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Products found: 138

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DIN/ PIN/ NPN	Generic Name	Brand Name, Strength & Dosage Form	MFR	Drug Benefit Price or Unit Price	Amount MOH Pays	Inter- change- able	Limited Use	Thera- peutic Notes
00226327	ACETYLSALICYLIC ACID & BUTALBITAL & CAFFEINE	Fiorinal (Off-Formulary Interchangeable) 330mg & 50mg & 40mg Cap	NOV	N/A	N/A	YES	NO	YES
00176206	ACETYLSALICYLIC ACID & BUTALBITAL & CAFFEINE & CODEINE PHOSPHATE	Fiorinal C1/2 (Off-Formulary Interchangeable) 330mg & 50mg & 40mg & 30mg Cap	NOV	N/A	N/A	YES	NO	YES
00176192	ACETYLSALICYLIC ACID & BUTALBITAL & CAFFEINE & CODEINE PHOSPHATE	Fiorinal C1/4 (Off-Formulary Interchangeable) 330mg & 50mg & 40mg & 15mg Cap	NOV	N/A	N/A	YES	NO	YES
02163136	ALUMINUM HYDROXIDE & MAGNESIUM HYDROXIDE	Maalox (Not a Benefit) 40mg & 40mg/mL O/L	NOV	N/A	N/A	YES	NO	NO
02162369	ALUMINUM HYDROXIDE & MAGNESIUM HYDROXIDE	Maalox TC (Not a Benefit) 120mg & 60mg/mL O/L	NOV	N/A	N/A	YES	NO	NO
02208253	ALUMINUM HYDROXIDE & MAGNESIUM HYDROXIDE	Maalox (Not a Benefit) 400mg & 400mg Tab	NOV	N/A	N/A	YES	NO	NO
02131064	BACLOFEN	Lioresal Intrathecal (Off-Formulary Interchangeable) 2mg/mL Inj Sol (Preservative-Free)	NOV	N/A	N/A	YES	NO	YES
02131048	BACLOFEN	Lioresal Intrathecal (Off-Formulary Interchangeable) 0.05mg/mL Inj Sol-1mL Pk (Preservative-Free)	NOV	N/A	N/A	YES	NO	YES
02131056	BACLOFEN	Lioresal Intrathecal (Off-Formulary Interchangeable) 0.5mg/mL Inj Sol-20mL Pk (Preservative-Free)	NOV	N/A	N/A	YES	NO	YES
00455881	BACLOFEN	Lioresal 10mg Tab	NOV	0.8795	0.1595	YES	NO	YES
00636576	BACLOFEN	Lioresal DS 20mg Tab	NOV	1.7122	0.3104	YES	NO	YES
00885835	BENAZEPRIL	Lotensin (Not a Benefit) 5mg Tab	NOV	N/A	N/A	YES	NO	NO
00885851	BENAZEPRIL	Lotensin (Not a Benefit) 20mg Tab	NOV	N/A	N/A	YES	NO	NO
00885843	BENAZEPRIL	Lotensin (Not a Benefit) 10mg Tab	NOV	N/A	N/A	YES	NO	NO
01908448	BETAXOLOL HCL	Betoptic S 0.25% Oph Susp	NOV	2.5580	2.5580	NO	NO	NO
02238873	BRINZOLAMIDE	Azopt 1% Oph Susp	NOV	3.5560	3.5560	NO	YES	NO
02435411	BRINZOLAMIDE & BRIMONIDINE TARTRATE	Simbrinza 1.0% & 0.2% Oph Susp-10mL Pk	NOV	50.6900	50.6900	NO	YES	NO
02331624	BRINZOLAMIDE & TIMOLOL MALEATE	Azarga 1% & 0.5% Oph Susp-5mL Pk	NOV	20.4000	20.4000	NO	YES	NO
02496976	BROLUCIZUMAB	Beovu 6mg/0.05mL Inj Sol-0.05mL Pref Syr (Preservative-Free)	NOV	1390.0000	1390.0000	NO	YES	NO
00568643	BROMOCRIPTINE	Parlodel (Not a Benefit) 5mg Cap	NOV	N/A	N/A	YES	NO	NO
00371033	BROMOCRIPTINE	Parlodel (Not a Benefit) 2.5mg Tab	NOV	N/A	N/A	YES	NO	NO
00369810	CARBAMAZEPINE	Tegretol (Not a Benefit) 100mg Chew Tab	NOV	N/A	N/A	YES	NO	NO
00665088	CARBAMAZEPINE	Tegretol (Not a Benefit) 200mg Chew Tab	NOV	N/A	N/A	YES	NO	NO
00773611	CARBAMAZEPINE	Tegretol CR 200mg LA Tab	NOV	0.5599	0.3845	YES	YES	NO
00755583	CARBAMAZEPINE	Tegretol CR 400mg LA Tab	NOV	1.1198	0.7689	YES	YES	NO
02194333	CARBAMAZEPINE	Tegretol 100mg/5mL Oral Susp	NOV	0.1074	0.0578	YES	NO	NO
00010405	CARBAMAZEPINE	Tegretol (Not a Benefit) 200mg Tab	NOV	N/A	N/A	YES	NO	NO
01945270	CIPROFLOXACIN	Ciloxan (Off-Formulary Interchangeable) 0.3% Oph Sol-5mL Pk	NOV	N/A	N/A	YES	NO	YES
02252716	CIPROFLOXACIN AND DEXAMETHASONE	Ciprodex 0.3% w/v & 0.1% w/v Otic Susp-7.5mL Pk (With Preservative)	NOV	29.6400	14.4203	YES	YES	NO
00894737	CLOZAPINE	Clozaril (Off-Formulary Interchangeable) 25mg Tab	NOV	N/A	N/A	YES	NO	NO
00894745	CLOZAPINE	Clozaril (Off-Formulary Interchangeable) 100mg Tab	NOV	N/A	N/A	YES	NO	NO
00252506	CYCLOPENTOLATE HCL	Cyclogyl (Off-Formulary Interchangeable) 1% Oph Sol	NOV	N/A	N/A	YES	NO	NO
02237671	CYCLOSPORINE	Neoral 10mg Cap	NOV	0.7115	0.7115	NO	NO	NO
02150689	CYCLOSPORINE	Neoral 25mg Cap	NOV	1.6543	0.7870	YES	NO	NO
02150662	CYCLOSPORINE	Neoral 50mg Cap	NOV	3.2267	1.5350	YES	NO	NO
02150670	CYCLOSPORINE	Neoral 100mg Cap	NOV	6.4573	3.0720	YES	NO	NO
02150697	CYCLOSPORINE	Neoral 100mg/mL O/L	NOV	5.7410	5.7410	NO	NO	NO
02452219	DEFERASIROX	Jadenu 90mg Tab	NOV	10.8920	2.6303	YES	NO	NO
02452227	DEFERASIROX	Jadenu 180mg Tab	NOV	21.7850	5.2610	YES	NO	NO
02452235	DEFERASIROX	Jadenu 360mg Tab	NOV	43.5730	10.5228	YES	NO	NO
02287447	DEFERASIROX	Exjade 500mg Tab for Susp	NOV	44.1507	20.9649	YES	NO	NO
02287439	DEFERASIROX	Exjade 250mg Tab for Susp	NOV	22.0757	10.4820	YES	NO	NO
02287420	DEFERASIROX	Exjade 125mg Tab for Susp	NOV	11.0375	5.2408	YES	NO	NO
00042579	DEXAMETHASONE	Maxidex 0.1% Oph Oint-3.5g Pk	NOV	9.7200	9.7200	NO	NO	YES
00042560	DEXAMETHASONE	Maxidex 0.1% Oph Susp	NOV	1.7900	1.7900	NO	NO	YES
00881635	DICLOFENAC POTASSIUM	Voltaren Rapide (Off-Formulary Interchangeable) 50mg Tab	NOV	N/A	N/A	YES	NO	YES
00514012	DICLOFENAC SODIUM	Voltaren 50mg Ent Tab	NOV	1.1384	0.2064	YES	NO	YES
00782459	DICLOFENAC SODIUM	Voltaren SR (Not a Benefit) 75mg LA Tab	NOV	N/A	N/A	YES	NO	YES
00590827	DICLOFENAC SODIUM	Voltaren SR (Not a Benefit) 100mg LA Tab	NOV	N/A	N/A	YES	NO	YES
01940414	DICLOFENAC SODIUM	Voltaren Ophtha 0.1% Oph Sol	NOV	4.0340	1.2397	YES	NO	YES
00632732	DICLOFENAC SODIUM	Voltaren (Not a Benefit) 100mg Sup	NOV	N/A	N/A	YES	NO	YES
00632724	DICLOFENAC SODIUM	Voltaren 50mg Sup	NOV	1.8657	1.2818	YES	NO	YES
02369257	EVEROLIMUS	Afinitor (Off-Formulary Interchangeable) 2.5mg Tab	NOV	202.6540	172.2559	YES	NO	NO
02339528	EVEROLIMUS	Afinitor (Off-Formulary Interchangeable) 10mg Tab	NOV	202.6540	172.2559	YES	NO	NO
02339501	EVEROLIMUS	Afinitor (Off-Formulary Interchangeable) 5mg Tab	NOV	202.6540	172.2559	YES	NO	NO
02365480	FINGOLIMOD	Gilenya (Off-Formulary Interchangeable) 0.5mg Cap	NOV	86.9525	73.9100	YES	NO	NO
00756784	FLUOROMETHOLONE ACETATE	Flarex 0.1% Oph Susp	NOV	2.0240	2.0240	NO	NO	YES
02061562	FLUVASTATIN SODIUM	Lescol (Not a Benefit) 20mg Cap	NOV	N/A	N/A	YES	NO	NO
02061570	FLUVASTATIN SODIUM	Lescol (Not a Benefit) 40mg Cap	NOV	N/A	N/A	YES	NO	NO
02250527	FLUVASTATIN SODIUM	Lescol XL 80mg ER Tab	NOV	1.6225	1.6225	NO	NO	NO
02230898	FORMOTEROL FUMARATE	Foradil 12mcg/Cap Inh Pd-Device Pk	NOV	55.7700	55.7700	NO	YES	NO
02394936	GLYCOPYRRONIUM BROMIDE	Seebri Breezhaler 50mcg Inh Pd-Cap	NOV	1.8302	1.8302	NO	NO	YES
00005541	HYDRALAZINE HCL	Apresoline (Not a Benefit) 50mg Tab	NOV	N/A	N/A	YES	NO	NO
00005525	HYDRALAZINE HCL	Apresoline (Not a Benefit) 10mg Tab	NOV	N/A	N/A	YES	NO	NO
02253283	IMATINIB MESYLATE	Gleevec 400mg Tab	NOV	118.9900	20.8314	YES	NO	YES
02253275	IMATINIB MESYLATE	Gleevec 100mg Tab	NOV	29.7475	5.2079	YES	NO	YES
00010480	IMIPRAMINE	Tofranil (Not a Benefit) 50mg Tab	NOV	N/A	N/A	YES	NO	NO
00010464	IMIPRAMINE	Tofranil (Not a Benefit) 10mg Tab	NOV	N/A	N/A	YES	NO	NO
00010472	IMIPRAMINE	Tofranil (Not a Benefit) 25mg Tab	NOV	N/A	N/A	YES	NO	NO
02376938	INDACATEROL	Onbrez Breezhaler 75mcg Inh Pd-Cap	NOV	1.5500	1.5500	NO	YES	NO
02418282	INDACATEROL & GLYCOPYRRONIUM	Ultibro Breezhaler 110mcg & 50mcg Inh Pd-Cap	NOV	2.5830	2.5830	NO	YES	NO
02501244	INDACATEROL ACETATE & GLYCOPYRRONIUM BROMIDE & MOMETASONE FUROATE	Enerzair Breezhaler 150mcg & 50mcg & 160mcg Inh Pd-Cap	NOV	3.4277	3.4277	NO	YES	NO
02498685	INDACATEROL ACETATE & MOMETASONE FUROATE	Atectura Breezhaler 150mcg & 80mcg Inh Pd-Cap	NOV	1.0731	1.0731	NO	YES	NO
02498707	INDACATEROL ACETATE & MOMETASONE FUROATE	Atectura Breezhaler 150mcg & 160mcg Inh Pd-Cap	NOV	1.3419	1.3419	NO	YES	NO
02498693	INDACATEROL ACETATE & MOMETASONE FUROATE	Atectura Breezhaler 150mcg & 320mcg Inh Pd-Cap	NOV	1.8473	1.8473	NO	YES	NO
02231384	LETROZOLE	Femara 2.5mg Tab	NOV	8.1127	1.3780	YES	NO	NO
00893560	LODOXAMIDE TROMETHAMINE	Alomide 0.1% Oph Sol	NOV	1.3810	1.3810	NO	NO	YES
00632775	METHYLPHENIDATE HCL	Ritalin SR (Not a Benefit) 20mg ER Tab	NOV	N/A	N/A	YES	NO	YES
00005606	METHYLPHENIDATE HCL	Ritalin 10mg Tab	NOV	0.4556	0.2216	YES	NO	YES
00005614	METHYLPHENIDATE HCL	Ritalin (Off-Formulary Interchangeable) 20mg Tab	NOV	N/A	N/A	YES	NO	YES
00534560	METOPROLOL TARTRATE	Lopresor SR (Not a Benefit) 200mg LA Tab	NOV	N/A	N/A	YES	NO	NO
00658855	METOPROLOL TARTRATE	Lopresor SR (Not a Benefit) 100mg LA Tab	NOV	N/A	N/A	YES	NO	NO
00397423	METOPROLOL TARTRATE	Lopresor (Not a Benefit) 50mg Tab	NOV	N/A	N/A	YES	NO	NO
00397431	METOPROLOL TARTRATE	Lopresor (Not a Benefit) 100mg Tab	NOV	N/A	N/A	YES	NO	NO
02252260	MOXIFLOXACIN HYDROCHLORIDE	Vigamox (Off-Formulary Interchangeable) 0.5% Oph Sol-3mL Pk (Preservative-Free)	NOV	N/A	N/A	YES	NO	NO
02264579	MYCOPHENOLATE SODIUM	Myfortic 360mg Ent Tab	NOV	3.9953	1.9977	YES	NO	NO
02264560	MYCOPHENOLATE SODIUM	Myfortic 180mg Ent Tab	NOV	1.9977	0.9989	YES	NO	NO
02046156	NITROGLYCERIN	Transderm-Nitro 0.6mg/Hr/30 Sq Cm Patch	NOV	1.0290	1.0290	NO	NO	NO
00852384	NITROGLYCERIN	Transderm-Nitro 0.4mg/Hr/20 Sq Cm Patch	NOV	1.0010	1.0010	NO	NO	NO
02239325	OCTREOTIDE	Sandostatin LAR 30mg Inj Kit Pk	NOV	2189.5200	1642.1400	YES	NO	NO
02239324	OCTREOTIDE	Sandostatin LAR 20mg Inj Kit Pk	NOV	1706.5800	1279.9350	YES	NO	NO
02239323	OCTREOTIDE	Sandostatin LAR 10mg Inj Kit Pk	NOV	1320.9300	990.6975	YES	NO	NO
00839205	OCTREOTIDE	Sandostatin 100mcg/mL Inj Sol - 1mL Amp Pk	NOV	10.0880	7.5660	YES	NO	NO
00839191	OCTREOTIDE	Sandostatin 50mcg/mL Inj Sol - 1mL Amp Pk	NOV	5.3440	4.0080	YES	NO	NO
00839213	OCTREOTIDE	Sandostatin (Not a Benefit) 500mcg/mL Inj Sol - 1mL Amp Pk	NOV	N/A	N/A	YES	NO	NO
02049392	OCTREOTIDE	Sandostatin 200mcg/mL Inj Sol - 5mL Vial Pk	NOV	97.0300	72.7725	YES	NO	NO
02362171	OLOPATADINE HCL	Pataday (Off-Formulary Interchangeable) 0.2% Oph Sol-2.5mL Pk	NOV	N/A	N/A	YES	NO	NO
02233143	OLOPATADINE HCL	Patanol (Off-Formulary Interchangeable) 0.1% Oph Sol-5mL Pk	NOV	N/A	N/A	YES	NO	NO
02213745	ONDANSETRON HCL DIHYDRATE	Zofran (Off-Formulary Interchangeable) 2mg/mL Inj Sol-2mL Pk	NOV	N/A	N/A	YES	NO	NO
09857324	ONDANSETRON HCL DIHYDRATE	Zofran (Off-Formulary Interchangeable) 2mg/mL Inj Sol-4mL Pk	NOV	N/A	N/A	YES	NO	NO
02229639	ONDANSETRON HYDROCHLORIDE	Zofran 4mg/5mL O/L	NOV	2.3612	1.1360	YES	YES	NO
02213575	ONDANSETRON HYDROCHLORIDE	Zofran 8mg Tab	NOV	23.6170	3.8840	YES	YES	NO
02213567	ONDANSETRON HYDROCHLORIDE	Zofran 4mg Tab	NOV	15.4760	2.5450	YES	YES	NO
02242068	OXCARBAZEPINE	Trileptal (Off-Formulary Interchangeable) 300mg Tab	NOV	N/A	N/A	YES	NO	NO
02242067	OXCARBAZEPINE	Trileptal (Not a Benefit) 150mg Tab	NOV	N/A	N/A	YES	NO	NO
02242069	OXCARBAZEPINE	Trileptal (Off-Formulary Interchangeable) 600mg Tab	NOV	N/A	N/A	YES	NO	NO
02059762	PAMIDRONATE DISODIUM	Aredia (Off-Formulary Interchangeable) 3mg/mL Inj Sol-10mL Vial	NOV	N/A	N/A	YES	NO	NO
02059789	PAMIDRONATE DISODIUM	Aredia (Off-Formulary Interchangeable) 9mg/mL Inj Sol-10mL Vial	NOV	N/A	N/A	YES	NO	NO
02059770	PAMIDRONATE DISODIUM	Aredia (Off-Formulary Interchangeable) 6mg/mL Inj Sol-10mL Vial	NOV	N/A	N/A	YES	NO	NO
00000884	PILOCARPINE HCL	Isopto Carpine 4% Oph Sol	NOV	0.3360	0.3360	NO	NO	NO
00000868	PILOCARPINE HCL	Isopto Carpine 2% Oph Sol	NOV	0.3087	0.3087	YES	NO	NO
00417289	PINDOLOL	Visken (Not a Benefit) 15mg Tab	NOV	N/A	N/A	YES	NO	NO
02296810	RANIBIZUMAB	Lucentis 10mg/mL Inj Sol-0.23mL Vial Pk	NOV	1616.5500	1616.5500	NO	YES	NO
02425629	RANIBIZUMAB	Lucentis 10mg/mL Inj Sol-Pref Syr 0.165mL Pk	NOV	1616.5500	1616.5500	NO	YES	NO
02446928	SACUBITRIL & VALSARTAN	Entresto 24.3mg & 25.7mg Tab	NOV	3.7060	3.7060	NO	YES	NO
02446936	SACUBITRIL & VALSARTAN	Entresto 48.6mg & 51.4mg Tab	NOV	3.7060	3.7060	NO	YES	NO
02446944	SACUBITRIL & VALSARTAN	Entresto 97.2mg & 102.8mg Tab	NOV	3.7060	3.7060	NO	YES	NO
09857548	SECUKINUMAB	Cosentyx 150mg/mL Inj-Sol Pref Pen	NOV	882.5900	882.5900	NO	YES	NO
02438070	SECUKINUMAB	Cosentyx 150mg/mL Inj-Sol Pref Syr	NOV	882.5900	882.5900	NO	YES	NO
02031094	TERBINAFINE HCL	Lamisil 1% Cr	NOV	0.6117	0.6117	NO	NO	YES
02031116	TERBINAFINE HCL	Lamisil (Not a Benefit) 250mg Tab	NOV	N/A	N/A	YES	NO	NO
09857513	TIMOLOL MALEATE & TRAVOPROST	DuoTrav PQ 0.5% & 0.004% Oph Sol-5mL Pk	NOV	56.7000	44.2125	YES	YES	YES
00614254	TOBRAMYCIN	Tobrex 0.3% Oph Oint	NOV	2.7514	2.7514	NO	NO	NO
00513962	TOBRAMYCIN	Tobrex 0.3% Oph Sol	NOV	1.9400	1.3620	YES	NO	NO
00778915	TOBRAMYCIN & DEXAMETHASONE	TobraDex 0.3% & 0.1% Oph Oint	NOV	3.3171	3.3171	NO	NO	NO
00778907	TOBRAMYCIN & DEXAMETHASONE	TobraDex 0.3% & 0.1% Oph Susp	NOV	2.2500	2.2500	NO	NO	NO
02457997	TRAVOPROST	IZBA 0.003% Oph Sol (with Preservative)	NOV	3.9400	3.9400	NO	YES	NO
09857332	TRAVOPROST	Travatan Z 0.004% Oph Sol-5mL Pk	NOV	58.9600	43.1400	YES	YES	NO
02289504	VALSARTAN	Diovan 320mg Tab	NOV	1.3743	0.2098	YES	NO	NO
02244782	VALSARTAN	Diovan 160mg Tab	NOV	1.4111	0.2159	YES	NO	NO
02244781	VALSARTAN	Diovan 80mg Tab	NOV	1.4161	0.2159	YES	NO	NO
02270528	VALSARTAN	Diovan (Off-Formulary Interchangeable) 40mg Tab	NOV	N/A	N/A	YES	NO	NO
02308908	VALSARTAN & HYDROCHLOROTHIAZIDE	Diovan-HCT 320mg & 12.5mg Tab	NOV	1.4161	0.2235	YES	NO	NO
02246955	VALSARTAN & HYDROCHLOROTHIAZIDE	Diovan-HCT 160mg & 25mg Tab	NOV	1.4189	0.2238	YES	NO	NO
02241901	VALSARTAN & HYDROCHLOROTHIAZIDE	Diovan-HCT 160mg & 12.5mg Tab	NOV	1.4189	0.2240	YES	NO	NO
02308916	VALSARTAN & HYDROCHLOROTHIAZIDE	Diovan-HCT 320mg & 25mg Tab	NOV	1.4136	0.2231	YES	NO	NO
02241900	VALSARTAN & HYDROCHLOROTHIAZIDE	Diovan-HCT 80mg & 12.5mg Tab	NOV	1.4032	0.2213	YES	NO	NO
02248296	ZOLEDRONIC ACID	Zometa Concentrate (Off-Formulary Interchangeable) 4mg/5mL Inj Sol-5mL Pk (Preservative-Free)	NOV	N/A	N/A	YES	NO	NO

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