Magellan Rx Management



Generic Upper Limits changing effective June 1, 2014

Amoxicillin; Clavulanate 500 mg; 125 mg, Tablet, Oral 0.94016

Amoxicillin; Clavulanate 875 mg; 125 mg, Tablet, Oral 0.96960

Azelastine 137 mcg, Nasal Spray 1.47100

Chlorpromazine 10 mg, Tablet, Oral 0.76320

Chlorpromazine 25 mg, Tablet, Oral 1.06640

Chlorpromazine 50 mg, Tablet, Oral 1.50030

Chlorpromazine 100 mg, Tablet, Oral 2.20310

Chlorpromazine 200 mg, Tablet, Oral 3.11440

Clindamycin 75 mg/5 ml, Pediatric Granules, Solution, Oral 0.44530

Cyclosporine Modified 25 mg, Capsule, Oral 0.72360

Cyclosporine Modified 100 mg, Capsule, Oral 2.58740

Escitalopram Oxalate 5 mg/5 ml, Solution, Oral 0.51310

Fentanyl Transdermal Patches 25 mcg/hr Transdermal Patch 3.41794

Fentanyl Transdermal Patches 50 mcg/hr Transdermal Patch 6.22897

Fentanyl Transdermal Patches 75 mcg/hr Transdermal Patch 9.62367

Fentanyl Transdermal Patches 100 mcg/hr Transdermal Patch 12.22295

Finasteride 5 mg, Tablet, Oral 0.26201

Fluticasone Propionate 50 mcg, Nasal Spray 0.65292

Irbesartan 75 mg, Tablet, Oral 0.23470

Irbesartan 150 mg, Tablet, Oral 0.28860

Irbesartan 300 mg, Tablet, Oral 0.39090

Irbesartan; Hydrochlorothiazide 150 mg; 12.5 mg, Tablet, Oral 0.28330

Irbesartan; Hydrochlorothiazide 300 mg; 12.5 mg, Tablet, Oral 0.54860

Levalbuterol 0.31 mg/3 ml, Inhalation Solution 1.10250

Levalbuterol 0.63 mg/3 ml, Inhalation Solution 1.10250

Levalbuterol 1.25 mg/3 ml, Inhalation Solution 1.10250

Methotrexate 2.5 mg, Tablet, Oral 2.22620

Montelukast Sodium 4 mg, Tablet, Chewable, Oral 0.41410

Montelukast Sodium 5 mg, Tablet, Chewable, Oral 0.39490

Montelukast Sodium 10 mg, Tablet, Oral 0.28880

Olanzapine 2.5 mg, Tablet, Oral 0.35071

Olanzapine 5 mg, Tablet, Oral 0.39172

Olanzapine 7.5 mg, Tablet, Oral 0.45404

Olanzapine 10 mg, Tablet, Oral 0.54064

Olanzapine 15 mg, Tablet, Oral 0.76846

Olanzapine 20 mg, Tablet, Oral 0.98344

Oxcarbazepine 150 mg, Tablet, Oral 0.24623

Oxcarbazepine 300 mg, Tablet, Oral 0.34597

Oxcarbazepine 600 mg, Tablet, Oral 0.60808

Quetiapine Fumarate 25 mg, Tablet, Oral 0.21718

Quetiapine Fumarate 50 mg, Tablet, Oral 0.28932

Quetiapine Fumarate 100 mg, Tablet, Oral 0.30789

Quetiapine Fumarate 200 mg, Tablet, Oral 0.53194

Quetiapine Fumurate 300 mg, Tablet, Oral 0.61671

Quetiapine Fumurate 400 mg, Tablet, Oral 0.63864

Repaglinide 0.5 mg, Tablet, Oral 0.67190

Repaglinide 1 mg, Tablet, Oral 0.67190

Repaglinide 2 mg, Tablet, Oral 0.67190

Tacrolimus 0.5 mg, Capsule, Oral 0.95330

Tacrolimus 1 mg, Capsule, Oral 1.63281

Tacrolimus 5 mg, Capsule, Oral 11.51006

Venlafaxine Hydrochloride 37.5 mg, Extended Release, Capsule, Oral 0.22730

Venlafaxine Hydrochloride 75 mg, Extended Release, Capsule, Oral 0.18110

Venlafaxine Hydrochloride 150 mg, Extended Release, Capsule, Oral 0.25040

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