HEALTH SERVICES AGENCY

MIA FORMULARY-By Classification

Effective: 4/30/08
(Replaces 1/1/08 Version)

Denotes E-recovery drugs

DRUGS LISTED BY CLASSIFICATION COST PER UNIT

Central Nervous System Agents
First Line Agents - Analgesics
Acetaminophen/Codeine #3 0.05
Acetaminophen/Hydrocodone 5 mg/500 mg 0.03
Acetaminophen/Hydrocodone 7.5 mg/500 mg 0.04
Acetaminophen Syrup ml 0.01
Sulfasalazine 500 mg 0.05
Gabapentin 100 mg 0.04
Gabapentin 300 mg 0.08
Gabapentin 400 mg 0.10
Gabapentin 600 mg 0.24
Gabapentin 800 mg 0.31
Ibuprofen 400 mg 0.02
Ibuprofen 600 mg 0.02
Ibuprofen 800 mg 0.03
Tramadol 50 mg 0.02
Amitriptyline 10 mg 0.01
Amitriptyline 100 mg 0.04
Amitriptyline 150 mg 0.05
Amitriptyline 25 mg 0.23
Amitriptyline 75 mg 0.04
Nabumetone 500 mg 0.21
Nabumetone 750 mg 0.02
Sulindac 150 mg 0.06
Sulindac 200 mg 0.06
Meloxicam 7.5 mg 0.03
Meloxicam 15 mg 0.04
Indomethacin 25 mg 0.04
Indomethacin 50 mg 0.04
Diclofenac 50 mg 0.14
Diclofenac 75 mg 0.13
Desipramine 25 mg 0.15
Imipramine 10 mg 0.11
Imipramine 25 mg 0.14
Imipramine 50 mg 0.23
Naproxen 250 mg 0.03
Naproxen 375 mg 0.04
Naproxen 500 mg 0.04
Salsalate 500 mg 0.03
Salsalate 750 mg 0.04
Choline Mag Trisalicylate 1000 mg 0.02
Choline Mag Trisalicylate 500 mg 0.09

1 of 15
 HEALTH SERVICES AGENCY
MIA FORMULARY-By Classification
Effective: 4/30/08
(Replaces 1/1/08 Version)

DRUGS LISTED BY CLASSIFICATION COST PER UNIT

Choline Mag Trisalicylate 750 mg 0.04
Migraine Agents
Ergotamine/Caffeine 100 mg 0.61
Imitrex 25 mg 20.53
Imitrex 50 mg 19.08
Imitrex 100 mg 18.09
Opiate Agonists (C-II)
Morphine Sulfate ER 15 mg 0.63
Morphine Sulfate ER 30 mg 1.21
Morphine Sulfate ER 60 mg 0.62
Morphine Sulfate (Roxanol) 20 mg/ml soln 0.03
Hydromorphone 2 mg 0.08
Hydromorphone 4 mg 0.11
Methadone 5 mg 0.05
Methadone 10 mg 0.09
Anti-Convulsant Agents
Carbamazepine 100 mg 0.16
Carbamazepine 200 mg 0.04
Carbatrol 200 mg 1.10
Tegretol XR 400 mg 1.36
Tegretol XR 200 mg 0.68
Depakote ER 250 mg 1.30
Depakote ER 500 mg 2.28
Valproic Acid 250 mg 0.16
Depakote 250 mg 1.33
Depakote 500 mg 2.46
Keppra 500 mg 2.60
Keppra 750 mg 3.53
Phenobarbital 15 mg 0.01
Phenobarbital 30 mg 0.02
Phenobarbital 60 mg 0.02
Phenobarbital 100 mg 0.03
Dilantin 30 mg 0.28
Dilantin 100 mg 0.21
Topamax 25 mg 1.78
Primidone 50 mg 0.26
Primidone 250 mg 0.14
Anti-Parkinsonian Agents
Amantadine 100 mg 0.12
Carbidopa/Levodopa 10/100 0.22
Carbidopa/Levodopa 25/100 0.18
Requip 0.5 mg 2.03
Requip 1 mg 2.02
Requip 2 mg 2.02
Requip 0.25 mg 2.04
Trihexyphenidyl 2 mg 0.17

2 of 15
 HEALTH SERVICES AGENCY
MIA FORMULARY-By Classification
Effective: 4/30/08
(Replaces 1/1/08 Version)

DRUGS LISTED BY CLASSIFICATION COST PER UNIT

Trihexyphenidyl 5 mg 0.20
Trihexyphenidyl 2 mg/5ml 0.13
Benztropine Mesylate 1 mg 0.10
Benztropine Mesylate 2 mg 0.13
Benztropine Mesylate 0.5 mg 0.07
Muscle Relaxant Agents
Baclofen 10 mg 0.05
Baclofen 20 mg 0.08
Anti-Alzheimers Agents
Aricept 5 mg 4.80
Aricept 10 mg 4.80
Tricyclic Anti-Depressant Agents
Amitriptyline 100 mg 0.04
Amitriptyline 150 mg 0.05
Amitriptyline 25 mg 0.02
Amitriptyline 75 mg 0.04
Doxepine 10 mg 0.06
Doxepine 25 mg 0.04
Doxepine 50 mg 0.06
Doxepine 75 mg 0.07
Doxepine 100 mg 0.01
Doxepine 150 mg 0.23
Nortriptyline 10 mg 0.03
Nortriptyline 25 mg 0.03
Nortriptyline 50 mg 0.04
Nortriptyline 75 mg 0.06
Miscellaneous Anti-Depressants/Insomnia
Trazadone 50 mg 0.02
Trazadone 100 mg 0.04
Trazadone 150 mg 0.10
Mirtazapine 15 mg 0.12
Mirtazapine 30 mg 0.20
Mirtazapine 45 mg 0.30
S.S.R.I. Agents
Celexa 10 mg 0.05
Celexa 20 mg 0.05
Celexa 40 mg 0.05
Fluoxetine 10 mg 0.27
Fluoxetine 20 mg 0.28
Zoloft 100 mg 0.10
Zoloft 25 mg 0.10
Zoloft 50 mg 0.10
Paroxetine 10 mg 0.21
Paroxetine 20 mg 0.19
Paroxetine 30 mg 0.24
Paroxetine 40 mg 0.23

3 of 15
 HEALTH SERVICES AGENCY
MIA FORMULARY-By Classification
Effective: 4/30/08
(Replaces 1/1/08 Version)

DRUGS LISTED BY CLASSIFICATION COST PER UNIT

S.N.R.I. Agents
Effexor XR 37.5 mg 2.99
Effexor XR 75 mg 3.35
Effexor XR 150 mg 3.65
Cymbalta 20 mg 3.10
Cymbalta 30 mg 3.48
Cymbalta 60 mg 3.48
Miscellaneous Anti-Depressant Agents
Bupropion 100 mg 0.18
Bupropion 75 mg 0.16
Bupropion 100 SR 0.64
Bupropion 150 SR 0.69
Chloral Hydrate Liq. 500 mg/5ml (per pint) 4.73
Hydroxyzine Pamoate 25 mg 0.05
Hydroxyzine Pamoate 50 mg 0.06
Hydroxyzine Pamoate 100 mg 0.25
Anti-Manic Agents
Lithium 150 mg caps 0.08
Lithium 300 mg caps 0.03
Lithium ER 450 mg 0.22
Benzodiazepines (Anti-Anxiety)
Clonazepam 0.5 mg 0.16
Clonazepam 1 mg 0.27
Clonazepam 2 mg 0.46
Lorazepam 0.5 mg 0.32
Lorazepam 1 mg 0.04
Lorazepam 2 mg 0.06
Non-Benzodiazepines (Anti-Anxiety)
Buspirone 10 mg 0.40
Buspirone 15 mg 0.56
Buspirone 30 mg 0.64
ADHD
Strattera 10 mg 3.62
Strattera 18 mg 3.62
Strattera 25 mg 3.62
Strattera 40 mg 3.93
Strattera 60 mg 3.93
Strattera 80 mg 4.24
Strattera 100 mg 4.24
Miscellaneous Anxiolytics, Sedatives, and Hypnotics
Hydroxyzine 10 mg/1 ml 0.12
Hydroxyzine 50 mg/1 ml 0.99
Hydroxyzine 6.25/ 5 ml 0.12
Hydroxyzine 10 mg 0.55
Hydroxyzine 50 mg/1 ml 0.40
Hydroxyzine 25 mg 0.28

4 of 15
 HEALTH SERVICES AGENCY
MIA FORMULARY-By Classification
Effective: 4/30/08
(Replaces 1/1/08 Version)

DRUGS LISTED BY CLASSIFICATION COST PER UNIT

Promethazine 25 mg 0.26
Promethazine 50 mg 0.78
Cardiovascular/Blood Agents
Antiarrhythmic Agents
Amiodarone 200 mg 0.17
Beta-Adrenergic Antagonist Agents
Atenolol 100 mg 0.28
Atenolol 50 mg 0.27
Atenolol 25 mg 0.24
Metoprolol 50 mg 0.27
Metoprolol 100 mg 0.37
Metoprolol 25 mg 0.03
Metoprolol ER 25 mg 0.43
Toprol XL 100 mg 0.73
Toprol XL 50 mg 0.51
Propranolol 20 mg 0.04
Propranolol 10 mg 0.03
Propranolol 40 mg 0.13
Propranolol 60 mg 0.29
Combination Alpha-Beta Antagonist Agents
Carvedilol - Coreg 25 mg 0.05
Carvedilol 12.5 mg 0.05
Carvedilol 6.25 mg 0.05
Carvedilol 3.125 mg 0.05
Angiotensin Converting Enzyme Inhibitor Agents
Enalapril 5 mg 0.02
Enalapril 10 mg 0.01
Enalapril 20 mg 0.03
Benazepril 5 mg 0.08
Benazepril 10 mg 0.11
Benazepril 20 mg 0.07
Benazepril 40 mg 0.09
Captopril 12.5 mg 0.02
Captopril 25 mg 0.01
Captopril 50 mg 0.03
Captopril 100 mg 0.06
Lisinopril 5 mg 0.26
Lisinopril 2.5 mg 0.02
Lisinopril 10 mg 0.03
Lisinopril 20 mg 0.05
Lisinopril 40 mg 0.09
ARB
Cozaar 25 mg 1.53
Cozaar 50 mg 1.63
Cozaar 100 mg 2.21
Diovan 80 mg 1.71

5 of 15
 HEALTH SERVICES AGENCY
MIA FORMULARY-By Classification
Effective: 4/30/08
(Replaces 1/1/08 Version)

DRUGS LISTED BY CLASSIFICATION COST PER UNIT

Diovan 40 mg 1.43
Diovan 160 mg 1.84
Diovan 320 mg 2.32
Diovan 160/12.5 mg 1.63
Diovan 160/25 mg 2.27
Diovan 80/12.5 mg 1.84
Diovan 320/12.5 mg 2.53
Diovan 320/25 mg 2.53
Micardis 40/12.5 mg 1.85
Micardis 80/12.5 mg 2.03
Micardis 80/25 mg 2.31
Hyzaar 50/12.5 mg 1.72
Hyzaar 100/12.5 mg 2.30
Hyzaar 100/25 mg 2.30
Calcium Channel Blocking Agents
Norvasc 2.5 mg 0.07
Norvasc 5 mg 0.07
Norvasc 10 mg 0.09
Nifedipine 20 mg 1.17
Nifedipine 10 mg 0.19
Nifedipine SR 30 XL 0.65
Nifedipine SR 60 XL 0.96
Diltiazem 30 mg 0.03
Diltiazem 60 mg 0.09
Diltiazem 90 mg 0.13
Diltiazem 120 mg 0.09
Diltiazem CD 240 0.32
Diltiazem ER120 0.57
Diltiazem ER180 0.57
Diltiazem ER360 1.07
Tiazac ER 360 mg 2.40
Tiazac ER 120 mg 1.06
Verapamil 40 mg 0.01
Verapamil 80 mg 0.04
Verapamil 120 mg 0.06
Verapamil SR 120 mg 0.31
Verapamil SR 360 mg 0.57
Verapamil SR 240 mg 0.26
Centrally Acting Anti-Hypertensive Agents
Clonidine 0.1 mg 0.04
Clonidine 0.2 mg 0.10
Clonidine 0.3 mg 0.06
Methyldopa 250 mg 0.09
Methyldopa 500 mg 0.18
Tenex 1 mg 0.07
Tenex 2 mg 0.10

6 of 15
 HEALTH SERVICES AGENCY
MIA FORMULARY-By Classification
Effective: 4/30/08
(Replaces 1/1/08 Version)

DRUGS LISTED BY CLASSIFICATION COST PER UNIT

Combination Anti-Hypertensive Agents
(ACE/Ca++ Channel Blocker)
Potassium-Sparing Diuretics
Spironolactone 25 mg 0.10
Triamterene 50/25 0.28
Triamterene 75/50 0.25
Triamterene 37.5/25 0.34
Loop Diuretics
Furosemide 40 mg 0.19
Furosemide 20 mg 0.13
Furosemide 80 mg 0.19
Thiazide and Related Diuretics
HCTZ 25 mg 0.01
Vasodilator Anti-Hypertensive Agents
Isosorbide dinitrate 10 mg 0.15
Isosorbide dinitrate 20 mg 0.11
Isosorbide dinitrate 30 mg 0.09
Isosorbide Mononitrate 10 mg 0.02
Isosorbide Mononitrate 20 mg 0.09
Isosorbide Mononitrate 30 mg 0.03
Isosorbide Mononitrate 60 mg 0.04
Alpha Blockers/BPH/HTN
Terazosin 1 mg 0.09
Terazosin 2 mg 0.20
Terazosin 5 mg 0.07
Terazosin 10 mg 0.12
Flomax .4 mg 2.27
Doxazosin 1 mg 0.05
Doxazosin 2 mg 0.04
Doxazosin 8 mg 0.10
Lipid-Lowering Agents
Atorvastatin 10 mg 2.39
Atorvastatin 20 mg 3.41
Atorvastatin 40 mg 3.41
Atorvastatin 80 mg 3.41
Gemfibrozil 600 mg 0.09
Lovastatin 10 mg 0.17
Lovastatin 20 mg 0.26
Lovastatin 40 mg 0.41
Niaspan ER 500 mg 1.79
Pravastatin 10 mg 0.31
Pravastatin 20 mg 0.18
Pravachol 40 mg 0.17
Pravachol 80 mg 2.27
Tricor 145 mg 3.11
Vytorin 10/40 mg 2.84

7 of 15
 HEALTH SERVICES AGENCY
MIA FORMULARY-By Classification
Effective: 4/30/08
(Replaces 1/1/08 Version)

DRUGS LISTED BY CLASSIFICATION COST PER UNIT

Vytorin 10/80 mg 2.84
Vytorin 10/10 mg 2.84
Vytorin 10/20 mg 2.84
Zetia 10 mg 2.64
Zocor 20 mg 0.06
Zocor 40 mg 0.09
Zocor 80 mg 0.10
Blood Agents
Anti-Coagulants
Warfarin 1 mg 0.11
Warfarin 2 mg 0.12
Warfarin 3 mg 0.16
Warfarin 5 mg 0.40
Warfarin 7.5 mg 0.20
Warfarin 10 mg 0.21
LMWH-SQ
Lovenox 30 mg 19.19
Lovenox 40 mg 25.58
Lovenox 60 mg 38.42
Lovenox 80 mg 51.23
Lovenox 100 mg 64.04
Lovenox 120 mg 76.87
Lovenox 150 mg 96.09
Lovenox 300 mg (per vial) 191.90
Cardiac Glycoside Agents
Digoxin 0.25 mg 0.08
Digoxin 0.125 mg 0.08
Anti-Platelet Agents
Plavix 75 mg 3.84
Aspirin
ASA 81 EC 0.016
ASA 325 mg 0.01
ASA 325 EC 0.02
Miscellaneous Blood Agents
Trental 400 mg 0.07
Plaquenil 200 mg 0.67
Vasodilating Agents
Nitroglycerin ointment 1 tube 10.62
Nitroglycerin sublingal 0.4 mg 0.02
Nitroglycerin sublingal 0.3 mg 0.02
Nitroglycerin sublingal 0.6 mg 0.02
Anti-Diarrheal Agents
Dicyclomine 10 mg 0.01
Dicyclomine 20 mg 0.03
Lomotil 0.03
Belladonna/Phenobarbital 1 tab 0.90

8 of 15
 HEALTH SERVICES AGENCY
MIA FORMULARY-By Classification
Effective: 4/30/08
(Replaces 1/1/08 Version)

DRUGS LISTED BY CLASSIFICATION COST PER UNIT

Anti-Emetic Agents
Promethazine 25 mg 0.22
Promethazine 50 mg 0.45
Meclizine 25 mg 0.10
Meclizine 12.5 mg 0.03
Compazine 5 mg 0.05
Compazine 10 mg 0.05
Anti-Prostate/BPH
Dutasteride-Avodart 2.75
Anti-Ulcer/Anti-Peptic Agents
Nexium 40 mg 4.43
Omeprazole 10 mg 0.24
Omeprazole 20 mg 0.43
Prevacid 15 mg 4.47
Prevacid 30 mg 4.47
H2 Antagonist Agents
Cimetidine 300 mg 0.04
Cimetidine 400 mg 0.04
Cimetidine 800 mg 0.09
Famotidine 20 mg 0.03
Famotidine 40 mg 0.06
Ranitidine 150 mg 0.36
Anti-Infective Agents
Amoxicillin 500 mg 0.05
Amoxicillin 250 mg 0.04
Amoxicillin 250/5 bt 2.11
Amoxicillin 125/5 bt 1.93
Augmentin 500 mg 0.81
Augmentin 875 mg 0.85
Azithromycin 250 mg 2.66
Azithromycin 600 mg 4.05
Ceftriaxone 1 gm 43.06
Ceftriaxone 250 IM 13.88
Ceftriaxone 500 mg IM 25.16
Cephalexin 500 mg 0.60
Cephalexin 250 mg 0.07
Cephalexin 250/5 ml 8.65
Cephalexin 125/5 ml 2.81
Ciprofloxacin 500 mg 0.07
Ciprofloxacin 750 mg 0.24
Ciprofloxacin 250 mg 0.15
Clindamycin 150 mg 0.08
Cortisporin Otic Suspension 9.25
Gentamycin eye drop 5 ml 1.18
Erythromycin eye ointment 4 gm 1.13
Doxyclycline 100 mg 0.01

9 of 15
 HEALTH SERVICES AGENCY
MIA FORMULARY-By Classification
Effective: 4/30/08
(Replaces 1/1/08 Version)

DRUGS LISTED BY CLASSIFICATION COST PER UNIT

Doxyclycline 50 mg 0.07
Erythromycin ESS 333 mg 0.28
Erythromycin ESS 500 mg 0.17
Erythromycin ESS 250 mg 0.07
Isoniazid 100 mg 0.03
Isoniazid 300 mg 0.06
Metronidazole 500 mg 0.06
Metronidazole 250 mg 0.04
Mupirocin tube 10.00
Neomycin 500 mg 0.60
Nitrofurantoin 100 mg 0.09
Nitrofurantoin 50 mg 0.69
Penicillin G Benzathine 500 mg 0.17
Penicillin G Benzathine 250 mg 0.08
Penicillin G Benzathine 250 /5ml 1.66
Rifampin 150 mg 0.92
Rifampin 300 mg 1.04
Trimethoprim/Sulfamethoxazole 0.10
Eryth/Sulfameth Susp 250 mg 0.08
Eryth/Sulfameth Susp 250 mg 0.06
Erythromycin, Base 500 mg 0.28
Sulfacetamide 15 ml 1.60
Clarithromycin 500 mg 0.50
Anti-Fungal Agents
Ketoconazole 200 mg 0.18
Griseofulvin (Micro) 250 mg 0.29
Griseofulvin (Micro) 500 mg 0.52
Clotrimazole 7 tab pk 0.86
Fluconazole 150 mg 0.21
Fluconazole 200 mg 0.24
Lamisil 250 mg 0.20
Nystatin 30 gm topical 1.52
Nystatin oral 0.44
Mycelex Troche 0.75
Ketoconazole Cream 60 gm 11.88
Anti-Gout
Allopurinol 100 mg 0.06
Allopurinol 300 mg 0.05
Colchicine 0.6 mg 0.03
Colchicine 0.5 mg 0.37
Probenecid 500 mg 0.11
HIV Anti-Retroviral Agents
Abacavir-Ziagen 7.11
Amprenavir-Agenerase 0.52
Acarbavir/Lamivudine/Zidovudine 50 mg 0.79
Acarbavir/Lamivudine/Zidovudine 100 mg 0.95

10 of 15
 HEALTH SERVICES AGENCY
MIA FORMULARY-By Classification
Effective: 4/30/08
(Replaces 1/1/08 Version)

DRUGS LISTED BY CLASSIFICATION COST PER UNIT

Acarbavir/Lamivudine/Zidovudine 25 mg 0.73
Truvada 25.57
Norvir 8.44
Kaletra 100/25 mg 2.88
Kaletra 200/50 mg 5.76
Zerit 15 mg 5.06
Zerit 20 mg 5.19
Zerit 30 mg 5.51
Zerit 40 mg 5.61
Reyataz 100 mg 12.68
Reyataz 150 mg 12.68
Sustiva 600 mg 14.53
Other Anti-Viral Agents
Amantadine 100 mg 0.34
Acyclovir 200 mg 0.06
Acyclovir 400 mg 0.12
Acyclovir 800 mg 0.13
Rebetol 200 mg 8.70
Anti-Histamine/Decongestant/Cough Agents
Promethazine with Codeine ml 0.02
Robitussin AC 0.01
Promethazine DM 0.01
Flonase 74.66
Nasonex 75.70
Nasacort AQ 77.11
Loratidine 10 mg 0.08
Asthma/COPD/Pulmonary Agents
Aerobid 73.00
Aerobid-M 73.00
QVAR 40 mcg 54.41
QVAR 80 mcg 68.56
Albuterol 34.65
Salmeterol Diskus 31.90
Azmacort 110.00
Atrovent HFA 74.31
Combivent HFA 82.24
Proventil HFA 34.65
Zopenex HFA 39.21
Singulair 10 mg 3.01
Spiriva Handihaler 125.06
Prednisolone 15/5 ml 0.77
Prednisone 1 mg 0.09
Prednisone 2.5 mg 0.05
Prednisone 5 mg 0.01
Prednisone 10 mg 0.03
Prednisone 20 mg 0.04

11 of 15
 HEALTH SERVICES AGENCY
MIA FORMULARY-By Classification
Effective: 4/30/08
(Replaces 1/1/08 Version)

DRUGS LISTED BY CLASSIFICATION COST PER UNIT

Prednisone 50 mg 0.18
Dexamethasone .5 mg 0.05
Dexamethasone 1 mg 0.20
Dexamethasone 2 mg 0.39
Dexamethasone 4 mg 0.10
Anti-Osteoporosis Agents
Actonel 5 mg 2.71
Actonel 30 mg 18.97
Actonel 35 mg 18.97
Actonel 75 mg 41.11
Evista 60 mg 2.78
Fosamax 10 mg 2.60
Fosamax 70 mg 17.94
Organ Transplant Rejection Prophlyaxis Drugs
Cellcept 250 mg 3.01
Cellcept 500 mg 6.02
Neoral 25 mg 1.25
Neoral 100 mg 5.01
Diabetic and Thyroid Agents
Glimepiride 1 mg 0.03
Glimepiride 2 mg 0.05
Glimepiride 4 mg 0.10
Glipizide 10 mg 0.04
Glipizide 5 mg 0.03
Thyroid, Dessicated 120 mg 0.07
Thyroid, Dessicated 15 mg 0.08
Thyroid, Dessicated 180 mg 0.15
Levothyroxine .025 mg 0.17
Levothyroxine 0.137 mg 0.38
Levothyroxine .112 mg 0.04
Levothyroxine .088 mg 0.14
Levothyroxine .1 mg 0.09
Levothyroxine .125 mg 0.12
Levothyroxine .15 mg 0.13
Levothyroxine .175 mg 0.16
Levothyroxine .2 mg 0.16
Levothyroxine .3 mg 0.23
Propylthiouracil (PTU) 0.05
Methimazole 5 mg 0.31
Methimazole 10 mg 0.29
Non-Sulfonylureas (Biguanide)
Metformin 1000 mg 0.14
Metformin 850 mg 0.19
Metformin 500 mg 0.06
Metformin XR 500 mg 0.05
Insulin Agents

12 of 15
 HEALTH SERVICES AGENCY
MIA FORMULARY-By Classification
Effective: 4/30/08
(Replaces 1/1/08 Version)

DRUGS LISTED BY CLASSIFICATION COST PER UNIT

Novolin R 32.51
Novolin N 32.51
Novolin 70/30 32.51
Lantus 69.48
Novolog 75.43
Miscellaneous
Actos 15 mg 3.39
Actos 30 mg 5.43
Actos 45 mg 5.89
Starlix 120 mg 1.25
Freestyle Test Strips 82.63
Freestyle Lancets 7.48
Antabuse 250mg 2.80
Hormone Agents
Estrogen/Progesterone Agents
Premphase 0.625 mg/5 mg 40.81
Medroxyprogesterone 0.1 mg patch 3.27
Medroxyprogesterone Acetate 10 mg 0.25
Medroxyprogesterone Acetate 5 mg 0.19
Medroxyprogesterone Acetate 2.5 mg 0.06
Estradiol 0.5 mg 0.02
Estradiol 1 mg 0.03
Estradiol 2 mg 0.15
Estratest 0.05
Estratest HS 0.05
Premarin Vaginal Cream 75.28
Premarin .3 mg 1.22
Premarin .625 mg 1.22
Premarin .9 mg 1.22
Premarin 1.25 mg 1.22
Prempro .3/1.5 mg 43.26
Prempro .45/1.5 mg 43.26
Prempro .625 mg/2.5 mg 43.26
Prempro .625 mg/5 mg 43.26
Urinary (Anti-Spasmodic) Agents
Detrol LA 2 mg 3.17
Detrol LA 4 mg 3.17
Oxybutinin 5 mg 0.03
Urinary Analgesic Agents
Phenazopyridine 100 mg 0.53
Phenazopyridine 200 mg 0.89
Miscellaneous Urinary Agents
Bethanechol 10 mg 0.26
Bethanechol 25 mg 0.36
Bethanechol 50 mg 0.89
Potassium Agents

13 of 15
 HEALTH SERVICES AGENCY
MIA FORMULARY-By Classification
Effective: 4/30/08
(Replaces 1/1/08 Version)

DRUGS LISTED BY CLASSIFICATION COST PER UNIT

Potassium Chloride ER 8 Meq 0.03
Potassium Chloride 10% (20 Meq/15 ml) 0.04
Potassium Chloride 20% (40 Meq/15 ml) 0.20
Digestive Enzymes
Pancrelipase Delayed Release (4500) 0.12
Pancrelipase Delayed Release (10,000) 0.09
Anti-Tuberculosis Agents
Call Pharmacy or Public Health per Protocol
Hepatitis C Anti-Viral Agents
Ribavirin 200 mg 5.91
PEG-INTRON 80 mcg 378.29
PEG-INTRON 120 mcg 397.22
PEG-INTRON 150 mcg 417.09
Oral Contraceptive Agents
Medi-Cal Coverage - Call Pharmacy For Details
Genitournary Agents
Podofilox topical 0.5% soln 16.35
Condylox topical gel 0.5% 29.59
PO CA-Chemotherapy
Xeloda 150 mg 4.56
Xeloda 500 mg 15.20
Gleevec 100 mg 25.01
Gleevec 400 mg 93.59
PO Hormonal Oncologics
Femara 2.5 mg 8.47
ESRD Agents
Renagel 400 mg 0.84
Renagel 800 mg 1.68
Anti-Glaucoma Agents
Cosopt 2% 102.27
Topical Steroids - Call Pharmacy for Additional Coverage
Lowest Potency
Hydrocortisone 1% oint 454 g 0.02
Medium Potency
Fluocinolone .01% 60 g cream 1.47
Fluocinolone .0025% 15 g oint 0.83
Fluocinolone .0025% 60 g cream 1.69
Fluocinolone .0025% 60 g oint 1.74
Triamcinolone .1% 80 g cream 1.32
Triamcinolone .1% 80 g oint 0.35
Triamcinolone .1% 15 g cream 1.17
Triamcinolone .1% 15 g oint 1.17
Triamcinolone .025% 15 g cream 0.73
Triamcinolone .025% 15 g oint 0.76
Triamcinolone .025% 80 g cream 2.34
Triamcinolone .025% 80 g oint 2.34

14 of 15
 HEALTH SERVICES AGENCY
MIA FORMULARY-By Classification
Effective: 4/30/08
(Replaces 1/1/08 Version)

DRUGS LISTED BY CLASSIFICATION COST PER UNIT

High Potency
Triamcinolone .5% 15 g oint 2.15
Triamcinolone .5% 15 g cream 4.00
Fluocinonide 0.05% 30 g oint 2.09
Fluocinonide 0.05% 60 g cream 0.07
Highest Potency
Clobetasol .05% 45 g cream 4.25
Clobetasol .05% 60 g oint 5.25
Clobetasol .05% 60 g cream 5.39
Acne Care
Clindamycin 1% soln (60 ml) 0.08
Clindamycin 1% gel 30 g 0.23
Erythromycin 2% soln (60 ml) 0.03
Erythromycin 2% gel 30 g 0.13
Miscellaneous Topical Agents
Elimite Cream 60 gm tube 5.50
Silvadene Cream gm tube 3.50
Vitamins
Thiamin 50 mg 0.02
Thiamin 100 mg 0.02
Vitamin K 5 mg 1.6
Folic Acid 1 mg 0.01
Hepatic Encephalopathy
Lactulose 946 ml 14.56

15 of 15