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 |
|---|---|---|---|---|
| 13999T | CICLOSPORINciclosporin 10 mg capsule, 60 | 60 | $41.95 | NV |
| 8657P | CICLOSPORINciclosporin 10 mg capsule, 60 | 60 | $42.40 | NV |
| 13911E | CICLOSPORINciclosporin 100 mg capsule, 30 | 30 | $105.45 | NM,NV,WG |
| 8660T | CICLOSPORINciclosporin 100 mg capsule, 30 | 30 | $105.40 | NM,NV,TX,WG |
| 14001X | CICLOSPORINciclosporin 100 mg/mL oral liquid, 50 mL | 1 | $345.74 | NV |
| 8661W | CICLOSPORINciclosporin 100 mg/mL oral liquid, 50 mL | 1 | $345.69 | NV |
| 8658Q | CICLOSPORINciclosporin 25 mg capsule, 30 | 30 | $26.10 | NM,NV,TX,WG |
| 8659R | CICLOSPORINciclosporin 50 mg capsule, 30 | 30 | $51.72 | NM,NV,TX,WG |
| 1217C | CIPROFLOXACINciprofloxacin 0.3% eye drops, 5 mL | 1 | $11.99 | NM |
| 1217C | CIPROFLOXACINciprofloxacin 0.3% eye drops, 5 mL | 1 | $14.17 | NV |
| 5564W | CIPROFLOXACINciprofloxacin 0.3% eye drops, 5 mL | 1 | $11.99 | NM |
| 5564W | CIPROFLOXACINciprofloxacin 0.3% eye drops, 5 mL | 1 | $14.17 | NV |
| 14313H | CITALOPRAMcitalopram 10 mg tablet, 28 | 28 | $5.11 | AF,RW,WG |
| 14490P | CITALOPRAMcitalopram 20 mg tablet, 28 | 28 | $5.11 | AF,RW,SZ,TX,TY,VO,WG |
| 14490P | CITALOPRAMcitalopram 20 mg tablet, 28 | 28 | $18.26 | LU |
| 14518D | CITALOPRAMcitalopram 40 mg tablet, 28 | 28 | $5.15 | AF,RW,SZ,TX,VO,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 | $13.07 | 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 | $14.27 | AE |
| 5481L | CITRULLINE WITH CARBOHYDRATEcitrulline with carbohydrate containing 1 g citrulline powder for oral liquid, 30 x 4 g sachets | 1 | $109.92 | VF |
| 11604R | CLADRIBINEcladribine 10 mg tablet, 4 | 4 | $14642.53 | SG |
| 3138E | CLINDAMYCINclindamycin 150 mg capsule, 24 | 24 | $6.88 | AF,PF,RW,TX,WG,XT |
| 1808E | CLONAZEPAMclonazepam 2.5 mg/mL (0.1 mg/drop) oral liquid, 10 mL | 1 | $6.16 | PB |
| 1806C | CLONAZEPAMclonazepam 2 mg tablet, 100 | 100 | $11.89 | AF |
| 1805B | CLONAZEPAMclonazepam 500 microgram tablet, 100 | 100 | $9.17 | AF |
| 11559J | CLONAZEPAMclonazepam 500 microgram tablet, 50 | 50 | $5.51 | PB |
| 13578P | CLONIDINEclonidine hydrochloride 100 microgram tablet, 100 | 100 | $14.73 | GQ,IX,TX |
| 13548C | CLONIDINEclonidine hydrochloride 150 microgram tablet, 100 | 100 | $20.90 | IX |
| 13365K | CLOPIDOGRELclopidogrel 75 mg tablet, 28 | 28 | $6.49 | RF,RW,WG |
| 13399F | CLOPIDOGRELclopidogrel 75 mg tablet, 28 | 28 | $6.49 | AF,AV,BG,CR,GQ,HX,WA |
| 13427Q | CLOPIDOGREL + ASPIRINclopidogrel 75 mg + aspirin 100 mg tablet, 30 | 30 | $6.70 | AF,AV,GZ,TY,WA |
| 12054K | CODEINEcodeine phosphate hemihydrate 30 mg tablet, 20 | 20 | $13.95 | AS |
| 12065B | CODEINEcodeine phosphate hemihydrate 30 mg tablet, 20 | 20 | $13.95 | AS |
| 14132T | COLESTYRAMINEcolestyramine 4 g powder for oral liquid, 60 pouches | 60 | $122.45 | CR |
| 14145L | COLESTYRAMINEcolestyramine 4 g powder for oral liquid, 60 pouches | 60 | $122.45 | CR |
| 14477Y | COLESTYRAMINEcolestyramine 4 g powder for oral liquid, 50 sachets | 1 | $36.39 | GO |
| 2967E | COLESTYRAMINEcolestyramine 4 g powder for oral liquid, 50 sachets | 1 | $37.11 | GO |
| 13347L | COLESTYRAMINEcolestyramine 4 g powder for oral liquid, 30 sachets | 30 | $61.21 | DZ |
| 13351Q | COLESTYRAMINEcolestyramine 4 g powder for oral liquid, 30 sachets | 30 | $61.21 | DZ |
| 13862N | CORTISONEcortisone acetate 25 mg tablet, 60 | 60 | $14.86 | AS |
| 13946B | CORTISONEcortisone acetate 5 mg tablet, 50 | 50 | $9.73 | AS |
| 14022B | CYPROTERONEcyproterone acetate 100 mg tablet, 50 | 50 | $51.42 | GH |
| 14022B | CYPROTERONEcyproterone acetate 100 mg tablet, 50 | 50 | $50.21 | HX,RW |
| 13925X | CYPROTERONEcyproterone acetate 50 mg tablet, 20 | 20 | $14.68 | HX,RW |
| 1270W | CYPROTERONEcyproterone acetate 50 mg tablet, 50 | 50 | $34.08 | GH |
| 1270W | CYPROTERONEcyproterone acetate 50 mg tablet, 50 | 50 | $33.10 | HX,RW |
| 14023C | CYPROTERONEcyproterone acetate 50 mg tablet, 50 | 50 | $33.21 | GH |
| 14023C | CYPROTERONEcyproterone acetate 50 mg tablet, 50 | 50 | $32.18 | HX,RW |
| 9318K | DABIGATRANdabigatran etexilate 75 mg capsule, 10 | 10 | $13.51 | BY |
| 9322P | DABIGATRANdabigatran etexilate 75 mg capsule, 10 | 10 | $13.51 | BY |
| 9319L | DABIGATRANdabigatran etexilate 110 mg capsule, 10 | 10 | $9.06 | BY |
| 9323Q | DABIGATRANdabigatran etexilate 110 mg capsule, 10 | 10 | $9.06 | BY |
| 13489Y | DABIGATRANdabigatran etexilate 150 mg capsule, 60 | 60 | $42.05 | BY,CR,SZ,XT |
| 13523R | DABIGATRANdabigatran etexilate 110 mg capsule, 60 | 60 | $42.33 | BY,CR,SZ,XT |
| 13844P | DAPAGLIFLOZINdapagliflozin 10 mg tablet, 28 | 28 | $44.99 | AP |
| 14054Q | DAPAGLIFLOZINdapagliflozin 10 mg tablet, 28 | 28 | $44.99 | AP |
| 13851B | DAPAGLIFLOZIN + METFORMINdapagliflozin 5 mg + metformin hydrochloride 1 g modified release tablet, 56 | 56 | $47.95 | AP |
| 13875G | DAPAGLIFLOZIN + METFORMINdapagliflozin 10 mg + metformin hydrochloride 1 g modified release tablet, 28 | 28 | $46.52 | AP |
| 14028H | DAPAGLIFLOZIN + METFORMINdapagliflozin 10 mg + metformin hydrochloride 500 mg modified release tablet, 28 | 28 | $45.75 | AP |
| 14645T | DAPAGLIFLOZIN + SITAGLIPTINdapagliflozin 10 mg + sitagliptin 100 mg tablet, 28 | 28 | $59.50 | AP |
| 12458Q | DESMOPRESSINdesmopressin acetate 10 microgram/actuation nasal spray, 50 actuations | 1 | $112.01 | DZ |
| 8711L | DESMOPRESSINdesmopressin acetate 10 microgram/actuation nasal spray, 60 actuations | 1 | $46.80 | FP |
| 13889B | DESMOPRESSINdesmopressin acetate 200 microgram tablet, 30 | 30 | $34.84 | FP |
| 13945Y | DESMOPRESSINdesmopressin acetate 200 microgram tablet, 30 | 30 | $35.61 | FP |
| 8662X | DESMOPRESSINdesmopressin acetate 200 microgram tablet, 30 | 30 | $34.81 | FP |
| 14004C | DESMOPRESSINdesmopressin 120 microgram sublingual wafer, 30 | 30 | $39.41 | FP |
| 13890C | DESMOPRESSINdesmopressin 240 microgram sublingual wafer, 30 | 30 | $65.94 | FP |
| 14384C | DESVENLAFAXINEdesvenlafaxine 100 mg modified release tablet, 28 | 28 | $10.92 | GQ,TX |
| 14489N | DESVENLAFAXINEdesvenlafaxine 100 mg modified release tablet, 28 | 28 | $10.92 | AF,BG,RW,SZ,WG |
| 14545M | DESVENLAFAXINEdesvenlafaxine 100 mg modified release tablet, 28 | 28 | $10.92 | PF |
| 14383B | DESVENLAFAXINEdesvenlafaxine 50 mg modified release tablet, 28 | 28 | $9.34 | AF,BG,RW,SZ,WG |
| 14418W | DESVENLAFAXINEdesvenlafaxine 50 mg modified release tablet, 28 | 28 | $9.34 | GQ,TX |
| 14451N | DESVENLAFAXINEdesvenlafaxine 50 mg modified release tablet, 28 | 28 | $9.34 | PF |
| 14007F | DEXAMETHASONEdexamethasone 500 microgram tablet, 30 | 30 | $5.11 | AS |
| 14521G | DEXTRAN-70 + HYPROMELLOSEdextran-70 0.1% + hypromellose 0.3% eye drops, 15 mL | 1 | $6.16 | IQ |
| 14521G | DEXTRAN-70 + HYPROMELLOSEdextran-70 0.1% + hypromellose 0.3% eye drops, 15 mL | 1 | $10.16 | AQ |
| 1302M | DICLOFENACdiclofenac sodium 100 mg suppository, 20 | 20 | $10.61 | NV |
| 5079H | DICLOFENACdiclofenac sodium 100 mg suppository, 20 | 20 | $10.61 | NV |
| 1299J | DICLOFENACdiclofenac sodium 25 mg enteric tablet, 50 | 50 | $5.11 | AL,RW,SZ,WG |
| 1299J | DICLOFENACdiclofenac sodium 25 mg enteric tablet, 50 | 50 | $6.81 | NV |
| 5076E | DICLOFENACdiclofenac sodium 25 mg enteric tablet, 50 | 50 | $5.11 | AL,RW,SZ,WG |
| 5076E | DICLOFENACdiclofenac sodium 25 mg enteric tablet, 50 | 50 | $6.81 | NV |
| 10790X | DICLOXACILLINdicloxacillin 500 mg capsule, 24 | 24 | $10.50 | MQ |
| 10790X | DICLOXACILLINdicloxacillin 500 mg capsule, 24 | 24 | $12.45 | AF |
| 3164M | DIGOXINdigoxin 50 microgram/mL oral liquid, 60 mL | 1 | $17.50 | AS |
| 14508N | DILTIAZEMdiltiazem hydrochloride 240 mg modified release capsule, 30 | 30 | $11.88 | SW |
| 14508N | DILTIAZEMdiltiazem hydrochloride 240 mg modified release capsule, 30 | 30 | $10.24 | AV,SZ |
| 14565N | DILTIAZEMdiltiazem hydrochloride 360 mg modified release capsule, 30 | 30 | $16.21 | SW |
| 14565N | DILTIAZEMdiltiazem hydrochloride 360 mg modified release capsule, 30 | 30 | $14.31 | AV,SZ |
| 14479C | DILTIAZEMdiltiazem hydrochloride 60 mg tablet, 90 | 90 | $12.26 | SW |
| 14479C | DILTIAZEMdiltiazem hydrochloride 60 mg tablet, 90 | 90 | $10.36 | AV |
| 14564M | DILTIAZEMdiltiazem hydrochloride 180 mg modified release capsule, 30 | 30 | $9.84 | SW |
| 14564M | DILTIAZEMdiltiazem hydrochloride 180 mg modified release capsule, 30 | 30 | $8.20 | AV,SZ |
| 2896K | DIMETHYL FUMARATEdimethyl fumarate 120 mg enteric capsule, 14 | 14 | $129.30 | BD,CR,LR,SZ,XT |
| 2943X | DIMETHYL FUMARATEdimethyl fumarate 120 mg enteric capsule, 14 | 14 | $129.30 | BD,CR,LR,SZ,XT |
| 13280Y | DISOPYRAMIDEdisopyramide 100 mg capsule, 84 | 84 | $59.50 | OJ |
| 14524K | DORZOLAMIDEdorzolamide 2% eye drops, 5 mL | 1 | $7.70 | AF,MF |
| 14386E | DORZOLAMIDE + TIMOLOLdorzolamide 2% + timolol 0.5% eye drops, 5 mL | 1 | $10.93 | AE,AF |
| 14386E | DORZOLAMIDE + TIMOLOLdorzolamide 2% + timolol 0.5% eye drops, 5 mL | 1 | $11.73 | MF |
| 10777F | DOXYCYCLINEdoxycycline 100 mg modified release capsule, 7 | 7 | $6.84 | YN |
| 10777F | DOXYCYCLINEdoxycycline 100 mg modified release capsule, 7 | 7 | $5.43 | YT |
| 14443E | DOXYCYCLINEdoxycycline 100 mg modified release capsule, 7 | 7 | $6.24 | YN |
| 14443E | DOXYCYCLINEdoxycycline 100 mg modified release capsule, 7 | 7 | $4.83 | YT |
| 2703G | DOXYCYCLINEdoxycycline 100 mg modified release capsule, 7 | 7 | $6.84 | YN |
| 2703G | DOXYCYCLINEdoxycycline 100 mg modified release capsule, 7 | 7 | $5.43 | YT |
| 14484H | DOXYCYCLINEdoxycycline 50 mg modified release capsule, 25 | 25 | $10.28 | YN |
| 14484H | DOXYCYCLINEdoxycycline 50 mg modified release capsule, 25 | 25 | $7.86 | YT |
| 10779H | DOXYCYCLINEdoxycycline 100 mg tablet, 7 | 7 | $3.89 | AF,RW,TX,WG |
| 10781K | DOXYCYCLINEdoxycycline 100 mg tablet, 7 | 7 | $3.89 | HX |
| 14480D | DOXYCYCLINEdoxycycline 100 mg tablet, 7 | 7 | $3.29 | AF,RW,TX,WG |
| 14511R | DOXYCYCLINEdoxycycline 100 mg tablet, 7 | 7 | $3.29 | HX |
| 2702F | DOXYCYCLINEdoxycycline 100 mg tablet, 7 | 7 | $3.89 | AF,RW,TX,WG |
| 2714W | DOXYCYCLINEdoxycycline 100 mg tablet, 7 | 7 | $4.29 | AF,RW,TX,WG |
| 9107H | DOXYCYCLINEdoxycycline 100 mg tablet, 7 | 7 | $3.89 | HX |
| 9108J | DOXYCYCLINEdoxycycline 100 mg tablet, 7 | 7 | $4.29 | HX |
| 14307B | DOXYCYCLINEdoxycycline 50 mg tablet, 25 | 25 | $5.28 | AF,RW,TX,WG |
| 14513W | DOXYCYCLINEdoxycycline 50 mg tablet, 25 | 25 | $5.28 | HX |
| 13900N | DUTASTERIDEdutasteride 500 microgram capsule, 30 | 30 | $18.76 | TX |
| 13900N | DUTASTERIDEdutasteride 500 microgram capsule, 30 | 30 | $25.76 | GK |
| 13929D | DUTASTERIDE + TAMSULOSINdutasteride 500 microgram + tamsulosin hydrochloride 400 microgram modified release capsule, 30 | 30 | $20.30 | GC,TN |
| 13929D | DUTASTERIDE + TAMSULOSINdutasteride 500 microgram + tamsulosin hydrochloride 400 microgram modified release capsule, 30 | 30 | $23.80 | GK |
| 13845Q | EMPAGLIFLOZINempagliflozin 10 mg tablet, 30 | 30 | $50.18 | BY |
| 14018T | EMPAGLIFLOZINempagliflozin 10 mg tablet, 30 | 30 | $50.18 | BY |
| 13920P | EMPAGLIFLOZINempagliflozin 25 mg tablet, 30 | 30 | $50.42 | BY |
| 13904T | EMPAGLIFLOZIN + LINAGLIPTINempagliflozin 10 mg + linagliptin 5 mg tablet, 30 | 30 | $69.16 | BY |
| 13958P | EMPAGLIFLOZIN + LINAGLIPTINempagliflozin 25 mg + linagliptin 5 mg tablet, 30 | 30 | $69.16 | BY |
| 14029J | EMPAGLIFLOZIN + METFORMINempagliflozin 5 mg + metformin hydrochloride 500 mg tablet, 60 | 60 | $52.02 | BY |
| 13852C | EMPAGLIFLOZIN + METFORMINempagliflozin 5 mg + metformin hydrochloride 1 g tablet, 60 | 60 | $53.59 | BY |
| 13903R | EMPAGLIFLOZIN + METFORMINempagliflozin 12.5 mg + metformin hydrochloride 500 mg tablet, 60 | 60 | $52.02 | BY |
| 13987E | EMPAGLIFLOZIN + METFORMINempagliflozin 12.5 mg + metformin hydrochloride 1 g tablet, 60 | 60 | $53.59 | BY |
| 13465Q | ENALAPRILenalapril maleate 10 mg tablet, 30 | 30 | $6.02 | AL,RW,SZ,TX,WG |
| 13465Q | ENALAPRILenalapril maleate 10 mg tablet, 30 | 30 | $16.43 | AF |
| 13401H | ENALAPRILenalapril maleate 20 mg tablet, 30 | 30 | $6.32 | AL,RW,SZ,TX,WG |
| 13401H | ENALAPRILenalapril maleate 20 mg tablet, 30 | 30 | $16.72 | AF |
| 13369P | ENALAPRILenalapril maleate 5 mg tablet, 30 | 30 | $5.11 | AL,RW,SZ,TX,WG |
| 13439H | ENALAPRIL + HYDROCHLOROTHIAZIDEenalapril maleate 20 mg + hydrochlorothiazide 6 mg tablet, 30 | 30 | $7.77 | AF,SZ |
| 11937G | ENCORAFENIBencorafenib 50 mg capsule, 28 | 28 | $780.72 | FB |
| 11954E | ENCORAFENIBencorafenib 50 mg capsule, 28 | 28 | $780.72 | FB |
| 11938H | ENCORAFENIBencorafenib 75 mg capsule, 42 | 42 | $1756.62 | FB |
| 11949X | ENCORAFENIBencorafenib 75 mg capsule, 42 | 42 | $1756.62 | FB |
| 12814K | ENCORAFENIBencorafenib 75 mg capsule, 42 | 42 | $1764.93 | FB |
| 12815L | ENCORAFENIBencorafenib 75 mg capsule, 42 | 42 | $1764.93 | FB |
| 5435C | ENOXAPARIN SODIUMenoxaparin sodium 100 mg/mL injection, 10 x 1 mL syringes | 10 | $103.31 | AV,JU |
| 8640R | ENOXAPARIN SODIUMenoxaparin sodium 60 mg/0.6 mL injection, 10 x 0.6 mL syringes | 10 | $73.25 | AV,JU |
| 5434B | ENOXAPARIN SODIUMenoxaparin sodium 80 mg/0.8 mL injection, 10 x 0.8 mL syringes | 10 | $77.88 | AV,JU |
| 8510X | ENOXAPARIN SODIUMenoxaparin sodium 40 mg/0.4 mL injection, 10 x 0.4 mL syringes | 10 | $42.75 | AV,JU |
| 8639Q | ENOXAPARIN SODIUMenoxaparin sodium 40 mg/0.4 mL injection, 10 x 0.4 mL syringes | 10 | $42.75 | AV,JU |
| 8558K | ENOXAPARIN SODIUMenoxaparin sodium 20 mg/0.2 mL injection, 10 x 0.2 mL syringes | 10 | $38.51 | AV,JU |
| 8716R | ENOXAPARIN SODIUMenoxaparin sodium 20 mg/0.2 mL injection, 10 x 0.2 mL syringes | 10 | $38.51 | AV,JU |
| 14542J | ENTACAPONEentacapone 200 mg tablet, 100 | 100 | $85.33 | SZ |
| 8367J | ENTACAPONEentacapone 200 mg tablet, 100 | 100 | $85.28 | SZ |
| 13590G | EPLERENONEeplerenone 25 mg tablet, 30 | 30 | $43.03 | AF,RW,TX,UJ |
| 13379E | EPLERENONEeplerenone 50 mg tablet, 30 | 30 | $43.03 | AF,RW,TX,UJ |
| 13861M | EPROSARTANeprosartan 600 mg tablet, 28 | 28 | $16.68 | GO |
| 13912F | EPROSARTANeprosartan 600 mg tablet, 28 | 28 | $16.68 | GO |
| 14337N | EPROSARTAN + HYDROCHLOROTHIAZIDEeprosartan 600 mg + hydrochlorothiazide 12.5 mg tablet, 28 | 28 | $15.19 | GO |
| 10780J | ERYTHROMYCINerythromycin 250 mg enteric capsule, 25 | 25 | $14.40 | YT |
| 14409J | ERYTHROMYCINerythromycin 250 mg enteric capsule, 25 | 25 | $13.20 | YT |
| 14546N | ESCITALOPRAMescitalopram 20 mg/mL oral liquid, 15 mL | 1 | $28.37 | LU |
| 14349F | ESCITALOPRAMescitalopram 10 mg tablet, 28 | 28 | $5.11 | AF,BG,CF,HQ,HX,RW,TX,TY,VO,ZS |
| 14349F | ESCITALOPRAMescitalopram 10 mg tablet, 28 | 28 | $19.29 | LU |
| 14519E | ESCITALOPRAMescitalopram 10 mg tablet, 28 | 28 | $5.11 | AF,BG,CF,HQ,HX,RW,TX,TY,VO |
| 14519E | ESCITALOPRAMescitalopram 10 mg tablet, 28 | 28 | $19.29 | LU |
| 14415Q | ESCITALOPRAMescitalopram 20 mg tablet, 28 | 28 | $5.11 | AF,BG,CF,HQ,HX,RW,TX,TY,VO,ZS |
| 14415Q | ESCITALOPRAMescitalopram 20 mg tablet, 28 | 28 | $19.64 | LU |
| 14416R | ESCITALOPRAMescitalopram 20 mg tablet, 28 | 28 | $5.11 | BG,CF,HQ,HX,RW,TX,TY,VO |
| 14416R | ESCITALOPRAMescitalopram 20 mg tablet, 28 | 28 | $19.64 | LU |
| 12275C | ESOMEPRAZOLEesomeprazole 20 mg enteric capsule, 30 | 30 | $6.70 | AL |
| 14303T | ESOMEPRAZOLEesomeprazole 20 mg enteric capsule, 30 | 30 | $6.70 | AL |
| 14510Q | ESOMEPRAZOLEesomeprazole 20 mg enteric capsule, 30 | 30 | $6.70 | AL |
| 12287Q | ESOMEPRAZOLEesomeprazole 20 mg enteric tablet, 30 | 30 | $6.70 | AF,AL,BG,GQ,MQ,RA,RF,RW,TY,WG |
| 12287Q | ESOMEPRAZOLEesomeprazole 20 mg enteric tablet, 30 | 30 | $13.70 | AP |
| 14308C | ESOMEPRAZOLEesomeprazole 20 mg enteric tablet, 30 | 30 | $6.70 | AF,AL,BG,GQ,MQ,RA,RF,RW,TY,WG |
| 14308C | ESOMEPRAZOLEesomeprazole 20 mg enteric tablet, 30 | 30 | $13.70 | AP |
| 14444F | ESOMEPRAZOLEesomeprazole 20 mg enteric tablet, 30 | 30 | $6.70 | AF,AL,BG,GQ,MQ,RA,RF,RW,TY,WG |
| 14444F | ESOMEPRAZOLEesomeprazole 20 mg enteric tablet, 30 | 30 | $13.70 | AP |
| 14481E | ESOMEPRAZOLEesomeprazole 20 mg enteric tablet, 30 | 30 | $5.50 | AF,AL,BG,GQ,MQ,RA,RF,RW,TY,WG |
| 14481E | ESOMEPRAZOLEesomeprazole 20 mg enteric tablet, 30 | 30 | $12.50 | AP |
| 12283L | ESOMEPRAZOLEesomeprazole 40 mg enteric tablet, 30 | 30 | $9.70 | AF,AL,BG,GQ,MQ,RA,RF,RW,TY,WG |
| 12283L | ESOMEPRAZOLEesomeprazole 40 mg enteric tablet, 30 | 30 | $16.70 | AP |
| 14373L | ESOMEPRAZOLEesomeprazole 40 mg enteric tablet, 30 | 30 | $9.70 | AF,AL,BG,GQ,MQ,RA,RF,RW,TY,WG |
| 14373L | ESOMEPRAZOLEesomeprazole 40 mg enteric tablet, 30 | 30 | $16.70 | AP |
| 14512T | ESOMEPRAZOLEesomeprazole 40 mg enteric tablet, 30 | 30 | $8.50 | AF,AL,GQ,RA,TY |
| 12290W | ESOMEPRAZOLEesomeprazole 40 mg enteric capsule, 30 | 30 | $9.70 | AL |
| 14405E | ESOMEPRAZOLEesomeprazole 40 mg enteric capsule, 30 | 30 | $9.70 | AL |
| 14445G | ESOMEPRAZOLEesomeprazole 40 mg enteric capsule, 30 | 30 | $8.50 | AL |
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