Browse by Standard Packs
Standard Packs and Prices for Ready Prepared Pharmaceutical Benefits
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| Item code | Drug name Form and Strength |
Pack size | Price | Manufacturer |
|---|---|---|---|---|
| 13600T | ATENOLOLatenolol 50 mg/10 mL oral liquid, 300 mL | 1 | $35.63 | AE |
| 11930X | ATEZOLIZUMABatezolizumab 840 mg/14 mL injection, 14 mL vial | 1 | $0.00 | RO |
| 11931Y | ATEZOLIZUMABatezolizumab 840 mg/14 mL injection, 14 mL vial | 1 | $0.00 | RO |
| 11940K | ATEZOLIZUMABatezolizumab 840 mg/14 mL injection, 14 mL vial | 1 | $0.00 | RO |
| 11957H | ATEZOLIZUMABatezolizumab 840 mg/14 mL injection, 14 mL vial | 1 | $0.00 | RO |
| 12076N | ATEZOLIZUMABatezolizumab 840 mg/14 mL injection, 14 mL vial | 1 | $0.00 | RO |
| 12078Q | ATEZOLIZUMABatezolizumab 840 mg/14 mL injection, 14 mL vial | 1 | $0.00 | RO |
| 12097Q | ATEZOLIZUMABatezolizumab 840 mg/14 mL injection, 14 mL vial | 1 | $0.00 | RO |
| 12098R | ATEZOLIZUMABatezolizumab 840 mg/14 mL injection, 14 mL vial | 1 | $0.00 | RO |
| 12159Y | ATEZOLIZUMABatezolizumab 840 mg/14 mL injection, 14 mL vial | 1 | $0.00 | RO |
| 12174R | ATEZOLIZUMABatezolizumab 840 mg/14 mL injection, 14 mL vial | 1 | $0.00 | RO |
| 13170E | ATEZOLIZUMABatezolizumab 840 mg/14 mL injection, 14 mL vial | 1 | $0.00 | RO |
| 13173H | ATEZOLIZUMABatezolizumab 840 mg/14 mL injection, 14 mL vial | 1 | $0.00 | RO |
| 11277M | ATEZOLIZUMABatezolizumab 1.2 g/20 mL injection, 20 mL vial | 1 | $0.00 | RO |
| 11284X | ATEZOLIZUMABatezolizumab 1.2 g/20 mL injection, 20 mL vial | 1 | $0.00 | RO |
| 11297N | ATEZOLIZUMABatezolizumab 1.2 g/20 mL injection, 20 mL vial | 1 | $0.00 | RO |
| 11309F | ATEZOLIZUMABatezolizumab 1.2 g/20 mL injection, 20 mL vial | 1 | $0.00 | RO |
| 11792P | ATEZOLIZUMABatezolizumab 1.2 g/20 mL injection, 20 mL vial | 1 | $0.00 | RO |
| 11801D | ATEZOLIZUMABatezolizumab 1.2 g/20 mL injection, 20 mL vial | 1 | $0.00 | RO |
| 11802E | ATEZOLIZUMABatezolizumab 1.2 g/20 mL injection, 20 mL vial | 1 | $0.00 | RO |
| 11807K | ATEZOLIZUMABatezolizumab 1.2 g/20 mL injection, 20 mL vial | 1 | $0.00 | RO |
| 11926Q | ATEZOLIZUMABatezolizumab 1.2 g/20 mL injection, 20 mL vial | 1 | $0.00 | RO |
| 11927R | ATEZOLIZUMABatezolizumab 1.2 g/20 mL injection, 20 mL vial | 1 | $0.00 | RO |
| 11928T | ATEZOLIZUMABatezolizumab 1.2 g/20 mL injection, 20 mL vial | 1 | $0.00 | RO |
| 11929W | ATEZOLIZUMABatezolizumab 1.2 g/20 mL injection, 20 mL vial | 1 | $0.00 | RO |
| 12155R | ATEZOLIZUMABatezolizumab 1.2 g/20 mL injection, 20 mL vial | 1 | $0.00 | RO |
| 12167J | ATEZOLIZUMABatezolizumab 1.2 g/20 mL injection, 20 mL vial | 1 | $0.00 | RO |
| 12168K | ATEZOLIZUMABatezolizumab 1.2 g/20 mL injection, 20 mL vial | 1 | $0.00 | RO |
| 12171N | ATEZOLIZUMABatezolizumab 1.2 g/20 mL injection, 20 mL vial | 1 | $0.00 | RO |
| 13172G | ATEZOLIZUMABatezolizumab 1.2 g/20 mL injection, 20 mL vial | 1 | $0.00 | RO |
| 13174J | ATEZOLIZUMABatezolizumab 1.2 g/20 mL injection, 20 mL vial | 1 | $0.00 | RO |
| 9092M | ATOMOXETINEatomoxetine 10 mg capsule, 28 | 28 | $33.15 | SZ,TX |
| 9093N | ATOMOXETINEatomoxetine 18 mg capsule, 28 | 28 | $33.15 | SZ,TX |
| 9094P | ATOMOXETINEatomoxetine 25 mg capsule, 28 | 28 | $33.15 | SZ,TX |
| 9095Q | ATOMOXETINEatomoxetine 40 mg capsule, 28 | 28 | $33.15 | SZ,TX |
| 9096R | ATOMOXETINEatomoxetine 60 mg capsule, 28 | 28 | $33.15 | SZ,TX |
| 13495G | ATORVASTATINatorvastatin 10 mg tablet, 30 | 30 | $5.02 | AF,AS,BG,CR,GQ,HX,IB,RA,RF,TX,VO |
| 13529C | ATORVASTATINatorvastatin 20 mg tablet, 30 | 30 | $5.12 | AF,AS,BG,CR,HX,IB,RA,RF,TX,VO |
| 13468W | ATORVASTATINatorvastatin 40 mg tablet, 30 | 30 | $6.02 | AF,AS,BG,CR,GQ,HX,IB,RA,RF,TX,VO |
| 13374X | ATORVASTATINatorvastatin 80 mg tablet, 30 | 30 | $6.61 | AF,AS,BG,CR,GQ,HX,IB,RA,RF,TX,VO |
| 11671G | AVELUMABavelumab 200 mg/10 mL injection, 10 mL vial | 1 | $0.00 | SG |
| 11679Q | AVELUMABavelumab 200 mg/10 mL injection, 10 mL vial | 1 | $0.00 | SG |
| 11685B | AVELUMABavelumab 200 mg/10 mL injection, 10 mL vial | 1 | $0.00 | SG |
| 11695M | AVELUMABavelumab 200 mg/10 mL injection, 10 mL vial | 1 | $0.00 | SG |
| 13122P | AVELUMABavelumab 200 mg/10 mL injection, 10 mL vial | 1 | $0.00 | SG |
| 13123Q | AVELUMABavelumab 200 mg/10 mL injection, 10 mL vial | 1 | $0.00 | SG |
| 13126W | AVELUMABavelumab 200 mg/10 mL injection, 10 mL vial | 1 | $0.00 | SG |
| 13132E | AVELUMABavelumab 200 mg/10 mL injection, 10 mL vial | 1 | $0.00 | SG |
| 10539Q | AXITINIBaxitinib 1 mg tablet, 28 | 28 | $530.97 | PF |
| 10572K | AXITINIBaxitinib 1 mg tablet, 28 | 28 | $530.97 | PF |
| 10540R | AXITINIBaxitinib 5 mg tablet, 28 | 28 | $2470.88 | PF |
| 10556N | AXITINIBaxitinib 5 mg tablet, 28 | 28 | $2470.88 | PF |
| 12771E | AZACITIDINEazacitidine 100 mg injection, 1 vial | 1 | $40.79 | JO,JU,OC,RI,SZ,TB |
| 12784W | AZACITIDINEazacitidine 100 mg injection, 1 vial | 1 | $42.42 | JO,JU,OC,RI,SZ,TB |
| 13028Q | AZACITIDINEazacitidine 100 mg injection, 1 vial | 1 | $40.79 | JO,JU,OC,RI,SZ,TB |
| 13033Y | AZACITIDINEazacitidine 100 mg injection, 1 vial | 1 | $42.42 | JO,JU,OC,RI,SZ,TB |
| 13036D | AZACITIDINEazacitidine 100 mg injection, 1 vial | 1 | $40.79 | JO,JU,OC,RI,SZ,TB |
| 13038F | AZACITIDINEazacitidine 100 mg injection, 1 vial | 1 | $42.42 | JO,JU,OC,RI,SZ,TB |
| 13039G | AZACITIDINEazacitidine 100 mg injection, 1 vial | 1 | $42.42 | JO,JU,OC,RI,SZ,TB |
| 13040H | AZACITIDINEazacitidine 100 mg injection, 1 vial | 1 | $42.42 | JO,JU,OC,RI,SZ,TB |
| 13042K | AZACITIDINEazacitidine 100 mg injection, 1 vial | 1 | $40.79 | JO,JU,OC,RI,SZ,TB |
| 13044M | AZACITIDINEazacitidine 100 mg injection, 1 vial | 1 | $40.79 | JO,JU,OC,RI,SZ,TB |
| 6100C | AZACITIDINEazacitidine 100 mg injection, 1 vial | 1 | $42.42 | JO,JU,OC,RI,SZ,TB |
| 6138C | AZACITIDINEazacitidine 100 mg injection, 1 vial | 1 | $42.42 | JO,JU,OC,RI,SZ,TB |
| 9597D | AZACITIDINEazacitidine 100 mg injection, 1 vial | 1 | $40.79 | JO,JU,OC,RI,SZ,TB |
| 9598E | AZACITIDINEazacitidine 100 mg injection, 1 vial | 1 | $40.79 | JO,JU,OC,RI,SZ,TB |
| 13623B | AZACITIDINEazacitidine 200 mg tablet, 7 | 7 | $6690.76 | CJ |
| 13619T | AZACITIDINEazacitidine 300 mg tablet, 7 | 7 | $6681.74 | CJ |
| 13624C | AZACITIDINEazacitidine 300 mg tablet, 7 | 7 | $6665.14 | CJ |
| 5616N | AZITHROMYCINazithromycin 600 mg tablet, 8 | 8 | $55.38 | PF |
| 6221K | AZITHROMYCINazithromycin 600 mg tablet, 8 | 8 | $57.60 | PF |
| 5617P | BACLOFENbaclofen 10 mg/5 mL intrathecal injection, 5 mL ampoule | 1 | $76.27 | DZ,NV |
| 6284R | BACLOFENbaclofen 10 mg/5 mL intrathecal injection, 5 mL ampoule | 1 | $79.32 | DZ,NV |
| 13522Q | BACLOFENbaclofen 10 mg tablet, 100 | 100 | $12.29 | AF,NV,RW,TX |
| 13359D | BACLOFENbaclofen 25 mg tablet, 100 | 100 | $24.12 | AF,NV,RW,TX |
| 11194E | BACLOFENbaclofen 40 mg/20 mL intrathecal injection, 20 mL ampoule | 1 | $317.92 | BZ |
| 11195F | BACLOFENbaclofen 40 mg/20 mL intrathecal injection, 20 mL ampoule | 1 | $305.69 | BZ |
| 13484Q | BALSALAZIDEbalsalazide sodium 750 mg capsule, 280 | 280 | $110.90 | PK |
| 4598B | BANDAGE COMPRESSIONbandage compression four layer bandage, 1 | 1 | $39.32 | SN |
| 4658E | BANDAGE COMPRESSIONbandage compression four layer bandage, 1 | 1 | $59.57 | SN |
| 4748X | BANDAGE COMPRESSIONbandage compression 10 cm x 3 m high stretch bandage, 1 | 1 | $13.01 | CC |
| 4748X | BANDAGE COMPRESSIONbandage compression 10 cm x 3 m high stretch bandage, 1 | 1 | $29.06 | BV |
| 4657D | BANDAGE COMPRESSIONbandage compression 10 cm x 3.5 m high stretch bandage, 1 | 1 | $14.04 | MH |
| 4654Y | BANDAGE COMPRESSIONbandage compression 8 cm x 2.6 m short stretch bandage, 1 | 1 | $14.08 | BV |
| 4813H | BANDAGE RETENTION COHESIVE HEAVYbandage retention cohesive heavy 10 cm x 1.3 m bandage, 1 | 1 | $8.68 | MM |
| 4660G | BANDAGE RETENTION COHESIVE HEAVYbandage retention cohesive heavy 10 cm x 2 m bandage, 1 | 1 | $7.94 | MM |
| 4814J | BANDAGE RETENTION COHESIVE HEAVYbandage retention cohesive heavy 15 cm x 1.3 m bandage, 1 | 1 | $11.77 | MM |
| 4811F | BANDAGE RETENTION COHESIVE HEAVYbandage retention cohesive heavy 5 cm x 1.3 m bandage, 1 | 1 | $5.61 | MM |
| 4812G | BANDAGE RETENTION COHESIVE HEAVYbandage retention cohesive heavy 7.5 cm x 1.3 m bandage, 1 | 1 | $7.04 | MM |
| 4662J | BANDAGE RETENTION COHESIVE LIGHTbandage retention cohesive light 10 cm x 2 m bandage, 1 | 1 | $13.50 | BV |
| 4719J | BANDAGE RETENTION COHESIVE LIGHTbandage retention cohesive light 6 cm x 2 m bandage, 1 | 1 | $6.57 | BV |
| 4729X | BANDAGE RETENTION COTTON CREPEbandage retention cotton crepe 10 cm x 2.3 m bandage, 1 | 1 | $10.55 | KE |
| 4729X | BANDAGE RETENTION COTTON CREPEbandage retention cotton crepe 10 cm x 2.3 m bandage, 1 | 1 | $13.27 | BV |
| 4727T | BANDAGE RETENTION COTTON CREPEbandage retention cotton crepe 5 cm x 2.3 m bandage, 1 | 1 | $7.09 | KE |
| 4727T | BANDAGE RETENTION COTTON CREPEbandage retention cotton crepe 5 cm x 2.3 m bandage, 1 | 1 | $8.42 | BV |
| 4728W | BANDAGE RETENTION COTTON CREPEbandage retention cotton crepe 7.5 cm x 2.3 m bandage, 1 | 1 | $9.18 | KE |
| 4728W | BANDAGE RETENTION COTTON CREPEbandage retention cotton crepe 7.5 cm x 2.3 m bandage, 1 | 1 | $10.70 | BV |
| 4799N | BANDAGE TUBULAR LONG STOCKINGbandage tubular long stocking large size bandage, 1 | 1 | $15.66 | MH |
| 4797L | BANDAGE TUBULAR LONG STOCKINGbandage tubular long stocking medium size bandage, 1 | 1 | $15.66 | MH |
| 4674B | BANDAGE TUBULAR LONG STOCKINGbandage tubular long stocking small size bandage, 1 | 1 | $15.66 | MH |
| 4675C | BANDAGE TUBULAR LONG STOCKINGbandage tubular long stocking XX/large size bandage, 1 | 1 | $15.67 | MH |
| 4816L | BANDAGE TUBULAR SHORT STOCKINGbandage tubular short stocking large D/E size bandage, 1 | 1 | $10.55 | MH |
| 4815K | BANDAGE TUBULAR SHORT STOCKINGbandage tubular short stocking medium C/D size bandage, 1 | 1 | $10.55 | MH |
| 4661H | BANDAGE TUBULAR SHORT STOCKINGbandage tubular short stocking small B/C size bandage, 1 | 1 | $10.55 | MH |
| 4669R | BANDAGE ZINC PASTEbandage zinc paste 7.5 cm x 6 m bandage, 1 | 1 | $12.41 | MH |
| 4750B | BANDAGE ZINC PASTEbandage zinc paste 7.5 cm x 6 m bandage, 1 | 1 | $46.52 | SN |
| 10760H | BENDAMUSTINEbendamustine hydrochloride 25 mg injection, 1 vial | 1 | $0.00 | AF,JC,JU,SZ |
| 10763L | BENDAMUSTINEbendamustine hydrochloride 25 mg injection, 1 vial | 1 | $0.00 | AF,JC,JU,SZ |
| 13790T | BENZATHINE BENZYLPENICILLINbenzathine benzylpenicillin 1.2 million units powder for injection [1 vial] (&) inert substance diluent [5 mL vial], 1 pack | 1 | $50.31 | OJ |
| 13801J | BENZATHINE BENZYLPENICILLINbenzathine benzylpenicillin 1.2 million units powder for injection [1 vial] (&) inert substance diluent [5 mL vial], 1 pack | 1 | $50.31 | OJ |
| 13816E | BENZATHINE BENZYLPENICILLINbenzathine benzylpenicillin 1.2 million units powder for injection [1 vial] (&) inert substance diluent [5 mL vial], 1 pack | 1 | $50.31 | OJ |
| 2647H | BENZYLPENICILLINbenzylpenicillin 3 g injection, 1 vial | 1 | $10.04 | CS |
| 3399X | BENZYLPENICILLINbenzylpenicillin 3 g injection, 1 vial | 1 | $10.04 | CS |
| 1775K | BENZYLPENICILLINbenzylpenicillin 600 mg injection, 1 vial | 1 | $6.40 | CS |
| 3398W | BENZYLPENICILLINbenzylpenicillin 600 mg injection, 1 vial | 1 | $6.40 | CS |
| 3486L | BENZYLPENICILLINbenzylpenicillin 600 mg injection, 1 vial | 1 | $6.86 | CS |
| 10800K | BETAMETHASONE DIPROPIONATEbetamethasone (as dipropionate) 0.05% cream, 15 g | 1 | $7.53 | AF |
| 10800K | BETAMETHASONE DIPROPIONATEbetamethasone (as dipropionate) 0.05% cream, 15 g | 1 | $5.08 | AL |
| 10801L | BETAMETHASONE DIPROPIONATEbetamethasone (as dipropionate) 0.05% cream, 15 g | 1 | $6.95 | AF |
| 10801L | BETAMETHASONE DIPROPIONATEbetamethasone (as dipropionate) 0.05% cream, 15 g | 1 | $4.50 | AL |
| 10802M | BETAMETHASONE DIPROPIONATEbetamethasone (as dipropionate) 0.05% cream, 15 g | 1 | $6.83 | AF |
| 10802M | BETAMETHASONE DIPROPIONATEbetamethasone (as dipropionate) 0.05% cream, 15 g | 1 | $4.38 | AL |
| 10813D | BETAMETHASONE DIPROPIONATEbetamethasone (as dipropionate) 0.05% cream, 15 g | 1 | $7.14 | AF |
| 10813D | BETAMETHASONE DIPROPIONATEbetamethasone (as dipropionate) 0.05% cream, 15 g | 1 | $4.69 | AL |
| 10824Q | BETAMETHASONE DIPROPIONATEbetamethasone (as dipropionate) 0.05% cream, 15 g | 1 | $8.68 | AF |
| 10824Q | BETAMETHASONE DIPROPIONATEbetamethasone (as dipropionate) 0.05% cream, 15 g | 1 | $6.23 | AL |
| 10795E | BETAMETHASONE DIPROPIONATEbetamethasone (as dipropionate) 0.05% ointment, 15 g | 1 | $8.68 | AF |
| 10795E | BETAMETHASONE DIPROPIONATEbetamethasone (as dipropionate) 0.05% ointment, 15 g | 1 | $6.23 | AL |
| 10816G | BETAMETHASONE DIPROPIONATEbetamethasone (as dipropionate) 0.05% ointment, 15 g | 1 | $6.95 | AF |
| 10816G | BETAMETHASONE DIPROPIONATEbetamethasone (as dipropionate) 0.05% ointment, 15 g | 1 | $4.50 | AL |
| 10820L | BETAMETHASONE DIPROPIONATEbetamethasone (as dipropionate) 0.05% ointment, 15 g | 1 | $7.53 | AF |
| 10820L | BETAMETHASONE DIPROPIONATEbetamethasone (as dipropionate) 0.05% ointment, 15 g | 1 | $5.08 | AL |
| 10821M | BETAMETHASONE DIPROPIONATEbetamethasone (as dipropionate) 0.05% ointment, 15 g | 1 | $7.14 | AF |
| 10821M | BETAMETHASONE DIPROPIONATEbetamethasone (as dipropionate) 0.05% ointment, 15 g | 1 | $4.69 | AL |
| 10823P | BETAMETHASONE DIPROPIONATEbetamethasone (as dipropionate) 0.05% ointment, 15 g | 1 | $6.83 | AF |
| 10823P | BETAMETHASONE DIPROPIONATEbetamethasone (as dipropionate) 0.05% ointment, 15 g | 1 | $4.38 | AL |
| 2812B | BETAMETHASONE VALERATEbetamethasone (as valerate) 0.02% cream, 100 g | 1 | $7.61 | AL,LN |
| 2812B | BETAMETHASONE VALERATEbetamethasone (as valerate) 0.02% cream, 100 g | 1 | $9.66 | AS |
| 2812B | BETAMETHASONE VALERATEbetamethasone (as valerate) 0.02% cream, 100 g | 1 | $10.11 | AF |
| 10794D | BETAMETHASONE VALERATEbetamethasone (as valerate) 0.05% cream, 15 g | 1 | $6.41 | AS |
| 10794D | BETAMETHASONE VALERATEbetamethasone (as valerate) 0.05% cream, 15 g | 1 | $3.85 | LN |
| 10799J | BETAMETHASONE VALERATEbetamethasone (as valerate) 0.05% cream, 15 g | 1 | $7.56 | AS |
| 10799J | BETAMETHASONE VALERATEbetamethasone (as valerate) 0.05% cream, 15 g | 1 | $5.00 | LN |
| 10807T | BETAMETHASONE VALERATEbetamethasone (as valerate) 0.05% cream, 15 g | 1 | $5.83 | AS |
| 10807T | BETAMETHASONE VALERATEbetamethasone (as valerate) 0.05% cream, 15 g | 1 | $3.27 | LN |
| 10808W | BETAMETHASONE VALERATEbetamethasone (as valerate) 0.05% cream, 15 g | 1 | $6.02 | AS |
| 10808W | BETAMETHASONE VALERATEbetamethasone (as valerate) 0.05% cream, 15 g | 1 | $3.46 | LN |
| 10810Y | BETAMETHASONE VALERATEbetamethasone (as valerate) 0.05% cream, 15 g | 1 | $5.71 | AS |
| 10810Y | BETAMETHASONE VALERATEbetamethasone (as valerate) 0.05% cream, 15 g | 1 | $3.15 | LN |
| 12479T | BEVACIZUMABbevacizumab 100 mg/4 mL injection, 4 mL vial | 1 | $0.00 | AN,LR,SZ |
| 12508H | BEVACIZUMABbevacizumab 100 mg/4 mL injection, 4 mL vial | 1 | $0.00 | AN,LR,SZ |
| 13933H | BICARBONATEsodium bicarbonate 840 mg capsule, 100 | 100 | $10.50 | AS |
| 11649D | BICTEGRAVIR + EMTRICITABINE + TENOFOVIR ALAFENAMIDEbictegravir 50 mg + emtricitabine 200 mg + tenofovir alafenamide 25 mg tablet, 30 | 30 | $875.32 | GI |
| 11948W | BINIMETINIBbinimetinib 15 mg tablet, 84 | 84 | $3693.99 | FB |
| 11961M | BINIMETINIBbinimetinib 15 mg tablet, 84 | 84 | $3693.99 | FB |
| 10578R | BISACODYLbisacodyl 10 mg suppository, 10 | 1 | $6.18 | VZ |
| 10578R | BISACODYLbisacodyl 10 mg suppository, 10 | 1 | $5.75 | PP |
| 1260H | BISACODYLbisacodyl 10 mg suppository, 10 | 1 | $6.18 | VZ |
| 1260H | BISACODYLbisacodyl 10 mg suppository, 10 | 1 | $5.75 | PP |
| 10580W | BISACODYLbisacodyl 10 mg suppository, 12 | 1 | $5.30 | PP |
| 1258F | BISACODYLbisacodyl 10 mg suppository, 12 | 1 | $5.30 | PP |
| 13444N | BISOPROLOLbisoprolol fumarate 10 mg tablet, 28 | 28 | $7.85 | AF,GQ,LR,RW,SZ,TX,VO |
| 13444N | BISOPROLOLbisoprolol fumarate 10 mg tablet, 28 | 28 | $12.36 | AL |
| 13419G | BISOPROLOLbisoprolol fumarate 2.5 mg tablet, 28 | 28 | $6.61 | AF,GQ,LR,RW,SZ,TX,VO |
| 13419G | BISOPROLOLbisoprolol fumarate 2.5 mg tablet, 28 | 28 | $12.12 | AL |
| 13443M | BISOPROLOLbisoprolol fumarate 5 mg tablet, 28 | 28 | $6.74 | AF,GQ,LR,RW,SZ,TX,VO |
| 13443M | BISOPROLOLbisoprolol fumarate 5 mg tablet, 28 | 28 | $11.24 | AL |
| 4433H | BLEOMYCINbleomycin sulfate 15 000 international units injection, 1 vial | 1 | $0.00 | PF |
| 7244G | BLEOMYCINbleomycin sulfate 15 000 international units injection, 1 vial | 1 | $0.00 | PF |
| 11115B | BLINATUMOMABblinatumomab 38.5 microgram injection [1 vial] (&) inert substance solution [10 mL vial], 1 pack | 1 | $0.00 | AN |
| 11116C | BLINATUMOMABblinatumomab 38.5 microgram injection [1 vial] (&) inert substance solution [10 mL vial], 1 pack | 1 | $0.00 | AN |
| 11117D | BLINATUMOMABblinatumomab 38.5 microgram injection [1 vial] (&) inert substance solution [10 mL vial], 1 pack | 1 | $0.00 | AN |
| 11118E | BLINATUMOMABblinatumomab 38.5 microgram injection [1 vial] (&) inert substance solution [10 mL vial], 1 pack | 1 | $0.00 | AN |
| 11119F | BLINATUMOMABblinatumomab 38.5 microgram injection [1 vial] (&) inert substance solution [10 mL vial], 1 pack | 1 | $0.00 | AN |
| 11120G | BLINATUMOMABblinatumomab 38.5 microgram injection [1 vial] (&) inert substance solution [10 mL vial], 1 pack | 1 | $0.00 | AN |
| 11850Q | BLINATUMOMABblinatumomab 38.5 microgram injection [1 vial] (&) inert substance solution [10 mL vial], 1 pack | 1 | $0.00 | AN |
| 11867N | BLINATUMOMABblinatumomab 38.5 microgram injection [1 vial] (&) inert substance solution [10 mL vial], 1 pack | 1 | $0.00 | AN |
| 12219D | BORTEZOMIBbortezomib 3.5 mg injection, 1 vial | 1 | $0.00 | BX,CR,IT,JC,JU,OC,PF,SZ,TB |
| 12227M | BORTEZOMIBbortezomib 3.5 mg injection, 1 vial | 1 | $0.00 | BX,CR,IT,JC,JU,OC,PF,SZ,TB |
| 10993N | BOTULINUM TOXIN TYPE Abotulinum toxin type A 100 units injection, 1 vial | 1 | $272.50 | VE |
| 10997T | BOTULINUM TOXIN TYPE Abotulinum toxin type A 100 units injection, 1 vial | 1 | $272.50 | VE |
| 10998W | BOTULINUM TOXIN TYPE Abotulinum toxin type A 100 units injection, 1 vial | 1 | $272.50 | VE |
| 10999X | BOTULINUM TOXIN TYPE Abotulinum toxin type A 100 units injection, 1 vial | 1 | $272.50 | VE |
| 11000Y | BOTULINUM TOXIN TYPE Abotulinum toxin type A 100 units injection, 1 vial | 1 | $272.50 | VE |
| 11004E | BOTULINUM TOXIN TYPE Abotulinum toxin type A 100 units injection, 1 vial | 1 | $272.50 | VE |
| 11016T | BOTULINUM TOXIN TYPE Abotulinum toxin type A 100 units injection, 1 vial | 1 | $272.50 | VE |
| 11023E | BOTULINUM TOXIN TYPE Abotulinum toxin type A 100 units injection, 1 vial | 1 | $272.50 | VE |
| 11751L | BOTULINUM TOXIN TYPE Abotulinum toxin type A 100 units injection, 1 vial | 1 | $272.50 | VE |
| 12017L | BOTULINUM TOXIN TYPE Abotulinum toxin type A 100 units injection, 1 vial | 1 | $272.50 | VE |
| 10166C | BRENTUXIMAB VEDOTINbrentuximab vedotin 50 mg injection, 1 vial | 1 | $0.00 | TK |
| 10171H | BRENTUXIMAB VEDOTINbrentuximab vedotin 50 mg injection, 1 vial | 1 | $0.00 | TK |
| 10172J | BRENTUXIMAB VEDOTINbrentuximab vedotin 50 mg injection, 1 vial | 1 | $0.00 | TK |
| 10180T | BRENTUXIMAB VEDOTINbrentuximab vedotin 50 mg injection, 1 vial | 1 | $0.00 | TK |
| 11067L | BRENTUXIMAB VEDOTINbrentuximab vedotin 50 mg injection, 1 vial | 1 | $0.00 | TK |
| 11073T | BRENTUXIMAB VEDOTINbrentuximab vedotin 50 mg injection, 1 vial | 1 | $0.00 | TK |
| 11079D | BRENTUXIMAB VEDOTINbrentuximab vedotin 50 mg injection, 1 vial | 1 | $0.00 | TK |
| 11080E | BRENTUXIMAB VEDOTINbrentuximab vedotin 50 mg injection, 1 vial | 1 | $0.00 | TK |
| 11086L | BRENTUXIMAB VEDOTINbrentuximab vedotin 50 mg injection, 1 vial | 1 | $0.00 | TK |
| 11087M | BRENTUXIMAB VEDOTINbrentuximab vedotin 50 mg injection, 1 vial | 1 | $0.00 | TK |
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