Browse by Standard Packs
Standard Packs and Prices for Ready Prepared Pharmaceutical Benefits
| Item code | Drug name Form and Strength |
Pack size | Price | Manufacturer |
|---|---|---|---|---|
| 10953L | BUPRENORPHINEbuprenorphine 15 microgram/hour patch, 2 | 2 | $19.71 | IU,MF,SZ,TX |
| 10964C | BUPRENORPHINEbuprenorphine 25 microgram/hour patch, 2 | 2 | $26.88 | MF,SZ,TX |
| 10949G | BUPRENORPHINEbuprenorphine 30 microgram/hour patch, 2 | 2 | $30.36 | MF,SZ,TX |
| 10959T | BUPRENORPHINEbuprenorphine 40 microgram/hour patch, 2 | 2 | $37.35 | MF,SZ,TX |
| 10948F | BUPRENORPHINEbuprenorphine 10 microgram/hour patch, 2 | 2 | $16.03 | IU,MF,SZ,TX |
| 10970J | BUPRENORPHINEbuprenorphine 20 microgram/hour patch, 2 | 2 | $23.39 | IU,MF,SZ,TX |
| 10957Q | BUPRENORPHINEbuprenorphine 5 microgram/hour patch, 2 | 2 | $10.00 | IU,MF,SZ,TX |
| 5331N | 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 |
| 5339B | CLONAZEPAMclonazepam 2.5 mg/mL (0.1 mg/drop) oral liquid, 10 mL | 1 | $6.22 | PB |
| 11520H | CLONAZEPAMclonazepam 500 microgram tablet, 50 | 50 | $6.77 | PB |
| 10697B | FENTANYLfentanyl 200 microgram orally disintegrating tablet, 4 | 4 | $31.71 | TB |
| 5407N | FENTANYLfentanyl 200 microgram lozenge, 30 | 30 | $250.43 | TB |
| 10698C | FENTANYLfentanyl 200 microgram orally disintegrating tablet, 28 | 28 | $214.91 | TB |
| 10737D | FENTANYLfentanyl 400 microgram orally disintegrating tablet, 28 | 28 | $135.72 | TB |
| 10713W | FENTANYLfentanyl 600 microgram orally disintegrating tablet, 28 | 28 | $135.72 | TB |
| 5408P | FENTANYLfentanyl 400 microgram lozenge, 30 | 30 | $250.43 | TB |
| 5409Q | FENTANYLfentanyl 600 microgram lozenge, 30 | 30 | $181.83 | TB |
| 5410R | FENTANYLfentanyl 800 microgram lozenge, 30 | 30 | $181.83 | TB |
| 10738E | FENTANYLfentanyl 800 microgram orally disintegrating tablet, 28 | 28 | $135.72 | TB |
| 10684H | FENTANYLfentanyl 100 microgram orally disintegrating tablet, 28 | 28 | $214.91 | TB |
| 10610K | FENTANYLfentanyl 300 microgram sublingual tablet, 30 | 30 | $198.02 | FK |
| 10613N | FENTANYLfentanyl 600 microgram sublingual tablet, 30 | 30 | $198.02 | FK |
| 10611L | FENTANYLfentanyl 800 microgram sublingual tablet, 30 | 30 | $198.02 | FK |
| 12504D | FENTANYLfentanyl 25 microgram/hour patch, 5 | 5 | $11.58 | SZ,TX |
| 12477Q | FENTANYLfentanyl 50 microgram/hour patch, 5 | 5 | $19.20 | SZ,TX |
| 12474M | FENTANYLfentanyl 75 microgram/hour patch, 5 | 5 | $25.39 | SZ,TX |
| 12509J | FENTANYLfentanyl 100 microgram/hour patch, 5 | 5 | $30.92 | SZ,TX |
| 12541C | FENTANYLfentanyl 12 microgram/hour patch, 5 | 5 | $9.62 | SZ,TX |
| 10602B | FENTANYLfentanyl 100 microgram sublingual tablet, 30 | 30 | $198.02 | FK |
| 10607G | FENTANYLfentanyl 200 microgram sublingual tablet, 30 | 30 | $198.02 | FK |
| 10608H | FENTANYLfentanyl 400 microgram sublingual tablet, 30 | 30 | $198.02 | FK |
| 10601Y | FENTANYLfentanyl 100 microgram sublingual tablet, 10 | 10 | $65.98 | FK |
| 10600X | FENTANYLfentanyl 200 microgram sublingual tablet, 10 | 10 | $65.98 | FK |
| 10729Q | FENTANYLfentanyl 100 microgram orally disintegrating tablet, 4 | 4 | $31.71 | TB |
| 12531M | HYDROMORPHONEhydromorphone hydrochloride 10 mg/mL injection, 5 x 1 mL ampoules | 5 | $10.55 | DZ,HW,JU,MF |
| 12493M | HYDROMORPHONEhydromorphone hydrochloride 2 mg/mL injection, 5 x 1 mL ampoules | 5 | $8.52 | DZ,HW,JU,MF |
| 12497R | HYDROMORPHONEhydromorphone hydrochloride 2 mg tablet, 20 | 20 | $9.05 | MF |
| 12484C | HYDROMORPHONEhydromorphone hydrochloride 4 mg tablet, 20 | 20 | $11.32 | MF |
| 12515Q | HYDROMORPHONEhydromorphone hydrochloride 8 mg tablet, 20 | 20 | $19.73 | MF |
| 5317W | HYOSCINE BUTYLBROMIDEhyoscine butylbromide 20 mg/mL injection, 5 x 1 mL ampoules | 5 | $7.88 | AE,DZ,VZ,XN |
| 5368M | IBUPROFENibuprofen 400 mg tablet, 30 | 30 | $4.33 | TX,WG |
| 5368M | IBUPROFENibuprofen 400 mg tablet, 30 | 30 | $6.84 | GO |
| 5377B | INDOMETACINindometacin 25 mg capsule, 50 | 50 | $5.79 | AF |
| 5377B | INDOMETACINindometacin 25 mg capsule, 50 | 50 | $7.81 | AS |
| 5426N | MACROGOL-3350macrogol-3350 1 g/g powder for oral liquid, 510 g | 1 | $11.93 | KY |
| 5389P | MACROGOL-3350 + SODIUM CHLORIDE + BICARBONATE + POTASSIUM CHLORIDEmacrogol-3350 13.125 g + sodium chloride 350.7 mg + sodium bicarbonate 178.5 mg + potassium chloride 46.6 mg powder for oral liquid, 30 sachets | 1 | $8.73 | GX,OW,RF,RW,TX,XT |
| 12520Y | METHADONEmethadone hydrochloride 10 mg tablet, 20 | 20 | $6.12 | AE,AS |
| 14193B | METHADONEmethadone hydrochloride 10 mg/mL injection, 5 x 1 mL vials | 5 | $37.21 | AS |
| 5423K | METHYLNALTREXONEmethylnaltrexone bromide 12 mg/0.6 mL injection, 0.6 mL vial | 1 | $24.96 | LM |
| 10762K | METOCLOPRAMIDEmetoclopramide hydrochloride 10 mg/2 mL injection, 10 x 2 mL ampoules | 10 | $8.86 | DZ,WZ |
| 12507G | METOCLOPRAMIDEmetoclopramide hydrochloride 10 mg tablet, 25 | 25 | $3.92 | AF,RW,TX,WG |
| 12507G | METOCLOPRAMIDEmetoclopramide hydrochloride 10 mg tablet, 25 | 25 | $7.47 | IL |
| 12500X | MORPHINEmorphine sulfate pentahydrate 30 mg modified release tablet, 28 | 28 | $19.95 | MF |
| 12492L | MORPHINEmorphine sulfate pentahydrate 5 mg modified release tablet, 28 | 28 | $9.23 | MF |
| 12549L | MORPHINEmorphine hydrochloride trihydrate 5 mg/mL oral liquid, 200 mL | 200 | $90.28 | XT |
| 12544F | MORPHINEmorphine sulfate pentahydrate 60 mg modified release tablet, 28 | 28 | $33.17 | MF |
| 12501Y | MORPHINEmorphine sulfate pentahydrate 10 mg modified release capsule, 28 | 28 | $11.94 | YN |
| 12529K | MORPHINEmorphine sulfate pentahydrate 100 mg modified release capsule, 28 | 28 | $44.38 | YN |
| 12502B | MORPHINEmorphine hydrochloride trihydrate 10 mg/mL injection, 5 x 1 mL ampoules | 5 | $6.60 | JU |
| 12494N | MORPHINEmorphine hydrochloride trihydrate 20 mg/mL injection, 5 x 1 mL ampoules | 5 | $8.79 | JU |
| 12512M | MORPHINEmorphine sulfate pentahydrate 120 mg modified release capsule, 14 | 14 | $33.16 | MF |
| 12539Y | MORPHINEmorphine sulfate pentahydrate 20 mg modified release capsule, 28 | 28 | $12.84 | YN |
| 12490J | MORPHINEmorphine sulfate pentahydrate 30 mg modified release capsule, 14 | 14 | $12.32 | MF |
| 12470H | MORPHINEmorphine hydrochloride trihydrate 50 mg/5 mL injection, 5 x 5 mL ampoules | 5 | $14.59 | JU |
| 12537W | MORPHINEmorphine hydrochloride trihydrate 100 mg/5 mL injection, 5 x 5 mL ampoules | 5 | $20.64 | JU |
| 12489H | MORPHINEmorphine sulfate pentahydrate 50 mg modified release capsule, 28 | 28 | $24.80 | YN |
| 12487F | MORPHINEmorphine sulfate pentahydrate 60 mg modified release capsule, 14 | 14 | $19.93 | MF |
| 12514P | MORPHINEmorphine sulfate pentahydrate 90 mg modified release capsule, 14 | 14 | $23.58 | MF |
| 12499W | MORPHINEmorphine sulfate pentahydrate 10 mg/mL injection, 5 x 1 mL ampoules | 5 | $7.42 | DZ |
| 12548K | MORPHINEmorphine sulfate pentahydrate 15 mg/mL injection, 5 x 1 mL ampoules | 5 | $10.18 | DZ |
| 12503C | MORPHINEmorphine sulfate pentahydrate 30 mg/mL injection, 5 x 1 mL ampoules | 5 | $12.28 | DZ |
| 12547J | MORPHINEmorphine sulfate pentahydrate 10 mg modified release tablet, 28 | 28 | $9.60 | MF |
| 12483B | MORPHINEmorphine sulfate pentahydrate 100 mg modified release tablet, 28 | 28 | $45.78 | MF |
| 12476P | MORPHINEmorphine sulfate pentahydrate 15 mg modified release tablet, 28 | 28 | $15.59 | MF |
| 5391R | MORPHINEmorphine sulfate pentahydrate 200 mg modified release tablet, 28 | 28 | $107.56 | MF |
| 12472K | MORPHINEmorphine hydrochloride trihydrate 10 mg/mL oral liquid, 200 mL | 200 | $141.08 | XT |
| 5345H | NAPROXENnaproxen 250 mg tablet, 50 | 50 | $7.18 | IX |
| 5359C | NITRAZEPAMnitrazepam 5 mg tablet, 25 | 25 | $5.17 | AF,IL |
| 5371Q | OXAZEPAMoxazepam 15 mg tablet, 25 | 25 | $5.17 | AF,AS |
| 5372R | OXAZEPAMoxazepam 30 mg tablet, 25 | 25 | $5.17 | AF,TX,WG |
| 5372R | OXAZEPAMoxazepam 30 mg tablet, 25 | 25 | $6.01 | RW |
| 5372R | OXAZEPAMoxazepam 30 mg tablet, 25 | 25 | $9.09 | AS |
| 12518W | OXYCODONEoxycodone hydrochloride 10 mg modified release tablet, 28 | 28 | $13.46 | MF,SZ |
| 12545G | OXYCODONEoxycodone hydrochloride 15 mg modified release tablet, 28 | 28 | $21.70 | MF |
| 12510K | OXYCODONEoxycodone hydrochloride 20 mg modified release tablet, 28 | 28 | $21.94 | MF,SZ |
| 12538X | OXYCODONEoxycodone hydrochloride 30 mg modified release tablet, 28 | 28 | $35.28 | MF |
| 12525F | OXYCODONEoxycodone hydrochloride 40 mg modified release tablet, 28 | 28 | $31.92 | MF,SZ |
| 12527H | OXYCODONEoxycodone hydrochloride 80 mg modified release tablet, 28 | 28 | $50.73 | MF,SZ |
| 12511L | OXYCODONE + NALOXONEoxycodone hydrochloride 60 mg + naloxone hydrochloride 30 mg modified release tablet, 28 | 28 | $68.86 | MF,TX |
| 12498T | OXYCODONE + NALOXONEoxycodone hydrochloride 80 mg + naloxone hydrochloride 40 mg modified release tablet, 28 | 28 | $72.52 | MF,TX |
| 12471J | OXYCODONE + NALOXONEoxycodone hydrochloride 2.5 mg + naloxone hydrochloride 1.25 mg modified release tablet, 28 | 28 | $12.32 | MF,TX |
| 12540B | OXYCODONE + NALOXONEoxycodone hydrochloride 15 mg + naloxone hydrochloride 7.5 mg modified release tablet, 28 | 28 | $25.54 | MF,TX |
| 12532N | OXYCODONE + NALOXONEoxycodone hydrochloride 30 mg + naloxone hydrochloride 15 mg modified release tablet, 28 | 28 | $41.83 | MF,TX |
| 12523D | OXYCODONE + NALOXONEoxycodone hydrochloride 10 mg + naloxone hydrochloride 5 mg modified release tablet, 28 | 28 | $16.51 | MF,TX |
| 12486E | OXYCODONE + NALOXONEoxycodone hydrochloride 20 mg + naloxone hydrochloride 10 mg modified release tablet, 28 | 28 | $27.38 | MF,TX |
| 12475N | OXYCODONE + NALOXONEoxycodone hydrochloride 40 mg + naloxone hydrochloride 20 mg modified release tablet, 28 | 28 | $40.12 | MF,TX |
| 12522C | OXYCODONE + NALOXONEoxycodone hydrochloride 5 mg + naloxone hydrochloride 2.5 mg modified release tablet, 28 | 28 | $15.66 | MF,TX |
| 5343F | PARACETAMOLparacetamol 665 mg modified release tablet, 96 | 96 | $6.22 | CR,GQ,RF,TX,XT |
| 12210P | PARACETAMOLparacetamol 500 mg suppository, 10 | 10 | $8.99 | GJ |
| 5375X | TEMAZEPAMtemazepam 10 mg tablet, 25 | 25 | $5.17 | AF,LN,TX,WG |
| 5375X | TEMAZEPAMtemazepam 10 mg tablet, 25 | 25 | $10.24 | AS |
