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Wells Pharmacy Network Master Formulary 7-27-2020 Without Pricing

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Wells Pharmacy Network Master Formulary 7-27-2020 Without Pricing BHRT Pellets & Numbing Cream Medication Form Strength Pellet Size (mm) 6 mg (3 mm) 10 mg (3 mm) 12.5 mg (3 mm) Estradiol Pellet 15 mg (3 mm) 18 mg (3 mm) 20 mg (3 mm) 25 mg (3 mm) 50 mg (3 mm) Progesterone Pellet 100 mg (3 mm) 12.5 mg (3 mm) 25 mg (3 mm) 37.5 mg (3 mm) 50 mg (3 mm) Testosterone Pellet 62.5 mg (3 mm) 87.5 mg (3 mm) 100 mg (3 mm) 200 mg (4.5 mm) 100 mg / 4 mg (3 mm) Testosterone / Anastrozole Pellet 200 mg / 8 mg (4.5 mm) 200 mg / 20 mg (4.5 mm) Disposable - Each Plastic Tip (3.2 mm) Disposable - Stainless Steel Tip Each Trocar Kit for Pellet Insertion Trocar (3.2 mm & 4.5 mm) Reusable - Titanium Or Each Stainless Steel (3.2 mm & 4.5 mm) 3.2 mm Trocars are meant to be used with 3 mm Pellets & 4.5 mm Trocars are meant to be used with 4.5 mm Pellets Medication Form Strength Package Size Cream Benzocaine / Lidocaine/ Tetracaine 20% / 6% / 4% 120 gm Topi-Pump® Items marked in Yellow: (new items added with-in 90 days) Price effective July 27th, 2020 | Pricing Subject to Change | Products may be subject to additional fees based on availability 503B IV Therapy Medication Form Strength Package Size Arginine IV 100 mg / ml 30 mL Glutathione IV 200 mg / ml 30 mL Lipoic Acid (DL-Thioctic Acid) IV 2.5% (25 mg / ml) 30 mL Methylcobalamin IV 1000 mcg / ml 10 mL Pyridoxine HCL IV 100 mg / ml 30 mL Taurine IV 50 mg/ ml 30 mL Items marked in Yellow: (new items added with-in 90 days) Price effective July 27th, 2020 | Pricing Subject to Change | Products may be subject to additional fees based on availability Peptides Package Medication Form Strength Size Oral / Topical / Nasal Spray Peptides AOD-9604 Cream 0.6 mg / mL 30 gm Capsule 0.25 mg (250 mcg) 30 Capsules BPC-157 *Ship Cold* Capsule 0.5 mg (500 mcg) 30 Capsules Cream 20 mg / mL 30 gm Dihexa Acetate Capsule 10 mg Per Capsule Capsule 20 mg Per Capsule Facial Cream 0.5% 15 gm GHK-Cu Scalp Foam 0.5% 50 mL 10 mg Per Tablet Ibutamoren Mesylate Tablet 25 mg Per Tablet PT-141 (Eros Love Spray) ™ Nasal Spray 10 mg / mL (1 mg / Spray) 5 mL Bottle PTD-DPM Topical Spray 0.001% 25 mL Bottle Sarcotropin® (Medical Food Order) Liquid Medical Food 120 mL Bottle Selank *Ship Cold* Nasal Spray 7.5 mg / mL 3 mL Bottle Semax *Ship Cold* Nasal Spray 7.5 mg / mL 3 mL Bottle Sermorelin Acetate 400 mcg Per Tablet Rapid Dissolve Mini-Tab Sermorelin / Ipamorelin / Theanine 300 mcg / 180 mcg / 2.5 mg Per Tablet Zinc-Thymullin/GHK-Cu Topical Spray 0.001% / 0.5% / mL 25 mL Bottle Injectable Peptides Injectable AOD-9604 *Ship Cold* 1.2 mg / mL 5 mL Vial Solution Injectable BPC-157 *Ship Cold* 2 mg / mL 5 mL Vial Solution Injectable 1 mg / 1 mg / mL 2 mL Vial Solution Injectable 2 mg / 1 mg / mL 2 mL Vial Solution CJC-1295 / Ipamorelin *Ship Cold* 2 mL Vial Injectable 2 mg / 2 mg / mL Solution 5 mL Vial Package Medication Form Strength Size DSIP (Delta Sleep Inducing Peptide) Injectable 1 mg / mL 3 mL Vial *Ship Cold* Solution Injectable GHK-Cu *Ship Cold* 10 mg / mL 5 mL Vial Solution IGF-1(LR3)/CJC-1295/Ipamorelin *Ship Injectable 100 mcg / 1.2 mg / 0.75 mg / 6 mL Vial Cold* Solution mL Lyophilized Ipamorelin 9 mg Per Kit* Injectable Injectable Kisspeptin-10 *Ship Cold* 1 mg / mL 2 mL Vial Solution Injectable LL-37 Acetate *Ship Cold* 2000 mg / mL 5 mL Vial Solution Injectable Melanotan II *Ship Cold* 2 mg / mL 5 mL Vial Solution 5 mg Per Kit* Lyophilized MOTS-C Injectable 10 mg Per Kit* Injectable PEG-MGF *Ship Cold* 2 mg / mL 5 mL Vial Solution Injectable PT-141 *Ship Cold* 10 mg / mL 2 mL Vial Solution Injectable Semax *Ship Cold* 1 mg / mL 5 mL Vial Solution Lyophilized Sermorelin 15 mg Per Kit* Injectable 9 mg / 9 mg Per Kit* Lyophilized Sermorelin / Ipamorelin Injectable 15 mg / 15 mg Per Kit* Injectable Thymosin Alpha-1 *Ship Cold* 3 mg / mL 5 mL Vial Solution Injectable Thymosin Beta-4 *Ship Cold* 3 mg / mL 5 mL Vial Solution *Kit Includes: Vial of Medication, Diluent, Mixing Syringe/Needle (Injection supplies sold separately) Items marked in Yellow: (new items added with-in 90 days) Price effective July 27th, 2020 | Pricing Subject to Change | Products may be subject to additional fees based on availability Hormone Replacement/Thyroid Health Medication Form Strength Package Size Oral Preparations Rapid 0.25 mg Per Mini-Tab Anastrozole Dissolve Mini-Tab 0.5 mg Per Mini-Tab Anastrozole (Commercial Product) Tablet 1 mg Per Tablet Biotin/Finasteride Capsule 5 mg / 1 mg Per Capsule Clomiphene Citrate (Commercial Product) Tablet 50 mg Per Tablet Clomiphene Citrate (During Retail B/O) Capsule 50 mg Per Capsule Exemestane Capsule 20 mg Per Capsule 1 mg Per Tablet Finasteride (Commercial Product) Tablet 5 mg Per Tablet Letrozole (Commercial Product) Tablet 2.5 mg Per Tablet 1.5 mg Per Capsule Naltrexone (LDN) Capsule 3 mg Per Capsule 4.5 mg Per Capsule N-Dim (Commercial Product) Capsule 200 mg Per Capsule Tablet 6 mg Per Tablet Tablet 12 mg Per Tablet Oxandrolone Tablet 25 mg Per Tablet Tablet 50 mg Per Tablet Tamoxifen Citrate (Commercial Product) Tablet 20 mg Per Tablet Capsule 50 mg / 50 mg / 3 mg Per Capsule Theanine / Magnesium / Melatonin Capsule 100 mg / 100 mg / 12 mg Per Capsule Oral Thyroid Preparations Armour Thyroid® (Commercial Product) Tablet ¼ grain - 5 grain Per Tablet Nature-Throid® (Commercial Product) Tablet ¼ grain - 4 grain Per Tablet T3 SR (Slow Release) up to and including 59 mcg* #30 / #60 / #90 Commonly Stocked Strengths: 5 mcg, 7.5 mcg, 10 mcg, 12.5mcg, 15 mcg, 20 mcg, 25 mcg, 50 mcg 60 mcg - 90 mcg* #30 / #60 / #90 T3/T4 SR (Slow Release) Capsule Commonly Stocked Strengths: 91 mcg - 120 mcg* #30 / #60 / #90 4.5 mcg / 19 mcg, 9 mcg / 38 mcg, 13.5 mcg / 57 mcg, 18 mcg / 76 mcg, 121 mcg - 200 mcg* #30 / #60 / #90 22.5 mcg / 95 mcg, 27 mcg / 114 mcg 50 mcg / 12.5 mcg 201 mcg and higher* #30 / #60 / #90 *Price is based on the total amount of mcgs of either T3 by iteslf or T3/T4 combined WP-Thyroid® (Commercial Product) Tablet ¼ grain - 2 grain Per Tablet For a complete list of topical & oral preparations, please see (Non-Sterile BHRT Formulary) Medication Form Strength Package Size Injectable Preparations Bi-Test (Enanthate 75%/Cypionate 25%) Injectable 200 mg / mL 10 mL Vial Depo-Estradiol® (Commercial Product) Injectable 5 mg / mL 5 mL Vial Depo® Testosterone (Commercial Product) Injectable 200 mg / mL 10 mL Vial Nandrolone Decanoate Injectable 200 mg / mL 10 mLVial Testosterone Cypionate in Grapeseed Oil Injectable 20 mg / mL (Low Dose) 5 mL Vial 200 mg / 0.5 mg / mL 10 mL Vial Testosterone Cypionate / Anastrozole Injectable 5 mL Vial 200 mg / 1 mg / mL 10 mL Vial 5 mL Vial Testosterone Cypionate / DHEA Injectable 200 mg / 25 mg / mL 10 mL Vial Testosterone Enanthate / DHEA Injectable 200 mg / 25 mg / mL 10 mL Vial Testosterone Propionate Injectable 100 mg / mL 10 mL Vial Ultra-Test 200 mg / mL 10 mL Vial Injectable (Cypionate 80% / Propionate 20%) 250 mg / mL 10 mL Vial Tri-Test 4 mL Vial (Cypionate 50% / Enanthate 37.5% / Propionate 12.5% Injectable 200 mg / mL 10 mL Vial Items marked in Yellow: (new items added with-in 90 days) Price effective July 27th, 2020 | Pricing Subject to Change | Products may be subject to additional fees based on availability Weight Management / Vitamin & Amino Acids Package Medication Form Strength Size Oral Preparations Rapid Dissolve 200 U Per Tablet hCG Mini-Tablet 500 U Per Tablet Rapid Dissolve hCG / B12(M) 500 U / 300 mcg Per Tablet Mini-Tablet Phendimetrazine (Commercial Product) Tablet 35 mg Per Tablet Capsule 15 mg / 10 mg / 100 mg Per Capsule Phentermine / 7-Keto DHEA / Capsule 30 mg / 10 mg / 100 mg Per Capsule Calcium Pyruvate SR (Slow Release) Capsule 37.5 mg / 10 mg / 100 mg Per Capsule Phentermine HCL (Commercial Product) Tablet 37.5 mg Per Tablet Capsule 50 mg / 50 mg / 3 mg Per Capsule Theanine / Magnesium / Melatonin Capsule 100 mg / 100 mg / 12 mg Per Capsule Injectable Preparations Ascorbic Acid (Commercial Product) Injectable 50% (500 mg / mL) SDPF 50 mL Vial B-Complex (B2, B3, B6, B12(C)) + 2 mg / 20 mg / 2 mg / Injectable 30 mL Vial Vitamin C 300 mcg + 20 mg / mL Cyanocobalamin (B12) Injectable 1,000 mcg / mL 10 mL Vial (Commercial Product) Injectable 1,000 mcg / mL 30 mL Vial GAC (Glutamine / Arginine / Carnitine) Injectable 25 mg / 100 mg / 200 mg / mL 30 mL Vial *Refrigerate Upon Arrival* GACLIV (Glutamine / Arginine / Carnitine/ 25 mg / 100 mg / 200 mg / Leucine / Isoleucine / Valine) Injectable 30 mL Vial 10 mg / 10 mg / 5 mg / mL *Refrigerate Upon Arrival* GOAL (Glutamine / Ornithine / 75 mg / 75 mg / 150 mg / Arginine / Lysine) + Lidocaine Injectable 30 mL Vial 150 mg / mL + 10 mg / mL *Refrigerate Upon Arrival* Glutathione-L 10 ml Vial Injectable 200 mg / mL *Ship Cold* 30 mL Vial *Kit Includes: Vial of Medication, Diluent, Mixing Syringe/Needle (Injection supplies sold separately) Package Medication Form Strength Size 25 mg / 25 mg / 5 mg / 2.5 mg / IC / B-Complex (B1, B2, B3, B5, B6, B12(C)) + Injectable 25 mg / 5 mg / 5 mg / 0.1 mg / 30 mL Vial Leucine + Carnitine + Chromium + Lidocaine 1.5 mg / 25 mg / 25 mcg / 10 mg / mL Leucine / Isoleucine / Valine (BCAA) Injectable 10 mg / 10 mg / 5 mg / mL 10 mL Vial 15 mg / 50 mg / 100 mg / MIC / B12(M) Injectable 30 mL Vial 1000 mcg / mL 25 mg / 50 mg / 50 mg / MIC / Chromium / B12(M) Injectable 10 mL Vial 25 mcg / 1 mg / mL 15 mg / 50 mg / 100 mg / MIC / B-Complex (B2, B3, B6, B12(M)) Injectable 2.5 mg / 0.4 mg / 2.5 mg / 30 mL Vial 0.25 mg / mL 15 mg / 30 mg / 30 mg / MIC / B-Complex (B2, B3, B6, B12(M)) + Injectable 0.5 mg / 20mg / 20 mg / 30 mL Vial Carnitine + Lidocaine 0.5 mg / 85 mg / 20 mg / mL 12.5 mg / 25 mg / 25 mg / MIC / B-Complex (B1, B2, B6) + Carnitine
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