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 | $19.65 | IU,MF,SZ,TX |
| 10948F | BUPRENORPHINEbuprenorphine 10 microgram/hour patch, 2 | 2 | $15.97 | IU,MF,SZ,TX |
| 10964C | BUPRENORPHINEbuprenorphine 25 microgram/hour patch, 2 | 2 | $26.82 | MF,SZ,TX |
| 10949G | BUPRENORPHINEbuprenorphine 30 microgram/hour patch, 2 | 2 | $30.30 | MF,SZ,TX |
| 10970J | BUPRENORPHINEbuprenorphine 20 microgram/hour patch, 2 | 2 | $23.33 | IU,MF,SZ,TX |
| 10957Q | BUPRENORPHINEbuprenorphine 5 microgram/hour patch, 2 | 2 | $9.94 | IU,MF,SZ,TX |
| 10959T | BUPRENORPHINEbuprenorphine 40 microgram/hour patch, 2 | 2 | $37.29 | 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 | $14.27 | AE |
| 5339B | CLONAZEPAMclonazepam 2.5 mg/mL (0.1 mg/drop) oral liquid, 10 mL | 1 | $6.16 | PB |
| 11520H | CLONAZEPAMclonazepam 500 microgram tablet, 50 | 50 | $6.71 | PB |
| 10602B | FENTANYLfentanyl 100 microgram sublingual tablet, 30 | 30 | $197.96 | FK |
| 10607G | FENTANYLfentanyl 200 microgram sublingual tablet, 30 | 30 | $197.96 | FK |
| 10608H | FENTANYLfentanyl 400 microgram sublingual tablet, 30 | 30 | $197.96 | FK |
| 10601Y | FENTANYLfentanyl 100 microgram sublingual tablet, 10 | 10 | $65.92 | FK |
| 10600X | FENTANYLfentanyl 200 microgram sublingual tablet, 10 | 10 | $65.92 | FK |
| 5407N | FENTANYLfentanyl 200 microgram lozenge, 30 | 30 | $250.37 | TB |
| 5408P | FENTANYLfentanyl 400 microgram lozenge, 30 | 30 | $250.37 | TB |
| 5409Q | FENTANYLfentanyl 600 microgram lozenge, 30 | 30 | $181.77 | TB |
| 5410R | FENTANYLfentanyl 800 microgram lozenge, 30 | 30 | $181.77 | TB |
| 10729Q | FENTANYLfentanyl 100 microgram orally disintegrating tablet, 4 | 4 | $31.65 | TB |
| 10697B | FENTANYLfentanyl 200 microgram orally disintegrating tablet, 4 | 4 | $31.65 | TB |
| 10698C | FENTANYLfentanyl 200 microgram orally disintegrating tablet, 28 | 28 | $214.85 | TB |
| 10737D | FENTANYLfentanyl 400 microgram orally disintegrating tablet, 28 | 28 | $135.66 | TB |
| 10713W | FENTANYLfentanyl 600 microgram orally disintegrating tablet, 28 | 28 | $135.66 | TB |
| 10738E | FENTANYLfentanyl 800 microgram orally disintegrating tablet, 28 | 28 | $135.66 | TB |
| 10684H | FENTANYLfentanyl 100 microgram orally disintegrating tablet, 28 | 28 | $214.85 | TB |
| 10610K | FENTANYLfentanyl 300 microgram sublingual tablet, 30 | 30 | $197.96 | FK |
| 10613N | FENTANYLfentanyl 600 microgram sublingual tablet, 30 | 30 | $197.96 | FK |
| 12504D | FENTANYLfentanyl 25 microgram/hour patch, 5 | 5 | $8.98 | JC,SZ,TX |
| 12516R | FENTANYLfentanyl 25 microgram/hour patch, 5 | 5 | $8.98 | AF |
| 12521B | FENTANYLfentanyl 25 microgram/hour patch, 5 | 5 | $10.53 | RW |
| 12477Q | FENTANYLfentanyl 50 microgram/hour patch, 5 | 5 | $14.49 | JC,SZ,TX |
| 12513N | FENTANYLfentanyl 50 microgram/hour patch, 5 | 5 | $17.33 | RW |
| 12546H | FENTANYLfentanyl 50 microgram/hour patch, 5 | 5 | $14.49 | AF |
| 10611L | FENTANYLfentanyl 800 microgram sublingual tablet, 30 | 30 | $197.96 | FK |
| 12474M | FENTANYLfentanyl 75 microgram/hour patch, 5 | 5 | $18.96 | JC,SZ,TX |
| 12517T | FENTANYLfentanyl 75 microgram/hour patch, 5 | 5 | $22.87 | RW |
| 12526G | FENTANYLfentanyl 75 microgram/hour patch, 5 | 5 | $18.96 | AF |
| 12480W | FENTANYLfentanyl 100 microgram/hour patch, 5 | 5 | $27.58 | RW |
| 12509J | FENTANYLfentanyl 100 microgram/hour patch, 5 | 5 | $22.95 | JC,SZ,TX |
| 12533P | FENTANYLfentanyl 100 microgram/hour patch, 5 | 5 | $22.95 | AF |
| 12491K | FENTANYLfentanyl 12 microgram/hour patch, 5 | 5 | $7.57 | AF |
| 12530L | FENTANYLfentanyl 12 microgram/hour patch, 5 | 5 | $8.79 | RW |
| 12541C | FENTANYLfentanyl 12 microgram/hour patch, 5 | 5 | $7.57 | JC,SZ,TX |
| 12531M | HYDROMORPHONEhydromorphone hydrochloride 10 mg/mL injection, 5 x 1 mL ampoules | 5 | $10.49 | DZ,HW,JU,MF |
| 12493M | HYDROMORPHONEhydromorphone hydrochloride 2 mg/mL injection, 5 x 1 mL ampoules | 5 | $8.46 | DZ,HW,JU,MF |
| 12497R | HYDROMORPHONEhydromorphone hydrochloride 2 mg tablet, 20 | 20 | $8.99 | MF |
| 12484C | HYDROMORPHONEhydromorphone hydrochloride 4 mg tablet, 20 | 20 | $11.26 | MF |
| 12515Q | HYDROMORPHONEhydromorphone hydrochloride 8 mg tablet, 20 | 20 | $19.67 | MF |
| 5317W | HYOSCINE BUTYLBROMIDEhyoscine butylbromide 20 mg/mL injection, 5 x 1 mL ampoules | 5 | $7.86 | AE,DZ,VZ,XN |
| 5368M | IBUPROFENibuprofen 400 mg tablet, 30 | 30 | $4.29 | TX |
| 5368M | IBUPROFENibuprofen 400 mg tablet, 30 | 30 | $6.80 | GO |
| 5377B | INDOMETACINindometacin 25 mg capsule, 50 | 50 | $5.73 | AF |
| 5377B | INDOMETACINindometacin 25 mg capsule, 50 | 50 | $7.75 | AS |
| 5426N | MACROGOL-3350macrogol-3350 1 g/g powder for oral liquid, 510 g | 1 | $11.87 | 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 | $8.67 | GX,RF,RW,TX,XT |
| 12520Y | METHADONEmethadone hydrochloride 10 mg tablet, 20 | 20 | $6.10 | AS |
| 14193B | METHADONEmethadone hydrochloride 10 mg/mL injection, 5 x 1 mL vials | 5 | $37.20 | AS |
| 5423K | METHYLNALTREXONEmethylnaltrexone bromide 12 mg/0.6 mL injection, 0.6 mL vial | 1 | $33.76 | LM |
| 10762K | METOCLOPRAMIDEmetoclopramide hydrochloride 10 mg/2 mL injection, 10 x 2 mL ampoules | 10 | $8.83 | DZ,WZ |
| 12507G | METOCLOPRAMIDEmetoclopramide hydrochloride 10 mg tablet, 25 | 25 | $3.89 | AF,RW,TX,WG |
| 12507G | METOCLOPRAMIDEmetoclopramide hydrochloride 10 mg tablet, 25 | 25 | $7.44 | IL |
| 12476P | MORPHINEmorphine sulfate pentahydrate 15 mg modified release tablet, 28 | 28 | $15.53 | MF |
| 5391R | MORPHINEmorphine sulfate pentahydrate 200 mg modified release tablet, 28 | 28 | $107.50 | MF |
| 12502B | MORPHINEmorphine hydrochloride trihydrate 10 mg/mL injection, 5 x 1 mL ampoules | 5 | $7.15 | JU |
| 12500X | MORPHINEmorphine sulfate pentahydrate 30 mg modified release tablet, 28 | 28 | $19.89 | AF,MF,TX |
| 12492L | MORPHINEmorphine sulfate pentahydrate 5 mg modified release tablet, 28 | 28 | $9.17 | MF |
| 12494N | MORPHINEmorphine hydrochloride trihydrate 20 mg/mL injection, 5 x 1 mL ampoules | 5 | $9.68 | JU |
| 12470H | MORPHINEmorphine hydrochloride trihydrate 50 mg/5 mL injection, 5 x 5 mL ampoules | 5 | $14.53 | JU |
| 12537W | MORPHINEmorphine hydrochloride trihydrate 100 mg/5 mL injection, 5 x 5 mL ampoules | 5 | $20.58 | JU |
| 12544F | MORPHINEmorphine sulfate pentahydrate 60 mg modified release tablet, 28 | 28 | $33.11 | AF,MF,TX |
| 12472K | MORPHINEmorphine hydrochloride trihydrate 10 mg/mL oral liquid, 200 mL | 200 | $19.38 | XT |
| 14187Q | MORPHINEmorphine hydrochloride trihydrate 10 mg/mL oral liquid, 200 mL | 200 | $141.02 | WZ |
| 12549L | MORPHINEmorphine hydrochloride trihydrate 5 mg/mL oral liquid, 200 mL | 200 | $16.83 | XT |
| 14186P | MORPHINEmorphine hydrochloride trihydrate 5 mg/mL oral liquid, 200 mL | 200 | $90.22 | WZ |
| 13742G | MORPHINEmorphine sulfate 10 mg/5 mL oral solution, 100 mL | 100 | $67.43 | LM |
| 13741F | MORPHINEmorphine sulfate 10 mg/5 mL oral solution, 300 mL | 300 | $101.52 | LM |
| 13743H | MORPHINEmorphine sulfate 2 mg/mL oral solution, 100 mL | 100 | $47.99 | DZ |
| 13748N | MORPHINEmorphine sulfate 2 mg/mL oral solution, 500 mL | 500 | $108.37 | DZ |
| 12501Y | MORPHINEmorphine sulfate pentahydrate 10 mg modified release capsule, 28 | 28 | $11.88 | YN |
| 12529K | MORPHINEmorphine sulfate pentahydrate 100 mg modified release capsule, 28 | 28 | $44.32 | YN |
| 14081D | MORPHINEmorphine hydrochloride trihydrate 10 mg/mL oral liquid, 20 mL | 20 | $55.25 | DZ |
| 12512M | MORPHINEmorphine sulfate pentahydrate 120 mg modified release capsule, 14 | 14 | $33.10 | MF |
| 12539Y | MORPHINEmorphine sulfate pentahydrate 20 mg modified release capsule, 28 | 28 | $12.78 | YN |
| 12490J | MORPHINEmorphine sulfate pentahydrate 30 mg modified release capsule, 14 | 14 | $12.26 | MF |
| 12489H | MORPHINEmorphine sulfate pentahydrate 50 mg modified release capsule, 28 | 28 | $24.74 | YN |
| 12487F | MORPHINEmorphine sulfate pentahydrate 60 mg modified release capsule, 14 | 14 | $19.87 | MF |
| 12514P | MORPHINEmorphine sulfate pentahydrate 90 mg modified release capsule, 14 | 14 | $23.52 | MF |
| 12499W | MORPHINEmorphine sulfate pentahydrate 10 mg/mL injection, 5 x 1 mL ampoules | 5 | $7.36 | DZ |
| 12548K | MORPHINEmorphine sulfate pentahydrate 15 mg/mL injection, 5 x 1 mL ampoules | 5 | $10.12 | DZ |
| 12503C | MORPHINEmorphine sulfate pentahydrate 30 mg/mL injection, 5 x 1 mL ampoules | 5 | $12.22 | DZ |
| 12547J | MORPHINEmorphine sulfate pentahydrate 10 mg modified release tablet, 28 | 28 | $9.54 | AF,MF,TX |
| 12483B | MORPHINEmorphine sulfate pentahydrate 100 mg modified release tablet, 28 | 28 | $45.72 | AF,MF,TX |
| 5345H | NAPROXENnaproxen 250 mg tablet, 50 | 50 | $6.61 | IX |
| 5359C | NITRAZEPAMnitrazepam 5 mg tablet, 25 | 25 | $5.11 | AF,IL |
| 5371Q | OXAZEPAMoxazepam 15 mg tablet, 25 | 25 | $5.11 | AF,AS |
| 5372R | OXAZEPAMoxazepam 30 mg tablet, 25 | 25 | $5.11 | AF,TX,WG |
| 5372R | OXAZEPAMoxazepam 30 mg tablet, 25 | 25 | $5.95 | RW |
| 5372R | OXAZEPAMoxazepam 30 mg tablet, 25 | 25 | $9.03 | AS |
| 12518W | OXYCODONEoxycodone hydrochloride 10 mg modified release tablet, 28 | 28 | $13.40 | MF,SZ |
| 12545G | OXYCODONEoxycodone hydrochloride 15 mg modified release tablet, 28 | 28 | $21.64 | MF |
| 12510K | OXYCODONEoxycodone hydrochloride 20 mg modified release tablet, 28 | 28 | $21.88 | MF,SZ |
| 12538X | OXYCODONEoxycodone hydrochloride 30 mg modified release tablet, 28 | 28 | $35.22 | MF |
| 12525F | OXYCODONEoxycodone hydrochloride 40 mg modified release tablet, 28 | 28 | $31.86 | MF,SZ |
| 12527H | OXYCODONEoxycodone hydrochloride 80 mg modified release tablet, 28 | 28 | $50.67 | MF,SZ |
| 12511L | OXYCODONE + NALOXONEoxycodone hydrochloride 60 mg + naloxone hydrochloride 30 mg modified release tablet, 28 | 28 | $68.80 | MF |
| 12498T | OXYCODONE + NALOXONEoxycodone hydrochloride 80 mg + naloxone hydrochloride 40 mg modified release tablet, 28 | 28 | $72.46 | MF |
| 12471J | OXYCODONE + NALOXONEoxycodone hydrochloride 2.5 mg + naloxone hydrochloride 1.25 mg modified release tablet, 28 | 28 | $12.26 | MF |
| 12540B | OXYCODONE + NALOXONEoxycodone hydrochloride 15 mg + naloxone hydrochloride 7.5 mg modified release tablet, 28 | 28 | $25.48 | MF |
| 12532N | OXYCODONE + NALOXONEoxycodone hydrochloride 30 mg + naloxone hydrochloride 15 mg modified release tablet, 28 | 28 | $41.77 | MF |
| 12523D | OXYCODONE + NALOXONEoxycodone hydrochloride 10 mg + naloxone hydrochloride 5 mg modified release tablet, 28 | 28 | $21.13 | MF |
| 12486E | OXYCODONE + NALOXONEoxycodone hydrochloride 20 mg + naloxone hydrochloride 10 mg modified release tablet, 28 | 28 | $35.62 | MF |
| 12475N | OXYCODONE + NALOXONEoxycodone hydrochloride 40 mg + naloxone hydrochloride 20 mg modified release tablet, 28 | 28 | $52.63 | MF |
| 12522C | OXYCODONE + NALOXONEoxycodone hydrochloride 5 mg + naloxone hydrochloride 2.5 mg modified release tablet, 28 | 28 | $20.00 | MF |
| 5343F | PARACETAMOLparacetamol 665 mg modified release tablet, 96 | 96 | $6.16 | CR,TX,XT |
| 12210P | PARACETAMOLparacetamol 500 mg suppository, 10 | 10 | $8.98 | GJ |
| 5375X | TEMAZEPAMtemazepam 10 mg tablet, 25 | 25 | $5.11 | AF,LN,TX,WG |
| 5375X | TEMAZEPAMtemazepam 10 mg tablet, 25 | 25 | $10.18 | AS |
