DRUG ITEM_DESCRIPTION BILL_ITEM_ID GROUP_ID CDM PYXIS_ID RXMNEMONIC THERAPY_CLASS NDC DISPENSE_QTY DISPENSE_QTY_UOM DISPENSE_FACTOR DISPENSE_FACTOR_UOM DISPENSE_CATEGORY PRICE_SCHEDULE COST_BASE COST COST_BEG_EFFECTIVE PRICE_SCHED_BASE CDM_COST HCPCS_COST PATIENT_PRICE FORMULARY_STATUS HCPCS HCPCS_DESC QCF REVCODE CPT4 CPT4_MOD ketorolac ophthalmic ketorolac 0.5% ophthalmic 5mL 8341562 283924256 60000591850 60000591850 ket0.55 ophthalmic anti-inflammatory agents 42571-0137-25 1 bottle 5 mL Bulk PMC - MED PMC COST 1.41 1/8/2024 8:41 7.05 7.05 0 45.8 Formulary 0 259 lisinopril lisinopril 40mg tablet 8317579 693793 60006500052 60006500052 lis40 angiotensin converting enzyme (ace) inhibitors 00904-6800-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0812 11/30/2021 23:17 0.0812 0.0812 0 10 Formulary 0 637 acetaminophen acetaminophen 120mg suppository 8317899 846883 60006504963 60006504963 ace120 miscellaneous analgesics 51672-2115-02 1 supp 1 EA MED - COA PMC - DIRECT COST PMC COST 0.74 11/11/2021 9:52 0.74 0.74 0 0.74 Formulary 0 637 acetaminophen acetaminophen 650mg suppository 8316227 696551 60006504971 60006504971 apap650pr miscellaneous analgesics 45802-0730-30 1 supp 1 EA MED - COA PMC - MED PMC COST 0.235 11/11/2021 9:52 0.235 0.235 0 10 Formulary 0 637 acetaminophen acetaminophen 325mg tab 8316224 696499 60006504997 60006504997 apap miscellaneous analgesics 57896-0104-10 1 tab(s) 1 EA MED - COA PMC - DIRECT COST PMC COST 0.00974 11/11/2021 9:52 0.00974 0.00974 0 0.01 Formulary 0 637 acetaminophen acetaminophen 500mg tablet 8316226 696519 60006505028 60006505028 apap500 miscellaneous analgesics 00904-6730-61 1 tab(s) 1 EA MED - COA PMC - DIRECT COST PMC COST 0.0332 1/8/2024 7:47 0.0332 0.0332 0 0.03 Formulary 0 637 acetylcysteine acetylcysteine 20% oral 30mL vial 8316240 696740 60006505119 60006505119 aceoralinh30 respiratory inhalant products 00409-3308-03 1 vial(s) 30 mL MED - COA PMC - MED PMC COST 0.38289 12/28/2023 8:29 11.4867 11.4867 0 72.5 Formulary 0 259 allopurinol allopurinol 100mg tablet 8316278 697287 60006505408 60006505408 all100 antigout agents 55111-0729-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.065 11/30/2021 23:47 0.065 0.065 0 10 Formulary 0 637 ampicillin ampicillin 1gm vial 8316357 687722 60006506026 60006506026 amp1 aminopenicillins 55150-0113-10 1 vial(s) 1 EA IVPB - COA PMC - INJ PMC COST 1.751 11/11/2021 9:52 1.751 1.751 0.88 28.3 Formulary J0290 Ampicillin 500 mg inj 2 636 ascorbic acid ascorbic acid 500mg tablet 8316389 688712 60006506257 60006506257 asc500 vitamins 00904-0523-61 1 EA 1 EA MED - COA PMC - DIRECT COST PMC COST 0.03 12/3/2021 10:14 0.03 0.03 0 0.03 Formulary 0 637 aspirin aspirin 325mg tab 8316393 688849 60006506372 60006506372 asp325 salicylates 47682-0805-48 1 EA 1 EA MED - COA PMC - DIRECT COST PMC COST 0.0312 12/28/2023 12:55 0.0312 0.0312 0 0.03 Formulary 0 637 aspirin aspirin 81mg chewable tablet 8316396 688938 60006506406 60006506406 asp81 salicylates 00904-6794-30 1 tab(s) 1 EA MED - COA PMC - DIRECT COST PMC COST 0.0706 12/28/2023 12:50 0.0706 0.0706 0 0.07 Formulary 0 637 atropine ophthalmic atropine 1% ophthalmic 2mL soln 8322655 36602717 60006506463 60006506463 atr1opht mydriatics 60219-1748-02 1 bottle 2 mL Bulk PMC - MED PMC COST 12.12 12/28/2023 13:01 24.24 24.24 0 124.7 Formulary 0 259 atropine ophthalmic atropine 1% ophthalmic 5mL soln 8316418 689877 60006506471 60006506471 atr1oph ophthalmic glaucoma agents 60219-1749-03 1 bottle 5 mL Bulk PMC - MED PMC COST 7.896 12/28/2023 13:02 39.48 39.48 0 200.9 Formulary 0 259 sulfamethoxazole-trimethoprim sulfa-trimeth DS 800-160mg tab 8317398 687432 60006506745 60006506745 smzDS miscellaneous antibiotics 00904-2725-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.1164 1/8/2024 7:47 0.1164 0.1164 0 10 Formulary 0 637 bisacodyl bisacodyl 10mg suppository 8316486 691902 60006507321 60006507321 bis10 laxatives 00574-7050-50 1 EA 1 EA MED - COA PMC - MED PMC COST 0.1806 11/11/2021 9:52 0.1806 0.1806 0 10 Formulary 0 637 bisacodyl BISAcodyl 5mg tablet 8316488 691943 60006507339 60006507339 bis5 laxatives 81421-0020-04 1 EA 1 EA MED - COA PMC - DIRECT COST PMC COST 0.1729 12/28/2023 16:55 0.1729 0.1729 0 0.17 Formulary 0 637 calcium carbonate calcium carbonate 500mg chew tab 8316539 693078 60006507834 60006507834 cal500 antacids 57896-0763-15 1 EA 1 EA MED - COA PMC - DIRECT COST PMC COST 0.0148 12/28/2023 13:17 0.0148 0.0148 0 0.01 Formulary 0 637 calcium chloride calcium chloride 100mg/mL 10mL syringe 8316543 693163 60006507875 60006507875 caclsyr minerals and electrolytes 64253-0900-91 1 syringe(s) 10 mL INJ - COA PMC - INJ PMC COST 0.8026 12/28/2023 13:19 8.026 8.026 0 57.2 Formulary 0 259 calcium gluconate calcium gluc 100mg (0.465mEq)/mL 10mL vial (G/K) 8316545 693193 60006507909 60006507909 cagluc minerals and electrolytes 75834-0171-19 1 vial(s) 10 mL INJ - COA PMC - INJ PMC COST 1.002 1/8/2024 7:47 10.02 10.02 0.1 69.2 Formulary J0612 "Injection, calcium gluconate (fresenius kabi), per 10 mg" 100 636 JZ ceFAZolin ceFAZolin 1gm vial 8316600 694286 60006508345 60006508345 cefaz1 penicillins/beta-lactamase inhibitors 60505-6142-05 1 vial(s) 1 EA MED - COA PMC - INJ PMC COST 0.6328 11/11/2021 9:52 0.6328 0.6328 0.32 17.3 Formulary J0690 Cefazolin sodium injection 2 636 cephalexin cephalexin 250mg capsule 8316125 691580 60006508451 60006508451 cep250 first generation cephalosporins 60687-0152-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.29 12/4/2023 13:08 0.29 0.29 0 10 Formulary 0 637 cephalexin cephalexin 500mg capsule 8316126 691620 60006508477 60006508477 cep500 first generation cephalosporins 50268-0152-15 1 cap(s) 1 EA MED - COA PMC - MED PMC COST 0.26 12/4/2023 13:19 0.26 0.26 0 10 Formulary 0 637 chlordiazePOXIDE chlordiazePOXIDE 5mg capsule 8316650 695165 60006508881 60006508881 chl5 benzodiazepines 51079-0374-20 1 EA 1 EA MED - COA PMC - MED PMC COST 0.5899 1/19/2024 12:13 0.5899 0.5899 0 11.2 Formulary 0 637 chlordiazePOXIDE chlordiazePOXIDE 10mg capsule 8317968 1004034 60006508907 60006508907 chl10 benzodiazepines 00555-0033-02 1 EA 1 EA MED - COA PMC - MED PMC COST 0.1187 12/28/2023 15:14 0.1187 0.1187 0 10 Formulary 0 637 clindamycin clindamycin 150mg capsule 8316705 696034 60006509434 60006509434 cli150 lincomycin derivatives 00904-5959-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.14 12/4/2023 13:25 0.14 0.14 0 10 Formulary 0 637 clindamycin clindamycin 150mg/mL 2mL vial (G/K) 8316694 695901 60006509442 60006509442 cli300 lincomycin derivatives 00009-0870-26 1 vial(s) 2 mL IVPB - COA PMC - INJ PMC COST 0.7776 11/11/2021 9:52 1.5552 1.5552 1.56 26.2 Formulary J0736 "Inj, clindamycin phosp 300mg" 1 636 JZ clindamycin clindamycin 150mg/mL 4mL vial (G/K) 8318235 2898453 60006509459 60006509459 cli600soln lincomycin derivatives 00009-0775-26 1 vial(s) 4 mL IVPB - COA PMC - INJ PMC COST 0.675 1/8/2024 7:47 2.7 2.7 1.35 36 Formulary J0736 "Inj, clindamycin phosp 300mg" 2 636 JZ clonazePAM clonazePAM 0.5mg tablet 8316709 696096 60006509509 60006509509 clo0.5 benzodiazepines 59651-0722-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0271 12/28/2023 15:37 0.0271 0.0271 0 10 Formulary 0 637 cloNIDine cloNIDine 0.1mg tablet 8316715 696175 60006509517 60006509517 clo0.1 "antiadrenergic agents, centrally acting" 60687-0113-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.2553 12/28/2023 15:39 0.2553 0.2553 0 10 Formulary 0 637 colchicine colchicine 0.6mg tablet 8316747 696699 60006509921 60006509921 col0.6 antigout agents 70710-1351-03 1 tab(s) 1 EA MED - COA PMC - MED PMC COST 1.72 12/3/2021 7:35 1.72 1.72 0 22.5 Formulary 0 637 hydrocortisone/neomycin/polymyxin B otic neomyc-polymyx-HC otic soln 10mL 8316457 686864 60006510176 60006510176 hydsoln otic steroids with anti-infectives 24208-0631-10 1 bottle 10 mL Bulk PMC - MED PMC COST 5.096 11/11/2021 9:52 50.96 50.96 0 207.4 Formulary 0 637 hydrocortisone/neomycin/polymyxin B otic neomycin-polymyxin-HC otic susp 10mL 8316461 686910 60006510184 60006510184 hydsusp otic steroids with anti-infectives 61314-0645-11 1 bottle 10 mL Bulk PMC - MED PMC COST 4.439 1/12/2024 7:09 44.39 44.39 0 200 Formulary 0 637 hydroxocobalamin hydroxocobalamin 5 gm inj 8327321 45698373 60006510234 60006510234 hyd5 vitamins 50633-0310-11 1 vial(s) 1 EA IVPB - COA PMC - INJ PMC COST 888.86 12/28/2023 15:55 888.86 888.86 0 1786.8 Formulary 0 259 cyanocobalamin cyanocobalamin 1000mcg/mL 1mL vial 8316761 696957 60006510242 60006510242 B12inj vitamins 71288-0303-02 1 vial(s) 1 mL INJ - COA PMC - INJ PMC COST 1.5648 12/28/2023 15:51 1.5648 1.5648 1.56 26.3 Formulary J3420 Vitamin B12 injection 1 636 cyclobenzaprine cyclobenzaprine 10mg tab 8316764 696997 60006510275 60006510275 cyc10 skeletal muscle relaxants 60687-0558-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.16 8/1/2022 16:44 0.16 0.16 0 10 Formulary 0 637 cyclopentolate ophthalmic cyclopentolate 1% ophthalmic 2mL 8316768 697046 60006510333 60006510333 cyc1oph mydriatics 17478-0100-02 1 bottle 2 mL Bulk PMC - MED PMC COST 3.12 11/11/2021 9:52 6.24 6.24 0 41 Formulary 0 259 dexamethasone dexamethasone PF 10mg/mL 1mL vial 8345071 320692435 60006510929 60006510929 dexa10inj glucocorticoids 63323-0506-16 1 vial(s) 1 mL INJ - COA PMC - INJ PMC COST 1.5396 11/11/2021 9:52 1.5396 1.5396 0.15 26 Formulary J1100 Dexamethasone sodium phos 10 636 dexamethasone dexamethasone 4mg/mL 1mL vial 8316861 686824 60006510937 60006510937 dex4inj adrenal cortical steroids 63323-0165-16 1 vial(s) 1 mL INJ - COA PMC - INJ PMC COST 0.5964 12/28/2023 16:06 0.5964 0.5964 0.15 16.8 Formulary J1100 Dexamethasone sodium phos 4 636 dexamethasone dexamethasone 4mg tablet 8316203 695568 60006511000 60006511000 dex4 adrenal cortical steroids 47781-0914-01 1 tab(s) 1 EA MED - COA PMC - MED PMC COST 0.85 5/9/2023 15:48 0.85 0.85 0.05 14.6 Formulary J8540 Oral dexamethasone 16 636 Dextrose 50% in Water intravenous soluti dextrose 50% water syringe 50mL 8316889 687744 60006511117 60006511117 D50syr intravenous nutritional products 00409-7517-16 1 syringe(s) 50 mL INJ - COA PMC - INJ PMC COST 0.2355 11/11/2021 9:52 11.775 11.775 0 79.7 Formulary 0 259 diazePAM diazePAM 5mg tablet 8316899 688146 60006511174 60006511174 dia5 benzodiazepines 51079-0285-20 1 EA 1 EA MED - COA PMC - MED PMC COST 0.05 12/4/2023 13:26 0.05 0.05 0 10 Formulary 0 637 digoxin digoxin 0.125mg tab 8316914 688672 60006511604 60006511604 dig0.125 inotropic agents 00904-5921-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.67 12/28/2023 16:16 0.67 0.67 0 12.3 Formulary 0 637 diltiaZEM diltiaZEM 60mg tab 8317935 945282 60006511687 60006511687 dil60 calcium channel blocking agents 60687-0728-01 1 tab(s) 1 EA MED - COA PMC - MED PMC COST 0.4918 12/28/2023 16:18 0.4918 0.4918 0 10 Formulary 0 637 docusate docusate sodium 50mg capsule 8317912 848933 60006511802 60006511802 doc50 laxatives 67618-0111-28 1 EA 1 EA MED - COA PMC - DIRECT COST PMC COST 0.25929 11/11/2021 9:52 0.25929 0.25929 0 0.26 Formulary 0 637 docusate docusate sodium 100mg capsule 8316966 690496 60006511828 60006511828 doc100 laxatives 00904-7183-61 1 cap(s) 1 EA MED - COA PMC - DIRECT COST PMC COST 0.0499 12/28/2023 16:41 0.0499 0.0499 0 0.05 Formulary 0 637 diphenhydrAMINE diphenhydrAMINE 25mg capsule 8317836 695820 60006511877 60006511877 dip25 "miscellaneous anxiolytics, sedatives and hypnotics" 00904-7237-61 1 cap(s) 1 EA MED - COA PMC - DIRECT COST PMC COST 0.0418 12/28/2023 16:27 0.0418 0.0418 0 0.04 Formulary 0 637 diphenhydrAMINE diphenhydrAMINE 50 mg/mL 1mL inj 8336258 186020084 60006511927 60006511927 dip50inj antihistamines 63323-0664-01 1 vial(s) 1 mL INJ - COA PMC - INJ PMC COST 0.5504 11/11/2021 9:52 0.5504 0.5504 0.55 16.2 Formulary J1200 Diphenhydramine hcl injectio 1 636 DOBUTamine DOBUTamine 12.5mg/mL 20mL vial 8317841 695939 60006512123 60006512123 dob12.5 vasopressors 00409-2344-01 1 vial(s) 20 mL LVP - COA PMC - INJ PMC COST 0.274 11/11/2021 9:52 5.48 5.48 5.48 41.9 Formulary J1250 Inj dobutamine HCl/250 mg 1 636 atropine/hyoscyamine/PB/scopolamine atrop-hyoscyam-PB-scop 16.2mg/5mL 120mL MDC 8316455 691000 60006512172 60006512172 antispasmodic anticholinergics/antispasmodics 75826-0127-04 1 bottle 120 mL Special Delivery MDC COA PMC - MED PMC COST 1.6383 1/8/2024 7:47 196.596 196.596 0 450 Formulary 0 637 doxycycline doxycycline 100mg vial 8316988 691390 60006512446 60006512446 dox100 tetracyclines 63323-0130-11 1 vial(s) 1 EA IVPB - COA PMC - INJ PMC COST 10.182 11/11/2021 9:52 10.182 10.182 0 70.1 Formulary 0 259 EPINEPHrine EPINEPHrine 1mg/mL 1mL amp 8320568 34247594 60006512859 60006512859 epi1t vasopressors 54288-0103-10 1 vial(s) 1 mL INJ - COA PMC - INJ PMC COST 8.249 11/11/2021 9:52 8.249 8.249 0.82 58.5 Formulary J0171 Adrenalin epinephrine inject 10 636 EPINEPHrine EPINEPHrine 1mg/10mL syringe 8335601 169855878 60006512867 60006512867 epi vasopressors 76329-3318-01 1 syringe(s) 10 mL INJ - COA PMC - INJ PMC COST 0.8714 1/12/2024 7:09 8.714 8.714 0.87 61.3 Formulary J0171 Adrenalin epinephrine inject 10 636 ferrous sulfate ferrous sulfate 325mg tab 8317132 694680 60006513600 60006513600 fer325bc iron products 00904-7591-61 1 EA 1 EA MED - COA PMC - DIRECT COST PMC COST 0.025 11/30/2021 23:10 0.025 0.025 0 0.03 Formulary 0 637 folic acid folic acid 1mg tablet 8317195 696032 60006514061 60006514061 fol1 vitamins 11534-0165-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.1864 1/8/2024 7:47 0.1864 0.1864 0 10 Formulary 0 637 furosemide furosemide 20mg/2mL vial 8317206 696215 60006514137 60006514137 fur20I loop diuretics 63323-0280-16 1 vial(s) 2 mL INJ - COA PMC - INJ PMC COST 0.394 11/11/2021 9:52 0.788 0.788 0.79 19.3 Formulary J1940 Furosemide injection 1 636 furosemide furosemide 40mg tab 8317208 696234 60006514145 60006514145 fur40 loop diuretics 43547-0402-10 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0294 1/8/2024 7:47 0.0294 0.0294 0 10 Formulary 0 637 gentamicin ophthalmic gentamicin 0.3% ophth soln 5mL 8317227 696518 60006514368 60006514368 gen ophthalmic anti-infectives 61314-0633-05 1 bottle 5 mL Bulk PMC - MED PMC COST 0.77 11/11/2021 9:52 3.85 3.85 0 38.2 Formulary 0 637 gentamicin gentamicin 40mg/mL 2mL vial 8317230 696574 60006514384 60006514384 gen40 aminoglycosides 63323-0010-02 1 vial(s) 2 mL IVPB - COA PMC - INJ PMC COST 0.2944 11/11/2021 9:52 0.5888 0.5888 0.59 16.7 Formulary J1580 Garamycin gentamicin inj 1 636 haloperidol haloperidol lactate 5mg/mL 1mL vial 8317280 697335 60006514756 60006514756 hal5inj miscellaneous antipsychotic agents 63323-0474-01 1 vial(s) 1 mL INJ - COA PMC - INJ PMC COST 0.7248 1/12/2024 7:09 0.7248 0.7248 0.72 18.5 Formulary J1630 Haloperidol injection 1 636 heparin "heparin 10,000 Unit(s)/mL 1mL vial" 8317288 697433 60006514848 60006514848 hep10000 heparins 71288-0424-96 1 vial(s) 1 mL INJ - COA PMC - INJ PMC COST 1.4324 1/8/2024 7:47 1.4324 1.4324 0.14 24.8 Formulary J1644 Inj heparin sodium per 1000u 10 636 hydrALAZINE hydrALAZINE 25mg tablet 8317849 696108 60006515050 60006515050 hyda25 peripheral vasodilators 63739-0327-10 1 EA 1 EA MED - COA PMC - MED PMC COST 0.1059 1/8/2024 8:36 0.1059 0.1059 0 10 Formulary 0 637 hydroCHLOROthiazide hydroCHLOROthiazide 25mg tab 8317317 685419 60006515134 60006515134 hctz25 thiazide and thiazide-like diuretics 23155-0008-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.019 1/12/2024 7:09 0.019 0.019 0 10 Formulary 0 637 hydrocortisone hydrocortisone sod succ PF 100mg/2mL vial 8326069 40517886 60006515233 60006515233 hyd glucocorticoids 00009-0825-01 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 12.26 1/8/2024 7:47 12.26 12.26 12.26 82.6 Formulary J1720 Hydrocortisone sodium succ I 1 636 hydrocortisone hydrocortisone sod succ PF 250mg/2mL vial 8317893 846193 60006515241 60006515241 hyd250 adrenal cortical steroids 00009-0013-05 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 10.2 11/15/2021 9:35 10.2 10.2 3.4 70.2 Formulary J1720 Hydrocortisone sodium succ I 3 636 hydrOXYzine hydrOXYzine HCl 25mg/mL 1mL vial 8317855 696279 60006515522 60006515522 hyd25 "miscellaneous anxiolytics, sedatives and hypnotics" 00517-4201-25 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 15.0252 1/8/2024 7:47 15.0252 15.0252 15.03 99.2 Formulary J3410 Hydroxyzine hcl injection 1 636 hydrOXYzine hydrOXYzine HCl 25mg tablet 8317854 696253 60006515605 60006515605 hyd25tab "miscellaneous anxiolytics, sedatives and hypnotics" 00904-6617-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.1389 1/8/2024 8:39 0.1389 0.1389 0 10 Formulary 0 637 hydrOXYzine hydrOXYzine pamoate 25mg cap 8316083 697729 60006515613 60006515613 hp25 "miscellaneous anxiolytics, sedatives and hypnotics" 50268-0398-50 1 cap(s) 1 EA MED - COA PMC - MED PMC COST 0.31 12/4/2023 13:27 0.31 0.31 0 10 Formulary 0 637 indomethacin indomethacin 25mg capsule 8317402 688905 60006515902 60006515902 ind25 nonsteroidal anti-inflammatory agents 50268-0430-15 1 EA 1 EA MED - COA PMC - MED PMC COST 0.2346 1/12/2024 7:09 0.2346 0.2346 0 10 Formulary 0 637 iron dextran iron dextran complex 50mg/mL 2mL vial (G/K) 8317439 690178 60006516264 60006516264 iro50 iron products 00023-6082-10 1 vial(s) 2 mL INJ - COA PMC - INJ PMC COST 15.5025 1/8/2024 7:47 31.005 31.005 15.5 164.1 Formulary J1750 Inj iron dextran 2 636 JZ ocular lubricant min oil-white petrolat ophth oint 3.5gm 8317483 691616 60006516694 60006516694 lacr3.5 ophthalmic lubricants and irrigations 63736-0143-08 1 tube 3.5 gm Bulk PMC - MED PMC COST 1.59714 1/12/2024 7:09 5.58999 5.58999 0 40 Formulary 0 637 norepinephrine NORepinephrine 1mg/mL 4mL vial 8320573 34249170 60006516819 60006516819 nor1t vasopressors 63323-0940-04 1 vial(s) 4 mL LVP - COA PMC - INJ PMC COST 0.7325 1/10/2024 15:18 2.93 2.93 0 38.3 Formulary 0 259 levothyroxine levothyroxine 25mcg tab 8317526 692721 60006516876 60006516876 lev25 thyroid hormones 00904-6949-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.3045 1/12/2024 7:09 0.3045 0.3045 0 10 Formulary 0 637 levothyroxine levothyroxine 50mcg tablet 8317529 692811 60006516892 60006516892 lev50 thyroid hormones 00904-6950-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.3189 1/12/2024 7:09 0.3189 0.3189 0 10 Formulary 0 637 levothyroxine levothyroxine 100mcg tab 8317514 692418 60006516918 60006516918 lev100 thyroid hormones 00904-6953-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.3976 1/8/2024 7:47 0.3976 0.3976 0 10 Formulary 0 637 levothyroxine levothyroxine 150mcg tab 8317520 692569 60006516934 60006516934 lev150 thyroid hormones 00904-6956-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.4987 1/12/2024 7:09 0.4987 0.4987 0 10 Formulary 0 637 lidocaine topical lidocaine 2% viscous 100mL MDC 8317549 693244 60006517064 60006517064 bulklid2visc topical anesthetics 00054-3500-49 1 bottle 100 mL Special Delivery MDC COA PMC - MED PMC COST 0.0916 1/12/2024 7:09 9.16 9.16 0 58.5 Formulary 0 259 EPINEPHrine-lidocaine lidocaine-epi 1-0.001% 20mL vial MDV 8317561 693446 60006517106 60006517106 epilido1MDV antiarrhythmic agents 63323-0482-27 1 vial(s) 20 mL MDV INJ - COA PMC - INJ PMC COST 0.197 1/8/2024 7:47 3.94 3.94 0 44.5 Formulary 0 259 lidocaine lidocaine 1% 20mL vial MDV 8317536 692938 60006517114 60006517114 lid120mL antiarrhythmic agents 63323-0485-27 1 vial(s) 20 mL MDV INJ - COA PMC - INJ PMC COST 0.15502 1/12/2024 7:09 3.1004 3.1004 0.16 37 Formulary J2001 Lidocaine injection 20 259 lidocaine lidocaine PF 1% 5mL inj 8334689 85086485 60006517122 60006517122 lido1 local injectable anesthetics 63323-0492-57 1 amp 5 mL INJ - COA PMC - INJ PMC COST 0.2495 1/8/2024 7:47 1.2475 1.2475 0.25 22.8 Formulary J2001 Lidocaine injection 5 636 lidocaine lidocaine 2% 20mL vial MDV 8317543 693118 60006517171 60006517171 lid220 antiarrhythmic agents 63323-0486-27 1 vial(s) 20 mL MDV INJ - COA PMC - INJ PMC COST 0.1757 1/8/2024 7:47 3.514 3.514 0 40.7 Formulary 0 259 loperamide loperamide 2mg cap 8317594 694058 60006517395 60006517395 lop2 antidiarrheals 50268-0482-15 1 EA 1 EA MED - COA PMC - MED PMC COST 0.7184 1/12/2024 7:09 0.7184 0.7184 0 12.9 Formulary 0 637 LORazepam LORazepam 0.5mg tablet 8317595 694081 60006517403 60006517403 lor0.5 benzodiazepines 00904-6007-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0732 1/12/2024 7:09 0.0732 0.0732 0 10 Formulary 0 637 magnesium citrate magnesium citrate oral solution 300mL 8317616 694468 60006517643 60006517643 mag laxatives 71399-0051-01 1 bottle 300 mL Bulk PMC - MED PMC COST 0.0106 1/8/2024 7:47 3.18 3.18 0 32.2 Formulary 0 637 magnesium sulfate magnesium sulfate 500mg/mL 2mL vial 8317619 694525 60006517676 60006517676 magsulf laxatives 63323-0064-43 1 vial(s) 2 mL IVPB - COA PMC - INJ PMC COST 0.5274 1/12/2024 7:09 1.0548 1.0548 0.53 20.7 Formulary J3475 Inj magnesium sulfate 2 636 magnesium oxide magnesium oxide 400mg tablet (OTC) 8317860 696389 60006517684 60006517684 magox400otc minerals and electrolytes 00603-0209-22 1 tab(s) 1 EA MED - COA PMC - DIRECT COST PMC COST 0.02742 1/12/2024 7:09 0.02742 0.02742 0 0.03 Formulary 0 637 mannitol mannitol 25% 50mL vial 8317627 694694 60006517734 60006517734 man25 miscellaneous diuretics 00409-4031-01 1 vial(s) 50 mL IVPB - COA PMC - INJ PMC COST 0.0401 1/8/2024 7:47 2.005 2.005 2 29.1 Formulary J2150 Mannitol injection 1 636 meclizine meclizine 25mg tablet (otc) 8317635 694894 60006517866 60006517866 mec25otc anticholinergic antiemetics 00904-6517-61 1 EA 1 EA MED - COA PMC - DIRECT COST PMC COST 0.36 7/6/2022 17:20 0.36 0.36 0 0.36 Formulary 0 259 meperidine meperidine 50mg/mL 1mL syr 8317652 695200 60006518039 60006518039 mep50inj narcotic analgesics 00409-1178-30 1 syringe(s) 1 mL MED - COA PMC - INJ PMC COST 5.913 1/8/2024 7:47 5.913 5.913 0 44.5 Formulary 0 259 methocarbamol methocarbamol 750mg tablet 8334696 85103238 60006518690 60006518690 met750 skeletal muscle relaxants 76385-0124-01 1 tab(s) 1 EA MED - COA PMC - MED PMC COST 0.44 12/3/2021 7:39 0.44 0.44 0 10 Formulary 0 637 methylPREDNISolone methylPREDNISolone sod succ PF 40mg/mL 8341103 269153065 60006519011 60006519011 met40PF glucocorticoids 00009-0039-28 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 4.4632 11/11/2021 9:52 4.4632 4.4632 4.46 44.8 Formulary J2920 Methylprednisolone injection up to 40 mg 1 636 methylPREDNISolone methylPREDNISolone 1000mg vial 8317866 696545 60006519029 60006519029 met1000 glucocorticoids 00009-0698-02 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 11.09 1/12/2024 7:09 11.09 11.09 1.39 75.6 Formulary J2930 Methylprednisolone injection up to 125 mg 8 636 methylPREDNISolone methylPREDNISolone sod succ PF 125mg/2mL 8320405 33687429 60006519037 60006519037 met125PF glucocorticoids 00009-0047-22 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 7.1028 11/11/2021 9:52 7.1028 7.1028 7.1 51.7 Formulary J2930 Methylprednisolone injection up to 125 mg 1 636 metoclopramide metoclopramide 5mg/mL 2mL vial 8317720 696282 60006519193 60006519193 met5inj gi stimulants 00409-3414-01 1 vial(s) 2 mL INJ - COA PMC - INJ PMC COST 0.399 1/8/2024 7:47 0.798 0.798 0.8 19.4 Formulary J2765 Metoclopramide hcl injection 1 636 metOLazone metOLazone 5mg tablet 8317726 696395 60006519227 60006519227 met5 thiazide and thiazide-like diuretics 00185-0055-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.619 1/12/2024 7:09 0.619 0.619 0 11.6 Formulary 0 637 metoprolol metoprolol 50mg tablet 8317731 696464 60006519250 60006519250 met50 "beta blockers, cardioselective" 62332-0113-31 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0233 1/12/2024 7:09 0.0233 0.0233 0 10 Formulary 0 637 metroNIDAZOLE metroNIDAZOLE 500mg/100mL NS IVPB (G/K) 8316228 696612 60006519300 60006519300 met500 amebicides 00338-1055-48 1 bag 100 mL IVPB - COA PMC - IV FLUIDS PMC COST 0.00945 1/12/2024 7:09 0.945 0.945 0.02 28 Formulary J1836 "Inj, metronidazole, 10 mg" 50 636 JZ morphine morphine 4mg/mL 1mL inj 8316330 697467 60006519623 60006519623 mor4 narcotic analgesics 63323-0454-01 1 syringe(s) 1 mL MED - COA PMC - INJ PMC COST 1.642 1/12/2024 7:09 1.642 1.642 1.64 27.1 Formulary J2270 Morphine sulfate injection 1 636 multivitamin multivitamins adult 10mL vial 8316376 697749 60006519706 60006519706 mvi12 vitamin and mineral combinations 54643-5649-01 1 vial(s) 10 mL LVP - COA PMC - INJ PMC COST 0.7994 1/8/2024 7:47 7.994 7.994 0 57 Formulary 0 259 naloxone naloxone 0.4mg/mL 1mL soln 8316424 686106 60006519979 60006519979 nal0.4t antidotes 00641-6132-25 1 amp 1 mL INJ - COA PMC - INJ PMC COST 2.9872 1/8/2024 7:47 2.9872 2.9872 2.99 38.9 Formulary J2310 Inj naloxone hydrochloride 1 636 nitroglycerin nitroglycerin 0.4mg SL tab 8320682 35074356 60006520407 60006520407 nit0.4tab antianginal agents 59762-3304-03F 1 tab(s) 1 EA MED - COA PMC - MED PMC COST 0.3756 11/11/2021 10:11 0.3756 0.3756 0 10 Formulary 0 637 oxybutynin oxybutynin 5mg tablet 8316651 690573 60006521041 60006521041 oxyb5 urinary antispasmodics 00904-7027-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.2831 1/12/2024 7:09 0.2831 0.2831 0 10 Formulary 0 637 oxytocin oxytocin 10 Unit(s)/mL 1mL vial 8316677 691006 60006521157 60006521157 oxy10 miscellaneous hormones 63323-0012-11 1 vial(s) 1 mL INJ - COA PMC - INJ PMC COST 3.1648 1/8/2024 7:47 3.1648 3.1648 3.16 37.5 Formulary J2590 Oxytocin injection 1 636 penicillin G benzathine pen G benzathine 1.2 MillionUnits (G/K) 8316722 691640 60006521306 60006521306 bicLA natural penicillins 60793-0701-10 1 syringe(s) 2 mL INJ - COA PMC - INJ PMC COST 10.5085 10/10/2023 16:25 21.017 21.017 1.75 120 Formulary J0561 Penicillin G benzathine inj 12 636 JZ phenazopyridine phenazopyridine 100mg tablet 8316762 692151 60006521777 60006521777 phe100 miscellaneous genitourinary tract agents 65162-0681-10 1 EA 1 EA MED - COA PMC - MED PMC COST 0.2 12/4/2023 13:52 0.2 0.2 0 10 Formulary 0 637 phenylephrine nasal phenylephrine 0.5% nasal spr 15mL 8316793 692513 60006522098 60006522098 phe nasal antihistamines and decongestants 00225-0805-47 1 bottle 15 mL Bulk PMC - DIRECT COST PMC COST 0.224 11/11/2021 9:52 3.36 3.36 0 3.36 Formulary 0 637 phenytoin phenytoin 50mg/mL 2mL inj 8316813 692726 60006522171 60006522171 phe50I hydantoin anticonvulsants 00641-0493-25 1 syringe(s) 2 mL INJ - COA PMC - INJ PMC COST 0.573 11/11/2021 9:52 1.146 1.146 0.57 21.7 Formulary J1165 Phenytoin sodium injection 2 636 phenytoin phenytoin ER 100mg capsule 8316816 692763 60006522213 60006522213 phe100 hydantoin anticonvulsants 00904-6187-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.38 12/4/2023 13:54 0.38 0.38 0 10 Formulary 0 637 phytonadione phytonadione 10mg/mL 1mL amp 8316825 692874 60006522254 60006522254 phy10 vitamins 69097-0708-96 1 amp 1 mL INJ - COA PMC - INJ PMC COST 19.02 1/12/2024 7:09 19.02 19.02 1.9 123.2 Formulary J3430 Vitamin k phytonadione inj 10 636 potassium chloride potassium chloride 2mEq/mL 20mL vial 8316913 693757 60006522676 60006522676 kcl 00409-6653-05 1 vial(s) 20 mL IVPB - COA PMC - INJ PMC COST 0.17808 1/12/2024 7:09 3.5616 3.5616 0.18 41.1 Formulary J3480 Inj potassium chloride 20 636 prednisoLONE ophthalmic prednisoLONE 1% ophthalmic 5mL 8316178 694513 60006522882 60006522882 pre1% ophthalmic steroids 61314-0637-05 1 bottle 5 mL Bulk PMC - MED PMC COST 5.824 1/12/2024 7:09 29.12 29.12 0 149.1 Formulary 0 637 predniSONE predniSONE 20mg tablet 8317886 696981 60006523104 60006523104 pre20 adrenal cortical steroids 00904-7127-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.101 1/12/2024 7:09 0.101 0.101 0.01 10 Formulary J7512 Prednisone ir or dr oral 1mg 20 636 prochlorperazine prochlorperazine 25mg suppository 8316982 694450 60006523351 60006523351 pro25 phenothiazine antiemetics 00574-7226-12 1 EA 1 EA MED - COA PMC - MED PMC COST 6.14417 1/12/2024 7:09 6.14417 6.14417 0 40.4 Formulary 0 637 prochlorperazine prochlorperazine 10mg tablet 8316979 694406 60006523385 60006523385 proc10tab phenothiazine antiemetics 50268-0685-15 1 EA 1 EA MED - COA PMC - MED PMC COST 0.97 12/4/2023 13:55 0.97 0.97 0 16.2 Formulary 0 259 prochlorperazine prochlorperazine 5mg/mL 2mL vial 8316106 686731 60006523401 60006523401 proc5soln antihistamines 23155-0523-41 1 vial(s) 2 mL INJ - COA PMC - INJ PMC COST 1.1675 1/12/2024 7:09 2.335 2.335 2.33 32.4 Formulary J0780 Prochlorperazine injection 1 636 promethazine promethazine 25mg/mL vial 8317003 694664 60006523500 60006523500 pro25inj antihistamines 00641-6208-25 1 vial(s) 1 mL IVPB - COA PMC - INJ PMC COST 1.5256 1/8/2024 7:47 1.5256 1.5256 1.53 25.8 Formulary J2550 Promethazine hcl injection 1 259 promethazine promethazine 50mg/mL amp 8317009 694723 60006523518 60006523518 prom50soln antihistamines 00641-0929-21 1 amp 1 mL INJ - COA PMC - INJ PMC COST 3.17 3/30/2023 14:54 3.17 3.17 3.17 37.6 Formulary J2550 Promethazine hcl injection 1 636 promethazine promethazine 25mg suppository 8316998 694606 60006523526 60006523526 pro25supp antihistamines 00713-0526-12 1 EA 1 EA MED - COA PMC - MED PMC COST 3.9833 1/8/2024 7:47 3.9833 3.9833 0 39.4 Formulary 0 637 promethazine promethazine 12.5mg suppository 8316995 694576 60006523559 60006523559 pro12.5supp antihistamines 00713-0536-12 1 EA 1 EA MED - COA PMC - MED PMC COST 4.8175 1/12/2024 7:09 4.8175 4.8175 0 42.1 Formulary 0 637 promethazine promethazine 25mg tab 8317001 694642 60006523583 60006523583 pro25tab antihistamines 00904-7304-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.15 11/20/2023 12:34 0.15 0.15 0 10 Formulary 0 637 proparacaine ophthalmic proparacaine 0.5% ophthalmic 15mL 8316048 697098 60006523625 60006523625 pro0.5 ophthalmic anesthetics 61314-0016-01 1 bottle 15 mL Bulk PMC - MED PMC COST 1.8607 1/8/2024 7:47 27.9105 27.9105 0 143.1 Formulary 0 259 propranolol propranolol 1mg/mL vial 8317032 694916 60006523724 60006523724 pro1 "beta blockers, non-cardioselective" 63323-0604-01 1 vial(s) 1 mL INJ - COA PMC - INJ PMC COST 1.578 1/8/2024 7:47 1.578 1.578 1.58 26.4 Formulary J1800 Propranolol injection 1 636 protamine protamine 10mg/mL 25mL vial 8317055 695146 60006523831 60006523831 pro10inj25 heparin antagonists 63323-0229-30 1 vial(s) 25 mL INJ - COA PMC - INJ PMC COST 1.2008 1/8/2024 7:47 30.02 30.02 1.2 159.1 Formulary J2720 Inj protamine sulfate/10 mg 25 636 scopolamine scopolamine (delivers 1mg/72hr) patch 8317199 696547 60006524433 60006524433 sco1.5 anticholinergics/antispasmodics 50742-0505-04 1 EA 1 EA MED - COA PMC - MED PMC COST 7.2675 1/8/2024 7:47 7.2675 7.2675 0 47.2 Formulary 0 637 carbidopa-levodopa carbidopa-levodopa 10mg-100mg tablet 8316577 693848 60006524680 60006524680 car10-100 dopaminergic antiparkinsonism agents 62756-0517-88 1 tab(s) 1 EA MED - COA PMC - MED PMC COST 0.12 11/30/2021 23:16 0.12 0.12 0 10 Formulary 0 637 sodium bicarbonate sodium bicarbonate 8.4% 50mL syringe 8317266 697086 60006524763 60006524763 sodbicsyringe antacids 76329-3352-01 1 syringe(s) 50 mL INJ - COA PMC - INJ PMC COST 0.271 1/8/2024 8:49 13.55 13.55 0 90.3 Formulary 0 259 sodium bicarbonate sodium bicarbonate 8.4% 50mL vial 8317269 697106 60006524771 60006524771 sodbicvial antacids 51754-5001-05 1 vial(s) 50 mL INJ - COA PMC - INJ PMC COST 0.1054 11/11/2021 9:52 5.27 5.27 0 40.7 Formulary 0 259 sodium bicarbonate sodium bicarbonate 650mg tab 8317263 697063 60006524797 60006524797 sodbicpo antacids 69618-0034-10 1 EA 1 EA MED - COA PMC - MED PMC COST 0.01085 1/12/2024 7:09 0.01085 0.01085 0 10 Formulary 0 637 spironolactone spironolactone 25mg tablet 8317363 686612 60006524995 60006524995 spi25 potassium-sparing diuretics 63739-0544-10 1 EA 1 EA MED - COA PMC - MED PMC COST 0.1276 1/12/2024 7:09 0.1276 0.1276 0 10 Formulary 0 637 succinylcholine succinylcholine 20mg/mL 10mL MDV vial 8317369 686755 60006525117 60006525117 suc20 neuromuscular blocking agents 69918-0700-11 1 vial(s) 10 mL MDV INJ - COA PMC - INJ PMC COST 0.4293 1/12/2024 7:09 4.293 4.293 0.43 43.4 Formulary J0330 Succinycholine chloride inj 10 636 sulfacetamide sodium ophthalmic sulfacetamide sod 10% ophth soln 15mL 8317384 687090 60006525174 60006525174 sulfac ophthalmic anti-infectives 24208-0670-04 1 bottle 15 mL Bulk PMC - MED PMC COST 2.03333 11/11/2021 9:52 30.49995 30.49995 0 156 Formulary 0 637 terbutaline terbutaline 1mg/mL 1mL ampule 8317437 688177 60006525240 60006525240 ter1 adrenergic bronchodilators 00143-9746-10 1 amp 1 mL INJ - COA PMC - INJ PMC COST 1.057 11/11/2021 9:52 1.057 1.057 1.06 20.7 Formulary J3105 Terbutaline sulfate inj 1 636 traZODone traZODone 50mg tablet 8317631 691861 60006526701 60006526701 traz50 miscellaneous antidepressants 00904-6868-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0827 1/12/2024 7:09 0.0827 0.0827 0 10 Formulary 0 637 triamcinolone triamcinolone acetonide 40mg/mL 1mL 8317655 692215 60006526800 60006526800 tri40 adrenal cortical steroids 70121-1049-05 1 vial(s) 1 mL INJ - COA PMC - INJ PMC COST 2.596 1/12/2024 7:09 2.596 2.596 0.65 35 Formulary J3301 Triamcinolone acet inj NOS 4 636 triamcinolone topical triamcinolone 0.1% cream 15gm 8317639 691971 60006526875 60006526875 tri0.1crm topical steroids 67877-0251-15 1 tube 15 gm Bulk PMC - MED PMC COST 0.09733 1/12/2024 7:09 1.45995 1.45995 0 19.6 Formulary 0 637 triamcinolone topical triamcinolone 0.5% cream 15gm 8318483 6367414 60006526891 60006526891 tri0.5 topical steroids 67877-0318-15 1 tube 15 gm Bulk PMC - MED PMC COST 0.30867 11/11/2021 9:52 4.63005 4.63005 0 40.6 Formulary 0 637 tuberculin purified protein derivative tuberculin unit(s) per 0.1mL 1mL PPD MDV 8341429 278410074 60006527469 60006527469 tub5 in vivo diagnostic biologicals 49281-0752-21 1 EA 1 mL MDV INJ - COA PMC - INJ PMC COST 84.04 1/8/2024 7:47 84.04 84.04 0 300 Formulary 0 302 86580 acetaminophen-codeine acetaminophen-codeine 300-30mg tab 8316233 696650 60006527576 60006527576 t3 narcotic analgesic combinations 00406-0484-62 1 tab(s) 1 EA MED - COA PMC - MED PMC COST 0.292 1/8/2024 7:47 0.292 0.292 0 10 Formulary 0 637 vasopressin vasopressin 20 Unit(s)/mL 1mL vial MDV 8317733 693112 60006527782 60006527782 vas20t miscellaneous hormones 00548-9701-00 1 vial(s) 1 mL MDV INJ - COA PMC - INJ PMC COST 25.653 1/12/2024 7:09 25.653 25.653 1.28 137.3 Formulary J2598 "Inj, vasopressin, 1 unit" 20 636 verapamil verapamil 2.5mg/mL 2mL vial 8317744 693419 60006527824 60006527824 ver2.5solnt calcium channel blocking agents 51754-0203-04 1 vial(s) 2 mL INJ - COA PMC - INJ PMC COST 1.8484 1/12/2024 7:09 3.6968 3.6968 0 42.3 Formulary 0 259 warfarin warfarin 2mg tablet 8318224 2850424 60006528053 60006528053 war2 coumarins and indanediones 00093-1713-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0794 11/11/2021 9:52 0.0794 0.0794 0 10 Formulary 0 637 warfarin warfarin 5mg tablet 8317761 693991 60006528079 60006528079 war5 coumarins and indanediones 00093-1721-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.1003 11/11/2021 9:52 0.1003 0.1003 0 10 Formulary 0 637 sterile water water for inject bacteriostatic 30mL 8317766 694140 60006528145 60006528145 water miscellaneous uncategorized agents 00409-3977-03 1 vial(s) 30 mL INJ - COA PMC - INJ PMC COST 0.0501 1/8/2024 7:47 1.503 1.503 0 25.6 Formulary 0 258 sterile water water for injection (sterile) 10mL vial 8317765 694107 60006528152 60006528152 ste10mlbc sterile irrigating solutions 00409-4887-10 1 vial(s) 10 mL LVP - COA PMC - INJ PMC COST 0.0652 1/8/2024 7:47 0.652 0.652 0 17.5 Formulary 0 259 chlordiazePOXIDE chlordiazePOXIDE 25mg capsule 8316649 695144 60006528343 60006528343 chl25 benzodiazepines 00555-0159-02 1 EA 1 EA MED - COA PMC - MED PMC COST 0.1524 12/28/2023 15:15 0.1524 0.1524 0 10 Formulary 0 637 acetaminophen acetaminophen 325mg suppository 8316223 696475 60006528590 60006528590 apap325pr miscellaneous analgesics 51672-2116-02 1 supp 1 EA MED - COA PMC - DIRECT COST PMC COST 0.68333 11/11/2021 9:52 0.68333 0.68333 0 0.68 Formulary 0 637 vecuronium vecuronium 10mg vial 8316052 697180 60006528608 60006528608 vec10 neuromuscular blocking agents 55150-0235-10 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 2.293 1/12/2024 7:09 2.293 2.293 0 32 Formulary 0 259 glipiZIDE glipiZIDE 5mg tablet 8316206 695636 60006528624 60006528624 gli5 sulfonylureas 60505-0141-00 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0251 11/11/2021 9:52 0.0251 0.0251 0 10 Formulary 0 637 labetalol labetalol 5mg/mL 20mL vial MDV 8320570 34248288 60006528798 60006528798 lab5t "beta blockers, non-cardioselective" 00143-9622-01 1 vial(s) 20 mL MDV INJ - COA PMC - INJ PMC COST 0.0855 1/8/2024 7:47 1.71 1.71 0.09 27.9 Formulary J1920 "Inj, labetalol hcl, 5mg" 20 636 cefTRIAXone cefTRIAXone 1gm vial 8316636 694896 60006528871 DONOTLOAD ceftri1 third generation cephalosporins 00409-7332-01 1 vial(s) 1 EA IVPB - COA PMC - INJ PMC COST 1.522 1/12/2024 7:09 1.522 1.522 0.38 25.8 Formulary J0696 Ceftriaxone sodium injection 4 636 cefTRIAXone cefTRIAXone 1000mg IM inj 8322560 36141732 60006528871 60006528871 cef1000inj third generation cephalosporins 00409-7332-01 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 1.522 1/12/2024 7:09 1.522 1.522 0.38 25.8 Formulary J0696 Ceftriaxone sodium injection 4 636 clotrimazole clotrimazole 10mg lozenge 8316734 696480 60006528939 60006528939 clo10 mouth and throat products 00054-8146-22 1 lozenge(s) 1 EA MED - COA PMC - MED PMC COST 1.0524 12/28/2023 15:41 1.0524 1.0524 0 15.1 Formulary 0 637 cefTAZidime cefTAZidime 1000mg vial 8316626 694758 60006528996 60006528996 ceftaz1 third generation cephalosporins 44567-0235-25 1 vial(s) 1 EA IVPB - COA PMC - INJ PMC COST 2.6784 12/28/2023 15:05 2.6784 2.6784 1.34 35.8 Formulary J0713 Inj ceftazidime per 500 mg 2 636 ibuprofen ibuprofen 200mg tab 8317367 687486 60006529192 60006529192 ibu200 nonsteroidal anti-inflammatory agents 70000-0175-05 1 tab(s) 1 EA MED - COA PMC - DIRECT COST PMC COST 0.0176 1/8/2024 7:47 0.0176 0.0176 0 0.02 Formulary 0 637 enalapril enalapril 10mg tablet 8316999 691766 60006529622 60006529622 ena10 angiotensin converting enzyme (ace) inhibitors 23155-0772-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0626 1/8/2024 7:47 0.0626 0.0626 0 10 Formulary 0 637 furosemide furosemide 40mg/4mL vial 8317209 696257 60006529689 60006529689 fur40I loop diuretics 63323-0280-26 1 vial(s) 4 mL INJ - COA PMC - INJ PMC COST 0.1445 1/8/2024 7:47 0.578 0.578 0.29 16.6 Formulary J1940 Furosemide injection 2 636 lidocaine lidocaine 1% PF 30mL vial 8317982 1031533 60006529796 60006529796 lidpf1 antiarrhythmic agents 63323-0492-26 1 vial(s) 30 mL MED - COA PMC - INJ PMC COST 0.07491 1/12/2024 7:09 2.2473 2.2473 0 31.5 Formulary 0 259 lidocaine lidocaine 1% 2mL PF inj 8317537 692973 60006530232 60006530232 lidopf1 antiarrhythmic agents 63323-0492-27 1 amp 2 mL INJ - COA PMC - INJ PMC COST 0.4678 1/12/2024 7:09 0.9356 0.9356 0 21.2 Formulary 0 259 amiodarone amiodarone 200mg tablet 8316311 685343 60006530349 60006530349 ami200 antiarrhythmic agents 00904-6993-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.1599 12/28/2023 12:21 0.1599 0.1599 0 10 Formulary 0 637 famotidine famotidine 10mg/mL 2mL vial 8317990 1053539 60006530786 60006530786 fam20inj h2 antagonists 63323-0739-16 1 vial(s) 2 mL MED - COA PMC - INJ PMC COST 0.2752 1/8/2024 7:47 0.5504 0.5504 0.55 16.2 Formulary S0028 "Injection, famotidine, 20 mg" 1 259 erythromycin ophthalmic erythromycin ophth oint 3.5gm 8317033 692652 60006530794 60006530794 ery3.5 ophthalmic anti-infectives 17478-0070-35 1 tube 3.5 gm Bulk PMC - MED PMC COST 1.75429 11/11/2021 9:52 6.14002 6.14002 0 40.4 Formulary 0 637 ciprofloxacin ciprofloxacin 250mg tab 8316668 695456 60006530851 60006530851 cip250 quinolones 55111-0126-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.1 12/4/2023 13:23 0.1 0.1 0 10 Formulary 0 637 ciprofloxacin ciprofloxacin 500mg tab 8316670 695492 60006530869 60006530869 cip500 quinolones 00904-7083-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.17 9/21/2023 16:58 0.17 0.17 0 10 Formulary 0 637 enalapril enalaprilat 1.25mg/mL 2mL vial 8317005 691925 60006531040 60006531040 ena1.25 angiotensin converting enzyme (ace) inhibitors 00143-9786-10 1 vial(s) 2 mL INJ - COA PMC - INJ PMC COST 3.914 12/29/2023 10:06 7.828 7.828 0 56 Formulary 0 259 bupivacaine bupivacaine PF 0.25% 30mL vial (G/K) 8316513 692535 60006531164 60006531164 bup0.25 local injectable anesthetics 00409-1559-30 1 vial(s) 30 mL INJ - COA PMC - INJ PMC COST 0.1144 1/8/2024 8:43 3.432 3.432 0.02 39.9 Formulary J0665 "Inj, bupivacaine, nos, 0.5mg" 150 636 JZ bupivacaine bupivacaine PF 0.5% 10mL (G/K) 8318811 9499371 60006531255 60006531255 bupPF0.5 local injectable anesthetics 00409-1162-01 1 vial(s) 10 mL INJ - COA PMC - INJ PMC COST 0.1753 11/11/2021 9:52 1.753 1.753 0.02 28.3 Formulary J0665 "Inj, bupivacaine, nos, 0.5mg" 100 636 JZ charcoal activated charcoal aqueous 50gm 8316242 696763 60006531313 60006531313 charcoal miscellaneous gi agents 00574-0521-76 1 bottle 240 mL MED - COA PMC - MED PMC COST 0.09225 1/12/2024 7:09 22.14 22.14 0 120 Formulary 0 259 lisinopril lisinopril 20mg tablet 8317578 693762 60006531859 60006531859 lis20 angiotensin converting enzyme (ace) inhibitors 68180-0981-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0605 1/8/2024 7:47 0.0605 0.0605 0 10 Formulary 0 637 metoprolol metoprolol 1mg/mL 5mL soln 8317729 696440 60006531966 60006531966 met1 "beta blockers, cardioselective" 36000-0033-10 1 amp 5 mL INJ - COA PMC - INJ PMC COST 0.132 1/8/2024 7:47 0.66 0.66 0 17.6 Formulary 0 259 nystatin topical nystatin topical powder 15gm 8316587 689349 60006531974 60006531974 nyspowder topical antifungals 00832-0465-15 1 bottle 15 gm Bulk PMC - MED PMC COST 0.26 11/11/2021 9:52 3.9 3.9 0 38.6 Formulary 0 637 vancomycin vancomycin 500mg vial 8317727 693022 60006532113 60006532113 van500inj miscellaneous antibiotics 72611-0761-10 1 vial(s) 1 EA IVPB - COA PMC - INJ PMC COST 2 1/12/2024 7:09 2 2 2 31 Formulary J3370 Vancomycin hcl injection 1 636 vancomycin vancomycin 1gm vial 8317719 692919 60006532121 60006532121 van1inj miscellaneous antibiotics 63323-0284-26 1 vial(s) 1 EA IVPB - COA PMC - INJ PMC COST 1.853 1/12/2024 7:09 1.853 1.853 0.93 29.4 Formulary J3370 Vancomycin hcl injection 2 636 omeprazole omeprazole 20mg capsule 8318633 8499392 60006532535 60006532535 ome20 proton pump inhibitors 00904-6917-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.1126 1/12/2024 7:09 0.1126 0.1126 0 10 Formulary 0 637 ketorolac ketorolac 30mg/mL vial 8317466 691109 60006532915 60006532915 ket30 nonsteroidal anti-inflammatory agents 72266-0118-25 1 vial(s) 1 mL INJ - COA PMC - INJ PMC COST 1.5588 1/12/2024 7:09 1.5588 1.5588 0.78 26.2 Formulary J1885 Ketorolac tromethamine inj 2 636 bumetanide bumetanide 0.25 mg/mL 10mL MDV 8318274 3413156 60006533038 60006533038 bum+ loop diuretics 00641-6007-10 1 vial(s) 10 mL MDV INJ - COA PMC - INJ PMC COST 0.2745 11/11/2021 9:52 2.745 2.745 0.55 36.5 Formulary J1939 "Injection, bumetanide, 0.5 mg" 5 636 adenosine adenosine 3mg/mL 2mL soln 8316253 696914 60006533111 60006533111 aden3 antiarrhythmic agents 67457-0855-02 1 vial(s) 2 mL INJ - COA PMC - INJ PMC COST 2.7515 11/11/2021 9:52 5.503 5.503 0.92 42.1 Formulary J0153 Adenosine inj 1mg 6 636 metoclopramide metoclopramide 5mg tablet 8317721 696307 60006533319 60006533319 met5tab gi stimulants 00093-2204-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0282 11/11/2021 9:52 0.0282 0.0282 0 10 Formulary 0 637 levothyroxine levothyroxine 75mcg tab 8317531 692844 60006533590 60006533590 lev75 thyroid hormones 60687-0475-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.3934 1/12/2024 7:09 0.3934 0.3934 0 10 Formulary 0 637 famotidine famotidine 20mg tablet 8316078 697673 60006533640 60006533640 fam20 h2 antagonists 63739-0645-10 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0784 1/12/2024 7:09 0.0784 0.0784 0 10 Formulary 0 637 fentaNYL fentaNYL patch 25mcg/hr 8317121 694487 60006534002 60006534002 fen25 00378-9121-98 1 EA 1 EA MED - COA PMC - MED PMC COST 6.774 11/11/2021 9:52 6.774 6.774 0 44.2 Formulary 0 637 ciprofloxacin ciprofloxacin 400mg/200mL D5W premix 8316673 695547 60006534044 60006534044 cip400pb quinolones 25021-0114-87 1 bag 200 mL IVPB - COA PMC - IV FLUIDS PMC COST 0.013 12/3/2021 10:22 2.6 2.6 1.3 28 Formulary J0744 Ciprofloxacin IV 2 636 albumin human albumin human 25% 100mL (G/K) 8316256 696970 60006536437 60006536437 alb25 plasma expanders 44206-0251-10 1 bottle 100 mL IVPB - COA PMC - IV FLUIDS PMC COST 0.68 11/11/2021 9:52 68 68 34 160 Formulary P9047 "Albumin (human), 25%, 50ml" 2 636 JZ albumin human albumin human 25% 50mL (G/K) 8316258 697000 60006536445 60006536445 alb2550 plasma expanders 44206-0251-05 1 bottle 50 mL IVPB - COA PMC - IV FLUIDS PMC COST 0.68 12/28/2023 12:05 34 34 34 100 Formulary P9047 "Albumin (human), 25%, 50ml" 1 636 JZ albumin human albumin human 5% 250mL (G/K) 8316259 697019 60006536452 60006536452 alb5250 plasma expanders 44206-0310-25 1 bottle 250 mL IVPB - COA PMC - IV FLUIDS PMC COST 0.15 11/11/2021 9:52 37.5 37.5 37.5 100 Formulary P9045 "Albumin (human), 5%, 250 ml" 1 636 JZ Dextrose 5% with 0.45% NaCl intravenous D5-0.45 NaCl 1000mL 8316792 697463 60006536627 60006536627 D5.451000 intravenous nutritional products 00264-7612-00 1 bag 1000 mL LVP - COA PMC - IV FLUIDS PMC COST 0.00229 11/15/2021 15:48 2.29 2.29 0 28 Formulary 0 259 Dextrose 5% with 0.45% NaCl intravenous D5-0.45 NaCl 1000mL soln 8327042 41754716 60006536627 60006536627 D51/2NS1000int intravenous nutritional products 00990-7926-09 1 bag 1000 mL IVPB - COA PMC - IV FLUIDS PMC COST 0.0055 1/8/2024 8:41 5.5 5.5 0 38 Formulary 0 259 Dextrose 5% with 0.9% NaCl intravenous s D5-NS 1000mL 8316809 697644 60006536643 60006536643 D5NS1000 intravenous nutritional products 00264-7610-00 1 bag 1000 mL LVP - COA PMC - IV FLUIDS PMC COST 0.0023 11/15/2021 15:49 2.3 2.3 1.15 28 Formulary J7042 5% dextrose/normal saline 2 636 Dextrose 5% with 0.9% NaCl intravenous s D5-NS 500mL 8316812 697681 60006536650 60006536650 D5NS500 intravenous nutritional products 63323-0870-10 1 bag 500 mL LVP - COA PMC - IV FLUIDS PMC COST 0.0069 1/8/2024 8:42 3.45 3.45 3.45 28 Formulary J7042 5% dextrose/normal saline 1 636 Dextrose 5% in Water intravenous solutio dextrose 5% water 1000mL 8316817 685014 60006536692 60006536692 D51000 intravenous nutritional products 00264-7510-00 1 bag 1000 mL LVP - COA PMC - IV FLUIDS PMC COST 0.0026 11/15/2021 9:41 2.6 2.6 2.6 28 Formulary J7070 D5w infusion 1 636 nitroglycerin USE IV SET - nitroglycerin 25mg/250mL D5W (G/K) 8320555 34223023 60006536841 DONOTLOAD IVSETnitrogtt antianginal agents 00338-1047-02 1 bottle 250 mL LVP - COA PMC - IV FLUIDS PMC COST 0.0714 1/8/2024 7:47 17.85 17.85 3.57 58 Formulary J2305 "Inj, nitroglycerin, 5 mg" 5 636 JZ nitroglycerin nitroglycerin 25mg/250mL D5W premix (G/K) 8322816 37035902 60006536841 60006536841 nitrogttpremix antianginal agents 00338-1047-02P 1 bottle 250 mL LVP - COA PMC - IV FLUIDS PMC COST 0.06436 11/30/2021 8:01 16.09 16.09 3.22 58 Formulary J2305 "Inj, nitroglycerin, 5 mg" 5 636 JZ lidocaine USE IV SET - lidocaine 2gm/250mL D5W 8317557 693385 60006537294 DONOTLOAD IVSETlidogttpremix antiarrhythmic agents 00338-0411-02 1 bag 250 mL LVP - COA PMC - IV FLUIDS PMC COST 0.02668 11/11/2021 9:52 6.67 6.67 0.03 38 Formulary J2001 Lidocaine injection 200 636 lidocaine lidocaine 2gm/250mL D5W premix 8322828 37045183 60006537294 60006537294 lidogttpbpremix local injectable anesthetics 00338-0411-02P 1 bag 250 mL LVP - COA PMC - IV FLUIDS PMC COST 0.02668 11/30/2021 8:08 6.67 6.67 0.03 38 Formulary J2001 Lidocaine injection 200 636 DOPamine USE IV SET - DOPamine 400mg/250mL D5W 8320553 34214861 60006537328 DONOTLOAD IVSETdoppremixreal inotropic agents 00338-1007-02 1 bag 250 mL LVP - COA PMC - IV FLUIDS PMC COST 0.0495 1/8/2024 7:47 12.375 12.375 1.24 48 Formulary J1265 Dopamine injection 10 636 DOPamine DOPamine 400mg/250mL D5W premix 8322813 37034976 60006537328 60006537328 dopgttpremix vasopressors 00338-1007-02P 1 bag 250 mL LVP - COA PMC - IV FLUIDS PMC COST 0.0495 12/28/2023 16:47 12.375 12.375 1.24 48 Formulary J1265 Dopamine injection 10 636 glucose dextrose 40% gel 15gm (OTC) 8316886 687634 60006537997 60006537997 gluc40 00574-0069-30 1 tube 15 gm Bulk PMC - DIRECT COST PMC COST 0.1089 1/8/2024 7:47 1.6335 1.6335 0 1.63 Formulary 0 259 nicotine nicotine 7mg patch 8316481 687302 60006538052 60006538052 nic7 miscellaneous uncategorized agents 00536-5894-88 1 patch(es) 1 EA MED - COA PMC - DIRECT COST PMC COST 1.555 12/3/2021 10:23 1.555 1.555 0 1.55 Formulary 0 637 nicotine nicotine 14mg patch 8316475 687193 60006538060 60006538060 nic14 miscellaneous uncategorized agents 00135-0195-02 1 patch(es) 1 EA MED - COA PMC - DIRECT COST PMC COST 1.58929 1/12/2024 7:09 1.58929 1.58929 0 1.59 Formulary 0 637 nicotine nicotine 21mg patch 8316478 687232 60006538078 60006538078 nic21 miscellaneous uncategorized agents 00135-0194-02 1 patch(es) 1 EA MED - COA PMC - DIRECT COST PMC COST 1.58929 1/12/2024 7:09 1.58929 1.58929 0 1.59 Formulary 0 637 metroNIDAZOLE metroNIDAZOLE 500mg tablet 8316225 696584 60006538268 60006538268 met500 amebicides 00904-7126-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.4689 1/12/2024 7:09 0.4689 0.4689 0 10 Formulary 0 637 diltiaZEM diltiaZEM 5mg/mL 5mL vial 8338092 216063081 60006538276 60006538276 dil5Inj5mL calcium channel blocking agents 17478-0937-05 1 vial(s) 5 mL INJ - COA PMC - INJ PMC COST 0.5146 11/11/2021 9:52 2.573 2.573 0 34.8 Formulary 0 259 warfarin warfarin 1mg tablet 8317757 693846 60006538607 60006538607 war1 coumarins and indanediones 00093-1712-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0725 11/11/2021 9:52 0.0725 0.0725 0 10 Formulary 0 637 levothyroxine levothyroxine 112mcg tab 8317515 692458 60006538631 60006538631 lev112 thyroid hormones 00904-6954-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.4861 1/12/2024 7:09 0.4861 0.4861 0 10 Formulary 0 637 alteplase alteplase 100mg vial (G/K) 8316288 697436 60006538680 60006538680 alt100 thrombolytics 50242-0085-27 1 vial(s) 1 EA IVPB - COA PMC - INJ PMC COST 8065.53 11/11/2021 9:52 8065.53 8065.53 80.66 16140.1 Formulary J2997 Alteplase recombinant 100 636 JZ diltiaZEM diltiaZEM CD 120mg cap 8316930 689312 60006538714 60006538714 dil120CD calcium channel blocking agents 68682-0367-90 1 EA 1 EA MED - COA PMC - MED PMC COST 0.1821 12/28/2023 16:20 0.1821 0.1821 0 10 Formulary 0 637 SUMAtriptan SUMAtriptan 6mg/0.5mL vial 8317416 687801 60006538979 60006538979 sum6 antimigraine agents 55150-0173-01 1 vial(s) 0.5 mL INJ - COA PMC - INJ PMC COST 7.044 1/8/2024 7:47 3.522 3.522 3.52 40.7 Formulary J3030 Sumatriptan succinate / 6 mg 1 637 enoxaparin enoxaparin 30mg/0.3mL syringe 8317013 692077 60006539209 60006539209 eno30 heparins 00075-8013-10 1 syringe(s) 0.3 mL INJ - COA PMC - INJ PMC COST 7.533 11/11/2021 9:52 2.2599 2.2599 0.75 31.6 Formulary J1650 Inj enoxaparin sodium 3 636 zolpidem zolpidem 5mg tablet 8317777 694476 60006539423 60006539423 zol5 "miscellaneous anxiolytics, sedatives and hypnotics" 00904-6082-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0616 1/12/2024 7:09 0.0616 0.0616 0 10 Formulary 0 637 ondansetron ondansetron 2mg/mL 2mL soln 8316145 692366 60006539514 60006539514 onda2 5ht3 receptor antagonists 23155-0548-42 1 vial(s) 2 mL INJ - COA PMC - INJ PMC COST 0.1802 1/8/2024 7:47 0.3604 0.3604 0.09 13.7 Formulary J2405 Ondansetron hcl injection 4 636 venlafaxine venlafaxine 75mg tablet 8317739 693284 60006539712 60006539712 ven75 miscellaneous antidepressants 68084-0856-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.6723 1/12/2024 7:09 0.6723 0.6723 0 12.3 Formulary 0 637 ipratropium ipratropium 0.2mg/mL neb soln 2.5mL 8317429 689831 60006539779 60006539779 ipr0.2neb respiratory inhalant products 76204-0100-25 1 amp 2.5 mL MED - COA PMC - MED PMC COST 0.0632 1/12/2024 7:09 0.158 0.158 0 10 Formulary 0 259 venlafaxine venlafaxine 100mg tablet 8317736 693187 60006539951 60006539951 ven100 miscellaneous antidepressants 57237-0176-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.1045 1/12/2024 7:09 0.1045 0.1045 0 10 Formulary 0 637 medroxyPROGESTERone medroxyPROGESTERone 150mg/mL 1mL vial 8317862 696444 60006539985 60006539985 med150 00548-5400-00 1 vial(s) 1 mL INJ - COA PMC - INJ PMC COST 16.91 11/11/2021 9:52 16.91 16.91 0.11 110.5 Formulary J1050 Medroxyprogesterone acetate 150 636 rocuronium rocuronium 10mg/mL 5mL vial 8318694 8671757 60006540264 60006540264 roc50 neuromuscular blocking agents 71288-0700-06 1 vial(s) 5 mL INJ - COA PMC - INJ PMC COST 0.3878 1/12/2024 7:09 1.939 1.939 0 30.4 Formulary 0 259 aspirin aspirin enteric coated 81mg tablet 8316400 689132 60006540298 60006540298 asa81ec salicylates 63739-0212-02 1 tab(s) 1 EA MED - COA PMC - DIRECT COST PMC COST 0.0572 12/28/2023 12:48 0.0572 0.0572 0 0.06 Formulary 0 637 measles/mumps/rubella virus vaccine measles-mumps-rubella vaccine 8317632 694792 60006540561 60006540561 mmr vaccine combinations 00006-4681-00 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 76.24 11/15/2021 9:42 76.24 76.24 0 300 Formulary 0 636 90707 venlafaxine venlafaxine 50mg tab 8317738 693251 60006540868 60006540868 ven50 miscellaneous antidepressants 57664-0394-88 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0782 1/12/2024 7:09 0.0782 0.0782 0 10 Formulary 0 637 acetaminophen-oxyCODONE acetaminophen-oxyCODONE 325-5mg tab 8316672 690919 60006540934 60006540934 oxycod5 narcotic analgesic combinations 50268-0644-15 1 EA 1 EA MED - COA PMC - MED PMC COST 0.274 1/8/2024 7:47 0.274 0.274 0 10 Formulary 0 637 amLODIPine amLODIPine 5mg tab 8316324 686059 60006541254 60006541254 aml5 calcium channel blocking agents 00904-6370-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0685 12/28/2023 12:23 0.0685 0.0685 0 10 Formulary 0 637 phenol topical phenol-sodium phenolate spray 180mL 8316784 692405 60006541338 60006541338 phe topical anesthetics 70000-0458-01 1 bottle 180 mL Bulk PMC - DIRECT COST PMC COST 0.00638 11/11/2021 9:52 1.1484 1.1484 0 1.15 Formulary 0 637 guaiFENesin guaiFENesin 200mg tablet 8317259 697009 60006541478 60006541478 gua200 expectorants 00904-5154-60 1 EA 1 EA MED - COA PMC - DIRECT COST PMC COST 0.033 1/12/2024 7:09 0.033 0.033 0 0.03 Formulary 0 637 metFORMIN metFORMIN 500mg tablet 8317674 695581 60006541783 60006541783 metfor500 70010-0063-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0179 1/12/2024 7:09 0.0179 0.0179 0 10 Formulary 0 637 finasteride finasteride 5mg tablet 8317143 694875 60006541874 60006541874 fin5 00904-6830-06 1 EA 1 EA MED - COA PMC - MED PMC COST 0.402 1/8/2024 8:22 0.402 0.402 0 10 Formulary 0 637 levothyroxine levothyroxine 88mcg tab 8317533 692870 60006541957 60006541957 lev88 thyroid hormones 00904-6952-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.3944 1/12/2024 7:09 0.3944 0.3944 0 10 Formulary 0 637 amLODIPine amLODIPine 10mg tablet 8316321 685923 60006542005 60006542005 aml10 calcium channel blocking agents 00904-6371-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0515 12/28/2023 12:21 0.0515 0.0515 0 10 Formulary 0 637 simvastatin simvastatin 20mg tablet 8317231 696803 60006542179 60006542179 sim20 hmg-coa reductase inhibitors (statins) 16729-0005-15 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0231 11/30/2021 23:34 0.0231 0.0231 0 10 Formulary 0 637 gabapentin gabapentin 300mg capsule 8317214 696328 60006542195 60006542195 gab300 miscellaneous anticonvulsants 63739-0903-10 1 EA 1 EA MED - COA PMC - MED PMC COST 0.1156 1/12/2024 7:09 0.1156 0.1156 0 10 Formulary 0 637 amiodarone amiodarone 50mg/mL 3mL vial 8316313 685415 60006542526 60006542526 amio50 antiarrhythmic agents 63323-0616-03 1 vial(s) 3 mL INJ - COA PMC - INJ PMC COST 0.58346 11/11/2021 9:52 1.75038 1.75038 0.35 28.3 Formulary J0282 Amiodarone HCl 5 636 racepinephrine epinephrine (racemic) 2.25% 0.5mL 8336542 192179857 60006542658 60006542658 rac2.25 adrenergic bronchodilators 00487-2784-01 1 EA 1 EA MED - COA PMC - MED PMC COST 1.816 11/11/2021 9:52 1.816 1.816 0 23.5 Formulary 0 259 polymyxin B-trimethoprim ophthalmic polymyxin B-trimeth 0.1% ophth 10mL Soln 8871128 342840205 60006542948 60006542948 pol ophthalmic anti-infectives 60758-0908-10 1 bottle 10 mL Bulk PMC - MED PMC COST 0.633 11/11/2021 9:11 6.33 6.33 0 41.5 Formulary 0 637 losartan losartan 50mg tablet 8318622 8497507 60006543003 60006543003 los50 angiotensin ii inhibitors 68084-0347-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.2342 1/12/2024 7:09 0.2342 0.2342 0 10 Formulary 0 637 albuterol albuterol 2.5mg/3mL neb solution 8316266 697112 60006543052 60006543052 alb2.5mgneb adrenergic bronchodilators 76204-0200-25 1 EA 3 mL MED - COA PMC - MED PMC COST 0.05387 12/28/2023 12:10 0.16161 0.16161 0.16 10 Formulary J7613 Albuterol non-comp unit 1 259 testosterone testosterone cypionate 200mg/mL 1mL 8317443 688309 60006543136 60006543136 tes200 androgens and anabolic steroids 00409-6562-02 1 mL 1 mL INJ - COA PMC - INJ PMC COST 8.53 11/11/2021 9:52 8.53 8.53 0.04 60.2 Formulary J1071 Inj testosterone cypionate 200 636 varicella virus vaccine varicella virus vaccine live vial 8317730 693074 60006543219 60006543219 var viral vaccines 00006-4827-00 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 128 11/15/2021 9:43 128 128 0 393 Formulary 0 636 90716 fluticasone nasal fluticasone 50mcg nasal spray 16 gm 8317924 912213 60006543367 60006543367 flut nasal steroids 60505-0829-01 1 EA 16 gm Bulk PMC - MED PMC COST 0.2713 1/8/2024 8:25 4.3408 4.3408 0 38.3 Formulary 0 637 traMADol traMADol 50mg tablet 8317617 691624 60006543466 60006543466 tram50 miscellaneous analgesics 68084-0808-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.1192 1/8/2024 7:47 0.1192 0.1192 0 10 Formulary 0 637 famotidine famotidine 10mg tablet 8317103 694108 60006543730 60006543730 fam10 h2 antagonists 37205-0614-65 1 EA 1 EA MED - COA PMC - MED PMC COST 0.02733 11/11/2021 9:52 0.02733 0.02733 0 10 Formulary 0 637 SUMAtriptan SUMAtriptan 50mg tablet 8320604 34860050 60006544050 60006544050 sum50 antimigraine agents 65862-0147-36 1 tab(s) 1 EA MED - COA PMC - MED PMC COST 0.33111 1/12/2024 7:09 0.33111 0.33111 0 10 Formulary 0 637 hydrALAZINE hydrALAZINE 20mg/mL 1mL vial 8316082 697720 60006544852 60006544852 hydra20/1 peripheral vasodilators 63323-0614-16 1 vial(s) 1 mL INJ - COA PMC - INJ PMC COST 2.7976 1/8/2024 7:47 2.7976 2.7976 2.8 37 Formulary J0360 Hydralazine hcl injection 1 636 gabapentin gabapentin 100mg capsule 8317212 696304 60006545115 60006545115 gab100 miscellaneous anticonvulsants 00904-6665-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0612 1/8/2024 7:47 0.0612 0.0612 0 10 Formulary 0 637 metoprolol metoprolol SA 100mg tablet 8317732 696483 60006545263 60006545263 met100SA "beta blockers, cardioselective" 50742-0617-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.32 12/3/2021 7:31 0.32 0.32 0 10 Formulary 0 637 "poliovirus vaccine, inactivated" poliovirus vaccine inj inactivated 8316882 693452 60006545446 60006545446 pol viral vaccines 49281-0860-10 1 EA 0.5 mL INJ - COA PMC - INJ PMC COST 36 1/26/2024 16:18 18 18 0 117 Formulary 0 636 90713 OLANZapine OLANZapine 5mg tablet 8316627 690140 60006545974 60006545974 ola5 miscellaneous antipsychotic agents 43598-0164-30 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0493 1/8/2024 7:47 0.0493 0.0493 0 10 Formulary 0 637 OLANZapine OLANZapine 10mg tablet 8316617 689928 60006545982 60006545982 ola10 miscellaneous antipsychotic agents 43598-0166-30 1 EA 1 EA MED - COA PMC - MED PMC COST 0.095 1/29/2024 19:11 0.095 0.095 0 10 Formulary 0 637 fluconazole fluconazole 150mg tab 8317151 695018 60006546584 60006546584 flu150 azole antifungals 57237-0005-11 1 EA 1 EA MED - COA PMC - MED PMC COST 1.0308 1/8/2024 8:23 1.0308 1.0308 0 14.9 Formulary 0 637 glimepiride glimepiride 2mg tablet 8317237 696676 60006546592 60006546592 gli2 sulfonylureas 61442-0116-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.74 12/3/2021 8:06 0.74 0.74 0 13.2 Formulary 0 637 latanoprost ophthalmic latanoprost 0.005% ophthalmic soln 2.5mL 8317488 691734 60006546600 60006546600 latan ophthalmic glaucoma agents 61314-0547-01 1 bottle 2.5 mL Bulk PMC - MED PMC COST 9.22 12/30/2021 11:47 23.05 23.05 0 120 Formulary 0 637 donepezil donepezil 5mg tablet 8316971 690706 60006546808 60006546808 don5 miscellaneous central nervous system agents 00904-6477-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.1072 12/28/2023 16:43 0.1072 0.1072 0 10 Formulary 0 637 carvedilol carVEDilol 25mg tablet 8316591 694135 60006547376 60006547376 car25 "beta blockers, non-cardioselective" 00904-6303-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0828 12/28/2023 13:23 0.0828 0.0828 0 10 Formulary 0 637 melatonin melatonin 3mg tab 8318488 6417368 60006547582 60006547582 mel3 nutraceutical products 80681-0085-00 1 EA 1 EA MED - COA PMC - DIRECT COST PMC COST 0.04583 1/12/2024 7:09 0.04583 0.04583 0 0.05 Formulary 0 637 azithromycin azithromycin 250mg tab 8318845 9917657 60006547806 60006547806 azi250tab macrolides 00781-8089-26 1 EA 1 EA MED - COA PMC - MED PMC COST 0.30167 11/11/2021 9:52 0.30167 0.30167 0 10 Formulary 0 637 tamsulosin tamsulosin 0.4mg capsule 8317425 687950 60006547897 60006547897 tam0.4 "antiadrenergic agents, peripherally acting" 68084-0299-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.2321 1/12/2024 7:09 0.2321 0.2321 0 10 Formulary 0 637 QUEtiapine QUEtiapine 25mg tablet 8317098 695528 60006548077 60006548077 que25 miscellaneous antipsychotic agents 00904-6638-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0851 1/8/2024 7:47 0.0851 0.0851 0 10 Formulary 0 637 venlafaxine venlafaxine XR 75mg capsule 8317742 693368 60006548119 60006548119 venXR75 miscellaneous antidepressants 68084-0709-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.4715 1/12/2024 7:09 0.4715 0.4715 0 10 Formulary 0 637 carvedilol carVEDilol 3.125mg tablet 8316592 694160 60006548150 60006548150 car3.125 "beta blockers, non-cardioselective" 00904-6300-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0828 12/28/2023 13:24 0.0828 0.0828 0 10 Formulary 0 637 carvedilol carVEDilol 6.25mg tablet 8316594 694184 60006548168 60006548168 car6.25 "beta blockers, non-cardioselective" 51079-0930-20 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0795 12/28/2023 13:22 0.0795 0.0795 0 10 Formulary 0 637 azithromycin azithromycin 500mg vial 8318131 1498496 60006548200 60006548200 azi500 macrolides 63323-0398-10 1 vial(s) 1 EA IVPB - COA PMC - INJ PMC COST 1.578 11/11/2021 9:52 1.578 1.578 1.58 26.4 Formulary J0456 Azithromycin 1 636 venlafaxine venlafaxine XR 37.5mg cap 8317741 693342 60006548267 60006548267 venXR37.5 miscellaneous antidepressants 68084-0698-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.4152 1/8/2024 8:52 0.4152 0.4152 0 10 Formulary 0 637 atorvastatin atorvastatin 20mg tablet 8318629 8498158 60006548317 60006548317 ato20 hmg-coa reductase inhibitors (statins) 00904-6291-06 1 EA 1 EA MED - COA PMC - MED PMC COST 0.1502 12/28/2023 12:57 0.1502 0.1502 0 10 Formulary 0 637 diltiaZEM diltiaZEM 5mg/mL 10mL vial 8316927 689188 60006548622 60006548622 dil5 calcium channel blocking agents 70860-0301-10 1 vial(s) 10 mL LVP - COA PMC - INJ PMC COST 0.2421 12/28/2023 16:24 2.421 2.421 0 33.3 Formulary 0 259 clopidogrel clopidogrel 75mg tablet 8316724 696330 60006548663 60006548663 clo75 platelet aggregation inhibitors 00904-6294-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.132 1/8/2024 7:47 0.132 0.132 0 10 Formulary 0 637 venlafaxine venlafaxine XR 150mg capsule 8317740 693314 60006548994 60006548994 venXR150 miscellaneous antidepressants 00904-7076-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.3708 1/12/2024 7:09 0.3708 0.3708 0 10 Formulary 0 637 montelukast montelukast 10mg tablet 8316306 697275 60006549091 60006549091 mon10 leukotriene modifiers 00904-6808-06 1 EA 1 EA MED - COA PMC - MED PMC COST 0.197 1/12/2024 7:09 0.197 0.197 0 10 Formulary 0 637 levoFLOXacin levoFLOXacin 500mg tablet 8317507 692273 60006549158 60006549158 lev500 quinolones 00904-6352-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.2448 1/8/2024 7:47 0.2448 0.2448 0 10 Formulary 0 637 valACYclovir valACYclovir 1gm tablet 8317698 692695 60006549265 60006549265 val1 purine nucleosides 57237-0043-30 1 EA 1 EA MED - COA PMC - MED PMC COST 0.44 12/4/2023 13:57 0.44 0.44 0 10 Formulary 0 637 cefePIME cefePIME 2gm vial 8316604 694377 60006549380 60006549380 cefep2 fourth generation cephalosporins 00409-9735-10 1 vial(s) 1 EA IVPB - COA PMC - INJ PMC COST 6.885 12/28/2023 15:03 6.885 6.885 1.72 50.4 Formulary J0692 Cefepime HCl for injection 4 636 inFLIXimab inFLIXimab (Remicade) 100mg vial (G/K) 8317406 689059 60006549398 60006549398 inf100 immunosuppressive monoclonal antibodies 57894-0030-01 1 vial(s) 1 EA IVPB - COA PMC - INJ PMC COST 1138.06 1/8/2024 7:47 1138.06 1138.06 113.81 2285.2 Formulary J1745 Infliximab not biosimil 10mg 10 636 JZ eptifibatide USE IV SET - eptifibatide INFUSION 0.75mg/mL 100mL vial (G/K) 8320670 35065553 60006549430 DONOTLOAD IVSETept0.75inf glycoprotein platelet inhibitors 70436-0163-80 1 vial(s) 100 mL LVP - COA PMC - IV FLUIDS PMC COST 0.515 1/10/2024 16:03 51.5 51.5 3.43 160 Formulary J1327 Eptifibatide injection 15 636 JZ eptifibatide eptifibatide INFUSION 0.75mg/mL 100mL premix (G/K) 8322814 37035316 60006549430 60006549430 ept0.75infpremix glycoprotein platelet inhibitors 70436-0163-80P 1 bottle 100 mL LVP - COA PMC - IV FLUIDS PMC COST 0.515 1/11/2024 10:08 51.5 51.5 3.43 160 Formulary J1327 Eptifibatide injection 15 636 JZ propofol propofol 10mg/mL 50mL vial 8318030 1208535 60006550032 60006550032 pro general anesthetics 23155-0345-42 1 bottle 50 mL LVP - COA PMC - IV FLUIDS PMC COST 0.07769 1/12/2024 7:09 3.8845 3.8845 0.08 28 Formulary J2704 "Inj, propofol, 10 mg" 50 636 EPINEPHrine EPINEPHrine 0.3mg/0.3mL syringe 8318791 9063219 60006550123 60006550123 epi0.3 vasopressors 78670-0130-02 1 EA 1 EA INJ - COA PMC - INJ PMC COST 91.73 11/11/2021 9:52 91.73 91.73 30.58 300 Formulary J0171 Adrenalin epinephrine inject 3 636 epoetin alfa "epoetin alfa (Procrit) 40,000Unit(s)/mL 1mL vial (G/K)" 8316175 694125 60006550156 60006550156 epo40000 erythropoiesis-stimulating agents 59676-0340-01 1 mL 1 mL MED - COA PMC - INJ PMC COST 562.8275 1/2/2024 0:00 562.8275 562.8275 14.07 1134.7 Formulary J0885 "Epoetin alfa, non-ESRD" 40 636 JZ celecoxib celecoxib 100mg capsule 8318147 1736453 60006550362 60006550362 cel100 cox-2 inhibitors 69097-0422-07 1 EA 1 EA MED - COA PMC - MED PMC COST 0.43 12/3/2021 7:33 0.43 0.43 0 10 Formulary 0 637 levoFLOXacin levoFLOXacin 250mg tablet 8317504 692182 60006550826 60006550826 lev250 quinolones 00904-6351-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.16 5/23/2023 0:00 0.16 0.16 0 10 Formulary 0 637 levoFLOXacin levoFLOXacin 500mg/100mL D5W premix 8317509 692315 60006550941 60006550941 lev500pb quinolones 00143-9721-24 1 bag 100 mL IVPB - COA PMC - IV FLUIDS PMC COST 0.02088 1/12/2024 7:09 2.088 2.088 1.04 28 Formulary J1956 Levofloxacin injection 2 636 piperacillin-tazobactam piperacillin-tazobactam 4-0.5gm vial 8316873 693361 60006550990 60006550990 pip4.5vial penicillins/beta-lactamase inhibitors 60505-6159-04 1 vial(s) 1 EA IVPB - COA PMC - INJ PMC COST 2.867 1/12/2024 7:09 2.867 2.867 0.72 37.7 Formulary J2543 Piperacillin/tazobactam 4 636 phytonadione phytonadione 1mg/0.5mL pediatric 8316827 692909 60006551287 60006551287 phy1 vitamins 69097-0709-96 1 amp 0.5 mL INJ - COA PMC - INJ PMC COST 8.41 1/12/2024 7:09 4.205 4.205 4.21 42.7 Formulary J3430 Vitamin k phytonadione inj 1 636 EPINEPHrine-lidocaine lidocaine-epi 2-0.001% 20mL vial MDV 8317562 693480 60006551451 60006551451 epilido2MDV local injectable anesthetics 63323-0483-27 1 vial(s) 20 mL MDV INJ - COA PMC - INJ PMC COST 0.2 1/8/2024 7:47 4 4 0 45 Formulary 0 259 glucagon glucagon 1mg kit with diluent (G/K) 8317791 694747 60006551469 60006551469 gluc1 hormones/hormone modifiers 00548-5850-00 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 168.42 1/12/2024 7:09 168.42 168.42 168.42 450 Formulary J1610 Glucagon hydrochloride/1 mg 1 636 JZ hepatitis B pediatric vaccine hepatitis B vaccine ped 5mcg/0.5mL 8316124 691533 60006551634 60006551634 hep5 viral vaccines 00006-4093-02 1 vial(s) 0.5 mL INJ - COA PMC - INJ PMC COST 37.64 11/15/2021 9:43 18.82 18.82 0 122 Formulary 0 636 90744 leuprolide leuprolide 22.5mg kit (URO) (G/K) 8317497 692000 60006551758 60006551758 leu22.5 antineoplastic hormones 00074-3346-03 1 EA 1 EA MED - COA PMC - INJ PMC COST 5357.27 1/12/2024 7:09 5357.27 5357.27 1785.76 10723.6 Formulary J9217 Leuprolide acetate suspnsion 3 636 JZ oseltamivir oseltamivir 75mg capsule 8316643 690418 60006551782 60006551782 ose75 neuraminidase inhibitors 68180-0677-11 1 EA 1 EA MED - COA PMC - MED PMC COST 1.077 1/8/2024 7:47 1.077 1.077 0 15.4 Formulary 0 637 levothyroxine levothyroxine 137mcg tab 8317518 692533 60006551972 60006551972 lev137 thyroid hormones 60687-0563-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.5103 1/12/2024 7:09 0.5103 0.5103 0 10.2 Formulary 0 637 oxyCODONE oxyCODONE IR 5mg tablet 8319032 13122318 60006552079 60006552079 oxy5IR narcotic analgesics 00406-0552-62 1 tab(s) 1 EA MED - COA PMC - MED PMC COST 0.3278 1/8/2024 7:47 0.3278 0.3278 0 10 Formulary 0 637 cyanocobalamin cyanocobalamin 500mcg tab 8316763 696980 60006552517 60006552517 B12 vitamins 80681-0072-00 1 EA 1 EA MED - COA PMC - DIRECT COST PMC COST 0.0216 12/28/2023 15:49 0.0216 0.0216 0 0.02 Formulary 0 637 lidocaine lidocaine PF 2% 10mL inj 8317556 693359 60006552665 60006552665 lidPF2 antiarrhythmic agents 00409-4282-02 1 amp 10 mL INJ - COA PMC - INJ PMC COST 0.20364 1/12/2024 7:09 2.0364 2.0364 0 29.4 Formulary 0 259 ketamine ketamine 50mg/mL 10mL MDV 8317459 690877 60006553267 60006553267 ket50 general anesthetics 00409-2053-10 1 vial(s) 10 mL MDV INJ - COA PMC - INJ PMC COST 0.3623 1/12/2024 7:09 3.623 3.623 0 41.7 Formulary 0 259 piperacillin-tazobactam piperacillin-tazobactam 2-0.25gm vial 8316866 693311 60006553648 60006553648 pip2.25vial penicillins/beta-lactamase inhibitors 60505-6156-04 1 vial(s) 1 EA IVPB - COA PMC - INJ PMC COST 1.564 1/12/2024 7:09 1.564 1.564 0.78 26.3 Formulary J2543 Piperacillin/tazobactam 2 636 collagenase topical collagenase 250 units/gm ointment 30gm 8318711 8673439 60006554026 60006554026 col0 miscellaneous topical agents 50484-0010-30 1 tube 30 gm Bulk PMC - MED PMC COST 8.629 11/11/2021 9:52 258.87 258.87 0 521.3 Formulary 0 259 tenecteplase tenecteplase 50mg kit (G/K) 8317434 688108 60006554570 60006554570 tene50 thrombolytics 50242-0120-47 1 kit(s) 1 EA INJ - COA PMC - INJ PMC COST 6768.08 1/8/2024 7:47 6768.08 6768.08 135.36 13545.2 Formulary J3101 Tenecteplase injection 50 636 JZ hylan G-F 20 hyaluronate sodium 8mg/mL 2mL (Synvisc) syringe (G/K) 8318989 11872580 60006554927 60006554927 hyl16 viscosupplementation agents 58468-0090-01 1 syringe(s) 2 mL MED - COA PMC - INJ PMC COST 104.69667 11/11/2021 9:52 209.39334 209.39334 13.09 450 Formulary J7325 Synvisc or Synvisc-One 16 636 JZ pantoprazole pantoprazole 40mg tab 8318529 6911387 60006555288 60006555288 pan40 proton pump inhibitors 65862-0560-90 1 EA 1 EA MED - COA PMC - MED PMC COST 0.07789 11/11/2021 9:52 0.07789 0.07789 0 10 Formulary 0 637 enoxaparin enoxaparin 40mg/0.4mL syringe 8317014 692127 60006555320 60006555320 eno40 heparins 00075-8014-10 1 syringe(s) 0.4 mL INJ - COA PMC - INJ PMC COST 7.51 11/11/2021 9:52 3.004 3.004 0.75 36.1 Formulary J1650 Inj enoxaparin sodium 4 636 enoxaparin enoxaparin 60mg/0.6mL syringe 8317016 692172 60006555338 60006555338 eno60 heparins 00075-0621-60 1 syringe(s) 0.6 mL INJ - COA PMC - INJ PMC COST 7.49167 12/29/2023 10:32 4.495 4.495 0.75 45 Formulary J1650 Inj enoxaparin sodium 6 636 enoxaparin enoxaparin 80mg/0.8mL syringe 8317017 692205 60006555346 60006555346 eno80 heparins 00075-0622-80 1 syringe(s) 0.8 mL INJ - COA PMC - INJ PMC COST 7.223 12/29/2023 10:35 5.7784 5.7784 0.72 43.7 Formulary J1650 Inj enoxaparin sodium 8 636 enoxaparin enoxaparin 100mg/1mL syringe 8317007 691952 60006555353 60006555353 eno100 heparins 71288-0410-89 1 EA 1 mL INJ - COA PMC - INJ PMC COST 13.95 12/29/2023 10:37 13.95 13.95 1.4 92.7 Formulary J1650 Inj enoxaparin sodium 10 636 APAP/ASA/caffeine acetam-aspirin-caffeine 250-250-65mg tablet 8318057 1235310 60006555601 60006555601 APA analgesic combinations 00536-1326-01 1 tab(s) 1 EA MED - COA PMC - MED PMC COST 0.028 1/12/2024 7:09 0.028 0.028 0 10 Formulary 0 637 pantoprazole pantoprazole 40mg vial 8316195 695379 60006555809 60006555809 pan40i proton pump inhibitors 00008-0923-55 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 1.491 1/8/2024 7:47 1.491 1.491 1.49 25.5 Formulary C9113 "Inj pantoprazole sodium, via" 1 636 piperacillin-tazobactam piperacillin-tazobactam 3-0.375gm vial 8316870 693333 60006555825 60006555825 pip3.75vial penicillins/beta-lactamase inhibitors 60505-6157-04 1 vial(s) 1 EA IVPB - COA PMC - INJ PMC COST 1.929 1/12/2024 7:09 1.929 1.929 0.64 30.3 Formulary J2543 Piperacillin/tazobactam 3 636 iron sucrose iron sucrose complex 20mg/mL 5mL vial 8317441 690222 60006556344 60006556344 iro20 iron products 00517-2340-99 1 vial(s) 5 mL IVPB - COA PMC - INJ PMC COST 6.223 1/12/2024 7:09 31.115 31.115 0.31 164.6 Formulary J1756 Iron sucrose injection 100 636 zoledronic acid zoledronic acid 4mg/5mL vial 8316153 693011 60006557268 60006557268 zol4 bisphosphonates 55111-0685-07 1 EA 5 mL INJ - COA PMC - INJ PMC COST 1.134 1/12/2024 7:09 5.67 5.67 1.42 43.1 Formulary J3489 Zoledronic acid 1mg 4 636 hepatitis A adult vaccine hepatitis A vaccine adult 1440 Unit(s)/mL 8331249 59041076 60006557334 60006557334 hep1440susp viral vaccines 58160-0826-52 1 syringe(s) 1 mL INJ - COA PMC - INJ PMC COST 85 2/24/2023 15:03 85 85 0 300 Formulary 0 636 90632 omega-3 polyunsaturated fatty acids omega-3 1000mg capsule (OTC) 8322737 36942521 60006557466 60006557466 fishoilotc nutraceutical products 77333-0308-10 1 cap(s) 1 EA MED - COA PMC - DIRECT COST PMC COST 0.16 12/3/2021 7:36 0.16 0.16 0 0.16 Formulary 0 637 ertapenem ertapenem 1gm vial 8316075 697614 60006557755 60006557755 ert1 carbapenems 42023-0221-10 1 vial(s) 1 EA IVPB - COA PMC - INJ PMC COST 21.302 1/8/2024 7:47 21.302 21.302 10.65 120 Formulary J1335 Ertapenem injection 2 636 pegfilgrastim pegfilgrastim (Neulasta) 6mg/0.6mL syringe (G/K) 8334196 71837448 60006557847 60006557847 pegf6 colony stimulating factors 55513-0190-01 1 syringe(s) 0.6 mL INJ - COA PMC - INJ PMC COST 7531.88333 1/12/2024 7:09 4519.13 4519.13 376.59 9047.3 Formulary J2506 Inj pegfilgrast ex bio 0.5mg 12 636 JZ escitalopram escitalopram 10mg tablet 8317047 692972 60006557979 60006557979 esc10 ssri antidepressants 00904-6426-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.144 1/8/2024 7:47 0.144 0.144 0 10 Formulary 0 637 cefePIME cefePIME 1gm vial 8316603 694353 60006557987 60006557987 cefep1 fourth generation cephalosporins 44567-0240-10 1 vial(s) 1 EA IVPB - COA PMC - INJ PMC COST 5.488 12/28/2023 15:02 5.488 5.488 2.74 42 Formulary J0692 Cefepime HCl for injection 2 636 escitalopram escitalopram 20mg tablet 8317048 692999 60006558241 60006558241 esc20 ssri antidepressants 00904-6427-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.151 1/8/2024 8:18 0.151 0.151 0 10 Formulary 0 637 digoxin digoxin 0.25mg/mL 2mL ampule 8318731 8683316 60006558258 60006558258 dig0.5i inotropic agents 00641-1410-35 1 amp 2 mL INJ - COA PMC - INJ PMC COST 1.4402 12/28/2023 16:17 2.8804 2.8804 2.88 37.9 Formulary J1160 Digoxin injection 1 636 docusate-senna docusate-senna 50-8.6mg tab 8316072 697566 60006558373 60006558373 doc-sen laxatives 70000-0526-01 1 tab(s) 1 EA MED - COA PMC - DIRECT COST PMC COST 0.0153 11/11/2021 9:52 0.0153 0.0153 0 0.02 Formulary 0 637 LORazepam LORazepam 2mg/mL 1mL vial 8317598 694150 60006558480 60006558480 lor2inj benzodiazepines 00641-6207-25 1 EA 1 mL INJ - COA PMC - INJ PMC COST 0.9724 1/8/2024 7:47 0.9724 0.9724 0.97 21.7 Formulary J2060 Lorazepam injection 1 636 albuterol-ipratropium albuterol-ipratropium 2.5-0.5mg/3mL neb 8318579 7707512 60006558845 60006558845 duoneb3mL bronchodilator combinations 69097-0173-53 1 EA 3 mL MED - COA PMC - MED PMC COST 0.09155 11/11/2021 9:52 0.27465 0.27465 0 10 Formulary 0 259 bumetanide bumetanide 0.25mg/mL 4mL vial 8316508 692431 60006558977 60006558977 BumexIV4 loop diuretics 65219-0570-04 1 vial(s) 4 mL INJ - COA PMC - INJ PMC COST 0.3875 12/28/2023 13:13 1.55 1.55 0.78 26.1 Formulary J1939 "Injection, bumetanide, 0.5 mg" 2 636 mupirocin topical mupirocin 2% topical ointment 22gm 8316385 697774 60006559074 60006559074 mup2 topical antibiotics 51672-1312-00 1 tube 22 gm Bulk PMC - MED PMC COST 0.18955 11/11/2021 9:52 4.1701 4.1701 0 36.9 Formulary 0 637 diazePAM diazePAM 5mg/mL 2mL syringe 8316900 688190 60006559082 60006559082 dia5I benzodiazepines 00641-6244-10 1 syringe(s) 2 mL MED - COA PMC - INJ PMC COST 6.88 12/28/2023 16:15 13.76 13.76 6.88 91.6 Formulary J3360 Diazepam injection 2 636 nitroglycerin nitroglycerin 2% ointment 1gm UD pkt 8316521 688046 60006559181 60006559181 nitoint antianginal agents 00281-0326-30 1 packet(s) 1 gm MED - COA PMC - MED PMC COST 1.04133 1/12/2024 7:09 1.04133 1.04133 0 15 Formulary 0 637 bupivacaine bupivacaine 0.5% 50mL vial MDV 8320719 35213784 60006560288 60006560288 bup250 local injectable anesthetics 00409-1610-50 1 vial(s) 50 mL MDV INJ - COA PMC - INJ PMC COST 0.0644 11/11/2021 9:52 3.22 3.22 0.01 38 Formulary J0665 "Inj, bupivacaine, nos, 0.5mg" 500 636 metoprolol metoprolol SA 25mg tablet 8317734 696503 60006560619 60006560619 met25SA "beta blockers, cardioselective" 70436-0202-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.81 11/15/2023 0:00 0.81 0.81 0 14.1 Formulary 0 637 thiamine thiamine 100mg/mL 2mL vial 8317496 689285 60006560726 60006560726 thi100I vitamins 63323-0013-26 1 vial(s) 2 mL INJ - COA PMC - INJ PMC COST 1.885 1/8/2024 7:47 3.77 3.77 1.89 43 Formulary J3411 Thiamine HCl 100 mg 2 636 diphtheria/tetanus/pertussis (DTaP) ped diphtheria/tetanus/pertussis (DTaP) peds 0.5mL 8320708 35160297 60006561344 60006561344 DTaPpeds 58160-0810-52 1 syringe(s) 0.5 mL INJ - COA PMC - INJ PMC COST 105.28 12/1/2021 8:27 52.64 52.64 0 219.6 Formulary 0 636 90700 "diphtheria/hepB/pertussis,acel/polio/tet" "diphth/hepB/pertussis,acel/polio/tetanus vaccine 0.5mL syringe" 8320621 34922578 60006561377 60006561377 pediarix0.5syr 58160-0811-52 1 syringe(s) 0.5 mL INJ - COA PMC - INJ PMC COST 172.6 11/15/2021 9:46 86.3 86.3 0 300 Formulary 0 636 90723 "typhoid vaccine, inactivated" "typhoid vaccine, inactivated 0.5mL syringe" 8322912 38249772 60006561401 60006561401 typ bacterial vaccines 49281-0790-51 1 syringe(s) 0.5 mL INJ - COA PMC - INJ PMC COST 119.63 2/8/2023 10:25 59.815 59.815 0 248.3 Formulary 0 636 90691 hepatitis A pediatric vaccine hepatitis A pediatric PF vaccine 720 units/0.5 mL syringe 8320633 34936123 60006561484 60006561484 hep720 viral vaccines 58160-0825-52 1 syringe(s) 0.5 mL INJ - COA PMC - INJ PMC COST 50 9/13/2022 0:00 25 25 0 134 Formulary 0 636 90633 yellow fever vaccine "yellow fever vaccine, live 0.5mL vial" 8327122 42606327 60006561559 60006561559 yelfev viral vaccines 49281-0915-01 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 167.73 12/12/2022 21:39 167.73 167.73 0 450 Formulary 0 636 90717 hepatitis A pediatric vaccine hepatitis A peds vaccine 25 Unit(s)/0.5mL (VFC) 8320228 32430472 60006561567 60006561567 hep25vfc viral vaccines 00006-4095-02V 1 vial(s) 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 11/22/2021 0:00 0.01 0.01 0 0.01 Formulary 0 636 90633 SL diphtheria/tetanus/pertussis (DTaP) ped diphtheria/tetanus/pertussis (DTaP) peds (VFC) 0.5mL syringe 8320241 32432649 60006561658 60006561658 dipvfc vaccine combinations 58160-0810-11V 1 syringe(s) 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 10/11/2023 8:38 0.01 0.01 0 0.01 Formulary 0 636 90700 SL measles/mumps/rubella virus vaccine measles/mumps/rubella virus vacc 0.5mL (VFC) 8320232 32430971 60006561674 60006561674 meavfc vaccine combinations 00006-4681-00V 1 EA 1 EA INJ - COA PMC - DIRECT COST PMC COST 0.01 11/22/2021 7:28 0.01 0.01 0 0.01 Formulary 0 636 90707 SL "poliovirus vaccine, inactivated" poliovirus vaccine 0.5mL (VFC) 8320236 32431355 60006561690 60006561690 polvfc viral vaccines 49281-0860-10V 1 EA 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 11/22/2021 11:24 0.01 0.01 0 0.01 Formulary 0 636 90713 SL varicella virus vaccine varicella virus vacc 0.5mL (VFC) 8320239 32431643 60006561708 60006561708 varvfc viral vaccines 00006-4827-00V 1 vial(s) 1 EA INJ - COA PMC - DIRECT COST PMC COST 0.01 11/22/2021 11:58 0.01 0.01 0 0.01 Formulary 0 636 90716 SL "diphtheria/hepB/pertussis,acel/polio/tet" "diphth/hepB/pertuss,acel/polio/tetanus vacc 0.5mL (VFC)" 8320233 32431074 60006561757 60006561757 dipvfc vaccine combinations 58160-0811-52V 1 syringe(s) 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 11/22/2021 0:00 0.01 0.01 0 0.01 Formulary 0 636 90723 SL hepatitis B pediatric vaccine hepatitis B peds vacc 10mcg/0.5mL (VFC) 8320240 32432159 60006561773 60006561773 hep10vfc viral vaccines 58160-0820-11V 1 EA 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 2/18/2022 16:53 0.01 0.01 0 0.01 Formulary 0 636 90744 SL lidocaine topical lidocaine 2% jelly uroject 20mL 8317970 1005845 60006561864 60006561864 lid2uroject topical anesthetics 76329-3015-05 1 syringe(s) 20 mL MED - COA PMC - MED PMC COST 0.45676 1/12/2024 7:09 9.1352 9.1352 0 58.4 Formulary 0 259 meropenem meropenem 500 mg vial 8320928 35472075 60006561906 60006561906 mer500 carbapenems 55150-0207-20 1 vial(s) 1 EA IVPB - COA PMC - INJ PMC COST 1.741 1/1/2022 9:20 1.741 1.741 0.35 28.2 Formulary J2185 Meropenem 5 636 palonosetron palonosetron 0.05mg/mL 5mL vial 8317999 1077534 60006561914 60006561914 pal 5ht3 receptor antagonists 70860-0785-05 1 vial(s) 5 mL INJ - COA PMC - INJ PMC COST 1.122 1/12/2024 7:09 5.61 5.61 0.56 42.7 Formulary J2469 Palonosetron HCl 10 636 diltiaZEM diltiaZEM 5 mg/mL 25mL soln 8335029 154200953 60006562029 60006562029 dil5inj25mL. calcium channel blocking agents 00641-6015-10 1 vial(s) 25 mL LVP - COA PMC - INJ PMC COST 0.30076 12/28/2023 16:23 7.519 7.519 0 54.2 Formulary 0 259 niCARdipine niCARdipine 2.5mg/mL 10mL vial 8318580 7707667 60006562151 60006562151 niC2.5i calcium channel blocking agents 00143-9689-10 1 vial(s) 10 mL LVP - COA PMC - INJ PMC COST 0.917 4/6/2023 15:33 9.17 9.17 0.04 64.1 Formulary J2404 "Injection, nicardipine, 0.1 mg" 250 636 Non-Formulary Medication nonformulary oral medication 8316101 697827 60006562813 DONOTLOAD NFpo 10000-1111-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0 10/10/2023 17:01 0 0 0 0 TNF 0 637 Non-Formulary Medication nonformulary bulk medication 8316098 697818 60006562821 DONOTLOAD NFbulk 10000-1111-02 1 EA 1 EA Bulk PMC - MED PMC COST 0 10/10/2023 16:58 0 0 0 0 TNF 0 637 Non-Formulary Medication nonformulary injectable medication 8316099 697821 60006562839 DONOTLOAD NFinj1 miscellaneous agents 10000-1111-03 1 EA 1 EA INJ - COA PMC - INJ PMC COST 0 10/10/2023 17:01 0 0 0 0 TNF 0 259 Non-Formulary Medication nonformulary chemo injection 8318513 6705695 60006562839 DONOTLOAD NFinjchemo 00001-0001-58 1 EA 1 EA INJ - COA PMC - INJ PMC COST 0 10/10/2023 17:02 0 0 0 0 TNF 0 259 Miscellaneous Medication miscellaneous medication 8334746 86846672 60006562839 DONOTLOAD miscmed 11111-1111-19 1 EA 1 EA MED - COA PMC - MED PMC COST 0 10/10/2023 17:07 0 0 0 0 TNF 0 637 OLANZapine OLANZapine 10mg vial (G/K) 8316191 695286 60006562862 60006562862 ola10vial antipsychotics 00781-9105-72 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 13.92 1/8/2024 7:47 13.92 13.92 0.7 92.6 Formulary J2359 "J2359 Injection, olanzapine, 0.5 mg" 20 636 JZ tacrolimus tacrolimus 0.5mg capsule 8317901 847375 60006562987 60006562987 tac0.5 immunosuppressive agents 00781-2102-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.6 12/30/2021 11:49 0.6 0.6 0.6 11.3 Formulary J7507 Tacrolimus imme rel oral 1mg 1 636 insulin aspart insulin aspart 100 Unit(s)/mL per unit 8316134 691900 60006563001 60006563001 insasp insulin 00169-7501-11 1 EA 0.01 mL MDV INJ - COA PMC - INJ PMC COST 4.408 11/11/2021 9:52 0.04408 0.04408 0.22 10 Formulary J1815 Insulin injection 0.2 637 insulin glargine insulin glargine 100 Unit(s)/mL per 1 unit 8317408 689133 60006563019 60006563019 insgla insulin 00088-2220-33 1 EA 0.01 mL INJ - COA PMC - INJ PMC COST 7.803 11/11/2021 9:52 0.07803 0.07803 0.39 10.1 Formulary J1815 Insulin injection 0.2 637 insulin regular insulin Regular 100 Unit(s)/mL per unit (10mL) 8316140 692137 60006563068 60006563068 insreg10mL insulin 00169-1833-11 1 EA 0.01 mL INJ - COA PMC - INJ PMC COST 1.295 1/12/2024 7:09 0.01295 0.01295 0.06 10 Formulary J1815 Insulin injection 0.2 637 citalopram citalopram 10mg tablet 8317977 1009992 60006563142 60006563142 cit10 ssri antidepressants 00904-6084-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0621 12/28/2023 15:21 0.0621 0.0621 0 10 Formulary 0 637 glycerin glycerin suppository pediatric 8317244 696792 60006563209 60006563209 glypediatric laxatives 58980-0409-12 1 EA 1 EA MED - COA PMC - DIRECT COST PMC COST 0.36 1/8/2024 7:47 0.36 0.36 0 0.36 Formulary 0 637 cefTRIAXone cefTRIAXone 2gm vial 8316633 694854 60006563217 60006563217 ceftri2 third generation cephalosporins 00409-7335-03 1 vial(s) 1 EA IVPB - COA PMC - INJ PMC COST 2.892 12/28/2023 15:10 2.892 2.892 0.36 38 Formulary J0696 Ceftriaxone sodium injection 8 636 fulvestrant fulvestrant 50 mg/mL 5mL syringe (G/K) 8318000 1078037 60006563340 60006563340 fulv250 antineoplastic hormones 00310-0720-10 1 syringe(s) 5 mL MED - COA PMC - INJ PMC COST 189.057 1/12/2024 7:09 945.285 945.285 94.53 1899.6 Formulary J9395 "Injection, fulvestrant" 10 636 JZ metoprolol metoprolol 25mg tablet 8318104 1366543 60006563571 60006563571 metop25 "beta blockers, cardioselective" 00378-0018-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.0209 11/30/2021 23:09 0.0209 0.0209 0 10 Formulary 0 637 ondansetron ondansetron 4mg ODT tablet 8318099 1357377 60006563977 60006563977 ond4odt 5ht3 receptor antagonists 68462-0157-13 1 EA 1 EA MED - COA PMC - MED PMC COST 0.183 1/8/2024 7:47 0.183 0.183 0 10 Formulary 0 637 meningococcal conjugate vaccine meningococcal conjugate (Menactra) vaccine 8333409 68654586 60006564082 60006564082 men bacterial vaccines 49281-0589-05 1 syringe(s) 0.5 mL INJ - COA PMC - INJ PMC COST 165 9/13/2022 0:00 82.5 82.5 0 300 Formulary 0 636 90734 DULoxetine DULoxetine 20mg capsule 8318134 1666344 60006564116 60006564116 dul20 ssnri antidepressants 00904-7043-04 1 EA 1 EA MED - COA PMC - MED PMC COST 0.806 12/28/2023 16:51 0.806 0.806 0 14 Formulary 0 637 DULoxetine DULoxetine 30mg capsule 8318135 1666425 60006564124 60006564124 dul30 ssnri antidepressants 00904-7044-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.9038 12/28/2023 16:52 0.9038 0.9038 0 15.3 Formulary 0 637 fluticasone fluticasone CFC free 220mcg inhaler 12gm 8333421 68656753 60006564165 60006564165 fluti220 inhaled corticosteroids 66993-0080-96 1 EA 12 gm Bulk PMC - MED PMC COST 20.75833 1/12/2024 7:09 249.09996 249.09996 0 501.7 Formulary 0 637 tetanus/diphth/pertuss (Tdap) adult/adol tetanus/diphth/pertuss acel (Tdap) 8333418 68656024 60006564470 60006564470 Tdapbc vaccine combinations 58160-0842-52 1 EA 0.5 mL INJ - COA PMC - INJ PMC COST 69.562 1/8/2024 7:47 34.781 34.781 0 183 Formulary 0 636 90715 nonformulary IVPB nonformulary IVPB medication 8318175 2290949 60006564496 DONOTLOAD NFivpb 10000-1111-12 1 EA 1 EA IVPB - COA PMC - INJ PMC COST 0 10/10/2023 17:01 0 0 0 0 TNF 0 259 DAPTOmycin DAPTOmycin 500mg vial 8318226 2872416 60006564868 60006564868 dap500 miscellaneous antibiotics 25021-0174-15 1 vial(s) 1 EA IVPB - COA PMC - INJ PMC COST 23.31 12/28/2023 0:00 23.31 23.31 0.05 125.6 Formulary J0878 Daptomycin injection 500 636 measles/mumps/rubella/varicella virus va measles/mumps/rubella/varicella virus vaccine vial (G/K) 8320634 34936556 60006565014 60006565014 proquad vaccine combinations 00006-4171-00 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 255 9/13/2022 0:00 255 255 0 519 Formulary 0 636 90710 JZ lidocaine-prilocaine topical lidocaine-prilocaine 2.5-2.5% cream 5gm 8344298 313096493 60006565071 60006565071 emla5gm topical anesthetics 62332-0582-04 1 tube 5 gm Bulk PMC - MED PMC COST 1.1008 12/29/2023 10:05 5.504 5.504 0 40 Formulary 0 637 fentaNYL fentaNYL patch 12mcg/hr 8318289 3727242 60006565576 60006565576 fen12 narcotic analgesics 00378-9119-98 1 EA 1 EA MED - COA PMC - MED PMC COST 9.16 1/8/2024 7:47 9.16 9.16 0 58.5 Formulary 0 637 tetanus/diphth/pertuss (Tdap) adult/adol tetanus/diphth/pertuss acel (Tdap) (VFC) 8320099 32074437 60006565584 60006565584 Tdapvfcbc toxoids 58160-0842-52V 1 EA 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 11/22/2021 7:25 0.01 0.01 0 0.01 Formulary 0 636 90715 SL acetylcysteine acetylcysteine 0.2gm/mL 30mL inj 8318294 3807431 60006565600 60006565600 aceinj respiratory inhalant products 63323-0963-30 1 vial(s) 30 mL MED - COA PMC - INJ PMC COST 1.49667 11/11/2021 9:52 44.9001 44.9001 0.75 200 Formulary J0132 Acetylcysteine injection 60 636 meningococcal conjugate vaccine meningococcal conj (Menactra) vacc 0.5mL (VFC) 8333414 68655509 60006565642 60006565642 menvfc bacterial vaccines 49281-0589-05V 1 vial(s) 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 2/18/2022 15:10 0.01 0.01 0 0.01 Formulary 0 636 90734 SL acetaminophen-HYDROcodone acetaminophen-HYDROcodone 325-5mg tab 8318301 4063168 60006565667 60006565667 hydrocod5 narcotic analgesic combinations 00406-0123-62 1 EA 1 EA MED - COA PMC - MED PMC COST 0.3895 1/12/2024 7:09 0.3895 0.3895 0 10 Formulary 0 637 tetanus-diphth toxoids (Td) adult/adol tetanus-diphtheria (Tenivac) 5-2LFU/ 0.5mL 7 years and over 8318083 1343630 60006565741 60006565741 td 49281-0215-15 1 syringe(s) 0.5 mL INJ - COA PMC - INJ PMC COST 69.28 11/15/2021 9:47 34.64 34.64 0 182.2 Formulary 0 636 90714 sucralfate sucralfate 1gm/10mL susp 10mL UD 8318331 4823854 60006565972 60006565972 suc1ud miscellaneous gi agents 00904-7269-18 1 EA 10 mL MED - COA PMC - MED PMC COST 0.5225 1/12/2024 7:09 5.225 5.225 0 40 Formulary 0 637 measles/mumps/rubella/varicella virus va measles/mumps/rubella/varicella vacc 0.5mL (VFC) (G/K) 8320235 32431273 60006566137 60006566137 meavfc vaccine combinations 00006-4171-00V 1 EA 1 EA INJ - COA PMC - DIRECT COST PMC COST 0.01 2/18/2022 16:29 0.01 0.01 0 0.01 Formulary 0 636 90710 JZ rotavirus vaccine rotavirus vaccine pentavalent 2mL oral soln (VFC) 8320237 32431439 60006566145 60006566145 rotpentavalentvfc viral vaccines 00006-4047-41V 1 EA 2 mL MED - COA PMC - DIRECT COST PMC COST 0.005 2/18/2022 16:42 0.01 0.01 0 0.01 Formulary 0 636 90680 SL levETIRAcetam levETIRAcetam 100mg/mL 5mL vial 8318476 6283170 60006567895 60006567895 leve500I miscellaneous anticonvulsants 63323-0400-44 1 vial(s) 5 mL INJ - COA PMC - INJ PMC COST 0.3116 11/11/2021 9:52 1.558 1.558 0.03 26.2 Formulary J1953 Levetiracetam injection 50 636 sodium chloride sodium chloride PF (Sterile) 0.9% 10mL syringe 8318945 11396750 60006568000 60006568000 salineflushSTERILE minerals and electrolytes 08290-3065-53 1 syringe(s) 10 mL INJ - COA PMC - INJ PMC COST 0.042 11/15/2021 9:49 0.42 0.42 0 14.5 Formulary 0 259 hepatitis A-hepatitis B vaccine hep A-hepB vacc 720 units-20 mcg/mL 8327173 43462837 60006568349 60006568349 hepABvac vaccine combinations 58160-0815-52 1 syringe(s) 1 mL INJ - COA PMC - INJ PMC COST 115 9/22/2022 0:00 115 115 0 354 Formulary 0 636 90636 nitrofurantoin nitrofurantoin monohydrate 100mg cap 8318534 7303204 60006568414 60006568414 nit100bid urinary anti-infectives 00904-7137-61 1 EA 1 EA MED - COA PMC - MED PMC COST 1.78 12/4/2023 13:33 1.78 1.78 0 23.1 Formulary 0 637 potassium chloride potassium chloride 10mEq ER tab 8318582 7835224 60006568612 60006568612 pot10tab minerals and electrolytes 00904-7216-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.219 1/12/2024 7:09 0.219 0.219 0 10 Formulary 0 637 abatacept abatacept 250mg inj (G/K) 8318568 7393351 60006568620 60006568620 aba250 antirheumatics 00003-2187-13 1 EA 1 EA LVP - COA PMC - INJ PMC COST 1345.4 11/11/2021 9:52 1345.4 1345.4 53.82 2699.8 Formulary J0129 Abatacept injection 25 636 JZ Sodium Chloride 0.9% sodium chloride 0.9% 100mL 8317286 697254 60006568984 60006568984 NS100 00264-1800-32 1 bag 100 mL IVPB - COA PMC - IV FLUIDS PMC COST 0.0164 11/22/2021 17:52 1.64 1.64 0 28 Formulary 0 259 Sodium Chloride 0.9% sodium chloride 0.9% 50mL 8317304 697385 60006568992 60006568992 NS50 intravenous nutritional products 00264-1800-31 1 bag 50 mL IVPB - COA PMC - IV FLUIDS PMC COST 0.02 11/30/2021 8:55 1 1 0 28 Formulary 0 259 Sodium Chloride 0.9% sodium chloride 0.9% 250mL 8317294 697316 60006569008 60006569008 NS250 00409-7983-02 1 bag 250 mL IVPB - COA PMC - IV FLUIDS PMC COST 0.00668 11/15/2021 9:49 1.67 1.67 1.67 28 Formulary J7050 Normal saline solution infus 250 cc 1 636 Dextrose 5% in Water intravenous solutio dextrose 5% water 100mL 8316818 685072 60006569024 60006569024 D5100 intravenous nutritional products 00264-1510-32 1 bag 100 mL IVPB - COA PMC - IV FLUIDS PMC COST 0.0092 11/29/2021 12:53 0.92 0.92 0 28 Formulary 0 259 Sodium Chloride 0.9% sodium chloride 0.9% 500mL 8317301 697362 60006569032 60006569032 NS500 intravenous nutritional products 00264-7800-10 1 bag 500 mL LVP - COA PMC - IV FLUIDS PMC COST 0.00394 11/15/2021 10:10 1.97 1.97 1.97 28 Formulary J7040 Normal saline solution infus sterile 1 636 Sodium Chloride 0.9% sodium chloride 0.9% 1000mL 8317283 697229 60006569081 60006569081 NS1000 00264-7800-00 1 bag 1000 mL LVP - COA PMC - IV FLUIDS PMC COST 0.00158 11/15/2021 10:11 1.58 1.58 1.58 28 Formulary J7030 Normal saline solution infus 1000 cc 1 636 Patient's Own Medication Patient's Own Medication 8316141 692168 60006569271 DONOTLOAD POM 10000-0010-00 1 EA 1 EA Patient's Own Med No Charge AWP 0 1/30/2004 10:18 0 0 0 0 TNF 0 9999 influenza vaccine-contraindicated vaccine influenza contraindicated 8320768 35372994 60006569271 8300303063 vacinfcon 00000-0002-01 1 EA 1 EA MED - COA No Charge AWP 0 1/4/2012 10:55 0 0 0 0 Formulary 0 9999 influenza vaccine-refused vaccine influenza refused 8320770 35373318 60006569271 8300303062 vacinfref 00000-0002-02 1 EA 1 EA MED - COA No Charge AWP 0 1/4/2012 13:00 0 0 0 0 Formulary 0 9999 pneumococcal 23-valent vaccine-contraind vaccine pneumococcal 23-valent contraindicated 8320771 35373366 60006569271 DONOTLOAD vacpne23con 00000-0002-03 1 EA 1 EA MED - COA No Charge AWP 0 1/4/2012 13:03 0 0 0 0 Formulary 0 9999 pneumococcal 23-valent vaccine-refused* vaccine pneumococcal 23-valent refused 8320772 35373414 60006569271 DONOTLOAD vacpne23ref 00000-0002-04 1 EA 1 EA MED - COA No Charge AWP 0 1/4/2012 13:05 0 0 0 0 Formulary 0 9999 pneumococcal 13-valent vaccine-refused* vaccine pneumococcal 13-valent refused 8327363 46758132 60006569271 DONOTLOAD vacpne13ref 00000-0002-05 1 EA 1 EA MED - COA No Charge AWP 0 11/7/2013 16:52 0 0 0 0 Formulary 0 9999 patient refused immunization patient refused immunization 8334672 84583977 60006569271 DONOTLOAD vacref 00000-0002-08 1 EA 1 EA MED - COA No Charge AWP 0 2/25/2015 10:53 0 0 0 0 Formulary 0 9999 tetanus diphtheria vaccine - refused tetanus diphtheria-refused 8339229 252431594 60006569271 DONOTLOAD vactdref 00000-0002-09 1 EA 1 EA MED - COA No Charge AWP 0 3/30/2018 13:43 0 0 0 0 Formulary 0 9999 tetanus diphtheria - contraindicated* tetanus diphtheria contraindicated 8339253 253700777 60006569271 DONOTLOAD vactetcon 00000-0002-10 1 EA 1 EA MED - COA No Charge AWP 0 4/11/2018 11:26 0 0 0 0 Formulary 0 9999 tetanus/diphth/adacel/pertuss-contraindi tetanus/diphth/adacel/pertuss contraindicated 8339255 253703574 60006569271 DONOTLOAD vactdapcon 00000-0002-11 1 EA 1 EA MED - COA No Charge AWP 0 4/11/2018 15:52 0 0 0 0 Formulary 0 9999 tetanus diphtheria and pertussis - refus "TDAP (tetanus, diphtheria and pertussis) - refused" 8341360 274260967 60006569271 DONOTLOAD vactdapref 00000-0002-12 1 EA 1 EA MED - COA No Charge AWP 0 11/14/2018 19:21 0 0 0 0 Formulary 0 9999 alteplase alteplase 2mg vial (Cathflo) (G/K) 8316183 694930 60006570295 60006570295 alt2t thrombolytics 50242-0041-64 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 154.06 11/11/2021 9:52 154.06 154.06 77.03 450 Formulary J2997 Alteplase recombinant 2 636 JZ etomidate etomidate 2mg/mL 10mL vial 8318812 9509219 60006570329 60006570329 eto20amp general anesthetics 55150-0221-10 1 amp 10 mL INJ - COA PMC - INJ PMC COST 0.2477 11/11/2021 9:52 2.477 2.477 0 33.8 Formulary 0 259 darbepoetin alfa darbepoetin 40mcg/0.4mL syringe (G/K) 8318828 9745968 60006570485 60006570485 dar40syr erythropoiesis-stimulating agents 55513-0021-04 1 syringe(s) 0.4 mL MED - COA PMC - INJ PMC COST 399.9625 11/11/2021 9:52 159.985 159.985 4 450 Formulary J0881 "Darbepoetin alfa, non-ESRD" 40 636 JZ darbepoetin alfa darbepoetin 60mcg/0.3mL syringe (G/K) 8318829 9746101 60006570493 60006570493 dar60syr erythropoiesis-stimulating agents 55513-0023-04 1 syringe(s) 0.3 mL INJ - COA PMC - INJ PMC COST 799.933 11/11/2021 9:52 239.9799 239.9799 4 489 Formulary J0881 "Darbepoetin alfa, non-ESRD" 60 636 JZ darbepoetin alfa darbepoetin 100mcg/0.5mL syringe (G/K) 8318830 9746234 60006570501 60006570501 dar100syr erythropoiesis-stimulating agents 55513-0025-04 1 syringe(s) 0.5 mL MED - COA PMC - INJ PMC COST 822.57 11/11/2021 9:52 411.285 411.285 4.11 831.6 Formulary J0881 "Darbepoetin alfa, non-ESRD" 100 636 JZ darbepoetin alfa darbepoetin 200mcg/0.4mL syringe (G/K) 8318832 9746497 60006570519 60006570519 dar200mcgsyr erythropoiesis-stimulating agents 55513-0028-01 1 syringe(s) 0.4 mL MED - COA PMC - INJ PMC COST 2056.425 11/11/2021 9:52 822.57 822.57 4.11 1654.2 Formulary J0881 "Darbepoetin alfa, non-ESRD" 200 636 JZ "diphtheria/pertussis,acel/tetanus/polio" diphtheria/pertussis/tetanus/polio peds (Kinrix) 0.5mL 8320622 34922755 60006570550 60006570550 kinrix0.5mL vaccine combinations 58160-0812-52 1 syringe(s) 0.5 mL INJ - COA PMC - INJ PMC COST 52.64 11/15/2021 10:13 26.32 26.32 0 140.6 Formulary 0 636 90696 hepatitis B adult vaccine hepatitis B vaccine adult 20mcg/mL 8318673 8591599 60006570626 60006570626 hepb20 viral vaccines 58160-0821-52 1 syringe(s) 1 mL INJ - COA PMC - INJ PMC COST 73 11/15/2021 10:14 73 73 0 301 Formulary 0 636 90746 diphth/haemophilus/pertussis/tetanus/pol diphth/haemophilus/pertussis/tetanus/polio (VFC) peds 0.5mL syringe 8320650 35012363 60006570642 DONOTLOAD pentacelVFC vaccine combinations 49281-0510-05V 1 vial(s) 1 EA INJ - COA PMC - DIRECT COST PMC COST 0.01 2/18/2022 16:04 0.01 0.01 0 0.01 Formulary 0 636 90698 SL PACLitaxel protein-bound PACLitaxel protein-bound 5mg/mL 20ml vial (G/K) 8318585 8035247 60006570733 60006570733 pac100 mitotic inhibitors 68817-0134-50 1 vial(s) 1 EA CHEMO IVPB - COA PMC - INJ PMC COST 1540.56 11/1/2022 16:08 1540.56 1540.56 15.41 3090.2 Formulary J9264 Paclitaxel protein bound 100 636 JZ ciprofloxacin ciprofloxacin 200mg/100mL D5W 8318856 10164823 60006570915 60006570915 cip200pb quinolones 00409-2300-24 1 bag 100 mL IVPB - COA PMC - IV FLUIDS PMC COST 0.02091 12/28/2023 15:19 2.091 2.091 2.09 28 Formulary J0744 Ciprofloxacin IV 1 636 oxymetazoline nasal oxymetazoline 0.05% nasal 15mL 8320583 34264633 60006571749 60006571749 oxymet15 nasal antihistamines and decongestants 41100-0811-27 1 bottle 15 mL Bulk PMC - DIRECT COST PMC COST 0.45067 1/12/2024 7:09 6.76005 6.76005 0 6.76 Formulary 0 637 cefdinir cefdinir 300mg capsule 8318758 8727678 60006572036 60006572036 cef300 third generation cephalosporins 60687-0699-21 1 EA 1 EA MED - COA PMC - MED PMC COST 2.549 12/28/2023 13:27 2.549 2.549 0 29 Formulary 0 637 ethyl chloride topical ethyl chloride topical spray per DOSE 8319054 13784879 60006572150 60006572150 ethylchloride topical anesthetics 00386-0001-02 1 EA 2 mL MED - COA PMC - MED PMC COST 0.26686 1/12/2024 7:09 0.53372 0.53372 0 10.5 Formulary 0 259 sorbitol sorbitol 70% solution 30mL UD 8318952 11616572 60006572267 60006572267 sor70soln laxatives 46287-0500-30 1 EA 30 mL MED - COA PMC - MED PMC COST 0.0545 11/11/2021 9:52 1.635 1.635 0 21.5 Formulary 0 637 heparin flush heparin 10 Unit(s)/mL 5mL syringe 8319009 12480105 60006572937 60006572937 hep10flush heparins 08290-3064-14 1 syringe(s) 5 mL INJ - COA PMC - INJ PMC COST 0.00495 1/12/2024 7:09 0.02475 0.02475 0 10 Formulary J1642 Inj heparin sodium per 10 u 5 636 heparin flush heparin 100 Unit(s)/mL 5mL syringe 8319010 12480198 60006572945 60006572945 hep100flush heparins 08290-3064-24 1 syringe(s) 5 mL INJ - COA PMC - INJ PMC COST 0.00516 1/12/2024 7:09 0.0258 0.0258 0 10 Formulary J1642 Inj heparin sodium per 10 u 50 636 cholecalciferol cholecalciferol 25mcg (1000 IntlUnits) tab (OTC) 8319038 13358319 60006573000 60006573000 cho1000otc vitamins 57896-0876-01 1 EA 1 EA MED - COA PMC - DIRECT COST PMC COST 0.0105 1/8/2024 7:47 0.0105 0.0105 0 0.01 Formulary 0 637 adenosine adenosine 3mg/mL 20mL soln 8319041 13584160 60006573059 60006573059 ade3inj20 cardiac stressing agents 67457-0856-20 1 vial(s) 20 mL INJ - COA PMC - INJ PMC COST 1.7245 11/11/2021 9:52 34.49 34.49 0.57 181.5 Formulary J0153 Adenosine inj 1mg 60 636 "rabies vaccine, purified chick embryo ce" "rabies vacc, chick embryo, 2.5 Unit(s)/1mL (G/K)" 8316109 686935 60006573240 60006573240 rab viral vaccines 50632-0010-01 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 312.07 1/12/2024 7:09 312.07 312.07 0 633.2 Formulary 0 636 90675 JZ atropine atropine 1mg/10mL syringe 8316414 689760 60006573935 60006573935 atr0.1 anticholinergics/antispasmodics 00409-4911-34 1 syringe(s) 10 mL INJ - COA PMC - INJ PMC COST 1.258 11/11/2021 9:52 12.58 12.58 0.13 84.5 Formulary J0461 Atropine sulfate injection 100 636 pneumococcal 13-valent vaccine pneumococcal 13-valent vacc 0.5mL (VFC) 8320234 32431184 60006574891 60006574891 pnevfc bacterial vaccines 00005-1971-02V 1 EA 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 11/22/2021 7:27 0.01 0.01 0 0.01 Formulary 0 636 90670 SL haemophilus b conjugate (PRP-OMP) vaccin haemophilus b conjugate (PRP-OMP) vaccine 8318091 1352985 60006574925 60006574925 haeHIB bacterial vaccines 00006-4897-00 1 vial(s) 0.5 mL INJ - COA PMC - INJ PMC COST 25.18 11/15/2021 10:19 12.59 12.59 0 84.6 Formulary 0 636 90647 pneumococcal 13-valent vaccine pneumococcal 13-valent conjugate vacc 0.5mL 8320626 34923067 60006575476 60006575476 pne13 bacterial vaccines 00005-1971-02 1 EA 0.5 mL INJ - COA PMC - INJ PMC COST 526 11/15/2021 10:20 263 263 0 535 Formulary 0 636 90670 fluticasone-salmeterol fluticasone-salmeterol HFA 115-21mcg 8gm 8319380 26280694 60006575856 60006575856 flu115-21 bronchodilator combinations 00173-0716-22 1 EA 8 gm Bulk PMC - MED PMC COST 17.94125 1/19/2024 8:43 143.53 143.53 0 434.1 Formulary 0 637 lidocaine lidocaine PF 2% 100mg/5mL vial 8319399 27144298 60006575922 60006575922 lid100vial local injectable anesthetics 55150-0165-05 1 vial(s) 5 mL INJ - COA PMC - INJ PMC COST 0.184 1/8/2024 7:47 0.92 0.92 0.09 21 Formulary J2001 Lidocaine injection 10 636 Sodium Chloride 0.9% sodium chloride 0.9% PF 20mL vial 8322463 35883847 60006576078 60006576078 sod20 minerals and electrolytes 00409-4888-20 1 vial(s) 20 mL MED - COA PMC - INJ PMC COST 0.0572 1/10/2024 15:19 1.144 1.144 0 21.6 Formulary 0 259 HYDROmorphone HYDROmorphone 1mg/mL 1mL injection 8320688 35104329 60006576110 60006576110 hyd1 narcotic analgesics 76045-0009-11 1 syringe(s) 1 mL MED - COA PMC - INJ PMC COST 2.266 1/8/2024 7:47 2.266 2.266 2.27 31.7 Formulary J1170 Hydromorphone injection 1 636 denosumab denosumab 60 mg/mL 1mL syringe (G/K) 8334899 89011111 60006579098 60006579098 den60i miscellaneous bone resorption inhibitors 55513-0710-01 1 EA 1 mL INJ - COA PMC - INJ PMC COST 1409.19 11/11/2021 9:52 1409.19 1409.19 23.49 2827.4 Formulary J0897 Denosumab injection 60 636 JZ tocilizumab tocilizumab 20mg/mL 10mL (G/K) 8319188 22062134 60006580542 60006580542 toc200i immunosuppressive monoclonal antibodies 50242-0136-01 1 vial(s) 10 mL IVPB - COA PMC - INJ PMC COST 132.791 1/8/2024 7:47 1327.91 1327.91 6.64 2664.9 Formulary J3262 Tocilizumab injection 200 636 JZ tocilizumab tocilizumab 20mg/mL 20mL (G/K) 8319189 22062255 60006580559 60006580559 toc400i immunosuppressive monoclonal antibodies 50242-0137-01 1 vial(s) 20 mL IVPB - COA PMC - INJ PMC COST 112.408 11/11/2021 9:52 2248.16 2248.16 5.62 4505.4 Formulary J3262 Tocilizumab injection 400 636 JZ sodium ferric gluconate complex sodium ferric gluconate 62.5mg/5mL vial 8334124 70220785 60006580955 60006580955 sod12.5 iron products 00143-9570-10 1 vial(s) 5 mL IVPB - COA PMC - INJ PMC COST 5.528 1/12/2024 7:09 27.64 27.64 5.53 147.2 Formulary J2916 Na ferric gluconate complex 5 636 cholecalciferol cholecalciferol 50mcg (2000 IntlUnits) cap (OTC) 8320018 31851121 60006581102 60006581102 cho2000otc vitamins 54629-0909-70 1 EA 1 EA MED - COA PMC - DIRECT COST PMC COST 0.09 12/1/2021 0:33 0.09 0.09 0 0.09 Formulary 0 637 fosaprepitant fosaprepitant 150mg SDV 8320043 31924055 60006581227 60006581227 fos150 miscellaneous antiemetics 31722-0165-31 1 vial(s) 1 EA IVPB - COA PMC - INJ PMC COST 15.61 1/8/2024 8:33 15.61 15.61 0.1 102.7 Formulary J1453 Fosaprepitant injection 150 636 JG cefTAZidime cefTAZidime 2000mg vial 8316629 694803 60006581557 60006581557 ceftaz2 third generation cephalosporins 44567-0236-10 1 vial(s) 1 EA IVPB - COA PMC - INJ PMC COST 5.247 12/28/2023 15:06 5.247 5.247 1.31 40.5 Formulary J0713 Inj ceftazidime per 500 mg 4 636 eriBULin eriBULin mesylate 1mg/2mL SDV (G/K) 8333433 68658407 60006581698 60006581698 erib1 mitotic inhibitors 62856-0389-01 1 vial(s) 2 mL CHEMO IVPB - COA PMC - INJ PMC COST 6834 1/8/2024 7:47 13668 13668 1366.8 27345 Formulary J9179 Eribulin mesylate injection 10 636 JZ belimumab belimumab 120 mg vial (G/K) 8320347 33511577 60006581847 60006581847 bel120 blys-specific inhibitors 49401-0101-01 1 vial(s) 1 EA IVPB - COA PMC - INJ PMC COST 613.1 6/21/2022 15:03 613.1 613.1 51.09 1235.2 Formulary J0490 Belimumab injection 12 636 JZ magnesium sulfate magnesium sulfate 500mg/mL 10mL vial 8319067 13991776 60006581870 60006581870 magsuf10 minerals and electrolytes 63323-0064-11 1 vial(s) 10 mL IVPB - COA PMC - INJ PMC COST 0.12556 11/11/2021 9:52 1.2556 1.2556 0.13 22.9 Formulary J3475 Inj magnesium sulfate 10 636 denosumab denosumab 120mg/1.7 mL vial (G/K) 8320217 32407545 60006582431 60006582431 den120i miscellaneous bone resorption inhibitors 55513-0730-01 1 vial(s) 1.7 mL INJ - COA PMC - INJ PMC COST 1342.965 1/19/2022 8:53 2283.0405 2283.0405 19.03 4575.1 Formulary J0897 Denosumab injection 120 636 JZ phenylephrine ophthalmic phenylephrine 2.5% ophthalmic 2mL 8316805 692634 60006583447 60006583447 phe ophthalmic antihistamines and decongestants 70756-0629-25 1 bottle 2 mL Bulk PMC - MED PMC COST 11.81 1/12/2024 7:09 23.62 23.62 0 121.6 Formulary 0 259 belimumab belimumab 400 mg vial (G/K) 8320346 33511491 60006583512 60006583512 bel400 blys-specific inhibitors 49401-0102-01 1 vial(s) 1 EA IVPB - COA PMC - INJ PMC COST 2032.73 6/1/2022 0:00 2032.73 2032.73 50.82 4074.5 Formulary J0490 Belimumab injection 40 636 JZ tranexamic acid tranexamic acid 100mg/mL 10mL vial 8320584 34264765 60006584445 60006584445 tra100 miscellaneous coagulation modifiers 23155-0166-41 1 vial(s) 10 mL IVPB - COA PMC - INJ PMC COST 0.2134 1/8/2024 7:47 2.134 2.134 0 30.4 Formulary 0 259 rivaroxaban rivaroxaban 10mg tablet 8320589 34301201 60006584486 60006584486 riv10 factor xa inhibitors 50458-0580-10 1 tab(s) 1 EA MED - COA PMC - MED PMC COST 12.4399 1/12/2024 7:09 12.4399 12.4399 0 78.2 Formulary 0 637 meningococcal conjugate vaccine meningococcal conj (Menveo) vaccine 0.5mL 8320627 34923233 60006585673 60006585673 men0.5 bacterial vaccines 58160-0955-09 1 EA 1 EA INJ - COA PMC - INJ PMC COST 139.26 11/15/2021 10:21 139.26 139.26 0 426.8 Formulary 0 636 90734 potassium chloride potassium chloride 2mEq/mL 10mL inj 8322718 36903934 60006585707 60006585707 kcl20 minerals and electrolytes 63323-0965-10 1 vial(s) 10 mL LVP - COA PMC - INJ PMC COST 0.08528 11/11/2021 9:52 0.8528 0.8528 0.09 20.1 Formulary J3480 Inj potassium chloride 10 636 oseltamivir oseltamivir 6mg/mL 5mL UD susp 8323004 38801972 60006586507 60006586507 ose6susp neuraminidase inhibitors 47781-0384-26 1 syringe(s) 5 mL MED - COA PMC - MED PMC COST 0.4001 1/11/2024 10:20 2.0005 2.0005 0 23.6 Formulary 0 637 verapamil verapamil 2.5mg/mL 4mL inj 8323204 38869132 60006586515 60006586515 ver10t calcium channel blocking agents 00409-1144-02 1 vial(s) 4 mL INJ - COA PMC - INJ PMC COST 3.7845 11/11/2021 9:52 15.138 15.138 0 99.9 Formulary 0 259 apixaban apixaban 2.5mg tablet 8326497 40783384 60006587471 60006587471 api2.5 factor xa inhibitors 00003-0893-31 1 tab(s) 1 EA MED - COA PMC - MED PMC COST 8.574 12/28/2023 12:43 8.574 8.574 0 55 Formulary 0 637 apixaban apixaban 5mg tablet 8326498 40783484 60006587489 60006587489 api5 factor xa inhibitors 00003-0894-21 1 tab(s) 1 EA MED - COA PMC - MED PMC COST 7.62333 11/11/2021 9:52 7.62333 7.62333 0 49.3 Formulary 0 637 senna senna 8.6mg tab 8317820 695412 60006587927 60006587927 sen8.6 laxatives 57896-0454-01 1 EA 1 EA MED - COA PMC - DIRECT COST PMC COST 0.0142 11/30/2021 23:33 0.0142 0.0142 0 0.01 Formulary 0 637 hepatitis A pediatric vaccine hepatitis A peds vaccine 25 units/0.5 mL syringe 8320638 34987743 60006588263 60006588263 hep25 viral vaccines 00006-4095-02 1 vial(s) 0.5 mL INJ - COA PMC - INJ PMC COST 45 11/30/2021 9:04 22.5 22.5 0 121.5 Formulary 0 636 90633 doxycycline doxycycline monohydrate 100mg cap 8327239 44506362 60006588313 60006588313 doxmono100 tetracyclines 60687-0716-21 1 EA 1 EA MED - COA PMC - MED PMC COST 0.62367 12/28/2023 16:48 0.62367 0.62367 0 11.7 Formulary 0 637 albuterol albuterol HFA 8gm inhaler 8318283 3551157 60006589287 60006589287 albuterolHFA adrenergic bronchodilators 68180-0963-01 1 EA 8 gm Bulk PMC - MED PMC COST 2.2106 1/8/2024 7:47 17.6848 17.6848 0 109.7 Formulary 0 637 Sodium Chloride 0.45% sodium chloride 0.45% 1000mL 8317275 697160 60006589584 60006589584 1/2NS1000 intravenous nutritional products 00264-7802-00 1 bag 1000 mL LVP - COA PMC - IV FLUIDS PMC COST 0.0025 11/16/2023 0:00 2.5 2.5 0 28 Formulary 0 259 haemophilus b conjugate (PRP-OMP) vaccin haemophilus b conj (PRP-OMP) vacc (VFC) 0.5mL 8320230 32430731 60006589675 60006589675 haevfc bacterial vaccines 00006-4897-00V 1 vial(s) 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 11/22/2021 7:34 0.01 0.01 0 0.01 Formulary 0 636 90647 SL tbo-filgrastim tbo-filgrastim (Granix) 300mcg/0.5mL syringe (G/K) 8331292 60029900 60006589881 60006589881 tbo300 colony stimulating factors 63459-0910-11 1 syringe(s) 0.5 mL INJ - COA PMC - INJ PMC COST 370.28 11/11/2021 9:52 185.14 185.14 0.62 450 Formulary J1447 Inj tbo filgrastim 1 microg 300 636 JZ tetanus/diphth/pertuss (Tdap) adult/adol tetanus/diphth/pertuss (Adacel) (Tdap) (VFC) 8326503 40796154 60006590046 DONOTLOAD TdapAdacel vaccine combinations 49281-0400-20V 1 EA 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0 11/2/2022 12:15 0 0 0 0 Formulary 0 636 90715 SL enalapril enalaprilat 1.25mg/mL 1mL vial 8331346 61549814 60006590061 60006590061 enal1.25 angiotensin converting enzyme (ace) inhibitors 00143-9787-10 1 vial(s) 1 mL INJ - COA PMC - INJ PMC COST 3.985 11/11/2021 9:52 3.985 3.985 0 44.9 Formulary 0 259 Lactated Ringers Injection intravenous s lactated ringers 1000mL 8317607 694280 60006590087 60006590087 LR1000 00264-7750-00 1 bag 1000 mL LVP - COA PMC - IV FLUIDS PMC COST 0.0018 12/3/2021 9:23 1.8 1.8 1.8 28 Formulary J7120 Ringers lactate infusion 1 636 phenol topical phenol topical 89% swab 8320741 35282845 60006590251 60006590251 phe89 topical anesthetics 00884-6297-30 1 EA 1 EA MED - COA PMC - MED PMC COST 4.45433 11/11/2021 9:52 4.45433 4.45433 0 39.2 Formulary 0 637 dexamethasone dexamethasone 10mg/mL 10mL inj MDV 8322637 36559373 60006590525 60006590525 dexa10MDV glucocorticoids 63323-0516-10 1 EA 10 mL MDV Intermittent - COA PMC - INJ PMC COST 0.2291 11/11/2021 9:52 2.291 2.291 0.02 32 Formulary J1100 Dexamethasone sodium phos 100 636 rotavirus vaccine rotavirus vaccine pentavalent 2mL oral susp 8320623 34922842 60006590715 60006590715 rotpentavalent viral vaccines 00006-4047-20 1 syringe(s) 2 mL MED - COA PMC - INJ PMC COST 80.62 2/21/2023 9:34 161.24 161.24 0 450 Formulary 0 636 90680 zoledronic acid zoledronic acid 5mg/100mL soln 8318613 8473308 60006590723 60006590723 zoled5 bisphosphonates 55111-0688-52 1 bottle 100 mL IVPB - COA PMC - IV FLUIDS PMC COST 0.2548 1/12/2024 7:09 25.48 25.48 5.1 100 Formulary J3489 Zoledronic acid 1mg 5 636 "diphtheria/pertussis,acel/tetanus/polio" diphtheria/pertussis/tetanus/polio 0.5mL (VFC) 8320643 34996169 60006590749 60006590749 kinVFC vaccine combinations 58160-0812-52V 1 EA 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 2/18/2022 16:08 0.01 0.01 0 0.01 Formulary 0 636 90696 SL ferumoxytol ferumoxytol 30mg/mL 17mL vial (G/K) 8322577 36219726 60006590798 60006590798 fer30 iron products 00781-3154-01 1 EA 17 mL IVPB - COA PMC - INJ PMC COST 12.99412 1/12/2024 7:09 220.90004 220.90004 0.43 450.9 Formulary Q0138 "Ferumoxytol, non-ESRD" 510 636 JZ golimumab golimumab 50mg/4mL soln (G/K) 8334460 78111208 60006590909 60006590909 goli50 tnf alpha inhibitors 57894-0350-01 1 vial(s) 4 mL IVPB - COA PMC - INJ PMC COST 443.04 11/11/2021 9:52 1772.16 1772.16 35.44 3553.4 Formulary J1602 Golimumab for IV use 1mg 50 636 JZ diphtheria/tetanus/pertussis (DTaP) ped diphtheria/tetanus/pertussis (DTaP)(VFC) ped 0.5 mL susp 8327267 45219365 60006590928 DONOTLOAD dip15vfc vaccine combinations 49281-0286-10V 1 vial(s) 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 2/18/2022 15:19 0.01 0.01 0 0.01 Formulary 0 636 90700 SL human papillomavirus vaccine human papillomavirus vaccine 9-valent susp 0.5mL 8334923 150527614 60006590943 60006590943 hum9 viral vaccines 00006-4121-02 1 syringe(s) 0.5 mL INJ - COA PMC - INJ PMC COST 275 9/13/2022 0:00 137.5 137.5 0 421.5 Formulary 0 636 90651 human papillomavirus vaccine human papillomavirus vaccine 9-valent (VFC) susp 0.5mL 8334941 151279080 60006590945 60006590945 hum9VFC viral vaccines 00006-4121-02V 1 EA 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 11/22/2021 7:30 0.01 0.01 0 0.01 Formulary 0 636 90651 SL heparin "heparin 5,000 units/mL 1mL inject" 8317287 697413 60006590956 60006590956 hep5000inj heparins 71288-0422-96 1 syringe(s) 1 mL INJ - COA PMC - INJ PMC COST 0.8264 1/8/2024 7:47 0.8264 0.8264 0.17 19.8 Formulary J1644 Inj heparin sodium per 1000u 5 636 meningococcal group B vaccine meningococcal group B (Bexsero) vaccine recombinant 0.5mL 8335186 157561325 60006590978 60006590978 menBex0.5 bacterial vaccines 58160-0976-20 1 syringe(s) 0.5 mL INJ - COA PMC - INJ PMC COST 275 9/13/2022 0:00 137.5 137.5 0 421.5 Formulary 0 636 90620 leuprolide leuprolide 45mg/6month kit (URO) (G/K) 8322900 38190302 60006590997 60006590997 leu45uro antineoplastic hormones 00074-3473-03 1 EA 1 EA MED - COA PMC - INJ PMC COST 10714.72 1/8/2024 7:47 10714.72 10714.72 1785.79 21438.5 Formulary J9217 Leuprolide acetate suspnsion 6 636 JZ leuprolide leuprolide 7.5mg kit (URO) (G/K) 8317500 692065 60006591001 60006591001 leu7.5 antineoplastic hormones 00074-3642-03 1 EA 1 EA MED - COA PMC - INJ PMC COST 1785.76 1/12/2024 7:09 1785.76 1785.76 1785.76 3580.6 Formulary J9217 Leuprolide acetate suspnsion 1 636 JZ bacitracin topical bacitracin 500 Unit(s)/gm oint 28gm 8335646 171685160 60006591029 60006591029 baczinc28gm topical antibiotics 00536-1256-28 1 tube 28.35 gm Bulk PMC - DIRECT COST PMC COST 0.05933 12/28/2023 13:07 1.68201 1.68201 0 1.68 Formulary 0 637 guaiFENesin guaiFENesin 100mg/5mL liq 5mL UD 8335752 176967443 60006591050 60006591050 guaif100UD expectorants 00121-1744-00 1 EA 5 mL MED - COA PMC - DIRECT COST PMC COST 0.36062 1/19/2024 12:16 1.8031 1.8031 0 1.8 Formulary 0 637 meningococcal group B vaccine meningococcal group B (Bexsero) vaccine recombinant 0.5mL (VFC) 8335771 177709721 60006591058 60006591058 menBexVFC bacterial vaccines 58160-0976-20V 1 EA 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 2/18/2022 14:35 0.01 0.01 0 0.01 Formulary 0 636 90620 SL diatrizoate RAD diatrizoate 66%-10% 30mL soln 8335883 178090445 60006591072 DONOTLOAD RAD diatrizoate (Gastrografin) 66%-10% 30mL soln B ionic iodinated contrast media 00270-0445-35 1 bottle 30 mL MED - COA PMC - DIRECT COST PMC COST 0 12/1/2021 0:00 0 0 0 0 Formulary Q9963 "HOCM 350-399mg/ml iodine,1ml" 30 636 iopamidol RAD iopamidol 76% 100mL soln 8335914 178452672 60006591087 DONOTLOAD RAD iopamidol (Isovue-370) 76% 100mL soln BC non-ionic iodinated contrast media 00270-1316-35 1 vial(s) 100 mL INJ - COA PMC - DIRECT COST PMC COST 0 12/1/2021 0:00 0 0 0 0 Formulary Q9967 "LOCM 300-399mg/ml iodine,1ml" 100 636 gadoteridol RAD gadoteridol 279.3mg/mL 20mL soln 8336121 182636850 60006591113 DONOTLOAD RAD gadoteridol (Prohance) 279.3mg/mL 20mL soln BC magnetic resonance imaging contrast media 00270-1111-03 1 vial(s) 20 mL INJ - COA PMC - DIRECT COST PMC COST 0 12/29/2021 10:04 0 0 0 0 Formulary A9579 "Gad-base MR contrast NOS,1ml" 20 636 ciprofloxacin ophthalmic ciprofloxacin ophthalmic 0.3% 5mL soln 8336169 184111224 60006591125 60006591125 cip0.3 ophthalmic anti-infectives 69315-0308-05 1 bottle 5 mL Bulk PMC - MED PMC COST 1.964 11/11/2021 9:52 9.82 9.82 0 62.5 Formulary 0 259 brimonidine-timolol ophthalmic brimonidine-timolol 0.2%-0.5% ophth 5mL soln 8322485 35921901 60006591138 60006591138 com5 ophthalmic glaucoma agents 00023-9211-05 1 bottle 5 mL MED - COA PMC - MED PMC COST 44.258 12/30/2021 11:53 221.29 221.29 0 450 Formulary 0 637 benoxinate-fluorescein ophthalmic benoxinate-fluorescein 0.4%-0.25% ophth 5mL soln 8336295 187120856 60006591141 60006591141 benofluo ophthalmic diagnostic agents 59390-0218-05 1 bottle 5 mL Bulk PMC - MED PMC COST 4.032 11/11/2021 9:52 20.16 20.16 0 120 Formulary 0 259 ustekinumab ustekinumab 5mg/mL 26mL vial (G/K) 8337805 206507964 60006591229 60006591229 ustek130 57894-0054-27 1 vial(s) 26 mL IVPB - COA PMC - INJ PMC COST 74.1208 1/8/2024 7:47 1927.1408 1927.1408 14.82 3863.3 Formulary J3358 "Ustekinumab, IV inject, 1 mg" 130 636 JZ sodium chloride sodium chloride 3% neb conc 4mL 8337938 210155474 60006591243 60006591243 sod3%4mL minerals and electrolytes 76204-0022-60 1 EA 4 mL MED - COA PMC - MED PMC COST 0.09833 1/12/2024 7:09 0.39332 0.39332 0 10 Formulary 0 637 iopamidol RAD iopamidol 76% 125mL soln 8338000 213231769 60006591249 DONOTLOAD RAD iopamidol (Isovue-370) 76% 125mL soln BC non-ionic iodinated contrast media 00270-1316-04 1 vial(s) 125 mL INJ - COA PMC - DIRECT COST PMC COST 0 10/10/2023 17:22 0 0 0 0 Formulary Q9967 "LOCM 300-399mg/ml iodine,1ml" 125 636 sulfamethoxazole-trimethoprim sulfa-trimethoprim 200 mg-40 mg/5mL 473mL oral susp MDC 8326743 41167356 60006591272 60006591272 sul miscellaneous antibiotics 70954-0258-10 1 bottle 473 mL Special Delivery MDC COA PMC - MED PMC COST 0.07797 1/6/2024 0:00 36.87981 36.87981 0 187.9 Formulary 0 637 diphenhydrAMINE diphenhydrAMINE 12.5mg/5mL oral liquid 120mL MDC 8330372 53165410 60006591298 60006591298 dip300 antihistamines 00904-6985-20 1 bottle 120 mL Special Delivery MDC COA PMC - DIRECT COST PMC COST 0.011 12/28/2023 16:37 1.32 1.32 0 1.32 Formulary 0 637 tetracaine ophthalmic tetracaine 0.5% ophth 4mL 8338188 219279104 60006591309 60006591309 tetr0.5%4mL ophthalmic anesthetics 00065-0741-14 1 bottle 4 mL Bulk PMC - MED PMC COST 2.8458 1/8/2024 7:47 11.3832 11.3832 0 71.8 Formulary 0 259 albuterol albuterol HFA 18gm inhaler 8338233 220773379 60006591327 60006591327 albinh18 adrenergic bronchodilators 66993-0019-68 1 EA 18 gm Bulk PMC - MED PMC COST 2.0067 12/28/2023 12:12 36.1206 36.1206 0 184.2 Formulary 0 637 sterile water water for injection (sterile) 20mL vial 8338252 220966621 60006591330 60006591330 ste20ml sterile irrigating solutions 00409-4887-20 1 vial(s) 20 mL INJ - COA PMC - INJ PMC COST 0.04678 11/11/2021 9:52 0.9356 0.9356 0 21.2 Formulary 0 259 tetanus-diphth toxoids (Td) adult/adol tetanus-diphth toxoids (Td) adult/adol 2-2LFU/0.5 mL syringe 8338254 221134921 60006591332 60006591332 td22 vaccine combinations 13533-0131-01 1 vial(s) 0.5 mL INJ - COA PMC - INJ PMC COST 43.364 1/8/2024 7:47 21.682 21.682 0 120 Formulary 0 636 90714 esomeprazole esomeprazole 40mg capsule 8318165 2172473 60006591362 60006591362 eso40 proton pump inhibitors 43598-0510-30 1 cap(s) 1 EA MED - COA PMC - MED PMC COST 0.34 1/8/2024 8:19 0.34 0.34 0 10 Formulary 0 637 potassium chloride potassium chloride 2mEq/mL 30mL vial 8338349 224498868 60006591378 60006591378 pot30 minerals and electrolytes 63323-0967-30 1 vial(s) 30 mL LVP - COA PMC - INJ PMC COST 0.07103 1/12/2024 7:09 2.1309 2.1309 0.07 30.4 Formulary J3480 Inj potassium chloride 30 636 meloxicam meloxicam 15mg tablet 8319089 16173646 60006591393 60006591393 mel15 nonsteroidal anti-inflammatory agents 50268-0526-15 1 tab(s) 1 EA MED - COA PMC - MED PMC COST 0.1246 1/12/2024 7:09 0.1246 0.1246 0 10 Formulary 0 637 immune globulin intravenous and subcutan USE IV SET immune globulin (Gammagard) 10gm/100mL premix (G/K) 8338553 232749471 60006591429 DONOTLOAD USEIVSETgammagard10 immune globulins 00944-2700-05 1 bottle 100 mL LVP - COA PMC - IV FLUIDS PMC COST 9.9837 11/11/2021 9:52 998.37 998.37 49.92 1497.6 Formulary J1569 Gammagard liquid injection 20 636 JZ immune globulin intravenous and subcutan immune globulin (Gammagard) 10gm/100mL premix (G/K) 8338554 232760635 60006591429 60006591429 premixgammagard10 immune globulins 00944-2700-05I 1 bottle 100 mL LVP - COA PMC - IV FLUIDS PMC COST 9.9837 11/22/2021 10:03 998.37 998.37 49.92 1497.6 Formulary J1569 Gammagard liquid injection 20 636 JZ immune globulin intravenous and subcutan USE IV SET - immune globulin (Gammagard) 20gm/200mL premix (G/K) 8338555 232772727 60006591430 DONOTLOAD USEIVSETgammagard20 immune globulins 00944-2700-06 1 bottle 200 mL LVP - COA PMC - IV FLUIDS PMC COST 10.3831 1/8/2024 7:47 2076.62 2076.62 51.92 3115 Formulary J1569 Gammagard liquid injection 40 636 JZ immune globulin intravenous and subcutan immune globulin (Gammagard) 20gm/200mL premix (G/K) 8338556 232775517 60006591430 60006591430 premixgammagard20 immune globulins 00944-2700-06I 1 bottle 200 mL LVP - COA PMC - IV FLUIDS PMC COST 9.9837 11/22/2021 10:01 1996.74 1996.74 49.92 2995.2 Formulary J1569 Gammagard liquid injection 40 636 JZ Al hydroxide/Mg hydroxide/simethicone alum-mag-simeth 200-200-20mg/5mL 360mL MDC oral susp 8322755 36970466 60006591455 60006591455 almagbulk antacids 57896-0629-12 1 bottle 360 mL Special Delivery MDC COA PMC - MED PMC COST 0.0064 1/8/2024 7:47 2.304 2.304 0 26.6 Formulary 0 637 ketorolac ketorolac 10mg tab 8318628 8498065 60006591457 60006591457 ket10 nonsteroidal anti-inflammatory agents 60687-0104-21 1 EA 1 EA MED - COA PMC - MED PMC COST 4.24 12/4/2023 13:29 4.24 4.24 0 37.5 Formulary 0 637 potassium chloride potassium chloride 20 mEq ER tab 8338656 235859555 60006591460 60006591460 pot20tab minerals and electrolytes 00904-7086-61 1 tab(s) 1 EA MED - COA PMC - MED PMC COST 0.2813 11/30/2021 23:28 0.2813 0.2813 0 10 Formulary 0 637 acetaminophen-codeine acetaminophen-codeine 120-12 mg/5mL 5mL UD 8338659 235860169 60006591462 60006591462 tyelnolwcodeine5mL narcotic analgesic combinations 00121-0504-00 1 EA 5 mL MED - COA PMC - MED PMC COST 0.378 12/28/2023 8:13 1.89 1.89 0 24.3 Formulary 0 637 Al hydroxide/Mg hydroxide/simethicone alum-mag-simeth 400-400-40mg/5mL 30mL 8338660 235860518 60006591463 60006591463 magalplus30mL antacids 00904-7326-73 1 bottle 30 mL MED - COA PMC - DIRECT COST PMC COST 0.10248 1/12/2024 7:09 3.0744 3.0744 0 3.07 Formulary 0 637 amoxicillin amoxicillin 125mg/5mL susp 150mL 8338662 235860838 60006591464 60006591464 amox125mg5mL150mL aminopenicillins 00781-6039-55 1 bottle 150 mL Bulk PMC - MED PMC COST 0.0204 11/11/2021 10:05 3.06 3.06 0 31.1 Formulary 0 637 amoxicillin amoxicillin 250mg/5mL susp 150mL 8338664 235861074 60006591466 60006591466 amox250mg5mL150mL aminopenicillins 00781-6041-55 1 bottle 150 mL Bulk PMC - MED PMC COST 0.02973 1/2/2024 10:31 4.4595 4.4595 0 39.2 Formulary 0 637 multivitamin with minerals multivitamin with minerals/lutein capsule 8334683 84926862 60006591476 60006591476 mulMinlutcaprp vitamin and mineral combinations 24208-0632-10 1 cap(s) 1 EA MED - COA PMC - DIRECT COST PMC COST 0.29 12/3/2021 7:40 0.29 0.29 0 0.29 Formulary 0 637 guaiFENesin guaiFENesin 100 mg/5 mL syrup 120mL 8338676 235863215 60006591487 60006591487 gua100mg5mL120mL expectorants 00121-0744-04 1 bottle 120 mL Bulk PMC - MED PMC COST 0.00889 11/22/2021 8:02 1.0668 1.0668 0 15.3 Formulary 0 637 insulin glargine insulin glargine 100units/mL 3mL pen 8338677 235863269 60006591488 60006591488 insglar100pen3mL insulin 00088-2219-05 1 vial(s) 3 mL Bulk PMC - INJ PMC COST 6.4213 12/29/2023 13:42 19.2639 19.2639 0.32 124.6 Formulary J1815 Insulin injection 60 637 acetylcysteine acetylcysteine 20% 4mL vial 8338810 240105291 60006591543 60006591543 aceoralinh20 antidotes 00517-7604-25 1 vial(s) 4 mL MED - COA PMC - MED PMC COST 3.2886 12/28/2023 8:27 13.1544 13.1544 0 82.5 Formulary 0 637 orphenadrine orphenadrine 60mg/2mL soln 8338826 241312782 60006591552 60006591552 orp60inj skeletal muscle relaxants 00641-6182-10 1 vial(s) 2 mL INJ - COA PMC - INJ PMC COST 1.705 1/12/2024 7:09 3.41 3.41 3.41 39.7 Formulary J2360 Orphenadrine injection 1 636 lidocaine lidocaine PF 2% 2mL vial 8338841 241901764 60006591558 60006591558 lidpf2mLstw local injectable anesthetics 63323-0495-27 1 vial(s) 2 mL INJ - COA PMC - INJ PMC COST 0.8394 1/12/2024 7:09 1.6788 1.6788 0 27.5 Formulary 0 259 naproxen naproxen sodium 220 mg tab 8339052 247279297 60006591593 60006591593 nap220 nonsteroidal anti-inflammatory agents 45802-0490-71 1 tab(s) 1 EA MED - COA PMC - DIRECT COST PMC COST 0.043 11/11/2021 9:52 0.043 0.043 0 0.04 Formulary 0 637 "Zoster Vaccine Recombinant, Adjuvanted" zoster vaccine recomb vial 8339142 248831268 60006591611 60006591611 zosarecom viral vaccines 58160-0823-11 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 215 9/13/2022 0:00 215 215 0 450 Formulary 0 636 90750 fentaNYL fentaNYL 50mcg/mL 2mL inj 8339233 252751675 60006591629 60006591629 fen50inj narcotic analgesics 00409-9094-22 1 vial(s) 2 mL INJ - COA PMC - INJ PMC COST 0.7698 1/8/2024 7:47 1.5396 1.5396 1.54 26 Formulary J3010 Fentanyl citrate injection 1 636 FLUoxetine FLUoxetine 10mg cap 8318693 8671664 60006591655 60006591655 flu10 ssri antidepressants 00904-5784-61 1 EA 1 EA MED - COA PMC - MED PMC COST 0.088 1/8/2024 8:24 0.088 0.088 0 10 Formulary 0 637 barium sulfate RAD barium sulfate 2% 450mL susp 8339484 258555858 60006591688 DONOTLOAD RAD barium sulfate (Smoothie Readi-Cat2) 2% 450mL non-iodinated contrast media 32909-0756-03 1 bottle 450 mL MED - COA PMC - DIRECT COST PMC COST 0.00592 11/11/2021 9:52 2.664 2.664 0 2.66 Formulary 0 259 cholecalciferol "cholecalciferol 1,250mcg (50,000 IntlUnits) capsule" 8341362 274529644 60006591796 60006591796 cho50000IntUnits vitamins 80681-0174-00 1 EA 1 EA MED - COA PMC - MED PMC COST 0.15 11/30/2021 23:14 0.15 0.15 0 10 Formulary 0 637 lidocaine topical lidocaine 2% jelly uroject 6mL 8341391 276616900 60006591803 60006591803 lid2uroject6mL topical anesthetics 25021-0673-76 1 syringe(s) 6 mL MED - COA PMC - MED PMC COST 0.594 11/11/2021 9:52 3.564 3.564 0 35.6 Formulary 0 259 hepatitis A pediatric vaccine hepatitis A pediatric PF vaccine 720 units/0.5 mL syringe (VFC) 8320654 35039101 60006591815 60006591815 hep720VFC viral vaccines 58160-0825-52V 1 syringe(s) 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 2/18/2022 15:55 0.01 0.01 0 0.01 Formulary 0 636 90633 SL cephalexin cephalexin 250mg/5mL oral susp 100mL 8341516 282258385 60006591835 60006591835 cep250susp first generation cephalosporins 67877-0545-88 1 bottle 100 mL Bulk PMC - MED PMC COST 0.1133 12/4/2023 13:20 11.33 11.33 0 71.5 Formulary 0 637 nystatin "nystatin 100,000 units/mL susp 60mL" 8341525 282468984 60006591838 60006591838 nys100000stw polyenes 00121-0868-02 1 bottle 60 mL Bulk PMC - MED PMC COST 0.0918 12/4/2023 13:50 5.508 5.508 0 40 Formulary 0 637 leuprolide leuprolide 30mg/4months kit (URO) (G/K) 8327054 41755630 60006591839 60006591839 leu30 antineoplastic hormones 00074-3683-03 1 EA 1 EA MED - COA PMC - INJ PMC COST 7143.04 1/12/2024 7:09 7143.04 7143.04 1785.76 14295.1 Formulary J9217 Leuprolide acetate suspnsion 4 636 JZ lactulose lactulose 10gm/15mL syrup UD 15mL 8341536 283127834 60006591841 60006591841 lact15ud laxatives 00121-4577-40 1 bottle 15 mL MED - COA PMC - MED PMC COST 0.0866 1/19/2024 8:39 1.299 1.299 0 17.8 Formulary 0 637 oseltamivir oseltamivir 6mg/mL 60mL susp 8341543 283203277 60006591846 60006591846 osel6susp neuraminidase inhibitors 47781-0384-26 1 bottle 60 mL Bulk PMC - MED PMC COST 0.8695 11/11/2021 9:52 52.17 52.17 0 212.2 Formulary 0 637 filgrastim filgrastim-aafi (Nivestym) 300 mcg/0.5 mL Soln (G/K) 8341845 299496205 60006591945 60006591945 filaafi3000.5 colony stimulating factors 00069-0291-01 1 EA 1 mL INJ - COA PMC - INJ PMC COST 273.78 11/11/2021 9:52 273.78 273.78 0.91 556.6 Formulary Q5110 Nivestym 300 636 JZ iopamidol RAD iopamidol 61% 100mL soln 8343389 305336562 60006592051 DONOTLOAD RAD iopamidol (Isovue-300) 61% 100mL soln BC non-ionic iodinated contrast media 00270-1315-35 1 vial(s) 100 mL INJ - COA PMC - DIRECT COST PMC COST 0 10/10/2023 17:22 0 0 0 0 Formulary Q9967 "LOCM 300-399mg/ml iodine,1ml" 100 636 polyethylene glycol 3350 polyethylene glycol powder 17gm pack 8343621 306445877 60006592077 60006592077 miralax17 laxatives 00904-6931-81 1 EA 1 EA MED - COA PMC - MED PMC COST 0.997 11/30/2021 23:36 0.997 0.997 0 16.5 Formulary 0 637 bupivacaine bupivacaine PF 0.25% 10mL vial (G/K) 8343827 307924479 60006592104 60006592104 bup0.2510 local injectable anesthetics 00409-1159-01 1 vial(s) 10 mL INJ - COA PMC - INJ PMC COST 0.17972 11/11/2021 9:52 1.7972 1.7972 0.04 28.8 Formulary J0665 "Inj, bupivacaine, nos, 0.5mg" 50 636 JZ DOPamine DOPamine 40mg/mL 5mL soln 8343960 309429386 60006592131 60006592131 DOP40t5 catecholamines 00143-9252-25 1 vial(s) 5 mL LVP - COA PMC - INJ PMC COST 0.48424 11/11/2021 9:52 2.4212 2.4212 0.48 33.3 Formulary J1265 Dopamine injection 5 636 riTUXimab riTUXimab-abbs (Truxima) 10mg/mL 10 mL vial (G/K) 8344007 310038010 60006592142 60006592142 riTabbs10 cd20 monoclonal antibodies 63459-0103-10 1 vial(s) 10 mL LVP - COA PMC - INJ PMC COST 53.958 1/1/2022 15:41 539.58 539.58 53.96 1088.2 Formulary Q5115 Inj truxima 10 mg 10 636 JZ riTUXimab riTUXimab-abbs (Truxima) 10mg/mL 50mL vial (G/K) 8344008 310038275 60006592143 60006592143 riTabbs50 cd20 monoclonal antibodies 63459-0104-50 1 vial(s) 50 mL LVP - COA PMC - INJ PMC COST 59.3576 1/1/2022 0:00 2967.88 2967.88 59.36 5944.8 Formulary Q5115 Inj truxima 10 mg 50 636 JZ azithromycin azithromycin 500 mg tablet 8344153 311424844 60006592177 60006592177 azi500tab macrolides 00781-8090-03 1 EA 1 EA MED - COA PMC - MED PMC COST 0.73 11/11/2021 9:52 0.73 0.73 0 13 Formulary 0 637 eptifibatide eptifibatide 2 mg/mL10mL vial (G/K) 8344157 311429735 60006592182 60006592182 ept20mgbolus glycoprotein platelet inhibitors 70860-0303-10 1 vial(s) 10 mL INJ - COA PMC - INJ PMC COST 1.562 12/29/2023 13:11 15.62 15.62 3.9 102.8 Formulary J1327 Eptifibatide injection 4 636 JZ insulin lispro insulin lispro 100 Unit(s)/mL per 1 unit 8344166 311433289 60006592191 60006592191 inslisperu insulin 00002-7510-17 1 EA 0.01 mL INJ - COA PMC - INJ PMC COST 5.16 11/15/2021 10:28 0.0516 0.0516 0.26 10 Formulary J1815 Insulin injection 0.2 637 lidocaine-prilocaine topical lidocaine-prilocaine 2.5%-2.5% cream 30gm 8344170 311435642 60006592198 60006592198 emla30gm topical anesthetics 00168-0357-30 1 EA 30 gm Bulk PMC - MED PMC COST 0.316 1/12/2024 7:09 9.48 9.48 0 60.4 Formulary 0 637 nitroglycerin nitroglycerin 2% ointment 30gm 8344173 311436107 60006592201 60006592201 nit2%30gm vasodilators 00281-0326-30 1 tube 30 gm Bulk PMC - MED PMC COST 1.04133 1/12/2024 7:09 31.2399 31.2399 0 159.7 Formulary 0 637 diphtheria/tetanus/pertussis (DTaP) ped diphtheria/tetanus/pertussis (DTaP) ped 0.5 mL susp 8344253 312134428 60006592239 60006592239 dip150.5 vaccine combinations 49281-0286-10 1 vial(s) 0.5 mL INJ - COA PMC - INJ PMC COST 22.14 8/10/2023 14:48 11.07 11.07 0 75.5 Formulary 0 636 90700 midazolam midazolam 5 mg/mL 2mL inj 8344255 312134882 60006592241 60006592241 mid10inj benzodiazepines 00641-6063-25 1 vial(s) 2 mL INJ - COA PMC - INJ PMC COST 0.3474 1/12/2024 7:09 0.6948 0.6948 0.07 18.1 Formulary J2250 Inj midazolam hydrochloride 10 636 loperamide loperamide 2 mg tablet 8344257 312138426 60006592243 60006592243 lop2tab antidiarrheals 50580-0317-03 1 tab(s) 1 EA MED - COA PMC - DIRECT COST PMC COST 0.44583 1/12/2024 7:09 0.44583 0.44583 0 0.45 Formulary 0 637 levoFLOXacin levoFLOXacin 25mg/mL 20mL vial 8344269 312222279 60006592249 60006592249 levo500iv quinolones 17478-0107-20 1 vial(s) 20 mL IVPB - COA PMC - INJ PMC COST 1.1005 11/11/2021 9:52 22.01 22.01 11.01 120 Formulary J1956 Levofloxacin injection 2 636 charcoal-sorbitol activated charcoal w/sorbitol 50 gm / 240 mL 8344212 311699910 60006592326 60006592326 char/sorb50/240 antidotes 00574-0520-76 1 bottle 240 mL MED - COA PMC - MED PMC COST 0.08333 11/11/2021 9:52 19.9992 19.9992 0 123.5 Formulary 0 259 triamcinolone topical triamcinolone 0.5% ointment 15 gm 8344324 313202946 60006592341 60006592341 triam0.5O15 topical steroids 45802-0049-35 1 tube 15 gm Bulk PMC - MED PMC COST 0.26467 11/11/2021 9:52 3.97005 3.97005 0 39.3 Formulary 0 637 hydrocortisone topical hydrocortisone 2.5% cream 28 gm 8344335 313276172 60006592345 60006592345 HC2.5crm28 topical steroids 00168-0080-31 1 tube 28 gm Bulk PMC - MED PMC COST 0.067 1/8/2024 8:37 1.876 1.876 0 24.2 Formulary 0 637 naloxone naloxone 1 mg/mL injection 2 mL 8344338 313297772 60006592346 60006592346 nalox2i2 antidotes 76329-3369-01 1 EA 2 mL INJ - COA PMC - INJ PMC COST 4.692 1/8/2024 7:47 9.384 9.384 4.69 65.4 Formulary J2310 Inj naloxone hydrochloride 2 636 prednisoLONE prednisoLONE Sod Phos 15mg/5 mL soln 8344455 314706295 60006592351 60006592351 presodiumphos glucocorticoids 00121-0759-08 1 EA 5 mL MED - COA PMC - MED PMC COST 0.13675 1/12/2024 7:09 0.68375 0.68375 0.23 12.4 Formulary J7510 Prednisolone oral per 5 mg 3 636 amoxicillin-clavulanate amoxicillin-clav 200 mg-28.5 mg/5 mL 100mL 8344503 315644992 60006592371 60006592371 amoxclav200susp100 penicillins/beta-lactamase inhibitors 65862-0533-01 1 bottle 100 mL Bulk PMC - MED PMC COST 0.0379 1/23/2024 15:53 3.79 3.79 0 37.7 Formulary 0 637 benzocaine/butamben/tetracaine topical benzocaine/butamben/tetracaine topical 14%-2%-2% Aerosol 20 gm 8344672 316529019 60006592422 60006592422 benzbuttet14.2.2aer mouth and throat products 10223-0201-03 1 EA 20 gm Bulk PMC - MED PMC COST 2.651 11/11/2021 9:52 53.02 53.02 0 215.6 Formulary 0 259 ibuprofen ibuprofen 100 mg/5 mL susp 118 mL MDC 8344666 316528767 60006592463 60006592463 ibup100susp nonsteroidal anti-inflammatory agents 00904-5577-20 1 EA 118 mL Special Delivery MDC COA PMC - MED PMC COST 0.03153 1/12/2024 7:09 3.72054 3.72054 0 37 Formulary 0 637 multivitamin Multiple Vitamins oral tablet 8344665 316528726 60006592481 60006592481 multiVtab vitamin and mineral combinations 00904-0530-80 1 EA 1 EA MED - COA PMC - MED PMC COST 0.01 11/30/2021 23:55 0.01 0.01 0 10 Formulary 0 637 prednisoLONE prednisoLONE 15 mg/5 mL syrup 240 mL MDC 8344674 316529101 60006592499 60006592499 predni15syr240 glucocorticoids 00121-0759-08 1 EA 240 mL Special Delivery MDC COA PMC - MED PMC COST 0.13675 1/12/2024 7:09 32.82 32.82 32.82 167.6 Formulary J7510 Prednisolone oral per 5 mg 1 637 propofol propofol 10 mg/mL 10 mL vial 8344661 316528556 60006592501 60006592501 prop10emul general anesthetics 63323-0269-10 1 EA 10 mL IVPB - COA PMC - INJ PMC COST 0.1027 11/11/2021 9:52 1.027 1.027 0.1 20.3 Formulary J2704 "Inj, propofol, 10 mg" 10 636 hydrocortisone/neomycin/polymyxin B otic THP 10 mL HC/neomycin/polymyxin B otic suspension 8344781 316981688 60006592518 60006592518 thphcneopolyB10.sus 61314-0645-11T 1 EA 10 mL Bulk PMC - DIRECT COST PMC COST 3.5 12/13/2023 0:00 35 35 0 35 Formulary 0 253 polymyxin B-trimethoprim ophthalmic THP 10 mL polymyxin B-trimeth ophthalmic 0.1% Kit 8875374 342841608 60006592519 60006592519 thppolyB-trim10.sol ophthalmic anti-infectives 61314-0628-10T 1 EA 10 mL Bulk PMC - DIRECT COST PMC COST 3.5 12/13/2023 0:00 35 35 0 35 Formulary 0 253 cephalexin THP 100 mL cephalexin 250 mg/5 mL suspension 8344736 316979843 60006592522 60006592522 thpceph100.pow 67877-0545-88T 1 EA 100 mL Bulk PMC - DIRECT COST PMC COST 0.35 1/5/2024 14:01 35 35 0 35 Formulary 0 253 sulfacetamide sodium ophthalmic THP 15 mL sulfacetamide sod 10% ophth soln 8344809 316982834 60006592543 60006592543 thpsulfac15.sol 61314-0701-01T 1 EA 15 mL Bulk PMC - DIRECT COST PMC COST 2.33333 12/13/2023 0:00 34.99995 34.99995 0 35 Formulary 0 253 amoxicillin THP 150 mL amoxicillin 125mg/5mL suspension 8344719 316978950 60006592544 60006592544 thpamox150.sus 00781-6039-55T 1 EA 150 mL Bulk PMC - DIRECT COST PMC COST 0.2333 1/2/2024 10:28 34.995 34.995 0 34.99 Formulary 0 253 amoxicillin THP 150 mL amoxicillin 250 mg/5 mL powder 8344720 316978991 60006592545 60006592545 thpamox150.pow 00093-4155-80T 1 EA 150 mL Bulk PMC - DIRECT COST PMC COST 0.23333 12/13/2023 0:00 34.9995 34.9995 0 35 Formulary 0 253 mupirocin topical THP 22 gm mupirocin 2% topical ointment 8344780 316981647 60006592548 60006592548 thpmupi22.oin 51672-1312-00T 1 EA 22 gm Bulk PMC - DIRECT COST PMC COST 1.5909 1/5/2024 13:43 34.9998 34.9998 0 35 Formulary 0 253 azithromycin THP 3 EA azithromycin 500 mg tablet 8344728 316979319 60006592549 60006592549 thpazi500.tab 00904-7351-04T 1 EA 3 EA Bulk PMC - DIRECT COST PMC COST 11.6667 1/5/2024 11:52 35.0001 35.0001 0 35 Formulary 0 253 erythromycin ophthalmic THP 3.5 gm erythromycin ophth oint 8344754 316980581 60006592557 60006592557 thpery3.5.oin 00574-4024-35T 1 EA 3.5 gm Bulk PMC - DIRECT COST PMC COST 10 12/13/2023 0:00 35 35 0 35 Formulary 0 253 azithromycin THP 30 mL azithromycin 200 mg/5 mL 8344726 316979237 60006592558 60006592558 thpazi30.pow 42806-0151-34T 1 EA 30 mL Bulk PMC - DIRECT COST PMC COST 1.1667 1/5/2024 13:40 35.001 35.001 0 35 Formulary 0 253 azithromycin THP 6 EA azithromycin 250mg tablet 8344727 316979278 60006592579 60006592579 thpazi250.tab 00904-7350-06T 1 EA 6 EA Bulk PMC - DIRECT COST PMC COST 5.8333 1/5/2024 11:38 34.9998 34.9998 0 35 Formulary 0 253 acetaminophen-codeine THP 60 mL acetamin-codeine 120-12mg/5mL 8344712 316978662 60006592591 60006592591 thpacecod60.sol 00121-0504-04T 1 EA 60 mL Bulk PMC - DIRECT COST PMC COST 0.5833 12/13/2023 0:00 34.998 34.998 0 35 Formulary 0 253 cefdinir THP 60 mL cefdinir 250 mg/5 mL powder 8344730 316979401 60006592593 60006592593 thpcef60.pow 65862-0219-60T 1 EA 60 mL Bulk PMC - DIRECT COST PMC COST 0.5833 1/5/2024 13:53 34.998 34.998 0 35 Formulary 0 253 nystatin THP 60 mL nystatin 100000 units/mL suspension 8344784 316981811 60006592597 60006592597 thpnyst60.susp 00121-0868-02T 1 EA 60 mL Bulk PMC - DIRECT COST PMC COST 0.5833 1/5/2024 15:51 34.998 34.998 0 35 Formulary 0 253 oseltamivir THP 60 mL oseltamivir 6 mg/mL 8344789 316982016 60006592598 60006592598 thposel60.pow 00004-0822-05T 1 EA 60 mL Bulk PMC - DIRECT COST PMC COST 0.58333 12/13/2023 0:00 34.9998 34.9998 0 35 Formulary 0 253 acetaminophen-codeine THP 8 EA acetaminophen-codeine 300 mg-30 mg tablet 8344714 316978745 60006592602 60006592602 thpacecod8.tab 00093-0150-01TH 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 acetaminophen-HYDROcodone THP 8 EA acetaminophen-HYDROcodone 325-5mg tablet 8344760 316980827 60006592603 60006592603 thpacehydro8.tab 00406-0123-01T 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 albuterol THP 8 gm albuterol CFC free 90 mcg/inh aerosol 8344716 316978827 60006592610 60006592610 thpalb8.aer 00173-0682-24T 1 EA 8 gm Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 codeine-promethazine codeine-promethazine 10 mg-6.25 mg/5 mL soln 473mL MDC 8322874 37926268 60006592630 60006592630 codphen upper respiratory combinations 27808-0065-02 1 bottle 473 mL Special Delivery MDC COA PMC - MED PMC COST 0.0513 1/8/2024 8:47 24.2649 24.2649 0 124.9 Formulary 0 637 rotavirus vaccine rotavirus vaccine monovalent 1mL (Rotarix VFC) 8344909 317935019 60006592642 DONOTLOAD rot1VFCmono viral vaccines 58160-0854-52V 1 EA 1 mL MED - COA PMC - DIRECT COST PMC COST 0.01 2/18/2022 0:00 0.01 0.01 0 0.01 Formulary 0 636 90681 SL amoxicillin amoxicillin 125 mg/5 mL susp 80mL 8344998 319281305 60006592657 60006592657 amo12580 aminopenicillins 00781-6039-58 1 bottle 80 mL Bulk PMC - MED PMC COST 0.02425 1/16/2024 11:31 1.94 1.94 0 24.9 Formulary 0 637 amoxicillin-clavulanate amoxicillin-clav 400-57mg/5mL100mL Susp 8345001 319285650 60006592659 60006592659 aug400100 penicillins/beta-lactamase inhibitors 00143-9982-01 1 bottle 100 mL Bulk PMC - MED PMC COST 0.0561 11/15/2021 10:28 5.61 5.61 0 40 Formulary 0 637 barium sulfate RAD barium sulfate 2.1% 450mL susp 8345015 319324283 60006592670 60006592670 RAD barium sulfate (Volumen) 2.1% 450mL susp BC non-iodinated contrast media 32909-0715-03 1 bottle 450 mL MED - COA PMC - DIRECT COST PMC COST 0 10/10/2023 17:23 0 0 0 0 Formulary 0 259 lactulose lactulose 10gm/15mL oral syrup 473mL MDC 8322744 36956906 60006592677 60006592677 BULKlac10 laxatives 45963-0438-64 1 bottle 473 mL Special Delivery MDC COA PMC - MED PMC COST 0.01366 1/12/2024 7:09 6.46118 6.46118 0 42.3 Formulary 0 637 polyethylene glycol 3350 polyethylene glycol 238gm powder 8345115 321264915 60006592689 60006592689 miralax238 laxatives 00536-1052-24 1 bottle 238 gm Bulk PMC - MED PMC COST 0.02332 1/12/2024 7:09 5.55016 5.55016 0 40 Formulary 0 637 albuterol albuterol HFA 6.7 gm inhaler 8345156 321745148 60006592709 60006592709 alb906.7 adrenergic bronchodilators 00781-7296-85 1 EA 6.7 gm Bulk PMC - MED PMC COST 2.1835 12/28/2023 12:18 14.62945 14.62945 0 91.3 Formulary 0 637 azithromycin azithromycin 200mg/5mL 30mL susp 8345160 321747024 60006592713 60006592713 azi1200susp macrolides 42806-0151-34 1 bottle 30 mL Bulk PMC - MED PMC COST 0.34967 11/11/2021 9:52 10.4901 10.4901 0 66.5 Formulary 0 637 melatonin melatonin 5mg tab 8345166 321753583 60006592719 60006592719 melat5tab nutraceutical products 30768-0157-45 1 EA 1 EA MED - COA PMC - DIRECT COST PMC COST 0.05344 1/12/2024 7:09 0.05344 0.05344 0 0.05 Formulary 0 637 fluticasone-salmeterol fluticasone-salmeterol 250-50mcg 60dose 8345188 321833315 60006592739 60006592739 flu2505060 bronchodilator combinations 00054-0327-56 1 EA 60 EA Bulk PMC - MED PMC COST 1.5523 1/20/2024 0:00 93.138 93.138 0 300 Formulary 0 637 naloxone 0.04mg/mL dilution naloxone 0.04mg/mL dilution 8320377 33604164 60006592776 8300301915 naldil 00000-0000-81 1 EA 1 EA MED - COA Cost 2 COST2 3.66 3/6/2020 0:00 3.66 3.66 91.5 3.66 Formulary J2310 Inj naloxone hydrochloride 0.04 636 magnesium hydroxide magnesium hydroxide 80mg/mL susp 480mL MDC 8345240 322306552 60006592783 60006592783 maghy480mdc antacids 00904-0788-16 1 bottle 480 mL Special Delivery MDC COA PMC - DIRECT COST PMC COST 0.00423 11/11/2021 9:52 2.0304 2.0304 0 2.03 Formulary 0 637 flumazenil flumazenil 0.1mg/mL 5mL MDV inj soln 8345242 322307238 60006592785 60006592785 flu0.5mdv antidotes 63323-0424-05 1 vial(s) 5 mL MDV INJ - COA PMC - INJ PMC COST 0.6048 11/11/2021 9:52 3.024 3.024 0 36.3 Formulary 0 636 sodium polystyrene sulfonate sodium polystyrene 15gm/60mL 473mL MDC 8345260 322382764 60006592797 60006592797 kay473MDC cation exchange resins 46287-0006-01 1 bottle 473 mL Special Delivery MDC COA PMC - MED PMC COST 0.3506 1/8/2024 7:47 165.8338 165.8338 0 450 Formulary 0 637 potassium chloride potassium chloride 20 mEq/15 mL oral soln 473mL MDC 8345284 322599282 60006592814 60006592814 pot20473mdc minerals and electrolytes 00904-7061-51 1 bottle 473 mL Special Delivery MDC COA PMC - MED PMC COST 0.1379 1/8/2024 8:46 65.2267 65.2267 0 264.5 Formulary 0 637 EPINEPHrine/lidocaine/tetracaine topical lidocaine-EPINEPHrine-tetracaine 100mL MDC 8345287 322678770 60006592817 60006592817 let100mdc topical anesthetics 51552-1345-01 1 bottle 100 mL Special Delivery MDC COA PMC - MED PMC COST 0.6611 1/12/2024 7:09 66.11 66.11 0 268 Formulary 0 259 sodium nitrite-sodium thiosulfate sodium nitrite-sodium thiosulfate 30 mg-250 mg/mL 60mL kit 8345308 322961221 60006592828 60006592828 sodnit60 antidotes 60267-0812-00 1 kit(s) 60 mL MED - COA PMC - INJ PMC COST 2.83333 11/11/2021 9:52 169.9998 169.9998 0 450 Formulary 0 259 EPINEPHrine-lidocaine "lidocaine-epi 1%-1:100,000 10mL MDV" 8345461 324954098 60006592977 60006592977 epilid110inj local injectable anesthetics 63323-0482-17 1 vial(s) 10 mL MDV INJ - COA PMC - INJ PMC COST 0.21008 1/12/2024 7:09 2.1008 2.1008 0 30.1 Formulary 0 259 testosterone testosterone cypionate 100mg/mL 10mL MDV 8345462 324954320 60006592978 60006592978 testdep10010 androgens and anabolic steroids 00009-0347-02 1 vial(s) 10 mL MDV INJ - COA PMC - INJ PMC COST 2.671 1/2/2024 0:00 26.71 26.71 0.03 142.6 Formulary J1071 Inj testosterone cypionate 1000 637 acetaminophen acetaminophen 160 mg/5 mL oral liq 118mL MDC 8345604 326112138 60006593010 60006593010 acetaminliq118mLMDC miscellaneous analgesics 00904-7014-20 1 bottle 118 mL Special Delivery MDC COA PMC - MED PMC COST 0.0222 12/28/2023 8:06 2.6196 2.6196 0 29.7 Formulary 0 637 predniSONE predniSONE 5 mg/5 mL oral soln 120mL MDC 8345625 326375490 60006593014 70001030008 pre5MDC glucocorticoids 00054-3722-50 1 bottle 120 mL Special Delivery MDC COA PMC - MED PMC COST 0.53966 10/1/2022 0:00 64.7592 64.7592 0.54 262.6 Formulary J7512 Prednisone ir or dr oral 1mg 120 636 acetylcysteine acetylcysteine 100mg/mL soln 30mL 8345685 327008700 60006593016 60006593016 acet10soln mucolytics 00409-3307-03 1 vial(s) 30 mL MED - COA PMC - MED PMC COST 0.3896 12/28/2023 8:21 11.688 11.688 0 73.7 Formulary 0 259 adenosine adenosine 3mg/mL 4mL soln 8345686 327008779 60006593017 60006593017 adeno3 cardiac stressing agents 67457-0854-04 1 vial(s) 4 mL INJ - COA PMC - INJ PMC COST 2.293 12/28/2023 11:01 9.172 9.172 0.76 64.1 Formulary J0153 Adenosine inj 1mg 12 636 benzocaine-menthol topical benzocaine-menthol topical 15mg-2.6mg lozenge 8345690 327009444 60006593021 60006593021 benzocaine15mgloz mouth and throat products 63824-0732-16 1 EA 1 EA MED - COA PMC - DIRECT COST PMC COST 0.1412 12/28/2023 15:42 0.1412 0.1412 0 0.14 Formulary 0 637 insulin aspart insulin aspart 100 Unit(s)/mL 3mL pen 8345700 327037702 60006593030 60006593030 insulin100pen insulin 73070-0103-15 1 syringe(s) 3 mL Bulk PMC - INJ PMC COST 4.464 12/29/2023 13:41 13.392 13.392 0.22 89.4 Formulary J1815 Insulin injection 60 637 sacituzumab govitecan sacituzumab govitecan 180mg (G/K) 8345647 326700158 60006593053 60006593053 sacit180 miscellaneous antineoplastics 55135-0132-01 1 EA 1 EA CHEMO IVPB - COA PMC - INJ PMC COST 2345.23 1/12/2024 7:09 2345.23 2345.23 32.57 4699.5 Formulary J9317 Sacituzumab govitecan-hziy 72 636 JZ dexamethasone dexamethasone 10mg/mL 1mL inj 8345649 326878999 60006593055 60006593055 dexainj10 glucocorticoids 00641-0367-25 1 mL 1 mL INJ - COA PMC - INJ PMC COST 1.1796 11/11/2021 9:52 1.1796 1.1796 0.12 22 Formulary J1100 Dexamethasone sodium phos 10 636 rotavirus vaccine rotavirus vaccine monovalent 1mL (Rotarix) 8345651 326892561 60006593057 60006593057 rotmonovalent viral vaccines 58160-0854-52 1 EA 1 mL MED - COA PMC - INJ PMC COST 126.28 11/15/2021 10:33 126.28 126.28 0 387.9 Formulary 0 636 90681 silver sulfADIAZINE topical silver sulfADIAZINE 1% cream 20gm 8345652 326892971 60006593058 60006593058 sil20gm topical antibiotics 67877-0124-20 1 tube 20 gm Bulk PMC - MED PMC COST 0.2215 11/11/2021 9:52 4.43 4.43 0 39 Formulary 0 637 iron sucrose iron sucrose complex 20mg/mL 10mL vial 8345653 326894739 60006593059 60006593059 iro20010 iron products 00517-2310-05 1 vial(s) 10 mL IVPB - COA PMC - INJ PMC COST 5.866 11/15/2021 10:34 58.66 58.66 0.29 243.7 Formulary J1756 Iron sucrose injection 200 636 guaiFENesin guaiFENesin 400 mg tablet 8345655 326921713 60006593061 60006593061 gua400tab expectorants 00536-1311-08 1 tab(s) 1 EA MED - COA PMC - DIRECT COST PMC COST 0.055 12/29/2023 13:22 0.055 0.055 0 0.06 Formulary 0 637 haloperidol haloperidol 2 mg/mL oral conc 120mL MDC 8345656 326921949 60006593062 60006593062 hal240mdc miscellaneous antipsychotic agents 54838-0501-40 1 bottle 120 mL Special Delivery MDC COA PMC - MED PMC COST 0.15358 12/29/2023 13:26 18.4296 18.4296 0 114.1 Formulary 0 637 nitroglycerin nitroglycerin 2% ointment 60gm tube 8345657 326922046 60006593063 60006593063 nitooint60 vasodilators 00281-0326-60 1 tube 60 gm Bulk PMC - MED PMC COST 1.04067 11/11/2021 9:52 62.4402 62.4402 0 253.3 Formulary 0 637 midazolam midazolam 1 mg/mL 2mL inj 8345659 326928999 60006593065 60006593065 mid2mlinj benzodiazepines 00641-6057-25 1 vial(s) 2 mL INJ - COA PMC - INJ PMC COST 0.135 1/12/2024 7:09 0.27 0.27 0.14 12.6 Formulary J2250 Inj midazolam hydrochloride 2 636 amoxicillin-clavulanate amoxicillin-clav 200 mg-28.5 mg/5 mL 50 mL 8345661 326931554 60006593066 60006593066 amoxclav200su50 penicillins/beta-lactamase inhibitors 65862-0533-50 1 bottle 50 mL Bulk PMC - MED PMC COST 0.0628 11/11/2021 9:52 3.14 3.14 0 31.8 Formulary 0 637 cefdinir cefdinir 125 mg/5 mL 100mL Susp 8345663 326932774 60006593067 60006593067 cefd125100 third generation cephalosporins 68180-0722-05 1 bottle 100 mL Bulk PMC - MED PMC COST 0.0962 11/11/2021 9:52 9.62 9.62 0 61.3 Formulary 0 637 morphine morphine 20mg/mL 15 mL oral conc 8345665 326934385 60006593069 60006593069 mor30015conc narcotic analgesics 00406-8003-15 1 bottle 15 mL Bulk PMC - MED PMC COST 0.25733 11/11/2021 9:52 3.85995 3.85995 0 38.3 Formulary 0 637 fluticasone-salmeterol fluticasone-salmeterol 100-50mcg 60 dose 8345740 327060872 60006593071 60006593071 flusal100mcg50mcgpowder bronchodilator combinations 00054-0326-56 1 EA 1 EA Bulk PMC - MED PMC COST 73.86 1/8/2024 8:25 73.86 73.86 0 299 Formulary 0 637 mupirocin topical mupirocin 2% topical ointment 15gm 8345749 327061656 60006593075 60006593075 mupirocin2top15g topical antibiotics 51672-1312-01 1 tube 15 gm Bulk PMC - MED PMC COST 0.24267 1/12/2024 7:09 3.64005 3.64005 0 36.3 Formulary 0 637 meningococcal conjugate vaccine meningococcal conj vacc (MenQuadfi) ACYW (VFC) 0.5mL 8345746 327061403 60006593083 60006593083 menquadfivfc bacterial vaccines 49281-0590-05V 1 vial(s) 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0.02 2/18/2022 13:54 0.01 0.01 0 0.01 Formulary 0 636 90619 SL meningococcal conjugate vaccine meningococcal conjugate vacc (MenQuadfi) ACYW 0.5mL 8345747 327061497 60006593087 60006593087 medquadfi bacterial vaccines 49281-0590-05 1 vial(s) 0.5 mL INJ - COA PMC - INJ PMC COST 228.24 8/19/2022 16:47 114.12 114.12 0 351.4 Formulary 0 636 90619 ondansetron ondansetron 4mg tab 8345750 327062092 60006593090 60006593090 ondan4tab 5ht3 receptor antagonists 65862-0187-30 1 EA 1 EA MED - COA PMC - MED PMC COST 0.07833 11/11/2021 9:52 0.07833 0.07833 0 10 Formulary 0 637 levoFLOXacin levoFLOXacin 25 mg/mL 30mL vial 8345758 327083988 60006593108 60006593108 lev2530inj quinolones 55150-0157-30 1 vial(s) 30 mL IVPB - COA PMC - INJ PMC COST 1.07533 11/11/2021 9:52 32.2599 32.2599 0.36 170.3 Formulary J1956 Levofloxacin injection 90 636 valACYclovir THP 8 EA valACYclovir 1000 mg tablet 8345805 327502831 60006593134 60006593134 thpvalac8.tab purine nucleosides 65862-0449-30 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 diazePAM THP 8 EA diazePAM 5 mg tablet 8345806 327503605 60006593135 60006593135 THPdiaz58.tab benzodiazepine anticonvulsants 51079-0285-20T 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 dexamethasone THP 8 EA dexamethasone 4 mg tablet 8345807 327504206 60006593136 60006593136 THPdexam4.8tab glucocorticoids 00054-8175-25T 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 sulfamethoxazole-trimethoprim THP 120 mL ER sulfameth-trimethoprim 200-40mg/5mL 8345808 327506337 60006593137 60006593137 thpsulfa-trim120susp sulfonamides 65862-0496-47A 1 EA 120 mL Bulk PMC - DIRECT COST PMC COST 0.29167 12/13/2023 0:00 35.0004 35.0004 0 35 Formulary 0 253 omeprazole THP 8 EA omeprazole 20mg cap 8345809 327506786 60006593138 60006593138 THPome208cap proton pump inhibitors 68382-0412-05T 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 pantoprazole THP 8 EA pantoprazole 40mg EC tablet 8345810 327507611 60006593139 60006593139 THPpant40.8tab proton pump inhibitors 65862-0560-90T 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 cyclobenzaprine THP 8 EA cyclobenzaprine 10 mg tablet 8345811 327508117 60006593140 60006593140 THPcyclo108.tab skeletal muscle relaxants 43547-0400-10P 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 nitrofurantoin THP 8 EA nitrofurantoin monohydrate 100mg cap 8345812 327508253 60006593141 60006593141 THPnitrof100.8cap urinary anti-infectives 47781-0303-01T 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 clindamycin THP 8 EA clindamycin 150 mg capsule 8345813 327508656 60006593142 60006593142 THPclind1508.cap lincomycin derivatives 00904-5959-61T 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 ciprofloxacin THP 8 EA ciprofloxacin 500 mg tablet 8345814 327510036 60006593143 60006593143 THPcipro5008.tab quinolones 00904-7083-61T 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 1/5/2024 14:11 35 35 0 35 Formulary 0 253 ciprofloxacin THP 8 EA ciprofloxacin 250 mg tablet 8345815 327510538 60006593144 60006593144 THPcipro2508.tab quinolones 65862-0076-01T 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 1/5/2024 14:04 35 35 0 35 Formulary 0 253 cephalexin THP 8 EA cephalexin 500 mg capsule 8345816 327511026 60006593145 60006593145 THPcepha5008.cap first generation cephalosporins 50268-0152-15K 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 1/5/2024 14:00 35 35 0 35 Formulary 0 253 cephalexin THP 8 EA cephalexin 250 mg capsule 8345817 327511572 60006593146 60006593146 THPcepha2508.cap first generation cephalosporins 50268-0151-15T 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 1/5/2024 13:58 35 35 0 35 Formulary 0 253 amoxicillin THP 8 EA amoxicillin 250mg chew tab 8345818 327511680 60006593147 60006593147 THPamox250.8chew aminopenicillins 00093-2268-01A 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 hydrOXYzine THP 8 EA hydrOXYzine pamoate 25 mg capsule 8345820 327512586 60006593148 60006593148 THPhydroxpam258.cap antihistamines 00185-0674-01T 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 amoxicillin-clavulanate THP 8 EA amoxicillin-clavulanate 875 mg-125 mg tablet 8345825 327614407 60006593152 60006593152 THPamoxclav875.8tab penicillins/beta-lactamase inhibitors 42571-0162-42T 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 1/5/2024 11:05 35 35 0 35 Formulary 0 253 ketorolac THP 8 EA ketorolac 10 mg tablet 8345827 327617767 60006593153 60006593153 THPketor10.8tab nonsteroidal anti-inflammatory agents 60687-0104-21P 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 1/8/2024 8:56 35 35 0 35 Formulary 0 253 levoFLOXacin THP 8 EA levoFLOXacin 500 mg tablet 8345828 327619174 60006593154 60006593154 THPlevofl500.8tab quinolones 00904-6352-61P 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 LORazepam THP 8 EA LORazepam 0.5 mg tablet 8345829 327621453 60006593155 60006593155 THPLORaz0.5.8tab benzodiazepine anticonvulsants 60687-0401-01P 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 meclizine THP 8 EA meclizine 25 mg tablet 8345830 327622382 60006593156 60006593156 THPmecli25.8tab anticholinergic antiemetics 42806-0014-01T 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 metoclopramide THP 8 EA metoclopramide 5 mg tablet 8345831 327623609 60006593157 60006593157 THPmetocl5.8tab miscellaneous antiemetics 00093-2204-01T 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 metroNIDAZOLE THP 8 EA metroNIDAZOLE 500 mg tablet 8345832 327624342 60006593158 60006593158 THPmetron500.8tab amebicides 50111-0334-01P 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 ondansetron THP 8 EA ondansetron 4 mg tablet 8345834 327653612 60006593159 60006593159 THPondans4.8tab 5ht3 receptor antagonists 51079-0524-20T 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 phenazopyridine THP 8 EA phenazopyridine 100 mg tablet 8345835 327660760 60006593160 60006593160 THPphenaz100.8tab miscellaneous genitourinary tract agents 75826-0114-10T 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 phenytoin THP 8 EA phenytoin 100 mg ER capsule 8345837 327661855 60006593161 60006593161 THPphenytER100.8cap group i antiarrhythmics 65162-0212-10T 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 prochlorperazine THP 8 EA prochlorperazine 10 mg tablet 8345840 327664198 60006593162 60006593162 THPprochl10.8tab phenothiazine antiemetics 59746-0115-06T 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 promethazine THP 8 EA promethazine 25 mg tablet 8345843 327665039 60006593163 60006593163 THPprometh25.8tab phenothiazine antiemetics 00591-5307-01T 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 sulfamethoxazole-trimethoprim THP 8 EA sulfamethoxazole-trimethoprim 800 mg-160 mg tablet 8345844 327665407 60006593164 60006593164 THPsulf-trimDS.8tab sulfonamides 00904-2725-61K 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 12/13/2023 0:00 35 35 0 35 Formulary 0 253 oseltamivir THP 10 EA oseltamivir 75 mg capsule 8345845 327666398 60006593165 60006593165 THPose75.10cap neuraminidase inhibitors 00004-0800-85P 1 EA 10 EA Bulk PMC - DIRECT COST PMC COST 3.5 12/13/2023 0:00 35 35 0 35 Formulary 0 253 amoxicillin-clavulanate THP 100 mL amoxicillin-clavulanate 400 mg-57 mg/5 mL powder 8345870 327931875 60006593176 60006593176 thpamoxclav100.pow penicillins/beta-lactamase inhibitors 00143-9982-01T 1 EA 100 mL Bulk PMC - DIRECT COST PMC COST 0.0561 1/30/2024 0:00 5.61 5.61 0 5.61 Formulary 0 253 cefdinir THP 100 mL cefdinir 125 mg/5 mL Powder 8345873 327979845 60006593179 60006593179 THPcefdi125100.pow third generation cephalosporins 68180-0722-05T 1 EA 100 mL Bulk PMC - DIRECT COST PMC COST 0.35 12/13/2023 0:00 35 35 0 35 Formulary 0 253 amoxicillin-clavulanate THP 50 mL amoxicillin-clavulanate 200 mg-28.5 mg/5 mL powder 8345874 327980368 60006593180 60006593180 THPamoxclav20050.pow penicillins/beta-lactamase inhibitors 65862-0533-50T 1 EA 50 mL Bulk PMC - DIRECT COST PMC COST 0.7 12/13/2023 0:00 35 35 0 35 Formulary 0 253 oxymetazoline nasal THP 15 mL oxymetazoline nasal 0.05% spray 8345875 327981450 60006593181 60006593181 THPoxymet0.0515.spray nasal antihistamines and decongestants 00904-7006-35T 1 EA 15 mL Bulk PMC - DIRECT COST PMC COST 2.33333 12/13/2023 0:00 34.99995 34.99995 0 35 Formulary 0 253 amoxicillin-clavulanate THP 50 mL amoxicillin-clavulanate 400 mg-57 mg/5 mL powder 8345876 327982365 60006593182 60006593182 THPamoxclav40050.pow penicillins/beta-lactamase inhibitors 65862-0534-50T 1 EA 50 mL Bulk PMC - DIRECT COST PMC COST 0.7 12/13/2023 0:00 35 35 0 35 Formulary 0 253 ciprofloxacin ophthalmic THP 5 mL ciprofloxacin ophthalmic 0.3% soln 8345877 327982617 60006593183 60006593183 THPcipro0.35.opth ophthalmic anti-infectives 69315-0308-05T 1 EA 5 mL Bulk PMC - DIRECT COST PMC COST 7 1/5/2024 14:15 35 35 0 35 Formulary 0 253 gentamicin ophthalmic THP 5 mL gentamicin ophthalmic 0.3% soln 8345878 327983043 60006593184 60006593184 THPgen0.35.opthsoln ophthalmic anti-infectives 61314-0633-05T 1 EA 5 mL Bulk PMC - DIRECT COST PMC COST 7 12/13/2023 0:00 35 35 0 35 Formulary 0 253 nystatin topical THP 15 gm nystatin topical 100000 units/g powder 8345879 327983553 60006593185 60006593185 THPnyst10000015.pow topical antifungals 00832-0465-15T 1 EA 15 gm Bulk PMC - DIRECT COST PMC COST 2.33333 12/13/2023 0:00 34.99995 34.99995 0 35 Formulary 0 253 calcium carbonate calcium carbonate 750 mg Chew tab 8345908 328033195 60006593209 60006593209 calchew750 antacids 00135-0074-25 1 tab(s) 1 EA MED - COA PMC - DIRECT COST PMC COST 0.0395 1/8/2024 8:51 0.0395 0.0395 0 0.04 Formulary 0 637 acetylcysteine acetylcysteine 10% 4mL soln 8345909 328033335 60006593210 60006593210 aceinh10 mucolytics 00517-7504-25 1 vial(s) 4 mL MED - COA PMC - MED PMC COST 2.4614 12/28/2023 8:17 9.8456 9.8456 0 62.6 Formulary 0 636 amoxicillin-clavulanate amoxicillin-clav 400-57mg/5mL 50mL susp 8346020 329058669 60006593220 60006593220 amoxclav40057 penicillins/beta-lactamase inhibitors 65862-0534-50 1 bottle 50 mL Bulk PMC - MED PMC COST 0.077 1/23/2024 15:51 3.85 3.85 0 38.2 Formulary 0 637 benzocaine/butamben/tetracaine topical benzocaine/butamben/tetracaine topical 14%-2%-2% aerosol 5gm 8346024 329058871 60006593224 60006593224 benbuttet5 mouth and throat products 10223-0201-04 1 bottle 5 gm Bulk PMC - MED PMC COST 10.632 12/28/2023 13:11 53.16 53.16 0 216.2 Formulary 0 637 clindamycin clindamycin 600mg/50mL NS IVPB (Baxter) (G/K) 8346036 329059393 60006593232 60006593232 cli600NSpremix lincomycin derivatives 00338-9549-24 1 bag 50 mL IVPB - COA PMC - IV FLUIDS PMC COST 0.08164 1/11/2024 13:14 4.082 4.082 4.08 28 Formulary J0737 "Inj, clindamycin (baxter)" 1 636 JZ nystatin topical nystatin topical powder 60gm 8345939 328329174 60006593277 60006593277 nyspwdr60 topical antifungals 68308-0152-60 1 bottle 60 gm Bulk PMC - MED PMC COST 0.33 1/11/2024 9:24 19.8 19.8 0 122.3 Formulary 0 637 pneumococcal 20-valent conjugate vaccine pneumococcal 20-valent conjugate vaccine 0.5mL 8345955 328423599 60006593290 60006593290 prevnar20 bacterial vaccines 00005-2000-10 1 EA 0.5 mL INJ - COA PMC - INJ PMC COST 463.74 11/22/2023 0:00 231.87 231.87 0 472.8 Formulary 0 636 90677 pneumococcal 20-valent vaccine-refused* vaccine pneumococcal 20-valent refused 8346243 331210969 60006593371 DONOTLOAD vacpne20ref 00000-0002-20 1 EA 1 EA MED - COA No Charge AWP 0 2/18/2022 7:59 0 0 0 0 Formulary 0 9999 pneumococcal 20-valent vaccine-contraind vaccine pneumococcal 20-valent contraindicated 8346244 331211685 60006593372 DONOTLOAD vacpne20con 00000-0002-21 1 EA 1 EA MED - COA No Charge AWP 0 2/18/2022 8:22 0 0 0 0 Formulary 0 9999 Dextrose 5% in Water intravenous solutio dextrose 5% water 250mL 8316821 685176 60006593414 60006593414 D5250 intravenous nutritional products 00264-7510-20 1 bag 250 mL LVP - COA PMC - IV FLUIDS PMC COST 0.01712 11/15/2021 10:16 4.28 4.28 4.28 28 Formulary J7060 5% dextrose/water 1 636 Dextrose 10% in Water intravenous soluti dextrose 10% water 500mL 8316786 697377 60006593415 60006593415 d10500 63323-0824-75 1 bag 500 mL LVP - COA PMC - IV FLUIDS PMC COST 0.00665 12/28/2023 16:13 3.325 3.325 0 28 Formulary 0 259 "diphtheria/haem/hepB/pert,acel/polio/tet" "VFC - diphtheria/haem/hepB/pert,acel/polio/tetan 0.5mL syringe" 8408164 331917041 60006593445 DONOTLOAD vaxelis0.5VFC vaccine combinations 63361-0243-15V 1 EA 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0 4/14/2023 10:04 0 0 0 0 Formulary 0 636 90697 SL magnesium oxide magnesium oxide 400mg tab 8410333 331967655 60006593472 60006593472 magox400oral minerals and electrolytes 00603-0209-22 1 EA 1 EA MED - COA PMC - MED PMC COST 0.02742 1/12/2024 7:09 0.02742 0.02742 0 10 Formulary 0 637 ibuprofen ibuprofen 100 mg/5 mL susp 120 mL 8532429 333274974 60006593514 60006593514 ibu100bulk nonsteroidal anti-inflammatory agents 00904-5577-20 1 bottle 120 mL Bulk PMC - MED PMC COST 0.03153 1/12/2024 7:09 3.7836 3.7836 0 37.6 Formulary 0 637 melatonin melatonin 1 mg tab 8674079 335142757 60006593610 60006593610 melato1 nutraceutical products 80681-0041-00 1 EA 1 EA MED - COA PMC - MED PMC COST 0.01767 1/12/2024 7:09 0.01767 0.01767 0 10 Formulary 0 637 clobetasol topical clobetasol topical 0.05% 30gm cream 8674271 335149394 60006593612 60006593612 clo0.0530 topical steroids 21922-0016-05 1 tube 30 gm Bulk PMC - MED PMC COST 0.2353 12/28/2023 15:34 7.059 7.059 0 45.9 Formulary 0 637 loratadine loratadine 10mg tab 8760047 336263315 60006593641 60006593641 lort10 antihistamines 50268-0489-15 1 tab(s) 1 EA MED - COA PMC - MED PMC COST 0.2028 1/12/2024 7:09 0.2028 0.2028 0 10 Formulary 0 637 riTUXimab riTUXimab-arrx (Riabni) 10mg/mL 50mL vial (G/K) 8806932 337024488 60006593662 60006593662 riTarrx500 cd20 monoclonal antibodies 55513-0326-01 1 vial(s) 50 mL IVPB - COA PMC - INJ PMC COST 48.9216 1/12/2024 7:09 2446.08 2446.08 48.92 4901.2 Formulary Q5123 "Inj. riabni, 10 mg" 50 636 JZ riTUXimab riTUXimab-arrx (Riabni) 10mg/mL 10mL vial (G/K) 8808400 337146071 60006593666 60006593666 riTarrx100 cd20 monoclonal antibodies 55513-0224-01 1 vial(s) 10 mL IVPB - COA PMC - INJ PMC COST 48.922 1/12/2024 7:09 489.22 489.22 48.92 987.5 Formulary Q5123 "Inj. riabni, 10 mg" 10 636 JZ amoxicillin THP 8 EA amoxicillin 500 mg capsule 8824430 338268734 60006593712 60006593712 THPamox5008.cap aminopenicillins 00781-2613-01T 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 1/5/2024 16:23 35 35 0 35 Formulary 0 253 methylPREDNISolone methylPREDNISolone sod succ 40mg vial 8867311 341928949 60006593803 60006593803 metsodsucc40 glucocorticoids 43598-0127-25 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 1.8164 1/12/2024 7:09 1.8164 1.8164 1.82 29 Formulary J2920 Methylprednisolone injection up to 40 mg 1 636 methylPREDNISolone methylPREDNISolone sod succ 125mg vial 8869859 341927014 60006593804 60006593804 metsodsuc125 glucocorticoids 43598-0129-25 1 vial(s) 1 EA INJ - COA PMC - INJ PMC COST 2.1188 1/18/2024 0:00 2.1188 2.1188 2.12 30.2 Formulary J2930 Methylprednisolone injection up to 125 mg 1 636 menthol topical menthol 7.5mg lozenge 8867331 341926516 60006593819 60006593819 menth7.5 topical rubefacient 12546-0628-69 1 lozenge(s) 1 EA MED - COA PMC - DIRECT COST PMC COST 0.069 1/19/2024 9:17 0.069 0.069 0 0.07 Formulary 0 637 venlafaxine venlafaxine 25mg tablet 8869930 341927809 60006593824 60006593824 ven25tab ssnri antidepressants 68084-0896-25 1 tab(s) 1 EA MED - COA PMC - MED PMC COST 0.741 1/12/2024 7:09 0.741 0.741 0 13.2 Formulary 0 637 lidocaine topical lidocaine 2% viscous 100mL 8876218 343497035 60006593858 60006593858 lid2visc100 topical anesthetics 00054-3500-49 1 bottle 100 mL Bulk PMC - MED PMC COST 0.0916 1/12/2024 7:09 9.16 9.16 0 58.5 Formulary 0 259 gadobutrol RAD gadobutrol 1mmol/mL 15mL soln 8920701 349763937 60006594041 60006594041 RAD gadobutrol (Gadavist) 1mmol/mL 15mL soln magnetic resonance imaging contrast media 50419-0325-13 1 vial(s) 15 mL INJ - COA PMC - DIRECT COST PMC COST 2.90866 4/10/2023 11:43 43.6299 43.6299 0.29 43.63 Formulary A9585 Gadobutrol injection 150 636 fluconazole fluconazole 10mg/mL 35mL susp 8952092 354498743 60006594159 60006594159 flu10suspbulk azole antifungals 57237-0149-35 1 bottle 35 mL Bulk PMC - MED PMC COST 0.2291 12/29/2023 13:14 8.0185 8.0185 0 51.7 Formulary 0 637 "influenza vaccine, inact" "influenza vacc (FluLaval) quad PF, 6 months and over" 8948586 354742635 60006594195 60006594195 Flulaval2023 viral vaccines 19515-0814-52 1 syringe(s) 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 32.286 1/12/2024 7:09 16.143 16.143 0 16.14 Formulary 0 636 90686 "influenza vaccine, inact" "influenza vacc (Fluzone HD) high-dose PF, 65 years & over 0.7mL" 8948593 354747696 60006594197 60006594197 FluzoneHD2023 viral vaccines 49281-0123-65 1 syringe(s) 0.7 mL INJ - COA PMC - DIRECT COST PMC COST 107.1428 9/27/2023 10:10 74.99996 74.99996 0 75 Formulary 0 636 90662 "influenza vaccine, inact" "influenza vacc (FluZone) quad PF, 6 months and over 0.5mL" 8954798 355012102 60006594200 60006594200 Fluzone2023 viral vaccines 49281-0423-50 1 syringe(s) 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 70 9/27/2023 10:08 35 35 0 35 Formulary 0 636 90686 "diphtheria/pertussis,acel/tetanus/polio" diphtheria/pertussis/tetanus/polio peds (Quadracel) 0.5mL 8954895 355091819 60006594202 60006594202 Quadracel vaccine combinations 49281-0564-15 1 syringe(s) 0.5 mL INJ - COA PMC - INJ PMC COST 130 8/10/2023 9:33 65 65 0 269 Formulary 0 636 90696 "influenza vaccine, inact" influenza vacc (Flublok) 18 years and older 8951726 355093850 60006594204 60006594204 Flublok2023 viral vaccines 49281-0723-10 1 syringe(s) 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 156 8/30/2023 0:00 78 78 0 78 Formulary 0 636 90682 "influenza virus vaccine, live" "VFC - influenza vacc (FluMist nasal) quad, live 0.2mL" 8954981 355133516 60006594207 60006594207 FluMistVFC2023 viral vaccines 66019-0310-10 1 EA 1 EA MED - COA PMC - DIRECT COST PMC COST 0 9/27/2023 10:11 0 0 0 0 Formulary 0 636 90672 "influenza vaccine, inact" "VFC - influenza vacc (FluZone) quad PF, 6 months and over" 8957013 355644536 60006594223 60006594223 Fluzone2023VFC viral vaccines 49281-0423-50 1 syringe(s) 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0 9/27/2023 10:09 0 0 0 0 Formulary 0 636 90686 "influenza virus vaccine, live" "influenza vacc (FluMist nasal) quad, live 0.2mL" 8958268 355727483 60006594227 60006594227 FluMist2023 viral vaccines 66019-0310-10 1 EA 1 EA MED - COA PMC - DIRECT COST PMC COST 45 8/30/2023 0:00 45 45 0 45 Formulary 0 636 90672 SARS-CoV-2 (COVID-19) mRNA-LNP(12+yr) va SARS-CoV-2 (COVID-19) (Moderna) mRNA-LNP 0.5 mL vaccine 8964921 356912949 60006594261 60006594261 Spikevax50 viral vaccines 80777-0102-93 1 vial(s) 0.5 mL INJ - COA PMC - INJ PMC COST 56.4 11/2/2023 0:00 28.2 28.2 0 150 Formulary 0 636 91322 SARS-CoV-2 (COVID-19) mRNA-LNP(6mo-12yr) SARS-CoV-2 (COVID-19) (PED Moderna 6mo-11yr) 0.25mL vaccine 8963530 357026838 60006594262 60006594262 SARPEDMOD0.25 viral vaccines 80777-0287-92 1 EA 0.25 mL INJ - COA PMC - INJ PMC COST 600 11/29/2023 11:04 150 150 0 459 Formulary 0 636 91321 SARS-CoV-2 (COVID-19) mRNA-LNP(6mo-12yr) VFC- SARS-CoV-2 (COVID-19) (PED Moderna 6mo-11yr) 0.25mL vaccine 8966635 357028111 60006594263 60006594263 SARPEDMOD0.25VFC viral vaccines 80777-0287-92 1 EA 0.25 mL INJ - COA PMC - DIRECT COST PMC COST 0 11/11/2023 0:00 0 0 0 0 Formulary 0 636 91321 SARS-CoV-2 (COVID-19) mRNA-LNP(12+yr) va VFC - SARS-CoV-2 (COVID-19) (Moderna) mRNA-LNP 0.5 mL vaccine 8966643 357028456 60006594264 60006594264 Spikevax50VFC viral vaccines 80777-0102-93 1 EA 0.5 mL INJ - COA PMC - DIRECT COST PMC COST 0 11/11/2023 0:00 0 0 0 0 Formulary 0 636 91322 Sodium Chloride 0.9% sodium chloride 0.9% 100mL (ADC) 8968238 357518926 60006594277 60006594277 NS100adc intravenous nutritional products 00264-1800-32 1 bag 100 mL IVPB - COA PMC - IV FLUIDS PMC COST 0.0164 1/10/2024 9:31 1.64 1.64 0 28 Formulary 0 259 Sodium Chloride 0.9% sodium chloride 0.9% 50mL (ADC) 8970085 357523146 60006594278 60006594278 NS50adc intravenous nutritional products 00264-1800-31 1 bag 50 mL IVPB - COA PMC - IV FLUIDS PMC COST 0.02 10/16/2023 8:10 1 1 0 28 Formulary 0 259 Sodium Chloride 0.9% sodium chloride 0.9% 250mL (ADC) 8971931 358967749 60006594314 60006594314 NS250ADC intravenous nutritional products 00409-7983-02 1 bag 250 mL IVPB - COA PMC - IV FLUIDS PMC COST 0.00668 1/10/2024 9:33 1.67 1.67 1.67 28 Formulary J7050 Normal saline solution infus 250 cc 1 636 amoxicillin amoxicillin 500mg tablet 8974869 359591974 60006594328 60006594328 amox500tab aminopenicillins 65862-0014-01 1 EA 1 EA MED - COA PMC - MED PMC COST 0.07 12/4/2023 12:54 0.07 0.07 0 10 Formulary 0 637 cyclopentolate ophthalmic THP 2 mL cyclopentolate opthalmic 1% 8981105 360750573 60006594362 60006594362 THPcyclop2.sol 61314-0396-01T 1 EA 2 mL Bulk PMC - DIRECT COST PMC COST 17.5 1/5/2024 15:45 35 35 0 35 Formulary 0 253 phenylephrine nasal THP 15 mL phenylephrine nasal 0.5% 8986646 360750718 60006594363 60006594363 THPphenyl0.515spray 00225-0805-47T 1 EA 15 mL Bulk PMC - DIRECT COST PMC COST 2.333 1/8/2024 9:05 34.995 34.995 0 34.99 Formulary 0 253 venlafaxine venlafaxine ER 225mg tablet 8981293 360879151 60006594369 60006594369 venXR225mg ssnri antidepressants 67877-0729-30 1 tab(s) 1 EA MED - COA PMC - MED PMC COST 0.98 1/9/2024 15:03 0.98 0.98 0 16.3 Formulary 0 637 immune globulin intravenous immune globulin (Octagam) 2gm/20mL premix (G/K) 8984805 360882264 60006594370 60006594370 octa2gmpremix immune globulins 68982-0850-01P 1 vial(s) 20 mL LVP - COA PMC - IV FLUIDS PMC COST 8.95 1/9/2024 15:30 179 179 44.75 285 Formulary J1568 Octagam injection 4 636 JZ immune globulin intravenous USE IV SET - immune globulin (Octagam) 2gm/20mL vial (G/K) 8986867 360882444 60006594370 DONOTLOAD USEIVSETOCTA2gm immune globulins 68982-0850-01 1 vial(s) 20 mL LVP - COA PMC - IV FLUIDS PMC COST 8.95 1/9/2024 15:38 179 179 44.75 285 Formulary J1568 Octagam injection 4 636 JW dexamethasone dexAMETHasone 1mg/mL ORAL conc 30mL MDC 8984814 360882657 60006594371 60006594371 dexamethconc glucocorticoids 00054-3176-44 1 bottle 30 mL Special Delivery MDC COA PMC - MED PMC COST 0.7286 1/9/2024 16:15 21.858 21.858 0 120 Formulary 0 637 dexamethasone dexAMETHasone 0.5 mg/5 mL ORAL liquid 240mL MDC 8986869 360882845 60006594372 60006594372 dex0.5240mLMDC glucocorticoids 00054-3177-57 1 bottle 240 mL Special Delivery MDC COA PMC - MED PMC COST 0.1737 1/9/2024 16:56 41.688 41.688 0 200 Formulary 0 637 testosterone testosterone cypionate 200mg/mL 10mL MDV 8981323 360910445 60006594373 60006594373 test200MDV androgens and anabolic steroids 00009-0417-02 1 vial(s) 10 mL MDV INJ - COA PMC - INJ PMC COST 3.63 1/10/2024 8:40 36.3 36.3 0.02 190.5 Formulary J1071 Inj testosterone cypionate 2000 636 cyanocobalamin cyanocobalamin 250mcg tablet 8986924 360917057 60006594374 60006594374 cyan250mcg vitamins 50268-0853-15 1 tab(s) 1 EA MED - COA PMC - DIRECT COST PMC COST 0.164 1/11/2024 8:29 0.164 0.164 0 0.16 Formulary 0 637 amoxicillin THP 80mL amoxicillin 125mg/5mL Powder 8985545 361196199 60006594375 60006594375 thpamox125.80.pow aminopenicillins 00781-6039-58T 1 EA 80 mL Bulk PMC - DIRECT COST PMC COST 0.4375 1/16/2024 13:50 35 35 0 35 Formulary 0 253 levoFLOXacin THP 8 EA levoFLOXacin 250 mg tablet 8987488 361256610 60006594377 60006594377 thplevo250.8tab 00904-6351-61P 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 1/17/2024 11:19 35 35 0 35 Formulary 0 253 nystatin topical "THP 60gm nystatin 100,000 units/g powder" 8987493 361257963 60006594378 60006594378 THPnystpow.60gm topical antifungals 00832-0465-60T 1 EA 60 gm Bulk PMC - DIRECT COST PMC COST 0.5833 1/17/2024 11:36 34.998 34.998 0 35 Formulary 0 253 venlafaxine venlafaxine ER 150mg tablet 8988341 361433578 60006594382 60006594382 venER150tab ssnri antidepressants 67877-0728-90 1 tab(s) 1 EA MED - COA PMC - MED PMC COST 0.3217 1/19/2024 11:58 0.3217 0.3217 0 10 Formulary 0 637 dexamethasone dexAMETHasone 0.5 mg/5 mL ORAL liquid 500mL MDC 8992093 361435239 60006594383 60006594383 dex0.5500MDC glucocorticoids 00054-3177-63 1 bottle 500 mL Special Delivery MDC COA PMC - MED PMC COST 0.02964 1/19/2024 14:46 14.82 14.82 0 92.5 Formulary 0 637 clobetasol topical clobetasol 0.05% ointment 30gm 8988364 361437441 60006594384 60006594384 clob0.0530 topical steroids 51672-1259-02 1 tube 30 gm Bulk PMC - MED PMC COST 0.2533 1/19/2024 14:59 7.599 7.599 0 49.1 Formulary 0 637 amoxicillin-clavulanate amoxicillin-clav 200-28.5mg/5 mL 75mL 8992297 361557079 60006594386 60006594386 amoxclav200susp75 penicillins/beta-lactamase inhibitors 65862-0533-75 1 bottle 75 mL Bulk PMC - MED PMC COST 0.04413 1/23/2024 16:06 3.30975 3.30975 0 33.3 Formulary 0 637 amoxicillin THP 8 EA amoxicillin 250 mg capsule 8994309 361603826 60006594387 60006594387 THPamox2508.cap aminopenicillins 00781-2020-01P 1 EA 8 EA Bulk PMC - DIRECT COST PMC COST 4.375 1/24/2024 12:38 35 35 0 35 Formulary 0 253 amoxicillin-clavulanate THP 75 mL amoxicillin-clavulanate 200-28.5mg/5 mL powder 8994363 361680160 60006594388 60006594388 THPaugm20075.pow penicillins/beta-lactamase inhibitors 65862-0533-75T 1 EA 75 mL Bulk PMC - DIRECT COST PMC COST 0.4667 1/26/2024 11:34 35.0025 35.0025 0 35 Formulary 0 253 mupirocin topical THP 15 gm mupirocin 2% topical ointment 8996478 361744499 60006594391 60006594391 thpmup15.oint topical antibiotics 51672-1312-01T 1 EA 15 gm Bulk PMC - DIRECT COST PMC COST 2.333 1/29/2024 12:09 34.995 34.995 0 34.99 Formulary 0 253 atropine ophthalmic THP 2mL atropine 1% ophthalmic soln 8992461 361744627 60006594392 60006594392 THPatrop2mL.soln mydriatics 60219-1748-02T 1 bottle 2 mL Bulk PMC - DIRECT COST PMC COST 17.5 1/29/2024 12:24 35 35 0 35 Formulary 0 253 pneumococcal 23-valent vaccine pneumococcal 23-valent vaccine 0.5 mL 8318214 2778674 60006800163 60006800163 pneumo23 bacterial vaccines 00006-4943-00 1 vial(s) 0.5 mL MED - COA PMC - INJ PMC COST 124 11/15/2021 10:34 62 62 0 257 Formulary 0 636 90732 Normal Saline Diluent Normal Saline Diluent Premix 8322801 37013741 PREMIX PREMIX NSPremix 11111-1111-14 1 mL 1 mL LVP - COA No Charge AWP 0 9/25/2012 15:53 0 0 0 0 Formulary 0 9999 Dextrose 5% Diluent Dextrose 5% Diluent Premix 8322802 37015660 PREMIX PREMIX DexPremix 11111-1111-15 1 mL 1 mL LVP - COA No Charge AWP 0 9/25/2012 16:09 0 0 0 0 Formulary 0 9999 Sterile Water Diluent Sterile Water Diluent Premix 8322804 37017951 PREMIX PREMIX SWPremix 11111-1111-16 1 mL 1 mL LVP - COA No Charge AWP 1 9/25/2012 16:18 1 1 0 0 Formulary 0 9999