tablet 500-200 mg-unit oral ................. 135

oyster shell calcium + d tablet 500-200 mg-unit oral .............................. 135oyster shell calcium + d3 tablet 500-400 mg-unit oral .............................. 135oyster shell calcium 250+d tablet 250-125 mg-unit oral .............................. 136oyster shell calcium 500 + d tablet 500-125 mg-unit oral .............................. 136oyster shell calcium 500+d tablet chewable 500-400 mg-unit oral ................. 136oyster shell calcium plus d tablet 500-200 mg-unit oral .............................. 136oyster shell calcium tablet 500 mg oral ................. 136oyster shell calcium/d tablet 250-125 mg-unit oral ... 136oyster shell calcium/d tablet 500-200 mg-unit oral ... 136oyster shell calcium/d3 tablet 500-400 mg-unit oral .............................. 136oyster shell calcium/vitamin d tablet 250-125 mg-unit oral .............................. 136oyster shell calcium/vitamin d tablet 500-200 mg-unit oral .............................. 136oystercal-d tablet 500-400 mg-unit oral ................. 136OZEMPIC (0.25 OR 0.5 MG/DOSE) ................. 102OZEMPIC (1 MG/ DOSE) ........................ 102Ppacerone oral tablet 100 mg, 200 mg, 400 mg ... 113paclitaxel intravenous concentrate 100 mg/16.7ml, 150 mg/25ml, 30 mg/ 5ml ................................ 69


paliperidone er oral tablet extended release 24 hour 1.5 mg ........................... 80paliperidone er oral tablet extended release 24 hour 3 mg ................................. 80paliperidone er oral tablet extended release 24 hour 6 mg ................................. 80paliperidone er oral tablet extended release 24 hour 9 mg ................................. 80pamidronate disodium intravenous solution 30 mg/ 10ml, 90 mg/10ml ....... 180PAMIDRONATE DISODIUM INTRAVENOUS SOLUTION 6 MG/ML ..................... 180pamidronate disodium intravenous solution reconstituted ............... 180PANRETIN ................... 69pantoprazole sodium intravenous ................. 149pantoprazole sodium oral .............................. 149paricalcitol oral capsule 1 mcg, 2 mcg ................. 180paricalcitol oral capsule 4 mcg ............................. 180paroex ......................... 119paromomycin sulfate oral ................................ 34paroxetine hcl oral tablet 10 mg ................................. 48paroxetine hcl oral tablet 10 mg ................................. 93paroxetine hcl oral tablet 20 mg ................................. 48paroxetine hcl oral tablet 20 mg ................................. 93paroxetine hcl oral tablet 30 mg ................................. 48paroxetine hcl oral tablet 30 mg ................................. 93paroxetine hcl oral tablet 40 mg ................................. 48

paroxetine hcl oral tablet 40 mg ................................. 93PASER ......................... 57PAXIL ORAL SUSPENSION .............. 48PAXIL ORAL SUSPENSION .............. 93PAZEO ....................... 184PC UNIFINE PENTIPS 29G X 12MM ...................... 102PEAK AIR PEAK FLOW METER DEVICE ......... 192PEDIARIX ................... 176PEDVAX HIB INTRAMUSCULAR SUSPENSION ............ 176peg 3350 packet oral ... 150peg 3350 powder oral .............................. 150peg 3350-kcl-na bicarb- nacl ............................. 150peg 3350/ electrolytes ................. 150peg-3350/ electrolytes ................. 150PEGANONE ................. 40PEGASYS PROCLICK SUBCUTANEOUS SOLUTION 180 MCG/ 0.5ML ............................ 87PEGASYS SUBCUTANEOUS SOLUTION ................... 87PEGINTRON SUBCUTANEOUS KIT 50 MCG/0.5ML .................. 87PENICILLIN G POT IN DEXTROSE .................. 34penicillin g potassium .... 34PENICILLIN G PROCAINE ................... 34penicillin g sodium ........ 34penicillin v potassium .... 34PENTACEL ................. 176PENTAM ....................... 75pentamidine isethionate .................... 75

PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG .............................. 179PENTASA ORAL CAPSULE EXTENDED RELEASE 500 MG .............................. 179pentoxifylline er .......... 113peptic relief tablet chewable 262 mg oral ................. 150pepto-bismol tablet chewable 262 mg oral .............................. 150pepto-bismol to-go tablet chewable 262 mg oral .............................. 150periogard .................... 119PERJETA ..................... 69permethrin external cream ............................ 75perphenazine oral ......... 51perphenazine oral ......... 80pfizerpen ....................... 34pharbedryl capsule 25 mg oral .............................. 192pharbedryl capsule 50 mg oral .............................. 192PHAZYME ULTRA STRENGTH CAPSULE 180 MG ORAL ................... 150phenelzine sulfate oral .. 48phenobarbital oral elixir .............................. 40phenobarbital oral tablet 100 mg .......................... 40phenobarbital oral tablet 15 mg ................................. 41phenobarbital oral tablet 16.2 mg ......................... 41phenobarbital oral tablet 30 mg ................................. 41phenobarbital oral tablet 32.4 mg ......................... 41phenobarbital oral tablet 60 mg ................................. 41phenobarbital oral tablet 64.8 mg ......................... 41phenobarbital oral tablet 97.2 mg ......................... 41


phentermine hcl capsule 15 mg oral ........................ 117phentermine hcl capsule 30 mg oral ........................ 117phentermine hcl capsule 37.5 mg oral ................ 117phentermine hcl tablet 37.5 mg oral ........................ 117PHENYTEK .................. 41phenytoin oral suspension 125 mg/5ml ................... 41phenytoin oral tablet chewable ...................... 41phenytoin sodium extended ....................... 41phenytoin sodium injection ........................ 41philith .......................... 167PHOSLYRA ................ 155PHOSPHOLINE IODIDE ....................... 184PICATO ...................... 122PIFELTRO .................... 87pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % ................................ 184pilocarpine hcl oral ..... 119pimecrolimus .............. 122pimecrolimus .............. 176pimozide ....................... 80pimtrea ........................ 167pindolol ....................... 113pioglitazone hcl oral tablet 15 mg .......................... 102pioglitazone hcl oral tablet 30 mg .......................... 102pioglitazone hcl oral tablet 45 mg .......................... 102piperacillin sod-tazobactam so intravenous solution reconstituted 2.25 (2-0.25) gm, 3.375 (3-0.375) gm, 4.5 (4-0.5) gm, 40.5 (36-4.5) gm ................................. 34PIQRAY (200 MG DAILY DOSE) .......................... 69PIQRAY (250 MG DAILY DOSE) .......................... 69

PIQRAY (300 MG DAILY DOSE) .......................... 69pirmella 1/35 ............... 167pirmella 7/7/7 .............. 167piroxicam oral ............... 18piroxicam oral ............... 25PLAN B ONE-STEP TABLET 1.5 MG ORAL (OTC) .......................... 167PLASMA-LYTE 148 .... 136pnv-dha ....................... 136podofilox external ....... 123POLIVY ......................... 69poly-iron 150 capsule 150 mg oral ........................ 136polycin ........................ 184polyethylene glycol 3350 oral packet .................. 150polyethylene glycol 3350 oral powder ................. 150polyethylene glycol 3350 packet oral (otc) .......... 150polyethylene glycol 3350 powder oral (otc) ........ 150polymyxin b- trimethoprim ................ 184POMALYST ORAL CAPSULE 1 MG ........... 69POMALYST ORAL CAPSULE 2 MG ........... 69POMALYST ORAL CAPSULE 3 MG, 4 MG ................................ 69portia-28 ..................... 167PORTRAZZA ................ 69potassium chloride crys er ................................ 136potassium chloride er ................................ 136potassium chloride in dextrose intravenous solution 20-5 meq/l-%, 40-5 meq/l-% ...................... 136potassium chloride in nacl intravenous solution 20-0.45 meq/l-%, 20-0.9 meq/l- % ................................ 136

potassium chloride intravenous solution 10 meq/100ml, 2 meq/ml, 20 meq/100ml, 40 meq/ 100ml .......................... 136potassium chloride intravenous solution 10 meq/50ml, 20 meq/ 50ml ............................ 137potassium chloride oral solution 20 meq/15ml (10%), 40 meq/15ml (20%) .......................... 137potassium citrate er .... 155POTELIGEO ................. 69PRADAXA .................. 106PRALUENT SUBCUTANEOUS SOLUTION PEN- INJECTOR .................. 113pramipexole dihydrochloride ............. 76prasugrel hcl ............... 106pravastatin sodium ..... 113praziquantel oral ........... 75prazosin hcl oral ......... 113prazosin hcl oral ......... 155prednisolone acetate ophthalmic .................... 25prednisolone acetate ophthalmic .................. 179prednisolone acetate ophthalmic .................. 184prednisolone oral solution ......................... 25prednisolone oral solution ....................... 158prednisolone oral solution ....................... 179PREDNISOLONE SODIUM PHOSPHATE OPHTHALMIC .............. 26PREDNISOLONE SODIUM PHOSPHATE OPHTHALMIC ............ 184prednisolone sodium phosphate oral solution 15


mg/5ml, 6.7 (5 base) mg/ 5ml ................................ 26prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml ......... 158prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml ......... 179PREDNISONE INTENSOL .................... 26PREDNISONE INTENSOL .................. 159PREDNISONE INTENSOL .................. 179prednisone oral ............. 26prednisone oral ........... 159prednisone oral solution ....................... 179prednisone oral tablet ........................... 179preferred plus glucose tablet chewable 4-6 gm-mg oral .............................. 102PREFERRED PLUS INSULIN SYRINGE 28G X 1/2" 0.5 ML ................. 102pregabalin oral capsule 100 mg ................................. 41pregabalin oral capsule 150 mg ................................. 41pregabalin oral capsule 200 mg ................................. 41pregabalin oral capsule 225 mg, 300 mg ................... 41pregabalin oral capsule 25 mg ................................. 41pregabalin oral capsule 50 mg ................................. 42pregabalin oral capsule 75 mg ................................. 42pregabalin oral solution ......................... 42PREMARIN ORAL ...... 167PREMARIN VAGINAL .................... 167PREMASOL INTRAVENOUS SOLUTION 10 % ........................... 137

PREMIUM CONDOMS LUBRICATED ............. 185PREMPRO ................. 167prenatal low iron tablet 27- 0.8 mg oral .................. 137prenatal one daily tablet 27- 0.8 mg oral .................. 137prenatal tablet 27-0.8 mg oral (otc) ..................... 137prenatal tablet 28-0.8 mg oral .............................. 137prenatal vitamin and mineral tablet 28-0.8 mg oral ... 137prenatal vitamins tablet 28- 0.8 mg oral .................. 137prevalite ...................... 113previfem ...................... 167PREZCOBIX ................. 87PREZISTA ORAL SUSPENSION .............. 87PREZISTA ORAL TABLET 150 MG ......................... 87PREZISTA ORAL TABLET 600 MG, 800 MG .......... 88PREZISTA ORAL TABLET 75 MG ........................... 88PRIFTIN ........................ 57primaquine phosphate oral ................................ 75primidone oral ............... 42PROAIR HFA .............. 192PROAIR RESPICLICK .............. 192probenecid oral ............. 55procainamide hcl injection ...................... 113prochlorperazine ........... 51prochlorperazine edisylate injection solution 10 mg/2ml, 50 mg/10ml ................... 80prochlorperazine maleate oral ................................ 51prochlorperazine maleate oral ................................ 80PROCRIT INJECTION SOLUTION 10000 UNIT/

ML, 2000 UNIT/ML, 3000 UNIT/ML, 4000 UNIT/ ML ............................... 106PROCRIT INJECTION SOLUTION 20000 UNIT/ ML, 40000 UNIT/ML .... 106procto-med hc ............. 179procto-pak ................... 159proctosol hc ................ 179proctozone-hc rectal .... 150proctozone-hc rectal .... 159PRODIGY TWIST TOP LANCETS 28G ........... 102progesterone micronized oral .............................. 167PROGLYCEM ............. 102PROGRAF INTRAVENOUS .......... 176PROGRAF ORAL PACKET ..................... 176PROLASTIN-C INTRAVENOUS SOLUTION ................. 192PROLEUKIN ................. 70PROLIA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE ................... 181PROMACTA ORAL PACKET ..................... 106PROMACTA ORAL TABLET 12.5 MG, 25 MG, 75 MG ......................... 106PROMACTA ORAL TABLET 50 MG .......... 106promethazine hcl oral tablet ............................. 52promethazine hcl oral tablet ........................... 192promethazine-codeine solution 6.25-10 mg/5ml oral .............................. 192promethazine-codeine syrup 6.25-10 mg/5ml oral .... 192promethazine-dm syrup 6.25-15 mg/5ml oral .... 192promethazine-phenyleph- codeine syrup 6.25-5-10 mg/5ml oral ................. 192


propafenone hcl .......... 113propranolol hcl er ........ 113propranolol hcl intravenous ................. 113propranolol hcl oral ..... 113propylthiouracil oral .... 171PROQUAD SUBCUTANEOUS SUSPENSION RECONSTITUTED ..... 176protriptyline hcl ............. 48provil tablet 200 mg oral ................................ 26pseudoephedrine hcl tablet 30 mg oral (otc) .......... 192PULMOZYME ............. 192PULMOZYME ............. 192pureway-c tablet 500 mg oral .............................. 137PURIXAN ...................... 70px gas relief extra strength capsule 125 mg oral .... 150px gas relief ultra strength capsule 180 mg oral .... 150px glucose tablet chewable 4-6 gm-mg oral ........... 102px stomach relief max st suspension 525 mg/15ml oral .............................. 150px stomach relief suspension 262 mg/15ml oral .............................. 150px stomach relief tablet chewable 262 mg oral .............................. 150pyrazinamide oral ......... 57pyridostigmine bromide oral solution ......................... 56pyridostigmine bromide oral tablet 60 mg .................. 56Qqc 3 day cream 4 % vaginal ........................ 123qc acid controller max st tablet 20 mg oral ......... 150qc acid controller tablet 10 mg oral ........................ 150

qc all day allergy tablet 10 mg oral ........................ 193qc antacid suspension 200- 200-20 mg/5ml oral .... 150qc antacid/anti-gas suspension 200-200-20 mg/ 5ml oral ....................... 151qc aspirin low dose tablet chewable 81 mg oral .... 18qc aspirin tablet 325 mg oral ................................ 18qc calamine lotion external ....................... 123qc enteric aspirin tablet delayed release 325 mg oral ................................ 18qc gentle laxative suppository 10 mg rectal ........................... 151qc heartburn antacid tablet chewable 160-105 mg oral .............................. 151qc ibuprofen ib tablet 200 mg oral .......................... 26qc ibuprofen tablet 200 mg oral ................................ 26qc loratadine allergy relief tablet 10 mg oral ......... 193qc magnesium citrate solution 1.745 gm/30ml oral .............................. 151qc miconazole 7 cream 2 % vaginal ........................ 123qc milk of magnesia suspension 400 mg/5ml oral .............................. 151qc mineral oil heavy oil oral .............................. 151qc naproxen sodium tablet 220 mg oral ................... 18qc tolnaftate cream 1 % external ......................... 54QUADRACEL ............. 176quetiapine fumarate er oral tablet extended release 24 hour 150 mg ................. 48

quetiapine fumarate er oral tablet extended release 24 hour 150 mg ................. 80quetiapine fumarate er oral tablet extended release 24 hour 150 mg ................. 95quetiapine fumarate er oral tablet extended release 24 hour 200 mg ................. 48quetiapine fumarate er oral tablet extended release 24 hour 200 mg ................. 80quetiapine fumarate er oral tablet extended release 24 hour 200 mg ................. 95quetiapine fumarate er oral tablet extended release 24 hour 300 mg ................. 48quetiapine fumarate er oral tablet extended release 24 hour 300 mg ................. 80quetiapine fumarate er oral tablet extended release 24 hour 300 mg ................. 95quetiapine fumarate er oral tablet extended release 24 hour 400 mg ................. 48quetiapine fumarate er oral tablet extended release 24 hour 400 mg ................. 80quetiapine fumarate er oral tablet extended release 24 hour 400 mg ................. 95quetiapine fumarate er oral tablet extended release 24 hour 50 mg ................... 49quetiapine fumarate er oral tablet extended release 24 hour 50 mg ................... 80quetiapine fumarate er oral tablet extended release 24 hour 50 mg ................... 95quetiapine fumarate oral tablet 100 mg ................ 49quetiapine fumarate oral tablet 100 mg ................ 80quetiapine fumarate oral tablet 100 mg ................ 95


quetiapine fumarate oral tablet 200 mg ................ 49quetiapine fumarate oral tablet 200 mg ................ 80quetiapine fumarate oral tablet 200 mg ................ 95quetiapine fumarate oral tablet 25 mg .................. 49quetiapine fumarate oral tablet 25 mg .................. 81quetiapine fumarate oral tablet 25 mg .................. 95quetiapine fumarate oral tablet 300 mg ................ 49quetiapine fumarate oral tablet 300 mg ................ 81quetiapine fumarate oral tablet 300 mg ................ 95quetiapine fumarate oral tablet 400 mg ................ 49quetiapine fumarate oral tablet 400 mg ................ 81quetiapine fumarate oral tablet 400 mg ................ 95quetiapine fumarate oral tablet 50 mg .................. 49quetiapine fumarate oral tablet 50 mg .................. 81quetiapine fumarate oral tablet 50 mg .................. 95quinapril hcl ................ 113quinapril- hydrochlorothiazide .... 113quinidine sulfate oral ... 113QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 40 MCG/ACT ................... 193QVAR REDIHALER INHALATION AEROSOL BREATH ACTIVATED 80 MCG/ACT ................... 193Rra calcium 600 tablet 600 mg oral ........................ 137RA CALCIUM CIT-VIT D-3 PETITES TABLET 200-250 MG-UNIT ORAL ......... 137

ra folic acid tablet 400 mcg oral .............................. 137ra folic acid tablet 800 mcg oral .............................. 137ra gas relief capsule 125 mg oral .............................. 151ra gas relief extra strength tablet chewable 125 mg oral .............................. 151ra glucose tablet chewable 6-4 mg-gm oral ........... 102ra glycerin adult suppository 80.7 % rectal ............... 151ra hi cal tablet 500-200 mg- unit oral ....................... 137ra high potency iron tablet 27 mg oral ................... 137ra iron tablet 325 (65 fe) mg oral .............................. 137ra lice maximum strength shampoo 0.33-4 % external ....................... 123ra magnesium capsule 500 mg oral ........................ 137ra mineral oil oil oral .... 151ra niacin tablet 100 mg oral .............................. 137ra niacin tablet 500 mg oral .............................. 137ra oyster shell calcium/d tablet 500-200 mg-unit oral .............................. 137ra pink bismuth tablet 262 mg oral ........................ 151ra pink bismuth tablet chewable 262 mg oral .............................. 151ra stomach relief max st suspension 525 mg/15ml oral .............................. 151ra stomach relief suspension 262 mg/15ml oral .............................. 151ra vitamin c tablet 500 mg oral .............................. 137ra vitamin c/rose hips tablet 1000 mg oral ............... 137

ra vitamin c/rose hips tablet 500 mg oral ................. 137ra vitamin d-3 capsule 2000 unit oral ....................... 137ra vitamin d-3 capsule 5000 unit oral ....................... 137RABAVERT ................ 176raloxifene hcl .............. 168ramelteon .................... 195ramipril ........................ 114RANEXA ..................... 114ranitidine hcl injection ...................... 151ranitidine hcl oral syrup ........................... 151ranitidine hcl oral tablet 150 mg, 300 mg ................. 151ranitidine hcl tablet 150 mg oral (otc) ..................... 151ranolazine er ............... 114rasagiline mesylate oral ................................ 76RAVICTI ..................... 154reclipsen ..................... 168RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML (1ML SYRINGE) .................. 176RECOMBIVAX HB INJECTION SUSPENSION 10 MCG/ML, 40 MCG/ML, 5 MCG/0.5ML ............. 176RECTIV ...................... 114REESES PINWORM MEDICINE SUSPENSION 144 (50 BASE) MG/ML ORAL .......................... 123RELENZA DISKHALER ................. 88RELI-ON INSULIN SYRINGE 29G 0.3 ML ............................... 102relion glucose gel 15 gm/ 38gm oral .................... 102relion glucose tablet chewable 4-6 gm-mg oral .............................. 102


RELION PEN NEEDLES 29G X 12MM .............. 102RELISTOR SUBCUTANEOUS SOLUTION 12 MG/ 0.6ML .......................... 151RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML (0.6ML SYRINGE) ...... 151RELISTOR SUBCUTANEOUS SOLUTION 8 MG/ 0.4ML .......................... 151remedy phytoplex antifungal powder 2 % external .... 123REMICADE ................. 152repaglinide oral tablet 0.5 mg ............................... 102repaglinide oral tablet 1 mg ............................... 102repaglinide oral tablet 2 mg ............................... 102REPATHA ................... 114REPATHA PUSHTRONEX SYSTEM ..................... 114REPATHA SURECLICK ............... 114RESCRIPTOR ORAL TABLET 200 MG .......... 88RETROVIR INTRAVENOUS ............ 88REVLIMID ORAL CAPSULE 10 MG ......... 70REVLIMID ORAL CAPSULE 15 MG, 25 MG ................................ 70REVLIMID ORAL CAPSULE 2.5 MG, 20 MG ................................ 70REVLIMID ORAL CAPSULE 5 MG ........... 70REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG ................................ 81REXULTI ORAL TABLET 3 MG, 4 MG ..................... 81

REYATAZ ORAL PACKET ....................... 88ribasphere oral capsule ......................... 88ribasphere oral capsule ......................... 88ribasphere oral tablet 200 mg ................................. 88ribavirin oral capsule .... 88ribavirin oral capsule .... 88ribavirin oral tablet 200 mg ................................. 88ribavirin oral tablet 200 mg ................................. 88rid complete lice elimination kit combination ............ 123RIDAURA ................... 176rifabutin ......................... 57rifampin intravenous ..... 57rifampin oral .................. 57RIFATER ...................... 57riluzole ........................ 117rimantadine hcl ............. 88ringers ......................... 138ringers irrigation .......... 138risacal-d tablet 105-81-120 mg-mg-unit oral .......... 138RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG ................... 81RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG ................... 95RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 37.5 MG, 50 MG ................... 81RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 37.5 MG, 50 MG ................... 96

risperidone oral solution ......................... 81risperidone oral solution ......................... 96risperidone oral tablet 0.25 mg ................................. 81risperidone oral tablet 0.25 mg ................................. 96risperidone oral tablet 0.5 mg ................................. 81risperidone oral tablet 0.5 mg ................................. 96risperidone oral tablet 1 mg ................................. 81risperidone oral tablet 1 mg ................................. 96risperidone oral tablet 2 mg ................................. 81risperidone oral tablet 2 mg ................................. 96risperidone oral tablet 3 mg ................................. 81risperidone oral tablet 3 mg ................................. 96risperidone oral tablet 4 mg ................................. 81risperidone oral tablet 4 mg ................................. 96risperidone oral tablet dispersible 0.25 mg ...... 81risperidone oral tablet dispersible 0.25 mg ...... 96risperidone oral tablet dispersible 0.5 mg ........ 81risperidone oral tablet dispersible 0.5 mg ........ 96risperidone oral tablet dispersible 1 mg ........... 81risperidone oral tablet dispersible 1 mg ........... 96risperidone oral tablet dispersible 2 mg ........... 81risperidone oral tablet dispersible 2 mg ........... 96risperidone oral tablet dispersible 3 mg ........... 81risperidone oral tablet dispersible 3 mg ........... 96


risperidone oral tablet dispersible 4 mg ........... 81risperidone oral tablet dispersible 4 mg ........... 96ritonavir ......................... 88RITUXAN HYCELA ...... 70RITUXAN INTRAVENOUS SOLUTION ................... 70rivastigmine .................. 44rivastigmine tartrate ...... 44rizatriptan benzoate ...... 56romidepsin .................... 70ropinirole hcl ................. 76rosadan external cream .......................... 123rosadan external gel .... 123rosuvastatin calcium .... 114ROTARIX .................... 177ROTATEQ ORAL SOLUTION ................. 177roweepra ....................... 42roweepra xr oral tablet extended release 24 hour 500 mg .......................... 42roweepra xr oral tablet extended release 24 hour 750 mg .......................... 42ROZEREM .................. 195RUBRACA ORAL TABLET 200 MG ......................... 70RUBRACA ORAL TABLET 250 MG, 300 MG .......... 70RYDAPT ....................... 70rydex liquid 10-1.33-6.33 mg/5ml oral ................. 193SSABRIL ORAL PACKET ....................... 42SANTYL ...................... 123SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG ................................ 81SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG ................................ 96SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 2.5 MG ................................ 81

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 2.5 MG ................................ 96SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 5 MG ................................ 81SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 5 MG ................................ 96SAVELLA ORAL TABLET 100 MG ....................... 117SAVELLA ORAL TABLET 12.5 MG ...................... 117SAVELLA ORAL TABLET 25 MG ......................... 117SAVELLA ORAL TABLET 50 MG ......................... 117SAVELLA TITRATION PACK .......................... 118sb antacid anti-gas suspension 200-200-20 mg/ 5ml oral ....................... 152sb aspirin tablet 325 mg oral ................................ 18sb ibuprofen tablet 200 mg oral ................................ 19sb lice killing max st shampoo 0.33-4 % external ....................... 123sb naproxen sodium tablet 220 mg oral ................... 26sb omeprazole tablet delayed release 20 mg oral .............................. 152sb vitamin c tablet 500 mg oral .............................. 138scalpicin maximum strength solution 1 % external ... 123scopolamine ................. 52scopolamine ............... 152selegiline hcl oral .......... 76selenium sulfide external lotion ........................... 123SELZENTRY ORAL SOLUTION ................... 88SELZENTRY ORAL TABLET 150 MG, 300 MG ................................ 88

SELZENTRY ORAL TABLET 25 MG ............ 89SELZENTRY ORAL TABLET 75 MG ............ 89SEREVENT DISKUS ... 193sertraline hcl oral concentrate ................... 49sertraline hcl oral concentrate ................... 93sertraline hcl oral tablet 100 mg ................................. 49sertraline hcl oral tablet 100 mg ................................. 93sertraline hcl oral tablet 25 mg ................................. 49sertraline hcl oral tablet 25 mg ................................. 93sertraline hcl oral tablet 50 mg ................................. 49sertraline hcl oral tablet 50 mg ................................. 93setlakin ....................... 168sevelamer carbonate oral packet 0.8 gm ............. 155sevelamer carbonate oral packet 2.4 gm ............. 155sevelamer carbonate oral tablet ........................... 155sharobel ...................... 168SHINGRIX INTRAMUSCULAR SUSPENSION RECONSTITUTED 50 MCG/0.5ML ................ 177SIGNIFOR .................. 171silace liquid 150 mg/15ml oral .............................. 152silace syrup 60 mg/15ml oral .............................. 152siladryl allergy liquid 12.5 mg/5ml oral ................. 193sildenafil citrate oral tablet 20 mg .......................... 193silver sulfadiazine external ......................... 34SIMBRINZA ................ 184simethicone capsule 125 mg oral ........................ 152


simethicone capsule 180 mg oral ........................ 152simethicone tablet chewable 125 mg oral ................. 152simethicone tablet chewable 80 mg oral ................... 152SIMULECT ................. 177simvastatin oral ........... 114sirolimus oral solution ....................... 177sirolimus oral tablet .... 177SIRTURO ..................... 57slow iron tablet extended release 160 (50 fe) mg oral .............................. 138slow release iron tablet extended release 160 (50 fe) mg oral .................. 138sm 3-day vaginal cream 2 % vaginal .................... 123sm acid reducer max st tablet 20 mg oral ......... 152sm acid reducer tablet 10 mg oral ........................ 152sm acid reducer tablet 75 mg oral ........................ 152sm all day allergy tablet 10 mg oral ........................ 193sm allergy relief capsule 25 mg oral ........................ 193sm allergy relief liquid 12.5 mg/5ml oral ................. 193sm antacid advanced max st suspension 400-400-40 mg/5ml oral ................. 152sm antacid anti-gas suspension 200-200-20 mg/ 5ml oral ....................... 152sm antacid/antigas suspension 200-200-20 mg/ 5ml oral ....................... 138sm antifungal clotrimazole cream 1 % external ...... 54sm antifungal miconazole cream 2 % external ...... 54sm antifungal tolnaftate cream 1 % external ...... 54

sm aspirin adult low strength tablet chewable 81 mg oral .......................... 19sm aspirin adult low strength tablet delayed release 81 mg oral ........ 19sm aspirin ec low strength tablet delayed release 81 mg oral .......................... 19sm aspirin ec tablet delayed release 325 mg oral ...... 19sm aspirin low dose tablet chewable 81 mg oral .... 19sm aspirin tablet 325 mg oral ................................ 19sm athletes foot cream 1 % external ......................... 54sm calcium 600/vitamin d tablet 600-400 mg-unit oral .............................. 138sm calcium antacid ex st tablet chewable 750 mg oral .............................. 152SM CALCIUM CITRATE W/ VIT D3 TABLET 315-250 MG-UNIT ORAL ......... 138SM CALCIUM CITRATE+/ VIT D3 TABLET 315-250 MG-UNIT ORAL ......... 138sm calcium-vitamin d tablet 500-200 mg-unit oral ... 138sm chewable c tablet chewable 500 mg oral .............................. 138sm childrens aspirin tablet chewable 81 mg oral .... 19sm clearlax powder oral .............................. 152sm clotrimazole vaginal cream 1 % vaginal ...... 123sm cold & allergy pe tablet 4-10 mg oral ............... 193sm double antibiotic ointment 500-10000 unit/gm external ......................... 34sm eye itch relief solution 0.025 % ophthalmic .... 184

sm eye wash solution 0.002 % ophthalmic .............. 184sm foaming antacid tablet chewable 80-20 mg oral .............................. 152sm folic acid tablet 400 mcg oral .............................. 138sm gas relief antiflatuent capsule 180 mg oral .... 152sm glucose tablet chewable 4 gm oral ..................... 103sm glucose tablet chewable 4-6 gm-mg oral ........... 103sm hydrocortisone max st ointment 1 % external ....................... 123sm ibuprofen ib tablet 200 mg oral .......................... 26sm ibuprofen tablet 200 mg oral ................................ 26sm iron slow release tablet extended release 160 (50 fe) mg oral .................. 138sm iron tablet 325 (65 fe) mg oral ........................ 138sm lice killing max strength shampoo 0.33-4 % external ....................... 123sm lice killing shampoo 0.33-4 % external ....... 123sm lice treatment lotion 1 % external ....................... 123sm loratadine tablet 10 mg oral .............................. 193SM LUBRICANT EYE DROPS SOLUTION 0.4-0.3 % OPHTHALMIC ........ 184SM LUBRICATING TEARS SOLUTION 0.4-0.3 % OPHTHALMIC ............ 184sm magnesium citrate solution 1.745 gm/30ml oral .............................. 152sm miconazole 3 kit 200 & 2 mg-% (9gm) vaginal ... 54sm miconazole 7 cream 2 % vaginal .................... 123


sm miconazole 7 suppository 100 mg vaginal .......................... 54sm milk of magnesia suspension 1200 mg/15ml oral .............................. 152sm mineral oil enema rectal ........................... 152sm motion sickness tablet 25 mg oral ..................... 52sm naproxen sodium tablet 220 mg oral ................... 26sm nasal decongestant max st tablet 30 mg oral ..... 193sm niacin cr tablet extended release 250 mg oral .... 138sm nicotine gum 4 mg mouth/throat ................. 22sm nicotine lozenge 2 mg mouth/throat ................. 22sm nicotine patch 24 hour 14 mg/24hr transdermal ................... 22sm nicotine patch 24 hour 21 mg/24hr transdermal ................... 22sm nicotine patch 24 hour 7 mg/24hr transdermal .... 22sm nicotine polacrilex gum 2 mg mouth/throat ........ 22sm nicotine polacrilex gum 4 mg mouth/throat ........ 22sm nicotine polacrilex lozenge 4 mg mouth/ throat ............................ 22sm omeprazole tablet delayed release 20 mg oral .............................. 153sm oyster shell calcium/vit d3 tablet 500-400 mg-unit oral .............................. 138sm prenatal vitamins tablet 28-0.8 mg oral ............ 138sm stomach relief tablet 262 mg oral ........................ 153sm stomach relief tablet chewable 262 mg oral .............................. 153

sm stool softener capsule 100 mg oral ................. 153sm stool softener capsule 240 mg oral ................. 153sm triple antibiotic ointment 3.5-400-5000 external ... 34sm urinary pain relief tablet 95 mg oral ..................... 19sm vit c/rose hips tablet 1000 mg oral ............... 138sm vitamin b-12 tablet 100 mcg oral ...................... 138sm vitamin b-12 tablet 500 mcg oral ...................... 138sm vitamin b-6 tablet 100 mg oral ........................ 138sm vitamin b1 tablet 100 mg oral .............................. 139sm vitamin c tablet 1000 mg oral .............................. 139sm vitamin c tablet 250 mg oral .............................. 139sm vitamin c tablet 500 mg oral .............................. 139sm vitamin c/rose hips tablet 500 mg oral ................. 139sm vitamin d3 capsule 2000 unit oral ....................... 139sm vitamin d3 tablet 1000 unit oral ....................... 139sm vitamin e capsule 1000 unit oral ....................... 139sm vitamin e capsule 200 unit oral ....................... 139sm vitamin e capsule 400 unit oral ....................... 139SMART SENSE COLOR LANCETS 33G ........... 103smart sense glucose tablet chewable 4-6 gm-mg oral .............................. 103SMART SENSE SUPER THIN LANCETS .......... 103SMART SENSE THIN LANCETS 26G ........... 103sodium chloride (hypertonic) ointment 5 % ophthalmic .................. 185

SODIUM CHLORIDE (HYPERTONIC) OINTMENT 5 % OPHTHALMIC ............ 185sodium chloride (hypertonic) solution 5 % ophthalmic .................. 185sodium chloride injection solution 2.5 meq/ml .... 139sodium chloride intravenous solution 0.45 %, 0.9 %, 3 %, 5 % ............................. 139sodium chloride intravenous solution 4 meq/ml ....... 139sodium chloride irrigation solution 0.9 % ............. 139sodium fluoride oral tablet 2.2 (1 f) mg ................. 139sodium fluoride oral tablet chewable 2.2 (1 f) mg ............................... 139sodium phenylbutyrate oral tablet ........................... 154sodium polystyrene sulfonate oral suspension ................. 139sodium polystyrene sulfonate rectal ........... 139SOFOSBUVIR- VELPATASVIR ............. 89solifenacin succinate ... 155SOLTAMOX .................. 70SOMATULINE DEPOT ....................... 171SOMAVERT ............... 171soothe & cool inzo antifungal cream 2 % external ......................... 54soothe suspension 262 mg/ 15ml oral ..................... 153soothe tablet 262 mg oral .............................. 153soothe tablet chewable 262 mg oral ........................ 153sorine .......................... 114sotalol hcl (af) oral tablet 120 mg ........................ 114


sotalol hcl (af) oral tablet 160 mg, 80 mg ............ 114sotalol hcl oral ............. 114SPIRIVA HANDIHALER ............ 193SPIRIVA RESPIMAT ... 193spironolactone oral ..... 114spironolactone-hctz .... 114SPRAVATO (56 MG DOSE) .......................... 49SPRAVATO (84 MG DOSE) .......................... 49sprintec 28 .................. 168SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MG, 250 MG, 500 MG ................. 42SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 750 MG ....... 42SPRYCEL ..................... 70sps .............................. 139sronyx ......................... 168ssd ................................ 34STAMARIL .................. 177stavudine oral capsule 15 mg, 20 mg ..................... 89stavudine oral capsule 30 mg, 40 mg ..................... 89STELARA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 45 MG/ 0.5ML .......................... 124sterile water for irrigation ...................... 139STIMATE .................... 159stimulant laxative tablet delayed release 5 mg oral .............................. 153STIOLTO RESPIMAT ................. 193STIVARGA ................... 70stomach relief max st suspension 525 mg/15ml oral .............................. 153stomach relief suspension 262 mg/15ml oral ........ 153

stomach relief tablet chewable 262 mg oral .............................. 153stool softener capsule 100 mg oral ........................ 153stool softener capsule 240 mg oral ........................ 153stool softener capsule 250 mg oral ........................ 153stop lice maximum strength shampoo 0.33-4 % external ....................... 124streptomycin sulfate intramuscular ................ 34STRIBILD ..................... 89subvenite ...................... 42sucralfate oral tablet .... 153sudogest sinus/allergy tablet 4-60 mg oral ............... 193sudogest tablet 30 mg oral .............................. 193sudogest tablet 60 mg oral .............................. 193sulfacetamide sodium (acne) ........................... 34sulfacetamide sodium ophthalmic solution ....... 35sulfacetamide-prednisolone ophthalmic solution ....... 26sulfacetamide-prednisolone ophthalmic solution ..... 185SULFADIAZINE ORAL ............................ 35sulfamethoxazole- trimethoprim intravenous ................... 35sulfamethoxazole- trimethoprim oral suspension 200-40 mg/ 5ml ................................ 35sulfamethoxazole- trimethoprim oral tablet ............................. 35SULFAMYLON EXTERNAL CREAM ......................... 35sulfasalazine oral ........ 179sulfazine ....................... 26sulindac oral ................. 19

sulindac oral ................. 26sumatriptan nasal ......... 56sumatriptan succinate oral ................................ 56sumatriptan succinate subcutaneous solution auto- injector .......................... 56super calcium 600 + d 400 tablet 600-400 mg-unit oral .............................. 139super calcium 600 + d3 tablet 600-400 mg-unit oral .............................. 139super calcium tablet 600 mg oral .............................. 140SUTENT ORAL CAPSULE 12.5 MG ........................ 70SUTENT ORAL CAPSULE 25 MG, 37.5 MG, 50 MG ................................ 70syeda .......................... 168SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG ............................. 71SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG ............................. 89SYMFI ........................... 89SYMFI LO ..................... 89SYMJEPI .................... 193SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN- INJECTOR .................. 103SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN- INJECTOR .................. 103SYMPAZAN ORAL FILM 10 MG, 20 MG ................... 42SYMPAZAN ORAL FILM 5 MG ................................ 42SYMTUZA .................... 89SYNAGIS .................... 177SYNAREL ................... 171SYNERCID ................... 35


SYNJARDY ................ 103SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10- 1000 MG, 12.5-1000 MG, 5-1000 MG .................. 103SYNJARDY XR ORAL TABLET EXTENDED RELEASE 24 HOUR 25- 1000 MG ..................... 103SYNRIBO ..................... 71SYNTHAMIN 17 ......... 140SYNTHROID .............. 170TTABLOID ...................... 71tacrolimus external ..... 124tacrolimus oral capsule 0.5 mg, 1 mg ..................... 177tacrolimus oral capsule 5 mg ............................... 177TAFINLAR .................... 71TAGRISSO ORAL TABLET 40 MG ........................... 71TAGRISSO ORAL TABLET 80 MG ........................... 71TAKE ACTION TABLET 1.5 MG ORAL ................... 168TALZENNA ORAL CAPSULE 0.25 MG ...... 71TALZENNA ORAL CAPSULE 1 MG ........... 71tamoxifen citrate oral .... 71tamsulosin hcl ............. 155TARGRETIN EXTERNAL ................... 71tarina fe 1/20 ............... 168tarina fe 1/20 eq ......... 168TASIGNA ...................... 71TAXOTERE INTRAVENOUS CONCENTRATE 20 MG/ ML, 80 MG/4ML ............ 71tazarotene external ..... 124tazicef injection ............. 35TAZORAC EXTERNAL CREAM 0.05 % .......... 124TAZORAC EXTERNAL GEL ............................ 124

taztia xt ....................... 114TDVAX ........................ 177TECENTRIQ INTRAVENOUS SOLUTION 1200 MG/20ML ............. 71TECENTRIQ INTRAVENOUS SOLUTION 840 MG/14ML ............... 71TECFIDERA ............... 118TECHLITE PEN NEEDLES 29G X 12MM .............. 103TEFLARO ..................... 35TEKTURNA ................ 114telmisartan .................. 114telmisartan-amlodipine oral tablet 80-5 mg ............. 114telmisartan-hctz .......... 114temazepam oral capsule 15 mg, 30 mg ................... 195temsirolimus ................. 71TENIVAC .................... 177tenofovir disoproxil fumarate ....................... 89tenofovir disoproxil fumarate ....................... 89terazosin hcl oral ........ 115terazosin hcl oral ........ 155terbinafine hcl cream 1 % external ......................... 54terbinafine hcl oral ........ 54terbutaline sulfate injection ...................... 193terbutaline sulfate oral .............................. 193terconazole ................... 54testosterone cypionate intramuscular solution 100 mg/ml, 200 mg/ml ....... 168testosterone enanthate intramuscular solution ....................... 168testosterone transdermal gel 20.25 mg/1.25gm (1.62%) ....................... 168testosterone transdermal gel 20.25 mg/act (1.62%), 40.5 mg/2.5gm (1.62%) ....................... 168

testosterone transdermal gel 25 mg/2.5gm (1%), 50 mg/5gm (1%) .............. 168tetrabenazine oral tablet 12.5 mg ....................... 118tetrabenazine oral tablet 25 mg ............................... 118tetracycline hcl oral ....... 35TGT CALCIUM + VITAMIN D3 TABLET 600-800 MG- UNIT ORAL ................ 140tgt glucose tablet chewable 4-6 gm-mg oral ........... 103TGT LANCET MICRO THIN 33G ............................. 103TGT LANCET THIN 26G ............................. 103TGT LANCET ULTRA THIN 30G ............................. 103THALOMID ORAL CAPSULE 100 MG, 50 MG ................................ 71THALOMID ORAL CAPSULE 150 MG, 200 MG ................................ 71theophylline er oral tablet extended release 12 hour 300 mg, 450 mg ......... 194theophylline er oral tablet extended release 24 hour ............................ 194thera-d rapid repletion tablet 2000 unit oral .............. 140thiamine hcl tablet 100 mg oral .............................. 140thioridazine hcl oral ...... 82thiotepa injection .......... 72thiothixene oral ............. 82THYMOGLOBULIN .... 177tiagabine hcl ................. 42TIBSOVO ...................... 72TICE BCG ..................... 72tigecycline ..................... 35timolol maleate ophthalmic .................. 185timolol maleate oral ...... 56timolol maleate oral .... 115tis-u-sol ....................... 140


TIVICAY ORAL TABLET 10 MG ................................ 89TIVICAY ORAL TABLET 25 MG, 50 MG ................... 89tizanidine hcl oral tablet ............................. 82tizanidine hcl oral tablet ........................... 194tobramycin inhalation .... 35tobramycin ophthalmic .. 35tobramycin sulfate injection solution ......................... 35tobramycin sulfate injection solution reconstituted .... 35tobramycin- dexamethasone .......... 185tolcapone ...................... 76tolnaftate cream 1 % external ......................... 54tolterodine tartrate ...... 156tolterodine tartrate er ... 156topiramate oral capsule sprinkle ......................... 42topiramate oral capsule sprinkle ......................... 56topiramate oral tablet 100 mg ................................. 42topiramate oral tablet 100 mg ................................. 56topiramate oral tablet 200 mg ................................. 42topiramate oral tablet 200 mg ................................. 56topiramate oral tablet 25 mg ................................. 43topiramate oral tablet 25 mg ................................. 56topiramate oral tablet 50 mg ................................. 43topiramate oral tablet 50 mg ................................. 56toposar intravenous solution 1 gm/50ml, 100 mg/ 5ml ................................ 72TOPOTECAN HCL INTRAVENOUS SOLUTION ................... 72

topotecan hcl intravenous solution reconstituted .... 72toremifene citrate .......... 72torsemide oral ............. 115TOUJEO MAX SOLOSTAR ................ 103TOUJEO SOLOSTAR ................ 103TOVIAZ ....................... 156TRACLEER ORAL TABLET SOLUBLE ................... 194TRADJENTA .............. 103tramadol hcl oral ........... 19tramadol- acetaminophen ............. 19trandolapril .................. 115tranexamic acid intravenous solution 1000 mg/ 10ml ............................ 106tranexamic acid oral .... 106TRANSDERM SCOP (1.5 MG) ............................... 52tranylcypromine sulfate ........................... 49TRAVASOL ................ 140TRAVATAN Z ............. 185travel sickness tablet chewable 25 mg oral .... 52trazodone hcl oral ......... 49TREANDA INTRAVENOUS SOLUTION RECONSTITUTED ....... 72TRECATOR .................. 57TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 11.25 MG .............................. 171TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 22.5 MG .............................. 171TRELSTAR MIXJECT INTRAMUSCULAR SUSPENSION RECONSTITUTED 3.75 MG .............................. 171

tretinoin external cream ............................ 72tretinoin external cream .......................... 124tretinoin external gel 0.01 %, 0.025 % ................... 72tretinoin external gel 0.01 %, 0.025 % ................. 124tretinoin oral .................. 72TREXALL .................... 177tri femynor ................... 168tri-estarylla .................. 168tri-linyah ...................... 168tri-mili .......................... 169tri-previfem .................. 169tri-sprintec ................... 169tri-vylibra ..................... 169triamcinolone acetonide external cream ............ 159triamcinolone acetonide external lotion ............. 159triamcinolone acetonide external ointment ........ 159triamcinolone acetonide injection suspension 40 mg/ ml .................................. 26triamcinolone acetonide mouth/throat ............... 119triamterene-hctz oral capsule 37.5-25 mg .... 115triamterene-hctz oral tablet ........................... 115triderm external cream 0.1 % ................................ 159triderm external cream 0.5 % ................................ 124trientine hcl ................. 140trifluoperazine hcl oral ... 82trifluridine ophthalmic .... 89trihexyphenidyl hcl ........ 77trilyte ........................... 153trimethoprim oral ........... 35trimipramine maleate oral ................................ 49trinessa (28) ................ 169TRINTELLIX ORAL TABLET 10 MG ............ 49


TRINTELLIX ORAL TABLET 20 MG ............ 49TRINTELLIX ORAL TABLET 5 MG .............. 49triple antibiotic ointment 3.5- 400-5000 external ........ 35triple antibiotic ointment 5- 400-5000 external ........ 35TRISENOX INTRAVENOUS SOLUTION 12 MG/ 6ML ............................... 72TRIUMEQ ..................... 89trivora (28) .................. 169TROGARZO ................. 89TROPHAMINE ............ 140TRULICITY ................. 103TRUMENBA ............... 177TRUSTEX LUB/RIBBED/ STUDDED .................. 185TRUSTEX LUB/ SPERMICIDE EX ST ... 185TRUSTEX LUB/ SPERMICIDE XL ........ 185TRUSTEX LUBRICATED ............. 185TRUSTEX LUBRICATED EX LARGE .................. 185TRUSTEX LUBRICATED EXTRA ST .................. 185TRUSTEX LUBRICATED/ SPERMICIDE ............. 186TRUSTEX RIA LUB/ SPERMICIDE ............. 186TRUSTEX RIA LUBRICATED ............. 186TRUSTEX-NONOXYNOL- 9/RIB/STUD ................ 186TRUVADA .................... 90tulana .......................... 169tums ultra 1000 tablet chewable 1000 mg oral .............................. 153TURALIO ...................... 72TWINRIX INTRAMUSCULAR SUSPENSION PREFILLED SYRINGE ................... 177TYBOST ....................... 90

TYKERB ....................... 72TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/ 0.5ML .......................... 177TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG/0.5ML (0.5ML SYRINGE) ...... 177TYSABRI .................... 118UULORIC ........................ 55UNILET COMFORTOUCH LANCET ..................... 103UNILET GP 28 ULTRA THIN ........................... 103UNILET MICRO-THIN 33G ............................. 104UNILET SUPER-THIN 30G ............................. 104UNILET ULTRA-THIN 28G ............................. 104unithroid oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg ............................. 170unithroid oral tablet 25 mcg ............................. 170UNIVERSAL 1 LANCETS ULTRA THIN .............. 104up & up glucose tablet chewable 4-6 gm-mg oral .............................. 104UPTRAVI ORAL TABLET ...................... 115UPTRAVI ORAL TABLET THERAPY PACK ........ 115ursodiol oral ................ 153Vvalacyclovir hcl oral tablet 1 gm ................................. 90valacyclovir hcl oral tablet 500 mg .......................... 90VALCHLOR .................. 72VALCHLOR ................ 124

valganciclovir hcl oral tablet ............................. 90valproate sodium intravenous ................... 43valproic acid oral capsule ......................... 43valproic acid oral capsule ......................... 56valproic acid oral capsule ......................... 96valproic acid oral solution ......................... 43valproic acid oral solution ......................... 56valproic acid oral solution ......................... 96valsartan ..................... 115valsartan- hydrochlorothiazide .... 115VANCOMYCIN HCL IN DEXTROSE INTRAVENOUS SOLUTION 1-5 GM/200ML-%, 500-5 MG/100ML-%, 750-5 MG/ 150ML-% ...................... 36VANCOMYCIN HCL IN NACL INTRAVENOUS SOLUTION 1-0.9 GM/ 200ML-%, 500-0.9 MG/ 100ML-%, 750-0.9 MG/ 150ML-% ...................... 36vancomycin hcl intravenous solution reconstituted 1 gm, 10 gm, 5 gm, 500 mg .... 36VANCOMYCIN HCL INTRAVENOUS SOLUTION RECONSTITUTED 1.25 GM, 1.5 GM, 250 MG .... 36vancomycin hcl intravenous solution reconstituted 750 mg ................................. 36vancomycin hcl oral capsule 125 mg .......................... 36vancomycin hcl oral capsule 250 mg .......................... 36vandazole ..................... 36VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/


0.5ML 0.5 ML, 50 UNIT/ML 1 ML ............................ 178VAQTA INTRAMUSCULAR SUSPENSION 25 UNIT/ 0.5ML, 50 UNIT/ML .... 178VARIVAX .................... 178VARIZIG INTRAMUSCULAR SOLUTION ................. 178VASCEPA ................... 115vcf vaginal contraceptive foam 12.5 % vaginal .... 169VECAMYL .................. 118VECTIBIX INTRAVENOUS SOLUTION 100 MG/5ML, 400 MG/20ML ............... 72VELCADE INJECTION ................... 72velivet ......................... 169VELPHORO ................ 140VELPHORO ................ 156VEMLIDY ...................... 90VENCLEXTA ORAL TABLET 10 MG ............ 73VENCLEXTA ORAL TABLET 100 MG .......... 73VENCLEXTA ORAL TABLET 50 MG ............ 73VENCLEXTA STARTING PACK ............................ 73venlafaxine hcl er oral capsule extended release 24 hour 150 mg ............ 49venlafaxine hcl er oral capsule extended release 24 hour 150 mg ............ 93venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg ........... 50venlafaxine hcl er oral capsule extended release 24 hour 37.5 mg ........... 93venlafaxine hcl er oral capsule extended release 24 hour 75 mg .............. 50venlafaxine hcl er oral capsule extended release 24 hour 75 mg .............. 93

venlafaxine hcl er oral tablet extended release 24 hour 150 mg .......................... 50venlafaxine hcl er oral tablet extended release 24 hour 150 mg .......................... 93venlafaxine hcl er oral tablet extended release 24 hour 37.5 mg ......................... 50venlafaxine hcl er oral tablet extended release 24 hour 37.5 mg ......................... 93venlafaxine hcl er oral tablet extended release 24 hour 75 mg ............................ 50venlafaxine hcl er oral tablet extended release 24 hour 75 mg ............................ 94venlafaxine hcl oral tablet 100 mg .......................... 50venlafaxine hcl oral tablet 100 mg .......................... 94venlafaxine hcl oral tablet 25 mg ............................ 50venlafaxine hcl oral tablet 25 mg ............................ 94venlafaxine hcl oral tablet 37.5 mg ......................... 50venlafaxine hcl oral tablet 37.5 mg ......................... 94venlafaxine hcl oral tablet 50 mg ............................ 50venlafaxine hcl oral tablet 50 mg ............................ 94venlafaxine hcl oral tablet 75 mg ............................ 50venlafaxine hcl oral tablet 75 mg ............................ 94VENTAVIS .................. 194VENTOLIN HFA ......... 194verapamil hcl er oral capsule extended release 24 hour 100 mg, 120 mg, 180 mg, 200 mg, 240 mg, 300 mg ........................ 115verapamil hcl er oral capsule extended release 24 hour 360 mg .......... 115

verapamil hcl er oral tablet extended release ........ 115verapamil hcl intravenous ................. 115verapamil hcl oral ....... 115VERSACLOZ ................ 82VERZENIO ................... 73VESICARE ................. 156VICTOZA SUBCUTANEOUS SOLUTION PEN- INJECTOR .................. 104VIDEX EC ORAL CAPSULE DELAYED RELEASE 125 MG ................................ 90VIDEX ORAL SOLUTION RECONSTITUTED 2 GM ................................ 90vienva ......................... 169vigabatrin ...................... 43vigadrone ...................... 43VIIBRYD ORAL TABLET 10 MG ................................ 50VIIBRYD ORAL TABLET 20 MG ................................ 50VIIBRYD ORAL TABLET 40 MG ................................ 50VIMPAT INTRAVENOUS ............ 43VIMPAT ORAL SOLUTION ................... 43VIMPAT ORAL TABLET 100 MG ......................... 43VIMPAT ORAL TABLET 150 MG, 200 MG .......... 43VIMPAT ORAL TABLET 50 MG ................................ 43vinblastine sulfate intravenous solution ..... 73vincristine sulfate intravenous ................... 73vinorelbine tartrate ........ 73viorele ......................... 169VIRACEPT ORAL TABLET 250 MG ......................... 90VIRACEPT ORAL TABLET 625 MG ......................... 90VIRAZOLE .................... 90


VIREAD ORAL POWDER ..................... 90VIREAD ORAL POWDER ..................... 90VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG ................................ 90VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG ................................ 90virtussin a/c solution 100-10 mg/5ml oral ................. 194VITAMIN A PALMITATE TABLET 10000 UNIT ORAL .......................... 140VITAMIN A PALMITATE TABLET 15000 UNIT ORAL .......................... 140vitamin b-1 tablet 100 mg oral .............................. 140vitamin b-1 tablet 250 mg oral .............................. 140vitamin b-1 tablet 50 mg oral .............................. 140vitamin b-12 er tablet extended release 1000 mcg oral .............................. 140vitamin b-12 tablet 100 mcg oral .............................. 140vitamin b-12 tablet 1000 mcg oral ...................... 140vitamin b-12 tablet 250 mcg oral .............................. 140vitamin b-12 tablet 500 mcg oral .............................. 140vitamin b-2 tablet 100 mg oral .............................. 140vitamin b-2 tablet 25 mg oral .............................. 140vitamin b-2 tablet 50 mg oral .............................. 140vitamin b-6 tablet 100 mg oral .............................. 141vitamin b-6 tablet 50 mg oral .............................. 141vitamin b12 tablet 100 mcg oral .............................. 141

vitamin c tablet 1000 mg oral .............................. 141vitamin c tablet 250 mg oral .............................. 141vitamin c tablet 500 mg oral .............................. 141vitamin c-rose hips tablet 1000 mg oral ............... 141vitamin c-rose hips tablet 500 mg oral ................. 141vitamin c/rose hips tablet 500 mg oral ................. 141vitamin d (cholecalciferol) capsule 1000 unit oral .............................. 141vitamin d (cholecalciferol) capsule 400 unit oral ... 141vitamin d (cholecalciferol) tablet 1000 unit oral .... 141vitamin d (cholecalciferol) tablet 400 unit oral ...... 141vitamin d (ergocalciferol) capsule 50000 unit oral .............................. 141vitamin d capsule 2000 unit oral .............................. 141vitamin d high potency capsule 1000 unit oral .............................. 141vitamin d liquid 400 unit/ml oral .............................. 141vitamin d tablet 1000 unit oral .............................. 141vitamin d tablet 2000 unit oral .............................. 141vitamin d-3 capsule 1000 unit oral ....................... 141vitamin d2 tablet 400 unit oral .............................. 141vitamin d3 capsule 1000 unit oral ....................... 141vitamin d3 capsule 2000 unit oral ....................... 141vitamin d3 capsule 400 unit oral .............................. 141vitamin d3 capsule 5000 unit oral ....................... 141

vitamin d3 maximum strength capsule 5000 unit oral .............................. 141vitamin d3 tablet 1000 unit oral .............................. 141vitamin d3 tablet 2000 unit oral .............................. 141vitamin d3 tablet 400 unit oral .............................. 142vitamin d3 tablet 5000 unit oral .............................. 142vitamin e capsule 100 unit oral .............................. 142vitamin e capsule 1000 unit oral .............................. 142vitamin e capsule 200 unit oral .............................. 142vitamin e capsule 400 unit oral .............................. 142vitamin e water soluble capsule 1000 unit oral .............................. 142VITRAKVI ORAL CAPSULE 100 MG ......................... 73VITRAKVI ORAL CAPSULE 25 MG ........................... 73VITRAKVI ORAL SOLUTION ................... 73VIZIMPRO ORAL TABLET 15 MG ........................... 73VIZIMPRO ORAL TABLET 30 MG, 45 MG .............. 73voriconazole intravenous ................... 54voriconazole oral suspension reconstituted ................. 54voriconazole oral tablet 200 mg ................................. 55voriconazole oral tablet 50 mg ................................. 55VOSEVI ........................ 90VOTRIENT ................... 73VPRIV ......................... 142VRAYLAR ORAL CAPSULE ..................... 82VRAYLAR ORAL CAPSULE ..................... 96


VRAYLAR ORAL CAPSULE THERAPY PACK .......... 82VRAYLAR ORAL CAPSULE THERAPY PACK .......... 96vyfemla ....................... 169vylibra ......................... 169VYXEOS INTRAVENOUS SUSPENSION RECONSTITUTED 44-100 MG ................................ 73Wwalgreens glucose tablet chewable 4 gm oral .... 104walgreens glucose tablet chewable 4-6 gm-mg oral .............................. 104warfarin sodium oral .... 106wera ............................ 169wixela inhub ................ 194wixela inhub ................ 194XXALKORI ...................... 73XARELTO ORAL TABLET 10 MG, 20 MG ............ 106XARELTO ORAL TABLET 15 MG ......................... 106XARELTO ORAL TABLET 2.5 MG ........................ 106XARELTO STARTER PACK .......................... 106XATMEP ..................... 178XELJANZ .................... 178XGEVA ....................... 181XIIDRA ........................ 185XOFLUZA ..................... 90XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED ..... 194XOSPATA ..................... 73XPOVIO (100 MG ONCE WEEKLY) ..................... 74XPOVIO (60 MG ONCE WEEKLY) ..................... 74XPOVIO (80 MG ONCE WEEKLY) ..................... 74

XPOVIO (80 MG TWICE WEEKLY) ..................... 74XTANDI ........................ 74XYREM ....................... 195YYERVOY ....................... 74YF-VAX ....................... 178YONDELIS ................... 74YONSA ......................... 74Zzafirlukast ................... 194zaleplon oral capsule 10 mg ............................... 195zaleplon oral capsule 5 mg ............................... 195ZALTRAP ..................... 74ZANOSAR .................... 74zarah ........................... 169ZARXIO ...................... 106zeasorb-af powder 2 % external ....................... 124ZEJULA ........................ 74ZELBORAF ................... 74zenatane ..................... 124ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 25000- 79000 UNIT, 3000-14000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT ....... 154zenzedi oral tablet 10 mg ............................... 118zenzedi oral tablet 5 mg ............................... 118zidovudine oral capsule ......................... 91zidovudine oral syrup .... 91zidovudine oral tablet .... 91ziprasidone hcl oral capsule 20 mg ............................ 82ziprasidone hcl oral capsule 20 mg ............................ 96ziprasidone hcl oral capsule 40 mg ............................ 82

ziprasidone hcl oral capsule 40 mg ............................ 96ziprasidone hcl oral capsule 60 mg, 80 mg ................ 82ziprasidone hcl oral capsule 60 mg, 80 mg ................ 96ZIRGAN ........................ 91zoledronic acid intravenous concentrate ................. 181zoledronic acid intravenous solution 4 mg/100ml .... 181ZOLINZA ...................... 55ZOLINZA ...................... 74zolmitriptan oral ............ 56zolpidem tartrate oral ... 195zonisamide oral ............ 43ZORTRESS ................ 178ZOSTAVAX SUBCUTANEOUS SUSPENSION RECONSTITUTED ..... 178zovia 1/35e (28) .......... 169ZULRESSO ................ 118zumandimine .............. 169ZYDELIG ...................... 74ZYKADIA ORAL CAPSULE ..................... 74ZYKADIA ORAL TABLET ........................ 74ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG ................................ 82ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 210 MG ................................ 97ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION RECONSTITUTED 300 MG, 405 MG ......................... 82ZYTIGA ORAL TABLET 500 MG ................................ 74


Để biết thêm thông tin gần đây hoặc các câu hỏi khác, hãy liên lạc với chúng tôi theo số

1-833-370-7466 (TTY: 711) 24 giờ một ngày, 7 ngày một tuần hoặc truy cập vào duals.anthem.com.

Danh mục thuốc này được cập nhật vào ngày 10/9/2019.

Anthem Blue Cross Cal MediConnect Plan là một chương trình bảo hiểm sức khỏe có hợp đồng với cả Medicare và Medi-Cal để cung cấp phúc lợi của cả hai chương trình cho các thành viên.

Anthem Blue Cross là tên thương mại của Blue Cross of California. Anthem Blue Cross và Blue Cross of California Partnership Plan, Inc. là các tổ chức được cấp phép độc lập của Blue Cross Association.

ANTHEM là nhãn hiệu thương mại đã đăng ký của Anthem Insurance Companies, Inc.

H6229_20_107805_T_VN_0001 CMS Approved 09/11/2019ID danh mục thuốc: CA_MMP_20210_v8_2001_1 Phiên bản: v8Đã phát hành 10/15/2019

Danh Sách Thuốc Được Chi Trả - mss.anthem.com · Danh Sách Thuốc Được Chi Trả...

Documents

Transcript of Danh Sách Thuốc Được Chi Trả - mss.anthem.com · Danh Sách Thuốc Được Chi Trả...