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Drugs-Biologicals FORMULARY for INTERNET PAGE 12 26 18

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Drugs-Biologicals FORMULARY for INTERNET PAGE 12 26 18 AVG ITEM Average Patient Item Charge Code Description BIL AWP /pkg COST Price 25000041 SODIUM and POTASSIUM BICARBONATE TBEF UD $3.61 $0.12 $1.00 25000054 GLIMEPIRIDE TAB 1 MG UD $8.25 $0.11 $1.30 25000086 amLODIPine TAB 5 MG UD $8.65 $0.06 $1.00 25000087 AMMONIA AROMATIC SOLN 15 % (W/V) UD $3.53 $0.17 $1.00 25000090 AMOXICILLIN CAP 500 MG UD $20.12 $0.19 $1.00 25000102 ABACAVIR TAB 300 MG UD $507.10 $8.45 $16.90 25000103 ACAMPROSATE TBEC 333 MG UD $182.38 $0.80 $1.76 25000104 ACARBOSE TAB 25 MG UD $16.70 $0.27 $1.00 25000106 ACETAMINOPHEN SUPP 120 MG UD $5.09 $0.42 $1.00 25000108 ACETAMINOPHEN SUPP 325 MG UD $4.91 $0.44 $1.00 25000109 ACETAMINOPHEN TAB 325 MG UD $12.39 $0.02 $1.00 25000111 ACETAMINOPHEN TAB 500 MG UD $2.34 $0.02 $1.00 25000112 ACETAMINOPHEN SUPP 650 MG UD $3.83 $0.17 $1.00 25000113 ACETAMINOPHEN SOLN 650 MG/20.3 ML UD $75.74 $0.48 $1.22 25000117 ACETAMINOPHEN-CODEINE TAB 300-30 MG UD $12.41 $0.09 $1.00 25000121 ACETYLCYSTEINE SOLN 200 MG/ML (20 %) UD $18.18 $7.66 $15.32 25000140 ALBUTEROL SULFATE NEBU 2.5MG/3ML (0.083 %) UD $8.58 $0.29 $1.00 25000147 ALLOPURINOL TAB 100 MG UD $18.45 $0.12 $1.00 25000150 ALPRAZolam TAB 0.25 MG UD $8.87 $0.09 $1.00 25000151 ALPRAZolam TAB 0.5 MG UD $4.16 $0.04 $1.00 25000182 AMIODARONE TAB 200 MG UD $15.70 $0.20 $1.00 25000184 AMITRIPTYLINE TAB 10 MG UD $8.73 $0.06 $1.00 25000186 AMITRIPTYLINE TAB 25 MG UD $17.46 $0.08 $1.00 25000188 AMITRIPTYLINE TAB 50 MG UD $34.90 $0.16 $1.00 25000205 HYDROCORTISONE ACETATE SUPP 25 MG UD $127.30 $5.75 $11.50 25000206 HEMORRHOIDAL SUPPOSITORY SUPP 0.25 % UD $1.02 $1.02 $1.00 25000209 ACETAMINOPHEN-CODEINE ELIX 120-12 MG/5 ML UD $114.09 $0.85 $1.90 25000214 ARIPiprazole TAB 5 MG UD $2,821.13 $24.69 $49.38 25000215 ARIPiprazole TAB 10 MG UD $2,821.13 $25.85 $51.70 25000216 ARIPiprazole TAB 15 MG UD $2,800.92 $23.90 $47.80 25000224 ASPIRIN TBEC 325 MG UD $16.91 $0.02 $1.00 25000226 ASPIRIN CHEW 81 MG UD $27.12 $0.05 $1.00 25000227 ASPIRIN TBEC 81 MG UD $2.78 $0.03 $1.00 25000229 ASPIRIN TAB 325 MG UD $0.73 $0.01 $1.00 25000230 RACEPINEPHRINE NEBU 2.25 % UD $41.51 $1.22 $2.80 25000232 ATENOLOL TAB 50 MG UD $3.32 $0.04 $1.00 25000233 ATORVASTATIN TAB 10 MG UD $24.43 $0.24 $1.00 25000241 AMOXICILLIN-POT CLAVULANATE TAB 875-125 MG UD $36.89 $0.65 $1.00 25000248 AZITHROMYCIN TAB 250 MG UD $113.58 $2.29 $4.58 25000253 sulfaSALAzine TAB 500 MG UD $19.40 $0.09 $1.00 25000277 BENZTROPINE TAB 1 MG UD $6.78 $0.07 $1.00 25000292 BICALUTAMIDE TAB 50 MG UD $38.40 $1.28 $2.56 25000296 SODIUM CITRATE-CITRIC ACID SOLN 500-334 MG/5 ML UD $123.17 $0.79 $2.50 25000299 BISACODYL SUPP 10 MG UD $2.81 $0.07 $1.00 25000300 BISACODYL TBEC 5 MG UD $2.99 $0.02 $1.00 25000302 BISMUTH SUBSALICYLATE SUSP 524 MG/30 ML UD $54.99 $1.37 $110.00 25000318 BUMETANIDE TAB 1 MG UD $13.77 $0.14 $1.56 25000323 BUPRENORPHINE-NALOXONE SUBL 2-0.5 MG UD $115.32 $2.25 $4.72 25000324 buPROPion TAB 100 MG UD $109.09 $0.57 $1.36 25000328 busPIRone TAB 5 MG UD $6.42 $0.06 $1.00 25000329 BUTAMBEN-TETRACAINE-BENZOCAINE SPRA 2 %-2 %-14 % (200 MG/SEC) UD $41.78 $0.76 $1.50 25000340 CALCIUM ACETATE CAP 667 MG UD $104.90 $0.53 $1.30 25000347 CAPTOPRIL TAB 12.5 MG UD $8.34 $0.08 $1.00 25000348 CAPTOPRIL TAB 25 MG UD $112.47 $0.05 $1.00 25000351 carBAMazepine CHEW 100 MG UD $13.98 $0.14 $1.00 25000353 carBAMazepine TAB 200 MG UD $53.32 $0.18 $1.03 25000362 CARVEDILOL TAB 12.5 MG UD $5.30 $0.07 $1.00 25000364 CARVEDILOL TAB 3.125 MG UD $4.62 $0.03 $1.00 25000367 cloNIDine PTWK 0.1 MG/24 HR UD $59.81 $15.41 $97.55 25000368 cloNIDine PTWK 0.2 MG/24 HR UD $378.66 $80.92 $186.73 25000386 CEFUROXIME TAB 250 MG UD $26.12 $0.38 $2.71 25000390 CELECOXIB CAP 200 MG UD $1,112.23 $6.13 $12.27 25000391 CITALOPRAM TAB 10 MG UD $4.84 $0.05 $1.00 25000392 CITALOPRAM TAB 20 MG UD $5.09 $0.05 $1.00 25000394 CEPACOL lozenge (benz-menthol) LOZG 15-4 MG UD $2.55 $0.16 $1.00 25000397 CEPHALEXIN CAP 500 MG UD $9.50 $0.11 $1.00 25000405 CETIRIZINE TAB 10 MG UD $8.42 $0.09 $1.00 25000409 ACTIVATED CHARCOAL SUSP 25 GRAM/120 ML UD $12.28 $12.01 $24.20 25000418 chlordiazePOXIDE CAP 25 MG UD $12.56 $0.13 $1.00 25000419 chlordiazePOXIDE CAP 5 MG UD $44.86 $0.27 $1.00 25000429 chlorproMAZINE TAB 25 MG UD $112.09 $1.12 $7.61 25000453 MAGNESIUM CITRATE SOLN UD $11.41 $1.76 $3.53 25000458 CLARITHROMYCIN TAB 250 MG UD $100.43 $1.18 $2.10 25000461 CLINDAMYCIN HCL CAP 150 MG UD $28.25 $0.28 $1.00 25000469 glipiZIDE TR24 5 MG UD $48.24 $0.29 $1.00 25000475 clonazePAM TAB 0.5 MG UD $3.54 $0.04 $1.00 25000476 clonazePAM TAB 1 MG UD $8.38 $0.05 $1.00 25000479 cloNIDine TAB 0.1 MG UD $3.57 $0.04 $1.00 25000483 CLOPIDOGREL TAB 75 MG UD $604.34 $6.13 $12.27 25000489 cloZAPine TAB 100 MG UD $67.78 $0.97 $1.14 25000490 cloZAPine TAB 25 MG UD $26.70 $0.40 $1.00 25000497 BENZTROPINE TAB 0.5 MG UD $23.07 $0.16 $1.00 25000498 DOCUSATE SODIUM LIQD 100MG/10ML UD $38.06 $0.41 $1.00 25000499 COLCHICINE TAB 0.6 MG UD $6.93 $0.07 $2.80 25000504 PROCHLORPERAZINE MALEATE TAB 5 MG UD $28.23 $0.21 $1.00 25000507 CONJUGATED ESTROGENS TAB 0.625 MG UD $494.01 $3.29 $9.80 25000517 LIPASE-PROTEASE-AMYLASE CPDR 10,000-34,000 -55,000 UNIT UD $175.05 $1.71 $5.13 25000520 SODIUM NITRITE-SOD THIOSULFATE SOLN 300 MG/10 ML- 12.5 GRAM/50 ML UD $170.00 $1.00 25000521 CYANOCOBALAMIN (VITAMIN B-12) TAB 1,000 MCG UD $3.17 $0.03 $1.00 25000546 DAPSONE TAB 100 MG UD $77.49 $1.67 $5.10 25000571 DIVALPROEX TB24 500 MG UD $33.13 $0.33 $3.54 25000572 DIVALPROEX TBEC 500 MG UD $272.64 $2.67 $5.33 25000573 DIVALPROEX TBEC 250 MG UD $14.42 $0.15 $1.00 25000581 traZODone TAB 100 MG UD $12.93 $0.10 $1.00 25000583 traZODone TAB 50 MG UD $8.96 $0.06 $1.00 25000615 acetaZOLAMIDE TAB 250 MG UD $126.84 $1.51 $2.60 25000620 DIAZEPAM TAB 5 MG UD $3.43 $0.04 $1.00 25000624 DICYCLOMINE CAP 10 MG UD $36.72 $0.11 $1.00 25000630 DIGOXIN TAB 125 MCG UD $1,127.45 $5.09 $17.05 25000631 DIGOXIN TAB 250 MCG UD $30.27 $0.90 $1.53 25000634 DILTIAZEM HCL TAB 30 MG UD $5.63 $0.06 $1.00 25000638 DILTIAZEM HCL CP24 120 MG UD $19.55 $0.20 $25.37 25000639 DILTIAZEM HCL CP24 180 MG UD $27.60 $0.27 $1.00 25000645 VALSARTAN TAB 80 MG UD $308.98 $2.76 $5.52 25000649 DIPHENOXYLATE-ATROPINE TAB 2.5-0.025 MG UD $20.48 $0.21 $1.19 25000650 diphenhydrAMINE CAP 25 MG UD $2.73 $0.03 $1.00 25000652 diphenhydrAMINE ELIX 12.5 MG/5 ML UD $105.05 $0.58 $2.20 25000662 OXYBUTYNIN CHLORIDE TAB 5 MG UD $35.93 $0.41 $1.00 25000664 DIVALPROEX TB24 250 MG UD $195.58 $1.41 $3.52 25000669 DOCUSATE SODIUM CAP 100 MG UD $20.35 $0.02 $1.00 25000671 SENNOSIDES-DOCUSATE SODIUM TAB 8.6-50 MG UD $0.00 $0.01 $1.00 25000676 DONEPEZIL TAB 5 MG UD $16.32 $0.16 $1.00 25000683 DOXAZOSIN TAB 2 MG UD $231.13 $0.63 $1.22 25000686 DOXYCYCLINE HYCLATE CAP 100 MG UD $6.95 $0.07 $3.44 25000690 DULoxetine CPDR 30 MG UD $690.51 $6.54 $13.07 25000691 fentaNYL PT72 25 MCG/HR UD $31.34 $7.16 $13.83 25000692 fentaNYL PT72 50 MCG/HR UD $18.40 $3.68 $6.82 25000699 EFAVIRENZ CAP 200 MG UD $904.63 $6.65 $13.29 25000700 VENLAFAXINE CP24 75 MG UD $24.08 $0.27 $1.00 25000725 lamiVUDine TAB 150 MG UD $116.16 $5.71 $11.42 25000735 ALUM-MAG HYDROXIDE-SIMETH SUSP 200-200-20 MG/5 ML UD $168.93 $0.90 $3.26 25000741 ERYTHROMYCIN TBEC 500 MG UD $999.71 $7.52 $18.56 25000742 ERYTHROMYCIN TAB 250 MG UD $12.73 $0.12 $19.40 25000743 BUTALBITAL-ACETAMINOPHEN-CAFF TAB 50-325-40 MG UD $43.82 $0.31 $1.83 25000744 LITHIUM CARBONATE TBER 450 MG UD $41.41 $0.41 $1.00 25000750 ETHAMBUTOL TAB 400 MG UD $72.45 $1.21 $2.42 25000762 FENOFIBRATE TAB 48 MG UD $78.54 $0.79 $1.51 25000769 FERROUS SULFATE TAB 325 MG (65 MG IRON) UD $2.45 $0.02 $1.00 25000770 FERROUS SULFATE LIQD 300 MG (60 MG IRON)/5 ML UD $165.32 $0.43 $3.40 25000779 CYCLOBENZAPRINE TAB 10 MG UD $4.29 $0.05 $1.00 25000781 TAMSULOSIN CP24 0.4 MG UD $24.90 $0.25 $1.00 25000783 FLUCONAZOLE TAB 100 MG UD $13.78 $0.14 $2.19 25000785 FLUCONAZOLE TAB 150 MG UD $22.90 $1.52 $3.81 25000793 FLUDROCORTISONE TAB 0.1 MG UD $43.56 $0.45 $1.00 25000798 FLUORESCEIN STRP 1 MG UD $12.58 $0.09 $1.00 25000801 FLUoxetine CAP 20 MG UD $15.66 $0.16 $1.00 25000814 FOLIC ACID TAB 1 MG UD $10.15 $0.05 $1.00 25000819 ALENDRONATE TAB 70 MG UD $12.57 $0.63 $1.30 25000822 FUROSEMIDE TAB 20 MG UD $3.59 $0.04 $1.00 25000825 FUROSEMIDE TAB 40 MG UD $17.41 $0.11 $1.00 25000826 GABAPENTIN CAP 100 MG UD $6.21 $0.06 $1.00 25000830 GABAPENTIN CAP 300 MG UD $9.49 $0.09 $1.00 25000844 ZIPRASIDONE HCL CAP 20 MG UD $1,235.55 $12.61 $25.21 25000845 ZIPRASIDONE HCL CAP 40 MG UD $107.94 $3.08 $5.40 25000850 GLIMEPIRIDE TAB 4 MG UD $25.22 $0.11 $1.29 25000851 glipiZIDE TAB 5 MG UD $6.04 $0.05 $1.00 25000853 glipiZIDE TR24 2.5 MG UD $6.94 $0.22 $1.00 25000857 DEXTROSE GEL 40 % UD $8.39 $2.86 $5.63 25000859 glyBURIDE TAB 2.5 MG UD $21.52 $0.22 $1.00 25000860 glyBURIDE TAB 5 MG UD $23.76 $0.36 $1.00 25000862 GLYCERIN (CHILD) SUPP UD $1.32 $0.10 $1.00 25000863 GLYCERIN (ADULT) SUPP UD $8.17 $0.26 $1.00 25000870 DEXTROMETHORPHAN-guaiFENesin SYRP 10-100 MG/5 ML UD $43.14 $0.47 $1.00 25000872 guaiFENesin LIQD 100 MG/5 ML UD $26.87 $0.39 $1.00 25000873 CODEINE-GUAIFENESIN LIQD 10-100 MG/5 ML UD $44.28 $0.46 $1.00 25000874 guanFACINE TAB 1 MG UD $14.33 $0.48 $1.00 25000878 HALOPERIDOL TAB 1 MG UD $12.17 $0.25 $1.00 25000880 HALOPERIDOL TAB 5 MG UD $21.15 $0.42 $1.23 25000887 HYDROCHLOROTHIAZIDE CAP 12.5 MG UD $7.38 $0.09 $1.00 25000888 HYDROCHLOROTHIAZIDE TAB 25 MG UD $8.24 $0.06 $1.00 25000908 guaiFENesin TBER 600 MG UD $37.03 $0.37 $1.35 25000915 hydrALAZINE TAB 10 MG UD $13.43 $0.14 $1.00 25000916 hydrALAZINE TAB 25 MG UD $9.41 $0.14 $1.00 25000934 HYDROXYUREA CAP 500 MG UD $71.04 $0.42 $1.03 25000937 hydrOXYzine TAB 25 MG UD $14.73 $0.17 $1.00 25000941 IBUPROFEN SUSP 100
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