| 09858237 | AMOXICILLIN | Moxilen Forte 250mg/5mL (Temporary Benefit) 50mg/mL Pd for Oral Susp | JUN | 0.0810 | 0.0810 | NO | NO | NO |
| 02460955 | CASPOFUNGIN | Caspofungin for Injection (Off-Formulary Interchangeable) 70mg/Vial Inj Pd-Vial Pk | JUN | 222.0000 | 222.0000 | YES | NO | NO |
| 02460947 | CASPOFUNGIN ACETATE | Caspofungin for Injection (Off-Formulary Interchangeable) 50mg/Vial Inj-Vial Pk | JUN | 222.0000 | 222.0000 | YES | NO | NO |
| 09858335 | CHOLESTYRAMINE RESIN | Cholestyramine for Oral Suspension USP (Temporary Benefit) 4g Pd for Oral Susp | JUN | 0.9000 | 0.9000 | NO | NO | NO |
| 02511738 | DAPTOMYCIN | Daptomycin for Injection (Off-Formulary Interchangeable) 500mg/Vial Pd for Inj Sol-Vial Pk | JUN | 162.3500 | 162.3500 | YES | NO | NO |
| 02506440 | ENOXAPARIN | Noromby 20mg/0.2mL Inj Sol-0.2mL Pref Syr (Preservative-Free) | JUN | 3.5280 | 3.5280 | NO | NO | NO |
| 02506459 | ENOXAPARIN | Noromby 30mg/0.3mL Inj Sol-0.3mL Pref Syr (Preservative-Free) | JUN | 4.9124 | 4.9124 | NO | NO | NO |
| 02506467 | ENOXAPARIN | Noromby 40mg/0.4mL Inj Sol-0.4mL Pref Syr (Preservative-Free) | JUN | 6.5498 | 6.5498 | NO | NO | NO |
| 02506475 | ENOXAPARIN | Noromby 60mg/0.6mL Inj Sol-0.6mL Pref Syr (Preservative-Free) | JUN | 9.8248 | 9.8248 | NO | NO | NO |
| 02506483 | ENOXAPARIN | Noromby 80mg/0.8mL Inj Sol-0.8mL Pref Syr (Preservative-Free) | JUN | 13.0997 | 13.0997 | NO | NO | NO |
| 02506505 | ENOXAPARIN | Noromby HP 120mg/0.8mL Inj Sol-0.8mL Pref Syr (Preservative-Free) | JUN | 19.6495 | 19.6495 | NO | NO | NO |
| 02506491 | ENOXAPARIN | Noromby 100mg/mL Inj Sol-1mL Pref Syr (Preservative-Free) | JUN | 16.3746 | 16.3746 | NO | NO | NO |
| 02506513 | ENOXAPARIN | Noromby HP 150mg/mL Inj Sol-1mL Pref Syr (Preservative-Free) | JUN | 24.5619 | 24.5619 | NO | NO | NO |
| 02490773 | ERTAPENEM | Ertapenem for Injection (Off-Formulary Interchangeable) 1g/Vial Inj Pd-Vial Pk | JUN | 52.2650 | 52.2650 | YES | NO | NO |
| 02524961 | MICAFUNGIN SODIUM | Micafungin Sodium for Injection (Off-Formulary Interchangeable) 100mg/Vial Inj Pd-10mL Vial Pk | JUN | 186.2000 | 186.2000 | YES | NO | NO |
| 02524953 | MICAFUNGIN SODIUM | Micafungin Sodium for Injection (Off-Formulary Interchangeable) 50mg/Vial Inj Pd-10mL Vial Pk | JUN | 93.1000 | 93.1000 | YES | NO | NO |
| 09858317 | NITROGLYCERIN | Nitrolingual Pumpspray (Temporary Benefit) 0.4mg/Metered Dose Sp-180 Dose Pk | JUN | 8.4200 | 8.4200 | NO | NO | NO |