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
10957Q BUPRENORPHINEbuprenorphine 5 microgram/hour patch, 2 2 $10.00 IU,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
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
11520H CLONAZEPAMclonazepam 500 microgram tablet, 50 50 $6.77 PB
5339B CLONAZEPAMclonazepam 2.5 mg/mL (0.1 mg/drop) oral liquid, 10 mL 1 $6.22 PB
10729Q FENTANYLfentanyl 100 microgram orally disintegrating tablet, 4 4 $31.71 TB
5407N FENTANYLfentanyl 200 microgram lozenge, 30 30 $250.43 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
10697B FENTANYLfentanyl 200 microgram orally disintegrating tablet, 4 4 $31.71 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
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
10602B FENTANYLfentanyl 100 microgram sublingual tablet, 30 30 $198.02 FK
12504D FENTANYLfentanyl 25 microgram/hour patch, 5 5 $9.04 JC,SZ,TX
12516R FENTANYLfentanyl 25 microgram/hour patch, 5 5 $9.04 AF
12521B FENTANYLfentanyl 25 microgram/hour patch, 5 5 $10.59 RW
12477Q FENTANYLfentanyl 50 microgram/hour patch, 5 5 $14.55 JC,SZ,TX
12513N FENTANYLfentanyl 50 microgram/hour patch, 5 5 $17.39 RW
12546H FENTANYLfentanyl 50 microgram/hour patch, 5 5 $14.55 AF
10607G FENTANYLfentanyl 200 microgram sublingual tablet, 30 30 $198.02 FK
10608H FENTANYLfentanyl 400 microgram sublingual tablet, 30 30 $198.02 FK
12474M FENTANYLfentanyl 75 microgram/hour patch, 5 5 $19.02 JC,SZ,TX
12517T FENTANYLfentanyl 75 microgram/hour patch, 5 5 $22.93 RW
12526G FENTANYLfentanyl 75 microgram/hour patch, 5 5 $19.02 AF
12480W FENTANYLfentanyl 100 microgram/hour patch, 5 5 $27.64 RW
12509J FENTANYLfentanyl 100 microgram/hour patch, 5 5 $23.01 JC,SZ,TX
12533P FENTANYLfentanyl 100 microgram/hour patch, 5 5 $23.01 AF
10601Y FENTANYLfentanyl 100 microgram sublingual tablet, 10 10 $65.98 FK
10600X FENTANYLfentanyl 200 microgram sublingual tablet, 10 10 $65.98 FK
12491K FENTANYLfentanyl 12 microgram/hour patch, 5 5 $7.63 AF
12530L FENTANYLfentanyl 12 microgram/hour patch, 5 5 $8.85 RW
12541C FENTANYLfentanyl 12 microgram/hour patch, 5 5 $7.63 JC,SZ,TX
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
5391R MORPHINEmorphine sulfate pentahydrate 200 mg modified release tablet, 28 28 $107.56 MF
12500X MORPHINEmorphine sulfate pentahydrate 30 mg modified release tablet, 28 28 $19.95 MF,TX
12492L MORPHINEmorphine sulfate pentahydrate 5 mg modified release tablet, 28 28 $9.23 MF
12544F MORPHINEmorphine sulfate pentahydrate 60 mg modified release tablet, 28 28 $33.17 MF,TX
12472K MORPHINEmorphine hydrochloride trihydrate 10 mg/mL oral liquid, 200 mL 200 $141.08 XT
14187Q MORPHINEmorphine hydrochloride trihydrate 10 mg/mL oral liquid, 200 mL 200 $141.08 WZ
12549L MORPHINEmorphine hydrochloride trihydrate 5 mg/mL oral liquid, 200 mL 200 $90.28 XT
13742G MORPHINEmorphine sulfate 10 mg/5 mL oral solution, 100 mL 100 $67.44 LM
13741F MORPHINEmorphine sulfate 10 mg/5 mL oral solution, 300 mL 300 $101.53 LM
13743H MORPHINEmorphine sulfate 2 mg/mL oral solution, 100 mL 100 $48.00 DZ
13748N MORPHINEmorphine sulfate 2 mg/mL oral solution, 500 mL 500 $108.40 DZ
14081D MORPHINEmorphine hydrochloride trihydrate 10 mg/mL oral liquid, 20 mL 20 $55.26 DZ
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
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
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
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
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,TX
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
12483B MORPHINEmorphine sulfate pentahydrate 100 mg modified release tablet, 28 28 $45.78 MF,TX
12476P MORPHINEmorphine sulfate pentahydrate 15 mg modified release tablet, 28 28 $15.59 MF
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
12210P PARACETAMOLparacetamol 500 mg suppository, 10 10 $8.99 GJ
5343F PARACETAMOLparacetamol 665 mg modified release tablet, 96 96 $6.22 CR,GQ,RF,TX,XT
5375X TEMAZEPAMtemazepam 10 mg tablet, 25 25 $5.17 AF,LN,TX,WG
5375X TEMAZEPAMtemazepam 10 mg tablet, 25 25 $10.24 AS