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 |
|---|---|---|---|---|
| 8661W | CICLOSPORINciclosporin 100 mg/mL oral liquid, 50 mL | 1 | $345.75 | NV |
| 8660T | CICLOSPORINciclosporin 100 mg capsule, 30 | 30 | $105.46 | NV,TX,WG |
| 8659R | CICLOSPORINciclosporin 50 mg capsule, 30 | 30 | $51.78 | NV,WG |
| 1217C | CIPROFLOXACINciprofloxacin 0.3% eye drops, 5 mL | 1 | $17.57 | NM |
| 1217C | CIPROFLOXACINciprofloxacin 0.3% eye drops, 5 mL | 1 | $22.32 | NV |
| 5564W | CIPROFLOXACINciprofloxacin 0.3% eye drops, 5 mL | 1 | $17.57 | NM |
| 5564W | CIPROFLOXACINciprofloxacin 0.3% eye drops, 5 mL | 1 | $22.32 | NV |
| 14313H | CITALOPRAMcitalopram 10 mg tablet, 28 | 28 | $5.17 | AF,RW,WG |
| 14490P | CITALOPRAMcitalopram 20 mg tablet, 28 | 28 | $5.17 | AF,RW,SZ,TX,TY,WG |
| 14490P | CITALOPRAMcitalopram 20 mg tablet, 28 | 28 | $18.32 | LU |
| 14518D | CITALOPRAMcitalopram 40 mg tablet, 28 | 28 | $5.21 | AF,RW,SZ,TX,WG |
| 14534Y | CITRIC ACID + LAURYL SULFOACETATE SODIUM + SORBITOLsodium citrate dihydrate 450 mg/5 mL + lauryl sulfoacetate sodium 45 mg/5 mL + sorbitol 3.125 g/5 mL enema, 12 x 5 mL | 1 | $13.10 | AE |
| 2091C | CITRIC ACID + LAURYL SULFOACETATE SODIUM + SORBITOLsodium citrate dihydrate 450 mg/5 mL + lauryl sulfoacetate sodium 45 mg/5 mL + sorbitol 3.125 g/5 mL enema, 12 x 5 mL | 1 | $14.33 | AE |
| 5481L | CITRULLINE WITH CARBOHYDRATEcitrulline with carbohydrate containing 1 g citrulline powder for oral liquid, 30 x 4 g sachets | 1 | $109.95 | VF |
| 11604R | CLADRIBINEcladribine 10 mg tablet, 4 | 4 | $14642.59 | SG |
| 3138E | CLINDAMYCINclindamycin 150 mg capsule, 24 | 24 | $6.94 | AF,PF,RW,TX,WG,XT |
| 1808E | CLONAZEPAMclonazepam 2.5 mg/mL (0.1 mg/drop) oral liquid, 10 mL | 1 | $6.22 | PB |
| 1806C | CLONAZEPAMclonazepam 2 mg tablet, 100 | 100 | $11.95 | AF |
| 1805B | CLONAZEPAMclonazepam 500 microgram tablet, 100 | 100 | $9.23 | AF |
| 11559J | CLONAZEPAMclonazepam 500 microgram tablet, 50 | 50 | $5.54 | PB |
| 13578P | CLONIDINEclonidine hydrochloride 100 microgram tablet, 100 | 100 | $14.79 | GQ,IX,TX |
| 13548C | CLONIDINEclonidine hydrochloride 150 microgram tablet, 100 | 100 | $20.96 | IX |
| 13365K | CLOPIDOGRELclopidogrel 75 mg tablet, 28 | 28 | $6.55 | RF,RW,WG |
| 13399F | CLOPIDOGRELclopidogrel 75 mg tablet, 28 | 28 | $6.55 | AF,AV,BG,CR,GQ,HX,WA |
| 13427Q | CLOPIDOGREL + ASPIRINclopidogrel 75 mg + aspirin 100 mg tablet, 30 | 30 | $6.76 | AF,AV,GZ,TY |
| 12054K | CODEINEcodeine phosphate hemihydrate 30 mg tablet, 20 | 20 | $14.19 | AS |
| 12065B | CODEINEcodeine phosphate hemihydrate 30 mg tablet, 20 | 20 | $14.19 | AS |
| 14477Y | COLESTYRAMINEcolestyramine 4 g powder for oral liquid, 50 sachets | 1 | $36.42 | GO |
| 2967E | COLESTYRAMINEcolestyramine 4 g powder for oral liquid, 50 sachets | 1 | $37.17 | GO |
| 13862N | CORTISONEcortisone acetate 25 mg tablet, 60 | 60 | $14.92 | AS |
| 13946B | CORTISONEcortisone acetate 5 mg tablet, 50 | 50 | $9.79 | AS |
| 14022B | CYPROTERONEcyproterone acetate 100 mg tablet, 50 | 50 | $51.48 | GH |
| 14022B | CYPROTERONEcyproterone acetate 100 mg tablet, 50 | 50 | $50.27 | HX,RW |
| 13925X | CYPROTERONEcyproterone acetate 50 mg tablet, 20 | 20 | $14.74 | HX,RW |
| 1270W | CYPROTERONEcyproterone acetate 50 mg tablet, 50 | 50 | $34.14 | GH |
| 1270W | CYPROTERONEcyproterone acetate 50 mg tablet, 50 | 50 | $33.16 | HX,RW |
| 14023C | CYPROTERONEcyproterone acetate 50 mg tablet, 50 | 50 | $33.24 | GH |
| 14023C | CYPROTERONEcyproterone acetate 50 mg tablet, 50 | 50 | $32.21 | HX,RW |
| 9318K | DABIGATRANdabigatran etexilate 75 mg capsule, 10 | 10 | $11.60 | BY |
| 9322P | DABIGATRANdabigatran etexilate 75 mg capsule, 10 | 10 | $11.60 | BY |
| 9319L | DABIGATRANdabigatran etexilate 110 mg capsule, 10 | 10 | $8.41 | BY |
| 9323Q | DABIGATRANdabigatran etexilate 110 mg capsule, 10 | 10 | $8.41 | BY |
| 13489Y | DABIGATRANdabigatran etexilate 150 mg capsule, 60 | 60 | $37.88 | AF,CR,SZ,XT |
| 13489Y | DABIGATRANdabigatran etexilate 150 mg capsule, 60 | 60 | $46.81 | BY |
| 13523R | DABIGATRANdabigatran etexilate 110 mg capsule, 60 | 60 | $38.14 | AF,CR,SZ,XT |
| 13523R | DABIGATRANdabigatran etexilate 110 mg capsule, 60 | 60 | $47.07 | BY |
| 14755N | DABRAFENIBdabrafenib 50 mg capsule, 120 | 120 | $4740.52 | NV |
| 14760W | DABRAFENIBdabrafenib 50 mg capsule, 120 | 120 | $4740.52 | NV |
| 14778T | DABRAFENIBdabrafenib 50 mg capsule, 120 | 120 | $4740.52 | NV |
| 14752K | DABRAFENIBdabrafenib 10 mg dispersible tablet, 2 x 210 | 420 | $3341.47 | NV |
| 14753L | DABRAFENIBdabrafenib 10 mg dispersible tablet, 2 x 210 | 420 | $3341.47 | NV |
| 14773M | DABRAFENIBdabrafenib 10 mg dispersible tablet, 2 x 210 | 420 | $3341.47 | NV |
| 13844P | DAPAGLIFLOZINdapagliflozin 10 mg tablet, 28 | 28 | $41.82 | AP |
| 14054Q | DAPAGLIFLOZINdapagliflozin 10 mg tablet, 28 | 28 | $41.82 | AP |
| 13851B | DAPAGLIFLOZIN + METFORMINdapagliflozin 5 mg + metformin hydrochloride 1 g modified release tablet, 56 | 56 | $43.65 | AP |
| 13875G | DAPAGLIFLOZIN + METFORMINdapagliflozin 10 mg + metformin hydrochloride 1 g modified release tablet, 28 | 28 | $42.35 | AP |
| 14028H | DAPAGLIFLOZIN + METFORMINdapagliflozin 10 mg + metformin hydrochloride 500 mg modified release tablet, 28 | 28 | $41.57 | AP |
| 14645T | DAPAGLIFLOZIN + SITAGLIPTINDapagliflozin 10 mg + sitagliptin 100 mg tablet, 28 | 28 | $55.96 | AP |
| 12458Q | DESMOPRESSINdesmopressin acetate 10 microgram/actuation nasal spray, 50 actuations | 1 | $112.07 | DZ |
| 8711L | DESMOPRESSINdesmopressin acetate 10 microgram/actuation nasal spray, 60 actuations | 1 | $46.86 | FP |
| 13889B | DESMOPRESSINdesmopressin acetate 200 microgram tablet, 30 | 30 | $34.86 | FP |
| 13945Y | DESMOPRESSINdesmopressin acetate 200 microgram tablet, 30 | 30 | $35.67 | FP |
| 8662X | DESMOPRESSINdesmopressin acetate 200 microgram tablet, 30 | 30 | $34.85 | FP |
| 14004C | DESMOPRESSINdesmopressin 120 microgram sublingual wafer, 30 | 30 | $39.47 | FP |
| 13890C | DESMOPRESSINdesmopressin 240 microgram sublingual wafer, 30 | 30 | $66.00 | FP |
| 14384C | DESVENLAFAXINEdesvenlafaxine 100 mg modified release tablet, 28 | 28 | $10.98 | GQ,TX |
| 14489N | DESVENLAFAXINEdesvenlafaxine 100 mg modified release tablet, 28 | 28 | $10.98 | AF,BG,RW,SZ,WG |
| 14545M | DESVENLAFAXINEdesvenlafaxine 100 mg modified release tablet, 28 | 28 | $13.98 | PF |
| 14383B | DESVENLAFAXINEdesvenlafaxine 50 mg modified release tablet, 28 | 28 | $9.40 | AF,BG,RW,SZ,WG |
| 14418W | DESVENLAFAXINEdesvenlafaxine 50 mg modified release tablet, 28 | 28 | $9.40 | GQ,TX |
| 14451N | DESVENLAFAXINEdesvenlafaxine 50 mg modified release tablet, 28 | 28 | $12.39 | PF |
| 14007F | DEXAMETHASONEdexamethasone 500 microgram tablet, 30 | 30 | $5.17 | AS |
| 14521G | DEXTRAN-70 + HYPROMELLOSEdextran-70 0.1% + hypromellose 0.3% eye drops, 15 mL | 1 | $6.22 | IQ |
| 14521G | DEXTRAN-70 + HYPROMELLOSEdextran-70 0.1% + hypromellose 0.3% eye drops, 15 mL | 1 | $10.22 | AQ |
| 1302M | DICLOFENACdiclofenac sodium 100 mg suppository, 20 | 20 | $10.67 | NV |
| 5079H | DICLOFENACdiclofenac sodium 100 mg suppository, 20 | 20 | $10.67 | NV |
| 1299J | DICLOFENACdiclofenac sodium 25 mg enteric tablet, 50 | 50 | $5.17 | AL,RW,SZ,WG |
| 1299J | DICLOFENACdiclofenac sodium 25 mg enteric tablet, 50 | 50 | $10.15 | NV |
| 5076E | DICLOFENACdiclofenac sodium 25 mg enteric tablet, 50 | 50 | $5.17 | AL,RW,SZ,WG |
| 5076E | DICLOFENACdiclofenac sodium 25 mg enteric tablet, 50 | 50 | $10.15 | NV |
| 10790X | DICLOXACILLINdicloxacillin 500 mg capsule, 24 | 24 | $10.56 | MQ |
| 10790X | DICLOXACILLINdicloxacillin 500 mg capsule, 24 | 24 | $12.51 | AF |
| 3164M | DIGOXINdigoxin 50 microgram/mL oral liquid, 60 mL | 1 | $17.56 | AS |
| 14564M | DILTIAZEMdiltiazem hydrochloride 180 mg modified release capsule, 30 | 30 | $9.90 | SW |
| 14564M | DILTIAZEMdiltiazem hydrochloride 180 mg modified release capsule, 30 | 30 | $8.26 | AV,SZ |
| 14508N | DILTIAZEMdiltiazem hydrochloride 240 mg modified release capsule, 30 | 30 | $11.94 | SW |
| 14508N | DILTIAZEMdiltiazem hydrochloride 240 mg modified release capsule, 30 | 30 | $10.30 | AV,SZ |
| 14565N | DILTIAZEMdiltiazem hydrochloride 360 mg modified release capsule, 30 | 30 | $16.27 | SW |
| 14565N | DILTIAZEMdiltiazem hydrochloride 360 mg modified release capsule, 30 | 30 | $14.37 | AV,SZ |
| 14479C | DILTIAZEMdiltiazem hydrochloride 60 mg tablet, 90 | 90 | $12.32 | SW |
| 14479C | DILTIAZEMdiltiazem hydrochloride 60 mg tablet, 90 | 90 | $10.42 | AV |
| 2896K | DIMETHYL FUMARATEdimethyl fumarate 120 mg enteric capsule, 14 | 14 | $129.36 | BD,CR,SZ,XT |
| 2943X | DIMETHYL FUMARATEdimethyl fumarate 120 mg enteric capsule, 14 | 14 | $129.36 | BD,CR,SZ,XT |
| 13280Y | DISOPYRAMIDEdisopyramide 100 mg capsule, 84 | 84 | $59.60 | OJ |
| 14524K | DORZOLAMIDEdorzolamide 2% eye drops, 5 mL | 1 | $7.76 | AF,MF |
| 14386E | DORZOLAMIDE + TIMOLOLdorzolamide 2% + timolol 0.5% eye drops, 5 mL | 1 | $10.99 | AE,AF |
| 14386E | DORZOLAMIDE + TIMOLOLdorzolamide 2% + timolol 0.5% eye drops, 5 mL | 1 | $11.79 | MF |
| 10779H | DOXYCYCLINEdoxycycline 100 mg tablet, 7 | 7 | $3.92 | AF,RW,TX,WG |
| 10781K | DOXYCYCLINEdoxycycline 100 mg tablet, 7 | 7 | $3.92 | HX |
| 14480D | DOXYCYCLINEdoxycycline 100 mg tablet, 7 | 7 | $3.30 | AF,RW,TX,WG |
| 14511R | DOXYCYCLINEdoxycycline 100 mg tablet, 7 | 7 | $3.30 | HX |
| 2702F | DOXYCYCLINEdoxycycline 100 mg tablet, 7 | 7 | $3.92 | AF,RW,TX,WG |
| 2714W | DOXYCYCLINEdoxycycline 100 mg tablet, 7 | 7 | $4.33 | AF,RW,TX,WG |
| 9107H | DOXYCYCLINEdoxycycline 100 mg tablet, 7 | 7 | $3.92 | HX |
| 9108J | DOXYCYCLINEdoxycycline 100 mg tablet, 7 | 7 | $4.33 | HX |
| 10777F | DOXYCYCLINEdoxycycline 100 mg modified release capsule, 7 | 7 | $6.87 | YN |
| 10777F | DOXYCYCLINEdoxycycline 100 mg modified release capsule, 7 | 7 | $5.46 | YT |
| 14443E | DOXYCYCLINEdoxycycline 100 mg modified release capsule, 7 | 7 | $6.25 | YN |
| 14443E | DOXYCYCLINEdoxycycline 100 mg modified release capsule, 7 | 7 | $4.84 | YT |
| 2703G | DOXYCYCLINEdoxycycline 100 mg modified release capsule, 7 | 7 | $6.87 | YN |
| 2703G | DOXYCYCLINEdoxycycline 100 mg modified release capsule, 7 | 7 | $5.46 | YT |
| 14484H | DOXYCYCLINEdoxycycline 50 mg modified release capsule, 25 | 25 | $10.34 | YN |
| 14484H | DOXYCYCLINEdoxycycline 50 mg modified release capsule, 25 | 25 | $7.92 | YT |
| 14307B | DOXYCYCLINEdoxycycline 50 mg tablet, 25 | 25 | $5.34 | AF,RW,TX,WG |
| 14513W | DOXYCYCLINEdoxycycline 50 mg tablet, 25 | 25 | $5.34 | HX |
| 14875X | DROSPIRENONEdrospirenone 4 mg tablet [24] (&) inert substance tablet [4], 28 | 1 | $17.52 | HB |
| 14710F | DROSPIRENONE + ETHINYLESTRADIOLdrospirenone 3 mg + ethinylestradiol 20 microgram tablet [24] (&) inert substance tablet [4], 28 | 1 | $17.93 | BN |
| 14954C | DROSPIRENONE + ETHINYLESTRADIOLdrospirenone 3 mg + ethinylestradiol 20 microgram tablet [24] (&) inert substance tablet [4], 28 | 1 | $17.93 | GQ,SZ,XT |
| 14711G | DROSPIRENONE + ETHINYLESTRADIOLdrospirenone 3 mg + ethinylestradiol 30 microgram tablet [21] (&) inert substance tablet [7], 28 | 1 | $17.93 | BN,GQ,SZ,XT |
| 14712H | DULOXETINEduloxetine 60 mg enteric capsule, 28 | 28 | $6.76 | AL,BG,CR,HX,RW,SZ,TX |
| 13900N | DUTASTERIDEdutasteride 500 microgram capsule, 30 | 30 | $18.82 | TX |
| 13900N | DUTASTERIDEdutasteride 500 microgram capsule, 30 | 30 | $25.82 | GK |
| 13929D | DUTASTERIDE + TAMSULOSINdutasteride 500 microgram + tamsulosin hydrochloride 400 microgram modified release capsule, 30 | 30 | $20.36 | GC,GQ,SZ,TN |
| 13929D | DUTASTERIDE + TAMSULOSINdutasteride 500 microgram + tamsulosin hydrochloride 400 microgram modified release capsule, 30 | 30 | $23.86 | GK |
| 13845Q | EMPAGLIFLOZINempagliflozin 10 mg tablet, 30 | 30 | $44.41 | BY |
| 14018T | EMPAGLIFLOZINempagliflozin 10 mg tablet, 30 | 30 | $44.41 | BY |
| 13920P | EMPAGLIFLOZINempagliflozin 25 mg tablet, 30 | 30 | $44.63 | BY |
| 13904T | EMPAGLIFLOZIN + LINAGLIPTINempagliflozin 10 mg + linagliptin 5 mg tablet, 30 | 30 | $67.37 | BY |
| 13958P | EMPAGLIFLOZIN + LINAGLIPTINempagliflozin 25 mg + linagliptin 5 mg tablet, 30 | 30 | $67.37 | BY |
| 14029J | EMPAGLIFLOZIN + METFORMINempagliflozin 5 mg + metformin hydrochloride 500 mg tablet, 60 | 60 | $44.93 | BY |
| 13852C | EMPAGLIFLOZIN + METFORMINempagliflozin 5 mg + metformin hydrochloride 1 g tablet, 60 | 60 | $46.36 | BY |
| 13903R | EMPAGLIFLOZIN + METFORMINempagliflozin 12.5 mg + metformin hydrochloride 500 mg tablet, 60 | 60 | $44.93 | BY |
| 13987E | EMPAGLIFLOZIN + METFORMINempagliflozin 12.5 mg + metformin hydrochloride 1 g tablet, 60 | 60 | $46.36 | BY |
| 13465Q | ENALAPRILenalapril maleate 10 mg tablet, 30 | 30 | $6.08 | AL,RW,SZ,TX,WG |
| 13465Q | ENALAPRILenalapril maleate 10 mg tablet, 30 | 30 | $16.49 | AF |
| 13401H | ENALAPRILenalapril maleate 20 mg tablet, 30 | 30 | $6.38 | AL,RW,SZ,TX,WG |
| 13401H | ENALAPRILenalapril maleate 20 mg tablet, 30 | 30 | $16.78 | AF |
| 13369P | ENALAPRILenalapril maleate 5 mg tablet, 30 | 30 | $5.17 | AL,RW,SZ,TX,WG |
| 13439H | ENALAPRIL + HYDROCHLOROTHIAZIDEenalapril maleate 20 mg + hydrochlorothiazide 6 mg tablet, 30 | 30 | $6.99 | SZ |
| 13439H | ENALAPRIL + HYDROCHLOROTHIAZIDEenalapril maleate 20 mg + hydrochlorothiazide 6 mg tablet, 30 | 30 | $12.87 | AF |
| 11937G | ENCORAFENIBencorafenib 50 mg capsule, 28 | 28 | $780.73 | FB |
| 11954E | ENCORAFENIBencorafenib 50 mg capsule, 28 | 28 | $780.73 | FB |
| 11938H | ENCORAFENIBencorafenib 75 mg capsule, 42 | 42 | $1713.70 | FB |
| 11949X | ENCORAFENIBencorafenib 75 mg capsule, 42 | 42 | $1713.70 | FB |
| 12814K | ENCORAFENIBencorafenib 75 mg capsule, 42 | 42 | $1722.02 | FB |
| 12815L | ENCORAFENIBencorafenib 75 mg capsule, 42 | 42 | $1722.02 | FB |
| 8510X | ENOXAPARIN SODIUMenoxaparin sodium 40 mg/0.4 mL injection, 10 x 0.4 mL syringes | 10 | $33.85 | AV,JO,JU |
| 8639Q | ENOXAPARIN SODIUMenoxaparin sodium 40 mg/0.4 mL injection, 10 x 0.4 mL syringes | 10 | $33.85 | AV,JO,JU |
| 8558K | ENOXAPARIN SODIUMenoxaparin sodium 20 mg/0.2 mL injection, 10 x 0.2 mL syringes | 10 | $30.54 | AV,JO,JU |
| 8716R | ENOXAPARIN SODIUMenoxaparin sodium 20 mg/0.2 mL injection, 10 x 0.2 mL syringes | 10 | $30.54 | AV,JO,JU |
| 5435C | ENOXAPARIN SODIUMenoxaparin sodium 100 mg/mL injection, 10 x 1 mL syringes | 10 | $80.39 | AV,JO,JU |
| 8640R | ENOXAPARIN SODIUMenoxaparin sodium 60 mg/0.6 mL injection, 10 x 0.6 mL syringes | 10 | $57.00 | AV,JO,JU |
| 5434B | ENOXAPARIN SODIUMenoxaparin sodium 80 mg/0.8 mL injection, 10 x 0.8 mL syringes | 10 | $60.60 | AV,JO,JU |
| 14542J | ENTACAPONEentacapone 200 mg tablet, 100 | 100 | $85.36 | SZ |
| 8367J | ENTACAPONEentacapone 200 mg tablet, 100 | 100 | $85.34 | SZ |
| 13590G | EPLERENONEeplerenone 25 mg tablet, 30 | 30 | $43.09 | AF,GO,RW,TX |
| 13379E | EPLERENONEeplerenone 50 mg tablet, 30 | 30 | $43.09 | AF,GO,RW,TX |
| 13861M | EPROSARTANeprosartan 600 mg tablet, 28 | 28 | $16.74 | GO |
| 13912F | EPROSARTANeprosartan 600 mg tablet, 28 | 28 | $16.74 | GO |
| 14337N | EPROSARTAN + HYDROCHLOROTHIAZIDEeprosartan 600 mg + hydrochlorothiazide 12.5 mg tablet, 28 | 28 | $15.25 | GO |
| 10780J | ERYTHROMYCINerythromycin 250 mg enteric capsule, 25 | 25 | $14.46 | YT |
| 14409J | ERYTHROMYCINerythromycin 250 mg enteric capsule, 25 | 25 | $13.23 | YT |
| 14349F | ESCITALOPRAMescitalopram 10 mg tablet, 28 | 28 | $5.17 | AF,BG,CF,HQ,HX,RW,TX,TY,WG,ZS |
| 14349F | ESCITALOPRAMescitalopram 10 mg tablet, 28 | 28 | $19.35 | LU |
| 14519E | ESCITALOPRAMescitalopram 10 mg tablet, 28 | 28 | $5.17 | AF,BG,CF,HQ,HX,RW,TX,TY,WG |
| 14519E | ESCITALOPRAMescitalopram 10 mg tablet, 28 | 28 | $19.35 | LU |
| 14415Q | ESCITALOPRAMescitalopram 20 mg tablet, 28 | 28 | $5.17 | AF,BG,CF,HQ,HX,RW,TX,TY,WG,ZS |
| 14415Q | ESCITALOPRAMescitalopram 20 mg tablet, 28 | 28 | $19.70 | LU |
| 14416R | ESCITALOPRAMescitalopram 20 mg tablet, 28 | 28 | $5.17 | AF,BG,CF,HQ,HX,RW,TX,TY,WG |
| 14416R | ESCITALOPRAMescitalopram 20 mg tablet, 28 | 28 | $19.70 | LU |
| 14546N | ESCITALOPRAMescitalopram 20 mg/mL oral liquid, 15 mL | 1 | $28.43 | LU |
| 14812N | ESKETAMINEesketamine 28 mg/2 actuations nasal spray, 2 actuations | 1 | $315.95 | JC |
| 14836W | ESKETAMINEesketamine 28 mg/2 actuations nasal spray, 2 actuations | 1 | $313.42 | JC |
| 14794P | ESKETAMINEesketamine 28 mg/2 actuations nasal spray, 2 x 2 actuations | 2 | $620.07 | JC |
| 14815R | ESKETAMINEesketamine 28 mg/2 actuations nasal spray, 2 x 2 actuations | 2 | $607.58 | JC |
| 14786F | ESKETAMINEesketamine 28 mg/2 actuations nasal spray, 3 x 2 actuations | 3 | $901.74 | JC |
| 14830M | ESKETAMINEesketamine 28 mg/2 actuations nasal spray, 3 x 2 actuations | 3 | $914.23 | JC |
| 12275C | ESOMEPRAZOLEesomeprazole 20 mg enteric capsule, 30 | 30 | $6.76 | AL |
| 14303T | ESOMEPRAZOLEesomeprazole 20 mg enteric capsule, 30 | 30 | $6.76 | AL |
| 12290W | ESOMEPRAZOLEesomeprazole 40 mg enteric capsule, 30 | 30 | $9.76 | AL |
| 14405E | ESOMEPRAZOLEesomeprazole 40 mg enteric capsule, 30 | 30 | $9.76 | AL |
| 14445G | ESOMEPRAZOLEesomeprazole 40 mg enteric capsule, 30 | 30 | $8.53 | AL |
| 12287Q | ESOMEPRAZOLEesomeprazole 20 mg enteric tablet, 30 | 30 | $6.76 | AF,BG,GQ,MQ,RA,RF,RW,TY,WG |
| 12287Q | ESOMEPRAZOLEesomeprazole 20 mg enteric tablet, 30 | 30 | $13.76 | AP |
| 14308C | ESOMEPRAZOLEesomeprazole 20 mg enteric tablet, 30 | 30 | $6.76 | AF,BG,GQ,MQ,RA,RF,RW,TY,WG |
| 14308C | ESOMEPRAZOLEesomeprazole 20 mg enteric tablet, 30 | 30 | $13.76 | AP |
| 14444F | ESOMEPRAZOLEesomeprazole 20 mg enteric tablet, 30 | 30 | $6.76 | AF,BG,GQ,MQ,RA,RF,RW,TY,WG |
| 14444F | ESOMEPRAZOLEesomeprazole 20 mg enteric tablet, 30 | 30 | $13.76 | AP |
| 14481E | ESOMEPRAZOLEesomeprazole 20 mg enteric tablet, 30 | 30 | $5.53 | AF,GQ,RA,TY |
| 12283L | ESOMEPRAZOLEesomeprazole 40 mg enteric tablet, 30 | 30 | $9.76 | AF,BG,GQ,MQ,RA,RF,RW,TY,WG |
| 12283L | ESOMEPRAZOLEesomeprazole 40 mg enteric tablet, 30 | 30 | $16.76 | AP |
| 14373L | ESOMEPRAZOLEesomeprazole 40 mg enteric tablet, 30 | 30 | $9.76 | AF,BG,GQ,MQ,RA,RF,RW,TY,WG |
| 14373L | ESOMEPRAZOLEesomeprazole 40 mg enteric tablet, 30 | 30 | $16.76 | AP |
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